Table of Contents

ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS...... 13 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH...... 22 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 52 DERMATOLOGICALS/TOPICAL THERAPY ...... 67 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 84 EAR, NOSE / THROAT MEDICATIONS ...... 90 ENDOCRINE/DIABETES...... 92 GASTROENTEROLOGY ...... 143 IMMUNOLOGY, / BIOTECHNOLOGY ...... 161 MUSCULOSKELETAL / RHEUMATOLOGY ...... 169 OBSTETRICS / GYNECOLOGY ...... 172 OPHTHALMOLOGY ...... 181 RESPIRATORY AND ALLERGY ...... 190 UROLOGICALS ...... 203 VITAMINS, HEMATINICS / ELECTROLYTES ...... 205 Index ...... 235

1 List of Abbreviations

1: MassHealth Unified Formulary Drugs 2: BMCHP Covered Drugs 1 Copay: $1 Copay Drug. These drugs are available at a $1 copay.

ACA: Affordable Care Act. This medication is required to be covered as a result of the Affordable Care Act.

OTC: Over the Counter. An OTC drug is a drug that can be purchased at the store without a prescription. If your doctor gives you a prescription for this drug, we will cover it as a plan benefit.

PA: Prior Authorization. This drug must be approved before we will cover it. Your physician must request a coverage review from us on your behalf. If approval is not granted, we may not cover the drug.

PBH: Pediatric Behavioral Health. These drugs may require authorization for members less than 18 years of age under the Pediatric Behavioral Health Medication Initiative.

PrefD: Preferred Drugs. These drugs are preferred on MassHealth's Plan Unified Formulary

QL: Quantity Limit. This is the maximum amount of a drug that we will cover for each prescription fill. Any amount greater than this requires prior approval.

SP: Specialty. This drug must be filled by our specialty pharmacy partner.

ST: Step Therapy. We require that you try another drug to treat your medical condition before this one will be covered. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES nystatin oral 2 suspension 100,000 ANTIFUNGAL AGENTS unit/ml clotrimazole mucous 2 nystatin oral tablet 2 membrane troche 10 500,000 unit mg ORAVIG BUCCAL 2 CRESEMBA 2 PA MUCO-ADHESIVE INTRAVENOUS BUCCAL TABLET RECON SOLN 372 50 MG MG posaconazole oral 2 PA CRESEMBA ORAL 2 PA tablet,delayed CAPSULE 186 MG release (dr/ec) 100 fluconazole oral 2 mg suspension for terbinafine hcl oral 2 reconstitution 10 tablet 250 mg mg/ml, 40 mg/ml voriconazole oral 2 PA fluconazole oral 2 suspension for tablet 100 mg, 150 reconstitution 200 mg, 200 mg, 50 mg mg/5 ml (40 mg/ml) flucytosine oral 2 voriconazole oral 2 PA capsule 250 mg, 500 tablet 200 mg, 50 mg mg ANTIVIRALS griseofulvin 2 microsize oral abacavir oral 2 suspension 125 mg/5 solution 20 mg/ml ml abacavir oral tablet 2 griseofulvin 2 300 mg microsize oral tablet abacavir-lamivudine 2 500 mg oral tablet 600-300 griseofulvin 2 mg ultramicrosize oral abacavir- 2 tablet 125 mg, 250 lamivudine- mg zidovudine oral oral 2 PA; QL (180 tablet 300-150-300 capsule 100 mg per 365 days) mg itraconazole oral 2 PA acyclovir oral 2 solution 10 mg/ml capsule 200 mg oral 2 acyclovir oral 2 tablet 200 mg suspension 200 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acyclovir oral tablet 2 DESCOVY ORAL 1 PrefD; ACA 400 mg, 800 mg TABLET 200-25 adefovir oral tablet 2 MG 10 mg didanosine oral 2 amantadine hcl oral 2 capsule,delayed capsule 100 mg release(dr/ec) 250 mg, 400 mg amantadine hcl oral 2 solution 50 mg/5 ml DOVATO ORAL 1 PrefD TABLET 50-300 amantadine hcl oral 2 MG tablet 100 mg EDURANT ORAL 2 APTIVUS ORAL 2 TABLET 25 MG CAPSULE 250 MG efavirenz oral 2 atazanavir oral 2 capsule 200 mg, 50 capsule 150 mg, 200 mg mg, 300 mg efavirenz oral tablet 2 BARACLUDE 2 600 mg ORAL SOLUTION 0.05 MG/ML efavirenz- 2 emtricitabin-tenofov BIKTARVY ORAL 1 PrefD oral tablet 600-200- TABLET 50-200-25 300 mg MG efavirenz-lamivu- 2 CABENUVA 1 SP; QL (99 per tenofov disop oral INTRAMUSCULA 99 days) tablet 400-300-300 R mg, 600-300-300 mg SUSPENSION,EXT ENDED RELEASE emtricitabine oral 2 400 MG/2 ML- 600 capsule 200 mg MG/2 ML, 600 emtricitabine- 2 MG/3 ML- 900 tenofovir (tdf) oral MG/3 ML tablet 100-150 mg, CIMDUO ORAL 2 133-200 mg, 167- 250 mg, 200-300 mg TABLET 300-300 MG EMTRIVA ORAL 2 COMPLERA ORAL 2 SOLUTION 10 TABLET 200-25- MG/ML 300 MG entecavir oral tablet 2 DELSTRIGO 1 PrefD 0.5 mg, 1 mg ORAL TABLET 100-300-300 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EPIVIR HBV 2 KALETRA ORAL 2 ORAL SOLUTION TABLET 100-25 25 MG/5 ML (5 MG, 200-50 MG MG/ML) lamivudine oral 2 oral tablet 2 solution 10 mg/ml 100 mg, 200 mg lamivudine oral 2 EVOTAZ ORAL 2 tablet 100 mg, 150 TABLET 300-150 mg, 300 mg MG lamivudine- 2 famciclovir oral 2 zidovudine oral tablet 125 mg, 250 tablet 150-300 mg mg, 500 mg LEDIPASVIR- 1 PA; SP; PrefD fosamprenavir oral 2 SOFOSBUVIR tablet 700 mg ORAL TABLET 90- FUZEON 2 SP 400 MG SUBCUTANEOUS LEXIVA ORAL 2 RECON SOLN 90 SUSPENSION 50 MG MG/ML GENVOYA ORAL 1 PrefD lopinavir-ritonavir 2 TABLET 150-150- oral solution 400- 200-10 MG 100 mg/5 ml INTELENCE ORAL 2 lopinavir-ritonavir 2 TABLET 100 MG, oral tablet 100-25 200 MG, 25 MG mg, 200-50 mg INVIRASE ORAL 2 MAVYRET ORAL 1 PA; SP; PrefD TABLET 500 MG TABLET 100-40 ISENTRESS HD 2 MG ORAL TABLET nevirapine oral 2 600 MG suspension 50 mg/5 ISENTRESS ORAL 2 ml POWDER IN nevirapine oral 2 PACKET 100 MG tablet 200 mg ISENTRESS ORAL 2 nevirapine oral 2 TABLET 400 MG tablet extended ISENTRESS ORAL 2 release 24 hr 100 TABLET,CHEWAB mg, 400 mg LE 100 MG, 25 MG NORVIR ORAL 2 JULUCA ORAL 1 PrefD POWDER IN TABLET 50-25 MG PACKET 100 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NORVIR ORAL 2 ribavirin inhalation 2 SOLUTION 80 recon soln 6 gram MG/ML ribavirin oral 2 SP NORVIR ORAL 1 PrefD capsule 200 mg TABLET 100 MG ribavirin oral tablet 2 SP ODEFSEY ORAL 1 PrefD 200 mg TABLET 200-25-25 rimantadine oral 2 MG tablet 100 mg oseltamivir oral 2 QL (20 per 23 RUKOBIA ORAL 1 PrefD; QL (2 capsule 30 mg days) TABLET per 1 day) oseltamivir oral 2 QL (10 per 23 EXTENDED capsule 45 mg, 75 days) RELEASE 12 HR mg 600 MG oseltamivir oral 2 SELZENTRY 2 suspension for ORAL SOLUTION reconstitution 6 20 MG/ML mg/ml SELZENTRY 2 PIFELTRO ORAL 1 PrefD ORAL TABLET TABLET 100 MG 150 MG, 25 MG, PREZCOBIX 1 PrefD 300 MG, 75 MG ORAL TABLET SOFOSBUVIR- 1 PA; SP; PrefD 800-150 MG-MG VELPATASVIR PREZISTA ORAL 1 PrefD ORAL TABLET SUSPENSION 100 400-100 MG MG/ML stavudine oral 2 PREZISTA ORAL 2 capsule 15 mg, 20 TABLET 150 MG, mg, 30 mg, 40 mg 75 MG STRIBILD ORAL 2 TABLET 150-150- PREZISTA ORAL 1 PrefD TABLET 600 MG, 200-300 MG 800 MG SYMTUZA ORAL 1 PrefD RELENZA 2 TABLET 800-150- DISKHALER 200-10 MG INHALATION SYNAGIS 2 PA; SP; QL (2 BLISTER WITH INTRAMUSCULA per 23 days) DEVICE 5 R SOLUTION 100 MG/ACTUATION MG/ML REYATAZ ORAL 2 POWDER IN PACKET 50 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 6 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SYNAGIS 2 PA; SP; QL (1 VIEKIRA PAK 2 PA; SP; QL INTRAMUSCULA per 23 days) ORAL (112 per 21 R SOLUTION 50 TABLETS,DOSE days) MG/0.5 ML PACK 12.5 MG-75 TEMIXYS ORAL 2 MG -50 MG/250 TABLET 300-300 MG MG VIRACEPT ORAL 2 tenofovir disoproxil 2 TABLET 250 MG, fumarate oral tablet 625 MG 300 mg VIREAD ORAL 2 TIVICAY ORAL 2 POWDER 40 TABLET 10 MG, 25 MG/SCOOP (40 MG/GRAM) MG, 50 MG TIVICAY PD 2 VIREAD ORAL 2 ORAL TABLET TABLET 150 MG, FOR SUSPENSION 200 MG, 250 MG 5 MG VOSEVI ORAL 1 PA; SP TRIUMEQ ORAL 1 PrefD TABLET 400-100- TABLET 600-50- 100 MG 300 MG ZEPATIER ORAL 1 PA; SP TABLET 50-100 TRUVADA ORAL 2 ACA TABLET 100-150 MG MG, 133-200 MG, zidovudine oral 2 167-250 MG capsule 100 mg TYBOST ORAL 2 zidovudine oral 2 TABLET 150 MG syrup 10 mg/ml valacyclovir oral 2 zidovudine oral 2 tablet 1 gram, 500 tablet 300 mg mg CEPHALOSPORINS valganciclovir oral 2 cefaclor oral capsule 2 recon soln 50 mg/ml 250 mg, 500 mg valganciclovir oral 2 cefaclor oral 2 tablet 450 mg suspension for VEMLIDY ORAL 2 QL (30 per 23 reconstitution 125 TABLET 25 MG days) mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet 2 extended release 12 hr 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 7 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefadroxil oral 2 ceftriaxone in 2 capsule 500 mg dextrose,iso-os cefadroxil oral 2 intravenous suspension for piggyback 1 gram/50 reconstitution 250 ml, 2 gram/50 ml mg/5 ml, 500 mg/5 ceftriaxone 2 ml intravenous recon cefadroxil oral tablet 2 soln 1 gram, 2 gram 1 gram cefuroxime axetil 2 oral tablet 250 mg, cefdinir oral capsule 2 300 mg 500 mg cefdinir oral 2 cephalexin oral 2 suspension for capsule 250 mg, 500 reconstitution 125 mg, 750 mg mg/5 ml, 250 mg/5 cephalexin oral 2 ml suspension for cefditoren pivoxil 2 reconstitution 125 oral tablet 200 mg, mg/5 ml, 250 mg/5 400 mg ml cefixime oral 2 cephalexin oral 2 tablet 250 mg, 500 suspension for reconstitution 100 mg mg/5 ml, 200 mg/5 SPECTRACEF 2 ml ORAL TABLET cefpodoxime oral 2 400 MG suspension for SUPRAX ORAL 2 reconstitution 100 CAPSULE 400 MG mg/5 ml, 50 mg/5 ml SUPRAX ORAL 2 cefpodoxime oral 2 SUSPENSION FOR tablet 100 mg, 200 RECONSTITUTIO mg N 500 MG/5 ML cefprozil oral 2 SUPRAX ORAL 2 suspension for TABLET,CHEWAB reconstitution 125 LE 100 MG, 200 mg/5 ml, 250 mg/5 MG ml ERYTHROMYCINS / OTHER

cefprozil oral tablet 2 MACROLIDES 250 mg, 500 mg azithromycin oral 2 packet 1 gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 8 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits azithromycin oral 2 erythromycin 2 suspension for ethylsuccinate oral reconstitution 100 tablet 400 mg mg/5 ml, 200 mg/5 erythromycin oral 2 ml capsule,delayed azithromycin oral 2 release(dr/ec) 250 tablet 250 mg, 500 mg mg, 600 mg erythromycin oral 2 clarithromycin oral 2 tablet 250 mg, 500 suspension for mg reconstitution 125 ZITHROMAX 2 mg/5 ml, 250 mg/5 ORAL PACKET 1 ml GRAM clarithromycin oral 2 MISCELLANEOUS tablet 250 mg, 500 mg ANTIINFECTIVES clarithromycin oral 2 albendazole oral 2 tablet extended tablet 200 mg release 24 hr 500 mg ALINIA ORAL 2 DIFICID ORAL 2 PA; QL (60 SUSPENSION FOR TABLET 200 MG per 23 days) RECONSTITUTIO N 100 MG/5 ML e.e.s. 400 oral tablet 2 400 mg ALINIA ORAL 2 TABLET 500 MG ery-tab oral 2 tablet,delayed atovaquone oral 2 release (dr/ec) 250 suspension 750 mg/5 mg, 333 mg ml ERY-TAB ORAL 2 atovaquone- 2 TABLET,DELAYE proguanil oral tablet D RELEASE 250-100 mg, 62.5-25 (DR/EC) 500 MG mg erythrocin (as 2 BENZNIDAZOLE 2 stearate) oral tablet ORAL TABLET 250 mg 100 MG, 12.5 MG erythromycin 2 BILTRICIDE 2 ethylsuccinate oral ORAL TABLET suspension for 600 MG reconstitution 200 mg/5 ml, 400 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 9 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CAYSTON 2 SP linezolid oral 2 PA; QL (900 INHALATION suspension for per 14 days) SOLUTION FOR reconstitution 100 NEBULIZATION mg/5 ml 75 MG/ML linezolid oral tablet 2 PA; QL (60 chloroquine 2 QL (12 per 90 600 mg per 23 days) phosphate oral days) linezolid-0.9% 2 PA tablet 250 mg, 500 sodium chloride mg intravenous clindamycin hcl oral 2 parenteral solution capsule 150 mg, 300 600 mg/300 ml mg, 75 mg mefloquine oral 2 clindamycin 2 tablet 250 mg pediatric oral recon metronidazole oral 2 soln 75 mg/5 ml tablet 250 mg, 500 COARTEM ORAL 2 mg TABLET 20-120 neomycin oral tablet 2 MG 500 mg CYCLOSERINE 2 paromomycin oral 2 SP ORAL CAPSULE capsule 250 mg 250 MG PASER ORAL 2 dapsone oral tablet 2 GRANULES DR 100 mg, 25 mg FOR SUSP IN ethambutol oral 2 PACKET 4 GRAM tablet 100 mg, 400 pentamidine 2 mg inhalation recon hydroxychloroquine 2 soln 300 mg oral tablet 200 mg praziquantel oral 2 IMPAVIDO ORAL 2 PA; QL (84 tablet 600 mg CAPSULE 50 MG per 21 days) PRETOMANID 2 isoniazid oral 2 ORAL TABLET solution 50 mg/5 ml 200 MG isoniazid oral tablet 2 PRIFTIN ORAL 2 100 mg, 300 mg TABLET 150 MG ivermectin oral 2 PRIMAQUINE 2 tablet 3 mg ORAL TABLET 26.3 MG linezolid in dextrose 2 PA 5% intravenous pyrazinamide oral 2 piggyback 600 tablet 500 mg mg/300 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 10 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits pyrimethamine oral 2 PA; SP; QL amoxicillin oral 2 tablet 25 mg (90 per 23 suspension for days) reconstitution 125 quinine sulfate oral 2 mg/5 ml, 200 mg/5 capsule 324 mg ml, 250 mg/5 ml, 400 mg/5 ml rifabutin oral 2 capsule 150 mg amoxicillin oral 2 tablet 500 mg, 875 rifampin oral 2 QL (2 per 1 mg capsule 150 mg day) amoxicillin oral 2 rifampin oral 2 tablet,chewable 125 capsule 300 mg mg, 250 mg SIRTURO ORAL 2 amoxicillin-pot 2 TABLET 100 MG, clavulanate oral 20 MG suspension for SIVEXTRO 2 PA; QL (30 reconstitution 200- INTRAVENOUS per 23 days) 28.5 mg/5 ml, 250- RECON SOLN 200 62.5 mg/5 ml, 400- MG 57 mg/5 ml, 600- 42.9 mg/5 ml SIVEXTRO ORAL 2 PA; QL (30 TABLET 200 MG per 23 days) amoxicillin-pot 2 clavulanate oral tinidazole oral tablet 2 tablet 250-125 mg, 250 mg, 500 mg 500-125 mg, 875- tobramycin in 0.225 2 SP 125 mg % nacl inhalation amoxicillin-pot 2 solution for clavulanate oral nebulization 300 tablet extended mg/5 ml release 12 hr 1,000- TRECATOR ORAL 2 62.5 mg TABLET 250 MG amoxicillin-pot 2 XIFAXAN ORAL 2 PA clavulanate oral TABLET 200 MG tablet,chewable 200- 28.5 mg, 400-57 mg XIFAXAN ORAL 2 PA; QL (60 TABLET 550 MG per 23 days) ampicillin oral 2 capsule 500 mg PENICILLINS AUGMENTIN 2 amoxicillin oral 2 ORAL capsule 250 mg, 500 SUSPENSION FOR mg RECONSTITUTIO N 125-31.25 MG/5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 11 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BICILLIN C-R 2 ciprofloxacin hcl 2 INTRAMUSCULA oral tablet 100 mg, R SYRINGE 250 mg, 500 mg, 750 1,200,000 UNIT/ 2 mg ML(600K/600K), ciprofloxacin oral 2 1,200,000 UNIT/ 2 suspension,microcap ML(900K/300K) sule recon 500 mg/5 BICILLIN L-A 2 ml INTRAMUSCULA levofloxacin oral 2 R SYRINGE solution 250 mg/10 1,200,000 UNIT/2 ml ML, 2,400,000 UNIT/4 ML, levofloxacin oral 2 600,000 UNIT/ML tablet 250 mg, 500 mg, 750 mg dicloxacillin oral 2 capsule 250 mg, 500 moxifloxacin oral 2 mg tablet 400 mg MOXATAG ORAL 2 ofloxacin oral tablet 2 TABLET, ER 400 mg MULTIPHASE 24 SULFA'S / RELATED AGENTS HR 775 MG sulfadiazine oral 2 penicillin g procaine 2 tablet 500 mg intramuscular syringe 600,000 sulfamethoxazole- 2 unit/ml trimethoprim oral suspension 200-40 penicillin v 2 mg/5 ml potassium oral recon soln 125 mg/5 ml, sulfamethoxazole- 2 250 mg/5 ml trimethoprim oral tablet 400-80 mg, penicillin v 2 800-160 mg potassium oral tablet 250 mg, 500 mg sulfatrim oral 2 suspension 200-40 QUINOLONES mg/5 ml CIPRO ORAL 2 TETRACYCLINES SUSPENSION,MIC ROCAPSULE avidoxy oral tablet 2 RECON 250 MG/5 100 mg ML, 500 MG/5 ML demeclocycline oral 2 tablet 150 mg, 300 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 12 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits doxycycline hyclate 2 methenamine 2 oral capsule 50 mg hippurate oral tablet doxycycline hyclate 2 1 gram oral tablet 100 mg, methenamine 2 20 mg mandelate oral doxycycline 2 tablet 0.5 g, 1 gram monohydrate oral MONUROL ORAL 2 capsule 100 mg, 150 PACKET 3 GRAM mg, 50 mg, 75 mg nitrofurantoin 2 doxycycline 2 macrocrystal oral monohydrate oral capsule 100 mg, 25 suspension for mg, 50 mg reconstitution 25 nitrofurantoin 2 mg/5 ml monohyd/m-cryst doxycycline 2 oral capsule 100 mg monohydrate oral nitrofurantoin oral 2 tablet 100 mg, 50 mg suspension 25 mg/5 minocycline oral 2 ml capsule 100 mg, 50 PRIMSOL ORAL 2 mg, 75 mg SOLUTION 50 MORGIDOX 1X100 2 MG/5 ML KIT 100 MG trimethoprim oral 2 MORGIDOX 2X100 2 tablet 100 mg KIT 100 MG VANCOMYCIN morgidox oral 2 FIRVANQ ORAL 2 capsule 100 mg RECON SOLN 25 SOLODYN ORAL 2 PA; QL (30 MG/ML, 50 TABLET per 23 days) MG/ML EXTENDED vancomycin oral 2 RELEASE 24 HR capsule 125 mg, 250 55 MG mg tetracycline oral 2 capsule 250 mg, 500 ANTINEOPLASTIC / mg IMMUNOSUPPRESSANT VIBRAMYCIN 2 DRUGS ORAL SYRUP 50 ADJUNCTIVE AGENTS MG/5 ML leucovorin calcium 2 URINARY TRACT AGENTS oral tablet 10 mg, 15 mg, 25 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 13 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MESNEX ORAL 2 ALUNBRIG ORAL 1 PA; SP; QL (1 TABLET 400 MG TABLETS,DOSE per 1 day) XGEVA 2 PA; SP; QL PACK 90 MG (7)- SUBCUTANEOUS (23.8 per 365 180 MG (23) SOLUTION 120 days) anastrozole oral 2 MG/1.7 ML (70 tablet 1 mg MG/ML) AYVAKIT ORAL 2 PA; SP ANTINEOPLASTIC / TABLET 100 MG,

IMMUNOSUPPRESSANT DRUGS 200 MG, 25 MG, 300 MG, 50 MG abiraterone oral 2 PA; SP tablet 250 mg AZASAN ORAL 2 TABLET 100 MG, abiraterone oral 2 PA; SP; QL 75 MG tablet 500 mg (60 per 23 days) azathioprine oral 2 tablet 50 mg ADAKVEO 2 PA; SP INTRAVENOUS BALVERSA ORAL 1 PA; SP SOLUTION 10 TABLET 3 MG, 4 MG/ML MG, 5 MG AFINITOR 1 PA; SP; QL (1 bexarotene oral 2 SP DISPERZ ORAL per 1 day) capsule 75 mg TABLET FOR bicalutamide oral 2 SP SUSPENSION 2 tablet 50 mg MG, 3 MG, 5 MG BLENREP 2 PA; SP AFINITOR ORAL 1 PA; SP; QL (1 INTRAVENOUS TABLET 10 MG, per 1 day) RECON SOLN 100 2.5 MG, 5 MG, 7.5 MG MG BOSULIF ORAL 1 PA; SP; PrefD ALECENSA ORAL 1 PA; SP; QL (8 TABLET 100 MG, CAPSULE 150 MG per 1 day) 400 MG, 500 MG ALIQOPA 1 PA; SP BRAFTOVI ORAL 1 PA; SP INTRAVENOUS CAPSULE 50 MG, RECON SOLN 60 75 MG MG BRUKINSA ORAL 1 PA; SP ALUNBRIG ORAL 1 PA; SP; QL (1 CAPSULE 80 MG TABLET 180 MG, per 1 day) 90 MG CABOMETYX 1 PA; SP; QL (1 ORAL TABLET 20 per 1 day) ALUNBRIG ORAL 1 PA; SP; QL (2 MG, 40 MG, 60 MG TABLET 30 MG per 1 day) CALQUENCE 1 PA; SP ORAL CAPSULE 100 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 14 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits capecitabine oral 2 SP doxorubicin 2 SP tablet 150 mg, 500 intravenous recon mg soln 10 mg CAPRELSA ORAL 1 PA; SP; QL DROXIA ORAL 2 SP TABLET 100 MG (60 per 23 CAPSULE 200 MG, days) 300 MG, 400 MG CAPRELSA ORAL 1 PA; SP; QL ELIGARD (3 2 PA; SP TABLET 300 MG (30 per 23 MONTH) days) SUBCUTANEOUS SYRINGE 22.5 MG COMETRIQ ORAL 1 PA; SP; QL CAPSULE 100 (30 per 23 ELIGARD (4 2 PA; SP MG/DAY(80 MG days) MONTH) X1-20 MG X1), 140 SUBCUTANEOUS MG/DAY(80 MG SYRINGE 30 MG X1-20 MG X3), 60 ELIGARD (6 2 PA; SP MG/DAY (20 MG X MONTH) 3/DAY) SUBCUTANEOUS COPIKTRA ORAL 1 PA; SP SYRINGE 45 MG CAPSULE 15 MG, ELIGARD 2 PA; SP 25 MG SUBCUTANEOUS COTELLIC ORAL 1 PA; SP SYRINGE 7.5 MG TABLET 20 MG (1 MONTH) cyclophosphamide 2 SP EMCYT ORAL 2 SP intravenous recon CAPSULE 140 MG soln 500 mg ENHERTU 2 PA; SP cyclophosphamide 2 SP INTRAVENOUS oral capsule 25 mg, RECON SOLN 100 50 mg MG cyclosporine 2 ERIVEDGE ORAL 2 SP modified oral CAPSULE 150 MG capsule 100 mg, 25 ERLEADA ORAL 2 PA; SP mg, 50 mg TABLET 60 MG cyclosporine 2 erlotinib oral tablet 1 PA; SP; QL (1 modified oral 100 mg, 150 mg, 25 per 1 day) solution 100 mg/ml mg cyclosporine oral 2 etoposide oral 2 SP capsule 100 mg, 25 capsule 50 mg mg DAURISMO ORAL 2 PA; SP TABLET 100 MG, 25 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 15 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits everolimus 1 HERZUMA 2 SP (immunosuppressive INTRAVENOUS ) oral tablet 0.25 mg, RECON SOLN 150 0.5 mg, 0.75 mg MG, 420 MG exemestane oral 2 SP HYCAMTIN ORAL 2 SP tablet 25 mg CAPSULE 0.25 FARYDAK ORAL 2 PA; SP MG, 1 MG CAPSULE 10 MG, HYDROXYUREA 2 SP 15 MG, 20 MG (BULK) POWDER 100 % FIRMAGON KIT W 2 PA; SP DILUENT hydroxyurea oral 2 SP SYRINGE capsule 500 mg SUBCUTANEOUS IBRANCE ORAL 1 PA; SP; PrefD; RECON SOLN 120 CAPSULE 100 MG, QL (1 per 1 MG, 80 MG 125 MG, 75 MG day) flutamide oral 2 SP IBRANCE ORAL 1 PA; SP; PrefD; capsule 125 mg TABLET 100 MG, QL (1 per 1 GAVRETO ORAL 2 PA; SP 125 MG, 75 MG day) CAPSULE 100 MG ICLUSIG ORAL 1 PA; SP gengraf oral capsule 2 TABLET 10 MG, 15 100 mg, 25 mg MG, 30 MG, 45 MG gengraf oral solution 2 IDHIFA ORAL 2 PA; SP 100 mg/ml TABLET 100 MG, GILOTRIF ORAL 1 PA; SP; QL (1 50 MG TABLET 20 MG, 30 per 1 day) imatinib oral tablet 1 SP MG, 40 MG 100 mg, 400 mg GLEOSTINE ORAL 2 PA; SP IMBRUVICA 1 PA; SP CAPSULE 10 MG, ORAL CAPSULE 100 MG, 40 MG 140 MG, 70 MG HERCEPTIN 2 SP IMBRUVICA 1 PA; SP HYLECTA ORAL TABLET SUBCUTANEOUS 140 MG, 280 MG, SOLUTION 600 420 MG, 560 MG MG-10,000 UNIT/5 INLYTA ORAL 1 PA; SP; PrefD ML TABLET 1 MG, 5 HERCEPTIN 2 SP MG INTRAVENOUS INQOVI ORAL 2 PA; SP RECON SOLN 150 TABLET 35-100 MG MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 16 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INREBIC ORAL 1 PA; SP; QL LENVIMA ORAL 1 PA; SP; QL (3 CAPSULE 100 MG (120 per 23 CAPSULE 10 per 1 day) days) MG/DAY (10 MG X IRESSA ORAL 1 PA; SP; QL 1), 12 MG/DAY (4 TABLET 250 MG (30 per 23 MG X 3), 14 days) MG/DAY(10 MG X 1-4 MG X 1), 18 JAKAFI ORAL 1 PA; SP; QL MG/DAY (10 MG X TABLET 10 MG, 15 (60 per 23 1-4 MG X2), 20 MG, 20 MG, 25 days) MG/DAY (10 MG X MG, 5 MG 2), 24 MG/DAY(10 JELMYTO INTRA- 2 PA; SP MG X 2-4 MG X 1), PYELOCALYCEA 4 MG, 8 MG/DAY L KIT 40 MG (4 MG X 2) JEMPERLI 2 SP letrozole oral tablet 2 INTRAVENOUS 2.5 mg SOLUTION 50 LEUKERAN ORAL 2 SP MG/ML TABLET 2 MG KANJINTI 2 SP leuprolide 2 PA; SP INTRAVENOUS subcutaneous kit 1 RECON SOLN 150 mg/0.2 ml MG, 420 MG LONSURF ORAL 2 PA; SP KISQALI FEMARA 1 PA; SP TABLET 15-6.14 CO-PACK ORAL MG, 20-8.19 MG TABLET 200 MG/DAY(200 MG LORBRENA ORAL 1 PA; SP; QL (1 X 1)-2.5 MG, 400 TABLET 100 MG, per 1 day) MG/DAY(200 MG 25 MG X 2)-2.5 MG, 600 LUPRON DEPOT 2 PA; SP MG/DAY(200 MG (3 MONTH) X 3)-2.5 MG INTRAMUSCULA KISQALI ORAL 1 PA; SP R SYRINGE KIT TABLET 200 11.25 MG, 22.5 MG MG/DAY (200 MG LUPRON DEPOT 2 PA; SP X 1), 400 MG/DAY (4 MONTH) (200 MG X 2), 600 INTRAMUSCULA MG/DAY (200 MG R SYRINGE KIT 30 X 3) MG LUPRON DEPOT 2 PA; SP (6 MONTH) INTRAMUSCULA R SYRINGE KIT 45 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 17 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LUPRON DEPOT 2 PA; SP methotrexate sodium 2 INTRAMUSCULA injection solution 25 R SYRINGE KIT mg/ml 3.75 MG, 7.5 MG methotrexate sodium 2 LUPRON DEPOT- 2 PA; SP oral tablet 2.5 mg PED (3 MONTH) MONJUVI 2 PA; SP INTRAMUSCULA INTRAVENOUS R SYRINGE KIT RECON SOLN 200 11.25 MG, 30 MG MG LUPRON DEPOT- 2 PA; SP MVASI 2 SP PED INTRAVENOUS INTRAMUSCULA SOLUTION 25 R KIT 11.25 MG, 15 MG/ML MG, 7.5 MG (PED) mycophenolate 2 LYNPARZA ORAL 2 PA; SP mofetil oral capsule TABLET 100 MG, 250 mg 150 MG mycophenolate 2 LYSODREN ORAL 2 SP mofetil oral TABLET 500 MG suspension for MATULANE 2 SP reconstitution 200 ORAL CAPSULE mg/ml 50 MG mycophenolate 2 megestrol oral 2 mofetil oral tablet suspension 400 500 mg mg/10 ml (10 ml), mycophenolate 2 400 mg/10 ml (40 sodium oral mg/ml), 625 mg/5 ml tablet,delayed (125 mg/ml) release (dr/ec) 180 megestrol oral tablet 2 mg, 360 mg 20 mg, 40 mg MYLERAN ORAL 2 SP MEKINIST ORAL 1 PA; SP TABLET 2 MG TABLET 0.5 MG, 2 NERLYNX ORAL 1 PA; SP; QL (6 MG TABLET 40 MG per 1 day) MEKTOVI ORAL 1 PA; SP NEXAVAR ORAL 1 PA; SP; QL TABLET 15 MG TABLET 200 MG (120 per 23 melphalan oral 2 SP days) tablet 2 mg nilutamide oral 2 SP mercaptopurine oral 2 SP tablet 150 mg tablet 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 18 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NINLARO ORAL 2 PA; SP POMALYST ORAL 2 PA; SP CAPSULE 2.3 MG, CAPSULE 1 MG, 2 3 MG, 4 MG MG, 3 MG, 4 MG octreotide acetate 2 SP PURIXAN ORAL 2 SP injection solution SUSPENSION 20 100 mcg/ml, 200 MG/ML mcg/ml, 50 mcg/ml, QINLOCK ORAL 2 PA; SP 500 mcg/ml TABLET 50 MG ODOMZO ORAL 2 PA; SP REVLIMID ORAL 2 SP; QL (30 per CAPSULE 200 MG CAPSULE 10 MG, 23 days) OGIVRI 2 SP 20 MG, 5 MG INTRAVENOUS REVLIMID ORAL 2 SP; QL (21 per RECON SOLN 150 CAPSULE 15 MG, 21 days) MG, 420 MG 2.5 MG, 25 MG ONTRUZANT 2 SP RIABNI 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 150 SOLUTION 10 MG, 420 MG MG/ML ONUREG ORAL 2 PA; SP ROZLYTREK 1 PA; SP; QL TABLET 200 MG, ORAL CAPSULE (30 per 23 300 MG 100 MG, 200 MG days) PADCEV 2 PA; SP RUBRACA ORAL 2 PA; SP INTRAVENOUS TABLET 200 MG, RECON SOLN 20 250 MG, 300 MG MG, 30 MG RUXIENCE 2 PA; SP PEMAZYRE ORAL 2 PA; SP INTRAVENOUS TABLET 13.5 MG, SOLUTION 10 4.5 MG, 9 MG MG/ML PEPAXTO 2 PA; SP RYDAPT ORAL 1 PA; SP; QL (4 INTRAVENOUS CAPSULE 25 MG per 1 day) RECON SOLN 20 MG SANDIMMUNE 2 ORAL SOLUTION PIQRAY ORAL 1 PA; SP 100 MG/ML TABLET 200 MG/DAY (200 MG SANDOSTATIN 2 SP X 1), 250 MG/DAY LAR DEPOT (200 MG X1-50 MG INTRAMUSCULA X1), 300 MG/DAY R (150 MG X 2) SUSPENSION,EXT ENDED REL RECON 10 MG, 20 MG, 30 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 19 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SARCLISA 2 PA; SP SYNRIBO 1 PA; SP INTRAVENOUS SUBCUTANEOUS SOLUTION 20 RECON SOLN 3.5 MG/ML MG SIGNIFOR LAR 2 PA; SP TABLOID ORAL 2 SP INTRAMUSCULA TABLET 40 MG R SUSPENSION TABRECTA ORAL 1 PA; SP; QL (4 FOR TABLET 150 MG, per 1 day) RECONSTITUTIO 200 MG N 10 MG, 20 MG, 30 MG, 40 MG, 60 tacrolimus oral 2 MG capsule 0.5 mg, 1 mg, 5 mg SIGNIFOR 2 PA; SP SUBCUTANEOUS TAFINLAR ORAL 1 PA; SP SOLUTION 0.3 CAPSULE 50 MG, MG/ML (1 ML), 0.6 75 MG MG/ML (1 ML), 0.9 TAGRISSO ORAL 1 PA; SP; QL (1 MG/ML (1 ML) TABLET 40 MG, 80 per 1 day) sirolimus oral 2 MG solution 1 mg/ml TALZENNA ORAL 2 PA; SP sirolimus oral tablet 2 CAPSULE 0.25 0.5 mg, 1 mg, 2 mg MG, 1 MG SOLTAMOX 2 SP; ACA tamoxifen oral tablet 2 ACA ORAL SOLUTION 10 mg, 20 mg 20 MG/10 ML TARGRETIN 2 SP SPRYCEL ORAL 1 SP TOPICAL GEL 1 % TABLET 100 MG, TASIGNA ORAL 1 SP 140 MG, 20 MG, 50 CAPSULE 150 MG, MG, 70 MG, 80 MG 200 MG, 50 MG STIVARGA ORAL 1 PA; SP TAZVERIK ORAL 2 PA; SP TABLET 40 MG TABLET 200 MG SUPPRELIN LA 2 PA; SP; QL (1 temozolomide oral 2 SP IMPLANT KIT 50 per 365 days) capsule 100 mg, 140 MG (65 MCG/DAY) mg, 180 mg, 20 mg, SUTENT ORAL 1 PA; SP; PrefD; 250 mg, 5 mg CAPSULE 12.5 QL (30 per 23 temsirolimus 1 SP MG, 25 MG, 50 MG days) intravenous recon SUTENT ORAL 1 PA; SP; PrefD; soln 30 mg/3 ml (10 CAPSULE 37.5 MG QL (1 per 1 mg/ml) (first) day)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 20 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits THALOMID ORAL 2 SP; QL (30 per TUKYSA ORAL 2 PA; SP CAPSULE 100 MG, 23 days) TABLET 150 MG, 150 MG, 50 MG 50 MG THALOMID ORAL 2 SP; QL (60 per TURALIO ORAL 1 PA; SP CAPSULE 200 MG 23 days) CAPSULE 200 MG TIBSOVO ORAL 2 PA; SP TYKERB ORAL 1 SP TABLET 250 MG TABLET 250 MG toremifene oral 2 SP UKONIQ ORAL 2 PA; SP tablet 60 mg TABLET 200 MG TRAZIMERA 2 SP UPLIZNA 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 420 SOLUTION 10 MG MG/ML TRELSTAR 2 PA; SP VANTAS 2 PA; SP INTRAMUSCULA IMPLANT KIT 50 R SUSPENSION MG (50 MCG/DAY) FOR VENCLEXTA 1 PA; SP RECONSTITUTIO ORAL TABLET 10 N 11.25 MG, 22.5 MG, 100 MG, 50 MG, 3.75 MG MG tretinoin 2 SP VENCLEXTA 1 PA; SP (antineoplastic) oral STARTING PACK capsule 10 mg ORAL TREXALL ORAL 2 SP TABLETS,DOSE TABLET 10 MG, 15 PACK 10 MG-50 MG, 5 MG, 7.5 MG MG- 100 MG TRIPTODUR 2 PA; SP VERZENIO ORAL 1 PA; SP; QL (2 INTRAMUSCULA TABLET 100 MG, per 1 day) R SUSPENSION 150 MG, 200 MG, FOR 50 MG RECONSTITUTIO VITRAKVI ORAL 1 PA; SP; QL N 22.5 MG CAPSULE 100 MG, (60 per 23 TRODELVY 2 PA; SP 25 MG days) INTRAVENOUS VITRAKVI ORAL 1 PA; SP; QL RECON SOLN 180 SOLUTION 20 (300 per 23 MG MG/ML days) TRUXIMA 2 PA; SP VIZIMPRO ORAL 1 PA; SP; QL (1 INTRAVENOUS TABLET 15 MG, 30 per 1 day) SOLUTION 10 MG, 45 MG MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 21 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VOTRIENT ORAL 1 PA; SP; QL ZIRABEV 2 SP TABLET 200 MG (120 per 23 INTRAVENOUS days) SOLUTION 25 XALKORI ORAL 1 PA; SP; QL (2 MG/ML CAPSULE 200 MG, per 1 day) ZOLADEX 2 SP 250 MG SUBCUTANEOUS XATMEP ORAL 2 PA; SP IMPLANT 10.8 SOLUTION 2.5 MG, 3.6 MG MG/ML ZOLINZA ORAL 2 SP; QL (120 CAPSULE 100 MG per 23 days) XERMELO ORAL 2 PA; SP; QL TABLET 250 MG (90 per 23 ZORTRESS ORAL 2 SP days) TABLET 1 MG XOSPATA ORAL 1 PA; SP; QL (3 ZYDELIG ORAL 1 PA; SP TABLET 40 MG per 1 day) TABLET 100 MG, XPOVIO ORAL 2 PA; SP 150 MG TABLET 100 ZYKADIA ORAL 1 PA; SP; QL (3 MG/WEEK (50 MG TABLET 150 MG per 1 day) X 2), 40 MG/WEEK AUTONOMIC / CNS DRUGS, (40 MG X 1), 40MG TWICE WEEK (40 NEUROLOGY / PSYCH MG X 2), 60 ANTICONVULSANTS MG/WEEK (60 MG X 1), 60MG TWICE APTIOM ORAL 2 ST; PBH; QL WEEK (120 TABLET 200 MG, (30 per 23 MG/WEEK), 80 400 MG, 800 MG days) MG/WEEK (40 MG APTIOM ORAL 2 ST; PBH; QL X 2), 80MG TWICE TABLET 600 MG (60 per 23 WEEK (160 days) MG/WEEK) BANZEL ORAL 2 ST; QL (2760 XTANDI ORAL 2 SP SUSPENSION 40 per 23 days) CAPSULE 40 MG MG/ML ZEJULA ORAL 2 PA; SP BANZEL ORAL 2 ST; QL (60 per CAPSULE 100 MG TABLET 200 MG 23 days) ZELBORAF ORAL 2 SP BANZEL ORAL 2 ST; QL (240 TABLET 240 MG TABLET 400 MG per 23 days) ZEPZELCA 2 PA; SP BRIVIACT ORAL 2 ST; PBH; QL INTRAVENOUS SOLUTION 10 (600 per 23 RECON SOLN 4 MG/ML days) MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 22 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BRIVIACT ORAL 2 ST; PBH; QL DIACOMIT ORAL 2 PA; QL (360 TABLET 10 MG, (60 per 23 CAPSULE 250 MG, per 23 days) 100 MG, 25 MG, 50 days) 500 MG MG, 75 MG DIACOMIT ORAL 2 PA; QL (360 carbamazepine oral 2 POWDER IN per 23 days) capsule, er PACKET 250 MG multiphase 12 hr DIACOMIT ORAL 2 PA; QL (180 100 mg, 200 mg, 300 POWDER IN per 23 days) mg PACKET 500 MG carbamazepine oral 2 PBH diazepam rectal kit 2 QL (99 per 99 suspension 100 mg/5 12.5-15-17.5-20 mg, days) ml 2.5 mg, 5-7.5-10 mg carbamazepine oral 2 PBH DILANTIN ORAL 2 tablet 200 mg CAPSULE 30 MG carbamazepine oral 2 divalproex oral 2 PBH tablet extended capsule, delayed rel release 12 hr 100 mg sprinkle 125 mg carbamazepine oral 2 PBH divalproex oral 2 PBH tablet extended tablet extended release 12 hr 200 release 24 hr 250 mg, 400 mg mg, 500 mg carbamazepine oral 2 PBH divalproex oral 2 tablet,chewable 100 tablet,delayed mg release (dr/ec) 125 CELONTIN ORAL 2 mg, 250 mg, 500 mg CAPSULE 300 MG EPIDIOLEX ORAL 2 SP clobazam oral 2 ST; PBH SOLUTION 100 suspension 2.5 MG/ML mg/ml epitol oral tablet 200 2 PBH clobazam oral tablet 2 ST; PBH mg 10 mg, 20 mg EQUETRO ORAL 2 PBH clonazepam oral 2 PBH CAPSULE, ER tablet 0.5 mg MULTIPHASE 12 clonazepam oral 2 HR 100 MG, 200 tablet 1 mg, 2 mg MG, 300 MG clonazepam oral 2 PBH ethosuximide oral 2 tablet,disintegrating capsule 250 mg 0.125 mg, 0.25 mg, ethosuximide oral 2 0.5 mg, 1 mg, 2 mg solution 250 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 23 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits felbamate oral 2 LAMICTAL ODT 2 ST; PBH suspension 600 mg/5 STARTER ml (ORANGE) ORAL felbamate oral tablet 2 TABLET 400 mg, 600 mg DISINTEGRATING , DOSE PK 25 FINTEPLA ORAL 2 SP MG(14)-50 MG SOLUTION 2.2 (14)-100 MG (7) MG/ML LAMICTAL XR 2 ST; PBH; QL FYCOMPA ORAL 2 ST; QL (2 per STARTER (BLUE) (1 per 720 SUSPENSION 0.5 21 days) ORAL TABLET days) MG/ML EXTENDED FYCOMPA ORAL 2 ST; QL (30 per REL,DOSE PACK TABLET 10 MG, 12 23 days) 25 MG (21) -50 MG MG, 2 MG, 4 MG, 6 (7) MG, 8 MG LAMICTAL XR 2 ST; PBH; QL gabapentin oral 2 PBH STARTER (1 per 720 capsule 100 mg, 300 (GREEN) ORAL days) mg, 400 mg TABLET EXTENDED gabapentin oral 2 PBH REL,DOSE PACK solution 250 mg/5 50 MG(14)-100MG ml, 250 mg/5 ml (5 (14)-200 MG (7) ml) LAMICTAL XR 2 ST; PBH; QL gabapentin oral 2 PBH STARTER (1 per 720 tablet 600 mg, 800 (ORANGE) ORAL days) mg TABLET LAMICTAL ODT 2 ST; PBH EXTENDED STARTER (BLUE) REL,DOSE PACK ORAL TABLET 25MG (14)-50 MG DISINTEGRATING (14)-100MG (7) , DOSE PK 25 MG lamotrigine oral 2 PBH (21) -50 MG (7) tablet 100 mg, 150 LAMICTAL ODT 2 ST; PBH mg, 200 mg, 25 mg STARTER lamotrigine oral 2 ST; PBH; QL (GREEN) ORAL tablet extended (30 per 23 TABLET release 24hr 100 mg, days) DISINTEGRATING 25 mg, 50 mg , DOSE PK 50 MG (42) -100 MG (14) lamotrigine oral 2 ST; PBH; QL tablet extended (90 per 23 release 24hr 200 mg days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 24 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lamotrigine oral 2 ST; PBH; QL NAYZILAM 2 PBH; QL (99 tablet extended (60 per 23 NASAL per 99 days) release 24hr 250 mg, days) SPRAY,NON- 300 mg AEROSOL 5 lamotrigine oral 2 MG/SPRAY (0.1 tablet, chewable ML) dispersible 25 mg, 5 oxcarbazepine oral 2 PBH mg suspension 300 mg/5 lamotrigine oral 2 ST; PBH; QL ml (60 mg/ml) tablet,disintegrating (60 per 23 oxcarbazepine oral 2 PBH 100 mg, 200 mg days) tablet 150 mg, 300 lamotrigine oral 2 ST; PBH; QL mg, 600 mg tablet,disintegrating (180 per 23 phenobarbital oral 2 25 mg days) elixir 20 mg/5 ml (4 lamotrigine oral 2 ST; PBH; QL mg/ml) tablet,disintegrating (90 per 23 phenobarbital oral 2 50 mg days) tablet 100 mg, 15 lamotrigine oral 2 PBH mg, 16.2 mg, 30 mg, tablets,dose pack 25 32.4 mg, 60 mg, 64.8 mg (35), 25 mg (42) mg, 97.2 mg -100 mg (7), 25 mg phenytoin oral 2 (84) -100 mg (14) suspension 100 mg/4 levetiracetam oral 2 ml, 125 mg/5 ml solution 100 mg/ml phenytoin oral 2 levetiracetam oral 2 tablet,chewable 50 tablet 1,000 mg, 250 mg mg, 500 mg, 750 mg phenytoin sodium 2 levetiracetam oral 2 QL (180 per extended oral tablet extended 23 days) capsule 100 mg, 200 release 24 hr 500 mg mg, 300 mg levetiracetam oral 2 QL (120 per pregabalin oral 2 PA; PBH; QL tablet extended 23 days) capsule 100 mg, 150 (90 per 23 release 24 hr 750 mg mg, 200 mg, 25 mg, days) 50 mg, 75 mg LYRICA ORAL 2 PA; PBH; QL pregabalin oral 2 PA; PBH; QL SOLUTION 20 (900 per 23 MG/ML days) capsule 225 mg, 300 (60 per 23 mg days) primidone oral 2 tablet 250 mg, 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 25 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits roweepra oral tablet 2 VALTOCO NASAL 2 QL (99 per 99 1,000 mg, 500 mg, SPRAY,NON- days) 750 mg AEROSOL 10 rufinamide oral 2 MG/SPRAY (0.1 tablet 200 mg, 400 ML), 15 MG/2 mg SPRAY (7.5/0.1ML X 2), 20 MG/2 SABRIL ORAL 1 PA; ST; SP; SPRAY POWDER IN QL (6 per 1 (10MG/0.1ML X2), PACKET 500 MG day) 5 MG/SPRAY (0.1 SABRIL ORAL 1 PA; ST; SP; ML) TABLET 500 MG QL (180 per VIMPAT ORAL 2 ST; QL (1395 23 days) SOLUTION 10 per 23 days) SPRITAM ORAL 2 ST; QL (60 per MG/ML TABLET FOR 23 days) VIMPAT ORAL 2 ST; QL (90 per SUSPENSION TABLET 100 MG, 23 days) 1,000 MG, 250 MG, 50 MG 500 MG, 750 MG VIMPAT ORAL 2 ST; QL (60 per tiagabine oral tablet 2 TABLET 150 MG, 23 days) 12 mg, 16 mg, 2 mg, 200 MG 4 mg zonisamide oral 2 oral 2 PBH capsule 100 mg, 25 capsule, sprinkle 15 mg, 50 mg mg, 25 mg ANTIPARKINSONISM AGENTS topiramate oral 2 ST; PBH capsule,sprinkle,er APOKYN 2 SP 24hr 100 mg, 150 SUBCUTANEOUS mg, 200 mg, 25 mg, CARTRIDGE 10 50 mg MG/ML topiramate oral 2 PBH benztropine oral 2 tablet 100 mg, 200 tablet 0.5 mg, 1 mg, mg, 25 mg, 50 mg 2 mg valproic acid (as 2 PBH bromocriptine oral 2 sodium salt) oral capsule 5 mg solution 250 mg/5 bromocriptine oral 2 ml, 250 mg/5 ml (5 tablet 2.5 mg ml) carbidopa oral 2 valproic acid oral 2 PBH tablet 25 mg capsule 250 mg carbidopa-levodopa 2 oral tablet 25-100 mg, 25-250 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 26 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits carbidopa-levodopa 2 selegiline hcl oral 2 PBH oral tablet extended capsule 5 mg release 25-100 mg, selegiline hcl oral 2 PBH 50-200 mg tablet 5 mg carbidopa-levodopa 2 PA trihexyphenidyl oral 2 oral elixir 0.4 mg/ml tablet,disintegrating 10-100 mg, 25-100 trihexyphenidyl oral 2 mg, 25-250 mg tablet 2 mg, 5 mg entacapone oral 2 MIGRAINE / CLUSTER HEADACHE

tablet 200 mg THERAPY INBRIJA 2 PA; SP; QL AIMOVIG 1 PA; SP INHALATION (300 per 23 AUTOINJECTOR CAPSULE, days) SUBCUTANEOUS W/INHALATION AUTO-INJECTOR DEVICE 42 MG 140 MG/ML, 70 KYNMOBI 2 MG/ML SUBLINGUAL AJOVY 1 PA; SP; PrefD FILM 10 MG, 15 AUTOINJECTOR MG, 20 MG, 25 SUBCUTANEOUS MG, 30 MG AUTO-INJECTOR pramipexole oral 2 225 MG/1.5 ML tablet 0.125 mg, 0.25 AJOVY SYRINGE 1 PA; SP; PrefD mg, 0.5 mg, 0.75 mg, SUBCUTANEOUS 1 mg, 1.5 mg SYRINGE 225 pramipexole oral 2 ST; QL (30 per MG/1.5 ML tablet extended 23 days) malate 2 ST; QL (12 per release 24 hr 0.375 oral tablet 12.5 mg, 23 days) mg, 0.75 mg, 1.5 mg, 6.25 mg 2.25 mg, 3 mg eletriptan oral tablet 2 ST; QL (12 per pramipexole oral 2 ST 20 mg, 40 mg 23 days) tablet extended EMGALITY PEN 1 PA; SP release 24 hr 3.75 SUBCUTANEOUS mg, 4.5 mg PEN INJECTOR ropinirole oral tablet 2 120 MG/ML 0.25 mg, 0.5 mg, 1 EMGALITY 1 PA; SP mg, 2 mg, 3 mg, 4 SYRINGE mg, 5 mg SUBCUTANEOUS ropinirole oral tablet 2 ST; QL (30 per SYRINGE 120 extended release 24 23 days) MG/ML hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 27 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EMGALITY 1 PA; SP; PrefD sumatriptan 2 SYRINGE succinate SUBCUTANEOUS subcutaneous SYRINGE 300 cartridge 4 mg/0.5 MG/3 ML (100 ml, 6 mg/0.5 ml MG/ML X 3) sumatriptan 2 ST; QL (5 per ERGOMAR 2 succinate 23 days) SUBLINGUAL subcutaneous pen TABLET 2 MG injector 4 mg/0.5 ml, ergotamine-caffeine 2 6 mg/0.5 ml oral tablet 1-100 mg sumatriptan 2 frovatriptan oral 2 ST; QL (12 per succinate subcutaneous tablet 2.5 mg 23 days) solution 6 mg/0.5 ml migergot rectal 2 suppository 2-100 sumatriptan 2 mg succinate subcutaneous naratriptan oral 2 QL (12 per 23 syringe 6 mg/0.5 ml tablet 1 mg, 2.5 mg days) UBRELVY ORAL 2 PA NURTEC ODT 2 TABLET 100 MG, ORAL 50 MG TABLET,DISINTE GRATING 75 MG ZOLMITRIPTAN 2 ST; QL (12 per NASAL 23 days) REYVOW ORAL 2 PA SPRAY,NON- TABLET 100 MG, AEROSOL 2.5 MG, 50 MG 5 MG rizatriptan oral 2 QL (12 per 23 zolmitriptan oral 2 ST; QL (12 per tablet 10 mg, 5 mg days) tablet 2.5 mg 23 days) rizatriptan oral 2 QL (12 per 23 zolmitriptan oral 2 ST tablet,disintegrating days) tablet 5 mg 10 mg, 5 mg zolmitriptan oral 2 QL (12 per 23 sumatriptan nasal 2 ST; QL (12 per tablet,disintegrating days) spray,non-aerosol 23 days) 2.5 mg, 5 mg 20 mg/actuation, 5 mg/actuation ZOMIG NASAL 2 ST; QL (12 per SPRAY,NON- 23 days) sumatriptan 2 QL (12 per 23 AEROSOL 2.5 MG, succinate oral tablet days) 5 MG 100 mg, 25 mg, 50 MISCELLANEOUS mg NEUROLOGICAL THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 28 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMONDYS-45 2 PA; SP FIRDAPSE ORAL 2 PA; SP; QL INTRAVENOUS TABLET 10 MG (240 per 23 SOLUTION 50 days) MG/ML galantamine oral 2 AUBAGIO ORAL 1 PA; SP; QL (1 capsule,ext rel. TABLET 14 MG per 1 day) pellets 24 hr 16 mg, AUBAGIO ORAL 1 PA; SP; QL 24 mg, 8 mg TABLET 7 MG (30 per 23 galantamine oral 2 days) solution 4 mg/ml AUSTEDO ORAL 2 PA; SP; QL galantamine oral 2 TABLET 12 MG, 6 (120 per 23 tablet 12 mg, 4 mg, 8 MG, 9 MG days) mg BAFIERTAM 1 SP; QL (4 per GILENYA ORAL 1 PA; SP; QL ORAL 1 day) CAPSULE 0.5 MG (30 per 23 CAPSULE,DELAY days) ED INGREZZA 2 SP RELEASE(DR/EC) INITIATION PACK 95 MG ORAL COPAXONE 1 SP CAPSULE,DOSE SUBCUTANEOUS PACK 40 MG (7)- SYRINGE 20 80 MG (21) MG/ML INGREZZA ORAL 2 SP COPAXONE 1 SP; QL (12 per CAPSULE 40 MG, SUBCUTANEOUS 21 days) 80 MG SYRINGE 40 KESIMPTA PEN 2 PA; SP MG/ML SUBCUTANEOUS dalfampridine oral 2 PA; SP PEN INJECTOR 20 tablet extended MG/0.4 ML release 12 hr 10 mg MAVENCLAD (10 2 PA; SP donepezil oral tablet 2 PBH TABLET PACK) 10 mg, 23 mg, 5 mg ORAL TABLET 10 donepezil oral 2 PBH MG tablet,disintegrating MAVENCLAD (4 2 PA; SP 10 mg, 5 mg TABLET PACK) ORAL TABLET 10 EVRYSDI ORAL 2 PA; SP RECON SOLN 0.75 MG MG/ML MAVENCLAD (5 2 PA; SP EXONDYS-51 2 PA; SP TABLET PACK) INTRAVENOUS ORAL TABLET 10 SOLUTION 50 MG MG/ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 29 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MAVENCLAD (6 2 PA; SP NAMENDA XR 2 PBH TABLET PACK) ORAL ORAL TABLET 10 CAP,SPRINKLE,ER MG 24HR DOSE PACK MAVENCLAD (7 2 PA; SP 7-14-21-28 MG TABLET PACK) NAMZARIC ORAL 2 ORAL TABLET 10 CAP,SPRINKLE,ER MG 24HR DOSE PACK MAVENCLAD (8 2 PA; SP 7/14/21/28 MG-10 TABLET PACK) MG ORAL TABLET 10 NAMZARIC ORAL 2 MG CAPSULE,SPRINK LE,ER 24HR 14-10 MAVENCLAD (9 2 PA; SP TABLET PACK) MG, 21-10 MG, 28- ORAL TABLET 10 10 MG, 7-10 MG MG NUEDEXTA ORAL 2 PA; QL (60 MAYZENT ORAL 1 PA; SP CAPSULE 20-10 per 23 days) TABLET 0.25 MG, MG 2 MG OCREVUS 2 PA; SP MAYZENT 1 SP INTRAVENOUS STARTER PACK SOLUTION 30 ORAL MG/ML TABLETS,DOSE ONPATTRO 1 SP; PrefD PACK 0.25 MG (12 INTRAVENOUS TABS) SOLUTION 2 memantine oral 2 PBH MG/ML capsule,sprinkle,er rivastigmine tartrate 2 24hr 14 mg, 21 mg, oral capsule 1.5 mg, 28 mg, 7 mg 3 mg, 4.5 mg, 6 mg memantine oral 2 PBH rivastigmine 2 solution 2 mg/ml transdermal patch memantine oral 2 PBH 24 hour 13.3 mg/24 tablet 10 mg, 5 mg hour, 4.6 mg/24 hour, 9.5 mg/24 MEMANTINE 2 PBH hour ORAL TABLETS,DOSE RUZURGI ORAL 2 PA; QL (300 PACK 5-10 MG TABLET 10 MG per 23 days) SPINRAZA (PF) 2 PA; SP INTRATHECAL SOLUTION 12 MG/5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 30 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TECFIDERA ORAL 1 PA; SP; PrefD; ZEPOSIA 1 PA; SP CAPSULE,DELAY QL (2 per 1 STARTER PACK ED day) ORAL RELEASE(DR/EC) CAPSULE,DOSE 120 MG (14)- 240 PACK 0.23 MG (4)- MG (46) 0.46 MG (3) TECFIDERA ORAL 1 PA; SP; PrefD; MUSCLE RELAXANTS /

CAPSULE,DELAY QL (60 per 23 ANTISPASMODIC THERAPY ED days) RELEASE(DR/EC) baclofen oral tablet 2 120 MG, 240 MG 10 mg, 20 mg, 5 mg tetrabenazine oral 2 SP carisoprodol oral 2 QL (120 per tablet 12.5 mg, 25 tablet 350 mg 180 days) mg carisoprodol-aspirin 2 QL (240 per TYSABRI 2 SP oral tablet 200-325 180 days) INTRAVENOUS mg SOLUTION 300 carisoprodol- 2 QL (240 per MG/15 ML aspirin-codeine oral 180 days) VILTEPSO 2 PA; SP tablet 200-325-16 INTRAVENOUS mg SOLUTION 50 chlorzoxazone oral 2 QL (120 per MG/ML tablet 500 mg 23 days) VUMERITY ORAL 1 SP; QL (120 COMFORT PAC- 2 CAPSULE,DELAY per 23 days) TIZANIDINE KIT 4 ED MG RELEASE(DR/EC) cyclobenzaprine oral 2 231 MG tablet 10 mg, 5 mg VYONDYS-53 2 PA; SP dantrolene oral 2 INTRAVENOUS capsule 100 mg, 25 SOLUTION 50 mg, 50 mg MG/ML LIORESAL 2 SP ZEPOSIA ORAL 1 PA; SP; QL (1 INTRATHECAL CAPSULE 0.92 MG per 1 day) SOLUTION 2,000 ZEPOSIA 1 PA; SP MCG/ML STARTER KIT meprobamate oral 2 PBH ORAL tablet 200 mg, 400 CAPSULE,DOSE mg PACK 0.23-0.46- 0.92 MG MESTINON ORAL 2 SYRUP 60 MG/5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 31 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits methocarbamol oral 2 BELBUCA 2 PA tablet 500 mg, 750 BUCCAL FILM 450 mg MCG, 600 MCG orphenadrine citrate 2 buprenorphine hcl 2 PA; ACA; QL oral tablet extended sublingual tablet 2 (90 per 23 release 100 mg mg, 8 mg days) pyridostigmine 2 buprenorphine 2 QL (99 per 99 bromide oral syrup transdermal patch days) 60 mg/5 ml weekly 10 mcg/hour, 15 mcg/hour, 20 pyridostigmine 2 bromide oral tablet mcg/hour, 5 60 mg mcg/hour pyridostigmine 2 buprenorphine 2 PA; QL (4 per bromide oral tablet transdermal patch 21 days) extended release 180 weekly 7.5 mcg/hour mg butalbital compound 2 QL (60 per 23 tizanidine oral tablet 2 w/codeine oral days) 2 mg, 4 mg capsule 30-50-325- 40 mg NARCOTIC ANALGESICS butalbital- 2 QL (180 per acetaminophen- 2 QL (150 per 1 acetaminop-caf-cod 23 days) codeine oral solution day) oral capsule 50-325- 120 mg-12 mg /5 ml 40-30 mg (5 ml), 120-12 mg/5 butalbital- 2 QL (180 per ml acetaminophen oral 23 days) acetaminophen- 2 QL (360 per tablet 50-325 mg codeine oral tablet 23 days) butalbital- 2 QL (180 per 300-15 mg, 300-30 acetaminophen-caff 23 days) mg oral capsule 50-325- acetaminophen- 2 QL (180 per 40 mg codeine oral tablet 23 days) butalbital- 2 QL (180 per 300-60 mg acetaminophen-caff 23 days) ascomp with codeine 2 QL (60 per 23 oral tablet 50-325- oral capsule 30-50- days) 40 mg 325-40 mg butalbital-aspirin- 2 QL (180 per BELBUCA 2 PA; QL (60 caffeine oral capsule 23 days) BUCCAL FILM 150 per 23 days) 50-325-40 mg MCG, 300 MCG, 75 butalbital-aspirin- 2 QL (180 per MCG, 750 MCG, caffeine oral tablet 23 days) 900 MCG 50-325-40 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 32 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits codeine sulfate oral 2 QL (12 per 1 hydrocodone- 2 QL (180 per tablet 15 mg, 30 mg day) acetaminophen oral 23 days) codeine sulfate oral 2 QL (180 per tablet 10-300 mg, tablet 60 mg 23 days) 10-325 mg, 5-300 mg, 5-325 mg, 7.5- codeine-butalbital- 2 QL (60 per 23 300 mg, 7.5-325 mg asa-caff oral capsule days) 30-50-325-40 mg hydrocodone- 2 acetaminophen oral endocet oral tablet 2 QL (360 per tablet 2.5-325 mg 10-325 mg, 5-325 23 days) hydrocodone- 2 QL (240 per mg, 7.5-325 mg oral tablet 23 days) citrate 2 PA; QL (15 10-200 mg, 5-200 buccal lozenge on a per 23 days) mg, 7.5-200 mg handle 1,200 mcg, 1,600 mcg, 200 mcg, hydromorphone oral 2 QL (32 per 1 400 mcg, 600 mcg, liquid 1 mg/ml day) 800 mcg hydromorphone oral 2 QL (16 per 1 fentanyl transdermal 2 QL (20 per 23 tablet 2 mg day) patch 72 hour 100 days) hydromorphone oral 2 QL (8 per 1 mcg/hr, 12 mcg/hr, tablet 4 mg day) 25 mcg/hr, 37.5 hydromorphone oral 2 QL (4 per 1 mcg/hour, 50 tablet 8 mg day) mcg/hr, 62.5 mcg/hour, 75 hydromorphone oral 2 PA; QL (30 mcg/hr, 87.5 tablet extended per 23 days) mcg/hour release 24 hr 12 mg, 16 mg, 32 mg, 8 mg hydrocodone 2 PA; QL (60 bitartrate oral per 23 days) hydromorphone 2 QL (10 per 1 capsule, oral only, rectal suppository 3 day) er 12hr 10 mg, 15 mg mg, 20 mg, 30 mg, HYSINGLA ER 2 PA; QL (30 40 mg, 50 mg ORAL per 23 days) hydrocodone 2 PA; QL (30 TABLET,ORAL bitartrate oral per 23 days) ONLY,EXT.REL.24 tablet,oral HR 100 MG, 120 only,ext.rel.24 hr MG, 20 MG, 30 100 mg, 120 mg, 20 MG, 40 MG, 60 mg, 30 mg, 40 mg, MG, 80 MG 60 mg, 80 mg levorphanol tartrate 2 QL (60 per 23 hydrocodone- 2 QL (160 per 1 oral tablet 2 mg days) acetaminophen oral day) LORTAB ELIXIR 2 QL (120 per 1 solution 7.5-325 ORAL SOLUTION day) mg/15 ml 10-300 MG/15 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 33 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits meperidine oral 2 QL (120 per 1 morphine oral 2 PA solution 50 mg/5 ml day) capsule,extend.relea meperidine oral 2 QL (12 per 1 se pellets 40 mg tablet 50 mg day) morphine oral 2 QL (60 per 1 methadone injection 2 PA solution 10 mg/5 ml day) solution 10 mg/ml morphine oral 2 QL (30 per 1 solution 20 mg/5 ml day) methadone intensol 2 PA; QL (15 oral concentrate 10 per 1 day) (4 mg/ml) mg/ml morphine oral tablet 2 QL (240 per methadone oral 2 PA; QL (15 15 mg 23 days) concentrate 10 per 1 day) morphine oral tablet 2 QL (120 per mg/ml 30 mg 23 days) methadone oral 2 PA; QL (15 morphine oral tablet 2 QL (2 per 1 solution 10 mg/5 ml per 1 day) extended release 100 day) mg, 15 mg, 30 mg, methadone oral 2 PA; QL (30 solution 5 mg/5 ml per 1 day) 60 mg methadone oral 2 PA; QL (3 per morphine oral tablet 2 QL (1 per 1 tablet 10 mg 1 day) extended release 200 day) mg methadone oral 2 PA; QL (5 per tablet 5 mg 1 day) morphine rectal 2 QL (12 per 1 suppository 10 mg day) morphine 2 QL (6 per 1 concentrate oral day) morphine rectal 2 QL (6 per 1 suppository 20 mg day) solution 100 mg/5 ml (20 mg/ml) morphine rectal 2 QL (4 per 1 morphine oral 2 PA; QL (30 suppository 30 mg day) capsule, er per 23 days) morphine rectal 2 QL (24 per 1 multiphase 24 hr suppository 5 mg day) 120 mg, 30 mg, 45 OXAYDO ORAL 2 PA; QL (16 mg, 60 mg, 75 mg, TABLET, ORAL per 1 day) 90 mg ONLY 5 MG morphine oral 2 PA; QL (60 OXAYDO ORAL 2 PA; QL (10 capsule,extend.relea per 23 days) TABLET, ORAL per 10 days) se pellets 10 mg, 100 ONLY 7.5 MG mg, 30 mg, 50 mg, 60 mg, 80 mg oxycodone oral 2 QL (16 per 1 capsule 5 mg day) morphine oral 2 PA; QL (120 capsule,extend.relea per 23 days) oxycodone oral 2 QL (4 per 1 se pellets 20 mg concentrate 20 day) mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxycodone oral 2 QL (80 per 1 PROBUPHINE 2 PA; SP; QL (4 solution 5 mg/5 ml day) SUBDERMAL per 180 days) oxycodone oral 2 QL (8 per 1 IMPLANT 74.2 MG tablet 10 mg day) SUBLOCADE 1 SP; PrefD; oxycodone oral 2 QL (5 per 1 SUBCUTANEOUS ACA tablet 15 mg day) SOLUTION, EXTENDED REL oxycodone oral 2 QL (4 per 1 SYRINGE 100 tablet 20 mg day) MG/0.5 ML, 300 oxycodone oral 2 QL (2 per 1 MG/1.5 ML tablet 30 mg day) vicodin hp oral 2 QL (180 per oxycodone oral 2 QL (16 per 1 tablet 10-300 mg 23 days) tablet 5 mg day) vtol lq oral solution 2 oxycodone- 2 QL (360 per 50-325-40 mg/15 ml acetaminophen oral 23 days) XTAMPZA ER 2 PA; QL (60 tablet 10-325 mg, ORAL per 23 days) 2.5-325 mg, 5-325 CAP,SPRINKL,ER1 mg, 7.5-325 mg 2HR(DONT OXYCONTIN 2 PA; QL (90 CRUSH) 13.5 MG, ORAL per 23 days) 18 MG, 27 MG, 36 TABLET,ORAL MG, 9 MG ONLY,EXT.REL.12 zebutal oral capsule 2 QL (180 per HR 10 MG, 15 MG, 50-325-40 mg 23 days) 30 MG, 60 MG, 80 MG NON-NARCOTIC ANALGESICS OXYCONTIN 2 PA 8 hour pain reliever 2 OTC ORAL oral tablet extended TABLET,ORAL release 650 mg ONLY,EXT.REL.12 8hr muscle aches- 2 OTC HR 20 MG, 40 MG pain oral tablet oxymorphone oral 2 PA; QL (8 per extended release 650 tablet 10 mg 1 day) mg oxymorphone oral 2 PA; QL (16 acetaminophen extra 2 OTC tablet 5 mg per 1 day) strength oral tablet 500 mg oxymorphone oral 2 PA; QL (90 tablet extended per 23 days) acetaminophen oral 2 OTC release 12 hr 10 mg, elixir 160 mg/5 ml 15 mg, 20 mg, 30 acetaminophen oral 2 OTC mg, 40 mg, 5 mg, 7.5 liquid 160 mg/5 ml, mg 500 mg/15 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 35 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acetaminophen oral 2 OTC antacid and pain 2 OTC solution 160 mg/5 ml relief oral tablet, (5 ml), 325 mg/10.15 effervescent 325- ml, 650 mg/20.3 ml 1,916-1,000 mg acetaminophen oral 2 OTC aphen oral tablet 2 OTC suspension 160 mg/5 325 mg ml, 160 mg/5 ml (5 arthritis pain 2 OTC; QL (200 ml) (diclofenac) topical per 23 days) acetaminophen oral 2 OTC gel 1 % tablet 325 mg, 500 arthritis pain relief 2 OTC mg (acetam) oral tablet acetaminophen oral 2 OTC extended release 650 tablet extended mg release 650 mg arthritis pain 2 OTC acetaminophen oral 2 OTC reliever oral tablet tablet,chewable 160 extended release 650 mg mg acetaminophen oral 2 OTC aspirin childrens 2 ACA; OTC tablet,disintegrating oral tablet,chewable 80 mg 81 mg addaprin oral tablet 2 OTC aspirin low dose 2 ACA; OTC; 200 mg oral tablet,delayed QL (365 per adult aspirin 2 ACA; OTC; release (dr/ec) 81 365 days) regimen oral QL (365 per mg tablet,delayed 365 days) aspirin oral tablet 2 OTC release (dr/ec) 81 325 mg mg aspirin oral 2 ACA; OTC advil junior strength 2 OTC tablet,chewable 81 oral tablet,chewable mg 100 mg aspirin oral 2 ACA; OTC; alka-seltzer original 2 OTC tablet,delayed QL (365 per oral tablet, release (dr/ec) 325 365 days) effervescent 325- mg, 81 mg 1,916-1,000 mg aspir-trin oral 2 ACA; OTC; all day pain relief 2 OTC tablet,delayed QL (365 per oral tablet 220 mg release (dr/ec) 325 365 days) all day relief oral 2 OTC mg tablet 220 mg athenol oral tablet 2 OTC 325 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 36 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bayer aspirin oral 2 OTC children's aspirin 2 ACA; OTC tablet 325 mg oral tablet,chewable betatemp oral 2 OTC 81 mg suspension 160 mg/5 children's easy-melts 2 OTC ml oral buprenorphine- 1 PA; ACA; QL tablet,disintegrating naloxone sublingual (3 per 1 day) 80 mg tablet 2-0.5 mg, 8-2 children's ibuprofen 2 OTC mg oral suspension 100 mg/5 ml butorphanol 2 injection solution 1 children's mapap 2 OTC mg/ml, 2 mg/ml oral tablet,chewable butorphanol nasal 2 QL (5 per 23 160 mg, 80 mg spray,non-aerosol days) children's non- 2 OTC 10 mg/ml aspirin oral celecoxib oral 2 ST; QL (60 per suspension 160 mg/5 capsule 100 mg, 200 23 days) ml mg, 400 mg, 50 mg children's pain relief 2 OTC child fever reducer- 2 OTC oral elixir 160 mg/5 pain relvr oral ml suspension 160 mg/5 children's pain relief 2 OTC ml oral suspension 160 children's 2 OTC mg/5 ml acetaminophen oral children's pain relief 2 OTC liquid 160 mg/5 ml oral tablet,chewable children's 2 OTC 160 mg acetaminophen oral children's pain 2 OTC suspension 160 mg/5 reliever oral ml, 160 mg/5 ml (5 suspension 160 mg/5 ml) ml children's 2 OTC children's pain-fever 2 OTC acetaminophen oral relief oral tablet,chewable 160 suspension 160 mg/5 mg, 80 mg ml children's 2 OTC children's pain-fever 2 OTC acetaminophen oral relief oral tablet,disintegrating tablet,chewable 160 80 mg mg children's advil oral 2 OTC children's profen ib 2 OTC suspension 100 mg/5 oral suspension 100 ml mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 37 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits children's 2 OTC efferves pain relief 2 OTC oral tablet,chewable antacid oral tablet, 160 mg effervescent 325- diclofenac potassium 2 1,916-1,000 mg oral tablet 50 mg effervescent pain 2 OTC diclofenac sodium 2 relief oral tablet, oral tablet extended effervescent 324 mg release 24 hr 100 mg etodolac oral 2 diclofenac sodium 2 capsule 200 mg, 300 mg oral tablet,delayed release (dr/ec) 25 etodolac oral tablet 2 mg, 50 mg, 75 mg 400 mg, 500 mg diclofenac sodium 2 OTC; QL (200 etodolac oral tablet 2 topical gel 1 % per 23 days) extended release 24 diclofenac- 2 hr 400 mg, 500 mg, misoprostol oral 600 mg tablet,ir,delayed EUFLEXXA 2 PA; SP; QL rel,biphasic 50-200 INTRA- (12 per 180 mg-mcg, 75-200 mg- ARTICULAR days) mcg SYRINGE 10 MG/ML(MW 2.4 - DICLOPAK 2 TOPICAL KIT, 3.6 MILLION) CREAM AND fenoprofen oral 2 SOLUTION 1.5- tablet 600 mg 0.025 % flanax (naproxen) 2 OTC diflunisal oral tablet 2 oral tablet 220 mg 500 mg FLEXIPAK KIT 75 2 ec-naproxen oral 2 MG- 0.025 % tablet,delayed flurbiprofen oral 2 release (dr/ec) 375 tablet 100 mg mg, 500 mg HYALGAN 2 PA; SP; QL ecotrin low strength 2 ACA; OTC; INTRA- (20 per 180 oral tablet,delayed QL (365 per ARTICULAR days) release (dr/ec) 81 365 days) SOLUTION 10 mg MG/ML ecotrin oral 2 ACA; OTC; HYALGAN 2 PA; SP; QL tablet,delayed QL (365 per INTRA- (20 per 180 release (dr/ec) 325 365 days) ARTICULAR days) mg SYRINGE 10 ed-apap oral liquid 2 OTC MG/ML 160 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 38 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ibu-200 oral tablet 2 OTC infant fever reducer- 2 OTC 200 mg pain relf oral ibuprofen ib oral 2 OTC suspension 160 mg/5 tablet 200 mg ml ibuprofen ib oral 2 OTC infant pain reliever 2 OTC tablet,chewable 100 oral suspension 160 mg mg/5 ml ibuprofen jr strength 2 OTC infant's 2 OTC oral tablet,chewable acetaminophen oral suspension 160 mg/5 100 mg ml ibuprofen oral 2 OTC capsule 200 mg infant's advil oral 2 OTC drops,suspension 50 ibuprofen oral 2 OTC mg/1.25 ml drops,suspension 50 mg/1.25 ml infant's ibuprofen 2 OTC oral ibuprofen oral 2 OTC drops,suspension 50 suspension 100 mg/5 mg/1.25 ml ml infant's motrin oral 2 OTC ibuprofen oral tablet 2 OTC drops,suspension 50 100 mg, 200 mg mg/1.25 ml ibuprofen oral tablet 2 infants' pain and 2 OTC 400 mg, 600 mg, 800 fever oral mg suspension 160 mg/5 ibuprofen oral 2 OTC ml tablet,chewable 100 infants' pain relief 2 OTC mg oral suspension 160 INDOCIN ORAL 2 mg/5 ml SUSPENSION 25 infants profenib oral 2 OTC MG/5 ML drops,suspension 50 INDOCIN RECTAL 2 mg/1.25 ml SUPPOSITORY 50 i-prin oral tablet 200 2 OTC MG mg indomethacin oral 2 ketorolac injection 2 capsule 25 mg, 50 solution 15 mg/ml mg ketorolac 2 indomethacin oral 2 intramuscular capsule, extended cartridge 60 mg/2 ml release 75 mg ketorolac oral tablet 2 10 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 39 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits little remedies fever 2 OTC nabumetone oral 2 and pain oral liquid tablet 500 mg, 750 160 mg/5 ml mg LUCEMYRA 2 PA NALFON ORAL 2 ORAL TABLET CAPSULE 400 MG 0.18 MG naloxone injection 2 ACA mapap 2 OTC solution 0.4 mg/ml (acetaminophen) naloxone injection 2 ACA oral capsule 500 mg syringe 1 mg/ml mapap 2 OTC naltrexone oral 2 PBH; ACA (acetaminophen) tablet 50 mg oral liquid 500 mg/15 ml naproxen oral 2 suspension 125 mg/5 mapap 2 OTC ml (acetaminophen) oral tablet 325 mg naproxen oral tablet 2 250 mg, 375 mg, 500 mapap arthritis pain 2 OTC mg oral tablet extended release 650 mg naproxen oral 2 tablet,delayed masophen oral tablet 2 OTC release (dr/ec) 375 325 mg, 500 mg mg, 500 mg meclofenamate oral 2 naproxen sodium 2 OTC capsule 100 mg, 50 oral capsule 220 mg mg naproxen sodium 2 OTC mediproxen oral 2 OTC oral tablet 220 mg tablet 220 mg naproxen sodium 2 QL (200 per medi-seltzer oral 2 OTC oral tablet 275 mg 365 days) tablet, effervescent 324 mg naproxen sodium 2 oral tablet 550 mg meloxicam oral 2 tablet 15 mg, 7.5 mg NARCAN NASAL 2 ACA; QL (4 SPRAY,NON- per 23 days) MONOVISC 2 PA; SP; QL (8 AEROSOL 4 INTRA- per 23 days) MG/ACTUATION ARTICULAR SYRINGE 88 MG/4 non-aspirin extra 2 OTC ML strength oral tablet 500 mg motrin ib oral 2 OTC capsule 200 mg non-aspirin oral 2 OTC suspension 160 mg/5 m-pap oral liquid 2 OTC ml 160 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 40 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits non-aspirin oral 2 OTC pain relief extra 2 OTC tablet 325 mg strength oral tablet non-aspirin oral 2 OTC 500 mg tablet,chewable 80 pain relief regular 2 OTC mg strength oral tablet non-aspirin pain 2 OTC 325 mg relief oral tablet 500 pain reliever 2 OTC mg (acetaminophen) nortemp oral 2 OTC oral tablet 325 mg, 500 mg suspension 160 mg/5 ml pain reliever extra 2 OTC NUCYNTA ER 2 PA; QL (60 strength oral tablet ORAL TABLET per 23 days) 500 mg EXTENDED pain reliever jr 2 OTC RELEASE 12 HR strength oral 100 MG, 150 MG, tablet,chewable 160 200 MG, 250 MG, mg 50 MG pediacare fever 2 OTC NUCYNTA ORAL 2 PA; QL (180 reducer oral TABLET 100 MG, per 23 days) suspension 160 mg/5 50 MG, 75 MG ml ORTHOVISC 2 PA; SP; QL pentazocine- 2 INTRA- (16 per 180 naloxone oral tablet ARTICULAR days) 50-0.5 mg SYRINGE 30 MG/2 pharbetol oral tablet 2 OTC ML 325 mg, 500 mg oxaprozin oral tablet 2 piroxicam oral 2 600 mg capsule 10 mg, 20 pain relief 2 OTC mg (acetaminophen) PRIALT 2 SP oral liquid 160 mg/5 INTRATHECAL ml SOLUTION 100 pain relief 2 OTC MCG/ML, 25 (acetaminophen) MCG/ML oral tablet 500 mg salsalate oral tablet 2 pain relief 2 OTC 500 mg, 750 mg (acetaminophen) shake that ache oral 2 OTC oral tablet extended tablet 500 mg release 650 mg silapap oral liquid 2 OTC pain relief adult oral 2 OTC 160 mg/5 ml liquid 500 mg/15 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 41 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits st joseph aspirin 2 ACA; OTC oral tablet 2 PA; QL (30 oral tablet,chewable extended release 24 per 23 days) 81 mg hr 100 mg, 200 mg, st. joseph aspirin 2 ACA; OTC; 300 mg oral tablet,delayed QL (365 per tramadol oral tablet, 2 PA; QL (30 release (dr/ec) 81 365 days) er multiphase 24 hr per 23 days) mg 100 mg, 200 mg, 300 SUBOXONE 1 PrefD; ACA; mg SUBLINGUAL QL (2 per 1 tramadol- 2 QL (8 per 1 FILM 12-3 MG day) acetaminophen oral day) SUBOXONE 1 PrefD; ACA; tablet 37.5-325 mg SUBLINGUAL QL (12 per 1 tylophen oral 2 OTC FILM 2-0.5 MG day) capsule 500 mg SUBOXONE 1 PrefD; ACA; VIVITROL 1 SP; ACA SUBLINGUAL QL (6 per 1 INTRAMUSCULA FILM 4-1 MG day) R SUBOXONE 1 PrefD; ACA; SUSPENSION,EXT SUBLINGUAL QL (3 per 1 ENDED REL FILM 8-2 MG day) RECON 380 MG sulindac oral tablet 2 wal-profen oral 2 OTC capsule 200 mg 150 mg, 200 mg SYNVISC INTRA- 2 PA; SP; QL wal-profen oral 2 OTC ARTICULAR (12 per 180 tablet 200 mg SYRINGE 16 MG/2 days) wal-proxen oral 2 OTC ML tablet 220 mg SYNVISC-ONE 2 PA; SP; QL PSYCHOTHERAPEUTIC DRUGS INTRA- (12 per 365 ABILIFY 1 PA; PBH; QL ARTICULAR days) MAINTENA (1 per 21 days) SYRINGE 48 MG/6 INTRAMUSCULA ML R tactinal oral tablet 2 OTC SUSPENSION,EXT 325 mg ENDED REL tolmetin oral capsule 2 RECON 300 MG, 400 mg 400 MG tolmetin oral tablet 2 200 mg, 600 mg tramadol oral tablet 2 QL (8 per 1 50 mg day)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 42 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ABILIFY 1 PA; PBH; QL alprazolam oral 2 PBH MAINTENA (1 per 21 days) tablet extended INTRAMUSCULA release 24 hr 0.5 mg, R 1 mg, 2 mg, 3 mg SUSPENSION,EXT alprazolam oral 2 PBH ENDED REL tablet,disintegrating SYRING 300 MG, 0.25 mg, 0.5 mg, 1 400 MG mg, 2 mg ADASUVE 2 PBH amitriptyline oral 2 PBH INHALATION tablet 10 mg, 100 AEROSOL POWDR mg, 150 mg, 25 mg, BREATH 50 mg, 75 mg ACTIVATED 10 MG amitriptyline- 2 PBH chlordiazepoxide ADDERALL XR 1 PrefD; PBH; oral tablet 12.5-5 ORAL QL (60 per 23 mg, 25-10 mg CAPSULE,EXTEN days) DED RELEASE amoxapine oral 2 PBH 24HR 10 MG, 15 tablet 100 mg, 150 MG, 20 MG, 25 mg, 25 mg, 50 mg MG, 30 MG, 5 MG AMPHETAMINE 2 PBH; QL (450 ADZENYS ER 2 PA; PBH; QL ORAL SUSPEN, IR per 23 days) ORAL SUSPEN, IR (450 per 23 - ER, BIPHASIC - ER, BIPHASIC days) 24HR 1.25 MG/ML 24HR 1.25 MG/ML aripiprazole oral 2 PBH; QL (900 ADZENYS XR- 2 PA; PBH; QL solution 1 mg/ml per 23 days) ODT ORAL (30 per 23 aripiprazole oral 2 PBH; QL (30 TABLET,DISINTE days) tablet 10 mg, 15 mg, per 23 days) G ER BIPHASE 2 mg, 20 mg, 30 mg, 24H 12.5 MG, 15.7 5 mg MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 aripiprazole oral 2 PBH; QL (60 MG tablet,disintegrating per 23 days) 10 mg, 15 mg alprazolam intensol 2 PBH oral concentrate 1 ARISTADA INITIO 1 PrefD; PBH; mg/ml INTRAMUSCULA QL (2.4 per 21 R days) alprazolam oral 2 PBH SUSPENSION,EXT tablet 0.25 mg, 0.5 ENDED REL mg, 1 mg, 2 mg SYRING 675 MG/2.4 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 43 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARISTADA 1 PrefD; PBH; BELSOMRA ORAL 2 PA; PBH; QL INTRAMUSCULA QL (3.9 per 56 TABLET 10 MG, 15 (30 per 23 R days) MG, 20 MG, 5 MG days) SUSPENSION,EXT BRISDELLE ORAL 2 PA; PBH; QL ENDED REL CAPSULE 7.5 MG (30 per 23 SYRING 1,064 days) MG/3.9 ML bupropion hcl oral 2 PBH; QL (90 ARISTADA 1 PrefD; PBH; tablet 100 mg, 75 mg per 23 days) INTRAMUSCULA QL (1.6 per 21 R days) bupropion hcl oral 2 PBH; QL (30 SUSPENSION,EXT tablet extended per 23 days) ENDED REL release 24 hr 150 SYRING 441 mg, 300 mg MG/1.6 ML bupropion hcl oral 2 PBH; QL (60 ARISTADA 1 PrefD; PBH; tablet sustained- per 23 days) INTRAMUSCULA QL (2.4 per 21 release 12 hr 100 R days) mg, 200 mg SUSPENSION,EXT bupropion hcl oral 2 PBH; QL (90 ENDED REL tablet sustained- per 23 days) SYRING 662 release 12 hr 150 mg MG/2.4 ML buspirone oral tablet 2 PBH ARISTADA 1 PrefD; PBH; 10 mg, 15 mg, 30 INTRAMUSCULA QL (3.2 per 21 mg, 5 mg, 7.5 mg R days) SUSPENSION,EXT chlordiazepoxide hcl 2 PBH ENDED REL oral capsule 10 mg, SYRING 882 25 mg, 5 mg MG/3.2 ML chlorpromazine oral 2 PBH armodafinil oral 2 PA; PBH; QL tablet 10 mg, 100 tablet 150 mg, 200 (30 per 23 mg, 200 mg, 25 mg, mg, 250 mg days) 50 mg armodafinil oral 2 PA; PBH; QL citalopram oral 2 PBH tablet 50 mg (60 per 23 solution 10 mg/5 ml days) citalopram oral 2 PBH; QL (45 asenapine maleate 2 PA; PBH; QL tablet 10 mg per 23 days) sublingual tablet 10 (60 per 23 citalopram oral 2 mg, 2.5 mg, 5 mg days) tablet 20 mg atomoxetine oral 2 PBH; QL (60 citalopram oral 2 PBH; QL (30 capsule 10 mg, 100 per 23 days) tablet 40 mg per 23 days) mg, 18 mg, 25 mg, clomipramine oral 2 PBH 40 mg, 60 mg, 80 mg capsule 25 mg, 50 mg, 75 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clonidine hcl oral 2 PBH; QL (60 DESVENLAFAXIN 2 ST; PBH tablet extended per 23 days) E ORAL TABLET release 12 hr 0.1 mg EXTENDED clorazepate 2 PBH RELEASE 24 HR dipotassium oral 100 MG, 50 MG tablet 15 mg, 3.75 desvenlafaxine 2 PBH; QL (1 mg, 7.5 mg succinate oral tablet per 1 day) clozapine oral tablet 2 PBH extended release 24 100 mg, 200 mg, 25 hr 100 mg, 25 mg, mg, 50 mg 50 mg clozapine oral 2 PBH dexmethylphenidate 2 PBH; QL (60 tablet,disintegrating oral tablet 10 mg, per 23 days) 2.5 mg, 5 mg 100 mg, 150 mg, 200 mg, 25 mg dextroamphetamine 2 PBH; QL (150 clozapine oral 2 PA oral capsule, per 23 days) tablet,disintegrating extended release 10 12.5 mg mg CONCERTA ORAL 1 PBH; QL (60 dextroamphetamine 2 PBH; QL (120 TABLET per 23 days) oral capsule, per 23 days) EXTENDED extended release 15 RELEASE 24HR 18 mg MG, 27 MG, 36 dextroamphetamine 2 PBH; QL (90 MG, 54 MG oral capsule, per 23 days) extended release 5 COTEMPLA XR- 2 PA; PBH; QL ODT ORAL (60 per 23 mg TABLET,DISINTE days) dextroamphetamine 2 PBH G ER BIPHASE oral solution 5 mg/5 24H 17.3 MG, 25.9 ml MG, 8.6 MG dextroamphetamine 2 PBH; QL (180 DAYTRANA 2 PA; PBH; QL oral tablet 10 mg per 23 days) TRANSDERMAL (30 per 23 dextroamphetamine 2 PBH; QL (90 PATCH 24 HOUR days) oral tablet 5 mg per 23 days) 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 dextroamphetamine- 2 PBH; QL (90 HR, 30 MG/9 HR amphetamine oral per 23 days) tablet 10 mg, 12.5 DAYVIGO ORAL 2 PA; PBH mg, 15 mg, 20 mg, TABLET 10 MG, 5 30 mg, 5 mg, 7.5 mg MG diazepam intensol 2 PBH desipramine oral 2 PBH oral concentrate 5 tablet 10 mg, 100 mg/ml mg, 150 mg, 25 mg, 50 mg, 75 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 45 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diazepam oral 2 PBH escitalopram oxalate 2 PBH; QL (45 solution 5 mg/5 ml oral tablet 10 mg, 20 per 23 days) (1 mg/ml) mg, 5 mg diazepam oral tablet 2 PBH estazolam oral tablet 2 PBH 10 mg, 2 mg, 5 mg 1 mg, 2 mg DORAL ORAL 2 PBH eszopiclone oral 2 PBH; QL (30 TABLET 15 MG tablet 1 mg, 2 mg, 3 per 23 days) doxepin oral capsule 2 PBH mg 10 mg, 100 mg, 150 FANAPT ORAL 2 PA; PBH; QL mg, 25 mg, 50 mg, TABLET 1 MG, 10 (60 per 23 75 mg MG, 12 MG, 2 MG, days) doxepin oral 2 4 MG, 6 MG, 8 MG concentrate 10 FANAPT ORAL 2 PA; PBH mg/ml TABLETS,DOSE doxepin oral tablet 3 2 PBH; QL (30 PACK 1MG(2)- mg, 6 mg per 23 days) 2MG(2)- 4MG(2)- 6MG(2) duloxetine oral 2 PBH; QL (60 FETZIMA ORAL 2 PBH capsule,delayed per 23 days) release(dr/ec) 20 CAPSULE,EXT mg, 30 mg, 60 mg REL 24HR DOSE PACK 20 MG (2)- DYANAVEL XR 2 PA; PBH 40 MG (26) ORAL SUSPEN, IR - ER, BIPHASIC FETZIMA ORAL 2 ST; PBH; QL 24HR 2.5 MG/ML CAPSULE,EXTEN (30 per 23 DED RELEASE 24 days) EDLUAR 2 PA; PBH; QL HR 120 MG, 20 SUBLINGUAL (30 per 23 MG, 40 MG, 80 MG TABLET 10 MG, 5 days) MG fluoxetine oral 2 PBH; QL (30 capsule 10 mg per 23 days) EMSAM 2 PBH TRANSDERMAL fluoxetine oral 2 PBH; QL (90 PATCH 24 HOUR capsule 20 mg per 23 days) 12 MG/24 HR, 6 fluoxetine oral 2 PBH; QL (60 MG/24 HR, 9 capsule 40 mg per 23 days) MG/24 HR fluoxetine oral 2 ergoloid oral tablet 2 solution 20 mg/5 ml 1 mg (4 mg/ml) escitalopram oxalate 2 PBH fluoxetine oral tablet 2 PBH; QL (45 oral solution 5 mg/5 10 mg per 23 days) ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 46 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluoxetine oral tablet 2 PA; PBH; QL lactate 2 PBH 20 mg (60 per 23 oral concentrate 2 days) mg/ml fluoxetine oral tablet 2 PA; PBH; QL haloperidol oral 2 PBH 60 mg (30 per 23 tablet 0.5 mg, 1 mg, days) 10 mg, 2 mg, 20 mg, fluphenazine hcl oral 2 PBH 5 mg concentrate 5 mg/ml HETLIOZ ORAL 2 PA; SP; QL fluphenazine hcl oral 2 PBH CAPSULE 20 MG (30 per 23 days) elixir 2.5 mg/5 ml fluphenazine hcl oral 2 PBH imipramine hcl oral 2 PBH tablet 1 mg, 10 mg, tablet 10 mg, 25 mg, 2.5 mg, 5 mg 50 mg flurazepam oral 2 PBH imipramine pamoate 2 PBH capsule 15 mg, 30 oral capsule 100 mg, mg 125 mg, 150 mg, 75 mg fluvoxamine oral 2 ST; PBH; QL INVEGA 1 PrefD; PBH; capsule,extended (60 per 23 release 24hr 100 mg, days) SUSTENNA QL (0.75 per 150 mg INTRAMUSCULA 21 days) R SYRINGE 117 fluvoxamine oral 2 PBH; QL (90 MG/0.75 ML tablet 100 mg per 23 days) INVEGA 1 PrefD; PBH; fluvoxamine oral 2 PBH; QL (60 SUSTENNA QL (1 per 21 tablet 25 mg, 50 mg per 23 days) INTRAMUSCULA days) FOCALIN XR 1 PrefD; PBH; R SYRINGE 156 ORAL QL (60 per 23 MG/ML CAPSULE,ER days) INVEGA 1 PrefD; PBH; BIPHASIC 50-50 10 SUSTENNA QL (1.5 per 21 MG, 15 MG, 20 INTRAMUSCULA days) MG, 25 MG, 30 R SYRINGE 234 MG, 35 MG, 40 MG/1.5 ML MG, 5 MG INVEGA 1 PrefD; PBH; guanfacine oral 2 PBH; QL (30 SUSTENNA QL (0.25 per tablet extended per 23 days) INTRAMUSCULA 21 days) release 24 hr 1 mg, 2 R SYRINGE 39 mg, 3 mg, 4 mg MG/0.25 ML haloperidol 2 PBH INVEGA 1 PrefD; PBH; decanoate SUSTENNA QL (0.5 per 21 intramuscular INTRAMUSCULA days) solution 100 mg/ml, R SYRINGE 78 50 mg/ml MG/0.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 47 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INVEGA TRINZA 1 PrefD; PBH; lorazepam oral 2 INTRAMUSCULA QL (0.875 per tablet 2 mg R SYRINGE 273 84 days) loxapine succinate 2 PBH MG/0.875 ML oral capsule 10 mg, INVEGA TRINZA 1 PrefD; PBH; 25 mg, 5 mg, 50 mg INTRAMUSCULA QL (1.315 per maprotiline oral 2 PBH R SYRINGE 410 84 days) tablet 25 mg, 50 mg, MG/1.315 ML 75 mg INVEGA TRINZA 1 PrefD; PBH; MARPLAN ORAL 2 PBH INTRAMUSCULA QL (1.75 per TABLET 10 MG R SYRINGE 546 84 days) MG/1.75 ML methamphetamine 2 PBH oral tablet 5 mg INVEGA TRINZA 1 PrefD; PBH; INTRAMUSCULA QL (2.625 per hcl 2 PBH; QL (900 R SYRINGE 819 84 days) oral solution 10 per 23 days) MG/2.625 ML mg/5 ml LATUDA ORAL 2 PA; PBH; QL methylphenidate hcl 2 PBH TABLET 120 MG, (30 per 23 oral solution 5 mg/5 20 MG, 40 MG, 60 days) ml MG methylphenidate hcl 2 PBH; QL (90 LATUDA ORAL 2 PA; PBH; QL oral tablet 10 mg, 20 per 23 days) TABLET 80 MG (60 per 23 mg, 5 mg days) methylphenidate hcl 2 PBH lithium carbonate 2 PBH oral tablet,chewable oral capsule 150 mg, 10 mg, 2.5 mg, 5 mg 300 mg, 600 mg midazolam oral 2 PBH lithium carbonate 2 PBH syrup 2 mg/ml oral tablet 300 mg mirtazapine oral 2 PBH; QL (30 lithium carbonate 2 PBH tablet 15 mg, 30 mg, per 23 days) oral tablet extended 45 mg, 7.5 mg release 300 mg, 450 mirtazapine oral 2 PBH; QL (30 mg tablet,disintegrating per 23 days) lorazepam intensol 2 PBH 15 mg, 30 mg, 45 mg oral concentrate 2 modafinil oral tablet 2 PA; PBH; QL mg/ml 100 mg (30 per 23 lorazepam oral 2 PBH days) concentrate 2 mg/ml modafinil oral tablet 2 PA; PBH; QL lorazepam oral 2 PBH 200 mg (60 per 23 tablet 0.5 mg, 1 mg days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 48 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nefazodone oral 2 PBH oral 2 PBH; QL (30 tablet 100 mg, 150 tablet extended per 23 days) mg, 200 mg, 250 mg, release 24hr 1.5 mg, 50 mg 3 mg, 9 mg nighttime sleep-aid 2 OTC paliperidone oral 2 PBH; QL (60 (doxylamn) oral tablet extended per 23 days) tablet 25 mg release 24hr 6 mg nortriptyline oral 2 PBH paroxetine hcl oral 2 PBH; QL (30 capsule 10 mg, 25 tablet 10 mg, 20 mg per 23 days) mg, 50 mg, 75 mg paroxetine hcl oral 2 PBH; QL (60 nortriptyline oral 2 PBH tablet 30 mg, 40 mg per 23 days) solution 10 mg/5 ml paroxetine hcl oral 2 PBH; QL (30 NUPLAZID ORAL 2 PA; SP; QL tablet extended per 23 days) CAPSULE 34 MG (30 per 23 release 24 hr 12.5 days) mg NUPLAZID ORAL 2 PA; SP; QL paroxetine hcl oral 2 PBH; QL (60 TABLET 10 MG (30 per 23 tablet extended per 23 days) days) release 24 hr 25 mg, olanzapine 2 QL (6 per 23 37.5 mg intramuscular recon days) paroxetine 2 PBH; QL (30 soln 10 mg mesylate(menop.sym per 23 days) olanzapine oral 2 PBH; QL (60 ) oral capsule 7.5 tablet 10 mg, 2.5 mg, per 23 days) mg 20 mg, 5 mg, 7.5 mg PAXIL ORAL 2 PBH olanzapine oral 2 QL (2 per 1 SUSPENSION 10 tablet 15 mg day) MG/5 ML olanzapine oral 2 ST; PBH; QL perphenazine oral 2 PBH tablet,disintegrating (60 per 23 tablet 16 mg, 2 mg, 4 10 mg, 15 mg, 5 mg days) mg, 8 mg olanzapine oral 2 PBH; QL (2 perphenazine- 2 PBH tablet,disintegrating per 1 day) amitriptyline oral tablet 2-10 mg, 2-25 20 mg mg, 4-10 mg, 4-25 olanzapine- 2 PBH; QL (30 mg, 4-50 mg fluoxetine oral per 23 days) capsule 12-25 mg, phenelzine oral 2 PBH 12-50 mg, 3-25 mg, tablet 15 mg 6-25 mg, 6-50 mg pimozide oral tablet 2 PBH oxazepam oral 2 1 mg, 2 mg capsule 10 mg, 15 protriptyline oral 2 PBH mg, 30 mg tablet 10 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 49 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits QUAZEPAM 2 PBH RISPERDAL 2 PA; PBH; QL ORAL TABLET 15 CONSTA (2 per 21 days) MG INTRAMUSCULA quetiapine oral 2 PBH; QL (90 R tablet 100 mg per 23 days) SUSPENSION,EXT ENDED REL quetiapine oral 2 PBH; QL (120 RECON 12.5 MG/2 tablet 200 mg, 25 per 23 days) ML, 25 MG/2 ML mg, 50 mg RISPERDAL 2 PA; PBH; QL quetiapine oral 2 PBH; QL (60 CONSTA (1 per 21 days) tablet 300 mg, 400 per 23 days) INTRAMUSCULA mg R quetiapine oral 2 ST; PBH; QL SUSPENSION,EXT tablet extended (30 per 23 ENDED REL release 24 hr 150 days) RECON 37.5 MG/2 mg, 200 mg, 300 mg, ML, 50 MG/2 ML 400 mg oral 2 PBH; QL (120 quetiapine oral 2 ST; PBH; QL solution 1 mg/ml per 23 days) tablet extended (60 per 23 risperidone oral 2 PBH; QL (60 release 24 hr 50 mg days) tablet 0.25 mg, 1 mg, per 23 days) QUILLICHEW ER 2 PA; PBH; QL 2 mg, 3 mg, 4 mg ORAL (30 per 23 risperidone oral 2 PBH; QL (120 TABLET,CHEW,IR days) tablet 0.5 mg per 23 days) - risperidone oral 2 PA; PBH; QL ER.BIPHASIC24HR 20 MG, 30 MG, 40 tablet,disintegrating (60 per 23 MG 0.25 mg days) risperidone oral 2 PBH; QL (120 QUILLIVANT XR 2 PA; PBH ORAL tablet,disintegrating per 23 days) SUSPENSION,EXT 0.5 mg REL 24HR,RECON risperidone oral 2 PBH; QL (60 5 MG/ML (25 MG/5 tablet,disintegrating per 23 days) ML) 1 mg, 2 mg, 4 mg ramelteon oral tablet 2 PA; QL (30 risperidone oral 2 PBH 8 mg per 23 days) tablet,disintegrating REXULTI ORAL 2 PA; PBH; QL 3 mg TABLET 0.25 MG, (30 per 23 seconal sodium oral 2 0.5 MG, 1 MG, 2 days) capsule 100 mg MG, 3 MG, 4 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 50 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SECUADO 2 PA; PBH; QL trimipramine oral 2 PBH TRANSDERMAL (30 per 23 capsule 100 mg, 25 PATCH 24 HOUR days) mg, 50 mg 3.8 MG/24 HOUR, TRINTELLIX 2 ST; PBH; QL 5.7 MG/24 HOUR, ORAL TABLET 10 (30 per 23 7.6 MG/24 HOUR MG, 20 MG, 5 MG days) sertraline oral 2 PBH venlafaxine oral 2 PBH; QL (60 concentrate 20 capsule,extended per 23 days) mg/ml release 24hr 150 mg, sertraline oral tablet 2 QL (2 per 1 37.5 mg, 75 mg 100 mg day) venlafaxine oral 2 PBH; QL (90 sertraline oral tablet 2 QL (1.5 per 1 tablet 100 mg, 25 per 23 days) 25 mg, 50 mg day) mg, 37.5 mg, 50 mg, sleep aid 2 OTC 75 mg (doxylamine) oral venlafaxine oral 2 PA; PBH; QL tablet 25 mg tablet extended (60 per 23 SUNOSI ORAL 2 PA; QL (1 per release 24hr 150 mg, days) TABLET 150 MG, 1 day) 37.5 mg 75 MG venlafaxine oral 2 PA; PBH; QL temazepam oral 2 PBH tablet extended (2 per 1 day) release 24hr 75 mg capsule 15 mg, 30 mg VERSACLOZ 2 thioridazine oral 2 PBH ORAL tablet 10 mg, 100 SUSPENSION 50 mg, 25 mg, 50 mg MG/ML thiothixene oral 2 PBH VIIBRYD ORAL 2 ST; PBH; QL capsule 1 mg, 10 mg, TABLET 10 MG, 40 (60 per 23 2 mg, 5 mg MG days) tranylcypromine 2 PBH VIIBRYD ORAL 2 ST; PBH; QL oral tablet 10 mg TABLET 20 MG (30 per 23 days) trazodone oral tablet 2 VIIBRYD ORAL 2 PBH; QL (30 100 mg, 50 mg TABLETS,DOSE per 23 days) trazodone oral tablet 2 PBH PACK 10 MG (7)- 150 mg, 300 mg 20 MG (23) triazolam oral tablet 2 PBH VRAYLAR ORAL 2 PA; PBH; QL 0.125 mg, 0.25 mg CAPSULE 1.5 MG, (30 per 23 trifluoperazine oral 2 PBH 3 MG, 4.5 MG, 6 days) tablet 1 mg, 10 mg, 2 MG mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 51 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VRAYLAR ORAL 2 PA; PBH; QL ZOLPIMIST ORAL 2 PA; PBH; QL CAPSULE,DOSE (4 per 21 days) SPRAY,NON- (7.7 per 23 PACK 1.5 MG (1)- AEROSOL 5 days) 3 MG (6) MG/SPRAY (0.1 VYVANSE ORAL 1 PrefD; PBH; ML) CAPSULE 10 MG, QL (60 per 23 ZYPREXA 2 PA; PBH; QL 20 MG, 30 MG, 40 days) RELPREVV (2 per 21 days) MG, 50 MG, 60 INTRAMUSCULA MG, 70 MG R SUSPENSION VYVANSE ORAL 1 PrefD; PBH; FOR TABLET,CHEWAB QL (60 per 23 RECONSTITUTIO LE 10 MG, 20 MG, days) N 210 MG, 300 MG 30 MG, 40 MG, 50 ZYPREXA 2 PA; PBH; QL MG, 60 MG RELPREVV (1 per 21 days) WAKIX ORAL 2 PA; SP; QL INTRAMUSCULA R SUSPENSION TABLET 17.8 MG, (60 per 23 4.45 MG days) FOR RECONSTITUTIO wal-som 2 OTC N 405 MG (doxylamine) oral CARDIOVASCULAR, tablet 25 mg XYREM ORAL 2 PA; SP; QL HYPERTENSION / LIPIDS SOLUTION 500 (540 per 23 ANTIARRHYTHMIC AGENTS MG/ML days) amiodarone oral 2 XYWAV ORAL 2 SP tablet 100 mg, 200 SOLUTION 0.5 mg, 400 mg GRAM/ML disopyramide 2 zaleplon oral 2 PBH; QL (30 phosphate oral capsule 10 mg, 5 mg per 23 days) capsule 100 mg, 150 ziprasidone hcl oral 2 PBH; QL (60 mg capsule 20 mg, 40 per 23 days) dofetilide oral 2 mg, 60 mg, 80 mg capsule 125 mcg, zolpidem oral tablet 2 PBH; QL (30 250 mcg, 500 mcg 10 mg, 5 mg per 23 days) flecainide oral tablet 2 zolpidem oral 2 PBH; QL (30 100 mg, 150 mg, 50 tablet,ext release per 23 days) mg multiphase 12.5 mg, mexiletine oral 2 6.25 mg capsule 150 mg, 200 zolpidem sublingual 2 PBH; QL (30 mg, 250 mg tablet 1.75 mg, 3.5 per 23 days) MULTAQ ORAL 2 mg TABLET 400 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 52 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NORPACE CR 2 aliskiren oral tablet 2 QL (30 per 23 ORAL CAPSULE, 150 mg, 300 mg days) EXTENDED amiloride oral tablet 2 RELEASE 100 MG, 5 mg 150 MG amiloride- 2 pacerone oral tablet 2 hydrochlorothiazide 100 mg, 200 mg, 400 oral tablet 5-50 mg mg amlodipine oral 2 propafenone oral 2 tablet 10 mg, 2.5 mg, capsule,extended 5 mg release 12 hr 225 mg, 325 mg, 425 mg amlodipine- 2 benazepril oral propafenone oral 2 capsule 10-20 mg, tablet 150 mg, 225 10-40 mg, 2.5-10 mg, 300 mg mg, 5-10 mg, 5-20 quinidine gluconate 2 mg, 5-40 mg oral tablet extended amlodipine- 2 ST release 324 mg olmesartan oral quinidine sulfate 2 tablet 10-20 mg, 10- oral tablet 200 mg, 40 mg, 5-20 mg, 5- 300 mg 40 mg sorine oral tablet 2 atenolol oral tablet 2 120 mg, 160 mg, 240 100 mg, 25 mg, 50 mg, 80 mg mg sotalol af oral tablet 2 atenolol- 2 120 mg, 160 mg, 80 chlorthalidone oral mg tablet 100-25 mg, sotalol oral tablet 2 50-25 mg 120 mg, 160 mg, 240 benazepril oral 2 1 Copay mg, 80 mg tablet 10 mg, 20 mg, SOTYLIZE ORAL 2 PA 40 mg, 5 mg SOLUTION 5 benazepril- 2 MG/ML hydrochlorothiazide oral tablet 10-12.5

ANTIHYPERTENSIVE THERAPY mg, 20-12.5 mg, 20- acebutolol oral 2 25 mg, 5-6.25 mg capsule 200 mg, 400 betaxolol oral tablet 2 mg 10 mg, 20 mg ALDACTAZIDE 2 BIDIL ORAL 2 ORAL TABLET 50- TABLET 20-37.5 50 MG MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 53 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bisoprolol fumarate 2 CARDURA XL 2 PA; QL (30 oral tablet 10 mg, 5 ORAL TABLET per 23 days) mg EXTENDED bisoprolol- 2 RELEASE 24HR 4 hydrochlorothiazide MG, 8 MG oral tablet 10-6.25 cartia xt oral 2 mg, 2.5-6.25 mg, 5- capsule,extended 6.25 mg release 24hr 120 mg, bumetanide oral 2 180 mg, 240 mg, 300 tablet 0.5 mg, 1 mg, mg 2 mg carvedilol oral tablet 2 BYSTOLIC ORAL 2 ST 12.5 mg, 25 mg, 3.125 mg, 6.25 mg TABLET 10 MG, 2.5 MG, 20 MG carvedilol phosphate 2 ST BYSTOLIC ORAL 2 oral capsule, er TABLET 5 MG multiphase 24 hr 10 mg, 20 mg, 40 mg, candesartan oral 2 ST; 1 Copay 80 mg tablet 16 mg, 32 mg, 4 mg, 8 mg chlorthalidone oral 2 tablet 25 mg, 50 mg candesartan- 2 ST clonidine hcl oral 2 1 Copay; PBH hydrochlorothiazid oral tablet 16-12.5 tablet 0.1 mg, 0.2 mg, 32-12.5 mg, 32- mg, 0.3 mg 25 mg clonidine 2 1 Copay; PBH captopril oral tablet 2 ST; 1 Copay transdermal patch 100 mg, 12.5 mg, 25 weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg, 50 mg mg/24 hr captopril- 2 hydrochlorothiazide diltiazem hcl oral 2 oral tablet 25-15 mg, capsule,extended 25-25 mg, 50-15 mg, release 12 hr 120 50-25 mg mg, 60 mg, 90 mg CARDIZEM LA 2 diltiazem hcl oral 2 ORAL TABLET capsule,extended EXTENDED release 24 hr 120 RELEASE 24 HR mg, 180 mg, 240 mg, 120 MG 300 mg, 360 mg, 420 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diltiazem hcl oral 2 epoprostenol 2 PA; SP capsule,extended (glycine) release 24hr 120 mg, intravenous recon 180 mg, 240 mg, 300 soln 0.5 mg, 1.5 mg mg, 360 mg eprosartan oral 2 ST; 1 Copay diltiazem hcl oral 2 tablet 600 mg tablet 120 mg, 30 ethacrynic acid oral 2 mg, 60 mg, 90 mg tablet 25 mg dilt-xr oral 2 felodipine oral tablet 2 capsule,ext.rel 24h extended release 24 degradable 120 mg, hr 10 mg, 2.5 mg, 5 180 mg, 240 mg mg DIURIL ORAL 2 fosinopril oral tablet 2 1 Copay SUSPENSION 250 10 mg, 20 mg, 40 mg MG/5 ML fosinopril- 2 doxazosin oral tablet 2 hydrochlorothiazide 1 mg, 2 mg, 4 mg, 8 oral tablet 10-12.5 mg mg, 20-12.5 mg DUTOPROL ORAL 2 ST furosemide oral 2 TABLET solution 10 mg/ml, EXTENDED 40 mg/5 ml (8 RELEASE 24 HR mg/ml) 100-12.5 MG, 25- 12.5 MG, 50-12.5 furosemide oral 2 MG tablet 20 mg, 40 mg, 80 mg DYRENIUM ORAL 2 CAPSULE 100 MG, guanfacine oral 2 1 Copay; PBH 50 MG tablet 1 mg, 2 mg enalapril maleate 2 1 Copay HEMANGEOL 2 PA oral tablet 10 mg, ORAL SOLUTION 2.5 mg, 20 mg, 5 mg 4.28 MG/ML enalapril- 2 hydralazine oral 2 1 Copay hydrochlorothiazide tablet 10 mg, 100 oral tablet 10-25 mg, mg, 25 mg, 50 mg 5-12.5 mg hydrochlorothiazide 2 EPANED ORAL 2 PA oral capsule 12.5 mg SOLUTION 1 hydrochlorothiazide 2 MG/ML oral tablet 12.5 mg, eplerenone oral 2 25 mg, 50 mg tablet 25 mg, 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 55 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits indapamide oral 2 methyldopa- 2 1 Copay tablet 1.25 mg, 2.5 hydrochlorothiazide mg oral tablet 250-15 irbesartan oral 2 1 Copay mg, 250-25 mg tablet 150 mg, 300 metolazone oral 2 mg, 75 mg tablet 10 mg, 2.5 mg, irbesartan- 2 5 mg hydrochlorothiazide metoprolol succinate 2 oral tablet 150-12.5 oral tablet extended mg, 300-12.5 mg release 24 hr 100 isradipine oral 2 mg, 200 mg, 25 mg, capsule 2.5 mg, 5 mg 50 mg labetalol oral tablet 2 metoprolol ta- 2 100 mg, 200 mg, 300 hydrochlorothiaz mg oral tablet 100-25 mg, 100-50 mg, 50- lisinopril oral tablet 2 1 Copay 25 mg 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 metoprolol tartrate 2 mg oral tablet 100 mg, 25 mg, 50 mg lisinopril- 2 metyrosine oral 2 hydrochlorothiazide oral tablet 10-12.5 capsule 250 mg mg, 20-12.5 mg, 20- oral tablet 2 1 Copay 25 mg 10 mg, 2.5 mg losartan oral tablet 2 1 Copay moexipril oral tablet 2 1 Copay 100 mg, 25 mg, 50 15 mg, 7.5 mg mg nadolol oral tablet 2 losartan- 2 20 mg, 40 mg, 80 mg hydrochlorothiazide nadolol- 2 oral tablet 100-12.5 bendroflumethiazide mg, 100-25 mg, 50- oral tablet 80-5 mg 12.5 mg nicardipine oral 2 matzim la oral tablet 2 capsule 20 mg, 30 extended release 24 mg hr 180 mg, 240 mg, 300 mg, 360 mg, 420 nifedipine oral 2 mg capsule 10 mg, 20 mg methyldopa oral 2 1 Copay tablet 250 mg, 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 56 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nifedipine oral tablet 2 propranolol oral 2 extended release solution 20 mg/5 ml 24hr 30 mg, 60 mg, (4 mg/ml), 40 mg/5 90 mg ml (8 mg/ml) nifedipine oral tablet 2 propranolol oral 2 extended release 60 tablet 10 mg, 20 mg, mg, 90 mg 40 mg, 60 mg, 80 mg nimodipine oral 2 propranolol- 2 capsule 30 mg hydrochlorothiazid oral tablet 40-25 mg, nisoldipine oral 2 tablet extended 80-25 mg release 24 hr 17 mg, QBRELIS ORAL 2 PA 20 mg, 25.5 mg, 30 SOLUTION 1 mg, 34 mg, 40 mg, MG/ML 8.5 mg quinapril oral tablet 2 1 Copay olmesartan oral 2 1 Copay 10 mg, 20 mg, 40 tablet 20 mg, 40 mg, mg, 5 mg 5 mg quinapril- 2 olmesartan- 2 hydrochlorothiazide hydrochlorothiazide oral tablet 10-12.5 oral tablet 20-12.5 mg, 20-12.5 mg, 20- mg, 40-12.5 mg, 40- 25 mg 25 mg ramipril oral 2 1 Copay perindopril 2 1 Copay capsule 1.25 mg, 10 erbumine oral tablet mg, 2.5 mg, 5 mg 2 mg, 4 mg, 8 mg spironolactone oral 2 pindolol oral tablet 2 tablet 100 mg, 25 10 mg, 5 mg mg, 50 mg prazosin oral 2 spironolacton- 2 capsule 1 mg, 2 mg, hydrochlorothiaz 5 mg oral tablet 25-25 mg PRESTALIA ORAL 2 ST taztia xt oral 2 TABLET 14-10 capsule,extended MG, 3.5-2.5 MG, 7- release 24 hr 120 5 MG mg, 180 mg, 240 mg, propranolol oral 2 ST 300 mg, 360 mg capsule,extended TEKTURNA HCT 2 QL (30 per 23 release 24 hr 120 ORAL TABLET days) mg, 160 mg, 60 mg, 150-12.5 MG, 150- 80 mg 25 MG, 300-12.5 MG, 300-25 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 57 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits telmisartan oral 2 1 Copay UPTRAVI ORAL 2 PA; SP tablet 20 mg, 40 mg, TABLET 1,000 80 mg MCG, 1,200 MCG, telmisartan- 2 ST 1,400 MCG, 1,600 amlodipine oral MCG, 200 MCG, tablet 40-10 mg, 40- 400 MCG, 600 5 mg, 80-10 mg, 80- MCG, 800 MCG 5 mg UPTRAVI ORAL 2 PA; SP telmisartan- 2 TABLETS,DOSE hydrochlorothiazid PACK 200 MCG oral tablet 40-12.5 (140)- 800 MCG mg, 80-12.5 mg, 80- (60) 25 mg valsartan oral tablet 2 1 Copay terazosin oral 2 160 mg, 320 mg, 40 capsule 1 mg, 10 mg, mg, 80 mg 2 mg, 5 mg valsartan- 2 timolol maleate oral 2 hydrochlorothiazide tablet 10 mg, 20 mg, oral tablet 160-12.5 5 mg mg, 160-25 mg, 320- 12.5 mg, 320-25 mg, torsemide oral tablet 2 80-12.5 mg 10 mg, 100 mg, 20 mg, 5 mg verapamil oral 2 capsule, 24 hr er trandolapril oral 2 1 Copay pellet ct 100 mg, 200 tablet 1 mg, 2 mg, 4 mg, 300 mg mg verapamil oral 2 trandolapril- 2 capsule,ext rel. verapamil oral pellets 24 hr 120 mg, tablet, ir - er, 180 mg, 240 mg, 360 biphasic 24hr 1-240 mg mg, 2-180 mg, 2-240 mg, 4-240 mg verapamil oral tablet 2 120 mg, 40 mg, 80 triamterene- 2 mg hydrochlorothiazid oral capsule 37.5-25 verapamil oral tablet 2 mg extended release 120 mg, 180 mg, 240 mg triamterene- 2 hydrochlorothiazid VERELAN ORAL 2 oral tablet 37.5-25 CAPSULE,EXT mg, 75-50 mg REL. PELLETS 24 HR 360 MG CARDIAC GLYCOSIDES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 58 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits digitek oral tablet 2 AFSTYLA 2 PA; SP 125 mcg (0.125 mg), INTRAVENOUS 250 mcg (0.25 mg) RECON SOLN digox oral tablet 125 2 1,000 (+/-) UNIT mcg (0.125 mg), 250 RANGE, 1,500 (+/-) mcg (0.25 mg) UNIT RANGE, 2,000 (+/-) UNIT digoxin oral solution 2 RANGE, 2,500 (+/-) 50 mcg/ml (0.05 UNIT RANGE, 250 mg/ml) (+/-) UNIT RANGE, digoxin oral tablet 2 3,000 (+/-) UNIT 125 mcg (0.125 mg), RANGE, 500 (+/-) 250 mcg (0.25 mg) UNIT RANGE LANOXIN ORAL 2 ALPHANATE 2 PA; SP TABLET 62.5 MCG INTRAVENOUS (0.0625 MG) RECON SOLN 1,000 (400 VWF) COAGULATION THERAPY UNIT/10 ML, 1,500 ADVATE 2 PA; SP (600 VWF) INTRAVENOUS UNIT/10 ML, 2,000 RECON SOLN (800 VWF) 1,000 (+/-) UNIT, UNIT/10 ML, 250 1,500 (+/-) UNIT, (100 VWF) UNIT/5 2,000 (+/-) UNIT, ML, 500 (200 VWF) 250 (+/-) UNIT, UNIT/5 ML 3,000 (+/-) UNIT, ALPHANINE SD 2 PA; SP 4,000 (+/-) UNIT, INTRAVENOUS 500 (+/-) UNIT RECON SOLN ADYNOVATE 2 PA; SP 1,000 (+/-) UNIT, INTRAVENOUS 1,500 (+/-) UNIT, SOLUTION 1,000 500 (+/-) UNIT (+/-) UNIT, 1,500 ALPROLIX 2 PA; SP (+/-) UNIT, 2,000 INTRAVENOUS (+/-) UNIT, 250 (+/- RECON SOLN ) UNIT, 3,000 (+/-) 1,000 UNIT, 2,000 UNIT, 500 (+/-) UNIT, 250 UNIT, UNIT, 750 (+/-) 3,000 UNIT, 4,000 UNIT UNIT, 500 UNIT aminocaproic acid 2 oral solution 250 mg/ml (25 %)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 59 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits aminocaproic acid 2 dipyridamole oral 2 oral tablet 1,000 mg, tablet 25 mg, 50 mg, 500 mg 75 mg aspirin-dipyridamole 2 ELIQUIS DVT-PE 1 PrefD oral capsule, er TREAT 30D multiphase 12 hr 25- START ORAL 200 mg TABLETS,DOSE BENEFIX 1 SP PACK 5 MG (74 INTRAVENOUS TABS) RECON SOLN ELIQUIS ORAL 1 PrefD 1,000 UNIT, 2,000 TABLET 2.5 MG, 5 UNIT, 250 UNIT, MG 3,000 UNIT, 500 ELOCTATE 2 PA; SP UNIT INTRAVENOUS BRILINTA ORAL 2 PA; ST; QL RECON SOLN TABLET 60 MG, 90 (60 per 23 1,000 UNIT, 2,000 MG days) UNIT, 250 UNIT, CEPROTIN (BLUE 2 SP 4,000 UNIT, 6,000 BAR) UNIT INTRAVENOUS ELOCTATE 2 SP RECON SOLN 500 INTRAVENOUS UNIT RECON SOLN CEPROTIN 2 SP 1,500 UNIT, 3,000 (GREEN BAR) UNIT, 5,000 UNIT, INTRAVENOUS 500 UNIT, 750 RECON SOLN UNIT 1,000 UNIT enoxaparin 2 cilostazol oral tablet 2 subcutaneous 100 mg, 50 mg solution 300 mg/3 ml enoxaparin 2 clopidogrel oral 2 tablet 300 mg, 75 mg subcutaneous syringe 100 mg/ml, COAGADEX 2 PA; SP 120 mg/0.8 ml, 150 INTRAVENOUS mg/ml, 30 mg/0.3 ml, RECON SOLN 250 40 mg/0.4 ml, 60 (+/-) UNIT RANGE, mg/0.6 ml, 80 mg/0.8 500 (+/-) UNIT ml RANGE CORIFACT 2 PA; SP INTRAVENOUS RECON SOLN 1,000-1,600 UNIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 60 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FEIBA NF 2 PA; SP HEMOFIL M MID 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN RECON SOLN 401- 1,750-3,250 UNIT, 800 UNIT 350-650 UNIT, 700- HEMOFIL M 2 PA; SP 1,300 UNIT SUPER HIGH fondaparinux 2 INTRAVENOUS subcutaneous RECON SOLN syringe 10 mg/0.8 1,501-2,000 UNIT ml, 2.5 mg/0.5 ml, 5 heparin (porcine) 2 mg/0.4 ml, 7.5 injection solution mg/0.6 ml 1,000 unit/ml, FRAGMIN 2 20,000 unit/ml, SUBCUTANEOUS 5,000 unit/ml SOLUTION 25,000 heparin 2 ANTI-XA flush(porcine)- UNIT/ML 0.9nacl intravenous FRAGMIN 2 kit 100 unit/ml SUBCUTANEOUS heparin lock flush 2 SYRINGE 10,000 (porcine) ANTI-XA intravenous solution UNIT/ML, 12,500 10 unit/ml ANTI-XA UNIT/0.5 ML, 15,000 ANTI- heparin 2 XA UNIT/0.6 ML, lockflush(porcine)(pf 18,000 ANTI-XA ) intravenous syringe UNIT/0.72 ML, 100 unit/ml 2,500 ANTI-XA heparin, porcine (pf) 2 UNIT/0.2 ML, 5,000 injection solution ANTI-XA UNIT/0.2 1,000 unit/ml ML, 7,500 ANTI- XA UNIT/0.3 ML heparin, porcine (pf) 2 intravenous syringe HEMOFIL M HIGH 2 PA; SP 1 unit/ml INTRAVENOUS RECON SOLN 801- HEPARIN, 2 1,500 UNIT PORCINE (PF) SUBCUTANEOUS HEMOFIL M LOW 2 PA; SP SYRINGE 5,000 INTRAVENOUS UNIT/0.5 ML RECON SOLN 220- 400 UNIT HUMATE-P 2 PA; SP INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 500-1,200 UNIT You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 61 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMATE-P 2 SP KOGENATE FS 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 250- RECON SOLN 600 UNIT 1,000 (+/-) UNIT, IDELVION 2 PA; SP 2,000 (+/-) UNIT, INTRAVENOUS 250 (+/-) UNIT, RECON SOLN 3,000 (+/-) UNIT, 1,000 (+/-) UNIT, 500 (+/-) UNIT 2,000 (+/-) UNIT, KOVALTRY 2 PA; SP 250 (+/-) UNIT, INTRAVENOUS 3,500 (+/-) UNIT, RECON SOLN 500 (+/-) UNIT 1,000 (+/-) UNIT, IXINITY 2 PA; SP 2,000 (+/-) UNIT, INTRAVENOUS 250 (+/-) UNIT, RECON SOLN 3,000 (+/-) UNIT, 1,000 UNIT, 1,500 500 (+/-) UNIT UNIT, 2,000 UNIT, MONONINE 2 PA; SP 250 UNIT, 3,000 INTRAVENOUS UNIT, 500 UNIT RECON SOLN jantoven oral tablet 2 1,000 (+/-) UNIT 1 mg, 10 mg, 2 mg, NOVOEIGHT 2 PA; SP 2.5 mg, 3 mg, 4 mg, INTRAVENOUS 5 mg, 6 mg, 7.5 mg RECON SOLN KCENTRA 2 SP 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, INTRAVENOUS RECON SOLN 2,000 (+/-) UNIT, 1,000 UNIT (800- 250 (+/-) UNIT, 3,000 (+/-) UNIT, 1240 UNIT), 500 UNIT (400-620 500 (+/-) UNIT UNIT) NOVOSEVEN RT 2 PA; SP KOATE 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 1 RECON SOLN MG (1,000 MCG), 2 1,000 (+/-) UNIT, MG (2,000 MCG), 5 250 (+/-) UNIT, 500 MG (5,000 MCG), 8 (+/-) UNIT MG (8,000 MCG) NPLATE 2 PA; SP SUBCUTANEOUS RECON SOLN 250 MCG, 500 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 62 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NUWIQ 2 PA; SP REBINYN 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 1000 RECON SOLN (+/-) UNIT, 2,000 1,000 (+/-) UNIT, (+/-) UNIT, 2,500 2,000 (+/-) UNIT, UNIT, 250 (+/-) 500 (+/-) UNIT UNIT, 3,000 UNIT, RECOMBINATE 2 PA; SP 4,000 UNIT, 500 INTRAVENOUS (+/-) UNIT RECON SOLN OBIZUR 2 PA; SP 1,000 (+/-) UNIT, INTRAVENOUS 1,500 (+/-) UNIT, RECON SOLN 500 2,000 (+/-) UNIT, (+/-) UNIT RANGE 250 (+/-) UNIT, 500 pentoxifylline oral 2 (+/-) UNIT tablet extended RIASTAP 2 SP release 400 mg INTRAVENOUS PHYTONADIONE 2 RECON SOLN 1 (VITAMIN K1) GRAM (900MG- 1,300MG) INJECTION SYRINGE 1 MG/0.5 RIXUBIS 2 PA; SP ML INTRAVENOUS PRADAXA ORAL 1 QL (70 per RECON SOLN CAPSULE 110 MG 365 days) 1,000 UNIT, 2,000 UNIT, 250 UNIT, PRADAXA ORAL 1 3,000 UNIT, 500 CAPSULE 150 MG, UNIT 75 MG SAVAYSA ORAL 1 PA prasugrel oral tablet 2 ST TABLET 15 MG, 30 10 mg, 5 mg MG, 60 MG PROFILNINE 2 PA; SP TAVALISSE ORAL 2 PA; SP; QL INTRAVENOUS TABLET 100 MG, (60 per 23 RECON SOLN 150 MG days) 1,000 (+/-) UNIT, THROMBATE III 2 SP 1,500 (+/-) UNIT, 500 (+/-) UNIT INTRAVENOUS RECON SOLN 500 PROMACTA 2 PA; SP (+/-) UNIT ORAL POWDER IN PACKET 12.5 MG, TRETTEN 2 PA; SP 25 MG INTRAVENOUS RECON SOLN PROMACTA 2 PA; SP 2,500 UNIT ORAL TABLET 12.5 MG, 25 MG, 50 vitamin k injection 2 MG, 75 MG solution 1 mg/0.5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 63 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VONVENDI 2 PA; SP LIPID/CHOLESTEROL LOWERING

INTRAVENOUS AGENTS RECON SOLN 1,300 (+/-) UNIT atorvastatin oral 2 1 Copay; ACA RANGE, 650 (+/-) tablet 10 mg, 20 mg, UNIT RANGE 40 mg, 80 mg warfarin oral tablet 2 cholestyramine (with 2 1 mg, 10 mg, 2 mg, sugar) oral powder 2.5 mg, 3 mg, 4 mg, 4 gram 5 mg, 6 mg, 7.5 mg cholestyramine (with 2 WILATE 2 PA; SP sugar) oral powder INTRAVENOUS in packet 4 gram RECON SOLN colesevelam oral 2 PA 1,000-1,000 UNIT, powder in packet 500-500 UNIT 3.75 gram XARELTO DVT-PE 1 colesevelam oral 2 PA TREAT 30D tablet 625 mg START ORAL colestipol oral 2 TABLETS,DOSE granules 5 gram PACK 15 MG (42)- 20 MG (9) colestipol oral 2 packet 5 gram XARELTO ORAL 1 TABLET 10 MG, 15 colestipol oral tablet 2 MG, 20 MG 1 gram XARELTO ORAL 1 PA; QL (60 endur-acin oral 2 OTC TABLET 2.5 MG per 23 days) tablet extended release 250 mg, 500 XYNTHA 1 SP mg INTRAVENOUS SOLUTION 1,000 ezetimibe oral tablet 2 (+/-) UNIT, 2,000 10 mg (+/-) UNIT, 250 (+/- fenofibrate 2 QL (30 per 23 ) UNIT, 500 (+/-) micronized oral days) UNIT capsule 134 mg, 200 XYNTHA 1 SP mg, 67 mg SOLOFUSE fenofibrate 2 QL (1 per 1 INTRAVENOUS nanocrystallized day) SYRINGE 1,000 oral tablet 145 mg (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/- fenofibrate 2 QL (60 per 23 ) UNIT, 3,000 (+/-) nanocrystallized days) UNIT, 500 (+/-) oral tablet 48 mg UNIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 64 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fenofibrate oral 2 niacin oral tablet 2 OTC tablet 160 mg extended release 250 fenofibrate oral 2 QL (60 per 23 mg, 500 mg tablet 54 mg days) NIACOR ORAL 2 fenofibric acid oral 2 QL (30 per 23 TABLET 500 MG tablet 105 mg days) omega-3 acid ethyl 2 PA; QL (120 esters oral capsule 1 per 23 days) fenofibric acid oral 2 QL (60 per 23 tablet 35 mg days) gram FIBRICOR ORAL 2 QL (30 per 23 omega-3 fatty acids 2 OTC TABLET 105 MG days) oral capsule 1,000 mg FIBRICOR ORAL 2 QL (60 per 23 TABLET 35 MG days) PRALUENT PEN 2 PA; SP SUBCUTANEOUS fish oil concentrate 2 OTC PEN INJECTOR oral capsule 1,000 150 MG/ML, 75 mg MG/ML gemfibrozil oral 2 pravastatin oral 2 1 Copay; ACA tablet 600 mg tablet 10 mg, 20 mg, JUXTAPID ORAL 2 PA; SP; QL 40 mg, 80 mg CAPSULE 10 MG, (30 per 23 prevalite oral 2 20 MG, 30 MG, 40 days) powder 4 gram MG, 5 MG, 60 MG prevalite oral 2 lovastatin oral tablet 2 1 Copay; ACA powder in packet 4 10 mg, 20 mg, 40 mg gram maxepa oral capsule 2 OTC REPATHA 2 PA; SP; QL 500 mg PUSHTRONEX (3.5 per 23 niacin (inositol 2 OTC SUBCUTANEOUS days) niacinate) oral WEARABLE capsule 500 mg INJECTOR 420 MG/3.5 ML niacin oral capsule, 2 OTC extended release 250 REPATHA 2 PA; SP; QL (3 mg, 500 mg SURECLICK per 23 days) SUBCUTANEOUS niacin oral tablet 2 OTC PEN INJECTOR 100 mg, 250 mg, 50 140 MG/ML mg, 500 mg REPATHA 2 PA; SP; QL (3 niacin oral tablet 2 SYRINGE per 23 days) extended release 24 SUBCUTANEOUS hr 1,000 mg, 500 SYRINGE 140 mg, 750 mg MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 65 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits rosuvastatin oral 2 1 Copay NITRATES tablet 10 mg, 20 mg, DILATRATE-SR 2 40 mg, 5 mg ORAL CAPSULE, simvastatin oral 2 1 Copay; ACA EXTENDED tablet 10 mg, 20 mg, RELEASE 40 MG 40 mg, 5 mg isosorbide dinitrate 2 simvastatin oral 2 1 Copay oral tablet 10 mg, 20 tablet 80 mg mg, 30 mg, 5 mg slo-niacin oral tablet 2 OTC isosorbide 2 extended release 500 mononitrate oral mg tablet 10 mg, 20 mg super omega-3 oral 2 OTC isosorbide 2 capsule 1,000 mg mononitrate oral SUPER TWIN EPA- 2 OTC tablet extended DHA ORAL release 24 hr 120 CAPSULE 1,250 mg, 30 mg, 60 mg MG MINITRAN 2 MISCELLANEOUS TRANSDERMAL PATCH 24 HOUR CARDIOVASCULAR AGENTS 0.1 MG/HR, 0.2 cardioplegic soln 2 MG/HR, 0.4 perfusion solution 16 MG/HR, 0.6 meq/l (= k+) MG/HR ENTRESTO ORAL 2 PA; QL (60 nitro-bid 2 TABLET 24-26 per 23 days) transdermal MG, 49-51 MG ointment 2 % ENTRESTO ORAL 2 PA; QL (2 per NITRO-DUR 2 TABLET 97-103 1 day) TRANSDERMAL MG PATCH 24 HOUR ranolazine oral 2 PA; QL (60 0.3 MG/HR, 0.8 tablet extended per 23 days) MG/HR release 12 hr 1,000 nitroglycerin oral 2 mg, 500 mg capsule, extended VECAMYL ORAL 2 release 6.5 mg, 9 mg TABLET 2.5 MG nitroglycerin 2 VYNDAMAX 2 PA; SP; QL sublingual tablet 0.3 ORAL CAPSULE (30 per 23 mg, 0.4 mg, 0.6 mg 61 MG days) VYNDAQEL 2 PA; SP; QL ORAL CAPSULE (120 per 23 20 MG days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 66 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nitroglycerin 2 COSENTYX 1 PA; SP transdermal patch SUBCUTANEOUS 24 hour 0.1 mg/hr, SYRINGE 150 0.2 mg/hr, 0.4 MG/ML mg/hr, 0.6 mg/hr dandruff shampoo 2 OTC nitroglycerin 2 (selenium) topical translingual shampoo 1 % spray,non-aerosol drithocreme hp 2 400 mcg/spray topical cream 1 % DERMATOLOGICALS/TOPICA ILUMYA 1 PA; SP L THERAPY SUBCUTANEOUS SYRINGE 100 ANTIPSORIATIC / MG/ML ANTISEBORRHEIC selenium sulfide 2 acitretin oral 2 SP topical lotion 2.5 % capsule 10 mg, 17.5 mg, 25 mg selenium sulfide 2 topical shampoo 2.3 anti-dandruff topical 2 OTC % shampoo 1 % selsun blue topical 2 OTC calcipotriene scalp 2 shampoo 1 % solution 0.005 % SILIQ 1 PA; SP calcipotriene topical 2 SUBCUTANEOUS cream 0.005 % SYRINGE 210 calcipotriene topical 2 MG/1.5 ML ointment 0.005 % SKYRIZI 1 PA; SP COSENTYX (2 1 PA; SP SUBCUTANEOUS SYRINGES) SYRINGE KIT SUBCUTANEOUS 150MG/1.66ML(75 SYRINGE 150 MG/0.83 ML X2) MG/ML STELARA 1 PA; SP; PrefD COSENTYX PEN 1 PA; SP INTRAVENOUS (2 PENS) SOLUTION 130 SUBCUTANEOUS MG/26 ML PEN INJECTOR STELARA 1 PA; SP; PrefD 150 MG/ML SUBCUTANEOUS COSENTYX PEN 1 PA; SP SOLUTION 45 SUBCUTANEOUS MG/0.5 ML PEN INJECTOR 150 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 67 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits STELARA 1 PA; SP; PrefD ssd topical cream 1 2 SUBCUTANEOUS % SYRINGE 45 KERATOLYTICS MG/0.5 ML, 90 MG/ML BENSAL HP 2 TOPICAL sulfacetamide 2 OINTMENT 3 % sodium topical cleanser 10 % KERALYT SCALP 2 COMPLETE TALTZ 1 PA; SP; PrefD TOPICAL AUTOINJECTOR KIT,SHAMPOO (2 PACK) AND GEL 6-6 % SUBCUTANEOUS AUTO-INJECTOR PODOCON 2 80 MG/ML TOPICAL LIQUID 25 % TALTZ 1 PA; SP; PrefD AUTOINJECTOR salicylic acid topical 2 (3 PACK) cream 6 % SUBCUTANEOUS salicylic acid topical 2 AUTO-INJECTOR film forming liquid 80 MG/ML w/appl 27.5 % TALTZ 1 PA; SP; PrefD salicylic acid topical 2 AUTOINJECTOR foam 6 % SUBCUTANEOUS AUTO-INJECTOR salicylic acid topical 2 80 MG/ML gel 6 % TALTZ SYRINGE 1 PA; SP; PrefD salicylic acid topical 2 SUBCUTANEOUS liquid 26 % SYRINGE 80 salicylic acid topical 2 MG/ML lotion 6 % TREMFYA 1 PA; SP salicylic acid topical 2 SUBCUTANEOUS shampoo 6 % AUTO-INJECTOR 100 MG/ML SALVAX DUO 2 PLUS TOPICAL TREMFYA 1 PA; SP FOAM 6-35 % SUBCUTANEOUS MISCELLANEOUS SYRINGE 100 MG/ML DERMATOLOGICALS BURN THERAPY a and d (lan, pet) 2 OTC topical ointment silver sulfadiazine 2 topical cream 1 % advanced healing 2 OTC (petrolatum) topical ointment 41 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 68 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ameriphor topical 2 OTC camphor topical 2 OTC ointment spirit ammonium lactate 2 OTC capsaicin topical 2 OTC topical cream 12 % adhesive ammonium lactate 2 OTC patch,medicated topical lotion 12 % 0.025 % capsaicin topical 2 OTC anti-dandruff with 2 OTC menthol topical cream 0.025 %, 0.1 shampoo 1 % % antiseptic skin 2 OTC CAPSAICIN 2 OTC clnsr(chlorhe) TOPICAL LIQUID topical liquid 4 % 0.15 % aquaphilic topical 2 OTC capsicum topical 2 OTC ointment adhesive patch,medicated AQUAPHOR 2 OTC 0.025 % BABY DIAPER RASH TOPICAL CAPZASIN 2 OTC TOPICAL LIQUID CREAM 15 % 0.15 % arthritis pain 2 OTC relief(capsaic) capzasin-hp topical 2 OTC topical cream 0.1 % cream 0.1 % benzoin compound 2 OTC CARAC TOPICAL 2 PA; QL (30 topical tincture , 10- CREAM 0.5 % per 23 days) 2-8-4 % CASTIVA 2 OTC benzoin topical 2 OTC WARMING tincture TOPICAL LIQUID 0.035 % betasept surgical 2 OTC scrub topical liquid celacyn topical gel 2 with pump 4 % BOUDREAUXS 2 OTC CERAMAX 2 BUTT PASTE TOPICAL CREAM TOPICAL chlorhexidine 2 OTC OINTMENT 16 % gluconate topical BOUDREAUXS 2 OTC liquid 2 %, 4 % BUTT PASTE CONDYLOX 2 PA; QL (7 per TOPICAL TOPICAL GEL 0.5 21 days) OINTMENT IN % PACKET 16 % dandruff shampoo 2 OTC calamine-zinc oxide 2 OTC (selen-aloe) topical topical lotion 8-8 % shampoo 1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 69 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits daylogic advanced 2 OTC EMU-LAC 2 OTC healing topical TOPICAL CREAM ointment 41 % 10 % dermaphor topical 2 OTC emulsion sb topical 2 ointment emulsion diaper rash topical 2 OTC EPICERAM 2 ointment 40 % TOPICAL diclofenac sodium 2 PA; QL (100 EMULSION, topical gel 3 % per 23 days) EXTENDED RELEASE doxepin topical 2 PA cream 5 % EUCRISA 1 PA; PrefD; QL TOPICAL (99 per 99 DR. SMITH'S 2 OTC OINTMENT 2 % days) ADULT BARRIER TOPICAL FLUOROPLEX 2 AEROSOL,SPRAY TOPICAL CREAM 10 % 1 % DR. SMITH'S 2 OTC FLUOROURACIL 2 PA; QL (30 TOPICAL CREAM per 23 days) DIAPER RASH TOPICAL 0.5 % AEROSOL,SPRAY fluorouracil topical 2 SP 10 % cream 5 % DRYSOL DAB-O- 2 fluorouracil topical 2 SP MATIC TOPICAL solution 2 %, 5 % SOLUTION 20 % GENADUR 2 DRYSOL TOPICAL 2 TOPICAL LIQUID SOLUTION 20 % hand wash topical 2 OTC DUPIXENT PEN 1 PA; SP liquid 2 % SUBCUTANEOUS hemorrhoidal 2 OTC PEN INJECTOR hygiene topical 300 MG/2 ML pads, medicated 50 DUPIXENT 1 PA; SP % SYRINGE hemorrhoidal 2 OTC SUBCUTANEOUS medicated topical SYRINGE 200 pads, medicated MG/1.14 ML, 300 MG/2 ML hibiclens topical 2 OTC liquid 4 % dyna-hex topical 2 OTC liquid 4 % hydrolatum topical 2 OTC ointment ELIDEL TOPICAL 1 QL (30 per 23 CREAM 1 % days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 70 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hygienic cleansing 2 OTC methoxsalen oral 2 topical pads, capsule,liqd- medicated filled,rapid rel 10 imiquimod topical 2 QL (23 per 14 mg cream in packet 3.75 days) natural oatmeal bath 2 OTC % treatment topical imiquimod topical 2 PA; QL (48 packet cream in packet 5 % per 112 days) oatmeal bath regular 2 OTC iodine topical 2 OTC topical packet tincture 2 % PANRETIN 2 iodine-sodium iodide 2 OTC TOPICAL GEL 0.1 topical tincture , 2 % % pediatric oint (cod 2 OTC IODOFLEX 2 liver oil) topical TOPICAL PADS, ointment MEDICATED 0.9 % petrolatum topical 2 OTC lanolin anhydrous 2 OTC ointment topical ointment petrolatum, yellow 2 OTC LEVICYN 2 (bulk) gel 100 % DERMAL petroleum jelly 2 OTC TOPICAL topical gel SPRAY,NON- petroleum jelly, 2 OTC AEROSOL 0.009 % white topical gel LEVULAN 2 PICATO TOPICAL 2 PA; QL (3 per TOPICAL GEL 0.015 % 60 days) SOLUTION 20 % PICATO TOPICAL 2 PA; QL (2 per mb hydrogel topical 2 GEL 0.05 % 60 days) kit,cream and gel 96.53-3-0.4 -0.066 podofilox topical 2 % solution 0.5 % medicated pads 2 OTC pr cream topical 2 topical pads, cream medicated 50 % pre-moistened 2 OTC medicated wipes 2 OTC hemorrhoidal topical pads, topical pads, medicated 50 % medicated medi-pads topical 2 OTC pre-moistened 2 OTC pads, medicated 50 medicated wipes % topical pad

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 71 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits preparation h (witch 2 OTC vitamin a and d 2 OTC hazel) topical pads, diaper rash topical medicated 50 % ointment protective ointment 2 OTC vitamin a and d 2 OTC topical ointment topical ointment PROTOPIC 1 QL (30 per 23 vits a and d-white 2 OTC TOPICAL days) pet-lanolin topical OINTMENT 0.03 ointment %, 0.1 % vits a and d-white 2 OTC prudoxin topical 2 PA pet-lanolin topical cream 5 % ointment in packet scar gel topical gel 2 OTC walgreens dry skin 2 OTC SECURA EXTRA 2 OTC treatment topical PROTECTIVE ointment 41 % TOPICAL CREAM white petrolatum 2 OTC 30.6 % topical gel secura protective 2 OTC white petrolatum 2 OTC topical ointment topical ointment silver nitrate 2 white petrolatum 2 OTC applicators topical topical ointment in stick 75-25 % packet silver nitrate topical 2 white petroleum jelly 2 OTC solution 0.5 %, 10 topical gel %, 25 %, 50 % Z-BUM TOPICAL 2 OTC skin protectant a and 2 OTC CREAM 22 % d topical ointment zinc oxide topical 2 OTC skin treatment 2 OTC ointment , 20 %, 40 topical lotion 12 % % tri-chlor topical 2 ZONALON 2 PA solution 80 % TOPICAL CREAM VALCHLOR 2 PA; SP 5 % TOPICAL GEL zostrix topical cream 2 OTC 0.016 % 0.033 % vaseline topical gel 2 OTC zostrix-hp foot 2 OTC VEREGEN 2 topical cream 0.1 % TOPICAL zostrix-hp topical 2 OTC OINTMENT 15 % cream 0.1 % THERAPY FOR ACNE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 72 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acne cleansing bar 2 OTC ADVANCED 2 OTC topical bar 10 % ACNE WASH acne control 2 OTC TOPICAL cleanser topical CLEANSER,EXTE cleanser 10 % NDED RELEASE 4.4 % acne foaming wash 2 OTC topical cleanser 10 advanced exfoliating 2 OTC % cleanser topical cleanser 5 % acne medication 2 OTC amnesteem oral 2 topical gel 2.5 % capsule 10 mg, 20 acne treatment 2 OTC mg, 40 mg (benzoyl perox) topical gel 10 % avar topical cleanser 2 10-5 % (w/w) acne vanishing 2 OTC topical cream 10 % azelaic acid topical 2 gel 15 % acne-clear topical 2 OTC gel 10 % AZELEX TOPICAL 2 PA; ST CREAM 20 % ACNEFREE ACNE 2 OTC CLEARING benzepro topical 2 OTC SYSTEM TOPICAL foam 5.3 %, 9.8 % COMBO PACK 2.5- benzepro topical 2 3.7 % towelette 6 % ACNEFREE 2 OTC benzoyl peroxide 2 OTC SEVERE ACNE topical cleanser 10 CLEARING %, 5 % TOPICAL KIT 2.5- benzoyl peroxide 2 10 % topical cleanser 7 % ACZONE 2 ST benzoyl peroxide 2 TOPICAL GEL topical foam 9.8 % WITH PUMP 7.5 % benzoyl peroxide 2 OTC adapalene topical 2 ST topical gel 10 %, 2.5 cream 0.1 % %, 5 % adapalene topical 2 ST bp 10-1 topical 2 gel 0.3 % cleanser 10-1 % adapalene-benzoyl 2 bp topical gel 10 %, 2 OTC peroxide topical gel 5 % with pump 0.1-2.5 % bp wash topical 2 OTC cleanser 10 %, 5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 73 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bpo topical towelette 2 daylogic acne 2 OTC 6 % foaming wash claravis oral capsule 2 topical cleanser 10 10 mg, 20 mg, 30 % mg, 40 mg DIFFERIN 2 OTC CLEAR PORE 2 OTC TOPICAL GEL 0.1 CLEANSER-MASK % TOPICAL ery pads topical 2 CLEANSER 3.5 % swab 2 % clearasil daily 2 OTC erythromycin with 2 clear(benzoyl) ethanol topical gel 2 topical cream 10 % % clindacin etz topical 2 erythromycin with 2 swab 1 % ethanol topical clindacin p topical 2 solution 2 % swab 1 % erythromycin- 2 clindamycin 2 benzoyl peroxide topical gel 3-5 % phosphate topical gel 1 % FINACEA 2 PA clindamycin 2 TOPICAL GEL 15 phosphate topical % lotion 1 % foaming acne face 2 OTC clindamycin 2 wash topical phosphate topical cleanser 10 % solution 1 % ivermectin topical 2 clindamycin 2 cream 1 % phosphate topical metronidazole 2 swab 1 % topical cream 0.75 % clindamycin-benzoyl 2 peroxide topical gel metronidazole 2 1.2 %(1 % base) -5 topical gel 0.75 %, 1 % % clindamycin-benzoyl 2 ST metronidazole 2 peroxide topical gel topical lotion 0.75 % 1-5 % myorisan oral 2 creamy acne face 2 OTC capsule 10 mg, 20 topical cleanser 4 % mg, 30 mg, 40 mg dapsone topical gel 2 ST neuac topical gel 1.2 2 ST 5 % %(1 % base) -5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 74 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OC8 TOPICAL 2 OTC targeted acne spot 2 OTC GEL 7 % treatment topical ONEXTON 2 ST cream 2.5 % TOPICAL GEL tazarotene topical 2 PA WITH PUMP 1.2 cream 0.1 % %(1 % BASE) -3.75 TAZORAC 2 PA % TOPICAL CREAM panoxyl topical 2 OTC 0.1 % cleanser 10 %, 4 % TAZORAC 2 PA persa-gel topical gel 2 OTC TOPICAL GEL 0.05 10 % %, 0.1 % RHOFADE 2 ST tretinoin topical 2 PA TOPICAL CREAM cream 0.025 %, 0.05 1 % %, 0.1 % rosadan topical 2 tretinoin topical gel 2 PA cream 0.75 % 0.01 %, 0.025 %, rosadan topical gel 2 0.05 % 0.75 % VANOXIDE-HC 2 ROSADAN 2 TOPICAL TOPICAL KIT, SUSPENSION 5-0.5 CLEANSER AND % GEL 0.75 % TOPICAL ANESTHETICS ROSANIL 2 aloe burn relief 2 OTC TOPICAL topical aerosol,spray CLEANSER 10-5 % 0.5 % (W/W) anecream topical 2 OTC sss 10-5 topical 2 cream 4 % foam 10-5 % anecream5 topical 2 OTC sulfacetamide 2 cream 5 % sodium-sulfur burn relief with aloe 2 OTC topical cleanser 10-5 topical aerosol,spray % (w/w), 9-4 %, 9- 0.5 % 4.5 % ethyl chloride 2 sulfacetamide 2 topical aerosol,spray sodium-sulfur 100 % topical lotion 10-5 % (w/v) lc-5 topical cream 5 2 OTC % SUMAXIN CP 2 TOPICAL KIT 10-4 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 75 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine hcl 2 antibiotic (neomy- 2 OTC laryngotracheal bacit-polym) topical solution 4 % ointment 3.5mg-400 lidocaine hcl topical 2 unit- 5,000 cream 3 % unit/gram lidocaine topical 2 antibiotic plus 2 OTC adhesive (pramoxine) topical patch,medicated 5 % cream 3.5-10,000-10 mg-unit-mg/gram lidocaine topical 2 ST antibiotic-pain relief 2 OTC ointment 5 % (bacit) topical lidocaine viscous 2 ointment 3.5-500- mucous membrane 10,000 mg-unit- solution 2 % unit/g lidocaine-prilocaine 2 antiseptic topical 2 OTC topical cream 2.5- solution 10 % 2.5 % bacitracin topical 2 OTC lidocaine-prilocaine 2 ointment 500 topical kit 2.5-2.5 % unit/gram PAIN EASE 2 bacitracin topical 2 OTC MEDIUM STREAM packet 500 SPRAY TOPICAL unit/gram AEROSOL,SPRAY bacitracin zinc 2 OTC PAIN EASE MIST 2 topical ointment 500 SPRAY TOPICAL unit/gram AEROSOL,SPRAY bacitracin zinc 2 OTC SPRAY AND 2 topical ointment in STRETCH packet 500 TOPICAL unit/gram AEROSOL,SPRAY bacitraycin plus 2 OTC SYNERA TOPICAL 2 topical ointment 500 PATCH, unit/gram MEDICATED SELF-HEATING BETADINE 2 OTC 70-70 MG TOPICAL SPRAY,NON- TOPICAL ANTIBACTERIALS AEROSOL 5 % antibiotic 2 OTC CENTANY AT 2 (bacitracin zinc) TOPICAL topical ointment 500 OINTMENT KIT 2 unit/gram %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 76 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CENTANY 2 povidone-iodine 2 OTC TOPICAL topical spray,non- OINTMENT 2 % aerosol 10 % first aid antibiotic- 2 OTC sulfacetamide 2 pain rlf topical sodium (acne) ointment 3.5-500- topical suspension 10,000 mg-unit- 10 % unit/g SULFAMYLON 2 first aid 2 OTC TOPICAL CREAM antiseptic(povidone) 85 MG/G topical solution 10 triple antibiotic plus 2 OTC % topical ointment 3.5- gentamicin topical 2 500-10,000 mg-unit- cream 0.1 % unit/g gentamicin topical 2 TRIPLE 2 OTC ointment 0.1 % ANTIBIOTIC lugols topical 2 SPRAY TOPICAL solution 5-10 % AEROSOL,SPRAY 3.5-400-5,000 MG- mafenide acetate 2 UNIT-UNIT topical packet 50 triple antibiotic 2 OTC gram topical ointment multi antibiotic plus 2 OTC 3.5mg-400 unit- topical cream 3.5- 5,000 unit/gram 10,000-10 mg-unit- mg/gram triple antibiotic 2 OTC topical ointment in mupirocin calcium 2 packet 3.5-400- topical cream 2 % 5,000 mg-unit-unit mupirocin topical 2 triple antibiotic-pain 2 OTC ointment 2 % relief topical neosporin plus 2 OTC ointment 3.5-500- painrelief(bac) 10,000 mg-unit- topical ointment 3.5- unit/g 500-10,000 mg-unit- TOPICAL ANTIFUNGALS unit/g ALEVAZOL 2 OTC povidone-iodine 2 OTC TOPICAL topical liquid in OINTMENT 1 % packet 10 % antifungal 2 OTC povidone-iodine 2 OTC (clotrimazole) topical solution 10 topical cream 1 % %, 7.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 77 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits antifungal 2 OTC athletic foot cream 2 OTC (tolnaftate) topical topical cream 1 % aerosol,spray 1 % azolen tincture 2 OTC antifungal 2 OTC topical tincture 2 % (tolnaftate) topical baza antifungal 2 OTC cream 1 % topical cream 2 % antifungal 2 OTC blis-to-sol 2 OTC (tolnaftate) topical (tolnaftate) topical powder 1 % solution 1 % antifungal cream 2 OTC CICLODAN KIT 2 (miconazole) topical TOPICAL COMBO cream 2 % PACK 0.77 % antifungal spray 2 OTC ciclodan topical 2 topical aerosol cream 0.77 % powder 1 % ciclodan topical 2 PA anti-fungal topical 2 OTC solution 8 % powder 2 % ciclopirox topical 2 athlete's foot 2 OTC cream 0.77 % (clotrimazole) topical cream 1 % ciclopirox topical 2 shampoo 1 % athlete's foot 2 OTC (terbinafine) topical ciclopirox topical 2 PA cream 1 % solution 8 % athlete's foot 2 OTC ciclopirox topical 2 (tolnaftate) topical suspension 0.77 % aerosol powder 1 % clotrimazole af 2 OTC athlete's foot 2 OTC topical cream 1 % (tolnaftate) topical clotrimazole topical 2 OTC aerosol,spray 1 % cream 1 % athlete's foot 2 OTC clotrimazole topical 2 OTC (tolnaftate) topical solution 1 % cream 1 % clotrimazole- 2 athlete's foot topical 2 OTC betamethasone aerosol powder 2 % topical cream 1-0.05 ATHLETE'S FOOT 2 OTC % TOPICAL clotrimazole- 2 AEROSOL,SPRAY betamethasone 2 % topical lotion 1-0.05 athlete's foot topical 2 OTC % powder 2 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 78 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits critic-aid clear 2 OTC LAMISIL 2 OTC af(miconazol) (AEROSOL) topical ointment 2 % TOPICAL desenex topical 2 OTC AEROSOL,SPRAY powder 2 % 1 % econazole topical 2 lamisil af topical 2 OTC cream 1 % aerosol powder 1 % EXODERM 2 lamisil at topical 2 OTC TOPICAL LOTION cream 1 % 25-1 % lotrimin af powder 2 OTC foot and sneaker 2 OTC topical aerosol topical aerosol powder 2 % powder 1 % LOTRIMIN AF 2 OTC formula 3 topical 2 OTC TOPICAL solution 1 % AEROSOL,SPRAY 2 % fungoid tincture 2 OTC topical tincture 2 % lotrimin ultra topical 2 OTC cream 1 % fungoid-d topical 2 OTC cream 1 % micatin topical 2 OTC cream 2 % inzo antifungal 2 OTC topical cream 2 % miconazole nitrate 2 OTC topical aerosol itch relief 2 OTC powder 2 % (clotrimazole) topical cream 1 % miconazole nitrate 2 OTC topical cream 2 % jock itch 2 OTC miconazorb af 2 OTC (clotrimazole) topical cream 1 % topical powder 2 % jock itch 2 OTC micro-guard topical 2 OTC (terbinafine) topical powder 2 % cream 1 % mycozyl ap topical 2 OTC jock itch topical 2 OTC powder 2 % aerosol powder 1 % NIZORAL A-D 2 OTC ketoconazole topical 2 TOPICAL SHAMPOO 1 % cream 2 % ketoconazole topical 2 nystatin topical 2 shampoo 2 % cream 100,000 unit/gram nystatin topical 2 ointment 100,000 unit/gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 79 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nystatin- 2 zeasorb af topical 2 OTC triamcinolone powder 2 % topical cream TOPICAL ANTIVIRALS 100,000-0.1 unit/g- % acyclovir topical 2 ointment 5 % nystatin- 2 triamcinolone TOPICAL CORTICOSTEROIDS topical ointment ala-cort topical 2 100,000-0.1 cream 1 % unit/gram-% alclometasone 2 nystop topical 2 topical cream 0.05 powder 100,000 % unit/gram alclometasone 2 odor control foot- 2 OTC topical ointment sneaker topical 0.05 % aerosol powder 1 % anti-itch (hc) topical 2 OTC remedy antifungal 2 OTC cream 1 % topical cream 2 % anti-itch (hc) topical 2 OTC remedy antifungal 2 OTC ointment 1 % topical powder 2 % beta-hc topical 2 OTC remedy phytoplex 2 OTC lotion 1 % antifungal topical powder 2 % betamethasone 2 dipropionate topical secura antifungal 2 OTC cream 0.05 % topical cream 2 % betamethasone 2 terbinafine hcl 2 OTC dipropionate topical topical cream 1 % lotion 0.05 % tinactin topical 2 OTC betamethasone 2 aerosol powder 1 % dipropionate topical tolnaftate topical 2 OTC ointment 0.05 % aerosol powder 1 % betamethasone 2 tolnaftate topical 2 OTC valerate topical cream 1 % cream 0.1 % tolnaftate topical 2 OTC betamethasone 2 powder 1 % valerate topical TRIPLE DYE 2 OTC lotion 0.1 % TOPICAL SWAB betamethasone 2 2.29-2.29-1.14 valerate topical MG/ML ointment 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 80 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits betamethasone, 2 cortizone-10 topical 2 OTC augmented topical cream 1 % cream 0.05 % cortizone-10 topical 2 OTC betamethasone, 2 gel 1 % augmented topical cortizone-10 topical 2 OTC lotion 0.05 % ointment 1 % betamethasone, 2 cortizone-10 with 2 OTC augmented topical aloe topical cream 1 ointment 0.05 % % clobetasol scalp 2 dermarest eczema 2 OTC solution 0.05 % (hydrocort) topical clobetasol topical 2 lotion 1 % cream 0.05 % DESONATE 2 clobetasol topical 2 ST TOPICAL GEL 0.05 foam 0.05 % % clobetasol topical 2 desonide topical 2 ST gel 0.05 % cream 0.05 % clobetasol topical 2 ST desonide topical 2 ST lotion 0.05 % lotion 0.05 % clobetasol topical 2 desonide topical 2 ST ointment 0.05 % ointment 0.05 % clobetasol topical 2 ST desoximetasone 2 shampoo 0.05 % topical cream 0.05 clobetasol topical 2 ST %, 0.25 % spray,non-aerosol desoximetasone 2 0.05 % topical gel 0.05 % clobetasol-emollient 2 desoximetasone 2 topical cream 0.05 topical ointment % 0.05 %, 0.25 % cortisone 2 OTC fluocinolone and 2 (hydrocortisone) shower cap scalp oil topical cream 1 % 0.01 % cortisone cooling 2 OTC fluocinolone topical 2 topical gel 1 % cream 0.01 %, 0.025 cortisone with aloe 2 OTC % topical cream 1 % fluocinolone topical 2 cortizone-10 plus 2 OTC oil 0.01 % topical cream 1 % fluocinolone topical 2 ointment 0.025 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 81 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluocinolone topical 2 hydrocortisone plus 2 OTC solution 0.01 % topical cream 1 % fluocinonide topical 2 hydrocortisone 2 OTC cream 0.05 % topical cream 0.5 %, fluocinonide topical 2 1 % gel 0.05 % hydrocortisone 2 topical cream 2.5 % fluocinonide topical 2 ointment 0.05 % hydrocortisone 2 OTC fluocinonide topical 2 topical cream in solution 0.05 % packet 1 % fluocinonide-e 2 hydrocortisone 2 OTC topical cream 0.05 topical lotion 1 % % hydrocortisone 2 fluticasone 2 topical lotion 2.5 % propionate topical hydrocortisone 2 OTC cream 0.05 % topical ointment 0.5 fluticasone 2 %, 1 % propionate topical hydrocortisone 2 ointment 0.005 % topical ointment 2.5 halobetasol 2 % propionate topical hydrocortisone 2 cream 0.05 % valerate topical cream 0.2 % halobetasol 2 propionate topical hydrocortisone 2 ointment 0.05 % valerate topical ointment 0.2 % hydrocortisone 2 OTC acetate topical hydrocortisone-aloe 2 OTC cream 0.5 %, 1 % vera topical cream hydrocortisone 2 OTC 0.5 %, 1 % acetate topical hydrocream topical 2 OTC ointment 1 % cream 1 % hydrocortisone 2 mometasone topical 2 butyrate topical cream 0.1 % cream 0.1 % mometasone topical 2 hydrocortisone 2 ointment 0.1 % butyrate topical mometasone topical 2 ointment 0.1 % solution 0.1 % hydrocortisone 2 noble formula hc 2 OTC butyrate topical topical cream 1 % solution 0.1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 82 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits scalp relief topical 2 OTC lice bedding spray 2 OTC solution 1 % aerosol,spray 0.5 % scalpicin anti-itch 2 OTC lice complete kit 1-2- 2 OTC topical solution 1 % 3 topical kit 4-0.33- soothing care 2 OTC 0.5 % (hydrocortisone) lice killing 2 OTC topical cream 1 % (permethrin) topical SYNALAR 2 liquid 1 % CREAM KIT lice killing topical 2 OTC TOPICAL CREAM shampoo 0.33-4 % 0.025 % lice pyrinyl shampoo 2 OTC triamcinolone 2 topical shampoo acetonide topical 0.33-4 % cream 0.025 %, 0.1 lice solution topical 2 OTC %, 0.5 % kit 4-0.33-0.5 % triamcinolone 2 lice treatment 2 OTC acetonide topical (permethrin) topical lotion 0.025 %, 0.1 liquid 1 % % lice treatment 2 OTC triamcinolone 2 topical liquid 1 % acetonide topical ointment 0.025 %, lice treatment 2 OTC 0.05 %, 0.1 %, 0.5 % topical shampoo 0.33-4 % triderm topical 2 cream 0.1 % lindane topical 2 shampoo 1 % vanicream hc topical 2 OTC cream 1 % malathion topical 2 lotion 0.5 % TOPICAL ENZYMES NATROBA 2 SANTYL TOPICAL 2 TOPICAL OINTMENT 250 SUSPENSION 0.9 UNIT/GRAM % TOPICAL SCABICIDES / permethrin topical 2 PEDICULICIDES cream 5 % complete lice 2 OTC rid complete lice 2 OTC treatment topical kit elim kit topical kit 4- 4-0.33-0.5 % 0.33-0.5 % crotan topical lotion 2 rid lice killing 2 OTC 10 % topical shampoo 0.33-4 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 83 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits spinosad topical 2 NEOQ10 ORAL 2 OTC suspension 0.9 % CAPSULE 125 MG stop lice 2 OTC q-sorb co q-10 oral 2 OTC aerosol,spray 0.5 % capsule 100 mg, 200 ULESFIA 2 mg TOPICAL LOTION IRRIGATING SOLUTIONS 5 % neomycin-polymyxin 2 DIAGNOSTICS / b gu irrigation

MISCELLANEOUS AGENTS solution 40 mg- 200,000 unit/ml ANOREXIANTS SORBITOL 2 ALLI ORAL 2 OTC IRRIGATION CAPSULE 60 MG SOLUTION 3 % ENZYMES SORBITOL- 2 MANNITOL CHEW Q ORAL 2 OTC TRANSURETHRA TABLET,CHEWAB L SOLUTION 2.7- LE 100 MG, 30 MG 0.54 GRAM/100 CHEW Q ORAL 2 OTC ML WAFER 600 MG MISCELLANEOUS AGENTS co q-10 oral capsule 2 OTC 10 mg, 100 mg, 150 acamprosate oral 2 ACA mg, 200 mg, 30 mg, tablet,delayed 50 mg release (dr/ec) 333 mg coenzyme q10 oral 2 OTC capsule 10 mg, 100 acetic acid irrigation 2 mg, 200 mg, 30 mg, solution 0.25 % 50 mg, 60 mg ammonia aromatic 2 OTC COENZYME Q10 2 OTC inhalation solution ORAL TABLET 15 % (w/v) 100 MG, 50 MG AMMONIA 2 OTC COENZYME Q10 2 OTC AROMATIC ORAL INHALATION TABLET,CHEWAB SPIRIT LE 50 MG anagrelide oral 2 coq-10 oral capsule 2 OTC capsule 0.5 mg, 1 mg 100 mg, 30 mg ARALAST NP 2 SP h2q oral capsule 100 2 OTC INTRAVENOUS mg RECON SOLN 1,000 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 84 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AURYXIA ORAL 2 DEX4 GLUCOSE 2 OTC TABLET 210 MG ORAL LIQUID 15 IRON GRAM/59 ML bd pre-filled normal 2 dex4 glucose oral 2 OTC saline injection tablet,chewable 4 syringe gram caffeine citrate oral 2 dex4 glucose pouch 2 OTC solution 60 mg/3 ml pack oral (20 mg/ml) tablet,chewable 4 gram CAPHOSOL 2 MUCOUS dex4 glucose quick 2 OTC MEMBRANE dissolve oral SOLUTION tablet,chewable 4 CARBAGLU ORAL 2 PA; SP gram TABLET, DEXTROSE ORAL 2 OTC DISPERSIBLE 200 LIQUID 15 MG GRAM/59 ML, 15 cevimeline oral 2 GRAM/60 ML capsule 30 mg diluent for 2 PA; SP CHEMET ORAL 2 epoprostenol/flola intravenous solution CAPSULE 100 MG deferasirox oral 2 SP disulfiram oral 2 ACA tablet 360 mg, 90 mg tablet 250 mg, 500 mg deferasirox oral 2 SP tablet, dispersible droxidopa oral 2 SP; QL (90 per 125 mg, 250 mg, 500 capsule 100 mg 23 days) mg droxidopa oral 2 SP; QL (180 deferoxamine 2 SP capsule 200 mg, 300 per 23 days) injection recon soln mg 2 gram, 500 mg etidronate disodium 2 dex4 glucose bits 2 OTC oral tablet 200 mg oral tablet,chewable FERRIPROX (2 2 SP 1 gram TIMES A DAY) dex4 glucose oral 2 OTC ORAL TABLET gel 40 % 1,000 MG DEX4 GLUCOSE 2 OTC FERRIPROX ORAL 2 SP ORAL GEL IN SOLUTION 100 PACKET 15 MG/ML GRAM/33 GRAM

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 85 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FERRIPROX ORAL 2 SP ISOPROPYL 2 OTC TABLET 1,000 MG, ALCOHOL 500 MG TOPICAL GIVLAARI 1 PA; SP; PrefD SPRAY,NON- SUBCUTANEOUS AEROSOL 70 %, 91 SOLUTION 189 % MG/ML JADENU ORAL 2 SP GLASSIA 2 SP TABLET 180 MG INTRAVENOUS lanthanum oral 2 SOLUTION 1 tablet,chewable GRAM/50 ML (2 1,000 mg, 500 mg, %) 750 mg gluco burst oral gel 2 OTC levocarnitine (with 2 40 % sugar) oral solution GLUCO SHOT 2 OTC 100 mg/ml ORAL LIQUID 15 levocarnitine oral 2 GRAM/59 ML tablet 330 mg glucose bits oral 2 OTC LITHOSTAT ORAL 2 tablet,chewable 1 TABLET 250 MG gram meladox oral tablet 2 OTC glucose gel oral gel 2 OTC extended release 3 40 % mg glucose oral 2 OTC melatin oral tablet 3 2 OTC tablet,chewable 4 mg gram MELATONIN 2 OTC GLUTOSE-15 2 OTC ORAL DROPS 1 ORAL GEL 40 % MG/4 ML GLUTOSE-45 2 OTC MELATONIN 2 OTC ORAL GEL 40 % ORAL LIQUID 1 glutose-5 oral gel 40 2 OTC MG/ML, 2.5 MG/10 % ML hydrogen peroxide 2 OTC melatonin oral liquid 2 OTC solution 3 % 5 mg/15 ml INCRELEX 2 PA; SP MELATONIN 2 OTC SUBCUTANEOUS ORAL LOZENGE 5 SOLUTION 10 MG MG/ML melatonin oral tablet 2 OTC isopropyl alcohol 2 OTC 1 mg, 10 mg, 3 mg, 5 solution 91 %, 99 % mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 86 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits melatonin oral tablet 2 OTC NORTHERA ORAL 2 PA; SP; QL extended release 3 CAPSULE 100 MG (90 per 23 mg days) MELATONIN 2 OTC NORTHERA ORAL 2 PA; SP; QL ORAL TABLET, IR CAPSULE 200 MG, (180 per 23 AND ER, 300 MG days) BIPHASIC 5 MG NUMOISYN 2 MELATONIN 2 OTC MUCOUS ORAL MEMBRANE TABLET,CHEWAB LIQUID LE 2.5 MG, 5 MG ORFADIN ORAL 2 SP melatonin oral 2 OTC SUSPENSION 4 tablet,disintegrating MG/ML 3 mg OXBRYTA ORAL 2 PA; SP MELATONIN 2 OTC TABLET 500 MG SUBLINGUAL pilocarpine hcl oral 2 TABLET 1 MG tablet 5 mg, 7.5 mg MELATONIN 2 OTC PROLASTIN-C 2 SP SUBLINGUAL INTRAVENOUS TABLET,DISINTE RECON SOLN GRATING 500 1,000 MG MCG PROLASTIN-C 2 SP MEXSANA 2 OTC INTRAVENOUS (CORNSTARCH) SOLUTION 1,000 TOPICAL MG (+/-)/20 ML POWDER 83.7 % RADIOGARDASE 2 midodrine oral 2 ORAL CAPSULE tablet 10 mg, 2.5 mg, 0.5 GRAM 5 mg RAVICTI ORAL 2 PA; SP; QL mineral oil oil 2 OTC LIQUID 1.1 (525 per 23 monoject prefill 2 GRAM/ML days) advanced ns riluzole oral tablet 2 SP injection syringe 50 mg MURI-LUBE OIL 2 risedronate oral 2 ST nitisinone oral 2 SP tablet 30 mg capsule 10 mg, 2 mg, sevelamer carbonate 2 5 mg oral powder in normal saline flush 2 packet 0.8 gram, 2.4 injection syringe gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 87 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sevelamer carbonate 2 THYROGEN 2 SP oral tablet 800 mg INTRAMUSCULA sevelamer hcl oral 2 R RECON SOLN tablet 800 mg 0.9 MG sodium chloride 0.9 2 trientine oral 2 PA; SP % (flush) injection capsule 250 mg syringe TRUEPLUS 2 OTC sodium chloride 0.9 2 GLUCOSE ORAL % intravenous GEL IN PACKET 15 GRAM/32 ML parenteral solution sodium chloride 2 TRUEPLUS 2 OTC injection syringe 0.9 GLUCOSE ORAL % LIQUID 15 GRAM/60 ML sodium ferric 2 gluconat-sucrose TRUEPLUS 2 OTC intravenous solution GLUCOSE ORAL 62.5 mg/5 ml TABLET,CHEWAB LE 4 GRAM sodium 2 SP phenylbutyrate oral ULTOMIRIS 2 PA; SP powder 0.94 INTRAVENOUS SOLUTION 100 gram/gram MG/ML sodium 2 SP phenylbutyrate oral VELPHORO ORAL 2 tablet 500 mg TABLET,CHEWAB LE 500 MG sodium polystyrene 2 sulfonate oral VITAJOY 2 OTC powder MELATONIN ORAL SOLIRIS 2 PA; SP TABLET,CHEWAB INTRAVENOUS LE 2.5 MG SOLUTION 300 MG/30 ML XIAFLEX 2 PA; SP; QL (2 INJECTION per 23 days) sps (with sorbitol) 2 RECON SOLN 0.9 oral suspension 15- MG 20 gram/60 ml ZEMAIRA 2 SP SWABFLUSH 2 INTRAVENOUS INJECTION RECON SOLN SYRINGE, WITH 1,000 MG SWAB CAP ZOKINVY ORAL 2 PA; SP THIOLA ORAL 2 CAPSULE 50 MG, TABLET 100 MG 75 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 88 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits zoledronic acid- 2 SP; QL (100 CHANTIX 2 ACA mannitol-water per 365 days) STARTING intravenous MONTH BOX piggyback 5 mg/100 ORAL ml TABLETS,DOSE PACK 0.5 MG (11)- MISCELLANEOUS DEVICES 1 MG (42) dermafix topical 2 OTC buccal gum 2 ACA; OTC ointment 4 mg dy-o-derm solution 2 OTC nicotine (polacrilex) 2 ACA; OTC INSTACLEAN 2 OTC buccal gum 2 mg, 4 SOLUTION mg isopropyl alcohol 2 OTC nicotine (polacrilex) 2 ACA; OTC solution 70 % buccal lozenge 2 mg, 4 mg NEUTRACEUTICALS nicotine (polacrilex) 2 ACA; OTC complete premium 2 OTC buccal mini lozenge vitamin oral tablet 2 mg, 4 mg MELATONIN- 2 OTC nicotine transdermal 2 ACA; OTC LEMON BALM patch 24 hour 14 LEAF EXTR ORAL mg/24 hr, 21 mg/24 TABLET 3 MG- hr, 7 mg/24 hr 500 MCG nicotine transdermal 2 ACA; OTC melatonin- 2 OTC patch, td daily, pyridoxine hcl (b6) sequential 21-14-7 oral tablet 3-10 mg mg/24 hr

SMOKING DETERRENTS NICOTROL 2 ACA bupropion hcl 2 PBH; ACA INHALATION (smoking deter) oral CARTRIDGE 10 tablet extended MG release 12 hr 150 mg NICOTROL NS 2 ACA CHANTIX 2 ACA NASAL CONTINUING SPRAY,NON- MONTH BOX AEROSOL 10 ORAL TABLET 1 MG/ML MG quit 2 buccal gum 2 2 ACA; OTC CHANTIX ORAL 2 ACA mg TABLET 0.5 MG, 1 quit 2 buccal 2 ACA; OTC MG lozenge 2 mg quit 4 buccal gum 4 2 ACA; OTC mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 89 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits quit 4 buccal 2 ACA; OTC DEBACTEROL 2 lozenge 4 mg MUCOUS stop smoking aid 2 ACA; OTC MEMBRANE buccal lozenge 2 mg, SWAB 30-50 % 4 mg deep sea nasal nasal 2 OTC aerosol,spray 0.65 EAR, NOSE / THROAT % MEDICATIONS denta 5000 plus 2 MISCELLANEOUS AGENTS dental cream 1.1 % altamist nasal 2 OTC dentagel dental gel 2 aerosol,spray 0.65 1.1 % % fluoride (sodium) 2 ARESTIN DENTAL 2 SP dental solution 0.2 CARTRIDGE 1 MG % ayr saline nasal 2 OTC FLUORIDEX 2 aerosol,spray 0.65 DAILY DEFENSE % DENTAL PASTE 1.1 % ayr saline nasal 2 OTC drops 0.65 % FLUORIDEX 2 SENSITIVITY azelastine nasal 2 RELIEF DENTAL aerosol,spray 137 PASTE 1.1-5 % mcg (0.1 %) GELCLAIR 2 azelastine nasal 2 ST MUCOUS spray,non-aerosol MEMBRANE GEL 205.5 mcg (0.15 %) IN PACKET baby ayr saline 2 OTC ipratropium bromide 2 nasal drops 0.65 % nasal spray,non- children's saline 2 OTC aerosol 21 mcg (0.03 nasal spray nasal %), 42 mcg (0.06 %) aerosol,spray 0.65 little remedies nasal 2 OTC % aerosol,spray 0.65 chlorhexidine 2 % gluconate mucous nasal moisturizing 2 OTC membrane nasal aerosol,spray mouthwash 0.12 % 0.65 % CLINPRO 5000 2 nasal spray (sodium 2 OTC DENTAL PASTE chloride) nasal 1.1 % aerosol,spray 0.65 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 90 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ocean nasal nasal 2 OTC triamcinolone 2 aerosol,spray 0.65 acetonide dental % paste 0.1 % olopatadine nasal 2 ST MISCELLANEOUS OTIC

spray,non-aerosol PREPARATIONS 0.6 % acetic acid otic (ear) 2 oralone dental paste 2 solution 2 % 0.1 % CETRAXAL OTIC 2 ORAMAGICRX 2 (EAR) MUCOUS DROPPERETTE 0.2 MEMBRANE % MOUTHWASH ciprofloxacin hcl 2 paroex oral rinse 2 otic (ear) mucous membrane dropperette 0.2 % mouthwash 0.12 % CLEARCANAL 2 OTC perio med dental 2 OTC EAR WAX OTIC solution 0.63 % (EAR) COMBO periogard mucous 2 PACK 6.5-0.9 % membrane ear drops 2 OTC mouthwash 0.12 % (carbamide saline mist nasal 2 OTC peroxide) otic (ear) aerosol,spray 0.65 drops 6.5 % % ear wax removal 2 OTC saline nasal mist 2 OTC drops otic (ear) nasal aerosol,spray drops 6.5 % 0.65 % ear wax removal kit 2 OTC saline nasal nasal 2 OTC otic (ear) drops 6.5 aerosol,spray 0.65 % % EAR WAX 2 OTC saline nose nasal 2 OTC REMOVAL aerosol,spray 0.65 SYSTEM OTIC % (EAR) COMBO PACK 6.5 % sf 5000 plus dental 2 cream 1.1 % fluocinolone 2 acetonide oil otic sf dental gel 1.1 % 2 (ear) drops 0.01 % sodium fluoride 2 hydrocortisone- 2 5000 dry mouth acetic acid otic (ear) dental gel 1.1 % drops 1-2 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 91 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits murine ear wax 2 OTC dexamethasone oral 2 removal system otic tablet 0.5 mg, 0.75 (ear) drops 6.5 % mg, 1 mg, 1.5 mg, 2 ofloxacin otic (ear) 2 mg, 4 mg, 6 mg drops 0.3 % dexamethasone oral 2 tablets,dose pack 1.5

OTIC STEROID / ANTIBIOTIC mg (21 tabs), 1.5 mg CIPRO HC OTIC 2 (35 tabs), 1.5 mg (51 (EAR) tabs) DROPS,SUSPENSI EMFLAZA ORAL 2 PA; SP ON 0.2-1 % SUSPENSION CIPRODEX OTIC 2 22.75 MG/ML (EAR) EMFLAZA ORAL 2 PA; SP DROPS,SUSPENSI TABLET 18 MG, 30 ON 0.3-0.1 % MG, 36 MG, 6 MG neomycin- 2 fludrocortisone oral 2 polymyxin-hc otic tablet 0.1 mg (ear) drops,suspension hydrocortisone oral 2 3.5-10,000-1 mg/ml- tablet 10 mg, 20 mg, unit/ml-% 5 mg neomycin- 2 MEDROL ORAL 2 polymyxin-hc otic TABLET 2 MG (ear) solution 3.5- methylprednisolone 2 10,000-1 mg/ml- oral tablet 16 mg, 32 unit/ml-% mg, 4 mg, 8 mg ENDOCRINE/DIABETES methylprednisolone 2 oral tablets,dose ADRENAL HORMONES pack 4 mg ACTHAR 2 PA; SP methylprednisolone 2 INJECTION GEL sodium succ 80 UNIT/ML injection recon soln dexamethasone 2 125 mg, 40 mg intensol oral drops 1 millipred dp oral 2 mg/ml tablets,dose pack 5 dexamethasone oral 2 mg (48 tabs) elixir 0.5 mg/5 ml millipred oral tablet 2 dexamethasone oral 2 5 mg solution 0.5 mg/5 ml prednisolone oral 2 solution 15 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 92 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prednisolone sodium 2 1ST TIER UNIFINE 2 OTC phosphate oral PENTIPS NEEDLE solution 15 mg/5 ml 29 GAUGE X 1/2", (3 mg/ml), 15 mg/5 31 GAUGE X 1/4", ml (5 ml), 25 mg/5 31 GAUGE X 3/16", ml (5 mg/ml), 5 mg 31 GAUGE X 5/16", base/5 ml (6.7 mg/5 32 GAUGE X 5/32" ml) 1ST TIER UNIFINE 2 OTC prednisone intensol 2 PENTIPS PLUS oral concentrate 5 NEEDLE 29 mg/ml GAUGE X 1/2", 31 prednisone oral 2 GAUGE X 1/4", 31 solution 5 mg/5 ml GAUGE X 3/16", 31 GAUGE X 5/16", 32 prednisone oral 2 GAUGE X 5/32" tablet 1 mg, 10 mg, 1ST TIER UNILET 2 OTC; QL (200 2.5 mg, 20 mg, 5 mg, 50 mg COMFORTOUCH per 23 days) 28 GAUGE, 30 prednisone oral 2 GAUGE tablets,dose pack 10 mg, 5 mg 2-IN-1 LANCET 2 OTC; QL (200 DEVICE 30 per 23 days) SOLU-CORTEF 2 GAUGE ACT-O-VIAL (PF) INJECTION ABOUTTIME PEN 2 OTC RECON SOLN 100 NEEDLE NEEDLE MG/2 ML 30 GAUGE X 5/16", 31 GAUGE X 3/16", TRIESENCE (PF) 2 31 GAUGE X 5/16", INTRAOCULAR 32 GAUGE X 5/32" SUSPENSION 40 MG/ML acarbose oral tablet 2 1 Copay 100 mg, 25 mg, 50 ANTITHYROID AGENTS mg methimazole oral 2 ACCU-CHEK 2 OTC tablet 10 mg, 5 mg FASTCLIX propylthiouracil oral 2 LANCET DRUM tablet 50 mg ACCU-CHEK 2 OTC SSKI ORAL 2 FASTCLIX SOLUTION 1 LANCING DEV GRAM/ML KIT ACCU-CHEK 2 OTC DIABETES THERAPY MULTICLIX LANCET

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 93 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ACCU-CHEK 2 OTC ADVOCATE 2 OTC; QL (200 MULTICLIX LANCET 26 per 23 days) LANCET KIT GAUGE, 30 ACCU-CHEK 2 OTC GAUGE SAFE-T-PRO 23 ADVOCATE PEN 2 OTC GAUGE NEEDLE NEEDLE ACCU-CHEK 2 OTC 29 GAUGE X 1/2", SAFE-T-PRO PLUS 31 GAUGE X 3/16", 23 GAUGE 31 GAUGE X 5/16", 33 GAUGE X 5/32" ACCU-CHEK 2 OTC SOFT DEV ADVOCATE 2 LANCETS KIT SYRINGES SYRINGE 0.3 ML ACCU-CHEK 2 OTC 29 GAUGE X 1/2", SOFTCLIX 0.3 ML 30 GAUGE LANCETS X 5/16", 0.3 ML 31 acti-lance lancets 17 2 OTC GAUGE X 5/16", gauge, 23 gauge 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 acti-lance lancets 28 2 OTC; QL (200 GAUGE X 5/16", gauge per 23 days) 0.5 ML 31 GAUGE ADMELOG 1 PA X 5/16", 1 ML 29 SOLOSTAR U-100 GAUGE X 1/2", 1 INSULIN ML 30 GAUGE X SUBCUTANEOUS 5/16, 1 ML 31 INSULIN PEN 100 GAUGE X 5/16 UNIT/ML AEROCHAMBER 2 QL (2 per 365 ADMELOG U-100 1 PA MINI SPACER days) INSULIN LISPRO AEROCHAMBER 2 QL (2 per 365 SUBCUTANEOUS MV SPACER days) SOLUTION 100 UNIT/ML AEROCHAMBER 2 QL (2 per 365 PLUS FLOW-VU days) ADVANCED 2 OTC SPACER LANCING DEVICE KIT AEROCHAMBER 2 QL (2 per 365 PLUS FLOW-VU,L days) ADVANCED 2 OTC; QL (200 MSK SPACER TRAVEL per 23 days) LANCETS 28 AEROCHAMBER 2 QL (2 per 365 GAUGE, 30 PLUS FLOW-VU,M days) GAUGE MSK SPACER AEROCHAMBER 2 QL (2 per 365 PLUS FLOW-VU,S days) MSK SPACER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 94 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AEROCHAMBER 2 QL (2 per 365 ALLERGY 2 OTC PLUS Z STAT LG days) SYRINGE MSK SPACER SYRINGE 1 ML 27 AEROCHAMBER 2 QL (2 per 365 GAUGE X 3/8", 1 PLUS Z STAT MD days) ML 27 X 1/2" MSK SPACER ALOGLIPTIN 1 PA AEROCHAMBER 2 QL (2 per 365 ORAL TABLET PLUS Z STAT SM days) 12.5 MG, 25 MG, MSK SPACER 6.25 MG ALOGLIPTIN- 1 PA AEROCHAMBER 2 QL (2 per 365 WITH days) METFORMIN FLOWSIGNAL ORAL TABLET 12.5-1,000 MG, SPACER 12.5-500 MG AEROCHAMBER 2 QL (2 per 365 Z-STAT PLUS- days) ALTERNATE SITE 2 OTC; QL (200 FLW SG SPACER LANCET 26 per 23 days) GAUGE AEROVENT PLUS 2 QL (2 per 365 SPACER days) ANTI-EMBOLISM 2 OTC STOCKINGS AIRZONE PEAK 2 OTC; QL (2 FLOW METER per 365 days) ARGYLE 2 OTC TRACHEOSTOM DEVICE TUBE HOLDER ALCOH-GLOVE 2 OTC TOWELETTE 70 % ASSURE 2 OTC HAEMOLANCE alcohol pads topical 2 OTC PLUS 1.2 MM, 18 pads, medicated GAUGE, 21 alcohol prep pads 2 OTC GAUGE, 25 topical pads, GAUGE medicated ASSURE 2 OTC; QL (200 alcohol swabs 2 OTC HAEMOLANCE per 23 days) topical pads, PLUS 28 GAUGE medicated ASSURE ID 2 alcohol wipes 2 OTC INSULIN SAFETY topical pads, SYRINGE 0.5 ML medicated 29 GAUGE X 1/2", 1 ML 29 GAUGE X ALCOH-WIPE 2 OTC 1/2" TOWELETTE 70 % ASSURE ID PEN 2 OTC NEEDLE NEEDLE 30 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16" You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 95 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ASSURE LANCE 2 OTC BASAGLAR 1 PA 25 GAUGE KWIKPEN U-100 ASSURE LANCE 2 OTC; QL (200 INSULIN 28 GAUGE per 23 days) SUBCUTANEOUS INSULIN PEN 100 ASSURE LANCE 2 OTC UNIT/ML (3 ML) PLUS 21 GAUGE, 25 GAUGE BD ALCOHOL 2 OTC SWABS TOPICAL ASSURE LANCE 2 OTC; QL (200 PADS, PLUS 30 GAUGE per 23 days) MEDICATED ASTHMA CHECK 2 OTC; QL (2 BD ALLERGY 2 OTC METER DEVICE per 365 days) SYRINGE AUTODROP 2 OTC SYRINGE 1 ML 28 GAUGE X 1/2" AUTOJECT 2 2 OTC; QL (2 INJECTION per 365 days) BD AUTOSHIELD 2 OTC DEVICE DUO PEN NEEDLE SUBCUTANEOUS NEEDLE 30 INSULIN PEN GAUGE X 3/16" AUTOLET 2 OTC BD BULK 2 OTC IMPRESSION SYRINGE SLIP TIP LANC DEV KIT SYRINGE 1 ML AUTOPEN 1 TO 21 2 OTC; QL (2 BD ECLIPSE 2 UNITS per 365 days) LUER-LOK SUBCUTANEOUS NEEDLE 21 INSULIN PEN GAUGE X 1 1/2", 22 GAUGE X 1", 25 AUTOPEN 2 TO 42 2 OTC; QL (2 GAUGE X 1 1/2", UNITS per 365 days) 30 X 1/2 " SUBCUTANEOUS INSULIN PEN BD ECLIPSE 2 OTC LUER-LOK AUTOSQUEEZE 2 OTC SYRINGE 1 ML 27 BAQSIMI NASAL 1 PrefD X 1/2", 3 ML 22 SPRAY,NON- GAUGE X 1 1/2", 3 AEROSOL 3 ML 25 X 5/8" MG/ACTUATION BD ECLIPSE 2 BARD CATHETER 2 OTC LUER-LOK STRAP SYRINGE 1 ML 30 GAUGE X 1/2" BARD 2 OTC CUNNINGHAM BD ECLIPSE 2 INCONTIN NEEDLE 21 CLAMP GAUGE X 1", 25 GAUGE X 1"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 96 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD FILTER 2 BD INSULIN 2 NEEDLE 5- SYRINGE ULTRA- MICRON NOKO FINE SYRINGE 0.3 NEEDLE 18 ML 30 GAUGE X GAUGE X 1 1/2" 1/2", 0.3 ML 31 BD FILTER 2 GAUGE X 5/16", NEEDLE-5 0.5 ML 30 GAUGE MICRON NEEDLE X 1/2", 0.5 ML 31 19 X 1 1/2 " GAUGE X 5/16", 1 ML 30 GAUGE X BD INSULIN 2 1/2", 1 ML 31 SYRINGE (HALF GAUGE X 5/16 UNIT) SYRINGE 0.3 ML 31 GAUGE BD INTEGRA 2 X 5/16" NEEDLE NEEDLE 23 GAUGE X 1" BD INSULIN 2 BD INTEGRA 2 OTC SYRINGE SAFETY-LOK SYRINGE SYRINGE 1 ML 29 SYRINGE 3 ML 21 GAUGE X 1 1/2", 3 GAUGE X 1/2" ML 22 GAUGE X 1 BD INSULIN 2 1/2", 3 ML 23 SYRINGE SLIP TIP GAUGE X 1", 3 ML SYRINGE 1 ML 25 GAUGE X 1", 3 BD INSULIN 2 ML 25 GAUGE X SYRINGE 5/8" SYRINGE 0.3 ML BD 2 29 GAUGE X 1/2", INTRADERMAL 0.5 ML 29 GAUGE BEVEL NEEDLES X 1/2", 1 ML 25 NEEDLE 26 GAUGE X 5/8", 1 GAUGE X 3/8" ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 BD LO-DOSE 2 GAUGE X 1/2", 1 MICRO-FINE IV ML 29 GAUGE X SYRINGE 1/2 ML 1/2" 28 GAUGE X 1/2" BD INSULIN 2 BD LO-DOSE 2 SYRINGE U-500 ULTRA-FINE SYRINGE 1/2 ML SYRINGE 0.5 ML 31 GAUGE X 29 GAUGE X 1/2" 15/64" BD LUER-LOK 2 OTC BULK SYRINGE SYRINGE 20 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 97 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD LUER-LOK 2 OTC BD NOKOR 2 SYRINGE ADMIX NEEDLE SYRINGE 1 ML, 1 NEEDLE 18 ML 20 GAUGE X GAUGE X 1 1/2" 1", 10 ML 20 X 1 BD 2 1/2", 10 ML 20 X PRECISIONGLIDE 1", 10 ML 21 NEEDLE 25 GAUGE X 1", 10 GAUGE X 1", 27 ML 21 X 1 1/2", 10 GAUGE X 1 1/2" ML 22 X 1", 10 ML 23X 1 1/4 ", 20 ML, BD 2 3 ML, 3 ML 18 X 1 PRECISIONGLIDE 1/2", 3 ML 20 NON-STERILE GAUGE X 1 1/2", 3 NEEDLE 18 ML 23 X 1", 3 ML GAUGE X 1 1/2", 25 GAUGE X 1", 3 19 GAUGE X 1 ML 25 X 1 1/2 ", 3 1/2", 20 GAUGE X ML 25 X 5/8", 5 1 1/2", 21 GAUGE ML, 5 ML 20 X 1 X 1 1/2", 22 1/2", 5 ML 20 X 1", GAUGE X 1 1/2", 5 ML 21 GAUGE X 23 GAUGE X 1", 25 1 1/2", 5 ML 21 GAUGE X 1", 25 GAUGE X 1", 5 ML GAUGE X 5/8" 22 GAUGE X 1 BD 2 OTC 1/2", 5 ML 22 X 1", PRECISIONGLIDE 50 ML SYRINGE 3 ML 22 BD LUER-LOK TIP 2 OTC GAUGE X 3/4" CONTROL BD REGULAR 2 SYRING SYRINGE BEVEL NEEDLES 10 ML NEEDLE 18 BD 2 OTC GAUGE X 1 1/2", MICROTAINER 18 GAUGE X 1", 19 LANCET 1.5 X 2 GAUGE X 1 1/2", MM, 21 GAUGE 19 GAUGE X 1", 20 GAUGE X 1 1/2", BD 2 OTC; QL (200 20 GAUGE X 1", 21 MICROTAINER per 23 days) GAUGE X 1 1/2", LANCET 30 21 GAUGE X 1", 22 GAUGE GAUGE X 1 1/2", BD NANO 2ND 2 OTC 22 GAUGE X 1", 23 GEN PEN NEEDLE GAUGE X 3/4", 25 NEEDLE 32 GAUGE X 1 1/2", GAUGE X 5/32" 25 GAUGE X 5/8", 26 GAUGE X 1/2", 27 GAUGE X 1/2" You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 98 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD SAFETYGLIDE 2 OTC BD SAFETYGLIDE 2 OTC ALLERGIST TRAY SYRINGE SYRINGE 1 ML 26 SYRINGE 10 ML GAUGE X 3/8" 22 X 1 1/2", 3 ML BD SAFETYGLIDE 2 23 X 1", 3 ML 25 INSULIN GAUGE X 1", 3 ML SYRINGE 25 X 5/8", 5 ML 22 SYRINGE 0.3 ML GAUGE X 1 1/2" 29 GAUGE X 1/2", BD SAFETYGLIDE 2 OTC 0.3 ML 31 GAUGE TB REG BEVEL X 15/64", 0.3 ML 31 SYRINGE 1 ML 27 GAUGE X 5/16", X 1/2" 0.5 ML 30 GAUGE BD SAFETYGLIDE 2 OTC X 5/16", 0.5 ML 31 TUBERCULIN GAUGE X 15/64", 1 SYRINGE 1 ML 26 ML 29 GAUGE X GAUGE X 3/8" 1/2", 1 ML 31 GAUGE X 15/64" BD SAFETY-LOK 2 OTC DETACHABLE BD SAFETYGLIDE 2 NEEDL SYRINGE NEEDLE NEEDLE 10 ML 21 GAUGE 18 GAUGE X 1 X 1 1/2", 3 ML 25 1/2", 21 GAUGE X GAUGE X 5/8", 5 1 1/2", 21 GAUGE ML 21 GAUGE X 1 X 1", 22 GAUGE X 1/2" 1 1/2", 25 GAUGE X 1", 25 X 5/8 ", 27 BD SAFETY-LOK 2 OTC X 5/8 " TUBERCULIN SYRINGE 1 ML 27 BD SAFETYGLIDE 2 OTC GAUGE X 1/2" SHIELDING REG SYRINGE 1 ML 25 BD SAFETY-LOK 2 OTC GAUGE X 5/8", 3 WITH LUER-LOK ML 21 GAUGE X 1 SYRINGE 10 ML, 3 1/2" ML, 5 ML BD SAFETYGLIDE 2 BD SLIP TIP 2 OTC SYRINGE SYRINGE SYRINGE 1 ML 27 SYRINGE 1 ML 26 GAUGE X 5/8" GAUGE X 5/8", 10 ML, 3 ML B-D SLIP TIP 2 OTC SYRINGE SYRINGE 20 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 99 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD SPECIALTY 2 BD TUBERCULIN 2 OTC USE NEEDLES SYRINGE NEEDLE 16 SYRINGE 1 ML 21 GAUGE X 1 1/2", GAUGE X 1", 1 ML 16 GAUGE X 1", 21 25 GAUGE X 5/8", GAUGE X 2", 23 1 ML 26 GAUGE X GAUGE X 1 1/4", 3/8", 1/2 ML 27 X 25 GAUGE X 7/8", 1/2 " 27 GAUGE X 1 BD ULTRA FINE 2 OTC; QL (200 1/4", 30 GAUGE X LANCETS 33 per 23 days) 1", 30 GAUGE X GAUGE 1/2" BD ULTRA-FINE II 2 OTC; QL (200 BD SYRINGE 2 OTC LANCETS 30 per 23 days) CATH TIP GAUGE NONSTERILE SYRINGE 50 ML BD ULTRA-FINE 2 OTC MICRO PEN BD SYRINGE 2 OTC NEEDLE NEEDLE CATHETER TIP 32 GAUGE X 1/4" SYRINGE 50 ML BD ULTRA-FINE 2 OTC BD SYRINGE 2 OTC MINI PEN LUER-LOK NEEDLE NEEDLE NONSTERILE 31 GAUGE X 3/16" SYRINGE 10 ML, 20 ML, 5 ML, 50 BD ULTRA-FINE 2 OTC ML NANO PEN NEEDLE NEEDLE BD SYRINGE 2 OTC 32 GAUGE X 5/32" LUER-LOK STERILE BD ULTRA-FINE 2 OTC SYRINGE 10 ML, ORIG PEN 50 ML NEEDLE NEEDLE 29 GAUGE X 1/2" BD SYRINGE SLIP 2 OTC TIP NONSTERILE BD ULTRA-FINE 2 SYRINGE 50 ML SHORT PEN NEEDLE NEEDLE BD SYRINGE 2 OTC 31 GAUGE X 5/16" STORAGE BINS BD VEO INSULIN 2 BD SYRINGE 2 OTC SYR (HALF UNIT) SYRINGE 1 ML SYRINGE 0.3 ML BD SYRINGE TIP 2 OTC 31 GAUGE X CAP 15/64" BD TUBERCULIN 2 OTC SLIP-TIP SYRINGE 1 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 100 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD VEO INSULIN 2 BREATHERITE 2 QL (2 per 365 SYRINGE UF SPACER- days) SYRINGE 0.3 ML MASK,S.CHLD 31 GAUGE X SPACER 15/64", 1 ML 31 BREATHERITE 2 QL (2 per 365 GAUGE X 15/64", VALVED MDI days) 1/2 ML 31 GAUGE CHAMBER X 15/64" SPACER BD YALE 2 BREATHERITE 2 QL (2 per 365 REGULAR BEVEL VALVED MDI days) NEEDLE 27 SPACER SPACER GAUGE X 1" BULLSEYE MINI 2 OTC BEUTLICH PH 2 OTC SAFETY TEST ROLL LANCETS 21 BLOOD 2 OTC GAUGE, 25 PRESSURE CUFF GAUGE BLUNT NEEDLE, 2 BULLSEYE MINI 2 OTC; QL (200 DISPOSABLE SAFETY per 23 days) NEEDLE 18 X 1 1/2 LANCETS 28 ", 22 X 1 1/2 " GAUGE BREATHERITE 2 QL (2 per 365 BUTTERFLY 2 OTC; QL (200 MDI SPACER days) TOUCH LANCET per 23 days) SPACER 30 GAUGE BREATHERITE 2 QL (2 per 365 BYDUREON 1 PA; QL (3.4 SPACER-MASK, days) BCISE per 23 days) NEO. SPACER SUBCUTANEOUS AUTO-INJECTOR BREATHERITE 2 QL (2 per 365 SPACER- days) 2 MG/0.85 ML MASK,ADULT BYETTA 1 SPACER SUBCUTANEOUS BREATHERITE 2 QL (2 per 365 PEN INJECTOR 10 SPACER- days) MCG/DOSE(250 MASK,CHILD MCG/ML) 2.4 ML, SPACER 5 MCG/DOSE (250 MCG/ML) 1.2 ML BREATHERITE 2 QL (2 per 365 SPACER- days) MASK,INFANT SPACER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 101 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CAREFINE PEN 2 OTC CHEMSTRIP 2 GP 2 OTC NEEDLE NEEDLE STRIP 29 GAUGE X 1/2", CHEMSTRIP 50B 2 OTC 30 GAUGE X 5/16", STRIP 31 GAUGE X 1/4", 31 GAUGE X 5/16", CHEMSTRIP 7 2 OTC 32 GAUGE X 1/4", STRIP 32 GAUGE X 3/16", CHEMSTRIP 9 2 OTC 32 GAUGE X 5/32" STRIP CAREONE ULTRA 2 OTC CLEVER CHEK 2 OTC; QL (200 THIN LANCET LANCETS 30 per 23 days) CAREPOINT LUER 2 OTC GAUGE SLIP SYRINGE CLEVER CHOICE 2 QL (2 per 365 SYRINGE 1 ML CHAMBER-LRG days) CARETOUCH 2 OTC MASK SPACER ALCOHOL PREP CLEVER CHOICE 2 QL (2 per 365 PAD TOPICAL CHAMBER-MED days) PADS, MASK SPACER MEDICATED CLEVER CHOICE 2 QL (2 per 365 CARETOUCH 2 CHAMBER-SM days) INSULIN MASK SPACER SYRINGE SYRINGE 1 ML 28 CLEVER CHOICE 2 OTC; QL (2 X 5/16", 1 ML 29 PEAK FLOW per 365 days) GAUGE X 5/16 METER DEVICE CARETOUCH PEN 2 OTC CLICKFINE PEN 2 OTC NEEDLE NEEDLE NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" 32 GAUGE X 3/16", COAGUCHEK 2 OTC 32 GAUGE X 5/32" LANCETS CARETOUCH 2 OTC; QL (200 COLOR LANCETS 2 OTC TWIST LANCET 28 per 23 days) 21 GAUGE GAUGE, 30 GAUGE, 33 GAUGE CHEMSTRIP 10 2 OTC MD STRIP CHEMSTRIP 10/SG 2 OTC STRIP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 102 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COMFORT EZ 2 COMFORT 2 OTC INSULIN LANCETS SYRINGE COMPACT SPACE 2 QL (2 per 365 SYRINGE 0.3 ML CHAMBER days) 29 GAUGE X 1/2", SPACER 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 COMPACT SPACE 2 QL (2 per 365 GAUGE X 5/16", CHAMBER-LRG days) 0.3 ML 31 GAUGE MASK SPACER X 5/16", 0.5 ML 29 COMPACT SPACE 2 QL (2 per 365 GAUGE X 1/2", 0.5 CHAMBER-MED days) ML 30 GAUGE X MASK SPACER 1/2", 0.5 ML 31 GAUGE X 5/16", 1 COMPACT SPACE 2 QL (2 per 365 ML 28 GAUGE X CHAMBER-SM days) 1/2", 1 ML 29 MASK SPACER GAUGE X 1/2", 1 COOL MIST 2 OTC ML 30 GAUGE X HUMIDIFIER 1/2", 1 ML 30 CURITY 2 OTC GAUGE X 5/16, 1 ALCOHOL SWABS ML 31 GAUGE X TOPICAL PADS, 5/16, 1/2 ML 28 MEDICATED GAUGE X 1/2" CURITY 2 OTC COMFORT EZ 2 OTC TRIANGULAR LANCETS 23 BANDAGE GAUGE CUT N CRUSH 2 OTC COMFORT EZ 2 OTC; QL (200 LANCETS 28 per 23 days) DAVOL 2 OTC GAUGE IRRIGATION SYRINGE COMFORT EZ PEN 2 OTC SYRINGE NEEDLES NEEDLE 29 DAVOL PISTON 2 OTC GAUGE X 1/2", 31 IRRIGATION GAUGE X 1/4", 31 SYRINGE GAUGE X 3/16", 31 DEXCOM G6 1 GAUGE X 5/16", 32 RECEIVER GAUGE X 1/4", 32 GAUGE X 3/16", 32 DEXCOM G6 1 GAUGE X 5/16", 32 SENSOR DEVICE GAUGE X 5/32", 33 DEXCOM G6 1 GAUGE X 1/4", 33 TRANSMITTER GAUGE X 3/16", 33 DEVICE GAUGE X 5/16", 33 GAUGE X 5/32" diazoxide oral 2 suspension 50 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 103 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DISPOSABLE 2 DROPLET 2 NEEDLES INSULIN NEEDLE 22 SYRINGE GAUGE X 3/4" SYRINGE 0.3 ML DISPOSABLE 2 OTC 29 GAUGE X 1/2", PAPER 0.3 ML 30 GAUGE MOUTHPIECE X 1/2", 0.3 ML 30 GAUGE X 15/64", DOVER TWO- 2 OTC 0.3 ML 30 GAUGE SIDED ADHESIVE X 5/16", 0.3 ML 31 STRAP GAUGE X 15/64", DRAIN-TUBE 2 OTC 0.3 ML 31 GAUGE ATTACHMENT X 5/16", 1 ML 29 DEVICE GAUGE X 1/2", 1 ML 30 GAUGE X DROPLET 2 1/2", 1 ML 30 INSULIN GAUGE X 15/64", 1 SYR(HALF UNIT) ML 30 GAUGE X SYRINGE 0.5 ML 5/16, 1 ML 31 29 GAUGE X 1/2", GAUGE X 15/64", 1 0.5 ML 30 GAUGE ML 31 GAUGE X X 1/2", 0.5 ML 30 5/16 GAUGE X 5/16", 0.5 ML 31 GAUGE DROPLET 2 OTC; QL (200 X 15/64", 0.5 ML 31 LANCETS 30 per 23 days) GAUGE X 5/16", GAUGE 0.5ML 30 GAUGE DROPLET 2 OTC X 15/64" MICRON PEN NEEDLE NEEDLE 34 GAUGE X 9/64" DROPLET PEN 2 OTC NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 104 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DROPSAFE PEN 2 OTC EASY COMFORT 2 OTC NEEDLE NEEDLE PEN NEEDLES 31 GAUGE X 1/4", NEEDLE 31 31 GAUGE X 5/16" GAUGE X 1/4", 31 EASIVENT 2 QL (2 per 365 GAUGE X 3/16", 31 HOLDING days) GAUGE X 5/16", 32 CHAMBER GAUGE X 5/32", 33 SPACER GAUGE X 1/4", 33 GAUGE X 3/16", 33 EASIVENT MASK 2 QL (2 per 365 GAUGE X 5/32" LARGE DEVICE days) EASY GLIDE 2 EASIVENT MASK 2 QL (2 per 365 INSULIN MEDIUM DEVICE days) SYRINGE EASIVENT MASK 2 QL (2 per 365 SYRINGE 0.3 ML SMALL DEVICE days) 31 GAUGE X 15/64", 1 ML 31 EASY COMFORT 2 OTC GAUGE X 15/64", ALCOHOL PAD 1/2 ML 31 GAUGE TOPICAL PADS, X 15/64" MEDICATED EASY GLIDE 2 OTC EASY COMFORT 2 LUER LOCK INSULIN SYRINGE SYRINGE SYRINGE 1 ML SYRINGE 0.3 ML 30 GAUGE X 5/16", EASY GLIDE PEN 2 OTC 0.5 ML 30 GAUGE NEEDLE NEEDLE X 1/2", 0.5 ML 30 33 GAUGE X 5/32" GAUGE X 5/16", EASY TOUCH 2 OTC 0.5 ML 31 GAUGE ALCOHOL PREP X 5/16", 1 ML 30 PADS TOPICAL GAUGE X 1/2", 1 PADS, ML 30 GAUGE X MEDICATED 5/16, 1 ML 31 GAUGE X 5/16, 1 EASY TOUCH 2 ML 32 GAUGE X FLIPLOCK 5/16", 1/2 ML 32 INSULIN GAUGE X 5/16" SYRINGE 1 ML 29 GAUGE X 1/2", 1 EASY COMFORT 2 OTC; QL (200 ML 30 GAUGE X LANCETS 30 per 23 days) 1/2", 1 ML 30 GAUGE GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 105 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EASY TOUCH 2 EASY TOUCH 2 OTC FLIPLOCK FLIPLOCK NEEDLE NEEDLE SYRINGE 18 GAUGE X 1 SYRINGE 1 ML 25 1/2", 18 GAUGE X GAUGE X 1", 1 ML 1", 19 GAUGE X 1 26 GAUGE X 3/8", 1/2", 19 GAUGE X 1 ML 27 GAUGE X 1", 20 GAUGE X 1 1/2", 10 ML 20 1/2", 20 GAUGE X GAUGE X 1 1/2", 1", 21 GAUGE X 1 10 ML 20 GAUGE 1/2", 21 GAUGE X X 1", 10 ML 21 1", 22 GAUGE X 1 GAUGE X 1 1/2", 1/2", 22 GAUGE X 10 ML 21 X 1", 10 1", 22 GAUGE X ML 22 GAUGE X 1 3/4", 23 GAUGE X 1/2", 10 ML 25 1 1/2", 23 GAUGE GAUGE X 1", 3 ML X 1", 23 GAUGE X 20 GAUGE X 1 5/8", 25 GAUGE X 1/2", 3 ML 20 1 1/2", 25 GAUGE GAUGE X 1", 3 ML X 1", 25 X 5/8 ", 26 21 GAUGE X 1 GAUGE X 1", 26 1/2", 3 ML 21 GAUGE X 1/2", 27 GAUGE X 1", 3 ML GAUGE X 1", 27 22 GAUGE X 1 GAUGE X 1/2", 28 1/2", 3 ML 22 GAUGE X 1/2", 29 GAUGE X 1", 3 ML GAUGE X 1/2", 30 23 GAUGE X 1 GAUGE X 5/16", 30 1/2", 3 ML 23 X 1/2 ", 31 GAUGE GAUGE X 1", 3 ML X 5/16" 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1", 5 ML 25 GAUGE X 5/8"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 106 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EASY TOUCH 2 OTC EASY TOUCH 2 FLURINGE HYPODERMIC FLIPLOCK NEEDLE NEEDLE SYRINGE 1 ML 25 16 GAUGE X 1 GAUGE X 1", 1 ML 1/2", 18 GAUGE X 25 GAUGE X 5/8" 1 1/2", 18 GAUGE EASY TOUCH 2 OTC X 1 1/4", 18 FLURINGE FLU GAUGE X 1", 19 TRAY TRAY 1 ML GAUGE X 1 1/2", 25 GAUGE X 1" 19 GAUGE X 1", 20 GAUGE X 1 1/2", EASY TOUCH 2 OTC 20 GAUGE X 1", 21 FLURINGE GAUGE X 1 1/2", SHEATHLOCK 21 GAUGE X 1", 22 SYRINGE 1 ML 25 GAUGE X 1 1/2", GAUGE X 1", 1 ML 22 GAUGE X 1", 23 25 GAUGE X 5/8" GAUGE X 1 1/2", EASY TOUCH 2 OTC 23 GAUGE X 1 FLURINGE 1/4", 23 GAUGE X SYRINGE 1 ML 25 1", 23 GAUGE X GAUGE X 1", 1 ML 3/4", 24 GAUGE X 25 GAUGE X 5/8" 1 1/4", 24 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 GAUGE X 1/2", 26 GAUGE X 3/8", 26 GAUGE X 5/8", 27 GAUGE X 1 1/2", 27 GAUGE X 1 1/4", 27 GAUGE X 1/2", 30 GAUGE X 1", 30 GAUGE X 1/2", 31 GAUGE X 5/16", 32 GAUGE X 5/16" EASY TOUCH 2 INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 107 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EASY TOUCH 2 EASY TOUCH 2 OTC INSULIN NEEDLE 29 SYRINGE GAUGE X 1/2", 31 SYRINGE 0.3 ML GAUGE X 1/4", 31 30 GAUGE X 1/2", GAUGE X 3/16", 31 0.3 ML 30 GAUGE GAUGE X 5/16", 32 X 5/16", 0.5 ML 29 GAUGE X 1/4", 32 GAUGE X 1/2", 0.5 GAUGE X 3/16", 32 ML 30 GAUGE X GAUGE X 5/32" 1/2", 1 ML 27 EASY TOUCH PEN 2 OTC GAUGE X 1/2", 1 NEEDLE NEEDLE ML 28 GAUGE X 30 GAUGE X 5/16" 1/2", 1 ML 29 GAUGE X 1/2", 1 EASY TOUCH 2 OTC ML 30 GAUGE X SAFETY 1/2", 1 ML 31 LANCETS 21 GAUGE X 5/16, 1/2 GAUGE, 23 ML 27 GAUGE X GAUGE, 32 1/2", 1/2 ML 28 GAUGE GAUGE X 1/2" EASY TOUCH 2 OTC; QL (200 EASY TOUCH 2 OTC; QL (200 SAFETY per 23 days) LANCETS 26 per 23 days) LANCETS 26 GAUGE, 28 GAUGE, 28 GAUGE, 30 GAUGE, 30 GAUGE GAUGE EASY TOUCH 2 OTC EASY TOUCH 2 OTC LANCETS 32 SAFETY PEN GAUGE NEEDLE NEEDLE 29 GAUGE X 3/16", EASY TOUCH 2 30 GAUGE X 3/16" LUER LOCK INSULIN EASY TOUCH 2 SYRINGE 1 ML SHEATHLOCK INSULIN EASY TOUCH 2 OTC SYRINGE 1 ML 29 LUER LOCK GAUGE X 1/2", 1 SYRINGE ML 30 GAUGE X SYRINGE 1 ML, 10 1/2", 1 ML 30 ML, 3 ML, 5 ML GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 108 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EASY TOUCH 2 OTC EASY TOUCH 2 OTC SHEATHLOCK SYRINGE 1 ML 25 SYRG-NDL GAUGE X 1", 1 ML SYRINGE 10 ML 25 GAUGE X 5/8", 21 GAUGE X 1 3 ML 20 GAUGE X 1/2", 10 ML 22 1", 3 ML 21 GAUGE X 1 1/2", GAUGE X 1", 3 ML 10 ML 25 GAUGE 22 GAUGE X 1", 3 X 1", 3 ML 21 ML 22 X 1 1/2", 3 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML ML 21 GAUGE X 25 GAUGE X 1", 3 1", 3 ML 22 ML 25 X 5/8" GAUGE X 1 1/2", 3 EASY TOUCH 2 OTC ML 22 GAUGE X TUBERCULIN 1", 3 ML 23 FLIPLOCK GAUGE X 1", 3 ML SYRINGE 1 ML 26 25 GAUGE X 1", 3 GAUGE X 5/8", 1 ML 25 GAUGE X ML 27 GAUGE X 5/8", 5 ML 21 1/2", 1 ML 28 GAUGE X 1 1/2", 5 GAUGE X 1/2" ML 22 GAUGE X 1 1/2", 5 ML 25 EASY TOUCH 2 OTC GAUGE X 1" TUBERCULIN SHEATHLK EASY TOUCH 2 OTC SYRINGE 1 ML 25 SHEATHLOCK GAUGE X 5/8", 1 SYRINGE ML 26 GAUGE X SYRINGE 10 ML, 3 5/8", 1 ML 27 ML GAUGE X 1/2", 1 EASY TOUCH SYR 2 OTC ML 28 GAUGE X ALLERGY TRAY 1/2" TRAY 1 ML 26 EASY TOUCH 2 OTC; QL (200 GAUGE X 3/8", 1 TWIST LANCETS per 23 days) ML 27 GAUGE X 26 GAUGE, 28 1/2" GAUGE, 30 GAUGE, 33 GAUGE EASY TOUCH 2 OTC TWIST LANCETS 32 GAUGE EASY TOUCH 2 UNI-SLIP SYRINGE 1 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 109 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EASY TOUCH 2 OTC EXEL 2 UNI-SLIP HYPODERMIC SYRINGE 10 ML, 3 NEEDLES ML, 5 ML NEEDLE 18 EASY TWIST AND 2 OTC; QL (200 GAUGE X 1 1/2", CAP LANCETS 28 per 23 days) 19 GAUGE X 1", 20 GAUGE GAUGE X 1 1/2", 20 GAUGE X 1", 20 EASYPOINT 2 X 3/4 ", 21 GAUGE NEEDLE NEEDLE X 1 1/2", 21 18 GAUGE X 1 GAUGE X 1", 22 1/2", 18 GAUGE X GAUGE X 1 1/2", 1", 20 GAUGE X 1 22 GAUGE X 1", 22 1/2", 20 GAUGE X GAUGE X 3/4", 23 1", 21 GAUGE X 1 GAUGE X 3/4", 25 1/2", 21 GAUGE X GAUGE X 1 1/2", 1", 22 GAUGE X 1 25 GAUGE X 1", 25 1/2", 22 GAUGE X GAUGE X 3/4", 25 1", 25 GAUGE X 1 GAUGE X 5/8", 26 1/2", 25 GAUGE X GAUGE X 1 1/2", 1" 26 GAUGE X 1/2", ECLIPSE NEEDLE 2 26 GAUGE X 3/8", NEEDLE 23 26 GAUGE X 5/8", GAUGE X 1", 25 X 27 GAUGE X 1/2", 5/8 ", 27 GAUGE X 30 GAUGE X 1/2" 1/2" EXEL INSULIN 2 ECLIPSE 2 OTC SYRINGE 0.3 ML SYRINGE 29 GAUGE X 1/2", SYRINGE 1 ML 25 0.5 ML 30 GAUGE GAUGE X 5/8" X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ELASTIC FOAM 2 OTC ML 28 GAUGE X STRAPS 1/2" EMBRACE 2 OTC; QL (200 EXEL SYRINGE 2 OTC LANCETS 30 per 23 days) SYRINGE 10 ML, 3 GAUGE ML 27 GAUGE X 1 EXCEL SYRINGE 2 OTC 1/4", 30 ML, 50 ML SYRINGE 3 ML 23 e-z ject lancets , 32 2 OTC X 1" gauge e-z ject lancets 26 2 OTC; QL (200 gauge, 30 gauge, 33 per 23 days) gauge

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 110 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits e-z ject thin lancets 2 OTC; QL (200 FLEXICHAMBER- 2 QL (99 per 99 28 gauge per 23 days) SM ADULT MASK days) EZ SMART 2 OTC; QL (200 DEVICE LANCETS 28 per 23 days) FLEXICHAMBER- 2 QL (99 per 99 GAUGE SM CHILD MASK days) EZ-LETS 26 2 OTC; QL (200 DEVICE GAUGE per 23 days) FLOW-EZE 2 FACE SPLASH 2 OTC VENTED NEEDLE SHIELD, FULL NEEDLE FACE SPLASH 2 OTC FORA V10-V12- 2 OTC SHIELD, SHORT D10-D20 STRP- LNCT COMBO FARXIGA ORAL 1 QL (1 per 1 PACK 30 GAUGE TABLET 10 MG, 5 day) MG FORACARE 2 OTC; QL (200 LANCETS 30 per 23 days) FC2 FEMALE 2 OTC GAUGE CONDOM FREESTYLE 2 OTC FEEDING TUBE 2 OTC FLASH SYSTEM ATTACHMENT KIT DEVICE FREESTYLE 2 OTC FIFTY50 SAFETY 2 OTC; QL (200 FREEDOM KIT SEAL LANCETS 30 per 23 days) GAUGE FREESTYLE 2 OTC FREEDOM LITE FIFTY50 SAFETY 2 OTC KIT SEAL LANCETS 32 GAUGE FREESTYLE 2 OTC INSULINX FILTER NEEDLES 2 NEEDLE 18 FREESTYLE 1 PrefD; OTC; GAUGE X 1 1/2" INSULINX STRIP QL (100 per 23 days) FINE 30 2 OTC; QL (200 UNIVERSAL per 23 days) FREESTYLE 1 PrefD; OTC; LANCETS 30 INSULINX TEST QL (100 per GAUGE STRIPS STRIP 23 days) FINGERSTIX 2 OTC FREESTYLE 2 OTC; QL (200 LANCETS LANCETS 28 per 23 days) GAUGE FLEXICHAMBER 2 QL (99 per 99 SPACER days) FREESTYLE 1 LIBRE 14 DAY FLEXICHAMBER- 2 QL (99 per 99 READER LG CHILD MASK days) DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 111 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FREESTYLE 1 glipizide oral tablet 2 1 Copay LIBRE 14 DAY 10 mg, 5 mg SENSOR KIT glipizide oral tablet 2 1 Copay FREESTYLE 1 PA extended release LIBRE 2 READER 24hr 10 mg, 2.5 mg, FREESTYLE 1 PA 5 mg LIBRE 2 SENSOR glipizide-metformin 2 1 Copay KIT oral tablet 2.5-250 FREESTYLE LITE 2 OTC mg, 2.5-500 mg, 5- 500 mg METER KIT FREESTYLE LITE 1 PrefD; OTC; GLUCAGEN 2 STRIPS STRIP QL (100 per HYPOKIT 23 days) INJECTION RECON SOLN 1 FREESTYLE 2 OTC MG PRECISION NEO METER glucagon emergency 2 kit (human) injection FREESTYLE 2 PA; OTC; QL recon soln 1 mg PRECISION NEO (100 per 23 STRIPS STRIP days) GLUCOCOM 2 OTC; QL (200 LANCETS 28 per 23 days) FREESTYLE 2 GAUGE, 30 PRECISION GAUGE, 33 SYRINGE 0.5 ML GAUGE 30 GAUGE X 5/16", 0.5 ML 31 GAUGE glyburide 2 1 Copay X 5/16", 1 ML 30 micronized oral GAUGE X 5/16, 1 tablet 1.5 mg, 3 mg, 6 mg ML 31 GAUGE X 5/16 glyburide oral tablet 2 1 Copay FREESTYLE 2 OTC 1.25 mg, 2.5 mg, 5 SIDEKICK II KIT mg FREESTYLE 2 OTC glyburide-metformin 2 1 Copay SYSTEM KIT KIT oral tablet 1.25-250 mg, 2.5-500 mg, 5- FREESTYLE TEST 1 PA; OTC; QL 500 mg STRIP (100 per 23 GLYXAMBI ORAL 1 PA; QL (1 per days) TABLET 10-5 MG, 1 day) FREESTYLE 2 OTC 25-5 MG UNISTIK 2 GOJJI LANCET- 2 OTC glimepiride oral 2 1 Copay GLUCOSE TEST tablet 1 mg, 2 mg, 4 STRP COMBO mg PACK 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 112 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GOJJI LANCETS 2 OTC; QL (200 HEALTHWISE 2 OTC 30 GAUGE per 23 days) PEN NEEDLE GVOKE HYPOPEN 1 PA NEEDLE 31 1-PACK GAUGE X 3/16", 31 SUBCUTANEOUS GAUGE X 5/16", 32 AUTO-INJECTOR GAUGE X 5/32" 0.5 MG/0.1 ML, 1 HEALTHY 2 OTC MG/0.2 ML ACCENTS GVOKE HYPOPEN 1 PA UNIFINE PENTIP 2-PACK NEEDLE 29 SUBCUTANEOUS GAUGE X 1/2", 31 AUTO-INJECTOR GAUGE X 1/4", 31 0.5 MG/0.1 ML, 1 GAUGE X 3/16", 31 MG/0.2 ML GAUGE X 5/16", 32 GAUGE X 5/32" GVOKE PFS 1- 1 PA HEALTHY 2 OTC; QL (200 PACK SYRINGE SUBCUTANEOUS ACCENTS UNILET per 23 days) SYRINGE 0.5 LANCET 30 GAUGE MG/0.1 ML, 1 MG/0.2 ML HORIZONTAL 2 OTC GVOKE PFS 2- 1 PA DRAIN-TUBE ATT PACK SYRINGE DEV SUBCUTANEOUS huber safety needles 2 SYRINGE 0.5 (disp.) needle 22 x MG/0.1 ML, 1 3/4 " MG/0.2 ML HUMALOG 1 HEALTHMIST 2 OTC JUNIOR KWIKPEN HEALTHWISE 2 U-100 INSULIN SUBCUTANEOUS SYRINGE INSULIN PEN, SYRINGE 0.3 ML HALF-UNIT 100 30 GAUGE X 5/16", UNIT/ML 0.3 ML 31 GAUGE HUMALOG 1 X 5/16", 0.5 ML 30 KWIKPEN GAUGE X 5/16", INSULIN 0.5 ML 31 GAUGE SUBCUTANEOUS X 5/16", 1 ML 30 INSULIN PEN 100 GAUGE X 5/16, 1 UNIT/ML, 200 ML 31 GAUGE X UNIT/ML (3 ML) 5/16

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 113 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMALOG MIX 2 HUMULIN 70/30 2 50-50 INSULN U- U-100 KWIKPEN 100 SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 100 SUSPENSION 100 UNIT/ML (70-30) UNIT/ML (50-50) HUMULIN N NPH 2 HUMALOG MIX 1 INSULIN 50-50 KWIKPEN KWIKPEN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 100 INSULIN PEN 100 UNIT/ML (50-50) UNIT/ML (3 ML) HUMALOG MIX 1 HUMULIN N NPH 2 75-25 KWIKPEN U-100 INSULIN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 100 SUSPENSION 100 UNIT/ML (75-25) UNIT/ML HUMALOG MIX 2 HUMULIN R 2 75-25(U- REGULAR U-100 100)INSULN INSULN SUBCUTANEOUS INJECTION SUSPENSION 100 SOLUTION 100 UNIT/ML (75-25) UNIT/ML HUMALOG U-100 1 HUMULIN R U-500 2 INSULIN (CONC) INSULIN SUBCUTANEOUS SUBCUTANEOUS CARTRIDGE 100 SOLUTION 500 UNIT/ML UNIT/ML HUMALOG U-100 1 HUMULIN R U-500 2 INSULIN (CONC) KWIKPEN SUBCUTANEOUS SUBCUTANEOUS SOLUTION 100 INSULIN PEN 500 UNIT/ML UNIT/ML (3 ML) HUMIDIFIERS 2 OTC HURRICAINE 2 OTC HUMULIN 70/30 2 LIQUID U-100 INSULIN DISPENSER SUBCUTANEOUS HURRICAINE 2 OTC SUSPENSION 100 SPRAY UNIT/ML (70-30) EXTENSION

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 114 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HYPODERMIC 2 INPEN (FOR 2 QL (2 per 365 NEEDLES HUMALOG) days) NEEDLE 21 SUBCUTANEOUS GAUGE X 1", 23 INSULIN PEN GAUGE X 1 1/2", INPEN (FOR 2 QL (2 per 365 26 GAUGE X 5/8" NOVOLOG OR days) HYPOLANCE AST 2 OTC FIASP) LANCING KIT SUBCUTANEOUS IN-CHECK NASAL 2 OTC; QL (2 INSULIN PEN WITH MASK per 365 days) INSPIRACHAMBE 2 QL (2 per 365 DEVICE R SPACER days) IN-CHECK ORAL 2 OTC; QL (2 INSPIRACHAMBE 2 QL (2 per 365 FLOW METER per 365 days) R WITH MASK- days) DEVICE LARGE SPACER INCONTROL 2 OTC INSPIRACHAMBE 2 QL (2 per 365 ALCOHOL PADS R WITH MASK- days) TOPICAL PADS, MED SPACER MEDICATED INSPIRACHAMBE 2 QL (2 per 365 INCONTROL PEN 2 OTC R WITH MASK- days) NEEDLE NEEDLE SMALL SPACER 29 GAUGE X 1/2", insta-glucose (with 2 OTC 31 GAUGE X 1/4", dextrin) oral gel 24 31 GAUGE X 3/16", gram/31 gram 31 GAUGE X 5/16", 32 GAUGE X 5/32" INSULIN 2 SYR/NDL U100 INCONTROL 2 OTC; QL (200 HALF MARK SUPER THIN per 23 days) SYRINGE 0.3 ML LANCETS 30 31 GAUGE X 1/4" GAUGE INSULIN 2 INCONTROL 2 OTC; QL (200 SYRINGE ULTRA THIN per 23 days) MICROFINE LANCETS 28 SYRINGE 1 ML 27 GAUGE GAUGE X 5/8" INJECT EASE 2 OTC; QL (200 INSULIN 2 LANCETS 28 per 23 days) SYRINGE GAUGE, 30 NEEDLELESS GAUGE SYRINGE 1 ML INJECT-EASE 2 OTC DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 115 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INSULIN 2 INSULIN 2 SYRINGE SYRINGE- SYRINGE 0.5 ML NEEDLE U-100 29 GAUGE X 1/2", SYRINGE 0.3 ML 1 ML 29 GAUGE X 29 GAUGE, 0.3 ML 1/2" 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 7/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16, 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE X 15/64"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 116 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits insulin syringe- 2 JANUMET XR 1 needle u-100 syringe ORAL TABLET, 1 ml 30 gauge x 3/8" ER MULTIPHASE INSUPEN NEEDLE 2 OTC 24 HR 100-1,000 29 GAUGE X 1/2", MG, 50-1,000 MG, 30 GAUGE X 5/16", 50-500 MG 31 GAUGE X 1/4", JANUVIA ORAL 1 31 GAUGE X 3/16", TABLET 100 MG, 31 GAUGE X 5/16", 25 MG, 50 MG 32 GAUGE X 1/4", JARDIANCE 1 QL (1 per 1 32 GAUGE X 5/16", ORAL TABLET 10 day) 32 GAUGE X 5/32", MG, 25 MG 33 GAUGE X 5/32" JENTADUETO 1 INTEGRA 2 ORAL TABLET PRECISIONGLIDE 2.5-1,000 MG, 2.5- NEEDLE NEEDLE 500 MG, 2.5-850 25 X 5/8 " MG INVACARE 2 OTC; QL (200 JENTADUETO XR 1 LANCETS 30 per 23 days) ORAL TABLET, IR GAUGE - ER, BIPHASIC INVOKAMET 1 24HR 2.5-1,000 ORAL TABLET MG, 5-1,000 MG 150-1,000 MG, 150- KETONE CARE 2 OTC 500 MG, 50-1,000 STRIP MG, 50-500 MG KETONE URINE 2 OTC INVOKAMET XR 1 TEST STRIP ORAL TABLET, IR - ER, BIPHASIC KETOSTIX STRIP 2 OTC 24HR 150-1,000 KOMBIGLYZE XR 1 MG, 150-500 MG, ORAL TABLET, 50-1,000 MG, 50- ER MULTIPHASE 500 MG 24 HR 2.5-1,000 INVOKANA ORAL 1 QL (1 per 1 MG, 5-1,000 MG, 5- TABLET 100 MG, day) 500 MG 300 MG LANCETS , 21 2 OTC IV PREP WIPES 2 OTC GAUGE TOPICAL PADS, LANCETS 26 2 OTC; QL (200 MEDICATED GAUGE, 28 per 23 days) JANUMET ORAL 1 GAUGE, 30 TABLET 50-1,000 GAUGE, 33 MG, 50-500 MG GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 117 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LANCETS, SUPER 2 OTC LITE TOUCH 2 THIN INSULIN LANCETS,THIN , 2 OTC SYRINGE 23 GAUGE SYRINGE 0.3 ML 29 GAUGE X 1/2", LANCETS,THIN 28 2 OTC; QL (200 0.3 ML 30 GAUGE GAUGE per 23 days) X 5/16", 0.3 ML 31 LANCETS,ULTRA 2 OTC GAUGE X 5/16", THIN 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 LANCETS,ULTRA 2 OTC; QL (200 GAUGE X 5/16", THIN 26 GAUGE per 23 days) 0.5 ML 31 GAUGE LANCING DEVICE 2 OTC X 5/16", 1 ML 28 WITH LANCETS GAUGE, 1 ML 28 KIT GAUGE X 1/2", 1 ML 29 GAUGE X LANTUS 1 1/2", 1 ML 30 SOLOSTAR U-100 GAUGE X 5/16, 1 INSULIN ML 31 GAUGE X SUBCUTANEOUS 5/16, 1/2 ML 28 INSULIN PEN 100 GAUGE, 1/2 ML 28 UNIT/ML (3 ML) GAUGE X 1/2" LANTUS U-100 1 LITE TOUCH 2 OTC; QL (200 INSULIN LANCETS 28 per 23 days) SUBCUTANEOUS GAUGE, 30 SOLUTION 100 GAUGE, 33 UNIT/ML GAUGE LANZO LANCING 2 OTC LITE TOUCH- 2 QL (2 per 365 DEVICE KIT MEDIUM MASK days) LIFESHIELD 2 DEVICE BLUNT CANNULA LITEAIRE MDI 2 QL (2 per 365 NEEDLE 18 CHAMBER days) GAUGE X 1" SPACER LITE TOUCH 2 OTC LITETOUCH- 2 QL (2 per 365 INSULIN PEN LARGE MASK days) NEEDLES DEVICE NEEDLE 29 GAUGE X 1/2", 31 LITETOUCH- 2 QL (2 per 365 GAUGE X 1/4", 31 SMALL MASK days) GAUGE X 3/16" DEVICE LUER LOCK 2 OTC SYRINGE SYRINGE 30 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 118 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LUER SLIP TIP 2 OTC MEDISENSE THIN 2 OTC; QL (200 SYRINGE TRAY LANCETS 28 per 23 days) SYRINGE 1 ML GAUGE LUER-LOK TIP 2 OTC medlance plus 2 OTC; QL (200 SYRINGE 30 ML lancets 21 gauge, 30 per 23 days) MAGELLAN 2 gauge INSULIN SAFETY medlance plus 2 OTC SYRNG SYRINGE lancets 25 gauge 0.3 ML 29 X 1/2", MEDLANCE PLUS 2 OTC 0.5 ML 29 GAUGE SPECIAL BLADE X 1/2", 1 ML 29 0.8 X 2 MM GAUGE X 1/2" metformin oral 1 1 Copay MAGELLAN 2 tablet 1,000 mg, 500 SYRINGE mg, 850 mg SYRINGE 0.3 ML 30 X 5/16", 0.5 ML metformin oral 1 1 Copay 30 GAUGE X 5/16" tablet extended release 24 hr 500 MAXICOMFORT II 2 OTC mg, 750 mg PEN NEEDLE NEEDLE 31 metformin oral 1 PA; 1 Copay GAUGE X 1/4" tablet extended release 24hr 1,000 MAXICOMFORT 2 mg, 500 mg INSULIN SYRINGE metformin oral 1 PA; 1 Copay SYRINGE 1 ML 27 tablet,er GAUGE X 1/2", 1/2 gast.retention 24 hr ML 27 GAUGE X 1,000 mg, 500 mg 1/2" MICRO THIN 2 OTC; QL (200 MAXI-COMFORT 2 LANCETS 33 per 23 days) INSULIN GAUGE SYRINGE MICROCHAMBER 2 QL (2 per 365 SYRINGE 1 ML 28 SPACER days) GAUGE X 1/2", 1/2 ML 28 GAUGE X MICRODOT 2 OTC 1/2" INSULIN PEN NEEDLE NEEDLE MAXICOMFORT 2 OTC 31 GAUGE X 1/4", SAFETY PEN 32 GAUGE X 5/32", NEEDLE NEEDLE 33 GAUGE X 5/32" 29 GAUGE X 3/16", 29 GAUGE X 5/16" MICROLET 2 2 OTC LANCING DEVICE KIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 119 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MICROLET 2 OTC MONOJECT 2 OTC LANCET ECCENTRIC NON- MICROLET NEXT 2 OTC STERILE LANCING DEVICE SYRINGE 35 ML KIT MONOJECT 2 MICROLIFE PEAK 2 OTC; QL (2 FILTER FLOW METER per 365 days) ASPIRATOR DEVICE NEEDLE 18 X 3 " MICROSPACER 2 QL (2 per 365 MONOJECT 2 OTC FILTER SPACER days) CONNECTOR miglitol oral tablet 2 1 Copay 100 mg, 25 mg, 50 MONOJECT 2 mg FILTER NEEDLE NEEDLE 5 MINI ULTRA- 2 OTC MICRON 20 X 1 THIN II NEEDLE 1/2" 31 GAUGE X 3/16" MONOJECT 2 OTC MONOJECT 3CC 2 OTC FINGER GRIP SYR 25GX1" EXTENDERS SYRINGE 3 ML 25 GAUGE X 1" MONOJECT 2 HYPODERMIC MONOJECT 2 NEEDLES BLOOD NEEDLE 14 COLLECTION GAUGE X 1 1/2", NEEDLE 20 18 GAUGE X 1 GAUGE X 1", 20 X 1/2", 18 GAUGE X 1 1/2 ", 21 GAUGE 1", 19 GAUGE X 1 X 1", 22 GAUGE X 1/2", 19 GAUGE X 1" 1", 20 GAUGE X 1 MONOJECT 2 OTC 1/2", 20 GAUGE X BRACKET- 1", 21 GAUGE X 1 SHARPS CONT 1/2", 21 GAUGE X 1", 22 GAUGE X 1 MONOJECT 2 1/2", 22 GAUGE X CONTROL 1", 23 GAUGE X SYRINGE LUER 1", 25 GAUGE X 1 SYRINGE 12 ML 1/2", 25 GAUGE X MONOJECT 2 OTC 1", 25 GAUGE X DISPOSABLE 5/8", 26 GAUGE X SYRINGE 1 1/2", 27 GAUGE SYRINGE 20 ML X 1 1/2", 27 GAUGE X 1/2", 30 GAUGE X 3/4"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 120 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MONOJECT 2 MONOJECT 2 OTC HYPODERMIC PHARMACY POLYPROPYL TRAY LUER NEEDLE 18 SYRINGE 12 ML, GAUGE X 1 1/2" 20 ML, 3 ML, 35 MONOJECT 2 ML, 6 ML, 60 ML INSULIN SAFETY MONOJECT REG 2 OTC SYRING SYRINGE TIP NON-STERILE 0.3 ML 29 GAUGE SYRINGE 12 ML, X 1/2", 0.3 ML 30 20 ML, 3 ML, 6 ML GAUGE X 5/16", MONOJECT 2 OTC 0.5 ML 29 GAUGE REGULAR LUER X 1/2", 0.5 ML 30 SYRINGE 35 ML, 6 GAUGE X 5/16", 29 ML GAUGE X 1/2" MONOJECT 2 OTC MONOJECT 2 SAFETY LUER INSULIN LOCK TIP SYRINGE SYRINGE 3 ML SYRINGE 0.3 ML 29 GAUGE X 1/2", MONOJECT 2 OTC 0.3 ML 31 GAUGE SAFETY SYR TIP X 5/16", 0.5 ML 29 CAP GAUGE X 1/2", 0.5 MONOJECT 2 OTC ML 31 GAUGE X SAFETY 5/16", 1 ML , 1 ML SYRINGES 27 GAUGE X 1/2", SYRINGE , 12 ML, 1 ML 28 GAUGE X 12 ML 20 X 1 1/2", 1/2", 1 ML 30 3 ML 20 GAUGE X GAUGE X 5/16, 1/2 1 1/2", 3 ML 21 ML 28 GAUGE X GAUGE X 1" 1/2" MONOJECT 2 MONOJECT 2 OTC SAFETY LUER-LOCK TIP SYRINGES SYRINGE 12 ML SYRINGE 6 ML MONOJECT 2 MONOJECT 2 OTC MEDICATION SHARPS WALL TRANSF NDL CABINET NEEDLE 20 X 1 " MONOJECT 2 OTC SYRINGE LUER LOK SYRINGE 35 ML, 60 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 121 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MONOJECT 2 OTC MONOJECT TIP 2 OTC SYRINGE CAPS/FLEX/LUER REGULAR LUER MONOJECT 2 OTC SYRINGE 60 ML TUBERCULIN MONOJECT 2 SYRINGE SYRINGE SYRINGE 1 ML, 1 SYRINGE 1/2 ML ML 25 GAUGE X 28 GAUGE, 6 ML 5/8", 1 ML 26 22 X 1 1/2" GAUGE X 3/8", 1 MONOJECT 2 OTC ML 27 X 1/2", 1 ML SYRINGE 28 GAUGE X 1/2", SYRINGE 12 ML 1/2 ML 28 X 1/2" 18 GAUGE X 1", 12 MONOJECT 2 ML 20 X 1 1/2", 12 ULTRA COMFORT ML 21 GAUGE X 1 INSULIN 1/2", 12 ML 21 SYRINGE 1/2 ML GAUGE X 1", 3 ML 28 GAUGE 20 GAUGE X 1 MONOLET 2 OTC 1/2", 3 ML 20 LANCETS 21 GAUGE X 1", 3 ML GAUGE 20 X 3/4", 3 ML 21 GAUGE X 1 1/2", 3 MONOLET THIN 2 OTC; QL (200 ML 21 GAUGE X LANCETS 28 per 23 days) 1", 3 ML 22 GAUGE GAUGE X 1", 3 ML MULTI-DRAW 2 22 X 1 1/2", 3 ML NEEDLE NEEDLE 23 X 1", 3 ML 25 20 GAUGE X 1", 21 GAUGE X 1", 3 ML GAUGE X 1", 22 25 X 1 1/4", 3 ML GAUGE X 1" 25 X 5/8", 3 ML 27 GAUGE X 1 1/4" MULTI-LANCET 2 OTC DEVICE 2 KIT MONOJECT TB 2 LUER LOK MULTISTIX 9 SG 2 OTC SYRINGE 1 ML STRIP MONOJECT TB 2 OTC MULTISTIX 9 2 OTC SAFETY SYRINGE STRIP SYRINGE 1 ML 25 MULTISTIX STRIP 2 OTC GAUGE X 5/8", 1 MYGLUCOHEALT 2 OTC; QL (200 ML 28 GAUGE X H LANCETS 30 per 23 days) 1/2" GAUGE MONOJECT TB 2 OTC nateglinide oral 2 1 Copay SYRINGE 1 ML 28 tablet 120 mg, 60 mg GAUGE X 1/2"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 122 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NEEDLE (DISP) 16 2 NOVOLIN 70/30 U- 2 G NEEDLE 16 100 INSULIN GAUGE X 1" SUBCUTANEOUS NEEDLE (DISP) 18 2 SUSPENSION 100 G NEEDLE 18 UNIT/ML (70-30) GAUGE X 1" NOVOLIN 70-30 2 NEEDLE (DISP) 19 2 FLEXPEN U-100 G NEEDLE 19 SUBCUTANEOUS GAUGE X 1 1/2" INSULIN PEN 100 UNIT/ML (70-30) NEEDLE (DISP) 23 2 GAUGE NEEDLE NOVOLIN N 2 23 GAUGE X 1" FLEXPEN SUBCUTANEOUS NEEDLES, HUBER 2 INSULIN PEN 100 DISPOSABLE UNIT/ML (3 ML) NEEDLE 22 X 1 " NOVOLIN N NPH 2 NOKOR NEEDLE 2 U-100 INSULIN NEEDLE 16 SUBCUTANEOUS GAUGE X 1", 18 SUSPENSION 100 GAUGE X 1" UNIT/ML NOVA SAFETY 2 OTC NOVOLIN R 2 LANCETS 23 FLEXPEN GAUGE SUBCUTANEOUS NOVA SAFETY 2 OTC; QL (200 INSULIN PEN 100 LANCETS 28 per 23 days) UNIT/ML (3 ML) GAUGE NOVOLIN R 2 NOVA SUREFLEX 2 OTC REGULAR U-100 LANCETS INSULN INJECTION NOVOFINE 32 2 OTC SOLUTION 100 NEEDLE 32 UNIT/ML GAUGE X 1/4" NOVOLOG 1 NOVOFINE 2 OTC FLEXPEN U-100 AUTOCOVER INSULIN NEEDLE 30 SUBCUTANEOUS GAUGE X 1/3" INSULIN PEN 100 NOVOFINE PLUS 2 OTC UNIT/ML (3 ML) NEEDLE 32 GAUGE X 1/6"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 123 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NOVOLOG MIX 1 ON CALL PLUS 2 OTC; QL (200 70-30 U-100 LANCET 30 per 23 days) INSULN GAUGE SUBCUTANEOUS ONETOUCH 2 OTC SOLUTION 100 DELICA LANC UNIT/ML (70-30) DEVICE KIT NOVOLOG MIX 1 ONETOUCH 2 OTC; QL (200 70-30FLEXPEN U- DELICA LANCETS per 23 days) 100 30 GAUGE, 33 SUBCUTANEOUS GAUGE INSULIN PEN 100 UNIT/ML (70-30) ONETOUCH 2 OTC DELICA PLUS NOVOLOG 1 LANC DEV KIT PENFILL U-100 INSULIN ONETOUCH 2 OTC; QL (200 SUBCUTANEOUS DELICA PLUS per 23 days) CARTRIDGE 100 LANCET 30 UNIT/ML GAUGE, 33 GAUGE NOVOLOG U-100 1 INSULIN ASPART ONETOUCH 2 OTC SUBCUTANEOUS SURESOFT SOLUTION 100 LANCING DEV 18 UNIT/ML GAUGE, 21 GAUGE NOVOPEN ECHO 2 QL (2 per 365 SUBCUTANEOUS days) ONETOUCH 2 OTC; QL (200 INSULIN PEN SURESOFT per 23 days) LANCING DEV 28 NOVOTWIST 2 OTC GAUGE NEEDLE 32 GAUGE X 1/5" ONETOUCH 2 OTC ULTRASOFT OMNIPOD DASH 5 1 LANCETS PACK POD SUBCUTANEOUS ONGLYZA ORAL 1 CARTRIDGE TABLET 2.5 MG, 5 MG OMNIPOD 1 PA INSULIN ON-THE-GO 2 OTC; QL (200 MANAGEMENT LANCETS 30 per 23 days) GAUGE OMNIPOD 1 PA INSULIN REFILL OPTICHAMBER 2 QL (2 per 365 SUBCUTANEOUS ADULT MASK- days) CARTRIDGE LARGE DEVICE ON CALL LANCET 2 OTC; QL (200 30 GAUGE per 23 days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 124 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OPTICHAMBER 2 QL (2 per 365 PEN NEEDLE 2 OTC DIAMOND LG days) NEEDLE 29 MASK SPACER GAUGE X 1/2", 31 OPTICHAMBER 2 QL (2 per 365 GAUGE X 1/4", 31 DIAMOND VHC days) GAUGE X 3/16", 31 SPACER GAUGE X 5/16", 32 GAUGE X 5/32" OPTICHAMBER 2 QL (2 per 365 DIAMOND-MED days) PEN NEEDLE 2 MSK SPACER NEEDLE 30 GAUGE X 5/16" OPTICHAMBER 2 QL (2 per 365 DIAMOND-SML days) PEN NEEDLE, 2 OTC MASK SPACER DIABETIC NEEDLE 29 OZEMPIC 1 PA; QL (3 per GAUGE X 1/2", 31 SUBCUTANEOUS 23 days) GAUGE X 1/3", 31 PEN INJECTOR GAUGE X 1/4", 31 0.25 MG OR 0.5 GAUGE X 1/6", 31 MG(2 MG/1.5 ML), GAUGE X 3/16", 31 1 MG/DOSE (2 GAUGE X 5/16", 32 MG/1.5 ML) GAUGE X 1/4", 32 OZEMPIC 1 QL (99 per 99 GAUGE X 3/16", 32 SUBCUTANEOUS days) GAUGE X 5/32", 33 PEN INJECTOR 1 GAUGE X 5/32" MG/DOSE (4 MG/3 PENTIPS NEEDLE 2 OTC ML) 29 GAUGE X 1/2", PARAGARD T 2 QL (1 per 720 31 GAUGE X 1/4", 380A days) 31 GAUGE X 3/16", INTRAUTERINE 31 GAUGE X 5/16", INTRAUTERINE 32 GAUGE X 5/32" DEVICE 380 PERSONAL BEST 2 OTC; QL (2 SQUARE MM FULL RANGE per 365 days) PEAK AIR PEAK 2 OTC; QL (2 DEVICE FLOW METER per 365 days) PHASEAL 2 DEVICE PROTECTOR PEDIATRIC 2 OTC DEVICE 13 MM, 20 MOUTHPIECES MM, 28 MM PEDIATRIC- 2 OTC PIKO 1 DEVICE 2 OTC; QL (2 SMALL MOUTH per 365 days) ADAPTOR pioglitazone oral 2 1 Copay tablet 15 mg, 30 mg, 45 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 125 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits pioglitazone- 2 1 Copay PRECISION XTRA 1 PA; OTC; QL glimepiride oral TEST STRIP (100 per 23 tablet 30-2 mg, 30-4 days) mg PRESSURE 2 OTC pioglitazone- 2 1 Copay ACTIVATED metformin oral LANCETS 21 tablet 15-500 mg, GAUGE 15-850 mg PRESSURE 2 OTC; QL (200 PIP LANCET 28 2 OTC; QL (200 ACTIVATED per 23 days) GAUGE, 30 per 23 days) LANCETS 28 GAUGE GAUGE POCKET 2 QL (2 per 365 PRIMEAIRE 2 QL (2 per 365 CHAMBER days) SPACER days) SPACER PRO COMFORT 2 OTC POCKET PEAK 2 OTC; QL (2 ALCOHOL PADS FLOW METER per 365 days) TOPICAL PADS, DEVICE MEDICATED POLY HUB 2 PRO COMFORT 2 NEEDLE NEEDLE INSULIN 18 GAUGE X 1 SYRINGE 1/2", 18 GAUGE X SYRINGE 0.5 ML 1", 21 GAUGE X 1 30 GAUGE X 1/2", 1/2", 21 GAUGE X 0.5 ML 30 GAUGE 1", 22 GAUGE X 1 X 5/16", 0.5 ML 31 1/2", 22 GAUGE X GAUGE X 5/16", 1 1", 23 GAUGE X 1 ML 30 GAUGE X 1/2", 23 GAUGE X 1/2", 1 ML 30 1", 25 GAUGE X 1 GAUGE X 5/16, 1 1/2", 25 GAUGE X ML 31 GAUGE X 1", 25 GAUGE X 5/16 5/8", 27 GAUGE X PRO COMFORT 2 OTC; QL (200 1 1/4", 27 GAUGE LANCET 30 per 23 days) X 1/2", 30 GAUGE GAUGE X 1/2" PRO COMFORT 2 OTC PRECISION XTRA 2 OTC LANCET 31 B-KETONE STRIP GAUGE PRECISION XTRA 2 OTC KETONE- GLUCOSE KIT PRECISION XTRA 2 OTC MONITOR

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 126 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PRO COMFORT 2 OTC PRODIGY TWIST 2 OTC; QL (200 PEN NEEDLE TOP LANCET 28 per 23 days) NEEDLE 31 GAUGE GAUGE X 5/16", 32 PURE COMFORT 2 OTC GAUGE X 1/4", 32 ALCOHOL PADS GAUGE X 3/16", 32 TOPICAL PADS, GAUGE X 5/32" MEDICATED PRO COMFORT 2 QL (2 per 365 PURE COMFORT 2 OTC SPACER-ADULT days) HUMIDIFIER MASK SPACER PURE COMFORT 2 OTC; QL (200 PRO COMFORT 2 QL (2 per 365 LANCETS 30 per 23 days) SPACER-CHILD days) GAUGE MASK SPACER PURE COMFORT 2 OTC PROCARE 2 OTC PEN NEEDLE HUMIDIFIER NEEDLE 32 PROCARE 2 QL (2 per 365 GAUGE X 1/4", 32 SPACER WITH days) GAUGE X 3/16", 32 ADULT MASK GAUGE X 5/16", 32 SPACER GAUGE X 5/32" PROCARE 2 QL (2 per 365 PURE COMFORT 2 OTC; QL (200 SPACER WITH days) SAFETY per 23 days) CHILD MASK LANCETS 30 SPACER GAUGE PROCHAMBER 2 QL (2 per 365 PURECOMFORT 2 OTC; QL (2 SPACER days) PEAK FLOW per 365 days) PRODIGY COUNT- 2 OTC METER DEVICE A-DOSE PUSH BUTTON 2 OTC; QL (200 PRODIGY 2 SAFETY per 23 days) INSULIN LANCETS 28 SYRINGE GAUGE SYRINGE 0.3 ML READYLANCE 2 OTC 31 GAUGE X 5/16", SAFETY 0.5 ML 31 GAUGE LANCETS 21 X 5/16", 1 ML 28 GAUGE, 23 GAUGE X 1/2" GAUGE PRODIGY 2 OTC; QL (200 READYLANCE 2 OTC; QL (200 LANCETS 26 per 23 days) SAFETY per 23 days) GAUGE, 28 LANCETS 26 GAUGE GAUGE, 28 GAUGE, 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 127 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RELIAMED 2 OTC; QL (200 RIOMET ER ORAL 1 PA LANCET 28 per 23 days) SUSPENSION,EXT GAUGE, 30 ENDED REL GAUGE RECON 500 MG/5 RELIAMED 2 OTC; QL (200 ML SAFETY SEAL per 23 days) RIOMET ORAL 1 PA LANCETS 28 SOLUTION 500 GAUGE, 30 MG/5 ML GAUGE RITEFLO 2 QL (2 per 365 relion glucose oral 2 OTC AEROCHAMBER days) liquid 15-400 gram- SPACER unit/60 ml RYBELSUS ORAL 1 PA; QL (1 per RELION NEEDLES 2 OTC TABLET 14 MG, 3 1 day) NEEDLE 31 MG, 7 MG GAUGE X 1/4" SAFESNAP 2 RELION PEN 2 OTC INSULIN NEEDLES SYRINGE NEEDLE 32 SYRINGE 0.3 ML GAUGE X 5/32" 30 GAUGE X 5/16", RELION THIN 2 OTC; QL (200 0.5 ML 29 GAUGE LANCETS 26 per 23 days) X 1/2", 1 ML 28 GAUGE GAUGE X 1/2" RELION ULTRA 2 OTC SAFESNAP 2 OTC SYRINGE THIN PLUS LANCETS SYRINGE 1 ML 25 GAUGE X 5/8", 1 repaglinide oral 2 1 Copay ML 27 GAUGE X tablet 0.5 mg, 1 mg, 1/2", 10 ML, 10 ML 2 mg 22 GAUGE X 1", 3 repaglinide- 2 1 Copay ML, 3 ML 25 metformin oral GAUGE X 5/8", 5 tablet 1-500 mg, 2- ML, 5 ML 20 500 mg GAUGE X 1", 5 ML 22 GAUGE X 1" REPLACEMENT 2 OTC NECKBAND SAFETY 2 OTC STRAPS LANCETS 21 GAUGE RIGHTEST GL300 2 OTC; QL (200 LANCETS 30 per 23 days) SAFETY 2 OTC; QL (200 GAUGE LANCETS 26 per 23 days) GAUGE, 28 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 128 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SAFETY NEEDLES 2 SMARTEST 2 OTC NEEDLE 18 LANCET GAUGE X 1 1/2" SOFT TOUCH 2 OTC SAFETY PEN 2 OTC LANCETS NEEDLE NEEDLE SOLIQUA 100/33 1 PA; QL (6 per 31 GAUGE X 3/16" SUBCUTANEOUS 23 days) SAFETY SEAL 2 OTC; QL (200 INSULIN PEN 100 LANCETS 28 per 23 days) UNIT-33 MCG/ML GAUGE, 30 SOLUS V2 2 OTC; QL (200 GAUGE LANCETS 28 per 23 days) SAFETY-LET 2 OTC; QL (200 GAUGE, 30 LANCETS 30 per 23 days) GAUGE GAUGE SOLUS V2 2 OTC SEAL TIGHT 2 OTC LANCING DEVICE SECURESAFE PEN 2 OTC KIT NEEDLE NEEDLE SPACE CHAMBER 2 QL (2 per 365 30 GAUGE X 5/16" SPACER days) SEGLUROMET 1 PA SPACE CHAMBER 2 QL (2 per 365 ORAL TABLET WITH LARGE days) 2.5-1,000 MG, 2.5- MASK SPACER 500 MG, 7.5-1,000 SPACE CHAMBER 2 QL (2 per 365 MG, 7.5-500 MG WITH MEDIUM days) SEMGLEE PEN U- 1 PA MASK SPACER 100 INSULIN SPACE CHAMBER 2 QL (2 per 365 SUBCUTANEOUS WITH SMALL days) INSULIN PEN 100 MASK SPACER UNIT/ML (3 ML) SPLASH SHIELD 2 OTC SEMGLEE U-100 1 PA FLEX INSULIN SUBCUTANEOUS STEGLATRO 1 PA; QL (1 per SOLUTION 100 ORAL TABLET 15 1 day) UNIT/ML MG, 5 MG SINGLE-LET 2 OTC STERILANCE TL 2 OTC; QL (200 30 GAUGE per 23 days) SMART SENSE 2 OTC LANCETS 21 STERILANCE TL 2 OTC GAUGE 32 GAUGE SMART SENSE 2 OTC; QL (200 SUCTION TUBE 2 OTC LANCETS 26 per 23 days) ATTACHMENT GAUGE, 33 DEVICE GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 129 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SUPER THIN 2 OTC; QL (200 SURE-FINE PEN 2 OTC LANCETS 28 per 23 days) NEEDLES GAUGE, 30 NEEDLE 29 GAUGE GAUGE X 1/2", 31 SURE COMFORT 2 OTC GAUGE X 3/16", 31 ALCOHOL PREP GAUGE X 5/16" PADS TOPICAL SUREFLEX 2 OTC PADS, DEVICE WITH MEDICATED LANCETS KIT SURE COMFORT 2 SURE-JECT 2 INSULIN INSULIN SYRINGE SYRINGE SYRINGE 0.3 ML SYRINGE 0.3 ML 30 GAUGE X 1/2", 29 GAUGE X 1/2", 0.3 ML 31 GAUGE 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 X 5/16", 0.5 ML 31 GAUGE X 5/16", GAUGE X 5/16", 1 0.5 ML 30 GAUGE ML 28 GAUGE X X 1/2", 1 ML 30 1/2", 1 ML 29 GAUGE X 1/2", 1 GAUGE X 1/2", 1 ML 31 GAUGE X ML 31 GAUGE X 1/4", 1/2 ML 31 5/16, 1/2 ML 28 GAUGE X 1/4" GAUGE X 1/2" SURE COMFORT 2 OTC SURE-LANCE 2 OTC LANCETS 18 SURE-LANCE 26 2 OTC; QL (200 GAUGE, 21 GAUGE, 28 per 23 days) GAUGE, 23 GAUGE GAUGE SURE-LANCE 2 OTC; QL (200 SURE COMFORT 2 OTC; QL (200 ULTRA THIN 30 per 23 days) LANCETS 28 per 23 days) GAUGE GAUGE, 30 GAUGE SURE-PREP 2 OTC ALCOHOL PREP SURE COMFORT 2 OTC PADS TOPICAL PEN NEEDLE PADS, NEEDLE 29 MEDICATED GAUGE X 1/2", 30 GAUGE X 5/16", 31 SURE-TOUCH 2 OTC GAUGE X 3/16", 31 LANCET GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 130 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SURGUARD2 2 SYRINGE 2 OTC SAFETY NEEDLE (DISPOSABLE) 18 GAUGE X 1 SYRINGE 20 ML, 3 1/2", 18 GAUGE X ML, 30 ML, 5 ML, 1", 19 GAUGE X 1 60 ML 1/2", 19 GAUGE X SYRINGE 2 OTC 1", 20 GAUGE X 1 3CC/20GX1" 1/2", 20 GAUGE X SYRINGE 3 ML 20 1", 21 GAUGE X 1 GAUGE X 1" 1/2", 21 GAUGE X 1", 22 GAUGE X 1 SYRINGE 2 OTC 1/2", 22 GAUGE X 3CC/21GX1" 1", 23 GAUGE X 1 SYRINGE 3 ML 21 1/2", 23 GAUGE X GAUGE X 1" 1", 25 GAUGE X 1 SYRINGE 2 OTC 1/2", 25 GAUGE X 3CC/21GX1-1/2" 1", 25 X 5/8 ", 26 SYRINGE 3 ML 21 GAUGE X 1/2", 27 GAUGE X 1 1/2" GAUGE X 1/2", 30 GAUGE X 1 1/2" SYRINGE 2 OTC 3CC/22GX1" SYMLINPEN 120 2 SYRINGE 3 ML 22 SUBCUTANEOUS GAUGE X 1" PEN INJECTOR 2,700 MCG/2.7 ML SYRINGE 2 OTC 3CC/22GX3/4" SYMLINPEN 60 2 SYRINGE 3 ML 22 SUBCUTANEOUS GAUGE X 3/4" PEN INJECTOR 1,500 MCG/1.5 ML SYRINGE 2 OTC 3CC/25GX1" SYNJARDY ORAL 1 SYRINGE 3 ML 25 TABLET 12.5-1,000 GAUGE X 1" MG, 12.5-500 MG, 5-1,000 MG, 5-500 SYRINGE LUER 2 OTC MG TIP CAP SYNJARDY XR 1 SYRINGE TIP 2 OTC ORAL TABLET, IR CONNECTOR - ER, BIPHASIC SYRINGE WITH 2 OTC 24HR 10-1,000 MG, NEEDLE SYRINGE 12.5-1,000 MG, 25- 1 ML 25 GAUGE X 1,000 MG, 5-1,000 1", 3 ML 20 MG GAUGE X 1 1/2", 3 ML 22 X 1 1/2" TABLET CUTTER 2 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 131 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TECHLITE 2 TECHLITE PEN 2 OTC INSULIN NEEDLE NEEDLE SYRINGE 29 GAUGE X 1/2", SYRINGE 1 ML 29 29 GAUGE X 3/8", GAUGE X 1/2", 1 31 GAUGE X 1/4", ML 30 GAUGE X 31 GAUGE X 3/16", 1/2", 1 ML 30 31 GAUGE X 5/16", GAUGE X 5/16, 1 32 GAUGE X 1/4", ML 31 GAUGE X 32 GAUGE X 5/16", 15/64", 1 ML 31 32 GAUGE X 5/32" GAUGE X 5/16 TELCARE 2 OTC; QL (200 TECHLITE 2 LANCETS 30 per 23 days) INSULN GAUGE SYR(HALF UNIT) TERUMO 2 OTC SYRINGE 0.3 ML ALLERGY 29 GAUGE X 1/2", SYRINGE 0.3 ML 30 GAUGE SYRINGE 1 ML 27 X 1/2", 0.3 ML 30 X 1/2" GAUGE X 5/16", 0.3 ML 31 GAUGE TERUMO 2 OTC X 15/64", 0.3 ML 31 HYPODERMIC GAUGE X 5/16", NEEDLE/SYRIN 0.5 ML 29 GAUGE SYRINGE 5 ML 21 X 1/2", 0.5 ML 30 GAUGE X 1 1/2" GAUGE X 1/2", 0.5 TERUMO INSULIN 2 ML 30 GAUGE X SYRINGE 5/16", 0.5 ML 31 SYRINGE 0.3 ML GAUGE X 15/64", 30 X 3/8", 1 ML 27 0.5 ML 31 GAUGE GAUGE X 1/2", 1/2 X 5/16" ML 27 GAUGE X TECHLITE 2 OTC 1/2", 1/2 ML 30 X LANCETS 25 3/8" GAUGE TERUMO 2 OTC TECHLITE 2 OTC; QL (200 SYRINGE LANCETS 28 per 23 days) SYRINGE 3 ML 23 GAUGE, 30 X 1", 30 ML GAUGE THIN LANCETS 26 2 OTC; QL (200 GAUGE per 23 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 132 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits thinpro insulin 2 TOUJEO 2 syringe syringe 0.3 SOLOSTAR U-300 ml 29 gauge x 1/2", INSULIN 0.5 ml 29 gauge x SUBCUTANEOUS 1/2", 1 ml 29 gauge INSULIN PEN 300 x 1/2" UNIT/ML (1.5 ML) THINPRO 2 TRADJENTA 1 INSULIN ORAL TABLET 5 SYRINGE MG SYRINGE 0.3 ML TRESIBA 2 31 X 3/8", 0.5 ML FLEXTOUCH U- 31 X 3/8", 1 ML 31 100 X 3/8" SUBCUTANEOUS TOPCARE 2 OTC INSULIN PEN 100 CLICKFINE UNIT/ML (3 ML) NEEDLE 31 TRESIBA 2 GAUGE X 1/4", 31 FLEXTOUCH U- GAUGE X 5/16" 200 TOPCARE ULTRA 2 SUBCUTANEOUS COMFORT INSULIN PEN 200 SYRINGE 0.3 ML UNIT/ML (3 ML) 29 GAUGE X 1/2", TRESIBA U-100 2 0.5 ML 29 GAUGE INSULIN X 1/2", 1 ML 29 SUBCUTANEOUS GAUGE X 1/2" SOLUTION 100 TOPCARE 2 OTC UNIT/ML UNIVERSAL1 TRUE COMFORT 2 OTC LANCET ALCOHOL PADS TOPCARE 2 OTC; QL (200 TOPICAL PADS, UNIVERSAL1 per 23 days) MEDICATED LANCET 33 TRUE COMFORT 2 GAUGE INSULIN TOUJEO MAX U- 2 SYRINGE 300 SOLOSTAR SYRINGE 0.5 ML SUBCUTANEOUS 31 GAUGE X 5/16", INSULIN PEN 300 1 ML 31 GAUGE X UNIT/ML (3 ML) 5/16 TRUE COMFORT 2 OTC; QL (200 LANCET 30 per 23 days) GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 133 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRUE COMFORT 2 OTC TRUEPLUS PEN 2 OTC PEN NEEDLE NEEDLE NEEDLE NEEDLE 31 29 GAUGE X 1/2", GAUGE X 1/4", 31 31 GAUGE X 1/4", GAUGE X 3/16", 32 31 GAUGE X 3/16", GAUGE X 5/32" 31 GAUGE X 5/16", TRUE COMFORT 2 OTC 32 GAUGE X 5/32" PRO ALCOHOL TRULICITY 1 PrefD PADS TOPICAL SUBCUTANEOUS PADS, PEN INJECTOR MEDICATED 0.75 MG/0.5 ML, TRUEPLUS 2 1.5 MG/0.5 ML INSULIN TRULICITY 2 SYRINGE 0.3 ML SUBCUTANEOUS 29 GAUGE X 1/2", PEN INJECTOR 3 0.3 ML 30 GAUGE MG/0.5 ML, 4.5 X 5/16", 0.3 ML 31 MG/0.5 ML GAUGE X 5/16", TUBERCULIN 2 OTC 0.5 ML 29 GAUGE SYRINGE X 1/2", 0.5 ML 30 SYRINGE 1 ML, 1 GAUGE X 5/16", ML 25 GAUGE X 0.5 ML 31 GAUGE 5/8", 1 ML 27 X X 5/16", 1 ML 28 1/2" GAUGE X 1/2", 1 ML 29 GAUGE X TUBERCULIN- 2 OTC 1/2", 1 ML 30 ALLERGY GAUGE X 5/16, 1 SYRINGES ML 31 GAUGE X SYRINGE 1 ML 26 5/16, 1/2 ML 28 GAUGE X 3/8" GAUGE X 1/2" TWIST LANCETS 2 OTC; QL (200 TRUEPLUS 2 OTC 30 GAUGE per 23 days) KETONE STRIP TWIST LANCETS 2 OTC TRUEPLUS 2 OTC; QL (200 32 GAUGE LANCETS 28 per 23 days) ULTICARE 2 GAUGE, 30 INSULIN GAUGE, 33 SYRINGE GAUGE SYRINGE 0.3 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE X 1/4"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 134 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ULTICARE 2 ULTIGUARD 2 OTC INSULN SAFEPACK-PEN SYR(HALF UNIT) NEEDLE NEEDLE SYRINGE 0.3 ML 31 GAUGE X 1/4", 31 GAUGE X 1/4" 31 GAUGE X 3/16", ULTICARE PEN 2 OTC 31 GAUGE X 5/16", NEEDLE NEEDLE 32 GAUGE X 1/4", 29 GAUGE X 1/2", 32 GAUGE X 5/32" 31 GAUGE X 1/4", ULTI-LANCE KIT 2 OTC 31 GAUGE X 3/16", ULTILET 2 OTC 31 GAUGE X 5/16", ALCOHOL SWAB 32 GAUGE X 1/4", TOPICAL PADS, 32 GAUGE X 5/32" MEDICATED ULTICARE 2 OTC ULTILET BASIC 2 OTC; QL (200 SAFETY SYRINGE LANCETS 30 per 23 days) SYRINGE 3 ML, 3 GAUGE ML 21 GAUGE X 1 1/2", 3 ML 22 ULTILET CLASSIC 2 OTC GAUGE X 1 1/2", 3 LANCETS ML 22 GAUGE X ULTILET CLASSIC 2 OTC; QL (200 1", 3 ML 23 LANCETS 28 per 23 days) GAUGE X 1", 3 ML GAUGE, 30 25 GAUGE X 1", 3 GAUGE, 33 ML 25 GAUGE X GAUGE 5/8" ULTILET INSULIN 2 ulticare syringe 0.3 2 SYRINGE ml 30 gauge x 1/2", SYRINGE 0.3 ML 0.5 ml 30 gauge x 29 GAUGE, 0.3 ML 1/2", 1 ml 30 gauge 29 GAUGE X 1/2", x 1/2" 0.5 ML 29 GAUGE ULTICARE 2 X 1/2", 1 ML 29 SYRINGE 0.3 ML GAUGE, 1 ML 29 31 GAUGE X 5/16", GAUGE X 1/2", 1/2 0.5 ML 31 GAUGE ML 29 X 5/16", 1 ML 31 ULTILET 2 OTC; QL (200 GAUGE X 5/16 LANCETS 28 per 23 days) ULTICARE TB 2 OTC GAUGE, 30 SAFETY SYRINGE GAUGE, 33 SYRINGE 1 ML 27 GAUGE GAUGE X 1/2", 1 ULTILET PEN 2 OTC ML 27 GAUGE X NEEDLE NEEDLE 5/8", 1 ML 28 29 GAUGE, 32 GAUGE X 1/2" GAUGE X 5/32"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 135 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ULTILET SAFETY 2 OTC ULTRA FLO PEN 2 OTC LANCETS 23 NEEDLE NEEDLE GAUGE 29 GAUGE X 1/2" ULTRA CMFT INS 2 ULTRA THIN II 2 OTC; QL (200 SYR (HALF UNIT) LANCETS 30 per 23 days) SYRINGE 0.3 ML GAUGE 29 GAUGE X 1/2", ULTRA THIN 2 OTC 0.3 ML 30 GAUGE LANCETS , 31 X 5/16", 0.3 ML 31 GAUGE GAUGE X 5/16" ULTRA THIN 2 OTC; QL (200 ULTRA COMFORT 2 LANCETS 28 per 23 days) INSULIN GAUGE, 30 SYRINGE GAUGE, 33 SYRINGE 0.3 ML GAUGE 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML ULTRA THIN PEN 2 OTC 30 GAUGE X 5/16", NEEDLE NEEDLE 0.5 ML 29 GAUGE 32 GAUGE X 5/32" X 1/2", 0.5 ML 30 ULTRA THIN 2 OTC; QL (200 GAUGE X 5/16", PLUS LANCETS 33 per 23 days) 0.5 ML 31 GAUGE GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ULTRA TLC 2 OTC ML 29 GAUGE, 1 LANCETS ML 29 GAUGE X ULTRACARE 2 1/2", 1 ML 30 INSULIN GAUGE X 5/16, 1 SYRINGE ML 31 GAUGE X SYRINGE 0.3 ML 5/16, 1/2 ML 28 30 GAUGE X 5/16", GAUGE, 1/2 ML 28 0.3 ML 31 GAUGE GAUGE X 1/2", 1/2 X 5/16", 0.5 ML 30 ML 29 , 1/2 ML 30 GAUGE X 1/2", 0.5 GAUGE ML 30 GAUGE X ultra comfort insulin 2 5/16", 0.5 ML 31 syringe syringe 1 ml GAUGE X 5/16", 1 28 gauge ML 30 GAUGE X 1/2", 1 ML 30 ULTRA FLO 2 GAUGE X 5/16, 1 INSULIN ML 31 GAUGE X SYRINGE 5/16 SYRINGE 0.3 ML 29 GAUGE X 1/2" ULTRA-CARE 2 OTC; QL (200 LANCETS 30 per 23 days) GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 136 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ULTRACARE PEN 2 OTC UNIFINE PENTIPS 2 OTC NEEDLE NEEDLE MAXFLOW 31 GAUGE X 1/4", NEEDLE 30 31 GAUGE X 3/16", GAUGE X 3/16" 31 GAUGE X 5/16", UNIFINE PENTIPS 2 OTC 32 GAUGE X 1/4", NEEDLE 29 32 GAUGE X 3/16", GAUGE, 29 32 GAUGE X 5/32", GAUGE X 1/2", 31 33 GAUGE X 5/32" GAUGE X 1/4", 31 ULTRALANCE 2 OTC; QL (200 GAUGE X 3/16", 31 LANCETS 26 per 23 days) GAUGE X 5/16", 32 GAUGE, 28 GAUGE X 1/4", 32 GAUGE GAUGE X 5/32", 33 ULTRA-THIN II 2 GAUGE X 5/32" (SHORT) INS SYR UNIFINE PENTIPS 2 OTC SYRINGE 0.3 ML PLUS MAXFLOW 30 GAUGE X 5/16", NEEDLE 30 0.3 ML 31 GAUGE GAUGE X 3/16" X 5/16", 0.5 ML 30 UNIFINE PENTIPS 2 OTC GAUGE X 5/16", PLUS NEEDLE 29 0.5 ML 31 GAUGE GAUGE X 1/2", 31 X 5/16", 1 ML 30 GAUGE X 1/4", 31 GAUGE X 5/16, 1 GAUGE X 3/16", 31 ML 31 GAUGE X GAUGE X 5/16", 32 5/16 GAUGE X 5/32", 33 ULTRA-THIN II 2 OTC GAUGE X 5/32" (SHORT) PEN NDL UNIFINE 2 OTC NEEDLE 31 SAFECONTROL GAUGE X 5/16" NEEDLE 30 ULTRA-THIN II 2 OTC GAUGE X 3/16", 30 INS PEN NEEDLES GAUGE X 5/16" NEEDLE 29 UNILET 2 OTC GAUGE X 1/2" COMFORTOUCH ULTRA-THIN II 2 LANCET INSULIN UNILET 2 OTC; QL (200 SYRINGE COMFORTOUCH per 23 days) SYRINGE 0.5 ML LANCET 26 29 GAUGE X 1/2", GAUGE 1 ML 29 GAUGE X 1/2" UNILET 2 OTC EXCELITE II ULTRA-THIN II 2 OTC; QL (200 LANCET LANCETS 28 per 23 days) GAUGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 137 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UNILET 2 OTC UNISTIK 3 2 OTC EXCELITE NORMAL LANCET LANCET 23 UNILET GP 2 OTC GAUGE LANCET UNISTIK CZT 2 OTC UNILET LANCET 2 OTC; QL (200 LANCET 23 28 GAUGE, 33 per 23 days) GAUGE GAUGE UNISTIK CZT 2 OTC; QL (200 UNILET LANCETS 2 OTC; QL (200 LANCET 28 per 23 days) GAUGE 30 GAUGE per 23 days) UNILET SUPER 2 OTC; QL (200 UNISTIK 2 OTC THIN LANCETS 30 per 23 days) NORMAL GAUGE LANCETS 23 GAUGE UNISTIK 2 2 OTC DEVICE KIT UNISTIK PRO 2 OTC LANCET 21 UNISTIK 2 2 OTC GAUGE, 25 NORMAL GAUGE LANCET,DEVICE KIT UNISTIK PRO 2 OTC; QL (200 LANCET 28 per 23 days) UNISTIK 3 2 OTC GAUGE COMFORT DEVICE KIT UNISTIK SAFETY 2 OTC; QL (200 28 GAUGE, 30 per 23 days) UNISTIK 3 2 OTC GAUGE COMFORT LANCET UNISTIK TOUCH 2 OTC LANCETS 21 UNISTIK 3 EXTRA 2 OTC GAUGE, 23 LANCET 21 GAUGE GAUGE UNISTIK TOUCH 2 OTC; QL (200 UNISTIK 3 2 OTC; QL (200 LANCETS 28 per 23 days) GENTLE 30 per 23 days) GAUGE, 30 GAUGE GAUGE UNISTIK 3 KIT 2 OTC UNIVERSAL 1 2 OTC UNISTIK 3 2 OTC LANCETS 21 LANCETS 21 GAUGE GAUGE UNIVERSAL 1 2 OTC; QL (200 UNISTIK 3 2 OTC LANCETS 26 per 23 days) NEONATAL GAUGE, 30 DEVICE KIT GAUGE, 33 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 138 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UNIVERSAL 2 OTC VANISHPOINT 2 OTC CATHETER TUBERCULIN ACCESS PORT SYRINGE UNIVERSAL 2 OTC SYRINGE 1 ML 25 SYRINGE TIP GAUGE X 5/8", 1 ADAPTOR ML 27 X 1/2" URI-DRAIN 2 OTC VAPORIZERS 2 OTC URISTIX 4 STRIP 2 OTC VERTICAL 2 OTC DRAIN-TUBE ATT URISTIX 2 OTC DEVICE REAGENT STRIP V-GO 20 DEVICE 1 VANISHPOINT 2 INSULIN V-GO 30 DEVICE 1 SYRINGE V-GO 40 DEVICE 1 SYRINGE 1 ML 30 VICTOZA 2-PAK 1 GAUGE X 3/16" SUBCUTANEOUS VANISHPOINT 2 PEN INJECTOR 0.6 SYRINGE MG/0.1 ML (18 SYRINGE 0.5 ML MG/3 ML) 30 GAUGE X 1/2", VICTOZA 3-PAK 1 1 ML 29 GAUGE X SUBCUTANEOUS 1/2" PEN INJECTOR 0.6 VANISHPOINT 2 OTC MG/0.1 ML (18 SYRINGE MG/3 ML) SYRINGE 1 ML 25 VIVAGUARD 2 OTC; QL (200 GAUGE X 1", 10 LANCET 30 per 23 days) ML 21 GAUGE X 1 GAUGE 1/2", 3 ML 20 GAUGE X 1", 3 ML WARM STEAM 2 OTC 21 GAUGE X 1 VAPORIZER 1/2", 3 ML 21 WEBCOL 2 OTC GAUGE X 1", 3 ML TOPICAL PADS, 22 GAUGE X 1", 3 MEDICATED ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 XIGDUO XR 1 1/2", 3 ML 23 X 1", ORAL TABLET, IR 3 ML 25 GAUGE X - ER, BIPHASIC 1", 3 ML 25 X 5/8", 24HR 10-1,000 MG, 5 ML 21 GAUGE X 10-500 MG, 2.5- 1 1/2", 5 ML 21 1,000 MG, 5-1,000 GAUGE X 1", 5 ML MG, 5-500 MG 22 GAUGE X 1 1/2"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 139 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XULTOPHY 1 PA; QL (15 CEREZYME 2 SP 100/3.6 per 23 days) INTRAVENOUS SUBCUTANEOUS RECON SOLN 400 INSULIN PEN 100 UNIT UNIT-3.6 MG /ML cinacalcet oral 2 SP (3 ML) tablet 30 mg, 60 mg, YALE 2 90 mg DISPOSABLE CRYSVITA 2 PA; SP; QL NEEDLES SUBCUTANEOUS (90 per 21 NEEDLE 21 SOLUTION 10 days) GAUGE X 1 1/4" MG/ML, 20 MISCELLANEOUS HORMONES MG/ML, 30 MG/ML ANDRODERM 2 TRANSDERMAL danazol oral capsule 2 PATCH 24 HOUR 2 100 mg, 200 mg, 50 MG/24 HOUR, 4 mg MG/24 HR desmopressin 2 SP BRINEURA 2 PA; SP injection solution 4 INTRAVENTRICU mcg/ml LAR KIT 300 desmopressin nasal 2 MG/10 ML spray with pump 10 (150MG/5ML X2) mcg/spray (0.1 ml) cabergoline oral 2 desmopressin nasal 2 tablet 0.5 mg spray,non-aerosol calcitonin (salmon) 2 10 mcg/spray (0.1 injection solution ml) 200 unit/ml desmopressin oral 2 calcitonin (salmon) 2 tablet 0.1 mg, 0.2 mg nasal spray,non- doxercalciferol oral 2 aerosol 200 capsule 0.5 mcg, 1 unit/actuation mcg, 2.5 mcg calcitriol oral 2 FABRAZYME 2 PA; SP capsule 0.25 mcg, INTRAVENOUS 0.5 mcg RECON SOLN 35 calcitriol oral 2 MG, 5 MG solution 1 mcg/ml CERDELGA ORAL 2 PA; SP; QL CAPSULE 84 MG (56 per 21 days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 140 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FORTESTA 2 NATESTO NASAL 2 TRANSDERMAL GEL IN GEL IN METERED-DOSE METERED-DOSE PUMP 5.5 PUMP 10 MG/0.5 MG/0.122 GRAM GRAM/ACTUATIO /ACTUATION N ISTURISA ORAL 2 PA; SP NATPARA 2 PA; SP; QL (2 TABLET 1 MG, 10 SUBCUTANEOUS per 21 days) MG, 5 MG CARTRIDGE 100 KANUMA 2 PA; SP MCG/DOSE, 25 INTRAVENOUS MCG/DOSE, 50 SOLUTION 2 MCG/DOSE, 75 MG/ML MCG/DOSE KORLYM ORAL 2 PA; SP; QL ORILISSA ORAL 2 PA; SP TABLET 150 MG, TABLET 300 MG (120 per 23 days) 200 MG MEPSEVII 2 PA; SP oxandrolone oral 2 PA INTRAVENOUS tablet 10 mg, 2.5 mg SOLUTION 2 pamidronate 2 SP MG/ML intravenous solution METHITEST 2 30 mg/10 ml (3 ORAL TABLET 10 mg/ml), 90 mg/10 ml MG (9 mg/ml) methyltestosterone 2 paricalcitol oral 2 oral capsule 10 mg capsule 1 mcg, 2 mcg, 4 mcg MIACALCIN 2 INJECTION RAYALDEE ORAL 2 PA SOLUTION 200 CAPSULE,EXTEN DED RELEASE 24 UNIT/ML HR 30 MCG miglustat oral 2 SP capsule 100 mg SAMSCA ORAL 2 PA; SP; QL TABLET 15 MG (30 per 23 MYALEPT 2 PA; SP days) SUBCUTANEOUS RECON SOLN 5 sapropterin oral 2 PA; SP MG/ML (FINAL powder in packet CONC.) 100 mg, 500 mg sapropterin oral 2 PA; SP tablet,soluble 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 141 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SOMAVERT 2 SP testosterone 2 SUBCUTANEOUS transdermal gel in RECON SOLN 10 metered-dose pump MG, 15 MG, 20 10 mg/0.5 gram MG, 25 MG, 30 MG /actuation, 12.5 mg/ STRENSIQ 2 PA; SP 1.25 gram (1 %), SUBCUTANEOUS 20.25 mg/1.25 gram SOLUTION 18 (1.62 %) MG/0.45 ML, 28 testosterone 2 MG/0.7 ML, 40 transdermal gel in MG/ML, 80 MG/0.8 packet 1 % (25 ML mg/2.5gram), 1 % SYNAREL NASAL 2 SP (50 mg/5 gram), SPRAY,NON- 1.62 % (20.25 AEROSOL 2 mg/1.25 gram), 1.62 MG/ML % (40.5 mg/2.5 gram) TEPEZZA 2 PA; SP; QL (8 INTRAVENOUS per 720 days) testosterone 2 transdermal solution RECON SOLN 500 MG in metered pump w/app 30 TESTONE CIK 2 mg/actuation (1.5 INTRAMUSCULA ml) R KIT 200 MG/ML TOLVAPTAN 2 PA; SP; QL TESTOPEL 2 ORAL TABLET 15 (30 per 23 IMPLANT PELLET MG days) 75 MG tolvaptan oral tablet 2 PA; SP; QL testosterone 2 30 mg (60 per 23 cypionate days) intramuscular oil 100 mg/ml, 200 VIMIZIM 2 SP; QL (60 per mg/ml INTRAVENOUS 23 days) SOLUTION 5 MG/5 testosterone 2 ML (1 MG/ML) enanthate intramuscular oil VOGELXO 2 200 mg/ml TRANSDERMAL GEL 50 MG/5 testosterone 2 GRAM (1 %) transdermal gel 50 mg/5 gram (1 %) VOGELXO 2 TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 142 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VPRIV 2 SP TIROSINT ORAL 2 INTRAVENOUS CAPSULE 100 RECON SOLN 400 MCG, 112 MCG, UNIT 125 MCG, 13 MCG, ZAVESCA ORAL 2 SP 137 MCG, 150 CAPSULE 100 MG MCG, 25 MCG, 50 MCG, 75 MCG, 88 zoledronic acid- 2 SP MCG mannitol-water intravenous unithroid oral tablet 2 piggyback 4 mg/100 100 mcg, 112 mcg, ml 125 mcg, 137 mcg, 150 mcg, 175 mcg, THYROID HORMONES 200 mcg, 25 mcg, ARMOUR 2 300 mcg, 50 mcg, 75 THYROID ORAL mcg, 88 mcg TABLET 180 MG, westhroid oral tablet 2 240 MG, 300 MG 130 mg, 195 mg, levothyroxine oral 2 32.5 mg, 65 mg, 97.5 tablet 100 mcg, 112 mg mcg, 125 mcg, 137 GASTROENTEROLOGY mcg, 150 mcg, 175 ANTIDIARRHEALS / mcg, 200 mcg, 25 mcg, 300 mcg, 50 ANTISPASMODICS mcg, 75 mcg, 88 mcg anti-diarrheal 2 OTC levoxyl oral tablet 2 () oral 100 mcg, 112 mcg, capsule 2 mg 125 mcg, 137 mcg, anti-diarrheal 2 OTC 200 mcg, 25 mcg, 50 (loperamide) oral mcg, 75 mcg, 88 mcg liquid 1 mg/7.5 ml liothyronine oral 2 anti-diarrheal 2 OTC tablet 25 mcg, 5 (loperamide) oral mcg, 50 mcg tablet 2 mg np thyroid oral 2 anti-diarrheal oral 2 OTC tablet 120 mg, 15 suspension 262 mg, 30 mg, 60 mg, mg/15 ml 90 mg belladonna 2 THYQUIDITY 2 alkaloids-opium ORAL SOLUTION rectal suppository 20 MCG/ML 16.2-30 mg, 16.2-60 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 143 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bismatrol oral 2 OTC dicyclomine oral 2 tablet,chewable 262 solution 10 mg/5 ml mg dicyclomine oral 2 bismuth oral 2 OTC tablet 20 mg tablet,chewable 262 digestive relief oral 2 OTC mg tablet 262 mg bismuth 2 OTC diotame oral 2 OTC subsalicylate oral tablet,chewable 262 suspension 262 mg mg/15 ml diphenoxylate- 2 CULTURELLE 2 OTC atropine oral liquid DIGESTIVE 2.5-0.025 mg/5 ml HEALTH ORAL CAPSULE 10 diphenoxylate- 2 BILLION CELL - atropine oral tablet 200 MG 2.5-0.025 mg CULTURELLE 2 OTC ed-spaz oral 2 DIGESTIVE tablet,disintegrating HEALTH ORAL 0.125 mg CAPSULE, geri-pectate oral 2 OTC SPRINKLE 10 suspension 262 BILLION CELL - mg/15 ml 200 MG glycopyrrolate oral 2 CULTURELLE 2 OTC tablet 1 mg, 2 mg KIDS GENTLE-GO ORAL POWDER IN hyoscyamine sulfate 2 PACKET 2.5 oral drops 0.125 BILLION CELL-3.5 mg/ml GRAM hyoscyamine sulfate 2 CUVPOSA ORAL 2 PA oral elixir 0.125 SOLUTION 1 MG/5 mg/5 ml ML (0.2 MG/ML) hyoscyamine sulfate 2 diamode oral tablet 2 OTC oral tablet extended 2 mg release 12 hr 0.375 mg diarrhea relief 2 OTC (bismuth subs) oral hyoscyamine sulfate 2 suspension 262 oral mg/15 ml tablet,disintegrating 0.125 mg dicyclomine oral 2 capsule 10 mg hyoscyamine sulfate 2 sublingual tablet 0.125 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 144 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits kaopectate (bismuth 2 OTC oscimin sl sublingual 2 subsalicy) oral tablet 0.125 mg suspension 262 oscimin sr oral 2 mg/15 ml tablet extended k-pec antidiarrheal 2 OTC release 12 hr 0.375 (bism sub) oral mg suspension 262 peptic relief oral 2 OTC mg/15 ml tablet,chewable 262 l.acidophilus- 2 OTC mg bifido.longum oral pepto-bismol oral 2 OTC capsule,delayed tablet,chewable 262 release(dr/ec) 16 mg mg LACTOBACILLUS 2 OTC pepto-bismol to-go 2 OTC ACIDOPH-L. BIFID oral tablet,chewable ORAL WAFER 1 262 mg BILLION CELL pink bismuth oral 2 OTC loperamide oral 2 OTC suspension 262 capsule 2 mg mg/15 ml loperamide oral 2 OTC pink bismuth oral 2 OTC liquid 1 mg/7.5 ml tablet 262 mg loperamide oral 2 OTC pink bismuth oral 2 OTC tablet 2 mg tablet,chewable 262 methscopolamine 2 mg oral tablet 2.5 mg, 5 probiotic colon care 2 OTC mg oral capsule 1.5 MOTOFEN ORAL 2 billion cell TABLET 1-0.025 probiotic oral 2 OTC MG capsule 20 billion MYTESI ORAL 2 PA; SP cell, 3 billion cell TABLET,DELAYE risaquad oral 2 OTC D RELEASE capsule 8 billion cell (DR/EC) 125 MG risaquad-2 oral 2 OTC NULEV ORAL 2 capsule 16 billion TABLET,DISINTE cell GRATING 0.125 MG soothe (bismuth 2 OTC subsalicylate) oral opium tincture oral 2 tablet 262 mg tincture 10 mg/ml (morphine)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 145 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits soothe (bismuth 2 OTC acid gone antacid 2 OTC subsalicylate) oral oral suspension 95- tablet,chewable 262 358 mg/15 ml mg advanced antacid- 2 OTC soothe regular 2 OTC antigas oral strength oral suspension 200-200- suspension 262 20 mg/5 ml, 400- mg/15 ml 400-40 mg/5 ml stomach relief oral 2 OTC AKYNZEO 2 PA suspension 262 (FOSNETUPITANT mg/15 ml ) INTRAVENOUS stomach relief oral 2 OTC RECON SOLN 235- 0.25 MG tablet 262 mg stomach relief oral 2 OTC AKYNZEO 2 PA tablet,chewable 262 (FOSNETUPITANT mg ) INTRAVENOUS SOLUTION 235 stomach relief 2 OTC MG-0.25 MG /20 original oral ML suspension 262 mg/15 ml AKYNZEO 2 PA; QL (4 per (NETUPITANT) 23 days) super probiotic oral 2 OTC ORAL CAPSULE capsule 20 billion 300-0.5 MG cell almacone-2 oral 2 OTC SYMAX DUOTAB 2 suspension 400-400- ORAL 40 mg/5 ml TABLET,EXT alophen (bisacodyl) 2 ACA; OTC RELEASE MULTIPHASE oral tablet,delayed 0.125 MG-0.25 MG release (dr/ec) 5 mg (0.375 MG) alosetron oral tablet 2 symax-sr oral tablet 2 0.5 mg, 1 mg extended release 12 aluminum hydroxide 2 OTC hr 0.375 mg gel oral suspension 320 mg/5 ml MISCELLANEOUS

GASTROINTESTINAL AGENTS alum-mag 2 OTC hydroxide-simeth acid gone antacid 2 OTC oral suspension 200- e.strength oral 200-20 mg/5 ml, tablet,chewable 160- 400-400-40 mg/5 ml 105 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 146 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMITIZA ORAL 2 PA; QL (60 antacid ultra 2 OTC CAPSULE 24 MCG, per 23 days) strength oral 8 MCG tablet,chewable 470 antacid anti-gas (ca 2 OTC mg calcium (1,177 carb-sim) oral mg) tablet,chewable antacid-antigas oral 2 OTC 1,000-60 mg suspension 200-200- antacid anti-gas oral 2 OTC 20 mg/5 ml, 400- suspension 200-200- 400-40 mg/5 ml 20 mg/5 ml, 400- antacid-simethicone 2 OTC 400-40 mg/5 ml oral suspension 400- antacid exst (mag 2 OTC 400-40 mg/5 ml carb-al hyd) oral anti-gas ultra 2 OTC tablet,chewable 160- strength oral capsule 105 mg 180 mg antacid extra- 2 OTC aprepitant oral 2 PA; QL (4 per strength oral capsule 125 mg 23 days) suspension 200-200- aprepitant oral 2 PA; QL (1 per 20 mg/5 ml capsule 40 mg 23 days) antacid m oral 2 OTC aprepitant oral 2 PA; QL (8 per suspension 200-200- capsule 80 mg 23 days) 20 mg/5 ml aprepitant oral 2 PA; QL (12 antacid maximum 2 OTC capsule,dose pack per 23 days) strength oral 125 mg (1)- 80 mg suspension 400-400- (2) 40 mg/5 ml balsalazide oral 2 antacid oral 2 OTC capsule 750 mg suspension 200-200- 20 mg/5 ml bisacodyl oral 2 ACA; OTC tablet,delayed antacid plus anti-gas 2 OTC release (dr/ec) 5 mg oral suspension 200- 200-20 mg/5 ml, bisacodyl rectal 2 OTC 400-400-40 mg/5 ml suppository 10 mg antacid regular 2 OTC bisa-lax (bisacodyl) 2 ACA; OTC strength oral oral tablet,delayed suspension 200-200- release (dr/ec) 5 mg 20 mg/5 ml oral 2 capsule,delayed,exte nd.release 3 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 147 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits budesonide oral 2 QL (90 per 23 citrate of magnesia 2 OTC tablet,delayed and days) oral solution ext.release 9 mg citroma oral solution 2 OTC castor oil oral oil 2 OTC clearlax oral powder 2 ACA; OTC 100 % 17 gram/dose CHENODAL ORAL 2 SP clearlax oral powder 2 OTC TABLET 250 MG in packet 17 gram children's pepto oral 2 OTC col-rite oral capsule 2 OTC tablet,chewable 160 100 mg, 250 mg mg calcium (400 mg) comfort gel extra 2 OTC strength oral children's soothe 2 OTC suspension 400-400- oral tablet,chewable 40 mg/5 ml 160 mg calcium (400 mg) comfort gel oral 2 OTC suspension 200-200- chocolate laxative 2 OTC 20 mg/5 ml oral tablet,chewable 15 mg compro rectal 2 suppository 25 mg CHOLBAM ORAL 2 PA; SP; QL CAPSULE 250 MG, (240 per 23 constulose oral 2 50 MG days) solution 10 gram/15 ml CIMZIA POWDER 1 PA; SP FOR RECONST CORTIFOAM 2 SUBCUTANEOUS RECTAL FOAM 10 KIT 400 MG (200 % (80 MG) MG X 2 VIALS) CREON ORAL 2 CIMZIA STARTER 1 PA; SP CAPSULE,DELAY KIT ED SUBCUTANEOUS RELEASE(DR/EC) SYRINGE KIT 400 12,000-38,000 - MG/2 ML (200 60,000 UNIT, MG/ML X 2) 24,000-76,000 - 120,000 UNIT, CIMZIA 1 PA; SP 3,000-9,500- 15,000 SUBCUTANEOUS UNIT, 36,000- SYRINGE KIT 400 114,000- 180,000 MG/2 ML (200 UNIT, 6,000-19,000 MG/ML X 2) -30,000 UNIT CINVANTI 2 PA; SP cromolyn oral 2 INTRAVENOUS concentrate 100 EMULSION 7.2 mg/5 ml MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 148 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CYSTADANE 2 SP docuzen oral tablet 2 OTC ORAL POWDER 1 8.6-50 mg GRAM/1.7 ML dok oral capsule 100 2 OTC DAILY FIBER 2 OTC mg (PSYLLIUM- dok oral tablet 100 2 OTC SUCROSE) ORAL mg POWDER 3 GRAM/7 GRAM dramamine less 2 OTC drowsy oral tablet daily fiber oral 2 OTC 25 mg capsule 0.52 gram dramamine oral 2 OTC; QL (2 dairy aid oral 2 OTC tablet 50 mg per 1 day) tablet,chewable 3,000 unit driminate oral tablet 2 OTC; QL (2 50 mg per 1 day) dairy digestive oral 2 OTC tablet 9,000 unit dronabinol oral 2 PA; QL (60 capsule 10 mg, 2.5 per 23 days) dairy digestive 2 OTC mg, 5 mg supplement oral tablet 9,000 unit dss oral capsule 250 2 OTC mg dairy relief oral 2 OTC tablet 3,000 unit, dulcoease oral 2 OTC 9,000 unit capsule 100 mg dimenhydrinate oral 2 OTC; QL (2 dulcolax 2 OTC tablet 50 mg per 1 day) (magnesium hydroxide) oral diocto oral liquid 50 2 OTC suspension 400 mg/5 mg/5 ml ml docu oral liquid 50 2 OTC dulcolax stool 2 OTC mg/5 ml softener (dss) oral docuprene oral 2 OTC capsule 100 mg tablet 100 mg EMEND ORAL 2 PA; SP docusate calcium 2 OTC SUSPENSION FOR oral capsule 240 mg RECONSTITUTIO docusate sodium 2 OTC N 125 MG (25 MG/ oral capsule 100 mg, ML FINAL CONC.) 250 mg enema disposable 2 OTC docusate sodium 2 OTC rectal enema 19-7 oral liquid 50 mg/5 gram/118 ml ml enema rectal enema 2 OTC docusate sodium 2 OTC 19-7 gram/118 ml oral tablet 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 149 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENTYVIO 2 PA; SP fiber therapy (ca 2 OTC INTRAVENOUS polycarboph) oral RECON SOLN 300 tablet 625 mg MG FIBER THERAPY 2 OTC enulose oral solution 2 (PSYLLIUM- 10 gram/15 ml SUCRO) ORAL epsom salt (laxative) 2 OTC POWDER 3 oral granules 495 GRAM/12 GRAM, mg/5 gram 3 GRAM/7 GRAM fiber therapy 2 OTC EQUALACTIN 2 OTC ORAL laxative (husk) oral TABLET,CHEWAB capsule 0.52 gram LE 500 MG fiber-caps (psyllium 2 OTC evac-u-gen 2 OTC husk) oral capsule (sennosides) oral 0.52 gram tablet 8.6 mg fiber-lax oral tablet 2 OTC E-Z-GAS II ORAL 2 OTC 625 mg GRANULES, fiber-tabs oral tablet 2 OTC EFFERVESCENT 625 mg PACKET 2.21-1.53 FLEET 2 OTC GRAM/4 GRAM BISACODYL fiber (calcium 2 OTC RECTAL ENEMA polycarbophil) oral 10 MG/30 ML tablet 625 mg fleet enema rectal 2 OTC fiber (psyllium husk) 2 OTC enema 19-7 oral capsule 0.52 gram/118 ml gram fleet glycerin (adult) 2 OTC fiber (psyllium husk- 2 OTC rectal suppository sugar) oral powder FLEET GLYCERIN 2 OTC 3.4 gram/12 gram, LAXATIVE 3.4 gram/7 gram RECTAL fiber (with 2 OTC SOLUTION 5.4 aspartame) oral GRAM/5.4 ML powder 3.4 gram/5.8 fleet laxative 2 ACA; OTC gram (bisacodyl) oral fiber laxative (ca 2 OTC tablet,delayed polycarbo) oral release (dr/ec) 5 mg tablet 625 mg foaming antacid oral 2 OTC fiber laxative 2 OTC suspension 95-358 (psyllium husk) oral mg/15 ml capsule 0.52 gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 150 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fosaprepitant 2 PA; SP gavilyte-n oral recon 2 ACA intravenous recon soln 420 gram soln 150 mg generlac oral 2 gas relief 2 OTC solution 10 gram/15 (simethicone) oral ml capsule 180 mg gentle laxative 2 ACA; OTC gas relief 2 OTC (bisacodyl) oral (simethicone) oral tablet,delayed drops,suspension 40 release (dr/ec) 5 mg mg/0.6 ml gentle laxative 2 OTC gas relief 2 OTC (bisacodyl) rectal (simethicone) oral suppository 10 mg tablet,chewable 125 gentlelax oral 2 ACA; OTC mg, 80 mg powder 17 gas relief 80 2 OTC gram/dose (simethicone) oral geri-kot oral tablet 2 OTC tablet,chewable 80 8.6 mg mg geri-lanta oral 2 OTC gas relief extra 2 OTC suspension 200-200- strength oral 20 mg/5 ml, 400- tablet,chewable 125 400-40 mg/5 ml mg geri-mox antacid- 2 OTC gas relief ultra 2 OTC antigas oral strength oral capsule suspension 200-200- 180 mg 20 mg/5 ml GATTEX 30-VIAL 2 PA; SP; QL GERI-MUCIL 2 OTC SUBCUTANEOUS (30 per 23 (SUGAR) ORAL KIT 5 MG days) POWDER 3.4 GATTEX ONE- 2 PA; SP; QL GRAM/12 GRAM VIAL (30 per 23 GERI-MUCIL 2 OTC SUBCUTANEOUS days) ORAL POWDER KIT 5 MG 3.4 GRAM/5.4 gavilax oral powder 2 ACA; OTC GRAM 17 gram/dose glycerin (adult) 2 OTC gavilyte-c oral recon 2 ACA rectal suppository soln 240-22.72-6.72 glycerin (child) 2 OTC -5.84 gram rectal suppository gavilyte-g oral recon 2 ACA glycolax oral 2 ACA; OTC soln 236-22.74-6.74 powder 17 -5.86 gram gram/dose

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 151 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits granisetron (pf) 2 SP konsyl (sugar) oral 2 OTC intravenous solution powder 3.4 gram/12 100 mcg/ml gram granisetron hcl 2 SP konsyl (sugar) oral 2 OTC intravenous solution powder in packet 3.4 1 mg/ml gram granisetron hcl oral 2 PA; QL (10 konsyl formula-d 2 OTC tablet 1 mg per 23 days) oral powder 3.4 healthylax oral 2 OTC gram/ 6.5 gram powder in packet 17 konsyl sugar-free 2 OTC gram oral powder 6 heartburn antacid 2 OTC gram/6 gram oral tablet,chewable konsyl sugar-free 2 OTC 160-105 mg oral powder in heartburn relief oral 2 OTC packet 6 gram tablet,chewable 160- KRISTALOSE 2 105 mg ORAL PACKET 10 GRAM, 20 GRAM hydrocortisone 2 rectal enema 100 lactase fast acting 2 OTC mg/60 ml oral tablet 9,000 unit hydrocortisone 2 lactase oral tablet 2 OTC topical cream with 3,000 unit perineal applicator 1 lactulose oral 2 % solution 10 gram/15 hydrocortisone- 2 ml, 10 gram/15 ml pramoxine rectal (15 ml), 20 gram/30 cream 2.5-1 % ml infants gas relief 2 OTC laxa basic oral 2 OTC oral capsule 100 mg drops,suspension 40 laxacin oral tablet 2 OTC mg/0.6 ml 8.6-50 mg infants' mylicon oral 2 OTC laxaclear oral 2 ACA; OTC drops,suspension 40 powder 17 mg/0.6 ml gram/dose INFLECTRA 2 PA; SP laxative (bisacodyl) 2 ACA; OTC INTRAVENOUS oral tablet 5 mg RECON SOLN 100 MG laxative (bisacodyl) 2 ACA; OTC oral tablet,delayed release (dr/ec) 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 152 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits laxative (bisacodyl) 2 OTC little tummys gas 2 OTC rectal suppository 10 relief oral mg drops,suspension 40 laxative (glycerin- 2 OTC mg/0.6 ml pediatric) rectal maalox maximum 2 OTC suppository strength oral laxative (sennosides) 2 OTC suspension 400-400- oral tablet 15 mg, 25 40 mg/5 ml mg mag-al plus extra 2 OTC strength oral laxative peg 3350 2 ACA; OTC oral powder 17 suspension 400-400- gram/dose 40 mg/5 ml laxative pills oral 2 OTC mag-al plus oral 2 OTC tablet 25 mg suspension 200-200- 20 mg/5 ml laxative pills regular 2 OTC oral tablet 15 mg magnesium citrate 2 OTC oral solution laxative plus stool 2 OTC magnesium oral 2 OTC softener oral tablet 8.6-50 mg tablet 250 mg lidocaine hcl- 2 meclizine oral tablet 2 OTC hydrocortison ac 12.5 mg rectal cream 3-0.5 % meclizine oral tablet 2 lidocaine hcl- 2 25 mg hydrocortison ac medi-meclizine oral 2 OTC rectal kit 2 %-2 % (7 tablet 25 mg gram), 3-0.5 %, 3-1 mesalamine oral 2 % (7 gram) capsule,extended lidocaine- 2 release 24hr 0.375 hydrocortisone-aloe gram rectal gel 2.8-0.55 % mesalamine oral 2 lidocaine- 2 tablet,delayed hydrocortisone-aloe release (dr/ec) 1.2 rectal kit 3-2.5 % (7 gram gram) mesalamine rectal 2 LINZESS ORAL 2 PA; QL (30 enema 4 gram/60 ml CAPSULE 145 per 23 days) mesalamine rectal 2 MCG, 290 MCG, 72 suppository 1,000 MCG mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 153 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits METAMUCIL 2 OTC milk of magnesia 2 OTC (WITH SUGAR) oral suspension 400 ORAL POWDER mg/5 ml 3.4 GRAM/12 mineral oil extra 2 OTC GRAM heavy oral oil METAMUCIL 2 OTC mineral oil heavy 2 OTC (WITH SUGAR) oral oil ORAL POWDER IN PACKET 3.4 mineral oil oral oil 2 OTC GRAM mineral oil rectal 2 OTC metamucil fiber 2 OTC enema singles oral powder mintox maximum 2 OTC in packet 3.4 gram strength oral METAMUCIL 2 OTC suspension 400-400- FIBER THIN ORAL 40 mg/5 ml WAFER 2 GRAM, mintox oral 2 OTC 2.5 GRAM suspension 200-200- METAMUCIL 2 OTC 20 mg/5 ml FREE ORAL mintox plus oral 2 OTC POWDER 3 tablet,chewable 200- GRAM/7 GRAM 200-25 mg METAMUCIL 2 OTC miralax oral powder 2 OTC ORAL POWDER in packet 17 gram 3.4 GRAM/5.4 GRAM motion sickness 2 OTC (meclizine) oral metoclopramide hcl 2 tablet 25 mg oral solution 5 mg/5 ml motion sickness oral 2 OTC; QL (2 tablet 50 mg per 1 day) metoclopramide hcl 2 oral tablet 10 mg, 5 motion sickness 2 OTC; QL (2 mg relief oral tablet 50 per 1 day) mg mi-acid gas 2 OTC relief(simethicon) motion sickness 2 OTC oral tablet,chewable relief(mecliz) oral 80 mg tablet 25 mg milk of magnesia 2 OTC MOVANTIK ORAL 2 PA; QL (30 concentrated oral TABLET 12.5 MG, per 23 days) suspension 2,400 25 MG mg/10 ml move it along oral 2 OTC tablet 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 154 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MUCILIN SF 2 OTC OCALIVA ORAL 2 PA; SP; QL ORAL POWDER IN TABLET 10 MG, 5 (30 per 23 PACKET 3.5 MG days) GRAM ondansetron hcl (pf) 2 GAS 2 OTC injection solution 4 MINIS ORAL mg/2 ml TABLET,CHEWAB ondansetron hcl 2 LE 42 MG intravenous solution mylanta maximum 2 OTC 2 mg/ml strength oral ondansetron hcl oral 2 QL (75 per 23 suspension 400-400- solution 4 mg/5 ml days) 40 mg/5 ml ondansetron hcl oral 2 QL (5 per 23 MYLANTA 2 OTC tablet 24 mg days) TONIGHT ORAL SUSPENSION 800- ondansetron hcl oral 2 QL (30 per 23 270-80 MG/10 ML tablet 4 mg days) natural fiber laxative 2 OTC ondansetron hcl oral 2 (sugar) oral powder tablet 8 mg , 3.4 gram/7 gram ondansetron oral 2 QL (30 per 23 natural fiber laxative 2 OTC tablet,disintegrating days) oral capsule 0.52 4 mg, 8 mg gram OSMOPREP ORAL 2 ACA natural fiber 2 OTC TABLET 1.5 laxative(aspart) oral GRAM powder PALONOSETRON 2 PA natural veg 2 OTC INTRAVENOUS laxative(sennosid) SOLUTION 0.25 oral tablet 8.6 mg MG/2 ML natural vegetable 2 OTC palonosetron 2 PA; SP (psyllium) oral intravenous solution powder 0.25 mg/5 ml natural vegetable 2 OTC palonosetron 2 PA oral powder intravenous syringe 0.25 mg/5 ml natural vegetable 2 OTC powder oral powder 3.4 gram/12 gram natura-lax oral 2 ACA; OTC powder 17 gram/dose

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 155 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PANCREAZE 2 PHILLIPS MILK 2 OTC ORAL OF MAGNESIA CAPSULE,DELAY ORAL ED TABLET,CHEWAB RELEASE(DR/EC) LE 311 MG 10,500-35,500- polyethylene glycol 2 ACA; OTC 61,500 UNIT, 3350 oral powder 17 16,800-56,800- gram/dose 98,400 UNIT, 21,000-54,700- polyethylene glycol 2 83,900 UNIT, 4,200- 3350 oral powder in 14,200- 24,600 packet 17 gram UNIT powderlax oral 2 ACA; OTC p-col rite oral tablet 2 OTC powder 17 8.6-50 mg gram/dose PEDIA-LAX ORAL 2 OTC powderlax oral 2 OTC TABLET,CHEWAB powder in packet 17 LE 400 MG (170 gram MG MAGNESIUM) prochlorperazine 2 PEDIA-LAX 2 OTC maleate oral tablet RECTAL 10 mg, 5 mg SOLUTION 2.8 prochlorperazine 2 GRAM/2.7 ML rectal suppository 25 peg 3350- 2 ACA mg electrolytes oral PROCTOFOAM HC 2 recon soln 236- RECTAL FOAM 1- 22.74-6.74 -5.86 1 % gram procto-pak topical 2 peg-electrolyte soln 2 ACA cream with perineal oral recon soln 420 applicator 1 % gram proctosol hc topical 2 peg-prep oral kit 5- 2 ACA cream with perineal 210 mg-gram applicator 2.5 % PENTASA ORAL 2 promolaxin oral 2 OTC CAPSULE, tablet 100 mg EXTENDED RELEASE 500 MG psyllium husk oral 2 OTC capsule 0.52 gram perdiem overnight 2 OTC relief oral tablet 15 pure and gentle 2 OTC mg disposable rectal enema 19-7 gram/118 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 156 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits purelax oral powder 2 ACA; OTC senna oral tablet 8.6 2 OTC 17 gram/dose mg purelax oral powder 2 OTC senna plus oral 2 OTC in packet 17 gram tablet 8.6-50 mg ready-to-use enema 2 OTC senna with docusate 2 OTC (min oil) rectal sodium oral tablet enema 8.6-50 mg ready-to-use enema 2 OTC senna-s oral tablet 2 OTC rectal enema 19-7 8.6-50 mg gram/118 ml senna-time s oral 2 OTC REGULOID 2 OTC tablet 8.6-50 mg (PSYLLIUM sennosides oral 2 OTC HUSK-SUCRO) syrup 8.8 mg/5 ml ORAL POWDER 3 GRAM/12 GRAM, sennosides-docusate 2 OTC 3 GRAM/7 GRAM sodium oral tablet 8.6-50 mg REMICADE 2 PA; SP INTRAVENOUS sen-o-tab oral tablet 2 OTC RECON SOLN 100 8.6 mg MG SFROWASA 2 RENFLEXIS 2 PA; SP RECTAL ENEMA 4 INTRAVENOUS GRAM/60 ML RECON SOLN 100 silace oral liquid 50 2 OTC MG mg/5 ml scopolamine base 2 simethicone oral 2 OTC transdermal patch 3 capsule 180 mg day 1 mg over 3 days simethicone oral 2 OTC drops,suspension 40 senexon-s oral tablet 2 OTC mg/0.6 ml 8.6-50 mg simethicone oral 2 OTC senna lax oral tablet 2 OTC tablet,chewable 125 8.6 mg mg, 80 mg senna laxative oral 2 OTC smoothlax oral 2 ACA; OTC tablet 8.6 mg powder 17 SENNA ORAL 2 OTC gram/dose SYRUP 176 MG/5 smoothlax oral 2 OTC ML powder in packet 17 senna oral syrup 8.8 2 OTC gram mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 157 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium bicarbonate 2 OTC trilyte with flavor 2 ACA oral tablet 325 mg, packets oral recon 650 mg soln 420 gram sof-lax oral capsule 2 OTC trimethobenzamide 2 100 mg oral capsule 300 mg stimulant laxative 2 OTC tums ultra oral 2 OTC plus oral tablet 8.6- tablet,chewable 470 50 mg mg calcium (1,177 stool softener 2 OTC mg) (docusate cal) oral ultra dairy digestive 2 OTC capsule 240 mg oral tablet 9,000 unit stool softener oral 2 OTC ursodiol oral 2 capsule 100 mg, 250 capsule 300 mg mg ursodiol oral tablet 2 stool softener oral 2 OTC 250 mg, 500 mg liquid 50 mg/5 ml VARUBI 2 PA; SP stool softener oral 2 OTC INTRAVENOUS tablet 100 mg EMULSION 166.5 stool softener- 2 OTC MG/92.5 ML laxative oral tablet VARUBI ORAL 2 PA 8.6-50 mg TABLET 90 MG stool softener- 2 OTC vegetable laxative 2 OTC stimulant laxat oral oral tablet 8.6 mg tablet 8.6-50 mg vegetable lax-stool 2 OTC sulfasalazine oral 2 softener oral tablet tablet 500 mg 8.6-50 mg sulfasalazine oral 2 VIOKACE ORAL 2 tablet,delayed TABLET 10,440- release (dr/ec) 500 39,150- 39,150 mg UNIT, 20,880- surfak oral capsule 2 OTC 78,300- 78,300 240 mg UNIT the magic bullet 2 OTC wal-dram 2 oral 2 OTC rectal suppository 10 tablet 25 mg mg wal-dram oral tablet 2 OTC; QL (2 travel sickness oral 2 OTC; QL (2 50 mg per 1 day) tablet 50 mg per 1 day) wal-mucil fiber 2 OTC travel-ease 2 OTC (aspartame) oral (meclizine) oral powder 3.4 gram/5.8 tablet 25 mg gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 158 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits wal-mucil fiber 2 OTC acid controller oral 2 OTC (sugar) oral powder tablet 10 mg, 20 mg 3.4 gram/7 gram acid reducer 2 OTC wal-mucil fiber oral 2 OTC (cimetidine) oral capsule 0.52 gram tablet 200 mg wal-mucil natural 2 OTC acid reducer 2 OTC fiber lax oral () oral powder 3.4 gram/12 tablet 10 mg, 20 mg gram acid reducer 2 OTC woman's laxative 2 ACA; OTC (omeprazole) oral (bisacodyl) oral capsule,delayed tablet 5 mg release(dr/ec) 20 mg women's gentle 2 ACA; OTC acid-pep oral tablet 2 OTC laxative(bisac) oral 20 mg tablet,delayed cimetidine hcl oral 2 release (dr/ec) 5 mg solution 300 mg/5 ml women's laxative 2 ACA; OTC cimetidine oral 2 OTC (bisacodyl) oral tablet 200 mg tablet 5 mg cimetidine oral 2 women's laxative 2 ACA; OTC tablet 300 mg, 400 (bisacodyl) oral mg, 800 mg tablet,delayed release (dr/ec) 5 mg DEXILANT ORAL 2 ST CAPSULE,BIPHAS ZENPEP ORAL 2 E DELAYED CAPSULE,DELAY RELEAS 30 MG ED RELEASE(DR/EC) DEXILANT ORAL 2 ST; QL (30 per 10,000-32,000 - CAPSULE,BIPHAS 23 days) 42,000 UNIT, E DELAYED 15,000-47,000 - RELEAS 60 MG 63,000 UNIT, esomeprazole 2 OTC; QL (60 20,000-63,000- magnesium oral per 23 days) 84,000 UNIT, 3,000- capsule,delayed 10,000 -14,000- release(dr/ec) 20 mg UNIT, 40,000- 126,000- 168,000 esomeprazole 2 ST; QL (30 per UNIT, 5,000- magnesium oral 23 days) 17,000- 24,000 capsule,delayed UNIT release(dr/ec) 40 mg ULCER THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 159 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ESOMEPRAZOLE 2 QL (30 per 23 nizatidine oral 2 STRONTIUM days) solution 150 mg/10 ORAL ml CAPSULE,DELAY omeprazole 2 OTC ED magnesium oral RELEASE(DR/EC) capsule,delayed 49.3 MG release(dr/ec) 20 mg famotidine oral 2 omeprazole oral 2 QL (30 per 23 suspension 40 mg/5 capsule,delayed days) ml (8 mg/ml) release(dr/ec) 10 famotidine oral 2 OTC mg, 20 mg, 40 mg tablet 10 mg, 20 mg omeprazole oral 2 OTC famotidine oral 2 tablet,delayed tablet 40 mg release (dr/ec) 20 heartburn 2 OTC mg prevention oral omeprazole oral 2 OTC tablet 10 mg, 20 mg tablet,disintegrat, heartburn relief 2 OTC delay rel 20 mg (cimetidine) oral omeprazole-sodium 2 ST tablet 200 mg bicarbonate oral capsule 20-1.1 mg- heartburn relief 2 OTC (famotidine) oral gram tablet 10 mg, 20 mg omeprazole-sodium 2 ST; QL (3 per lansoprazole oral 2 OTC; QL (30 bicarbonate oral 1 day) capsule,delayed per 23 days) capsule 40-1.1 mg- release(dr/ec) 15 mg gram lansoprazole oral 2 QL (30 per 23 pantoprazole oral 2 QL (30 per 23 capsule,delayed days) tablet,delayed days) release(dr/ec) 30 mg release (dr/ec) 20 mg, 40 mg misoprostol oral 2 tablet 100 mcg, 200 pepcid ac oral tablet 2 OTC mcg 20 mg NEXIUM 24HR 2 OTC; QL (60 PRILOSEC OTC 2 OTC ORAL per 23 days) ORAL TABLET,DELAYE TABLET,DELAYE D RELEASE D RELEASE (DR/EC) 20 MG (DR/EC) 20 MG nizatidine oral 2 oral 2 QL (30 per 23 capsule 150 mg, 300 tablet,delayed days) mg release (dr/ec) 20 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 160 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sucralfate oral 2 AVONEX 2 SP suspension 100 INTRAMUSCULA mg/ml R PEN INJECTOR sucralfate oral tablet 2 KIT 30 MCG/0.5 1 gram ML tagamet hb oral 2 OTC AVONEX 2 SP tablet 200 mg INTRAMUSCULA R SYRINGE KIT 30 IMMUNOLOGY, VACCINES / MCG/0.5 ML

BIOTECHNOLOGY BETASERON 2 SP SUBCUTANEOUS BIOTECHNOLOGY DRUGS KIT 0.3 MG ARANESP (IN 1 PA; SP EGRIFTA SV 2 PA; SP; QL POLYSORBATE) SUBCUTANEOUS (60 per 23 INJECTION RECON SOLN 2 days) SOLUTION 100 MG MCG/ML, 150 MCG/0.75 ML, 200 EPOGEN 1 PA; SP MCG/ML, 25 INJECTION MCG/ML, 300 SOLUTION 10,000 MCG/ML, 40 UNIT/ML, 2,000 MCG/ML, 60 UNIT/ML, 20,000 MCG/ML UNIT/2 ML, 3,000 UNIT/ML, 4,000 ARANESP (IN 1 PA; SP UNIT/ML POLYSORBATE) INJECTION EPOGEN 1 SP SYRINGE 10 INJECTION MCG/0.4 ML, 100 SOLUTION 20,000 MCG/0.5 ML, 150 UNIT/ML MCG/0.3 ML, 200 EXTAVIA 2 SP MCG/0.4 ML, 25 SUBCUTANEOUS MCG/0.42 ML, 300 KIT 0.3 MG MCG/0.6 ML, 40 MCG/0.4 ML, 500 EXTAVIA 2 SP MCG/ML, 60 SUBCUTANEOUS MCG/0.3 ML RECON SOLN 0.3 MG ARCALYST 1 PA; SP SUBCUTANEOUS FULPHILA 1 SP RECON SOLN 220 SUBCUTANEOUS MG SYRINGE 6 MG/0.6 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 161 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GENOTROPIN 1 PA; SP; PrefD LEUKINE 1 SP MINIQUICK INJECTION SUBCUTANEOUS RECON SOLN 250 SYRINGE 0.2 MCG MG/0.25 ML, 0.4 MOZOBIL 2 PA; SP MG/0.25 ML, 0.6 SUBCUTANEOUS MG/0.25 ML, 0.8 SOLUTION 24 MG/0.25 ML, 1 MG/1.2 ML (20 MG/0.25 ML, 1.2 MG/ML) MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 NEULASTA 1 SP MG/0.25 ML, 1.8 ONPRO MG/0.25 ML, 2 SUBCUTANEOUS MG/0.25 ML SYRINGE, W/ WEARABLE GENOTROPIN 1 PA; SP; PrefD INJECTOR 6 SUBCUTANEOUS MG/0.6 ML CARTRIDGE 12 MG/ML (36 NEULASTA 1 SP UNIT/ML), 5 SUBCUTANEOUS MG/ML (15 SYRINGE 6 MG/0.6 UNIT/ML) ML GRANIX 1 PA; SP NEUPOGEN 1 SP SUBCUTANEOUS INJECTION SOLUTION 300 SOLUTION 300 MCG/ML, 480 MCG/ML, 480 MCG/1.6 ML MCG/1.6 ML GRANIX 1 PA; SP NEUPOGEN 1 SP SUBCUTANEOUS INJECTION SYRINGE 300 SYRINGE 300 MCG/0.5 ML, 480 MCG/0.5 ML, 480 MCG/0.8 ML MCG/0.8 ML ILARIS (PF) 1 PA; SP NIVESTYM 1 PA; SP SUBCUTANEOUS INJECTION SOLUTION 150 SOLUTION 300 MG/ML MCG/ML, 480 MCG/1.6 ML INTRON A 2 SP INJECTION NIVESTYM 1 PA; SP RECON SOLN 10 SUBCUTANEOUS MILLION UNIT (1 SYRINGE 300 ML), 18 MILLION MCG/0.5 ML, 480 UNIT (1 ML), 50 MCG/0.8 ML MILLION UNIT (1 ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 162 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NYVEPRIA 1 SP VACCINES / MISCELLANEOUS

SUBCUTANEOUS IMMUNOLOGICALS SYRINGE 6 MG/0.6 ML ADACEL(TDAP 2 ACA; QL (1 ADOLESN/ADULT per 1 day) PROCRIT 1 PA; SP )(PF) INJECTION INTRAMUSCULA SOLUTION 10,000 R SUSPENSION 2 UNIT/ML, 2,000 LF-(2.5-5-3-5 UNIT/ML, 20,000 MCG)-5LF/0.5 ML UNIT/2 ML, 20,000 UNIT/ML, 3,000 AFLURIA QD 2 UNIT/ML, 4,000 2021-22(3YR UNIT/ML, 40,000 UP)(PF) UNIT/ML INTRAMUSCULA R SYRINGE 60 REBLOZYL 2 PA; SP MCG (15 MCG X SUBCUTANEOUS 4)/0.5 ML RECON SOLN 25 MG, 75 MG AFLURIA QD 2 2021-22(6- RETACRIT 1 PA; SP 35MO)(PF) INJECTION INTRAMUSCULA SOLUTION 10,000 R SYRINGE 30 UNIT/ML, 2,000 MCG (7.5 MCG X UNIT/ML, 20,000 4)/0.25 ML UNIT/2 ML, 20,000 UNIT/ML, 3,000 AFLURIA QUAD 2 UNIT/ML, 4,000 2021-2022(6MO UNIT/ML, 40,000 UP) UNIT/ML INTRAMUSCULA R SUSPENSION 60 UDENYCA 1 SP MCG (15 MCG X SUBCUTANEOUS 4)/0.5 ML SYRINGE 6 MG/0.6 ML BCG , 2 LIVE (PF) ZARXIO 1 SP PERCUTANEOUS INJECTION SUSPENSION FOR SYRINGE 300 RECONSTITUTIO MCG/0.5 ML, 480 N 50 MG MCG/0.8 ML BEXSERO 2 ACA; QL (2 ZIEXTENZO 1 SP INTRAMUSCULA per 1 day) SUBCUTANEOUS R SYRINGE 50-50- SYRINGE 6 MG/0.6 50-25 MCG/0.5 ML ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 163 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BIOTHRAX 2 FLEBOGAMMA 2 PA; SP INTRAMUSCULA DIF R SUSPENSION 0.5 INTRAVENOUS ML/DOSE SOLUTION 10 %, 5 BIVIGAM 2 PA; SP % INTRAVENOUS FLUAD QUAD 2 QL (99 per 99 SOLUTION 10 % 2021-22(65Y days) BOOSTRIX TDAP 2 ACA UP)(PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION R SYRINGE 60 2.5-8-5 LF-MCG- MCG (15 MCG X LF/0.5ML 4)/0.5 ML FLUARIX QUAD 2 BOOSTRIX TDAP 2 ACA; QL (1 INTRAMUSCULA per 1 day) 2021-2022 (PF) R SYRINGE 2.5-8-5 INTRAMUSCULA R SYRINGE 60 LF-MCG-LF/0.5ML MCG (15 MCG X BOTOX 2 PA; SP 4)/0.5 ML INJECTION RECON SOLN 100 FLUBLOK QUAD 2 UNIT, 200 UNIT 2021-2022 (PF) INTRAMUSCULA CUVITRU 2 PA; SP R SYRINGE 180 SUBCUTANEOUS MCG (45 MCG X SOLUTION 1 4)/0.5 ML GRAM/5 ML (20 %), 2 GRAM/10 FLUCELVAX 2 ML (20 %), 4 QUAD 2021-2022 GRAM/20 ML (20 (PF) %), 8 GRAM/40 ML INTRAMUSCULA (20 %) R SYRINGE 60 MCG (15 MCG X ENGERIX-B (PF) 2 ACA 4)/0.5 ML INTRAMUSCULA R SUSPENSION 20 FLUCELVAX 2 MCG/ML QUAD 2021-2022 INTRAMUSCULA ENGERIX-B (PF) 2 ACA R SUSPENSION 60 INTRAMUSCULA MCG (15 MCG X R SYRINGE 20 4)/0.5 ML MCG/ML FLULAVAL QUAD 2 ENGERIX-B 2 ACA 2021-2022 (PF) PEDIATRIC (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 60 R SYRINGE 10 MCG (15 MCG X MCG/0.5 ML 4)/0.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 164 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUMIST QUAD 2 GAMMAGARD S- 2 PA; SP 2021-2022 NASAL D (IGA < 1 NASAL SPRAY MCG/ML) SYRINGE INTRAVENOUS 10EXP6.5-7.5 FF RECON SOLN 10 UNIT/0.2 ML GRAM, 5 GRAM FLUZONE 2 GAMMAKED 2 PA; SP HIGHDOSE QUAD INJECTION 21-22 PF SOLUTION 1 INTRAMUSCULA GRAM/10 ML (10 R SYRINGE 240 %), 10 GRAM/100 MCG/0.7 ML ML (10 %), 20 FLUZONE QUAD 2 GRAM/200 ML (10 2021-2022 (PF) %), 5 GRAM/50 ML INTRAMUSCULA (10 %) R SUSPENSION 60 GAMMAPLEX 2 PA; SP MCG (15 MCG X (WITH SORBITOL) 4)/0.5 ML INTRAVENOUS SOLUTION 5 % FLUZONE QUAD 2 2021-2022 (PF) GAMMAPLEX 2 PA; SP INTRAMUSCULA INTRAVENOUS R SYRINGE 60 SOLUTION 10 % MCG (15 MCG X GAMUNEX-C 2 PA; SP 4)/0.5 ML INJECTION FLUZONE QUAD 2 SOLUTION 1 2021-2022 GRAM/10 ML (10 INTRAMUSCULA %), 10 GRAM/100 R SUSPENSION 60 ML (10 %), 2.5 MCG (15 MCG X GRAM/25 ML (10 4)/0.5 ML %), 20 GRAM/200 GAMASTAN S/D 2 PA; SP ML (10 %), 40 INTRAMUSCULA GRAM/400 ML (10 R SOLUTION 15-18 %), 5 GRAM/50 ML % RANGE (10 %) GAMMAGARD 2 PA; SP GARDASIL 9 (PF) 2 PA; ACA; QL LIQUID INTRAMUSCULA (3 per 720 INJECTION R SUSPENSION 0.5 days) SOLUTION 10 % ML GARDASIL 9 (PF) 2 PA; ACA; QL INTRAMUSCULA (1.5 per 365 R SYRINGE 0.5 ML days)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 165 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GRASTEK 2 PA; QL (30 HYQVIA 2 PA; SP SUBLINGUAL per 23 days) SUBCUTANEOUS TABLET 2,800 SOLUTION 10 BAU GRAM /100 ML (10 HEPAGAM B 2 SP %), 2.5 GRAM /25 INJECTION ML (10 %), 20 SOLUTION >312 GRAM /200 ML (10 UNIT/ML %), 30 GRAM /300 ML (10 %), 5 HEPLISAV-B (PF) 2 ACA; QL (2 GRAM /50 ML (10 INTRAMUSCULA per 1 day) %) R SYRINGE 20 MCG/0.5 ML IMOVAX RABIES 2 QL (5 per 1 VACCINE (PF) day) HIZENTRA 2 PA; SP INTRAMUSCULA SUBCUTANEOUS R RECON SOLN SOLUTION 1 2.5 UNIT GRAM/5 ML (20 %), 10 GRAM/50 INFANRIX (DTAP) 2 ML (20 %), 2 (PF) INTRAMUSCULA GRAM/10 ML (20 %), 4 GRAM/20 ML R SYRINGE 25-58- (20 %) 10 LF-MCG- LF/0.5ML HYPERHEP B 2 SP INTRAMUSCULA IPOL INJECTION 2 QL (4 per 1 R SOLUTION 220 SUSPENSION 40-8- day) 32 UNIT/0.5 ML UNIT/ML, 220 UNIT/ML (5 ML) IXIARO (PF) 2 QL (2 per 1 HYPERHEP B 2 SP INTRAMUSCULA day) INTRAMUSCULA R SYRINGE 6 R SYRINGE 220 MCG/0.5 ML UNIT/ML JANSSEN COVID- 2 HYPERHEP B 2 SP 19 VACCINE NEONATAL (EUA) INTRAMUSCULA INTRAMUSCULA R SYRINGE 110 R SUSPENSION 0.5 UNIT/0.5 ML ML MENACTRA (PF) 2 ACA; QL (2 INTRAMUSCULA per 1 day) R SOLUTION 4 MCG/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 166 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MENQUADFI (PF) 2 PENTACEL (PF) 2 INTRAMUSCULA INTRAMUSCULA R SOLUTION 10 R KIT 15 LF UNIT- MCG/0.5 ML 20 MCG-5 LF/0.5 MENVEO A-C-Y- 2 ACA; QL (1 ML, 15LF-48MCG- W-135-DIP (PF) per 1 day) 62DU -10 INTRAMUSCULA MCG/0.5ML R KIT 10-5 PENTACEL 2 MCG/0.5 ML ACTHIB M-M-R II (PF) 2 ACA COMPONENT (PF) SUBCUTANEOUS INTRAMUSCULA RECON SOLN R RECON SOLN 10 1,000-12,500 MCG/0.5 ML TCID50/0.5 ML COVID-19 2 MODERNA 2 VACCINE (EUA) INTRAMUSCULA COVID-19 VACCINE (EUA) R SUSPENSION INTRAMUSCULA FOR RECONSTITUTIO R SUSPENSION 100 MCG/0.5 ML N 30 MCG/0.3 ML OCTAGAM 2 PA; SP PNEUMOVAX-23 2 ACA INTRAVENOUS INJECTION SOLUTION 10 %, 5 SOLUTION 25 % MCG/0.5 ML ODACTRA 2 PA PNEUMOVAX-23 2 ACA; QL (1 SUBLINGUAL INJECTION per 1 day) TABLET 12 SQ- SYRINGE 25 HDM MCG/0.5 ML ORALAIR 2 PA; SP; QL PREVNAR 13 (PF) 2 ACA; QL (4 SUBLINGUAL (30 per 23 INTRAMUSCULA per 1 day) TABLET 300 INDX days) R SYRINGE 0.5 ML REACTIVITY PRIVIGEN 2 PA; SP INTRAVENOUS PANZYGA 2 PA; SP INTRAVENOUS SOLUTION 10 % SOLUTION 10 % QUADRACEL (PF) 2 PEDIARIX (PF) 2 INTRAMUSCULA INTRAMUSCULA R SUSPENSION 15 R SYRINGE 10 LF-48 MCG- 5 LF MCG-25LF-25 UNIT/0.5ML MCG-10LF/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 167 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RABAVERT (PF) 2 STAMARIL (PF) 2 INTRAMUSCULA SUBCUTANEOUS R SUSPENSION SUSPENSION FOR FOR RECONSTITUTIO RECONSTITUTIO N 1,000 UNIT/0.5 N 2.5 UNIT ML RAGWITEK 2 PA; QL (30 TENIVAC (PF) 2 ACA; QL (1 SUBLINGUAL per 23 days) INTRAMUSCULA per 10 days) TABLET 12 AMB R SUSPENSION 5 A 1 UNIT LF UNIT- 2 LF RECOMBIVAX HB 2 ACA UNIT/0.5ML (PF) TENIVAC (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SUSPENSION 10 R SYRINGE 5-2 LF MCG/ML, 5 UNIT/0.5 ML MCG/0.5 ML TRUMENBA 2 ACA; QL (3 RECOMBIVAX HB 2 ACA; QL (3 INTRAMUSCULA per 1 day) (PF) per 1 day) R SYRINGE 120 INTRAMUSCULA MCG/0.5 ML R SUSPENSION 40 TWINRIX (PF) 2 ACA; QL (3 MCG/ML INTRAMUSCULA per 1 day) RECOMBIVAX HB 2 ACA; QL (3 R SYRINGE 720 (PF) per 1 day) ELISA UNIT- 20 INTRAMUSCULA MCG/ML R SYRINGE 10 TYPHIM VI 2 QL (1 per 1 MCG/ML, 5 INTRAMUSCULA day) MCG/0.5 ML R SOLUTION 25 ROTARIX ORAL 2 MCG/0.5 ML SUSPENSION FOR TYPHIM VI 2 RECONSTITUTIO INTRAMUSCULA N 10EXP6 R SYRINGE 25 CCID50/ML MCG/0.5 ML ROTATEQ 2 VAQTA (PF) 2 VACCINE ORAL INTRAMUSCULA SOLUTION 2 ML R SYRINGE 25 SHINGRIX (PF) 2 PA; ACA UNIT/0.5 ML INTRAMUSCULA VARIVAX (PF) 2 ACA; QL (2 R SUSPENSION SUBCUTANEOUS per 1 day) FOR SUSPENSION FOR RECONSTITUTIO RECONSTITUTIO N 50 MCG/0.5 ML N 1,350 UNIT/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 168 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VAXELIS (PF) 2 DUZALLO ORAL 2 PA; QL (30 INTRAMUSCULA TABLET 200-200 per 23 days) R SUSPENSION 15 MG, 200-300 MG UNIT-5 UNIT- 10 febuxostat oral 2 ST MCG/0.5 ML tablet 40 mg, 80 mg VAXELIS (PF) 2 KRYSTEXXA 2 PA; SP; QL (2 INTRAMUSCULA INTRAVENOUS per 21 days) R SYRINGE 15 SOLUTION 8 UNIT-5 UNIT- 10 MG/ML MCG/0.5 ML probenecid oral 2 XEMBIFY 2 PA; SP tablet 500 mg SUBCUTANEOUS SOLUTION 1 probenecid- 2 GRAM/5 ML (20 colchicine oral %), 10 GRAM/50 tablet 500-0.5 mg ML (20 %), 2 OSTEOPOROSIS THERAPY GRAM/10 ML (20 %), 4 GRAM/20 ML alendronate oral 2 (20 %) solution 70 mg/75 ml YF-VAX (PF) 2 alendronate oral 2 SUBCUTANEOUS tablet 10 mg, 35 mg, SUSPENSION FOR 5 mg, 70 mg RECONSTITUTIO EVENITY 2 PA; SP; QL (2 N 10 EXP4.74 SUBCUTANEOUS per 23 days) UNIT/0.5 ML SYRINGE 105 ZOSTAVAX (PF) 2 PA; ACA MG/1.17 ML, SUBCUTANEOUS 210MG/2.34ML ( SUSPENSION FOR 105MG/1.17MLX2) RECONSTITUTIO ibandronate oral 2 N 19,400 UNIT/0.65 tablet 150 mg ML PROLIA 2 PA; SP MUSCULOSKELETAL / SUBCUTANEOUS

RHEUMATOLOGY SYRINGE 60 MG/ML GOUT THERAPY raloxifene oral tablet 2 ACA allopurinol oral 2 60 mg tablet 100 mg, 300 risedronate oral 2 ST mg tablet 150 mg, 35 colchicine oral 2 mg, 5 mg tablet 0.6 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 169 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TYMLOS 2 PA; SP ENBREL 1 PA; SP; PrefD SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR 80 RECON SOLN 25 MCG (3,120 MG (1 ML) MCG/1.56 ML) ENBREL 1 SP; PrefD OTHER RHEUMATOLOGICALS SUBCUTANEOUS SOLUTION 25 ACTEMRA 1 PA; SP MG/0.5 ML ACTPEN SUBCUTANEOUS ENBREL 1 PA; SP; PrefD PEN INJECTOR SUBCUTANEOUS 162 MG/0.9 ML SYRINGE 25 MG/0.5 ML (0.5), ACTEMRA 1 PA; SP 50 MG/ML (1 ML) INTRAVENOUS SOLUTION 200 ENBREL 1 PA; SP; PrefD MG/10 ML (20 SURECLICK MG/ML), 400 SUBCUTANEOUS MG/20 ML (20 PEN INJECTOR 50 MG/ML), 80 MG/4 MG/ML (1 ML) ML (20 MG/ML) HUMIRA PEN 1 PA; SP; PrefD ACTEMRA 1 PA; SP CROHNS-UC-HS SUBCUTANEOUS START SYRINGE 162 SUBCUTANEOUS MG/0.9 ML PEN INJECTOR KIT 40 MG/0.8 ML BENLYSTA 2 PA; SP INTRAVENOUS HUMIRA PEN 1 PA; SP; PrefD RECON SOLN 120 PSOR-UVEITS- MG, 400 MG ADOL HS SUBCUTANEOUS BENLYSTA 2 PA; SP PEN INJECTOR SUBCUTANEOUS KIT 40 MG/0.8 ML AUTO-INJECTOR 200 MG/ML HUMIRA PEN 1 PA; SP; PrefD SUBCUTANEOUS BENLYSTA 2 PA; SP PEN INJECTOR SUBCUTANEOUS KIT 40 MG/0.8 ML SYRINGE 200 MG/ML HUMIRA 1 PA; SP; PrefD SUBCUTANEOUS ENBREL MINI 1 SP; PrefD SYRINGE KIT 40 SUBCUTANEOUS MG/0.8 ML CARTRIDGE 50 MG/ML (1 ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 170 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMIRA(CF) PEDI 1 PA; SP; PrefD KEVZARA 1 PA; SP CROHNS SUBCUTANEOUS STARTER SYRINGE 150 SUBCUTANEOUS MG/1.14 ML, 200 SYRINGE KIT 80 MG/1.14 ML MG/0.8 ML, 80 KINERET 1 PA; SP MG/0.8 ML-40 SUBCUTANEOUS MG/0.4 ML SYRINGE 100 HUMIRA(CF) PEN 1 PA; SP; PrefD MG/0.67 ML CROHNS-UC-HS leflunomide oral 2 SUBCUTANEOUS tablet 10 mg, 20 mg PEN INJECTOR KIT 80 MG/0.8 ML OLUMIANT ORAL 1 PA; SP; QL TABLET 1 MG, 2 (30 per 23 HUMIRA(CF) PEN 1 PA; SP; PrefD MG days) PEDIATRIC UC SUBCUTANEOUS ORENCIA (WITH 1 PA; SP PEN INJECTOR MALTOSE) KIT 80 MG/0.8 ML INTRAVENOUS RECON SOLN 250 HUMIRA(CF) PEN 1 PA; SP; PrefD MG PSOR-UV-ADOL HS ORENCIA 1 PA; SP SUBCUTANEOUS CLICKJECT PEN INJECTOR SUBCUTANEOUS KIT 80 MG/0.8 ML- AUTO-INJECTOR 40 MG/0.4 ML 125 MG/ML HUMIRA(CF) PEN 1 PA; SP; PrefD ORENCIA 1 PA; SP SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR SYRINGE 125 KIT 40 MG/0.4 ML, MG/ML, 50 MG/0.4 80 MG/0.8 ML ML, 87.5 MG/0.7 ML HUMIRA(CF) 1 PA; SP; PrefD SUBCUTANEOUS OTEZLA ORAL 1 PA; SP; QL (2 SYRINGE KIT 10 TABLET 30 MG per 1 day) MG/0.1 ML, 20 OTEZLA 1 PA; SP; QL (1 MG/0.2 ML, 40 STARTER ORAL per 21 days) MG/0.4 ML TABLETS,DOSE KEVZARA 1 PA; SP PACK 10 MG (4)- SUBCUTANEOUS 20 MG (4)-30 MG PEN INJECTOR (47), 10 MG (4)-20 150 MG/1.14 ML, MG (4)-30 MG(19) 200 MG/1.14 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 171 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OTREXUP (PF) 2 PA; SP SIMPONI ARIA 1 PA; SP SUBCUTANEOUS INTRAVENOUS AUTO-INJECTOR SOLUTION 12.5 10 MG/0.4 ML, 12.5 MG/ML MG/0.4 ML, 15 SIMPONI 1 PA; SP MG/0.4 ML, 17.5 SUBCUTANEOUS MG/0.4 ML, 20 PEN INJECTOR MG/0.4 ML, 22.5 100 MG/ML, 50 MG/0.4 ML, 25 MG/0.5 ML MG/0.4 ML SIMPONI 1 PA; SP penicillamine oral 2 SP SUBCUTANEOUS tablet 250 mg SYRINGE 100 RASUVO (PF) 2 PA; SP MG/ML, 50 MG/0.5 SUBCUTANEOUS ML AUTO-INJECTOR XELJANZ ORAL 1 PA; SP; PrefD; 10 MG/0.2 ML, 12.5 TABLET 10 MG, 5 QL (60 per 23 MG/0.25 ML, 15 MG days) MG/0.3 ML, 17.5 MG/0.35 ML, 20 XELJANZ XR 1 PA; SP; PrefD; MG/0.4 ML, 22.5 ORAL TABLET QL (1 per 1 MG/0.45 ML, 25 EXTENDED day) MG/0.5 ML, 30 RELEASE 24 HR MG/0.6 ML, 7.5 11 MG MG/0.15 ML XELJANZ XR 1 PA; SP; PrefD; RIDAURA ORAL 2 ORAL TABLET QL (30 per 23 CAPSULE 3 MG EXTENDED days) RELEASE 24 HR RINVOQ ORAL 1 PA; SP; QL (1 22 MG TABLET per 1 day) EXTENDED OBSTETRICS / GYNECOLOGY RELEASE 24 HR 15 MG ESTROGENS / PROGESTINS SAVELLA ORAL 2 PA; QL (60 ANGELIQ ORAL 2 TABLET 100 MG, per 23 days) TABLET 0.25-0.5 12.5 MG, 25 MG, 50 MG, 0.5-1 MG MG camila oral tablet 2 SAVELLA ORAL 2 PA 0.35 mg TABLETS,DOSE CLIMARA PRO 2 PACK 12.5 MG (5)- TRANSDERMAL 25 MG(8)-50 PATCH WEEKLY MG(42) 0.045-0.015 MG/24 HR

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 172 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COMBIPATCH 2 ESTRING 2 TRANSDERMAL VAGINAL RING 2 PATCH MG (7.5 MCG /24 SEMIWEEKLY HOUR) 0.05-0.14 MG/24 FEMRING 2 HR, 0.05-0.25 VAGINAL RING MG/24 HR 0.05 MG/24 HR, 0.1 DUAVEE ORAL 2 MG/24 HR TABLET 0.45-20 heather oral tablet 2 MG 0.35 mg errin oral tablet 0.35 2 hydroxyprogest(pf)(p 2 PA; SP; QL (5 mg reg presv) per 23 days) estradiol oral tablet 2 intramuscular oil 0.5 mg, 1 mg, 2 mg 250 mg/ml (1 ml) estradiol 2 hydroxyprogesterone 2 SP transdermal patch cap(ppres) semiweekly 0.025 intramuscular oil mg/24 hr, 0.0375 250 mg/ml mg/24 hr, 0.05 hydroxyprogesterone 2 SP mg/24 hr, 0.075 caproate mg/24 hr, 0.1 mg/24 intramuscular oil hr 250 mg/ml estradiol 2 jencycla oral tablet 2 transdermal patch 0.35 mg weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, jinteli oral tablet 1-5 2 0.05 mg/24 hr, 0.06 mg-mcg mg/24 hr, 0.075 lyza oral tablet 0.35 2 mg/24 hr, 0.1 mg/24 mg hr MAKENA (PF) 2 PA; SP; QL estradiol vaginal 2 SUBCUTANEOUS (4.4 per 23 cream 0.01 % (0.1 AUTO-INJECTOR days) mg/gram) 275 MG/1.1 ML estradiol valerate 2 medroxyprogesteron 2 QL (99 per 99 intramuscular oil 20 e intramuscular days) mg/ml, 40 mg/ml suspension 150 estradiol- 2 mg/ml norethindrone acet medroxyprogesteron 2 oral tablet 0.5-0.1 e oral tablet 10 mg, mg, 1-0.5 mg 2.5 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 173 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mimvey oral tablet 2 sharobel oral tablet 2 ACA 1-0.5 mg 0.35 mg nora-be oral tablet 2 yuvafem vaginal 2 0.35 mg tablet 10 mcg norethindrone 2 MISCELLANEOUS OB/GYN (contraceptive) oral 3 day vaginal 2 OTC tablet 0.35 mg vaginal cream 200 norethindrone 2 mg/5 gram (4 %) acetate oral tablet 5 3-day vaginal 2 OTC mg vaginal cream 2 % norethindrone ac-eth 2 CLEOCIN 2 estradiol oral tablet VAGINAL 0.5-2.5 mg-mcg, 1-5 SUPPOSITORY 100 mg-mcg MG PREFEST ORAL 2 clindamycin 2 TABLET 1 MG phosphate vaginal (15)/1 MG- 0.09 MG cream 2 % (15) CLINDESSE 2 PREMARIN ORAL 2 VAGINAL TABLET 0.3 MG, CREAM,EXTENDE 0.45 MG, 0.625 MG, D RELEASE 2 % 0.9 MG, 1.25 MG clotrimazole 3 day 2 OTC PREMARIN 2 vaginal cream 2 % VAGINAL CREAM 0.625 MG/GRAM clotrimazole vaginal 2 OTC cream 1 % PREMPHASE 2 ORAL TABLET clotrimazole-3 2 OTC 0.625 MG (14)/ vaginal cream 2 % 0.625MG-5MG(14) clotrimazole-7 2 OTC PREMPRO ORAL 2 vaginal cream 1 % TABLET 0.3-1.5 eluryng vaginal ring 2 MG, 0.45-1.5 MG, 0.12-0.015 mg/24 hr 0.625-2.5 MG, 0.625-5 MG etonogestrel-ethinyl 2 estradiol vaginal progesterone 2 SP ring 0.12-0.015 intramuscular oil 50 mg/24 hr mg/ml GYNAZOLE-1 2 progesterone 2 VAGINAL CREAM micronized oral 2 % capsule 100 mg, 200 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 174 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gynol ii vaginal gel 3 2 OTC miconazole-3 2 OTC % vaginal cream 200 KYLEENA 2 SP; QL (1 per mg/5 gram (4 %) INTRAUTERINE 720 days) miconazole-3 2 OTC INTRAUTERINE vaginal kit 200 mg- DEVICE 17.5 2 % (9 gram) MCG/24 HRS (5 miconazole-3 2 YRS) 19.5 MG vaginal suppository LILETTA 2 SP; QL (1 per 200 mg INTRAUTERINE 700 days) miconazole-7 2 OTC INTRAUTERINE vaginal cream 2 % DEVICE 20.1 MCG/24 HRS (6 miconazole-7 2 OTC YRS) 52 MG vaginal suppository 100 mg LUPANETA PACK 2 PA; SP (1 MONTH) KIT. miconazole-skin 2 OTC SYRINGE AND clnsr17 vaginal kit 4 TABLET 3.75 MG - % (200 mg)- 2 % (9 5 MG (30) gram) LUPANETA PACK 2 PA; SP MIRENA 2 SP (3 MONTH) KIT. INTRAUTERINE SYRINGE AND INTRAUTERINE TABLET 11.25 MG DEVICE 20 -5 MG (90) MCG/24 HOURS (6 YRS) 52 MG metronidazole 2 vaginal gel 0.75 % MONISTAT 7 2 OTC VAGINAL COMB miconazole nitrate 2 OTC PACK,PREFILL vaginal comb APPL, CREAM 2 % pack,prefill appl, (100 MG)- 2 % (9 cream 4 % (200 GRAM) mg)- 2 % (9 gram) NEXPLANON 2 SP; QL (1 per miconazole nitrate 2 OTC SUBDERMAL 720 days) vaginal cream 2 % IMPLANT 68 MG miconazole nitrate 2 OTC OSPHENA ORAL 2 PA; QL (30 vaginal kit 1,200-2 TABLET 60 MG per 23 days) mg-% SKYLA 2 SP; QL (1 per miconazole-3 2 OTC INTRAUTERINE 720 days) vaginal comb INTRAUTERINE pack,prefill appl, DEVICE 14 cream 4 % (200 MCG/24 HRS (3 mg)- 2 % (9 gram) YRS) 13.5 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 175 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vaginal 2 ashlyna oral 2 ACA cream 0.4 %, 0.8 % tablets,dose pack,3 terconazole vaginal 2 month 0.15 mg-30 suppository 80 mg mcg (84)/10 mcg (7) TODAY 2 OTC aubra oral tablet 2 CONTRACEPTIVE 0.1-20 mg-mcg SPONGE aviane oral tablet 2 VAGINAL 0.1-20 mg-mcg CONTRACEPTIVE azurette (28) oral 2 SPONGE 1,000 MG tablet 0.15-0.02 tranexamic acid oral 2 PA; QL (30 mgx21 /0.01 mg x 5 tablet 650 mg per 21 days) balziva (28) oral 2 vandazole vaginal 2 tablet 0.4-35 mg- gel 0.75 % mcg xulane transdermal 2 blisovi 24 fe oral 2 ACA patch weekly 150-35 tablet 1 mg-20 mcg mcg/24 hr (24)/75 mg (4) ORAL CONTRACEPTIVES / blisovi fe 1.5/30 (28) 2 ACA

RELATED AGENTS oral tablet 1.5 mg-30 mcg (21)/75 mg (7) altavera (28) oral 2 tablet 0.15-0.03 mg blisovi fe 1/20 (28) 2 ACA oral tablet 1 mg-20 alyacen 1/35 (28) 2 mcg (21)/75 mg (7) oral tablet 1-35 mg- mcg briellyn oral tablet 2 0.4-35 mg-mcg alyacen 7/7/7 (28) 2 oral tablet 0.5/0.75/1 camrese lo oral 2 mg- 35 mcg tablets,dose pack,3 month 0.10 mg-20 amethia oral 2 mcg (84)/10 mcg (7) tablets,dose pack,3 month 0.15 mg-30 camrese oral 2 mcg (84)/10 mcg (7) tablets,dose pack,3 month 0.15 mg-30 amethyst (28) oral 2 mcg (84)/10 mcg (7) tablet 90-20 mcg (28) caziant (28) oral 2 tablet 0.1/.125/.15- apri oral tablet 0.15- 2 25 mg-mcg 0.03 mg chateal (28) oral 2 ACA aranelle (28) oral 2 tablet 0.15-0.03 mg tablet 0.5/1/0.5-35 mg-mcg chateal eq (28) oral 2 tablet 0.15-0.03 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 176 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cryselle (28) oral 2 econtra ez oral 2 OTC tablet 0.3-30 mg- tablet 1.5 mg mcg econtra one-step 2 OTC cyclafem 1/35 (28) 2 oral tablet 1.5 mg oral tablet 1-35 mg- elinest oral tablet 2 mcg 0.3-30 mg-mcg cyclafem 7/7/7 (28) 2 ELLA ORAL 2 oral tablet 0.5/0.75/1 TABLET 30 MG mg- 35 mcg emoquette oral 2 cyred eq oral tablet 2 ACA tablet 0.15-0.03 mg 0.15-0.03 mg enpresse oral tablet 2 cyred oral tablet 2 ACA 50-30 (6)/75-40 0.15-0.03 mg (5)/125-30(10) dasetta 1/35 (28) 2 enskyce oral tablet 2 oral tablet 1-35 mg- 0.15-0.03 mg mcg estarylla oral tablet 2 dasetta 7/7/7 (28) 2 0.25-35 mg-mcg oral tablet 0.5/0.75/1 mg- 35 mcg ethynodiol diac-eth 2 estradiol oral tablet daysee oral 2 1-35 mg-mcg, 1-50 tablets,dose pack,3 mg-mcg month 0.15 mg-30 mcg (84)/10 mcg (7) falmina (28) oral 2 tablet 0.1-20 mg- desog- 2 ACA mcg e.estradiol/e.estradio l oral tablet 0.15- fayosim oral 2 0.02 mgx21 /0.01 mg tablets,dose pack,3 x 5 month 0.15 mg-20 mcg/ 0.15 mg-25 desogestrel-ethinyl 2 mcg estradiol oral tablet 0.15-0.03 mg jolessa oral 2 tablets,dose pack,3 drospirenone- 2 month 0.15 mg-30 e.estradiol-lm.fa mcg (91) oral tablet 3-0.02- 0.451 mg (24) (4), 3- juleber oral tablet 2 ACA 0.03-0.451 mg (21) 0.15-0.03 mg (7) junel 1.5/30 (21) 2 drospirenone-ethinyl 2 oral tablet 1.5-30 estradiol oral tablet mg-mcg 3-0.02 mg, 3-0.03 junel 1/20 (21) oral 2 mg tablet 1-20 mg-mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 177 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits junel fe 1.5/30 (28) 2 layolis fe oral 2 ACA oral tablet 1.5 mg-30 tablet,chewable mcg (21)/75 mg (7) 0.8mg-25mcg(24) junel fe 1/20 (28) 2 and 75 mg (4) oral tablet 1 mg-20 leena 28 oral tablet 2 mcg (21)/75 mg (7) 0.5/1/0.5-35 mg-mcg junel fe 24 oral 2 ACA lessina oral tablet 2 tablet 1 mg-20 mcg 0.1-20 mg-mcg (24)/75 mg (4) levonest (28) oral 2 kaitlib fe oral 2 tablet 50-30 (6)/75- tablet,chewable 40 (5)/125-30(10) 0.8mg-25mcg(24) levonorgestrel oral 2 OTC and 75 mg (4) tablet 1.5 mg kariva (28) oral 2 levonorgestrel- 2 tablet 0.15-0.02 ethinyl estrad oral mgx21 /0.01 mg x 5 tablet 0.1-20 mg- kelnor 1/35 (28) oral 2 mcg tablet 1-35 mg-mcg levonorgestrel- 2 ACA kurvelo (28) oral 2 ethinyl estrad oral tablet 0.15-0.03 mg tablet 0.15-0.03 mg, l norgest/e.estradiol- 2 90-20 mcg (28) e.estrad oral levonorgestrel- 2 ACA tablets,dose pack,3 ethinyl estrad oral month 0.10 mg-20 tablets,dose pack,3 mcg (84)/10 mcg (7) month 0.15 mg-30 l norgest/e.estradiol- 2 ACA mcg (91) e.estrad oral levonorg-eth estrad 2 ACA tablets,dose pack,3 triphasic oral tablet month 0.15 mg-20 50-30 (6)/75-40 mcg/ 0.15 mg-25 (5)/125-30(10) mcg, 0.15 mg-30 levora-28 oral tablet 2 mcg (84)/10 mcg (7) 0.15-0.03 mg larin 24 fe oral 2 ACA LO LOESTRIN FE 2 tablet 1 mg-20 mcg ORAL TABLET 1 (24)/75 mg (4) MG-10 MCG larin fe 1.5/30 (28) 2 ACA (24)/10 MCG (2) oral tablet 1.5 mg-30 loryna (28) oral 2 mcg (21)/75 mg (7) tablet 3-0.02 mg larin fe 1/20 (28) 2 ACA oral tablet 1 mg-20 mcg (21)/75 mg (7) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 178 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits low-ogestrel (28) 2 noreth-ethinyl 2 oral tablet 0.3-30 estradiol-iron oral mg-mcg tablet,chewable lutera (28) oral 2 0.4mg-35mcg(21) tablet 0.1-20 mg- and 75 mg (7), mcg 0.8mg-25mcg(24) and 75 mg (4) marlissa (28) oral 2 tablet 0.15-0.03 mg norethindrone ac-eth 2 ACA estradiol oral tablet microgestin 1.5/30 2 1-20 mg-mcg, 1.5-30 (21) oral tablet 1.5- mg-mcg 30 mg-mcg norethindrone- 2 ACA microgestin 1/20 2 e.estradiol-iron oral (21) oral tablet 1-20 capsule 1 mg-20 mg-mcg mcg (24)/75 mg (4) microgestin fe 1.5/30 2 norethindrone- 2 ACA (28) oral tablet 1.5 e.estradiol-iron oral mg-30 mcg (21)/75 tablet 1 mg-20 mcg mg (7) (21)/75 mg (7), 1.5 microgestin fe 1/20 2 mg-30 mcg (21)/75 (28) oral tablet 1 mg (7) mg-20 mcg (21)/75 norethindrone- 2 ACA mg (7) e.estradiol-iron oral mono-linyah oral 2 tablet,chewable 1 tablet 0.25-35 mg- mg-20 mcg(24) /75 mcg mg (4) my choice oral tablet 2 OTC norgestimate-ethinyl 2 ACA 1.5 mg estradiol oral tablet 0.18/0.215/0.25 mg- my way oral tablet 2 OTC 25 mcg 1.5 mg norgestimate-ethinyl 2 NATAZIA ORAL 2 estradiol oral tablet TABLET 3 MG/2 0.18/0.215/0.25 mg- MG-2 MG/ 2 MG-3 35 mcg (28), 0.25-35 MG/1 MG mg-mcg necon 0.5/35 (28) 2 nortrel 0.5/35 (28) 2 oral tablet 0.5-35 oral tablet 0.5-35 mg-mcg mg-mcg new day oral tablet 2 OTC nortrel 1/35 (21) 2 1.5 mg oral tablet 1-35 mg- nikki (28) oral tablet 2 ACA mcg (21) 3-0.02 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 179 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nortrel 1/35 (28) 2 tilia fe oral tablet 1- 2 oral tablet 1-35 mg- 20(5)/1-30(7) /1mg- mcg 35mcg (9) nortrel 7/7/7 (28) 2 tri-estarylla oral 2 oral tablet 0.5/0.75/1 tablet mg- 35 mcg 0.18/0.215/0.25 mg- ocella oral tablet 3- 2 35 mcg (28) 0.03 mg tri-legest fe oral 2 opcicon one-step 2 OTC tablet 1-20(5)/1- 30(7) /1mg-35mcg oral tablet 1.5 mg (9) option-2 oral tablet 2 OTC 1.5 mg tri-linyah oral tablet 2 0.18/0.215/0.25 mg- orsythia oral tablet 2 35 mcg (28) 0.1-20 mg-mcg tri-lo-estarylla oral 2 ACA philith oral tablet 2 tablet 0.4-35 mg-mcg 0.18/0.215/0.25 mg- pimtrea (28) oral 2 ACA 25 mcg tablet 0.15-0.02 tri-lo-marzia oral 2 ACA mgx21 /0.01 mg x 5 tablet pirmella oral tablet 2 0.18/0.215/0.25 mg- 0.5/0.75/1 mg- 35 25 mcg mcg, 1-35 mg-mcg tri-lo-sprintec oral 2 ACA portia 28 oral tablet 2 tablet 0.15-0.03 mg 0.18/0.215/0.25 mg- 25 mcg previfem oral tablet 2 0.25-35 mg-mcg tri-previfem (28) 2 oral tablet reclipsen (28) oral 2 0.18/0.215/0.25 mg- tablet 0.15-0.03 mg 35 mcg (28) setlakin oral 2 ACA tri-sprintec (28) oral 2 tablets,dose pack,3 tablet month 0.15 mg-30 0.18/0.215/0.25 mg- mcg (91) 35 mcg (28) sprintec (28) oral 2 trivora (28) oral 2 tablet 0.25-35 mg- tablet 50-30 (6)/75- mcg 40 (5)/125-30(10) sronyx oral tablet 2 velivet triphasic 2 0.1-20 mg-mcg regimen (28) oral syeda oral tablet 3- 2 tablet 0.1/.125/.15- 0.03 mg 25 mg-mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 180 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vestura (28) oral 2 ciprofloxacin hcl 2 tablet 3-0.02 mg ophthalmic (eye) vienva oral tablet 2 ACA drops 0.3 % 0.1-20 mg-mcg erythromycin 2 viorele (28) oral 2 ophthalmic (eye) tablet 0.15-0.02 ointment 5 mg/gram mgx21 /0.01 mg x 5 (0.5 %) vyfemla (28) oral 2 ACA gatifloxacin 2 PA tablet 0.4-35 mg- ophthalmic (eye) drops 0.5 % mcg wera (28) oral tablet 2 gentak ophthalmic 2 0.5-35 mg-mcg (eye) ointment 0.3 % (3 mg/gram) wymzya fe oral 2 tablet,chewable gentamicin 2 0.4mg-35mcg(21) ophthalmic (eye) and 75 mg (7) drops 0.3 % zarah oral tablet 3- 2 levofloxacin 2 PA ophthalmic (eye) 0.03 mg drops 0.5 % zovia 1/35e (28) oral 2 tablet 1-35 mg-mcg moxifloxacin 2 PA ophthalmic (eye) zovia 1-35 (28) oral 2 drops 0.5 % tablet 1-35 mg-mcg NATACYN 2 OPHTHALMOLOGY OPHTHALMIC (EYE) ANTIBIOTICS DROPS,SUSPENSI bacitracin 2 ON 5 % ophthalmic (eye) neomycin- 2 ointment 500 bacitracin- unit/gram polymyxin bacitracin- 2 ophthalmic (eye) polymyxin b ointment 3.5-400- ophthalmic (eye) 10,000 mg-unit- ointment 500-10,000 unit/g unit/gram neomycin- 2 BETADINE 2 polymyxin- OPHTHALMIC gramicidin PREP ophthalmic (eye) OPHTHALMIC drops 1.75 mg- (EYE) SOLUTION 10,000 unit- 5 % 0.025mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 181 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits neo-polycin 2 levobunolol 2 ophthalmic (eye) ophthalmic (eye) ointment 3.5-400- drops 0.5 % 10,000 mg-unit- metipranolol 2 unit/g ophthalmic (eye) ofloxacin ophthalmic 2 drops 0.3 % (eye) drops 0.3 % timolol maleate 2 polycin ophthalmic 2 ophthalmic (eye) (eye) ointment 500- drops 0.25 %, 0.5 % 10,000 unit/gram timolol maleate 2 ST polymyxin b sulf- 2 ophthalmic (eye) trimethoprim drops, once daily 0.5 ophthalmic (eye) % drops 10,000 unit- 1 timolol maleate 2 ST mg/ml ophthalmic (eye) gel tobramycin 2 forming solution 0.5 ophthalmic (eye) % drops 0.3 % CYCLOPLEGIC MYDRIATICS

ANTIVIRALS atropine ophthalmic 2 trifluridine 2 (eye) drops 1 % ophthalmic (eye) atropine ophthalmic 2 drops 1 % (eye) ointment 1 % ZIRGAN 2 cyclopentolate 2 OPHTHALMIC ophthalmic (eye) (EYE) GEL 0.15 % drops 0.5 %, 1 %, 2 BETA-BLOCKERS % betaxolol ophthalmic 2 homatropaire 2 (eye) drops 0.5 % ophthalmic (eye) drops 5 % BETIMOL 2 OPHTHALMIC PAREMYD 2 (EYE) DROPS 0.25 OPHTHALMIC %, 0.5 % (EYE) DROPS 1- 0.25 % BETOPTIC S 2 ST OPHTHALMIC tropicamide 2 (EYE) ophthalmic (eye) DROPS,SUSPENSI drops 0.5 %, 1 % ON 0.25 % DIRECT ACTING MIOTICS carteolol ophthalmic 2 (eye) drops 1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 182 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MIOCHOL-E 2 artificial 2 OTC INTRAOCULAR tears(dext70-hypro) KIT 1 % (10 ophthalmic (eye) MG/ML) drops , 0.1-0.3 % pilocarpine hcl 2 artificial 2 OTC ophthalmic (eye) tears(glycerin-peg) drops 1 %, 2 %, 4 % ophthalmic (eye) drops 1-0.3 % MISCELLANEOUS

OPHTHALMOLOGICS artificial tears(pg- 2 OTC hypm-glyc) advanced eye relief 2 OTC ophthalmic (eye) ophthalmic (eye) drops 1-0.2-0.2 % drops 1-0.3 % artificial 2 OTC alaway ophthalmic 2 OTC tears(pvalch-povid) (eye) drops 0.025 % ophthalmic (eye) (0.035 %) drops 0.5-0.6 % allergy eye 2 OTC azelastine 2 ST (ketotifen) ophthalmic (eye) ophthalmic (eye) drops 0.05 % drops 0.025 % (0.035 %) balanced salt 2 intraocular solution altacaine ophthalmic 2 (eye) drops 0.5 % BEVACIZUMAB 2 SP INTRAVITREAL ARTIFICIAL 2 OTC SYRINGE 2.5 TEARS (CMC) MG/0.1 ML OPHTHALMIC (EYE) DROPS 1 % BEVACIZUMAB 2 INTRAVITREAL artificial tears 2 OTC SYRINGE 3.25 (petro/min) MG/0.13 ML ophthalmic (eye) ointment 83-15 % bioglo ophthalmic 2 (eye) strip 1 mg artificial tears (pf) 2 OTC ophthalmic (eye) bion tears (pf) 2 OTC dropperette , 0.1-0.3 ophthalmic (eye) % dropperette 0.1-0.3 % artificial tears 2 OTC (polyvin alc) BLINK GEL 2 OTC ophthalmic (eye) TEARS drops 1.4 % OPHTHALMIC (EYE) DROPS 0.25 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 183 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BLINK TEARS 2 OTC for sty relief 2 OTC OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.25 ointment % FRESHKOTE 2 OTC bss intraocular 2 OPHTHALMIC solution (EYE) DROPS 2.7-2 children's alaway 2 OTC % ophthalmic (eye) FUL-GLO 2 drops 0.025 % OPHTHALMIC (0.035 %) (EYE) STRIP 0.6 clear eyes natural 2 OTC MG tears ophthalmic ful-glo ophthalmic 2 (eye) drops 0.5-0.6 (eye) strip 1 mg % GENTEAL TEARS 2 OTC cromolyn 2 SEVERE GEL ophthalmic (eye) OPHTHALMIC drops 4 % (EYE) GEL 0.3 % CYSTARAN 2 SP green glo 2 OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.44 strip 1.5 mg % IMPROVUE 2 OTC dry eye relief 2 OTC OPHTHALMIC ophthalmic (eye) (EYE) DROPS drops 1-0.2-0.2 % WITH epinastine 2 ST APPLICATOR 1.7 ophthalmic (eye) % drops 0.05 % ISOPTO TEARS 2 OTC eye itch relief 2 OTC OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.5 drops 0.025 % % (0.035 %) ketotifen fumarate 2 OTC EYLEA 2 SP; QL (0.1 ophthalmic (eye) INTRAVITREAL per 21 days) drops 0.025 % SOLUTION 2 (0.035 %) MG/0.05 ML LACRISERT 2 fluorescein- 2 OPHTHALMIC proparacaine (EYE) INSERT 5 MG ophthalmic (eye) drops 0.25-0.5 % lubricant (p-glycol- 2 OTC glycerin) ophthalmic (eye) drops 1-0.3 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 184 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lubricant eye (pg- 2 OTC polyvinyl alcohol 2 OTC peg 400) ophthalmic ophthalmic (eye) (eye) drops 0.4-0.3 drops 1.4 % % proparacaine 2 lubricant eye drops 2 OTC ophthalmic (eye) ophthalmic (eye) drops 0.5 % dropperette 0.5 % pure and gentle eye 2 OTC lubricant eye drops 2 OTC ophthalmic (eye) ophthalmic (eye) drops 0.3 % drops 0.5 % REFRESH 2 OTC lubricant eye 2 OTC CLASSIC (PF) ophthalmic (eye) OPHTHALMIC ointment 57.3-42.5 (EYE) % DROPPERETTE lubricating plus 2 OTC 1.4-0.6 % ophthalmic (eye) REFRESH 2 OTC dropperette 0.5 % DIGITAL lubrifresh pm 2 OTC OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.5- ointment 83-15 % 1-0.5 % REFRESH 2 OTC LUCENTIS 2 SP INTRAVITREAL DIGITAL PF SOLUTION 0.3 OPHTHALMIC (EYE) MG/0.05 ML, 0.5 MG/0.05 ML DROPPERETTE 0.5-1-0.5 % LUCENTIS 2 SP REFRESH 2 OTC INTRAVITREAL SYRINGE 0.3 LIQUIGEL MG/0.05 ML, 0.5 OPHTHALMIC (EYE) DROPS, MG/0.05 ML LIQUID GEL 1 % moisture drops 2 OTC ophthalmic (eye) REFRESH OPTIVE 2 OTC drops 1-0.3 % ADVANCED (PF) OPHTHALMIC natural tears (pf) 2 OTC (EYE) ophthalmic (eye) DROPPERETTE dropperette 0.1-0.3 0.5-1-0.5 % % REFRESH OPTIVE 2 OTC olopatadine 2 OTC ADVANCED ophthalmic (eye) OPHTHALMIC drops 0.1 % (EYE) DROPS 0.5- 1-0.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 185 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits REFRESH OPTIVE 2 OTC SOOTHE 2 OTC MEGA-3 (PF) LUBRICANT OPHTHALMIC OPHTHALMIC (EYE) (EYE) DROPPERETTE DROPPERETTE 0.5-1-0.5 % 0.6-0.6 % REFRESH OPTIVE 2 OTC STERILE 2 OTC OPHTHALMIC LUBRICANT (EYE) DROPS,GEL OPHTHALMIC 1-0.9 % (EYE) DROPS, REFRESH OPTIVE 2 OTC LIQUID GEL 0.7 % SENSITIVE (PF) SYSTANE 2 OTC OPHTHALMIC (PROPYLENE (EYE) GLYCOL) DROPPERETTE OPHTHALMIC 0.5-0.9 % (EYE) DROPS 0.4- REFRESH 2 OTC 0.3 % RELIEVA PF SYSTANE GEL 2 OTC OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.5- (EYE) DROPS,GEL 0.9 % 0.4-0.3 % RESTASIS 2 PA SYSTANE GEL 2 OTC MULTIDOSE OPHTHALMIC OPHTHALMIC (EYE) GEL 0.3 % (EYE) DROPS 0.05 SYSTANE ULTRA 2 OTC % OPHTHALMIC RESTASIS 2 PA; QL (60 (EYE) DROPS 0.4- OPHTHALMIC per 23 days) 0.3 % (EYE) TETRACAINE 2 DROPPERETTE HCL (PF) 0.05 % OPHTHALMIC restore plus 2 OTC (EYE) DROPS 0.5 (cmcellulose) % ophthalmic (eye) THERATEARS 2 OTC dropperette 0.5 % OPHTHALMIC revive plus 2 OTC (EYE) ophthalmic (eye) DROPPERETTE dropperette 0.5 % 0.25 % ultra fresh 2 OTC ophthalmic (eye) drops 0.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 186 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ULTRA 2 OTC acetazolamide oral 2 LUBRICANT EYE capsule, extended OPHTHALMIC release 500 mg (EYE) DROPS 0.4- acetazolamide oral 2 0.3 % tablet 125 mg, 250 TIRED 2 OTC mg EYE RELIEF methazolamide oral 2 OPHTHALMIC tablet 25 mg, 50 mg (EYE) DROPS 1- 0.36-0.2 % OTHER GLAUCOMA DRUGS VISUDYNE 2 SP AZOPT 2 ST INTRAVENOUS OPHTHALMIC RECON SOLN 15 (EYE) MG DROPS,SUSPENSI ON 1 % wal-zyr (ketotifen) 2 OTC ophthalmic (eye) bimatoprost 2 ST drops 0.025 % ophthalmic (eye) (0.035 %) drops 0.03 % XIIDRA 2 PA; QL (2 per brinzolamide 2 ST OPHTHALMIC 1 day) ophthalmic (eye) (EYE) drops,suspension 1 DROPPERETTE 5 % % COMBIGAN 2 ST NON-STEROIDAL ANTI- OPHTHALMIC

INFLAMMATORY AGENTS (EYE) DROPS 0.2- 0.5 % bromfenac 2 ST ophthalmic (eye) dorzolamide 2 drops 0.09 % ophthalmic (eye) drops 2 % diclofenac sodium 2 ophthalmic (eye) dorzolamide-timolol 2 drops 0.1 % ophthalmic (eye) drops 22.3-6.8 flurbiprofen sodium 2 mg/ml ophthalmic (eye) drops 0.03 % latanoprost 2 ophthalmic (eye) ketorolac 2 ST drops 0.005 % ophthalmic (eye) drops 0.4 %, 0.5 % LUMIGAN 2 ST OPHTHALMIC ORAL DRUGS FOR GLAUCOMA (EYE) DROPS 0.01 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 187 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits miostat intraocular 2 neomycin- 2 solution 0.01 % polymyxin-hc RHOPRESSA 2 PA; QL (5 per ophthalmic (eye) OPHTHALMIC 23 days) drops,suspension (EYE) DROPS 0.02 3.5-10,000-10 mg- % unit-mg/ml SIMBRINZA 2 ST neo-polycin hc 2 OPHTHALMIC ophthalmic (eye) (EYE) ointment 3.5-400- DROPS,SUSPENSI 10,000 mg-unit/g- ON 1-0.2 % 1% travoprost 2 ST PRED-G 2 OPHTHALMIC ophthalmic (eye) drops 0.004 % (EYE) DROPS,SUSPENSI ZIOPTAN (PF) 2 ON 0.3-1 % OPHTHALMIC (EYE) PRED-G S.O.P. 2 DROPPERETTE OPHTHALMIC 0.0015 % (EYE) OINTMENT 0.3-0.6 % STEROID-ANTIBIOTIC tobramycin- 2 COMBINATIONS dexamethasone neomycin- 2 ophthalmic (eye) bacitracin-poly-hc drops,suspension ophthalmic (eye) 0.3-0.1 % ointment 3.5-400- STEROIDS 10,000 mg-unit/g- 1% dexamethasone 2 sodium phosphate neomycin-polymyxin 2 ophthalmic (eye) b-dexameth drops 0.1 % ophthalmic (eye) drops,suspension DUREZOL 2 ST 3.5mg/ml-10,000 OPHTHALMIC unit/ml-0.1 % (EYE) DROPS 0.05 % neomycin-polymyxin 2 b-dexameth FLAREX 2 ophthalmic (eye) OPHTHALMIC ointment 3.5 mg/g- (EYE) 10,000 unit/g-0.1 % DROPS,SUSPENSI ON 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 188 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluorometholone 2 prednisolone sodium 2 ophthalmic (eye) phosphate drops,suspension 0.1 ophthalmic (eye) % drops 1 % FML FORTE 2 STEROID-SULFONAMIDE

OPHTHALMIC COMBINATIONS (EYE) DROPS,SUSPENSI sulfacetamide- 2 ON 0.25 % prednisolone ophthalmic (eye) FML S.O.P. 2 drops 10 %-0.23 % OPHTHALMIC (0.25 %) (EYE) OINTMENT 0.1 % SULFONAMIDES LOTEMAX 2 ST sulfacetamide 2 OPHTHALMIC sodium ophthalmic (EYE) DROPS,GEL (eye) drops 10 % 0.5 % sulfacetamide 2 loteprednol 2 ST sodium ophthalmic etabonate (eye) ointment 10 % ophthalmic (eye) SYMPATHOMIMETICS drops,gel 0.5 % ALPHAGAN P 2 ST MAXIDEX 2 OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.1 (EYE) % DROPS,SUSPENSI ON 0.1 % apraclonidine 2 ophthalmic (eye) PRED FORTE 2 drops 0.5 % OPHTHALMIC (EYE) brimonidine 2 ST DROPS,SUSPENSI ophthalmic (eye) ON 1 % drops 0.15 % PRED MILD 2 brimonidine 2 OPHTHALMIC ophthalmic (eye) (EYE) drops 0.2 % DROPS,SUSPENSI IOPIDINE 2 ON 0.12 % OPHTHALMIC prednisolone acetate 2 (EYE) ophthalmic (eye) DROPPERETTE 1 drops,suspension 1 % % VASOCONSTRICTOR

DECONGESTANTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 189 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CYCLOMYDRIL 2 all day allergy 2 OTC OPHTHALMIC () oral (EYE) DROPS 0.2-1 solution 1 mg/ml % all day allergy 2 OTC phenylephrine hcl 2 (cetirizine) oral ophthalmic (eye) tablet 10 mg drops 10 %, 2.5 % all day allergy-d 2 OTC RESPIRATORY AND oral tablet extended release 12 hr 5-120

ALLERGY mg ANTIHISTAMINE / aller-chlor oral 2 OTC ANTIALLERGENIC AGENTS tablet 4 mg 12 hour 2 OTC allerclear d-12hr 2 OTC decongestant oral oral tablet extended tablet extended release 12 hr 5-120 release 120 mg mg 12 hour nasal 2 OTC allerclear d-24hr 2 OTC decongest (pse) oral oral tablet extended tablet extended release 24 hr 10-240 release 120 mg mg 24hour allergy oral 2 OTC allerclear oral tablet 2 OTC tablet 10 mg 10 mg 24hr allergy relief 2 OTC aller-ease oral tablet 2 ST; OTC oral tablet 5 mg 180 mg, 60 mg adrenalin injection 2 aller-fex oral tablet 2 ST; OTC solution 1 mg/ml, 1 180 mg mg/ml (1 ml) aller-g-time oral 2 OTC alavert d-12 allergy- 2 OTC tablet 25 mg sinus oral tablet extended release 12 allergy 2 OTC hr 5-120 mg (chlorpheniramine) oral tablet 4 mg alavert oral 2 OTC tablet,disintegrating allergy 2 OTC 10 mg (diphenhydramine) oral capsule 25 mg aler-cap oral 2 OTC capsule 25 mg allergy 2 OTC (diphenhydramine) alka-seltzer plus 2 OTC oral liquid 12.5 mg/5 allergy oral tablet ml 25 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 190 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits allergy 2 OTC allergy relief 2 OTC (diphenhydramine) (levocetirizin) oral oral tablet 25 mg tablet 5 mg allergy 4-hour oral 2 OTC allergy relief 2 OTC tablet 4 mg (loratadine) oral allergy and 2 OTC solution 5 mg/5 ml congestion relief allergy relief 2 OTC oral tablet extended (loratadine) oral release 12 hr 5-120 tablet 10 mg mg allergy relief 2 OTC allergy and 2 OTC (loratadine) oral congestion relief tablet,disintegrating oral tablet extended 10 mg release 24 hr 10-240 allergy relief d12 2 OTC mg oral tablet extended allergy complete-d 2 OTC release 12 hr 5-120 oral tablet extended mg release 12 hr 5-120 allergy relief d-24hr 2 OTC mg oral tablet extended allergy medication 2 OTC release 24 hr 10-240 oral capsule 25 mg mg allergy medicine 2 OTC allergy 2 OTC oral tablet 25 mg relief(chlorpheniram allergy oral liquid 2 OTC n) oral tablet 4 mg 12.5 mg/5 ml allergy 2 OTC allergy plus severe 2 OTC relief(diphenhydrami sinus ha oral tablet n) oral capsule 25 25-5-325 mg mg allergy relief 2 OTC allergy 2 OTC (cetirizine) oral relief(diphenhydrami capsule 10 mg n) oral liquid 12.5 mg/5 ml allergy relief 2 OTC (cetirizine) oral allergy 2 OTC solution 1 mg/ml relief(diphenhydrami n) oral tablet 25 mg allergy relief 2 OTC (cetirizine) oral allergy relief,nasal 2 OTC tablet 10 mg decongest oral tablet extended release 24 allergy relief 2 ST; OTC hr 10-240 mg (fexofenadine) oral tablet 180 mg, 60 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 191 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits allergy relief-d 2 OTC benzonatate oral 2 (cetirizine) oral capsule 100 mg, 150 tablet extended mg, 200 mg release 12 hr 5-120 carbinoxamine 2 mg maleate oral liquid 4 allergy relief-d 2 OTC mg/5 ml (loratadine) oral carbinoxamine 2 tablet extended maleate oral tablet 4 release 12 hr 5-120 mg mg cetiri-d oral tablet 2 OTC allergy relief- 2 ST; OTC extended release 12 d(fexofenadine) oral hr 5-120 mg tablet extended release 12 hr 60-120 cetirizine oral 2 mg solution 1 mg/ml allergy-congest 2 ST; OTC cetirizine oral 2 OTC relief-d(fexo) oral solution 5 mg/5 ml tablet extended cetirizine oral tablet 2 OTC release 12 hr 60-120 10 mg, 5 mg mg cetirizine oral 2 OTC allergy-congestion 2 OTC tablet,chewable 10 relief-d oral tablet mg, 5 mg extended release 24 hr 10-240 mg cetirizine- 2 OTC allergy-time oral 2 OTC oral tablet extended tablet 4 mg release 12 hr 5-120 aller-tec d oral 2 OTC mg tablet extended child allergy 2 OTC release 12 hr 5-120 relf(cetirizine) oral mg solution 1 mg/ml aller-tec oral tablet 2 OTC child allergy relief 2 OTC 10 mg (diphen) oral ap-hist dm oral 2 OTC tablet,disintegrating liquid 4-7.5-15 mg/5 12.5 mg ml children's allegra 2 ST; OTC banophen oral 2 OTC allergy oral capsule 25 mg, 50 suspension 30 mg/5 mg ml banophen oral tablet 2 OTC 25 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 192 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits children's allegra 2 ST; OTC children's wal-dryl 2 OTC allergy oral allergy oral tablet,disintegrating tablet,disintegrating 30 mg 12.5 mg children's allergy 2 OTC children's wal-zyr 2 OTC (diphenhyd) oral oral solution 1 liquid 12.5 mg/5 ml mg/ml children's allergy 2 OTC children's wal-zyr 2 OTC (diphenhyd) oral oral tablet,chewable tablet,chewable 12.5 10 mg mg child's all day 2 OTC children's allergy 2 OTC allergy(cetir) oral relief(lor) oral solution 1 mg/ml solution 5 mg/5 ml chlorhist oral tablet 2 OTC children's 2 OTC 4 mg allergy(cetirizine) chlorpheniramine 2 OTC oral solution 1 maleate oral tablet 4 mg/ml mg children's 2 OTC chlorpheniramine 2 OTC allergy oral maleate oral tablet tablet,chewable 12.5 extended release 12 mg mg children's cetirizine 2 OTC chlortabs oral tablet 2 OTC oral solution 1 4 mg mg/ml CLARITIN 2 OTC children's cetirizine 2 OTC REDITABS ORAL oral tablet,chewable TABLET,DISINTE 10 mg, 5 mg GRATING 5 MG children's 2 OTC clemastine oral 2 diphenhydramine tablet 2.68 mg oral liquid 12.5 mg/5 ml complete allergy 2 OTC medicine oral children's wal-dryl 2 OTC capsule 25 mg allergy oral liquid 12.5 mg/5 ml complete allergy 2 OTC medicine oral tablet children's wal-dryl 2 OTC 25 mg allergy oral prefilled spoon 12.5 mg/5 ml complete allergy 2 OTC oral tablet 25 mg cyproheptadine oral 2 syrup 2 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 193 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cyproheptadine oral 2 ed chlorped jr oral 2 OTC tablet 4 mg syrup 2 mg/5 ml daytime-nighttime 2 OTC EPINEPHRINE 2 QL (4 per 23 oral capsule, INJECTION AUTO- days) sequential 10-5- INJECTOR 0.15 325mg(d)/ 15-325- MG/0.15 ML 6.25mg epinephrine 2 QL (4 per 23 desloratadine oral 2 ST injection auto- days) tablet 5 mg injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml desloratadine oral 2 ST tablet,disintegrating fexofenadine oral 2 ST; OTC 2.5 mg, 5 mg tablet 180 mg, 60 mg despec eda cough- 2 OTC fexofenadine- 2 ST; OTC cold drops oral pseudoephedrine drops 2.5-5-50 oral tablet extended mg/ml release 12 hr 60-120 diphedryl allergy 2 OTC mg oral liquid 12.5 mg/5 geri-dryl oral liquid 2 OTC ml 12.5 mg/5 ml diphedryl oral liquid 2 OTC geri-dryl oral tablet 2 OTC 12.5 mg/5 ml 25 mg diphen oral tablet 25 2 OTC HYDROXYZINE 2 mg HCL ORAL diphenhist oral 2 OTC SOLUTION 10 capsule 25 mg MG/5 ML diphenhydramine hcl 2 OTC hydroxyzine hcl oral 2 oral capsule 25 mg tablet 10 mg, 25 mg, 50 mg diphenhydramine hcl 2 hydroxyzine 2 oral capsule 50 mg pamoate oral diphenhydramine hcl 2 capsule 100 mg, 25 oral elixir 12.5 mg/5 mg, 50 mg ml KARBINAL ER 2 diphenhydramine hcl 2 OTC ORAL oral liquid 12.5 mg/5 SUSPENSION,EXT ml ENDED REL 12 HR diphenhydramine hcl 2 OTC 4 MG/5 ML oral tablet 25 mg levocetirizine oral 2 ed a-hist dm oral 2 OTC tablet 5 mg liquid 4-10-15 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 194 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits loradamed oral 2 OTC nighttime sleep aid 2 OTC tablet 10 mg (diphen) oral lorata-d oral tablet 2 OTC capsule 50 mg extended release 24 nighttime sleep aid 2 OTC hr 10-240 mg (diphen) oral tablet lorata-dine d oral 2 OTC 25 mg tablet extended nohist-dm oral liquid 2 OTC release 24 hr 10-240 4-10-15 mg/5 ml mg pharbechlor oral 2 OTC loratadine oral 2 OTC tablet 4 mg solution 5 mg/5 ml pharbedryl oral 2 OTC loratadine oral 2 OTC capsule 25 mg, 50 tablet 10 mg mg loratadine oral 2 OTC promethazine oral 2 tablet,disintegrating syrup 6.25 mg/5 ml 10 mg promethazine oral 2 loratadine-d oral 2 OTC tablet 12.5 mg, 25 tablet extended mg, 50 mg release 12 hr 5-120 promethazine rectal 2 mg suppository 12.5 mg, loratadine-d oral 2 OTC 25 mg, 50 mg tablet extended promethazine vc oral 2 release 24 hr 10-240 syrup 6.25-5 mg/5 mg ml m-dryl oral liquid 2 OTC promethazine vc- 2 12.5 mg/5 ml codeine oral syrup nasal decongestant 2 OTC 6.25-5-10 mg/5 ml (pseudoeph) oral promethazine- 2 tablet 30 mg codeine oral syrup nasal decongestant 2 OTC 6.25-10 mg/5 ml (pseudoeph) oral promethazine-dm 2 tablet extended oral syrup 6.25-15 release 120 mg mg/5 ml nightime sleep oral 2 OTC promethazine- 2 capsule 50 mg phenyleph-codeine nighttime allergy 2 OTC oral syrup 6.25-5-10 relief oral tablet 25 mg/5 ml mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 195 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits promethazine- 2 sudogest oral tablet 2 OTC phenylephrine oral 30 mg, 60 mg syrup 6.25-5 mg/5 suphedrin oral tablet 2 OTC ml 30 mg promethegan rectal 2 suphedrine 12 hour 2 OTC suppository 12.5 mg, oral tablet extended 25 mg, 50 mg release 120 mg pseudoephedrine hcl 2 OTC suphedrine oral 2 OTC oral tablet 30 mg, 60 tablet 30 mg mg supress dx oral 2 OTC pseudoephedrine hcl 2 OTC drops 2.5-5-50 oral tablet extended mg/ml release 120 mg SYMJEPI 2 QL (4 per 23 siladryl sa oral 2 OTC INJECTION days) liquid 12.5 mg/5 ml SYRINGE 0.15 simply sleep oral 2 OTC MG/0.3 ML, 0.3 tablet 25 mg MG/0.3 ML sinus 12 hour oral 2 OTC total allergy 2 OTC tablet extended medicine oral tablet release 120 mg 25 mg sleep aid 2 OTC unisom sleepgels 2 OTC (diphenhydramine) oral capsule 50 mg oral capsule 50 mg valu-dryl allergy 2 OTC sleep aid 2 OTC oral capsule 25 mg (diphenhydramine) wal-dryl allergy oral 2 OTC oral tablet 25 mg capsule 25 mg sleep aid max str 2 OTC wal-dryl allergy oral 2 OTC (diphenhydr) oral liquid 12.5 mg/5 ml capsule 50 mg wal-dryl allergy oral 2 OTC sleep ii oral tablet 2 OTC tablet 25 mg 25 mg wal-dryl severe 2 OTC sleep tablet 2 OTC allergy-sinus oral (diphenhydramine) tablet 25-5-325 mg oral tablet 25 mg wal-dryl-d allergy 2 OTC sleep-tabs oral tablet 2 OTC and sinus oral tablet 25 mg 25-10 mg sudogest 12-hour 2 OTC wal-fex allergy oral 2 ST; OTC oral tablet extended tablet 180 mg, 60 mg release 120 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 196 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits wal-fex d 12 hour 2 ST; OTC wal-zyr (cetirizine) 2 OTC oral tablet extended oral tablet 10 mg release 12 hr 60-120 wal-zyr d oral tablet 2 OTC mg extended release 12 wal-fex d 24 hour 2 ST; OTC hr 5-120 mg oral tablet extended

release 24 hr 180- PULMONARY AGENTS 240 mg acetylcysteine 2 solution 100 mg/ml wal-finate oral tablet 2 OTC (10 %), 200 mg/ml 4 mg (20 %) wal-itin d 12 hour 2 OTC ADEMPAS ORAL 2 PA; SP oral tablet extended TABLET 0.5 MG, 1 release 12 hr 5-120 MG, 1.5 MG, 2 MG, mg 2.5 MG wal-itin d oral tablet 2 OTC ADRENALIN 2 extended release 24 NASAL hr 10-240 mg SOLUTION 1 wal-itin oral solution 2 OTC MG/ML 5 mg/5 ml ADVAIR DISKUS 1 QL (1 per 23 wal-itin oral tablet 2 OTC INHALATION days) 10 mg BLISTER WITH wal-phed 12 hour 2 OTC DEVICE 100-50 oral tablet extended MCG/DOSE, 250-50 release 120 mg MCG/DOSE, 500-50 MCG/DOSE wal-phed d oral 2 OTC tablet extended ADVAIR HFA 1 QL (1 per 23 release 120 mg INHALATION HFA days) AEROSOL wal-phed oral tablet 2 OTC INHALER 115-21 30 mg MCG/ACTUATION wal-phed pe 2 OTC , 230-21 nighttime cold oral MCG/ACTUATION tablet 25-5-325 mg , 45-21 MCG/ACTUATION wal-som 2 OTC (diphenhydramine) albuterol sulfate 1 oral capsule 50 mg inhalation solution for nebulization 0.63 wal-zyr (cetirizine) 2 OTC mg/3 ml, 1.25 mg/3 oral capsule 10 mg ml, 2.5 mg /3 ml wal-zyr (cetirizine) 2 OTC (0.083 %), 2.5 oral solution 1 mg/0.5 ml, 5 mg/ml mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 197 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits albuterol sulfate oral 1 ASMANEX HFA 1 syrup 2 mg/5 ml INHALATION HFA albuterol sulfate oral 2 AEROSOL tablet 2 mg, 4 mg INHALER 100 MCG/ACTUATION albuterol sulfate oral 2 , 200 tablet extended MCG/ACTUATION release 12 hr 4 mg, 8 , 50 mg MCG/ACTUATION aller-flo nasal 2 OTC ASMANEX 1 PA spray,suspension 50 TWISTHALER mcg/actuation INHALATION ALVESCO 1 PA; QL (12.2 AEROSOL POWDR INHALATION HFA per 23 days) BREATH AEROSOL ACTIVATED 110 INHALER 160 MCG/ MCG/ACTUATION ACTUATION (30), , 80 220 MCG/ MCG/ACTUATION ACTUATION (120), 220 MCG/ ambrisentan oral 2 PA; SP ACTUATION (30), tablet 10 mg, 5 mg 220 MCG/ ANORO ELLIPTA 2 ACTUATION (60) INHALATION ASMANEX 1 BLISTER WITH TWISTHALER DEVICE 62.5-25 INHALATION MCG/ACTUATION AEROSOL POWDR ARNUITY 1 PA; QL (30 BREATH ELLIPTA per 23 days) ACTIVATED 220 INHALATION MCG/ BLISTER WITH ACTUATION (14) DEVICE 100 ATROVENT HFA 2 MCG/ACTUATION INHALATION HFA , 200 AEROSOL MCG/ACTUATION INHALER 17 , 50 MCG/ACTUATION MCG/ACTUATION azelastine- 2 ST fluticasone nasal spray,non-aerosol 137-50 mcg/spray

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 198 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BECONASE AQ 2 ST CINRYZE 2 PA; SP; QL NASAL INTRAVENOUS (16 per 23 SPRAY,NON- RECON SOLN 500 days) AEROSOL 42 MCG UNIT (5 ML) (0.042 %) COMBIVENT 2 BERINERT 2 PA; SP RESPIMAT INTRAVENOUS INHALATION KIT 500 UNIT (10 MIST 20-100 ML) MCG/ACTUATION BEVESPI 2 QL (1 per 23 cromolyn inhalation 2 AEROSPHERE days) solution for INHALATION HFA nebulization 20 mg/2 AEROSOL ml INHALER 9-4.8 DALIRESP ORAL 2 PA MCG TABLET 250 MCG, oral tablet 2 PA; SP 500 MCG 125 mg, 62.5 mg DULERA 1 QL (1 per 23 BREO ELLIPTA 1 PA; QL (1 per INHALATION HFA days) INHALATION 23 days) AEROSOL BLISTER WITH INHALER 100-5 DEVICE 100-25 MCG/ACTUATION MCG/DOSE, 200-25 , 200-5 MCG/DOSE MCG/ACTUATION BROVANA 2 , 50-5 INHALATION MCG/ACTUATION SOLUTION FOR ESBRIET ORAL 2 PA; SP; QL NEBULIZATION CAPSULE 267 MG (270 per 23 15 MCG/2 ML days) budesonide 1 PA; QL (120 ESBRIET ORAL 2 PA; SP; QL inhalation per 23 days) TABLET 267 MG, (270 per 23 suspension for 801 MG days) nebulization 0.25 FASENRA PEN 1 PA; SP mg/2 ml, 0.5 mg/2 SUBCUTANEOUS ml, 1 mg/2 ml AUTO-INJECTOR budesonide nasal 2 OTC 30 MG/ML spray,non-aerosol FASENRA 1 PA; SP 32 mcg/actuation SUBCUTANEOUS CINQAIR 1 PA; SP SYRINGE 30 INTRAVENOUS MG/ML SOLUTION 10 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 199 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLOVENT DISKUS 1 icatibant 2 PA; SP INHALATION subcutaneous BLISTER WITH syringe 30 mg/3 ml DEVICE 100 INCRUSE 1 MCG/ACTUATION ELLIPTA , 250 INHALATION MCG/ACTUATION BLISTER WITH , 50 DEVICE 62.5 MCG/ACTUATION MCG/ACTUATION FLOVENT HFA 1 ipratropium bromide 2 INHALATION HFA inhalation solution AEROSOL 0.02 % INHALER 110 MCG/ACTUATION ipratropium- 2 QL (18 per 1 , 220 albuterol inhalation day) MCG/ACTUATION solution for , 44 nebulization 0.5 mg- MCG/ACTUATION 3 mg(2.5 mg base)/3 ml flunisolide nasal 2 ST spray,non-aerosol KALBITOR 2 PA; SP 25 mcg (0.025 %) SUBCUTANEOUS SOLUTION 10 fluticasone 2 OTC MG/ML (1 ML) propionate nasal spray,suspension 50 KALYDECO ORAL 1 PA; SP; PrefD; mcg/actuation GRANULES IN QL (60 per 23 PACKET 25 MG, 50 days) FLUTICASONE 1 PA; QL (1 per MG, 75 MG PROPION- 23 days) SALMETEROL KALYDECO ORAL 1 PA; SP; PrefD; INHALATION TABLET 150 MG QL (60 per 23 AEROSOL POWDR days) BREATH levalbuterol hcl 1 PA ACTIVATED 113- inhalation solution 14 for nebulization 1.25 MCG/ACTUATION mg/0.5 ml, 1.25 mg/3 , 232-14 ml MCG/ACTUATION , 55-14 LONHALA 1 PA; QL (60 MCG/ACTUATION MAGNAIR REFILL per 23 days) INHALATION HAEGARDA 2 PA; SP SOLUTION FOR SUBCUTANEOUS NEBULIZATION RECON SOLN 25 MCG/ML 2,000 UNIT, 3,000 UNIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 200 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LONHALA 1 PA; QL (60 OPSUMIT ORAL 2 PA; SP MAGNAIR per 23 days) TABLET 10 MG STARTER ORKAMBI ORAL 1 PA; SP; PrefD; INHALATION GRANULES IN QL (2 per 1 SOLUTION FOR PACKET 100-125 day) NEBULIZATION MG, 150-188 MG 25 MCG/ML ORKAMBI ORAL 1 PA; SP; PrefD; metaproterenol oral 2 TABLET 100-125 QL (120 per syrup 10 mg/5 ml MG, 200-125 MG 23 days) mometasone nasal 2 ST PERFOROMIST 2 spray,non-aerosol INHALATION 50 mcg/actuation SOLUTION FOR montelukast oral 2 ST NEBULIZATION granules in packet 4 20 MCG/2 ML mg PROAIR 1 PA montelukast oral 2 DIGIHALER tablet 10 mg INHALATION montelukast oral 2 AERO POWDR tablet,chewable 4 BREATH ACT mg, 5 mg W/SENSOR 90 MCG/ACTUATION nasal allergy nasal 2 OTC; QL (1 aerosol,spray 55 per 23 days) PROAIR HFA 1 mcg INHALATION HFA AEROSOL nebusal inhalation 2 INHALER 90 solution for MCG/ACTUATION nebulization 3 % PROAIR 1 NUCALA 1 PA; SP RESPICLICK SUBCUTANEOUS INHALATION AUTO-INJECTOR AEROSOL POWDR 100 MG/ML BREATH NUCALA 1 PA; SP ACTIVATED 90 SUBCUTANEOUS MCG/ACTUATION RECON SOLN 100 PULMICORT 1 MG FLEXHALER NUCALA 1 PA; SP INHALATION SUBCUTANEOUS AEROSOL POWDR SYRINGE 100 BREATH MG/ML ACTIVATED 180 MCG/ACTUATION OFEV ORAL 2 PA; SP; QL , 90 CAPSULE 100 MG, (60 per 23 MCG/ACTUATION 150 MG days) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 201 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PULMOZYME 2 SP SPIRIVA 1 INHALATION RESPIMAT SOLUTION 1 INHALATION MG/ML MIST 1.25 QNASL NASAL 2 ST MCG/ACTUATION HFA AEROSOL , 2.5 INHALER 40 MCG/ACTUATION MCG/ACTUATION SPIRIVA WITH 1 QL (1 per 1 , 80 HANDIHALER day) MCG/ACTUATION INHALATION QVAR 1 PA; QL (2 per CAPSULE, REDIHALER 23 days) W/INHALATION INHALATION HFA DEVICE 18 MCG AEROSOL STRIVERDI 2 QL (4 per 23 BREATH RESPIMAT days) ACTIVATED 40 INHALATION MCG/ACTUATION MIST 2.5 , 80 MCG/ACTUATION MCG/ACTUATION SYMBICORT 1 QL (2 per 23 RUCONEST 2 PA; SP INHALATION HFA days) INTRAVENOUS AEROSOL RECON SOLN INHALER 160-4.5 2,100 UNIT MCG/ACTUATION SEREVENT 2 QL (60 per 23 , 80-4.5 MCG/ACTUATION DISKUS days) INHALATION SYMDEKO ORAL 1 PA; SP; PrefD; BLISTER WITH TABLETS, QL (60 per 23 DEVICE 50 SEQUENTIAL 100- days) MCG/DOSE 150 MG (D)/ 150 sildenafil 2 PA; SP MG (N), 50-75 MG (pulm.hypertension) (D)/ 75 MG (N) intravenous solution TAKHZYRO 2 PA; SP 10 mg/12.5 ml SUBCUTANEOUS sildenafil 2 PA; SP SOLUTION 300 (pulm.hypertension) MG/2 ML (150 oral tablet 20 mg MG/ML) sodium chloride 2 terbutaline oral 2 inhalation solution tablet 2.5 mg, 5 mg for nebulization 0.9 %, 10 %, 3 %, 7 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 202 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits THEO-24 ORAL 2 XOLAIR 1 PA; SP CAPSULE,EXTEN SUBCUTANEOUS DED RELEASE RECON SOLN 150 24HR 300 MG, 400 MG MG XOLAIR 1 PA; SP theophylline oral 2 SUBCUTANEOUS elixir 80 mg/15 ml SYRINGE 150 theophylline oral 2 MG/ML, 75 MG/0.5 solution 80 mg/15 ml ML XOPENEX HFA 1 theophylline oral 2 tablet extended INHALATION HFA release 12 hr 300 AEROSOL INHALER 45 mg, 450 mg MCG/ACTUATION theophylline oral 2 tablet extended YUPELRI 1 PA; QL (90 release 24 hr 400 INHALATION per 23 days) mg, 600 mg SOLUTION FOR NEBULIZATION TRACLEER ORAL 2 PA; SP 175 MCG/3 ML TABLET FOR SUSPENSION 32 zafirlukast oral 2 ST MG tablet 10 mg, 20 mg triamcinolone 2 OTC; QL (1 UROLOGICALS acetonide nasal per 23 days) ANTICHOLINERGICS / aerosol,spray 55 ANTISPASMODICS mcg flavoxate oral tablet 2 TRIKAFTA ORAL 1 PA; SP; PrefD; 100 mg TABLETS, QL (84 per 21 SEQUENTIAL 100- days) MYRBETRIQ 2 ST; QL (30 per 50-75 MG(D) /150 ORAL TABLET 23 days) MG (N) EXTENDED RELEASE 24 HR TRIKAFTA ORAL 1 SP; PrefD; QL 25 MG, 50 MG TABLETS, (3 per 1 day) SEQUENTIAL 50- oxybutynin chloride 2 25-37.5 MG (D)/75 oral syrup 5 mg/5 ml MG (N) oxybutynin chloride 2 TUDORZA 1 oral tablet 5 mg PRESSAIR oxybutynin chloride 2 INHALATION oral tablet extended AEROSOL POWDR release 24hr 10 mg, BREATH 15 mg ACTIVATED 400 MCG/ACTUATION You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 203 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxybutynin chloride 2 QL (30 per 23 CYSTAGON ORAL 2 SP oral tablet extended days) CAPSULE 150 MG, release 24hr 5 mg 50 MG solifenacin oral 2 ST; QL (30 per cytra-k oral solution 2 OTC tablet 10 mg, 5 mg 23 days) 1,100-334 mg/5 ml tolterodine oral 2 ELMIRON ORAL 2 capsule,extended CAPSULE 100 MG release 24hr 2 mg glycine urologic 2 tolterodine oral 2 QL (30 per 23 irrigation solution capsule,extended days) 1.5 % release 24hr 4 mg glycine urologic 2 tolterodine oral 2 solution irrigation tablet 1 mg, 2 mg solution 1.5 % trospium oral 2 QL (30 per 23 hyophen oral tablet 2 capsule,extended days) 81.6-0.12-10.8 mg release 24hr 60 mg K-PHOS NO 2 2 trospium oral tablet 2 ORAL TABLET 20 mg 305-700 MG BENIGN PROSTATIC K-PHOS 2

HYPERPLASIA(BPH) THERAPY ORIGINAL ORAL TABLET,SOLUBL alfuzosin oral tablet 2 QL (30 per 23 E 500 MG extended release 24 days) hr 10 mg ORACIT ORAL 2 SOLUTION 490- dutasteride oral 2 PA 640 MG/5 ML capsule 0.5 mg phosphasal oral 2 dutasteride- 2 PA; QL (30 tablet 81.6-10.8-40.8 tamsulosin oral per 23 days) mg capsule, er multiphase 24 hr pot,sodium citrate- 2 OTC 0.5-0.4 mg citric acid oral solution 550-500- finasteride oral 2 QL (30 per 23 334 mg/5 ml tablet 5 mg days) potassium citrate 2 tamsulosin oral 2 oral tablet extended capsule 0.4 mg release 10 meq CHOLINERGIC STIMULANTS (1,080 mg), 15 meq, 5 meq (540 mg) bethanechol chloride 2 oral tablet 10 mg, 25 mg, 5 mg, 50 mg MISCELLANEOUS UROLOGICALS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 204 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits potassium citrate- 2 OTC VITAMINS, HEMATINICS / citric acid oral

solution 1,100-334 ELECTROLYTES mg/5 ml ELECTROLYTES RENACIDIN 2 alcalak oral 2 OTC IRRIGATION tablet,chewable 168 SOLUTION 1980.6 mg calcium (420 MG-59.4 MG- mg) 980.4MG/30ML antacid (calcium 2 OTC tadalafil oral tablet 2 PA carbonate) oral 5 mg tablet,chewable 200 tricitrates oral 2 OTC mg calcium (500 solution 550-500- mg), 215 mg calcium 334 mg/5 ml (500 mg), 320 mg calcium (750 mg) uretron d-s oral 2 tablet 81.6-10.8-40.8 antacid ext str 2 OTC mg (calcium carb) oral tablet,chewable 300 URIBEL ORAL 2 mg (750 mg) CAPSULE 118-10- 40.8-36 MG antacid extra- 2 OTC strength oral urimar-t oral tablet 2 tablet,chewable 168 120-0.12-10.8 mg mg calcium (420 uryl oral tablet 81.6- 2 mg), 300 mg (750 40.8-0.12 mg mg) ustell oral capsule 2 antacid ultra 2 OTC 120-0.12 mg strength oral tablet,chewable 400 utira-c oral tablet 2 mg calcium (1,000 81.6-10.8-40.8 mg mg), 430 mg calcium virtrate-3 oral 2 OTC (1,000 mg) solution 550-500- CAL-CITRATE 2 OTC 334 mg/5 ml ORAL TABLET virtrate-k oral 2 OTC 250 MG-2.5 MCG solution 1,100-334 (100 UNIT) mg/5 ml calcium 500 + d oral 2 OTC URINARY ANESTHETICS tablet 500 mg(1,250mg) -200 phenazopyridine 2 unit oral tablet 100 mg, 200 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 205 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits calcium 500 + d oral 2 OTC CALCIUM AMINO 2 OTC tablet,chewable 500 ACID CHELATE mg(1,250mg) -400 ORAL TABLET unit 200 MG CALCIUM calcium 500 with d 2 OTC calcium antacid oral 2 OTC oral tablet 500 tablet,chewable 200 mg(1,250mg) -400 mg calcium (500 unit mg), 300 mg (750 calcium 600 + d(3) 2 OTC mg), 320 mg calcium oral capsule 600 mg (750 mg), 400 mg calcium- 200 unit calcium (1,000 mg), 430 mg calcium calcium 600 + d(3) 2 OTC (1,000 mg) oral tablet 600 mg(1,500mg) -400 calcium carbonate 2 OTC unit oral suspension 500 mg/5 ml (1,250 mg/5 calcium 600 oral 2 OTC ml) tablet 600 mg calcium (1,500 mg) calcium carbonate 2 OTC oral tablet 260 mg calcium 600 with 2 OTC calcium (648 mg), vitamin d3 oral 500 mg calcium capsule 600 (1,250 mg), 600 mg mg(1,500mg) -500 calcium (1,500 mg) unit calcium carbonate 2 OTC calcium 600 with 2 OTC oral tablet,chewable vitamin d3 oral 200 mg calcium (500 tablet,chewable 600 mg), 300 mg (750 mg(1,500mg) -400 mg), 400 mg calcium unit (1,000 mg), 500 mg CALCIUM 2 OTC calcium (1,250 mg) ACETATE ORAL CALCIUM 2 OTC TABLET 668 MG CARBONATE (169 MG ORAL CALCIUM) TABLET,CHEWAB calcium 2 LE 260 MG acetate(phosphat CALCIUM (650 bind) oral capsule MG) 667 mg calcium 2 acetate(phosphat bind) oral tablet 667 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 206 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CALCIUM 2 OTC calcium citrate + d 2 OTC CARBONATE- oral tablet 315 mg-5 VITAMIN D3 mcg (200 unit) ORAL CAPSULE CALCIUM 2 OTC 600 MG (1,500 CITRATE ORAL MG)-2,500 UNIT, GRANULES 760 600MG (1,500MG) - MG CALCIUM /3.5 1,000 UNIT GRAM calcium carbonate- 2 OTC calcium citrate oral 2 OTC vitamin d3 oral tablet 200 mg (950 capsule 600 mg), 250 mg calcium mg(1,500mg) -400 unit calcium citrate- 2 OTC vitamin d3 oral CALCIUM 2 OTC liquid 1,000 mg-10 CARBONATE- mcg /30 ml VITAMIN D3 ORAL TABLET calcium citrate- 2 OTC 1,000 MG(2,500 vitamin d3 oral MG)-800 UNIT tablet 200 mg-3.125 mcg (125 unit), 200 calcium carbonate- 2 OTC mg-6.25 mcg (250 vitamin d3 oral unit), 250 mg-5 mcg tablet 250-125 mg- (200 unit), 315 mg-5 unit, 500 mcg (200 unit), 315 mg(1,250mg) -125 mg-6.25 mcg (250 unit, 500 unit) mg(1,250mg) -200 unit, 500 CALCIUM 2 OTC mg(1,250mg) -400 GLUCONATE unit, 500mg ORAL TABLET 50 (1,250mg) -600 unit, MG CALCIUM 600 mg(1,500mg) - CALCIUM 2 OTC 200 unit, 600 LACTATE ORAL mg(1,500mg) -400 TABLET 100 MG unit, 600 CALCIUM mg(1,500mg) -800 unit cal-gest antacid oral 2 OTC tablet,chewable 200 calcium carbonate- 2 OTC mg calcium (500 vitamin d3 oral mg) tablet,chewable 500 mg(1,250mg) -400 CAL-MINT ORAL 2 OTC unit, 500-100 mg- TABLET,CHEWAB unit LE 260 MG CALCIUM (650 MG)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 207 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CAL-QUICK ORAL 2 OTC CERASPORT 2 OTC LIQUID 500 MG ORAL POWDER IN CALCIUM- 400 PACKET 200 MG- UNIT/5 ML 75 MG-80 KCAL/20 CALTRATE 600 2 OTC GRAM PLUS D ORAL citrus calcium- 2 OTC TABLET,CHEWAB vitamin d3 oral LE 600 MG (1,500 tablet 200 mg-6.25 MG)-800 UNIT mcg (250 unit) CERALYTE 50 2 OTC DRIPDROP ORAL 2 OTC ORAL POWDER IN POWDER IN PACKET 240-300- PACKET 305-175- 32 MG-MG- 70 MG, 320-190-70 KCAL/10 G MG, 670-380-150 CERALYTE 50 2 OTC MG, 700-410-150 MG POTASSIUM FREE ORAL POWDER IN EFFER-K ORAL 2 PACKET 50-20-30 TABLET, MEQ EFFERVESCENT CERALYTE 90 2 OTC 10 MEQ, 20 MEQ ORAL PACKET 90- effer-k oral tablet, 2 80-20-30 MEQ effervescent 25 meq CERALYTE-70 2 OTC electrolytes-dextrose 2 OTC ORAL PACKET 70- oral solution 60-20-30 MEQ flavor chews antacid 2 OTC CERALYTE-70 2 OTC oral tablet,chewable ORAL POWDER IN 300 mg (750 mg) PACKET 2.3-1.5- GALZIN ORAL 2 2.9-160 G-G-G- CAPSULE 25 MG KCAL/50 G, 440- (ZINC), 50 MG 300-32 MG-MG- (ZINC) KCAL/10 G hi-cal plus vit d oral 2 OTC CERASPORT EX1 2 OTC tablet 500 ORAL POWDER IN mg(1,250mg) -200 PACKET 400-200- unit 40 MG-KCAL/12.5 G kinderlyte oral 2 OTC solution CERASPORT 2 OTC ORAL POWDER klor-con 10 oral 2 115 MG-40 MG-40 tablet extended KCAL/10.5 GRAM release 10 meq

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 208 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits klor-con 8 oral 2 NORMALYTE 2 OTC tablet extended ORAL POWDER IN release 8 meq PACKET 1-2-0.75- klor-con m10 oral 2 6.75 GRAM/10.7 tablet,er GRAM particles/crystals 10 NORMALYTE ORS 2 OTC meq ORAL POWDER IN klor-con m15 oral 2 PACKET 1.3-1.45- tablet,er 0.75 GRAM/10.5 particles/crystals 15 GRAM meq NU-MAG ORAL 2 OTC klor-con m20 oral 2 TABLET,DELAYE D RELEASE tablet,er particles/crystals 20 (DR/EC) 71.5 MG meq oralyte oral solution 2 OTC klor-con/ef oral 2 oysco 500/d oral 2 OTC tablet, effervescent tablet 500 25 meq mg(1,250mg) -200 k-phos-neutral oral 2 OTC unit tablet 250 mg oyster shell + d3 2 OTC oral tablet 250-125 MAGNESIUM 2 OTC CITRATE ORAL mg-unit TABLET 100 MG oyster shell calcium 2 OTC magnesium oral 2 OTC 500 oral tablet 500 tablet 200 mg mg calcium (1,250 mg) magnesium oxide 2 OTC oral capsule 500 mg oyster shell calcium- 2 OTC vit d3 oral tablet magnesium oxide 2 OTC 250-125 mg-unit, oral tablet 250 mg 500 mg(1,250mg) - magnesium, 400 mg 200 unit, 500 (241.3 mg mg(1,250mg) -400 magnesium), 400 mg unit magnesium, 420 mg oystercal-d oral 2 OTC MEDI-LYTE ORAL 2 OTC tablet 500 TABLET 40-18-9 mg(1,250mg) -400 MG unit mgo oral tablet 400 2 OTC pedialyte freezer 2 OTC mg (241.3 mg pops oral solution magnesium)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 209 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PEDIALYTE ORAL 2 OTC potassium chloride 2 POWDER IN oral capsule, PACKET 10.6-4.7 extended release 10 MEQ/8.5 GRAM, meq, 8 meq 10.6-4.7 MEQ/9 potassium chloride 2 GRAM oral liquid 20 pedialyte oral 2 OTC meq/15 ml, 40 solution meq/15 ml pedialyte singles 2 OTC potassium chloride 2 oral solution oral tablet extended PEDIALYTE 2 OTC release 10 meq, 20 SPARKLING meq, 8 meq RUSH ORAL potassium chloride 2 POWDER oral tablet,er EFFERVESCENT particles/crystals 10 IN PACKET 28.3 meq MEQ-18.2 MEQ- REPLACE SR 2 OTC 16.6 MEQ ORAL TABLET PEDIATRIC 2 OTC EXTENDED ELECTROLYTE RELEASE 175-65- ORAL POWDER IN 211-10 MG PACKET 10.6-4.7 SLOW-MAG ORAL 2 OTC MEQ/8.5 GRAM TABLET,DELAYE pediatric electrolyte 2 OTC D RELEASE oral solution (DR/EC) 71.5 MG pediatric freezer 2 OTC smooth antacid oral 2 OTC pops oral solution tablet,chewable 300 PHOSLYRA ORAL 2 mg (750 mg) SOLUTION 667 super calcium oral 2 OTC MG (169 MG tablet 600 mg CALCIUM)/5 ML calcium (1,500 mg) phospha 250 neutral 2 OTC thermotabs oral 2 OTC oral tablet 250 mg tablet 287-180-15 phosphorous oral 2 OTC mg tablet 250 mg tums ultra oral 2 OTC phospho-trin 250 2 OTC tablet,chewable 400 neutral oral tablet mg calcium (1,000 mg) 250 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 210 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ultra strength 2 OTC CULTURELLE 2 OTC antacid oral KIDS PROBIOTICS tablet,chewable 400 ORAL POWDER IN mg calcium (1,000 PACKET 5 mg) BILLION CELL virt-phos 250 neutral 2 OTC CULTURELLE 2 OTC oral tablet 250 mg KIDS PROBIOTICS ORAL MISCELLANEOUS NUTRITION TABLET,CHEWAB PRODUCTS LE 5 BILLION ABATREX WITH 2 OTC CELL ALA ORAL CULTURELLE 2 OTC TABLET 200-8-4- KIDS ULTIM 600 MG BALANCE ORAL acidophilus oral 2 OTC TABLET,CHEWAB capsule LE 10 BILLION CELL amino acid oral 2 OTC capsule CULTURELLE 2 OTC ORAL CAPSULE, biotect plus oral 2 OTC SPRINKLE 15 liquid BILLION CELL CALCIUM 2 OTC DOJOLVI ORAL 2 PA; SP CITRATE LIQUID 8.3 MALATE-VIT D3 KCAL/ML ORAL TABLET 250 MG-2.5 MCG ear care oral tablet 2 OTC (100 UNIT) 200-100 mg co q-10 (with vit e) 2 OTC fish oil extra 2 OTC oral capsule 100-5 strength oral capsule mg-unit, 50-5 mg- 435-880 mg unit fish oil oral capsule 2 OTC coenzyme q10- 2 OTC 100-160-1,000 mg, vitamin e oral 120-180 mg, 300- capsule 100-5 mg- 1,000 mg, 300-500 unit mg, 340-1,000 mg, 360-1,200 mg COROMEGA 2 OTC ORAL EMULSION FISH OIL ORAL 2 OTC IN PACKET 2,000- CAPSULE 183.3 650-12 MG/2.5 MG-75 MG -91.6 GRAM, 284-850 MG-306 MG, 900 MG/2.5 GRAM MG (320 MG- 580MG)-1,360 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 211 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FISH OIL ORAL 2 OTC omega 3-dha-epa- 2 OTC CAPSULE,DELAY fish oil oral capsule ED 1,000 mg (120 mg- RELEASE(DR/EC) 180 mg), 300-1,000 150-217-840 MG, mg 900-1,400 MG OMEGA 3-DHA- 2 OTC fish oil oral 2 OTC EPA-FISH OIL capsule,delayed ORAL CAPSULE release(dr/ec) 300- 100-150-750 MG, 1,000 mg, 60-90-500 356 MG (100 MG- mg 256 MG)-554 MG FISH OIL PEARLS 2 OTC omega 3-dha-epa- 2 OTC ORAL CAPSULE fish oil oral 150-400 MG, 180- capsule,delayed 400 MG release(dr/ec) 300 mg (120 mg- floranex oral tablet 2 OTC 1 million cell 180mg)-1,000 mg, 300-1,000 mg lactobacillus 2 OTC acidophilus oral OMEGA-3 (WITH 2 OTC capsule 100 million DPA) ORAL cell CAPSULE 1,050- 1,200 MG lactobacillus 2 OTC acidophilus oral OMEGA-3 2100 2 OTC tablet 0.5 mg (100 ORAL CAPSULE million cell), 1 1,050-1,200 MG billion cell omega-3 fatty acids- 2 OTC LACTOBACILLUS 2 OTC fish oil oral capsule ACIDOPHILUS 300-1,000 mg, 360- ORAL WAFER 1 1,200 mg MG OMEGA-3 FATTY 2 OTC niacin (inositol 2 OTC ACIDS-FISH OIL niacinate) oral ORAL CAPSULE 440-880 MG capsule 400 mg niacin (500 mg) OMEGA-3 FISH 2 OTC niacin flush free oral 2 OTC OIL ORAL capsule 400 mg CAPSULE 910- niacin (500 mg) 1,400 MG NIACIN FLUSH 2 OTC FREE ORAL CAPSULE 750 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 212 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OMEGA-3 ORAL 2 OTC a thru z oral tablet 2 OTC CAPSULE,DELAY 18-500-300-250 mg- ED mcg-mcg-mcg RELEASE(DR/EC) a thru z select 50plus 2 OTC 350 MG-235 MG- formula oral tablet 90 MG-597 MG 0.4-300-250 mg- OMEGA-3S-DHA- 2 OTC mcg-mcg EPA-FISH OIL a thru z select oral 2 OTC ORAL tablet , 500-300-250 CAPSULE,DELAY mcg ED RELEASE(DR/EC) a thru z select 2 OTC 1,000-1,400 MG, women's oral tablet 980-253-647 MG abc plus oral tablet 2 OTC probiotic oral 2 OTC 0.4-300-250 mg- capsule 10 billion mcg-mcg cell actical oral capsule 2 OTC Q-GEL ORAL 2 OTC adult one daily 2 OTC CAPSULE 15-3 multivitamin oral MG-UNIT tablet 0.4 mg resource 2.0 oral 2 OTC adults 50 plus oral 2 OTC liquid tablet 0.4-300-250 salmon oil-1000 oral 2 OTC mg-mcg-mcg capsule 1,000-200 ALIVE PRENATAL 2 OTC mg ORAL sea-omega oral 2 OTC TABLET,CHEWAB capsule 200 mg-300 LE 400 MCG- 25 mg- 100 mg-1,000 MG mg animal chews oral 2 OTC tyr cooler oral liquid 2 OTC tablet,chewable ultra omega-3 oral 2 OTC ANIMAL SHAPES 2 OTC capsule 500-1,000 COMPLETE ORAL mg TABLET,CHEWAB LE 18 MG IRON VITAMINS / HEMATINICS animal shapes plus 2 OTC a thru z advanced 2 OTC iron oral formula oral tablet tablet,chewable 18-400 mg-mcg antioxidant 2 OTC a thru z high potency 2 OTC a/c/e/selenium oral oral tablet capsule

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 213 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits antioxidant vitamins 2 OTC balanced b-100 2 OTC oral tablet 1,000 complex oral tablet unit-200 mg-60 unit- extended release 100 2 mg mg apatate forte oral 2 OTC balanced b-50 oral 2 OTC liquid tablet ascorbic acid 2 OTC bal-care dha oral 2 (vitamin c) oral combo pack,tablet tablet 1,000 mg, 250 and cap,dr 27-1-430 mg, 500 mg mg ascorbic acid 2 OTC b-complex with 2 OTC (vitamin c) oral vitamin c oral tablet tablet extended , 400-500 mcg-mg release 500 mg biocel (with lutein) 2 OTC ascorbic acid 2 OTC oral tablet 800-250- (vitamin c) oral 750 mcg tablet,chewable 500 BIO-D-MULSION 2 OTC mg FORTE ORAL b complex-vitamin 2 OTC DROPS 50 b12 oral tablet MCG/DROP (2, 000 UNIT/DROP) b complex-vitamin c- 2 OTC folic acid oral tablet BIO-D-MULSION 2 OTC 400 mcg ORAL DROPS 10 b-100 complex oral 2 OTC MCG/DROP (400 tablet extended UNIT/DROP) release 100 mg BRAINSTRONG 2 OTC b-12 dots oral tablet 2 OTC PRENATAL ORAL 500 mcg COMBO PACK 33 MG IRON- 800 BABY DDROPS 2 OTC MCG-350 MG ORAL DROPS 10 MCG/DROP (400 c complex oral tablet 2 OTC UNIT/DROP) extended release 1,000 mg, 500 mg BABY VITAMIN 2 OTC D3 ORAL DROPS c-1000 oral tablet 2 OTC 1,000 mg 10 MCG/DROP (400 UNIT/DROP) c-1000 oral tablet 2 OTC BABY'S SUPER 2 OTC extended release DAILY D3 ORAL 1,000 mg DROPS 10 c-1000 with rose 2 OTC MCG/DROP (400 hips oral tablet UNIT/DROP) 1,000 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 214 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits c-500 oral tablet 500 2 OTC centravites oral 2 OTC mg tablet 0.4-162-18 mg c-500 oral tablet 2 OTC CENTRUM ORAL 2 OTC extended release 500 LIQUID 9 MG mg IRON/15 ML c-500 oral 2 OTC centrum women oral 2 OTC tablet,chewable 500 tablet 18-400 mg- mg mcg CADEAU DHA 2 OTC century adults 50 2 OTC ORAL CAPSULE plus oral tablet 0.4- 29 MG IRON- 1 300-250 mg-mcg- MG-150 MG mcg calcidol oral drops 2 OTC century cardio oral 2 OTC 200 mcg/ml (8,000 tablet 3-200-400 mg- unit/ml) mcg-mg calcium 600 + 2 OTC century mature oral 2 OTC minerals oral tablet tablet 0.4-300-250 600 mg calcium- 400 mg-mcg-mcg, 400- unit 30 mcg calcium carbonate- 2 OTC century oral tablet 2 OTC vit d3-min oral 18-400 mg-mcg tablet 600 mg century ultimate 2 OTC calcium- 400 unit women's oral tablet calcium-folic acid- 2 OTC 18-400 mg-mcg, 8 vitamin d oral wafer mg iron-400 mcg- 500-50-300-1 mg- 300 mcg mg-unit-mg cerovite jr oral 2 OTC centamin oral liquid 2 OTC tablet,chewable 18 9 mg iron/15 ml mg iron- 10 mcg CENTRAM-CARE 2 OTC cerovite senior oral 2 OTC ORAL LIQUID 9 tablet MG IRON/15 ML certa plus oral tablet 2 OTC centratex oral 2 OTC 18-0.4-250 mg-mg- capsule 106 mg mcg iron- 1 mg certavite senior oral 2 OTC centravites 50 plus 2 OTC tablet 0.4-300-250 oral tablet , 0.4- mg-mcg-mcg 300-250 mg-mcg- certavite-antioxidant 2 OTC mcg oral tablet 18-400 mg-mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 215 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHILD 2 OTC CHILD'S OMEGA- 2 OTC CHEWABLE 3 DHA VITAMN MULTIVITAM COMPLETE ORAL ORAL TABLET,CHEWAB TABLET,CHEWAB LE 18 MG IRON LE 250-3-50 CHILD 2 OTC UNIT,MG,UNIT COMPLETE childs/iron oral 2 OTC MULTIVITAMIN tablet,chewable ORAL cholecalciferol 2 OTC TABLET,CHEWAB (vitamin d3) oral LE 18 MG IRON capsule 1,250 mcg CHILD 2 OTC (50,000 unit), 10 MULTIVITAMIN mcg (400 unit), 125 PLUS IRON ORAL mcg (5,000 unit), 25 TABLET,CHEWAB mcg (1,000 unit), LE 18 MG IRON 250 mcg (10,000 children's chew 2 OTC unit), 50 mcg (2,000 unit) multivitamin oral tablet,chewable CHOLECALCIFER 2 OTC children's chewable 2 OTC OL (VITAMIN D3) multivitmn oral ORAL DROPS 10 tablet,chewable 300 MCG/DROP (400 mcg UNIT/DROP), 125 MCG/0.5 ML (5K children's chewable 2 OTC UNIT/0.5ML) vitamin oral tablet,chewable cholecalciferol 2 OTC (vitamin d3) oral children's chewables 2 OTC drops 10 mcg/ml extra c oral (400 unit/ml), 125 tablet,chewable 300 mcg/ml (5,000 mcg unit/ml) children's chewables 2 OTC CHOLECALCIFER 2 OTC oral tablet,chewable OL (VITAMIN D3) 300 mcg ORAL LIQUID 10 children's iron oral 2 OTC MCG/5 ML (400 drops 15 mg iron (75 UNIT/5 ML), 12.5 mg)/ml MCG/5 ML (500 UNIT/5 ML) children's 2 OTC multivitamin oral tablet,chewable

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 216 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cholecalciferol 2 OTC COMPLETE 2 OTC (vitamin d3) oral MULTIVITAMIN- tablet 10 mcg (400 MINERAL ORAL unit), 125 mcg LIQUID 9 MG (5,000 unit), 25 mcg IRON/15 ML (1,000 unit), 50 mcg complete 2 OTC (2,000 unit) multivitamin-mineral CHOLECALCIFER 2 OTC oral tablet 18-400 OL (VITAMIN D3) mg-mcg ORAL TABLET complete mv adult 2 OTC 250 MCG (10,000 50 plus oral tablet UNIT), 75 MCG 0.4-300-250 mg- (3,000 UNIT) mcg-mcg cholecalciferol 2 OTC complete natal dha 2 (vitamin d3) oral oral combo pack 29- tablet,chewable 10 1-250-200 mg mcg (400 unit), 25 mcg (1,000 unit) complete oral tablet 2 OTC 18-500-300-250 mg- CHOLECALCIFER 2 OTC mcg-mcg-mcg OL (VITAMIN D3) ORAL complete senior oral 2 OTC TABLET,DISINTE tablet , 0.4-300-250 GRATING 125 mg-mcg-mcg MCG (5,000 UNIT) complex b-100 oral 2 OTC CHOLECALCIFER 2 OTC tablet extended OL (VITAMIN D3) release SUBLINGUAL corvita 150 oral 2 OTC SPRAY,SUSPENSI tablet 150-1.25-120- ON 25 10 mg MCG/SPRAY 1,000UNIT/SPRAY corvita oral tablet 2 OTC 1.25-2.5-7 mg c-nate dha oral 2 capsule 28 mg iron- CORVITE 150 2 OTC 1 mg -200 mg ORAL TABLET 150 MG IRON- 1 cod liver oil oral oil 2 OTC MG complete 50 plus 2 OTC CORVITE FE 2 OTC oral tablet 0.4-300- ORAL TABLET 250 mg-mcg-mcg 150 MG IRON- 1 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 217 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cyanocobalamin 2 CYANOCOBALA 2 OTC (vitamin b-12) MIN (VITAMIN B- injection solution 12) SUBLINGUAL 1,000 mcg/ml LOZENGE 1,000 CYANOCOBALA 2 OTC MCG MIN (VITAMIN B- cyanocobalamin 2 OTC 12) ORAL (vitamin b-12) CAPSULE 1,000 sublingual lozenge MCG, 3,000 MCG, 2,500 mcg 5,000 MCG cyanocobalamin 2 OTC CYANOCOBALA 2 OTC (vitamin b-12) MIN (VITAMIN B- sublingual tablet 12) ORAL 1,000 mcg, 2,500 LOZENGE 250 mcg MCG d3-2000 oral 2 OTC cyanocobalamin 2 OTC capsule 50 mcg (vitamin b-12) oral (2,000 unit) tablet 1,000 mcg, daily multiple 2 OTC 500 mcg vitamins/iron oral CYANOCOBALA 2 OTC tablet MIN (VITAMIN B- daily multi-vitamin 2 OTC 12) ORAL TABLET oral tablet 2,500 MCG daily multivitamin 2 OTC cyanocobalamin 2 OTC with iron oral tablet (vitamin b-12) oral 18-400 mg-mcg tablet extended release 1,000 mcg, daily multivitamin- 2 OTC 2,000 mcg minerals oral tablet CYANOCOBALA 2 OTC daily value oral 2 OTC MIN (VITAMIN B- tablet 12) ORAL daily vitamin 2 OTC TABLET, IR AND formula oral tablet ER, BIPHASIC 5,000 MCG daily vitamin 2 OTC formula-iron oral cyanocobalamin 2 OTC tablet 18-400 mg- (vitamin b-12) mcg sublingual drops 3,000 mcg/ml daily vitamin 2 OTC formula-minerals oral tablet daily vitamin with 2 OTC iron oral tablet

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 218 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits daily vites/iron oral 2 OTC dino-life 2 OTC tablet multivitamin oral daily-vite (with folic 2 OTC tablet,chewable acid) oral tablet 400 dino-life with iron- 2 OTC mcg zinc oral daily-vite oral tablet 2 OTC tablet,chewable 4.5 mg DDROPS ORAL 2 OTC DROPS 25 d-vi-sol oral drops 2 OTC MCG/DROP ( 1000 10 mcg/ml (400 unit/ml) UNIT/DROP), 50 MCG/DROP (2, 000 e-200 oral capsule 2 OTC UNIT/DROP) 90 mg (200 unit) DECARA ORAL 2 OTC e-400 c-500 and 2 OTC CAPSULE 625 beta carotene oral MCG (25,000 tablet UNIT) EMERGEN-C 2 OTC DEKAS 2 OTC ELECTRO MIX ESSENTIAL ORAL ORAL POWDER IN LIQUID 2,000 PACKET 408-100- UNIT- 2,000 120-2 MG MCG/ML endur-c with rose 2 OTC DEKAS PLUS 2 OTC hips oral tablet LIQUID ORAL extended release LIQUID 500 1,000 mg, 500 mg MCG/ML ERGOCAL ORAL 2 OTC delta d3 oral tablet 2 OTC CAPSULE 62.5 10 mcg (400 unit) MCG (2,500 UNIT) dexifol oral tablet 5 2 OTC ergocalciferol 2 mg (vitamin d2) oral dialyvite 800 oral 2 OTC capsule 1,250 mcg tablet 0.8 mg (50,000 unit) ERGOCALCIFERO 2 OTC dialyvite oral tablet 2 OTC 100-1 mg L (VITAMIN D2) ORAL CAPSULE dialyvite vitamin d 2 OTC 50 MCG (2,000 oral capsule 125 UNIT) mcg (5,000 unit) ergocalciferol 2 OTC dino-life extra c 2 OTC (vitamin d2) oral multivitamin oral drops 200 mcg/ml tablet,chewable (8,000 unit/ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 219 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ergocalciferol 2 OTC ferretts oral tablet 2 OTC (vitamin d2) oral 325 mg (106 mg tablet 10 mcg (400 iron) unit) ferrex 150 forte oral 2 OTC ERGOCALCIFERO 2 OTC capsule 150-25-1 L (VITAMIN D2) mg-mcg-mg ORAL TABLET 50 ferrex 150 forte plus 2 OTC MCG (2,000 UNIT) oral capsule 150-60- essentia oral tablet 2 OTC 25-1 mg-mg-mcg-mg 18-400 mg-mcg ferrex 150 oral 2 OTC EXPECTA 2 OTC capsule 150 mg iron PRENATAL ORAL ferric x-150 oral 2 OTC COMBO PACK 28 capsule 150 mg iron MG IRON-800 MCG-200 MG FERRIMIN 150 2 OTC ORAL TABLET eye health plus 2 OTC 456 MG (150 MG lutein oral tablet IRON) 1,000 unit-200 mg- 60 unit-2 mg ferrocite oral tablet 2 OTC 324 mg (106 mg ezfe 200 oral 2 OTC iron) capsule 200 mg iron ferrocite plus oral 2 OTC fabb oral tablet 2.2- 2 OTC tablet 106 mg iron- 1 25-1 mg mg feosol oral tablet 2 OTC ferro-time oral tablet 2 OTC 325 mg (65 mg iron) 325 mg (65 mg iron) FERAHEME 2 ferrous fumarate 2 OTC INTRAVENOUS oral tablet 324 mg SOLUTION 510 (106 mg iron) MG/17 ML (30 MG/ML) FERROUS 2 OTC FUMARATE ORAL ferate oral tablet 2 OTC TABLET 89 MG 240 mg (27 mg iron) (29 MG IRON) ferocon oral capsule 2 OTC ferrous gluconate 2 OTC 110-0.5 mg oral tablet 236 mg ferosul oral tablet 2 OTC (27 mg iron), 240 325 mg (65 mg iron) mg (27 mg iron), FERRETTS IPS 2 OTC 256 mg (28 mg ORAL LIQUID 40 iron), 324 mg (37.5 MG/15 ML mg iron), 324 mg (38 mg iron)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 220 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ferrous sulfate oral 2 OTC folbee plus oral 2 OTC drops 15 mg iron (75 tablet 5 mg mg)/ml folic acid injection 2 ferrous sulfate oral 2 OTC solution 5 mg/ml elixir 220 mg (44 mg FOLIC ACID 2 OTC iron)/5 ml ORAL CAPSULE ferrous sulfate oral 2 OTC 20 MG liquid 300 mg (60 folic acid oral tablet 2 ACA; OTC mg iron)/5 ml 1 mg, 400 mcg, 800 ferrous sulfate oral 2 OTC mcg solution 220 mg (44 FOLINIC-PLUS 2 OTC mg iron)/5 ml ORAL TABLET 4- ferrous sulfate oral 2 OTC 50-2 MG tablet 325 mg (65 folivane-f oral 2 OTC mg iron) capsule 125-1-40-3 ferrous sulfate oral 2 OTC mg tablet,delayed folivane-plus oral 2 OTC release (dr/ec) 324 capsule 125 mg mg (65 mg iron), iron- 1 mg 325 mg (65 mg iron) folplex 2.2 oral 2 OTC fish oil-dha-epa oral 2 OTC tablet 2.2-25-0.5 mg capsule 1,200-144- 216 mg foltabs 800 oral 2 OTC tablet 0.8-10-115 FLINTSTONES 2 OTC mg-mg-mcg COMPLETE (IRON) ORAL fosfree oral tablet 2 OTC TABLET,CHEWAB 175.5-14.5 mg LE 18 MG IRON fruit c-500 oral 2 OTC fluoride (sodium) 2 OTC tablet,chewable 500 oral drops 0.5 mg mg (1.1 mg full spectrum b- 2 OTC sod.fluorid)/ml vitamin c oral tablet fluoride (sodium) 2 OTC 0.8 mg oral tablet,chewable gummi bear 2 OTC 0.25 mg(0.55 mg multivitamin oral sod. fluoride), 0.5 tablet,chewable mg (1.1 mg sodium fluorid), 1 mg (2.2 hair vitamins oral 2 OTC mg sod. fluoride) tablet folbee oral tablet 2 OTC hair, skin and nails 2 OTC 2.5-25-1 mg advanced oral tablet 3.3 mg iron-25 mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 221 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hair,skin and nails 2 OTC hydroxocobalamin 2 oral tablet intramuscular healthy eyes oral 2 OTC solution 1,000 tablet 1,000 unit-200 mcg/ml mg-60 unit-2 mg icaps areds oral 2 OTC healthy eyes 2 OTC capsule 14,320-226- supervision oral 200 unit-mg-unit capsule 14,320-226- iferex 150 forte oral 2 OTC 200 unit-mg-unit capsule 150-25-1 mg-mcg-mg HEARTBURN 2 OTC AND ACID iferex 150 oral 2 OTC REFLUX-ALOE capsule 150 mg iron ORAL TABLET INFED INJECTION 2 120-1,000-10 MG- SOLUTION 50 UNIT-MG MG/ML HEMATEX ORAL 2 OTC INTRINSI B12- 2 OTC LIQUID 100 MG FOLATE ORAL IRON/5 ML TABLET 500-20- hematinic plus 2 OTC 800 MCG-MG- vit/minerals oral MCG tablet 106 mg iron- 1 iron (dried) oral 2 OTC mg tablet extended hematinic/folic acid 2 OTC release 160 mg (50 oral tablet 324 mg mg iron) (106 mg iron)-1 mg iron (ferrous sulfate) 2 OTC hematogen fa oral 2 OTC oral tablet 325 mg capsule 200-250- (65 mg iron) 0.01-1 mg iron chews oral 2 OTC hematogen forte oral 2 OTC tablet,chewable 15 capsule 460-60- mg 0.01-1 mg IRON ORAL 2 OTC high potency iron 2 OTC TABLET 18 MG oral tablet 134 mg iron oral tablet 325 2 OTC (27 mg iron) mg (65 mg iron) HOMOCYSTEINE 2 OTC iron oral tablet 2 OTC FORMULA ORAL extended release 159 TABLET 0.8-50-100 mg (45 mg iron) MG-MG-MCG iron, carbonyl oral 2 OTC honey bears 2 OTC tablet 45 mg multivitamin oral tablet,chewable You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 222 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits IRONUP ORAL 2 OTC mega 2 OTC DROPS 15 MG multiple/chelated IRON/0.5 ML mineral oral tablet i-vite oral tablet 2 OTC mega multivitamin 2 OTC 1,000 unit-200 mg- for men oral tablet 60 unit-2 mg 200-175-250 mcg kids vitamin d3 oral 2 OTC men's daily multivit- 2 OTC tablet,chewable 10 mineral oral tablet mcg (400 unit) 0.4-600 mg-mcg kpn oral tablet 2 OTC men's one daily oral 2 OTC KPN ORAL 2 OTC tablet TABLET 9 MG milltrium senior oral 2 OTC IRON- 267 MCG tablet liquid b-12 oral 2 OTC MINI PRENATAL 2 OTC liquid 1,000 mcg/15 ORAL TABLET ml 6.75 MG IRON- 200 little animals oral 2 OTC MCG tablet,chewable m-natal plus oral 2 little animals-iron 2 OTC tablet 27 mg iron- 1 oral tablet,chewable mg ludent fluoride oral 2 OTC multi complete with 2 OTC tablet,chewable 0.25 iron oral tablet 18- mg(0.55 mg sod. 400 mg-mcg fluoride), 0.5 mg multi for her oral 2 OTC (1.1 mg sodium tablet 18 mg iron- fluorid), 1 mg (2.2 600 mcg-80 mcg mg sod. fluoride) MULTI VITAMIN 2 OTC lysiplex plus oral 2 OTC ORAL LIQUID 9 liquid MG IRON/15 ML macuvite eye care 2 OTC multi-day with iron 2 OTC oral tablet 7,160 oral tablet 18-400 unit- 113 mg-1 mg mg-mcg maximum daily 2 OTC multi-delyn with iron 2 OTC multivitamin oral oral liquid 10 mg tablet 18-0.4 mg iron/5 ml mega multi for 2 OTC multigen folic oral 2 OTC women oral tablet tablet 70-150-10-1-2 13.5-200-250 mg- mg-mg-mcg-mg-mg mcg-mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 223 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits multigen oral tablet 2 OTC multivitamins with 2 OTC 70 mg-150 mg-10 fluoride oral mcg-2 mg-75 mg tablet,chewable 0.25 multigen plus oral 2 OTC mg, 0.5 mg, 1 mg tablet 151-60-10-1 MULTI-VITE 2 OTC mg-mg-mcg-mg ORAL LIQUID 9 multiple vitamin- 2 OTC MG IRON/15 ML minerals oral tablet mvc-fluoride oral 2 OTC multiple vitamins 2 OTC tablet,chewable 0.25 mg, 0.5 mg, 1 mg oral tablet multi-vit with 2 OTC MVW COMPLETE 2 OTC fluoride-iron oral FORMUL drops 0.25mg PEDIATRIC ORAL fluoride -10 mg DROPS 750-500 iron/ml UNIT-MCG/0.5 ML multivitamin 50 plus 2 OTC myferon 150 forte 2 OTC oral tablet oral capsule 150-25- 1 mg-mcg-mg multivitamin oral 2 OTC tablet myferon 150 oral 2 OTC capsule 150 mg iron multi-vitamin with 2 OTC fluoride oral drops mynatal oral capsule 2 0.25 mg/ml, 0.5 65 mg iron- 1 mg mg/ml mynatal plus oral 2 multivitamin with 2 OTC tablet 65 mg iron- 1 fluoride oral mg tablet,chewable 0.5 mynatal-z oral tablet 2 mg 65 mg iron- 1 mg multivitamin with 2 OTC mynephrocaps oral 2 OTC iron oral tablet capsule 1 mg multivitamin with 2 OTC mynephron oral 2 OTC minerals oral liquid capsule 1 mg 9 mg iron/15 ml my-vitalife oral 2 OTC multivitamin with 2 OTC capsule minerals oral tablet NANO VM 1-3 2 OTC multivitamin women 2 OTC ORAL POWDER 50 plus oral tablet 8 3.5-75 MG-MCG mg iron-400 mcg- NANO VM 4-8 2 OTC 300 mcg ORAL POWDER 5- 100 MG-MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 224 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NANOVM 9-18 2 OTC O-CAL F.A. ORAL 2 OTC ORAL POWDER 2 TABLET 27 MG MG IRON/ 2.6 IRON- 1 MG GRAM ocutabs oral tablet 2 OTC NANOVM T-F 2 OTC omnicap oral tablet 2 OTC FEEDING TUBE 0.4 mg POWDER 2.75 MG IRON/ 5.4 GRAM ONE A DAY 2 OTC WOMEN'S NASCOBAL 2 PRENATAL DHA NASAL ORAL COMBO SPRAY,NON- PACK 28 MG AEROSOL 500 IRON- 800 MCG MCG/SPRAY one daily 2 OTC nephronex-sl oral 2 OTC calcium/iron oral tablet,disintegrating tablet 800-2,000 mcg-unit one daily complete 2 OTC nephro-vite rx oral 2 OTC oral tablet , 18-0.4 tablet 1-60-300 mg- mg mg-mcg one daily energy 2 OTC newgen oral tablet 2 oral tablet 32-1,000 mg-mcg one daily essential 2 OTC NIFEREX 2 OTC oral tablet , 0.4 mg, (SUMALATE- 400 mcg QUATREFOLIC) ORAL TABLET one daily for men 2 OTC 150 MG IRON- 60 50+ advanced oral MG-1 MG tablet 400-600-120 mcg-mcg-mg NOVAFERRUM 50 2 OTC ORAL CAPSULE one daily for men 2 OTC 50 MG IRON oral tablet 0.4-600 mg-mcg NOVAFERRUM 2 OTC ORAL DROPS 15 one daily for women 2 OTC MG IRON/ML oral tablet 18-0.4 mg NUFERA ORAL 2 OTC one daily maximum 2 OTC TABLET 125 MG-1 oral tablet 18-0.4 mg MG-170 MG-1,000 one daily men's 50 2 OTC UNIT plus memory oral OB COMPLETE 2 tablet 400-600-120 ONE ORAL mcg-mcg-mg CAPSULE 40-10-1- 300 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 225 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits one daily multi-vit 2 OTC ONE-A-DAY 2 OTC w-mineral oral PRENATAL-1 tablet 4.5 mg iron ORAL CAPSULE one daily 2 OTC 27 MG IRON- 800 multivitamin oral MCG-235 MG tablet one-a-day teen 2 OTC one daily multivit- 2 OTC advantage oral iron(folic) oral tablet 18-400 mg- tablet 18-400 mg- mcg, 9 mg iron-400 mcg mcg one daily oral tablet 2 OTC ONE-A-DAY 2 OTC 0.4-600 mg-mcg VITACRAVES OMEGA-3 ORAL one daily plus iron 2 OTC TABLET,CHEWAB oral tablet 18-400 LE 200-16 MCG- mg-mcg MG one daily plus 2 OTC OPTIMAL D3 M 2 OTC minerals oral tablet ORAL CAPSULE ONE DAILY 2 OTC 350 MCG (14,000 PRENATAL ORAL UNIT) COMBO PACK 28 opti-vitamins oral 2 OTC MG IRON- 800 tablet 1,000 unit-200 MCG mg-60 unit-2 mg one daily prenatal 2 OTC pedia iron oral 2 OTC oral combo pack 28- drops 15 mg iron (75 800-440 mg-mcg-mg mg)/ml one daily women 50 2 OTC perry prenatal oral 2 OTC plus oral tablet 400- capsule 13.5-0.4 mg 120 mcg-mg pnv 29-1 oral tablet 2 one daily womens 50 2 OTC 29 mg iron- 1 mg plus oral tablet 0.4 mg pnv-select oral tablet 2 27-1 mg one daily women's 2 OTC oral tablet 18 mg poly-iron 150 forte 2 OTC iron-400 mcg-450 oral capsule 150-25- 1 mg-mcg-mg mg ca, 27-0.4 mg one-a-day essential 2 OTC poly-iron oral 2 OTC oral tablet capsule 150 mg iron one-a-day maximum 2 OTC polysaccharide iron 2 OTC formula oral tablet complex oral capsule 150 mg iron

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 226 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits POLY-VI-SOL 2 OTC prenatal + dha oral 2 OTC ORAL DROPS 250 combo pack 28 mg MCG-50 MG- 10 iron- 975 mcg-200 MCG/ML mg POLY-VI-SOL 2 OTC PRENATAL + DHA 2 OTC WITH IRON ORAL ORAL COMBO DROPS 11 MG PACK 28 MG IRON/ML IRON-800 MCG- pr natal 400 ec oral 2 200 MG combo pack,tablet PRENATAL 19 2 and cap,dr 29-1-400 ORAL mg TABLET,CHEWAB LE 29 MG IRON- 1 pr natal 400 oral 2 combo pack 29-1- MG 400 mg prenatal complete 2 OTC pr natal 430 ec oral 2 oral tablet 14 mg combo pack,tablet iron- 400 mcg and cap,dr 29-1-430 PRENATAL 2 OTC mg FORMULA ORAL pr natal 430 oral 2 TABLET 9 MG combo pack 29 mg IRON- 267 MCG iron-1 mg -430 mg PRENATAL 2 OTC prena1 chew oral 2 GUMMIES ORAL TABLET,CHEWAB tablet,chew,ir - dr,biphase 1.4 mg LE 400 MCG-35 MG- 25 MG-5 MG prena1 pearl oral 2 prenatal low iron 2 capsule,ir - delay rel,biphase 30-1.4- oral tablet 27 mg 200 mg iron- 1 mg prena1 true oral 2 PRENATAL 2 OTC combo pack 30 mg MULTI ORAL iron- 1.4 mg-300 mg TABLET 27-800 MG-MCG PRENATA ORAL 2 TABLET,CHEWAB prenatal multi-dha 2 OTC LE 29 MG IRON- 1 (algal oil) oral MG capsule 27mg iron- 800 mcg-250 mg prenatabs fa oral 2 tablet 29-1 mg prenatabs rx oral 2 tablet 29 mg iron- 1 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 227 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PRENATAL 2 OTC prenatal vit-iron 2 OTC MULTI- fum-folic ac oral DHA(WITH VIT K) tablet 28 mg iron- ORAL CAPSULE 800 mcg 27 MG IRON-800 prenatal vits96-iron 2 OTC MCG-260 MG fum-folic oral tablet prenatal 2 OTC 27 mg iron- 800 mcg multivitamins oral PRENATAL WITH 2 OTC tablet 28 mg iron- DHA-FOLIC ACID 800 mcg ORAL prenatal one daily 2 OTC TABLET,CHEWAB oral tablet 27 mg LE 400-32.5 MCG- iron- 800 mcg MG prenatal oral tablet 2 OTC preplus oral tablet 2 28 mg iron- 800 mcg 27 mg iron- 1 mg PRENATAL ORAL 2 OTC pretab oral tablet 2 TABLET 28-800 29-1 mg MG-MCG PRO FE ORAL 2 OTC PRENATAL ORAL 2 OTC CAPSULE 180 MG TABLET,CHEWAB IRON LE 400 MCG PROFERRIN ES 2 OTC prenatal plus 2 ORAL TABLET 12 (calcium carb) oral MG tablet 27 mg iron- 1 prosight oral tablet 2 OTC mg 5,000-60-30 unit- prenatal plus oral 2 mg-unit tablet 29 mg iron- 1 purevit dualfe plus 2 OTC mg oral capsule 162- prenatal tablet oral 2 OTC 115.2-1 mg tablet 28 mg iron- pyridoxine (vitamin 2 OTC 800 mcg b6) oral tablet 100 prenatal vitamin 2 OTC mg, 25 mg, 250 mg, oral tablet 27 mg 50 mg iron- 0.8 mg pyridoxine (vitamin 2 OTC prenatal vitamin 2 b6) oral tablet plus low iron oral extended release 200 tablet 27 mg iron- 1 mg mg quintabs-m iron free 2 OTC oral tablet 0.4 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 228 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RAPID B-12 2 OTC SIMILAC 2 OTC ENERGY PRENATAL ORAL SUBLINGUAL COMBO PACK 27 SPRAY,SUSPENSI MG IRON-800 ON 200 MCG-200 MG MCG/SPRAY SLOW RELEASE 2 OTC renal caps oral 2 OTC IRON ORAL capsule 1 mg TABLET rena-vite oral tablet 2 OTC EXTENDED 0.8 mg RELEASE 140 MG (45 MG IRON) rena-vite rx oral 2 OTC tablet 1-60-300 mg- slow release iron 2 OTC oral tablet extended mg-mcg release 142 mg (45 reno caps oral 2 OTC mg iron), 143 mg capsule 1 mg (45 mg iron), 160 REPLESTA NX 2 OTC mg (50 mg iron), ORAL WAFER 350 250 mg (50 mg iron) MCG (14,000 soothing pureway-c 2 OTC UNIT) oral tablet 500 mg replesta oral wafer 2 OTC spectravite adult 50 2 OTC 1,250 mcg (50,000 plus oral tablet 0.4- unit) 300-250 mg-mcg- se-natal 19 chewable 2 mcg oral tablet,chewable spectravite advanced 2 OTC 29 mg iron- 1 mg formula oral tablet se-natal-19 oral 2 18-400 mg-mcg tablet 29 mg iron- 1 spectravite men's 2 OTC mg oral tablet 8 mg senior tabs oral 2 OTC iron- 200 mcg-600 tablet 0.4-300-250 mcg mg-mcg-mcg spectravite women 2 OTC sentry oral tablet 18- 2 OTC oral tablet 18-400 400 mg-mcg mg-mcg sentry senior oral 2 OTC stress b with zinc 2 OTC tablet 0.4-300-250 oral tablet mg-mcg-mcg, 500- stress formula 600 c 2 OTC 300-250 mcg oral tablet se-tan plus oral 2 OTC stress formula oral 2 OTC capsule 162-115.2-1 tablet mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 229 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits stress formula with 2 OTC thera m plus (ferrous 2 OTC iron oral tablet 500 fumarat) oral tablet mg-400 mcg- 18 mg 9 mg iron-400 mcg iron thera oral tablet 400 2 OTC stress formula with 2 OTC mcg iron(sulf) oral tablet THERA-D 4000 2 OTC 500 mg-400 mcg- 27 ORAL TABLET mg iron 100 MCG (4,000 stress formula with 2 OTC UNIT) zinc oral tablet thera-d oral tablet 2 OTC sunvite oral tablet 2 OTC 50 mcg (2,000 unit) 18 mg iron-400 mcg- theralogix 2 OTC 25 mcg companion oral super antioxidant 2 OTC tablet 0.4 mg oral capsule thera-m oral tablet 2 OTC SUPER DAILY D3 2 OTC 27-0.4 mg, 9 mg ORAL DROPS 25 iron-400 mcg MCG/DROP ( 1000 THERANATAL 2 OTC UNIT/DROP), 50 COMPLETE ORAL MCG/DROP (2, 000 COMBO PACK 27 UNIT/DROP) MG IRON- 1 MG- super multiple oral 2 OTC 150 MG tablet THERANATAL 2 OTC super multivitamin 2 OTC ONE ORAL oral tablet CAPSULE 27 MG super quints b-50 2 OTC IRON-1000 MCG- oral tablet 300 MG super thera vite m 2 OTC THERANATAL 2 OTC oral tablet ORAL TABLET 27 MG IRON- 1 MG support oral liquid 2 OTC THERANATAL 2 OTC tab-a-vite 2 OTC OVAVITE ORAL multivitamin w-iron COMBO PACK 18- oral tablet 15 mg 1-125 MG-MG- iron- 400 mcg UNIT tab-a-vite oral tablet 2 OTC THERANATAL 2 OTC 400 mcg PLUS ORAL taron forte oral 2 OTC COMBO PACK 27 capsule 150-60-25-1 MG IRON- 1 MG- mg-mg-mcg-mg 300 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 230 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits therapeutic liquid 2 OTC trigels-f forte oral 2 OTC oral liquid capsule 460-60- therapeutic-m oral 2 OTC 0.01-1 mg tablet 9 mg iron-400 trinatal rx 1 oral 2 mcg tablet 60 mg iron-1 thera-tabs m oral 2 OTC mg tablet 27 mg iron- trinate oral tablet 28 2 400 mcg mg iron- 1 mg thera-tabs oral 2 OTC triphrocaps oral 2 OTC tablet capsule 1 mg theratrum complete 2 OTC triveen-duo dha oral 2 50 plus/lut oral combo pack 29-1- tablet 400 mg theratrum complete 2 OTC TRI-VI-SOL ORAL 2 OTC 50 plus-lyc oral DROPS 250 MCG- tablet 0.4-300-250 50 MG- 10 mg-mcg-mcg MCG/ML theratrum complete 2 OTC tri-vitamin with 2 OTC with lutein oral fluoride oral drops tablet 0.25 mg fluor. (0.55 therems multivitamin 2 OTC mg)/ml, 0.5 mg oral tablet 400 mcg fluoride (1.1 mg)/ml therems-m oral 2 OTC tri-vite with fluoride 2 OTC tablet 9 mg iron-400 oral drops 0.25 mg mcg fluor. (0.55 mg)/ml, 0.5 mg fluoride (1.1 thiamine hcl 2 OTC mg)/ml (vitamin b1) oral tablet 100 mg, 250 ultimate women's 2 OTC mg complete 50+ oral tablet 8 mg iron-400 THIAMINE HCL 2 OTC mcg-300 mcg (VITAMIN B1) ultra antioxidant 2 OTC ORAL TABLET 500 MG formula oral tablet thiamine 2 OTC ULTRA 2 OTC mononitrate (vit b1) PRENATAL PLUS oral tablet 100 mg DHA ORAL CAPSULE 27 MG- tricon oral capsule 2 OTC 800 MCG- 250 MG- 110-0.5 mg 200 MG v-c forte oral 2 OTC capsule 1 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 231 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vic-forte oral 2 OTC vitamin b-12 oral 2 OTC capsule 1 mg lozenge 500 mcg virt-fefa plus oral 2 OTC vitamin b-12 oral 2 OTC capsule 125 mg tablet 1,000 mcg, iron- 1 mg 100 mcg, 250 mcg, virt-gard oral tablet 2 OTC 50 mcg, 500 mcg 2.2-25-1 mg vitamin b-12 oral 2 OTC virt-nate dha oral 2 tablet extended capsule 28 mg iron- release 1,000 mcg, 2,000 mcg 1 mg -200 mg vit 3 oral capsule 2 OTC VITAMIN B-12 2 OTC 500 mg-500 mcg -1 SUBLINGUAL mg-12.5 mg DROPS 5,000 MCG/ML vitacel (with lutein) 2 OTC oral tablet 800-250- vitamin b-12 2 OTC 750 mcg sublingual tablet 2,500 mcg, 5,000 vitajoy daily d oral 2 OTC mcg tablet,chewable 25 mcg (1,000 unit) vitamin b-6 oral 2 OTC tablet 100 mg, 25 vitalee oral tablet 2 OTC mg, 250 mg, 50 mg 0.4 mg vitamin c oral tablet 2 OTC vitalets oral 2 OTC 1,000 mg, 100 mg, tablet,chewable , 10 250 mg, 500 mg mg iron vitamin c oral tablet 2 OTC vitamin b complex 2 OTC extended release oral capsule 1,000 mg, 500 mg vitamin b complex 2 OTC vitamin c oral 2 OTC oral tablet tablet,chewable 500 vitamin b-1 2 OTC mg (mononitrate) oral vitamin c with rose 2 OTC tablet 100 mg hips oral tablet vitamin b-1 oral 2 OTC 1,000 mg, 500 mg tablet 100 mg, 250 vitamin c with rose 2 OTC mg, 50 mg hips oral tablet VITAMIN B-12 2 OTC extended release ORAL DROPS 1,000 mg, 500 mg 1,000 MCG/ML vitamin c with rose 2 OTC VITAMIN B-12 2 OTC hips oral ORAL LOZENGE tablet,chewable 500 50 MCG mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 232 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vitamin d3 oral 2 OTC vitamins for hair 2 OTC capsule 10 mcg (400 oral tablet unit), 25 mcg (1,000 vitatrum oral tablet 2 OTC unit), 50 mcg (2,000 18-500-300-250 mg- unit) mcg-mcg-mcg vitamin d3 oral 2 OTC vitrum senior oral 2 OTC tablet 10 mcg (400 tablet unit), 125 mcg (5,000 unit), 25 mcg vp-vite rx oral tablet 2 OTC (1,000 unit), 50 mcg 1-60-300 mg-mg- (2,000 unit) mcg vitamin d3 oral 2 OTC wee care oral 2 OTC tablet,chewable 10 suspension 15 mcg (400 unit), 25 mg/1.25 ml mcg (1,000 unit) WELLESSE 2 OTC VITAMIN D-3 2 OTC MULTI VITAMIN WITH ALOE ORAL PLUS ORAL TABLET 120-1,000- LIQUID 400 MCG- 10 MG-UNIT-MG 200 MG/30 ML vitamin e (dl, 2 OTC westab mini oral 2 OTC acetate) oral capsule tablet 2.2-25-1 mg 180 mg (400 unit), westab one oral 2 OTC 45 mg (100 unit), 90 tablet 2.5-25-1 mg mg (200 unit) westgel dha oral 2 vitamin e acetate 2 OTC capsule 31 mg iron- oral capsule 134 mg 1 mg-200 mg (200 unit) women's daily 2 OTC vitamin e mixed oral 2 OTC formula oral tablet capsule 400 unit 27-0.4 mg vitamin e oral 2 OTC women's one daily 2 OTC capsule 100 unit, oral tablet 18 mg 200 unit, 400 unit iron-400 mcg-500 vitamins a,c,d and 2 OTC mg ca fluoride oral drops women's prenatal 2 OTC 0.25 mg fluor. (0.55 plus dha oral combo mg)/ml, 0.5 mg pack 28 mg-975 fluoride (1.1 mg)/ml mcg- 200 mg vitamins b complex 2 OTC yelets oral tablet 18- 2 OTC oral capsule 400 mg-mcg vitamins b complex 2 OTC oral tablet

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 233 Drug Name Drug Requirements Tier / Limits YOGURT PLUS 2 OTC CALCIUM GUMMIES ORAL TABLET,CHEWAB LE 250 MG-2.5 MCG (100 UNIT)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 234 Index

1 ACCU-CHEK MULTICLIX ADACEL(TDAP 12 hour decongestant ...... 193 LANCET ...... 95 ADOLESN/ADULT)(PF) 12 hour nasal decongest (pse) ACCU-CHEK SAFE-T-PRO ...... 166 ...... 193 ...... 95 ADAKVEO ...... 14 1ST TIER UNIFINE PENTIPS ACCU-CHEK SAFE-T-PRO adapalene ...... 74 ...... 94 PLUS...... 95 adapalene-benzoyl peroxide .74 1ST TIER UNIFINE PENTIPS ACCU-CHEK SOFT DEV ADASUVE ...... 43 PLUS ...... 94 LANCETS ...... 95 addaprin ...... 36 1ST TIER UNILET ACCU-CHEK SOFTCLIX ADDERALL XR ...... 43 COMFORTOUCH ...... 95 LANCETS ...... 95 adefovir ...... 4 2 acebutolol ...... 53 ADEMPAS ...... 201 24hour allergy ...... 193 acetaminophen...... 36 ADMELOG SOLOSTAR U- 24hr allergy relief ...... 193 acetaminophen extra strength 100 INSULIN ...... 95 2-IN-1 LANCET DEVICE ...95 ...... 36 ADMELOG U-100 INSULIN 3 acetaminophen-codeine ...... 32 LISPRO ...... 95 3 day vaginal ...... 177 acetazolamide ...... 190 adrenalin ...... 193 3-day vaginal...... 177 acetic acid ...... 85, 92 ADRENALIN ...... 201 8 acetylcysteine ...... 201 adult aspirin regimen ...... 36 8 hour pain reliever...... 35 acid controller ...... 162 adult one daily multivitamin 8hr muscle aches-pain ...... 35 acid gone antacid ...... 149 ...... 217 A acid gone antacid e.strength 149 adults 50 plus ...... 217 a and d (lan, pet) ...... 69 acid reducer (cimetidine) .... 162 ADVAIR DISKUS ...... 201 a thru z ...... 217 acid reducer (famotidine) ... 162 ADVAIR HFA ...... 201 a thru z advanced formula .. 217 acid reducer (omeprazole) .. 162 ADVANCED ACNE WASH a thru z high potency ...... 217 acidophilus...... 215 ...... 74 a thru z select ...... 217 acid-pep ...... 162 advanced antacid-antigas ... 149 a thru z select 50plus formula acitretin ...... 67 advanced exfoliating cleanser ...... 217 acne cleansing bar ...... 73 ...... 74 a thru z select women's...... 217 acne control cleanser ...... 73 advanced eye relief ...... 186 abacavir ...... 3 acne foaming wash ...... 73 advanced healing (petrolatum) abacavir-lamivudine ...... 3 acne medication ...... 73 ...... 69 abacavir-lamivudine- acne treatment (benzoyl perox) ADVANCED LANCING zidovudine ...... 3 ...... 73 DEVICE ...... 95 ABATREX WITH ALA .... 215 acne vanishing ...... 73 ADVANCED TRAVEL abc plus...... 217 acne-clear ...... 74 LANCETS ...... 95 ABILIFY MAINTENA...... 43 ACNEFREE ACNE ADVATE ...... 59 abiraterone...... 14 CLEARING SYSTEM ..... 74 advil junior strength...... 36 ABOUTTIME PEN NEEDLE ACNEFREE SEVERE ACNE ADVOCATE LANCET ...... 95 ...... 95 CLEARING ...... 74 ADVOCATE PEN NEEDLE acamprosate ...... 85 ACTEMRA ...... 173 ...... 95 acarbose ...... 95 ACTEMRA ACTPEN ...... 173 ADVOCATE SYRINGES ....96 ACCU-CHEK FASTCLIX ACTHAR ...... 93 ADYNOVATE ...... 59 LANCET DRUM ...... 95 actical ...... 217 ADZENYS ER...... 43 ACCU-CHEK FASTCLIX acti-lance lancets ...... 95 ADZENYS XR-ODT ...... 43 LANCING DEV ...... 95 acyclovir ...... 3, 4, 81 AEROCHAMBER MINI ...... 96 ACZONE ...... 74 AEROCHAMBER MV...... 96

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 235 AEROCHAMBER PLUS alcohol prep pads ...... 96 allergy relief(chlorpheniramn) FLOW-VU ...... 96 alcohol swabs ...... 96 ...... 195 AEROCHAMBER PLUS alcohol wipes ...... 96 allergy relief(diphenhydramin) FLOW-VU,L MSK ...... 96 ALCOH-WIPE ...... 96 ...... 195 AEROCHAMBER PLUS ALDACTAZIDE ...... 53 allergy relief,nasal decongest FLOW-VU,M MSK ...... 96 ALECENSA ...... 14 ...... 195 AEROCHAMBER PLUS alendronate ...... 172 allergy relief-d (cetirizine) . 195 FLOW-VU,S MSK...... 96 aler-cap ...... 193 allergy relief-d (loratadine) 195 AEROCHAMBER PLUS Z ALEVAZOL...... 78 allergy relief-d(fexofenadine) STAT LG MSK ...... 96 alfuzosin...... 208 ...... 195 AEROCHAMBER PLUS Z ALINIA ...... 9 ALLERGY SYRINGE ...... 96 STAT MD MSK ...... 96 ALIQOPA...... 14 allergy-congest relief-d(fexo) AEROCHAMBER PLUS Z aliskiren ...... 54 ...... 195 STAT SM MSK ...... 96 ALIVE PRENATAL...... 217 allergy-congestion relief-d . 195 AEROCHAMBER WITH alka-seltzer original...... 36 allergy-time ...... 195 FLOWSIGNAL ...... 96 alka-seltzer plus allergy ...... 193 aller-tec ...... 195 AEROCHAMBER Z-STAT all day allergy (cetirizine) .. 193, aller-tec d...... 195 PLUS-FLW SG ...... 96 194 ALLI ...... 85 AEROVENT PLUS ...... 96 all day allergy-d...... 194 allopurinol ...... 172 AFINITOR ...... 14 all day pain relief...... 36 almacone-2 ...... 149 AFINITOR DISPERZ ...... 14 all day relief ...... 36 almotriptan malate ...... 27 AFLURIA QD 2021-22(3YR aller-chlor ...... 194 aloe burn relief ...... 76 UP)(PF) ...... 166 allerclear ...... 194 ALOGLIPTIN...... 96 AFLURIA QD 2021-22(6- allerclear d-12hr ...... 194 ALOGLIPTIN-METFORMIN 35MO)(PF)...... 166 allerclear d-24hr ...... 194 ...... 97 AFLURIA QUAD 2021- aller-ease ...... 194 alophen (bisacodyl) ...... 149 2022(6MO UP) ...... 166 aller-fex ...... 194 alosetron ...... 149 AFSTYLA...... 60 aller-flo ...... 201 ALPHAGAN P ...... 193 AIMOVIG AUTOINJECTOR aller-g-time ...... 194 ALPHANATE ...... 60 ...... 27 allergy ...... 194 ALPHANINE SD ...... 60 AIRZONE PEAK FLOW allergy (chlorpheniramine) . 194 alprazolam ...... 43 METER ...... 96 allergy (diphenhydramine) . 194 alprazolam intensol...... 43 AJOVY AUTOINJECTOR ..27 allergy 4-hour ...... 194 ALPROLIX ...... 60 AJOVY SYRINGE...... 27 allergy and congestion relief altacaine...... 186 AKYNZEO ...... 194 altamist ...... 91 (FOSNETUPITANT) ..... 149 allergy complete-d ...... 194 altavera (28) ...... 179 AKYNZEO (NETUPITANT) allergy eye (ketotifen) ...... 186 ALTERNATE SITE LANCET ...... 149 allergy medication ...... 194 ...... 97 ala-cort...... 81 allergy medicine ...... 194 aluminum hydroxide gel .... 149 alavert ...... 193 allergy plus severe sinus ha 194 alum-mag hydroxide-simeth alavert d-12 allergy-sinus ... 193 allergy relief (cetirizine) ..... 194 ...... 149 alaway...... 186 allergy relief (fexofenadine) ALUNBRIG ...... 14 albendazole ...... 9 ...... 194 ALVESCO ...... 201 albuterol sulfate ...... 201 allergy relief (levocetirizin) 194 alyacen 1/35 (28) ...... 179 alcalak...... 209 allergy relief (loratadine) .... 195 alyacen 7/7/7 (28) ...... 179 alclometasone ...... 81 allergy relief d12 ...... 195 amantadine hcl ...... 4 ALCOH-GLOVE ...... 96 allergy relief d-24hr ...... 195 ambrisentan ...... 201 alcohol pads ...... 96 ameriphor ...... 69

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 236 amethia ...... 179 antacid maximum strength . 149 ARGYLE TRACHEOSTOM amethyst (28) ...... 179 antacid plus anti-gas...... 149 TUBE HOLDER ...... 97 amiloride ...... 54 antacid regular strength ...... 150 aripiprazole ...... 44 amiloride-hydrochlorothiazide antacid ultra strength ...150, 209 ARISTADA ...... 44 ...... 54 antacid-antigas...... 150 ARISTADA INITIO ...... 44 amino acid ...... 215 antacid-simethicone ...... 150 armodafinil ...... 44 aminocaproic acid ...... 60 antibiotic (bacitracin zinc) .... 77 ARMOUR THYROID ...... 145 amiodarone ...... 53 antibiotic (neomy-bacit-polym) ARNUITY ELLIPTA ...... 202 AMITIZA ...... 149 ...... 77 arthritis pain (diclofenac) ...... 36 amitriptyline ...... 43 antibiotic plus (pramoxine) .. 77 arthritis pain relief (acetam) ..36 amitriptyline-chlordiazepoxide antibiotic-pain relief (bacit) .. 77 arthritis pain relief(capsaic) ..69 ...... 43 anti-dandruff ...... 67 arthritis pain reliever ...... 36 amlodipine...... 54 anti-dandruff with menthol ... 69 ARTIFICIAL TEARS (CMC) amlodipine-benazepril ...... 54 anti-diarrheal ...... 146 ...... 186 amlodipine-olmesartan ...... 54 anti-diarrheal (loperamide) . 146 artificial tears (petro/min) .. 186 ammonia aromatic ...... 85 ANTI-EMBOLISM artificial tears (pf) ...... 186 AMMONIA AROMATIC ....86 STOCKINGS ...... 97 artificial tears (polyvin alc) 186 ammonium lactate ...... 69 anti-fungal...... 79 artificial tears(dext70-hypro) amnesteem...... 74 antifungal (clotrimazole) ...... 78 ...... 186 AMONDYS-45 ...... 29 antifungal (tolnaftate) ...... 78 artificial tears(glycerin-peg) amoxapine ...... 44 antifungal cream (miconazole) ...... 186 amoxicillin ...... 11 ...... 78 artificial tears(pg-hypm-glyc) amoxicillin-pot clavulanate...11 antifungal spray ...... 79 ...... 186 AMPHETAMINE...... 44 anti-gas ultra strength ...... 150 artificial tears(pvalch-povid) ampicillin ...... 11 anti-itch (hc) ...... 81 ...... 186 anagrelide ...... 86 antioxidant a/c/e/selenium .. 217 ascomp with codeine ...... 32 anastrozole ...... 14 antioxidant vitamins ...... 217 ascorbic acid (vitamin c) ... 217, ANDRODERM ...... 142 antiseptic ...... 77 218 anecream ...... 76 antiseptic skin clnsr(chlorhe) 69 asenapine maleate ...... 44 anecream5 ...... 76 apatate forte ...... 217 ashlyna...... 179 ANGELIQ ...... 175 aphen ...... 36 ASMANEX HFA ...... 202 animal chews...... 217 ap-hist dm ...... 195 ASMANEX TWISTHALER ANIMAL SHAPES APOKYN ...... 26 ...... 202 COMPLETE ...... 217 apraclonidine ...... 193 aspirin ...... 36, 37 animal shapes plus iron ...... 217 aprepitant ...... 150 aspirin childrens ...... 36 ANORO ELLIPTA...... 201 apri ...... 179 aspirin low dose ...... 36 antacid ...... 149 APTIOM ...... 22 aspirin-dipyridamole ...... 60 antacid (calcium carbonate) 209 APTIVUS ...... 4 aspir-trin ...... 37 antacid and pain relief ...... 36 aquaphilic ...... 69 ASSURE HAEMOLANCE antacid anti-gas ...... 149 AQUAPHOR BABY DIAPER PLUS ...... 97 antacid anti-gas (ca carb-sim) RASH...... 69 ASSURE ID INSULIN ...... 149 ARALAST NP ...... 86 SAFETY ...... 97 antacid exst (mag carb-al hyd) aranelle (28) ...... 179 ASSURE ID PEN NEEDLE .97 ...... 149 ARANESP (IN ASSURE LANCE ...... 97 antacid ext str (calcium carb) POLYSORBATE) ...... 164 ASSURE LANCE PLUS ...... 97 ...... 209 ARCALYST ...... 164 ASTHMA CHECK METER 97 antacid extra-strength . 149, 209 ARESTIN ...... 91 atazanavir ...... 4 antacid m ...... 149 atenolol ...... 54

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 237 atenolol-chlorthalidone ...... 54 b-12 dots ...... 218 BD INSULIN SYRINGE athenol ...... 37 baby ayr saline...... 91 SAFETY-LOK ...... 98 athlete's foot ...... 79 BABY DDROPS ...... 218 BD INSULIN SYRINGE SLIP ATHLETE'S FOOT...... 79 BABY VITAMIN D3 ...... 218 TIP ...... 98 athlete's foot (clotrimazole) ..79 BABY'S SUPER DAILY D3 BD INSULIN SYRINGE U- athlete's foot (terbinafine) .....79 ...... 218 500 ...... 98 athlete's foot (tolnaftate)...... 79 bacitracin ...... 77, 184 BD INSULIN SYRINGE athletic foot cream ...... 79 bacitracin zinc ...... 77 ULTRA-FINE ...... 99 atomoxetine ...... 44 bacitracin-polymyxin b ...... 184 BD INTEGRA NEEDLE ...... 99 atorvastatin ...... 65 bacitraycin plus ...... 77 BD INTEGRA SYRINGE ....99 atovaquone ...... 9 baclofen ...... 31 BD INTRADERMAL BEVEL atovaquone-proguanil ...... 9 BAFIERTAM ...... 29 NEEDLES ...... 99 atropine ...... 186 balanced b-100 complex ..... 218 BD LO-DOSE MICRO-FINE ATROVENT HFA ...... 202 balanced b-50 ...... 218 IV ...... 99 AUBAGIO ...... 29 balanced salt ...... 187 BD LO-DOSE ULTRA-FINE aubra ...... 179 bal-care dha ...... 218 ...... 99 AUGMENTIN ...... 12 balsalazide ...... 150 BD LUER-LOK BULK AURYXIA ...... 86 BALVERSA ...... 14 SYRINGE ...... 99 AUSTEDO ...... 29 balziva (28) ...... 179 BD LUER-LOK SYRINGE..99 AUTODROP ...... 97 banophen...... 195 BD LUER-LOK TIP AUTOJECT 2 INJECTION BANZEL ...... 22, 23 CONTROL SYRING ...... 99 DEVICE ...... 97 BAQSIMI ...... 97 BD MICROTAINER AUTOLET IMPRESSION BARACLUDE ...... 4 LANCET ...... 99 LANC DEV ...... 97 BARD CATHETER STRAP 97 BD NANO 2ND GEN PEN AUTOPEN 1 TO 21 UNITS .97 BARD CUNNINGHAM NEEDLE ...... 99 AUTOPEN 2 TO 42 UNITS .97 INCONTIN CLAMP ...... 97 BD NOKOR ADMIX AUTOSQUEEZE ...... 97 BASAGLAR KWIKPEN U- NEEDLE ...... 100 avar ...... 74 100 INSULIN ...... 97 BD PRECISIONGLIDE .... 100 aviane ...... 179 bayer aspirin ...... 37 BD PRECISIONGLIDE NON- avidoxy ...... 13 baza antifungal ...... 79 STERILE...... 100 AVONEX ...... 164 BCG VACCINE, LIVE (PF) bd pre-filled normal saline ....86 ayr saline ...... 91 ...... 166 BD REGULAR BEVEL AYVAKIT ...... 14 b-complex with vitamin c ... 218 NEEDLES ...... 100 AZASAN ...... 14 BD ALCOHOL SWABS ...... 98 BD SAFETYGLIDE azathioprine ...... 14 BD ALLERGY SYRINGE .. 98 ALLERGIST TRAY ...... 100 azelaic acid ...... 74 BD AUTOSHIELD DUO PEN BD SAFETYGLIDE INSULIN azelastine ...... 91, 187 NEEDLE ...... 98 SYRINGE ...... 100 azelastine-fluticasone ...... 202 BD BULK SYRINGE SLIP BD SAFETYGLIDE NEEDLE AZELEX ...... 74 TIP ...... 98 ...... 101 azithromycin ...... 8, 9 BD ECLIPSE...... 98 BD SAFETYGLIDE azolen tincture ...... 79 BD ECLIPSE LUER-LOK ... 98 SHIELDING REG...... 101 AZOPT ...... 191 BD FILTER NEEDLE 5- BD SAFETYGLIDE azurette (28) ...... 179 MICRON NOKO ...... 98 SYRINGE ...... 101 B BD FILTER NEEDLE-5 BD SAFETYGLIDE TB REG b complex-vitamin b12 ...... 218 MICRON ...... 98 BEVEL ...... 101 b complex-vitamin c-folic acid BD INSULIN SYRINGE ..... 98 BD SAFETYGLIDE ...... 218 BD INSULIN SYRINGE TUBERCULIN ...... 101 b-100 complex ...... 218 (HALF UNIT) ...... 98

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 238 BD SAFETY-LOK BECONASE AQ ...... 202 BIO-D-MULSION FORTE 218 DETACHABLE NEEDL101 BELBUCA ...... 32 bioglo ...... 187 BD SAFETY-LOK belladonna alkaloids-opium 146 bion tears (pf) ...... 187 TUBERCULIN ...... 101 BELSOMRA ...... 44 biotect plus ...... 215 BD SAFETY-LOK WITH benazepril ...... 54 BIOTHRAX ...... 166 LUER-LOK ...... 101 benazepril-hydrochlorothiazide bisacodyl ...... 150 BD SLIP TIP SYRINGE.... 101 ...... 54 bisa-lax (bisacodyl) ...... 150 B-D SLIP TIP SYRINGE .. 101 BENEFIX ...... 60 bismatrol...... 146 BD SPECIALTY USE BENLYSTA ...... 173 bismuth ...... 146 NEEDLES ...... 101 BENSAL HP ...... 69 bismuth subsalicylate ...... 146 BD SYRINGE ...... 102 benzepro...... 74 bisoprolol fumarate...... 54 BD SYRINGE CATH TIP BENZNIDAZOLE ...... 9 bisoprolol-hydrochlorothiazide NONSTERILE ...... 101 benzoin...... 70 ...... 54 BD SYRINGE CATHETER benzoin compound ...... 70 BIVIGAM ...... 167 TIP ...... 102 benzonatate ...... 195 BLENREP ...... 14 BD SYRINGE LUER-LOK benzoyl peroxide ...... 74 BLINK GEL TEARS ...... 187 NONSTERILE ...... 102 benztropine ...... 26 BLINK TEARS ...... 187 BD SYRINGE LUER-LOK BERINERT ...... 202 blisovi 24 fe ...... 179 STERILE...... 102 BETADINE ...... 77 blisovi fe 1.5/30 (28) ...... 179 BD SYRINGE SLIP TIP BETADINE OPHTHALMIC blisovi fe 1/20 (28) ...... 179 NONSTERILE ...... 102 PREP ...... 184 blis-to-sol (tolnaftate) ...... 79 BD SYRINGE STORAGE beta-hc...... 81 BLOOD PRESSURE CUFF BINS ...... 102 betamethasone dipropionate . 81 ...... 102 BD SYRINGE TIP CAP .... 102 betamethasone valerate ...... 81 BLUNT NEEDLE, BD TUBERCULIN SLIP-TIP betamethasone, augmented .. 81, DISPOSABLE ...... 103 ...... 102 82 BOOSTRIX TDAP...... 167 BD TUBERCULIN SYRINGE betasept surgical scrub ...... 70 bosentan...... 202 ...... 102 BETASERON ...... 164 BOSULIF ...... 14 BD ULTRA FINE LANCETS betatemp...... 37 BOTOX ...... 167 ...... 102 betaxolol ...... 54, 185 BOUDREAUXS BUTT BD ULTRA-FINE II bethanechol chloride ...... 208 PASTE ...... 70 LANCETS ...... 102 BETIMOL ...... 185 bp ...... 74 BD ULTRA-FINE MICRO BETOPTIC S...... 185 bp 10-1 ...... 74 PEN NEEDLE ...... 102 BEUTLICH PH TEST ROLL bp wash...... 74 BD ULTRA-FINE MINI PEN ...... 102 bpo ...... 74 NEEDLE ...... 102 BEVACIZUMAB ...... 187 BRAFTOVI ...... 14 BD ULTRA-FINE NANO BEVESPI AEROSPHERE . 202 BRAINSTRONG PRENATAL PEN NEEDLE ...... 102 bexarotene...... 14 ...... 218 BD ULTRA-FINE ORIG PEN BEXSERO ...... 166 BREATHERITE MDI NEEDLE ...... 102 bicalutamide ...... 14 SPACER ...... 103 BD ULTRA-FINE SHORT BICILLIN C-R ...... 12 BREATHERITE SPACER- PEN NEEDLE ...... 102 BICILLIN L-A ...... 12 MASK, NEO...... 103 BD VEO INSULIN SYR BIDIL ...... 54 BREATHERITE SPACER- (HALF UNIT)...... 102 BIKTARVY ...... 4 MASK,ADULT ...... 103 BD VEO INSULIN SYRINGE BILTRICIDE ...... 9 BREATHERITE SPACER- UF ...... 102 bimatoprost ...... 191 MASK,CHILD ...... 103 BD YALE REGULAR biocel (with lutein) ...... 218 BREATHERITE SPACER- BEVEL ...... 102 BIO-D-MULSION ...... 218 MASK,INFANT ...... 103

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 239 BREATHERITE SPACER- c-1000 with rose hips ...... 218 CALTRATE 600 PLUS D . 211 MASK,S.CHLD ...... 103 c-500 ...... 218, 219 camila ...... 175 BREATHERITE VALVED CABENUVA ...... 4 camphor ...... 70 MDI CHAMBER ...... 103 cabergoline ...... 142 camrese ...... 179 BREATHERITE VALVED CABOMETYX ...... 15 camrese lo ...... 179 MDI SPACER ...... 103 CADEAU DHA ...... 219 candesartan ...... 54 BREO ELLIPTA ...... 202 caffeine citrate ...... 86 candesartan-hydrochlorothiazid briellyn ...... 179 calamine-zinc oxide ...... 70 ...... 54 BRILINTA ...... 60 calcidol ...... 219 capecitabine ...... 15 brimonidine ...... 193 calcipotriene ...... 67 CAPHOSOL ...... 86 BRINEURA ...... 142 calcitonin (salmon)...... 142 CAPRELSA ...... 15 brinzolamide ...... 191 CAL-CITRATE...... 209 capsaicin ...... 70 BRISDELLE ...... 44 calcitriol ...... 142 CAPSAICIN ...... 70 BRIVIACT ...... 23 calcium 500 + d ...... 209 capsicum...... 70 bromfenac...... 190 calcium 500 with d ...... 209 captopril...... 54 bromocriptine ...... 26 calcium 600 ...... 209 captopril-hydrochlorothiazide BROVANA ...... 202 calcium 600 + d(3) ...... 209 ...... 54 BRUKINSA ...... 14 calcium 600 + minerals...... 219 CAPZASIN ...... 70 bss ...... 187 calcium 600 with vitamin d3 capzasin-hp ...... 70 budesonide ...... 150, 203 ...... 210 CARAC ...... 70 BULLSEYE MINI SAFETY CALCIUM ACETATE...... 210 CARBAGLU ...... 86 LANCETS ...... 103 calcium acetate(phosphat bind) carbamazepine ...... 23 bumetanide ...... 54 ...... 210 carbidopa ...... 26 buprenorphine ...... 32 CALCIUM AMINO ACID carbidopa-levodopa ...... 26, 27 buprenorphine hcl ...... 32 CHELATE ...... 210 carbinoxamine maleate...... 196 buprenorphine-naloxone ...... 37 calcium antacid...... 210 cardioplegic soln ...... 66 bupropion hcl ...... 44, 45 calcium carbonate ...... 210 CARDIZEM LA ...... 54 bupropion hcl (smoking deter) CALCIUM CARBONATE 210 CARDURA XL ...... 55 ...... 90 calcium carbonate-vit d3-min CAREFINE PEN NEEDLE 103 burn relief with aloe ...... 76 ...... 219 CAREONE ULTRA THIN buspirone ...... 45 calcium carbonate-vitamin d3 LANCET ...... 103 butalbital compound w/codeine ...... 210, 211 CAREPOINT LUER SLIP ...... 32 CALCIUM CARBONATE- SYRINGE ...... 103 butalbital-acetaminop-caf-cod VITAMIN D3...... 210 CARETOUCH ALCOHOL ...... 32 calcium citrate ...... 211 PREP PAD ...... 103 butalbital-acetaminophen ...... 32 CALCIUM CITRATE ...... 211 CARETOUCH INSULIN butalbital-acetaminophen-caff calcium citrate + d ...... 211 SYRINGE ...... 104 ...... 32 CALCIUM CITRATE CARETOUCH PEN NEEDLE butalbital-aspirin-caffeine .....32 MALATE-VIT D3 ...... 215 ...... 104 butorphanol ...... 37 calcium citrate-vitamin d3 .. 211 CARETOUCH TWIST BUTTERFLY TOUCH CALCIUM GLUCONATE 211 LANCET ...... 104 LANCET ...... 103 CALCIUM LACTATE...... 211 carisoprodol ...... 31 BYDUREON BCISE ...... 103 calcium-folic acid-vitamin d carisoprodol-aspirin ...... 31 BYETTA ...... 103 ...... 219 carisoprodol-aspirin-codeine 31 BYSTOLIC ...... 54 cal-gest antacid ...... 211 carteolol ...... 185 C CAL-MINT ...... 211 cartia xt ...... 55 c complex ...... 218 CALQUENCE...... 15 carvedilol ...... 55 c-1000 ...... 218 CAL-QUICK ...... 211 carvedilol phosphate ...... 55

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 240 CASTIVA WARMING ...... 70 certavite-antioxidant ...... 219 children's chewable vitamin 220 castor oil ...... 150 cetiri-d ...... 196 children's chewables ...... 220 CAYSTON ...... 10 cetirizine ...... 196 children's chewables extra c220 caziant (28)...... 180 cetirizine-pseudoephedrine . 196 children's diphenhydramine 196 cefaclor ...... 7 CETRAXAL...... 92 children's easy-melts ...... 37 cefadroxil ...... 8 cevimeline...... 86 children's ibuprofen ...... 37 cefdinir ...... 8 CHANTIX ...... 90 children's iron...... 220 cefditoren pivoxil...... 8 CHANTIX CONTINUING children's mapap ...... 37 cefixime ...... 8 MONTH BOX...... 90 children's multivitamin ...... 220 cefpodoxime...... 8 CHANTIX STARTING children's non-aspirin ...... 37 cefprozil...... 8 MONTH BOX...... 90 children's pain relief ...... 37 ceftriaxone...... 8 chateal (28) ...... 180 children's pain reliever ...... 38 ceftriaxone in dextrose,iso-os .8 chateal eq (28) ...... 180 children's pain-fever relief ....38 cefuroxime axetil ...... 8 CHEMET ...... 86 children's pepto ...... 150 celacyn...... 70 CHEMSTRIP 10 MD ...... 104 children's profen ib ...... 38 celecoxib ...... 37 CHEMSTRIP 10/SG ...... 104 children's saline nasal spray ..91 CELONTIN ...... 23 CHEMSTRIP 2 GP ...... 104 children's soothe ...... 150 centamin ...... 219 CHEMSTRIP 50B ...... 104 children's tylenol ...... 38 CENTANY ...... 77 CHEMSTRIP 7 ...... 104 children's wal-dryl allergy.. 196 CENTANY AT ...... 77 CHEMSTRIP 9 ...... 104 children's wal-zyr...... 197 CENTRAM-CARE ...... 219 CHENODAL ...... 150 child's all day allergy(cetir) 197 centratex ...... 219 CHEW Q ...... 85 CHILD'S OMEGA-3 DHA centravites ...... 219 child allergy relf(cetirizine) 196 MULTIVITAM ...... 220 centravites 50 plus ...... 219 child allergy relief (diphen) 196 childs/iron ...... 220 CENTRUM ...... 219 CHILD CHEWABLE chlordiazepoxide hcl ...... 45 centrum women ...... 219 VITAMN COMPLETE .. 220 chlorhexidine gluconate . 70, 91 century ...... 219 CHILD COMPLETE chlorhist ...... 197 century adults 50 plus ...... 219 MULTIVITAMIN ...... 220 chloroquine phosphate ...... 10 century cardio ...... 219 child fever reducer-pain relvr chlorpheniramine maleate .. 197 century mature ...... 219 ...... 37 chlorpromazine ...... 45 century ultimate women's .. 219 CHILD MULTIVITAMIN chlortabs ...... 197 cephalexin ...... 8 PLUS IRON ...... 220 chlorthalidone ...... 55 CEPROTIN (BLUE BAR) ....60 children's acetaminophen...... 37 chlorzoxazone ...... 31 CEPROTIN (GREEN BAR) .60 children's advil ...... 37 chocolate laxative ...... 150 CERALYTE 50 ...... 211 children's alaway ...... 187 CHOLBAM ...... 150 CERALYTE 50 POTASSIUM children's allegra allergy ..... 196 cholecalciferol (vitamin d3) FREE ...... 212 children's allergy (diphenhyd) ...... 220, 221 CERALYTE 90 ...... 212 ...... 196 CHOLECALCIFEROL CERALYTE-70 ...... 212 children's allergy relief(lor) 196 (VITAMIN D3) ...... 220, 221 CERAMAX ...... 70 children's allergy(cetirizine) cholestyramine (with sugar)..65 CERASPORT ...... 212 ...... 196 ciclodan ...... 79 CERASPORT EX1...... 212 children's aspirin ...... 37 CICLODAN KIT ...... 79 CERDELGA ...... 142 children's benadryl allergy.. 196 ciclopirox ...... 79 CEREZYME ...... 143 children's cetirizine ...... 196 cilostazol ...... 60 cerovite jr ...... 219 children's chew multivitamin CIMDUO ...... 4 cerovite senior ...... 219 ...... 220 cimetidine ...... 162 certa plus ...... 219 children's chewable multivitmn cimetidine hcl...... 162 certavite senior ...... 219 ...... 220 CIMZIA...... 150

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 241 CIMZIA POWDER FOR clindamycin-benzoyl peroxide comfort gel extra strength .. 151 RECONST ...... 150 ...... 75 COMFORT LANCETS ..... 105 CIMZIA STARTER KIT ... 150 CLINDESSE ...... 177 COMFORT PAC- cinacalcet ...... 143 CLINPRO 5000...... 91 TIZANIDINE ...... 31 CINQAIR ...... 203 clobazam ...... 23 COMPACT SPACE CINRYZE ...... 203 clobetasol ...... 82 CHAMBER...... 105 CINVANTI ...... 151 clobetasol-emollient ...... 82 COMPACT SPACE CIPRO ...... 12 clomipramine ...... 45 CHAMBER-LRG MASK CIPRO HC ...... 93 clonazepam ...... 23 ...... 105 CIPRODEX ...... 93 clonidine ...... 55 COMPACT SPACE ciprofloxacin ...... 12 clonidine hcl ...... 45, 55 CHAMBER-MED MASK ciprofloxacin hcl ..... 12, 92, 184 clopidogrel ...... 60 ...... 105 citalopram ...... 45 clorazepate dipotassium ...... 45 COMPACT SPACE citrate of magnesia...... 151 clotrimazole ...... 3, 79, 177 CHAMBER-SM MASK 105 citroma...... 151 clotrimazole 3 day ...... 177 COMPLERA ...... 4 citrus calcium-vitamin d3... 212 clotrimazole af ...... 79 complete ...... 221 claravis ...... 74 clotrimazole-3...... 177 complete 50 plus ...... 221 clarithromycin ...... 9 clotrimazole-7...... 177 complete allergy ...... 197 CLARITIN REDITABS .... 197 clotrimazole-betamethasone . 79 complete allergy medicine . 197 clear eyes natural tears ...... 187 clozapine ...... 45 complete lice treatment ...... 84 CLEAR PORE CLEANSER- c-nate dha...... 221 complete multivitamin-mineral MASK ...... 74 co q-10 ...... 85 ...... 221 clearasil daily clear(benzoyl) 74 co q-10 (with vit e) ...... 215 COMPLETE CLEARCANAL EAR WAX 92 COAGADEX ...... 60 MULTIVITAMIN- clearlax ...... 151 COAGUCHEK LANCETS 104 MINERAL ...... 221 clemastine ...... 197 COARTEM ...... 10 complete mv adult 50 plus . 221 CLEOCIN ...... 177 cod liver oil ...... 221 complete natal dha ...... 221 CLEVER CHEK LANCETS codeine sulfate ...... 33 complete premium vitamin ...90 ...... 104 codeine-butalbital-asa-caff ... 33 complete senior ...... 221 CLEVER CHOICE coenzyme q10 ...... 85 complex b-100 ...... 221 CHAMBER-LRG MASK COENZYME Q10 ...... 85 compro...... 151 ...... 104 coenzyme q10-vitamin e ..... 215 CONCERTA ...... 45 CLEVER CHOICE colchicine ...... 172 CONDYLOX ...... 70 CHAMBER-MED MASK colesevelam ...... 65 constulose ...... 151 ...... 104 colestipol...... 65 COOL MIST HUMIDIFIER CLEVER CHOICE COLOR LANCETS ...... 104 ...... 105 CHAMBER-SM MASK 104 col-rite ...... 151 COPAXONE ...... 29 CLEVER CHOICE PEAK COMBIGAN ...... 191 COPIKTRA ...... 15 FLOW METER ...... 104 COMBIPATCH ...... 176 coq-10 ...... 85 CLICKFINE PEN NEEDLE COMBIVENT RESPIMAT 203 CORIFACT ...... 60 ...... 104 COMETRIQ ...... 15 COROMEGA ...... 215 CLIMARA PRO ...... 176 COMFORT EZ INSULIN CORTIFOAM ...... 151 clindacin etz ...... 74 SYRINGE ...... 104 cortisone (hydrocortisone) ....82 clindacin p ...... 74 COMFORT EZ LANCETS cortisone cooling...... 82 clindamycin hcl...... 10 ...... 104, 105 cortisone with aloe...... 82 clindamycin pediatric ...... 10 COMFORT EZ PEN cortizone-10 ...... 82 clindamycin phosphate . 75, 177 NEEDLES ...... 105 cortizone-10 plus ...... 82 comfort gel ...... 151 cortizone-10 with aloe ...... 82

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 242 corvita ...... 221 cyproheptadine ...... 197 daysee ...... 180 corvita 150 ...... 221 cyred...... 180 daytime-nighttime...... 197 CORVITE 150 ...... 221 cyred eq...... 180 DAYTRANA ...... 45 CORVITE FE ...... 221 CYSTADANE...... 151 DAYVIGO ...... 45 COSENTYX ...... 68 CYSTAGON ...... 208 DDROPS ...... 223 COSENTYX (2 SYRINGES) CYSTARAN ...... 187 DEBACTEROL ...... 91 ...... 68 cytra-k ...... 208 DECARA ...... 223 COSENTYX PEN ...... 68 D deep sea nasal ...... 91 COSENTYX PEN (2 PENS) 68 d3-2000 ...... 222 deferasirox...... 86 COTELLIC ...... 15 daily fiber...... 151 deferoxamine ...... 86 COTEMPLA XR-ODT ...... 45 DAILY FIBER (PSYLLIUM- DEKAS ESSENTIAL ...... 223 creamy acne face ...... 75 SUCROSE)...... 151 DEKAS PLUS LIQUID ..... 223 CREON ...... 151 daily multiple vitamins/iron 222 DELSTRIGO ...... 4 CRESEMBA ...... 3 daily multi-vitamin...... 222 delta d3 ...... 223 critic-aid clear af(miconazol) 79 daily multivitamin with iron demeclocycline ...... 13 cromolyn ...... 151, 187, 203 ...... 222 denta 5000 plus ...... 91 crotan ...... 84 daily multivitamin-minerals222 dentagel ...... 91 cryselle (28) ...... 180 daily value ...... 222 dermafix ...... 90 CRYSVITA ...... 143 daily vitamin formula ...... 222 dermaphor ...... 70 CULTURELLE ...... 215 daily vitamin formula-iron . 222 dermarest eczema (hydrocort) CULTURELLE DIGESTIVE daily vitamin formula-minerals ...... 82 HEALTH...... 146 ...... 222 DESCOVY ...... 4 CULTURELLE KIDS daily vitamin with iron...... 222 desenex ...... 79 GENTLE-GO...... 146 daily vites/iron ...... 223 desipramine ...... 45 CULTURELLE KIDS daily-vite ...... 223 desloratadine ...... 197 PROBIOTICS ...... 215 daily-vite (with folic acid) .. 223 desmopressin ...... 143 CULTURELLE KIDS ULTIM dairy aid ...... 151 desog-e.estradiol/e.estradiol BALANCE...... 215 dairy digestive ...... 151 ...... 180 CURITY ALCOHOL SWABS dairy digestive supplement . 151 desogestrel-ethinyl estradiol ...... 105 dairy relief ...... 151 ...... 180 CURITY TRIANGULAR dalfampridine ...... 29 DESONATE ...... 82 BANDAGE ...... 105 DALIRESP ...... 203 desonide...... 82 CUT N CRUSH ...... 105 danazol ...... 143 desoximetasone ...... 82 CUVITRU ...... 167 dandruff shampoo (selen-aloe) despec eda cough-cold drops CUVPOSA ...... 146 ...... 70 ...... 197 cyanocobalamin (vitamin b-12) dandruff shampoo (selenium) DESVENLAFAXINE ...... 45 ...... 222 ...... 68 desvenlafaxine succinate ...... 46 CYANOCOBALAMIN dantrolene ...... 31 dex4 glucose ...... 86 (VITAMIN B-12) ...... 222 dapsone ...... 10, 75 DEX4 GLUCOSE ...... 86 cyclafem 1/35 (28)...... 180 dasetta 1/35 (28) ...... 180 dex4 glucose bits ...... 86 cyclafem 7/7/7 (28) ...... 180 dasetta 7/7/7 (28) ...... 180 dex4 glucose pouch pack ...... 86 cyclobenzaprine ...... 31 DAURISMO...... 15 dex4 glucose quick dissolve .86 CYCLOMYDRIL ...... 193 DAVOL IRRIGATION dexamethasone ...... 93 cyclopentolate ...... 186 SYRINGE ...... 105 dexamethasone intensol ...... 93 cyclophosphamide ...... 15 DAVOL PISTON dexamethasone sodium CYCLOSERINE...... 10 IRRIGATION ...... 105 phosphate ...... 192 cyclosporine ...... 15 daylogic acne foaming wash 75 DEXCOM G6 RECEIVER 105 cyclosporine modified ...... 15 daylogic advanced healing ... 70 DEXCOM G6 SENSOR .... 105

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 243 DEXCOM G6 diphedryl allergy ...... 197 DROPLET INSULIN TRANSMITTER ...... 105 diphen ...... 197 SYR(HALF UNIT) ...... 106 dexifol...... 223 diphenhist ...... 197 DROPLET INSULIN DEXILANT ...... 162 diphenhydramine hcl...... 197 SYRINGE ...... 106 dexmethylphenidate...... 46 diphenoxylate-atropine ...... 147 DROPLET LANCETS ...... 106 dextroamphetamine ...... 46 dipyridamole...... 61 DROPLET MICRON PEN dextroamphetamine- disopyramide phosphate ...... 53 NEEDLE ...... 106 amphetamine ...... 46 DISPOSABLE NEEDLES . 105 DROPLET PEN NEEDLE 106 DEXTROSE...... 86 DISPOSABLE PAPER DROPSAFE PEN NEEDLE DIACOMIT ...... 23 MOUTHPIECE ...... 105 ...... 106 dialyvite ...... 223 disulfiram ...... 86 drospirenone-e.estradiol-lm.fa dialyvite 800 ...... 223 DIURIL ...... 55 ...... 180 dialyvite vitamin d ...... 223 divalproex ...... 23 drospirenone-ethinyl estradiol diamode ...... 146 docu ...... 152 ...... 180 diaper rash ...... 70 docuprene ...... 152 DROXIA ...... 15 diarrhea relief (bismuth subs) docusate calcium ...... 152 droxidopa ...... 86 ...... 146 docusate sodium ...... 152 dry eye relief ...... 187 diazepam ...... 23, 46 docuzen ...... 152 DRYSOL ...... 71 diazepam intensol ...... 46 dofetilide ...... 53 DRYSOL DAB-O-MATIC...71 diazoxide ...... 105 DOJOLVI ...... 215 dss ...... 152 diclofenac potassium ...... 38 dok...... 152 DUAVEE ...... 176 diclofenac sodium ... 38, 70, 190 donepezil...... 29 dulcoease ...... 152 diclofenac-misoprostol ...... 38 DORAL ...... 46 dulcolax (magnesium DICLOPAK ...... 38 dorzolamide ...... 191 hydroxide) ...... 152 dicloxacillin ...... 12 dorzolamide-timolol...... 191 dulcolax stool softener (dss) dicyclomine ...... 146, 147 DOVATO ...... 4 ...... 152 didanosine ...... 4 DOVER TWO-SIDED DULERA ...... 203 DIFFERIN...... 75 ADHESIVE STRAP ...... 105 duloxetine ...... 46 DIFICID ...... 9 doxazosin ...... 55 DUPIXENT PEN...... 71 diflunisal...... 38 doxepin ...... 46, 70 DUPIXENT SYRINGE ...... 71 digestive relief ...... 147 doxercalciferol...... 143 DUREZOL ...... 192 digitek ...... 59 doxorubicin ...... 15 dutasteride ...... 208 digox ...... 59 doxycycline hyclate ...... 13 dutasteride-tamsulosin...... 208 digoxin...... 59 doxycycline monohydrate .... 13 DUTOPROL ...... 55 DILANTIN ...... 23 DR. SMITH'S ADULT DUZALLO ...... 172 DILATRATE-SR ...... 67 BARRIER ...... 70 d-vi-sol ...... 223 diltiazem hcl ...... 55 DR. SMITH'S DIAPER RASH DYANAVEL XR ...... 46 dilt-xr ...... 55 ...... 71 dyna-hex ...... 71 diluent for epoprostenol/flola DRAIN-TUBE dy-o-derm ...... 90 ...... 86 ATTACHMENT DEVICE DYRENIUM ...... 55 dimenhydrinate ...... 151 ...... 105 E dino-life extra c multivitamin dramamine ...... 152 e.e.s. 400...... 9 ...... 223 dramamine less drowsy ...... 152 e-200 ...... 223 dino-life multivitamin ...... 223 driminate ...... 152 e-400 c-500 and beta carotene dino-life with iron-zinc ...... 223 DRIPDROP ...... 212 ...... 223 diocto ...... 151 drithocreme hp ...... 68 ear care ...... 215 diotame ...... 147 dronabinol ...... 152 ear drops (carbamide peroxide) diphedryl ...... 197 ...... 93

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 244 ear wax removal drops ...... 93 EASY TOUCH INSULIN EDLUAR ...... 46 ear wax removal kit ...... 93 SYRINGE ...... 110 ed-spaz...... 147 EAR WAX REMOVAL EASY TOUCH LANCETS 110 EDURANT ...... 4 SYSTEM ...... 93 EASY TOUCH LUER LOCK efavirenz ...... 4 EASIVENT HOLDING INSULIN ...... 110 efavirenz-emtricitabin-tenofov CHAMBER...... 106 EASY TOUCH LUER LOCK ...... 4 EASIVENT MASK LARGE SYRINGE ...... 110 efavirenz-lamivu-tenofov disop ...... 106 EASY TOUCH PEN NEEDLE ...... 4 EASIVENT MASK MEDIUM ...... 110 effer-k ...... 212 ...... 106 EASY TOUCH SAFETY EFFER-K ...... 212 EASIVENT MASK SMALL LANCETS ...... 110 efferves pain relief antacid ....38 ...... 106 EASY TOUCH SAFETY PEN effervescent pain relief ...... 38 EASY COMFORT NEEDLE ...... 110 EGRIFTA SV ...... 164 ALCOHOL PAD ...... 106 EASY TOUCH ELASTIC FOAM STRAPS 112 EASY COMFORT INSULIN SHEATHLOCK INSULIN electrolytes-dextrose...... 212 SYRINGE ...... 107 ...... 111 eletriptan...... 27 EASY COMFORT LANCETS EASY TOUCH ELIDEL ...... 71 ...... 107 SHEATHLOCK SYRG- ELIGARD ...... 15 EASY COMFORT PEN NDL ...... 111 ELIGARD (3 MONTH) ...... 15 NEEDLES ...... 107 EASY TOUCH ELIGARD (4 MONTH) ...... 15 EASY GLIDE INSULIN SHEATHLOCK SYRINGE ELIGARD (6 MONTH) ...... 15 SYRINGE ...... 107 ...... 111 elinest ...... 180 EASY GLIDE LUER LOCK EASY TOUCH SYR ELIQUIS ...... 61 SYRINGE ...... 107 ALLERGY TRAY ...... 111 ELIQUIS DVT-PE TREAT EASY GLIDE PEN NEEDLE EASY TOUCH 30D START ...... 61 ...... 107 TUBERCULIN FLIPLOCK ELLA ...... 180 EASY TOUCH ...... 110, 111 ...... 111 ELMIRON ...... 208 EASY TOUCH ALCOHOL EASY TOUCH ELOCTATE ...... 61 PREP PADS...... 107 TUBERCULIN eluryng...... 177 EASY TOUCH FLIPLOCK SHEATHLK ...... 111 EMBRACE LANCETS ..... 112 INSULIN...... 107 EASY TOUCH TWIST EMCYT ...... 15 EASY TOUCH FLIPLOCK LANCETS ...... 111 EMEND...... 152 NEEDLE ...... 108 EASY TOUCH UNI-SLIP 111, EMERGEN-C ELECTRO EASY TOUCH FLIPLOCK 112 MIX ...... 223 SYRINGE ...... 108 EASY TWIST AND CAP EMFLAZA ...... 93 EASY TOUCH FLURINGE LANCETS ...... 112 EMGALITY PEN ...... 27 ...... 109 EASYPOINT NEEDLE ..... 112 EMGALITY SYRINGE ...... 28 EASY TOUCH FLURINGE ECLIPSE NEEDLE ...... 112 emoquette ...... 180 FLIPLOCK ...... 109 ECLIPSE SYRINGE ...... 112 EMSAM ...... 46 EASY TOUCH FLURINGE ec-naproxen ...... 38 emtricitabine ...... 4 FLU TRAY ...... 109 econazole ...... 79 emtricitabine-tenofovir (tdf) ...4 EASY TOUCH FLURINGE econtra ez ...... 180 EMTRIVA ...... 4 SHEATHLOCK ...... 109 econtra one-step ...... 180 EMU-LAC ...... 71 EASY TOUCH ecotrin ...... 38 emulsion sb ...... 71 HYPODERMIC NEEDLE ecotrin low strength ...... 38 enalapril maleate ...... 55 ...... 109 ed a-hist dm ...... 197 enalapril-hydrochlorothiazide EASY TOUCH INSULIN ed chlorped jr ...... 198 ...... 55 SAFETY SYR ...... 110 ed-apap ...... 38 ENBREL ...... 173

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 245 ENBREL MINI...... 173 ERY-TAB ...... 9 EXONDYS-51 ...... 29 ENBREL SURECLICK ..... 173 erythrocin (as stearate) ...... 9 EXPECTA PRENATAL .... 224 endocet ...... 33 erythromycin ...... 9, 184 EXTAVIA ...... 164 endur-acin...... 65 erythromycin ethylsuccinate .. 9 eye health plus lutein ...... 224 endur-c with rose hips ...... 223 erythromycin with ethanol.... 75 eye itch relief ...... 187 enema ...... 152 erythromycin-benzoyl peroxide EYLEA ...... 187 enema disposable ...... 152 ...... 75 e-z ject lancets...... 112 ENGERIX-B (PF) ...... 167 ESBRIET ...... 203 e-z ject thin lancets ...... 113 ENGERIX-B PEDIATRIC escitalopram oxalate ...... 46 EZ SMART LANCETS ..... 113 (PF) ...... 167 esomeprazole magnesium ... 162 ezetimibe ...... 65 ENHERTU ...... 15 ESOMEPRAZOLE ezfe 200 ...... 224 enoxaparin ...... 61 STRONTIUM ...... 162 E-Z-GAS II ...... 152 enpresse ...... 180 essentia...... 224 EZ-LETS ...... 113 enskyce ...... 180 estarylla ...... 180 F entacapone...... 27 estazolam ...... 46 fabb ...... 224 entecavir ...... 4 estradiol ...... 176 FABRAZYME...... 143 ENTRESTO ...... 66 estradiol valerate ...... 176 FACE SPLASH SHIELD, ENTYVIO ...... 152 estradiol-norethindrone acet FULL ...... 113 enulose...... 152 ...... 176 FACE SPLASH SHIELD, EPANED ...... 55 ESTRING ...... 176 SHORT...... 113 EPICERAM ...... 71 eszopiclone ...... 47 falmina (28)...... 180 EPIDIOLEX...... 23 ethacrynic acid ...... 56 famciclovir ...... 5 epinastine ...... 187 ethambutol ...... 10 famotidine ...... 162 epinephrine ...... 198 ethosuximide ...... 24 FANAPT ...... 47 EPINEPHRINE ...... 198 ethyl chloride ...... 76 FARXIGA ...... 113 epitol ...... 23 ethynodiol diac-eth estradiol FARYDAK ...... 16 EPIVIR HBV ...... 5 ...... 180 FASENRA ...... 203 eplerenone ...... 55 etidronate disodium...... 86 FASENRA PEN ...... 203 EPOGEN ...... 164 etodolac ...... 38 fayosim ...... 180 epoprostenol (glycine) ...... 56 etonogestrel-ethinyl estradiol FC2 FEMALE CONDOM . 113 eprosartan ...... 56 ...... 177 febuxostat ...... 172 epsom salt (laxative)...... 152 etoposide ...... 16 FEEDING TUBE EQUALACTIN ...... 152 etravirine ...... 5 ATTACHMENT DEVICE EQUETRO ...... 24 EUCRISA ...... 71 ...... 113 ERGOCAL ...... 223 EUFLEXXA ...... 38 FEIBA NF ...... 61 ergocalciferol (vitamin d2) 223, evac-u-gen (sennosides) ..... 152 felbamate ...... 24 224 EVENITY ...... 172 felodipine ...... 56 ERGOCALCIFEROL everolimus FEMRING...... 176 (VITAMIN D2) ...... 223, 224 (immunosuppressive)...... 16 fenofibrate ...... 65 ergoloid ...... 46 EVOTAZ ...... 5 fenofibrate micronized ...... 65 ERGOMAR ...... 28 EVRYSDI ...... 29 fenofibrate nanocrystallized ..65 ergotamine-caffeine ...... 28 EXCEL SYRINGE ...... 112 fenofibric acid ...... 65 ERIVEDGE ...... 15 EXEL HYPODERMIC fenoprofen ...... 38 ERLEADA ...... 16 NEEDLES ...... 112 fentanyl ...... 33 erlotinib ...... 16 EXEL INSULIN ...... 112 fentanyl citrate ...... 33 errin ...... 176 EXEL SYRINGE ...... 112 feosol ...... 224 ery pads ...... 75 exemestane ...... 16 FERAHEME ...... 224 ery-tab...... 9 EXODERM ...... 80 ferate ...... 224

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 246 ferocon...... 224 FINE 30 UNIVERSAL FLUBLOK QUAD 2021-2022 ferosul ...... 224 LANCETS ...... 113 (PF) ...... 167 ferretts...... 224 FINGERSTIX LANCETS .. 113 FLUCELVAX QUAD 2021- FERRETTS IPS ...... 224 FINTEPLA ...... 24 2022 ...... 167 ferrex 150 ...... 224 FIRDAPSE ...... 29 FLUCELVAX QUAD 2021- ferrex 150 forte ...... 224 FIRMAGON KIT W 2022 (PF) ...... 167 ferrex 150 forte plus ...... 224 DILUENT SYRINGE...... 16 fluconazole ...... 3 ferric x-150...... 224 first aid antibiotic-pain rlf ..... 77 flucytosine ...... 3 FERRIMIN 150 ...... 224 first aid antiseptic(povidone) 77 fludrocortisone ...... 94 FERRIPROX ...... 87 FIRVANQ ...... 13 FLULAVAL QUAD 2021- FERRIPROX (2 TIMES A fish oil ...... 215 2022 (PF) ...... 168 DAY) ...... 87 FISH OIL ...... 215 FLUMIST QUAD 2021-2022 ferrocite ...... 224 fish oil concentrate ...... 65 ...... 168 ferrocite plus ...... 224 fish oil extra strength ...... 215 flunisolide ...... 203 ferro-time ...... 224 FISH OIL PEARLS ...... 216 fluocinolone ...... 82, 83 ferrous fumarate ...... 224 fish oil-dha-epa...... 225 fluocinolone acetonide oil .....93 FERROUS FUMARATE... 224 flanax (naproxen) ...... 39 fluocinolone and shower cap 82 ferrous gluconate ...... 224 FLAREX...... 192 fluocinonide ...... 83 ferrous sulfate ...... 225 flavor chews antacid ...... 212 fluocinonide-e ...... 83 FETZIMA ...... 47 flavoxate ...... 207 fluorescein-proparacaine .... 187 fexofenadine...... 198 FLEBOGAMMA DIF ...... 167 fluoride (sodium) ...... 91, 225 fexofenadine-pseudoephedrine flecainide ...... 53 FLUORIDEX DAILY ...... 198 FLEET BISACODYL ...... 153 DEFENSE ...... 91 fiber (calcium polycarbophil) fleet enema ...... 153 FLUORIDEX SENSITIVITY ...... 153 fleet glycerin (adult)...... 153 RELIEF ...... 92 fiber (psyllium husk) ...... 153 FLEET GLYCERIN fluorometholone...... 192 fiber (psyllium husk-sugar) 153 LAXATIVE ...... 153 FLUOROPLEX ...... 71 fiber (with aspartame) ...... 153 fleet laxative (bisacodyl) .... 153 fluorouracil ...... 71 fiber laxative (ca polycarbo) FLEXICHAMBER ...... 113 FLUOROURACIL ...... 71 ...... 153 FLEXICHAMBER-LG fluoxetine ...... 47 fiber laxative (psyllium husk) CHILD MASK ...... 113 fluphenazine hcl ...... 47 ...... 153 FLEXICHAMBER-SM flurazepam...... 47 fiber therapy (ca polycarboph) ADULT MASK ...... 113 flurbiprofen ...... 39 ...... 153 FLEXICHAMBER-SM flurbiprofen sodium ...... 190 FIBER THERAPY CHILD MASK ...... 113 flutamide ...... 16 (PSYLLIUM-SUCRO) .. 153 FLEXIPAK ...... 39 fluticasone propionate .. 83, 203 fiber therapy laxative (husk) FLINTSTONES COMPLETE FLUTICASONE PROPION- ...... 153 (IRON) ...... 225 SALMETEROL ...... 204 fiber-caps (psyllium husk) . 153 floranex ...... 216 fluvoxamine ...... 47 fiber-lax ...... 153 FLOVENT DISKUS ...... 203 FLUZONE HIGHDOSE fiber-tabs ...... 153 FLOVENT HFA ...... 203 QUAD 21-22 PF ...... 168 FIBRICOR ...... 65 FLOW-EZE VENTED FLUZONE QUAD 2021-2022 FIFTY50 SAFETY SEAL NEEDLE ...... 113 ...... 168 LANCETS ...... 113 FLUAD QUAD 2021-22(65Y FLUZONE QUAD 2021-2022 FILTER NEEDLES ...... 113 UP)(PF)...... 167 (PF) ...... 168 FINACEA ...... 75 FLUARIX QUAD 2021-2022 FML FORTE...... 192 finasteride ...... 208 (PF) ...... 167 FML S.O.P...... 192 foaming acne face wash ...... 75

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 247 foaming antacid ...... 153 FREESTYLE PRECISION GELCLAIR ...... 92 FOCALIN XR ...... 47 NEO METER ...... 114 gemfibrozil ...... 65 folbee ...... 225 FREESTYLE PRECISION GENADUR ...... 71 folbee plus ...... 225 NEO STRIPS ...... 114 generlac ...... 154 folic acid ...... 225 FREESTYLE SIDEKICK II gengraf...... 16 FOLIC ACID ...... 225 ...... 114 GENOTROPIN ...... 165 FOLINIC-PLUS ...... 225 FREESTYLE SYSTEM KIT GENOTROPIN MINIQUICK folivane-f ...... 225 ...... 114 ...... 164 folivane-plus ...... 225 FREESTYLE TEST ...... 114 gentak ...... 184 folplex 2.2 ...... 225 FREESTYLE UNISTIK 2 .. 114 gentamicin ...... 77, 184 foltabs 800 ...... 225 FRESHKOTE ...... 187 GENTEAL TEARS SEVERE fondaparinux ...... 61 frovatriptan ...... 28 GEL ...... 188 foot and sneaker ...... 80 fruit c-500 ...... 225 gentle laxative (bisacodyl) . 154 for sty relief ...... 187 ful-glo ...... 187 gentlelax ...... 154 FORA V10-V12-D10-D20 FUL-GLO ...... 187 GENVOYA ...... 5 STRP-LNCT ...... 113 full spectrum b-vitamin c.... 225 geri-dryl ...... 198 FORACARE LANCETS ... 113 FULPHILA ...... 164 geri-kot ...... 154 formula 3 ...... 80 fungoid tincture ...... 80 geri-lanta ...... 154 FORTESTA ...... 143 fungoid-d ...... 80 geri-mox antacid-antigas .... 154 fosamprenavir ...... 5 furosemide ...... 56 GERI-MUCIL ...... 154 fosaprepitant...... 153 FUZEON ...... 5 GERI-MUCIL (SUGAR) ... 154 fosfree ...... 225 FYCOMPA ...... 24 geri-pectate ...... 147 fosinopril ...... 56 G GILENYA ...... 29 fosinopril-hydrochlorothiazide gabapentin...... 24 GILOTRIF ...... 16 ...... 56 galantamine ...... 29 GIVLAARI ...... 87 FRAGMIN ...... 61 GALZIN ...... 212 GLASSIA ...... 87 FREESTYLE FLASH GAMASTAN S/D ...... 168 GLEOSTINE ...... 16 SYSTEM ...... 113 GAMMAGARD LIQUID .. 168 glimepiride ...... 114 FREESTYLE FREEDOM . 113 GAMMAGARD S-D (IGA < 1 glipizide ...... 114 FREESTYLE FREEDOM MCG/ML) ...... 168 glipizide-metformin ...... 114 LITE ...... 113 GAMMAKED ...... 168 GLUCAGEN HYPOKIT ... 114 FREESTYLE INSULINX . 113 GAMMAPLEX ...... 168 glucagon emergency kit FREESTYLE INSULINX GAMMAPLEX (WITH (human) ...... 114 TEST STRIPS...... 113 SORBITOL) ...... 168 gluco burst ...... 87 FREESTYLE LANCETS .. 113 GAMUNEX-C ...... 168 GLUCO SHOT ...... 87 FREESTYLE LIBRE 14 DAY GARDASIL 9 (PF) .....168, 169 GLUCOCOM LANCETS .. 114 READER...... 113 gas relief (simethicone) ...... 153 glucose...... 87 FREESTYLE LIBRE 14 DAY gas relief 80 (simethicone) . 153 glucose bits...... 87 SENSOR ...... 114 gas relief extra strength...... 154 glucose gel ...... 87 FREESTYLE LIBRE 2 gas relief ultra strength ...... 154 GLUTOSE-15 ...... 87 READER...... 114 gatifloxacin ...... 184 GLUTOSE-45 ...... 87 FREESTYLE LIBRE 2 GATTEX 30-VIAL...... 154 glutose-5 ...... 87 SENSOR ...... 114 GATTEX ONE-VIAL ...... 154 glyburide ...... 114 FREESTYLE LITE METER gavilax...... 154 glyburide micronized...... 114 ...... 114 gavilyte-c ...... 154 glyburide-metformin ...... 114 FREESTYLE LITE STRIPS gavilyte-g ...... 154 glycerin (adult)...... 154 ...... 114 gavilyte-n ...... 154 glycerin (child)...... 154 FREESTYLE PRECISION 114 GAVRETO ...... 16 glycine urologic ...... 208

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 248 glycine urologic solution .... 208 healthy eyes supervision ..... 226 huber safety needles (disp.) 115 glycolax ...... 154 healthylax ...... 154 HUMALOG JUNIOR glycopyrrolate ...... 147 HEARTBURN AND ACID KWIKPEN U-100 ...... 115 GLYXAMBI ...... 114 REFLUX-ALOE ...... 226 HUMALOG KWIKPEN GOJJI LANCET-GLUCOSE heartburn antacid ...... 154 INSULIN...... 115 TEST STRP ...... 114 heartburn prevention ...... 163 HUMALOG MIX 50-50 GOJJI LANCETS ...... 115 heartburn relief ...... 154 INSULN U-100 ...... 116 granisetron (pf) ...... 154 heartburn relief (cimetidine) HUMALOG MIX 50-50 granisetron hcl ...... 154 ...... 163 KWIKPEN ...... 116 GRANIX ...... 165 heartburn relief (famotidine) HUMALOG MIX 75-25 GRASTEK ...... 169 ...... 163 KWIKPEN ...... 116 green glo ...... 188 heather...... 176 HUMALOG MIX 75-25(U- griseofulvin microsize ...... 3 HEMANGEOL ...... 56 100)INSULN ...... 116 griseofulvin ultramicrosize .....3 HEMATEX ...... 226 HUMALOG U-100 INSULIN guanfacine ...... 47, 56 hematinic plus vit/minerals 226 ...... 116 gummi bear multivitamin ... 225 hematinic/folic acid...... 226 HUMATE-P ...... 62 GVOKE HYPOPEN 1-PACK hematogen fa ...... 226 HUMIDIFIERS ...... 116 ...... 115 hematogen forte ...... 226 HUMIRA ...... 174 GVOKE HYPOPEN 2-PACK HEMOFIL M HIGH ...... 61 HUMIRA PEN...... 173 ...... 115 HEMOFIL M LOW ...... 61 HUMIRA PEN CROHNS-UC- GVOKE PFS 1-PACK HEMOFIL M MID ...... 62 HS START ...... 173 SYRINGE ...... 115 HEMOFIL M SUPER HIGH62 HUMIRA PEN PSOR- GVOKE PFS 2-PACK hemorrhoidal hygiene ...... 71 UVEITS-ADOL HS ...... 173 SYRINGE ...... 115 hemorrhoidal medicated ...... 71 HUMIRA(CF)...... 174 GYNAZOLE-1 ...... 178 HEPAGAM B ...... 169 HUMIRA(CF) PEDI gynol ii ...... 178 heparin (porcine) ...... 62 CROHNS STARTER ..... 174 H heparin flush(porcine)-0.9nacl HUMIRA(CF) PEN ...... 174 h2q ...... 85 ...... 62 HUMIRA(CF) PEN HAEGARDA ...... 204 heparin lock flush (porcine) . 62 CROHNS-UC-HS ...... 174 hair vitamins ...... 225 heparin lockflush(porcine)(pf) HUMIRA(CF) PEN hair, skin and nails advanced ...... 62 PEDIATRIC UC...... 174 ...... 226 heparin, porcine (pf) ...... 62 HUMIRA(CF) PEN PSOR- hair,skin and nails ...... 226 HEPARIN, PORCINE (PF) . 62 UV-ADOL HS ...... 174 halobetasol propionate ...... 83 HEPLISAV-B (PF) ...... 169 HUMULIN 70/30 U-100 haloperidol ...... 48 HERCEPTIN ...... 16 INSULIN...... 116 haloperidol decanoate ...... 47 HERCEPTIN HYLECTA .... 16 HUMULIN 70/30 U-100 haloperidol lactate ...... 47 HERZUMA ...... 16 KWIKPEN ...... 116 hand wash...... 71 HETLIOZ ...... 48 HUMULIN N NPH INSULIN HEALTHMIST ...... 115 hibiclens ...... 71 KWIKPEN ...... 116 HEALTHWISE INSULIN hi-cal plus vit d ...... 212 HUMULIN N NPH U-100 SYRINGE ...... 115 high potency iron ...... 226 INSULIN...... 116 HEALTHWISE PEN HIZENTRA ...... 169 HUMULIN R REGULAR U- NEEDLE ...... 115 homatropaire...... 186 100 INSULN...... 116 HEALTHY ACCENTS HOMOCYSTEINE HUMULIN R U-500 (CONC) UNIFINE PENTIP ...... 115 FORMULA ...... 226 INSULIN...... 116 HEALTHY ACCENTS honey bears multivitamin ... 226 HUMULIN R U-500 (CONC) UNILET LANCET ...... 115 HORIZONTAL DRAIN- KWIKPEN ...... 116 healthy eyes...... 226 TUBE ATT DEV ...... 115

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 249 HURRICAINE LIQUID I infants gas relief...... 155 DISPENSER ...... 116 ibandronate ...... 172 infant's ibuprofen ...... 39 HURRICAINE SPRAY IBRANCE...... 16 infant's motrin ...... 39 EXTENSION ...... 116 ibu-200 ...... 39 infants' mylicon...... 155 HYALGAN ...... 39 ibuprofen...... 39 infants' pain and fever ...... 39 HYCAMTIN ...... 16 ibuprofen ib ...... 39 infants' pain relief ...... 40 hydralazine ...... 56 ibuprofen jr strength...... 39 infants profenib ...... 40 hydrochlorothiazide ...... 56 icaps areds ...... 226 INFED ...... 226 hydrocodone bitartrate ...... 33 icatibant ...... 204 INFLECTRA ...... 155 hydrocodone-acetaminophen 33 ICLUSIG ...... 16 INGREZZA ...... 29 hydrocodone-ibuprofen ...... 33 IDELVION ...... 62 INGREZZA INITIATION hydrocortisone ...... 83, 94, 155 IDHIFA ...... 16 PACK ...... 29 hydrocortisone acetate ...... 83 iferex 150 ...... 226 INJECT EASE LANCETS 117 hydrocortisone butyrate ...... 83 iferex 150 forte ...... 226 INJECT-EASE...... 117 hydrocortisone plus ...... 83 ILARIS (PF) ...... 165 INLYTA ...... 17 hydrocortisone valerate ...... 83 ILUMYA ...... 68 INPEN (FOR HUMALOG) 117 hydrocortisone-acetic acid ....93 imatinib ...... 16 INPEN (FOR NOVOLOG OR hydrocortisone-aloe vera ...... 83 IMBRUVICA ...... 16, 17 FIASP) ...... 117 hydrocortisone-pramoxine . 155 imipramine hcl ...... 48 INQOVI...... 17 hydrocream ...... 83 imipramine pamoate ...... 48 INREBIC ...... 17 hydrogen peroxide ...... 87 imiquimod...... 71 INSPIRACHAMBER...... 117 hydrolatum ...... 71 IMOVAX RABIES VACCINE INSPIRACHAMBER WITH hydromorphone ...... 33 (PF) ...... 169 MASK-LARGE ...... 117 hydroxocobalamin ...... 226 IMPAVIDO ...... 10 INSPIRACHAMBER WITH hydroxychloroquine...... 10 IMPROVUE ...... 188 MASK-MED...... 117 hydroxyprogest(pf)(preg presv) INBRIJA ...... 27 INSPIRACHAMBER WITH ...... 176 IN-CHECK NASAL WITH MASK-SMALL ...... 117 hydroxyprogesterone MASK ...... 117 INSTACLEAN ...... 90 cap(ppres)...... 176 IN-CHECK ORAL FLOW insta-glucose (with dextrin) 117 hydroxyprogesterone caproate METER...... 117 INSULIN SYR/NDL U100 ...... 176 INCONTROL ALCOHOL HALF MARK ...... 117 hydroxyurea ...... 16 PADS ...... 117 INSULIN SYRINGE...... 118 HYDROXYUREA (BULK) .16 INCONTROL PEN NEEDLE INSULIN SYRINGE hydroxyzine hcl ...... 198 ...... 117 MICROFINE ...... 117 HYDROXYZINE HCL...... 198 INCONTROL SUPER THIN INSULIN SYRINGE hydroxyzine pamoate ...... 198 LANCETS ...... 117 NEEDLELESS ...... 117 hygienic cleansing ...... 71 INCONTROL ULTRA THIN insulin syringe-needle u-100 hyophen ...... 208 LANCETS ...... 117 ...... 119 hyoscyamine sulfate ...... 147 INCRELEX ...... 87 INSULIN SYRINGE- HYPERHEP B ...... 169 INCRUSE ELLIPTA ...... 204 NEEDLE U-100 ...... 118 HYPERHEP B NEONATAL indapamide ...... 56 INSUPEN ...... 119 ...... 169 INDOCIN ...... 39 INTEGRA HYPODERMIC NEEDLES indomethacin ...... 39 PRECISIONGLIDE ...... 117 INFANRIX (DTAP) (PF) ... 169 NEEDLE ...... 119 HYPOLANCE AST infant fever reducer-pain relf 39 INTELENCE ...... 5 LANCING ...... 117 infant pain reliever ...... 39 INTRINSI B12-FOLATE .. 226 HYQVIA ...... 169 infant's acetaminophen ...... 39 INTRON A...... 165 HYSINGLA ER ...... 33 infant's advil ...... 39 INVACARE LANCETS .... 119

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 250 INVEGA SUSTENNA...... 48 jantoven ...... 62 KINERET ...... 174 INVEGA TRINZA ...... 48 JANUMET ...... 119 KISQALI ...... 17 INVIRASE ...... 5 JANUMET XR...... 119 KISQALI FEMARA CO- INVOKAMET ...... 119 JANUVIA ...... 119 PACK ...... 17 INVOKAMET XR ...... 119 JARDIANCE ...... 119 klor-con 10 ...... 212 INVOKANA ...... 119 JELMYTO ...... 17 klor-con 8 ...... 212 inzo antifungal ...... 80 JEMPERLI ...... 17 klor-con m10 ...... 212 iodine ...... 71 jencycla ...... 176 klor-con m15 ...... 213 iodine-sodium iodide ...... 71 JENTADUETO ...... 119 klor-con m20 ...... 213 IODOFLEX ...... 71 JENTADUETO XR ...... 119 klor-con/ef ...... 213 IOPIDINE ...... 193 jinteli ...... 176 KOATE ...... 62 IPOL ...... 169 jock itch ...... 80 KOGENATE FS ...... 63 ipratropium bromide ..... 92, 204 jock itch (clotrimazole) ...... 80 KOMBIGLYZE XR ...... 119 ipratropium-albuterol ...... 204 jock itch (terbinafine) ...... 80 konsyl (sugar) ...... 155 i-prin ...... 40 jolessa ...... 181 konsyl formula-d...... 155 irbesartan ...... 56 juleber ...... 181 konsyl sugar-free ...... 155 irbesartan-hydrochlorothiazide JULUCA ...... 5 KORLYM ...... 143 ...... 56 junel 1.5/30 (21) ...... 181 KOVALTRY ...... 63 IRESSA ...... 17 junel 1/20 (21) ...... 181 k-pec antidiarrheal (bism sub) iron...... 227 junel fe 1.5/30 (28) ...... 181 ...... 147 IRON ...... 226 junel fe 1/20 (28) ...... 181 K-PHOS NO 2 ...... 208 iron (dried) ...... 226 junel fe 24 ...... 181 K-PHOS ORIGINAL ...... 208 iron (ferrous sulfate) ...... 226 JUXTAPID ...... 65 k-phos-neutral ...... 213 iron chews ...... 226 K kpn ...... 227 iron, carbonyl ...... 227 kaitlib fe ...... 181 KPN ...... 227 IRONUP ...... 227 KALBITOR ...... 204 KRISTALOSE ...... 155 ISENTRESS...... 5 KALETRA ...... 5 KRYSTEXXA ...... 172 ISENTRESS HD ...... 5 KALYDECO ...... 204 kurvelo (28)...... 181 isoniazid ...... 10 KANJINTI ...... 17 KYLEENA ...... 178 isopropyl alcohol ...... 87, 90 KANUMA ...... 143 KYNMOBI ...... 27 ISOPROPYL ALCOHOL .....87 kaopectate (bismuth subsalicy) L ISOPTO TEARS ...... 188 ...... 147 l norgest/e.estradiol-e.estrad isosorbide dinitrate ...... 67 KARBINAL ER ...... 198 ...... 181 isosorbide mononitrate ...... 67 kariva (28) ...... 181 l.acidophilus-bifido.longum 147 isradipine ...... 56 KCENTRA ...... 62 labetalol ...... 56 ISTURISA...... 143 kelnor 1/35 (28) ...... 181 LACRISERT ...... 188 itch relief (clotrimazole)...... 80 KERALYT SCALP lactase ...... 155 itraconazole ...... 3 COMPLETE ...... 69 lactase fast acting ...... 155 IV PREP WIPES ...... 119 KESIMPTA PEN ...... 29 lactobacillus acidophilus .... 216 ivermectin ...... 10, 75 ketoconazole ...... 3, 80 LACTOBACILLUS i-vite...... 227 KETONE CARE ...... 119 ACIDOPHILUS ...... 216 IXIARO (PF) ...... 169 KETONE URINE TEST .... 119 LACTOBACILLUS IXINITY...... 62 ketorolac ...... 40, 190 ACIDOPH-L. BIFID ...... 147 J KETOSTIX ...... 119 lactulose...... 155 JADENU ...... 87 ketotifen fumarate ...... 188 LAMICTAL ODT STARTER JAKAFI ...... 17 KEVZARA ...... 174 (BLUE)...... 24 JANSSEN COVID-19 kids vitamin d3 ...... 227 LAMICTAL ODT STARTER VACCINE (EUA) ...... 169 kinderlyte ...... 212 (GREEN)...... 24

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 251 LAMICTAL ODT STARTER leena 28 ...... 181 lindane ...... 84 (ORANGE) ...... 24 leflunomide ...... 174 linezolid ...... 10 LAMICTAL XR STARTER LENVIMA...... 17 linezolid in dextrose 5% ...... 10 (BLUE)...... 24 lessina ...... 181 linezolid-0.9% sodium chloride LAMICTAL XR STARTER letrozole ...... 17 ...... 10 (GREEN)...... 24 leucovorin calcium ...... 14 LINZESS ...... 156 LAMICTAL XR STARTER LEUKERAN ...... 17 LIORESAL ...... 31 (ORANGE) ...... 24 LEUKINE ...... 165 liothyronine ...... 145 LAMISIL (AEROSOL) ...... 80 leuprolide ...... 17 liquid b-12 ...... 227 lamisil af ...... 80 levalbuterol hcl ...... 204 lisinopril ...... 56 lamisil at ...... 80 levetiracetam ...... 25 lisinopril-hydrochlorothiazide lamivudine...... 5 LEVICYN DERMAL ...... 72 ...... 56 lamivudine-zidovudine ...... 5 levobunolol ...... 185 LITE TOUCH INSULIN PEN lamotrigine ...... 24, 25 levocarnitine ...... 87 NEEDLES ...... 120 LANCETS...... 119 levocarnitine (with sugar) ..... 87 LITE TOUCH INSULIN LANCETS, SUPER THIN. 120 levocetirizine ...... 198 SYRINGE ...... 120 LANCETS,THIN...... 120 levofloxacin ...... 12, 185 LITE TOUCH LANCETS . 120 LANCETS,ULTRA THIN . 120 levonest (28) ...... 181 LITE TOUCH-MEDIUM LANCING DEVICE WITH levonorgestrel ...... 181 MASK ...... 120 LANCETS ...... 120 levonorgestrel-ethinyl estrad LITEAIRE MDI CHAMBER lanolin anhydrous ...... 72 ...... 181, 182 ...... 120 LANOXIN ...... 59 levonorg-eth estrad triphasic LITETOUCH-LARGE MASK lansoprazole ...... 163 ...... 182 ...... 120 lanthanum ...... 87 levora-28 ...... 182 LITETOUCH-SMALL MASK LANTUS SOLOSTAR U-100 levorphanol tartrate ...... 34 ...... 120 INSULIN...... 120 levothyroxine ...... 145 lithium carbonate ...... 48 LANTUS U-100 INSULIN 120 levoxyl ...... 145 LITHOSTAT ...... 87 LANZO LANCING DEVICE LEVULAN ...... 72 little animals ...... 227 ...... 120 LEXIVA ...... 5 little animals-iron...... 227 larin 24 fe ...... 181 lice bedding spray ...... 84 little remedies...... 92 larin fe 1.5/30 (28) ...... 181 lice complete kit 1-2-3 ...... 84 little remedies fever and pain 40 larin fe 1/20 (28) ...... 181 lice killing ...... 84 little tummys gas relief ...... 156 latanoprost ...... 191 lice killing (permethrin) ...... 84 LO LOESTRIN FE ...... 182 LATUDA ...... 48 lice pyrinyl shampoo ...... 84 LONHALA MAGNAIR laxa basic ...... 155 lice solution ...... 84 REFILL ...... 204 laxacin ...... 155 lice treatment ...... 84 LONHALA MAGNAIR laxaclear ...... 155 lice treatment (permethrin) ... 84 STARTER ...... 204 laxative (bisacodyl) ...... 155 lidocaine...... 76 LONSURF ...... 17 laxative (glycerin-pediatric)155 lidocaine hcl ...... 76 loperamide...... 147 laxative (sennosides) ...... 155 lidocaine hcl-hydrocortison ac lopinavir-ritonavir...... 5 laxative peg 3350 ...... 155 ...... 156 loradamed ...... 198 laxative pills ...... 155 lidocaine viscous ...... 76 lorata-d ...... 198 laxative pills regular ...... 155 lidocaine-hydrocortisone-aloe loratadine ...... 198 laxative plus stool softener. 156 ...... 156 lorata-dine d ...... 198 layolis fe ...... 181 lidocaine-prilocaine...... 76, 77 loratadine-d ...... 198 lc-5 ...... 76 LIFESHIELD BLUNT lorazepam ...... 48, 49 LEDIPASVIR-SOFOSBUVIR CANNULA ...... 120 lorazepam intensol ...... 48 ...... 5 LILETTA ...... 178 LORBRENA ...... 17

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 252 LORTAB ELIXIR ...... 34 M maximum daily multivitamin loryna (28) ...... 182 maalox maximum strength . 156 ...... 227 losartan ...... 56 macuvite eye care ...... 227 MAYZENT ...... 30 losartan-hydrochlorothiazide 56 mafenide acetate ...... 78 MAYZENT STARTER PACK LOTEMAX ...... 192 mag-al plus ...... 156 ...... 30 loteprednol etabonate ...... 192 mag-al plus extra strength .. 156 mb hydrogel ...... 72 LOTRIMIN AF...... 80 MAGELLAN INSULIN m-dryl ...... 198 lotrimin af powder ...... 80 SAFETY SYRNG ...... 121 meclizine ...... 156 lotrimin ultra ...... 80 MAGELLAN SYRINGE ... 121 meclofenamate ...... 40 lovastatin ...... 65 magnesium...... 156, 213 medicated pads...... 72 low-ogestrel (28)...... 182 magnesium citrate ...... 156 medicated wipes ...... 72 loxapine succinate ...... 49 MAGNESIUM CITRATE . 213 MEDI-LYTE ...... 213 lubricant (p-glycol-glycerin) magnesium oxide ...... 213 medi-meclizine ...... 156 ...... 188 MAKENA (PF) ...... 176 medi-pads ...... 72 lubricant eye ...... 188 malathion ...... 84 mediproxen ...... 40 lubricant eye (pg-peg 400) . 188 mapap (acetaminophen) ...... 40 medi-seltzer ...... 40 lubricant eye drops ...... 188 mapap arthritis pain ...... 40 MEDISENSE THIN lubricating plus ...... 188 maprotiline...... 49 LANCETS ...... 121 lubrifresh pm ...... 188 marlissa (28) ...... 182 medlance plus lancets ...... 121 LUCEMYRA ...... 40 MARPLAN ...... 49 MEDLANCE PLUS SPECIAL LUCENTIS ...... 188 masophen ...... 40 BLADE ...... 121 ludent fluoride ...... 227 MATULANE ...... 18 MEDROL ...... 94 LUER LOCK SYRINGE ... 120 matzim la ...... 56 medroxyprogesterone . 176, 177 LUER SLIP TIP SYRINGE MAVENCLAD (10 TABLET mefloquine ...... 10 TRAY ...... 121 PACK) ...... 29 mega multi for women ...... 227 LUER-LOK TIP ...... 121 MAVENCLAD (4 TABLET mega multiple/chelated mineral lugols ...... 78 PACK) ...... 29 ...... 227 LUMIGAN ...... 191 MAVENCLAD (5 TABLET mega multivitamin for men 227 LUPANETA PACK (1 PACK) ...... 30 megestrol ...... 18 MONTH)...... 178 MAVENCLAD (6 TABLET MEKINIST ...... 18 LUPANETA PACK (3 PACK) ...... 30 MEKTOVI ...... 18 MONTH)...... 178 MAVENCLAD (7 TABLET meladox ...... 87 LUPRON DEPOT ...... 18 PACK) ...... 30 melatin ...... 87 LUPRON DEPOT (3 MAVENCLAD (8 TABLET melatonin ...... 88 MONTH)...... 17 PACK) ...... 30 MELATONIN...... 87, 88 LUPRON DEPOT (4 MAVENCLAD (9 TABLET MELATONIN-LEMON MONTH)...... 18 PACK) ...... 30 BALM LEAF EXTR ...... 90 LUPRON DEPOT (6 MAVYRET ...... 5 melatonin-pyridoxine hcl (b6) MONTH)...... 18 maxepa ...... 65 ...... 90 LUPRON DEPOT-PED ...... 18 MAXICOMFORT II PEN meloxicam ...... 40 LUPRON DEPOT-PED (3 NEEDLE ...... 121 melphalan ...... 18 MONTH)...... 18 MAXICOMFORT INSULIN memantine ...... 30 lutera (28) ...... 182 SYRINGE ...... 121 MEMANTINE ...... 30 LYNPARZA ...... 18 MAXI-COMFORT INSULIN MENACTRA (PF) ...... 169 LYRICA ...... 25 SYRINGE ...... 121 MENQUADFI (PF) ...... 170 lysiplex plus ...... 227 MAXICOMFORT SAFETY men's daily multivit-mineral LYSODREN ...... 18 PEN NEEDLE...... 121 ...... 227 lyza ...... 176 MAXIDEX ...... 192 men's one daily ...... 227

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 253 MENVEO A-C-Y-W-135-DIP MEXSANA (CORNSTARCH) minoxidil ...... 57 (PF) ...... 170 ...... 88 mintox...... 157 meperidine...... 34 mgo ...... 213 mintox maximum strength . 157 meprobamate ...... 31 MIACALCIN ...... 143 mintox plus...... 157 MEPSEVII ...... 143 mi-acid gas relief(simethicon) MIOCHOL-E ...... 186 mercaptopurine ...... 18 ...... 157 miostat ...... 191 mesalamine ...... 156 micatin ...... 80 miralax...... 157 MESNEX ...... 14 miconazole nitrate ...... 80, 178 MIRENA ...... 178 MESTINON ...... 31 miconazole-3 ...... 178 mirtazapine ...... 49 METAMUCIL ...... 157 miconazole-7 ...... 178 misoprostol ...... 163 METAMUCIL (WITH miconazole-skin clnsr17 ..... 178 M-M-R II (PF) ...... 170 SUGAR) ...... 156 miconazorb af ...... 80 m-natal plus...... 227 metamucil fiber singles ...... 156 MICRO THIN LANCETS . 121 modafinil ...... 49 METAMUCIL FIBER THIN MICROCHAMBER...... 121 MODERNA COVID-19 ...... 156 MICRODOT INSULIN PEN VACCINE (EUA) ...... 170 METAMUCIL FREE ...... 157 NEEDLE ...... 121 moexipril ...... 57 metaproterenol ...... 204 microgestin 1.5/30 (21)...... 182 moisture drops ...... 188 metformin ...... 121 microgestin 1/20 (21) ...... 182 mometasone ...... 83, 84, 204 methadone ...... 34 microgestin fe 1.5/30 (28) .. 182 MONISTAT 7 ...... 178 methadone intensol ...... 34 microgestin fe 1/20 (28) ..... 182 MONJUVI...... 18 methamphetamine...... 49 micro-guard ...... 80 MONOJECT 3CC SYR methazolamide ...... 191 MICROLET 2 LANCING 25GX1 ...... 122 methenamine hippurate ...... 13 DEVICE ...... 121 MONOJECT BLOOD methenamine mandelate ...... 13 MICROLET LANCET ...... 122 COLLECTION ...... 122 methimazole ...... 94 MICROLET NEXT MONOJECT BRACKET- METHITEST ...... 143 LANCING DEVICE ...... 122 SHARPS CONT ...... 122 methocarbamol ...... 32 MICROLIFE PEAK FLOW MONOJECT CONTROL methotrexate sodium ...... 18 METER...... 122 SYRINGE LUER ...... 122 methoxsalen ...... 72 MICROSPACER ...... 122 MONOJECT DISPOSABLE methscopolamine ...... 147 midazolam ...... 49 SYRINGE ...... 122 methyldopa ...... 56 midodrine ...... 88 MONOJECT ECCENTRIC methyldopa- migergot ...... 28 NON-STERILE ...... 122 hydrochlorothiazide ...... 57 miglitol...... 122 MONOJECT FILTER methylphenidate hcl ...... 49 miglustat ...... 143 ASPIRATOR ...... 122 methylprednisolone ...... 94 milk of magnesia ...... 157 MONOJECT FILTER methylprednisolone sodium milk of magnesia concentrated CONNECTOR ...... 122 succ ...... 94 ...... 157 MONOJECT FILTER methyltestosterone ...... 143 millipred...... 94 NEEDLE ...... 122 metipranolol ...... 185 millipred dp ...... 94 MONOJECT FINGER GRIP metoclopramide hcl ...... 157 milltrium senior ...... 227 EXTENDERS ...... 122 metolazone ...... 57 mimvey ...... 177 MONOJECT HYPODERMIC metoprolol succinate ...... 57 mineral oil ...... 88, 157 NEEDLES ...... 122 metoprolol ta-hydrochlorothiaz mineral oil extra heavy ...... 157 MONOJECT HYPODERMIC ...... 57 mineral oil heavy ...... 157 POLYPROPYL ...... 123 metoprolol tartrate ...... 57 MINI PRENATAL...... 227 MONOJECT INSULIN metronidazole ...... 10, 75, 178 MINI ULTRA-THIN II ...... 122 SAFETY SYRING ...... 123 metyrosine ...... 57 MINITRAN ...... 67 MONOJECT INSULIN mexiletine ...... 53 minocycline ...... 13 SYRINGE ...... 123

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 254 MONOJECT LUER-LOCK motion sickness ...... 157 murine ear wax removal TIP ...... 123 motion sickness (meclizine) system...... 93 MONOJECT MEDICATION ...... 157 MVASI ...... 18 TRANSF NDL...... 123 motion sickness relief ...... 157 mvc-fluoride...... 228 MONOJECT PHARMACY motion sickness relief(mecliz) MVW COMPLETE FORMUL TRAY LUER ...... 123 ...... 157 PEDIATRIC ...... 228 monoject prefill advanced ns 88 MOTOFEN ...... 147 my choice ...... 182 MONOJECT REG TIP NON- motrin ib ...... 40 my way ...... 182 STERILE...... 123 MOVANTIK ...... 157 MYALEPT ...... 143 MONOJECT REGULAR move it along ...... 157 mycophenolate mofetil ...... 18 LUER ...... 123 MOXATAG...... 12 mycophenolate sodium...... 18 MONOJECT SAFETY LUER moxifloxacin...... 12, 185 mycozyl ap ...... 80 LOCK TIP...... 123 MOZOBIL ...... 165 myferon 150 ...... 228 MONOJECT SAFETY SYR m-pap ...... 40 myferon 150 forte ...... 228 TIP CAP ...... 123 MUCILIN SF ...... 157 MYGLUCOHEALTH MONOJECT SAFETY MULTAQ ...... 53 LANCETS ...... 124 SYRINGES ...... 123 multi antibiotic plus ...... 78 MYLANTA GAS MINIS .. 157 MONOJECT SHARPS WALL multi complete with iron..... 227 mylanta maximum strength 157 CABINET ...... 123 multi for her ...... 227 MYLANTA TONIGHT ..... 157 MONOJECT SYRINGE .... 124 MULTI VITAMIN...... 227 MYLERAN ...... 18 MONOJECT SYRINGE multi-day with iron ...... 227 mynatal ...... 228 LUER LOK ...... 123 multi-delyn with iron ...... 228 mynatal plus ...... 228 MONOJECT SYRINGE MULTI-DRAW NEEDLE . 124 mynatal-z ...... 228 REGULAR LUER...... 124 multigen ...... 228 mynephrocaps ...... 228 MONOJECT TB ...... 124 multigen folic ...... 228 mynephron ...... 228 MONOJECT TB LUER LOK multigen plus ...... 228 myorisan ...... 75 ...... 124 MULTI-LANCET DEVICE 2 MYRBETRIQ ...... 207 MONOJECT TB SAFETY ...... 124 MYTESI ...... 147 SYRINGE ...... 124 multiple vitamin-minerals .. 228 my-vitalife ...... 228 MONOJECT TIP multiple vitamins...... 228 N CAPS/FLEX/LUER ...... 124 MULTISTIX ...... 124 nabumetone ...... 40 MONOJECT TUBERCULIN MULTISTIX 9 ...... 124 nadolol ...... 57 SYRINGE ...... 124 MULTISTIX 9 SG ...... 124 nadolol-bendroflumethiazide 57 MONOJECT ULTRA multi-vit with fluoride-iron 228 NALFON ...... 40 COMFORT INSULIN ... 124 multivitamin ...... 228 naloxone ...... 40 MONOLET LANCETS ..... 124 multivitamin 50 plus ...... 228 naltrexone ...... 40 MONOLET THIN LANCETS multivitamin with fluoride.. 228 NAMENDA XR ...... 30 ...... 124 multi-vitamin with fluoride 228 NAMZARIC ...... 30 mono-linyah ...... 182 multivitamin with iron ...... 228 NANO VM 1-3 ...... 229 MONONINE ...... 63 multivitamin with minerals 228 NANO VM 4-8 ...... 229 MONOVISC ...... 40 multivitamin women 50 plus NANOVM 9-18 ...... 229 montelukast ...... 204 ...... 228 NANOVM T-F ...... 229 MONUROL ...... 13 multivitamins with fluoride 228 naproxen ...... 40 morgidox ...... 13 MULTI-VITE ...... 228 naproxen sodium...... 40, 41 MORGIDOX 1X100 ...... 13 mupirocin ...... 78 naratriptan ...... 28 MORGIDOX 2X100 ...... 13 mupirocin calcium ...... 78 NARCAN ...... 41 morphine ...... 34 MURI-LUBE ...... 88 nasal allergy ...... 204 morphine concentrate ...... 34

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 255 nasal decongestant neomycin-polymyxin-hc...... 93, NITRO-DUR ...... 67 (pseudoeph)...... 198 191 nitrofurantoin ...... 13 nasal moisturizing ...... 92 neo-polycin ...... 185 nitrofurantoin macrocrystal...13 nasal spray (sodium chloride) neo-polycin hc ...... 192 nitrofurantoin monohyd/m- ...... 92 NEOQ10 ...... 85 cryst ...... 13 NASCOBAL ...... 229 neosporin plus painrelief(bac) nitroglycerin ...... 67 NATACYN ...... 185 ...... 78 NIVESTYM ...... 165 NATAZIA ...... 182 nephronex-sl ...... 229 nizatidine ...... 163 nateglinide ...... 124 nephro-vite rx ...... 229 NIZORAL A-D...... 80 NATESTO ...... 144 NERLYNX ...... 19 noble formula hc ...... 84 NATPARA ...... 144 neuac ...... 75 nohist-dm ...... 199 NATROBA ...... 84 NEULASTA ...... 165 NOKOR NEEDLE ...... 125 natural fiber laxative...... 158 NEULASTA ONPRO ...... 165 non-aspirin ...... 41 natural fiber laxative (sugar) NEUPOGEN ...... 165 non-aspirin extra strength...... 41 ...... 157 nevirapine ...... 5 non-aspirin pain relief ...... 41 natural fiber laxative(aspart) new day ...... 182 nora-be...... 177 ...... 158 newgen ...... 229 noreth-ethinyl estradiol-iron natural oatmeal bath treatment NEXAVAR ...... 19 ...... 182 ...... 72 NEXIUM 24HR ...... 163 norethindrone (contraceptive) natural tears (pf)...... 188 NEXPLANON ...... 178 ...... 177 natural veg laxative(sennosid) niacin ...... 66 norethindrone acetate ...... 177 ...... 158 niacin (inositol niacinate) .... 65, norethindrone ac-eth estradiol natural vegetable ...... 158 216 ...... 177, 182 natural vegetable (psyllium) niacin flush free ...... 216 norethindrone-e.estradiol-iron ...... 158 NIACIN FLUSH FREE ...... 216 ...... 182, 183 natural vegetable powder ... 158 NIACOR ...... 66 norgestimate-ethinyl estradiol natura-lax ...... 158 nicardipine ...... 57 ...... 183 NAYZILAM ...... 25 nicorette ...... 90 normal saline flush ...... 88 nebusal...... 205 nicotine ...... 90, 91 NORMALYTE ...... 213 necon 0.5/35 (28) ...... 182 nicotine (polacrilex) ...... 90 NORMALYTE ORS ...... 213 NEEDLE (DISP) 16 G ...... 125 NICOTROL ...... 91 NORPACE CR ...... 53 NEEDLE (DISP) 18 G ...... 125 NICOTROL NS ...... 91 nortemp ...... 41 NEEDLE (DISP) 19 G ...... 125 nifedipine ...... 57 NORTHERA ...... 88 NEEDLE (DISP) 23 GAUGE NIFEREX (SUMALATE- nortrel 0.5/35 (28) ...... 183 ...... 125 QUATREFOLIC) ...... 229 nortrel 1/35 (21) ...... 183 NEEDLES, HUBER nightime sleep ...... 198 nortrel 1/35 (28) ...... 183 DISPOSABLE ...... 125 nighttime allergy relief ...... 198 nortrel 7/7/7 (28)...... 183 nefazodone ...... 49 nighttime sleep aid (diphen) nortriptyline ...... 49 neomycin ...... 10 ...... 199 NORVIR ...... 5, 6 neomycin-bacitracin-poly-hc nighttime sleep-aid (doxylamn) NOVA SAFETY LANCETS ...... 191 ...... 49 ...... 125 neomycin-bacitracin- nikki (28) ...... 182 NOVA SUREFLEX polymyxin ...... 185 nilutamide ...... 19 LANCETS ...... 125 neomycin-polymyxin b gu ....85 nimodipine ...... 57 NOVAFERRUM ...... 229 neomycin-polymyxin b- NINLARO ...... 19 NOVAFERRUM 50 ...... 229 dexameth ...... 191 nisoldipine ...... 57 NOVOEIGHT ...... 63 neomycin-polymyxin- nitisinone ...... 88 NOVOFINE 32 ...... 125 gramicidin ...... 185 nitro-bid ...... 67

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 256 NOVOFINE AUTOCOVER O-CAL F.A...... 229 ON CALL PLUS LANCET126 ...... 125 OCALIVA ...... 158 ondansetron ...... 158 NOVOFINE PLUS ...... 125 ocean nasal ...... 92 ondansetron hcl ...... 158 NOVOLIN 70/30 U-100 ocella ...... 183 ondansetron hcl (pf)...... 158 INSULIN...... 125 OCREVUS ...... 30 ONE A DAY WOMEN'S NOVOLIN 70-30 FLEXPEN OCTAGAM ...... 170 PRENATAL DHA ...... 229 U-100...... 125 octreotide acetate...... 19 one daily ...... 230 NOVOLIN N FLEXPEN ... 125 ocutabs ...... 229 one daily calcium/iron ...... 229 NOVOLIN N NPH U-100 ODACTRA ...... 170 one daily complete...... 229 INSULIN...... 125 ODEFSEY ...... 6 one daily energy...... 229 NOVOLIN R FLEXPEN ... 125 ODOMZO...... 19 one daily essential...... 229 NOVOLIN R REGULAR U- odor control foot-sneaker ..... 81 one daily for men ...... 229 100 INSULN...... 125 OFEV ...... 205 one daily for men 50+ NOVOLOG FLEXPEN U-100 ofloxacin ...... 12, 93, 185 advanced ...... 229 INSULIN...... 125 OGIVRI ...... 19 one daily for women ...... 229 NOVOLOG MIX 70-30 U-100 olanzapine ...... 49 one daily maximum ...... 230 INSULN ...... 126 olanzapine-fluoxetine ...... 49 one daily men's 50 plus NOVOLOG MIX 70- olmesartan...... 57 memory ...... 230 30FLEXPEN U-100 ...... 126 olmesartan- one daily multi-vit w-mineral NOVOLOG PENFILL U-100 hydrochlorothiazide ...... 57 ...... 230 INSULIN...... 126 olopatadine ...... 92, 188 one daily multivitamin ...... 230 NOVOLOG U-100 INSULIN OLUMIANT...... 174 one daily multivit-iron(folic) ASPART ...... 126 omega 3-dha-epa-fish oil .... 216 ...... 230 NOVOPEN ECHO ...... 126 OMEGA 3-DHA-EPA-FISH one daily plus iron ...... 230 NOVOSEVEN RT ...... 63 OIL ...... 216 one daily plus minerals...... 230 NOVOTWIST...... 126 OMEGA-3 ...... 216 one daily prenatal ...... 230 np thyroid ...... 145 OMEGA-3 (WITH DPA) ... 216 ONE DAILY PRENATAL 230 NPLATE ...... 63 OMEGA-3 2100 ...... 216 one daily women 50 plus ... 230 NUCALA ...... 205 omega-3 acid ethyl esters ..... 66 one daily women's ...... 230 NUCYNTA ...... 41 omega-3 fatty acids ...... 66 one daily womens 50 plus .. 230 NUCYNTA ER...... 41 omega-3 fatty acids-fish oil 216 one-a-day essential ...... 230 NUEDEXTA ...... 30 OMEGA-3 FATTY ACIDS- one-a-day maximum formula NUFERA ...... 229 FISH OIL ...... 216 ...... 230 NULEV ...... 147 OMEGA-3 FISH OIL ...... 216 ONE-A-DAY PRENATAL-1 NU-MAG ...... 213 OMEGA-3S-DHA-EPA-FISH ...... 230 NUMOISYN ...... 88 OIL ...... 216 one-a-day teen advantage ... 230 NUPLAZID ...... 49 omeprazole ...... 163 ONE-A-DAY VITACRAVES NURTEC ODT ...... 28 omeprazole magnesium ...... 163 OMEGA-3 ...... 230 NUWIQ ...... 63 omeprazole-sodium ONETOUCH DELICA LANC nystatin ...... 3, 80 bicarbonate ...... 163 DEVICE ...... 126 nystatin-triamcinolone.... 80, 81 omnicap ...... 229 ONETOUCH DELICA nystop ...... 81 OMNIPOD DASH 5 PACK LANCETS ...... 126 NYVEPRIA ...... 165 POD ...... 126 ONETOUCH DELICA PLUS O OMNIPOD INSULIN LANC DEV ...... 126 oatmeal bath regular ...... 72 MANAGEMENT...... 126 ONETOUCH DELICA PLUS OB COMPLETE ONE ...... 229 OMNIPOD INSULIN REFILL LANCET ...... 126 OBIZUR ...... 63 ...... 126 ONETOUCH SURESOFT OC8 ...... 75 ON CALL LANCET ...... 126 LANCING DEV ...... 126

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 257 ONETOUCH ULTRASOFT oxandrolone ...... 144 PASER ...... 10 LANCETS ...... 126 oxaprozin ...... 41 PAXIL ...... 50 ONEXTON ...... 75 OXAYDO ...... 34, 35 p-col rite ...... 158 ONGLYZA ...... 126 oxazepam ...... 49 PEAK AIR PEAK FLOW ONPATTRO ...... 30 OXBRYTA ...... 88 METER ...... 127 ON-THE-GO LANCETS... 126 oxcarbazepine ...... 25 pedia iron...... 230 ONTRUZANT ...... 19 oxybutynin chloride ...... 207 pediacare fever reducer ...... 42 ONUREG ...... 19 oxycodone...... 35 PEDIA-LAX ...... 158 opcicon one-step ...... 183 oxycodone-acetaminophen ... 35 pedialyte ...... 214 opium tincture ...... 148 OXYCONTIN ...... 35 PEDIALYTE ...... 213 OPSUMIT ...... 205 oxymorphone ...... 35 pedialyte freezer pops...... 213 OPTICHAMBER ADULT oysco 500/d...... 213 pedialyte singles ...... 214 MASK-LARGE ...... 127 oyster shell + d3 ...... 213 PEDIALYTE SPARKLING OPTICHAMBER DIAMOND oyster shell calcium 500 ..... 213 RUSH ...... 214 LG MASK...... 127 oyster shell calcium-vit d3.. 213 PEDIARIX (PF) ...... 170 OPTICHAMBER DIAMOND oystercal-d ...... 213 pediatric electrolyte ...... 214 VHC ...... 127 OZEMPIC...... 127 PEDIATRIC ELECTROLYTE OPTICHAMBER DIAMOND- P ...... 214 MED MSK ...... 127 pacerone ...... 53 pediatric freezer pops ...... 214 OPTICHAMBER DIAMOND- PADCEV ...... 19 PEDIATRIC MOUTHPIECES SML MASK...... 127 PAIN EASE MEDIUM ...... 127 OPTIMAL D3 M ...... 230 STREAM SPRAY ...... 77 pediatric oint (cod liver oil) ..72 option-2 ...... 183 PAIN EASE MIST SPRAY . 77 PEDIATRIC-SMALL opti-vitamins ...... 230 pain relief (acetaminophen) .. 41 MOUTH ADAPTOR ..... 127 ORACIT ...... 208 pain relief adult ...... 41 peg 3350-electrolytes ...... 159 ORALAIR ...... 170 pain relief extra strength ...... 41 peg-electrolyte soln ...... 159 oralone ...... 92 pain relief regular strength.... 41 peg-prep...... 159 oralyte ...... 213 pain reliever (acetaminophen) PEMAZYRE ...... 19 ORAMAGICRX ...... 92 ...... 41 PEN NEEDLE ...... 127 ORAVIG ...... 3 pain reliever extra strength ... 41 PEN NEEDLE, DIABETIC127 ORENCIA ...... 174 pain reliever jr strength ...... 41 penicillamine ...... 175 ORENCIA (WITH paliperidone ...... 50 penicillin g procaine ...... 12 MALTOSE) ...... 174 palonosetron ...... 158 penicillin v potassium...... 12 ORENCIA CLICKJECT .... 174 PALONOSETRON ...... 158 PENTACEL (PF)...... 170 ORFADIN ...... 88 pamidronate ...... 144 PENTACEL ACTHIB ORILISSA...... 144 PANCREAZE ...... 158 COMPONENT (PF) ...... 170 ORKAMBI ...... 205 panoxyl ...... 75 pentamidine ...... 10 orphenadrine citrate ...... 32 PANRETIN ...... 72 PENTASA...... 159 orsythia ...... 183 pantoprazole ...... 163 pentazocine-naloxone ...... 42 ORTHOVISC ...... 41 PANZYGA ...... 170 PENTIPS ...... 127 oscimin sl ...... 148 PARAGARD T 380A ...... 127 pentoxifylline ...... 63 oscimin sr ...... 148 PAREMYD ...... 186 PEPAXTO...... 19 oseltamivir...... 6 paricalcitol ...... 144 pepcid ac ...... 163 OSMOPREP ...... 158 paroex oral rinse ...... 92 peptic relief ...... 148 OSPHENA ...... 178 paromomycin ...... 10 pepto-bismol ...... 148 OTEZLA ...... 174 paroxetine hcl ...... 50 pepto-bismol to-go ...... 148 OTEZLA STARTER...... 175 paroxetine perdiem overnight relief ..... 159 OTREXUP (PF) ...... 175 mesylate(menop.sym) ...... 50 PERFOROMIST...... 205

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 258 perindopril erbumine ...... 57 PIQRAY ...... 19 PRECISION XTRA perio med...... 92 pirmella ...... 183 KETONE-GLUCOSE .... 128 periogard ...... 92 piroxicam ...... 42 PRECISION XTRA permethrin ...... 84 PNEUMOVAX-23 ...... 170 MONITOR ...... 128 perphenazine ...... 50 pnv 29-1 ...... 230 PRECISION XTRA TEST 128 perphenazine-amitriptyline ...50 pnv-select ...... 230 PRED FORTE ...... 192 perry prenatal ...... 230 POCKET CHAMBER ...... 128 PRED MILD ...... 192 persa-gel ...... 75 POCKET PEAK FLOW PRED-G ...... 192 PERSONAL BEST FULL METER...... 128 PRED-G S.O.P...... 192 RANGE ...... 127 PODOCON ...... 69 prednisolone ...... 94 petrolatum ...... 72 podofilox...... 72 prednisolone acetate ...... 192 petrolatum, yellow (bulk)...... 72 POLY HUB NEEDLE ...... 128 prednisolone sodium phosphate petroleum jelly ...... 72 polycin ...... 185 ...... 94, 192 petroleum jelly, white ...... 72 polyethylene glycol 3350 ... 159 prednisone ...... 94 PFIZER COVID-19 poly-iron ...... 231 prednisone intensol ...... 94 VACCINE (EUA) ...... 170 poly-iron 150 forte ...... 231 PREFEST ...... 177 pharbechlor ...... 199 polymyxin b sulf-trimethoprim pregabalin ...... 25 pharbedryl ...... 199 ...... 185 PREMARIN ...... 177 pharbetol...... 42 polysaccharide iron complex pre-moistened hemorrhoidal .72 PHASEAL PROTECTOR . 127 ...... 231 pre-moistened medicated wipes phenazopyridine...... 209 polyvinyl alcohol...... 188 ...... 72 phenelzine ...... 50 POLY-VI-SOL ...... 231 PREMPHASE ...... 177 phenobarbital ...... 25 POLY-VI-SOL WITH IRON PREMPRO ...... 177 phenylephrine hcl ...... 193 ...... 231 prena1 chew ...... 231 phenytoin ...... 25 POMALYST ...... 19 prena1 pearl...... 231 phenytoin sodium extended ..25 portia 28 ...... 183 prena1 true ...... 231 philith ...... 183 posaconazole ...... 3 PRENATA ...... 231 PHILLIPS MILK OF pot,sodium citrate-citric acid prenatabs fa ...... 231 MAGNESIA ...... 159 ...... 208 prenatabs rx ...... 231 PHOSLYRA ...... 214 potassium chloride ...... 214 prenatal ...... 232 phospha 250 neutral...... 214 potassium citrate ...... 208 PRENATAL...... 232 phosphasal ...... 208 potassium citrate-citric acid 208 prenatal + dha ...... 231 phosphorous ...... 214 povidone-iodine...... 78 PRENATAL + DHA ...... 231 phospho-trin 250 neutral .... 214 powderlax ...... 159 PRENATAL 19 ...... 231 PHYTONADIONE pr cream ...... 72 prenatal complete...... 231 (VITAMIN K1) ...... 63 pr natal 400 ...... 231 PRENATAL FORMULA .. 231 PICATO ...... 72 pr natal 400 ec ...... 231 PRENATAL GUMMIES ... 231 PIFELTRO ...... 6 pr natal 430 ...... 231 prenatal low iron ...... 231 PIKO 1 ...... 127 pr natal 430 ec ...... 231 PRENATAL MULTI ...... 232 pilocarpine hcl ...... 88, 186 PRADAXA ...... 63 prenatal multi-dha (algal oil) pimozide ...... 50 PRALUENT PEN ...... 66 ...... 232 pimtrea (28)...... 183 pramipexole ...... 27 PRENATAL MULTI- pindolol ...... 57 prasugrel ...... 63 DHA(WITH VIT K) ...... 232 pink bismuth ...... 148 pravastatin...... 66 prenatal multivitamins ...... 232 pioglitazone ...... 127 praziquantel ...... 10 prenatal one daily ...... 232 pioglitazone-glimepiride .... 128 prazosin ...... 57 prenatal plus ...... 232 pioglitazone-metformin ...... 128 PRECISION XTRA B- prenatal plus (calcium carb)232 PIP LANCET ...... 128 KETONE ...... 128 prenatal tablet...... 232

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 259 prenatal vitamin ...... 232 probiotic colon care ...... 148 protriptyline ...... 50 prenatal vitamin plus low iron PROBUPHINE ...... 35 prudoxin ...... 72 ...... 232 PROCARE HUMIDIFIER . 129 pseudoephedrine hcl ...... 199 prenatal vit-iron fum-folic ac PROCARE SPACER WITH psyllium husk ...... 159 ...... 232 ADULT MASK ...... 129 PULMICORT FLEXHALER prenatal vits96-iron fum-folic PROCARE SPACER WITH ...... 205 ...... 232 CHILD MASK ...... 129 PULMOZYME ...... 205 PRENATAL WITH DHA- PROCHAMBER ...... 129 pure and gentle disposable . 159 FOLIC ACID ...... 232 prochlorperazine...... 159 pure and gentle eye ...... 188 preparation h (witch hazel) ...72 prochlorperazine maleate.... 159 PURE COMFORT ALCOHOL preplus ...... 232 PROCRIT ...... 166 PADS...... 129 PRESSURE ACTIVATED PROCTOFOAM HC...... 159 PURE COMFORT LANCETS ...... 128 procto-pak ...... 159 HUMIDIFIER ...... 129 PRESTALIA ...... 57 proctosol hc ...... 159 PURE COMFORT LANCETS pretab ...... 232 PRODIGY COUNT-A-DOSE ...... 129 PRETOMANID ...... 10 ...... 129 PURE COMFORT PEN prevalite ...... 66 PRODIGY INSULIN NEEDLE ...... 129 previfem ...... 183 SYRINGE ...... 129 PURE COMFORT SAFETY PREVNAR 13 (PF) ...... 170 PRODIGY LANCETS...... 129 LANCETS ...... 129 PREZCOBIX ...... 6 PRODIGY TWIST TOP PURECOMFORT PEAK PREZISTA ...... 6 LANCET ...... 129 FLOW METER ...... 129 PRIALT ...... 42 PROFERRIN ES ...... 232 purelax ...... 159 PRIFTIN...... 10 PROFILNINE...... 63 purevit dualfe plus ...... 232 PRILOSEC OTC ...... 163 progesterone ...... 177 PURIXAN ...... 19 PRIMAQUINE ...... 11 progesterone micronized..... 177 PUSH BUTTON SAFETY PRIMEAIRE ...... 128 PROLASTIN-C ...... 88 LANCETS ...... 129 primidone ...... 26 PROLIA ...... 172 pyrazinamide ...... 11 PRIMSOL ...... 13 PROMACTA ...... 63, 64 pyridostigmine bromide ...... 32 PRIVIGEN ...... 170 promethazine ...... 199 pyridoxine (vitamin b6)..... 232, PRO COMFORT ALCOHOL promethazine vc ...... 199 233 PADS...... 128 promethazine vc-codeine .... 199 pyrimethamine ...... 11 PRO COMFORT INSULIN promethazine-codeine ...... 199 Q SYRINGE ...... 128 promethazine-dm ...... 199 QBRELIS ...... 58 PRO COMFORT LANCET promethazine-phenyleph- Q-GEL ...... 217 ...... 128 codeine ...... 199 QINLOCK...... 19 PRO COMFORT PEN promethazine-phenylephrine QNASL ...... 205 NEEDLE ...... 129 ...... 199 q-sorb co q-10 ...... 85 PRO COMFORT SPACER- promethegan ...... 199 QUADRACEL (PF) ...... 170 ADULT MASK ...... 129 promolaxin...... 159 QUAZEPAM ...... 50 PRO COMFORT SPACER- propafenone ...... 53 quetiapine ...... 50 CHILD MASK ...... 129 proparacaine ...... 188 QUILLICHEW ER ...... 50 PRO FE ...... 232 propranolol ...... 57, 58 QUILLIVANT XR ...... 50 PROAIR DIGIHALER ...... 205 propranolol-hydrochlorothiazid quinapril ...... 58 PROAIR HFA ...... 205 ...... 58 quinapril-hydrochlorothiazide PROAIR RESPICLICK ..... 205 propylthiouracil ...... 94 ...... 58 probenecid ...... 172 prosight ...... 232 quinidine gluconate ...... 53 probenecid-colchicine ...... 172 protective ointment ...... 72 quinidine sulfate ...... 53 probiotic ...... 148, 217 PROTOPIC ...... 72 quinine sulfate ...... 11

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 260 quintabs-m iron free ...... 233 RELION NEEDLES ...... 130 RINVOQ ...... 175 quit 2 ...... 91 RELION PEN NEEDLES .. 130 RIOMET ...... 130 quit 4 ...... 91 RELION THIN LANCETS 130 RIOMET ER ...... 130 QVAR REDIHALER ...... 205 RELION ULTRA THIN PLUS risaquad ...... 148 R LANCETS ...... 130 risaquad-2 ...... 148 RABAVERT (PF) ...... 171 remedy antifungal ...... 81 risedronate ...... 89, 173 rabeprazole ...... 163 remedy phytoplex antifungal 81 RISPERDAL CONSTA ...... 51 RADIOGARDASE ...... 88 REMICADE ...... 159 risperidone...... 51 RAGWITEK ...... 171 RENACIDIN ...... 208 RITEFLO AEROCHAMBER raloxifene ...... 172 renal caps ...... 233 ...... 130 ramelteon ...... 50 rena-vite ...... 233 rivastigmine ...... 30 ramipril ...... 58 rena-vite rx ...... 233 rivastigmine tartrate ...... 30 ranolazine ...... 67 RENFLEXIS ...... 160 RIXUBIS ...... 64 RAPID B-12 ENERGY...... 233 reno caps ...... 233 rizatriptan ...... 28 RASUVO (PF) ...... 175 repaglinide ...... 130 ropinirole ...... 27 RAVICTI ...... 89 repaglinide-metformin ...... 130 rosadan ...... 76 RAYALDEE ...... 144 REPATHA PUSHTRONEX 66 ROSADAN ...... 76 READYLANCE SAFETY REPATHA SURECLICK .... 66 ROSANIL ...... 76 LANCETS ...... 129 REPATHA SYRINGE...... 66 rosuvastatin ...... 66 ready-to-use enema...... 159 REPLACE SR ...... 214 ROTARIX ...... 171 ready-to-use enema (min oil) REPLACEMENT ROTATEQ VACCINE ...... 171 ...... 159 NECKBAND STRAPS .. 130 roweepra ...... 26 REBINYN ...... 64 replesta ...... 233 ROZLYTREK...... 19 REBLOZYL...... 166 REPLESTA NX ...... 233 RUBRACA ...... 19 reclipsen (28) ...... 183 resource 2.0 ...... 217 RUCONEST ...... 206 RECOMBINATE ...... 64 RESTASIS...... 189 rufinamide ...... 26 RECOMBIVAX HB (PF) .. 171 RESTASIS MULTIDOSE . 189 RUKOBIA ...... 6 REFRESH CLASSIC (PF) 189 restore plus (cmcellulose) ... 189 RUXIENCE ...... 19 REFRESH DIGITAL ...... 189 RETACRIT ...... 166 RUZURGI ...... 30 REFRESH DIGITAL PF ... 189 revive plus ...... 189 RYBELSUS ...... 130 REFRESH LIQUIGEL...... 189 REVLIMID ...... 19 RYDAPT ...... 19 REFRESH OPTIVE ...... 189 REXULTI ...... 50 S REFRESH OPTIVE REYATAZ ...... 6 SABRIL ...... 26 ADVANCED ...... 189 REYVOW...... 28 SAFESNAP INSULIN REFRESH OPTIVE RHOFADE ...... 75 SYRINGE ...... 130 ADVANCED (PF) ...... 189 RHOPRESSA ...... 191 SAFESNAP SYRINGE ..... 130 REFRESH OPTIVE MEGA-3 RIABNI ...... 19 SAFETY LANCETS ...... 130 (PF) ...... 189 RIASTAP ...... 64 SAFETY NEEDLES ...... 131 REFRESH OPTIVE ribavirin ...... 6 SAFETY PEN NEEDLE ... 131 SENSITIVE (PF) ...... 189 rid complete lice elim kit ...... 85 SAFETY SEAL LANCETS REFRESH RELIEVA PF .. 189 rid lice killing ...... 85 ...... 131 REGULOID (PSYLLIUM RIDAURA ...... 175 SAFETY-LET LANCETS . 131 HUSK-SUCRO) ...... 159 rifabutin ...... 11 salicylic acid ...... 69 RELENZA DISKHALER ...... 6 rifampin ...... 11 saline mist ...... 92 RELIAMED LANCET ...... 130 RIGHTEST GL300 LANCETS saline nasal ...... 92 RELIAMED SAFETY SEAL ...... 130 saline nasal mist ...... 92 LANCETS ...... 130 riluzole ...... 89 saline nose ...... 92 relion glucose ...... 130 rimantadine ...... 6 salmon oil-1000 ...... 217

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 261 salsalate ...... 42 sennosides-docusate sodium sleep aid max str (diphenhydr) SALVAX DUO PLUS ...... 69 ...... 160 ...... 199 SAMSCA ...... 144 sen-o-tab ...... 160 sleep ii ...... 199 SANDIMMUNE...... 19 sentry ...... 233 sleep tablet (diphenhydramine) SANDOSTATIN LAR sentry senior ...... 233 ...... 199 DEPOT ...... 20 SEREVENT DISKUS ...... 206 sleep-tabs ...... 199 SANTYL ...... 84 sertraline ...... 51 slo-niacin ...... 66 sapropterin...... 144 se-tan plus ...... 233 slow release iron ...... 233 SARCLISA ...... 20 setlakin ...... 183 SLOW RELEASE IRON ... 233 SAVAYSA ...... 64 sevelamer carbonate ...... 89 SLOW-MAG ...... 214 SAVELLA ...... 175 sevelamer hcl ...... 89 SMART SENSE LANCETS scalp relief ...... 84 sf 92 ...... 131 scalpicin anti-itch...... 84 sf 5000 plus ...... 92 SMARTEST LANCET ...... 131 scar gel ...... 72 SFROWASA ...... 160 smooth antacid ...... 214 scopolamine base ...... 160 shake that ache ...... 42 smoothlax ...... 160 SEAL TIGHT ...... 131 sharobel ...... 177 sodium bicarbonate...... 160 sea-omega...... 217 SHINGRIX (PF) ...... 171 sodium chloride ...... 89, 206 seconal sodium...... 51 SIGNIFOR...... 20 sodium chloride 0.9 %...... 89 SECUADO ...... 51 SIGNIFOR LAR ...... 20 sodium chloride 0.9 % (flush) secura antifungal ...... 81 silace ...... 160 ...... 89 SECURA EXTRA siladryl sa ...... 199 sodium ferric gluconat-sucrose PROTECTIVE ...... 72 silapap ...... 42 ...... 89 secura protective ...... 73 sildenafil (pulm.hypertension) sodium fluoride 5000 dry SECURESAFE PEN NEEDLE ...... 206 mouth...... 92 ...... 131 SILIQ ...... 68 sodium phenylbutyrate ...... 89 SEGLUROMET ...... 131 silver nitrate ...... 73 sodium polystyrene sulfonate selegiline hcl ...... 27 silver nitrate applicators...... 73 ...... 89 selenium sulfide ...... 68 silver sulfadiazine ...... 69 sof-lax ...... 160 selsun blue ...... 68 SIMBRINZA ...... 191 SOFOSBUVIR- SELZENTRY ...... 6 simethicone ...... 160 VELPATASVIR ...... 6 SEMGLEE PEN U-100 SIMILAC PRENATAL ...... 233 SOFT TOUCH LANCETS 131 INSULIN...... 131 simply sleep ...... 199 solifenacin ...... 207 SEMGLEE U-100 INSULIN SIMPONI ...... 175 SOLIQUA 100/33 ...... 131 ...... 131 SIMPONI ARIA ...... 175 SOLIRIS...... 89 se-natal 19 chewable ...... 233 simvastatin ...... 66 SOLODYN ...... 13 se-natal-19 ...... 233 SINGLE-LET ...... 131 SOLTAMOX ...... 20 senexon-s ...... 160 sinus 12 hour ...... 199 SOLU-CORTEF ACT-O- senior tabs ...... 233 sirolimus ...... 20 VIAL (PF) ...... 94 senna ...... 160 SIRTURO ...... 11 SOLUS V2 LANCETS ...... 131 SENNA ...... 160 SIVEXTRO ...... 11 SOLUS V2 LANCING senna lax ...... 160 skin protectant a and d ...... 73 DEVICE ...... 131 senna laxative...... 160 skin treatment ...... 73 SOMAVERT ...... 144 senna plus ...... 160 SKYLA ...... 179 soothe (bismuth subsalicylate) senna with docusate sodium SKYRIZI ...... 68 ...... 148 ...... 160 sleep aid (diphenhydramine) SOOTHE LUBRICANT .... 189 senna-s ...... 160 ...... 199 soothe regular strength ...... 148 senna-time s ...... 160 sleep aid (doxylamine) ...... 51 soothing care (hydrocortisone) sennosides ...... 160 ...... 84

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 262 soothing pureway-c ...... 233 stomach relief ...... 148 super multivitamin ...... 234 SORBITOL ...... 85 stomach relief original ...... 148 super omega-3 ...... 66 SORBITOL-MANNITOL ....85 stool softener ...... 160 super probiotic ...... 148 sorine ...... 53 stool softener (docusate cal) super quints b-50 ...... 234 sotalol ...... 53 ...... 160 super thera vite m ...... 234 sotalol af ...... 53 stool softener-laxative ...... 161 SUPER THIN LANCETS.. 132 SOTYLIZE ...... 53 stool softener-stimulant laxat SUPER TWIN EPA-DHA ....66 SPACE CHAMBER ...... 131 ...... 161 suphedrin ...... 200 SPACE CHAMBER WITH stop lice ...... 85 suphedrine ...... 200 LARGE MASK ...... 131 stop smoking aid ...... 91 suphedrine 12 hour ...... 200 SPACE CHAMBER WITH STRENSIQ ...... 144 support ...... 234 MEDIUM MASK ...... 131 stress b with zinc ...... 234 SUPPRELIN LA ...... 20 SPACE CHAMBER WITH stress formula ...... 234 SUPRAX ...... 8 SMALL MASK ...... 131 stress formula 600 c ...... 234 supress dx ...... 200 SPECTRACEF ...... 8 stress formula with iron ...... 234 SURE COMFORT ALCOHOL spectravite adult 50 plus ..... 233 stress formula with iron(sulf) PREP PADS...... 132 spectravite advanced formula ...... 234 SURE COMFORT INSULIN ...... 233 stress formula with zinc ...... 234 SYRINGE ...... 132 spectravite men's ...... 233 STRIBILD ...... 6 SURE COMFORT LANCETS spectravite women ...... 233 STRIVERDI RESPIMAT .. 206 ...... 132 spinosad ...... 85 SUBLOCADE ...... 35 SURE COMFORT PEN SPINRAZA (PF) ...... 30 SUBOXONE ...... 42 NEEDLE ...... 132 SPIRIVA RESPIMAT ...... 206 sucralfate...... 163 SURE-FINE PEN NEEDLES SPIRIVA WITH SUCTION TUBE ...... 132 HANDIHALER ...... 206 ATTACHMENT DEVICE SUREFLEX DEVICE WITH spironolactone ...... 58 ...... 131 LANCETS ...... 132 spironolacton-hydrochlorothiaz sudogest ...... 200 SURE-JECT INSULIN ...... 58 sudogest 12-hour ...... 199 SYRINGE ...... 132 SPLASH SHIELD FLEX .. 131 sulfacetamide sodium ... 68, 193 SURE-LANCE ...... 132 SPRAY AND STRETCH .....77 sulfacetamide sodium (acne) 78 SURE-LANCE ULTRA THIN sprintec (28) ...... 183 sulfacetamide sodium-sulfur 76 ...... 132 SPRITAM ...... 26 sulfacetamide-prednisolone 193 SURE-PREP ALCOHOL SPRYCEL ...... 20 sulfadiazine ...... 12 PREP PADS...... 132 sps (with sorbitol) ...... 89 sulfamethoxazole-trimethoprim SURE-TOUCH LANCET . 132 sronyx ...... 183 ...... 12 surfak ...... 161 ssd ...... 69 SULFAMYLON ...... 78 SURGUARD2 SAFETY.... 133 SSKI ...... 94 sulfasalazine ...... 161 SUTENT ...... 20 sss 10-5 ...... 76 sulfatrim ...... 12 SWABFLUSH ...... 89 st joseph aspirin ...... 42 sulindac ...... 42 syeda ...... 183 st. joseph aspirin ...... 42 sumatriptan ...... 28 SYMAX DUOTAB ...... 148 STAMARIL (PF)...... 171 sumatriptan succinate...... 28 symax-sr ...... 148 stavudine ...... 6 SUMAXIN CP ...... 76 SYMBICORT ...... 206 STEGLATRO ...... 131 SUNOSI ...... 51 SYMDEKO ...... 206 STELARA...... 68 sunvite ...... 234 SYMJEPI ...... 200 STERILANCE TL ...... 131 super antioxidant ...... 234 SYMLINPEN 120 ...... 133 STERILE LUBRICANT .... 190 super calcium...... 214 SYMLINPEN 60 ...... 133 stimulant laxative plus...... 160 SUPER DAILY D3 ...... 234 SYMTUZA ...... 6 STIVARGA ...... 20 super multiple ...... 234 SYNAGIS ...... 6, 7

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 263 SYNALAR CREAM KIT .....84 tamsulosin ...... 208 tetracycline ...... 13 SYNAREL ...... 144 targeted acne spot treatment . 76 THALOMID ...... 21 SYNERA ...... 77 TARGRETIN ...... 20 the magic bullet ...... 161 SYNJARDY...... 133 taron forte ...... 234 THEO-24 ...... 206 SYNJARDY XR ...... 133 TASIGNA...... 20 theophylline ...... 206 SYNRIBO ...... 20 TAVALISSE ...... 64 thera ...... 234 SYNVISC ...... 42 tazarotene ...... 76 thera m plus (ferrous fumarat) SYNVISC-ONE...... 42 TAZORAC ...... 76 ...... 234 SYRINGE (DISPOSABLE) taztia xt...... 58 thera-d...... 234 ...... 133 TAZVERIK ...... 20 THERA-D 4000 ...... 234 SYRINGE 3CC/20GX1 ..... 133 TECFIDERA ...... 31 theralogix companion ...... 234 SYRINGE 3CC/21GX1 ..... 133 TECHLITE INSULIN thera-m ...... 234 SYRINGE 3CC/21GX1-1/2 SYRINGE ...... 134 THERANATAL ...... 234 ...... 133 TECHLITE INSULN THERANATAL COMPLETE SYRINGE 3CC/22GX1 ..... 133 SYR(HALF UNIT) ...... 134 ...... 234 SYRINGE 3CC/22GX3/4 .. 133 TECHLITE LANCETS ...... 134 THERANATAL ONE ...... 234 SYRINGE 3CC/25GX1 ..... 133 TECHLITE PEN NEEDLE 134 THERANATAL OVAVITE SYRINGE LUER TIP CAP 133 TEKTURNA HCT ...... 58 ...... 235 SYRINGE TIP CONNECTOR TELCARE LANCETS ...... 134 THERANATAL PLUS ...... 235 ...... 133 telmisartan ...... 58 therapeutic liquid ...... 235 SYRINGE WITH NEEDLE telmisartan-amlodipine ...... 58 therapeutic-m ...... 235 ...... 133 telmisartan-hydrochlorothiazid thera-tabs ...... 235 SYSTANE (PROPYLENE ...... 58 thera-tabs m...... 235 GLYCOL) ...... 190 temazepam ...... 51 THERATEARS ...... 190 SYSTANE GEL ...... 190 TEMIXYS ...... 7 theratrum complete 50 plus/lut SYSTANE ULTRA ...... 190 temozolomide ...... 21 ...... 235 T temsirolimus ...... 21 theratrum complete 50 plus-lyc tab-a-vite ...... 234 TENIVAC (PF) ...... 171 ...... 235 tab-a-vite multivitamin w-iron tenofovir disoproxil fumarate . 7 theratrum complete with lutein ...... 234 TEPEZZA ...... 144 ...... 235 TABLET CUTTER ...... 133 terazosin ...... 58 therems multivitamin...... 235 TABLOID ...... 20 terbinafine hcl ...... 3, 81 therems-m ...... 235 TABRECTA ...... 20 terbutaline ...... 206 thermotabs ...... 214 tacrolimus ...... 20 terconazole...... 179 thiamine hcl (vitamin b1) ... 235 tactinal ...... 42 TERUMO ALLERGY THIAMINE HCL (VITAMIN tadalafil ...... 208 SYRINGE ...... 134 B1) ...... 235 TAFINLAR ...... 20 TERUMO HYPODERMIC thiamine mononitrate (vit b1) tagamet hb ...... 163 NEEDLE/SYRIN ...... 134 ...... 235 TAGRISSO ...... 20 TERUMO INSULIN THIN LANCETS...... 134 TAKHZYRO ...... 206 SYRINGE ...... 134 thinpro insulin syringe...... 135 TALTZ AUTOINJECTOR ...68 TERUMO SYRINGE ...... 134 THINPRO INSULIN TALTZ AUTOINJECTOR (2 TESTONE CIK ...... 144 SYRINGE ...... 135 PACK) ...... 68 TESTOPEL ...... 144 THIOLA ...... 89 TALTZ AUTOINJECTOR (3 testosterone ...... 144, 145 thioridazine ...... 51 PACK) ...... 68 testosterone cypionate ...... 144 thiothixene...... 51 TALTZ SYRINGE ...... 69 testosterone enanthate ...... 144 THROMBATE III ...... 64 TALZENNA ...... 20 tetrabenazine...... 31 THYQUIDITY ...... 145 tamoxifen ...... 20 TETRACAINE HCL (PF) .. 190 THYROGEN ...... 89

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 264 tiagabine ...... 26 TREMFYA ...... 69 TRIPTODUR ...... 21 TIBSOVO ...... 21 TRESIBA FLEXTOUCH U- tri-sprintec (28) ...... 184 tilia fe...... 183 100 ...... 135 TRIUMEQ ...... 7 timolol maleate ..... 58, 185, 186 TRESIBA FLEXTOUCH U- triveen-duo dha ...... 235 tinactin ...... 81 200 ...... 135 TRI-VI-SOL...... 235 tinidazole ...... 11 TRESIBA U-100 INSULIN tri-vitamin with fluoride ..... 235 TIROSINT ...... 146 ...... 135 tri-vite with fluoride ...... 235 TIVICAY ...... 7 tretinoin ...... 76 trivora (28) ...... 184 TIVICAY PD ...... 7 tretinoin (antineoplastic) ...... 21 TRODELVY ...... 21 tizanidine ...... 32 TRETTEN ...... 64 tropicamide ...... 186 tobramycin ...... 185 TREXALL ...... 21 trospium ...... 207 tobramycin in 0.225 % nacl ..11 triamcinolone acetonide . 84, 92, TRUE COMFORT tobramycin-dexamethasone 192 207 ALCOHOL PADS...... 135 TODAY CONTRACEPTIVE triamterene-hydrochlorothiazid TRUE COMFORT INSULIN SPONGE ...... 179 ...... 58 SYRINGE ...... 135 tolmetin ...... 42 triazolam ...... 51 TRUE COMFORT LANCET tolnaftate...... 81 tri-chlor ...... 73 ...... 135 tolterodine ...... 207 tricitrates ...... 208 TRUE COMFORT PEN tolvaptan ...... 145 tricon ...... 235 NEEDLE ...... 136 TOLVAPTAN ...... 145 triderm...... 84 TRUE COMFORT PRO TOPCARE CLICKFINE.... 135 trientine ...... 89 ALCOHOL PADS...... 136 TOPCARE ULTRA TRIESENCE (PF) ...... 94 TRUEPLUS GLUCOSE ...... 89 COMFORT ...... 135 tri-estarylla...... 183 TRUEPLUS INSULIN...... 136 TOPCARE UNIVERSAL1 trifluoperazine ...... 51 TRUEPLUS KETONE...... 136 LANCET ...... 135 trifluridine ...... 185 TRUEPLUS LANCETS .... 136 topiramate ...... 26 trigels-f forte ...... 235 TRUEPLUS PEN NEEDLE toremifene ...... 21 trihexyphenidyl ...... 27 ...... 136 torsemide ...... 58 TRIKAFTA ...... 207 TRULICITY ...... 136 total allergy medicine ...... 200 tri-legest fe ...... 183 TRUMENBA ...... 171 TOUJEO MAX U-300 tri-linyah ...... 183 TRUVADA ...... 7 SOLOSTAR ...... 135 tri-lo-estarylla ...... 183 TRUXIMA ...... 21 TOUJEO SOLOSTAR U-300 tri-lo-marzia ...... 184 TUBERCULIN SYRINGE 136 INSULIN...... 135 tri-lo-sprintec ...... 184 TUBERCULIN-ALLERGY TRACLEER ...... 206 trilyte with flavor packets ... 161 SYRINGES ...... 136 TRADJENTA ...... 135 trimethobenzamide ...... 161 TUDORZA PRESSAIR ..... 207 tramadol...... 42 trimethoprim ...... 13 TUKYSA ...... 21 tramadol-acetaminophen ...... 42 trimipramine ...... 52 tums ultra...... 161, 214 trandolapril ...... 58 trinatal rx 1 ...... 235 TURALIO ...... 21 trandolapril-verapamil ...... 58 trinate ...... 235 TWINRIX (PF) ...... 171 tranexamic acid ...... 179 TRINTELLIX...... 52 TWIST LANCETS ...... 136 tranylcypromine ...... 51 triphrocaps ...... 235 TYBOST ...... 7 travel sickness ...... 161 triple antibiotic ...... 78 TYKERB ...... 21 travel-ease (meclizine) ...... 161 triple antibiotic plus ...... 78 tylophen ...... 42 travoprost ...... 191 TRIPLE ANTIBIOTIC TYMLOS ...... 173 TRAZIMERA ...... 21 SPRAY ...... 78 TYPHIM VI ...... 171 trazodone ...... 51 triple antibiotic-pain relief .... 78 tyr cooler ...... 217 TRECATOR ...... 11 TRIPLE DYE ...... 81 TYSABRI ...... 31 TRELSTAR ...... 21 tri-previfem (28) ...... 184

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 265 U ULTRA LUBRICANT EYE UNILET SUPER THIN UBRELVY ...... 28 ...... 190 LANCETS ...... 140 UDENYCA ...... 166 ultra omega-3...... 217 unisom sleepgels ...... 200 UKONIQ ...... 21 ULTRA PRENATAL PLUS UNISTIK 2 DEVICE ...... 140 ULESFIA ...... 85 DHA ...... 236 UNISTIK 2 NORMAL ulticare ...... 137 ultra strength antacid ...... 214 LANCET,DEVICE ...... 140 ULTICARE ...... 137 ULTRA THIN II LANCETS UNISTIK 3...... 140 ULTICARE INSULIN ...... 138 UNISTIK 3 COMFORT SYRINGE ...... 136 ULTRA THIN LANCETS . 138 DEVICE ...... 140 ULTICARE INSULN ULTRA THIN PEN NEEDLE UNISTIK 3 COMFORT SYR(HALF UNIT) ...... 137 ...... 138 LANCET ...... 140 ULTICARE PEN NEEDLE ULTRA THIN PLUS UNISTIK 3 EXTRA LANCET ...... 137 LANCETS ...... 138 ...... 140 ULTICARE SAFETY ULTRA TLC LANCETS ... 138 UNISTIK 3 GENTLE ...... 140 SYRINGE ...... 137 ULTRACARE INSULIN UNISTIK 3 LANCETS ...... 140 ULTICARE TB SAFETY SYRINGE ...... 139 UNISTIK 3 NEONATAL SYRINGE ...... 137 ULTRA-CARE LANCETS 139 DEVICE ...... 140 ULTIGUARD SAFEPACK- ULTRACARE PEN NEEDLE UNISTIK 3 NORMAL PEN NEEDLE ...... 137 ...... 139 LANCET ...... 140 ULTI-LANCE...... 137 ULTRALANCE LANCETS UNISTIK CZT LANCET .. 141 ULTILET ALCOHOL SWAB ...... 139 UNISTIK NORMAL ...... 137 ULTRA-THIN II (SHORT) LANCETS ...... 141 ULTILET BASIC LANCETS INS SYR ...... 139 UNISTIK PRO LANCET .. 141 ...... 137 ULTRA-THIN II (SHORT) UNISTIK SAFETY ...... 141 ULTILET CLASSIC PEN NDL ...... 139 UNISTIK TOUCH LANCETS LANCETS ...... 137 ULTRA-THIN II INS PEN ...... 141 ULTILET INSULIN NEEDLES ...... 139 unithroid ...... 146 SYRINGE ...... 137 ULTRA-THIN II INSULIN UNIVERSAL 1 LANCETS 141 ULTILET LANCETS ...... 137 SYRINGE ...... 139 UNIVERSAL CATHETER ULTILET PEN NEEDLE .. 138 ULTRA-THIN II LANCETS ACCESS PORT ...... 141 ULTILET SAFETY ...... 139 UNIVERSAL SYRINGE TIP LANCETS ...... 138 UNIFINE PENTIPS ...... 140 ADAPTOR...... 141 ultimate women's complete UNIFINE PENTIPS UPLIZNA ...... 21 50+ ...... 235 MAXFLOW ...... 139 UPTRAVI ...... 59 ULTOMIRIS ...... 89 UNIFINE PENTIPS PLUS 140 uretron d-s ...... 208 ultra antioxidant formula .... 236 UNIFINE PENTIPS PLUS URIBEL ...... 209 ULTRA CMFT INS SYR MAXFLOW ...... 140 URI-DRAIN...... 141 (HALF UNIT)...... 138 UNIFINE SAFECONTROL urimar-t ...... 209 ultra comfort insulin syringe ...... 140 URISTIX 4 ...... 141 ...... 138 UNILET COMFORTOUCH URISTIX REAGENT ...... 141 ULTRA COMFORT INSULIN LANCET ...... 140 ursodiol ...... 161 SYRINGE ...... 138 UNILET EXCELITE II uryl...... 209 ultra dairy digestive ...... 161 LANCET ...... 140 ustell ...... 209 ULTRA FLO INSULIN UNILET EXCELITE utira-c ...... 209 SYRINGE ...... 138 LANCET ...... 140 V ULTRA FLO PEN NEEDLE UNILET GP LANCET ...... 140 valacyclovir ...... 7 ...... 138 UNILET LANCET ...... 140 VALCHLOR ...... 73 ultra fresh ...... 190 UNILET LANCETS ...... 140 valganciclovir ...... 7

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 266 valproic acid ...... 26 V-GO 40 ...... 142 vitamin k ...... 64 valproic acid (as sodium salt) VIBRAMYCIN ...... 13 vitamins a,c,d and fluoride . 237 ...... 26 vic-forte ...... 236 vitamins b complex ...... 237 valsartan ...... 59 vicodin hp ...... 35 vitamins for hair...... 237 valsartan-hydrochlorothiazide VICTOZA 2-PAK ...... 142 vitatrum ...... 237 ...... 59 VICTOZA 3-PAK ...... 142 VITRAKVI ...... 22 VALTOCO ...... 26 VIEKIRA PAK ...... 7 vitrum senior ...... 237 valu-dryl allergy ...... 200 vienva ...... 184 vits a and d-white pet-lanolin vancomycin ...... 13 VIIBRYD ...... 52 ...... 73 vandazole ...... 179 VILTEPSO ...... 31 VIVAGUARD LANCET... 142 vanicream hc ...... 84 VIMIZIM ...... 145 VIVITROL ...... 43 VANISHPOINT INSULIN VIMPAT ...... 26 VIZIMPRO ...... 22 SYRINGE ...... 141 VIOKACE ...... 161 VOGELXO ...... 145 VANISHPOINT SYRINGE viorele (28) ...... 184 VONVENDI ...... 64 ...... 141 VIRACEPT ...... 7 voriconazole ...... 3 VANISHPOINT VIREAD ...... 7 VOSEVI ...... 7 TUBERCULIN SYRINGE virt-fefa plus ...... 236 VOTRIENT ...... 22 ...... 142 virt-gard ...... 236 VPRIV ...... 145 VANOXIDE-HC ...... 76 virt-nate dha ...... 236 vp-vite rx ...... 237 VANTAS ...... 21 virt-phos 250 neutral ...... 214 VRAYLAR ...... 52 VAPORIZERS...... 142 virtrate-3 ...... 209 vtol lq...... 35 VAQTA (PF) ...... 171 virtrate-k ...... 209 VUMERITY ...... 31 VARIVAX (PF) ...... 172 VISINE TIRED EYE RELIEF vyfemla (28) ...... 184 VARUBI ...... 161 ...... 190 VYNDAMAX...... 67 vaseline ...... 73 VISUDYNE...... 190 VYNDAQEL ...... 67 VAXELIS (PF) ...... 172 vit 3 ...... 236 VYONDYS-53 ...... 31 v-c forte ...... 236 vitacel (with lutein) ...... 236 VYVANSE ...... 52 VECAMYL ...... 67 vitajoy daily d ...... 236 W vegetable laxative ...... 161 VITAJOY MELATONIN .... 90 WAKIX ...... 52 vegetable lax-stool softener 161 vitalee ...... 236 wal-dram ...... 161 velivet triphasic regimen (28) vitalets ...... 236 wal-dram 2 ...... 161 ...... 184 vitamin a and d ...... 73 wal-dryl allergy...... 200 VELPHORO ...... 89 vitamin a and d diaper rash... 73 wal-dryl severe allergy-sinus VEMLIDY ...... 7 vitamin b complex...... 236 ...... 200 VENCLEXTA ...... 21 vitamin b-1 ...... 236 wal-dryl-d allergy and sinus VENCLEXTA STARTING vitamin b-1 (mononitrate)... 236 ...... 200 PACK ...... 21 vitamin b-12 ...... 236 wal-fex allergy ...... 200 venlafaxine ...... 52 VITAMIN B-12 ...... 236 wal-fex d 12 hour...... 200 verapamil ...... 59 vitamin b-6 ...... 236 wal-fex d 24 hour...... 200 VEREGEN ...... 73 vitamin c ...... 236, 237 wal-finate ...... 200 VERELAN ...... 59 vitamin c with rose hips ...... 237 walgreens dry skin treatment 73 VERSACLOZ ...... 52 vitamin d3 ...... 237 wal-itin ...... 200 VERTICAL DRAIN-TUBE VITAMIN D-3 WITH ALOE wal-itin d ...... 200 ATT DEVICE ...... 142 ...... 237 wal-itin d 12 hour ...... 200 VERZENIO ...... 21 vitamin e ...... 237 wal-mucil fiber...... 161 vestura (28) ...... 184 vitamin e (dl, acetate) ...... 237 wal-mucil fiber (aspartame) 161 V-GO 20 ...... 142 vitamin e acetate...... 237 wal-mucil fiber (sugar) ...... 161 V-GO 30 ...... 142 vitamin e mixed ...... 237 wal-mucil natural fiber lax . 161

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 267 wal-phed ...... 200 XARELTO DVT-PE TREAT zebutal ...... 35 wal-phed 12 hour ...... 200 30D START ...... 64 ZEJULA ...... 22 wal-phed d ...... 200 XATMEP ...... 22 ZELBORAF ...... 22 wal-phed pe nighttime cold 200 XELJANZ...... 175 ZEMAIRA ...... 90 wal-profen ...... 43 XELJANZ XR ...... 175 ZENPEP ...... 162 wal-proxen ...... 43 XEMBIFY ...... 172 ZEPATIER ...... 7 wal-som (diphenhydramine) XERMELO ...... 22 ZEPOSIA ...... 31 ...... 200 XGEVA ...... 14 ZEPOSIA STARTER KIT ....31 wal-som (doxylamine) ...... 52 XIAFLEX ...... 90 ZEPOSIA STARTER PACK wal-zyr (cetirizine) ..... 200, 201 XIFAXAN ...... 11 ...... 31 wal-zyr (ketotifen) ...... 190 XIGDUO XR...... 142 ZEPZELCA ...... 22 wal-zyr d ...... 201 XIIDRA ...... 190 zidovudine ...... 7 warfarin ...... 64 XOLAIR ...... 207 ZIEXTENZO ...... 166 WARM STEAM XOPENEX HFA ...... 207 zinc oxide ...... 73 VAPORIZER ...... 142 XOSPATA...... 22 ZIOPTAN (PF) ...... 191 WEBCOL ...... 142 XPOVIO ...... 22 ziprasidone hcl ...... 52 wee care ...... 237 XTAMPZA ER ...... 35 ZIRABEV ...... 22 WELLESSE MULTI XTANDI ...... 22 ZIRGAN...... 185 VITAMIN PLUS ...... 237 xulane ...... 179 ZITHROMAX ...... 9 wera (28) ...... 184 XULTOPHY 100/3.6 ...... 142 ZOKINVY ...... 90 westab mini ...... 237 XYNTHA ...... 64 ZOLADEX ...... 22 westab one ...... 237 XYNTHA SOLOFUSE ...... 65 zoledronic acid-mannitol-water westgel dha...... 237 XYREM ...... 52 ...... 90, 145 westhroid ...... 146 XYWAV ...... 52 ZOLINZA ...... 22 white petrolatum ...... 73 Y zolmitriptan ...... 28 white petroleum jelly ...... 73 YALE DISPOSABLE ZOLMITRIPTAN...... 28 WILATE ...... 64 NEEDLES ...... 142 zolpidem ...... 52 woman's laxative (bisacodyl) yelets ...... 238 ZOLPIMIST...... 53 ...... 161 YF-VAX (PF)...... 172 ZOMIG ...... 28 women's daily formula ...... 238 YOGURT PLUS CALCIUM ZONALON ...... 73 women's gentle laxative(bisac) GUMMIES ...... 238 zonisamide ...... 26 ...... 162 YUPELRI ...... 207 ZORTRESS ...... 22 women's laxative (bisacodyl) yuvafem ...... 177 ZOSTAVAX (PF) ...... 172 ...... 162 Z zostrix ...... 73 women's one daily ...... 238 zafirlukast ...... 207 zostrix-hp ...... 73 women's prenatal plus dha . 238 zaleplon ...... 52 zostrix-hp foot ...... 73 wymzya fe ...... 184 zarah ...... 184 zovia 1/35e (28) ...... 184 X ZARXIO ...... 166 zovia 1-35 (28) ...... 184 XALKORI...... 22 ZAVESCA...... 145 ZYDELIG ...... 22 XARELTO ...... 64 Z-BUM ...... 73 ZYKADIA ...... 22 zeasorb af ...... 81 ZYPREXA RELPREVV...... 53

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. This drug list was last updated on 09/01/2021. 268