Preferred Drug List (PDL)

Home , Bakuchiol, Nicotinamide, Phenylalanine

Ohio Effective Date: 7/1/2021

UnitedHealthcare Community Plan of Ohio, Inc. does not discriminate because of sex, age, race, color, disability or national origin.

If you believe that we have failed to provide these services or discriminated in another way on the basis of sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. o Online: [email protected] o Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608, Salt Lake City, UT 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call 1-800-895-2017 (TTY 711) from 7 a.m. to 7 p.m. Monday through Friday (voicemail available 24 hours a day/7 days a week).

You can also file a complaint with the U.S. Dept. of Health and Human Services. o Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. o Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) o Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 1-800-895-2017 (TTY 711) from 7 a.m. to 7 p.m. Monday through Friday (voicemail available 24 hours a day/7 days a week).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call 1-800-895-2017, TTY 711.

ATENCIÓN: si habla espaol (Spanish), tiene a su disposicin servicios gratuitos de asistencia lingística. Llame al 1-800-895-2017, TTY 711.

注意：如果您說中文 (Chinese)，您可獲得免費語言協助服務。請致電 1-800-895-2017，或聽障專線 (TTY) 711。

LƯU Ý: Nếu qu vị ni Tiếng Việt (Vietnamese), chng ti c các dịch vụ hỗ trợ ngn ngữ miễn phí cho qu vị. Vui lng gọi số 1-800-895-2017, TTY 711.

참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다. 1-800-895-2017, TTY 711 로 전화하십시오.

ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo ng pantulong sa wika, nang walang bayad. Tumawag sa 1-800-895-2017, TTY 711.

CSOH18MC4385073_000 ВНИМАНИЕ: Если вы говори е по-русском (Russian), вы може е воспользова ься беспла ными услугами переводчика. Звони е по ел 1-800-895-2017, TTY 711.

تنبيه: إذا كنت تتحدث العربية (Arabic)، تتوفر لك خدمات المساعدة اللغوية ًمجانا. اتصل على الرقم 2017-895-800-1، الهاتف النصي 711.

ATANSYON: Si w pale Kreyl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nan 1-800-895-2017, TTY 711.

ATTENTION : Si vous parlez français (French), vous pouvez obtenir une assistance linguistique gratuite. Appelez le 1-800-895-2017, TTY 711.

UWAGA: Jeżeli mwisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod numer 1-800-895-2017, TTY 711.

ATENÇÃO: Se fala português (Portuguese), encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-895-2017, TTY 711.

ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.

HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur Verfgung. Wählen Sie: 1-800-895-2017, TTY 711.

ご注意：日本語 (Japanese) をお話しになる場合は、言語支援サービスを無料でご利用いただけます。電話番号1-800-895-2017、または TTY 711（聴覚障害者・難聴者の方用）までご連絡ください。

توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. 2017-895-800-1 تماس بگیرید، TTY 711.

ध्봾न द:ᴂ ्दद आप हिन्饀 (Hindi) भ봾ष봾 बोलत े हℂ तो भ봾ष봾 सह봾्त봾 सव봾एे ंआपक े ललए ननःशलकु उपलब㔧 ह।ℂ कॉल कर ᴂ 1-800-895-2017, TTY 711.

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 1-800-895-2017, TTY 711.

ចំ㮶ប់讶រមណ៍៖䮘 បបើសិនអកនិ架យ䮓徶羶ខ្រ揂 (Khmer) បស玶ជំនយ徶羶បោយឥតគិតថ្ួ 濃 គឺ掶នសំ殶ប់អក។䮓 សមទរស័ពបៅបេខ ូ ូ 䮑 1-800-895-2017។ TTY 711។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kaniam. Maidawat nga awagan iti 1-800-895-2017, TTY 711.

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné ЁNavajoЂ Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-895-2017, TTY 711.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac 1-800-895-2017, TTY 711. ध्봾न ददनहोस:ु ् ्दद तप봾ℂ नपाल饀े (Nepali) भ봾ष봾 बोलनहन㔛ु ु भने तप봾ℂको ल봾गि नन:शलकु भ봾ष봾 सह봾्त봾 सव봾ह셂े उपलब㔧㔛न ।् कृ प्봾 1-800-895-2017, TTY 711, म봾 फोन िनहोस।ुꅁ ्

XIYYEEFFANNOO: Afaan Kushaitii (Cushite) dubbattu yoo ta’e, tajaajilli gargaarsa afaanii, kanfaltii malee isiniif ni argama. Maaloo lak. 1-800-895-2017 n TTY 711 n bilbila’a.

LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel 1-800-895-2017, TTY 711.

WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.

ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică gratuite. Sunați la 1-800-895-2017, TTY 711.

УВАГА: Якщо ви не говори е українською (Ukrainian) мовою, ви може е скорис а ися безкош овними послугами перекладача. Телефонуй е за номером 1-800-895-2017, TTY 711.

သတိမူရန္ - အကယ္၍ သင္သည္ ျမန္မာ (Burmese) စကားေျပာလွ်င္၊ ဘာသာစကားဆိုင္ရာ ပံ့ပိုးေထာက္ပံ့မႈ ဝန္ေဆာင္မႈမ်ားကို သင္ အခမဲ့ ရ႐ွႏင္မည္ျဖစ္သည္။ ိ ုိ ေက်းဇူးျပဳၿပီး 1-800-895-2017, TTY 711 သို႔ ေခၚဆိုပါ။ UnitedHealthcare Community Plan of Ohio, Inc. no discrimina por motivos de sexo, edad, raza, color, discapacidad o nacionalidad.

Si considera que no hemos proporcionado estos servicios o hemos discriminado de otro modo en funcin del sexo, la edad, la raza, el color, la discapacidad o la nacionalidad, puede enviar una reclamacin al Coordinador de derechos civiles. o En línea: [email protected] o Por correo postal: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608, Salt Lake City, UT 84130

Debe enviar la reclamacin dentro de un plazo de 60 días desde que se enter de la situacin. Se le enviará una decisin dentro de un plazo de 30 días. Si no está de acuerdo con la decisin, tiene 15 días para pedirnos que analicemos la situacin nuevamente. Si necesita ayuda con su reclamacin, llame al 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).

También puede presentar una reclamacin ante el Departamento de Salud y Servicios Humanos de los EE. UU. (U.S. Department of Health and Human Services). o En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Los formularios de reclamacin están disponibles en http://www.hhs.gov/ocr/office/file/index.html. o Por teléfono: línea gratuita 1-800-368-1019, 800-537-7697 (TDD) o Por correo postal: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para solicitar ayuda, llame a 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call 1-800-895-2017, TTY 711.

ATENCIÓN: si habla espaol (Spanish), tiene a su disposicin servicios gratuitos de asistencia lingística. Llame al 1-800-895-2017, TTY 711.

注意：如果您說中文 (Chinese)，您可獲得免費語言協助服務。請致電 1-800-895-2017，或聽障專線 (TTY) 711。

LƯU Ý: Nếu qu vị ni Tiếng Việt (Vietnamese), chng ti c các dịch vụ hỗ trợ ngn ngữ miễn phí cho qu vị. Vui lng gọi số 1-800-895-2017, TTY 711.

CSOH18MC4385074_000 참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다. 1-800-895-2017, TTY 711 로 전화하십시오.

ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo ng pantulong sa wika, nang walang bayad. Tumawag sa 1-800-895-2017, TTY 711.

ВНИМАНИЕ: Если вы говори е по-русском (Russian), вы може е воспользова ься беспла ными услугами переводчика. Звони е по ел 1-800-895-2017, TTY 711.

ATANSYON: Si w pale Kreyl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nan 1-800-895-2017, TTY 711.

ATTENTION : Si vous parlez français (French), vous pouvez obtenir une assistance linguistique gratuite. Appelez le 1-800-895-2017, TTY 711.

UWAGA: Jeżeli mwisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod numer 1-800-895-2017, TTY 711.

ATENÇÃO: Se fala português (Portuguese), encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-895-2017, TTY 711.

ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.

HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur Verfgung. Wählen Sie: 1-800-895-2017, TTY 711.

توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. 2017-895-800-1 تماس بگیرید، TTY 711.TTY.711

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 1-800-895-2017, TTY 711.

ចំ㮶ប់讶រម䮘ណ៍៖ បបើសិនអ䮓កនិ架យ徶羶ខ្揂រ (Khmer) បស玶ជំនួយ徶羶បោយឥតគិតថ្濃 គឺ掶នសំ殶ប់អ䮓ក។ សូមទូរស័ព䮑បៅបេខ 1-800-895-2017។ TTY 711។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kaniam. Maidawat nga awagan iti 1-800-895-2017, TTY 711.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac 1-800-895-2017, TTY 711.

ध्봾न ददनहोस: ु ् ्दद तप봾ℂ नपाल饀 े (Nepali) भ봾ष봾 बोलनहन㔛ु ु भने तप봾ℂको ल봾गि नन:शलकु भ봾ष봾 सह봾्त봾 स ेव봾ह셂 उपलब㔧㔛न ।् क ृ प्봾 1-800-895-2017, TTY 711, म봾 फोन िनहोसुꅁ ।्

XIYYEEFFANNOO: Afaan Kushaitii (Cushite) dubbattu yoo ta’e, tajaajilli gargaarsa afaanii, kanfaltii malee isiniif ni argama. Maaloo lak. 1-800-895-2017 n TTY 711 n bilbila’a.

LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel 1-800-895-2017, TTY 711.

WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.

ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică gratuite. Sunați la 1-800-895-2017, TTY 711.

УВАГА: Якщо ви не говори е українською (Ukrainian) мовою, ви може е скорис а ися безкош овними послугами перекладача. Телефонуй е за номером 1-800-895-2017, TTY 711. INSIDE:

UnitedHealthcare Community Plan List of Preferred Drugs

Frequently Asked Questions (FAQ) Find answers here to questions you have about this UnitedHealthcare Community Plan List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1 What drugs are on the Preferred Drug List? (We call the Preferred Drug List the “Drug List” for short.) The drugs on Preferred Drug List that starts on page <4> are the drugs covered by UnitedHealthcare Community Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

UnitedHealthcare will cover all medically necessary drugs if: · your doctor or other prescriber says you need them to get better or stay healthy, and · you fill the prescription at a UnitedHealthcare Community Plan network pharmacy. UnitedHealthcare may have additional steps to access certain drugs (see question <#5> below). You can also see an up-to-date drug list on our website at or call Member Services at <1-800-895-2017> TTY 711.

2 Does the Drug List ever change? Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: · a cheaper drug comes along that works as well as a drug on the Drug List now, or · we learn that a drug is not safe. We may also change our rules about drugs. For example, we could:

9/28/2016 · Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Community Plan before you can get a drug.) · Add or change the amount of a drug you can get (called “quantity limits”). · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see pages <4, 5 and 9>. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check the up-to-date Drug List online at You can also call Member Services to check the current Drug List at <1-800-895-2017>, TTY 711>.

3 What happens when another drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because another drug that works just as well is available, we will tell you. You will get a letter letting you know about the change. We will also tell you what alternate drugs are available to you. Contact your doctor or other prescriber to make sure another drug will work for you.

4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases your doctor must do something before you can get the drug. For example: · Prior approval (or prior authorization): For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. · Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug you can get.

9/28/2016 · Step therapy: Sometimes UnitedHealthcare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages <4-58>. You can also get more information by visiting our website at . We have posted online documents that explain our prior authorization and step therapy restrictions. You may also call Member Services and ask us to send you information about our prior authorization and step therapy restrictions.

6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The Preferred Drug List on pages <4-58>. has a column labeled “Requirements and Limits.”

7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you before the restriction is added.. This gives you time to talk to your doctor or other prescriber about what to do next.

8 How can you find a drug on the Drug List? There are two ways to find a drug: · You can search by medical condition. To search by medical condition, find the section labeled “List of drugs by medical condition” on pages <4-58>. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. · You can also search for drugs alphabetically. To search alphabetically, go to the starting on page <59 >

9/28/2016 Find the name of your drug. The page number where you can find the drug will be next to it.

9 What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services and ask about it. If you learn that UnitedHealthcare does not prefer the drug, you can do one of these things: · Ask Member Services for a list of drugs that are similar to the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or · You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

10 What if you just joined UnitedHealthcare Community Plan and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to request an exception.

11Can you ask for an exception to cover your drug? Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to cover a drug that is not on the Drug List. Your doctor can also ask us to change the rules on your drug. · For example, we may limit the amount of a drug we will cover. If your drug has a limit, your doctor can ask us to change the limit and cover more. · Other examples: Your doctor can ask us to drop step therapy restrictions or prior approval requirements.

12 How long does it take to get an exception? First, we must receive some information from your doctor supporting your request for an exception. After we receive the information, we will give you a decision on your exception request within the timeframes required by the state, generally within 24 hours.

9/28/2016 13 How can you ask for an exception? To ask for an exception, you can do one of two things: - Call Member Services. A Member Services representative will work with you and your doctor to help ask for an exception. - Call your doctor and ask them to request an exception by calling the Prior Notification Service at <1-800-310-6826>, or they can fax a request to<866-940- 7328>.

14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). In most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand name drug is medically necessary, you will need to ask your doctor to submit for prior approval.

15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs are preferred.

16 Does UnitedHealthcare cover OTC non-drug products? UnitedHealthcare covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC non- drug products are covered.

17 What is a Specialty Pharmacy Medication? A specialty pharmacy medication is a drug that generally has one or more of the following characteristics:  It’s used by a small number of people  It treats rare, chronic, and/or potentially life-threatening diseases

9/28/2016  It has special storage or handling requirements such as needing to be refrigerated  It may need close monitoring, ongoing clinical support and management, and complete patient education and engagement  It’s a high cost medication  It may not be available at retail pharmacies  It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network. If you have questions, call Member Services at <1-800-895-2017, TTY 711>.

List of Preferred Drugs The List of Preferred Drugs that begins gives you information about the drugs covered by UnitedHealthcare Community Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page <59> . The first column of the chart lists the generic name of the drug. The second column of the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR). The third column in the list tells you if the preferred drug covered is the brand or generic version. The information in the “Requirements & Limits” column tells you if UnitedHealthcare has any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization) For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare Community Plan before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Community Plan limits the amount of a drug you can get. ST - Step therapy

9/28/2016 Sometimes UnitedHealthcare Community Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then your doctor can ask for approval to cover the second.

Other special requirements for coverage

SP – Specialty Pharmacy Drug needs to be accessed through a network Specialty Pharmacy. Specialty Pharmacy Drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.

Drug Tiers

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy * = Available without PA for participating Behavioral Health Prescribers

[You can find information on what the symbols and abbreviations in this table mean by going to page <4>]

9/28/2016 注意：如果您說中文，您可獲得免費語言協助服務。請致電：。或聽障專線。

9/28/2016 Table of Contents Analgesics...... 4 Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions ...... 4 Anesthetics - Drugs for Numbing ...... 15 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence ...... 18 Antibacterials ...... 20 Antibacterials - Drugs to Treat Bacterial Infections ...... 20 Anticonvulsants - Drugs to Treat Seizures ...... 26 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia ...... 28 Antidepressants - Drugs to Treat Depression ...... 29 Antiemetics - Drugs to Treat Nausea and Vomiting ...... 31 Antifungals ...... 32 Antifungals - Drugs to Treat Fungal Infections ...... 33 Antigout Agents - Drugs to Treat Gout ...... 36 Anti-inflammatory Agents - Drugs to Treat Inflammation ...... 36 Antimigraine Agents - Drugs to Treat Migraines...... 36 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis ...... 38 Antimycobacterials - Drugs to Treat Infections ...... 38 Antineoplastics ...... 39 Antineoplastics - Drugs to Treat Cancer ...... 39 Antiparasitics ...... 44 Antiparasitics - Drugs to Treat Parasitic Infections ...... 44 Antiparkinson Agents ...... 45 Antiparkinson Agents - Drugs to Treat Parkinson's Disease ...... 45 Antipsychotics - Drugs to Treat Mood Disorders ...... 47 Antispasticity Agents ...... 48 Antivirals - Drugs to Treat Viral Infections ...... 49

1 Anxiolytics - Drugs to Treat Anxiety ...... 52 Bipolar Agents - Drugs to Treat Mood Disorders ...... 53 Blood Glucose Regulators - Drugs to Regulate Blood Sugar ...... 53 Blood Products and Modifiers ...... 57 Blood Products and Modifiers - Drugs to Treat Blood Disorders ...... 57 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders ...... 57 Cardiovascular Agents ...... 59 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions ...... 59 Central Nervous System Agents ...... 67 Central Nervous System Agents - Drugs to Treat Nerve Conditions ...... 67 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions ...... 70 Dermatological Agents ...... 72 Dermatological Agents - Drugs to Treat Skin Conditions ...... 72 Electrolytes/Minerals/ Metals/ Vitamins ...... 85 Electrolytes/Minerals/Metals/Vitamins ...... 86 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions ...... 103 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ...... 120 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions ...... 121 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones ...... 123 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones ...... 124 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones ...... 125 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones ...... 125 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones ...... 134 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones ...... 135 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones ...... 135 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones ...... 136 Immunological Agents...... 136 Immunological Agents - Drugs that Stimulate or Suppress the Immune System ...... 136 2 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease ...... 139 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions ...... 141 Metabolic Bone Disease Agents - Other ...... 141 Miscellaneous Therapeutic Agents ...... 141 Not Specified ...... 154 Ophthalmic Agents - Drugs to Treat Eye Conditions ...... 155 Otic Agents - Drugs to Treat Ear Conditions ...... 162 Regulators - Drugs to Regulate Blood Sugar ...... 163 Respiratory Tract Agents ...... 163 Respiratory Tract/Pulmonary Agents ...... 163 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions ...... 163 Sedatives/Hypnotics - Drugs for Sedation and Sleep ...... 184 Skeletal Muscle Relaxants ...... 185 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm ...... 185 Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions ...... 186 Sleep Disorder Agents - Drugs for Sedation and Sleep ...... 186 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies ...... 188

3 Preferred Agents Non-Preferred Agents Analgesics Nonsteroidal Anti-inflammatory Drugs GABAPENTIN-NAPROXEN CMPD KIT - Tier 2; PA

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL A.A.G.C. KIT IN TERODERM - Tier 2; PA 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen rapid tabs child - Tier 1; PA 8 hour pain relief oral tablet extended release 650 mg (generic for BUPAP (brand for butalbital-acetaminophen) - Tier 2; PA TYLENOL 8 HOUR) - Tier 1; QL butalbital-acetaminophen capsule 50-300 mg oral - Tier 1; PA; QL 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL - Tier 2; 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL PA; QL 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL butalbital-apap-caffeine oral capsule 50-300-40 mg (generic for FIORICET) 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL - Tier 1; PA acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL CAPSAICIN-MENTHOL - Tier 2; PA acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL DOANS PM EXTRA STRENGTH - Tier 2; PA acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; ELIXSURE FEVER/PAIN - Tier 2; PA QL enovarx-tramadol - Tier 1; PA acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; ESGIC (brand for butalbital-apap-caffeine) - Tier 2; PA; QL QL EXCEDRIN TENSION HEADACHE (brand for tension headache) - Tier 2; acetaminophen childrens - Tier 1; QL PA acetaminophen childrens oral suspension 160 mg/5ml (generic for FIORICET (brand for butalbital-apap-caffeine) - Tier 2; PA PANADOL CHILDRENS) - Tier 1; QL FLEXIN - Tier 2; PA acetaminophen childrens oral tablet chewable 160 mg (generic for LEVATIO - Tier 2; PA MAPAP CHILDRENS) - Tier 1; QL MAPAP HEADACHE PLUS - Tier 2; PA acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL menstrual pain relief (generic for PAMPRIN MAX PAIN FORMULA) - Tier 1; acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP PA ACETAMINOPHEN EXTRA STR) - Tier 1 NEURAPTINE - Tier 2; PA; QL acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA PANADOL EXTRA (brand for tension headache) - Tier 2; PA STRENGTH) - Tier 1; QL rapid melts junior oral tablet dispersible 160 mg - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; *: Available without PA for participating Behavioral Health Prescribers; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy

4 Preferred Agents Non-Preferred Agents acetaminophen extra strength (generic for PANADOL EXTRA tension headache (generic for EXCEDRIN TENSION HEADACHE) - Tier 1; STRENGTH) - Tier 1; QL PA acetaminophen infants oral suspension 160 mg/5ml (generic for TURPENTINE EXTERNAL - Tier 2; PA PANADOL CHILDRENS) - Tier 1; QL TYLENOL EXTRA STRENGTH TABLET 500 MG ORAL 500 MG (brand for acetaminophen oral liquid 500 mg/15ml (generic for MAPAP meijer aspirin free) - Tier 2; PA; QL ACETAMINOPHEN EXTRA STR) - Tier 1 VTOL LQ - Tier 2; PA acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 ZEBUTAL (brand for butalbital-apap-caffeine) - Tier 2; PA; QL mg/20.3ml - Tier 1; QL acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1; QL ALLZITAL (brand for butalbital-acetaminophen) - Tier 2; QL apra (generic for MEDI-TABS CHILDRENS) - Tier 1; QL arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL bac (generic for BAC) - Tier 1; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL butalbital-acetaminophen oral tablet 25-325 mg (generic for ALLZITAL) - Tier 1; QL butalbital-acetaminophen oral tablet 50-300 mg (generic for BUPAP) - Tier 1

5 Preferred Agents Non-Preferred Agents butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1; QL butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1; QL butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL butalbital-aspirin-caffeine - Tier 1; QL capsaicin external cream 0.025 % (generic for DERMACINRX PENETRAL) - Tier 1; QL CASTIVA WARMING - Tier 2; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1; QL childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for qc headache relief) - Tier 2 EXCEDRIN MIGRAINE (brand for qc headache relief) - Tier 2 fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1; QL fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL FEVERALL INFANTS - Tier 2; QL FEVERALL JUNIOR STRENGTH - Tier 2; QL headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1; QL

6 Preferred Agents Non-Preferred Agents infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL mapap oral capsule - Tier 1; QL migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1; QL non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL

7 Preferred Agents Non-Preferred Agents pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain reliever extra strength oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever oral tablet (generic for PHARBETOL) - Tier 1; QL pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 PANADOL CHILDRENS (brand for infants pain & fever) - Tier 2; QL

8 Preferred Agents Non-Preferred Agents PANADOL EXTRA STRENGTH (brand for meijer aspirin free) - Tier 2; QL PANADOL INFANTS (brand for infants pain & fever) - Tier 2; QL PHARBETOL EXTRA STRENGTH (brand for meijer aspirin free) - Tier 2; QL PHARBETOL ORAL TABLET 325 MG (brand for tactinal) - Tier 2; QL sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1; QL TENCON (brand for butalbital-acetaminophen) - Tier 2; QL TYLENOL EXTRA STRENGTH TABLET 500 MG ORAL 500 MG (brand for meijer aspirin free) - Tier 2; QL TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for infants pain & fever) - Tier 2; QL TYLENOL ORAL TABLET 325 MG (brand for tactinal) - Tier 2; QL TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for cvs pain relief childrens) - Tier 2; QL TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for 8 hour pain reliever) - Tier 2; QL

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs addaprin (generic for ADDAPRIN) - Tier 1; QL ADVIL LIQUI-GELS MINIS (brand for goodsense ibuprofen) - Tier 2; PA; ADVIL JUNIOR STRENGTH (brand for sm ibuprofen jr) - Tier 2; QL QL ADVIL ORAL TABLET (brand for sm ibuprofen) - Tier 2; QL ADVIL MIGRAINE (brand for goodsense ibuprofen) - Tier 2; PA; QL ALEVE ORAL TABLET (brand for qc naproxen sodium) - Tier 2; QL ADVIL ORAL CAPSULE (brand for goodsense ibuprofen) - Tier 2; PA; QL all day pain relief (generic for MEDIPROXEN) - Tier 1; QL aif #2 drug preparation kit - Tier 1; PA all day relief (generic for MEDIPROXEN) - Tier 1; QL AIF #3 DRUG PREPARATION KIT - Tier 2; PA aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ARTHROTEC (brand for diclofenac-misoprostol) - Tier 2; PA; QL aspirin ec (generic for BAYER ASPIRIN) - Tier 1; QL aspirin tri-buffered (generic for BUFFERIN) - Tier 1; PA

9 Preferred Agents Non-Preferred Agents aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1; QL BIIFENAC 1000 - Tier 2; PA; QL aspirin oral (generic for ST JOSEPH LOW DOSE) - Tier 1; QL BIIFENAC 500 - Tier 2; PA; QL ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for aspirin BUFFERIN (brand for sm aspirin tri-buffered) - Tier 2; PA ec low strength) - Tier 2; QL CAPSFENAC PAK - Tier 2; PA; QL aspirin rectal - Tier 1 CAPSINAC - Tier 2; PA; QL BAYER ASPIRIN (brand for gnp aspirin) - Tier 2; QL CATAFLAM (brand for diclofenac potassium) - Tier 2; PA; QL celecoxib oral (generic for CELEBREX) - Tier 1; QL; AL CELEBREX (brand for celecoxib) - Tier 2; PA; QL; AL childrens aspirin oral tablet chewable 81 mg (generic for ST JOSEPH DAYPRO (brand for oxaprozin) - Tier 2; PA; QL LOW DOSE) - Tier 1; QL DFS DR/MS/MENTH/CAP PAK - Tier 2; PA; QL diclofenac potassium (generic for CATAFLAM) - Tier 1; QL DFS/MS/MENTH/CAP PAK - Tier 2; PA; QL diclofenac sodium er - Tier 1; QL DICLOFENAC - Tier 2; PA; QL diclofenac sodium external gel 1 % (generic for ASPERCREME DICLOFENAC PATCH 1.3% - Tier 2; PA; QL ARTHRITIS PAIN) - Tier 1; QL diclofenac sodium external solution - Tier 1; PA; QL diclofenac sodium oral - Tier 1; QL diclofenac-misoprostol (generic for ARTHROTEC) - Tier 1; PA; QL diflunisal oral - Tier 1; QL DICLOFONO - Tier 2; PA; QL enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL DICLOPR - Tier 2; PA; QL etodolac - Tier 1; QL DICLOSTREAM - Tier 2; PA; QL etodolac er - Tier 1; QL DICLOTREX - Tier 2; PA; QL fenoprofen calcium oral tablet (generic for NALFON) - Tier 1; QL DICLOVIX - Tier 2; PA; QL flurbiprofen oral - Tier 1; QL DICLOVIX M - Tier 2; PA h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL DIMENTHO - Tier 2; PA; QL ibu (generic for IBU) - Tier 1; QL DUAL COMPLEX FORMULA 1 KIT - Tier 2; PA ibu-200 (generic for ADDAPRIN) - Tier 1; QL DUEXIS - Tier 2; PA; QL ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL EC-NAPROSYN (brand for naproxen) - Tier 2; PA; QL JUNIOR STRENGTH) - Tier 1; QL ec-naproxen (generic for EC-NAPROSYN) - Tier 1; PA; QL ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier 1; ENOVARX-DICLOFENAC SODIUM - Tier 2; PA QL enovarx-ibuprofen - Tier 1; PA; QL ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL enovarx-naproxen - Tier 1; PA ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR FBL KIT - Tier 2; PA STRENGTH) - Tier 1; QL FELDENE (brand for piroxicam) - Tier 2; PA; QL ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS fenoprofen calcium oral capsule (generic for FENORTHO) - Tier 1; PA ADVIL) - Tier 1; QL fenortho (generic for FENORTHO) - Tier 1; PA ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR STRENGTH) FLECTOR (brand for diclofenac epolamine) - Tier 2; PA; QL - Tier 1; QL FROTEK - Tier 2; PA; QL

10 Preferred Agents Non-Preferred Agents ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL IBUPAK - Tier 2; PA; QL ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier ibuprofen oral capsule 200 mg (generic for ADVIL) - Tier 1; PA; QL 1; QL inavix (generic for INFLAMMACIN) - Tier 1; PA ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS ADVIL) INDOMETHACIN ORAL CAPSULE 20 MG - Tier 2; PA; QL - Tier 1; QL INFLAMMACIN (brand for previdolrx plus analgesic) - Tier 2; PA ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL INFLATHERM - Tier 2; PA; QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1; K.B.G.L IN TERODERM - Tier 2; PA QL kapzin dc (generic for NUDICLO SOLUPAK) - Tier 1; PA; QL INDOCIN - Tier 2; QL KETOPHENE RAPIDPAQ - Tier 2; PA indomethacin er - Tier 1; QL ketoprofen oral - Tier 1; PA; QL indomethacin oral capsule 25 mg, 50 mg - Tier 1; QL KETOROLAC TROMETHAMINE EXTERNAL - Tier 2; PA INFANTS ADVIL (brand for sm infants ibuprofen) - Tier 2; QL KETOROLAC TROMETHAMINE NASAL - Tier 2; PA infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL LICART - Tier 2; PA ketoprofen er - Tier 1; QL LODINE (brand for etodolac) - Tier 2; PA; QL ketorolac tromethamine oral - Tier 1; QL meloxicam oral capsule (generic for VIVLODEX) - Tier 1; PA; QL meclofenamate sodium oral - Tier 1; QL MOBIC (brand for meloxicam) - Tier 2; PA; QL mediproxen (generic for MEDIPROXEN) - Tier 1; QL MOTRIN IB ORAL CAPSULE (brand for goodsense ibuprofen) - Tier 2; PA; mefenamic acid oral - Tier 1; QL QL meloxicam oral tablet (generic for MOBIC) - Tier 1; QL NALFON ORAL CAPSULE (brand for fenoprofen calcium) - Tier 2; PA MOTRIN CHILDRENS (brand for gnp ibuprofen childrens) - Tier 2; QL NALFON ORAL TABLET (brand for fenoprofen calcium) - Tier 2; PA; QL MOTRIN IB ORAL TABLET (brand for sm ibuprofen) - Tier 2; QL NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, MOTRIN INFANTS DROPS (brand for sm infants ibuprofen) - Tier 2; QL 750 MG (brand for naproxen sodium er) - Tier 2; PA nabumetone oral (generic for RELAFEN) - Tier 1; QL NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG naproxen oral suspension (generic for NAPROSYN) - Tier 1; QL (brand for naproxen sodium er) - Tier 2; PA; QL naproxen oral tablet - Tier 1; QL NAPROSYN (brand for naproxen) - Tier 2; PA; QL naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier naproxen oral tablet delayed release (generic for EC-NAPROSYN) - Tier 1; 1; QL PA; QL naproxen sodium oral tablet 275 mg - Tier 1; QL naproxen sodium er oral tablet extended release 24 hour 375 mg (generic naproxen sodium oral tablet 550 mg (generic for ANAPROX DS) - Tier for NAPRELAN) - Tier 1; PA 1; QL naproxen sodium er oral tablet extended release 24 hour 500 mg (generic oxaprozin (generic for DAYPRO) - Tier 1; QL for NAPRELAN) - Tier 1; PA; QL piroxicam oral (generic for FELDENE) - Tier 1; QL NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 salsalate oral - Tier 1; QL HOUR 750 MG - Tier 2; PA naproxen-esomeprazole (generic for VIMOVO) - Tier 1; PA; QL

11 Preferred Agents Non-Preferred Agents sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC NP #2 DRUG PREPARATION KIT - Tier 2; PA LOW DOSE) - Tier 1; QL NUDICLO SOLUPAK (brand for capsfenac pak) - Tier 2; PA; QL ST JOSEPH LOW DOSE (brand for aspirin low strength) - Tier 2; QL NUDICLO TABPAK (brand for previdolrx plus analgesic) - Tier 2; PA sulindac oral - Tier 1; QL NUDROXIPAK - Tier 2; PA; QL NUDROXIPAK DSDR-50 - Tier 2; PA; QL NUDROXIPAK DSDR-75 (brand for dfs dr/ms/menth/cap pak) - Tier 2; PA; QL NUDROXIPAK E-400 - Tier 2; PA; QL NUDROXIPAK I-800 - Tier 2; PA; QL NUDROXIPAK M-15 - Tier 2; PA; QL NUDROXIPAK N-500 - Tier 2; PA; QL ORMECA - Tier 2; PA; QL PENNSAID - Tier 2; PA; QL PRASTERA - Tier 2; PA PREVIDOLRX ANALGESIC - Tier 2; PA previdolrx plus analgesic (generic for INFLAMMACIN) - Tier 1; PA QMIIZ ODT - Tier 2; PA; QL RELAFEN (brand for nabumetone) - Tier 2; PA; QL RELAFEN DS - Tier 2; PA; QL SPRIX (brand for ketorolac tromethamine) - Tier 2; PA sure result dss premium pack (generic for NUDICLO SOLUPAK) - Tier 1; PA; QL TIVORBEX (brand for indomethacin) - Tier 2; PA; QL tolmetin sodium - Tier 1; PA; QL tri-buffered aspirin (generic for BUFFERIN) - Tier 1; PA TRIPLE COMPLEX FORMULA 3 KIT - Tier 2; PA; QL VAROPHEN - Tier 2; PA; QL VIMOVO (brand for naproxen-esomeprazole) - Tier 2; PA; QL VIVLODEX (brand for meloxicam) - Tier 2; PA; QL VP FC KIT - Tier 2; PA VP GKL KIT - Tier 2; PA; QL ZIPSOR - Tier 2; PA; QL ZORVOLEX - Tier 2; PA; QL

12 Preferred Agents Non-Preferred Agents Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS (brand for buprenorphine) - Tier 2; PA; QL BELBUCA - Tier 2; PA; QL morphine sulfate er oral tablet extended release (generic for MS buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL CONTIN) - Tier 1; PA; QL CONZIP (brand for tramadol hcl er) - Tier 2; PA; QL DURAGESIC-100 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-12 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-25 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-50 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-75 (brand for fentanyl) - Tier 2; PA; QL fentanyl (generic for DURAGESIC-25) - Tier 1; PA; QL hydrocodone bitartrate er (generic for ZOHYDRO ER) - Tier 1; PA; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL levorphanol tartrate oral - Tier 1; PA; QL methadone hcl intensol (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL methadone hcl oral - Tier 1; PA; QL methadose oral concentrate 10 mg/ml (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL methadose oral tablet soluble (generic for METHADOSE) - Tier 1; PA; QL methadose sugar-free (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL morphine sulfate er beads - Tier 1; PA; QL MS CONTIN (brand for morphine sulfate er) - Tier 2; PA; QL NUCYNTA ER - Tier 2; PA; QL OXYCODONE HCL ER - Tier 2; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL oxymorphone hcl er - Tier 1; PA; QL SYNAPRYN FUSEPAQ - Tier 2; PA; QL TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL XTAMPZA ER - Tier 2; PA; QL ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL

13 Preferred Agents Non-Preferred Agents Opioid Analgesics, Short-acting - Opioid Pain Relievers acetaminophen-codeine - Tier 1; QL ACTIQ (brand for fentanyl citrate) - Tier 2; PA; QL acetaminophen-codeine #2 - Tier 1; QL APADAZ (brand for benzhydrocodone-acetaminophen) - Tier 2; PA; QL acetaminophen-codeine #3 - Tier 1; QL apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA; QL acetaminophen-codeine #4 - Tier 1; QL BENZHYDROCODONE-ACETAMINOPHEN - Tier 2; PA; QL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butalbital-apap-caff-cod oral capsule 50-300-40-30 mg (generic for butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL FIORICET/CODEINE) - Tier 1; PA; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; carisoprodol-aspirin-codeine - Tier 1; PA; QL QL DILAUDID ORAL (brand for hydromorphone hcl) - Tier 2; PA; QL butorphanol tartrate nasal - Tier 1; QL fentanyl citrate buccal lozenge on a handle (generic for ACTIQ) - Tier 1; codeine sulfate - Tier 1; QL PA; QL endocet (generic for ENDOCET) - Tier 1; QL FENTANYL CITRATE BUCCAL TABLET - Tier 2; PA hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QL FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 100 MCG/2ML - Tier 2; PA mg - Tier 1; QL FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL MG/100ML-%, 2-0.9 MG/100ML-%, 2.5-0.9 MG/250ML-% - Tier 2; PA hydromorphone hcl rectal - Tier 1; QL FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier SYRINGE 500-0.9 MCG/50ML-% - Tier 2; PA 1; QL FENTORA (brand for fentanyl citrate) - Tier 2; PA morphine sulfate oral - Tier 1; QL FIORICET/CODEINE (brand for butalbital-apap-caff-cod) - Tier 2; PA; QL morphine sulfate rectal - Tier 1; QL hydrocodone-acetaminophen oral solution 10-325 mg/15ml - Tier 1; PA; QL OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL hydrocodone-acetaminophen oral tablet 10-300 mg, 7.5-300 mg - Tier 1; oxycodone hcl oral capsule - Tier 1; QL PA; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL hydrocodone-acetaminophen oral tablet 5-300 mg (generic for XODOL) - oxycodone hcl oral solution - Tier 1; QL Tier 1; PA; QL oxycodone hcl oral tablet - Tier 1; QL hydrocodone-ibuprofen - Tier 1; PA; QL oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 hydromorphone hcl er - Tier 1; PA; QL mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 25-0.9 oxycodone-aspirin - Tier 1; QL MG/50ML-%, 50-0.9 MG/50ML-% - Tier 2; PA tramadol hcl ir (generic for ULTRAM) - Tier 1; QL HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED tramadol-acetaminophen (generic for ULTRACET) - Tier 1; QL SYRINGE 15-0.9 MG/30ML-% - Tier 2; PA LAZANDA - Tier 2; PA; QL LORTAB - Tier 2; PA; QL meperidine hcl oral - Tier 1; PA; QL

14 Preferred Agents Non-Preferred Agents MORPHINE SULFATE (BULK) - Tier 2; PA morphine sulfate er oral capsule extended release 24 hour - Tier 1; PA; QL MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-0.9 MG/50ML-% - Tier 2; PA NALOCET - Tier 2; PA; QL NUCYNTA - Tier 2; PA; QL OXAYDO ORAL TABLET 7.5 MG - Tier 2; PA; QL OXYCODONE-ACETAMINOPHEN ORAL SOLUTION - Tier 2; PA; QL OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG - Tier 2; PA; QL oxymorphone hcl - Tier 1; PA; QL pentazocine-naloxone hcl - Tier 1; PA; QL PERCOCET (brand for oxycodone-acetaminophen) - Tier 2; PA; QL PROLATE (brand for oxycodone-acetaminophen) - Tier 2; PA; QL QDOLO - Tier 2; PA; QL ROXICODONE (brand for oxycodone hcl) - Tier 2; PA; QL SUBSYS - Tier 2; PA; QL tramadol hcl er (biphasic) - Tier 1; PA; QL tramadol hcl er oral tablet extended release 24 hour - Tier 1; PA; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL ULTRACET (brand for tramadol-acetaminophen) - Tier 2; PA; QL ULTRAM (brand for tramadol hcl) - Tier 2; PA; QL

Anesthetics - Drugs for Numbing Local Anesthetics 7T LIDO - Tier 2 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 % - anecream external cream (generic for ANECREAM) - Tier 1; QL Tier 2; PA; QL blue tube/ aloe (generic for ANECREAM) - Tier 1; QL AGONEAZE - Tier 2; PA; QL glydo (generic for GLYDO) - Tier 1 ANACAINE - Tier 2; PA lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL ANODYNE LPT - Tier 2; PA; QL lidocaine external ointment 5 % - Tier 1; QL APRIZIO PAK (brand for prilovixil) - Tier 2; PA; QL lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; QL APRIZIO PAK II (brand for prilovixil) - Tier 2; PA; QL lidocaine hcl mouth/throat - Tier 1 ASTERO - Tier 2; PA

15 Preferred Agents Non-Preferred Agents lidocaine hcl urethral/mucosal - Tier 1 CADIRAMD - Tier 2; PA lidocaine viscous hcl - Tier 1; QL CETACAINE EXTERNAL AEROSOL - Tier 2; PA lidocaine-prilocaine external cream - Tier 1; QL CETACAINE EXTERNAL GEL - Tier 2; PA LMX 4 (brand for lidocaine) - Tier 2; QL cough drops mouth/throat lozenge 5.4 mg (generic for CEPACOL SORE premium lidocaine - Tier 1; QL THROAT) - Tier 1; PA DERMALID - Tier 2; PA; QL EHA - Tier 2; PA EMPRICAINE-II (brand for prilovixil) - Tier 2; PA; QL enovarx-lidocaine hcl - Tier 1; PA ENZNONUTY - Tier 2; PA; QL ethyl chloride - Tier 1; PA GEBAUERS PAIN EASE - Tier 2; PA GEBAUERS SPRAY AND STRETCH - Tier 2; PA GEN7T - Tier 2; PA; QL GEN7T PLUS - Tier 2; PA; QL LDO PLUS - Tier 2; PA lets - Tier 1; PA LIDO BDK (brand for anodyne lpt) - Tier 2; PA; QL lidocaine hcl external cream 3 % - Tier 1; PA; QL lidocaine hcl external cream 4 % (generic for ASPERCREME LIDOCAINE) - Tier 1; PA LIDOCAINE HCL EXTERNAL CREAM 4.12 % - Tier 2; PA; QL lidocaine hcl external lotion (generic for LIDO-SORB) - Tier 1; PA lidocaine hcl external solution - Tier 1; PA lidocaine maximum strength (generic for ASPERCREME LIDOCAINE) - Tier 1; PA lidocaine pain relieving external cream 4 % (generic for ASPERCREME LIDOCAINE) - Tier 1; PA lidocaine plus (generic for ASPERCREME LIDOCAINE) - Tier 1; PA lidocaine-prilocaine external kit (generic for LIDO BDK) - Tier 1; PA; QL LIDOCAINE-TETRACAINE - Tier 2; PA LIDOCANNA - Tier 2; PA LIDODERM (brand for lidocaine) - Tier 2; PA; QL LIDOPAC - Tier 2; PA; QL

16 Preferred Agents Non-Preferred Agents lidopin external cream 3 % - Tier 1; PA; QL LIDOPIN EXTERNAL CREAM 3.25 % - Tier 2; PA LIDOPRIL - Tier 2; PA; QL LIDOPRIL XR - Tier 2; PA; QL LIDO-PRILO CAINE PACK (brand for anodyne lpt) - Tier 2; PA; QL LIDOPURE PATCH - Tier 2; PA; QL LIDORX - Tier 2; PA LIDO-SORB (brand for zionodil) - Tier 2; PA LIDOSTREAM - Tier 2; PA; QL LIDOTHOL - Tier 2; PA; QL LIDOVIX L - Tier 2; PA; QL LIDTOPIC MAX - Tier 2; PA LIVIXIL PAK (brand for anodyne lpt) - Tier 2; PA; QL LMR PLUS - Tier 2; PA; QL NUVAKAAN (brand for anodyne lpt) - Tier 2; PA; QL NUVAKAAN-II - Tier 2; PA; QL PAIN RELIEF EXTERNAL CREAM 4 % - Tier 2; PA pain relieving + lidocaine (generic for ASPERCREME LIDOCAINE) - Tier 1; PA pain relieving external cream 4 % (generic for ASPERCREME LIDOCAINE) - Tier 1; PA PAINGO KFT - Tier 2; PA; QL PLIAGLIS EXTERNAL CREAM (brand for lidocaine-tetracaine) - Tier 2; PA pramox - Tier 1; PA PREMIUM SCAR - Tier 2; PA PRILO PATCH - Tier 2; PA; QL PRILO PATCH II - Tier 2; PA; QL PRILOLID - Tier 2; PA; QL PRILOVIX - Tier 2; PA; QL PRILOVIX LITE - Tier 2; PA; QL PRILOVIX LITE PLUS - Tier 2; PA; QL PRILOVIX PLUS - Tier 2; PA; QL PRILOVIX ULTRALITE - Tier 2; PA; QL PRILOVIX ULTRALITE PLUS - Tier 2; PA; QL

17 Preferred Agents Non-Preferred Agents PRILOVIXIL - Tier 2; PA; QL PRIZOPAK II (brand for prilovixil) - Tier 2; PA; QL RELADOR PAK (brand for anodyne lpt) - Tier 2; PA; QL RELADOR PAK PLUS (brand for anodyne lpt) - Tier 2; PA; QL SKYADERM-LP (brand for prilovixil) - Tier 2; PA; QL SOLARAVIX - Tier 2; PA; QL SOOTHEE - Tier 2; PA SYNERA - Tier 2; PA VENIPUNCTURE PX1 PHLEBOTOMY - Tier 2; PA VEXATROL - Tier 2; PA; QL WPR PLUS WOUND HEALING SYSTEM - Tier 2; PA; QL XOLIDO XP - Tier 2; PA ZERUVIA - Tier 2; PA ZILACAINE PATCH - Tier 2; PA; QL ZIONODIL - Tier 2; PA ZIONODIL 100 - Tier 2; PA ZTLIDO - Tier 2; PA; QL

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium - Tier 1; QL LUCEMYRA - Tier 2; PA; QL disulfiram oral tablet 250 mg - Tier 1; QL disulfiram oral tablet 500 mg - Tier 1 naltrexone hcl oral - Tier 1

Opioid Dependence Treatments - Antidotes/Deterrents/Protectants BUNAVAIL - Tier 2; QL buprenorphine hcl sublingual - Tier 1; PA; QL; GE; AL buprenorphine hcl-naloxone hcl - Tier 1; QL SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; QL ZUBSOLV - Tier 2; QL

18 Preferred Agents Non-Preferred Agents

Opioid Reversal Agents - Antidotes/Deterrents/Protectants naloxone hcl injection - Tier 1; QL NARCAN - Tier 2; QL

Smoking Cessation Agents - Deterrents bupropion hcl er (smoking det) - Tier 1 nicotine transdermal kit 21-14-7 mg/24hr - Tier 1; PA; QL CHANTIX - Tier 2; QL CHANTIX CONTINUING MONTH PAK - Tier 2; QL CHANTIX STARTING MONTH PAK - Tier 2; QL habitrol (generic for HABITROL) - Tier 1; QL mini nicotine (generic for KLS QUIT2) - Tier 1; QL NICODERM CQ (brand for eq nicotine step 3) - Tier 2; QL NICORETTE (brand for ra nicotine gum) - Tier 2; QL NICORETTE MINI (brand for cvs nicotine) - Tier 2; QL NICORETTE STARTER KIT (brand for ra nicotine gum) - Tier 2; QL nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mini (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL nicotine step 1 (generic for HABITROL) - Tier 1; QL

19 Preferred Agents Non-Preferred Agents nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; QL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; QL NICOTROL - Tier 2; QL NICOTROL NS - Tier 2; QL quit2 (generic for KLS QUIT2) - Tier 1; QL quit4 (generic for KLS QUIT4) - Tier 1; QL THRIVE (brand for ra nicotine gum) - Tier 2; QL

Antibacterials Antibacterials, Other methenamine hippurate (generic for HIPREX) - Tier 1; QL fosfomycin tromethamine (generic for MONUROL) - Tier 1; PA nitrofurantoin - Tier 1; QL HIPREX (brand for methenamine hippurate) - Tier 2; PA; QL nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL MACROBID (brand for nitrofurantoin monohyd macro) - Tier 2; PA; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - MACRODANTIN (brand for nitrofurantoin macrocrystal) - Tier 2; PA; QL Tier 1; QL MONUROL (brand for fosfomycin tromethamine) - Tier 2; PA

Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics ARIKAYCE - Tier 2; PA; SP; QL HUMATIN (brand for paromomycin sulfate) - Tier 2; PA; QL gentamicin sulfate external - Tier 1; QL neomycin sulfate oral - Tier 1; QL paromomycin sulfate oral (generic for HUMATIN) - Tier 1; QL

Antibacterials, Other - Antibiotics antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL AEMCOLO - Tier 2; PA; QL

20 Preferred Agents Non-Preferred Agents antibiotic pain/scar (generic for NEOSPORIN + PAIN RELIEF MAX ST) alcohol prep pads external 70 % - Tier 1; PA; QL - Tier 1 ALTABAX - Tier 2; PA; QL antibiotic/pain relief external ointment 1 % (generic for NEOSPORIN + ARZOL SILVER NIT APPLICATORS - Tier 2; PA PAIN RELIEF MAX ST) - Tier 1 BENZALKONIUM CHLORIDE EXTERNAL SOLUTION - Tier 2; PA antiseptic (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 benzalkonium chloride external solution 50 % - Tier 1; PA bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; QL BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2; PA bacitracin zinc external - Tier 1; QL CENTANY (brand for mupirocin) - Tier 2; PA; QL bacitracin zinc first aid - Tier 1; QL CENTANY AT - Tier 2; PA CLEOCIN VAGINAL SUPPOSITORY - Tier 2; QL CLEOCIN ORAL (brand for clindamycin hcl) - Tier 2; PA; QL clindamycin hcl oral (generic for CLEOCIN) - Tier 1; QL CLEOCIN VAGINAL CREAM (brand for clindamycin phosphate) - Tier 2; clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL PA; QL clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL colistimethate sodium (cba) (generic for COLY-MYCIN M) - Tier 1; PA CLINDESSE - Tier 2; QL COLY-MYCIN M (brand for colistimethate sodium (cba)) - Tier 2; PA double antibiotic (generic for POLYSPORIN) - Tier 1 FEM PH - Tier 2; PA first aid antibiotic external ointment 1 % (generic for NEOSPORIN + FIRST-METRONIDAZOLE - Tier 2; PA PAIN RELIEF MAX ST) - Tier 1 FIRVANQ - Tier 2; PA; QL first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg-unit FLAGYL (brand for metronidazole) - Tier 2; PA; QL (generic for NEOSPORIN ORIGINAL) - Tier 1; QL GLUTARALDEHYDE EXTERNAL - Tier 2; PA first aid antiseptic external solution 10 % (generic for SCRUB CARE iodine tincture external tincture 2 % - Tier 1; PA POVIDONE-IODINE) - Tier 1 LUGOLS STRONG IODINE - Tier 2; PA linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA; mafenide acetate external (generic for SULFAMYLON) - Tier 1; PA QL METROCREAM (brand for metronidazole) - Tier 2; PA; QL linezolid oral tablet (generic for ZYVOX) - Tier 1; PA METROGEL (brand for metronidazole) - Tier 2; PA; QL me/naphos/mb/hyo1 (generic for UROGESIC-BLUE) - Tier 1 METROLOTION (brand for metronidazole) - Tier 2; PA; QL medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; METRONIDAZOLE BENZO+SYRSPEND - Tier 2; PA QL metronidazole oral capsule (generic for FLAGYL) - Tier 1; PA; QL methenamine mandelate oral - Tier 1 NEO-SYNALAR EXTERNAL KIT - Tier 2; PA metronidazole external (generic for ROSADAN) - Tier 1; QL NUVESSA - Tier 2; PA; QL metronidazole oral tablet - Tier 1; QL POVIDONE-IODINE OPHTHALMIC - Tier 2; PA metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL PRIMSOL - Tier 2; PA; QL mupirocin calcium - Tier 1; QL silver nitrate external solution 10 %, 25 %, 50 % - Tier 1; PA mupirocin external (generic for CENTANY) - Tier 1; QL SIVEXTRO ORAL - Tier 2; PA; QL NEOSPORIN + PAIN RELIEF MAX ST (brand for triple antibiotic plus) - SOLOSEC - Tier 2; PA; QL Tier 2

21 Preferred Agents Non-Preferred Agents NEOSPORIN ORIGINAL (brand for eq triple antibiotic) - Tier 2; QL SULFAMYLON EXTERNAL PACKET (brand for mafenide acetate) - Tier 2; NORITATE - Tier 2 PA poly bacitracin (generic for POLYSPORIN) - Tier 1 SUTAB - Tier 2; PA POLYSPORIN (brand for cvs poly bacitracin) - Tier 2 tinidazole oral tablet 250 mg - Tier 1; PA povidone iodine (generic for SCRUB CARE POVIDONE-IODINE) - Tier tinidazole oral tablet 500 mg - Tier 1; PA; QL 1 TRIMO-SAN VAGINAL GEL 0.025-0.01 % - Tier 2; PA; QL povidone-iodine external solution (generic for SCRUB CARE VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL POVIDONE-IODINE) - Tier 1 VANCOCIN HCL (brand for vancomycin hcl) - Tier 2; PA; QL rosadan external cream (generic for ROSADAN) - Tier 1; QL vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-% - Tier 1; PA rosadan external gel (generic for ROSADAN) - Tier 1; QL vancomycin hcl oral solution reconstituted (generic for FIRVANQ) - Tier 1; SCRUB CARE POVIDONE-IODINE (brand for eq povidone-iodine) - PA; QL Tier 2 VANCOMYCIN+SYRSPEND SF - Tier 2; PA SULFAMYLON EXTERNAL CREAM - Tier 2 XENLETA ORAL - Tier 2; PA; QL trimethoprim oral - Tier 1; QL ZYVOX ORAL SUSPENSION RECONSTITUTED (brand for linezolid) - Tier triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL 2; PA; QL triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX ZYVOX ORAL TABLET (brand for linezolid) - Tier 2; PA ST) - Tier 1 triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1; QL triple antibiotic plus (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic plus max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic/pain (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 triple antibiotic+pain relief (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1 UROGESIC-BLUE (brand for me/naphos/mb/hyo1) - Tier 2 vancomycin hcl oral capsule (generic for VANCOCIN HCL) - Tier 1; QL vandazole (generic for VANDAZOLE) - Tier 1; QL

Beta-Lactam, Cephalosporins - Antibiotics

22 Preferred Agents Non-Preferred Agents cefaclor - Tier 1; QL cefazolin sodium-dextrose intravenous solution 2-4 gm/100ml-% - Tier 1; cefaclor er - Tier 1; QL PA cefadroxil - Tier 1; QL cefixime (generic for SUPRAX) - Tier 1; PA; QL cefdinir - Tier 1; QL cefpodoxime proxetil - Tier 1; PA; QL cefprozil - Tier 1; QL cephalexin oral capsule 750 mg (generic for KEFLEX) - Tier 1; PA cefuroxime axetil - Tier 1; QL KEFLEX (brand for cephalexin) - Tier 2; PA cephalexin oral capsule 250 mg, 500 mg - Tier 1; QL SUPRAX ORAL CAPSULE (brand for cefixime) - Tier 2; PA; QL cephalexin oral suspension reconstituted - Tier 1; QL SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 cephalexin oral tablet 250 mg - Tier 1 MG/5ML (brand for cefixime) - Tier 2; PA; QL cephalexin oral tablet 500 mg - Tier 1; QL SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML - Tier 2; PA SUPRAX ORAL TABLET CHEWABLE - Tier 2; PA

Beta-Lactam, Penicillins - Antibiotics amoxicillin - Tier 1; QL AUGMENTIN ES-600 (brand for amoxicillin-pot clavulanate) - Tier 2; PA; amoxicillin-potassium clavulanate er - Tier 1; QL QL amoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML 1; QL (brand for amoxicillin-pot clavulanate) - Tier 2; PA; QL ampicillin - Tier 1; QL AUGMENTIN ORAL TABLET (brand for amoxicillin-pot clavulanate) - Tier AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 2; PA; QL MG/5ML - Tier 2; QL RECARBRIO - Tier 2; PA dicloxacillin sodium - Tier 1; QL penicillin v potassium - Tier 1; QL

Macrolides - Antibiotics azithromycin oral (generic for ZITHROMAX) - Tier 1; QL E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL clarithromycin er - Tier 1; QL ZITHROMAX ORAL (brand for azithromycin) - Tier 2; PA; QL clarithromycin oral - Tier 1; QL ZITHROMAX TRI-PAK (brand for azithromycin) - Tier 2; PA; QL DIFICID - Tier 2; QL ZITHROMAX Z-PAK (brand for azithromycin) - Tier 2; PA; QL ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYPED 400 (brand for erythromycin ethylsuccinate) - Tier 2; QL ERY-TAB (brand for erythromycin) - Tier 2; QL

23 Preferred Agents Non-Preferred Agents ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; QL erythromycin base - Tier 1; QL erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QL erythromycin oral (generic for ERY-TAB) - Tier 1; QL

Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL; AL BAXDELA ORAL - Tier 2; PA; QL ciprofloxacin hcl oral - Tier 1; QL CIPRO ORAL TABLET (brand for ciprofloxacin hcl) - Tier 2; PA; QL levofloxacin oral (generic for LEVAQUIN) - Tier 1; QL MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QL moxifloxacin hcl ophthalmic solution (generic for VIGAMOX) - Tier 1; QL moxifloxacin hcl (2x day) (generic for MOXEZA) - Tier 1; PA; QL ofloxacin oral - Tier 1; QL moxifloxacin hcl oral - Tier 1; PA; QL VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL XEPI - Tier 2; PA; QL

Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1; QL BACTRIM (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL ssd (generic for SSD) - Tier 1; QL BACTRIM DS (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL sulfacetamide sodium ophthalmic solution (generic for BLEPH-10) - Tier BLEPH-10 (brand for sulfacetamide sodium) - Tier 2; PA; QL 1; QL SILVADENE (brand for silver sulfadiazine) - Tier 2; PA; QL sulfadiazine oral - Tier 1; QL sulfacetamide sodium ophthalmic ointment - Tier 1; PA; QL sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1; QL sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL

Tetracyclines - Antibiotics avidoxy - Tier 1; QL ACTICLATE (brand for doxycycline hyclate) - Tier 2; PA; QL doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; QL AVIDOXY DK - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL BENZODOX - Tier 2; PA; QL doxycycline monohydrate oral capsule 100 mg (generic for coremino (generic for COREMINO) - Tier 1; PA MONDOXYNE NL) - Tier 1; QL demeclocycline hcl - Tier 1; PA; QL

24 Preferred Agents Non-Preferred Agents doxycycline monohydrate oral capsule 50 mg - Tier 1; QL DORYX (brand for doxycycline hyclate) - Tier 2; PA; QL doxycycline monohydrate oral suspension reconstituted (generic for DORYX MPC - Tier 2; PA VIBRAMYCIN) - Tier 1; AL doxycycline (generic for ORACEA) - Tier 1; PA doxycycline monohydrate oral tablet 100 mg, 50 mg - Tier 1; QL doxycycline hyclate oral tablet 150 mg, 75 mg (generic for ACTICLATE) - minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1; QL Tier 1; PA; QL minocycline hcl oral capsule 50 mg - Tier 1; QL doxycycline hyclate oral tablet 20 mg - Tier 1; PA minocycline hcl oral capsule 75 mg - Tier 1 doxycycline hyclate oral tablet 50 mg (generic for TARGADOX) - Tier 1; PA mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - doxycycline hyclate oral tablet delayed release 100 mg - Tier 1; PA; QL Tier 1; QL doxycycline hyclate oral tablet delayed release 150 mg, 75 mg - Tier 1; PA tetracycline hcl oral - Tier 1; QL doxycycline hyclate oral tablet delayed release 200 mg, 50 mg (generic for VIBRAMYCIN ORAL SYRUP - Tier 2 DORYX) - Tier 1; PA; QL DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG - Tier 2; PA; QL doxycycline monohydrate oral capsule 150 mg - Tier 1; PA doxycycline monohydrate oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA doxycycline monohydrate oral tablet 150 mg - Tier 1; PA doxycycline monohydrate oral tablet 75 mg - Tier 1; PA; QL MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL minocycline hcl er oral tablet extended release 24 hour (generic for COREMINO) - Tier 1; PA minocycline hcl oral tablet 100 mg - Tier 1; PA; QL minocycline hcl oral tablet 50 mg, 75 mg - Tier 1; PA MINOLIRA - Tier 2; PA; QL mondoxyne nl oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA MORGIDOX COMBINATION - Tier 2; PA morgidox oral (generic for MORGIDOX) - Tier 1; PA; QL NUTRIDOX - Tier 2; PA NUZYRA ORAL - Tier 2; PA; QL ORACEA (brand for doxycycline) - Tier 2; PA SEYSARA - Tier 2; PA; QL SOLODYN (brand for minocycline hcl er) - Tier 2; PA

25 Preferred Agents Non-Preferred Agents TARGADOX (brand for doxycycline hyclate) - Tier 2; PA VIBRAMYCIN ORAL CAPSULE (brand for doxycycline hyclate) - Tier 2; PA; QL VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED (brand for doxycycline monohydrate) - Tier 2; PA; AL XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL

Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other - Seizure Control Drugs DIACOMIT - Tier 2; PA; SP; QL BRIVIACT ORAL - Tier 2; PA; QL EPIDIOLEX - Tier 2; PA; SP; QL ELEPSIA XR - Tier 2; PA; QL levetiracetam oral (generic for KEPPRA) - Tier 1; QL KEPPRA ORAL (brand for levetiracetam) - Tier 2; PA; QL NAYZILAM - Tier 2; QL KEPPRA XR (brand for levetiracetam er) - Tier 2; PA; QL phenobarbital oral tablet - Tier 1; QL levetiracetam er (generic for KEPPRA XR) - Tier 1; PA; QL roweepra (generic for ROWEEPRA) - Tier 1; QL SPRITAM - Tier 2; PA; QL XCOPRI - Tier 2; PA; QL XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL

Calcium Channel Modifying Agents - Seizure Control Drugs ethosuximide oral (generic for ZARONTIN) - Tier 1; QL CELONTIN - Tier 2; PA; QL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL ZARONTIN (brand for ethosuximide) - Tier 2; PA; QL ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL

Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs clobazam oral suspension (generic for ONFI) - Tier 1; QL DIASTAT ACUDIAL (brand for diazepam) - Tier 2; PA; QL clobazam oral tablet (generic for ONFI) - Tier 1; PA; *; QL DIASTAT PEDIATRIC (brand for diazepam) - Tier 2; PA; QL diazepam rectal (generic for DIASTAT PEDIATRIC) - Tier 1; QL FANATREX FUSEPAQ - Tier 2; PA; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL FINTEPLA - Tier 2; PA; QL GABITRIL (brand for tiagabine hcl) - Tier 2; PA; QL

26 Preferred Agents Non-Preferred Agents gabapentin oral solution 250 mg/5ml (generic for NEURONTIN) - Tier 1; MYSOLINE (brand for primidone) - Tier 2; PA; QL QL NEURONTIN (brand for gabapentin) - Tier 2; PA; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL ONFI ORAL SUSPENSION (brand for clobazam) - Tier 2; PA; QL phenobarbital oral elixir - Tier 1; QL ONFI ORAL TABLET (brand for clobazam) - Tier 2; PA; *; QL primidone oral (generic for MYSOLINE) - Tier 1; QL SABRIL (brand for vigabatrin) - Tier 2; PA; SP; QL valproic acid oral - Tier 1; QL SYMPAZAN - Tier 2; PA; QL VALTOCO 10 MG DOSE - Tier 2; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL VALTOCO 15 MG DOSE - Tier 2; QL vigabatrin (generic for SABRIL) - Tier 1; PA; SP; QL VALTOCO 20 MG DOSE - Tier 2; QL vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL VALTOCO 5 MG DOSE - Tier 2; QL

Glutamate Reducing Agents - Seizure Control Drugs FYCOMPA - Tier 2; ST; QL felbamate (generic for FELBATOL) - Tier 1; PA; QL lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL FELBATOL (brand for felbamate) - Tier 2; PA; QL lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; QL LAMICTAL (brand for lamotrigine) - Tier 2; PA; QL topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL LAMICTAL ODT (brand for lamotrigine) - Tier 2; PA; QL LAMICTAL STARTER (brand for lamotrigine starter kit-green) - Tier 2; PA; QL LAMICTAL XR (brand for lamotrigine er) - Tier 2; PA; QL lamotrigine er (generic for LAMICTAL XR) - Tier 1; PA; QL lamotrigine oral kit (generic for LAMICTAL ODT) - Tier 1; PA; QL lamotrigine oral tablet dispersible (generic for LAMICTAL ODT) - Tier 1; PA; QL lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE) - Tier 1; PA; QL lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; PA; QL lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; PA; QL QUDEXY XR (brand for topiramate er) - Tier 2; PA; QL subvenite (generic for SUBVENITE) - Tier 1; PA; QL subvenite starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE) - Tier 1; PA; QL

27 Preferred Agents Non-Preferred Agents subvenite starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; PA; QL subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; PA; QL TOPAMAX (brand for topiramate) - Tier 2; PA; QL TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; QL topiramate er (generic for QUDEXY XR) - Tier 1; PA; QL topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier 1; PA; QL TROKENDI XR - Tier 2; PA; QL

Sodium Channel Agents - Seizure Control Drugs carbamazepine er (generic for CARBATROL) - Tier 1; QL APTIOM - Tier 2; PA; QL carbamazepine oral - Tier 1; QL BANZEL (brand for rufinamide) - Tier 2; PA; QL DILANTIN ORAL CAPSULE 30 MG - Tier 2; QL CARBATROL (brand for carbamazepine er) - Tier 2; PA; QL epitol (generic for EPITOL) - Tier 1; QL DILANTIN INFATABS (brand for phenytoin) - Tier 2; PA; QL oxcarbazepine (generic for TRILEPTAL) - Tier 1; QL DILANTIN ORAL CAPSULE 100 MG (brand for phenytoin sodium phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL extended) - Tier 2; PA; QL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; DILANTIN ORAL SUSPENSION (brand for phenytoin) - Tier 2; PA; QL QL OXTELLAR XR - Tier 2; PA; QL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - PHENYTEK (brand for phenytoin sodium extended) - Tier 2; PA; QL Tier 1; QL rufinamide (generic for BANZEL) - Tier 1; PA; QL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL TEGRETOL (brand for carbamazepine) - Tier 2; PA; QL VIMPAT ORAL SOLUTION - Tier 2; ST; QL TEGRETOL-XR (brand for carbamazepine er) - Tier 2; PA; QL VIMPAT ORAL TABLET - Tier 2; ST; *; QL TRILEPTAL (brand for oxcarbazepine) - Tier 2; PA; QL

Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1; QL ARICEPT (brand for donepezil hcl) - Tier 2; PA; QL

28 Preferred Agents Non-Preferred Agents galantamine hydrobromide er (generic for RAZADYNE ER) - Tier 1; QL donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; PA; QL galantamine hydrobromide oral solution - Tier 1; QL donepezil hcl oral tablet dispersible - Tier 1; PA; QL galantamine hydrobromide oral tablet - Tier 1; QL; AL EXELON (brand for rivastigmine) - Tier 2; PA; QL rivastigmine tartrate - Tier 1; QL; AL RAZADYNE ER (brand for galantamine hydrobromide er) - Tier 2; PA; QL rivastigmine (generic for EXELON) - Tier 1; PA; QL

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl oral tablet (generic for NAMENDA) - Tier 1; QL memantine hcl er (generic for NAMENDA XR) - Tier 1; PA; QL memantine hcl oral solution 2 mg/ml - Tier 1; PA; QL NAMENDA (brand for memantine hcl) - Tier 2; PA; QL NAMENDA TITRATION PAK (brand for memantine hcl) - Tier 2; PA; QL NAMENDA XR (brand for memantine hcl er) - Tier 2; PA; QL NAMENDA XR TITRATION PACK - Tier 2; PA; QL

Antidepressants - Drugs to Treat Depression Antidepressants, Other - Antidepressants bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; PA; *; QL APLENZIN - Tier 2; PA; *; QL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 mg (generic for WELLBUTRIN XL) - Tier 1; PA; *; QL HOUR 450 MG - Tier 2; PA; *; QL bupropion hcl oral - Tier 1; PA; *; QL FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; *; QL chlordiazepoxide-amitriptyline - Tier 1; PA; * olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg - Tier mirtazapine oral - Tier 1; PA; *; QL 1; PA; *; QL perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50 olanzapine-fluoxetine hcl oral capsule 3-25 mg (generic for SYMBYAX) - mg - Tier 1; PA; * Tier 1; PA; *; QL; AL perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; PA; *; QL olanzapine-fluoxetine hcl oral capsule 6-25 mg (generic for SYMBYAX) - Tier 1; PA; *; QL REMERON (brand for mirtazapine) - Tier 2; PA; *; QL REMERON SOLTAB (brand for mirtazapine) - Tier 2; PA; *; QL SPRAVATO (56 MG DOSE) - Tier 2; PA; *; QL SPRAVATO (84 MG DOSE) - Tier 2; PA; *; QL

29 Preferred Agents Non-Preferred Agents SYMBYAX ORAL CAPSULE 3-25 MG (brand for olanzapine-fluoxetine hcl) - Tier 2; PA; *; QL; AL SYMBYAX ORAL CAPSULE 6-25 MG (brand for olanzapine-fluoxetine hcl) - Tier 2; PA; *; QL WELLBUTRIN SR (brand for bupropion hcl er (sr)) - Tier 2; PA; *; QL WELLBUTRIN XL (brand for bupropion hcl er (xl)) - Tier 2; PA; *; QL

Monoamine Oxidase Inhibitors - Antidepressants tranylcypromine sulfate (generic for PARNATE) - Tier 1; PA; *; QL EMSAM - Tier 2; PA; *; QL MARPLAN - Tier 2; PA; *; QL NARDIL (brand for phenelzine sulfate) - Tier 2; PA; *; QL PARNATE (brand for tranylcypromine sulfate) - Tier 2; PA; *; QL phenelzine sulfate oral (generic for NARDIL) - Tier 1; PA; *; QL

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide (generic for CELEXA) - Tier 1; PA; *; QL BRISDELLE (brand for paroxetine mesylate) - Tier 2; PA; QL duloxetine hcl oral (generic for CYMBALTA) - Tier 1; PA; *; QL CELEXA (brand for citalopram hydrobromide) - Tier 2; PA; *; QL escitalopram oxalate (generic for LEXAPRO) - Tier 1; PA; *; QL CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; *; QL fluoxetine hcl oral (generic for PROZAC) - Tier 1; PA; *; QL DESVENLAFAXINE ER - Tier 2; PA; *; QL fluvoxamine maleate - Tier 1; PA; *; QL desvenlafaxine succinate er (generic for PRISTIQ) - Tier 1; PA; *; QL maprotiline hcl - Tier 1; PA; *; QL DRIZALMA SPRINKLE - Tier 2; PA; *; QL nefazodone hcl - Tier 1; PA; *; QL EFFEXOR XR (brand for venlafaxine hcl er) - Tier 2; PA; *; QL paroxetine hcl (generic for PAXIL) - Tier 1; PA; *; QL FETZIMA - Tier 2; PA; *; QL sertraline hcl oral (generic for ZOLOFT) - Tier 1; PA; *; QL FETZIMA TITRATION - Tier 2; PA; *; QL trazodone hcl oral - Tier 1; PA; *; QL fluoxetine hcl (pmdd) - Tier 1; PA; QL venlafaxine hcl - Tier 1; PA; *; QL fluvoxamine maleate er - Tier 1; PA; *; QL venlafaxine hcl er (generic for EFFEXOR XR) - Tier 1; PA; *; QL LEXAPRO (brand for escitalopram oxalate) - Tier 2; PA; *; QL paroxetine hcl er (generic for PAXIL CR) - Tier 1; PA; *; QL paroxetine mesylate (generic for BRISDELLE) - Tier 1; PA; QL PAXIL (brand for paroxetine hcl) - Tier 2; PA; *; QL PAXIL CR (brand for paroxetine hcl er) - Tier 2; PA; *; QL

30 Preferred Agents Non-Preferred Agents PEXEVA - Tier 2; PA; *; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; *; QL PROZAC (brand for fluoxetine hcl) - Tier 2; PA; *; QL TRINTELLIX - Tier 2; PA; *; QL VIIBRYD - Tier 2; PA; *; QL VIIBRYD STARTER PACK - Tier 2; PA; *; QL ZOLOFT (brand for sertraline hcl) - Tier 2; PA; *; QL

Tricyclics - Antidepressants amitriptyline hcl oral - Tier 1; PA; *; QL ANAFRANIL (brand for clomipramine hcl) - Tier 2; PA; *; QL amoxapine - Tier 1; PA; *; QL clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; PA; *; QL desipramine hcl oral (generic for NORPRAMIN) - Tier 1; PA; *; QL NORPRAMIN (brand for desipramine hcl) - Tier 2; PA; *; QL doxepin hcl oral capsule - Tier 1; PA; *; QL PAMELOR (brand for nortriptyline hcl) - Tier 2; PA; *; QL doxepin hcl oral concentrate - Tier 1; PA; *; QL imipramine hcl oral - Tier 1; PA; *; QL imipramine pamoate - Tier 1; PA; *; QL nortriptyline hcl oral (generic for PAMELOR) - Tier 1; PA; *; QL protriptyline hcl - Tier 1; PA; *; QL trimipramine maleate oral - Tier 1; PA; *; QL

Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea - Tier 1 DICLEGIS (brand for doxylamine-pyridoxine) - Tier 2; PA; QL BONINE (brand for cvs motion sickness relief) - Tier 2 doxylamine-pyridoxine (generic for DICLEGIS) - Tier 1; PA; QL BONJESTA - Tier 2; QL GIMOTI - Tier 2; PA; QL compro (generic for COMPRO) - Tier 1; PA; *; QL meclizine hcl oral tablet 50 mg - Tier 1; PA driminate (generic for DRIMINATE) - Tier 1 metoclopramide hcl oral tablet dispersible 10 mg - Tier 1; PA; QL meclizine hcl oral tablet 12.5 mg - Tier 1; QL meclizine hcl oral tablet 25 mg (generic for TRAVEL-EASE) - Tier 1; QL meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 metoclopramide hcl oral solution - Tier 1; QL motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1

31 Preferred Agents Non-Preferred Agents motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier 1 motion sickness relief oral tablet chewable 25 mg (generic for BONINE) - Tier 1 motion-time (generic for BONINE) - Tier 1 nausea control - Tier 1 nausea relief - Tier 1 perphenazine oral - Tier 1; PA; *; QL prochlorperazine (generic for COMPRO) - Tier 1; PA; *; QL scopolamine (generic for TRANSDERM SCOP (1.5 MG)) - Tier 1; QL TRANSDERM SCOP (1.5 MG) (brand for scopolamine) - Tier 2; QL TRANSDERM-SCOP (1.5 MG) (brand for scopolamine) - Tier 2; QL travel ease (generic for BONINE) - Tier 1 trimethobenzamide hcl oral - Tier 1; QL

Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs aprepitant oral capsule 125 mg, 40 mg - Tier 1; QL AKYNZEO ORAL - Tier 2; PA; QL dronabinol (generic for MARINOL) - Tier 1; QL aprepitant oral (generic for EMEND TRI-PACK) - Tier 1; PA; QL EMEND ORAL (brand for aprepitant) - Tier 2; QL aprepitant oral capsule 80 & 125 mg (generic for EMEND TRI-PACK) - Tier EMEND TRI-PACK (brand for aprepitant) - Tier 2; QL 1; PA; QL ondansetron hcl oral (generic for ZOFRAN) - Tier 1; QL aprepitant oral capsule 80 mg (generic for EMEND) - Tier 1; PA; QL ondansetron odt - Tier 1; QL granisetron hcl oral - Tier 1; PA; QL MARINOL (brand for dronabinol) - Tier 2; PA; QL SANCUSO - Tier 2; PA; QL SYNDROS - Tier 2; PA VARUBI (180 MG DOSE) - Tier 2; PA; QL ZOFRAN (brand for ondansetron hcl) - Tier 2; PA; QL ZUPLENZ - Tier 2; PA; QL

Antifungals ONYCHO-MED - Tier 2; PA

32 Preferred Agents Non-Preferred Agents Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day (generic for MONISTAT 3) - Tier 1 ALCORTIN A (brand for iodoquinol-hc-aloe polysacch) - Tier 2; PA 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 ANCOBON ORAL CAPSULE 250 MG (brand for flucytosine) - Tier 2; PA; 3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - Tier QL 1 ANCOBON ORAL CAPSULE 500 MG (brand for flucytosine) - Tier 2; PA ALOE VESTA CLEAR ANTIFUNGAL - Tier 2 AZOLEN TINCTURE - Tier 2; PA antifungal (tolnaftate) (generic for TINACTIN) - Tier 1 ciclopirox treatment - Tier 1; PA antifungal external cream (generic for TINACTIN) - Tier 1 CRESEMBA ORAL - Tier 2; PA; QL antifungal foot care (generic for LAMISIL AT) - Tier 1; QL DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL antifungal miconazole (generic for CAVILON) - Tier 1 DIFMETIOXRIME - Tier 2; PA; QL antifungal tolnaftate (generic for TINACTIN) - Tier 1 ECONASIL - Tier 2; PA; QL atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier ECOZA - Tier 2; PA; QL 1 ERTACZO - Tier 2; PA athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL EXELDERM EXTERNAL CREAM (brand for sulconazole nitrate) - Tier 2; athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) - PA Tier 1 EXTINA (brand for ketoconazole) - Tier 2; PA athletes foot external aerosol powder 2 % (generic for CRUEX FUNGIMEZ - Tier 2; PA PRESCRIPTION STRENGTH) - Tier 1 FUNGOID TINCTURE - Tier 2; PA athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1; QL HIXDEFRIMA - Tier 2; PA; QL athletes foot powder spray (generic for CRUEX PRESCRIPTION hydrocortisone-iodoquinol (generic for DERMAZENE) - Tier 1; PA STRENGTH) - Tier 1 IMIOXIA - Tier 2; PA; QL athletes foot spray (generic for TINACTIN) - Tier 1 IODOQUIMEZ-HC - Tier 2; PA athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) - iodoquinol-hc-aloe polysacch (generic for ALCORTIN A) - Tier 1; PA Tier 1 iodoquinol-hydrocortisone-aloe (generic for VYTONE) - Tier 1; PA CAVILON (brand for antifungal) - Tier 2 itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL ciclodan (generic for CICLODAN) - Tier 1; QL JUBLIA - Tier 2; PA; QL ciclopirox external gel - Tier 1 KERYDIN (brand for tavaborole) - Tier 2; PA; QL ciclopirox external shampoo (generic for LOPROX) - Tier 1 ketoconazole external foam (generic for KETODAN) - Tier 1; PA ciclopirox external solution (generic for CICLODAN) - Tier 1; QL ketodan external foam (generic for KETODAN) - Tier 1; PA ciclopirox olamine external cream (generic for LOPROX) - Tier 1; QL KETODAN EXTERNAL KIT - Tier 2; PA ciclopirox olamine suspension 0.77 % external (generic for LOPROX) - LAMISIL AT JOCK ITCH CREAM 1 % EXTERNAL (brand for gnp Tier 1 terbinafine hydrochloride) - Tier 2; PA; QL

33 Preferred Agents Non-Preferred Agents ciclopirox olamine suspension 0.77 % external (generic for LOPROX) - LOPROX EXTERNAL CREAM (brand for ciclopirox olamine) - Tier 2; PA; Tier 1; QL QL clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 LOPROX EXTERNAL KIT 0.77 % - Tier 2; PA clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL LOPROX EXTERNAL KIT 0.77 % (SUSP) - Tier 2; PA; QL clotrimazole external (generic for DESENEX) - Tier 1; QL LOPROX EXTERNAL SHAMPOO (brand for ciclopirox) - Tier 2; PA clotrimazole mouth/throat - Tier 1; QL LOPROX EXTERNAL SUSPENSION (brand for ciclopirox olamine) - Tier 2; clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL PA clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL LULICONAZOLE - Tier 2; PA; QL CRUEX PRESCRIPTION STRENGTH (brand for athletes foot powder LUZU (brand for luliconazole) - Tier 2; PA; QL spray) - Tier 2 MENTAX (brand for butenafine hcl) - Tier 2; PA DESENEX JOCK ITCH (brand for athletes foot powder spray) - Tier 2 miconazole 1 (generic for MONISTAT 1 COMBO PACK) - Tier 1; PA econazole nitrate external - Tier 1; QL miconazole 1 combo pack (generic for MONISTAT 1 COMBO PACK) - Tier fluconazole oral (generic for DIFLUCAN) - Tier 1; QL 1; PA flucytosine oral capsule 250 mg (generic for ANCOBON) - Tier 1; QL MICONAZOLE-ZINC OXIDE-PETROLAT - Tier 2; PA; QL flucytosine oral capsule 500 mg (generic for ANCOBON) - Tier 1 naftifine hcl external cream - Tier 1; PA foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - NAFTIN (brand for naftifine hcl) - Tier 2; PA Tier 1 NOXAFIL ORAL SUSPENSION - Tier 2; PA foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL NOXAFIL ORAL TABLET DELAYED RELEASE (brand for posaconazole) - fungi-guard (generic for TINACTIN) - Tier 1 Tier 2; PA; QL griseofulvin microsize oral - Tier 1; QL ORAVIG - Tier 2; PA; QL griseofulvin ultramicrosize - Tier 1; QL oxiconazole nitrate (generic for OXISTAT) - Tier 1; PA; QL GYNAZOLE-1 - Tier 2 OXISTAT EXTERNAL CREAM (brand for oxiconazole nitrate) - Tier 2; PA; GYNE-LOTRIMIN (brand for sm clotrimazole vaginal) - Tier 2; QL QL GYNE-LOTRIMIN 3 (brand for gnp clotrimazole 3) - Tier 2 OXISTAT EXTERNAL LOTION - Tier 2; PA jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; QL PEDIZOLPAK - Tier 2; PA; QL jock itch max st (generic for ODOR EATERS FOOT/SNEAKER SPRAY) PHEODOYO - Tier 2; PA; QL - Tier 1 PHEYO - Tier 2; PA; QL jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER posaconazole (generic for NOXAFIL) - Tier 1; PA; QL SPRAY) - Tier 1 QUINJA - Tier 2; PA ketoconazole external cream - Tier 1; QL RECURA - Tier 2; PA ketoconazole external shampoo - Tier 1; QL SPORANOX (brand for itraconazole) - Tier 2; PA; QL ketoconazole oral - Tier 1; QL SPORANOX PULSEPAK (brand for itraconazole) - Tier 2; PA; QL LAMISIL AT EXTERNAL CREAM (brand for gnp terbinafine SULCONAZOLE NITRATE EXTERNAL CREAM - Tier 2; PA hydrochloride) - Tier 2; QL tavaborole (generic for KERYDIN) - Tier 1; PA; QL

34 Preferred Agents Non-Preferred Agents LAMISIL AT JOCK ITCH CREAM 1 % EXTERNAL (brand for gnp tioconazole 1 vaginal ointment 6.5 % (generic for MONISTAT 1-DAY) - Tier terbinafine hydrochloride) - Tier 2; QL 1; PA; QL micaderm (generic for CAVILON) - Tier 1 tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1; PA; QL miconazole 3 - Tier 1; QL TOLSURA - Tier 2; PA; QL miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for VFEND ORAL SUSPENSION RECONSTITUTED (brand for voriconazole) - MONISTAT 3 COMBO PACK APP) - Tier 1; QL Tier 2; PA miconazole 3 combo pack app (generic for MONISTAT 3 COMBO VFEND ORAL TABLET (brand for voriconazole) - Tier 2; PA; QL PACK APP) - Tier 1; QL voriconazole oral suspension reconstituted (generic for VFEND) - Tier 1; miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for PA MONISTAT 3 COMBINATION PACK) - Tier 1; QL voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) - VUSION (brand for miconazole-zinc oxide-petrolat) - Tier 2; PA; QL Tier 1; QL VYTONE (brand for iodoquinol-hydrocortisone-aloe) - Tier 2; PA miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY XOLEGEL - Tier 2; PA CURE) - Tier 1; QL XOLEGEL COREPAK - Tier 2; PA miconazole 7 vaginal suppository 100 mg - Tier 1 XOLEGEL DUO/HEAD & SHOULDERS - Tier 2; PA miconazole antifungal (generic for CAVILON) - Tier 1 XOLEGEL DUO/XOLEX - Tier 2; PA miconazole nitrate external (generic for CAVILON) - Tier 1 ZOLPAK - Tier 2; PA; QL miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL naftifine hcl external gel (generic for NAFTIN) - Tier 1 NATACYN - Tier 2 nyamyc (generic for NYAMYC) - Tier 1; QL nystatin external - Tier 1; QL nystatin mouth/throat - Tier 1; QL nystatin oral - Tier 1; QL nystatin-triamcinolone - Tier 1; QL nystop (generic for NYAMYC) - Tier 1; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1; QL terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1; QL terconazole - Tier 1; QL THE TREATMENT FORMULA 3 EXTERNAL SOLUTION 1 % (brand for medicated anti-fungal) - Tier 2

35 Preferred Agents Non-Preferred Agents TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2 TINACTIN EXTERNAL CREAM (brand for eq athletes foot (tolnaftate)) - Tier 2 tinaspore (generic for BLIS-TO-SOL) - Tier 1 tolnaftate antifungal (generic for TINACTIN) - Tier 1 tolnaftate external cream (generic for TINACTIN) - Tier 1

Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL COLCHICINE ORAL CAPSULE - Tier 2; PA; QL febuxostat (generic for ULORIC) - Tier 1; PA; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL GLOPERBA - Tier 2; PA; QL colchicine-probenecid - Tier 1; QL MITIGARE (brand for colchicine) - Tier 2; PA; QL probenecid - Tier 1; QL ULORIC (brand for febuxostat) - Tier 2; PA; QL ZYLOPRIM (brand for allopurinol) - Tier 2; PA; QL

Anti-inflammatory Agents - Drugs to Treat Inflammation Glucocorticoids - Drugs to Treat Inflammation anucort-hc (generic for ANUSOL-HC) - Tier 1; PA ANUSOL-HC RECTAL (brand for anucort-hc) - Tier 2; PA HEMMOREX-HC (brand for anucort-hc) - Tier 2; PA hydrocortisone acetate rectal (generic for ANUSOL-HC) - Tier 1; PA PROCTOCORT RECTAL (brand for hydrocortisone acetate) - Tier 2; PA

Antimigraine Agents - Drugs to Treat Migraines Antimigraine Agents, Other CAMBIA - Tier 2; PA; QL

36 Preferred Agents Non-Preferred Agents Ergot Alkaloids - Migraine Drugs ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL CAFERGOT (brand for ergotamine-caffeine) - Tier 2; PA; QL D.H.E. 45 (brand for dihydroergotamine mesylate) - Tier 2; PA; QL dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; PA; QL dihydroergotamine mesylate nasal (generic for MIGRANAL) - Tier 1; PA; QL ERGOMAR - Tier 2; PA MIGERGOT - Tier 2; PA; QL MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA; QL

Prophylactic - Migraine Drugs AIMOVIG - Tier 2; ST; QL EMGALITY - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; ST; EMGALITY (300 MG DOSE) - Tier 2; PA; QL QL REYVOW - Tier 2; PA; QL NURTEC - Tier 2; ST; QL UBRELVY - Tier 2; PA; QL

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs naratriptan hcl (generic for AMERGE) - Tier 1; QL almotriptan malate - Tier 1; PA; QL rizatriptan benzoate - Tier 1; QL AMERGE (brand for naratriptan hcl) - Tier 2; PA; QL sumatriptan nasal (generic for IMITREX) - Tier 1; QL eletriptan hydrobromide (generic for RELPAX) - Tier 1; PA; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - frovatriptan succinate (generic for FROVA) - Tier 1; PA; QL Tier 1; QL IMITREX (brand for sumatriptan succinate) - Tier 2; PA; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL IMITREX STATDOSE REFILL (brand for sumatriptan succinate refill) - Tier 2; PA; QL IMITREX STATDOSE SYSTEM (brand for sumatriptan succinate) - Tier 2; PA; QL MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL MAXALT-MLT (brand for rizatriptan benzoate) - Tier 2; PA; QL MIGRAINE PACK - Tier 2; PA; QL ONZETRA XSAIL - Tier 2; PA; QL

37 Preferred Agents Non-Preferred Agents RELPAX (brand for eletriptan hydrobromide) - Tier 2; PA; QL SUMANSETRON - Tier 2; PA; QL sumatriptan-naproxen sodium (generic for TREXIMET) - Tier 1; PA; QL TOSYMRA - Tier 2; PA; QL TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA; QL ZEMBRACE SYMTOUCH - Tier 2; PA; QL ZOLMITRIPTAN NASAL - Tier 2; PA; QL zolmitriptan oral (generic for ZOMIG) - Tier 1; PA; QL ZOMIG (brand for zolmitriptan) - Tier 2; PA; QL ZOMIG ZMT (brand for zolmitriptan) - Tier 2; PA; QL

Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL GUANIDINE HCL - Tier 2; PA pyridostigmine bromide oral tablet (generic for MESTINON) - Tier 1; QL MESTINON (brand for pyridostigmine bromide) - Tier 2; PA; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; PA; QL

Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1; QL MYCOBUTIN (brand for rifabutin) - Tier 2; PA; QL rifabutin (generic for MYCOBUTIN) - Tier 1; QL PRETOMANID - Tier 2; PA; QL

Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL MYAMBUTOL (brand for ethambutol hcl) - Tier 2; PA; QL ethambutol hcl oral tablet 100 mg - Tier 1 RIFAMPIN+SYRSPEND SF - Tier 2; PA; QL ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QL isoniazid oral - Tier 1; QL PASER - Tier 2; QL

38 Preferred Agents Non-Preferred Agents PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1; QL rifampin oral - Tier 1; QL SIRTURO - Tier 2; QL TRECATOR - Tier 2; QL

Antineoplastics Molecular Target Inhibitors INQOVI - Tier 2; PA; SP; QL

Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide injection solution reconstituted 500 mg - Tier 1 ALKERAN ORAL (brand for melphalan) - Tier 2; PA cyclophosphamide oral capsule - Tier 1 TEMODAR ORAL (brand for temozolomide) - Tier 2; PA; SP; QL CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 VALCHLOR - Tier 2; PA; SP; QL GLEOSTINE - Tier 2 LEUKERAN - Tier 2 MATULANE - Tier 2; SP; QL melphalan (generic for ALKERAN) - Tier 1 MYLERAN - Tier 2 temozolomide - Tier 1; PA; SP; QL

Antiandrogens - Hormone Suppressants abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL CASODEX (brand for bicalutamide) - Tier 2; PA; QL bicalutamide (generic for CASODEX) - Tier 1; QL NILANDRON (brand for nilutamide) - Tier 2; PA; QL ERLEADA - Tier 2; PA; SP; QL nilutamide (generic for NILANDRON) - Tier 1; PA; QL flutamide - Tier 1; QL XTANDI - Tier 2; PA; SP; QL NUBEQA - Tier 2; PA; SP; QL YONSA - Tier 2; PA; SP; QL ORGOVYX - Tier 2; PA; SP; QL ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL

39 Preferred Agents Non-Preferred Agents Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL

Antiestrogens/Modifiers - Chemotherapy Agents tamoxifen citrate oral - Tier 1; QL EMCYT - Tier 2; PA; QL toremifene citrate (generic for FARESTON) - Tier 1; QL FARESTON (brand for toremifene citrate) - Tier 2; PA; QL SOLTAMOX - Tier 2; PA; QL

Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; SP; QL HYDREA (brand for hydroxyurea) - Tier 2; PA; QL DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2 PURIXAN - Tier 2; PA; QL DROXIA ORAL CAPSULE 400 MG - Tier 2; QL SIKLOS - Tier 2; PA; QL hydroxyurea oral (generic for HYDREA) - Tier 1; QL XELODA (brand for capecitabine) - Tier 2; PA; SP; QL mercaptopurine oral - Tier 1; QL TABLOID - Tier 2; SP; QL

Antineoplastics, Other - Chemotherapy Agents KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL COPIKTRA - Tier 2; PA; SP; QL KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL dexrazoxane hcl - Tier 1; PA KISQALI FEMARA(200 MG DOSE) - Tier 2; PA; SP; QL INREBIC - Tier 2; PA; SP; QL leucovorin calcium oral - Tier 1; QL KHAPZORY - Tier 2; PA LONSURF - Tier 2; PA; SP; QL KISQALI (200 MG DOSE) - Tier 2; PA; QL NINLARO - Tier 2; PA; SP; QL KISQALI (400 MG DOSE) - Tier 2; PA; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) - Tier 2; PA; QL PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL KOSELUGO - Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL leucovorin calcium injection solution 500 mg/50ml - Tier 1; PA ROZLYTREK - Tier 2; PA; SP; QL levoleucovorin calcium pf intravenous solution 250 mg/25ml - Tier 1; PA VERZENIO - Tier 2; PA; SP; QL LUMAKRAS - Tier 2; PA XPOVIO (60 MG TWICE WEEKLY) - Tier 2; PA; SP; QL PROLEUKIN - Tier 2; PA

40 Preferred Agents Non-Preferred Agents ZOLINZA - Tier 2; PA; SP; QL SYNRIBO - Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL TAZVERIK - Tier 2; PA; QL TOTECT (brand for dexrazoxane hcl) - Tier 2; PA XPOVIO (100 MG ONCE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (40 MG ONCE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (40 MG TWICE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (60 MG ONCE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (80 MG ONCE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (80 MG TWICE WEEKLY) - Tier 2; PA; SP; QL

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1; QL ARIMIDEX (brand for anastrozole) - Tier 2; PA; QL exemestane (generic for AROMASIN) - Tier 1; QL AROMASIN (brand for exemestane) - Tier 2; PA; QL letrozole oral (generic for FEMARA) - Tier 1; QL FEMARA (brand for letrozole) - Tier 2; PA; QL

Enzyme Inhibitors - Chemotherapy Agents BALVERSA - Tier 2; PA; SP; QL PEMAZYRE - Tier 2; PA; SP; QL etoposide oral - Tier 1; QL TALZENNA - Tier 2; PA; SP; QL HYCAMTIN ORAL - Tier 2; PA; SP; QL TRUSELTIQ (100MG DAILY DOSE) - Tier 2; PA RUBRACA - Tier 2; PA; SP; QL TRUSELTIQ (125MG DAILY DOSE) - Tier 2; PA ZEJULA - Tier 2; PA; SP; QL TRUSELTIQ (50MG DAILY DOSE) - Tier 2; PA TRUSELTIQ (75MG DAILY DOSE) - Tier 2; PA

Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL AFINITOR (brand for everolimus) - Tier 2; PA; SP; QL ALECENSA - Tier 2; PA; SP; QL AYVAKIT - Tier 2; PA; SP; QL ALUNBRIG - Tier 2; PA; SP; QL BRAFTOVI - Tier 2; PA; SP; QL BOSULIF - Tier 2; PA; SP; QL FOTIVDA - Tier 2; PA; SP; QL BRUKINSA - Tier 2; PA; SP; QL GLEEVEC (brand for imatinib mesylate) - Tier 2; PA; SP; QL CABOMETYX - Tier 2; PA; SP; QL lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL CALQUENCE - Tier 2; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL

41 Preferred Agents Non-Preferred Agents CAPRELSA - Tier 2; PA; SP; QL LYNPARZA - Tier 2; PA COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL MEKTOVI - Tier 2; PA; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL NERLYNX - Tier 2; PA; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL TAGRISSO - Tier 2; PA; SP; QL COTELLIC - Tier 2; PA; SP; QL TARCEVA (brand for erlotinib hcl) - Tier 2; PA; SP; QL DAURISMO - Tier 2; PA; SP; QL TUKYSA - Tier 2; PA; SP; QL ERIVEDGE - Tier 2; PA; SP; QL UKONIQ - Tier 2; PA; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL VIZIMPRO - Tier 2; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - XOSPATA - Tier 2; PA; SP; QL Tier 1; PA; SP; QL FARYDAK - Tier 2; PA; SP; QL GAVRETO - Tier 2; PA; SP; QL GILOTRIF - Tier 2; PA; SP; QL IBRANCE - Tier 2; PA; SP; QL ICLUSIG - Tier 2; PA; SP; QL IDHIFA - Tier 2; PA; SP; QL imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL IMBRUVICA - Tier 2; PA; SP; QL INLYTA - Tier 2; PA; SP; QL IRESSA - Tier 2; PA; SP; QL JAKAFI - Tier 2; PA; SP; QL LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL MEKINIST - Tier 2; PA; SP; QL NEXAVAR - Tier 2; PA; SP; QL ODOMZO - Tier 2; PA; SP; QL QINLOCK - Tier 2; PA RETEVMO - Tier 2; PA

42 Preferred Agents Non-Preferred Agents RYDAPT - Tier 2; PA; QL SPRYCEL - Tier 2; PA; SP; QL STIVARGA - Tier 2; PA; SP; QL SUTENT - Tier 2; PA; SP; QL TABRECTA - Tier 2; PA TAFINLAR - Tier 2; PA; SP; QL TASIGNA - Tier 2; PA; SP; QL TEPMETKO - Tier 2; PA; SP; QL TIBSOVO - Tier 2; PA; SP; QL TURALIO - Tier 2; PA; SP; QL TYKERB (brand for lapatinib ditosylate) - Tier 2; PA; SP; QL VENCLEXTA - Tier 2; PA; SP; QL VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL VITRAKVI - Tier 2; PA; SP; QL VOTRIENT - Tier 2; PA; SP; QL XALKORI - Tier 2; PA; SP; QL ZELBORAF - Tier 2; PA; SP; QL ZYDELIG - Tier 2; PA; SP; QL

Monoclonal Antibodies - Chemotherapy Agents BESPONSA - Tier 2; PA MARGENZA - Tier 2; PA RITUXAN - Tier 2; PA TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG - Tier 2; PA

Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL TARGRETIN (brand for bexarotene) - Tier 2; PA; SP; QL PANRETIN - Tier 2; PA tretinoin oral - Tier 1; SP; QL

Treatment Adjuncts - Supportive Chemotherapy Drugs

43 Preferred Agents Non-Preferred Agents MESNEX ORAL - Tier 2; SP; QL

Antiparasitics Antiprotozoals LAMPIT - Tier 2; PA; QL

Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; QL ALBENZA (brand for albendazole) - Tier 2; PA; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL BILTRICIDE (brand for praziquantel) - Tier 2; PA; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; QL EGATEN - Tier 2; PA; QL EMVERM - Tier 2; PA; QL ivermectin external lotion - Tier 1; PA; QL STROMECTOL (brand for ivermectin) - Tier 2; PA; QL

Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; QL ALINIA ORAL TABLET (brand for nitazoxanide) - Tier 2; PA; QL atovaquone oral (generic for MEPRON) - Tier 1; QL ARAKODA - Tier 2; PA; QL atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; QL BENZNIDAZOLE - Tier 2; PA; QL chloroquine phosphate oral - Tier 1; QL KRINTAFEL - Tier 2; PA; QL COARTEM - Tier 2 MALARONE (brand for atovaquone-proguanil hcl) - Tier 2; PA; QL DARAPRIM (brand for pyrimethamine) - Tier 2; SP; QL MEPRON (brand for atovaquone) - Tier 2; PA; QL hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; QL NEBUPENT (brand for pentamidine isethionate) - Tier 2; PA IMPAVIDO - Tier 2; PA; QL PLAQUENIL (brand for hydroxychloroquine sulfate) - Tier 2; PA; QL mefloquine hcl - Tier 1; QL pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL nitazoxanide (generic for ALINIA) - Tier 1; PA; QL PYRIMETHAMINE-LEUCOVORIN - Tier 2; PA; QL pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1 QUALAQUIN (brand for quinine sulfate) - Tier 2; PA primaquine phosphate - Tier 1 quinine sulfate oral (generic for QUALAQUIN) - Tier 1

44 Preferred Agents Non-Preferred Agents Pediculicides/Scabicides - Scabies and Lice Drugs lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 crotan - Tier 1; PA; QL lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 ELIMITE (brand for permethrin) - Tier 2; PA; QL lice killing max strength (generic for RID LICE KILLING SHAMPOO) - lice solution 3-step - Tier 1; PA; QL Tier 1 lice solution combination kit (generic for CVS LICE SOLUTION) - Tier 1; lice killing maximum strength (generic for RID LICE KILLING PA; QL SHAMPOO) - Tier 1 lice solution kit (generic for CVS LICE SOLUTION) - Tier 1; PA; QL lice maximum strength (generic for RID LICE KILLING SHAMPOO) - lindane - Tier 1; PA; QL Tier 1 malathion (generic for OVIDE) - Tier 1; PA; QL lice treatment - Tier 1 OVIDE (brand for malathion) - Tier 2; PA; QL lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1 spinosad (generic for NATROBA) - Tier 1; PA; QL lice treatment external shampoo 0.33-4 % (generic for RID LICE stop lice complete treatment (generic for CVS LICE SOLUTION) - Tier 1; KILLING SHAMPOO) - Tier 1 PA; QL NATROBA (brand for spinosad) - Tier 2; QL SULFURATED LIME - Tier 2; PA permethrin external (generic for ELIMITE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for ra lice maximum strength) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1

Antiparkinson Agents Antiparkinson Agents, Other ONGENTYS - Tier 2; PA; QL

Antiparkinson Agents - Drugs to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease Drugs benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL

Antiparkinson Agents - Parkinson's Disease Drugs

45 Preferred Agents Non-Preferred Agents NOURIANZ - Tier 2; PA; QL

Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral - Tier 1; QL COMTAN (brand for entacapone) - Tier 2; PA; QL entacapone (generic for COMTAN) - Tier 1; QL GOCOVRI - Tier 2; PA; QL OSMOLEX ER - Tier 2; PA; QL TASMAR (brand for tolcapone) - Tier 2; PA; QL tolcapone (generic for TASMAR) - Tier 1; PA; QL

Dopamine Agonists - Parkinson's Disease Drugs bromocriptine mesylate oral (generic for PARLODEL) - Tier 1; QL APOKYN - Tier 2; PA; SP; *; QL pramipexole dihydrochloride (generic for MIRAPEX) - Tier 1; QL KYNMOBI - Tier 2; PA; SP; QL ropinirole hcl - Tier 1; QL KYNMOBI TITRATION KIT - Tier 2; PA; SP; QL MIRAPEX (brand for pramipexole dihydrochloride) - Tier 2; PA; QL MIRAPEX ER (brand for pramipexole dihydrochloride er) - Tier 2; PA; QL NEUPRO - Tier 2; PA; QL PARLODEL (brand for bromocriptine mesylate) - Tier 2; PA; QL pramipexole dihydrochloride er (generic for MIRAPEX ER) - Tier 1; PA; QL ropinirole hcl er - Tier 1; PA; QL

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa er - Tier 1; QL carbidopa oral (generic for LODOSYN) - Tier 1; PA; QL carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1; QL carbidopa-levodopa oral tablet dispersible - Tier 1; PA; QL carbidopa-levodopa-entacapone (generic for STALEVO 50) - Tier 1; PA; QL DUOPA - Tier 2; PA LODOSYN (brand for carbidopa) - Tier 2; PA; QL RYTARY - Tier 2; PA; QL SINEMET (brand for carbidopa-levodopa) - Tier 2; PA; QL STALEVO 100 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 125 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL

46 Preferred Agents Non-Preferred Agents STALEVO 150 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 200 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 50 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL STALEVO 75 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs selegiline hcl oral - Tier 1; QL AZILECT (brand for rasagiline mesylate) - Tier 2; PA; QL rasagiline mesylate oral (generic for AZILECT) - Tier 1; PA; QL XADAGO - Tier 2; PA; QL ZELAPAR - Tier 2; PA; QL

Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs chlorpromazine hcl oral - Tier 1; PA; *; QL HALDOL DECANOATE (brand for haloperidol decanoate) - Tier 2; PA; *; fluphenazine decanoate injection - Tier 1; PA; * QL fluphenazine hcl injection - Tier 1; PA; * fluphenazine hcl oral concentrate - Tier 1; PA; * fluphenazine hcl oral elixir - Tier 1; PA; * fluphenazine hcl oral tablet - Tier 1; PA; *; QL haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1; PA; *; QL haloperidol lactate oral - Tier 1; PA; *; QL haloperidol oral - Tier 1; PA; *; QL loxapine succinate - Tier 1; PA; *; QL molindone hcl - Tier 1; PA; *; QL pimozide - Tier 1; QL prochlorperazine maleate oral - Tier 1; PA; *; QL thioridazine hcl oral - Tier 1; PA; *; QL thiothixene - Tier 1; PA; *; QL trifluoperazine hcl - Tier 1; PA; *; QL

47 Preferred Agents Non-Preferred Agents

2nd Generation/Atypical - Mood Disorder Drugs ABILIFY MAINTENA - Tier 2; PA; *; QL ABILIFY (brand for aripiprazole) - Tier 2; PA; *; QL aripiprazole oral tablet (generic for ABILIFY) - Tier 1; PA; *; QL ABILIFY MYCITE - Tier 2; PA; *; QL ARISTADA - Tier 2; PA; *; QL ABILIFY MYCITE MAINTENANCE KIT - Tier 2; PA; *; QL ARISTADA INITIO - Tier 2; PA; *; QL ABILIFY MYCITE STARTER KIT - Tier 2; PA; *; QL FANAPT - Tier 2; PA; ST; *; QL; AL aripiprazole oral solution - Tier 1; PA; *; QL FANAPT TITRATION PACK - Tier 2; PA; ST; *; QL; AL aripiprazole oral tablet dispersible - Tier 1; PA; *; QL; AL INVEGA SUSTENNA - Tier 2; PA; *; QL asenapine maleate (generic for SAPHRIS) - Tier 1; PA; ST; *; QL; AL INVEGA TRINZA - Tier 2; PA; *; QL CAPLYTA - Tier 2; PA; *; QL LATUDA - Tier 2; PA; ST; *; QL GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; *; QL; AL olanzapine oral (generic for ZYPREXA) - Tier 1; PA; *; QL; AL INVEGA (brand for paliperidone er) - Tier 2; PA; *; QL PERSERIS - Tier 2; PA; *; QL NUPLAZID - Tier 2; PA; *; QL quetiapine fumarate (generic for SEROQUEL) - Tier 1; PA; *; QL paliperidone er (generic for INVEGA) - Tier 1; PA; *; QL quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA; *; QL REXULTI - Tier 2; PA; *; QL RISPERDAL CONSTA - Tier 2; PA; *; QL; AL RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA; *; QL risperidone oral solution (generic for RISPERDAL) - Tier 1; PA; *; QL RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; PA; *; QL; AL risperidone oral tablet - Tier 1; PA; *; QL; AL SECUADO - Tier 2; PA; *; QL risperidone oral tablet dispersible - Tier 1; PA; *; QL; AL SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; *; QL SAPHRIS (brand for asenapine maleate) - Tier 2; PA; ST; *; QL; AL SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; *; QL ziprasidone hcl (generic for GEODON) - Tier 1; PA; *; QL; AL VRAYLAR - Tier 2; PA; *; QL ZYPREXA RELPREVV - Tier 2; PA; *; QL ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; *; QL; AL ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; *; QL; AL

Treatment-Resistant - Mood Disorder Drugs clozapine (generic for CLOZARIL) - Tier 1; PA; *; QL CLOZARIL (brand for clozapine) - Tier 2; PA; *; QL VERSACLOZ - Tier 2; PA; *; QL

Antispasticity Agents BACLOFEN EXTERNAL - Tier 2; PA enovarx-baclofen - Tier 1; PA

48 Preferred Agents Non-Preferred Agents

Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs VALCYTE ORAL SOLUTION RECONSTITUTED (brand for PREVYMIS ORAL - Tier 2; PA; QL valganciclovir hcl) - Tier 2 VALCYTE ORAL TABLET (brand for valganciclovir hcl) - Tier 2; PA; QL valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL valganciclovir hcl oral solution reconstituted (generic for VALCYTE) - Tier 1; PA ZIRGAN - Tier 2; PA; QL

Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs adefovir dipivoxil (generic for HEPSERA) - Tier 1; SP; QL BARACLUDE ORAL TABLET (brand for entecavir) - Tier 2; PA; SP; QL BARACLUDE ORAL SOLUTION - Tier 2; SP; QL EPIVIR HBV (brand for lamivudine) - Tier 2; PA; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL HEPSERA (brand for adefovir dipivoxil) - Tier 2; PA; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; QL VEMLIDY - Tier 2; SP; QL

Anti-hepatitis C (HCV) Agents, Direct Acting Agents - Hepatitis C Drugs MAVYRET - Tier 2; PA; SP; QL EPCLUSA ORAL TABLET 200-50 MG - Tier 2; PA SOFOSBUVIR-VELPATASVIR - Tier 2; PA; SP; QL EPCLUSA ORAL TABLET 400-100 MG (brand for sofosbuvir-velpatasvir) - Tier 2; PA; SP; QL HARVONI ORAL PACKET - Tier 2; PA HARVONI ORAL TABLET 45-200 MG - Tier 2; PA; QL HARVONI ORAL TABLET 90-400 MG (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL LEDIPASVIR-SOFOSBUVIR - Tier 2; PA; SP; QL SOVALDI ORAL PACKET - Tier 2; PA SOVALDI ORAL TABLET 200 MG - Tier 2; PA; QL SOVALDI ORAL TABLET 400 MG - Tier 2; PA; SP; QL

49 Preferred Agents Non-Preferred Agents VIEKIRA PAK - Tier 2; PA; SP; QL VOSEVI - Tier 2; PA; SP; QL ZEPATIER - Tier 2; PA; SP; QL

Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP; QL PEGASYS - Tier 2; PA; SP; QL PEGINTRON - Tier 2; PA; SP; QL ribavirin oral - Tier 1; QL

Antiherpetic Agents - Herpes Drugs ABREVA (brand for docosanol) - Tier 2; QL ACYCLOVIX - Tier 2; PA; QL acyclovir external (generic for ZOVIRAX) - Tier 1; QL famciclovir oral - Tier 1; PA; QL acyclovir oral - Tier 1; QL SITAVIG - Tier 2; PA; QL DENAVIR - Tier 2 VALTREX (brand for valacyclovir hcl) - Tier 2; PA; QL docosanol external (generic for ABREVA) - Tier 1; QL XERESE - Tier 2; PA; QL trifluridine - Tier 1; QL ZOVIRAX (brand for acyclovir) - Tier 2; PA; QL valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs DOVATO - Tier 2; QL STRIBILD - Tier 2; PA; QL GENVOYA - Tier 2; QL TYBOST - Tier 2; PA; QL ISENTRESS - Tier 2; QL ISENTRESS HD - Tier 2; QL TIVICAY - Tier 2; QL TIVICAY PD - Tier 2; QL TRIUMEQ - Tier 2; QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs

50 Preferred Agents Non-Preferred Agents ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; QL EDURANT - Tier 2; PA; QL COMPLERA - Tier 2; QL efavirenz-emtricitab-tenofovir (generic for ATRIPLA) - Tier 1; PA; QL DELSTRIGO - Tier 2; QL efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; PA; QL efavirenz (generic for SUSTIVA) - Tier 1; QL etravirine (generic for INTELENCE) - Tier 1; PA; QL JULUCA - Tier 2; QL INTELENCE (brand for etravirine) - Tier 2; PA; QL ODEFSEY - Tier 2; QL nevirapine (generic for VIRAMUNE) - Tier 1; PA; QL PIFELTRO - Tier 2; QL nevirapine er (generic for VIRAMUNE XR) - Tier 1; PA; QL SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; QL SUSTIVA (brand for efavirenz) - Tier 2; PA; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; QL VIRAMUNE (brand for nevirapine) - Tier 2; PA; QL VIRAMUNE XR (brand for nevirapine er) - Tier 2; PA; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs abacavir sulfate oral tablet (generic for ZIAGEN) - Tier 1; QL abacavir sulfate oral solution (generic for ZIAGEN) - Tier 1; PA; QL abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL COMBIVIR (brand for lamivudine-zidovudine) - Tier 2; PA; QL abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; QL emtricitabine (generic for EMTRIVA) - Tier 1; PA; QL BIKTARVY - Tier 2; QL emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; PA; QL CIMDUO - Tier 2; QL EPIVIR (brand for lamivudine) - Tier 2; PA; QL DESCOVY - Tier 2; QL EPZICOM (brand for abacavir sulfate-lamivudine) - Tier 2; PA; QL EMTRIVA - Tier 2; QL lamivudine oral solution (generic for EPIVIR) - Tier 1; PA; QL tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; PA; QL TRUVADA (brand for emtricitabine-tenofovir df) - Tier 2; QL lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; PA; QL VIREAD ORAL POWDER - Tier 2; QL RETROVIR ORAL (brand for zidovudine) - Tier 2; PA; QL VIREAD ORAL TABLET 150 MG, 200 MG - Tier 2; QL stavudine - Tier 1; PA; QL zidovudine (generic for RETROVIR) - Tier 1; QL TEMIXYS - Tier 2; PA; QL TRIZIVIR (brand for abacavir-lamivudine-zidovudine) - Tier 2; PA; QL VIREAD ORAL TABLET 250 MG - Tier 2; PA; QL VIREAD ORAL TABLET 300 MG (brand for tenofovir disoproxil fumarate) - Tier 2; PA; QL ZIAGEN (brand for abacavir sulfate) - Tier 2; PA; QL

Anti-HIV Agents, Other - HIV Drugs

51 Preferred Agents Non-Preferred Agents FUZEON - Tier 2; PA; QL RUKOBIA - Tier 2; PA; QL SELZENTRY - Tier 2; PA; QL VOCABRIA - Tier 2; PA; QL

Anti-HIV Agents, Protease Inhibitors - HIV Drugs atazanavir sulfate (generic for REYATAZ) - Tier 1; QL APTIVUS - Tier 2; PA; QL EVOTAZ - Tier 2; QL CRIXIVAN - Tier 2; PA; QL KALETRA ORAL TABLET (brand for lopinavir-ritonavir) - Tier 2; QL fosamprenavir calcium (generic for LEXIVA) - Tier 1; PA; QL lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL INVIRASE - Tier 2; PA; QL NORVIR ORAL PACKET - Tier 2; QL KALETRA ORAL SOLUTION (brand for lopinavir-ritonavir) - Tier 2; PA; QL NORVIR ORAL SOLUTION - Tier 2; QL LEXIVA (brand for fosamprenavir calcium) - Tier 2; PA; QL PREZCOBIX - Tier 2; QL NORVIR ORAL TABLET (brand for ritonavir) - Tier 2; PA; QL PREZISTA - Tier 2; QL REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA; QL REYATAZ ORAL PACKET - Tier 2; QL SYMTUZA - Tier 2; PA; QL ritonavir (generic for NORVIR) - Tier 1; QL VIRACEPT - Tier 2; PA; QL

Anti-Influenza Agents FAVIPIRAVIR - Tier 2; PA; QL

Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral (generic for TAMIFLU) - Tier 1; QL TAMIFLU (brand for oseltamivir phosphate) - Tier 2; PA; QL RELENZA DISKHALER - Tier 2; QL XOFLUZA (40 MG DOSE) - Tier 2; PA; QL rimantadine hcl - Tier 1; QL XOFLUZA (80 MG DOSE) - Tier 2; PA; QL

Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs buspirone hcl oral - Tier 1; QL hydroxyzine hcl oral - Tier 1; QL meprobamate - Tier 1; QL

52 Preferred Agents Non-Preferred Agents

Benzodiazepines - Anxiety Drugs alprazolam oral tablet (generic for XANAX) - Tier 1; QL alprazolam er (generic for XANAX XR) - Tier 1; PA; QL chlordiazepoxide hcl - Tier 1; QL alprazolam intensol - Tier 1; PA; QL clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL alprazolam oral tablet dispersible - Tier 1; PA; QL clorazepate dipotassium - Tier 1; QL alprazolam xr (generic for XANAX XR) - Tier 1; PA; QL diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; QL ATIVAN ORAL (brand for lorazepam) - Tier 2; PA; QL diazepam oral (generic for VALIUM) - Tier 1; QL clonazepam oral tablet dispersible - Tier 1; PA; QL estazolam - Tier 1; QL DORAL (brand for quazepam) - Tier 2; PA; QL lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1; QL HALCION (brand for triazolam) - Tier 2; PA; QL lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM KLONOPIN (brand for clonazepam) - Tier 2; PA; QL INTENSOL) - Tier 1; QL MIDAZOLAM+SYRSPEND SF - Tier 2; PA; QL lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL quazepam (generic for DORAL) - Tier 1; PA; QL midazolam hcl oral - Tier 1; QL RESTORIL ORAL CAPSULE 22.5 MG (brand for temazepam) - Tier 2; PA oxazepam - Tier 1; QL temazepam oral capsule 22.5 mg (generic for RESTORIL) - Tier 1; PA triazolam - Tier 1; QL TRANXENE-T (brand for clorazepate dipotassium) - Tier 2; PA; QL VALIUM (brand for diazepam) - Tier 2; PA; QL XANAX (brand for alprazolam) - Tier 2; PA; QL XANAX XR (brand for alprazolam xr) - Tier 2; PA; QL

Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs divalproex sodium er (generic for DEPAKOTE ER) - Tier 1; QL DEPAKOTE (brand for divalproex sodium) - Tier 2; PA; QL divalproex sodium oral (generic for DEPAKOTE) - Tier 1; QL DEPAKOTE ER (brand for divalproex sodium er) - Tier 2; PA; QL EQUETRO - Tier 2; PA; *; QL DEPAKOTE SPRINKLES (brand for divalproex sodium) - Tier 2; PA; QL lithium - Tier 1; PA; *; QL LITHOBID (brand for lithium carbonate er) - Tier 2; PA; *; QL lithium carbonate er (generic for LITHOBID) - Tier 1; PA; *; QL lithium carbonate oral - Tier 1; PA; *; QL

Blood Glucose Regulators - Drugs to Regulate Blood Sugar

53 Preferred Agents Non-Preferred Agents Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1; QL ACTOPLUS MET (brand for pioglitazone hcl-metformin hcl) - Tier 2; PA; QL FARXIGA - Tier 2; ST; QL ACTOS (brand for pioglitazone hcl) - Tier 2; PA; QL glimepiride (generic for AMARYL) - Tier 1; QL ADLYXIN - Tier 2; PA; QL glipizide er (generic for GLUCOTROL XL) - Tier 1; QL ADLYXIN STARTER PACK - Tier 2; PA; QL glipizide ir - Tier 1; QL ALOGLIPTIN BENZOATE - Tier 2; PA; QL glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL ALOGLIPTIN-METFORMIN HCL - Tier 2; PA; QL glipizide-metformin hcl - Tier 1; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; PA; QL glyburide micronized (generic for GLYNASE) - Tier 1; QL AMARYL (brand for glimepiride) - Tier 2; PA; QL glyburide oral - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL glyburide-metformin - Tier 1; QL BYETTA 10 MCG PEN - Tier 2; PA; QL INVOKAMET - Tier 2; ST; QL BYETTA 5 MCG PEN - Tier 2; PA; QL INVOKANA - Tier 2; ST; QL CYCLOSET - Tier 2; PA; QL JANUMET - Tier 2; ST; QL DUETACT (brand for pioglitazone hcl-glimepiride) - Tier 2; PA; QL JANUMET XR - Tier 2; ST; QL FORTAMET (brand for metformin hcl er (osm)) - Tier 2; PA; QL JANUVIA - Tier 2; ST; QL GLUCOTROL XL (brand for glipizide er) - Tier 2; PA; QL JARDIANCE - Tier 2; ST; QL GLUMETZA (brand for metformin hcl er (mod)) - Tier 2; PA; QL JENTADUETO - Tier 2; ST; QL GLYNASE (brand for glyburide micronized) - Tier 2; PA; QL metformin hcl er - Tier 1; QL GLYXAMBI - Tier 2; PA; QL metformin hcl oral tablet - Tier 1; QL INVOKAMET XR - Tier 2; PA; QL miglitol - Tier 1; ST; QL JENTADUETO XR - Tier 2; PA; QL nateglinide - Tier 1; QL KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; QL pioglitazone hcl (generic for ACTOS) - Tier 1; QL KOMBIGLYZE XR - Tier 2; PA; QL pioglitazone hcl-metformin hcl (generic for ACTOPLUS MET) - Tier 1; metformin hcl er (mod) (generic for GLUMETZA) - Tier 1; PA; QL QL metformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA; QL repaglinide - Tier 1; QL metformin hcl oral solution (generic for RIOMET) - Tier 1; PA; QL SYMLINPEN 120 - Tier 2; ST; QL NESINA (brand for alogliptin benzoate) - Tier 2; PA; QL SYMLINPEN 60 - Tier 2; ST; QL ONGLYZA - Tier 2; PA; QL SYNJARDY - Tier 2; ST; QL OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; QL tolbutamide - Tier 1; QL OZEMPIC - Tier 2; PA; QL TRADJENTA - Tier 2; ST; QL pioglitazone hcl-glimepiride (generic for DUETACT) - Tier 1; PA; QL TRULICITY - Tier 2; ST; QL PRECOSE (brand for acarbose) - Tier 2; PA; QL VICTOZA - Tier 2; ST; QL QTERN - Tier 2; PA; QL RIOMET (brand for metformin hcl) - Tier 2; PA; QL

54 Preferred Agents Non-Preferred Agents RYBELSUS - Tier 2; PA; QL SEGLUROMET - Tier 2; PA; QL SOLIQUA - Tier 2; PA; QL STEGLATRO - Tier 2; PA; QL STEGLUJAN - Tier 2; PA; QL SYNJARDY XR - Tier 2; PA; QL TRIJARDY XR - Tier 2; PA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG - Tier 2; PA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG - Tier 2; PA; QL XULTOPHY - Tier 2; PA; QL

Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL diazoxide oral (generic for PROGLYCEM) - Tier 1; PA; QL BAQSIMI TWO PACK - Tier 2; QL glucose liquid shot oral liquid - Tier 1; PA GLUCAGEN HYPOKIT - Tier 2; QL GLUCOSE NURSETTE - Tier 2; PA GLUCAGON EMERGENCY INJECTION SOLUTION glucose oral tablet chewable 4-6 gm-mg (generic for DEX4) - Tier 1; PA RECONSTITUTED - Tier 2; QL GOOD START 5% GLUCOSE WATER - Tier 2; PA glucagon emergency kit 1 mg injection - Tier 1; QL GVOKE HYPOPEN 1-PACK - Tier 2; PA; QL GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; QL GVOKE HYPOPEN 2-PACK - Tier 2; PA; QL glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GVOKE PFS - Tier 2; PA; QL GLUCOSE) - Tier 1; QL INSTA-GLUCOSE - Tier 2; PA PROGLYCEM (brand for diazoxide) - Tier 2; QL TRUEPLUS GLUCOSE ORAL GEL - Tier 2; PA soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; ZEGALOGUE - Tier 2; PA; QL QL

Insulins - Diabetic Drugs HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR ADMELOG (brand for insulin lispro) - Tier 2; PA; QL 200 UNIT/ML - Tier 2; QL ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; PA; HUMALOG MIX 50/50 - Tier 2; QL QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; QL AFREZZA - Tier 2; PA; QL

55 Preferred Agents Non-Preferred Agents HUMALOG MIX 75/25 - Tier 2; QL APIDRA SOLOSTAR - Tier 2; PA; QL HUMULIN 70/30 KWIKPEN - Tier 2; QL APIDRA VIAL - Tier 2; PA; QL HUMULIN 70/30 VIAL - Tier 2; QL BASAGLAR KWIKPEN - Tier 2; PA; QL HUMULIN N KWIKPEN - Tier 2; QL FIASP - Tier 2; PA; QL HUMULIN N VIAL - Tier 2; QL FIASP FLEXTOUCH - Tier 2; PA; QL HUMULIN R U-500 KWIKPEN - Tier 2; QL FIASP PENFILL - Tier 2; PA; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; QL HUMALOG (brand for insulin lispro) - Tier 2; PA; QL HUMULIN R VIAL - Tier 2; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - INSULIN ASP PROT & ASP FLEXPEN - Tier 2; QL Tier 2; PA; QL INSULIN ASPART - Tier 2; QL HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR INSULIN ASPART FLEXPEN - Tier 2; QL 100 UNIT/ML (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QL INSULIN ASPART PENFILL - Tier 2; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - INSULIN ASPART PROT & ASPART - Tier 2; QL Tier 2; PA; QL INSULIN LISPRO - Tier 2; QL NOVOLIN R FLEXPEN - Tier 2; PA; QL INSULIN LISPRO (1 UNIT DIAL) - Tier 2; QL NOVOLIN R FLEXPEN RELION - Tier 2; PA; QL INSULIN LISPRO JUNIOR KWIKPEN - Tier 2; QL NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL INSULIN LISPRO PROT & LISPRO - Tier 2; QL NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) LANTUS SOLOSTAR - Tier 2; QL - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; LEVEMIR U-100 FLEXTOUCH - Tier 2; QL PA; QL LEVEMIR U-100 VIAL - Tier 2; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN - Tier 2; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN RELION - Tier 2; QL SEMGLEE - Tier 2; PA; QL NOVOLIN 70/30 RELION - Tier 2; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL NOVOLIN 70/30 VIAL - Tier 2; QL TOUJEO SOLOSTAR - Tier 2; PA; QL NOVOLIN N FLEXPEN - Tier 2; QL NOVOLIN N FLEXPEN RELION - Tier 2; QL NOVOLIN N RELION - Tier 2; QL NOVOLIN N VIAL - Tier 2; QL NOVOLIN R RELION - Tier 2; QL NOVOLIN R VIAL - Tier 2; QL TRESIBA - Tier 2; ST; QL TRESIBA FLEXTOUCH - Tier 2; ST; QL

56 Preferred Agents Non-Preferred Agents Blood Products and Modifiers Blood Products and Modifiers, Other NYVEPRIA - Tier 2; PA; SP

Blood Products and Modifiers - Drugs to Treat Blood Disorders Blood Formation Modifiers - Blood Formation Drugs EMPAVELI - Tier 2; PA; SP; QL

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2; QL ACD-A NOCLOT-50 (brand for acd formula a) - Tier 2; PA ELIQUIS DVT/PE STARTER PACK - Tier 2; QL ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 7.5 MG/0.6ML enoxaparin sodium (generic for LOVENOX) - Tier 1; QL (brand for fondaparinux sodium) - Tier 2; PA; QL heparin sodium (porcine) - Tier 1 ARIXTRA SUBCUTANEOUS SOLUTION 2.5 MG/0.5ML, 5 MG/0.4ML heparin sodium (porcine) pf - Tier 1 (brand for fondaparinux sodium) - Tier 2; PA jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 7.5 mg/0.6ml mg (generic for JANTOVEN) - Tier 1; QL (generic for ARIXTRA) - Tier 1; PA; QL jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1 fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml, 5 mg/0.4ml PRADAXA - Tier 2; QL (generic for ARIXTRA) - Tier 1; PA warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 FRAGMIN - Tier 2; PA mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL LOVENOX (brand for enoxaparin sodium) - Tier 2; PA; QL warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1 SAVAYSA - Tier 2; PA; QL XARELTO - Tier 2; QL TRICITRASOL - Tier 2; PA XARELTO STARTER PACK - Tier 2; QL ZONTIVITY - Tier 2; PA; QL

Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 AGRYLIN (brand for anagrelide hcl) - Tier 2; PA ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL DOPTELET - Tier 2; PA; SP; QL

57 Preferred Agents Non-Preferred Agents EPOGEN - Tier 2; PA; SP; QL FULPHILA - Tier 2; PA; SP; QL GRANIX - Tier 2; PA; SP; QL LEUKINE - Tier 2; PA; SP; QL ONUREG - Tier 2; PA; SP; QL MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2; 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP; QL PA; QL RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP MOZOBIL - Tier 2; PA; SP; QL UDENYCA - Tier 2; PA; SP; QL MULPLETA - Tier 2; PA; SP; QL ZIEXTENZO - Tier 2; PA; SP NEULASTA - Tier 2; PA; SP; QL NEULASTA ONPRO - Tier 2; PA; SP; QL NEUPOGEN - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP; QL OXBRYTA - Tier 2; PA; QL PROCRIT - Tier 2; PA; SP; QL PROMACTA - Tier 2; PA; SP; QL ZARXIO - Tier 2; PA; SP; QL

Hemostasis Agents - Drugs to Stop Bleeding AMICAR ORAL SOLUTION (brand for aminocaproic acid) - Tier 2; QL ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, aminocaproic acid oral tablet (generic for AMICAR) - Tier 1; QL 2000 UNIT, 500 UNIT - Tier 2; PA HEMLIBRA - Tier 2; PA; SP; QL AMICAR ORAL TABLET (brand for aminocaproic acid) - Tier 2; PA; QL tranexamic acid oral (generic for LYSTEDA) - Tier 1; QL aminocaproic acid oral solution (generic for AMICAR) - Tier 1; PA; QL ASTRINGYN - Tier 2; PA COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT - Tier 2; PA ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 4000 UNIT, 5000 UNIT, 6000 UNIT - Tier 2; PA ESPEROCT - Tier 2; PA LYSTEDA (brand for tranexamic acid) - Tier 2; PA; QL monsels ferric subsulfate - Tier 1; PA RECOTHROM - Tier 2; PA RECOTHROM SPRAY KIT - Tier 2; PA TAVALISSE - Tier 2; PA; SP; QL THROMBOGEN - Tier 2; PA

58 Preferred Agents Non-Preferred Agents

Platelet Modifying Agents - Platelet Modifying Drugs aspirin-dipyridamole er - Tier 1; QL ASPIRIN-OMEPRAZOLE - Tier 2; PA; QL BRILINTA - Tier 2; QL CABLIVI - Tier 2; PA; SP; QL cilostazol - Tier 1; QL DURLAZA - Tier 2; PA; QL clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL EFFIENT (brand for prasugrel hcl) - Tier 2; PA; QL dipyridamole oral - Tier 1; QL PLAVIX (brand for clopidogrel bisulfate) - Tier 2; PA; QL prasugrel hcl (generic for EFFIENT) - Tier 1; QL YOSPRALA (brand for aspirin-omeprazole) - Tier 2; PA; QL

Cardiovascular Agents Cardiovascular Agents, Other NEXLIZET - Tier 2; PA; QL

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs clonidine (generic for CATAPRES-TTS-1) - Tier 1; QL CATAPRES-TTS-1 (brand for clonidine) - Tier 2; PA; QL clonidine hcl oral - Tier 1; QL CATAPRES-TTS-2 (brand for clonidine) - Tier 2; PA; QL guanfacine hcl - Tier 1; QL CATAPRES-TTS-3 (brand for clonidine) - Tier 2; PA; QL methyldopa - Tier 1; QL droxidopa (generic for NORTHERA) - Tier 1; PA; SP; QL midodrine hcl - Tier 1; QL NORTHERA (brand for droxidopa) - Tier 2; PA; SP; QL PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/10ML-%, 100-0.9 MCG/10ML-%, 20-0.9 MG/50ML-% - Tier 2; PA PHENYLEPHRINE HCL-NACL SOLUTION PREFILLED SYRINGE 5-0.9 MG/50ML-% INTRAVENOUS - Tier 2; PA

Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL CARDURA (brand for doxazosin mesylate) - Tier 2; PA; QL

59 Preferred Agents Non-Preferred Agents prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL DIBENZYLINE (brand for phenoxybenzamine hcl) - Tier 2; PA; QL MINIPRESS (brand for prazosin hcl) - Tier 2; PA; QL phenoxybenzamine hcl oral (generic for DIBENZYLINE) - Tier 1; PA; QL

Angiotensin II Receptor Antagonists - Blood Pressure Drugs irbesartan (generic for AVAPRO) - Tier 1; QL ATACAND (brand for candesartan cilexetil) - Tier 2; PA; QL losartan potassium oral (generic for COZAAR) - Tier 1; QL AVAPRO (brand for irbesartan) - Tier 2; PA; QL valsartan (generic for DIOVAN) - Tier 1; QL BENICAR (brand for olmesartan medoxomil) - Tier 2; PA; QL candesartan cilexetil (generic for ATACAND) - Tier 1; PA; QL COZAAR (brand for losartan potassium) - Tier 2; PA; QL DIOVAN (brand for valsartan) - Tier 2; PA; QL EDARBI - Tier 2; PA; QL MICARDIS (brand for telmisartan) - Tier 2; PA; QL olmesartan medoxomil oral (generic for BENICAR) - Tier 1; PA; QL telmisartan (generic for MICARDIS) - Tier 1; PA; QL

Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL ACCUPRIL (brand for quinapril hcl) - Tier 2; PA; QL captopril oral - Tier 1; QL ALTACE (brand for ramipril) - Tier 2; PA; QL enalapril maleate oral (generic for VASOTEC) - Tier 1; QL LOTENSIN (brand for benazepril hcl) - Tier 2; PA; QL EPANED - Tier 2; QL PRINIVIL (brand for lisinopril) - Tier 2; PA; QL fosinopril sodium - Tier 1; QL QBRELIS - Tier 2; PA; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL VASOTEC (brand for enalapril maleate) - Tier 2; PA; QL moexipril hcl - Tier 1; QL ZESTRIL (brand for lisinopril) - Tier 2; PA; QL perindopril erbumine - Tier 1; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL ramipril (generic for ALTACE) - Tier 1; QL trandolapril - Tier 1; QL

Antiarrhythmics - Heart Regulation Drugs

60 Preferred Agents Non-Preferred Agents amiodarone hcl oral tablet 200 mg (generic for PACERONE) - Tier 1; QL amiodarone hcl oral tablet 100 mg, 400 mg (generic for PACERONE) - Tier disopyramide phosphate (generic for NORPACE) - Tier 1; QL 1; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL flecainide acetate - Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL mexiletine hcl oral - Tier 1; QL MULTAQ - Tier 2; PA; QL NORPACE CR - Tier 2; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL PACERONE ORAL TABLET 200 MG (brand for amiodarone hcl) - Tier PACERONE ORAL TABLET 100 MG, 400 MG (brand for amiodarone hcl) - 2; QL Tier 2; PA; QL propafenone hcl - Tier 1; QL RYTHMOL SR (brand for propafenone hcl er) - Tier 2; PA; QL propafenone hcl er (generic for RYTHMOL SR) - Tier 1; QL SOTYLIZE - Tier 2; PA; QL quinidine gluconate er - Tier 1; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL quinidine sulfate - Tier 1; QL sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

Beta-adrenergic Blocking Agents - Blood Pressure Drugs acebutolol hcl oral - Tier 1; QL ATENOLOL+SYRSPEND SF - Tier 2; PA; QL atenolol oral (generic for TENORMIN) - Tier 1; QL BYSTOLIC - Tier 2; PA; QL betaxolol hcl oral - Tier 1; QL carvedilol phosphate er (generic for COREG CR) - Tier 1; PA; QL bisoprolol fumarate oral - Tier 1; QL COREG (brand for carvedilol) - Tier 2; PA; QL carvedilol (generic for COREG) - Tier 1; QL COREG CR (brand for carvedilol phosphate er) - Tier 2; PA; QL HEMANGEOL - Tier 2; QL CORGARD (brand for nadolol) - Tier 2; PA; QL labetalol hcl oral - Tier 1; QL ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE - Tier metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL 2; PA metoprolol tartrate oral (generic for LOPRESSOR) - Tier 1; QL INDERAL LA (brand for propranolol hcl er) - Tier 2; PA; QL nadolol oral (generic for CORGARD) - Tier 1; QL INDERAL XL - Tier 2; PA; QL pindolol - Tier 1; QL INNOPRAN XL - Tier 2; PA; QL propranolol hcl er (generic for INDERAL LA) - Tier 1; QL KAPSPARGO SPRINKLE - Tier 2; PA; QL propranolol hcl oral - Tier 1; QL LOPRESSOR (brand for metoprolol tartrate) - Tier 2; PA; QL timolol maleate oral - Tier 1; QL TENORMIN (brand for atenolol) - Tier 2; PA; QL TOPROL XL (brand for metoprolol succinate er) - Tier 2; PA; QL

Calcium Channel Blocking Agents - Blood Pressure Drugs

61 Preferred Agents Non-Preferred Agents amlodipine besylate oral (generic for NORVASC) - Tier 1; QL CALAN SR (brand for verapamil hcl er) - Tier 2; PA; QL cartia xt (generic for CARTIA XT) - Tier 1; QL CARDIZEM (brand for diltiazem hcl) - Tier 2; PA; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL CARDIZEM CD (brand for diltiazem hcl er coated beads) - Tier 2; PA; QL diltiazem hcl er coated beads oral capsule extended release 24 hour CARDIZEM LA - Tier 2; PA; QL (generic for CARTIA XT) - Tier 1; QL CONJUPRI - Tier 2; PA; QL diltiazem hcl er oral capsule extended release 12 hour - Tier 1; QL diltiazem hcl er coated beads oral tablet extended release 24 hour (generic diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg - for MATZIM LA) - Tier 1; PA; QL Tier 1; QL diltiazem hcl er oral capsule extended release 24 hour 240 mg - Tier 1; PA; diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL QL dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg - Tier 1; dilt-xr oral capsule extended release 24 hour 240 mg - Tier 1; PA; QL QL isradipine - Tier 1; PA; QL felodipine er - Tier 1; QL KATERZIA - Tier 2; PA; QL nicardipine hcl oral - Tier 1; QL matzim la (generic for MATZIM LA) - Tier 1; PA; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL nimodipine oral - Tier 1; PA; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; QL nisoldipine er - Tier 1; PA; QL nifedipine oral - Tier 1; QL NORVASC (brand for amlodipine besylate) - Tier 2; PA; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL NYMALIZE - Tier 2; PA; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL PROCARDIA XL (brand for nifedipine er osmotic release) - Tier 2; PA; QL verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 SULAR (brand for nisoldipine er) - Tier 2; PA; QL mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QL TIAZAC (brand for diltiazem hcl er beads) - Tier 2; PA; QL verapamil hcl er oral tablet extended release (generic for CALAN SR) - verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, Tier 1; QL 300 mg (generic for VERELAN PM) - Tier 1; PA; QL verapamil hcl oral - Tier 1; QL VERELAN (brand for verapamil hcl er) - Tier 2; PA; QL VERELAN PM (brand for verapamil hcl er) - Tier 2; PA; QL

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL ACCURETIC (brand for quinapril-hydrochlorothiazide) - Tier 2; PA; QL amlodipine besylate-benazepril hcl - Tier 1; QL ALDACTAZIDE (brand for spironolactone-hctz) - Tier 2; PA; QL amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1; QL aliskiren fumarate (generic for TEKTURNA) - Tier 1; PA; QL amlodipine-olmesartan (generic for AZOR) - Tier 1; QL amlodipine-atorvastatin (generic for CADUET) - Tier 1; PA; QL amlodipine-valsartan-hctz (generic for EXFORGE HCT) - Tier 1; QL ATACAND HCT (brand for candesartan cilexetil-hctz) - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL AVALIDE (brand for irbesartan-hydrochlorothiazide) - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL AZOR (brand for amlodipine-olmesartan) - Tier 2; PA; QL

62 Preferred Agents Non-Preferred Agents bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL BENICAR HCT (brand for olmesartan medoxomil-hctz) - Tier 2; PA; QL captopril-hydrochlorothiazide - Tier 1; QL BIDIL - Tier 2; PA; QL digitek (generic for DIGITEK) - Tier 1; QL CADUET (brand for amlodipine-atorvastatin) - Tier 2; PA; QL digox (generic for DIGITEK) - Tier 1; QL candesartan cilexetil-hctz (generic for ATACAND HCT) - Tier 1; PA; QL digoxin oral (generic for DIGITEK) - Tier 1; QL CONSENSI - Tier 2; PA; QL enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL CORLANOR - Tier 2; PA; QL ENTRESTO - Tier 2; PA; QL DEMSER (brand for metyrosine) - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL DIOVAN HCT (brand for valsartan-hydrochlorothiazide) - Tier 2; PA; QL irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; QL DUTOPROL - Tier 2; PA; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED methyldopa-hydrochlorothiazide - Tier 1; QL SYRINGE 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% - Tier 2; PA metoprolol-hydrochlorothiazide - Tier 1; QL EXFORGE (brand for amlodipine besylate-valsartan) - Tier 2; PA; QL pentoxifylline er - Tier 1; QL EXFORGE HCT (brand for amlodipine-valsartan-hctz) - Tier 2; PA; QL propranolol-hctz - Tier 1; QL HYZAAR (brand for losartan potassium-hctz) - Tier 2; PA; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL isoxsuprine hcl oral - Tier 1; PA ranolazine er (generic for RANEXA) - Tier 1; QL LANOXIN ORAL (brand for digoxin) - Tier 2; PA; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL LOTENSIN HCT (brand for benazepril-hydrochlorothiazide) - Tier 2; PA; QL telmisartan-amlodipine (generic for TWYNSTA) - Tier 1; QL LOTREL (brand for amlodipine besy-benazepril hcl) - Tier 2; PA; QL trandolapril-verapamil hcl er - Tier 1; QL MAXZIDE (brand for triamterene-hctz) - Tier 2; PA; QL triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL MAXZIDE-25 (brand for triamterene-hctz) - Tier 2; PA; QL valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL metyrosine (generic for DEMSER) - Tier 1; PA; QL MICARDIS HCT (brand for telmisartan-hctz) - Tier 2; PA; QL olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; PA; QL olmesartan-amlodipine-hctz (generic for TRIBENZOR) - Tier 1; PA; QL PRESTALIA - Tier 2; PA; QL RANEXA (brand for ranolazine er) - Tier 2; PA; QL SURE RESULT O3D3 SYSTEM - Tier 2; PA TARKA (brand for trandolapril-verapamil hcl er) - Tier 2; PA; QL TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL TEKTURNA HCT - Tier 2; PA; QL telmisartan-hctz (generic for MICARDIS HCT) - Tier 1; PA; QL TENORETIC 100 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL TENORETIC 50 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL

63 Preferred Agents Non-Preferred Agents TRIBENZOR (brand for olmesartan-amlodipine-hctz) - Tier 2; PA; QL TWYNSTA (brand for telmisartan-amlodipine) - Tier 2; PA; QL VASERETIC (brand for enalapril-hydrochlorothiazide) - Tier 2; PA; QL VECAMYL - Tier 2; PA; QL VERQUVO - Tier 2; PA; QL VYNDAMAX - Tier 2; PA; SP; QL VYNDAQEL - Tier 2; PA; SP; QL ZESTORETIC (brand for lisinopril-hydrochlorothiazide) - Tier 2; PA; QL ZIAC (brand for bisoprolol-hydrochlorothiazide) - Tier 2; PA; QL

Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral - Tier 1; QL KEVEYIS - Tier 2; PA; SP; QL

Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1; QL BUMEX (brand for bumetanide) - Tier 2; PA; QL ethacrynic acid (generic for EDECRIN) - Tier 1; QL EDECRIN (brand for ethacrynic acid) - Tier 2; PA; QL furosemide oral - Tier 1; QL LASIX (brand for furosemide) - Tier 2; PA; QL torsemide - Tier 1; QL

Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL ALDACTONE (brand for spironolactone) - Tier 2; PA; QL eplerenone (generic for INSPRA) - Tier 1; QL CAROSPIR - Tier 2; PA; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL DYRENIUM (brand for triamterene) - Tier 2; PA; QL triamterene oral (generic for DYRENIUM) - Tier 1; QL INSPRA (brand for eplerenone) - Tier 2; PA; QL

Diuretics, Thiazide - Cardiac Drugs chlorthalidone - Tier 1; QL DIURIL - Tier 2; QL hydrochlorothiazide oral - Tier 1; QL indapamide - Tier 1; QL

64 Preferred Agents Non-Preferred Agents metolazone - Tier 1; QL

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate oral tablet 145 mg, 48 mg (generic for TRICOR) - Tier 1; QL ANTARA - Tier 2; PA; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL fenofibrate micronized - Tier 1; PA; QL fenofibrate oral capsule - Tier 1; PA; QL fenofibrate oral tablet 120 mg, 40 mg (generic for FENOGLIDE) - Tier 1; PA; QL fenofibrate oral tablet 160 mg, 54 mg - Tier 1; PA; QL fenofibric acid (generic for FIBRICOR) - Tier 1; PA; QL FENOGLIDE (brand for fenofibrate) - Tier 2; PA; QL FIBRICOR (brand for fenofibric acid) - Tier 2; PA; QL LIPOFEN (brand for fenofibrate) - Tier 2; PA; QL LOPID (brand for gemfibrozil) - Tier 2; PA; QL TRICOR (brand for fenofibrate) - Tier 2; PA; QL TRILIPIX (brand for fenofibric acid) - Tier 2; PA; QL

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL ALTOPREV - Tier 2; PA; QL lovastatin oral - Tier 1; QL CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL pravastatin sodium - Tier 1; QL EZALLOR SPRINKLE - Tier 2; PA; QL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL FLOLIPID - Tier 2; PA; QL simvastatin oral (generic for ZOCOR) - Tier 1; QL fluvastatin sodium - Tier 1; PA; QL fluvastatin sodium er (generic for LESCOL XL) - Tier 1; PA; QL LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA; QL LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL LIVALO - Tier 2; PA; QL ZOCOR (brand for simvastatin) - Tier 2; PA; QL ZYPITAMAG - Tier 2; PA; QL

65 Preferred Agents Non-Preferred Agents Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light (generic for PREVALITE) - Tier 1; QL colesevelam hcl (generic for WELCHOL) - Tier 1; PA; QL cholestyramine oral (generic for QUESTRAN) - Tier 1; QL COLESTID (brand for colestipol hcl) - Tier 2; PA; QL colestipol hcl oral tablet (generic for COLESTID) - Tier 1; QL COLESTID FLAVORED (brand for colestipol hcl) - Tier 2; PA; QL ezetimibe (generic for ZETIA) - Tier 1; QL colestipol hcl oral granules (generic for COLESTID) - Tier 1; PA; QL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QL colestipol hcl oral packet (generic for COLESTID) - Tier 1; PA; QL niacor (generic for NIACOR) - Tier 1; QL ezetimibe-simvastatin (generic for VYTORIN) - Tier 1; PA; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL icosapent ethyl (generic for VASCEPA) - Tier 1; PA; QL prevalite (generic for PREVALITE) - Tier 1; QL JUXTAPID - Tier 2; PA; SP; QL LOVAZA (brand for omega-3-acid ethyl esters) - Tier 2; PA; QL NEXLETOL - Tier 2; PA; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; PA; QL NIASPAN (brand for niacin er (antihyperlipidemic)) - Tier 2; PA; QL OMEGA-3 RX COMPLETE - Tier 2; PA; QL PRALUENT - Tier 2; PA; SP; QL QUESTRAN (brand for cholestyramine) - Tier 2; PA; QL QUESTRAN LIGHT (brand for cholestyramine light) - Tier 2; PA; QL REPATHA - Tier 2; PA; SP; QL ROSZET - Tier 2; PA; QL VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL WELCHOL (brand for colesevelam hcl) - Tier 2; PA; QL ZETIA (brand for ezetimibe) - Tier 2; PA; QL

Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate - Tier 1; QL DILATRATE-SR - Tier 2; PA; QL isosorbide mononitrate - Tier 1; QL GONITRO - Tier 2; PA; QL isosorbide mononitrate er - Tier 1; QL ISORDIL TITRADOSE (brand for isosorbide dinitrate) - Tier 2; PA; QL

66 Preferred Agents Non-Preferred Agents minitran (generic for MINITRAN) - Tier 1; QL NITRO-DUR (brand for nitroglycerin) - Tier 2; PA; QL NITRO-BID - Tier 2; QL NITROLINGUAL (brand for nitroglycerin) - Tier 2; PA; QL nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL NITROMIST - Tier 2; PA nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.6 MG (brand nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL for nitroglycerin) - Tier 2; PA; QL NITROSTAT TABLET SUBLINGUAL 0.4 MG SUBLINGUAL (brand for NITROSTAT TABLET SUBLINGUAL 0.4 MG SUBLINGUAL (brand for nitroglycerin) - Tier 2; QL nitroglycerin) - Tier 2; PA; QL RECTIV - Tier 2; DX2RX NITRO-TIME - Tier 2; PA; QL

Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; QL ZEPOSIA STARTER KIT - Tier 2; PA; SP; QL

Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA KESIMPTA - Tier 2; PA; SP; QL

Central Nervous System Agents - Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; QL ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2; PA; QL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - Tier ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2; PA; QL 1; QL ADZENYS ER (brand for amphetamine er) - Tier 2; PA; QL dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1; QL ADZENYS XR-ODT - Tier 2; PA; QL dextroamphetamine sulfate oral tablet (generic for ZENZEDI) - Tier 1; AMPHETAMINE ER - Tier 2; PA; QL QL amphetamine sulfate (generic for EVEKEO) - Tier 1; PA; QL VYVANSE ORAL CAPSULE - Tier 2; QL DESOXYN (brand for methamphetamine hcl) - Tier 2; PA; QL VYVANSE ORAL TABLET CHEWABLE - Tier 2; PA; QL; AL DEXEDRINE (brand for dextroamphetamine sulfate er) - Tier 2; PA; QL

67 Preferred Agents Non-Preferred Agents dextroamphetamine sulfate oral solution (generic for PROCENTRA) - Tier 1; PA; QL DYANAVEL XR - Tier 2; PA; QL EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL EVEKEO ODT - Tier 2; PA; QL methamphetamine hcl (generic for DESOXYN) - Tier 1; PA; QL MYDAYIS - Tier 2; PA; QL PROCENTRA (brand for dextroamphetamine sulfate) - Tier 2; PA; QL ZENZEDI - Tier 2; PA; QL

Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2 ADHANSIA XR - Tier 2; PA; QL atomoxetine hcl (generic for STRATTERA) - Tier 1; QL clonidine hcl er (generic for KAPVAY) - Tier 1; PA; QL dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; QL CONCERTA (brand for methylphenidate hcl er) - Tier 2; PA; QL dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; QL; AL COTEMPLA XR-ODT - Tier 2; PA; QL guanfacine hcl er (generic for INTUNIV) - Tier 1; QL DAYTRANA - Tier 2; PA; QL; AL methylphenidate hcl er (generic for CONCERTA) - Tier 1; QL FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL methylphenidate hcl er (cd) - Tier 1; QL FOCALIN XR (brand for dexmethylphenidate hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er (la) (generic for RITALIN LA) - Tier 1; QL INTUNIV (brand for guanfacine hcl er) - Tier 2; PA; QL methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; QL JORNAY PM - Tier 2; PA; QL QUILLICHEW ER - Tier 2; QL; AL KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL METHYLIN ORAL SOLUTION 10 MG/5ML (brand for methylphenidate hcl) - Tier 2; PA; QL METHYLIN ORAL SOLUTION 5 MG/5ML (brand for methylphenidate hcl) - Tier 2; PA methylphenidate hcl er (xr) (generic for APTENSIO XR) - Tier 1; PA methylphenidate hcl oral solution 10 mg/5ml (generic for METHYLIN) - Tier 1; PA; QL methylphenidate hcl oral solution 5 mg/5ml (generic for METHYLIN) - Tier 1; PA methylphenidate hcl oral tablet chewable - Tier 1; PA QELBREE - Tier 2; PA; QL; AL

68 Preferred Agents Non-Preferred Agents QUILLIVANT XR - Tier 2; PA; QL relexxii (generic for RELEXXII) - Tier 1; PA; QL RITALIN (brand for methylphenidate hcl) - Tier 2; PA; QL RITALIN LA (brand for methylphenidate hcl er (la)) - Tier 2; PA; QL STRATTERA (brand for atomoxetine hcl) - Tier 2; PA; QL

Central Nervous System, Other - Miscellaneous Central Nervous System Drugs AUSTEDO - Tier 2; PA; SP; QL CONVENIENCE PAK - Tier 2; PA caffeine citrate oral - Tier 1; QL EXSERVAN - Tier 2; PA; QL INGREZZA - Tier 2; PA; SP; QL GRALISE - Tier 2; PA; QL riluzole (generic for RILUTEK) - Tier 1; QL HORIZANT - Tier 2; PA; QL tetrabenazine (generic for XENAZINE) - Tier 1; PA; SP; QL NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK - Tier 2; PA; XENAZINE (brand for tetrabenazine) - Tier 2; PA; SP; QL QL NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL; AL NUEDEXTA - Tier 2; PA; QL RILUTEK (brand for riluzole) - Tier 2; PA; QL SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 140 MG/7ML - Tier 2; PA TIGLUTIK - Tier 2; PA; QL

Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain pregabalin oral (generic for LYRICA) - Tier 1; QL LYRICA (brand for pregabalin) - Tier 2; PA; QL LYRICA CR (brand for pregabalin er) - Tier 2; PA; QL pregabalin er (generic for LYRICA CR) - Tier 1; PA; QL SAVELLA - Tier 2; PA; QL SAVELLA TITRATION PACK - Tier 2; PA; QL

Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO - Tier 2; SP; QL AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL

69 Preferred Agents Non-Preferred Agents AVONEX PEN - Tier 2; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; PA; SP; QL AVONEX PREFILLED - Tier 2; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; PA; SP; BETASERON - Tier 2; SP; QL QL COPAXONE (brand for glatiramer acetate) - Tier 2; SP; QL EXTAVIA - Tier 2; PA; SP; QL dalfampridine er (generic for AMPYRA) - Tier 1; SP; QL glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP; QL GILENYA - Tier 2; SP; QL glatopa (generic for GLATOPA) - Tier 1; PA; SP; QL REBIF - Tier 2; SP; QL MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL REBIF REBIDOSE - Tier 2; SP; QL MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL PLEGRIDY - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; PA; SP; QL PONVORY - Tier 2; PA; SP; QL PONVORY STARTER PACK - Tier 2; PA; SP; QL TECFIDERA (brand for dimethyl fumarate) - Tier 2; PA; SP; QL VUMERITY - Tier 2; PA; SP; QL

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 ANBESOL MAXIMUM STRENGTH MOUTH/THROAT GEL (brand for cevimeline hcl (generic for EVOXAC) - Tier 1; QL goodsense oral pain relief) - Tier 2; PA chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier 1; ANBESOL MOUTH/THROAT GEL - Tier 2; PA QL AQUORAL (brand for ra dry mouth) - Tier 2; PA; QL DENTA 5000 PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; QL BABY ANBESOL (brand for cvs baby teething oral pain) - Tier 2; PA DENTAGEL (brand for sf) - Tier 2 baby teething oral pain (generic for BABY ANBESOL) - Tier 1; PA easygel - Tier 1 cherry cough drops (generic for DENTIVA) - Tier 1; PA fluoridex daily renewal - Tier 1 cherry menthol drops (generic for DENTIVA) - Tier 1; PA oralone (generic for ORALONE) - Tier 1; QL CLINPRO 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA periogard (generic for PERIOGARD) - Tier 1; QL cold sore treatment external liquid 0.13-3 % - Tier 1; PA

70 Preferred Agents Non-Preferred Agents pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL DEBACTEROL - Tier 2; PA PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2 dry mouth (generic for AQUORAL) - Tier 1; PA; QL PREVIDENT 5000 PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; EPISIL - Tier 2; PA QL EVOXAC (brand for cevimeline hcl) - Tier 2; PA; QL PREVIDENT DENTAL (brand for sf) - Tier 2 FIRST-MOUTHWASH BLM - Tier 2; PA sf (generic for CAVAREST) - Tier 1 FLUORIDEX (brand for sodium fluoride 5000 ppm) - Tier 2; PA sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL FLUORIDEX ENHANCED WHITENING (brand for sodium fluoride 5000 sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL ppm) - Tier 2; PA sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 FLUORIDEX SENSITIVITY RELIEF (brand for sodium fluoride 5000 PLUS) - Tier 1; QL enamel) - Tier 2; PA sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; GELCLAIR - Tier 2; PA; QL QL GELX - Tier 2; PA sodium fluoride dental gel (generic for CAVAREST) - Tier 1 honey lemon drops (generic for DENTIVA) - Tier 1; PA triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; HURRICAINE MOUTH/THROAT GEL (brand for goodsense oral pain relief) QL - Tier 2; PA instant oral pain relief max (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA menthol drops (generic for DENTIVA) - Tier 1; PA MOUTH KOTE REMINT (brand for ra dry mouth) - Tier 2; PA; QL MUCOSITISRX - Tier 2; PA MUCOTROL - Tier 2; PA MUGARD - Tier 2; PA NAFRINSE DAILY ACIDULATED - Tier 2; PA NAFRINSE DAILY/NEUTRAL - Tier 2; PA NAFRINSE WEEKLY - Tier 2; PA oral analgesic max st mouth/throat gel (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA oral anesthetic max str (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA oral pain relief mouth/throat gel 20 % (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA ORAMAGICRX - Tier 2; PA PERIDEX (brand for chlorhexidine gluconate) - Tier 2; PA; QL

71 Preferred Agents Non-Preferred Agents PREVIDENT 5000 BOOSTER PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; PA PREVIDENT 5000 ENAMEL PROTECT (brand for sodium fluoride 5000 enamel) - Tier 2; PA PREVIDENT 5000 ORTHO DEFENSE (brand for sodium fluoride 5000 ppm) - Tier 2; PA PREVIDENT 5000 SENSITIVE (brand for sodium fluoride 5000 enamel) - Tier 2; PA SALAGEN (brand for pilocarpine hcl) - Tier 2; PA; QL SALIVAMAX - Tier 2; PA sodium fluoride 5000 enamel (generic for FLUORIDEX SENSITIVITY RELIEF) - Tier 1; PA sodium fluoride 5000 ppm dental paste (generic for CLINPRO 5000) - Tier 1; PA sodium fluoride 5000 sensitive (generic for FLUORIDEX SENSITIVITY RELIEF) - Tier 1; PA sore throat mouth/throat lozenge 6-10 mg (generic for DENTIVA) - Tier 1; PA XEROSTOMIA RELIEF SPRAY (brand for ra dry mouth) - Tier 2; PA; QL ZILACTIN BABY - Tier 2; PA

Dermatological Agents WINLEVI - Tier 2; PA; QL

Dermatological Agents - Drugs to Treat Skin Conditions accutane oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL accutane oral capsule 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; ABSORICA LD - Tier 2; PA; QL PA; QL ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL acne (generic for CLEARSKIN) - Tier 1 ACIOXIAY - Tier 2; PA; QL acne control cleanser (generic for CLEARSKIN) - Tier 1 acitretin (generic for SORIATANE) - Tier 1; PA; QL acne medication 10 external lotion - Tier 1; QL ACNESIC - Tier 2; PA acne medication 5 external lotion - Tier 1 ACZONE (brand for dapsone) - Tier 2; PA; QL

72 Preferred Agents Non-Preferred Agents adapalene external gel 0.1 % (generic for DIFFERIN) - Tier 1; QL ADAINZDE - Tier 2; PA; QL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE ADAINZOXIA - Tier 2; PA; QL WASH) - Tier 1 adapalene external cream (generic for DIFFERIN) - Tier 1; PA; QL advanced acne spot treat (generic for CLEAN & CLEAR ACNE SCRUB) adapalene external gel 0.3 % (generic for DIFFERIN) - Tier 1; PA; QL - Tier 1 ADAPALENE EXTERNAL PAD - Tier 2; PA; QL advanced healing external ointment (generic for FLANDERS ADAPALENE EXTERNAL SOLUTION - Tier 2; PA; QL BUTTOCKS) - Tier 1 adapalene-benzoyl peroxide external gel (generic for EPIDUO) - Tier 1; PA; ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL QL ALOE VESTA DAILY MOISTURIZER - Tier 2 ADAPALENE-BENZOYL PEROXIDE EXTERNAL PAD - Tier 2; PA; QL alum sulfate-ca acetate (generic for DOMEBORO) - Tier 1 ADVANCED ALLERGY COLLECTION - Tier 2; PA; QL amcinonide - Tier 1 AKLIEF - Tier 2; PA; QL ammonium lactate external (generic for AL12) - Tier 1; QL ALA SCALP - Tier 2; PA amnesteem oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; alclometasone dipropionate - Tier 1; PA; QL QL ALDARA (brand for imiquimod) - Tier 2; PA; QL amnesteem oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL ALEVAMAX - Tier 2; PA amnesteem oral capsule 40 mg (generic for ACCUTANE) - Tier 1; PA; ALTRENO - Tier 2; PA; QL QL AMELUZ - Tier 2; PA anti-dandruff (generic for SELSUN BLUE) - Tier 1 americerin (generic for AMERICERIN) - Tier 1; PA arthritis pain relieving - Tier 1; QL AMZEEQ - Tier 2; PA; QL astringent solution (generic for DOMEBORO) - Tier 1 ana-lex (generic for ANA-LEX) - Tier 1; PA; QL AVAR CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2 APEXICON E - Tier 2; PA; QL AVITA (brand for tretinoin) - Tier 2; QL AQUAPHILIC (brand for e-ointment) - Tier 2; PA AZELEX - Tier 2; QL ARAZLO - Tier 2; PA; SP; QL; AL baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - ATOPICLAIR (brand for calicylic) - Tier 2; PA Tier 1; QL ATRALIN (brand for tretinoin) - Tier 2; PA; QL beauty 360 pure glycerin - Tier 1 AVAR LS CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; PA BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2; QL AVAR-E EMOLLIENT (brand for sulfacetamide sodium-sulfur) - Tier 2; PA benzepro external foam 5.3 % - Tier 1; QL AVAR-E GREEN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA BENZOIN - Tier 2 AVAR-E LS (brand for sulfacetamide sodium-sulfur) - Tier 2; PA benzoin compound (generic for STERI-STRIP COMPOUND BENZOIN) AVEIDAOXIA - Tier 2; PA; QL - Tier 1 azelaic acid external (generic for FINACEA) - Tier 1; PA; QL BENZOYL PEROXIDE EXTERNAL GEL 8 % - Tier 2 BASLE (brand for eucerin advanced repair) - Tier 2; PA benzoyl peroxide-erythromycin (generic for BENZAMYCIN) - Tier 1; QL BENSAL HP - Tier 2; PA betamethasone valerate external cream - Tier 1; QL BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL

73 Preferred Agents Non-Preferred Agents betamethasone valerate external lotion - Tier 1 BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - betamethasone valerate external ointment - Tier 1; QL Tier 2; PA; QL boro-packs (generic for DOMEBORO) - Tier 1 BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % (brand for BENZEPRO CREAMY WASH (brand for bp wash) - Tier 2; PA zinc oxide) - Tier 2; QL BENZEPRO EXTERNAL - Tier 2; PA; QL bp 10-1 - Tier 1 BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % - Tier 2; PA; QL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 BENZEPRO EXTERNAL LIQUID - Tier 2; PA; QL calamine external lotion , 8-8 % - Tier 1 BENZEPRO FOAMING CLOTHS (brand for bpo foaming cloths) - Tier 2; calamine-zinc oxide external lotion - Tier 1 PA calcipotriene external cream (generic for DOVONEX) - Tier 1; QL BENZEPRO SHORT CONTACT (brand for benzoyl peroxide) - Tier 2; PA; calcipotriene external ointment (generic for CALCITRENE) - Tier 1; QL QL calcipotriene external solution - Tier 1; QL BENZOYL PEROX-HYDROCORTISONE - Tier 2; PA calcipotriene-betameth diprop external ointment (generic for benzoyl peroxide external foam (generic for BENZEPRO SHORT TACLONEX) - Tier 1; QL CONTACT) - Tier 1; PA; QL calcitriol external (generic for VECTICAL) - Tier 1; QL BENZOYL PEROXIDE EXTERNAL GEL 6.5 % - Tier 2; PA; QL capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; QL BENZOYL PEROXIDE FORTE- HC - Tier 2; PA; QL capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL BESER EXTERNAL KIT - Tier 2; PA; QL capzix (generic for ZOSTRIX HP) - Tier 1; QL beser external lotion (generic for BESER) - Tier 1; PA; QL cerovel (generic for CEROVEL) - Tier 1; QL betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier 1; PA; claravis oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; QL QL claravis oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL betamethasone dipropionate external cream - Tier 1; PA; QL claravis oral capsule 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; betamethasone dipropionate external lotion - Tier 1; PA PA; QL betamethasone dipropionate external ointment - Tier 1; PA; QL clearskin (generic for CLEARSKIN) - Tier 1 betamethasone valerate external foam (generic for LUXIQ) - Tier 1; PA; QL clindamycin phosphate-benzoyl peroxide (generic for BENZACLIN) - BETASEPT SURGICAL SCRUB - Tier 2; PA Tier 1; QL BOUDREAUXS BABY BUTT SMOOTH (brand for e-ointment) - Tier 2; PA clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; bp cleansing wash - Tier 1; PA QL bp wash external liquid 7 % (generic for BENZEPRO CREAMY WASH) - clindamycin phosphate external solution - Tier 1; QL Tier 1; PA CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL - Tier 2; QL BRYHALI - Tier 2; PA; QL clindamycin phosphate gel 1 % external (generic for CLINDAGEL) - Tier CALCIPOTRIENE EXTERNAL FOAM - Tier 2; PA; QL 1; QL calcipotriene-betameth diprop external suspension (generic for clobetasol prop emollient base - Tier 1; QL TACLONEX) - Tier 1; PA; QL clobetasol propionate e - Tier 1; QL CALCITRENE (brand for calcipotriene) - Tier 2; PA; QL

74 Preferred Agents Non-Preferred Agents clobetasol propionate emulsion (generic for TOVET) - Tier 1; QL calicylic (generic for ATOPICLAIR) - Tier 1; PA clobetasol propionate external (generic for TEMOVATE) - Tier 1; QL CAPEX - Tier 2; PA; QL clodan external shampoo (generic for CLODAN) - Tier 1; QL CARAC (brand for fluorouracil) - Tier 2; PA; QL clotrimazole-betamethasone - Tier 1; QL CEM-UREA - Tier 2; PA corn & callus remover (generic for COMPOUND W) - Tier 1 CHLOOXIA - Tier 2; PA; QL daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - CLENIA PLUS - Tier 2; PA; QL Tier 1 CLEOCIN-T (brand for clindamycin phosphate) - Tier 2; PA; QL dandruff shampoo external lotion (generic for SELSUN BLUE) - Tier 1 CLINDACIN ETZ EXTERNAL KIT - Tier 2; PA DERMAPHOR (brand for e-ointment) - Tier 2; QL clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; PA; QL desonide external cream (generic for DESOWEN) - Tier 1; QL CLINDACIN PAC - Tier 2; PA desonide external ointment - Tier 1; QL clindacin-p (generic for CLINDACIN ETZ) - Tier 1; PA; QL diaper rash external ointment (generic for BOUDREAUXS BUTT CLINDAGEL (brand for clindamycin phosphate) - Tier 2; PA; QL PASTE) - Tier 1; QL clindamycin phosphate external foam (generic for EVOCLIN) - Tier 1; PA; DIFFERIN (brand for adapalene) - Tier 2; QL QL diflorasone diacetate external cream - Tier 1; QL clindamycin phosphate external swab (generic for CLINDACIN ETZ) - Tier diflorasone diacetate external ointment - Tier 1 1; PA; QL doxepin hcl external (generic for PRUDOXIN) - Tier 1; QL clindamycin-tretinoin (generic for VELTIN) - Tier 1; PA; QL DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL CLINOIN - Tier 2; PA DR SMITHS DIAPER - Tier 2; QL CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL DRYSOL - Tier 2; QL CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL erythromycin external (generic for ERYGEL) - Tier 1; QL clocortolone pivalate (generic for CLODERM) - Tier 1; PA; QL flanders buttocks (generic for FLANDERS BUTTOCKS) - Tier 1 CLODAN EXTERNAL KIT - Tier 2; PA fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) CLODERM (brand for clocortolone pivalate) - Tier 2; PA; QL - Tier 1; QL COAL TAR EXTERNAL - Tier 2; PA fluocinolone acetonide external cream 0.01 % - Tier 1; QL CONDYLOX - Tier 2; PA fluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; COPADERM (brand for scar gel) - Tier 2; PA QL COPASIL EXTERNAL (brand for scar gel) - Tier 2; PA fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS CORDRAN EXTERNAL CREAM (brand for flurandrenolide) - Tier 2; PA; SCALP) - Tier 1; QL QL fluocinonide emulsified base - Tier 1; QL CORDRAN EXTERNAL LOTION (brand for flurandrenolide) - Tier 2; PA; fluocinonide external cream 0.05 % - Tier 1; QL QL fluocinonide external gel - Tier 1; QL CORDRAN EXTERNAL OINTMENT (brand for flurandrenolide) - Tier 2; PA fluocinonide external ointment - Tier 1; QL CORDRAN EXTERNAL TAPE - Tier 2; PA; QL fluocinonide external solution - Tier 1; QL CORTANE-B - Tier 2; PA

75 Preferred Agents Non-Preferred Agents fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL cortisone maximum strength external gel (generic for CORTIZONE-10) - fluorouracil external solution - Tier 1 Tier 1; PA fluticasone propionate external cream - Tier 1; QL COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML fluticasone propionate external ointment - Tier 1; QL - Tier 2; PA; SP; QL glycerin external - Tier 1 COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 glycerin external liquid 99.5 % - Tier 1 MG/ML - Tier 2; PA; SP; QL gormel - Tier 1; QL COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 gormel 10 (generic for NUTRAPLUS) - Tier 1; QL MG/0.5ML - Tier 2; PA hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 cure-all (generic for ATOPICLAIR) - Tier 1; PA hydrocortisone acetate external cream (generic for GYNECORT 10) - CUTIVATE (brand for fluticasone propionate) - Tier 2; PA; QL Tier 1 dapsone external gel 5 % (generic for ACZONE) - Tier 1; PA; QL hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL dapsone gel 7.5 % external (generic for ACZONE) - Tier 1; PA; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL DAPSONE GEL 7.5 % EXTERNAL - Tier 2; PA; QL hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH DEOXIA - Tier 2; PA; QL MAX ST) - Tier 1; QL DERMACERIN (brand for hydrocerin) - Tier 2; PA hydrocortisone external lotion 2.5 % - Tier 1; QL DERMA-SMOOTHE/FS BODY (brand for fluocinolone acetonide body) - hydrocortisone external ointment 0.5 % - Tier 1 Tier 2; PA; QL hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH DERMA-SMOOTHE/FS SCALP (brand for fluocinolone acetonide scalp) - RELIEF MAX STR) - Tier 1; QL Tier 2; PA; QL hydrocortisone external ointment 2.5 % - Tier 1; QL DERMELLE (brand for scar gel) - Tier 2; PA hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 DESONATE (brand for desonide) - Tier 2; PA; QL INTENSIVE HEALING) - Tier 1 desonide external gel (generic for DESRX) - Tier 1; PA; QL hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE desonide external lotion - Tier 1; PA; QL HEALING) - Tier 1 DESOWEN (brand for desonide) - Tier 2; PA; QL hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE desoximetasone external (generic for TOPICORT) - Tier 1; PA; QL HEALING) - Tier 1 desrx (generic for DESRX) - Tier 1; PA; QL hydrocortisone-aloe - Tier 1 DEXERYL (brand for calicylic) - Tier 2; PA hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE DIADIMAXIA - Tier 2; PA; QL HEALING) - Tier 1 DIAOXIA - Tier 2; PA; QL hydrolatum (generic for FLANDERS BUTTOCKS) - Tier 1 DIASDIMAXIA - Tier 2; PA; QL imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL DIASOXIA - Tier 2; PA; QL instacort 5 - Tier 1; QL dibucaine (perianal) (generic for NUPERCAINAL) - Tier 1; PA isotretinoin oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; diclofenac sodium external gel 3 % - Tier 1; PA; QL QL DIMOXIA - Tier 2; PA; QL

76 Preferred Agents Non-Preferred Agents isotretinoin oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL DIOCHLOY - Tier 2; PA; QL isotretinoin oral capsule 25 mg, 35 mg (generic for ABSORICA) - Tier 1; DIPROLENE (brand for betamethasone dipropionate aug) - Tier 2; PA; QL PA; QL DIPROLENE AF (brand for betamethasone dipropionate aug) - Tier 2; PA; isotretinoin oral capsule 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; QL PA; QL DOVONEX (brand for calcipotriene) - Tier 2; PA; QL KERALAC (brand for urea) - Tier 2 DRAXACE - Tier 2; PA; QL LAC-HYDRIN FIVE - Tier 2; QL DRAXACE LOTION CLEANSER - Tier 2; PA; QL lactic acid external - Tier 1 DRITHO-CREME HP - Tier 2; PA lidocaine-hydrocort (perianal) (generic for LIDOCORT) - Tier 1 DRIXECE - Tier 2; PA; QL LIDOCORT (brand for lidocaine-hydrocort (perianal)) - Tier 2 DUOBRII - Tier 2; PA; QL medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1 DUPIXENT - Tier 2; PA; SP; QL methoxsalen rapid - Tier 1 ECEOXIA - Tier 2; PA; QL moisturel - Tier 1 EFUDEX (brand for fluorouracil) - Tier 2; PA; QL mometasone furoate external - Tier 1; QL ELETONE (brand for calicylic) - Tier 2; PA myorisan oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; ELIDEL (brand for pimecrolimus) - Tier 2; PA; QL QL ENSTILAR - Tier 2; PA; QL myorisan oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL ENZOCLEAR (brand for benzoyl peroxide) - Tier 2; PA; QL myorisan oral capsule 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL PA; QL EPIDUO FORTE - Tier 2; PA; QL neuac external gel (generic for NEUAC) - Tier 1; QL EPIFOAM - Tier 2; PA NEUTROGENA OIL-FREE ACNE WASH (brand for eql apricot scrub) - ery - Tier 1; PA; QL Tier 2 ERYGEL (brand for erythromycin) - Tier 2; PA; QL NUTRAPLUS (brand for urea 10 hydrating) - Tier 2; QL ETHOXIA - Tier 2; PA; QL ointment base (generic for FLANDERS BUTTOCKS) - Tier 1 EUCRISA - Tier 2; PA; QL PANOXYL (brand for bp wash) - Tier 2 EVOCLIN (brand for clindamycin phosphate) - Tier 2; PA; QL podofilox external - Tier 1; QL FABIOR (brand for tazarotene) - Tier 2; PA; QL prednicarbate external cream - Tier 1; QL FINACEA (brand for azelaic acid) - Tier 2; PA; QL prednicarbate external ointment - Tier 1 fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - PROTOPIC (brand for tacrolimus) - Tier 2; PA; QL Tier 1; PA; QL REGRANEX - Tier 2; DX2RX; QL fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; renewal soothing bath (generic for AVEENO BABY BATH PA; QL TREATMENT) - Tier 1 fluocinonide external cream 0.1 % (generic for VANOS) - Tier 1; PA; QL salicylic acid external gel (generic for KERALYT) - Tier 1; QL FLUOPAR - Tier 2; PA; QL SANTYL - Tier 2; QL FLUOROPLEX - Tier 2; PA; QL

77 Preferred Agents Non-Preferred Agents selenium sulfide external lotion - Tier 1; QL FLUOROURACIL EXTERNAL CREAM 0.5 % - Tier 2; PA; QL selenium sulfide external shampoo 2.25 % - Tier 1 FLUOVIX - Tier 2; PA; QL soothing bath treatment external packet (generic for AVEENO BABY FLUOVIX PLUS - Tier 2; PA; QL BATH TREATMENT) - Tier 1 flurandrenolide external cream (generic for NOLIX) - Tier 1; PA; QL SORIATANE (brand for acitretin) - Tier 2; QL flurandrenolide external lotion (generic for NOLIX) - Tier 1; PA; QL sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1 flurandrenolide external ointment (generic for CORDRAN) - Tier 1; PA sulfacetamide sodium (acne) (generic for KLARON) - Tier 1; QL fluticasone propionate external lotion (generic for BESER) - Tier 1; PA; QL sulfacetamide sodium-sulfur external cream 10-2 % (generic for AVAR- formaldehyde external solution 10 % - Tier 1; PA E LS) - Tier 1 FORMALDEHYDE EXTERNAL SOLUTION 37 % - Tier 2; PA sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR- GENADUR EXTERNAL (brand for liquid bandage) - Tier 2; PA E EMOLLIENT) - Tier 1 GORDOFILM - Tier 2; PA sulfacetamide sodium-sulfur external emulsion (generic for AVAR GUANENDRUX - Tier 2; PA; QL CLEANSER) - Tier 1 halcinonide (generic for HALOG) - Tier 1; PA; QL sulfacetamide sodium-sulfur external liquid 9.8-4.8 % (generic for halobetasol propionate external cream - Tier 1; PA; QL PLEXION CLEANSER) - Tier 1 HALOBETASOL PROPIONATE EXTERNAL FOAM - Tier 2; PA; QL sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for halobetasol propionate external ointment - Tier 1; PA; QL SUMADAN WASH) - Tier 1; QL HALOG (brand for halcinonide) - Tier 2; PA; QL sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1 HALUCORT - Tier 2; PA sulfacetamide sodium-sulfur external suspension 8-4 % (generic for HAXCHLO - Tier 2; PA; QL SULFACLEANSE 8/4) - Tier 1 hemorrhoidal rectal ointment 0.25-3-14-71.9 % - Tier 1; PA sulfacetamide sodium-sulfur liquid 9-4 % external (generic for SUMAXIN HIBICLENS - Tier 2; PA WASH) - Tier 1 HPR PLUS EXTERNAL CREAM (brand for calicylic) - Tier 2; PA sulfacetamide sod-sulfur wash external liquid 9-4 % (generic for hpr plus external foam - Tier 1; PA SUMAXIN WASH) - Tier 1 HPR PLUS HYDROGEL - Tier 2; PA sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for HYDRO 40 - Tier 2; PA SUMADAN WASH) - Tier 1; QL hydrocerin (generic for AMERICERIN) - Tier 1; PA sulfamez wash - Tier 1 hydrocortisone ace-pramoxine external cream 2.5-1 % (generic for TALTZ - Tier 2; PA; SP; QL PRAMOSONE) - Tier 1; PA TAZORAC - Tier 2; QL hydrocortisone acetate external ointment - Tier 1; PA tovet external foam (generic for TOVET) - Tier 1; QL hydrocortisone butyr lipo base (generic for LOCOID LIPOCREAM) - Tier 1; tretinoin external (generic for AVITA) - Tier 1; QL PA; QL tretinoin microsphere (generic for RETIN-A MICRO) - Tier 1; QL hydrocortisone butyrate - Tier 1; PA; QL tretinoin microsphere pump (generic for RETIN-A MICRO) - Tier 1; QL hydrocortisone valerate - Tier 1; PA; QL triamcinolone acetonide external cream - Tier 1; QL HYLATOPIC PLUS (brand for calicylic) - Tier 2; PA

78 Preferred Agents Non-Preferred Agents triamcinolone acetonide external lotion 0.025 % - Tier 1 ILUMYA - Tier 2; PA; SP; QL triamcinolone acetonide external lotion 0.1 % - Tier 1; QL imiquimod external cream 3.75 % (generic for ZYCLARA) - Tier 1; PA; QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier IMIQUIMOD PUMP - Tier 2; PA; QL 1; QL IMPEKLO - Tier 2; PA; QL triamcinolone acetonide external ointment 0.05 % (generic for IMPOYZ - Tier 2; PA; QL TRITOCIN) - Tier 1 INOVA - Tier 2; PA TRIANEX (brand for triamcinolone acetonide) - Tier 2 INOVA 4/1 ACNE CONTROL THERAPY - Tier 2; PA triderm (generic for TRIDERM) - Tier 1; QL INOVA 8/2 ACNE CONTROL THERAPY - Tier 2; PA tritocin (generic for TRITOCIN) - Tier 1 IONIL-T (brand for cvs therapeutic dandruff) - Tier 2; PA urea 20 intensive hydrating - Tier 1; QL ITHOXIA - Tier 2; PA; QL urea external cream 39 % (generic for UREDEB) - Tier 1 ivermectin external cream (generic for SOOLANTRA) - Tier 1; PA; QL urea external cream 40 % - Tier 1; QL KELARX (brand for scar gel) - Tier 2; PA urea external cream 41 % (generic for UTOPIC) - Tier 1 KENALOG EXTERNAL (brand for triamcinolone acetonide) - Tier 2; PA; QL urea external cream 47 % (generic for KERALAC) - Tier 1 KERALYT EXTERNAL GEL 6 % (brand for salicylic acid) - Tier 2; PA; QL urea external lotion (generic for CEROVEL) - Tier 1; QL KERALYT EXTERNAL SHAMPOO (brand for salicylic acid) - Tier 2; PA ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL KERALYT SCALP - Tier 2; PA ureacin-20 - Tier 1; QL KLARON (brand for sulfacetamide sodium (acne)) - Tier 2; PA; QL UREMEZ-40 - Tier 2; QL lactic acid e - Tier 1; PA wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1 LANAPHILIC (brand for e-ointment) - Tier 2; PA wart remover maximum strength external liquid (generic for LEVULAN KERASTICK - Tier 2; PA COMPOUND W) - Tier 1 LEXETTE (brand for halobetasol propionate) - Tier 2; PA; QL zaclir cleansing - Tier 1 LIDOCAINE (ANORECTAL) RECTAL - Tier 2; PA; QL zenatane oral capsule 10 mg (generic for AMNESTEEM) - Tier 1; PA; LIDOCAINE-HYDROCORTISONE ACE EXTERNAL - Tier 2; PA; QL QL LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL - Tier 2; PA zenatane oral capsule 20 mg (generic for ACCUTANE) - Tier 1; QL lidocaine-hydrocortisone ace rectal kit 2-2 % (generic for ANA-LEX) - Tier zenatane oral capsule 30 mg, 40 mg (generic for ACCUTANE) - Tier 1; 1; PA; QL PA; QL lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-2.5 % - Tier 1; PA zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT lidocaine-hydrocortisone ace rectal kit 3-1 % - Tier 1; PA; QL PASTE) - Tier 1; QL LOCOID (brand for hydrocortisone butyrate) - Tier 2; PA; QL ZOSTRIX HP (brand for capsaicin hp) - Tier 2; QL LOCOID LIPOCREAM (brand for hydrocortisone butyr lipo base) - Tier 2; PA; QL LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL MEDERMA (brand for scar gel) - Tier 2; PA MEDERMA FOR KIDS (brand for scar gel) - Tier 2; PA

79 Preferred Agents Non-Preferred Agents MEDERMA SPF 30 (brand for scarcin) - Tier 2; PA methyl salicylate external liquid - Tier 1; PA MIMYX (brand for calicylic) - Tier 2; PA minerin creme (generic for AMERICERIN) - Tier 1; PA MIRVASO - Tier 2; PA; QL NEOSALUS - Tier 2; PA NEO-SYNALAR EXTERNAL CREAM - Tier 2; PA; QL NEUAC EXTERNAL KIT - Tier 2; PA nolix (generic for NOLIX) - Tier 1; PA; QL NOVACORT - Tier 2; PA NUCARACLINPAK - Tier 2; PA; QL NUCARARXPAK - Tier 2; PA; QL NUCORT - Tier 2; PA NUDERMRXPAK 120 - Tier 2; PA; QL NUDERMRXPAK 60 - Tier 2; PA; QL NUPERCAINAL (brand for dibucaine (perianal)) - Tier 2; PA NUSURGEPAK SURGICAL PREP/CARE - Tier 2; PA NUTRASEB - Tier 2; PA NUTRIARX CREAMPAK (brand for sanadermrx skin repair) - Tier 2; PA; QL NUVAIL - Tier 2; PA OLUX (brand for clobetasol propionate) - Tier 2; PA; QL OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL ONEXTON - Tier 2; PA; QL ONZDEOXIA - Tier 2; PA; QL OVACE PLUS EXTERNAL CREAM - Tier 2; PA OVACE PLUS EXTERNAL FOAM - Tier 2; PA; QL OVACE PLUS EXTERNAL LOTION - Tier 2; PA OVACE PLUS EXTERNAL SHAMPOO (brand for sodium sulfacetamide) - Tier 2; PA OVACE PLUS WASH (brand for sulfacetamide sodium) - Tier 2; PA OVACE WASH (brand for sulfacetamide sodium) - Tier 2; PA OXIANUJO - Tier 2; PA; QL OXIATAR - Tier 2; PA; QL

80 Preferred Agents Non-Preferred Agents OXIAVARRY - Tier 2; PA; QL OXIAZAR - Tier 2; PA; QL PANDEL - Tier 2; PA pimecrolimus (generic for ELIDEL) - Tier 1; PA; QL PLEXION (brand for sulfacetamide sodium-sulfur) - Tier 2; PA PLEXION CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; PA PLEXION CLEANSING CLOTH (brand for sulfacetamide sodium-sulfur) - Tier 2; PA podocon - Tier 1; PA PR BENZOYL PEROXIDE - Tier 2; PA; QL PR BENZOYL PEROXIDE WASH (brand for bp wash) - Tier 2; PA PR CREAM - Tier 2; PA pramosone external cream 1-1 % - Tier 1; PA PRAMOSONE EXTERNAL CREAM 1-2.5 % (brand for hydrocortisone ace- pramoxine) - Tier 2; PA PRAMOSONE EXTERNAL LOTION - Tier 2; PA PRAMOSONE EXTERNAL OINTMENT - Tier 2; PA PRE & POST SX POUCH - Tier 2; PA; QL PRESERA - Tier 2; PA PROMISEB - Tier 2; PA PROSILK EXTERNAL - Tier 2; PA PROTEXA - Tier 2; PA; QL PRUCLAIR (brand for calicylic) - Tier 2; PA PRUDOXIN (brand for doxepin hcl) - Tier 2; PA; QL PRUMYX (brand for calicylic) - Tier 2; PA PSORCON - Tier 2; PA; QL PYROGALLIC ACID - Tier 2; PA QBREXZA - Tier 2; PA; QL QUIHOXVAR - Tier 2; PA; QL QUINIXIL - Tier 2; PA; QL REA-LO - Tier 2; PA RECEDO (brand for scar gel) - Tier 2; PA REMIGEN - Tier 2; PA RESORCINOL-SULFUR - Tier 2; PA

81 Preferred Agents Non-Preferred Agents RETIN-A (brand for tretinoin) - Tier 2; PA; QL RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) - Tier 2; PA; QL RETIN-A MICRO PUMP (brand for tretinoin microsphere) - Tier 2; PA; QL RHOFADE - Tier 2; PA; QL ROSADAN EXTERNAL KIT - Tier 2; PA SALEX (brand for salicylic acid) - Tier 2; PA salicylic acid er (generic for ULTRASAL-ER) - Tier 1; PA salicylic acid external foam (generic for SALVAX) - Tier 1; PA salicylic acid external shampoo (generic for KERALYT) - Tier 1; PA salicylic acid external solution - Tier 1; PA salicylic acid wart remover (generic for VIRASAL) - Tier 1; PA; QL salicylic acid-cleanser - Tier 1; PA salimez - Tier 1; PA SALIMEZ FORTE - Tier 2; PA SALVAX (brand for salicylic acid) - Tier 2; PA SALVAX DUO PLUS - Tier 2; PA SANADERMRX SKIN REPAIR - Tier 2; PA; QL SCALACORT DK - Tier 2; PA scar external gel (generic for COPADERM) - Tier 1; PA SCARCIN - Tier 2; PA SCARSILK EXTERNAL - Tier 2; PA SCARZEN SKIN REPAIR - Tier 2; PA; QL selenium sulfide external shampoo 2.3 % (generic for SELRX) - Tier 1; PA SELRX (brand for selenium sulfide) - Tier 2; PA SERNIVO - Tier 2; PA; QL SILA III - Tier 2; PA; QL SILIPAC - Tier 2; PA SILIQ - Tier 2; PA; SP; QL skarjel (generic for COPADERM) - Tier 1; PA sodium sulfacetamide (generic for OVACE PLUS) - Tier 1; PA sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1; PA SODIUM SULFACETAMIDE-BAKUCHIOL - Tier 2; PA SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL

82 Preferred Agents Non-Preferred Agents SORBIDON HYDRATE (brand for hydrocerin) - Tier 2; PA SORILUX (brand for calcipotriene) - Tier 2; PA; QL sss 10-5 external foam - Tier 1; PA STRATA CTX - Tier 2; PA STRATA MARK - Tier 2; PA STRATA TRIZ (brand for scar gel) - Tier 2; PA STRATA XRT - Tier 2; PA sulfacetamide sodium external (generic for OVACE PLUS WASH) - Tier 1; PA sulfacetamide sodium-sulfur external cream 9.8-4.8 % (generic for PLEXION) - Tier 1; PA sulfacetamide sodium-sulfur external liquid 10-2 % (generic for AVAR LS CLEANSER) - Tier 1; PA sulfacetamide sodium-sulfur external lotion 9.8-4.8 % (generic for PLEXION) - Tier 1; PA sulfacetamide sodium-sulfur external pad (generic for PLEXION CLEANSING CLOTH) - Tier 1; PA sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; PA; QL sulfacetamide-sulfur in urea - Tier 1; PA SULFACLEANSE 8/4 (brand for sulfacetamide sodium-sulfur) - Tier 2; PA SUMADAN WASH (brand for sulfacetamide sodium-sulfur) - Tier 2; PA; QL SUMADAN XLT - Tier 2; PA SUMAXIN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA SUMAXIN CP - Tier 2; PA; QL SUMAXIN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA SYNALAR (brand for fluocinolone acetonide) - Tier 2; PA; QL SYNALAR (CREAM) - Tier 2; PA; QL SYNALAR (OINTMENT) - Tier 2; PA; QL SYNALAR TS - Tier 2; PA; QL TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL tacrolimus external (generic for PROTOPIC) - Tier 1; PA; QL TARDEOXIA - Tier 2; PA; QL TARDIMAXIA - Tier 2; PA; QL TAROXIA - Tier 2; PA; QL

83 Preferred Agents Non-Preferred Agents TASOPROL - Tier 2; PA; QL tazarotene external cream (generic for TAZORAC) - Tier 1; PA; QL TAZAROTENE EXTERNAL FOAM - Tier 2; PA; QL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL TETRIX (brand for calicylic) - Tier 2; PA TEXACORT - Tier 2; PA therapeutic dandruff external shampoo 1 % (generic for IONIL-T) - Tier 1; PA THERASEAL HAND PROTECTION - Tier 2; PA TOPICORT (brand for desoximetasone) - Tier 2; PA; QL TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL TOVET EXTERNAL KIT - Tier 2; PA; QL TREMFYA - Tier 2; PA; SP; QL triamcinolone acetonide external aerosol solution (generic for KENALOG) - Tier 1; PA; QL TRI-CHLOR - Tier 2; PA TRIDESILON (brand for desonide) - Tier 2; PA; QL TRI-LUMA - Tier 2; PA TRIVIX (brand for sanadermrx skin repair) - Tier 2; PA; QL ULTRASAL-ER (brand for salicylic acid er) - Tier 2; PA ULTRAVATE - Tier 2; PA; QL UMECTA MOUSSE - Tier 2; PA URAMAXIN (brand for urea nail) - Tier 2; PA urea external cream 45 % - Tier 1; PA UREA EXTERNAL FOAM - Tier 2; PA; QL urea hydrating - Tier 1; PA urea nail (generic for URAMAXIN) - Tier 1; PA uredeb (generic for UREDEB) - Tier 1; PA URESOL - Tier 2; PA; QL UTOPIC (brand for urea) - Tier 2; PA VANICREAM EXTERNAL OINTMENT (brand for e-ointment) - Tier 2; PA VANOS (brand for fluocinonide) - Tier 2; PA; QL VANOXIDE-HC (brand for benzoyl perox-hydrocortisone) - Tier 2; PA VARDIMAXIA - Tier 2; PA; QL

84 Preferred Agents Non-Preferred Agents VAROXIA - Tier 2; PA; QL VECTICAL (brand for calcitriol) - Tier 2; PA; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL VERDESO - Tier 2; PA; QL VEREGEN - Tier 2; PA; QL VIRASAL (brand for salicylic acid wart remover) - Tier 2; PA; QL WYNZORA - Tier 2; PA; QL XALIX - Tier 2; PA; QL XERAC AC - Tier 2; PA XERALUX (brand for calicylic) - Tier 2; PA xurea (generic for UREDEB) - Tier 1; PA ZACARE - Tier 2; PA ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL ZITHRANOL - Tier 2; PA ZONALON (brand for doxepin hcl) - Tier 2; PA; QL ZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL ZYCLARA PUMP (brand for imiquimod pump) - Tier 2; PA; QL

Dermatological Agents - Skin Agents CLINDAVIX - Tier 2; PA; QL CLOBETAVIX - Tier 2; PA; QL GEAMETDRAY - Tier 2; PA; QL KLISYRI - Tier 2; PA; QL ROAOXIA - Tier 2; PA; QL SCENESSE - Tier 2; PA TRILOCICLO - Tier 2; PA; QL ZILXI - Tier 2; PA; QL

Electrolytes/Minerals/ Metals/ Vitamins Vitamins NEONATAL FE - Tier 2; PA; QL

85 Preferred Agents Non-Preferred Agents Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement UPNEEQ - Tier 2; PA; QL

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs BPROTECTED PEDIA IRON (brand for ferrous sulfate) - Tier 2; QL ABATRON - Tier 2; PA cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM) - abatron af (generic for ABATRON AF) - Tier 1; PA Tier 1; QL ACTIVE FE - Tier 2; PA calcium 500/d oral tablet (generic for RA HI CAL) - Tier 1; QL anticavity fluoride rinse mouth/throat solution 0.05 % (generic for ACT calcium 500/vitamin d3 - Tier 1 ANTICAVITY FLUORIDE RINSE) - Tier 1; PA calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL aqueous vitamin e oral solution 15 unit/0.3ml (generic for SOLUVITA E) - calcium 600/vit d/minerals oral tablet 600-200 mg-unit - Tier 1; QL Tier 1; PA calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit - Tier 1 BEELITH - Tier 2; PA calcium 600/vitamin d - Tier 1 cal-citrate - Tier 1; PA calcium 600/vitamin d-3 - Tier 1; QL calcium 500 +d3 (generic for OS-CAL EXTRA D3) - Tier 1; PA calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1; QL calcium 500/d oral tablet chewable - Tier 1; PA calcium 600+d oral tablet 600-400 mg-unit - Tier 1 calcium 600+d oral capsule 600-500 mg-unit - Tier 1; PA calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL calcium 600+d3 oral capsule 600-500 mg-unit - Tier 1; PA calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL calcium citrate malate-vit d - Tier 1; PA calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1; QL calcium citrate oral tablet 1040 mg - Tier 1; PA calcium carbonate-vitamin d oral tablet 600-200 mg-unit - Tier 1; QL calcium citrate+d3 petites oral tablet 200-6.25 mg-mcg (generic for calcium carbonate-vitamin d oral tablet 600-400 mg-unit - Tier 1 CITRACAL PETITES/VITAMIN D) - Tier 1; PA calcium carbonate-vitamin d3 - Tier 1; QL calcium citrate-vitamin d oral tablet 200-125 mg-unit - Tier 1; PA calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1 calcium cit-vit d-3 petites (generic for CITRACAL PETITES/VITAMIN D) - calcium citrate + d oral tablet 315-250 mg-unit (generic for Tier 1; PA CALCITRATE) - Tier 1 calcium high potency - Tier 1; PA calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1 calcium oral tablet 500 mg, 600 mg - Tier 1; PA calcium citrate +d3 (generic for CALCITRATE) - Tier 1 calcium soft chews oral tablet chewable 500-100-40 - Tier 1; PA calcium citrate plus vit d - Tier 1; QL calcium-boron - Tier 1; PA calcium citrate+d oral tablet 315-250 mg-unit (generic for CALCITRATE) calcium-vitamin d oral tablet chewable 250-400 mg-unit (generic for - Tier 1 CALTRATE GUMMY BITES) - Tier 1; PA

86 Preferred Agents Non-Preferred Agents calcium citrate+d3 oral tablet 315-250 mg-unit (generic for cal-mag aspartate - Tier 1; PA CALCITRATE) - Tier 1 CALTRATE GUMMY BITES (brand for eql calcium gummies) - Tier 2; PA calcium citrate+d3 w/magne (generic for ADVANCED CARBAGLU - Tier 2; PA; SP; QL CALCIUM/D/MAGNESIUM) - Tier 1; QL CARNITOR ORAL SOLUTION (brand for levocarnitine) - Tier 2; PA; QL calcium citrate-vit d - Tier 1; QL CARNITOR ORAL TABLET (brand for levocarnitine) - Tier 2; PA calcium citrate-vitamin d oral tablet 315-200 mg-unit - Tier 1; QL CARNITOR SF (brand for levocarnitine) - Tier 2; PA; QL calcium fast dissolution - Tier 1; QL CENTRATEX - Tier 2; PA calcium high potency/vitamin d - Tier 1; QL citrus calcium/vitamin d (generic for CITRACAL PETITES/VITAMIN D) - calcium oral tablet 1500 (600 ca) mg - Tier 1; QL Tier 1; PA calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; QL coral calcium oral capsule 185-50-100 mg-mg-unit - Tier 1; PA calcium plus 600 +d - Tier 1; QL CORAL CALCIUM ORAL TABLET 1000 (390 CA) MG - Tier 2; PA calcium plus vitamin d oral tablet 500-5 mg-mcg (generic for OYSCO CORVITE 150 - Tier 2; PA 500+D) - Tier 1; QL corvite fe (generic for CORVITE 150) - Tier 1; PA calcium plus vitamin d oral tablet 600-200 mg-unit - Tier 1; QL cytra k crystals - Tier 1; PA calcium plus vitamin d oral tablet 600-400 mg-unit - Tier 1 EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ - Tier 2; PA; calcium plus vitamin d3 - Tier 1; QL QL calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier 1 ENDARI - Tier 2; PA; QL calcium/minerals/vitamin d - Tier 1 fe c tab (generic for ICAR-C) - Tier 1; PA calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5 mg FERIVA 21/7 - Tier 2; PA - Tier 1 FERIVAFA - Tier 2; PA calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL FERRALET 90 - Tier 2; PA; QL calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL ferraplus 90 - Tier 1; PA CHROMAGEN (brand for iron complex) - Tier 2 ferretts ips - Tier 1; PA effer-k oral tablet effervescent 25 meq - Tier 1; QL FERRIMIN 150 - Tier 2; PA electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1; ferrocite plus (generic for FERROCITE PLUS) - Tier 1; PA QL FERRO-PLEX HEMATINIC - Tier 2; PA ENFAMIL ENFALYTE (brand for pediatric electrolyte) - Tier 2; QL ferrous sulfate oral syrup - Tier 1; PA; QL EZFE 200 - Tier 2 FLORICAL - Tier 2; PA ferate (generic for FERATE) - Tier 1 FLORIVA ORAL LIQUID - Tier 2; PA FER-IN-SOL (brand for ferrous sulfate) - Tier 2; QL FUSION PLUS - Tier 2; PA ferocon (generic for TRICON) - Tier 1 glutamine oral capsule - Tier 1; PA ferosul (generic for FEROSUL) - Tier 1; QL hematinic plus vit/minerals (generic for FERROCITE PLUS) - Tier 1; PA ferotrinsic (generic for TRICON) - Tier 1 HEMATOGEN FA - Tier 2; PA ferretts - Tier 1 HEMATRON-AF (brand for tl-hem 150) - Tier 2; PA

87 Preferred Agents Non-Preferred Agents ferrex 150 (generic for FERREX 150) - Tier 1 HEMAX (brand for tl-hem 150) - Tier 2; PA ferric x-150 (generic for FERREX 150) - Tier 1 HEMETAB - Tier 2; PA ferrous fumarate oral tablet 324 (106 fe) mg (generic for FERROCITE) - HEMOCYTE PLUS - Tier 2; PA Tier 1 high potency iron - Tier 1; PA ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) - Tier ICAR (brand for wee care) - Tier 2; PA 1 ICAR-C (brand for fe c tab) - Tier 2; PA ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1 ICAR-C PLUS (brand for iron 100 plus) - Tier 2; PA ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL INTEGRA - Tier 2; PA ferrous sulfate oral elixir - Tier 1 INTEGRA F - Tier 2; PA ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for BPROTECTED INTEGRA PLUS (brand for virt-fefa plus) - Tier 2; PA PEDIA IRON) - Tier 1; QL IROFOL - Tier 2; PA ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier iron 100/c (generic for ICAR-C) - Tier 1; PA 1; QL iron chews pediatric - Tier 1; PA ferrous sulfate oral tablet delayed release - Tier 1; QL iron oral tablet 200 (65 fe) mg (generic for FEOSOL) - Tier 1; PA fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL iron oral tablet 27 mg - Tier 1; PA fluoritab (generic for NAFRINSE DROPS) - Tier 1; QL iron oral tablet extended release 142 (45 fe) mg (generic for SLOW FE) - folic acid oral tablet 1 mg - Tier 1; QL Tier 1; PA folic acid oral tablet 400 mcg, 800 mcg - Tier 1 iron slow release oral tablet extended release 160 (50 fe) mg - Tier 1; PA foltrin (generic for TRICON) - Tier 1 IROSPAN 24/6 - Tier 2; PA GALZIN ORAL CAPSULE 25 MG - Tier 2 kelp oral tablet 0.15 mg - Tier 1; PA GALZIN ORAL CAPSULE 50 MG - Tier 2; QL K-MAG - Tier 2; PA hematinic/folic acid (generic for HEMOCYTE-F) - Tier 1 K-PHOS NO 2 - Tier 2; PA HEMATOGEN (brand for iron complex) - Tier 2 K-PHOS-NEUTRAL (brand for phosphorous) - Tier 2; PA; QL hemocyte-f (generic for HEMOCYTE-F) - Tier 1 K-TAB (brand for potassium chloride er) - Tier 2; PA; QL hi cal (generic for RA HI CAL) - Tier 1; QL k-tan plus (generic for K-TAN PLUS) - Tier 1; PA iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1 levocarnitine oral solution (generic for CARNITOR) - Tier 1; PA; QL iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 levocarnitine oral tablet (generic for CARNITOR) - Tier 1; PA iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL levocarnitine sf (generic for CARNITOR) - Tier 1; PA; QL iron supplement - Tier 1 liquid calcium with d3 oral capsule 600-500 mg-unit - Tier 1; PA iron supplement childrens (generic for BPROTECTED PEDIA IRON) - liquid calcium/vitamin d - Tier 1; PA Tier 1; QL m2 magnesium - Tier 1; PA klor-con (generic for KLOR-CON) - Tier 1; QL MAG-200 (brand for kp mag-oxide magnesium) - Tier 2; PA klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL mag-g - Tier 1; PA klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL MAGNEBIND 300 - Tier 2; PA

88 Preferred Agents Non-Preferred Agents KLOR-CON M15 - Tier 2; QL magnesium lactate (generic for MAG-TAB SR) - Tier 1; PA klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL magnesium oral capsule 300 mg, 500 mg - Tier 1; PA klor-con/ef - Tier 1; QL magnesium oral tablet 250 mg, 30 mg - Tier 1; PA K-PHOS - Tier 2; QL MAGONATE - Tier 2; PA k-prime - Tier 1; QL mag-oxide (generic for MAG-OXIDE) - Tier 1; PA magnesium chloride oral tablet delayed release (generic for MAG64) - mag-oxide magnesium (generic for MAG-OXIDE) - Tier 1; PA Tier 1; QL MAG-TAB SR (brand for magnesium lactate) - Tier 2; PA magnesium oral tablet 500 mg - Tier 1 MONOCAL - Tier 2; PA magnesium oxide oral tablet 400 (241.3 mg) mg (generic for MULTIGEN - Tier 2; PA MAGNESIUM-OXIDE) - Tier 1 MULTIGEN FOLIC - Tier 2; PA magnesium oxide oral tablet 500 mg - Tier 1 MULTIGEN PLUS - Tier 2; PA magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 natural magnesium - Tier 1; PA myferon 150 (generic for FERREX 150) - Tier 1 NIFEREX (brand for corvite fe) - Tier 2; PA myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 NUFERA (brand for corvite fe) - Tier 2; PA nafrinse (generic for NAFRINSE) - Tier 1; QL NU-MAG - Tier 2; PA nafrinse drops (generic for NAFRINSE DROPS) - Tier 1; QL ORACIT - Tier 2; PA NU-IRON (brand for ferric x-150) - Tier 2 ORAZINC ORAL TABLET - Tier 2; PA oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; OS-CAL - Tier 2; PA QL OS-CAL EXTRA D3 (brand for calcium extra d3) - Tier 2; PA OS-CAL CALCIUM + D3 (brand for oyster shell calcium + d) - Tier 2; QL OS-CAL ULTRA - Tier 2; PA oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium + d oral tablet 500-400 mg-unit (generic for oyster shell calcium 500 + d - Tier 1; QL OYSTERCAL-D) - Tier 1; PA oyster shell calcium oral tablet 500 mg (generic for OYSTERCAL) - Tier oyster shell calcium + d3 (generic for OYSTERCAL-D) - Tier 1; PA 1; QL oyster shell calcium/vit d3 (generic for OYSTERCAL-D) - Tier 1; PA oyster shell calcium plus d oral tablet 500-200 mg-unit (generic for PHOS-NAK - Tier 2; PA OYSCO 500+D) - Tier 1; QL phosphorus supplement - Tier 1; PA oyster shell calcium/d oral tablet 250-125 mg-unit - Tier 1; QL phosphorus w/sod & potassium - Tier 1; PA oyster shell calcium/d oral tablet 250-250 mg-unit, 500-400 mg-unit - PHOXILLUM B22K4/0 - Tier 2; PA Tier 1 PHOXILLUM BK4/2.5 - Tier 2; PA oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2; PA CAL) - Tier 1; QL PROFERRIN ES - Tier 2; PA; QL oyster shell calcium/vit d - Tier 1 purevit dualfe plus (generic for K-TAN PLUS) - Tier 1; PA oyster shell calcium/vitamin d oral tablet (generic for OYSCO 500+D) - risacal-d - Tier 1; PA Tier 1; QL se-tan plus (generic for K-TAN PLUS) - Tier 1; PA

89 Preferred Agents Non-Preferred Agents ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - SLOW FE (brand for iron slow release) - Tier 2; PA Tier 1; QL slow release iron oral tablet extended release 143 (45 fe) mg - Tier 1; PA ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - SLOW-MAG - Tier 2; PA Tier 1; QL SLOWMAG MG MUSCLE/HEART - Tier 2; PA PEDIALYTE FREEZER POPS (brand for pediatric electrolyte) - Tier 2; sodium chloride oral solution 4 meq/ml - Tier 1; PA QL sodium chloride oral tablet 1 gm - Tier 1; PA PEDIALYTE ORAL SOLUTION (brand for pediatric electrolyte) - Tier 2; sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1; PA QL soluvita e (generic for SOLUVITA E) - Tier 1; PA PEDIALYTE SINGLES (brand for pediatric electrolyte) - Tier 2; QL tl-hem 150 (generic for ABATRON AF) - Tier 1; PA pediatric electrolyte oral solution (generic for ORALYTE FREEZER UROCIT-K 10 (brand for potassium citrate er) - Tier 2; PA; QL POPS) - Tier 1; QL UROCIT-K 15 (brand for potassium citrate er) - Tier 2; PA PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL UROCIT-K 5 (brand for potassium citrate er) - Tier 2; PA phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL VIRT-FEFA PLUS - Tier 2; PA phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - vitamin e oral solution 15 unit/0.3ml (generic for SOLUVITA E) - Tier 1; PA Tier 1; QL wee care (generic for ICAR) - Tier 1; PA poly-iron 150 (generic for FERREX 150) - Tier 1 ZINC 15 - Tier 2; PA poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 zinc gluconate oral tablet 100 mg, 50 mg - Tier 1; PA polysaccharide iron complex (generic for FERREX 150) - Tier 1 zinc oral tablet 50 mg - Tier 1; PA polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1 zinc sulfate oral tablet 220 (50 zn) mg - Tier 1; PA polysaccharide-iron complex (generic for FERREX 150) - Tier 1 zn-50 - Tier 1; PA potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL potassium chloride er (generic for KLOR-CON 10) - Tier 1; QL potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) - Tier 1; QL potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL potassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1 potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 potassium citrate-citric acid - Tier 1 PROFE - Tier 2 REHYDRALYTE (brand for pediatric electrolyte) - Tier 2; QL

90 Preferred Agents Non-Preferred Agents sod citrate-citric acid - Tier 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1; QL sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1 sodium fluoride oral tablet 2.2 (1 f) mg - Tier 1; QL sodium fluoride oral tablet chewable - Tier 1; QL tricitrates - Tier 1 TRICON (brand for ferocon) - Tier 2 virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL WILZIN - Tier 2 zinc chelated oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL

Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2 deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL clovique (generic for CLOVIQUE) - Tier 1; SP; QL deferasirox oral packet (generic for JADENU SPRINKLE) - Tier 1; PA; SP; deferasirox oral tablet 360 mg, 90 mg (generic for JADENU) - Tier 1; QL SP; QL deferasirox oral tablet 180 mg (generic for JADENU) - Tier 1; PA; SP; QL deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; SP; QL deferiprone (generic for FERRIPROX) - Tier 1; PA; SP; QL FERRIPROX ORAL TABLET (brand for deferiprone) - Tier 2; SP; QL EXJADE (brand for deferasirox) - Tier 2; PA; SP; QL FERRIPROX TWICE-A-DAY - Tier 2; SP; QL FERRIPROX ORAL SOLUTION - Tier 2; PA; SP; QL sodium polystyrene sulfonate - Tier 1 JADENU (brand for deferasirox) - Tier 2; PA; SP; QL sps - Tier 1; QL JADENU SPRINKLE (brand for deferasirox granules) - Tier 2; PA; SP; QL trientine hcl (generic for CLOVIQUE) - Tier 1; SP; QL JYNARQUE ORAL TABLET (brand for tolvaptan) - Tier 2; PA; SP; QL JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG - Tier 2; PA; SP; QL JYNARQUE ORAL TABLET THERAPY PACK 30 & 15 MG - Tier 2; PA LOKELMA - Tier 2; PA; QL OVEEZA - Tier 2; PA SAMSCA (brand for tolvaptan) - Tier 2; PA; SP; QL SYPRINE (brand for trientine hcl) - Tier 2; PA; SP; QL TOLVAPTAN ORAL TABLET 15 MG - Tier 2; PA; SP; QL tolvaptan oral tablet 30 mg (generic for JYNARQUE) - Tier 1; PA; SP; QL

91 Preferred Agents Non-Preferred Agents VELTASSA - Tier 2; PA; QL

Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; QL AURYXIA - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; QL calcium acetate oral tablet 668 (169 ca) mg - Tier 1; PA PHOSLYRA - Tier 2; QL FOSRENOL (brand for lanthanum carbonate) - Tier 2; PA; QL sevelamer carbonate (generic for RENVELA) - Tier 1; QL lanthanum carbonate (generic for FOSRENOL) - Tier 1; PA; QL sevelamer hcl - Tier 1; QL RENAGEL (brand for sevelamer hcl) - Tier 2; PA; QL RENVELA (brand for sevelamer carbonate) - Tier 2; PA; QL VELPHORO - Tier 2; PA; QL

Vitamins a-25 - Tier 1; QL ABANEU-SL (brand for neurin-sl) - Tier 2; PA ACTIVITE - Tier 2; PA; QL ACEROLA C 500 - Tier 2; PA adc/f (0.5mg/ml) - Tier 1 ACTIFLOVIT EAR HEALTH (brand for nat-rul b-50) - Tier 2; PA advanced stress formula/zinc - Tier 1 ACTITROM (brand for grape seed) - Tier 2; PA airavite (generic for AIRAVITE) - Tier 1 ACTITROM-D (brand for grape seed) - Tier 2; PA animal shapes complete (generic for CEROVITE JR) - Tier 1; QL ADRENAL C FORMULA (brand for vitamin c/bioflavonoids) - Tier 2; PA animal shapes kids first (generic for DINO-LIFE) - Tier 1; QL airshield (generic for CVS AIRSHIELD) - Tier 1; PA; QL animal shapes/iron (generic for CEROVITE JR) - Tier 1; QL AIRSHIELD IMMUNITY SUPPORT (brand for womens multi gummies) - AQUADEKS - Tier 2; QL Tier 2; PA; QL aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1 algal-900 dha (generic for ALGAL-900 DHA) - Tier 1; PA ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL ANIMI-3 - Tier 2; PA ATABEX OB - Tier 2; QL ANIMI-3/VITAMIN D - Tier 2; PA b complex oral capsule - Tier 1; QL APETEX (brand for biopetit) - Tier 2; PA b complex vitamins - Tier 1; QL APETIGEN (brand for biopetit) - Tier 2; PA b complex-c oral capsule - Tier 1 APETIGEN-PLUS - Tier 2; PA b-1 - Tier 1; QL ascorbic acid oral powder - Tier 1; PA b6 - Tier 1; QL ATABEX EC - Tier 2; PA; QL b-complex oral tablet - Tier 1 b complex formula 1 - Tier 1; PA b-complex with b-12 - Tier 1 b complex plus c (generic for ALLBEE/C) - Tier 1; PA b-complex/b-12 oral - Tier 1 b complex-biotin-fa (generic for BIG 100) - Tier 1; PA

92 Preferred Agents Non-Preferred Agents biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b complex-folic acid - Tier 1; PA b-plex - Tier 1 b-100 complex cr (generic for ENDUR-B) - Tier 1; PA b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL b12 - Tier 1; PA BPROTECTED PEDIA D-VITE (brand for vitamin d infant) - Tier 2 b12 gummies - Tier 1; PA; QL BPROTECTED PEDIA POLY-VITE/FE (brand for poly-vitamin/iron) - b-12 mouth/throat lozenge 1000-400 mcg - Tier 1; PA Tier 2; QL b-12 oral liquid 1000 mcg/15ml - Tier 1; PA BPROTECTED VITAMIN C (brand for ascorbic acid) - Tier 2; QL b-12 oral tablet 1000 mcg, 500 mcg - Tier 1; PA c 250 oral tablet - Tier 1; QL b12 quick dissolve - Tier 1; PA c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL b-12 sublingual tablet sublingual 2500 mcg, 5000 mcg - Tier 1; PA c-1000/rose hips - Tier 1; QL B-2-400 - Tier 2; PA calcidol (generic for CALCIDOL) - Tier 1; QL b-6 folic acid - Tier 1; PA CENTRUM FLAVOR BURST KIDS (brand for disney princess gummies) BACMIN (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL - Tier 2; QL balance b-100 (generic for CVS BALANCED B50) - Tier 1; PA CENTRUM KIDS (brand for disney princess gummies) - Tier 2; QL balance b-50 (generic for BIG 100) - Tier 1; PA cerovite jr (generic for CEROVITE JR) - Tier 1; QL balanced b100 - Tier 1; PA chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL balanced b-100 cr (generic for ENDUR-B) - Tier 1; PA chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; balanced b-100 oral tablet - Tier 1; PA QL balanced b50 (generic for CVS BALANCED B50) - Tier 1; PA chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL balanced b-50 oral tablet (generic for BIG 100) - Tier 1; PA childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL balanced b-50 tr (generic for ENDUR-B) - Tier 1; PA childrens chewable vitamins (generic for DINO-LIFE) - Tier 1; QL b-complex/vitamin c cr - Tier 1; PA childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1; beta carotene oral capsule 15 mg, 25000 unit - Tier 1; PA QL bioflex (generic for ESTER-C) - Tier 1; PA childrens chewables/iron (generic for LAND BEFORE TIME biopetit (generic for APETEX) - Tier 1; PA MULTIVITAMIN) - Tier 1; QL biotin forte - Tier 1; PA childrens complete oral tablet chewable 18 mg (generic for CEROVITE biotin high potency - Tier 1; PA; QL JR) - Tier 1; QL biotin oral capsule 2500 mcg (generic for HARD NAILS) - Tier 1; PA childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; biotin oral capsule 5000 mcg (generic for MERIBIN) - Tier 1; PA QL biotin oral tablet 1000 mcg - Tier 1; PA; QL childrens vitamins/iron (generic for LAND BEFORE TIME biotin oral tablet 5 mg - Tier 1; PA MULTIVITAMIN) - Tier 1; QL bp vit 3 (generic for TALIVA) - Tier 1; PA classic prenatal - Tier 1; QL BPROTECTED PEDIA POLY-VITE (brand for poly-vite pediatric) - Tier 2; CO-NATAL FA (brand for prenatabs fa) - Tier 2; QL PA; QL cyanocobalamin injection solution 1000 mcg/ml - Tier 1 brewers yeast oral tablet 487.5 mg - Tier 1; PA

93 Preferred Agents Non-Preferred Agents d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1 b-stress - Tier 1; PA d 400 oral tablet - Tier 1; QL c 1000-bioflavonoids-rose hips (generic for ACTITROM) - Tier 1; PA d 400 oral tablet chewable (generic for HEALTHY KIDS VITAMIN D3) - c complex (generic for ESTER-C) - Tier 1; PA Tier 1 CADEAU DHA - Tier 2; PA d 5000 oral tablet (generic for RADIANCE PLATINUM VITAMIN D3) - CALCIFOL - Tier 2; PA Tier 1 calcium-folic acid plus d - Tier 1; PA d3 high potency oral capsule 25 mcg (1000 ut) (generic for CENFOL - Tier 2; PA PRONUTRIENTS VITAMIN D3) - Tier 1 CENTRUM FLAVOR BURST (brand for womens multi gummies) - Tier 2; d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; QL PA; QL d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D CENTRUM FLAVOR BURST ADULT (brand for womens multi gummies) - 5000) - Tier 1 Tier 2; PA; QL d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS CENTRUM FRESH/FRUITY 50+ (brand for womens multi gummies) - Tier VITAMIN D3) - Tier 1 2; PA; QL d3 super strength - Tier 1; QL CENTRUM MULTI + OMEGA 3 (brand for womens multi gummies) - Tier 2; d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 PA; QL d3-50 (generic for D3-50) - Tier 1; QL CENTRUM ORAL TABLET CHEWABLE (brand for womens multi daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - gummies) - Tier 2; PA; QL Tier 1 CENTRUM SILVER ORAL TABLET CHEWABLE (brand for womens multi daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA gummies) - Tier 2; PA; QL CAROTENE) - Tier 1; QL CENTRUM SPECIALIST PRENATAL - Tier 2; PA daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA CENTRUM VITAMINTS (brand for womens multi gummies) - Tier 2; PA; QL CAROTENE) - Tier 1; QL CEREFOLIN (brand for l-methyl-mc) - Tier 2; PA daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 cerefolin nac (generic for CEREFOLIN NAC) - Tier 1; PA; QL daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 chlorella - Tier 1; PA daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 CHOICEFUL MULTIVITAMIN ORAL TABLET CHEWABLE (brand for daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 womens multi gummies) - Tier 2; PA; QL DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3) - CHOLECAL DF - Tier 2; PA; QL Tier 2; QL CIFEREX (brand for ortho df) - Tier 2; PA DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for cvs vitamin CITRANATAL 90 DHA - Tier 2; PA; QL d3) - Tier 2 CITRANATAL ASSURE - Tier 2; PA; QL DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2 CITRANATAL B-CALM - Tier 2; PA DIALYVITE (brand for folika-nc) - Tier 2; PA; QL CITRANATAL BLOOM - Tier 2; PA DIALYVITE 800 ORAL TABLET (brand for rena-vite) - Tier 2; QL CITRANATAL BLOOM DHA - Tier 2; PA; QL DIALYVITE VITAMIN D 5000 (brand for ra vitamin d-3) - Tier 2 CITRANATAL DHA - Tier 2; PA; QL

94 Preferred Agents Non-Preferred Agents dino-life (generic for DINO-LIFE) - Tier 1; QL CITRANATAL HARMONY - Tier 2; PA dino-life w/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL CITRANATAL MEDLEY - Tier 2; PA; QL D-VI-SOL (brand for vitamin d infant) - Tier 2 CITRANATAL RX - Tier 2; PA; QL d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1 C-NATE DHA - Tier 2; PA e - Tier 1 cod liver oil oral capsule , 1250-133 unit, 1250-135 unit, 4000-200 unit - e-400-clear - Tier 1; QL Tier 1; PA ELDERTONIC (brand for senior tonic) - Tier 2 COD LIVER OIL ORAL OIL - Tier 2; PA ENFAMIL EXPECTA - Tier 2; QL complex b-100-inositol - Tier 1; PA ergocalciferol oral (generic for DRISDOL) - Tier 1; QL CONCEPT DHA (brand for virt-c dha) - Tier 2; PA essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 CONCEPT OB - Tier 2; PA essentials (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 crush vitamin c drops (generic for CRUSH VITAMIN C DROPS) - Tier 1; PA folbee (generic for AIRAVITE) - Tier 1 daflonex-xl (generic for ESTER-C) - Tier 1; PA fruity c - Tier 1; QL daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL daily gummies adult (generic for CVS AIRSHIELD) - Tier 1; PA; QL gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; DAYAVITE - Tier 2; PA; QL QL DERMACINRX ZINTREXYL-C (brand for gnp one daily mens/lycopene) - gummy multivitamin kids (generic for CENTRUM FLAVOR BURST Tier 2; PA; QL KIDS) - Tier 1; QL DEXIFOL (brand for folbee plus) - Tier 2; PA healthy hair/skin/nails (generic for TAB-A-VITE/BETA CAROTENE) - DIALYVITE 3000 - Tier 2; PA Tier 1 DIALYVITE 5000 - Tier 2; PA HYLAVITE - Tier 2 DIALYVITE 800/IRON - Tier 2; PA INATAL GT - Tier 2; QL DIALYVITE 800/ZINC - Tier 2; PA little ones childrens (generic for DINO-LIFE) - Tier 1; QL DIALYVITE 800-ZINC 15 - Tier 2; PA lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL DIALYVITE SUPREME D - Tier 2; PA M-NATAL PLUS - Tier 2; QL DIALYVITE/ZINC - Tier 2; PA multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DINO-LIFE W/IRON-ZINC - Tier 2; PA; QL multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DOC OMEGA - Tier 2; PA multiple vitamin-folic acid (generic for TAB-A-VITE/BETA CAROTENE) - DRISDOL (brand for ergocalciferol) - Tier 2; PA; QL Tier 1 DUET DHA BALANCED - Tier 2; PA multiple vitamins essential (generic for TAB-A-VITE/BETA CAROTENE) ecee plus - Tier 1; PA - Tier 1 effervescent formula (generic for GERM DEFENSE PM) - Tier 1; PA multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA ELFOLATE (brand for l-methylfolate) - Tier 2; PA CAROTENE) - Tier 1; QL ELFOLATE PLUS (brand for l-methylfolate-b6-b12) - Tier 2; PA MULTIPRO - Tier 2 ENBRACE HR - Tier 2; PA

95 Preferred Agents Non-Preferred Agents multi-vit/iron/fluoride - Tier 1; QL ERGOCAL - Tier 2; PA; QL multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 ester-c oral tablet (generic for ESTER-C) - Tier 1; PA multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL estro support es (generic for HCU EASY) - Tier 1; PA multivitamin/fluoride oral solution (generic for FLORIVA PLUS) - Tier 1; estro vital nutrients ex st (generic for HCU EASY) - Tier 1; PA QL fa-8 - Tier 1; PA multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg fabb (generic for VIRT-GARD) - Tier 1; PA (generic for QUFLORA PEDIATRIC) - Tier 1; QL fa-vitamin b-6-vitamin b-12 - Tier 1; PA multi-vitamin/fluoride/iron - Tier 1; QL flexgen (generic for ESTER-C) - Tier 1; PA multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - FLORIVA ORAL TABLET CHEWABLE - Tier 2; PA Tier 1; QL FLORIVA PLUS (brand for multivitamin/fluoride) - Tier 2; PA; QL mynephrocaps (generic for MYNEPHRON) - Tier 1 folbee plus (generic for DEXIFOL) - Tier 1; PA MYNEPHRON (brand for reno caps) - Tier 2 FOLBEE PLUS CZ - Tier 2; PA natural vitamin e - Tier 1; QL FOLBIC RF - Tier 2; PA NEOMULTIVITE (brand for daily vitamins) - Tier 2 FOLGARD OS - Tier 2; PA NEONATAL COMPLETE - Tier 2; QL FOLGARD RX (brand for fabb) - Tier 2; PA NEONATAL PLUS (brand for prenatal plus) - Tier 2; QL folic acid oral capsule 20 mg, 5 mg - Tier 1; PA NEONATAL VITAMIN (brand for prenatal one daily) - Tier 2; QL FOLIC D3 - Tier 2; PA nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL FOLIC-K - Tier 2; PA; QL NEPHRO-VITE (brand for rena-vite) - Tier 2; QL FOLI-D - Tier 2; PA niacin er oral capsule extended release 250 mg - Tier 1; QL FOLITE - Tier 2; PA; QL niacin er oral capsule extended release 500 mg - Tier 1 FOLITIN-Z (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL niacin er oral tablet extended release - Tier 1 FOLIXAPURE - Tier 2; PA; QL niacin oral tablet 100 mg, 250 mg, 50 mg - Tier 1 folplex 2.2 - Tier 1; PA NIVA-PLUS (brand for prenatal plus) - Tier 2; QL foltabs 800 - Tier 1; PA NOVAMV PEDIATRIC MULTI-VITAMIN - Tier 2; QL foltanx (generic for FOLTANX) - Tier 1; PA nufol (generic for AIRAVITE) - Tier 1 FOLTANX RF (brand for l-methylfolate-algae-b12-b6) - Tier 2; PA; QL nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL FOLTRATE (brand for vitamin b12-folic acid) - Tier 2; PA O-CAL PRENATAL - Tier 2; QL FOLTREXYL - Tier 2; PA; QL once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 FOLTX - Tier 2; PA one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 FOLVITE-D - Tier 2; PA; QL ONE VITE WOMENS - Tier 2; QL FOSTEUM - Tier 2; PA ONE VITE WOMENS PLUS - Tier 2; QL GENICIN VITA-D - Tier 2; PA; QL one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - GENICIN VITA-Q - Tier 2; PA Tier 1 geravine - Tier 1; PA

96 Preferred Agents Non-Preferred Agents one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA HARD NAILS (brand for ra biotin) - Tier 2; PA CAROTENE) - Tier 1 HCU EASY (brand for bladder 2.2) - Tier 2; PA one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA HONEY BEARS - Tier 2; PA; QL CAROTENE) - Tier 1; QL HONEY BEARS W/IRON-ZINC - Tier 2; PA; QL one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier inner ear plus (generic for CVS BALANCED B50) - Tier 1; PA 1; QL JENLIVA PRENATAL/POSTNATAL - Tier 2; PA pediavit - Tier 1; QL kosher prenatal plus iron - Tier 1; PA phytonadione oral (generic for MEPHYTON) - Tier 1; QL LEXINAL - Tier 2; PA pnv tabs 29-1 (generic for PRENATABS RX) - Tier 1; QL lipoflavovit (generic for CVS BALANCED B50) - Tier 1; PA PRENATABS RX (brand for thrivite rx) - Tier 2; QL l-methylfolate (generic for ELFOLATE) - Tier 1; PA prenatal formula oral tablet 28-0.8 mg - Tier 1; QL l-methylfolate ca me-cbl nac (generic for CEREFOLIN NAC) - Tier 1; PA; prenatal multi+dha - Tier 1; QL QL prenatal multivitamins - Tier 1; QL l-methylfolate calcium oral (generic for ELFOLATE) - Tier 1; PA prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier l-methylfolate-algae-b12-b6 (generic for FOLTANX RF) - Tier 1; PA; QL 1; QL l-methylfolate-b6-b12 (generic for FOLTANX) - Tier 1; PA prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; QL l-methyl-mc (generic for METAFOLBIC) - Tier 1; PA prenatal oral tablet 28-0.8 mg - Tier 1; QL l-methyl-mc nac (generic for METAFOLBIC PLUS) - Tier 1; PA prenatal plus iron (generic for PRENATABS RX) - Tier 1; QL LORID - Tier 2; PA; QL prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; mega multiple/chelated mineral (generic for CVS BALANCED B50) - Tier 1; QL PA prenatal vitamins oral tablet 28-0.8 mg - Tier 1; QL mens daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL prenatal/iron - Tier 1; QL MEPHYTON (brand for phytonadione) - Tier 2; PA; QL PRENATAL-U - Tier 2; QL MERIBIN (brand for biotin) - Tier 2; PA PRENATVITE RX - Tier 2; QL metafolbic (generic for METAFOLBIC) - Tier 1; PA preplus (generic for NEONATAL PLUS) - Tier 1; QL metafolbic plus (generic for METAFOLBIC PLUS) - Tier 1; PA PRETAB - Tier 2; QL METAFOLBIC PLUS RF (brand for l-methylfolate ca me-cbl nac) - Tier 2; PRONUTRIENTS VITAMIN D3 (brand for gnp d 1000) - Tier 2 PA; QL pyridoxine hcl oral - Tier 1; QL METANX (brand for l-methylfolate-algae-b12-b6) - Tier 2; PA; QL QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML (brand for multi- methylfol-algae-b12-acetylcyst (generic for CEREFOLIN NAC) - Tier 1; PA; vitamin/fluoride) - Tier 2; QL QL radiance platinum vitamin d3 (generic for RADIANCE PLATINUM MSUD EASY (brand for bladder 2.2) - Tier 2; PA VITAMIN D3) - Tier 1 multi-vitamin hp/minerals - Tier 1; PA RENAL (brand for reno caps) - Tier 2 MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 0.5- RENAL MULTIVITAMIN FORMULA (brand for rena-vite) - Tier 2; QL 0.3 MG, 1-0.3 MG - Tier 2; PA

97 Preferred Agents Non-Preferred Agents renal-vite (generic for DIALYVITE 800) - Tier 1; QL MYNATAL (brand for jenliva prenatal/postnatal) - Tier 2; PA rena-vite (generic for DIALYVITE 800) - Tier 1; QL MYNATAL PLUS - Tier 2; PA; QL senior tonic (generic for ELDERTONIC) - Tier 1 MYNATAL-Z - Tier 2; PA; QL SLO-NIACIN (brand for hm niacin) - Tier 2 n-acetyl-l-cysteine oral (generic for NF FORMULAS NAC) - Tier 1; PA stress formula - Tier 1 NAIL-EX - Tier 2; PA stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - NASCOBAL - Tier 2; PA; QL Tier 1; QL NATACHEW - Tier 2; PA stress formula/zinc - Tier 1 NATALVIT - Tier 2; PA super b/c - Tier 1 NEEVO DHA - Tier 2; PA tab-a-vite (generic for LYSIPLEX PLUS) - Tier 1 NEONATAL + DHA - Tier 2; PA; QL tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - NEONATAL 19 - Tier 2; PA; QL Tier 1 NEPHPLEX RX - Tier 2; PA tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier nephronex oral tablet (generic for NEPHRONEX) - Tier 1; PA; QL 1; QL NEPHRO-VITE RX (brand for folika-nc) - Tier 2; PA; QL thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 NESTABS - Tier 2; PA thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 NESTABS DHA - Tier 2; PA thiamine hcl oral - Tier 1; QL NESTABS ONE - Tier 2; PA; QL thiamine mononitrate oral - Tier 1; QL NEURIN-SL - Tier 2; PA THRIVITE RX - Tier 2; QL niacin flush free oral capsule 400-100 mg - Tier 1; PA TRINATE - Tier 2; QL NICOMIDE (brand for nicotinamide) - Tier 2; PA tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1; nicotinamide oral (generic for NICOMIDE) - Tier 1; PA QL no flush niacin oral capsule - Tier 1; PA tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QL NUTRICAP (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL tri-vite/fluoride oral solution 0.5 mg/ml - Tier 1 NUTRIVIT - Tier 2; PA v-c forte (generic for VIC-FORTE) - Tier 1 OB COMPLETE - Tier 2; PA vic-forte (generic for VIC-FORTE) - Tier 1 OB COMPLETE ONE - Tier 2; PA VINATE II - Tier 2; QL OB COMPLETE PETITE - Tier 2; PA VINATE ONE - Tier 2; QL OB COMPLETE PREMIER - Tier 2; PA virt-caps (generic for MYNEPHRON) - Tier 1 OB COMPLETE/DHA - Tier 2; PA vit c/rose hips - Tier 1; QL OBSTETRIX DHA - Tier 2; PA vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL OBSTETRIX EC - Tier 2; PA vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL OBSTETRIX ONE - Tier 2; PA vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST OBTREX - Tier 2; PA KIDS) - Tier 1; QL OCUVEL - Tier 2; PA

98 Preferred Agents Non-Preferred Agents VITAFOL FE+ - Tier 2; QL one daily womens health oral tablet (generic for HM VITA-MINI MULTI VITAL-D RX - Tier 2 COMPLETE) - Tier 1; PA vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1; QL ONEVITE - Tier 2; PA; QL vitamin b complex-c - Tier 1 ORTHO DF - Tier 2; PA vitamin b-1 oral tablet 100 mg, 250 mg - Tier 1; QL pantothenic acid - Tier 1; PA vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1 PERIDIN-C (brand for vitamin c/bioflavonoids) - Tier 2; PA vitamin b12 oral tablet extended release 1000 mcg - Tier 1 PERRY PRENATAL - Tier 2; PA vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1 PKU EASY (brand for bladder 2.2) - Tier 2; PA vitamin b-6 - Tier 1; QL PNV TABS 20-1 - Tier 2; PA; QL vitamin b-6 er - Tier 1; QL pnv-dha - Tier 1; PA vitamin c cr oral tablet extended release 500 mg (generic for ENDUR-C) pnv-dha+docusate - Tier 1; PA - Tier 1; QL pnv-omega - Tier 1; PA vitamin c er oral tablet extended release 1500 mg - Tier 1; QL pnv-select - Tier 1; PA vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN PODIAPN - Tier 2; PA C) - Tier 1; QL POLY-VI-FLOR ORAL SUSPENSION - Tier 2; PA vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG - Tier 2; PA; QL vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL POLY-VI-FLOR ORAL TABLET CHEWABLE 0.5 MG, 1 MG - Tier 2; PA vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; QL POLY-VI-FLOR/IRON - Tier 2; PA vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN POLY-VI-SOL (brand for poly-vite pediatric) - Tier 2; PA; QL C) - Tier 1; QL POLY-VITE PEDIATRIC - Tier 2; PA; QL vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL POTABA - Tier 2; PA vitamin c/rose hips oral tablet 1000 mg - Tier 1; QL PREGEN DHA - Tier 2; PA; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier PREGENNA - Tier 2; PA; QL 1; QL PREMESISRX - Tier 2; PA vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; QL PRENA 1 TRUE - Tier 2; PA; QL vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit) - Tier 1; QL PRENA1 - Tier 2; PA vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for PRENA1 PEARL - Tier 2; PA VITAMIN D-1000 MAX ST) - Tier 1 PRENAISSANCE - Tier 2; PA vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for PRENAISSANCE PLUS - Tier 2; PA DRISDOL) - Tier 1; QL prenatal 19 - Tier 1; PA; QL vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS prenatal gummy oral tablet chewable 0.4-113.5 mg - Tier 1; PA VITAMIN D3) - Tier 1 PRENATE - Tier 2; PA vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier 1 PRENATE AM - Tier 2; PA PRENATE DHA - Tier 2; PA

99 Preferred Agents Non-Preferred Agents vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 PRENATE ELITE - Tier 2; PA MAX ST) - Tier 1 PRENATE ENHANCE - Tier 2; PA vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier PRENATE ESSENTIAL - Tier 2; PA 1; QL PRENATE MINI - Tier 2; PA vitamin d oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY PRENATE PIXIE - Tier 2; PA KIDS VITAMIN D3) - Tier 1 PRENATE RESTORE - Tier 2; PA vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1; PRENATVITE COMPLETE - Tier 2; PA; QL QL PRENATVITE PLUS - Tier 2; PA; QL vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE PRIMACARE - Tier 2; PA; QL VITAMIN D 5000) - Tier 1 PRO HERS RX - Tier 2; PA vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE PRO HIS RX - Tier 2; PA VITAMIN D 5000) - Tier 1 PRO PCOS RX - Tier 2; PA vitamin d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS PRONUTRIENTS SUPER B COMPLEX - Tier 2; PA VITAMIN D3) - Tier 1 PROVIDA OB - Tier 2; PA vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier QUFLORA FE - Tier 2; PA 1 QUFLORA FE PEDIATRIC - Tier 2; PA; QL vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL QUFLORA GUMMIES - Tier 2; PA; QL vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML (brand for vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- multivitamin/fluoride) - Tier 2; PA; QL VITE) - Tier 1 QUFLORA PEDIATRIC ORAL TABLET CHEWABLE (brand for vitamin d3 oral liquid 125 mcg/ml - Tier 1 multivitamin + fluoride) - Tier 2; PA; QL vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; QL RELNATE DHA - Tier 2; PA vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE REMEDIENT - Tier 2; PA PLATINUM VITAMIN D3) - Tier 1 RENATABS - Tier 2; PA vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 RENATABS WITH IRON - Tier 2; PA MAX ST) - Tier 1 REQ 49+ (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 REVESTA - Tier 2; PA MAX ST) - Tier 1 risanoid plus (generic for CVS BALANCED B50) - Tier 1; PA vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG - Tier 2; PA Tier 1; QL SELECT-OB ORAL TABLET CHEWABLE 29-1 MG - Tier 2; PA; QL vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY SELECT-OB+DHA - Tier 2; PA KIDS VITAMIN D3) - Tier 1 SE-NATAL 19 - Tier 2; PA; QL vitamin d3 oral tablet chewable 25 mcg, 25 mcg (1000 ut) (generic for spectravite adult 50+ oral tablet chewable (generic for CVS AIRSHIELD) - KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1 Tier 1; PA; QL

100 Preferred Agents Non-Preferred Agents vitamin d-400 - Tier 1; QL spectravite women (generic for CVS AIRSHIELD) - Tier 1; PA; QL vitamin e natural - Tier 1 STROVITE FORTE ORAL SYRUP - Tier 2; PA vitamin e oral capsule 100 unit, 1000 unit, 200 unit, 450 mg - Tier 1 STROVITE FORTE ORAL TABLET (brand for gnp one daily vitamin e oral capsule 400 unit - Tier 1; QL mens/lycopene) - Tier 2; PA; QL vitamin-b complex - Tier 1 STROVITE ONE (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL vitamins acd-fluoride - Tier 1; QL STUART ONE - Tier 2; PA vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL super b complex/c (generic for ALLBEE/C) - Tier 1; PA VITATHELY WITH GINGER (brand for prenatal plus) - Tier 2; QL super b complex/vitamin c (generic for ALLBEE/C) - Tier 1; PA vp-vite rx (generic for NEPHRONEX) - Tier 1; PA; QL SUPER B-50 B COMPLEX (brand for super b-complex) - Tier 2; PA weekly-d (generic for D3-50) - Tier 1; QL SUPERVITE - Tier 2; PA westab one (generic for AIRAVITE) - Tier 1 SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE (brand for WESTAB PLUS - Tier 2; QL womens multi gummies) - Tier 2; PA; QL WEST-VITE W/FOLIC ACID - Tier 2; QL TALIVA (brand for bp vit 3) - Tier 2; PA womens prenatal+dha - Tier 1; QL TARON-PREX - Tier 2; PA zoo friends (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; QL THRIVITE 19 - Tier 2; PA; QL zoo friends complete (generic for CENTRUM FLAVOR BURST KIDS) - totalday multiple (generic for ENDUR-VM) - Tier 1; PA Tier 1; QL TRICARE PRENATAL DHA ONE - Tier 2; PA zoo friends gummies (generic for CENTRUM FLAVOR BURST KIDS) - TRISTART DHA - Tier 2; PA Tier 1; QL TRISTART FREE - Tier 2; PA; QL zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; TRISTART ONE - Tier 2; PA; QL QL TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (brand for tri-vi-floro) - Tier zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) 2; PA; QL - Tier 1; QL TRI-VI-FLOR ORAL SUSPENSION 0.5 MG/ML (brand for tri-vi-floro) - Tier ZYVANA - Tier 2 2; PA TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML - Tier 2; PA; QL TRI-VI-FLORO ORAL SUSPENSION 0.5 MG/ML - Tier 2; PA TROMBONEX (brand for grape seed) - Tier 2; PA TROMBONEX-D (brand for grape seed) - Tier 2; PA TYR EASY (brand for bladder 2.2) - Tier 2; PA UDAMIN SP (brand for onevite) - Tier 2; PA; QL ultra energy (generic for HCU EASY) - Tier 1; PA ultra-mega (generic for ENDUR-VM) - Tier 1; PA urosex (generic for ALLERWELL ALLERGY FORMULA) - Tier 1; PA vasoflex forte (generic for ACTITROM) - Tier 1; PA

101 Preferred Agents Non-Preferred Agents vasoflex hd (generic for ESTER-C) - Tier 1; PA VASOFLEX ORAL CAPSULE (brand for grape seed) - Tier 2; PA vasoflex oral tablet (generic for ESTER-C) - Tier 1; PA VENEXA (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VENEXA FE (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VINATE DHA RF - Tier 2; PA virt-c dha (generic for CONCEPT DHA) - Tier 1; PA virt-gard (generic for VIRT-GARD) - Tier 1; PA virt-nate dha (generic for VIVA DHA) - Tier 1; PA virt-pn dha - Tier 1; PA virt-pn plus - Tier 1; PA VITAFOL GUMMIES - Tier 2; PA VITAFOL STRIPS - Tier 2; PA; QL VITAFOL ULTRA - Tier 2; PA VITAFOL-NANO - Tier 2; PA VITAFOL-OB (brand for mynatal-z) - Tier 2; PA; QL VITAFOL-OB+DHA - Tier 2; PA; QL VITAFOL-ONE - Tier 2; PA VITAMEDMD ONE RX/QUATREFOLIC - Tier 2; PA VITAMEDMD REDICHEW RX (brand for prena1) - Tier 2; PA VITAMEZ (brand for bp vit 3) - Tier 2; PA VITAMIN A FISH - Tier 2; PA vitamin b-12 oral liquid 1000 mcg/ml - Tier 1; PA vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg - Tier 1; PA vitamin b12 oral tablet 1000 mcg - Tier 1; PA vitamin b12 oral tablet extended release 2000 mcg - Tier 1; PA vitamin b-12 oral tablet extended release 2000 mcg - Tier 1; PA vitamin b12 sublingual liquid 3000 mcg/ml - Tier 1; PA vitamin b-12 sublingual tablet sublingual 2500 mcg, 5000 mcg - Tier 1; PA vitamin b-2 oral tablet 100 mg, 25 mg - Tier 1; PA vitamin c cr oral tablet extended release (generic for ESTER-C) - Tier 1; PA vitamin c drops mouth/throat lozenge 60 mg (generic for CRUSH VITAMIN C DROPS) - Tier 1; PA

102 Preferred Agents Non-Preferred Agents vitamin c er oral capsule extended release - Tier 1; PA vitamin c/bioflavonoids (generic for ESTER-C) - Tier 1; PA vitamin k (phytonadione) - Tier 1; PA; QL VITAPEARL (brand for prena1 pearl) - Tier 2; PA VITAROCA PLUS (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VITA-RX DIABETIC VITAMIN - Tier 2; PA VITASURE - Tier 2; PA; QL VITATRUE (brand for prena 1 true) - Tier 2; PA; QL VITRANOL FE (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VITREXYL (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VITREXYL + IRON (brand for gnp one daily mens/lycopene) - Tier 2; PA; QL VIVA DHA (brand for virt-nate dha) - Tier 2; PA vp-pnv-dha - Tier 1; PA westab max (generic for FOLBIC) - Tier 1; PA westab mini (generic for VIRT-GARD) - Tier 1; PA WESTGEL DHA - Tier 2; PA WHEAT GERM OIL - Tier 2; PA womens daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL XAQUIL XR - Tier 2; PA XVITE - Tier 2; PA; QL ZE-PLUS (brand for multivitamins) - Tier 2; PA zinc oral lozenge - Tier 1; PA

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs belladonna alkaloids-opium - Tier 1; QL ANASPAZ (brand for ed-spaz) - Tier 2; PA; QL dicyclomine hcl oral capsule - Tier 1; QL chlordiazepoxide-clidinium (generic for LIBRAX) - Tier 1; PA; QL dicyclomine hcl oral solution - Tier 1 CUVPOSA - Tier 2; PA; QL dicyclomine hcl oral tablet - Tier 1; QL DONNATAL (brand for phenobarbital-belladonna alk) - Tier 2; PA ED-SPAZ - Tier 2; QL GLYCATE (brand for glycopyrrolate) - Tier 2; PA glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 GLYCOPYRROLATE ORAL TABLET 1.5 MG - Tier 2; PA

103 Preferred Agents Non-Preferred Agents hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL LEVSIN ORAL (brand for hyoscyamine sulfate) - Tier 2; PA; QL hyoscyamine sulfate oral - Tier 1; QL LEVSIN/SL (brand for hyoscyamine sulfate sl) - Tier 2; PA; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL LIBRAX (brand for chlordiazepoxide-clidinium) - Tier 2; PA; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL pb-hyoscy-atropine-scopolamine (generic for DONNATAL) - Tier 1; PA hyosyne - Tier 1; QL phenobarbital-belladonna alk (generic for DONNATAL) - Tier 1; PA LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL PHENOHYTRO (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA methscopolamine bromide oral - Tier 1 SYMAX DUOTAB - Tier 2; PA NULEV (brand for ed-spaz) - Tier 2; QL SYMAX-SL (brand for hyoscyamine sulfate sl) - Tier 2; PA; QL oscimin (generic for LEVSIN) - Tier 1; QL oscimin sr (generic for LEVBID) - Tier 1; QL SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex (generic for ABATINEX) - Tier 1 alvimopan (generic for ENTEREG) - Tier 1; PA acid gone (generic for ACID GONE) - Tier 1 amoxicill-clarithro-lansopraz - Tier 1; PA; QL acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1 antacid antigas multi-sympt - Tier 1; PA acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1 antacid multi-symptom oral tablet chewable 675-135-60 mg - Tier 1; PA acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier anti-diarrheal oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1; PA 1 CHENODAL - Tier 2; PA; SP; QL acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) - Tier dairy aid (generic for LACTAID) - Tier 1; PA 1 dairy relief ex st - Tier 1; PA acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1 dairy relief fast acting oral tablet 9000 unit (generic for LACTAID FAST ACTIPHLORA (brand for probiomax daily df) - Tier 2; QL ACT) - Tier 1; PA adult 50+ probiotic (generic for ACTIPHLORA) - Tier 1; QL dairy relief oral tablet 3000 unit (generic for LACTAID) - Tier 1; PA adult probiotic (generic for ACTIPHLORA) - Tier 1; QL ENTEREG (brand for alvimopan) - Tier 2; PA advanced antacid max st (generic for ALMACONE DOUBLE ENZADYNE - Tier 2; PA STRENGTH) - Tier 1; QL GASTROCROM (brand for cromolyn sodium) - Tier 2; PA; QL almacone double strength (generic for ALMACONE DOUBLE GATTEX - Tier 2; PA; SP; QL STRENGTH) - Tier 1; QL HELIDAC THERAPY - Tier 2; PA alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL IMODIUM A-D ORAL LIQUID (brand for loperamide hcl) - Tier 2; PA alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL LACTAID (brand for ra dairy aid) - Tier 2; PA

104 Preferred Agents Non-Preferred Agents antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for LACTAID FAST ACT ORAL TABLET (brand for eq dairy digestive fast MINTOX) - Tier 1; QL acting) - Tier 2; PA antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for lactase enzyme (generic for LACTAID) - Tier 1; PA ALMACONE DOUBLE STRENGTH) - Tier 1; QL lactase enzyme ultra str (generic for LACTAID FAST ACT) - Tier 1; PA antacid & gas relief (generic for MINTOX) - Tier 1; QL lactase fast acting (generic for LACTAID FAST ACT) - Tier 1; PA antacid advanced (generic for MINTOX) - Tier 1; QL lactose fast acting relief oral tablet (generic for LACTAID FAST ACT) - Tier antacid advanced max st (generic for ALMACONE DOUBLE 1; PA STRENGTH) - Tier 1; QL LOMOTIL (brand for diphenoxylate-atropine) - Tier 2; PA; QL antacid anti-gas (generic for MINTOX) - Tier 1; QL loperamide hcl oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1; antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for PA ALMACONE DOUBLE STRENGTH) - Tier 1; QL loperamide hcl oral suspension 1 mg/7.5ml (generic for IMODIUM A-D) - antacid anti-gas max strength (generic for ALMACONE DOUBLE Tier 1; PA STRENGTH) - Tier 1; QL metoclopramide hcl oral tablet dispersible 5 mg - Tier 1; PA; QL antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL MOTEGRITY - Tier 2; PA; QL antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 MYALEPT - Tier 2; PA; SP; *; QL antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 MYTESI - Tier 2; PA; QL antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier OCALIVA - Tier 2; PA; SP; QL 1 OMECLAMOX-PAK - Tier 2; PA antacid extra strength oral suspension (generic for ALMACONE opium - Tier 1; PA; QL DOUBLE STRENGTH) - Tier 1; QL PYLERA - Tier 2; PA antacid extra strength oral tablet chewable 160-105 mg (generic for REGLAN (brand for metoclopramide hcl) - Tier 2; PA; QL ACID GONE) - Tier 1 RELISTOR - Tier 2; PA; QL antacid extra strength oral tablet chewable 750 mg (generic for CVS RELTONE - Tier 2; PA; QL CHEWY NOT CHALKY FLAVOR) - Tier 1 RESTORA RX - Tier 2; PA antacid fast relief (generic for MINTOX) - Tier 1; QL SEROSTIM - Tier 2; PA; SP; QL antacid i (generic for MINTOX) - Tier 1; QL SODIUM BICARBONATE ORAL POWDER - Tier 2; PA antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL surelac (generic for LACTAID) - Tier 1; PA antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 SYMPROIC - Tier 2; PA; QL antacid liquid (generic for MINTOX) - Tier 1; QL TITRALAC - Tier 2; PA antacid m (generic for MINTOX) - Tier 1; QL TRULANCE - Tier 2; PA; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 ultra dairy digestive (generic for LACTAID FAST ACT) - Tier 1; PA antacid maximum strength (generic for ALMACONE DOUBLE URSO 250 (brand for ursodiol) - Tier 2; PA STRENGTH) - Tier 1; QL URSO FORTE (brand for ursodiol) - Tier 2; PA XERMELO - Tier 2; PA; SP; QL

105 Preferred Agents Non-Preferred Agents antacid maximum strength oral tablet chewable 1000 mg (generic for ZELNORM - Tier 2; PA; QL TUMS ULTRA 1000) - Tier 1 ZORBTIVE - Tier 2; PA; SP; QL antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1; QL antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid regular strength oral suspension (generic for MINTOX) - Tier 1; QL antacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 antacid supreme - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1

106 Preferred Agents Non-Preferred Agents anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1 anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 BACICAP - Tier 2; QL biotinex (generic for ABATINEX) - Tier 1 bismatrol maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL bismuth (generic for SOOTHE) - Tier 1; QL bismuth subsalicylate oral suspension (generic for SOOTHE) - Tier 1 bismuth subsalicylate oral tablet chewable (generic for SOOTHE) - Tier 1; QL calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium carbonate antacid oral suspension - Tier 1; QL calcium carbonate antacid oral tablet - Tier 1 calcium carbonate antacid oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 calcium carbonate oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 childrens soothe - Tier 1 comfort gel (generic for MINTOX) - Tier 1; QL comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL cromolyn sodium oral (generic for GASTROCROM) - Tier 1; QL DERMACINRX PROBITRAN (brand for probiomax daily df) - Tier 2; QL

107 Preferred Agents Non-Preferred Agents diamode (generic for IMODIUM A-D) - Tier 1 diarrhea (generic for SOOTHE) - Tier 1 diarrhea relief (generic for SOOTHE) - Tier 1 digestive probiotic oral capsule (generic for ACTIPHLORA) - Tier 1; QL digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 diotame instydose (generic for SOOTHE) - Tier 1 diphenoxylate-atropine oral liquid - Tier 1 diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1; QL floranex tablet oral (generic for FLORANEX) - Tier 1 FLORANEX TABLET ORAL (brand for cvs acidophilus probiotic) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1 gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension 20 mg/0.3ml (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral tablet chewable 80 mg - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for px gas relief extra strength) - Tier 2

108 Preferred Agents Non-Preferred Agents GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for simethicone) - Tier 2 GAS-X ULTRA STRENGTH (brand for px gas relief ultra strength) - Tier 2 GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for antacid extra strength) - Tier 2 GAVISCON ORAL SUSPENSION - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1; QL geri-lanta supreme - Tier 1 geri-mox (generic for MINTOX) - Tier 1; QL geri-pectate (generic for SOOTHE) - Tier 1 heartburn antacid (generic for ACID GONE) - Tier 1 heartburn antacid ex st (generic for ACID GONE) - Tier 1 heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1 heartburn relief oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 high potency probiotic (generic for ACTIPHLORA) - Tier 1; QL IMODIUM A-D ORAL TABLET (brand for cvs anti-diarrheal) - Tier 2 IMODIUM MULTI-SYMPTOM RELIEF (brand for hm anti-diarrheal anti- gas) - Tier 2 infant gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants simethicone (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 lactobacillus oral tablet (generic for FLORANEX) - Tier 1 lacto-pectin (generic for ACTIPHLORA) - Tier 1; QL long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1

109 Preferred Agents Non-Preferred Agents MAALOX - Tier 2 MAALOX CHILDRENS (brand for childrens pepto) - Tier 2 MAALOX MAX ORAL SUSPENSION (brand for antacid advanced) - Tier 2; QL MAALOX MULTI SYMPTOM MAX ST (brand for antacid advanced) - Tier 2; QL mag-al plus (generic for MINTOX) - Tier 1; QL mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL magnesium oxide oral tablet 400 mg - Tier 1 magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1 MAOX (brand for magnesium oxide) - Tier 2 mega probiotic (generic for ACTIPHLORA) - Tier 1; QL meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1 metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL mi-acid gas relief - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mintox plus - Tier 1 mood support probiotic (generic for ACTIPHLORA) - Tier 1; QL MOTOFEN - Tier 2; QL MOVANTIK - Tier 2; ST; QL peptic relief (generic for SOOTHE) - Tier 1; QL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for cvs stomach relief) - Tier 2 PHAZYME (brand for simethicone) - Tier 2 PHAZYME ULTRA STRENGTH (brand for px gas relief ultra strength) - Tier 2 pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1

110 Preferred Agents Non-Preferred Agents pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1 pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL pink-bismuth (generic for SOOTHE) - Tier 1; QL pro-biotic blend (generic for ACTIPHLORA) - Tier 1; QL probiotic colon care (generic for ACTIPHLORA) - Tier 1; QL probiotic complex (generic for ACTIPHLORA) - Tier 1; QL probiotic maximum strength (generic for ACTIPHLORA) - Tier 1; QL probiotic oral capsule (generic for ACTIPHLORA) - Tier 1; QL probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 probiotic pearls ex st (generic for ACTIPHLORA) - Tier 1; QL PRODIGEN - Tier 2; QL PROVAD - Tier 2; QL quad-probiotic (generic for ACTIPHLORA) - Tier 1; QL RESTORA (brand for probiomax daily df) - Tier 2; QL RISAQUAD (brand for probiomax daily df) - Tier 2; QL RISAQUAD-2 (brand for probiomax daily df) - Tier 2; QL saccharomyces boulardii (generic for FLORASTOR) - Tier 1 senior probiotic (generic for ACTIPHLORA) - Tier 1; QL simeped (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 simethicone oral (generic for GAS-X EXTRA STRENGTH) - Tier 1 simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 smooth antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sodium bicarbonate oral tablet - Tier 1 soothe maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 soothe oral suspension (generic for SOOTHE) - Tier 1 soothe oral tablet (generic for SOOTHE) - Tier 1 soothe oral tablet chewable (generic for SOOTHE) - Tier 1; QL

111 Preferred Agents Non-Preferred Agents stomach relief extra strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max st oral suspension 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527 mg/30ml (generic for SOOTHE) - Tier 1 stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1 stomach relief oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 TUMS (brand for px calcium antacid) - Tier 2 TUMS CHEWY BITES (brand for antacid extra strength) - Tier 2 TUMS E-X 750 (brand for antacid extra strength) - Tier 2 TUMS EXTRA STRENGTH 750 (brand for antacid extra strength) - Tier 2 TUMS LASTING EFFECTS (brand for px calcium antacid) - Tier 2 TUMS SMOOTHIES (brand for antacid extra strength) - Tier 2 TUMS ULTRA 1000 (brand for qc antacid ultra strength) - Tier 2 ursodiol oral capsule - Tier 1; QL ursodiol oral tablet (generic for URSO 250) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for probiomax daily df) - Tier 2; QL womens 50 billion (generic for ACTIPHLORA) - Tier 1; QL ZELAC - Tier 2; QL

112 Preferred Agents Non-Preferred Agents Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1; QL nizatidine - Tier 1; PA; QL acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL PEPCID (brand for sb acid controller max st) - Tier 2; PA; QL acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL cimetidine hcl - Tier 1; QL cimetidine oral (generic for TAGAMET HB) - Tier 1; QL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL famotidine oral tablet 20 mg, 40 mg (generic for PEPCID) - Tier 1; QL famotidine orig st (generic for PEPCID AC) - Tier 1; QL heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs AMITIZA (brand for lubiprostone) - Tier 2; ST; QL alosetron hcl (generic for LOTRONEX) - Tier 1; PA; QL LINZESS ORAL CAPSULE 145 MCG, 290 MCG - Tier 2; ST; QL LINZESS ORAL CAPSULE 72 MCG - Tier 2; PA; QL LOTRONEX (brand for alosetron hcl) - Tier 2; PA; QL LUBIPROSTONE - Tier 2; PA; ST; QL TALICIA - Tier 2; PA VIBERZI - Tier 2; PA; QL XIFAXAN ORAL TABLET 200 MG - Tier 2; PA XIFAXAN ORAL TABLET 550 MG - Tier 2; PA; QL

Laxatives - Drugs to treat Constipation bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1 cascara sagrada oral fluid extract - Tier 1; PA bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1; QL chocolate laxative pieces (generic for EX-LAX) - Tier 1; PA bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL chocolated laxative (generic for EX-LAX) - Tier 1; PA citrate of magnesia (generic for CITROMA) - Tier 1; QL CLENPIQ - Tier 2; PA; QL

113 Preferred Agents Non-Preferred Agents citroma (generic for CITROMA) - Tier 1; QL EX-LAX (brand for chocolated laxative) - Tier 2; PA CITRUCEL - Tier 2 gavilyte-c - Tier 1; PA c-lax laxative (generic for EX-LAX ULTRA) - Tier 1 GIALAX - Tier 2; PA clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL GOLYTELY (brand for peg-3350/electrolytes) - Tier 2; PA; QL COLACE (brand for gnp stool softener) - Tier 2; QL KRISTALOSE (brand for lactulose) - Tier 2; PA; QL col-rite oral capsule 250 mg - Tier 1; QL lactulose oral packet (generic for KRISTALOSE) - Tier 1; PA; QL constulose - Tier 1; QL laxative oral tablet chewable 15 mg (generic for EX-LAX) - Tier 1; PA daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL docu (generic for DOCU LIQUID) - Tier 1; QL NULYTELY LEMON-LIME (brand for peg 3350-kcl-na bicarb-nacl) - Tier 2; docu liquid (generic for DOCU LIQUID) - Tier 1; QL PA; QL docusate calcium (generic for SURFAK) - Tier 1 OSMOPREP - Tier 2; PA; QL docusate mini (generic for DOCUSOL MINI) - Tier 1; QL PCP 100 - Tier 2; PA docusate sodium oral capsule (generic for DOK) - Tier 1; QL peg-3350/electrolytes/ascorbat (generic for MOVIPREP) - Tier 1; PA; QL docusate sodium oral liquid 50 mg/5ml (generic for DOCU LIQUID) - peg-kcl-nacl-nasulf-na asc-c (generic for MOVIPREP) - Tier 1; PA; QL Tier 1; QL peg-prep - Tier 1; PA docusate sodium oral syrup - Tier 1 PLENVU - Tier 2; PA; QL docusate sodium oral tablet (generic for DOK) - Tier 1 senna oral capsule - Tier 1; PA DOCUSOL MINI (brand for docusate mini) - Tier 2; QL senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1; PA docuzen (generic for SENEXON-S) - Tier 1 SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2; PA dok oral capsule (generic for DOK) - Tier 1; QL SUPREP BOWEL PREP KIT - Tier 2; PA; QL dok oral tablet (generic for DOK) - Tier 1 dss (generic for DOK) - Tier 1; QL easy-lax plus (generic for SENEXON-S) - Tier 1 enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema , 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL enulose - Tier 1; QL EVAC (brand for cvs natural fiber supplement) - Tier 2 EX-LAX ULTRA (brand for cvs gentle laxative womens) - Tier 2 fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL

114 Preferred Agents Non-Preferred Agents fiber laxative - Tier 1 fiber laxative + calcium - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber oral powder 30.9 % - Tier 1 fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 625 mg - Tier 1 fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 625 mg - Tier 1 fiber-caps - Tier 1 FIBERCON ORAL TABLET 625 MG (brand for cvs fiber laxative) - Tier 2 fiber-lax - Tier 1 FLEET BISACODYL - Tier 2; QL FLEET ENEMA (brand for qc enema) - Tier 2 FLEET OIL (brand for enema mineral oil) - Tier 2 FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; QL gavilyte-g (generic for GAVILYTE-G) - Tier 1; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL generlac - Tier 1; QL gentle laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) - Tier 1 gentle laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1; QL gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1

115 Preferred Agents Non-Preferred Agents gentlelax (generic for CLEARLAX) - Tier 1; QL geri-kot (generic for SENOKOT) - Tier 1 glycerin (adult) rectal suppository 2 gm - Tier 1 glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA- LAX) - Tier 1 glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin adult rectal suppository 2 gm - Tier 1 glycerin child rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin child rectal suppository 1.2 gm - Tier 1 glycerin childrens (generic for PEDIA-LAX) - Tier 1 glycerin pediatric rectal suppository 1.2 gm - Tier 1 glycolax (generic for CLEARLAX) - Tier 1; QL KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL lactulose encephalopathy - Tier 1; QL lactulose oral solution - Tier 1; QL laxacin (generic for SENEXON-S) - Tier 1 laxaclear (generic for CLEARLAX) - Tier 1; QL laxative max str - Tier 1 laxative maximum strength oral tablet 25 mg - Tier 1 laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA) - Tier 1 laxative pills (generic for SENNA SMOOTH) - Tier 1 laxative pills max st - Tier 1 laxative pills oral tablet 25 mg - Tier 1 laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1; QL laxative regular strength (generic for SENNA SMOOTH) - Tier 1 magnesium citrate oral solution (generic for CITROMA) - Tier 1; QL milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 milk of magnesia concentrate - Tier 1

116 Preferred Agents Non-Preferred Agents mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for peg 3350) - Tier 2; QL mm clearlax (generic for CLEARLAX) - Tier 1; QL mm stool softener laxative (generic for DOK) - Tier 1; QL natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL natural fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber supplement (generic for EVAC) - Tier 1 natural laxative (generic for SENOKOT) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENOKOT) - Tier 1 natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natural vegetable laxative (generic for SENOKOT) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; QL p col-rite (generic for SENEXON-S) - Tier 1 PEDIA-LAX ORAL LIQUID - Tier 2 PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for cvs glycerin child) - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1; QL PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2

117 Preferred Agents Non-Preferred Agents PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for eql milk of magnesia) - Tier 2 polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; QL psyldex - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; QL ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 saline enema (generic for FLEET ENEMA) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENOKOT) - Tier 1 senna laxative (generic for SENOKOT) - Tier 1 senna oral liquid - Tier 1 senna oral syrup - Tier 1 senna oral tablet (generic for SENOKOT) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-lax (generic for SENOKOT) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENOKOT) - Tier 1 senna-time (generic for SENOKOT) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1 SENOKOT (brand for senna-time) - Tier 2 SENOKOT S (brand for hm senna-s) - Tier 2 silace oral liquid (generic for DOCU LIQUID) - Tier 1; QL silace oral syrup - Tier 1 smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL soluble fiber therapy - Tier 1

118 Preferred Agents Non-Preferred Agents sorbitol oral - Tier 1 stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener laxative oral capsule (generic for DOK) - Tier 1; QL stool softener oral capsule 100 mg (generic for DOK) - Tier 1; QL stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral capsule 250 mg - Tier 1; QL stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral tablet 100 mg (generic for DOK) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 womans laxative (generic for EX-LAX ULTRA) - Tier 1 womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1 womens laxative (generic for EX-LAX ULTRA) - Tier 1

Protectants - Ulcer and Stomach Acid Drugs CARAFATE ORAL SUSPENSION (brand for sucralfate) - Tier 2; QL CARAFATE ORAL TABLET (brand for sucralfate) - Tier 2; PA; QL misoprostol oral (generic for CYTOTEC) - Tier 1; QL CYTOTEC (brand for misoprostol) - Tier 2; PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; PA; QL

Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs acid reducer oral capsule delayed release - Tier 1; QL acid reducer oral tablet delayed release (generic for PRILOSEC OTC) - Tier lansoprazole oral capsule delayed release 15 mg, 30 mg (generic for 1; PA; QL PREVACID) - Tier 1; QL ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL NEXIUM ORAL PACKET (brand for esomeprazole magnesium) - Tier 2; ACIPHEX SPRINKLE - Tier 2; PA; QL QL DEXILANT - Tier 2; PA; QL omeprazole magnesium oral capsule delayed release - Tier 1; QL esomeprazole magnesium (generic for NEXIUM) - Tier 1; PA; QL

119 Preferred Agents Non-Preferred Agents omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20 base) ESOMEPRAZOLE STRONTIUM - Tier 2; PA; QL mg, 40 mg - Tier 1; QL FIRST-LANSOPRAZOLE - Tier 2; PA; QL pantoprazole sodium oral tablet delayed release (generic for FIRST-OMEPRAZOLE - Tier 2; PA; QL PROTONIX) - Tier 1; QL lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg (generic PROTONIX ORAL PACKET (brand for pantoprazole sodium) - Tier 2; for PREVACID SOLUTAB) - Tier 1; PA; QL QL NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for ra esomeprazole magnesium) - Tier 2; PA; QL omeprazole magnesium oral tablet delayed release (generic for PRILOSEC OTC) - Tier 1; PA; QL omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL OMEPRAZOLE+SYRSPEND SF ALKA - Tier 2; PA; QL omeprazole-sod bicarbonate (generic for ZEGERID) - Tier 1; PA; QL omeprazole-sodium bicarb oral capsule 20-1100 mg (generic for ZEGERID) - Tier 1; PA; QL omeprazole-sodium bicarbonate (generic for ZEGERID) - Tier 1; PA; QL pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA; QL PREVACID (brand for lansoprazole) - Tier 2; PA; QL PREVACID 24HR (brand for lansoprazole) - Tier 2; PA; QL PREVACID SOLUTAB (brand for lansoprazole) - Tier 2; PA; QL PRILOSEC - Tier 2; PA; QL PRILOSEC OTC (brand for acid reducer) - Tier 2; PA; QL PROTONIX ORAL TABLET DELAYED RELEASE (brand for pantoprazole sodium) - Tier 2; PA; QL RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE - Tier 2; PA; QL rabeprazole sodium oral tablet delayed release (generic for ACIPHEX) - Tier 1; PA; QL ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment BUPHENYL (brand for sodium phenylbutyrate) - Tier 2; SP; QL CERDELGA - Tier 2; PA; SP; QL CREON - Tier 2; QL CHOLBAM - Tier 2; PA; SP; QL NITYR - Tier 2; DX2RX; SP; QL CYSTADANE - Tier 2; PA; SP; QL ZENPEP - Tier 2; QL CYSTAGON - Tier 2; PA; SP; QL

120 Preferred Agents Non-Preferred Agents EVRYSDI - Tier 2; PA; SP; QL GALAFOLD - Tier 2; PA; SP; QL KUVAN (brand for sapropterin dihydrochloride) - Tier 2; PA; SP; QL miglustat (generic for ZAVESCA) - Tier 1; PA; SP; QL nitisinone (generic for ORFADIN) - Tier 1; DX2RX; SP; QL ORFADIN (brand for nitisinone) - Tier 2; DX2RX; SP; QL PALYNZIQ - Tier 2; PA; SP; QL PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 37000-97300 UNIT ORAL - Tier 2; PA PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500- 35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 4200-14200 UNIT - Tier 2; PA; QL PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600- 6200 UNIT - Tier 2; PA PERTZYE - Tier 2; PA; QL PROCYSBI - Tier 2; PA; SP; QL RAVICTI - Tier 2; PA; SP; QL sapropterin dihydrochloride (generic for KUVAN) - Tier 1; PA; SP; QL sodium phenylbutyrate oral (generic for BUPHENYL) - Tier 1; PA; SP; QL STRENSIQ - Tier 2; PA; SP; QL SUCRAID - Tier 2; PA; SP; QL TEGSEDI - Tier 2; PA; SP; QL VIOKACE - Tier 2; PA; QL XURIDEN - Tier 2; PA; SP; QL ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs flavoxate hcl - Tier 1; QL darifenacin hydrobromide er - Tier 1; PA; QL oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; QL oxybutynin chloride oral - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL OXYTROL - Tier 2; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL

121 Preferred Agents Non-Preferred Agents OXYTROL FOR WOMEN - Tier 2; QL GELNIQUE - Tier 2; PA; QL solifenacin succinate (generic for VESICARE) - Tier 1; ST; QL GEMTESA - Tier 2; PA; QL MYRBETRIQ - Tier 2; PA; QL tolterodine tartrate (generic for DETROL) - Tier 1; PA; QL tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA; QL TOVIAZ - Tier 2; PA; QL trospium chloride - Tier 1; PA; QL trospium chloride er - Tier 1; PA; QL VESICARE (brand for solifenacin succinate) - Tier 2; PA; ST; QL VESICARE LS - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL AVODART (brand for dutasteride) - Tier 2; PA; QL dutasteride oral (generic for AVODART) - Tier 1; QL CARDURA XL - Tier 2; PA; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL CIALIS ORAL TABLET 5 MG (brand for tadalafil) - Tier 2; PA; QL; GE tadalafil oral tablet 5 mg (generic for CIALIS) - Tier 1; PA; QL; GE dutasteride-tamsulosin hcl (generic for JALYN) - Tier 1; PA; QL tamsulosin hcl (generic for FLOMAX) - Tier 1; QL FLOMAX (brand for tamsulosin hcl) - Tier 2; PA; QL terazosin hcl - Tier 1; QL JALYN (brand for dutasteride-tamsulosin hcl) - Tier 2; PA; QL PROSCAR (brand for finasteride) - Tier 2; PA; QL RAPAFLO (brand for silodosin) - Tier 2; PA; QL silodosin (generic for RAPAFLO) - Tier 1; PA; QL UROXATRAL (brand for alfuzosin hcl er) - Tier 2; PA; QL

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 CERVIDIL - Tier 2; PA azo tabs (generic for PHENAZO) - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL bethanechol chloride oral - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL ELMIRON - Tier 2; QL LITHOSTAT - Tier 2; PA penicillamine oral (generic for CUPRIMINE) - Tier 1; SP; QL OPTIONS GYNOL II CONTRACEPTIVE - Tier 2; PA phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL PENTOSAN POLYSULFATE SODIUM ORAL - Tier 2; PA; QL phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 PHEXXI - Tier 2; PA; QL

122 Preferred Agents Non-Preferred Agents phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1; PREPIDIL - Tier 2; PA QL PROSTIN E2 - Tier 2; PA phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; PA; QL QL THIOLA (brand for tiopronin) - Tier 2; PA; SP; QL SHUR-SEAL CONTRACEPTIVE - Tier 2; GE THIOLA EC - Tier 2; PA; SP; QL urin ds (generic for UTIRA-C) - Tier 1; QL tiopronin oral (generic for THIOLA) - Tier 1; PA; SP; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 URELLE (brand for uroav-81) - Tier 2; PA UTIRA-C (brand for urin ds) - Tier 2; QL URIMAR-T ORAL TABLET 120 MG - Tier 2; PA VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2; GE URO-458 - Tier 2; PA uro-mp (generic for VILAMIT MB) - Tier 1; PA USTELL - Tier 2; PA VCF VAGINAL CONTRACEPTIVE VAGINAL FILM - Tier 2; PA vcf vaginal contraceptive vaginal gel - Tier 1; PA VILAMIT MB (brand for uro-mp) - Tier 2; PA VILEVEV MB (brand for uroav-81) - Tier 2; PA

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs DECADRON ORAL TABLET 0.5 MG, 0.75 MG (brand for ACTHAR - Tier 2; PA; SP; QL dexamethasone) - Tier 2 ALKINDI SPRINKLE - Tier 2; PA; QL DECADRON ORAL TABLET 4 MG, 6 MG (brand for dexamethasone) - CONTRAST ALLERGY PREMED PACK - Tier 2; PA; QL Tier 2; QL CORTEF (brand for hydrocortisone) - Tier 2; PA; QL dexamethasone intensol - Tier 1 DEXABLISS - Tier 2; PA; QL dexamethasone oral elixir - Tier 1; QL dexamethasone oral tablet therapy pack (generic for HIDEX 6-DAY) - Tier dexamethasone oral solution - Tier 1; QL 1; PA dexamethasone oral tablet 0.5 mg, 0.75 mg (generic for DECADRON) - DXEVO 11-DAY (brand for dexabliss) - Tier 2; PA; QL Tier 1 EMFLAZA - Tier 2; PA; SP; QL dexamethasone oral tablet 1 mg, 2 mg - Tier 1 HEMADY - Tier 2; PA; QL dexamethasone oral tablet 1.5 mg - Tier 1; QL HIDEX 6-DAY (brand for dexamethasone) - Tier 2; PA

123 Preferred Agents Non-Preferred Agents dexamethasone oral tablet 4 mg, 6 mg (generic for DECADRON) - Tier MEDROL ORAL TABLET 16 MG, 32 MG, 8 MG (brand for 1; QL methylprednisolone) - Tier 2; PA; QL fludrocortisone acetate oral - Tier 1; QL MEDROL ORAL TABLET 4 MG (brand for methylprednisolone) - Tier 2; hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - PA; QL Tier 1; QL MEDROL ORAL TABLET THERAPY PACK (brand for methylprednisolone) MEDROL ORAL TABLET 2 MG - Tier 2 - Tier 2; PA; QL methylprednisolone oral (generic for MEDROL) - Tier 1; QL MILLIPRED - Tier 2; PA; QL prednisolone oral solution - Tier 1; QL ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 30 MG (brand for prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml - prednisolone sodium phosphate) - Tier 2; PA Tier 1; QL ORAPRED ODT ORAL TABLET DISPERSIBLE 15 MG (brand for prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml - prednisolone sodium phosphate) - Tier 2; PA; QL Tier 1 PEDIAPRED (brand for prednisolone sodium phosphate) - Tier 2; PA; QL prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml RAYOS - Tier 2; PA; QL (generic for PEDIAPRED) - Tier 1; QL TAPERDEX 12-DAY - Tier 2; PA; QL prednisolone sodium phosphate oral tablet dispersible 10 mg, 30 mg TAPERDEX 6-DAY (brand for dexamethasone) - Tier 2; PA (generic for ORAPRED ODT) - Tier 1 TAPERDEX 7-DAY - Tier 2; PA; QL prednisolone sodium phosphate oral tablet dispersible 15 mg (generic ZCORT 7-DAY - Tier 2; PA; QL for ORAPRED ODT) - Tier 1; QL prednisone intensol - Tier 1; QL prednisone oral solution - Tier 1; QL prednisone oral tablet - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) - Tier 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP RHINAL TUBE - Tier 2; QL chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; PA desmopressin ace spray refrig - Tier 1; QL DDAVP INJECTION (brand for desmopressin acetate) - Tier 2; PA desmopressin acetate injection (generic for DDAVP) - Tier 1 DDAVP ORAL (brand for desmopressin acetate) - Tier 2; PA; QL

124 Preferred Agents Non-Preferred Agents desmopressin acetate oral (generic for DDAVP) - Tier 1; QL DDAVP PF (brand for desmopressin acetate pf) - Tier 2; PA desmopressin acetate pf (generic for DDAVP PF) - Tier 1 HUMATROPE - Tier 2; PA; SP; QL desmopressin acetate spray - Tier 1; QL NOCDURNA - Tier 2; PA; QL GENOTROPIN - Tier 2; PA; SP; QL novarel intramuscular solution reconstituted 10000 unit (generic for GENOTROPIN MINIQUICK - Tier 2; PA; SP; QL NOVAREL) - Tier 1; PA INCRELEX - Tier 2; PA; SP; QL NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL - Tier 2; PA NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QL NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QL NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QL OMNITROPE - Tier 2; PA; SP; QL OVIDREL - Tier 2; PA pregnyl (generic for NOVAREL) - Tier 1; PA SAIZEN - Tier 2; PA; SP; QL SAIZENPREP - Tier 2; PA; SP; QL STIMATE - Tier 2; PA; QL ZOMACTON - Tier 2; PA; SP; QL ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL MIFEPREX (brand for mifepristone) - Tier 2; PA mifepristone (generic for MIFEPREX) - Tier 1; PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs ANDRODERM - Tier 2; PA; QL ANDROGEL (brand for testosterone) - Tier 2; PA; QL danazol oral - Tier 1; ST; QL ANDROGEL PUMP (brand for testosterone) - Tier 2; PA; QL

125 Preferred Agents Non-Preferred Agents testosterone cypionate intramuscular solution 100 mg/ml (generic for DEPO-TESTOSTERONE (brand for testosterone cypionate) - Tier 2; PA; DEPO-TESTOSTERONE) - Tier 1; QL QL testosterone cypionate solution 200 mg/ml intramuscular (generic for EC-RX TESTOSTERONE - Tier 2; PA DEPO-TESTOSTERONE) - Tier 1; QL FORTESTA (brand for testosterone) - Tier 2; PA testosterone enanthate intramuscular - Tier 1; QL JATENZO - Tier 2; PA; QL testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO METHITEST - Tier 2; PA; QL PUMP) - Tier 1; PA; QL methyltestosterone oral - Tier 1; PA; QL testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) NATESTO - Tier 2; PA; QL (generic for ANDROGEL) - Tier 1; PA; QL oxandrolone oral - Tier 1; PA; QL TESTIM (brand for testosterone) - Tier 2; PA; QL TESTONE CIK - Tier 2; PA; QL TESTOSTERONE CYPIONATE INJECTION - Tier 2; PA; QL testosterone cypionate solution 200 mg/ml intramuscular (generic for DEPO-TESTOSTERONE) - Tier 1; PA; QL testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic for ANDROGEL PUMP) - Tier 1; PA; QL testosterone transdermal gel 10 mg/act (2%) (generic for FORTESTA) - Tier 1; PA testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm (1.62%) (generic for ANDROGEL) - Tier 1; PA; QL testosterone transdermal solution - Tier 1; PA; QL VOGELXO (brand for testosterone) - Tier 2; PA; QL VOGELXO PUMP (brand for testosterone) - Tier 2; PA; QL XYOSTED - Tier 2; PA; QL

Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL; GE ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE ANGELIQ - Tier 2; PA; QL alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE ANNOVERA - Tier 2; PA; QL amabelz (generic for AMABELZ) - Tier 1; QL BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL amethia (generic for AMETHIA) - Tier 1; QL BIJUVA - Tier 2; PA; QL amethyst (generic for AMETHYST) - Tier 1; QL CLIMARA (brand for estradiol) - Tier 2; PA; QL

126 Preferred Agents Non-Preferred Agents apri (generic for APRI) - Tier 1; QL; GE COVARYX (brand for est estrogens-methyltest) - Tier 2; PA; QL aranelle - Tier 1; QL; GE COVARYX HS (brand for est estrogens-methyltest hs) - Tier 2; PA; QL ashlyna (generic for AMETHIA) - Tier 1; QL DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1; QL; GE DELESTROGEN INTRAMUSCULAR OIL 40 MG/ML (brand for estradiol aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE valerate) - Tier 2; PA; QL aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE DEPO-ESTRADIOL - Tier 2; PA; QL aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE DIVIGEL - Tier 2; PA; QL aurovela 24 fe - Tier 1; QL DUAVEE - Tier 2; PA; QL aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE EC-RX ESTRADIOL - Tier 2; PA aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE EEMT (brand for est estrogens-methyltest) - Tier 2; PA; QL aviane (generic for AFIRMELLE) - Tier 1; QL; GE ELESTRIN - Tier 2; PA ayuna (generic for ALTAVERA) - Tier 1; QL; GE est estrogens-methyltest (generic for COVARYX HS) - Tier 1; PA; QL azurette (generic for AZURETTE) - Tier 1; QL; GE est estrogens-methyltest ds (generic for COVARYX) - Tier 1; PA; QL BALCOLTRA - Tier 2; QL est estrogens-methyltest hs (generic for COVARYX HS) - Tier 1; PA; QL balziva (generic for BALZIVA) - Tier 1; QL; GE ESTRACE (brand for estradiol) - Tier 2; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL; GE estradiol vaginal tablet (generic for YUVAFEM) - Tier 1; PA; QL blisovi 24 fe - Tier 1; QL estradiol valerate intramuscular oil 40 mg/ml (generic for DELESTROGEN) blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE - Tier 1; PA; QL blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE ESTROGEL - Tier 2; PA; QL briellyn (generic for BALZIVA) - Tier 1; QL; GE ESTROSTEP FE - Tier 2; PA; QL; GE camrese (generic for AMETHIA) - Tier 1; QL EVAMIST - Tier 2; PA; QL camrese lo (generic for CAMRESE LO) - Tier 1; QL FALESSA - Tier 2; PA; QL caziant - Tier 1; QL fayosim (generic for FAYOSIM) - Tier 1; PA; QL charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE FEMHRT (brand for norethindrone-eth estradiol) - Tier 2; PA; QL chateal (generic for ALTAVERA) - Tier 1; QL; GE FEMRING - Tier 2; PA; QL chateal eq (generic for ALTAVERA) - Tier 1; QL; GE GENERESS FE (brand for norethin-eth estradiol-fe) - Tier 2; PA; QL CLIMARA PRO - Tier 2; QL levonorgest-eth est & eth est (generic for FAYOSIM) - Tier 1; PA; QL COMBIPATCH - Tier 2; QL LOESTRIN 1.5/30 (21) (brand for norethindrone acet-ethinyl est) - Tier 2; cryselle-28 - Tier 1; QL; GE PA; QL; GE cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE LOESTRIN 1/20 (21) (brand for norethindrone acet-ethinyl est) - Tier 2; PA; cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE QL; GE cyred (generic for APRI) - Tier 1; QL; GE LOESTRIN FE 1/20 (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL; cyred eq (generic for APRI) - Tier 1; QL; GE GE dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE

127 Preferred Agents Non-Preferred Agents dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE LOSEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; PA; daysee (generic for AMETHIA) - Tier 1; QL QL delyla (generic for AFIRMELLE) - Tier 1; QL; GE MENOSTAR - Tier 2; PA; QL desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GE MINASTRIN 24 FE (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL; dolishale (generic for AMETHYST) - Tier 1; QL GE dotti (generic for DOTTI) - Tier 1; QL MINIVELLE (brand for estradiol) - Tier 2; PA; QL drospiren-eth estrad-levomefol (generic for BEYAZ) - Tier 1; QL MIRCETTE (brand for viorele) - Tier 2; PA; QL; GE drospirenone-ethinyl estradiol (generic for OCELLA) - Tier 1; QL MYFEMBREE - Tier 2; PA elinest - Tier 1; QL; GE NEXTSTELLIS - Tier 2; PA; QL eluryng (generic for ELURYNG) - Tier 1; QL; GE PREFEST - Tier 2; PA; QL emoquette (generic for APRI) - Tier 1; QL; GE rivelsa (generic for FAYOSIM) - Tier 1; PA; QL enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GE SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL enskyce (generic for APRI) - Tier 1; QL; GE SEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; PA; QL estarylla (generic for ESTARYLLA) - Tier 1; QL; GE TAYTULLA (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL estradiol oral (generic for ESTRACE) - Tier 1; QL VAGIFEM (brand for estradiol) - Tier 2; PA; QL estradiol transdermal (generic for DOTTI) - Tier 1; QL VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL estradiol vaginal cream (generic for ESTRACE) - Tier 1; QL YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; QL estradiol-norethindrone acet (generic for AMABELZ) - Tier 1; QL yuvafem (generic for YUVAFEM) - Tier 1; PA; QL ESTRING - Tier 2; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL; GE etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE falmina (generic for AFIRMELLE) - Tier 1; QL; GE femynor (generic for ESTARYLLA) - Tier 1; QL; GE fyavolv (generic for FYAVOLV) - Tier 1; QL gemmily (generic for GEMMILY) - Tier 1; QL hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE hailey 24 fe - Tier 1; QL hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE iclevia (generic for ICLEVIA) - Tier 1; QL introvale (generic for ICLEVIA) - Tier 1; QL isibloom (generic for APRI) - Tier 1; QL; GE jaimiess (generic for AMETHIA) - Tier 1; QL jasmiel (generic for JASMIEL) - Tier 1; QL

128 Preferred Agents Non-Preferred Agents jinteli (generic for FYAVOLV) - Tier 1; QL jolessa (generic for ICLEVIA) - Tier 1; QL juleber (generic for APRI) - Tier 1; QL; GE junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) - Tier 1; QL; GE junel fe oral tablet 1-20 mg-mcg(24) - Tier 1; QL kaitlib fe (generic for KAITLIB FE) - Tier 1; QL kalliga (generic for APRI) - Tier 1; QL; GE kariva (generic for AZURETTE) - Tier 1; QL; GE kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GE kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GE kurvelo (generic for ALTAVERA) - Tier 1; QL; GE larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE larin 24 fe - Tier 1; QL larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE larissia (generic for AFIRMELLE) - Tier 1; QL; GE layolis fe (generic for KAITLIB FE) - Tier 1; QL leena - Tier 1; QL; GE lessina (generic for AFIRMELLE) - Tier 1; QL; GE levonest (generic for ENPRESSE-28) - Tier 1; QL; GE levonorgest-eth estrad 91-day (generic for ICLEVIA) - Tier 1; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1; QL; GE levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1; QL; GE levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (generic for AMETHYST) - Tier 1; QL

129 Preferred Agents Non-Preferred Agents levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL; GE levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GE lillow (generic for ALTAVERA) - Tier 1; QL; GE LO LOESTRIN FE - Tier 2; QL LOESTRIN FE 1.5/30 (brand for norethin ace-eth estrad-fe) - Tier 2; QL; GE lojaimiess (generic for CAMRESE LO) - Tier 1; QL loryna (generic for JASMIEL) - Tier 1; QL low-ogestrel - Tier 1; QL; GE lo-zumandimine (generic for JASMIEL) - Tier 1; QL lutera (generic for AFIRMELLE) - Tier 1; QL; GE lyllana (generic for DOTTI) - Tier 1; QL marlissa (generic for ALTAVERA) - Tier 1; QL; GE MENEST - Tier 2; QL merzee (generic for GEMMILY) - Tier 1; QL mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE microgestin 24 fe - Tier 1; QL microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE mili (generic for ESTARYLLA) - Tier 1; QL; GE mimvey (generic for AMABELZ) - Tier 1; QL mono-linyah (generic for ESTARYLLA) - Tier 1; QL; GE NATAZIA - Tier 2; QL necon 0.5/35 (28) - Tier 1; QL; GE nikki (generic for JASMIEL) - Tier 1; QL norethin ace-eth estrad-fe oral capsule (generic for GEMMILY) - Tier 1; QL norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

130 Preferred Agents Non-Preferred Agents norethin ace-eth estrad-fe oral tablet chewable (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE norethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL; GE norethindrone-eth estradiol (generic for FYAVOLV) - Tier 1; QL norethin-eth estradiol-fe (generic for WYMZYA FE) - Tier 1; QL norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GE norgestimate-ethinyl estradiol triphasic (generic for TRI-LO- ESTARYLLA) - Tier 1; QL; GE nortrel 0.5/35 (28) - Tier 1; QL; GE nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; QL; GE nylia 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nymyo (generic for ESTARYLLA) - Tier 1; QL; GE ocella (generic for OCELLA) - Tier 1; QL orsythia (generic for AFIRMELLE) - Tier 1; QL; GE philith (generic for BALZIVA) - Tier 1; QL; GE pimtrea (generic for AZURETTE) - Tier 1; QL; GE pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE portia-28 (generic for ALTAVERA) - Tier 1; QL; GE PREMARIN ORAL - Tier 2; QL PREMARIN VAGINAL - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1; QL; GE QUARTETTE (brand for levonorgest-eth est & eth est) - Tier 2; QL reclipsen (generic for APRI) - Tier 1; QL; GE setlakin (generic for ICLEVIA) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1; QL; GE simpesse (generic for AMETHIA) - Tier 1; QL sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GE

131 Preferred Agents Non-Preferred Agents sronyx (generic for AFIRMELLE) - Tier 1; QL; GE syeda (generic for OCELLA) - Tier 1; QL tarina 24 fe - Tier 1; QL tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tilia fe - Tier 1; QL; GE tri femynor (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-legest fe - Tier 1; QL; GE tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE tri-mili (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-nymyo (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-previfem (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL; GE trivora (28) (generic for ENPRESSE-28) - Tier 1; QL; GE tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE TWIRLA - Tier 2; QL tyblume - Tier 1; QL; GE tydemy (generic for TYDEMY) - Tier 1; QL velivet - Tier 1; QL vestura (generic for JASMIEL) - Tier 1; QL vienva (generic for AFIRMELLE) - Tier 1; QL; GE viorele (generic for AZURETTE) - Tier 1; QL; GE volnea (generic for AZURETTE) - Tier 1; QL; GE vyfemla (generic for BALZIVA) - Tier 1; QL; GE vylibra (generic for ESTARYLLA) - Tier 1; QL; GE wera - Tier 1; QL; GE wymzya fe (generic for WYMZYA FE) - Tier 1; QL xulane - Tier 1; QL; GE

132 Preferred Agents Non-Preferred Agents YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; QL zafemy - Tier 1; QL; GE zarah (generic for OCELLA) - Tier 1; QL zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL; GE zovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL; GE zumandimine (generic for OCELLA) - Tier 1; QL

Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL; GE AYGESTIN (brand for norethindrone acetate) - Tier 2; PA; QL camila (generic for CAMILA) - Tier 1; QL; GE DEPO-PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; CRINONE - Tier 2 QL; GE deblitane (generic for CAMILA) - Tier 1; QL; GE EC-RX PROGESTERONE - Tier 2; PA DEPO-SUBQ PROVERA 104 - Tier 2; ST; QL ENDOMETRIN - Tier 2; PA econtra ez (generic for AFTERA) - Tier 1; QL; GE FIRST-PROGESTERONE VGS - Tier 2; PA econtra one-step (generic for AFTERA) - Tier 1; QL; GE PROGESTERONE MICRONIZED TRANSDERMAL - Tier 2; PA ELLA - Tier 2; QL PROMETRIUM (brand for progesterone) - Tier 2; PA; QL errin (generic for CAMILA) - Tier 1; QL; GE PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; QL heather (generic for CAMILA) - Tier 1; QL; GE incassia (generic for CAMILA) - Tier 1; QL; GE jencycla (generic for CAMILA) - Tier 1; QL; GE levonorgestrel (generic for AFTERA) - Tier 1; QL; GE lyleq (generic for CAMILA) - Tier 1; QL; GE lyza (generic for CAMILA) - Tier 1; QL; GE medroxyprogesterone acetate intramuscular (generic for DEPO- PROVERA) - Tier 1; QL; GE medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QL megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml - Tier 1; QL megestrol acetate oral tablet 20 mg - Tier 1 megestrol acetate oral tablet 40 mg - Tier 1; QL my choice (generic for AFTERA) - Tier 1; QL; GE my way (generic for AFTERA) - Tier 1; QL; GE new day (generic for AFTERA) - Tier 1; QL; GE nora-be (generic for CAMILA) - Tier 1; QL; GE

133 Preferred Agents Non-Preferred Agents norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1; QL; GE norlyda (generic for CAMILA) - Tier 1; QL; GE norlyroc (generic for CAMILA) - Tier 1; QL; GE opcicon one-step (generic for AFTERA) - Tier 1; QL; GE option 2 (generic for AFTERA) - Tier 1; QL; GE PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GE progesterone intramuscular - Tier 1 progesterone oral (generic for PROMETRIUM) - Tier 1; QL react (generic for AFTERA) - Tier 1; QL; GE sharobel (generic for CAMILA) - Tier 1; QL; GE SLYND - Tier 2; QL take action (generic for AFTERA) - Tier 1; QL; GE tulana (generic for CAMILA) - Tier 1; QL; GE

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs raloxifene hcl (generic for EVISTA) - Tier 1; QL EVISTA (brand for raloxifene hcl) - Tier 2; PA; QL OSPHENA - Tier 2; PA; QL; GE

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYROID (brand for np thyroid) - Tier 2; QL CYTOMEL (brand for liothyronine sodium) - Tier 2; PA; QL euthyrox (generic for EUTHYROX) - Tier 1; QL LEVOTHYROXINE SODIUM ORAL CAPSULE - Tier 2; PA; QL levo-t (generic for EUTHYROX) - Tier 1; QL NATURE-THROID - Tier 2; PA; QL levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL SYNTHROID (brand for levothyroxine sodium) - Tier 2; PA; QL levoxyl (generic for EUTHYROX) - Tier 1; QL THYQUIDITY - Tier 2; PA; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL TIROSINT (brand for levothyroxine sodium) - Tier 2; PA; QL np thyroid (generic for ARMOUR THYROID) - Tier 1; QL TIROSINT-SOL - Tier 2; PA; QL

134 Preferred Agents Non-Preferred Agents unithroid (generic for EUTHYROX) - Tier 1; QL WESTHROID - Tier 2; PA; QL WP THYROID - Tier 2; PA; QL

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2; PA; QL ISTURISA - Tier 2; PA; SP; QL

Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL ELIGARD - Tier 2; PA; SP; QL EGRIFTA SV - Tier 2; DX2RX; SP; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL leuprolide acetate injection - Tier 1; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPANETA PACK - Tier 2; ST; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG - Tier 2; MYCAPSSA - Tier 2; PA; SP; QL PA; ST; SP; QL SANDOSTATIN (brand for octreotide acetate) - Tier 2; PA; SP; QL LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG - Tier 2; SYNAREL - Tier 2; PA PA; SP; QL TRIPTODUR - Tier 2; PA; SP; QL LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG - Tier 2; PA; ST; SP; QL LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG - Tier 2; PA; SP; QL LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL ORIAHNN - Tier 2; PA; QL

135 Preferred Agents Non-Preferred Agents ORILISSA - Tier 2; ST; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL ZOLADEX - Tier 2; ST

Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1; QL TAPAZOLE (brand for methimazole) - Tier 2; PA; QL propylthiouracil oral - Tier 1; QL

Immunological Agents Immunomodulators ENSPRYNG - Tier 2; PA; SP; QL

Vaccines ORLADEYO - Tier 2; PA; SP; QL

Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin HAEGARDA - Tier 2; PA; SP; QL BERINERT - Tier 2; PA; SP; QL RUCONEST - Tier 2; PA; SP; QL CINRYZE - Tier 2; PA; SP; QL TAKHZYRO - Tier 2; PA; SP; QL FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL icatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL

136 Preferred Agents Non-Preferred Agents Immune Suppressants - Immune System Drugs AZASAN - Tier 2 ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 azathioprine oral (generic for IMURAN) - Tier 1; QL MG, 1 MG - Tier 2; PA; QL cyclosporine modified oral capsule 100 mg, 25 mg (generic for ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG - GENGRAF) - Tier 1; QL Tier 2; PA cyclosporine modified oral capsule 50 mg - Tier 1 CELLCEPT (brand for mycophenolate mofetil) - Tier 2; PA; QL cyclosporine modified oral solution (generic for GENGRAF) - Tier 1; QL CIMZIA - Tier 2; PA; SP; QL cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL ENVARSUS XR - Tier 2; PA; QL ENBREL - Tier 2; PA; SP; QL IMURAN (brand for azathioprine) - Tier 2; PA; QL everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for KINERET - Tier 2; PA; SP; QL ZORTRESS) - Tier 1 LUPKYNIS - Tier 2; PA; QL gengraf (generic for GENGRAF) - Tier 1; QL MYFORTIC (brand for mycophenolate sodium) - Tier 2; PA; QL HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL NEORAL (brand for cyclosporine modified) - Tier 2; PA; QL HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL OLUMIANT - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 ORENCIA CLICKJECT - Tier 2; PA; SP; QL MG/0.8ML - Tier 2; PA; SP; QL ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML - Tier OTREXUP - Tier 2; PA; QL 2; PA; SP; QL PROGRAF ORAL CAPSULE 0.5 MG, 5 MG (brand for tacrolimus) - Tier 2; HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, PA 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML, 80 PROGRAF ORAL CAPSULE 1 MG (brand for tacrolimus) - Tier 2; PA; QL MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL PROGRAF ORAL PACKET - Tier 2; PA methotrexate oral - Tier 1; QL RAPAMUNE ORAL SOLUTION (brand for sirolimus) - Tier 2; PA; QL methotrexate sodium (pf) - Tier 1 RAPAMUNE ORAL TABLET 0.5 MG, 1 MG (brand for sirolimus) - Tier 2; methotrexate sodium injection - Tier 1 PA; QL methotrexate sodium oral - Tier 1; QL RAPAMUNE ORAL TABLET 2 MG (brand for sirolimus) - Tier 2; PA mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL RASUVO - Tier 2; PA; QL mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL REDITREX - Tier 2; PA; QL sirolimus oral solution (generic for RAPAMUNE) - Tier 1; QL SANDIMMUNE ORAL (brand for cyclosporine) - Tier 2; PA; QL sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; QL SIMPONI - Tier 2; PA; SP; QL sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1 SKYRIZI - Tier 2; PA; SP; QL tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1 SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL SKYRIZI PEN - Tier 2; PA; SP; QL XELJANZ - Tier 2; PA; SP; QL STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL ZORTRESS ORAL TABLET 1 MG - Tier 2 TREXALL - Tier 2; PA

137 Preferred Agents Non-Preferred Agents XATMEP - Tier 2; PA; QL XELJANZ XR - Tier 2; PA; SP; QL ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG (brand for everolimus) - Tier 2; PA

Immunizing Agents, Passive - Immune System Drugs ATGAM - Tier 2; PA CYTOGAM - Tier 2; PA FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 20 GM/400ML - Tier 2; PA GAMASTAN - Tier 2; PA GAMMAPLEX INTRAVENOUS SOLUTION 20 GM/400ML - Tier 2; PA GAMUNEX-C INJECTION SOLUTION 40 GM/400ML - Tier 2; PA HYPERRHO S/D - Tier 2; PA MICRHOGAM ULTRA-FILTERED PLUS - Tier 2; PA RHOGAM ULTRA-FILTERED PLUS - Tier 2; PA RHOPHYLAC - Tier 2; PA WINRHO SDF - Tier 2; PA

Immunomodulators - Immune System Drugs ACTIMMUNE - Tier 2; PA; SP; QL ACTEMRA ACTPEN - Tier 2; PA; SP; QL leflunomide oral (generic for ARAVA) - Tier 1; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL RIDAURA - Tier 2; QL ARAVA (brand for leflunomide) - Tier 2; PA; QL SYNAGIS - Tier 2; PA; SP; QL ARCALYST - Tier 2; PA; SP; QL BENLYSTA SUBCUTANEOUS - Tier 2; PA; SP; QL ILARIS - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL OTEZLA - Tier 2; PA; SP; QL RINVOQ - Tier 2; PA; SP; QL XOLAIR - Tier 2; PA; SP; QL

Vaccines

138 Preferred Agents Non-Preferred Agents ADACEL - Tier 2; QL ASTRAZENECA COVID-19 VACCINE - Tier 2; PA BEXSERO - Tier 2; QL MODERNA COVID-19 VACCINE - Tier 2; PA BOOSTRIX - Tier 2; QL PFIZER-BIONTECH COVID-19 VACC - Tier 2; PA DAPTACEL - Tier 2; QL DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QL ENGERIX-B - Tier 2; QL GARDASIL 9 - Tier 2; QL HAVRIX - Tier 2; QL HEPLISAV-B - Tier 2; QL; AL HYPERTET S/D - Tier 2; QL INFANRIX - Tier 2; QL JANSSEN COVID-19 VACCINE - Tier 2; QL MENACTRA - Tier 2; QL MENQUADFI - Tier 2; QL MENVEO - Tier 2; QL M-M-R II - Tier 2; QL PNEUMOVAX 23 - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL; AL TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL TENIVAC - Tier 2; QL TETANUS-DIPHTHERIA TOXOIDS TD - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL

Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs balsalazide disodium (generic for COLAZAL) - Tier 1; QL APRISO (brand for mesalamine er) - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; QL ASACOL HD (brand for mesalamine) - Tier 2; PA; QL

139 Preferred Agents Non-Preferred Agents mesalamine er oral capsule 0.375 gm (generic for APRISO) - Tier 1; QL CANASA (brand for mesalamine) - Tier 2; PA; QL mesalamine oral capsule delayed release 400 mg (generic for COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL DELZICOL) - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL mesalamine rectal enema - Tier 1; QL DIPENTUM - Tier 2; PA; QL mesalamine-cleanser (generic for ROWASA) - Tier 1; QL mesalamine oral tablet delayed release (generic for ASACOL HD) - Tier 1; PENTASA - Tier 2; QL PA; QL SFROWASA - Tier 2; QL mesalamine rectal suppository (generic for CANASA) - Tier 1; PA; QL ROWASA (brand for mesalamine-cleanser) - Tier 2; PA; QL

Glucocorticoids - Drugs to Treat Inflammation budesonide er (generic for UCERIS) - Tier 1; QL ANALPRAM HC (brand for hydrocort-pramoxine (perianal)) - Tier 2; PA budesonide oral (generic for ENTOCORT EC) - Tier 1; QL ANALPRAM HC SINGLES (brand for hydrocort-pramoxine (perianal)) - Tier hydrocortisone (perianal) (generic for PROCTO-PAK) - Tier 1; QL 2; PA hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) - ANALPRAM-HC (brand for hydrocortisone ace-pramoxine) - Tier 2; PA Tier 1; QL ANUSOL-HC EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; PA; procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL QL procto-pak (generic for PROCTO-PAK) - Tier 1; QL CORTENEMA (brand for hydrocortisone) - Tier 2; PA; QL proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL CORTIFOAM - Tier 2; PA; QL ENTOCORT EC (brand for budesonide) - Tier 2; PA; QL hydrocortisone ace-pramoxine external cream 1-1 % (generic for ANALPRAM-HC) - Tier 1; PA hydrocort-pramoxine (perianal) (generic for ANALPRAM HC) - Tier 1; PA ORTIKOS - Tier 2; PA; QL PROCORT - Tier 2; PA PROCTOCORT EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; PA; QL PROCTOFOAM HC - Tier 2; PA; QL UCERIS (brand for budesonide er) - Tier 2; PA; QL

Sulfonamides - Antibiotics sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL AZULFIDINE (brand for sulfasalazine) - Tier 2; PA; QL AZULFIDINE EN-TABS (brand for sulfasalazine) - Tier 2; PA; QL

140 Preferred Agents Non-Preferred Agents

Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium oral tablet - Tier 1; QL ACTONEL (brand for risedronate sodium) - Tier 2; PA; QL calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL alendronate sodium oral solution - Tier 1; PA; QL ibandronate sodium oral (generic for BONIVA) - Tier 1; QL ATELVIA (brand for risedronate sodium) - Tier 2; PA; QL SENSIPAR (brand for cinacalcet hcl) - Tier 2; QL BINOSTO - Tier 2; PA; QL BONIVA ORAL (brand for ibandronate sodium) - Tier 2; PA; QL cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL FORTEO (brand for teriparatide (recombinant)) - Tier 2; PA; SP; QL FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL FOSAMAX PLUS D - Tier 2; PA; QL RAYALDEE - Tier 2; PA; QL risedronate sodium - Tier 1; PA; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL TYMLOS - Tier 2; PA; SP; QL

Metabolic Bone Disease Agents - Other calcitriol oral (generic for ROCALTROL) - Tier 1; QL NATPARA - Tier 2; PA; SP; QL doxercalciferol oral - Tier 1 ROCALTROL (brand for calcitriol) - Tier 2; PA; QL paricalcitol oral (generic for ZEMPLAR) - Tier 1 ZEMPLAR ORAL (brand for paricalcitol) - Tier 2; PA

Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA DEVICE (brand for verasens glucose control) - Tier ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for gnp easy touch 2; QL glucose test) - Tier 2; PA; QL ACCU-CHEK COMPACT PLUS CONTROL (brand for verasens glucose ACCU-CHEK COMPACT PLUS (brand for gnp easy touch glucose test) - control) - Tier 2; QL Tier 2; PA; QL ACCU-CHEK GUIDE CONTROL (brand for verasens glucose control) - ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite device/lancets) Tier 2; QL - Tier 2; PA; QL ACCU-CHEK MULTICLIX LANCETS (brand for walgreens lancets super ACCU-CHEK GUIDE TEST STRIPS (brand for kroger blood glucose) - Tier thin) - Tier 2; QL 2; PA; QL

141 Preferred Agents Non-Preferred Agents ACCU-CHEK SMARTVIEW CONTROL (brand for verasens glucose ACCU-CHEK LINKASSIST - Tier 2; PA control) - Tier 2; QL ACCU-CHEK MULTICLIX LANCETS (brand for walgreens lancets super ACCUTREND GLUCOSE CONTROL (brand for verasens glucose thin) - Tier 2; PA; QL control) - Tier 2; QL ACCU-CHEK SMARTVIEW (brand for gnp easy touch glucose test) - Tier ACE AEROSOL CLOUD ENHANCER (brand for silicone 2; PA; QL mask/pediatric) - Tier 2; QL ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite ADULT AEROSOL MASK - Tier 2; QL device/lancets) - Tier 2; PA; QL AERIVA CONCENTRATOR NEBULIZER - Tier 2 ACCU-CHEK SPIRIT COMBO PACK - Tier 2; PA AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; ACCU-CHEK TENDER 1 INFUSION - Tier 2; PA ST; QL ACCUTREND GLUCOSE (brand for gnp easy touch glucose test) - Tier 2; ALCOHOL PREP PADS PAD - Tier 2; QL PA; QL ALCOHOL PREP PADS PAD 70 % - Tier 2; QL ACTIFOAM COLLAGEN SPONGE - Tier 2; PA antifungal external powder (generic for DESENEX) - Tier 1; QL ACTIPOCHOL PLUS - Tier 2; PA athletes foot external powder 2 % (generic for DESENEX) - Tier 1; QL ACUNOL (brand for bhi sinus relief) - Tier 2; PA BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier ADVANCED GLUCOSE TEST (brand for gnp easy touch glucose test) - 2; QL Tier 2; PA; QL BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL AEROCHAMBER PLUS FLO-VU (brand for breathe ease large) - Tier 2; BD ULTRA-FINE PEN NEEDLES (brand for sure comfort pen needles) - PA; QL Tier 2; QL AEROCHAMBER PLUS FLO-VU LARGE (brand for breathe ease large) - BLOOD GLUCOSE TEST STRIPS (brand for gnp easy touch glucose Tier 2; PA; QL test) - Tier 2; ST; QL AEROCHAMBER PLUS FLO-VU SMALL (brand for breathe ease large) - BREATHE EASE NEB MASK/CHILD - Tier 2; QL Tier 2; PA; QL BREATHE EASE NEB MASK/INFANT - Tier 2; QL AEROCHAMBER PLUS FLO-VU W/MASK (brand for breathe ease large) - BUBBLES THE FISH II PEDI MASK (brand for silicone mask/pediatric) - Tier 2; PA; QL Tier 2; QL amino action (generic for PRE PROTEIN) - Tier 1; PA CARETOUCH 2 CPAP HOSE HANGER (brand for silicone aminoamrms - Tier 1; PA mask/pediatric) - Tier 2; QL aminoreliefrms - Tier 1; PA CARETOUCH CONTROL SOL LEVEL 2 (brand for verasens glucose anti-fungal external powder (generic for ODOR EATERS ANTIFUNGAL) - control) - Tier 2; QL Tier 1; PA CARETOUCH CPAP & BIPAP HOSE (brand for silicone mask/pediatric) arginine - Tier 1; PA - Tier 2; QL ARNICARE ARNICA EXTERNAL OINTMENT (brand for ichthammol CARETOUCH CPAP MASK WIPES (brand for silicone mask/pediatric) - drawing salve) - Tier 2; PA Tier 2; QL ASPARTAME - Tier 2; PA ASPARTAME (NUTRASWEET) (brand for aspartame) - Tier 2; PA

142 Preferred Agents Non-Preferred Agents CARETOUCH CPAP PRE-WASH SOLN (brand for silicone atabex dha 200 - Tier 1; PA mask/pediatric) - Tier 2; QL AVAILNEX - Tier 2; PA CARETOUCH CPAP TUBE BRUSH (brand for silicone mask/pediatric) - AVENOC (brand for ichthammol drawing salve) - Tier 2; PA Tier 2; QL AVITENE - Tier 2; PA CARETOUCH UNIVERSL CPAP FILTER (brand for silicone AVITENE FLOUR - Tier 2; PA mask/pediatric) - Tier 2; QL AXONA (brand for pro-critic) - Tier 2; PA CAYA - Tier 2; QL AZALGIA - Tier 2; PA CHEMSTRIP 10 MD - Tier 2 bee pollen oral capsule 580 mg - Tier 1; PA CHEMSTRIP 10/SG - Tier 2 BHI URI-CONTROL - Tier 2; PA CHEMSTRIP 2 GP - Tier 2 BLOOD GLUCOSE TEST IN VITRO STRIP - Tier 2; PA; QL CHEMSTRIP 5 OB - Tier 2 BLOOD GLUCOSE TEST STRIPS (brand for gnp easy touch glucose test) CHEMSTRIP 7 - Tier 2 - Tier 2; PA; QL CHEMSTRIP 9 - Tier 2 BLUESTAR - Tier 2; PA CHEMSTRIP K (brand for ketone test) - Tier 2; QL CALENDULA EXTERNAL OINTMENT - Tier 2; PA CHEMSTRIP UGK - Tier 2; QL CAMINO PRO COMPLETE/GLYTACTIN - Tier 2; PA COMPRESSOR NEBULIZER - Tier 2 CANTHARIDIN EXTERNAL - Tier 2; PA; QL CONDOMS - Tier 2; QL CARETOUCH MONITOR SYSTEM (brand for kroger blood glucose) - Tier COOL MIST HUMIDIFER - Tier 2; QL 2; PA; QL COVID-19 SPECIMEN COLLECTION - Tier 2 CARETOUCH TEST (brand for gnp easy touch glucose test) - Tier 2; PA; DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2; QL QL DIASTIX - Tier 2 CHEMSTRIP MICRAL - Tier 2; PA EASIVENT (brand for breathe ease large) - Tier 2; QL CITRULLINE 1000 - Tier 2; PA EASIVENT MASK LARGE (brand for breathe ease large) - Tier 2; QL co-enzyme q10 (generic for PRONUTRIENTS COQ10) - Tier 1; PA EASIVENT MASK MEDIUM (brand for breathe ease large) - Tier 2; QL coenzyme q10 oral capsule 100 mg (generic for PRONUTRIENTS COQ10) EASIVENT MASK SMALL (brand for breathe ease large) - Tier 2; QL - Tier 1; PA EASYMAX 15 LEVEL 2 CONTROL (brand for verasens glucose control) coenzyme q-10 oral capsule 100 mg (generic for PRONUTRIENTS - Tier 2; QL COQ10) - Tier 1; PA EASYMAX 15 LEVEL 2-3 CONTROL (brand for verasens glucose coenzyme q-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier control) - Tier 2; QL 1; PA GLUCOSE CONTROL SOLUTIONS (brand for verasens glucose coenzyme q10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA control) - Tier 2; QL co-enzyme q-10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA EBASE CONTROLLER KIT (brand for silicone mask/pediatric) - Tier 2; coenzyme q10 oral tablet 200 mg (generic for VITALINE COQ10) - Tier 1; QL PA COLCIGEL (brand for arnicare) - Tier 2; PA

143 Preferred Agents Non-Preferred Agents enteric fish oil (generic for VITEYES OMEGA-3 VISION SUPPORT) - COLD-EEZE (brand for zinc) - Tier 2; PA Tier 1; QL COLD-EEZE NATURAL MULTI-SYMP MOUTH/THROAT (brand for zinc) - ergoloid mesylates oral - Tier 1; QL Tier 2; PA FILTER AIR PP - Tier 2; QL COLD-EEZE PLUS DEFENSE MOUTH/THROAT (brand for zinc) - Tier 2; fish oil concentrate oral capsule 1000 mg (generic for SEA-OMEGA) - PA Tier 1; QL COLD-EEZE SUGAR FREE (brand for zinc) - Tier 2; PA fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1; QL COMFORT TOUCH INSULIN PEN NEED (brand for easy comfort pen fish oil oral capsule delayed release 1000 mg (generic for VITEYES needles) - Tier 2; PA; QL OMEGA-3 VISION SUPPORT) - Tier 1; QL COMFORT TOUCH LANCETS 31G (brand for walgreens lancets super fish oil oral capsule delayed release 1200 mg - Tier 1; QL thin) - Tier 2; PA; QL FREESTYLE LIBRE 14 DAY READER - Tier 2; PA; QL COMFORT TOUCH PLUS LANCETS 30G (brand for walgreens lancets FREESTYLE LIBRE 14 DAY SENSOR (brand for guardian sensor 3) - super thin) - Tier 2; PA; QL Tier 2; PA; QL CONTOUR MONITOR (brand for kroger blood glucose) - Tier 2; PA; QL FREESTYLE LIBRE 2 READER - Tier 2; PA; QL CONTOUR CONTROL SOLUTION (brand for diatrue control level 1) - Tier FREESTYLE LIBRE 2 SENSOR (brand for guardian sensor 3) - Tier 2; 2; PA; QL PA; QL CONTOUR MONITOR (brand for verasens blood glucose meter) - Tier 2; FREESTYLE LIBRE READER - Tier 2; PA; QL PA; QL FREESTYLE LIBRE SENSOR SYSTEM (brand for guardian sensor 3) - CONTOUR NEXT EZ KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; PA; QL Tier 2; PA; QL GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for CONTOUR NEXT LINK KIT W/DEVICE (brand for kroger blood glucose) - verasens glucose control) - Tier 2; QL Tier 2; PA; QL INSPIREASE (brand for breathe ease large) - Tier 2; QL CONTOUR NEXT MONITOR KIT W/DEVICE (brand for kroger blood INSPIREASE RESERVOIR BAGS - Tier 2; QL glucose) - Tier 2; PA; QL INSULIN SYRINGES 28G X 1/2" 0.5 ML (brand for gnp ultra com insulin CONTOUR NEXT ONE KIT - Tier 2; PA; QL syringe) - Tier 2; QL CONTOUR NEXT TEST STRIPS (brand for gnp easy touch glucose test) - INSULIN SYRINGES (brand for sure comfort insulin syringe) - Tier 2; Tier 2; PA; QL QL CONTOUR TEST STRIPS (brand for gnp easy touch glucose test) - Tier 2; INSULIN SYRINGES 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML (brand for PA; QL techlite insulin syringe) - Tier 2; QL coq-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier 1; PA INSULIN SYRINGES 29G X 1/2" 0.5 ML (brand for reality insulin coq-10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA syringe) - Tier 2; QL cystine - Tier 1; PA INSULIN SYRINGES 29G X 5/16" 1 ML - Tier 2; QL D-CARE BLOOD GLUCOSE (brand for gnp easy touch glucose test) - Tier INSULIN SYRINGES 30G X 5/16" 0.3 ML (brand for insulin syringe) - 2; PA; QL Tier 2; QL D-CARE GLUCOMETER (brand for kroger blood glucose) - Tier 2; PA; QL

144 Preferred Agents Non-Preferred Agents INSULIN SYRINGES 30G X 5/16" 0.5 ML (brand for preferred plus DEPLIN 15 (brand for l-methylfolate-algae) - Tier 2; PA insulin syringe) - Tier 2; QL DEPLIN 7.5 (brand for l-methylfolate forte) - Tier 2; PA INSULIN SYRINGES 30G X 5/16" 1 ML (brand for mm insulin dha - Tier 1; PA syringe/needle) - Tier 2; QL DIALYVITE OMEGA-3 CONCENTRATE (brand for fish oil) - Tier 2; PA KETO-DIASTIX - Tier 2; QL diuretic maximum strength - Tier 1; PA KETONE CARE - Tier 2; QL EASY TOUCH TEST (brand for gnp easy touch glucose test) - Tier 2; PA; KETONE TEST - Tier 2; QL QL KETOSTIX (brand for ketone test) - Tier 2; QL EASYMAX 15 TEST (brand for gnp easy touch glucose test) - Tier 2; PA; LANCETS (brand for walgreens lancets super thin) - Tier 2; QL QL LOTRIMIN AF EXTERNAL POWDER (brand for antifungal) - Tier 2; QL EASYMAX CONTROL (brand for glucose control) - Tier 2; PA; QL MASK VORTEX/CHILD/FROG - Tier 2; QL EASYMAX NG BLOOD GLUCOSE (brand for kroger blood glucose) - Tier MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL 2; PA; QL MEDISENSE GLUCOSE KETONE CONTR (brand for verasens glucose BLOOD GLUCOSE TEST STRIPS (brand for gnp easy touch glucose test) control) - Tier 2; QL - Tier 2; PA; QL MEDISENSE HI/MID/LOW CONTROL (brand for verasens glucose EASYMAX V BLOOD GLUCOSE (brand for verasens blood glucose meter) control) - Tier 2; QL - Tier 2; PA; QL MEDISENSE HIGH/LOW CONTROL (brand for verasens glucose EC-RX DHEA - Tier 2; PA; QL control) - Tier 2; QL ECZEMOL (brand for bhi sinus relief) - Tier 2; PA MEDISENSE MID CONTROL (brand for verasens glucose control) - Tier ENDO AVITENE - Tier 2; PA 2; QL ENLITE GLUCOSE SENSOR (brand for guardian sensor 3) - Tier 2; PA; methergine (generic for METHERGINE) - Tier 1; QL QL methylergonovine maleate oral (generic for METHERGINE) - Tier 1; QL enovarx-amitriptyline - Tier 1; PA miconazorb af (generic for DESENEX) - Tier 1; QL evening primrose oil oral capsule 500 mg - Tier 1; PA MINI COMPRESSOR (brand for soothe neb mesh nebulizer) - Tier 2 EXACTECH R-S-G TEST (brand for gnp easy touch glucose test) - Tier 2; MYCOZYL AP (brand for antifungal) - Tier 2; QL PA; QL natural fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1; EXACTECH TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL QL FEONYX - Tier 2; PA; QL NEODOT THERMOMETER - Tier 2; QL FIRDAPSE - Tier 2; PA; SP; QL NEUTEK 2TEK CONTROL (brand for verasens glucose control) - Tier 2; fish oil half-the-size (generic for OVEGA-3) - Tier 1; PA QL fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH OIL odorless coated fish oil (generic for VITEYES OMEGA-3 VISION CONC) - Tier 1; PA SUPPORT) - Tier 1; QL fish oil oral capsule 500 mg (generic for OVEGA-3) - Tier 1; PA omega-3 fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier FLEXICHAMBER (brand for breathe ease large) - Tier 2; PA; QL 1; QL FLEXICHAMBER ADULT MASK/SMALL - Tier 2; PA

145 Preferred Agents Non-Preferred Agents omega-3 fish oil oral capsule delayed release 1200 mg - Tier 1; QL FLEXICHAMBER CHILD MASK/LARGE - Tier 2; PA omega-3 oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1; QL FLEXICHAMBER CHILD MASK/SMALL - Tier 2; PA OMNIFLEX DIAPHRAGM - Tier 2; QL; GE FLOGEN - Tier 2; PA ONETOUCH ULTRA (brand for gnp easy touch glucose test) - Tier 2; FLUID ADMINISTRATION SET - Tier 2; PA QL FORTISCARE CONTROL (brand for diatrue control level 1) - Tier 2; PA; ONETOUCH ULTRA 2 KIT W/DEVICE (brand for kroger blood glucose) QL - Tier 2; QL FORTISCARE GLUCOSE SYSTEM (brand for kroger blood glucose) - Tier ONETOUCH ULTRA CONTROL (brand for verasens glucose control) - 2; PA; QL Tier 2; QL FORTISCARE T1 GLUCOSE SYSTEM (brand for verasens blood glucose ONETOUCH VERIO KIT W/DEVICE (brand for kroger blood glucose) - meter) - Tier 2; PA; QL Tier 2; QL FORTISCARE TEST (brand for gnp easy touch glucose test) - Tier 2; PA; ONETOUCH VERIO FLEX SYSTEM (brand for kroger blood glucose) - QL Tier 2; QL FREESTYLE PRECISION NEO SYSTEM (brand for kroger blood glucose) ONETOUCH VERIO IN VITRO SOLUTION (brand for verasens glucose - Tier 2; PA; QL control) - Tier 2; QL FREESTYLE PRECISION NEO TEST (brand for gnp easy touch glucose ONETOUCH VERIO TEST STRIPS (brand for gnp easy touch glucose test) - Tier 2; PA; QL test) - Tier 2; QL GELFILM EXTERNAL - Tier 2; PA ONETOUCH VERIO IQ SYSTEM (brand for kroger blood glucose) - Tier GELFOAM - Tier 2; PA 2; QL GELFOAM COMPRESSED SIZE 100 - Tier 2; PA ONETOUCH VERIO REFLECT (brand for kroger blood glucose) - Tier GELFOAM DENTAL PACK SIZE 4 - Tier 2; PA 2; QL GELFOAM SPONGE SIZE 200 - Tier 2; PA ONETOUCH VERIO SYNC SYSTEM (brand for kroger blood glucose) - GELFOAM SPONGE SIZE 50 - Tier 2; PA Tier 2; QL GENADUR COMBINATION - Tier 2; PA PARI ALTERA NEBULIZER HANDSET (brand for silicone GENTLE-LET PLATFORMS (brand for lancet transporter case) - Tier 2; mask/pediatric) - Tier 2; QL PA; QL PARI ALTERA NEBULIZER SYSTEM (brand for soothe neb mesh GIVLAARI - Tier 2; PA nebulizer) - Tier 2 gla-45 - Tier 1; PA PARI BABY CONVERSION KIT (brand for silicone mask/pediatric) - Tier GLUCOSE CONTROL SOLUTION IN VITRO LIQUID (brand for glucose 2; QL control) - Tier 2; PA; QL PARI ERAPID NEBULIZER HANDSET (brand for silicone GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION HIGH (brand for mask/pediatric) - Tier 2; QL easy talk control) - Tier 2; PA; QL PARI ERAPID NEBULIZER SYSTEM (brand for soothe neb mesh GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION LOW (brand for nebulizer) - Tier 2 diatrue control level 1) - Tier 2; PA; QL

146 Preferred Agents Non-Preferred Agents PARI LC PLUS NEB SET PED MASK (brand for soothe neb mesh GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION NORMAL (brand nebulizer) - Tier 2 for glucose control) - Tier 2; PA; QL PARI LC PLUS NEBULIZER (brand for soothe neb mesh nebulizer) - GLUCOSE METER TEST STRIPS - Tier 2; PA; QL Tier 2 GLYTACTIN COMPLETE 10PE - Tier 2; PA PARI LC PLUS VIOS PRO NEB (brand for soothe neb mesh nebulizer) - G-PREPROTEIN - Tier 2; PA Tier 2 GUARDIAN CONNECT TRANSMITTER - Tier 2; PA; QL PARI LC SPRINT NEBULIZER SET (brand for soothe neb mesh GUARDIAN LINK 3 TRANSMITTER - Tier 2; PA; QL nebulizer) - Tier 2 GUARDIAN REAL-TIME REPLACE PED - Tier 2; PA; QL PARI SINUS AEROSOL SYSTEM (brand for soothe neb mesh GUARDIAN SENSOR (3) (brand for guardian sensor 3) - Tier 2; PA; QL nebulizer) - Tier 2 HUMATROPEN FOR 12MG (brand for inject-ease) - Tier 2; PA PARI TREK S W/12V DC ADAPTOR (brand for soothe neb mesh HUMATROPEN FOR 24MG (brand for inject-ease) - Tier 2; PA nebulizer) - Tier 2 HUMATROPEN FOR 6MG (brand for inject-ease) - Tier 2; PA PARI VIOS PRO LC PLUS SYSTEM (brand for soothe neb mesh hydro-tabs - Tier 1; PA nebulizer) - Tier 2 HYLAFEM - Tier 2; PA PARI VIOS PRO LC SPRINT SYSTEM (brand for soothe neb mesh ICHTHAMMOL DRAWING SALVE - Tier 2; PA nebulizer) - Tier 2 INBRIJA - Tier 2; PA; SP; QL PARI VORTEX ADULT MASK (brand for silicone mask/pediatric) - Tier INSPIRACHAMBER/LARGE (brand for breathe ease large) - Tier 2; PA; QL 2; QL INSPIRACHAMBER/MEDIUM (brand for breathe ease large) - Tier 2; PA; PEDIATRIC COMPRESSOR NEBULIZER - Tier 2 QL PRECISION GLUCOSE CONTROL (brand for verasens glucose INSPIRACHAMBER/MOUTHPIECE (brand for breathe ease large) - Tier 2; control) - Tier 2; QL PA; QL PRECISION GLUCOSE CONTROL SOLN (brand for verasens glucose INSPIRACHAMBER/SMALL (brand for breathe ease large) - Tier 2; PA; QL control) - Tier 2; QL INSULIN PEN NEEDLES 29G X 12.7MM , 30G X 8 MM , 32G X 6 MM PRECISION GLUCOSE KETONE CONTR (brand for verasens glucose (brand for sure comfort pen needles) - Tier 2; PA; QL control) - Tier 2; QL INSULIN PEN NEEDLES 29G X 12MM , 29G X 5MM , 29G X 8MM , 31G X PRECISION GLUCOSE/KETONE CONTR (brand for verasens glucose 5 MM , 31G X 6 MM , 31G X 8 MM - Tier 2; PA; QL control) - Tier 2; QL INSULIN PEN NEEDLES 32G X 4 MM (brand for healthwise unifine PREMIUM CONDOMS LUBRICATED - Tier 2; QL pentips) - Tier 2; PA; QL PRONEB ULTRA FILTER SET (brand for silicone mask/pediatric) - Tier INSULIN PEN NEEDLES 32G X 5 MM (brand for pure comfort pen needle) 2; QL - Tier 2; PA; QL QUINTET CONTROL HIGH/NORMAL (brand for verasens glucose INSULIN PEN NEEDLES 33G X 4 MM (brand for easy comfort pen control) - Tier 2; QL needles) - Tier 2; PA; QL REPLACEMENT FILTERS - Tier 2; QL INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 31G X 5/16" 1 SAFE-T-LANCE (brand for walgreens lancets super thin) - Tier 2; QL ML (brand for insulin syringe) - Tier 2; PA; QL

147 Preferred Agents Non-Preferred Agents sea-omega (generic for SEA-OMEGA) - Tier 1; QL INSULIN SYRINGES 28G X 5/16" 1 ML, 30G X 3/8" 0.5 ML - Tier 2; PA; SOLARTEK GLUCOSE CONTROL (brand for verasens glucose control) QL - Tier 2; QL INSULIN SYRINGES 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 SSKI - Tier 2; QL ML (brand for sure comfort insulin syringe) - Tier 2; PA; QL TRUE METRIX AIR GLUCOSE METER KIT (brand for kroger blood INSULIN SYRINGES 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML (brand for glucose) - Tier 2; QL global easy glide insulin syr) - Tier 2; PA; QL TRUE METRIX GO GLUCOSE METER (brand for kroger blood glucose) INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for ms insulin syringe) - - Tier 2; QL Tier 2; PA; QL TRUE METRIX METER KIT (brand for kroger blood glucose) - Tier 2; INSULIN SYRINGES 31G X 5/16" 0.5 ML (brand for longs insulin syringe) - QL Tier 2; PA; QL TRUECONTROL GLUCOSE CONT LEV 0 (brand for verasens glucose IODINE STRONG ORAL - Tier 2; PA; QL control) - Tier 2; QL IOSAT - Tier 2; PA TRUECONTROL GLUCOSE CONT LEV 1 (brand for verasens glucose isoleucine - Tier 1; PA control) - Tier 2; QL ISOLEUCINE 1000 - Tier 2; PA TRUEPLUS LANCETS 30G (brand for walgreens lancets super thin) - kelp-b6-lecithin-vinegar - Tier 1; PA Tier 2; QL KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION TRUEPLUS SAFETY LANCETS 28G (brand for walgreens lancets PREFILLED SYRINGE 50-0.9 MG/5ML-% - Tier 2; PA super thin) - Tier 2; QL KEY OMEGA - Tier 2; PA TUBING/WING TIP - Tier 2; QL korean ginseng oral capsule 250 mg, 350 mg - Tier 1; PA VAPORIZER WARM STEAM - Tier 2; QL KROGER BLOOD GLUCOSE KIT - Tier 2; PA; QL VIOS AEROSOL DELIVERY SYSTEM (brand for soothe neb mesh KROGER TEST - Tier 2; PA; QL nebulizer) - Tier 2 LANCETS - Tier 2; PA; QL VIOS LC PLUS (brand for soothe neb mesh nebulizer) - Tier 2 l-arginine oral capsule - Tier 1; PA VIOS LC PLUS DELUXE (brand for soothe neb mesh nebulizer) - Tier 2 l-carnitine - Tier 1; PA VIOS LC PLUS PEDIATRIC (brand for soothe neb mesh nebulizer) - L-CYSTINE - Tier 2; PA Tier 2 lecithin oral capsule - Tier 1; PA VIOS LC SPRINT (brand for soothe neb mesh nebulizer) - Tier 2 leucine oral - Tier 1; PA VIOS LC SPRINT PEDIATRIC (brand for soothe neb mesh nebulizer) - LIMBREL - Tier 2; PA Tier 2 LIMBREL250 - Tier 2; PA VISTOGARD - Tier 2; QL LIMBREL500 - Tier 2; PA WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL L-ISOLEUCINE - Tier 2; PA WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL l-lysine hcl oral tablet 500 mg - Tier 1; PA WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL l-lysine oral tablet 1000 mg, 500 mg - Tier 1; PA WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL l-methylfolate forte (generic for DEPLIN 7.5) - Tier 1; PA

148 Preferred Agents Non-Preferred Agents WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL l-methylfolate-algae (generic for DEPLIN 15) - Tier 1; PA WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL LTXF PRIM CNV PIN MICRODRIP (brand for solution transfer device) - WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL Tier 2; PA WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL LTXF PRIM IV SET/CNVT PIN (brand for solution transfer device) - Tier 2; ZEASORB-AF (brand for antifungal) - Tier 2; QL PA LTXF SECONDARY/CNV PIN/32INC (brand for solution transfer device) - Tier 2; PA l-tyrosine oral capsule - Tier 1; PA lysine hcl oral tablet 1000 mg - Tier 1; PA MACRILEN - Tier 2; PA; SP; QL methionine oral - Tier 1; PA METHOHEXITAL SODIUM - Tier 2; PA METOPIRONE - Tier 2; PA MICRODOT PEN NEEDLE (brand for true comfort pro pen needles) - Tier 2; PA; QL MICRODOT TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL MINILINK REAL-TIME TRANSMITTER - Tier 2; PA; QL MKO MELT DOSE PACK - Tier 2; PA; QL MM EASY TOUCH GLUCOSE METER (brand for kroger blood glucose) - Tier 2; PA; QL MORCIN - Tier 2; PA natural fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH OIL CONC) - Tier 1; PA NERVE PAIN RELIEF - Tier 2; PA NEURAGEN PN (brand for ichthammol drawing salve) - Tier 2; PA NEUTEK 2TEK TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL NICAPRIN (brand for zyvexol) - Tier 2; PA NICAZYME - Tier 2; PA NORDIPEN 5 INJECTION DEVICE (brand for inject-ease) - Tier 2; PA NORDIPEN DELIVERY SYSTEM (brand for inject-ease) - Tier 2; PA NOVOTWIST PEN NEEDLE (brand for pure comfort pen needle) - Tier 2; PA; QL OCEAN BLUE MINICAPS OMEGA-3 - Tier 2; PA

149 Preferred Agents Non-Preferred Agents omega-3 fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH OIL CONC) - Tier 1; PA omega-3 fish oil oral capsule 300 mg (generic for FISH OIL PEARLS) - Tier 1; PA omega-3 oral capsule 1400 mg - Tier 1; PA OMNITROPE PEN 5 INJ DEVICE (brand for inject-ease) - Tier 2; PA OMNIVEX - Tier 2; PA ONETOUCH SURESOFT LANCING DEVICE (brand for lancet transporter case) - Tier 2; PA; QL ONETOUCH ULTRA MINI KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; PA; QL ONETOUCH ULTRALINK (brand for kroger blood glucose) - Tier 2; PA; QL ONETOUCH VERIO IN VITRO SOLUTION HIGH (brand for easy talk control) - Tier 2; PA; QL OPTIUM BLOOD GLUCOSE MONITOR (brand for kroger blood glucose) - Tier 2; PA; QL OPTIUM GLUCOSE MONITOR SYSTEM (brand for verasens blood glucose meter) - Tier 2; PA; QL OPTIUM TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL OPTIUMEZ TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL PALFORZIA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (120 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (160 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (200 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (240 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (3 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (300 MG MAINTENANCE) - Tier 2; PA; SP; QL PALFORZIA (300 MG TITRATION) - Tier 2; PA; SP; QL PALFORZIA (40 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (6 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA (80 MG DAILY DOSE) - Tier 2; PA; SP; QL PALFORZIA INITIAL ESCALATION - Tier 2; PA; SP; QL PARADIGM REAL-TIME TRANSMITTER - Tier 2; PA; QL

150 Preferred Agents Non-Preferred Agents PARI TREK S COMBO PACK (brand for co monitor) - Tier 2; PA PENLET II BLOOD SAMPLER (brand for select-lite device/lancets) - Tier 2; PA; QL PENLET II REPLACEMENT CAP (brand for lancet transporter case) - Tier 2; PA; QL phenylalanine - Tier 1; PA PKU EASY MICROTABS - Tier 2; PA pre protein oral tablet (generic for PRE PROTEIN) - Tier 1; PA PRECISION LINK (brand for kroger blood glucose) - Tier 2; PA; QL PRECISION PCX (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION PCX PLUS TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION POINT OF CARE TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION QID MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION QID TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION SOF-TACT MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION SOF-TACT TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION XTRA (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION XTRA BLOOD GLUCOSE (brand for gnp easy touch glucose test) - Tier 2; PA; QL PRECISION XTRA KETONE - Tier 2; PA; QL PRECISION XTRA MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PREMIUM BLOOD GLUCOSE TEST - Tier 2; PA; QL prenatal dha - Tier 1; PA PREPROTEIN - Tier 2; PA PREPROTEIN 20 - Tier 2; PA PRID (brand for ichthammol drawing salve) - Tier 2; PA

151 Preferred Agents Non-Preferred Agents PRO NUTRIENTS OMEGA 3 - Tier 2; PA PRO-CRITIC - Tier 2; PA PROLEVA - Tier 2; PA PRONUTRIENTS COQ10 (brand for co q 10) - Tier 2; PA PROTEINEX ORAL LIQUID - Tier 2; PA proteinex oral tablet (generic for PRE PROTEIN) - Tier 1; PA PROTEINEX P100 - Tier 2; PA PROTEINEX P18 - Tier 2; PA PROTEINEX-18 - Tier 2; PA PSORIZIDE FORTE (brand for bhi sinus relief) - Tier 2; PA PSORIZIDE ULTRA (brand for bhi sinus relief) - Tier 2; PA PSS SELECT PLATFORMS (brand for lancet transporter case) - Tier 2; PA; QL pure l-arginine hcl - Tier 1; PA pure l-citrulline oral capsule - Tier 1; PA pure l-tyrosine - Tier 1; PA QUINTET AC BLOOD GLUCOSE (brand for verasens blood glucose meter) - Tier 2; PA; QL QUINTET AC BLOOD GLUCOSE TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL QUINTET BLOOD GLUCOSE SYSTEM (brand for verasens blood glucose meter) - Tier 2; PA; QL QUINTET BLOOD GLUCOSE TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL RADIOGARDASE - Tier 2; PA RAPID GEL RX - Tier 2; PA RELION TRUE MET AIR GLUC METER (brand for kroger blood glucose) - Tier 2; PA; QL RELION TRUE METRIX TEST STRIPS (brand for gnp easy touch glucose test) - Tier 2; PA; QL RELION ULTIMA GLUCOSE SYSTEM (brand for kroger blood glucose) - Tier 2; PA; QL RELION ULTIMA TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL

152 Preferred Agents Non-Preferred Agents RUZURGI - Tier 2; PA; SP; QL SAFE-T-LANCE (brand for walgreens lancets super thin) - Tier 2; PA; QL sam-e.p.a. (generic for OVEGA-3) - Tier 1; PA SOLUTION TRANSFER DEVICE - Tier 2; PA SOLVIL - Tier 2; PA soya lecithin - Tier 1; PA SPEEDGEL RX (brand for arnicare) - Tier 2; PA SYRINGE AVITENE - Tier 2; PA taurine oral - Tier 1; PA THERATEARS NUTRITION - Tier 2; PA THROMBI-GEL 10 - Tier 2; PA THROMBI-GEL 100 - Tier 2; PA THROMBI-GEL 40 - Tier 2; PA THROMBI-PAD - Tier 2; PA tolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) - Tier 1; PA TRANZGEL (brand for arnicare) - Tier 2; PA TRAUMEEL EXTERNAL (brand for ichthammol drawing salve) - Tier 2; PA TRAUMEEL ORAL (brand for bhi sinus relief) - Tier 2; PA TRUE FOCUS BLOOD GLUCOSE STRIP - Tier 2; PA; QL TRUE METRIX AIR GLUCOSE METER DEVICE (brand for verasens blood glucose meter) - Tier 2; PA; QL TRUEPLUS LANCETS 30G (brand for walgreens lancets super thin) - Tier 2; PA; QL TRUEPLUS SAFETY LANCETS 28G (brand for walgreens lancets super thin) - Tier 2; PA; QL TRUETRACK BLOOD GLUCOSE (brand for verasens blood glucose meter) - Tier 2; PA; QL TRUETRACK TEST (brand for gnp easy touch glucose test) - Tier 2; PA; QL TYLACTIN COMPLETE 15 PE - Tier 2; PA tyrosine - Tier 1; PA ULTIMA - Tier 2; PA; QL ULTRA HERS RX - Tier 2; PA

153 Preferred Agents Non-Preferred Agents ULTRA HIS - Tier 2; PA ULTRA PCOS - Tier 2; PA ULTRAFOAM SPONGE 2X6.25X7CM - Tier 2; PA ULTRAFOAM SPONGE 8X12.5X1CM - Tier 2; PA ULTRAFOAM SPONGE 8X12.5X3CM - Tier 2; PA ULTRAFOAM SPONGE 8X25X1CM - Tier 2; PA ULTRAFOAM SPONGE 8X6.25X1CM - Tier 2; PA UNISTRIP CONTROL (brand for easy talk control) - Tier 2; PA; QL UNISTRIP1 GENERIC (brand for gnp easy touch glucose test) - Tier 2; PA; QL VALINE 1000 - Tier 2; PA valine oral - Tier 1; PA VASCULERA (brand for zyvexol) - Tier 2; PA VASOFLEX D1 - Tier 2; PA venaliv - Tier 1; PA VORTEX HOLD CHMBR/MASK/CHILD (brand for co monitor) - Tier 2; PA VORTEX HOLD CHMBR/MASK/TODDLER (brand for co monitor) - Tier 2; PA VORTEX VALVED HOLDING CHAMBER (brand for breathe ease large) - Tier 2; PA; QL water tabs - Tier 1; PA WELLMIND VERTIGO (brand for bhi sinus relief) - Tier 2; PA XYZBAC - Tier 2; PA XYZMUNE - Tier 2; PA ZEEL EXTERNAL (brand for ichthammol drawing salve) - Tier 2; PA ZOKINVY - Tier 2; PA; SP; QL ZYVEXOL - Tier 2; PA ZYVIT - Tier 2; PA

Not Specified ADUHELM - Tier 2; PA SODIUM IODIDE I-131 - Tier 2; PA WEGOVY - Tier 2; PA

154 Preferred Agents Non-Preferred Agents

Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1; QL altafrin (generic for ALTAFRIN) - Tier 1; PA altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 artificial tears ophthalmic solution 0.5-0.6 %, 5-6 mg/ml - Tier 1; PA altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL artificial tears ophthalmic solution 1-0.3 % (generic for MOISTURE EYES) - altalube (generic for ALTALUBE) - Tier 1; QL Tier 1; PA artificial eye (generic for ALTALUBE) - Tier 1; QL ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % - Tier 2; PA; QL artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1; QL BIO GLO - Tier 2; PA artificial tears ophthalmic solution (generic for GENTEAL TEARS) - BLEPHAMIDE (brand for sulfacetamide-prednisolone) - Tier 2; PA; QL Tier 1 BLEPHAMIDE S.O.P. - Tier 2; PA artificial tears ophthalmic solution 1.4 % - Tier 1 CEQUA - Tier 2; PA; QL astringent eye drops (generic for VISINE-AC) - Tier 1; QL CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (brand for atropine sulfate ophthalmic ointment - Tier 1 cyclopentolate hcl) - Tier 2; PA atropine sulfate ophthalmic solution 1 % (generic for ISOPTO CYCLOGYL OPHTHALMIC SOLUTION 1 % (brand for cyclopentolate hcl) - ATROPINE) - Tier 1; QL Tier 2; PA; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1; QL CYCLOSPORINE IN KLARITY - Tier 2; PA; QL bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; CYSTADROPS - Tier 2; PA; SP; QL QL CYSTARAN - Tier 2; PA; SP; QL BIOLLE TEARS (brand for eq restore plus lubricant eye) - Tier 2 FLUCAINE (brand for proparacaine-fluorescein) - Tier 2; PA carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) fluor-i-strips a.t. - Tier 1; PA - Tier 1; QL FLURA-SAFE - Tier 2; PA cyclopentolate hcl ophthalmic solution 0.5 %, 2 % (generic for FRESHKOTE - Tier 2; PA CYCLOGYL) - Tier 1 FUL-GLO - Tier 2; PA cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - GELFILM OPHTHALMIC - Tier 2; PA Tier 1; QL GLOSTRIPS OPHTHALMIC STRIP 1 MG - Tier 2; PA dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL GONAK - Tier 2; PA eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - goniotaire - Tier 1; PA Tier 1; QL GONIOVISC OPHTHALMIC SOLUTION 2.5 % - Tier 2; PA eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL GREEN GLO LISSAMINE GREEN - Tier 2; PA eye drops long lasting (generic for SYSTANE) - Tier 1; QL HYPOCYN - Tier 2; PA eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; PA; QL ADVANCED RELIEF) - Tier 1; QL ISOPTO TEARS - Tier 2; PA

155 Preferred Agents Non-Preferred Agents eye lubricant (generic for ALTALUBE) - Tier 1; QL LACRISERT - Tier 2; PA for sty relief (generic for ALTALUBE) - Tier 1; QL LASTACAFT - Tier 2; PA GENTEAL SEVERE - Tier 2; QL lubricant eye ophthalmic solution 1-0.3 % (generic for MOISTURE EYES) - GENTEAL TEARS (brand for sm artificial tears) - Tier 2 Tier 1; PA GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) - Tier lubricating eye drops ophthalmic solution 0.5-0.9 % (generic for REFRESH 2 OPTIVE) - Tier 1; PA GENTEAL TEARS NIGHT-TIME (brand for lubricant pm) - Tier 2; QL lubricating/dry eye (generic for REFRESH OPTIVE) - Tier 1; PA GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2 MAXITROL (brand for neomycin-polymyxin-dexameth) - Tier 2; PA; QL GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL MEMBRANEBLUE - Tier 2; PA HYPOTEARS (brand for lubricant pm) - Tier 2; QL neomycin-polymyxin-hc ophthalmic - Tier 1; PA; QL lubricant drops fast act (generic for SYSTANE) - Tier 1; QL OXERVATE - Tier 2; PA; SP; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL PAREMYD - Tier 2; PA lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1; PA lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) POLYTRIM (brand for polymyxin b-trimethoprim) - Tier 2; PA; QL - Tier 1; QL PRED-G - Tier 2; PA lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for PRED-G S.O.P. - Tier 2; PA SYSTANE HYDRATION PF) - Tier 1; QL PREDNISOLONE-BROMFENAC - Tier 2; PA; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE proparacaine-fluorescein (generic for FLUCAINE) - Tier 1; PA TEARS) - Tier 1 REFRESH OPTIVE OPHTHALMIC SOLUTION (brand for lubricating eye lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for drops) - Tier 2; PA SYSTANE) - Tier 1; QL REFRESH OPTIVE PF - Tier 2; PA lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA REFRESH RELIEVA (brand for lubricating eye drops) - Tier 2; PA FRESH) - Tier 1; QL REFRESH RELIEVA PF OPHTHALMIC SOLUTION 0.5-0.9 % - Tier 2; PA lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE RESTASIS MULTIDOSE - Tier 2; PA; QL COMPLETE) - Tier 1; QL RHOPRESSA - Tier 2; PA; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 ROCKLATAN - Tier 2; PA; QL lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL TOBRADEX ST - Tier 2; PA; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; PA; QL Tier 1; QL VISIONBLUE - Tier 2; PA lubricant eye pm (generic for ALTALUBE) - Tier 1; QL XIIDRA - Tier 2; PA; QL lubricant pm (generic for ALTALUBE) - Tier 1; QL ZYLET - Tier 2; PA; QL lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL

156 Preferred Agents Non-Preferred Agents lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 MURO 128 OPHTHALMIC OINTMENT (brand for sodium chloride (hypertonic)) - Tier 2 MURO 128 OPHTHALMIC SOLUTION 5 % (brand for sodium chloride (hypertonic)) - Tier 2; QL natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-gramicidin - Tier 1; QL neo-polycin (generic for NEO-POLYCIN) - Tier 1 neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL polycin (generic for POLYCIN) - Tier 1; QL polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QL polyvinyl alcohol ophthalmic - Tier 1 PURALUBE (brand for lubricant pm) - Tier 2; QL pure & gentle lubricant - Tier 1 REFRESH LACRI-LUBE (brand for lubricant pm) - Tier 2; QL REFRESH P.M. (brand for lubricant pm) - Tier 2; QL REFRESH PLUS (brand for eq restore plus lubricant eye) - Tier 2 REFRESH TEARS (brand for ra lubricant eye drops) - Tier 2; QL relief eye drops (generic for VISINE-AC) - Tier 1; QL RESTASIS - Tier 2; PA; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1 restore pm (generic for ALTALUBE) - Tier 1; QL sodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1

157 Preferred Agents Non-Preferred Agents sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) - Tier 1 sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - Tier 1; QL sulfacetamide-prednisolone ophthalmic solution - Tier 1 SYSTANE (brand for goodsense ultra lubricant drop) - Tier 2; QL SYSTANE COMPLETE (brand for ra lubricant eye drops) - Tier 2; QL SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2 SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE NIGHTTIME (brand for lubricant pm) - Tier 2; QL SYSTANE OVERNIGHT THERAPY - Tier 2; QL SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops (pf)) - Tier 2; QL SYSTANE ULTRA (brand for goodsense ultra lubricant drop) - Tier 2; QL SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2; QL TEARS AGAIN (brand for lubricant pm) - Tier 2; QL TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for sm artificial tears) - Tier 2 tears pure (generic for GENTEAL TEARS) - Tier 1 TOBRADEX - Tier 2; QL ultra fresh (generic for ULTRA FRESH) - Tier 1; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL VISINE ADVANCED RELIEF (brand for eye drops advanced relief) - Tier 2; QL VISTA GEL DRY EYE RELIEF - Tier 2; QL VISTA MEIBO TEARS (brand for ra lubricant eye drops) - Tier 2; QL VISTA TEARS (brand for goodsense ultra lubricant drop) - Tier 2; QL

158 Preferred Agents Non-Preferred Agents

Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs azelastine hcl ophthalmic - Tier 1 ALOCRIL - Tier 2; PA cromolyn sodium ophthalmic - Tier 1; QL ALOMIDE - Tier 2; PA CYCLOMYDRIL - Tier 2 bepotastine besilate (generic for BEPREVE) - Tier 1; PA; QL eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE BEPREVE (brand for bepotastine besilate) - Tier 2; PA; QL COMFORT) - Tier 1 epinastine hcl - Tier 1; PA NAPHCON-A (brand for eye allergy relief) - Tier 2 eye allergy relief (generic for OPCON-A) - Tier 1; PA olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL TROPICAMIDE-CYCLOPENTOLATE-PE - Tier 2; PA; QL PATADAY OPHTHALMIC SOLUTION 0.1 % (brand for hm eye allergy ZERVIATE - Tier 2; PA; QL itch/red relief) - Tier 2; QL PATADAY OPHTHALMIC SOLUTION 0.2 % (brand for eye allergy itch relief) - Tier 2; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; QL VASOCLEAR-A - Tier 2; QL VISINE (brand for eye allergy relief) - Tier 2

Ophthalmic Antibiotics - Drugs to treat Eye Infections CILOXAN OPHTHALMIC OINTMENT - Tier 2 AZASITE - Tier 2; PA; QL ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QL bacitracin ophthalmic - Tier 1; PA; QL erythromycin ophthalmic - Tier 1; QL BESIVANCE - Tier 2; PA; QL gentamicin sulfate ophthalmic - Tier 1; QL CILOXAN OPHTHALMIC SOLUTION (brand for ciprofloxacin hcl) - Tier 2; ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL PA; QL tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL gatifloxacin ophthalmic (generic for ZYMAXID) - Tier 1; PA; QL TOBREX OPHTHALMIC OINTMENT - Tier 2; QL gentak - Tier 1; PA; QL KLARITY-A - Tier 2; PA; QL levofloxacin ophthalmic - Tier 1; PA OCUFLOX (brand for ofloxacin) - Tier 2; PA; QL TOBREX OPHTHALMIC SOLUTION (brand for tobramycin) - Tier 2; PA; QL

159 Preferred Agents Non-Preferred Agents ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL

Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL apraclonidine hcl - Tier 1; PA; QL acetazolamide oral - Tier 1; QL BETIMOL - Tier 2; PA; QL ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % - Tier 2; PA; QL BETOPTIC-S - Tier 2; PA; QL ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brand for brimonidine brimonidine tartrate ophthalmic solution 0.15 % (generic for ALPHAGAN P) tartrate) - Tier 2; QL - Tier 1; PA; QL AZOPT (brand for brinzolamide) - Tier 2; PA; ST; QL BRIMONIDINE-DORZOLAMIDE - Tier 2; PA; QL betaxolol hcl ophthalmic - Tier 1; QL brinzolamide (generic for AZOPT) - Tier 1; PA; ST; QL brimonidine tartrate ophthalmic solution 0.2 % - Tier 1; QL COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL carteolol hcl - Tier 1; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL COMBIGAN - Tier 2; PA; QL IOPIDINE - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL ISOPTO CARPINE (brand for pilocarpine hcl) - Tier 2; PA; QL dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISTALOL (brand for timolol maleate) - Tier 2; PA; QL 1; QL LATANOPROST-TIMOLOL MALEATE - Tier 2; PA; QL dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL timolol maleate ocudose (generic for TIMOPTIC OCUDOSE) - Tier 1; PA; dorzolamide hcl-timolol mal pf (generic for COSOPT PF) - Tier 1; QL QL levobunolol hcl - Tier 1; QL timolol maleate ophthalmic solution 0.5 % (daily) (generic for ISTALOL) - pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1; QL Tier 1; PA; QL SIMBRINZA - Tier 2; QL timolol maleate pf (generic for TIMOPTIC OCUDOSE) - Tier 1; PA; QL timolol maleate ophthalmic gel forming solution (generic for TIMOPTIC- TIMOLOL-BRIMON-DORZOL-LATANOPR - Tier 2; PA; QL XE) - Tier 1; QL TIMOLOL-BRIMONIDINE-DORZOLAMID - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for TIMOLOL-DORZOLAMID-LATANOPROST - Tier 2; PA; QL TIMOPTIC) - Tier 1; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL TIMOPTIC OCUDOSE - Tier 2; PA; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALAWAY (brand for sm eye itch relief) - Tier 2; QL ACULAR (brand for ketorolac tromethamine) - Tier 2; PA; QL

160 Preferred Agents Non-Preferred Agents ALAWAY CHILDRENS ALLERGY (brand for sm eye itch relief) - Tier 2; ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA QL ACUVAIL - Tier 2; PA; QL allergy eye drops (generic for ALAWAY) - Tier 1; QL ALREX - Tier 2; PA; QL CLARITIN EYE (brand for sm eye itch relief) - Tier 2; QL bromfenac sodium (once-daily) - Tier 1; PA dexamethasone sodium phosphate ophthalmic - Tier 1 BROMSITE - Tier 2; PA; QL diclofenac sodium ophthalmic - Tier 1; QL DOUBLE PM - Tier 2; PA DUREZOL - Tier 2; QL EYSUVIS - Tier 2; PA; QL eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - Tier FLAREX - Tier 2; PA; QL 1; QL FML LIQUIFILM (brand for fluorometholone) - Tier 2; PA; QL fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL ILEVRO - Tier 2; PA; QL flurbiprofen sodium - Tier 1; QL INVELTYS - Tier 2; PA; QL FML - Tier 2; QL KLARITY-L - Tier 2; PA; QL FML FORTE - Tier 2; QL LOTEMAX OPHTHALMIC GEL (brand for loteprednol etabonate) - Tier 2; ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR PA; QL LS) - Tier 1 LOTEMAX OPHTHALMIC OINTMENT - Tier 2; PA ketorolac tromethamine ophthalmic solution 0.5 % (generic for LOTEMAX OPHTHALMIC SUSPENSION (brand for loteprednol etabonate) ACULAR) - Tier 1; QL - Tier 2; PA; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL LOTEMAX SM - Tier 2; PA; QL PRED MILD - Tier 2; QL loteprednol etabonate (generic for LOTEMAX) - Tier 1; PA; QL prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; MAXIDEX - Tier 2; PA QL MITOSOL - Tier 2; PA prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL NEVANAC - Tier 2; PA; QL prednisolone sodium phosphate ophthalmic - Tier 1 PRED FORTE (brand for prednisolone acetate) - Tier 2; PA; QL ZADITOR (brand for sm eye itch relief) - Tier 2; QL PREDNISOL ACE-MOXIFLOX-BROMFEN - Tier 2; PA; QL PREDNISOLONE ACETATE-NEPAFENAC - Tier 2; PA; QL PREDNISOLONE ACET-MOXIFLOXACIN - Tier 2; PA; QL PREDNISOLONE-GATIFLOXACIN - Tier 2; PA; QL PREDNISOLONE-MOXIFLOXACIN - Tier 2; PA PREDNISOLON-GATIFLOX-BROMFENAC - Tier 2; PA; QL PREDNISOLON-MOXIFLOX-BROMFENAC - Tier 2; PA; QL PREDNISOLON-MOXIFLOX-NEPAFENAC - Tier 2; PA; QL PROLENSA - Tier 2; PA; QL TRIPLE PMB - Tier 2; PA TRIPLE PMK - Tier 2; PA

161 Preferred Agents Non-Preferred Agents

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL bimatoprost ophthalmic - Tier 1; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; ST; QL LUMIGAN - Tier 2; PA; QL travoprost (bak free) (generic for TRAVATAN Z) - Tier 1; PA; ST; QL VYZULTA - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL XELPROS - Tier 2; PA; QL ZIOPTAN - Tier 2; PA; QL

Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1; QL CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA; QL ciprofloxacin hcl otic (generic for CETRAXAL) - Tier 1; PA; QL CIPROFLOXACIN-FLUOCINOLONE PF - Tier 2; PA; QL OTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA; QL

Otic Agents - Drugs for the Ear acetic acid otic - Tier 1 ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; PA; QL CIPRO HC - Tier 2; QL cortic-nd - Tier 1; PA CIPRODEX (brand for ciprofloxacin-dexamethasone) - Tier 2; QL CORTISPORIN-TC - Tier 2; PA CLEARCANAL EARWAX SOFTENER (brand for cvs ear drops) - Tier 2 DERMOTIC (brand for fluocinolone acetonide) - Tier 2; PA; QL ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1; PA; QL ear drops earwax aid (generic for CLEARCANAL EARWAX PRAMOTIC - Tier 2; PA SOFTENER) - Tier 1 ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1

162 Preferred Agents Non-Preferred Agents ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal kit otic solution 6.5 % (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 flac (generic for FLAC) - Tier 1; QL fluocinolone acetonide otic (generic for FLAC) - Tier 1; QL neomycin-polymyxin-hc otic - Tier 1; QL

Regulators - Drugs to Regulate Blood Sugar Insulins - Diabetic Drugs LYUMJEV - Tier 2; PA; QL LYUMJEV KWIKPEN - Tier 2; PA; QL

Respiratory Tract Agents Respiratory Tract Agents, Other DUAKLIR PRESSAIR - Tier 2; PA; QL

Respiratory Tract/Pulmonary Agents Respiratory Tract Agents, Other BREZTRI AEROSPHERE - Tier 2; PA

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions

163 Preferred Agents Non-Preferred Agents Antihistamines - Allergy Drugs allergy oral tablet extended release 12 mg (generic for CHLOR- CLOBETEX - Tier 2; PA; QL TRIMETON ALLERGY) - Tier 1; QL allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1; QL CHLOR-TRIMETON ALLERGY (brand for allergy) - Tier 2; QL CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2; QL ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; QL

Antihistamines - Drugs to Treat Allergies ALAVERT (brand for cvs allergy relief) - Tier 2; QL 24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; PA; QL all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; ALLEGRA ALLERGY (brand for sm fexofenadine hcl) - Tier 2; PA; QL QL ALLEGRA ALLERGY CHILDRENS ORAL SUSPENSION (brand for cvs aller-chlor (generic for CHLOR-TRIMETON) - Tier 1; QL allergy relief childrens) - Tier 2; PA; QL allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE - Tier 2; allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1; QL PA allergy 4 hour (generic for CHLOR-TRIMETON) - Tier 1; QL aller-ease (generic for KLS ALLER-FEX) - Tier 1; PA; QL allergy antihistamine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; aller-fex (generic for KLS ALLER-FEX) - Tier 1; PA; QL QL allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; PA; QL allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief childrens oral suspension 30 mg/5ml (generic for ALLEGRA allergy medication (generic for BANOPHEN) - Tier 1; QL ALLERGY CHILDRENS) - Tier 1; PA; QL allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL allergy relief oral capsule 10 mg (generic for ZYRTEC ALLERGY) - Tier 1; allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) PA - Tier 1; QL allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; PA; allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL QL allergy oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; QL allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier 1; allergy rel child (loratadine) (generic for CLARITIN ALLERGY PA; QL CHILDRENS) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS ALLER- allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-TEC) FEX) - Tier 1; PA; QL - Tier 1; QL

164 Preferred Agents Non-Preferred Agents allergy relief 4-hour (generic for CHLOR-TRIMETON) - Tier 1; QL carbinoxamine maleate oral tablet 6 mg (generic for RYVENT) - Tier 1; PA; allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL QL allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL CLARINEX (brand for desloratadine) - Tier 2; PA; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - Tier CLARITIN ORAL CAPSULE (brand for goodsense allergy relief) - Tier 2; 1; QL PA allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG - Tier 2; PA DIPHEDRYL ALLERGY) - Tier 1; QL desloratadine oral tablet (generic for CLARINEX) - Tier 1; PA; QL allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN desloratadine oral tablet dispersible 5 mg - Tier 1; PA; QL ALLERGY CHILDRENS) - Tier 1; QL DICOPANOL FUSEPAQ - Tier 2; PA allergy relief childrens oral tablet chewable 5 mg (generic for CLARITIN) DICOPANOL RAPIDPAQ - Tier 2; PA - Tier 1 fexofenadine hcl oral (generic for ALLEGRA ALLERGY) - Tier 1; PA; QL allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL fexofenadine hydrochloride (generic for KLS ALLER-FEX) - Tier 1; PA; QL allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA HISTEX PD (brand for triprolidine hcl) - Tier 2; PA DIPHEDRYL ALLERGY) - Tier 1; QL KARBINAL ER - Tier 2; PA; QL allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; levocetirizine dihydrochloride oral solution (generic for XYZAL ALLERGY QL 24HR CHILDRENS) - Tier 1; PA allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY allergy relief oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; 24HR) - Tier 1; PA; QL QL loratadine oral capsule (generic for CLARITIN) - Tier 1; PA allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL m-hist pd (generic for PEDIACLEAR PD CHILDRENS) - Tier 1; PA ALLERGY CHILDRENS) - Tier 1; QL nighttime sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1; PA allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier PATANASE (brand for olopatadine hcl) - Tier 2; PA; QL 1; QL pediaclear pd childrens (generic for PEDIACLEAR PD CHILDRENS) - Tier allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL 1; PA allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- RYCLORA (brand for dexchlorpheniramine maleate) - Tier 2; PA; QL TEC) - Tier 1; QL ryvent (generic for RYVENT) - Tier 1; PA; QL aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1; PA anti-hist allergy (generic for BANOPHEN) - Tier 1; QL sleep aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier - Tier 1; PA 1; QL sleep aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; azelastine hcl nasal - Tier 1; QL PA banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL sleep-aid max st (generic for UNISOM SLEEPGELS) - Tier 1; PA banophen oral tablet (generic for BANOPHEN) - Tier 1; QL sleep-aid nighttime oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; PA

165 Preferred Agents Non-Preferred Agents BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for gnp sleep-aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1; allergy antihistamine) - Tier 2; QL PA BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE triprolidine hcl oral liquid 0.313 mg/ml - Tier 1; PA; QL (brand for diphenhydramine hcl) - Tier 2; QL triprolidine hcl oral liquid 0.625 mg/ml (generic for PEDIACLEAR PD BENADRYL ALLERGY ORAL TABLET (brand for total allergy) - Tier 2; CHILDRENS) - Tier 1; PA QL triprolidine hcl oral liquid 0.938 mg/ml (generic for HISTEX PD) - Tier 1; PA carbinoxamine maleate oral solution - Tier 1; QL VISTARIL (brand for hydroxyzine pamoate) - Tier 2; PA; QL carbinoxamine maleate oral tablet 4 mg - Tier 1; QL ZYRTEC ALLERGY CHILDRENS - Tier 2; PA cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1; QL ZYRTEC ALLERGY ORAL CAPSULE (brand for allergy relief) - Tier 2; PA cetirizine hcl childrens oral tablet chewable (generic for WAL-ZYR ZYRTEC ALLERGY ORAL TABLET DISPERSIBLE - Tier 2; PA CHILDRENS) - Tier 1; QL childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL chlor-pheniramine (generic for CHLOR-TRIMETON) - Tier 1; QL chlorpheniramine maleate oral (generic for CHLOR-TRIMETON) - Tier 1; QL chlortabs (generic for CHLOR-TRIMETON) - Tier 1; QL CHLOR-TRIMETON ORAL TABLET (brand for hm allergy relief) - Tier 2; QL CLARITIN ALLERGY CHILDRENS (brand for sm childrens loratadine) - Tier 2; QL CLARITIN CHILDRENS (brand for eq loratadine childrens) - Tier 2 CLARITIN ORAL TABLET (brand for qc loratadine allergy relief) - Tier 2; QL CLARITIN ORAL TABLET CHEWABLE (brand for eq loratadine childrens) - Tier 2 CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for cvs allergy relief) - Tier 2; QL clemastine fumarate oral syrup - Tier 1; QL clemastine fumarate oral tablet 2.68 mg - Tier 1; QL complete allergy (generic for BANOPHEN) - Tier 1; QL

166 Preferred Agents Non-Preferred Agents complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1; QL complete allergy relief (generic for BANOPHEN) - Tier 1; QL cyproheptadine hcl oral - Tier 1; QL DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2; QL diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphen - Tier 1; QL di-phen - Tier 1; QL diphenhist (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral elixir - Tier 1; QL diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral tablet chewable (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL dye-free allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL geri-dryl (generic for BANOPHEN) - Tier 1; QL h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL hydroxyzine pamoate oral - Tier 1; QL indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL loradamed (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL

167 Preferred Agents Non-Preferred Agents loratadine childrens oral tablet chewable (generic for CLARITIN) - Tier 1 loratadine oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine oral tablet (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL MICLARA LQ - Tier 2 mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1; QL NARAMIN (brand for gnp allergy antihistamine) - Tier 2; QL olopatadine hcl nasal (generic for PATANASE) - Tier 1; QL pharbechlor (generic for CHLOR-TRIMETON) - Tier 1; QL pharbedryl (generic for BANOPHEN) - Tier 1; QL promethazine hcl oral - Tier 1; QL promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL promethegan - Tier 1; QL sb allergy medicine oral tablet (generic for BANOPHEN) - Tier 1; QL siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL total allergy (generic for BANOPHEN) - Tier 1; QL total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2; QL triprolidine hcl oral liquid 2.5 mg/5ml - Tier 1; QL ZYRTEC ALLERGY ORAL TABLET (brand for qc all day allergy) - Tier 2; QL

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL ALVESCO - Tier 2; PA; QL aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL ARMONAIR DIGIHALER - Tier 2; PA; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - ARNUITY ELLIPTA - Tier 2; PA; QL Tier 1; QL ASMANEX HFA - Tier 2; PA; QL ASMANEX (120 METERED DOSES) - Tier 2; QL BECONASE AQ - Tier 2; PA; QL ASMANEX (14 METERED DOSES) - Tier 2; QL mometasone furoate nasal (generic for NASONEX) - Tier 1; PA; QL

168 Preferred Agents Non-Preferred Agents ASMANEX (30 METERED DOSES) - Tier 2; QL NASONEX (brand for mometasone furoate) - Tier 2; PA; QL ASMANEX (60 METERED DOSES) - Tier 2; QL OMNARIS - Tier 2; PA; QL ASMANEX (7 METERED DOSES) - Tier 2; QL PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA; QL budesonide inhalation (generic for PULMICORT) - Tier 1; QL QNASL - Tier 2; PA; QL FLOVENT DISKUS - Tier 2; QL QNASL CHILDRENS - Tier 2; PA; QL FLOVENT HFA - Tier 2; QL QVAR REDIHALER - Tier 2; PA; QL flunisolide nasal - Tier 1; QL XHANCE - Tier 2; PA; QL fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL ZETONNA - Tier 2; PA; QL NASACORT ALLERGY 24HR (brand for triamcinolone acetonide) - Tier 2; QL NASACORT ALLERGY 24HR CHILDREN (brand for triamcinolone acetonide) - Tier 2; QL nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; QL PULMICORT FLEXHALER - Tier 2; QL

Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL ACCOLATE (brand for zafirlukast) - Tier 2; PA; ST; QL zafirlukast (generic for ACCOLATE) - Tier 1; ST; QL SINGULAIR (brand for montelukast sodium) - Tier 2; PA; QL zileuton er - Tier 1; PA; QL ZYFLO - Tier 2; PA; QL

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL INCRUSE ELLIPTA - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL LONHALA MAGNAIR REFILL KIT - Tier 2; PA; QL ipratropium bromide nasal - Tier 1; QL LONHALA MAGNAIR STARTER KIT - Tier 2; PA; QL SPIRIVA HANDIHALER - Tier 2; QL TUDORZA PRESSAIR - Tier 2; PA; QL SPIRIVA RESPIMAT - Tier 2; QL YUPELRI - Tier 2; PA; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs

169 Preferred Agents Non-Preferred Agents albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg - ADRENALIN INJECTION SOLUTION 1 MG/ML - Tier 2; PA; QL Tier 1 ADYPHREN (brand for epinephrine professional) - Tier 2; PA; QL albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation ADYPHREN AMP (brand for epinephrine professional) - Tier 2; PA; QL (generic for PROAIR HFA) - Tier 1; QL ADYPHREN AMP II (brand for epinephrine professional) - Tier 2; PA; QL albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation ADYPHREN II (brand for epinephrine professional) - Tier 2; PA; QL (generic for PROAIR HFA) - Tier 1; PA; QL ARFORMOTEROL TARTRATE - Tier 2; PA; QL ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) asthmanefrin refill - Tier 1; PA MCG/ACT INHALATION - Tier 2; QL AUVI-Q (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml - Tier 1; QL epinephrine injection solution auto-injector 0.15 mg/0.15ml (generic for ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% AUVI-Q) - Tier 1; PA; QL INHALATION - Tier 2; QL EPINEPHRINE PROFESSIONAL - Tier 2; PA; QL albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier 1; epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for QL EPIPEN JR 2-PAK) - Tier 1; PA; QL albuterol sulfate oral syrup - Tier 1; QL epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for AUVI- albuterol sulfate oral tablet 2 mg - Tier 1 Q) - Tier 1; PA; QL albuterol sulfate oral tablet 4 mg - Tier 1; QL EPINEPHRINESNAP-EMS (brand for epinephrine professional) - Tier 2; epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for PA; QL EPIPEN JR 2-PAK) - Tier 1; QL EPINEPHRINESNAP-V (brand for epinephrine professional) - Tier 2; PA; epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for QL AUVI-Q) - Tier 1; QL EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL PROAIR RESPICLICK - Tier 2; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL SEREVENT DISKUS - Tier 2; QL EPISNAP (brand for epinephrine professional) - Tier 2; PA; QL SYMJEPI - Tier 2; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; PA; QL terbutaline sulfate oral - Tier 1; QL LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT - Tier 2; PA; QL PERFOROMIST - Tier 2; PA; QL PROAIR DIGIHALER - Tier 2; PA; QL PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL S2 (RACEPINEPHRINE) - Tier 2; PA STRIVERDI RESPIMAT - Tier 2; PA; QL VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL XOPENEX NEB (brand for levalbuterol hcl) - Tier 2; PA; QL

170 Preferred Agents Non-Preferred Agents XOPENEX CONCENTRATE (brand for levalbuterol hcl) - Tier 2; PA; QL XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis KALYDECO - Tier 2; PA; SP; QL BETHKIS (brand for tobramycin) - Tier 2; PA; SP; QL KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL BRONCHITOL - Tier 2; PA; QL ORKAMBI - Tier 2; PA; SP; QL CAYSTON - Tier 2; PA; SP; QL SYMDEKO - Tier 2; PA; SP; QL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL tobramycin nebulization solution 300 mg/5ml inhalation (generic for TOBI PODHALER - Tier 2; PA; SP; QL KITABIS PAK) - Tier 1; PA; SP; QL tobramycin inhalation nebulization solution 300 mg/4ml (generic for TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION BETHKIS) - Tier 1; PA; SP; QL - Tier 2; PA; SP; QL TRIKAFTA TABLET THERAPY PACK 50-25-37.5 & 75 MG ORAL - Tier 2; TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG - PA Tier 2; PA; SP; QL

Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1; QL cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL NASALCROM (brand for cromolyn sodium) - Tier 2; QL

Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN - Tier 2; QL DALIRESP - Tier 2; PA; QL THEO-24 - Tier 2; QL theophylline - Tier 1; QL theophylline er - Tier 1; QL

Pulmonary Antihypertensives - Asthma/Lung Drugs alyq (generic for ALYQ) - Tier 1; PA; SP; QL ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP; QL ADEMPAS - Tier 2; PA; SP; QL

171 Preferred Agents Non-Preferred Agents sildenafil citrate oral suspension reconstituted (generic for REVATIO) - bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL Tier 1; PA; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA; OPSUMIT - Tier 2; PA; SP; QL SP; QL ORENITRAM - Tier 2; PA; SP; QL tadalafil (pah) (generic for ALYQ) - Tier 1; PA; SP; QL REMODULIN (brand for treprostinil) - Tier 2; PA TRACLEER (brand for bosentan) - Tier 2; PA; SP; QL REVATIO INTRAVENOUS (brand for sildenafil citrate) - Tier 2; PA REVATIO ORAL (brand for sildenafil citrate) - Tier 2; PA; SP; QL sildenafil citrate intravenous (generic for REVATIO) - Tier 1; PA treprostinil (generic for REMODULIN) - Tier 1; PA TYVASO - Tier 2; PA TYVASO REFILL - Tier 2; PA TYVASO STARTER - Tier 2; PA UPTRAVI - Tier 2; PA; SP; QL VENTAVIS INHALATION SOLUTION 10 MCG/ML - Tier 2; PA; QL VENTAVIS INHALATION SOLUTION 20 MCG/ML - Tier 2; PA

Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis ESBRIET - Tier 2; PA; SP; QL OFEV - Tier 2; PA; SP; QL

Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL 12hr allergy & congestion (generic for ALLEGRA-D ALLERGY & 12 hour decongestant (generic for SUDAFED SINUS CONGESTION CONGESTION) - Tier 1; PA; QL 12HR) - Tier 1 ADRENALIN NASAL - Tier 2; PA 12 hour mucus relief oral tablet extended release 12 hour 1200 mg ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL (generic for EQ MUCUS ER) - Tier 1; QL ADVAIR HFA - Tier 2; PA; QL 12 hour nasal decongestant (generic for SUDAFED SINUS AIRDUO DIGIHALER - Tier 2; PA; QL CONGESTION 12HR) - Tier 1 AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - Tier PA; QL 1 AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 PA; QL

172 Preferred Agents Non-Preferred Agents 4-WAY FAST ACTING (brand for sm nose drops nasal decongest) - Tier AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; PA; 2 QL 4-WAY MENTHOL (brand for sm nose drops nasal decongest) - Tier 2 ALAHIST CF - Tier 2; PA; QL acetylcysteine inhalation solution 10 % - Tier 1; QL ALAHIST DM - Tier 2; PA; QL acetylcysteine inhalation solution 20 % - Tier 1 ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG RELEASE 12 HOUR (brand for antihistamine & nasal deconges) - Tier 2; DM CHILD) - Tier 1 PA; QL ADVIL COLD/SINUS (brand for ra ibu-profen cold/sinus) - Tier 2 ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED AFRIN NODRIP ORIGINAL (brand for anefrin spray) - Tier 2 RELEASE 24 HOUR (brand for fexofenadine-pseudoephed er) - Tier 2; PA AFRIN SALINE NASAL MIST (brand for qc saline nasal relief) - Tier 2 allergy relief d (generic for ALLEGRA-D ALLERGY & CONGESTION) - Tier AFRIN SINUS (brand for anefrin spray) - Tier 2 1; PA; QL ALAVERT ALLERGY/SINUS (brand for allergy relief d-12) - Tier 2 allergy-d allergy & conges (generic for ALLEGRA-D ALLERGY & all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL CONGESTION) - Tier 1; PA; QL all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL ANORO ELLIPTA - Tier 2; PA; QL all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL antihistamine & nasal deconges (generic for ALLEGRA-D ALLERGY & allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1 CONGESTION) - Tier 1; PA; QL allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1 AYR SALINE NASAL (brand for saline) - Tier 2; PA allergy & congestion (generic for KLS ALLERCLEAR D-12HR) - Tier 1 AYR SALINE NASAL NO-DRIP (brand for saline) - Tier 2; PA allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; QL azelastine-fluticasone (generic for DYMISTA) - Tier 1; PA; QL allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1 benzonatate oral capsule 150 mg - Tier 1; PA allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1 BREO ELLIPTA - Tier 2; PA; QL allergy relief oral tablet extended release 12 hour 5-120 mg (generic for BUDESONIDE-FORMOTEROL FUMARATE - Tier 2; PA; QL KLS ALLER-TEC D) - Tier 1; QL capcof - Tier 1; PA; QL allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - CLARINEX-D 12 HOUR - Tier 2; PA Tier 1 coditussin ac - Tier 1; PA; QL allergy relief/nasal decongest oral tablet extended release 12 hour cold & flu oral liquid 10-5-325 mg/15ml (generic for THERAFLU (generic for KLS ALLER-TEC D) - Tier 1; QL EXPRESSMAX) - Tier 1; PA allergy relief/nasal decongest oral tablet extended release 24 hour cold & flu relief daytime (generic for MUCINEX FAST-MAX CONG (generic for KLS ALLERCLEAR D-24HR) - Tier 1 HEADACHE) - Tier 1; PA allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic cold head congestion daytime (generic for MAPAP COLD FORMULA for KLS ALLER-TEC D) - Tier 1; QL MULTI-SYMPT) - Tier 1; PA allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic cold max (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; for KLS ALLERCLEAR D-12HR) - Tier 1 PA

173 Preferred Agents Non-Preferred Agents allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic cold max daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - for KLS ALLERCLEAR D-24HR) - Tier 1 Tier 1; PA allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1 cold multi-symptom daytime (generic for MAPAP COLD FORMULA MULTI- allergy/congestion relief (generic for KLS ALLERCLEAR D-24HR) - Tier SYMPT) - Tier 1; PA 1 cold relief oral tablet 12.5-500 mg - Tier 1; PA aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL cold/flu daytime relief (generic for MUCINEX FAST-MAX CONG altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 HEADACHE) - Tier 1; PA altarussin (generic for DIABETIC TUSSIN EX) - Tier 1 cold/flu relief daytime (generic for MUCINEX FAST-MAX CONG altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL HEADACHE) - Tier 1; PA altarussin-pe - Tier 1 COMTREX COLD & COUGH MAX ST (brand for cold multi-symptom anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1 daytime) - Tier 2; PA aprodine - Tier 1 cough & sore throat nighttime (generic for CORICIDIN HBP NIGHTTIME AYR (brand for qc saline nasal relief) - Tier 2 COLD) - Tier 1; PA AYR NASAL MIST ALLERGY/SINUS - Tier 2 cough/sore throat daytime oral liquid 1000-30 mg/30ml - Tier 1; PA AYR SALINE NASAL DROPS - Tier 2 cough/sore throat nighttime (generic for CORICIDIN HBP NIGHTTIME BABY AYR SALINE (brand for qc saline nasal relief) - Tier 2 COLD) - Tier 1; PA benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML - Tier 2; PA Tier 1; QL day time cold & flu oral capsule (generic for MUCINEX FAST-MAX CONG benzonatate oral capsule 200 mg - Tier 1; QL HEADACHE) - Tier 1; PA BEVESPI AEROSPHERE - Tier 2; QL day time cold & flu relief (generic for THERAFLU EXPRESSMAX) - Tier 1; cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL PA cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; day time cold/flu (generic for MUCINEX FAST-MAX CONG HEADACHE) - QL Tier 1; PA chest congest/cough child (generic for DELSYM CGH/CHEST CONG daytime (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; DM CHILD) - Tier 1 PA chest congestion relief (generic for XPECT) - Tier 1 daytime cold & flu oral liquid (generic for THERAFLU EXPRESSMAX) - Tier chest congestion relief dm (generic for ROBAFEN DM COUGH CLEAR) 1; PA - Tier 1; QL daytime cold & flu relief (generic for THERAFLU EXPRESSMAX) - Tier 1; childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier PA 1 daytime cold/flu ms relief (generic for MUCINEX FAST-MAX CONG childrens cough (generic for DELSYM CGH/CHEST CONG DM CHILD) HEADACHE) - Tier 1; PA - Tier 1 daytime cold/flu oral capsule 10-5-325 mg (generic for MUCINEX FAST- childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG MAX CONG HEADACHE) - Tier 1; PA DM CHILD) - Tier 1

174 Preferred Agents Non-Preferred Agents CLARITIN-D 12 HOUR (brand for allergy relief d-12) - Tier 2 daytime cold/flu oral liquid 10-5-325 mg/15ml (generic for THERAFLU CLARITIN-D 24 HOUR (brand for ra lorata-d) - Tier 2 EXPRESSMAX) - Tier 1; PA cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1 daytime cold/flu relief (generic for THERAFLU EXPRESSMAX) - Tier 1; PA cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1 daytime cold/flu relief oral liquid 325-10-5 mg/15ml (generic for THERAFLU cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for EXPRESSMAX) - Tier 1; PA DIMAPHEN DM COLD/COUGH) - Tier 1; QL daytime liquid (generic for MUCINEX FAST-MAX CONG HEADACHE) - cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for Tier 1; PA DIMAPHEN DM COLD/COUGH) - Tier 1; QL despec dm - Tier 1; PA cold & sinus relief oral tablet 30-200 mg (generic for ADVIL despec dm-g - Tier 1; PA COLD/SINUS) - Tier 1 DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA; QL cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL ENTSOL NASAL - Tier 2; PA cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier fexofenadine-pseudoephed er oral tablet extended release 12 hour (generic 1; QL for ALLEGRA-D ALLERGY & CONGESTION) - Tier 1; PA; QL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for fexofenadine-pseudoephed er oral tablet extended release 24 hour (generic DIMAPHEN DM COLD/COUGH) - Tier 1; QL for ALLEGRA-D ALLERGY & CONGESTION) - Tier 1; PA cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM flu/cold/daytime (generic for THERAFLU SEVERE COLD) - Tier 1; PA COLD/COUGH) - Tier 1; QL flu/severe cold & cough day (generic for WAL-FLU SEVERE COLD & COMBIVENT RESPIMAT - Tier 2; QL COUGH) - Tier 1; PA CORICIDIN HBP COUGH/COLD (brand for sb cold & cough hbp) - Tier flu/severe cold daytime oral liquid 10-5-325 mg/15ml (generic for 2 THERAFLU EXPRESSMAX) - Tier 1; PA cough & chest congestion (generic for DELSYM CGH/CHEST CONG flu/severe cold daytime oral packet 20-10-500 mg (generic for THERAFLU DM CHILD) - Tier 1 SEVERE COLD) - Tier 1; PA cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1 fluticasone-salmeterol aerosol powder breath activated 100-50 mcg/dose cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1 inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) fluticasone-salmeterol aerosol powder breath activated 250-50 mcg/dose - Tier 1 inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL cough dm (generic for DELSYM) - Tier 1; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER cough dm childrens (generic for DELSYM) - Tier 1; QL BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 cough dm er (generic for DELSYM) - Tier 1; QL MCG/ACT - Tier 2; PA; QL cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH) - GILPHEX TR - Tier 2; PA Tier 1 GRASTEK - Tier 2; PA; QL cough/chest congestion dm (generic for ROBAFEN DM COUGH herbiomed fast acting - Tier 1; PA; QL CLEAR) - Tier 1; QL HISTEX-AC - Tier 2; PA; QL HYCODAN (brand for hydrocodone-homatropine) - Tier 2; PA; QL

175 Preferred Agents Non-Preferred Agents cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST hydrocodone polst-cpm polst er - Tier 1; PA; QL CONG DM CHILD) - Tier 1 HYPERSAL (brand for sodium chloride) - Tier 2; PA cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1 mapap cold formula multi-sympt (generic for MAPAP COLD FORMULA decongestant 12hour max st (generic for SUDAFED SINUS MULTI-SYMPT) - Tier 1; PA CONGESTION 12HR) - Tier 1 MAR-COF BP - Tier 2; PA; QL deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 MAR-COF CG EXPECTORANT (brand for trymine cg) - Tier 2; PA; QL DELSYM (brand for cvs cough dm childrens) - Tier 2; QL maxi-tuss cd - Tier 1; PA; QL DELSYM CGH/CHEST CONG DM CHILD (brand for mucus relief dm) - M-END PE - Tier 2; PA; QL Tier 2 MUCINEX FAST-MAX CONG HEADACHE (brand for eq daytime cold/flu DELSYM COUGH CHILDRENS (brand for cvs cough dm childrens) - ms relief) - Tier 2; PA Tier 2; QL MUCINEX SINUS-MAX CONG & PAIN ORAL CAPSULE (brand for eq DELSYM COUGH/CHEST CONGEST DM (brand for mucus relief dm) - daytime cold/flu ms relief) - Tier 2; PA Tier 2 multi symptom flu/severe cold (generic for THERAFLU SEVERE COLD) - desgen dm oral liquid (generic for DESGEN DM) - Tier 1 Tier 1; PA dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL night time cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM CORICIDIN HBP NIGHTTIME COLD) - Tier 1; PA COUGH CLEAR) - Tier 1; QL nighttime cold medicine (generic for CORICIDIN HBP NIGHTTIME COLD) - DIABETIC TUSSIN MAX ST (brand for hm tussin adult dm) - Tier 2 Tier 1; PA dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - nighttime cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for Tier 1; QL CORICIDIN HBP NIGHTTIME COLD) - Tier 1; PA DIMETAPP COLD RELIEF CHILDRENS (brand for eql cold/cough) - NINJACOF-XG - Tier 2; PA; QL Tier 2; QL ODACTRA - Tier 2; PA; QL DIMETAPP COLD/ALLERGY (brand for rynex pe) - Tier 2 ORALAIR - Tier 2; PA; QL DIMETAPP DM COLD/COUGH (brand for eql cold/cough) - Tier 2; QL ORALAIR ADULT STARTER PACK - Tier 2; PA; QL dm maximum adult (generic for DELSYM CGH/CHEST CONG DM ORALAIR CHILDRENS STARTER PACK - Tier 2; PA; QL CHILD) - Tier 1 poly-tussin ac - Tier 1; PA; QL DRISTAN SPRAY (brand for anefrin spray) - Tier 2 PONARIS - Tier 2; PA DULERA - Tier 2; QL PRO-RED AC - Tier 2; PA; QL ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL RAGWITEK - Tier 2; PA; QL ed bron gp - Tier 1 ribavirin inhalation (generic for VIRAZOLE) - Tier 1; PA ENDACOF-DM (brand for eql cold/cough) - Tier 2; QL ROBITUSSIN COLD+FLU DAYTIME (brand for eq daytime cold/flu ms ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 relief) - Tier 2; PA FASENRA PEN - Tier 2; PA; QL rydex - Tier 1; PA; QL rymed - Tier 1; PA; QL

176 Preferred Agents Non-Preferred Agents fluticasone-salmeterol aerosol powder breath activated 100-50 severe allergy - Tier 1; PA mcg/dose inhalation (generic for WIXELA INHUB) - Tier 1; QL severe cold/cough (generic for THERAFLU EXPRESSMAX) - Tier 1; PA fluticasone-salmeterol aerosol powder breath activated 250-50 severe cold/cough daytime (generic for WAL-FLU SEVERE COLD & mcg/dose inhalation (generic for WIXELA INHUB) - Tier 1; QL COUGH) - Tier 1; PA fluticasone-salmeterol inhalation aerosol powder breath activated 500- severe cold/cough/flu (generic for WAL-FLU SEVERE COLD & COUGH) - 50 mcg/dose (generic for WIXELA INHUB) - Tier 1; QL Tier 1; PA g tussin ac - Tier 1; QL severe cold/flu daytime (generic for THERAFLU EXPRESSMAX) - Tier 1; genaphed (generic for SUDOGEST) - Tier 1; QL PA geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL STIOLTO RESPIMAT - Tier 2; PA; QL giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 TESSALON PERLES (brand for benzonatate) - Tier 2; PA; QL guaiatussin ac - Tier 1; QL THERAFLU EXPRESSMAX (brand for cvs daytime cold/flu relief) - Tier 2; guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL PA guaifenesin ac - Tier 1; QL THERAFLU EXPRESSMAX SEV CLD/CG ORAL TABLET 10-5-325 MG guaifenesin er oral tablet extended release 12 hour 1200 mg (generic for (brand for cold multi-symptom daytime) - Tier 2; PA EQ MUCUS ER) - Tier 1; QL THERAFLU POWERPODS SEVERE COLD ORAL 20-10-650 MG - Tier 2; guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1 PA; QL guaifenesin-codeine - Tier 1; QL THERAFLU SEVERE COLD (brand for eql flu/severe cold daytime) - Tier 2; guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) PA - Tier 1; QL THERAFLU SEVERE COLD DAYTIME - Tier 2; PA hydrocodone-homatropine (generic for HYCODAN) - Tier 1; QL THERAFLU SEVERE COLD/CGH DAY (brand for cold multi-symptom hydromet (generic for HYCODAN) - Tier 1; QL daytime) - Tier 2; PA ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1 TRELEGY ELLIPTA - Tier 2; PA; QL ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL trymine cg (generic for MAR-COF CG EXPECTORANT) - Tier 1; PA; QL COLD/SINUS) - Tier 1 TUSNEL C - Tier 2; PA; QL ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL TUSSICAPS - Tier 2; PA; QL COLD/SINUS) - Tier 1 tussin cf cough & cold oral syrup 5-10-100 mg/5ml - Tier 1; PA ipratropium-albuterol - Tier 1; QL TUXARIN ER - Tier 2; PA; QL liquibid (generic for XPECT) - Tier 1 TUZISTRA XR - Tier 2; PA; QL long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 TYLENOL COLD MAX (brand for cold multi-symptom daytime) - Tier 2; PA long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 VIRAZOLE (brand for ribavirin) - Tier 2; PA lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1 wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1 loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1 loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1

177 Preferred Agents Non-Preferred Agents loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1 loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1 maxi-tuss ac - Tier 1; QL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1 maxi-tuss pe max - Tier 1 m-clear wc - Tier 1; QL medifin 400 (generic for XPECT) - Tier 1 meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1 MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for mucus relief dm) - Tier 2 MUCINEX CHILDRENS STUFFY NOSE (brand for anefrin spray) - Tier 2 MUCINEX COUGH CHILDRENS (brand for mucus relief dm) - Tier 2 MUCINEX D (brand for mucus relief d) - Tier 2 MUCINEX D MAX STRENGTH (brand for pseudoephedrine-guaifenesin er) - Tier 2 MUCINEX DM (brand for eq mucus relief dm) - Tier 2; QL MUCINEX FAST-MAX DM MAX (brand for mucus relief dm) - Tier 2 MUCINEX MAXIMUM STRENGTH (brand for qc mucus relief er) - Tier 2; QL MUCINEX SINUS-MAX CLEAR & COOL (brand for anefrin spray) - Tier 2 MUCINEX SINUS-MAX SINUS/ALLRGY (brand for anefrin spray) - Tier 2 mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus d (generic for MUCINEX D) - Tier 1 mucus d extended release (generic for MUCINEX D) - Tier 1 mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1 mucus dm (generic for MUCINEX DM) - Tier 1; QL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL

178 Preferred Agents Non-Preferred Agents mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1 mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1 mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1 mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; QL mucus relief er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL mucus relief max strength oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL mucus relief oral tablet (generic for XPECT) - Tier 1 mucus-d (generic for MUCINEX D) - Tier 1 mucus-dm (generic for MUCINEX DM) - Tier 1; QL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL nasal decongestant 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL

179 Preferred Agents Non-Preferred Agents nasal decongestant oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal four (generic for 4-WAY FAST ACTING) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for qc saline nasal relief) - Tier 2 nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray anti-drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1 nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for sm nose drops nasal decongest) - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2 no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1

180 Preferred Agents Non-Preferred Agents nohist-lq (generic for ED A-HIST) - Tier 1; QL non-pseudo sinus decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal decongest (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal solution 1 % (generic for 4-WAY FAST ACTING) - Tier 1 NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; SP; QL NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP; QL OCEAN FOR KIDS (brand for qc saline nasal relief) - Tier 2 OCEAN NASAL SPRAY (brand for qc saline nasal relief) - Tier 2 pharbinex (generic for XPECT) - Tier 1 phenylephrine hcl oral (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 promethazine vc - Tier 1; QL promethazine vc/codeine - Tier 1; QL promethazine-codeine - Tier 1; QL promethazine-dm - Tier 1; QL promethazine-phenyleph-codeine - Tier 1; QL promethazine-phenylephrine - Tier 1; QL pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL pseudoephedrine-bromphen-dm - Tier 1; QL pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1 PULMOZYME - Tier 2; SP; QL refenesen 400 (generic for XPECT) - Tier 1 robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1

181 Preferred Agents Non-Preferred Agents ROBITUSSIN 12 HOUR COUGH (brand for cvs cough dm childrens) - Tier 2; QL ROBITUSSIN 12 HOUR COUGH CHILD (brand for cvs cough dm childrens) - Tier 2; QL ROBITUSSIN CHILD COUGH/COLD LA - Tier 2 ROBITUSSIN CHILDRENS COUGH LA - Tier 2 ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for mucus relief dm) - Tier 2 ROBITUSSIN NIGHTTIME COUGH - Tier 2 ROBITUSSIN PEAK COLD MULTI-SYM (brand for hm tussin adult multi-symptom) - Tier 2 rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1 rynex pse - Tier 1 saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 sb mucus relief (generic for XPECT) - Tier 1 siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1 siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 sinus pe decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1 sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1 sinus/congestion relief pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 % - Tier 1 sodium chloride inhalation nebulization solution 7 % (generic for HYPERSAL) - Tier 1

182 Preferred Agents Non-Preferred Agents SUDAFED (brand for decongestant) - Tier 2; QL SUDAFED CHILDRENS - Tier 2; QL SUDAFED CONGESTION (brand for decongestant) - Tier 2; QL SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for qc nasal decongestant pe) - Tier 2 SUDAFED PE SINUS CONGESTION (brand for qc nasal decongestant pe) - Tier 2 SUDAFED SINUS CONGESTION (brand for decongestant) - Tier 2; QL SUDAFED SINUS CONGESTION 12HR (brand for sudogest 12 hour) - Tier 2 sudogest 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine maximum strength (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; QL tab tussin (generic for XPECT) - Tier 1 tussin adult dm oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1 tussin adult multi-symptom (generic for DESGEN DM) - Tier 1 tussin cf cough & cold oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1 tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1 tussin cf oral liquid 30-10-100 mg/5ml - Tier 1 tussin chest congestion oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1 tussin cough dm sugar free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL tussin cough long acting (generic for WAL-TUSSIN COUGH) - Tier 1 tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1

183 Preferred Agents Non-Preferred Agents tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1 tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1 tussin dm cough/chest cong (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL tussin dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1 tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max st (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL tussin maximum strength oral syrup 15 mg/5ml (generic for WAL- TUSSIN COUGH) - Tier 1 tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1 tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1 tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1 virtussin a/c - Tier 1; QL virtussin ac w/alc - Tier 1; QL virtussin dac - Tier 1; QL XPECT (brand for sb mucus relief) - Tier 2 ZYRTEC-D ALLERGY & CONGESTION (brand for allergy relief d) - Tier 2; QL

Sedatives/Hypnotics - Drugs for Sedation and Sleep

184 Preferred Agents Non-Preferred Agents Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs XYWAV - Tier 2; PA; QL

Skeletal Muscle Relaxants CYCLOPAK - Tier 2; PA; QL

Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1; QL AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA; QL chlorzoxazone oral tablet 250 mg, 500 mg - Tier 1; QL carisoprodol oral (generic for SOMA) - Tier 1; PA; QL cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL chlorzoxazone oral tablet 375 mg, 750 mg (generic for LORZONE) - Tier 1; dantrolene sodium oral - Tier 1; QL PA methocarbamol oral - Tier 1; QL CYCLO/GABA 10/300 - Tier 2; PA OZOBAX - Tier 2; PA; QL cyclobenzaprine hcl er (generic for AMRIX) - Tier 1; PA; QL tizanidine hcl oral tablet - Tier 1; QL cyclobenzaprine hcl oral tablet 7.5 mg (generic for FEXMID) - Tier 1; PA CYCLOPHENE RAPIDPAQ - Tier 2; PA DANTRIUM ORAL (brand for dantrolene sodium) - Tier 2; PA; QL enovarx-cyclobenzaprine hcl - Tier 1; PA FEXMID (brand for cyclobenzaprine hcl) - Tier 2; PA FIRST-BACLOFEN - Tier 2; PA GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 50 MCG/ML - Tier 2; PA LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/5ML - Tier 2; PA LORZONE (brand for chlorzoxazone) - Tier 2; PA METAXALL CP - Tier 2; PA metaxalone oral tablet 400 mg - Tier 1; PA metaxalone oral tablet 800 mg (generic for SKELAXIN) - Tier 1; PA; QL NORGESIC FORTE - Tier 2; PA; QL orphenadrine citrate er - Tier 1; PA; QL

185 Preferred Agents Non-Preferred Agents orphenadrine-asa-caffeine (generic for ORPHENGESIC FORTE) - Tier 1; PA; QL ORPHENGESIC FORTE (brand for norgesic forte) - Tier 2; PA; QL SKELAXIN (brand for metaxalone) - Tier 2; PA; QL SOMA (brand for carisoprodol) - Tier 2; PA; QL TABRADOL FUSEPAQ - Tier 2; PA; QL TABRADOL RAPIDPAQ - Tier 2; PA; QL tizanidine hcl oral capsule 2 mg (generic for ZANAFLEX) - Tier 1; PA; QL tizanidine hcl oral capsule 4 mg, 6 mg (generic for ZANAFLEX) - Tier 1; PA VANADOM (brand for carisoprodol) - Tier 2; PA; QL ZANAFLEX ORAL CAPSULE 2 MG (brand for tizanidine hcl) - Tier 2; PA; QL ZANAFLEX ORAL CAPSULE 4 MG, 6 MG (brand for tizanidine hcl) - Tier 2; PA ZANAFLEX ORAL TABLET (brand for tizanidine hcl) - Tier 2; PA; QL

Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Skeletal Muscle Relaxants - Pain/Swelling Management Drugs NOPIOID-LMC KIT - Tier 2; PA; QL

Sleep Disorder Agents - Drugs for Sedation and Sleep GABA Receptor Modulators - Drugs for Sleeping flurazepam hcl - Tier 1; QL AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier 1; AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA QL EDLUAR - Tier 2; PA; QL zaleplon - Tier 1; QL eszopiclone oral tablet 1 mg (generic for LUNESTA) - Tier 1; PA; QL zolpidem tartrate oral (generic for AMBIEN) - Tier 1; QL eszopiclone oral tablet 2 mg, 3 mg (generic for LUNESTA) - Tier 1; PA LUNESTA ORAL TABLET 1 MG (brand for eszopiclone) - Tier 2; PA; QL LUNESTA ORAL TABLET 2 MG, 3 MG (brand for eszopiclone) - Tier 2; PA

186 Preferred Agents Non-Preferred Agents RESTORIL ORAL CAPSULE 15 MG, 30 MG, 7.5 MG (brand for temazepam) - Tier 2; PA; QL temazepam oral capsule 7.5 mg (generic for RESTORIL) - Tier 1; PA; QL zolpidem tartrate er (generic for AMBIEN CR) - Tier 1; PA zolpidem tartrate sublingual - Tier 1; PA; QL ZOLPIMIST - Tier 2; PA

Sleep Disorders, Other - Drugs for Sleeping armodafinil (generic for NUVIGIL) - Tier 1; QL BELSOMRA - Tier 2; PA modafinil (generic for PROVIGIL) - Tier 1; QL DAYVIGO - Tier 2; PA; QL doxepin hcl oral tablet (generic for SILENOR) - Tier 1; PA; QL HETLIOZ - Tier 2; PA; SP; QL HETLIOZ LQ - Tier 2; PA; SP; QL; AL night time sleep aid (generic for SIMPLY SLEEP) - Tier 1; PA; QL nighttime sleep aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA nighttime sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; PA; QL NUVIGIL (brand for armodafinil) - Tier 2; PA; QL PROVIGIL (brand for modafinil) - Tier 2; PA; QL ramelteon (generic for ROZEREM) - Tier 1; PA; QL rest simply (generic for SIMPLY SLEEP) - Tier 1; PA; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QL SILENOR (brand for doxepin hcl) - Tier 2; PA; QL SIMPLY SLEEP (brand for sleep aid (diphenhydramine)) - Tier 2; PA; QL sleep aid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; PA; QL sleep aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA sleep aid nighttime oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; PA; QL sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; PA; QL sleep ii (generic for SIMPLY SLEEP) - Tier 1; PA; QL sleep tabs (generic for SIMPLY SLEEP) - Tier 1; PA; QL

187 Preferred Agents Non-Preferred Agents sleepaid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; PA; QL sleep-aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA sleep-aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA sleeptime oral capsule (generic for WAL-SLEEP Z) - Tier 1; PA SUNOSI - Tier 2; PA; QL WAKIX - Tier 2; PA; QL XYREM - Tier 2; PA; SP; QL z-sleep oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs prenatal gummy oral tablet chewable 0.4-25 mg (generic for ALIVE ACCRUFER - Tier 2; PA; QL PRENATAL) - Tier 1; QL prenatal gummy oral tablet chewable 0.4 mg - Tier 1; PA; QL

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs CITRANATAL ESSENCE - Tier 2; PA; QL

188 Prior Authorization / Class Criteria

Title Drugs Impacted Prior Authorization Criteria / Class Criteria

189 Index of Drugs

1 abacavir-lamivudine-zidovudine ...... ACCUTREND GLUCOSE ...... 12 hour allergy-d ...... ABANEU-SL ...... ACCUTREND GLUCOSE CONTROL ...... 12 hour decongestant ...... abatinex ...... ACD-A NOCLOT-50 ...... 12 hour mucus relief oral tablet extended ABATRON ...... ACE AEROSOL CLOUD ENHANCER ...... release 12 hour 1200 mg ...... abatron af ...... acebutolol hcl oral ...... 12 hour nasal decongestant ...... ABILIFY ...... ACEROLA C 500 ...... 12 hour nasal relief spray ...... ABILIFY MAINTENA ...... acetaminophen 8 hour ...... 12 hour nasal spray ...... ABILIFY MYCITE ...... acetaminophen 8 hours ...... 12hr allergy & congestion ...... ABILIFY MYCITE MAINTENANCE KIT ...... acetaminophen 8hr arth pain ...... 1ST MEDX-PATCH/ LIDOCAINE ABILIFY MYCITE STARTER KIT ...... acetaminophen 8hr musc ache ...... EXTERNAL PATCH 4-0.0375-5-20 % ...... abiraterone acetate ...... acetaminophen childrens ...... 2 ABREVA ...... acetaminophen childrens oral suspension 24 hour nasal allergy ...... ABSORICA ...... 160 mg/5ml ...... 24hr allergy relief ...... ABSORICA LD ...... acetaminophen childrens oral tablet 3 acamprosate calcium ...... chewable 160 mg...... 3 day ...... ACANYA ...... acetaminophen er ...... 3 day vaginal ...... acarbose oral ...... acetaminophen ex st oral liquid 500 mg/15ml 3-day vaginal vaginal cream 2 % ...... ACCOLATE ...... 4 ACCRUFER ...... acetaminophen ex st oral tablet 500 mg ...... 4-WAY FAST ACTING ...... ACCU-CHEK AVIVA DEVICE ...... acetaminophen extra strength ...... 4-WAY MENTHOL ...... ACCU-CHEK AVIVA PLUS TEST STRIPS .. acetaminophen infants oral suspension 160 7 ACCU-CHEK COMPACT PLUS ...... mg/5ml ...... 7T LIDO ...... ACCU-CHEK COMPACT PLUS CONTROL. acetaminophen oral liquid 500 mg/15ml ...... 8 ACCU-CHEK FASTCLIX LANCET KIT...... acetaminophen oral solution 160 mg/5ml, 8 hour arthritis pain reliever...... ACCU-CHEK GUIDE CONTROL ...... 325 mg/10.15ml, 650 mg/20.3ml ...... 8 hour arthritis relief ...... ACCU-CHEK GUIDE TEST STRIPS ...... acetaminophen oral suspension 160 8 hour pain relief oral tablet extended ACCU-CHEK LINKASSIST ...... mg/5ml, 650 mg/20.3ml ...... release 650 mg ...... ACCU-CHEK MULTICLIX LANCETS ...... , acetaminophen oral tablet 325 mg ...... 8 hour pain reliever ...... ACCU-CHEK SMARTVIEW ...... acetaminophen oral tablet 500 mg ...... 8 hr arthritis pain relief ...... ACCU-CHEK SMARTVIEW CONTROL ...... acetaminophen oral tablet chewable 160 mg 8hr arthritis pain relief ...... ACCU-CHEK SOFTCLIX LANCET DEVICE acetaminophen rapid tabs child ...... 8hr muscle aches & pain ...... KIT ...... acetaminophen rectal suppository 120 mg .... A ACCU-CHEK SPIRIT COMBO PACK...... acetaminophen rectal suppository 650 mg .... A.A.G.C. KIT IN TERODERM ...... ACCU-CHEK TENDER 1 INFUSION...... acetaminophen-codeine ...... a-25 ...... ACCUPRIL ...... acetaminophen-codeine #2 ...... abacavir sulfate oral solution ...... ACCURETIC ...... acetaminophen-codeine #3 ...... abacavir sulfate oral tablet ...... accutane oral capsule 20 mg ...... acetaminophen-codeine #4 ...... abacavir sulfate-lamivudine ...... accutane oral capsule 30 mg, 40 mg ...... acetazolamide er ......

190 acetazolamide oral ...... ACTOPLUS MET ...... adult probiotic ...... acetic acid otic ...... ACTOS ...... adult tussin cough & chest ...... acetylcysteine inhalation solution 10 % ...... ACULAR ...... adv acne spot treatment ...... acetylcysteine inhalation solution 20 % ...... ACULAR LS ...... ADVAIR DISKUS ...... acid controller ...... ACUNOL ...... ADVAIR HFA ...... acid gone ...... ACUVAIL ...... advanced acne spot treat ...... acid reducer oral capsule delayed release .... acyclovir external ...... ADVANCED ALLERGY COLLECTION ...... acid reducer oral tablet 10 mg ...... acyclovir oral ...... advanced antacid max st ...... acid reducer oral tablet 200 mg ...... ACYCLOVIX ...... ADVANCED GLUCOSE TEST ...... acid reducer oral tablet delayed release ...... ACZONE ...... advanced healing external ointment ...... acidophilus lactobacillus oral ...... ADACEL ...... advanced stress formula/zinc ...... acidophilus oral capsule , 10 mg ...... ADAINZDE ...... ADVIL COLD/SINUS ...... acidophilus probiotic oral capsule 10 mg ...... ADAINZOXIA ...... ADVIL JUNIOR STRENGTH ...... acidophilus probiotic oral tablet , 0.5 mg ...... adapalene external cream ...... ADVIL LIQUI-GELS MINIS ...... acidophilus/l-sporogenes ...... adapalene external gel 0.1 % ...... ADVIL MIGRAINE ...... ACIOXIAY ...... adapalene external gel 0.3 % ...... ADVIL ORAL CAPSULE ...... ACIPHEX ...... ADAPALENE EXTERNAL PAD ...... ADVIL ORAL TABLET ...... ACIPHEX SPRINKLE ...... ADAPALENE EXTERNAL SOLUTION ...... ADYNOVATE INTRAVENOUS SOLUTION acitretin ...... adapalene-benzoyl peroxide external gel ..... RECONSTITUTED 1000 UNIT, 2000 acne ...... ADAPALENE-BENZOYL PEROXIDE UNIT, 500 UNIT ...... acne control cleanser ...... EXTERNAL PAD ...... ADYPHREN ...... acne medication 10 external lotion...... adc/f (0.5mg/ml) ...... ADYPHREN AMP ...... acne medication 5 external lotion...... ADCIRCA ...... ADYPHREN AMP II ...... ACNESIC ...... addaprin ...... ADYPHREN II ...... ACTEMRA ACTPEN ...... ADDERALL ...... ADZENYS ER ...... ACTEMRA SUBCUTANEOUS ...... ADDERALL XR ...... ADZENYS XR-ODT ...... ACTHAR ...... adefovir dipivoxil ...... AEMCOLO ...... ACTICLATE ...... ADEMPAS ...... AERIVA CONCENTRATOR NEBULIZER ..... ACTIFLOVIT EAR HEALTH ...... ADHANSIA XR ...... AEROCHAMBER PLUS FLO-VU ...... ACTIFOAM COLLAGEN SPONGE ...... ADLYXIN ...... AEROCHAMBER PLUS FLO-VU LARGE ..... ACTIMMUNE ...... ADLYXIN STARTER PACK ...... AEROCHAMBER PLUS FLO-VU SMALL ..... ACTIPHLORA ...... ADMELOG ...... AEROCHAMBER PLUS FLO-VU W/MASK .. ACTIPOCHOL PLUS ...... ADMELOG SOLOSTAR ...... AFINITOR ...... ACTIQ ...... ADRENAL C FORMULA ...... AFINITOR DISPERZ ...... ACTITROM ...... ADRENALIN INJECTION SOLUTION 1 afirmelle ...... ACTITROM-D...... MG/ML ...... AFREZZA ...... ACTIVE FE ...... ADRENALIN NASAL ...... AFRIN NODRIP ORIGINAL ...... ACTIVELLA ...... ADUHELM ...... AFRIN SALINE NASAL MIST ...... ACTIVITE ...... adult 50+ probiotic ...... AFRIN SINUS ...... ACTONEL ...... ADULT AEROSOL MASK ...... aftera ......

191 AGONEAZE ...... albuterol sulfate nebulization solution (5 ALLEGRA-D ALLERGY & CONGESTION AGRYLIN ...... mg/ml) 0.5% inhalation ...... ORAL TABLET EXTENDED RELEASE 12 aif #2 drug preparation kit ...... ALBUTEROL SULFATE NEBULIZATION HOUR ...... AIF #3 DRUG PREPARATION KIT ...... SOLUTION (5 MG/ML) 0.5% ALLEGRA-D ALLERGY & CONGESTION AIMOVIG ...... INHALATION ...... ORAL TABLET EXTENDED RELEASE 24 airavite ...... albuterol sulfate oral syrup ...... HOUR ...... AIRDUO DIGIHALER ...... albuterol sulfate oral tablet 2 mg ...... aller-chlor ...... AIRDUO RESPICLICK 113/14 ...... albuterol sulfate oral tablet 4 mg ...... allerclear ...... AIRDUO RESPICLICK 232/14 ...... alclometasone dipropionate ...... allerclear d-12hr ...... AIRDUO RESPICLICK 55/14 ...... alcohol prep pads external 70 % ...... allerclear d-24hr ...... airshield ...... ALCOHOL PREP PADS PAD ...... aller-cort ...... AIRSHIELD IMMUNITY SUPPORT ...... ALCOHOL PREP PADS PAD 70 % ...... aller-ease ...... AJOVY SUBCUTANEOUS SOLUTION ALCORTIN A ...... aller-fex ...... AUTO-INJECTOR ...... ALDACTAZIDE ...... allergy & congestion ...... AJOVY SUBCUTANEOUS SOLUTION ALDACTONE ...... allergy 24hour indoor/outdoor ...... PREFILLED SYRINGE ...... ALDARA ...... allergy 24-hr ...... AKLIEF ...... ALECENSA ...... allergy 4 hour ...... ak-poly-bac ...... alendronate sodium oral solution ...... allergy antihistamine ...... AKYNZEO ORAL ...... alendronate sodium oral tablet ...... allergy childrens ...... ALA SCALP ...... ALEVAMAX ...... allergy complete-d ...... ala-cort ...... ALEVE ORAL TABLET ...... allergy eye drops ...... ALAHIST CF ...... alfuzosin hcl er ...... allergy medication ...... ALAHIST DM ...... algal-900 dha ...... allergy oral capsule 25 mg ...... ALAVERT ...... ALINIA ORAL SUSPENSION allergy oral liquid 12.5 mg/5ml ...... ALAVERT ALLERGY/SINUS ...... RECONSTITUTED ...... allergy oral tablet 25 mg ...... ALAWAY ...... ALINIA ORAL TABLET ...... allergy oral tablet 4 mg ...... ALAWAY CHILDRENS ALLERGY ...... aliskiren fumarate ...... allergy oral tablet extended release 12 mg .... albendazole oral ...... ALKERAN ORAL ...... allergy rel child (loratadine) ...... ALBENZA ...... ALKINDI SPRINKLE ...... allergy relief (cetirizine) oral tablet 10 mg ...... albuterol sulfate er oral tablet extended all day allergy d ...... allergy relief 4-hour ...... release 12 hour 4 mg, 8 mg ...... all day allergy d-12 ...... allergy relief adult ...... albuterol sulfate hfa aerosol solution 108 (90 all day allergy oral tablet 10 mg ...... allergy relief cetirizine ...... base) mcg/act inhalation ...... , all day allergy-d ...... allergy relief child ...... ALBUTEROL SULFATE HFA AEROSOL all day pain relief ...... allergy relief childrens oral liquid 12.5 SOLUTION 108 (90 BASE) MCG/ACT all day relief ...... mg/5ml ...... INHALATION ...... ALLEGRA ALLERGY ...... allergy relief childrens oral suspension 30 albuterol sulfate inhalation nebulization ALLEGRA ALLERGY CHILDRENS ORAL mg/5ml ...... solution (2.5 mg/3ml) 0.083%, 0.63 SUSPENSION ...... allergy relief childrens oral syrup 5 mg/5ml ... mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml ...... ALLEGRA ALLERGY CHILDRENS ORAL allergy relief childrens oral tablet chewable 5 TABLET DISPERSIBLE ...... mg ......

192 allergy relief d ...... almacone double strength ...... alyacen 1/35 ...... allergy relief d-12 ...... almotriptan malate ...... alyacen 7/7/7 ...... allergy relief d-24 ...... ALOCRIL ...... alyq ...... allergy relief oral capsule 10 mg ...... ALOE VESTA CLEAR ANTIFUNGAL ...... amabelz ...... allergy relief oral capsule 25 mg ...... ALOE VESTA DAILY MOISTURIZER ...... amantadine hcl oral ...... allergy relief oral liquid 12.5 mg/5ml, 25 ALOGLIPTIN BENZOATE ...... AMARYL ...... mg/10ml ...... ALOGLIPTIN-METFORMIN HCL ...... AMBIEN ...... allergy relief oral tablet 10 mg ...... ALOGLIPTIN-PIOGLITAZONE ...... AMBIEN CR ...... allergy relief oral tablet 180 mg ...... ALOMIDE ...... ambrisentan ...... allergy relief oral tablet 25 mg ...... ALORA ...... amcinonide ...... allergy relief oral tablet 4 mg ...... alosetron hcl ...... AMELUZ ...... allergy relief oral tablet 60 mg ...... ALPHAGAN P OPHTHALMIC SOLUTION AMERGE ...... allergy relief oral tablet chewable 12.5 mg .... 0.1 % ...... americerin ...... allergy relief oral tablet dispersible 10 mg ..... ALPHAGAN P OPHTHALMIC SOLUTION amethia ...... allergy relief oral tablet extended release 12 0.15 % ...... amethyst ...... hour 5-120 mg ...... alprazolam er ...... AMICAR ORAL SOLUTION ...... allergy relief oral tablet extended release 12 alprazolam intensol ...... AMICAR ORAL TABLET ...... mg ...... alprazolam oral tablet ...... amiloride hcl oral ...... allergy relief(cetirizine) ...... alprazolam oral tablet dispersible ...... amiloride-hydrochlorothiazide ...... allergy relief/indoor/outdoor oral tablet 10 mg alprazolam xr ...... amino action ...... ALREX ...... aminoamrms ...... allergy relief/indoor/outdoor oral tablet 180 ALTABAX ...... aminocaproic acid oral solution ...... mg ...... ALTACE ...... aminocaproic acid oral tablet ...... allergy relief/nasal decong ...... altachlore ophthalmic ointment ...... aminoreliefrms ...... allergy relief/nasal decongest oral tablet altachlore ophthalmic solution ...... amiodarone hcl oral tablet 100 mg, 400 mg .. extended release 12 hour ...... altafrin ...... amiodarone hcl oral tablet 200 mg ...... allergy relief/nasal decongest oral tablet altalube ...... AMITIZA ...... extended release 24 hour ...... altamist spray ...... amitriptyline hcl oral ...... allergy relief-d oral tablet extended release altarussin ...... amlodipine besylate oral ...... 12 hour 5-120 mg ...... , altarussin dm ...... amlodipine besylate-benazepril hcl ...... allergy relief-d oral tablet extended release altarussin-pe ...... amlodipine besylate-valsartan ...... 24 hour 10-240 mg ...... altavera ...... amlodipine-atorvastatin ...... allergy relief-d12 ...... ALTOPREV ...... amlodipine-olmesartan ...... allergy spray 24 hour nasal aerosol ...... ALTRENO ...... amlodipine-valsartan-hctz ...... allergy/congestion relief ...... alum & mag hydroxide-simeth ...... ammonium lactate external ...... allergy-d allergy & conges ...... alum sulfate-ca acetate ...... amnesteem oral capsule 10 mg ...... aller-tec ...... alumina-magnesia-simethicone ...... amnesteem oral capsule 20 mg ...... aller-tec d ...... ALUNBRIG ...... amnesteem oral capsule 40 mg ...... allopurinol oral ...... ALVESCO ...... amoxapine ...... ALLZITAL ...... alvimopan ...... amoxicill-clarithro-lansopraz ......

193 amoxicillin ...... antacid & anti-gas oral suspension 200-200- antacid regular strength oral suspension ...... amoxicillin-potassium clavulanate er...... 20 mg/5ml ...... antacid regular strength oral tablet chewable amoxicillin-potassium clavulanate oral ...... antacid & anti-gas oral suspension 400-400- antacid supreme ...... AMPHETAMINE ER ...... 40 mg/5ml ...... antacid ultra strength oral tablet chewable amphetamine sulfate ...... antacid & gas relief ...... 1000 mg ...... amphetamine-dextroamphetamine ...... antacid advanced ...... antacid/anti-gas ...... amphetamine-dextroamphetamine er ...... antacid advanced max st ...... antacid/anti-gas max st ...... ampicillin ...... antacid anti-gas ...... antacid/antigas oral suspension 200-200-20 AMPYRA ...... antacid anti-gas ex st oral suspension 400- mg/5ml ...... AMRIX ...... 400-40 mg/5ml ...... antacid/gas relief max st ...... AMZEEQ ...... antacid anti-gas max strength ...... ANTARA ...... ANACAINE ...... antacid antigas multi-sympt ...... antibiotic ...... ANAFRANIL ...... antacid anti-gas reg strength ...... antibiotic pain/scar ...... anagrelide hcl ...... antacid calcium ...... antibiotic/pain relief external ointment 1 % .... ana-lex ...... antacid calcium rich ...... anticavity fluoride rinse mouth/throat solution ANALPRAM HC ...... antacid extra ...... 0.05 % ...... ANALPRAM HC SINGLES ...... antacid extra strength oral suspension ...... anti-dandruff ...... ANALPRAM-HC ...... antacid extra strength oral tablet chewable anti-diarr/ant-gas ...... ANASPAZ ...... 160-105 mg ...... anti-diarrheal anti-gas ...... anastrozole oral ...... antacid extra strength oral tablet chewable anti-diarrheal oral liquid 1 mg/5ml ...... ANBESOL MAXIMUM STRENGTH 750 mg ...... anti-diarrheal oral liquid 1 mg/7.5ml ...... MOUTH/THROAT GEL ...... antacid fast relief ...... anti-diarrheal oral suspension 262 mg/15ml .. ANBESOL MOUTH/THROAT GEL ...... antacid i ...... anti-diarrheal oral tablet 2 mg ...... ANCOBON ORAL CAPSULE 250 MG ...... antacid iii ...... antifungal (tolnaftate) ...... ANCOBON ORAL CAPSULE 500 MG ...... antacid kids ...... antifungal external cream ...... ANDRODERM ...... antacid liquid ...... antifungal external powder ...... ANDROGEL ...... antacid m ...... anti-fungal external powder ...... ANDROGEL PUMP ...... antacid maximum ...... antifungal foot care ...... anecream external cream ...... antacid maximum strength ...... antifungal miconazole ...... anefrin spray ...... antacid maximum strength oral tablet antifungal tolnaftate ...... ANGELIQ ...... chewable 1000 mg ...... anti-gas oral capsule 180 mg ...... animal shapes complete ...... antacid multi-symptom oral tablet chewable anti-hist allergy ...... animal shapes kids first ...... 675-135-60 mg...... antihistamine & nasal deconges ...... animal shapes/iron ...... antacid oral suspension 200-200-20 mg/5ml, anti-nausea ...... ANIMI-3 ...... 400-400-40 mg/10ml ...... antiseptic ...... ANIMI-3/VITAMIN D ...... antacid oral tablet chewable 1000 mg ...... anucort-hc ...... ANNOVERA ...... antacid oral tablet chewable 500 mg ...... ANUSOL-HC EXTERNAL ...... ANODYNE LPT ...... antacid oral tablet chewable 750 mg ...... ANUSOL-HC RECTAL ...... ANORO ELLIPTA...... antacid plus antigas ...... APADAZ ...... antacid plus anti-gas relief ...... apap-caff-dihydrocodeine ......

194 APETEX ...... aripiprazole oral tablet dispersible ...... ASMANEX HFA ...... APETIGEN ...... ARISTADA ...... ASPARTAME ...... APETIGEN-PLUS ...... ARISTADA INITIO ...... ASPARTAME (NUTRASWEET) ...... APEXICON E ...... ARIXTRA SUBCUTANEOUS SOLUTION 10 aspirin childrens ...... APIDRA SOLOSTAR ...... MG/0.8ML, 7.5 MG/0.6ML ...... aspirin ec ...... APIDRA VIAL ...... ARIXTRA SUBCUTANEOUS SOLUTION aspirin ec oral tablet 325 mg ...... APLENZIN ...... 2.5 MG/0.5ML, 5 MG/0.4ML ...... aspirin oral ...... APOKYN ...... armodafinil ...... ASPIRIN ORAL TABLET DELAYED apra ...... ARMONAIR DIGIHALER ...... RELEASE 81 MG ...... apraclonidine hcl ...... ARMOUR THYROID ...... aspirin rectal ...... aprepitant oral ...... ARNICARE ARNICA EXTERNAL aspirin tri-buffered ...... aprepitant oral capsule 125 mg, 40 mg ...... OINTMENT ...... aspirin-dipyridamole er ...... aprepitant oral capsule 80 & 125 mg ...... ARNUITY ELLIPTA ...... ASPIRIN-OMEPRAZOLE ...... aprepitant oral capsule 80 mg ...... AROMASIN ...... ASTAGRAF XL ORAL CAPSULE apri ...... arthritis pain oral tablet extended release EXTENDED RELEASE 24 HOUR 0.5 MG, APRISO ...... 650 mg ...... 1 MG ...... APRIZIO PAK ...... arthritis pain relief oral tablet extended ASTAGRAF XL ORAL CAPSULE APRIZIO PAK II ...... release 650 mg ...... EXTENDED RELEASE 24 HOUR 5 MG ... aprodine ...... arthritis pain reliever oral ...... ASTERO ...... APTENSIO XR ...... arthritis pain relieving ...... asthmanefrin refill ...... APTIOM ...... ARTHROTEC ...... ASTRAZENECA COVID-19 VACCINE ...... APTIVUS ...... artificial eye ...... astringent eye drops ...... AQUADEKS ...... artificial tears ophthalmic ointment ...... astringent solution ...... AQUAPHILIC ...... artificial tears ophthalmic solution ...... ASTRINGYN ...... aqueous vitamin d ...... artificial tears ophthalmic solution 0.5-0.6 %, atabex dha 200 ...... aqueous vitamin e oral solution 15 unit/0.3ml 5-6 mg/ml ...... ATABEX EC ...... AQUORAL ...... artificial tears ophthalmic solution 1.4 % ...... ATABEX OB ...... ARAKODA ...... artificial tears ophthalmic solution 1-0.3 %.... ATACAND ...... aranelle ...... ARZOL SILVER NIT APPLICATORS ...... ATACAND HCT ...... ARANESP (ALBUMIN FREE) ...... ASACOL HD ...... atazanavir sulfate ...... ARAVA ...... ascomp-codeine ...... ATELVIA ...... ARAZLO ...... ascorbic acid oral powder ...... atenolol oral ...... ARCALYST ...... ascorbic acid oral tablet 500 mg ...... ATENOLOL+SYRSPEND SF ...... ARFORMOTEROL TARTRATE ...... asenapine maleate ...... atenolol-chlorthalidone ...... arginine ...... ashlyna ...... ATGAM ...... ARICEPT ...... ASMANEX (120 METERED DOSES) ...... atheletes foot ...... ARIKAYCE ...... ASMANEX (14 METERED DOSES) ...... athletes foot (terbinafine) ...... ARIMIDEX ...... ASMANEX (30 METERED DOSES) ...... athletes foot (tolnaftate) external cream 1 % . aripiprazole oral solution ...... ASMANEX (60 METERED DOSES) ...... athletes foot external aerosol powder 2 % .... aripiprazole oral tablet ...... ASMANEX (7 METERED DOSES) ...... athletes foot external cream 1 % ......

195 athletes foot external powder 2 % ...... AVAR LS CLEANSER ...... AZULFIDINE ...... athletes foot powder spray ...... AVAR-E EMOLLIENT ...... AZULFIDINE EN-TABS ...... athletes foot spray ...... AVAR-E GREEN ...... azurette ...... athletes foot spray external aerosol 2 % ...... AVAR-E LS ...... B ATIVAN ORAL ...... AVEIDAOXIA ...... b complex formula 1 ...... atomoxetine hcl ...... AVENOC ...... b complex oral capsule ...... ATOPICLAIR ...... aviane ...... b complex plus c ...... atorvastatin calcium oral ...... avidoxy ...... b complex vitamins ...... atovaquone oral ...... AVIDOXY DK ...... b complex-biotin-fa ...... atovaquone-proguanil hcl ...... AVITA ...... b complex-c oral capsule ...... ATRALIN ...... AVITENE ...... b complex-folic acid ...... ATRIPLA ...... AVITENE FLOUR ...... b-1 ...... atropine sulfate ophthalmic ointment ...... AVODART ...... b-100 complex cr ...... ATROPINE SULFATE OPHTHALMIC AVONEX PEN ...... b12 ...... SOLUTION 0.01 % ...... AVONEX PREFILLED ...... b12 gummies ...... atropine sulfate ophthalmic solution 1 %...... AXONA ...... b-12 mouth/throat lozenge 1000-400 mcg ..... ATROVENT HFA ...... AYGESTIN ...... b-12 oral liquid 1000 mcg/15ml ...... AUBAGIO ...... AYR ...... b-12 oral tablet 1000 mcg, 500 mcg ...... aubra ...... AYR NASAL MIST ALLERGY/SINUS...... b12 quick dissolve ...... aubra eq ...... AYR SALINE NASAL ...... b-12 sublingual tablet sublingual 2500 mcg, AUGMENTIN ES-600 ...... AYR SALINE NASAL DROPS ...... 5000 mcg ...... AUGMENTIN ORAL SUSPENSION AYR SALINE NASAL NO-DRIP ...... B-2-400 ...... RECONSTITUTED 125-31.25 MG/5ML .... ayuna ...... b6 ...... AUGMENTIN ORAL SUSPENSION AYVAKIT ...... b-6 folic acid ...... RECONSTITUTED 250-62.5 MG/5ML ...... AZALGIA ...... BABY ANBESOL ...... AUGMENTIN ORAL TABLET ...... AZASAN ...... BABY AYR SALINE ...... aurodryl allergy childrens ...... AZASITE ...... baby basics diaper rash ...... aurophen childrens ...... azathioprine oral ...... baby teething oral pain ...... aurovela 1.5/30 ...... azelaic acid external ...... bac ...... aurovela 1/20 ...... azelastine hcl nasal ...... BACICAP ...... aurovela 24 fe ...... azelastine hcl ophthalmic ...... bacitracin external ...... aurovela fe 1.5/30 ...... azelastine-fluticasone ...... bacitracin ophthalmic ...... aurovela fe 1/20 ...... AZELEX ...... bacitracin zinc external ...... AURYXIA ...... AZILECT ...... bacitracin zinc first aid ...... AUSTEDO ...... azithromycin oral ...... bacitracin-polymyxin b ophthalmic ...... AUVI-Q ...... azo ...... bacitra-neomycin-polymyxin-hc ...... AVAILNEX ...... azo tabs ...... BACLOFEN EXTERNAL ...... AVALIDE ...... AZOLEN TINCTURE ...... baclofen oral ...... AVAPRO ...... AZOPT ...... BACMIN ...... AVAR CLEANSER ...... AZOR ...... BACTRIM ......

196 BACTRIM DS ...... BENADRYL ALLERGY CHILDRENS ORAL BENZOYL PEROXIDE EXTERNAL GEL 8 BAFIERTAM ...... LIQUID ...... % ...... balance b-100 ...... BENADRYL ALLERGY CHILDRENS ORAL BENZOYL PEROXIDE FORTE- HC ...... balance b-50 ...... TABLET CHEWABLE ...... benzoyl peroxide-erythromycin ...... balanced b100 ...... BENADRYL ALLERGY ORAL TABLET ...... benztropine mesylate oral ...... balanced b-100 cr ...... benazepril hcl oral ...... bepotastine besilate ...... balanced b-100 oral tablet ...... benazepril-hydrochlorothiazide ...... BEPREVE ...... balanced b50 ...... BENICAR ...... BERINERT ...... balanced b-50 oral tablet ...... BENICAR HCT ...... BESER EXTERNAL KIT ...... balanced b-50 tr ...... BENLYSTA SUBCUTANEOUS ...... beser external lotion ...... BALCOLTRA ...... BENSAL HP ...... BESIVANCE ...... balsalazide disodium ...... BENZAC AC WASH ...... BESPONSA ...... BALVERSA ...... BENZACLIN ...... beta carotene oral capsule 15 mg, 25000 balziva ...... BENZACLIN WITH PUMP ...... unit ...... banophen oral capsule 25 mg ...... BENZALKONIUM CHLORIDE EXTERNAL BETADINE OPHTHALMIC PREP ...... banophen oral tablet ...... SOLUTION ...... betamethasone dipropionate aug ...... BANZEL ...... benzalkonium chloride external solution 50 betamethasone dipropionate external cream BAQSIMI ONE PACK ...... % ...... betamethasone dipropionate external lotion .. BAQSIMI TWO PACK ...... BENZAMYCIN ...... betamethasone dipropionate external BARACLUDE ORAL SOLUTION ...... BENZEPRO CREAMY WASH ...... ointment ...... BARACLUDE ORAL TABLET ...... BENZEPRO EXTERNAL ...... betamethasone valerate external cream ...... BASAGLAR KWIKPEN ...... BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 betamethasone valerate external foam ...... BASLE ...... % ...... betamethasone valerate external lotion ...... BAXDELA ORAL ...... benzepro external foam 5.3 % ...... betamethasone valerate external ointment ... BAYER ASPIRIN ...... BENZEPRO EXTERNAL LIQUID ...... BETAPACE ...... b-complex oral tablet ...... BENZEPRO FOAMING CLOTHS ...... BETAPACE AF ...... b-complex with b-12 ...... BENZEPRO SHORT CONTACT ...... BETASEPT SURGICAL SCRUB ...... b-complex/b-12 oral ...... BENZHYDROCODONE-ACETAMINOPHEN BETASERON ...... b-complex/vitamin c cr ...... BENZNIDAZOLE ...... betatemp childrens ...... BD AUTOSHIELD DUO PEN NEEDLES ...... BENZODOX ...... betaxolol hcl ophthalmic ...... BD ULTRA-FINE INSULIN SYRINGES ...... BENZOIN ...... betaxolol hcl oral ...... BD ULTRA-FINE PEN NEEDLES ...... benzoin compound ...... bethanechol chloride oral ...... beauty 360 pure glycerin ...... benzonatate oral capsule 100 mg ...... BETHKIS ...... BECONASE AQ ...... benzonatate oral capsule 150 mg ...... BETIMOL ...... bee pollen oral capsule 580 mg ...... benzonatate oral capsule 200 mg ...... BETOPTIC-S ...... BEELITH ...... BENZOYL PEROX-HYDROCORTISONE .... BEVESPI AEROSPHERE ...... bekyree ...... benzoyl peroxide external foam ...... bexarotene ...... BELBUCA ...... BENZOYL PEROXIDE EXTERNAL GEL 6.5 BEXSERO ...... belladonna alkaloids-opium ...... % ...... BEYAZ ...... BELSOMRA ...... BHI URI-CONTROL ......

197 bicalutamide ...... BLUESTAR ...... bromocriptine mesylate oral ...... BIDIL ...... BONINE ...... BROMSITE ...... BIIFENAC 1000 ...... BONIVA ORAL ...... BRONCHITOL ...... BIIFENAC 500 ...... BONJESTA ...... BROVANA ...... BIJUVA ...... BOOSTRIX ...... BRUKINSA ...... BIKTARVY ...... boro-packs ...... BRYHALI ...... BILTRICIDE ...... bosentan ...... b-stress ...... bimatoprost ophthalmic ...... BOSULIF ...... BUBBLES THE FISH II PEDI MASK ...... BINOSTO ...... BOUDREAUXS BABY BUTT SMOOTH ...... budesonide er ...... BIO GLO ...... BOUDREAUXS BUTT PASTE EXTERNAL budesonide inhalation ...... biocel ...... OINTMENT 40 % ...... budesonide oral ...... bioflex ...... bp 10-1 ...... BUDESONIDE-FORMOTEROL FUMARATE BIOLLE TEARS ...... bp cleansing wash ...... BUFFERIN ...... biopetit ...... bp vit 3 ...... bumetanide oral ...... biotin forte ...... bp wash external liquid 2.5 % ...... BUMEX ...... biotin high potency ...... bp wash external liquid 7 % ...... BUNAVAIL ...... biotin oral capsule 2500 mcg ...... b-plex ...... BUPAP ...... biotin oral capsule 5000 mcg ...... b-plex plus ...... BUPHENYL ...... biotin oral tablet 1000 mcg ...... BPROTECTED PEDIA D-VITE ...... buprenorphine hcl sublingual ...... biotin oral tablet 5 mg ...... BPROTECTED PEDIA IRON ...... buprenorphine hcl-naloxone hcl ...... biotinex ...... BPROTECTED PEDIA POLY-VITE ...... buprenorphine transdermal ...... bisacodyl ec ...... BPROTECTED PEDIA POLY-VITE/FE ...... bupropion hcl er (smoking det) ...... bisacodyl laxative ...... BPROTECTED VITAMIN C ...... bupropion hcl er (sr) ...... bisacodyl rectal ...... BRAFTOVI ...... bupropion hcl er (xl) oral tablet extended bismatrol maximum strength ...... BREATHE EASE NEB MASK/CHILD ...... release 24 hour 150 mg, 300 mg ...... bismatrol oral tablet chewable ...... BREATHE EASE NEB MASK/INFANT ...... BUPROPION HCL ER (XL) ORAL TABLET bismuth ...... BREO ELLIPTA ...... EXTENDED RELEASE 24 HOUR 450 MG bismuth subsalicylate oral suspension ...... brewers yeast oral tablet 487.5 mg ...... bismuth subsalicylate oral tablet chewable ... BREZTRI AEROSPHERE ...... bupropion hcl oral ...... bisoprolol fumarate oral ...... briellyn ...... buspirone hcl oral ...... bisoprolol-hydrochlorothiazide ...... BRILINTA ...... butalbital-acetaminophen capsule 50-300 BLEPH-10 ...... brimonidine tartrate ophthalmic solution 0.15 mg oral ...... BLEPHAMIDE ...... % ...... BUTALBITAL-ACETAMINOPHEN BLEPHAMIDE S.O.P...... brimonidine tartrate ophthalmic solution 0.2 CAPSULE 50-300 MG ORAL ...... blisovi 24 fe ...... % ...... butalbital-acetaminophen oral tablet 25-325 blisovi fe 1.5/30 ...... BRIMONIDINE-DORZOLAMIDE ...... mg ...... blisovi fe 1/20 ...... brinzolamide ...... butalbital-acetaminophen oral tablet 50-300 BLOOD GLUCOSE TEST IN VITRO STRIP . BRISDELLE ...... mg ...... BLOOD GLUCOSE TEST STRIPS ...... , , BRIVIACT ORAL ...... butalbital-acetaminophen oral tablet 50-325 blue tube/ aloe ...... bromfenac sodium (once-daily) ...... mg ......

198 butalbital-apap-caff-cod oral capsule 50-300- calcipotriene external solution ...... calcium carbonate oral tablet 1500 (600 ca) 40-30 mg ...... calcipotriene-betameth diprop external mg ...... butalbital-apap-caff-cod oral capsule 50-325- ointment ...... calcium carbonate oral tablet chewable 1250 40-30 mg ...... calcipotriene-betameth diprop external (500 ca) mg...... butalbital-apap-caffeine oral capsule 50-300- suspension ...... calcium carbonate oral tablet chewable 500 40 mg ...... calcitonin (salmon) nasal ...... mg ...... butalbital-apap-caffeine oral capsule 50-325- cal-citrate ...... calcium carbonate-vitamin d oral tablet 600- 40 mg ...... CALCITRENE ...... 200 mg-unit ...... butalbital-apap-caffeine oral tablet ...... calcitriol external ...... calcium carbonate-vitamin d oral tablet 600- butalbital-asa-caff-codeine ...... calcitriol oral ...... 400 mg-unit ...... butalbital-aspirin-caffeine ...... calcium 500 +d3 ...... calcium carbonate-vitamin d3 ...... butorphanol tartrate nasal ...... calcium 500/d oral tablet ...... calcium cit plus vit d-3 ...... BUTRANS ...... calcium 500/d oral tablet chewable ...... calcium citrate + d oral tablet 315-250 mg- BYDUREON BCISE AUTOINJECTOR ...... calcium 500/vitamin d3 ...... unit ...... BYETTA 10 MCG PEN ...... calcium 600 oral tablet 1500 (600 ca) mg ..... calcium citrate + d3 maximum ...... BYETTA 5 MCG PEN ...... calcium 600/vit d/minerals oral tablet 600- calcium citrate +d3 ...... BYSTOLIC ...... 200 mg-unit ...... calcium citrate malate-vit d ...... C calcium 600/vit d/minerals oral tablet calcium citrate oral tablet 1040 mg ...... c 1000-bioflavonoids-rose hips ...... chewable 600-400 mg-unit ...... calcium citrate plus vit d ...... c 250 oral tablet ...... calcium 600/vitamin d ...... calcium citrate+d oral tablet 315-250 mg-unit c 500/rose hips ...... calcium 600/vitamin d-3 ...... calcium citrate+d3 oral tablet 315-250 mg- c complex ...... calcium 600+d oral capsule 600-500 mg-unit unit ...... c-1000/rose hips ...... calcium 600+d oral tablet 600-200 mg-unit, calcium citrate+d3 petites oral tablet 200- cabergoline ...... 600-400 mg-unit ...... 6.25 mg-mcg ...... CABLIVI ...... calcium 600+d oral tablet 600-400 mg-unit ... calcium citrate+d3 w/magne ...... CABOMETYX ...... calcium 600+d3 oral capsule 600-500 mg- calcium citrate-vit d ...... CADEAU DHA ...... unit ...... calcium citrate-vitamin d oral tablet 200-125 CADIRAMD ...... calcium acetate (phos binder) ...... mg-unit ...... CADUET ...... calcium acetate oral tablet 667 mg ...... calcium citrate-vitamin d oral tablet 315-200 CAFERGOT ...... calcium acetate oral tablet 668 (169 ca) mg . mg-unit ...... caffeine citrate oral ...... calcium antacid ...... calcium cit-vit d-3 petites ...... cal mag zinc +d3 ...... calcium antacid ex st ...... calcium fast dissolution ...... calamine external lotion , 8-8 % ...... calcium antacid extra strength ...... calcium high potency ...... calamine-zinc oxide external lotion ...... calcium carb-cholecalciferol oral tablet 600- calcium high potency/vitamin d ...... CALAN SR ...... 400 mg-unit ...... calcium oral tablet 1500 (600 ca) mg ...... calcidol ...... calcium carbonate antacid oral suspension .. calcium oral tablet 500 mg, 600 mg ...... CALCIFOL ...... calcium carbonate antacid oral tablet ...... calcium oyster shell oral tablet 1250 (500 ca) calcipotriene external cream ...... calcium carbonate antacid oral tablet mg ...... CALCIPOTRIENE EXTERNAL FOAM ...... chewable ...... calcium plus 600 +d ...... calcipotriene external ointment ......

199 calcium plus vitamin d oral tablet 500-5 mg- CAPLYTA ...... CARETOUCH UNIVERSL CPAP FILTER ..... mcg ...... CAPRELSA ...... carisoprodol oral ...... calcium plus vitamin d oral tablet 600-200 capsaicin external cream 0.025 % ...... carisoprodol-aspirin-codeine ...... mg-unit ...... capsaicin external cream 0.1 % ...... CARNITOR ORAL SOLUTION ...... calcium plus vitamin d oral tablet 600-400 capsaicin hp ...... CARNITOR ORAL TABLET ...... mg-unit ...... CAPSAICIN-MENTHOL ...... CARNITOR SF ...... calcium plus vitamin d3 ...... CAPSFENAC PAK ...... CAROSPIR ...... calcium soft chews oral tablet chewable 500- CAPSINAC ...... carteolol hcl ...... 100-40 ...... captopril oral ...... cartia xt ...... calcium soft chews oral tablet chewable 500- captopril-hydrochlorothiazide ...... carvedilol ...... 200-40 mg-unt-mcg ...... capzix ...... carvedilol phosphate er ...... calcium/minerals/vitamin d ...... CARAC ...... cascara sagrada oral fluid extract ...... calcium-boron ...... CARAFATE ORAL SUSPENSION ...... CASODEX ...... calcium-folic acid plus d ...... CARAFATE ORAL TABLET ...... CASTIVA WARMING ...... calcium-magnesium-zinc oral tablet 333- CARBAGLU ...... CATAFLAM ...... 133-5 mg, 333.33-133.33-5 mg ...... carbamazepine er ...... CATAPRES-TTS-1 ...... calcium-vitamin d oral tablet 600-400 mg- carbamazepine oral ...... CATAPRES-TTS-2 ...... unit ...... CARBATROL ...... CATAPRES-TTS-3 ...... calcium-vitamin d oral tablet chewable 250- carbidopa oral ...... cavarest ...... 400 mg-unit ...... carbidopa-levodopa er ...... CAVILON ...... calcium-vitamin d3 oral tablet 600-400 mg- carbidopa-levodopa oral tablet ...... CAYA ...... unit ...... carbidopa-levodopa oral tablet dispersible ... CAYSTON ...... CALENDULA EXTERNAL OINTMENT ...... carbidopa-levodopa-entacapone ...... caziant ...... cal-gest antacid ...... carbinoxamine maleate oral solution ...... cefaclor ...... calicylic ...... carbinoxamine maleate oral tablet 4 mg ...... cefaclor er ...... cal-mag aspartate ...... carbinoxamine maleate oral tablet 6 mg ...... cefadroxil ...... CALQUENCE ...... carboxymethylcellulose sodium ophthalmic .. cefazolin sodium-dextrose intravenous CALTRATE GUMMY BITES ...... CARDIZEM ...... solution 2-4 gm/100ml-% ...... CAMBIA ...... CARDIZEM CD ...... cefdinir ...... camila ...... CARDIZEM LA ...... cefixime ...... CAMINO PRO COMPLETE/GLYTACTIN ..... CARDURA ...... cefpodoxime proxetil ...... camrese ...... CARDURA XL ...... cefprozil ...... camrese lo ...... CARETOUCH 2 CPAP HOSE HANGER ...... cefuroxime axetil ...... CANASA ...... CARETOUCH CONTROL SOL LEVEL 2 ..... CELEBREX ...... candesartan cilexetil ...... CARETOUCH CPAP & BIPAP HOSE ...... celecoxib oral ...... candesartan cilexetil-hctz ...... CARETOUCH CPAP MASK WIPES ...... CELEXA ...... CANTHARIDIN EXTERNAL...... CARETOUCH CPAP PRE-WASH SOLN ..... CELLCEPT ...... capcof ...... CARETOUCH CPAP TUBE BRUSH ...... CELONTIN ...... capecitabine ...... CARETOUCH MONITOR SYSTEM ...... CEM-UREA ...... CAPEX ...... CARETOUCH TEST ...... CENFOL ......

200 CENTANY ...... CHEMET ...... CHLOOXIA ...... CENTANY AT ...... CHEMSTRIP 10 MD ...... chlordiazepoxide hcl ...... CENTRATEX ...... CHEMSTRIP 10/SG ...... chlordiazepoxide-amitriptyline ...... CENTRUM FLAVOR BURST ...... CHEMSTRIP 2 GP ...... chlordiazepoxide-clidinium ...... CENTRUM FLAVOR BURST ADULT ...... CHEMSTRIP 5 OB ...... chlorella ...... CENTRUM FLAVOR BURST KIDS ...... CHEMSTRIP 7 ...... chlorhexidine gluconate mouth/throat ...... CENTRUM FRESH/FRUITY 50+ ...... CHEMSTRIP 9 ...... chloroquine phosphate oral ...... CENTRUM KIDS ...... CHEMSTRIP K ...... chlor-pheniramine ...... CENTRUM MULTI + OMEGA 3 ...... CHEMSTRIP MICRAL ...... chlorpheniramine maleate er ...... CENTRUM ORAL TABLET CHEWABLE ...... CHEMSTRIP UGK ...... chlorpheniramine maleate oral ...... CENTRUM SILVER ORAL TABLET CHENODAL ...... chlorpromazine hcl oral ...... CHEWABLE ...... cherry cough drops ...... chlortabs ...... CENTRUM SPECIALIST PRENATAL ...... cherry menthol drops ...... chlorthalidone ...... CENTRUM VITAMINTS ...... chest congest/cough child ...... CHLOR-TRIMETON ALLERGY ...... cephalexin oral capsule 250 mg, 500 mg...... chest congestion relief ...... CHLOR-TRIMETON ORAL SYRUP ...... cephalexin oral capsule 750 mg...... chest congestion relief dm ...... CHLOR-TRIMETON ORAL TABLET ...... cephalexin oral suspension reconstituted ..... chewable c ...... chlorzoxazone oral tablet 250 mg, 500 mg .... cephalexin oral tablet 250 mg ...... chewable c with rose hips ...... chlorzoxazone oral tablet 375 mg, 750 mg .... cephalexin oral tablet 500 mg ...... chewable childrens vitamin ...... chocolate laxative pieces ...... CEQUA ...... chewy not chalky flavor ...... chocolated laxative ...... CERDELGA ...... childrens acetaminophen ...... CHOICEFUL MULTIVITAMIN ORAL CEREFOLIN ...... childrens allergy oral liquid 12.5 mg/5ml ...... TABLET CHEWABLE ...... cerefolin nac ...... childrens animal shapes ...... CHOLBAM ...... cerovel ...... childrens apap ...... CHOLECAL DF ...... cerovite jr ...... childrens aspirin oral tablet chewable 81 mg cholestyramine light ...... CERVIDIL ...... childrens chewable vitamins ...... cholestyramine oral ...... CETACAINE EXTERNAL AEROSOL ...... childrens chewables/ex c ...... chorionic gonadotropin intramuscular ...... CETACAINE EXTERNAL GEL ...... childrens chewables/iron ...... CHROMAGEN ...... cetiri-d ...... childrens cold & allergy ...... CIALIS ORAL TABLET 5 MG ...... cetirizine hcl ...... childrens complete oral tablet chewable 18 ciclodan ...... cetirizine hcl childrens oral tablet chewable .. mg ...... ciclopirox external gel ...... cetirizine-pseudoephedrine er ...... childrens cough ...... ciclopirox external shampoo ...... CETRAXAL ...... childrens loratadine ...... ciclopirox external solution ...... cevimeline hcl ...... childrens mucus relief cough ...... ciclopirox olamine external cream ...... CHANTIX ...... childrens non-aspirin ...... ciclopirox olamine suspension 0.77 % CHANTIX CONTINUING MONTH PAK ...... childrens silapap ...... external ...... , CHANTIX STARTING MONTH PAK ...... childrens soothe ...... ciclopirox treatment ...... charlotte 24 fe ...... childrens vitamins/extra c ...... CIFEREX ...... chateal ...... childrens vitamins/iron ...... cilostazol ...... chateal eq ...... childs non-aspirin ...... CILOXAN OPHTHALMIC OINTMENT......

201 CILOXAN OPHTHALMIC SOLUTION ...... CLARITIN ALLERGY CHILDRENS ...... CLINDAMYCIN PHOSPHATE GEL 1 % CIMDUO ...... CLARITIN CHILDRENS ...... EXTERNAL ...... cimetidine hcl ...... CLARITIN EYE ...... clindamycin phosphate vaginal ...... cimetidine oral ...... CLARITIN ORAL CAPSULE ...... clindamycin phosphate-benzoyl peroxide ...... CIMZIA ...... CLARITIN ORAL TABLET ...... clindamycin-tretinoin ...... cinacalcet hcl ...... CLARITIN ORAL TABLET CHEWABLE ...... CLINDAVIX ...... CINRYZE ...... CLARITIN REDITABS ORAL TABLET CLINDESSE ...... CIPRO HC ...... DISPERSIBLE 10 MG ...... CLINOIN ...... CIPRO ORAL SUSPENSION CLARITIN REDITABS ORAL TABLET CLINPRO 5000 ...... RECONSTITUTED ...... DISPERSIBLE 5 MG ...... clobazam oral suspension ...... CIPRO ORAL TABLET ...... CLARITIN-D 12 HOUR ...... clobazam oral tablet ...... CIPRODEX ...... CLARITIN-D 24 HOUR ...... clobetasol prop emollient base ...... ciprofloxacin hcl ophthalmic ...... classic prenatal ...... clobetasol propionate e ...... ciprofloxacin hcl oral ...... c-lax laxative ...... clobetasol propionate emulsion ...... ciprofloxacin hcl otic ...... CLEARCANAL EARWAX SOFTENER ...... clobetasol propionate external ...... ciprofloxacin-dexamethasone ...... clearlax oral powder 17 gm/scoop ...... CLOBETAVIX ...... CIPROFLOXACIN-FLUOCINOLONE PF ...... clearskin ...... CLOBETEX ...... citalopram hydrobromide ...... clemastine fumarate oral syrup ...... CLOBEX ...... CITRANATAL 90 DHA ...... clemastine fumarate oral tablet 2.68 mg ...... CLOBEX SPRAY ...... CITRANATAL ASSURE ...... CLENIA PLUS ...... clocortolone pivalate ...... CITRANATAL B-CALM ...... CLENPIQ ...... CLODAN EXTERNAL KIT ...... CITRANATAL BLOOM ...... CLEOCIN ORAL ...... clodan external shampoo ...... CITRANATAL BLOOM DHA ...... CLEOCIN VAGINAL CREAM ...... CLODERM ...... CITRANATAL DHA ...... CLEOCIN VAGINAL SUPPOSITORY ...... clomipramine hcl oral ...... CITRANATAL ESSENCE ...... CLEOCIN-T ...... clonazepam oral tablet ...... CITRANATAL HARMONY ...... CLIMARA ...... clonazepam oral tablet dispersible ...... CITRANATAL MEDLEY ...... CLIMARA PRO ...... clonidine ...... CITRANATAL RX ...... CLINDACIN ETZ EXTERNAL KIT ...... clonidine hcl er ...... citrate of magnesia ...... clindacin etz external swab ...... clonidine hcl oral ...... citroma ...... CLINDACIN PAC ...... clopidogrel bisulfate oral ...... CITRUCEL ...... clindacin-p ...... clorazepate dipotassium ...... CITRULLINE 1000 ...... CLINDAGEL ...... clotrimazole 3 ...... citrus calcium/vitamin d ...... clindamycin hcl oral ...... clotrimazole 7 ...... claravis oral capsule 10 mg ...... clindamycin palmitate hcl ...... clotrimazole external ...... claravis oral capsule 20 mg ...... clindamycin phosphate external foam ...... clotrimazole mouth/throat ...... claravis oral capsule 30 mg, 40 mg...... clindamycin phosphate external lotion ...... clotrimazole vaginal ...... , CLARINEX ...... clindamycin phosphate external solution ...... clotrimazole-betamethasone ...... CLARINEX-D 12 HOUR ...... clindamycin phosphate external swab ...... clovique ...... clarithromycin er ...... clindamycin phosphate gel 1 % external ...... clozapine ...... clarithromycin oral ...... CLOZARIL ......

202 C-NATE DHA ...... cold/cough ...... COMPRESSOR NEBULIZER ...... COAGADEX INTRAVENOUS SOLUTION cold/cough childrens ...... compro ...... RECONSTITUTED 500 UNIT ...... cold/cough dm childrens oral liquid 2.5-1-5 COMTAN ...... COAL TAR EXTERNAL ...... mg/5ml ...... COMTREX COLD & COUGH MAX ST ...... COARTEM ...... cold/cough dm oral liquid 2.5-1-5 mg/5ml ..... CO-NATAL FA ...... cod liver oil oral capsule , 1250-133 unit, cold/flu daytime relief ...... CONCEPT DHA ...... 1250-135 unit, 4000-200 unit ...... cold/flu relief daytime ...... CONCEPT OB ...... COD LIVER OIL ORAL OIL ...... COLD-EEZE ...... CONCERTA ...... codeine sulfate ...... COLD-EEZE NATURAL MULTI-SYMP CONDOMS ...... coditussin ac ...... MOUTH/THROAT ...... CONDYLOX ...... co-enzyme q10 ...... COLD-EEZE PLUS DEFENSE CONJUPRI ...... coenzyme q10 oral capsule 100 mg ...... MOUTH/THROAT ...... CONSENSI ...... coenzyme q-10 oral capsule 100 mg ...... COLD-EEZE SUGAR FREE ...... constulose ...... coenzyme q-10 oral capsule 200 mg ...... colesevelam hcl ...... CONTOUR CONTROL SOLUTION ...... coenzyme q10 oral capsule 50 mg ...... COLESTID ...... CONTOUR MONITOR ...... , co-enzyme q-10 oral capsule 50 mg ...... COLESTID FLAVORED ...... CONTOUR NEXT EZ KIT W/DEVICE ...... coenzyme q10 oral tablet 200 mg ...... colestipol hcl oral granules ...... CONTOUR NEXT LINK KIT W/DEVICE ...... COLACE ...... colestipol hcl oral packet ...... CONTOUR NEXT MONITOR KIT COLAZAL ...... colestipol hcl oral tablet ...... W/DEVICE ...... COLCHICINE ORAL CAPSULE ...... colistimethate sodium (cba) ...... CONTOUR NEXT ONE KIT ...... colchicine oral tablet ...... col-rite oral capsule 250 mg ...... CONTOUR NEXT TEST STRIPS ...... colchicine-probenecid ...... COLY-MYCIN M ...... CONTOUR TEST STRIPS ...... COLCIGEL ...... COMBIGAN ...... CONTRAST ALLERGY PREMED PACK ...... COLCRYS ...... COMBIPATCH ...... CONVENIENCE PAK ...... cold & allergy ...... COMBIVENT RESPIMAT ...... CONZIP ...... cold & allergy childrens oral elixir 1-15 COMBIVIR ...... COOL MIST HUMIDIFER ...... mg/5ml ...... COMETRIQ (100 MG DAILY DOSE) ...... COPADERM ...... cold & cough childrens oral liquid 2.5-1-5 COMETRIQ (140 MG DAILY DOSE) ...... COPASIL EXTERNAL ...... mg/5ml ...... COMETRIQ (60 MG DAILY DOSE) ...... COPAXONE ...... cold & cough dm childrens oral liquid 2.5-1-5 comfort gel ...... COPIKTRA ...... mg/5ml ...... comfort gel antacid anti-gas oral suspension coq-10 oral capsule 200 mg ...... cold & flu oral liquid 10-5-325 mg/15ml ...... 400-400-40 mg/5ml ...... coq-10 oral capsule 50 mg ...... cold & flu relief daytime ...... COMFORT TOUCH INSULIN PEN NEED ... coral calcium oral capsule 185-50-100 mg- cold & sinus relief oral tablet 30-200 mg ...... COMFORT TOUCH LANCETS 31G ...... mg-unit ...... cold head congestion daytime ...... COMFORT TOUCH PLUS LANCETS 30G .. CORAL CALCIUM ORAL TABLET 1000 cold max ...... COMPLERA ...... (390 CA) MG...... cold max daytime ...... complete allergy ...... CORDRAN EXTERNAL CREAM ...... cold multi-symptom daytime...... complete allergy medicine oral capsule ...... CORDRAN EXTERNAL LOTION ...... cold relief oral tablet 12.5-500 mg ...... complete allergy relief ...... CORDRAN EXTERNAL OINTMENT ...... cold sore treatment external liquid 0.13-3 % . complex b-100-inositol ...... CORDRAN EXTERNAL TAPE ......

203 COREG ...... cough/sore throat daytime oral liquid 1000- cyclopentolate hcl ophthalmic solution 0.5 COREG CR ...... 30 mg/30ml ...... %, 2 % ...... coremino ...... cough/sore throat nighttime ...... cyclopentolate hcl ophthalmic solution 1 % ... CORGARD ...... COVARYX ...... CYCLOPHENE RAPIDPAQ ...... CORICIDIN HBP COUGH/COLD ...... COVARYX HS ...... cyclophosphamide injection solution CORLANOR ...... COVID-19 SPECIMEN COLLECTION ...... reconstituted 500 mg ...... corn & callus remover ...... COZAAR ...... cyclophosphamide oral capsule ...... CORTANE-B ...... CREON ...... CYCLOPHOSPHAMIDE ORAL TABLET ...... CORTEF ...... CRESEMBA ORAL ...... cycloserine oral ...... CORTENEMA ...... CRESTOR ...... CYCLOSET ...... cortic-nd ...... CRINONE ...... CYCLOSPORINE IN KLARITY ...... CORTIFOAM ...... CRIXIVAN ...... cyclosporine modified oral capsule 100 mg, cortisone maximum strength external gel ..... cromolyn sodium inhalation ...... 25 mg ...... CORTISPORIN-TC ...... cromolyn sodium nasal ...... cyclosporine modified oral capsule 50 mg ..... CORVITE 150 ...... cromolyn sodium ophthalmic ...... cyclosporine modified oral solution ...... corvite fe ...... cromolyn sodium oral ...... cyclosporine oral ...... COSENTYX SUBCUTANEOUS SOLUTION crotan ...... CYMBALTA ...... AUTO-INJECTOR 150 MG/ML ...... CRUEX PRESCRIPTION STRENGTH ...... cyproheptadine hcl oral ...... COSENTYX SUBCUTANEOUS SOLUTION crush vitamin c drops ...... cyred ...... PREFILLED SYRINGE 150 MG/ML ...... cryselle-28 ...... cyred eq ...... COSENTYX SUBCUTANEOUS SOLUTION CUPRIMINE ...... CYSTADANE ...... PREFILLED SYRINGE 75 MG/0.5ML ...... cure-all ...... CYSTADROPS ...... COSOPT ...... CUROSURF INTRATRACHEAL CYSTAGON ...... COSOPT PF ...... SUSPENSION 120 MG/1.5ML ...... CYSTARAN ...... COTELLIC ...... CUTIVATE ...... cystine ...... COTEMPLA XR-ODT...... CUVPOSA ...... CYTOGAM ...... cough & chest congestion ...... cyanocobalamin injection solution 1000 CYTOMEL ...... cough & cold ...... mcg/ml ...... CYTOTEC ...... cough & cold hbp ...... cyclafem 1/35 ...... cytra k crystals ...... cough & sore throat nighttime ...... cyclafem 7/7/7 ...... D cough childrens ...... CYCLO/GABA 10/300 ...... d 1000 oral tablet ...... cough dm ...... cyclobenzaprine hcl er ...... d 400 oral tablet ...... cough dm childrens ...... cyclobenzaprine hcl oral tablet 10 mg, 5 mg d 400 oral tablet chewable ...... cough dm er ...... cyclobenzaprine hcl oral tablet 7.5 mg ...... d 5000 oral tablet ...... cough drops mouth/throat lozenge 5.4 mg .... CYCLOGYL OPHTHALMIC SOLUTION 0.5 D.H.E. 45 ...... cough relief oral syrup 15 mg/5ml ...... %, 2 %...... d3 high potency oral capsule 25 mcg (1000 cough/chest congestion dm ...... CYCLOGYL OPHTHALMIC SOLUTION 1 % ut) ...... cough/chest dm childrens oral liquid ...... CYCLOMYDRIL ...... d3 oral capsule 10 mcg (400 unit), 50 mcg cough/cold hbp ...... CYCLOPAK ...... (2000 ut) ...... d3 oral capsule 125 mcg (5000 ut) ......

204 d3 oral capsule 25 mcg (1000 ut) ...... DAYHIST ALLERGY 12 HOUR RELIEF...... deferiprone ...... d3 super strength ...... DAYPRO ...... DELESTROGEN INTRAMUSCULAR OIL 10 d-3-5 ...... daysee ...... MG/ML ...... d3-50 ...... daytime ...... DELESTROGEN INTRAMUSCULAR OIL 40 daflonex-xl ...... daytime cold & flu oral liquid ...... MG/ML ...... daily acne wash ...... daytime cold & flu relief ...... DELSTRIGO ...... daily fiber oral capsule 0.52 gm ...... daytime cold/flu ms relief ...... DELSYM ...... daily gummies ...... daytime cold/flu oral capsule 10-5-325 mg ... DELSYM CGH/CHEST CONG DM CHILD.... daily gummies adult ...... daytime cold/flu oral liquid 10-5-325 DELSYM COUGH CHILDRENS ...... daily multiple vitamins ...... mg/15ml ...... DELSYM COUGH/CHEST CONGEST DM ... daily multivitamins/iron ...... daytime cold/flu relief ...... delyla ...... daily vitamin formula+iron ...... daytime cold/flu relief oral liquid 325-10-5 DELZICOL ...... daily vitamins ...... mg/15ml ...... demeclocycline hcl ...... daily vite ...... daytime liquid ...... DEMSER ...... daily vites ...... DAYTRANA ...... DENAVIR ...... daily-vite ...... DAYVIGO ...... DENTA 5000 PLUS ...... dairy aid ...... D-CARE BLOOD GLUCOSE ...... DENTAGEL ...... dairy relief ex st ...... D-CARE GLUCOMETER ...... DEOXIA ...... dairy relief fast acting oral tablet 9000 unit.... DDAVP INJECTION ...... DEPAKOTE ...... dairy relief oral tablet 3000 unit ...... DDAVP ORAL ...... DEPAKOTE ER ...... dalfampridine er ...... DDAVP PF ...... DEPAKOTE SPRINKLES ...... DALIRESP ...... DDAVP RHINAL TUBE ...... DEPEN TITRATABS ...... danazol oral ...... DEBACTEROL ...... DEPLIN 15 ...... dandruff shampoo external lotion ...... deblitane ...... DEPLIN 7.5 ...... DANTRIUM ORAL ...... DECADRON ORAL TABLET 0.5 MG, 0.75 DEPO-ESTRADIOL ...... dantrolene sodium oral ...... MG ...... DEPO-PROVERA ...... dapsone external gel 5 % ...... DECADRON ORAL TABLET 4 MG, 6 MG ... DEPO-SUBQ PROVERA 104 ...... dapsone gel 7.5 % external ...... DECARA ORAL CAPSULE 1.25 MG (50000 DEPO-TESTOSTERONE ...... DAPSONE GEL 7.5 % EXTERNAL ...... UT) ...... DERMACERIN ...... dapsone oral ...... DECARA ORAL CAPSULE 250 MCG DERMACINRX PROBITRAN ...... DAPTACEL ...... (10000 UT) ...... DERMACINRX ZINTREXYL-C ...... DARAPRIM ...... DECARA ORAL CAPSULE 625 MCG DERMALID ...... darifenacin hydrobromide er ...... (25000 UT) ...... DERMAPHOR ...... dasetta 1/35 ...... decongestant 12hour max st ...... DERMA-SMOOTHE/FS BODY ...... dasetta 7/7/7 ...... deep sea nasal spray ...... DERMA-SMOOTHE/FS SCALP ...... DAURISMO ...... deferasirox granules ...... DERMELLE ...... day time cold & flu oral capsule ...... deferasirox oral packet ...... DERMOTIC ...... day time cold & flu relief ...... deferasirox oral tablet 180 mg ...... DESCOVY ...... day time cold/flu ...... deferasirox oral tablet 360 mg, 90 mg ...... DESENEX EXTERNAL POWDER ...... DAYAVITE ...... deferasirox oral tablet soluble ...... DESENEX JOCK ITCH ......

205 desgen dm oral liquid ...... dexmethylphenidate hcl ...... dibucaine (perianal) ...... desipramine hcl oral ...... dexmethylphenidate hcl er ...... DICLEGIS ...... desloratadine oral tablet ...... dexrazoxane hcl ...... DICLOFENAC ...... desloratadine oral tablet dispersible 5 mg..... dextroamphetamine sulfate er ...... DICLOFENAC PATCH 1.3% ...... desmopressin ace spray refrig ...... dextroamphetamine sulfate oral solution ...... diclofenac potassium ...... desmopressin acetate injection ...... dextroamphetamine sulfate oral tablet ...... diclofenac sodium er ...... desmopressin acetate oral ...... dextromethorphan polistirex er ...... diclofenac sodium external gel 1 % ...... desmopressin acetate pf ...... dextromethorphan-guaifenesin oral syrup .... diclofenac sodium external gel 3 % ...... desmopressin acetate spray ...... DFS DR/MS/MENTH/CAP PAK ...... diclofenac sodium external solution ...... desogestrel-ethinyl estradiol ...... DFS/MS/MENTH/CAP PAK ...... diclofenac sodium ophthalmic ...... DESONATE ...... dha ...... diclofenac sodium oral ...... desonide external cream ...... DIABETIC TUSSIN MAX ST ...... diclofenac-misoprostol ...... desonide external gel ...... DIACOMIT ...... DICLOFONO ...... desonide external lotion ...... DIADIMAXIA ...... DICLOPR ...... desonide external ointment ...... DIALYVITE ...... DICLOSTREAM ...... DESOWEN ...... DIALYVITE 3000 ...... DICLOTREX ...... desoximetasone external ...... DIALYVITE 5000 ...... DICLOVIX ...... DESOXYN ...... DIALYVITE 800 ORAL TABLET ...... DICLOVIX M ...... despec dm ...... DIALYVITE 800/IRON ...... dicloxacillin sodium ...... despec dm-g ...... DIALYVITE 800/ZINC ...... DICOPANOL FUSEPAQ ...... desrx ...... DIALYVITE 800-ZINC 15 ...... DICOPANOL RAPIDPAQ ...... DESVENLAFAXINE ER ...... DIALYVITE OMEGA-3 CONCENTRATE ...... dicyclomine hcl oral capsule ...... desvenlafaxine succinate er ...... DIALYVITE SUPREME D ...... dicyclomine hcl oral solution ...... DETROL ...... DIALYVITE VITAMIN D 5000 ...... dicyclomine hcl oral tablet ...... DETROL LA ...... DIALYVITE/ZINC ...... DIFFERIN ...... DEXABLISS ...... diamode ...... DIFICID ...... dexamethasone intensol ...... DIAOXIA ...... diflorasone diacetate external cream ...... dexamethasone oral elixir ...... diaper rash external ointment ...... diflorasone diacetate external ointment ...... dexamethasone oral solution ...... diarrhea ...... DIFLUCAN ...... dexamethasone oral tablet 0.5 mg, 0.75 mg . diarrhea relief ...... diflunisal oral ...... dexamethasone oral tablet 1 mg, 2 mg ...... DIASDIMAXIA ...... DIFMETIOXRIME ...... dexamethasone oral tablet 1.5 mg ...... DIASOXIA ...... digestive probiotic oral capsule ...... dexamethasone oral tablet 4 mg, 6 mg ...... DIASTAT ACUDIAL ...... digestive probiotic oral capsule 250 mg ...... dexamethasone oral tablet therapy pack ...... DIASTAT PEDIATRIC ...... digitek ...... dexamethasone sodium phosphate DIASTIX ...... digox ...... ophthalmic ...... diazepam intensol ...... digoxin oral ...... DEXEDRINE ...... diazepam oral ...... dihydroergotamine mesylate injection ...... DEXERYL ...... diazepam rectal ...... dihydroergotamine mesylate nasal ...... DEXIFOL ...... diazoxide oral ...... DILANTIN INFATABS ...... DEXILANT ...... DIBENZYLINE ...... DILANTIN ORAL CAPSULE 100 MG ......

206 DILANTIN ORAL CAPSULE 30 MG ...... diphenhydramine hcl oral capsule ...... donepezil hcl oral tablet dispersible ...... DILANTIN ORAL SUSPENSION ...... diphenhydramine hcl oral elixir ...... DONNATAL ...... DILATRATE-SR ...... diphenhydramine hcl oral liquid 12.5 mg/5ml DOPTELET ...... DILAUDID ORAL ...... diphenhydramine hcl oral tablet ...... DORAL ...... diltiazem hcl er beads ...... diphenhydramine hcl oral tablet chewable .... DORYX ...... diltiazem hcl er coated beads oral capsule diphenoxylate-atropine oral liquid ...... DORYX MPC ...... extended release 24 hour ...... diphenoxylate-atropine oral tablet ...... dorzolamide hcl solution 2 % ophthalmic ...... diltiazem hcl er coated beads oral tablet DIPHTHERIA-TETANUS TOXOIDS DT ...... DORZOLAMIDE HCL SOLUTION 2 % extended release 24 hour ...... DIPROLENE ...... OPHTHALMIC ...... diltiazem hcl er oral capsule extended DIPROLENE AF ...... dorzolamide hcl-timolol mal ...... release 12 hour ...... dipyridamole oral ...... dorzolamide hcl-timolol mal pf ...... diltiazem hcl er oral capsule extended disopyramide phosphate ...... dotti ...... release 24 hour 120 mg, 180 mg ...... disulfiram oral tablet 250 mg ...... double antibiotic ...... diltiazem hcl er oral capsule extended disulfiram oral tablet 500 mg ...... DOUBLE PM ...... release 24 hour 240 mg ...... DITROPAN XL ...... DOVATO ...... diltiazem hcl oral ...... diuretic maximum strength ...... DOVONEX ...... dilt-xr oral capsule extended release 24 hour DIURIL ...... doxazosin mesylate oral ...... 120 mg, 180 mg ...... divalproex sodium er ...... doxepin hcl external ...... dilt-xr oral capsule extended release 24 hour divalproex sodium oral ...... doxepin hcl oral capsule ...... 240 mg ...... DIVIGEL ...... doxepin hcl oral concentrate ...... dimaphen dm cold/cough ...... dm maximum adult ...... doxepin hcl oral tablet ...... DIMENTHO ...... DOANS PM EXTRA STRENGTH ...... doxercalciferol oral ...... DIMETAPP COLD RELIEF CHILDRENS ..... DOC OMEGA ...... doxycycline ...... DIMETAPP COLD/ALLERGY ...... docosanol external ...... doxycycline hyclate oral capsule ...... DIMETAPP DM COLD/COUGH ...... docu ...... doxycycline hyclate oral tablet 100 mg ...... dimethyl fumarate oral...... docu liquid ...... doxycycline hyclate oral tablet 150 mg, 75 dimethyl fumarate starter pack ...... docusate calcium ...... mg ...... DIMOXIA ...... docusate mini ...... doxycycline hyclate oral tablet 20 mg ...... dino-life ...... docusate sodium oral capsule ...... doxycycline hyclate oral tablet 50 mg ...... dino-life w/extra c ...... docusate sodium oral liquid 50 mg/5ml ...... doxycycline hyclate oral tablet delayed DINO-LIFE W/IRON-ZINC ...... docusate sodium oral syrup ...... release 100 mg ...... DIOCHLOY ...... docusate sodium oral tablet ...... doxycycline hyclate oral tablet delayed diotame instydose ...... DOCUSOL MINI ...... release 150 mg, 75 mg ...... DIOVAN ...... docuzen ...... doxycycline hyclate oral tablet delayed DIOVAN HCT ...... dofetilide ...... release 200 mg, 50 mg ...... DIPENTUM ...... dok oral capsule ...... DOXYCYCLINE HYCLATE ORAL TABLET diphedryl allergy ...... dok oral tablet ...... DELAYED RELEASE 80 MG ...... diphen ...... dolishale ...... doxycycline monohydrate oral capsule 100 di-phen ...... donepezil hcl oral tablet 10 mg, 5 mg ...... mg ...... diphenhist ...... donepezil hcl oral tablet 23 mg ......

207 doxycycline monohydrate oral capsule 150 DULERA ...... EASY TOUCH TEST ...... mg ...... duloxetine hcl oral ...... easygel ...... doxycycline monohydrate oral capsule 50 DUOBRII ...... easy-lax plus ...... mg ...... DUOPA ...... EASYMAX 15 LEVEL 2 CONTROL ...... doxycycline monohydrate oral capsule 75 DUPIXENT ...... EASYMAX 15 LEVEL 2-3 CONTROL ...... mg ...... DURAGESIC-100 ...... EASYMAX 15 TEST ...... doxycycline monohydrate oral suspension DURAGESIC-12 ...... EASYMAX CONTROL ...... reconstituted ...... DURAGESIC-25 ...... EASYMAX NG BLOOD GLUCOSE ...... doxycycline monohydrate oral tablet 100 mg, DURAGESIC-50 ...... EASYMAX V BLOOD GLUCOSE ...... 50 mg ...... DURAGESIC-75 ...... EBASE CONTROLLER KIT ...... doxycycline monohydrate oral tablet 150 mg DUREZOL ...... ecee plus ...... doxycycline monohydrate oral tablet 75 mg .. DURLAZA ...... ECEOXIA ...... doxylamine-pyridoxine ...... dutasteride oral ...... EC-NAPROSYN ...... DR SMITHS ADULT BARRIER EXTERNAL dutasteride-tamsulosin hcl ...... ec-naproxen ...... OINTMENT ...... DUTOPROL ...... ECONASIL ...... DR SMITHS DIAPER ...... D-VI-SOL ...... econazole nitrate external ...... DRAXACE ...... d-vite pediatric ...... econtra ez ...... DRAXACE LOTION CLEANSER ...... DXEVO 11-DAY ...... econtra one-step ...... driminate ...... DYANAVEL XR ...... ECOZA ...... DRISDOL ...... dye-free allergy relief ...... EC-RX DHEA ...... DRISTAN SPRAY ...... DYMISTA ...... EC-RX ESTRADIOL ...... DRITHO-CREME HP ...... DYRENIUM ...... EC-RX PROGESTERONE ...... DRIXECE ...... E EC-RX TESTOSTERONE ...... DRIZALMA SPRINKLE ...... e ECZEMOL ...... dronabinol ...... E.E.S. GRANULES ...... ED A-HIST ORAL LIQUID ...... drospiren-eth estrad-levomefol ...... e-400-clear ...... ed bron gp ...... drospirenone-ethinyl estradiol ...... ear drops ...... ed chlorped jr ...... DROXIA ORAL CAPSULE 200 MG, 300 MG ear drops earwax aid ...... ed-apap ...... DROXIA ORAL CAPSULE 400 MG ...... ear wax kit ...... EDARBI ...... droxidopa ...... ear wax removal ...... EDARBYCLOR ...... dry mouth ...... ear wax removal drops ...... EDECRIN ...... dry-eye relief nighttime ...... ear wax removal kit ...... EDLUAR ...... DRYSOL ...... ear wax removal system ...... ED-SPAZ ...... dss ...... earwax removal ...... EDURANT ...... DUAKLIR PRESSAIR ...... earwax removal drops ...... EEMT ...... DUAL COMPLEX FORMULA 1 KIT ...... earwax removal kit otic solution 6.5 % ...... efavirenz ...... DUAVEE ...... EASIVENT ...... efavirenz-emtricitab-tenofovir ...... DUET DHA BALANCED ...... EASIVENT MASK LARGE ...... efavirenz-lamivudine-tenofovir ...... DUETACT ...... EASIVENT MASK MEDIUM ...... EFFER-K ORAL TABLET EFFERVESCENT DUEXIS ...... EASIVENT MASK SMALL ...... 10 MEQ, 20 MEQ ......

208 effer-k oral tablet effervescent 25 meq...... emtricitabine ...... enteric aspirin ...... effervescent formula ...... emtricitabine-tenofovir df ...... enteric fish oil ...... EFFEXOR XR ...... EMTRIVA ...... ENTOCORT EC ...... EFFIENT ...... EMVERM ...... ENTRESTO ...... EFUDEX ...... enalapril maleate oral ...... ENTSOL NASAL ...... EGATEN ...... enalapril-hydrochlorothiazide ...... enulose ...... EGRIFTA SV ...... ENBRACE HR ...... ENVARSUS XR ...... EHA ...... ENBREL ...... ENZADYNE ...... ELDERTONIC ...... ENDACOF-DM ...... ENZNONUTY ...... electrolyte solution ...... ENDARI ...... ENZOCLEAR ...... ELEPSIA XR ...... ENDO AVITENE ...... EPANED ...... ELESTRIN ...... endocet ...... EPCLUSA ORAL TABLET 200-50 MG ...... ELETONE ...... ENDOMETRIN ...... EPCLUSA ORAL TABLET 400-100 MG ...... eletriptan hydrobromide ...... enema ...... EPHEDRINE SULFATE-NACL ELFOLATE ...... enema disposable ...... INTRAVENOUS SOLUTION PREFILLED ELFOLATE PLUS ...... enema mineral oil ...... SYRINGE 50-0.9 MG/10ML-%, 50-0.9 ELIDEL ...... enema ready-to-use ...... MG/5ML-%...... ELIGARD ...... enema rectal enema , 16-6 gm/133ml, 19-7 ephrine nose drops ...... ELIMITE ...... gm/118ml ...... EPIDIOLEX ...... elinest ...... ENEMEEZ MINI ...... EPIDUO ...... ELIQUIS ...... ENFAMIL ENFALYTE ...... EPIDUO FORTE ...... ELIQUIS DVT/PE STARTER PACK ...... ENFAMIL EXPECTA ...... EPIFOAM ...... ELIXOPHYLLIN ...... ENGERIX-B ...... epinastine hcl ...... ELIXSURE FEVER/PAIN ...... ENLITE GLUCOSE SENSOR ...... epinephrine injection solution auto-injector ELLA ...... enovarx-amitriptyline ...... 0.15 mg/0.15ml ...... ELMIRON ...... enovarx-baclofen ...... EPINEPHRINE PROFESSIONAL ...... ELOCTATE INTRAVENOUS SOLUTION enovarx-cyclobenzaprine hcl ...... epinephrine solution auto-injector 0.15 RECONSTITUTED 4000 UNIT, 5000 ENOVARX-DICLOFENAC SODIUM ...... mg/0.3ml injection ...... , UNIT, 6000 UNIT ...... enovarx-ibuprofen ...... epinephrine solution auto-injector 0.3 eluryng ...... enovarx-lidocaine hcl ...... mg/0.3ml injection ...... , EMCYT ...... enovarx-naproxen ...... EPINEPHRINESNAP-EMS ...... EMEND ORAL ...... enovarx-tramadol ...... EPINEPHRINESNAP-V ...... EMEND TRI-PACK ...... enoxaparin sodium ...... EPIPEN 2-PAK ...... EMFLAZA ...... enpresse-28 ...... EPIPEN JR 2-PAK ...... EMGALITY ...... enskyce ...... EPISIL ...... EMGALITY (300 MG DOSE) ...... ENSPRYNG ...... EPISNAP ...... emoquette ...... ENSTILAR ...... epitol ...... EMPAVELI ...... entacapone ...... EPIVIR ...... EMPRICAINE-II ...... entecavir ...... EPIVIR HBV ...... EMSAM ...... ENTEREG ...... eplerenone ......

209 EPOGEN ...... ESTRACE ...... EVRYSDI ...... EPZICOM ...... estradiol oral ...... EXACTECH R-S-G TEST ...... EQUETRO ...... estradiol transdermal ...... EXACTECH TEST ...... ERGOCAL ...... estradiol vaginal cream ...... EXCEDRIN EXTRA STRENGTH ...... ergocalciferol oral ...... estradiol vaginal tablet ...... EXCEDRIN MIGRAINE ...... ergoloid mesylates oral ...... estradiol valerate intramuscular oil 40 mg/ml EXCEDRIN TENSION HEADACHE ...... ERGOMAR ...... estradiol-norethindrone acet ...... EXELDERM EXTERNAL CREAM ...... ergotamine-caffeine ...... ESTRING ...... EXELON ...... ERIVEDGE ...... estro support es ...... exemestane ...... ERLEADA ...... estro vital nutrients ex st ...... EXFORGE ...... erlotinib hcl ...... ESTROGEL ...... EXFORGE HCT ...... errin ...... ESTROSTEP FE ...... EXJADE ...... ERTACZO ...... eszopiclone oral tablet 1 mg ...... EX-LAX ...... ery ...... eszopiclone oral tablet 2 mg, 3 mg ...... EX-LAX ULTRA ...... ERYGEL ...... ethacrynic acid ...... EXSERVAN ...... ERYPED 200 ...... ethambutol hcl oral tablet 100 mg ...... EXTAVIA ...... ERYPED 400 ...... ethambutol hcl oral tablet 400 mg ...... EXTINA ...... ERY-TAB ...... ethosuximide oral ...... eye allergy relief ...... ERYTHROCIN STEARATE ...... ETHOXIA ...... eye drops advanced relief ...... erythromycin base ...... ethyl chloride ...... eye drops allergy relief ...... erythromycin ethylsuccinate oral ...... ethynodiol diac-eth estradiol ...... eye drops long lasting ...... erythromycin external ...... etodolac ...... eye drops ophthalmic solution 0.05 % ...... erythromycin ophthalmic ...... etodolac er ...... eye drops ophthalmic solution 0.05-0.1-1-1 erythromycin oral ...... etonogestrel-ethinyl estradiol ...... % ...... ESBRIET ...... etoposide oral ...... eye itch relief ophthalmic solution 0.025 % ... escitalopram oxalate ...... etravirine ...... eye lubricant ...... ESGIC ...... EUCRISA ...... EYSUVIS ...... ESMOLOL HCL INTRAVENOUS euthyrox ...... EZALLOR SPRINKLE ...... SOLUTION PREFILLED SYRINGE ...... EVAC ...... ezetimibe ...... esomeprazole magnesium ...... EVAMIST ...... ezetimibe-simvastatin ...... ESOMEPRAZOLE STRONTIUM ...... EVEKEO ...... EZFE 200 ...... ESPEROCT ...... EVEKEO ODT ...... F essential one daily ...... evening primrose oil oral capsule 500 mg .... fa-8 ...... essentials ...... everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 fabb ...... est estrogens-methyltest ...... mg ...... FABIOR ...... est estrogens-methyltest ds ...... everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg . FALESSA ...... est estrogens-methyltest hs ...... EVISTA ...... falmina ...... estarylla ...... EVOCLIN ...... famciclovir oral ...... estazolam ...... EVOTAZ ...... famotidine oral suspension reconstituted 40 ester-c oral tablet ...... EVOXAC ...... mg/5ml ......

210 famotidine oral tablet 10 mg ...... FENTANYL CITRATE INTRAVENOUS ferrous sulfate oral tablet delayed release ..... famotidine oral tablet 20 mg, 40 mg ...... SOLUTION PREFILLED SYRINGE 100 FETZIMA ...... famotidine orig st ...... MCG/2ML ...... FETZIMA TITRATION ...... FANAPT ...... FENTANYL CITRATE-NACL fever reducer/pain reliever ...... FANAPT TITRATION PACK ...... INTRAVENOUS SOLUTION 1-0.9 fever reducing childrens ...... FANATREX FUSEPAQ ...... MG/100ML-%, 2-0.9 MG/100ML-%, 2.5- feverall adults ...... FARESTON ...... 0.9 MG/250ML-% ...... feverall childrens ...... FARXIGA ...... FENTANYL CITRATE-NACL FEVERALL INFANTS ...... FARYDAK ...... INTRAVENOUS SOLUTION PREFILLED FEVERALL JUNIOR STRENGTH ...... FASENRA PEN ...... SYRINGE 500-0.9 MCG/50ML-% ...... fe-vite iron ...... fast relief laxative ...... FENTORA ...... FEXMID ...... FAVIPIRAVIR ...... FEONYX ...... fexofenadine hcl oral ...... fa-vitamin b-6-vitamin b-12 ...... ferate ...... fexofenadine hydrochloride ...... fayosim ...... FER-IN-SOL ...... fexofenadine-pseudoephed er oral tablet FBL KIT ...... FERIVA 21/7 ...... extended release 12 hour ...... fe c tab ...... FERIVAFA ...... fexofenadine-pseudoephed er oral tablet febuxostat ...... ferocon ...... extended release 24 hour ...... felbamate ...... ferosul ...... FIASP ...... FELBATOL ...... ferotrinsic ...... FIASP FLEXTOUCH ...... FELDENE ...... FERRALET 90 ...... FIASP PENFILL ...... felodipine er ...... ferraplus 90 ...... fiber laxative ...... FEM PH ...... ferretts ...... fiber laxative + calcium ...... FEMARA ...... ferretts ips ...... fiber laxative oral capsule 0.52 gm ...... FEMHRT ...... ferrex 150 ...... fiber laxative oral tablet 500 mg ...... FEMRING ...... ferric x-150 ...... fiber oral capsule 0.52 gm ...... femynor ...... FERRIMIN 150 ...... fiber oral powder 28.3 % ...... fenofibrate micronized ...... FERRIPROX ORAL SOLUTION ...... fiber oral powder 30.9 % ...... fenofibrate oral capsule ...... FERRIPROX ORAL TABLET ...... fiber oral powder 48.57 % ...... fenofibrate oral tablet 120 mg, 40 mg ...... FERRIPROX TWICE-A-DAY ...... fiber oral powder 58.6 % ...... fenofibrate oral tablet 145 mg, 48 mg ...... ferrocite plus ...... fiber oral tablet 500 mg ...... fenofibrate oral tablet 160 mg, 54 mg ...... FERRO-PLEX HEMATINIC ...... fiber oral tablet 625 mg ...... fenofibric acid ...... ferrous fumarate oral tablet 324 (106 fe) mg fiber therapy oral capsule 0.52 gm ...... FENOGLIDE ...... ferrous gluconate oral tablet 240 (27 fe) mg . fiber therapy oral powder 28.3 % ...... fenoprofen calcium oral capsule ...... ferrous gluconate oral tablet 324 (37.5 fe) fiber therapy oral tablet 500 mg ...... fenoprofen calcium oral tablet ...... mg ...... fiber therapy oral tablet 625 mg ...... fenortho ...... ferrous gluconate oral tablet 324 (38 fe) mg . fiber-caps ...... FENSOLVI (6 MONTH) ...... ferrous sulfate oral elixir ...... FIBERCON ORAL TABLET 625 MG ...... fentanyl ...... ferrous sulfate oral solution 75 (15 fe) mg/ml fiber-lax ...... fentanyl citrate buccal lozenge on a handle .. ferrous sulfate oral syrup ...... FIBRICOR ...... FENTANYL CITRATE BUCCAL TABLET ..... ferrous sulfate oral tablet 325 (65 fe) mg ...... FILTER AIR PP ......

211 FINACEA ...... flexgen ...... fluocinonide external cream 0.05 % ...... finasteride oral tablet 5 mg ...... FLEXICHAMBER ...... fluocinonide external cream 0.1 % ...... FINTEPLA ...... FLEXICHAMBER ADULT MASK/SMALL ..... fluocinonide external gel ...... FIORICET ...... FLEXICHAMBER CHILD MASK/LARGE ...... fluocinonide external ointment ...... FIORICET/CODEINE ...... FLEXICHAMBER CHILD MASK/SMALL ...... fluocinonide external solution ...... FIRAZYR ...... FLEXIN ...... FLUOPAR ...... FIRDAPSE ...... FLOGEN ...... FLUORIDEX ...... first aid antibiotic external ointment 1 % ...... FLOLIPID ...... fluoridex daily renewal ...... first aid antibiotic external ointment 3.5-400- FLOMAX ...... FLUORIDEX ENHANCED WHITENING ...... 5000 , 3.5-400-5000 mg-unit ...... floranex tablet oral ...... FLUORIDEX SENSITIVITY RELIEF ...... first aid antiseptic external solution 10 % ...... FLORANEX TABLET ORAL ...... fluor-i-strips a.t...... FIRST-BACLOFEN ...... FLORICAL ...... fluoritab ...... FIRST-LANSOPRAZOLE ...... FLORIVA ORAL LIQUID ...... fluorometholone ...... FIRST-METRONIDAZOLE...... FLORIVA ORAL TABLET CHEWABLE ...... FLUOROPLEX ...... FIRST-MOUTHWASH BLM ...... FLORIVA PLUS ...... FLUOROURACIL EXTERNAL CREAM 0.5 FIRST-OMEPRAZOLE...... FLOVENT DISKUS ...... % ...... FIRST-PROGESTERONE VGS ...... FLOVENT HFA ...... fluorouracil external cream 5 % ...... FIRVANQ ...... flu/cold/daytime ...... fluorouracil external solution ...... fish oil concentrate oral capsule 1000 mg ..... flu/severe cold & cough day ...... FLUOVIX ...... fish oil half-the-size ...... flu/severe cold daytime oral liquid 10-5-325 FLUOVIX PLUS ...... fish oil oral capsule 1000 mg ...... mg/15ml ...... fluoxetine hcl (pmdd) ...... fish oil oral capsule 1200 mg ...... flu/severe cold daytime oral packet 20-10- fluoxetine hcl oral ...... fish oil oral capsule 500 mg ...... 500 mg ...... fluphenazine decanoate injection ...... fish oil oral capsule delayed release 1000 FLUCAINE ...... fluphenazine hcl injection ...... mg ...... fluconazole oral ...... fluphenazine hcl oral concentrate ...... fish oil oral capsule delayed release 1200 flucytosine oral capsule 250 mg ...... fluphenazine hcl oral elixir ...... mg ...... flucytosine oral capsule 500 mg ...... fluphenazine hcl oral tablet ...... flac ...... fludrocortisone acetate oral ...... flurandrenolide external cream ...... FLAGYL ...... FLUID ADMINISTRATION SET ...... flurandrenolide external lotion ...... flanders buttocks ...... flunisolide nasal ...... flurandrenolide external ointment ...... FLAREX ...... fluocinolone acetonide body ...... FLURA-SAFE ...... flavoxate hcl ...... fluocinolone acetonide external cream 0.01 flurazepam hcl ...... FLEBOGAMMA DIF INTRAVENOUS % ...... flurbiprofen oral ...... SOLUTION 0.5 GM/10ML, 20 GM/400ML fluocinolone acetonide external cream 0.025 flurbiprofen sodium ...... flecainide acetate ...... % ...... flutamide ...... FLECTOR ...... fluocinolone acetonide external ointment ..... fluticasone propionate external cream ...... FLEET BISACODYL ...... fluocinolone acetonide external solution ...... fluticasone propionate external lotion ...... FLEET ENEMA ...... fluocinolone acetonide otic ...... fluticasone propionate external ointment ...... FLEET OIL ...... fluocinolone acetonide scalp ...... fluticasone propionate nasal ...... FLEET PEDIATRIC ...... fluocinonide emulsified base ......

212 fluticasone-salmeterol aerosol powder foltanx ...... FREESTYLE LIBRE SENSOR SYSTEM ...... breath activated 100-50 mcg/dose FOLTANX RF ...... FREESTYLE PRECISION NEO SYSTEM .... inhalation ...... , FOLTRATE ...... FREESTYLE PRECISION NEO TEST ...... fluticasone-salmeterol aerosol powder FOLTREXYL ...... freeze dried acidophilus ...... breath activated 250-50 mcg/dose foltrin ...... FRESHKOTE ...... inhalation ...... , FOLTX ...... FROTEK ...... FLUTICASONE-SALMETEROL FOLVITE-D ...... FROVA ...... INHALATION AEROSOL POWDER fondaparinux sodium subcutaneous solution frovatriptan succinate ...... BREATH ACTIVATED 113-14 MCG/ACT, 10 mg/0.8ml, 7.5 mg/0.6ml ...... fruity c ...... 232-14 MCG/ACT, 55-14 MCG/ACT ...... fondaparinux sodium subcutaneous solution FUL-GLO ...... fluticasone-salmeterol inhalation aerosol 2.5 mg/0.5ml, 5 mg/0.4ml ...... full spectrum b/vitamin c ...... powder breath activated 500-50 mcg/dose foot & sneaker ...... FULPHILA ...... fluvastatin sodium ...... foot care (terbinafine) ...... fungi-guard ...... fluvastatin sodium er ...... for sty relief ...... FUNGIMEZ ...... fluvoxamine maleate ...... FORFIVO XL ...... FUNGOID TINCTURE ...... fluvoxamine maleate er ...... formaldehyde external solution 10 % ...... furosemide oral ...... FML ...... FORMALDEHYDE EXTERNAL SOLUTION FUSION PLUS ...... FML FORTE ...... 37 % ...... FUZEON ...... FML LIQUIFILM ...... FORTAMET ...... fyavolv ...... foaming antacid oral tablet chewable 80-20 FORTEO ...... FYCOMPA ...... mg ...... FORTESTA ...... G FOCALIN ...... FORTISCARE CONTROL ...... g tussin ac ...... FOCALIN XR ...... FORTISCARE GLUCOSE SYSTEM ...... gabapentin oral capsule ...... folbee ...... FORTISCARE T1 GLUCOSE SYSTEM ...... gabapentin oral solution 250 mg/5ml ...... folbee plus ...... FORTISCARE TEST ...... gabapentin oral tablet ...... FOLBEE PLUS CZ ...... FOSAMAX ...... GABAPENTIN-NAPROXEN CMPD KIT ...... FOLBIC RF ...... FOSAMAX PLUS D ...... GABITRIL ...... FOLGARD OS ...... fosamprenavir calcium ...... GABLOFEN INTRATHECAL SOLUTION FOLGARD RX ...... fosfomycin tromethamine ...... PREFILLED SYRINGE 50 MCG/ML ...... folic acid oral capsule 20 mg, 5 mg ...... fosinopril sodium ...... GALAFOLD ...... folic acid oral tablet 1 mg ...... fosinopril sodium-hctz ...... galantamine hydrobromide er ...... folic acid oral tablet 400 mcg, 800 mcg ...... FOSRENOL ...... galantamine hydrobromide oral solution ...... FOLIC D3 ...... FOSTEUM ...... galantamine hydrobromide oral tablet ...... FOLIC-K ...... FOTIVDA ...... GALZIN ORAL CAPSULE 25 MG ...... FOLI-D ...... FRAGMIN ...... GALZIN ORAL CAPSULE 50 MG ...... FOLITE ...... FREESTYLE LIBRE 14 DAY READER ...... GAMASTAN ...... FOLITIN-Z ...... FREESTYLE LIBRE 14 DAY SENSOR ...... GAMMAPLEX INTRAVENOUS SOLUTION FOLIXAPURE ...... FREESTYLE LIBRE 2 READER ...... 20 GM/400ML ...... folplex 2.2 ...... FREESTYLE LIBRE 2 SENSOR ...... GAMUNEX-C INJECTION SOLUTION 40 foltabs 800 ...... FREESTYLE LIBRE READER ...... GM/400ML ......

213 GARDASIL 9 ...... GELNIQUE ...... geri-mox ...... gas relief antiflatuent ...... GELUSIL ...... geri-pectate ...... gas relief drops infants ...... GELX ...... geri-tussin dm ...... gas relief extra strength...... gemfibrozil oral ...... GIALAX ...... gas relief extstrength ...... gemmily ...... GILENYA ...... gas relief infants ...... GEMTESA ...... GILOTRIF ...... gas relief infants drops ...... GEN7T ...... GILPHEX TR ...... gas relief oral capsule 125 mg ...... GEN7T PLUS ...... giltuss severe sinus ...... gas relief oral suspension 20 mg/0.3ml ...... GENADUR COMBINATION ...... GIMOTI ...... gas relief oral tablet chewable 125 mg ...... GENADUR EXTERNAL ...... GIVLAARI ...... gas relief oral tablet chewable 80 mg...... genaphed ...... gla-45 ...... gas relief ultra strength...... GENERESS FE ...... glatiramer acetate ...... gas relief ultstrength ...... generlac ...... glatopa ...... GASTROCROM ...... gengraf ...... GLEEVEC ...... GAS-X EXTRA STRENGTH ORAL GENICIN VITA-D ...... GLEOSTINE ...... CAPSULE ...... GENICIN VITA-Q ...... glimepiride ...... GAS-X EXTRA STRENGTH ORAL TABLET GENOTROPIN ...... glipizide er ...... CHEWABLE ...... GENOTROPIN MINIQUICK ...... glipizide ir ...... GAS-X ULTRA STRENGTH ...... gentak ...... glipizide xl ...... gatifloxacin ophthalmic ...... gentamicin sulfate external ...... glipizide-metformin hcl ...... GATTEX ...... gentamicin sulfate ophthalmic ...... GLOPERBA ...... gavilax oral powder ...... GENTEAL SEVERE ...... GLOSTRIPS OPHTHALMIC STRIP 1 MG .... gavilyte-c ...... GENTEAL TEARS ...... GLUCAGEN HYPOKIT ...... gavilyte-g ...... GENTEAL TEARS MODERATE PF ...... GLUCAGON EMERGENCY INJECTION gavilyte-n with flavor pack ...... GENTEAL TEARS NIGHT-TIME ...... SOLUTION RECONSTITUTED ...... GAVISCON EXTRA RELIEF FORMULA ...... GENTEAL TEARS PF ...... glucagon emergency kit 1 mg injection ...... GAVISCON EXTRA STRENGTH ...... GENTEAL TEARS SEVERE DAY/NIGHT .... GLUCAGON EMERGENCY KIT 1 MG GAVISCON ORAL SUSPENSION ...... gentle laxative oral tablet delayed release 5 INJECTION ...... GAVRETO ...... mg ...... GLUCOSE CONTROL SOLUTION IN GEAMETDRAY ...... gentle laxative rectal suppository 10 mg ...... VITRO LIQUID ...... GEBAUERS PAIN EASE ...... gentle laxative womens ...... GLUCOSE CONTROL SOLUTION IN GEBAUERS SPRAY AND STRETCH ...... gentlelax ...... VITRO SOLUTION ...... GELCLAIR ...... GENTLE-LET PLATFORMS ...... GLUCOSE CONTROL SOLUTION IN GELFILM EXTERNAL ...... GENVOYA ...... VITRO SOLUTION HIGH ...... GELFILM OPHTHALMIC ...... GEODON ORAL ...... GLUCOSE CONTROL SOLUTION IN GELFOAM ...... geravine ...... VITRO SOLUTION LOW ...... GELFOAM COMPRESSED SIZE 100 ...... geri-dryl ...... GLUCOSE CONTROL SOLUTION IN GELFOAM DENTAL PACK SIZE 4 ...... geri-kot ...... VITRO SOLUTION NORMAL ...... GELFOAM SPONGE SIZE 200 ...... geri-lanta ...... GLUCOSE CONTROL SOLUTIONS ...... GELFOAM SPONGE SIZE 50 ...... geri-lanta supreme ...... glucose liquid shot oral liquid ......

214 GLUCOSE METER TEST STRIPS ...... gormel ...... hailey fe 1/20 ...... GLUCOSE NURSETTE ...... gormel 10 ...... halcinonide ...... glucose oral tablet chewable 4 gm ...... G-PREPROTEIN ...... HALCION ...... glucose oral tablet chewable 4-6 gm-mg ...... GRALISE ...... HALDOL DECANOATE ...... GLUCOTROL XL ...... granisetron hcl oral ...... halobetasol propionate external cream ...... GLUMETZA ...... GRANIX ...... HALOBETASOL PROPIONATE EXTERNAL glutamine oral capsule ...... GRASTEK ...... FOAM ...... GLUTARALDEHYDE EXTERNAL ...... GREEN GLO LISSAMINE GREEN ...... halobetasol propionate external ointment ...... glyburide micronized ...... griseofulvin microsize oral ...... HALOG ...... glyburide oral ...... griseofulvin ultramicrosize ...... haloperidol decanoate intramuscular ...... glyburide-metformin ...... guaiatussin ac ...... haloperidol lactate oral ...... GLYCATE ...... guaicon dms ...... haloperidol oral ...... glycerin (adult) rectal suppository 2 gm ...... guaifenesin ac ...... HALUCORT ...... glycerin (infants & children) rectal guaifenesin er oral tablet extended release HARD NAILS ...... suppository 1 gm ...... 12 hour 1200 mg ...... HARVONI ORAL PACKET ...... glycerin (pediatric) rectal suppository 1 gm ... guaifenesin oral tablet 400 mg ...... HARVONI ORAL TABLET 45-200 MG ...... glycerin adult rectal suppository 2 gm ...... guaifenesin-codeine ...... HARVONI ORAL TABLET 90-400 MG ...... glycerin child rectal suppository 1 gm ...... guaifenesin-dm oral syrup ...... HAVRIX ...... glycerin child rectal suppository 1.2 gm ...... GUANENDRUX ...... HAXCHLO ...... glycerin childrens ...... guanfacine hcl ...... HCU EASY ...... glycerin external ...... guanfacine hcl er ...... headache formula ...... glycerin external liquid 99.5 % ...... GUANIDINE HCL ...... headache relief ...... glycerin pediatric rectal suppository 1.2 gm .. GUARDIAN CONNECT TRANSMITTER...... headache relief extra str ...... glycolax ...... GUARDIAN LINK 3 TRANSMITTER ...... healthy hair/skin/nails ...... glycopyrrolate oral tablet 1 mg, 2 mg ...... GUARDIAN REAL-TIME REPLACE PED .... heartburn antacid ...... GLYCOPYRROLATE ORAL TABLET 1.5 GUARDIAN SENSOR (3) ...... heartburn antacid ex st ...... MG ...... gummy dinos ...... heartburn prevention oral tablet 10 mg ...... glydo ...... gummy multivitamin kids ...... heartburn relief ex st ...... GLYNASE ...... GVOKE HYPOPEN 1-PACK ...... heartburn relief oral tablet 10 mg ...... GLYTACTIN COMPLETE 10PE ...... GVOKE HYPOPEN 2-PACK ...... heartburn relief oral tablet 200 mg ...... GLYXAMBI ...... GVOKE PFS ...... heartburn relief oral tablet chewable 160-105 GOCOVRI ...... GYNAZOLE-1 ...... mg ...... GOLYTELY ...... GYNE-LOTRIMIN ...... heather ...... GONAK ...... GYNE-LOTRIMIN 3 ...... h-e-b aspirin ...... goniotaire ...... H h-e-b childrens allergy ...... GONIOVISC OPHTHALMIC SOLUTION 2.5 habitrol ...... HELIDAC THERAPY ...... % ...... HAEGARDA ...... HEMADY ...... GONITRO ...... hailey 1.5/30 ...... HEMANGEOL ...... GOOD START 5% GLUCOSE WATER ...... hailey 24 fe ...... hematinic plus vit/minerals ...... GORDOFILM ...... hailey fe 1.5/30 ...... hematinic/folic acid ......

215 HEMATOGEN ...... HUMALOG KWIKPEN SUBCUTANEOUS HYDRO 40 ...... HEMATOGEN FA ...... SOLUTION PEN-INJECTOR 100 hydrocerin ...... HEMATRON-AF ...... UNIT/ML ...... hydrochlorothiazide oral ...... HEMAX ...... HUMALOG KWIKPEN SUBCUTANEOUS hydrocodone bitartrate er ...... HEMETAB ...... SOLUTION PEN-INJECTOR 200 hydrocodone polst-cpm polst er ...... HEMLIBRA ...... UNIT/ML ...... hydrocodone-acetaminophen oral solution HEMMOREX-HC...... HUMALOG MIX 50/50 ...... 10-325 mg/15ml ...... HEMOCYTE PLUS ...... HUMALOG MIX 50/50 KWIKPEN ...... hydrocodone-acetaminophen oral solution hemocyte-f ...... HUMALOG MIX 75/25 ...... 7.5-325 mg/15ml ...... hemorrhoidal rectal ointment 0.25-3-14-71.9 HUMALOG MIX 75/25 KWIKPEN ...... hydrocodone-acetaminophen oral tablet 10- % ...... HUMATIN ...... 300 mg, 7.5-300 mg...... hemorrhoidal rectal suppository 0.25-3-85.5 HUMATROPE ...... hydrocodone-acetaminophen oral tablet 10- % ...... HUMATROPEN FOR 12MG ...... 325 mg, 5-325 mg, 7.5-325 mg ...... heparin sodium (porcine) ...... HUMATROPEN FOR 24MG ...... hydrocodone-acetaminophen oral tablet 5- heparin sodium (porcine) pf ...... HUMATROPEN FOR 6MG ...... 300 mg ...... HEPLISAV-B ...... HUMIRA PEN-PEDIATRIC UC START ...... hydrocodone-homatropine ...... HEPSERA ...... HUMIRA PEN-PSOR/UVEIT STARTER ...... hydrocodone-ibuprofen ...... herbiomed fast acting ...... HUMIRA SUBCUTANEOUS PEN- hydrocortisone (perianal) ...... HETLIOZ ...... INJECTOR KIT 40 MG/0.4ML, 40 hydrocortisone ace-pramoxine external HETLIOZ LQ ...... MG/0.8ML ...... cream 1-1 % ...... hi cal ...... HUMIRA SUBCUTANEOUS PEN- hydrocortisone ace-pramoxine external HIBICLENS ...... INJECTOR KIT 80 MG/0.8ML ...... cream 2.5-1 % ...... HIDEX 6-DAY ...... HUMIRA SUBCUTANEOUS PREFILLED hydrocortisone acetate external cream ...... high potency iron ...... SYRINGE KIT 10 MG/0.1ML, 20 hydrocortisone acetate external ointment ...... high potency probiotic ...... MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, hydrocortisone acetate rectal ...... HIPREX ...... 80 MG/0.8ML, 80 MG/0.8ML & hydrocortisone anti-itch external cream 0.5 HISTEX PD ...... 40MG/0.4ML ...... % ...... HISTEX-AC ...... HUMULIN 70/30 KWIKPEN ...... hydrocortisone butyr lipo base ...... HIXDEFRIMA ...... HUMULIN 70/30 VIAL ...... hydrocortisone butyrate ...... HONEY BEARS ...... HUMULIN N KWIKPEN ...... hydrocortisone external cream 0.5 %, 2.5 % . HONEY BEARS W/IRON-ZINC ...... HUMULIN N VIAL ...... hydrocortisone external cream 1 % ...... honey lemon drops ...... HUMULIN R U-500 KWIKPEN...... hydrocortisone external lotion 2.5 % ...... HORIZANT ...... HUMULIN R U-500 VIAL hydrocortisone external ointment 0.5 % ...... HPR PLUS EXTERNAL CREAM ...... (CONCENTRATED) ...... hydrocortisone external ointment 1 % ...... hpr plus external foam ...... HUMULIN R VIAL ...... hydrocortisone external ointment 2.5 % ...... HPR PLUS HYDROGEL ...... HURRICAINE MOUTH/THROAT GEL ...... hydrocortisone oral tablet 10 mg, 20 mg, 5 HUMALOG ...... HYCAMTIN ORAL ...... mg ...... HUMALOG JUNIOR KWIKPEN ...... HYCODAN ...... hydrocortisone plus external cream 1 % ...... hydralazine hcl oral ...... hydrocortisone rectal enema 100 mg/60ml ... HYDREA ...... hydrocortisone valerate ......

216 hydrocortisone/aloe ...... IBRANCE ...... imiquimod external cream 3.75 % ...... hydrocortisone/aloe max str ...... ibu ...... imiquimod external cream 5 % ...... hydrocortisone-acetic acid ...... ibu-200 ...... IMIQUIMOD PUMP ...... hydrocortisone-aloe ...... IBUPAK ...... IMITREX ...... hydrocortisone-aloe max st ...... ibuprofen childrens oral tablet chewable 100 IMITREX STATDOSE REFILL ...... hydrocortisone-iodoquinol ...... mg ...... IMITREX STATDOSE SYSTEM ...... hydrocort-pramoxine (perianal) ...... ibuprofen cold & sinus ...... IMODIUM A-D ORAL LIQUID ...... hydrolatum ...... ibuprofen cold/sinus oral tablet 30-200 mg ... IMODIUM A-D ORAL TABLET ...... hydromet ...... ibu-profen cold/sinus oral tablet 30-200 mg .. IMODIUM MULTI-SYMPTOM RELIEF ...... hydromorphone hcl er ...... ibuprofen ib childrens ...... IMPAVIDO ...... hydromorphone hcl oral ...... ibuprofen ib oral tablet 200 mg ...... IMPEKLO ...... hydromorphone hcl rectal ...... ibuprofen ib oral tablet chewable 100 mg ..... IMPOYZ ...... HYDROMORPHONE HCL-NACL ibuprofen infants oral suspension 50 IMURAN ...... INTRAVENOUS SOLUTION 25-0.9 mg/1.25ml ...... INATAL GT ...... MG/50ML-%, 50-0.9 MG/50ML-% ...... ibuprofen jr oral tablet 100 mg ...... inavix ...... HYDROMORPHONE HCL-NACL ibuprofen junior ...... INBRIJA ...... INTRAVENOUS SOLUTION PREFILLED ibuprofen junior strength ...... incassia ...... SYRINGE 15-0.9 MG/30ML-% ...... ibuprofen oral capsule 200 mg ...... INCRELEX ...... hydro-tabs ...... ibuprofen oral suspension 100 mg/5ml ...... INCRUSE ELLIPTA ...... hydroxychloroquine sulfate oral ...... ibuprofen oral tablet 200 mg ...... indapamide ...... hydroxyurea oral ...... ibuprofen oral tablet 400 mg, 600 mg, 800 INDERAL LA ...... hydroxyzine hcl oral ...... mg ...... INDERAL XL ...... hydroxyzine pamoate oral ...... ICAR ...... INDOCIN ...... HYLAFEM ...... ICAR-C ...... indomethacin er ...... HYLATOPIC PLUS ...... ICAR-C PLUS ...... INDOMETHACIN ORAL CAPSULE 20 MG .. HYLAVITE ...... icatibant acetate ...... indomethacin oral capsule 25 mg, 50 mg ...... hyoscyamine sulfate er ...... ICHTHAMMOL DRAWING SALVE ...... indoor/outdoor allergy rlf ...... hyoscyamine sulfate oral ...... iclevia ...... INFANRIX ...... hyoscyamine sulfate sl ...... ICLUSIG ...... infant gas relief ...... hyoscyamine sulfate sublingual ...... icosapent ethyl ...... INFANTS ADVIL ...... hyosyne ...... IDHIFA ...... infants gas relief ...... HYPERRHO S/D ...... iferex 150 forte ...... infants ibuprofen ...... HYPERSAL ...... ILARIS ...... infants pain & fever ...... HYPERTET S/D ...... ILEVRO ...... infants pain relief drops ...... HYPOCYN ...... ILUMYA ...... infants pain/fever ...... HYPOTEARS ...... imatinib mesylate ...... infants simethicone ...... HYSINGLA ER ...... IMBRUVICA ...... INFLAMMACIN ...... HYZAAR ...... IMIOXIA ...... INFLATHERM ...... I imipramine hcl oral ...... INGREZZA ...... ibandronate sodium oral ...... imipramine pamoate ...... INLYTA ......

217 inner ear plus ...... INSULIN SYRINGES 30G X 1/2 ...... 148 iron oral tablet extended release 142 (45 fe) INNOPRAN XL ...... INSULIN SYRINGES 30G X 5/16 ...... 141 mg ...... INOVA ...... INSULIN SYRINGES 31G X 15/64 ...... iron slow release oral tablet extended INOVA 4/1 ACNE CONTROL THERAPY ..... INSULIN SYRINGES 31G X 5/16 ...... 148 release 160 (50 fe) mg ...... INOVA 8/2 ACNE CONTROL THERAPY ..... INTEGRA ...... iron supplement ...... INQOVI ...... INTEGRA F ...... iron supplement childrens ...... INREBIC ...... INTEGRA PLUS ...... IROSPAN 24/6 ...... INSPIRACHAMBER/LARGE ...... INTELENCE ...... ISENTRESS ...... INSPIRACHAMBER/MEDIUM ...... INTRON A ...... ISENTRESS HD ...... INSPIRACHAMBER/MOUTHPIECE ...... introvale ...... isibloom ...... INSPIRACHAMBER/SMALL ...... INTUNIV ...... isoleucine ...... INSPIREASE ...... INVEGA ...... ISOLEUCINE 1000 ...... INSPIREASE RESERVOIR BAGS ...... INVEGA SUSTENNA ...... isoniazid oral ...... INSPRA ...... INVEGA TRINZA ...... ISOPTO ATROPINE ...... instacort 5 ...... INVELTYS ...... ISOPTO CARPINE ...... INSTA-GLUCOSE ...... INVIRASE ...... ISOPTO TEARS ...... instant oral pain relief max ...... INVOKAMET ...... ISORDIL TITRADOSE ...... INSULIN ASP PROT & ASP FLEXPEN ...... INVOKAMET XR ...... isosorbide dinitrate ...... INSULIN ASPART ...... INVOKANA ...... isosorbide mononitrate ...... INSULIN ASPART FLEXPEN ...... IODINE STRONG ORAL ...... isosorbide mononitrate er ...... INSULIN ASPART PENFILL ...... iodine tincture external tincture 2 % ...... isotretinoin oral capsule 10 mg ...... INSULIN ASPART PROT & ASPART ...... IODOQUIMEZ-HC ...... isotretinoin oral capsule 20 mg ...... INSULIN LISPRO ...... iodoquinol-hc-aloe polysacch ...... isotretinoin oral capsule 25 mg, 35 mg ...... INSULIN LISPRO (1 UNIT DIAL) ...... iodoquinol-hydrocortisone-aloe ...... isotretinoin oral capsule 30 mg, 40 mg ...... INSULIN LISPRO JUNIOR KWIKPEN ...... IONIL-T ...... isoxsuprine hcl oral ...... INSULIN LISPRO PROT & LISPRO ...... IOPIDINE ...... isradipine ...... INSULIN PEN NEEDLES 29G X 12.7MM , IOSAT ...... ISTALOL ...... 30G X 8 MM , 32G X 6 MM ...... ipratropium bromide inhalation ...... ISTURISA ...... INSULIN PEN NEEDLES 29G X 12MM , ipratropium bromide nasal ...... ITHOXIA ...... 29G X 5MM , 29G X 8MM , 31G X 5 MM , ipratropium-albuterol ...... itraconazole oral ...... 31G X 6 MM , 31G X 8 MM ...... irbesartan ...... ivermectin external cream ...... INSULIN PEN NEEDLES 32G X 4 MM ...... irbesartan-hydrochlorothiazide ...... ivermectin external lotion ...... INSULIN PEN NEEDLES 32G X 5 MM ...... IRESSA ...... ivermectin oral ...... INSULIN PEN NEEDLES 33G X 4 MM ...... IROFOL ...... J INSULIN SYRINGES ...... iron 100/c ...... JADENU ...... INSULIN SYRINGES 27G X 1/2 ...... 147 iron chews pediatric ...... JADENU SPRINKLE ...... INSULIN SYRINGES 28G X 1/2 ...... 141 iron oral tablet 200 (65 fe) mg ...... jaimiess ...... INSULIN SYRINGES 28G X 5/16 ...... iron oral tablet 240 (27 fe) mg ...... JAKAFI ...... INSULIN SYRINGES 29G X 1/2 ...... 141, iron oral tablet 27 mg ...... JALYN ...... INSULIN SYRINGES 29G X 5/16 ...... 141 iron oral tablet 325 (65 fe) mg ...... JANSSEN COVID-19 VACCINE ......

218 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 KALYDECO ...... KETOROLAC TROMETHAMINE NASAL ..... mg, 3 mg, 4 mg, 5 mg, 7.5 mg ...... KAPSPARGO SPRINKLE ...... ketorolac tromethamine ophthalmic solution jantoven oral tablet 6 mg ...... KAPVAY ...... 0.4 % ...... JANUMET ...... kapzin dc ...... ketorolac tromethamine ophthalmic solution JANUMET XR ...... KARBINAL ER ...... 0.5 % ...... JANUVIA ...... kariva ...... ketorolac tromethamine oral ...... JARDIANCE ...... KATERZIA ...... KETOSTIX ...... jasmiel ...... KAZANO ...... ketotifen fumarate ophthalmic ...... JATENZO ...... KEFLEX ...... KEVEYIS ...... jencycla ...... KELARX ...... KEVZARA ...... JENLIVA PRENATAL/POSTNATAL ...... kelnor 1/35 ...... KEY OMEGA ...... JENTADUETO ...... kelnor 1/50 ...... KHAPZORY ...... JENTADUETO XR ...... kelp oral tablet 0.15 mg ...... KINERET ...... jinteli ...... kelp-b6-lecithin-vinegar ...... KISQALI (200 MG DOSE) ...... jock itch external cream 1 % ...... KENALOG EXTERNAL ...... KISQALI (400 MG DOSE) ...... jock itch max st ...... KEPPRA ORAL ...... KISQALI (600 MG DOSE) ...... jock itch spray powder ...... KEPPRA XR ...... KISQALI FEMARA (400 MG DOSE) ...... jolessa ...... KERALAC ...... KISQALI FEMARA (600 MG DOSE) ...... JORNAY PM ...... KERALYT EXTERNAL GEL 6 % ...... KISQALI FEMARA(200 MG DOSE) ...... JUBLIA ...... KERALYT EXTERNAL SHAMPOO ...... KITABIS PAK ...... juleber ...... KERALYT SCALP ...... KLARITY-A ...... JULUCA ...... KERYDIN ...... KLARITY-L ...... junel 1.5/30 ...... KESIMPTA ...... KLARON ...... junel 1/20 ...... KETAMINE HCL-SODIUM CHLORIDE KLISYRI ...... junel fe oral tablet 1.5-30 mg-mcg...... INTRAVENOUS SOLUTION PREFILLED KLONOPIN ...... junel fe oral tablet 1-20 mg-mcg...... SYRINGE 50-0.9 MG/5ML-% ...... klor-con ...... junel fe oral tablet 1-20 mg-mcg(24) ...... ketoconazole external cream ...... klor-con 10 ...... JUXTAPID ...... ketoconazole external foam ...... klor-con m10 ...... JYNARQUE ORAL TABLET ...... ketoconazole external shampoo ...... KLOR-CON M15 ...... JYNARQUE ORAL TABLET THERAPY ketoconazole oral ...... klor-con m20 ...... PACK 15 MG, 45 & 15 MG, 60 & 30 MG, ketodan external foam ...... klor-con/ef ...... 90 & 30 MG ...... KETODAN EXTERNAL KIT ...... K-MAG ...... JYNARQUE ORAL TABLET THERAPY KETO-DIASTIX ...... KOMBIGLYZE XR ...... PACK 30 & 15 MG ...... KETONE CARE ...... KONSYL DAILY FIBER ORAL POWDER K KETONE TEST ...... 100 % ...... K.B.G.L IN TERODERM ...... KETOPHENE RAPIDPAQ ...... konsyl daily fiber oral powder 28.3 % ...... kaitlib fe ...... ketoprofen er ...... korean ginseng oral capsule 250 mg, 350 KALETRA ORAL SOLUTION ...... ketoprofen oral ...... mg ...... KALETRA ORAL TABLET ...... KETOROLAC TROMETHAMINE KORLYM ...... kalliga ...... EXTERNAL ...... KOSELUGO ......

219 kosher prenatal plus iron ...... lamivudine oral tablet 100 mg ...... laxative oral tablet chewable 15 mg ...... K-PHOS ...... lamivudine oral tablet 150 mg, 300 mg ...... laxative oral tablet delayed release 5 mg ...... K-PHOS NO 2 ...... lamivudine-zidovudine ...... laxative pills ...... K-PHOS-NEUTRAL ...... lamotrigine er ...... laxative pills max st ...... k-prime ...... lamotrigine oral kit ...... laxative pills oral tablet 25 mg ...... KRINTAFEL ...... lamotrigine oral tablet ...... laxative rectal suppository 10 mg ...... KRISTALOSE ...... lamotrigine oral tablet chewable ...... laxative regular strength ...... KROGER BLOOD GLUCOSE KIT ...... lamotrigine oral tablet dispersible ...... layolis fe ...... KROGER TEST ...... lamotrigine starter kit-blue ...... LAZANDA ...... K-TAB ...... lamotrigine starter kit-green ...... l-carnitine ...... k-tan plus ...... lamotrigine starter kit-orange ...... L-CYSTINE ...... kurvelo ...... LAMPIT ...... LDO PLUS ...... KUVAN ...... LANAPHILIC ...... lecithin oral capsule ...... KYNMOBI ...... LANCETS ...... , LEDIPASVIR-SOFOSBUVIR ...... KYNMOBI TITRATION KIT ...... LANOXIN ORAL ...... leena ...... L lansoprazole oral capsule delayed release leflunomide oral ...... labetalol hcl oral ...... 15 mg, 30 mg ...... LENVIMA (10 MG DAILY DOSE) ...... LAC-HYDRIN FIVE ...... lansoprazole oral tablet delayed release LENVIMA (12 MG DAILY DOSE) ...... LACRISERT ...... dispersible 15 mg, 30 mg ...... LENVIMA (14 MG DAILY DOSE) ...... LACTAID ...... lanthanum carbonate ...... LENVIMA (18 MG DAILY DOSE) ...... LACTAID FAST ACT ORAL TABLET ...... LANTUS SOLOSTAR ...... LENVIMA (20 MG DAILY DOSE) ...... lactase enzyme ...... LANTUS U-100 VIAL ...... LENVIMA (24 MG DAILY DOSE) ...... lactase enzyme ultra str ...... lapatinib ditosylate ...... LENVIMA (4 MG DAILY DOSE) ...... lactase fast acting ...... l-arginine oral capsule ...... LENVIMA (8 MG DAILY DOSE) ...... lactic acid e ...... larin 1.5/30 ...... LESCOL XL ...... lactic acid external ...... larin 1/20 ...... lessina ...... lactobacillus oral tablet ...... larin 24 fe ...... LETAIRIS ...... lacto-pectin ...... larin fe 1.5/30 ...... letrozole oral ...... lactose fast acting relief oral tablet ...... larin fe 1/20 ...... lets ...... lactulose encephalopathy ...... larissia ...... leucine oral ...... lactulose oral packet ...... LASIX ...... leucovorin calcium injection solution 500 lactulose oral solution ...... LASTACAFT ...... mg/50ml ...... LAMICTAL ...... latanoprost ophthalmic ...... leucovorin calcium oral ...... LAMICTAL ODT ...... LATANOPROST-TIMOLOL MALEATE ...... LEUKERAN ...... LAMICTAL STARTER ...... LATUDA ...... LEUKINE ...... LAMICTAL XR ...... laxacin ...... leuprolide acetate injection ...... LAMISIL AT EXTERNAL CREAM ...... laxaclear ...... levalbuterol hcl inhalation ...... LAMISIL AT JOCK ITCH CREAM 1 % laxative max str ...... LEVALBUTEROL HFA INHALATION EXTERNAL ...... , laxative maximum strength oral tablet 25 mg AEROSOL 45 MCG/ACT ...... lamivudine oral solution ...... laxative oral powder 17 gm/scoop ...... LEVATIO ......

220 LEVBID ...... LIALDA ...... lidocaine-prilocaine external cream ...... LEVEMIR U-100 FLEXTOUCH ...... LIBRAX ...... lidocaine-prilocaine external kit ...... LEVEMIR U-100 VIAL ...... LICART ...... LIDOCAINE-TETRACAINE ...... levetiracetam er ...... lice killing ...... LIDOCANNA ...... levetiracetam oral ...... lice killing max st ...... LIDOCORT ...... levobunolol hcl ...... lice killing max strength ...... LIDODERM ...... levocarnitine oral solution...... lice killing maximum strength ...... LIDOPAC ...... levocarnitine oral tablet ...... lice maximum strength ...... lidopin external cream 3 % ...... levocarnitine sf ...... lice solution 3-step ...... LIDOPIN EXTERNAL CREAM 3.25 % ...... levocetirizine dihydrochloride oral solution.... lice solution combination kit ...... LIDOPRIL ...... levocetirizine dihydrochloride oral tablet ...... lice solution kit ...... LIDOPRIL XR ...... levofloxacin ophthalmic ...... lice treatment ...... LIDO-PRILO CAINE PACK ...... levofloxacin oral ...... lice treatment creme rinse ...... LIDOPURE PATCH ...... levoleucovorin calcium pf intravenous lice treatment external shampoo 0.33-4 % ... LIDORX ...... solution 250 mg/25ml ...... LIDO BDK ...... LIDO-SORB ...... levonest ...... LIDOCAINE (ANORECTAL) RECTAL ...... LIDOSTREAM ...... levonorgest-eth est & eth est ...... lidocaine external cream 4 % ...... LIDOTHOL ...... levonorgest-eth estrad 91-day ...... lidocaine external ointment 5 % ...... LIDOVIX L ...... levonorgestrel ...... lidocaine external patch 5 % ...... LIDTOPIC MAX ...... levonorgestrel-ethinyl estrad oral tablet 0.1- lidocaine hcl external cream 3 % ...... lillow ...... 20 mg-mcg ...... lidocaine hcl external cream 4 % ...... LIMBREL ...... levonorgestrel-ethinyl estrad oral tablet 0.15- LIDOCAINE HCL EXTERNAL CREAM 4.12 LIMBREL250 ...... 30 mg-mcg ...... % ...... LIMBREL500 ...... levonorgestrel-ethinyl estrad oral tablet 90- lidocaine hcl external lotion ...... lindane ...... 20 mcg ...... lidocaine hcl external solution ...... linezolid oral suspension reconstituted ...... levonorg-eth estrad triphasic ...... lidocaine hcl mouth/throat ...... linezolid oral tablet ...... levora 0.15/30 (28) ...... lidocaine hcl urethral/mucosal ...... LINZESS ORAL CAPSULE 145 MCG, 290 levorphanol tartrate oral ...... lidocaine maximum strength ...... MCG ...... levo-t ...... lidocaine pain relieving external cream 4 % . LINZESS ORAL CAPSULE 72 MCG ...... LEVOTHYROXINE SODIUM ORAL lidocaine plus ...... LIORESAL INTRATHECAL SOLUTION 0.05 CAPSULE ...... lidocaine viscous hcl ...... MG/ML, 10 MG/5ML ...... levothyroxine sodium oral tablet...... lidocaine-hydrocort (perianal) ...... liothyronine sodium oral ...... levoxyl ...... LIDOCAINE-HYDROCORTISONE ACE LIPITOR ...... LEVSIN ORAL ...... EXTERNAL ...... LIPOFEN ...... LEVSIN/SL ...... LIDOCAINE-HYDROCORTISONE ACE lipoflavovit ...... LEVULAN KERASTICK ...... RECTAL GEL ...... liquibid ...... LEXAPRO ...... lidocaine-hydrocortisone ace rectal kit 2-2 % liquid acetaminophen ...... LEXETTE ...... lidocaine-hydrocortisone ace rectal kit 3-0.5 liquid allergy relief ...... LEXINAL ...... %, 3-2.5 % ...... liquid calcium with d3 oral capsule 600-500 LEXIVA ...... lidocaine-hydrocortisone ace rectal kit 3-1 % mg-unit ......

221 liquid calcium/vitamin d ...... long lasting nasal spray ...... LORZONE ...... liquid pain relief ...... LONHALA MAGNAIR REFILL KIT ...... losartan potassium oral ...... lisinopril oral ...... LONHALA MAGNAIR STARTER KIT ...... losartan potassium-hctz ...... lisinopril-hydrochlorothiazide ...... LONSURF ...... LOSEASONIQUE ...... L-ISOLEUCINE ...... loperamide hcl oral capsule ...... LOTEMAX OPHTHALMIC GEL ...... lithium ...... loperamide hcl oral liquid 1 mg/7.5ml ...... LOTEMAX OPHTHALMIC OINTMENT ...... lithium carbonate er ...... loperamide hcl oral suspension 1 mg/7.5ml . LOTEMAX OPHTHALMIC SUSPENSION .... lithium carbonate oral ...... loperamide hcl oral tablet ...... LOTEMAX SM ...... LITHOBID ...... LOPID ...... LOTENSIN ...... LITHOSTAT ...... lopinavir-ritonavir ...... LOTENSIN HCT ...... little ones childrens ...... LOPRESSOR ...... loteprednol etabonate ...... LIVALO ...... LOPROX EXTERNAL CREAM ...... LOTREL ...... LIVIXIL PAK ...... LOPROX EXTERNAL KIT 0.77 % ...... LOTRIMIN AF EXTERNAL POWDER ...... l-lysine hcl oral tablet 500 mg ...... LOPROX EXTERNAL KIT 0.77 % (SUSP) ... LOTRONEX ...... l-lysine oral tablet 1000 mg, 500 mg ...... LOPROX EXTERNAL SHAMPOO ...... lovastatin oral ...... l-methylfolate ...... LOPROX EXTERNAL SUSPENSION ...... LOVAZA ...... l-methylfolate ca me-cbl nac ...... loradamed ...... LOVENOX ...... l-methylfolate calcium oral...... lorata-d ...... low-ogestrel ...... l-methylfolate forte ...... loratadine allergy relief oral tablet 10 mg ...... loxapine succinate ...... l-methylfolate-algae ...... loratadine allergy relief oral tablet dispersible lo-zumandimine ...... l-methylfolate-algae-b12-b6 ...... 10 mg ...... LTXF PRIM CNV PIN MICRODRIP ...... l-methylfolate-b6-b12 ...... loratadine childrens oral solution 5 mg/5ml .. LTXF PRIM IV SET/CNVT PIN ...... l-methyl-mc ...... loratadine childrens oral syrup 5 mg/5ml ...... LTXF SECONDARY/CNV PIN/32INC ...... l-methyl-mc nac ...... loratadine childrens oral tablet chewable ...... l-tyrosine oral capsule ...... LMR PLUS ...... lorata-dine d ...... LUBIPROSTONE ...... LMX 4 ...... loratadine d 12hr ...... lubricant drops fast act ...... LO LOESTRIN FE ...... loratadine oral capsule ...... lubricant drops long last ...... LOCOID ...... loratadine oral syrup 5 mg/5ml ...... lubricant drops ophthalmic gel 0.25-0.3 % .... LOCOID LIPOCREAM ...... loratadine oral tablet ...... lubricant drops ophthalmic solution ...... LODINE ...... loratadine oral tablet dispersible 10 mg ...... lubricant eye drops (pf) ophthalmic solution LODOSYN ...... loratadine-d ...... 0.4-0.3 % ...... LOESTRIN 1.5/30 (21) ...... loratadine-d 12hr ...... lubricant eye drops (pf) ophthalmic solution LOESTRIN 1/20 (21) ...... loratadine-d 24hr ...... 0.5 % ...... LOESTRIN FE 1.5/30 ...... lorazepam intensol ...... lubricant eye drops ophthalmic solution 0.4- LOESTRIN FE 1/20 ...... lorazepam oral concentrate 2 mg/ml ...... 0.3 % ...... lojaimiess ...... lorazepam oral tablet ...... lubricant eye drops ophthalmic solution 0.5 LOKELMA ...... LORBRENA ...... % ...... LOMOTIL ...... LORID ...... lubricant eye drops ophthalmic solution 0.6 long acting nasal spray ...... LORTAB ...... % ...... long lasting antacid ...... loryna ...... lubricant eye drops pf ......

222 lubricant eye nighttime ...... LUXIQ ...... magnesium oxide oral tablet 500 mg ...... lubricant eye ophthalmic solution 0.4-0.3 % .. LUZU ...... magnesium-oxide ...... lubricant eye ophthalmic solution 1-0.3 % ..... lyleq ...... MAGONATE ...... lubricant eye pm ...... lyllana ...... mag-oxide ...... lubricant pm ...... LYNPARZA ...... mag-oxide magnesium ...... lubricating eye drop ...... LYRICA ...... MAG-TAB SR ...... lubricating eye drops ophthalmic solution LYRICA CR ...... MALARONE ...... 0.4-0.3 % ...... lysine hcl oral tablet 1000 mg ...... malathion ...... lubricating eye drops ophthalmic solution lysiplex plus oral tablet ...... MAOX ...... 0.5-0.9 % ...... LYSODREN ...... mapap acetaminophen extra str ...... lubricating eye/overnight ...... LYSTEDA ...... mapap arthritis pain ...... lubricating plus ...... LYUMJEV ...... mapap childrens ...... lubricating plus eye drops ...... LYUMJEV KWIKPEN ...... mapap cold formula multi-sympt ...... lubricating tears ...... lyza ...... MAPAP HEADACHE PLUS ...... lubricating tears eye drops ...... M mapap oral capsule ...... lubricating/dry eye ...... m2 magnesium ...... maprotiline hcl ...... LUCEMYRA ...... MAALOX ...... MAR-COF BP ...... LUGOLS STRONG IODINE ...... MAALOX CHILDRENS ...... MAR-COF CG EXPECTORANT ...... LULICONAZOLE ...... MAALOX MAX ORAL SUSPENSION ...... MARGENZA ...... LUMAKRAS ...... MAALOX MULTI SYMPTOM MAX ST...... MARINOL ...... LUMIGAN ...... MACRILEN ...... marlissa ...... LUNESTA ORAL TABLET 1 MG ...... MACROBID ...... MARPLAN ...... LUNESTA ORAL TABLET 2 MG, 3 MG ...... MACRODANTIN ...... MASK VORTEX/CHILD/FROG ...... LUPANETA PACK ...... mafenide acetate external ...... MASK VORTEX/TODDLER/LADYBUG ...... LUPKYNIS ...... MAG-200 ...... MATULANE ...... LUPRON DEPOT (1-MONTH) mag-al plus ...... matzim la ...... INTRAMUSCULAR KIT 3.75 MG ...... mag-al plus xs ...... MAVENCLAD (10 TABS) ...... LUPRON DEPOT (1-MONTH) mag-g ...... MAVENCLAD (4 TABS) ...... INTRAMUSCULAR KIT 7.5 MG ...... MAGNEBIND 300 ...... MAVENCLAD (5 TABS) ...... LUPRON DEPOT (3-MONTH) magnesium chloride oral tablet delayed MAVENCLAD (6 TABS) ...... INTRAMUSCULAR KIT 11.25 MG ...... release ...... MAVENCLAD (7 TABS) ...... LUPRON DEPOT (3-MONTH) magnesium citrate oral solution ...... MAVENCLAD (8 TABS) ...... INTRAMUSCULAR KIT 22.5 MG ...... magnesium lactate ...... MAVENCLAD (9 TABS) ...... LUPRON DEPOT (4-MONTH) magnesium oral capsule 300 mg, 500 mg .... MAVYRET ...... INTRAMUSCULAR KIT 30MG ...... magnesium oral tablet 250 mg, 30 mg ...... MAXALT ...... LUPRON DEPOT (6-MONTH) magnesium oral tablet 500 mg ...... MAXALT-MLT ...... INTRAMUSCULAR KIT 45MG ...... magnesium oxide oral tablet 400 (241.3 mg) MAXIDEX ...... LUPRON DEPOT-PED (1-MONTH) ...... mg ...... MAXITROL ...... LUPRON DEPOT-PED (3-MONTH) ...... magnesium oxide oral tablet 400 mg ...... maxi-tuss ac ...... lutera ...... magnesium oxide oral tablet 420 mg ...... maxi-tuss cd ......

223 maxi-tuss gmx ...... meijer antacid ...... METANX ...... maxi-tuss pe max ...... meijer anti-diarrheal ...... METAXALL CP ...... MAXZIDE ...... MEKINIST ...... metaxalone oral tablet 400 mg ...... MAXZIDE-25 ...... MEKTOVI ...... metaxalone oral tablet 800 mg ...... MAYZENT ...... meloxicam oral capsule ...... metformin hcl er ...... m-clear wc ...... meloxicam oral tablet ...... metformin hcl er (mod) ...... m-dryl ...... melphalan ...... metformin hcl er (osm) ...... me/naphos/mb/hyo1 ...... memantine hcl er ...... metformin hcl oral solution ...... meclizine hcl oral tablet 12.5 mg ...... memantine hcl oral solution 2 mg/ml ...... metformin hcl oral tablet ...... meclizine hcl oral tablet 25 mg ...... memantine hcl oral tablet ...... methadone hcl intensol ...... meclizine hcl oral tablet 50 mg ...... MEMBRANEBLUE ...... methadone hcl oral ...... meclizine hcl oral tablet chewable ...... MENACTRA ...... methadose oral concentrate 10 mg/ml ...... meclofenamate sodium oral ...... M-END PE ...... methadose oral tablet soluble ...... MEDERMA ...... MENEST ...... methadose sugar-free ...... MEDERMA FOR KIDS ...... MENOSTAR ...... methamphetamine hcl ...... MEDERMA SPF 30 ...... MENQUADFI ...... methazolamide oral ...... medicated spot ...... mens daily gummies ...... methenamine hippurate ...... medifin 400 ...... menstrual pain relief ...... methenamine mandelate oral ...... medi-first triple antibiotic ...... MENTAX ...... methergine ...... mediproxen ...... menthol drops ...... methimazole oral ...... MEDISENSE GLUCOSE KETONE CONTR . MENVEO ...... methionine oral ...... MEDISENSE HI/MID/LOW CONTROL ...... meperidine hcl oral ...... METHITEST ...... MEDISENSE HIGH/LOW CONTROL ...... MEPHYTON ...... methocarbamol oral ...... MEDISENSE MID CONTROL ...... meprobamate ...... METHOHEXITAL SODIUM ...... MEDROL ORAL TABLET 16 MG, 32 MG, 8 MEPRON ...... methotrexate oral ...... MG ...... mercaptopurine oral ...... methotrexate sodium (pf) ...... MEDROL ORAL TABLET 2 MG ...... MERIBIN ...... methotrexate sodium injection ...... MEDROL ORAL TABLET 4 MG ...... merzee ...... methotrexate sodium oral ...... MEDROL ORAL TABLET THERAPY PACK . mesalamine er oral capsule 0.375 gm ...... methoxsalen rapid ...... medroxyprogesterone acetate intramuscular mesalamine oral capsule delayed release methscopolamine bromide oral ...... medroxyprogesterone acetate oral ...... 400 mg ...... methyl salicylate external liquid ...... mefenamic acid oral ...... mesalamine oral tablet delayed release ...... methyldopa ...... mefloquine hcl ...... mesalamine rectal enema ...... methyldopa-hydrochlorothiazide ...... mega multiple/chelated mineral ...... mesalamine rectal suppository ...... methylergonovine maleate oral ...... mega probiotic ...... mesalamine-cleanser ...... methylfol-algae-b12-acetylcyst ...... megestrol acetate oral suspension 40 MESNEX ORAL ...... METHYLIN ORAL SOLUTION 10 MG/5ML .. mg/ml, 625 mg/5ml ...... MESTINON ...... METHYLIN ORAL SOLUTION 5 MG/5ML .... megestrol acetate oral tablet 20 mg ...... metafolbic ...... methylphenidate hcl er ...... megestrol acetate oral tablet 40 mg ...... metafolbic plus ...... methylphenidate hcl er (cd) ...... meijer allergy relief-d ...... METAFOLBIC PLUS RF ...... methylphenidate hcl er (la) ......

224 methylphenidate hcl er (xr) ...... miconazole 3 combo pack app ...... mineral oil oral oil ...... methylphenidate hcl oral solution 10 mg/5ml miconazole 3 combo pack vaginal kit 200 & MINERAL OIL ORAL OIL ...... methylphenidate hcl oral solution 5 mg/5ml .. 2 mg-% (9gm) ...... mineral oil rectal enema ...... methylphenidate hcl oral tablet ...... miconazole 7 day treatment ...... minerin creme ...... methylphenidate hcl oral tablet chewable ..... miconazole 7 vaginal cream 2 % ...... MINI COMPRESSOR ...... methylprednisolone oral ...... miconazole 7 vaginal suppository 100 mg .... mini nicotine ...... methyltestosterone oral ...... miconazole antifungal ...... MINILINK REAL-TIME TRANSMITTER ...... metoclopramide hcl oral solution ...... miconazole nitrate external ...... MINIPRESS ...... metoclopramide hcl oral tablet ...... miconazole nitrate vaginal ...... minitran ...... metoclopramide hcl oral tablet dispersible 10 MICONAZOLE-ZINC OXIDE-PETROLAT .... MINIVELLE ...... mg ...... miconazorb af ...... MINOCYCLINE HCL ER ORAL CAPSULE metoclopramide hcl oral tablet dispersible 5 MICRHOGAM ULTRA-FILTERED PLUS ..... EXTENDED RELEASE 24 HOUR ...... mg ...... MICRODOT PEN NEEDLE ...... minocycline hcl er oral tablet extended metolazone ...... MICRODOT TEST ...... release 24 hour ...... METOPIRONE ...... microgestin 1.5/30 ...... minocycline hcl oral capsule 100 mg ...... metoprolol succinate er ...... microgestin 1/20 ...... minocycline hcl oral capsule 50 mg ...... metoprolol tartrate oral ...... microgestin 24 fe ...... minocycline hcl oral capsule 75 mg ...... metoprolol-hydrochlorothiazide ...... microgestin fe 1.5/30 ...... minocycline hcl oral tablet 100 mg ...... METROCREAM ...... microgestin fe 1/20 ...... minocycline hcl oral tablet 50 mg, 75 mg ...... METROGEL ...... midazolam hcl oral ...... MINOLIRA ...... METROLOTION ...... MIDAZOLAM+SYRSPEND SF ...... minoxidil oral ...... METRONIDAZOLE BENZO+SYRSPEND .... midodrine hcl ...... mintox maximum strength ...... metronidazole external ...... MIFEPREX ...... mintox plus ...... metronidazole oral capsule ...... mifepristone ...... MIRALAX ORAL POWDER ...... metronidazole oral tablet ...... MIGERGOT ...... MIRAPEX ...... metronidazole vaginal ...... miglitol ...... MIRAPEX ER ...... metyrosine ...... miglustat ...... MIRCERA INJECTION SOLUTION mexiletine hcl oral ...... migraine formula ...... PREFILLED SYRINGE 100 MCG/0.3ML, m-hist pd ...... MIGRAINE PACK ...... 200 MCG/0.3ML, 50 MCG/0.3ML, 75 mi-acid gas relief ...... migraine relief ...... MCG/0.3ML ...... mibelas 24 fe ...... MIGRANAL ...... MIRCETTE ...... micaderm ...... mili ...... mirtazapine oral ...... MICARDIS ...... milk of magnesia ...... MIRVASO ...... MICARDIS HCT ...... milk of magnesia concentrate ...... misoprostol oral ...... MICLARA LQ ...... MILLIPRED ...... MITIGARE ...... miconazole 1 ...... mimvey ...... MITOSOL ...... miconazole 1 combo pack...... MIMYX ...... MKO MELT DOSE PACK ...... miconazole 3 ...... MINASTRIN 24 FE ...... mm arthritis pain ...... miconazole 3 applicator vaginal kit 200 & 2 mineral oil enema ...... mm cetirizine hcl ...... mg-% (9gm) ...... mineral oil heavy oral ...... mm clearlax ......

225 MM EASY TOUCH GLUCOSE METER ...... motion sickness relief oral tablet chewable mucus dm ...... mm stool softener laxative ...... 25 mg ...... mucus er oral tablet extended release 12 M-M-R II ...... motion-time ...... hour 1200 mg ...... M-NATAL PLUS ...... MOTOFEN ...... mucus extended release oral tablet MOBIC ...... MOTRIN CHILDRENS ...... extended release 12 hour 1200 mg ...... modafinil ...... MOTRIN IB ORAL CAPSULE ...... mucus relief chest oral tablet 400 mg ...... MODERNA COVID-19 VACCINE ...... MOTRIN IB ORAL TABLET ...... mucus relief cough children ...... moexipril hcl ...... MOTRIN INFANTS DROPS ...... mucus relief cough childrens ...... moisturel ...... MOUTH KOTE REMINT ...... mucus relief d max strength ...... molindone hcl ...... MOVANTIK ...... mucus relief d oral tablet extended release mometasone furoate external ...... MOVIPREP ...... 12 hour 60-600 mg ...... mometasone furoate nasal...... MOXEZA ...... mucus relief dm max oral liquid ...... mondoxyne nl oral capsule 100 mg ...... moxifloxacin hcl (2x day) ...... mucus relief dm oral liquid ...... mondoxyne nl oral capsule 75 mg ...... moxifloxacin hcl ophthalmic solution ...... mucus relief dm oral tablet extended release MONOCAL ...... moxifloxacin hcl oral ...... 12 hour 30-600 mg ...... mono-linyah ...... MOZOBIL ...... mucus relief er oral tablet extended release monsels ferric subsulfate ...... m-pap ...... 12 hour 1200 mg ...... montelukast sodium oral ...... MS CONTIN ...... mucus relief max st ...... MONUROL ...... MSUD EASY ...... mucus relief max strength oral tablet mood support probiotic ...... MUCINEX CHILDRENS FREEFROM ORAL extended release 12 hour 1200 mg ...... MORCIN ...... LIQUID 5-100 MG/5ML ...... mucus relief oral tablet ...... MORGIDOX COMBINATION ...... MUCINEX CHILDRENS STUFFY NOSE ..... mucus-d ...... morgidox oral ...... MUCINEX COUGH CHILDRENS ...... mucus-dm ...... MORPHINE SULFATE (BULK) ...... MUCINEX D ...... mucus-er oral tablet extended release 12 morphine sulfate (concentrate) oral solution MUCINEX D MAX STRENGTH ...... hour 1200 mg ...... 100 mg/5ml, 20 mg/ml ...... MUCINEX DM ...... MUGARD ...... morphine sulfate er beads ...... MUCINEX FAST-MAX CONG HEADACHE . MULPLETA ...... morphine sulfate er oral capsule extended MUCINEX FAST-MAX DM MAX ...... MULTAQ ...... release 24 hour ...... MUCINEX MAXIMUM STRENGTH ...... multi symptom flu/severe cold ...... morphine sulfate er oral tablet extended MUCINEX SINUS-MAX CLEAR & COOL ..... multi vitamin ...... release ...... MUCINEX SINUS-MAX CONG & PAIN multi vitamin w/d-3 ...... morphine sulfate oral ...... ORAL CAPSULE ...... MULTIGEN ...... morphine sulfate rectal ...... MUCINEX SINUS-MAX SINUS/ALLRGY ..... MULTIGEN FOLIC ...... MORPHINE SULFATE-NACL MUCOSITISRX ...... MULTIGEN PLUS ...... INTRAVENOUS SOLUTION PREFILLED MUCOTROL ...... multiple vitamin-folic acid ...... SYRINGE 50-0.9 MG/50ML-% ...... mucus & cough relief child ...... multiple vitamins essential ...... MOTEGRITY ...... mucus & cough relief childrens ...... multiple vitamins/iron ...... motion sickness oral tablet 50 mg ...... mucus d ...... MULTIPRO ...... motion sickness relief oral tablet 50 mg ...... mucus d extended release ...... multi-vit/iron/fluoride ...... mucus d max st er ...... multi-vitamin ......

226 multi-vitamin hp/minerals ...... N NAPROXEN SODIUM ER ORAL TABLET multi-vitamin/fluoride ...... nabumetone oral ...... EXTENDED RELEASE 24 HOUR 750 MG multivitamin/fluoride oral solution ...... n-acetyl-l-cysteine oral ...... multivitamin/fluoride oral tablet chewable nadolol oral ...... naproxen sodium oral tablet 220 mg ...... 0.25 mg, 0.5 mg, 1 mg ...... nafrinse ...... naproxen sodium oral tablet 275 mg ...... MULTIVITAMIN/FLUORIDE ORAL TABLET NAFRINSE DAILY ACIDULATED ...... naproxen sodium oral tablet 550 mg ...... CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1- NAFRINSE DAILY/NEUTRAL ...... naproxen-esomeprazole ...... 0.3 MG ...... nafrinse drops ...... NARAMIN ...... multi-vitamin/fluoride/iron ...... NAFRINSE WEEKLY ...... naratriptan hcl ...... multi-vitamin/iron ...... naftifine hcl external cream ...... NARCAN ...... mupirocin calcium ...... naftifine hcl external gel ...... NARDIL ...... mupirocin external ...... NAFTIN ...... NASACORT ALLERGY 24HR ...... MURO 128 OPHTHALMIC OINTMENT ...... NAIL-EX ...... NASACORT ALLERGY 24HR CHILDREN ... MURO 128 OPHTHALMIC SOLUTION 5 % . NALFON ORAL CAPSULE ...... nasal allergy 24 hour ...... my choice ...... NALFON ORAL TABLET ...... nasal allergy nasal aerosol 55 mcg/act ...... my way ...... NALOCET ...... nasal allergy spray ...... MYALEPT ...... naloxone hcl injection ...... nasal decongestant 12 hour ...... MYAMBUTOL ...... naltrexone hcl oral ...... nasal decongestant 12hr ...... MYCAPSSA ...... NAMENDA ...... nasal decongestant max st ...... MYCOBUTIN ...... NAMENDA TITRATION PAK ...... nasal decongestant oral tablet 30 mg ...... mycophenolate mofetil oral ...... NAMENDA XR ...... nasal decongestant oral tablet extended mycophenolate sodium ...... NAMENDA XR TITRATION PACK ...... release 12 hour 120 mg ...... MYCOZYL AP ...... NAMZARIC ORAL CAPSULE ER 24 HOUR nasal decongestant pe max st ...... MYDAYIS ...... THERAPY PACK ...... nasal decongestant pe oral tablet 10 mg ...... MYFEMBREE ...... NAMZARIC ORAL CAPSULE EXTENDED nasal decongestant spray ...... myferon 150 ...... RELEASE 24 HOUR ...... nasal four ...... myferon 150 forte ...... NAPHCON-A ...... nasal mist nasal solution ...... MYFORTIC ...... NAPRELAN ORAL TABLET EXTENDED NASAL MOIST NASAL SOLUTION ...... MYLERAN ...... RELEASE 24 HOUR 375 MG, 750 MG .... nasal moisturizing spray ...... MYNATAL ...... NAPRELAN ORAL TABLET EXTENDED nasal relief ...... MYNATAL PLUS ...... RELEASE 24 HOUR 500 MG ...... nasal relief moisturizing ...... MYNATAL-Z ...... NAPROSYN ...... nasal spray ...... mynephrocaps ...... naproxen oral suspension ...... nasal spray 12 hour ...... MYNEPHRON ...... naproxen oral tablet ...... nasal spray anti-drip ...... myorisan oral capsule 10 mg ...... naproxen oral tablet delayed release ...... nasal spray extra moist ...... myorisan oral capsule 20 mg ...... naproxen sodium er oral tablet extended nasal spray extra moisturizing ...... myorisan oral capsule 30 mg, 40 mg ...... release 24 hour 375 mg ...... nasal spray fast acting ...... MYRBETRIQ ...... naproxen sodium er oral tablet extended nasal spray moisturizing ...... MYSOLINE ...... release 24 hour 500 mg ...... nasal spray no drip ...... MYTESI ...... nasal spray saline ......

227 nasal spray sinus ...... NEOMULTIVITE ...... NEULASTA ...... NASALCROM ...... neomycin sulfate oral ...... NEULASTA ONPRO ...... NASCOBAL ...... neomycin-bacitracin zn-polymyx ...... NEUPOGEN ...... NASONEX ...... neomycin-polymyxin-dexameth ophthalmic NEUPRO ...... NATACHEW ...... ointment ...... NEURAGEN PN ...... NATACYN ...... neomycin-polymyxin-dexameth ophthalmic NEURAPTINE ...... NATALVIT ...... suspension 3.5-10000-0.1 ...... NEURIN-SL ...... NATAZIA ...... neomycin-polymyxin-gramicidin ...... NEURONTIN ...... nateglinide ...... neomycin-polymyxin-hc ophthalmic ...... NEUTEK 2TEK CONTROL ...... NATESTO ...... neomycin-polymyxin-hc otic ...... NEUTEK 2TEK TEST ...... NATPARA ...... NEONATAL + DHA ...... NEUTROGENA OIL-FREE ACNE WASH ..... NATROBA ...... NEONATAL 19 ...... NEVANAC ...... natural daily fiber ...... NEONATAL COMPLETE ...... nevirapine ...... natural fiber laxative oral powder 58.6 % ...... NEONATAL FE ...... nevirapine er ...... natural fiber oral capsule 0.52 gm ...... NEONATAL PLUS ...... new day ...... natural fiber oral powder 28.3 % ...... NEONATAL VITAMIN ...... NEXAVAR ...... natural fiber oral powder 48.57 % ...... neo-polycin ...... NEXIUM ORAL CAPSULE DELAYED natural fiber oral powder 58.6 % ...... neo-polycin hc ...... RELEASE ...... natural fiber supplement ...... NEORAL ...... NEXIUM ORAL PACKET ...... natural fish oil oral capsule 1000 mg...... NEOSALUS ...... NEXLETOL ...... natural fish oil oral capsule 1200 mg...... NEOSPORIN + PAIN RELIEF MAX ST ...... NEXLIZET ...... natural laxative ...... NEOSPORIN ORIGINAL ...... NEXTSTELLIS ...... natural laxative/stool soft ...... NEO-SYNALAR EXTERNAL CREAM ...... niacin (antihyperlipidemic) ...... natural magnesium ...... NEO-SYNALAR EXTERNAL KIT ...... niacin er (antihyperlipidemic) ...... natural senna laxative ...... NEO-SYNEPHRINE COLD/ALLRG MILD .... niacin er oral capsule extended release 250 natural tears pf ...... NEO-SYNEPHRINE COLD/ALLRGY EXT ... mg ...... natural vegetable ...... NEO-SYNEPHRINE COLD/ALLRGY REG .. niacin er oral capsule extended release 500 natural vegetable fiber ...... NEPHPLEX RX ...... mg ...... natural vegetable laxative ...... nephro vitamins ...... niacin er oral tablet extended release ...... natural vitamin e ...... nephronex oral tablet ...... niacin flush free oral capsule 400-100 mg ..... natura-lax ...... NEPHRO-VITE ...... niacin oral tablet 100 mg, 250 mg, 50 mg ..... NATURE-THROID ...... NEPHRO-VITE RX ...... niacor ...... nausea control ...... NERLYNX ...... NIASPAN ...... nausea relief ...... NERVE PAIN RELIEF ...... NICAPRIN ...... NAYZILAM ...... NESINA ...... nicardipine hcl oral ...... NEBUPENT ...... NESTABS ...... NICAZYME ...... necon 0.5/35 (28) ...... NESTABS DHA ...... NICODERM CQ ...... NEEVO DHA ...... NESTABS ONE ...... NICOMIDE ...... nefazodone hcl ...... neuac external gel ...... NICORETTE ...... NEODOT THERMOMETER ...... NEUAC EXTERNAL KIT ...... NICORETTE MINI ......

228 NICORETTE STARTER KIT ...... nilutamide ...... nora-be ...... nicotinamide oral ...... nimodipine oral ...... NORDIPEN 5 INJECTION DEVICE ...... nicotine gum mouth/throat gum 2 mg...... NINJACOF-XG ...... NORDIPEN DELIVERY SYSTEM ...... nicotine gum mouth/throat gum 4 mg...... NINLARO ...... NORDITROPIN FLEXPRO ...... nicotine gum mouth/throat lozenge 2 mg ...... nisoldipine er ...... norethin ace-eth estrad-fe oral capsule ...... nicotine gum mouth/throat lozenge 4 mg ...... nitazoxanide ...... norethin ace-eth estrad-fe oral tablet ...... nicotine mini ...... nitisinone ...... norethin ace-eth estrad-fe oral tablet nicotine mouth/throat gum 2 mg ...... NITRO-BID ...... chewable ...... nicotine mouth/throat gum 4 mg ...... NITRO-DUR ...... norethindrone acetate oral ...... nicotine mouth/throat lozenge 2 mg ...... nitrofurantoin ...... norethindrone acet-ethinyl est ...... nicotine mouth/throat lozenge 4 mg ...... nitrofurantoin macrocrystal ...... norethindrone oral ...... nicotine polacrilex mini ...... nitrofurantoin monohydrate macrocrystals .... norethindrone-eth estradiol ...... nicotine polacrilex mouth/throat ...... nitroglycerin sublingual ...... norethin-eth estradiol-fe ...... nicotine step 1 ...... nitroglycerin transdermal ...... NORGESIC FORTE ...... nicotine step 2 ...... nitroglycerin translingual ...... norgestimate-eth estradiol ...... nicotine step 3 ...... NITROLINGUAL ...... norgestimate-ethinyl estradiol triphasic ...... nicotine transdermal kit 21-14-7 mg/24hr ...... NITROMIST ...... NORITATE ...... nicotine transdermal patch 24 hour 14 NITROSTAT SUBLINGUAL TABLET norlyda ...... mg/24hr, 7 mg/24hr ...... SUBLINGUAL 0.3 MG, 0.6 MG ...... norlyroc ...... nicotine transdermal patch 24 hour 21 NITROSTAT TABLET SUBLINGUAL 0.4 NORPACE ...... mg/24hr ...... MG SUBLINGUAL ...... , NORPACE CR ...... nicotine transdermal system ...... NITRO-TIME ...... NORPRAMIN ...... NICOTROL ...... NITYR ...... NORTHERA ...... NICOTROL NS ...... NIVA-PLUS ...... nortrel 0.5/35 (28) ...... nifedipine er ...... NIVESTYM ...... nortrel 1/35 (21) ...... nifedipine er osmotic release ...... nizatidine ...... nortrel 1/35 (28) ...... nifedipine oral ...... no drip nasal relief ...... nortrel 7/7/7 ...... NIFEREX ...... no drip nasal spray ...... nortriptyline hcl oral ...... night time cold/flu relief oral liquid 15-6.25- no flush niacin oral capsule ...... NORVASC ...... 500 mg/15ml ...... NOCDURNA ...... NORVIR ORAL PACKET ...... night time sleep aid ...... nohist-lq ...... NORVIR ORAL SOLUTION ...... nighttime cold medicine...... nolix ...... NORVIR ORAL TABLET ...... nighttime cold/flu relief oral liquid 15-6.25- non-aspirin ...... nose drops extstrength ...... 500 mg/15ml ...... non-aspirin 8 hour ...... nose drops nasal decongest ...... nighttime dry-eye relief ...... non-aspirin childrens ...... nose drops nasal solution 1 % ...... nighttime sleep aid max st ...... non-aspirin extra strength ...... NOURIANZ ...... nighttime sleep aid oral capsule 25 mg ...... non-aspirin jr strength ...... NOVACORT ...... nighttime sleep aid oral tablet 25 mg ...... non-aspirin pain relief ...... NOVAMV PEDIATRIC MULTI-VITAMIN ...... nikki ...... non-pseudo sinus decongestant ...... novarel intramuscular solution reconstituted NILANDRON ...... NOPIOID-LMC KIT ...... 10000 unit ......

229 NOVAREL INTRAMUSCULAR SOLUTION NUDROXIPAK DSDR-50 ...... nystatin oral ...... RECONSTITUTED 5000 UNIT ...... NUDROXIPAK DSDR-75 ...... nystatin-triamcinolone ...... NOVOLIN 70/30 FLEXPEN ...... NUDROXIPAK E-400 ...... nystop ...... NOVOLIN 70/30 FLEXPEN RELION ...... NUDROXIPAK I-800 ...... NYVEPRIA ...... NOVOLIN 70/30 RELION...... NUDROXIPAK M-15 ...... O NOVOLIN 70/30 VIAL ...... NUDROXIPAK N-500 ...... OB COMPLETE ...... NOVOLIN N FLEXPEN ...... NUEDEXTA ...... OB COMPLETE ONE ...... NOVOLIN N FLEXPEN RELION ...... NUFERA ...... OB COMPLETE PETITE ...... NOVOLIN N RELION ...... nufol ...... OB COMPLETE PREMIER ...... NOVOLIN N VIAL...... NU-IRON ...... OB COMPLETE/DHA ...... NOVOLIN R FLEXPEN ...... NULEV ...... OBSTETRIX DHA ...... NOVOLIN R FLEXPEN RELION ...... NULYTELY LEMON-LIME ...... OBSTETRIX EC ...... NOVOLIN R RELION ...... NU-MAG ...... OBSTETRIX ONE ...... NOVOLIN R VIAL...... NUPERCAINAL ...... OBTREX ...... NOVOLOG FLEXPEN...... NUPLAZID ...... O-CAL PRENATAL ...... NOVOLOG MIX 70/30 FLEXPEN ...... NURTEC ...... OCALIVA ...... NOVOLOG MIX 70/30 VIAL ...... NUSURGEPAK SURGICAL PREP/CARE.... OCEAN BLUE MINICAPS OMEGA-3 ...... NOVOLOG PENFILL ...... NUTRAPLUS ...... OCEAN FOR KIDS ...... NOVOLOG U-100 VIAL ...... NUTRASEB ...... OCEAN NASAL SPRAY ...... NOVOTWIST PEN NEEDLE...... NUTRIARX CREAMPAK ...... ocella ...... NOXAFIL ORAL SUSPENSION ...... NUTRICAP ...... octreotide acetate ...... NOXAFIL ORAL TABLET DELAYED NUTRIDOX ...... OCUFLOX ...... RELEASE ...... nutrifac zx ...... OCUVEL ...... NP #2 DRUG PREPARATION KIT ...... NUTRIVIT ...... ODACTRA ...... np thyroid ...... NUTROPIN AQ NUSPIN 10 ...... ODEFSEY ...... NUBEQA ...... NUTROPIN AQ NUSPIN 20 ...... ODOMZO ...... NUCALA SUBCUTANEOUS SOLUTION NUTROPIN AQ NUSPIN 5 ...... odorless coated fish oil ...... AUTO-INJECTOR ...... NUVAIL ...... OFEV ...... NUCALA SUBCUTANEOUS SOLUTION NUVAKAAN ...... ofloxacin ophthalmic ...... PREFILLED SYRINGE ...... NUVAKAAN-II ...... ofloxacin oral ...... NUCARACLINPAK...... NUVARING ...... ofloxacin otic ...... NUCARARXPAK ...... NUVESSA ...... ointment base ...... NUCORT ...... NUVIGIL ...... olanzapine oral ...... NUCYNTA ...... NUZYRA ORAL ...... olanzapine-fluoxetine hcl oral capsule 12-25 NUCYNTA ER ...... nyamyc ...... mg, 12-50 mg, 6-50 mg ...... NUDERMRXPAK 120 ...... nylia 7/7/7 ...... olanzapine-fluoxetine hcl oral capsule 3-25 NUDERMRXPAK 60 ...... NYMALIZE ...... mg ...... NUDICLO SOLUPAK ...... nymyo ...... olanzapine-fluoxetine hcl oral capsule 6-25 NUDICLO TABPAK ...... nystatin external ...... mg ...... NUDROXIPAK ...... nystatin mouth/throat ...... olmesartan medoxomil oral ......

230 olmesartan medoxomil-hctz ...... ONE VITE WOMENS ...... OPTIUMEZ TEST ...... olmesartan-amlodipine-hctz ...... ONE VITE WOMENS PLUS ...... ORACEA ...... olopatadine hcl nasal ...... one-daily multi vitamins ...... ORACIT ...... olopatadine hcl ophthalmic ...... one-daily multi-vitamin oral tablet ...... oral analgesic max st mouth/throat gel ...... OLUMIANT ...... one-daily multi-vitamin/iron ...... oral anesthetic max str ...... OLUX ...... one-daily/iron ...... oral pain relief mouth/throat gel 20 % ...... OLUX-E ...... ONETOUCH SURESOFT LANCING ORALAIR ...... OMECLAMOX-PAK ...... DEVICE...... ORALAIR ADULT STARTER PACK ...... omega-3 fish oil oral capsule 1000 mg ...... ONETOUCH ULTRA ...... ORALAIR CHILDRENS STARTER PACK .... omega-3 fish oil oral capsule 1200 mg ...... ONETOUCH ULTRA 2 KIT W/DEVICE ...... oralone ...... omega-3 fish oil oral capsule 300 mg ...... ONETOUCH ULTRA CONTROL ...... oralyte freezer pops ...... omega-3 fish oil oral capsule delayed ONETOUCH ULTRA MINI KIT W/DEVICE... ORAMAGICRX ...... release 1200 mg ...... ONETOUCH ULTRALINK ...... ORAPRED ODT ORAL TABLET omega-3 oral capsule 1000 mg ...... ONETOUCH VERIO FLEX SYSTEM ...... DISPERSIBLE 10 MG, 30 MG ...... omega-3 oral capsule 1400 mg ...... ONETOUCH VERIO IN VITRO SOLUTION . ORAPRED ODT ORAL TABLET OMEGA-3 RX COMPLETE ...... ONETOUCH VERIO IN VITRO SOLUTION DISPERSIBLE 15 MG ...... omega-3-acid ethyl esters ...... HIGH ...... ORAVIG ...... omeprazole magnesium oral capsule ONETOUCH VERIO IQ SYSTEM ...... ORAZINC ORAL TABLET ...... delayed release ...... ONETOUCH VERIO KIT W/DEVICE ...... ORENCIA CLICKJECT ...... omeprazole magnesium oral tablet delayed ONETOUCH VERIO REFLECT ...... ORENCIA SUBCUTANEOUS ...... release ...... ONETOUCH VERIO SYNC SYSTEM ...... ORENITRAM ...... omeprazole oral capsule delayed release 10 ONETOUCH VERIO TEST STRIPS ...... ORFADIN ...... mg, 20 mg, 20.6 (20 base) mg, 40 mg ...... ONEVITE ...... ORGOVYX ...... omeprazole oral tablet delayed release 20 ONEXTON ...... ORIAHNN ...... mg ...... ONFI ORAL SUSPENSION ...... ORILISSA ...... OMEPRAZOLE+SYRSPEND SF ALKA ...... ONFI ORAL TABLET ...... ORKAMBI ...... omeprazole-sod bicarbonate ...... ONGENTYS ...... ORLADEYO ...... omeprazole-sodium bicarb oral capsule 20- ONGLYZA ...... ORMECA ...... 1100 mg ...... ONUREG ...... orphenadrine citrate er ...... omeprazole-sodium bicarbonate ...... ONYCHO-MED ...... orphenadrine-asa-caffeine ...... OMNARIS ...... ONZDEOXIA ...... ORPHENGESIC FORTE ...... OMNIFLEX DIAPHRAGM ...... ONZETRA XSAIL ...... orsythia ...... OMNITROPE ...... opcicon one-step ...... ORTHO DF ...... OMNITROPE PEN 5 INJ DEVICE ...... opium ...... ORTIKOS ...... OMNIVEX ...... OPSUMIT ...... OS-CAL ...... once daily ...... option 2 ...... OS-CAL CALCIUM + D3 ...... ondansetron hcl oral ...... OPTIONS GYNOL II CONTRACEPTIVE...... OS-CAL EXTRA D3 ...... ondansetron odt ...... OPTIUM BLOOD GLUCOSE MONITOR ...... OS-CAL ULTRA ...... one daily ...... OPTIUM GLUCOSE MONITOR SYSTEM .... oscimin ...... one daily womens health oral tablet ...... OPTIUM TEST ...... oscimin sr ......

231 oseltamivir phosphate oral ...... OXYCODONE-ACETAMINOPHEN ORAL pain & fever childrens oral suspension 160 OSENI ...... SOLUTION ...... mg/5ml ...... OSMOLEX ER ...... OXYCODONE-ACETAMINOPHEN ORAL pain & fever infants ...... OSMOPREP ...... TABLET 10-300 MG, 2.5-300 MG, 5-300 pain relief childrens oral suspension 160 OSPHENA ...... MG ...... mg/5ml ...... OTEZLA ...... oxycodone-acetaminophen oral tablet 10- pain relief childrens oral tablet chewable 160 OTOVEL ...... 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg ...... OTREXUP ...... mg ...... PAIN RELIEF EXTERNAL CREAM 4 % ...... OVACE PLUS EXTERNAL CREAM ...... oxycodone-aspirin ...... pain relief extra st ...... OVACE PLUS EXTERNAL FOAM ...... OXYCONTIN ...... pain relief extra strength ...... OVACE PLUS EXTERNAL LOTION ...... oxymorphone hcl ...... pain relief infants oral suspension 160 OVACE PLUS EXTERNAL SHAMPOO ...... oxymorphone hcl er ...... mg/5ml ...... OVACE PLUS WASH ...... OXYTROL ...... pain relief oral liquid 500 mg/15ml ...... OVACE WASH ...... OXYTROL FOR WOMEN ...... pain relief oral tablet 325 mg ...... OVEEZA ...... oysco 500+d ...... pain relief oral tablet 500 mg ...... OVIDE ...... oyster shell calcium + d oral tablet 500-400 pain relief oral tablet extended release 650 OVIDREL ...... mg-unit ...... mg ...... oxandrolone oral ...... oyster shell calcium + d3 ...... pain relief regular st ...... oxaprozin ...... oyster shell calcium 500 + d ...... pain relief regular strength ...... OXAYDO ORAL TABLET 5 MG ...... oyster shell calcium oral tablet 500 mg ...... pain relief/rapid burst ...... OXAYDO ORAL TABLET 7.5 MG ...... oyster shell calcium plus d oral tablet 500- pain relieve child dye-free ...... oxazepam ...... 200 mg-unit ...... pain reliever childrens oral suspension 160 OXBRYTA ...... oyster shell calcium/d oral tablet 250-125 mg/5ml ...... oxcarbazepine ...... mg-unit ...... pain reliever ex st oral liquid 500 mg/15ml .... OXERVATE ...... oyster shell calcium/d oral tablet 250-250 pain reliever ex st oral tablet 500 mg ...... OXIANUJO ...... mg-unit, 500-400 mg-unit ...... pain reliever ex st oral tablet extended OXIATAR ...... oyster shell calcium/d oral tablet 500-200 release 650 mg ...... OXIAVARRY ...... mg-unit ...... pain reliever extra strength oral tablet 250- OXIAZAR ...... oyster shell calcium/vit d ...... 250-65 mg...... oxiconazole nitrate ...... oyster shell calcium/vit d3 ...... pain reliever extra strength oral tablet 500 OXISTAT EXTERNAL CREAM ...... oyster shell calcium/vitamin d oral tablet ...... mg ...... OXISTAT EXTERNAL LOTION ...... OZEMPIC ...... pain reliever infants oral suspension 160 OXTELLAR XR ...... OZOBAX ...... mg/5ml ...... oxybutynin chloride er ...... P pain reliever oral tablet ...... oxybutynin chloride oral ...... p col-rite ...... pain reliever plus ...... OXYCODONE HCL ER...... PACERONE ORAL TABLET 100 MG, 400 pain relieving + lidocaine ...... oxycodone hcl oral capsule ...... MG ...... pain relieving external cream 4 % ...... oxycodone hcl oral concentrate 100 mg/5ml . PACERONE ORAL TABLET 200 MG ...... PAINGO KFT ...... oxycodone hcl oral solution ...... pain & fever child ...... pain-off ...... oxycodone hcl oral tablet ...... PALFORZIA (12 MG DAILY DOSE) ......

232 PALFORZIA (120 MG DAILY DOSE) ...... PARI ERAPID NEBULIZER HANDSET ...... peg 3350 oral powder ...... PALFORZIA (160 MG DAILY DOSE) ...... PARI ERAPID NEBULIZER SYSTEM ...... peg 3350-kcl-na bicarb-nacl ...... PALFORZIA (20 MG DAILY DOSE) ...... PARI LC PLUS NEB SET PED MASK...... peg-3350/electrolytes ...... PALFORZIA (200 MG DAILY DOSE) ...... PARI LC PLUS NEBULIZER ...... peg-3350/electrolytes/ascorbat ...... PALFORZIA (240 MG DAILY DOSE) ...... PARI LC PLUS VIOS PRO NEB ...... PEGASYS ...... PALFORZIA (3 MG DAILY DOSE) ...... PARI LC SPRINT NEBULIZER SET ...... PEGINTRON ...... PALFORZIA (300 MG MAINTENANCE) ...... PARI SINUS AEROSOL SYSTEM ...... peg-kcl-nacl-nasulf-na asc-c ...... PALFORZIA (300 MG TITRATION) ...... PARI TREK S COMBO PACK ...... peg-prep ...... PALFORZIA (40 MG DAILY DOSE) ...... PARI TREK S W/12V DC ADAPTOR ...... PEMAZYRE ...... PALFORZIA (6 MG DAILY DOSE) ...... PARI VIOS PRO LC PLUS SYSTEM ...... penicillamine oral ...... PALFORZIA (80 MG DAILY DOSE) ...... PARI VIOS PRO LC SPRINT SYSTEM...... penicillin v potassium ...... PALFORZIA INITIAL ESCALATION ...... PARI VORTEX ADULT MASK ...... PENLET II BLOOD SAMPLER ...... paliperidone er ...... paricalcitol oral ...... PENLET II REPLACEMENT CAP ...... PALYNZIQ ...... PARLODEL ...... PENNSAID ...... PAMELOR ...... PARNATE ...... pentamidine isethionate inhalation ...... PANADOL CHILDRENS ...... paromomycin sulfate oral ...... PENTASA ...... PANADOL EXTRA ...... paroxetine hcl ...... pentazocine-naloxone hcl ...... PANADOL EXTRA STRENGTH ...... paroxetine hcl er ...... PENTOSAN POLYSULFATE SODIUM PANADOL INFANTS...... paroxetine mesylate ...... ORAL ...... PANCREAZE CAPSULE DELAYED PASER ...... pentoxifylline er ...... RELEASE PARTICLES 37000-97300 PATADAY OPHTHALMIC SOLUTION 0.1 % PEPCID ...... UNIT ORAL ...... PATADAY OPHTHALMIC SOLUTION 0.2 % peptic relief ...... PANCREAZE ORAL CAPSULE DELAYED PATANASE ...... PEPTO-BISMOL ORAL SUSPENSION 524 RELEASE PARTICLES 10500-35500 PAXIL ...... MG/30ML ...... UNIT, 16800-56800 UNIT, 21000-54700 PAXIL CR ...... PERCOCET ...... UNIT, 4200-14200 UNIT ...... pb-hyoscy-atropine-scopolamine ...... PERDIEM OVERNIGHT RELIEF ...... PANCREAZE ORAL CAPSULE DELAYED PCP 100 ...... PERFOROMIST ...... RELEASE PARTICLES 2600-6200 UNIT . ped electrolyte freeze pop ...... PERIDEX ...... PANDEL ...... ped electrolyte freezer pops ...... PERIDIN-C ...... PANOXYL ...... pediaclear pd childrens ...... perindopril erbumine ...... PANRETIN ...... PEDIA-LAX ORAL LIQUID ...... periogard ...... pantoprazole sodium oral packet ...... PEDIA-LAX RECTAL SUPPOSITORY 1 GM permethrin external ...... pantoprazole sodium oral tablet delayed PEDIALYTE FREEZER POPS ...... perphenazine oral ...... release ...... PEDIALYTE ORAL SOLUTION ...... perphenazine-amitriptyline oral tablet 2-10 pantothenic acid ...... PEDIALYTE SINGLES ...... mg, 4-10 mg, 4-25 mg, 4-50 mg ...... PARADIGM REAL-TIME TRANSMITTER .... PEDIAPRED ...... perphenazine-amitriptyline oral tablet 2-25 PAREMYD ...... PEDIATRIC COMPRESSOR NEBULIZER .. mg ...... PARI ALTERA NEBULIZER HANDSET ...... pediatric electrolyte oral solution ...... PERRY PRENATAL ...... PARI ALTERA NEBULIZER SYSTEM ...... pediavit ...... PERSERIS ...... PARI BABY CONVERSION KIT ...... PEDIZOLPAK ...... PERTZYE ......

233 PEXEVA ...... PHOSLYRA ...... PLEXION CLEANSER ...... PFIZER-BIONTECH COVID-19 VACC ...... PHOS-NAK ...... PLEXION CLEANSING CLOTH ...... pharbechlor ...... PHOSPHA 250 NEUTRAL ...... PLIAGLIS EXTERNAL CREAM ...... pharbedryl ...... phosphorous ...... PNEUMOVAX 23 ...... PHARBETOL EXTRA STRENGTH ...... phosphorus supplement ...... PNV TABS 20-1 ...... PHARBETOL ORAL TABLET 325 MG ...... phosphorus w/sod & potassium ...... pnv tabs 29-1 ...... pharbinex ...... phospho-trin 250 neutral ...... pnv-dha ...... PHAZYME ...... PHOXILLUM B22K4/0 ...... pnv-dha+docusate ...... PHAZYME ULTRA STRENGTH ...... PHOXILLUM BK4/2.5 ...... pnv-omega ...... phenazo oral tablet 200 mg ...... phytonadione oral ...... pnv-select ...... phenazo oral tablet 95 mg ...... PIFELTRO ...... PODIAPN ...... phenazopyridine hcl oral tablet 100 mg ...... pilocarpine hcl ophthalmic ...... podocon ...... phenazopyridine hcl oral tablet 200 mg ...... pilocarpine hcl oral ...... podofilox external ...... phenelzine sulfate oral ...... pimecrolimus ...... poly bacitracin ...... phenobarbital oral elixir ...... pimozide ...... polycin ...... phenobarbital oral tablet ...... pimtrea ...... polyethylene glycol 3350 oral powder ...... phenobarbital-belladonna alk ...... pindolol ...... polyethylene glycol 3350-grx oral powder ..... PHENOHYTRO ...... pink bismuth maximum strength ...... poly-iron 150 ...... phenoxybenzamine hcl oral ...... pink bismuth oral suspension 262 mg/15ml .. poly-iron 150 forte ...... phenylalanine ...... pink bismuth oral tablet 262 mg ...... polymyxin b-trimethoprim ...... phenylephrine hcl ophthalmic ...... pink bismuth oral tablet chewable 262 mg .... polysaccharide iron complex ...... phenylephrine hcl oral ...... pink-bismuth ...... polysaccharide iron forte ...... PHENYLEPHRINE HCL-NACL pioglitazone hcl ...... polysaccharide-iron complex ...... INTRAVENOUS SOLUTION PREFILLED pioglitazone hcl-glimepiride ...... POLYSPORIN ...... SYRINGE 1-0.9 MG/10ML-%, 100-0.9 pioglitazone hcl-metformin hcl ...... POLYTRIM ...... MCG/10ML-%, 20-0.9 MG/50ML-% ...... PIQRAY (200 MG DAILY DOSE) ...... poly-tussin ac ...... PHENYLEPHRINE HCL-NACL SOLUTION PIQRAY (250 MG DAILY DOSE) ...... POLY-VI-FLOR ORAL SUSPENSION ...... PREFILLED SYRINGE 5-0.9 MG/50ML-% PIQRAY (300 MG DAILY DOSE) ...... POLY-VI-FLOR ORAL TABLET INTRAVENOUS ...... pirmella 1/35 ...... CHEWABLE 0.25 MG ...... PHENYTEK ...... pirmella 7/7/7 ...... POLY-VI-FLOR ORAL TABLET phenytoin infatabs ...... piroxicam oral ...... CHEWABLE 0.5 MG, 1 MG ...... phenytoin oral suspension 125 mg/5ml ...... PKU EASY ...... POLY-VI-FLOR/IRON ...... phenytoin oral tablet chewable ...... PKU EASY MICROTABS ...... polyvinyl alcohol ophthalmic ...... phenytoin sodium extended ...... PLAN B ONE-STEP ...... POLY-VI-SOL ...... PHEODOYO ...... PLAQUENIL ...... POLY-VITE PEDIATRIC ...... PHEXXI ...... PLAVIX ...... POMALYST ...... PHEYO ...... PLEGRIDY ...... PONARIS ...... philith ...... PLEGRIDY STARTER PACK ...... PONVORY ...... PHILLIPS MILK OF MAGNESIA ORAL PLENVU ...... PONVORY STARTER PACK ...... SUSPENSION 400 MG/5ML ...... PLEXION ...... portia-28 ......

234 posaconazole ...... PRECISION GLUCOSE/KETONE CONTR .. PREDNISOLON-GATIFLOX-BROMFENAC . POTABA ...... PRECISION LINK ...... PREDNISOLON-MOXIFLOX-BROMFENAC. potassium chloride crys er ...... PRECISION PCX ...... PREDNISOLON-MOXIFLOX-NEPAFENAC.. potassium chloride er ...... PRECISION PCX PLUS TEST ...... prednisone intensol ...... potassium chloride oral packet...... PRECISION POINT OF CARE TEST ...... prednisone oral solution ...... potassium chloride oral solution 20 PRECISION QID MONITOR ...... prednisone oral tablet ...... meq/15ml (10%), 40 meq/15ml (20%) ...... PRECISION QID TEST ...... prednisone oral tablet therapy pack 10 mg potassium citrate er oral tablet extended PRECISION SOF-TACT MONITOR ...... (21) ...... release 10 meq (1080 mg) ...... PRECISION SOF-TACT TEST ...... prednisone oral tablet therapy pack 10 mg potassium citrate er oral tablet extended PRECISION XTRA ...... (48), 5 mg (21), 5 mg (48) ...... release 15 meq (1620 mg) ...... PRECISION XTRA BLOOD GLUCOSE ...... PREFEST ...... potassium citrate er oral tablet extended PRECISION XTRA KETONE ...... pregabalin er ...... release 5 meq (540 mg) ...... PRECISION XTRA MONITOR...... pregabalin oral ...... potassium citrate-citric acid ...... PRECOSE ...... PREGEN DHA ...... povidone iodine ...... PRED FORTE ...... PREGENNA ...... povidone-iodine external solution ...... PRED MILD ...... pregnyl ...... POVIDONE-IODINE OPHTHALMIC ...... PRED-G ...... PREMARIN ORAL ...... PR BENZOYL PEROXIDE ...... PRED-G S.O.P...... PREMARIN VAGINAL ...... PR BENZOYL PEROXIDE WASH ...... prednicarbate external cream ...... PREMESISRX ...... PR CREAM ...... prednicarbate external ointment ...... PREMIUM BLOOD GLUCOSE TEST ...... PRADAXA ...... PREDNISOL ACE-MOXIFLOX-BROMFEN .. PREMIUM CONDOMS LUBRICATED ...... PRALUENT ...... prednisolone acetate ophthalmic ...... premium lidocaine ...... pramipexole dihydrochloride ...... prednisolone acetate p-f ...... PREMIUM SCAR ...... pramipexole dihydrochloride er ...... PREDNISOLONE ACETATE-NEPAFENAC PREMPHASE ...... pramosone external cream 1-1 % ...... PREDNISOLONE ACET-MOXIFLOXACIN .. PREMPRO ...... PRAMOSONE EXTERNAL CREAM 1-2.5 % prednisolone oral solution ...... PRENA 1 TRUE ...... PRAMOSONE EXTERNAL LOTION ...... prednisolone sodium phosphate ophthalmic PRENA1 ...... PRAMOSONE EXTERNAL OINTMENT ...... prednisolone sodium phosphate oral solution PRENA1 PEARL ...... PRAMOTIC ...... 10 mg/5ml, 20 mg/5ml ...... PRENAISSANCE ...... pramox ...... prednisolone sodium phosphate oral solution PRENAISSANCE PLUS ...... PRASTERA ...... 15 mg/5ml, 25 mg/5ml ...... PRENATABS RX ...... prasugrel hcl ...... prednisolone sodium phosphate oral solution prenatal 19 ...... pravastatin sodium ...... 6.7 (5 base) mg/5ml ...... prenatal dha ...... praziquantel oral ...... prednisolone sodium phosphate oral tablet prenatal formula oral tablet 28-0.8 mg ...... prazosin hcl oral ...... dispersible 10 mg, 30 mg ...... prenatal gummy oral tablet chewable 0.4 mg PRE & POST SX POUCH ...... prednisolone sodium phosphate oral tablet prenatal gummy oral tablet chewable 0.4- pre protein oral tablet ...... dispersible 15 mg ...... 113.5 mg ...... PRECISION GLUCOSE CONTROL ...... PREDNISOLONE-BROMFENAC ...... prenatal gummy oral tablet chewable 0.4-25 PRECISION GLUCOSE CONTROL SOLN .. PREDNISOLONE-GATIFLOXACIN ...... mg ...... PRECISION GLUCOSE KETONE CONTR .. PREDNISOLONE-MOXIFLOXACIN ...... prenatal multi+dha ......

235 prenatal multivitamins ...... PREVIDENT MOUTH/THROAT ...... probiotic maximum strength ...... prenatal oral tablet 27-0.8 mg ...... PREVIDOLRX ANALGESIC ...... probiotic oral capsule ...... prenatal oral tablet 27-1 mg ...... previdolrx plus analgesic ...... probiotic oral capsule 250 mg ...... prenatal oral tablet 28-0.8 mg ...... previfem ...... probiotic pearls ex st ...... prenatal plus iron ...... PREVNAR 13 ...... PROCARDIA XL ...... prenatal vitamin plus low iron ...... PREVYMIS ORAL ...... PROCENTRA ...... prenatal vitamins oral tablet 28-0.8 mg ...... PREZCOBIX ...... prochlorperazine ...... prenatal/iron ...... PREZISTA ...... prochlorperazine maleate oral ...... PRENATAL-U ...... PRID ...... PROCORT ...... PRENATE ...... PRIFTIN ...... PROCRIT ...... PRENATE AM ...... PRILO PATCH ...... PRO-CRITIC ...... PRENATE DHA ...... PRILO PATCH II ...... PROCTOCORT EXTERNAL ...... PRENATE ELITE ...... PRILOLID ...... PROCTOCORT RECTAL ...... PRENATE ENHANCE...... PRILOSEC ...... PROCTOFOAM HC ...... PRENATE ESSENTIAL ...... PRILOSEC OTC ...... procto-med hc ...... PRENATE MINI ...... PRILOVIX ...... procto-pak ...... PRENATE PIXIE ...... PRILOVIX LITE ...... proctozone-hc ...... PRENATE RESTORE ...... PRILOVIX LITE PLUS ...... PROCYSBI ...... PRENATVITE COMPLETE ...... PRILOVIX PLUS ...... PRODIGEN ...... PRENATVITE PLUS ...... PRILOVIX ULTRALITE ...... PROFE ...... PRENATVITE RX ...... PRILOVIX ULTRALITE PLUS ...... PROFERRIN ES ...... PREPIDIL ...... PRILOVIXIL ...... progesterone intramuscular ...... preplus ...... PRIMACARE ...... PROGESTERONE MICRONIZED PREPROTEIN ...... primaquine phosphate ...... TRANSDERMAL ...... PREPROTEIN 20 ...... primidone oral ...... progesterone oral ...... PRESERA ...... PRIMSOL ...... PROGLYCEM ...... PRESTALIA ...... PRINIVIL ...... PROGRAF ORAL CAPSULE 0.5 MG, 5 MG . PRETAB ...... PRISTIQ ...... PROGRAF ORAL CAPSULE 1 MG ...... PRETOMANID ...... PRIZOPAK II ...... PROGRAF ORAL PACKET ...... PREVACID ...... PRO HERS RX ...... PROLATE ...... PREVACID 24HR ...... PRO HIS RX ...... PROLENSA ...... PREVACID SOLUTAB ...... PRO NUTRIENTS OMEGA 3 ...... PROLEUKIN ...... prevalite ...... PRO PCOS RX ...... PROLEVA ...... PREVIDENT 5000 BOOSTER PLUS...... PROAIR DIGIHALER ...... PROMACTA ...... PREVIDENT 5000 DRY MOUTH ...... PROAIR HFA ...... promethazine hcl oral ...... PREVIDENT 5000 ENAMEL PROTECT ...... PROAIR RESPICLICK ...... promethazine hcl rectal ...... PREVIDENT 5000 ORTHO DEFENSE ...... probenecid ...... promethazine vc ...... PREVIDENT 5000 PLUS ...... pro-biotic blend ...... promethazine vc/codeine ...... PREVIDENT 5000 SENSITIVE ...... probiotic colon care ...... promethazine-codeine ...... PREVIDENT DENTAL ...... probiotic complex ...... promethazine-dm ......

236 promethazine-phenyleph-codeine ...... pseudoephedrine hcl 12 hr ...... QTERN ...... promethazine-phenylephrine ...... pseudoephedrine hcl er ...... quad-probiotic ...... promethegan ...... pseudoephedrine hcl oral tablet 30 mg ...... QUALAQUIN ...... PROMETRIUM ...... pseudoephedrine-bromphen-dm ...... QUARTETTE ...... PROMISEB ...... pseudoephedrine-guaifenesin er ...... quazepam ...... PRONEB ULTRA FILTER SET ...... PSORCON ...... QUDEXY XR ...... PRONUTRIENTS COQ10 ...... PSORIZIDE FORTE ...... QUESTRAN ...... PRONUTRIENTS SUPER B COMPLEX ...... PSORIZIDE ULTRA ...... QUESTRAN LIGHT ...... PRONUTRIENTS VITAMIN D3 ...... PSS SELECT PLATFORMS ...... quetiapine fumarate ...... propafenone hcl ...... psyldex ...... quetiapine fumarate er ...... propafenone hcl er ...... PULMICORT FLEXHALER ...... QUFLORA FE ...... proparacaine-fluorescein ...... PULMICORT SUSPENSION ...... QUFLORA FE PEDIATRIC ...... propranolol hcl er ...... PULMOZYME ...... QUFLORA GUMMIES ...... propranolol hcl oral ...... PURALUBE ...... QUFLORA PEDIATRIC ORAL SOLUTION propranolol-hctz ...... pure & gentle lubricant ...... 0.25 MG/ML ...... propylthiouracil oral ...... pure l-arginine hcl ...... QUFLORA PEDIATRIC ORAL SOLUTION PRO-RED AC ...... pure l-citrulline oral capsule ...... 0.5 MG/ML ...... PROSCAR ...... pure l-tyrosine ...... QUFLORA PEDIATRIC ORAL TABLET PROSILK EXTERNAL ...... purelax oral powder ...... CHEWABLE...... PROSTIN E2 ...... purevit dualfe plus ...... QUIHOXVAR ...... PROTEINEX ORAL LIQUID...... PURIXAN ...... QUILLICHEW ER ...... proteinex oral tablet ...... PYLERA ...... QUILLIVANT XR ...... PROTEINEX P100 ...... pyrazinamide oral ...... quinapril hcl ...... PROTEINEX P18 ...... PYRIDIUM ...... quinapril-hydrochlorothiazide ...... PROTEINEX-18 ...... pyridostigmine bromide er ...... quinidine gluconate er ...... PROTEXA ...... pyridostigmine bromide oral solution ...... quinidine sulfate ...... PROTONIX ORAL PACKET ...... pyridostigmine bromide oral tablet ...... quinine sulfate oral ...... PROTONIX ORAL TABLET DELAYED pyridoxine hcl oral ...... QUINIXIL ...... RELEASE ...... pyrimethamine oral ...... QUINJA ...... PROTOPIC ...... PYRIMETHAMINE-LEUCOVORIN ...... QUINTET AC BLOOD GLUCOSE ...... protriptyline hcl ...... PYROGALLIC ACID ...... QUINTET AC BLOOD GLUCOSE TEST ...... PROVAD ...... Q QUINTET BLOOD GLUCOSE SYSTEM ...... PROVENTIL HFA ...... QBRELIS ...... QUINTET BLOOD GLUCOSE TEST ...... PROVERA ...... QBREXZA ...... QUINTET CONTROL HIGH/NORMAL ...... PROVIDA OB ...... QDOLO ...... quit2 ...... PROVIGIL ...... QELBREE ...... quit4 ...... PROZAC ...... QINLOCK ...... QVAR REDIHALER ...... PRUCLAIR ...... QMIIZ ODT ...... R PRUDOXIN ...... QNASL ...... RABEPRAZOLE SODIUM ORAL CAPSULE PRUMYX ...... QNASL CHILDRENS ...... SPRINKLE ......

237 rabeprazole sodium oral tablet delayed redness relief ophthalmic solution 0.012-0.2 RENATABS ...... release ...... % ...... RENATABS WITH IRON ...... radiance platinum vitamin d3 ...... refenesen 400 ...... rena-vite ...... RADIOGARDASE ...... REFRESH LACRI-LUBE ...... renewal soothing bath ...... RAGWITEK ...... REFRESH OPTIVE OPHTHALMIC RENVELA ...... raloxifene hcl ...... SOLUTION ...... repaglinide ...... ramelteon ...... REFRESH OPTIVE PF ...... REPATHA ...... ramipril ...... REFRESH P.M...... REPLACEMENT FILTERS ...... RANEXA ...... REFRESH PLUS ...... REQ 49+ ...... ranolazine er ...... REFRESH RELIEVA ...... RESORCINOL-SULFUR ...... RAPAFLO ...... REFRESH RELIEVA PF OPHTHALMIC rest simply ...... RAPAMUNE ORAL SOLUTION ...... SOLUTION 0.5-0.9 % ...... RESTASIS ...... RAPAMUNE ORAL TABLET 0.5 MG, 1 MG . REFRESH TEARS ...... RESTASIS MULTIDOSE ...... RAPAMUNE ORAL TABLET 2 MG...... REGLAN ...... RESTORA ...... RAPID GEL RX ...... REGRANEX ...... RESTORA RX ...... rapid melts junior oral tablet dispersible 160 REHYDRALYTE ...... restore plus lubricant eye ...... mg ...... RELADOR PAK ...... restore pm ...... rasagiline mesylate oral ...... RELADOR PAK PLUS ...... RESTORIL ORAL CAPSULE 15 MG, 30 RASUVO ...... RELAFEN ...... MG, 7.5 MG ...... RAVICTI ...... RELAFEN DS ...... RESTORIL ORAL CAPSULE 22.5 MG ...... RAYALDEE ...... RELENZA DISKHALER ...... RETACRIT INJECTION SOLUTION 10000 RAYOS ...... relexxii ...... UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, RAZADYNE ER ...... relief eye drops ...... 4000 UNIT/ML, 40000 UNIT/ML ...... react ...... RELION TRUE MET AIR GLUC METER ..... RETACRIT INJECTION SOLUTION 20000 ready-to-use enema rectal enema ...... RELION TRUE METRIX TEST STRIPS ...... UNIT/ML ...... REA-LO ...... RELION ULTIMA GLUCOSE SYSTEM ...... RETEVMO ...... REBIF ...... RELION ULTIMA TEST ...... RETIN-A ...... REBIF REBIDOSE ...... RELISTOR ...... RETIN-A MICRO GEL 0.04 %, 0.1 % ...... REBIF REBIDOSE TITRATION PACK ...... RELNATE DHA ...... RETIN-A MICRO PUMP ...... REBIF TITRATION PACK ...... RELPAX ...... RETROVIR ORAL ...... RECARBRIO ...... RELTONE ...... REVATIO INTRAVENOUS ...... RECEDO ...... REMEDIENT ...... REVATIO ORAL ...... reclipsen ...... REMERON ...... REVESTA ...... RECOMBIVAX HB ...... REMERON SOLTAB ...... REVLIMID ...... RECOTHROM...... REMIGEN ...... REXULTI ...... RECOTHROM SPRAY KIT ...... REMODULIN ...... REYATAZ ORAL CAPSULE ...... RECTIV ...... RENAGEL ...... REYATAZ ORAL PACKET ...... RECURA ...... RENAL ...... REYVOW ...... REDITREX ...... RENAL MULTIVITAMIN FORMULA ...... RHOFADE ...... renal-vite ...... RHOGAM ULTRA-FILTERED PLUS ......

238 RHOPHYLAC ...... ROBITUSSIN COUGH+CHEST CONG DM SAIZEN ...... RHOPRESSA ...... ORAL LIQUID 20-400 MG/20ML ...... SAIZENPREP ...... ribavirin inhalation ...... ROBITUSSIN NIGHTTIME COUGH ...... SALAGEN ...... ribavirin oral ...... ROBITUSSIN PEAK COLD MULTI-SYM...... SALEX ...... RID LICE KILLING SHAMPOO ...... ROCALTROL ...... salicylic acid er ...... RIDAURA ...... ROCKLATAN ...... salicylic acid external foam ...... rifabutin ...... ropinirole hcl ...... salicylic acid external gel ...... rifampin oral ...... ropinirole hcl er ...... salicylic acid external shampoo ...... RIFAMPIN+SYRSPEND SF ...... rosadan external cream ...... salicylic acid external solution ...... RILUTEK ...... rosadan external gel ...... salicylic acid wart remover ...... riluzole ...... ROSADAN EXTERNAL KIT ...... salicylic acid-cleanser ...... rimantadine hcl ...... rosuvastatin calcium ...... salimez ...... RINVOQ ...... ROSZET ...... SALIMEZ FORTE ...... RIOMET ...... ROWASA ...... saline enema ...... risacal-d ...... roweepra ...... saline mist spray ...... risanoid plus ...... ROXICODONE ...... saline nasal spray ...... RISAQUAD ...... ROZEREM ...... SALIVAMAX ...... RISAQUAD-2 ...... ROZLYTREK ...... salsalate oral ...... risedronate sodium ...... RUBRACA ...... SALVAX ...... RISPERDAL CONSTA ...... RUCONEST ...... SALVAX DUO PLUS ...... RISPERDAL ORAL SOLUTION ...... rufinamide ...... sam-e.p.a...... RISPERDAL ORAL TABLET ...... RUKOBIA ...... SAMSCA ...... risperidone oral solution ...... RUZURGI ...... SANADERMRX SKIN REPAIR ...... risperidone oral tablet ...... RYBELSUS ...... SANCUSO ...... risperidone oral tablet dispersible ...... RYCLORA ...... SANDIMMUNE ORAL ...... RITALIN ...... RYDAPT ...... SANDOSTATIN ...... RITALIN LA ...... rydex ...... SANTYL ...... ritonavir ...... rymed ...... SAPHRIS ...... RITUXAN ...... rynex dm ...... sapropterin dihydrochloride ...... rivastigmine ...... rynex pe ...... SAVAYSA ...... rivastigmine tartrate ...... rynex pse ...... SAVELLA ...... rivelsa ...... RYTARY ...... SAVELLA TITRATION PACK ...... rizatriptan benzoate ...... RYTHMOL SR ...... sb allergy medicine oral tablet ...... ROAOXIA ...... ryvent ...... sb arthritis pain relief ...... robafen cf multi-symptom cold ...... S sb aspirin oral tablet delayed release ...... ROBITUSSIN 12 HOUR COUGH ...... S2 (RACEPINEPHRINE) ...... sb docusate sodium/senna ...... ROBITUSSIN 12 HOUR COUGH CHILD ..... SABRIL ...... sb lice killing max st ...... ROBITUSSIN CHILD COUGH/COLD LA ...... saccharomyces boulardii ...... sb mucus relief ...... ROBITUSSIN CHILDRENS COUGH LA ...... SAFE-T-LANCE ...... , sb pain reliever childrens ...... ROBITUSSIN COLD+FLU DAYTIME ...... SAFYRAL ...... sb pain reliever ex st ......

239 SCALACORT DK ...... senna-plus ...... sildenafil citrate oral suspension scar external gel ...... senna-s ...... reconstituted ...... SCARCIN ...... senna-tabs ...... sildenafil citrate oral tablet 20 mg ...... SCARSILK EXTERNAL ...... senna-time ...... SILENOR ...... SCARZEN SKIN REPAIR ...... senna-time s ...... SILIPAC ...... SCENESSE ...... sennazon ...... SILIQ ...... scopolamine ...... SENOKOT ...... silodosin ...... SCRUB CARE POVIDONE-IODINE ...... SENOKOT EXTRA STRENGTH...... siltussin sa ...... sea-omega ...... SENOKOT S ...... siltussin-dm alcohol free ...... SEASONIQUE ...... SENSIPAR ...... SILVADENE ...... SECUADO ...... SEREVENT DISKUS ...... silver nitrate external solution 10 %, 25 %, SEGLUROMET ...... SERNIVO ...... 50 % ...... SELECT-OB ORAL TABLET CHEWABLE SEROQUEL ...... silver sulfadiazine external ...... 29-0.6-0.4 MG ...... SEROQUEL XR ...... SIMBRINZA ...... SELECT-OB ORAL TABLET CHEWABLE SEROSTIM ...... simeped ...... 29-1 MG ...... sertraline hcl oral ...... simethicone oral ...... SELECT-OB+DHA ...... se-tan plus ...... simethicone ultra strength ...... selegiline hcl oral ...... setlakin ...... simliya ...... selenium sulfide external lotion ...... sevelamer carbonate ...... simpesse ...... selenium sulfide external shampoo 2.25 %... sevelamer hcl ...... SIMPLY SLEEP ...... selenium sulfide external shampoo 2.3 %..... severe allergy ...... SIMPONI ...... SELRX ...... severe cold/cough ...... simvastatin oral ...... SELZENTRY ...... severe cold/cough daytime ...... SINEMET ...... SEMGLEE ...... severe cold/cough/flu ...... SINGULAIR ...... SE-NATAL 19 ...... severe cold/flu daytime ...... sinus 12 hour ...... senexon-s ...... SEYSARA ...... sinus congestion max strength ...... senior probiotic ...... sf sinus nasal spray ...... senior tonic ...... sf 5000 plus ...... sinus pe decongestant ...... senna lax ...... SFROWASA ...... sinus relief ext st ...... senna laxative ...... sharobel ...... sinus relief extra strength ...... senna oral capsule ...... SHINGRIX ...... sinus/congestion relief pe ...... senna oral liquid ...... SHUR-SEAL CONTRACEPTIVE ...... sirolimus oral solution ...... senna oral syrup ...... SIGNIFOR ...... sirolimus oral tablet 0.5 mg, 1 mg ...... senna oral tablet ...... SIKLOS ...... sirolimus oral tablet 2 mg ...... senna plus oral tablet ...... SILA III ...... SIRTURO ...... senna s ...... silace oral liquid ...... SITAVIG ...... senna smooth ...... silace oral syrup ...... SIVEXTRO ORAL ...... senna-docusate sodium ...... siladryl allergy ...... skarjel ...... senna-extra ...... sildenafil citrate intravenous ...... SKELAXIN ...... senna-lax ...... SKYADERM-LP ......

240 SKYRIZI ...... sodium chloride inhalation nebulization SOOLANTRA ...... SKYRIZI (150 MG DOSE) ...... solution 7 % ...... soothe maximum strength ...... SKYRIZI PEN ...... sodium chloride ophthalmic ointment 5 % .... soothe oral suspension ...... sleep aid (diphenhydramine) ...... sodium chloride ophthalmic solution 5 % ...... soothe oral tablet ...... sleep aid max st ...... sodium chloride oral solution 4 meq/ml ...... soothe oral tablet chewable ...... sleep aid nighttime oral capsule 25 mg ...... sodium chloride oral tablet 1 gm ...... SOOTHEE ...... sleep aid nighttime oral capsule 50 mg ...... sodium fluoride 5000 enamel ...... soothing bath treatment external packet ...... sleep aid nighttime oral tablet 25 mg ...... sodium fluoride 5000 plus ...... SORBIDON HYDRATE ...... sleep aid oral capsule 50 mg ...... sodium fluoride 5000 ppm dental cream ...... sorbitol oral ...... sleep aid oral tablet 25 mg ...... sodium fluoride 5000 ppm dental paste ...... sore throat mouth/throat lozenge 6-10 mg .... sleep ii ...... sodium fluoride 5000 sensitive ...... SORIATANE ...... sleep tabs ...... sodium fluoride dental cream ...... SORILUX ...... sleepaid (diphenhydramine) ...... sodium fluoride dental gel ...... sotalol hcl (af) ...... sleep-aid max st ...... sodium fluoride mouth/throat ...... sotalol hcl oral ...... sleep-aid nighttime oral capsule 25 mg ...... sodium fluoride oral solution 1.1 (0.5 f) SOTYLIZE ...... sleep-aid nighttime oral capsule 50 mg ...... mg/ml ...... SOVALDI ORAL PACKET ...... sleep-aid oral capsule 25 mg ...... sodium fluoride oral tablet 1.1 (0.5 f) mg ...... SOVALDI ORAL TABLET 200 MG ...... sleep-aid oral capsule 50 mg ...... sodium fluoride oral tablet 2.2 (1 f) mg ...... SOVALDI ORAL TABLET 400 MG ...... sleeptime oral capsule ...... sodium fluoride oral tablet chewable ...... soya lecithin ...... SLO-NIACIN ...... SODIUM IODIDE I-131 ...... spectravite adult 50+ oral tablet chewable .... SLOW FE ...... sodium phenylbutyrate oral ...... spectravite women ...... slow release iron oral tablet extended sodium polystyrene sulfonate ...... SPEEDGEL RX ...... release 143 (45 fe) mg ...... sodium sulfacetamide ...... spinosad ...... SLOW-MAG ...... sodium sulfacetamide wash ...... SPIRIVA HANDIHALER ...... SLOWMAG MG MUSCLE/HEART ...... SODIUM SULFACETAMIDE-BAKUCHIOL .. SPIRIVA RESPIMAT ...... SLYND ...... SOFOSBUVIR-VELPATASVIR ...... spironolactone oral ...... smooth antacid ex st oral tablet chewable soft glucose ...... spironolactone-hctz ...... 750 mg ...... SOLARAVIX ...... SPORANOX ...... smooth antacid extra st ...... SOLARTEK GLUCOSE CONTROL...... SPORANOX PULSEPAK ...... smooth lax oral powder ...... solifenacin succinate ...... SPRAVATO (56 MG DOSE) ...... sod citrate-citric acid ...... SOLIQUA ...... SPRAVATO (84 MG DOSE) ...... SODIUM BICARBONATE ORAL POWDER . SOLODYN ...... sprintec 28 ...... sodium bicarbonate oral tablet ...... SOLOSEC ...... SPRITAM ...... sodium chloride (hypertonic) ophthalmic SOLTAMOX ...... SPRIX ...... ointment ...... soluble fiber therapy ...... SPRYCEL ...... sodium chloride (hypertonic) ophthalmic SOLUTION TRANSFER DEVICE ...... sps ...... solution ...... soluvita e ...... sronyx ...... sodium chloride inhalation nebulization SOLVIL ...... ssd ...... solution 0.9 %, 10 %, 3 % ...... SOMA ...... SSKI ...... SOMAVERT ...... sss 10-5 external cream ......

241 sss 10-5 external foam ...... STRATA CTX ...... SULCONAZOLE NITRATE EXTERNAL ST JOSEPH LOW DOSE ...... STRATA MARK ...... CREAM ...... STALEVO 100 ...... STRATA TRIZ ...... sulfacetamide sodium (acne) ...... STALEVO 125 ...... STRATA XRT ...... sulfacetamide sodium external ...... STALEVO 150 ...... STRATTERA ...... sulfacetamide sodium ophthalmic ointment ... STALEVO 200 ...... STRENSIQ ...... sulfacetamide sodium ophthalmic solution .... STALEVO 50 ...... stress formula ...... sulfacetamide sodium-sulfur external cream STALEVO 75 ...... stress formula/iron ...... 10-2 % ...... stavudine ...... stress formula/zinc ...... sulfacetamide sodium-sulfur external cream STEGLATRO ...... STRIBILD ...... 10-5 % ...... STEGLUJAN ...... STRIVERDI RESPIMAT ...... sulfacetamide sodium-sulfur external cream STELARA SUBCUTANEOUS ...... STROMECTOL ...... 9.8-4.8 % ...... STIMATE ...... STROVITE FORTE ORAL SYRUP ...... sulfacetamide sodium-sulfur external stimulant laxative oral tablet 8.6-50 mg...... STROVITE FORTE ORAL TABLET ...... emulsion ...... STIOLTO RESPIMAT ...... STROVITE ONE ...... sulfacetamide sodium-sulfur external liquid STIVARGA ...... STUART ONE ...... 10-2 % ...... stomach relief extra strength ...... SUBOXONE ...... sulfacetamide sodium-sulfur external liquid stomach relief max st oral suspension 525 SUBSYS ...... 9.8-4.8 % ...... mg/15ml ...... subvenite ...... sulfacetamide sodium-sulfur external liquid stomach relief max strength ...... subvenite starter kit-blue ...... 9-4.5 % ...... stomach relief oral suspension 1050 subvenite starter kit-green ...... sulfacetamide sodium-sulfur external lotion mg/30ml, 525 mg/15ml ...... subvenite starter kit-orange ...... 10-5 % ...... stomach relief oral suspension 262 mg/15ml, SUCCINYLCHOLINE CHLORIDE sulfacetamide sodium-sulfur external lotion 525 mg/30ml, 527 mg/30ml ...... INTRAVENOUS SOLUTION PREFILLED 9.8-4.8 % ...... stomach relief oral tablet 262 mg ...... SYRINGE 140 MG/7ML ...... sulfacetamide sodium-sulfur external pad ..... stomach relief oral tablet chewable 262 mg .. SUCRAID ...... sulfacetamide sodium-sulfur external stomach relief plus ...... sucralfate oral suspension ...... suspension 10-5 % ...... stomach relief ultra ...... sucralfate oral tablet ...... sulfacetamide sodium-sulfur external stool softener laxative oral capsule ...... SUDAFED ...... suspension 8-4 % ...... stool softener oral capsule 100 mg ...... SUDAFED CHILDRENS ...... sulfacetamide sodium-sulfur liquid 9-4 % stool softener oral capsule 240 mg ...... SUDAFED CONGESTION ...... external ...... stool softener oral capsule 250 mg ...... SUDAFED PE CONGESTION ORAL sulfacetamide sod-sulfur wash external stool softener oral capsule 50 mg ...... TABLET 10 MG ...... liquid 9-4 % ...... stool softener oral tablet 100 mg ...... SUDAFED PE SINUS CONGESTION ...... sulfacetamide sod-sulfur wash external stool softener oral tablet 8.6-50 mg...... SUDAFED SINUS CONGESTION ...... liquid 9-4.5 % ...... stool softener pls laxative ...... SUDAFED SINUS CONGESTION 12HR ..... sulfacetamide-prednisolone ophthalmic stool softener plus laxative ...... sudogest 12 hour ...... solution ...... stool softener/laxative ...... sudogest maximum strength ...... sulfacetamide-sulfur in urea ...... stool softener/stimulant ...... sudogest oral tablet 30 mg ...... SULFACLEANSE 8/4 ...... stop lice complete treatment ...... SULAR ...... sulfadiazine oral ......

242 sulfamethoxazole-trimethoprim oral ...... surelac ...... SYSTANE ICAPS AREDS2 ORAL TABLET sulfamez wash ...... SUSTIVA ...... CHEWABLE...... SULFAMYLON EXTERNAL CREAM ...... SUTAB ...... SYSTANE NIGHTTIME ...... SULFAMYLON EXTERNAL PACKET ...... SUTENT ...... SYSTANE OVERNIGHT THERAPY ...... sulfasalazine oral ...... syeda ...... SYSTANE PRESERVATIVE FREE ...... sulfatrim pediatric ...... SYMAX DUOTAB ...... SYSTANE ULTRA ...... SULFURATED LIME ...... SYMAX-SL ...... SYSTANE ULTRA PF ...... sulindac oral ...... SYMAX-SR ...... T SUMADAN WASH ...... SYMBICORT ...... tab tussin ...... SUMADAN XLT ...... SYMBYAX ORAL CAPSULE 3-25 MG ...... tab-a-vite ...... SUMANSETRON ...... SYMBYAX ORAL CAPSULE 6-25 MG ...... tab-a-vite/beta carotene ...... sumatriptan nasal ...... SYMDEKO ...... tab-a-vite/iron ...... sumatriptan succinate oral ...... SYMFI ...... TABLOID ...... sumatriptan succinate refill...... SYMFI LO ...... TABRADOL FUSEPAQ ...... sumatriptan succinate subcutaneous ...... SYMJEPI ...... TABRADOL RAPIDPAQ ...... sumatriptan-naproxen sodium...... SYMLINPEN 120 ...... TABRECTA ...... SUMAXIN ...... SYMLINPEN 60 ...... TACLONEX ...... SUMAXIN CP ...... SYMPAZAN ...... tacrolimus external ...... SUMAXIN WASH ...... SYMPROIC ...... tacrolimus oral capsule 0.5 mg, 5 mg ...... SUNOSI ...... SYMTUZA ...... tacrolimus oral capsule 1 mg ...... super b complex/c ...... SYNAGIS ...... tadalafil (pah) ...... super b complex/vitamin c ...... SYNALAR ...... tadalafil oral tablet 5 mg ...... super b/c ...... SYNALAR (CREAM) ...... TAFINLAR ...... SUPER B-50 B COMPLEX ...... SYNALAR (OINTMENT) ...... TAGRISSO ...... SUPERVITE ...... SYNALAR TS ...... take action ...... suphedrine maximum strength ...... SYNAPRYN FUSEPAQ ...... TAKHZYRO ...... suphedrine oral tablet 30 mg ...... SYNAREL ...... TALICIA ...... suphedrine oral tablet extended release 12 SYNDROS ...... TALIVA ...... hour 120 mg ...... SYNERA ...... TALTZ ...... SUPRAX ORAL CAPSULE ...... SYNJARDY ...... TALZENNA ...... SUPRAX ORAL SUSPENSION SYNJARDY XR ...... TAMIFLU ...... RECONSTITUTED 100 MG/5ML, 200 SYNRIBO ...... tamoxifen citrate oral ...... MG/5ML ...... SYNTHROID ...... tamsulosin hcl ...... SUPRAX ORAL SUSPENSION SYPRINE ...... TAPAZOLE ...... RECONSTITUTED 500 MG/5ML ...... SYRINGE AVITENE ...... TAPERDEX 12-DAY ...... SUPRAX ORAL TABLET CHEWABLE ...... SYSTANE ...... TAPERDEX 6-DAY ...... SUPREP BOWEL PREP KIT ...... SYSTANE COMPLETE ...... TAPERDEX 7-DAY ...... sure result dss premium pack ...... SYSTANE CONTACTS ...... TARCEVA ...... SURE RESULT O3D3 SYSTEM ...... SYSTANE HYDRATION PF ...... TARDEOXIA ...... sure result sr relief...... TARDIMAXIA ......

243 TARGADOX ...... temozolomide ...... TETRIX ...... TARGRETIN ...... TENCON ...... TEXACORT ...... tarina 24 fe ...... TENIVAC ...... THALOMID ...... tarina fe 1/20 ...... tenofovir disoproxil fumarate ...... the magic bullet ...... tarina fe 1/20 eq ...... TENORETIC 100 ...... THE TREATMENT FORMULA 3 TARKA ...... TENORETIC 50 ...... EXTERNAL SOLUTION 1 % ...... TARON-PREX ...... TENORMIN ...... THEO-24 ...... TAROXIA ...... tension headache ...... theophylline ...... TASIGNA ...... TEPMETKO ...... theophylline er ...... TASMAR ...... terazosin hcl ...... thera ...... TASOPROL ...... terbinafine hcl external ...... THERAFLU EXPRESSMAX ...... taurine oral ...... terbinafine hcl oral ...... THERAFLU EXPRESSMAX SEV CLD/CG tavaborole ...... terbinafine hydrochloride external cream 1 % ORAL TABLET 10-5-325 MG ...... TAVALISSE ...... THERAFLU POWERPODS SEVERE COLD TAYTULLA ...... terbutaline sulfate oral ...... ORAL 20-10-650 MG ...... tazarotene external cream ...... terconazole ...... THERAFLU SEVERE COLD ...... TAZAROTENE EXTERNAL FOAM ...... TERIPARATIDE (RECOMBINANT) ...... THERAFLU SEVERE COLD DAYTIME ...... TAZORAC ...... TESSALON PERLES ...... THERAFLU SEVERE COLD/CGH DAY ...... taztia xt ...... TESTIM ...... therapeutic dandruff external shampoo 1 % .. TAZVERIK ...... TESTONE CIK ...... THERASEAL HAND PROTECTION ...... TDVAX ...... TESTOSTERONE CYPIONATE INJECTION thera-tabs ...... TEARS AGAIN ...... testosterone cypionate intramuscular THERATEARS NUTRITION ...... TEARS AGAIN ADVANCED EYELID solution 100 mg/ml ...... thiamine hcl oral ...... OPHTHALMIC ...... testosterone cypionate solution 200 mg/ml thiamine mononitrate oral ...... tears pure ...... intramuscular ...... , THIOLA ...... TECFIDERA ...... testosterone enanthate intramuscular ...... THIOLA EC ...... TEGRETOL ...... testosterone transdermal gel 1.62 %, 20.25 thioridazine hcl oral ...... TEGRETOL-XR ...... mg/act (1.62%) ...... thiothixene ...... TEGSEDI ...... testosterone transdermal gel 10 mg/act (2%) THRIVE ...... TEKTURNA ...... testosterone transdermal gel 12.5 mg/act THRIVITE 19 ...... TEKTURNA HCT ...... (1%) ...... THRIVITE RX ...... telmisartan ...... testosterone transdermal gel 20.25 THROMBI-GEL 10 ...... telmisartan-amlodipine ...... mg/1.25gm (1.62%), 40.5 mg/2.5gm THROMBI-GEL 100 ...... telmisartan-hctz ...... (1.62%) ...... THROMBI-GEL 40 ...... temazepam oral capsule 15 mg, 30 mg ...... testosterone transdermal gel 25 mg/2.5gm THROMBI-PAD ...... temazepam oral capsule 22.5 mg ...... (1%), 50 mg/5gm (1%) ...... THROMBOGEN ...... temazepam oral capsule 7.5 mg ...... testosterone transdermal solution ...... THYQUIDITY ...... TEMIXYS ...... TETANUS-DIPHTHERIA TOXOIDS TD ...... tiadylt er ...... TEMODAR ORAL ...... tetrabenazine ...... tiagabine hcl ...... TEMOVATE ...... tetracycline hcl oral ...... TIAZAC ......

244 TIBSOVO ...... TOBRADEX ST ...... TOVET EXTERNAL KIT ...... TIGLUTIK ...... tobramycin inhalation nebulization solution TOVIAZ ...... TIKOSYN ...... 300 mg/4ml ...... TRACLEER ...... tilia fe ...... tobramycin nebulization solution 300 mg/5ml TRADJENTA ...... timolol maleate ocudose ...... inhalation...... tramadol hcl er (biphasic) ...... timolol maleate ophthalmic gel forming TOBRAMYCIN NEBULIZATION SOLUTION TRAMADOL HCL ER ORAL CAPSULE solution ...... 300 MG/5ML INHALATION ...... EXTENDED RELEASE 24 HOUR ...... timolol maleate ophthalmic solution 0.25 %, tobramycin ophthalmic ...... tramadol hcl er oral tablet extended release 0.5 % ...... tobramycin-dexamethasone ...... 24 hour ...... timolol maleate ophthalmic solution 0.5 % TOBREX OPHTHALMIC OINTMENT ...... tramadol hcl ir ...... (daily) ...... TOBREX OPHTHALMIC SOLUTION ...... tramadol-acetaminophen ...... timolol maleate oral ...... tolbutamide ...... trandolapril ...... timolol maleate pf ...... tolcapone ...... trandolapril-verapamil hcl er ...... TIMOLOL-BRIMON-DORZOL-LATANOPR .. tolmetin sodium ...... tranexamic acid oral ...... TIMOLOL-BRIMONIDINE-DORZOLAMID .... tolnaftate antifungal ...... TRANSDERM SCOP (1.5 MG) ...... TIMOLOL-DORZOLAMID-LATANOPROST . tolnaftate external cream ...... TRANSDERM-SCOP (1.5 MG) ...... TIMOPTIC ...... tolnaftate external powder ...... TRANXENE-T ...... TIMOPTIC OCUDOSE ...... TOLSURA ...... tranylcypromine sulfate ...... TIMOPTIC-XE ...... tolterodine tartrate ...... TRANZGEL ...... TINACTIN EXTERNAL AEROSOL ...... tolterodine tartrate er ...... TRAUMEEL EXTERNAL ...... TINACTIN EXTERNAL CREAM ...... TOLVAPTAN ORAL TABLET 15 MG ...... TRAUMEEL ORAL ...... tinaspore ...... tolvaptan oral tablet 30 mg ...... TRAVATAN Z ...... tinidazole oral tablet 250 mg ...... TOPAMAX ...... travel ease ...... tinidazole oral tablet 500 mg ...... TOPAMAX SPRINKLE ...... travoprost (bak free) ...... tioconazole 1 vaginal ointment 6.5 % ...... TOPICORT ...... TRAZIMERA INTRAVENOUS SOLUTION tioconazole-1 ...... TOPICORT SPRAY ...... RECONSTITUTED 150 MG ...... tiopronin oral ...... topiramate er ...... trazodone hcl oral ...... TIROSINT ...... topiramate oral capsule sprinkle ...... TRECATOR ...... TIROSINT-SOL ...... topiramate oral tablet ...... TRELEGY ELLIPTA ...... TITRALAC ...... TOPROL XL ...... TREMFYA ...... TIVICAY ...... toremifene citrate ...... treprostinil ...... TIVICAY PD ...... torsemide ...... TRESIBA ...... TIVORBEX ...... TOSYMRA ...... TRESIBA FLEXTOUCH ...... tizanidine hcl oral capsule 2 mg ...... total allergy ...... tretinoin external ...... tizanidine hcl oral capsule 4 mg, 6 mg ...... total allergy medicine ...... tretinoin microsphere ...... tizanidine hcl oral tablet ...... totalday multiple ...... tretinoin microsphere pump ...... tl-hem 150 ...... TOTECT ...... tretinoin oral ...... TOBI NEBULIZER ...... TOUJEO MAX SOLOSTAR ...... TREXALL ...... TOBI PODHALER ...... TOUJEO SOLOSTAR ...... TREXIMET ...... TOBRADEX ...... tovet external foam ...... TREZIX ......

245 tri femynor ...... tri-linyah ...... TRI-VI-FLOR ORAL SUSPENSION 0.5 triamcinolone acetonide external aerosol TRILIPIX ...... MG/ML ...... solution ...... TRILOCICLO ...... TRI-VI-FLORO ORAL SUSPENSION 0.25 triamcinolone acetonide external cream ...... tri-lo-estarylla ...... MG/ML ...... triamcinolone acetonide external lotion 0.025 tri-lo-marzia ...... TRI-VI-FLORO ORAL SUSPENSION 0.5 % ...... tri-lo-mili ...... MG/ML ...... triamcinolone acetonide external lotion 0.1 tri-lo-sprintec ...... tri-vite pediatric ...... % ...... TRI-LUMA ...... tri-vite/fluoride oral solution 0.25 mg/ml ...... triamcinolone acetonide external ointment trimethobenzamide hcl oral ...... tri-vite/fluoride oral solution 0.5 mg/ml ...... 0.025 %, 0.1 %, 0.5 % ...... trimethoprim oral ...... TRIVIX ...... triamcinolone acetonide external ointment tri-mili ...... trivora (28) ...... 0.05 % ...... trimipramine maleate oral ...... tri-vylibra ...... triamcinolone acetonide mouth/throat ...... TRIMO-SAN VAGINAL GEL 0.025-0.01 % .. tri-vylibra lo ...... TRIAMINIC ALLERCHEWS ...... TRINATE ...... TRIZIVIR ...... triamterene oral ...... TRINTELLIX ...... TROKENDI XR ...... triamterene-hctz ...... tri-nymyo ...... TROMBONEX ...... TRIANEX ...... triple antibiotic ...... TROMBONEX-D ...... triazolam ...... triple antibiotic max st ...... TROPICAMIDE-CYCLOPENTOLATE-PE ..... TRIBENZOR ...... triple antibiotic original ...... trospium chloride ...... tri-buffered aspirin ...... triple antibiotic plus ...... trospium chloride er ...... TRICARE PRENATAL DHA ONE ...... triple antibiotic plus max st ...... TRUE FOCUS BLOOD GLUCOSE STRIP.... TRI-CHLOR ...... triple antibiotic/pain ...... TRUE METRIX AIR GLUCOSE METER TRICITRASOL ...... triple antibiotic+pain relief ...... DEVICE ...... tricitrates ...... TRIPLE COMPLEX FORMULA 3 KIT ...... TRUE METRIX AIR GLUCOSE METER KIT TRICON ...... TRIPLE PMB ...... TRUE METRIX GO GLUCOSE METER ...... TRICOR ...... TRIPLE PMK ...... TRUE METRIX METER KIT ...... triderm ...... tri-previfem ...... TRUECONTROL GLUCOSE CONT LEV 0 ... TRIDESILON ...... triprolidine hcl oral liquid 0.313 mg/ml ...... TRUECONTROL GLUCOSE CONT LEV 1 ... trientine hcl ...... triprolidine hcl oral liquid 0.625 mg/ml ...... TRUEPLUS GLUCOSE ORAL GEL ...... tri-estarylla ...... triprolidine hcl oral liquid 0.938 mg/ml ...... TRUEPLUS LANCETS 30G ...... , trifluoperazine hcl ...... triprolidine hcl oral liquid 2.5 mg/5ml ...... TRUEPLUS SAFETY LANCETS 28G ...... , trifluridine ...... TRIPTODUR ...... TRUETRACK BLOOD GLUCOSE ...... trihexyphenidyl hcl ...... tri-sprintec ...... TRUETRACK TEST ...... TRIJARDY XR ...... TRISTART DHA ...... TRULANCE ...... TRIKAFTA ORAL TABLET THERAPY TRISTART FREE ...... TRULICITY ...... PACK 100-50-75 & 150 MG ...... TRISTART ONE ...... TRUMENBA ...... TRIKAFTA TABLET THERAPY PACK 50- tritocin ...... TRUSELTIQ (100MG DAILY DOSE) ...... 25-37.5 & 75 MG ORAL ...... TRIUMEQ ...... TRUSELTIQ (125MG DAILY DOSE) ...... tri-legest fe ...... TRI-VI-FLOR ORAL SUSPENSION 0.25 TRUSELTIQ (50MG DAILY DOSE) ...... TRILEPTAL ...... MG/ML ...... TRUSELTIQ (75MG DAILY DOSE) ......

246 TRUSOPT ...... tussin dm max adult ...... UKONIQ ...... TRUVADA ...... tussin dm max daytime ...... ULORIC ...... trymine cg ...... tussin dm max st ...... ULTIMA ...... TUBING/WING TIP ...... tussin dm oral syrup 100-10 mg/5ml ...... ultra dairy digestive ...... TUDORZA PRESSAIR...... tussin maximum strength oral syrup 15 ultra energy ...... TUKYSA ...... mg/5ml ...... ultra fresh ...... tulana ...... tussin mucus+chest congestion oral syrup ... ultra fresh pm ...... TUMS ...... tussin multi-symptom cold cf ...... ULTRA HERS RX ...... TUMS CHEWY BITES ...... tussin oral syrup 100 mg/5ml ...... ULTRA HIS ...... TUMS E-X 750 ...... TUXARIN ER ...... ultra lubricant drop ...... TUMS EXTRA STRENGTH 750 ...... TUZISTRA XR ...... ultra lubricating eye drops ...... TUMS LASTING EFFECTS ...... TWINRIX ...... ULTRA PCOS ...... TUMS SMOOTHIES ...... TWIRLA ...... ULTRACET ...... TUMS ULTRA 1000 ...... TWYNSTA ...... ULTRAFOAM SPONGE 2X6.25X7CM ...... TURALIO ...... tyblume ...... ULTRAFOAM SPONGE 8X12.5X1CM ...... TURPENTINE EXTERNAL ...... TYBOST ...... ULTRAFOAM SPONGE 8X12.5X3CM ...... TUSNEL C ...... tydemy ...... ULTRAFOAM SPONGE 8X25X1CM ...... TUSSICAPS ...... TYKERB ...... ULTRAFOAM SPONGE 8X6.25X1CM ...... tussin adult dm oral liquid 10-200 mg/5ml ..... TYLACTIN COMPLETE 15 PE ...... ULTRAM ...... tussin adult multi-symptom...... TYLENOL COLD MAX ...... ultra-mega ...... tussin cf cough & cold oral liquid 5-10-100 TYLENOL EXTRA STRENGTH TABLET ULTRASAL-ER ...... mg/5ml ...... 500 MG ORAL 500 MG ...... , ULTRAVATE ...... tussin cf cough & cold oral syrup 5-10-100 TYLENOL ORAL SUSPENSION 160 UMECTA MOUSSE ...... mg/5ml ...... MG/5ML ...... UNISTRIP CONTROL ...... tussin cf multi-symptom cold ...... TYLENOL ORAL TABLET 325 MG ...... UNISTRIP1 GENERIC ...... tussin cf oral liquid 30-10-100 mg/5ml ...... TYLENOL ORAL TABLET CHEWABLE 160 unithroid ...... tussin chest congestion oral syrup 100 MG ...... UPNEEQ ...... mg/5ml ...... TYLENOL ORAL TABLET EXTENDED UPTRAVI ...... tussin cough dm sugar free ...... RELEASE 650 MG ...... URAMAXIN ...... tussin cough long acting ...... TYMLOS ...... urea 20 intensive hydrating ...... tussin cough long-acting ...... TYR EASY ...... urea external cream 39 % ...... tussin cough oral syrup ...... tyrosine ...... urea external cream 40 % ...... tussin cough/chest congest oral syrup 100- TYVASO ...... urea external cream 41 % ...... 10 mg/5ml ...... TYVASO REFILL ...... urea external cream 45 % ...... tussin cough/chest dm max oral liquid 10- TYVASO STARTER ...... urea external cream 47 % ...... 200 mg/5ml ...... U UREA EXTERNAL FOAM ...... tussin dm cough/chest cong ...... UBRELVY ...... urea external lotion ...... tussin dm cough/chest oral syrup 10-100 UCERIS ...... urea hydrating ...... mg/5ml ...... UDAMIN SP ...... urea nail ...... tussin dm max ...... UDENYCA ...... ureacin-10 ......

247 ureacin-20 ...... VALTOCO 20 MG DOSE ...... vegetable lax+stool softener ...... uredeb ...... VALTOCO 5 MG DOSE ...... velivet ...... URELLE ...... VALTREX ...... VELPHORO ...... UREMEZ-40 ...... VANADOM ...... VELTASSA ...... URESOL ...... VANCOCIN ...... VELTIN ...... URIMAR-T ORAL TABLET 120 MG ...... VANCOCIN HCL ...... VEMLIDY ...... urin ds ...... vancomycin hcl in nacl intravenous solution venaliv ...... urinary pain relief oral tablet 95 mg ...... 1-0.9 gm/200ml-% ...... VENCLEXTA ...... URO-458 ...... vancomycin hcl oral capsule ...... VENCLEXTA STARTING PACK ...... UROCIT-K 10 ...... vancomycin hcl oral solution reconstituted ... VENEXA ...... UROCIT-K 15 ...... VANCOMYCIN+SYRSPEND SF ...... VENEXA FE ...... UROCIT-K 5 ...... vandazole ...... VENIPUNCTURE PX1 PHLEBOTOMY...... UROGESIC-BLUE ...... VANICREAM EXTERNAL OINTMENT ...... venlafaxine hcl ...... uro-mp ...... VANOS ...... venlafaxine hcl er ...... urosex ...... VANOXIDE-HC ...... VENTAVIS INHALATION SOLUTION 10 UROXATRAL ...... VAPORIZER WARM STEAM ...... MCG/ML ...... URSO 250 ...... VAQTA ...... VENTAVIS INHALATION SOLUTION 20 URSO FORTE ...... VARDIMAXIA ...... MCG/ML ...... ursodiol oral capsule ...... VARIVAX ...... VENTOLIN HFA ...... ursodiol oral tablet ...... VAROPHEN ...... verapamil hcl er oral capsule extended USTELL ...... VAROXIA ...... release 24 hour 100 mg, 200 mg, 300 mg . UTIRA-C ...... VARUBI (180 MG DOSE) ...... verapamil hcl er oral capsule extended UTOPIC ...... VASCEPA ...... release 24 hour 120 mg, 180 mg, 240 mg, V VASCULERA ...... 360 mg ...... VAGIFEM ...... VASERETIC ...... verapamil hcl er oral tablet extended release valacyclovir hcl oral ...... VASOCLEAR-A ...... verapamil hcl oral ...... VALCHLOR ...... VASOFLEX D1 ...... VERDESO ...... VALCYTE ORAL SOLUTION vasoflex forte ...... VEREGEN ...... RECONSTITUTED ...... vasoflex hd ...... VERELAN ...... VALCYTE ORAL TABLET ...... VASOFLEX ORAL CAPSULE ...... VERELAN PM ...... valganciclovir hcl oral solution reconstituted . vasoflex oral tablet ...... VERQUVO ...... valganciclovir hcl oral tablet ...... VASOTEC ...... VERSACLOZ ...... VALINE 1000 ...... v-c forte ...... VERZENIO ...... valine oral ...... VCF VAGINAL CONTRACEPTIVE VESICARE ...... VALIUM ...... VAGINAL FILM ...... VESICARE LS ...... valproic acid oral ...... VCF VAGINAL CONTRACEPTIVE vestura ...... valsartan ...... VAGINAL FOAM ...... VEXATROL ...... valsartan-hydrochlorothiazide ...... vcf vaginal contraceptive vaginal gel ...... VFEND ORAL SUSPENSION VALTOCO 10 MG DOSE ...... VECAMYL ...... RECONSTITUTED ...... VALTOCO 15 MG DOSE ...... VECTICAL ...... VFEND ORAL TABLET ......

248 VIBERZI ...... virt-caps ...... vitamin b-1 oral tablet 100 mg, 250 mg ...... VIBRAMYCIN ORAL CAPSULE ...... VIRT-FEFA PLUS ...... vitamin b-12 er oral tablet extended release VIBRAMYCIN ORAL SUSPENSION virt-gard ...... 1000 mcg ...... RECONSTITUTED ...... virt-nate dha ...... vitamin b-12 oral liquid 1000 mcg/ml ...... VIBRAMYCIN ORAL SYRUP ...... virt-phos 250 neutral ...... vitamin b-12 oral tablet 100 mcg, 1000 mcg, vic-forte ...... virt-pn dha ...... 250 mcg, 500 mcg ...... VICTOZA ...... virt-pn plus ...... vitamin b12 oral tablet 1000 mcg ...... VIEKIRA PAK ...... virtussin a/c ...... vitamin b12 oral tablet extended release vienva ...... virtussin ac w/alc ...... 1000 mcg ...... vigabatrin ...... virtussin dac ...... vitamin b12 oral tablet extended release vigadrone ...... VISBIOME HIGH POTENCY ORAL 2000 mcg ...... VIGAMOX ...... CAPSULE ...... vitamin b-12 oral tablet extended release VIIBRYD ...... VISINE ...... 2000 mcg ...... VIIBRYD STARTER PACK ...... VISINE ADVANCED RELIEF ...... vitamin b12 sublingual liquid 3000 mcg/ml .... VILAMIT MB ...... VISIONBLUE ...... vitamin b-12 sublingual tablet sublingual VILEVEV MB ...... VISTA GEL DRY EYE RELIEF ...... 2500 mcg, 5000 mcg ...... VIMOVO ...... VISTA MEIBO TEARS ...... vitamin b-12 tr oral tablet extended release VIMPAT ORAL SOLUTION ...... VISTA TEARS ...... 1000 mcg ...... VIMPAT ORAL TABLET ...... VISTARIL ...... vitamin b-2 oral tablet 100 mg, 25 mg ...... VINATE DHA RF ...... VISTOGARD ...... vitamin b-6 ...... VINATE II ...... vit c/rose hips ...... vitamin b-6 er ...... VINATE ONE ...... vita s forte ...... vitamin c cr oral tablet extended release ...... VIOKACE ...... vitacel ...... vitamin c cr oral tablet extended release 500 viorele ...... vitachew multiple vitamin ...... mg ...... VIOS AEROSOL DELIVERY SYSTEM...... VITAFOL FE+ ...... vitamin c drops mouth/throat lozenge 60 mg . VIOS LC PLUS ...... VITAFOL GUMMIES ...... vitamin c er oral capsule extended release ... VIOS LC PLUS DELUXE ...... VITAFOL STRIPS ...... vitamin c er oral tablet extended release VIOS LC PLUS PEDIATRIC ...... VITAFOL ULTRA ...... 1500 mg ...... VIOS LC SPRINT ...... VITAFOL-NANO ...... vitamin c oral liquid 500 mg/5ml ...... VIOS LC SPRINT PEDIATRIC...... VITAFOL-OB ...... vitamin c oral tablet 1000 mg, 250 mg ...... VIRACEPT ...... VITAFOL-OB+DHA ...... vitamin c oral tablet 500 mg ...... VIRAMUNE ...... VITAFOL-ONE ...... vitamin c oral tablet chewable 100 mg, 250 VIRAMUNE XR ...... VITAL-D RX ...... mg ...... VIRASAL ...... VITAMEDMD ONE RX/QUATREFOLIC ...... vitamin c oral tablet chewable 500 mg ...... VIRAZOLE ...... VITAMEDMD REDICHEW RX ...... vitamin c/acerola ...... VIREAD ORAL POWDER ...... VITAMEZ ...... vitamin c/bioflavonoids ...... VIREAD ORAL TABLET 150 MG, 200 MG ... VITAMIN A FISH ...... vitamin c/rose hips oral tablet 1000 mg ...... VIREAD ORAL TABLET 250 MG ...... vitamin a oral capsule 2400 mcg (8000 ut), 3 vitamin c/rose hips oral tablet 500 mg ...... VIREAD ORAL TABLET 300 MG ...... mg (10000 ut) ...... vitamin c-rose hips oral tablet ...... virt-c dha ...... vitamin b complex-c ......

249 vitamin d (cholecalciferol) oral tablet 10 mcg VITAPEARL ...... VYVANSE ORAL TABLET CHEWABLE ...... (400 unit) ...... VITAROCA PLUS ...... VYZULTA ...... vitamin d (cholecalciferol) oral tablet 25 mcg VITA-RX DIABETIC VITAMIN...... W (1000 ut) ...... VITASURE ...... WAKIX ...... vitamin d (ergocalciferol) oral capsule 1.25 VITATHELY WITH GINGER ...... warfarin sodium oral tablet 1 mg, 10 mg, 2 mg (50000 ut) ...... VITATRUE ...... mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg ...... vitamin d oral capsule 25 mcg (1000 ut) ...... VITRAKVI ...... warfarin sodium oral tablet 6 mg ...... vitamin d oral liquid ...... VITRANOL FE ...... wart remover external liquid 17 % ...... vitamin d oral tablet 25 mcg (1000 ut) ...... VITREXYL ...... wart remover maximum strength external vitamin d oral tablet 50 mcg (2000 ut) ...... VITREXYL + IRON ...... liquid ...... vitamin d oral tablet chewable 10 mcg (400 VIVA DHA ...... water tabs ...... unit) ...... VIVELLE-DOT ...... wee care ...... vitamin d3 oral capsule 1.25 mg (50000 ut) .. VIVLODEX ...... weekly-d ...... vitamin d3 oral capsule 125 mcg (5000 ut) ... VIZIMPRO ...... WEGOVY ...... vitamin d-3 oral capsule 125 mcg (5000 ut) .. VOCABRIA ...... WELCHOL ...... vitamin d3 oral capsule 25 mcg (1000 ut) ..... VOGELXO ...... WELLBUTRIN SR ...... vitamin d3 oral capsule 250 mcg (10000 ut) . VOGELXO PUMP ...... WELLBUTRIN XL ...... vitamin d3 oral capsule 50 mcg (2000 ut) ..... volnea ...... WELLMIND VERTIGO ...... vitamin d-3 oral capsule 50 mcg (2000 ut) .... voriconazole oral suspension reconstituted .. wera ...... vitamin d3 oral liquid 10 mcg/ml ...... voriconazole oral tablet ...... westab max ...... vitamin d3 oral liquid 125 mcg/ml ...... VORTEX HOLD CHMBR/MASK/CHILD ...... westab mini ...... vitamin d3 oral tablet 10 mcg (400 unit) ...... VORTEX HOLD CHMBR/MASK/TODDLER . westab one ...... vitamin d3 oral tablet 125 mcg (5000 ut) ...... VORTEX VALVED HOLDING CHAMBER.... WESTAB PLUS ...... vitamin d3 oral tablet 25 mcg (1000 ut) ...... VOSEVI ...... WESTGEL DHA ...... vitamin d-3 oral tablet 25 mcg (1000 ut)...... VOTRIENT ...... WESTHROID ...... vitamin d3 oral tablet 50 mcg (2000 ut) ...... VP FC KIT ...... WEST-VITE W/FOLIC ACID ...... vitamin d3 oral tablet chewable 10 mcg (400 VP GKL KIT ...... WHEAT GERM OIL ...... unit) ...... vp-pnv-dha ...... WIDE-SEAL DIAPHRAGM 60 ...... vitamin d3 oral tablet chewable 25 mcg, 25 vp-vite rx ...... WIDE-SEAL DIAPHRAGM 65 ...... mcg (1000 ut) ...... VRAYLAR ...... WIDE-SEAL DIAPHRAGM 70 ...... vitamin d-400 ...... VTOL LQ ...... WIDE-SEAL DIAPHRAGM 75 ...... vitamin e natural ...... VUMERITY ...... WIDE-SEAL DIAPHRAGM 80 ...... vitamin e oral capsule 100 unit, 1000 unit, VUSION ...... WIDE-SEAL DIAPHRAGM 85 ...... 200 unit, 450 mg ...... vyfemla ...... WIDE-SEAL DIAPHRAGM 90 ...... vitamin e oral capsule 400 unit...... vylibra ...... WIDE-SEAL DIAPHRAGM 95 ...... vitamin e oral solution 15 unit/0.3ml ...... VYNDAMAX ...... WILZIN ...... vitamin k (phytonadione) ...... VYNDAQEL ...... WINLEVI ...... vitamin-b complex ...... VYTONE ...... WINRHO SDF ...... vitamins acd-fluoride ...... VYTORIN ...... wixela inhub ...... vitamins complete childrens ...... VYVANSE ORAL CAPSULE ...... womans laxative ......

250 womens 50 billion ...... XIGDUO XR ORAL TABLET EXTENDED Y womens daily gummies ...... RELEASE 24 HOUR 10-1000 MG, 10-500 YASMIN 28 ...... womens gentle laxative ...... MG ...... YAZ ...... womens laxative ...... XIGDUO XR ORAL TABLET EXTENDED YONSA ...... womens prenatal+dha ...... RELEASE 24 HOUR 2.5-1000 MG, 5- YOSPRALA ...... WP THYROID ...... 1000 MG, 5-500 MG ...... YUPELRI ...... WPR PLUS WOUND HEALING SYSTEM .... XIIDRA ...... yuvafem ...... wymzya fe ...... XIMINO ...... Z WYNZORA ...... XOFLUZA (40 MG DOSE) ...... ZACARE ...... X XOFLUZA (80 MG DOSE) ...... zaclir cleansing ...... XADAGO ...... XOLAIR ...... ZADITOR ...... XALATAN ...... XOLEGEL ...... zafemy ...... XALIX ...... XOLEGEL COREPAK ...... zafirlukast ...... XALKORI ...... XOLEGEL DUO/HEAD & SHOULDERS ...... zaleplon ...... XANAX ...... XOLEGEL DUO/XOLEX ...... ZANAFLEX ORAL CAPSULE 2 MG ...... XANAX XR ...... XOLIDO XP ...... ZANAFLEX ORAL CAPSULE 4 MG, 6 MG ... XAQUIL XR ...... XOPENEX CONCENTRATE ...... ZANAFLEX ORAL TABLET ...... XARELTO ...... XOPENEX HFA ...... zarah ...... XARELTO STARTER PACK ...... XOPENEX NEB ...... ZARONTIN ...... XATMEP ...... XOSPATA ...... ZARXIO ...... XCOPRI ...... XPECT ...... ZAVESCA ...... XCOPRI (250 MG DAILY DOSE)...... XPOVIO (100 MG ONCE WEEKLY) ...... ZCORT 7-DAY ...... XCOPRI (350 MG DAILY DOSE)...... XPOVIO (40 MG ONCE WEEKLY) ...... ZEASORB-AF ...... XELJANZ ...... XPOVIO (40 MG TWICE WEEKLY) ...... ZEBUTAL ...... XELJANZ XR ...... XPOVIO (60 MG ONCE WEEKLY) ...... ZEEL EXTERNAL ...... XELODA ...... XPOVIO (60 MG TWICE WEEKLY) ...... ZEGALOGUE ...... XELPROS ...... XPOVIO (80 MG ONCE WEEKLY) ...... ZEGERID ...... XENAZINE ...... XPOVIO (80 MG TWICE WEEKLY) ...... ZEJULA ...... XENLETA ORAL ...... XTAMPZA ER ...... ZELAC ...... XEPI ...... XTANDI ...... ZELAPAR ...... XERAC AC ...... xulane ...... ZELBORAF ...... XERALUX ...... XULTOPHY ...... ZELNORM ...... XERESE ...... xurea ...... ZEMBRACE SYMTOUCH ...... XERMELO ...... XURIDEN ...... ZEMPLAR ORAL ...... XEROSTOMIA RELIEF SPRAY ...... XVITE ...... zenatane oral capsule 10 mg ...... XHANCE ...... XYOSTED ...... zenatane oral capsule 20 mg ...... XIFAXAN ORAL TABLET 200 MG ...... XYREM ...... zenatane oral capsule 30 mg, 40 mg ...... XIFAXAN ORAL TABLET 550 MG ...... XYWAV ...... ZENPEP ...... XYZBAC ...... ZENZEDI ...... XYZMUNE ...... ZEPATIER ......

251 ZE-PLUS ...... ZITHROMAX Z-PAK ...... zovia 1/35 (28) ...... ZEPOSIA ...... zn-50 ...... zovia 1/35e (28) ...... ZEPOSIA 7-DAY STARTER PACK ...... ZOCOR ...... ZOVIRAX ...... ZEPOSIA STARTER KIT ...... ZOFRAN ...... z-sleep oral capsule 25 mg ...... ZERUVIA ...... ZOHYDRO ER ...... ZTLIDO ...... ZERVIATE ...... ZOKINVY ...... ZUBSOLV ...... ZESTORETIC ...... ZOLADEX ...... zumandimine ...... ZESTRIL ...... ZOLINZA ...... ZUPLENZ ...... ZETIA ...... ZOLMITRIPTAN NASAL ...... ZYCLARA ...... ZETONNA ...... zolmitriptan oral ...... ZYCLARA PUMP ...... ZIAC ...... ZOLOFT ...... ZYDELIG ...... ZIAGEN ...... ZOLPAK ...... ZYFLO ...... ZIANA ...... zolpidem tartrate er ...... ZYKADIA ...... zidovudine ...... zolpidem tartrate oral ...... ZYLET ...... ZIEXTENZO ...... zolpidem tartrate sublingual ...... ZYLOPRIM ...... ZILACAINE PATCH ...... ZOLPIMIST ...... ZYMAXID ...... ZILACTIN BABY ...... ZOMACTON ...... ZYPITAMAG ...... zileuton er ...... ZOMACTON (FOR ZOMA-JET 10) ...... ZYPREXA ORAL ...... ZILXI ...... ZOMIG ...... ZYPREXA RELPREVV ...... ZINC 15 ...... ZOMIG ZMT ...... ZYPREXA ZYDIS ...... zinc chelated oral tablet 50 mg ...... ZONALON ...... ZYRTEC ALLERGY CHILDRENS ...... zinc gluconate oral tablet 100 mg, 50 mg ..... ZONEGRAN ...... ZYRTEC ALLERGY ORAL CAPSULE ...... zinc oral lozenge ...... zonisamide oral ...... ZYRTEC ALLERGY ORAL TABLET ...... zinc oral tablet 50 mg ...... , ZONTIVITY ...... ZYRTEC ALLERGY ORAL TABLET zinc oxide external ointment 40 % ...... zoo friends ...... DISPERSIBLE ...... zinc sulfate oral tablet 220 (50 zn) mg ...... zoo friends complete ...... ZYRTEC-D ALLERGY & CONGESTION ...... ZIONODIL ...... zoo friends gummies ...... ZYTIGA ...... ZIONODIL 100 ...... zoo friends plus extra c ...... ZYVANA ...... ZIOPTAN ...... zoo friends plus iron ...... ZYVEXOL ...... ziprasidone hcl ...... ZORBTIVE ...... ZYVIT ...... ZIPSOR ...... ZORTRESS ORAL TABLET 0.25 MG, 0.5 ZYVOX ORAL SUSPENSION ZIRGAN ...... MG, 0.75 MG ...... RECONSTITUTED ...... ZITHRANOL ...... ZORTRESS ORAL TABLET 1 MG ...... ZYVOX ORAL TABLET ...... ZITHROMAX ORAL ...... ZORVOLEX ...... ZITHROMAX TRI-PAK ...... ZOSTRIX HP ......

252