Formulary-Centene-Employee-Plan-2021.Pdf

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Centene Employee

PREFERRED DRUG LIST

The Centene Employee Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website at https://pharmacy.envolvehealth.com/members/formulary.html or call us at 1-844-262-6337. Updated: September 1, 2021

Table of Contents

What is the Centene Employee Formulary?...... ii

How are the drugs listed in the categorical list?...... ii

How much will I pay for my drugs?...... ii

How do I find a drug on the Drug List?...... iii

Are there any limits on my drug coverage?...... iv

Can I go to any pharmacy?...... iv

Can I use a mail order pharmacy?...... v

How can I get prior authorization or an exception to the rules for drug coverage?...... v

How can I save money on my prescription drugs?...... v

How often does the Drug List change?...... v

What drugs are under my medical benefit?...... v

Definitions...... vi

Categorical list of prescription drugs...... 1

Alphabetical index of prescription drugs...... Index 1

What is the Centene Employee Formulary? The Centene Employee Formulary is a list of covered drugs used to treat common diseases or health problems. The formulary is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class. Example:

The generic drug name for a brand drug is included after the brand name in parentheses and all lowercase italicized letters. Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase italicized letters. Generic Drug Example: terbutaline sulfate tabs

If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand drug will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Generic Drug Marketed Under A Brand Name Example: levothyroxine sodium (Levoxyl) TABS

How much will I pay for my drugs? To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on the formulary. The copayment or coinsurance for each tier is defined in your Summary of Benefits or other plan documents. After any deductible has been satisfied, the maximum cost share is $100 per 30-day prescription for any oral cancer drug or $100 for all other drugs for a 30-day supply.

Benefit Phase Maximum Cost Share Days Supply Drug Class/Plan Deductible met $100 30 days Oral Cancer Drugs Only Deductible met $100 30 days All Other (non-oral cancer) Drugs

Below is a description for each tier:

Abbreviation Description 1 Value generic drugs

2 Preferred generic drugs

3 Value brand drugs 4 Preferred brand drugs 5 Non-preferred brand or generic drugs

6 Prevention Drug $0 (ACA regulated)

NC Drugs listed as NC are drugs that are not covered on the Centene Employee Preferred Drug List.

How do I find a drug in the Drug List? You can search for a drug by using the search tool, alphabetical index or by medical condition. There are three ways to find out if your drug is covered.

Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.

Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.

Medical Condition: The drugs are grouped into categories by type of medical condition that they are used to treat. For example, “Cardiovascular Agents – Drugs to Treat Heart and Circulation Conditions." If you know what your drug is used for look through the list to find the category. Then look under the category for your drug.

If a generic equivalent for a brand name drug is not available in the market or not covered, the generic drug will not be listed separately. The presence of a drug on the drug list does not guarantee that your doctor will prescribe the drug for a particular medical condition.

iii

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the formulary:

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations.

PA Prior Authorization These drugs require prior authorization for coverage, effectiveness, or safety reasons. This means that your doctor must request approval from the plan before the drug will be covered.

PV Preventive Drugs Preventive benefit drugs covered at no cost to members under the Affordable Care Act. A deductible does not apply. To get a brand drug that has a generic available, your doctor must request prior authorization to show medical necessity. You will be responsible for the difference in cost between the brand and the generic drug.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug.

RX/OTC Prescription & Over- Certain drugs are available both in a prescription form and in an OTC the-Counter (OTC) form. Only prescription drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs.

SP Specialty Drugs Specialty drugs are used to treat complex, chronic conditions that may require special handling, storage or clinical management. Specialty drugs are limited to a 30 day supply and in most cases must be obtained from one of the plan’s Specialty Pharmacies. ST Step Therapy Step Therapy is when you are required to use one drug before another, in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy.

Can I go to any pharmacy? You must use pharmacies that are in the network. These pharmacies have a contract with Envolve Pharmacy Solutions. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at https://pharmacy.envolvehealth.com or call us at the telephone number on your member ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy will not be able to bill us online so you will have to pay the full cost of your drug.

Some injectable and high cost drugs may be considered “specialty drugs”. Specialty drugs are limited to a 30 day supply and in most cases must be must be obtained from one of the plan’s Specialty Pharmacies.

iv Can I use a mail order pharmacy? You can use CVS Caremark Mail Service Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those that you take regularly and are needed for a long term condition.

Your doctor must provide a prescription that allows up to a 90-day supply of each drug. To use mail service pharmacy, log on to the Envolve Pharmacy Solutions member portal Members.EnvolveRx.com. Click on Mail Service and Refills. Follow the guided steps to enroll.

How can I get prior authorization or an exception to the rules for drug coverage? Requests for prior authorization, step therapy exception or other exceptions to the rules for drug coverage may be submitted electronically, by phone at the phone number shown on your Centene ID card or by fax at 1-844-262-7239. Expedited/exigent requests will be processed and the prescriber notified, within 24 hours after receipt of the request. Non-urgent requests will be processed and the prescriber notified, within 72 hours after receipt of request.

If you are suffering from a condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug that is not on the Centene Employee Preferred Drug List, then you, your designee or your doctor can request an expedited/exigent circumstances review. Expedited requests for authorizations are processed, and providers notified of coverage determination within 24 hours after receipt of request and 72 hours for non-urgent requests.

How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at network pharmacies. • Be sure your doctor prescribes drugs on the formulary. • Fill your maintenance drugs through our mail order pharmacy.

How often does the Drug List change? The formulary will be updated with changes on a monthly basis. The types of changes may include the following:

• Removal of a drug or dosage form of a drug from the formulary; • Any change in tier placement of a drug that results in an increase in cost sharing; • Adding or changing utilization management procedures applicable to a drug.

If these changes occur, you will be notified at least 60 days in advance of the change, unless the drug is removed for safety reasons.

What drugs are under my medical benefit? Drugs that are not considered self-injectable and are administered by your doctor will be covered under you medical benefit. If your doctor does not have the drug, your doctor will give you instructions on where you can receive the drug. Certain drugs that are self-administered are covered under your

v pharmacy benefit. Refer to your coverage information and exceptions.

Contacting Envolve Pharmacy Solutions Call Envolve Pharmacy Solutions Customer Service Center at 1-844-262-6337 To access TTY service for hearing impaired members, call 1-866-492-9674

Definitions

Brand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters. Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible: Is the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If the plan has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. The plan pay the rest. Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug. Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or your doctor submits a request for coverage of a non-formulary drug, the plan must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances: Is when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or prescription drug list: Is the list of drugs that is covered by the plan under the prescription drug benefit of the policy. Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list in italicized lowercase letters. Medically Necessary: Is health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary. Non-formulary drug: Is a prescription drug that is not listed on the drug list. Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan. Out- of-pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered paid by the Member. Prescribing provider: This is a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug: Is a drug that by law requires a prescription. vi Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug.

vii Nondiscrimination Notice

Envolve Pharmacy Solutions, Inc. on behalf of itself and its affiliates does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Email: [email protected]

Mail: Civil Rights Coordinator Envolve Pharmacy Solutions 1850 W. Rio Salado Parkway, Suite 211

Tempe, AZ 85281 Phone: 800-460-8988 or (800) 413-7721 Fax: 888-246-1422 TTY: 866-492-9674

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, or TTY 711.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

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

Language Assistance Notices

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 1-844-262-6337, or TTY 711. We have free services to help you communicate with us. Such as, letters in other languages or large print. ENGLISH Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number on your ID card or TTY 711. Brindamos servicios gratuitos para ayudarle a comunicarse con nosotros. Ofrecemos cartas en otros SPANISH idiomas o en letra grande. Puede pedir un intérprete. Para obtener ayuda, llame al nmero telefnico gratuito de su tarjeta de identificacin o TTY 711. Nous avons des services gratuits pour nous aider à communiquer avec vous, comme des lettres écrites FRENCH dans d’autres langues ou imprimées en gros caractères. Vous pouvez également solliciter un interprète. Pour toute demande d’assistance, veuillez appeler le numéro gratuit figurant sur votre carte d’identification ou bien TTY 711 Wir bieten kostenlose Services an, um Ihnen dabei zu helfen, mit uns Verbindung aufzunehmen, GERMAN beispielsweise durch Briefe in anderen Sprachen oder Großdruck. Sie knnen auch einen Dolmetscher anfordern. Wenn Sie Hilfe bentigen, rufen Sie bitte die gebhrenfreie Nummer auf Ihrem Ausweis oder TTY 711 an. Offriamo servizi gratuiti per aiutarla a comunicare con noi, come lettere in altre lingue o a caratteri pi ITALIAN grandi, oppure il servizio di interpretariato. Per chiedere aiuto, chiami il numero verde sulla sua tessera ID o TTY 711. Temos serviços gratuitos para ajudar a se comunicar conosco – tais como, cartas em outros idiomas ou PORTUGUESE impressão em letras grandes. Ou você pode obter a ajuda de um intérprete. Para pedir ajuda, por favor ligue para o nmero de telefone gratuito em seu cartão de identidade ou TTY 711. Nou gen sèvis ki gratis pou sa ede w kominike avè n. Tankou lèt nan lt lang oubyen eki ak lèt laj. FR CREOLE Oubyen, ou kapab mande pou yon entèprèt. Pou w mande pou n sa ede w, sonnen nimewo telefn gratis la ki sou kat idantifikasyon ou an oubyen TTY ka sonnen 711. 我们有有费有务有有帮有您与有们有有，例如提供其他语有有有有有有号有有有有有有有。或者您有有 CHINESE 有有有有有有译员。有有帮有，请有电您 ID 卡上的免费电话号码有有 TTY 711。言語サービスは無料でご提供いたします。通訳を依頼できます。 JAPANESE また文書の代読および、ご希望の言語による文書の郵送が可能です。支援が必要な場合は、ID カードの裏側に記載されている[ 電話番号を記入 ]までお電話ください。 귀하께서 저희와 소통하시는 데 도움이 되는 무료 서비스를 제공해드립니 다다. 른 언어로 또는 대형 활자본으로 서신을 KOREAN 제공하는 것이 그러한 예입니다통. 역사 를 요청하실 수도 있습니다도. 움이 필요하시면 귀하의ID 카드에 안내된 수신자 부담 전화 번호로 또는T TY 의 경우71 1번으 로 연락해 주십시오. Oferujemy bezpłatne usługi ułatwiające komunikowanie się z nami, na przykład pisma w innym języku POLISH lub duża czcionka. Można również poprosić o pomoc tłumacza. Aby poprosić o pomoc, proszę zadzwonić pod bezpłatny numer znajdujący się na karcie identyfikacyjnej lub numer TTY 711. Мы предоставляем бесплатные услуги, которые помогут вам поддерживать с нами связь. Такие как, например, отправка писем на различных языках или писем, выполненных RUSSIAN крупным шрифтом. Вы также можете обратиться за помощью переводчика. Чтобы получить соответствующую помощь, позвоните нам, пожалуйста, по бесплатному номеру телефона, указанному в вашем членском удостоверении, или наберите номер 771 на телекоммуникационном аппарате (телетайпе) для слабослышащих. Mayroon kaming mga libreng serbisyo upang tulungan kang makipagkomunika sa amin. Halimbawa, mga TAGALOG letra sa mga ibang wika o large print. O kaya’y maaari kang humingi ng interpreter. Upang humingi ng tulong, mangyaring tawagan ang toll-free na numero na nakasulat sa iyong ID card o tawagan ang TTY 711. Chng ti c các dịch vụ miễn phí để gip qu vị liên lạc với chng tôi. Như, thư từ bằng các ngn ngữ VIETNAMESE khác hoặc chữ in khổ lớn. Hoặc, qu vị c thể yêu cầu một thng dịch viên. Để yêu cầu gip đỡ, xin gọi số điện thoại miễn phí c ghi trên thẻ ID của qu vị hoặc TTY 711.

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Disclaimer:

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New- to-market products and new variations of products already in the marketplace may not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by an independent Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Please contact Envolve Pharmacy Solutions Customer Service at 1- 844-262-6337 to check coverage and copay information for a specific medicine.

The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

Member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, please contact an Envolve Pharmacy Solutions Customer Service representative at 1-844-262-6337.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- dextroamphetamine sulfate 2 QL(2 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat cp24 10 mg, 15 mg, 5 mg ADHD, Sleep and Eating Disorders dextroamphetamine sulfate 2 QL(60 ml daily) soln 5 mg/5ml Amphetamines ADDERALL TABS (Use QL(2 ea daily) dextroamphetamine sulfate 2 QL(2 ea daily) amphetamine- NC tabs 10 mg dextroamphetamine) dextroamphetamine sulfate ADDERALL XR CP24 (Use QL(2 ea daily) tabs 2.5 mg, 7.5 mg, 15 2 amphetamine- 2 mg, 20 mg, 30 mg, 5 mg dextroamphetamine) DYANAVEL XR SUER 5 QL(8 ml daily) ADZENYS ER SUER (Use NC amphetamine) EVEKEO ODT TBDP NC ADZENYS XR-ODT TBED NC QL(1 ea daily) EVEKEO TABS 10 MG NC QL(6 ea daily) (Use amphetamine sulfate) amphetamine suer 2 EVEKEO TABS 5 MG (Use NC QL(12 ea daily) amphetamine sulfate) amphetamine sulfate tabs 2 QL(6 ea daily) 10 mg methamphetamine hcl tabs 2 QL(2 ea daily) amphetamine sulfate tabs 2 QL(12 ea daily) 5 mg MYDAYIS CP24 4 amphetamine- dextroamphetamine cp24 VYVANSE CAPS 10 MG 4 1.25 mg-1.25 mg-1.25 mg- 1.25 mg, 2.5 mg-2.5 mg- VYVANSE CAPS 20 MG, QL(1 ea daily) 30 MG, 40 MG, 50 MG, 60 4 2.5 mg-2.5 mg, 3.75 mg- NC 3.75 mg-3.75 mg-3.75 mg, MG, 70 MG 5 mg-5 mg-5 mg-5 mg, VYVANSE CHEW 10 MG, QL(1 ea daily) 6.25 mg-6.25 mg-6.25 mg- 20 MG, 30 MG, 40 MG, 50 4 6.25 mg, 7.5 mg-7.5 mg- MG, 60 MG 7.5 mg-7.5 mg Analeptics amphetamine- QL(2 ea daily) CAFCIT SOLN (Use 5 dextroamphetamine tabs caffeine citrate) 1.25 mg-1.25 mg-1.25 mg- 1.25 mg, 1.875 mg-1.875 caffeine & sodium 2 mg-1.875 mg-1.875 mg, benzoate soln CAFFEINE ANHYDROUS RX/OTC 2.5 mg-2.5 mg-2.5 mg-2.5 2 5 mg, 3.125 mg-3.125 mg- POWD 3.125 mg-3.125 mg, 3.75 caffeine citrate soln 2 mg-3.75 mg-3.75 mg-3.75 mg, 5 mg-5 mg-5 mg-5 mg, CAFFEINE CITRATED 5 7.5 mg-7.5 mg-7.5 mg-7.5 POWD mg DOPRAM SOLN 5 DESOXYN TABS (Use 5 QL(2 ea daily) methamphetamine hcl) Attention-Deficit/Hyperactivity Disorder (ADHD) DEXEDRINE CP24 (Use QL(2 ea daily) atomoxetine hcl caps 10 2 PA; QL(2 ea dextroamphetamine 5 mg, 18 mg, 25 mg, 40 mg daily) sulfate) atomoxetine hcl caps 100 2 PA; QL(1 ea mg, 60 mg, 80 mg daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(4 ea clonidine hcl (adhd) tb12 2 dexmethylphenidate hcl 2 daily) cp24 25 mg, 35 mg PA; QL(1 ea dexmethylphenidate hcl guanfacine hcl (adhd) tb24 2 daily) cp24 25 mg, 35 mg, 10 mg, NC 15 mg, 20 mg, 30 mg, 40 INTUNIV TB24 (Use NC PA; QL(1 ea guanfacine hcl (adhd)) daily) mg, 5 mg dexmethylphenidate hcl QL(2 ea daily) KAPVAY TB12 (Use 5 PA; QL(4 ea 2 clonidine hcl (adhd)) daily) tabs 2.5 mg, 10 mg, 5 mg FOCALIN TABS (Use 5 QL(2 ea daily) QELBREE CP24 NC dexmethylphenidate hcl) STRATTERA CAPS 10 PA; QL(2 ea FOCALIN XR CP24 (Use NC MG, 18 MG, 25 MG, 40 MG 5 daily) dexmethylphenidate hcl) (Use atomoxetine hcl) JORNAY PM CP24 NC STRATTERA CAPS 100 PA; QL(1 ea MG, 60 MG, 80 MG (Use 5 daily) METHYLIN SOLN (Use 5 atomoxetine hcl) methylphenidate hcl) Dopamine and Norepinephrine Reuptake methylphenidate hcl chew 2 or 10 mg, 2.5 mg, 5 mg PA SUNOSI TABS 4 methylphenidate hcl cp24 QL(1 ea daily) or 10 mg, 15 mg, 20 mg, 30 2 Histamine H3-Receptor Antagonist/Inverse mg, 40 mg, 50 mg, 60 mg WAKIX TABS NC SP methylphenidate hcl cp24 2 QL(2 ea daily) or 10 mg, 20 mg, 30 mg Stimulants - Misc. methylphenidate hcl cpcr or 2 QL(2 ea daily) ADHANSIA XR CP24 NC 20 mg, 30 mg methylphenidate hcl cpcr or APTENSIO XR CP24 (Use NC QL(1 ea daily) 40 mg, 60 mg, 10 mg, 50 2 methylphenidate hcl) mg armodafinil tabs 150 mg, QL(1 ea daily) 2 methylphenidate hcl soln or 2 250 mg, 50 mg 10 mg/5ml, 5 mg/5ml armodafinil tabs 200 mg 2 methylphenidate hcl tabs or 2 QL(2 ea daily) 10 mg, 20 mg, 5 mg CONCERTA TBCR 36 MG 2 QL(2 ea daily) (Use methylphenidate hcl) methylphenidate hcl tb24 or 18 mg, 27 mg, 36 mg, 54 NC CONCERTA TBCR 54 MG, QL(1 ea daily) mg 18 MG, 27 MG (Use 2 methylphenidate hcl) methylphenidate hcl tbcr or 2 QL(1 ea daily) 10 mg, 20 mg COTEMPLA XR-ODT NC QL(2 ea daily) TBED 17.3 MG, 25.9 MG methylphenidate hcl tbcr or 54 mg, 18 mg, 27 mg, 36 NC COTEMPLA XR-ODT NC QL(3 ea daily) mg TBED 8.6 MG METHYLPHENIDATE DAYTRANA PTCH NC QL(1 ea daily) HYDROCHLORIDE ER 5 TBCR dexmethylphenidate hcl QL(1 ea daily) QL(1 ea daily) cp24 10 mg, 15 mg, 20 mg, 2 modafinil tabs 2 30 mg, 40 mg, 5 mg

1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUVIGIL TABS 150 MG, QL(1 ea daily) IODOQUINOL POWD 5 250 MG, 50 MG (Use NC armodafinil) SOLOSEC PACK NC NUVIGIL TABS 200 MG NC (Use armodafinil) AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections PROVIGIL TABS (Use NC QL(1 ea daily) modafinil) Aminoglycosides QUILLICHEW ER CHER PA; QL(1 ea 5 AMIKACIN SULFATE 5 20 MG, 40 MG daily) POWD XX QUILLICHEW ER CHER PA; QL(2 ea 5 amikacin sulfate soln ij 1 2 30 MG daily) gm/4ml, 500 mg/2ml QUILLIVANT XR SRER 5 PA; QL(12 ml PA; SP daily) ARIKAYCE SUSP 5 RELEXXII TBCR NC BETHKIS NEBU (Use NC PA; SP tobramycin) RITALIN LA CP24 10 MG, QL(2 ea daily) 20 MG, 30 MG (Use 5 gentamicin in saline soln 2 methylphenidate hcl) gentamicin sulfate soln ij 10 2 RITALIN LA CP24 40 MG 5 QL(1 ea daily) mg/ml, 40 mg/ml (Use methylphenidate hcl) HUMATIN CAPS (Use NC PA; SP RITALIN TABS (Use 5 QL(2 ea daily) paromomycin sulfate) methylphenidate hcl) KITABIS PAK NEBU (Use 5 PA; SP ALTERNATIVE MEDICINES tobramycin) Alternative Medicine - A's neomycin sulfate tabs or 2 paromomycin sulfate caps PA; SP ALPHA-LIPOIC ACID NC 2 SOLN or CYTO RALA POWD NC RX/OTC STREPTOMYCIN 5 SULFATE POWD XX RX/OTC NEOKE RA LIPOIC POWD NC streptomycin sulfate solr im 2

Alternative Medicine - P's TOBI NEBU (Use NC SP tobramycin) EC- RX DHEA 4% CREA NC TOBI PODHALER CAPS NC EC-RX DHEA 10% CREA NC tobramycin nebu in 300 2 PA; SP Alternative Medicine - U mg/4ml, 300 mg/5ml TOBRAMYCIN SULFATE 5 COENZYME Q-10 SOLN IJ NC POWD XX Alternative Medicine Combinations tobramycin sulfate soln ij 1.2 gm/30ml, 10 mg/ml, 40 2 CO-VERATROL CAPS NC mg/ml, 80 mg/2ml tobramycin sulfate solr ij 2 AMEBICIDES 1.2 gm Amebicides ZEMDRI SOLN 5

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANALGESICS - ANTI-INFLAMMATORY - Drugs REDITREX SOSY NC SP to Treat Pain, Swelling, Muscle and Joint Conditions Gold Compounds Analgesics - Anti-inflammatory Combinations RIDAURA CAPS 5 EQUAPAX/IBUPROFEN/M NC INREX THPK Interleukin-1 Blockers PA; SP PRASTERA KIT 5 ARCALYST SOLR 5 Anti-TNF-alpha - Monoclonal Antibodies Interleukin-1 Receptor Antagonist (IL-1Ra) HUMIRA PEDIATRIC PA; SP KINERET SOSY NC SP CROHNS DISEASE 4 STARTER PACK PSKT Interleukin-1beta Blockers PA; SP HUMIRA PEN PNKT 4 ILARIS SOLN 4 PA; SP HUMIRA PEN-CD/UC/HS 4 PA; SP Interleukin-6 Receptor Inhibitors STARTER PNKT HUMIRA PEN-PEDIATRIC PA; SP ACTEMRA ACTPEN SOAJ NC 4 UC STARTER PACK ACTEMRA SOLN IV 200 PNKT NC MG/10ML HUMIRA PEN-PS/UV 4 PA; SP ACTEMRA SOLN IV 400 SP STARTER PNKT NC MG/20ML, 80 MG/4ML HUMIRA PSKT 4 PA; SP ACTEMRA SOSY SC 162 NC MG/0.9ML SIMPONI ARIA SOLN 4 PA; SP KEVZARA SOAJ 4 PA; SP SIMPONI SOAJ NC SP KEVZARA SOSY 4 PA; SP SIMPONI SOSY NC SP Nonsteroidal Anti-inflammatory Agents (NSAIDs) Antirheumatic - Enzyme Inhibitors ACTIVE INJECTION KIT 5 KET-L KIT OLUMIANT TABS NC ACTIVE INJECTION KIT 5 KETMARC-L KIT RINVOQ TB24 4 PA; SP ANJESO INJ NC XELJANZ SOLN 4 PA; SP ARTHROTEC 50 TBEC XELJANZ TABS 4 PA; SP (Use diclofenac w/ NC misoprostol) XELJANZ XR TB24 4 PA; SP ARTHROTEC 75 TBEC (Use diclofenac w/ NC Antirheumatic Antimetabolites misoprostol) METHOTREXATE TABS NC CALDOLOR SOLN 5 OR PA; SP CELEBREX CAPS (Use NC QL(2 ea daily) OTREXUP SOAJ 5 celecoxib) PA; SP celecoxib caps or 100 mg, 2 QL(2 ea daily) RASUVO SOAJ 4 200 mg, 400 mg, 50 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHILDRENS ADVIL SUSP NC RX/OTC flurbiprofen tabs or 100 mg, 2 (Use ibuprofen) 50 mg CHILDRENS MOTRIN NC RX/OTC IBU 600-EZS KIT NC SUSP (Use ibuprofen) DAYPRO TABS (Use 5 IBUPAK KIT NC oxaprozin) DFS DR/MS/MENTH/CAP NC ibuprofen lysine soln 2 PAK KIT IBUPROFEN POWD XX 5 DICLOFENAC CAPS NC QL(3 ea daily) ibuprofen susp or 100 2 RX/OTC diclofenac potassium tabs 2 mg/5ml ibuprofen tabs or 400 mg, diclofenac sodium tb24 or 2 2 100 mg 600 mg, 800 mg PA diclofenac sodium tbec or 2 ibuprofen-famotidine tabs 5 25 mg, 50 mg, 75 mg INDOCIN SUPP NC diclofenac sodium- NC capsaicin thpk INDOCIN SUSP NC diclofenac w/ misoprostol 2 tbec indomethacin caps or 20 NC DUEXIS TABS (Use 5 PA mg ibuprofen-famotidine) indomethacin caps or 25 2 EC-NAPROSYN TBEC 5 QL(2 ea daily) mg, 50 mg (Use naproxen) indomethacin cpcr or 75 2 etodolac caps 200 mg, 300 2 mg mg INDOMETHACIN POWD 5 etodolac tabs 400 mg, 500 2 XX mg indomethacin sodium solr 2 etodolac tb24 400 mg, 500 2 QL(2 ea daily) mg, 600 mg INFLAMMATION NC REDUCTION PACK THPK FELDENE CAPS (Use 5 piroxicam) INFLATHERM KIT NC FENOPROFEN CALCIUM NC CAPS OR 200 MG INFLATHERM THPK NC fenoprofen calcium caps or NC 200 mg, 400 mg KETAMINE HYDROCHLORIDE/ROPIV FENOPROFEN CALCIUM 5 ACAINE NC POWD XX HYDROCHLORIDE/KETO fenoprofen calcium tabs or NC ROLAC T SOSY 600 mg ketoprofen caps or 25 mg NC FENORTHO CAPS NC ketoprofen caps or 50 mg, 2 FLEXIZOL COMBIPAK NC 75 mg THPK ketoprofen cp24 or 200 mg NC FLURBIPROFEN POWD 5 XX

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KETOROCAINE-L KIT 5 NALFON TABS 600 MG 2 (Use fenoprofen calcium) KETOROCAINE-LM KIT 5 NAPRELAN TB24 (Use NC naproxen sodium) ketorolac tromethamine 2 NAPROSYN SUSP (Use 5 soln ij 15 mg/ml, 30 mg/ml naproxen) KETOROLAC NAPROSYN TABS (Use 5 TROMETHAMINE SOLN IJ 4 naproxen) 30 MG/ML NAPROXEN COMFORT 5 ketorolac tromethamine PAC KIT soln im 30 mg/ml, 60 2 mg/2ml NAPROXEN POWD XX 5 KETOROLAC QL(1 ea daily) NAPROXEN SODIUM 5 TROMETHAMINE SOLN NC POWD XX NA 15.75 MG/SPRAY naproxen sodium tabs or 2 QL(20 ea per 550 mg, 275 mg ketorolac tromethamine 2 fill retail,20 ea tabs or 10 mg per 30 days naproxen sodium tb24 or NC retail) 750 mg, 375 mg, 500 mg KETOROLAC naproxen susp or 125 5 TROMETHAMINE/BUPIVA mg/5ml NC CAINE naproxen tabs or 250 mg, 2 HYDROCHLORIDE/KETA 375 mg, 500 mg MINE HY SOSY naproxen tbec or 375 mg, 2 QL(2 ea daily) LIDOVIX KIT NC 500 mg naproxen-esomeprazole NC LODINE TABS (Use NC magnesium tbec etodolac) NEOPROFEN SOLN (Use 5 meclofenamate sodium 2 ibuprofen lysine) caps or 100 mg, 50 mg NUDROXIPAK DSDR-50 NC MECLOFENAMATE 5 KIT SODIUM POWD XX NUDROXIPAK DSDR-75 NC mefenamic acid caps or 2 KIT NUDROXIPAK E-400 KIT NC mefenamic acid caps or NC NUDROXIPAK I-800 KIT NC MEFENAMIC ACID POWD 5 XX NUDROXIPAK M-15 KIT NC meloxicam caps or 10 mg, NC 5 mg NUDROXIPAK N-500 KIT NC meloxicam tabs or 15 mg, 2 QL(1 ea daily) 7.5 mg NUDROXIPAK THPK NC MOBIC TABS (Use 5 QL(1 ea daily) meloxicam) oxaprozin tabs 2 nabumetone tabs or 500 2 mg, 750 mg PHENYLBUTAZONE 5 POWD NALFON CAPS 400 MG NC

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits piroxicam caps or 10 mg, 2 OTEZLA TBPK 4 PA; SP 20 mg PIROXICAM POWD XX 5 Pyrimidine Synthesis Inhibitors ARAVA TABS 10 MG (Use 4 QL(2 ea daily) PREVIDOLRX NC leflunomide) ANALGESIC PAK THPK ARAVA TABS 20 MG (Use 4 QL(1 ea daily) QMIIZ ODT TBDP NC leflunomide) QL(2 ea daily) READYSHARP leflunomide tabs or 10 mg 2 ANESTHETICS NC QL(1 ea daily) +KETOROLAC KIT leflunomide tabs or 20 mg 2 READYSHARP NC KETOROLAC KIT Selective Costimulation Modulators ORENCIA CLICKJECT NC SP RELAFEN DS TABS NC SOAJ SP SPRIX SOLN NC QL(1 ea daily) ORENCIA SOLR NC SP SULINDAC POWD XX 5 ORENCIA SOSY NC Soluble Tumor Necrosis Factor Receptor Agents sulindac tabs or 150 mg, 2 200 mg ENBREL MINI SOCT 4 PA; SP TIVORBEX CAPS 20 MG NC ENBREL SOLN 4 PA; SP TIVORBEX CAPS 40 MG NC QL(3 ea daily) ENBREL SOLR 4 PA; SP tolmetin sodium caps 2 ENBREL SOSY 4 PA; SP tolmetin sodium tabs 2 ENBREL SURECLICK 4 PA; SP TORONOVA II SUIK KIT NC SOAJ ANALGESICS - NonNarcotic - Drugs to Treat TORONOVA SUIK KIT NC Pain, Muscle and Joint Conditions VIMOVO TBEC (Use PA Analgesic Combinations naproxen-esomeprazole 5 acetaminophen- magnesium) salicylamide- 2 phenyltoloxamine caps VIVLODEX CAPS (Use NC meloxicam) ALLZITAL TABS NC QL(8 ea daily) ZIPSOR CAPS 5 ST ALLZITAL TABS NC ZORVOLEX CAPS 18 MG, NC QL(3 ea daily) 35 MG butalbital-acetaminophen 2 caps 50 mg-300 mg ZYNRELEF SOLN NC butalbital-acetaminophen 2 QL(8 ea daily) Phosphodiesterase 4 (PDE4) Inhibitors tabs 25 mg-325 mg PA; SP butalbital-acetaminophen QL(6 ea daily) OTEZLA TABS 4 tabs 325 mg-50 mg, 50 mg- 2 325 mg

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits butalbital-acetaminophen NC Analgesics-Peptide Channel Blockers tabs 50 mg-300 mg PA; SP butalbital-acetaminophen- QL(6 ea daily) PRIALT SOLN 5 caffeine caps 40 mg-50 NC mg-300 mg, 40 mg-50 mg- Salicylates 325 mg ACETYL SALICYLIC ACID 5 RX/OTC butalbital-acetaminophen- QL(90 ml daily) POWD caffeine soln 40 mg/15ml- 2 AL(At least 12 50 mg/15ml-325 mg/15ml aspirin chew or 81 mg 6 yrs old - Up to butalbital-acetaminophen- QL(90 ml daily) 59 yrs old) caffeine soln 40 mg/15ml- NC ASPIRIN POWD XX 5 RX/OTC 50 mg/15ml-325 mg/15ml butalbital-acetaminophen- QL(6 ea daily) AL(At least 45 aspirin tabs or 325 mg 2 yrs old - Up to caffeine tabs 325 mg-40 2 mg-50 mg, 40 mg-50 mg- 79 yrs old) 325 mg AL(At least 12 aspirin tbec or 81 mg 6 yrs old - Up to butalbital-aspirin-caffeine 2 QL(6 ea daily) caps 59 yrs old) BUTALBITAL/ACETAMINO DIFLUNISAL POWD XX 5 PHEN CAPS (Use NC butalbital-acetaminophen) diflunisal tabs or 2 BUTALBITAL/ASPIRIN/CA NC FFEINE TABS salsalate tabs or 500 mg, 2 750 mg ESGIC TABS (Use QL(6 ea daily) butalbital-acetaminophen- 5 SODIUM SALICYLATE 5 caffeine) CRYS FIORICET CAPS (Use QL(6 ea daily) SODIUM SALICYLATE 5 butalbital-acetaminophen- NC POWD caffeine) ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions FIORINAL CAPS (Use 5 QL(6 ea daily) butalbital-aspirin-caffeine) Opioid Agonists Analgesics Other ABSTRAL SUBL 100 MCG, 5 PA; QL(4 ea 800 MCG daily) 7T GUMMY ES CHEW NC ABSTRAL SUBL 200 MCG, 300 MCG, 400 MCG, 600 5 acetaminophen soln iv 10 5 mg/ml, 1000 mg/100ml MCG ACTIQ LPOP (Use fentanyl PA; QL(4 ea ACETAMINOPHEN SOSY NC 5 IV 100 MG/10ML citrate) daily) clonidine hcl (analgesia) 2 alfentanil hcl soln 2 soln ALFENTANIL CLONIDINE 5 5 HYDROCHLORIDE SOLN HYDROCHLORIDE SOLN QL(3 ea daily) DURACLON SOLN (Use 5 ARYMO ER TBEA NC clonidine hcl (analgesia)) CODEINE PHOSPHATE OFIRMEV SOLN (Use 5 5 acetaminophen) POWD

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CODEINE SULFATE TABS 2 fentanyl citrate soln ij 1000 15 MG mcg/20ml, 250 mcg/5ml, 2 QL(6 ea daily) 2500 mcg/50ml, 500 codeine sulfate tabs 30 mg 2 mcg/10ml, 100 mcg/2ml FENTANYL CITRATE CODEINE SULFATE TABS 5 QL(6 ea daily) NC 60 MG SOLN IJ 1500 MCG/30ML FENTANYL CITRATE CONZIP CP24 (Use 5 QL(1 ea daily) tramadol hcl) SOLN IJ 250 MCG/5ML, 5 DEMEROL SOLN 100 100 MCG/2ML (Use MG/2ML, 25 MG/0.5ML, 75 5 fentanyl citrate) MG/1.5ML, 75 MG/ML fentanyl citrate soln ij 50 NC DEMEROL SOLN 100 mcg/ml FENTANYL CITRATE MG/ML, 25 MG/ML, 50 5 MG/ML (Use meperidine SOLN IJ 50 MCG/ML (Use NC hcl) fentanyl citrate) DILAUDID LIQD OR 1 FENTANYL CITRATE MG/ML (Use 5 SOLN IV 2500 MCG/50ML, NC hydromorphone hcl) 5000 MCG/100ML FENTANYL CITRATE DILAUDID SOLN IJ 0.2 NC 5 MG/ML SOLN XX 500 MG/50ML DILAUDID SOLN IJ 1 FENTANYL CITRATE NC MG/ML, 2 MG/ML (Use NC SOSY IJ 50 MCG/ML hydromorphone hcl) FENTANYL CITRATE SOSY IV 100 MCG/10ML, DILAUDID TABS OR 2 MG 5 QL(8 ea daily) (Use hydromorphone hcl) 100 MCG/2ML, 1000 DILAUDID TABS OR 4 MCG/20ML, 1500 MG, 8 MG (Use 5 MCG/30ML, 20 MCG/2ML, NC hydromorphone hcl) 250 MCG/5ML, 2500 MCG/50ML, 2750 DOLOPHINE TABS (Use 5 QL(12 ea daily) MCG/55ML, 50 MCG/5ML, methadone hcl) 500 MCG/50ML DSUVIA SUBL 5 fentanyl citrate tabs bu 100 PA; QL(3 ea mcg, 200 mcg, 400 mcg, 2 daily) DURAGESIC PT72 (Use 5 QL(0.5 ea 600 mcg, 800 mcg fentanyl) daily) FENTANYL EMBEDA CPCR 4 CITRATE/SODIUM NC CHLORIDE SOLN fentanyl citrate lpop bu PA; QL(4 ea FENTANYL 1200 mcg, 1600 mcg, 200 2 daily) CITRATE/SODIUM NC mcg, 400 mcg, 600 mcg, CHLORIDE SOSY 800 mcg fentanyl pt72 td 37.5 QL(0.5 ea FENTANYL CITRATE 5 mcg/hr, 62.5 mcg/hr, 87.5 daily) POWD XX mcg/hr, 100 mcg/hr, 12 2 fentanyl citrate soct ij 100 2 mcg/hr, 25 mcg/hr, 50 mcg/2ml mcg/hr, 75 mcg/hr FENTANYL SOLN IV 1500 NC MCG/30ML

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENTORA TABS (Use 5 PA; QL(3 ea HYDROMORPHONE fentanyl citrate) daily) HYDROCHLORIDE SOLN NC hydrocodone bitartrate t24a IV 0.2 MG/ML or 100 mg, 120 mg, 20 mg, NC HYDROMORPHONE 30 mg, 40 mg, 60 mg, 80 HYDROCHLORIDE SOLN 5 mg XX 7500 MG/75ML hydromorphone hcl liqd or 2 HYDROMORPHONE 1 mg/ml HYDROCHLORIDE/ NC SODIUM CHLORIDE HYDROMORPHONE HCL 5 POWD XX SOLN hydromorphone hcl soln ij 1 HYDROMORPHONE mg/ml, 2 mg/ml, 10 mg/ml, 2 HYDROCHLORIDE/SODIU NC 50 mg/5ml, 500 mg/50ml M CHLORIDE SOLN HYDROMORPHONE hydromorphone hcl soln ij 4 NC mg/ml HYDROCHLORIDE/SODIU NC M CHLORIDE SOSY HYDROMORPHONE HCL 5 SUPP RE 3 MG HYDROMORPHONE/SODI NC UM CHLORIDE SOLN hydromorphone hcl tabs or 2 QL(8 ea daily) 2 mg HYSINGLA ER T24A (Use NC hydrocodone bitartrate) hydromorphone hcl tabs or 2 4 mg, 8 mg INFUMORPH 200 SOLN (Use morphine sulfate for 5 hydromorphone hcl tb24 or 2 QL(4 ea daily) continuous microinfusion) 12 mg, 16 mg, 8 mg INFUMORPH 500 SOLN hydromorphone hcl tb24 or 2 QL(2 ea daily) (Use morphine sulfate for 5 32 mg continuous microinfusion) HYDROMORPHONE HCL/SODIUMCHLORIDE NC IONSYS PTCH NC SOLN KADIAN CP24 10 MG, 100 QL(2 ea daily) HYDROMORPHONE MG, 20 MG, 30 MG, 40 5 HCL/SODIUMCHLORIDE NC MG, 50 MG, 60 MG, 80 MG SOSY (Use morphine sulfate) HYDROMORPHONE KADIAN CP24 200 MG 5 HYDROCHLORIDE SOLN NC IJ 0.2 MG/ML, 1 MG/ML, 4 LAZANDA SOLN 100 NC MG/ML MCG/ACT, 400 MCG/ACT HYDROMORPHONE LAZANDA SOLN 300 NC PA HYDROCHLORIDE SOLN 5 MCG/ACT IJ 1 MG/ML levorphanol tartrate tabs or NC HYDROMORPHONE 2 mg, 3 mg HYDROCHLORIDE SOLN 5 IJ 10 MG/ML (Use MEPERIDINE HCL POWD 5 hydromorphone hcl) XX HYDROMORPHONE meperidine hcl soln ij 100 2 mg/ml, 25 mg/ml, 50 mg/ml HYDROCHLORIDE SOLN NC IJ 2 MG/ML (Use meperidine hcl soln or 50 2 QL(500 ml per hydromorphone hcl) mg/5ml fill retail)

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits meperidine hcl tabs or 50 2 QL(6 ea daily) MORPHINE SULFATE mg SOLN IJ 10 MG/ML, 2 NC MG/ML, 4 MG/ML, 5 methadone hcl conc or 10 2 QL(10 ml daily) mg/ml MG/ML, 8 MG/ML morphine sulfate soln ij 10 METHADONE HCL POWD 5 XX mg/ml, 8 mg/ml, 0.5 mg/ml, 2 1 mg/ml methadone hcl soln ij 10 2 mg/ml MORPHINE SULFATE NC SOLN IV 0.5 MG/ML METHADONE HCL SOLN IJ 10 MG/ML (Use 5 MORPHINE SULFATE 2 methadone hcl) SOLN IV 1 MG/ML MORPHINE SULFATE methadone hcl soln or 10 2 QL(50 ml daily) mg/5ml SOLN IV 10 MG/ML (Use NF morphine sulfate) methadone hcl soln or 5 2 QL(100 ml mg/5ml daily) MORPHINE SULFATE SOLN IV 150 MG/30ML, 2 5 methadone hcl tabs or 5 2 QL(12 ea daily) MG/ML mg, 10 mg morphine sulfate soln iv 4 methadone hcl tbso or 40 2 QL(2 ea daily) mg/ml, 50 mg/ml, 8 mg/ml, 2 mg 1 mg/ml, 10 mg/ml METHADONE MORPHINE SULFATE HYDROCHLORIDE/SODIU 5 SOLN IV 4 MG/ML, 8 5 M CHLORIDE SOSY MG/ML, 10 MG/ML (Use METHADOSE CONC (Use 5 QL(10 ml daily) morphine sulfate) methadone hcl) morphine sulfate soln or 10 2 QL(100 ml METHADOSE SUGAR- QL(10 ml daily) mg/5ml daily) FREE CONC (Use 5 morphine sulfate soln or 20 methadone hcl) mg/5ml, 100 mg/5ml, 20 2 MORPHABOND ER T12A NC QL(2 ea daily) mg/ml MORPHINE SULFATE morphine sulfate beads 2 QL(1 ea daily) SOLN XX 7812.5 5 cp24 MG/125ML morphine sulfate cp24 or QL(2 ea daily) morphine sulfate supp re 2 QL(24 ea per 10 mg, 100 mg, 20 mg, 30 2 10 mg, 20 mg, 5 mg fill retail) mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate supp re 2 30 mg MORPHINE SULFATE 5 DEVI IM 10 MG/0.7ML morphine sulfate tabs or 15 2 QL(6 ea daily) mg, 30 mg morphine sulfate for continuous microinfusion 2 morphine sulfate tbcr or QL(3 ea daily) soln 100 mg, 15 mg, 200 mg, 30 2 mg, 60 mg MORPHINE SULFATE 5 POWD XX MORPHINE SULFATE/DEXTROSE NC MORPHINE SULFATE SOLN SOLN IJ 1 MG/ML, 2 5 MG/ML, 4 MG/ML, 5 MORPHINE MG/ML SULFATE/SODIUM NC CHLORIDE SOLN

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MORPHINE ROXYBOND TABA 15 MG, NC SULFATE/SODIUM NC 30 MG CHLORIDE SOSY ROXYBOND TABA 5 MG NC QL(4 ea daily) MS CONTIN TBCR (Use 5 QL(3 ea daily) morphine sulfate) SUBSYS LIQD 100 MCG 4 PA; QL(4 ea daily) NUCYNTA ER TB12 4 QL(2 ea daily) SUBSYS LIQD 1200 MCG, PA; QL(8 ea NUCYNTA TABS 4 QL(6 ea daily) 1600 MCG, 200 MCG, 400 4 daily) MCG, 600 MCG, 800 MCG OLINVYK SOLN NC sufentanil citrate soln iv 50 mcg/ml, 100 mcg/2ml, 250 2 OPANA TABS 10 MG (Use 5 QL(12 ea daily) mcg/5ml oxymorphone hcl) SUFENTANIL CITRATE OPANA TABS 5 MG (Use QL(6 ea daily) 5 SOLN IV 50 MCG/ML, 100 5 oxymorphone hcl) MCG/2ML, 250 MCG/5ML (Use sufentanil citrate) OXAYDO TABS 5 QL(6 ea daily) SUFENTANIL CITRATE 5 oxycodone hcl caps or 5 2 SOLN XX 25 MG/25ML mg SYNAPRYN FUSEPAQ 5 oxycodone hcl conc or 100 2 QL(6 ml daily) SUSR mg/5ml tramadol hcl cp24 or 100 OXYCODONE HCL POWD 5 mg, 200 mg, 300 mg, 150 NC XX mg oxycodone hcl soln or 5 2 tramadol hcl tabs or 100 NC mg/5ml mg oxycodone hcl t12a or 15 QL(3 ea daily) tramadol hcl tabs or 50 mg 2 QL(8 ea daily) mg, 30 mg, 60 mg, 80 mg, 2 10 mg, 20 mg, 40 mg tramadol hcl tb24 or 100 2 QL(1 ea daily) oxycodone hcl tabs or 10 QL(6 ea daily) mg, 200 mg, 300 mg mg, 20 mg, 15 mg, 30 mg, 2 ULTIVA SOLR (Use 5 5 mg remifentanil hcl) OXYCONTIN T12A NC ULTRAM TABS (Use 5 QL(8 ea daily) tramadol hcl) oxymorphone hcl tabs 10 2 QL(12 ea daily) QL(2 ea daily) mg XTAMPZA ER C12A 4 oxymorphone hcl tabs 5 2 QL(6 ea daily) Opioid Combinations mg acetaminophen w/ codeine 2 oxymorphone hcl tb12 10 soln mg, 15 mg, 20 mg, 30 mg, NC 40 mg, 5 mg, 7.5 mg acetaminophen w/ codeine 2 tabs QDOLO SOLN NC acetaminophen-caff- QL(12 ea daily) dihydrocod caps 16 mg-30 2 remifentanil hcl solr 2 mg-320.5 mg, 320.5 mg-16 mg-30 mg ROXICODONE TABS (Use 5 QL(6 ea daily) oxycodone hcl) acetaminophen-caff- dihydrocod tabs 16 mg-30 2 mg-325 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APADAZ TABS NC FENTANYL CITRATE/ROPIVACAINE NC HYDROCHLORIDE/SODIU BENZHYDROCODONE/A NC CETAMINOPHEN TABS M CHLORIDE SOSY butalbital-acetaminophen- FENTANYL/BUPIVACAINE HYDROCHLORIDE/SODIU NC caffeine w/ codeine caps 2 30 mg-40 mg-50 mg-300 M CHLORIDE SOLN mg FENTANYL/BUPIVACAINE NC butalbital-acetaminophen- QL(6 ea daily) /NACL SOLN caffeine w/ codeine caps FENTANYL/ROPIVACAIN 30 mg-40 mg-50 mg-325 2 E NC mg, 325 mg-30 mg-40 mg- HYDROCHLORIDE/SODIU 50 mg M CHLORIDE SOLN butalbital-aspirin-caffeine 2 QL(6 ea daily) FIORICET/CODEINE w/cod caps CAPS (Use butalbital- 5 FENTANYL acetaminophen-caffeine w/ codeine) CITRATE/BUPIVACAINE NC HCL/SODIUM CHLORIDE FIORINAL/CODEINE #3 QL(6 ea daily) SOLN CAPS (Use butalbital- 5 FENTANYL aspirin-caffeine w/cod) CITRATE/BUPIVACAINE NC hydrocodone- HYDROCHLORIDE SOLN acetaminophen soln 10 NC FENTANYL mg/15ml-325 mg/15ml, 325 mg/15ml-10 mg/15ml CITRATE/BUPIVACAINE NC HYDROCHLORIDE/SODIU hydrocodone- QL(180 ml M CHLORIDE SOLN acetaminophen soln 2.5 daily) FENTANYL mg/5ml-108 mg/5ml, 325 2 mg/15ml-7.5 mg/15ml, 5 CITRATE/BUPIVACAINE NC HYDROCHLORIDE/SODIU mg/10ml-217 mg/10ml, 7.5 M CHLORIDE SOSY mg/15ml-325 mg/15ml FENTANYL hydrocodone- QL(13 ea daily) acetaminophen tabs 10 CITRATE/BUPIVICAINE NC 2 HCL/SODIUM CHLORIDE mg-300 mg, 7.5 mg-300 SOLN mg FENTANYL hydrocodone- acetaminophen tabs 5 mg- 2 CITRATE/BUPIVICAINE NC HYDROCHLORIDE/SODIU 300 mg M CHLORIDE SOLN hydrocodone- QL(12 ea FENTANYL acetaminophen tabs 5 mg- daily,240 ea CITRATE/ROPIVACAINE NC 325 mg, 10 mg-325 mg, 2 per fill retail) HYDROCHLORIDE SOLN 325 mg-10 mg, 325 mg-7.5 FENTANYL mg, 7.5 mg-325 mg hydrocodone-ibuprofen QL(5 ea daily) CITRATE/ROPIVACAINE NC 2 HYDROCHLORIDE/SODIU tabs M CHLORIDE SOLN LORTAB ELIX 5

NALOCET TABS NC

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORCO TABS (Use QL(12 ea buprenorphine hcl subl sl 2 2 PA; QL(3 ea hydrocodone- 5 daily,240 ea mg daily) acetaminophen) per fill retail) buprenorphine hcl subl sl 8 2 PA; QL(4 ea OXYCODONE mg daily) HYDROCHLORIDE/ACET NC buprenorphine hcl- QL(3 ea daily) AMINOPHEN SOLN naloxone hcl dihydrate film 2 oxycodone w/ 2 QL(12 ea daily) 0.5 mg-2 mg, 1 mg-4 mg, 2 acetaminophen tabs mg-8 mg oxycodone-aspirin tabs 2 buprenorphine hcl- QL(2 ea daily) naloxone hcl dihydrate film 2 oxycodone-ibuprofen tabs 2 QL(4 ea daily) 3 mg-12 mg buprenorphine hcl- QL(3 ea daily) OXYCODONE/ACETAMIN NC naloxone hcl dihydrate subl 2 OPHEN TABS 0.5 mg-2 mg, 2 mg-8 mg, 8 PERCOCET TABS (Use QL(12 ea daily) mg-2 mg oxycodone w/ NC buprenorphine ptwk td 10 acetaminophen) mcg/hr, 15 mcg/hr, 20 2 mcg/hr, 5 mcg/hr, 7.5 PRIMLEV TABS NC mcg/hr PROLATE SOLN 10 NC butorphanol tartrate soln ij 2 MG/5ML-300 MG/5ML 1 mg/ml, 2 mg/ml PROLATE TABS 10 MG- butorphanol tartrate soln na 2 QL(0.25 ml 300 MG, 5 MG-300 MG, NC 10 mg/ml daily) 7.5 MG-300 MG BUTRANS PTWK (Use NC tramadol-acetaminophen 2 QL(8 ea daily) buprenorphine) tabs nalbuphine hcl soln ij 10 2 QL(8 ml daily) TYLENOL/CODEINE #3 mg/ml, 20 mg/ml TABS (Use acetaminophen 5 pentazocine w/ naloxone 2 QL(12 ea daily) w/ codeine) tabs TYLENOL/CODEINE #4 PROBUPHINE IMPLANT NC SP TABS (Use acetaminophen 5 KIT IMPL w/ codeine) SUBLOCADE SOSY 5 PA; SP ULTRACET TABS (Use 5 QL(8 ea daily) tramadol-acetaminophen) SUBOXONE FILM 0.5 MG- QL(3 ea daily) Opioid Partial Agonists 2 MG, 1 MG-4 MG, 2 MG- QL(2 ea daily) 0.5 MG, 2 MG-8 MG (Use NC BELBUCA FILM 4 buprenorphine hcl- naloxone hcl dihydrate) BUNAVAIL FILM 5 PA; QL(3 ea daily) SUBOXONE FILM 3 MG- QL(2 ea daily) 12 MG (Use buprenorphine NC BUPRENEX SOLN (Use 5 buprenorphine hcl) hcl-naloxone hcl dihydrate) buprenorphine hcl film bu QL(2 ea daily) ZUBSOLV SUBL 0.18 MG- PA; QL(3 ea 0.7 MG, 0.36 MG-1.4 MG, daily) 150 mcg, 300 mcg, 450 2 4 mcg, 600 mcg, 75 mcg, 0.71 MG-2.9 MG, 1.4 MG- 750 mcg, 900 mcg 5.7 MG ZUBSOLV SUBL 2.1 MG- PA; QL(2 ea buprenorphine hcl soln ij 2 4 0.3 mg/ml 8.6 MG, 2.9 MG-11.4 MG daily)

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.78 gm ANDROGENS-ANABOLIC - Drugs to Regulate NATESTO GEL 4 Hormones daily) QL(2 ea daily) Androgens STRIANT MISC 5 QL(1 ea daily) ANDRODERM PT24 4 TESTIM GEL (Use NC testosterone) ANDROGEL GEL 40.5 QL(10 gm MG/2.5GM, 20.25 daily) TESTONE CIK KIT NC MG/1.25GM, 25 NC MG/2.5GM (Use TESTOPEL PLLT 5 PA; SP testosterone) TESTOSTERONE ANDROGEL GEL 50 COMPOUNDINGKIT NC MG/5GM (Use NC CREA testosterone) TESTOSTERONE ANDROGEL PUMP GEL QL(10 gm NC CYPIONATE SOLN IJ 100 NC (Use testosterone) daily) MG/ML, 150 MG/ML, 200 AVEED SOLN 5 PA; SP MG/ML, 50 MG/ML TESTOSTERONE danazol caps or 100 mg, 2 CYPIONATE SOLN IJ 200 2 200 mg, 50 mg MG/ML DANAZOL POWD XX 5 testosterone cypionate soln 2 PA; QL(0.334 im 100 mg/ml, 200 mg/ml ml daily) DEPO-TESTOSTERONE PA; QL(0.334 SOLN (Use testosterone 5 ml daily) TESTOSTERONE cypionate) CYPIONATE/TESTOSTER NC ONE PROPIONATE SOLN EC-RX TESTOSTERONE NC 0.2% CREA TESTOSTERONE NC ENANTHATE SOLN IJ EC-RX TESTOSTERONE NC 0.4% CREA testosterone enanthate 2 PA soln im EC-RX TESTOSTERONE NC 10% CREA testosterone gel td 1 % NC EC-RX TESTOSTERONE NC testosterone gel td 1 %, 50 2 PA; QL(10 gm 20% CREA mg/5gm daily) FORTESTA GEL (Use PA; QL(3.5 gm NC testosterone gel td 10 2 PA; QL(3.5 gm testosterone) daily) mg/act daily) JATENZO CAPS NC testosterone gel td 40.5 QL(10 gm mg/2.5gm, 1.62 %, 20.25 2 daily) METHITEST TABS 5 mg/1.25gm, 25 mg/2.5gm, 1 % methyltestosterone caps or 2 TESTOSTERONE PLLT IL 100 MG, 200 MG, 25 MG, NC METHYLTESTOSTERONE 5 50 MG POWD XX TESTOSTERONE NC NANDROLONE PROPIONATE SOLN IJ DECANOATE/TESTOSTE RONE NC testosterone soln td 30 2 PA; QL(6 ml CYPIONATE/TESTOSTER mg/act daily) ONE ENA OIL

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VOGELXO GEL (Use NC SODIUM BICARBONATE 5 RX/OTC testosterone) POWD OR VOGELXO PUMP GEL NC Antacids - Magnesium Salts (Use testosterone) MAGNESIUM OXIDE 5 RX/OTC XYOSTED SOAJ NC HEAVY POWD MAGNESIUM OXIDE 5 RX/OTC ANORECTAL AND RELATED PRODUCTS - LIGHT POWD Rectal Drugs to Treat Pain, Swelling and Itching MAGNESIUM Intrarectal Steroids TRISILICATE HYDRATE 5 POWD CORTENEMA ENEM (Use 5 QL(420 ml per hydrocortisone (intrarectal)) fill retail) MAGNESIUM 5 TRISILICATE POWD CORTIFOAM FOAM 4 ANTHELMINTICS - Drugs to Treat Worm hydrocortisone (intrarectal) 2 QL(420 ml per Infections enem fill retail) Anthelmintics UCERIS FOAM RE 2 5 MG/ACT albendazole tabs or 2 Rectal Combinations ALBENZA TABS (Use 5 LIDOCAINE HCL- albendazole) HYDROCORTISONE 5 PA; SP ACETATE WITH ALOE BENZNIDAZOLE TABS 5 GEL BILTRICIDE TABS (Use 5 lidocaine-hydrocortisone 2 praziquantel) acetate (rectal) crea QL(6 ea per fill EMVERM CHEW 4 lidocaine-hydrocortisone 2 retail) acetate (rectal) kit ivermectin tabs or 3 mg 2 PROCTOFOAM HC FOAM 4 MEBENDAZOLE POWD 5 Rectal Local Anesthetics PIPERAZINE CITRATE LIDOCAINE SUPP RE 50 NC 5 MG POWD Rectal Steroids praziquantel tabs or 2 ANUSOL-HC CREA (Use 4 STROMECTOL TABS (Use 5 hydrocortisone (rectal)) ivermectin) hydrocortisone (rectal) crea 2 THIABENDAZOLE POWD 5 PROCTOCORT CREA ANTI-INFECTIVE AGENTS - MISC. - Drugs to (Use hydrocortisone 5 Treat Bacterial Infections (rectal)) Anti-infective Agents - Misc. Vasodilating Agents AEMCOLO TBEC 5 RECTIV OINT 5 bacitracin solr im 2 ANTACIDS FIRST-METRONIDAZOLE NC Antacids - Bicarbonate 100 SUSR 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRST-METRONIDAZOLE NC methenamine-hyosc- 50 SUSR methylene blue-benzoic 2 acid-phenyl sal tabs FLAGYL CAPS (Use 5 metronidazole) methenamine-hyosc- methylene blue-sod phos- 2 FLAGYL TABS (Use 5 metronidazole) phenyl sal caps methenamine-hyosc- IMPAVIDO CAPS 5 methylene blue-sod phos- 2 METRONIDAZOLE phenyl sal tabs BENZOATE/SYRSPEND NC methenamine-hyoscamine- SF PH4 SUSR methylene blue-sodium 2 phosphate tabs metronidazole caps or 375 2 mg sulfamethoxazole- 2 trimethoprim soln metronidazole in nacl soln 2 sulfamethoxazole- 2 METRONIDAZOLE SOLN trimethoprim susp IV 0.74 %-500 MG/100ML 5 sulfamethoxazole- 2 (Use metronidazole in nacl) trimethoprim tabs METRONIDAZOLE SOLN 5 2 IV 5 MG/ML URIMAR-T TABS UROGESIC-BLUE TABS metronidazole tabs or 250 2 mg, 500 mg (Use methenamine- 5 hyoscamine-methylene NEBUPENT SOLR (Use 5 pentamidine isethionate) blue-sodium phosphate) Antiprotozoal Agents PENTAM 300 SOLR (Use 5 pentamidine isethionate) ALINIA SUSR 100 MG/5ML 5 pentamidine isethionate 2 solr ALINIA TABS 500 MG (Use 5 nitazoxanide) PRIMSOL SOLN 5 atovaquone susp or 2 tinidazole tabs or 250 mg, 2 500 mg LAMPIT TABS 5 TRIMETHOPRIM POWD 5 XX MEPRON SUSP (Use 5 atovaquone) trimethoprim tabs or 2 nitazoxanide tabs or 5 PA; QL(9 ea XIFAXAN TABS 200 MG 5 per fill retail) Carbapenems XIFAXAN TABS 550 MG 4 PA; QL(2 ea doripenem solr 2 daily) Anti-infective Misc. - Combinations ertapenem sodium solr 2 BACTRIM DS TABS (Use sulfamethoxazole- 4 imipenem-cilastatin solr 2 trimethoprim) INVANZ SOLR (Use 5 BACTRIM TABS (Use ertapenem sodium) sulfamethoxazole- 4 trimethoprim) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits meropenem solr 2 vancomycin hcl caps or 2 125 mg, 250 mg MEROPENEM/SODIUM NC VANCOMYCIN HCL SOLN 5 CHLORIDE SOLR IV 0.9 %-1 GM/200ML MERREM SOLR (Use 5 vancomycin hcl solr iv 1 2 QL(14 ea per meropenem) gm, 1000 mg fill retail) PRIMAXIN IV SOLR (Use 5 vancomycin hcl solr iv 1.5 5 imipenem-cilastatin) gm RECARBRIO SOLR 5 vancomycin hcl solr iv 100 2 gm, 750 mg, 10 gm, 5 gm VABOMERE SOLR 5 vancomycin hcl solr iv 500 2 QL(0.4667 ea mg daily) Chloramphenicols VANCOMYCIN chloramphenicol sodium 2 HYDROCHLORIDE SOLN succinate solr IV 1000 MG/10ML, 1000 Cyclic Lipopeptides MG/200ML, 1250 MG/12.5ML, 1250 CUBICIN RF SOLR (Use 5 MG/250ML, 1500 daptomycin) MG/15ML, 1500 5 CUBICIN SOLR (Use 5 MG/300ML, 1750 daptomycin) MG/17.5ML, 1750 MG/350ML, 2000 DAPTOMYCIN SOLR 350 5 MG (Use daptomycin) MG/20ML, 500 MG/100ML, 750 MG/150ML, 750 daptomycin solr 500 mg, 2 MG/7.5ML 350 mg VANCOMYCIN DAPTOMYCIN SOLR 500 5 HYDROCHLORIDE SOLR 5 MG, 350 MG IV 1.25 GM, 250 MG, 1.5 Glycopeptides GM DALVANCE SOLR 5 VANCOMYCIN HYDROCHLORIDE SOLR 2 IV 750 MG FIRST-VANCOMYCIN 25 5 SOLN VANCOMYCIN HYDROCHLORIDE SOLR NC FIRST-VANCOMYCIN 50 5 SOLN OR 250 MG/5ML VANCOMYCIN FIRVANQ SOLR NC HYDROCHLORIDE/DEXT 5 ROSE SOLN KIMYRSA SOLR NC VANCOMYCIN ORBACTIV SOLR 5 HYDROCHLORIDE/SODIU 5 M CHLORIDE SOLN VANCOCIN CAPS (Use 4 vancomycin hcl) VANCOMYCIN SOLN 5 VANCOCIN HCL CAPS 4 VIBATIV SOLR 5 (Use vancomycin hcl) VANCOMYCIN HCL + NC Leprostatics SYRSPENDSF PH4 SUSP dapsone tabs or 100 mg, 2 25 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Lincosamides linezolid soln iv 600 2 mg/300ml CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use 4 linezolid susr or 100 2 QL(210 ml per clindamycin hcl) mg/5ml 90 days retail) QL(20 ea per CLEOCIN PEDIATRIC linezolid tabs or 600 mg 2 90 days retail) GRANULES SOLR (Use 4 clindamycin palmitate SIVEXTRO SOLR IV 5 hydrochloride) QL(6 ea per 90 CLEOCIN PHOSPHATE SIVEXTRO TABS OR 5 SOLN IJ 300 MG/2ML, 600 days retail) MG/4ML, 900 MG/6ML, 9 5 ZYVOX SOLN IV 200 5 GM/60ML (Use MG/100ML clindamycin phosphate) ZYVOX SOLN IV 600 5 CLEOCIN PHOSPHATE MG/300ML (Use linezolid) SOLN IV 300 MG/2ML, 600 5 ZYVOX SUSR OR 100 5 QL(210 ml per MG/4ML, 900 MG/6ML MG/5ML (Use linezolid) 90 days retail) clindamycin hcl caps or 75 2 ZYVOX TABS OR 600 MG 5 QL(20 ea per mg, 150 mg, 300 mg (Use linezolid) 90 days retail) clindamycin palmitate 2 hydrochloride solr Pleuromutilins XENLETA SOLN IV 150 clindamycin phosphate in 2 5 d5w soln MG/15ML clindamycin phosphate XENLETA TABS OR 600 5 PA; SP MG soln ij 300 mg/2ml, 600 2 mg/4ml, 900 mg/6ml, 9 Polymyxins gm/60ml, 9000 mg/60ml clindamycin phosphate colistimethate sodium solr ij 2 soln iv 300 mg/2ml, 600 2 COLY-MYCIN M SOLR mg/4ml, 900 mg/6ml (Use colistimethate 5 sodium) CLINDAMYCIN/SODIUM NC CHLORIDE SOLN POLYMYXIN B SULFATE 5 POWD XX 100 MU, LINCOCIN SOLN (Use 5 lincomycin hcl) polymyxin b sulfate solr ij 2 lincomycin hcl soln ij 2 500000 unit Streptogramins Monobactams SYNERCID SOLR 5 AZACTAM SOLR (Use 5 aztreonam) Urinary Anti-infectives aztreonam solr 2 FURADANTIN SUSP (Use 5 QL(40 ml daily) nitrofurantoin) CAYSTON SOLR 5 PA; SP HIPREX TABS (Use 5 methenamine hippurate) Oxazolidinones MACROBID CAPS (Use linezolid in sodium chloride 2 nitrofurantoin monohyd 4 soln macro)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACRODANTIN CAPS NITRO-BID OINT 5 (Use nitrofurantoin NC macrocrystal) NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4 methenamine hippurate 2 4 tabs MG/HR, 0.6 MG/HR (Use methenamine mandelate nitroglycerin) tabs or 1 gm, 0.5 gm, 500 2 NITRO-DUR PT24 0.3 4 mg MG/HR, 0.8 MG/HR nitroglycerin cpcr or 6.5 nitrofurantoin macrocrystal 2 2 caps mg, 9 mg, 2.5 mg nitrofurantoin monohyd 2 nitroglycerin in d5w soln 2 macro caps QL(40 ml daily) nitroglycerin pt24 td 0.1 nitrofurantoin susp or 2 mg/hr, 0.2 mg/hr, 0.4 2 mg/hr, 0.6 mg/hr nitrofurantoin susp or NC NITROGLYCERIN SOLN 5 IV 5 MG/ML ANTIANGINAL AGENTS - Drugs to Treat Chest Pain nitroglycerin soln tl 0.4 2 mg/spray Antianginals-Other nitroglycerin subl sl 0.3 mg, 2 RANEXA TB12 1000 MG 5 QL(2 ea daily) 0.4 mg, 0.6 mg (Use ranolazine) NITROLINGUAL RANEXA TB12 500 MG 5 QL(4 ea daily) PUMPSPRAY SOLN (Use 5 (Use ranolazine) nitroglycerin) QL(2 ea daily) ranolazine tb12 1000 mg 2 NITROMIST AERS 5 QL(4 ea daily) ranolazine tb12 500 mg 2 NITROSTAT SUBL (Use 5 nitroglycerin) Nitrates ANTIANXIETY AGENTS - Drugs to Treat Anxiety DILATRATE SR CPCR 5 Antianxiety Agents - Misc. GONITRO PACK NC buspirone hcl tabs or 10 QL(3 ea daily) mg, 30 mg, 5 mg, 7.5 mg, 2 ISORDIL TITRADOSE 15 mg TABS (Use isosorbide 5 dinitrate) DROPERIDOL POWD XX 5 isosorbide dinitrate tabs 30 2 mg, 10 mg, 20 mg, 5 mg droperidol soln ij 2 isosorbide dinitrate tabs 40 NC mg DROPERIDOL SOLN IJ 4 isosorbide dinitrate tbcr 40 2 DROPERIDOL/SODIUM NC mg CHLORIDE SOSY isosorbide mononitrate QL(2 ea daily) 2 hydroxyzine hcl soln im 25 2 tabs 10 mg, 20 mg mg/ml, 50 mg/ml isosorbide mononitrate QL(1 ea daily) 2 hydroxyzine hcl syrp or 10 2 tb24 120 mg, 30 mg, 60 mg mg/5ml

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydroxyzine hcl tabs or 10 2 lorazepam tabs or 0.5 mg, 2 QL(4 ea daily) mg, 25 mg, 50 mg 1 mg, 2 mg hydroxyzine pamoate caps 2 oxazepam caps 2 QL(4 ea daily) or 100 mg, 50 mg, 25 mg TRANXENE T TABS (Use QL(4 ea daily) HYDROXYZINE 5 5 PAMOATE POWD XX clorazepate dipotassium) VALIUM TABS (Use 4 QL(4 ea daily) meprobamate tabs 2 diazepam) VISTARIL CAPS (Use 5 XANAX TABS (Use NC QL(4 ea daily) hydroxyzine pamoate) alprazolam) Benzodiazepines XANAX XR TB24 (Use NC alprazolam) ALPRAZOLAM INTENSOL 5 CONC ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms alprazolam tabs or 0.25 2 QL(4 ea daily) mg, 0.5 mg, 1 mg, 2 mg Antiarrhythmics - Misc. alprazolam tb24 or 0.5 mg, 2 ADENOCARD SOLN (Use 5 1 mg, 2 mg, 3 mg adenosine) alprazolam tbdp or 0.25 2 adenosine soln iv 12 2 mg, 0.5 mg, 1 mg, 2 mg mg/4ml, 3 mg/ml, 6 mg/2ml ATIVAN SOLN IJ 4 ADENOSINE SOSY IV 60 NC MG/ML, 2 MG/ML (Use NC MG/20ML, 90 MG/30ML lorazepam) Antiarrhythmics Type I-A ATIVAN TABS OR 0.5 MG, QL(4 ea daily) 1 MG, 2 MG (Use NC disopyramide phosphate 2 lorazepam) caps QL(4 ea daily) NORPACE CAPS (Use NC chlordiazepoxide hcl caps 2 disopyramide phosphate) clorazepate dipotassium 2 QL(4 ea daily) NORPACE CR CP12 4 tabs PROCAINAMIDE HCL 5 diazepam conc or 5 mg/ml 2 POWD XX procainamide hcl soln ij DIAZEPAM SOAJ IM 10 5 2 MG/2ML 500 mg/ml, 100 mg/ml DIAZEPAM SOLN IJ 5 2 quinidine gluconate tbcr 2 MG/ML diazepam soln ij 5 mg/ml, 2 quinidine sulfate tabs 2 50 mg/10ml Antiarrhythmics Type I-B diazepam soln or 5 mg/5ml 2 lidocaine hcl (cardiac) sosy 2 diazepam tabs or 10 mg, 2 2 QL(4 ea daily) mg, 5 mg LIDOCAINE HCL SOLN IV NC 100 MG/5ML lorazepam conc or 2 mg/ml 2 QL(5 ml daily) LIDOCAINE HYDROCHLORIDE SOSY NC lorazepam soln ij 4 mg/ml, 2 2 mg/ml, 20 mg/10ml IV 100 MG/10ML

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDOCAINE CROMOLYN SODIUM 5 HYDROCHLORIDE SOSY 4 POWD XX IV 100 MG/5ML Antiasthmatic - Monoclonal Antibodies LIDOCAINE HYDROCHLORIDE/DEXT NC CINQAIR SOLN NC SP ROSE SOLN FASENRA PEN SOAJ 4 PA; SP lidocaine in d5w soln 2 FASENRA SOSY 4 PA; SP mexiletine hcl caps 2 NUCALA SOAJ 4 PA; SP Antiarrhythmics Type I-C PA; SP flecainide acetate tabs 2 NUCALA SOLR 4 PA; SP propafenone hcl cp12 2 NUCALA SOSY 4 PA; SP propafenone hcl tabs 2 XOLAIR SOLR 4 PA; SP RYTHMOL SR CP12 (Use 4 XOLAIR SOSY 4 propafenone hcl) Antiarrhythmics Type III Asthma and Bronchodilator Agent Combinations amiodarone hcl soln 2 dyphylline-guaifenesin liqd 2 amiodarone hcl tabs 2 Bronchodilators - Anticholinergics ATROVENT HFA AERS 3 QL(0.86 gm AMIODARONE daily) HYDROCHLORIDE/DEXT NC QL(1 ea daily) ROSE SOLN INCRUSE ELLIPTA AEPB NC BRETYLIUM TOSYLATE NC IPRATROPIUM BROMIDE 5 SOLN MONOHYDRATE POWD CORVERT SOLN (Use 5 IPRATROPIUM BROMIDE 5 ibutilide fumarate) POWD XX QL(12.5 ml dofetilide caps 2 ipratropium bromide soln in 1 daily) ibutilide fumarate soln 2 LONHALA MAGNAIR NC QL(2 ml daily) REFILL KIT SOLN MULTAQ TABS 4 LONHALA MAGNAIR NC QL(2 ml daily) STARTER KIT SOLN NEXTERONE SOLN 5 SEEBRI NEOHALER NC QL(2 ea daily) CAPS TIKOSYN CAPS (Use 4 dofetilide) SPIRIVA HANDIHALER 3 QL(1 ea daily) CAPS ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions SPIRIVA RESPIMAT 4 QL(0.14 gm AERS daily) Anti-Inflammatory Agents TUDORZA PRESSAIR NC cromolyn sodium nebu in 2 QL(8 ml daily) AEPB YUPELRI SOLN 4

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Leukotriene Modulators ASMANEX TWISTHALER 30 METERED DOSES NC ACCOLATE TABS (Use 5 QL(2 ea daily) zafirlukast) AEPB ASMANEX TWISTHALER montelukast sodium chew 1 QL(1 ea daily) NC or 4 mg, 5 mg 60 METERED DOSES AEPB montelukast sodium pack 1 QL(1 ea daily) or 4 mg ASMANEX TWISTHALER 7 METERED DOSES NC montelukast sodium tabs or 1 QL(1 ea daily) AEPB 10 mg budesonide (inhalation) 1 QL(8 ml daily) SINGULAIR CHEW (Use NC QL(1 ea daily) susp 0.25 mg/2ml montelukast sodium) budesonide (inhalation) 1 QL(4 ml daily) SINGULAIR PACK (Use NC QL(1 ea daily) susp 0.5 mg/2ml montelukast sodium) budesonide (inhalation) 1 QL(2 ml daily) SINGULAIR TABS (Use NC QL(1 ea daily) susp 1 mg/2ml montelukast sodium) FLOVENT DISKUS AEPB 3 QL(20 ea daily) zafirlukast tabs 2 QL(2 ea daily) 100 MCG/BLIST FLOVENT DISKUS AEPB 3 QL(8 ea daily) zileuton tb12 2 250 MCG/BLIST FLOVENT DISKUS AEPB 3 QL(40 ea daily) zileuton tb12 NC 50 MCG/BLIST FLOVENT HFA AERO 110 3 QL(0.8 gm ZYFLO TABS 5 MCG/ACT, 220 MCG/ACT daily) Selective Phosphodiesterase 4 (PDE4) Inhibitors FLOVENT HFA AERO 44 3 QL(0.36 gm MCG/ACT daily) DALIRESP TABS 3 QL(1 ea daily) FLUNISOLIDE 5 ANHYDROUS POWD Steroid Inhalants PULMICORT FLEXHALER 3 QL(0.07 ea ALVESCO AERS NC QL(0.41 gm AEPB 180 MCG/ACT daily) daily) PULMICORT FLEXHALER 3 QL(0.27 ea ARMONAIR DIGIHALER AEPB 90 MCG/ACT daily) AEPB 113 MCG/ACT, 55 NC MCG/ACT PULMICORT SUSP 0.25 QL(8 ml daily) MG/2ML (Use budesonide 5 ARNUITY ELLIPTA AEPB QL(1 ea daily) (inhalation)) 100 MCG/ACT, 200 4 MCG/ACT PULMICORT SUSP 0.5 QL(4 ml daily) MG/2ML (Use budesonide 5 ARNUITY ELLIPTA AEPB 4 (inhalation)) 50 MCG/ACT PULMICORT SUSP 1 QL(2 ml daily) ASMANEX HFA AERO NC MG/2ML (Use budesonide 5 (inhalation)) ASMANEX TWISTHALER 120 METERED DOSES NC QVAR REDIHALER AERB 3 QL(0.36 gm AEPB 40 MCG/ACT daily) ASMANEX TWISTHALER QVAR REDIHALER AERB 3 QL(0.72 gm 14 METERED DOSES NC 80 MCG/ACT daily) AEPB Sympathomimetics

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVAIR DISKUS AEPB QL(2 ea daily) ARCAPTA NEOHALER 5 QL(1 ea daily) (Use fluticasone- 1 CAPS salmeterol) arformoterol tartrate nebu 5 QL(4 ml daily) ADVAIR HFA AERO 21 QL(0.4 gm MCG/ACT-115 MCG/ACT, daily) BEVESPI AEROSPHERE NC QL(0.36 gm 21 MCG/ACT-230 3 AERO daily) MCG/ACT, 45 MCG/ACT- BREO ELLIPTA AEPB 25 3 QL(2 ea daily) 21 MCG/ACT MCG/INH-100 MCG/INH ADVAIR HFA AERO 21 BREO ELLIPTA AEPB 25 MCG/ACT-115 MCG/ACT, MCG/INH-100 MCG/INH, NC 21 MCG/ACT-230 NC 25 MCG/INH-200 MCG/ACT, 45 MCG/ACT- MCG/INH 21 MCG/ACT BREO ELLIPTA AEPB 25 4 QL(2 ea daily) AIRDUO DIGIHALER NC MCG/INH-200 MCG/INH 113/14 AEPB BREZTRI AEROSPHERE 4 AIRDUO DIGIHALER NC AERO 232/14 AEPB BROVANA NEBU (Use 5 QL(4 ml daily) AIRDUO DIGIHALER NC arformoterol tartrate) 55/14 AEPB budesonide-formoterol NC AIRDUO RESPICLICK QL(0.04 ea fumarate dihydrate aero 113/14 AEPB (Use NC daily) fluticasone-salmeterol) COMBIVENT RESPIMAT 3 QL(0.2 gm AERS daily) AIRDUO RESPICLICK QL(0.04 ea 232/14 AEPB (Use NC daily) DUAKLIR PRESSAIR NC fluticasone-salmeterol) AEPB AIRDUO RESPICLICK QL(0.04 ea DULERA AERO 5 QL(0.45 gm 55/14 AEPB (Use NC daily) MCG/ACT-100 MCG/ACT, NC daily) fluticasone-salmeterol) 5 MCG/ACT-200 MCG/ACT albuterol sulfate aers in 1 QL(1.2 gm 108 mcg/act daily) DULERA AERO 5 NC MCG/ACT-50 MCG/ACT ALBUTEROL SULFATE 3 QL(2 ml daily) NEBU IN 0.5 % EPHEDRINE HCL POWD 5 albuterol sulfate nebu in QL(2 ml daily) 1 EPHEDRINE SULFATE 5 0.5 %, 2.5 mg/0.5ml POWD XX albuterol sulfate nebu in QL(12.5 ml fluticasone-salmeterol aepb 0.63 mg/3ml, 1.25 mg/3ml, 1 daily) 100 mcg/act-50 mcg/act, NC 0.083 % 50 mcg/act-250 mcg/act ALBUTEROL SULFATE 5 fluticasone-salmeterol aepb QL(0.04 ea POWD XX 14 mcg/act-113 mcg/act, NC daily) albuterol sulfate syrp or 2 1 14 mcg/act-232 mcg/act, mg/5ml 14 mcg/act-55 mcg/act albuterol sulfate tabs or 2 1 fluticasone-salmeterol aepb QL(2 ea daily) mg, 4 mg 50 mcg/dose-500 mcg/dose, 50 mcg/dose- NC albuterol sulfate tb12 or 4 1 mg, 8 mg 100 mcg/dose, 50 mcg/dose-250 mcg/dose ANORO ELLIPTA AEPB 4 QL(2 ea daily)

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits formoterol fumarate nebu 2 QL(4 ml daily) TRELEGY ELLIPTA AEPB in 200 MCG/INH-25 QL(18 ml daily) MCG/INH-62.5 MCG/INH, 4 ipratropium-albuterol soln 1 25 MCG/INH-62.5 MCG/INH-200 MCG/INH isoproterenol hcl soln ij 2 TRELEGY ELLIPTA AEPB QL(2 ea daily) ISOPROTERENOL 25 MCG/INH-62.5 4 HYDROCHLORIDE/SODIU NC MCG/INH-100 MCG/INH M CHLORIDE SOLN UTIBRON NEOHALER NC QL(2 ea daily) CAPS ISUPREL SOLN (Use 5 isoproterenol hcl) VENTOLIN HFA AERS NC QL(1.2 gm levalbuterol hcl nebu in QL(9.6 ml (Use albuterol sulfate) daily) 0.31 mg/3ml, 0.63 mg/3ml, 1 daily) XOPENEX QL(2 ea daily) 1.25 mg/3ml CONCENTRATE NEBU 5 (Use levalbuterol hcl) levalbuterol hcl nebu in 2 QL(2 ea daily) 1.25 mg/0.5ml XOPENEX HFA AERO NC QL(0.6 gm QL(0.6 gm (Use levalbuterol tartrate) daily) levalbuterol tartrate aero 1 daily) XOPENEX NEBU (Use NC QL(9.6 ml levalbuterol hcl) daily) METAPROTERENOL 5 SULFATE POWD Xanthines PERFOROMIST NEBU QL(4 ml daily) NC AMINOPHYLLINE 5 (Use formoterol fumarate) ANHYDROUS POWD PROAIR DIGIHALER NC AMINOPHYLLINE POWD 5 AEPB XX PROAIR HFA AERS (Use NC QL(1.2 gm albuterol sulfate) daily) aminophylline soln iv 2 PROAIR RESPICLICK NC AEPB ELIXOPHYLLIN ELIX 5 PROVENTIL HFA AERS NC QL(1.2 gm THEO-24 CP24 NC (Use albuterol sulfate) daily) THEOPHYLLINE SEREVENT DISKUS 3 QL(2 ea daily) AEPB ETHYLENEDIAMINE EP 5 POWD STIOLTO RESPIMAT 4 QL(0.14 gm AERS daily) theophylline soln 2 STRIVERDI RESPIMAT 4 QL(0.14 gm AERS daily) theophylline tb12 2 SYMBICORT AERO (Use QL(0.34 gm budesonide-formoterol 3 daily) theophylline tb24 2 fumarate dihydrate) THEOPHYLLINE/D5W 5 TERBUTALINE SULFATE 5 SOLN POWD XX ANTICOAGULANTS - Blood Thinners terbutaline sulfate soln ij 1 1 mg/ml Anticoagulants - Misc. terbutaline sulfate tabs or 1 2.5 mg, 5 mg ANTICOAGULANT SODIUM CITRATE SOSY NC 4 %

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM CITRATE LOCK NC heparin sod (porcine) in SP FLUSH SOSY d5w soln 5 %-25000 2 unit/500ml SODIUM CITRATE SOLN NC IV heparin sod (porcine) in 2 d5w soln 5 %-40 unit/ml SODIUM CITRATE SOSY NC IV heparin sodium (porcine) lock flush & nacl lock flush 2 Coumarin Anticoagulants kit COUMADIN TABS (Use NC warfarin sodium) heparin sodium (porcine) 2 lock flush soln WARFARIN SODIUM 5 CLATHRATEFORM POWD heparin sodium (porcine) 2 soln warfarin sodium tabs 2 HEPARIN SODIUM SOLN NC IJ 5000 UNIT/ML Direct Factor Xa Inhibitors HEPARIN SODIUM SOSY QL(43 ea per NC BEVYXXA CAPS NC IJ 5000 UNIT/0.5ML 42 days retail) HEPARIN ELIQUIS STARTER PACK 4 SODIUM/DEXTROSE NC TBPK SOLN 5 %-25000 ELIQUIS TABS 4 UNIT/250ML HEPARIN SP SAVAYSA TABS NC SODIUM/DEXTROSE 5 SOLN 5 %-25000 XARELTO STARTER 4 UNIT/500ML PACK TBPK HEPARIN SODIUM/NACL XARELTO TABS 10 MG 4 QL(1 ea daily) 0.45% SOLN 0.45 %- 5 12500 UNIT/250ML XARELTO TABS 15 MG, 4 HEPARIN SODIUM/NACL 2.5 MG, 20 MG 0.45% SOLN 0.45 %- NC Heparins And Heparinoid-Like Agents 25000 UNIT/250ML HEPARIN ARIXTRA SOLN (Use 4 SP fondaparinux sodium) SODIUM/SODIUM 5 CHLORIDE 0.9% SOLN SP enoxaparin sodium soln 2 HEPARIN SP SODIUM/SODIUM NC fondaparinux sodium soln 2 CHLORIDE SOLN PA; SP HEPARIN FRAGMIN SOLN 4 SODIUM/SODIUM NC CHLORIDE SOSY heparin (porcine) in sodium 2 chloride soln HEPARIN/SODIUM NC HEPARIN LOCK FLUSH CHLORIDE SOLN SOLN (Use heparin sodium 2 HEPMED KIT NC (porcine) lock flush) LOVENOX SOLN (Use SP heparin sod (porcine) in NC 5 d5w soln 5 %-100 unit/ml enoxaparin sodium) In Vitro/Lock Anticoagulants

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACD FORMULA A SOLN 5 FYCOMPA SUSP 4

ACD-A NOCLOT-50 SOLN 5 FYCOMPA TABS 4 ANTICOAGULANT Anticonvulsants - Benzodiazepines CITRATE DEXTROSE 5 SOLUTION A SOLN clobazam susp 2 ANTICOAGULANT SODIUM CITRATE SOLN 5 clobazam tabs 2 4 GM/100ML clonazepam tabs or 0.5 2 QL(4 ea daily) REGIOCIT SOLN 5 mg, 1 mg, 2 mg clonazepam tbdp or 0.125 QL(4 ea daily) SODIUM mg, 0.25 mg, 0.5 mg, 1 mg, 2 CITRATE/GENTAMICIN NC 2 mg SOLN DIASTAT ACUDIAL GEL QL(1 ea per fill TRICITRASOL CONC 5 (Use diazepam 5 retail,4 ea per (anticonvulsant)) 22 days retail) Thrombin Inhibitors DIASTAT PEDIATRIC GEL QL(1 ea per fill ANGIOMAX SOLR (Use 5 (Use diazepam 5 retail,4 ea per bivalirudin trifluoroacetate) (anticonvulsant)) 22 days retail) ARGATROBAN SOLN 0.9 QL(1 ea per fill 5 diazepam (anticonvulsant) 2 retail,4 ea per %-125 MG/125ML, 125 gel MG/125ML-0.9 % 22 days retail) argatroban soln 250 2 KLONOPIN TABS (Use 5 QL(4 ea daily) mg/2.5ml clonazepam) ARGATROBAN SOLN 250 5 NAYZILAM SOLN 4 MG/2.5ML, 50 MG/50ML ARGATROBAN SOLN 250 ONFI SUSP (Use NC MG/2.5ML, 50 MG/50ML 5 clobazam) (Use argatroban) ONFI TABS (Use NC clobazam) argatroban soln 50 5 mg/50ml SYMPAZAN FILM NC ARGATROBAN/SODIUM NC CHLORIDE SOLN VALTOCO LIQD 4 BIVALIRUDIN RTU SOLN 5 VALTOCO LQPK 4 bivalirudin trifluoroacetate 2 solr Anticonvulsants - Misc. APTIOM TABS 200 MG, QL(2 ea daily) BIVALIRUDIN/SODIUM NC 5 CHLORIDE SOLN 400 MG, 600 MG QL(1 ea daily) PRADAXA CAPS 110 MG, NC APTIOM TABS 800 MG 5 75 MG QL(2 ea daily) BANZEL SUSP 40 MG/ML NC PA; SP PRADAXA CAPS 150 MG NC (Use rufinamide) BANZEL TABS 200 MG, 5 PA; SP ANTICONVULSANTS - Drugs to Treat Seizures 400 MG (Use rufinamide) AMPA Glutamate Receptor Antagonists 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRIVIACT SOLN IV 50 5 PA; SP gabapentin soln or 250 2 QL(60 ml daily) MG/5ML mg/5ml, 300 mg/6ml BRIVIACT SOLN OR 10 5 gabapentin tabs or 600 mg, 2 QL(4 ea daily) MG/ML 800 mg BRIVIACT TABS OR 10 KEPPRA SOLN IV 500 MG, 100 MG, 25 MG, 50 5 MG/5ML (Use 5 MG, 75 MG levetiracetam) carbamazepine chew or 2 KEPPRA SOLN OR 100 5 QL(30 ml daily) 100 mg MG/ML (Use levetiracetam) carbamazepine cp12 or 2 KEPPRA TABS OR 1000 5 QL(3 ea daily) 100 mg MG (Use levetiracetam) carbamazepine cp12 or 2 QL(6 ea daily) KEPPRA TABS OR 250 QL(4 ea daily) 200 mg MG, 750 MG, 500 MG (Use 5 levetiracetam) carbamazepine cp12 or 2 QL(4 ea daily) 300 mg KEPPRA XR TB24 (Use 5 QL(4 ea daily) levetiracetam) CARBAMAZEPINE POWD 5 XX LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use 5 carbamazepine susp or 2 100 mg/5ml lamotrigine) carbamazepine tabs or 200 2 LAMICTAL ODT KIT 5 mg LAMICTAL ODT KIT (Use carbamazepine tb12 or 100 2 5 mg lamotrigine) LAMICTAL ODT TBDP 100 carbamazepine tb12 or 200 2 QL(6 ea daily) mg MG, 200 MG, 25 MG, 50 5 MG (Use lamotrigine) carbamazepine tb12 or 400 2 QL(4 ea daily) mg LAMICTAL STARTER/NOT TAKING 5 CARBATROL CP12 100 5 CARBAMAZEPINE KIT MG (Use carbamazepine) (Use lamotrigine) CARBATROL CP12 200 5 QL(6 ea daily) LAMICTAL MG (Use carbamazepine) STARTER/TAKING 5 CARBATROL CP12 300 5 QL(4 ea daily) CARBAMAZEPINE/NOT MG (Use carbamazepine) TAKING VALPROATE KIT (Use lamotrigine) DIACOMIT CAPS 5 LAMICTAL DIACOMIT PACK 5 STARTER/TAKING 5 VALPROATE KIT (Use lamotrigine) ELEPSIA XR TB24 NC LAMICTAL TABS (Use 5 EPIDIOLEX SOLN 5 PA; SP lamotrigine) LAMICTAL XR KIT 5 FANATREX FUSEPAQ NC SUSP LAMICTAL XR TB24 100 QL(1 ea daily) FINTEPLA SOLN NC MG, 300 MG, 50 MG (Use 5 lamotrigine) gabapentin caps or 100 2 QL(4 ea daily) mg, 300 mg, 400 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR TB24 200 LYRICA SOLN 20 MG/ML NC PA; QL(30 ml MG, 25 MG (Use 5 (Use pregabalin) daily) lamotrigine) MYSOLINE TABS (Use 5 LAMICTAL XR TB24 250 5 QL(2 ea daily) primidone) MG (Use lamotrigine) NEURONTIN CAPS 100 QL(4 ea daily) lamotrigine chew or 25 mg, 2 MG, 300 MG, 400 MG (Use 5 5 mg gabapentin) lamotrigine kit or 25 mg, 2 NEURONTIN SOLN 250 5 QL(60 ml daily) MG/5ML (Use gabapentin) lamotrigine tabs or 100 mg, 2 NEURONTIN TABS 600 QL(4 ea daily) 150 mg, 200 mg, 25 mg MG, 800 MG (Use 5 gabapentin) lamotrigine tb24 or 100 mg, 2 QL(1 ea daily) 300 mg, 50 mg oxcarbazepine susp 300 2 QL(40 ml daily) mg/5ml, 60 mg/ml lamotrigine tb24 or 200 mg, 2 25 mg oxcarbazepine tabs 150 2 QL(4 ea daily) lamotrigine tb24 or 250 mg 2 QL(2 ea daily) mg, 300 mg, 600 mg OXTELLAR XR TB24 4 ST lamotrigine tbdp or 100 mg, 2 200 mg, 25 mg, 50 mg pregabalin caps or 100 mg, PA; QL(3 ea 200 mg, 25 mg, 50 mg, 75 2 daily) levetiracetam in sodium 2 chloride soln mg LEVETIRACETAM SOLN pregabalin caps or 150 mg, 2 PA; QL(2 ea IV 500 MG/100ML-820 225 mg, 300 mg daily) MG/100ML, 540 pregabalin soln or 20 2 PA; QL(30 ml MG/100ML-1500 mg/ml daily) MG/100ML, 750 5 primidone tabs or 250 mg, 2 MG/100ML-1000 50 mg MG/100ML (Use levetiracetam in sodium QUDEXY XR CS24 (Use 5 chloride) topiramate) PA; SP levetiracetam soln iv 500 2 rufinamide susp 40 mg/ml 2 mg/5ml rufinamide tabs 200 mg, PA; SP levetiracetam soln or 100 2 QL(30 ml daily) 5 mg/ml, 500 mg/5ml 400 mg SPRITAM TB3D NC levetiracetam tabs or 1000 2 QL(3 ea daily) mg TEGRETOL SUSP (Use 5 levetiracetam tabs or 250 2 QL(4 ea daily) carbamazepine) mg, 750 mg, 500 mg TEGRETOL TABS (Use 5 levetiracetam tb24 or 500 2 QL(4 ea daily) carbamazepine) mg, 750 mg TEGRETOL-XR TB12 100 5 LYRICA CAPS 100 MG, PA; QL(3 ea MG (Use carbamazepine) 200 MG, 25 MG, 50 MG, NC daily) 75 MG (Use pregabalin) TEGRETOL-XR TB12 200 5 QL(6 ea daily) MG (Use carbamazepine) LYRICA CAPS 150 MG, PA; QL(2 ea 225 MG, 300 MG (Use NC daily) TEGRETOL-XR TB12 400 5 QL(4 ea daily) pregabalin) MG (Use carbamazepine)

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPAMAX SPRINKLE QL(6 ea daily) zonisamide caps or 25 mg 2 CPSP 15 MG (Use 5 topiramate) Carbamates TOPAMAX SPRINKLE QL(8 ea daily) QL(120 ml felbamate susp 600 mg/5ml 2 CPSP 25 MG (Use 5 daily) topiramate) felbamate tabs 400 mg 2 QL(9 ea daily) TOPAMAX TABS 100 MG 5 QL(3 ea daily) (Use topiramate) felbamate tabs 600 mg 2 QL(6 ea daily) TOPAMAX TABS 200 MG 5 QL(8 ea daily) (Use topiramate) FELBATOL SUSP 600 5 QL(120 ml MG/5ML (Use felbamate) daily) TOPAMAX TABS 25 MG, 5 QL(4 ea daily) 50 MG (Use topiramate) FELBATOL TABS 400 MG 5 QL(9 ea daily) topiramate cpsp or 15 mg 2 QL(6 ea daily) (Use felbamate) FELBATOL TABS 600 MG 5 QL(6 ea daily) topiramate cpsp or 25 mg 2 QL(8 ea daily) (Use felbamate) topiramate cs24 or 100 mg, XCOPRI TABS 4 150 mg, 200 mg, 25 mg, 50 NC mg XCOPRI TBPK 4 topiramate tabs or 100 mg 2 QL(3 ea daily) GABA Modulators QL(8 ea daily) GABITRIL TABS (Use 5 topiramate tabs or 200 mg 2 tiagabine hcl) SABRIL PACK (Use SP topiramate tabs or 25 mg, 2 QL(4 ea daily) NC 50 mg vigabatrin) TRILEPTAL SUSP 300 QL(40 ml daily) SABRIL TABS (Use NC PA; SP MG/5ML (Use 5 vigabatrin) oxcarbazepine) tiagabine hcl tabs 2 TRILEPTAL TABS 150 QL(4 ea daily) MG, 300 MG, 600 MG (Use 5 vigabatrin pack 2 PA; SP oxcarbazepine) PA; SP TROKENDI XR CP24 4 vigabatrin tabs 2 Hydantoins VIMPAT SOLN IV 200 4 MG/20ML CEREBYX SOLN (Use 5 fosphenytoin sodium) VIMPAT SOLN OR 10 4 QL(40 ml daily) MG/ML DILANTIN CAPS 100 MG VIMPAT TABS OR 100 QL(2 ea daily) (Use phenytoin sodium 5 MG, 150 MG, 200 MG, 50 4 extended) MG DILANTIN CAPS 30 MG 5 ZONEGRAN CAPS 100 NC QL(6 ea daily) MG (Use zonisamide) DILANTIN INFATABS 5 CHEW (Use phenytoin) ZONEGRAN CAPS 25 MG NC (Use zonisamide) DILANTIN-125 SUSP (Use 5 phenytoin) zonisamide caps or 100 2 QL(6 ea daily) mg, 50 mg fosphenytoin sodium soln 2

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGANONE TABS 5 valproate sodium soln iv 2 100 mg/ml, 500 mg/5ml PHENYTEK CAPS (Use valproate sodium soln or 2 phenytoin sodium 5 250 mg/5ml extended) valproic acid caps or 2 phenytoin chew or 50 mg 2 ANTIDEPRESSANTS - Drugs to Treat phenytoin sodium extended 2 Depression caps Alpha-2 Receptor Antagonists (Tetracyclics) PHENYTOIN SODIUM 5 POWD XX mirtazapine tabs or 15 mg, 2 30 mg, 45 mg, 7.5 mg phenytoin sodium soln ij 2 mirtazapine tbdp or 15 mg, 2 30 mg, 45 mg phenytoin susp or 100 2 mg/4ml, 125 mg/5ml REMERON SOLTAB TBDP 5 Succinimides (Use mirtazapine) REMERON TABS (Use 5 CELONTIN CAPS 5 mirtazapine) ethosuximide caps or 250 2 Antidepressants - Misc. mg APLENZIN TB24 5 ethosuximide soln or 250 2 QL(30 ml daily) mg/5ml bupropion hcl tabs or 100 2 mg, 75 mg ZARONTIN CAPS 250 MG 5 (Use ethosuximide) bupropion hcl tb12 or 100 2 ZARONTIN SOLN 250 QL(30 ml daily) mg, 150 mg, 200 mg MG/5ML (Use 5 bupropion hcl tb24 or 150 2 QL(1 ea daily) ethosuximide) mg, 300 mg Valproic Acid bupropion hcl tb24 or 450 NC mg DEPACON SOLN (Use 5 valproate sodium) FORFIVO XL TB24 (Use 5 bupropion hcl) DEPAKENE CAPS (Use 5 valproic acid) maprotiline hcl tabs 2 DEPAKOTE ER TB24 (Use 5 divalproex sodium) WELLBUTRIN SR TB12 5 (Use bupropion hcl) DEPAKOTE SPRINKLES CSDR (Use divalproex 5 WELLBUTRIN XL TB24 5 QL(1 ea daily) sodium) (Use bupropion hcl) GABA Receptor Modulator - Neuroactive Steroid DEPAKOTE TBEC (Use 5 divalproex sodium) ZULRESSO SOLN NC divalproex sodium csdr or 2 125 mg Monoamine Oxidase Inhibitors (MAOIs) divalproex sodium tb24 or 2 QL(1 ea daily) 250 mg, 500 mg EMSAM PT24 5 divalproex sodium tbec or 2 MARPLAN TABS 5 125 mg, 250 mg, 500 mg

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NARDIL TABS (Use 4 FLUOXETINE PA; QL(1 ea phenelzine sulfate) HYDROCHLORIDE TABS 5 daily) (Use fluoxetine hcl) PARNATE TABS (Use 4 tranylcypromine sulfate) fluvoxamine maleate cp24 2 100 mg, 150 mg phenelzine sulfate tabs or 2 fluvoxamine maleate tabs 2 ST 100 mg, 25 mg, 50 mg tranylcypromine sulfate 2 tabs LEXAPRO TABS (Use NC N-Methyl-D-aspartic acid (NMDA) Receptor escitalopram oxalate) SPRAVATO 56MG DOSE 5 PA; SP paroxetine hcl tabs 2 SOPK paroxetine hcl tb24 2 SPRAVATO 84MG DOSE 5 PA; SP SOPK PAXIL CR TB24 (Use NC Selective Serotonin Reuptake Inhibitors (SSRIs) paroxetine hcl) CELEXA TABS 10 MG QL(4 ea daily) PAXIL SUSP 10 MG/5ML 5 (Use citalopram 5 hydrobromide) PAXIL TABS 10 MG, 20 CELEXA TABS 20 MG QL(2 ea daily) MG, 30 MG, 40 MG (Use NC (Use citalopram 5 paroxetine hcl) hydrobromide) PEXEVA TABS NC CELEXA TABS 40 MG QL(1 ea daily) (Use citalopram 5 PROZAC CAPS (Use NC hydrobromide) fluoxetine hcl) sertraline hcl conc or 20 citalopram hydrobromide 2 QL(20 ml daily) 2 soln 10 mg/5ml mg/ml sertraline hcl tabs or 100 citalopram hydrobromide 2 QL(4 ea daily) 2 tabs 10 mg mg, 25 mg, 50 mg ZOLOFT CONC 20 MG/ML citalopram hydrobromide 2 QL(2 ea daily) 5 tabs 20 mg (Use sertraline hcl) ZOLOFT TABS 100 MG, citalopram hydrobromide 2 QL(1 ea daily) tabs 40 mg 25 MG, 50 MG (Use NC sertraline hcl) escitalopram oxalate soln 2 Serotonin Modulators escitalopram oxalate tabs 2 nefazodone hcl tabs 2 fluoxetine hcl caps or 10 2 TRAZODONE HCL POWD 5 mg, 40 mg, 20 mg XX fluoxetine hcl cpdr or 90 2 trazodone hcl tabs or 300 mg mg, 100 mg, 150 mg, 50 2 fluoxetine hcl soln or 20 2 mg mg/5ml ST; QL(1 ea TRINTELLIX TABS 4 fluoxetine hcl tabs or 10 2 daily) mg, 20 mg VIIBRYD STARTER PACK NC fluoxetine hcl tabs or 60 mg NC KIT VIIBRYD TABS NC

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Serotonin-Norepinephrine Reuptake Inhibitors venlafaxine hcl tb24 225 2 mg CYMBALTA CPEP 20 MG, NC QL(2 ea daily) 30 MG (Use duloxetine hcl) venlafaxine hcl tb24 75 mg NC QL(1 ea daily) CYMBALTA CPEP 60 MG NC (Use duloxetine hcl) Tricyclic Agents amitriptyline hcl tabs or 10 DESVENLAFAXINE ER 5 QL(1 ea daily) TB24 mg, 50 mg, 100 mg, 150 2 mg, 25 mg, 75 mg desvenlafaxine succinate 2 QL(1 ea daily) tb24 amoxapine tabs 2 desvenlafaxine tb24 2 QL(1 ea daily) ANAFRANIL CAPS (Use 4 clomipramine hcl) DRIZALMA SPRINKLE NC CSDR clomipramine hcl caps or 2 25 mg, 50 mg, 75 mg duloxetine hcl cpep or 20 2 QL(2 ea daily) mg, 60 mg, 30 mg DESIPRAMINE HCL 5 POWD XX duloxetine hcl cpep or 40 2 mg desipramine hcl tabs or 100 mg, 150 mg, 75 mg, 10 mg, 2 EFFEXOR XR CP24 150 NC QL(2 ea daily) MG (Use venlafaxine hcl) 25 mg, 50 mg EFFEXOR XR CP24 75 QL(1 ea daily) doxepin hcl caps or 150 MG, 37.5 MG (Use NC mg, 25 mg, 75 mg, 10 mg, 2 venlafaxine hcl) 100 mg, 50 mg doxepin hcl conc or 10 FETZIMA CP24 120 MG, 5 ST; QL(1 ea 2 40 MG, 80 MG daily) mg/ml IMIPRAMINE HCL POWD FETZIMA CP24 20 MG 5 ST; QL(2 ea 5 daily) XX imipramine hcl tabs or 10 FETZIMA TITRATION 5 ST 2 PACK C4PK mg, 25 mg, 50 mg imipramine pamoate caps 2 KHEDEZLA TB24 (Use 5 QL(1 ea daily) desvenlafaxine) NORPRAMIN TABS (Use 4 PRISTIQ TB24 100 MG, 50 desipramine hcl) MG (Use desvenlafaxine NC succinate) nortriptyline hcl caps or 10 2 mg, 50 mg, 25 mg, 75 mg PRISTIQ TB24 25 MG QL(1 ea daily) (Use desvenlafaxine NC NORTRIPTYLINE HCL 5 succinate) POWD XX nortriptyline hcl soln or 10 venlafaxine hcl cp24 150 2 QL(2 ea daily) 2 mg mg/5ml PAMELOR CAPS (Use venlafaxine hcl cp24 75 2 QL(1 ea daily) 4 mg, 37.5 mg nortriptyline hcl) venlafaxine hcl tabs 100 protriptyline hcl tabs 2 mg, 25 mg, 37.5 mg, 50 2 mg, 75 mg TOFRANIL TABS (Use 4 imipramine hcl) venlafaxine hcl tb24 150 NC mg, 37.5 mg trimipramine maleate caps 2 or 100 mg, 25 mg, 50 mg

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIMIPRAMINE MALEATE 5 INVOKAMET XR TB24 NC POWD XX ANTIDIABETICS - Drugs to Regulate Blood JANUMET TABS 3 QL(2 ea daily) Sugar JANUMET XR TB24 100 QL(1 ea daily) Alpha-Glucosidase Inhibitors MG-1000 MG, 50 MG-500 3 MG, 500 MG-50 MG acarbose tabs or 100 mg, 2 QL(3 ea daily) 25 mg, 50 mg JANUMET XR TB24 1000 QL(2 ea daily) MG-50 MG, 50 MG-1000 3 GLYSET TABS (Use 5 QL(3 ea daily) miglitol) MG QL(2 ea daily) miglitol tabs 2 QL(3 ea daily) JENTADUETO TABS NC

PRECOSE TABS (Use 4 QL(3 ea daily) JENTADUETO XR TB24 NC acarbose) KAZANO TABS (Use NC Antidiabetic - Amylin Analogs alogliptin-metformin hcl) SYMLINPEN 120 SOPN 4 QL(0.36 ml daily) KOMBIGLYZE XR TB24 NC QL(0.2 ml SYMLINPEN 60 SOPN 3 OSENI TABS (Use NC daily) alogliptin-pioglitazone) Antidiabetic Combinations pioglitazone hcl-glimepiride 2 QL(1 ea daily) ACTOPLUS MET TABS QL(2 ea daily) tabs (Use pioglitazone hcl- 5 pioglitazone hcl-metformin 1 QL(2 ea daily) metformin hcl) hcl tabs alogliptin-metformin hcl NC QTERN TABS NC tabs repaglinide-metformin hcl 2 QL(2 ea daily) alogliptin-pioglitazone tabs NC tabs DUETACT TABS (Use QL(1 ea daily) SEGLUROMET TABS NC pioglitazone hcl- 5 glimepiride) SOLIQUA 100/33 SOPN 4 glipizide-metformin hcl tabs QL(2 ea daily) QL(1 ea daily) 2.5 mg-250 mg, 250 mg- 2 STEGLUJAN TABS NC 2.5 mg, 2.5 mg-500 mg, 500 mg-2.5 mg SYNJARDY TABS 3 glipizide-metformin hcl tabs 2 QL(4 ea daily) 5 mg-500 mg SYNJARDY XR TB24 3 glyburide-metformin tabs QL(2 ea daily) 2.5 mg-500 mg, 500 mg- 1 TRIJARDY XR TB24 4 2.5 mg, 1.25 mg-250 mg, 250 mg-1.25 mg XIGDUO XR TB24 4 glyburide-metformin tabs 5 1 QL(4 ea daily) mg-500 mg XULTOPHY 100/3.6 SOPN 3 GLYXAMBI TABS 4 Biguanides FORTAMET TB24 1000 NC PA; QL(2 ea INVOKAMET TABS NC MG (Use metformin hcl) daily)

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FORTAMET TB24 500 MG NC PA; QL(4 ea GVOKE HYPOPEN 2- 4 (Use metformin hcl) daily) PACK SOAJ GLUMETZA TB24 1000 NC PA; QL(2 ea GVOKE PFS SOSY 4 MG (Use metformin hcl) daily) PA; SP GLUMETZA TB24 500 MG NC PA; QL(4 ea KORLYM TABS 5 (Use metformin hcl) daily) PROGLYCEM SUSP (Use metformin hcl soln or 500 2 5 mg/5ml diazoxide) metformin hcl tabs or 1000 1 QL(2 ea daily) ZEGALOGUE SOAJ NC mg ZEGALOGUE SOSY NC metformin hcl tabs or 500 1 QL(5 ea daily) mg Dipeptidyl Peptidase-4 (DPP-4) Inhibitors metformin hcl tabs or 850 1 QL(3 ea daily) mg alogliptin benzoate tabs NC metformin hcl tb24 or 1000 NC PA; QL(2 ea mg daily) JANUVIA TABS 3 QL(1 ea daily) metformin hcl tb24 or 500 PA; QL(4 ea NC NESINA TABS (Use NC mg daily) alogliptin benzoate) metformin hcl tb24 or 500 1 QL(4 ea daily) mg ONGLYZA TABS NC metformin hcl tb24 or 750 1 QL(3 ea daily) QL(1 ea daily) mg TRADJENTA TABS NC RIOMET ER SRER NC Dopamine Receptor Agonists - Antidiabetic CYCLOSET TABS 5 RIOMET SOLN (Use NC metformin hcl) Incretin Mimetic Agents (GLP-1 Receptor Diabetic Other ADLYXIN SOPN NC BAQSIMI ONE PACK 4 POWD ADLYXIN STARTER PACK NC BAQSIMI TWO PACK 4 PNKT POWD BYDUREON BCISE AUIJ NC diazoxide susp or 2 BYDUREON PEN PEN NC GLUCAGEN HYPOKIT 4 QL(1 ea per fill SOLR retail) BYETTA SOPN NC QL(1 ea per fill glucagon (rdna) kit 1 retail) OZEMPIC SOPN 4 GLUCAGON EMERGENCY KIT FOR NC RYBELSUS TABS 4 LOW BLOOD SUGAR SOLR TRULICITY SOPN 4 GLUCAGON QL(1 ea per fill QL(0.3 ml EMERGENCY KIT KIT 3 retail) VICTOZA SOPN 3 (Use glucagon (rdna)) daily) Insulin Sensitizing Agents GVOKE HYPOPEN 1- 4 PACK SOAJ

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTOS TABS 15 MG, 30 QL(1 ea daily) NC HUMALOG SOCT NC QL(1.5 ml MG (Use pioglitazone hcl) daily) ACTOS TABS 45 MG (Use NC HUMALOG SOLN NC QL(1.5 ml pioglitazone hcl) daily) AVANDIA TABS 5 HUMULIN 70/30 KWIKPEN NC SUPN pioglitazone hcl tabs 15 1 QL(1 ea daily) mg, 30 mg HUMULIN 70/30 SUSP NC pioglitazone hcl tabs 45 mg 1 HUMULIN N KWIKPEN NC SUPN Insulin HUMULIN N SUSP NC QL(1.5 ml ADMELOG SOLN NC daily) HUMULIN R SOLN NC ADMELOG SOLOSTAR NC SOPN HUMULIN R U-500 3 QL(1.34 ml (CONCENTRATED) SOLN daily) AFREZZA POWD NC HUMULIN R U-500 3 QL(1.5 ml KWIKPEN SOPN daily) AFREZZA POWD 12 UNIT, NC QL(3 ea daily) 4 UNIT, 8 UNIT, INSULIN ASPART NC PENFILL SOCT APIDRA SOLN NC QL(1.34 ml daily) INSULIN ASPART PROTAMINE/INSULIN NC APIDRA SOLOSTAR QL(1.5 ml NC ASPART FLEXPEN SUPN SOPN daily) INSULIN ASPART BASAGLAR KWIKPEN 3 QL(1.5 ml PROTAMINE/INSULIN NC SOPN daily) ASPART SUSP FIASP FLEXTOUCH 3 INSULIN LISPRO JUNIOR QL(1.5 ml SOPN NC KWIKPEN SOPN daily) FIASP PENFILL SOCT 3 INSULIN LISPRO NC KWIKPEN SOPN FIASP SOLN 3 INSULIN LISPRO QL(1.5 ml PROTAMINE/INSULIN NC daily) HUMALOG JUNIOR NC QL(1.5 ml KWIKPEN SOPN daily) LISPRO KWIKPEN SUPN QL(1.5 ml HUMALOG KWIKPEN NC INSULIN LISPRO SOLN NC SOPN 100 UNIT/ML daily) HUMALOG KWIKPEN NC QL(0.8 ml LANTUS SOLN NC SOPN 200 UNIT/ML daily) LANTUS SOLOSTAR NC QL(1.5 ml HUMALOG MIX 50/50 NC QL(1.5 ml SOPN daily) KWIKPEN SUPN daily) LANTUS SOLOSTAR NC HUMALOG MIX 50/50 NC QL(1.5 ml SOPN SUSP daily) LEVEMIR FLEXTOUCH 3 QL(1.5 ml HUMALOG MIX 75/25 NC QL(1.5 ml SOPN daily) KWIKPEN SUPN daily) QL(1.5 ml LEVEMIR SOLN 3 HUMALOG MIX 75/25 NC QL(1.34 ml daily) SUSP daily) LYUMJEV KWIKPEN NC SOPN 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LYUMJEV SOLN NC NOVOLOG MIX 70/30 3 SUSP MYXREDLIN SOLN NC NOVOLOG PENFILL 3 QL (1.5 ml SOCT daily) NOVOLIN 70/30 FLEXPEN NC NOVOLOG PENFILL 3 QL(1.5 ml RELION SUPN SOCT daily) NOVOLIN 70/30 FLEXPEN QL(1.5 ml 3 NOVOLOG RELION SOLN 5 QL(1.67 ml SUPN daily) daily) NOVOLIN 70/30 RELION QL(1.67 ml NC NOVOLOG SOLN 3 SUSP daily NOVOLIN 70/30 SUSP 3 QL(1.34 ml daily) SEMGLEE SOLN NC NOVOLIN N FLEXPEN NC RELION SUPN SEMGLEE SOPN NC NOVOLIN N FLEXPEN 3 QL(1.5 ml TOUJEO MAX SOLOSTAR 4 QL(0.5 ml SUPN daily) SOPN daily) NOVOLIN N RELION NC TOUJEO SOLOSTAR 4 QL(0.5 ml SUSP SOPN daily) QL(1.34 ml TRESIBA FLEXTOUCH QL(1.5 ml NOVOLIN N SUSP 3 3 daily) SOPN 100 UNIT/ML daily) NOVOLIN R FLEXPEN NC TRESIBA FLEXTOUCH 3 QL(0.9 ml RELION SOPN SOPN 200 UNIT/ML daily) NOVOLIN R FLEXPEN 4 TRESIBA SOLN 3 SOPN NOVOLIN R RELION NC Meglitinide Analogues SOLN nateglinide tabs 1 QL(3 ea daily) NOVOLIN R SOLN 3 QL(1.34 ml daily) PRANDIN TABS 1 MG 5 QL(4 ea daily) (Use repaglinide) NOVOLOG FLEXPEN 5 QL(1.5 ml RELION SOPN daily) PRANDIN TABS 2 MG 5 QL(8 ea daily) (Use repaglinide) NOVOLOG FLEXPEN 3 QL (1.5 ml SOPN daily) repaglinide tabs 0.5 mg, 1 2 QL(4 ea daily) NOVOLOG MIX 70/30 QL(1.5 ml mg PREFILLED FLEXPEN 5 daily) QL(8 ea daily) RELION SUPN repaglinide tabs 2 mg 2 NOVOLOG MIX 70/30 QL (1.5 ml STARLIX TABS (Use 5 QL(3 ea daily) PREFILLED FLEXPEN 3 daily) nateglinide) SUPN Sodium-Glucose Co-Transporter 2 (SGLT2) NOVOLOG MIX 70/30 QL(1.5 ml PREFILLED FLEXPEN 3 daily) FARXIGA TABS 3 SUPN INVOKANA TABS NC NOVOLOG MIX 70/30 5 RELION SUSP JARDIANCE TABS 4 NOVOLOG MIX 70/30 3 QL (1.34 ml SUSP daily) STEGLATRO TABS NC QL(1 ea daily)

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Sulfonylureas CULTURELLE KIDS 5 RX/OTC GROW THRIVE PACK AMARYL TABS (Use 5 QL(2 ea daily) glimepiride) DIFF-STAT PACK 5 RX/OTC glimepiride tabs 1 QL(2 ea daily) FLORAJEN ACIDOPHILUS NC RX/OTC CAPS GLIPIZIDE POWD XX 5 FLORAJEN WOMEN NC RX/OTC CAPS glipizide tabs or 10 mg, 5 1 mg FLORATUMMYS KIDS 5 RX/OTC PACK glipizide tb24 or 10 mg, 2.5 1 mg, 5 mg lactobacillus caps NC RX/OTC GLUCOTROL TABS (Use 5 glipizide) OMNI-BIOTIC AB 10 PACK 5 RX/OTC GLUCOTROL XL TB24 5 (Use glipizide) OMNI-BIOTIC HETOX 5 RX/OTC PACK glyburide micronized tabs 2 PRO NUTRIENTS 5 RX/OTC PROBIOTIC PACK GLYBURIDE POWD XX 5 PROBIOMAX PLUS DF 5 RX/OTC PACK glyburide tabs or 1.25 mg, 1 2.5 mg, 5 mg PROBIOTIC + 5 RX/OTC COLOSTRUM PACK GLYNASE TABS (Use 5 glyburide micronized) PROBIOTIC CAPS NC RX/OTC tolbutamide tabs 2 PROBIOTIC GOLD EXTRA NC RX/OTC STRENGTH CAPS ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea RE:IIMMUNE PACK 5 RX/OTC Antidiarrheal - Chloride Channel Antagonists REPHRESH PRO-B CAPS NC RX/OTC MYTESI TBEC NC RESTORE PACK 5 RX/OTC Antidiarrheal/Probiotic Agents - Misc. AZO DUAL PROTECTION RX/OTC SIMILAC PROBIOTIC TRI- 5 RX/OTC URINARY+VAGINAL NC BLEND PACK SUPPORT CAPS VISBIOME PACK 5 RX/OTC BIO-KULT INFANTIS 5 RX/OTC PACK VISBIOME PROBIOTIC 5 RX/OTC HIGH POTENCY PACK BIOMEPRO CAPS NC RX/OTC VSL#3 DS PACK 5 RX/OTC BISMUTH SUBGALLATE 5 RX/OTC POWD VSL#3 JUNIOR PACK 5 RX/OTC CULTURELLE BABY RX/OTC 5 RX/OTC GROW THRIVE PACK VSL#3 PACK 5 CULTURELLE DIGESTIVE RX/OTC Antidiarrheal/Probiotic Combinations HEALTH WOMENS NC HEALTHY BALANCE PROBICHEW CHEW NC RX/OTC CAPS

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTORA RX CAPS 5 EXJADE TBSO 125 MG 5 PA; SP (Use deferasirox) Antiperistaltic Agents EXJADE TBSO 250 MG, NC PA; SP 500 MG (Use deferasirox) diphenoxylate w/ atropine 2 liqd FERRIPROX SOLN 100 NC MG/ML diphenoxylate w/ atropine 2 tabs FERRIPROX TABS 1000 NC SP MG LOMOTIL TABS (Use 4 diphenoxylate w/ atropine) FERRIPROX TABS 500 NC PA; SP MG (Use deferiprone) LOPERAMIDE HCL POWD 5 XX FERRIPROX TWICE-A- NC SP DAY TABS loperamide hcl soln or 1 NC mg/7.5ml, 2 mg/15ml JADENU SPRINKLE PACK NC PA; SP (Use deferasirox) MOTOFEN TABS NC JADENU TABS (Use NC PA; SP deferasirox) opium tincture tinc 2 PENTETATE CALCIUM NC paregoric tinc 2 TRISODIUM SOLN PENTETATE ZINC NC Gastrointestinal Adsorbents TRISODIUM SOLN KAOLIN COLLOIDAL 5 RX/OTC Antidotes and Specific Antagonists POWD ACETADOTE SOLN (Use 5 KAOLIN POWD 5 RX/OTC acetylcysteine (antidote)) acetylcysteine (antidote) 2 PECTIN POWD 5 RX/OTC soln ANDEXXA SOLR 5 PA; SP ANTIDOTES AND SPECIFIC ANTAGONISTS Antidote Combinations BAL IN OIL SOLN 5 DUODOTE SOAJ 5 BRIDION SOLN NC

NITHIODOTE KIT 5 CALCIUM DISODIUM 5 VERSENATE SOLN Antidotes - Chelating Agents CHARCOAL ACTIVATED 5 RX/OTC POWD CHEMET CAPS 5 CHARCOAL POWD 5 RX/OTC deferasirox pack 2 PA; SP CYANOKIT SOLR 5 deferasirox tabs 2 PA; SP deferoxamine mesylate solr 2 PA; SP deferasirox tbso 2 PA; SP DESFERAL SOLR (Use NC PA; SP deferiprone tabs 2 PA; SP deferoxamine mesylate) DIGIFAB SOLR 5 DIMERCAPTOPROPANE NC SULFONATE DMPS SOLN EDETATE CALCIUM 5 DISODIUM POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fomepizole soln 2 VIVITROL SUSR 5 PA; SP methylene blue (antidote) 2 ANTIEMETICS - Drugs to Treat Nausea and soln Vomiting PHYSOSTIGMINE 5 5-HT3 Receptor Antagonists SALICYLATE SOLN ALOXI SOLN (Use 5 PRALIDOXIME CHLORIDE 5 palonosetron hcl) SOAJ ANZEMET TABS 5 QL(2 ea per fill PRAXBIND SOLN 5 retail) granisetron hcl soln iv 1 PROTOPAM CHLORIDE 5 2 SOLR mg/ml, 4 mg/4ml Limit 10 per PROVAYBLUE SOLN NC granisetron hcl tabs or 1 2 month;QL(2 ea mg daily) RADIOGARDASE CAPS 5 ondansetron hcl soln ij 40 2 mg/20ml, 4 mg/2ml SODIUM NITRITE SOLN 5 IV ondansetron hcl soln or 4 2 QL(50 ml per mg/5ml fill retail) SODIUM THIOSULFATE 2 SOLN IV ondansetron hcl tabs or 24 2 QL(0.143 ea mg daily) sodium thiosulfate soln iv 2 QL(2 ea ondansetron hcl tabs or 4 2 daily,30 ea per VISTOGARD PACK 4 mg, 8 mg fill retail) Benzodiazepine Antagonists QL(2 ea ondansetron tbdp 2 daily,30 ea per flumazenil soln iv 0.5 2 mg/5ml, 1 mg/10ml fill retail) Opioid Antagonists palonosetron hcl soln 2 EVZIO SOAJ NC QL(1.6 ml per 30 days retail) palonosetron hcl sosy 2 LIFEMS NALOXONE NC PALONOSETRON 5 PSKT HYDROCHLORIDE SOLN naloxone hcl soaj ij 2 NC QL(1.6 ml per QL(0.0667 ea mg/0.4ml 30 days retail) SANCUSO PTCH 4 daily,1 ea per 21 days retail) naloxone hcl soct ij 0.4 2 mg/ml SUSTOL PRSY NC naloxone hcl soln ij 0.4 2 mg/ml, 4 mg/10ml QL(2 ea ZOFRAN TABS (Use 5 daily,30 ea per naloxone hcl sosy ij 2 2 ondansetron hcl) mg/2ml fill retail) ZUPLENZ FILM NC QL(30 ea per naltrexone hcl tabs or 2 fill retail) NALTREXONE IMPL SC NC Antiemetics - Anticholinergic DIMENHYDRINATE SOLN 5 NARCAN LIQD 4 QL(4 ea per 30 days retail)

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MECLIZINE HCL 5 aprepitant caps 125 mg, 80 2 QL(1 ea per 30 MONOHYDRATE POWD mg days retail) QL(2 ea per 30 MECLIZINE HCL POWD 5 aprepitant caps 40 mg 2 XX days retail) RX/OTC QL(3 ea per 30 meclizine hcl tabs or 12.5 2 aprepitant misc 2 mg days retail) scopolamine pt72 2 CINVANTI EMUL NC TIGAN CAPS OR 300 MG EMEND CAPS OR 125 QL(1 ea per 30 (Use trimethobenzamide 5 MG, 80 MG (Use 5 days retail) hcl) aprepitant) TIGAN SOLN IM 100 5 EMEND CAPS OR 40 MG 5 QL(2 ea per 30 MG/ML (Use aprepitant) days retail) TRANSDERM SCOP PT72 NC EMEND SOLR IV 150 MG (Use scopolamine) (Use fosaprepitant 5 dimeglumine) TRANSDERM-SCOP PT72 NC (Use scopolamine) EMEND SUSR OR 125 5 QL(1 ea per 30 MG/5ML days retail) trimethobenzamide hcl 2 caps or EMEND TRIPACK CAPS 5 QL(3 ea per 30 (Use aprepitant) days retail) Antiemetics - Antidopaminergic fosaprepitant dimeglumine 2 BARHEMSYS SOLN NC solr VARUBI TBPK 5 QL(4 ea per fill Antiemetics - Miscellaneous retail) AKYNZEO CAPS OR 0.5 5 QL(2 ea per 28 MG-300 MG days retail) ANTIFUNGALS - Drugs to Treat Fungal Infections AKYNZEO SOLN IV 0.25 5 MG/20ML-235 MG/20ML Antifungal - Glucan Synthesis Inhibitors CANCIDAS SOLR (Use 5 AKYNZEO SOLR IV 0.25 5 caspofungin acetate) MG-235 MG caspofungin acetate solr 50 QL(2 ea daily) 2 BONJESTA TBCR NC mg, 70 mg CASPOFUNGIN ACETATE CESAMET CAPS 5 PA; QL(2 ea 5 daily) SOLR 50 MG, 70 MG DICLEGIS TBEC (Use 5 QL(4 ea daily) ERAXIS SOLR 5 doxylamine-pyridoxine) micafungin sodium solr 2 doxylamine-pyridoxine tbec 2 QL(4 ea daily) PA MYCAMINE SOLR (Use 5 dronabinol caps 2 micafungin sodium) Antifungals MARINOL CAPS (Use 5 PA dronabinol) ABELCET SUSP 5 SYNDROS SOLN NC AMBISOME SUSR 5 Substance P/Neurokinin 1 (NK1) Receptor QL(3 ea per 30 amphotericin b solr iv 50 2 aprepitant caps 2 mg days retail)

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANCOBON CAPS (Use 5 itraconazole soln or 10 2 flucytosine) mg/ml flucytosine caps or 250 mg 2 ketoconazole tabs or 2 QL(2 ea daily) flucytosine caps or 500 mg NC MICONAZOLE POWD 5 griseofulvin microsize susp 2 NOXAFIL SOLN IV 300 NC MG/16.7ML griseofulvin microsize tabs 2 NOXAFIL SUSP OR 40 NC MG/ML griseofulvin ultramicrosize 2 NOXAFIL TBEC OR 100 NC tabs MG (Use posaconazole) QL(6 ea daily) nystatin tabs or 2 posaconazole tbec NC QL(1 ea daily) terbinafine hcl tabs or 2 SPORANOX CAPS 100 5 PA; QL(1 ea MG (Use itraconazole) daily) Imidazole-Related Antifungals SPORANOX PULSEPAK 5 PA; QL(1 ea CRESEMBA CAPS OR NC CAPS (Use itraconazole) daily) 186 MG SPORANOX SOLN 10 5 CRESEMBA SOLR IV 372 5 MG/ML (Use itraconazole) MG TOLSURA CAPS NC DIFLUCAN SUSR 10 QL(70 ml per MG/ML, 40 MG/ML (Use 5 fill retail) VFEND IV SOLR (Use 5 fluconazole) voriconazole) DIFLUCAN TABS 100 MG QL(1 ea daily) 5 VFEND SUSR 40 MG/ML 4 (Use fluconazole) (Use voriconazole) DIFLUCAN TABS 150 MG QL(2 ea per fill 5 VFEND TABS 200 MG, 50 4 QL(2 ea daily) (Use fluconazole) retail) MG (Use voriconazole) DIFLUCAN TABS 200 MG 5 QL(2 ea daily) (Use fluconazole) voriconazole solr iv 200 mg 2 voriconazole susr or 40 DIFLUCAN TABS 50 MG 5 QL(7 ea per fill 2 (Use fluconazole) retail) mg/ml fluconazole in nacl soln 2 voriconazole tabs or 200 2 QL(2 ea daily) mg, 50 mg fluconazole susr or 10 2 QL(70 ml per mg/ml, 40 mg/ml fill retail) ANTIHISTAMINES - Drugs to Treat Allergies fluconazole tabs or 100 mg 2 QL(1 ea daily) Antihistamines - Alkylamines BROMPHENIRAMINE QL(2 ea per fill 5 fluconazole tabs or 150 mg 2 MALEATE POWD retail) BROMPHENIRAMINE NC fluconazole tabs or 200 mg 2 QL(2 ea daily) SOLN QL(7 ea per fill CHLORPHENIRAMINE fluconazole tabs or 50 mg 2 5 retail) MALEATE POWD dexchlorpheniramine itraconazole caps or 100 2 PA; QL(1 ea NC mg daily) maleate soln or Antihistamines - Combinations

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLOBETEX THPK NC desloratadine tbdp 2 QL(1 ea daily) Antihistamines - Ethanolamines levocetirizine QL(10 ml dihydrochloride soln or 2.5 2 daily); RX/OTC carbinoxamine maleate 2 mg/5ml soln 4 mg/5ml levocetirizine QL(1 ea daily); carbinoxamine maleate 2 2 RX/OTC tabs 4 mg dihydrochloride tabs or 5 mg CARBINOXAMINE NC MALEATE TABS 6 MG QUZYTTIR SOLN NC CLEMASTINE FUMARATE 5 XYZAL ALLERGY 24HR QL(10 ml POWD XX CHILDRENS SOLN (Use NC daily); RX/OTC clemastine fumarate tabs 2 levocetirizine or dihydrochloride) DICOPANOL FUSEPAQ 5 XYZAL ALLERGY 24HR QL(1 ea daily); SUSR TABS (Use levocetirizine 5 RX/OTC dihydrochloride) DICOPANOL RAPIDPAQ 5 SUSR Antihistamines - Phenothiazines diphenhydramine hcl elix or QL(240 ml per 2 PHENERGAN SOLN (Use 5 12.5 mg/5ml fill retail) promethazine hcl) diphenhydramine hcl elix or NC promethazine hcl soln ij 50 2 12.5 mg/5ml mg/ml, 25 mg/ml DIPHENHYDRAMINE HCL 5 promethazine hcl soln or 2 QL(240 ml per POWD XX 6.25 mg/5ml fill retail) diphenhydramine hcl soln ij 2 promethazine hcl supp re 2 QL(12 ea per 50 mg/ml 50 mg, 12.5 mg, 25 mg fill retail) DOXYLAMINE RX/OTC 5 promethazine hcl syrp or 2 QL(240 ml per SUCCINATE POWD 6.25 mg/5ml fill retail) KARBINAL ER SUER 5 promethazine hcl tabs or 2 25 mg, 12.5 mg, 50 mg RYVENT TABS NC Antihistamines - Piperidines Antihistamines - Ethylenediamines cyproheptadine hcl syrp or 2 2 mg/5ml PYRILAMINE MALEATE 5 CRYS cyproheptadine hcl tabs or 2 4 mg PYRILAMINE MALEATE 5 POWD ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol TRIPELENNAMINE HCL 5 POWD Adenosine Triphosphate-Citrate Lyase (ACL) Antihistamines - Non-Sedating NEXLETOL TABS 4 QL(240 ml per cetirizine hcl soln 2 fill retail); Angiopoietin-like Protein Inhibitors RX/OTC EVKEEZA SOLN NC SP CLARINEX TABS (Use 5 QL(1 ea daily) desloratadine) Antihyperlipidemics - Combinations desloratadine tabs 2 QL(1 ea daily)

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST; QL(1 ezetimibe-simvastatin tabs 2 COLESTID PACK 5 GM 5 QL(6 ea daily) ea daily) (Use colestipol hcl) NEXLIZET TABS 4 COLESTID TABS 1 GM 5 QL(16 ea daily) (Use colestipol hcl) OMEGA-3 RX COMPLETE NC QL(6 gm daily) THPK colestipol hcl gran 5 gm 2 OMEGA-3/D-3 WELLNESS NC colestipol hcl pack 5 gm 2 QL(6 ea daily) PACK KIT QL(16 ea daily) ROSZET TABS NC colestipol hcl tabs 1 gm 2 QUESTRAN LIGHT POWD QL(6 gm daily) SURE RESULT O3D3 NC 5 SYSTEM KIT (Use cholestyramine light) QUESTRAN PACK 4 GM QL(6 ea daily) VYTORIN TABS (Use 5 PA; ST; QL(1 5 ezetimibe-simvastatin) ea daily) (Use cholestyramine) Antihyperlipidemics - Misc. QUESTRAN POWD 4 QL(6 gm daily) GM/DOSE (Use 5 icosapent ethyl caps NC cholestyramine) WELCHOL PACK 3.75 GM 5 QL(1 ea daily) LOVAZA CAPS (Use 5 QL(4 ea daily) ) omega-3-acid ethyl esters) (Use colesevelam hcl omega-3-acid ethyl esters QL(4 ea daily) WELCHOL TABS 625 MG 5 QL(7 ea daily) 2 (Use colesevelam hcl) caps Fibric Acid Derivatives VASCEPA CAPS 0.5 GM 4 ST ANTARA CAPS 5 VASCEPA CAPS 1 GM 2 choline fenofibrate cpdr 2 QL(1 ea daily) Bile Acid Sequestrants fenofibrate caps or 150 mg 2 QL(1 ea daily) cholestyramine light pack 4 2 QL(6 ea daily) gm fenofibrate caps or 50 mg NC cholestyramine light powd 2 QL(6 gm daily) 4 gm/dose fenofibrate micronized caps NC cholestyramine pack or 4 2 QL(6 ea daily) 130 mg gm fenofibrate micronized caps QL(1 ea daily) cholestyramine powd or 4 2 QL(6 gm daily) 134 mg, 43 mg, 200 mg, 67 2 gm/dose mg colesevelam hcl pack 3.75 QL(1 ea daily) 2 fenofibrate tabs or 120 mg, NC gm 40 mg colesevelam hcl tabs 625 QL(7 ea daily) 2 fenofibrate tabs or 145 mg, 2 QL(1 ea daily) mg 48 mg, 54 mg, 160 mg COLESTID FLAVORED QL(6 gm daily) GRAN 5 GM (Use 5 fenofibrate tabs or 160 mg 2 colestipol hcl) FENOFIBRATE TABS OR NC COLESTID FLAVORED QL(6 ea daily) 160 MG PACK 5 GM/7.5GM (Use 5 colestipol hcl) fenofibric acid tabs 105 mg 2 COLESTID GRAN 5 GM QL(6 gm daily) 5 FENOFIBRIC ACID TABS NC (Use colestipol hcl) 105 MG

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fenofibric acid tabs 35 mg 2 QL(1 ea daily) FLOLIPID SUSP NC

FENOGLIDE TABS 120 NC $0 copay for MG (Use fenofibrate) Generic only, fluvastatin sodium caps 20 2 age 40 to FENOGLIDE TABS 40 MG 5 QL(1 ea daily) mg, 40 mg (Use fenofibrate) 76;QL(1 ea daily) FIBRICOR TABS 105 MG 5 (Use fenofibric acid) $0 copay for Generic only, fluvastatin sodium tb24 80 FIBRICOR TABS 35 MG 5 QL(1 ea daily) 2 age 40 to (Use fenofibric acid) mg 75;QL(1 ea GEMFIBROZIL POWD XX 5 daily) $0 copay for gemfibrozil tabs or 2 QL(2 ea daily) Generic only, LESCOL XL TB24 (Use NC fluvastatin sodium) age 40 to LIPOFEN CAPS (Use 5 QL(1 ea daily) 75;QL(1 ea fenofibrate) daily) LOPID TABS (Use 5 QL(2 ea daily) $0 copay for gemfibrozil) LIPITOR TABS 10 MG, 20 Generic only, TRICOR TABS (Use NC QL(1 ea daily) MG (Use atorvastatin NC age 40 to fenofibrate) calcium) 75;QL(1 ea daily) TRIGLIDE TABS 5 QL(1 ea daily) LIPITOR TABS 40 MG, 80 QL(1 ea daily) MG (Use atorvastatin NC TRILIPIX CPDR (Use 5 QL(1 ea daily) choline fenofibrate) calcium) HMG CoA Reductase Inhibitors LIVALO TABS NC QL(1 ea daily) ALTOPREV TB24 NC $0 copay for Generic only, $0 copay for lovastatin tabs 10 mg, 20 2 age 40 to Generic only, mg atorvastatin calcium tabs or 76;QL(1 ea 2 age 40 to daily) 10 mg, 20 mg 75;QL(1 ea daily) ST; $0 copay for Generic atorvastatin calcium tabs or 2 QL(1 ea daily) lovastatin tabs 40 mg 2 only, age 40 to 40 mg, 80 mg 76;QL(2 ea $0 copay for daily) CRESTOR TABS 10 MG, 5 Generic only, PA; ST; $0 MG (Use rosuvastatin NC age 40 to PRAVACHOL TABS 20 copay for calcium) 75;QL(1 ea Generic only, daily) MG, 80 MG (Use 5 ) age 40 to CRESTOR TABS 20 MG, QL(1 ea daily) pravastatin sodium 76;QL(1 ea 40 MG (Use rosuvastatin NC daily) calcium) PA; ST; $0 EQUAPAX/ATORVASTATI NC copay for N CALCIUM/COQ10 THPK PRAVACHOL TABS 40 5 Generic only, MG (Use pravastatin age 40 to EZALLOR SPRINKLE NC sodium) CPSP 76;QL(2 ea daily)

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits $0 copay for ZETIA TABS (Use NC Generic only, ezetimibe) pravastatin sodium tabs 10 2 age 40 to mg ZETIA TABS (Use NF 76;QL(1 ea ezetimibe) daily) PA; ST; $0 Microsomal Triglyceride Transfer Protein (MTP) copay for JUXTAPID CAPS 5 PA; SP pravastatin sodium tabs 20 2 Generic only, mg, 80 mg age 40 to Nicotinic Acid Derivatives 76;QL(1 ea niacin (antihyperlipidemic) NC daily) tabs 500 mg PA; ST; $0 niacin (antihyperlipidemic) 2 QL(2 ea daily) copay for tbcr 1000 mg, 750 mg pravastatin sodium tabs 40 2 Generic only, mg age 40 to niacin (antihyperlipidemic) 2 QL(1 ea daily) 76;QL(2 ea tbcr 500 mg daily) NIASPAN TBCR 1000 MG, QL(2 ea daily) $0 copay for 750 MG (Use niacin 5 Generic only, (antihyperlipidemic)) rosuvastatin calcium tabs 2 age 40 to NIASPAN TBCR 500 MG QL(1 ea daily) 10 mg, 5 mg 75;QL(1 ea (Use niacin 5 daily) (antihyperlipidemic)) rosuvastatin calcium tabs 2 QL(1 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 20 mg, 40 mg PRALUENT SOAJ 4 PA; SP SIMVASTATIN SUSP OR NC 20 MG/5ML REPATHA PUSHTRONEX NC SP PA; ST; $0 SYSTEM SOCT copay for REPATHA SOSY NC SP simvastatin tabs or 5 mg, 2 Generic only, 10 mg, 20 mg, 40 mg age 40 to REPATHA SURECLICK NC SP 76;QL(1 ea SOAJ daily) PA; ST; QL(1 ANTIHYPERTENSIVES - Drugs to Treat High simvastatin tabs or 80 mg 2 ea daily) Blood Pressure PA; ST; $0 ACE Inhibitors copay for ZOCOR TABS 5 MG, 10 ACCUPRIL TABS (Use 5 QL(2 ea daily) 5 Generic only, quinapril hcl) MG, 20 MG, 40 MG (Use age 40 to simvastatin) ALTACE CAPS (Use 5 QL(2 ea daily) 76;QL(1 ea ramipril) daily) benazepril hcl tabs or 10 2 QL(2 ea daily) ZOCOR TABS 80 MG (Use 5 PA; ST; QL(1 mg, 20 mg, 40 mg simvastatin) ea daily) benazepril hcl tabs or 5 mg 2 QL(1 ea daily) ZYPITAMAG TABS NC QL(1 ea daily) captopril tabs or 100 mg, 2 QL(3 ea daily) Intestinal Cholesterol Absorption Inhibitors 12.5 mg, 25 mg, 50 mg QL(1 ea daily) ezetimibe tabs 2 enalapril maleate soln or 1 5 QL(5 ml daily) mg/ml

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits enalapril maleate tabs or QL(2 ea daily) phenoxybenzamine hcl 2 10 mg, 2.5 mg, 20 mg, 5 2 caps or mg phentolamine mesylate solr 2 enalaprilat inj 2 ij Angiotensin II Receptor Antagonists EPANED SOLN (Use 5 QL(5 ml daily) enalapril maleate) ATACAND TABS (Use NC candesartan cilexetil) fosinopril sodium tabs 10 2 QL(1 ea daily) mg, 20 mg AVAPRO TABS (Use 5 QL(1 ea daily) irbesartan) fosinopril sodium tabs 40 2 QL(2 ea daily) mg BENICAR TABS (Use NC olmesartan medoxomil) lisinopril tabs or 10 mg, 20 2 QL(2 ea daily) mg, 30 mg, 40 mg, 5 mg candesartan cilexetil tabs 2 QL(2 ea daily) 16 mg, 4 mg, 8 mg lisinopril tabs or 2.5 mg 2 QL(1 ea daily) candesartan cilexetil tabs 2 QL(1 ea daily) 32 mg LOTENSIN TABS (Use 5 QL(2 ea daily) benazepril hcl) candesartan cilexetil tabs 2 32 mg moexipril hcl tabs 2 QL(2 ea daily) COZAAR TABS 100 MG NC QL(1 ea daily) (Use losartan potassium) perindopril erbumine tabs 2 QL(2 ea daily) COZAAR TABS 25 MG, 50 QL(2 ea daily) MG (Use losartan 5 PRINIVIL TABS (Use 5 QL(2 ea daily) lisinopril) potassium) QBRELIS SOLN 5 QL(5 ml daily) DIOVAN TABS (Use NC valsartan) QL(2 ea daily) quinapril hcl tabs 2 EDARBI TABS NC QL(2 ea daily) ramipril caps 2 eprosartan mesylate tabs 2 QL(1 ea daily) trandolapril tabs 1 mg, 2 2 QL(1 ea daily) QL(1 ea daily) mg irbesartan tabs 2 trandolapril tabs 4 mg 2 QL(2 ea daily) losartan potassium tabs or 2 QL(1 ea daily) 100 mg VASOTEC TABS (Use QL(2 ea daily) 5 losartan potassium tabs or 2 QL(2 ea daily) enalapril maleate) 25 mg, 50 mg ZESTRIL TABS 10 MG, 20 QL(2 ea daily) MICARDIS TABS (Use NC QL(1 ea daily) MG, 30 MG, 40 MG, 5 MG 5 telmisartan) (Use lisinopril) olmesartan medoxomil tabs 2 QL(1 ea daily) ZESTRIL TABS 2.5 MG 5 QL(1 ea daily) or 20 mg, 40 mg (Use lisinopril) olmesartan medoxomil tabs 2 QL(2 ea daily) Agents for Pheochromocytoma or 5 mg QL(1 ea daily) DEMSER CAPS (Use 5 PA; SP telmisartan tabs 2 metyrosine) valsartan tabs 160 mg, 80 QL(2 ea daily) DIBENZYLINE CAPS (Use 5 2 phenoxybenzamine hcl) mg PA; SP valsartan tabs 320 mg, 40 2 QL(1 ea daily) metyrosine caps 5 mg

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits valsartan tabs 320 mg, 40 2 amlodipine besylate- 2 QL(1 ea daily) mg benazepril hcl caps Antiadrenergic Antihypertensives amlodipine besylate- 2 QL(1 ea daily) olmesartan medoxomil tabs CARDURA TABS (Use 5 doxazosin mesylate) amlodipine besylate- 2 QL(1 ea daily) valsartan tabs CATAPRES TABS (Use 4 clonidine hcl) amlodipine-valsartan- 2 QL(1 ea daily) hydrochlorothiazide tabs CATAPRES-TTS-1 PTWK 4 (Use clonidine) ATACAND HCT TABS (Use candesartan cilexetil- NC CATAPRES-TTS-2 PTWK 4 ) (Use clonidine) hydrochlorothiazide atenolol & chlorthalidone 2 QL(1 ea daily) CATAPRES-TTS-3 PTWK 4 (Use clonidine) tabs AVALIDE TABS (Use QL(1 ea daily) CLONIDINE HCL POWD 5 irbesartan- 5 XX hydrochlorothiazide) clonidine hcl tabs or 0.1 2 AZOR TABS (Use QL(1 ea daily) mg, 0.2 mg, 0.3 mg amlodipine besylate- NC CLONIDINE 5 olmesartan medoxomil) HYDROCHLORIDE POWD benazepril & 2 QL(1 ea daily) clonidine ptwk 2 hydrochlorothiazide tabs BENAZEPRIL QL(1 ea daily) doxazosin mesylate tabs or 2 HCL/HYDROCHLOROTHI 4 1 mg, 2 mg, 4 mg, 8 mg AZIDE TABS guanfacine hcl tabs 2 BENICAR HCT TABS (Use olmesartan medoxomil- NC methyldopa tabs 2 hydrochlorothiazide) bisoprolol & QL(1 ea daily) MINIPRESS CAPS (Use 5 prazosin hcl) hydrochlorothiazide tabs 5 2 mg-6.25 mg, 2.5 mg-6.25 prazosin hcl caps 2 mg, 6.25 mg-2.5 mg bisoprolol & QL(2 ea daily) PRAZOSIN 5 hydrochlorothiazide tabs 2 HYDROCHLORIDE POWD 6.25 mg-10 mg RESERPINE POWD 5 candesartan cilexetil- 2 QL(1 ea daily) hydrochlorothiazide tabs terazosin hcl caps 2 captopril & QL(3 ea daily) hydrochlorothiazide tabs 15 2 Antihypertensive Combinations mg-25 mg, 15 mg-50 mg ACCURETIC TABS 12.5 QL(2 ea daily) captopril & QL(2 ea daily) MG-20 MG (Use quinapril- 5 hydrochlorothiazide tabs 25 2 hydrochlorothiazide) mg-25 mg, 25 mg-50 mg ACCURETIC TABS 20 QL(1 ea daily) DIOVAN HCT TABS (Use MG-25 MG, 12.5 MG-10 5 valsartan- NC MG (Use quinapril- hydrochlorothiazide) hydrochlorothiazide) DUTOPROL TB24 NC

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDARBYCLOR TABS NC metoprolol & 2 QL(2 ea daily) hydrochlorothiazide tabs enalapril maleate & 2 QL(2 ea daily) METOPROLOL hydrochlorothiazide tabs SUCCINATE NC EXFORGE HCT TABS NC ER/HYDROCHLOROTHIA ZIDE TB24 EXFORGE TABS (Use MICARDIS HCT TABS QL(2 ea daily) amlodipine besylate- NC 12.5 MG-80 MG (Use NC valsartan) telmisartan- fosinopril sodium & QL(1 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 10 2 MICARDIS HCT TABS 25 QL(1 ea daily) mg-12.5 mg, 12.5 mg-10 MG-80 MG, 12.5 MG-40 NC mg MG (Use telmisartan- fosinopril sodium & QL(4 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 2 olmesartan medoxomil- QL(1 ea daily) 12.5 mg-20 mg amlodipine- 2 HYZAAR TABS (Use QL(1 ea daily) hydrochlorothiazide tabs losartan potassium & NC olmesartan medoxomil- QL(1 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 2 12.5 mg-40 mg, 25 mg-40 irbesartan- 2 QL(1 ea daily) hydrochlorothiazide tabs mg, 12.5 mg-20 mg lisinopril & QL(1 ea daily) olmesartan medoxomil- hydrochlorothiazide tabs 25 hydrochlorothiazide tabs 10 2 2 mg-12.5 mg, 12.5 mg-10 mg-40 mg, 12.5 mg-20 mg, mg 20 mg-12.5 mg lisinopril & QL(4 ea daily) PRESTALIA TABS NC hydrochlorothiazide tabs 2 12.5 mg-20 mg propranolol & 2 QL(2 ea daily) lisinopril & QL(2 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs 20 2 quinapril- QL(2 ea daily) mg-25 mg hydrochlorothiazide tabs 2 LOPRESSOR HCT TABS QL(2 ea daily) 12.5 mg-20 mg (Use metoprolol & 4 quinapril- QL(1 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 20 2 mg-25 mg, 10 mg-12.5 mg, losartan potassium & 2 QL(1 ea daily) hydrochlorothiazide tabs 12.5 mg-10 mg LOTENSIN HCT TABS QL(1 ea daily) TARKA TBCR (Use 4 QL(1 ea daily) (Use benazepril & 5 trandolapril-verapamil hcl) hydrochlorothiazide) TEKTURNA HCT TABS 4 LOTREL CAPS (Use QL(1 ea daily) amlodipine besylate- 4 telmisartan-amlodipine tabs 2 QL(1 ea daily) benazepril hcl) methyldopa & QL(3 ea daily) telmisartan- QL(2 ea daily) hydrochlorothiazide tabs 15 2 hydrochlorothiazide tabs 2 mg-250 mg 12.5 mg-80 mg methyldopa & QL(2 ea daily) hydrochlorothiazide tabs 25 2 mg-250 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits telmisartan- QL(1 ea daily) TEKTURNA TABS 150 MG 5 QL(2 ea daily) hydrochlorothiazide tabs 25 2 (Use aliskiren fumarate) mg-80 mg, 12.5 mg-40 mg, TEKTURNA TABS 300 MG 5 QL(1 ea daily) 40 mg-12.5 mg (Use aliskiren fumarate) TENORETIC 100 TABS QL(1 ea daily) (Use atenolol & 5 Selective Aldosterone Receptor Antagonists chlorthalidone) eplerenone tabs 2 QL(2 ea daily) TENORETIC 50 TABS QL(1 ea daily) (Use atenolol & 5 INSPRA TABS (Use 4 QL(2 ea daily) chlorthalidone) eplerenone) Vasodilators trandolapril-verapamil hcl 2 QL(1 ea daily) tbcr CORLOPAM SOLN 5 TRIBENZOR TABS (Use QL(1 ea daily) hydralazine hcl soln ij 20 olmesartan medoxomil- 5 2 amlodipine- mg/ml hydrochlorothiazide) hydralazine hcl tabs or 100 2 mg, 25 mg, 50 mg, 10 mg TWYNSTA TABS (Use 5 QL(1 ea daily) telmisartan-amlodipine) minoxidil tabs or 10 mg, 2.5 2 mg valsartan- 2 QL(1 ea daily) hydrochlorothiazide tabs NIPRIDE RTU SOLN NC VASERETIC TABS (Use QL(2 ea daily) enalapril maleate & 5 NITROPRESS SOLN (Use 5 hydrochlorothiazide) nitroprusside sodium) ZESTORETIC TABS 10 QL(1 ea daily) nitroprusside sodium soln 2 MG-12.5 MG (Use lisinopril NC & hydrochlorothiazide) ANTIMALARIALS - Drugs to Treat Malaria ZESTORETIC TABS 12.5 QL(4 ea daily) (Parasitic Infections) MG-20 MG (Use lisinopril & NC hydrochlorothiazide) Antimalarial Combinations ZESTORETIC TABS 20 QL(2 ea daily) atovaquone-proguanil hcl 2 MG-25 MG (Use lisinopril & NC tabs QL(24 ea per hydrochlorothiazide) COARTEM TABS 5 ZIAC TABS 5 MG-6.25 QL(1 ea daily) fill retail) MALARONE TABS (Use MG, 6.25 MG-2.5 MG (Use 4 4 bisoprolol & atovaquone-proguanil hcl) hydrochlorothiazide) PYRIMETHAMINE/LEUCO NC ZIAC TABS 6.25 MG-10 QL(2 ea daily) VORIN CAPS MG (Use bisoprolol & 4 Antimalarials hydrochlorothiazide) ARAKODA TABS NC Antihypertensives - Misc. VECAMYL TABS 5 PA; SP ARTESUNATE SOLR NC

Direct Renin Inhibitors CHLOROQUINE 5 PHOSPHATE POWD XX aliskiren fumarate tabs 150 2 QL(2 ea daily) mg chloroquine phosphate tabs 2 or 250 mg, 500 mg aliskiren fumarate tabs 300 2 QL(1 ea daily) mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DARAPRIM TABS (Use NC SP MESTINON TABS (Use 5 pyrimethamine) pyridostigmine bromide) hydroxychloroquine sulfate 2 MESTINON TIMESPAN tabs or TBCR (Use pyridostigmine 5 bromide) KRINTAFEL TABS NC neostigmine methylsulfate QL(6 ea per fill soln iv 10 mg/10ml, 5 2 mefloquine hcl tabs 2 retail) mg/10ml NEOSTIGMINE PLAQUENIL TABS (Use 4 hydroxychloroquine sulfate) METHYLSULFATE SOLN 5 IV 10 MG/10ML, 5 primaquine phosphate tabs 2 MG/10ML PRIMAQUINE NEOSTIGMINE PHOSPHATE TABS (Use 5 METHYLSULFATE SOLN NC primaquine phosphate) IV 3 MG/3ML, 5 MG/5ML NEOSTIGMINE pyrimethamine tabs or 2 PA; SP METHYLSULFATE SOSY NC QL(2 ea IV 2 MG/2ML, 3 MG/3ML, 4 QUALAQUIN CAPS (Use 5 MG/4ML, 5 MG/5ML quinine sulfate) daily,84 ea per fill retail) pyridostigmine bromide 2 QUINACRINE soln or 60 mg/5ml DIHYDROCHLORIDE 5 pyridostigmine bromide NC DIHYDRATE POWD tabs or 30 mg QUINACRINE pyridostigmine bromide 2 DIHYDROCHLORIDE 5 tabs or 60 mg POWD pyridostigmine bromide tbcr 2 QUINACRINE HCL POWD 5 or 180 mg QL(2 ea REGONOL SOLN 5 quinine sulfate caps or 2 daily,84 ea per PA; SP fill retail) RUZURGI TABS 5 QUININE SULFATE 5 ANTIMYCOBACTERIAL AGENTS - Drugs to DIHYDRATE POWD Treat Tuberculosis (Bacterial Infections) QUININE SULFATE 5 POWD XX Anti TB Combinations RIFAMATE CAPS 5 ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimyasthenic/Cholinergic Agents RIFATER TABS 5 BLOXIVERZ SOLN (Use 5 Antimycobacterial Agents neostigmine methylsulfate) AMINOSALICYLIC ACID 5 FIRDAPSE TABS 5 PA; SP POWD CAPASTAT SULFATE 5 GUANIDINE HCL TABS 5 SOLR MESTINON SOLN (Use 5 cycloserine caps or 2 pyridostigmine bromide) ETHAMBUTOL HCL 5 POWD XX 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ethambutol hcl tabs or 100 2 BELRAPZO SOLN NC SP mg, 400 mg BENDAMUSTINE 5 PA; SP ISONIAZID POWD XX 5 HYDROCHLORIDE SOLN isoniazid soln ij 100 mg/ml 2 BENDEKA SOLN 5 PA; SP isoniazid syrp or 50 mg/5ml 2 BICNU SOLR (Use 5 carmustine) isoniazid tabs or 100 mg, 2 300 mg busulfan soln 2 MYAMBUTOL TABS (Use 4 BUSULFEX SOLN (Use 5 ethambutol hcl) busulfan) MYCOBUTIN CAPS (Use 5 carboplatin soln 1000 2 PA; SP rifabutin) mg/100ml PASER PACK 5 carboplatin soln 450 mg/45ml, 50 mg/5ml, 600 2 PRETOMANID TABS 5 mg/60ml, 150 mg/15ml carmustine solr 2 PRIFTIN TABS 5 cisplatin soln iv 200 pyrazinamide tabs or 2 mg/200ml, 100 mg/100ml, 2 50 mg/50ml rifabutin caps 2 CISPLATIN SOLR IV 50 NC MG RIFADIN CAPS OR 150 cyclophosphamide caps or 2 MG, 300 MG (Use 4 25 mg, 50 mg rifampin) cyclophosphamide solr ij 1 2 RIFADIN SOLR IV 600 MG 5 gm, 2 gm, 500 mg (Use rifampin) EVOMELA SOLR NC SP rifampin caps or 150 mg, 2 300 mg GLEOSTINE CAPS 5 rifampin solr iv 600 mg 2 GLIADEL WAFER WAFR 5 RIFAMPIN/SYRSPEND SF NC PH4 SUSP IFEX SOLR 1 GM (Use 5 SIRTURO TABS 5 ifosfamide) IFEX SOLR 3 GM 5 TRECATOR TABS 5 ifosfamide soln 1 gm/20ml, 2 ANTINEOPLASTICS AND ADJUNCTIVE 3 gm/60ml THERAPIES - Drugs to Treat Cancer ifosfamide solr 1 gm 2 Alkylating Agents ALKERAN SOLR IV 50 MG 5 SP IFOSFAMIDE SOLR 3 GM 5 (Use melphalan hcl) LEUKERAN TABS 4 ALKERAN TABS OR 2 MG 4 (Use melphalan) melphalan hcl solr 2 SP

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits melphalan tabs 2 cytarabine soln 2

MYLERAN TABS 4 DACOGEN SOLR (Use 5 SP decitabine) oxaliplatin soln 2 decitabine solr 2 SP oxaliplatin solr 2 floxuridine solr ij 2 SP PEPAXTO SOLR NC fludarabine phosphate soln 2 TEMODAR CAPS OR 100 PA; SP fludarabine phosphate solr 2 MG, 140 MG, 180 MG, 20 4 MG, 250 MG, 5 MG (Use fluorouracil soln iv 1 temozolomide) gm/20ml, 2.5 gm/50ml, 5 2 TEMODAR SOLR IV 100 5 PA; SP gm/100ml, 500 mg/10ml MG FOLOTYN SOLN 5 PA; SP temozolomide caps 2 PA; SP gemcitabine hcl soln 2 TEPADINA SOLR 100 MG 5 PA; SP (Use thiotepa) gemcitabine hcl solr 2 TEPADINA SOLR 15 MG 5 (Use thiotepa) GEMCITABINE PA; SP HYDROCHLORIDE SOLN thiotepa solr ij 100 mg 2 1 GM/10ML, 2 GM/20ML, 200 MG/2ML, 1 5 thiotepa solr ij 15 mg 2 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML (Use TREANDA SOLR 5 PA; SP gemcitabine hcl) PA; SP GEMCITABINE YONDELIS SOLR 5 HYDROCHLORIDE SOLN 5 1.5 GM/15ML ZANOSAR SOLR 5 INFUGEM SOLN NC ZEPZELCA SOLR NC mercaptopurine tabs or 2 Antimetabolites METHOTREXATE POWD 5 ALIMTA SOLR 5 PA; SP XX

ARRANON SOLN 5 methotrexate sodium soln 2 azacitidine susr 2 SP methotrexate sodium solr 2 capecitabine tabs 2 PA; SP methotrexate sodium tabs 2 SP cladribine soln 2 ONUREG TABS NC clofarabine soln 2 PURIXAN SUSP 5 TABLOID TABS 4 PA; SP CLOLAR SOLN (Use 5 clofarabine) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TREXALL TABS 4 OGIVRI SOLR NC SP

VIDAZA SUSR (Use 5 SP ONTRUZANT SOLR NC SP azacitidine) PA; SP XATMEP SOLN 5 PERJETA SOLN 4 PA; SP XELODA TABS (Use 4 PA; SP TRAZIMERA SOLR 4 capecitabine) PA; SP Antineoplastic - Angiogenesis Inhibitors TUKYSA TABS 5 AVASTIN SOLN NC SP Antineoplastic - Antibodies PA; SP CYRAMZA SOLN 5 PA; SP ADCETRIS SOLR 5 PA; SP INLYTA TABS 5 PA; SP ARZERRA CONC 5 PA; SP LENVIMA 10 MG DAILY 5 PA; SP BAVENCIO SOLN 5 DOSE CPPK BESPONSA SOLR 5 PA; SP LENVIMA 12MG DAILY 5 PA; SP DOSE CPPK BLENREP SOLR NC SP LENVIMA 14 MG DAILY 5 PA; SP DOSE CPPK BLINCYTO SOLR 5 PA; SP LENVIMA 18 MG DAILY 5 PA; SP DOSE CPPK DARZALEX SOLN 5 PA; SP LENVIMA 20 MG DAILY 5 PA; SP DOSE CPPK EMPLICITI SOLR 5 PA; SP LENVIMA 24 MG DAILY 5 PA; SP DOSE CPPK ENHERTU SOLR NC LENVIMA 4 MG DAILY 5 PA; SP DOSE CPPK GAZYVA SOLN 5 PA; SP LENVIMA 8 MG DAILY 5 PA; SP PA; SP DOSE CPPK IMFINZI SOLN 5 MVASI SOLN NC JEMPERLI SOLN NC SP PA; SP ZALTRAP SOLN 5 KADCYLA SOLR 5 PA; SP PA; SP ZIRABEV SOLN 4 KEYTRUDA SOLN 5 PA; SP

Antineoplastic - Anti-HER2 Agents LIBTAYO SOLN 5 PA; SP HERCEPTIN SOLR NC SP LUMOXITI SOLR 5 PA; SP HERZUMA SOLR NC SP MONJUVI SOLR NC SP KANJINTI SOLR 4 PA; SP MYLOTARG SOLR 5 PA; SP MARGENZA SOLN NC SP OPDIVO SOLN 5 PA; SP

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PADCEV SOLR NC SP ERBITUX SOLN 5 PA; SP

POLIVY SOLR 140 MG NC SP erlotinib hcl tabs 2 PA; SP

POLIVY SOLR 30 MG NC GILOTRIF TABS 5 PA; SP

POTELIGEO SOLN 5 PA; SP IRESSA TABS 4 PA; SP

RIABNI SOLN NC SP PORTRAZZA SOLN 5 PA; SP

RITUXAN SOLN NC SP TAGRISSO TABS 5 PA; SP

RUXIENCE SOLN 4 PA; SP TARCEVA TABS (Use 5 PA; SP erlotinib hcl) SP RYBREVANT SOLN NC VECTIBIX SOLN 5 PA; SP PA; SP SARCLISA SOLN 5 VIZIMPRO TABS NC SP TECENTRIQ SOLN 5 PA; SP Antineoplastic - Hedgehog Pathway Inhibitors

TRUXIMA SOLN NC SP DAURISMO TABS NC PA; SP UNITUXIN SOLN 5 PA; SP ERIVEDGE CAPS 4 PA; SP YERVOY SOLN 5 PA; SP ODOMZO CAPS 4 Antineoplastic - Hormonal and Related Agents ZEVALIN Y-90 KIT 5 PA; SP abiraterone acetate tabs 2 PA; SP ZYNLONTA SOLR NC SP 250 mg abiraterone acetate tabs NC SP Antineoplastic - BCL-2 Inhibitors 500 mg VENCLEXTA STARTING 5 PA; SP anastrozole tabs or 2 PACK TBPK PA; SP ARIMIDEX TABS (Use 4 VENCLEXTA TABS 5 anastrozole) Antineoplastic - Cellular Immunotherapy AROMASIN TABS (Use 4 exemestane) ABECMA SUSP 5 PA; SP bicalutamide tabs 2 BREYANZI SUSP 5 PA; SP CASODEX TABS (Use 5 bicalutamide) KYMRIAH SUSP 5 PA; SP DEPO-PROVERA SUSP 5 PROVENGE SUSP 5 PA; SP ELIGARD KIT 4 PA; SP YESCARTA SUSP 5 PA; SP EMCYT CAPS 4 PA; SP Antineoplastic - EGFR Inhibitors ERLEADA TABS 4 PA; QL(4 ea daily); SP 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits exemestane tabs 2 SOLTAMOX SOLN 5

FARESTON TABS (Use 5 tamoxifen citrate tabs or 20 6 AL(At least 40 toremifene citrate) mg, 10 mg yrs old) FASLODEX SOLN (Use 5 toremifene citrate tabs 2 fulvestrant) TRELSTAR MIXJECT SP FEMARA TABS (Use 4 NC letrozole) SUSR PA; SP FIRMAGON SOLR 4 PA; SP VANTAS KIT 5 PA; SP flutamide caps 2 XTANDI CAPS 4 PA; SP fulvestrant soln 2 XTANDI TABS 4 hydroxyprogesterone YONSA TABS 4 PA; SP caproate (antineoplastic) 2 soln ZOLADEX IMPL NC SP letrozole tabs or 2 ZYTIGA TABS 250 MG NC PA; SP (Use abiraterone acetate) leuprolide acetate kit ij 2 SP ZYTIGA TABS 500 MG NC SP LEUPROLIDE (Use abiraterone acetate) ACETATE/BUPIVACAINE NC Antineoplastic - Immunomodulators HYDROCHLORIDE SOLN LEVAMISOLE HCL POWD 5 LUPRON DEPOT (1- NC SP MONTH) KIT POMALYST CAPS 4 PA; SP LUPRON DEPOT (3- NC SP MONTH) KIT Antineoplastic - PDGFR-alpha Inhibitors LUPRON DEPOT (4- NC SP SP MONTH) KIT AYVAKIT TABS NC LUPRON DEPOT (6- NC SP PA; SP MONTH) KIT LARTRUVO SOLN 5 LYSODREN TABS 4 PA; SP Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE NC MEGESTROL ACETATE 5 WEEKLY TBPK POWD XX XPOVIO 40 MG ONCE NC megestrol acetate susp or 2 WEEKLY TBPK 40 mg/ml, 400 mg/10ml XPOVIO 40 MG TWICE NC megestrol acetate tabs or 2 WEEKLY TBPK 40 mg, 20 mg XPOVIO 60 MG ONCE NC NILANDRON TABS (Use NC WEEKLY TBPK nilutamide) XPOVIO 60 MG TWICE NC nilutamide tabs 2 WEEKLY TBPK PA; SP XPOVIO 80 MG ONCE NC NUBEQA TABS 4 WEEKLY TBPK SP XPOVIO 80 MG TWICE NC ORGOVYX TABS NC WEEKLY TBPK 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XPOVIO TBPK NC SP DARZALEX FASPRO NC SOLN Antineoplastic Antibiotics HERCEPTIN HYLECTA NC SP SOLN bleomycin sulfate solr 2 INQOVI TABS NC SP COSMEGEN SOLR (Use 5 dactinomycin) KISQALI FEMARA 200 4 PA; SP DOSE TBPK dactinomycin solr 2 KISQALI FEMARA 400 4 PA; SP DOSE TBPK daunorubicin hcl soln 2 PA; SP KISQALI FEMARA 600 4 PA; SP DAUNORUBICIN PA; SP DOSE TBPK HYDROCHLORIDE SOLN 5 PA; SP 20 MG/4ML (Use LONSURF TABS 4 daunorubicin hcl) PA; SP DAUNORUBICIN PA; SP PHESGO SOLN 4 HYDROCHLORIDE SOLN 5 PA; SP 50 MG/10ML RITUXAN HYCELA SOLN 5 DOXIL INJ (Use 5 VYXEOS SUSR 5 PA; SP doxorubicin hcl liposomal) doxorubicin hcl liposomal 2 Antineoplastic Enzyme Inhibitors inj AFINITOR DISPERZ TBSO 4 PA; SP doxorubicin hcl soln 2 AFINITOR TABS 10 MG 4 PA; SP doxorubicin hcl solr 2 AFINITOR TABS 2.5 MG, 5 PA; SP ELLENCE SOLN (Use 5 MG, 7.5 MG (Use 4 epirubicin hcl) everolimus) epirubicin hcl soln 2 ALECENSA CAPS 4 PA; SP

IDAMYCIN PFS SOLN 5 ALIQOPA SOLR NC (Use idarubicin hcl) PA; SP idarubicin hcl soln 2 ALUNBRIG TABS 4 PA; SP JELMYTO SOLR NC ALUNBRIG TBPK 4 mitomycin solr iv 20 mg, 40 2 BALVERSA TABS NC mg, 5 mg PA; SP MITOMYCIN SOSY IS 20 5 BELEODAQ SOLR 5 MG/40ML PA; SP mitoxantrone hcl conc 2 SP BORTEZOMIB SOLR NC PA; SP valrubicin soln 2 PA; SP BOSULIF TABS 4 BRAFTOVI CAPS 5 PA; SP VALSTAR SOLN (Use 5 PA; SP valrubicin) BRUKINSA CAPS 5 PA; SP Antineoplastic Combinations

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CABOMETYX TABS 4 PA; SP lapatinib ditosylate tabs 2 PA; SP

CALQUENCE CAPS 5 PA; SP LORBRENA TABS 5 PA; SP

CAPRELSA TABS 5 PA; SP LUMAKRAS TABS NC SP

COMETRIQ KIT 5 PA; SP LYNPARZA TABS 4 PA; SP

COPIKTRA CAPS 4 PA; SP MEKINIST TABS 5 PA; SP

COTELLIC TABS 5 PA; SP MEKTOVI TABS 5 PA; SP everolimus tabs 2 PA; SP NERLYNX TABS 5 PA; SP

FARYDAK CAPS NC SP NEXAVAR TABS 5 PA; SP

FOTIVDA CAPS NC SP NINLARO CAPS 4 PA; SP

GAVRETO CAPS NC SP PEMAZYRE TABS NC

GLEEVEC TABS (Use NC PA; SP PIQRAY 200MG DAILY NC imatinib mesylate) DOSE TBPK IBRANCE CAPS 4 PA; SP PIQRAY 250MG DAILY NC DOSE TBPK PA; SP IBRANCE TABS 4 PIQRAY 300MG DAILY NC DOSE TBPK ICLUSIG TABS 10 MG, 15 5 PA; QL(1 ea SP MG, 30 MG, 45 MG daily); SP QINLOCK TABS NC PA; SP IDHIFA TABS 5 RETEVMO CAPS NC SP PA; SP imatinib mesylate tabs 2 ROMIDEPSIN SOLN 27.5 5 PA; SP MG/5.5ML PA; SP IMBRUVICA CAPS 5 ROMIDEPSIN SOLR 10 5 PA; SP MG IMBRUVICA TABS 5 PA; SP ROZLYTREK CAPS NC INREBIC CAPS NC RUBRACA TABS 4 PA; SP ISTODAX (OVERFILL) 5 PA; SP SOLR RYDAPT CAPS 4 PA; SP PA; SP JAKAFI TABS 5 SPRYCEL TABS 4 PA; SP PA; SP KISQALI TBPK 4 STIVARGA TABS 4 PA; SP PA; SP KOSELUGO CAPS 5 sunitinib malate caps 2 PA; SP PA; SP KYPROLIS SOLR NC SUTENT CAPS (Use NC PA; SP sunitinib malate)

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TABRECTA TABS NC SP Antineoplastic Enzymes ASPARLAS SOLN 5 PA; SP TAFINLAR CAPS 5 PA; SP ERWINASE SOLR 5 PA; SP TALZENNA CAPS NC ERWINAZE SOLR 5 PA; SP TASIGNA CAPS NC SP ONCASPAR SOLN 5 PA; SP TAZVERIK TABS NC RYLAZE SOLN NC SP temsirolimus soln 2 SP Antineoplastic Radiopharmaceuticals TEPMETKO TABS NC AZEDRA DOSIMETRIC 5 PA; SP SOLN TIBSOVO TABS 5 PA; SP AZEDRA THERAPEUTIC 5 PA; SP TORISEL SOLN (Use 5 SP SOLN temsirolimus) LUTATHERA SOLN 5 PA; SP TRUSELTIQ CPPK NC SP QUADRAMET SOLN 5 TURALIO CAPS NC SP STRONTIUM CHLORIDE NC TYKERB TABS (Use 5 PA; SP SR-89 SOLN lapatinib ditosylate) XOFIGO SOLN NC UKONIQ TABS NC Antineoplastics Misc. VELCADE SOLR 4 PA; SP ACTIMMUNE SOLN 5 PA; SP VERZENIO TABS 5 PA; SP ALFERON N SOLN 5 PA; SP VITRAKVI CAPS 5 PA; SP arsenic trioxide soln iv 10 2 mg/10ml VITRAKVI SOLN 5 PA; SP arsenic trioxide soln iv 12 2 PA; SP mg/6ml VOTRIENT TABS 4 PA; SP bexarotene caps 2 PA; SP XALKORI CAPS 5 PA; SP dacarbazine solr 2 XOSPATA TABS 4 PA; SP ELZONRIS SOLN 5 ZEJULA CAPS 4 PA; SP HYDREA CAPS (Use 4 hydroxyurea) ZELBORAF TABS 5 PA; SP hydroxyurea caps or 2 ZOLINZA CAPS 4 PA; SP INTRON A SOLN 4 PA; SP ZYDELIG TABS NC INTRON A SOLR 4 PA; SP ZYKADIA TABS 5 PA; SP

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MATULANE CAPS 4 PA; SP levoleucovorin calcium solr 2 SP

NIPENT SOLR 5 mesna soln 2 SP

PHOTOFRIN SOLR 5 PA; SP MESNEX SOLN IV 100 5 SP MG/ML (Use mesna) PA; SP PROLEUKIN SOLR 5 MESNEX TABS OR 400 5 PA; SP MG PA; SP SYLATRON KIT 4 TOTECT SOLR NC PA; SP SYNRIBO SOLR 5 VORAXAZE SOLR 5 PA; SP TARGRETIN CAPS OR 75 PA; SP 4 ZINECARD SOLR (Use 5 MG (Use bexarotene) dexrazoxane hcl) TICE BCG SUSR 5 Mitotic Inhibitors PA; SP tretinoin (chemotherapy) 2 SP ABRAXANE SUSR 5 caps docetaxel conc 160 PA; SP TRISENOX SOLN (Use 5 PA; SP arsenic trioxide) mg/8ml, 20 mg/ml, 80 2 mg/4ml UVADEX SOLN 5 DOCETAXEL CONC 160 5 PA; SP MG/8ML, 80 MG/4ML Chemotherapy Adjuncts DOCETAXEL CONC 160 PA; SP ELITEK SOLR 5 MG/8ML, 80 MG/4ML (Use 5 docetaxel) KEPIVANCE SOLR 5 PA; SP DOCETAXEL CONC 20 2 PA; SP MG/ML Chemotherapy Rescue/Antidote/Protective Agents DOCETAXEL CONC 20 2 PA; SP COSELA SOLR NC MG/ML (Use docetaxel) DOCETAXEL CONC 200 NC SP dexrazoxane hcl solr 2 MG/10ML docetaxel soln 160 ETHYOL SOLR 5 mg/16ml, 20 mg/2ml, 80 2 mg/8ml FUSILEV SOLR (Use 5 SP levoleucovorin calcium) DOCETAXEL SOLN 160 MG/16ML, 20 MG/2ML, 80 5 KHAPZORY SOLR NC MG/8ML DOCETAXEL SOLN 160 leucovorin calcium soln ij 2 100 mg/10ml, 500 mg/50ml MG/16ML, 20 MG/2ML, 80 5 MG/8ML (Use docetaxel) leucovorin calcium solr ij 500 mg, 100 mg, 200 mg, 2 ETOPOPHOS SOLR 5 350 mg, 50 mg etoposide caps or 50 mg 2 PA; SP leucovorin calcium tabs or 2 10 mg, 15 mg, 25 mg, 5 mg etoposide soln iv 1 2 levoleucovorin calcium soln 2 SP gm/50ml, 500 mg/25ml

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits etoposide soln iv 100 2 SP topotecan hcl soln 4 2 SP mg/5ml mg/4ml HALAVEN SOLN 5 PA; SP TOPOTECAN HCL SOLN 5 SP 4 MG/4ML IXEMPRA KIT SOLR 5 PA; SP TOPOTECAN HCL SOLN SP 4 MG/4ML (Use topotecan 5 JEVTANA SOLN 5 PA; SP hcl) topotecan hcl solr 4 mg 2 SP MARQIBO SUSP 5 PA; SP TRODELVY SOLR 5 PA; SP NAVELBINE SOLN (Use 5 vinorelbine tartrate) ANTIPARKINSON AND RELATED THERAPY paclitaxel conc 150 AGENTS - Drugs to Treat Parkinson's Disease mg/25ml, 100 mg/16.7ml, 2 30 mg/5ml, 300 mg/50ml, 6 Antiparkinson Adjunctive Therapy mg/ml carbidopa tabs or 2 TAXOTERE CONC (Use 2 PA; SP docetaxel) LODOSYN TABS (Use 5 carbidopa) TENIPOSIDE SOLN 5 NOURIANZ TABS NC vinblastine sulfate soln 2 Antiparkinson Anticholinergics PA; SP vincristine sulfate soln 2 benztropine mesylate soln 2 vinorelbine tartrate soln 2 benztropine mesylate tabs 2 Oncolytic Viral Agents COGENTIN SOLN (Use 5 benztropine mesylate) IMLYGIC SUSP 5 PA; SP trihexyphenidyl hcl soln 0.4 2 QL(16.67 ml Topoisomerase I Inhibitors mg/ml daily) CAMPTOSAR SOLN 100 trihexyphenidyl hcl tabs 2 2 MG/5ML, 40 MG/2ML (Use 5 mg, 5 mg irinotecan hcl) Antiparkinson COMT Inhibitors CAMPTOSAR SOLN 300 PA; SP COMTAN TABS (Use 5 MG/15ML (Use irinotecan 5 entacapone) hcl) entacapone tabs 2 HYCAMTIN CAPS OR 0.25 4 PA; SP MG, 1 MG ONGENTYS CAPS NC HYCAMTIN SOLR IV 4 MG 5 SP (Use topotecan hcl) TASMAR TABS (Use 5 tolcapone) irinotecan hcl soln 300 2 PA; SP mg/15ml tolcapone tabs 2 irinotecan hcl soln 500 mg/25ml, 100 mg/5ml, 40 2 Antiparkinson Dopaminergics mg/2ml amantadine hcl caps or 100 2 ONIVYDE INJ 5 mg

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amantadine hcl syrp or 50 2 pramipexole 2 mg/5ml dihydrochloride tabs amantadine hcl tabs or 100 2 pramipexole 2 mg dihydrochloride tb24 APOKYN SOCT NC SP REQUIP XL TB24 12 MG, QL(2 ea daily) 8 MG (Use ropinirole 5 hydrochloride) bromocriptine mesylate 2 caps or 5 mg REQUIP XL TB24 4 MG, 6 QL(1 ea daily) MG (Use ropinirole 5 BROMOCRIPTINE 5 MESYLATE POWD XX hydrochloride) ropinirole hydrochloride QL(6 ea daily) bromocriptine mesylate 2 2 tabs or 2.5 mg tabs 0.25 mg, 3 mg, 4 mg carbidopa-levodopa tabs 2 ropinirole hydrochloride QL(3 ea daily) tabs 0.5 mg, 1 mg, 2 mg, 5 2 mg carbidopa-levodopa tbcr 2 ropinirole hydrochloride 2 QL(2 ea daily) carbidopa-levodopa tbdp 2 tb24 12 mg, 8 mg ropinirole hydrochloride 2 QL(1 ea daily) carbidopa-levodopa- 2 tb24 2 mg, 4 mg, 6 mg entacapone tabs RYTARY CPCR NC CARBIDOPA/LEVODOPA 4 ODT TBDP SINEMET CR TBCR (Use 5 DUOPA SUSP 5 carbidopa-levodopa) SINEMET TABS (Use 5 GOCOVRI CP24 NC carbidopa-levodopa) STALEVO 100 TABS (Use INBRIJA CAPS 4 carbidopa-levodopa- 5 entacapone) KYNMOBI FILM 4 STALEVO 100 TABS (Use carbidopa-levodopa- NF LEVODOPA POWD 5 entacapone) MIRAPEX ER TB24 (Use STALEVO 125 TABS (Use pramipexole 5 carbidopa-levodopa- 5 dihydrochloride) entacapone) MIRAPEX TABS (Use STALEVO 150 TABS (Use pramipexole 5 carbidopa-levodopa- 5 dihydrochloride) entacapone) QL(1 ea daily) STALEVO 150 TABS (Use NEUPRO PT24 4 carbidopa-levodopa- NF entacapone) OSMOLEX ER T4PK NC STALEVO 200 TABS (Use carbidopa-levodopa- 5 OSMOLEX ER TB24 NC entacapone) STALEVO 200 TABS (Use PARLODEL CAPS (Use 5 bromocriptine mesylate) carbidopa-levodopa- NF entacapone) PARLODEL TABS (Use 5 bromocriptine mesylate)

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 50 TABS (Use EQUETRO CP12 5 carbidopa-levodopa- 5 entacapone) GEODON CAPS (Use 5 STALEVO 50 TABS (Use ziprasidone hcl) carbidopa-levodopa- NF GEODON SOLR (Use 5 entacapone) ziprasidone mesylate) STALEVO 75 TABS (Use LATUDA TABS 4 carbidopa-levodopa- 5 entacapone) NUPLAZID CAPS 5 STALEVO 75 TABS (Use carbidopa-levodopa- NF NUPLAZID TABS 5 entacapone) Antiparkinson Monoamine Oxidase Inhibitors VRAYLAR CAPS 4 ST AZILECT TABS (Use 5 QL(1 ea daily) ST rasagiline mesylate) VRAYLAR CPPK 4 rasagiline mesylate tabs or 2 QL(1 ea daily) 0.5 mg, 1 mg ziprasidone hcl caps 2 selegiline hcl caps or 2 ziprasidone mesylate solr 2

SELEGILINE HCL POWD 5 Benzisoxazoles XX FANAPT TABS NC selegiline hcl tabs or 2 FANAPT TITRATION NC XADAGO TABS NC PACK TABS INVEGA SUSTENNA PA; QL(0.034 ZELAPAR TBDP 5 SUSY 117 MG/0.75ML, 5 ml daily); SP 156 MG/ML, 39 ANTIPSYCHOTICS/ANTIMANIC AGENTS - MG/0.25ML, 78 MG/0.5ML Drugs to Treat Mood Disorders INVEGA SUSTENNA 5 PA; SP Antimanic Agents SUSY 234 MG/1.5ML INVEGA TB24 (Use lithium carbonate caps or 2 5 150 mg, 300 mg, 600 mg paliperidone) PA; LITHIUM CARBONATE 5 INVEGA TRINZA SUSY NC POWD XX lithium carbonate tabs or 2 paliperidone tb24 2 300 mg PERSERIS PRSY 4 PA; SP lithium carbonate tbcr or 2 300 mg, 450 mg RISPERDAL CONSTA 5 PA; SP LITHIUM SOLN 5 SRER RISPERDAL SOLN (Use 5 LITHOBID TBCR (Use 4 risperidone) lithium carbonate) RISPERDAL TABS (Use 5 Antipsychotics - Misc. risperidone) CAPLYTA CAPS NC risperidone soln 2

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits risperidone tabs 2 SAPHRIS SUBL 10 MG, ST 2.5 MG, 5 MG (Use 5 risperidone tbdp 2 asenapine maleate) SAPHRIS SUBL 5 MG 5 ST Butyrophenones HALDOL DECANOATE SECUADO PT24 NC 100 SOLN (Use haloperidol 5 decanoate) SEROQUEL TABS (Use 5 quetiapine fumarate) HALDOL DECANOATE 50 SOLN (Use haloperidol 5 SEROQUEL XR TB24 (Use NC decanoate) quetiapine fumarate) QL(18 ml daily) HALDOL SOLN (Use 5 VERSACLOZ SUSP 5 haloperidol lactate) ZYPREXA RELPREVV PA; SP haloperidol decanoate soln 2 5 im 100 mg/ml, 50 mg/ml SUSR ZYPREXA SOLR (Use 5 haloperidol lactate conc 2 olanzapine) ZYPREXA TABS (Use 5 haloperidol lactate soln 2 olanzapine) haloperidol tabs or 0.5 mg, ZYPREXA ZYDIS TBDP 5 1 mg, 10 mg, 2 mg, 20 mg, 2 (Use olanzapine) 5 mg Dihydroindolones Dibenzapines molindone hcl tabs 2 ADASUVE AEPB 5 Phenothiazines asenapine maleate subl 5 ST chlorpromazine hcl soln ij 2 25 mg/ml clozapine tabs 200 mg, 50 2 mg, 100 mg, 25 mg chlorpromazine hcl soln ij 5 50 mg/2ml clozapine tbdp 100 mg, 12.5 mg, 200 mg, 25 mg, 2 chlorpromazine hcl tabs or 150 mg 10 mg, 100 mg, 200 mg, 25 2 mg, 50 mg CLOZARIL TABS (Use 5 clozapine) fluphenazine decanoate 2 soln ij FAZACLO TBDP (Use 5 clozapine) fluphenazine hcl conc 2 loxapine succinate caps 2 fluphenazine hcl elix 2 olanzapine solr 2 fluphenazine hcl soln 2 olanzapine tabs 2 fluphenazine hcl tabs 2 olanzapine tbdp 2 perphenazine tabs or 16 2 mg, 2 mg, 4 mg, 8 mg quetiapine fumarate tabs 2 prochlorperazine edisylate soln ij 10 mg/2ml, 50 2 quetiapine fumarate tb24 2 mg/10ml 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCHLORPERAZINE 5 GLUTARALDEHYDE 5 MALEATE POWD XX SOLN prochlorperazine maleate 2 hydrogen peroxide soln 2 tabs or 10 mg, 5 mg prochlorperazine supp 2 PHENOL CRYS XX 5 thioridazine hcl tabs or 10 2 PHENOL LIQD XX 89 %, 5 mg, 100 mg, 25 mg, 50 mg Chlorine Antiseptics trifluoperazine hcl tabs 2 BENZALKONIUM 5 RX/OTC Quinolinone Derivatives CHLORIDE SOLN PA; SP BENZALKONIUM 5 ABILIFY MAINTENA PRSY 4 CHLORIDE SOLN ABILIFY MAINTENA SRER 4 PA; SP CHLORHEXIDINE 5 GLUCONATE SOLN ABILIFY MYCITE NC Iodine Antiseptics MAINTENANCE KIT TABS CVS IODINE TINCTURE 5 RX/OTC ABILIFY MYCITE NC TINC STARTER KIT TABS DECOLORIZED IODINE 5 RX/OTC ABILIFY MYCITE TABS NC TINC GNP IODIDES TINCTURE RX/OTC ABILIFY TABS (Use NC 5 aripiprazole) TINC GNP IODINE TINCTURE 5 RX/OTC aripiprazole soln 2 TINC GOODSENSE IODINE 5 RX/OTC aripiprazole tabs 2 TINC aripiprazole tbdp 2 HM IODIDES TINCTURE 5 RX/OTC TINC PA; SP ARISTADA INITIO PRSY 5 HM IODINE TINCTURE 5 RX/OTC TINC PA; SP ARISTADA PRSY 5 IODINE TINCTURE MILD 5 RX/OTC TINC REXULTI TABS 5 ST IODINE TINCTURE TINC 5 RX/OTC Thioxanthenes LUGOLS STRONG 5 thiothixene caps 2 IODINE SOLN QC IODIDES TINCTURE 5 RX/OTC ANTISEPTICS & DISINFECTANTS TINC QC IODINE TINCTURE 5 RX/OTC Antiseptics & Disinfectants TINC CETYLCIDE-G CONC 5 RA FIRST AID IODINE 5 RX/OTC TINC QL(90 ml per formaldehyde soln 10 % 2 SM IODIDES TINCTURE 5 RX/OTC fill retail) TINC FORMALDEHYDE SOLN RX/OTC 5 SM IODINE TINCTURE 5 RX/OTC 37 % TINC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Mercury Antiseptics didanosine cpdr 250 mg, 2 QL(1 ea daily) 400 mg THIMEROSAL POWD 5 DOVATO TABS 4 PA; SP Silver Antiseptics EDURANT TABS 4 QL(1 ea daily) SILVER PROTEIN MILD 5 POWD efavirenz caps 200 mg 2 QL(2 ea daily) ANTIVIRALS - Drugs to Treat Viral Infections efavirenz caps 50 mg 2 QL(3 ea daily) Antiretrovirals QL(1 ea daily) abacavir sulfate soln 20 2 efavirenz tabs 600 mg 2 mg/ml efavirenz-emtricitabine- QL(1 ea daily) abacavir sulfate tabs 300 2 QL(2 ea daily) tenofovir disoproxil 2 mg fumarate tabs abacavir sulfate-lamivudine 2 QL(1 ea daily) efavirenz-lamivudine- tabs tenofovir disoproxil 2 abacavir sulfate- 2 QL(2 ea daily) fumarate tabs lamivudine-zidovudine tabs emtricitabine caps 2 QL(1 ea daily) APTIVUS CAPS NC emtricitabine-tenofovir 2 QL(1 ea daily) APTIVUS SOLN NC disoproxil fumarate tabs EMTRIVA CAPS 200 MG 4 QL(1 ea daily) atazanavir sulfate caps 150 2 QL(2 ea daily) (Use emtricitabine) mg, 200 mg EMTRIVA SOLN 10 4 QL(24 ml daily) atazanavir sulfate caps 300 2 QL(1 ea daily) MG/ML mg EPIVIR SOLN 10 MG/ML 5 QL(30 ml daily) ATRIPLA TABS (Use QL(1 ea daily) (Use lamivudine) efavirenz-emtricitabine- 5 tenofovir disoproxil EPIVIR TABS 150 MG 5 QL(2 ea daily) fumarate) (Use lamivudine) QL(1 ea daily) EPIVIR TABS 300 MG 5 QL(1 ea daily) BIKTARVY TABS 4 (Use lamivudine) EPZICOM TABS (Use QL(1 ea daily) CABENUVA SUER NC abacavir sulfate- 5 lamivudine) CIMDUO TABS 4 etravirine tabs 100 mg 2 QL(4 ea daily) COMBIVIR TABS (Use 5 QL(2 ea daily) lamivudine-zidovudine) etravirine tabs 200 mg 2 QL(2 ea daily) COMPLERA TABS 4 QL(1 ea daily) EVOTAZ TABS 4 CRIXIVAN CAPS 5 fosamprenavir calcium tabs 2 DELSTRIGO TABS NC FUZEON SOLR 4 PA; SP DESCOVY TABS 4 QL(1 ea daily) GENVOYA TABS 4 QL(1 ea daily) didanosine cpdr 200 mg 2 QL(2 ea daily)

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INTELENCE TABS 100 NC QL(4 ea daily) nevirapine tb24 400 mg 2 QL(1 ea daily) MG (Use etravirine) QL(12 ea daily) INTELENCE TABS 200 NC QL(2 ea daily) NORVIR PACK 100 MG 4 MG (Use etravirine) QL(15 ml daily) INTELENCE TABS 25 MG 4 QL(8 ea daily) NORVIR SOLN 80 MG/ML 4 NORVIR TABS 100 MG 4 QL(12 ea daily) INVIRASE TABS NC (Use ritonavir) QL(1 ea daily) ISENTRESS CHEW 100 4 ODEFSEY TABS 4 MG, 25 MG ISENTRESS HD TABS 4 QL(2 ea daily) PIFELTRO TABS NC

ISENTRESS PACK 100 4 PREZCOBIX TABS 4 MG PREZISTA SUSP 100 4 ISENTRESS TABS 400 4 QL(2 ea daily) MG/ML MG PREZISTA TABS 150 MG, 4 SL(2 ea daily) JULUCA TABS 5 600 MG, 75 MG KALETRA SOLN 400 QL(12.5 ml PREZISTA TABS 800 MG 4 QL(1 ea daily) MG/5ML-100 MG/5ML 5 daily) (Use lopinavir-ritonavir) RESCRIPTOR TABS 5 KALETRA TABS 100 MG- QL(4 ea daily) RETROVIR CAPS 100 MG QL(6 ea daily) 25 MG, 200 MG-50 MG, 50 5 4 MG-200 MG (Use lopinavir- (Use zidovudine) ritonavir) RETROVIR IV INFUSION 5 SOLN lamivudine soln 10 mg/ml 2 QL(30 ml daily) RETROVIR SYRP 50 4 QL(60 ml daily) MG/5ML (Use zidovudine) lamivudine tabs 150 mg 2 QL(2 ea daily) REYATAZ CAPS 150 MG, QL(2 ea daily) QL(1 ea daily) 200 MG (Use atazanavir 5 lamivudine tabs 300 mg 2 sulfate) QL(2 ea daily) lamivudine-zidovudine tabs 2 REYATAZ CAPS 300 MG 5 QL(1 ea daily) (Use atazanavir sulfate) LEXIVA SUSP 50 MG/ML NC REYATAZ PACK 50 MG 5 LEXIVA TABS 700 MG QL(12 ea daily) (Use fosamprenavir NC ritonavir tabs 2 calcium) RUKOBIA TB12 NC lopinavir-ritonavir soln 100 2 QL(12.5 ml mg/5ml-400 mg/5ml daily) SELZENTRY SOLN 5 lopinavir-ritonavir tabs 100 2 QL(4 ea daily) mg-25 mg, 50 mg-200 mg SELZENTRY TABS 5 nevirapine susp 50 mg/5ml 2 QL(40 ml daily) stavudine caps 15 mg, 20 2 QL(2 ea daily) mg, 30 mg, 40 mg nevirapine tabs 200 mg 2 QL(2 ea daily) STAVUDINE CAPS 15 MG, 4 QL(2 ea daily) 20 MG, 30 MG, 40 MG nevirapine tb24 100 mg 2

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRIBILD TABS 4 VIDEX EC CPDR 250 MG, 4 QL(1 ea daily) 400 MG (Use didanosine) SUSTIVA CAPS 200 MG 5 QL(2 ea daily) (Use efavirenz) VIDEXPEDIATRIC SOLR 5 SUSTIVA CAPS 50 MG 5 QL(3 ea daily) VIRACEPT TABS NC (Use efavirenz) VIRAMUNE SUSP 50 QL(40 ml daily) SUSTIVA TABS 600 MG 5 QL(1 ea daily) 5 (Use efavirenz) MG/5ML (Use nevirapine) SYMFI LO TABS (Use VIRAMUNE TABS 200 MG 5 QL(2 ea daily) (Use nevirapine) efavirenz-lamivudine- 5 tenofovir disoproxil VIRAMUNE XR TB24 (Use 5 QL(1 ea daily) fumarate) nevirapine) SYMFI TABS (Use VIREAD POWD 40 MG/GM 4 efavirenz-lamivudine- 5 tenofovir disoproxil VIREAD TABS 150 MG, 4 fumarate) 200 MG, 250 MG SYMTUZA TABS 4 VIREAD TABS 300 MG QL(1 ea daily) (Use tenofovir disoproxil 4 TEMIXYS TABS 4 fumarate) ZIAGEN SOLN 20 MG/ML 5 tenofovir disoproxil 2 QL(1 ea daily) (Use abacavir sulfate) fumarate tabs ZIAGEN TABS 300 MG 5 QL(2 ea daily) TIVICAY PD TBSO 4 (Use abacavir sulfate) zidovudine caps 100 mg 2 QL(6 ea daily) TIVICAY TABS 4 zidovudine syrp 50 mg/5ml 2 QL(60 ml daily) TRIUMEQ TABS 4 QL(1 ea daily) QL(2 ea daily) TRIZIVIR TABS (Use QL(2 ea daily) zidovudine tabs 300 mg 2 abacavir sulfate- 5 lamivudine-zidovudine) Antiviral Combinations TROGARZO SOLN 5 PA; SP ACYCLOVIX THPK NC TRUVADA TABS 133 MG- QL(1 ea daily) CMV Agents 200 MG, 150 MG-100 MG, 167 MG-250 MG (Use NC cidofovir soln 2 emtricitabine-tenofovir CYTOVENE SOLR (Use 5 disoproxil fumarate) ganciclovir sodium) TRUVADA TABS 200 MG- QL(1 ea daily) foscarnet sodium soln 5 300 MG (Use emtricitabine- 4 tenofovir disoproxil FOSCAVIR SOLN (Use 5 fumarate) foscarnet sodium) TYBOST TABS 5 ganciclovir sodium solr 2 QL(2 ea daily) VIDEX EC CPDR 125 MG 4 GANCICLOVIR SOLN NC VIDEX EC CPDR 200 MG 4 QL(2 ea daily) PA; SP (Use didanosine) PREVYMIS SOLN 5

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREVYMIS TABS 5 PA; SP PEGASYS SOLN 180 4 PA; QL(0.143 MCG/ML ml daily); SP VALCYTE SOLR 50 QL(21 ml daily) PA; SP MG/ML (Use valganciclovir NC PEGINTRON KIT 5 hcl) RIBASPHERE RIBAPAK 5 VALCYTE TABS 450 MG NC QL(4 ea daily) TBPK (Use valganciclovir hcl) RIBASPHERE RIBAPAK 5 PA; SP valganciclovir hcl solr 50 2 QL(21 ml daily) TBPK 400 MG, 600 MG mg/ml RIBASPHERE TABS 400 NC SP valganciclovir hcl tabs 450 2 QL(4 ea daily) MG mg RIBASPHERE TABS 600 2 PA; QL(2 ea Hepatitis Agents MG daily); SP PA; QL(1 ea PA; QL(7 ea adefovir dipivoxil tabs 2 ribavirin (hepatitis c) caps 2 daily); SP daily); SP PA; QL(7 ea BARACLUDE SOLN 0.05 4 QL(20 ml daily) ribavirin (hepatitis c) tabs 2 MG/ML daily); SP SOFOSBUVIR/VELPATAS PA; SP BARACLUDE TABS 0.5 NC QL(1 ea daily) NC MG, 1 MG (Use entecavir) VIR TABS PA; SP entecavir tabs 2 QL(1 ea daily) SOVALDI PACK 5 PA; SP EPCLUSA TABS 200 MG- 4 PA; SP SOVALDI TABS 5 50 MG VEMLIDY TABS 4 PA; SP EPCLUSA TABS 400 MG- NC PA; SP 100 MG VIEKIRA PAK TBPK NC SP EPIVIR HBV SOLN 5 4 QL(60 ml daily) MG/ML VOSEVI TABS 4 PA; SP EPIVIR HBV TABS 100 5 QL(3 ea daily) MG (Use lamivudine (hbv)) ZEPATIER TABS NC SP HARVONI PACK 33.75 PA; SP MG-150 MG, 45 MG-200 4 Herpes Agents MG acyclovir caps or 200 mg 2 HARVONI TABS 400 MG- 4 PA; SP 90 MG, 45 MG-200 MG acyclovir sodium soln 2 HEPSERA TABS (Use 5 PA; QL(1 ea adefovir dipivoxil) daily); SP acyclovir susp or 200 2 lamivudine (hbv) tabs 2 QL(3 ea daily) mg/5ml acyclovir tabs or 400 mg, 2 LEDIPASVIR/SOFOSBUVI NC 800 mg R TABS famciclovir tabs or 125 mg, 2 MAVYRET TABS NC SP 250 mg, 500 mg SITAVIG TABS 5 PEGASYS PROCLICK 4 PA; QL(0.0714 SOLN ml daily); SP valacyclovir hcl tabs or 500 2 PEGASYS SOLN 180 4 PA; QL(0.0714 mg, 1 gm, 1000 mg MCG/0.5ML ml daily); SP VALTREX TABS (Use NC valacyclovir hcl)

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOVIRAX CAPS OR 200 5 REMDESIVIR SOLR 5 MG (Use acyclovir) ZOVIRAX SUSP OR 200 5 VEKLURY SOLN 5 MG/5ML (Use acyclovir) ZOVIRAX TABS OR 400 VEKLURY SOLR 5 MG, 800 MG (Use 5 acyclovir) Respiratory Syncytial Virus (RSV) Agents Influenza Agents ribavirin solr in 2 FLUMADINE TABS (Use 5 QL(2 ea daily) rimantadine hydrochloride) VIRAZOLE SOLR (Use 5 ribavirin) QL(20 ea per BETA BLOCKERS - Drugs to Treat High Blood oseltamivir phosphate caps 2 fill retail,20 ea or 30 mg per 30 days Pressure retail) Alpha-Beta Blockers QL(10 ea per carvedilol phosphate cp24 2 QL(1 ea daily) oseltamivir phosphate caps 2 fill retail,10 ea or 45 mg, 75 mg per 30 days carvedilol tabs 12.5 mg, 2 QL(3 ea daily) retail) 3.125 mg, 6.25 mg QL(120 ml per carvedilol tabs 25 mg 2 QL(4 ea daily) oseltamivir phosphate susr 2 fill retail,120 ml or 6 mg/ml per 30 days COREG CR CP24 (Use NC QL(1 ea daily) retail) carvedilol phosphate) RAPIVAB SOLN 5 COREG TABS 12.5 MG, QL(3 ea daily) 3.125 MG, 6.25 MG (Use 5 QL(0.6667 ea carvedilol) RELENZA DISKHALER 4 daily,20 ea per AEPB 30 days retail) COREG TABS 25 MG (Use 5 QL(4 ea daily) carvedilol) rimantadine hydrochloride 2 QL(2 ea daily) tabs labetalol hcl soln iv 5 mg/ml 2 QL(20 ea per QL(3 ea daily) TAMIFLU CAPS 30 MG fill retail,20 ea labetalol hcl tabs or 100 mg 2 (Use oseltamivir 5 phosphate) per 30 days retail) labetalol hcl tabs or 200 mg 2 QL(6 ea daily) QL(10 ea per TAMIFLU CAPS 45 MG, 75 labetalol hcl tabs or 300 mg 2 QL(8 ea daily) MG ( 5 fill retail,10 ea Use oseltamivir per 30 days phosphate) LABETALOL NC retail) HYDROCHLORIDE SOLN QL(120 ml per LABETALOL TAMIFLU SUSR 6 MG/ML fill retail,120 ml NC (Use oseltamivir 5 HYDROCHLORIDE SOSY phosphate) per 30 days retail) LABETALOL HYDROCHLORIDE/DEXT NC XOFLUZA TBPK 20 MG, NC ROSE SOLN 40 MG LABETALOL Misc. Antivirals HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN FAVIPIRAVIR TABS 5 Beta Blockers Cardio-Selective

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acebutolol hcl caps or 400 2 LOPRESSOR TABS 100 QL(2 ea daily) mg, 200 mg MG (Use metoprolol 5 tartrate) ACEBUTOLOL HCL 5 POWD XX LOPRESSOR TABS 50 QL(3 ea daily) MG (Use metoprolol 5 ATENOLOL POWD XX 5 tartrate) metoprolol succinate tb24 QL(1 ea daily) atenolol tabs or 100 mg, 25 2 QL(2 ea daily) 2 mg, 50 mg 100 mg, 25 mg, 50 mg metoprolol succinate tb24 QL(2 ea daily) ATENOLOL/SYRSPEND NC 2 SF PH4 SUSP 200 mg betaxolol hcl tabs 2 METOPROLOL 5 TARTRATE POWD XX bisoprolol fumarate tabs or QL(1 ea daily) 2 metoprolol tartrate soln iv 5 2 10 mg, 5 mg mg/5ml BREVIBLOC PREMIXED metoprolol tartrate tabs or 2 QL(2 ea daily) DOUBLESTRENGTH 5 100 mg, 25 mg SOLN (Use esmolol hcl- metoprolol tartrate tabs or 2 sodium chloride) 37.5 mg, 75 mg BREVIBLOC PREMIXED metoprolol tartrate tabs or 2 QL(3 ea daily) SOLN (Use esmolol hcl- 5 50 mg sodium chloride) TENORMIN TABS (Use 5 QL(2 ea daily) BREVIBLOC SOLN (Use 5 atenolol) esmolol hcl) TOPROL XL TB24 (Use NC BREVIBLOC SOLN (Use metoprolol succinate) esmolol hcl-sodium 5 chloride) Beta Blockers Non-Selective BETAPACE AF TABS (Use NC BYSTOLIC TABS 4 sotalol hcl (afib/afl)) esmolol hcl soln 2 BETAPACE TABS 120 MG, 80 MG (Use sotalol NC hcl) esmolol hcl-sodium 2 chloride soln BETAPACE TABS 160 MG NC QL(2 ea daily) ESMOLOL (Use sotalol hcl) HYDROCHLORIDE 5 CORGARD TABS (Use 5 QL(2 ea daily) INWATER DOUBLE nadolol) STRENGTH SOLN PA; QL(1 ml ESMOLOL HEMANGEOL SOLN 5 per fill retail); HYDROCHLORIDE 5 SP INWATER SOLN INDERAL LA CP24 (Use NC QL(2 ea daily) ESMOLOL NC propranolol hcl) HYDROCHLORIDE SOSY INDERAL XL CP24 NC FIRST - METOPROLOL NC SOLN INNOPRAN XL CP24 NC FIRST-ATENOLOL SOLN NC NADOLOL POWD XX 5 KAPSPARGO SPRINKLE NC CS24

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nadolol tabs or 20 mg, 40 2 QL(2 ea daily) AMLODIPINE mg, 80 mg BESYLATE/SYRSPEND NC SF PH4 SUSP nadolol tabs or 20 mg, 40 2 mg, 80 mg CALAN SR TBCR (Use 5 QL(2 ea daily) verapamil hcl) pindolol tabs 2 CALAN TABS (Use 5 QL(3 ea daily) propranolol hcl cp24 or 60 QL(2 ea daily) verapamil hcl) mg, 80 mg, 120 mg, 160 2 mg CARDENE IV SOLN 5 PROPRANOLOL HCL 5 CARDIZEM CD CP24 (Use NC POWD XX diltiazem hcl coated beads) propranolol hcl soln iv 1 2 CARDIZEM LA TB24 120 NC mg/ml MG propranolol hcl soln or 20 2 CARDIZEM LA TB24 180 mg/5ml, 40 mg/5ml MG, 240 MG, 300 MG, 360 NC propranolol hcl tabs or 10 MG, 420 MG (Use mg, 20 mg, 80 mg, 40 mg, 2 diltiazem hcl coated beads) 60 mg CARDIZEM TABS (Use NC diltiazem hcl) sotalol hcl (afib/afl) tabs 2 QL(2 ea daily) 120 mg, 80 mg, 160 mg CLEVIPREX EMUL 5 sotalol hcl tabs 120 mg, 2 QL(2 ea daily) 160 mg, 80 mg CONJUPRI TABS NC sotalol hcl tabs 240 mg 2 diltiazem hcl coated beads cp24 120 mg, 180 mg, 240 2 SOTALOL 5 HYDROCHLORIDE SOLN mg, 300 mg, 360 mg diltiazem hcl coated beads QL(1 ea daily) SOTYLIZE SOLN 5 cp24 120 mg, 180 mg, 300 2 mg TIMOLOL MALEATE 5 POWD XX diltiazem hcl coated beads 2 QL(2 ea daily) cp24 240 mg timolol maleate tabs or 20 2 mg, 5 mg, 10 mg diltiazem hcl coated beads tb24 180 mg, 240 mg, 300 NC CALCIUM CHANNEL BLOCKERS - Drugs to mg, 360 mg, 420 mg Treat High Blood Pressure diltiazem hcl cp12 or 120 2 QL(2 ea daily) Calcium Channel Blocker Combinations mg, 60 mg, 90 mg CONSENSI TABS NC diltiazem hcl cp24 or 120 2 QL(1 ea daily) mg, 180 mg Calcium Channel Blockers diltiazem hcl cp24 or 240 2 QL(2 ea daily) mg ADALAT CC TB24 30 MG, 5 QL(1 ea daily) 90 MG (Use nifedipine) diltiazem hcl extended 2 QL(1 ea daily) release beads cp24 ADALAT CC TB24 60 MG 5 QL(2 ea daily) (Use nifedipine) diltiazem hcl soln iv 25 mg/5ml, 125 mg/25ml, 50 2 amlodipine besylate tabs or 2 QL(1 ea daily) 10 mg, 2.5 mg, 5 mg mg/10ml DILTIAZEM HCL SOLR IV 5 100 MG

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl tabs or 120 2 QL(3 ea daily) SULAR TB24 (Use 5 mg, 30 mg, 60 mg, 90 mg nisoldipine) DILTIAZEM TIAZAC CP24 (Use QL(1 ea daily) HYDROCHLORIDE/DEXT NC diltiazem hcl extended 5 ROSE SOLN release beads) DILTIAZEM verapamil hcl cp24 or 100 2 HYDROCHLORIDE/SODIU NC mg, 300 mg, 200 mg M CHLORIDE SOLN verapamil hcl cp24 or 120 2 QL(2 ea daily) felodipine tb24 2 QL(1 ea daily) mg, 180 mg, 240 mg verapamil hcl cp24 or 360 2 QL(1 ea daily) isradipine caps 2 mg VERAPAMIL HCL POWD 5 KATERZIA SUSP NC XX verapamil hcl soln iv 2.5 2 nicardipine hcl caps 2 mg/ml verapamil hcl tabs or 40 2 QL(3 ea daily) nicardipine hcl soln 2 mg, 120 mg, 80 mg verapamil hcl tbcr or 120 QL(2 ea daily) NICARDIPINE NC 2 HYDROCHLORIDE SOLN mg, 180 mg, 240 mg NICARDIPINE VERELAN CP24 120 MG, QL(2 ea daily) HYDROCHLORIDE/SODIU NC 180 MG, 240 MG (Use 5 M CHLORIDE SOLN verapamil hcl) NICARDIPINE VERELAN CP24 360 MG 5 QL(1 ea daily) HYDROCHLORIDE/SODIU NC (Use verapamil hcl) M CHLORIDE SOSY VERELAN PM CP24 (Use 5 verapamil hcl) nifedipine caps 10 mg, 20 2 QL(4 ea daily) mg CARDIOTONICS - Drugs to Treat Heart Failure nifedipine tb24 30 mg, 90 2 QL(1 ea daily) and Abnormal Heart Rhythm mg Cardiac Glycosides nifedipine tb24 60 mg 2 QL(2 ea daily) digoxin soln ij 0.25 mg/ml 2 nimodipine caps or 2 digoxin soln or 0.05 mg/ml 2 nisoldipine tb24 2 digoxin tabs or 0.25 mg, 250 mcg, 0.125 mg, 125 2 NORVASC TABS (Use NC QL(1 ea daily) amlodipine besylate) mcg LANOXIN PEDIATRIC 5 NYMALIZE SOLN 5 SOLN LANOXIN SOLN IJ 0.25 PROCARDIA CAPS (Use 5 QL(4 ea daily) 5 nifedipine) MG/ML (Use digoxin) PROCARDIA XL TB24 30 QL(1 ea daily) LANOXIN TABS OR 250 MG, 90 MG (Use 5 MCG, 125 MCG (Use NC nifedipine) digoxin) LANOXIN TABS OR 62.5 PROCARDIA XL TB24 60 5 QL(2 ea daily) 4 MG (Use nifedipine) MCG Inotropes 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dobutamine hcl soln 2 CARDIOPLEGIA INDUCTION PLASMALYTE/TROMETH 5 DOBUTAMINE HCL/D5W 4 SOLN AMINE HIGH POTASSIU DOBUTAMINE SOLN HYDROCHLORIDE/ 4 CARDIOPLEGIA DEXTROSE 5% SOLN MAINTENANCELOW 5 DOBUTAMINE DEXTROSE/LOW HYDROCHLORIDE/DEXT 4 POTASSIUM SOLN ROSE 5% SOLN CARDIOPLEGIA MAINTENANCELOW 5 dopamine hcl soln 2 POTASSIUM SOLN DOPAMINE CARDIOPLEGIA HYDROCHLORIDE SOLN NC MAINTENANCELOW 5 IV (Use dopamine hcl) TROMETHAMINE/LOW DOPAMINE POTASSIUM SOLN HYDROCHLORIDE/DEXT 4 CARDIOPLEGIA ROSE SOLN MAINTENANCEPLASMAL 5 YTE/TROMETHAMINE DOPAMINE/D5W SOLN 4 LOW POTASSI SOLN CARDIOPLEGIA milrinone lactate in 2 dextrose soln REPERFUSATE/LOW 5 POTASSIUM SOLN milrinone lactate soln 2 CARDIOPLEGIC SOLN 5 CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions cardioplegic soln soln 2 Cardioplegic Solutions MICROPLEGIA MSA/MSG 5 SOLN ADENOCAINE SOSY 5 PLEGISOL SOLN (Use 5 CARDIOPLEGIA DEL 5 cardioplegic soln) NIDO FORMULA SOLN Cardiovascular Agents Misc. - Combinations CARDIOPLEGIA 5 amlodipine besylate- 2 QL(1 ea daily) INDUCTION HIGH atorvastatin calcium tabs POTASSIUM SOLN CARDIOPLEGIA BIDIL TABS 4 INDUCTION HIGH 5 POTASSIUM/LOW CADUET TABS (Use QL(1 ea daily) DEXTROSE SOLN amlodipine besylate- 5 atorvastatin calcium) CARDIOPLEGIA ENTRESTO TABS 4 INDUCTION HIGH 5 POTASSIUM/NON- ENRICHED SOLN Impotence Agents CARDIOPLEGIA CIALIS TABS (Use NC PA; QL(1 ea tadalafil) daily) INDUCTION 5 PLASMALYTE/HIGH tadalafil tabs or 2.5 mg, 5 2 PA; QL(1 ea POTASSIUM SOLN mg daily) Peripheral Vasodilators 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NYLIDRIN 5 REVATIO SOLN (Use PA; SP HYDROCHLORIDE POWD sildenafil citrate (pulmonary 5 hypertension)) PAPAVERINE HCL POWD 5 XX REVATIO SUSR (Use PA; SP sildenafil citrate (pulmonary 5 papaverine hcl soln ij 30 2 mg/ml, 60 mg/2ml hypertension)) REVATIO TABS (Use PA; SP PAPAVERINE 5 HYDROCHLORIDE POWD sildenafil citrate (pulmonary 5 hypertension)) Prostaglandin Vasodilators sildenafil citrate (pulmonary 2 PA; SP epoprostenol sodium solr 2 PA; SP hypertension) soln sildenafil citrate (pulmonary 2 PA; SP FLOLAN SOLR (Use 4 PA; SP hypertension) susr epoprostenol sodium) sildenafil citrate (pulmonary 2 PA; SP ORENITRAM TBCR 4 PA; SP hypertension) tabs SP tadalafil (pulmonary 2 PA; SP REMODULIN SOLN NC hypertension) tabs treprostinil soln 2 PA; SP Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS OR 1000 PA; SP TYVASO REFILL SOLN 5 PA; SP MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 4 TYVASO SOLN 5 PA; SP MCG, 400 MCG, 600 MCG, 800 MCG PA; SP TYVASO STARTER SOLN 5 UPTRAVI TBPK OR 4 PA; SP VELETRI SOLR (Use 5 PA; SP epoprostenol sodium) Pulmonary Hypertension - Sol Guanylate Cyclase PA; SP VENTAVIS SOLN 5 PA; SP ADEMPAS TABS 4 Pulmonary Hypertension - Endothelin Receptor Septal Agents PA; QL(1 ea ABLYSINOL SOLN NC ambrisentan tabs 2 daily); SP Sinus Node Inhibitors bosentan tabs 2 PA; SP CORLANOR SOLN 5 5 MG/5ML LETAIRIS TABS (Use NC PA; QL(1 ea ambrisentan) daily); SP CORLANOR TABS 5 MG, 4 7.5 MG OPSUMIT TABS 4 PA; SP Transthyretin Stabilizers TRACLEER TABS 125 PA; SP PA; SP MG, 62.5 MG (Use NC VYNDAMAX CAPS 5 bosentan) VYNDAQEL CAPS NC TRACLEER TBSO 32 MG NC PA; SP Vasoactive Soluble Guanylate Cyclase Stimulator Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use PA; SP VERQUVO TABS NC tadalafil (pulmonary 5 hypertension)) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEPHALOSPORINS - Drugs to Treat Bacterial Cephalosporins - 2nd Generation Infections cefaclor caps 2 Cephalosporin Combinations AVYCAZ SOLR 5 CEFACLOR ER TB12 5

ZERBAXA SOLR 5 cefaclor susr 2 CEFOTAN SOLR (Use 5 Cephalosporins - 1st Generation cefotetan disodium) cefadroxil caps 2 cefotetan disodium solr 2 cefadroxil susr 2 CEFOTETAN/DEXTROSE 5 SOLR cefadroxil tabs 2 cefoxitin sodium solr ij 10 2 gm CEFAZOLIN SODIUM 5 SOLN IV 4 %-1 GM/50ML CEFOXITIN SODIUM SOLR IV 1 GM-4 %, 2 GM- 5 CEFAZOLIN SODIUM 5 2.2 % SOLR IJ 100 GM, 300 GM cefoxitin sodium solr iv 2 2 cefazolin sodium solr ij 20 2 gm, 1 gm gm, 500 mg, 1 gm, 10 gm cefprozil susr 125 mg/5ml, 2 cefazolin sodium solr iv 1 2 250 mg/5ml gm cefprozil tabs 250 mg, 500 2 QL(20 ea per CEFAZOLIN SODIUM mg fill retail) SOSY IV 1 GM/10ML, 2 NC QL(20 ea per GM/20ML cefuroxime axetil tabs 2 fill retail) CEFAZOLIN SODIUM/DEXTROSE NC cefuroxime sodium solr 2 SOLN 5 %-2 GM/100ML CEFAZOLIN Cephalosporins - 3rd Generation SODIUM/DEXTROSE QL(20 ea per 5 cefdinir caps 300 mg 2 SOLR 3 %-2 GM, 4 %-1 fill retail) GM cefdinir susr 125 mg/5ml, 2 CEFAZOLIN 250 mg/5ml SODIUM/SODIUM NC CHLORIDE SOLN cefditoren pivoxil tabs 2 CEFAZOLIN SOLN NC cefixime caps 2 CEFAZOLIN/SODIUM NC 2 CHLORIDE SOLN cefixime susr cephalexin caps 2 cefotaxime sodium solr 2 cephalexin susr 2 cefpodoxime proxetil susr 2 cephalexin tabs 2 cefpodoxime proxetil tabs 2 ceftazidime solr ij 2 gm, 1 KEFLEX CAPS (Use 5 2 cephalexin) gm, 6 gm

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ceftazidime solr iv 1 gm, 2 2 Cephalosporins - 5th Generation gm TEFLARO SOLR 5 CEFTAZIDIME/DEXTROS 5 E SOLR Cephalosporins - Siderophores ceftriaxone sodium in 2 dextrose soln FETROJA SOLR 5 ceftriaxone sodium solr ij 1 2 QL(0.1 ea gm, 250 mg, 500 mg daily) CHEMICALS CEFTRIAXONE SODIUM 5 Acids, Bases, & Buffers SOLR IJ 100 GM ACETIC ACID GLACIAL 5 RX/OTC ceftriaxone sodium solr ij 2 2 SOLN gm ACETIC ACID SOLN XX 5 5 ceftriaxone sodium solr iv 1 2 % gm, 2 gm, 10 gm AMMONIUM HYDROXIDE 5 RX/OTC CEFTRIAXONE/DEXTROS 5 SOLN E SOLR FUMARIC ACID POWD 5 FORTAZ SOLR IJ 1 GM 5 (Use ceftazidime) GLYCOLIC ACID CRYS 5 RX/OTC FORTAZ SOLR IJ 500 MG 5 GLYCOLIC ACID GRAN 5 FORTAZ SOLR IV 2 GM 2 HYDROCHLORIC ACID 5 SUPRAX CAPS 400 MG 4 LIQD 10 %, (Use cefixime) HYDROCHLORIC ACID 5 RX/OTC SUPRAX CHEW 100 MG, 4 LIQD 37 % 200 MG LACTIC ACID RACEMIC 5 RX/OTC SUPRAX SUSR 100 SOLN MG/5ML, 200 MG/5ML 4 LACTIC ACID SOLN XX 85 5 RX/OTC (Use cefixime) %, 88 %, SUPRAX SUSR 500 4 MG/5ML NITRIC ACID LIQD 5

TAZICEF SOLN 5 OXALIC ACID 5 DIHYDRATE POWD Cephalosporins - 4th Generation PHOSPHORIC ACID 5 cefepime hcl solr 2 SOLN POTASSIUM HYDROXIDE 5 RX/OTC CEFEPIME NC PLLT XX HYDROCHLORIDE SOLR POTASSIUM HYDROXIDE 5 CEFEPIME SOLN 5 SOLN EX 5 % POTASSIUM HYDROXIDE 5 CEFEPIME/DEXTROSE 5 SOLN XX 45 % SOLR SODIUM BORATE 5 RX/OTC MAXIPIME SOLR IJ 1 GM, 5 DECAHYDRATE POWD 2 GM (Use cefepime hcl) SODIUM BORATE POWD 5 RX/OTC MAXIPIME SOLR IV 1 GM, 5 2 GM

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM CARBONATE 5 ACETYL-L-CARNITINE 5 RX/OTC ANHYDROUS POWD HYDROCHLORIDE POWD SODIUM CARBONATE 5 ACETYLCHOLINE 5 MONOHYDRATE POWD CHLORIDE POWD SODIUM HYDROXIDE 5 RX/OTC ACTIPHYTE OF ALGAE 5 PLLT XX GL LIQD SODIUM HYDROXIDE 5 ACYCLOVIR POWD XX 5 SOLN EX ADEMETIONINE SULFURIC ACID SOLN 5 DISULFATE TOSYLATE 5 POWD TARTARIC ACID GRAN 5 RX/OTC ADENOSINE POWD XX 5 TARTARIC ACID POWD 5 AGAR GRAN 5 Bulk Chemicals - A's AGAR POWD 5 6-AMINOCAPROIC ACID 5 POWD ALASKAN RED ALGAE 5 9-AMINOACRIDINE HCL 5 POWD POWD ALBENDAZOLE POWD XX 5 A-LIPOIC ACID (DL- 5 RX/OTC THIOCTIC ACID) POWD ALDOSTERONE POWD 5 ACARBOSE POWD XX 5 ALGINIC ACID POWD 5 ACEPROMAZINE 5 MALEATE POWD ALKYL BENZOATE C12- 5 15 LIQD ACESULFAME 5 RX/OTC POTASSIUM POWD ALLOPURINOL POWD XX 5 ACETAMINOPHEN 5 CRYSTAL 60MESH CRYS ALOE VERA FREEZE 5 RX/OTC DRIED POWD ACETAMINOPHEN GRAN 5 XX ALOE VERA LEAF POWD 5 RX/OTC ACETAMINOPHEN POWD 5 RX/OTC XX ALOE VERA OIL 5 ACETARSONE POWD 5 ALOE VERA POWD 5 RX/OTC ACETAZOLAMIDE POWD 5 XX ALPHA LIPOIC ACID 5 RX/OTC POWD ACETYL DIPEPTIDE-1 5 CETYLESTER SOLN ALPHA-KETOGLUTARIC 5 ACID CRYS ACETYL HEXAPEPTIDE-8 5 POWD ALPHA-KETOGLUTARIC 5 ACID POWD ACETYL HEXAPEPTIDE-8 5 SOLN ALPRAZOLAM POWD XX 5 ACETYL-D- 5 GLUCOSAMINE POWD ALTRENOGEST POWD 5

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALUMINUM ACETATE 5 ANTIPYRINE CRYS 5 BASIC POWD ALUMINUM RX/OTC ANTIPYRINE POWD 5 CHLOROHYDRATE 5 POWD APOMORPHINE HCL 5 HEMIHYDRATE POWD AMANTADINE HCL POWD 5 XX APOMORPHINE HCL 5 POWD AMINOCAPROIC ACID 5 POWD XX APOMORPHINE 5 HYDROCHLORIDE POWD AMINOLEVULINIC ACID 5 HCL POWD ARBUTIN ALPHA POWD 5 AMINOLEVULINIC ACID 5 HYDROCHLORIDE POWD ARGININE HCL POWD 5 RX/OTC AMINOLEVULINIC ACID 5 HYDROCHOLRIDE POWD ARNICA LG LIQD 5 AMINOPROPYL ARSENIC TRIOXIDE 5 MENTHYL PHOSPHATE 5 POWD XX POWD ASCORBIC ACID 5 RX/OTC AMITRIPTYLINE HCL 5 CASSAVE POWD POWD XX ASCORBIC ACID GRAN 5 RX/OTC AMITRIPTYLINE 5 XX HYDROCHLORIDE POWD ASCORBIC ACID POWD 5 RX/OTC AMLODIPINE BESYLATE 5 XX POWD XX ASCORBYL PALMITATE 5 RX/OTC AMMONIUM LAURYL 5 POWD SULFATE LIQD ASPARAGINE 5 AMMONIUM MOLYBDATE 5 MONOHYDRATE POWD TETRAHYDRATE POWD ATORVASTATIN 5 AMMONIUM CALCIUM POWD XX TETRATHIOMOLYBDATE 5 POWD ATOVAQUONE POWD XX 5 AMOXICILLIN/CLAVULAN ATTAPULGITE ATE POTASSIUM 4:1 5 ACTIVATED COLLODIAL 5 POWD POWD ANASTROZOLE POWD 5 AVIPTADIL ACETATE 5 XX POWD ANDROSTENEDIONE 5 POWD AVOCADO OIL OIL 5 ANISINDIONE POWD 5 AZELAIC ACID FLAK XX 5 RX/OTC ANTIMONY POTASSIUM 5 AZELASTINE HCL POWD 5 TARTRATE POWD XX ANTIMONY 5 AZITHROMYCIN 5 TRICHLORIDE CRYS DIHYDRATE POWD ANTIMONY TRISULFIDE 5 AZITHROMYCIN POWD 5 POWD XX

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLUE AGAVE ORGANIC 5 BENZETHONIUM 5 LIQD CHLORIDE POWD DL-ALPHA LIPOIC ACID 5 RX/OTC BENZOCAINE POWD 5 RX/OTC POWD ENOVARX- 5 BENZOIN GUM POWD 5 AMITRIPTYLINE KIT BENZOQUINONE (PARA) GINSENG (AMERICAN) 5 5 POWD CRYS L-ARGININE HCL POWD 5 RX/OTC BETA CAROTENE BEAD 5 RX/OTC BETA CYCLODEXTRIN 5 LIPOIC ACID POWD 5 POWD LIPOIC ACID/DL-ALPHA RX/OTC BETA GLUCAN POWD 5 (DL-THIOCTIC ACID) 5 POWD BETAHISTINE DIHYDROCHLORIDE 5 MAGNASWEET 110 LIQD 5 POWD MAGNASWEET 135 5 BETAHISTINE HCL POWD 5 POWD SODIUM 4- BETAINE ANHYDROUS 5 RX/OTC AMINOSALICYLATEDIHY 5 POWD DRATE POWD BETAINE HCL POWD 5 Bulk Chemicals - B's BETAMETHASONE BACITRACIN 5 ACETATE MICRONIZED 5 MICRONIZED POWD POWD BASIC FUCHSIN HCL RX/OTC 5 BETAMETHASONE 5 POWD ACETATE POWD BECLOMETHASONE BETAMETHASONE 5 DIPROPIONATE 5 POWD ANYDROUS POWD BETANAPHTHOL POWD 5 BECLOMETHASONE 5 DIPROPIONATE POWD BETHANECHOL 5 belladonna (bulk) tinc 2 CHLORIDE POWD XX BHA FLAK 5 BELLADONNA EXTRACT 5 POWD BIMATOPROST POWD XX 5 BELLADONNA TINC 5 BIOTIN POWD 5 RX/OTC BENACTYZINE 5 HYDROCHLORIDE POWD BIOTIN-D POWD 5 RX/OTC BENAZEPRIL HCL POWD 5 XX BISABOLOL ALPHA-L 5 LIQD BENAZEPRIL 5 HYDROCHLORIDE POWD BISMUTH CITRATE 5 RX/OTC POWD BENFOTIAMINE POWD 5 BISOPROLOL FUMARATE 5 POWD XX 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BITTER ORANGE POWD 5 BUTORPHANOL 5 TARTRATE POWD XX BOLDENONE 17- 5 UNDECYLENATE LIQD BUTYL ALCOHOL LIQD 5 BORON AMORPHOUS 5 BUTYLATED FINE POWD HYDROXYANISOLE 5 POWD BORON CITRATE POWD 5 BUTYLENE GLYCOL LIQD 5 BOSWELLIA SERRATA 5 EXTRACT POWD TINOGARD TL LIQD 5 BOSWELLIA SERRATA 5 EXTRACT65% POWD Bulk Chemicals - C's BOSWELLIA SERRATA 5 ACTIPHYTE OF 5 EXTRACT70% POWD CUCUMBER LIQD BREMELANOTIDE 5 ADENOSYLCOBALAMIN 5 RX/OTC ACETATE POWD POWD RX/OTC BRILLIANT GREEN POWD 5 ADRENOCHROME 5 SEMICARBAZONE POWD BRIMONIDINE TARTRATE 5 ADRENOCORTICOTROP 5 POWD XX HIC HORMONE POWD BROMFENAC SODIUM 5 AVICEL PH 101 RX/OTC MISC MICROCRYSTALLINE 5 CELLULOSE POWD BROMFENAC SODIUM 5 POWD AVICEL PH 105 RX/OTC MICROCRYSTALLINE 5 BROMFENAC SODIUM 5 SESQUIHYDRATE POWD CELLULOSE POWD C INDICUM EXTRACT/C BUDESONIDE 5 MICRONIZED POWD SINESIS LEAF EXTRACT 5 LIQD BUDESONIDE POWD XX 5 CALCIPOTRIENE 5 MONOHYDRATE POWD BUFLOMEDIL HCL POWD 5 CALCIPOTRIENE POWD 5 BUPRENORPHINE HCL 5 XX POWD XX CALCIPOTRIOL POWD 5 BUPRENORPHINE POWD 5 XX CALCITRIOL IN ALMOND 5 OIL OIL BUPROPION HCL POWD 5 XX CALCITRIOL POWD XX 5 BUPROPION 5 HYDROCHLORIDE POWD CALCIUM ACETATE 5 POWD BUSPIRONE HCL POWD 5 XX CALCIUM ALGINATE 5 POWD BUSPIRONE 5 HYDROCHLORIDE POWD CALCIUM AMINO ACID 5 CHELATE 30% GRAN BUTALBITAL POWD 5 CALCIUM CHLORIDE 5 ANHYDROUS POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCIUM CITRATE 5 RX/OTC CARBIMAZOLE POWD 5 POWD RX/OTC CALCIUM CITRATE 5 RX/OTC CARBOMER 934P POWD 5 TETRAHYDRATE POWD CARBOMER 934P RESIN RX/OTC CALCIUM 5 5 FRUCTOBORATE POWD POWD RX/OTC CALCIUM GLUBIONATE 5 CARBOMER 940 POWD 5 MONOHYDRATE POWD CARBOMER 941 POWD 5 RX/OTC CALCIUM GLUBIONATE 5 POWD CARBOMER RX/OTC CALCIUM HOMOPOLYMER TYPE C 5 GLYCEROPHOSPHATE 5 POWD POWD CARBOPOL 940 NF 5 RX/OTC CALCIUM LEVULINATE 5 POWD DIHYDRATE POWD CARBOPOL 940 POWD 5 RX/OTC CALCIUM OXIDE POWD 5 CARMINE POWD 5 CALCIUM PROPIONATE 5 POWD CARNAUBA WAX FLAK 5 CALCIUM PYRUVATE 5 POWD CARNOSINE L POWD 5 CALCIUM STEARATE 5 POWD CEFTAZIDIME POWD XX 5 CALCIUM THIOGLYCOLATE 5 CEFTAZIDIME/SODIUM 5 TRIHYDRATE POWD CARBONATE POWD RX/OTC CEFTRIAXONE SODIUM 5 CANADIAN BALSAM LIQD 5 POWD XX CANNABIDIOL POWD 5 CELECOXIB POWD XX 5

CAPRYLIC ACID LIQD 5 CELLULASE POWD 5 RX/OTC CELLULOSE RX/OTC CAPRYLIC/CAPRIC 5 TRIGLYCERIDE LIQD MICROCRYSTALLINE 5 CRYS CAPRYLIC/CAPRIC 5 TRIGLYCERIDES LIQD CELLULOSE RX/OTC MICROCRYSTALLINE 5 CAPSAICIN PALMITATE 5 POWD POWD CELLULOSE PARTIALLY 5 RX/OTC CAPTOPRIL POWD XX 5 DEPOLYMERIZED POWD CELLULOSE/CMC NA CARBACHOL POWD 5 MICROCRYSTALLINE 5 POWD CARBAMIDE PEROXIDE 5 RX/OTC POWD CERESIN WAX FLAK 5 CARBAZOCHROME 5 POWD CESIUM CHLORIDE 5 POWD

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CETEARYL CHOLESTEROL POWD 5 RX/OTC ALCOHOL/CETEARETH- 5 20 POWD CHOLESTYRAMINE 5 POWD XX CETOSTEARYL 5 ALCOHOL MISC CHOLESTYRAMINE 5 RESIN POWD CETYL MYRISTOLEATE 5 OIL CHOLINE CHLORIDE 5 POWD CETYL MYRISTOLEATE 5 POWD CHOLINE MAGNESIUM 5 TRISALICYLATE POWD CETYL MYRISTOLEATE 5 WAX CHONDROITIN SULFATE 5 RX/OTC SODIUM POWD CETYLPYRIDINIUM 5 CHLORIDE CRYS CHORIONIC CETYLPYRIDINIUM GONADOTROPIN POWD 5 CHLORIDEMONOHYDRA 5 XX TE CRYS CHORIONIC GONADOTROPIN(HUMAN 5 CHICKEN PROTEIN 5 POWD ) POWD CHROMIC CHLORIDE 5 RX/OTC CHLORAMBUCIL POWD 5 CRYS XX CHLORAMPHENICOL 5 CHROMIUM CHLORIDE RX/OTC CRYS HEXAHYDRATE 5 REAGENT CRYS CHLORAMPHENICOL 5 PALMITATE POWD CHROMIUM CHLORIDE 5 POWD CHLORAMPHENICOL 5 POWD CHROMIUM PICOLINATE 5 RX/OTC CHLORHEXIDINE POWD DIACETATE HYDRATE 5 CHROMIUM 5 POWD POLYNICOTINATE POWD CHLOROPHYLLIN 5 CHROMIUM POTASSIUM SODIUM COPPER POWD SULFATE 5 DODECAHYDRATE CRYS CHLOROTHIAZIDE POWD 5 XX CHRYSIN POWD 5 RX/OTC CHLOROXINE POWD 5 CICLOPIROX POWD XX 5 CHLOROXYLENOL POWD 5 CIDOFOVIR ANHYDROUS 5 POWD CHLORPROMAZINE HCL 5 POWD XX CIDOFOVIR DIHYDRATE 5 POWD CHOLECALCIFEROL 5 CRYS XX CINNAMON BARK 5 CASSIA POWD CHOLECALCIFEROL 5 RX/OTC POWD XX CIPROFLOXACIN HCL 5 POWD XX CHOLESTEROL 5 RX/OTC ACETATE POWD CIPROFLOXACIN POWD 5 XX CHOLESTEROL FLAK 5

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CISAPRIDE 5 COPPER PEPTIDE POWD 5 MONOHYDRATE POWD CISPLATIN POWD XX 5 CORAL CALCIUM POWD 5 RX/OTC CITRULLINE(L) POWD 5 RX/OTC CORN OIL OIL 5

CITRUS BIOFLAVONOIDS 5 COUMARIN POWD 5 POWD CLARITHROMYCIN 5 CRANBERRY POWD 5 POWD XX CREATINE ANHYDROUS 5 CLEMIZOLE HCL POWD 5 POWD CREATINE RX/OTC CLIDINIUM BROMIDE 5 5 POWD MONOHYDRATE POWD CLINDAMYCIN HCL 5 CREATINE POWD 5 MONOHYDRATE POWD CREATININE POWD 5 RX/OTC CLINDAMYCIN HCL 5 POWD XX CRESOL LIQD 5 CLINDAMYCIN 5 PHOSPHATE POWD XX CROSCARMELLOSE 5 CLOFAZIMINE POWD 5 SODIUM POWD CROTAMITON LIQD XX 5 CLOMIPRAMINE HCL 5 POWD XX CROTON OIL OIL 5 RX/OTC CLONAZEPAM POWD XX 5 CUPRIC CHLORIDE 5 CLOPIDOGREL 5 DIHYDRATE CRYS BISULFATE POWD XX CUPUACU BUTTER MISC 5 CLORSULON POWD 5 CYANOCOBALAMIN 5 RX/OTC COBALT GLUCONATE 5 CRYS XX POWD CYANOCOBALAMIN 5 COBAMAMIDE POWD 5 RX/OTC POWD XX CYCLANDELATE POWD 5 COCAMIDE DEA LIQD 5 CYCLOBENZAPRINE HCL 5 COLHIBIN SOLN 5 POWD XX CYCLOBENZAPRINE 5 COLISTIMETHATE 5 HYDROCHLORIDE POWD SODIUM POWD XX CYCLOBENZAPRINE 5 COLLAGEN 5 POWD HYDROLYSATE POWD CYCLOMETHICONE LIQD 5 COPPER GLUCONATE 5 POWD CYCLOPENTASILOXANE/ COPPER GLYCINATE 5 PEG/PPG-18/18 5 POWD DIMETHICONE LIQD

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYCLOPENTOLATE HCL 5 MICROCRYSTALLINE RX/OTC POWD XX CELLULOSE NF 101 5 POWD CYCLOPENTOLATE 5 HYDROCHLORIDE POWD MICROCRYSTALLINE RX/OTC CELLULOSE NF 105 5 CYCLOPHOSPHAMIDE 5 MONOHYDRATE POWD POWD RX/OTC CYCLOPHOSPHAMIDE 5 UREA PEROXIDE POWD 5 POWD XX VITAMIN D3 LIQD XX CYCLOSERINE POWD XX 5 1000000 UNIT/GM, 2400 5 UNIT/ML, CYCLOSPORINE A POWD 5 VITAMIN D3 POWD XX 5 RX/OTC CYCLOSPORINE POWD 5 XX VITAMIN D3 POWD XX 5 100000 UNIT/GM CYPROHEPTADINE HCL 5 POWD XX YLANG-YLANG OIL 5 FRAGRANCE OIL CYSTEAMINE HCL POWD 5 Bulk Chemicals - D's DERMACINRX ETHOXY RX/OTC 5 2-DEOXY-D-GLUCOSE 5 RX/OTC DIGLYCOL LIQD POWD DIETHYLENE GLYCOL RX/OTC 2-DEOXY-D-GLUCOSE 5 RX/OTC MONOETHYL ETHER 5 REAGANTGRADE POWD LIQD CALCIUM DIETHYLENE GLYCOL RX/OTC HYDROXYAPATITE 5 MONOETHYL ETHER NF 5 POWD LIQD D-MANNOSE POWD 5 ETHOXY DIGLYCOL LIQD 5 RX/OTC ETHOXY ETHOXY RX/OTC D-RIBOSE POWD 5 ETHANOL REAGENT 5 D-RIBOSE REAGENT 5 LIQD POWD FREEDOM ESTERDERM 5 DANTROLENE SODIUM 5 LIQD POWD XX HUMAN CHORIONIC 5 DAPIPRAZOLE HCL 5 GONADOTROPIN POWD POWD L-CARNOSINE POWD 5 DAPSONE POWD XX 5 RX/OTC L-CITRULLINE POWD 5 DEHYDROCHOLIC ACID 5 POWD L-CYSTEINE CRYS 5 DEMECARIUM BROMIDE 5 POWD L-CYSTEINE HCL 5 RX/OTC MONOHYDRATE POWD DENATONIUM 5 BENZOATE GRAN L-CYSTEINE POWD 5 DEOXYCHOLIC ACID 5 POWD LOCUST BEAN GUM 5 POWD DESICCATED BEEF 5 LIVER POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DESMOPRESSIN 5 DICHLOROACETIC ACID 5 ACETATE POWD XX LIQD DESOXIMETASONE 5 DICLAZURIL POWD 5 POWD XX DICLOFENAC SODIUM DESOXYCORTICOSTERO 5 5 NE ACETATE POWD POWD XX DEVILS CLAW POWD 5 DICUMAROL POWD 5 DEXAMETHASONE DICYCLOMINE 5 ACETATE ANHYDROUS 5 HYDROCHLORIDE POWD POWD DIETHANOLAMINE LIQD 5 DEXAMETHASONE 5 ACETATE POWD DIETHYL PHTHALATE 5 LIQD DEXAMETHASONE BASE 5 POWD DIETHYL-M-TOLUAMIDE 5 LIQD DEXAMETHASONE 5 ISONICOTINATE POWD DIETHYLCARBAMAZINE 5 CITRATE POWD DEXAMETHASONE 5 POWD XX DIETHYLPROPION DEXAMETHASONE HYDROCHLORIDE/TART 5 SODIUM PHOSPHATE 5 ARIC ACID POWD POWD XX DIETHYLSTILBESTROL 5 POWD DEXCHLORPHENIRAMIN 5 E MALEATE POWD XX DIGOXIN MICRONIZED 5 POWD DEXPANTHENOL LIQD 5 RX/OTC XX DIGOXIN POWD XX 5 DEXPANTHENOL POWD 5 XX DIHYDROCODEINE 5 BITARTRATE POWD DEXTRAN 40000 POWD 5 DIHYDROXYACETONE 5 (1,3) DIMER POWD DEXTRAN 75000 POWD 5 DIINDOLYLMETHANE 5 POWD DEXTROMETHORPHAN 5 POWD DIIODO-L-THYRONINE 5 3,5 POWD DIAMINOPYRIDINE 5 POWD DILTIAZEM HCL POWD 5 XX DIAZEPAM POWD XX 5 DIMETHYL FUMARATE 5 DIAZOXIDE POWD XX 5 POWD XX DIMETHYL SILOXANE DIBUCAINE HCL POWD 5 HYDROXYALKYL- 5 TERMINATED LIQD DIBUCAINE POWD 5 DIMETHYLACETAMIDE 5 LIQD DICHLORALPHENAZONE 5 POWD DIMETHYLAMINOETHAN 5 OL (DEANOL) LIQD

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIMETHYLGLYCINE HCL 5 RX/OTC DYCLONINE 5 POWD HYDROCHLORIDE CRYS DIOSGENIN POWD 5 DYPHYLLINE POWD 5

DIOSMIN POWD 5 GERMALL PLUS LIQD 5

DIOXYBENZONE POWD 5 PCCA DMAE COMPLEX 5 LIQD DIPHENIDOL 5 PROSTAGLANDIN E2 5 HYDROCHLORIDE POWD POWD DIPHENYLCYCLOPROPE 5 NONE POWD RIBOSE (D) POWD 5 DIPYRIDAMOLE POWD 5 SYN-AKE LIQD 5 XX DISOPHENOL POWD 5 Bulk Chemicals - E's ECONAZOLE NITRATE 5 DISULFIRAM POWD XX 5 POWD XX EDROPHONIUM 5 DIVALPROEX SODIUM 5 CHLORIDE POWD POWD XX EMU OIL OIL 5 DMAE BITARTRATE 5 POWD ENALAPRIL MALEATE 5 DOCOSANOL POWD 5 POWD XX DOPAMINE ENROFLOXACIN POWD 5 HYDROCHLORIDE POWD 5 XX EPINEPHRINE 5 BITARTRATE POWD DORZOLAMIDE 5 HYDROCHLORIDE POWD ERGOLOID MESYLATES 5 POWD XX DOW CORNING 1501 5 FLUID LIQD ERYTHROMYCIN 5 ESTOLATE POWD DOXAZOSIN MESYLATE 5 POWD XX ESTRADIOL BENZOATE 5 POWD DOXEPIN HCL POWD XX 5 ESTRADIOL 5 CONCENTRATE CREA DOXEPIN 5 HYDROCHLORIDE POWD ESTRADIOL CYPIONATE 5 POWD DOXYCYCLINE 5 MONOHYDRATE POWD ESTRADIOL 5 HEMIHYDRATE POWD DULOXETINE HCL POWD 5 XX ESTRADIOL MICRONIZED 5 POWD DULOXETINE 5 HYDROCHLORIDE POWD ESTRADIOL POWD XX 5 DUTASTERIDE POWD XX 5 ESTRADIOL VALERATE 5 CRYS XX DYCLONINE HCL POWD 5 ESTRADIOL VALERATE 5 POWD XX 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESTRIOL CONCENTRATE 5 FENOFIBRATE POWD XX 5 CREA FERRIC AMMONIUM ESTRIOL MICRONIZED 5 5 POWD CITRATE POWD FERRIC CHLORIDE 5 ESTRIOL POWD 5 HEXAHYDRATE MISC ESTRIOL ULTRA 5 FERRIC SUBSULFATE 5 RX/OTC MICRONIZED POWD SOLN ESTRONE 5 FERRIC SULFATE 5 CONCENTRATE CREA HYDRATE POWD ESTRONE CRYS 5 FERROUS BISGLYCINATE CHELATE 5 ESTRONE POWD 5 POWD FERROUS FUMARATE 5 ETHOSUXIMIDE POWD 5 POWD XX FERROUS GLUCONATE 5 ETHYL OLEATE LIQD 5 RX/OTC DIHYDRATE GRAN FERROUS GLUCONATE 5 ETHYL VANILLIN FLAK 5 DIHYDRATE POWD FERROUS GLUCONATE 5 ETHYLCELLULOSE 5 POWD POWD FERULIC ACID POWD 5 ETHYLENEDIAMINE LIQD 5 FEVERFEW POWD 5 ETOMIDATE POWD XX 5 FEXOFENADINE HCL 5 ETOPOSIDE POWD XX 5 POWD

EUCALYPTOL LIQD 5 RX/OTC FINASTERIDE CRYS XX 5

GREEN TEA POWD 5 FINASTERIDE POWD XX 5 Bulk Chemicals - F's FLIBANSERIN POWD 5 4-AMINOPYRIDINE POWD 5 FLOXURIDINE POWD XX 5 4-METHYLPYRAZOLE 5 FLUCONAZOLE POWD 5 LIQD XX 5-FLUOROURACIL POWD 5 FLUCYTOSINE POWD XX 5 DALFAMPRIDINE POWD 5 XX FLUMAZENIL POWD XX 5 FAMCICLOVIR POWD XX 5 FLUNIXIN MEGLUMINE 5 POWD FAMOTIDINE POWD XX 5 FLUOROURACIL POWD 5 XX FENBENDAZOLE POWD 5 FLUOXETINE HCL POWD 5 XX

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUPHENAZINE 5 GLUCOSAMINE SULFATE DECANOATE LIQD XX SODIUM CHLORIDE 5 POWD FLUPHENAZINE 5 DECANOATE POWD XX GLUTARALDEHYDE IN 5 WATER LIQD FLUTICASONE 5 PROPIONATE POWD XX GLYCEROL 5 MONOOLEATE POWD FORMOTEROL 5 FUMARATE POWD XX GLYCERYL 5 RX/OTC MONOSTEARATE FLAK FORSKOLIN POWD 5 GLYCOFUROL LIQD 5 FURAZOLIDONE POWD 5 GLYCOPYRROLATE 5 Bulk Chemicals - G's POWD XX GLYCOSAMINOGLYCANS 4-AMINOBUTYRIC ACID 5 5 CRYS LIQD GLYCYRRHIZIC ACID 5 ALPHA-GPC 50% POWD 5 POWD GOLD SODIUM 5 ARLACEL 165 POWD 5 THIOMALATE POWD EGCG POWD 5 RX/OTC GRAMICIDIN D POWD 5

GABAPENTIN POWD XX 5 GRAPE SEED OIL 5 RX/OTC

GALACTOSE POWD 5 GRAPESEED OIL 5 RX/OTC

GAMMA-AMINOBUTYRIC 5 GREEN SOAP EMUL 5 ACID CRYS GREEN TEA OIL GARDENIA FRAGRANCE 5 5 OIL FRAGRANCE OIL RX/OTC GATIFLOXACIN 5 GREEN TEA POWD 5 SESQUIHYDRATE POWD GRISEOFULVIN 5 GENISTEIN POWD 5 MICRONIZED POWD GINGER OIL 5 GRISEOFULVIN POWD 5

GUANABENZ ACETATE 5 GINSENG ROOT POWD 5 POWD GLUCONOLACTONE 5 GUANETHIDINE 5 POWD HEMISULFATE POWD GLUCOSAMINE RX/OTC 5 GUANIDINEACETIC ACID 5 HYDROCHLORIDE POWD POWD GLUCOSAMINE SULFATE GUAR GUM POWD 5 POTASSIUM CHLORIDE 5 POWD GUARANA SEED 5 EXTRACT POWD GLUCOSAMINE SULFATE 5 RX/OTC POWD GYMNEMA SYLVESTRIS 5 LEAF POWD

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bulk Chemicals - H's HYDROXOCOBALAMIN 5 HYDROCHLORIDE POWD ACTIPHYTE OF IVY LIQD 5 HYDROXOCOBALAMIN 5 RX/OTC POWD HALOPERIDOL 5 DECANOATE POWD XX HYDROXYAMPHETAMINE 5 HYDROBROMIDE POWD HALOPERIDOL POWD XX 5 HYDROXYCHLOROQUIN 5 E SULFATE POWD XX HAWTHORN BERRY 5 POWD HYDROXYETHYL CELLULOSE 100 CPS 5 HEMATOXYLIN POWD 5 POWD HEPARIN SODIUM POWD 5 HYDROXYETHYL XX CELLULOSE 4500-6500 5 CPS POWD HEPES POWD 5 HYDROXYETHYL HEPTAMINOL POWD 5 CELLULOSE 5000 CPS 5 POWD HISTAMINE PHOSPHATE 5 HYDROXYETHYL 5 CRYS CELLULOSE POWD HONEY ALMOND 5 HYDROXYETHYL 5 FRAGRANCE LIQD METHACRYLATE POWD HUPERZINE SERRATE A 5 HYDROXYPROGESTERO 5 POWD NE CAPROATE POWD XX HYALURONATE SODIUM 5 HYDROXYPROPYL RX/OTC POWD CELLULOSE 150-400 CPS 5 POWD HYALURONIC ACID 5 HYDROLYZED POWD HYDROXYPROPYL RX/OTC CELLULOSE 1500 CPS 5 HYALURONIC ACID 5 SODIUM POWD POWD HYDROXYPROPYL RX/OTC HYALURONIC ACID 5 SODIUM SALT POWD CELLULOSE 1500-3000 5 CPS POWD HYALURONIDASE POWD 5 XX HYDROXYPROPYL RX/OTC CELLULOSE 4000-6500 5 HYDRALAZINE HCL 5 POWD XX CPS POWD HYDROXYPROPYL RX/OTC HYDRAZINE SULFATE 5 CRYS CELLULOSE 75-100 CPS 5 POWD HYDROCODONE 5 BITARTRATE CRYS XX HYDROXYPROPYL 5 RX/OTC CELLULOSE POWD HYDROCODONE 5 BITARTRATE POWD XX HYDROXYPROPYL RX/OTC METHYLCELLULOSE 5 HYDROCORTISONE POWD HEMISUCCINATE 5 MONOHYDRATE POWD HYDROXYPROPYL-BETA- 5 CYCLODEXTRIN POWD HYDROFLUORIC ACID 5 LIQD HYDROXYUREA POWD 5 XX 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROXYZINE HCL 5 INOSITOL 5 RX/OTC POWD XX HEXANICOTINATE POWD HYPROMELLOSE 100000 5 RX/OTC INOSITOL POWD 5 MPA-S POWD HYPROMELLOSE 5 RX/OTC IODINE FLAK 5 100000CPS POWD IODINE RESUBLIMED HYPROMELLOSE 4000 5 RX/OTC 5 MPA-S POWD GRAN iodine strong (lugol's) (bulk) RX/OTC HYPROMELLOSE 5 RX/OTC 2 4000CPS POWD soln HYPROMELLOSE RX/OTC IODINE STRONG SOLN 5 RX/OTC METHOCEL K100M 5 POWD IOPANOIC ACID POWD 5 HYPROMELLOSE TYPE 5 RX/OTC 2910 POWD ISOMETHEPTENE 5 MUCATE POWD METHOCEL E4M POWD 5 RX/OTC ISOPROPYL MYRISTATE 5 SOLN METHOCEL E4M 5 RX/OTC PREMIUM CR POWD ISOPROTERENOL HCL 5 POWD XX METHOCEL E4M 5 RX/OTC PREMIUM POWD ISOSORBIDE POWD 5 METHOCEL K100 5 RX/OTC PREMIUM POWD ISOTRETINOIN POWD XX 5 METHOCEL K100M RX/OTC 5 ISOXSUPRINE HCL 5 PREMIUM POWD POWD SODIUM HYALURONATE ITRACONAZOLE POWD 5 (INJECTION GRADE) 5 XX POWD IVERMECTIN POWD XX 5 SODIUM HYALURONATE 5 POWD LIPACTIVE INCA INCHI 5 WITCH HAZEL EXTR 5 WO LIQD Bulk Chemicals - J's Bulk Chemicals - I's JASMINE FRAGRANCE 5 CERAPHYL SLK LIQD 5 LIQD

IDEBENONE POWD 5 JOJOBA OIL OIL 5 Bulk Chemicals - K's IDOXURIDINE POWD 5 7-KETO DHEA POWD 5 RX/OTC IMIDUREA POWD 5 ACTIPHYTE OF SEA 5 IMIQUIMOD POWD XX 5 KELP LIQD ACTIPHYTE OF SUGAR 5 INDOCYANINE GREEN 5 KELP LIQD POWD KANAMYCIN SULFATE 5 INDOLE-3-CARBINOL 5 RX/OTC POWD POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KETAMINE HCL POWD 5 L-SELENOMETHIONINE 5 XX BLEND POWD KETOPROFEN 5 L-SELENOMETHIONINE 5 MICRONIZED POWD POWD KETOPROFEN POWD XX 5 LABETALOL HCL POWD 5 XX KETOPROFEN ULTRA 5 MICRONIZED POWD LACTASE 5000 POWD 5 KETOROLAC LAMOTRIGINE POWD XX 5 TROMETHAMINE POWD 5 XX LANSOPRAZOLE POWD 5 RX/OTC XX KETOTIFEN FUMARATE 5 POWD LATANOPROST POWD 5 XX KETOTIFEN HYDROGEN 5 FUMARATE POWD LAURETH-9 5 POLIDOCANOL LIQD KINETIN POWD 5 LAURIC ACID POWD 5 KIWI FRAGRANCE LIQD 5 LEAD TETROXIDE POWD 5 KUDZU ROOT POWD 5 LEFLUNOMIDE POWD XX 5 Bulk Chemicals - L's 5- LETROZOLE POWD XX 5 METHYLTETRAHYDROF OLIC 5 LEUCOVORIN CALCIUM 5 ACID/GLUCOSAMINE POWD XX SALT POWD LEUPROLIDE ACETATE 5 POWD XX ACIDOPHILUS 5 LACTOBACILLUS POWD LEVALBUTEROL HCL 5 POWD XX CALCIUM FOLINATE 5 POWD LEVETIRACETAM POWD 5 XX CARNITINE (L) POWD 5 RX/OTC LEVOCARNITINE POWD 5 RX/OTC L-5- LEVOCETIRIZINE METHYLTETRAHYDROF 5 OLICACID CALCIUM DIHYDROCHLORIDE 5 POWD POWD XX L-CARNITINE POWD XX 5 RX/OTC LEVOFLOXACIN 5 HEMIHYDRATE POWD RX/OTC L-LYSINE HCL POWD 5 LEVOMEFOLATE 5 CALCIUM POWD L-LYSINE RX/OTC LEVORPHANOL 5 MONOHYDROCHLORIDE 5 TARTRATE POWD XX POWD LEVOTHYROXINE 5 L-METHYLFOLATE 5 SODIUM (T4) POWD CALCIUM POWD LEVOTHYROXINE 5 SODIUM POWD XX

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LICORICE PINENE (L-ALPHA) POWD 5 DEGLYCYRRHIZINATED 5 POWD Bulk Chemicals - M's LIDOCAINE BASE POWD 5 2-METHOXYESTRADIOL 5 POWD LIDOCAINE CRYS XX 5 5- RX/OTC METHYLTETRAHYDROF 5 LIDOCAINE HCL 5 OLATE POWD MONOHYDRATE POWD 5- RX/OTC LIDOCAINE HCL POWD 5 METHYLTETRAHYDROF 5 XX OLATECALCIUM POWD LIDOCAINE CALCIUM L-5 RX/OTC HYDROCHLORIDE POWD 5 METHYLTETRAHYDROF 5 XX OLATE POWD LIDOCAINE POWD XX 5 DIMETHYL SULFONE 5 POWD LIMONENE LIQD 5 DL-MALIC ACID POWD 5 RX/OTC LINCOMYCIN HCL POWD 5 XX L-GLUTAMIC ACID 5 MONOSODIUM POWD LINOLEIC ACID LIQD 5 MACA ROOT POWD 5 LIOTHYRONINE POWD 5 MAFENIDE ACETATE 5 POWD XX LIOTHYRONINE SODIUM 5 (T3) POWD MAGNESIUM ALUMINUM 5 SILICATE POWD LIOTHYRONINE SODIUM 5 POWD XX MAGNESIUM AMINO ACID CHELLATE 20% 5 LISINOPRIL POWD XX 5 POWD MAGNESIUM LITHIUM CITRATE 5 5 TETRAHYDRATE POWD ASCORBATE POWD RX/OTC MAGNESIUM LORATADINE POWD 5 BISGLYCINATE CHELATE 5 POWD LORAZEPAM POWD XX 5 MAGNESIUM BISGLYCINATE 5 LOSARTAN POTASSIUM 5 POWD XX DIHYDRATE POWD MAGNESIUM CITRATE 5 RX/OTC LUTEIN BEAD 5 POWD LUTEIN POWD 5 MAGNESIUM CITRATE 5 RX/OTC TRIBASIC POWD LYSINE HCL GRAN 5 MAGNESIUM 5 GLUCONATE POWD PCCA T3 SODIUM 5 MAGNESIUM GLYCINATE 5 DILUTION POWD POWD PCCA T4 SODIUM 5 MAGNESIUM 5 DILUTION POWD HYDROXIDE POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGNESIUM MALATE 5 MEQUINOL POWD 5 POWD MAGNESIUM MERCAPTOPURINE 5 PHOSPHATE DIBASIC 5 MONOHYDRATE POWD TRIHYDRATE POWD MERCAPTOPURINE 5 POWD XX MAGNESIUM 5 SALICYLATE POWD METACRESOL ACETATE 5 LIQD MALEIC ACID POWD 5 METFORMIN HCL POWD 5 MALIC ACID POWD 5 RX/OTC XX METHACHOLINE 5 MALTODEXTRIN POWD 5 CHLORIDE CRYS METHACHOLINE 5 MANDELIC ACID POWD 5 CHLORIDE POWD METHACRYLIC ACID MANGANESE CHLORIDE 5 TETRAHYDRATE POWD COPOLYMER TYPE A 5 POWD MANGANESE 5 GLUCONATE POWD METHANESULFONIC 5 ACID LIQD MANGANESE SULFATE 5 POWD XX METHOCARBAMOL 5 POWD XX MECAMYLAMINE HCL 5 POWD METHOXYAMINE 5 HYDROCHLORIDE POWD MECHLORETHAMINE 5 HCL POWD METHOXYETHANOL LIQD 5 MECLOFENOXATE 5 METHSCOPOLAMINE 5 HYDROCHLORIDE POWD BROMIDE POWD XX MEDIUM CHAIN 5 METHSCOPOLAMINE 5 TRIGLYCERIDES LIQD NITRATE POWD MEDROXYPROGESTERO NE ACETATE 5 METHYL FOLATE POWD 5 MICRONIZED POWD METHYL MEDROXYPROGESTERO 5 METHACRYLATE 5 NE ACETATE POWD XX CROSSPOLYMER POWD MEDROXYPROGESTERO 5 RX/OTC NE ACETATE YAM POWD METHYL SULFONE CRYS 5 MEDROXYPROGESTERO 5 METHYLCOBALAMIN 5 RX/OTC NE MICRONIZED POWD POWD XX MEGLUMINE POWD 5 METHYLENE CHLORIDE 5 LIQD MELOXICAM POWD XX 5 METHYLMETHACRYLATE CROSSPOLYMER (310) 5 MEMANTINE 5 POWD HYDROCHLORIDE POWD METHYLPHENIDATE HCL 5 MENADIONE POWD 5 POWD XX METHYLSULFONYLMETH 5 ANE POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLTETRAHYDROF 5 RX/OTC N-ACETYL-L-CARNOSINE 5 OLATE CALCIUM POWD POWD METHYSERGIDE 5 NABUMETONE POWD XX 5 MALEATE POWD METRONIDAZOLE 5 NADH POWD 5 BENZOATE POWD NALBUPHINE HCL POWD METRONIDAZOLE POWD 5 5 XX XX NALOXONE HCL MEXILETINE 5 5 HYDROCHLORIDE POWD DIHYDRATE POWD NALOXONE HCL POWD 5 MIDAZOLAM POWD XX 5 XX NALOXONE MILK THISTLE POWD 5 HYDROCHLORIDE 5 DIHYDRATE POWD MIRTAZAPINE POWD XX 5 NALTREXONE HCL 5 POWD XX MISOPROSTOL POWD 5 XX 1 % NALTREXONE 5 HYDROCHLORIDE POWD MISOPROSTOL-HPMC 5 POWD NALTREXONE 5 MITOMYCIN POWD XX 5 HYDROCHLORIDEDIHYD RATE POWD MITOTANE POWD 5 NALTREXONE POWD XX 5

MOLYBDENUM POWD 5 NANDROLONE 5 DECANOATE POWD MOMETASONE FUROATE 5 NAPHAZOLINE HCL 5 POWD XX POWD MONOBENZONE POWD 5 NEOSTIGMINE METHYLSULFATE POWD 5 MONOETHANOLAMINE 5 XX LIQD NEPAFENAC POWD 5 MONTELUKAST SODIUM 5 POWD XX NETTLE LEAF POWD 5 MORANTEL TARTRATE 5 POWD NICLOSAMIDE POWD 5 MOXIFLOXACIN HCL 5 POWD XX NICOTINAMIDE ADENINE RX/OTC DINUCLEOTIDE (NAD) 5 MOXISYLYTE HCL POWD 5 POWD NICOTINAMIDE ADENINE 5 RX/OTC MUPIROCIN POWD XX 5 DINUCLEOTIDE POWD MYCOPHENOLATE 5 NICOTINAMIDE MOFETIL POWD XX RIBOSIDE CHLORIDE 5 POWD VITAMIN K2 POWD 5 NICOTINE POLACRILEX 5 RX/OTC Bulk Chemicals - N's POWD XX

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICOTINE TARTRATE 5 OXYBUTYNIN CHLORIDE 5 POWD POWD XX NIMODIPINE POWD XX 5 OXYMETAZOLINE HCL 5 POWD NITROFURANTOIN 5 OXYTETRACYCLINE 5 ANHYDROUS POWD DIHYDRATE POWD NITROFURANTOIN 5 OXYTOCIN ACETATE 5 MONOHYDRATE POWD POWD NITROFURANTOIN 5 POWD XX OXYTOCIN POWD XX 5 NOREPINEPHRINE 5 TRITON X-100 LIQD 5 BITARTRATE POWD XX NORETHINDRONE POWD 5 Bulk Chemicals - P's BRIJ 35 WAX 5 NYSTATIN FOREIGN 5 POWD BRIJ 700 WAX 5 NYSTATIN POWD XX 5 BRIJ 93 LIQD 5 Bulk Chemicals - O's HYDROXYQUINOLINE 5 COSMOCIL CQ LIQD 5 SULFATE POWD DL-PANTHENOL 5 L-ORNITHINE 5 RX/OTC ALCOHOL POWD HYDROCHLORIDE POWD DL-PANTHENOL POWD 5 OCTINOXATE LIQD 5 PALMAROSA OIL OIL 5 OCTYL STEARATE LIQD 5 PALMITAMIDE MEA 5 OLMESARTAN 5 (PMEA) POWD MEDOXOMIL POWD XX PALMITOYL 5 OMEPRAZOLE POWD XX 5 PENTAPEPTIDE-3 GEL PALMITOYL TRIPEPTIDE- ONDANSETRON HCL 5 5 DIHYDRATE POWD 3 SOLN ONDANSETRON HCL 5 PANCREATIN POWD 5 POWD XX PANTHENOL POWD 5 ORIGANUM OIL 5 PANTOPRAZOLE 5 ORLISTAT POWD 5 SODIUM POWD XX PANTOPRAZOLE ORNITHINE 5 RX/OTC HYDROCHLORIDE POWD SODIUM 5 SESQUIHYDRATE POWD OSELTAMIVIR 5 PHOSPHATE POWD XX PAPAIN POWD 5 OXANDROLONE POWD 5 PARACHLOROPHENOL 5 POWD OXYBUTININ CHLORIDE 5 POWD

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARAFORMALDEHYDE 5 PHENTOLAMINE 5 POWD MESYLATE POWD XX PAROMOMYCIN 5 PHENYL SALICYLATE 5 SULFATE POWD XX CRYS PEG 400 5 PHENYLETHYL ALCOHOL 5 MONOSTEARATE POWD LIQD PEG-40 CASTOR OIL OIL 5 PHENYLETHYLAMINE 5 HCL POWD PENICILLAMINE POWD 5 PHENYLTOLOXAMINE XX DIHYDROGEN CITRATE 5 PENNYROYAL OIL OIL 5 POWD 5 PENTOSAN PHENYTOIN POWD XX POLYSULFATE SODIUM 5 PHOSPHATIDYLCHOLINE 5 RX/OTC POWD POWD PENTOXIFYLLINE POWD 5 PHYTIC ACID IN WATER 5 XX LIQD PENTYLENE GLYCOL 5 PHYTONADIONE CRYS 5 LIQD XX PENTYLENETETRAZOLE 5 RX/OTC CRYS PHYTONADIONE LIQD XX 5 PERFLUORODECALIN 5 PIMOBENDAN POWD 5 LIQD PINE BARK EXTRACT PERGOLIDE MESYLATE 5 5 POWD POWD PERMETHRIN 5 PINE NEEDLE OIL OIL 5 TECHNICAL LIQD PINEAPPLE EXTRACT PERPHENAZINE POWD 5 5 XX LIQD PEUCEDANUM PIPERINE POWD 5 OSTRUTHIUM EXTRACT 5 SOLN PIRACETAM POWD 5 PHENELZINE SULFATE 5 POWD XX PODOFILOX POWD XX 5 PHENINDIONE POWD 5 POLYACRYLATE CROSSPOLYMER-6 5 PHENIRAMINE MALEATE 5 POWD POWD POLYHEXAMETHYLENE 5 PHENOLSULFONIC ACID 5 BIGUANIDE SOLN LIQD POLYVINYL ALCOHOL 5 PHENOXYBENZAMINE 5 POWD HCL POWD XX POLYVINYLPYRROLIDON 5 PHENOXYETHANOL LIQD 5 E K-30 POWD POLYVINYLPYRROLIDON 5 PHENTERMINE 5 E K-90 POWD HYDROCHLORIDE POWD

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POMEGRANATE SEED 5 POVIDONE-IODINE FLAK 5 OIL POVIDONE-IODINE 5 PONAZURIL POWD 5 POWD POTASSIUM ACETATE 5 RX/OTC POWDER SCENT 5 CRYS XX FRAGRANCE LIQD POTASSIUM ACETATE 5 PRALIDOXIME CHLORIDE 5 POWD XX POWD POTASSIUM ASPARTATE 5 PRAZIQUANTEL POWD 5 POWD XX POTASSIUM AZELAOYL 5 PREGABALIN POWD XX 5 DIGLYCINATE LIQD POTASSIUM BENZOATE 5 PRILOCAINE HCL POWD 5 POWD PRILOCAINE HCLUSP POTASSIUM IODIDE 5 RX/OTC 5 CRYS POWD PRILOCAINE POTASSIUM IODIDE 5 5 GRAN HYDROCHLORIDE POWD POTASSIUM IODIDE 5 PRILOCAINE POWD 5 POWD PRIMIDONE POWD XX 5 POTASSIUM 5 METABISULFITE CRYS PROCARBAZINE HCL 5 POTASSIUM 5 POWD METABISULFITE POWD PROCHLORPERAZINE 5 POTASSIUM 5 RX/OTC EDISYLATE POWD XX PERMANGANATE GRAN PROFLAVINE 5 POTASSIUM HEMISULFATE POWD PHOSPHATE DIBASIC 5 ANHYDROUS GRAN PROGESTERONE 5 CONCENTRATE CREA POTASSIUM PHOSPHATE DIBASIC 5 PROGESTERONE GRAN MICRONIZED (SOY) 5 POWD POTASSIUM PHOSPHATE 5 PROGESTERONE 5 MONOBASIC CRYS MICRONIZED (YAM) POWD POTASSIUM PHOSPHATE 5 PROGESTERONE 5 MONOBASIC POWD MICRONIZED POWD POTASSIUM SODIUM PROGESTERONE 5 5 TARTRATE GRAN MICRONIZED PREMIUM POWD POTASSIUM SULFATE 5 POWD PROGESTERONE 5 MILLED POWD POVIDONE K-30 POWD 5 PROGESTERONE POWD 5 XX POVIDONE POWD 5 PROGESTERONE ULTRA 5 MICRONIZED POWD

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROGESTERONE 5 QUININE HCL CRYS 5 WETTABLE (YAM) POWD PROGESTERONE 5 Bulk Chemicals - R's WETTABLE POWD RACEPINEPHRINE HCL 5 RX/OTC PROMAZINE HCL POWD 5 POWD RANITIDINE HCL POWD 5 PROMETHAZINE HCL 5 XX POWD XX RANITIDINE 5 PROPANEDIOL LIQD 5 HYDROCHLORIDE POWD RAPESEED OIL OIL 5 PROPARACAINE HCL 5 POWD XX RASAGILINE MESYLATE 5 PROPIONIC ACID LIQD 5 POWD XX RAUWOLFIA 5 PROPYL GALLATE POWD 5 SERPENTINA POWD RED YEAST RICE RX/OTC PROPYLENE GLYCOL 5 RX/OTC 5 LIQD XX EXTRACT POWD RX/OTC PROPYLENE GLYCOL 5 RED YEAST RICE POWD 5 MONOSTEARATE BEAD RESVERATROL 98% 5 PROPYLTHIOURACIL 5 POWD POWD XX RESVERATROL 98+% 5 PROTAMINE SULFATE 5 POWD POWD RESVERATROL POWD 5 PSYLLIUM HUSK POWD 5 RETINALDEHYDE POWD 5 PULLULAN POWD 5 RIBAVIRIN POWD XX 5 PYRANTEL PAMOATE 5 POWD RIBOFLAVIN POWD 5 RX/OTC PYRAZINAMIDE POWD 5 XX RIBOFLAVIN-5- RX/OTC PYRIDOSTIGMINE 5 PHOSPHATE SODIUM 5 BROMIDE POWD XX ANHYDROUS POWD PYRIDOXAL-5- RX/OTC RIBOFLAVIN-5- RX/OTC PHOSPHATE 5 PHOSPHATE SODIUM 5 MONOHYDRATE POWD POWD PYRIMETHAMINE POWD 5 RIFAMPIN POWD XX 5 XX ZINC PYRITHIONE LIQD 5 RIFAXIMIN POWD 5

Bulk Chemicals - Q's ROCURONIUM BROMIDE 5 POWD XX QUATERNIUM-15 POWD 5 RONIDAZOLE POWD 5 QUERCETIN DIHYDRATE 5 POWD

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROPIVACAINE NICE PURE BAKING 5 RX/OTC HYDROCHLORIDE POWD 5 SODA POWD XX NOURISIL GEL 5 ROSE BENGAL B POWD 5 PHOSPHATIDYLSERINE 5 RUBIDIUM CHLORIDE 5 POWD POWD PMX-1184 SILICONE LIQD 5 RX/OTC RUTIN POWD 5 SACCHARIN CALCIUM 5 Bulk Chemicals - S's CRYS 2,3- SAGE LEAF POWD 5 DIMERCAPTOSUCCINIC 5 ACID(DMSA) POWD SALICYLIC ACID CRYS 5 XX AC DERMAPEPTIDE LIQD 5 SALICYLIC ACID POWD 5 RX/OTC XX CALCIUM SACCHARIN 5 CRYS SALICYLIC ACID SOLN 5 XX 50 % CETYL ESTERS WAX 5 WAX SALSALATE POWD XX 5 COPASIL GEL XX 5 SAW PALMETTO BERRY 5 POWD DEOXYCHOLIC ACID 5 SODIUM POWD SCARLET RED POWD 5 DIBUTYL SQUARATE 5 RX/OTC LIQD SECRETIN-MANNITOL 5 POWD DIMERCAPTOSUCCINIC 5 ACID CRYS SELENIUM SULFIDE 5 POWD XX DIMERCAPTOSUCCINIC 5 ACID POWD SELENIUM YEAST POWD 5 DL-3-HYDROXYBUTYRIC 5 ACIDSODIUM POWD SENNA EXTR 5 DOW CORNING 200 LIQD 5 RX/OTC SERMORELIN ACETATE 5 POWD L-ASPARTIC ACID RX/OTC SODIUM MONOHYDRATE 5 SEROTONIN HCL POWD 5 POWD SERTRALINE HCL POWD 5 L-ASPARTIC ACID 5 XX SODIUM SALT POWD SHARK CARTILAGE 5 L-SERINE POWD 5 RX/OTC POWD SHOWER FRESH 5 LECITHIN GRAN XX 5 FRAGRANCE LIQD SIBERIAN GINSENG 5 LECITHIN SOYA GRAN 5 POWD LECITHIN SOYA POWD 5 SILDENAFIL CITRATE 5 POWD

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SILICONE BLEND 5 SODIUM FLUORIDE 5 CUSTOM PSTE POWD XX SILICONE ELASTOMER 5 SODIUM BLEND GEL FLUOROPHOSPHATE 5 POWD SILICONE ELASTOMER 5 RX/OTC BLEND LIQD SODIUM GLUCONATE 5 POWD SILICONE FLUID 556 5 RX/OTC LIQD SODIUM IODIDE CRYS 5 SILVER SULFADIAZINE 5 POWD XX SODIUM IODIDE GRAN 5 SIMVASTATIN POWD XX 5 SODIUM L-ASPARTATE 5 RX/OTC POWD SINCALIDE IN MANNITOL 5 POWD SODIUM LACTATE SOLN 5 SIROLIMUS POWD XX 5 SODIUM LAURETH 5 SULFATE LIQD SODIUM ACETATE 5 TRIHYDRATE POWD SODIUM METABISULFITE 5 RX/OTC ANHYDROUS GRAN SODIUM ALGINATE 5 POWD SODIUM METABISULFITE 5 RX/OTC GRAN SODIUM BICARBONATE 5 RX/OTC POWD XX SODIUM METABISULFITE 5 POWD SODIUM BISULFITE 5 RX/OTC GRAN SODIUM MOLYBDATE 5 POWD SODIUM BITARTRATE 5 MONOHYDRATE POWD SODIUM MONOFLUOROPHOSPHA 5 SODIUM CAPRATE 5 POWD TE POWD SODIUM NITRATE ACS SODIUM CAPYRLATE 5 5 FOOD GRADE POWD POWD SODIUM CHLORITE FLAK 5 SODIUM OLEATE POWD 5 SODIUM SODIUM CITRATE 5 DIHYDRATE POWD PHENYLBUTYRATE 5 POWD XX SODIUM COCOYL 5 GLUTAMATE LIQD SODIUM PHOSPHATE 5 DIBASIC CRYS SODIUM DEHYDROACETATE 5 SODIUM PHOSPHATE 5 POWD DIBASIC POWD SODIUM PHOSPHATE SODIUM 5 DEOXYCHOLATE POWD DIBASICANHYDROUS 5 POWD SODIUM DIACETATE 5 POWD SODIUM PHOSPHATE DIBASICDIHYDRATE 5 SODIUM POWD DICHLOROACETATE 5 POWD SODIUM PHOSPHATE 5 RX/OTC DIBASICDRIED GRAN

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM PHOSPHATE SOYABEAN CASEIN 5 DIBASICHEPTAHYDRATE 5 DIGEST MEDIUM POWD CRYS SPAN 80 LIQD 5 SODIUM PHOSPHATE 5 DIBASICHEPTAHYDRATE SPIRULINA POWD 5 POWD SODIUM PHOSPHATE RX/OTC SQUALANE LIQD 5 MONOBASIC 5 ANHYDROUS POWD SQUALANE OIL 5 SODIUM PHOSPHATE 5 MONOBASIC GRAN SQUARIC ACID IN 5 RX/OTC BUTANOL LIQD SODIUM PHOSPHATE 5 TRIBASIC CRYS SQUARIC ACID POWD 5 SODIUM PROPIONATE 5 RX/OTC POWD ST JOHNS WORT POWD 5 SODIUM PYRROLIDONE 5 STANNOUS CHLORIDE 5 CARBOXYLATE LIQD DIHYDRATE CRYS SODIUM SELENITE 5 POWD STANOZOLOL POWD 5 SODIUM STEARATE 5 RX/OTC POWD STEVIA EXTRACT POWD 5 SODIUM STEARYL 5 STEVIA EXTRACT POWD 5 FUMARATE POWD STEVIA POWDER RX/OTC SODIUM SUCCINATE 5 5 POWD EXTRACT POWD STEVIOL GLYCOSIDES SODIUM TARTRATE 5 5 DIHYDRATE POWD POWD SODIUM TETRADECYL 5 STEVIOSIDE EXTR 5 SULFATE POWD XX STRONTIUM CHLORIDE SODIUM TETRADECYL 5 5 SULFATE SOLN XX 27 % CRYS SODIUM-L-ASCORBYL-2- SUCCIMER DMSA POWD 5 PHOSPHATE DIHYDRATE 5 POWD SUCCINIC ACID CRYS 5 SORBITAN 5 MONOLAURATE LIQD SUCCINYLCHOLINE 5 CHLORIDE POWD XX SORBITAN 5 MONOOLEATE LIQD SUCCINYLCHOLINE CHLORIDEDIHYDRATE 5 SORBITAN POWD MONOPALMITATE BASE I 5 POWD SUCROSE 5 OCTAACETATE CRYS SORBITAN 5 MONOPALMITATE POWD SUFENTANIL CITRATE 5 POWD XX SORBITAN 5 MONOSTEARATE PLLT SULFACETAMIDE POWD 5

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFADIMETHOXINE 5 TEA COCOYL 5 POWD GLUTAMINE SOLN SULFAMERAZINE POWD 5 TEA TREE OIL OIL 5 RX/OTC

SULFOSALICYLIC ACID 5 TERBINAFINE HCL POWD 5 DIHYDRATE POWD XX SULFUR POWD 5 RX/OTC TESTOSTERONE 5 CONCENTRATE CREA SULFUR PRECIPITATED RX/OTC 5 TESTOSTERONE 5 POWD CYPIONATE POWD XX SULFUR SUBLIMED RX/OTC 5 TESTOSTERONE 5 POWD ENANTHATE POWD XX SULPIRIDE POWD 5 TESTOSTERONE MICRONIZED (SOY) 5 SUMATRIPTAN POWD XX 5 POWD TESTOSTERONE SUMATRIPTAN 5 MICRONIZED (YAM) 5 SUCCINATE POWD XX POWD SUPEROXIDE 5 TESTOSTERONE 5 DISMUTASE POWD MICRONIZED POWD SUPEROXIDE 5 TESTOSTERONE 5 DISMUTASE SOLN MICRONIZED SOY POWD THIOSALICYLIC ACID 5 TESTOSTERONE 5 SODIUMSALT POWD MICRONIZED YAM CRYS Bulk Chemicals - T's TESTOSTERONE NON- 5 MICRONIZED SOY POWD CURCUMIN EXTRACT 5 POWD TESTOSTERONE POWD 5 XX CURCUMIN POWD 5 TESTOSTERONE 5 NATURAL MIXED PROPIONATE POWD XX TOCOPHEROLS30% 5 TETRACAINE HCL POWD 5 POWD XX RENOVAGE LIQD 5 TETRACAINE POWD 5 TACROLIMUS TETRAHYDRO-L- MONOHYDRATE POWD 5 BIOPTERIN 5 XX DIHYDROCHLORIDE TACROLIMUS POWD XX 5 POWD TETRAHYDROBIOPTERIN TADALAFIL POWD XX 5 DIHYDROCHLORIDE 5 POWD TAMOXIFEN CITRATE 5 TETRAHYDROBIOPTERIN 5 MICRONIZED POWD HYDROCHLORIDE POWD TAMOXIFEN CITRATE 5 TETRAHYDROCURCUMI 5 POWD XX NOIDS (THC) POWD TAZAROTENE POWD XX 5 TETRAHYDROZOLINE 5 HCL POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THEANINE POWD 5 TRANILAST CRYS 5

THEOBROMINE POWD 5 TRANILAST POWD 5

THIOGUANINE POWD 5 TRIACETIN LIQD 5

THIORIDAZINE HCL 5 TRIAMCINOLONE 5 POWD XX HEXACETONIDE POWD THIOTEPA POWD XX 5 TRIAMCINOLONE POWD 5

THYMUS POWD 5 TRIAMCINOLONEUSP, 5 MICRONIZED POWD THYROID POWD XX 5 TRICHLORMETHIAZIDE 5 POWD TICARCILLIN TRICHLOROACETIC ACID 5 RX/OTC DISODIUM/CLAVULANAT 5 CRYS E POTASSIUM POWD TRICHLOROACETIC ACID 5 TIOPRONIN POWD XX 5 POWD

TITANIUM DIOXIDE LIQD 5 TRICLOSAN POWD 5 TRIETHANOLAMINE TITANIUM DIOXIDE 5 5 POWD LAURYL SULFATE LIQD TRIETHYL CITRATE LIQD 5 TIZANIDINE HCL POWD 5 XX TRILOSTANE POWD 5 TOBRAMYCIN POWD XX 5 TRIMEPRAZINE 5 TOCOTRIENOLS SUSP 5 TARTRATE POWD TRIMETHOBENZAMIDE TOFACITINIB CITRATE 5 5 POWD HCL POWD XX TRIOXSALEN POWD 5 TOLAZOLINE 5 HYDROCHLORIDE POWD TRIPROLIDINE HCL 5 TOLTRAZURIL POWD 5 CRYS

TOLU BALSAM MISC 5 TROMETHAMINE POWD 5 TROPOLONE POWD 5 TOLUIDINE BLUE O 5 POWD TRYPSIN POWD 5 TOPIRAMATE POWD XX 5 TURMERIC POWD 5 TRAMADOL HCL POWD 5 XX TURMERIC ROOT POWD 5 TRAMADOL 5 HYDROCHLORIDE POWD TYLOSIN TARTRATE 5 TRANEXAMIC ACID 5 RX/OTC POWD POWD XX TYLOXAPOL LIQD 5

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bulk Chemicals - U's VECURONIUM BROMIDE 5 POWD XX UBIQUINOL POWD 5 VIDARABINE POWD 5 UREA POWD XX 5 RX/OTC VINPOCETINE POWD 5 URIDINE POWD 5 VITAMIN A ACETATE 5 BEAD URSODIOL POWD XX 5 VITAMIN A PALMITATE 5 RX/OTC Bulk Chemicals - V's LIQD ALPHA-TOCOPHEROL 5 VITAMIN A POWD 5 LIQD VITAMIN E ACETATE RX/OTC D-VITAMIN E SUCCINATE 5 RX/OTC LIQD 1 UNIT/MG, 125 5 POWD UNIT/ML, RETINOL MOLECULAR 5 FILM OIL VITAMIN E LIQD 5 SODIUM VALPROATE 5 VITAMIN E SUCCINATE 5 RX/OTC POWD POWD TOCOPHERYL ACID RX/OTC VORICONAZOLE POWD 5 SUCCINATED-ALPHA 5 XX POWD Bulk Chemicals - W's VALACYCLOVIR HCL 5 POWD XX SEPICALM VG LIQD 5 VALACYCLOVIR 5 HYDROCHLORIDE POWD WHEY PROTEIN ISOLATE 5 INSTANIZED POWD VALERIAN ROOT POWD 5 WHITE KIDNEY BEAN 5 EXTRACT POWD VALPROATE SODIUM 5 POWD XX WHITE WILLOW BARK 5 POWD VALPROIC ACID POWD 5 XX Bulk Chemicals - X VANADIUM POWD 5 XYLAZINE 5 HYDROCHLORIDE POWD VANADYL SULFATE 5 RX/OTC RX/OTC HYDRATE CRYS XYLITOL NF POWD 5 VANCOMYCIN HCL 5 XYLITOL POWD 5 RX/OTC POWD XX VANCOMYCIN XYLOMETAZOLINE HCL 5 HYDROCHLORIDE POWD 5 POWD XX XYLOMETAZOLINE 5 HYDROCHLORIDE POWD VANILLIN CRYS 5 Bulk Chemicals - Y's VANILLIN POWD 5 YEAST EXTRACT LIQD 5 VARDENAFIL 5 HYDROCHLORIDE POWD YOHIMBINE HCL POWD 5

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bulk Chemicals - Z's POLYOX WSR-301 POWD 5 ZEAXANTHIN POWD 5 SODIUM PYROPHOSPHATE 5 RX/OTC ZINC ACETATE POWD 5 ANHYDROUS POWD VICTORIAS SECRET ZINC CHLORIDE GRAN 5 RX/OTC 5 XX VANILLALACE LIQD Liquids ZINC CITRATE 5 DIHYDRATE POWD ACETONE SOLN 5 RX/OTC ZINC GLUCONATE POWD 5 XX ACTIPHYTE OF 5 LEMONGRASS LIQD ZINC MONOMETHIONINE 5 POWD ALCOHOL SOLN XX 95 % 5 RX/OTC ZINC OXIDE POWD 5 RX/OTC ALMOND OIL OIL 5 RX/OTC ZINC PICOLINATE POWD 5 ALMOND OIL SWEET OIL 5 RX/OTC ZINC UNDECYLENATE 5 POWD AMMONIUM LACTATE 5 SOLN ZIRCONIUM OXIDE 5 POWD BASE G ALMOND OIL 5 RX/OTC SWEET OIL ZOLMITRIPTAN POWD 5 XX BAY OIL OIL 5 ZONISAMIDE POWD XX 5 BENZYL BENZOATE LIQD 5 RX/OTC Bulk Chemicals CASTOR OIL OIL 5 RX/OTC BAY RUM LIQD 5 RX/OTC CEDAR LEAF OIL OIL 5 BIORE HYDRATING 5 MOISTURIZER LIQD CHLORHEXIDINE 5 CUCUMBER MELON LIQD 5 GLUCONATE SOLN CHLOROFORM SOLN 5 RX/OTC DRAKKAR NOIR LIQD 5 CITRONELLA OIL OIL 5 RX/OTC ETHYLPARABEN POWD 5 RX/OTC FERRIC CLOVE OIL OIL 5 PYROPHOSPHATE 5 RX/OTC POWD COCONUT OIL OIL 5 FRESH LINEN 5 COTTONSEED OIL OIL 5 RX/OTC FRAGRANCE LIQD RX/OTC L-ASPARAGINE 5 CRYOSERV SOLN 5 MONOHYDRATE POWD RX/OTC DIMETHYL SULFOXIDE 5 RX/OTC NATAPRES LIQD 5 SOLN POLYETHYLENE GLYCOL 5 RX/OTC ETHER SOLN 5 600 LIQD

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ETHYL ALCOHOL 190 5 RX/OTC JUNIPER TAR OIL 5 PROOF SOLN LAVENDER OIL RX/OTC ETHYL ALCOHOL SDA- 5 RX/OTC 5 40B 190 PROOF SOLN FRAGRANCE OIL RX/OTC LAVENDER OIL NATURAL 5 RX/OTC ETHYL ALCOHOL SOLN 5 OIL EUCALYPTUS OIL OIL 5 RX/OTC LAVENDER OIL OIL 5 RX/OTC

EUGENOL SOLN 5 RX/OTC LIME OIL OIL 5 RX/OTC

GERANIUM NATURAL OIL 5 RX/OTC LINSEED OIL RAW OIL 5

GERANIUM OIL OIL 5 RX/OTC MACADAMIA NUT OIL OIL 5

GLYCERIN LIQD 99 %, 5 RX/OTC METHANOL SOLN 5 RX/OTC 99.5 %, RX/OTC GLYCERIN SOLN 5 METHYL ALCOHOL SOLN 5

GLYCERINE LIQD 5 RX/OTC NIAOULI OIL 5 RX/OTC GLYCEROL FORMAL 5 RX/OTC OIL-ALMOND SWEET OIL 5 LIQD RX/OTC GLYCINE SOYA PROTEIN 5 OIL-COCONUT OIL 5 SOLN OLIVE OIL OIL 5 RX/OTC GNP EUCALYPTUS OIL 5 RX/OTC OIL ORGANIC COCONUT OIL 5 RX/OTC GNP ISOPROPYL 5 RX/OTC OIL ALCOHOL SOLN RX/OTC GOODSENSE RX/OTC PEANUT OIL OIL 5 ISOPROPYL ALCOHOL 5 RX/OTC SOLN PEPPERMINT OIL OIL 5 GUAIACOL SOLN 5 PINE OIL OIL 5 RX/OTC HM CASTOR OIL OIL 5 PINE TAR LIQD 5 HM ISOPROPYL RX/OTC RX/OTC RUBBING ALCOHOL 5 POLYSORBATE 20 SOLN 5 SOLN POLYSORBATE 40 SOLN 5 HM ISOPRPYL RUBBING 5 RX/OTC ALCOHOL SOLN POLYSORBATE 60 LIQD 5 ISOPROPANOL SOLN 5 RX/OTC POLYSORBATE 80 LIQD 5 RX/OTC ISOPROPYL ALCOHOL 5 RX/OTC SOLN 100 %, 70 % QC CASTOR OIL OIL 5 RX/OTC isopropyl alcohol soln 99 % 2 RX/OTC QC SWEET OIL OIL 5 RX/OTC ISOPROPYL PALMITATE 5 RX/OTC LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROSE OIL OIL 5 RX/OTC ALUMINUM POTASSIUM 5 RX/OTC SULFATE POWD RX/OTC ROSEMARY OIL OIL 5 ALUMINUM SULFATE 5 HYDRATE GRAN RX/OTC SAFFLOWER OIL OIL 5 AMMONIUM BROMIDE 5 ACS POWD SASSAFRAS OIL OIL 5 AMMONIUM BROMIDE 5 GRAN SESAME OIL OIL 5 RX/OTC AMMONIUM CHLORIDE 5 RX/OTC SM ISOPROPYL RX/OTC GRAN ALCOHOL RUBBING 5 AMMONIUM PHOSPHATE 5 SOLN DIBASIC GRAN AMMONIUM SULFATE SM ISOPROPYL 5 RX/OTC 5 ALCOHOL SOLN GRAN SM SWEET OIL OIL 5 RX/OTC BHT GRAN 5

SOYBEAN OIL OIL 5 RX/OTC BISMUTH 5 RX/OTC SUBCARBONATE POWD RX/OTC SPEARMINT OIL 5 BISMUTH SUBNITRATE 5 RX/OTC POWD RX/OTC SPEARMINT OIL OIL 5 BISMUTH 5 RX/OTC SUBSALICYLATE POWD SWEET OIL OIL 5 RX/OTC BORIC ACID CRYS XX 5 UNDECYLENIC ACID 5 RX/OTC LIQD BORIC ACID NF POWD 5 RX/OTC WA-001 EXPERIMENTAL 5 RX/OTC SOILSURFACTANT OIL BORIC ACID POWD XX 5 Semi-Solids BUTYLATED RX/OTC HYDROXYTOLUENE 5 COAL TAR SOLN 5 GRAN BUTYLATED COAL TAR TAR 5 HYDROXYTOLUENE 5 POWD PERUVIAN BALSAM MISC 5 CALCIUM HYDROXIDE 5 RX/OTC POWD PERUVIAN BALSAM 5 POWD CALCIUM SULFATE 5 RX/OTC Solids ANHYDROUS POWD CALCIUM SULFATE RX/OTC 5-HYDROXY-L- 5 5 TRYPTOPHAN POWD HEMIHYDRATE POWD RX/OTC CALCIUM SULFATE 5 RX/OTC ALLANTOIN POWD 5 POWD CAPSICUM OLEORESIN 5 ALPROSTADIL POWD XX 5 LIQD ALUMINUM HYDROXIDE RX/OTC 5 CARBIDOPA 5 DRIEDGEL POWD ANHYDROUS POWD

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARBIDOPA POWD XX 5 DHEA POWD 5 RX/OTC

CARBOXYMETHYLCELLU RX/OTC DIMENHYDRINATE 5 LOSE SODIUM HIGH 5 POWD VISCOSITY POWD DIMERCAPTO-1- CARBOXYMETHYLCELLU RX/OTC PROPANESULFONIC 5 LOSE SODIUM LOW 5 ACID (DMPS) POWD VISCOSITY POWD DIMERCAPTO-1- CARBOXYMETHYLCELLU PROPANESULFONIC 5 LOSE SODIUM MEDIUM 5 ACID SODIUM SALT VISCOSITY GRAN POWD CARBOXYMETHYLCELLU RX/OTC DIMERCAPTOPROPANE- LOSE SODIUM MEDIUM 5 SULFONATE (2,3) 5 VISCOSITY POWD SODIUM POWD CARBOXYMETHYLCELLU 5 RX/OTC DINITROCHLOROBENZE 5 LOSE SODIUM POWD NE CRYS CITRIC ACID 5 RX/OTC DOCUSATE ANHYDROUS GRAN SODIUM/SODIUM 5 BENZOATE POWD CITRIC ACID 5 RX/OTC ANHYDROUS POWD EDETATE ACID POWD 5 CITRIC ACID 5 RX/OTC MONOHYDRATE GRAN EDETATE DISODIUM 5 RX/OTC DIHYDRATE POWD CITRIC ACID 5 MONOHYDRATE POWD EDETATE DISODIUM 5 RX/OTC POWD CITRIC ACID POWD 5 RX/OTC EDETATE TETRASODIUM 5 TETRAHYDRATE POWD CO-ENZYME Q 10 POWD 5 RX/OTC EPINEPHRINE BASE 5 POWD COENZYME Q-10 POWD 5 RX/OTC XX EPINEPHRINE POWD XX 5 COENZYME Q10 POWD 5 RX/OTC FLUORESCEIN POWD 5 CORN STARCH POWD 5 RX/OTC FLUORESCEIN SODIUM 5 POWD CROSCARMELLOSE 5 RX/OTC SODIUM POWD FULLERS EARTH POWD 5 RX/OTC DEHYDROEPIANDROSTE RONE MICRONIZED 2 GERMANIUM 5 POWD SESQUIOXIDE POWD DEHYDROEPIANDROSTE GINGER ROOT POWD 5 RONE MICRONIZED 5 POWD GNP BORIC ACID POWD 5 RX/OTC DEHYDROEPIANDROSTE 5 RX/OTC RONE POWD HM BORIC ACID POWD 5 RX/OTC DHEA MICRONIZED 5 POWD HOMATROPINE 5 METHYLBROMIDE POWD

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROXYTRYPTOPHAN 5 PILOCARPINE NITRATE 5 L-5 POWD POWD HYDROXYTRYPTOPHAN 5 POTASH SULFURATED 5 POWD LUMP MISC IODOFORM POWD 5 RX/OTC POTASSIUM ALUM 5 RX/OTC POWD KETOCONAZOLE POWD 5 POTASSIUM 5 RX/OTC XX BITARTRATE POWD RX/OTC KOJIC ACID POWD 5 POTASSIUM BROMIDE 5 RX/OTC CRYS RX/OTC L-ASPARTIC ACID POWD 5 POTASSIUM BROMIDE 5 GRAN L-MENTHOL CRYS 5 RX/OTC POTASSIUM BROMIDE 5 POWD LEAD ACETATE 5 TRIHYDRATE POWD POTASSIUM 5 CARBONATE GRAN LICORICE ROOT POWD 5 POTASSIUM RX/OTC RX/OTC GLUCONATE 5 MANNITOL POWD XX 5 ANHYDROUS POWD RX/OTC POTASSIUM NITRATE 5 MELATONIN POWD 5 CRYS MENADIONE SODIUM 5 POTASSIUM NITRATE 5 BISULFITE CRYS POWD RX/OTC MENTHOL CRYS 5 POTASSIUM 5 PERCHLORATE CRYS RX/OTC MENTHOL-L CRYS 5 PREGNENOLONE 5 MICRONIZED POWD METHENAMINE 5 MANDELATE POWD XX PREGNENOLONE POWD 5 METHENAMINE POWD 5 PROSTAGLANDIN E1 5 POWD METHYLENE BLUE 5 POWD PUMICE (FLOUR) POWD 5 METHYLENE BLUE 5 TRIHYDRATE POWD PYROGALLOL CRYS 5 MINOXIDIL POWD XX 5 PYRUVIC ACID LIQD 5 RX/OTC

OXYBENZONE POWD 5 PYRUVIC ACID POWD 5

PHENYLMERCURIC 5 QC BORIC ACID POWD 5 RX/OTC ACETATE POWD QUINIDINE SULFATE PHENYLMERCURIC 5 5 NITRATE POWD DIHYDRATE CRYS RX/OTC PILOCARPINE HCL 5 RA BORIC ACID POWD 5 POWD XX RX/OTC PILOCARPINE NITRATE 5 RESORCINOL CRYS 5 CRYS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESORCINOL POWD 5 RX/OTC SUCROSE 5 CONFECTIONERS POWD ROSIN LUMP MISC 5 SUCROSE POWD 5 RX/OTC SILICA GEL GEL 5 SUCROSE POWDERED 5 CONFECTIONERS POWD SILICA GEL 5 RX/OTC ULTRAMICRONIZED GEL SULFANILAMIDE POWD 5 SILICON DIOXIDE 5 RX/OTC (SYLOID 244 FP) POWD TALC POWD 5 SILICON DIOXIDE POWD 5 THEOPHYLLINE 5 RX/OTC ANHYDROUS POWD RX/OTC SM BORIC ACID POWD 5 THYMOL CRYS 5 RX/OTC RX/OTC SODIUM BROMIDE GRAN 5 THYMOL IODIDE POWD 5 SODIUM BUTYRATE RX/OTC 5 THYMOL IODIDE 5 POWD PURIFIED POWD SODIUM CACODYLATE 5 POWD TINIDAZOLE POWD XX 5 SODIUM RX/OTC UBIDECARENONE POWD 5 RX/OTC CARBOXYMETHYLCELLU 5 LOSE MEDIUM CONTRACEPTIVES - Drugs to Prevent VISCOSITY POWD Pregnancy SODIUM CHLORIDE/SODIUM 5 Combination Contraceptives - Oral BICARBONATE POWD BALCOLTRA TABS 6 SODIUM NITRITE GRAN 5 RX/OTC XX BEYAZ TABS (Use drospirenone-ethinyl NC SODIUM PERBORATE 5 RX/OTC estradiol-levomefolate MONOHYDRATE POWD calcium) SODIUM PERBORATE RX/OTC 5 desogestrel & ethinyl 6 QL(1 ea daily) TETRAHYDRATE POWD estradiol tabs SODIUM SULFATE POWD 5 desogestrel-ethinyl 6 estradiol (biphasic) tabs SODIUM SULFITE 5 RX/OTC ANHYDROUS POWD desogestrel-ethinyl 6 QL(1 ea daily) estradiol (triphasic) tabs RX/OTC SODIUM SULFITE POWD 5 drospirenone-ethinyl estradiol tabs 0.03 mg-3 6 SORBITOL POWD XX 5 mg, 0.02 mg-3 mg, 3 mg- 0.02 mg STANNOUS FLUORIDE 5 POWD drospirenone-ethinyl QL(1 ea daily) estradiol tabs 0.03 mg-3 6 STARCH POWD 5 RX/OTC mg, 3 mg-0.03 mg drospirenone-ethinyl STRONTIUM NITRATE 5 CRYS estradiol-levomefolate 6 calcium tabs

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESTROSTEP FE TABS norethin acet & estrad-fe (Use norethindrone 5 tabs 1 mg-20 mcg-75 mg, 6 acetate-ethinyl estradiol-fe) 75 mg-1 mg-20 mcg ethynodiol diacet & eth 6 QL(1 ea daily) norethin acet & estrad-fe QL(1 ea daily) estrad tabs 1 mg-35 mcg tabs 1.5 mg-30 mcg-75 mg, 75 mg-1.5 mg-30 mcg, 1 6 ethynodiol diacet & eth 6 estrad tabs 1 mg-50 mcg mg-20 mcg-75 mg, 75 mg- 1 mg-20 mcg FALESSA KIT 6 norethindrone & eth 6 QL(1 ea daily) GENERESS FE CHEW estradiol tabs (Use norethindrone & 5 norethindrone & ethinyl 6 ethinyl estradiol-fe) estradiol-fe chew norethindrone acet & eth QL(1 ea daily) levonorgestrel & eth 6 QL(1 ea daily) 6 estradiol tabs estra tabs norethindrone acetate- levonorgestrel-eth estradiol 6 QL(1 ea daily) 6 (triphasic) tabs ethinyl estradiol-fe tabs norethindrone-eth estradiol QL(1 ea daily) levonorgestrel-ethinyl 6 QL(1 ea daily) 6 estradiol (91-day) tabs (triphasic) tabs levonorgestrel-ethinyl QL(1 ea norgestimate-ethinyl 6 estradiol (triphasic) tabs estradiol (91-day) tabs 0.03 6 daily,91 day(s) mg-0.15 mg, 0.15 mg-0.03 limit) norgestimate-ethinyl 6 QL(1 ea daily) mg estradiol (triphasic) tabs levonorgestrel-ethinyl 6 norgestimate-ethinyl 6 QL(1 ea daily) estradiol (continuous) tabs estradiol tabs LO LOESTRIN FE TABS 6 QL(1 ea daily) norgestrel & ethinyl QL(2 ea daily) estradiol tabs 0.3 mg-30 6 LOSEASONIQUE TABS QL(1 ea mcg, 30 mcg-0.3 mg (Use levonorgestrel-ethinyl 5 daily,91 day(s) norgestrel & ethinyl QL(1 ea daily) estradiol (91-day)) limit) estradiol tabs 0.5 mg-50 6 MINASTRIN 24 FE CHEW mcg (Use norethin acet & NC ORTHO TRI-CYCLEN LO estrad-fe) TABS (Use norgestimate- NC MIRCETTE TABS (Use ethinyl estradiol (triphasic)) desogestrel-ethinyl 5 ORTHO-NOVUM 1/35 QL(1 ea daily) estradiol (biphasic)) TABS (Use norethindrone 5 NATAZIA TABS NC & eth estradiol) ORTHO-NOVUM 7/7/7 QL(1 ea daily) NEXTSTELLIS TABS NC TABS (Use norethindrone- 5 eth estradiol (triphasic)) norethin acet & estrad-fe QUARTETTE TABS (Use QL(1 ea caps 1 mg-20 mcg-75 mg, NC levonorgestrel-ethinyl 5 daily,91 day(s) 1 mg-75 mg-20 mcg, 75 estradiol (91-day)) limit) mg-1 mg-20 mcg SAFYRAL TABS (Use norethin acet & estrad-fe drospirenone-ethinyl 5 chew 1 mg-20 mcg-75 mg, 6 estradiol-levomefolate 75 mg-1 mg-20 mcg calcium)

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SEASONIQUE TABS (Use Progestin Contraceptives - IUD levonorgestrel-ethinyl NC estradiol (91-day)) KYLEENA IUD 6 SP TAYTULLA CAPS (Use NC SP norethin acet & estrad-fe) LILETTA IUD 6 TYBLUME CHEW 6 QL(1 ea daily) QL(1 ea per 365 days YASMIN 28 TABS (Use MIRENA IUD 6 retail,1 ea per drospirenone-ethinyl NC 365 days mail); estradiol) SP YAZ TABS (Use SKYLA IUD 6 SP drospirenone-ethinyl NC estradiol) Progestin Contraceptives - Implants Combination Contraceptives - Transdermal NEXPLANON IMPL 6 PA; SP norelgestromin-ethinyl 6 QL(0.1071 ea estradiol ptwk daily) Progestin Contraceptives - Injectable TWIRLA PTWK NC DEPO-PROVERA CONTRACEPTIVE SUSP 5 Combination Contraceptives - Vaginal (Use medroxyprogesterone acetate (contraceptive)) ANNOVERA RING 6 DEPO-PROVERA CONTRACEPTIVE SUSY etonogestrel-ethinyl 6 QL(0.04 ea 5 estradiol ring daily) (Use medroxyprogesterone acetate (contraceptive)) NUVARING RING 0.015 DEPO-SUBQ PROVERA MG/24HR-0.12 MG/24HR NC 6 (Use etonogestrel-ethinyl 104 SUSY estradiol) medroxyprogesterone NUVARING RING 0.015 acetate (contraceptive) 6 MG/24HR-0.12 MG/24HR, susp 0.12 MG/24HR-0.015 NF medroxyprogesterone MG/24HR (Use acetate (contraceptive) 6 etonogestrel-ethinyl susy estradiol) Progestin Contraceptives - Oral Copper Contraceptives - IUD norethindrone 6 QL(1 ea daily) PARAGARD PV (contraceptive) tabs INTRAUTERINE COPPER 6 ORTHO MICRONOR QL(1 ea daily) CONTRACEPTIVE T380A TABS (Use norethindrone 5 IUD (contraceptive)) Emergency Contraceptives SLYND TABS NC ELLA TABS 6 CORTICOSTEROIDS - Steroid Hormone Drugs to levonorgestrel (emergency 6 Treat Systemic Swelling Conditions oc) tabs Glucocorticosteroids PLAN B ONE-STEP TABS (Use levonorgestrel 5 ACTIVE INJECTION KIT 5 (emergency oc)) BLM-1 KIT

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTIVE INJECTION KIT 5 BUPIVACAINE BM KIT HYDROCHLORIDE/DEXA METHASONE SOD NC ACTIVE INJECTION KIT D 5 KIT PHOS/EPINEPHRINE SOSY ACTIVE INJECTION KIT 5 DL KIT BUPIVILOG KIT KIT 5 ACTIVE INJECTION KIT 5 DLM KIT CELESTONE SOLUSPAN SUSP (Use betamethasone NF ACTIVE INJECTION KIT 5 sod phosphate & acetate) KL-3 KIT CELESTONE-SOLUSPAN ACTIVE INJECTION KIT 5 SUSP (Use betamethasone NC KM KIT sod phosphate & acetate) ACTIVE INJECTION KIT L 5 CONTRAST ALLERGY NC KIT PREMED PACK KIT ACTIVE INJECTION KIT 5 CORTEF TABS (Use 5 LM-DEP-1 KIT hydrocortisone) ACTIVE INJECTION KIT 5 CORTISONE ACETATE 5 LM-DEP-2 KIT POWD XX ACTIVE INJECTION KIT 5 M-1 KIT cortisone acetate tabs or 2 ALKINDI SPRINKLE CPSP NC DEPO-MEDROL SUSP 20 5 MG/ML BETA 1 KIT KIT NC DEPO-MEDROL SUSP 80 MG/ML, 40 MG/ML (Use 5 BETALIDO KIT 5 methylprednisolone acetate) BETALOAN SUIK KIT 5 DEXABLISS TBPK NC BETAMETHASONE DEXAMETHASONE (LA) 5 ACETATE/BETAMETHAS NC SUSP 16 MG/ML ONE SUSP DEXAMETHASONE (LA) NC BETAMETHASONE NC SUSP 8 MG/ML COMBO SUSP DEXAMETHASONE betamethasone sod 2 ACETATE/DEXAMETHAS 5 phosphate & acetate susp ONE PHOSPHATE SUSP BETAMETHASONE dexamethasone elix or 0.5 2 SODIUM PHOSPHATE 5 mg/5ml POWD DEXAMETHASONE 5 BETAMETHASONE INTENSOL CONC SODIUM PHOSPHATE 5 SOLN DEXAMETHASONE SODIUM PHOSPHATE 2 BSP 0820 KIT NC SOLN IJ 10 MG/ML dexamethasone sodium budesonide cpep or 3 mg 1 phosphate soln ij 10 mg/ml, 100 mg/10ml, 120 2 budesonide tb24 or 9 mg 2 mg/30ml, 20 mg/5ml, 4 mg/ml 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXAMETHASONE EMFLAZA SUSP NC SP SODIUM PHOSPHATE 4 SOLN IJ 4 MG/ML EMFLAZA TABS NC SP DEXAMETHASONE SODIUM PHOSPHATE NC ENTOCORT EC CPEP 5 SOSY IJ 10 MG/ML (Use budesonide) DEXAMETHASONE HEMADY TABS NC SODIUM PHOSPHATE NC SOSY IV 8 MG/2ML hydrocortisone tabs or 10 2 DEXAMETHASONE mg, 20 mg, 5 mg SODIUM NC JTT PHYSICIANS KIT KIT 5 PHOSPHATE/DEXTROSE SOLN KENALOG-10 SUSP 5 DEXAMETHASONE KENALOG-40 SUSP (Use SODIUM NC 5 PHOSPHATE/SODIUM triamcinolone acetonide) CHLORIDE SOLN KENALOG-80 SUSP 5 dexamethasone soln or 0.5 2 mg/5ml LIDOCIDEX I SOLN NC dexamethasone tabs or 1 mg, 1.5 mg, 2 mg, 4 mg, 2 LIDOCILONE I SUSP NC 0.5 mg, 0.75 mg, 6 mg LIDOLOG KIT KIT 5 dexamethasone tbpk or 1.5 2 mg MARBETA-25 KIT 5 dexamethasone tbpk or 1.5 NC mg MARBETA-L KIT 5 DEXAMETHASONE/SODI NC UM PHOSPHATE SOSY MARDEX-25 KIT 5 DEXLIDO KIT 5 MAS CARE-PAK KIT 5 DEXLIDO-M KIT 5 MEDROL DOSEPAK TBPK 5 DEXONTO 0.4% SOLN NC (Use methylprednisolone) MEDROL TABS 16 MG, 32 DMT SUIK KIT NC MG, 8 MG, 4 MG (Use 5 methylprednisolone) DOUBLEDEX KIT 5 MEDROL TABS 2 MG 5

DXEVO 11-DAY TBPK NC MEDROLOAN II SUIK KIT NC

DYURAL-40 KIT 5 MEDROLOAN SUIK KIT NC

DYURAL-80 KIT 5 METHYLPREDNISOLONE 5 ACETATE POWD XX DYURAL-L KIT 5 METHYLPREDNISOLONE ACETATE SUSP IJ 50 NC DYURAL-LM KIT 5 MG/ML

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLPREDNISOLONE P-CARE D80MX KIT NC ACETATE SUSP IJ 80 5 MG/ML P-CARE K40 KIT 5 methylprednisolone acetate 2 susp ij 80 mg/ml, 40 mg/ml P-CARE K40G KIT 5 METHYLPREDNISOLONE ACETATE/BUPIVACAINE NC P-CARE K40MX KIT 5 HYDROCHLORIDE SUSP P-CARE K80 KIT 5 METHYLPREDNISOLONE 5 POWD XX P-CARE K80G KIT 5 methylprednisolone sod 2 succ solr P-CARE K80MX KIT 5 methylprednisolone tabs or 2 16 mg, 32 mg, 8 mg, 4 mg PEDIAPRED SOLN (Use prednisolone sodium 5 methylprednisolone tbpk or 2 4 mg phosphate) PHYSICIANS EZ USE METHYLPREDNISOLONE/ NC LIDOCAINE SUSP JOINT TUNNEL AND 5 TRIGGER KIT MILLIPRED DP TBPK NC PHYSICIANS EZ USE M- 5 PRED KIT MILLIPRED TABS NC POD-CARE 100C KIT NC MLK F1 KIT KIT 5 POD-CARE 100CG KIT 5 MLK F2 KIT KIT 5 POD-CARE 100CMX KIT 5 MLK F3 KIT KIT 5 POD-CARE 100K KIT 5 MLK F4 KIT KIT 5 POD-CARE 100KG KIT 5 MULTI-SPECIALTY KIT 5 KIT POD-CARE 100KMX KIT 5 ORAPRED ODT TBDP (Use prednisolone sodium 5 POINT OF CARE KM KIT 5 phosphate) ORTIKOS CP24 NC POINT OF CARE L.2 KIT 5

P-CARE D40 KIT NC POINT OF CARE L.5 KIT 5 POINT OF CARE LM DEP 5 P-CARE D40G KIT NC 2 KIT P-CARE D40MX KIT NC PREDNISOLONE 5 ACETATE POWD P-CARE D80 KIT NC PREDNISOLONE 5 ANHYDROUS POWD P-CARE D80G KIT NC PREDNISOLONE POWD 5 XX

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISOLONE SODIUM 5 READYSHARP NC PHOSPHATE POWD XX BETAMETHASONE KIT prednisolone sodium READYSHARP NC phosphate soln or 10 DEXAMETHASONE KIT mg/5ml, 20 mg/5ml, 25 2 mg/5ml, 5 mg/5ml, 6.7 READYSHARP-K KIT 5 mg/5ml ROPIDEX KIT NC prednisolone sodium QL(240 ml per phosphate soln or 15 2 fill retail) mg/5ml SOLU-CORTEF SOLR 5 prednisolone sodium SOLU-MEDROL SOLR 2 5 phosphate tbdp or 10 mg, 2 GM 15 mg, 30 mg SOLU-MEDROL SOLR 500 MG, 1000 MG, 125 MG, 40 PREDNISOLONE SODIUM 5 PHOSPHATE, USP POWD MG (Use 5 methylprednisolone sod prednisolone soln or 2 succ) PREDNISOLONEUSP, TOPIDEX KIT 5 MICRONIZED 5 ANHYDROUS POWD TRIAMCINOLONE 5 ACETONIDE PF SUSP PREDNISONE INTENSOL 5 CONC triamcinolone acetonide susp ij 200 mg/5ml, 40 2 PREDNISONE POWD XX 5 mg/ml, 400 mg/10ml TRIAMCINOLONE prednisone soln or 5 2 mg/5ml ACETONIDE SUSP IJ 40 2 prednisone tabs or 1 mg, MG/ML 10 mg, 2.5 mg, 5 mg, 50 2 TRIAMCINOLONE mg, 20 mg ACETONIDE SUSP IJ 50 5 MG/ML prednisone tbpk or 10 mg, 2 5 mg TRIAMCINOLONE ACETONIDE/BUPIVACAIN NC PRO-C-DURE 5 KIT KIT 5 E HYDROCHLORIDE SUSP PRO-C-DURE 6 KIT KIT NC TRIAMCINOLONE DIACETATE MICRONIZED 5 RAYOS TBEC NC POWD READYSHARP TRIAMCINOLONE 5 ANESTHETICS 5 DIACETATE POWD XX +BETAMETHASONE KIT TRIAMCINOLONE READYSHARP DIACETATE SUSP IJ 40 5 ANESTHETICS NC MG/ML +DEXAMETHASONE KIT TRIAMCINOLONE READYSHARP DIACETATE SUSP IJ 80 NC MG/ML ANESTHETICS NC +METHYLPREDNISOLON E 80 KIT TRIAMCINOLONE SUSP 5

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRILOAN II SUIK KIT 5 guaifenesin-codeine liqd 10 2 mg/5ml-100 mg/5ml TRILOAN SUIK KIT 5 guaifenesin-codeine liqd 5 225 mg/5ml-7.5 mg/5ml UCERIS TB24 OR 9 MG 5 guaifenesin-codeine soln (Use budesonide) 10 mg/5ml-100 mg/5ml, 2 ZCORT 7-DAY TBPK NC 100 mg/5ml-10 mg/5ml guaifenesin-codeine syrp ZILRETTA SRER NC SP 10 mg/5ml-100 mg/5ml, 2 100 mg/5ml-10 mg/5ml Mineralocorticoids hydrocodone polistirex- QL(10 ml daily) chlorpheniramine polistirex 2 FLUDROCORTISONE 5 ACETATE POWD XX suer MAR-COF CG fludrocortisone acetate 2 tabs or EXPECTORANT LIQD 5 (Use guaifenesin-codeine) COUGH/COLD/ALLERGY - Drugs to Treat Cough, Cold and Allergy Symptoms NEOTUSS PLUS LIQD 5 Antitussives phenylephrine w/ dm-gg 2 benzonatate caps 100 mg, 2 liqd 200 mg, 150 mg promethazine & 2 QL(240 ml per benzonatate caps 150 mg NC phenylephrine syrp fill retail) promethazine w/codeine 2 DEXTROMETHORPHAN soln HBR MONOHYDRATE 5 promethazine w/codeine CRYS 2 syrp DEXTROMETHORPHAN HBR MONOHYDRATE 5 promethazine-dm syrp 2 POWD promethazine- 2 DEXTROMETHORPHAN 5 phenylephrine-codeine syrp HBR POWD pseudoephed-bromphen- 2 HYCODAN SYRP (Use dm syrp hydrocodone w/ NC homatropine) pseudoephed-cpm w/ 2 hydrocod soln hydrocodone w/ 2 homatropine syrp SEMPREX-D CAPS 5 hydrocodone w/ 2 homatropine tabs TUSSICAPS CP12 5 TESSALON PERLES 4 TUSSLIN PEDIATRIC 4 CAPS (Use benzonatate) LIQD Cough/Cold/Allergy Combinations TUXARIN ER TB12 NC CLARINEX-D 12 HOUR 5 TB12 TUZISTRA XR SUER 5 RX/OTC GILPHEX TR TABS 5 Expectorants RX/OTC GILTUSS TR TABS 5 BROMHEXINE HCL 5 POWD

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUAIFENESIN POWD 5 ACZONE GEL 5 % (Use 5 dapsone (topical)) SSKI SOLN 5 ACZONE GEL 7.5 % (Use 5 QL(2 gm daily) dapsone (topical)) TERPIN HYDRATE 5 MONOHYDRATE POWD ADAINZDE GEL NC TERPIN HYDRATE POWD 5 ADAINZOXIA GEL NC

Misc. Respiratory Inhalants adapalene crea 0.1 % 2 HYPER-SAL NEBU (Use 5 sodium chloride (inhalant)) QL(45 gm per adapalene gel 0.1 % 2 fill retail); HYPERSAL NEBU 3.5 % 5 RX/OTC HYPERSAL NEBU 7 % adapalene gel 0.3 % 2 (Use sodium chloride 5 QL(1.97 ml (inhalant)) adapalene lotn 0.1 % 2 daily) NEBUSAL NEBU 5 adapalene pads 0.1 % NC sodium chloride (inhalant) 2 nebu ADAPALENE SOLN 0.1 % NC Mucolytics adapalene-benzoyl 2 QL(1.5 gm ACETYLCYSTEINE POWD 5 peroxide gel daily) XX ADAPALENE/BENZOYL NC acetylcysteine soln in 10 2 PEROXIDE PADS %, 20 % ADAPALENE/BENZOYL N-ACETYL-L-CYSTEINE 5 PEROXIDE/CLINDAMYCI NC POWD N GEL DERMATOLOGICALS - Drugs to Treat Skin ADAPALENE/BENZOYL Conditions PEROXIDE/NIACINAMIDE NC GEL Acne Products AKLIEF CREA NC ABSORICA CAPS 10 MG 5 QL(4 ea daily) (Use isotretinoin) AKTIPAK PACK NC QL(2 ea daily) ABSORICA CAPS 20 MG 5 QL(5 ea daily) (Use isotretinoin) ALTRENO LOTN NC ABSORICA CAPS 25 MG, 5 35 MG (Use isotretinoin) AMZEEQ FOAM NC ABSORICA CAPS 30 MG, 5 QL(2 ea daily) 40 MG (Use isotretinoin) ARAZLO LOTN NC ABSORICA LD CAPS NC ATRALIN GEL (Use 5 QL(1.5 gm ACANYA GEL (Use tretinoin) daily) clindamycin phosphate- 4 AVAR LS CLEANSER benzoyl peroxide) LIQD (Use sulfacetamide 5 sodium w/ sulfur) ACIOXIAY CREA NC AVAR LS FOAM NC

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVAR LS PADS 5 benzoyl peroxide- hydrocortisone lotn 0.5 %-5 2 AVAR PADS 5 % benzoyl peroxide- AVAR-E LS CREA (Use hydrocortisone lotn 5 %-0.5 NC sulfacetamide sodium w/ 5 % sulfur) BENZOYL AZELAIC NC PEROXIDE/CLINDAMYCI NC ACID/NIACINAMIDE CREA N/NIACINAMIDE GEL AZELEX CREA NC BENZOYL PEROXIDE/CLINDAMYCI NC BENZACLIN GEL (Use N/NIACINAMIDE/TRETINO clindamycin phosphate- NC IN GEL benzoyl peroxide) CLENIA PLUS SUSP NC BENZACLIN WITH PUMP GEL (Use clindamycin NC CLEOCIN-T GEL (Use phosphate-benzoyl clindamycin phosphate 5 peroxide) (topical)) BENZAMYCIN GEL (Use QL(2 gm daily) CLEOCIN-T LOTN (Use benzoyl peroxide- 5 clindamycin phosphate 5 erythromycin) (topical)) BENZEPRO FOAM NC CLINDACIN ETZ KIT 5

BENZEPRO LIQD NC CLINDACIN PAC KIT 5 BENZEPRO MISC NC CLINDAGEL GEL (Use clindamycin phosphate 5 BENZOLYL PEROXIDE NC (topical)) FORTE-HC LOTN clindamycin phosphate 2 benzoyl peroxide foam ex 2 RX/OTC (topical) foam 5.3 % clindamycin phosphate 2 benzoyl peroxide foam ex 2 (topical) gel 9.8 % clindamycin phosphate NC BENZOYL PEROXIDE NC (topical) gel GEL EX 6.5 % clindamycin phosphate 2 BENZOYL PEROXIDE 5 (topical) lotn HYDROUS POWD clindamycin phosphate 2 benzoyl peroxide liqd ex 2 RX/OTC (topical) soln 2.5 % clindamycin phosphate 2 benzoyl peroxide liqd ex 7 2 (topical) swab % clindamycin phosphate- benzoyl peroxide misc ex 6 2 RX/OTC benzoyl peroxide 2 % (refrigerate) gel BENZOYL PEROXIDE 5 clindamycin phosphate- 2 POWD XX 70 % benzoyl peroxide gel benzoyl peroxide- QL(2 gm daily) 2 clindamycin phosphate- 2 QL(1 gm daily) erythromycin gel tretinoin gel

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDAMYCIN DRAXACE LOTION NC PHOSPHATE/NIACINAMI NC CLEANSER SUSP DE GEL DRAXACE SUSP NC CLINDAMYCIN NC PHOSPHATE/NIACINAMI DRIXECE SUSP NC DE LOTN CLINDAMYCIN DUAC GEL (Use PHOSPHATE/NIACINAMI NC clindamycin phosphate- 5 DE/TRETINOIN CREA benzoyl peroxide CLINDAMYCIN/NIACINAM (refrigerate)) IDE/SPIRONOLACTONE/T NC ECEOXIA CREA NC RETINOIN GEL EPIDUO FORTE GEL 4 QL(1.5 gm CLINDAVIX KIT NC daily) EPIDUO GEL (Use QL(1.5 gm 5 CLINOIN CREA adapalene-benzoyl 4 daily) peroxide) dapsone (topical) gel 5 % 2 ERYGEL GEL (Use 5 dapsone (topical) gel 7.5 % 2 QL(2 gm daily) erythromycin (acne aid)) erythromycin (acne aid) gel 2 DAPSONE/NIACINAMIDE NC GEL erythromycin (acne aid) 2 DAPSONE/NIACINAMIDE/ NC pads SPIRONOLACTONE GEL erythromycin (acne aid) 2 DEOXIA GEL NC soln ETHOXIA CREA NC DEOXIA LOTN NC EVOCLIN FOAM (Use DIADIMAXIA GEL NC clindamycin phosphate 5 (topical)) DIAOXIA GEL NC FABIOR FOAM NC DIASDIMAXIA GEL NC HYALURONIC ACID SODIUM/NIACINAMIDE/T NC DIASOXIA GEL NC RETINOIN CREA INOVA 4/1 ACNE 5 DIFFERIN CREA 0.1 % 5 CONTROL THERAPY KIT (Use adapalene) INOVA 8/2 ACNE 5 QL(45 gm per CONTROL THERAPY KIT DIFFERIN GEL 0.1 % (Use 5 adapalene) fill retail); RX/OTC INOVA KIT 5 DIFFERIN GEL 0.3 % (Use 5 adapalene) isotretinoin caps or 10 mg 2 QL(4 ea daily)

DIFFERIN LOTN 0.1 % NC isotretinoin caps or 20 mg 2 QL(5 ea daily)

DIMOXIA GEL NC isotretinoin caps or 25 mg, 5 35 mg

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits isotretinoin caps or 30 mg, 2 QL(2 ea daily) PLEXION LOTN (Use 40 mg sulfacetamide sodium w/ 5 sulfur) ITHOXIA CREA NC PLIXDA PADS NC KLARON LOTN (Use QL(120 ml per sulfacetamide sodium 5 fill retail) PR BENZOYL PEROXIDE NC (acne)) LIQD NEUAC KIT KIT 5 resorcinol-sulfur lotn 2 RX/OTC

NIACINAMIDE/SPIRONOL NC RETIN-A CREA (Use 5 ACTONE GEL tretinoin) NIACINAMIDE/SPIRONOL NC RETIN-A GEL (Use 5 ACTONE/TRETINOIN GEL tretinoin) NIACINAMIDE/SULFACET RETIN-A MICRO GEL 0.04 QL(1.7 gm AMIDE SODIUM NC %, 0.1 % (Use tretinoin 5 daily) MONOHYDRATE CREA microsphere) NIACINAMIDE/TAZAROTE NC RETIN-A MICRO GEL 0.06 5 QL(1.7 gm NE CREA % daily) NIACINAMIDE/TRETINOIN NC RETIN-A MICRO PUMP QL(1.7 gm CREA GEL 0.04 %, 0.1 % (Use 5 daily) tretinoin microsphere) NIACINAMIDE/TRETINOIN NC GEL RETIN-A MICRO PUMP 5 PA; QL(1.7 gm GEL 0.08 % daily) NUCARACLINPAK KIT NC RETINOIC ACID POWD 5 NUCARARXPAK KIT NC RETINOIC ACID-ALL 5 ONEXTON GEL 4 TRANS POWD REZAMID LOTN (Use NC RX/OTC ONZDEOXIA GEL NC resorcinol-sulfur) RIAX FOAM 5 ST OXIATAR CREA NC SALICYLIC OXIAVARRY CREA NC ACID/SULFACETAMIDE NC SODIUM MONOHYDRATE OXIAZAR CREA NC SUSP SODIUM PANOXYL LIQD (Use RX/OTC 5 SULFACETAMIDE/SULFU 5 benzoyl peroxide) R CLEANSER IN UREA PLEXION CLEANSER EMUL LIQD (Use sulfacetamide 5 SODIUM sodium w/ sulfur) SULFACETAMIDE/SULFU 5 PLEXION CLEANSING 5 R PADS CLOTHS PADS SODIUM PLEXION CREA (Use SULFACETAMIDE/SULFU 5 sulfacetamide sodium w/ 5 R SUSP sulfur) sulfacetamide sodium 2 QL(120 ml per (acne) lotn fill retail)

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfacetamide sodium w/ TAROXIA GEL NC sulfur crea 2 %-10 %, 4.8 2 %-9.8 %, 5 %-10 % TAZAROTENE FOAM EX NC sulfacetamide sodium w/ sulfur emul 1 %-10 %, 10 2 TRETINOIN (ALL-TRANS 5 %-5 %, 5 %-10 % RETINOIC ACID) POWD tretinoin crea ex 0.05 %, sulfacetamide sodium w/ 2 2 sulfur foam 5 %-10 % 0.1 %, 0.025 % sulfacetamide sodium w/ tretinoin gel ex 0.01 %, 2 0.025 % sulfur liqd 2 %-10 %, 4 %-9 2 %, 4.5 %-9 %, 9 %-4 %, QL(1.5 gm tretinoin gel ex 0.05 % 2 4.8 %-9.8 %, 9.8 %-4.8 % daily) sulfacetamide sodium w/ QL(1.7 gm 2 tretinoin microsphere gel 2 sulfur lotn 4.8 %-9.8 % daily) sulfacetamide sodium w/ 2 QL(30 gm per sulfur lotn 5 %-10 % fill retail) TRETINOIN POWD XX 5 sulfacetamide sodium w/ VARDIMAXIA GEL NC sulfur pads 4 %-10 %, 4 %- 2 4 %-10 %-10 % VAROXIA CREA NC sulfacetamide sodium w/ sulfur susp 4 %-8 %, 8 %-4 2 VAROXIA GEL NC % VELTIN GEL (Use QL(1 gm daily) sulfacetamide sodium- 2 sulfur in urea vehicle emul clindamycin phosphate- NC tretinoin) sulfacetamide sodium- 2 sulfur w/ skin cleanser kit WINLEVI CREA NC SUMADAN KIT KIT 5 ZACARE 4% KIT KIT 5 SUMADAN WASH LIQD (Use sulfacetamide sodium 5 ZACARE 8% KIT KIT 5 w/ sulfur) ZACLIR CLEANSING 5 SUMADAN XLT KIT 5 LOTN ZIANA GEL (Use QL(1 gm daily) SUMAXIN CP KIT KIT 5 clindamycin phosphate- NC tretinoin) SUMAXIN PADS (Use sulfacetamide sodium w/ 5 Agents for External Genital and Perianal Warts sulfur) QL(30 gm per VEREGEN OINT NC SUMAXIN WASH LIQD fill retail) (Use sulfacetamide sodium 5 Analgesics - Topical w/ sulfur) A.A.G.C. KIT IN 5 TARDEOXIA CREA NC TERODERM CREA ACTIVE-PREP KIT IV 5 TARDIMAXIA GEL NC CREA ACTIVE-TRAMADOL KIT 5 TAROXIA CREA NC CREA

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACLOFEN CREA EX 2 % 5 DICLOVIX KIT NC

ENOVARX-BACLOFEN 5 DICLOVIX M THPK NC CREA ENOVARX-TRAMADOL 5 DICLOZOR THPK NC CREA NEURAPTINE CREA NC DIMENTHO THPK NC DUAL COMPLEX 5 Anti-inflammatory Agents - Topical FORMULA 1 KIT CREA ACTIVE-KETOPROFEN NC KIT CREA DYNABAC 5.0 THPK NC ACTIVE-PREP KIT I CREA 5 ENOVARX-DICLOFENAC NC SODIUM CREA ACTIVE-PREP KIT II 5 ENOVARX-IBUPROFEN 5 CREA CREA ACTIVE-PREP KIT III 5 ENOVARX-NAPROXEN 5 CREA CREA AIF #2 DRUG 5 PREPARATIONKIT CREA FBL KIT CREA 5 AIF #3 DRUG 5 FLECTOR PTCH (Use 5 PREPARATION KIT CREA diclofenac epolamine) BIIFENAC 1000 THPK NC FROTEK CREA NC BIIFENAC 500 THPK NC GABAPENTIN/NAPROXE N SOD MULTI-PHASIC NC DERMACINRX LEXITRAL TRANSDERMAL CMPD PHARMAPAK THPK (Use NC KIT CREA diclofenac sodium- K.B.G.L. IN TERODERM 5 capsaicin (topical)) CREAM CREA DFS/MS/MENTH/CAP PAK NC KETOPHENE RAPIDPAQ NC KIT CREA diclofenac epolamine ptch 2 KETOROLAC 2% GEL 5 GEL diclofenac sodium (topical) 2 RX/OTC gel 1 % LICART PT24 NC diclofenac sodium (topical) 2 QL(5 ml daily) NAPRO 15% soln 1.5 % COMPOUNDING KIT 5 diclofenac sodium- NC CREA capsaicin (topical) thpk NP #2 DRUG 5 DICLOFONO GEL NC PREPARATION KIT CREA PENNSAID SOLN NC QL(4 gm daily) DICLOPR KIT NC REXAPHENAC CREA 5 DICLOSTREAM THPK NC TRIPLE COMPLEX NC DICLOTREX THPK NC FORMULA 3KIT CREA

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIXYLITRAL THPK NC ACTIVE-PREP KIT V 5 CREA VAROPHEN KIT NC BENZOIC ACID CRYS 5 RX/OTC

VENNGEL ONE KIT NC BENZOIC ACID POWD 5 VOLTAREN GEL (Use 5 RX/OTC RX/OTC diclofenac sodium (topical)) butenafine hcl crea 5 VP FC KIT CREA 5 CICLODAN SOLUTION 5 KIT KIT (Use ciclopirox) VP GKL KIT CREA NC ciclopirox gel ex 0.77 % 2

XRYLIX THPK NC ciclopirox kit ex 8 % 2

Antibiotics - Topical ciclopirox olamine crea ex 2 ALTABAX OINT 5 CICLOPIROX OLAMINE 5 POWD XX BACITRACIN POWD XX 5 ciclopirox olamine susp ex 2 BACITRACIN ZINC POWD 5 ciclopirox sham ex 1 % 2 CENTANY AT KIT 5 ciclopirox soln ex 8 % 2 CENTANY OINT 5 CLIOQUINOL POWD 5 RX/OTC gentamicin sulfate (topical) 2 crea clotrimazole (topical) soln 2 RX/OTC gentamicin sulfate (topical) 2 oint CLOTRIMAZOLE CRYS 5 XX GENTAMICIN SULFATE 5 POWD XX CLOTRIMAZOLE POWD 5 XX mupirocin calcium (topical) NC crea clotrimazole w/ 2 betamethasone crea mupirocin oint ex 2 clotrimazole w/ 2 betamethasone lotn NEO-SYNALAR CREA NC DERMACINRX NC THERAZOLE PAK THPK NEO-SYNALAR KIT KIT NC DIFMETIOXRIME SOLN NC NEOMYCIN SULFATE 5 POWD XX ECONASIL KIT NC TETRACYCLINE HCL 5 POWD XX econazole nitrate crea ex 2 TETRACYCLINE 5 HYDROCHLORIDE POWD ECONAZOLE NITRATE/NIACINAMIDE NC XEPI CREA NC CREA Antifungals - Topical 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ECOZA FOAM 5 QL(2.5 gm LOPROX KIT KIT NC daily) LOPROX SHAMPOO 5 ERTACZO CREA 5 SHAM (Use ciclopirox) EXELDERM CREA (Use 5 LOPROX SUSP (Use NC sulconazole nitrate) ciclopirox olamine) EXELDERM SOLN (Use 5 LOTRIMIN ULTRA CREA 5 RX/OTC sulconazole nitrate) (Use butenafine hcl) EXODERM LOTN 5 LOTRISONE CREA (Use clotrimazole w/ 5 betamethasone) EXTINA FOAM (Use 5 ketoconazole (topical)) luliconazole crea NC FLUCONAZOLE/IBUPROF EN/ITRACONAZOLE/TER NC LUZU CREA (Use 5 BINAFINE luliconazole) HYDROCHLORIDE SOLN MENTAX CREA 5 RX/OTC FUNGIMEZ SOLN NC RX/OTC MICONAZOLE NITRATE 5 G-MYCO NAIL SOLN NC RX/OTC POWD miconazole-zinc oxide- 2 GENTIAN VIOLET POWD 5 white petrolatum oint MYCO NAIL SOLN NC RX/OTC HIXDEFRIMA SOLN NC RX/OTC HYDROCORTISONE/IOD MYCO-NAIL SOLN NC OQUINOL/KETOCONAZO NC LE CREA naftifine hcl crea 2 HYDROCORTISONE/KET NC OCONAZOLE CREA naftifine hcl gel 2 IMIOXIA CREA NC NAFTIFINE HYDROCHLORIDE CREA 4 JUBLIA SOLN 5 PA (Use naftifine hcl) NAFTIN CREA 2 % (Use 4 KERYDIN SOLN (Use 5 QL(10 ml per naftifine hcl) tavaborole) fill retail) NAFTIN GEL 1 % (Use 4 ketoconazole (topical) crea 2 naftifine hcl) NAFTIN GEL 2 % 4 ketoconazole (topical) foam NC NIZORAL SHAM (Use 5 QL(120 ml per ketoconazole (topical) 2 QL(120 ml per ketoconazole (topical)) fill retail) sham fill retail) nystatin (topical) crea 2 KETODAN KIT KIT 5 nystatin (topical) oint 2 LOPROX CREA (Use NC ciclopirox olamine) nystatin (topical) powd 2 LOPROX KIT 5 nystatin-triamcinolone crea 2

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nystatin-triamcinolone oint 2 diclofenac sodium (actinic 2 keratoses) gel ONYCHO-MED KIT NC DICLOFENAC SODIUM/HYALURONIC NC oxiconazole nitrate crea 2 ACID SODIUM SALT/NIACINAMIDE GEL oxiconazole nitrate crea NC EFUDEX CREA (Use 5 QL(40 gm per fluorouracil (topical)) fill retail) OXISTAT CREA (Use 5 oxiconazole nitrate) FLUOROPLEX CREA 5

OXISTAT LOTN 5 fluorouracil (topical) crea NC QL(1 gm daily) 0.5 % PEDIZOLPAK THPK NC fluorouracil (topical) crea 5 2 QL(40 gm per % fill retail) PENLAC NAIL LACQUER 5 SOLN (Use ciclopirox) fluorouracil (topical) soln 2 2 QL(10 ml per %, 5 % fill retail) PHEODOYO CREA NC HYALUCIL-4 CREA NC PHEYO CREA NC IMIQUIMOD/LEVOCETIRI ZINEDIHYDROCHLORIDE NC RECURA CREA NC /NIACINAMIDE GEL IMIQUIMOD/LEVOCETIRI sulconazole nitrate crea 2 ZINEDIHYDROCHLORIDE NC /TRETINOIN GEL sulconazole nitrate soln 2 KLISYRI OINT NC QL(10 ml per tavaborole soln 5 fill retail) LEVULAN KERASTICK 5 PA; SP SOLR TOLNAFTATE POWD 5 ORMECA KIT NC VUSION OINT (Use miconazole-zinc oxide- 5 PANRETIN GEL 5 white petrolatum) XOLEGEL COREPAK KIT 5 PICATO GEL 4

XOLEGEL DUO/HEAD & 5 QUIHOXVAR GEL NC SHOULDERS KIT ROAOXIA GEL NC XOLEGEL DUO/XOLEX 5 KIT SOLARAVIX THPK NC XOLEGEL GEL NC TARGRETIN GEL EX 1 % 5 PA; SP ZOLPAK KIT NC Antineoplastic or Premalignant Lesion Agents - TOLAK CREA 4 AMELUZ GEL NC VALCHLOR GEL 5 PA; SP

CARAC CREA (Use NC QL(1 gm daily) Antipruritics - Topical fluorouracil (topical))

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAMPHOR CRYS 5 RX/OTC NUDERMRXPAK 60 THPK NC

CAMPHOR GRAN 5 RX/OTC OXSORALEN ULTRA QL(4 ea daily) CAPS (Use methoxsalen 5 rapid) doxepin hcl (antipruritic) NC crea SILIQ SOSY NC PA PRUDOXIN CREA (Use NC doxepin hcl (antipruritic)) SKYRIZI PEN SOAJ 4 PA; SP ZONALON CREA (Use NC doxepin hcl (antipruritic)) SKYRIZI PSKT 4 PA; SP Antipsoriatics SKYRIZI SOSY 4 PA; SP acitretin caps 17.5 mg, 10 2 QL(1 ea daily) mg SORIATANE CAPS 10 MG 5 QL(1 ea daily) acitretin caps 25 mg 2 QL(2 ea daily) (Use acitretin) SORIATANE CAPS 25 MG 5 QL(2 ea daily) ANTHRALIN POWD 5 (Use acitretin) SORILUX FOAM NC QL(4 gm daily) calcipotriene crea ex NC STELARA SOLN 4 PA; SP CALCIPOTRIENE FOAM NC QL(4 gm daily) EX STELARA SOSY 4 PA; SP calcipotriene foam ex NC QL(4 gm daily) TALTZ SOAJ NC calcipotriene oint ex 2 QL(5 gm daily) QL(60 ml per TALTZ SOSY NC calcipotriene soln ex 2 fill retail) tazarotene crea ex 2 QL(1 gm daily) QL(3.4 gm calcitriol (topical) oint NC daily) TAZORAC CREA 0.05 % NC QL(1 gm daily) COSENTYX 4 PA; SP SENSOREADY PEN SOAJ TAZORAC CREA 0.1 % NC QL(1 gm daily) (Use tazarotene) COSENTYX SOSY 150 4 PA; SP MG/ML TAZORAC GEL 0.05 %, NC QL(1 gm daily) 0.1 % COSENTYX SOSY 75 NC SP MG/0.5ML TREMFYA SOPN 4 PA; SP QL(5 gm DOVONEX CREA (Use 5 PA; SP calcipotriene) daily,60 gm per TREMFYA SOSY 4 fill retail) VECTICAL OINT (Use NC QL(3.4 gm DRITHO-CREME HP 5 calcitriol (topical)) daily) CREA ZITHRANOL SHAM 5 ILUMYA SOSY NC Antiseborrheic Products methoxsalen rapid caps 2 QL(4 ea daily) CICLOPIROX OLAMINE/CLOBETASOL NUDERMRXPAK 120 NC NC THPK PROPIONATE/SALICYLIC ACID SHAM

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CICLOPIROX sulfacetamide sodium liqd 2 OLAMINE/CLOBETASOL NC ex SHAM SULFACETAMIDE 5 CICLOPIROX/SALICYLIC NC SODIUM POWD XX ACID SHAM sulfacetamide sodium 2 DERMAZINC CREAM 5 RX/OTC sham ex CREA Antivirals - Topical ESKATA SOLN NC acyclovir topical crea NC GLYCOLIC ACID 70% RX/OTC 5 QL(1 gm daily) HIGH PURITY SOLN acyclovir topical oint 2 RX/OTC GLYCOLIC ACID SOLN 5 DENAVIR CREA 5 QL(0.17 gm daily) HAXCHLO SHAM NC QL(0.17 gm XERESE CREA 5 daily) NUTRASEB CREA 5 RX/OTC ZOVIRAX CREA EX 5 % 5 (Use acyclovir topical) OVACE PLUS CREA 10 % 5 ZOVIRAX OINT EX 5 % 5 QL(1 gm daily) (Use acyclovir topical) OVACE PLUS FOAM 9.8 NC % Burn Products OVACE PLUS LOTN 9.8 % 5 mafenide acetate pack ex 2 OVACE PLUS SHAM 10 % (Use sulfacetamide 5 NITROFURAZONE POWD 5 sodium) SILVADENE CREA (Use 4 OVACE PLUS WASH GEL silver sulfadiazine) (Use sulfacetamide 5 sodium) silver sulfadiazine crea ex 2 OVACE PLUS WASH LIQD SULFAMYLON CREA 85 5 (Use sulfacetamide 5 MG/GM sodium) SULFAMYLON PACK 5 % 5 OVACE WASH LIQD (Use 5 (Use mafenide acetate) sulfacetamide sodium) Cauterizing Agents PROMISEB CREA 5 RX/OTC ARZOL SILVER NITRATE 2 APPLICATORS MISC selenium sulfide lotn ex 2.5 2 QL(120 ml per % fill retail) CHLOROACETIC ACID 5 POWD selenium sulfide sham ex 2 2.3 %, 2.25 % SILVER NITRATE CRYS 5 RX/OTC XX SELRX SHAM (Use 5 selenium sulfide) SILVER NITRATE SOLN SODIUM EX 0.5 %, 10 %, 25 %, 50 5 SULFACETAMIDE WASH 5 % LIQD silver nitrate-potassium 2 nitrate misc sulfacetamide sodium gel 2 ex TRI-CHLOR LIQD 5

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Corticosteroids - Topical BETAMETHASONE 5 VALERATE POWD XX ADVANCED ALLERGY NC COLLECTION KIT KIT BRYHALI LOTN 4 ALA-SCALP LOTN 5 CALCIPOTRIENE ANHYDROUS/CLOBETAS NC alclometasone dipropionate 2 OL PROPIONATE SOLN crea calcipotriene- alclometasone dipropionate 2 NC oint betamethasone dipropionate oint amcinonide crea 2 calcipotriene- betamethasone NC amcinonide lotn 2 dipropionate susp

AMCINONIDE OINT 5 CAPEX SHAM 4

APEXICON E CREA NC CHLOOXIA CREA NC

BESER KIT NC CHLOOXIA OINT NC betamethasone 2 CHLOOXIA SOLN NC dipropionate (topical) crea CLOBETASOL 17 5 betamethasone 2 QL(60 ml per PROPIONATE POWD dipropionate (topical) lotn fill retail) clobetasol propionate crea 2 betamethasone 2 ex dipropionate (topical) oint clobetasol propionate 2 betamethasone emollient base crea dipropionate augmented 2 crea clobetasol propionate 2 emulsion foam betamethasone dipropionate augmented 2 clobetasol propionate foam 2 gel ex betamethasone clobetasol propionate gel 2 dipropionate augmented 2 ex lotn clobetasol propionate liqd NC betamethasone ex dipropionate augmented 2 clobetasol propionate lotn 2 oint ex CLOBETASOL BETAMETHASONE 5 DIPROPIONATE POWD PROPIONATE 5 MICRONIZED USP POWD betamethasone valerate 2 crea ex 0.1 % clobetasol propionate oint 2 ex betamethasone valerate 2 foam ex 0.12 % CLOBETASOL 5 PROPIONATE POWD XX betamethasone valerate 2 QL(60 ml per lotn ex 0.1 % fill retail) clobetasol propionate sham 2 ex betamethasone valerate 2 oint ex 0.1 %

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clobetasol propionate soln 2 DERMA-SMOOTHE/FS ex SCALP OIL (Use 4 CLOBETASOL fluocinolone acetonide) PROPIONATE/LEVOCETI DERMASORB TA KIT 5 RIZINE NC DIHYDROCHLORIDE DESONATE GEL (Use 5 SHAM desonide) CLOBETASOL desonide crea ex 2 PROPIONATE/NIACINAMI NC DE CREA desonide gel ex NC CLOBETASOL PROPIONATE/NIACINAMI NC desonide lotn ex 2 DE OINT CLOBETASOL desonide oint ex 2 PROPIONATE/NIACINAMI NC DE SOLN DESONIDE POWD XX 5 CLOBETAVIX KIT NC DESOWEN CREA (Use 4 desonide) CLOBEX LIQD (Use NC clobetasol propionate) desoximetasone crea ex 2 0.05 %, 0.25 % CLOBEX LOTN (Use 4 clobetasol propionate) desoximetasone gel ex 2 0.05 % CLOBEX SHAM (Use 4 clobetasol propionate) desoximetasone liqd ex 2 0.25 % clocortolone pivalate crea NC desoximetasone oint ex NC 0.05 % CLODAN KIT KIT 5 desoximetasone oint ex 2 0.25 % CLODERM CREA (Use 5 clocortolone pivalate) diflorasone diacetate crea NC CORDRAN CREA 0.025 % 5 diflorasone diacetate oint NC CORDRAN CREA 0.05 % 5 (Use flurandrenolide) DIOCHLOY SOLN NC CORDRAN LOTN 0.05 % 5 (Use flurandrenolide) DIPROLENE AF CREA (Use betamethasone 5 CORDRAN OINT 0.05 % NC (Use flurandrenolide) dipropionate augmented) DIPROLENE OINT (Use CORDRAN TAPE 4 5 MCG/SQCM betamethasone 4 dipropionate augmented) CUTIVATE LOTN (Use 5 fluticasone propionate) DUOBRII LOTN 5 DERMA-SMOOTHE/FS BODY OIL (Use 4 ELLZIA PAK THPK NC fluocinolone acetonide) ELOCON CREA (Use 5 mometasone furoate)

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENSTILAR FOAM 5 fluticasone propionate oint 2 ex 0.005 % EPIFOAM FOAM 5 halcinonide crea NC fluocinolone acetonide crea 2 halobetasol propionate 2 ex 0.01 %, 0.025 % crea fluocinolone acetonide oil 2 HALOBETASOL NC ex 0.01 % PROPIONATE FOAM fluocinolone acetonide oint 2 ex 0.025 % halobetasol propionate oint 2 FLUOCINOLONE 5 HALOG CREA (Use 5 ACETONIDE POWD XX halcinonide) fluocinolone acetonide soln 2 HALOG OINT 5 ex 0.01 % FLUOCINOLONE HALOG SOLN 5 ACETONIDE/NIACINAMID NC E CREA hydrocortisone (topical) 2 RX/OTC crea 1 % fluocinonide crea ex 0.05 2 % hydrocortisone (topical) 2 crea 2.5 % fluocinonide crea ex 0.1 % NC hydrocortisone (topical) lotn 5 2 % fluocinonide emulsified 2 base crea hydrocortisone (topical) lotn 2 2.5 % fluocinonide gel ex 0.05 % 2 hydrocortisone (topical) oint 2 RX/OTC fluocinonide oint ex 0.05 % 2 1 % hydrocortisone (topical) oint NC RX/OTC FLUOCINONIDE POWD 5 1 % XX hydrocortisone (topical) oint 2 fluocinonide soln ex 0.05 % 2 2.5 % HYDROCORTISONE FLUOPAR KIT NC ACETATE MICRONIZED 5 POWD FLUOVIX PLUS THPK NC HYDROCORTISONE 5 ACETATE POWD FLUOVIX THPK NC hydrocortisone butyrate 2 crea flurandrenolide crea NC hydrocortisone butyrate NC hydrophilic lipo base crea flurandrenolide lotn NC hydrocortisone butyrate NC flurandrenolide oint NC lotn hydrocortisone butyrate 2 fluticasone propionate crea 2 oint ex 0.05 % hydrocortisone butyrate 2 fluticasone propionate lotn 2 soln ex 0.05 %

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCORTISONE 5 NUCORT LOTN 5 MICRONIZED POWD OLUX FOAM (Use HYDROCORTISONE 5 5 POWD XX clobetasol propionate) OLUX-E FOAM (Use hydrocortisone valerate 2 crea clobetasol propionate NC emulsion) hydrocortisone valerate 2 oint PANDEL CREA 5 IMPEKLO LOTN NC prednicarbate crea 2 IMPOYZ CREA NC prednicarbate oint 2 KENALOG AERS (Use triamcinolone acetonide 5 PSORCON CREA NC (topical)) QUINIXIL THPK NC LEXETTE FOAM NC QUINOSONE KIT NC lidocaine-hydrocortisone 2 acetate crea SCALACORT DK KIT 5 LOCOID CREA (Use 5 hydrocortisone butyrate) SCARZEN SKIN REPAIR NC LOCOID LIPOCREAM KIT CREA (Use hydrocortisone 5 butyrate hydrophilic lipo SERNIVO EMUL 5 base) SILA III THPK NC LOCOID LOTN (Use 5 hydrocortisone butyrate) SYNALAR CREA (Use 5 fluocinolone acetonide) LOCOID SOLN (Use 5 hydrocortisone butyrate) SYNALAR CREAM KIT KIT 5 LUXIQ FOAM (Use 5 betamethasone valerate) SYNALAR OINT (Use 5 fluocinolone acetonide) MICORT-HC CREA NC SYNALAR OINTMENT KIT 5 KIT mometasone furoate crea 2 ex SYNALAR SOLN (Use 5 fluocinolone acetonide) mometasone furoate oint 2 ex SYNALAR TS KIT 5 mometasone furoate soln 2 ex TACLONEX OINT (Use QL(2 gm daily) MONISTAT SOOTHING RX/OTC calcipotriene- 5 betamethasone CARE ITCH RELIEF CREA NC (Use hydrocortisone dipropionate) (topical)) TACLONEX SUSP (Use QL(2 gm daily) NIACINAMIDE/TRIAMCIN calcipotriene- 5 OLONE ACETONIDE NC betamethasone CREA dipropionate)

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TACLONEX SUSP (Use TRIAMCINOLONE calcipotriene- NF ACETONIDEUSP, 5 betamethasone MICRONIZED POWD dipropionate) TRIAMSIL COMBIPAK NC TASOPROL KIT NC THPK TRIAMSIL MULTIPAK NC TEMOVATE CREA (Use 4 THPK clobetasol propionate) PA; QL(2 gm TRIANEX OINT 5 TEMOVATE OINT (Use 4 daily) clobetasol propionate) TRIDESILON CREA (Use 4 TEXACORT SOLN 4 desonide) TRILOCICLO KIT NC TOPICORT CREA (Use 5 desoximetasone) ULTRAVATE LOTN 5 TOPICORT GEL (Use 5 desoximetasone) VANOS CREA (Use 5 TOPICORT LIQD (Use 5 fluocinonide) desoximetasone) VERDESO FOAM 5 TOPICORT OINT (Use 5 desoximetasone) WYNZORA CREA NC TOVET KIT KIT NC Eczema Agents triamcinolone acetonide NC DUPIXENT SOPN 300 4 PA; SP (topical) aers 0.147 mg/gm MG/2ML triamcinolone acetonide DUPIXENT SOSY 200 4 PA; SP (topical) crea 0.025 %, 0.1 2 MG/1.14ML, 300 MG/2ML % Emollient/Keratolytic Agents triamcinolone acetonide 2 QL(15 gm per (topical) crea 0.5 % fill retail) CEM-UREA SOLN 5 triamcinolone acetonide QL(60 ml per (topical) lotn 0.025 %, 0.1 2 fill retail) CEROVEL LOTN 4 % HYDRO 35 FOAM (Use 5 triamcinolone acetonide urea in lactic acid vehicle) (topical) oint 0.025 %, 0.1 2 % HYDRO 40 FOAM FOAM 5 (Use urea) triamcinolone acetonide 2 QL(2 gm daily) (topical) oint 0.05 % KERALAC CREA (Use 5 urea) triamcinolone acetonide NC (topical) oint 0.05 % PROTEXA CREA NC triamcinolone acetonide 2 QL(15 gm per (topical) oint 0.5 % fill retail) URAMAXIN GEL (Use 5 urea) TRIAMCINOLONE 5 ACETONIDE POWD XX urea crea ex 40 % 2 RX/OTC triamcinolone acetonide- 2 urea crea ex 45 %, 47 %, 2 dimethicone-silicone kit 41 %, 39 % UREA FOAM EX 35 % NC

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits urea foam ex 40 % 2 ZYCLARA CREA (Use 4 QL(1 ea daily) imiquimod) urea gel ex 45 % 2 ZYCLARA PUMP CREA 4 QL(0.6 gm 2.5 % daily) urea in lactic acid vehicle 2 ZYCLARA PUMP CREA 4 QL(1 gm daily) foam 3.75 % (Use imiquimod) urea lotn ex 40 % 2 Immunosuppressive Agents - Topical ELIDEL CREA (Use NC QL(1 gm daily) urea susp ex 40 % 2 pimecrolimus) URESOL CREA NC HYALURONIC ACID SODIUM/NIACINAMIDE/T NC ACROLIMUS CREA UREVAZ CREA NC NIACINAMIDE/TACROLIM NC UTOPIC CREA (Use urea) 5 US MONOHYDRATE OINT OXIANUJO CREA NC Emollients HPR PLUS/MB 5 OXIANUJO OINT NC HYDROGEL KIT QL(1 gm daily) HYLINATE LOTN NC pimecrolimus crea 2 LAC-HYDRIN CREA (Use RX/OTC PROTOPIC OINT (Use 5 QL(2 gm daily) lactic acid (ammonium 4 tacrolimus (topical)) lactate)) tacrolimus (topical) oint 2 QL(2 gm daily) LAC-HYDRIN TWELVE RX/OTC LOTN (Use lactic acid 4 TACROLIMUS (ammonium lactate)) MONOHYDRATE CREA NC EX lactic acid (ammonium 2 RX/OTC lactate) crea Keratolytic/Antimitotic Agents RX/OTC lactic acid (ammonium 2 RX/OTC BENSAL HP OINT NC lactate) lotn LACTIC ACID E CREA 4 CANTHARIDIN POWD XX 5

LACTIC ACID LOTN EX 10 4 CANTHARIDIN SOLN EX NC % CIMETIDINE/LIDOCAINE/ NC Enzymes - Topical SALICYLIC ACID CREA COLLAGENASE POWD 5 CONDYLOX GEL 4

SANTYL OINT 5 GEAMETDRAY GEL NC Immunomodulating Agents - Topical GORDOFILM SOLN 5 ALDARA CREA (Use 5 QL(0.2667 ea imiquimod) daily) GUANENDRUX CREA NC imiquimod crea ex 3.75 % 2 QL(1 gm daily) KERALYT GEL (Use 5 QL(0.2667 ea salicylic acid) imiquimod crea ex 5 % 2 daily)

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERALYT SCALP KIT 5 XALIX SOLN NC

MG217 PSORIASIS NC RX/OTC Liniments MULTI-SYMTOM OINT RX/OTC PODOCON 25 IN MEDI-DERM CREA 5 BENZOIN TINCTURE 5 RX/OTC SOLN MEDI-DERM-RX CREA 5 QL(4 ml per fill podofilox soln ex 2 retail) MEDROX-RX OINT 5 METHYL SALICYLATE RX/OTC PODOPHYLLUM RESIN 5 RX/OTC 5 POWD LIQD PYROGALLIC ACID OINT 5 TURPENTINE SPIRITS 5 SPRT SALEX CREAM KIT (Use 5 Local Anesthetics - Topical salicylic acid w/ cleanser) 1ST MEDX- 5 SALEX LOTION KIT 5 PATCH/LIDOCAINE PTCH ACCUCAINE KIT NC SALEX SHAM (Use 5 salicylic acid) ALIVIO PATCH PTCH NC RX/OTC salicylic acid crea ex 6 % 2 ALOCANE EMERGENCY QL(1 ml daily); salicylic acid foam ex 6 % 2 BURN MAXIMUM NC RX/OTC STRENGTH GEL salicylic acid gel ex 6 % 2 ANACAINE OINT 5 salicylic acid liqd ex 27.5 % 2 APRIZIO PAK II KIT NC salicylic acid lotn ex 6 % 2 APRIZIO PAK KIT NC salicylic acid sham ex 6 % 2 QL(1 ml daily); ASTERO GEL NC RX/OTC salicylic acid soln ex 26 %, 2 28.5 % AVADERM CREA 5 RX/OTC salicylic acid w/ cleanser kit 2 BENZOCAINE/LIDOCAINE NC /TETRACAINE OINT SALIMEZ CREA 4 CADIRAMD KIT NC SALIMEZ FORTE CREA 5 CAPSAICIN POWD 5 RX/OTC SALVAX DUO PLUS KIT 5 CBD4 FREEZE PUMP RX/OTC MAXIMUMSTRENGTH 5 SALVAX FOAM (Use 5 salicylic acid) CREA CBD4 FREEZE PUMP RX/OTC ULTRASAL-ER SOLN 5 5 (Use salicylic acid) VANISHING SCENT CREA VIRASAL LIQD (Use 5 COCAINE HCL POWD XX 5 salicylic acid) cocaine hcl soln ex 2

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CRYODOSE TA AERO 5 RX/OTC ICY HOT LIDOCAINE 5 RX/OTC PLUS MENTHOL CREA DERMACINRX PHN PAK NC ICY HOT MAX LIDOCAINE 5 RX/OTC THPK CREA DERMACINRX ZRM PAK NC THPK L.E.T. GEL NC DERMALID THPK NC LDO PLUS GEL NC QL(1 ml daily); RX/OTC RX/OTC EHA LOTION 4% LOTN 5 LEVATIO PATCH PTCH NC RX/OTC RX/OTC EHA LOTION LOTN 5 LEVIGOLT CREA 5 RX/OTC EMPRICAINE II KIT NC LIDOCAINE AND TETRACAINECREAM NC ENOVARX-LIDOCAINE 5 CREA HCL CREA lidocaine hcl crea ex 3 % 2 RX/OTC ENZNONUTY OINT NC lidocaine hcl gel ex 2 % 2 RX/OTC ethyl chloride aero 2 lidocaine hcl gel ex 2 % 2 ETHYL CHLORIDE/FINE 2 PINPOINT AERO lidocaine hcl lotn ex 3 % 2 ETHYL CHLORIDE/FINE 5 STREAM AERO lidocaine hcl prsy ex 2 % 2 ETHYL CHLORIDE/MEDIUM JET 2 lidocaine hcl soln ex 4 % 2 STREAM AERO ETHYL LIDOCAINE CHLORIDE/MEDIUM 5 HYDROCHLORIDE CREA NC STREAM AERO EX 4.12 % LIDOCAINE ETHYL CHLORIDE/MIST 2 AERO HYDROCHLORIDE/EPINE NC PHRINE/TETRACAINE FLEXIN PTCH NC RX/OTC HYDROCHLORIDE SOLN lidocaine oint ex 5 % 2 GEBAUERS INSTANT ICE 5 RX/OTC AERO PA; QL(3 ea lidocaine ptch ex 5 % 2 GEBAUERS PAIN EASE 5 RX/OTC daily) AERO lidocaine-menthol ptch 2 RX/OTC GEBAUERS SPRAY AND 5 RX/OTC STRETCH AERO lidocaine-prilocaine crea 2 GEN7T LOTN NC lidocaine-prilocaine kit 2 GEN7T PLUS LOTN NC lidocaine-transparent NC GEN7T PLUS PTCH NC dressing kit LIDOCAINE/TETRACAINE NC GEN7T PTCH NC CREA 7 %-23 %, 7 %-7 %

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDODERM PTCH (Use 4 PA; QL(3 ea PRAMOXINE HCL POWD 5 lidocaine) daily) RX/OTC PREMIUM SCAR PATCH NC LIDODOSE GEL 5 PTCH LIDODOSE PEDIATRIC 5 RX/OTC PREPIV SUPPLY KIT NC BULK PACK GEL LIDOPIN CREA 5 PRILO PATCH II KIT NC

LIDOPURE PATCH KIT NC PRILO PATCH KIT NC

LIDORX GEL 5 RX/OTC PRILOHEAL PLUS 30 KIT NC

LIDOSTREAM KIT NC PRILOVIXIL KIT NC

LIDOTHOL GEL NC PRIZOPAK II KIT NC

LIDOTHOL PTCH NC PRIZOTRAL II KIT NC

LIDOTRAL CREA NC PRIZOTRAL KIT NC

LIDOVEX CREA NC QUTENZA KIT 5

LIDTOPIC MAX CREA 5 REAL HEAL-I KIT NC RX/OTC LMR PLUS KIT NC RENOVO PTCH 5

LYDEXA CREA NC SKYADERM-LP KIT NC

MEDI-DERM/L CREA 5 RX/OTC SOOTHEE PTCH NC RX/OTC STERILE TOPICAL L.E.T. NC MEDI-DERM/L-RX CREA 5 GEL GEL MEDI-PATCH RX PTCH 5 RX/OTC SUN BURNT PLUS PAIN NC QL(1 ml daily); RELIEF GEL RX/OTC MEDI-PATCH/LIDOCAINE RX/OTC 5 SX1 MEDICATED POST- NC PTCH OPERATIVE SYSTEM KIT MICROVIX LP THPK NC SYNERA PTCH 5

NUVAKAAN II KIT NC SYNVEXIA TC CREA 5 RX/OTC PAINGO KFT KIT NC VEINPUNCTURE PX1 PHLEBOTOMY SYSTEM NC PLIAGLIS CREA NC KIT WPR PLUS WOUND NC PLIAGLIS KIT NC HEALING SYSTEM THPK ZENEVIX THPK NC PRAMOX GEL GEL 4 ZILACAINE PATCH THPK NC

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZTLIDO PTCH NC HPR FOAM 5

Misc. Dermatological Products HPR PLUS CREA 5 RX/OTC 5 DAY LIQD 5 RX/OTC HPR PLUS FOAM 5 ALEVAMAX CREA 5 RX/OTC HPR PLUS HYDROGEL 5 KIT KIT ALEVICYN ANTIPRURITIC NC RX/OTC GEL GEL HYLAGUARD CREA NC RX/OTC ALEVICYN ANTIPRURITIC NC RX/OTC SG GEL HYLAMIX CREA NC RX/OTC RX/OTC ATOPADERM CREA NC HYLATOPIC PLUS CREA 5 RX/OTC RX/OTC ATOPICLAIR CREA 5 HYLATOPIC PLUS FOAM 5

CERACADE EMUL 5 HYLATOPIC PLUS LOTN 5 RX/OTC

CERACADE EMUL NC HYLATOPIC PLUS LOTN NC RX/OTC RX/OTC CERAMAX CREA NC ILIDERM EMUL NC RX/OTC CERAMAX LOTN NC JOBST IT STAYS/ROLL- 5 RX/OTC ON LIQD dermatological products, 5 RX/OTC misc. liqd KAMDOY EMUL NC RX/OTC DEXERYL CREA 5 KERASAL FUNGAL NAIL 5 RX/OTC RENEWAL LIQD DIABETIDERM MASSAGE 5 RX/OTC STIMULATOR LIQD KERASAL MULTI- RX/OTC PURPOSE NAIL REPAIR 5 ELETONE CREA 5 RX/OTC LIQD KIVIK EMUL NC ELETONE TWINPACK 5 RX/OTC CREA LEVICYN GEL NC RX/OTC EMULSION SB EMUL 5 LOYON SOLN 5 ENTTY SPRAY EMUL 5 MB HYDROGEL KIT 5 EPICERAM EMUL NC MIMYX CREA 5 RX/OTC FREEDERM ADHESIVE 5 RX/OTC REMOVER LIQD NAIL SCRUB LIQD 5 RX/OTC GENADUR KIT KIT 5 NEOCERA CREA 5 RX/OTC GENADUR LIQD 5 RX/OTC NEOSALUS CP CREA 5 RX/OTC HALUCORT GEL NC RX/OTC NEOSALUS CREA 5 RX/OTC

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOSALUS FOAM 5 ACUICYN DAILY EYELID RX/OTC & EYELASH CLEANSER NC NEOSALUS LOTN 5 RX/OTC SOLN ALCOHOL WIPES MISC 5 NIVATOPIC PLUS CREA 5 RX/OTC ALUMINUM CHLORIDE 5 RX/OTC NUVAIL SOLN 5 ANHYDROUS POWD ALUMINUM CHLORIDE 5 RX/OTC PENLEN EMUL NC CRYS ALUMINUM CHLORIDE 5 RX/OTC PHLAG SPRAY EMUL 5 HEXAHYDRATE CRYS ALUMINUM CHLORIDE 5 RX/OTC PR CREAM KIT 5 HEXAHYDRATE POWD PRESERA FOAM 5 ARNICA FLOWER TINC 5 RX/OTC PRUCLAIR CREA 5 RX/OTC AVENOVA SOLN NC RX/OTC PRUMYX CREA 5 RX/OTC benzoin compound tinc 2

RX/OTC BENZOIN TINCTURE 5 RX/OTC REMIGEN CREAM CREA 5 PLAIN TINC REMOVE ADHESIVE RX/OTC 5 BENZOIN TINCTURE 5 RX/OTC REMOVER LIQD TINC SEBUDERM GEL 5 RX/OTC BORIC ACID GRAN EX 5 RX/OTC

STRATA CTX GEL NC RX/OTC CALAMINE POWD 5 RX/OTC RX/OTC STRATA MARK GEL NC CVS ISOPROPYL 5 ALCOHOL WIPES MISC RX/OTC STRATA XRT GEL NC DERMACINRX NC CLORHEXACIN KIT SUVICORT EMUL NC DERMACINRX SURGICAL NC COMBOPAK KIT SYNERDERM EMUL NC DERMACINRX SURGICAL NC PHARMAPAK KIT TETRIX CREA 5 RX/OTC DRYSOL SOLN 5 THUM LIQD 5 RX/OTC EPICYN SOLN NC XERALUX CREA 5 RX/OTC GNP ISOPROPYL 5 ALCOHOL WIPES MISC Misc. Topical ACUICYN RX/OTC HYCLODEX SOLN NC ANTIMICROBIAL EYELID NC & EYELASH HYGIENE HYPOCYN SOLN 5 RX/OTC SOLN ICHTHAMMOL POWD 5

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOPROPYL ALCOHOL 5 IVERMECTIN CREA EX 1 5 QL(1.5 gm WIPES MISC % daily) MEDPURA ALCOHOL 5 IVERMECTIN/METRONID PADS MISC AZOLE/NIACINAMIDE NC NUSURGEPAK GEL SURGICAL NC METROCREAM CREA QL(45 gm per PREP/CAREPAK KIT (Use metronidazole 5 fill retail) (topical)) PRE & POST SX POUCH NC THPK METROGEL GEL (Use 5 metronidazole (topical)) QBREXZA PADS NC METROLOTION LOTN (Use metronidazole 5 RA ISOPROPYL 5 ALCOHOL WIPES MISC (topical)) metronidazole (topical) QL(45 gm per SM BENZOIN TINCTURE 5 RX/OTC 2 TINC crea 0.75 % fill retail) TANNIC ACID POWD 5 RX/OTC metronidazole (topical) gel 2 QL(45 gm per 0.75 % fill retail) XERAC AC SOLN 5 metronidazole (topical) gel 2 1 % Phosphodiesterase 4 (PDE4) Inhibitors - Topical metronidazole (topical) lotn 2 PA; QL(2 gm 0.75 % EUCRISA OINT 4 daily) MIRVASO GEL NC Pigmenting-Depigmenting Agents NORITATE CREA NC HYDROQUINONE POWD 5 ORACEA CPDR (Use 2 LACTIC NC doxycycline (rosacea)) ACID/NIACINAMIDE CREA RHOFADE CREA 5 METHOXSALEN POWD 5 Protectives Against UV Radiation ROSADAN KIT KIT 5 SCENESSE IMPL 5 SOOLANTRA CREA (Use 4 QL(1.5 gm ivermectin (rosacea)) daily) Rosacea Agents ZILXI FOAM NC AVEIDAOXIA GEL NC Scabicides & Pediculicides azelaic acid gel ex 2 crotamiton lotn ex 2 doxycycline (rosacea) cpdr NC ELIMITE CREA (Use 4 permethrin) FINACEA FOAM 4 EURAX CREA 5 FINACEA GEL (Use NC EURAX LOTN (Use 5 azelaic acid) crotamiton) QL(1.5 gm ivermectin (rosacea) crea 2 ivermectin (pediculicide) 5 RX/OTC daily) lotn

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IVERMECTIN LOTN EX 5 RX/OTC coal tar extract soln 2 0.5 % lindane sham 2 Wound Care Products ACTICOAT FLEX 3 RX/OTC QL(59 ml per malathion lotn 2 BARRIER DRESSING 5 fill retail) 4"'X4" PADS NATROBA SUSP (Use 5 ACTIMARIS ALL- RX/OTC spinosad) NATURAL WOUND NC RINSE/ENERGIZED OVIDE LOTN (Use 4 QL(59 ml per malathion) fill retail) SINGLET OXYGEN SOLN permethrin crea 2 ACTIMARIS WOUND GEL NC RX/OTC GEL SKLICE LOTN (Use RX/OTC 5 ALEVICYN DERMAL NC RX/OTC ivermectin (pediculicide)) SPRAY SOLN spinosad susp 2 ALLEVYN GENTLE PADS 5 RX/OTC

SULFURATED LIME SOLN 5 AMERIGEL WOUND NC RX/OTC DRESSING GEL ULESFIA LOTN 5 AMERIGEL WOUND NC RX/OTC WASH SOLN Scar Treatment Products AQUACEL AG NC RX/OTC BEAU RX GEL NC RX/OTC ADVANTAGE PADS AQUACEL AG BURN NC RX/OTC COPASIL GEL EX 5 RX/OTC PADS AQUACEL AG EXTRA 4" X NC RX/OTC DERMELLE GEL NC RX/OTC 5"/HYDROFIBER PADS RX/OTC ATRAPRO ANTIPRURITIC NC RX/OTC KELARX GEL NC HYDROGEL GEL PALMERS COCOA RX/OTC ATRAPRO CP KIT NC RX/OTC BUTTER FORMULA SCAR NC SERUM LIQD BALSAM PERU & NC CASTOR OIL OINT RECEDO GEL NC RX/OTC BPCO OINT NC scar treatment products gel 2 RX/OTC CARRAKLENZ SOLN NC RX/OTC scar treatment products gel NC RX/OTC CARRASMART GEL EX NC RX/OTC SCARCIN GEL GEL 5 RX/OTC CARRASYN HYDROGEL NC RX/OTC WOUND DRESSING GEL SCARCIN ROLL-ON LIQD NC RX/OTC CARRASYN V RX/OTC SCARSILK GEL GEL NC RX/OTC HYDROGEL NC WOUNDDRESSING GEL SILIPAC KIT NC CICA-CARE SHEE 5 RX/OTC

Tar Products COOLMAGIC SHEE 5 RX/OTC

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COOLMAGIC TUBE SITE 5 RX/OTC EXU-DRY NON- RX/OTC DRESSING SHEE PERMEABLE SHEET 5 36"X72" SHEE CURAFIL GEL WOUND NC RX/OTC DRESSING GEL EXU-DRY PERMEABLE 5 RX/OTC CURITY HYPERTONIC RX/OTC QUILTED 36"X72" SHEE SODIUMCHLORIDE 5 EXUDERM LP 4" X 4" 5 RX/OTC PACKING STRIP 1/2"X15' PADS MISC EXUDERM LP 6" X 6" 5 RX/OTC CURITY SODIUM RX/OTC PADS CHLORIDE DRESSING 5 EXUDERM RCD 4" X 4" 5 RX/OTC 6"X6-3/4" PADS PADS CVS ADVANCED RX/OTC EXUDERM RCD 6" X 6" 5 RX/OTC HEALING 5 PADS HYDROCOLLOID ADHESIVE PADS PADS EXUDERM RCD 8" X 8" 5 RX/OTC PADS CVS MANUKA HONEY NC RX/OTC WOUND GEL GEL EXUDERM SACRUM 4" X 5 RX/OTC 3.6" PADS DELUO ANTIMICROBIAL RX/OTC WOUND& SKIN NC EXUDERM SATIN 2" X 2" 5 RX/OTC CLEANSER SOLN PADS DERMAGRAN RX/OTC EXUDERM SATIN 4" X 4" 5 RX/OTC HYDROGEL NC PADS WOUNDDRESSING GEL EXUDERM SATIN 6" X 6" 5 RX/OTC DERMAGRAN-B RX/OTC PADS HYDROPHILIC WOUND NC EXUDERM SATIN 8" X 8" 5 RX/OTC DRESSING GEL PADS RX/OTC EXUDERM ULTRA 4" X 4" 5 RX/OTC DERMASYN GEL NC PADS DERMULCERA OINT NC EXUDERM ULTRA RX/OTC HYDROCOLLOID WOUND 5 DERPIXA GEL NC RX/OTC DRESSING 4" X 4" PADS GRX WOUND GEL NC RX/OTC DIAB CREA 5 RX/OTC HAPRODERM GEL NC RX/OTC DIAB DAILY CARE GEL NC RX/OTC HYDROFERA BLUE RX/OTC DIAB F.D.G. FREEZE- NC RX/OTC FOAM DRESSING 2"X2" 5 DRIED GEL PADS DIAB GEL NC RX/OTC HYDROFERA BLUE RX/OTC FOAM DRESSING 4"X4" 5 DUODERM 5 RX/OTC PADS HYDROACTIVE MISC HYDROFERA BLUE RX/OTC DYNADERM 5 RX/OTC FOAM DRESSING 6"X6" 5 HYDROCOLLOID MISC PADS EXCEL-GEL GEL NC RX/OTC

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROFERA BLUE RX/OTC KENDALL ALGINATE RX/OTC FOAM HYDROCOLLOID 5 DRESSING/MOISTURE 5 DRESSING 4"X5" PADS RETENTIVE FILM/2-1/4X8 KENDALL ALGINATE RX/OTC PADS HYDROCOLLOID 5 HYDROFERA BLUE RX/OTC DRESSING 6"X6" PADS FOAM KENDALL ALGINATE RX/OTC DRESSING/MOISTURE 5 HYDROCOLLOID 5 RETENTIVE FILM/4"X4" DRESSING 6"X7" PADS PADS KENDALL ALGINATE RX/OTC HYDROFERA BLUE RX/OTC HYDROCOLLOID 5 FOAM DRESSING 8"X8" PADS DRESSING/MOISTURE 5 RETENTIVE FILM/ISLAND KENDALL AMORPHOUS RX/OTC PADS HYDROGEL WOUND NC DRESSING GEL HYDROFERA BLUE RX/OTC FOAM KENDALL HYDROGEL RX/OTC DRESSING/MOISTURE 5 IMPREGNATED GAUZE 5 RETENTIVE/OSTOMY/2.5" 2"X2" PADS PADS KENDALL HYDROGEL RX/OTC HYDROFERA BLUE RX/OTC IMPREGNATED GAUZE 5 4"X4" PADS FOAM 5 DRESSING/TUNNELING/9 KENDALL HYDROGEL RX/OTC MM PADS IMPREGNATED GAUZE 5 HYDROFERA BLUE RX/OTC 4"X8" PADS HEAVY DRAINAGE 4"X4" 5 KENDALL HYDROGEL RX/OTC PADS WOUND DRESSING 3" 5 HYDROFERA BLUE RX/OTC DISK MISC HEAVY DRAINAGE 6"X6" 5 KENDALL HYDROGEL RX/OTC PADS WOUND DRESSING 4-3/4" 5 HYDROFERA BLUE RX/OTC DISK MISC READY FOAMDRESSING 5 KENDALL ZINC CALCIUM RX/OTC 2.5"X2.5" PADS ALGINATE DRESSING 5 HYDROFERA BLUE RX/OTC 2"X2" PADS READY FOAMDRESSING 5 KENDALL ZINC CALCIUM RX/OTC 4"X5" PADS ALGINATE DRESSING 5 HYDROFERA BLUE RX/OTC 4"X4" PADS READY FOAMDRESSING 5 KENDALL ZINC CALCIUM RX/OTC 8"X8" PADS ALGINATE DRESSING 5 RX/OTC 4"X8" PADS HYDROGEL GEL EX NC KENDALL ZINC CALCIUM RX/OTC ALGINATE DRESSING 5 INTRASITE GEL NC RX/OTC APPLIPAK GEL ROPE 12" MISC KENDALL ALGINATE RX/OTC KERAGEL GEL NC RX/OTC HYDROCOLLOID 5 DRESSING 4"X4" PADS KERAGELT GEL NC RX/OTC

KERAMATRIX REPLICINE 5 RX/OTC 10CMX10CM SHEE 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERAMATRIX REPLICINE 5 RX/OTC REGENECARE GEL NC 5CMX5CM SHEE QL(15 gm per LAVARE WOUND WASH 5 REGRANEX GEL 5 GEL fill retail) RESTORE HYDROGEL RX/OTC LEVICYN DERMAL NC RX/OTC NC SPRAY SOLN DRESSING GEL REVITADERM WOUND NC RX/OTC LIDOTREX GEL NC CARE GEL LUXAMEND CREA 5 RX/OTC REXASIL PATCH/VITAMIN E KIT KIT (Use silicone- NC MEDIHONEY CALCIUM RX/OTC vitamin e) ALGINATE DRESSING NC RTD WOUND CARE 5 RX/OTC 4"X5" PADS DRESSING2" X 2" PADS MEDIHONEY CALCIUM RX/OTC RTD WOUND CARE 5 RX/OTC ALGINATE NC DRESSING4" X 4" PADS DRESSING/2"X2" PADS RTD WOUND CARE 5 RX/OTC MEDIHONEY WOUND & RX/OTC DRESSING4" X 5" PADS BURN DRESSING NC 3/4"X12" PADS silicone-vitamin e kit 2 MEDIHONEY RX/OTC SKINTEGRITY NC RX/OTC WOUND/BURNDRESSING NC HYDROGEL GEL 4"X5" PADS RX/OTC MEDIHONEY RX/OTC SOLOSITE GEL NC WOUND/BURNDRESSING NC RX/OTC GEL STIMULEN GEL NC MICROCYN GEL 0.002 %- RX/OTC 0.008 %-0.066 %-0.4 %-3 5 STRATA GRT GEL NC % TEGADERM RX/OTC MICROCYN LIQD 0.023 % 5 RX/OTC HYDROCOLLIOD THIN 5 DRESSING 5-1/8"X6" MISC MICROCYN SKIN AND 5 WOUND HYDROGEL GEL TEGADERM RX/OTC HYDROCOLLOID 5 NU-GEL COLLAGEN NC RX/OTC WOUND DRESSING GEL DRESSING 4"X4" MISC TEGADERM RX/OTC PRIMACOL THIN 5 RX/OTC DRESSING 4"X4" MISC HYDROCOLLOID 5 DRESSING 4"X4-3/4" PRIMACOL THIN 5 RX/OTC DRESSING 6"X6" MISC MISC TEGADERM RX/OTC RADIACARE POST 5 RX/OTC HEALING CREA HYDROCOLLOID 5 DRESSING 5-1/8"X6" RADIADRES GEL SHEET 5 RX/OTC MISC SHEE TEGADERM RX/OTC RADIAGEL GEL NC RX/OTC HYDROCOLLOID 5 DRESSING 6"X6" MISC RADIAPLEXRX GEL NC RX/OTC

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGADERM RX/OTC XEROFORM NON- HYDROCOLLOID 5 OCCLUSIVE OIL DRESSING 6-3/4"X6-3/8" EMULSION 5 MISC STRIP/OVERWRAP 1"X8" TEGADERM RX/OTC MISC HYDROCOLLOID 5 XEROFORM NON- 5 DRESSING 6-3/4"X8" OCCLUSIVE ROLL MISC MISC XEROFORM OCCLUSIVE TEGADERM RX/OTC PETROLATUM GAUZE 5 HYDROCOLLOID THIN 5 ROLL 4"X9' MISC DRESSING 4"X4" MISC XEROFORM OCCLUSIVE TEGADERM RX/OTC PETROLATUM GAUZE 5 HYDROCOLLOID THIN 5 STRIP 1"X8" MISC DRESSING 4"X4-3/4" XEROFORM OCCLUSIVE MISC PETROLATUM GAUZE 5 TEGADERM RX/OTC STRIP 5"X9" MISC HYDROCOLLOID THIN 5 XEROFORM OCCLUSIVE DRESSING 6-3/4"X8" PETROLATUM GAUZE 5 MISC STRIP/OVERWRAP 1"X8" TEGADERM HYDROGEL NC RX/OTC MISC WOUND FILLER GEL XEROFORM OCCLUSIVE THERAHONEY GEL NC RX/OTC PETROLATUM GAUZE 5 STRIP/OVERWRAP 5"X9" THERAHONEY SHEE 5 RX/OTC MISC XEROFORM OCCLUSIVE VASHE RX/OTC PETROLTUM GAUZE 5 SKIN/WOUND/BURN NC PATCH 2"X2" PADS CLEANSING SOLN XEROFORM OCCLUSIVE VASHE WOUND NC RX/OTC PETROLTUM GAUZE 5 THERAPY SOLN PATCH 4"X4" PADS VENELEX OINT NC ZANABIN ANTIPRURITIC NC RX/OTC HYDROGEL GEL RX/OTC VEXASYN GEL NC DIAGNOSTIC PRODUCTS RX/OTC WOUND GEL GEL NC Diagnostic Tests RX/OTC ACCU-CHEK AVIVA PLUS 3 QL(5 ea daily); WOUND GEL SPRAY GEL NC STRP VI RX/OTC XEROFORM NON- ACCU-CHEK COMPACT 3 QL(5 ea daily); PLUS STRP RX/OTC OCCLUSIVE OIL 5 EMULSION GAUZE STRIP ACCU-CHEK GUIDE 3 QL(5 ea daily); 5"X9" PADS STRP VI RX/OTC XEROFORM NON- ACCU-CHEK GUIDE 5 QL(5 ea daily); OCCLUSIVE OIL 5 STRP VI RX/OTC EMULSION PATCH 2"X2" ACCU-CHEK SMARTVIEW 3 QL(5 ea daily); PADS STRIPS STRP RX/OTC ACCUTREND GLUCOSE NC RX/OTC STRP

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVANCE INTUITION NC RX/OTC CAREONE BLOOD RX/OTC TEST STRIPS STRP GLUCOSE TEST NC STRIPS/PREMIUM STRP ADVANCE MICRO-DRAW NC RX/OTC TEST STRIPS STRP CAREONE BLOOD RX/OTC GLUCOSE TEST NC ADVOCATE REDI-CODE NC RX/OTC STRP VI STRIPS/VALUE STRP CARESENS N BLOOD RX/OTC ADVOCATE REDI-CODE+ NC RX/OTC TESTSTRIPS STRP GLUCOSETEST STRIPS NC STRP ADVOCATE TEST STRIPS NC RX/OTC STRP CARETOUCH BLOOD RX/OTC GLUCOSE TEST STRIPS NC AGAMATRIX AMP NO RX/OTC STRP CODE TEST STRIPS NC QL(100 ea per STRP CHEMSTRIP-K STRP 5 fill retail) AGAMATRIX JAZZ TEST NC RX/OTC STRIPS STRP CLEVER CHEK AUTO- RX/OTC CODE TEST STRIPS NC AGAMATRIX KEYNOTE NC RX/OTC STRP TEST STRIPS STRP CLEVER CHEK AUTO- RX/OTC AGAMATRIX PRESTO NC RX/OTC CODE VOICE TEST NC TEST STRIPS STRP STRIPS STRP ASSURE 3 TEST STRIPS RX/OTC NC CLEVER CHEK TEST NC RX/OTC STRP STRIPS STRP ASSURE 4 TEST STRIPS NC RX/OTC CLEVER CHOICE AUTO- RX/OTC STRP CODE PRO TEST STRIPS NC ASSURE II CHECK STRIP NC RX/OTC STRP STRP CLEVER CHOICE MICRO NC RX/OTC ASSURE II STRP NC RX/OTC TESTSTRIPS STRP CLEVER CHOICE NO RX/OTC ASSURE II TEST STRIPS NC RX/OTC CODING TEST STRIPS NC STRP STRP ASSURE PLATINUM TEST 5 QL(5 ea daily); CLEVER CHOICE TALK RX/OTC STRIPS STRP RX/OTC NO CODING TEST NC ASSURE PLATINUM TEST NC RX/OTC STRIPS STRP STRIPS STRP CONTOUR BLOOD RX/OTC ASSURE PRISM MULTI NC RX/OTC GLUCOSE TEST STRIPS NC TEST STRIPS STRP STRP ASSURE PRO TEST RX/OTC NC CONTOUR NEXT BLOOD NC RX/OTC STRIPS STRP GLUCOSE TEST STRP BIOSCANNER GLUCOSE RX/OTC NC COOL BLOOD GLUCOSE NC RX/OTC TEST STRIPS STRP TEST STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC CVS ADVANCED RX/OTC STRIPS PREMIUM STRP GLUCOSE METER TEST NC STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC STRIPS STRP CVS GLUCOSE METER NC RX/OTC TEST STRIPS STRP BLULINK GLUCOSE TEST NC RX/OTC STRIPS STRP D-CARE BLOOD NC RX/OTC GLUCOSE STRP

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIASTIX STRP 5 ELEMENT COMPACT NC RX/OTC TEST STRIPS STRP DIATHRIVE BLOOD RX/OTC ELEMENT TEST STRIPS NC RX/OTC GLUCOSE TEST STRIPS NC STRP STRP EMBRACE BLOOD RX/OTC DIATHRIVE+ BLOOD RX/OTC GLUCOSE TEST STRIPS NC GLUCOSETEST STRIPS NC STRP STRP EMBRACE EVO BLOOD RX/OTC DIATRUE PLUS BLOOD RX/OTC GLUCOSETEST STRIPS NC GLUCOSE TEST STRIPS NC STRP STRP EMBRACE PRO BLOOD RX/OTC DUO-CARE TEST STRIPS NC RX/OTC GLUCOSETEST STRIPS NC STRP STRP EASY PLUS II BLOOD NC RX/OTC EMBRACE TALK BLOOD RX/OTC GLUCOSE TEST STRP GLUCOSE TEST STRIPS NC STRP EASY STEP TEST STRIPS NC RX/OTC STRP EQ BLOOD GLUCOSE NC RX/OTC EASY TALK BLOOD RX/OTC TEST STRIPS STRP GLUCOSE TEST STRIPS NC EVENCARE + BLOOD QL(5 ea daily); STRP GLUCOSETEST STRIP 5 RX/OTC STRP EASY TOUCH GLUCOSE NC RX/OTC TEST STRIPS STRP EVENCARE BLOOD QL(5 ea daily); EASY TOUCH RX/OTC GLUCOSE TEST STRIP 5 RX/OTC HEALTHPRO GLUCOSE NC STRP TEST STRIPS STRP EVENCARE G2 TEST NC RX/OTC EASY TRAK BLOOD RX/OTC STRIPS STRP GLUCOSE TEST STRIPS NC EVENCARE G3 TEST 5 QL(5 ea daily); STRP STRIPS STRP RX/OTC EASY TRAK II BLOOD RX/OTC EVENCARE MINI BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS 5 RX/OTC STRP STRP QL(5 ea daily); EASYGLUCO PLUS STRP 5 EVENCARE PROVIEW QL(5 ea daily); RX/OTC BLOOD GLUCOSE TEST 5 RX/OTC STRIPS STRP EASYGLUCO STRP VI 5 QL(5 ea daily); RX/OTC EVOLUTION AUTOCODE NC RX/OTC EASYGLUCO STRP VI NC RX/OTC STRP VI EXACTECH R-S-G TEST NC RX/OTC EASYMAX 15 TEST NC RX/OTC STRIPS STRP STRIPS STRP EXACTECH TEST STRIPS NC RX/OTC EASYMAX TEST STRIPS NC RX/OTC STRP STRP FIFTY50 GLUCOSE TEST NC RX/OTC EASYPRO BLOOD RX/OTC STRIP 2.0 STRP GLUCOSE TEST STRIPS NC RX/OTC STRP FORA 6 CONNECT STRP NC RX/OTC EASYPRO PLUS STRP NC FORA BLOOD GLUCOSE NC RX/OTC TEST STRIPS STRP

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FORA D15G BLOOD RX/OTC FORTISCARE BLOOD RX/OTC GLUCOSE TEST STRIPS NC GLUCOSETEST STRIP NC STRP STRP FORA D20 BLOOD RX/OTC FREESTYLE INSULINX RX/OTC GLUCOSE TEST STRIPS NC BLOODGLUCOSE TEST NC STRP STRIPS STRP FORA D40/G31 BLOOD RX/OTC FREESTYLE INSULINX RX/OTC GLUCOSE TEST STRIPS NC BLOODGLUCOSE TEST NC STRP STRP FORA G20 BLOOD RX/OTC FREESTYLE LITE TEST NC RX/OTC GLUCOSE TEST STRIPS NC STRIPS STRP STRP FREESTYLE PRECISION RX/OTC FORA G30/PREMIUM V10 RX/OTC NEO BLOOD GLUCOSE NC BLOOD GLUCOSE TEST NC TEST STRIPS STRP STRIPS STRP FREESTYLE TEST NC RX/OTC FORA GD20 TEST NC RX/OTC STRIPS STRP STRIPS STRP GE100 BLOOD GLUCOSE NC RX/OTC FORA GD50 BLOOD RX/OTC TESTSTRIPS STRP GLUCOSE TEST STRIPS NC GENULTIMATE TEST NC RX/OTC STRP STRIPS STRP FORA GTEL BLOOD RX/OTC RX/OTC GLUCOSE TEST STRIPS NC GHT TEST STRIPS STRP NC STRP GLUCO PERFECT 3 TEST NC RX/OTC FORA TN'G ADVANCE RX/OTC STRIPS STRP PRO BLOOD GLUCOSE NC GLUCOCARD 01 SENSOR NC RX/OTC TEST STRIPS STRP PLUS STRP FORA TN'G/TN'G VOICE RX/OTC GLUCOCARD 01 SENSOR NC RX/OTC BLOOD GLUCOSE TEST NC PLUSTEST STRIPS STRP STRIPS STRP GLUCOCARD RX/OTC FORA V10 BLOOD RX/OTC EXPRESSION BLOOD NC GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS STRP STRP FORA V12 BLOOD RX/OTC GLUCOCARD SHINE NC RX/OTC GLUCOSE TEST STRIPS NC TEST STRIPS STRP STRP GLUCOCARD VITAL TEST NC RX/OTC FORA V20 BLOOD RX/OTC STRIPS STRP GLUCOSE TEST STRIPS NC STRP GLUCOCARD X-SENSOR NC RX/OTC STRP FORA V30A BLOOD RX/OTC GLUCOSE TEST STRIPS NC GLUCOCOM TEST NC RX/OTC STRP STRIPS STRP RX/OTC GLUCONAVII BLOOD RX/OTC FORACARE GD40 STRP NC GLUCOSETEST STRIPS NC STRP FORACARE PREMIUM NC RX/OTC V10 TESTSTRIPS STRP GLUCOSE METER TEST RX/OTC STRIPS ADVANCED NC FORACARE TEST N GO NC RX/OTC TEST STRIPS STRP STRP

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP EASY TOUCH RX/OTC KROGER PREMIUM RX/OTC GLUCOSE TEST STRIPS NC BLOOD GLUCOSE TEST NC STRP STRIPS STRP GOJJI BLOOD GLUCOSE RX/OTC NC KROGER TEST STRIPS NC RX/OTC TESTSTRIPS STRP STRP GOJJI BLOOD GLUCOSE RX/OTC LIBERTY NEXT RX/OTC TESTSTRIPS/GOJJI NC GENERATION BLOOD NC STERILE LANCETS 30G GLUCOSE TEST STRIPS STRP STRP GOODSENSE PREMIUM RX/OTC LIBERTY TEST STRIPS NC RX/OTC BLOOD GLUCOSE TEST NC STRP STRIPS STRP MEIJER BLOOD RX/OTC HARMONY BLOOD QL(5 ea daily); GLUCOSE TESTSTRIPS NC GLUCOSE TEST STRIPS 5 RX/OTC STRP STRP MEIJER ESSENTIAL RX/OTC HW EMBRACE PRO RX/OTC BLOOD GLUCOSE TEST NC BLOOD GLUCOSE TEST NC STRIPS STRP STRIPS STRP MEIJER PREMIUM RX/OTC HW EMBRACE TALK RX/OTC BLOOD GLUCOSE TEST NC BLOOD GLUCOSE TEST NC STRIPS STRP STRIPS STRP MEIJER TRUETEST RX/OTC IGLUCOSE BLOOD RX/OTC BLOOD GLUCOSE TEST NC GLUCOSE TEST STRIPS NC STRIPS STRP STRP MEIJER TRUETRACK RX/OTC IN TOUCH BLOOD RX/OTC BLOOD GLUCOSE TEST NC GLUCOSE TEST STRIPS NC STRIPS STRP STRP MICRODOT TEST STRIPS NC RX/OTC INFINITY BLOOD QL(5 ea daily); STRP GLUCOSE TEST STRIPS 5 RX/OTC MICRODOT XTRA TEST NC RX/OTC STRP STRIPS STRP INFINITY BLOOD RX/OTC MM EASY TOUCH RX/OTC GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS NC STRP STRP INFINITY VOICE STRP NC RX/OTC MYGLUCOHEALTH RX/OTC BLOOD GLUCOSE TEST NC QL(100 ea per KETONE STRP 5 STRP fill retail) NEUTEK 2TEK TEST NC RX/OTC KETONE TEST STRIPS 5 QL(100 ea per STRIPS STRP STRP fill retail) NOVA MAX GLUCOSE RX/OTC QL(100 ea per NC KETOSTIX STRP 5 TEST STRIPS STRP fill retail) ON CALL EXPRESS QL(5 ea daily); KROGER BLOOD RX/OTC BLOOD GLUCOSE TEST 5 RX/OTC GLUCOSE TESTSTRIPS NC STRIPS STRP STRP ON CALL PLUS BLOOD 5 QL(5 ea daily); KROGER HEALTHPRO RX/OTC GLUCOSE TEST STRP RX/OTC GLUCOSETEST STRIPS NC STRP

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ON CALL VIVID BLOOD QL(5 ea daily); PRO VOICE V8/V9 RX/OTC GLUCOSE TEST STRIPS 5 RX/OTC BLOOD GLUCOSE TEST NC STRP STRIPS STRP ON CALL VIVID BLOOD 5 QL(5 ea daily); PRODIGY NO CODING RX/OTC GLUCOSE TEST STRP RX/OTC BLOOD GLUCOSE TEST NC ONE DROP BLOOD RX/OTC STRIPS STRP NC GLUCOSE TEST STRIPS PTS PANELS GLUCOSE NC RX/OTC STRP TEST STRP QL(5 ea daily); QUICKTEK TEST STRIPS RX/OTC ONETOUCH ULTRA STRP 3 NC RX/OTC STRP ONETOUCH VERIO TEST 3 QL(5 ea daily); QUINTET AC BLOOD RX/OTC STRIPS STRP RX/OTC GLUCOSETEST STRIPS NC STRP OPTIUM TEST STRIPS NC RX/OTC STRP QUINTET BLOOD RX/OTC GLUCOSE TEST STRIPS NC OPTIUMEZ TEST STRIPS NC RX/OTC STRP STRP REFUAH PLUS BLOOD RX/OTC OPTUMRX BLOOD 5 QL(5 ea daily); GLUCOSE TEST STRP RX/OTC GLUCOSETEST STRIPS NC STRP PHARMACIST CHOICE RX/OTC RELION BLOOD RX/OTC AUTOCODE BLOOD NC GLUCOSE TEST STRIPS GLUCOSE TESTSTRIPS NC STRP STRP PHARMACIST CHOICE RX/OTC RELION CONFIRM/MICRO NC RX/OTC TEST STRIPS STRP NO CODING BLOOD NC GLUCOSE TEST STRIPS RELION KETONE TEST 5 QL(100 ea per STRP STRIPS STRP fill retail) POCKETCHEM EZ RX/OTC RELION PREMIER RX/OTC BLOOD GLUCOSE TEST NC BLOOD GLUCOSE TEST NC STRIPS STRP STRIPS STRP PRECISION PCX PLUS NC RX/OTC RELION PRIME BLOOD RX/OTC TEST STRIPS STRP GLUCOSE TEST STRIPS NC STRP PRECISION PCX STRP NC RX/OTC RELION TRUE METRIX RX/OTC PRECISION POINT OF RX/OTC BLOODGLUCOSE TEST NC CARE TEST STRIPS NC STRIPS STRP STRP RELION ULTIMA BLOOD RX/OTC GLUCOSE TEST STRIPS NC PRECISION QID TEST NC RX/OTC STRIPS STRP STRP REVEAL BLOOD QL(5 ea daily); PRECISION SOF-TACT NC RX/OTC 5 TEST STRIPS STRP GLUCOSE TEST STRP RX/OTC PRECISION XTRA BLOOD RX/OTC REXALL BLOOD RX/OTC GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS NC STRP STRP PREMIUM BLOOD RX/OTC RIGHTEST GS100 BLOOD RX/OTC GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS NC STRP STRP

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIGHTEST GS300 BLOOD RX/OTC TRUE METRIX SELF RX/OTC GLUCOSE TEST STRIPS NC MONITORING BLOOD NC STRP GLUCOSE STRIPS STRP RIGHTEST GS550 BLOOD RX/OTC TRUETEST STRIPS STRP NC RX/OTC GLUCOSE TEST STRIPS NC STRP TRUETRACK BLOOD NC RX/OTC SMART SENSE PREMIUM RX/OTC GLUCOSE TEST STRP BLOODGLUCOSE STRIPS NC TRUETRACK TEST STRP NC RX/OTC STRP SMART SENSE VALUE RX/OTC ULTRATRAK PRO TEST 5 QL(5 ea daily); BLOOD GLUCOSE NC STRIPS STRP RX/OTC STRIPS STRP ULTRATRAK ULTIMATE 5 QL(5 ea daily); SMARTEST BLOOD RX/OTC TEST STRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC UNISTRIP1 GENERIC NC RX/OTC STRP STRP SOLUS V2 AUDIBLE TEST NC RX/OTC VERASENS BLOOD RX/OTC STRP GLUCOSE TEST STRIPS NC STRP SUPREME TEST STRIPS NC RX/OTC STRP VIVAGUARD INO BLOOD RX/OTC SURE EDGE BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC GLUCOSE TEST STRIPS 5 RX/OTC STRP STRP VOCAL POINT BLOOD QL(5 ea daily); SURE-TEST EASYPLUS RX/OTC GLUCOSE TEST STRIPS 5 RX/OTC MINI BLOOD GLUCOSE NC STRP TEST STRIPS STRP WAVESENSE PRESTO 5 QL(5 ea daily); SURECHEK BLOOD QL(5 ea daily); TEST STRIPS STRP RX/OTC GLUCOSE TEST STRIPS 5 RX/OTC DIGESTIVE AIDS - Drugs to Treat Low Digestive STRP Enzymes TELCARE BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS 5 RX/OTC Digestive Enzymes STRP CREON CPEP 4 TGT BLOOD GLUCOSE RX/OTC TEST STRIPS PREMIUM NC ENZADYNE CAPS NC RX/OTC STRP PANCREAZE CPEP 10500 TGT BLOOD GLUCOSE NC RX/OTC TEST STRIPS STRP UNIT-35500 UNIT-61500 UNIT, 16800 UNIT-56800 TRUE FOCUS SELF RX/OTC UNIT-98400 UNIT, 21000 5 MONITORING BLOOD NC UNIT-54700 UNIT-83900 GLUCOSE TEST STRIPS UNIT, 24600 UNIT-4200 STRP UNIT-14200 UNIT TRUE METRIX BLOOD RX/OTC GLUCOSETEST STRIPS NC PEPSIN POWD 5 STRP PERTZYE CPEP 5 TRUE METRIX PRO RX/OTC GLUCOSE TEST STRIPS NC PA; SP STRP SUCRAID SOLN 5 VIOKACE TABS 4

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZENPEP CPEP 4 bumetanide soln 2

Gastric Acidifiers bumetanide tabs 2 L-GLUTAMIC ACID HCL 5 POWD BUMEX TABS (Use 5 bumetanide) DIURETICS - Drugs to Treat Heart, Circulation EDECRIN TABS (Use 5 Conditions and Blood Pressure ethacrynic acid) Carbonic Anhydrase Inhibitors ethacrynate sodium solr 2 acetazolamide cp12 or 500 2 mg ethacrynic acid tabs 2 acetazolamide sodium solr 2 FUROSEMIDE POWD XX 5 acetazolamide tabs or 125 2 mg, 250 mg furosemide soln ij 10 mg/ml 2 KEVEYIS TABS 5 furosemide soln or 10 2 mg/ml, 8 mg/ml METHAZOLAMIDE POWD 5 XX furosemide tabs or 20 mg, 2 40 mg, 80 mg methazolamide tabs or 50 2 mg, 25 mg FUROSEMIDE/SODIUM NC CHLORIDE SOLN Diuretic Combinations LASIX TABS (Use 5 ALDACTAZIDE TABS 25 furosemide) MG-25 MG (Use 5 SODIUM EDECRIN SOLR 5 spironolactone & ) hydrochlorothiazide) (Use ethacrynate sodium torsemide tabs 10 mg, 100 2 QL(1 ea daily) ALDACTAZIDE TABS 50 5 mg, 5 mg MG-50 MG torsemide tabs 20 mg 2 QL(4 ea daily) amiloride & 2 hydrochlorothiazide tabs DYAZIDE CAPS (Use QL(1 ea daily) Osmotic Diuretics triamterene & 5 mannitol soln iv 10 %, 15 2 hydrochlorothiazide) %, 25 %, 5 %, 20 % MAXZIDE TABS (Use QL(1 ea daily) Potassium Sparing Diuretics triamterene & 5 ALDACTONE TABS (Use 4 hydrochlorothiazide) spironolactone) MAXZIDE-25 TABS (Use QL(1 ea daily) AMILORIDE HCL POWD 5 triamterene & 5 XX hydrochlorothiazide) amiloride hcl tabs or 2 QL(4 ea daily) spironolactone & 2 hydrochlorothiazide tabs CAROSPIR SUSP NC triamterene & 2 QL(1 ea daily) hydrochlorothiazide caps DYRENIUM CAPS (Use NC triamterene) triamterene & 2 QL(1 ea daily) hydrochlorothiazide tabs SPIRONOLACTONE 5 Loop Diuretics POWD XX

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits spironolactone tabs or 100 2 alendronate sodium tabs 2 QL(0.15 ea mg, 25 mg, 50 mg 35 mg, 70 mg daily) triamterene caps or 100 2 alendronate sodium tabs 2 QL(1 ea daily) mg, 50 mg 40 mg, 5 mg, 10 mg TRIAMTERENE POWD XX 5 ATELVIA TBEC (Use 5 QL(0.15 ea risedronate sodium) daily) Thiazides and Thiazide-Like Diuretics BINOSTO TBEF 5 ST; QL(0.15 ea daily) chlorothiazide sodium solr 2 BONIVA SOLN IV 3 SP MG/3ML (Use ibandronate 5 chlorothiazide tabs or 250 2 QL(2 ea daily) mg sodium) BONIVA TABS OR 150 MG QL(0.04 ea chlorothiazide tabs or 500 2 QL(4 ea daily) 5 mg (Use ibandronate sodium) daily) calcitonin (salmon) soln ij NC QL(0.0667 ml chlorthalidone tabs 2 200 unit/ml daily) DIURIL SUSP 5 calcitonin (salmon) soln na 2 QL(0.1233 ml 200 unit/act daily) hydrochlorothiazide caps or 2 12.5 mg etidronate disodium tabs 2 HYDROCHLOROTHIAZID 5 EVENITY SOSY NC E POWD XX hydrochlorothiazide tabs or 2 FORTEO SOPN NC 12.5 mg, 25 mg, 50 mg FOSAMAX PLUS D TABS 5 ST; QL(0.15 ea indapamide tabs 2 daily) FOSAMAX TABS (Use 5 QL(0.15 ea metolazone tabs 2 alendronate sodium) daily) SODIUM DIURIL SOLR ibandronate sodium soln iv 2 PA; SP (Use chlorothiazide 5 3 mg/3ml sodium) ibandronate sodium tabs or 2 QL(0.04 ea ENDOCRINE AND METABOLIC AGENTS - 150 mg daily) MISC. - Drugs to Treat Bone Disease and MIACALCIN SOLN (Use NC QL(0.0667 ml Regulate Hormones calcitonin (salmon)) daily) Adrenal Steroid Inhibitors NATPARA CART 5 PA; SP ISTURISA TABS NC pamidronate disodium soln 2 SP 30 mg/10ml, 90 mg/10ml Bone Density Regulators PAMIDRONATE PA; SP ACTONEL TABS 150 MG 5 QL(0.04 ea DISODIUM SOLN 6 5 (Use risedronate sodium) daily) MG/ML ACTONEL TABS 35 MG QL(0.15 ea 5 pamidronate disodium solr 2 SP (Use risedronate sodium) daily) 30 mg, 90 mg ACTONEL TABS 5 MG 5 QL(1 ea daily) PA; SP (Use risedronate sodium) PROLIA SOSY 4 alendronate sodium soln QL(10.8 ml 2 RECLAST SOLN (Use 5 PA; SP 70 mg/75ml daily) zoledronic acid)

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits risedronate sodium tabs 2 QL(0.04 ea OVIDREL INJ 4 PA; SP 150 mg daily) PREGNYL W/DILUENT PA; SP risedronate sodium tabs 30 2 QL(1 ea daily) mg, 5 mg BENZYLALCOHOL/NACL 5 SOLR risedronate sodium tabs 35 2 QL(0.15 ea mg daily) GnRH/LHRH Antagonists risedronate sodium tbec 35 2 QL(0.15 ea CETROTIDE KIT 4 PA; SP mg daily) SP TERIPARATIDE SOPN NC ganirelix acetate sosy 2 PA; SP GANIRELIX ACETATE SP TYMLOS SOPN 4 SOSY (Use ganirelix 5 acetate) XGEVA SOLN 5 PA; SP ORILISSA TABS 4 PA; SP zoledronic acid conc 4 2 PA; SP mg/5ml Growth Hormone Receptor Antagonists ZOLEDRONIC ACID SOLN 5 PA; SP 4 MG/100ML SOMAVERT SOLR NC zoledronic acid soln 4 2 PA; SP Growth Hormone Releasing Hormones (GHRH) mg/100ml, 5 mg/100ml EGRIFTA SOLR 5 PA; SP ZOLEDRONIC ACID SOLR 5 PA; 4 MG EGRIFTA SV SOLR 5 PA; SP Corticotropin PA; SP GHRP-2/GHRP- ACTHAR GEL 5 6/SERMORELINACETATE NC SOLR Fertility Regulators GHRP-2/SERMORELIN NC CHORIONIC PA; SP ACETATE SOLR GONADOTROPIN SOLR 5 IM IPAMORELIN ACETATE NC SOLR CLOMIPHENE CITRATE 5 POWD XX Growth Hormones QL(15 ea per GENOTROPIN MINIQUICK PA; SP clomiphene citrate tabs or 2 4 30 days retail) SOLR SP GENOTROPIN SOLR 12 4 PA; SP FOLLISTIM AQ SOLN NC MG GONAL-F RFF REDIJECT PA; SP 4 GENOTROPIN SOLR 5 4 PA; SOLN MG PA; SP GONAL-F RFF SOLR 4 HUMATROPE COMBO NC PA; SP PACK SOLR PA; SP GONAL-F SOLR 4 HUMATROPE SOLR NC PA; SP

HCG SOLR NC NORDITROPIN FLEXPRO 4 PA; SP SOPN MENOPUR SOLR 5 PA; SP NUTROPIN AQ NUSPIN NC 10 SOPN NOVAREL SOLR 5 PA; SP

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUTROPIN AQ NUSPIN NC SYNAREL SOLN 5 PA; SP 20 SOPN PA; NUTROPIN AQ NUSPIN 5 NC TRIPTODUR SRER 4 SOPN Metabolic Modifiers OMNITROPE SOCT 10 NC PA; SP MG/1.5ML, 5 MG/1.5ML ALDURAZYME SOLN 5 PA; SP OMNITROPE SOLR 5.8 NC PA MG AMMONUL SOLN (Use PA; SP sod benzoate & sod 5 SAIZEN SOLR 5 MG NC phenylacetate) PA; SP SAIZEN SOLR 8.8 MG NC PA BRINEURA KIT 5 SAIZENPREP PA BUPHENYL POWD 3 PA; SP RECONSTITUTIONKIT NC GM/TSP (Use sodium 5 SOLR phenylbutyrate) PA; SP BUPHENYL TABS 500 MG SP SEROSTIM SOLR 5 (Use sodium 5 phenylbutyrate) ZOMACTON SOLR NC calcitriol caps or 0.25 mcg, 2 ZORBTIVE SOLR 5 PA; SP 0.5 mcg calcitriol soln iv 1 mcg/ml 2 Hormone Receptor Modulators QL(1 ea daily); calcitriol soln or 1 mcg/ml 2 EVISTA TABS (Use 5 raloxifene hcl) AL(At least 40 yrs old) CARBAGLU TABS 5 PA; SP OSPHENA TABS NC CARNITOR SF SOLN (Use QL(30 ml daily) QL(1 ea daily); levocarnitine (metabolic NC raloxifene hcl tabs 6 AL(At least 40 modifiers)) yrs old) CARNITOR SOLN IV 200 5 MG/ML Insulin-Like Growth Factor Receptor Inhibitors CARNITOR SOLN OR 1 QL(30 ml daily) PA; SP TEPEZZA SOLR 5 GM/10ML (Use NC levocarnitine (metabolic Insulin-Like Growth Factors (Somatomedins) modifiers)) INCRELEX SOLN 5 PA; SP CARNITOR TABS OR 330 QL(3 ea daily) MG (Use levocarnitine NC LHRH/GnRH Agonist Analog Pituitary (metabolic modifiers)) PA; SP FENSOLVI KIT 5 PA; SP cinacalcet hcl tabs 2

LUPANETA PACK KIT 5 PA; SP CITRULLINE EASY TBCR NC PA; SP LUPRON DEPOT-PED (1- NC SP CRYSVITA SOLN 5 MONTH) KIT CYSTADANE POWD 5 PA; SP LUPRON DEPOT-PED (3- NC SP MONTH) KIT doxercalciferol caps 2 SUPPRELIN LA KIT 4 PA; SP

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxercalciferol soln 2 paricalcitol caps or 1 mcg, 2 2 mcg, 4 mcg PA; SP ELAPRASE SOLN 5 paricalcitol soln iv 2 2 SP mcg/ml, 5 mcg/ml PA; SP FABRAZYME SOLR 5 PARSABIV SOLN NC SP PA; SP GALAFOLD CAPS 5 RAVICTI LIQD 5 PA; SP HECTOROL SOLN 2 5 MCG/ML RAYALDEE CPCR 5 HECTOROL SOLN 4 PA; SP MCG/2ML (Use 5 REVCOVI SOLN 5 doxercalciferol) ROCALTROL CAPS (Use 4 KANUMA SOLN 5 PA; SP calcitriol) ROCALTROL SOLN (Use 4 KUVAN PACK (Use PA; SP calcitriol) sapropterin NC sapropterin dihydrochloride 2 PA; SP dihydrochloride) pack KUVAN TABS (Use PA; SP sapropterin dihydrochloride 2 PA; SP sapropterin NC tabs dihydrochloride) SENSIPAR TABS (Use 5 PA; SP L-CARNITINE SOLN IJ NC cinacalcet hcl) sod benzoate & sod levocarnitine (metabolic 2 QL(30 ml daily) 2 modifiers) soln 1 gm/10ml phenylacetate soln sodium phenylbutyrate PA; SP levocarnitine (metabolic 2 QL(3 ea daily) 2 modifiers) tabs 330 mg powd or 3 gm/tsp PA; SP sodium phenylbutyrate tabs 2 SP LUMIZYME SOLR 5 or 500 mg PA; SP MEPSEVII SOLN 5 PA; SP STRENSIQ SOLN 5 PA; SP MYALEPT SOLR 5 PA; SP VIMIZIM SOLN 5 PA; SP NAGLAZYME SOLN 5 PA; SP XURIDEN PACK 5 PA; SP ZEMPLAR CAPS OR 1 nitisinone caps 2 MCG, 2 MCG (Use 4 paricalcitol) NITYR TABS 5 PA; SP ZEMPLAR SOLN IV 2 SP NULIBRY SOLR NC SP MCG/ML, 5 MCG/ML (Use 5 paricalcitol) ORFADIN CAPS 10 MG, 2 4 PA; SP Posterior Pituitary Hormones MG, 5 MG (Use nitisinone) DDAVP SOLN IJ 4 PA; SP ORFADIN CAPS 20 MG 4 PA; SP MCG/ML (Use 5 desmopressin acetate) PA; SP ORFADIN SUSP 4 MG/ML 4 DDAVP SOLN IJ 4 SP MCG/ML (Use 5 PALYNZIQ SOSY NC desmopressin acetate)

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP DDAVP SOLN NA 0.01 % 4 QL(5 ml per fill octreotide acetate soln 2 retail) DDAVP SOLN NA 0.01 % QL(5 ml per fill SANDOSTATIN LAR NC PA; SP (Use desmopressin acetate 4 retail); SP DEPOT KIT spray) SANDOSTATIN SOLN 5 PA; SP DDAVP TABS OR 0.1 MG QL(6 ea daily) (Use octreotide acetate) 4 (Use desmopressin SIGNIFOR LAR SRER NC PA; SP acetate) DDAVP TABS OR 0.2 MG QL(8 ea daily) SIGNIFOR SOLN 5 PA; SP (Use desmopressin 4 acetate) SOMATULINE DEPOT 4 PA; SP SOLN desmopressin acetate soln 2 PA; SP ij 4 mcg/ml Vasopressin Receptor Antagonists desmopressin acetate soln 2 SP PA; SP ij 4 mcg/ml JYNARQUE TABS 5 DESMOPRESSIN PA; SP JYNARQUE TBPK 5 PA; SP ACETATE SOLN NA 1.5 5 MG/ML SAMSCA TABS (Use 5 PA; SP tolvaptan) desmopressin acetate 2 QL(5 ml per fill spray refrigerated soln retail) tolvaptan tabs 15 mg 5 PA; SP desmopressin acetate 2 QL(5 ml per fill spray soln retail); SP tolvaptan tabs 30 mg 2 PA; SP desmopressin acetate tabs 2 QL(6 ea daily) or 0.1 mg VAPRISOL SOLN 5 desmopressin acetate tabs 2 QL(8 ea daily) or 0.2 mg ESTROGENS - Hormone Replacement/Modifying Drugs NOCDURNA SUBL NC Estrogen Combinations NOCTIVA EMUL NC ACTIVELLA TABS 0.1 MG- 0.5 MG (Use estradiol & 5 STIMATE SOLN 5 PA; SP norethindrone acetate) ACTIVELLA TABS 0.5 MG- QL(1 ea daily) VASOPRESSIN/DEXTROS NC 1 MG (Use estradiol & 5 E SOLN norethindrone acetate) VASOPRESSIN/SODIUM NC CHLORIDE SOLN ANGELIQ TABS 5 VASOSTRICT SOLN 5 BI-EST 50:50 COMPOUNDINGKIT NC Prolactin Inhibitors CREA BI-EST 50:50 cabergoline tabs 2 PROGESTERONE- TESTOSTERONE NC Somatostatic Agents COMPOUNDING KIT BYNFEZIA PEN SOPN NC CREA

MYCAPSSA CPDR NC SP

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BI-EST 80:20 DELESTROGEN OIL 20 5 PROGESTERONE NC MG/ML, 40 MG/ML (Use COMPOUNDING KIT estradiol valerate) CREA DEPO-ESTRADIOL OIL 5 BIJUVA CAPS 5 DIVIGEL GEL 4 CLIMARA PRO PTWK 4 QL(0.15 ea daily) EC-RX ESTRADIOL 0.4% NC CREA COMBIPATCH PTTW 0.05 4 MG/DAY-0.25 MG/DAY EC-RX ESTRADIOL 0.6% NC Limit 8 patches CREA COMBIPATCH PTTW 0.14 4 per ELESTRIN GEL 5 MG/DAY-0.05 MG/DAY month;QL(0.29 ea daily) ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use 5 DUAVEE TABS 4 estradiol) estradiol & norethindrone estradiol pttw td 0.025 QL(0.29 ea acetate tabs 0.1 mg-0.5 2 mg/24hr, 0.0375 mg/24hr, 2 daily) mg, 0.5 mg-0.1 mg 0.05 mg/24hr, 0.075 estradiol & norethindrone QL(1 ea daily) mg/24hr, 0.1 mg/24hr acetate tabs 0.5 mg-1 mg, 2 estradiol ptwk td 0.025 QL(0.15 ea 1 mg-0.5 mg mg/24hr, 0.075 mg/24hr, daily) ESTRIOL- 0.1 mg/24hr, 0.05 mg/24hr, 2 0.06 mg/24hr, 37.5 PROGESTERONE NC COMPOUNDING KIT mcg/24hr CREA estradiol tabs or 0.5 mg, 1 2 FEMHRT TABS (Use mg, 2 mg norethindrone acetate- 5 estradiol valerate oil im 20 2 ethinyl estradiol) mg/ml, 40 mg/ml MYFEMBREE TABS NC ESTROGEL GEL 5 QL(1.67 gm daily) norethindrone acetate- 2 ETHINYL ESTRADIOL 5 ethinyl estradiol tabs POWD ORIAHNN CPPK 4 EVAMIST SOLN 4 QL(0.27 ml daily) PREFEST TABS 5 MENEST TABS NC PREMPHASE TABS 4 QL(1 ea daily) MENOSTAR PTWK 5 QL(0.15 ea daily) QL(1 ea daily) PREMPRO TABS 4 MINIVELLE PTTW 0.025 MG/24HR, 0.05 MG/24HR, NC Estrogens 0.075 MG/24HR, 0.1 ALORA PTTW 5 QL(0.29 ea MG/24HR (Use estradiol) daily) MINIVELLE PTTW 0.0375 NC QL(0.29 ea CLIMARA PTWK (Use 5 QL(0.15 ea MG/24HR (Use estradiol) daily) estradiol) daily) PREMARIN SOLR IJ 25 5 DELESTROGEN OIL 10 5 MG MG/ML 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN TABS OR 0.3 QL(1 ea daily) moxifloxacin hcl tabs or 2 MG, 0.45 MG, 0.625 MG, NC 0.9 MG, 1.25 MG MOXIFLOXACIN NC VIVELLE-DOT PTTW HYDROCHLORIDE SOLN 0.025 MG/24HR, 0.05 ofloxacin tabs 300 mg 2 MG/24HR, 0.075 NC MG/24HR, 0.1 MG/24HR QL(56 ea per ofloxacin tabs 400 mg 2 (Use estradiol) fill retail) VIVELLE-DOT PTTW QL(0.29 ea GASTROINTESTINAL AGENTS - MISC. - 0.0375 MG/24HR (Use NC daily) Miscellaneous Gastrointestinal Drugs estradiol) 5-HT4 Receptor Agonists FLUOROQUINOLONES - Drugs to Treat Bacterial Infections MOTEGRITY TABS NC Fluoroquinolones Agents for Chronic Idiopathic Constipation (CIC) AVELOX SOLN (Use moxifloxacin hcl in sodium 5 TRULANCE TABS 5 chloride) Antiflatulents BAXDELA SOLR 5 SIMETHICONE LIQD 5 RX/OTC BAXDELA TABS 5 Bile Acid Synthesis Disorder Agents CIPRO SUSR 5 5 PA; SP GM/100ML, 500 MG/5ML CHOLBAM CAPS 5 CIPRO TABS 250 MG, 500 5 Farnesoid X Receptor (FXR) Agonists MG (Use ciprofloxacin hcl) OCALIVA TABS 5 PA; SP ciprofloxacin hcl tabs or 2 QL(6 ea per fill 100 mg retail) Gallstone Solubilizing Agents ciprofloxacin hcl tabs or 2 250 mg, 500 mg, 750 mg ACTIGALL CAPS (Use 4 QL(3 ea daily) ursodiol) ciprofloxacin in d5w soln 2 CHENODAL TABS 5 PA; SP ciprofloxacin susr or 2 RELTONE CAPS NC QL(1 ea LEVAQUIN TABS (Use 5 URSO 250 TABS (Use QL(7 ea daily) levofloxacin) daily,14 ea per 4 fill retail) ursodiol) URSO FORTE TABS (Use 4 levofloxacin in d5w soln 2 ursodiol) URSODIOL CAPS OR 200 levofloxacin soln iv 25 2 NC mg/ml MG, 400 MG QL(3 ea daily) levofloxacin soln or 25 2 ursodiol caps or 300 mg 2 mg/ml QL(1 ea ursodiol tabs or 250 mg 2 QL(7 ea daily) levofloxacin tabs or 250 2 daily,14 ea per mg, 500 mg, 750 mg fill retail) ursodiol tabs or 500 mg 2 moxifloxacin hcl in sodium 2 URSODIOL/SYRSPEND NC chloride soln SF PH4 SUSP 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Gastrointestinal Antiallergy Agents AZULFIDINE EN-TABS 5 TBEC (Use sulfasalazine) cromolyn sodium 2 (mastocytosis) conc AZULFIDINE TABS (Use 5 sulfasalazine) GASTROCROM CONC (Use cromolyn sodium 5 balsalazide disodium caps 2 QL(9 ea daily) (mastocytosis)) CANASA SUPP (Use 5 Gastrointestinal Chloride Channel Activators mesalamine) AMITIZA CAPS (Use NC lubiprostone) CIMZIA KIT 200 MG NC lubiprostone caps NC CIMZIA KIT 200 MG/ML NC SP

Gastrointestinal Stimulants CIMZIA STARTER KIT KIT NC DEXPANTHENOL SOLN IJ NC COLAZAL CAPS (Use NC QL(9 ea daily) balsalazide disodium) GIMOTI SOLN NC SP DELZICOL CPDR (Use NC QL(12 ea daily) mesalamine) METOCLOPRAMIDE HCL 5 MONOHYDRATE POWD DIPENTUM CAPS 5 METOCLOPRAMIDE HCL 5 POWD XX ENTYVIO SOLR NC SP metoclopramide hcl soln ij 2 5 mg/ml INFLECTRA SOLR NC SP metoclopramide hcl soln or 2 10 mg/10ml, 5 mg/5ml LIALDA TBEC (Use NC mesalamine) metoclopramide hcl tabs or 2 10 mg, 5 mg mesalamine cp24 or 0.375 2 gm metoclopramide hcl tbdp or 2 5 mg mesalamine cpdr or 400 2 QL(12 ea daily) mg METOCLOPRAMIDE 5 HYDROCHLORIDE POWD mesalamine enem re 4 gm 2 QL(60 ml daily) METOCLOPRAMIDE ODT 5 RX/OTC TBDP MESALAMINE POWD XX 5 METOCLOPRAMIDE ODT NC mesalamine supp re 1000 2 TBDP mg REGLAN TABS (Use 5 metoclopramide hcl) mesalamine tbec or 1.2 gm 2 Inflammatory Bowel Agents mesalamine tbec or 800 NC mg 5-AMINOSALICYLIC ACID 5 RX/OTC POWD mesalamine w/ cleanser kit 2 APRISO CP24 (Use 5 mesalamine) PENTASA CPCR 4 QL(8 ea daily) ASACOL HD TBEC (Use 2 PA; SP mesalamine) REMICADE SOLR 4 AVSOLA SOLR NC RENFLEXIS SOLR NC SP

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROWASA KIT (Use 5 FOSRENOL PACK 1000 NC mesalamine w/ cleanser) MG, 750 MG SFROWASA ENEM 5 lanthanum carbonate chew NC

SULFASALAZINE POWD 5 PHOSLYRA SOLN 4 XX RENAGEL TABS (Use 5 sulfasalazine tabs or 2 sevelamer hcl) sulfasalazine tbec or 2 RENVELA PACK (Use 5 sevelamer carbonate) Intestinal Acidifiers RENVELA TABS (Use 5 sevelamer carbonate) lactulose (encephalopathy) 2 soln sevelamer carbonate pack 2 Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate tabs 2 alosetron hcl tabs 2 QL(2 ea daily) sevelamer hcl tabs 2 LINZESS CAPS 4 VELPHORO CHEW 4 LOTRONEX TABS (Use 5 QL(2 ea daily) alosetron hcl) Short Bowel Syndrome (SBS) Agents VIBERZI TABS 4 GATTEX KIT 5 PA; SP ZELNORM TABS NC Tryptophan Hydroxylase Inhibitors Peripheral Opioid Receptor Antagonists XERMELO TABS 5 PA; SP alvimopan caps 5 GENERAL ANESTHETICS ENTEREG CAPS (Use 5 alvimopan) Anesthetics - Misc. AMIDATE SOLN (Use 5 MOVANTIK TABS 4 etomidate) RELISTOR SOLN 5 ANESTHESIA S/I-40 KIT NC

RELISTOR TABS 5 ANESTHESIA S/I-40A KIT NC

SYMPROIC TABS 4 ANESTHESIA S/I-40H KIT NC

Phosphate Binder Agents ANESTHESIA S/I-40S KIT NC AURYXIA TABS 5 ANESTHESIA S/I-60 KIT NC calcium acetate (phosphate 2 binder) caps DIPRIVAN EMUL 100 5 MG/10ML calcium acetate (phosphate 2 RX/OTC binder) tabs DIPRIVAN EMUL 200 MG/20ML, 500 MG/50ML, 5 FOSRENOL CHEW 1000 1000 MG/100ML (Use MG, 500 MG, 750 MG (Use NC propofol) lanthanum carbonate) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits etomidate soln iv 2 isoflurane soln 2

FRESENIUS PROPOVEN NC sevoflurane soln 2 2% EMUL SUPRANE SOLN (Use KETALAR SOLN (Use 5 5 ketamine hcl) desflurane) ketamine hcl soln ij 10 ULTANE SOLN (Use 5 mg/ml, 100 mg/ml, 50 2 sevoflurane) mg/ml GENITOURINARY AGENTS - MISCELLANEOUS KETAMINE - Miscellaneous Drugs to Treat Reproductive HYDROCHLORIDE SOLN NC Organs and Urinary System IJ 0.6 MG/ML, 1 MG/ML Acidifiers KETAMINE HYDROCHLORIDE SOLN 5 K-PHOS NO 2 TABS 5 IJ 10 MG/ML KETAMINE Alkalinizers HYDROCHLORIDE SOLN NC ORACIT SOLN 5 IV 100 MG/100ML KETAMINE pot & sod citrates w/citric 2 HYDROCHLORIDE SOSY ac soln IJ 20 MG/2ML, 30 NC potassium citrate 2 MG/3ML, 50 MG/5ML, 50 (alkalinizer) tbcr MG/ML POTASSIUM CITRATE 5 RX/OTC KETAMINE GRAN HYDROCHLORIDE SOSY POTASSIUM CITRATE 5 RX/OTC IV 100 MG/2ML, 30 NC MONOHYDRATE GRAN MG/3ML, 50 MG/5ML, 50 POTASSIUM CITRATE MG/ML 5 POWD KETAMINE NC potassium citrate-citric acid 2 HYDROCHLORIDE TROC pack SL 100 MG SODIUM CITRATE RX/OTC KETAMINE 5 HYDROCHLORIDE/SODIU NC ANHYDROUS GRAN M CHLORIDE SOSY SODIUM CITRATE 5 propofol emul 200 ANHYDROUS POWD mg/20ml, 500 mg/50ml, 2 SODIUM CITRATE CRYS 5 1000 mg/100ml XX Barbiturate Anesthetics UROCIT-K 10 TBCR (Use potassium citrate 4 BREVITAL SODIUM SOLR 5 (alkalinizer)) UROCIT-K 15 TBCR (Use METHOHEXITAL SODIUM NC potassium citrate 4 SOSY (alkalinizer)) Volatile Anesthetics UROCIT-K 5 TBCR (Use desflurane soln 2 potassium citrate 4 (alkalinizer)) FORANE SOLN (Use 5 Cystinosis Agents isoflurane)

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYSTAGON CAPS 5 PA; SP dutasteride caps or 2 QL(1 ea daily)

PROCYSBI CPDR 25 MG 5 PA; SP dutasteride-tamsulosin hcl 2 QL(1 ea daily) caps PROCYSBI CPDR 75 MG 5 PA; QL(0.034 QL(1 ea daily) ea daily); SP finasteride tabs or 2 PROCYSBI PACK 300 MG, NC FLOMAX CAPS (Use 5 QL(2 ea daily) 75 MG tamsulosin hcl) Genitourinary Irrigants JALYN CAPS (Use NC QL(1 ea daily) dutasteride-tamsulosin hcl) acetic acid soln ir 0.25 % 2 PROSCAR TABS (Use 5 QL(1 ea daily) finasteride) glycine (gu irrigant) soln 2 RAPAFLO CAPS (Use NC silodosin) GLYCINE (L) POWD 5 RX/OTC silodosin caps 2 GLYCINE POWD XX 5 RX/OTC tamsulosin hcl caps 2 QL(2 ea daily) neomycin/polymyxin b gu 2 soln UROXATRAL TB24 (Use NC QL(1 ea daily) alfuzosin hcl) RENACIDIN SOLN 5 Urinary Analgesics sodium chloride (gu 2 irrigant) soln PHENAZOPYRIDINE HCL 5 POWD XX SORBITOL SOLN IR 3 %, 5 3.3 % phenazopyridine hcl tabs or 2 100 mg, 200 mg SORBITOL-MANNITOL 5 SOLN PYRIDIUM TABS (Use 5 phenazopyridine hcl) SORBITOL/MANNITOL 5 IRRIGATION SOLN Urinary Stone Agents Hyperoxaluria Agents LITHOSTAT TABS NC SP OXLUMO SOLN NC THIOLA EC TBEC NC SP Interstitial Cystitis Agents THIOLA TABS (Use NC PA; SP tiopronin) ELMIRON CAPS NC tiopronin tabs or 2 PA; SP PENTOSAN POLYSULFATE SODIUM NC DR CPDR GOUT AGENTS - Drugs to Treat Gout RIMSO-50 SOLN NC Gout Agent Combinations colchicine w/ probenecid 2 Prostatic Hypertrophy Agents tabs alfuzosin hcl tb24 2 QL(1 ea daily) Gout Agents allopurinol sodium solr 2 AVODART CAPS (Use 5 QL(1 ea daily) dutasteride) allopurinol tabs or 100 mg, 2 CARDURA XL TB24 5 ST 300 mg

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALOPRIM SOLR (Use 5 CORIFACT KIT 5 PA; SP allopurinol sodium) PA; SP colchicine caps or NC ELOCTATE SOLR 4 PA; SP COLCHICINE POWD XX 5 FEIBA SOLR 5 PA; SP colchicine tabs or 2 FIBRYGA SOLR 5 PA; SP COLCRYS TABS (Use NC HELIXATE FS KIT NC colchicine) PA; SP febuxostat tabs 2 QL(1 ea daily) HEMOFIL M SOLR 5 PA; SP GLOPERBA SOLN NC HUMATE-P SOLR 5 PA; SP KRYSTEXXA SOLN 5 PA; SP IDELVION SOLR 5 PA; SP MITIGARE CAPS (Use 2 IXINITY SOLR 5 colchicine) JIVI SOLR 4 PA; SP ULORIC TABS (Use NC QL(1 ea daily) febuxostat) KOATE SOLR 5 PA; SP ZYLOPRIM TABS (Use 5 allopurinol) KOATE-DVI SOLR 5 PA; SP Uricosurics PA; SP probenecid tabs 2 KOGENATE FS KIT NC PA; SP HEMATOLOGICAL AGENTS - MISC. - Drugs to KOVALTRY SOLR 4 Treat Blood Disorders MONONINE SOLR 5 PA; SP Antihemophilic Products PA; SP ADVATE SOLR 4 PA; SP NOVOSEVEN RT SOLR 5 PA; SP ADYNOVATE SOLR 4 PA; SP NUWIQ KIT 4 PA; SP AFSTYLA KIT 4 PA; SP NUWIQ SOLR 4 PA; SP ALPHANATE SOLR 5 PA; SP OBIZUR SOLR 5 ALPHANATE/VON PA; SP PROFILNINE SD SOLR 5 PA; SP WILLEBRANDFACTOR 5 COMPLEX/HUMAN SOLR PROFILNINE SOLR 5 PA; SP ALPHANINE SD SOLR 5 PA; SP RECOMBINATE SOLR 5 PA; SP ALPROLIX SOLR NC RIASTAP SOLR 5 PA; SP BENEFIX KIT 5 PA; SP RIXUBIS SOLR 5 PA; SP COAGADEX SOLR 5 PA; SP TRETTEN SOLR 5 PA; SP

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WILATE KIT 5 PA; SP dipyridamole tabs or 25 2 mg, 50 mg, 75 mg PA; SP XYNTHA KIT 5 DURLAZA CP24 NC PA; SP XYNTHA SOLOFUSE KIT 5 EFFIENT TABS 10 MG 5 QL(1 ea daily) (Use prasugrel hcl) Bradykinin B2 Receptor Antagonists EFFIENT TABS 5 MG (Use 5 QL(2 ea daily) prasugrel hcl) FIRAZYR SOLN (Use 5 PA; SP icatibant acetate) PLAVIX TABS (Use NC clopidogrel bisulfate) icatibant acetate soln 2 PA; SP prasugrel hcl tabs 10 mg 2 QL(1 ea daily) Complement Inhibitors QL(2 ea daily) BERINERT KIT NC SP prasugrel hcl tabs 5 mg 2

CINRYZE SOLR 5 PA; SP YOSPRALA TBEC NC

HAEGARDA SOLR 5 PA; SP ZONTIVITY TABS NC HEMATOPOIETIC AGENTS - Drugs to Treat SOLIRIS SOLN 4 PA; SP Blood Disorders Hematorheologic Agents Agents for Gaucher Disease pentoxifylline tbcr or 2 CERDELGA CAPS 4 PA; SP

Plasma Kallikrein Inhibitors CEREZYME SOLR 4 PA; SP KALBITOR SOLN 5 PA; SP ELELYSO SOLR NC SP TAKHZYRO SOLN 4 PA; SP miglustat caps 2 PA; SP Platelet Aggregation Inhibitors VPRIV SOLR 5 PA; SP AGGRENOX CP12 (Use 5 aspirin-dipyridamole) ZAVESCA CAPS (Use 5 PA; SP miglustat) AGRYLIN CAPS (Use 4 anagrelide hcl) Agents for Sickle Cell Disease anagrelide hcl caps 2 ADAKVEO SOLN 5 PA; SP aspirin-dipyridamole cp12 2 DROXIA CAPS 5 ASPIRIN/OMEPRAZOLE NC PA; SP ER TBEC ENDARI PACK 5 ASPIRIN/OMEPRAZOLE NC TBEC OXBRYTA TABS NC BRILINTA TABS 4 SIKLOS TABS 5 cilostazol tabs 2 Cobalamins B-12 COMPLIANCE clopidogrel bisulfate tabs or 2 5 75 mg, 300 mg INJECTIONKIT KIT 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyanocobalamin soln ij 2 LEUKINE SOLR 5 PA; SP 1000 mcg/ml MIRCERA SOSY 100 SP CYANOCOBALAMIN NC SOLN IJ 2000 MCG/ML MCG/0.3ML, 150 MCG/0.3ML, 200 NC hydroxocobalamin acetate 2 soln MCG/0.3ML, 30 MCG/0.3ML METHYLCOBALAMIN SOLN IJ 150 MG/30ML, 30 NC MIRCERA SOSY 50 MG/30ML, 300 MG/30ML MCG/0.3ML, 75 NC MCG/0.3ML METHYLCOBALAMIN SOLR IJ 10000 MCG, NC MULPLETA TABS 4 PA; SP 50000 MCG NEULASTA ONPRO KIT NC PA; SP NASCOBAL SOLN 5 PSKT NEULASTA SOSY NC PA; SP PHYSICIANS EZ USE B- 5 12 COMPLIANCE KIT KIT SP VITAMIN DEFICIENCY NEUPOGEN SOLN NC INJECTABLE SYSTEM- 5 SP B12 KIT NEUPOGEN SOSY NC Folic Acid/Folates NIVESTYM SOLN 4 PA; SP folic acid caps or 0.8 mg, 6 AL(Up to 55 yrs 800 mcg old ) NIVESTYM SOSY 4 PA; SP FOLIC ACID POWD XX 5 RX/OTC NPLATE SOLR 5 PA; SP folic acid soln ij 5 mg/ml 2 NYVEPRIA SOSY NC RX/OTC folic acid tabs or 1 mg 2 PROCRIT SOLN 10000 SP UNIT/ML, 2000 UNIT/ML, folic acid tabs or 800 mcg, 6 AL(Up to 55 yrs 400 mcg old ) 20000 UNIT/ML, 3000 NC UNIT/ML, 4000 UNIT/ML, Hematopoietic Growth Factors 40000 UNIT/ML ARANESP ALBUMIN 4 PA; SP PROMACTA PACK 5 PA; SP FREE SOLN PA; SP ARANESP ALBUMIN 4 PA; SP PROMACTA TABS 5 FREE SOSY DOPTELET TABS 4 PA; SP REBLOZYL SOLR NC SP RETACRIT SOLN 10000 PA; SP EPOGEN SOLN NC UNIT/ML, 2000 UNIT/ML, PA 20000 UNIT/2ML, 20000 4 FULPHILA SOSY NC UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 GRANIX SOLN 300 NC MCG/ML, 480 MCG/1.6ML UNIT/ML GRANIX SOSY 300 SP UDENYCA SOSY NC PA; SP MCG/0.5ML, 480 NC MCG/0.8ML ZARXIO SOSY 300 NC SP MCG/0.5ML

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZARXIO SOSY 480 NC fe fumarate-vitamin c- 2 RX/OTC MCG/0.8ML vitamin b12-folic acid caps ZIEXTENZO SOSY 4 PA; SP FEONYX TABS NC

Hematopoietic Mixtures FERIVA 21/7 TABS NC ACTIVE FE TABS 5 FERIVAFA CAPS 5 ANIMI-3 CAPS 5 FERRALET 90 TABS 5 ANIMI-3/VITAMIN D CAPS 5 FERRAPLUS 90 TABS 5 AXIFOL CAPS NC FERRO-PLEX HEMATINIC 5 TABS B-6 FOLIC ACID CAPS 5 ferrous fumarate w/ b12-vit 2 c-fa-ifc caps BP VIT 3 CAPS 5 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu 2 CENFOL TABS 5 tabs CENTRATEX CAPS 5 ferrous fumarate-folic acid 2 tabs CHOLECAL DF TABS NC FOLGARD RX TABS (Use folic acid-vitamin b6-vitamin 5 CIFEREX CAPS 5 b12) FOLI-D TABS NC CIFRAZOL CAPS 5 RX/OTC CORVITE 150 TABS 1.25 FOLIC + B12 TABS 5 MG-10 MG-15 MCG-25 folic acid-cholecalciferol NC MG-120 MG-150 MG (Use 5 tabs iron-folic acid-vitamin c- vitamin b6-vitamin b12- folic acid-vitamin b6-vitamin 2 zinc) b12 tabs CORVITE 150 TABS 5 FOLIC D3 CAPS NC MG-10 MG-10 MG-20 MCG-25 MG-100 MCG- 5 FOLIKA-D TABS NC 120 MG-150 MG-300 MCG-700 MCG FOLITE TABS NC CORVITE FE TABS 5 FOLIVANE-F CAPS 5 cyanocobalamin- 2 methylcobalamin subl FOLIVANE-PLUS CAPS NC DERMACINRX 5 PUREFOLIX TABS FOLIXAPURE TABS NC DURACHOL CAPS 5 FOLTRATE TABS 5 RX/OTC fe fum-iron polysacch complex-fa-b complex-c- 2 FOLTREXYL TABS NC zn-mn-cu caps 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLVITE FE TABS NC METHIONINE/INOSITOL/C HOLINE/CYANOCOBALA NC FUSION PLUS CAPS 5 MIN SOLN MTX SUPPORT TABS 5 RX/OTC FUSION SPRINKLES NC PACK MULTIGEN FOLIC TABS 5 GENICIN VITA-D TABS (Use folic acid- NC MULTIGEN PLUS TABS 5 cholecalciferol) HEMATOGEN FA CAPS 5 MULTIGEN TABS 5 HEMATRON-AF TABS RX/OTC NEPHRON FA TABS 5 (Use iron-docusate-b12- 5 folic acid-vit c-vit e-copper- NEURIN-SL SUBL (Use biotin) cyanocobalamin- 5 methylcobalamin) HEMETAB TABS 5 NIFEREX TABS 5 HEMOCYTE PLUS CAPS 5 NUFERA TABS 5 ICAR-C PLUS TABS (Use RX/OTC iron-vitamin c-vitamin b12- NC OPURITY B12/FOLIC 5 RX/OTC folic acid) ACID TABS INTEGRA F CAPS 5 ORTHO DF CAPS NC

INTEGRA PLUS CAPS NC ORTHO-FOLIC CAPS NC iron combinations caps 2 RX/OTC OVEEZA CAPS NC iron polysaccharide REVESTA CAPS NC complex-vit b12-folic acid 2 caps TALIVA CAPS NC iron-docusate-b12-folic RX/OTC acid-vit c-vit e-copper-biotin 2 TARON FORTE CAPS 5 tabs iron-folic acid-vitamin c- VIRT-FEFA PLUS CAPS NC vitamin b6-vitamin b12-zinc 2 tabs VITAMEZ CAPS 5 iron-vitamin c-vitamin b12- NC RX/OTC VITAMIN B12/FOLIC ACID RX/OTC folic acid tabs 5 TABS IROSPAN 24/6 MISC 5 Iron IS 24/6 MISC 5 ACCRUFER CAPS NC

LIPO-B SOLN NC FERAHEME SOLN (Use 5 ferumoxytol) MAXFE TABS 5 FERRLECIT SOLN (Use sodium ferric gluconate 5 complex in sucrose)

169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERROUS SULFATE 5 RX/OTC tranexamic acid soln iv 2 ANHYDROUS POWD 1000 mg/10ml FERROUS SULFATE 5 RX/OTC tranexamic acid tabs or 650 2 QL(6 ea daily) GRAN mg FERROUS SULFATE 5 RX/OTC TRANEXAMIC HEPTAHYDRATE GRAN ACID/SODIUM CHLORIDE NC SOLN FERROUS SULFATE 5 RX/OTC POWD Hemostatics - Topical ferumoxytol soln 5 ARTISS SOLN 5

INFED SOLN 5 ASTRINGYN SOLN 5

INJECTAFER SOLN 5 GEL-FLOW KIT NC

MONOFERRIC SOLN NC GELFOAM-JMI POWDER NC KIT KIT sodium ferric gluconate 2 GELFOAM-JMI SPONGE NC complex in sucrose soln KIT KIT TRIFERIC PACK NC MONSELS FERRIC 5 SUBSULFATE SOLN TRIFERIC SOLN NC RECOTHROM SOLR 5 VENOFER SOLN 5 RECOTHROM SPRAY KIT 5 SOLR Stem Cell Mobilizers RECOTHROM/SPRAY 5 MOZOBIL SOLN 4 PA; SP APPLICATOR KIT SOLR HEMOSTATICS - Drugs to Stop Bleeding/Treat TACHOSIL PTCH 5 Blood Disorders THROMBIN-JMI DILUENT 5 Hemostatics - Systemic SOLR AMICAR SOLN 0.25 PA; SP THROMBIN-JMI 5 GM/ML (Use aminocaproic NC EPISTAXIS KIT acid) THROMBIN-JMI SYRINGE 5 AMICAR TABS 1000 MG, SPRAY KIT KIT 500 MG (Use aminocaproic 5 THROMBIN-JMI W/DIL acid) SPRAYPUMP ACTUATOR 5 KIT aminocaproic acid soln iv 2 PA; SP 250 mg/ml THROMBOGEN KIT 5 aminocaproic acid soln or 2 PA; SP 0.25 gm/ml THROMBOGEN SOLR 5 aminocaproic acid tabs or 2 1000 mg, 500 mg TISSEEL KIT 5 CYKLOKAPRON SOLN 5 (Use tranexamic acid) TISSEEL SOLN 5 LYSTEDA TABS (Use 5 QL(6 ea daily) tranexamic acid) HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Barbiturate Hypnotics BYFAVO SOLR NC AMYTAL SODIUM SOLR 5 CHLORAL HYDRATE 5 CRYS BUTISOL SODIUM TABS 5 dexmedetomidine hcl in 2 NEMBUTAL SODIUM sodium chloride soln SOLN (Use pentobarbital 5 DEXMEDETOMIDINE HCL sodium) SOLN 1000 MCG/10ML, NC 400 MCG/4ML PENTOBARBITAL 5 SODIUM POWD XX dexmedetomidine hcl soln 2 200 mcg/2ml pentobarbital sodium soln ij 2 DEXMEDETOMIDINE HYDROCHLORIDE/DEXT phenobarbital elix or 20 2 NC mg/5ml ROSE MONOHYDRATE SOLN PHENOBARBITAL POWD 5 XX DEXMEDETOMIDINE HYDROCHLORIDE/SODIU 5 PHENOBARBITAL 5 SODIUM POWD XX M CHLORIDE SOSY DORAL TABS (Use QL(1 ea daily) phenobarbital sodium soln 2 5 ij 130 mg/ml, 65 mg/ml quazepam) ST; QL(1 ea phenobarbital soln or 20 2 EDLUAR SUBL 5 mg/5ml daily) phenobarbital tabs or 100 estazolam tabs 2 mg, 60 mg, 64.8 mg, 97.2 2 mg, 15 mg, 16.2 mg, 30 eszopiclone tabs 2 QL(1 ea daily) mg, 32.4 mg flurazepam hcl caps 2 QL(1 ea daily) SECONAL SODIUM CAPS 5 HALCION TABS (Use 5 QL(1 ea daily) Hypnotic Combinations triazolam) MIDAZOLAM/KETAMINE INTERMEZZO SUBL (Use NC HYDROCHLORIDE/ONDA NC zolpidem tartrate) NSETRON HYDROCHLORIDE TROC LUNESTA TABS (Use NC QL(1 ea daily) eszopiclone) MKO MELT DOSE PACK NC TROC midazolam hcl soln 2 Hypnotics - Tricyclic Agents midazolam hcl syrp 2 doxepin hcl (sleep) tabs 2 QL(1 ea daily) MIDAZOLAM NC HYDROCHLORIDE SOLN SILENOR TABS (Use NC QL(1 ea daily) doxepin hcl (sleep)) MIDAZOLAM Non-Barbiturate Hypnotics HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN AMBIEN CR TBCR (Use 5 QL(1 ea daily) zolpidem tartrate) MIDAZOLAM HYDROCHLORIDE/SODIU NC AMBIEN TABS (Use 5 QL(1 ea daily) M CHLORIDE SOSY zolpidem tartrate)

171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIDAZOLAM SOLN IV 100 NC Selective Melatonin Receptor Agonists MG/100ML HETLIOZ CAPS 5 PA; SP MIDAZOLAM SOSY IJ 2 NC MG/2ML HETLIOZ LQ SUSP 5 PA; SP MIDAZOLAM SOSY IV 2 MG/2ML, 25 MG/25ML, 30 NC QL(1 ea daily) MG/30ML, 50 MG/50ML ramelteon tabs 2 ROZEREM TABS (Use QL(1 ea daily) MIDAZOLAM/SODIUM NC NC CHLORIDE SOLN ramelteon) MIDAZOLAM/SODIUM NC LAXATIVES - Bowel Treatment Drugs CHLORIDE SOSY MIDAZOLAM/SYRSPEND NC Laxative Combinations SF PH4 SUSP bisacodyl-peg 3350-pot QL(1 ea per fill chloride-sod bicarb-sod 2 retail) PRECEDEX SOLN 0.9 %- 5 1000 MCG/250ML chloride kit PRECEDEX SOLN 0.9 %- CLENPIQ SOLN 4 200 MCG/50ML, 0.9 %-400 MCG/100ML, 0.9 %-80 5 COLYTE-FLAVOR PACKS QL(4000 ml per MCG/20ML (Use SOLR (Use peg 3350-kcl- 5 fill retail) dexmedetomidine hcl in sod bicarb-sod chloride-sod sodium chloride) sulfate) PRECEDEX SOLN 200 GOLYTELY SOLR 2.82 MCG/2ML (Use 5 GM-5.53 GM-6.36 GM-21.5 NC dexmedetomidine hcl) GM-227.1 GM quazepam tabs NC GOLYTELY SOLR 2.97 QL(4000 ml per GM-5.86 GM-6.74 GM- fill retail) 22.74 GM-236 GM (Use NC RESTORIL CAPS (Use 5 QL(1 ea daily) temazepam) peg 3350-kcl-sod bicarb- sod chloride-sod sulfate) temazepam caps 2 QL(1 ea daily) MOVIPREP SOLR (Use QL(1 ea daily) peg 3350-kcl-nacl-na NC triazolam tabs 2 sulfate-na ascorbate- ascorbic acid) zaleplon caps 2 QL(1 ea daily) NULYTELY SOLR (Use zolpidem tartrate subl sl NC peg 3350-potassium 5 1.75 mg, 3.5 mg chloride-sod bicarbonate- sod chloride) zolpidem tartrate tabs or 10 2 QL(1 ea daily) mg, 5 mg NULYTELY/FLAVOR PACKS SOLR (Use peg zolpidem tartrate tbcr or 2 QL(1 ea daily) 6.25 mg, 12.5 mg 3350-potassium chloride- 5 sod bicarbonate-sod ZOLPIMIST SOLN NC QL(0.26 ml chloride) daily) Orexin Receptor Antagonists PCP 100 KIT NC ST; QL(1 ea BELSOMRA TABS 4 peg 3350-kcl-nacl-na daily) sulfate-na ascorbate- NC ascorbic acid solr DAYVIGO TABS NC

172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits peg 3350-kcl-sod bicarb- QL(4000 ml per BISACODYL POWD 5 sod chloride-sod sulfate 2 fill retail) solr CASCARA SAGRADA 5 peg 3350-potassium EXTR chloride-sod bicarbonate- 2 Surfactant Laxatives sod chloride solr DOCUSATE SODIUM 5 PLENVU SOLR NC POWD LOCAL ANESTHETICS-Parenteral - Drugs for PREPOPIK PACK 5 Numbing SUPREP BOWEL PREP NC Local Anesthetic Combinations KIT SOLN ACTIVE INJECTION KIT 5 SUTAB TABS NC LM-2 KIT 2 Laxatives - Miscellaneous articaine-epinephrine soct GIALAX KIT NC BUFFERED LIDOCAINE HYDROCHLORIDE/SODIU NC M BICARBONATE SOSY KRISTALOSE PACK 10 5 GM, 20 GM BUFFERED LIDOCAINE/SODIUMBICA NC LACTULOSE PACK 10 GM NC RBONATE SOSY lactulose soln 10 gm/15ml, 2 bupivacaine w/ epinephrine 2 20 gm/30ml soln Lubricant Laxatives CITANEST FORTE 5 DENTAL SOLN MINERAL OIL HEAVY OIL 5 RX/OTC D-CARE 100X KIT NC MINERAL OIL LIGHT OIL 5 RX/OTC LETS KIT KIT 5 RX/OTC MINERAL OIL OIL OR 4 LIDOCAINE HYDROCHLORIDE/SODIU NC mineral oil oil or 100 %, 2 RX/OTC 99.9 %, M BICARBONATE SOSY RX/OTC LIDOCAINE MINERAL OIL OIL XX 5 HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN MURI-LUBE OIL 5 RX/OTC LIDOCAINE Saline Laxatives HYDROCHLORIDE/SODIU NC M CHLORIDE SOSY EPSOM SALT POWD 5 RX/OTC lidocaine w/ epinephrine 2 soln MAGNESIUM SULFATE 5 RX/OTC HEPTAHYDRATE POWD LIDOMAR SOLN NC MAGNESIUM SULFATE 5 RX/OTC POWD XX MARCAINE/EPINEPHRIN E SOLN (Use bupivacaine 5 OSMOPREP TABS NC w/ epinephrine) Stimulant Laxatives MARLIDO KIT KIT 5

173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MARLIDO-25 KIT 5 BUPIVACAINE HCL 5 POWD XX MARVONA SUIK KIT 5 bupivacaine hcl soln ij 0.25 NC % ORABLOC SOCT 1 bupivacaine hcl soln ij 0.25 2 :100000-4 % (Use 5 %, 0.5 %, 0.75 % articaine-epinephrine) BUPIVACAINE HCL SOLN 5 ORABLOC SOCT 1 5 XX 4760 MG/119ML :200000-4 % BUPIVACAINE P-CARE 100MX KIT NC HYDROCHLORIDE SOLN 5 0.125 %, 312.5 MG/10ML P-CARE MG KIT 5 BUPIVACAINE HYDROCHLORIDE SOSY POINT OF CARE LM-2.2 5 0.125 %, 0.5 %, 125 NC KIT MG/4ML, 250 MG/8ML, POINT OF CARE LM-2.5 5 312.5 MG/10ML, 625 KIT MG/20ML READYSHARP-A KIT NC BUPIVACAINE HYDROCHLORIDE/SODIU NC RECK SOSY NC M CHLORIDE SOLN BUPIVACAINE ROPIVACAINE HYDROCHLORIDE/SODIU NC HYDROCHLORIDE/CLONI M CHLORIDE SOSY DINE NC HYDROCHLORIDE/KETO BUPIVACAINE ROLAC SOSY HYDROCHLORIDEMONO 5 HYDRATE POWD SENSORCAINE- 5 MPF/EPINEPHRINE SOLN bupivacaine in dextrose 2 soln XYLOCAINE- MPF/EPINEPHRINE SOLN 5 CARBOCAINE SOLN (Use 5 1 %-1 :200000 mepivacaine hcl) XYLOCAINE- CITANEST PLAIN 5 MPF/EPINEPHRINE SOLN DENTAL SOLN DURASAFE 1 :200000-1.5 %, 1 5 :200000-2 %, 1.5 %-1 SPINAL/EPIDURALTRAY/ :200000 (Use lidocaine w/ 1% 5 epinephrine) XYLOCAINE/19GX36"CLO XYLOCAINE/EPINEPHRIN SE CATH KIT E SOLN (Use lidocaine w/ 5 DURASAFE epinephrine) SPINAL/EPIDURALTRAY/ 1% 5 Local Anesthetics - Amides XYLOCAINE/19GX36"OPE BD PUDENDAL/LOCAL N CATH KIT BLOCKTRAY 1% 5 DURASAFE LIDOCAINE KIT SPINAL/EPIDURALTRAY/ BUPIVACAINE 5 1% 5 FISIOPHARMA SOLN XYLOCAINE/20GX36"CLO SE CATH KIT BUPIVACAINE HCL 5 MONOHYDRATE POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DURASAFE MONOJECT BONE SPINAL/EPIDURALTRAY/ MARROW BIOPSY 5 1% 5 TRAY/STERNAL-ILIAC XYLOCAINE/20GX36"OPE NEEDLE 16G KIT N CATH KIT NAROPIN SOLN (Use 5 EXPAREL SUSP 5 ropivacaine hcl) P-CARE M KIT NC lidocaine hcl (local anesth.) 2 jtaj id 0.5 mg P-CARE X KIT 5 lidocaine hcl (local anesth.) soln ij 0.5 %, 1 %, 1.5 %, 2 2 PF-LIDOCAINE NC %, 4 % HYDROCHLORIDE SOSY lidocaine hcl (local anesth.) NC READYSHARP 5 soln ij 1 % LIDOCAINE KIT LIDOCAINE 5 ropivacaine hcl soln 2 HCL/DEXTROSE SOLN LIDOCAINE ROPIVACAINE HYDROCHLORIDE SOLN 5 HYDROCHLORIDE SOLN NC IJ 1 %, 2 % EP 0.2 % LIDOCAINE ROPIVACAINE HYDROCHLORIDE SOSY HYDROCHLORIDE SOLN 2 IJ 10 MG/ML, 100 IJ 2 MG/ML MG/10ML, 100 MG/5ML, NC ROPIVACAINE 200 MG/10ML, 40 HYDROCHLORIDE SOLN NC MG/2ML, 400 MG/20ML, IJ 33.4 MG/ML 60 MG/3ML ROPIVACAINE LIDOMARK 1/5 KIT 5 HYDROCHLORIDE SOSY NC EP 0.5 % LIDOMARK 2/5 KIT 5 ROPIVACAINE HYDROCHLORIDE SOSY NC MARCAINE SOLN (Use 5 IJ 0.2 %, 0.5 % bupivacaine hcl) ROPIVACAINE MARCAINE SPINAL SOLN HYDROCHLORIDE/SODIU NC (Use bupivacaine in 5 M CHLORIDE SOLN dextrose) ROPIVACAINE MEPIVACAINE HCL 5 HYDROCHLORIDE/SODIU NC POWD XX M CHLORIDE SOSY mepivacaine hcl soln ij 1 2 %, 1.5 %, 2 % XARACOLL IMPL NC MONOJECT BONE XYLOCAINE SOLN (Use MARROW BIOPSY 5 lidocaine hcl (local 5 TRAY/BIOP ASPIR anesth.)) NEEDLE 11GX4" KIT XYLOCAINE-MPF SOLN MONOJECT BONE (Use lidocaine hcl (local 5 MARROW BIOPSY 5 anesth.)) TRAY/BIOP ASPIR ZINGO JTAJ (Use NEEDLE 8GX4" KIT lidocaine hcl (local 5 anesth.)) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Local Anesthetics - Esters ZITHROMAX Z-PAK TABS 5 QL(6 ea per fill (Use azithromycin) retail) chloroprocaine hcl soln 2 Clarithromycin CLOROTEKAL SOLN NC clarithromycin susr or 125 2 mg/5ml, 250 mg/5ml NESACAINE SOLN 5 clarithromycin tabs or 250 2 QL(28 ea per mg, 500 mg fill retail) NESACAINE-MPF SOLN 2 %, 3 % (Use 5 clarithromycin tb24 or 500 2 QL(14 ea per chloroprocaine hcl) mg fill retail) Erythromycins PROCAINE HCL CRYS 5 E.E.S. GRANULES SUSR tetracaine hcl soln ij 2 (Use erythromycin NC ethylsuccinate) MACROLIDES - Drugs to Treat Bacterial ERYPED 200 SUSR (Use Infections erythromycin NC ethylsuccinate) Azithromycin ERYPED 400 SUSR (Use QL(2 ea per fill azithromycin pack or 1 gm 2 erythromycin NC retail) ethylsuccinate) azithromycin solr iv 500 mg 2 ERYTHROCIN 5 LACTOBIONATE SOLR azithromycin susr or 100 2 mg/5ml, 200 mg/5ml erythromycin base cpep 2 azithromycin tabs or 250 2 QL(6 ea per fill mg retail) erythromycin base tabs 2 azithromycin tabs or 500 2 QL(3 ea daily) mg erythromycin base tbec 2 QL(1 ea ERYTHROMYCIN azithromycin tabs or 600 2 daily,10 ea per mg ETHYLSUCCINATE 5 fill retail) POWD XX ZITHROMAX PACK OR 1 5 QL(2 ea per fill erythromycin GM (Use azithromycin) retail) ethylsuccinate susr or 200 2 mg/5ml, 400 mg/5ml ZITHROMAX SOLR IV 500 5 MG (Use azithromycin) erythromycin ZITHROMAX SUSR OR ethylsuccinate tabs or 400 2 100 MG/5ML, 200 MG/5ML 5 mg (Use azithromycin) ERYTHROMYCIN POWD 5 ZITHROMAX TABS OR 5 QL(6 ea per fill 250 MG (Use azithromycin) retail) erythromycin stearate tabs 2 ZITHROMAX TABS OR 5 QL(3 ea daily) 500 MG (Use azithromycin) Fidaxomicin QL(1 ea DIFICID SUSR 4 ZITHROMAX TABS OR 5 daily,10 ea per 600 MG (Use azithromycin) fill retail) DIFICID TABS 4 ZITHROMAX TRI-PAK 5 QL(3 ea daily) TABS (Use azithromycin) MEDICAL DEVICES AND SUPPLIES

176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bandages-Dressings-Tape ADVANCED CURAD SOF- 5 RX/OTC GEL MISC 2ND SKIN BLISTER KIT 5 RX/OTC MISC AMD ANTIMICROBIAL 5 2ND SKIN BLISTER PADS RX/OTC FENESTRATED FOAM 5 DRESSING 3.5"X3" PADS MISC AMD FOAM DRESSING RX/OTC 2ND SKIN QUIKSTIK RX/OTC 5 4"X4" PADS ADHESIVE BANDAGES 5 MISC AMD FOAM DRESSING 5 RX/OTC 6"X6" PADS 2ND SKIN QUIKSTIK RX/OTC ADHESIVE BANDAGES 5 AMD FOAM RX/OTC SPORT PACK MISC DRESSING/TOPSHEET 5 4"X4" PADS 2ND SKIN SELF SEALING RX/OTC CUT CLOSURE 5 ANTIBACTERIAL RX/OTC BANDAGE MISC BANDAGES/EXTRA 5 LARGE MISC ADHESIVE BANDAGES 5 RX/OTC ANTIBACTERIAL MISC ANTIBACTERIAL CLEAR RX/OTC ADVANCED BANDAGES 5 ADHESIVE BANDAGES RX/OTC 5 MISC CLEAR MISC ANTIBACTERIAL CLEAR RX/OTC ADHESIVE BANDAGES 5 RX/OTC BANDAGES 7/8"/SPOT 5 FLEXIBLE FABRIC MISC MISC ADHESIVE BANDAGES 5 RX/OTC ANTIBACTERIAL PLASTIC RX/OTC FOAM MISC 5 BANDAGES 3/4"X3" MISC ADHESIVE BANDAGES RX/OTC BAND AID BUTTERFLY RX/OTC HEALTHAWARENESS 5 5 CLOSURE MEDIUM MISC MISC BAND-AID 1" MISC 5 RX/OTC ADHESIVE BANDAGES 5 RX/OTC HYPO-ALLERGENIC MISC BAND-AID ALL-IN-ONE ADHESIVE BANDAGES 5 RX/OTC ADHESIVE GAUZE 5 PLASTIC MISC PAD/LARGE PADS ADHESIVE BANDAGES 5 RX/OTC BAND-AID ALL-IN-ONE SHEER MISC ADHESIVE GAUZE 5 ADHESIVE BANDAGES 5 RX/OTC PAD/MEDIUM PADS STRONGSTRIPS MISC BAND-AID BABY SHARK 5 RX/OTC ADHESIVE BANDAGES 5 RX/OTC MISC WATER SHIELD MISC BAND-AID BUTTERFLY RX/OTC ADHESIVE 5 CLOSURE LARGE 2-3/4" 5 PADS/LARGE/3"X4" PADS X 1/2" MISC ADHESIVE BAND-AID CLEAR SPOTS 5 RX/OTC PADS/MEDIUM/2"X3" 5 7/8" MISC PADS BAND-AID DISNEY 5 RX/OTC ADVANCED CURAD 5 RX/OTC PRINCESS MISC AQUA-PROTECT MISC BAND-AID EMOJI MISC 5 RX/OTC ADVANCED CURAD 5 RX/OTC BLISTER-CARE MISC BAND-AID FAMILY PACK 5 RX/OTC MISC ADVANCED CURAD 5 RX/OTC COOL-WRAP MISC

177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BAND-AID FLEXIBLE 5 RX/OTC BAND-AID HYDRO SEAL RX/OTC FABRIC MISC BLISTER CUSHIONS 5 VARIETY MISC BAND-AID FLEXIBLE 5 RX/OTC FABRIC1" X 3" MISC BAND-AID HYDRO SEAL 5 RX/OTC EXTRA LARGE MISC BAND-AID FLEXIBLE 5 RX/OTC FABRICASSORTED MISC BAND-AID HYDRO SEAL 5 RX/OTC BAND-AID FLEXIBLE RX/OTC FINGERS MISC 5 FABRICEXTRA LARGE BAND-AID HYDRO SEAL 5 RX/OTC MISC LARGE MISC BAND-AID FLEXIBLE 5 RX/OTC BAND-AID INSIDE OUT 5 RX/OTC FABRICFINGERTIP MISC MISC BAND-AID FLEXIBLE RX/OTC BAND-AID ISLAND RX/OTC FABRICKNUCKLE & 5 SURGICALDRESSING 4" 5 FINGERTIP MISC X 10" PADS BAND-AID FLEXIBLE 5 RX/OTC BAND-AID ISLAND RX/OTC FABRICKNUCKLE MISC SURGICALDRESSING 4" 5 BAND-AID FLEXIBLE RX/OTC X 14" PADS FABRICTRAVEL PACK 5 BAND-AID KLING RX/OTC MISC ROLLED GAUZE LARGE 5 4" X 2.1 YDS MISC BAND-AID FLEXIBLE 5 RX/OTC MISC BAND-AID KLING RX/OTC RX/OTC ROLLED GAUZE LARGE 5 BAND-AID FROZEN MISC 5 4" X 2.5 YDS MISC BAND-AID KLING RX/OTC BAND-AID GAUZE PADS 5 RX/OTC LARGE4" X 4" PADS ROLLED GAUZE MEDIUM 5 3" X 2.1 YDS MISC BAND-AID GAUZE PADS 5 RX/OTC SMALL2" X 2" PADS BAND-AID KLING RX/OTC ROLLED GAUZE MEDIUM 5 BAND-AID GLOW IN THE 5 RX/OTC DARK3/4" X 3" MISC 3" X 2.5 YDS MISC BAND-AID KLING RX/OTC BAND-AID HOT COLORS 5 RX/OTC 3/4"X 3" MISC ROLLED GAUZE SMALL 5 2" X 2.5 YDS MISC BAND-AID HURT-FREE NON-STICK PADS LARGE 5 BAND-AID MEDICATED 5 RX/OTC 3" X 4" PADS STRIPS3/4" X 3" MISC BAND-AID HURT-FREE BAND-AID MICKEY 5 RX/OTC NON-STICK PADS 5 MOUSE MISC MEDIUM 2" X 3" PADS BAND-AID MIRASORB RX/OTC GAUZE SPONGES 5 BAND-AID HYDRO SEAL 5 RX/OTC ALL-PURPOSE MISC LARGE 4" X 4" PADS BAND-AID HYDRO SEAL RX/OTC BAND-AID MISC 5 RX/OTC BLISTER CUSHIONS 5 MEDIUM EXTREME MISC BAND-AID RX/OTC NICKELODEON 5 BAND-AID HYDRO SEAL RX/OTC PAWPATROL MISC BLISTER CUSHIONS 5 SMALL MISC BAND-AID OURTONE 5 RX/OTC MISC

178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BAND-AID PLASTIC MISC 5 RX/OTC BAND-AID WATER RX/OTC BLOCK 5 FLEX/KNUCKLE/FINGERT BAND-AID PLASTIC 5 RX/OTC SHEER MISC IP MISC BAND-AID WATER RX/OTC BAND-AID PLASTIC 5 RX/OTC STRIPS MISC BLOCK FLEX/LARGE 5 BAND-AID QUILTVENT MISC WATERPROOF PAD 5 BAND-AID WATER 5 RX/OTC LARGE 2.875" X 4" PADS BLOCK PLUS MISC BAND-AID WATER RX/OTC BAND-AID SHEER 5 RX/OTC COMFORT-FLEX MISC BLOCK PLUSFINGER 5 CARE MISC BAND-AID SHEER 5 RX/OTC STRIPS 3/4" X 3" MISC BAND-AID/EXTRA LARGE 5 RX/OTC MISC BAND-AID SHEER 5 RX/OTC STRIPS MISC BAND-AID/HELLO KITTY 5 RX/OTC MISC BAND-AID SKIN-FLEX 5 RX/OTC MISC BAND-AID/MICKEY 5 RX/OTC MOUSE MISC BAND-AID SPORT 5 RX/OTC STRIP/EXTRA WIDE MISC BAND-AID/PRINCESS 5 RX/OTC MISC BAND-AID STAR WARS 5 RX/OTC MISC BANDAGES FABRIC 5 RX/OTC KNUCKLE/FINGER MISC BAND-AID SUPER 5 RX/OTC STRIPS MISC BANDAGES FABRIC 5 RX/OTC STRIPS 3/4" MISC BAND-AID TOUGH 5 RX/OTC STRIPS MISC BIOGUARD BARRIER RX/OTC BAND-AID TOUGH- RX/OTC DRESSING/LARGE ROLL 5 STRIPS EXTRA LARGE 1- 5 MISC 3/4" X 4" MISC BIOGUARD GAUZE RX/OTC SPONGE 2"X2" 8 PLY 5 BAND-AID TOUGH- 5 RX/OTC STRIPS MISC PADS BAND-AID TOUGH- RX/OTC BIOGUARD GAUZE RX/OTC STRIPS WATERPROOF 5 SPONGES 4"X4" 12 PLY 5 MISC PADS BAND-AID TOUGH- RX/OTC BIOGUARD ISLAND 5 RX/OTC DRESSINGS4"X10" PADS STRIPS 5 WATERPROOF/EXTRA BIOGUARD ISLAND 5 RX/OTC LARGE MISC DRESSINGS4"X14" PADS BIOGUARD ISLAND RX/OTC BAND-AID VARIETY 5 RX/OTC 5 PACK MISC DRESSINGS4"X5" PADS BIOGUARD NON- RX/OTC BAND-AID WATER 5 RX/OTC BLOCK FLEX MISC ADHERENT DRESSINGS 5 BAND-AID WATER RX/OTC 3"X4" PADS BLOCK FLEX/EXTRA 5 BIOGUARD NON- RX/OTC LARGE MISC ADHERENT DRESSINGS 5 3"X8" PADS BLISTER RELIEF 5 RX/OTC BANDAGE MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BORDERED GAUZE 5 RX/OTC COVERLET STRIPS MISC 5 RX/OTC PADS COVRSITE COVER RX/OTC BUTTERFLY CLOSURES 5 RX/OTC 5 MISC DRESSING PADS COVRSITE PLUS RX/OTC CARPALAID EMPLOYEE 5 RX/OTC SURVIVAL/LARGE MISC COMPOSITE DRESSING 5 PADS CARPALAID EMPLOYEE 5 RX/OTC SURVIVAL/SMALL MISC CRAYON BANDAGES 5 RX/OTC CARPALAID RX/OTC STRIPS MISC PRACTIONER 5 CRUAD GAUZE PADS 4" 5 RX/OTC PACK/LARGE MISC X 4" PADS CARPALAID RX/OTC CURAD ACTI-FLEX FOAM 5 RX/OTC PRACTIONER 5 7/8" MISC PACK/SMALL MISC CURAD ACTI-FLEX FOAM 5 RX/OTC ASSORTED MISC CARPALAID/LARGE MISC 5 RX/OTC CURAD ADHESIVE RX/OTC CARPALAID/SMALL MISC 5 RX/OTC BANDAGES FLEX 5 ASSORTED MISC CARRASMART FOAM 5 RX/OTC CURAD ADHESIVE RX/OTC PADS BANDAGES FLEX FAMILY 5 CARRASMART PADS XX 5 RX/OTC ASSORTED MISC CURAD COMFORT 5 RX/OTC CLEAR BANDAGES MISC 5 RX/OTC FABRIC MISC RX/OTC COMPEED SKIN RX/OTC CURAD GODZILLA MISC 5 PROTECTOR 5 CURAD HOLD TITE RX/OTC DRESSING/MEDIUM/OVA TUBULAR STRETCH 5 L MISC BANDAGE/LARGE/5YDS COMPEED SKIN RX/OTC MISC PROTECTOR 5 CURAD JURASSIC PARK 5 RX/OTC DRESSING/SMALL/STRIP MISC MISC CURAD KID SIZE RX/OTC COPA ISLAND RX/OTC DINOSAUR BANDAGES 5 BORDERED FOAM 5 MISC DRESSING 4"X4" PADS CURAD NON-STICK 5 RX/OTC COPA ISLAND RX/OTC PADS 3"X4" PADS BORDERED FOAM 5 DRESSING 6"X6" PADS CURAD NON-STICK PADS WITHADHESIVE 5 COPA PLUS RX/OTC TABS 3"X4" PADS HYDROPHILIC FOAM 5 DRESSING 4"X4" PADS CURAD SENSITIVE SKIN 5 RX/OTC 3/4" MISC COPA PLUS RX/OTC HYDROPHILIC FOAM 5 CURAD SENSITIVE SKIN RX/OTC DRESSING 4"X8" PADS ASSORTED FAMILY 5 PACK MISC COPA PLUS RX/OTC HYDROPHILIC FOAM 5 CURAD SENSITIVE SKIN 5 RX/OTC DRESSING 6"X6" PADS EXTRA LARGE MISC

180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURAD SENSITIVE SKIN 5 RX/OTC CURITY ALL PURPOSE RX/OTC SPOTS MISC SPONGES 4"X4" 5 4PLY/SOFT POUCH PADS CURAD WILD STYLES 5 RX/OTC DESIGN-ITS MISC CURITY ALL PURPOSE 5 RX/OTC SPONGES 4"X4" PADS CURAD WILD STYLES 5 RX/OTC TATTOO-U MISC CURITY AMD RX/OTC CURITY #10 BURN RX/OTC ANTIMICROBIALGAUZE 5 DRESSING/READY CUT 5 SPONGES 2"X2" 8 PLY GAUZE/12"X12" MISC PADS CURITY #10 BURN RX/OTC CURITY AMD RX/OTC DRESSING/READY CUT 5 ANTIMICROBIALGAUZE 5 GAUZE/18"X18" MISC SPONGES 4"X4" 12 PLY PADS CURITY #10 BURN RX/OTC DRESSING/READY CUT 5 CURITY AMD RX/OTC GAUZE/36"X36" MISC ANTIMICROBIALPACKING 5 STRIPS 1"X3' MISC CURITY #10 GAUZE RX/OTC BOLT/OVAL 5 CURITY AMD RX/OTC FOLD/36"X300' MISC ANTIMICROBIALPACKING 5 STRIPS 1/2"X3' MISC CURITY ADHESIVE RX/OTC WOUND CLOSURE 5 CURITY AMD RX/OTC STRIPS 1/2"X4" MISC ANTIMICROBIALPACKING 5 STRIPS 1/4"X3' MISC CURITY ADHESIVE RX/OTC WOUND CLOSURE 5 CURITY COVER SPONGE 5 RX/OTC STRIPS 1/4"X1-1/2" MISC 4"X4" PADS CURITY ADHESIVE RX/OTC CURITY COVER 5 RX/OTC WOUND CLOSURE 5 SPONGES 3"X4" PADS STRIPS 1/4"X3" MISC CURITY COVER 5 RX/OTC CURITY ADHESIVE RX/OTC SPONGES 4"X3" PADS WOUND CLOSURE 5 CURITY COVER 5 RX/OTC STRIPS 1/4"X4" MISC SPONGES 4"X4" PADS CURITY ADHESIVE RX/OTC CURITY CURAD RX/OTC WOUND CLOSURE 5 ADHESIVE 5 STRIPS 1/8"X3" MISC BANDAGES/3/4" PLASTIC CURITY ALL PURPOSE RX/OTC MISC SPONGES 2"X2" 4PLY 5 CURITY CURAD RX/OTC PADS ADHESIVE 5 BANDAGES/3/4" SHEER CURITY ALL PURPOSE 5 RX/OTC SPONGES 2"X2" PADS MISC CURITY CURAD RX/OTC CURITY ALL PURPOSE 5 RX/OTC SPONGES 4 PLY PADS ADHESIVE 5 BANDAGES/PLASTIC CURITY ALL PURPOSE RX/OTC MISC SPONGES 4"X3" 4PLY 5 PADS CURITY CURAD RX/OTC ADHESIVE 5 CURITY ALL PURPOSE RX/OTC BANDAGES/SHEER MISC SPONGES 4"X4" 4PLY 5 PADS CURITY CURAD RX/OTC FLEXIBLE FABRIC 5 BANDAGES/3/4" MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY CURAD RX/OTC CURITY IODOFORM RX/OTC FLEXIBLE FABRIC 5 PACKING STRIP 1/2"X15' 5 BANDAGES/ASSORTED MISC MISC CURITY IODOFORM RX/OTC CURITY CURAD NEON RX/OTC PACKING STRIP 1/4"X15' 5 STRIPSBANDAGES/3/4"/A 5 MISC SSORTED COLORS MISC CURITY IODOFORM RX/OTC CURITY DRESSING RX/OTC PACKING STRIP 2"X15' 5 SPONGES 4"X3" 6 PLY 5 MISC PADS CURITY IODOFORM 5 RX/OTC CURITY DRESSING RX/OTC PACKING STRIP MISC SPONGES 4"X4" 6 PLY 5 CURITY KERLIX RX/OTC PADS BANDAGE ROLL/2- 5 CURITY GAUZE PADS 5 RX/OTC 1/4"X108" MISC 2"X2" 12 PLY PADS CURITY KERLIX RX/OTC CURITY GAUZE PADS 5 RX/OTC BANDAGE ROLL/4- 5 2"X2" PADS 1/2"X144" MISC CURITY GAUZE PADS RX/OTC 5 CURITY KERLIX ROLL 5 RX/OTC 4"X4" 12 PLY PADS 4.5X4.1 YARDS MISC CURITY GAUZE SPONGE 5 RX/OTC CURITY MESH GAUZE RX/OTC 2"X2" 8 PLY PADS BANDAGEROLL 1"X30' 5 MISC CURITY GAUZE SPONGE 5 RX/OTC 2"X2"12 PLY PADS CURITY MESH GAUZE RX/OTC BANDAGEROLL 2"X30' 5 CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 12 PLY PADS MISC CURITY MESH GAUZE RX/OTC CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 16 PLY PADS BANDAGEROLL 3"X30' 5 MISC CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 8 PLY PADS CURITY MESH GAUZE RX/OTC BANDAGEROLL 4"X30' 5 CURITY GAUZE SPONGE 5 RX/OTC MISC 4"X4"16 PLY PADS CURITY NON-ADHERENT 5 RX/OTC CURITY GAUZE SPONGE 5 RX/OTC STRIPS 1/2"X12' MISC 8"X4" 12 PLY PADS CURITY NON-ADHERENT 5 RX/OTC CURITY GAUZE SPONGE 5 RX/OTC STRIPS 3"X8" PADS 8"X4"12 PLY PADS CURITY NON-ADHERING 5 RX/OTC CURITY GAUZE RX/OTC DRESSINGS 3"X8" PADS SPONGES 4"X3"16 PLY 5 PADS CURITY PLAIN PACKING 5 RX/OTC STRIP MISC CURITY GAUZE RX/OTC SPONGES 4"X4" 12 PLY 5 CURITY RX/OTC PADS SPONGES/CELLULOSEFI 5 LLED/2"X2" PADS CURITY GAUZE RX/OTC SPONGES 4"X4" 8 PLY 5 CURITY RX/OTC PADS SPONGES/CELLULOSEFI 5 LLED/4"X4" PADS CURITY IODOFORM RX/OTC PACKING STRIP 1"X15' 5 MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY STRETCH RX/OTC CVS ANTI-BACTERIAL RX/OTC GAUZE 5 BANDAGES 5 BANDAGE/1"X4.1YD WATERPROOF MISC MISC CVS ANTIBACTERIAL RX/OTC CURITY STRETCH RX/OTC BANDAGES/HEAVY DUTY 5 GAUZE 5 FABRIC MISC BANDAGE/2"X4.1YD CVS BUTTERFLY 5 RX/OTC MISC CLOSURES MISC CURITY STRETCH RX/OTC CVS CLEAR BANDAGES 5 RX/OTC GAUZE 5 MISC BANDAGE/3"X4.1YD MISC CVS FLEXIBLE FABRIC RX/OTC ANTI-BACTERIAL 5 CURITY STRETCH RX/OTC BANDAGES MISC GAUZE 5 BANDAGE/4"X4.1YD CVS GAUZE PAD 8"X4" 5 RX/OTC MISC PADS CURITY TELFA STERILE RX/OTC CVS GAUZE PADS 2"X2" 5 RX/OTC ADHESIVE PADS/3"X4" 5 12-PLY PADS PADS CVS GAUZE PADS 4"X4" 5 RX/OTC CURITY TELFA STERILE RX/OTC 12-PLY PADS NON-STICK PADS/3"X4" 5 CVS GAUZE PADS RX/OTC PADS STERILE 4"X4" 12-PLY 5 CURITY TRIANGULAR RX/OTC PADS BANDAGE 40"X40"X56" 5 CVS NON-STICK PADS 5 RX/OTC MISC 3"X4" PADS CVS NON-STICK PADS RX/OTC CURITY WET DRESSING 5 RX/OTC 5 8"X4" PADS 3"X8" PADS CVS ADHESIVE RX/OTC CVS PLASTIC 5 RX/OTC BANDAGES FOAM TOE 5 BANDAGES MISC SIZE MISC CVS SHEER BANDAGES 5 RX/OTC CVS ADHESIVE GAUZE RX/OTC EXTRALARGE MISC PAD PREMIUM 4"X8" 5 CVS SHEER BANDAGES 5 RX/OTC PADS MISC CVS ADHESIVE PAD 5 CVS SPOT BANDAGE 5 RX/OTC 4"X4" PADS SHEER MISC CVS ADHESIVE PAD 5 CVS TUBULAR GAUZE 5 RX/OTC 6"X6" PADS MISC CVS ADHESIVE PADS 5 DERMACEA DRAIN 5 RX/OTC 2.25"X3" PADS SPONGES 4"X4" PADS CVS ADVANCED RX/OTC DERMACEA GAUZE RX/OTC HEALING PREMIUM 5 FLUFF ROLL 2"X3YD 5 BANDAGES/SMALL MISC MISC CVS ANTI-BACTERIAL RX/OTC DERMACEA GAUZE RX/OTC BANDAGES CHILDRENS 5 FLUFF ROLL 2.25"X3 YD 6 5 MISC PLY MISC CVS ANTI-BACTERIAL 5 RX/OTC DERMACEA GAUZE RX/OTC BANDAGES MISC FLUFF ROLL 3.4"X3- 5 1/2YD 6PLY MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN RX/OTC FLUFF ROLL 3.4"X3.6 YD 5 SPONGES 3"X4" 6 PLY 5 6 PLY MISC PADS DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN RX/OTC FLUFF ROLL 4-1/2"X4- 5 SPONGES 4"X4" 4 PLY 5 1/8YD 6PLY MISC PADS DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN RX/OTC FLUFF ROLL 4.5"X4.1 YD 5 SPONGES 4"X4" 6 PLY 5 6 PLY MISC PADS DERMACEA GAUZE ROLL 5 RX/OTC DERMACEA STRETCH RX/OTC 2"X4-1/8YD MISC BANDAGE ROLL 2"X12' 5 MISC DERMACEA GAUZE ROLL 5 RX/OTC 3"X4-1/8YD MISC DERMACEA STRETCH RX/OTC BANDAGE ROLL 3"X12' 5 DERMACEA GAUZE ROLL 5 RX/OTC 4"X4-1/8YD MISC MISC DERMACEA STRETCH RX/OTC DERMACEA GAUZE ROLL 5 RX/OTC 6"X4-1/8YD MISC BANDAGE ROLL 4"X12' 5 MISC DERMACEA GAUZE RX/OTC SPONGE 2"X2" 12 PLY 5 DERMACEA STRETCH RX/OTC PADS BANDAGE ROLL 6"X12' 5 MISC DERMACEA GAUZE RX/OTC SPONGE 2"X2" 8 PLY 5 DERMACEA STRETCH RX/OTC PADS BANDAGE2"X4-1/8YD 5 MISC DERMACEA GAUZE RX/OTC SPONGE 4"X4" 12 PLY 5 DERMACEA STRETCH RX/OTC PADS BANDAGE3"X4-1/8YD 5 MISC DERMACEA GAUZE RX/OTC SPONGE 4"X4" 16 PLY 5 DERMACEA STRETCH RX/OTC PADS BANDAGE4"X4-1/8YD 5 MISC DERMACEA GAUZE RX/OTC SPONGE 4"X4" 8 PLY 5 DERMACEA STRETCH 5 RX/OTC PADS BANDAGE6"X12.3' MISC DERMACEA STRETCH RX/OTC DERMACEA I.V. DRAIN 5 RX/OTC SPONGES 2"X2" PADS BANDAGE6"X4-1/8YD 5 MISC DERMACEA I.V. DRAIN 5 RX/OTC SPONGES 4"X4" PADS DERMACEA STRETCH RX/OTC BANDAGEROLL 3"X12' 5 DERMACEA I.V. 5 RX/OTC MISC SPONGES 2"X2" PADS DERMACEA STRETCH RX/OTC DERMACEA NON- RX/OTC BANDAGEROLL 4"X12' 5 ADHERENT DRESSING 5 MISC 3"X4" PADS DERMACEA STRETCH RX/OTC DERMACEA NON-WOVEN RX/OTC BANDAGEROLL 6"X12' 5 SPONGES 2"X2" 4 PLY 5 MISC PADS DERMACEA SUPER 5 RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGE 6"X6.75" PADS SPONGES 3"X4" 4 PLY 5 PADS

184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA TYPE VII RX/OTC EQL ADHESIVE PADS 5 RX/OTC GAUZE 2"X2" 12 PLY 5 MEDIUM MISC PADS EQL ADVANCED RX/OTC DERMACEA TYPE VII 5 RX/OTC HEALING ADHESIVE 5 GAUZE 2"X2" 8 PLY PADS BANDAGES MISC DERMACEA TYPE VII RX/OTC EQL ANIMAL PRINT 5 RX/OTC GAUZE 4"X4" 12 PLY 5 STRIPS MISC PADS EQL ANTIBACTERIAL 5 RX/OTC DERMACEA TYPE VII RX/OTC FABRICSTRIPS MISC GAUZE 4"X4" 16 PLY 5 EQL BUTTERFLY 5 RX/OTC PADS CLOSURES MISC DERMACEA TYPE VII 5 RX/OTC EQL FIRST AID RX/OTC GAUZE 4"X4" 8 PLY PADS ANTISEPTICBANDAGES 5 DERMACEA X-RAY RX/OTC MISC SPONGES 4"X4" 16 PLY 5 EQL FLEXIBLE FABRIC 5 RX/OTC PADS BANDAGES MISC DERMACEA X-RAY RX/OTC EQL FLEXIBLE FABRIC RX/OTC SPONGES 4"X8" 12 PLY 5 BANDAGES MULTI- 5 PADS PURPOSE MISC DERMACEA X-RAY RX/OTC EQL FLEXIBLE FABRIC RX/OTC SPONGES 4"X8" 12PLY 5 BANDAGES/EXTRA 5 PADS LARGE MISC DERMACEA X-RAY RX/OTC EQL FLEXIBLE FABRIC RX/OTC SPONGES 4"X8" 16 PLY 5 BANDAGES/KNUCKLE & 5 PADS FINGERTIP MISC DERMACEA X-RAY RX/OTC EQL FLEXIBLE FOAM 5 RX/OTC SPONGES 4"X8" 24 PLY 5 STRIPS MISC PADS EQL GAUZE PADS 5 RX/OTC DERMADRESS RX/OTC 2"X2"/SMALL PADS WATERPROOF 5 COMPOSITE DRESSING EQL GAUZE PADS 5 RX/OTC MISC 4"X4"/LARGE PADS DERMALEVIN ADHESIVE RX/OTC EQL GENTLE STRIPS 5 RX/OTC FOAMDRESSING 4"X4" 5 MISC PADS EQL HEAVY DUTY RX/OTC DERMALEVIN ADHESIVE RX/OTC BANDAGES EXTRA LONG 5 FOAMDRESSING 6"X6" 5 3/4"X4-3/4" MISC PADS EQL HEAVY DUTY RX/OTC RX/OTC FABRIC STRIPS MULTI- 5 DRYMAX EXTRA PADS 5 PURPOSE MISC EQ FLEXIBLE FABRIC RX/OTC EQL HEAVY DUTY RX/OTC BANDAGES/ANTIBACTER 5 FABRIC STRIPS/EXTRA 5 IAL MISC LARGE MISC EQ STRONG STRIPS RX/OTC EQL PLASTIC STRIPS 5 RX/OTC BANDAGES/ANTIBACTER 5 MISC IAL MISC EQL PLASTIC STRIPS 5 RX/OTC MULTI-PURPOSE MISC EQL ADHESIVE PADS 5 RX/OTC LARGE MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL SHEER SPOTS 5 RX/OTC GAUZE DRESSING 4"X4" 5 RX/OTC SMALL MISC PADS EQL SHEER STRIPS 5 RX/OTC GAUZE PADS 2"X2" PADS 5 RX/OTC EXTRA LARGE MISC RX/OTC EQL SHEER STRIPS 5 RX/OTC GAUZE PADS 4"X4" PADS 5 MISC GAUZE SPONGE TYPE RX/OTC EQL SHEER STRIPS 5 RX/OTC MULTI-PURPOSE MISC VII MEDI-PAK 2"X2" 8PLY 5 PADS EQL STERILE NON-STICK 5 RX/OTC PADS 3"X4"/LARGE PADS GAUZE SPONGES 4"X4" 5 RX/OTC 12 PLY PADS EQL STRIPS MISC 5 RX/OTC GAUZE STRETCH 5 RX/OTC BANDAGE 3"X2.5YD MISC EQL STRONG STRIPS 5 RX/OTC WATERPROOF MISC GENTLE ADHESIVE RX/OTC EQL VARIETY PACK RX/OTC BANDAGES/EXTRA 5 ADHESIVEBANDAGES 5 LARGE MISC MISC GNP STERILE GAUZE 5 RX/OTC EXCILON AMD RX/OTC PADS 2"X2" PADS HM ADHESIVE RX/OTC ANTIMICROBIALDRAIN 5 SPONGES 4"X4" 6 PLY BANDAGES 5 PADS ANTIBACTERIAL MISC EXCILON AMD RX/OTC HM ADHESIVE RX/OTC BANDAGES ANTIMICROBIALNON- 5 5 WOVEN SPONGES 4"X4" ANTIBACTERIAL/SHEER 6 PLY PADS MISC HM ADHESIVE RX/OTC EXCILON DRAIN 5 RX/OTC SPONGE 4"X4" PADS BANDAGES 5 EXCILON DRAIN RX/OTC ANTIBACTERIAL/SHEER/ SPONGES 4"X4" 6 PLY 5 XL MISC PADS HM ADHESIVE PADS ANTIBACTERIAL/SHEER 5 EXCILON I.V. SPONGES 5 RX/OTC 2"X2" 6 PLY PADS PADS FABRIC RX/OTC HM BUTTERFLY 5 RX/OTC BANDAGES/ASSORTED 5 CLOSURES MISC MISC HM FABRIC ADHESIVE RX/OTC BANDAGES ADVANCED 5 FLEXIBLE FABRIC 5 RX/OTC BANDAGES MISC ANTIBACTERIAL MISC FLEXIBLE FABRIC RX/OTC HM NON-STICK PADS 3" 5 RX/OTC BANDAGESASSORTED 5 X 4" PADS MISC HM STERILE PADS 2"X2" 5 RX/OTC PADS FLEXZAN 4 X 8 PADS 5 RX/OTC HM STERILE PADS PADS 5 RX/OTC GAUZE BANDAGE 3" 5 RX/OTC MISC HYDROCELL ADHESIVE 5 RX/OTC DRESSING 4"X4" PADS GAUZE BANDAGE/2" X 5 RX/OTC 4YDS MISC HYDROCELL ADHESIVE 5 RX/OTC DRESSING 6"X6" PADS

186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCELL DRESSING 5 RX/OTC KERLIX BANDAGE ROLL 5 RX/OTC 4"X4" PADS 2-1/4"X9' 6PLY MISC HYDROCELL DRESSING 5 RX/OTC KERLIX BANDAGE ROLL RX/OTC 6"X6" PADS 3-7/16"X3-3/16' 6PLY 5 MISC J & J ADHESIVE LARGE 5 PADS KERLIX BANDAGE ROLL RX/OTC 4-1/2"X4-1/8YD 6PLY 5 J & J GAUZE 2"X2" 8 PLY 5 RX/OTC PADS MISC KERLIX BANDAGE ROLL RX/OTC J & J GAUZE 4"X4" 12 PLY 5 RX/OTC 5 PADS 4-1/2"X9.3' 8PLY MISC KERLIX BANDAGE RX/OTC J & J GAUZE 4"X4" 8 PLY 5 RX/OTC PADS ROLL/6 PLY/MEDIUM 5 MISC J & J GAUZE SPONGES 5 RX/OTC 12-PLY 4" X 4" MISC KERLIX GAUZE ROLL RX/OTC LARGE 4.5"X 4.1YD 6 PLY 5 J & J GAUZE SPONGES 5 RX/OTC MISC 16-PLY 4" X 4" MISC KERLIX GAUZE ROLL RX/OTC J & J GAUZE SPONGES 5 RX/OTC MEDIUM3.4"X3.6YD 6 PLY 5 8-PLY4" X 4" MISC MISC J & J NON-STICK PADS 5 KERLIX GAUZE ROLL RX/OTC 100LARGE PADS SMALL 2.25"X 3YD 6 PLY 5 KENDALL HYDROPHILIC RX/OTC MISC FOAM DRESSING 4"X8" 5 KERLIX SPONGES 4" X 4" 5 RX/OTC PADS 12 PLY PADS KENDALL HYDROPHILIC RX/OTC KERLIX SPONGES 4" X 4" 5 RX/OTC FOAMDRESSING 2"X2" 5 16 PLY PADS PADS KERLIX SUPER RX/OTC KENDALL HYDROPHILIC RX/OTC SPONGES MEDIUM 6"X6- 5 FOAMDRESSING 4"X4" 5 3/4" PADS PADS KERLIX SUPER RX/OTC KENDALL HYDROPHILIC RX/OTC SPONGES MEDIUM 5 FOAMDRESSING 6"X6" 5 6"X6.75" PADS PADS KERLIX X-RAY RX/OTC KENDALL HYDROPHILIC RX/OTC DETECTABLE PACKING 5 FOAMPLUS DRESSING 5 SPONGE 4-1/2"X22" MISC 2"X2" PADS KERLIX X-RAY RX/OTC KERLIX AMD RX/OTC DETECTABLE SPONGES 5 ANTIMICROBIALBANDAG 5 EXTRA LARGE 1-5/8" E ROLL 4-1/2"X12.3YD 6 MISC PLY MISC RX/OTC KERLIX AMD RX/OTC KLING FLUFF MISC 5 ANTIMICROBIALBANDAG 5 E ROLL/6 PLY/4.5"X4- KLING FLUFF SPONGE 5 RX/OTC 1/8YD MISC 6X6.75 MISC KERLIX AMD RX/OTC LEUKOSTRIP 1/2"X4" 5 RX/OTC ANTIMICROBIALSUPER 5 MISC SPONGES PADS LEUKOSTRIP 1/4"X3" 5 RX/OTC MISC

187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEUKOSTRIP 1/4"X4" 5 RX/OTC NEXCARE COMFORT RX/OTC MISC FABRIC BANDAGES 5 KNEE/ELBOW MISC LEUKOSTRIP 1/8"X1-1/2" 5 RX/OTC MISC NEXCARE HEAVY DUTY RX/OTC MEDIPORE + PAD SOFT RX/OTC CLEAR& TOUGH 5 BANDAGES ASSORTED CLOTH ADHESIVE 5 WOUND DRESSING 6"X6" MISC PADS NEXCARE HEAVY DUTY RX/OTC CLEAR& TOUGH MIRASORB SPONGES 2" 5 RX/OTC 5 X 2" MISC BANDAGES KNEE/ELBOW MISC MIRASORB SPONGES 4" 5 RX/OTC X 4" MISC NEXCARE HEAVY DUTY RX/OTC FLEXIBLE FABRIC 5 MOLESKIN FOAM 5 BANDAGES 1-1/8"X3" PADDING PADS MISC NEXCARE ABSOLUTE NEXCARE HEAVY DUTY RX/OTC WATERPROOF PAD 5 FLEXIBLE FABRIC 5 PADS BANDAGES ASSORTED NEXCARE ABSOLUTE RX/OTC MISC WATERPROOF PREMIUM 5 NEXCARE HEAVY DUTY RX/OTC ADHESIVE PAD 2- FLEXIBLE FABRIC 5 3/8"X45" MISC BANDAGES NEXCARE ACTIVE RX/OTC KNEE/ELBOW MISC BRIGHTS BANDAGES 5 NEXCARE NON-STICK 5 RX/OTC ASSORTED MISC PADS 3"X 4" PADS NEXCARE ACTIVE RX/OTC NEXCARE PREMIUM RX/OTC SPORT FOAM 5 ADHESIVEGAUZE PAD 6" 5 BANDAGES 1-1/8" X 3" X 6" PADS MISC NEXCARE SOFT 'N FLEX 5 RX/OTC NEXCARE ACTIVE RX/OTC BANDAGES MISC SPORT FOAM 5 BANDAGES ASSORTED NEXCARE TATTOO RX/OTC MISC WATERPROOF 5 BANDAGES 1-1/16" X 2- NEXCARE ACTIVE RX/OTC 1/4" MISC SPORT FOAM 5 BANDAGES NEXCARE TATTOO RX/OTC KNEE/ELBOW MISC WATERPROOF 5 BANDAGES/EINSTEINS 1- NEXCARE ADHESIVE RX/OTC 1/16"X2-1/4" MISC DRESSING/PAD 5 WATERPROOF 6" X 6" NEXCARE TATTOO RX/OTC PADS WATERPROOF 5 BANDAGES/NEMO 1-1/16" NEXCARE COMFORT RX/OTC X 2-1/4" MISC FABRIC BANDAGES 3/4" 5 X 3" MISC NEXCARE TATTOO RX/OTC WATERPROOF 5 NEXCARE COMFORT RX/OTC BANDAGES/POOH 1-1/16" FABRIC BANDAGES 5 X 2-1/4" MISC ASSORTED MISC

188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXCARE TATTOO RX/OTC PRIMAPORE 4"X3-1/8" 5 RX/OTC WATERPROOF 5 MISC BANDAGES/PRINCESS 1- PRIMAPORE 6"X3-1/8" 5 RX/OTC 1/16" X 2-1/4" MISC MISC NEXCARE WATERPROOF RX/OTC RX/OTC BANDAGES 1-1/16" X 2- 5 PRIMAPORE 8"X4" MISC 5 1/4" MISC PROXI-STRIP 1/4" X 4" 5 RX/OTC NEXCARE WATERPROOF RX/OTC MISC BANDAGES ASSORTED 5 PROXI-STRIPS 1/2"X4" 5 RX/OTC MISC MISC NEXCARE WATERPROOF RX/OTC PX SUPERSTRIP 1" X 3" 5 RX/OTC BANDAGES 5 MISC KNEE/ELBOW MISC QC ALL PURPOSE 5 RX/OTC NEXCARE WATERPROOF 5 RX/OTC DRESSINGS4"X4" PADS BANDAGES MISC QC BORDER ISLAND 5 RX/OTC NON-STICK PADS 3"X4" 5 RX/OTC GAUZE PAD 2"X2" PADS PADS QC NON-ADHERENT 5 RX/OTC NU GAUZE 4PLY 4"X4" 5 RX/OTC PADS 3"X4" PADS PADS RX/OTC NU GAUZE GENERAL- RX/OTC QC STERILE PADS PADS 5 USE SPONGES 4"X4" 4 5 RA ADHESIVE RX/OTC PLY MISC BANDAGES FLEXIBLE 5 NU GAUZE PACKING RX/OTC FOAM MISC STRIPS PLAIN 1/2" X 5 5 RA ADHESIVE 5 RX/OTC YDS MISC BANDAGES MISC NU GAUZE UTERINE RX/OTC RA BANDAGES/EXTRA RX/OTC PACKINGSTRIPS 5 LONG FABRIC/HEAVY 5 IODOFORM 8" X 10 YDS DUTY MISC MISC RA CONFORMED 5 RX/OTC OPTIFOAM PADS 5 RX/OTC BANDAGE MISC RA FIRST AID FLEXIBLE RX/OTC PEANUTS BANDAGES 5 RX/OTC MISC FABRIC ADHESIVE 5 BANDAGE MISC PLASTIC ADHESIVE 5 RX/OTC BANDAGES 3/4" MISC RA FIRST AID NON-STICK 5 PADS PADS PLASTIC BANDAGES 3/4" 5 RX/OTC MISC RA GAUZE BANDAGE 5 RX/OTC MISC POLYMEM FILM DOT 5 PADS RA SHEER ADHESIVE 5 LARGE PADS POLYMEM NON- 5 RX/OTC ADHESIVE PAD PADS RA STERILE PADS 2"X2" 5 RX/OTC PADS PRIMAPORE 11-3/4"X4" 5 RX/OTC MISC RA STERILE PADS 4"X4" 5 RX/OTC PADS PRIMAPORE 13-3/4"X4" 5 RX/OTC MISC RAY-TEC X-RAY RX/OTC DETECTABLESPONGES 5 PRIMAPORE 2-7/8"X2" 5 RX/OTC 4" X 4" 16 PLY MISC MISC

189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RAY-TEC X-RAY RX/OTC SHEER BANDAGES 3/4" 5 RX/OTC DETECTABLESPONGES 5 MISC 8" X 4" 12 PLY MISC SHEER BANDAGES MISC 5 RX/OTC RAY-TEC X-RAY RX/OTC DETECTABLESPONGES 5 SHEER RX/OTC 8" X 4" 16 PLY MISC BANDAGES/ASSORTED 5 RELEASE NON- RX/OTC MISC ADHERING DRESSING 4" 5 SHEER BANDAGES/EX- 5 RX/OTC X 3" PADS LARGE MISC RELIAMED SELF- RX/OTC SM ADHESIVE PADS 5 ADHESIVE DRESSING 5 2"X3" PADS RETENTION SHEET MISC SM ADHESIVE PADS 5 RESTORE CONTACT RX/OTC 3"X4" PADS LAYER/NON-ADHERENT 5 SM BANDAGE ROLL 5 RX/OTC 2"X2" PADS 4.5"X144" MISC RESTORE DUO RX/OTC SM BANDAGES CLEAR 5 RX/OTC ABSORBENT DRESSING 5 SPOTS MISC 4"X5" PADS SM BANDAGES FABRIC 5 RX/OTC RESTORE FOAM RX/OTC 3/4" MISC DRESSING BORDERED 5 4"X4" PADS SM BANDAGES FABRIC 5 RX/OTC EXTRALARGE MISC RESTORE FOAM RX/OTC DRESSING BORDERED 5 SM BANDAGES FABRIC RX/OTC 6"X6" PADS KNUCKLE/FINGERTIP 5 MISC RESTORE FOAM RX/OTC DRESSING NON- 5 SM BANDAGES FOAM 5 RX/OTC BORDERED 4"X4" PADS EXTRA LARGE MISC RESTORE FOAM RX/OTC SM BANDAGES FOAM 5 RX/OTC DRESSING NON- 5 MISC BORDERED 6"X6" PADS SM BANDAGES PLASTIC 5 RX/OTC RESTORE LITE FOAM RX/OTC MISC DRESSING NON- 5 SM BANDAGES SHEER 5 RX/OTC BORDERED 4"X5" PADS EXTRA LARGE MISC RESTORE LITE FOAM RX/OTC SM BANDAGES SHEER 5 RX/OTC DRESSING NON- 5 MISC BORDERED 6"X6" PADS SM BANDAGES STRONG 5 RX/OTC RESTORE ODOR RX/OTC STRIPS 1" MISC ABSORBING DRESSING 5 SM BANDAGES 5 RX/OTC 4"X4" PADS WATERSHIELD MISC RESTORE TRIO RX/OTC SM RX/OTC ABSORBENT DRESSING 5 BANDAGES/ANTIBACTER 5 4"X5" PADS IAL MISC SHEER ADHESIVE RX/OTC SM RX/OTC BANDAGES 3/4" X 3" 5 BANDAGES/CLEAR/ASSO 5 MISC RTED MISC SHEER ADHESIVE 5 RX/OTC BANDAGES MISC

190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM RX/OTC STERI-STRIP 1/4" X 3" 5 RX/OTC BANDAGES/FLEXIBLE/AS 5 MISC SORTED MISC STERI-STRIP 1/4" X 4" 5 RX/OTC SM GAUZE PADS 2"X2" 5 RX/OTC MISC PADS STERI-STRIP 1/8" X 3" 5 RX/OTC SM GAUZE PADS 4"X4" 5 RX/OTC MISC PADS STERILE BANDAGE ROLL 5 RX/OTC SM HYPO-ALLERGENIC 5 RX/OTC 2.25"X3YD MISC BANDAGES MISC STERILE GAUZE PADS 5 RX/OTC SM ROLLED GAUZE RX/OTC 2"X2" PADS BANDAGE 2"X4.1YD 5 STERILE PADS 2"X2" 5 RX/OTC MISC PADS SM ROLLED GAUZE RX/OTC STERILE PADS 4"X4" 5 RX/OTC BANDAGE 3"X4.1YD 5 PADS MISC STRETCH GAUZE 5 RX/OTC SM STERILE PADS 2"X2" 5 RX/OTC BANDAGE MISC PADS SURESEAL EXTRA 5 RX/OTC SM STERILE PADS PADS 5 RX/OTC LARGE MISC SURESEAL LARGE MISC 5 RX/OTC SM STRONG STRIPS 5 RX/OTC MISC RX/OTC SM STURDY STRIP RX/OTC SURESEAL MISC 5 FABRIC BANDAGES 1"X3" 5 SURGICAL GAUZE 5 RX/OTC MISC SPONGE PADS SOF-SET ADHESIVE 5 TEGADERM CONTACT RX/OTC PATCH PADS LAYER/NON-ADHERENT 5 SOF-WICK 4"X4" PADS 5 RX/OTC 3"X4" PADS TEGADERM CONTACT RX/OTC SOF-WIK MISC 5 RX/OTC LAYER/NON-ADHERENT 5 3"X8" PADS SORESPOT BLISTER & RX/OTC TEGADERM FILM RX/OTC SKIN PROTECTION 5 TRANSPARENT 5 BANDAGES MISC DRESS/FRAME STYLE 1- SPENCO ADHESIVE KNIT 5 RX/OTC 3/4"X1-3/4" MISC 3"X5" MISC TEGADERM FOAM 5 RX/OTC STERI-STRIP 1 7/8" X RX/OTC DRESSING 2"X2" PADS 1/2"/DRESSING 2 3/8" X 1 5 TEGADERM FOAM 5 RX/OTC 7/8" MISC DRESSING 4"X4" PADS STERI-STRIP 1" X 5" RX/OTC 5 TEGADERM FOAM 5 RX/OTC MISC DRESSING 4"X8" PADS STERI-STRIP 1/2" X 2" 5 RX/OTC TEGADERM FOAM RX/OTC MISC DRESSING ROLL 4"X24" 5 STERI-STRIP 1/2" X 4 " 5 RX/OTC MISC MISC TELFA ADHESIVE 5 RX/OTC STERI-STRIP 1/4" X 1 1/2" 5 RX/OTC DRESSING 3"X4" PADS MISC TELFA AMD ADHESIVE 5 RX/OTC BANDAGE 2"X3.75" MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TELFA AMD RX/OTC Contraceptives ANTIMICROBIAL ISLAND 5 DRESSING 4"X5" PADS FC FEMALE CONDOM 6 MISC TELFA AMD RX/OTC FC2 FEMALE CONDOM ANTIMICROBIAL ISLAND 5 6 MISC DRESSING4"X8" PADS TELFA AMD RX/OTC Diabetic Supplies ANTIMICROBIAL NON- 5 1ST TIER UNILET QL(6.67 ea ADHERENT PAD 3"X8" COMFORTOUCH 3 daily) PADS LANCETS 28G MISC TELFA ISLAND 5 RX/OTC 1ST TIER UNILET QL(6.67 ea DRESSING 4"X10" PADS COMFORTOUCH 3 daily) LANCETS 30G MISC TELFA ISLAND 5 RX/OTC DRESSING 4"X14" PADS ACCU-CHEK AVIVA PLUS NC RX/OTC KIT XX TELFA ISLAND 5 RX/OTC DRESSING 4"X5" PADS ACCU-CHEK AVIVA SOLN 5 TELFA ISLAND 5 RX/OTC DRESSING 4"X8" PADS ACCU-CHEK COMPACT PLUS CLEAR CONTROL TELFA NON-ADHERENT 5 RX/OTC 5 DRESSING 3"X4" PADS SOLUTION (2 LEVELS) SOLN TELFA NON-ADHERENT 5 RX/OTC PAD 3"X8" PADS ACCU-CHEK FASTCLIX 3 QL(6.67 ea LANCETS MISC daily) TELFA NON-ADHERENT RX/OTC PAD PREPACK 8"X3" 5 ACCU-CHEK GUIDE PADS CONTROL 5 LEVEL1/LEVEL2 LIQD TELFA NON-ADHERENT RX/OTC PADS PREPACK 3"X4" 5 ACCU-CHEK GUIDE KIT NC RX/OTC PADS XX ACCU-CHEK GUIDE ME RX/OTC TENDEROL UNDERCAST 5 RX/OTC NC PADDING 2"X4 YD MISC KIT ACCU-CHEK MULTICLIX QL(6.67 ea TENDEROL UNDERCAST 5 RX/OTC 3 PADDING 3"X4 YD MISC LANCETS MISC daily) ACCU-CHEK NANO RX/OTC TENDEROL UNDERCAST 5 RX/OTC NC PADDING 4"X4 YD MISC SMARTVIEW KIT ACCU-CHEK SAFE-T-PRO QL(6.67 ea TENDEROL UNDERCAST 5 RX/OTC 3 PADDING 6"X4 YD MISC LANCETS MISC daily) RX/OTC ACCU-CHEK SAFE-T-PRO 3 QL(6.67 ea THERAGAUZE PADS 5 PLUSLANCETS MISC daily) ACCU-CHEK SMARTVIEW TOPPER DRESSING 5 RX/OTC 5 SPONGES 4"X4" MISC CONTROL LIQD ACCU-CHEK SOFTCLIX QL(6.67 ea TOPPER DRESSING 5 RX/OTC 3 SPONGES MISC LANCETS MISC daily) WATERSHIELD WATER- RX/OTC ACCUTREND GLUCOSE 5 RESISTANT BANDAGES 5 CONTROL SOLN MISC ACTI-LANCE LANCETS 3 QL(6.67 ea 28G MISC daily) WOUND TREATMENT KIT 5 KIT 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTI-LANCE LITE QL(6.67 ea ADVOCATE LANCETS 3 QL(6.67 ea SAFETY LANCETS 28G 3 daily) 30G MISC daily) MISC ADVOCATE LANCETS 3 QL(6.67 ea ACTI-LANCE SPECIAL QL(6.67 ea MISC daily) SAFETY LANCETS 17G 3 daily) ADVOCATE LANCING 5 MISC DEVICE MISC ACTI-LANCE SPECIAL QL(6.67 ea ADVOCATE RAPID-SAFE 5 SAFETYLANCETS 17G 3 daily) LANCING DEVICE MISC MISC ADVOCATE REDI-CODE NC ACTI-LANCE UNIVERSAL QL(6.67 ea DEVI XX SAFETY LANCETS 23G 3 daily) MISC ADVOCATE REDI-CODE+ BLOOD GLUCOSE NC ADJUSTABLE LANCING 5 SYSTEM/SPEAKING DEVI DEVICE MISC ADVOCATE REDI-CODE+ ADVANCE INTUITION BLOODGLUCOSE NC BLOOD GLUCOSE NC MONITORING SYSTEM METER DEVI DEVI ADVANCE INTUITION RX/OTC ADVOCATE REDI-CODE+ BLOOD GLUCOSE NC CONTROL SOLUTION 5 MONITORING SYSTEM HIGH SOLN KIT ADVOCATE REDI-CODE+ ADVANCE INTUITION CONTROL SOLUTION 5 CONTROL SOLUTION 5 LOW SOLN LIQD ADVOCATE REDI-CODE+/ NC RX/OTC ADVANCE MICRO-DRAW TALKING KIT CONTROL LEVEL 1-2 5 LIQD ADVOCATE REDI- NC RX/OTC CODE/TALKING KIT ADVANCE MICRO-DRAW NC METER DEVI ADVOCATE SAFETY 3 QL(6.67 ea LANCETS 26G MISC daily) ADVANCE MICRO-DRAW 5 NORMAL CONTROL LIQD ADVOCATE SAFETY 3 QL(6.67 ea LANCETS MISC daily) ADVANCED MOBILE 3 QL(6.67 ea LANCET 30G MISC daily) AGAMATRIX AMP NO CODE ADVANCED NC ADVOCATE BLOOD BLOOD GLUCOSE GLUCOSE MONITORING NC MONITORING SYST DEVI SYSTEM DEVI AGAMATRIX CONTROL 5 ADVOCATE BLOOD RX/OTC HIGH SOLN GLUCOSE MONITORING NC SYSTEM KIT AGAMATRIX CONTROL 5 NORMAL SOLN ADVOCATE BLOOD RX/OTC GLUCOSE MONITORING NC AGAMATRIX CONTROL 5 SYSTEM/TALKING KIT NORMAL& HIGH SOLN AGAMATRIX CONTROL ADVOCATE CONTROL 5 SOLUTIONHIGH LIQD SOLUTION LEVEL 2 5 SOLN ADVOCATE CONTROL 5 SOLUTIONLOW LIQD AGAMATRIX CONTROL SOLUTION LEVEL 4 5 SOLN 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AGAMATRIX JAZZ NC RX/OTC ASSURE HAEMOLANCE QL(6.67 ea WIRELESS 2 KIT PLUS PEDIATRIC BLADE 3 daily) MISC AGAMATRIX PRESTO KIT NC RX/OTC ASSURE II CONTROL 5 LEVEL 1 LIQD AGAMATRIX PRESTO NC PRO METER DEVI ASSURE II CONTROL 5 LEVEL 1/2 LIQD AGAMATRIX ULTRA-THIN 3 QL(6.67 ea LANCETS 33G MISC daily) ASSURE LANCE 3 QL(6.67 ea LANCETS 21G MISC daily) AIMSCO TWIST LANCETS 3 QL(6.67 ea 32G MISC daily) ASSURE LANCE 3 QL(6.67 ea LANCETS MISC daily) AIMSCO TWIST LANCETS 3 QL(6.67 ea 33G MISC daily) ASSURE LANCE PLUS QL(6.67 ea SAFETYLANCETS 25G 3 daily) ALTERNATE SITE 5 LANCING DEVICE MISC MISC AQUA LANCE ASSURE LANCE PLUS QL(6.67 ea ADJUSTABLE LANCING 5 SAFETYLANCETS 30G 3 daily) DEVICE DEVI MISC ASSURE LANCE SAFETY QL(6.67 ea AQUALANCE LANCETS 3 QL(6.67 ea 3 ULTRA THIN 30G MISC daily) LANCET 28G MISC daily) QL(6.67 ea ASSURE 3 CONTROL 5 ASSURE LANCETS MISC 3 LEVEL 1/2 LIQD daily) ASSURE 3 METER KIT NC ASSURE PLATINUM BLOOD GLUCOSE NC METER DEVI ASSURE 4 BLOOD NC GLUCOSE METER DEVI ASSURE PRISM CONTROL LEVEL 1/2 5 ASSURE 4 CONTROL 5 LEVEL 1/2 LIQD SOLN ASSURE COMFORT QL(6.67 ea ASSURE PRISM MULTI LANCETS ULTRA THIN 3 daily) BLOODGLUCOSE NC 28G MISC MONITORING SYSTEM DEVI ASSURE DOSE NORMAL 5 CONTROL SOLN ASSURE PRO BLOOD NC ASSURE DOSE GLUCOSE METER DEVI NORMAL/HIGH CONTROL 5 ASSURE PRO CONTROL 5 SOLN LEVEL1/2 LIQD ASSURE HAEMOLANCE QL(6.67 ea AURORA LANCET SUPER 3 QL(6.67 ea PLUS HIGH FLOW 18G 3 daily) THIN30G MISC daily) MISC AURORA LANCET THIN 3 QL(6.67 ea ASSURE HAEMOLANCE QL(6.67 ea 23G MISC daily) PLUS LOW FLOW 25G 3 daily) 5 MISC AUTO-LANCET MINI MISC ASSURE HAEMOLANCE QL(6.67 ea AUTO-LANCET MISC 5 PLUS MICRO FLOW 28G 3 daily) MISC AUTOLET IMPRESSION 5 ASSURE HAEMOLANCE QL(6.67 ea LANCING DEVICE MISC PLUS NORMAL FLOW 3 daily) AUTOLET LANCING 5 21G MISC DEVICE MISC

194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUTOLET MINI MISC 5 CARDIOCOM LANCING 5 DEVICE MISC AUTOLET PLUS MISC 5 CAREONE ADVANCED 5 LANCINGDEVICE MISC BAYER CONTOUR LINK RX/OTC CAREONE BLOOD RX/OTC 2.4 BLOOD GLUCOSE NC GLUCOSE MONITORING NC MONITORING SYSTEM SYSTEM/PREMIUM KIT KIT CAREONE BLOOD RX/OTC BD LANCET ULTRAFINE 3 QL(6.67 ea GLUCOSE MONITORING NC 30G MISC daily) SYSTEM/VALUE KIT BD LANCET ULTRAFINE QL(6.67 ea 3 CAREONE LANCET 3 QL(6.67 ea 33G MISC daily) SUPER THIN/30G MISC daily) BD LATITUDE DIABETES RX/OTC CAREONE LANCET THIN 3 QL(6.67 ea MANAGEMENT SYSTEM NC MISC daily) KIT CARESENS CONTROL A 5 BD LOGIC BLOOD NC RX/OTC SOLUTION SOLN GLUCOSE MONITOR KIT CARESENS LANCETS 3 QL(6.67 ea BD MICROTAINER 3 QL(6.67 ea MISC daily) LANCETS MISC daily) CARESENS N GLUCOSE BIOTEL CARE BLOOD RX/OTC MONITORING SYSTEM NC GLUCOSEMONITORING NC DEVI SYSTEM KIT CARESENS N VOICE BIOTEL CARE RX/OTC BLOOD GLUCOSE NC CONNECTED BLOOD NC MONITORING SYSTEM GLUCOSE MONITORING DEVI SYSTEM KIT CARETOUCH BLOOD RX/OTC BLOOD GLUCOSE RX/OTC GLUCOSE MONITORING NC MONITORINGSYSTEM NC SYSTEM KIT KIT CARETOUCH CONTROL 5 BLOOD GLUCOSE RX/OTC SOLUTION LEVEL 2 LIQD MONITORINGSYSTEM NC PREMIUM KIT CARETOUCH LANCING DEVICEWITH EJECTOR 5 BLOOD GLUCOSE NC RX/OTC MISC SYSTEM PAK KIT CARETOUCH SAFETY 3 QL(6.67 ea BLULINK BLOOD LANCETS/26G MISC daily) GLUCOSE MONITORING NC SYSTEM DEVI CARETOUCH SAFETY 3 QL(6.67 ea LANCETS/28G MISC daily) BLULINK CONTROL SOLUTION/HIGH & LOW 5 CARETOUCH SAFETY 3 QL(6.67 ea LIQD LANCETS/30G MISC daily) BREEZE 2 BLOOD CARETOUCH TWIST 3 QL(6.67 ea GLUCOSE MONITORING NC LANCETS 28G MISC daily) SYSTEM DEVI CARETOUCH TWIST 3 QL(6.67 ea LANCETS 30G MISC daily) BULLSEYE MINI SAFETY 3 QL(6.67 ea LANCETS MISC daily) CARETOUCH TWIST 3 QL(6.67 ea LANCETS 33G MISC daily) BULLSEYE SAFETY 3 QL(6.67 ea LANCETS MISC daily)

195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHOICE DM DIABETES CLEVER CHOICE MINI NC RISK IN-HOME TEST KIT BLOODGLUCOSE NC KIT MONITORING SYSTEM DEVI CLEANLET LANCETS 28G 3 QL(6.67 ea MISC daily) CLEVER CHOICE TALK CLEVER CHEK AUTO BLOODGLUCOSE NC MONITORING SYSTEM CODE VOICE BLOOD NC GLUCOSE MONITORING DEVI SYSTEM DEVI COAGUCHEK LANCETS 3 QL(6.67 ea CLEVER CHEK AUTO- MISC daily) CODE BLOOD GLUCOSE NC COMFORT ASSURED QL(6.67 ea MONITORING SYSTEM LANCETS MICRO THIN 3 daily) DEVI 33G MISC CLEVER CHEK AUTO- COMFORT ASSURED QL(6.67 ea CODE VOICE BLOOD NC LANCETS SUPER THIN 3 daily) GLUCOSE MONITORING 28G MISC SYSTEM DEVI COMFORT LANCETS 3 QL(6.67 ea CLEVER CHEK BLOOD RX/OTC MISC daily) GLUCOSE MONITORING NC COMFORT TOUCH QL(6.67 ea SYSTEM KIT LANCETS ULTRA THIN 3 daily) CLEVER CHEK LANCETS 3 QL(6.67 ea 31G MISC ULTRATHIN 30G MISC daily) COMFORT TOUCH PLUS QL(6.67 ea CLEVER CHEK LANCETS 3 QL(6.67 ea SAFETY LANCETS 3 daily) ULTRATHIN MISC daily) PRESSURE ACTIVATED CLEVER CHOICE AUTO- 30G MISC CODE PRO BLOOD NC CONTOUR BLOOD GLUCOSE MONITORING GLUCOSE MONITORING NC SYSTEM DEVI SYSTEM DEVI CLEVER CHOICE QL(6.67 ea CONTOUR BLOOD RX/OTC COMFORT EZLANCETS 3 daily) GLUCOSE MONITORING NC 21G MISC SYSTEM KIT CLEVER CHOICE QL(6.67 ea CONTOUR HIGH 5 COMFORT EZLANCETS 3 daily) CONTROL LIQD 23G MISC CONTOUR LOW 5 CLEVER CHOICE QL(6.67 ea CONTROL LIQD COMFORT EZLANCETS 3 daily) CONTOUR NEXT BLOOD RX/OTC 28G MISC GLUCOSE MONITORING NC CLEVER CHOICE SYSTEM KIT GLUCOSE CONTROL 5 CONTOUR NEXT 5 HIGH LIQD CONTROL LEVEL 1 SOLN CLEVER CHOICE CONTOUR NEXT 5 GLUCOSE CONTROL 5 CONTROL LEVEL 2 SOLN LOW LIQD CONTOUR NEXT EZ RX/OTC CLEVER CHOICE MICRO RX/OTC BLOOD GLUCOSE NC BLOODGLUCOSE NC MONITORING SYSTEM MONITORING SYSTEM KIT KIT

196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONTOUR NEXT LINK 2.4 RX/OTC CVS ULTRA THIN 3 QL(6.67 ea WIRELESS BLOOD NC LANCETS MISC daily) GLUCOSE MONITORING D-CARE GLUCOMETER RX/OTC SYST KIT KIT/GLUCOSE TEST NC CONTOUR NEXT LINK RX/OTC STRIPS KIT BLOOD GLUCOSE NC DIATHRIVE BLOOD NC MONITORING SYSTEM GLUCOSE METER DEVI KIT DIATHRIVE GLUCOSE CONTOUR NEXT LINK RX/OTC CONTROL SOLUTION 5 WIRELESS BLOOD NC LIQD GLUCOSE MONITORING SY KIT DIATHRIVE LANCETS 3 QL(6.67 ea MISC daily) CONTOUR NEXT ONE DIATHRIVE LANCETS QL(6.67 ea BLOOD GLUCOSE NC 3 MONITORING SYSTEM ULTRA THIN 30G MISC daily) KIT DIATHRIVE LANCING 5 DEVICE MISC CONTOUR NORMAL 5 CONTROL LIQD DIATHRIVE+ BLOOD GLUCOSEMONITORING CONTROL SOLUTION 5 NC NORMAL SOLN SYSTEM/BLUETOOTH DEVI COOL BLOOD GLUCOSE NC RX/OTC MONITORING KIT KIT DIATRUE GLUCOSE CONTROL SOLUTION 5 COOL BLOOD GLUCOSE LEVEL 1 SOLN MONITORING SYSTEM NC DEVI DIATRUE GLUCOSE CONTROL SOLUTION 5 COOL CONTROL 5 LEVEL 2 SOLN SOLUTION A SOLN DIATRUE GLUCOSE COOL CONTROL 5 CONTROL SOLUTION 5 SOLUTION B SOLN LEVEL 3 SOLN CVS ADVANCED NC RX/OTC DIATRUE PLUS BLOOD GLUCOSE METER KIT GLUCOSE MONITORING NC SYSTEM DEVI CVS LANCETS 21G MISC 3 QL(6.67 ea daily) DROPLET GENTEEL 5 CVS LANCETS MICRO 3 QL(6.67 ea LANCING DEVICE MISC THIN 33G MISC daily) DROPLET LANCETS 3 QL(6.67 ea CVS LANCETS MICRO- 3 QL(6.67 ea ULTRA THIN 30G MISC daily) THIN 33G MISC daily) DROPLET LANCING 5 CVS LANCETS ORIGINAL 3 QL(6.67 ea DEVICE MISC MISC daily) DROPLET PERSONAL 3 QL(6.67 ea CVS LANCETS THIN 26G 3 QL(6.67 ea LANCETS30G MISC daily) MISC daily) DRUG MART 5 CVS LANCETS ULTRA 3 QL(6.67 ea ADJUSTABLE LANCING THIN 30G MISC daily) DEVICE MISC CVS LANCETS ULTRA- 3 QL(6.67 ea DRUG MART LANCETS 3 QL(6.67 ea THIN 30G MISC daily) THIN MISC daily) CVS LANCING DEVICE 5 MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRUG MART ON-THE-GO QL(6.67 ea EASY PLUS II CONTROL 5 LANCETS GENTLE 30G 3 daily) SOLUTION LOW SOLN MISC EASY STEP BLOOD DRUG MART UNILET QL(6.67 ea GLUCOSE MONITOR NC LANCETSSUPER THIN 3 daily) DEVI 30G MISC EASY STEP CONTROL 5 DRUG MART UNILET QL(6.67 ea SOLUTION HIGH SOLN LANCETSULTRA THIN 3 daily) EASY STEP CONTROL 5 28G MISC SOLUTION LOW SOLN DRUG MART UNILET QL(6.67 ea EASY STEP CONTROL MICRO THIN LANCETS 3 daily) SOLUTION NORMAL 5 33G MISC SOLN DUO-CARE CONTROL 5 EASY TALK BLOOD SOLUTION LIQD GLUCOSE MONITORING NC E-Z JECT LANCETS 21G 3 QL(6.67 ea SYSTEM/TALKING DEVI MISC daily) EASY TALK CONTROL 5 E-Z JECT LANCETS 3 QL(6.67 ea SOLUTION HIGH SOLN COLOR MISC daily) EASY TALK CONTROL 5 QL(6.67 ea SOLUTION LOW SOLN E-Z JECT LANCETS MISC 3 daily) EASY TALK CONTROL 5 E-Z JECT LANCETS 3 QL(6.67 ea SOLUTION NORMAL SUPER THIN 30G MISC daily) SOLN E-Z JECT LANCETS THIN 3 QL(6.67 ea EASY TOUCH CONTROL 26G MISC daily) SOLUTION/HIGH & LOW 5 SOLN E-ZJECT LANCETS 3 QL(6.67 ea MICRO-THIN 33G MISC daily) EASY TOUCH GLUCOSE RX/OTC EASY COMFORT QL(6.67 ea MONITORING SYSTEM NC LANCETS 30G/PULL TOP 3 daily) KIT MISC EASY TOUCH LANCETS QL(6.67 ea EASY COMFORT QL(6.67 ea 21G/PRESSURE 3 daily) LANCETS 30G/THIN TOP 3 daily) ACTIVATED MISC MISC EASY TOUCH LANCETS QL(6.67 ea 23G/PRESSURE 3 daily) EASY COMFORT 3 QL(6.67 ea LANCETS MISC daily) ACTIVATED MISC EASY COMFORT QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea LANCETS TWIST TOP 3 daily) 26G/PRESSURE 3 daily) MISC ACTIVATED MISC EASY TOUCH LANCETS QL(6.67 ea EASY MINI EJECT 5 3 LANCING DEVICE MISC 26G/PULL-TOP MISC daily) EASY TOUCH LANCETS QL(6.67 ea EASY MINI LANCING 5 DEVICE MISC 28G/PRESSURE 3 daily) ACTIVATED MISC EASY PLUS II BLOOD GLUCOSE MONITORING NC EASY TOUCH LANCETS 3 QL(6.67 ea SYSTEM DEVI 28G/PULL-TOP MISC daily) EASY TOUCH LANCETS QL(6.67 ea EASY PLUS II CONTROL 5 3 SOLUTION HIGH SOLN 28G/TWIST MISC daily)

198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS QL(6.67 ea EASY TRAK GLUCOSE 30G/BUTTON-ACTIVATED 3 daily) CONTROLSOLUTION 5 MISC LOW SOLN EASY TOUCH LANCETS QL(6.67 ea EASY TRAK GLUCOSE 30G/PRESSURE 3 daily) CONTROLSOLUTION 5 ACTIVATED MISC NORMAL SOLN EASY TOUCH LANCETS 3 QL(6.67 ea EASY TRAK II BLOOD 30G/PULL-TOP MISC daily) GLUCOSE MONITORING NC SYSTEM DEVI EASY TOUCH LANCETS 3 QL(6.67 ea 30G/TWIST MISC daily) EASY TWIST & CAP 3 QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea LANCETS MISC daily) 32G/PRESSURE 3 daily) EASYGLUCO CONTROL 5 ACTIVATED MISC SOLUTION HIGH SOLN EASY TOUCH LANCETS 3 QL(6.67 ea EASYGLUCO CONTROL 5 32G/PULL-TOP MISC daily) SOLUTION LOW SOLN EASY TOUCH LANCETS 3 QL(6.67 ea EASYGLUCO CONTROL 32G/TWIST MISC daily) SOLUTION NORMAL 5 SOLN EASY TOUCH LANCETS 3 QL(6.67 ea 33G/TWIST MISC daily) EASYGLUCO KIT XX NC EASY TOUCH LANCING 5 DEVICE/EJECTOR MISC EASYGLUCO PLUS EASY TOUCH SAFETY QL(6.67 ea CONTROL SOLUTION 5 LANCETS21G/PRESSURE 3 daily) LEVEL 1 SOLN ACTIVATED MISC EASYGLUCO STARTER NC EASY TOUCH SAFETY QL(6.67 ea KIT KIT LANCETS23G/PRESSURE 3 daily) EASYMAX 15 GLUCOSE ACTIVATED MISC CONTROL SOLUTION 5 EASY TOUCH SAFETY QL(6.67 ea LEVEL 1/LEVEL 2 SOLN LANCETS26G/BUTTON 3 daily) EASYMAX 15 GLUCOSE ACTIVATED MISC CONTROL 5 EASY TOUCH SAFETY QL(6.67 ea SOLUTION/LEVEL LANCETS26G/PRESSURE 3 daily) 2/LEVEL 3 LIQD ACTIVATED MISC EASYMAX 15 LEVEL 2 EASY TOUCH SAFETY QL(6.67 ea GLUCOSE CONTROL 5 LANCETS28G/BUTTON 3 daily) SOLUTION SOLN ACTIVATED MISC EASYMAX CONTROL EASY TOUCH SAFETY QL(6.67 ea SOLUTIONNORMAL 5 LANCETS28G/PRESSURE 3 daily) SOLN ACTIVATED MISC EASYMAX GLUCOSE CONTROL SOLUTION 5 EASY TRAK II CONTROL 5 SOLUTION/NORMAL LIQD NORMAL/LOW SOLN EASY TRAK BLOOD EASYMAX GLUCOSE GLUCOSE MONITORING NC CONTROL 5 SYSTEM DEVI SOLUTION/NORMAL- HIGH LIQD EASY TRAK GLUCOSE CONTROLSOLUTION 5 EASYMAX NG SELF- HIGH SOLN MONITORING BLOOD NC GLUCOSE SYSTEM DEVI 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASYMAX NG SELF- RX/OTC EMBRACE EVO NC MONITORING BLOOD COMPACT NC GLUCOSE SYSTEM KIT BLOODGLUCOSE MONITOR DEVI EASYMAX V BLOOD NC GLUCOSE SYSTEM DEVI EMBRACE EVO EASYMAX V BLOOD RX/OTC GLUCOSE CONTROL 5 GLUCOSE NC SOLUTION LEVEL 1 LIQD SYSTEM/TALKING KIT EMBRACE GLUCOSE EASYPRO BLOOD RX/OTC CONTROL SOLUTION 5 GLUCOSE MONITORING NC HIGH LIQD SYSTEM KIT EMBRACE LANCETS 3 QL(6.67 ea ULTRA THIN 30G MISC daily) EASYPRO PLUS KIT NC RX/OTC EMBRACE LANCING DEVICE WITH EJECTOR 5 ELEMENT AUTOCODE NC RX/OTC SYSTEM KIT MISC ELEMENT COMPACT EMBRACE PRO BLOOD NC GLUCOSE METER DEVI BLOOD GLUCOSE NC MONITORING SYSTEM EMBRACE PRO DEVI GLUCOSE CONTROL 5 ELEMENT COMPACT SOLUTION LIQD CONTROL SOLUTION 5 EMBRACE TALK BLOOD LEVEL 2 SOLN GLUCOSE MONITOR NC ELEMENT COMPACT DEVI CONTROL SOLUTION 5 EMBRACE TALK BLOOD RX/OTC LEVEL 3 SOLN GLUCOSE MONITORING NC ELEMENT COMPACT V SYSTEM KIT BLOODGLUCOSE NC EMBRACE TALK MONITORING SYSTEM GLUCOSE CONTROL 5 DEVI SOLUTION HIGH SOLN ELEMENT HIGH 5 EMBRACE TALK CONTROL LIQD GLUCOSE CONTROL 5 SOLUTION LOW SOLN ELEMENT LOW 5 CONTROL LIQD EQL COLOR LANCETS 3 QL(6.67 ea 21G MISC daily) ELEMENT NORMAL 5 CONTROL LIQD EQL COLOR LANCETS 3 QL(6.67 ea MICRO THIN 33G MISC daily) ELEMENT PLUS BLOOD NC GLUCOSE METER DEVI EQL SUPER THIN 3 QL(6.67 ea EMBRACE BLOOD LANCETS 30G MISC daily) GLUCOSE MONITORING NC EQL THIN LANCETS 26G 3 QL(6.67 ea SYSTEM/TALKING DEVI MISC daily) EMBRACE CONTROL 5 EVENCARE BLOOD SOLUTIONLOW SOLN GLUCOSE MONITORING NC EMBRACE EVO BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING NC EVENCARE CONTROL 5 KIT KIT SOLUTION LIQD

200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVENCARE G2 BLOOD FORA CONTROL 5 GLUCOSEMONITORING NC SOLUTION HIGH SOLN SYSTEM DEVI FORA CONTROL 5 EVENCARE G2 GLUCOSE SOLUTION LOW SOLN CONTROL 5 FORA CONTROL SOLUTION/LOW-HIGH SOLUTION NORMAL 5 SOLN SOLN EVENCARE G3 BLOOD FORA G20 BLOOD RX/OTC GLUCOSEMONITORING NC GLUCOSE MONITORING NC SYSTEM DEVI SYSTEM KIT EVENCARE G3 GLUCOSE FORA G30A BLOOD CONTROL 5 GLUCOSE MONITORING NC SOLUTION/LOW-HIGH SYSTEM DEVI SOLN FORA GD20 BLOOD EVENCARE MINI BLOOD GLUCOSE MONITORING NC GLUCOSE MONITORING NC SYSTEM DEVI SYSTEM DEVI FORA GD50 BLOOD EVENCARE MINI GLUCOSE MONITORING NC GLUCOSE CONTROL 5 SYSTEM DEVI SOLUTION NORMAL SOLN FORA GTEL BLOOD GLUCOSE MONITORING NC EVOLUTION AUTOCODE NC SYSTEM/MULTI- DEVI XX FUNCTIONAL DEVI EVOLUTION CONTROL FORA LANCETS MISC 3 QL(6.67 ea SOLUTION NORMAL 5 daily) SOLN FORA LANCING DEVICE 5 EZ-LETS LANCETS 21G 3 QL(6.67 ea MISC MISC daily) FORA LANCING 5 EZ-LETS LANCETS 26G 3 QL(6.67 ea DEVICE/CLEARCAP MISC SUPER-SOFT MISC daily) FORA PREMIUM V10 BLE EZ-LETS LANCETS 28G QL(6.67 ea 3 BLOOD GLUCOSE NC ULTRA-SOFT MISC daily) MONITORING SYSTEM EZ-LETS LANCETS 30G 3 QL(6.67 ea DEVI MISC daily) FORA TEST N' GO VOICE FIFTY50 GLUCOSE NC RX/OTC BLOOD GLUCOSE NC METER 2.0 KIT MONITORING SYSTEM DEVI FIFTY50 SAFETY SEAL 3 QL(6.67 ea LANCETS 30G MISC daily) FORA TN'G VOICE RX/OTC BLOOD GLUCOSE FIFTY50 SAFETY SEAL 3 QL(6.67 ea NC LANCETS 32G MISC daily) MONITORING SYSTEM KIT FIFTY50 UNILET 3 QL(6.67 ea LANCETS 33G MISC daily) FORA V10 BLOOD GLUCOSE MONITORING NC FINE 30 MISC 3 QL(6.67 ea SYSTEM/TALKING DEVI daily) FORA V10/V12/D10/D20 FINGERSTIX LANCETS QL(6.67 ea 3 BLOOD GLUCOSE TEST NC MISC daily) STRIPS/LANCETS 30G KIT 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FORA V12 BLOOD FORTISCARE SELF- RX/OTC GLUCOSE MONITORING NC MONITORING BLOOD NC SYSTEM/NO-CODING GLUCOSE SYSTEM KIT DEVI FORTISCARE T1 SELF- FORA V12 BLOOD MONITORING BLOOD NC GLUCOSE MONITORING NC GLUCOSE SYSTEM DEVI SYSTEM/TALKING DEVI FREDS PHARMACY FORA V20 BLOOD AUTOLET LANCING 5 GLUCOSE MONITORING NC DEVICE MISC SYSTEM DEVI FREDS PHARMACY QL(6.67 ea FORA V30A BLOOD UNILET LANCETS SUPER 3 daily) GLUCOSE MONITORING NC THIN 30G MISC SYSTEM DEVI FREDS PHARMACY QL(6.67 ea FORA V30A BLOOD RX/OTC UNILET LANCETS ULTRA 3 daily) GLUCOSE MONITORING NC THIN 28G MISC SYSTEM KIT FREESTYLE CONTROL FORACARE GD40 BLOOD SOLUTION HIGH/LOW 5 GLUCOSE MONITORING NC LIQD SYSTEM DEVI FREESTYLE CONTROL 5 FORACARE GDH SOLUTION LIQD CONTROL SOLUTION 5 FREESTYLE FREEDOM NC RX/OTC HIGH SOLN KIT FORACARE GDH FREESTYLE FREEDOM NC RX/OTC CONTROL SOLUTION 5 LITE KIT LOW SOLN FREESTYLE INSULINX RX/OTC FORACARE GDH BLOODGLUCOSE NC CONTROL SOLUTION 5 MONITORING SYSTEM NORMAL SOLN KIT FORACARE PREMIUM FREESTYLE LANCETS 3 QL(6.67 ea V10 BLOOD GLUCOSE NC MISC daily) MONITORING SYSTEM DEVI FREESTYLE LITE BLOOD GLUCOSE MONITORING NC FORACARE TEST N GO SYSTEM DEVI BLOODGLUCOSE NC MONITORING SYSTEM FREESTYLE PRECISION RX/OTC DEVI NEO BLOOD GLUCOSE NC MONITORING SYSTEM FORTISCARE CONTROL 5 KIT SOLUTIONS HIGH SOLN FREESTYLE SIDEKICK II NC RX/OTC FORTISCARE CONTROL 5 VALUEPACK KIT SOLUTIONS LOW SOLN FREESTYLE UNISTICK II 3 QL(6.67 ea FORTISCARE CONTROL LANCETS MISC daily) SOLUTIONS NORMAL 5 SOLN GE100 BLOOD GLUCOSE MONITORING SYSTEM NC FORTISCARE SELF- DEVI MONITORING BLOOD NC GLUCOSE SYSTEM GE100 BLOOD GLUCOSE RX/OTC EMV3.1 DEVI MONITORING SYSTEM NC KIT

202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GE100 CONTROL GLOBAL INJECT EASE 3 QL(6.67 ea SOLUTION NORMAL 5 LANCETS 28G MISC daily) SOLN GLOBAL INJECT EASE 3 QL(6.67 ea GENTEEL BUTTERFLY 3 QL(6.67 ea LANCETS 30G MISC daily) TOUCH LANCETS MISC daily) GLOBAL LANCING 5 GENTEEL LANCING DEVICE MISC DEVICE/GLORIOUS 5 GLUCO PERFECT 3 GOLD MISC BLOOD GLUCOSE NC GENTEEL LANCING METER DEVI DEVICE/PRECIOUS 5 GLUCO PERFECT 3 PLATINUM MISC BLOOD GLUCOSE NC GENTEEL LANCING MONITORING DEVICE/STATELY SILVER 5 SYSTEM/VOICE DEVI MISC GLUCOCARD 01 BLOOD NC GENTEEL PLUS LANCING GLUCOSE METER DEVI DEVICE/BUFF BLACK 5 GLUCOCARD 01 BLOOD RX/OTC MISC GLUCOSE MONITORING NC GENTEEL PLUS LANCING SYSTEM KIT DEVICE/BUTTERFLY 5 GLUCOCARD 01 BLUE MISC CONTROL SOLUTION 5 GENTEEL PLUS LANCING NORMAL/HIGH LIQD DEVICE/PLAYFUL 5 GLUCOCARD 01 PURPLE MISC CONTROL 5 GENTEEL PLUS LANCING SOLUTION/NORMAL DEVICE/PRINCESS PINK 5 SOLN MISC GLUCOCARD 01-MINI RX/OTC GENTEEL PLUS LANCING BLOOD GLUCOSE NC DEVICE/WILLOWY WHITE 5 MONITORING SYSTEM MISC KIT GENTLE-LET GP 3 QL(6.67 ea GLUCOCARD RX/OTC LANCETS MISC daily) EXPRESSION AUDIO- GENTLE-LET LANCETS QL(6.67 ea ENABLED BLOOD NC GENERAL PURPOSE 3 daily) GLUCOSE MONITORING STYLE/FINE POINT MISC KIT GENTLE-LET LANCETS QL(6.67 ea GLUCOCARD EXPRESSION CONTROL GENERAL PURPOSE 3 daily) 5 STYLE/MEDIUM POINT SOLUTION LEVEL 1 MISC SOLN GENTLE-LET LANCETS QL(6.67 ea GLUCOCARD SHINE RX/OTC SAFETY STYLE/FINE 3 daily) CONNEX BLOOD NC POINT MISC GLUCOSE MONITORING SYSTEM KIT GENTLE-LET LANCETS QL(6.67 ea SAFETY STYLE/MEDIUM 3 daily) GLUCOCARD SHINE POINT MISC CONTROL SOLUTION 5 LEVEL 1 SOLN GHT BLOOD GLUCOSE RX/OTC MONITORING SYSTEM NC GLUCOCARD SHINE NC KIT DEVI

203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOCARD SHINE RX/OTC GLUCONAVII BLOOD RX/OTC EXPRESS BLOOD NC GLUCOSEMONITORING NC GLUCOSE MONITORING SYSTEM KIT SYSTEM KIT GLUCOSE CONTROL 5 GLUCOCARD SHINE KIT NC RX/OTC NORMAL SOLN GLUCOSE CONTROL 5 GLUCOCARD SHINE XL NC SOLUTION SOLN DEVI GNP EASY TOUCH GLUCOCARD VITAL RX/OTC CONTROL SOLUTION 5 BLOOD GLUCOSE NC HIGH/LOW SOLN MONITORING SYSTEM GNP EASY TOUCH BLACK KIT GLUCOSE MONITORING NC GLUCOCARD VITAL RX/OTC SYSTEM/NO CODING BLOOD GLUCOSE NC DEVI MONITORING SYSTEM GNP LANCETS 21G MISC 3 QL(6.67 ea BLUE KIT daily) GLUCOCARD VITAL RX/OTC GNP LANCETS MICRO 3 QL(6.67 ea BLOOD GLUCOSE NC THIN 33G MISC daily) MONITORING SYSTEM KIT GNP LANCETS SUPER 3 QL(6.67 ea THIN 30G MISC daily) GLUCOCARD VITAL RX/OTC GNP LANCETS THIN 26G QL(6.67 ea BLOOD GLUCOSE NC 3 MONITORING SYSTEM MISC daily) PINK KIT GNP LANCETS THIN 3 QL(6.67 ea GLUCOCARD X-METER MISC daily) CONTROLSOLUTION/NO 5 GOJJI CONTROL RMAL SOLN SOLUTION NORMAL 5 SOLN GLUCOCARD X-METER NC RX/OTC KIT GOJJI LANCING GLUCOCOM BLOOD DEVICE/CLEAR CAP 5 GLUCOSE MONITOR NC MISC DEVI GOJJI STERILE LANCETS 3 QL(6.67 ea GLUCOCOM BLOOD RX/OTC 30G MISC daily) GLUCOSE MONITORING NC GOODSENSE COLOR QL(6.67 ea SYSTEM KIT LANCETS MICRO-THIN 3 daily) GLUCOCOM BLOOD RX/OTC 33G UNIVERSAL MISC NC GLUCOSE MONITORING GOODSENSE LANCETS 5 QL(6.67 ea SYSTEM VALUE KIT KIT MICRO-THIN 33G MISC daily) GLUCOCOM HIGH 5 GOODSENSE LANCETS QL(6.67 ea CONTROL LIQD MICRO-THIN 33G 3 daily) UNIVERSAL MISC GLUCOCOM LANCETS 3 QL(6.67 ea 28G MISC daily) GOODSENSE LANCETS QL(6.67 ea ULTRA-THIN 26G 3 daily) GLUCOCOM LANCETS 3 QL(6.67 ea 30G MISC daily) UNIVERSAL MISC GOODSENSE LANCETS QL(6.67 ea GLUCOCOM LANCETS 3 QL(6.67 ea 3 33G MISC daily) ULTRA-THIN 30G MISC daily) GLUCOCOM NORMAL 5 CONTROL LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOODSENSE LANCETS QL(6.67 ea HW EMBRACE TALK ULTRA-THIN 30G 3 daily) BLOOD GLUCOSE NC UNIVERSAL MISC MONITOR DEVI GOODSENSE LANCING 5 HW EMBRACE TALK RX/OTC DEVICE MISC BLOOD GLUCOSE NC GOODSENSE PREMIUM RX/OTC MONITORING SYSTEM KIT BLOODGLUCOSE NC MONITORING SYSTEM HY-VEE LANCETS MISC 3 QL(6.67 ea KIT daily) H-E-B INCONTROL HY-VEE THIN LANCETS 3 QL(6.67 ea ADVANCEDLANCING 5 MISC daily) DEVICE MISC IGLUCOSE BLOOD RX/OTC H-E-B INCONTROL QL(6.67 ea GLUCOSE MOITORING NC LANCETS MICRO THIN 3 daily) SYSTEM KIT 33G MISC IN TOUCH DEVI NC H-E-B INCONTROL QL(6.67 ea LANCETS SUPER THIN 3 daily) IN TOUCH GLUCOSE 30G MISC CONTROLSOLUTION 5 H-E-B INCONTROL QL(6.67 ea SOLN LANCETS ULTRA THIN 3 daily) IN TOUCH LANCING 5 28G MISC DEVICE MISC HAEMOLANCE LOW QL(6.67 ea 3 IN TOUCH STERILE 3 QL(6.67 ea FLOW LANCETS MISC daily) LANCETS30G MISC daily) QL(6.67 ea HAEMOLANCE MISC 3 INFINITY BLOOD RX/OTC daily) GLUCOSE MONITORING NC SYSTEM KIT HAEMOLANCE PLUS 3 QL(6.67 ea HIGH FLOW MISC daily) INFINITY BLOOD RX/OTC GLUCOSE MONITORING HAEMOLANCE PLUS 3 QL(6.67 ea NC LOW FLOW MISC daily) SYSTEM/STARTER KIT KIT HAEMOLANCE PLUS 3 QL(6.67 ea MAX FLOW MISC daily) INFINITY CONTROL 5 SOLUTION HIGH SOLN HAEMOLANCE PLUS 3 QL(6.67 ea MISC daily) INFINITY CONTROL 5 SOLUTION LOW SOLN HAEMOLANCE PLUS 3 QL(6.67 ea PEDIATRIC FLOW MISC daily) INFINITY CONTROL SOLUTION NORMAL 5 HEALTH CARE LANCING 5 DEVICE MISC SOLN HEALTHY ACCENTS INFINITY VOICE KIT NC RX/OTC AUTOLET IMPRESSION 5 LANCING DEVICE MISC INFINITY VOICE LEVEL 2 5 LIQD HEALTHY ACCENTS QL(6.67 ea QL(6.67 ea UNILET LANCETS SUPER 3 daily) KINNEY LANCETS MISC 3 THIN 30G MISC daily) HW EMBRACE PRO KINNEY THIN LANCETS 3 QL(6.67 ea BLOOD GLUCOSE NC MISC daily) METER DEVI KROGER AUTOLET 5 LANCING DEVICE MISC

205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER BLOOD RX/OTC LANCETS 31G TWIST 3 QL(6.67 ea GLUCOSE MONITORING NC TOP MISC daily) KIT KIT LANCETS 33G EXTRA 3 QL(6.67 ea KROGER HEALTHPRO RX/OTC FINE MISC daily) BLOOD GLUCOSE NC LANCETS 33G QL(6.67 ea MONITORING SYSTEM UNIVERSAL DESIGN 3 daily) KIT MISC KROGER HEALTHPRO LANCETS MICRO THIN 3 QL(6.67 ea GLUCOSECONTROL 5 33G MISC daily) SOLUTION/HIGH/LOW QL(6.67 ea LIQD LANCETS MISC 3 daily) KROGER HEALTHPRO QL(6.67 ea TWIST LANCETS/26G 3 daily) LANCETS SAFETY SEAL 3 QL(6.67 ea MISC 21G MISC daily) LANCETS SAFETY SEAL QL(6.67 ea KROGER LANCETS 21G 3 QL(6.67 ea 3 MISC daily) 26G MISC daily) LANCETS SAFETY SEAL QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 MICRO THIN33G MISC daily) 28G MISC daily) LANCETS SAFETY SEAL QL(6.67 ea KROGER LANCETS MISC 3 QL(6.67 ea 3 daily) 30G MISC daily) LANCETS SUPER THIN QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 SUPER THIN MISC daily) 28G MISC daily) QL(6.67 ea KROGER LANCETS THIN 3 QL(6.67 ea LANCETS THIN MISC 3 26G MISC daily) daily) LANCETS TWIST TOP QL(6.67 ea KROGER LANCETS THIN 3 QL(6.67 ea 3 MISC daily) MISC daily) LANCETS ULTRA FINE QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 ULTRATHIN30G MISC daily) MISC daily) LANCETS ULTRA THIN QL(6.67 ea KROGER LANCING 5 3 DEVICE MISC 30G MISC daily) KROGER PREMIUM RX/OTC LANCETS ULTRA THIN 3 QL(6.67 ea BLOOD GLUCOSE NC MISC daily) MONITORING KIT KIT LANCETSBULLSEYE 3 QL(6.67 ea SAFETY MISC daily) LANCET DEVICE 5 ADJUSTABLE MISC LANCING DEVICE 5 ADJUSTABLE MISC LANCET DEVICE WITH 5 EJECTOR MISC LANCING DEVICE MISC 5 LANCETS 26G TWIST 3 QL(6.67 ea TOP MISC daily) LANZO MISC 5 QL(6.67 ea LANCETS 28G MISC 3 LDR BLOOD GLUCOSE NC RX/OTC daily) TRUETEST KIT KIT QL(6.67 ea LANCETS 30G MISC 3 LEADER ADVANCED 5 daily) LANCING DEVICE MISC LANCETS 30G TWIST QL(6.67 ea 3 LIBERTY BLOOD NC TOP MISC daily) GLUCOSE METER DEVI LANCETS 30G/TWIST 3 QL(6.67 ea TOP MISC daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIBERTY CONTROL 5 MEDICHOICE PRE-SET QL(6.67 ea SOLUTION HIGH SOLN SAFETY LANCET 3 daily) LIBERTY CONTROL MEDIUM FLOW MISC SOLUTIONNORMAL 5 MEDICHOICE PRE-SET QL(6.67 ea SOLN SAFETY LANCET 3 daily) MODERATE FLOW MISC LIBERTY GLUCOSE 5 CONTROL MID SOLN MEDICHOICE SAFETY 3 QL(6.67 ea LANCETEXTRA MISC daily) LIBERTY GLUCOSE 5 CONTROL NORMAL LIQD MEDICHOICE SAFETY 3 QL(6.67 ea LANCETNORMAL MISC daily) LIBERTY MEDICAL 3 QL(6.67 ea LANCETS 30G MISC daily) MEDISENSE GLUCOSE KETONECONTROL LIBERTY MINI LANCING 5 5 DEVICE MISC SOLUTION 1-LOW,1- MED,1 HIGH LIQD LIBERTY NEXT MEDISENSE GLUCOSE GENERATION BLOOD NC GLUCOSE MONITOR KETONECONTROL 5 DEVI SOLUTION 1-NORMAL LIQD LIFESCAN UNISTIK 2 QL(6.67 ea DEEP PENETRATION 3 daily) MEDISENSE HIGH/LOW MISC CONTROL SOLUTION 5 LIQD LIFESCAN UNISTIK II 3 QL(6.67 ea LANCETS MISC daily) MEDISENSE HIGH/MID/LOW 5 LITE TOUCH LANCETS 3 QL(6.67 ea CONTROL SOLUTION MISC daily) LIQD LITE TOUCH LANCING 5 MEDISENSE MID PEN MISC CONTROL SOLUTION 5 LITETOUCH LANCETS 3 QL(6.67 ea LIQD MICRO THIN 33G MISC daily) MEDISENSE THIN 3 QL(6.67 ea LIVE BETTER ADVANCED 5 LANCETS MISC daily) LANCING DEVICE MISC MEDLANCE PLUS EXTRA 3 QL(6.67 ea LIVE BETTER LANCET 3 QL(6.67 ea LANCETS 21G MISC daily) SUPERTHIN 30G MISC daily) MEDLANCE PLUS 3 QL(6.67 ea LIVE BETTER LANCET 3 QL(6.67 ea LANCETS LITE 25G MISC daily) ULTRATHIN 28G MISC daily) MEDLANCE PLUS 3 QL(6.67 ea LONGS LANCETS 3 QL(6.67 ea LANCETS MISC daily) STANDARD MISC daily) MEDLANCE PLUS LITE 3 QL(6.67 ea LONGS LANCETS THIN 3 QL(6.67 ea LANCETS 25G MISC daily) MISC daily) MEDLANCE PLUS QL(6.67 ea LONGS LANCETS ULTRA 3 QL(6.67 ea SPECIAL LANCETS 3 daily) THIN MISC daily) 0.8MM MISC MEDICHOICE PRE-SET QL(6.67 ea MEDLANCE PLUS 3 QL(6.67 ea SAFETY LANCET DUAL 3 daily) SUPERLITE 30G MISC daily) USE MISC MEDLANCE PLUS QL(6.67 ea MEDICHOICE PRE-SET QL(6.67 ea SUPERLITE 3 daily) SAFETY LANCET LOW 3 daily) 30G/COMFORT MAX FLOW MISC MISC

207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDLANCE PLUS QL(6.67 ea MICRODOT BLOOD RX/OTC UNIVERSAL LANCETS 3 daily) GLUCOSE MONITORING NC 21G MISC SYSTEM KIT MEDLANCE PLUS/LITE 3 QL(6.67 ea MICRODOT CONTROL 25G MISC daily) SOLUTIONHIGH/LOW 5 QL(6.67 ea SOLN MEDLANCE/EXTRA MISC 3 daily) MICROLET LANCETS 3 QL(6.67 ea QL(6.67 ea MISC daily) MEDLANCE/LITE MISC 3 daily) MICROLET NEXT MISC 5 MEDLANCE/UNIVERSAL 3 QL(6.67 ea MISC daily) MICROTAINER SAFETY QL(6.67 ea MEIJER BLOOD RX/OTC FLOW 3 daily) GLUCOSE MONITORING NC LANCET/STERILE/SINGL KIT KIT E-USE MISC MEIJER COLOR QL(6.67 ea MINI LANCING DEVICE 5 LANCETS UNIVERSAL 3 daily) MISC 33G MISC MM EASY TOUCH BLOOD NC RX/OTC MEIJER ESSENTIAL RX/OTC GLUCOSE METER KIT MM LANCING DEVICE BLOOD GLUCOSE NC 5 MONITORING SYSTEM MISC KIT MM TWIST LANCETS 3 QL(6.67 ea MISC daily) MEIJER LANCETS MISC 3 QL(6.67 ea daily) MONOLET LANCETS 3 QL(6.67 ea MISC daily) MEIJER LANCETS THIN 3 QL(6.67 ea MISC daily) MONOLET OPD LANCETS 3 QL(6.67 ea MISC daily) MEIJER LANCETS 3 QL(6.67 ea UNIVERSAL21G MISC daily) MONOLETTOR SAFETY 3 QL(6.67 ea LANCETS MISC daily) MEIJER LANCETS 3 QL(6.67 ea UNIVERSAL30G MISC daily) MPD SAFETY LANCET 3 QL(6.67 ea 21G/1.8MM MISC daily) MEIJER LANCETS 3 QL(6.67 ea UNIVERSAL33G MISC daily) MPD SAFETY LANCET 3 QL(6.67 ea MEIJER PREMIUM RX/OTC 28G/1.8MM MISC daily) BLOOD GLUCOSE NC MPD SAFETY LANCET 3 QL(6.67 ea MONITORING KIT KIT 30G/1.8MM MISC daily) MEIJER SUPER THIN QL(6.67 ea 3 MPD SAFETY LANCETS 3 QL(6.67 ea LANCETS MISC daily) 23G/1.8MM MISC daily) MEIJER TRUE2GO RX/OTC MULTI-LANCET DEVICE 5 BLOOD GLUCOSE NC MISC MONITORING SYSTEM MYGLUCOHEALTH RX/OTC KIT BLOOD GLUCOSE NC MEIJER TRUERESULT RX/OTC MONITORING SYSTEM BLOOD GLUCOSE NC KIT MONITORING SYSTEM MYGLUCOHEALTH KIT CONTROL 5 MEIJER TRUETRACK RX/OTC LOW/NORMAL/HIGH BLOOD GLUCOSE NC SOLN MONITORING KIT KIT

208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYGLUCOHEALTH MGH QL(6.67 ea ON CALL PLUS BLOOD NC RX/OTC SOFTLANCE LANCETS 3 daily) GLUCOSE METER KIT 30G MISC ON CALL PLUS BLOOD RX/OTC NEUTEK 2TEK CONTROL 5 GLUCOSE MONITORING NC SOLUTIONS SOLN SYSTEM KIT NOVA MAX BLOOD ON CALL PLUS GLUCOSE MONITORING NC GLUCOSE CONTROL 5 SYSTEM DEVI LEVEL 1/2 SOLN NOVA MAX BLOOD RX/OTC ON CALL PLUS LANCETS 3 QL(6.67 ea GLUCOSE MONITORING NC MISC daily) SYSTEM KIT ON CALL PLUS LANCING 5 NOVA MAX PLUS DEVICE MISC GLU/KET CONTROL 5 ON CALL VIVID BLOOD NC SOLUTION-MID LIQD GLUCOSE METER DEVI NOVA SAFETY LANCETS QL(6.67 ea 3 ON CALL VIVID BLOOD NC RX/OTC 23G MISC daily) GLUCOSE METER KIT NOVA SAFETY LANCETS 3 QL(6.67 ea ON CALL VIVID BLOOD RX/OTC 28G MISC daily) GLUCOSE MONITORING NC NOVA SUREFLEX 3 QL(6.67 ea SYSTEM KIT LANCETS MISC daily) ON CALL VIVID 5 NOVA SUREFLEX 5 GLUCOSE CONTROL LANCING DEVICE MISC LEVEL 1/2 SOLN OMNIPOD 5 PACK MISC 4 ON CALL VIVID PAL BLOOD GLUCOSE NC METER DEVI OMNIPOD DASH 5 PACK 4 MISC ON CALL VIVID PAL RX/OTC BLOOD GLUCOSE NC OMNIPOD DASH SYSTEM 4 KIT METER KIT ONE DROP BLOOD RX/OTC OMNIPOD STARTER KIT 4 KIT GLUCOSE MONITORING NC ON CALL EXPRESS SYSTEM KIT BLOOD GLUCOSE NC ONETOUCH CLUB QL(6.67 ea METER DEVI LANCETS FINE POINT 3 daily) ON CALL EXPRESS RX/OTC MISC ONETOUCH DELICA QL(6.67 ea BLOOD GLUCOSE NC MONITORING SYSTEM LANCETS EXTRA FINE 3 daily) KIT 33G MISC ON CALL EXPRESS ONETOUCH DELICA 3 QL(6.67 ea GLUCOSE CONTROL 5 LANCETS FINE 30G MISC daily) SOLUTION SOLN ONETOUCH DELICA 5 QL(6.67 ea LANCING DEVICE MISC ON CALL LANCETS MISC 3 daily) ONETOUCH DELICA QL(6.67 ea PLUS LANCETS EXTRA 3 daily) ON CALL LANCING 5 DEVICE MISC FINE 33G MISC ONETOUCH DELICA QL(6.67 ea ON CALL PLUS BLOOD NC GLUCOSE METER DEVI PLUS LANCETS FINE 30G 3 daily) MISC

209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONETOUCH DELICA OPTIUM BLOOD RX/OTC PLUS LANCING DEVICE 5 GLUCOSE MONITORING NC MISC SYSTEM KIT ONETOUCH DELICA OPTUMRX BLOOD NC RX/OTC SAFETY LACING DEVICE 5 GLUCOSE METER KIT MISC OPTUMRX BLOOD RX/OTC ONETOUCH FINEPOINT 3 QL(6.67 ea GLUCOSE MONITORING NC LANCETS MISC daily) SYSTEM KIT ONETOUCH ULTRA 2 KIT NC RX/OTC OPTUMRX GLUCOSE CONTROL LEVEL 1/2 5 SOLN ONETOUCH ULTRA 5 CONTROL SOLN PARADIGM LINK BLOOD NC RX/OTC GLUCOSE MONITOR KIT ONETOUCH ULTRA MINI NC RX/OTC KIT PC LANCETS SUPER 3 QL(6.67 ea THIN 30G MISC daily) ONETOUCH ULTRALINK NC RX/OTC SYSTEM (DEC) KIT PERFECT LANCETS 30G 3 QL(6.67 ea MISC daily) ONETOUCH ULTRALINK NC RX/OTC SYSTEM (HEX) KIT PERFECT PRESSURE QL(6.67 ea ACTIVATED SAFETY 3 daily) ONETOUCH ULTRASOFT 3 QL(6.67 ea LANCETS MISC daily) LANCETS 28G MISC ONETOUCH VERIO PHARMACIST CHOICE RX/OTC CONTROL SOLUTION 5 AUTOCODE BLOOD NC HIGH SOLN GLUCOSE MONITORING ONETOUCH VERIO FLEX RX/OTC SYSTEM KIT PHARMACIST CHOICE BLOOD GLUCOSE NC MONITORING SYSTEM MINI BLOOD GLUCOSE NC KIT MONITORING SYSTEM ONETOUCH VERIO IQ RX/OTC DEVI PHARMACIST CHOICE QL(6.67 ea BLOOD GLUCOSE NC MONITORING SYSTEM ULTRA THIN LANCETS 3 daily) KIT 28G MISC ONETOUCH VERIO KIT NC RX/OTC PHARMACIST CHOICE QL(6.67 ea ULTRA THIN LANCETS 3 daily) ONETOUCH VERIO MID 30G MISC CONTROL SOLUTION 5 PHARMACIST CHOICE QL(6.67 ea SOLN ULTRA THIN LANCETS 3 daily) 31G MISC ONETOUCH VERIO NC RX/OTC REFLECT KIT PHARMACIST CHOICE QL(6.67 ea ONETOUCH VERIO SYNC RX/OTC ULTRA THIN LANCETS 3 daily) 33G MISC BLOODGLUCOSE NC MONITORING SYSTEM PHARMACIST CHOICE QL(6.67 ea KIT ULTRA THIN LANCETS 3 daily) OPTIUM BLOOD MISC GLUCOSE MONITORING NC PHARMACY COUNTER 3 QL(6.67 ea SYSTEM DEVI LANCETS MISC daily) PIP LANCETS/28G MISC 3 QL(6.67 ea daily)

210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PIP LANCETS/30G MISC 3 QL(6.67 ea PREFERRED PLUS QL(6.67 ea daily) LANCETS SUPER THIN 3 daily) POCKETCHEM EZ RX/OTC 30G MISC BLOOD GLUCOSE NC PREFERRED PLUS 3 QL(6.67 ea MONITORING SYSTEM LANCETS THIN 26G MISC daily) KIT PRESSURE ACTIVATED QL(6.67 ea POCKETCHEM EZ 5 SAFETYLANCET 21G 3 daily) CONTROL LEVEL 1 SOLN MISC POGO AUTOMATIC PRO COMFORT 3 QL(6.67 ea BLOOD GLUCOSE NC LANCETS 30G MISC daily) MONITORING SYSTEM PRO COMFORT 3 QL(6.67 ea DEVI LANCETS 31G MISC daily) PRECISION GLUCOSE 5 PRO VOICE V8 BLOOD CONTROL LIQD GLUCOSE MONITORING NC PRECISION GLUCOSE SYSTEM DEVI CONTROLSOLUTION PRO VOICE V9 BLOOD (TRI- 5 GLUCOSE MONITORING NC LEVEL/HI/LO/NORMAL) SYSTEM DEVI SOLN PRODIGY AUTOCODE PRECISION GLUCOSE BLOOD GLUCOSE NC KETONECONTROL 5 MONITORING SYSTEM SOLUTION 1-LOW, 1- DEVI HIGH LIQD PRODIGY AUTOCODE RX/OTC PRECISION BLOOD GLUCOSE NC GLUCOSE/KETONECONT 5 MONITORING SYSTEM ROL SOLUTIONS 1-HI 1- KIT LO LIQD PRODIGY AUTOCODE RX/OTC RX/OTC PRECISION LINK KIT NC BLOOD GLUCOSE NC MONITORING/TALKING PRECISION QID NC KIT MONITOR DEVI PRODIGY CONTROL 5 PRECISION SOF-TACT NC SOLUTIONHIGH SOLN MONITOR DEVI PRODIGY CONTROL 5 PRECISION THINS GP 3 QL(6.67 ea SOLUTIONLOW SOLN LANCET MISC daily) PRODIGY LANCING 5 PRECISION XTRA DEVI NC DEVICE MISC PRODIGY NO CODING NC RX/OTC PRECISION XTRA KIT NC RX/OTC BLOOD GLUCOSE KIT PRODIGY POCKET RX/OTC PRECISION XTRA KIT NC BLOOD GLUCOSE NC METER KIT KIT PRECISION XTRA NC MONITOR DEVI PRODIGY PRESSURE QL(6.67 ea ACTIVATED SAFETY 3 daily) PREFERRED PLUS QL(6.67 ea LANCETS MISC LANCETS COLORED 21G 3 daily) MISC PRODIGY SAFETY 3 QL(6.67 ea LANCETS MISC daily)

211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRODIGY TWIST TOP 3 QL(6.67 ea QUINTET BLOOD LANCETS MISC daily) GLUCOSE MONITORING NC PRODIGY VOICE BLOOD RX/OTC SYSTEM DEVI GLUCOSE METER KIT NC QUINTET GLUCOSE KIT CONTROL/HIGH/NORMAL 5 SOLN PSS SELECT GP 3 QL(6.67 ea LANCETS MISC daily) RA E-ZJECT LANCETS 3 QL(6.67 ea 28G MISC daily) PSS SELECT SAFETY 3 QL(6.67 ea LANCETS MISC daily) RA E-ZJECT LANCETS 3 QL(6.67 ea THIN 26G MISC daily) PURE COMFORT 3 QL(6.67 ea LANCETS 30G MISC daily) RA E-ZJECT LANCETS 3 QL(6.67 ea THIN 28G MISC daily) PUSH BUTTON SAFETY 3 QL(6.67 ea LANCETS 21G MISC daily) RA E-ZJECT LANCETS 3 QL(6.67 ea ULTRATHIN 30G MISC daily) PUSH BUTTON SAFETY 3 QL(6.67 ea LANCETS 28G MISC daily) READYLANCE SAFETY QL(6.67 ea LANCETS/21G/2.2MM 3 daily) PX ADVANCED LANCING 5 DEVICE MISC MISC READYLANCE SAFETY QL(6.67 ea PX LANCET AUTO 5 INJECTOR MISC LANCETS/23G/1.8MM 3 daily) MISC PX LANCETS MICROTHIN 5 QL(6.67 ea 33G MISC daily) READYLANCE SAFETY QL(6.67 ea LANCETS/26G/1.8MM 3 daily) PX LANCETS ULTRA 3 QL(6.67 ea MISC THIN 28G MISC daily) READYLANCE SAFETY QL(6.67 ea PX LANCETS ULTRA 3 QL(6.67 ea LANCETS/28G/1.8MM 3 daily) THIN MISC daily) MISC QC ADVANCED LANCING 5 READYLANCE SAFETY QL(6.67 ea DEVICE MISC LANCETS/30G/1.6MM 3 daily) QC LANCETS SUPER 3 QL(6.67 ea MISC THIN MISC daily) QL(6.67 ea REALITY LANCETS MISC 3 QC LANCETS ULTRA 3 QL(6.67 ea daily) THIN MISC daily) REALITY TRIGGER 3 QL(6.67 ea QC UNILET LANCETS 3 QL(6.67 ea LANCETS MISC daily) 28G/ULTRA THIN MISC daily) REFUAH PLUS BLOOD RX/OTC QC UNILET LANCETS 3 QL(6.67 ea GLUCOSEMONITORING NC 33G/MICRO THIN MISC daily) SYSTEM KIT QUICKTEK CONTROL 5 REFUAH PLUS GLUCOSE SOLUTION LIQD CONTROL SOLUTION 5 QUICKTEK KIT NC RX/OTC SOLN RELION 2-IN-1 LANCET 5 QUICKTEK KIT NC DEVICES 30G MISC RELION 2-IN-1 LANCING 5 QUINTET AC BLOOD DEVICE 25G MISC GLUCOSEMONITORING NC SYSTEM DEVI RELION 2-IN-1 LANCING 5 DEVICE 30G MISC

212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION ALL-IN-ONE RELION ULTRA THIN QL(6.67 ea COMPACTBLOOD NC PLUS LANCETS 32G 3 daily) GLUCOSE TESTING MISC SYSTEM DEVI RELION ULTRA THIN QL(6.67 ea RELION CONFIRM RX/OTC PLUS LANCETS 33G 3 daily) BLOOD GLUCOSE NC MISC MONITORING SYSTEM REVEAL BLOOD NC RX/OTC KIT GLUCOSE MONITOR KIT RELION LANCETS 3 QL(6.67 ea REXALL BLOOD RX/OTC MICRO-THIN33G MISC daily) GLUCOSE MONITORING NC RELION LANCETS THIN 3 QL(6.67 ea SYSTEM KIT 26G MISC daily) REXALL LANCETS ULTRA 3 QL(6.67 ea RELION LANCETS 3 QL(6.67 ea THIN MISC daily) ULTRA-THIN30G MISC daily) RIGHTEST GC300 HIGH 5 RELION LANCING 5 CONTROL LIQD DEVICE MISC RIGHTEST GC300 5 RELION MICRO BLOOD RX/OTC NORMAL CONTROL LIQD GLUCOSE MONITORING NC RIGHTEST GD500 5 SYSTEM KIT LANCING DEVICE MISC RELION PREMIER BLU RIGHTEST GL300 3 QL(6.67 ea BLOOD GLUCOSE NC LANCETS MISC daily) MONITORING SYSTEM DEVI RIGHTEST GM100 RX/OTC BLOOD GLUCOSE NC RELION PREMIER MONITORING SYSTEM CLASSIC BLOOD NC KIT GLUCOSE MONITORING SYSTEM DEVI RIGHTEST GM300 RX/OTC BLOOD GLUCOSE NC RELION PREMIER RX/OTC MONITORING SYSTEM COMPACT BLOOD NC KIT GLUCOSE MONITORING SYSTEM KIT RIGHTEST GM550 RX/OTC BLOOD GLUCOSE NC RELION PREMIER VOICE MONITORING SYSTEM BLOOD GLUCOSE NC KIT MONITORING SYSTEM DEVI RIGHTEST GT333 BLOOD GLUCOSE MONITORING NC RELION PRIME BLOOD SYSTEM DEVI GLUCOSE MONITORING NC SYSTEM DEVI SAFE-T-LANCE LOW 3 QL(6.67 ea FLOW 25G MISC daily) RELION TRUE METRIX RX/OTC AIR BLOOD GLUCOSE NC SAFE-T-LANCE NORMAL 3 QL(6.67 ea METER/BLUETOOTH KIT FLOW21G MISC daily) RELION ULTIMA BLOOD RX/OTC SAFE-T-LANCE PLUS QL(6.67 ea GLUCOSE MONITORING NC SAFETYLANCET HIGH 3 daily) SYSTEM KIT FLOW MISC SAFE-T-LANCE PLUS QL(6.67 ea RELION ULTRA THIN 3 QL(6.67 ea LANCETS/30G MISC daily) SAFETYLANCET LOW 3 daily) FLOW MISC RELION ULTRA THIN 3 QL(6.67 ea LANCETS30G MISC daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFE-T-LANCE PLUS QL(6.67 ea SHOPKO UNILET QL(6.67 ea SAFETYLANCET 3 daily) LANCETS SUPER THIN 3 daily) NORMAL FLOW MISC 30G MISC SAFETY LANCET QL(6.67 ea SHOPKO UNILET QL(6.67 ea 21G/PRESSURE 3 daily) LANCETS ULTRA THIN 3 daily) ACTIVATED MISC 28G MISC SAFETY LANCET QL(6.67 ea SIDE BUTTON SAFETY 3 QL(6.67 ea 23G/PRESSURE 3 daily) LANCET21G MISC daily) ACTIVATED MISC SIDEKICK BLOOD NC SAFETY LANCET QL(6.67 ea GLUCOSE SYSTEM DEVI 28G/PRESSURE 3 daily) SIMPLE DIAGNOSTICS 5 ACTIVATED MISC LANCING DEVICE MISC SAFETY LANCET QL(6.67 ea SINGLE-LET MISC 3 QL(6.67 ea 30G/PRESSURE 3 daily) daily) ACTIVATED MISC SM MICRO THIN 3 QL(6.67 ea SAFETY LANCETS 21G 3 QL(6.67 ea LANCETS 33G MISC daily) MISC daily) SM TRUEDRAW LANCING 5 SAFETY LANCETS 28G 3 QL(6.67 ea DEVICE MISC MISC daily) SMART DIABETES QL(6.67 ea SAFETY LANCETS MISC 3 VANTAGE LANCING 5 daily) DEVICE MISC SAFETY LET LANCETS 3 QL(6.67 ea SMART SENSE COLOR QL(6.67 ea MISC daily) LANCETS UNIVERSAL 3 daily) SAFETY SEAL LANCETS 3 QL(6.67 ea 33G MISC 28G MISC daily) SMART SENSE PREMIUM RX/OTC SAFETY SEAL LANCETS 3 QL(6.67 ea BLOODGLUCOSE NC 30G MISC daily) MONITORING SYSTEM SAPS HEALTH CARE QL(6.67 ea KIT TWIST TOP LANCETS 3 daily) SMART SENSE QL(6.67 ea MISC STANDARD LANCETS 3 daily) UNIVERSAL 21G MISC SAPS HEALTH TWIST 5 QL(6.67 ea TOP LANCETS 30G MISC daily) SMART SENSE SUPER QL(6.67 ea THIN LANCETS 3 daily) SAPSCARE TWIST TOP 3 QL(6.67 ea LANCETS 30G MISC daily) UNIVERSAL 30G MISC QL(6.67 ea SMART SENSE THIN QL(6.67 ea SB LANCETS THIN MISC 3 daily) LANCETSUNIVERSAL 3 daily) 26G MISC SB LANCETS ULTRA 3 QL(6.67 ea THIN MISC daily) SMART SENSE VALUE RX/OTC BLOODGLUCOSE NC SELECT-LITE LANCING 5 MONITORING SYSTEM DEVICE MISC KIT SHOPKO AUTOLET 5 SMARTEST CONTROL 5 LANCING DEVICE MISC SOLUTIONMEDIUM SOLN SHOPKO ON-THE-GO QL(6.67 ea SMARTEST EJECT COMFORTLANCETS 30G 3 daily) BLOOD GLUCOSE NC MISC MONITORING SYSTEM DEVI

214 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SMARTEST EJECT NC RX/OTC SURE COMFORT 3 QL(6.67 ea STARTER KIT KIT LANCETS 23G MISC daily) SMARTEST LANCETS 3 QL(6.67 ea SURE COMFORT 3 QL(6.67 ea 28G MISC daily) LANCETS 28G MISC daily) SMARTEST PERSONA NC RX/OTC SURE COMFORT 3 QL(6.67 ea STARTERKIT KIT LANCETS 30G MISC daily) SMARTEST PRONTO NC RX/OTC SURE COMFORT 5 STARTERKIT KIT LANCING PEN MISC SMARTEST PROTEGE SURE EDGE BLOOD NC BLOOD GLUCOSE NC GLUCOSE MONITORING MONITORING SYSTEM SYSTEM DEVI DEVI SURE-LANCE FLAT 3 QL(6.67 ea SMARTEST PROTEGE NC RX/OTC LANCETS MISC daily) STARTERKIT KIT SURE-LANCE LANCETS 3 QL(6.67 ea SOLARTEK GLUCOSE 26G MISC daily) CONTROLSOLUTIONS 5 SURE-LANCE THIN 3 QL(6.67 ea LIQD LANCETS 28G MISC daily) SOLUS V2 AUDIBLE SURE-LANCE ULTRA 3 QL(6.67 ea BLOOD GLUCOSE NC THIN LANCETS MISC daily) MANAGEMENT SYSTEM DEVI SURE-PEN MISC 5 SOLUS V2 AUDIBLE RX/OTC SURE-TEST EASYPLUS BLOOD GLUCOSE NC MINI SELF MONITORING NC MANAGEMENT SYSTEM BLOOD GLUCOSE KIT METER DEVI SOLUS V2 CONTROL 5 SURE-TOUCH LANCETS 3 QL(6.67 ea HIGH SOLN UNIVERSAL MISC daily) SOLUS V2 CONTROL 5 SURECHEK BLOOD LOW SOLN GLUCOSE MONITORING NC SOLUS V2 LANCING 5 SYSTEM DEVI DEVICE MISC SURECHEK BLOOD RX/OTC SOLUS V2 PRESSURE QL(6.67 ea GLUCOSE MONITORING NC ACTIVATED SAFETY 3 daily) SYSTEM STARTER KIT LANCETS 28G MISC KIT SOLUS V2 TWIST QL(6.67 ea 3 SURELITE LANCETS 3 QL(6.67 ea LANCETS 30G MISC daily) MISC daily) QL(6.67 ea STERILANCE TL MISC 3 SURESTEP GLUCOSE 5 daily) CONTROL SOLN SUPER THIN LANCETS 3 QL(6.67 ea SURESTEP GLUCOSE MISC daily) CONTROLSOLUTION 5 SUPREME II HIGH/LOW SOLN CONTROL SOLUTION 5 SURESTEP PRO HIGH LIQD GLUCOSECONTROL 5 LIQD SURE COMFORT 3 QL(6.67 ea LANCETS 18G MISC daily) SURESTEP PRO LOW GLUCOSECONTROL 5 SURE COMFORT 3 QL(6.67 ea LANCETS 21G MISC daily) LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

215 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURESTEP PRO TRAVEL LANCETS 3 QL(6.67 ea NORMAL GLUCOSE 5 ADVANCED 28G MISC daily) CONTROL LIQD TRUE COMFORT TWIST 3 QL(6.67 ea TAI DOC CONTROL SOLN 5 TOP LANCETS 30G MISC daily) TRUE FOCUS BLOOD TECHLITE AST LANCETS QL(6.67 ea 3 GLUCOSESELF NC MISC daily) MONITORING METER DEVI TECHLITE LANCETS 30G 3 QL(6.67 ea MISC daily) TRUE METRIX AIR BLOOD GLUCOSE TECHLITE LANCETS 3 QL(6.67 ea NC MISC daily) METER/BLUETOOTH TELCARE BLOOD RX/OTC DEVI GLUCOSE MONITORING NC TRUE METRIX AIR RX/OTC SYSTEM KIT BLOOD GLUCOSE NC TELCARE GLUCOSE METER/BLUETOOTH CONTROL SOLUTION 5 SMART KIT LEVEL 1/2 SOLN TRUE METRIX AIR RX/OTC TGT BLOOD GLUCOSE RX/OTC W/BLUETOOTH SMART NC METER MONITORING NC KIT SYSTEM KIT TRUE METRIX BLOOD NC RX/OTC TGT BLOOD GLUCOSE RX/OTC GLUCOSEMETER KIT MONITORING SYSTEM NC TRUE METRIX CONTROL KIT SOLUTION LEVEL 1 5 TGT BLOOD GLUCOSE RX/OTC SOLN MONITORING SYSTEM NC TRUE METRIX CONTROL PREMIUM KIT SOLUTION LEVEL 2 5 SOLN TGT LANCET MICRO 3 QL(6.67 ea THIN 33G MISC daily) TRUE METRIX CONTROL SOLUTION LEVEL 3 5 TGT LANCET THIN 26G 3 QL(6.67 ea MISC daily) SOLN TGT LANCET ULTRA 3 QL(6.67 ea TRUE METRIX DEVI NC THIN 30G MISC daily) TRUE METRIX GO RX/OTC TGT LANCING DEVICE 5 BLOOD GLUCOSE NC MISC METER KIT THINLETS GP LANCETS 3 QL(6.67 ea TRUECONTROL MISC daily) GLUCOSE CONTROL 5 TODAYS HEALTH LEVEL 0 LIQD ADVANCED LANCING 5 TRUECONTROL DEVICE MISC GLUCOSE CONTROL 5 TODAYS HEALTH SUPER 3 QL(6.67 ea LEVEL 1 LIQD THINLANCETS 30G MISC daily) TRUEDRAW LANCING 5 TODAYS HEALTH ULTRA 3 QL(6.67 ea DEVICE MISC THINLANCETS 28G MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea TOPCARE LANCETS 3 QL(6.67 ea 26G MISC daily) MICRO-THIN 33G MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea TRAVEL LANCETS 30G 3 QL(6.67 ea 28G MISC daily) MISC daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

216 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS LANCETS 3 QL(6.67 ea ULTRA-THIN II AUTO 3 QL(6.67 ea 28G SUPER THIN MISC daily) LANCET MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea ULTRA-THIN II LANCETS 3 QL(6.67 ea 30G MISC daily) 28G MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea ULTRA-THIN II LANCETS 3 QL(6.67 ea 30G ULTRA THIN MISC daily) 30G MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea ULTRATRAK ACTIVE NC 33G MICRO THIN MISC daily) DEVI TRUEPLUS LANCETS 3 QL(6.67 ea ULTRATRAK PRO 33G MISC daily) CONTROL SOLUTION 2 5 LEVELS SOLN TRUEPLUS SAFETY 3 QL(6.67 ea LANCETS 28G MISC daily) ULTRATRAK PRO DEVI NC TRUERESULT BLOOD RX/OTC GLUCOSEMONITORING NC ULTRATRAK PRO SYSTEM/NO CODING KIT NORMAL CONTROL 5 TRUETRACK BLOOD SOLN GLUCOSE MONITORING NC ULTRATRAK ULTIMATE SYSTEM DEVI CONTROL SOLUTION 2 5 TRUETRACK BLOOD RX/OTC LEVELS SOLN GLUCOSE MONITORING NC ULTRATRAK ULTIMATE NC SYSTEM KIT MONITOR DEVI UNILET COMFORTOUCH QL(6.67 ea TRUETRACK SMART NC RX/OTC 3 SYSTEM KIT LANCET MISC daily) QL(6.67 ea ULTI-LANCE AUTOMATIC/ 5 UNILET EXCELITE II MISC 3 CLEAR TIP MISC daily) QL(6.67 ea ULTILET CLASSIC 3 QL(6.67 ea UNILET EXCELITE MISC 3 LANCETS MISC daily) daily) UNILET G.P. LANCET QL(6.67 ea ULTILET LANCETS 33G 3 QL(6.67 ea 3 MISC daily) MISC daily) UNILET G.P. SUPERLITE QL(6.67 ea ULTILET LANCETS MISC 3 QL(6.67 ea 3 daily) LANCET MISC daily) ULTILET SAFETY QL(6.67 ea UNILET GP 28 ULTRA 3 QL(6.67 ea LANCETS 21G X 2.2MM 3 daily) THIN MISC daily) MISC UNILET LANCET MISC 3 QL(6.67 ea daily) ULTILET SAFETY 3 QL(6.67 ea LANCETS 23G MISC daily) UNILET LANCETS 3 QL(6.67 ea MICRO-THIN33G MISC daily) ULTIMA KIT NC UNILET LANCETS 3 QL(6.67 ea ULTRA THIN LANCETS 3 QL(6.67 ea SUPER-THIN30G MISC daily) 31G MISC daily) UNILET LANCETS 3 QL(6.67 ea ULTRA TRAK PRO RX/OTC ULTRA-THIN 28G MISC daily) BLOOD GLUCOSE NC UNILET SUPERLITE 3 QL(6.67 ea MONITORING SYSTEM LANCET MISC daily) KIT QL(6.67 ea UNISTIK 3 GENTLE MISC 3 ULTRA-CARE LANCETS 3 QL(6.67 ea daily) 30G MISC daily)

217 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNISTIK PRO SAFETY 3 QL(6.67 ea VALUMARK LANCET 3 QL(6.67 ea LANCET 21G MISC daily) ULTRA THIN 28G MISC daily) UNISTIK PRO SAFETY 3 QL(6.67 ea VERASENS BLOOD RX/OTC LANCET 25G MISC daily) GLUCOSE MONITORING NC SYSTEM KIT UNISTIK PRO SAFETY 3 QL(6.67 ea LANCET 28G MISC daily) VERASENS BLOOD GLUCOSE MONITORING UNISTIK SAFETY 3 QL(6.67 ea NC LANCETS 28G MISC daily) SYSTEM METER KIT DEVI UNISTIK SAFETY 3 QL(6.67 ea LANCETS 30G MISC daily) VERASENS GLUCOSE 5 CONTROLLEVEL 1 LIQD UNISTIK TOUCH SAFETY 3 QL(6.67 ea LANCETS 21G MISC daily) VIDA MIA AUTOLET 5 LANCINGDEVICE MISC UNISTIK TOUCH SAFETY 3 QL(6.67 ea LANCETS 23G MISC daily) VIDA MIA UNILET QL(6.67 ea LANCETS SUPER THIN 3 daily) UNISTIK TOUCH SAFETY 3 QL(6.67 ea 30G MISC LANCETS 28G MISC daily) VIDA MIA UNILET QL(6.67 ea UNISTIK TOUCH SAFETY 3 QL(6.67 ea LANCETS ULTRA THIN 3 daily) LANCETS 30G MISC daily) 28G MISC UNISTRIP CONTROL 5 VITALET PRO LANCETS 3 QL(6.67 ea SOLUTIONHIGH SOLN MISC daily) UNISTRIP CONTROL 5 VITALET PRO PLUS 3 QL(6.67 ea SOLUTIONLOW SOLN LANCETS MISC daily) UNIVERSAL 1 LANCETS QL(6.67 ea 3 VIVAGUARD INO BLOOD NC THIN26G MISC daily) GLUCOSE METER DEVI UNIVERSAL 1 LANCETS 3 QL(6.67 ea VIVAGUARD INO ULTRA THIN 30G MISC daily) CONTROL SOLUTION 5 UNIVERSAL 1 QL(6.67 ea LIQD LANCETS/33G/MICRO- 3 daily) VIVAGUARD LANCETS 3 QL(6.67 ea THIN MISC MISC daily) V-GO 20 KIT 4 VIVAGUARD LANCING 5 DEVICE MISC V-GO 30 KIT 4 VOCAL POINT BLOOD GLUCOSE MONITORING NC V-GO 40 KIT 4 SYSTEM DEVI WALGREENS ADVANCED QL(6.67 ea VALUE PLUS LANCETS 3 QL(6.67 ea STANDARD 21G MISC daily) TRAVELLANCETS 28G 3 daily) MISC VALUE PLUS LANCETS 3 QL(6.67 ea SUPERTHIN 30G MISC daily) WALGREENS COMFORT QL(6.67 ea ASSUREDLANCETS 3 daily) VALUE PLUS LANCETS 3 QL(6.67 ea MICRO THIN/33G MISC THIN 26G MISC daily) WALGREENS COMFORT QL(6.67 ea VALUE PLUS LANCING 5 ASSUREDLANCETS 3 daily) DEVICE MISC SUPER THIN/28G MISC VALUMARK LANCET QL(6.67 ea 3 WALGREENS LANCETS 3 QL(6.67 ea SUPER THIN 30G MISC daily) MISC daily)

218 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WALGREENS THIN 3 QL(6.67 ea DR SCHOLLS HEAVY RX/OTC LANCETS MISC daily) DUTY 5 SUPPORT/MEN/SIZE 8-14 WALGREENS ULTRA 3 QL(6.67 ea THIN LANCETS MISC daily) MISC DR SCHOLLS PLANTAR RX/OTC WAVESENSE AMP KIT NC RX/OTC FASCIITIS 5 INSOLE/MEN/SIZE 8-13 WAVESENSE KEYNOTE NC RX/OTC KIT MISC DR SCHOLLS PLANTAR RX/OTC WAVESENSE KEYNOTE NC PRO METER DEVI FASCIITIS 5 INSOLE/WOMEN/SIZE 6- Foot Care Products 10 MISC AIR FOAM INSOLES 5 RX/OTC DR SCHOLLS TRI- RX/OTC MENS MISC COMFORT 5 INSOLES/WOMENS/SIZE AIR FOAM INSOLES 5 RX/OTC WOMENS MISC 6-10 MISC DUAL GEL INSOLES RX/OTC ALL GEL BUNION TOE 5 RX/OTC 5 SPREADER MISC MENS SIZE 8-13 MISC DUAL GEL INSOLES RX/OTC BIOFREQUENCY 5 RX/OTC 5 INSOLES MISC WOMENS SIZE 6-10 MISC RX/OTC EASY GRIP CALLUS 5 RX/OTC CALLUS REMOVER MISC 5 REMOVER MISC CALLUS/CORN SHAVER RX/OTC 5 EQL DUAL GEL INSOLES 5 RX/OTC BLADES MISC WOMENS MISC CALLUS/CORN SHAVER RX/OTC 5 EQL PUMICE 5 RX/OTC MISC STONE/ROPE MISC CVS ADVANCED GEL RX/OTC 5 EQL TOENAIL CLIPPER 5 RX/OTC ORTHOTICS/MENS MISC MISC DOUBLE AIR FOAM RX/OTC 5 EXFOLIATING STONE 5 RX/OTC INSOLES MENS MISC FILE MISC DOUBLE AIR FOAM RX/OTC 5 FOAM TOE 5 RX/OTC INSOLES WOMENS MISC SEPARATORS MISC DR SCHOLLS RX/OTC FOOT COMFORT RX/OTC COMFORT/ENERGY THERMAL ANKLE AND 5 MASSAGING GEL 5 FOOT STABILIZER MISC ADVANCED/MEN/SZ 8-14 FOOT SLEEP SUPPORT 5 RX/OTC MISC MISC DR SCHOLLS RX/OTC FOOT SMOOTHER DUAL 5 RX/OTC COMFORT/ENERGY 5 SURFACE MISC WORK MESSAGING GEL ADV/MEN/SZ 8-14 MISC FUTURO THERAPEUTIC RX/OTC ARCH SUPPORT FOOT 5 DR SCHOLLS RX/OTC MISC COMFORT/ENERGY 5 WORK MESSAGING GEL GEL BALL OF FOOT 5 RX/OTC ADV/WOM/SZ 6-10 MISC CUSHIONS MISC GEL CORN 5 RX/OTC PROTECTORS MISC

219 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GEL INSOLES MENS 5 RX/OTC RA GEL TOE 5 RX/OTC MISC SEPARATORS MISC GEL INSOLES WOMENS 5 RX/OTC RA PLANTAR FASCIITIS 5 RX/OTC MISC ARCH SLEEVE MISC GEL TOE PROTECTOR 5 RX/OTC SHOE HORN RX/OTC MISC DELUXE/CHROME FINISH 5 MISC GEL TOE SEPARATORS 5 RX/OTC MISC SLEEP-N-HEEL NIGHT RX/OTC RX/OTC CONDITIONING HEEL 5 GEL TOE SPACERS MISC 5 SLEEVES MISC GNP CUSHION RX/OTC SLEEP-N-HEEL+ NIGHT RX/OTC COMFORT INSOLES 5 CONDITIONING HEEL 5 MISC SLEEVES MISC SOCK AID DELUXE RX/OTC HEALTH 5 RX/OTC 5 SLIPPERS/UNISEX MISC MOLDED MISC SOFT FOAM TOE RX/OTC MEDICOOLS DIASOX 5 RX/OTC MISC SEPARATORSMEDIUM 5 MISC MEMORY WORK/SPORT 5 RX/OTC INSOLES MISC SPENCO ARCH RX/OTC ODOR CONTROL RX/OTC SUPPORT INSOLES SIZE 5 INSOLES 5 10/11 MENS MISC MENS/WOMENS MISC SPENCO ARCH RX/OTC SUPPORT INSOLES SIZE 5 ODOR EATERS ULTRA 5 RX/OTC COMFORT MISC 12/13 MENS MISC PREVALON FOOT/LEG RX/OTC SPENCO ARCH RX/OTC STABILIZER WEDGE 5 SUPPORT INSOLES SIZE 5 MISC 8/9 MENS MISC RX/OTC SPENCO COMFORT RX/OTC PREVALON MISC 5 INSOLES SIZE 10/11 5 PREVALON PRESSURE RX/OTC MENS MISC RELIEVING HEEL 5 SPENCO COMFORT RX/OTC PROTECTOR MISC INSOLES SIZE 12/13 5 PREVALON PRESSURE RX/OTC MENS MISC SPENCO COMFORT RX/OTC RELIEVING HEEL 5 PROTECTOR/PETITE INSOLES SIZE 14/15 5 MISC MENS MISC PREVALON PRESSURE RX/OTC SPENCO COMFORT RX/OTC INSOLES SIZE 8/9 MENS 5 RELIEVING HEEL 5 PROTECTOR/WEDGE MISC MISC SPENCO FOR HER RX/OTC INSOLES SIZE 11/12 5 PROFOOT PLANTAR 5 RX/OTC FASCIITIS MISC MISC RX/OTC SPENCO FOR HER RX/OTC PUMICE STONE MISC 5 INSOLES SIZE 11/12 5 TOTAL SUPPORT MISC RA CUSHION INSOLES 5 RX/OTC WOMENS MISC SPENCO FOR HER 5 RX/OTC INSOLES SIZE 3/4 MISC

220 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO FOR HER RX/OTC SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 3/4 TOTAL 5 SIZE 14/15 MISC SUPPORT MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO FOR HER 5 RX/OTC SIZE 3/4 MISC INSOLES SIZE 5/6 MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO FOR HER RX/OTC SIZE 5/6 MISC INSOLES SIZE 5/6 TOTAL 5 SPENCO GEL INSOLES 5 RX/OTC SUPPORT MISC SIZE 6/7-7/8 MISC SPENCO FOR HER RX/OTC 5 SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 7/8 MISC SIZE 8/9 MENS MISC SPENCO FOR HER RX/OTC SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 7/8 TOTAL 5 SIZE 8/9-9/10 MISC SUPPORT MISC SPENCO IRONMAN GEL 5 RX/OTC SPENCO FOR HER 5 RX/OTC INSOLES LARGE MISC INSOLES SIZE 9/10 MISC SPENCO IRONMAN GEL 5 RX/OTC SPENCO FOR HER RX/OTC INSOLES SMALL MISC INSOLES SIZE 9/10 5 TOTAL SUPPORT MISC SPENCO IRONMAN PLUS 5 RX/OTC INSOLES LARGE MISC SPENCO GEL ARCH RX/OTC INSOLES SIZE LARGE 5 SPENCO IRONMAN PLUS 5 RX/OTC MISC INSOLES SMALL MISC SPENCO GEL ARCH RX/OTC SPENCO KIDS COMFORT RX/OTC INSOLES SIZE MEDIUM 5 INSOLES SIZE 3 TO 4-1/2 5 MISC MISC SPENCO GEL ARCH RX/OTC SPENCO KIDS COMFORT RX/OTC INSOLES SIZE SMALL 5 INSOLES SIZE 5 TO 6-1/2 5 MISC MISC SPENCO KIDS COMFORT RX/OTC SPENCO GEL BALL OF 5 RX/OTC 5 FOOT ONE SIZE MISC INSOLES SIZE 7/8 MISC SPENCO GEL HEEL CUP RX/OTC SPENCO KIDS RX/OTC SIZEMEDIUM/LARGE 5 POLYSORB INSOLES 5 MISC SIZE 3 TO 4-1/2 MISC SPENCO GEL HEEL CUP RX/OTC SPENCO KIDS RX/OTC SIZESMALL/MEDIUM 5 POLYSORB INSOLES 5 MISC SIZE 5 TO 6-1/2 MISC SPENCO KIDS RX/OTC SPENCO GEL HEEL 5 RX/OTC INSOLES ONE SIZE MISC POLYSORB INSOLES 5 SIZE 7/8 MISC SPENCO GEL INSOLES 5 RX/OTC SIZE 10/11 MENS MISC SPENCO POLYSORB RX/OTC INSOLES SIZE 10/11- 5 SPENCO GEL INSOLES 5 RX/OTC 11/12 CROSS-TRAINER SIZE 10/11-11/12 MISC MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO POLYSORB RX/OTC SIZE 12/13 MENS MISC INSOLES SIZE 10/11- 5 SPENCO GEL INSOLES 5 RX/OTC 11/12 HEAVY DUTY MISC SIZE 12/13 MISC SPENCO POLYSORB RX/OTC SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 10/11- 5 SIZE 14/15 MENS MISC 11/12 HIKER MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

221 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 10/11- 5 INSOLES SIZE 3/4 5 11/12 TOTAL SUPPORT WALKER-RUNNER MISC MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 5/6 5 INSOLES SIZE 10/11- 5 CROSS-TRAINER MISC 11/12 WALKER-RUNNER SPENCO POLYSORB RX/OTC MISC INSOLES SIZE 5/6 HEAVY 5 SPENCO POLYSORB RX/OTC DUTY MISC INSOLES SIZE 12/13 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 5/6 HIKER 5 SPENCO POLYSORB RX/OTC MISC INSOLES SIZE 12/13 5 SPENCO POLYSORB RX/OTC HEAVY DUTY MISC INSOLES SIZE 5/6 TOTAL 5 SPENCO POLYSORB RX/OTC SUPPORT MISC INSOLES SIZE 12/13 5 SPENCO POLYSORB RX/OTC HIKER MISC INSOLES SIZE 5/6 5 SPENCO POLYSORB RX/OTC WALKER-RUNNER MISC INSOLES SIZE 12/13 5 SPENCO POLYSORB RX/OTC TOTAL SUPPORT MISC INSOLES SIZE 6/7-7/8 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 12/13 5 SPENCO POLYSORB RX/OTC WALKER-RUNNER MISC INSOLES SIZE 6/7-7/8 5 SPENCO POLYSORB RX/OTC HEAVY DUTY MISC INSOLES SIZE 14/15 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 6/7-7/8 5 SPENCO POLYSORB RX/OTC HIKER MISC INSOLES SIZE 14/15 5 SPENCO POLYSORB RX/OTC HEAVY DUTY MISC INSOLES SIZE 6/7-7/8 5 SPENCO POLYSORB RX/OTC TOTAL SUPPORT MISC INSOLES SIZE 14/15 5 SPENCO POLYSORB RX/OTC HIKER MISC INSOLES SIZE 6/7-7/8 5 SPENCO POLYSORB RX/OTC WALKER-RUNNER MISC INSOLES SIZE 14/15 5 SPENCO POLYSORB RX/OTC TOTAL SUPPORT MISC INSOLES SIZE 8/9-9/10 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 14/15 5 SPENCO POLYSORB RX/OTC WALKER-RUNNER MISC INSOLES SIZE 8/9-9/10 5 SPENCO POLYSORB RX/OTC HEAVY DUTY MISC INSOLES SIZE 3/4 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 8/9-9/10 5 SPENCO POLYSORB RX/OTC HIKER MISC INSOLES SIZE 3/4 HIKER 5 SPENCO POLYSORB RX/OTC MISC INSOLES SIZE 8/9-9/10 5 SPENCO POLYSORB RX/OTC TOTAL SUPPORT MISC INSOLES SIZE 3/4 TOTAL 5 SPENCO POLYSORB RX/OTC SUPPORT MISC INSOLES SIZE 8/9-9/10 5 WALKER-RUNNER MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

222 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 10/11- 5 INSOLES SIZE 12/13 5 11/12 BACKPACKER MISC MISC SPENCO RX ARCH RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 10/11- 5 MISC 11/12 DAY HIKER MISC SPENCO RX ARCH 5 RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 3/4 MISC INSOLES SIZE 12/13 5 SPENCO RX ARCH 5 RX/OTC BACKPACKER MISC INSOLES SIZE 5/6 MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 12/13 DAY 5 INSOLES SIZE 6/7-7/8 5 HIKER MISC MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 8/9-9/10 5 BACKPACKER MISC MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 14/15 DAY 5 FOOTCRADLES SIZE 10 5 HIKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 3/4 5 FOOTCRADLES SIZE 11 5 BACKPACKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 3/4 DAY 5 FOOTCRADLES SIZE 12 5 HIKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 5/6 5 FOOTCRADLES SIZE 6 5 BACKPACKER MISC WOMENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 5/6 DAY 5 FOOTCRADLES SIZE 7 5 HIKER MISC WOMENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 6/7-7/8 5 FOOTCRADLES SIZE 8 5 BACKPACKER MISC WOMENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 6/7-7/8 5 FOOTCRADLES SIZE 9 5 DAY HIKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 8/9-9/10 5 FOOTCRADLES SIZE 9 5 BACKPACKER MISC WOMENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX BALL OF 5 RX/OTC INSOLES SIZE 8/9-9/10 5 FOOT LARGE MISC DAY HIKER MISC SPENCO RX BALL OF 5 RX/OTC SPENCO RX ARCH RX/OTC FOOT MEDIUM MISC INSOLES SIZE 10/11- 5 11/12 MISC SPENCO RX BALL OF 5 RX/OTC FOOT SMALL MISC

223 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO RX DIABETIC RX/OTC SPENCO RX INSOLES 5 RX/OTC SUPPORT SIZE 10 MENS 5 SIZE 5/6 MISC MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX DIABETIC RX/OTC SIZE 6/7-7/8 MISC SUPPORT SIZE 11 MENS 5 SPENCO RX INSOLES 5 RX/OTC MISC SIZE 8/9-9/10 MISC SPENCO RX DIABETIC RX/OTC SPENCO RX ORTHOTIC RX/OTC SUPPORT SIZE 12 MENS 5 ARCH SUPPORTS SIZE 5 MISC 10/11-11/12 MISC SPENCO RX DIABETIC RX/OTC SPENCO RX ORTHOTIC RX/OTC SUPPORT SIZE 6 5 ARCH SUPPORTS SIZE 5 WOMENS MISC 10/11-11/12 THINSOLE SPENCO RX DIABETIC RX/OTC MISC SUPPORT SIZE 7 5 SPENCO RX ORTHOTIC RX/OTC WOMENS MISC ARCH SUPPORTS SIZE 5 SPENCO RX DIABETIC RX/OTC 12/13 MISC SUPPORT SIZE 8 5 SPENCO RX ORTHOTIC RX/OTC WOMENS MISC ARCH SUPPORTS SIZE 5 SPENCO RX DIABETIC RX/OTC 12/13 THINSOLE MISC SUPPORT SIZE 9 MENS 5 SPENCO RX ORTHOTIC RX/OTC MISC ARCH SUPPORTS SIZE 5 SPENCO RX DIABETIC RX/OTC 14/15 MISC SUPPORT SIZE 9 5 SPENCO RX ORTHOTIC RX/OTC WOMENS MISC ARCH SUPPORTS SIZE 5 SPENCO RX HEEL RX/OTC 14/15 THINSOLE MISC INSOLES SIZE 10/11- 5 SPENCO RX ORTHOTIC RX/OTC 11/12 MISC ARCH SUPPORTS SIZE 5 SPENCO RX HEEL RX/OTC 3/4 MISC INSOLES SIZE 12/13 5 SPENCO RX ORTHOTIC RX/OTC MISC ARCH SUPPORTS SIZE 5 SPENCO RX HEEL 5 RX/OTC 3/4 THINSOLE MISC INSOLES SIZE 5/6 MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX HEEL RX/OTC ARCH SUPPORTS SIZE 5 INSOLES SIZE 6/7-7/8 5 5/6 MISC MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX HEEL RX/OTC ARCH SUPPORTS SIZE 5 INSOLES SIZE 8/9-9/10 5 5/6 THINSOLE MISC MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX INSOLES 5 RX/OTC ARCH SUPPORTS SIZE 5 SIZE 10/11-11/12 MISC 6/7-7/8 MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX ORTHOTIC RX/OTC SIZE 12/13 MISC ARCH SUPPORTS SIZE 5 6/7-7/8 THINSOLE MISC SPENCO RX INSOLES 5 RX/OTC SIZE 14/15 MISC SPENCO RX ORTHOTIC RX/OTC ARCH SUPPORTS SIZE 5 SPENCO RX INSOLES 5 RX/OTC SIZE 3/4 MISC 8/9-9/10 MISC

224 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO RX ORTHOTIC RX/OTC VALULINE SHORT LEG 5 RX/OTC ARCH SUPPORTS SIZE 5 WALKER/LARGE MISC 8/9-9/10 THINSOLE MISC VALULINE SHORT LEG RX/OTC SPENCO SLIM FIT RX/OTC WALKER/LOW 5 INSOLES SIZE 10/11 5 TOP/LARGE MISC MENS MISC VALULINE SHORT LEG RX/OTC SPENCO SLIM FIT RX/OTC WALKER/LOW 5 INSOLES SIZE 12/13 5 TOP/MEDIUM MISC MENS MISC VALULINE SHORT LEG RX/OTC SPENCO SLIM FIT RX/OTC WALKER/LOW 5 INSOLES SIZE 14/15 5 TOP/SMALL MISC MENS MISC VALULINE SHORT LEG 5 RX/OTC SPENCO SLIM FIT RX/OTC WALKER/MEDIUM MISC INSOLES SIZE 8/9 MENS 5 VALULINE SHORT LEG 5 RX/OTC MISC WALKER/SMALL MISC SPORT & WORK RX/OTC VALULINE SHORT LEG RX/OTC CUSHION INSOLES 5 WALKER/STANDARD 5 MENS SIZE 7-13 MISC TOP/MEDIUM MISC TOENAIL CLIPPER MISC 5 RX/OTC VALULINE SHORT LEG RX/OTC WALKER/STANDARD 5 TOENAIL CLIPPER/FILE 5 RX/OTC TOP/SMALL MISC DELUXE MISC VALULINE SHORT LEG RX/OTC TOENAIL NIPPER MISC 5 RX/OTC WALKER/STANDARD/LAR 5 GE MISC VALULINE PNEUMATIC RX/OTC VALULINE SHORT LEG 5 RX/OTC SHORTLEG 5 WALKER/XLARGE MISC WALKER/LOW TOP/LARGE MISC VALULINE SHORT LEG 5 RX/OTC WALKER/XSMALL MISC VALULINE PNEUMATIC RX/OTC Misc. Devices SHORTLEG 5 WALKER/LOW ADVOCATE ALCOHOL 5 RX/OTC TOP/MEDIUM MISC PREP PADS PADS VALULINE PNEUMATIC RX/OTC ALCOH-GLOVE 5 RX/OTC SHORTLEG 5 CONTOURED WIPE PADS WALKER/LOW ALCOH-WIPE 12" X 12" 5 TOP/SMALL MISC SHEE VALULINE PNEUMATIC RX/OTC ALCOHOL PADS PADS 5 RX/OTC SHORTLEG 5 WALKER/STANDARD ALCOHOL PREP PADS RX/OTC TOP/LARGE MISC 5 PADS VALULINE PNEUMATIC RX/OTC ALCOHOL PREPS PADS 5 RX/OTC SHORTLEG 5 WALKER/STANDARD TOP/MEDIUM MISC ALCOHOL SWABS PADS 5 RX/OTC VALULINE PNEUMATIC RX/OTC ALCOHOL SWABSTICK 5 RX/OTC SHORTLEG 5 PADS WALKER/STANDARD TOP/SMALL MISC APLICARE ALCOHOL 5 RX/OTC SWABSTICK PADS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

225 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SWABS SINGLE USE 5 RX/OTC PHARMACIST CHOICE RX/OTC BUTTERFLY PADS ALCOHOLPREP PADS 5 PADS BD SWABS SINGLE USE 5 RX/OTC PADS PRO COMFORT 5 RX/OTC ALCOHOL PADS PADS CARETOUCH ALCOHOL 5 RX/OTC PREP PADS PADS PURE COMFORT RX/OTC COMFORT TOUCH RX/OTC ALCOHOL PREPPADS 5 ALCOHOL PREP PADS 5 PADS PADS QC ALCOHOL SWABS 5 RX/OTC CURITY ALCOHOL RX/OTC PADS 5 PREPS/MEDIUM 2 PLY RA ALCOHOL SWABS 5 RX/OTC PADS PADS CURITY ALCOHOL 5 RX/OTC REALITY SWABS PADS 5 RX/OTC SWABS PADS RELION ALCOHOL RX/OTC CVS ALCOHOL PREP 5 RX/OTC 5 PADS PADS SWABS PADS RX/OTC SAPS CARE ALCOHOL 5 RX/OTC CVS PREP PADS PADS 5 PREP PADS PADS EASY COMFORT 5 RX/OTC SAPS HEALTH ALCOHOL 5 RX/OTC ALCOHOL PADS PADS PREPPADS PADS EASY TOUCH ALCOHOL RX/OTC SAPS HEALTH CARE RX/OTC PREP PADS/MEDIUM 5 ALCOHOLPREP PADS 5 PADS PADS EQL ALCOHOL SWABS 5 RX/OTC SB ALCOHOL PREP 5 RX/OTC PADS PADS PADS ESSENTRA WIPES 9X9" SHOPKO ALCOHOL 5 RX/OTC CLEANROOM 5 SWABS PADS SUPPLIES/PRESATURAT SM ALCOHOL PREP 5 RX/OTC ED SHEE PADS PADS FIFTY50 ALCOHOL PREP 5 RX/OTC SURE COMFORT RX/OTC PADS PADS ALCOHOL PREP PADS 5 GLOBAL ALCOHOL PREP 5 RX/OTC PADS EASEPADS PADS SURE-PREP ALCOHOL 5 RX/OTC GNP ALCOHOL SWABS 5 RX/OTC PREP PADS PADS PADS TGT ALCOHOL SWABS 5 RX/OTC H-E-B INCONTROL 5 RX/OTC PADS ALCOHOL PADS PADS TRUE COMFORT RX/OTC HM STERILE ALCOHOL 5 RX/OTC ALCOHOL PREP PADS 5 PREP PADS PADS PADS MEIJER ALCOHOL RX/OTC TRUE COMFORT PRO RX/OTC SWABS EXTRA-THICK 5 ALCOHOLPREP PADS 5 PADS PADS PHARMACIST CHOICE RX/OTC ULTICARE ALCOHOL 5 RX/OTC ALCOHOL PRED PADS 5 SWABS PADS PADS ULTILET ALCOHOL 5 RX/OTC SWABS PADS

226 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-CARE ALCOHOL RX/OTC 5 LUMINEUX WHITENING 5 RX/OTC PREP PADS PADS TOOTHPASTE PSTE WEBCOL ALCOHOL RX/OTC MI PASTE PLUS PSTE 5 RX/OTC PREP LARGE 1 PLY 5 PADS MI PASTE PSTE 5 RX/OTC WEBCOL ALCOHOL RX/OTC PREP LARGE 2 PLY 5 QC SENSITIVE EXTREME 5 RX/OTC PADS PSTE WEBCOL ALCOHOL RX/OTC REMESENSE MISC 5 PREP MEDIUM 2 PLY 5 PADS SENSITIVE TOOTHPASTE RX/OTC ZEVRX STERILE RX/OTC EXTRA 5 ALCOHOL PREP PADS 5 WHITENING/FLUORIDE PADS MAX ST PSTE SENSITIVE RX/OTC Oral Hygiene Products TOOTHPASTE/FLUORIDE 5 AQUAFRESH CAVITY RX/OTC /MAXIMUM STRENGTH PROTECTION SUGAR 5 PSTE ACID PROTECTION PSTE SENSODYNE MAXIMUM 5 RX/OTC AQUAFRESH EXTREME 5 RX/OTC STRENGTH PSTE CLEAN PSTE SENSODYNE MAXIMUM RX/OTC AQUAFRESH SENSITIVE RX/OTC STRENGTH/FLUORIDE 5 MAXIMUM STRENGTH 5 PSTE PSTE SENSODYNE PRONAMEL 5 RX/OTC BIOTENE DRY MOUTH 5 RX/OTC FRESHBREATH PSTE GENTLEFORMULA PSTE SENSODYNE PRONAMEL 5 RX/OTC BIOTENE DRY MOUTH 5 RX/OTC PSTE PSTE Parenteral Therapy Supplies CREST TARTAR 5 RX/OTC CONTROL PSTE 1ST TIER UNIFINE RX/OTC PENTIPS/MINI/31GX5MM NC CREST TARTAR RX/OTC MISC CONTROL/BAKING SODA 5 TOOTHPASTE PSTE 1ST TIER UNIFINE RX/OTC PENTIPS29GX12MM NC CREST TOOTHPASTE 5 RX/OTC MISC PSTE 1ST TIER UNIFINE NC CREST RX/OTC PENTIPS31GX6MM MISC TOOTHPASTE/REGULAR 5 PSTE 1ST TIER UNIFINE NC RX/OTC PENTIPS31GX8MM MISC CREST RX/OTC TOOTHPASTEREGULAR 5 1ST TIER UNIFINE NC RX/OTC PSTE PENTIPS32GX4MM MISC LUMINEUX RX/OTC 1ST TIER UNIFINE NC CLEAN/FRESH 5 PENTIPS32GX6MM MISC TOOTHPASTE PSTE 1ST TIER UNIFINE 5 QL(5 ea daily) PENTIPS33GX4MM MISC LUMINEUX KIDS 5 RX/OTC TOOTHPASTE PSTE 1ST TIER UNIFINE RX/OTC PENTIPSPLUS 31GX8MM NC LUMINEUX SENSITIVITY 5 RX/OTC TOOTHPASTE PSTE MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

227 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNIFINE RX/OTC ADVOCATE INSULIN RX/OTC PENTIPSPLUS 32GX4MM NC SYRINGE/U- NC MISC 100/0.5ML/29GX1/2" MISC 1ST TIER UNIFINE QL(5 ea daily) ADVOCATE INSULIN RX/OTC PENTIPSPLUS 33GX4MM 5 SYRINGE/U- NC MISC 100/0.5ML/30GX5/16" 1ST TIER UNIFINE RX/OTC MISC PENTIPSPLUS/MINI/31GX NC ADVOCATE INSULIN 5MM MISC SYRINGE/U- NC 1ST TIER UNIFINE RX/OTC 100/0.5ML/31GX5/16" PENTIPSPLUS/ORIGINAL/ NC MISC 29GX12MM MISC ADVOCATE INSULIN RX/OTC 1ST TIER UNIFINE SYRINGE/U- NC PENTIPSPLUS/ULTRA NC 100/1ML/29GX1/2" MISC SHORT/31GX6MM MISC ADVOCATE INSULIN RX/OTC SYRINGE/U- NC ABOUTTIME PEN NC RX/OTC NEEDLE 32GX 5/32" MISC 100/1ML/30GX5/16" MISC ABOUTTIME PEN RX/OTC ADVOCATE INSULIN NEEDLES 30GX 5/16" NC SYRINGE/U- NC MISC 100/1ML/31GX5/16" MISC ABOUTTIME PEN RX/OTC ASSURE ID INSULIN RX/OTC NEEDLES 31G X 3/16" NC SAFETYSYRINGE/U- NC MISC 100/0.5ML/29G X 1/2" MISC ABOUTTIME PEN RX/OTC NEEDLES 31G X 5/16" NC ASSURE ID INSULIN RX/OTC MISC SAFETYSYRINGE/U- NC 100/1ML/29G X 1/2" MISC ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM NC ASSURE ID SAFETY PEN MISC NEEDLES 30G X 3/16" NC MISC ADVOCATE INSULIN PEN RX/OTC NEEDLES 31GX5MM NC ASSURE ID SAFETY PEN RX/OTC MISC NEEDLES 30G X 5/16" NC MISC ADVOCATE INSULIN PEN RX/OTC NEEDLES 31GX8MM NC ASSURE ID SAFETY PEN RX/OTC MISC NEEDLES 31G X 3/16" NC MISC ADVOCATE INSULIN PEN 5 QL(5 ea daily) NEEDLES MISC AURORA PEN NEEDLES NC RX/OTC 29GX12MM MISC ADVOCATE INSULIN RX/OTC SYRINGE/U- NC AURORA PEN NEEDLES NC 100/0.3ML/29GX1/2" MISC 31G X6MM MISC ADVOCATE INSULIN RX/OTC AURORA PEN NEEDLES NC RX/OTC 31G X8MM MISC SYRINGE/U- NC 100/0.3ML/30GX5/16" AURORA UNIFINE NC RX/OTC MISC PENTIPS/32GX5/32" MISC ADVOCATE INSULIN AURORA UNIFINE RX/OTC NC SYRINGE/U- NC PENTIPS/MINI/31GX3/16" 100/0.3ML/31GX5/16" MISC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

228 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE II/0.3ML/31G 3 SAFETYGLIDE/1ML/29G X 3 RX/OTC X 5/16" MISC 1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE 3 QL(5 ea daily); ULTRAFINE II/0.5ML/31G 3 SLIP TIP/U-100/1ML MISC RX/OTC X 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/30G X 3 ULTRAFINE II/1ML/31G X 3 12.7MM MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/31G X 3 ULTRAFINE/0.3ML/30G X 3 8MM MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.5ML/30G X 3 ULTRAFINE/0.5ML/30G X 3 12.7MM MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD LO-DOSE INSULIN QL(5 ea daily); ULTRA-FINE/0.5ML/31G X 3 SYRINGE MICROFINE 3 RX/OTC 8MM MISC IV/0.5ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD AUTOSHIELD 29G X 4 ULTRA-FINE/1/2 3 3/16" MISC UNIT/0.3ML/31G X 8MM MISC BD AUTOSHIELD 29G X 4 QL(5 ea daily) 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/1ML/30G X 3 BD AUTOSHIELD DUO 3 QL(5 ea daily) 30G X 5MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) LUER-LOK/U-100/1ML 3 RX/OTC ULTRA-FINE/1ML/31G X 3 MISC 8MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE HALF- MICROFINE IV/U- 3 RX/OTC 3 100/0.5ML/28G X 1/2" UNIT/0.3ML/31G X 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 3 ULTRAFINE/0.3ML/30G X 3 100/1ML/27G X 5/8" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 3 RX/OTC ULTRAFINE/0.3ML/31G X 3 100/1ML/28G X 1/2" MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 3 MICROFINE/U- 3 RX/OTC 100/0.5ML/28G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/31G X 3 MICROFINE/U- 3 5/16" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/1ML/30G X 3 MICROFINE/U- 3 RX/OTC 1/2" MISC 100/1ML/28G X 1/2" MISC

229 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily) 3 ULTRAFINE/U- 3 RX/OTC NEEDLE/MICRO/ULTRA- 100/0.3ML/29G X 1/2" FINE/32G X 6MM MISC MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/MINI/ULTRA- 3 RX/OTC ULTRAFINE/U- 3 RX/OTC FINE/31G X 5MM MISC 100/0.5ML/29G X 1/2" BD PEN NEEDLE/NANO QL(5 ea daily); MISC 2ND GEN/32G X 5/32" 3 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); MISC ULTRAFINE/U- 3 RX/OTC BD PEN QL(5 ea daily); 100/1ML/29G X 1/2" MISC NEEDLE/NANO/ULTRA- 3 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) FINE/32G X 4MM MISC ULTRAFINE/U- 3 BD PEN QL(5 ea daily) 100/1ML/31G X 5/16" NEEDLE/ORIGINAL/ULTR 3 MISC A-FINE/29G X 12.7MM BD INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X 3 RX/OTC BD PEN QL(5 ea daily); 12.7MM MISC NEEDLE/SHORT/ULTRA- 3 RX/OTC BD INSULIN QL(5 ea daily); FINE/31G X 8MM MISC SYRINGE/0.5ML/29G X 3 RX/OTC BD SAFETY-GLIDE QL(5 ea daily); 12.7MM MISC INSULIN 3 RX/OTC BD INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X SYRINGE/1ML/27G X 3 RX/OTC 1/2" MISC 12.7MM MISC BD SAFETY-LOK INSULIN QL(5 ea daily); BD INSULIN QL(5 ea daily); SYRINGE/PERM 3 RX/OTC SYRINGE/1ML/29G X 3 RX/OTC NEEDLE/UF/1ML/29G X 12.7MM MISC 1/2" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily); SYRINGE/DETACHABLE 3 INSULIN 3 RX/OTC NEEDLE/U-100/1ML/25G SYRINGE/0.3ML/29G X X 1" MISC 1/2" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE RX/OTC SYRINGE/DETACHABLE 3 INSULIN 3 NEEDLE/U-100/1ML/25G SYRINGE/0.3ML/31G X X 5/8" MISC 15/64" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily) SYRINGE/DETACHABLE 3 INSULIN 3 NEEDLE/U-100/1ML/26G SYRINGE/0.3ML/31G X X 1/2" MISC 5/16" MISC BD INSULIN SYRINGE/U- 3 QL(5 ea daily); BD SAFETYGLIDE 100/1ML/27G X 1/2" MISC RX/OTC INSULIN 3 BD INSULIN SYRINGE/U- SYRINGE/0.5ML/31G X 100/2ML/27.5G X 5/8" 3 15/64" MISC MISC BD SAFETYGLIDE BD INSULIN SYRINGE/U- QL(5 ea daily) INSULIN 3 500/0.5ML/31G X 6MM 3 SYRINGE/1ML/31G X MISC 15/64" MISC

230 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SAFETYGLIDE QL(5 ea daily); CAREFINE PEN RX/OTC INSULIN 3 RX/OTC NEEDLES 31GX8MM NC SYSYRINGE/0.5ML/30G X MISC 5/16" MISC CAREFINE PEN RX/OTC BD VEO INSULIN NEEDLES 32GX5MM NC SYRINGE ULTR-FINE/U- 3 MISC 100/0.5ML/31G X 15/64" CAREFINE PEN QL(5 ea daily) MISC NEEDLES 32GX6MM NC BD VEO INSULIN RX/OTC MISC SYRINGE ULTRA- 3 CAREONE INSULIN AFINE/0.3ML/31G X 6MM SYRINGES/0.3ML/30G X NC MISC 1/2" MISC BD VEO INSULIN RX/OTC CAREONE INSULIN SYRINGE ULTRA- 3 SYRINGES/0.3ML/31G X NC FINE/0.3ML/31G X 6MM 5/16" MISC MISC CAREONE INSULIN BD VEO INSULIN SYRINGES/0.5ML/30G X NC SYRINGE ULTRA- 3 1/2" MISC FINE/0.5ML/31G X 6MM MISC CAREONE INSULIN SYRINGES/0.5ML/31G X NC BD VEO INSULIN RX/OTC 5/16" MISC SYRINGE ULTRA- 3 FINE/1/2 UNIT/0.3ML/31G CAREONE INSULIN X 6MM MISC SYRINGES/1ML/30G X NC 1/2" MISC BD VEO INSULIN CAREONE INSULIN SYRINGE ULTRA- 3 FINE/1ML/31G X 6MM SYRINGES/1ML/31GX5/16 NC MISC " MISC BD VEO INSULIN RX/OTC CAREONE UNIFINE RX/OTC PENTIPS 29GX12MM NC SYRINGE ULTRA-FINE/U- 3 100/0.3ML/31G X 15/64" MISC MISC CAREONE UNIFINE NC RX/OTC BD VEO INSULIN PENTIPS 31GX5MM MISC CAREONE UNIFINE SYRINGE ULTRA-FINE/U- 3 NC 100/1ML/31G X 15/64" PENTIPS 31GX6MM MISC MISC CAREONE UNIFINE NC RX/OTC PENTIPS 31GX8MM MISC CAREFINE PEN NEEDLE NC QL(5 ea daily); 32GX4MM MISC RX/OTC CAREONE UNIFINE RX/OTC PENTIPS PEN NEEDLES NC CAREFINE PEN NC RX/OTC NEEDLES 29GX1/2" MISC 32GX4MM MISC CAREFINE PEN RX/OTC CAREONE UNIFINE RX/OTC NEEDLES 30GX5/16" NC PENTIPS PLUS PEN NC MISC NEEDLES 29GX12MM CAREFINE PEN MISC NEEDLES 31GX6MM NC CAREONE UNIFINE RX/OTC MISC PENTIPS PLUS PEN NC NEEDLES 31GX5MM MISC

231 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE CLEVER CHOICE RX/OTC PENTIPS PLUS PEN NC COMFORT EZINSULIN NC NEEDLES 31GX6MM SYRINGE/0.3ML/29G X MISC 1/2" MISC CAREONE UNIFINE RX/OTC CLEVER CHOICE PENTIPS PLUS PEN NC COMFORT EZINSULIN NC NEEDLES 31GX8MM SYRINGE/0.3ML/30G X MISC 1/2" MISC CAREONE UNIFINE RX/OTC CLEVER CHOICE RX/OTC PENTIPS PLUS PEN NC COMFORT EZINSULIN NC NEEDLES 32GX4MM SYRINGE/0.3ML/30G X MISC 5/16" MISC CAREONE UNIFINE QL(5 ea daily) CLEVER CHOICE PENTIPS PLUS PEN 5 COMFORT EZINSULIN NC NEEDLES/33G X 5/32" SYRINGE/0.3ML/31G X MISC 5/16" MISC CARETOUCH INSULIN QL(5 ea daily) CLEVER CHOICE RX/OTC SYRINGE/U-100/1ML/28G 5 COMFORT EZINSULIN NC X 5/16" MISC SYRINGE/0.5ML/28G X CARETOUCH INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U-100/1ML/29G 5 CLEVER CHOICE RX/OTC X 5/16" MISC COMFORT EZINSULIN NC CARETOUCH PEN SYRINGE/0.5ML/29G X NEEDLES 31G X 6 MM NC 1/2" MISC MISC CLEVER CHOICE CARETOUCH PEN RX/OTC COMFORT EZINSULIN NC NEEDLES 31GX 5MM NC SYRINGE/0.5ML/30G X MISC 1/2" MISC CARETOUCH PEN RX/OTC CLEVER CHOICE RX/OTC NEEDLES 31GX 8MM NC COMFORT EZINSULIN NC MISC SYRINGE/0.5ML/30G X 5/16" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 32GX 4MM NC RX/OTC CLEVER CHOICE MISC COMFORT EZINSULIN NC SYRINGE/0.5ML/31G X CARETOUCH PEN RX/OTC 5/16" MISC NEEDLES 32GX 5MM NC MISC CLEVER CHOICE COMFORT EZINSULIN NC CLEVER CHOICE RX/OTC SYRINGE/1.0ML/30G X COMFORT EZINSULIN NC 1/2" MISC PEN NEEDLES 31GX8MM MISC CLEVER CHOICE RX/OTC COMFORT EZINSULIN NC CLEVER CHOICE QL(5 ea daily) SYRINGE/1ML/28G X 1/2" COMFORT EZINSULIN 5 MISC PEN NEEDLES 33GX4MM MISC CLEVER CHOICE RX/OTC COMFORT EZINSULIN NC SYRINGE/1ML/29G X 1/2" MISC

232 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE RX/OTC CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN NC COMFORT EZPEN 5 SYRINGE/1ML/30G X NEEDLES 33GX6MM 5/16" MISC MISC CLEVER CHOICE CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN NC COMFORT EZPEN 5 SYRINGE/U- NEEDLES 33GX8MM 100/1ML/31GX5/16" MISC MISC CLEVER CHOICE RX/OTC CLICKFINE PEN NEEDLE NC RX/OTC COMFORT EZPEN NC 32GX5/32" MISC NEEDLES 29GX12MM CLICKFINE PEN NEEDLE MISC UNIVERSAL/31GX1/4" NC CLEVER CHOICE RX/OTC MISC COMFORT EZPEN NC CLICKFINE PEN NEEDLE RX/OTC NEEDLES 31GX5MM UNIVERSAL/31GX5/16" NC MISC MISC CLEVER CHOICE CLICKFINE PEN COMFORT EZPEN NC NEEDLES 31G X 1/4" NC NEEDLES 31GX6MM MISC MISC CLICKFINE PEN RX/OTC CLEVER CHOICE RX/OTC NEEDLES 31G X 3/16" NC COMFORT EZPEN NC MISC NEEDLES 31GX8MM MISC CLICKFINE PEN RX/OTC NEEDLES 31G X 5/16" NC CLEVER CHOICE RX/OTC MISC COMFORT EZPEN NC NEEDLES 32GX4MM CLICKFINE PEN RX/OTC MISC NEEDLES 31G X 8MM NC MISC CLEVER CHOICE RX/OTC CLICKFINE PEN RX/OTC COMFORT EZPEN NC NEEDLES 32GX5MM NEEDLES 32G X 5/32" NC MISC MISC CLEVER CHOICE CLICKFINE PEN NC NEEDLES/31GX1/4" MISC COMFORT EZPEN NC NEEDLES 32GX6MM CLICKFINE UNIVERSAL RX/OTC MISC PEN NEEDLES 31GX5/16" NC CLEVER CHOICE QL(5 ea daily) MISC COMFORT ASSIST RX/OTC COMFORT EZPEN 5 NEEDLES 32GX8MM INSULIN SYRINGE NC MISC 0.3ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST RX/OTC INSULIN COMFORT EZPEN 5 NC NEEDLES 33GX4MM SYRINGE/0.3ML/30G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST INSULIN COMFORT EZPEN 5 NC NEEDLES 33GX5MM SYRINGE/0.3ML/31G X MISC 5/16" MISC

233 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST RX/OTC COMFORT TOUCH PEN QL(5 ea daily) INSULIN NC NEEDLES/32G X 8MM 5 SYRINGE/0.5ML/29G X MISC 1/2" MISC COMFORT TOUCH PEN QL(5 ea daily) COMFORT ASSIST RX/OTC NEEDLES/33G X 5/32" 5 INSULIN NC MISC SYRINGE/0.5ML/30G X COMFORT TOUCH PEN QL(5 ea daily) 5/16" MISC NEEDLES/33GX 3/16" 5 COMFORT ASSIST MISC INSULIN NC COMFORT TOUCH PEN 5 QL(5 ea daily) SYRINGE/0.5ML/31G X NEEDLES/33GX1/4" MISC 5/16" MISC DIATHRIVE PEN COMFORT ASSIST RX/OTC NEEDLE/31 G X 6MM NC INSULIN NC MISC SYRINGE/1ML/29G X 1/2" MISC DIATHRIVE PEN RX/OTC NEEDLE/31 GX 8MM NC COMFORT ASSIST RX/OTC MISC INSULIN NC SYRINGE/1ML/30G X DIATHRIVE PEN NC RX/OTC 5/16" MISC NEEDLE/31GX 5MM MISC COMFORT ASSIST DIATHRIVE PEN NC RX/OTC NEEDLE/32GX 4MM MISC INSULIN NC SYRINGE/1ML/31G X DROPLET INSULIN RX/OTC 5/16" MISC SYRINGE 0.3ML/29G X NC COMFORT EZ INSULIN 1/2" MISC DROPLET INSULIN RX/OTC SYRINGE/U- NC 100/0.5ML/31G X 5/16" SYRINGE 0.5ML/29G X NC MISC 1/2" MISC COMFORT EZ INSULIN DROPLET INSULIN RX/OTC SYRINGE/U-100/1ML/31G NC SYRINGE 1ML/29G X 1/2" NC X 5/16" MISC MISC DROPLET INSULIN COMFORT EZ NC RX/OTC MICRO/32G X 4MM MISC SYRINGE U-100/0.3/31G X NC 5/16" MISC COMFORT EZ NC RX/OTC SHORT/31G X 8MM MISC DROPLET INSULIN SYRINGE U- COMFORT EZ/31G X 5MM NC RX/OTC NC MISC 100/0.3ML/30G X 1/2" MISC COMFORT EZ/31G X 6MM NC MISC DROPLET INSULIN SYRINGE U- NC COMFORT TOUCH PEN QL(5 ea daily) 100/0.3ML/30G X 15/64" NEEDLES/31G X 4MM 5 MISC MISC DROPLET INSULIN RX/OTC COMFORT TOUCH PEN SYRINGE U- NC NEEDLES/31G X 6 MM NC 100/0.3ML/30G X 5/16" MISC MISC COMFORT TOUCH PEN RX/OTC NEEDLES/32G X 5MM NC MISC

234 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN RX/OTC DROPLET INSULIN SYRINGE U- NC SYRINGE/U- NC 100/0.3ML/31G X 15/64" 100/0.5ML/31G X 15/64" MISC MISC DROPLET INSULIN DROPLET INSULIN SYRINGE U- NC SYRINGE/U- NC 100/0.5ML/30G X 1/2" 100/0.5ML/31G X 5/16" MISC MISC DROPLET INSULIN DROPLET INSULIN SYRINGE U- NC SYRINGE/U-100/1ML/30G NC 100/0.5ML/30G X 15/64" X 1/2" MISC MISC DROPLET INSULIN DROPLET INSULIN RX/OTC SYRINGE/U-100/1ML/31G NC SYRINGE U- NC X 15/64" MISC 100/0.5ML/30G X 5/16" DROPLET INSULIN MISC SYRINGE/U-100/1ML/31G NC DROPLET INSULIN X 5/16" MISC SYRINGE U- NC DROPLET PEN NEEDLES NC RX/OTC 100/0.5ML/31G X 5/16" 29G X1/2" MISC MISC DROPLET PEN NEEDLES 5 QL(5 ea daily) DROPLET INSULIN 29GX10MM MISC SYRINGE U-100/1ML/30G NC X 1/2" MISC DROPLET PEN NEEDLES NC RX/OTC 29GX12MM MISC DROPLET INSULIN SYRINGE U-100/1ML/30G NC DROPLET PEN NEEDLES NC RX/OTC X 15/64" MISC 30G X 5/16" MISC DROPLET INSULIN RX/OTC DROPLET PEN NEEDLES NC RX/OTC SYRINGE U-100/1ML/30G NC 31G X3/16" MISC X 5/16" MISC DROPLET PEN NEEDLES NC RX/OTC DROPLET INSULIN 31G X5/16" MISC SYRINGE U-100/1ML/31G NC DROPLET PEN NEEDLES NC RX/OTC X 15/64" MISC 31GX5MM MISC DROPLET INSULIN DROPLET PEN NEEDLES NC SYRINGE U-100/1ML/31G NC 31GX6MM MISC X 5/16" MISC DROPLET PEN NEEDLES NC RX/OTC DROPLET INSULIN RX/OTC 31GX8MM MISC SYRINGE/U- NC DROPLET PEN NEEDLES NC 100/0.3ML/31G X 15/64" 32G X 1/4" MISC MISC DROPLET PEN NEEDLES NC RX/OTC DROPLET INSULIN 32G X 3/16" MISC SYRINGE/U- NC DROPLET PEN NEEDLES 5 QL(5 ea daily) 100/0.3ML/31G X 5/16" 32G X 5/16" MISC MISC DROPLET PEN NEEDLES NC RX/OTC DROPLET INSULIN 32G X 5/32" MISC SYRINGE/U- NC 100/0.5ML/30G X 1/2" DROPLET PEN NEEDLES NC RX/OTC MISC 32GX4MM MISC DROPLET PEN NEEDLES NC RX/OTC 32GX5MM MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

235 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES NC EASY COMFORT PEN NC RX/OTC 32GX6MM MISC NEEDLES31GX3/16" MISC DROPLET PEN NEEDLES 5 QL(5 ea daily) EASY COMFORT PEN NC RX/OTC 32GX8MM MISC NEEDLES31GX5/16" MISC DROPSAFE SAFETY PEN RX/OTC EASY COMFORT PEN NC RX/OTC NEEDLES/31G X 5/16" NC NEEDLES32GX5/32" MISC MISC EASY COMFORT PEN QL(5 ea daily) DROPSAFE SAFTEY PEN NEEDLES33G X 4MM 5 NEEDLES/31G X 1/4" NC MISC MISC EASY COMFORT PEN QL(5 ea daily) DRUG MART UNIFINE NC RX/OTC NEEDLES33G X 5MM 5 PENTIPS 31GX5MM MISC MISC DRUG MART UNIFINE RX/OTC EASY COMFORT PEN QL(5 ea daily) PENTIPS29G X 12MM NC NEEDLES33G X 6MM 5 MISC MISC DRUG MART UNIFINE NC EASY GLIDE PEN QL(5 ea daily) PENTIPS31GX6MM MISC NEEDLES 33G X 5/32" 5 MISC DRUG MART UNIFINE NC RX/OTC PENTIPS31GX8MM MISC EASY TOUCH 32GX5MM NC RX/OTC MISC DRUG MART UNIFINE NC RX/OTC PENTIPS32GX4MM MISC EASY TOUCH 32GX6MM NC DRUG MART UNIFINE RX/OTC MISC PENTIPSPLUS 32GX4MM NC EASY TOUCH FLIPLOCK RX/OTC MISC SAFETY INSULIN NC EASY COMFORT INSULIN RX/OTC SYRINGE 1ML/29GX1/2" SYRINGE/0.5ML/30G X NC MISC 5/16" MISC EASY TOUCH FLIPLOCK EASY COMFORT INSULIN SAFETY INSULIN NC SYRINGE/0.5ML/31G X NC SYRINGE 1ML/30GX1/2" 5/16" MISC MISC EASY COMFORT INSULIN RX/OTC EASY TOUCH FLIPLOCK RX/OTC SYRINGE/1ML/30G X NC SAFETY INSULIN NC 5/16" MISC SYRINGE 1ML/30GX5/16" MISC EASY COMFORT INSULIN SYRINGE/1ML/31G X NC EASY TOUCH FLIPLOCK 5/16" MISC SAFETY INSULIN NC SYRINGE 1ML/31GX5/16" EASY COMFORT INSULIN MISC SYRINGE/U- NC 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN RX/OTC MISC SYRINGE/0.3ML/30G X NC 5/16" MISC EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G NC EASY TOUCH INSULIN X 1/2" MISC SYRINGE/0.3ML/31G X NC 5/16" MISC EASY COMFORT PEN NC NEEDLES31GX1/4" MISC EASY TOUCH INSULIN RX/OTC SYRINGE/0.5ML/29G X NC 1/2" MISC

236 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN RX/OTC EASY TOUCH INSULIN RX/OTC SYRINGE/0.5ML/30G X NC SYRINGE/U-100/1ML/28G NC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN RX/OTC EASY TOUCH INSULIN RX/OTC SYRINGE/1ML/30G X NC SYRINGE/U-100/1ML/29G NC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN RX/OTC EASY TOUCH INSULIN NC SYRINGE/SAFETY/U- NC SYRINGE/U-100/1ML/30G 100/0.5ML/29G X 1/2" X 1/2" MISC MISC EASY TOUCH INSULIN EASY TOUCH INSULIN RX/OTC SYRINGE/U-100/1ML/31G NC SYRINGE/SAFETY/U- NC X 5/16" MISC 100/0.5ML/30G X 5/16" EASY TOUCH PEN RX/OTC MISC NEEDLE 30G X 5/16" NC EASY TOUCH INSULIN RX/OTC MISC SYRINGE/SAFETY/U- NC EASY TOUCH PEN 100/1ML/29G X 1/2" MISC NEEDLE/30G X 3/16" NC EASY TOUCH INSULIN MISC SYRINGE/SAFETY/U- NC EASY TOUCH PEN NC RX/OTC 100/1ML/30G X 1/2" MISC NEEDLES 29GX1/2" MISC EASY TOUCH INSULIN EASY TOUCH PEN NC SYRINGE/U- NC NEEDLES 31GX1/4" MISC 100/0.3ML/30G X 1/2" MISC EASY TOUCH PEN RX/OTC NEEDLES 31GX5/16" NC EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/U- 5 100/0.5ML/27G X 1/2" EASY TOUCH PEN NC MISC NEEDLES 32GX1/4" MISC EASY TOUCH INSULIN RX/OTC EASY TOUCH PEN RX/OTC NEEDLES 32GX3/16" NC SYRINGE/U- NC 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH PEN RX/OTC EASY TOUCH INSULIN RX/OTC NEEDLES 32GX5/32" NC MISC SYRINGE/U- NC 100/0.5ML/29G X 1/2" EASY TOUCH PEN RX/OTC MISC NEEDLES/31G X 3/16" NC EASY TOUCH INSULIN MISC EASY TOUCH SAFETY SYRINGE/U- NC 100/0.5ML/30G X 1/2" PEN NEEDLES/29G X 4 MISC 5MM MISC EASY TOUCH INSULIN EASY TOUCH SAFETY QL(5 ea daily) PEN NEEDLES/29G X 4 SYRINGE/U- NC 100/0.5ML/31G X 5/16" 8MM MISC MISC EASY TOUCH SAFETY RX/OTC EASY TOUCH INSULIN RX/OTC PEN NEEDLES/30G X NC SYRINGE/U-100/1ML/27G NC 5/16" MISC X 1/2" MISC

237 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH RX/OTC ELITE-THIN INSULIN RX/OTC SHEATHLOCK SAFETY NC SYRINGE/U-100/1ML/28G NC INSULIN SYRINGE X 1/2" MISC 1ML/29GX1/2" MISC ELITE-THIN INSULIN QL(5 ea daily) EASY TOUCH RX/OTC SYRINGE/U-100/1ML/28G 5 SHEATHLOCK SAFETY NC X 5/16" MISC INSULIN SYRINGE ELITE-THIN INSULIN RX/OTC 1ML/30GX5/16" MISC SYRINGE/U-100/1ML/29G NC EASY TOUCH X 1/2" MISC SHEATHLOCK SAFETY NC ELITE-THIN INSULIN INSULIN SYRINGE SYRINGE/U-100/1ML/31G NC 1ML/31GX5/16" MISC X 5/16" MISC EASY TOUCH EQL INSULIN RX/OTC SHEATHLOCK SAFETY NC SYRINGE/0.3ML/29G X NC SYRINGE 1ML/30GX1/2" 1/2" MISC MISC EQL INSULIN RX/OTC ELITE-THIN INSULIN SYRINGE/0.3ML/30G X NC SYRINGE/0.3ML/31G X NC 5/16" MISC 5/16" MISC EQL INSULIN ELITE-THIN INSULIN RX/OTC SYRINGE/0.3ML/31G X NC SYRINGE/0.5ML/29G X NC 5/16" MISC 1/2" MISC EQL INSULIN RX/OTC ELITE-THIN INSULIN RX/OTC SYRINGE/0.5ML/29G X NC SYRINGE/0.5ML/30G X NC 1/2" MISC 5/16" MISC EQL INSULIN RX/OTC ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X NC SYRINGE/1ML/29G X 5 5/16" MISC 5/16" MISC EQL INSULIN ELITE-THIN INSULIN RX/OTC SYRINGE/0.5ML/31G X NC SYRINGE/1ML/30G X NC 5/16" MISC 5/16" MISC EQL INSULIN RX/OTC ELITE-THIN INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" NC SYRINGE/U- NC MISC 100/0.5ML/28G X 1/2" MISC EQL INSULIN RX/OTC SYRINGE/1ML/30G X NC ELITE-THIN INSULIN 5/16" MISC SYRINGE/U- 5 100/0.5ML/28G X 5/16" EQL INSULIN MISC SYRINGE/1ML/31G X NC 5/16" MISC ELITE-THIN INSULIN QL(5 ea daily) EXCEL COMFORT POINT QL(5 ea daily) SYRINGE/U- 5 100/0.5ML/29G X 5/16" INSULIN PEN NEEDLES 5 MISC 31G X 4MM MISC ELITE-THIN INSULIN EXEL COMFORT POINT RX/OTC INSULIN PEN NEEDLES NC SYRINGE/U- NC 100/0.5ML/31G X 5/16" 29G X 12MM MISC MISC EXEL COMFORT POINT INSULIN PEN NEEDLES NC 31G X 6MM MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

238 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT RX/OTC FIFTY50 PEN INSULIN PEN NEEDLES NC NEEDLES/32GX6MM NC 31G X 8MM MISC MISC EXEL COMFORT POINT RX/OTC FIFTY50 SUPERIOR INSULIN NC COMFORTINSULIN NC SYRINGE/0.3ML/29G X SYRINGE/0.3ML/31G X 1/2" MISC 5/16" MISC EXEL COMFORT POINT RX/OTC FIFTY50 SUPERIOR INSULIN NC COMFORTINSULIN NC SYRINGE/0.3ML/30G X SYRINGE/0.5ML/31G X 5/16" MISC 5/16" MISC EXEL COMFORT POINT RX/OTC FIFTY50 SUPERIOR INSULIN NC COMFORTINSULIN NC SYRINGE/0.5ML/28G X SYRINGE/1ML/31G X 1/2" MISC 5/16" MISC EXEL COMFORT POINT RX/OTC FREDS PHARMACY RX/OTC INSULIN NC UNIFINE PENTIPS PEN NC SYRINGE/0.5ML/29G X NEEDLES 32GX4MM 1/2" MISC MISC EXEL COMFORT POINT RX/OTC FREDS PHARMACY RX/OTC NC INSULIN NC UNIFINE PENTIPS PLUS SYRINGE/0.5ML/30G X 31GX5MM MISC 5/16" MISC FREDS PHARMACY RX/OTC EXEL COMFORT POINT RX/OTC UNIFINE PENTIPS PLUS NC INSULIN NC 31GX8MM MISC SYRINGE/1ML/28G X 1/2" FREESTYLE PRECISION RX/OTC MISC INSULIN SYRINGE/U- NC EXEL COMFORT POINT RX/OTC 100/0.5ML/30G X 5/16" INSULIN NC MISC SYRINGE/1ML/29G X 1/2" FREESTYLE PRECISION MISC INSULIN SYRINGE/U- NC EXEL COMFORT POINT RX/OTC 100/0.5ML/31G X 5/16" INSULIN NC MISC SYRINGE/1ML/30G X FREESTYLE PRECISION 5/16" MISC INSULIN SYRINGE/U- NC FIFTY50 PEN NEEDLES NC RX/OTC 100/1ML/31G X 5/16" 31G X3/16" (5MM) MISC MISC FIFTY50 PEN NEEDLES NC RX/OTC FREESTYLE PRECISION RX/OTC 31G X5/16" (8MM) MISC INSULIN SYRINGES/U- NC 100/1ML/30G X 5/16" FIFTY50 PEN NEEDLES NC RX/OTC 31GX5MM MISC MISC FIFTY50 PEN RX/OTC GLOBAL EASE INJECT RX/OTC NEEDLES/31GX8MM NC PEN NEEDLES NC MISC 29GX12MM MISC FIFTY50 PEN RX/OTC GLOBAL EASE INJECT RX/OTC NEEDLES/32GX4MM NC PEN NEEDLES 31GX8MM NC MISC MISC

239 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL EASE INJECT RX/OTC GLOBAL INJECT EASE RX/OTC NC PEN NEEDLES 32GX4MM INSULIN SYRINGE/U- NC MISC 100/0.5ML/29G X 1/2" GLOBAL EASE INJECT RX/OTC MISC PEN NEEEDLES NC GLOBAL INJECT EASE 31GX5MM MISC INSULIN SYRINGE/U- NC GLOBAL EASY GLIDE RX/OTC 100/0.5ML/30G X 1/2" MISC INSULIN NC SYRINGE/0.3ML/31G X GLOBAL INJECT EASE RX/OTC 15/64" MISC INSULIN SYRINGE/U- NC GLOBAL EASY GLIDE 100/0.5ML/30G X 5/16" MISC INSULIN NC SYRINGE/0.5ML/31G X GLOBAL INJECT EASE 15/64" MISC INSULIN SYRINGE/U- NC GLOBAL EASY GLIDE 100/0.5ML/31G X 5/16" MISC INSULIN NC SYRINGE/1ML/31G X GLOBAL INJECT EASE RX/OTC 15/64" MISC INSULIN SYRINGE/U- NC GLOBAL EASY GLIDE 100/1ML/28G X 1/2" MISC INSULINSYRINGE/U- NC GLOBAL INJECT EASE RX/OTC 100/0.3ML/31G X 5/16" INSULIN SYRINGE/U- NC MISC 100/1ML/29G X 1/2" MISC GLOBAL EASY GLIDE RX/OTC GLOBAL INJECT EASE PEN NEEDLES 32GX4MM NC INSULIN SYRINGE/U- NC MISC 100/1ML/30G X 1/2" MISC GLOBAL INJECT EASE RX/OTC GLOBAL INJECT EASE RX/OTC INSULIN SYRINGE/U- NC INSULIN SYRINGE/U- NC 100/0.3ML/29G X 1/2" 100/1ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE GLOBAL INJECT EASE INSULIN SYRINGE/U- NC INSULIN SYRINGE/U- NC 100/0.3ML/30G X 1/2" 100/1ML/31G X 5/16" MISC MISC GLOBAL INJECT EASE RX/OTC GLOBAL INSULIN INSULIN SYRINGE/U- NC SYRINGE/U- NC 100/0.3ML/30G X 5/16" 100/0.3ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE GLOBAL INSULIN RX/OTC INSULIN SYRINGE/U- NC SYRINGES/U- NC 100/0.3ML/31G X 5/16" 100/0.3ML/30GX5/16" MISC MISC GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- NC SYRINGE/U- NC 100/0.5ML/28G X 1/2" 100/0.3ML/30G X 1/2" MISC MISC

240 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN RX/OTC GNP INSULIN RX/OTC NC SYRINGE/U- NC SYRINGE/0.5ML/29G X 100/0.3ML/30G X 5/16" 1/2" MISC MISC GNP INSULIN RX/OTC GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X NC SYRINGE/U- NC 5/16" MISC 100/0.3ML/31G X 5/16" GNP INSULIN MISC SYRINGE/0.5ML/31G X NC GLUCOPRO INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- NC GNP INSULIN RX/OTC 100/0.5ML/30G X 1/2" SYRINGE/1ML/28G X 1/2" NC MISC MISC GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN RX/OTC SYRINGE/U- NC RX/OTC SYRINGE/1ML/29G X 1/2" NC 100/0.5ML/30G X 5/16" MISC MISC GNP INSULIN RX/OTC GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/1ML/30G X NC SYRINGE/U- NC 5/16" MISC 100/0.5ML/31G X 5/16" MISC GNP INSULIN SYRINGE/1ML/31G X NC GLUCOPRO INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/30G NC X 1/2" MISC GNP ULTICARE PEN RX/OTC NEEDLES/31GX5/16" NC GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G NC RX/OTC X 5/16" MISC GNP ULTICARE PEN RX/OTC NEEDLES/32GX 5/32" NC GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G NC X 5/16" MISC GNP ULTICARE PEN NC NEEDLES/32GX1/4" MISC GNP CLICKFINE UNIVERSAL PEN NC GNP ULTICARE PEN RX/OTC NEEDLES 31GX1/4" MISC NEEDLES31G X 5MM NC MISC GNP CLICKFINE RX/OTC GNP ULTRA COMFORT RX/OTC UNIVERSAL PEN NC NEEDLES 31GX5/16" INSULIN NC MISC SYRINGE/0.3ML/29G X 1/2" MISC GNP INSULIN RX/OTC SYRINGE/0.3ML/29G X NC GNP ULTRA COMFORT RX/OTC 1/2" MISC INSULIN NC SYRINGE/0.3ML/30G X GNP INSULIN RX/OTC 5/16" SHORT MISC SYRINGE/0.3ML/30G X NC 5/16" MISC GNP ULTRA COMFORT RX/OTC INSULIN NC GNP INSULIN SYRINGE/0.5ML/28G X SYRINGE/0.3ML/31G X NC 1/2" MISC 5/16" MISC GNP ULTRA COMFORT RX/OTC GNP INSULIN RX/OTC INSULIN NC SYRINGE/0.5ML/28G X NC SYRINGE/0.5ML/29G X 1/2" MISC 1/2" MISC

241 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT RX/OTC H-E-B IN CONTROL RX/OTC NC INSULIN NC UNIFINEPENTIPS PLUS SYRINGE/1ML/28G X 1/2" 31GX5/16" MISC MISC H-E-B IN CONTROL RX/OTC GNP ULTRA COMFORT RX/OTC UNIFINEPENTIPS PLUS NC INSULIN NC 31GX5MM MISC SYRINGE/1ML/29G X 1/2" H-E-B IN CONTROL RX/OTC MISC UNIFINEPENTIPS PLUS NC GOODSENSE CLICKFINE RX/OTC 32GX4MM MISC SAFETY PEN NC H-E-B IN CONTROL RX/OTC NEEDLE/31G X 3/16" UNIFINEPENTIPS PLUS NC MISC 32GX5/32" MISC GOODSENSE PEN RX/OTC H-E-B IN CONTROL QL(5 ea daily) NEEDLE/PENFINE NC UNIFINEPENTIPS PLUS 5 CLASSIC/31G X 3/16" 33GX5/32" MISC MISC H-E-B INCONTROL PEN RX/OTC GOODSENSE PEN RX/OTC NEEDLES 29GX12MM NC NEEDLE/PENFINE NC MISC CLASSIC/31G X 5/16" MISC HEALTHWISE INSULIN RX/OTC SYRINGE/U- NC GOODSENSE PEN 100/0.3ML/30G X 5/16" NEEDLE/PENFINE NC MISC CLASSIC/32G X 1/4" MISC HEALTHWISE INSULIN GOODSENSE PEN RX/OTC SYRINGE/U- NC NEEDLE/PENFINE NC 100/0.3ML/31G X 5/16" CLASSIC/32G X 5/32" MISC MISC HEALTHWISE INSULIN RX/OTC H-E-B IN CONTROL PEN RX/OTC NC SYRINGE/U- NC NEEDLE 31GX3/16" MISC 100/0.5ML/30G X 5/16" H-E-B IN CONTROL PEN RX/OTC MISC NEEDLES 31GX5MM NC HEALTHWISE INSULIN MISC SYRINGE/U- NC H-E-B IN CONTROL PEN 100/0.5ML/31G X 5/16" NEEDLES 31GX6MM NC MISC MISC HEALTHWISE INSULIN RX/OTC H-E-B IN CONTROL PEN RX/OTC SYRINGE/U-100/1ML/30G NC NEEDLES 31GX8MM NC X 5/16" MISC MISC HEALTHWISE INSULIN H-E-B IN CONTROL PEN RX/OTC SYRINGE/U-100/1ML/31G NC NEEDLES/NANO/32GX4M NC X 5/16" MISC M MISC HEALTHWISE MICRON RX/OTC H-E-B IN CONTROL PEN NEEDLES/32G X NC UNIFINEPENTIPS PLUS NC 5/32" MISC 31GX1/4" MISC HEALTHWISE MINI PEN H-E-B IN CONTROL RX/OTC NEEDLES 31GX6MM NC UNIFINEPENTIPS PLUS NC MISC 31GX3/16" MISC

242 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE PEN RX/OTC INSULIN SYRINGE 5 QL(5 ea daily) NEEDLES 29GX12MM NC 1ML/31G X1/4" MISC MISC INSULIN QL(5 ea daily) HEALTHWISE SHORT RX/OTC SYRINGE/0.3ML/29G X 1" 5 PEN NEEDLES 31GX8MM NC MISC MISC INSULIN RX/OTC HEALTHWISE SHORT RX/OTC SYRINGE/0.3ML/29G X NC PEN NEEDLES/31G X NC 1/2" MISC 3/16" MISC INSULIN RX/OTC HEALTHWISE SHORT RX/OTC SYRINGE/0.3ML/30G X NC PEN NEEDLES/31G X NC 5/16" MISC 5/16" MISC INSULIN HEALTHWISE UNIFINE RX/OTC SYRINGE/0.3ML/31G X NC PENTIPS PEN NEEDLES NC 5/16" MISC 32GX4MM MISC INSULIN QL(5 ea daily) HEALTHY ACCENTS RX/OTC SYRINGE/0.5ML/27G X 5 UNIFINE PENTIPS PEN NC 1/2" MISC NEEDLES 29GX12MM INSULIN RX/OTC MISC SYRINGE/0.5ML/28G X NC HEALTHY ACCENTS RX/OTC 1/2" MISC UNIFINE PENTIPS PEN NC INSULIN NEEDLES 31GX5MM SYRINGE/0.5ML/30G X NC MISC 1/2" MISC HEALTHY ACCENTS INSULIN RX/OTC UNIFINE PENTIPS PEN NC SYRINGE/0.5ML/30G X NC NEEDLES 31GX6MM 5/16" MISC MISC INSULIN HEALTHY ACCENTS RX/OTC SYRINGE/0.5ML/31G X NC UNIFINE PENTIPS PEN NC 5/16" MISC NEEDLES 31GX8MM MISC INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" NC HEALTHY ACCENTS RX/OTC MISC UNIFINE PENTIPS PEN NC NEEDLES 32GX4MM INSULIN RX/OTC MISC SYRINGE/1ML/29G X 1/2" NC MISC HM ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" NC INSULIN RX/OTC MISC SYRINGE/1ML/30G X NC 5/16" MISC HM ULTICARE INSULIN INSULIN RX/OTC SYRINGE/U- NC 100/0.3ML/31G X 5/16" SYRINGE/NEEDLE NC MISC 0.3ML/30G X 5/16" MISC HM ULTICARE MINI PEN RX/OTC INSULIN NEEDLES/31G X 5MM NC SYRINGE/NEEDLE NC (3/16") MISC 0.3ML/31G X 5/16" MISC HM ULTICARE SHORT RX/OTC INSULIN RX/OTC PEN NEEDLES 31GX8MM NC SYRINGE/NEEDLE NC MISC 0.5ML/29G X 1/2" MISC

243 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN RX/OTC INSULIN RX/OTC SYRINGE/NEEDLE NC SYRINGES/0.5ML/30GX5/ NC 0.5ML/30G X 5/16" MISC 16" MISC INSULIN INSULIN SYRINGE/NEEDLE NC SYRINGES/0.5ML/31GX NC 0.5ML/31G X 5/16" MISC 5/16" MISC INSULIN RX/OTC INSULIN SYRINGE/NEEDLE NC SYRINGES/0.5ML/31GX5/ NC 1ML/29G X 1/2" MISC 16" MISC INSULIN RX/OTC INSULIN RX/OTC SYRINGE/NEEDLE NC SYRINGES/1ML/27GX/1/2" NC 1ML/30G X 5/16" MISC MISC INSULIN INSULIN RX/OTC SYRINGE/NEEDLE NC SYRINGES/1ML/27GX1/2" NC 1ML/31G X 5/16" MISC MISC INSULIN SYRINGE/U- RX/OTC INSULIN RX/OTC 100/0.3ML/29G X 1/2" NC SYRINGES/1ML/28GX1/2" NC MISC MISC INSULIN SYRINGE/U- RX/OTC INSULIN RX/OTC 100/0.5ML/29G X 1/2" NC SYRINGES/1ML/29GX1/2" NC MISC MISC INSULIN SYRINGE/U- NC RX/OTC INSULIN 100/1ML/29G X 1/2" MISC SYRINGES/1ML/30GX1/2" NC INSULIN SYRINGE/U- RX/OTC MISC 100/1ML/30G X 5/16" NC INSULIN MISC SYRINGES/1ML/31GX5/16 NC INSULIN SYRINGE/U- " MISC 100/1ML/30G X 5/16" NC INSUPEN 29G X 12MM NC RX/OTC MISC MISC INSULIN SYRINGE/U- INSUPEN 31G X 5MM NC RX/OTC 100/1ML/31G X 5/16" NC MISC MISC INSUPEN 31G X 8MM NC RX/OTC INSULIN SYRINGES 5 QL(5 ea daily) MISC 0.3ML/31G X 1/4" MISC INSUPEN 32G X 4MM NC RX/OTC INSULIN SYRINGES 5 QL(5 ea daily) MISC 0.5ML/31G X 1/4" MISC INSUPEN 33GX4MM MISC 5 QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGES/0.5ML/27GX1/ 5 INSUPEN PEN NEEDLES NC RX/OTC 2" MISC 32G X4MM MISC INSULIN RX/OTC INSUPEN SENSITIVE NC SYRINGES/0.5ML/28GX1/ NC 32GX6MM MISC 2" MISC INSUPEN SENSITIVE 5 QL(5 ea daily) INSULIN RX/OTC 32GX8MM MISC SYRINGES/0.5ML/29GX1/ NC INSUPEN ULTRAFIN NC RX/OTC 2" MISC 29GX12MM MISC INSUPEN ULTRAFIN NC RX/OTC 30GX8MM MISC

244 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSUPEN ULTRAFIN NC KROGER INSULIN RX/OTC 31GX6MM MISC SYRINGE/0.5ML/29G X NC 1/2" MISC INSUPEN ULTRAFIN NC RX/OTC 31GX8MM MISC KROGER INSULIN RX/OTC KINRAY INSULIN SYRINGE/0.5ML/30G X NC 5/16" MISC SYRINGE PREFERRED NC PLUS/0.3ML/31G X 5/16" KROGER INSULIN MISC SYRINGE/0.5ML/31G X NC KINRAY INSULIN 5/16" MISC SYRINGE PREFERRED NC KROGER INSULIN RX/OTC PLUS/0.5ML/31G X 5/16" SYRINGE/1ML/29G X 1/2" NC MISC MISC KINRAY INSULIN KROGER INSULIN RX/OTC SYRINGE PREFERRED NC SYRINGE/1ML/30G X NC PLUS/1ML/31G X 5/16" 5/16" MISC MISC KROGER INSULIN KINRAY INSULIN RX/OTC SYRINGE/1ML/31G X NC SYRINGE/0.5ML/29G X NC 5/16" MISC 1/2" MISC KROGER PEN NEEDLES NC RX/OTC KMART VALU PLUS 29G X12MM MISC INSULIN 5 KROGER PEN NEEDLES NC RX/OTC SYRINGE/0.3ML/30G 31G X8MM MISC MISC KROGER PEN NEEDLES NC KMART VALU PLUS 31GX1/4" MISC INSULIN 5 SYRINGE/0.5ML/29G KROGER PEN NC MISC NEEDLES/31G X1/4" MISC KMART VALU PLUS KROGER PEN RX/OTC NEEDLES/31G X3/16" NC INSULIN 5 SYRINGE/0.5ML/30G MISC MISC KROGER PEN RX/OTC NEEDLES/31G X5/16" NC KMART VALU PLUS HDHP Generic Preventative MISC INSULIN NC KROGER PEN RX/OTC SYRINGE/1ML/29G MISC Drug $0 ;RX/OTC NEEDLES/32G X5/32" NC HDHP Generic MISC KMART VALU PLUS Preventative KROGER PEN QL(5 ea daily) INSULIN NC NEEDLES/33G X5/32" 5 SYRINGE/1ML/30G MISC Drug $0 ;RX/OTC MISC KROGER INSULIN RX/OTC LEADER INSULIN RX/OTC SYRINGE/0.3ML/29G X NC SYRINGE/0.3ML/29G X NC 1/2" MISC 1/2" MISC KROGER INSULIN RX/OTC LEADER INSULIN RX/OTC SYRINGE/0.3ML/30G X NC SYRINGE/0.3ML/30G X NC 5/16" MISC 5/16" MISC KROGER INSULIN LEADER INSULIN SYRINGE/0.3ML/31G X NC SYRINGE/0.3ML/31G X NC 5/16" MISC 5/16" MISC

245 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/0.5ML/28G X NC SYRINGE/0.3ML/30G X NC 1/2" MISC 5/16" MISC LEADER INSULIN RX/OTC LITETOUCH INSULIN SYRINGE/0.5ML/29G X NC SYRINGE/0.3ML/31G X NC 1/2" MISC 5/16" MISC LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/0.5ML/30G X NC SYRINGE/0.5ML/30G X NC 5/16" MISC 5/16" MISC LEADER INSULIN LITETOUCH INSULIN SYRINGE/0.5ML/31G X NC SYRINGE/0.5ML/31G X NC 5/16" MISC 5/16" MISC LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" NC SYRINGE/1ML/30G X NC MISC 5/16" MISC LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" NC SYRINGE/U- NC MISC 100/0.3ML/30G X 5/16" LEADER INSULIN RX/OTC MISC SYRINGE/1ML/30G X NC LITETOUCH INSULIN 5/16" MISC SYRINGE/U- NC LEADER INSULIN 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X NC MISC 5/16" MISC LITETOUCH INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/U- NC 100/0.5ML/28G X 1/2" PENTIPS NC PLUS/MINI/31GX3/16" MISC MISC LITETOUCH INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/U- NC 100/0.5ML/29G X 1/2" PENTIPS NC PLUS/SHORT/31GX5/16" MISC MISC LITETOUCH INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/U- NC PENTIPS/MINI/31GX3/16" NC 100/0.5ML/30G X 5/16" MISC MISC LEADER UNIFINE RX/OTC LITETOUCH INSULIN PENTIPS/NANO/32GX5/32 NC SYRINGE/U- NC " MISC 100/0.5ML/31G X 5/16" MISC LEADER UNIFINE RX/OTC PENTIPS/PLUS/32GX5/32 NC LITETOUCH INSULIN RX/OTC " MISC SYRINGE/U-100/1ML/28G NC X 1/2" MISC LITETOUCH INSULIN PEN RX/OTC NEEDLES/32G X NC LITETOUCH INSULIN RX/OTC 4MM/MINI MISC SYRINGE/U-100/1ML/29G NC X 1/2" MISC LITETOUCH INSULIN RX/OTC SYRINGE/0.3ML/29G X NC LITETOUCH INSULIN RX/OTC 1/2" MISC SYRINGE/U-100/1ML/30G NC X 5/16" MISC

246 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN MAGELLAN INSULIN RX/OTC NC SYRINGE/U-100/1ML/31G SAFETY SYRINGE/U- NC X 5/16" MISC 100/1ML/30G X 5/16" LITETOUCH PEN MISC NEEDLES 29GX12.7MM NC MARATHON MEDICAL RX/OTC MISC PENTIPS29GX12MM NC LITETOUCH PEN MISC NC NEEDLES 31G X 6MM MARATHON MEDICAL NC RX/OTC MISC PENTIPS31GX5MM MISC LITETOUCH PEN MARATHON MEDICAL NC RX/OTC NEEDLES 31G X NC PENTIPS31GX8MM MISC 6MM/ULTRA SHORT MARATHON MEDICAL NC RX/OTC MISC PENTIPS32GX4MM MISC LITETOUCH PEN RX/OTC MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLES 31GX8MM NC SYRINGE/U- NC RX/OTC SHORT MISC 100/0.5ML/28GX1/2" MISC LITETOUCH PEN RX/OTC MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLES/31G X 3/16" NC SYRINGE/U- NC RX/OTC MISC 100/1ML/28GX1/2" MISC LITETOUCH PEN RX/OTC MAXI-COMFORT SAFETY NEEDLES/31G X NC PEN NEEDLE/29G X 3/16" 4 5MM/MINI MISC MISC LITETOUCH PEN RX/OTC MAXI-COMFORT SAFETY QL(5 ea daily) NEEDLES/31G X NC PEN NEEDLE/29G X 5/16" 4 8MM/SHORT MISC MISC LONGS INSULIN MAXICOMFORT II PEN SYRINGE/0.5ML/31G X NC NEEDLES/31G X 1/4" NC 5/16" MISC MISC MAGELLAN INSULIN RX/OTC MAXICOMFORT INSULIN QL(5 ea daily) SAFETY SYRINGE/U- NC SYRINGES 27G X 1/2" 5 100/0.3ML/29G X 1/2" MISC MISC MAXICOMFORT INSULIN RX/OTC MAGELLAN INSULIN RX/OTC SYRINGES 27G X 1/2" NC SAFETY SYRINGE/U- NC MISC 100/0.3ML/30G X 5/16" MISC MEDIC INSULIN RX/OTC SYRINGE/0.3ML/30G X NC MAGELLAN INSULIN RX/OTC 5/16" MISC SAFETY SYRINGE/U- NC 100/0.5ML/29G X 1/2" MEDIC INSULIN RX/OTC MISC SYRINGE/0.5ML/30G X NC 5/16" MISC MAGELLAN INSULIN RX/OTC MEDICINE SHOPPE PEN RX/OTC SAFETY SYRINGE/U- NC 100/0.5ML/30G X 5/16" NEEDLES 29G X 12MM NC MISC MISC MAGELLAN INSULIN RX/OTC MEDICINE SHOPPE PEN SAFETY SYRINGE/U- NC NEEDLES 31G X 6MM NC 100/1ML/29G X 1/2" MISC MISC

247 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICINE SHOPPE PEN RX/OTC HDHP Generic NC NEEDLES 31G X 8MM MONOJECT INSULIN NC Preventative MISC SYRINGE/1ML MISC Drug $0 ;RX/OTC MEIJER PEN NEEDLES NC RX/OTC 29G X12MM MISC MONOJECT INSULIN SYRINGE/1ML/31G X NC MEIJER PEN NEEDLES NC 31G X6MM MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily) MEIJER PEN NEEDLES NC RX/OTC 31G X8MM MISC SYRINGE/DETACH 5 NEEDLE/1ML/25G X 5/8" MICRODOT PEN MISC NEEDLE/31G X 6 MM NC MISC MONOJECT INSULIN RX/OTC SYRINGE/DETACH NC MICRODOT PEN RX/OTC NEEDLE/1ML/27G X 1/2" NEEDLE/32G X 4 MM NC MISC MISC MONOJECT INSULIN RX/OTC MICRODOT PEN QL(5 ea daily) SYRINGE/PERM NC NEEDLE/33G X 4 MM 5 NEEDLE/1ML/28G X 1/2" MISC MISC MM INSULIN SYRINGE/U- RX/OTC MONOJECT INSULIN RX/OTC 100/0.3ML/30G X 5/16" NC SYRINGE/PERM NC MISC NEEDLE/U-100/0.5ML/28G MM INSULIN SYRINGE/U- X 1/2" MISC 100/0.3ML/31G X 5/16" NC MONOJECT INSULIN RX/OTC MISC SYRINGE/SAFETY/PERM NC MM INSULIN SYRINGE/U- RX/OTC NEEDLE/0.3ML/29G X 1/2" 100/1/2ML/30G X 5/16" NC MISC MISC MONOJECT INSULIN RX/OTC MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM NC 100/1/2ML/31G X 5/16" NC NEEDLE/0.3ML/29GX1/2" MISC MISC MM INSULIN SYRINGE/U- RX/OTC MONOJECT INSULIN RX/OTC 100/1ML/30G X 5/16" NC SYRINGE/SAFETY/PERM NC MISC NEEDLE/0.5ML/29G X 1/2" MM INSULIN SYRINGE/U- MISC 100/1ML/31G X 5/16" NC MONOJECT INSULIN RX/OTC MISC SYRINGE/SAFETY/PERM NC NEEDLE/1ML/29G X 1/2" MM PEN NEEDLES 31G X NC 1/4" MISC MISC MONOJECT INSULIN RX/OTC MM PEN NEEDLES 31G X NC RX/OTC 3/16" MISC SYRINGE/SOFTPACK/1M NC L/27G X 1/2" MISC MM PEN NEEDLES 31G X NC RX/OTC 5/16" MISC MONOJECT INSULIN RX/OTC SYRINGE/SOFTPACK/U- MM PEN NEEDLES 32G X NC RX/OTC NC 5/32" MISC 100/0.5ML/28G X 1/2" MISC

248 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT INSULIN RX/OTC MONOJECT ULTRA RX/OTC SYRINGE/U- NC COMFORT INSULIN NC 100/0.3ML/30G X 5/16" SYRINGE/1ML/28G X 1/2" MISC MISC MONOJECT INSULIN RX/OTC MONOJECT ULTRA RX/OTC SYRINGE/U- NC COMFORT INSULIN NC 100/0.5ML/30G X 5/16" SYRINGE/1ML/29G X 1/2" MISC MISC MONOJECT INSULIN RX/OTC MS INSULIN SYRINGE/U-100/1ML/28G NC SYRINGE/0.3ML/31G X NC X 1/2" MISC 5/16" MISC MONOJECT INSULIN RX/OTC MS INSULIN SYRINGE/U-100/1ML/30G NC SYRINGE/0.5ML/31G X NC X 5/16" MISC 5/16" MISC HDHP Generic MS INSULIN MONOJECT INSULIN SYRINGE/1ML/31G X NC SYRINGEREGULAR LUER NC Preventative Drug $0 5/16" MISC TIP/SOFTPACK/1ML MISC ;RX/OTC NOVOFINE AUTOCOVER RX/OTC MONOJECT ULTRA RX/OTC PEN NEEDLE 30G X 8MM NC COMFORT INSULIN NC MISC SYRINGE/0.3ML/29G X NOVOFINE PEN NEEDLE NC QL(5 ea daily) 1/2" MISC 32G X 4MM MISC MONOJECT ULTRA RX/OTC NOVOFINE PLUS PEN NC QL(5 ea daily); COMFORT INSULIN NC NEEDLE32G X 4MM MISC RX/OTC SYRINGE/0.3ML/30G X 5/16" MISC NOVOTWIST PEN NC RX/OTC NEEDLE 32GX 5MM MISC MONOJECT ULTRA PC UNIFINE PENTIPS RX/OTC COMFORT INSULIN NC NC SYRINGE/0.3ML/31G X 29G X1/2" MISC 5/16" MISC PC UNIFINE PENTIPS NC RX/OTC MONOJECT ULTRA RX/OTC 31G X5MM MINI MISC PC UNIFINE PENTIPS COMFORT INSULIN NC SYRINGE/0.5ML/28G X 31G X6MM ULTRA NC 1/2" MISC SHORT MISC MONOJECT ULTRA RX/OTC PC UNIFINE PENTIPS NC RX/OTC 31G X8MM SHORT MISC COMFORT INSULIN NC SYRINGE/0.5ML/29G X PEN NEEDLES 29G X NC RX/OTC 1/2" MISC 12MM MISC MONOJECT ULTRA RX/OTC PEN NEEDLES 29GX1/2" NC RX/OTC COMFORT INSULIN NC MISC SYRINGE/0.5ML/30G X PEN NEEDLES NC RX/OTC 5/16" MISC 29GX12MM MISC MONOJECT ULTRA PEN NEEDLES 30GX5/16" NC RX/OTC COMFORT INSULIN NC MISC SYRINGE/0.5ML/31G X 5/16" MISC PEN NEEDLES 30GX5MM NC MISC PEN NEEDLES 30GX8MM NC RX/OTC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

249 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES 31G X 1/4" NC PENTIPS 31G X 8MM NC RX/OTC SHORT MISC MISC PEN NEEDLES 31G X NC RX/OTC PENTIPS 31GX5MM MISC NC RX/OTC 3/16" MISC PEN NEEDLES 31G X NC RX/OTC PENTIPS 31GX6MM MISC NC 5MM MISC RX/OTC PEN NEEDLES 31G X NC PENTIPS 31GX8MM MISC NC 6MM MISC PENTIPS 32G X 4MM NC QL(5 ea daily); PEN NEEDLES 31G X NC RX/OTC MISC RX/OTC 8MM MISC PENTIPS 32GX4MM MISC NC RX/OTC PEN NEEDLES 31GX5/16" NC RX/OTC MISC PRECISION SURE-DOSE RX/OTC PEN NEEDLES 31GX6MM NC INSULIN NC (1/4") MISC SYRINGE/0.3ML/30G X 5/16" MISC PEN NEEDLES 31GX8MM NC RX/OTC (5/16") MISC PRECISION SURE-DOSE QL(5 ea daily); INSULIN RX/OTC PEN NEEDLES 31GX8MM NC RX/OTC NC MISC SYRINGE/0.5ML/28G X 1/2" MISC PEN NEEDLES 32G X NC RX/OTC 4MM MISC PRECISION SURE-DOSE QL(5 ea daily); INSULIN RX/OTC PEN NEEDLES 32G X NC RX/OTC NC 5MM MISC SYRINGE/0.5ML/29G X 1/2" MISC PEN NEEDLES 32G X NC 6MM MISC PRECISION SURE-DOSE QL(5 ea daily) INSULIN NC PEN NEEDLES 32GX4MM NC RX/OTC SYRINGE/0.5ML/30G X MISC 3/8" MISC PEN NEEDLES 33G X 5 QL(5 ea daily) PRECISION SURE-DOSE QL(5 ea daily); 5/32" MISC INSULIN NC RX/OTC PEN NEEDLES/29G X 1/2" NC RX/OTC SYRINGE/1ML/28G X 1/2" MISC MISC PEN NEEDLES/31G X 1/4" NC PRECISION SURE-DOSE QL(5 ea daily); MISC PLUSINSULIN NC RX/OTC SYRINGE/0.3ML/29G X PEN NEEDLES/31G X NC RX/OTC 3/16" MISC 1/2" MISC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES/31G X NC RX/OTC 5/16" MISC PLUSINSULIN NC RX/OTC SYRINGE/1ML/29G X 1/2" PEN NEEDLES/31G X NC 6MM MISC MISC PREFERRED PLUS RX/OTC PEN NEEDLES/32G X NC RX/OTC 5/32" MISC INSULIN SYRINGE/U- NC 100/0.3ML/29G X 1/2" PENTIPS 29G X 12MM NC RX/OTC MISC MISC PREFERRED PLUS RX/OTC PENTIPS 29GX12MM RX/OTC NC INSULIN SYRINGE/U- NC MISC 100/0.3ML/30G X 5/16" PENTIPS 31G X 5MM NC RX/OTC MISC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

250 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS RX/OTC PRO COMFORT INSULIN RX/OTC INSULIN SYRINGE/U- NC SYRINGES/0.5ML/30G X NC 100/0.5ML/28G X 1/2" 5/16" MISC MISC PRO COMFORT INSULIN PREFERRED PLUS RX/OTC SYRINGES/0.5ML/31G X NC INSULIN SYRINGE/U- NC 5/16" MISC 100/0.5ML/29G X 1/2" PRO COMFORT INSULIN MISC SYRINGES/1ML/30G X NC PREFERRED PLUS RX/OTC 1/2" MISC INSULIN SYRINGE/U- NC PRO COMFORT INSULIN RX/OTC 100/0.5ML/30G X 5/16" SYRINGES/1ML/30G X NC MISC 5/16" MISC PREFERRED PLUS RX/OTC PRO COMFORT INSULIN INSULIN SYRINGE/U- NC SYRINGES/1ML/31G X NC 100/1ML/28G X 1/2" MISC 5/16" MISC PREFERRED PLUS RX/OTC PRO COMFORT PEN RX/OTC INSULIN SYRINGE/U- NC NEEDLES/31G X 8MM NC 100/1ML/29G X 1/2" MISC MISC PREFERRED PLUS RX/OTC PRO COMFORT PEN RX/OTC INSULIN SYRINGE/U- NC NEEDLES/32G X 4MM NC 100/1ML/30G X 5/16" MISC MISC PRO COMFORT PEN RX/OTC PREFERRED PLUS RX/OTC NEEDLES/32G X 5MM NC UNIFINE PENTIPS 29G X NC MISC 12MM MISC PRO COMFORT PEN PREFERRED PLUS NEEDLES/32G X 6MM NC UNIFINE PENTIPS 31G X NC MISC 6MM ULTRA SHORT MISC PRODIGY INSULIN SYRING/U-100/0.3ML/31G NC PREFERRED PLUS RX/OTC X 5/16" MISC UNIFINE PENTIPS 31G X NC 8MM SHORT MISC PRODIGY INSULIN SYRINGE/1/2ML/31G X NC PREFERRED PLUS RX/OTC 5/16" MISC UNIFINE PENTIPS NC 32GX4MM MISC PRODIGY INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" NC PREFERRED PLUS RX/OTC MISC UNIFINE NC PENTIPS/MINI/31GX5MM PURE COMFORT PEN NC MISC NEEDLE 32G X6MM MISC PURE COMFORT PEN QL(5 ea daily) PREVENT SAFETY PEN NC 5 NEEDLES 31GX1/4" MISC NEEDLE 32G X8MM MISC PREVENT SAFETY PEN RX/OTC PURE COMFORT PEN RX/OTC NEEDLES 31GX5/16" NC NEEDLE/32G X 5MM NC MISC MISC PRO COMFORT INSULIN PURE COMFORT PEN NC RX/OTC SYRINGES/0.5ML/30G X NC NEEDLE/32G X4MM MISC 1/2" MISC

251 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX EXTRA SHORT PEN REALITY INSULIN RX/OTC NEEDLES 31GX6MM NC SYRINGE/U-100/1ML/28G NC MISC X 1/2" MISC PX INSULIN SYRINGE/U- REALITY INSULIN RX/OTC 100/0.5ML/30G X 1/2" NC SYRINGE/U-100/1ML/29G NC MISC X 1/2" MISC PX MINI PEN NEEDLES NC RX/OTC RELION INSULIN 31GX5MM MISC SYRINGE 0.5ML/31G X NC 15/64" MISC PX PEN NEEDLE NC RX/OTC 29GX12MM MISC RELION INSULIN SYRINGE NC PX PEN NEEDLE NC RX/OTC 31GX8MM MISC 1ML/31GX15/64" MISC PX SHORTLENGTH PEN RX/OTC RELION INSULIN RX/OTC NEEDLES/31GX8MM NC SYRINGE/U- NC MISC 100/0.3ML/31G X 15/64" MISC QC PEN NEEDLES 29G X NC RX/OTC 12MM MISC RELION INSULIN SYRINGE/U- NC QC PEN NEEDLES 31G X NC 100/0.3ML/31G X 5/16" 6MM MISC MISC QC PEN NEEDLES 31G X NC RX/OTC RELION INSULIN RX/OTC 8MM MISC SYRINGE/U- NC QC UNIFINE PENTIPS NC RX/OTC 100/0.5ML/29G X 1/2" 32GX4MM MISC MISC RA INSULIN QL(5 ea daily); RELION INSULIN SYRINGE/0.5ML/29G X NC RX/OTC SYRINGE/U- NC 1/2" MISC 100/0.5ML/31G X 5/16" RA INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" NC RX/OTC RELION INSULIN MISC SYRINGE/U-100/1ML/31G NC RA INSULIN SYRINGE/U- QL(5 ea daily); X 15/64" MISC 100/0.5ML/30G X 5/16" NC RX/OTC RELION INSULIN MISC SYRINGE/U-100/1ML/31G NC RA INSULIN SYRINGE/U- QL(5 ea daily); X 5/16" MISC 100/1 ML/30G X 5/16" NC RX/OTC RELION MINI PEN MISC NEEDLES 31GX6MM NC MISC RA PEN NEEDLES 31G X NC RX/OTC 5MM3/16" MISC RELION PEN NEEDLES NC RX/OTC 29GX12MM MISC RA PEN NEEDLES 31G X NC RX/OTC 8MM5/16" MISC RELION PEN NEEDLES NC REALITY INSULIN RX/OTC 31G X6MM MISC SYRINGE/U- NC RELION PEN NEEDLES NC RX/OTC 100/0.5ML/28G X 1/2" 31G X8MM MISC MISC RELION PEN NEEDLES NC RX/OTC REALITY INSULIN RX/OTC 31GX5/16" MISC SYRINGE/U- NC RELION PEN NEEDLES NC 100/0.5ML/29G X 1/2" 31GX6MM MISC MISC

252 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION PEN NEEDLES NC RX/OTC SB INSULIN SYRINGE/U- RX/OTC 31GX8MM MISC 100/0.5ML/29G X 1/2" NC MISC RELION PEN NEEDLES NC RX/OTC 32G X4MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" NC RX/OTC RELION PEN NEEDLES NC RX/OTC 32G X5/32" MISC MISC SB INSULIN SYRINGE/U- RX/OTC RELION PEN NEEDLES NC RX/OTC 32GX4MM MISC 100/0.5ML/30G X 5/16" NC MISC RELION PEN NEEDLES/31G X1/4" NC SB INSULIN SYRINGE/U- NC RX/OTC MISC 100/1ML/29G X 1/2" MISC SB INSULIN SYRINGE/U- RX/OTC RELION SHORT PEN NC RX/OTC NEEDLES31GX8MM MISC 100/1ML/30G X 5/16" NC MISC SAFESNAP INSULIN RX/OTC SYRINGE/0.3ML/30G X NC SB INSULIN SYRINGE/U- 5/16" MISC 100/1ML/31G X 5/16" NC MISC SAFESNAP INSULIN RX/OTC SYRINGE/0.5ML/29G X NC SECURESAFE SAFETY RX/OTC 1/2" MISC INSULIN SYRINGES/U- NC 100/0.5ML/29GX1/2" MISC SAFESNAP INSULIN RX/OTC SYRINGE/0.5ML/30G X NC SECURESAFE SAFETY RX/OTC 5/16" MISC INSULIN SYRINGES/U- NC 100/1ML/29GX1/2" MISC SAFESNAP INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" NC SECURESAFE SAFETY RX/OTC MISC PEN NEEDLES/30G X NC 5/16" MISC SAFESNAP INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" NC SHOPKO UNIFINE RX/OTC MISC PENTIPS PEN NC NEEDLES/MICRO/32GX4 SAFETY INSULIN RX/OTC MM MISC SYRINGES NC 0.5ML/29GX1/2" MISC SHOPKO UNIFINE RX/OTC PENTIPS PEN NC SAFETY INSULIN RX/OTC NEEDLES/MINI/31GX5MM SYRINGES NC MISC 0.5ML/30GX5/16" MISC SHOPKO UNIFINE RX/OTC SAFETY INSULIN RX/OTC PENTIPS PEN NC SYRINGES 1ML/27GX1/2" NC NEEDLES/ORIGINAL/29G MISC X12MM MISC SAFETY INSULIN RX/OTC SHOPKO UNIFINE RX/OTC SYRINGES 1ML/29GX1/2" NC PENTIPS PEN NC MISC NEEDLES/SHORT/31GX8 SAFETY INSULIN MM MISC SYRINGES 1ML/30GX1/2" NC SHOPKO UNIFINE RX/OTC MISC PENTIPS PLUS PEN NC SB INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/MICRO/REMOV 100/0.5ML/29G X 1/2" NC RX/OTC R/32GX4MM MISC MISC

253 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHOPKO UNIFINE RX/OTC SURE COMFORT RX/OTC PENTIPS PLUS PEN NC INSULIN SYRINGE/U- NC NEEDLES/MINI/REMOVE 100/0.5ML/30G X 5/16" R/31GX5MM MISC MISC SHOPKO UNIFINE RX/OTC SURE COMFORT PENTIPS PLUS PEN NC INSULIN SYRINGE/U- NC NEEDLES/REMOVER/29G 100/0.5ML/31G X 5/16 X12MM MISC MISC SHOPKO UNIFINE RX/OTC SURE COMFORT RX/OTC NC PENTIPS PLUS PEN NC INSULIN SYRINGE/U- NEEDLES/SHORT/REMO 100/1ML/28G X 1/2" MISC VR/31GX8MM MISC SURE COMFORT RX/OTC SURE COMFORT RX/OTC INSULIN SYRINGE/U- NC INSULIN SYRINGE/U- NC 100/1ML/29G X 1/2" MISC 100/0.3ML/29G X 1/2" SURE COMFORT MISC INSULIN SYRINGE/U- NC SURE COMFORT 100/1ML/30G X 1/2" MISC INSULIN SYRINGE/U- NC SURE COMFORT RX/OTC 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- NC MISC 100/1ML/30G X 5/16" SURE COMFORT RX/OTC MISC INSULIN SYRINGE/U- NC SURE COMFORT 100/0.3ML/30G X 5/16" INSULIN SYRINGE/U- NC MISC 100/1ML/31G X 5/16" SURE COMFORT MISC INSULIN SYRINGE/U- NC SURE COMFORT QL(5 ea daily) 100/0.3ML/31G X 5/16 INSULIN 5 MISC SYRINGES/0.5ML/31G X SURE COMFORT 6MM MISC INSULIN SYRINGE/U- NC SURE COMFORT QL(5 ea daily) 100/0.3ML/31G X 5/16" INSULIN SYRINGES/U- 5 MISC 100/1ML/31GX6MM MISC SURE COMFORT QL(5 ea daily) SURE COMFORT PEN INSULIN SYRINGE/U- 5 NEEDLES29GX1/2" NC 100/0.3ML/31GX1/4" MISC 12.7MM MISC SURE COMFORT RX/OTC SURE COMFORT PEN RX/OTC INSULIN SYRINGE/U- NC NEEDLES30GX5/16" NC 100/0.5ML/28G X 1/2" SHORT MISC MISC SURE COMFORT PEN RX/OTC SURE COMFORT RX/OTC NEEDLES31GX3/16" NC INSULIN SYRINGE/U- NC (5MM) MISC 100/0.5ML/29G X 1/2" MISC SURE COMFORT PEN RX/OTC NEEDLES31GX5/16" NC SURE COMFORT (8MM) MISC INSULIN SYRINGE/U- NC 100/0.5ML/30G X 1/2" SURE COMFORT PEN NC RX/OTC MISC NEEDLES32GX5/32" MISC SURE COMFORT PEN NC NEEDLES32GX6MM MISC

254 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-FINE PEN SURE-JECT INSULIN NEEDLES 29GX1/2" NC SYRINGE/U-100/1ML/31G NC 12.7MM MISC X 5/16" MISC SURE-FINE PEN RX/OTC TECHLITE INSULIN RX/OTC NEEDLES 31GX3/16" NC SYRINGEU- NC 5MM MISC 100/0.3ML/29G X 1/2" SURE-FINE PEN RX/OTC MISC NEEDLES 31GX5/16" NC TECHLITE INSULIN 8MM MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.3ML/30G X 1/2" MISC SYRINGE/U- NC 100/0.3ML/29G X 1/2" TECHLITE INSULIN RX/OTC MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.3ML/30G X 5/16" MISC SYRINGE/U- NC 100/0.3ML/30G X 5/16" TECHLITE INSULIN RX/OTC MISC SYRINGEU- NC SURE-JECT INSULIN 100/0.3ML/31G X 15/64" MISC SYRINGE/U- NC 100/0.3ML/31G X 5/16" TECHLITE INSULIN MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.3ML/31G X 5/16" MISC SYRINGE/U- NC 100/0.5ML/28G X 1/2" TECHLITE INSULIN RX/OTC MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.5ML/29G X 1/2" MISC SYRINGE/U- NC 100/0.5ML/29G X 1/2" TECHLITE INSULIN MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.5ML/30G X 1/2" MISC SYRINGE/U- NC 100/0.5ML/30G X 5/16" TECHLITE INSULIN RX/OTC MISC SYRINGEU- NC SURE-JECT INSULIN 100/0.5ML/30G X 5/16" MISC SYRINGE/U- NC 100/0.5ML/31G X 5/16" TECHLITE INSULIN MISC SYRINGEU- NC SURE-JECT INSULIN RX/OTC 100/0.5ML/31G X 15/64" SYRINGE/U-100/1ML/28G NC MISC X 1/2" MISC TECHLITE INSULIN SURE-JECT INSULIN RX/OTC SYRINGEU- NC SYRINGE/U-100/1ML/29G NC 100/0.5ML/31G X 5/16" X 1/2" MISC MISC SURE-JECT INSULIN RX/OTC TECHLITE INSULIN RX/OTC SYRINGE/U-100/1ML/30G NC SYRINGEU-100/1ML/29G NC X 5/16" MISC X 1/2" MISC

255 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN TOPCARE CLICKFINE SYRINGEU-100/1ML/30G NC UNIVERSAL PEN EEDLES NC X 1/2" MISC 31GX1/4" MISC TECHLITE INSULIN RX/OTC TOPCARE CLICKFINE RX/OTC SYRINGEU-100/1ML/30G NC UNIVERSAL PEN EEDLES NC X 5/16" MISC 31GX5/16" MISC TECHLITE INSULIN TOPCARE ULTRA RX/OTC SYRINGEU-100/1ML/31G NC COMFORT INSULIN NC X 15/64" MISC SYRINGE/0.3ML/30G X TECHLITE INSULIN 5/16" MISC SYRINGEU-100/1ML/31G NC TOPCARE ULTRA X 5/16" MISC COMFORT INSULIN NC SYRINGE/0.3ML/31G X TECHLITE PEN NEEDLES 5 QL(5 ea daily) 29GX 10MM MISC 5/16" MISC TOPCARE ULTRA RX/OTC TECHLITE PEN NEEDLES NC RX/OTC 29GX 12 MM MISC COMFORT INSULIN NC SYRINGE/0.5ML/30G X TECHLITE PEN NEEDLES NC RX/OTC 5/16" MISC 31GX 5MM MISC TOPCARE ULTRA TECHLITE PEN RX/OTC COMFORT INSULIN NC NEEDLES/31GX 5MM NC SYRINGE/0.5ML/31G X MISC 5/16" MISC TECHLITE PEN TOPCARE ULTRA RX/OTC NEEDLES/31GX 6 MM NC COMFORT INSULIN NC MISC SYRINGE/1ML/30G X TECHLITE PEN RX/OTC 5/16" MISC NEEDLES/31GX 8MM NC TOPCARE ULTRA MISC COMFORT INSULIN NC TECHLITE PEN RX/OTC SYRINGE/1ML/31G X NEEDLES/32GX 4MM NC 5/16" MISC MISC TOPCARE ULTRA RX/OTC TECHLITE PEN COMFORT INSULIN NEEDLES/32GX 6MM NC SYRINGE/U- NC MISC 100/0.3ML/29G X 1/2" TECHLITE PEN QL(5 ea daily) MISC NEEDLES/32GX 8MM 5 TOPCARE ULTRA RX/OTC MISC COMFORT INSULIN TODAYS HEALTH MINI SYRINGE/U- NC PEN NEEDLES 31G X 1/4" NC 100/0.5ML/29G X 1/2" MISC MISC TODAYS HEALTH RX/OTC TOPCARE ULTRA RX/OTC ORIGINAL PEN NEEDLES NC COMFORT INSULIN NC 29G X 1/2" MISC SYRINGE/U-100/1ML/29G TODAYS HEALTH SHORT RX/OTC X 1/2" MISC PEN NEEDLES 31G X NC TRUE COMFORT INSULIN 5/16" MISC SYRINGE/0.5ML/31G X NC 5/16" MISC

256 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT INSULIN TRUE COMFORT PRO SYRINGE/1ML/31G X NC PEN NEEDLES 32G X NC 5/16" MISC 6MM MISC TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO QL(5 ea daily) NEEDLES31G X 5MM NC PEN NEEDLES 33G X 5 MISC 4MM MISC TRUE COMFORT PEN TRUE COMFORT PRO QL(5 ea daily) NEEDLES31G X 6MM NC PEN NEEDLES 33G X 5 MISC 5MM MISC TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO QL(5 ea daily) NEEDLES32G X 4MM NC PEN NEEDLES 33G X 5 MISC 6MM MISC TRUE COMFORT PRO QL(5 ea daily); TRUEPLUS 5-BEVEL PEN INSULINSYRINGE/0.5ML/ 5 RX/OTC NEEDLES 29GX12.7MM NC 30G X 5/16" MISC MISC TRUE COMFORT PRO TRUEPLUS 5-BEVEL PEN RX/OTC INSULINSYRINGE/0.5ML/ NC NEEDLES 31GX5MM NC 31G X 5/16" MISC MISC TRUE COMFORT PRO QL(5 ea daily); TRUEPLUS 5-BEVEL PEN INSULINSYRINGE/1ML/30 5 RX/OTC NEEDLES 31GX6MM NC G X 5/16" MISC MISC TRUE COMFORT PRO TRUEPLUS 5-BEVEL PEN RX/OTC INSULINSYRINGE/1ML/31 NC NEEDLES 31GX8MM NC G X 5/16" MISC MISC TRUE COMFORT PRO QL(5 ea daily) TRUEPLUS 5-BEVEL PEN RX/OTC INSULINSYRINGE/U- 5 NEEDLES 32GX4MM NC 100/0.5ML/30G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily) SYRINGE/U- NC RX/OTC INSULINSYRINGE/U- 5 100/0.3ML/29G X 1/2" 100/1ML/30G X 1/2" MISC MISC TRUE COMFORT PRO RX/OTC TRUEPLUS INSULIN RX/OTC NC PEN NEEDLES 31G X SYRINGE/U- NC 5MM MISC 100/0.3ML/30G X 5/16" TRUE COMFORT PRO MISC PEN NEEDLES 31G X NC TRUEPLUS INSULIN QL(5 ea daily) 6MM MISC SYRINGE/U- NC TRUE COMFORT PRO RX/OTC 100/0.3ML/31G X 5/16" PEN NEEDLES 31G X NC MISC 8MM MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO RX/OTC SYRINGE/U- NC RX/OTC PEN NEEDLES 32G X NC 100/0.5ML/28G X 1/2" 4MM MISC MISC TRUE COMFORT PRO RX/OTC TRUEPLUS INSULIN QL(5 ea daily); PEN NEEDLES 32G X NC SYRINGE/U- NC RX/OTC 5MM MISC 100/0.5ML/29G X 1/2" MISC

257 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN SYRINGE/U- NC RX/OTC SYRINGE/0.3ML/30G X NC 100/0.5ML/30G X 5/16" 1/2" MISC MISC ULTICARE INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X NC SYRINGE/U- NC 5/16" MISC 100/0.5ML/31G X 5/16" ULTICARE INSULIN RX/OTC MISC SYRINGE/0.5ML/28G X NC TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/28G NC RX/OTC ULTICARE INSULIN RX/OTC X 1/2" MISC SYRINGE/0.5ML/29G X NC TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/29G NC RX/OTC ULTICARE INSULIN X 1/2" MISC SYRINGE/0.5ML/30G X NC TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/30G NC RX/OTC ULTICARE INSULIN RX/OTC X 5/16" MISC SYRINGE/0.5ML/30G X NC TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G NC ULTICARE INSULIN RX/OTC X 5/16" MISC SYRINGE/1ML/28G X 1/2" NC TRUEPLUS PEN RX/OTC MISC NEEDLES 29GX12MM NC ULTICARE INSULIN RX/OTC MISC SYRINGE/1ML/29G X 1/2" NC TRUEPLUS PEN RX/OTC MISC NEEDLES 31GX5MM NC ULTICARE INSULIN MISC SYRINGE/1ML/30G X 1/2" NC TRUEPLUS PEN MISC NEEDLES 31GX6MM NC ULTICARE INSULIN RX/OTC MISC SYRINGE/1ML/30G X NC TRUEPLUS PEN RX/OTC 5/16" MISC NEEDLES 31GX8MM NC ULTICARE INSULIN RX/OTC MISC SYRINGE/SHORT/0.3ML/3 NC TRUEPLUS PEN QL(5 ea daily); 0G X 5/16" MISC NEEDLES 32GX4MM NC RX/OTC ULTICARE INSULIN MISC SYRINGE/SHORT/0.3ML/3 NC ULTICARE INSULIN RX/OTC 1G X 5/16" MISC SAFETY NC ULTICARE INSULIN RX/OTC SYRINGE/0.5ML/29G X SYRINGE/SHORT/0.5ML/3 NC 1/2" MISC 0G X 5/16" MISC ULTICARE INSULIN RX/OTC ULTICARE INSULIN SAFETY NC SYRINGE/SHORT/0.5ML/3 NC SYRINGE/1ML/29G X 1/2" 1G X 5/16" MISC MISC ULTICARE INSULIN RX/OTC ULTICARE INSULIN RX/OTC SYRINGE/SHORT/1ML/30 NC SYRINGE/0.3ML/29G X NC G X 5/16" MISC 1/2" MISC ULTICARE INSULIN SYRINGE/SHORT/1ML/31 NC G X 5/16" MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

258 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN ULTICARE MICRO PEN RX/OTC NC SYRINGE/U- NC NEEDLES/32G X 4MM 100/0.3ML/30G X 1/2" MISC MISC ULTICARE MICRO PEN RX/OTC ULTICARE INSULIN NEEDLES/32G X 5/32" NC SYRINGE/U- NC MISC 100/0.3ML/31G X 5/16" ULTICARE MINI PEN MISC NEEDLES 31GX6MM NC ULTICARE INSULIN MISC SYRINGE/U- NC ULTICARE MINI PEN 100/0.5ML/30G X 1/2" NEEDLES ULTI-FINE IV NC MISC MISC ULTICARE INSULIN ULTICARE MINI PEN SYRINGE/U- NC NEEDLES/31G X 6MM NC 100/0.5ML/31G X 5/16" MISC MISC ULTICARE MINI PEN ULTICARE INSULIN NEEDLES/32G X 1/4" NC SYRINGE/U-100/1ML/30G NC MISC X 1/2" MISC ULTICARE MINI PEN NC ULTICARE INSULIN NEEDLES31GX6MM MISC SYRINGE/U-100/1ML/31G NC X 5/16" MISC ULTICARE MINI SAFETY PENNEEDLES 30G X NC ULTICARE INSULIN 3/16" MISC SYRINGEULTRAFINE U- NC 100/0.3ML/31G X 5/16" ULTICARE ORIGINAL MISC PEN NEEDLES ULTI-FINE NC MISC ULTICARE INSULIN ULTICARE PEN NEEDLES RX/OTC SYRINGEULTRAFINE U- NC NC 100/0.5ML/31G X 5/16" 31GX 5MM/MINI MISC MISC ULTICARE PEN ULTICARE INSULIN NEEDLES/29GX 12.7MM NC MISC SYRINGEULTRAFINE U- NC 100/1ML/31G X 5/16" ULTICARE SHORT PEN RX/OTC MISC NEEDLES 31GX8MM NC ULTICARE MICRO PEN RX/OTC MISC NEEDLES 31G X 8MM NC ULTICARE SHORT PEN RX/OTC MISC NEEDLES ULTI-FINE IV NC ULTICARE MICRO PEN RX/OTC MISC NEEDLES 32G X 4MM NC ULTICARE SHORT PEN RX/OTC MISC NEEDLES/31G X 8MM NC ULTICARE MICRO PEN MISC NEEDLES/31G X 1/4" NC ULTICARE SHORT RX/OTC MISC SAFETY PEN NEEDLES NC ULTICARE MICRO PEN RX/OTC 30G X 5/16" MISC NEEDLES/31G X 5/16" NC ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/31G X 5 1/4" MISC

259 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE U-100 INSULIN QL(5 ea daily) ULTIGUARD RX/OTC SYRINGES/0.3ML/31G 5 SAFEPACK/MICROPEN NC X1/4" MISC NEEDLE/32G X 5/32" ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/31G X 5 ULTIGUARD RX/OTC 1/4" MISC SAFEPACK/MICROPEN ULTICARE U-100 INSULIN QL(5 ea daily) NEEDLE/32G X NC SYRINGES/1ML/31G X 5 5/32"/SHARPS CONTA 1/4" MISC MISC ULTIGUARD SAFEPACK ULTIGUARD SAFEPACK/MINI PEN INSULIN SYRINGE NC 0.3ML/30G X NEEDLE/31G X NC 1/2"/SHARPS C MISC 1/4"/SHARPS CONTAIN MISC ULTIGUARD SAFEPACK ULTIGUARD RX/OTC INSULIN SYRINGE 1/2ML NC 30G X 1/2"/SHARPS C SAFEPACK/MINI PEN MISC NEEDLE/31G X NC 3/16"/SHARPS CONTAI ULTIGUARD SAFEPACK MISC INSULIN SYRINGE 1ML NC 30G X 1/2"/SHARPS CON ULTIGUARD MISC SAFEPACK/MINI PEN NEEDLE/32G X NC ULTIGUARD SAFEPACK 1/4"/SHARPS CONTAIN INSULIN SYRINGE 1ML NC MISC 31G X 5/16"/SHARPS CO MISC ULTIGUARD RX/OTC SAFEPACK/SHORTPEN ULTIGUARD SAFEPACK NEEDLE/31G X NC INSULIN NC 5/16"/SHARPS CONTA SYRINGE/0.3ML/30G X MISC 1/2"/SHARPS C MISC ULTIGUARD ULTIGUARD SAFEPACK SAFEPACK/SYRINGE/NE INSULIN NC EDLE/31G X NC SYRINGE/0.3ML/31G X 5/16"/SHARPS CONTAIN 5/16"/SHARPS MISC MISC ULTIGUARD SAFEPACK ULTILET INSULIN 5 QL(5 ea daily) INSULIN NC SYRINGE 31X6MM MISC SYRINGE/0.5ML/30G X 1/2"/SHARPS C MISC ULTILET INSULIN NC RX/OTC SYRINGE 31X6MM MISC ULTIGUARD SAFEPACK RX/OTC ULTILET INSULIN RX/OTC MINI PEN NEEDLE/31G X NC 3/16"/SHARPS CONTAI SYRINGE/0.3ML/30G X NC MISC 8MM MISC ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/0.3ML/31G X NC PEN NEEDLE/29G X NC 1/2"/SHARPS 8MM MISC CONTAINER MISC ULTILET INSULIN RX/OTC SYRINGE/0.5ML/30G X NC 8MM MISC

260 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN RX/OTC ULTILET PEN NEEDLE NC RX/OTC SYRINGE/1ML/30G X NC 32GX4MM/SHORT MISC 8MM MISC ULTILET SHORT PEN RX/OTC ULTILET INSULIN NEEDLES 31GX5/16" NC SYRINGE/1ML/31G X NC MISC 8MM MISC ULTILET SHORT PEN NC RX/OTC ULTILET INSULIN NEEDLES31GX3/16" MISC SYRINGE/SHORT/0.3ML/3 NC ULTILET U-100 INSULIN QL(5 ea daily) 0G X 12.7MM MISC SYRINGES/1ML/31G X 5 ULTILET INSULIN RX/OTC 6MM MISC SYRINGE/SHORT/0.3ML/3 NC ULTRA COMFORT RX/OTC 0G X 5/16" MISC INSULIN SYRINGE/U- NC ULTILET INSULIN 100/0.3ML/30G X 5/16" SYRINGE/SHORT/0.3ML/3 NC MISC 1G X 5/16" MISC ULTRA FLO INSULIN PEN NC RX/OTC ULTILET INSULIN RX/OTC NEEDLE 31GX5MM MISC SYRINGE/SHORT/0.5ML/3 NC ULTRA FLO INSULIN PEN NC RX/OTC 0G X 5/16" MISC NEEDLE 32GX4MM MISC ULTILET INSULIN ULTRA FLO INSULIN PEN 5 QL(5 ea daily) SYRINGE/SHORT/0.5ML/3 NC NEEDLE 33GX4MM MISC 1G X 5/16" MISC ULTRA FLO INSULIN PEN NC RX/OTC ULTILET INSULIN RX/OTC NEEDLES MISC SYRINGE/SHORT/1ML/30 NC G X 5/16" MISC ULTRA FLO INSULIN PEN NC RX/OTC NEELE 31GX8MM MISC ULTILET INSULIN SYRINGE/SHORT/1ML/31 NC ULTRA FLO INSULIN RX/OTC G X 5/16" MISC SYRINGE 0.3ML/29G X NC 1/2" MISC ULTILET INSULIN ULTRA FLO INSULIN SYRINGE/U- NC 100/0.5ML/30G X 1/2" SYRINGE 0.3ML/30GX1/2" NC MISC MISC ULTILET INSULIN ULTRA FLO INSULIN RX/OTC SYRINGE NC SYRINGE/U- NC 100/0.5ML/31GX6MM 0.3ML/30GX5/16" MISC MISC ULTRA FLO INSULIN ULTILET INSULIN SYRINGE NC SYRINGE/U-100/1ML/30G NC 0.3ML/31GX5/16" MISC X 1/2" MISC ULTRA FLO INSULIN RX/OTC SYRINGE 0.5ML/29GX1/2" NC ULTILET PEN NEEDLE NC 29GX12.7MM MISC MISC ULTRA FLO INSULIN ULTILET PEN NEEDLE NC RX/OTC 31GX5MM MISC SYRINGE 0.5ML/30GX1/2" NC MISC ULTILET PEN NEEDLE NC RX/OTC 31GX8MM MISC ULTRA FLO INSULIN RX/OTC SYRINGE NC ULTILET PEN NEEDLE NC RX/OTC 0.5ML/30GX5/16" MISC 32GX4MM MISC

261 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC SYRINGE NC INSULIN SYRINGE/U- NC 0.5ML/31GX5/16" MISC 100/0.5ML/29G X 1/2" ULTRA FLO INSULIN MISC SYRINGE 1/2 NC ULTRA-COMFORT RX/OTC UNIT/0.3ML/30GX1/2" INSULIN SYRINGE/U- NC MISC 100/0.5ML/30G X 5/16" ULTRA FLO INSULIN RX/OTC MISC SYRINGE 1/2 NC ULTRA-COMFORT UNIT/0.3ML/30GX5/16" INSULIN SYRINGE/U- NC MISC 100/0.5ML/31G X 5/16" ULTRA FLO INSULIN MISC SYRINGE 1/2 NC ULTRA-COMFORT RX/OTC UNIT/0.3ML/31GX5/16" INSULIN SYRINGE/U- NC MISC 100/1ML/28G X 1/2" MISC ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE 1M/29GX1/2" NC INSULIN SYRINGE/U- NC MISC 100/1ML/29G X 1/2" MISC ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC NC SYRINGE 1ML/30GX1/2" INSULIN SYRINGE/U- NC MISC 100/1ML/30G X 5/16" ULTRA FLO INSULIN RX/OTC MISC SYRINGE 1ML/30GX5/16" NC ULTRA-COMFORT MISC INSULIN SYRINGE/U- NC ULTRA FLO INSULIN 100/1ML/31G X 5/16" SYRINGE 1ML/31GX5/16" NC MISC MISC ULTRA-THIN II INSULIN RX/OTC ULTRA THIN PEN RX/OTC SYRINGE SHORT/U- NC NEEDLES 32G X 4MM NC 100/0.3ML/30GX5/16" MISC MISC ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- INSULIN SYRINGE/U- NC NC 100/0.3ML/29G X 1/2" 100/0.3ML/31GX5/16" MISC MISC ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE SHORT/U- RX/OTC INSULIN SYRINGE/U- NC NC 100/0.3ML/30G X 5/16" 100/0.5ML/30GX5/16" MISC MISC ULTRA-COMFORT ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- INSULIN SYRINGE/U- NC NC 100/0.3ML/31G X 5/16" 100/0.5ML/31GX5/16" MISC MISC ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE SHORT/U- NC RX/OTC INSULIN SYRINGE/U- NC 100/0.5ML/28G X 1/2" 100/1ML/30GX5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- NC 100/1ML/31GX5/16" MISC

262 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE PEN RX/OTC SYRINGE/U- NC RX/OTC NEEDLES/31G X 3/16" NC 100/0.5ML/29GX1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE PEN RX/OTC SYRINGE/U- NC RX/OTC NEEDLES/31G X 5/16" NC 100/1ML/29GX1/2" MISC MISC ULTRA-THIN II MINI PEN RX/OTC ULTRACARE PEN NEEEDLES/31GX3/16" NC NEEDLES/32G X 1/14" NC MISC MISC ULTRA-THIN II PEN NC QL(5 ea daily) ULTRACARE PEN RX/OTC NEEDLES 29GX1/2" MISC NEEDLES/32G X 3/16" NC ULTRA-THIN II PEN RX/OTC MISC NEEDLES/SHORT/31GX5/ NC ULTRACARE PEN RX/OTC 16" MISC NEEDLES/32G X 5/32" NC ULTRACARE INSULIN RX/OTC MISC SYRINGE/U- NC ULTRACARE PEN QL(5 ea daily) 100/0.3ML/30G X 5/16" NEEDLES/33G X 5/32" 5 MISC MISC ULTRACARE INSULIN UNIFINE PEN NC RX/OTC SYRINGE/U- NC NEEDLE/32G X4MM MISC 100/0.3ML/31G X 5/16" UNIFINE PENTIPS NC RX/OTC MISC 29GX12MM MISC ULTRACARE INSULIN UNIFINE PENTIPS 31G X NC RX/OTC SYRINGE/U- NC 3/16" MISC 100/0.5ML/30G X 1/2" MISC UNIFINE PENTIPS NC RX/OTC 31GX5MM MISC ULTRACARE INSULIN RX/OTC UNIFINE PENTIPS SYRINGE/U- NC NC 100/0.5ML/30G X 5/16" 31GX6MM MISC MISC UNIFINE PENTIPS NC RX/OTC ULTRACARE INSULIN 31GX8MM MISC UNIFINE PENTIPS RX/OTC SYRINGE/U- NC NC 100/0.5ML/31G X 5/16" 32GX4MM MISC MISC UNIFINE PENTIPS NC ULTRACARE INSULIN 32GX6MM MISC SYRINGE/U-100/1ML/30G NC UNIFINE PENTIPS 5 QL(5 ea daily) X 1/2" MISC 33GX4MM MISC ULTRACARE INSULIN RX/OTC UNIFINE PENTIPS PLUS NC RX/OTC SYRINGE/U-100/1ML/30G NC 29GX12MM MISC X 5/16" MISC UNIFINE PENTIPS PLUS NC RX/OTC ULTRACARE INSULIN 31GX5MM MISC SYRINGE/U-100/1ML/31G NC UNIFINE PENTIPS PLUS NC X 5/16" MISC 31GX6MM MISC ULTRACARE PEN UNIFINE PENTIPS PLUS NC RX/OTC NEEDLES/31G X 1/4" NC 31GX8MM MISC MISC UNIFINE PENTIPS PLUS NC QL(5 ea daily); 32GX4MM MISC RX/OTC

263 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS PLUS NC RX/OTC VANISHPOINT INSULIN 32GX4MM MISC SYRINGE/1ML/30G X 5 3/16" MISC UNIFINE PENTIPS PLUS 5 QL(5 ea daily) 33GX 5/32" MISC VANISHPOINT INSULIN RX/OTC SYRINGE/1ML/30G X NC UNIFINE PENTIPS PLUS 5 QL(5 ea daily) 33GX4MM MISC 5/16" MISC VIDA MIA UNIFINE RX/OTC UNIFINE PENTIPS NC NC PLUS/30GX 3/16" MISC PENTIPS32GX4MM MISC VIDA MIA UNIFINE UNIFINE PENTIPS/30G X NC 3/16" MISC PENTIPSMINI 31GX6MM NC MISC UNIFINE SAFECONTROL PEN NEEDLE/30G X 3/16" NC VIDA MIA UNIFINE RX/OTC MISC PENTIPSORIGINAL NC 29GX12MM MISC UNIFINE SAFECONTROL RX/OTC PEN NEEDLE/30G X 5/16" NC VIDA MIA UNIPFINE RX/OTC MISC PENTIPSSHORT NC 31GX8MM MISC VALUE HEALTH INSULIN RX/OTC VP INSULIN SYRINGE/U- RX/OTC SYRINGE/U- NC 100/0.5ML/29G X 1/2" 100/0.3ML/29G X 1/2" NC MISC MISC VALUE HEALTH INSULIN RX/OTC WEGMANS UNIFINE RX/OTC SYRINGE/U-100/1ML/29G NC PENTIPS PLUS 32GX4MM NC X 1/2" MISC MISC VALUMARK PEN RX/OTC WEGMANS UNIFINE RX/OTC NEEDLES 29GX12MM NC PENTIPS NC MISC PLUS/MINI/31GX5MM MISC VALUMARK PEN NEEDLES 31GX 6MM NC WEGMANS UNIFINE RX/OTC MISC PENTIPS NC PLUS/SHORT/31GX8MM VALUMARK PEN RX/OTC MISC NEEDLES 31GX 8MM NC MISC WEGMANS UNIFINE PENTIPS PLUS/ULTRA NC VANISHPOINT INSULIN SHORT/31GX6MM MISC SYRINGE/0.5ML/30G X NC 1/2" MISC ZEVRX PEN NEEDLES NC 31G X 6MM MISC VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 5 MIGRAINE PRODUCTS - Drugs to Treat Migraine 3/16" MISC Headaches VANISHPOINT INSULIN RX/OTC Calcitonin Gene-Related Peptide (CGRP) SYRINGE/0.5ML/30G X NC PA; SP 5/16" MISC AIMOVIG SOAJ 4 VANISHPOINT INSULIN RX/OTC PA; SP SYRINGE/1ML/29G X 1/2" NC AJOVY SOAJ 4 MISC AJOVY SOSY 4 PA; SP VANISHPOINT INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 5 PA; SP 5/16" MISC EMGALITY SOAJ 4

264 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMGALITY SOSY 4 PA; SP MIGRANAL SOLN (Use QL(0.27 ml dihydroergotamine 5 daily) NURTEC TBDP 4 mesylate) Serotonin Agonists UBRELVY TABS 4 QL(0.2 ea SP 2 daily); AL(At VYEPTI SOLN NC almotriptan malate tabs least 12 yrs old) Migraine Combinations QL(0.3 ea CAFERGOT TABS (Use NC AMERGE TABS (Use 5 daily); AL(At ergotamine w/ caffeine) naratriptan hcl) least 18 yrs old) ergotamine w/ caffeine NC supp QL(0.2 ea ergotamine w/ caffeine tabs NC eletriptan hydrobromide 2 daily); AL(At tabs least 18 yrs old) MIGRAINE PACK THPK NC QL(0.3 ea MIGRANOW THPK NC FROVA TABS (Use 5 daily); AL(At frovatriptan succinate) least 18 yrs SUMANSETRON TBPK NC old) QL(0.3 ea sumatriptan-naproxen QL(0.3 ea NC 2 daily); AL(At sodium tabs daily) frovatriptan succinate tabs least 18 yrs TREXIMET TABS (Use QL(0.3 ea old) sumatriptan-naproxen NC daily) QL(0.2 ea sodium) IMITREX SOLN NA 20 daily); AL(At MG/ACT, 5 MG/ACT (Use 5 Migraine Products - NSAIDs sumatriptan) least 18 yrs old) CAMBIA PACK NC IMITREX SOLN SC 6 QL(0.134 ml MG/0.5ML (Use 5 daily,4 ml per Migraine Products sumatriptan succinate) 30 days retail) D.H.E. 45 SOLN (Use IMITREX STATDOSE QL(0.134 ml dihydroergotamine 4 REFILL SOCT 4 MG/0.5ML 5 daily,4 ml per mesylate) (Use sumatriptan 30 days retail) DIHYDROERGOTAMINE 5 succinate) MESYLATE CRYS XX IMITREX STATDOSE QL(0.134 ml DIHYDROERGOTAMINE 5 REFILL SOCT 6 MG/0.5ML 5 daily) MESYLATE POWD XX (Use sumatriptan succinate) dihydroergotamine 2 mesylate soln ij 1 mg/ml IMITREX STATDOSE QL(0.134 ml SYSTEM SOAJ (Use 5 daily,4 ml per dihydroergotamine NC QL(0.27 ml mesylate soln na 4 mg/ml daily) sumatriptan succinate) 30 days retail) IMITREX TABS OR 50 MG, QL(0.3 ea dihydroergotamine NC mesylate soln na 4 mg/ml 100 MG, 25 MG (Use 5 daily) sumatriptan succinate) ERGOMAR SUBL 5 QL(0.6 ea MAXALT TABS (Use NC daily); AL(At ERGOTAMINE TARTRATE 5 rizatriptan benzoate) POWD least 6 yrs old) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

265 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.4 ea QL(0.2 ea MAXALT-MLT TBDP (Use NC daily); AL(At rizatriptan benzoate) daily); AL(At zolmitriptan soln na 2.5 mg, 2 least 6 yrs old) 5 mg least 12 yrs QL(0.3 ea old) daily); AL(At QL(0.2 ea naratriptan hcl tabs 2 least 18 yrs zolmitriptan tabs or 2.5 mg, 2 daily); AL(At old) 5 mg least 12 yrs ST; QL(16 ea old) ONZETRA XSAIL EXHP 4 per 30 days QL(0.2 ea retail) zolmitriptan tbdp or 2.5 mg, 2 daily); AL(At QL(0.2 ea 5 mg least 12 yrs old) RELPAX TABS (Use 5 daily); AL(At eletriptan hydrobromide) least 18 yrs QL(0.2 ea old) ZOMIG SOLN NA 2.5 MG, NC daily); AL(At 5 MG (Use zolmitriptan) least 12 yrs REYVOW TABS 4 old) QL(0.6 ea QL(0.2 ea rizatriptan benzoate tabs 2 daily); AL(At ZOMIG TABS OR 2.5 MG, daily); AL(At 10 mg, 5 mg 5 least 6 yrs old) 5 MG (Use zolmitriptan) least 12 yrs QL(0.4 ea old) rizatriptan benzoate tbdp 2 daily); AL(At QL(0.2 ea 10 mg, 5 mg least 6 yrs old) ZOMIG ZMT TBDP (Use 5 daily); AL(At QL(0.2 ea zolmitriptan) least 12 yrs old) sumatriptan soln na 20 2 daily); AL(At mg/act, 5 mg/act least 18 yrs MINERALS & ELECTROLYTES old) QL(0.134 ml Bicarbonates sumatriptan succinate soaj 2 daily,4 ml per sc 4 mg/0.5ml, 6 mg/0.5ml SODIUM ACETATE 5 30 days retail) ANHYDROUS CRYS QL(0.134 ml SODIUM ACETATE RX/OTC sumatriptan succinate soct 2 daily,4 ml per 5 sc 4 mg/0.5ml ANHYDROUS POWD 30 days retail) SODIUM ACETATE SOLN 5 sumatriptan succinate soct 2 QL(0.134 ml 2 MEQ/ML sc 6 mg/0.5ml daily) sodium acetate soln 2 5 QL(0.134 ml meq/ml sumatriptan succinate soln 2 daily,4 ml per sc 6 mg/0.5ml SODIUM ACETATE SOLN 30 days retail) 2 MEQ/ML (Use sodium 5 sumatriptan succinate sosy 2 QL(4 ml per 30 acetate) sc 6 mg/0.5ml days retail) sodium acetate soln 4 2 sumatriptan succinate tabs 2 QL(0.3 ea meq/ml or 50 mg, 100 mg, 25 mg daily) SODIUM ACETATE 5 TOSYMRA SOLN NC TRIHYDRATE GRAN SODIUM BICARBONATE 5 ST; QL(4 ml SOLN IJ 8.4 % ZEMBRACE SYMTOUCH 4 per 30 days SOAJ retail) sodium bicarbonate soln iv 2 4.2 %, 7.5 %, 8.4 %

266 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM BICARBONATE 2 CALCIUM PHOSPHATE 5 SOLN IV 8.4 % DIBASIC POWD SODIUM CALCIUM PHOSPHATE 5 RX/OTC BICARBONATE/DEXTROS NC TRIBASIC POWD E SOLN CALCIUM-FOLIC ACID 5 SODIUM LACTATE SOLN 5 PLUS D WAFR Electrolyte Mixtures THAM SOLN 5 DEXTROSE 5%/ELECTROLYTE #48 5 Calcium VIAFLEX SOLN CALCIFOL WAFR 5 DEXTROSE 10%/NACL 5 0.2% SOLN CALCIUM CARBONATE 5 RX/OTC EXTRA LIGHT POWD DEXTROSE 2.5%/NACL 0.45% SOLN (Use 2 CALCIUM CARBONATE 5 RX/OTC dextrose w/ sodium HEAVY POWD chloride) CALCIUM CARBONATE RX/OTC 5 DEXTROSE 5%/NACL 5 LIGHT POWD 0.3% SOLN CALCIUM CARBONATE 5 RX/OTC DEXTROSE 5%/NACL POWD 0.3% SOLN (Use dextrose 5 calcium chloride (dihydrate) 2 w/ sodium chloride) soln dextrose in lactated ringers 2 CALCIUM CHLORIDE 5 soln ANHYDROUS GRAN dextrose w/ sodium CALCIUM CHLORIDE 5 chloride soln 0.2 %-5 %, DIHYDRATE GRAN 0.45 %-10 %, 0.45 %-2.5 2 %, 0.33 %-5 %, 0.9 %-5 %, CALCIUM CHLORIDE 5 DIHYDRATE POWD 0.225 %-5 %, 5 %-0.225 % dextrose w/ sodium CALCIUM CHLORIDE 5 5 SOLN chloride soln 0.3 %-5 % DEXTROSE/SODIUM CALCIUM GLUCONATE 5 RX/OTC ANHYDROUS POWD CHLORIDE SOLN (Use 5 dextrose w/ sodium CALCIUM GLUCONATE 5 RX/OTC chloride) MONOHYDRATE POWD ELLIOTTS B SOLN 5 CALCIUM GLUCONATE 5 RX/OTC POWD XX IONOSOL-MB/DEXTROSE calcium gluconate soln iv 2 5% SOLN 3 MEQ/L-3 MEQ/L-5 %-20 MEQ/L-22 CALCIUM GLUCONATE 4 MEQ/L-23 MEQ/L-25 5 SOLN IV MEQ/L, 3 MEQ/L-3 CALCIUM MMOLE/L-5 %-20 MEQ/L- GLUCONATE/SODIUMCH NC 22 MEQ/L-23 MEQ/L-25 LORIDE SOLN MEQ/L ISOLYTE-P/DEXTROSE CALCIUM LACTATE 5 5 PENTAHYDRATE POWD 5% SOLN ISOLYTE-S PH 7.4 SOLN 5

267 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOLYTE-S SOLN 5 POTASSIUM CHLORIDE/SODIUM CHLORIDE SOLN 0.9 %- KCL 0.15%/D5W/NACL 5 NC 0.225% SOLN 10 MEQ/100ML, 0.9 %-40 MEQ/250ML, 0.9 %-40 KCL 0.3%/D5W/NACL 5 0.9% SOLN MEQ/500ML POTASSIUM lactated ringer's soln 2 CHLORIDE/SODIUM CHLORIDE SOLN 0.9 %- 2 NORMOSOL -R SOLN 5 40 MEQ/L, 0.45 %-20 MEQ/L (Use potassium NORMOSOL-M IN D5W 5 chloride in nacl) SOLN POTASSIUM NORMOSOL-M/D5W 5 CHLORIDE/SODIUMCHLO NC SOLN RIDE SOLN NORMOSOL-R IN D5W 5 SOLN ringer's soln 2

NORMOSOL-R SOLN 5 TPN ELECTROLYTES 5 CONC NORMOSOL-R/5% 5 DEXTROSE SOLN Fluoride parenteral electrolytes conc 2 FLORIVA LIQD 5

PLASMA-LYTE A SOLN 5 FLUORABON SOLN 5 sodium fluoride chew or PLASMA-LYTE-148 SOLN 5 0.25 mg, 0.5 mg, 1 mg, 2.2 6 potassium chloride in mg dextrose & sodium chloride 2 sodium fluoride soln or 6 soln 0.125 mg/drop sodium fluoride soln or 0.25 potassium chloride in 2 2 dextrose soln mg/drop sodium fluoride soln or 0.5 RX/OTC potassium chloride in nacl 2 2 soln mg/ml POTASSIUM sodium fluoride tabs or 0.5 6 CHLORIDE/DEXTROSE 5 mg, 1 mg SOLN Iodine Products POTASSIUM iodine strong (lugol's) soln 2 CHLORIDE/DEXTROSE/L 5 ACTATED RINGERS SOLN Magnesium POTASSIUM MAGNESIUM RX/OTC CARBONATE HEAVY 5 CHLORIDE/LIDOCAINE NC HYDROCHLORIDE/SODIU POWD M CHLORIDE SOLN MAGNESIUM RX/OTC CARBONATE LIGHT 5 POWD MAGNESIUM CHLORIDE 5 HEXAHYDRATE CRYS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

268 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGNESIUM CHLORIDE 5 RX/OTC K-PHOS NEUTRAL TABS QL(8 ea daily) POWD XX (Use pot phosphate monobasic w/ sod 5 magnesium chloride soln ij 2 phosphate dibasic & MAGNESIUM SULFATE IN monobasic) D5W SOLN (Use 5 K-PHOS TABS 5 magnesium sulfate in dextrose) pot phosphate monobasic QL(8 ea daily) w/ sod phosphate dibasic & 2 magnesium sulfate in 2 dextrose soln monobasic tabs potassium phosphates soln magnesium sulfate soln ij 2 2 50 % 224 mg/ml-236 mg/ml MAGNESIUM SULFATE POTASSIUM SOLN IV 1000 MG/1.6ML, PHOSPHATES SOLN 45 2000 MG/3.2ML, 3000 NC MMOLE/15ML-71 NC MG/4.8ML, 4000 MEQ/15ML, 224 MG/ML- MG/6.4ML 236 MG/ML magnesium sulfate soln iv SODIUM PHOSPHATE/DEXTROSE NC 2 gm/50ml, 20 gm/500ml, 4 2 gm/100ml, 4 gm/50ml, 40 SOLN gm/1000ml SODIUM MAGNESIUM SULFATE PHOSPHATE/SODIUM NC SOLN IV 2 GM/50ML, 20 CHLORIDE SOLN GM/500ML, 4 GM/100ML, 5 sodium phosphates 4 GM/50ML, 40 (sodium phosphate dibasic 2 GM/1000ML (Use & monobasic) soln magnesium sulfate) SODIUM MAGNESIUM PHOSPHATES/DEXTROS NC SULFATE/DEXTROSE NC E SOLN SOLN Potassium MAGNESIUM SULFATE/LACTATED NC EFFER-K TBEF 5 RINGERS SOLN K-TAB TBCR 10 MEQ (Use 4 MAGNESIUM potassium chloride) SULFATE/SODIUMCHLOR NC IDE SOLN K-TAB TBCR 20 MEQ, 8 MEQ (Use potassium 5 Manganese chloride) manganese chloride soln 2 potassium acetate soln iv 2 manganese sulfate soln iv 2 POTASSIUM 5 BICARBONATE GRAN XX Phosphate POTASSIUM 5 BICARBONATE POWD XX GLYCOPHOS SOLN 5 potassium bicarbonate tbef 2 or potassium chloride cpcr or 2 10 meq, 8 meq

269 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM CHLORIDE 5 RX/OTC cupric chloride soln 2 GRAN XX potassium chloride CUPRIC SULFATE 5 microencapsulated crystals 2 PENTAHYDRATE GRAN er tbcr CUPRIC SULFATE POWD 5 RX/OTC potassium chloride pack or 2 20 meq MULTITRACE-4 5 NEONATAL SOLN POTASSIUM CHLORIDE 5 POWD XX MULTITRACE-4 5 POTASSIUM CHLORIDE PEDIATRIC SOLN SOLN IV 0.4 MEQ/ML, 10 MULTITRACE-4 SOLN 5 MEQ/100ML, 10 MEQ/50ML, 20 NC MULTITRACE-5 SOLN 5 MEQ/100ML, 20 MEQ/50ML, 40 selenious acid soln 40 2 MEQ/100ML mcg/ml potassium chloride soln iv SELENIOUS ACID SOLN NC 10 meq/100ml, 10 60 MCG/ML meq/50ml, 20 meq/100ml, NC THE LIQUILIFT TRACE NC 20 meq/50ml, 40 KIT KIT meq/100ml TRACE ELEMENTS 5 potassium chloride soln iv 2 4/PEDIATRIC SOLN 2 meq/ml trace minerals (cr-cu-mn- 2 potassium chloride soln or 2 se-zn) soln 20 %, 10 % trace minerals (cr-cu-mn- 2 potassium chloride tbcr or 2 zn) soln 20 meq, 10 meq, 8 meq TRALEMENT SOLN NC Sodium LIQUIVIDA HYDRATION NC Zinc KIT KIT GALZIN CAPS 5 sodium chloride flush soln 2 WILZIN CAPS 5 SODIUM CHLORIDE 5 RX/OTC GRAN XX zinc chloride soln iv 2 SODIUM CHLORIDE 5 POWD XX ZINC SULFATE 5 RX/OTC GRANULAR POWD sodium chloride soln ij 0.9 NC % ZINC SULFATE 5 HEPTAHYDRATE GRAN sodium chloride soln ij 2.5 2 meq/ml, 0.9 % ZINC SULFATE 5 RX/OTC sodium chloride soln iv 3 HEPTAHYDRATE POWD %, 5 %, 0.9 %, 4 meq/ml, 2 ZINC SULFATE 5 RX/OTC 0.45 % MONOHYDRATE POWD Trace Minerals ZINC SULFATE POWD XX 5 RX/OTC chromic chloride soln iv 2 zinc sulfate soln iv 3 mg/ml, 2 1 mg/ml, 5 mg/ml

270 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHYMOTRYPSIN ALPHA 5 MISCELLANEOUS THERAPEUTIC CLASSES POWD Chelating Agents HYLENEX SOLN 5 CUPRIMINE CAPS (Use NC penicillamine) VITRASE SOLN 5 D-PENAMINE TABS 5 XIAFLEX SOLR 5 PA; SP DEPEN TITRATABS TABS 5 (Use penicillamine) Immunomodulators PA; SP penicillamine caps or 2 REVLIMID CAPS 4 PA; SP penicillamine tabs or 5 THALOMID CAPS 4

SYPRINE CAPS (Use NC PA; SP Immunosuppressive Agents trientine hcl) ASTAGRAF XL CP24 5 trientine hcl caps 2 PA; SP ATGAM INJ 5 Continuous Renal Replacement Therapy (CRRT) QL(3 ea daily) PHOXILLUM B22K4/0 NC AZASAN TABS 4 SOLN AZATHIOPRINE POWD 5 PHOXILLUM BK4/2.5 NC XX SOLN AZATHIOPRINE SOLR IJ NC PRISMASOL B22GK 4/0 5 100 MG SOLN azathioprine tabs or 50 mg 2 PRISMASOL BGK 0/2.5 5 SOLN CELLCEPT CAPS (Use 4 PRISMASOL BGK 2/0 5 mycophenolate mofetil) SOLN CELLCEPT PA PRISMASOL BGK 2/3.5 5 INTRAVENOUS SOLR 5 SOLN (Use mycophenolate mofetil hcl) PRISMASOL BGK 4/0/1.2 5 SOLN CELLCEPT SUSR (Use 4 mycophenolate mofetil) PRISMASOL BGK 4/2.5 5 SOLN CELLCEPT TABS (Use 4 mycophenolate mofetil) PRISMASOL BK 0/0/1.2 5 SOLN cyclosporine caps or 100 2 mg, 25 mg TRISODIUM NC CITRATE/CRRT SOLN cyclosporine modified (for 2 Enzymes microemulsion) caps cyclosporine modified (for 2 AMPHADASE SOLN NC microemulsion) soln cyclosporine soln iv 50 BROMELAIN 1200 GDU 5 RX/OTC 2 POWD mg/ml BROMELAIN POWD 5 RX/OTC ENSPRYNG SOSY NC SP

271 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENVARSUS XR TB24 NC PA SANDIMMUNE CAPS OR 100 MG, 25 MG (Use 4 everolimus PV cyclosporine) (immunosuppressant) tabs 2 SANDIMMUNE SOLN IV 0.25 mg 50 MG/ML (Use 5 everolimus PA; PV cyclosporine) (immunosuppressant) tabs 2 SANDIMMUNE SOLN OR 5 0.5 mg, 0.75 mg 100 MG/ML PA; SP GAMIFANT SOLN 5 SIMULECT SOLR 5 IMURAN TABS (Use 4 azathioprine) sirolimus soln or 1 mg/ml 2 LUPKYNIS CAPS NC sirolimus tabs or 0.5 mg, 1 2 mg, 2 mg mycophenolate mofetil 2 tacrolimus caps or 0.5 mg, 2 caps or 250 mg 1 mg, 5 mg mycophenolate mofetil hcl 2 PA solr THYMOGLOBULIN SOLR 5 mycophenolate mofetil susr 2 UPLIZNA SOLN NC SP or 200 mg/ml ZORTRESS TABS 0.25 PV mycophenolate mofetil tabs 2 or 500 mg MG (Use everolimus NC (immunosuppressant)) mycophenolate sodium 2 PA tbec ZORTRESS TABS 0.5 MG, PA; PV 0.75 MG (Use everolimus 2 MYFORTIC TBEC (Use 4 PA mycophenolate sodium) (immunosuppressant)) NEORAL CAPS (Use ZORTRESS TABS 1 MG NC cyclosporine modified (for 4 microemulsion)) Irrigation Solutions NEORAL SOLN (Use irrigation solutions, 2 cyclosporine modified (for 4 physiological soln microemulsion)) lactated ringer's (irrigation) 2 soln NULOJIX SOLR 5 PA; SP ringer's irrigation soln 2 PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG (Use 5 water for irrigation, sterile 2 tacrolimus) soln PROGRAF PACK OR 0.2 NC Lymphatic Agents MG, 1 MG SYLVANT SOLR 5 PROGRAF SOLN IV 5 5 PA MG/ML Misc Natural Products RAPAMUNE SOLN 1 NC MG/ML (Use sirolimus) ACAI+SUPERFRUIT/GRE 5 EN TEA TABS RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use 4 APPLE CIDER VINEGAR 5 sirolimus) DIET TABS

272 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARTHRI-FLEX 5 HDL RX TABS 5 ADVANTAGE TABS HM GLUCOSAMINE BEAUTY & SKIN 5 THERAPY TABS CHONDROITIN COMPLEX 5 TABS BRAINSTRONG MEMORY 5 SUPPORT TABS HOT FLASHEX TABS 5 CHROMIUM PICOLINATE 5 FORTIFIED TABS LAXATIVE FORMULA 5 TABS CHROMIUM PICOLINATE/KELP/LECIT 5 LYDIA PINKHAM TABS 5 HIN/B-6/GRAPE FRUIT EXTRACT TABS METABO-STYLE TABS 5 CHROMIUM XTRA TABS 5 misc natural products tabs 5 COMPLETE MENOPAUSE 5 HEALTH FORMULA TABS MISEFLEX-C TABS 5 COMPLETE PROSTATE 5 HEALTHFORMULA TABS ORTHODIET TABS 5 CURCUMAX PRO TABS 5 OSTEO BI-FLEX ADVANCED DOUBLE 5 CVS GLUCOSAMINE STRENGTH WITH JOINT CHONDROITIN/MSM 5 SHIELD TABS TRIPLE STRENGTH TABS OSTEO BI-FLEX ESTROMINERAL TABS 5 ADVANCED TRIPLE 5 STRENGTH TABS FLEX-A-MIN DOUBLE OSTEO BI-FLEX STRENGTH PLUS MSM 5 ADVANCED WITH JOINT 5 TABS SHIELD TABS FLEX-A-MIN SUPER OSTEO BI-FLEX JOINT GLUCOSAMINE 2000 5 HEALTH TRIPLE 5 PLUS TABS STRENGTH TABS FLEX-A-MIN TRIPLE OSTEO BI-FLEX JOINT STRENGTH/BONE 5 SHIELD FORMULA WITH 5 SHIELD PLUS VITAMINS 5-LOXIN TABS K2/D3 TABS OSTEO BI-FLEX TRIPLE FLEX-A-MIN TRIPLE STRENGTH WITH 5- 5 STRENGTH/JOINT FLEX 5 LOXIN TABS PLUS VITAMIN D3 TABS OSTEO BI-FLEX/5-LOXIN GINKGO BILOBA XTRA 5 ADVANCED JOINT CARE 5 TABS TABS GLUCOSAMINE PANTETHINE PLUS TABS 5 CHONDROITIN COMPLEX 5 PLUS MSM/TRIPLE STRENGTH TABS PINEAPPA TABS 5 GLUCOSAMINE PMS FORMULA 5 CHONDROITIN TRIPLE 5 INDOLPLEX TABS STRENGTH TABS

273 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POWER-V TABS 5 DELFLEX-SM/2.5% 5 DEXTROSE SOLN PRO NUTRIENTS FRUIT 5 DIANEAL LOW & VEGGIE TABS CALCIUM/1.5%DEXTROS 5 E SOLN PYCNOGENOL COMPLEX 5 TABS DIANEAL LOW QC GLUCOSAMINE & CALCIUM/2.5%DEXTROS 5 CHONDROITIN TRIPLE 5 E SOLN STRENGTH/MSM TABS DIANEAL LOW 5 R.N.A. - 180 TABS 5 CALCIUM/4.25%DEXTRO SE SOLN RA ESTROPLUS MAX 5 DIANEAL PD-2/1.5% 5 STRENGTH TABS DEXTROSE SOLN RELAX & SLEEP TABS 5 DIANEAL PD-2/2.5% 5 DEXTROSE SOLN SEASONAL IC TABS 5 DIANEAL PD-2/4.25% 5 DEXTROSE SOLN SLEEP TONITE TABS 5 EXTRANEAL SOLN 5 SM GLUCOSAMINE peritoneal dialysis solutions 5 CHONDROITIN COMPLEX 5 soln TRIPLE STRENGTH TABS ULTRABAG/DIANEAL TOTAL MEMORY & 5 LOW CALCIUM/1.5% 5 FOCUS FORMULA TABS DEXTROSE SOLN URINOZINC PLUS TABS 5 ULTRABAG/DIANEAL LOW CALCIUM/2.5% 5 WABANA TABS 5 DEXTROSE SOLN ULTRABAG/DIANEAL Miscellaneous Therapeutic Classes LOW CALCIUM/4.25% 5 ADENOSINE-5- DEXTROSE SOLN MONOPHOSPHATE 5 ULTRABAG/DIANEAL PD- 5 POWD 2/1.5% DEXTROSE SOLN ADENOSINE-5- 5 ULTRABAG/DIANEAL PD- 5 TRIPHOSPHATE POWD 2/2.5% DEXTROSE SOLN NEXAVIR SOLN 5 ULTRABAG/DIANEAL PD- 2/4.25% DEXTROSE 5 PHENOL SOLN IJ 6 % NC SOLN Potassium Removing Agents Peritoneal Dialysis Solutions LOKELMA PACK 4 DELFLEX-LC/1.5% 5 DEXTROSE SOLN sodium polystyrene 2 QL(454 gm per DELFLEX-LC/2.5% 5 sulfonate powd fill retail) DEXTROSE SOLN sodium polystyrene 2 DELFLEX-LC/4.25% 5 sulfonate susp DEXTROSE SOLN VELTASSA PACK 4 DELFLEX-SM/1.5% 5 DEXTROSE SOLN

274 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Progeria Treatment Agents clotrimazole troc mt 2 ZOKINVY CAPS 5 PA; SP nystatin (mouth-throat) 2 QL(120 ml per susp fill retail) Prostaglandins ORAVIG TABS 5 alprostadil soln ij 2 Antiseptics - Mouth/Throat PROSTIN VR PEDIATRIC 5 SOLN (Use alprostadil) chlorhexidine gluconate 2 (mouth-throat) soln Sclerosing Agents DEBACTEROL SOLN 5 ASCLERA SOLN 5 PERIDEX SOLN (Use ETHAMOLIN SOLN 5 chlorhexidine gluconate 5 (mouth-throat)) POLYOXYL LAURYL NC ETHER SOLN Periodontal Products PA; SP sodium tetradecyl sulfate 5 ARESTIN MISC 5 soln iv 3 % Steroids - Mouth/Throat/Dental SOTRADECOL SOLN 5 triamcinolone acetonide 2 QL(5 gm per fill VARITHENA FOAM 5 (mouth) pste retail) Throat Products - Misc. Systemic Lupus Erythematosus Agents AQUORAL SOLN 5 RX/OTC BENLYSTA SOAJ SC 200 NC MG/ML artificial saliva lozg 5 RX/OTC BENLYSTA SOLR IV 120 5 PA; SP MG, 400 MG BIOTENE DRY MOUTH RX/OTC MOISTURIZING SPRAY 5 BENLYSTA SOSY SC 200 NC MG/ML SOLN MOUTH/THROAT/DENTAL AGENTS BOCASAL PACK 5 RX/OTC Anesthetics Topical Oral CAPHOSOL SOLN 5 RX/OTC benzocaine (dental) aero 2 cevimeline hcl caps 2 FIRST-MOUTHWASH BLM 5 CVS DRY MOUTH SPRAY 5 RX/OTC SUSP SOLN HURRICAINE AERO (Use RX/OTC NC EQL DRY MOUTH ORAL 5 RX/OTC benzocaine (dental)) RINSE SOLN lidocaine hcl (mouth-throat) QL(100 ml per 2 EVOXAC CAPS (Use 4 soln 2 % fill retail) cevimeline hcl) lidocaine hcl (mouth-throat) 2 soln 4 % GELCLAIR GEL 5 Anti-infectives - Throat MOI-STIR SOLN 5 RX/OTC AMPHOTERICIN B POWD 5 XX 905 UNIT/MG, MOUTH KOTE REMINT 5 RX/OTC SOLN

275 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOUTH KOTE SOLN 5 RX/OTC b-complex w/ c & folic acid QL(1 ea daily); caps 1 mg-1.5 mg-1.7 mg-5 RX/OTC MUCOSITISRX PACK NC mg-6 mcg-10 mg-20 mg- 100 mg-150 mcg, 5 mg-1 2 mg-1.5 mg-1.7 mg-6 mcg- NEUTRASAL PACK 5 10 mg-20 mg-100 mg-150 mcg NUMOISYN LIQD 5 RX/OTC b-complex w/ c & folic acid QL(1 ea daily); tabs 0.01 mcg-1 mg-1.5 RX/OTC NUMOISYN LOZG (Use 5 RX/OTC artificial saliva) mg-1.7 mg-10 mg-10 mg- 20 mg-60 mg-300 mcg, 1 ORAFATE PSTE 5 mg-1.5 mg-1.7 mg-6 mcg- 2 ORAL RELIEF SPRAY RX/OTC 10 mg-10 mg-20 mg-60 FOR DRYMOUTH & 5 mg-300 mcg, 1.5 mg-0.006 DISCOMFORT SOLN mg-0.3 mg-1 mg-1.7 mg-10 mg-10 mg-20 mg-100 mg pilocarpine hcl (oral) tabs 5 2 QL(6 ea daily) mg b-complex w/ c & folic acid RX/OTC tabs 0.5 mg-4 mg-5 mcg-15 2 pilocarpine hcl (oral) tabs 2 mg-15 mg-18 mg-100 mg- 7.5 mg 500 mg PROTHELIAL PSTE 5 b-complex w/ c & folic acid RX/OTC tabs 1 mg-1 mg-1.5 mg-1.5 RA DRY MOUTH SOLN 5 RX/OTC mg-1.7 mg-1.7 mg-6 mcg-6 mcg-10 mg-10 mg-10 mg- SALAGEN TABS 5 MG 4 QL(6 ea daily) 10 mg-20 mg-20 mg-100 (Use pilocarpine hcl (oral)) mg-100 mg-300 mcg-300 mcg, 1 mg-1 mg-1.5 mg- SALAGEN TABS 7.5 MG 4 (Use pilocarpine hcl (oral)) 1.7 mg-8 mg-20 mg-30 mcg-200 mg-300 mcg, 1 SALIVAMAX PACK 5 mg-1.5 mg-1.7 mg-6 mcg- NC 10 mg-10 mg-20 mg-100 XEROSTOMIA RELIEF 5 RX/OTC SPRAY SOLN mg-300 mcg, 1.5 mg-1.7 mg-5 mg-6 mcg-10 mg-20 MULTIVITAMINS mg-100 mg-150 mcg-1000 mcg, 1.5 mg-1.7 mg-6 mcg- B-Complex Vitamins 10 mg-10 mg-20 mg-100 mg-300 mcg-1000 mcg, 1.5 B-COMPLEX INJ NC mg-1.7 mg-6 mcg-10 mg- 10 mg-20 mg-300 mcg- b-complex vitamins inj 2 1000 mcg-100 mg VITAMIN B b-complex w/ c & folic acid COMPLEX/HYDROXOCO NC tabs 1 mg-1.5 mg-1.5 mg-5 2 BALAMIN INJ mg-10 mg-20 mg-50 mg-60 mg-300 mcg B-Complex w/ Folic Acid b-complex w/ c & folic acid RX/OTC ACTRIVIT LIQD 5 tabs 1 mg-1.5 mg-1.5 mg-5 NC mg-10 mg-20 mg-50 mg-60 mg-300 mcg b-complex w/ c-biotin- 2 minerals & folic acid tabs

276 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIALYVITE 3000 TABS 5 MULTIVITAMIN WITH RX/OTC FLUORIDE CHEW 1.05 DIALYVITE 5000 TABS 5 MG-0.25 MG-0.3 MG-1.05 NC MG-1.2 MG-4.5 MCG-13.5 MG-15 UNIT-60 MG-400 DIALYVITE/ZINC TABS 5 UNIT-2500 UNIT FOLIC-K CAPS NC MULTIVITAMIN/FLUORID NC RX/OTC E CHEW FOLICA-BE CAPS NC Multiple Vitamins w/ Calcium

FOLICA-V CAPS NC ADVANCED AM/PM MISC 5 Multiple Vitamins w/ Minerals & Calcium-Folic Acid NEPHPLEX RX TABS 5 FOLGARD OS TABS 5 NUTRIVIT LIQD 5 RX/OTC TL G-FOL OS TABS 5 RENATABS TABS 5 Multiple Vitamins w/ Minerals & Fluoride-Iron-Folic RENATABS WITH IRON 5 MISC QUFLORA FE CHEW NC SUPERVITE LIQD 5 Multiple Vitamins w/ Minerals AIRBORNE+NATURAL 5 RX/OTC VITAL-D RX TABS 5 ENERGY LIQD Bioflavonoid Products ALIVE MULTI-VITAMIN 5 RX/OTC LIQD ADRENAL C FORMULA 5 RX/OTC TABS BACMIN TABS 5 RX/OTC ADVANCED C PLUS 5 RX/OTC TABS BIOSUPP LIQD 5 RX/OTC RX/OTC bioflavonoid products tabs 5 BIOTECT PLUS LIQD 5 RX/OTC PERIDIN-C TABS (Use 5 RX/OTC BURIED TREASURE RX/OTC bioflavonoid products) ACTIVE 55PLUS SENIOR 5 Iron w/ Vitamins COMPLEX LIQD RX/OTC CENTRUM LIQD (Use RX/OTC iron w/ vitamins tabs 5 multiple vitamins w/ 5 Multiple Vitamins & Fluoride-Folic Acid minerals) MULTIVITAMIN WITH CENTRUM SILVER RX/OTC FLUORIDE CHEW 0.3 MG- 50+WOMEN TABS (Use NF 0.5 MG-1.05 MG-1.05 MG- multiple vitamins w/ 1.2 MG-4.5 MCG-13.5 MG- minerals) CORVITE TABS (Use 15 UNIT-60 MG-400 UNIT- NC 2500 UNIT, 0.3 MG-1 MG- multiple vitamins w/ 5 1.05 MG-1.05 MG-1.2 MG- minerals & folic acid) 4.5 MCG-13.5 MG-15 DAYAVITE TABS NC RX/OTC UNIT-60 MG-400 UNIT- 2500 UNIT DERMACINRX NC RX/OTC ZINTREXYL-C TABS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

277 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIALYVITE SUPREME D 5 multiple vitamins w/ RX/OTC TABS minerals liqd 1.5 mg/15ml- RX/OTC 1.7 mg/15ml-2 mg/15ml-2 FOLITIN-Z TABS NC mg/15ml-3 mg/15ml-6 RX/OTC mcg/15ml-9 mg/15ml-10 FORTAVIT CAPS 5 mg/15ml-20 mg/15ml-25 RX/OTC mcg/15ml-25 mcg/15ml-30 FORTAVIT LIQD 5 unit/15ml-60 mg/15ml-150 RX/OTC mcg/15ml-300 mcg/15ml, HYLAZINC TABS NC 1.5 mg/15ml-1.7 mg/15ml-2 mg/15ml-2 mg/15ml-3 MULTI-VITE LIQD 5 RX/OTC mg/15ml-6 mcg/15ml-9 mg/15ml-10 mg/15ml-20 multiple vitamins w/ 2 mg/15ml-25 mcg/15ml-25 minerals & folic acid tabs mcg/15ml-30 unit/15ml-60 multiple vitamins w/ RX/OTC mg/15ml-150 mcg/15ml- minerals caps 1 mg-2 mg-2 300 mcg/15ml-1000 mg-3 mg-5 mg-6 mg-7 mg- NC unit/15ml-1300 unit/15ml, 10 mcg-10 mcg-25 mg-30 1.5 mg/15ml-1.7 mg/15ml-2 mg-30 mg-32 mg-300 mcg- mg/15ml-2 mg/15ml-3 315 mg-1000 mcg mg/15ml-6 mcg/15ml-9 multiple vitamins w/ RX/OTC mg/15ml-10 mg/15ml-20 minerals caps 1 mg-2 mg-4 mg/15ml-25 mcg/15ml-25 mg-5 mg-10 mcg-10 mg-10 mcg/15ml-30 unit/15ml-60 mg-25 mg-50 unit-70 mg- mg/15ml-150 mcg/15ml- 80 mg-150 mg-8000 unit, 5 2 300 mcg/15ml-400 5 mg-1 mg-2 mg-4 mg-10 unit/15ml-1300 unit/15ml, mcg-10 mg-10 mg-25 mg- 15 mg/15ml-2.25 mg/15ml- 50 unit-70 mg-80 mg-150 2.55 mg/15ml-3 mg/15ml- mg-8000 unit 15 mg/15ml-18 mcg/15ml- 37 mg/15ml-45 mg/15ml-45 unit/15ml-75 mg/15ml-90 mg/15ml-112.5 mcg/15ml- 150 mcg/15ml-300 mcg/15ml-600 unit/15ml- 5250 unit/15ml, 2 mg/15ml- 1.5 mg/15ml-1.7 mg/15ml-2 mg/15ml-3 mg/15ml-6 mcg/15ml-9 mg/15ml-10 mg/15ml-20 mg/15ml-25 mcg/15ml-30 unit/15ml-60 mg/15ml-150 mcg/15ml- 250 mcg/15ml-300 mcg/15ml-400 unit/15ml, 2 mg/15ml-10 mg/15ml-15 mcg/15ml-15 mg/15ml-15 mg/15ml-50 mcg/15ml-50 mg/15ml-50 mg/15ml-50 mg/15ml-50 mg/15ml-150 mcg/15ml-800 mcg/15ml- 1000 mg/15ml-5000 unit/15ml, 2.5 unit/5ml-5 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

278 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg/5ml-5 mg/5ml-7.5 multiple vitamins w/ RX/OTC mg/5ml-7.5 mg/5ml-10 minerals tabs 0.1 mg-0.15 mg/5ml-12.5 mg/5ml-25 mg-0.8 mg-3 mg-5 mg-20 mcg/5ml-75 mg/5ml-100 mg-20 mg-22.5 mg-25 mg- unit/5ml-200 mcg/5ml-225 25 mg-27 mg-30 unit-50 mg/5ml-750 mcg/5ml-2500 mcg-50 mg-100 mg-500 unit/5ml-250 mg/5ml-25 mg-5000 unit, 1 mg-10 mg- mcg/5ml 25 mg-25 mg-25 mg-25 mg-33 mg-50 mcg-50 mg- 60 mg-100 unit-125 mg- 200 unit-300 mcg-500 mg- 5000 unit, 2.5 mg-5 mg-20 mg-20 mg-20 mg-25 mg-25 mg-50 mcg-50 mcg-50 mg- 50 unit-66 mg-100 mg-200 mcg-200 mcg-400 unit-500 mg-1000 mcg-5000 unit, 25 mg-1 mg-10 mg-25 mg-25 mg-33 mg-50 mg-100 unit- 25 mg-50 mcg-80 mg-125 mg-200 unit-300 mcg-500 mg-5000 unit, 3 mg-0.05 2 mg-0.15 mg-1 mg-10 mg- 20 mg-15 mg-20 mcg-20 mg-25 mg-25 mg-50 mcg- 50 mcg-50 mg-60 unit-100 mg-400 unit-500 mg, 5 mcg-0.667 mg-1.667 mg- 3.333 mg-5 mg-5 mg- 16.667 mcg-16.667 mg- 16.667 mg-16.667 mg- 16.667 mg-26.667 mg- 33.333 mcg-50 mcg-66.667 mg-66.667 mg-66.667 unit- 133.333 mg-133.333 mg- 133.333 unit-166.667 mg- 333.333 mcg-333.333 mg- 1666.667 unit, 5 mg-1 mg- 1.25 mg-3.4 mg-10 mg-25 mg-35 mg-35 mg-35 mg-35 mg-35 mg-70 mcg-75 mcg- 125 mcg-125 mcg-125 unit- 150 mcg-400 mcg-400 unit- 500 mg NEOVITE TABS NC RX/OTC

NICADAN TABS NC RX/OTC

NICAZEL FORTE TABS NC RX/OTC

279 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUTRICAP TABS 5 RX/OTC VITAROCA PLUS TABS RX/OTC (Use multiple vitamins w/ 5 OCUVEL CAPS 5 minerals) VITRANOL FE TABS NC RX/OTC ONEVITE TABS 5 VITRANOL TABS NC RX/OTC REMEDIENT CAPS NC VITREXATE FE TABS NC RX/OTC REQ 49+ TABS 5 RX/OTC VITREXATE TABS NC RX/OTC SIDEROL TABS 5 RX/OTC NC RX/OTC STROVITE FORTE SYRP VITREXYL TABS 1 MG/15ML-3 MG/15ML-5 RX/OTC MG/15ML-10 MG/15ML-15 VITREXYL/IRON TABS NC MG/15ML-15 MG/15ML-17 RX/OTC MG/15ML-20 MCG/15ML- ZYVANA CAPS NC 20 MG/15ML-25 MG/15ML- 30 UNIT/15ML-50 5 Multivitamins MCG/15ML-50 MG/15ML- FOLIKA-V TABS NC 55 MCG/15ML-100 MG/15ML-150 MCG/15ML- GENICIN VITA-Q TABS NC 300 MG/15ML-400 UNIT/15ML-4000 INFUVITE ADULT INJ 5 UNIT/15ML STROVITE FORTE TABS RX/OTC M.V.I. ADULT INJ 5 15 MG-0.1 MG-0.8 MG-3 MG-10 MG-0.15 MG-20 multiple vitamin inj 5 MG-20 MG-25 MCG-25 MG-25 MG-50 MCG-50 5 VITAXYME TABS NC MCG-50 MG-60 UNIT-100 MG-500 MG-1000 UNIT- VITAZYME TABS NC 3000 UNIT (Use multiple vitamins w/ minerals) Ped MV w/ Fluoride STROVITE ONE TABS 5 RX/OTC QL(50 ml per fill retail); FLORIVA PLUS SOLN 5 SUPPORT LIQD 5 RX/OTC AL(Up to 12 yrs old ); RX/OTC THRIVITE 19 TABS 5 QL(1 ea daily); MULTIVITAMIN + 5 FLUORIDE CHEW AL(Up to 12 yrs UDAMIN SP TABS 5 old ); RX/OTC

VENEXA FE TABS NC RX/OTC

VENEXA TABS NC RX/OTC

VENTRIXYL TABS 5

280 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multivitamins w/fl QL(1 ea daily); POLY-VI-FLOR FS STRP chew 0.25 mg-0.3 mg-1.05 AL(Up to 12 yrs 0.25 MG-0.4 MG-0.5 MG- mg-1.05 mg-1.2 mg-4.5 old ); RX/OTC 0.6 MG-5 UNIT-8 MG-200 mcg-13.5 mg-15 unit-60 MCG-400 UNIT, 0.4 MG- NC mg-400 unit-2500 unit, 0.25 0.5 MG-0.5 MG-0.6 MG-5 mg-1.05 mg-1.05 mg-1.2 UNIT-8 MG-200 MCG-400 mg-4.5 mcg-13.5 mg-15 UNIT unit-60 mg-300 mcg-400 POLY-VI-FLOR FS STRP unit-2500 unit, 0.3 mg-1 0.4 MG-0.5 MG-0.6 MG-1 5 mg-1.05 mg-1.05 mg-1.2 MG-5 UNIT-8 MG-200 mg-4.5 mcg-13.5 mg-15 MCG-400 UNIT unit-60 mg-400 unit-2500 2 unit, 1 mg-1.05 mg-1.05 POLY-VI-FLOR SUSP 0.25 5 mg-1.2 mg-4.5 mcg-13.5 MG/ML-200 MCG/ML mg-15 unit-60 mg-300 QL(1 ea daily); QUFLORA GUMMIES NC AL(Up to 12 yrs mcg-400 unit-2500 unit, 0.3 CHEW mg-0.5 mg-1.05 mg-1.05 old ) mg-1.2 mg-4.5 mcg-13.5 QUFLORA PEDIATRIC QL(1 ea daily); mg-15 unit-60 mg-400 unit- CHEW 0.25 MG-1 MG-1.2 AL(Up to 12 yrs 2500 unit, 0.5 mg-1.05 mg- MG-1.3 MG-1.5 MG-4 old ); RX/OTC 1.05 mg-1.2 mg-4.5 mcg- MCG-5 MG-15 MG-15 13.5 mg-15 unit-60 mg-300 UNIT-60 MG-100 MCG-108 mcg-400 unit-2500 unit MCG-400 UNIT-1200 pediatric multivitamins w/fl QL(50 ml per UNIT, 1 MG-1 MG-1.2 MG- soln 0.4 mg/ml-0.5 mg/ml- fill retail); 1.3 MG-1.5 MG-4 MCG-5 5 0.5 mg/ml-0.6 mg/ml-2 AL(Up to 12 yrs MG-15 MG-15 UNIT-60 mcg/ml-5 unit/ml-8 mg/ml- old ); RX/OTC MG-100 MCG-108 MCG- 35 mg/ml-400 unit/ml-1500 400 UNIT-1200 UNIT, 0.5 unit/ml, 0.25 mg/ml-0.4 MG-1 MG-1.2 MG-1.3 MG- 1.5 MG-4 MCG-5 MG-15 mg/ml-0.5 mg/ml-0.6 2 mg/ml-2 mcg/ml-5 unit/ml-8 MG-15 UNIT-60 MG-100 mg/ml-35 mg/ml-400 MCG-108 MCG-400 UNIT- unit/ml-1500 unit/ml, 0.25 1200 UNIT mg/ml-2 mcg/ml-5 unit/ml- QUFLORA PEDIATRIC QL(50 ml per 0.4 mg/ml-0.5 mg/ml-0.6 SOLN 0.5 MG/ML-1 fill retail); mg/ml-8 mg/ml-35 mg/ml- MG/ML-1 MG/ML-1 AL(Up to 12 yrs 400 unit/ml-1500 unit/ml MG/ML-1 MG/ML-2 old ); RX/OTC pediatric vitamins acd w/ QL(50 ml per MG/ML-3 MCG/ML-12 MG/ML-12 UNIT/ML-45 fluoride soln 0.25 mg/ml-35 6 fill retail); mg/ml-400 unit/ml-1500 AL(Up to 12 yrs MG/ML-81 MCG/ML-150 unit/ml old ); RX/OTC MCG/ML-400 UNIT/ML- 5 pediatric vitamins acd w/ QL(50 ml per 1100 UNIT/ML, 0.25 MG/ML-0.4 MG/ML-0.5 fluoride soln 0.5 mg/ml-35 6 fill retail); mg/ml-400 unit/ml-1500 AL(Up to 12 yrs MG/ML-0.6 MG/ML-0.8 unit/ml old ) MG/ML-1 MG/ML-2 MCG/ML-5 UNIT/ML-10 POLY-VI-FLOR CHEW QL(6 ea per fill MG/ML-35 MCG/ML-35 0.25 MG-15 UNIT-200 retail) MG/ML-65 MCG/ML-400 MCG-400 UNIT, 0.5 MG-15 5 UNIT/ML-1000 UNIT/ML UNIT-200 MCG-400 UNIT, 1 MG-15 UNIT-200 MCG- TRI-VI-FLOR SUSP 5 400 UNIT 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

281 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRI-VI-FLORO SUSP 5 ATABEX EC TBEC NC

Ped Multi Vitamins w/Fl & FE ATABEX OB TABS NC ESCAVITE CHEW 5 AZESCHEW PRENATAL/POSTNATAL NC ESCAVITE D CHEW 5 CHEW ped multivitamins w/fl & AL(Up to 12 yrs AZESCO TABS NC iron liqd 0.25 mg/ml-0.4 old ) mg/ml-0.5 mg/ml-0.6 BAL-CARE DHA MISC NC mg/ml-0.9 mcg/ml-6 mg/ml- 6 7.5 unit/ml-8 mg/ml-35 C-NATE DHA CAPS NC mg/ml-400 unit/ml-1500 unit/ml CITRANATAL 90 DHA 4 ped multivitamins w/fl & QL(50 ml per MISC iron soln 0.25 mg/ml-0.4 fill retail); CITRANATAL ASSURE 4 MISC mg/ml-0.5 mg/ml-0.6 6 AL(Up to 12 yrs mg/ml-5 unit/ml-8 mg/ml-10 old ); RX/OTC CITRANATAL B-CALM 4 AL(Up to 45 yrs mg/ml-35 mg/ml-400 MISC old ) unit/ml-1500 unit/ml CITRANATAL BLOOM 4 POLY-VI-FLOR/IRON QL(6 ea per fill DHA MISC CHEW 0.5 MG-10 MG-15 5 retail) CITRANATAL BLOOM 4 UNIT-200 MCG-400 UNIT TABS POLY-VI-FLOR/IRON CITRANATAL DHA MISC 4 AL(Up to 45 yrs SUSP 200 MCG/ML-0.25 5 old ) MG/ML-7 MG/ML CITRANATAL ESSENCE 4 QUFLORA FE PEDIATRIC NC THPK LIQD CITRANATAL HARMONY 4 AL(Up to 45 yrs TL-FLUORIVITE CHEW 5 CAPS old ) CITRANATAL MEDLEY 4 Ped Multiple Vitamins w/ Minerals CAPS AL(Up to 12 yrs AQUADEKS LIQD 4 CITRANATAL RX TABS 4 AL(Up to 45 yrs old ); RX/OTC old ) pediatric multiple vitamin w/ 2 AL(Up to 12 yrs RX/OTC minerals & c soln old ); RX/OTC CO-NATAL FA TABS NC

Pediatric Multiple Vitamins & Minerals w/ Fluoride COMPLETE NATAL DHA NC MISC FLORIVA CHEW 5 COMPLETENATE CHEW NC Pediatric Multiple Vitamins CONCEPT DHA CAPS NC INFUVITE PEDIATRIC 5 SOLN CONCEPT OB CAPS NC M.V.I. PEDIATRIC SOLR 5 CVS PRENATAL NC Prenatal Vitamins GUMMIES CHEW ALIVE PRENATAL MULTI- DERMACINRX NC VITAMIN/PLANT DHA NC PRETRATE TABS CHEW 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

282 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUET DHA 400 MISC NC NEONATAL/DHA MISC NC

DUET DHA BALANCED NC NESTABS DHA MISC NC MISC ENBRACE HR CAPS NC NESTABS ONE CAPS NC

FOLET DHA THPK NC NESTABS TABS NC

FOLET ONE CAPS NC NEXA PLUS CAPS NC RX/OTC FOLIVANE-OB CAPS NC NIVA-PLUS TABS NC JENLIVA O-CAL FA TABS NC RX/OTC PRENATAL/POSTNATAL NC CAPS O-CAL PRENATAL TABS NC KOSHER PRENATAL NC PLUS IRON TABS OB COMPLETE ONE NC CAPS M-NATAL PLUS TABS NC RX/OTC OB COMPLETE PETITE NC CAPS MARNATAL-F CAPS NC OB COMPLETE PREMIER NC TABS MYNATAL ADVANCE NC TABS OB COMPLETE TABS NC MYNATAL CAPS NC OB COMPLETE/DHA NC CAPS MYNATAL PLUS TABS NC OBSTETRIX DHA MISC NC RX/OTC MYNATAL ULTRACAPLET NC TABS OBSTETRIX EC TABS NC RX/OTC MYNATAL-Z TABS NC OBSTETRIX ONE CAPS NC MYNATE 90 PLUS TBCR NC OBTREX DHA MISC NC RX/OTC NATACHEW CHEW NC OBTREX TABS NC RX/OTC NATALVIT TABS NC ONE A DAY PRENATAL NC CHEW NATELLE ONE CAPS NC ONE VITE WOMENS RX/OTC NEEVO DHA CAPS NC PRENATALVITAMIN PLUS NC TABS NEONATAL 19 TABS NC PNV TABS 20-1 TABS NC NEONATAL COMPLETE NC RX/OTC TABS PNV TABS 29-1 TABS NC NEONATAL FE TABS NC PNV-DHA+DOCUSATE NC CAPS RX/OTC NEONATAL PLUS TABS NC PNV-OMEGA CAPS NC

283 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PR NATAL 400 EC MISC NC PRENATAL 19 TABS 1 RX/OTC MG-3 MG-3 MG-12 MCG- PR NATAL 400 MISC NC 15 MG-20 MG-20 MG-25 MG-29 MG-30 UNIT-400 UNIT-7 MG-100 MG-200 PR NATAL 430 EC MISC NC MG-1000 UNIT, 1 MG-3 NC MG-3 MG-7 MG-12 MCG- PR NATAL 430 MISC NC 15 MG-20 MG-20 MG-25 MG-29 MG-30 UNIT-100 PREGEN DHA CAPS NC MG-200 MG-400 UNIT- 1000 UNIT PREGENNA TABS NC PRENATAL ADULT GUMMY/DHA/FOLIC ACID NC PREMESISRX TABS NC CHEW PRENA 1 TRUE MISC NC PRENATAL PLUS IRON NC TABS PRENA1 CHEW CHEW NC PRENATAL TABS NC RX/OTC PRENA1 PEARL CPCR NC QL(1 ea daily); prenatal vit w/ docusate- 2 AL(Up to 45 yrs iron carbonyl-folic acid tabs PRENAISSANCE CAPS NC old ) prenatal vit w/ ferrous QL(1 ea daily); PRENAISSANCE PLUS NC fumarate-folic acid chew 6 AL(Up to 45 yrs CAPS mg-1 mg-3 mg-3 mg-7 mg- 2 old ) PRENARA CAPS NC 12 mcg-20 mg-20 mg-25 mg-29 mg-30 unit-100 mg- 200 mg-400 unit-1000 unit PRENATABS FA TABS NC RX/OTC prenatal vit w/ ferrous AL(Up to 45 yrs PRENATAL + COMPLETE fumarate-folic acid tabs 1 old ) MULTI/DHA/CHOLINE/FO NC mg-1.8 mg-2 mg-4 mg-12 LATE THPK mcg-20 mg-22 mg-25 mg- 2 25 mg-25 mg-28 mg-120 PRENATAL + DHA THPK NC mg-200 mg-400 unit-3000 PRENATAL 19 CHEW 1 unit MG-3 MG-3 MG-15 MG-20 prenatal vit w/ ferrous MG-20 MG-30 UNIT-100 fumarate-l methylfolate-folic 2 MG-7 MG-12 MCG-29 MG- acid tabs 200 MG-400 UNIT-1000 NC prenatal vit w/ iron AL(Up to 45 yrs UNIT, 1 MG-3 MG-3 MG-7 carbonyl-folic acid tabs 1 old ) MG-12 MCG-15 MG-20 mg-1.25 mg-2 mg-3.4 mg- 2 MG-20 MG-29 MG-30 10 mg-10 mg-10 mg-15 UNIT-100 MG-200 MG-400 mcg-15 mg-20 unit-50 mg- UNIT-1000 UNIT 120 mg-315 unit-2100 unit

284 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prenatal vit w/ iron QL(1 ea daily); PROVIDA DHA CAPS NC carbonyl-folic acid tabs 3 AL(Up to 45 yrs mg-1 mg-3 mg-3 mg-3 mg- old ) PROVIDA OB CAPS NC 7 mg-8 mcg-15 mg-20 mg- 2 29 mg-30 mcg-30 unit-100 mg-120 mg-150 mcg-200 R-NATAL OB CAPS NC mg-400 unit-4000 unit RELNATE DHA CAPS NC PRENATAL VITAMINS NC RX/OTC PLUS LOW IRON TABS SE-NATAL 19 CHEW 7 prenatal without a w/ fe MG-1 MG-3 MG-3 MG-12 fumarate-l methylfolate-fa- 2 MCG-15 MG-20 MG-20 NC dha caps MG-29 MG-30 UNIT-100 MG-200 MG-400 UNIT- PRENATAL-U CAPS NC 1000 UNIT SE-NATAL 19 TABS 1 MG- RX/OTC PRENATE AM TABS NC 3 MG-3 MG-7 MG-12 MCG-15 MG-20 MG-20 NC PRENATE CHEW NC MG-29 MG-30 UNIT-100 MG-200 MG-400 UNIT- PRENATE DHA CAPS NC 1000 UNIT PRENATE ELITE TABS NC SELECT-OB CHEW NC

PRENATE ENHANCE NC SELECT-OB+DHA MISC NC CAPS TARON-BC MISC NC PRENATE ESSENTIAL NC CAPS TARON-C DHA CAPS NC PRENATE MINI CAPS NC TARON-PREX CAPS NC PRENATE PIXIE CAPS NC THERANATAL CORE NC RX/OTC PRENATE RESTORE NC NUTRITION TABS CAPS THRIVITE RX TABS NC PRENATRIX TABS NC RX/OTC TL FOLATE TABS NC PRENATRYL TABS NC RX/OTC TL-CARE DHA CAPS NC PRENATVITE COMPLETE NC TABS TL-SELECT CAPS NC PRENATVITE PLUS TABS NC TRI-TABS DHA MISC NC PRENATVITE RX TABS NC RX/OTC TRICARE PRENATAL NC PREPLUS TABS NC RX/OTC DHA ONE CAPS TRICARE TABS NC RX/OTC PRETAB TABS NC RX/OTC TRINATAL RX 1 TABS NC PRIMACARE CAPS NC

285 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRINAZ TABS NC VITAMEDMD REDICHEW NC RX CHEW TRISTART DHA CAPS NC VITAPEARL CPCR NC

TRISTART FREE CAPS NC VITATHELY/GINGER NC RX/OTC TABS TRISTART ONE CAPS NC VITATRUE MISC NC

TRIVEEN-DUO DHA MISC NC VIVA DHA CAPS NC ULTIMATECARE ONE NC CAPS VOL-NATE TABS NC VENA-BAL DHA MISC NC VOL-PLUS TABS NC RX/OTC

VINATE DHA RF CAPS NC VOL-TAB RX TABS NC

VINATE II TABS NC VP-PNV-DHA CAPS NC

VINATE ONE TABS NC WESTAB PLUS TABS NC RX/OTC

VIRT-C DHA CAPS NC WESTGEL DHA CAPS NC

VIRT-NATE DHA CAPS NC ZALVIT TABS NC

VIRT-PN DHA CAPS NC ZATEAN-PN DHA CAPS NC

VIRT-PN PLUS CAPS NC ZATEAN-PN PLUS CAPS NC VITAFOL FE+ CAPS NC Specialty Vitamins Products ADRENAL STRESS CALM 4 RX/OTC VITAFOL FE+ CPPK NC TABS RX/OTC VITAFOL GUMMIES NC ADRENOID CAPS 5 CHEW ADVANCED COLLAGEN 4 RX/OTC VITAFOL STRIPS FILM NC TABS ALLERWELL ALLERGY 4 RX/OTC VITAFOL ULTRA CAPS NC FORMULA TABS VITAFOL-NANO TABS NC BILBERRY PLUS CAPS 5 RX/OTC

VITAFOL-OB TABS NC BIOTIN PLUS KERATIN 4 RX/OTC TABS VITAFOL-OB+DHA MISC NC BRAIN MIGHT/DHA & CO 4 RX/OTC Q10 TABS VITAFOL-ONE CAPS NC CARDIOPRESS CAPS 5 RX/OTC VITAMEDMD ONE NC CENTRUM 4 RX/OTC RX/QUATREFOLIC CAPS PERFORMANCE TABS

286 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SPECIALIST 4 RX/OTC LIPOTRIAD VISION 5 RX/OTC ENERGY TABS SUPPORT CAPS CHOLASE CONTROL 5 RX/OTC LIPOTRIAD VISION 5 RX/OTC CAPS SUPPORTPLUS CAPS COLLAGEN ULTRA CAPS 5 RX/OTC LIPOTRIAD VISIONARY 5 RX/OTC CAPS CVS HAIR/SKIN/NAILS 4 RX/OTC RX/OTC TABS METHYL-GUARD CAPS 5 ELON MATRIX 5000 4 RX/OTC METHYL-GUARD PLUS 5 RX/OTC TABS CAPS ELON MATRIX PLUS 4 RX/OTC MG PLUS PROTEIN TABS 4 RX/OTC TABS RX/OTC ELON MATRIX 5000 4 RX/OTC MIL ADREGEN TABS 4 COMPLETE TABS MM BIOTIN/KERATIN RX/OTC ELON MATRIX 4 RX/OTC 5 COMPLETE TABS CAPS RX/OTC ELON R3 TABS 4 RX/OTC NEW LIFE HAIR TABS 4 RX/OTC GLUCO COR CAPS 5 RX/OTC PRO HERS RX CAPS 5 RX/OTC GLYCOTROL CAPS 5 RX/OTC PRO HIS RX CAPS 5 RX/OTC GLYCOTROL COMPLETE 5 RX/OTC PRO PCOS RX CAPS 5 CAPS RA EAR CARE TABS 4 RX/OTC GNP CENTURY ENERGY 4 RX/OTC METABOLISM TABS RETAINE VISION CAPS 5 RX/OTC GREEN SOURCE TABS 4 RX/OTC specialty vitamins products 2 RX/OTC HAIR FARE TABS 4 RX/OTC tabs SUPPORT-500 CAPS 5 RX/OTC HAIR NOURISHING 4 RX/OTC SUPPLEMENT TABS SYNERTROPIN CAPS 5 RX/OTC HEALTHY HEART 4 RX/OTC COMPLEX TABS THERABETIC EYE 4 RX/OTC HEART SAVIOR CAPS 5 RX/OTC HEALTH TABS UPSPRING HE NATAL 4 RX/OTC HEART TABS TABS 4 RX/OTC TABS VISTA ADVANCED RX/OTC HM ESTROPLUS TABS 4 RX/OTC CAROTENOIID FORMULA 5 CAPS IMMUNERX CAPS 5 RX/OTC VITA-RX DIABETIC 5 RX/OTC VITAMIN CAPS IMMUNICARE CAPS 5 RX/OTC VITAMINS FOR THE HAIR 4 RX/OTC TABS INULOSE BLOOD SUGAR 5 RX/OTC SUPPORT CAPS Vitamin Mixtures LIPIDSHIELD PLUS TABS 4 RX/OTC

287 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COD LIVER OIL FOR KIDS 5 RX/OTC CHLORZOXAZONE TABS NC OIL 250 MG COD LIVER OIL OIL 5 RX/OTC chlorzoxazone tabs 375 NC mg, 500 mg, 750 mg niacinamide w/ zinc- copper-methylfolate-se-cr NC chlorzoxazone tabs 500 mg 2 tabs cyclobenzaprine hcl cp24 NC QL(1 ea daily) NICOMIDE TABS (Use or 15 mg, 30 mg niacinamide w/ zinc- NC cyclobenzaprine hcl tabs or 2 QL(3 ea daily) copper-methylfolate-se-cr) 10 mg, 5 mg NORWEGIAN COD LIVER RX/OTC 5 cyclobenzaprine hcl tabs or NC OIL OIL 7.5 mg RX/OTC QC COD LIVER OIL OIL 5 CYCLOPHENE NC RAPIDPAQ CREA RA COD LIVER OIL OIL 5 RX/OTC ENOVARX- CYCLOBENZAPRINE HCL 5 MUSCULOSKELETAL THERAPY AGENTS - CREA Drugs to Treat Spasms FIRST-BACLOFEN 1 NC Articular Cartilage Repair Therapy SUSP FIRST-BACLOFEN 5 CARTICEL IMPL 5 NC SUSP MACI SHEE NC SP GABLOFEN SOLN 10000 MCG/20ML, 40000 5 Central Muscle Relaxants MCG/20ML ACTIVE- GABLOFEN SOLN 20000 5 CYCLOBENZAPRINE KIT NC MCG/20ML (Use baclofen) CREA GABLOFEN SOSY 10000 MCG/20ML, 20000 AMRIX CP24 (Use NC QL(1 ea daily) 5 cyclobenzaprine hcl) MCG/20ML, 40000 MCG/20ML, 50 MCG/ML BACLOFEN POWD XX 5 LIORESAL INTRATHECAL PA; SP baclofen soln it 20000 SOLN 0.05 MG/ML, 10 5 mcg/20ml, 40 mg/20ml, 2 MG/5ML 500 mcg/ml LIORESAL INTRATHECAL SOLN 10 MG/20ML, 40 5 BACLOFEN SOLN XX 500 5 MG/125ML MG/20ML (Use baclofen) baclofen tabs or 10 mg, 20 2 metaxalone tabs 400 mg NC mg, 5 mg metaxalone tabs 800 mg 2 QL(4 ea daily) CARISOPRODOL POWD 5 XX methocarbamol soln ij 1000 2 carisoprodol tabs or 250 NC mg/10ml mg methocarbamol tabs or 500 NC carisoprodol tabs or 350 2 QL(4 ea daily) mg, 750 mg mg methocarbamol tabs or 500 2 carisoprodol tabs or 350 NC QL(4 ea daily) mg, 750 mg mg

288 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORPHENADRINE 5 dantrolene sodium solr iv 2 CITRATE POWD XX 20 mg orphenadrine citrate soln ij 2 RYANODEX SUSR 5 30 mg/ml, 60 mg/2ml orphenadrine citrate tb12 2 QL(2 ea daily) Muscle Relaxant Combinations or 100 mg carisoprodol w/ aspirin & 2 QL(8 ea daily) OZOBAX SOLN NC codeine tabs carisoprodol w/ aspirin tabs 2 QL(8 ea daily) ROBAXIN SOLN (Use 5 methocarbamol) CYCLO/GABA10/300 NC ROBAXIN-750 TABS (Use 4 PACK THPK methocarbamol) CYCLOPAK THPK NC SKELAXIN TABS (Use 4 QL(4 ea daily) metaxalone) METAXALL CP KIT NC SOMA TABS 250 MG (Use 5 QL(3 ea daily) carisoprodol) NOPIOID-LMC KIT THPK NC SOMA TABS 350 MG (Use 5 QL(4 ea daily) carisoprodol) NOPIOID-TC KIT THPK NC TABRADOL FUSEPAQ NC SUSP NORGESIC FORTE TABS (Use orphenadrine w/ NC TABRADOL RAPIDPAQ NC aspirin & caff) SUSP orphenadrine w/ aspirin & NC tizanidine hcl caps or 2 mg 2 caff tabs TIZANIDINE COMFORT 5 tizanidine hcl caps or 4 mg 2 QL(9 ea daily) PAC MISC tizanidine hcl caps or 6 mg 2 QL(6 ea daily) Viscosupplements HYRONAN KIT NC SP tizanidine hcl tabs or 4 mg, 2 2 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - ZANAFLEX CAPS 2 MG 5 Drugs to treat the Nose or Sinus (Use tizanidine hcl) Nasal Agent Combinations ZANAFLEX CAPS 4 MG 5 QL(9 ea daily) (Use tizanidine hcl) azelastine hcl-fluticasone 2 QL(0.77 gm propionate susp daily) ZANAFLEX CAPS 6 MG 5 QL(6 ea daily) (Use tizanidine hcl) DERMACINRX AZENASE NC PAK THPK ZANAFLEX TABS 4 MG 5 (Use tizanidine hcl) DYMISTA SUSP (Use QL(0.77 gm azelastine hcl-fluticasone 4 daily) Direct Muscle Relaxants propionate) DANTRIUM CAPS (Use 4 QL(4 ea daily) Nasal Agents - Misc. dantrolene sodium) ALZAIR ALLERGY DANTRIUM IV SOLR (Use 5 BLOCKER NASAL SPRAY NC dantrolene sodium) POWD dantrolene sodium caps or QL(4 ea daily) 2 DERMACINRX TICANASE NC 100 mg, 25 mg, 50 mg PAK THPK

289 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOZIN NASAL SANITIZER 5 QNASL CHILDRENS NC SWAB AERS Nasal Anesthetics SINUVA IMPL NC COCAINE NC HYDROCHLORIDE SOLN XHANCE EXHU 5 QL(1.07 ml daily) GOPRELTO SOLN NC ZETONNA AERS NC QL(0.3 gm daily) NUMBRINO SOLN NC Sympathomimetic Decongestants Nasal Antiallergy ADRENALIN SOLN NA 0.1 5 % azelastine hcl soln na 0.1 2 QL(1.2 ml %, 0.15 %, 137 mcg/spray daily) epinephrine hcl (nasal) soln 2 olopatadine hcl (nasal) soln 2 PHENYLEPHRINE HCL 5 CRYS PATANASE SOLN (Use 5 olopatadine hcl (nasal)) PHENYLEPHRINE HCL 5 RX/OTC POWD Nasal Anticholinergics PHENYLEPHRINE RX/OTC ipratropium bromide (nasal) 1 HYDROCHLORIDE POWD 5 soln XX Nasal Steroids PHENYLPROPANOLAMIN E HYDROCHLORIDE USP 5 BECONASE AQ SUSP NC QL(1.67 gm daily) POWD QL(0.6 ml PSEUDOEPHEDRINE budesonide (nasal) susp 1 5 daily) HCL CRYS FLONASE ALLERGY QL(1.1 ml PSEUDOEPHEDRINE 5 HCL POWD RELIEF CHILDRENS 5 daily); RX/OTC SUSP (Use fluticasone NEUROMUSCULAR AGENTS - Drugs to propionate (nasal)) Relax/Paralyze Muscles FLONASE ALLERGY QL(1.1 ml ALS Agents RELIEF SUSP (Use 5 daily); RX/OTC fluticasone propionate EXSERVAN FILM NC SP (nasal)) PA; SP flunisolide (nasal) soln 2 RADICAVA SOLN 5 RILUTEK TABS (Use fluticasone propionate 2 QL(1.1 ml 5 (nasal) susp daily); RX/OTC riluzole) mometasone furoate 2 QL(1.22 gm riluzole tabs 2 (nasal) susp daily) NASONEX SUSP (Use QL(1.22 gm TIGLUTIK SUSP NC mometasone furoate 5 daily) (nasal)) Depolarizing Muscle Relaxants OMNARIS SUSP NC QL(0.42 gm ANECTINE SOLN 5 daily) QUELICIN SOLN (Use 5 QNASL AERS NC succinylcholine chloride)

290 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUCCINYLCHOLINE vecuronium bromide solr iv 2 CHLORIDE SOLN IJ 20 5 10 mg, 20 mg MG/ML VECURONIUM BROMIDE NC succinylcholine chloride SOSY IV 10 MG/10ML soln ij 20 mg/ml, 200 2 mg/10ml Spinal Muscular Atrophy Agents (SMA) PA; SP SUCCINYLCHOLINE EVRYSDI SOLR 5 CHLORIDE SOSY IJ 100 NC MG/5ML, 140 MG/7ML, SPINRAZA SOLN 5 PA; SP 200 MG/10ML ZOLGENSMA 10.1-10.5 5 PA; SP SUCCINYLCHOLINE KG KIT CHLORIDE SOSY IV 100 NC MG/5ML, 140 MG/7ML, ZOLGENSMA 10.6-11.0 5 PA; SP 200 MG/10ML KG KIT ZOLGENSMA 11.1-11.5 5 PA; SP Muscular Dystrophy Agents KG KIT AMONDYS 45 SOLN NC SP ZOLGENSMA 11.6-12.0 5 PA; SP KG KIT EXONDYS 51 SOLN 5 PA; SP ZOLGENSMA 12.1-12.5 5 PA; SP KG KIT VILTEPSO SOLN NC SP ZOLGENSMA 12.6-13.0 5 PA; SP KG KIT VYONDYS 53 SOLN NC ZOLGENSMA 13.1-13.5 5 PA; SP Neuromuscular Blocking Agent - Neurotoxins KG KIT PA; SP ZOLGENSMA 2.6-3.0 KG 5 PA; SP BOTOX SOLR 5 KIT PA; SP ZOLGENSMA 3.1-3.5 KG 5 PA; SP DYSPORT SOLR 5 KIT PA; SP MYOBLOC SOLN 5 ZOLGENSMA 3.6-4.0 KG 5 PA; SP KIT PA; SP XEOMIN SOLR 5 ZOLGENSMA 4.1-4.5 KG 5 PA; SP KIT Nondepolarizing Muscle Relaxants ZOLGENSMA 4.6-5.0 KG 5 PA; SP atracurium besylate soln 2 KIT ZOLGENSMA 5.1-5.5 KG 5 PA; SP cisatracurium besylate soln 2 KIT ZOLGENSMA 5.6-6.0 KG 5 PA; SP NIMBEX SOLN (Use 5 KIT cisatracurium besylate) ZOLGENSMA 6.1-6.5 KG 5 PA; SP pancuronium bromide soln 2 KIT ZOLGENSMA 6.6-7.0 KG PA; SP rocuronium bromide soln iv 2 5 100 mg/10ml, 50 mg/5ml KIT ROCURONIUM BROMIDE ZOLGENSMA 7.1-7.5 KG 5 PA; SP KIT SOSY IV 100 MG/10ML, NC 20 MG/2ML, 50 MG/5ML, ZOLGENSMA 7.6-8.0 KG 5 PA; SP 75 MG/7.5ML KIT

291 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOLGENSMA 8.1-8.5 KG 5 PA; SP SMOFLIPID EMUL 5 KIT ZOLGENSMA 8.6-9.0 KG 5 PA; SP Lipotropics KIT CHOLINE BITARTRATE 5 ZOLGENSMA 9.1-9.5 KG 5 PA; SP POWD KIT LECITHIN GRAN OR 5 RX/OTC ZOLGENSMA 9.6-10.0 KG 5 PA; SP KIT LECITHIN GRAN XX 5 RX/OTC NUTRIENTS LIPO SOLN NC Carbohydrates LIPO-C SOLN NC alcohol soln ij 98 % 2 MIC/L-CARNITINE SOLN NC DEXTROSE 20% SOLN 5 Misc. Nutritional Substances DEXTROSE 50% SOLN 2 CARDIOVID PLUS CAPS 5 DEXTROSE ANHYDROUS 5 RX/OTC POWD CYTOTINE POWD 5 DEXTROSE 5 RX/OTC MONOHYDRATE POWD Protein-Carbohydrate-Lipid Combinations DEXTROSE POWD XX 5 RX/OTC KABIVEN EMUL 5

DEXTROSE SOLN IV 20 5 PERIKABIVEN EMUL 5 %, 40 % dextrose soln iv 250 mg/ml, 2 Proteins 50 %, 10 %, 70 %, 5 % acetylcysteine (nutrient) 2 FRUCTOSE GRAN 5 RX/OTC caps ALANINE POWD 5 RX/OTC FRUCTOSE POWD 5 amino acid infusion soln 2 Lipids CLINOLIPID EMUL NC AMINO ACID SOLN NC RX/OTC DOJOLVI LIQD NC SP amino acids caps 2

INTRALIPID EMUL 20 NC AMINOPROTECT SOLN NC GM/100ML INTRALIPID EMUL 30 5 GM/100ML NEOKE MCT70 POWD NC RX/OTC

NUTRILIPID EMUL NC

OMEGAVEN EMUL NC

292 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMINOSYN II SOLN 172 AMINOSYN II SOLN 50 MG/100ML-200 MEQ/L-107.6 MEQ/L-258 MG/100ML-270 MG/100ML-300 MG/100ML-298 MG/100ML-405 MG/100ML-300 MG/100ML-447 MG/100ML-400 MG/100ML-450 MG/100ML-500 MG/100ML-600 MG/100ML-500 MG/100ML-750 MG/100ML-530 MG/100ML-750 MG/100ML-660 MG/100ML-795 5 MG/100ML-700 MG/100ML-990 MG/100ML-722 MG/100ML-1050 MG/100ML-738 MG/100ML-1083 MG/100ML-993 MG/100ML-1107 MG/100ML-1000 MG/100ML-1490 MG/100ML-1018 MG/100ML-1500 MG/100ML-1050 MG/100ML-1527 MG/100ML, 38 MEQ/L- 5 MG/100ML-1575 71.8 MEQ/L-172 MG/100ML (Use amino MG/100ML-200 acid infusion) MG/100ML-270 MG/100ML-298 AMINOSYN-PF 7% SOLN 5 MG/100ML-300 MG/100ML-400 AMINOSYN-PF SOLN 5 MG/100ML-500 MG/100ML-500 BCAA SOLN NC MG/100ML-530 MG/100ML-660 CALM SOLN NC MG/100ML-700 MG/100ML-722 CLINIMIX MG/100ML-738 4.25%/DEXTROSE 10% 5 MG/100ML-993 SOLN MG/100ML-1000 CLINIMIX MG/100ML-1018 4.25%/DEXTROSE 25% 5 MG/100ML-1050 SOLN MG/100ML CLINIMIX 4.25%/DEXTROSE 5% 5 SOLN CLINIMIX 5%/DEXTROSE 5 15% SOLN CLINIMIX 5%/DEXTROSE 5 20% SOLN CLINIMIX 5%/DEXTROSE 5 25% SOLN CLINIMIX 6/5 SOLN 5

CLINIMIX 8/10 SOLN 5

CLINIMIX 8/14 SOLN 5

293 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINIMIX E GABA SOLN NC 2.75%/DEXTROSE 10% 5 SOLN GLUTATHIONE (L) SOLN NC CLINIMIX E 2.75%/DEXTROSE 5% 5 GLUTATHIONE POWD 5 RX/OTC SOLN CLINIMIX E GLUTATHIONE NC 4.25%/DEXTROSE 10% 5 REDUCED SOLN SOLN GLUTATHIONE-L POWD 5 RX/OTC CLINIMIX E 4.25%/DEXTROSE 25% 5 GLUTATHIONE-L 5 RX/OTC SOLN REDUCED POWD CLINIMIX E GLYCINE SOLN IJ NC 4.25%/DEXTROSE 5% 5 SOLN L-ALANINE POWD 5 RX/OTC CLINIMIX E 5%/DEXTROSE 15% 5 L-ARGININE BASE POWD 5 RX/OTC SOLN L-ARGININE NC CLINIMIX E HYDROCHLORIDE SOLN 5%/DEXTROSE 20% 5 SOLN L-ARGININE POWD 5 RX/OTC CLINIMIX E 8/10 SOLN 5 L-CYSTINE POWD 5 RX/OTC CLINIMIX E 8/14 SOLN 5 L-GLUTAMIC ACID POWD 5 RX/OTC CLINIMIX N14G30E SOLN 5 L-GLUTAMINE CRYS 5 CLINIMIX N9G15E SOLN 5 L-GLUTAMINE POWD 5 RX/OTC CLINIMIX N9G20E SOLN 5 L-HISTIDINE MONOHYDROCHLORIDE 5 cysteine hcl soln 2 CRYS RX/OTC L-HISTIDINE CYTO CARN POWD NC MONOHYDROCHLORIDE 5 MONOHYDRATE POWD DL-ALANINE POWD 5 RX/OTC L-HISTIDINE POWD 5 RX/OTC DL-LEUCINE POWD 5 RX/OTC L-ISOLEUCINE POWD 5 RX/OTC DL-METHIONINE POWD 5 RX/OTC L-LEUCINE POWD 5 RX/OTC DL-PHENYLALANINE 5 RX/OTC POWD L-LYSINE NC HYDROCHLORIDE SOLN ELCYS SOLN NC L-METHIONINE POWD 5 RX/OTC FREAMINE HBC 6.9% 5 SOLN L-PHENYLALANINE 5 RX/OTC POWD FREAMINE III SOLN 5

294 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC L-PROLINE POWD 5 OPHTHALMIC AGENTS - Drugs to Treat the Eye L-THREONINE CRYS 5 Artificial Tears and Lubricants LACRISERT INST NC L-TRYPTOPHAN CAPS 5 OR Beta-blockers - Ophthalmic L-TRYPTOPHAN POWD 5 RX/OTC XX betaxolol hcl (ophth) soln 2 L-TYROSINE POWD 5 RX/OTC BETIMOL SOLN NC L-VALINE CRYS 5 BETOPTIC-S SUSP 4 L-VALINE POWD 5 RX/OTC carteolol hcl (ophth) soln 2 LEUCINE POWD 5 RX/OTC COMBIGAN SOLN 4 RX/OTC METHIONINE POWD 5 COSOPT PF SOLN (Use dorzolamide hcl-timolol 5 NEOKE ALCAR POWD NC RX/OTC maleate) COSOPT SOLN (Use NEPHRAMINE SOLN 5 dorzolamide hcl-timolol 5 maleate) PHLEXY-10 CAPS 4 RX/OTC dorzolamide hcl-timolol 2 maleate soln PREMASOL SOLN 5 ISTALOL SOLN (Use 5 PROCALAMINE SOLN 5 timolol maleate (ophth)) levobunolol hcl soln 2 PROSOL SOLN 5 timolol maleate (ophth) solg 2 SYNTHAMIN 17 SOLN 5 timolol maleate (ophth) soln 2 TAURINE LIQD XX 5 TIMOLOL/BRIMONIDE/DO NC TAURINE POWD XX 5 RZOLAMIDE SOLN TIMOLOL/BRIMONIDINE/ TAURINE SOLN IJ NC DORZOLAMIDE/LATANOP NC ROST SOLN THREONINE POWD 5 RX/OTC TIMOLOL/DORZOLAMIDE/ NC LATANOPROST SOLN TRAVASOL SOLN 5 TIMOLOL/LATANOPROST NC SOLN TRI-AMINO SOLN NC TIMOPTIC OCUDOSE NC SOLN 0.25 % TROPHAMINE SOLN 5 TIMOPTIC OCUDOSE TRYPTOPHAN POWD 5 RX/OTC SOLN 0.5 % (Use timolol NC maleate (ophth)) VALINE POWD 5 RX/OTC

295 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIMOPTIC SOLN (Use 5 TROPICAMIDE/CYCLOPE timolol maleate (ophth)) NTOLATE/PHENYLEPHRI NC NE/KETOROLAC/PROPA TIMOPTIC-XE SOLG (Use 5 timolol maleate (ophth)) RCA SOSY TROPICAMIDE/PHENYLE NC Cycloplegic Mydriatics PHRINE SOLN atropine sulfate 5 TROPICAMIDE/PROPARA (ophthalmic) oint CAINE/PHENYLEPHRINE/ NC ATROPINE SULFATE KETOROLAC SOLN MONOHYDRATE SOLN NC OP Miotics ISOPTO CARPINE SOLN ATROPINE SULFATE 2 5 SOLN OP 1 % (Use pilocarpine hcl) CYCLOGYL SOLN 0.5 % 5 QL(15 ml per MIOCHOL-E SOLR 5 (Use cyclopentolate hcl) fill retail) MIOSTAT SOLN 5 CYCLOGYL SOLN 2 %, 1 5 % (Use cyclopentolate hcl) PHOSPHOLINE IODIDE 5 CYCLOMYDRIL SOLN 5 SOLR pilocarpine hcl soln op 1 %, cyclopentolate hcl soln op 2 QL(15 ml per 2 0.5 % fill retail) 2 %, 4 % Ophthalmic - Angiogenesis Inhibitors cyclopentolate hcl soln op 2 2 %, 1 % BEOVU SOLN NC homatropine hbr soln 2 BEVACIZUMAB SOSY NC ISOPTO ATROPINE SOLN 2 EYLEA SOLN 4 PA; SP phenylephrine hcl 2 (mydriatic) soln EYLEA SOSY 4 PA; SP PHENYLEPHRINE HYDROCHLORIDE SOSY NC LUCENTIS SOLN 4 PA; SP IO 1.5 % LUCENTIS SOSY 4 PA; SP TROPICAMIDE POWD 5 PA; SP TROPICAMIDE/CYCLOPE MACUGEN SOLN 5 NTOLATE HYDROCHLORIDE/PHEN NC Ophthalmic Adrenergic Agents YLEPHRINE HYDRO ALPHAGAN P SOLN 0.1 % 4 SOLN TROPICAMIDE/CYCLOPE ALPHAGAN P SOLN 0.15 NTOLATE/PHENYLEPHRI NC % (Use brimonidine 4 NE SOLN tartrate) TROPICAMIDE/CYCLOPE apraclonidine hcl soln 2 NTOLATE/PHENYLEPHRI NC NE/KETOROLAC SOLN BRIMONIDE/DORZOLAMI NC TROPICAMIDE/CYCLOPE DE P-F SOLN NTOLATE/PHENYLEPHRI NC brimonidine tartrate soln op 2 NE/KETOROLAC SOSY 0.15 %, 0.2 %

296 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPINEPHRINE NC MITOSOL KIT 5 HYDROCHLORIDE SOSY MOXEZA SOLN (Use 5 IOPIDINE SOLN 5 moxifloxacin hcl (ophth)) SIMBRINZA SUSP 4 moxifloxacin hcl (ophth) 2 QL(3 ml per fill soln retail) Ophthalmic Anti-infectives moxifloxacin hcl (ophth) 2 QL(6 ml per 30 soln AZASITE SOLN NC days retail) MOXIFLOXACIN NC HYDROCHLORIDE SOLN BACIGUENT OINT 2 MOXIFLOXACIN NC HYDROCHLORIDE SOSY bacitracin (ophthalmic) oint 2 MOXIFLOXACIN bacitracin-polymyxin b 2 QL(4 gm per fill HYDROCHLORIDE/SODIU NC (ophth) oint retail) M CHLORIDE SOLN BESIVANCE SUSP 4 MOXIFLOXACIN SOLN NC

BETADINE OPHTHALMIC 5 NATACYN SUSP 5 PREP SOLN BLEPH-10 SOLN (Use QL(15 ml per neomycin-bacitracin zn- 2 QL(4 gm per fill sulfacetamide sodium 5 fill retail) polymyxin oint retail) (ophth)) neomycin-polymyxin- 2 QL(10 ml per CEFUROXIME gramicidin soln fill retail) SODIUM/SODIUMCHLORI NC OCUFLOX SOLN (Use 5 QL(5 ml per fill DE SOLN ofloxacin (ophth)) retail) QL(5 ml per fill CEFUROXIME SOSY NC ofloxacin (ophth) soln 2 retail) CILOXAN OINT NC polymyxin b-trimethoprim 2 QL(10 ml per soln fill retail) CILOXAN SOLN (Use NC ciprofloxacin hcl (ophth)) POLYTRIM SOLN (Use 5 QL(10 ml per polymyxin b-trimethoprim) fill retail) ciprofloxacin hcl (ophth) 2 soln POVIDONE IODINE SOLN 5 QL(4 gm per fill erythromycin (ophth) oint 2 sulfacetamide sodium 2 retail) (ophth) oint gatifloxacin (ophth) soln 2 sulfacetamide sodium 2 QL(15 ml per (ophth) soln fill retail) gentamicin sulfate (ophth) QL(4 gm per fill 2 QL(5 ml per fill oint retail) tobramycin (ophth) soln 2 retail) gentamicin sulfate (ophth) 2 soln TOBREX OINT 5 QL(6 ml per 30 KLARITY-A SOLN NC TOBREX SOLN (Use 5 QL(5 ml per fill days retail) tobramycin (ophth)) retail) QL(8 ml per fill levofloxacin (ophth) soln 2 trifluridine soln 2 retail) MITOMYCIN SOSY IO NC 0.02 %, 0.03 %, 0.04 %

297 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANCOMYCIN proparacaine hcl soln op 2 HYDROCHLORIDE SOSY NC OP 10 MG/ML tetracaine hcl (ophth) soln 2 VIGAMOX SOLN (Use 5 QL(3 ml per fill moxifloxacin hcl (ophth)) retail) Ophthalmic Nerve Growth Factors ZIRGAN GEL NC OXERVATE SOLN 5 PA; SP

ZYMAXID SOLN (Use 5 Ophthalmic Photodynamic Therapy Agents gatifloxacin (ophth)) 5 PA; SP Ophthalmic Gene Therapy VISUDYNE SOLR LUXTURNA SUSP 5 PA; SP Ophthalmic Photoenhancers PHOTREXA VISCOUS NC Ophthalmic Immunomodulators SOSY CEQUA SOLN NC PHOTREXA/PHOTREXA NC VISCOUS KIT SOSY CYCLOSPORINE IN NC KLARITY EMUL Ophthalmic Steroids RESTASIS EMUL 4 QL(2 ml daily) ALREX SUSP NC bacitracin-poly-neomycin- QL(4 gm per fill RESTASIS MULTIDOSE 4 QL(2 ml daily) 2 EMUL hc oint retail) BLEPHAMIDE S.O.P. 5 Ophthalmic Integrin Antagonists OINT XIIDRA SOLN 4 BLEPHAMIDE SUSP 5 Ophthalmic Kinase Inhibitors dexamethasone sodium 2 QL(5 ml per fill phosphate (ophth) soln retail) RHOPRESSA SOLN 4 DEXAMETHASONE/MOXI NC QL(0.09 ml FLOXACIN HCL SOLN ROCKLATAN SOLN 4 daily) DEXAMETHASONE/MOXI Ophthalmic Local Anesthetics FLOXACIN/KETOROLAC NC SOLN AKTEN GEL 5 DEXTENZA INST NC ALCAINE SOLN (Use 5 proparacaine hcl) DEXYCU SUSP NC LIDOCAINE HYDROCHLORIDE/EPINE NC DOUBLE PM SOLR NC PHRINE SOLN LIDOCAINE DUREZOL EMUL 4 HYDROCHLORIDE/PHEN NC YLEPHRINE EYSUVIS SUSP NC HYDROCHLORIDE SOLN LIDOCAINE FLAREX SUSP NC HYDROCHLORIDE/PHEN NC fluorometholone (ophth) 2 YLEPHRINE susp HYDROCHLORIDE SOSY FML FORTE SUSP NC

298 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FML LIQUIFILM SUSP PRED FORTE SUSP (Use (Use fluorometholone NC prednisolone acetate NC (ophth)) (ophth)) FML OINT NC PRED MILD SUSP NC

GATIFLOXACIN- NC PRED-G S.O.P. OINT 5 DEXAMETHASONE SOLN ILUVIEN IMPL 5 PA; SP PRED-G SUSP 5 prednisolone acetate 2 INVELTYS SUSP NC (ophth) susp KLARITY-B SOLN NC PREDNISOLONE 5 ACETATE P-F SUSP KLARITY-L EMUL NC PREDNISOLONE ACETATE/MOXIFLOXACI NC LOTEMAX GEL (Use NC N SUSP loteprednol etabonate) PREDNISOLONE LOTEMAX OINT NC ACETATE/MOXIFLOXACI NC N/BROMFENAC SUSP LOTEMAX SM GEL NC PREDNISOLONE ACETATE/MOXIFLOXACI NC LOTEMAX SUSP (Use NC N/NEPAFENAC SUSP loteprednol etabonate) PREDNISOLONE loteprednol etabonate gel 2 ACETATE/NEPAFENAC NC SUSP loteprednol etabonate susp 2 PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 5 MAXIDEX SUSP NC % MAXITROL OINT 0.1 %- QL(5 gm per fill PREDNISOLONE SODIUM PHOSPHATE/BROMFENA NC 3.5 MG/GM-10000 5 retail) UNIT/GM (Use neomycin- C SOLN polymy-dexameth) PREDNISOLONE SODIUM NC MAXITROL SUSP 0.1 %- QL(5 ml per fill PHOSPHATE/GATIFLOXA CIN SOLN 3.5 MG/ML-10000 5 retail) UNIT/ML (Use neomycin- PREDNISOLONE SODIUM polymy-dexameth) PHOSPHATE/GATIFLOXA NC neomycin-polymy- QL(5 gm per fill CIN/BROMFENAC SOLN dexameth oint 0.1 %-3.5 2 retail) PREDNISOLONE SODIUM mg/gm-10000 unit/gm PHOSPHATE/MOXIFLOXA NC neomycin-polymy- QL(5 ml per fill CIN SOLN dexameth susp 0.1 %-3.5 2 retail) PREDNISOLONE SODIUM mg/ml-10000 unit/ml PHOSPHATE/MOXIFLOXA NC CIN/BROMFENAC SOLN neomycin-polymyxin-hc 2 QL(8 ml per fill (ophth) susp retail) PREDNISOLONE- NC GATIFLOXACIN SUSP OZURDEX IMPL 5 PA; SP PREDNISOLONE/BROMF NC ENAC SUSP

299 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISOLONE/GATIFL HEALON5 PRO SOLN 4 OXACIN/BROMFENAC NC SUSP HEALON5 SOLN 4 RETISERT IMPL 5 PA; SP HYALURONIDASE SOLN NC IO sulfacetamide sod- 2 prednisolone soln MEMBRANEBLUE SOLN 4 QL(4 gm per fill TOBRADEX OINT 4 retail) OMIDRIA SOLN 4 TOBRADEX ST SUSP NC PROVISC SOLN 4 TOBRADEX SUSP (Use tobramycin- 5 VISIONBLUE SOLN 4 dexamethasone) Ophthalmics - Misc. tobramycin- 2 dexamethasone susp ACULAR LS SOLN (Use ketorolac tromethamine 5 TRIAMCINOLONE/MOXIF NC LOXACIN HCL SUSP (ophth)) ACULAR SOLN (Use TRIESENCE SUSP 5 ketorolac tromethamine 5 (ophth)) TRIPLE PMB SOLR NC ACUVAIL SOLN NC TRIPLE PMK SOLR NC ALOCRIL SOLN 4 YUTIQ IMPL NC ALOMIDE SOLN 4 QL(5 ml per fill ZYLET SUSP NC QL(6 ml per fill retail) azelastine hcl (ophth) soln 2 retail) Ophthalmic Surgical Aids AZOPT SUSP (Use NC QL(0.4 ml AMVISC PLUS SOLN 4 brinzolamide) daily) QL(0.34 ml bepotastine besilate soln 2 AMVISC SOLN 4 daily) BEPREVE SOLN (Use NC QL(0.34 ml BIOLON SOLN 4 bepotastine besilate) daily) QL(0.4 ml GELFILM OP FILM 4 brinzolamide susp 2 daily) HEALON DUET PRO 5 bromfenac sodium (ophth) 2 SOSY soln HEALON GV PRO SOLN 5 BROMSITE SOLN NC HEALON GV SOLN 4 BSS PLUS SOLN 0.154 MG/ML-0.184 MG/ML-0.2 HEALON PRO SOLN 4 MG/ML-0.38 MG/ML-0.42 5 MG/ML-0.92 MG/ML-2.1 HEALON SOLN 4 MG/ML-7.14 MG/ML

300 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BSS PLUS SOLN 0.395 PATADAY SOLN 0.1 % 5 QL(0.34 ml MG/ML-0.433 MG/ML-2.19 (Use olopatadine hcl) daily); RX/OTC MG/ML-2.19 MG/ML-3.85 PATADAY SOLN 0.2 % 5 QL(0.09 ml MG/ML-4.6 MG/ML-5 5 (Use olopatadine hcl) daily); RX/OTC MG/ML-7.44 MG/ML-23 MG/ML (Use ophthalmic PATANOL SOLN (Use 5 QL(0.34 ml irrigation solution - olopatadine hcl) daily); RX/OTC ST; QL(0.09 ml intraocular) PAZEO SOLN 4 BSS SOLN (Use daily); RX/OTC ophthalmic irrigation 5 PROLENSA SOLN 4 solution - intraocular) TRUSOPT SOLN (Use QL(0.34 ml CHONDROITIN SULFATE NC 5 SOLN dorzolamide hcl) daily) cromolyn sodium (ophth) 2 QL(10 ml per UPNEEQ SOLN NC soln fill retail) ZERVIATE SOLN NC CYSTADROPS SOLN NC SP PA; QL(2.15 ml Prostaglandins - Ophthalmic CYSTARAN SOLN 5 daily); SP bimatoprost soln op NC diclofenac sodium (ophth) 2 soln DURYSTA IMPL NC QL(0.34 ml dorzolamide hcl soln 2 QL(0.09 ml daily) latanoprost soln op 2 daily) DORZOLAMIDE HCL 5 QL(0.34 ml SOLN daily) LUMIGAN SOLN 4 ST; QL(0.09 ml daily) epinastine hcl (ophth) soln 2 TRAVATAN Z SOLN (Use NC QL(0.09 ml travoprost) daily) QL(3 ml per fill flurbiprofen sodium soln 2 QL(0.09 ml retail) travoprost soln 2 daily) ILEVRO SUSP 4 VYZULTA SOLN 5 PA JETREA SOLN 5 PA; SP XALATAN SOLN (Use 5 QL(0.09 ml latanoprost) daily) ketorolac tromethamine 2 (ophth) soln XELPROS EMUL NC LASTACAFT SOLN NC ZIOPTAN SOLN 4 ST; QL(1 ea daily) NEVANAC SUSP NC OTIC AGENTS - Drugs to Treat the Ear QL(0.34 ml olopatadine hcl soln 0.1 % 2 daily); RX/OTC Otic Agents - Miscellaneous QL(0.09 ml QL(15 ml per olopatadine hcl soln 0.2 % 2 acetic acid (otic) soln 2 daily); RX/OTC fill retail) ophthalmic irrigation 2 Otic Anti-infectives solution - intraocular soln CETRAXAL SOLN (Use 5 PATADAY EXTRA 4 ST; QL(0.09 ml ciprofloxacin hcl (otic)) STRENGTH SOLN daily); RX/OTC

301 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciprofloxacin hcl (otic) soln 2 oxytocin soln ij 2

FLOXIN OTIC SOLN (Use NC OXYTOCIN/DEXTROSE NC ofloxacin (otic)) SOLN ofloxacin (otic) soln 2 OXYTOCIN/LACTATED NC RINGERS SOLN OTIPRIO SUSP NC OXYTOCIN/SODIUM NC CHLORIDE SOLN Otic Combinations PITOCIN SOLN (Use 5 oxytocin) CIPRO HC SUSP NC PASSIVE IMMUNIZING AND TREATMENT CIPRODEX SUSP (Use QL(8 ml per fill AGENTS - Antibody Drugs to Treat Low Immune ciprofloxacin- NC retail) System dexamethasone) Antitoxins-Antivenins ciprofloxacin- 2 QL(8 ml per fill dexamethasone susp retail) ANASCORP SOLR 5 ciprofloxacin-fluocinolone NC QL(0.5 ea acetonide soln daily) ANAVIP SOLR 5 COLY-MYCIN S SUSP 5 ANTIVENIN LATRODECTUS 5 CORTISPORIN-TC SUSP 5 MACTANS KIT ANTIVENIN NORTH neomycin-polymyxin-hc 2 QL(10 ml per (otic) soln fill retail) AMERICANCORAL 5 SNAKE SOLR neomycin-polymyxin-hc 2 (otic) susp CROFAB SOLR 5 OTOVEL SOLN (Use QL(0.5 ea ciprofloxacin-fluocinolone NC daily) Immune Serums acetonide) ASCENIV SOLN NC PRAMOTIC LIQD 5 BIVIGAM SOLN 5 PA; SP Otic Steroids CARIMUNE 5 PA; SP DERMOTIC OIL (Use NANOFILTERED SOLR fluocinolone acetonide 5 PA; SP (otic)) CUTAQUIG SOLN 4 fluocinolone acetonide 2 CUVITRU SOLN 1 SP (otic) oil GM/5ML, 10 GM/50ML, 2 NC GM/10ML, 4 GM/20ML hydrocortisone w/acetic 2 QL(10 ml per acid soln fill retail) CUVITRU SOLN 8 NC OXYTOCICS - Drugs to Prevent/Control Uterine GM/40ML Bleeding CYTOGAM INJ 5 PA; SP Oxytocics FLEBOGAMMA DIF SOLN 5 PA; SP methylergonovine maleate 2 soln GAMASTAN INJ 5 PA; SP methylergonovine maleate 2 tabs

302 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAMMAGARD LIQUID 5 PA; SP RHOPHYLAC SOSY 5 PA; SP SOLN GAMMAGARD S/D IGA PA; SP VARIZIG SOLN 5 LESS THAN 1MCG/ML 5 SOLR WINRHO SDF SOLN 5 PA; SP GAMMAKED SOLN 5 PA; SP XEMBIFY SOLN NC GAMMAPLEX SOLN 5 PA; SP Monoclonal Antibodies PA; SP GAMUNEX-C SOLN 5 BAMLANIVIMAB SOLN 5 PA; SP HEPAGAM B SOLN 5 CASIRIVIMAB SOLN 5 PA; SP HIZENTRA SOLN 5 ETESEVIMAB SOLN 5 PA; SP HIZENTRA SOSY 5 IMDEVIMAB SOLN 5 HYPERHEP B SOLN 5 PA; SP REGEN-COV SOLN IV 1332 MG/11.1ML-1332 HYPERRAB S/D SOLN 5 MG/11.1ML, 300 5 MG/2.5ML-1332 MG/11.1ML, 300 HYPERRAB SOLN 1500 5 UNIT/5ML, 300 UNIT/ML MG/2.5ML-300 MG/2.5ML HYPERRAB SOLN 900 NC SOTROVIMAB SOLN NC UNIT/3ML PA; SP HYPERRHO S/D MINI- 5 PA; SP SYNAGIS SOLN 5 DOSE SOSY SP HYPERRHO S/D SOSY 5 PA; SP ZINPLAVA SOLN NC Passive Immunizing Agents - Combinations HYPERTET S/D INJ 5 HYQVIA KIT 5 PA; SP IMOGAM RABIES-HT 5 SOLN PENICILLINS - Drugs to Treat Bacterial Infections KEDRAB SOLN 5 Aminopenicillins MICRHOGAM ULTRA- 5 PA; SP FILTEREDPLUS SOSY amoxicillin caps 2 PA; SP NABI-HB SOLN 5 amoxicillin chew 2 PA; SP OCTAGAM SOLN 5 amoxicillin susr 2

PANZYGA SOLN NC amoxicillin tabs 2 PA; SP PRIVIGEN SOLN 5 AMOXICILLIN 5 TRIHYDRATE POWD RHOGAM ULTRA- 5 PA; SP FILTERED PLUS SOSY ampicillin caps 2

303 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin sodium solr 2 AUGMENTIN SUSR 31.25 5 MG/5ML-125 MG/5ML Natural Penicillins AUGMENTIN SUSR 62.5 MG/5ML-250 MG/5ML 5 BICILLIN L-A SUSP 5 (Use amoxicillin & pot PENICILLIN G clavulanate) AUGMENTIN TABS 125 QL(20 ea per POTASSIUM IN ISO- 5 OSMOTIC DEXTROSE MG-500 MG (Use 5 fill retail) SOLN amoxicillin & pot clavulanate) penicillin g potassium solr 2 BICILLIN C-R SUSP 5 PENICILLIN G PROCAINE 5 SUSP piperacillin sodium- 2 tazobactam sodium solr penicillin g sodium solr 2 UNASYN BULK PACK SOLR (Use ampicillin & 5 penicillin v potassium solr 2 sulbactam sodium) penicillin v potassium tabs 2 UNASYN SOLR (Use ampicillin & sulbactam 5 Penicillin Combinations sodium) amoxicillin & pot QL(20 ea per ZOSYN SOLN 0.25 clavulanate chew 28.5 mg- 2 fill retail) GM/50ML-2 GM/50ML-5 %, 200 mg, 57 mg-400 mg 0.375 GM/50ML-3 5 GM/50ML-5 %, 0.5 amoxicillin & pot GM/100ML-4 GM/100ML-5 clavulanate susr 57 % mg/5ml-400 mg/5ml, 200 mg/5ml-28.5 mg/5ml, 250 ZOSYN SOLR 0.25 GM-2 mg/5ml-62.5 mg/5ml, 28.5 2 GM, 0.375 GM-3 GM, 0.5 mg/5ml-200 mg/5ml, 42.9 GM-4 GM, 2 GM-0.25 GM, mg/5ml-600 mg/5ml, 600 3 GM-0.375 GM, 4 GM-0.5 5 mg/5ml-42.9 mg/5ml, 62.5 GM, 4.5 GM-36 GM (Use mg/5ml-250 mg/5ml piperacillin sodium- tazobactam sodium) amoxicillin & pot QL(20 ea per clavulanate tabs 125 mg- fill retail) Penicillinase-Resistant Penicillins 875 mg, 875 mg-125 mg, 2 125 mg-500 mg, 500 mg- dicloxacillin sodium caps 2 125 mg nafcillin sodium solr ij 1 gm, 2 amoxicillin & pot QL(30 ea per 2 gm clavulanate tabs 250 mg- 2 fill retail) nafcillin sodium solr iv 1 2 125 mg gm, 10 gm, 2 gm amoxicillin & pot QL(13.34 ea NAFCILLIN SODIUM 4 clavulanate tb12 1000 mg- 2 daily) SOLR IV 10 GM 62.5 mg, 62.5 mg-1000 mg NAFCILLIN SOLN 5 ampicillin & sulbactam 2 sodium solr OXACILLIN SODIUM AUGMENTIN ES-600 SOLN IV 1 GM/50ML-1.5 5 SUSR (Use amoxicillin & 5 GM/50ML, 2 GM/50ML-300 pot clavulanate) MG/50ML

304 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxacillin sodium solr ij 1 2 FDC BLUE 1 ALUMINUM 5 RX/OTC gm, 2 gm LAKE POWD oxacillin sodium solr iv 10 2 FDC BLUE 1 POWD 5 RX/OTC gm RX/OTC PHARMACEUTICAL ADJUVANTS FDC BLUE 2 POWD 5 Alkalizing Agents FDC GREEN #3 POWD 5 RX/OTC RX/OTC TROLAMINE LIQD 5 FDC RED #3 POWD 5 RX/OTC Antimicrobial Agents FDC RED 40 POWD 5 RX/OTC BENZYL ALCOHOL LIQD 5 RX/OTC FDC YELLOW 5 5 RX/OTC ALUMINUM LAKE POWD CHLOROBUTANOL 5 ANHYDROUS POWD FDC YELLOW 6 POWD 5 RX/OTC CHLOROBUTANOL CRYS 5 FOOD COLOR BLACK 5 RX/OTC POWD CHLOROBUTANOL 5 POWD FOOD COLOR BLUE LIQD 5 OR METHYLPARABEN POWD 5 RX/OTC FOOD COLOR BLUE 5 RX/OTC METHYLPARABEN 5 POWD XX SODIUM POWD FOOD COLOR BROWN 5 RX/OTC POTASSIUM SORBATE 5 POWD GRAN FOOD COLOR GREEN 5 POTASSIUM SORBATE 5 LIQD POWD FOOD COLOR GREEN 5 RX/OTC PROPYLPARABEN POWD 5 RX/OTC POWD FOOD COLOR LIME 5 RX/OTC PROPYLPARABEN 5 GREEN POWD SODIUM POWD FOOD COLOR ORANGE 5 RX/OTC SORBIC ACID POWD 5 RX/OTC POWD Coloring Agents FOOD COLOR PINK LIQD 5 AMARANTH POWD 5 FOOD COLOR RED LIQD 5 BRILLIANT BLUE G 5 FOOD COLOR RED 5 RX/OTC POWD POWD EVANS BLUE POWD 5 FOOD COLOR VIOLET 5 POWD RX/OTC FD&C BLUE #2 POWD 5 FOOD COLOR WHITE 5 LIQD FD&C RED #40 POWD 5 RX/OTC FOOD COLOR YELLOW 5 LIQD FD&C YELLOW #5 POWD 5 RX/OTC FOOD COLOR YELLOW 5 RX/OTC POWD FD&C YELLOW #6 5 RX/OTC ALUMINUM LAKE POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

305 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LISSAMINE GREEN B 5 BEEF FLAVOR POWD 5 RX/OTC POWD BEEF TYPE FLAVOR RX/OTC QUINIZARIN GREEN SS 5 5 POWD NATURAL LIQD BEEF TYPE FLAVOR RX/OTC SULPHAN BLUE POWD 5 NATURALCHLORIDE 5 FREE LIQD TRYPAN BLUE POWD 5 BEEF TYPE FLAVOR OS 5 RX/OTC Delivery Devices LIQD RX/OTC EXYDERM PTCH 5 BEEF-ADE POWD 5 BITTER STOP FLAVOR 5 RX/OTC Flavoring Agents LIQD ALFALFA FLAVOR POWD 5 RX/OTC BITTERNESS MASK 5 RX/OTC FLAVOR LIQD ALMOND OIL BITTER 5 RX/OTC FLAVOR LIQD BITTERNESS REDUCING 5 RX/OTC AGENT POWD RX/OTC ANISE EXTRACT LIQD 5 BITTERNESS RX/OTC RX/OTC SUPPRESSOR FLAVOR 5 ANISE FLAVOR OIL 5 LIQD RX/OTC BITTERNESS RX/OTC APPLE FLAVOR LIQD 5 SUPRESSOR FLAVOR 5 LIQD APPLE FLAVOR POWD 5 RX/OTC BLACKBERRY FLAVOR 5 RX/OTC LIQD APPLE FLAVOR WATER 5 RX/OTC MISCIBLE POWD BLUEBERRY FLAVOR 5 RX/OTC LIQD APRICOT FLAVOR LIQD 5 RX/OTC BUBBLE GUM 5 RX/OTC APRICOT FLAVOR POWD 5 RX/OTC CONCENTRATE LIQD BUBBLE GUM FLAVOR 5 RX/OTC BACON FLAVOR LIQD 5 RX/OTC LIQD BUBBLEGUM FLAVOR 5 RX/OTC BACON FLAVOR 5 RX/OTC LIQD NATURAL LIQD BUTTER FLAVOR LIQD 5 RX/OTC BANANA CONCENTRATE 5 RX/OTC LIQD BUTTER RUM FLAVOR 5 RX/OTC BANANA CREAM FLAVOR 5 RX/OTC LIQD LIQD BUTTERSCOTCH 5 RX/OTC BANANA CREME FLAVOR 5 RX/OTC FLAVOR LIQD LIQD CARAMEL FLAVOR LIQD 5 RX/OTC BANANA FLAVOR LIQD 5 RX/OTC CHEESE-ADE FLAVOR 5 RX/OTC BEEF BRAISED NATURAL 5 RX/OTC POWD FLAVOR LIQD CHEESECAKE FLAVOR 5 RX/OTC BEEF FLAVOR LIQD 5 RX/OTC LIQD CHERRY FLAVOR LIQD 5 RX/OTC

306 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHERRY-ADE FLAVOR 5 RX/OTC ENGLISH TOFFEE 5 RX/OTC POWD FLAVOR LIQD CHICKEN (GRILLED) 5 RX/OTC EUCALYPTUS FLAVOR 5 RX/OTC FLAVOR LIQD OIL CHICKEN BROTH RX/OTC EUGENOL FLAVOR LIQD 5 RX/OTC FLAVOR SPRAY DRIED 5 POWD FISH FLAVOR LIQD 5 RX/OTC 5 RX/OTC CHICKEN FLAVOR LIQD FLAVOR RX/OTC CONCENTRATE/CHLORH 5 CHICKEN FLAVOR OIL 5 RX/OTC SOLUBLE LIQD EXIDINE CONC RX/OTC CHICKEN FLAVOR POWD 5 RX/OTC FLAVORX LIQD 5 RX/OTC CHICKEN FLAVOR 5 RX/OTC GRAPE FLAVOR LIQD 5 WATER MISCIBLE LIQD GRAPEFRUIT FLAVOR RX/OTC CHICKEN ROASTED 5 RX/OTC 5 CONCENTRATE LIQD PINK OIL GRILLED BEEF FLAVOR RX/OTC CHOCOLATE 5 RX/OTC CONCENTRATE CONC NATURAL OIL SOLUBLE 5 LIQD CHOCOLATE FLAVOR 5 RX/OTC LIQD GRILLED CHICKEN RX/OTC FLAVOR NATURAL OIL 5 CHOCOLATE FLAVOR 5 RX/OTC MISCIBLE LIQD POWD GUAVA FLAVOR LIQD 5 RX/OTC CHOCOLATE HAZELNUT 5 RX/OTC FLAVOR LIQD RX/OTC CHOCOLATE NATURAL & RX/OTC HAM FLAVOR LIQD 5 ARTIFICAL FLAVOR 5 RX/OTC CONC HONEY FLAVOR LIQD 5 CINNAMON FLAVOR OIL 5 RX/OTC KAHLUA FLAVOR LIQD 5 RX/OTC

COCONUT FLAVOR LIQD 5 RX/OTC LEMON EXTRACT LIQD 5 RX/OTC

COFFEE FLAVOR LIQD 5 RX/OTC LEMON FLAVOR LIQD 5 RX/OTC

COLA FLAVOR LIQD 5 RX/OTC LEMON FLAVOR OIL 5 RX/OTC

COTTON CANDY FLAVOR 5 RX/OTC LEMONADE FLAVOR OIL 5 RX/OTC LIQD RX/OTC CRAN-RASPBERRY 5 RX/OTC LICORICE FLAVOR LIQD 5 FLAVOR LIQD RX/OTC CREME DE MENTHE 5 RX/OTC LIME FLAVOR OIL 5 FLAVOR LIQD LIVER CONCENTRATE RX/OTC CREME DE MENTHE RX/OTC 5 5 LIQD FLAVOR OIL LIVER FLAVOR LIQD 5 RX/OTC CREME DEMENTHE 5 RX/OTC FLAVOR LIQD LIVER FLAVOR POWD 5 RX/OTC

307 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MANGO FLAVOR LIQD 5 RX/OTC PRALINES AND CREAM 5 RX/OTC FLAVOR LIQD RX/OTC MANGO FLAVOR POWD 5 PUMPKIN FLAVOR LIQD 5 RX/OTC MANGO FLAVOR RX/OTC 5 RASPBERRY 5 RX/OTC SWEETENED POWD CONCENTRATE CONC RX/OTC MAPLE FLAVOR LIQD 5 RASPBERRY FLAVOR 5 RX/OTC ARTIFICIAL CONC MARSHMALLOW RX/OTC RASPBERRY FLAVOR 5 RX/OTC ARTIFICIAL FLAVOR 5 LIQD CONC RASPBERRY FLAVOR 5 RX/OTC MARSHMALLOW FLAVOR 5 RX/OTC POWD LIQD ROOT BEER FLAVOR 5 RX/OTC MINT CHOCOLATE CHIP 5 RX/OTC LIQD FLAVOR LIQD SARDINE FLAVOR LIQD 5 RX/OTC MOLASSES FLAVOR 5 RX/OTC POWD SHRIMP FLAVOR LIQD 5 RX/OTC NATURAL CARAMEL 5 RX/OTC LIQD SPEARMINT FLAVOR OIL 5 RX/OTC ORANGE CONCENTRATE 5 RX/OTC LIQD STEVIA GLYCERITE 5 RX/OTC LIQUID EXTRACT LIQD ORANGE CREAM 5 RX/OTC FLAVOR LIQD STRAWBERRY FLAVOR 5 RX/OTC LIQD ORANGE FLAVOR LIQD 5 RX/OTC SUPER SYNERSWEET 5 RX/OTC ORANGE FLAVOR POWD 5 RX/OTC FLAVOR POWD SWEET CORN FLAVOR 5 RX/OTC ORANGE OIL FLAVOR 5 RX/OTC CONCENTRATE CONC LIQD SWEETENING 5 RX/OTC PASSION FRUIT FLAVOR 5 RX/OTC ENHANCER LIQD POWD SWEETENING RX/OTC PASSION FRUIT FLAVOR 5 RX/OTC ENHANCER/FLAVORX 5 SWEETENED POWD LIQD PCCA SWEETNESS 5 RX/OTC RX/OTC ENHANCER LIQD TANGERINE FLAVOR OIL 5 PEACH FLAVOR LIQD 5 RX/OTC TANGERINE FLAVOR 5 RX/OTC POWD PEANUT BUTTER RX/OTC 5 TANGERINE FLAVOR 5 RX/OTC FLAVOR LIQD SWEETENED POWD PEANUT BUTTER 5 RX/OTC RX/OTC FLAVOR OIL TEABERRY FLAVOR OIL 5 PEPPERMINT FLAVOR 5 RX/OTC TROPICAL PUNCH 5 RX/OTC OIL FLAVOR LIQD PINA COLADA FLAVOR 5 RX/OTC TUNA FLAVOR LIQD 5 RX/OTC LIQD RX/OTC PINEAPPLE FLAVOR 5 RX/OTC TUNA FLAVOR POWD 5 LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

308 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUNA TYPE FLAVOR OS 5 RX/OTC CAPSULE CONI-SNAP 5 RX/OTC LIQD #00 WHITE/WHITE CAPS TUTTI FRUTTI 5 RX/OTC CAPSULE CONI-SNAP RX/OTC CONCENTRATE CONC #000 CLEAR/CLEAR 5 CAPS TUTTI FRUTTI FLAVOR 5 RX/OTC LIQD CAPSULE CONI-SNAP #1 RX/OTC AQUABLUE/AQUA BLUE 5 TUTTI-FRUTTI FLAVOR 5 RX/OTC LIQD CAPS CAPSULE CONI-SNAP #1 RX/OTC VANILLA BUTTERNUT 5 RX/OTC 5 FLAVOR LIQD BLUE/BLUE CAPS RX/OTC CAPSULE CONI-SNAP #1 5 RX/OTC VANILLA FLAVOR LIQD 5 BLUE/PINK CAPS VANILLIN FLAVOR POWD 5 RX/OTC CAPSULE CONI-SNAP #1 RX/OTC BLUE/POWDER BLUE 5 CAPS VITAMIN/IRON MASKING 5 RX/OTC AGENT FLAVOR LIQD CAPSULE CONI-SNAP #1 5 RX/OTC BROWN/IVORY CAPS WATERMELON FLAVOR 5 RX/OTC LIQD CAPSULE CONI-SNAP #1 RX/OTC BROWN/LIGHT BROWN 5 WILD CHERRY FLAVOR 5 RX/OTC LIQD CAPS WILD CHERRY SD N&A RX/OTC CAPSULE CONI-SNAP #1 5 RX/OTC FLAVOR CONCENTRATE 5 CLEAR/CLEAR CAPS POWD CAPSULE CONI-SNAP #1 RX/OTC Gelatin Capsules (Empty) DARKGREEN/DARK 5 GREEN CAPS CAPSULE CONI-SNAP #0 5 RX/OTC CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC DARKGREEN/ORANGE 5 CAPSULE CONI-SNAP #0 RX/OTC CAPS DARK BLUE/DARK BLUE 5 CAPS CAPSULE CONI-SNAP #1 5 RX/OTC GREEN/YELLOW CAPS CAPSULE CONI-SNAP #0 5 RX/OTC GREEN/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC LIGHT BLUE/WHITE 5 CAPSULE CONI-SNAP #0 RX/OTC CAPS LIGHT BLUE/WHITE 5 CAPS CAPSULE CONI-SNAP #1 5 RX/OTC LIGHT GREY/PINK CAPS CAPSULE CONI-SNAP #0 5 RX/OTC PINK/PINK CAPS CAPSULE CONI-SNAP #1 5 RX/OTC ORANGE CAPS CAPSULE CONI-SNAP #0 5 RX/OTC RED/WHITE CAPS CAPSULE CONI-SNAP #1 5 RX/OTC PINK/AQUA BLUE CAPS CAPSULE CONI-SNAP #0 5 RX/OTC WHITE/WHITE CAPS CAPSULE CONI-SNAP #1 5 RX/OTC PINK/CLEAR CAPS CAPSULE CONI-SNAP RX/OTC #0/PURPLE/OPAQUE/CLE 5 CAPSULE CONI-SNAP #1 5 RX/OTC AR CAPS PINK/PINK CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP 5 RX/OTC 5 #00 CLEAR/CLEAR CAPS PINK/WHITE CAPS CAPSULE CONI-SNAP #1 5 RX/OTC PINK/YELLOW CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

309 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC PURPLE/PURPLE CAPS RED/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC RED/BLUE CAPS RED/RED CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC RED/WHITE CAPS WHITE/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC WHITE CAPS WHITE/WHITE CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC WHITE/CLEAR CAPS YELLOW/YELLOW CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC WHITE/GREEN CAPS BLACK/GREEN CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC YELLOW/GREEN CAPS CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC YELLOW/YELLOW CAPS WHITE CAPS CAPSULE CONI-SNAP #2 RX/OTC 5 CAPSULE EZEEFIT #0 5 RX/OTC CLEAR/CLEAR CAPS CLEAR CAPS CAPSULE CONI-SNAP #2 RX/OTC 5 CAPSULE EZEEFIT #00 5 RX/OTC WHITE CAPS CLEAR CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 CAPSULE SIZE 1 5 RX/OTC BLUE/CLEAR CAPS LACTOSE CAPS CAPSULE CONI-SNAP #3 RX/OTC DRCAPS SIZE 00 CLEAR 5 RX/OTC BROWN/LIGHT BLUE 5 CAPS CAPS DRCAPS SIZE 1 CLEAR 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC CAPS CLEAR/CLEAR CAPS EMPTY CAPSULE #0 RED RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC TRANSLUCENT/WHITE 5 DARKGREY/PINK CAPS CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 EMPTY CAPSULE #00 5 RX/OTC GRAY/YELLOW CAPS BLACK/RED CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 EMPTY CAPSULE #00 5 RX/OTC GREEN/BLUE CAPS BLUE/WHITE CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 EMPTY CAPSULE #00 5 RX/OTC MAROON/BLUE CAPS PINK/PINK CAPS CAPSULE CONI-SNAP #3 RX/OTC EMPTY CAPSULE #00 5 RX/OTC MINTGREEN/MINT 5 PURPLE//PURPLE CAPS GREEN CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC PURPLE//WHITE CAPS OLIVE/CLEAR CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC RED/WHITE CAPS ORANGE/ORANGE CAPS RX/OTC EMPTY CAPSULE #00 5 CAPSULE CONI-SNAP #3 5 RX/OTC YELLOW/YELLOW CAPS PINK/CLEAR CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC BLUE CAPS CAPSULE CONI-SNAP #3 5 RX/OTC PINK/PINK CAPS

310 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 0 RX/OTC 5 EMPTY CAPSULE SIZE 0 5 RX/OTC BLUE/WHITE CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 0 RX/OTC 5 EMPTY CAPSULE SIZE 0 5 RX/OTC CLEAR CAPS WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC CLEAR LOCKING CAPS WHITE/OPAQUE 5 EMPTY CAPSULE SIZE 0 RX/OTC LOCKING CAPS FUNCAPS LOCKING 5 EMPTY CAPSULE SIZE 0 5 RX/OTC CAPS YELLOW CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC GREEN LOCKING CAPS YELLOW/OPAQUE 5 LOCKING CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC GREEN/CLEAR CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC BLUE/OPAQUE LOCKING 5 GREEN/CLEAR LOCKING 5 CAPS CAPS EMPTY CAPSULE SIZE 00 5 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC CLEAR CAPS MAROON/OPAQUE 5 EMPTY CAPSULE SIZE 00 5 RX/OTC LOCKING CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 0 RX/OTC 5 EMPTY CAPSULE SIZE 00 5 RX/OTC ORANGE CAPS DARK GREEN CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 00 RX/OTC ORANGE/OPAQUE 5 GREEN/OPAQUE 5 LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 00 RX/OTC PINK CAPS LIGGHT BLUE OPAQUE 5 CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC PINK LOCKING CAPS EMPTY CAPSULE SIZE 00 5 RX/OTC ORANGE CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC PURPLE CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC ORANGE/OPAQUE 5 PURPLE/OPAQUE 5 LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 00 5 RX/OTC RED CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC PURPLE/WHITE CAPS EMPTY CAPSULE SIZE 00 5 RX/OTC WHITE CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC RED CAPS EMPTY CAPSULE SIZE 00 RX/OTC WHITE OPAQUE 5 EMPTY CAPSULE SIZE 0 5 RX/OTC RED/CLEAR CAPS LOCKING CAPS EMPTY CAPSULE SIZE RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC 5 RED/WHITE CAPS 000 CLEAR CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE RX/OTC RED/WHITE LOCKING 5 000 CLEAR LOCKING 5 CAPS CAPS EMPTY CAPSULE SIZE RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC WHITE CAPS 000 WHITE/OPAQUE 5 LOCKING CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

311 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC AQUABLUE 5 GREEN 5 TRANSLUCENT CAPS TRANSLUCENT/YELLOW OPAQUE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN/ORANGE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/CLEAR CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN/WHITE CAPS BLUE/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 1 RX/OTC CAPS GREEN/WHITE OPAQUE 5 LOCKING CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/PINK CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN/YELLOW CAPS BLUE/PINK LOCKING 5 EMPTY CAPSULE SIZE 1 5 RX/OTC CAPS GREY/PINK CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/PINK 5 IVORY CAPS TRANSLUCENT CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC LIGHT BLUE OPAQUE 5 BLUE/POWDER BLUE 5 CAPS CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC MAROON TRANS/CLEAR 5 BLUE/RED OPAQUE 5 CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC MINTGREEN CAPS BLUE/WHITE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC ORANGE CAPS BLUETRANSLUCENT/PIN 5 EMPTY CAPSULE SIZE 1 RX/OTC K TRANSLUCENT CAPS ORANGE OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS BROWN/IVORY CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC ORANGE/CLEAR CAPS BROWN/IVORY OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS ORANGE/WHITE CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC CLEAR CAPS ORANGE/YELLOW CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC CLEAR LOCKING CAPS PINK CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC DARKGREEN CAPS PINK/CLEAR CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN CAPS PINK/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 1 RX/OTC CAPS GREEN CLEAR/YELLOW 5 EMPTY CAPSULE SIZE 1 RX/OTC LOCKING CAPS PINK/POWDER BLUE 5 CAPS

312 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 2 5 RX/OTC PINK/WHITE CAPS CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 2 5 RX/OTC PINK/YELLOW CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 2 5 RX/OTC PINK/YELLOW OPAQUE 5 GREEN CAPS LOCKING CAPS EMPTY CAPSULE SIZE 2 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC WHITE OPAQUE 5 POWDER BLUE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC POWDER BLUE/OPAQUE 5 BLACK/GREEN CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE CAPS PURPLE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUE/CLEAR CAPS PURPLE/OPAQUE 5 EMPTY CAPSULE SIZE 3 5 RX/OTC LOCKING CAPS BLUE/WHITE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC RED CAPS BLUEOPAQUE/CLEAR 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS RED/BLUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC CLEAR CAPS RED/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 3 5 RX/OTC CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC RED/WHITE CAPS DARKGREEN CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC WHITE CAPS GRAY/PINK OPAQUE 5 EMPTY CAPSULE SIZE 1 RX/OTC LOCKING CAPS WHITE OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS GRAY/YELLOW OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN CAPS WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN/BLUE CAPS YELLOW CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 10 5 RX/OTC GREEN/BLUE LOCKING 5 CLEAR CAPS CAPS EMPTY CAPSULE SIZE 11 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC CLEAR CAPS GREEN/BLUE 5 TRANSLUCENT CAPS EMPTY CAPSULE SIZE 13 5 RX/OTC CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC GREY/PINK CAPS EMPTY CAPSULE SIZE 2 5 RX/OTC BLUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC GREY/YELLOW CAPS

313 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC LIGHT BLUE OPAQUE 5 PURPLE CAPS CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC PURPLE/CLEAR CAPS MAROON/BLUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC RED CAPS MAROON/BLUE OPAQUE 5 EMPTY CAPSULE SIZE 3 5 RX/OTC CAPS RED/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC MAROON/CLEAR CAPS RED/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 3 5 RX/OTC CAPS MINT GREEN CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC RED/WHITE CAPS OLIVE/CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC REDOPAQUE/CLEAR 5 OLIVE/OPAQUE LOCKING 5 LOCKING CAPS CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC WHITE CAPS ORANGE CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC WHITE OPAQUE 5 ORANGE/OPAQUE 5 LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC WHITE OPAQUE/CLEAR 5 ORANGE/WHITE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC PINK CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/CLEAR CAPS WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/OPAQUE LOCKING 5 YELLOW CAPS CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC YELLOW 5 PINK/POWDER BLUE 5 OPAQUE/CLEAR CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/WHITE CAPS YELLOW/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC PINK/YELLOW CAPS YELLOW/OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS PINKOPAQUE/CLEAR 5 EMPTY CAPSULE SIZE 4 RX/OTC CAPS BLACK/GREEN OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS PINKOPAQUE/CLEAR 5 EMPTY CAPSULE SIZE 4 5 RX/OTC LOCKING CAPS BLUE/WHITE CAPS EMPTY CAPSULE SIZE 3 RX/OTC 5 EMPTY CAPSULE SIZE 4 5 RX/OTC POWDER BLUE CAPS CLEAR CAPS

314 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 4 5 RX/OTC ALCOHOL DEHYDRATED 5 RX/OTC CLEAR LOCKING CAPS SOLN EMPTY CAPSULE SIZE 4 RX/OTC bacteriostatic sodium 2 DARK BLUE/OPAQUE 5 chloride soln LOCKING CAPS BASE GELATIN GUMMY 5 EMPTY CAPSULE SIZE 4 5 RX/OTC TROCHE GEL PURPLE CAPS CHERRY CONCENTRATE 5 RX/OTC EMPTY CAPSULE SIZE 4 RX/OTC SYRP PURPLE/OPAQUE 5 RX/OTC LOCKING CAPS CHERRY SYRUP SYRP 5 EMPTY CAPSULE SIZE 4 RX/OTC 5 COLLODION FLEXIBLE 5 RX/OTC RED/WHITE CAPS LIQD EMPTY CAPSULE SIZE 4 5 RX/OTC COLLODION LIQD 5 RX/OTC WHITE CAPS EMPTY CAPSULE SIZE 4 RX/OTC CORN SYRUP SYRP 5 WHITE/OPAQUE 5 LOCKING CAPS CUSTOM POLYGLYCOL 5 RX/OTC TROCHEBASE FLAK EMPTY CAPSULE SIZE 4 5 RX/OTC YELLOW CAPS CUSTOM POLYGLYCOL 5 RX/OTC TROCHEBASE WAX EMPTY CAPSULE SIZE 5 5 RX/OTC CLEAR CAPS CVS DISTILLED WATER 5 RX/OTC LIQD EMPTY CAPSULE SIZE 7 5 RX/OTC CLEAR CAPS CVS PURIFIED WATER 5 RX/OTC EMPTY GELATIN RX/OTC LIQD CAPSULE/SNAP 5 DERMACINRX TSS BASE 5 RX/OTC CLOSURE #0 CAPS SOLN EMPTY GELATIN RX/OTC DISTILLATA DISTILLED 5 RX/OTC CAPSULE/SNAP 5 WATER LIQD CLOSURE #00 CAPS DISTILLED WATER LIQD 5 RX/OTC EMPTY GELATIN RX/OTC CAPSULE/SNAP 5 ETHYL ALCOHOL 200 5 RX/OTC CLOSURE #000 CAPS PROOF SOLN EMPTY GELATIN RX/OTC ETHYL ALCOHOL SOLN 5 RX/OTC CAPSULE/SNAP 5 CLOSURE #1 CAPS FIXED OIL SUSPENSION 5 EMPTY GELATIN RX/OTC LIQD CAPSULE/SNAP 5 RX/OTC CLOSURE #2 CAPS FLAVOR BLEND SUSP 5 EMPTY GELATIN RX/OTC FLAVOR PLUS LIQD 5 RX/OTC CAPSULE/SNAP 5 CLOSURE #3 CAPS FLAVOR SWEET SYRP 5 RX/OTC EMPTY GELATIN RX/OTC CAPSULE/SNAP 5 FLAVOR SWEET-SF 5 RX/OTC CLOSURE #4 CAPS SYRP Liquid Vehicles FOAMIL LIQD 5 ADA SHAMPOO SHAM 5

315 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREEDOM PEG TROCHE 5 PCCA ACACIA SYRUP 5 BASE POWD BASE SYRP glycine diluent soln 2 PA; SP PCCA CUSTOM RX/OTC NATATROCHE HMP 5 GRAPE SYRUP SYRP 5 RX/OTC BASE WAX PCCA CUSTOM TROCHE 5 GUM BASE GELATIN GEL 5 BASE POWD PCCA CUSTOM TROCHE 5 RX/OTC INFANT DRINKING 5 RX/OTC BASE WAX WATER LIQD PCCA FIXED OIL BASE 5 LOZIBASE MISC 5 RX/OTC LIQD PCCA NATATROCHE 5 RX/OTC LOZIBASE S MISC 5 RX/OTC BASE WAX RX/OTC PCCA POLYGLYCOL 5 MX-SOL BLEND SF SUSP 5 TROCHE POWD RX/OTC PCCA PRACAMAC BASE 5 MX-SOL BLEND SUSP 5 OIL MX-SOL SF SYRP 5 RX/OTC PCCA SWEET-SF SYRP 5 RX/OTC RX/OTC MX-SOL SUSPEND SUSP 5 PCCA SYRUP VEHICLE 5 RX/OTC SYRP RX/OTC MX-SOL SYRP 5 PCCA-PLUS SUSP 5 RX/OTC NICE DISTILLED WATER 5 RX/OTC LIQD PEG TROCHE BASE PLLT 5 ORA-BLEND SF SUSP 5 RX/OTC PH 12 STERILE DILUENT PA; SP FORFLOLAN SOLN (Use 5 ORA-BLEND SUSP 5 RX/OTC glycine diluent) PROPYLENE GLYCOL 5 ORA-PLUS LIQD 5 RX/OTC SOLN EX PURIFIED WATER LIQD 5 RX/OTC ORA-SWEET SF SYRP 5 RX/OTC PX PURIFIED WATER 5 RX/OTC ORA-SWEET SYRP 5 RX/OTC LIQD ORAL MIX FLAVORED RX/OTC RASPBERRY SYRUP 5 RX/OTC SUSPENDING VEHICLE 5 SYRP SUSP REGENT ALCOHOL SOLN 5 RX/OTC ORAL MIX SF SUSP 5 RX/OTC RHEOSPRAY LIQD 5 ORAL SUSPEND LIQD 5 RX/OTC SALINE/PHENOL SOLN 5 ORAL SUSPENDING 5 RX/OTC COMPOUNDPLUS SUSP SERAQUA LIQD 5 ORAL SYRUP FLAVORED 5 RX/OTC RX/OTC VEHICLE SYRP SIMPLE SYRUP SYRP 5 RX/OTC ORAL SYRUP SF SYRP 5 SOLYDRA LIQD 5

316 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SORBITOL SOLN XX 70 5 RX/OTC TROCHE BASE NS POWD 5 %, SOSWEET SYRP 5 RX/OTC TROCHE BASE POWD 5 STERILE DILUENT FOR PA; SP TROCHE BASE SF WITH 5 RX/OTC FLOLAN SOLN (Use 5 BITTER BLOC GRAN glycine diluent) TROCHIBASE FLAK 5 RX/OTC STERILE DILUENT FOR PA; SP TREPROSTINIL 5 TROCHIBASE S CLASSIC 5 RX/OTC INJECTION SOLN FLAK SUSPENDRX WITH RX/OTC U-MILD SHAMPOO SHAM 5 BITTER- 5 BLOC/SWEETENED UNISPEND ANHYDROUS 5 RX/OTC SUSP SWEETENED SUSP SUSPENDRX WITH RX/OTC UNISPEND ANHYDROUS 5 RX/OTC UNSWEETENED SUSP BITTER- 5 BLOC/UNSWEETENED RX/OTC SUSP VERSAFREE SYRP 5 SUSPENSION VEHICLE 5 RX/OTC VERSAPLUS SYRP 5 RX/OTC SUSP SWEETENING RX/OTC VERSAPRO SHAMPOO 5 SUSPENDING 5 SHAM COMPOUND SYRP VITATROCHE PLUS BASE RX/OTC RX/OTC SF WITH BITTER-BLOC 5 SYRPALTA SYRP 5 GRAN SYRSPEND SF ALKA 5 RX/OTC water for inject, SUSR bacteriostatic benzyl 2 alcohol soln SYRSPEND SF LIQD 5 RX/OTC water for injection, sterile 2 soln SYRSPEND SF PH4 5 RX/OTC SUSR Non Gelatin Capsules (Empty) SYRSPEND SF SUSR 5 RX/OTC AR CAPS #1 CLEAR/ACID 5 RX/OTC RESISTANT CAPS SYRUP NF SYRP 5 RX/OTC CAPS 0 CLEAR DELAYED 5 RX/OTC RELEASE CAPS SYRUP VEHICLE SF 5 RX/OTC SYRP CAPSULE #0 RX/OTC RX/OTC CLEAR/CLEAR 5 SYRUP VEHICLE SYRP 5 VEGETABLE CAPS RX/OTC CAPSULE #0 RX/OTC TDM SOLUTION SOLN 5 WHITE/WHITEOPAQUE 5 TECHNA 20 SF TROCHE RX/OTC VEGETABLE CAPS BASEWITH BITTER-BLOC 5 CAPSULE #1 RX/OTC FLAK CLEAR/CLEAR 5 TECHNA NATURAL SF RX/OTC VEGETABLE CAPS TROCHEBASE WITH 5 CAPSULE #1 RX/OTC BITTER-BLOC GRAN WHITE/WHITEOPAQUE 5 VEGETABLE CAPS

317 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE #3 RX/OTC VEGETABLE CAPSULE #1 5 RX/OTC CLEAR/CLEAR 5 WHITE CAPS VEGETABLE CAPS VEGETABLE CAPSULE #2 5 RX/OTC CAPSULE #3 RX/OTC WHITE CAPS WHITE/WHITEOPAQUE 5 VEGETABLE CAPSULE #3 5 RX/OTC VEGETABLE CAPS WHITE CAPS CAPSULE 0 CLEAR RX/OTC 5 VEGETABLE CAPSULE #4 5 RX/OTC VEGGIE CAPS WHITE CAPS CAPSULE 0 CLEAR 5 RX/OTC VEGGIE LOCKING CAPS Pharmaceutical Adjuvants Miscellanous METER BUFFER PH 10 CAPSULE 00 CLEAR 5 RX/OTC 5 VEGGIE LOCKING CAPS SOLN METER BUFFER PH 4 CAPSULE 1 CLEAR RX/OTC 5 5 SOLN VEGGIE CAPS METER BUFFER PH 7 CAPSULE 1 CLEAR RX/OTC 5 5 SOLN VEGGIE LOCKING CAPS PH 10 BUFFER SOLN 5 CAPSULE 3 CLEAR 5 RX/OTC VEGGIE CAPS PH 4 BUFFER SOLN 5 CAPSULE 3 CLEAR 5 RX/OTC VEGGIE LOCKING CAPS CAPSULE CONI-SNAP #0 RX/OTC PH 7 BUFFER SOLN 5 CLEAR/CLEAR VEGGIE 5 Pharmaceutical Excipients CAPS RX/OTC CAPSULE CONI-SNAP #1 RX/OTC ACACIA POWD 5 CLEAR/CLEAR VEGGIE 5 CAPS ACACIA SPRAY-DRIED 5 RX/OTC POWD CAPSULE CONI-SNAP #3 RX/OTC CLEAR/CLEAR VEGGIE 5 ASTRAGALUS ROOT 5 RX/OTC CAPS POWD EMPTY CAPSULE SIZE 1 RX/OTC BACOCALMINE LIQD 5 VEGETABLE CLEAR 5 CAPS BASE X FLAK 5 EMPTY VEGETABLE RX/OTC RX/OTC CAPSULE/SNAP 5 BEES WAX WAX 5 CLOSURE #0 CAPS RX/OTC EMPTY VEGETABLE RX/OTC BEESWAX WAX 5 CAPSULE/SNAP 5 RX/OTC CLOSURE #00 CAPS BENTONITE POWD 5 EMPTY VEGETABLE RX/OTC BITTER DRUG POWDER 5 RX/OTC CAPSULE/SNAP 5 POWD CLOSURE #1 CAPS C10-C30 ALKYL RX/OTC VEGETABLE CAPSULE #0 5 RX/OTC ACRYLATE 5 GREEN CAPS CROSSPOLYMER POWD VEGETABLE CAPSULE #0 5 RX/OTC WHITE CAPS CAPSUBLEND-H POWD 5 VEGETABLE CAPSULE 5 RX/OTC CAPSUBLEND-P POWD 5 #00 WHITE CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

318 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSUBLEND-S POWD 5 KARAYA GUM GUM 5 RX/OTC

CARRAGEENAN POWD 5 LACTOSE ANHYDROUS 5 RX/OTC POWD RX/OTC CETYL ALCOHOL FLAK 5 LACTOSE HYDROUS 5 RX/OTC POWD CETYL ALCOHOL POWD 5 LACTOSE 5 RX/OTC MONOHYDRATE POWD COCOA BUTTER 5 RX/OTC DEODORIZED MISC LACTOSE RX/OTC MONOHYDRATE 5 COCOA BUTTER MISC 5 RX/OTC SPRAYDRIED POWD LACTOSE POWD 5 RX/OTC COLLASIL OSA POWD 5 RX/OTC LECITHIN ISOPROPYL 5 EFFERVESCENT POWD 5 PALMITATE SOLN

EMULGADE CM LIQD 5 LIPMAX SOLN 5 LIQUIGEL COMPLEX 5 EMULSIFYING WAX WAX 5 LIQD RX/OTC EMULSION 5 LOLLIBASE POWD 5 CONCENTRATE LIQD RX/OTC ETHYL ACETATE SOLN 5 LOLLIPOP BASE POWD 5

F-MELT POWD 5 RX/OTC LOXORAL BASE POWD 5 MAGNESIUM STEARATE RX/OTC FAGRON CAPFILL PRO 5 5 POWD POWD RX/OTC FAGRON DISPERSAPRO 5 MEDI-RDT BASE POWD 5 POWD MEDI-RDT KIT 5 FATTYBLEND MISC 5 RX/OTC (MULTIDOSE) KIT

FIZZMIX BASE POWD 5 MEDI-RDT KIT KIT 5

FREEDOM LOLLIPOP 5 METHYLCELLULOSE GEL 5 BASE MISC METHYLCELLULOSE 5 RX/OTC FREEDOM ODT BASE 5 RX/OTC POWD POWD MUCOLOX LIQD 5 FREEDOM SIMPLECAP 5 POWDER POWD NATURAL BITTERNESS 5 RX/OTC GELATIN POWD 5 POWD NEXTOL SF MISC 5 RX/OTC GELATIN TYPE A POWD 5 OLEIC ACID LIQD 5 GUM ARABIC MILLED 5 RX/OTC POWD PARAFFIN WAX 5 RX/OTC GUM ARABIC SPRAY- 5 RX/OTC DRIED POWD

319 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PCCA CUSTOM RDT 5 RX/OTC SODIUM THIOSULFATE 5 POWDER POWD POWD XX PCCA EMULSIFIX-205 5 SORBITOL CANDY BASE 5 BASE LIQD CRYS PCCA LECITHIN SORBITOL HARD CANDY 5 RX/OTC ISOPROPYL PALMITATE 5 BASE-GRAPE MISC SOLN SPG SUPPOSI-BASE 5 RX/OTC PCCA LOXASPERSE 5 PLLT BASE POWD STEARIC ACID FLAK 5 PCCA RAPID DISSOLVE RX/OTC 5 TABLET POWDER BASE STEARIC ACID POWD 5 RX/OTC POWD STEARIC ACID TRIPLE RX/OTC PCCA SORBITOL 5 5 LOLLIPOP BASE FLAK PRESSED POWD STEARYL ALCOHOL RX/OTC PCCA XYLIFOS BASE 5 5 POWD FLAK STEARYL ALCOHOL 5 RX/OTC 5 PLURONIC F127 POWD POWD PLURONIC GEL 5 RX/OTC SUPPOSI-PLEX R36 PLLT 5 RX/OTC

PLURONIC L64 LIQD 5 SUPPOSI-PLEX V33 PLLT 5 RX/OTC

POLOX GEL 5 RX/OTC SUPPOSI-PURE MISC 5 RX/OTC

POLOXAMER 188 POWD 5 RX/OTC SUPPOSIBLEND PLLT 5 RX/OTC RX/OTC POLOXAMER 407 POWD 5 SUPPOSITORY BLEND 5 RX/OTC PLLT POLYMATRIX POWDER 5 RX/OTC RX/OTC POWD SYNAPSIN POWD 5 POLYPEG SUPPOSITORY 5 RX/OTC TRAGACANTH POWD 5 RX/OTC BASE MISC UCARE POLYMER JR-400 RX/OTC 5 RX/OTC 5 RDT BASE POWD POWD RX/OTC RDT-PLUS POWD 5 WAX PARAFFIN BEADS 5 RX/OTC WAX SEPINEO P 600 LIQD 5 WHITE BEES WAX WAX 5 RX/OTC RX/OTC SHEA BUTTER MISC 5 WHITE WAX PASTILLES 5 RX/OTC WAX SHEA BUTTER ORGANIC 5 RX/OTC RX/OTC MISC WHITE WAX WAX 5 SODIUM BENZOATE RX/OTC 5 WITEPSOL H15 BASE F 5 RX/OTC POWD PLLT SODIUM LAURYL 5 RX/OTC SULFATE POWD WITEPSOL H15 PLLT 5 SODIUM THIOSULFATE 5 WITEPSOL PLLT 5 RX/OTC PENTAHYDRATE CRYS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

320 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WITEPSOL WAX 5 BASE PCCA CLARIFYING 5 RX/OTC CREA RX/OTC XANTHAN GUM POWD 5 BASE W301 CREA 5 RX/OTC RX/OTC YELLOW WAX WAX 5 BHRT BASE CREA 5 RX/OTC

Semi Solid Vehicles BRAVURA ALL-IN-ONE 5 RX/OTC CREA 1ST BASE CREA 5 RX/OTC CARBOGEL 940 GEL 5 RX/OTC ALBA-DERM CREA 5 RX/OTC CARBOHOL 940 GEL 5 RX/OTC ALCOHOL BASE GEL GEL 5 CARBOMER GEL 5 RX/OTC AQUEOUS GEL ALPAWASH OINT 5 RX/OTC CARBOMER GEL 5 RX/OTC ALTADERM CREAM BASE 5 RX/OTC HYDROALCOHOLIC GEL CREA CELA BASE CREA 5 RX/OTC ANHYDROUS BASE 5 CREA CHEMSIL K-12 PSTE 5 ANHYDROUS BASE OINT 5 CHEMSIL K-51 GEL 5 RX/OTC ANHYDROUS CREAM 5 BASE CREA CHEW-HESIVE OINT 5 ANHYDROUS GEL BASE 5 RX/OTC GEL CHRYSADERM DAY 5 RX/OTC CREA ARBEM H-COSMETIC 5 RX/OTC CREA CHRYSADERM NIGHT 5 RX/OTC CREA ARBEM LIPOPEN CREA 5 RX/OTC CLEODERM CREA 5 RX/OTC ATREVIS HYDROGEL 5 RX/OTC CREA CLOVAGEL GEL 5 RX/OTC AUXIPRO VANISHING 5 RX/OTC CREAM CREA CREAM BASE CREA 5 RX/OTC RX/OTC AZ CREAM CREA 5 CREAM BASE NIOSOMES 5 CREA BASE A POLYETHYLENE 5 GLYCOL 1450 POWD CREAM CONCENTRATE 5 RX/OTC CREA BASE C POLYETHYLENE 5 RX/OTC GLYCOL 300 LIQD CREAM-HEAVY BASE 5 NIOSOME CREA BASE C POLYETHYLENE 5 RX/OTC GLYCOL E 300 LIQD CUTIS PLUS CREA 5 RX/OTC BASE CREAM WITH RX/OTC 5 DELBASE 5 RX/OTC LIPOSOME CREA COMPOUNDING OINT BASE D POLYETHYLENE 5 DERMASHIELD 5 RX/OTC GLYCOL 4500 POWD HYDROGEL GEL BASE D POLYETHYLENE 5 DURABASE ADVANCED 5 RX/OTC GLYCOL 4600 GRAN CREA 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

321 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DURABASE CREA 5 RX/OTC HRT BASE CREA 5 RX/OTC

EMOLIVAN CREA 5 RX/OTC HRT BASE FOR MEN GEL 5

EMOLLIENT CREAM 5 RX/OTC HRT BOTANICAL BASE 5 RX/OTC BASE CREA CREA EMOLLIENT CREAM 5 RX/OTC HRT BOTANICAL CREA 5 RX/OTC CREA RX/OTC ESPUMIL FOAM 5 HRT CREAM BASE CREA 5 RX/OTC HRT CREAM BASE 5 RX/OTC EXQUISITE HRT CREA 5 WOMEN CREA FAGRON LS PLUS CREA 5 RX/OTC HRT ESSENTIAL CREAM 5 RX/OTC CREA FAGRON NATURAL 5 RX/OTC RX/OTC CREAM CREA HRT HEAVY CREA 5 FAGRON SUPREME 5 RX/OTC HRT NATURAL LOTION 5 CREAM CREA LOTN FATTIBASE OINT 5 RX/OTC HYDROGEL GEL XX 5 RX/OTC

FITALITE CREA 5 RX/OTC HYDROPHILIC OINT 5 RX/OTC

FREEDOM ADAPTADERM 5 RX/OTC HYDROUS EMULSIFIED 5 RX/OTC CREA BASE CREA FREEDOM ADAPTADERM 5 RX/OTC JELENE OINT 5 RX/OTC GEL FREEDOM CEPAPRO 5 RX/OTC KRIS-ESTER 236 LIQD 5 GEL FREEDOM DERMA 5 RX/OTC KRISGEL 100 GEL 5 SERUM CREA LANOLIN ALCOHOL WAX 5 FREEDOM DERMA-D 5 RX/OTC CREA LANOLIN ANHYDROUS 5 RX/OTC FREEDOM DERMA-N 5 RX/OTC OINT CREA LANOLIN ANHYDROUS- 5 RX/OTC FREEDOM SILOMAC 5 RX/OTC GRX OINT ANHYDROUS GEL LANOLIN OIL XX 5 GRX WHITE 5 RX/OTC PETROLATUM OINT lanolin oint ex 2 RX/OTC HORMONE CREAM BASE 5 RX/OTC BOTANICAL CREA lanolin oint xx 2 RX/OTC HORMONE CREAM BASE 5 RX/OTC CREA LECITHIN ORGANOGEL 5 GEL HORMONE CREAM BASE 5 NIOSOMES CREA LIDOCAINE-PRILOCAINE- 5 HORMONE CREAM- CREAM BASE CREA HEAVY BASENIOSOMES 5 LIP BALM BASE OINT 5 RX/OTC CREA

322 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIPO CREAM BASE CREA 5 RX/OTC OLEABASE PLASTICIZED 5 RX/OTC OINT RX/OTC LIPOBASE CREA 5 OMNIBASE CREA 5 RX/OTC RX/OTC LIPOCREAM BASE CREA 5 P-SILOXAN DS CREA 5 RX/OTC

LIPOFOAM RX FOAM 5 PCCA ALADERM BASE 5 RX/OTC CREA RX/OTC LIPOGEL CR BASE GEL 5 PCCA ANHYDROUS 5 BASE OINT LIPOLAYER CREA 5 RX/OTC PCCA ANHYDROUS 5 RX/OTC LIPODERM BASE CREA LIPOPEN ABSORPTION 5 RX/OTC ENHANCING BASE CREA PCCA BASE 7542 CREA 5 RX/OTC LIPOPEN ANHYDROUS 5 LOTN PCCA BIOPEPTIDE BASE 5 RX/OTC CREA LIPOPEN ULTRA BASE 5 RX/OTC CREA PCCA CANNIDEX 2.0 5 RX/OTC CUSTOMBASE CREA LIPOSOMAL HEAVY 5 RX/OTC CREA PCCA CANNIDEX 5 RX/OTC CUSTOM BASE CREA LIPOSOMAL REGULAR 5 RX/OTC CREA PCCA COBASE #1 OINT 5 RX/OTC LIPOZYME CREA 5 PCCA COSMETIC HRT 5 RX/OTC BASE CREA LUBRAJEL NP GEL 5 RX/OTC PCCA CUSTOM LIPO- 5 RX/OTC MAX CREA MEDIBASE C LIQD 5 RX/OTC PCCA ELLAGE CREA 5 MEDIDERM CREA 5 RX/OTC PCCA EMOLLIENT 5 RX/OTC CREAM BASE CREA MEDIHOL BASE GEL 5 PCCA GELATIN BASE 5 OINT MICRODERM BASE CREA 5 RX/OTC PCCA LIPODERM BASE 5 RX/OTC MICROSOME BASE CREA 5 RX/OTC CREA PCCA LIPODERM 5 RX/OTC MULTIBASE CREA 5 RX/OTC CUSTOM BASE CREA PCCA LIPODERM HMW 5 RX/OTC NOURILITE CREA 5 RX/OTC GEL PCCA LIPOSOMIC BASE RX/OTC NOURIVAN ANTIOX 5 RX/OTC 5 CREAM BASE CREA FOR DRY SKIN CREA RX/OTC PCCA LIPOSOMIC BASE RX/OTC NOVAFILM GEL 5 FOR NORMAL SKIN 5 CREA OCCLUVAN OINT 5 RX/OTC PCCA LIPOSOMIC BASE 5 RX/OTC FOR OILY SKIN CREA OINTMENT BASE 5 EMULSIFYING OINT

323 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PCCA LIPOSOMIC BASE RX/OTC PENTAPHENE BASE 5 RX/OTC FOR SENSITIVE SKIN 5 CREA CREA PERFORMAX SALT 5 RX/OTC PCCA MVC BASE CREA 5 RX/OTC SUPPORTIVEBASE CREA PETROLATUM OINT 5 RX/OTC PCCA NATACREAM 5 RX/OTC CREA PETROLATUM WHITE 5 RX/OTC PCCA OCCLUSADERM 5 RX/OTC OINT GEL PETROLEUM JELLY OINT 5 RX/OTC PCCA PERME8 5 RX/OTC ANHYDROUS GEL PETROLEUM JELLYBABY 5 RX/OTC OINT PCCA PLASTICIZED 5 RX/OTC BASE OINT PFCB CREA 5 RX/OTC PCCA PLURONIC F127 5 BASE GEL PHARMABASE 5 RX/OTC ANTIOXIDANT CREA PCCA POLOXAMER 407 5 GEL PHARMABASE 5 RX/OTC COSMETIC CREA PCCA POLYPEG BASE 5 RX/OTC OINT PHARMABASE RX/OTC COSMETIC NATURAL 5 PCCA PRACASIL TM- 5 RX/OTC PLUS BASE CREA CREA PHARMABASE HEAVY RX/OTC PCCA SPIRA-WASH 5 RX/OTC 5 BASE GEL CREA PHARMABASE LIGHT RX/OTC PCCA VANISHING 5 RX/OTC 5 CREAM LIGHT CREA CREA PCCA VANISHING RX/OTC PHARMABASE VAGINAL 5 RX/OTC CREAM/LOTION BASE 5 MOISTURIZING CREA CREA PHYTOBASE CREA 5 RX/OTC PCCA VANPEN BASE 5 RX/OTC CREA PLASTIBASE OINT 5 RX/OTC PCCA W06 ANHYDROUS 5 RX/OTC TOPICAL GEL PLASTICIZED BASE OINT 5 RX/OTC PCCA WAV CUSTOM RX/OTC 5 PLO GEL - MEDIFLO 30 5 BASE CREA PRE-MIXED GEL RX/OTC PEG 300 LIQD 5 PLO GEL - MEDIFLO KIT 5 KIT PEG OINT 5 RX/OTC PLO GEL - MEDIFLO PRE- 5 MIXED GEL PEG OINTMENT BASE 5 RX/OTC OINT PLO TRANSDERMAL 5 CREAM CREA PENCREAM CREA 5 RX/OTC PLO20 BASE GEL 5 PENDERM CREA 5 RX/OTC PLO20 FLOWABLE GEL 5 PENSOMAL CREAM 5 RX/OTC CREA PLO20 NON-FLOWABLE 5 GEL

324 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLURONIC F127 GEL 5 SA3 DERM CREA 5 RX/OTC

PNA-HRT BASE CREA 5 RX/OTC SALT DURABLE CREAM 5 RX/OTC CREA RX/OTC POLYBASE OINT 5 SALT STABLE LS 5 RX/OTC ADVANCED CREA POLYETHYLENE GLYCOL 5 RX/OTC 1000 POWD SALTSTABLE LO CREA 5 POLYETHYLENE GLYCOL 5 SANARE ADVANCED 5 RX/OTC 1450 FLAK SCAR THERAPY CREA POLYETHYLENE GLYCOL RX/OTC 5 SANARE SCAR THERAPY 5 RX/OTC 1450 LIQD CREA POLYETHYLENE GLYCOL 5 SCAR CARE BASE 5 RX/OTC 1450 POWD ENHANCED GEL POLYETHYLENE GLYCOL 5 SCAR CARE CREAM 5 RX/OTC 1500 POWD CREA POLYETHYLENE GLYCOL RX/OTC 5 SILOSOME 5 300 LIQD TRANSDERMAL CREA POLYETHYLENE GLYCOL 5 RX/OTC 3350 GRAN SILPROTEX PLUS CREA 5 POLYETHYLENE GLYCOL 5 RX/OTC SIMPLGEL 30 GEL 5 RX/OTC 3350 POWD SKIN PROTECTANT RX/OTC POLYETHYLENE GLYCOL 5 RX/OTC 5 400 LIQD PETROLATUM OINT RX/OTC POLYETHYLENE GLYCOL 5 SKYY DERM CREA 5 4500 POWD RX/OTC POLYETHYLENE GLYCOL 5 STERA BASE CREA 5 600 LIQD SUSPENDIT GEL 5 RX/OTC POLYETHYLENE GLYCOL 5 8000 GRAN TDC MAX CREAM CREA 5 POLYETHYLENE GLYCOL 5 RX/OTC 8000 POWD TERODERM CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 8000BASE E OINT TERODERM-PLUS CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 RX/OTC BLEND OINT TIGHTENING BASE CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 NF POWD TOMMY GEL GEL 5 RX/OTC POLYMAC PROGEL GEL 5 RX/OTC TRANSDERMAL PAIN 5 BASE CREA Q-DERM CREA 5 RX/OTC U-BASE CREA 5 RX/OTC RA PETROLEUM JELLY 5 RX/OTC OINT ULTRADERM CREA 5 RX/OTC RENEWCREAM HRT 5 RX/OTC CREA UNIVERSAL WATER GEL 5 GEL

325 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits V-MAX CREA 5 RX/OTC WOUND CARE CREAM 5 RX/OTC CREA RX/OTC VANIBASE CREA 5 XCEL 100 CREA 5 RX/OTC RX/OTC VANISH-PEN CREA 5 XEMATOP BASE CREA 5 RX/OTC VANISHING CREAM RX/OTC 5 YELLOW PETROLATUM 5 RX/OTC BOTANICALBASE CREA OINT VANISHING CREAM RX/OTC 5 ZOE SCRIPTS 5 RX/OTC CREA IDEALBASE CREA VERSABASE CREA 5 ZOSIL PSTE 5 VERSABASE FOAM 5 Surfactants FOAM MYRJ 53 POWD 5 RX/OTC VERSABASE GEL 5 RX/OTC POLYOXYL 40 STEARATE 5 VERSABASE HRT GEL 5 RX/OTC PLLT POLYOXYL 40 STEARATE 5 RX/OTC VERSABASE LOTN 5 POWD VERSABASE SHAM 5 PROGESTINS - Hormone Replacement/Modifying Drugs VERSAPRO ANHYDROUS 5 RX/OTC Progestins BASE GEL AYGESTIN TABS (Use 5 VERSAPRO CREA EX 5 RX/OTC norethindrone acetate) EC-RX PROGESTERONE NC VERSAPRO FOAM XX 5 10% CREA RX/OTC EC-RX PROGESTERONE NC VERSAPRO GEL XX 5 20% CREA VERSAPRO LOTN XX 5 hydroxyprogesterone 2 PA; SP caproate oil im VERSATILE CREAM 5 RX/OTC MAKENA OIL IM 250 PA; SP BASE CREA MG/ML (Use 5 hydroxyprogesterone VERSATILE RICH CREAM 5 RX/OTC BASE CREA caproate) VERSIGEL CREA 5 RX/OTC MAKENA SOAJ SC 275 5 PA; SP MG/1.1ML VP DERMABASE CREA 5 RX/OTC medroxyprogesterone acetate tabs or 10 mg, 2.5 2 WATER BASE GEL GEL 5 mg, 5 mg MEGACE ES SUSP (Use white petrolatum gel xx 2 RX/OTC megestrol acetate 5 (appetite)) WHITE PETROLATUM RX/OTC 5 megestrol acetate 2 OINT EX (appetite) susp WILEY BASIC ELEMENTS RX/OTC 5 NORETHINDRONE 5 BHRTBASE CREA ACETATE POWD XX

326 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone acetate tabs 2 ARICEPT TABS (Use 5 QL(1 ea daily) or donepezil hydrochloride) PROGESTERONE 10% NC donepezil hydrochloride 2 QL(1 ea daily) KIT CREA tabs progesterone caps or 100 2 QL(1 ea daily) donepezil hydrochloride 2 QL(1 ea daily) mg tbdp progesterone caps or 100 NC EXELON PT24 13.3 mg, 200 mg MG/24HR (Use 5 rivastigmine) progesterone caps or 200 2 QL(0.6667 ea mg daily) EXELON PT24 4.6 QL(1 ea daily) PROGESTERONE MG/24HR, 9.5 MG/24HR 5 COMPOUNDINGKIT NC (Use rivastigmine) CREA galantamine hydrobromide 2 QL(1 ea daily) cp24 16 mg, 24 mg, 8 mg progesterone oil im 50 2 mg/ml galantamine hydrobromide 2 QL(6 ml daily) soln 4 mg/ml PROMETRIUM CAPS 100 5 QL(1 ea daily) MG (Use progesterone) galantamine hydrobromide 2 QL(2 ea daily) PROMETRIUM CAPS 100 tabs 12 mg, 4 mg, 8 mg MG, 200 MG (Use NC memantine hcl cp24 14 mg, 2 progesterone) 21 mg, 28 mg, 7 mg PROMETRIUM CAPS 200 5 QL(0.6667 ea memantine hcl soln 10 2 QL(10 ml daily) MG (Use progesterone) daily) mg/5ml, 2 mg/ml PROVERA TABS (Use memantine hcl tabs 2 medroxyprogesterone 5 acetate) memantine hcl tabs 10 mg, 2 QL(2 ea daily) PSYCHOTHERAPEUTIC AND NEUROLOGICAL 5 mg AGENTS - MISC. - Drugs to Treat Mental and NAMENDA TABS (Use 5 QL(2 ea daily) Emotional Conditions memantine hcl) Agents for Chemical Dependency NAMENDA TITRATION PAK TABS (Use 5 acamprosate calcium tbec 2 memantine hcl) NAMENDA XR CP24 (Use ANTABUSE TABS (Use 4 5 disulfiram) memantine hcl) NAMENDA XR TITRATION disulfiram tabs or 250 mg, 2 5 500 mg PACK CP24 LUCEMYRA TABS NC NAMZARIC C4PK 4 Anti-Cataplectic Agents NAMZARIC CP24 4 PA; SP XYREM SOLN 5 RAZADYNE ER CP24 (Use 5 QL(1 ea daily) galantamine hydrobromide) SP XYWAV SOLN NC RAZADYNE TABS (Use 5 QL(2 ea daily) galantamine hydrobromide) Antidementia Agents rivastigmine pt24 13.3 2 ADUHELM SOLN NC SP mg/24hr rivastigmine pt24 4.6 2 QL(1 ea daily) mg/24hr, 9.5 mg/24hr 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

327 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits rivastigmine tartrate caps 2 QL(2 ea daily) dimethyl fumarate misc or 2 PA; SP

Combination Psychotherapeutics EXTAVIA KIT NC PA; SP chlordiazepoxide- 2 amitriptyline tabs GILENYA CAPS 0.5 MG 4 PA; SP olanzapine-fluoxetine hcl 2 PA; SP caps glatiramer acetate sosy 2 perphenazine-amitriptyline 2 QL(4 ea daily) PA; SP tabs KESIMPTA SOAJ 4 SYMBYAX CAPS (Use 5 LEMTRADA SOLN 5 PA; SP olanzapine-fluoxetine hcl) Fibromyalgia Agents MAVENCLAD TBPK 5 PA; SP 5 QL(2 ea daily) SAVELLA TABS MAYZENT STARTER 4 PA; SP PACK TBPK SAVELLA TITRATION 5 QL(2 ea daily) PACK MISC MAYZENT TABS 4 PA; SP Movement Disorder Drug Therapy OCREVUS SOLN 4 PA; SP AUSTEDO TABS 4 PA; SP PLEGRIDY SOPN SC NC PA; SP INGREZZA CAPS 4 PA; SP PLEGRIDY SOSY IM NC INGREZZA CPPK 4 PA; SP PLEGRIDY SOSY SC NC PA; SP tetrabenazine tabs 2 PA; SP PLEGRIDY STARTER NC PA; SP PACK SOPN XENAZINE TABS (Use NC PA; SP tetrabenazine) PLEGRIDY STARTER NC PA; SP Multiple Sclerosis Agents PACK SOSY PONVORY 14-DAY SP AMPYRA TB12 (Use 5 PA; SP NC dalfampridine) STARTER PACK TBPK SP AUBAGIO TABS 4 PA; SP PONVORY TABS NC PA; SP AVONEX PEN AJKT NC PA; SP REBIF REBIDOSE SOAJ 4 PA; SP REBIF REBIDOSE 4 PA; SP AVONEX PSKT NC TITRATIONPACK SOAJ PA; SP BAFIERTAM CPDR NC REBIF SOSY 4

PA; SP REBIF TITRATION PACK 4 PA; SP BETASERON KIT 4 SOSY COPAXONE SOSY (Use PA; SP 4 TECFIDERA CPDR (Use NC PA; SP glatiramer acetate) dimethyl fumarate) dalfampridine tb12 or 2 PA; SP TECFIDERA STARTER PA; SP PACK MISC (Use dimethyl NC fumarate) dimethyl fumarate cpdr or 2 PA; SP 120 mg, 240 mg

328 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYSABRI CONC 4 PA; SP Psychotherapeutic and Neurological Agents - ergoloid mesylates tabs or 2 VUMERITY CPDR 4 PA; SP pimozide tabs 2 ZEPOSIA 7-DAY 4 PA; SP STARTER PACK CPPK Restless Leg Syndrome (RLS) Agents ZEPOSIA CAPS 4 PA; SP HORIZANT TBCR 300 MG NC QL(2 ea daily) ZEPOSIA STARTER KIT 4 PA; SP CPPK HORIZANT TBCR 600 MG NC QL(1 ea daily) Postherpetic Neuralgia (PHN)/Neuropathic Pain Smoking Deterrents CONVENIENCE PAK NC THPK APO-VARENICLINE TABS 6 QL(2 ea daily)

GABACAINE THPK NC bupropion hcl (smoking 6 QL(2 ea daily) deterrent) tb12 GABAPAL THPK NC CHANTIX CONTINUING 6 QL(2 ea daily) MONTHPAK TABS GPL PAK THPK NC CHANTIX STARTING 6 MONTH PAK TABS GRALISE TABS 300 MG, 4 PA 600 MG CHANTIX TABS 6 QL(2 ea daily) LIDO GB-300 THPK NC QL(1 ea daily); NICODERM CQ PT24 14 6 MG/24HR (Use nicotine) AL(At least 18 LIDOTIN THPK NC yrs old) NICODERM CQ PT24 7 QL(1 ea daily); LIPRITIN II THPK NC MG/24HR, 21 MG/24HR 4 AL(At least 18 (Use nicotine) yrs old) LIPRITIN THPK NC NICORETTE GUM (Use 5 nicotine polacrilex) LYRICA CR TB24 (Use NC PA pregabalin (once-daily)) NICORETTE LOZG (Use 5 PENTICAN THPK NC nicotine polacrilex) NICORETTE MINI LOZG 5 pregabalin (once-daily) NC PA (Use nicotine polacrilex) tb24 NICORETTE STARTER PRILOPENTIN THPK NC KIT GUM (Use nicotine 5 polacrilex) Premenstrual Dysphoric Disorder (PMDD) Agents nicotine polacrilex gum mt 6 4 mg, 2 mg fluoxetine hcl (pmdd) caps 2 PA; ST 10 mg, 20 mg nicotine polacrilex lozg mt 2 6 mg, 4 mg fluoxetine hcl (pmdd) tabs NC 10 mg, 20 mg QL(1 ea daily); nicotine pt24 6 AL(At least 18 SARAFEM TABS (Use 5 fluoxetine hcl (pmdd)) yrs old) Pseudobulbar Affect (PBA) Agents NICOTINE TRANSDERMAL SYSTEM 6 NUEDEXTA CAPS 4 QL(2 ea daily) KIT

329 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICOTROL INHALER 6 SYMDEKO TBPK 5 PA; SP INHA TRIKAFTA TBPK 25 MG- NC SP NICOTROL NS SOLN 6 50 MG Transthyretin Amyloidosis Agents TRIKAFTA TBPK 50 MG- 5 PA; SP 100 MG ONPATTRO SOLN 5 PA; SP Pleural Sclerosing Agents PA; SP TEGSEDI SOSY 4 SCLEROSOL 5 INTRAPLEURAL AERP Vasomotor Symptom Agents STERILE TALC POWDER 5 BRISDELLE CAPS (Use SUSR paroxetine mesylate 5 (vasomotor)) STERITALC POWD 5 paroxetine mesylate NC Pulmonary Fibrosis Agents (vasomotor) caps ESBRIET CAPS 4 PA; SP RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions ESBRIET TABS 4 PA; SP Alpha-Proteinase Inhibitor (Human) OFEV CAPS 4 PA; SP ARALAST NP SOLR 1000 NC SP MG Respiratory Agents - Misc. ARALAST NP SOLR 500 NC PA; SP MG CUROSURF SUSP 5 PA; SP GLASSIA SOLN NC INFASURF SUSP 5 PROLASTIN-C SOLN 1000 PA; 30 rtl lmt 4 SURVANTA 5 MG/20ML day(s),; SP INTRATRACHEAL SUSP PROLASTIN-C SOLR 1000 4 PA; SP MG SULFONAMIDES - Drugs to Treat Bacterial Infections ZEMAIRA SOLR NC SP Sulfonamides Cystic Fibrosis Agents SULFADIAZINE POWD 5 BRONCHITOL CAPS NC SULFADIAZINE SODIUM 5 POWD BRONCHITOL NC TOLERANCE TEST CAPS SULFADIAZINE TABS 5 KALYDECO PACK 5 PA; SP SULFAMETHOXAZOLE 5 MICRO POWD KALYDECO TABS 5 PA; SP SULFAMETHOXAZOLE 5 POWD ORKAMBI PACK 5 PA; SP SULFAPYRIDINE POWD 5 ORKAMBI TABS 5 PA; SP SULFATHIAZOLE POWD 5 PA; QL(5 ml PULMOZYME SOLN 4 daily); SP SULFISOXIZOLE CRYS 5

330 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TETRACYCLINES - Drugs to Treat Bacterial DOXYCYCLINE HYCLATE 5 Infections POWD XX doxycycline hyclate solr iv Aminomethylcyclines 2 100 mg NUZYRA SOLR 5 doxycycline hyclate tabs or 2 100 mg, 20 mg NUZYRA TABS 5 doxycycline hyclate tabs or NC 150 mg, 50 mg, 75 mg Fluorocyclines doxycycline hyclate tbec or 2 XERAVA SOLR 5 100 mg, 150 mg, 75 mg doxycycline hyclate tbec or NC Glycylcyclines 200 mg, 50 mg, 80 mg tigecycline solr 2 MINOCIN CAPS OR 50 NC MG (Use minocycline hcl) TIGECYCLINE SOLR NC MINOCIN SOLR IV 100 5 MG TYGACIL SOLR (Use NC tigecycline) minocycline hcl caps or 100 2 mg, 50 mg, 75 mg Tetracycline Combinations minocycline hcl cp24 or NC PA AVIDOXY DK KIT 5 135 mg, 45 mg, 90 mg MINOCYCLINE HCL 5 BENZODOX 30 KIT THPK NC POWD XX minocycline hcl tabs or 100 2 BENZODOX 60 KIT THPK NC mg, 50 mg, 75 mg Tetracyclines minocycline hcl tb24 or 105 mg, 115 mg, 55 mg, 65 mg, NC ACTICLATE TABS (Use NC 80 mg doxycycline hyclate) minocycline hcl tb24 or 135 NC PA demeclocycline hcl tabs 2 mg, 45 mg, 90 mg MINOLIRA TB24 NC DORYX MPC TBEC NC MORGIDOX 1X100MG KIT 5 DORYX TBEC (Use NC doxycycline hyclate) MORGIDOX 1X50MG KIT NC doxycycline (monohydrate) NC KIT caps 150 mg, 75 mg MORGIDOX 2X100MG KIT 5 doxycycline (monohydrate) 2 caps 50 mg, 100 mg NUTRIDOX KIT 5 doxycycline (monohydrate) 2 susr 25 mg/5ml OXYTETRACYCLINE HCL 5 doxycycline (monohydrate) POWD tabs 150 mg, 50 mg, 75 2 mg, 100 mg SEYSARA TABS NC doxycycline hyclate caps or 2 SOLODYN TB24 (Use 5 50 mg, 100 mg minocycline hcl) DOXYCYCLINE HYCLATE NC tetracycline hcl caps or 250 2 DR TBEC mg, 500 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

331 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIBRAMYCIN CAPS 100 LEVOTHYROXINE MG (Use doxycycline 5 SODIUM SOLR IV 100 2 hyclate) MCG, 500 MCG (Use VIBRAMYCIN SUSR 25 levothyroxine sodium) MG/5ML (Use doxycycline 4 LEVOTHYROXINE (monohydrate)) SODIUM SOLR IV 200 5 MCG (Use levothyroxine VIBRAMYCIN SYRP 50 4 MG/5ML sodium) levothyroxine sodium tabs XIMINO CP24 (Use NC PA minocycline hcl) or 300 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 2 THYROID AGENTS - Drugs to Regulate Thyroid 150 mcg, 175 mcg, 200 Hormones mcg, 25 mcg, 50 mcg, 75 Antithyroid Agents mcg, 88 mcg liothyronine sodium soln iv 2 METHIMAZOLE POWD XX 5 10 mcg/ml liothyronine sodium tabs or methimazole tabs or 10 2 2 mg, 5 mg 50 mcg, 25 mcg, 5 mcg NATURE-THROID NT-2.5 2 NC propylthiouracil tabs or TABS SODIUM IODIDE I-131 NC NATURE-THROID TABS NC SOLN SYNTHROID TABS (Use TAPAZOLE TABS (Use 4 4 methimazole) levothyroxine sodium) Thyroid Hormones THYQUIDITY SOLN NC ARMOUR THYROID TABS THYROID PORCINE 5 120 MG, 15 MG, 30 MG, 5 POWD 60 MG, 90 MG (Use thyroid) THYROID POWD XX 0.23 5 %, ARMOUR THYROID TABS 5 180 MG, 240 MG, 300 MG thyroid tabs or 120 mg, 15 2 mg, 30 mg, 60 mg, 90 mg CYTOMEL TABS (Use NC liothyronine sodium) TIROSINT CAPS 100 MCG, 112 MCG, 125 MCG, levothyroxine sodium caps 13 MCG, 137 MCG, 150 or 100 mcg, 112 mcg, 125 MCG, 175 MCG, 200 MCG, NC mcg, 13 mcg, 137 mcg, NC 25 MCG, 50 MCG, 75 150 mcg, 175 mcg, 200 MCG, 88 MCG (Use mcg, 25 mcg, 50 mcg, 75 levothyroxine sodium) mcg, 88 mcg LEVOTHYROXINE TIROSINT CAPS 75 MCG NC SODIUM SOLN IV 100 NC MCG/5ML, 200 MCG/5ML, 500 MCG/5ML levothyroxine sodium solr iv 100 mcg, 200 mcg, 500 2 mcg

332 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIROSINT-SOL SOLN 100 VAXELIS SUSP 6 PV MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, VAXELIS SUSY 6 PV 137 MCG/ML, 150 NC MCG/ML, 175 MCG/ML, ULCER DRUGS - Drugs to Treat Bowel, Intestine 200 MCG/ML, 25 MCG/ML, and Stomach Conditions 50 MCG/ML, 75 MCG/ML, 88 MCG/ML Antispasmodics TRIOSTAT SOLN (Use 5 ATROPEN SOAJ 5 liothyronine sodium) ATROPINE SULFATE WESTHROID TABS NC MONOHYDRATE POWD 5 XX WP THYROID TABS NC ATROPINE SULFATE 5 POWD XX TOXOIDS atropine sulfate soln ij 0.4 2 Toxoid Combinations mg/ml, 1 mg/ml, 8 mg/20ml AL(At least 7 ATROPINE SULFATE ADACEL SUSP 6 yrs old - Up to SOLN IJ 8 MG/20ML (Use 5 64 yrs old) atropine sulfate) ATROPINE SULFATE BOOSTRIX SUSP 6 AL(At least 7 yrs old) SOLN IV 0.4 MG/ML, 1 NC AL(Up to 6 yrs MG/ML DAPTACEL SUSP 6 old ) atropine sulfate sosy ij 0.25 DIPHTHERIA/TETANUS AL(Up to 6 yrs mg/5ml, 0.5 mg/5ml, 1 2 TOXOIDS ADSORBED 6 old ) mg/10ml PEDIATRIC SUSP ATROPINE SULFATE SOSY IV 0.8 MG/2ML, 1 INFANRIX SUSP 6 AL(Up to 6 yrs NC old ) MG/2.5ML, 1.2 MG/3ML, 2 MG/5ML AL(At least 4 KINRIX SUSP 6 yrs old - Up to BELLADONNA/OPIUM 5 6 yrs old) SUPP BENTYL SOLN (Use PEDIARIX SUSP 6 AL(Up to 6 yrs 5 old ) dicyclomine hcl) chlordiazepoxide hcl- PENTACEL SUSR 6 AL(Up to 4 yrs NC old ) clidinium bromide caps AL(At least 4 CUVPOSA SOLN 5 QUADRACEL SUSP 6 yrs old - Up to 6 yrs old) dicyclomine hcl caps 2 TDVAX SUSP 6 AL(At least 7 yrs old) dicyclomine hcl soln 2 TENIVAC INJ 6 AL(At least 7 yrs old) dicyclomine hcl tabs 2 TETANUS/DIPHTHERIA AL(At least 7 GLYCATE TABS NC TOXOIDS-ADSORBED 6 yrs old) ADULT SUSP

333 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits glycopyrrolate soln ij 0.2 H-2 Antagonists mg/ml, 0.4 mg/2ml, 1 2 QL(20 ml daily) mg/5ml, 4 mg/20ml cimetidine hcl soln 2 GLYCOPYRROLATE CIMETIDINE POWD XX 5 SOSY IJ 0.2 MG/ML, 0.4 NC MG/2ML, 0.6 MG/3ML, 1 QL(4 ea daily); cimetidine tabs or 200 mg 2 MG/5ML RX/OTC GLYCOPYRROLATE QL(4 ea daily) SOSY IV 0.4 MG/2ML, 0.6 NC cimetidine tabs or 300 mg 2 MG/3ML, 1 MG/5ML cimetidine tabs or 400 mg 2 QL(2 ea daily) glycopyrrolate tabs or 1 2 mg, 2 mg cimetidine tabs or 800 mg 2 QL(1 ea daily) GLYCOPYRROLATE NC TABS OR 1.5 MG DEPRIZINE FUSEPAQ 5 SUSR GLYRX-PF SOLN NC famotidine in nacl soln 2 GLYRX-PF SOSY NC famotidine soln iv 20 HYOSCYAMINE SULFATE 5 mg/2ml, 200 mg/20ml, 40 2 POWD XX mg/4ml hyoscyamine sulfate soln ij 2 famotidine susr or 40 2 0.5 mg/ml mg/5ml hyoscyamine sulfate subl sl QL(2 ea daily); 2 famotidine tabs or 20 mg 2 0.125 mg RX/OTC hyoscyamine sulfate tb12 NC famotidine tabs or 40 mg 2 or 0.375 mg FAMOTIDINE/SODIUM ISOPROPAMIDE IODIDE 5 NC POWD CHLORIDE SOSY GNP ACID CONTROL 150 QL(2 ea daily); LEVBID TB12 (Use 5 QL(4 ea daily) hyoscyamine sulfate) MAXIMUM STRENGTH 5 RX/OTC TABS LEVSIN SOLN (Use 5 hyoscyamine sulfate) nizatidine caps 150 mg 2 QL(2 ea daily) LEVSIN/SL SUBL (Use 4 hyoscyamine sulfate) nizatidine caps 300 mg 2 QL(1 ea daily) LIBRAX CAPS (Use QL(20 ml daily) chlordiazepoxide hcl- NC nizatidine soln 15 mg/ml 2 clidinium bromide) PEPCID AC MAXIMUM RX/OTC methscopolamine bromide 2 STRENGTH TABS (Use NF tabs or 2.5 mg, 5 mg famotidine) PROPANTHELINE 5 PEPCID AC TABS (Use NF RX/OTC BROMIDE POWD XX famotidine) propantheline bromide tabs 2 PEPCID TABS 20 MG (Use 5 QL(2 ea daily); or famotidine) RX/OTC SCOPOLAMINE HBR 5 PEPCID TABS 40 MG (Use 5 POWD famotidine) SYMAX DUOTAB TBCR 5

334 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl caps or 150 2 QL(2 ea daily) esomeprazole magnesium 2 QL(1 ea daily); mg cpdr 20 mg RX/OTC ranitidine hcl caps or 300 2 QL(1 ea daily) esomeprazole magnesium 2 RX/OTC mg cpdr 20 mg ranitidine hcl soln ij 1000 2 esomeprazole magnesium 2 QL(1 ea daily) mg/40ml, 150 mg/6ml cpdr 40 mg ranitidine hcl soln ij 50 2 QL(2 ml daily) esomeprazole magnesium 2 mg/2ml pack 10 mg, 20 mg, 40 mg ranitidine hcl syrp or 15 QL(20 ml daily) esomeprazole sodium solr 2 mg/ml, 150 mg/10ml, 75 2 mg/5ml ESOMEPRAZOLE 5 QL(1 ea daily) STRONTIUM CPDR ranitidine hcl tabs or 150 2 QL(2 ea daily); mg RX/OTC ESOMEPRAZOLE NC QL(1 ea daily) STRONTIUM CPDR ranitidine hcl tabs or 300 2 QL(2 ea daily) mg FIRST-LANSOPRAZOLE 5 SUSP TAGAMET HB TABS (Use 5 QL(4 ea daily); cimetidine) RX/OTC FIRST-OMEPRAZOLE 5 ZANTAC 150 MAXIMUM QL(2 ea daily); SUSP 5 STRENGTH TABS (Use RX/OTC lansoprazole cpdr or 15 mg 2 RX/OTC ranitidine hcl) QL(1 ea daily) ZANTAC SOLN 25 MG/ML 5 lansoprazole cpdr or 30 mg 2 (Use ranitidine hcl) QL(1 ea daily); ZANTAC SOLN 50 QL(2 ml daily) lansoprazole tbdd or 15 mg 2 MG/2ML (Use ranitidine 5 RX/OTC hcl) lansoprazole tbdd or 30 mg 2 QL(1 ea daily) Misc. Anti-Ulcer NEXIUM 24HR CLEAR QL(1 ea daily); CARAFATE SUSP 1 NC MINIS CPDR (Use 5 RX/OTC GM/10ML (Use sucralfate) esomeprazole magnesium) CARAFATE TABS 1 GM QL(4 ea daily) NC NEXIUM 24HR CPDR (Use 5 QL(1 ea daily); (Use sucralfate) esomeprazole magnesium) RX/OTC SUCRALFATE POWD XX 5 NEXIUM CPDR 20 MG QL(1 ea daily); (Use esomeprazole NC RX/OTC sucralfate susp or 1 NC magnesium) gm/10ml NEXIUM CPDR 40 MG QL(1 ea daily) sucralfate tabs or 1 gm 2 QL(4 ea daily) (Use esomeprazole NC magnesium) Proton Pump Inhibitors NEXIUM I.V. SOLR (Use 5 esomeprazole sodium) ACIPHEX SPRINKLE NC CPSP 10 MG, 5 MG NEXIUM PACK 10 MG, 20 MG, 40 MG (Use NC ACIPHEX TBEC (Use NC QL(2 ea daily) rabeprazole sodium) esomeprazole magnesium) NEXIUM PACK 2.5 MG, 5 DEXILANT CPDR 4 ST; QL(1 ea NC daily) MG OMEPRAZOLE + NC ESOMEP-EZS KIT SYRSPEND SFALKA 5 SUSP

335 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omeprazole cpdr or 10 mg, 2 HELIDAC THERAPY MISC NC 40 mg omeprazole cpdr or 20 mg 2 RX/OTC OMECLAMOX-PAK MISC 5 omeprazole-sodium QL(1 ea daily); pantoprazole sodium pack NC or 40 mg bicarbonate caps 1100 mg- NC RX/OTC 20 mg, 20 mg-1100 mg pantoprazole sodium solr iv 2 40 mg omeprazole-sodium QL(1 ea daily); bicarbonate caps 20 mg- 2 RX/OTC pantoprazole sodium tbec 2 QL(1 ea daily) or 20 mg, 40 mg 1100 mg omeprazole-sodium RX/OTC PREVACID 24HR CPDR NC RX/OTC (Use lansoprazole) bicarbonate caps 20 mg- NC 1100 mg PREVACID CPDR 15 MG NC RX/OTC (Use lansoprazole) omeprazole-sodium QL(1 ea daily) bicarbonate caps 40 mg- NC PREVACID CPDR 30 MG NC QL(1 ea daily) 1100 mg (Use lansoprazole) omeprazole-sodium PREVACID SOLUTAB QL(1 ea daily); bicarbonate pack 20 mg- NC TBDD 15 MG (Use NC RX/OTC 1680 mg, 40 mg-1680 mg lansoprazole) PREVACID SOLUTAB QL(1 ea daily) PYLERA CAPS 4 TBDD 30 MG (Use NC lansoprazole) TALICIA CPDR 5 PRILOSEC PACK NC ZEGERID CAPS 20 MG- QL(1 ea daily); 1100 MG (Use NC RX/OTC PROTONIX PACK OR 40 omeprazole-sodium MG (Use pantoprazole NC bicarbonate) sodium) ZEGERID CAPS 40 MG- QL(1 ea daily) PROTONIX SOLR IV 40 1100 MG (Use NC MG (Use pantoprazole 5 omeprazole-sodium sodium) bicarbonate) PROTONIX TBEC OR 20 QL(1 ea daily) ZEGERID OTC CAPS (Use QL(1 ea daily); MG, 40 MG (Use NC omeprazole-sodium 5 RX/OTC pantoprazole sodium) bicarbonate) RABEPRAZOLE SODIUM 5 ZEGERID PACK 20 MG- DR SPRINKLE CPSP 1680 MG, 40 MG-1680 MG NC QL(2 ea daily) (Use omeprazole-sodium rabeprazole sodium tbec 2 bicarbonate) Ulcer Drugs - Prostaglandins URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms CYTOTEC TABS (Use 4 QL(4 ea daily) misoprostol) Urinary Antispasmodic - Antimuscarinics misoprostol tabs or 100 QL(4 ea daily) 2 darifenacin hydrobromide 2 QL(1 ea daily) mcg, 200 mcg tb24 Ulcer Therapy Combinations DETROL LA CP24 (Use NC QL(1 ea daily) tolterodine tartrate) amoxicillin-clarithromycin 2 w/ lansoprazole misc DETROL TABS (Use 5 QL(2 ea daily) tolterodine tartrate)

336 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DITROPAN XL TB24 (Use 5 QL(2 ea daily) oxybutynin chloride) VACCINES ENABLEX TB24 (Use NC QL(1 ea daily) Bacterial Vaccines darifenacin hydrobromide) ACTHIB SOLR 6 GELNIQUE GEL 5 ST BCG VACCINE INJ 5 GELNIQUE PUMP GEL 5 ST AL(At least 10 BEXSERO SUSY 6 oxybutynin chloride syrp or 2 QL(16 ml daily) yrs old) 5 mg/5ml BIOTHRAX SUSP 5 oxybutynin chloride tabs or 2 QL(3 ea daily) 5 mg HIBERIX SOLR 6 oxybutynin chloride tb24 or 2 QL(2 ea daily) 10 mg, 15 mg, 5 mg MENACTRA INJ 6 OXYTROL PTTW NC RX/OTC MENQUADFI INJ 6 solifenacin succinate tabs 2 QL(1 ea daily) MENVEO SOLR 6 tolterodine tartrate cp24 2 2 QL(1 ea daily) mg, 4 mg PEDVAX HIB SUSP 6 tolterodine tartrate tabs 1 2 QL(2 ea daily) mg, 2 mg PNEUMOVAX 23 INJ 6 AL(At least 2 yrs old) ST; QL(1 ea TOVIAZ TB24 4 daily) PNEUMOVAX 23/1 DOSE 6 AL(At least 2 INJ yrs old) trospium chloride cp24 60 2 QL(1 ea daily) mg PREVNAR 13 SUSP 6 trospium chloride tabs 20 2 TRUMENBA SUSY 6 AL(At least 10 mg yrs old) VESICARE LS SUSP 5 TYPHIM VI SOLN 5 VESICARE TABS (Use 5 QL(1 ea daily) solifenacin succinate) VAXCHORA SUSR 5 Urinary Antispasmodics - Beta-3 Adrenergic VIVOTIF CPDR 5 GEMTESA TABS NC Viral Vaccines MYRBETRIQ TB24 25 MG, ST; QL(1 ea 4 AFLURIA QUADRIVALENT 6 50 MG daily) 2021-2022 SUSP Urinary Antispasmodics - Cholinergic Agonists AFLURIA QUADRIVALENT 6 AL(Up to 3 yrs bethanechol chloride tabs 2021-2022 SUSY old ) or 10 mg, 25 mg, 5 mg, 50 2 AFLURIA QUADRIVALENT 6 mg 2021-2022 SUSY ENGERIX-B INJ IM 10 AL(Up to 19 yrs URECHOLINE TABS (Use 4 6 bethanechol chloride) MCG/0.5ML old ) Urinary Antispasmodics - Direct Muscle Relaxants ENGERIX-B INJ IM 20 6 AL(At least 20 MCG/ML yrs old) flavoxate hcl tabs 2

337 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENGERIX-B SUSP IJ 10 AL(Up to 19 yrs 6 HEPLISAV-B SOSY 6 AL(At least 18 MCG/0.5ML old ) yrs old) ENGERIX-B SUSP IJ 20 6 AL(At least 20 IMOVAX RABIES 5 MCG/ML yrs old) (H.D.C.V.) INJ FLUAD QUADRIVALENT 6 AL(At least 65 IPOL INACTIVATED IPV 6 2021-2022 PRSY yrs old) INJ FLUARIX QUADRIVALENT 6 IXIARO SUSP 5 2021-2022 SUSY AL(At least 1 FLUBLOK AL(At least 18 M-M-R II SOLR 6 QUADRIVALENT 2021- 6 yrs old) yrs old) 2022 SOSY AL(At least 1 FLUCELVAX AL(At least 4 PROQUAD SUSR 6 yrs old - Up to QUADRIVALENT 2021- 6 yrs old) 12 yrs old) 2022 SUSP RABAVERT SUSR 5 FLUCELVAX AL(At least 4 QUADRIVALENT 2021- 6 yrs old) RECOMBIVAX HB SUSP 6 AL(At least 11 2022 SUSY 10 MCG/ML yrs old) FLULAVAL RECOMBIVAX HB SUSP 6 AL(At least 18 QUADRIVALENT 2021- 6 40 MCG/ML yrs old) 2022 SUSY RECOMBIVAX HB SUSP 5 6 AL(Up to 19 yrs AL(At least 2 MCG/0.5ML old ) FLUMIST 6 yrs old - Up to QUADRIVALENT SUSP ROTARIX SUSR 6 AL(Up to 1 yrs 49 yrs old) old ) FLUZONE HIGH-DOSE PF AL(At least 65 6 ROTATEQ SOLN 6 AL(Up to 1 yrs 2021-2022 SUSY yrs old) old ) FLUZONE SHINGRIX SUSR 6 AL(At least 50 QUADRIVALENT 2020- 6 yrs old) 2021 SUSP FLUZONE STAMARIL SUSR 5 QUADRIVALENT 2021- 6 TWINRIX SUSY 6 AL(At least 18 2022 SUSP yrs old) FLUZONE AL(At least 1 QUADRIVALENT 2021- 6 VAQTA SUSP 25 6 UNIT/0.5ML yrs old - Up to 2022 SUSY 18 yrs old) AL(At least 9 AL(At least 19 VAQTA SUSP 50 UNIT/ML 6 GARDASIL 9 SUSP 6 yrs old - Up to yrs old) 45 yrs old) VARIVAX INJ 6 AL(At least 1 AL(At least 9 yrs old) GARDASIL 9 SUSY 6 yrs old - Up to 45 yrs old) YF-VAX INJ 5 HAVRIX SUSP 1440 AL(At least 19 6 ZOSTAVAX SUSR 6 AL(At least 50 ELU/ML yrs old) yrs old) AL(At least 1 HAVRIX SUSP 720 6 VAGINAL AND RELATED PRODUCTS ELU/0.5ML yrs old - Up to 18 yrs old) Miscellaneous Vaginal Products AL(At least 18 HEPLISAV-B SOLN 6 yrs old) INTRAROSA INST NC

338 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIMO-SAN GEL NC terconazole vaginal crea 2 QL(45 gm per 0.4 % fill retail) Spermicides terconazole vaginal crea 2 QL(20 gm per 0.8 % fill retail) ENCARE SUPP 6 terconazole vaginal supp 2 QL(3 ea per fill OPTIONS CONCEPTROL 80 mg retail) VAGINAL 5 Vaginal Contraceptive - pH Modulators CONTRACEPTIVE GEL OPTIONS GYNOL II PHEXXI GEL NC VAGINALCONTRACEPTIV 6 E GEL Vaginal Estrogens ESTRACE CREA VA 0.1 QL(1.434 gm SHUR-SEAL GEL 6 MG/GM (Use estradiol 5 daily) vaginal) TODAY SPONGE MISC 6 estradiol vaginal crea 0.1 2 QL(1.434 gm VCF VAGINAL mg/gm daily) CONTRACEPTIVE FILM 6 estradiol vaginal tabs 10 NC FILM mcg VCF VAGINAL ESTRING RING NC CONTRACEPTIVE FOAM 6 FOAM FEMRING RING NC VCF VAGINAL CONTRACEPTIVEGEL 6 IMVEXXY MAINTENANCE 4 GEL PACK INST Vaginal Anti-infectives IMVEXXY STARTER 4 PACK INST AVC CREA 5 PREMARIN CREA VA NC QL(1.434 gm CLEOCIN CREA VA 2 % QL(40 gm per 0.625 MG/GM daily) (Use clindamycin 4 fill retail) VAGIFEM TABS (Use 2 phosphate vaginal) estradiol vaginal) CLEOCIN SUPP VA 100 5 Vaginal Progestins MG CRINONE GEL 4 clindamycin phosphate 2 QL(40 gm per vaginal crea fill retail) ENDOMETRIN INST 4 CLINDESSE CREA 5 FIRST-PROGESTERONE GYNAZOLE-1 CREA 5 VGS 100 COMPOUNDING 5 KIT SUPP METROGEL-VAGINAL QL(70 gm per FIRST-PROGESTERONE GEL (Use metronidazole 4 fill retail) VGS 200 5 vaginal) COMPOUNDING KIT QL(70 gm per SUPP metronidazole vaginal gel 2 fill retail) VASOPRESSORS - Drugs to Treat Heart and miconazole nitrate vaginal 2 QL(3 ea per fill Circulation Conditions supp retail) Anaphylaxis Therapy Agents NUVESSA GEL NC ADRENALIN SOLN IJ 1 5 MG/ML 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

339 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADRENALIN SOLN IJ 30 Neurogenic Orthostatic Hypotension (NOH) - 5 MG/30ML (Use PA; SP epinephrine (anaphylaxis)) droxidopa caps 5 ADYPHREN AMP II KIT NC NORTHERA CAPS (Use 5 PA; SP KIT droxidopa) ADYPHREN AMP KIT KIT NC Vasopressors AKOVAZ SOLN (Use ADYPHREN II KIT NC ephedrine sulfate 5 (pressors)) ADYPHREN KIT KIT NC AKOVAZ SOLN (Use ephedrine sulfate NC AUVI-Q SOAJ 0.1 NC MG/0.1ML, 0.3 MG/0.3ML (pressors)) QL(2 ea per fill BIORPHEN SOLN NC AUVI-Q SOAJ 0.15 5 retail,4 ea per MG/0.15ML 30 days retail) EMERPHED SOLN NC QL(2 ea per fill epinephrine (anaphylaxis) 2 retail,4 ea per ephedrine sulfate soaj 0.15 mg/0.15ml 2 30 days retail) (pressors) soln EPHEDRINE SULFATE epinephrine (anaphylaxis) 2 5 soaj 0.15 mg/0.3ml SOLN IV 50 MG/ML QL(0.0667 ea EPHEDRINE SULFATE epinephrine (anaphylaxis) 2 daily,4 ea per SOSY IJ 25 MG/5ML, 50 NC soaj 0.3 mg/0.3ml 22 days retail) MG/10ML, 50 MG/5ML QL(0.0667 ea EPHEDRINE SULFATE NC epinephrine (anaphylaxis) 2 daily,4 ea per SOSY IV 25 MG/5ML soaj 0.3 mg/0.3ml 30 days retail) EPHEDRINE SULFATE/SODIUMCHLOR NC epinephrine (anaphylaxis) 2 soln 30 mg/30ml IDE SOSY EPINEPHRINE NC EPINEPHRINE HCL SOLN 5 PROFESSIONAL KIT EPINEPHRINE HCL SOSY 5 EPINEPHRINESNAP-EMS NC KIT EPINEPHRINE EPINEPHRINESNAP-V NC HYDROCHLORIDE/DEXT NC KIT ROSE SOLN QL(0.0667 ea EPINEPHRINE daily,4 ea per HYDROCHLORIDE/SODIU NC EPIPEN 2-PAK SOAJ (Use 4 epinephrine (anaphylaxis)) 22 days retail)2 M CHLORIDE SOLN rtl MAX fill,30 rtl day(s) supply, EPINEPHRINE HYDROCHLORIDE/SODIU NC EPIPEN-JR 2-PAK SOAJ M CHLORIDE SOSY (Use epinephrine 4 (anaphylaxis)) epinephrine soln ij 1 mg/ml 2 EPISNAP KIT NC epinephrine soln ij 30 NC mg/30ml SYMJEPI SOSY 4 EPINEPHRINE SOLN IV 1 5 MG/10ML

340 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits epinephrine sosy ij 1 2 PHENYLEPHRINE mg/10ml HYDROCHLORIDE SOLN NC IV 0.4 MG/10ML EPINEPHRINE SOSY IJ 1 5 MG/10ML PHENYLEPHRINE HYDROCHLORIDE SOLN EPINEPHRINE SOSY IV 5 5 0.1 MG/10ML, 1 MG/10ML IV 0.8 MG/10ML, 1 MG/10ML EPINEPHRINE/DEXTROS NC E SOLN PHENYLEPHRINE HYDROCHLORIDE SOLN EPINEPHRINE/DEXTROS NC IV 10 MG/ML (Use 5 E SOSY phenylephrine hcl EPINEPHRINE/SODIUM NC (pressors)) CHLORIDE SOLN PHENYLEPHRINE EPINEPHRINE/SODIUM NC HYDROCHLORIDE SOSY 5 CHLORIDE SOSY IV 0.4 MG/10ML, 0.8 MG/10ML, 1 MG/10ML GIAPREZA SOLN NC PHENYLEPHRINE LEVOPHED SOLN (Use 5 HYDROCHLORIDE SOSY NC norepinephrine bitartrate) IV 0.5 MG/5ML midodrine hcl tabs 2 PHENYLEPHRINE HYDROCHLORIDE/DEXT NC NOREPHINEPHRINE ROSE SOLN BITARTRATE/SODIUM NC PHENYLEPHRINE CHLORIDE SOLN HYDROCHLORIDE/SODIU NC norepinephrine bitartrate 2 M CHLORIDE SOLN soln iv PHENYLEPHRINE NOREPINEPHRINE HYDROCHLORIDE/SODIU NC BITARTRATE/DEXTROSE NC M CHLORIDE SOSY SOLN VAZCULEP SOLN (Use NOREPINEPHRINE phenylephrine hcl 5 BITARTRATE/DEXTROSE NC (pressors)) SOSY NOREPINEPHRINE VITAMINS BITARTRATE/SODIUM NC Oil Soluble Vitamins CHLORIDE SOLN AQUASOL A 5 NOREPINEPHRINE PARENTERAL SOLN BITARTRATE/SODIUM NC CHLORIDE SOSY BABY DDROPS LIQD 5 NOREPINEPHRINE/DEXT NC cholecalciferol caps or 400 2 AL(At least 65 ROSE SOLN unit yrs old) NOREPINEPHRINE/SODI NC cholecalciferol chew or 400 2 AL(At least 65 UM CHLORIDE SOLN unit yrs old) NOREPINEPHRINE/SODI NC cholecalciferol liqd or 10 2 UM CHLORIDE SOSY mcg/ml, 400 unit/ml phenylephrine hcl 2 cholecalciferol tabs or 400 5 AL(At least 65 (pressors) soln unit yrs old)

341 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits D-VI-SOL LIQD (Use 5 PYRIDOXAL-5- NC cholecalciferol) PHOSPHATE SOLN DRISDOL CAPS (Use 5 PYRIDOXINE HCL POWD 5 RX/OTC ergocalciferol) XX ERGOCAL CAPS NC pyridoxine hcl soln ij 2 ergocalciferol caps or 1.25 2 PYRIDOXINE 5 RX/OTC mg, 50000 unit HYDROCHLORIDE POWD ERGOCALCIFEROL 5 SODIUM ASCORBATE 5 POWD XX GRAN MEPHYTON TABS (Use 5 SODIUM ASCORBATE 5 RX/OTC phytonadione) POWD phytonadione soln ij 1 2 THIAMINE HCL POWD XX 5 RX/OTC mg/0.5ml, 10 mg/ml phytonadione tabs or 5 mg 2 thiamine hcl soln ij 2 THIAMINE VITAMIN D3 IMMUNE 5 5 HEALTH LIQD MONONITRATE POWD VITAMIN D3 LIQD OR 5 1200 UNIT/15ML VITAMIN E ACETATE 5 POWD 500 UNIT/GM WHEAT GERM OIL 5 Water Soluble Vitamins AMINOBENZOIC ACID 5 POWD ASCOR SOLN NC ascorbic acid soln ij 500 2 mg/ml ASCORBIC ACID SOLN IV NC 15000 MG/30ML CALCIUM ASCORBATE 5 RX/OTC DIHYDRATE POWD CALCIUM ASCORBATE 5 RX/OTC POWD CALCIUM 5 RX/OTC PANTOTHENATE POWD NIACIN POWD 5 RX/OTC

NIACINAMIDE POWD 5 RX/OTC

NICOTINAMIDE POWD 5 RX/OTC

PARA-AMINOBENZOIC 5 ACID POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

342 Index 1ST BASE 321 5-AMINOSALICYLIC ACID ACAI+SUPERFRUIT/GREEN 1ST MEDX-PATCH/LIDOCAINE 161 TEA 272 136 5-FLUOROURACIL 88 acamprosate calcium 327 1ST TIER UNIFINE 5-HYDROXY-L-TRYPTOPHAN ACANYA 119 PENTIPS/MINI/31GX5MM 227 108 acarbose 34 1ST TIER UNIFINE 5- PENTIPS29GX12MM 227 METHYLTETRAHYDROFOLAT ACARBOSE 78 1ST TIER UNIFINE E 93 ACCOLATE 23 PENTIPS31GX6MM 227 5- ACCRUFER 169 1ST TIER UNIFINE METHYLTETRAHYDROFOLAT PENTIPS31GX8MM 227 ECALCIUM 93 ACCU-CHEK AVIVA 192 1ST TIER UNIFINE 5- ACCU-CHEK AVIVA PLUS 146 PENTIPS32GX4MM 227 METHYLTETRAHYDROFOLIC ACCU-CHEK COMPACT 1ST TIER UNIFINE ACID/GLUCOSAMINE SALT PLUS 146 PENTIPS32GX6MM 227 92 ACCU-CHEK COMPACT PLUS 1ST TIER UNIFINE 6-AMINOCAPROIC ACID 78 CLEAR CONTROL SOLUTION PENTIPS33GX4MM 227 (2 LEVELS) 192 1ST TIER UNIFINE 7-KETO DHEA 91 ACCU-CHEK FASTCLIX PENTIPSPLUS 31GX8MM 227 7T GUMMY ES 8 LANCETS 192 1ST TIER UNIFINE 9-AMINOACRIDINE HCL 78 ACCU-CHEK GUIDE 146 PENTIPSPLUS 32GX4MM 228 A-LIPOIC ACID (DL-THIOCTIC ACCU-CHEK GUIDE CONTROL 1ST TIER UNIFINE ACID) 78 LEVEL1/LEVEL2 192 PENTIPSPLUS 33GX4MM 228 A.A.G.C. KIT IN 1ST TIER UNIFINE ACCU-CHEK GUIDE ME 192 TERODERM 123 ACCU-CHEK MULTICLIX PENTIPSPLUS/MINI/31GX5MM abacavir sulfate 66 228 LANCETS 192 1ST TIER UNIFINE abacavir sulfate- ACCU-CHEK NANO lamivudine 66 SMARTVIEW 192 PENTIPSPLUS/ORIGINAL/29GX abacavir sulfate-lamivudine- 12MM 228 ACCU-CHEK SAFE-T-PRO 1ST TIER UNIFINE zidovudine 66 LANCETS 192 PENTIPSPLUS/ULTRA ABECMA 55 ACCU-CHEK SAFE-T-PRO SHORT/31GX6MM 228 ABELCET 41 PLUSLANCETS 192 ACCU-CHEK SMARTVIEW 1ST TIER UNILET ABILIFY 65 COMFORTOUCH LANCETS CONTROL 192 ABILIFY MAINTENA 65 ACCU-CHEK SMARTVIEW 28G 192 ABILIFY MYCITE 65 STRIPS 146 1ST TIER UNILET ACCU-CHEK SOFTCLIX COMFORTOUCH LANCETS ABILIFY MYCITE LANCETS 192 30G 192 MAINTENANCE KIT 65 2,3-DIMERCAPTOSUCCINIC ABILIFY MYCITE STARTER ACCUCAINE 136 ACID(DMSA) 100 KIT 65 ACCUPRIL 46 2-DEOXY-D-GLUCOSE 85 abiraterone acetate 55 ACCURETIC 48 2-DEOXY-D-GLUCOSE ABLYSINOL 75 ACCUTREND GLUCOSE 146 REAGANTGRADE 85 ABOUTTIME PEN NEEDLE ACCUTREND GLUCOSE 2-METHOXYESTRADIOL 93 32GX 5/32" 228 CONTROL 192 2ND SKIN BLISTER KIT 177 ABOUTTIME PEN NEEDLES ACD FORMULA A 27 30GX 5/16" 228 2ND SKIN BLISTER PADS 177 ABOUTTIME PEN NEEDLES ACD-A NOCLOT-50 27 2ND SKIN QUIKSTIK ADHESIVE 31G X 3/16" 228 acebutolol hcl 71 BANDAGES 177 ABOUTTIME PEN NEEDLES 2ND SKIN QUIKSTIK ADHESIVE ACEBUTOLOL HCL 71 31G X 5/16" 228 ACEPROMAZINE BANDAGES SPORT PACK ABRAXANE 60 177 MALEATE 78 2ND SKIN SELF SEALING CUT ABSORICA 119 ACESULFAME CLOSURE BANDAGE 177 ABSORICA LD 119 POTASSIUM 78 ACETADOTE 39 4-AMINOBUTYRIC ACID 89 ABSTRAL 8 acetaminophen 8 4-AMINOPYRIDINE 88 AC DERMAPEPTIDE 100 ACETAMINOPHEN 8,78 4-METHYLPYRAZOLE 88 ACACIA 318 5 DAY 139 ACACIA SPRAY-DRIED 318

Index 1 ACETAMINOPHEN CRYSTAL ACTICOAT FLEX 3 BARRIER ACTIVE-PREP KIT IV 123 60MESH 78 DRESSING 4"'X4" 142 ACTIVE-PREP KIT V 125 acetaminophen w/ codeine 12 ACTIGALL 160 ACTIVE-TRAMADOL KIT 123 acetaminophen-caff-dihydrocod ACTIMARIS ALL-NATURAL 12 WOUND RINSE/ENERGIZED ACTIVELLA 158 acetaminophen-salicylamide- SINGLET OXYGEN 142 ACTONEL 154 phenyltoloxamine 7 ACTIMARIS WOUND ACTOPLUS MET 34 GEL 142 ACETARSONE 78 ACTOS 36 ACTIMMUNE 59 ACETAZOLAMIDE 78 ACTRIVIT 276 acetazolamide 153 ACTIPHYTE OF ALGAE GL 78 ACUICYN ANTIMICROBIAL acetazolamide sodium 153 ACTIPHYTE OF EYELID & EYELASH ACETIC ACID 77 CUCUMBER 81 HYGIENE 140 ACTIPHYTE OF IVY 90 ACUICYN DAILY EYELID & acetic acid 164 EYELASH CLEANSER 140 acetic acid (otic) 301 ACTIPHYTE OF LEMONGRASS 106 ACULAR 300 ACETIC ACID GLACIAL 77 ACTIPHYTE OF SEA ACULAR LS 300 ACETONE 106 KELP 91 ACUVAIL 300 ACETYL DIPEPTIDE-1 ACTIPHYTE OF SUGAR acyclovir 69 CETYLESTER 78 KELP 91 ACETYL HEXAPEPTIDE-8 78 ACTIQ 8 ACYCLOVIR 78 ACETYL SALICYLIC ACID 8 ACTIVE FE 168 acyclovir sodium 69 ACETYL-D-GLUCOSAMINE ACTIVE INJECTION KIT BLM- acyclovir topical 129 78 1 113 ACYCLOVIX 68 ACETYL-L-CARNITINE ACTIVE INJECTION KIT ACZONE 119 HYDROCHLORIDE 78 BM 114 ACETYLCHOLINE ACTIVE INJECTION KIT ADA SHAMPOO 315 CHLORIDE 78 D 114 ADACEL 333 ACETYLCYSTEINE 119 ACTIVE INJECTION KIT ADAINZDE 119 acetylcysteine 119 DL 114 ACTIVE INJECTION KIT ADAINZOXIA 119 acetylcysteine (antidote) 39 DLM 114 ADAKVEO 166 acetylcysteine (nutrient) 292 ACTIVE INJECTION KIT KET- ADALAT CC 72 ACIDOPHILUS L 4 adapalene 119 ACTIVE INJECTION KIT LACTOBACILLUS 92 ADAPALENE 119 ACIOXIAY 119 KETMARC-L 4 ACTIVE INJECTION KIT KL- adapalene-benzoyl ACIPHEX 335 3 114 peroxide 119 ACIPHEX SPRINKLE 335 ACTIVE INJECTION KIT ADAPALENE/BENZOYL acitretin 128 KM 114 PEROXIDE 119 ADAPALENE/BENZOYL ACTEMRA 4 ACTIVE INJECTION KIT L 114 PEROXIDE/CLINDAMYCIN ACTEMRA ACTPEN 4 ACTIVE INJECTION KIT LM- 119 ACTHAR 155 2 173 ADAPALENE/BENZOYL ACTHIB 337 ACTIVE INJECTION KIT LM- PEROXIDE/NIACINAMIDE 119 ACTI-LANCE LANCETS DEP-1 114 ADASUVE 64 28G 192 ACTIVE INJECTION KIT LM- ADCETRIS 54 ACTI-LANCE LITE SAFETY DEP-2 114 ACTIVE INJECTION KIT M- ADCIRCA 75 LANCETS 28G 193 ADDERALL 1 ACTI-LANCE SPECIAL SAFETY 1 114 LANCETS 17G 193 ACTIVE-CYCLOBENZAPRINE ADDERALL XR 1 ACTI-LANCE SPECIAL KIT 288 adefovir dipivoxil 69 SAFETYLANCETS 17G 193 ACTIVE-KETOPROFEN KIT 124 ADEMETIONINE DISULFATE ACTI-LANCE UNIVERSAL TOSYLATE 78 ACTIVE-PREP KIT I 124 SAFETY LANCETS 23G 193 ADEMPAS 75 ACTIVE-PREP KIT II 124 ACTICLATE 331 ADENOCAINE 74 ACTIVE-PREP KIT III 124 ADENOCARD 21

Index 2 adenosine 21 ADVANCE INTUITION ADVOCATE INSULIN ADENOSINE 21,78 CONTROL SOLUTION 193 SYRINGE/U- ADVANCE INTUITION TEST 100/0.5ML/29GX1/2" 228 ADENOSINE-5- STRIPS 147 ADVOCATE INSULIN MONOPHOSPHATE 274 ADVANCE MICRO-DRAW ADENOSINE-5-TRIPHOSPHATE SYRINGE/U- CONTROL LEVEL 1-2 193 100/0.5ML/30GX5/16" 228 274 ADVANCE MICRO-DRAW ADVOCATE INSULIN ADENOSYLCOBALAMIN 81 METER 193 SYRINGE/U- ADHANSIA XR 2 ADVANCE MICRO-DRAW 100/0.5ML/31GX5/16" 228 ADHESIVE BANDAGES NORMAL CONTROL 193 ADVOCATE INSULIN ANTIBACTERIAL 177 ADVANCE MICRO-DRAW SYRINGE/U-100/1ML/29GX1/2" ADHESIVE BANDAGES TEST STRIPS 147 228 CLEAR 177 ADVANCED ALLERGY ADVOCATE INSULIN ADHESIVE BANDAGES COLLECTION KIT 130 SYRINGE/U-100/1ML/30GX5/16" FLEXIBLE FABRIC 177 ADVANCED AM/PM 277 228 ADHESIVE BANDAGES ADVANCED C PLUS 277 ADVOCATE INSULIN FOAM 177 SYRINGE/U-100/1ML/31GX5/16" ADHESIVE BANDAGES ADVANCED COLLAGEN 286 228 HEALTHAWARENESS 177 ADVANCED CURAD AQUA- ADVOCATE LANCETS 193 PROTECT 177 ADHESIVE BANDAGES HYPO- ADVOCATE LANCETS ALLERGENIC 177 ADVANCED CURAD BLISTER- CARE 177 30G 193 ADHESIVE BANDAGES ADVOCATE LANCING PLASTIC 177 ADVANCED CURAD COOL- WRAP 177 DEVICE 193 ADHESIVE BANDAGES ADVOCATE RAPID-SAFE SHEER 177 ADVANCED CURAD SOF- GEL 177 LANCING DEVICE 193 ADHESIVE BANDAGES ADVOCATE REDI-CODE 147 STRONGSTRIPS 177 ADVANCED MOBILE LANCET ADHESIVE BANDAGES WATER 30G 193 ADVOCATE REDI-CODE+ SHIELD 177 ADVATE 165 BLOOD GLUCOSE ADHESIVE ADVOCATE ALCOHOL PREP SYSTEM/SPEAKING 193 PADS/LARGE/3"X4" 177 PADS 225 ADVOCATE REDI-CODE+ ADHESIVE ADVOCATE BLOOD BLOODGLUCOSE PADS/MEDIUM/2"X3" 177 GLUCOSE MONITORING MONITORING SYSTEM 193 ADJUSTABLE LANCING SYSTEM 193 ADVOCATE REDI-CODE+ DEVICE 193 ADVOCATE BLOOD CONTROL SOLUTION ADLYXIN 35 GLUCOSE MONITORING HIGH 193 ADVOCATE REDI-CODE+ ADLYXIN STARTER PACK 35 SYSTEM/TALKING 193 ADVOCATE CONTROL CONTROL SOLUTION ADMELOG 36 SOLUTIONHIGH 193 LOW 193 ADMELOG SOLOSTAR 36 ADVOCATE CONTROL ADVOCATE REDI-CODE+ TESTSTRIPS 147 ADRENAL C FORMULA 277 SOLUTIONLOW 193 ADVOCATE INSULIN PEN ADVOCATE REDI-CODE+/ ADRENAL STRESS CALM 286 NEEDLES 228 TALKING 193 ADRENALIN 339,340 ADVOCATE INSULIN PEN ADVOCATE REDI- ADRENOCHROME NEEDLES 29GX12.7MM 228 CODE/TALKING 193 SEMICARBAZONE 81 ADVOCATE INSULIN PEN ADVOCATE SAFETY ADRENOCORTICOTROPHIC NEEDLES 31GX5MM 228 LANCETS 193 HORMONE 81 ADVOCATE INSULIN PEN ADVOCATE SAFETY LANCETS ADRENOID 286 NEEDLES 31GX8MM 228 26G 193 ADVOCATE TEST STRIPS 147 ADUHELM 327 ADVOCATE INSULIN SYRINGE/U- ADYNOVATE 165 ADVAIR DISKUS 24 100/0.3ML/29GX1/2" 228 ADYPHREN AMP II KIT 340 ADVAIR HFA 24 ADVOCATE INSULIN ADVANCE INTUITION BLOOD SYRINGE/U- ADYPHREN AMP KIT 340 GLUCOSE METER 193 100/0.3ML/30GX5/16" 228 ADYPHREN II 340 ADVANCE INTUITION BLOOD ADVOCATE INSULIN ADYPHREN KIT 340 GLUCOSE MONITORING SYRINGE/U- ADZENYS ER 1 SYSTEM 193 100/0.3ML/31GX5/16" 228 ADZENYS XR-ODT 1

Index 3 AEMCOLO 16 AIRDUO RESPICLICK ALEVICYN ANTIPRURITIC AFINITOR 57 113/14 24 GEL 139 AIRDUO RESPICLICK ALEVICYN ANTIPRURITIC AFINITOR DISPERZ 57 232/14 24 SG 139 AFLURIA QUADRIVALENT AIRDUO RESPICLICK ALEVICYN DERMAL 2021-2022 337 55/14 24 SPRAY 142 AFREZZA 36 AJOVY 264 ALFALFA FLAVOR 306 AFSTYLA 165 AKLIEF 119 alfentanil hcl 8 AGAMATRIX AMP NO CODE AKOVAZ 340 ALFENTANIL ADVANCED BLOOD GLUCOSE AKTEN 298 HYDROCHLORIDE 8 MONITORING SYST 193 ALFERON N 59 AGAMATRIX AMP NO CODE AKTIPAK 119 alfuzosin hcl 164 TEST STRIPS 147 AKYNZEO 41 ALGINIC ACID 78 AGAMATRIX CONTROL ALA-SCALP 130 HIGH 193 ALIMTA 53 ALANINE 292 AGAMATRIX CONTROL ALINIA 17 NORMAL 193 ALASKAN RED ALGAE 78 ALIQOPA 57 AGAMATRIX CONTROL ALBA-DERM 321 NORMAL& HIGH 193 aliskiren fumarate 50 albendazole 16 AGAMATRIX CONTROL ALIVE MULTI-VITAMIN 277 ALBENDAZOLE 78 SOLUTION LEVEL 2 193 ALIVE PRENATAL MULTI- AGAMATRIX CONTROL ALBENZA 16 VITAMIN/PLANT DHA 282 SOLUTION LEVEL 4 193 albuterol sulfate 24 AGAMATRIX JAZZ TEST ALIVIO PATCH 136 STRIPS 147 ALBUTEROL SULFATE 24 ALKERAN 52 AGAMATRIX JAZZ WIRELESS albuterol sulfate 24 ALKINDI SPRINKLE 114 2 194 ALBUTEROL SULFATE 24 ALKYL BENZOATE C12-15 78 AGAMATRIX KEYNOTE TEST STRIPS 147 albuterol sulfate 24 ALL GEL BUNION TOE SPREADER 219 AGAMATRIX PRESTO 194 ALCAINE 298 ALLANTOIN 108 AGAMATRIX PRESTO PRO alclometasone METER 194 dipropionate 130 ALLERWELL ALLERGY AGAMATRIX PRESTO TEST ALCOH-GLOVE CONTOURED FORMULA 286 STRIPS 147 WIPE 225 ALLEVYN GENTLE 142 AGAMATRIX ULTRA-THIN ALCOH-WIPE 12" X 12" 225 ALLOPURINOL 78 LANCETS 33G 194 ALCOHOL 106 allopurinol 164 AGAR 78 alcohol 292 allopurinol sodium 164 AGGRENOX 166 ALCOHOL BASE GEL 321 ALLZITAL 7 AGRYLIN 166 ALCOHOL ALMOND OIL 106 AIF #2 DRUG DEHYDRATED 315 ALMOND OIL BITTER PREPARATIONKIT 124 ALCOHOL PADS 225 FLAVOR 306 AIF #3 DRUG PREPARATION ALCOHOL PREP PADS 225 KIT 124 ALMOND OIL SWEET 106 AIMOVIG 264 ALCOHOL PREPS 225 almotriptan malate 265 AIMSCO TWIST LANCETS ALCOHOL SWABS 225 ALOCANE EMERGENCY BURN 32G 194 ALCOHOL SWABSTICK 225 MAXIMUM STRENGTH 136 AIMSCO TWIST LANCETS ALCOHOL WIPES 140 ALOCRIL 300 33G 194 ALDACTAZIDE 153 ALOE VERA 78 AIR FOAM INSOLES ALOE VERA FREEZE MENS 219 ALDACTONE 153 DRIED 78 AIR FOAM INSOLES ALDARA 135 ALOE VERA LEAF 78 WOMENS 219 AIRBORNE+NATURAL ALDOSTERONE 78 alogliptin benzoate 35 ENERGY 277 ALDURAZYME 156 alogliptin-metformin hcl 34 AIRDUO DIGIHALER 113/1424 ALECENSA 57 alogliptin-pioglitazone 34 AIRDUO DIGIHALER 232/1424 alendronate sodium 154 ALOMIDE 300 AIRDUO DIGIHALER 55/14 24 ALEVAMAX 139

Index 4 ALOPRIM 165 ALZAIR ALLERGY BLOCKER AMINOPROPYL MENTHYL ALORA 159 NASAL SPRAY 289 PHOSPHATE 79 amantadine hcl 61,62 AMINOPROTECT 292 alosetron hcl 162 AMANTADINE HCL 79 AMINOSALICYLIC ACID 51 ALOXI 40 AMARANTH 305 AMINOSYN II 293 ALPAWASH 321 AMARYL 38 AMINOSYN-PF 293 ALPHA LIPOIC ACID 78 AMBIEN 171 AMINOSYN-PF 7% 293 ALPHA-GPC 50% 89 ALPHA-KETOGLUTARIC AMBIEN CR 171 amiodarone hcl 22 ACID 78 AMBISOME 41 AMIODARONE ALPHA-LIPOIC ACID 3 ambrisentan 75 HYDROCHLORIDE/DEXTROSE 22 ALPHA-TOCOPHEROL 105 amcinonide 130 AMITIZA 161 ALPHAGAN P 296 AMCINONIDE 130 amitriptyline hcl 33 AMD ANTIMICROBIAL ALPHANATE 165 AMITRIPTYLINE HCL 79 ALPHANATE/VON FENESTRATED FOAM DRESSING 3.5"X3" 177 AMITRIPTYLINE WILLEBRANDFACTOR HYDROCHLORIDE 79 COMPLEX/HUMAN 165 AMD FOAM DRESSING amlodipine besylate 72 ALPHANINE SD 165 4"X4" 177 AMD FOAM DRESSING AMLODIPINE BESYLATE 79 alprazolam 21 6"X6" 177 amlodipine besylate-atorvastatin ALPRAZOLAM 78 AMD FOAM calcium 74 ALPRAZOLAM INTENSOL 21 DRESSING/TOPSHEET amlodipine besylate-benazepril 4"X4" 177 ALPROLIX 165 hcl 48 AMELUZ 127 amlodipine besylate-olmesartan ALPROSTADIL 108 AMERGE 265 medoxomil 48 alprostadil 275 AMERIGEL WOUND amlodipine besylate- ALREX 298 DRESSING 142 valsartan 48 ALTABAX 125 AMERIGEL WOUND AMLODIPINE BESYLATE/SYRSPEND SF ALTACE 46 WASH 142 AMICAR 170 PH4 72 ALTADERM CREAM BASE321 amlodipine-valsartan- ALTERNATE SITE LANCING AMIDATE 162 hydrochlorothiazide 48 DEVICE 194 AMIKACIN SULFATE 3 AMMONIUM BROMIDE 108 ALTOPREV 45 amikacin sulfate 3 AMMONIUM BROMIDE ALTRENO 119 amiloride & ACS 108 ALTRENOGEST 78 hydrochlorothiazide 153 AMMONIUM CHLORIDE 108 ALUMINUM ACETATE AMILORIDE HCL 153 AMMONIUM HYDROXIDE 77 BASIC 79 amiloride hcl 153 AMMONIUM LACTATE 106 ALUMINUM CHLORIDE 140 AMINO ACID 292 AMMONIUM LAURYL ALUMINUM CHLORIDE amino acid infusion 292 SULFATE 79 AMMONIUM MOLYBDATE ANHYDROUS 140 amino acids 292 ALUMINUM CHLORIDE TETRAHYDRATE 79 HEXAHYDRATE 140 AMINOBENZOIC ACID 342 AMMONIUM PHOSPHATE ALUMINUM AMINOCAPROIC ACID 79 DIBASIC 108 CHLOROHYDRATE 79 aminocaproic acid 170 AMMONIUM SULFATE 108 ALUMINUM HYDROXIDE AMINOLEVULINIC ACID AMMONIUM DRIEDGEL 108 HCL 79 TETRATHIOMOLYBDATE 79 ALUMINUM POTASSIUM AMINOLEVULINIC ACID AMMONUL 156 SULFATE 108 HYDROCHLORIDE 79 ALUMINUM SULFATE AMONDYS 45 291 AMINOLEVULINIC ACID amoxapine 33 HYDRATE 108 HYDROCHOLRIDE 79 ALUNBRIG 57 AMINOPHYLLINE 25 amoxicillin 303 amoxicillin & pot ALVESCO 23 aminophylline 25 alvimopan 162 clavulanate 304 AMINOPHYLLINE AMOXICILLIN ANHYDROUS 25 TRIHYDRATE 303

Index 5 amoxicillin-clarithromycin w/ ANISE EXTRACT 306 APPLE FLAVOR WATER lansoprazole 336 ANISE FLAVOR 306 MISCIBLE 306 AMOXICILLIN/CLAVULANATE apraclonidine hcl 296 ANISINDIONE 79 POTASSIUM 4:1 79 aprepitant 41 AMPHADASE 271 ANJESO 4 APRICOT FLAVOR 306 amphetamine 1 ANNOVERA 113 APRISO 161 amphetamine sulfate 1 ANORO ELLIPTA 24 APRIZIO PAK 136 amphetamine- ANTABUSE 327 APRIZIO PAK II 136 dextroamphetamine 1 ANTARA 44 APTENSIO XR 2 amphotericin b 41 ANTHRALIN 128 AMPHOTERICIN B 275 ANTIBACTERIAL APTIOM 27 ampicillin 303 BANDAGES/EXTRA APTIVUS 66 ampicillin & sulbactam LARGE 177 AQUA LANCE ADJUSTABLE sodium 304 ANTIBACTERIAL CLEAR LANCING DEVICE 194 ampicillin sodium 304 ADVANCED BANDAGES 177 AQUACEL AG ANTIBACTERIAL CLEAR ADVANTAGE 142 AMPYRA 328 BANDAGES 7/8"/SPOT 177 AQUACEL AG BURN 142 AMRIX 288 ANTIBACTERIAL PLASTIC AQUACEL AG EXTRA 4" X AMVISC 300 BANDAGES 3/4"X3" 177 5"/HYDROFIBER 142 AMVISC PLUS 300 ANTICOAGULANT CITRATE AQUADEKS 282 DEXTROSE SOLUTION A 27 AMYTAL SODIUM 171 ANTICOAGULANT SODIUM AQUAFRESH CAVITY AMZEEQ 119 CITRATE 25,27 PROTECTION SUGAR ACID PROTECTION 227 ANACAINE 136 ANTIMONY POTASSIUM TARTRATE 79 AQUAFRESH EXTREME ANAFRANIL 33 ANTIMONY CLEAN 227 anagrelide hcl 166 TRICHLORIDE 79 AQUAFRESH SENSITIVE MAXIMUM STRENGTH 227 ANASCORP 302 ANTIMONY TRISULFIDE 79 AQUALANCE LANCETS ULTRA anastrozole 55 ANTIPYRINE 79 THIN 30G 194 ANASTROZOLE 79 ANTIVENIN LATRODECTUS AQUASOL A ANAVIP 302 MACTANS 302 PARENTERAL 341 ANTIVENIN NORTH AQUORAL 275 ANCOBON 42 AMERICANCORAL AR CAPS #1 CLEAR/ACID ANDEXXA 39 SNAKE 302 RESISTANT 317 ANDRODERM 15 ANUSOL-HC 16 ARAKODA 50 ANDROGEL 15 ANZEMET 40 ARALAST NP 330 ANDROGEL PUMP 15 APADAZ 13 ARANESP ALBUMIN ANDROSTENEDIONE 79 APEXICON E 130 FREE 167 ANECTINE 290 APIDRA 36 ARAVA 7 ANESTHESIA S/I-40 162 APIDRA SOLOSTAR 36 ARAZLO 119 ANESTHESIA S/I-40A 162 APLENZIN 31 ARBEM H-COSMETIC 321 ANESTHESIA S/I-40H 162 APLICARE ALCOHOL ARBEM LIPOPEN 321 SWABSTICK 225 ANESTHESIA S/I-40S 162 ARBUTIN ALPHA 79 APO-VARENICLINE 329 ANESTHESIA S/I-60 162 ARCALYST 4 APOKYN 62 ANGELIQ 158 ARCAPTA NEOHALER 24 APOMORPHINE HCL 79 ANGIOMAX 27 ARESTIN 275 APOMORPHINE HCL arformoterol tartrate 24 ANHYDROUS BASE 321 HEMIHYDRATE 79 ANHYDROUS CREAM APOMORPHINE ARGATROBAN 27 BASE 321 HYDROCHLORIDE 79 argatroban 27 ANHYDROUS GEL BASE 321 APPLE CIDER VINEGAR ARGATROBAN 27 DIET 272 ANIMI-3 168 argatroban 27 APPLE FLAVOR 306 ANIMI-3/VITAMIN D 168 ARGATROBAN/SODIUM CHLORIDE 27

Index 6 ARGININE HCL 79 ASMANEX TWISTHALER 60 ASSURE ID SAFETY PEN ARICEPT 327 METERED DOSES 23 NEEDLES 31G X 3/16" 228 ASMANEX TWISTHALER 7 ASSURE II 147 ARIKAYCE 3 METERED DOSES 23 ASSURE II CHECK STRIP 147 ARIMIDEX 55 ASPARAGINE MONOHYDRATE 79 ASSURE II CONTROL LEVEL aripiprazole 65 1 194 ARISTADA 65 ASPARLAS 59 ASSURE II CONTROL LEVEL ARISTADA INITIO 65 aspirin 8 1/2 194 ARIXTRA 26 ASPIRIN 8 ASSURE II TEST STRIPS 147 ASSURE LANCE ARLACEL 165 89 aspirin 8 aspirin-dipyridamole 166 LANCETS 194 armodafinil 2 ASSURE LANCE LANCETS ARMONAIR DIGIHALER 23 ASPIRIN/OMEPRAZOLE 166 21G 194 ASPIRIN/OMEPRAZOLE ARMOUR THYROID 332 ASSURE LANCE PLUS ER 166 SAFETYLANCETS 25G 194 ARNICA FLOWER 140 ASSURE 3 CONTROL LEVEL ASSURE LANCE PLUS ARNICA LG 79 1/2 194 SAFETYLANCETS 30G 194 ARNUITY ELLIPTA 23 ASSURE 3 METER 194 ASSURE LANCE SAFETY LANCET 28G 194 AROMASIN 55 ASSURE 3 TEST STRIPS 147 ASSURE LANCETS 194 ARRANON 53 ASSURE 4 BLOOD GLUCOSE ASSURE PLATINUM BLOOD arsenic trioxide 59 METER 194 GLUCOSE METER 194 ARSENIC TRIOXIDE 79 ASSURE 4 CONTROL LEVEL ASSURE PLATINUM TEST 1/2 194 STRIPS 147 ARTESUNATE 50 ASSURE 4 TEST ASSURE PRISM CONTROL ARTHRI-FLEX STRIPS 147 LEVEL 1/2 194 ADVANTAGE 273 ASSURE COMFORT ASSURE PRISM MULTI ARTHROTEC 50 4 LANCETS ULTRA THIN BLOODGLUCOSE ARTHROTEC 75 4 28G 194 MONITORING SYSTEM 194 articaine-epinephrine 173 ASSURE DOSE NORMAL ASSURE PRISM MULTI TEST CONTROL 194 STRIPS 147 artificial saliva 275 ASSURE DOSE ASSURE PRO BLOOD ARTISS 170 NORMAL/HIGH GLUCOSE METER 194 ARYMO ER 8 CONTROL 194 ASSURE PRO CONTROL ASSURE HAEMOLANCE LEVEL1/2 194 ARZERRA 54 PLUS HIGH FLOW 18G 194 ASSURE PRO TEST ARZOL SILVER NITRATE ASSURE HAEMOLANCE STRIPS 147 APPLICATORS 129 PLUS LOW FLOW 25G 194 ASTAGRAF XL 271 ASACOL HD 161 ASSURE HAEMOLANCE ASTERO 136 ASCENIV 302 PLUS MICRO FLOW ASTRAGALUS ROOT 318 ASCLERA 275 28G 194 ASSURE HAEMOLANCE ASTRINGYN 170 ASCOR 342 PLUS NORMAL FLOW ATABEX EC 282 ASCORBIC ACID 79 21G 194 ATABEX OB 282 ascorbic acid 342 ASSURE HAEMOLANCE PLUS PEDIATRIC ATACAND 47 ASCORBIC ACID 342 BLADE 194 ATACAND HCT 48 ASCORBIC ACID CASSAVE79 ASSURE ID INSULIN atazanavir sulfate 66 ASCORBYL PALMITATE 79 SAFETYSYRINGE/U- ATELVIA 154 asenapine maleate 64 100/0.5ML/29G X 1/2" 228 ASSURE ID INSULIN ATENOLOL 71 ASMANEX HFA 23 SAFETYSYRINGE/U- atenolol 71 ASMANEX TWISTHALER 120 100/1ML/29G X 1/2" 228 METERED DOSES 23 ASSURE ID SAFETY PEN atenolol & chlorthalidone 48 ASMANEX TWISTHALER 14 NEEDLES 30G X 3/16" 228 ATENOLOL/SYRSPEND SF METERED DOSES 23 ASSURE ID SAFETY PEN PH4 71 ASMANEX TWISTHALER 30 NEEDLES 30G X 5/16" 228 ATGAM 271 METERED DOSES 23 ATIVAN 21

Index 7 atomoxetine hcl 1 AUTOLET LANCING azelaic acid 141 ATOPADERM 139 DEVICE 194 AZELAIC AUTOLET MINI 195 ATOPICLAIR 139 ACID/NIACINAMIDE 120 AUTOLET PLUS 195 AZELASTINE HCL 79 atorvastatin calcium 45 AUVI-Q 340 azelastine hcl 290 ATORVASTATIN CALCIUM 79 AUXIPRO VANISHING azelastine hcl (ophth) 300 atovaquone 17 CREAM 321 azelastine hcl-fluticasone ATOVAQUONE 79 AVADERM 136 propionate 289 atovaquone-proguanil hcl 50 AVALIDE 48 AZELEX 120 atracurium besylate 291 AVANDIA 36 AZESCHEW ATRALIN 119 AVAPRO 47 PRENATAL/POSTNATAL 282 AZESCO 282 ATRAPRO ANTIPRURITIC AVAR 120 HYDROGEL 142 AZILECT 63 AVAR LS 119 ATRAPRO CP 142 AZITHROMYCIN 79 AVAR LS CLEANSER 119 ATREVIS HYDROGEL 321 azithromycin 176 AVAR-E LS 120 ATRIPLA 66 AZITHROMYCIN AVASTIN 54 ATROPEN 333 DIHYDRATE 79 AVC 339 AZO DUAL PROTECTION ATROPINE SULFATE 296,333 AVEED 15 URINARY+VAGINAL atropine sulfate 333 SUPPORT 38 AVEIDAOXIA 141 ATROPINE SULFATE 333 AZOPT 300 AVELOX 160 atropine sulfate 333 AZOR 48 AVENOVA 140 ATROPINE SULFATE 333 aztreonam 19 AVICEL PH 101 atropine sulfate MICROCRYSTALLINE AZULFIDINE 161 (ophthalmic) 296 CELLULOSE 81 AZULFIDINE EN-TABS 161 ATROPINE SULFATE AVICEL PH 105 MONOHYDRATE 296 B-12 COMPLIANCE MICROCRYSTALLINE INJECTIONKIT 166 ATROVENT HFA 22 CELLULOSE 81 B-6 FOLIC ACID 168 ATTAPULGITE ACTIVATED AVIDOXY DK 331 COLLODIAL 79 B-COMPLEX 276 AVIPTADIL ACETATE 79 AUBAGIO 328 b-complex vitamins 276 AVOCADO OIL 79 AUGMENTIN 304 b-complex w/ c & folic acid 276 AVODART 164 AUGMENTIN ES-600 304 b-complex w/ c-biotin-minerals & AURORA LANCET SUPER AVONEX 328 folic acid 276 THIN30G 194 AVONEX PEN 328 B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X AURORA LANCET THIN AVSOLA 161 23G 194 5/16" 229 AURORA PEN NEEDLES AVYCAZ 76 B-D INSULIN SYRINGE 29GX12MM 228 AXIFOL 168 ULTRAFINE II/0.5ML/31G X AURORA PEN NEEDLES 31G AYGESTIN 326 5/16" 229 B-D INSULIN SYRINGE X6MM 228 AYVAKIT 56 AURORA PEN NEEDLES 31G ULTRAFINE II/1ML/31G X X8MM 228 AZ CREAM 321 5/16" 229 AURORA UNIFINE azacitidine 53 B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X PENTIPS/32GX5/32" 228 AZACTAM 19 AURORA UNIFINE 1/2" 229 PENTIPS/MINI/31GX3/16" 228 AZASAN 271 B-D INSULIN SYRINGE AURYXIA 162 AZASITE 297 ULTRAFINE/0.5ML/30G X AZATHIOPRINE 271 1/2" 229 AUSTEDO 328 341 azathioprine 271 BABY DDROPS AUTO-LANCET 194 297 AZEDRA DOSIMETRIC 59 BACIGUENT AUTO-LANCET MINI 194 bacitracin 16 AUTOLET IMPRESSION AZEDRA THERAPEUTIC 59 125 LANCING DEVICE 194 AZELAIC ACID 79 BACITRACIN bacitracin (ophthalmic) 297

Index 8 BACITRACIN MICRONIZED 80 BAND-AID FLEXIBLE 178 BAND-AID KLING ROLLED BACITRACIN ZINC 125 BAND-AID FLEXIBLE GAUZE LARGE 4" X 2.1 FABRIC 178 YDS 178 bacitracin-poly-neomycin-hc BAND-AID KLING ROLLED 298 BAND-AID FLEXIBLE bacitracin-polymyxin b FABRIC1" X 3" 178 GAUZE LARGE 4" X 2.5 BAND-AID FLEXIBLE YDS 178 (ophth) 297 BAND-AID KLING ROLLED BACLOFEN 124,288 FABRICASSORTED 178 BAND-AID FLEXIBLE GAUZE MEDIUM 3" X 2.1 baclofen 288 FABRICEXTRA LARGE 178 YDS 178 BACLOFEN 288 BAND-AID FLEXIBLE BAND-AID KLING ROLLED baclofen 288 FABRICFINGERTIP 178 GAUZE MEDIUM 3" X 2.5 BAND-AID FLEXIBLE YDS 178 BACMIN 277 FABRICKNUCKLE 178 BAND-AID KLING ROLLED BACOCALMINE 318 BAND-AID FLEXIBLE GAUZE SMALL 2" X 2.5 BACON FLAVOR 306 FABRICKNUCKLE & YDS 178 BACON FLAVOR FINGERTIP 178 BAND-AID MEDICATED NATURAL 306 BAND-AID FLEXIBLE STRIPS3/4" X 3" 178 bacteriostatic sodium FABRICTRAVEL PACK 178 BAND-AID MICKEY chloride 315 BAND-AID FROZEN 178 MOUSE 178 BAND-AID GAUZE PADS BAND-AID MIRASORB GAUZE BACTRIM 17 SPONGES LARGE 4" X 4" 178 BACTRIM DS 17 LARGE4" X 4" 178 BAND-AID GAUZE PADS BAND-AID NICKELODEON BAFIERTAM 328 SMALL2" X 2" 178 PAWPATROL 178 BAL IN OIL 39 BAND-AID GLOW IN THE BAND-AID OURTONE 178 BAL-CARE DHA 282 DARK3/4" X 3" 178 BAND-AID PLASTIC 179 BAND-AID HOT COLORS BALCOLTRA 111 BAND-AID PLASTIC 3/4"X 3" 178 SHEER 179 balsalazide disodium 161 BAND-AID HURT-FREE NON- BAND-AID PLASTIC BALSAM PERU & CASTOR STICK PADS LARGE 3" X STRIPS 179 OIL 142 4" 178 BAND-AID QUILTVENT BALVERSA 57 BAND-AID HURT-FREE NON- WATERPROOF PAD LARGE BAMLANIVIMAB 303 STICK PADS MEDIUM 2" X 2.875" X 4" 179 3" 178 BAND-AID SHEER COMFORT- BANANA CONCENTRATE 306 BAND-AID HYDRO SEAL ALL- FLEX 179 BANANA CREAM FLAVOR306 PURPOSE 178 BAND-AID SHEER BANANA CREME FLAVOR306 BAND-AID HYDRO SEAL STRIPS 179 BLISTER CUSHIONS MEDIUM BANANA FLAVOR 306 BAND-AID SHEER STRIPS 3/4" EXTREME 178 X 3" 179 BAND AID BUTTERFLY BAND-AID HYDRO SEAL BAND-AID SKIN-FLEX 179 CLOSURE MEDIUM 177 BLISTER CUSHIONS BAND-AID 178 BAND-AID SPORT SMALL 178 STRIP/EXTRA WIDE 179 BAND-AID 1" 177 BAND-AID HYDRO SEAL BAND-AID STAR WARS 179 BAND-AID ALL-IN-ONE BLISTER CUSHIONS VARIETY 178 BAND-AID SUPER ADHESIVE GAUZE STRIPS 179 PAD/LARGE 177 BAND-AID HYDRO SEAL EXTRA LARGE 178 BAND-AID TOUGH BAND-AID ALL-IN-ONE STRIPS 179 ADHESIVE GAUZE BAND-AID HYDRO SEAL FINGERS 178 BAND-AID TOUGH- PAD/MEDIUM 177 STRIPS 179 BAND-AID BABY SHARK 177 BAND-AID HYDRO SEAL LARGE 178 BAND-AID TOUGH-STRIPS BAND-AID BUTTERFLY EXTRA LARGE 1-3/4" X 4" 179 CLOSURE LARGE 2-3/4" X BAND-AID INSIDE OUT 178 BAND-AID TOUGH-STRIPS 1/2" 177 BAND-AID ISLAND WATERPROOF 179 BAND-AID CLEAR SPOTS SURGICALDRESSING 4" X BAND-AID TOUGH-STRIPS 7/8" 177 10" 178 WATERPROOF/EXTRA BAND-AID DISNEY BAND-AID ISLAND LARGE 179 PRINCESS 177 SURGICALDRESSING 4" X BAND-AID VARIETY PACK179 14" 178 BAND-AID EMOJI 177 BAND-AID WATER BLOCK BAND-AID FAMILY PACK 177 FLEX 179

Index 9 BAND-AID WATER BLOCK BCG VACCINE 337 BD INSULIN SYRINGE FLEX/EXTRA LARGE 179 BD LO-DOSE INSULIN ULTRAFINE/0.3ML/30G X BAND-AID WATER BLOCK SYRINGE MICROFINE 1/2" 229 FLEX/KNUCKLE/FINGERTIP IV/0.5ML/28G X 1/2" 229 BD INSULIN SYRINGE 179 BD AUTOSHIELD 29G X ULTRAFINE/0.3ML/31G X BAND-AID WATER BLOCK 3/16" 229 5/16" 229 FLEX/LARGE 179 BD AUTOSHIELD 29G X BD INSULIN SYRINGE BAND-AID WATER BLOCK 5/16" 229 ULTRAFINE/0.5ML/30G X PLUS 179 BD AUTOSHIELD DUO 30G X 1/2" 229 BAND-AID WATER BLOCK 5MM 229 BD INSULIN SYRINGE PLUSFINGER CARE 179 BD INSULIN SYRINGE LUER- ULTRAFINE/0.5ML/31G X BAND-AID/EXTRA LARGE 179 LOK/U-100/1ML 229 5/16" 229 BAND-AID/HELLO KITTY 179 BD INSULIN SYRINGE BD INSULIN SYRINGE BAND-AID/MICKEY MICROFINE IV/U- ULTRAFINE/1ML/30G X MOUSE 179 100/0.5ML/28G X 1/2" 229 1/2" 229 BD INSULIN SYRINGE BD INSULIN SYRINGE BAND-AID/PRINCESS 179 ULTRAFINE/U-100/0.3ML/29G X BANDAGES FABRIC MICROFINE IV/U- 100/1ML/27G X 5/8" 229 1/2" 230 KNUCKLE/FINGER 179 BD INSULIN SYRINGE BD INSULIN SYRINGE BANDAGES FABRIC STRIPS ULTRAFINE/U-100/0.5ML/29G X 3/4" 179 MICROFINE IV/U- 100/1ML/28G X 1/2" 229 1/2" 230 BANZEL 27 BD INSULIN SYRINGE BD INSULIN SYRINGE BAQSIMI ONE PACK 35 MICROFINE/U-100/0.5ML/28G ULTRAFINE/U-100/1ML/29G X BAQSIMI TWO PACK 35 X 1/2" 229 1/2" 230 BD INSULIN SYRINGE BARACLUDE 69 BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X ULTRAFINE/U-100/1ML/31G X BARHEMSYS 41 5/8" 229 5/16" 230 BASAGLAR KWIKPEN 36 BD INSULIN SYRINGE BD INSULIN BASE A POLYETHYLENE MICROFINE/U-100/1ML/28G X SYRINGE/0.3ML/29G X GLYCOL 1450 321 1/2" 229 12.7MM 230 BASE C POLYETHYLENE BD INSULIN SYRINGE BD INSULIN GLYCOL 300 321 SAFETYGLIDE/1ML/29G X SYRINGE/0.5ML/29G X BASE C POLYETHYLENE 1/2" 229 12.7MM 230 GLYCOL E 300 321 BD INSULIN SYRINGE SLIP BD INSULIN SYRINGE/1ML/27G BASE CREAM WITH TIP/U-100/1ML 229 X 12.7MM 230 LIPOSOME 321 BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/29G BASE D POLYETHYLENE ULTRA-FINE/0.3ML/30G X X 12.7MM 230 GLYCOL 4500 321 12.7MM 229 BD INSULIN BASE D POLYETHYLENE BD INSULIN SYRINGE SYRINGE/DETACHABLE GLYCOL 4600 321 ULTRA-FINE/0.3ML/31G X NEEDLE/U-100/1ML/25G X BASE G ALMOND OIL 8MM 229 1" 230 SWEET 106 BD INSULIN SYRINGE BD INSULIN BASE GELATIN GUMMY ULTRA-FINE/0.5ML/30G X SYRINGE/DETACHABLE TROCHE 315 12.7MM 229 NEEDLE/U-100/1ML/25G X BASE PCCA CLARIFYING 321 BD INSULIN SYRINGE 5/8" 230 BD INSULIN BASE W301 321 ULTRA-FINE/0.5ML/31G X 8MM 229 SYRINGE/DETACHABLE BASE X 318 BD INSULIN SYRINGE NEEDLE/U-100/1ML/26G X BASIC FUCHSIN HCL 80 ULTRA-FINE/1/2 1/2" 230 BAVENCIO 54 UNIT/0.3ML/31G X 8MM 229 BD INSULIN SYRINGE/U- BD INSULIN SYRINGE 100/1ML/27G X 1/2" 230 BAXDELA 160 ULTRA-FINE/1ML/30G X BD INSULIN SYRINGE/U- BAY OIL 106 12.7MM 229 100/2ML/27.5G X 5/8" 230 BAY RUM 106 BD INSULIN SYRINGE BD INSULIN SYRINGE/U- BAYER CONTOUR LINK 2.4 ULTRA-FINE/1ML/31G X 500/0.5ML/31G X 6MM 230 BLOOD GLUCOSE 8MM 229 BD LANCET ULTRAFINE MONITORING SYSTEM 195 BD INSULIN SYRINGE 30G 195 BD LANCET ULTRAFINE BCAA 293 ULTRAFINE HALF- UNIT/0.3ML/31G X 5/16" 229 33G 195

Index 10 BD LATITUDE DIABETES BD VEO INSULIN SYRINGE BENAZEPRIL MANAGEMENT SYSTEM 195 ULTRA-FINE/0.3ML/31G X HCL/HYDROCHLOROTHIAZIDE BD LOGIC BLOOD GLUCOSE 6MM 231 48 MONITOR 195 BD VEO INSULIN SYRINGE BENAZEPRIL BD MICROTAINER ULTRA-FINE/0.5ML/31G X HYDROCHLORIDE 80 LANCETS 195 6MM 231 BENDAMUSTINE BD PEN BD VEO INSULIN SYRINGE HYDROCHLORIDE 52 NEEDLE/MICRO/ULTRA- ULTRA-FINE/1/2 BENDEKA 52 FINE/32G X 6MM 230 UNIT/0.3ML/31G X 6MM 231 BENEFIX 165 BD PEN NEEDLE/MINI/ULTRA- BD VEO INSULIN SYRINGE FINE/31G X 5MM 230 ULTRA-FINE/1ML/31G X BENFOTIAMINE 80 BD PEN NEEDLE/NANO 2ND 6MM 231 BENICAR 47 GEN/32G X 5/32" 230 BD VEO INSULIN SYRINGE BENICAR HCT 48 BD PEN ULTRA-FINE/U-100/0.3ML/31G BENLYSTA 275 NEEDLE/NANO/ULTRA- X 15/64" 231 FINE/32G X 4MM 230 BD VEO INSULIN SYRINGE BENSAL HP 135 BD PEN ULTRA-FINE/U-100/1ML/31G BENTONITE 318 NEEDLE/ORIGINAL/ULTRA- X 15/64" 231 BENTYL 333 FINE/29G X 12.7MM 230 BEAU RX 142 BENZACLIN 120 BD PEN BEAUTY & SKIN NEEDLE/SHORT/ULTRA- THERAPY 273 BENZACLIN WITH PUMP 120 FINE/31G X 8MM 230 BECLOMETHASONE BENZALKONIUM BD PUDENDAL/LOCAL DIPROPIONATE 80 CHLORIDE 65 BLOCKTRAY 1% BECLOMETHASONE BENZAMYCIN 120 LIDOCAINE 174 DIPROPIONATE BD SAFETY-GLIDE INSULIN BENZEPRO 120 ANYDROUS 80 BENZETHONIUM SYRINGE/0.5ML/29G X BECONASE AQ 290 1/2" 230 CHLORIDE 80 BD SAFETY-LOK INSULIN BEEF BRAISED NATURAL BENZHYDROCODONE/ACETA SYRINGE/PERM FLAVOR 306 MINOPHEN 13 NEEDLE/UF/1ML/29G X BEEF FLAVOR 306 BENZNIDAZOLE 16 1/2" 230 BEEF TYPE FLAVOR BENZOCAINE 80 BD SAFETYGLIDE INSULIN NATURAL 306 benzocaine (dental) 275 SYRINGE/0.3ML/29G X BEEF TYPE FLAVOR NATURALCHLORIDE BENZOCAINE/LIDOCAINE/TET 1/2" 230 RACAINE 136 BD SAFETYGLIDE INSULIN FREE 306 SYRINGE/0.3ML/31G X BEEF TYPE FLAVOR OS306 BENZODOX 30 KIT 331 15/64" 230 BEEF-ADE 306 BENZODOX 60 KIT 331 BD SAFETYGLIDE INSULIN BEES WAX 318 BENZOIC ACID 125 SYRINGE/0.3ML/31G X benzoin compound 140 5/16" 230 BEESWAX 318 BD SAFETYGLIDE INSULIN BELBUCA 14 BENZOIN GUM 80 SYRINGE/0.5ML/31G X BELEODAQ 57 BENZOIN TINCTURE 140 15/64" 230 BENZOIN TINCTURE BD SAFETYGLIDE INSULIN BELLADONNA 80 PLAIN 140 SYRINGE/1ML/31G X belladonna (bulk) 80 BENZOLYL PEROXIDE FORTE- 15/64" 230 BELLADONNA EXTRACT 80 HC 120 BD SAFETYGLIDE INSULIN BELLADONNA/OPIUM 333 benzonatate 118 SYSYRINGE/0.5ML/30G X BENZOQUINONE (PARA) 80 5/16" 231 BELRAPZO 52 BD SWABS SINGLE USE 226 BELSOMRA 172 benzoyl peroxide 120 BD SWABS SINGLE USE BENACTYZINE BENZOYL PEROXIDE 120 BUTTERFLY 226 HYDROCHLORIDE 80 benzoyl peroxide 120 BD VEO INSULIN SYRINGE benazepril & BENZOYL PEROXIDE 120 hydrochlorothiazide 48 ULTR-FINE/U-100/0.5ML/31G X BENZOYL PEROXIDE 15/64" 231 benazepril hcl 46 HYDROUS 120 BD VEO INSULIN SYRINGE BENAZEPRIL HCL 80 benzoyl peroxide- ULTRA-AFINE/0.3ML/31G X erythromycin 120 6MM 231

Index 11 benzoyl peroxide- BETAMETHASONE BIOFREQUENCY hydrocortisone 120 VALERATE 130 INSOLES 219 BENZOYL BETANAPHTHOL 80 BIOGUARD BARRIER PEROXIDE/CLINDAMYCIN/NIAC BETAPACE 71 DRESSING/LARGE ROLL 179 INAMIDE 120 BIOGUARD GAUZE SPONGE BENZOYL BETAPACE AF 71 2"X2" 8 PLY 179 PEROXIDE/CLINDAMYCIN/NIAC BETASERON 328 BIOGUARD GAUZE SPONGES INAMIDE/TRETINOIN 120 betaxolol hcl 71 4"X4" 12 PLY 179 benztropine mesylate 61 BIOGUARD ISLAND betaxolol hcl (ophth) 295 DRESSINGS4"X10" 179 BENZYL ALCOHOL 305 BETHANECHOL BIOGUARD ISLAND BENZYL BENZOATE 106 CHLORIDE 80 DRESSINGS4"X14" 179 BEOVU 296 bethanechol chloride 337 BIOGUARD ISLAND bepotastine besilate 300 BETHKIS 3 DRESSINGS4"X5" 179 BETIMOL 295 BIOGUARD NON-ADHERENT BEPREVE 300 DRESSINGS 3"X4" 179 BERINERT 166 BETOPTIC-S 295 BIOGUARD NON-ADHERENT BESER 130 BEVACIZUMAB 296 DRESSINGS 3"X8" 179 BESIVANCE 297 BEVESPI AEROSPHERE 24 BIOLON 300 BESPONSA 54 BEVYXXA 26 BIOMEPRO 38 bexarotene 59 BIORE HYDRATING BETA 1 KIT 114 MOISTURIZER 106 BEXSERO 337 BETA CAROTENE 80 BIORPHEN 340 BETA CYCLODEXTRIN 80 BEYAZ 111 BIOSCANNER GLUCOSE TEST BETA GLUCAN 80 BHA 80 STRIPS 147 BETADINE OPHTHALMIC BHRT BASE 321 BIOSUPP 277 PREP 297 BHT 108 BIOTECT PLUS 277 BETAHISTINE BI-EST 50:50 BIOTEL CARE BLOOD DIHYDROCHLORIDE 80 COMPOUNDINGKIT 158 GLUCOSEMONITORING BETAHISTINE HCL 80 BI-EST 50:50 SYSTEM 195 BETAINE ANHYDROUS 80 PROGESTERONE- BIOTEL CARE CONNECTED BETAINE HCL 80 TESTOSTERONE BLOOD GLUCOSE COMPOUNDING KIT 158 MONITORING SYSTEM 195 BETALIDO 114 BI-EST 80:20 BIOTENE DRY MOUTH 227 BETALOAN SUIK 114 PROGESTERONE BIOTENE DRY MOUTH BETAMETHASONE 80 COMPOUNDING KIT 159 GENTLEFORMULA 227 BETAMETHASONE bicalutamide 55 BIOTENE DRY MOUTH ACETATE 80 BICILLIN C-R 304 MOISTURIZING SPRAY 275 BETAMETHASONE ACETATE BICILLIN L-A 304 BIOTHRAX 337 MICRONIZED 80 BIOTIN 80 BETAMETHASONE BICNU 52 ACETATE/BETAMETHASONE BIDIL 74 BIOTIN PLUS KERATIN 286 114 BIIFENAC 1000 124 BIOTIN-D 80 BETAMETHASONE BISABOLOL ALPHA-L 80 COMBO 114 BIIFENAC 500 124 BETAMETHASONE BIJUVA 159 BISACODYL 173 DIPROPIONATE 130 bisacodyl-peg 3350-pot chloride- BIKTARVY 66 sod bicarb-sod chloride 172 betamethasone dipropionate BILBERRY PLUS 286 (topical) 130 BISMUTH CITRATE 80 betamethasone dipropionate BILTRICIDE 16 BISMUTH augmented 130 BIMATOPROST 80 SUBCARBONATE 108 betamethasone sod phosphate & bimatoprost 301 BISMUTH SUBGALLATE 38 acetate 114 BISMUTH SUBNITRATE 108 BETAMETHASONE SODIUM BINOSTO 154 BISMUTH PHOSPHATE 114 BIO-KULT INFANTIS 38 SUBSALICYLATE 108 betamethasone valerate 130 bioflavonoid products 277 bisoprolol & hydrochlorothiazide 48

Index 12 bisoprolol fumarate 71 BORDERED GAUZE 180 BRISDELLE 330 BISOPROLOL FUMARATE 80 BORIC ACID 108 BRIVIACT 28 BITTER DRUG POWDER 318 BORIC ACID NF 108 BROMELAIN 271 BITTER ORANGE 81 BORON AMORPHOUS BROMELAIN 1200 GDU 271 BITTER STOP FLAVOR 306 FINE 81 BROMFENAC SODIUM 81 BORON CITRATE 81 BITTERNESS MASK bromfenac sodium (ophth) 300 FLAVOR 306 BORTEZOMIB 57 BROMFENAC SODIUM BITTERNESS REDUCING bosentan 75 SESQUIHYDRATE 81 AGENT 306 BOSULIF 57 BROMHEXINE HCL 118 BITTERNESS SUPPRESSOR FLAVOR 306 BOSWELLIA SERRATA bromocriptine mesylate 62 BITTERNESS SUPRESSOR EXTRACT 81 BROMOCRIPTINE FLAVOR 306 BOSWELLIA SERRATA MESYLATE 62 EXTRACT65% 81 bromocriptine mesylate 62 BIVALIRUDIN RTU 27 BOSWELLIA SERRATA bivalirudin trifluoroacetate 27 EXTRACT70% 81 BROMPHENIRAMINE 42 BIVALIRUDIN/SODIUM BOTOX 291 BROMPHENIRAMINE MALEATE 42 CHLORIDE 27 BP VIT 3 168 BIVIGAM 302 BROMSITE 300 BPCO 142 BLACKBERRY FLAVOR 306 BRONCHITOL 330 BRAFTOVI 57 BLENREP 54 BRONCHITOL TOLERANCE BRAIN MIGHT/DHA & CO TEST 330 bleomycin sulfate 57 Q10 286 BROVANA 24 BLEPH-10 297 BRAINSTRONG MEMORY BRUKINSA 57 BLEPHAMIDE 298 SUPPORT 273 BRAVURA ALL-IN-ONE 321 BRYHALI 130 BLEPHAMIDE S.O.P. 298 BREEZE 2 BLOOD GLUCOSE BSP 0820 114 BLINCYTO 54 MONITORING SYSTEM 195 BSS 301 BLISTER RELIEF BREMELANOTIDE BANDAGE 179 ACETATE 81 BSS PLUS 300,301 BLOOD GLUCOSE BREO ELLIPTA 24 BUBBLE GUM MONITORINGSYSTEM 195 CONCENTRATE 306 BLOOD GLUCOSE BRETYLIUM TOSYLATE 22 BUBBLE GUM FLAVOR 306 MONITORINGSYSTEM BREVIBLOC 71 BUBBLEGUM FLAVOR 306 PREMIUM 195 BREVIBLOC PREMIXED 71 BUDESONIDE 81 BLOOD GLUCOSE SYSTEM BREVIBLOC PREMIXED PAK 195 DOUBLESTRENGTH 71 budesonide 114 BLOOD GLUCOSE TEST BREVITAL SODIUM 163 budesonide (inhalation) 23 STRIPS 147 budesonide (nasal) 290 BLOOD GLUCOSE TEST BREYANZI 55 STRIPS PREMIUM 147 BREZTRI AEROSPHERE 24 BUDESONIDE MICRONIZED 81 BLOXIVERZ 51 BRIDION 39 budesonide-formoterol fumarate BLUE AGAVE ORGANIC 80 BRIJ 35 96 dihydrate 24 BLUEBERRY FLAVOR 306 BRIJ 700 96 BUFFERED LIDOCAINE HYDROCHLORIDE/SODIUM BLULINK BLOOD GLUCOSE BRIJ 93 96 MONITORING SYSTEM 195 BICARBONATE 173 BLULINK CONTROL BRILINTA 166 BUFFERED SOLUTION/HIGH & LOW 195 BRILLIANT BLUE G 305 LIDOCAINE/SODIUMBICARBON BLULINK GLUCOSE TEST BRILLIANT GREEN 81 ATE 173 STRIPS 147 BRIMONIDE/DORZOLAMIDE BUFLOMEDIL HCL 81 BOCASAL 275 P-F 296 BULLSEYE MINI SAFETY BOLDENONE 17- BRIMONIDINE LANCETS 195 UNDECYLENATE 81 TARTRATE 81 BULLSEYE SAFETY BONIVA 154 brimonidine tartrate 296 LANCETS 195 bumetanide 153 BONJESTA 41 BRINEURA 156 BUMEX 153 BOOSTRIX 333 brinzolamide 300

Index 13 BUNAVAIL 14 butalbital-aspirin-caffeine CALCIPOTRIENE 81 BUPHENYL 156 w/cod 13 calcipotriene 128 BUTALBITAL/ACETAMINOPH BUPIVACAINE EN 8 CALCIPOTRIENE FISIOPHARMA 174 BUTALBITAL/ASPIRIN/CAFFEI ANHYDROUS/CLOBETASOL BUPIVACAINE HCL 174 NE 8 PROPIONATE 130 bupivacaine hcl 174 CALCIPOTRIENE butenafine hcl 125 MONOHYDRATE 81 BUPIVACAINE HCL 174 BUTISOL SODIUM 171 calcipotriene-betamethasone BUPIVACAINE HCL butorphanol tartrate 14 dipropionate 130 MONOHYDRATE 174 BUTORPHANOL CALCIPOTRIOL 81 BUPIVACAINE TARTRATE 81 HYDROCHLORIDE 174 calcitonin (salmon) 154 BUPIVACAINE BUTRANS 14 CALCITRIOL 81 HYDROCHLORIDE/DEXAMETH BUTTER FLAVOR 306 calcitriol 156 ASONE SOD BUTTER RUM FLAVOR 306 calcitriol (topical) 128 PHOS/EPINEPHRINE 114 BUTTERFLY CALCITRIOL IN ALMOND BUPIVACAINE CLOSURES 180 HYDROCHLORIDE/SODIUM OIL 81 BUTTERSCOTCH CALCIUM ACETATE 81 CHLORIDE 174 FLAVOR 306 calcium acetate (phosphate BUPIVACAINE BUTYL ALCOHOL 81 HYDROCHLORIDEMONOHYDR binder) 162 BUTYLATED CALCIUM ALGINATE 81 ATE 174 HYDROXYANISOLE 81 bupivacaine in dextrose 174 BUTYLATED CALCIUM AMINO ACID bupivacaine w/ epinephrine 173 HYDROXYTOLUENE 108 CHELATE 30% 81 CALCIUM ASCORBATE 342 BUPIVILOG KIT 114 BUTYLENE GLYCOL 81 CALCIUM ASCORBATE BUPRENEX 14 BYDUREON BCISE 35 DIHYDRATE 342 buprenorphine 14 BYDUREON PEN 35 CALCIUM CARBONATE 267 BUPRENORPHINE 81 BYETTA 35 CALCIUM CARBONATE EXTRA buprenorphine hcl 14 BYFAVO 171 LIGHT 267 BYNFEZIA PEN 158 CALCIUM CARBONATE BUPRENORPHINE HCL 81 HEAVY 267 buprenorphine hcl-naloxone hcl BYSTOLIC 71 CALCIUM CARBONATE dihydrate 14 C INDICUM EXTRACT/C LIGHT 267 bupropion hcl 31 SINESIS LEAF EXTRACT 81 CALCIUM CHLORIDE 267 BUPROPION HCL 81 C-NATE DHA 282 calcium chloride (dihydrate)267 bupropion hcl (smoking C10-C30 ALKYL ACRYLATE CALCIUM CHLORIDE deterrent) 329 CROSSPOLYMER 318 ANHYDROUS 81 BUPROPION CABENUVA 66 CALCIUM CHLORIDE HYDROCHLORIDE 81 cabergoline 158 DIHYDRATE 267 BURIED TREASURE ACTIVE CALCIUM CITRATE 82 55PLUS SENIOR CABOMETYX 58 COMPLEX 277 CADIRAMD 136 CALCIUM CITRATE TETRAHYDRATE 82 buspirone hcl 20 CADUET 74 CALCIUM DISODIUM BUSPIRONE HCL 81 CAFCIT 1 VERSENATE 39 BUSPIRONE CAFERGOT 265 CALCIUM FOLINATE 92 HYDROCHLORIDE 81 caffeine & sodium benzoate 1 CALCIUM busulfan 52 CAFFEINE ANHYDROUS 1 FRUCTOBORATE 82 BUSULFEX 52 CALCIUM GLUBIONATE 82 caffeine citrate 1 BUTALBITAL 81 CALCIUM GLUBIONATE CAFFEINE CITRATED 1 butalbital-acetaminophen 7 MONOHYDRATE 82 CALAMINE 140 butalbital-acetaminophen- CALCIUM GLUCONATE 267 caffeine 8 CALAN 72 calcium gluconate 267 butalbital-acetaminophen- CALAN SR 72 CALCIUM GLUCONATE caffeine w/ codeine 13 CALCIFOL 267 ANHYDROUS 267 butalbital-aspirin-caffeine 8

Index 14 CALCIUM GLUCONATE CANTHARIDIN 135 CAPSULE CONI-SNAP #0 DARK MONOHYDRATE 267 CAPASTAT SULFATE 51 BLUE/DARK BLUE 309 CALCIUM CAPSULE CONI-SNAP #0 GLUCONATE/SODIUMCHLORID capecitabine 53 GREEN/CLEAR 309 E 267 CAPEX 130 CAPSULE CONI-SNAP #0 CALCIUM CAPHOSOL 275 LIGHT BLUE/WHITE 309 GLYCEROPHOSPHATE 82 CAPSULE CONI-SNAP #0 CAPLYTA 63 CALCIUM HYDROXIDE 108 PINK/PINK 309 CALCIUM CAPRELSA 58 CAPSULE CONI-SNAP #0 HYDROXYAPATITE 85 CAPRYLIC ACID 82 RED/WHITE 309 CALCIUM L-5 CAPRYLIC/CAPRIC CAPSULE CONI-SNAP #0 METHYLTETRAHYDROFOLATE TRIGLYCERIDE 82 WHITE/WHITE 309 93 CAPRYLIC/CAPRIC CAPSULE CONI-SNAP CALCIUM LACTATE TRIGLYCERIDES 82 #0/PURPLE/OPAQUE/CLEAR PENTAHYDRATE 267 CAPS 0 CLEAR DELAYED 309 CALCIUM LEVULINATE RELEASE 317 CAPSULE CONI-SNAP #00 DIHYDRATE 82 CAPSAICIN 136 CLEAR/CLEAR 309 CALCIUM OXIDE 82 CAPSULE CONI-SNAP #00 CAPSAICIN PALMITATE 82 WHITE/WHITE 309 CALCIUM CAPSICUM OLEORESIN 108 CAPSULE CONI-SNAP #000 PANTOTHENATE 342 CAPSUBLEND-H 318 CLEAR/CLEAR 309 CALCIUM PHOSPHATE CAPSULE CONI-SNAP #1 DIBASIC 267 CAPSUBLEND-P 318 AQUABLUE/AQUA BLUE 309 CALCIUM PHOSPHATE CAPSUBLEND-S 319 CAPSULE CONI-SNAP #1 TRIBASIC 267 CAPSULE #0 CLEAR/CLEAR BLUE/BLUE 309 CALCIUM PROPIONATE 82 VEGETABLE 317 CAPSULE CONI-SNAP #1 CALCIUM PYRUVATE 82 CAPSULE #0 BLUE/PINK 309 CALCIUM SACCHARIN 100 WHITE/WHITEOPAQUE CAPSULE CONI-SNAP #1 VEGETABLE 317 BLUE/POWDER BLUE 309 CALCIUM STEARATE 82 CAPSULE #1 CLEAR/CLEAR CAPSULE CONI-SNAP #1 CALCIUM SULFATE 108 VEGETABLE 317 BROWN/IVORY 309 CALCIUM SULFATE CAPSULE #1 CAPSULE CONI-SNAP #1 ANHYDROUS 108 WHITE/WHITEOPAQUE BROWN/LIGHT BROWN 309 CALCIUM SULFATE VEGETABLE 317 CAPSULE CONI-SNAP #1 HEMIHYDRATE 108 CAPSULE #3 CLEAR/CLEAR CLEAR/CLEAR 309 CALCIUM THIOGLYCOLATE VEGETABLE 318 CAPSULE CONI-SNAP #1 TRIHYDRATE 82 CAPSULE #3 CLEAR/CLEAR VEGGIE 318 CALCIUM-FOLIC ACID PLUS WHITE/WHITEOPAQUE CAPSULE CONI-SNAP #1 D 267 VEGETABLE 318 DARKGREEN/DARK CALDOLOR 4 CAPSULE 0 CLEAR GREEN 309 CALLUS REMOVER 219 VEGGIE 318 CAPSULE CONI-SNAP #1 CAPSULE 0 CLEAR VEGGIE DARKGREEN/ORANGE 309 CALLUS/CORN SHAVER 219 LOCKING 318 CAPSULE CONI-SNAP #1 CALLUS/CORN SHAVER CAPSULE 00 CLEAR VEGGIE GREEN/YELLOW 309 BLADES 219 LOCKING 318 CAPSULE CONI-SNAP #1 CALM 293 CAPSULE 1 CLEAR LIGHT BLUE/WHITE 309 CALQUENCE 58 VEGGIE 318 CAPSULE CONI-SNAP #1 CAPSULE 1 CLEAR VEGGIE LIGHT GREY/PINK 309 CAMBIA 265 LOCKING 318 CAPSULE CONI-SNAP #1 CAMPHOR 128 CAPSULE 3 CLEAR ORANGE 309 CAMPTOSAR 61 VEGGIE 318 CAPSULE CONI-SNAP #1 CANADIAN BALSAM 82 CAPSULE 3 CLEAR VEGGIE PINK/AQUA BLUE 309 LOCKING 318 CAPSULE CONI-SNAP #1 CANASA 161 CAPSULE CONI-SNAP #0 PINK/CLEAR 309 CANCIDAS 41 CLEAR/CLEAR 309 CAPSULE CONI-SNAP #1 candesartan cilexetil 47 CAPSULE CONI-SNAP #0 PINK/PINK 309 candesartan cilexetil- CLEAR/CLEAR VEGGIE 318 CAPSULE CONI-SNAP #1 PINK/WHITE 309 hydrochlorothiazide 48 CANNABIDIOL 82

Index 15 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 CARBOMER HOMOPOLYMER PINK/YELLOW 309 BLACK/GREEN 310 TYPE C 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 carboplatin 52 PURPLE/PURPLE 310 CLEAR/CLEAR 310 CARBOPOL 940 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 RED/BLUE 310 WHITE 310 CARBOPOL 940 NF 82 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #0 CARBOXYMETHYLCELLULOSE RED/WHITE 310 CLEAR 310 SODIUM 109 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #00 CARBOXYMETHYLCELLULOSE WHITE 310 CLEAR 310 SODIUM HIGH CAPSULE CONI-SNAP #1 CAPSULE SIZE 1 VISCOSITY 109 WHITE/CLEAR 310 LACTOSE 310 CARBOXYMETHYLCELLULOSE CAPSULE CONI-SNAP #1 captopril 46 SODIUM LOW VISCOSITY 109 CARBOXYMETHYLCELLULOSE WHITE/GREEN 310 CAPTOPRIL 82 CAPSULE CONI-SNAP #1 SODIUM MEDIUM YELLOW/GREEN 310 captopril & VISCOSITY 109 CAPSULE CONI-SNAP #1 hydrochlorothiazide 48 CARDENE IV 72 YELLOW/YELLOW 310 CARAC 127 CARDIOCOM LANCING CAPSULE CONI-SNAP #2 CARAFATE 335 DEVICE 195 CLEAR/CLEAR 310 CARAMEL FLAVOR 306 CARDIOPLEGIA DEL NIDO CAPSULE CONI-SNAP #2 CARBACHOL 82 FORMULA 74 WHITE 310 CARDIOPLEGIA INDUCTION CAPSULE CONI-SNAP #3 CARBAGLU 156 HIGH POTASSIUM 74 BLUE/CLEAR 310 carbamazepine 28 CARDIOPLEGIA INDUCTION CAPSULE CONI-SNAP #3 CARBAMAZEPINE 28 HIGH POTASSIUM/LOW BROWN/LIGHT BLUE 310 DEXTROSE 74 CAPSULE CONI-SNAP #3 carbamazepine 28 CARDIOPLEGIA INDUCTION CLEAR/CLEAR 310 CARBAMIDE PEROXIDE 82 HIGH POTASSIUM/NON- CAPSULE CONI-SNAP #3 CARBATROL 28 ENRICHED 74 CLEAR/CLEAR VEGGIE 318 CARBAZOCHROME 82 CARDIOPLEGIA INDUCTION CAPSULE CONI-SNAP #3 PLASMALYTE/HIGH DARKGREY/PINK 310 carbidopa 61 POTASSIUM 74 CAPSULE CONI-SNAP #3 CARBIDOPA 109 CARDIOPLEGIA INDUCTION GRAY/YELLOW 310 CARBIDOPA PLASMALYTE/TROMETHAMINE CAPSULE CONI-SNAP #3 ANHYDROUS 108 HIGH POTASSIU 74 GREEN/BLUE 310 CARDIOPLEGIA CAPSULE CONI-SNAP #3 carbidopa-levodopa 62 carbidopa-levodopa- MAINTENANCELOW MAROON/BLUE 310 DEXTROSE/LOW CAPSULE CONI-SNAP #3 entacapone 62 CARBIDOPA/LEVODOPA POTASSIUM 74 MINTGREEN/MINT CARDIOPLEGIA GREEN 310 ODT 62 CARBIMAZOLE 82 MAINTENANCELOW CAPSULE CONI-SNAP #3 POTASSIUM 74 OLIVE/CLEAR 310 carbinoxamine maleate 43 CARDIOPLEGIA CAPSULE CONI-SNAP #3 CARBINOXAMINE MAINTENANCELOW ORANGE/ORANGE 310 MALEATE 43 TROMETHAMINE/LOW CAPSULE CONI-SNAP #3 CARBOCAINE 174 POTASSIUM 74 PINK/CLEAR 310 CARDIOPLEGIA CAPSULE CONI-SNAP #3 CARBOGEL 940 321 CARBOHOL 940 321 MAINTENANCEPLASMALYTE/T PINK/PINK 310 ROMETHAMINE LOW CAPSULE CONI-SNAP #3 CARBOMER 934P 82 RED/CLEAR 310 POTASSI 74 CAPSULE CONI-SNAP #3 CARBOMER 934P RESIN 82 CARDIOPLEGIA RED/RED 310 CARBOMER 940 82 REPERFUSATE/LOW CAPSULE CONI-SNAP #3 CARBOMER 941 82 POTASSIUM 74 WHITE/CLEAR 310 CARBOMER GEL CARDIOPLEGIC 74 CAPSULE CONI-SNAP #3 AQUEOUS 321 cardioplegic soln 74 WHITE/WHITE 310 CARBOMER GEL CARDIOPRESS 286 CAPSULE CONI-SNAP #3 HYDROALCOHOLIC 321 YELLOW/YELLOW 310 CARDIOVID PLUS 292

Index 16 CARDIZEM 72 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES CARDIZEM CD 72 31GX6MM 231 32GX 4MM 232 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES CARDIZEM LA 72 31GX8MM 231 32GX 5MM 232 CARDURA 48 CAREONE UNIFINE PENTIPS CARETOUCH SAFETY CARDURA XL 164 PEN NEEDLES LANCETS/26G 195 CAREFINE PEN NEEDLE 32GX4MM 231 CARETOUCH SAFETY 32GX4MM 231 CAREONE UNIFINE PENTIPS LANCETS/28G 195 CAREFINE PEN NEEDLES PLUS PEN NEEDLES CARETOUCH SAFETY 29GX1/2" 231 29GX12MM 231 LANCETS/30G 195 CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPS CARETOUCH TWIST LANCETS 30GX5/16" 231 PLUS PEN NEEDLES 28G 195 CAREFINE PEN NEEDLES 31GX5MM 231 CARETOUCH TWIST LANCETS 31GX6MM 231 CAREONE UNIFINE PENTIPS 30G 195 CAREFINE PEN NEEDLES PLUS PEN NEEDLES CARETOUCH TWIST LANCETS 31GX8MM 231 31GX6MM 232 33G 195 CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPS CARIMUNE 32GX5MM 231 PLUS PEN NEEDLES NANOFILTERED 302 CAREFINE PEN NEEDLES 31GX8MM 232 CARISOPRODOL 288 32GX6MM 231 CAREONE UNIFINE PENTIPS carisoprodol 288 PLUS PEN NEEDLES CAREONE ADVANCED carisoprodol w/ aspirin 289 LANCINGDEVICE 195 32GX4MM 232 CAREONE UNIFINE PENTIPS carisoprodol w/ aspirin & CAREONE BLOOD GLUCOSE codeine 289 MONITORING PLUS PEN NEEDLES/33G X SYSTEM/PREMIUM 195 5/32" 232 CARMINE 82 CAREONE BLOOD GLUCOSE CARESENS CONTROL A carmustine 52 MONITORING SOLUTION 195 CARNAUBA WAX 82 CARESENS LANCETS 195 SYSTEM/VALUE 195 CARNITINE (L) 92 CAREONE BLOOD GLUCOSE CARESENS N BLOOD TEST STRIPS/PREMIUM 147 GLUCOSETEST STRIPS 147 CARNITOR 156 CAREONE BLOOD GLUCOSE CARESENS N GLUCOSE CARNITOR SF 156 TEST STRIPS/VALUE 147 MONITORING SYSTEM 195 CARNOSINE L 82 CAREONE INSULIN CARESENS N VOICE BLOOD SYRINGES/0.3ML/30G X GLUCOSE MONITORING CAROSPIR 153 1/2" 231 SYSTEM 195 CARPALAID EMPLOYEE CAREONE INSULIN CARETOUCH ALCOHOL SURVIVAL/LARGE 180 SYRINGES/0.3ML/31G X PREP PADS 226 CARPALAID EMPLOYEE 5/16" 231 CARETOUCH BLOOD SURVIVAL/SMALL 180 CAREONE INSULIN GLUCOSE MONITORING CARPALAID PRACTIONER SYRINGES/0.5ML/30G X SYSTEM 195 PACK/LARGE 180 1/2" 231 CARETOUCH BLOOD CARPALAID PRACTIONER CAREONE INSULIN GLUCOSE TEST PACK/SMALL 180 SYRINGES/0.5ML/31G X STRIPS 147 CARPALAID/LARGE 180 5/16" 231 CARETOUCH CONTROL CARPALAID/SMALL 180 CAREONE INSULIN SOLUTION LEVEL 2 195 CARRAGEENAN 319 SYRINGES/1ML/30G X CARETOUCH INSULIN 1/2" 231 SYRINGE/U-100/1ML/28G X CARRAKLENZ 142 CAREONE INSULIN 5/16" 232 CARRASMART 142 SYRINGES/1ML/31GX5/16" CARETOUCH INSULIN CARRASMART FOAM 180 231 SYRINGE/U-100/1ML/29G X CARRASYN HYDROGEL CAREONE LANCET SUPER 5/16" 232 WOUND DRESSING 142 THIN/30G 195 CARETOUCH LANCING CARRASYN V HYDROGEL CAREONE LANCET THIN 195 DEVICEWITH EJECTOR 195 WOUNDDRESSING 142 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES carteolol hcl (ophth) 295 31G X 6 MM 232 29GX12MM 231 CARTICEL 288 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES 31GX5MM 231 31GX 5MM 232 carvedilol 70 CARETOUCH PEN NEEDLES carvedilol phosphate 70 31GX 8MM 232

Index 17 CASCARA SAGRADA 173 CEFTAZIDIME/SODIUM CERAPHYL SLK 91 CASIRIVIMAB 303 CARBONATE 82 CERDELGA 166 ceftriaxone sodium 77 CASODEX 55 CEREBYX 30 CEFTRIAXONE SODIUM 77 caspofungin acetate 41 CERESIN WAX 82 ceftriaxone sodium 77 CASPOFUNGIN ACETATE 41 CEREZYME 166 CEFTRIAXONE SODIUM 82 CASTOR OIL 106 CEROVEL 134 ceftriaxone sodium in CATAPRES 48 dextrose 77 CESAMET 41 CATAPRES-TTS-1 48 CEFTRIAXONE/DEXTROSE CESIUM CHLORIDE 82 CATAPRES-TTS-2 48 77 CETEARYL CATAPRES-TTS-3 48 CEFUROXIME 297 ALCOHOL/CETEARETH-20 83 cetirizine hcl 43 CAYSTON 19 cefuroxime axetil 76 CBD4 FREEZE PUMP cefuroxime sodium 76 CETOSTEARYL ALCOHOL 83 MAXIMUMSTRENGTH 136 CEFUROXIME CETRAXAL 301 CBD4 FREEZE PUMP SODIUM/SODIUMCHLORIDE CETROTIDE 155 297 VANISHING SCENT 136 CETYL ALCOHOL 319 CEDAR LEAF OIL 106 CELA BASE 321 CETYL ESTERS WAX 100 cefaclor 76 CELEBREX 4 CETYL MYRISTOLEATE 83 CEFACLOR ER 76 celecoxib 4 CETYLCIDE-G 65 CELECOXIB 82 cefadroxil 76 CETYLPYRIDINIUM CEFAZOLIN 76 CELESTONE CHLORIDE 83 SOLUSPAN 114 CETYLPYRIDINIUM CEFAZOLIN SODIUM 76 CELESTONE- cefazolin sodium 76 CHLORIDEMONOHYDRATE SOLUSPAN 114 83 CEFAZOLIN SODIUM 76 CELEXA 32 cevimeline hcl 275 CEFAZOLIN CELLCEPT 271 CHANTIX 329 SODIUM/DEXTROSE 76 CELLCEPT CEFAZOLIN SODIUM/SODIUM CHANTIX CONTINUING INTRAVENOUS 271 MONTHPAK 329 CHLORIDE 76 CELLULASE 82 CEFAZOLIN/SODIUM CHANTIX STARTING MONTH CHLORIDE 76 CELLULOSE PAK 329 MICROCRYSTALLINE 82 CHARCOAL 39 cefdinir 76 CELLULOSE PARTIALLY cefditoren pivoxil 76 DEPOLYMERIZED 82 CHARCOAL ACTIVATED 39 CEFEPIME 77 CELLULOSE/CMC NA CHEESE-ADE FLAVOR 306 cefepime hcl 77 MICROCRYSTALLINE 82 CHEESECAKE FLAVOR 306 CEFEPIME CELONTIN 31 CHEMET 39 HYDROCHLORIDE 77 CEM-UREA 134 CHEMSIL K-12 321 CEFEPIME/DEXTROSE 77 CENFOL 168 CHEMSIL K-51 321 cefixime 76 CENTANY 125 CHEMSTRIP-K 147 CEFOTAN 76 CENTANY AT 125 CHENODAL 160 cefotaxime sodium 76 CENTRATEX 168 CHERRY CONCENTRATE 315 cefotetan disodium 76 CENTRUM 277 CHERRY FLAVOR 306 CEFOTETAN/DEXTROSE 76 CENTRUM CHERRY SYRUP 315 cefoxitin sodium 76 PERFORMANCE 286 CENTRUM SILVER CHERRY-ADE FLAVOR 307 CEFOXITIN SODIUM 76 50+WOMEN 277 CHEW-HESIVE 321 cefoxitin sodium 76 CENTRUM SPECIALIST CHICKEN (GRILLED) cefpodoxime proxetil 76 ENERGY 287 FLAVOR 307 cefprozil 76 cephalexin 76 CHICKEN BROTH FLAVOR SPRAY DRIED 307 ceftazidime 76,77 CEQUA 298 CERACADE 139 CHICKEN FLAVOR 307 CEFTAZIDIME 82 CHICKEN FLAVOR OIL CEFTAZIDIME/DEXTROSE 77 CERAMAX 139 SOLUBLE 307

Index 18 CHICKEN FLAVOR WATER CHOCOLATE HAZELNUT CHRYSIN 83 MISCIBLE 307 FLAVOR 307 CHYMOTRYPSIN ALPHA 271 CHICKEN PROTEIN 83 CHOCOLATE NATURAL & CIALIS 74 CHICKEN ROASTED ARTIFICAL FLAVOR 307 CONCENTRATE 307 CHOICE DM DIABETES RISK CICA-CARE 142 CHILDRENS ADVIL 5 IN-HOME TEST KIT 196 CICLODAN SOLUTION CHOLASE CONTROL 287 KIT 125 CHILDRENS MOTRIN 5 CHOLBAM 160 CICLOPIROX 83 CHLOOXIA 130 CHOLECAL DF 168 ciclopirox 125 CHLORAL HYDRATE 171 CHOLECALCIFEROL 83 ciclopirox olamine 125 CHLORAMBUCIL 83 cholecalciferol 341 CICLOPIROX OLAMINE 125 CHLORAMPHENICOL 83 CHOLESTEROL 83 CICLOPIROX CHLORAMPHENICOL OLAMINE/CLOBETASOL 129 PALMITATE 83 CHOLESTEROL ACETATE 83 CICLOPIROX chloramphenicol sodium OLAMINE/CLOBETASOL succinate 18 cholestyramine 44 PROPIONATE/SALICYLIC chlordiazepoxide hcl 21 CHOLESTYRAMINE 83 ACID 128 chlordiazepoxide hcl-clidinium cholestyramine light 44 CICLOPIROX/SALICYLIC bromide 333 CHOLESTYRAMINE ACID 129 chlordiazepoxide-amitriptyline RESIN 83 cidofovir 68 328 CHOLINE BITARTRATE 292 CHLORHEXIDINE DIACETATE CIDOFOVIR ANHYDROUS 83 HYDRATE 83 CHOLINE CHLORIDE 83 CIDOFOVIR DIHYDRATE 83 CHLORHEXIDINE choline fenofibrate 44 CIFEREX 168 GLUCONATE 65 CHOLINE MAGNESIUM CIFRAZOL 168 chlorhexidine gluconate (mouth- TRISALICYLATE 83 throat) 275 CHONDROITIN cilostazol 166 CHLOROACETIC ACID 129 SULFATE 301 CILOXAN 297 CHLOROBUTANOL 305 CHONDROITIN SULFATE CIMDUO 66 CHLOROBUTANOL SODIUM 83 CIMETIDINE 334 ANHYDROUS 305 CHORIONIC GONADOTROPIN 83 cimetidine 334 CHLOROFORM 106 CHORIONIC cimetidine hcl 334 CHLOROPHYLLIN SODIUM GONADOTROPIN(HUMAN) CIMETIDINE/LIDOCAINE/SALIC COPPER 83 83 YLIC ACID 135 chloroprocaine hcl 176 CHROMIC CHLORIDE 83 CIMZIA 161 CHLOROQUINE chromic chloride 270 PHOSPHATE 50 CIMZIA STARTER KIT 161 chloroquine phosphate 50 CHROMIUM CHLORIDE 83 cinacalcet hcl 156 CHROMIUM CHLORIDE CHLOROTHIAZIDE 83 CINNAMON BARK CASSIA 83 HEXAHYDRATE CINNAMON FLAVOR 307 chlorothiazide 154 REAGENT 83 chlorothiazide sodium 154 CHROMIUM PICOLINATE 83 CINQAIR 22 CHLOROXINE 83 CHROMIUM PICOLINATE CINRYZE 166 CHLOROXYLENOL 83 FORTIFIED 273 CINVANTI 41 CHROMIUM CHLORPHENIRAMINE CIPRO 160 42 PICOLINATE/KELP/LECITHIN/ MALEATE B-6/GRAPE FRUIT CIPRO HC 302 chlorpromazine hcl 64 EXTRACT 273 CIPRODEX 302 CHLORPROMAZINE HCL 83 CHROMIUM CIPROFLOXACIN 83 chlorthalidone 154 POLYNICOTINATE 83 ciprofloxacin 160 CHLORZOXAZONE 288 CHROMIUM POTASSIUM SULFATE CIPROFLOXACIN HCL 83 chlorzoxazone 288 DODECAHYDRATE 83 ciprofloxacin hcl 160 CHOCOLATE CHROMIUM XTRA 273 ciprofloxacin hcl (ophth) 297 CONCENTRATE 307 CHRYSADERM DAY 321 CHOCOLATE FLAVOR 307 ciprofloxacin hcl (otic) 302 CHRYSADERM NIGHT 321 ciprofloxacin in d5w 160

Index 19 ciprofloxacin-dexamethasone CLEODERM 321 CLEVER CHOICE COMFORT 302 CLEVER CHEK AUTO CODE EZINSULIN ciprofloxacin-fluocinolone VOICE BLOOD GLUCOSE SYRINGE/0.5ML/29G X acetonide 302 MONITORING SYSTEM 196 1/2" 232 CISAPRIDE CLEVER CHEK AUTO-CODE CLEVER CHOICE COMFORT MONOHYDRATE 84 BLOOD GLUCOSE EZINSULIN cisatracurium besylate 291 MONITORING SYSTEM 196 SYRINGE/0.5ML/30G X cisplatin 52 CLEVER CHEK AUTO-CODE 1/2" 232 CLEVER CHOICE COMFORT CISPLATIN 52,84 TEST STRIPS 147 CLEVER CHEK AUTO-CODE EZINSULIN citalopram hydrobromide 32 VOICE BLOOD GLUCOSE SYRINGE/0.5ML/30G X CITANEST FORTE MONITORING SYSTEM 196 5/16" 232 DENTAL 173 CLEVER CHEK AUTO-CODE CLEVER CHOICE COMFORT CITANEST PLAIN DENTAL174 VOICE TEST STRIPS 147 EZINSULIN CITRANATAL 90 DHA 282 CLEVER CHEK BLOOD SYRINGE/0.5ML/31G X 5/16" 232 CITRANATAL ASSURE 282 GLUCOSE MONITORING SYSTEM 196 CLEVER CHOICE COMFORT CITRANATAL B-CALM 282 CLEVER CHEK LANCETS EZINSULIN CITRANATAL BLOOM 282 ULTRATHIN 196 SYRINGE/1.0ML/30G X CITRANATAL BLOOM CLEVER CHEK LANCETS 1/2" 232 DHA 282 ULTRATHIN 30G 196 CLEVER CHOICE COMFORT CITRANATAL DHA 282 CLEVER CHEK TEST EZINSULIN SYRINGE/1ML/28G STRIPS 147 X 1/2" 232 CITRANATAL ESSENCE 282 CLEVER CHOICE AUTO- CLEVER CHOICE COMFORT CITRANATAL HARMONY 282 CODE PRO BLOOD EZINSULIN SYRINGE/1ML/29G CITRANATAL MEDLEY 282 GLUCOSE MONITORING X 1/2" 232 CLEVER CHOICE COMFORT CITRANATAL RX 282 SYSTEM 196 CLEVER CHOICE AUTO- EZINSULIN SYRINGE/1ML/30G CITRIC ACID 109 CODE PRO TEST X 5/16" 233 CITRIC ACID STRIPS 147 CLEVER CHOICE COMFORT ANHYDROUS 109 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U- CITRIC ACID EZINSULIN PEN NEEDLES 100/1ML/31GX5/16" 233 MONOHYDRATE 109 31GX8MM 232 CLEVER CHOICE COMFORT CITRONELLA OIL 106 CLEVER CHOICE COMFORT EZLANCETS 21G 196 CITRULLINE EASY 156 EZINSULIN PEN NEEDLES CLEVER CHOICE COMFORT 33GX4MM 232 EZLANCETS 23G 196 CITRULLINE(L) 84 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT CITRUS BIOFLAVONOIDS 84 EZINSULIN EZLANCETS 28G 196 cladribine 53 SYRINGE/0.3ML/29G X CLEVER CHOICE COMFORT CLARINEX 43 1/2" 232 EZPEN NEEDLES CLEVER CHOICE COMFORT 29GX12MM 233 CLARINEX-D 12 HOUR 118 EZINSULIN CLEVER CHOICE COMFORT CLARITHROMYCIN 84 SYRINGE/0.3ML/30G X EZPEN NEEDLES clarithromycin 176 1/2" 232 31GX5MM 233 CLEVER CHOICE COMFORT CLEANLET LANCETS 28G 196 CLEVER CHOICE COMFORT EZINSULIN EZPEN NEEDLES CLEAR BANDAGES 180 SYRINGE/0.3ML/30G X 31GX6MM 233 CLEMASTINE FUMARATE 43 5/16" 232 CLEVER CHOICE COMFORT clemastine fumarate 43 CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM 233 CLEMIZOLE HCL 84 EZINSULIN SYRINGE/0.3ML/31G X CLEVER CHOICE COMFORT CLENIA PLUS 120 5/16" 232 EZPEN NEEDLES CLENPIQ 172 CLEVER CHOICE COMFORT 32GX4MM 233 EZINSULIN CLEVER CHOICE COMFORT CLEOCIN 19,339 EZPEN NEEDLES CLEOCIN PEDIATRIC SYRINGE/0.5ML/28G X 1/2" 232 32GX5MM 233 GRANULES 19 CLEVER CHOICE COMFORT CLEOCIN PHOSPHATE 19 EZPEN NEEDLES CLEOCIN-T 120 32GX6MM 233

Index 20 CLEVER CHOICE COMFORT CLINDACIN ETZ 120 CLINIMIX E 4.25%/DEXTROSE EZPEN NEEDLES CLINDACIN PAC 120 10% 294 32GX8MM 233 CLINIMIX E 4.25%/DEXTROSE CLEVER CHOICE COMFORT CLINDAGEL 120 25% 294 EZPEN NEEDLES clindamycin hcl 19 CLINIMIX E 4.25%/DEXTROSE 33GX4MM 233 CLINDAMYCIN HCL 84 5% 294 CLEVER CHOICE COMFORT CLINDAMYCIN HCL CLINIMIX E 5%/DEXTROSE EZPEN NEEDLES MONOHYDRATE 84 15% 294 33GX5MM 233 clindamycin palmitate CLINIMIX E 5%/DEXTROSE CLEVER CHOICE COMFORT hydrochloride 19 20% 294 EZPEN NEEDLES clindamycin phosphate 19 CLINIMIX E 8/10 294 33GX6MM 233 CLINIMIX E 8/14 294 CLEVER CHOICE COMFORT CLINDAMYCIN EZPEN NEEDLES PHOSPHATE 84 CLINIMIX N14G30E 294 33GX8MM 233 clindamycin phosphate CLINIMIX N9G15E 294 CLEVER CHOICE GLUCOSE (topical) 120 clindamycin phosphate in CLINIMIX N9G20E 294 CONTROL HIGH 196 CLINOIN 121 CLEVER CHOICE GLUCOSE d5w 19 CONTROL LOW 196 clindamycin phosphate CLINOLIPID 292 CLEVER CHOICE MICRO vaginal 339 CLIOQUINOL 125 clindamycin phosphate-benzoyl BLOODGLUCOSE clobazam 27 196 peroxide 120 MONITORING SYSTEM clindamycin phosphate-benzoyl CLOBETASOL 17 CLEVER CHOICE MICRO PROPIONATE 130 TESTSTRIPS 147 peroxide (refrigerate) 120 CLEVER CHOICE MINI clindamycin phosphate- clobetasol propionate 130 tretinoin 120 CLOBETASOL BLOODGLUCOSE CLINDAMYCIN MONITORING SYSTEM 196 PROPIONATE 130 CLEVER CHOICE NO CODING PHOSPHATE/NIACINAMIDE clobetasol propionate emollient TEST STRIPS 147 121 base 130 CLEVER CHOICE TALK CLINDAMYCIN clobetasol propionate BLOODGLUCOSE PHOSPHATE/NIACINAMIDE/T emulsion 130 MONITORING SYSTEM 196 RETINOIN 121 CLOBETASOL PROPIONATE CLEVER CHOICE TALK NO CLINDAMYCIN/NIACINAMIDE/ MICRONIZED USP 130 CODING TEST STRIPS 147 SPIRONOLACTONE/TRETINO CLOBETASOL IN 121 CLEVIPREX 72 PROPIONATE/LEVOCETIRIZIN CLINDAMYCIN/SODIUM E DIHYDROCHLORIDE 131 CLICKFINE PEN NEEDLE CHLORIDE 19 CLOBETASOL 32GX5/32" 233 CLINDAVIX 121 PROPIONATE/NIACINAMIDE CLICKFINE PEN NEEDLE 131 UNIVERSAL/31GX1/4" 233 CLINDESSE 339 CLICKFINE PEN NEEDLE CLINIMIX 4.25%/DEXTROSE CLOBETAVIX 131 UNIVERSAL/31GX5/16" 233 10% 293 CLOBETEX 43 CLICKFINE PEN NEEDLES 31G CLINIMIX 4.25%/DEXTROSE CLOBEX 131 25% 293 X 1/4" 233 clocortolone pivalate 131 CLICKFINE PEN NEEDLES 31G CLINIMIX 4.25%/DEXTROSE X 3/16" 233 5% 293 CLODAN KIT 131 CLICKFINE PEN NEEDLES 31G CLINIMIX 5%/DEXTROSE CLODERM 131 X 5/16" 233 15% 293 clofarabine 53 CLICKFINE PEN NEEDLES 31G CLINIMIX 5%/DEXTROSE X 8MM 233 20% 293 CLOFAZIMINE 84 CLICKFINE PEN NEEDLES 32G CLINIMIX 5%/DEXTROSE CLOLAR 53 X 5/32" 233 25% 293 CLOMIPHENE CITRATE 155 CLICKFINE PEN CLINIMIX 6/5 293 clomiphene citrate 155 NEEDLES/31GX1/4" 233 CLINIMIX 8/10 293 CLICKFINE UNIVERSAL PEN clomipramine hcl 33 NEEDLES 31GX5/16" 233 CLINIMIX 8/14 293 CLOMIPRAMINE HCL 84 CLIDINIUM BROMIDE 84 CLINIMIX E 2.75%/DEXTROSE 10% 294 clonazepam 27 CLIMARA 159 CLINIMIX E 2.75%/DEXTROSE CLONAZEPAM 84 CLIMARA PRO 159 5% 294 clonidine 48

Index 21 CLONIDINE HCL 48 COENZYME Q10 109 COMFORT ASSIST INSULIN clonidine hcl 48 COFFEE FLAVOR 307 SYRINGE/1ML/29G X 1/2" 234 COMFORT ASSIST INSULIN clonidine hcl (adhd) 2 COGENTIN 61 SYRINGE/1ML/30G X clonidine hcl (analgesia) 8 COLA FLAVOR 307 5/16" 234 CLONIDINE COLAZAL 161 COMFORT ASSIST INSULIN SYRINGE/1ML/31G X HYDROCHLORIDE 8 colchicine 165 CLOPIDOGREL 5/16" 234 BISULFATE 84 COLCHICINE 165 COMFORT ASSURED clopidogrel bisulfate 166 colchicine w/ probenecid 164 LANCETS MICRO THIN COLCRYS 165 33G 196 clorazepate dipotassium 21 COMFORT ASSURED CLOROTEKAL 176 colesevelam hcl 44 LANCETS SUPER THIN CLORSULON 84 COLESTID 44 28G 196 CLOTRIMAZOLE 125 COLESTID FLAVORED 44 COMFORT EZ INSULIN colestipol hcl 44 SYRINGE/U-100/0.5ML/31G X clotrimazole 275 5/16" 234 clotrimazole (topical) 125 COLHIBIN 84 COMFORT EZ INSULIN clotrimazole w/ colistimethate sodium 19 SYRINGE/U-100/1ML/31G X betamethasone 125 COLISTIMETHATE 5/16" 234 CLOVAGEL 321 SODIUM 84 COMFORT EZ MICRO/32G X CLOVE OIL 106 COLLAGEN 4MM 234 HYDROLYSATE 84 COMFORT EZ SHORT/31G X clozapine 64 COLLAGEN ULTRA 287 8MM 234 CLOZARIL 64 COLLAGENASE 135 COMFORT EZ/31G X 5MM 234 CO-ENZYME Q 10 109 COLLASIL OSA 319 COMFORT EZ/31G X 6MM 234 CO-NATAL FA 282 COLLODION 315 COMFORT LANCETS 196 CO-VERATROL 3 COMFORT TOUCH ALCOHOL COLLODION FLEXIBLE 315 COAGADEX 165 PREP PADS 226 COLY-MYCIN M 19 COMFORT TOUCH LANCETS COAGUCHEK LANCETS 196 COLY-MYCIN S 302 ULTRA THIN 31G 196 COAL TAR 108 COLYTE-FLAVOR COMFORT TOUCH PEN coal tar extract 142 PACKS 172 NEEDLES/31G X 4MM 234 COARTEM 50 COMBIGAN 295 COMFORT TOUCH PEN NEEDLES/31G X 6 MM 234 COBALT GLUCONATE 84 COMBIPATCH 159 COMFORT TOUCH PEN COBAMAMIDE 84 COMBIVENT RESPIMAT 24 NEEDLES/32G X 5MM 234 COCAINE HCL 136 COMBIVIR 66 COMFORT TOUCH PEN NEEDLES/32G X 8MM 234 cocaine hcl 136 COMETRIQ 58 COMFORT TOUCH PEN COCAINE COMFORT ASSIST INSULIN NEEDLES/33G X 5/32" 234 HYDROCHLORIDE 290 SYRINGE 0.3ML/29G X COMFORT TOUCH PEN COCAMIDE DEA 84 1/2" 233 NEEDLES/33GX 3/16" 234 COCOA BUTTER 319 COMFORT ASSIST INSULIN COMFORT TOUCH PEN SYRINGE/0.3ML/30G X COCOA BUTTER NEEDLES/33GX1/4" 234 5/16" 233 COMFORT TOUCH PLUS DEODORIZED 319 COMFORT ASSIST INSULIN COCONUT FLAVOR 307 SAFETY LANCETS PRESSURE SYRINGE/0.3ML/31G X ACTIVATED 30G 196 COCONUT OIL 106 5/16" 233 COMPEED SKIN PROTECTOR COD LIVER OIL 288 COMFORT ASSIST INSULIN DRESSING/MEDIUM/OVAL COD LIVER OIL FOR KIDS288 SYRINGE/0.5ML/29G X 180 1/2" 234 COMPEED SKIN PROTECTOR CODEINE PHOSPHATE 8 COMFORT ASSIST INSULIN DRESSING/SMALL/STRIP 180 CODEINE SULFATE 9 SYRINGE/0.5ML/30G X COMPLERA 66 codeine sulfate 9 5/16" 234 COMPLETE MENOPAUSE COMFORT ASSIST INSULIN HEALTH FORMULA 273 CODEINE SULFATE 9 SYRINGE/0.5ML/31G X COENZYME Q-10 3 5/16" 234 COMPLETE NATAL DHA 282

Index 22 COMPLETE PROSTATE COOL CONTROL SOLUTION COSOPT 295 HEALTHFORMULA 273 A 197 COSOPT PF 295 COMPLETENATE 282 COOL CONTROL SOLUTION COTELLIC 58 COMTAN 61 B 197 COOLMAGIC 142 COTEMPLA XR-ODT 2 CONCEPT DHA 282 COOLMAGIC TUBE SITE COTTON CANDY FLAVOR307 CONCEPT OB 282 DRESSING 143 COTTONSEED OIL 106 CONCERTA 2 COPA ISLAND BORDERED COUMADIN 26 CONDYLOX 135 FOAM DRESSING 4"X4" 180 COPA ISLAND BORDERED COUMARIN 84 CONJUPRI 72 FOAM DRESSING 6"X6" 180 COVERLET STRIPS 180 CONSENSI 72 COPA PLUS HYDROPHILIC COVRSITE COVER CONTOUR BLOOD GLUCOSE FOAM DRESSING 4"X4" 180 DRESSING 180 MONITORING SYSTEM 196 COPA PLUS HYDROPHILIC COVRSITE PLUS COMPOSITE CONTOUR BLOOD GLUCOSE FOAM DRESSING 4"X8" 180 DRESSING 180 TEST STRIPS 147 COPA PLUS HYDROPHILIC COZAAR 47 CONTOUR HIGH FOAM DRESSING 6"X6" 180 CONTROL 196 CRAN-RASPBERRY COPASIL 100 FLAVOR 307 CONTOUR LOW COPAXONE 328 CONTROL 196 CRANBERRY 84 CONTOUR NEXT BLOOD COPIKTRA 58 CRAYON BANDAGES GLUCOSE MONITORING COPPER GLUCONATE 84 STRIPS 180 SYSTEM 196 COPPER GLYCINATE 84 CREAM BASE 321 CONTOUR NEXT BLOOD CREAM BASE NIOSOMES 321 GLUCOSE TEST 147 COPPER PEPTIDE 84 CONTOUR NEXT CONTROL CORAL CALCIUM 84 CREAM CONCENTRATE 321 LEVEL 1 196 CORDRAN 131 CREAM-HEAVY BASE NIOSOME 321 CONTOUR NEXT CONTROL COREG 70 LEVEL 2 196 CREATINE 84 CONTOUR NEXT EZ BLOOD COREG CR 70 CREATINE ANHYDROUS 84 GLUCOSE MONITORING CORGARD 71 CREATINE SYSTEM 196 CORIFACT 165 MONOHYDRATE 84 CONTOUR NEXT LINK 2.4 CORLANOR 75 CREATININE 84 WIRELESS BLOOD GLUCOSE CREME DE MENTHE MONITORING SYST 197 CORLOPAM 50 FLAVOR 307 CONTOUR NEXT LINK BLOOD CORN OIL 84 CREME DEMENTHE GLUCOSE MONITORING CORN STARCH 109 FLAVOR 307 SYSTEM 197 CONTOUR NEXT LINK CORN SYRUP 315 CREON 152 WIRELESS BLOOD GLUCOSE CORTEF 114 CRESEMBA 42 MONITORING SY 197 CORTENEMA 16 CRESOL 84 CONTOUR NEXT ONE BLOOD CORTIFOAM 16 CREST TARTAR GLUCOSE MONITORING CORTISONE ACETATE 114 CONTROL 227 SYSTEM 197 CREST TARTAR CONTOUR NORMAL cortisone acetate 114 CONTROL/BAKING SODA CONTROL 197 CORTISPORIN-TC 302 TOOTHPASTE 227 CONTRAST ALLERGY PREMED CREST TOOTHPASTE 227 PACK 114 CORVERT 22 CONTROL SOLUTION CORVITE 277 CREST NORMAL 197 TOOTHPASTE/REGULAR 227 CORVITE 150 168 CREST CONVENIENCE PAK 329 CORVITE FE 168 TOOTHPASTEREGULAR 227 CONZIP 9 COSELA 60 CRESTOR 45 COOL BLOOD GLUCOSE COSENTYX 128 CRINONE 339 MONITORING KIT 197 COOL BLOOD GLUCOSE COSENTYX SENSOREADY CRIXIVAN 66 MONITORING SYSTEM 197 PEN 128 CROFAB 302 COSMEGEN 57 COOL BLOOD GLUCOSE TEST cromolyn sodium 22 STRIPS 147 COSMOCIL CQ 96 CROMOLYN SODIUM 22

Index 23 cromolyn sodium CURAD SENSITIVE SKIN CURITY ALL PURPOSE (mastocytosis) 161 ASSORTED FAMILY SPONGES 4"X4" 4PLY 181 cromolyn sodium (ophth) 301 PACK 180 CURITY ALL PURPOSE CROSCARMELLOSE CURAD SENSITIVE SKIN SPONGES 4"X4" 4PLY/SOFT SODIUM 84 EXTRA LARGE 180 POUCH 181 CROTAMITON 84 CURAD SENSITIVE SKIN CURITY AMD SPOTS 181 ANTIMICROBIALGAUZE crotamiton 141 CURAD WILD STYLES SPONGES 2"X2" 8 PLY 181 CROTON OIL 84 DESIGN-ITS 181 CURITY AMD CRUAD GAUZE PADS 4" X CURAD WILD STYLES ANTIMICROBIALGAUZE 4" 180 TATTOO-U 181 SPONGES 4"X4" 12 PLY 181 CRYODOSE TA 137 CURAFIL GEL WOUND CURITY AMD DRESSING 143 CRYOSERV 106 ANTIMICROBIALPACKING CURCUMAX PRO 273 STRIPS 1"X3' 181 CRYSVITA 156 CURCUMIN 103 CURITY AMD CUBICIN 18 ANTIMICROBIALPACKING CURCUMIN EXTRACT 103 CUBICIN RF 18 STRIPS 1/2"X3' 181 CURITY #10 BURN CURITY AMD CUCUMBER MELON 106 DRESSING/READY CUT ANTIMICROBIALPACKING CULTURELLE BABY GROW GAUZE/12"X12" 181 STRIPS 1/4"X3' 181 THRIVE 38 CURITY #10 BURN CURITY COVER SPONGE CULTURELLE DIGESTIVE DRESSING/READY CUT 4"X4" 181 HEALTH WOMENS HEALTHY GAUZE/18"X18" 181 CURITY COVER SPONGES BALANCE 38 CURITY #10 BURN 3"X4" 181 CULTURELLE KIDS GROW DRESSING/READY CUT CURITY COVER SPONGES THRIVE 38 GAUZE/36"X36" 181 4"X3" 181 cupric chloride 270 CURITY #10 GAUZE CURITY COVER SPONGES CUPRIC CHLORIDE BOLT/OVAL 4"X4" 181 DIHYDRATE 84 FOLD/36"X300' 181 CURITY CURAD ADHESIVE CUPRIC SULFATE 270 CURITY ADHESIVE WOUND BANDAGES/3/4" PLASTIC 181 CUPRIC SULFATE CLOSURE STRIPS CURITY CURAD ADHESIVE PENTAHYDRATE 270 1/2"X4" 181 BANDAGES/3/4" SHEER 181 CURITY ADHESIVE WOUND CUPRIMINE 271 CURITY CURAD ADHESIVE CLOSURE STRIPS 1/4"X1- BANDAGES/PLASTIC 181 CUPUACU BUTTER 84 1/2" 181 CURITY CURAD ADHESIVE CURAD ACTI-FLEX FOAM CURITY ADHESIVE WOUND BANDAGES/SHEER 181 7/8" 180 CLOSURE STRIPS CURITY CURAD FLEXIBLE CURAD ACTI-FLEX FOAM 1/4"X3" 181 FABRIC BANDAGES/3/4" 181 ASSORTED 180 CURITY ADHESIVE WOUND CURITY CURAD FLEXIBLE CURAD ADHESIVE BANDAGES CLOSURE STRIPS FABRIC FLEX ASSORTED 180 1/4"X4" 181 BANDAGES/ASSORTED 182 CURAD ADHESIVE BANDAGES CURITY ADHESIVE WOUND CURITY CURAD NEON FLEX FAMILY ASSORTED 180 CLOSURE STRIPS STRIPSBANDAGES/3/4"/ASSOR CURAD COMFORT 1/8"X3" 181 TED COLORS 182 FABRIC 180 CURITY ALCOHOL CURITY DRESSING SPONGES CURAD GODZILLA 180 PREPS/MEDIUM 2 PLY 226 4"X3" 6 PLY 182 CURAD HOLD TITE TUBULAR CURITY ALCOHOL CURITY DRESSING SPONGES STRETCH SWABS 226 4"X4" 6 PLY 182 BANDAGE/LARGE/5YDS 180 CURITY ALL PURPOSE CURITY GAUZE PADS CURAD JURASSIC PARK 180 SPONGES 2"X2" 181 2"X2" 182 CURAD KID SIZE DINOSAUR CURITY ALL PURPOSE CURITY GAUZE PADS 2"X2" 12 SPONGES 2"X2" 4PLY 181 BANDAGES 180 PLY 182 CURAD NON-STICK PADS CURITY ALL PURPOSE CURITY GAUZE PADS 4"X4" 12 SPONGES 4 PLY 181 3"X4" 180 PLY 182 CURAD NON-STICK PADS CURITY ALL PURPOSE CURITY GAUZE SPONGE 2"X2" SPONGES 4"X3" 4PLY 181 WITHADHESIVE TABS 8 PLY 182 CURITY ALL PURPOSE CURITY GAUZE SPONGE 3"X4" 180 SPONGES 4"X4" 181 CURAD SENSITIVE SKIN 2"X2"12 PLY 182 3/4" 180

Index 24 CURITY GAUZE SPONGE 4"X4" CURITY CVS ANTI-BACTERIAL 12 PLY 182 SPONGES/CELLULOSEFILLE BANDAGES CURITY GAUZE SPONGE 4"X4" D/4"X4" 182 WATERPROOF 183 16 PLY 182 CURITY STRETCH GAUZE CVS ANTIBACTERIAL CURITY GAUZE SPONGE 4"X4" BANDAGE/1"X4.1YD 183 BANDAGES/HEAVY DUTY 8 PLY 182 CURITY STRETCH GAUZE FABRIC 183 CURITY GAUZE SPONGE BANDAGE/2"X4.1YD 183 CVS BUTTERFLY 4"X4"16 PLY 182 CURITY STRETCH GAUZE CLOSURES 183 CURITY GAUZE SPONGE 8"X4" BANDAGE/3"X4.1YD 183 CVS CLEAR BANDAGES 183 12 PLY 182 CURITY STRETCH GAUZE CVS DISTILLED WATER 315 CURITY GAUZE SPONGE BANDAGE/4"X4.1YD 183 8"X4"12 PLY 182 CURITY TELFA STERILE CVS DRY MOUTH SPRAY 275 CURITY GAUZE SPONGES ADHESIVE PADS/3"X4" 183 CVS FLEXIBLE FABRIC ANTI- 4"X3"16 PLY 182 CURITY TELFA STERILE BACTERIAL BANDAGES 183 CURITY GAUZE SPONGES NON-STICK PADS/3"X4" 183 CVS GAUZE PAD 8"X4" 183 4"X4" 12 PLY 182 CURITY TRIANGULAR CVS GAUZE PADS 2"X2" 12- CURITY GAUZE SPONGES BANDAGE 40"X40"X56" 183 PLY 183 4"X4" 8 PLY 182 CURITY WET DRESSING CVS GAUZE PADS 4"X4" 12- CURITY HYPERTONIC 8"X4" 183 PLY 183 SODIUMCHLORIDE PACKING CUROSURF 330 CVS GAUZE PADS STERILE STRIP 1/2"X15' 143 CUSTOM POLYGLYCOL 4"X4" 12-PLY 183 CURITY IODOFORM PACKING TROCHEBASE 315 CVS GLUCOSAMINE STRIP 182 CUTAQUIG 302 CHONDROITIN/MSM TRIPLE CURITY IODOFORM PACKING STRENGTH 273 STRIP 1"X15' 182 CUTIS PLUS 321 CVS GLUCOSE METER TEST CURITY IODOFORM PACKING CUTIVATE 131 STRIPS 147 STRIP 1/2"X15' 182 CUVITRU 302 CVS HAIR/SKIN/NAILS 287 CURITY IODOFORM PACKING STRIP 1/4"X15' 182 CUVPOSA 333 CVS IODINE TINCTURE 65 CURITY IODOFORM PACKING CVS ADHESIVE BANDAGES CVS ISOPROPYL ALCOHOL STRIP 2"X15' 182 FOAM TOE SIZE 183 WIPES 140 CURITY KERLIX BANDAGE CVS ADHESIVE GAUZE PAD CVS LANCETS 21G 197 ROLL/2-1/4"X108" 182 PREMIUM 4"X8" 183 CVS LANCETS MICRO THIN CURITY KERLIX BANDAGE CVS ADHESIVE PAD 33G 197 ROLL/4-1/2"X144" 182 4"X4" 183 CVS LANCETS MICRO-THIN CURITY KERLIX ROLL 4.5X4.1 CVS ADHESIVE PAD 33G 197 YARDS 182 6"X6" 183 CVS LANCETS ORIGINAL 197 CURITY MESH GAUZE CVS ADHESIVE PADS BANDAGEROLL 1"X30' 182 2.25"X3" 183 CVS LANCETS THIN 26G 197 CURITY MESH GAUZE CVS ADVANCED GEL CVS LANCETS ULTRA THIN BANDAGEROLL 2"X30' 182 ORTHOTICS/MENS 219 30G 197 CURITY MESH GAUZE CVS ADVANCED GLUCOSE CVS LANCETS ULTRA-THIN BANDAGEROLL 3"X30' 182 METER 197 30G 197 CURITY MESH GAUZE CVS ADVANCED GLUCOSE CVS LANCING DEVICE 197 BANDAGEROLL 4"X30' 182 METER TEST STRIPS 147 CVS MANUKA HONEY WOUND CURITY NON-ADHERENT CVS ADVANCED HEALING GEL 143 STRIPS 1/2"X12' 182 HYDROCOLLOID ADHESIVE CVS NON-STICK PADS CURITY NON-ADHERENT PADS 143 3"X4" 183 STRIPS 3"X8" 182 CVS ADVANCED HEALING CVS NON-STICK PADS CURITY NON-ADHERING PREMIUM 3"X8" 183 DRESSINGS 3"X8" 182 BANDAGES/SMALL 183 CVS PLASTIC BANDAGES183 CURITY PLAIN PACKING CVS ALCOHOL PREP CVS PRENATAL STRIP 182 PADS 226 GUMMIES 282 CVS ANTI-BACTERIAL CURITY SODIUM CHLORIDE CVS PREP PADS 226 DRESSING 6"X6-3/4" 143 BANDAGES 183 CURITY CVS ANTI-BACTERIAL CVS PURIFIED WATER 315 SPONGES/CELLULOSEFILLED/ BANDAGES CVS SHEER BANDAGES 183 2"X2" 182 CHILDRENS 183 CVS SHEER BANDAGES EXTRALARGE 183

Index 25 CVS SPOT BANDAGE CYSTADROPS 301 DAPTACEL 333 SHEER 183 CYSTAGON 164 DAPTOMYCIN 18 CVS TUBULAR GAUZE 183 CYSTARAN 301 daptomycin 18 CVS ULTRA THIN LANCETS 197 CYSTEAMINE HCL 85 DAPTOMYCIN 18 CYANOCOBALAMIN 84 cysteine hcl 294 DARAPRIM 51 cyanocobalamin 167 cytarabine 53 darifenacin hydrobromide 336 CYANOCOBALAMIN 167 CYTO CARN 294 DARZALEX 54 cyanocobalamin- CYTO RALA 3 DARZALEX FASPRO 57 methylcobalamin 168 CYTOGAM 302 daunorubicin hcl 57 CYANOKIT 39 CYTOMEL 332 DAUNORUBICIN CYCLANDELATE 84 CYTOTEC 336 HYDROCHLORIDE 57 CYCLO/GABA10/300 DAURISMO 55 CYTOTINE 292 PACK 289 DAYAVITE 277 CYTOVENE 68 CYCLOBENZAPRINE 84 DAYPRO 5 D-CARE 100X 173 CYCLOBENZAPRINE HCL 84 DAYTRANA 2 cyclobenzaprine hcl 288 D-CARE BLOOD GLUCOSE 147 DAYVIGO 172 CYCLOBENZAPRINE D-CARE GLUCOMETER HYDROCHLORIDE 84 DDAVP 157,158 KIT/GLUCOSE TEST DEBACTEROL 275 CYCLOGYL 296 STRIPS 197 CYCLOMETHICONE 84 D-MANNOSE 85 decitabine 53 CYCLOMYDRIL 296 D-PENAMINE 271 DECOLORIZED IODINE 65 CYCLOPAK 289 D-RIBOSE 85 deferasirox 39 CYCLOPENTASILOXANE/PEG/ D-RIBOSE REAGENT 85 deferiprone 39 PPG-18/18 DIMETHICONE 84 D-VI-SOL 342 deferoxamine mesylate 39 CYCLOPENTOLATE HCL 85 D-VITAMIN E DEHYDROCHOLIC ACID 85 cyclopentolate hcl 296 SUCCINATE 105 DEHYDROEPIANDROSTERON CYCLOPENTOLATE D.H.E. 45 265 E 109 HYDROCHLORIDE 85 DEHYDROEPIANDROSTERON dacarbazine 59 CYCLOPHENE RAPIDPAQ288 E MICRONIZED 109 DACOGEN 53 cyclophosphamide 52 DELBASE dactinomycin 57 COMPOUNDING 321 CYCLOPHOSPHAMIDE 85 DELESTROGEN 159 CYCLOPHOSPHAMIDE DALFAMPRIDINE 88 dalfampridine 328 DELFLEX-LC/1.5% MONOHYDRATE 85 DEXTROSE 274 cycloserine 51 DALIRESP 23 DELFLEX-LC/2.5% CYCLOSERINE 85 DALVANCE 18 DEXTROSE 274 CYCLOSET 35 danazol 15 DELFLEX-LC/4.25% DEXTROSE 274 CYCLOSPORINE 85 DANAZOL 15 DELFLEX-SM/1.5% cyclosporine 271 DANTRIUM 289 DEXTROSE 274 CYCLOSPORINE A 85 DANTRIUM IV 289 DELFLEX-SM/2.5% CYCLOSPORINE IN DANTROLENE SODIUM 85 DEXTROSE 274 KLARITY 298 DELSTRIGO 66 cyclosporine modified (for dantrolene sodium 289 DELUO ANTIMICROBIAL microemulsion) 271 DAPIPRAZOLE HCL 85 WOUND& SKIN CYKLOKAPRON 170 dapsone 18 CLEANSER 143 CYMBALTA 33 DAPSONE 85 DELZICOL 161 cyproheptadine hcl 43 dapsone (topical) 121 DEMECARIUM BROMIDE 85 CYPROHEPTADINE HCL 85 DAPSONE/NIACINAMIDE demeclocycline hcl 331 121 DEMEROL 9 CYRAMZA 54 DAPSONE/NIACINAMIDE/SPI CYSTADANE 156 RONOLACTONE 121 DEMSER 47 DENATONIUM BENZOATE 85

Index 26 DENAVIR 129 DERMACEA GAUZE SPONGE DERMACEA X-RAY SPONGES DEOXIA 121 4"X4" 8 PLY 184 4"X8" 12 PLY 185 DERMACEA I.V. DRAIN DERMACEA X-RAY SPONGES DEOXYCHOLIC ACID 85 SPONGES 2"X2" 184 4"X8" 12PLY 185 DEOXYCHOLIC ACID DERMACEA I.V. DRAIN DERMACEA X-RAY SPONGES SODIUM 100 SPONGES 4"X4" 184 4"X8" 16 PLY 185 DEPACON 31 DERMACEA I.V. SPONGES DERMACEA X-RAY SPONGES DEPAKENE 31 2"X2" 184 4"X8" 24 PLY 185 DERMACEA NON-ADHERENT DERMACINRX AZENASE DEPAKOTE 31 DRESSING 3"X4" 184 PAK 289 DEPAKOTE ER 31 DERMACEA NON-WOVEN DERMACINRX DEPAKOTE SPRINKLES 31 SPONGES 2"X2" 4 PLY 184 CLORHEXACIN 140 DEPEN TITRATABS 271 DERMACEA NON-WOVEN DERMACINRX ETHOXY SPONGES 3"X4" 4 PLY 184 DIGLYCOL 85 DEPO-ESTRADIOL 159 DERMACEA NON-WOVEN DERMACINRX LEXITRAL DEPO-MEDROL 114 SPONGES 3"X4" 6 PLY 184 PHARMAPAK 124 DEPO-PROVERA 55 DERMACEA NON-WOVEN DERMACINRX PHN PAK 137 DEPO-PROVERA SPONGES 4"X4" 4 PLY 184 DERMACINRX PRETRATE282 CONTRACEPTIVE 113 DERMACEA NON-WOVEN SPONGES 4"X4" 6 PLY 184 DERMACINRX DEPO-SUBQ PROVERA PUREFOLIX 168 104 113 DERMACEA STRETCH BANDAGE ROLL 2"X12' 184 DERMACINRX SURGICAL DEPO-TESTOSTERONE 15 DERMACEA STRETCH COMBOPAK 140 DEPRIZINE FUSEPAQ 334 BANDAGE ROLL 3"X12' 184 DERMACINRX SURGICAL DERMA-SMOOTHE/FS DERMACEA STRETCH PHARMAPAK 140 BODY 131 BANDAGE ROLL 4"X12' 184 DERMACINRX THERAZOLE DERMA-SMOOTHE/FS DERMACEA STRETCH PAK 125 SCALP 131 BANDAGE ROLL 6"X12' 184 DERMACINRX TICANASE DERMACEA DRAIN SPONGES DERMACEA STRETCH PAK 289 4"X4" 183 BANDAGE2"X4-1/8YD 184 DERMACINRX TSS BASE 315 DERMACEA GAUZE FLUFF DERMACEA STRETCH DERMACINRX ZINTREXYL- ROLL 2"X3YD 183 BANDAGE3"X4-1/8YD 184 C 277 DERMACEA GAUZE FLUFF DERMACEA STRETCH DERMACINRX ZRM PAK 137 ROLL 2.25"X3 YD 6 PLY 183 BANDAGE4"X4-1/8YD 184 DERMADRESS WATERPROOF DERMACEA GAUZE FLUFF DERMACEA STRETCH COMPOSITE DRESSING 185 ROLL 3.4"X3-1/2YD 6PLY 183 BANDAGE6"X12.3' 184 DERMAGRAN HYDROGEL DERMACEA GAUZE FLUFF DERMACEA STRETCH WOUNDDRESSING 143 ROLL 3.4"X3.6 YD 6 PLY 184 BANDAGE6"X4-1/8YD 184 DERMAGRAN-B HYDROPHILIC DERMACEA GAUZE FLUFF DERMACEA STRETCH WOUND DRESSING 143 ROLL 4-1/2"X4-1/8YD BANDAGEROLL 3"X12' 184 DERMALEVIN ADHESIVE 6PLY 184 DERMACEA STRETCH FOAMDRESSING 4"X4" 185 DERMACEA GAUZE FLUFF BANDAGEROLL 4"X12' 184 DERMALEVIN ADHESIVE ROLL 4.5"X4.1 YD 6 PLY 184 DERMACEA STRETCH FOAMDRESSING 6"X6" 185 DERMACEA GAUZE ROLL BANDAGEROLL 6"X12' 184 DERMALID 137 2"X4-1/8YD 184 DERMACEA SUPER SPONGE DERMASHIELD DERMACEA GAUZE ROLL 6"X6.75" 184 HYDROGEL 321 3"X4-1/8YD 184 DERMACEA TYPE VII GAUZE DERMACEA GAUZE ROLL 2"X2" 12 PLY 185 DERMASORB TA 131 4"X4-1/8YD 184 DERMACEA TYPE VII GAUZE DERMASYN 143 DERMACEA GAUZE ROLL 2"X2" 8 PLY 185 dermatological products, 6"X4-1/8YD 184 DERMACEA TYPE VII GAUZE misc. 139 DERMACEA GAUZE SPONGE 4"X4" 12 PLY 185 DERMAZINC CREAM 129 2"X2" 12 PLY 184 DERMACEA TYPE VII GAUZE DERMELLE 142 DERMACEA GAUZE SPONGE 4"X4" 16 PLY 185 2"X2" 8 PLY 184 DERMACEA TYPE VII GAUZE DERMOTIC 302 DERMACEA GAUZE SPONGE 4"X4" 8 PLY 185 DERMULCERA 143 4"X4" 12 PLY 184 DERMACEA X-RAY DERPIXA 143 DERMACEA GAUZE SPONGE SPONGES 4"X4" 16 PLY 185 4"X4" 16 PLY 184 DESCOVY 66

Index 27 DESFERAL 39 DEXAMETHASONE DEXTROSE 292 desflurane 163 ISONICOTINATE 86 dextrose 292 DEXAMETHASONE SODIUM DESICCATED BEEF LIVER 85 PHOSPHATE 86,114 DEXTROSE 5%/ELECTROLYTE DESIPRAMINE HCL 33 dexamethasone sodium #48 VIAFLEX 267 DEXTROSE 10%/NACL desipramine hcl 33 phosphate 114 DEXAMETHASONE SODIUM 0.2% 267 desloratadine 43 PHOSPHATE 115 DEXTROSE 2.5%/NACL DESMOPRESSIN dexamethasone sodium 0.45% 267 ACETATE 86 phosphate (ophth) 298 DEXTROSE 20% 292 desmopressin acetate 158 DEXAMETHASONE SODIUM DEXTROSE 5%/NACL DESMOPRESSIN PHOSPHATE/DEXTROSE 11 0.3% 267 ACETATE 158 5 DEXTROSE 50% 292 desmopressin acetate 158 DEXAMETHASONE SODIUM DEXTROSE ANHYDROUS 292 PHOSPHATE/SODIUM desmopressin acetate dextrose in lactated ringers 267 spray 158 CHLORIDE 115 DEXAMETHASONE/MOXIFLO DEXTROSE desmopressin acetate spray MONOHYDRATE 292 refrigerated 158 XACIN HCL 298 DEXAMETHASONE/MOXIFLO dextrose w/ sodium desogestrel & ethinyl chloride 267 estradiol 111 XACIN/KETOROLAC 298 DEXAMETHASONE/SODIUM DEXTROSE/SODIUM desogestrel-ethinyl estradiol CHLORIDE 267 (biphasic) 111 PHOSPHATE 115 desogestrel-ethinyl estradiol dexchlorpheniramine DEXYCU 298 (triphasic) 111 maleate 42 DFS DR/MS/MENTH/CAP DESONATE 131 DEXCHLORPHENIRAMINE PAK 5 MALEATE 86 DFS/MS/MENTH/CAP PAK 124 desonide 131 DEXEDRINE 1 DHEA 109 DESONIDE 131 DEXERYL 139 DHEA MICRONIZED 109 DESOWEN 131 DEXILANT 335 DIAB 143 DESOXIMETASONE 86 DEXLIDO 115 DIAB DAILY CARE 143 desoximetasone 131 DEXLIDO-M 115 DIAB F.D.G. FREEZE- DESOXYCORTICOSTERONE DEXMEDETOMIDINE DRIED 143 ACETATE 86 HCL 171 DIABETIDERM MASSAGE DESOXYN 1 dexmedetomidine hcl 171 STIMULATOR 139 desvenlafaxine 33 dexmedetomidine hcl in sodium DIACOMIT 28 DESVENLAFAXINE ER 33 chloride 171 DIADIMAXIA 121 desvenlafaxine succinate 33 DEXMEDETOMIDINE DIALYVITE 3000 277 HYDROCHLORIDE/DEXTROS DETROL 336 E MONOHYDRATE 171 DIALYVITE 5000 277 DETROL LA 336 DEXMEDETOMIDINE DIALYVITE SUPREME D 278 DEVILS CLAW 86 HYDROCHLORIDE/SODIUM DIALYVITE/ZINC 277 DEXABLISS 114 CHLORIDE 171 DIAMINOPYRIDINE 86 dexmethylphenidate hcl 2 DEXAMETHASONE 86 DIANEAL LOW DEXONTO 0.4% 115 dexamethasone 114,115 CALCIUM/1.5%DEXTROSE DEXPANTHENOL 86 274 DEXAMETHASONE (LA) 114 dexrazoxane hcl 60 DIANEAL LOW DEXAMETHASONE CALCIUM/2.5%DEXTROSE ACETATE 86 DEXTENZA 298 274 DEXAMETHASONE ACETATE DEXTRAN 40000 86 DIANEAL LOW ANHYDROUS 86 CALCIUM/4.25%DEXTROSE DEXAMETHASONE DEXTRAN 75000 86 dextroamphetamine sulfate 1 274 ACETATE/DEXAMETHASONE DIANEAL PD-2/1.5% PHOSPHATE 114 DEXTROMETHORPHAN 86 DEXTROSE 274 DEXAMETHASONE BASE 86 DEXTROMETHORPHAN DIANEAL PD-2/2.5% DEXAMETHASONE HBR 118 DEXTROSE 274 INTENSOL 114 DEXTROMETHORPHAN HBR DIANEAL PD-2/4.25% MONOHYDRATE 118 DEXTROSE 274

Index 28 DIAOXIA 121 DICLAZURIL 86 diflorasone diacetate 131 DIASDIMAXIA 121 DICLEGIS 41 DIFLUCAN 42 DIASOXIA 121 DICLOFENAC 5 DIFLUNISAL 8 DIASTAT ACUDIAL 27 diclofenac epolamine 124 diflunisal 8 DIASTAT PEDIATRIC 27 diclofenac potassium 5 DIFMETIOXRIME 125 DIASTIX 148 diclofenac sodium 5 DIGIFAB 39 DIATHRIVE BLOOD GLUCOSE DICLOFENAC SODIUM 86 digoxin 73 METER 197 diclofenac sodium (actinic DIGOXIN 86 DIATHRIVE BLOOD GLUCOSE keratoses) 127 DIGOXIN MICRONIZED 86 TEST STRIPS 148 diclofenac sodium (ophth)301 DIATHRIVE GLUCOSE DIHYDROCODEINE CONTROL SOLUTION 197 diclofenac sodium BITARTRATE 86 (topical) 124 DIATHRIVE LANCETS 197 DIHYDROERGOTAMINE diclofenac sodium-capsaicin5 DIATHRIVE LANCETS ULTRA MESYLATE 265 THIN 30G 197 diclofenac sodium-capsaicin dihydroergotamine DIATHRIVE LANCING (topical) 124 mesylate 265 DEVICE 197 DICLOFENAC DIHYDROXYACETONE (1,3) DIATHRIVE PEN NEEDLE/31 G SODIUM/HYALURONIC ACID DIMER 86 X 6MM 234 SODIUM DIINDOLYLMETHANE 86 DIATHRIVE PEN NEEDLE/31 SALT/NIACINAMIDE 127 DIIODO-L-THYRONINE 3,5 86 diclofenac w/ misoprostol 5 GX 8MM 234 DILANTIN 30 DIATHRIVE PEN NEEDLE/31GX DICLOFONO 124 DILANTIN INFATABS 30 5MM 234 DICLOPR 124 DIATHRIVE PEN NEEDLE/32GX DILANTIN-125 30 DICLOSTREAM 124 4MM 234 DILATRATE SR 20 DICLOTREX 124 DIATHRIVE+ BLOOD DILAUDID 9 GLUCOSEMONITORING DICLOVIX 124 diltiazem hcl 72 SYSTEM/BLUETOOTH 197 DICLOVIX M 124 DIATHRIVE+ BLOOD DILTIAZEM HCL 72 dicloxacillin sodium 304 GLUCOSETEST STRIPS 148 diltiazem hcl 73 DIATRUE GLUCOSE CONTROL DICLOZOR 124 DILTIAZEM HCL 86 SOLUTION LEVEL 1 197 DICOPANOL FUSEPAQ 43 DIATRUE GLUCOSE CONTROL diltiazem hcl coated beads 72 SOLUTION LEVEL 2 197 DICOPANOL RAPIDPAQ 43 diltiazem hcl extended release DIATRUE GLUCOSE CONTROL DICUMAROL 86 beads 72 SOLUTION LEVEL 3 197 dicyclomine hcl 333 DILTIAZEM DIATRUE PLUS BLOOD DICYCLOMINE HYDROCHLORIDE/DEXTROSE GLUCOSE MONITORING HYDROCHLORIDE 86 73 SYSTEM 197 didanosine 66 DILTIAZEM DIATRUE PLUS BLOOD HYDROCHLORIDE/SODIUM GLUCOSE TEST STRIPS 148 DIETHANOLAMINE 86 CHLORIDE 73 diazepam 21 DIETHYL PHTHALATE 86 DIMENHYDRINATE 40 DIAZEPAM 21 DIETHYL-M-TOLUAMIDE 86 DIMENTHO 124 diazepam 21 DIETHYLCARBAMAZINE DIMERCAPTO-1- DIAZEPAM 86 CITRATE 86 PROPANESULFONIC ACID DIETHYLENE GLYCOL (DMPS) 109 diazepam (anticonvulsant) 27 MONOETHYL ETHER 85 DIMERCAPTO-1- diazoxide 35 DIETHYLENE GLYCOL PROPANESULFONIC ACID DIAZOXIDE 86 MONOETHYL ETHER NF 85 SODIUM SALT 109 DIETHYLPROPION DIBENZYLINE 47 DIMERCAPTOPROPANE HYDROCHLORIDE/TARTARIC SULFONATE DMPS 39 DIBUCAINE 86 ACID 86 DIMERCAPTOPROPANE- DIBUCAINE HCL 86 DIETHYLSTILBESTROL 86 SULFONATE (2,3) DIBUTYL SQUARATE 100 DIFF-STAT 38 SODIUM 109 DIMERCAPTOSUCCINIC DICHLORALPHENAZONE 86 DIFFERIN 121 ACID 100 DICHLOROACETIC ACID 86 DIFICID 176

Index 29 DIMETHYL FUMARATE 86 DL-3-HYDROXYBUTYRIC DORZOLAMIDE dimethyl fumarate 328 ACIDSODIUM 100 HYDROCHLORIDE 87 DOUBLE AIR FOAM INSOLES DIMETHYL SILOXANE DL-ALANINE 294 DL-ALPHA LIPOIC ACID 80 MENS 219 HYDROXYALKYL-TERMINATED DOUBLE AIR FOAM INSOLES 86 DL-LEUCINE 294 WOMENS 219 DIMETHYL SULFONE 93 DL-MALIC ACID 93 DOUBLE PM 298 DIMETHYL SULFOXIDE 106 DL-METHIONINE 294 DOUBLEDEX 115 DIMETHYLACETAMIDE 86 DL-PANTHENOL 96 DOVATO 66 DIMETHYLAMINOETHANOL DL-PANTHENOL DOVONEX 128 (DEANOL) 86 ALCOHOL 96 DIMETHYLGLYCINE HCL 87 DOW CORNING 1501 DL-PHENYLALANINE 294 FLUID 87 DIMOXIA 121 DMAE BITARTRATE 87 DOW CORNING 200 100 DINITROCHLOROBENZENE DMT SUIK 115 109 doxazosin mesylate 48 DIOCHLOY 131 dobutamine hcl 74 DOXAZOSIN MESYLATE 87 DIOSGENIN 87 DOBUTAMINE HCL/D5W 74 doxepin hcl 33 DOBUTAMINE DOXEPIN HCL 87 DIOSMIN 87 HYDROCHLORIDE/ DIOVAN 47 DEXTROSE 5% 74 doxepin hcl (antipruritic) 128 DIOVAN HCT 48 DOBUTAMINE doxepin hcl (sleep) 171 DIOXYBENZONE 87 HYDROCHLORIDE/DEXTROS DOXEPIN E 5% 74 HYDROCHLORIDE 87 DIPENTUM 161 docetaxel 60 doxercalciferol 156 diphenhydramine hcl 43 DOCETAXEL 60 DOXIL 57 DIPHENHYDRAMINE HCL 43 docetaxel 60 doxorubicin hcl 57 diphenhydramine hcl 43 DOCETAXEL 60 doxorubicin hcl liposomal 57 DIPHENIDOL HYDROCHLORIDE 87 DOCOSANOL 87 doxycycline (monohydrate) 331 diphenoxylate w/ atropine 39 DOCUSATE SODIUM 173 doxycycline (rosacea) 141 DIPHENYLCYCLOPROPENONE DOCUSATE SODIUM/SODIUM doxycycline hyclate 331 87 BENZOATE 109 DOXYCYCLINE HYCLATE 331 dofetilide 22 DIPHTHERIA/TETANUS doxycycline hyclate 331 TOXOIDS ADSORBED DOJOLVI 292 PEDIATRIC 333 DOXYCYCLINE HYCLATE DOLOPHINE 9 DR 331 DIPRIVAN 162 donepezil hydrochloride 327 DOXYCYCLINE DIPROLENE 131 dopamine hcl 74 MONOHYDRATE 87 DIPROLENE AF 131 DOPAMINE DOXYLAMINE SUCCINATE 43 DIPYRIDAMOLE 87 HYDROCHLORIDE 74 doxylamine-pyridoxine 41 dipyridamole 166 DOPAMINE DR SCHOLLS DISOPHENOL 87 HYDROCHLORIDE/DEXTROS COMFORT/ENERGY E 74 MASSAGING GEL disopyramide phosphate 21 DOPAMINE/D5W 74 ADVANCED/MEN/SZ 8-14 219 DISTILLATA DISTILLED DOPRAM 1 DR SCHOLLS WATER 315 COMFORT/ENERGY WORK DISTILLED WATER 315 DOPTELET 167 MESSAGING GEL ADV/MEN/SZ DISULFIRAM 87 DORAL 171 8-14 219 doripenem 17 DR SCHOLLS disulfiram 327 COMFORT/ENERGY WORK DITROPAN XL 337 DORYX 331 MESSAGING GEL DIURIL 154 DORYX MPC 331 ADV/WOM/SZ 6-10 219 divalproex sodium 31 dorzolamide hcl 301 DR SCHOLLS HEAVY DUTY SUPPORT/MEN/SIZE 8-14 219 DIVALPROEX SODIUM 87 DORZOLAMIDE HCL 301 dorzolamide hcl-timolol DR SCHOLLS PLANTAR DIVIGEL 159 FASCIITIS INSOLE/MEN/SIZE 8- maleate 295 13 219

Index 30 DR SCHOLLS PLANTAR DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES FASCIITIS U-100/1ML/31G X 5/16" 235 32GX5MM 235 INSOLE/WOMEN/SIZE 6- DROPLET INSULIN DROPLET PEN NEEDLES 10 219 SYRINGE/U-100/0.3ML/31G X 32GX6MM 236 DR SCHOLLS TRI-COMFORT 15/64" 235 DROPLET PEN NEEDLES INSOLES/WOMENS/SIZE 6- DROPLET INSULIN 32GX8MM 236 10 219 SYRINGE/U-100/0.3ML/31G X DROPLET PERSONAL DRAKKAR NOIR 106 5/16" 235 LANCETS30G 197 DROPSAFE SAFETY PEN DRAXACE 121 DROPLET INSULIN SYRINGE/U-100/0.5ML/30G X NEEDLES/31G X 5/16" 236 DRAXACE LOTION 1/2" 235 DROPSAFE SAFTEY PEN CLEANSER 121 DROPLET INSULIN NEEDLES/31G X 1/4" 236 DRCAPS SIZE 00 CLEAR 310 SYRINGE/U-100/0.5ML/31G X drospirenone-ethinyl DRCAPS SIZE 1 CLEAR 310 15/64" 235 estradiol 111 DRISDOL 342 DROPLET INSULIN drospirenone-ethinyl estradiol- SYRINGE/U-100/0.5ML/31G X levomefolate calcium 111 DRITHO-CREME HP 128 5/16" 235 DROXIA 166 DRIXECE 121 DROPLET INSULIN droxidopa 340 DRIZALMA SPRINKLE 33 SYRINGE/U-100/1ML/30G X DRUG MART ADJUSTABLE dronabinol 41 1/2" 235 LANCING DEVICE 197 DROPLET INSULIN DROPERIDOL 20 DRUG MART LANCETS SYRINGE/U-100/1ML/31G X THIN 197 droperidol 20 15/64" 235 DRUG MART ON-THE-GO DROPERIDOL/SODIUM DROPLET INSULIN LANCETS GENTLE 30G 198 CHLORIDE 20 SYRINGE/U-100/1ML/31G X DRUG MART UNIFINE PENTIPS DROPLET GENTEEL LANCING 5/16" 235 31GX5MM 236 DEVICE 197 DROPLET LANCETS ULTRA DRUG MART UNIFINE DROPLET INSULIN SYRINGE THIN 30G 197 PENTIPS29G X 12MM 236 0.3ML/29G X 1/2" 234 DROPLET LANCING DRUG MART UNIFINE DROPLET INSULIN SYRINGE DEVICE 197 PENTIPS31GX6MM 236 0.5ML/29G X 1/2" 234 DROPLET PEN NEEDLES 29G DRUG MART UNIFINE DROPLET INSULIN SYRINGE X1/2" 235 PENTIPS31GX8MM 236 1ML/29G X 1/2" 234 DROPLET PEN NEEDLES DRUG MART UNIFINE DROPLET INSULIN SYRINGE 29GX10MM 235 PENTIPS32GX4MM 236 U-100/0.3/31G X 5/16" 234 DROPLET PEN NEEDLES DRUG MART UNIFINE DROPLET INSULIN SYRINGE 29GX12MM 235 PENTIPSPLUS 32GX4MM 236 U-100/0.3ML/30G X 1/2" 234 DROPLET PEN NEEDLES 30G DRUG MART UNILET DROPLET INSULIN SYRINGE X 5/16" 235 LANCETSSUPER THIN U-100/0.3ML/30G X 15/64" 234 DROPLET PEN NEEDLES 31G 30G 198 DROPLET INSULIN SYRINGE X3/16" 235 DRUG MART UNILET U-100/0.3ML/30G X 5/16" 234 DROPLET PEN NEEDLES 31G LANCETSULTRA THIN DROPLET INSULIN SYRINGE X5/16" 235 28G 198 U-100/0.3ML/31G X 15/64" 235 DROPLET PEN NEEDLES DRUG MART UNILET MICRO DROPLET INSULIN SYRINGE 31GX5MM 235 THIN LANCETS 33G 198 U-100/0.5ML/30G X 1/2" 235 DROPLET PEN NEEDLES DROPLET INSULIN SYRINGE 31GX6MM 235 DRYMAX EXTRA 185 U-100/0.5ML/30G X 15/64" 235 DROPLET PEN NEEDLES DRYSOL 140 DROPLET INSULIN SYRINGE 31GX8MM 235 DSUVIA 9 U-100/0.5ML/30G X 5/16" 235 DROPLET PEN NEEDLES 32G DUAC 121 DROPLET INSULIN SYRINGE X 1/4" 235 U-100/0.5ML/31G X 5/16" 235 DROPLET PEN NEEDLES 32G DUAKLIR PRESSAIR 24 DROPLET INSULIN SYRINGE X 3/16" 235 DUAL COMPLEX FORMULA 1 U-100/1ML/30G X 1/2" 235 DROPLET PEN NEEDLES 32G KIT 124 DROPLET INSULIN SYRINGE X 5/16" 235 DUAL GEL INSOLES MENS U-100/1ML/30G X 15/64" 235 DROPLET PEN NEEDLES 32G SIZE 8-13 219 DROPLET INSULIN SYRINGE X 5/32" 235 DUAL GEL INSOLES WOMENS U-100/1ML/30G X 5/16" 235 DROPLET PEN NEEDLES SIZE 6-10 219 DROPLET INSULIN SYRINGE 32GX4MM 235 DUAVEE 159 U-100/1ML/31G X 15/64" 235 DUET DHA 400 283

Index 31 DUET DHA BALANCED 283 DYMISTA 289 EASY COMFORT PEN DUETACT 34 DYNABAC 5.0 124 NEEDLES31GX5/16" 236 EASY COMFORT PEN DUEXIS 5 DYNADERM NEEDLES32GX5/32" 236 DULERA 24 HYDROCOLLOID 143 EASY COMFORT PEN DYPHYLLINE 87 duloxetine hcl 33 NEEDLES33G X 4MM 236 dyphylline-guaifenesin 22 EASY COMFORT PEN DULOXETINE HCL 87 DYRENIUM 153 NEEDLES33G X 5MM 236 DULOXETINE EASY COMFORT PEN HYDROCHLORIDE 87 DYSPORT 291 NEEDLES33G X 6MM 236 DUO-CARE CONTROL DYURAL-40 115 EASY GLIDE PEN NEEDLES SOLUTION 198 DYURAL-80 115 33G X 5/32" 236 DUO-CARE TEST STRIPS 148 DYURAL-L 115 EASY GRIP CALLUS DUOBRII 131 REMOVER 219 DYURAL-LM 115 DUODERM EASY MINI EJECT LANCING HYDROACTIVE 143 E-Z JECT LANCETS 198 DEVICE 198 DUODOTE 39 E-Z JECT LANCETS 21G198 EASY MINI LANCING E-Z JECT LANCETS DEVICE 198 DUOPA 62 EASY PLUS II BLOOD COLOR 198 DUPIXENT 134 E-Z JECT LANCETS SUPER GLUCOSE MONITORING DURABASE 322 THIN 30G 198 SYSTEM 198 E-Z JECT LANCETS THIN EASY PLUS II BLOOD DURABASE ADVANCED 321 GLUCOSE TEST 148 DURACHOL 168 26G 198 E-ZJECT LANCETS MICRO- EASY PLUS II CONTROL DURACLON 8 THIN 33G 198 SOLUTION HIGH 198 DURAGESIC 9 EASY PLUS II CONTROL E.E.S. GRANULES 176 SOLUTION LOW 198 DURASAFE EASY COMFORT ALCOHOL EASY STEP BLOOD GLUCOSE SPINAL/EPIDURALTRAY/1% PADS 226 MONITOR 198 XYLOCAINE/19GX36"CLOSE EASY COMFORT INSULIN EASY STEP CONTROL CATH 174 SYRINGE/0.5ML/30G X SOLUTION HIGH 198 DURASAFE 5/16" 236 EASY STEP CONTROL SPINAL/EPIDURALTRAY/1% EASY COMFORT INSULIN SOLUTION LOW 198 XYLOCAINE/19GX36"OPEN SYRINGE/0.5ML/31G X EASY STEP CONTROL CATH 174 5/16" 236 SOLUTION NORMAL 198 DURASAFE EASY COMFORT INSULIN EASY STEP TEST STRIPS148 SPINAL/EPIDURALTRAY/1% SYRINGE/1ML/30G X EASY TALK BLOOD GLUCOSE XYLOCAINE/20GX36"CLOSE 5/16" 236 174 MONITORING CATH EASY COMFORT INSULIN 198 DURASAFE SYRINGE/1ML/31G X SYSTEM/TALKING SPINAL/EPIDURALTRAY/1% EASY TALK BLOOD GLUCOSE 5/16" 236 TEST STRIPS 148 XYLOCAINE/20GX36"OPEN EASY COMFORT INSULIN EASY TALK CONTROL CATH 175 SYRINGE/U-100/0.5ML/30G X SOLUTION HIGH 198 DUREZOL 298 1/2" 236 EASY TALK CONTROL DURLAZA 166 EASY COMFORT INSULIN SOLUTION LOW 198 SYRINGE/U-100/1ML/30G X DURYSTA 301 EASY TALK CONTROL 1/2" 236 SOLUTION NORMAL 198 DUTASTERIDE 87 EASY COMFORT EASY TOUCH 32GX5MM 236 dutasteride 164 LANCETS 198 EASY COMFORT LANCETS EASY TOUCH 32GX6MM 236 dutasteride-tamsulosin hcl 164 30G/PULL TOP 198 EASY TOUCH ALCOHOL PREP DUTOPROL 48 EASY COMFORT LANCETS PADS/MEDIUM 226 DXEVO 11-DAY 115 30G/THIN TOP 198 EASY TOUCH CONTROL DYANAVEL XR 1 EASY COMFORT LANCETS SOLUTION/HIGH & LOW 198 TWIST TOP 198 EASY TOUCH FLIPLOCK DYAZIDE 153 EASY COMFORT PEN SAFETY INSULIN SYRINGE DYCLONINE HCL 87 NEEDLES31GX1/4" 236 1ML/29GX1/2" 236 DYCLONINE EASY COMFORT PEN HYDROCHLORIDE 87 NEEDLES31GX3/16" 236

Index 32 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH PEN SAFETY INSULIN SYRINGE SYRINGE/U-100/0.5ML/31G X NEEDLE/30G X 3/16" 237 1ML/30GX1/2" 236 5/16" 237 EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 29GX1/2" 237 SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/27G X EASY TOUCH PEN NEEDLES 1ML/30GX5/16" 236 1/2" 237 31GX1/4" 237 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/28G X 31GX5/16" 237 1ML/31GX5/16" 236 1/2" 237 EASY TOUCH PEN NEEDLES EASY TOUCH GLUCOSE EASY TOUCH INSULIN 32GX1/4" 237 MONITORING SYSTEM 198 SYRINGE/U-100/1ML/29G X EASY TOUCH PEN NEEDLES EASY TOUCH GLUCOSE TEST 1/2" 237 32GX3/16" 237 STRIPS 148 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES EASY TOUCH HEALTHPRO SYRINGE/U-100/1ML/30G X 32GX5/32" 237 GLUCOSE TEST STRIPS 148 1/2" 237 EASY TOUCH PEN EASY TOUCH INSULIN EASY TOUCH INSULIN NEEDLES/31G X 3/16" 237 SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G X EASY TOUCH SAFETY 5/16" 236 5/16" 237 LANCETS21G/PRESSURE EASY TOUCH INSULIN EASY TOUCH LANCETS ACTIVATED 199 SYRINGE/0.3ML/31G X 21G/PRESSURE EASY TOUCH SAFETY 5/16" 236 ACTIVATED 198 LANCETS23G/PRESSURE EASY TOUCH INSULIN EASY TOUCH LANCETS ACTIVATED 199 SYRINGE/0.5ML/29G X 23G/PRESSURE EASY TOUCH SAFETY 1/2" 236 ACTIVATED 198 LANCETS26G/BUTTON EASY TOUCH INSULIN EASY TOUCH LANCETS ACTIVATED 199 SYRINGE/0.5ML/30G X 26G/PRESSURE EASY TOUCH SAFETY 5/16" 237 ACTIVATED 198 LANCETS26G/PRESSURE EASY TOUCH INSULIN EASY TOUCH LANCETS ACTIVATED 199 SYRINGE/1ML/30G X 26G/PULL-TOP 198 EASY TOUCH SAFETY 5/16" 237 EASY TOUCH LANCETS LANCETS28G/BUTTON EASY TOUCH INSULIN 28G/PRESSURE ACTIVATED 199 SYRINGE/SAFETY/U- ACTIVATED 198 EASY TOUCH SAFETY 100/0.5ML/29G X 1/2" 237 EASY TOUCH LANCETS LANCETS28G/PRESSURE EASY TOUCH INSULIN 28G/PULL-TOP 198 ACTIVATED 199 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY TOUCH SAFETY PEN 100/0.5ML/30G X 5/16" 237 28G/TWIST 198 NEEDLES/29G X 5MM 237 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SAFETY PEN SYRINGE/SAFETY/U- 30G/BUTTON-ACTIVATED NEEDLES/29G X 8MM 237 100/1ML/29G X 1/2" 237 199 EASY TOUCH SAFETY PEN EASY TOUCH INSULIN EASY TOUCH LANCETS NEEDLES/30G X 5/16" 237 SYRINGE/SAFETY/U- 30G/PRESSURE EASY TOUCH SHEATHLOCK 100/1ML/30G X 1/2" 237 ACTIVATED 199 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN EASY TOUCH LANCETS 1ML/29GX1/2" 238 SYRINGE/U-100/0.3ML/30G X 30G/PULL-TOP 199 EASY TOUCH SHEATHLOCK 1/2" 237 EASY TOUCH LANCETS SAFETY INSULIN SYRINGE EASY TOUCH INSULIN 30G/TWIST 199 1ML/30GX5/16" 238 SYRINGE/U-100/0.5ML/27G X EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 1/2" 237 32G/PRESSURE SAFETY INSULIN SYRINGE EASY TOUCH INSULIN ACTIVATED 199 1ML/31GX5/16" 238 SYRINGE/U-100/0.5ML/28G X EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 1/2" 237 32G/PULL-TOP 199 SAFETY SYRINGE EASY TOUCH INSULIN EASY TOUCH LANCETS 1ML/30GX1/2" 238 SYRINGE/U-100/0.5ML/29G X 32G/TWIST 199 EASY TRAK II CONTROL 1/2" 237 EASY TOUCH LANCETS SOLUTION/NORMAL 199 EASY TOUCH INSULIN 33G/TWIST 199 EASY TRAK BLOOD GLUCOSE SYRINGE/U-100/0.5ML/30G X EASY TOUCH LANCING MONITORING SYSTEM 199 1/2" 237 DEVICE/EJECTOR 199 EASY TRAK BLOOD GLUCOSE EASY TOUCH PEN NEEDLE TEST STRIPS 148 30G X 5/16" 237

Index 33 EASY TRAK GLUCOSE EASYPRO BLOOD GLUCOSE EFFIENT 166 CONTROLSOLUTION TEST STRIPS 148 EFUDEX 127 HIGH 199 EASYPRO PLUS 148 EGCG 89 EASY TRAK GLUCOSE EC- RX DHEA 4% 3 CONTROLSOLUTION EGRIFTA 155 EC-NAPROSYN 5 LOW 199 EGRIFTA SV 155 EASY TRAK GLUCOSE EC-RX DHEA 10% 3 EHA LOTION 137 CONTROLSOLUTION EC-RX ESTRADIOL NORMAL 199 0.4% 159 EHA LOTION 4% 137 EASY TRAK II BLOOD EC-RX ESTRADIOL ELAPRASE 157 GLUCOSE MONITORING 0.6% 159 ELCYS 294 SYSTEM 199 EC-RX PROGESTERONE EASY TRAK II BLOOD 10% 326 ELELYSO 166 GLUCOSE TEST STRIPS 148 EC-RX PROGESTERONE ELEMENT AUTOCODE EASY TWIST & CAP 20% 326 SYSTEM 200 LANCETS 199 EC-RX TESTOSTERONE ELEMENT COMPACT BLOOD EASYGLUCO 148 0.2% 15 GLUCOSE MONITORING EC-RX TESTOSTERONE SYSTEM 200 EASYGLUCO CONTROL ELEMENT COMPACT SOLUTION HIGH 199 0.4% 15 EASYGLUCO CONTROL EC-RX TESTOSTERONE CONTROL SOLUTION LEVEL SOLUTION LOW 199 10% 15 2 200 EASYGLUCO CONTROL EC-RX TESTOSTERONE ELEMENT COMPACT SOLUTION NORMAL 199 20% 15 CONTROL SOLUTION LEVEL ECEOXIA 121 3 200 EASYGLUCO PLUS 148 ELEMENT COMPACT TEST EASYGLUCO PLUS CONTROL ECONASIL 125 STRIPS 148 SOLUTION LEVEL 1 199 ECONAZOLE NITRATE 87 ELEMENT COMPACT V EASYGLUCO STARTER econazole nitrate 125 BLOODGLUCOSE KIT 199 ECONAZOLE MONITORING SYSTEM 200 EASYMAX 15 GLUCOSE ELEMENT HIGH CONTROL SOLUTION LEVEL NITRATE/NIACINAMIDE 125 ECOZA 126 CONTROL 200 1/LEVEL 2 199 ELEMENT LOW EASYMAX 15 GLUCOSE EDARBI 47 CONTROL 200 CONTROL SOLUTION/LEVEL EDARBYCLOR 49 ELEMENT NORMAL 2/LEVEL 3 199 EDECRIN 153 CONTROL 200 EASYMAX 15 LEVEL 2 ELEMENT PLUS BLOOD GLUCOSE CONTROL EDETATE ACID 109 GLUCOSE METER 200 SOLUTION 199 EDETATE CALCIUM ELEMENT TEST STRIPS 148 EASYMAX 15 TEST DISODIUM 39 STRIPS 148 EDETATE DISODIUM 109 ELEPSIA XR 28 EASYMAX CONTROL EDETATE DISODIUM ELESTRIN 159 SOLUTIONNORMAL 199 DIHYDRATE 109 ELETONE 139 EASYMAX GLUCOSE EDETATE TETRASODIUM ELETONE TWINPACK 139 CONTROL SOLUTION TETRAHYDRATE 109 eletriptan hydrobromide 265 NORMAL/LOW 199 EDLUAR 171 EASYMAX GLUCOSE EDROPHONIUM ELIDEL 135 CONTROL CHLORIDE 87 ELIGARD 55 SOLUTION/NORMAL-HIGH 199 EDURANT 66 ELIMITE 141 EASYMAX NG SELF- efavirenz 66 ELIQUIS 26 MONITORING BLOOD efavirenz-emtricitabine- ELIQUIS STARTER PACK 26 GLUCOSE SYSTEM 199 tenofovir disoproxil ELITE-THIN INSULIN EASYMAX TEST STRIPS 148 fumarate 66 SYRINGE/0.3ML/31G X EASYMAX V BLOOD GLUCOSE efavirenz-lamivudine-tenofovir 5/16" 238 SYSTEM 200 disoproxil fumarate 66 ELITE-THIN INSULIN EASYMAX V BLOOD GLUCOSE EFFER-K 269 SYRINGE/0.5ML/29G X SYSTEM/TALKING 200 EFFERVESCENT 319 1/2" 238 EASYPRO BLOOD GLUCOSE EFFEXOR XR 33 MONITORING SYSTEM 200

Index 34 ELITE-THIN INSULIN EMBRACE BLOOD GLUCOSE EMPTY CAPSULE #00 SYRINGE/0.5ML/30G X TEST STRIPS 148 BLACK/RED 310 5/16" 238 EMBRACE CONTROL EMPTY CAPSULE #00 ELITE-THIN INSULIN SOLUTIONLOW 200 BLUE/WHITE 310 SYRINGE/1ML/29G X EMBRACE EVO BLOOD EMPTY CAPSULE #00 5/16" 238 GLUCOSE MONITORING PINK/PINK 310 ELITE-THIN INSULIN KIT 200 EMPTY CAPSULE #00 SYRINGE/1ML/30G X EMBRACE EVO BLOOD PURPLE//PURPLE 310 5/16" 238 GLUCOSETEST STRIPS 148 EMPTY CAPSULE #00 ELITE-THIN INSULIN EMBRACE EVO COMPACT PURPLE//WHITE 310 SYRINGE/U-100/0.5ML/28G X BLOODGLUCOSE EMPTY CAPSULE #00 1/2" 238 MONITOR 200 RED/WHITE 310 ELITE-THIN INSULIN EMBRACE EVO GLUCOSE EMPTY CAPSULE #00 SYRINGE/U-100/0.5ML/28G X CONTROL SOLUTION LEVEL YELLOW/YELLOW 310 5/16" 238 1 200 EMPTY CAPSULE SIZE 0 ELITE-THIN INSULIN EMBRACE GLUCOSE BLUE 310 SYRINGE/U-100/0.5ML/29G X CONTROL SOLUTION EMPTY CAPSULE SIZE 0 5/16" 238 HIGH 200 BLUE/WHITE 311 ELITE-THIN INSULIN EMBRACE LANCETS ULTRA EMPTY CAPSULE SIZE 0 SYRINGE/U-100/0.5ML/31G X THIN 30G 200 CLEAR 311 5/16" 238 EMBRACE LANCING DEVICE EMPTY CAPSULE SIZE 0 ELITE-THIN INSULIN WITH EJECTOR 200 CLEAR LOCKING 311 SYRINGE/U-100/1ML/28G X EMBRACE PRO BLOOD EMPTY CAPSULE SIZE 0 1/2" 238 GLUCOSE METER 200 FUNCAPS LOCKING 311 ELITE-THIN INSULIN EMBRACE PRO BLOOD EMPTY CAPSULE SIZE 0 SYRINGE/U-100/1ML/28G X GLUCOSETEST STRIPS 148 GREEN LOCKING 311 5/16" 238 EMBRACE PRO GLUCOSE EMPTY CAPSULE SIZE 0 ELITE-THIN INSULIN CONTROL SOLUTION 200 GREEN/CLEAR 311 SYRINGE/U-100/1ML/29G X EMBRACE TALK BLOOD EMPTY CAPSULE SIZE 0 1/2" 238 GLUCOSE MONITOR 200 GREEN/CLEAR LOCKING 311 ELITE-THIN INSULIN EMBRACE TALK BLOOD EMPTY CAPSULE SIZE 0 SYRINGE/U-100/1ML/31G X GLUCOSE MONITORING MAROON/OPAQUE 5/16" 238 SYSTEM 200 LOCKING 311 ELITEK 60 EMBRACE TALK BLOOD EMPTY CAPSULE SIZE 0 GLUCOSE TEST ORANGE 311 ELIXOPHYLLIN 25 STRIPS 148 EMPTY CAPSULE SIZE 0 ELLA 113 EMBRACE TALK GLUCOSE ORANGE/OPAQUE ELLENCE 57 CONTROL SOLUTION LOCKING 311 EMPTY CAPSULE SIZE 0 ELLIOTTS B 267 HIGH 200 EMBRACE TALK GLUCOSE PINK 311 ELLZIA PAK 131 CONTROL SOLUTION EMPTY CAPSULE SIZE 0 PINK ELMIRON 164 LOW 200 LOCKING 311 ELOCON 131 EMCYT 55 EMPTY CAPSULE SIZE 0 PURPLE 311 ELOCTATE 165 EMEND 41 EMPTY CAPSULE SIZE 0 ELON MATRIX 5000 287 EMEND TRIPACK 41 PURPLE/OPAQUE ELON MATRIX PLUS 287 EMERPHED 340 LOCKING 311 ELON MATRIX 5000 EMFLAZA 115 EMPTY CAPSULE SIZE 0 PURPLE/WHITE 311 COMPLETE 287 EMGALITY 264 ELON MATRIX EMPTY CAPSULE SIZE 0 COMPLETE 287 EMOLIVAN 322 RED 311 EMPTY CAPSULE SIZE 0 ELON R3 287 EMOLLIENT CREAM 322 EMOLLIENT CREAM RED/CLEAR 311 ELZONRIS 59 EMPTY CAPSULE SIZE 0 BASE 322 RED/WHITE 311 EMBEDA 9 EMPLICITI 54 EMBRACE BLOOD GLUCOSE EMPTY CAPSULE SIZE 0 MONITORING EMPRICAINE II 137 RED/WHITE LOCKING 311 SYSTEM/TALKING 200 EMPTY CAPSULE #0 RED EMPTY CAPSULE SIZE 0 TRANSLUCENT/WHITE 310 WHITE 311

Index 35 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 WHITE/CLEAR 311 BLUE/PINK ORANGE/CLEAR 312 EMPTY CAPSULE SIZE 0 TRANSLUCENT 312 EMPTY CAPSULE SIZE 1 WHITE/OPAQUE 311 EMPTY CAPSULE SIZE 1 ORANGE/WHITE 312 EMPTY CAPSULE SIZE 0 BLUE/POWDER BLUE 312 EMPTY CAPSULE SIZE 1 WHITE/OPAQUE EMPTY CAPSULE SIZE 1 ORANGE/YELLOW 312 LOCKING 311 BLUE/RED OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 LOCKING 312 PINK 312 YELLOW 311 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 BLUE/WHITE 312 PINK/CLEAR 312 YELLOW/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 LOCKING 311 BLUETRANSLUCENT/PINK PINK/OPAQUE LOCKING 312 EMPTY CAPSULE SIZE 00 TRANSLUCENT 312 EMPTY CAPSULE SIZE 1 BLUE/OPAQUE LOCKING 311 EMPTY CAPSULE SIZE 1 PINK/POWDER BLUE 312 EMPTY CAPSULE SIZE 00 BROWN/IVORY 312 EMPTY CAPSULE SIZE 1 CLEAR 311 EMPTY CAPSULE SIZE 1 PINK/WHITE 313 EMPTY CAPSULE SIZE 00 BROWN/IVORY OPAQUE EMPTY CAPSULE SIZE 1 CLEAR LOCKING 311 LOCKING 312 PINK/YELLOW 313 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 DARK GREEN 311 CLEAR 312 PINK/YELLOW OPAQUE EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 LOCKING 313 GREEN/OPAQUE CLEAR LOCKING 312 EMPTY CAPSULE SIZE 1 LOCKING 311 EMPTY CAPSULE SIZE 1 POWDER BLUE 313 EMPTY CAPSULE SIZE 00 DARKGREEN 312 EMPTY CAPSULE SIZE 1 LIGGHT BLUE OPAQUE 311 EMPTY CAPSULE SIZE 1 POWDER BLUE/OPAQUE EMPTY CAPSULE SIZE 00 GREEN 312 LOCKING 313 ORANGE 311 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 00 GREEN CLEAR/YELLOW PURPLE 313 ORANGE/OPAQUE LOCKING 312 EMPTY CAPSULE SIZE 1 LOCKING 311 EMPTY CAPSULE SIZE 1 PURPLE/OPAQUE EMPTY CAPSULE SIZE 00 GREEN LOCKING 313 RED 311 TRANSLUCENT/YELLOW EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 00 OPAQUE 312 RED 313 WHITE 311 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 00 GREEN/ORANGE 312 RED/BLUE 313 WHITE OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 LOCKING 311 GREEN/WHITE 312 RED/OPAQUE LOCKING 313 EMPTY CAPSULE SIZE 000 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 CLEAR 311 GREEN/WHITE OPAQUE RED/WHITE 313 EMPTY CAPSULE SIZE 000 LOCKING 312 EMPTY CAPSULE SIZE 1 CLEAR LOCKING 311 EMPTY CAPSULE SIZE 1 VEGETABLE CLEAR 318 EMPTY CAPSULE SIZE 000 GREEN/YELLOW 312 EMPTY CAPSULE SIZE 1 WHITE/OPAQUE EMPTY CAPSULE SIZE 1 WHITE 313 LOCKING 311 GREY/PINK 312 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 WHITE OPAQUE AQUABLUE IVORY 312 LOCKING 313 TRANSLUCENT 312 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 LIGHT BLUE OPAQUE 312 WHITE/CLEAR 313 BLUE 312 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 MAROON WHITE/OPAQUE 313 BLUE/CLEAR 312 TRANS/CLEAR 312 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 YELLOW 313 BLUE/OPAQUE LOCKING 312 MINTGREEN 312 EMPTY CAPSULE SIZE 10 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 CLEAR 313 BLUE/PINK 312 ORANGE 312 EMPTY CAPSULE SIZE 11 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 CLEAR 313 BLUE/PINK LOCKING 312 ORANGE OPAQUE EMPTY CAPSULE SIZE 13 LOCKING 312 CLEAR 313

Index 36 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 BLUE 313 OLIVE/OPAQUE YELLOW OPAQUE/CLEAR EMPTY CAPSULE SIZE 2 LOCKING 314 LOCKING 314 CLEAR 313 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 2 ORANGE 314 YELLOW/CLEAR 314 CLEAR LOCKING 313 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 2 ORANGE/OPAQUE YELLOW/OPAQUE GREEN 313 LOCKING 314 LOCKING 314 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 WHITE OPAQUE ORANGE/WHITE 314 BLACK/GREEN OPAQUE LOCKING 313 EMPTY CAPSULE SIZE 3 LOCKING 314 EMPTY CAPSULE SIZE 3 PINK 314 EMPTY CAPSULE SIZE 4 BLACK/GREEN 313 EMPTY CAPSULE SIZE 3 BLUE/WHITE 314 EMPTY CAPSULE SIZE 3 PINK/CLEAR 314 EMPTY CAPSULE SIZE 4 BLUE 313 EMPTY CAPSULE SIZE 3 CLEAR 314 EMPTY CAPSULE SIZE 3 PINK/OPAQUE EMPTY CAPSULE SIZE 4 BLUE/CLEAR 313 LOCKING 314 CLEAR LOCKING 315 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 DARK BLUE/WHITE 313 PINK/POWDER BLUE 314 BLUE/OPAQUE LOCKING 315 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 BLUEOPAQUE/CLEAR PINK/WHITE 314 PURPLE 315 LOCKING 313 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 EMPTY CAPSULE SIZE 3 PINK/YELLOW 314 PURPLE/OPAQUE CLEAR 313 EMPTY CAPSULE SIZE 3 LOCKING 315 EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR 314 EMPTY CAPSULE SIZE 4 CLEAR LOCKING 313 EMPTY CAPSULE SIZE 3 RED/WHITE 315 EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR EMPTY CAPSULE SIZE 4 DARKGREEN 313 LOCKING 314 WHITE 315 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 GRAY/PINK OPAQUE POWDER BLUE 314 WHITE/OPAQUE LOCKING 313 EMPTY CAPSULE SIZE 3 LOCKING 315 EMPTY CAPSULE SIZE 3 PURPLE 314 EMPTY CAPSULE SIZE 4 GRAY/YELLOW OPAQUE EMPTY CAPSULE SIZE 3 YELLOW 315 LOCKING 313 PURPLE/CLEAR 314 EMPTY CAPSULE SIZE 5 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 CLEAR 315 GREEN 313 RED 314 EMPTY CAPSULE SIZE 7 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 CLEAR 315 GREEN/BLUE 313 RED/CLEAR 314 EMPTY GELATIN EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 CAPSULE/SNAP CLOSURE GREEN/BLUE LOCKING 313 RED/OPAQUE LOCKING314 #0 315 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY GELATIN GREEN/BLUE RED/WHITE 314 CAPSULE/SNAP CLOSURE TRANSLUCENT 313 EMPTY CAPSULE SIZE 3 #00 315 EMPTY CAPSULE SIZE 3 REDOPAQUE/CLEAR EMPTY GELATIN GREY/PINK 313 LOCKING 314 CAPSULE/SNAP CLOSURE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 #000 315 GREY/YELLOW 313 WHITE 314 EMPTY GELATIN EMPTY CAPSULE SIZE 3 LIGHT EMPTY CAPSULE SIZE 3 CAPSULE/SNAP CLOSURE BLUE OPAQUE 314 WHITE OPAQUE #1 315 EMPTY CAPSULE SIZE 3 LOCKING 314 EMPTY GELATIN MAROON/BLUE 314 EMPTY CAPSULE SIZE 3 CAPSULE/SNAP CLOSURE EMPTY CAPSULE SIZE 3 WHITE OPAQUE/CLEAR #2 315 MAROON/BLUE OPAQUE 314 LOCKING 314 EMPTY GELATIN EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 CAPSULE/SNAP CLOSURE MAROON/CLEAR 314 WHITE/CLEAR 314 #3 315 EMPTY CAPSULE SIZE 3 MINT EMPTY CAPSULE SIZE 3 EMPTY GELATIN GREEN 314 WHITE/OPAQUE 314 CAPSULE/SNAP CLOSURE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 #4 315 OLIVE/CLEAR 314 YELLOW 314

Index 37 EMPTY VEGETABLE ENSPRYNG 271 EPINEPHRINE/DEXTROSE CAPSULE/SNAP CLOSURE ENSTILAR 132 341 #0 318 EPINEPHRINE/SODIUM EMPTY VEGETABLE entacapone 61 CHLORIDE 341 CAPSULE/SNAP CLOSURE entecavir 69 EPINEPHRINESNAP-EMS 340 #00 318 ENTEREG 162 EPINEPHRINESNAP-V 340 EMPTY VEGETABLE CAPSULE/SNAP CLOSURE ENTOCORT EC 115 EPIPEN 2-PAK 340 #1 318 ENTRESTO 74 EPIPEN-JR 2-PAK 340 EMSAM 31 ENTTY SPRAY 139 epirubicin hcl 57 emtricitabine 66 ENTYVIO 161 EPISNAP 340 emtricitabine-tenofovir disoproxil ENVARSUS XR 272 EPIVIR 66 fumarate 66 ENZADYNE 152 EPIVIR HBV 69 EMTRIVA 66 ENZNONUTY 137 eplerenone 50 EMU OIL 87 EPANED 47 EPOGEN 167 EMULGADE CM 319 EPCLUSA 69 epoprostenol sodium 75 EMULSIFYING WAX 319 EPHEDRINE HCL 24 eprosartan mesylate 47 EMULSION EPHEDRINE CONCENTRATE 319 EPSOM SALT 173 SULFATE 24,340 EMULSION SB 139 ephedrine sulfate EPZICOM 66 EMVERM 16 (pressors) 340 EQ BLOOD GLUCOSE TEST EPHEDRINE STRIPS 148 ENABLEX 337 EQ FLEXIBLE FABRIC enalapril maleate 46,47 SULFATE/SODIUMCHLORIDE 340 BANDAGES/ANTIBACTERIAL ENALAPRIL MALEATE 87 EPICERAM 139 185 enalapril maleate & EQ STRONG STRIPS hydrochlorothiazide 49 EPICYN 140 BANDAGES/ANTIBACTERIAL enalaprilat 47 EPIDIOLEX 28 185 EPIDUO 121 EQL ADHESIVE PADS ENBRACE HR 283 LARGE 185 ENBREL 7 EPIDUO FORTE 121 EQL ADHESIVE PADS ENBREL MINI 7 EPIFOAM 132 MEDIUM 185 ENBREL SURECLICK 7 epinastine hcl (ophth) 301 EQL ADVANCED HEALING EPINEPHRINE 109 ADHESIVE BANDAGES 185 ENCARE 339 EQL ALCOHOL SWABS 226 epinephrine 340 ENDARI 166 EQL ANIMAL PRINT ENDOMETRIN 339 EPINEPHRINE 340 STRIPS 185 ENGERIX-B 337 epinephrine 341 EQL ANTIBACTERIAL ENGLISH TOFFEE EPINEPHRINE 341 FABRICSTRIPS 185 EQL BUTTERFLY FLAVOR 307 epinephrine (anaphylaxis)340 CLOSURES 185 ENHERTU 54 EPINEPHRINE BASE 109 EQL COLOR LANCETS ENOVARX-AMITRIPTYLINE EPINEPHRINE 21G 200 80 BITARTRATE 87 EQL COLOR LANCETS MICRO ENOVARX-BACLOFEN 124 EPINEPHRINE HCL 340 THIN 33G 200 ENOVARX- epinephrine hcl (nasal) 290 EQL DRY MOUTH ORAL CYCLOBENZAPRINE HCL 288 RINSE 275 ENOVARX-DICLOFENAC EPINEPHRINE EQL DUAL GEL INSOLES SODIUM 124 HYDROCHLORIDE 297 WOMENS 219 EPINEPHRINE ENOVARX-IBUPROFEN 124 EQL FIRST AID HYDROCHLORIDE/DEXTROS ANTISEPTICBANDAGES 185 ENOVARX-LIDOCAINE E 340 HCL 137 EQL FLEXIBLE FABRIC EPINEPHRINE BANDAGES 185 ENOVARX-NAPROXEN 124 HYDROCHLORIDE/SODIUM EQL FLEXIBLE FABRIC ENOVARX-TRAMADOL 124 CHLORIDE 340 BANDAGES MULTI- enoxaparin sodium 26 EPINEPHRINE PURPOSE 185 PROFESSIONAL 340 ENROFLOXACIN 87

Index 38 EQL FLEXIBLE FABRIC EQL STERILE NON-STICK ESBRIET 330 BANDAGES/EXTRA PADS 3"X4"/LARGE 186 ESCAVITE 282 LARGE 185 EQL STRIPS 186 ESCAVITE D 282 EQL FLEXIBLE FABRIC EQL STRONG STRIPS BANDAGES/KNUCKLE & WATERPROOF 186 escitalopram oxalate 32 FINGERTIP 185 EQL SUPER THIN LANCETS ESGIC 8 EQL FLEXIBLE FOAM 30G 200 ESKATA 129 STRIPS 185 EQL THIN LANCETS EQL GAUZE PADS 26G 200 esmolol hcl 71 2"X2"/SMALL 185 EQL TOENAIL CLIPPER 219 esmolol hcl-sodium chloride 71 EQL GAUZE PADS ESMOLOL 4"X4"/LARGE 185 EQL VARIETY PACK ADHESIVEBANDAGES 186 HYDROCHLORIDE 71 EQL GENTLE STRIPS 185 EQUAPAX/ATORVASTATIN ESMOLOL HYDROCHLORIDE EQL HEAVY DUTY BANDAGES CALCIUM/COQ10 45 INWATER 71 EXTRA LONG 3/4"X4-3/4" 185 EQUAPAX/IBUPROFEN/MINR ESMOLOL HYDROCHLORIDE EQL HEAVY DUTY FABRIC EX 4 INWATER DOUBLE STRIPS MULTI-PURPOSE 185 EQUETRO 63 STRENGTH 71 EQL HEAVY DUTY FABRIC ESOMEP-EZS 335 ERAXIS 41 STRIPS/EXTRA LARGE 185 esomeprazole magnesium 335 EQL INSULIN ERBITUX 55 esomeprazole sodium 335 SYRINGE/0.3ML/29G X ERGOCAL 342 1/2" 238 ESOMEPRAZOLE EQL INSULIN ergocalciferol 342 STRONTIUM 335 SYRINGE/0.3ML/30G X ERGOCALCIFEROL 342 ESPUMIL 322 5/16" 238 ERGOLOID MESYLATES 87 ESSENTRA WIPES 9X9" EQL INSULIN ergoloid mesylates 329 CLEANROOM SYRINGE/0.3ML/31G X ERGOMAR 265 SUPPLIES/PRESATURATED 5/16" 238 226 ERGOTAMINE EQL INSULIN estazolam 171 SYRINGE/0.5ML/29G X TARTRATE 265 1/2" 238 ergotamine w/ caffeine 265 ESTRACE 159,339 EQL INSULIN ERIVEDGE 55 ESTRADIOL 87 SYRINGE/0.5ML/30G X ERLEADA 55 estradiol 159 5/16" 238 erlotinib hcl 55 estradiol & norethindrone EQL INSULIN acetate 159 SYRINGE/0.5ML/31G X ERTACZO 126 ESTRADIOL BENZOATE 87 5/16" 238 ertapenem sodium 17 ESTRADIOL EQL INSULIN CONCENTRATE 87 SYRINGE/1ML/29G X 1/2" 238 ERWINASE 59 EQL INSULIN ERWINAZE 59 ESTRADIOL CYPIONATE 87 SYRINGE/1ML/30G X ERYGEL 121 ESTRADIOL HEMIHYDRATE 87 5/16" 238 ERYPED 200 176 EQL INSULIN ESTRADIOL MICRONIZED 87 ERYPED 400 176 SYRINGE/1ML/31G X estradiol vaginal 339 ERYTHROCIN 5/16" 238 ESTRADIOL VALERATE 87 EQL PLASTIC STRIPS 185 LACTOBIONATE 176 estradiol valerate 159 EQL PLASTIC STRIPS MULTI- ERYTHROMYCIN 176 PURPOSE 185 erythromycin (acne aid) 121 ESTRING 339 EQL PUMICE erythromycin (ophth) 297 ESTRIOL 88 STONE/ROPE 219 ESTRIOL CONCENTRATE 88 EQL SHEER SPOTS erythromycin base 176 SMALL 186 ERYTHROMYCIN ESTRIOL MICRONIZED 88 EQL SHEER STRIPS 186 ESTOLATE 87 ESTRIOL ULTRA ERYTHROMYCIN MICRONIZED 88 EQL SHEER STRIPS EXTRA ETHYLSUCCINATE 176 ESTRIOL-PROGESTERONE LARGE 186 erythromycin COMPOUNDING KIT 159 EQL SHEER STRIPS MULTI- ethylsuccinate 176 PURPOSE 186 ESTROGEL 159 erythromycin stearate 176 ESTROMINERAL 273

Index 39 ESTRONE 88 ETOPOPHOS 60 everolimus ESTRONE CONCENTRATE 88 etoposide 60,61 (immunosuppressant) 272 EVISTA 156 ESTROSTEP FE 112 ETOPOSIDE 88 EVKEEZA 43 eszopiclone 171 etravirine 66 EVOCLIN 121 ETESEVIMAB 303 EUCALYPTOL 88 EVOLUTION AUTOCODE 148 ethacrynate sodium 153 EUCALYPTUS FLAVOR 307 EVOLUTION CONTROL ethacrynic acid 153 EUCALYPTUS OIL 107 SOLUTION NORMAL 201 ETHAMBUTOL HCL 51 EUCRISA 141 EVOMELA 52 ethambutol hcl 52 EUGENOL 107 EVOTAZ 66 ETHAMOLIN 275 EUGENOL FLAVOR 307 EVOXAC 275 ETHER 106 EURAX 141 EVRYSDI 291 ETHINYL ESTRADIOL 159 EVAMIST 159 EVZIO 40 ethosuximide 31 EVANS BLUE 305 EXACTECH R-S-G TEST ETHOSUXIMIDE 88 EVEKEO 1 STRIPS 148 ETHOXIA 121 EVEKEO ODT 1 EXACTECH TEST STRIPS 148 EVENCARE + BLOOD EXCEL COMFORT POINT ETHOXY DIGLYCOL 85 INSULIN PEN NEEDLES 31G X ETHOXY ETHOXY ETHANOL GLUCOSETEST STRIP 148 EVENCARE BLOOD 4MM 238 REAGENT 85 EXCEL-GEL 143 ETHYL ACETATE 319 GLUCOSE MONITORING SYSTEM 200 EXCILON AMD ETHYL ALCOHOL 107 EVENCARE BLOOD ANTIMICROBIALDRAIN ETHYL ALCOHOL 190 GLUCOSE TEST STRIP 148 SPONGES 4"X4" 6 PLY 186 PROOF 107 EVENCARE CONTROL EXCILON AMD ETHYL ALCOHOL 200 SOLUTION 200 ANTIMICROBIALNON-WOVEN PROOF 315 EVENCARE G2 BLOOD SPONGES 4"X4" 6 PLY 186 ETHYL ALCOHOL SDA-40B 190 GLUCOSEMONITORING EXCILON DRAIN SPONGE PROOF 107 SYSTEM 201 4"X4" 186 ethyl chloride 137 EVENCARE G2 GLUCOSE EXCILON DRAIN SPONGES ETHYL CHLORIDE/FINE CONTROL SOLUTION/LOW- 4"X4" 6 PLY 186 PINPOINT 137 HIGH 201 EXCILON I.V. SPONGES 2"X2" 6 ETHYL CHLORIDE/FINE EVENCARE G2 TEST PLY 186 STREAM 137 STRIPS 148 EXEL COMFORT POINT ETHYL CHLORIDE/MEDIUM EVENCARE G3 BLOOD INSULIN PEN NEEDLES 29G X JET STREAM 137 GLUCOSEMONITORING 12MM 238 ETHYL CHLORIDE/MEDIUM SYSTEM 201 EXEL COMFORT POINT STREAM 137 EVENCARE G3 GLUCOSE INSULIN PEN NEEDLES 31G X ETHYL CHLORIDE/MIST 137 CONTROL SOLUTION/LOW- 6MM 238 EXEL COMFORT POINT ETHYL OLEATE 88 HIGH 201 EVENCARE G3 TEST INSULIN PEN NEEDLES 31G X ETHYL VANILLIN 88 STRIPS 148 8MM 239 ETHYLCELLULOSE 88 EVENCARE MINI BLOOD EXEL COMFORT POINT ETHYLENEDIAMINE 88 GLUCOSE MONITORING INSULIN SYRINGE/0.3ML/29G X SYSTEM 201 1/2" 239 ETHYLPARABEN 106 EVENCARE MINI BLOOD EXEL COMFORT POINT ethynodiol diacet & eth GLUCOSE TEST INSULIN SYRINGE/0.3ML/30G X estrad 112 STRIPS 148 5/16" 239 ETHYOL 60 EVENCARE MINI GLUCOSE EXEL COMFORT POINT etidronate disodium 154 CONTROL SOLUTION INSULIN SYRINGE/0.5ML/28G X etodolac 5 NORMAL 201 1/2" 239 EVENCARE PROVIEW EXEL COMFORT POINT ETOMIDATE 88 BLOOD GLUCOSE TEST INSULIN SYRINGE/0.5ML/29G X etomidate 163 STRIPS 148 1/2" 239 etonogestrel-ethinyl EVENITY 154 EXEL COMFORT POINT estradiol 113 INSULIN SYRINGE/0.5ML/30G X everolimus 58 5/16" 239

Index 40 EXEL COMFORT POINT EZ-LETS LANCETS 28G FDC BLUE 1 ALUMINUM INSULIN SYRINGE/1ML/28G X ULTRA-SOFT 201 LAKE 305 1/2" 239 EZ-LETS LANCETS 30G 201 FDC BLUE 2 305 EXEL COMFORT POINT EZALLOR SPRINKLE 45 FDC GREEN #3 305 INSULIN SYRINGE/1ML/29G X 1/2" 239 ezetimibe 46 FDC RED #3 305 EXEL COMFORT POINT ezetimibe-simvastatin 44 FDC RED 40 305 INSULIN SYRINGE/1ML/30G X F-MELT 319 FDC YELLOW 5 ALUMINUM 5/16" 239 FABIOR 121 LAKE 305 EXELDERM 126 FDC YELLOW 6 305 FABRAZYME 157 fe fum-iron polysacch complex-fa- EXELON 327 FABRIC exemestane 56 b complex-c-zn-mn-cu 168 BANDAGES/ASSORTED 186 fe fumarate-vitamin c-vitamin EXFOLIATING STONE FAGRON CAPFILL PRO 319 b12-folic acid 168 FILE 219 FAGRON febuxostat 165 EXFORGE 49 DISPERSAPRO 319 FEIBA 165 EXFORGE HCT 49 FAGRON LS PLUS 322 felbamate 30 EXJADE 39 FAGRON NATURAL FELBATOL 30 EXODERM 126 CREAM 322 FAGRON SUPREME FELDENE 5 EXONDYS 51 291 CREAM 322 felodipine 73 EXPAREL 175 FALESSA 112 FEMARA 56 EXQUISITE HRT 322 famciclovir 69 FEMHRT 159 EXSERVAN 290 FAMCICLOVIR 88 FEMRING 339 EXTAVIA 328 FAMOTIDINE 88 FENBENDAZOLE 88 EXTINA 126 famotidine 334 fenofibrate 44 EXTRANEAL 274 famotidine in nacl 334 FENOFIBRATE 44,88 EXU-DRY NON-PERMEABLE FAMOTIDINE/SODIUM SHEET 36"X72" 143 CHLORIDE 334 fenofibrate micronized 44 EXU-DRY PERMEABLE FANAPT 63 fenofibric acid 44 QUILTED 36"X72" 143 FANAPT TITRATION FENOFIBRIC ACID 44 EXUDERM LP 4" X 4" 143 PACK 63 fenofibric acid 45 EXUDERM LP 6" X 6" 143 FANATREX FUSEPAQ 28 FENOGLIDE 45 EXUDERM RCD 4" X 4" 143 FARESTON 56 FENOPROFEN CALCIUM 5 EXUDERM RCD 6" X 6" 143 FARXIGA 37 fenoprofen calcium 5 EXUDERM RCD 8" X 8" 143 FARYDAK 58 FENOPROFEN CALCIUM 5 EXUDERM SACRUM 4" X FASENRA 22 3.6" 143 fenoprofen calcium 5 FASENRA PEN 22 EXUDERM SATIN 2" X 2" 143 FENORTHO 5 FASLODEX 56 EXUDERM SATIN 4" X 4" 143 FENSOLVI 156 FATTIBASE 322 EXUDERM SATIN 6" X 6" 143 fentanyl 9 FATTYBLEND 319 EXUDERM SATIN 8" X 8" 143 FENTANYL 9 FAVIPIRAVIR 70 EXUDERM ULTRA 4" X 4" 143 fentanyl citrate 9 EXUDERM ULTRA FAZACLO 64 FENTANYL CITRATE 9 HYDROCOLLOID WOUND FBL KIT 124 fentanyl citrate 9 DRESSING 4" X 4" 143 FC FEMALE CONDOM 192 FENTANYL CITRATE 9 EXYDERM 306 FC2 FEMALE CONDOM 192 fentanyl citrate 9 EYLEA 296 FD&C BLUE #2 305 FENTANYL CITRATE 9 EYSUVIS 298 FD&C RED #40 305 fentanyl citrate 9 EZ-LETS LANCETS 21G 201 FD&C YELLOW #5 305 FENTANYL EZ-LETS LANCETS 26G FD&C YELLOW #6 ALUMINUM CITRATE/BUPIVACAINE SUPER-SOFT 201 LAKE 305 HCL/SODIUM CHLORIDE 13 FDC BLUE 1 305

Index 41 FENTANYL ferrous fumarate w/ b12-vit c-fa- FIFTY50 SUPERIOR CITRATE/BUPIVACAINE ifc 168 COMFORTINSULIN HYDROCHLORIDE 13 ferrous fumarate-fa-b complex- SYRINGE/0.5ML/31G X FENTANYL c-zn-mg-mn-cu 168 5/16" 239 CITRATE/BUPIVACAINE ferrous fumarate-folic FIFTY50 SUPERIOR HYDROCHLORIDE/SODIUM acid 168 COMFORTINSULIN CHLORIDE 13 FERROUS GLUCONATE 88 SYRINGE/1ML/31G X FENTANYL FERROUS GLUCONATE 5/16" 239 CITRATE/BUPIVICAINE DIHYDRATE 88 FIFTY50 UNILET LANCETS HCL/SODIUM CHLORIDE 13 FERROUS SULFATE 170 33G 201 FENTANYL FERROUS SULFATE FINACEA 141 CITRATE/BUPIVICAINE ANHYDROUS 170 FINASTERIDE 88 HYDROCHLORIDE/SODIUM FERROUS SULFATE finasteride 164 CHLORIDE 13 HEPTAHYDRATE 170 FENTANYL FINE 30 201 FERULIC ACID 88 CITRATE/ROPIVACAINE FINGERSTIX LANCETS 201 ferumoxytol 170 HYDROCHLORIDE 13 FINTEPLA 28 FENTANYL FETROJA 77 FIORICET 8 CITRATE/ROPIVACAINE FETZIMA 33 HYDROCHLORIDE/SODIUM FETZIMA TITRATION FIORICET/CODEINE 13 CHLORIDE 13 33 FIORINAL 8 FENTANYL CITRATE/SODIUM PACK CHLORIDE 9 FEVERFEW 88 FIORINAL/CODEINE #3 13 FENTANYL/BUPIVACAINE FEXOFENADINE HCL 88 FIRAZYR 166 HYDROCHLORIDE/SODIUM FIASP 36 FIRDAPSE 51 CHLORIDE 13 FIASP FLEXTOUCH 36 FIRMAGON 56 FENTANYL/BUPIVACAINE/NAC L 13 FIASP PENFILL 36 FIRST - METOPROLOL 71 FENTANYL/ROPIVACAINE FIBRICOR 45 FIRST-ATENOLOL 71 HYDROCHLORIDE/SODIUM FIBRYGA 165 FIRST-BACLOFEN 1 288 CHLORIDE 13 FIFTY50 ALCOHOL PREP FIRST-BACLOFEN 5 288 FENTORA 10 PADS 226 FIRST-LANSOPRAZOLE 335 FEONYX 168 FIFTY50 GLUCOSE METER FIRST-METRONIDAZOLE FERAHEME 169 2.0 201 FIFTY50 GLUCOSE TEST 100 16 FERIVA 21/7 168 STRIP 2.0 148 FIRST-METRONIDAZOLE FERIVAFA 168 FIFTY50 PEN NEEDLES 31G 50 17 FERRALET 90 168 X3/16" (5MM) 239 FIRST-MOUTHWASH BLM 275 FERRAPLUS 90 168 FIFTY50 PEN NEEDLES 31G FIRST-OMEPRAZOLE 335 X5/16" (8MM) 239 FIRST-PROGESTERONE VGS FERRIC AMMONIUM FIFTY50 PEN NEEDLES CITRATE 88 100 COMPOUNDING KIT 339 31GX5MM 239 FIRST-PROGESTERONE VGS FERRIC CHLORIDE FIFTY50 PEN HEXAHYDRATE 88 200 COMPOUNDING KIT 339 NEEDLES/31GX8MM 239 FIRST-VANCOMYCIN 25 18 FERRIC FIFTY50 PEN PYROPHOSPHATE 106 NEEDLES/32GX4MM 239 FIRST-VANCOMYCIN 50 18 FERRIC SUBSULFATE 88 FIFTY50 PEN FIRVANQ 18 FERRIC SULFATE NEEDLES/32GX6MM 239 FISH FLAVOR 307 HYDRATE 88 FIFTY50 SAFETY SEAL FITALITE 322 FERRIPROX 39 LANCETS 30G 201 FIXED OIL SUSPENSION 315 FERRIPROX TWICE-A-DAY 39 FIFTY50 SAFETY SEAL LANCETS 32G 201 FIZZMIX BASE 319 FERRLECIT 169 FIFTY50 SUPERIOR FLAGYL 17 FERRO-PLEX HEMATINIC 168 COMFORTINSULIN FERROUS BISGLYCINATE SYRINGE/0.3ML/31G X FLAREX 298 CHELATE 88 5/16" 239 FLAVOR BLEND 315 FERROUS FUMARATE 88 FLAVOR CONCENTRATE/CHLORHEXIDI NE 307

Index 42 FLAVOR PLUS 315 fluconazole 42 fluphenazine decanoate 64 FLAVOR SWEET 315 FLUCONAZOLE 88 FLUPHENAZINE FLAVOR SWEET-SF 315 fluconazole in nacl 42 DECANOATE 89 fluphenazine hcl 64 FLAVORX 307 FLUCONAZOLE/IBUPROFEN/I flurandrenolide 132 flavoxate hcl 337 TRACONAZOLE/TERBINAFIN E HYDROCHLORIDE 126 flurazepam hcl 171 FLEBOGAMMA DIF 302 flucytosine 42 FLURBIPROFEN 5 flecainide acetate 22 FLUCYTOSINE 88 flurbiprofen 5 FLECTOR 124 fludarabine phosphate 53 FLEX-A-MIN DOUBLE flurbiprofen sodium 301 FLUDROCORTISONE flutamide 56 STRENGTH PLUS MSM 273 ACETATE 118 FLEX-A-MIN SUPER FLUTICASONE GLUCOSAMINE 2000 fludrocortisone acetate 118 PROPIONATE 89 PLUS 273 FLULAVAL QUADRIVALENT fluticasone propionate 132 338 FLEX-A-MIN TRIPLE 2021-2022 fluticasone propionate STRENGTH/BONE SHIELD FLUMADINE 70 (nasal) 290 PLUS VITAMINS K2/D3 273 flumazenil 40 fluticasone-salmeterol 24 FLEX-A-MIN TRIPLE FLUMAZENIL 88 STRENGTH/JOINT FLEX PLUS fluvastatin sodium 45 FLUMIST fluvoxamine maleate 32 VITAMIN D3 273 338 FLEXIBLE FABRIC QUADRIVALENT FLUZONE HIGH-DOSE PF 2021- BANDAGES 186 flunisolide (nasal) 290 2022 338 FLEXIBLE FABRIC FLUNISOLIDE FLUZONE QUADRIVALENT BANDAGESASSORTED 186 ANHYDROUS 23 2020-2021 338 FLEXIN 137 FLUNIXIN MEGLUMINE 88 FLUZONE QUADRIVALENT FLEXIZOL COMBIPAK 5 fluocinolone acetonide 132 2021-2022 338 FML 299 FLEXZAN 4 X 8 186 FLUOCINOLONE ACETONIDE 132 FML FORTE 298 FLIBANSERIN 88 fluocinolone acetonide FML LIQUIFILM 299 FLOLAN 75 (otic) 302 FOAM TOE SEPARATORS219 FLOLIPID 45 FLUOCINOLONE FOAMIL 315 FLOMAX 164 ACETONIDE/NIACINAMIDE 132 FLONASE ALLERGY FOCALIN 2 RELIEF 290 fluocinonide 132 FOCALIN XR 2 FLONASE ALLERGY RELIEF FLUOCINONIDE 132 FOLET DHA 283 fluocinonide emulsified CHILDRENS 290 FOLET ONE 283 FLORAJEN ACIDOPHILUS 38 base 132 FOLGARD OS 277 FLORAJEN WOMEN 38 FLUOPAR 132 FOLGARD RX 168 FLORATUMMYS KIDS 38 FLUORABON 268 FOLI-D 168 FLORIVA 268 FLUORESCEIN 109 FOLIC + B12 168 FLORIVA PLUS 280 FLUORESCEIN SODIUM 109 folic acid 167 FLOVENT DISKUS 23 fluorometholone (ophth) 298 FOLIC ACID 167 FLOVENT HFA 23 FLUOROPLEX 127 folic acid 167 FLOXIN OTIC 302 fluorouracil 53 folic acid-cholecalciferol 168 floxuridine 53 FLUOROURACIL 88 fluorouracil (topical) 127 folic acid-vitamin b6-vitamin FLOXURIDINE 88 b12 168 FLUAD QUADRIVALENT 2021- FLUOVIX 132 FOLIC D3 168 2022 338 FLUOVIX PLUS 132 FOLIC-K 277 FLUARIX QUADRIVALENT fluoxetine hcl 32 2021-2022 338 FOLICA-BE 277 FLUBLOK QUADRIVALENT FLUOXETINE HCL 88 FOLICA-V 277 2021-2022 338 fluoxetine hcl (pmdd) 329 FOLIKA-D 168 FLUCELVAX QUADRIVALENT FLUOXETINE 2021-2022 338 HYDROCHLORIDE 32 FOLIKA-V 280

Index 43 FOLITE 168 FORA G30/PREMIUM V10 FORA V12 BLOOD GLUCOSE FOLITIN-Z 278 BLOOD GLUCOSE TEST TEST STRIPS 149 STRIPS 149 FORA V20 BLOOD GLUCOSE FOLIVANE-F 168 FORA G30A BLOOD MONITORING SYSTEM 202 FOLIVANE-OB 283 GLUCOSE MONITORING FORA V20 BLOOD GLUCOSE FOLIVANE-PLUS 168 SYSTEM 201 TEST STRIPS 149 FORA GD20 BLOOD FORA V30A BLOOD GLUCOSE FOLIXAPURE 168 GLUCOSE MONITORING MONITORING SYSTEM 202 FOLLISTIM AQ 155 SYSTEM 201 FORA V30A BLOOD GLUCOSE FOLOTYN 53 FORA GD20 TEST TEST STRIPS 149 FOLTRATE 168 STRIPS 149 FORACARE GD40 149 FORA GD50 BLOOD FOLTREXYL 168 FORACARE GD40 BLOOD GLUCOSE MONITORING GLUCOSE MONITORING FOLVITE FE 169 SYSTEM 201 SYSTEM 202 fomepizole 40 FORA GD50 BLOOD FORACARE GDH CONTROL fondaparinux sodium 26 GLUCOSE TEST SOLUTION HIGH 202 STRIPS 149 FORACARE GDH CONTROL FOOD COLOR BLACK 305 FORA GTEL BLOOD SOLUTION LOW 202 FOOD COLOR BLUE 305 GLUCOSE MONITORING FORACARE GDH CONTROL FOOD COLOR BROWN 305 SYSTEM/MULTI-FUNCTIONAL SOLUTION NORMAL 202 201 FOOD COLOR GREEN 305 FORACARE PREMIUM V10 FORA GTEL BLOOD BLOOD GLUCOSE FOOD COLOR LIME GLUCOSE TEST MONITORING SYSTEM 202 GREEN 305 STRIPS 149 FORACARE PREMIUM V10 FOOD COLOR ORANGE 305 FORA LANCETS 201 TESTSTRIPS 149 FOOD COLOR PINK 305 FORA LANCING DEVICE201 FORACARE TEST N GO FOOD COLOR RED 305 FORA LANCING BLOODGLUCOSE DEVICE/CLEARCAP 201 MONITORING SYSTEM 202 FOOD COLOR VIOLET 305 FORACARE TEST N GO TEST FOOD COLOR WHITE 305 FORA PREMIUM V10 BLE BLOOD GLUCOSE STRIPS 149 FOOD COLOR YELLOW 305 MONITORING SYSTEM 201 FORANE 163 FOOT COMFORT THERMAL FORA TEST N' GO VOICE FORFIVO XL 31 ANKLE AND FOOT BLOOD GLUCOSE formaldehyde 65 STABILIZER 219 MONITORING SYSTEM 201 FOOT SLEEP SUPPORT 219 FORA TN'G ADVANCE PRO FORMALDEHYDE 65 FOOT SMOOTHER DUAL BLOOD GLUCOSE TEST formoterol fumarate 25 SURFACE 219 STRIPS 149 FORMOTEROL FUMARATE89 FORA 6 CONNECT 148 FORA TN'G VOICE BLOOD FORSKOLIN 89 GLUCOSE MONITORING FORA BLOOD GLUCOSE TEST FORTAMET 34,35 STRIPS 148 SYSTEM 201 FORA CONTROL SOLUTION FORA TN'G/TN'G VOICE FORTAVIT 278 HIGH 201 BLOOD GLUCOSE TEST FORTAZ 77 FORA CONTROL SOLUTION STRIPS 149 FORTEO 154 FORA V10 BLOOD GLUCOSE LOW 201 FORTESTA 15 FORA CONTROL SOLUTION MONITORING NORMAL 201 SYSTEM/TALKING 201 FORTISCARE BLOOD FORA D15G BLOOD GLUCOSE FORA V10 BLOOD GLUCOSE GLUCOSETEST STRIP 149 TEST STRIPS 149 TEST STRIPS 149 FORTISCARE CONTROL FORA D20 BLOOD GLUCOSE FORA V10/V12/D10/D20 SOLUTIONS HIGH 202 TEST STRIPS 149 BLOOD GLUCOSE TEST FORTISCARE CONTROL FORA D40/G31 BLOOD STRIPS/LANCETS 30G 201 SOLUTIONS LOW 202 GLUCOSE TEST STRIPS 149 FORA V12 BLOOD GLUCOSE FORTISCARE CONTROL FORA G20 BLOOD GLUCOSE MONITORING SYSTEM/NO- SOLUTIONS NORMAL 202 MONITORING SYSTEM 201 CODING 202 FORTISCARE SELF- FORA G20 BLOOD GLUCOSE FORA V12 BLOOD GLUCOSE MONITORING BLOOD TEST STRIPS 149 MONITORING GLUCOSE SYSTEM 202 SYSTEM/TALKING 202

Index 44 FORTISCARE SELF- FREEDOM SIMPLECAP fulvestrant 56 MONITORING BLOOD POWDER 319 FUMARIC ACID 77 GLUCOSE SYSTEM FREESTYLE CONTROL EMV3.1 202 SOLUTION 202 FUNGIMEZ 126 FORTISCARE T1 SELF- FREESTYLE CONTROL FURADANTIN 19 MONITORING BLOOD SOLUTION HIGH/LOW 202 FURAZOLIDONE 89 GLUCOSE SYSTEM 202 FREESTYLE FREEDOM 202 FUROSEMIDE 153 FOSAMAX 154 FREESTYLE FREEDOM furosemide 153 FOSAMAX PLUS D 154 LITE 202 FREESTYLE INSULINX FUROSEMIDE/SODIUM fosamprenavir calcium 66 BLOODGLUCOSE CHLORIDE 153 fosaprepitant dimeglumine 41 MONITORING SYSTEM 202 FUSILEV 60 foscarnet sodium 68 FREESTYLE INSULINX FUSION PLUS 169 FOSCAVIR 68 BLOODGLUCOSE TEST 149 FUSION SPRINKLES 169 FREESTYLE INSULINX fosinopril sodium 47 BLOODGLUCOSE TEST FUTURO THERAPEUTIC ARCH fosinopril sodium & STRIPS 149 SUPPORT FOOT 219 hydrochlorothiazide 49 FREESTYLE LANCETS 202 FUZEON 66 fosphenytoin sodium 30 FREESTYLE LITE BLOOD FYCOMPA 27 FOSRENOL 162 GLUCOSE MONITORING G-MYCO NAIL 126 FOTIVDA 58 SYSTEM 202 GABA 294 FRAGMIN 26 FREESTYLE LITE TEST STRIPS 149 GABACAINE 329 FREAMINE HBC 6.9% 294 FREESTYLE PRECISION GABAPAL 329 FREAMINE III 294 INSULIN SYRINGE/U- gabapentin 28 FREDS PHARMACY AUTOLET 100/0.5ML/30G X 5/16" 239 GABAPENTIN 89 LANCING DEVICE 202 FREESTYLE PRECISION GABAPENTIN/NAPROXEN SOD FREDS PHARMACY UNIFINE INSULIN SYRINGE/U- MULTI-PHASIC TRANSDERMAL 239 PENTIPS PEN NEEDLES 100/0.5ML/31G X 5/16" CMPD KIT 124 32GX4MM 239 FREESTYLE PRECISION FREDS PHARMACY UNIFINE INSULIN SYRINGE/U- GABITRIL 30 PENTIPS PLUS 31GX5MM 239 100/1ML/31G X 5/16" 239 GABLOFEN 288 FREDS PHARMACY UNIFINE FREESTYLE PRECISION GALACTOSE 89 PENTIPS PLUS 31GX8MM 239 INSULIN SYRINGES/U- GALAFOLD 157 FREDS PHARMACY UNILET 100/1ML/30G X 5/16" 239 LANCETS SUPER THIN FREESTYLE PRECISION NEO galantamine hydrobromide 327 30G 202 BLOOD GLUCOSE GALZIN 270 FREDS PHARMACY UNILET MONITORING SYSTEM 202 GAMASTAN 302 FREESTYLE PRECISION NEO LANCETS ULTRA THIN GAMIFANT 272 28G 202 BLOOD GLUCOSE TEST FREEDERM ADHESIVE STRIPS 149 GAMMA-AMINOBUTYRIC REMOVER 139 FREESTYLE SIDEKICK II ACID 89 FREEDOM ADAPTADERM 322 VALUEPACK 202 GAMMAGARD LIQUID 303 FREESTYLE TEST GAMMAGARD S/D IGA LESS FREEDOM CEPAPRO 322 STRIPS 149 THAN 1MCG/ML 303 FREEDOM DERMA FREESTYLE UNISTICK II GAMMAKED 303 SERUM 322 LANCETS 202 GAMMAPLEX 303 FREEDOM DERMA-D 322 FRESENIUS PROPOVEN FREEDOM DERMA-N 322 2% 163 GAMUNEX-C 303 FREEDOM ESTERDERM 85 FRESH LINEN GANCICLOVIR 68 106 FREEDOM LOLLIPOP FRAGRANCE ganciclovir sodium 68 BASE 319 FROTEK 124 ganirelix acetate 155 FREEDOM ODT BASE 319 FROVA 265 GANIRELIX ACETATE 155 FREEDOM PEG TROCHE frovatriptan succinate 265 GARDASIL 9 338 BASE 316 FRUCTOSE 292 GARDENIA FRAGRANCE 89 FREEDOM SILOMAC FULLERS EARTH 109 ANHYDROUS 322 GASTROCROM 161 FULPHILA 167

Index 45 gatifloxacin (ophth) 297 GEMCITABINE GENTLE-LET LANCETS GATIFLOXACIN HYDROCHLORIDE 53 GENERAL PURPOSE SESQUIHYDRATE 89 GEMFIBROZIL 45 STYLE/FINE POINT 203 GATIFLOXACIN- gemfibrozil 45 GENTLE-LET LANCETS GENERAL PURPOSE DEXAMETHASONE 299 GEMTESA 337 GATTEX 162 STYLE/MEDIUM POINT 203 GEN7T 137 GENTLE-LET LANCETS GAUZE BANDAGE 3" 186 GEN7T PLUS 137 SAFETY STYLE/FINE GAUZE BANDAGE/2" X POINT 203 4YDS 186 GENADUR 139 GENTLE-LET LANCETS GAUZE DRESSING 4"X4" 186 GENADUR KIT 139 SAFETY STYLE/MEDIUM GAUZE PADS 2"X2" 186 GENERESS FE 112 POINT 203 GAUZE PADS 4"X4" 186 GENICIN VITA-D 169 GENULTIMATE TEST STRIPS 149 GAUZE SPONGE TYPE VII GENICIN VITA-Q 280 GENVOYA 66 MEDI-PAK 2"X2" 8PLY 186 GENISTEIN 89 GAUZE SPONGES 4"X4" 12 GEODON 63 GENOTROPIN 155 PLY 186 GERANIUM NATURAL 107 GENOTROPIN GAUZE STRETCH BANDAGE GERANIUM OIL 107 3"X2.5YD 186 MINIQUICK 155 GAVRETO 58 gentamicin in saline 3 GERMALL PLUS 87 gentamicin sulfate 3 GERMANIUM GAZYVA 54 SESQUIOXIDE 109 GE100 BLOOD GLUCOSE GENTAMICIN SULFATE 125 GHRP-2/GHRP- MONITORING SYSTEM 202 gentamicin sulfate 6/SERMORELINACETATE 155 GE100 BLOOD GLUCOSE (ophth) 297 GHRP-2/SERMORELIN TESTSTRIPS 149 gentamicin sulfate ACETATE 155 GE100 CONTROL SOLUTION (topical) 125 GHT BLOOD GLUCOSE NORMAL 203 GENTEEL BUTTERFLY MONITORING SYSTEM 203 GEAMETDRAY 135 TOUCH LANCETS 203 GHT TEST STRIPS 149 GEBAUERS INSTANT ICE 137 GENTEEL LANCING DEVICE/GLORIOUS GIALAX 173 GEBAUERS PAIN EASE 137 GOLD 203 GIAPREZA 341 GEBAUERS SPRAY AND GENTEEL LANCING GILENYA 328 STRETCH 137 DEVICE/PRECIOUS GILOTRIF 55 GEL BALL OF FOOT PLATINUM 203 CUSHIONS 219 GENTEEL LANCING GILPHEX TR 118 GEL CORN DEVICE/STATELY GILTUSS TR 118 PROTECTORS 219 SILVER 203 GIMOTI 161 GEL INSOLES MENS 220 GENTEEL PLUS LANCING GINGER 89 GEL INSOLES WOMENS 220 DEVICE/BUFF BLACK 203 GINGER ROOT 109 GEL TOE PROTECTOR 220 GENTEEL PLUS LANCING DEVICE/BUTTERFLY GINKGO BILOBA XTRA 273 GEL TOE SEPARATORS 220 BLUE 203 GINSENG (AMERICAN) 80 GEL TOE SPACERS 220 GENTEEL PLUS LANCING GINSENG ROOT 89 GEL-FLOW 170 DEVICE/PLAYFUL PURPLE 203 GLASSIA 330 GELATIN 319 GENTEEL PLUS LANCING glatiramer acetate 328 GELATIN TYPE A 319 DEVICE/PRINCESS GLEEVEC 58 GELCLAIR 275 PINK 203 GLEOSTINE 52 GELFILM OP 300 GENTEEL PLUS LANCING DEVICE/WILLOWY GLIADEL WAFER 52 GELFOAM-JMI POWDER WHITE 203 KIT 170 glimepiride 38 GENTIAN VIOLET 126 GELFOAM-JMI SPONGE GLIPIZIDE 38 GENTLE ADHESIVE KIT 170 glipizide 38 GELNIQUE 337 BANDAGES/EXTRA LARGE 186 glipizide-metformin hcl 34 GELNIQUE PUMP 337 GENTLE-LET GP GLOBAL ALCOHOL PREP gemcitabine hcl 53 LANCETS 203 EASEPADS 226

Index 46 GLOBAL EASE INJECT PEN GLOBAL INJECT EASE GLUCOCARD EXPRESSION NEEDLES 29GX12MM 239 INSULIN SYRINGE/U- CONTROL SOLUTION LEVEL GLOBAL EASE INJECT PEN 100/1ML/30G X 5/16" 240 1 203 NEEDLES 31GX8MM 239 GLOBAL INJECT EASE GLUCOCARD SHINE 203 GLOBAL EASE INJECT PEN INSULIN SYRINGE/U- GLUCOCARD SHINE CONNEX NEEDLES 32GX4MM 240 100/1ML/31G X 5/16" 240 BLOOD GLUCOSE GLOBAL EASE INJECT PEN GLOBAL INJECT EASE MONITORING SYSTEM 203 NEEEDLES 31GX5MM 240 LANCETS 28G 203 GLUCOCARD SHINE CONTROL GLOBAL EASY GLIDE INSULIN GLOBAL INJECT EASE SOLUTION LEVEL 1 203 SYRINGE/0.3ML/31G X LANCETS 30G 203 GLUCOCARD SHINE EXPRESS 15/64" 240 GLOBAL INSULIN BLOOD GLUCOSE GLOBAL EASY GLIDE INSULIN SYRINGE/U-100/0.3ML/30G X MONITORING SYSTEM 204 SYRINGE/0.5ML/31G X 1/2" 240 GLUCOCARD SHINE TEST 15/64" 240 GLOBAL INSULIN STRIPS 149 GLOBAL EASY GLIDE INSULIN SYRINGES/U- GLUCOCARD SHINE XL 204 SYRINGE/1ML/31G X 100/0.3ML/30GX5/16" 240 15/64" 240 GLOBAL LANCING GLUCOCARD VITAL BLOOD GLOBAL EASY GLIDE DEVICE 203 GLUCOSE MONITORING INSULINSYRINGE/U- SYSTEM 204 GLOPERBA 165 GLUCOCARD VITAL BLOOD 100/0.3ML/31G X 5/16" 240 GLUCAGEN HYPOKIT 35 GLOBAL EASY GLIDE PEN GLUCOSE MONITORING NEEDLES 32GX4MM 240 glucagon (rdna) 35 SYSTEM BLACK 204 GLOBAL INJECT EASE INSULIN GLUCAGON EMERGENCY GLUCOCARD VITAL BLOOD SYRINGE/U-100/0.3ML/29G X KIT 35 GLUCOSE MONITORING 1/2" 240 GLUCAGON EMERGENCY SYSTEM BLUE 204 GLOBAL INJECT EASE INSULIN KIT FOR LOW BLOOD GLUCOCARD VITAL BLOOD SYRINGE/U-100/0.3ML/30G X SUGAR 35 GLUCOSE MONITORING 1/2" 240 GLUCO COR 287 SYSTEM PINK 204 GLOBAL INJECT EASE INSULIN GLUCOCARD VITAL TEST GLUCO PERFECT 3 BLOOD STRIPS 149 SYRINGE/U-100/0.3ML/30G X GLUCOSE METER 203 5/16" 240 GLUCO PERFECT 3 BLOOD GLUCOCARD X-METER 204 GLOBAL INJECT EASE INSULIN GLUCOSE MONITORING GLUCOCARD X-METER SYRINGE/U-100/0.3ML/31G X SYSTEM/VOICE 203 CONTROLSOLUTION/NORMAL 5/16" 240 GLUCO PERFECT 3 TEST 204 GLOBAL INJECT EASE INSULIN STRIPS 149 GLUCOCARD X-SENSOR 149 SYRINGE/U-100/0.5ML/28G X GLUCOCARD 01 BLOOD GLUCOCOM BLOOD GLUCOSE 1/2" 240 GLUCOSE METER 203 MONITOR 204 GLOBAL INJECT EASE INSULIN GLUCOCARD 01 BLOOD GLUCOCOM BLOOD GLUCOSE SYRINGE/U-100/0.5ML/29G X GLUCOSE MONITORING MONITORING SYSTEM 204 1/2" 240 SYSTEM 203 GLUCOCOM BLOOD GLUCOSE GLOBAL INJECT EASE INSULIN GLUCOCARD 01 CONTROL MONITORING SYSTEM VALUE SYRINGE/U-100/0.5ML/30G X SOLUTION KIT 204 1/2" 240 NORMAL/HIGH 203 GLUCOCOM HIGH GLOBAL INJECT EASE INSULIN GLUCOCARD 01 CONTROL CONTROL 204 SYRINGE/U-100/0.5ML/30G X SOLUTION/NORMAL 203 GLUCOCOM LANCETS 5/16" 240 GLUCOCARD 01 SENSOR 28G 204 GLOBAL INJECT EASE INSULIN PLUS 149 GLUCOCOM LANCETS SYRINGE/U-100/0.5ML/31G X GLUCOCARD 01 SENSOR 30G 204 5/16" 240 PLUSTEST STRIPS 149 GLUCOCOM LANCETS GLOBAL INJECT EASE INSULIN GLUCOCARD 01-MINI BLOOD 33G 204 SYRINGE/U-100/1ML/28G X GLUCOSE MONITORING GLUCOCOM NORMAL 1/2" 240 SYSTEM 203 CONTROL 204 GLOBAL INJECT EASE INSULIN GLUCOCARD EXPRESSION GLUCOCOM TEST SYRINGE/U-100/1ML/29G X AUDIO-ENABLED BLOOD STRIPS 149 1/2" 240 GLUCOSE GLUCONAVII BLOOD GLOBAL INJECT EASE INSULIN MONITORING 203 GLUCOSEMONITORING SYRINGE/U-100/1ML/30G X GLUCOCARD EXPRESSION SYSTEM 204 1/2" 240 BLOOD GLUCOSE TEST GLUCONAVII BLOOD STRIPS 149 GLUCOSETEST STRIPS 149

Index 47 GLUCONOLACTONE 89 GLUTATHIONE-L GNP CLICKFINE UNIVERSAL GLUCOPRO INSULIN REDUCED 294 PEN NEEDLES 31GX5/16" 241 SYRINGE/U-100/0.3ML/30G X GLYBURIDE 38 GNP CUSHION COMFORT 1/2" 240 glyburide 38 INSOLES 220 GNP EASY TOUCH CONTROL GLUCOPRO INSULIN glyburide micronized 38 SYRINGE/U-100/0.3ML/30G X SOLUTION HIGH/LOW 204 5/16" 241 glyburide-metformin 34 GNP EASY TOUCH GLUCOSE GLUCOPRO INSULIN GLYCATE 333 MONITORING SYSTEM/NO CODING 204 SYRINGE/U-100/0.3ML/31G X GLYCERIN 107 5/16" 241 GNP EASY TOUCH GLUCOSE GLUCOPRO INSULIN GLYCERINE 107 TEST STRIPS 150 SYRINGE/U-100/0.5ML/30G X GLYCEROL FORMAL 107 GNP EUCALYPTUS OIL 107 1/2" 241 GLYCEROL GNP INSULIN GLUCOPRO INSULIN MONOOLEATE 89 SYRINGE/0.3ML/29G X SYRINGE/U-100/0.5ML/30G X GLYCERYL 1/2" 241 5/16" 241 MONOSTEARATE 89 GNP INSULIN GLUCOPRO INSULIN GLYCINE 164 SYRINGE/0.3ML/30G X SYRINGE/U-100/0.5ML/31G X glycine (gu irrigant) 164 5/16" 241 5/16" 241 GNP INSULIN GLUCOPRO INSULIN GLYCINE (L) 164 SYRINGE/0.3ML/31G X SYRINGE/U-100/1ML/30G X glycine diluent 316 5/16" 241 1/2" 241 GLYCINE SOYA GNP INSULIN GLUCOPRO INSULIN PROTEIN 107 SYRINGE/0.5ML/28G X SYRINGE/U-100/1ML/30G X GLYCOFUROL 89 1/2" 241 5/16" 241 GLYCOLIC ACID 77 GNP INSULIN GLUCOPRO INSULIN SYRINGE/0.5ML/29G X GLYCOLIC ACID 70% HIGH 1/2" 241 SYRINGE/U-100/1ML/31G X PURITY 129 5/16" 241 GNP INSULIN GLUCOSAMINE CHONDROITIN GLYCOPHOS 269 SYRINGE/0.5ML/30G X COMPLEX PLUS MSM/TRIPLE GLYCOPYRROLATE 89 5/16" 241 STRENGTH 273 glycopyrrolate 334 GNP INSULIN SYRINGE/0.5ML/31G X GLUCOSAMINE CHONDROITIN GLYCOPYRROLATE 334 TRIPLE STRENGTH 273 5/16" 241 GLUCOSAMINE glycopyrrolate 334 GNP INSULIN HYDROCHLORIDE 89 GLYCOPYRROLATE 334 SYRINGE/1ML/28G X 1/2" 241 GLUCOSAMINE SULFATE 89 GLYCOSAMINOGLYCANS 8 GNP INSULIN GLUCOSAMINE SULFATE 9 SYRINGE/1ML/29G X 1/2" 241 POTASSIUM CHLORIDE 89 GLYCOTROL 287 GNP INSULIN SYRINGE/1ML/30G X GLUCOSAMINE SULFATE GLYCOTROL SODIUM CHLORIDE 89 5/16" 241 COMPLETE 287 GNP INSULIN GLUCOSE CONTROL GLYCYRRHIZIC ACID 89 NORMAL 204 SYRINGE/1ML/31G X GLUCOSE CONTROL GLYNASE 38 5/16" 241 SOLUTION 204 GLYRX-PF 334 GNP IODIDES TINCTURE 65 GLUCOSE METER TEST GLYSET 34 GNP IODINE TINCTURE 65 STRIPS ADVANCED 149 GLYXAMBI 34 GNP ISOPROPYL GLUCOTROL 38 GNP ACID CONTROL 150 ALCOHOL 107 GLUCOTROL XL 38 MAXIMUM STRENGTH 334 GNP ISOPROPYL ALCOHOL GLUMETZA 35 GNP ALCOHOL SWABS 226 WIPES 140 GNP LANCETS 21G 204 GLUTARALDEHYDE 65 GNP BORIC ACID 109 GNP LANCETS MICRO THIN GLUTARALDEHYDE IN GNP CENTURY ENERGY 33G 204 WATER 89 METABOLISM 287 GNP LANCETS SUPER THIN GLUTATHIONE 294 GNP CLICKFINE UNIVERSAL 30G 204 GLUTATHIONE (L) 294 PEN NEEDLES GNP LANCETS THIN 204 31GX1/4" 241 GLUTATHIONE REDUCED294 GNP LANCETS THIN 26G 204 GLUTATHIONE-L 294

Index 48 GNP STERILE GAUZE PADS GOODSENSE LANCETS GRISEOFULVIN 89 2"X2" 186 MICRO-THIN 33G 204 GRISEOFULVIN GNP ULTICARE PEN GOODSENSE LANCETS MICRONIZED 89 NEEDLES/31GX5/16" 241 MICRO-THIN 33G griseofulvin microsize 42 GNP ULTICARE PEN UNIVERSAL 204 NEEDLES/32GX 5/32" 241 GOODSENSE LANCETS griseofulvin ultramicrosize 42 GNP ULTICARE PEN ULTRA-THIN 26G GRX WHITE NEEDLES/32GX1/4" 241 UNIVERSAL 204 PETROLATUM 322 GNP ULTICARE PEN GOODSENSE LANCETS GRX WOUND 143 NEEDLES31G X 5MM 241 ULTRA-THIN 30G 204 GUAIACOL 107 GNP ULTRA COMFORT GOODSENSE LANCETS INSULIN SYRINGE/0.3ML/29G X ULTRA-THIN 30G GUAIFENESIN 119 1/2" 241 UNIVERSAL 205 guaifenesin-codeine 118 GNP ULTRA COMFORT GOODSENSE LANCING GUANABENZ ACETATE 89 INSULIN SYRINGE/0.3ML/30G X DEVICE 205 GUANENDRUX 135 5/16" SHORT 241 GOODSENSE PEN GNP ULTRA COMFORT GUANETHIDINE NEEDLE/PENFINE HEMISULFATE 89 INSULIN SYRINGE/0.5ML/28G X CLASSIC/31G X 3/16" 242 1/2" 241 GOODSENSE PEN guanfacine hcl 48 GNP ULTRA COMFORT NEEDLE/PENFINE guanfacine hcl (adhd) 2 INSULIN SYRINGE/0.5ML/29G X CLASSIC/31G X 5/16" 242 GUANIDINE HCL 51 1/2" 241 GOODSENSE PEN GUANIDINEACETIC ACID 89 GNP ULTRA COMFORT NEEDLE/PENFINE INSULIN SYRINGE/1ML/28G X CLASSIC/32G X 1/4" 242 GUAR GUM 89 1/2" 242 GOODSENSE PEN GUARANA SEED EXTRACT89 GNP ULTRA COMFORT NEEDLE/PENFINE GUAVA FLAVOR 307 INSULIN SYRINGE/1ML/29G X CLASSIC/32G X 5/32" 242 1/2" 242 GOODSENSE PREMIUM GUM ARABIC MILLED 319 GOCOVRI 62 BLOOD GLUCOSE TEST GUM ARABIC SPRAY- DRIED 319 GOJJI BLOOD GLUCOSE STRIPS 150 TESTSTRIPS 150 GOODSENSE PREMIUM GUM BASE GELATIN 316 GOJJI BLOOD GLUCOSE BLOODGLUCOSE GVOKE HYPOPEN 1-PACK 35 TESTSTRIPS/GOJJI STERILE MONITORING SYSTEM 205 GVOKE HYPOPEN 2-PACK 35 LANCETS 30G 150 GOPRELTO 290 GVOKE PFS 35 GOJJI CONTROL SOLUTION GORDOFILM 135 NORMAL 204 GYMNEMA SYLVESTRIS GOJJI LANCING GPL PAK 329 LEAF 89 DEVICE/CLEAR CAP 204 GRALISE 329 GYNAZOLE-1 339 GOJJI STERILE LANCETS GRAMICIDIN D 89 H-E-B IN CONTROL PEN 30G 204 granisetron hcl 40 NEEDLE 31GX3/16" 242 GOLD SODIUM H-E-B IN CONTROL PEN THIOMALATE 89 GRANIX 167 NEEDLES 31GX5MM 242 GOLYTELY 172 GRAPE FLAVOR 307 H-E-B IN CONTROL PEN GRAPE SEED 89 NEEDLES 31GX6MM 242 GONAL-F 155 H-E-B IN CONTROL PEN GONAL-F RFF 155 GRAPE SYRUP 316 NEEDLES 31GX8MM 242 GONAL-F RFF REDIJECT 155 GRAPEFRUIT FLAVOR H-E-B IN CONTROL PEN PINK 307 GONITRO 20 NEEDLES/NANO/32GX4MM GRAPESEED 89 242 GOODSENSE CLICKFINE H-E-B IN CONTROL SAFETY PEN NEEDLE/31G X GREEN SOAP 89 GREEN SOURCE 287 UNIFINEPENTIPS PLUS 3/16" 242 31GX1/4" 242 GOODSENSE COLOR GREEN TEA 88 H-E-B IN CONTROL LANCETS MICRO-THIN 33G GREEN TEA OIL UNIFINEPENTIPS PLUS UNIVERSAL 204 FRAGRANCE 89 31GX3/16" 242 GOODSENSE IODINE 65 GRILLED BEEF FLAVOR H-E-B IN CONTROL GOODSENSE ISOPROPYL NATURAL OIL SOLUBLE307 UNIFINEPENTIPS PLUS ALCOHOL 107 GRILLED CHICKEN FLAVOR 31GX5/16" 242 NATURAL OIL MISCIBLE307

Index 49 H-E-B IN CONTROL HALOPERIDOL HEALTHWISE SHORT PEN UNIFINEPENTIPS PLUS DECANOATE 90 NEEDLES/31G X 5/16" 243 31GX5MM 242 haloperidol lactate 64 HEALTHWISE UNIFINE H-E-B IN CONTROL HALUCORT 139 PENTIPS PEN NEEDLES UNIFINEPENTIPS PLUS 32GX4MM 243 32GX4MM 242 HAM FLAVOR 307 HEALTHY ACCENTS AUTOLET H-E-B IN CONTROL HAPRODERM 143 IMPRESSION LANCING UNIFINEPENTIPS PLUS HARMONY BLOOD GLUCOSE DEVICE 205 32GX5/32" 242 TEST STRIPS 150 HEALTHY ACCENTS UNIFINE H-E-B IN CONTROL HARVONI 69 PENTIPS PEN NEEDLES UNIFINEPENTIPS PLUS HAVRIX 338 29GX12MM 243 33GX5/32" 242 HEALTHY ACCENTS UNIFINE H-E-B INCONTROL HAWTHORN BERRY 90 PENTIPS PEN NEEDLES ADVANCEDLANCING HAXCHLO 129 31GX5MM 243 DEVICE 205 HCG 155 HEALTHY ACCENTS UNIFINE H-E-B INCONTROL ALCOHOL PENTIPS PEN NEEDLES PADS 226 HDL RX 273 31GX6MM 243 H-E-B INCONTROL LANCETS HEALON 300 HEALTHY ACCENTS UNIFINE MICRO THIN 33G 205 HEALON DUET PRO 300 PENTIPS PEN NEEDLES H-E-B INCONTROL LANCETS HEALON GV 300 31GX8MM 243 SUPER THIN 30G 205 HEALTHY ACCENTS UNIFINE H-E-B INCONTROL LANCETS HEALON GV PRO 300 PENTIPS PEN NEEDLES ULTRA THIN 28G 205 HEALON PRO 300 32GX4MM 243 H-E-B INCONTROL PEN HEALON5 300 HEALTHY ACCENTS UNILET NEEDLES 29GX12MM 242 LANCETS SUPER THIN HEALON5 PRO 300 HAEGARDA 166 30G 205 HEALTH CARE LANCING HEALTHY HEART HAEMOLANCE 205 DEVICE 205 HAEMOLANCE LOW FLOW COMPLEX 287 HEALTH HEART SAVIOR 287 LANCETS 205 SLIPPERS/UNISEX 220 HAEMOLANCE PLUS 205 HEALTHWISE INSULIN HEART TABS 287 HAEMOLANCE PLUS HIGH SYRINGE/U-100/0.3ML/30G X HECTOROL 157 FLOW 205 5/16" 242 HELIDAC THERAPY 336 HAEMOLANCE PLUS LOW HEALTHWISE INSULIN FLOW 205 SYRINGE/U-100/0.3ML/31G X HELIXATE FS 165 HAEMOLANCE PLUS MAX 5/16" 242 HEMADY 115 FLOW 205 HEALTHWISE INSULIN HEMANGEOL 71 HAEMOLANCE PLUS SYRINGE/U-100/0.5ML/30G X HEMATOGEN FA 169 PEDIATRIC FLOW 205 5/16" 242 HAIR FARE 287 HEALTHWISE INSULIN HEMATOXYLIN 90 HAIR NOURISHING SYRINGE/U-100/0.5ML/31G X HEMATRON-AF 169 SUPPLEMENT 287 5/16" 242 HEMETAB 169 HALAVEN 61 HEALTHWISE INSULIN SYRINGE/U-100/1ML/30G X HEMOCYTE PLUS 169 halcinonide 132 5/16" 242 HEMOFIL M 165 HALCION 171 HEALTHWISE INSULIN HEPAGAM B 303 HALDOL 64 SYRINGE/U-100/1ML/31G X heparin (porcine) in sodium HALDOL DECANOATE 100 64 5/16" 242 chloride 26 HEALTHWISE MICRON PEN HEPARIN LOCK FLUSH 26 HALDOL DECANOATE 50 64 NEEDLES/32G X 5/32" 242 halobetasol propionate 132 HEALTHWISE MINI PEN heparin sod (porcine) in d5w 26 HALOBETASOL NEEDLES 31GX6MM 242 HEPARIN SODIUM 26,90 PROPIONATE 132 HEALTHWISE PEN NEEDLES heparin sodium (porcine) 26 HALOG 132 29GX12MM 243 heparin sodium (porcine) lock HEALTHWISE SHORT PEN haloperidol 64 flush 26 NEEDLES 31GX8MM 243 heparin sodium (porcine) lock HALOPERIDOL 90 HEALTHWISE SHORT PEN flush & nacl lock flush 26 haloperidol decanoate 64 NEEDLES/31G X 3/16" 243 HEPARIN SODIUM/DEXTROSE 26

Index 50 HEPARIN SODIUM/NACL HM STERILE PADS HUMALOG MIX 75/25 0.45% 26 2"X2" 186 KWIKPEN 36 HEPARIN SODIUM/SODIUM HM ULTICARE INSULIN HUMAN CHORIONIC CHLORIDE 26 SYRINGE/1ML/30G X GONADOTROPIN 85 HEPARIN SODIUM/SODIUM 1/2" 243 HUMATE-P 165 CHLORIDE 0.9% 26 HM ULTICARE INSULIN HUMATIN 3 HEPARIN/SODIUM SYRINGE/U-100/0.3ML/31G X CHLORIDE 26 5/16" 243 HUMATROPE 155 HEPES 90 HM ULTICARE MINI PEN HUMATROPE COMBO PACK 155 HEPLISAV-B 338 NEEDLES/31G X 5MM (3/16") 243 HUMIRA 4 HEPMED 26 HM ULTICARE SHORT PEN HUMIRA PEDIATRIC CROHNS HEPSERA 69 NEEDLES 31GX8MM 243 DISEASE STARTER PACK 4 HEPTAMINOL 90 homatropine hbr 296 HUMIRA PEN 4 HERCEPTIN 54 HOMATROPINE HUMIRA PEN-CD/UC/HS HERCEPTIN HYLECTA 57 METHYLBROMIDE 109 STARTER 4 HONEY ALMOND HUMIRA PEN-PEDIATRIC UC HERZUMA 54 FRAGRANCE 90 STARTER PACK 4 HETLIOZ 172 HONEY FLAVOR 307 HUMIRA PEN-PS/UV HETLIOZ LQ 172 HORIZANT 329 STARTER 4 HIBERIX 337 HORMONE CREAM HUMULIN 70/30 36 HIPREX 19 BASE 322 HUMULIN 70/30 KWIKPEN 36 HORMONE CREAM BASE HUMULIN N 36 HISTAMINE PHOSPHATE 90 BOTANICAL 322 HIXDEFRIMA 126 HORMONE CREAM BASE HUMULIN N KWIKPEN 36 HIZENTRA 303 NIOSOMES 322 HUMULIN R 36 HM ADHESIVE BANDAGES HORMONE CREAM-HEAVY HUMULIN R U-500 ANTIBACTERIAL 186 BASENIOSOMES 322 (CONCENTRATED) 36 HM ADHESIVE BANDAGES HOT FLASHEX 273 HUMULIN R U-500 ANTIBACTERIAL/SHEER 186 HPR 139 KWIKPEN 36 HUPERZINE SERRATE A 90 HM ADHESIVE BANDAGES HPR PLUS 139 ANTIBACTERIAL/SHEER/XL HPR PLUS HYDROGEL HURRICAINE 275 186 KIT 139 HW EMBRACE PRO BLOOD HM ADHESIVE PADS HPR PLUS/MB GLUCOSE METER 205 ANTIBACTERIAL/SHEER 186 HYDROGEL 135 HW EMBRACE PRO BLOOD HM BORIC ACID 109 HRT BASE 322 GLUCOSE TEST STRIPS 150 HM BUTTERFLY HW EMBRACE TALK BLOOD CLOSURES 186 HRT BASE FOR MEN 322 GLUCOSE MONITOR 205 HM CASTOR OIL 107 HRT BOTANICAL 322 HW EMBRACE TALK BLOOD HRT BOTANICAL BASE 322 GLUCOSE MONITORING HM ESTROPLUS 287 SYSTEM 205 HM FABRIC ADHESIVE HRT CREAM BASE 322 HW EMBRACE TALK BLOOD BANDAGES ADVANCED HRT CREAM BASE GLUCOSE TEST STRIPS 150 ANTIBACTERIAL 186 WOMEN 322 HY-VEE LANCETS 205 HM GLUCOSAMINE HRT ESSENTIAL CHONDROITIN COMPLEX 273 CREAM 322 HY-VEE THIN LANCETS 205 HM IODIDES TINCTURE 65 HRT HEAVY 322 HYALUCIL-4 127 HM IODINE TINCTURE 65 HRT NATURAL LOTION 322 HYALURONATE SODIUM 90 HM ISOPROPYL RUBBING HUMALOG 36 HYALURONIC ACID ALCOHOL 107 HYDROLYZED 90 HUMALOG JUNIOR HYALURONIC ACID HM ISOPRPYL RUBBING KWIKPEN 36 SODIUM 90 ALCOHOL 107 HUMALOG KWIKPEN 36 HM NON-STICK PADS 3" X HYALURONIC ACID SODIUM 4" 186 HUMALOG MIX 50/50 36 SALT 90 HM STERILE ALCOHOL PREP HUMALOG MIX 50/50 HYALURONIC ACID PADS 226 KWIKPEN 36 SODIUM/NIACINAMIDE/TACRO HM STERILE PADS 186 HUMALOG MIX 75/25 36 LIMUS 135

Index 51 HYALURONIC ACID hydrocortisone valerate 133 HYDROMORPHONE SODIUM/NIACINAMIDE/TRETIN hydrocortisone w/acetic HYDROCHLORIDE/SODIUM OIN 121 acid 302 CHLORIDE 10 HYALURONIDASE 90 HYDROCORTISONE/IODOQUI HYDROMORPHONE/SODIUM HYCAMTIN 61 NOL/KETOCONAZOLE 126 CHLORIDE 10 HYDROPHILIC 322 HYCLODEX 140 HYDROCORTISONE/KETOCO NAZOLE 126 HYDROQUINONE 141 HYCODAN 118 HYDROFERA BLUE FOAM HYDROUS EMULSIFIED hydralazine hcl 50 DRESSING 2"X2" 143 BASE 322 HYDRALAZINE HCL 90 HYDROFERA BLUE FOAM HYDROXOCOBALAMIN 90 DRESSING 4"X4" 143 HYDRAZINE SULFATE 90 HYDROFERA BLUE FOAM hydroxocobalamin acetate 167 HYDREA 59 DRESSING 6"X6" 143 HYDROXOCOBALAMIN HYDRO 35 134 HYDROFERA BLUE FOAM HYDROCHLORIDE 90 HYDROXYAMPHETAMINE HYDRO 40 FOAM 134 DRESSING/MOISTURE RETENTIVE FILM/2- HYDROBROMIDE 90 HYDROCELL ADHESIVE 1/4X8 144 hydroxychloroquine sulfate 51 DRESSING 4"X4" 186 HYDROFERA BLUE FOAM HYDROXYCHLOROQUINE HYDROCELL ADHESIVE DRESSING/MOISTURE DRESSING 6"X6" 186 SULFATE 90 RETENTIVE FILM/4"X4" 144 HYDROXYETHYL HYDROCELL DRESSING HYDROFERA BLUE FOAM 4"X4" 187 CELLULOSE 90 HYDROCELL DRESSING DRESSING/MOISTURE HYDROXYETHYL CELLULOSE RETENTIVE 6"X6" 187 100 CPS 90 FILM/ISLAND 144 HYDROXYETHYL CELLULOSE HYDROCHLORIC ACID 77 HYDROFERA BLUE FOAM 4500-6500 CPS 90 hydrochlorothiazide 154 DRESSING/MOISTURE HYDROXYETHYL CELLULOSE HYDROCHLOROTHIAZIDE RETENTIVE/OSTOMY/2.5" 5000 CPS 90 154 144 HYDROXYETHYL hydrochlorothiazide 154 HYDROFERA BLUE FOAM METHACRYLATE 90 hydrocodone bitartrate 10 DRESSING/TUNNELING/9MM HYDROXYPROGESTERONE 144 CAPROATE 90 HYDROCODONE HYDROFERA BLUE HEAVY hydroxyprogesterone BITARTRATE 90 DRAINAGE 4"X4" 144 caproate 326 hydrocodone polistirex- HYDROFERA BLUE HEAVY hydroxyprogesterone caproate chlorpheniramine polistirex 118 DRAINAGE 6"X6" 144 (antineoplastic) 56 hydrocodone w/ HYDROFERA BLUE READY HYDROXYPROPYL homatropine 118 CELLULOSE 90 hydrocodone- FOAMDRESSING 2.5"X2.5" 144 HYDROXYPROPYL acetaminophen 13 HYDROFERA BLUE READY CELLULOSE 150-400 CPS 90 hydrocodone-ibuprofen 13 FOAMDRESSING 4"X5" 144 HYDROXYPROPYL hydrocortisone 115 HYDROFERA BLUE READY CELLULOSE 1500 CPS 90 HYDROCORTISONE 133 FOAMDRESSING 8"X8" 144 HYDROXYPROPYL HYDROFLUORIC ACID 90 CELLULOSE 1500-3000 hydrocortisone (intrarectal) 16 CPS 90 hydrocortisone (rectal) 16 HYDROGEL 144 HYDROXYPROPYL hydrocortisone (topical) 132 hydrogen peroxide 65 CELLULOSE 4000-6500 HYDROCORTISONE hydromorphone hcl 10 CPS 90 ACETATE 132 HYDROMORPHONE HCL 10 HYDROXYPROPYL CELLULOSE 75-100 CPS 90 HYDROCORTISONE ACETATE hydromorphone hcl 10 MICRONIZED 132 HYDROXYPROPYL HYDROMORPHONE HCL 10 hydrocortisone butyrate 132 METHYLCELLULOSE 90 hydromorphone hcl 10 HYDROXYPROPYL-BETA- hydrocortisone butyrate CYCLODEXTRIN 90 hydrophilic lipo base 132 HYDROMORPHONE HCL/SODIUMCHLORIDE 10 HYDROXYQUINOLINE HYDROCORTISONE SULFATE 96 HEMISUCCINATE HYDROMORPHONE MONOHYDRATE 90 HYDROCHLORIDE 10 HYDROXYTRYPTOPHAN 110 HYDROCORTISONE HYDROMORPHONE HYDROXYTRYPTOPHAN L- MICRONIZED 133 HYDROCHLORIDE/ SODIUM 5 110 CHLORIDE 10

Index 52 hydroxyurea 59 icatibant acetate 166 IMMUNERX 287 HYDROXYUREA 90 ICHTHAMMOL 140 IMMUNICARE 287 hydroxyzine hcl 20,21 ICLUSIG 58 IMOGAM RABIES-HT 303 HYDROXYZINE HCL 91 icosapent ethyl 44 IMOVAX RABIES hydroxyzine pamoate 21 ICY HOT LIDOCAINE PLUS (H.D.C.V.) 338 IMPAVIDO 17 HYDROXYZINE PAMOATE 21 MENTHOL 137 ICY HOT MAX IMPEKLO 133 HYLAGUARD 139 LIDOCAINE 137 IMPOYZ 133 HYLAMIX 139 IDAMYCIN PFS 57 IMURAN 272 HYLATOPIC PLUS 139 idarubicin hcl 57 IMVEXXY MAINTENANCE HYLAZINC 278 IDEBENONE 91 PACK 339 HYLENEX 271 IDELVION 165 IMVEXXY STARTER HYLINATE 135 IDHIFA 58 PACK 339 IN TOUCH 205 HYOSCYAMINE SULFATE 334 IDOXURIDINE 91 IN TOUCH BLOOD GLUCOSE hyoscyamine sulfate 334 IFEX 52 TEST STRIPS 150 HYPER-SAL 119 ifosfamide 52 IN TOUCH GLUCOSE HYPERHEP B 303 IFOSFAMIDE 52 CONTROLSOLUTION 205 HYPERRAB 303 IGLUCOSE BLOOD GLUCOSE IN TOUCH LANCING DEVICE 205 HYPERRAB S/D 303 MOITORING SYSTEM 205 IGLUCOSE BLOOD GLUCOSE IN TOUCH STERILE HYPERRHO S/D 303 TEST STRIPS 150 LANCETS30G 205 HYPERRHO S/D MINI- ILARIS 4 INBRIJA 62 DOSE 303 ILEVRO 301 INCRELEX 156 HYPERSAL 119 INCRUSE ELLIPTA 22 HYPERTET S/D 303 ILIDERM 139 ILUMYA 128 indapamide 154 HYPOCYN 140 INDERAL LA 71 HYPROMELLOSE 100000 MPA- ILUVIEN 299 S 91 imatinib mesylate 58 INDERAL XL 71 HYPROMELLOSE IMBRUVICA 58 INDOCIN 5 100000CPS 91 IMDEVIMAB 303 INDOCYANINE GREEN 91 HYPROMELLOSE 4000 MPA- INDOLE-3-CARBINOL 91 S 91 IMFINZI 54 HYPROMELLOSE 4000CPS91 IMIDUREA 91 indomethacin 5 HYPROMELLOSE METHOCEL IMIOXIA 126 INDOMETHACIN 5 K100M 91 imipenem-cilastatin 17 indomethacin sodium 5 HYPROMELLOSE TYPE IMIPRAMINE HCL 33 INFANRIX 333 2910 91 INFANT DRINKING HYQVIA 303 imipramine hcl 33 WATER 316 HYRONAN 289 imipramine pamoate 33 INFASURF 330 HYSINGLA ER 10 IMIQUIMOD 91 INFED 170 HYZAAR 49 imiquimod 135 INFINITY BLOOD GLUCOSE ibandronate sodium 154 IMIQUIMOD/LEVOCETIRIZINE MONITORING SYSTEM 205 DIHYDROCHLORIDE/NIACINA INFINITY BLOOD GLUCOSE IBRANCE 58 MIDE 127 MONITORING IBU 600-EZS 5 IMIQUIMOD/LEVOCETIRIZINE SYSTEM/STARTER KIT 205 IBUPAK 5 DIHYDROCHLORIDE/TRETIN INFINITY BLOOD GLUCOSE IBUPROFEN 5 OIN 127 TEST STRIPS 150 IMITREX 265 INFINITY CONTROL SOLUTION ibuprofen 5 IMITREX STATDOSE HIGH 205 ibuprofen lysine 5 REFILL 265 INFINITY CONTROL SOLUTION ibuprofen-famotidine 5 IMITREX STATDOSE LOW 205 SYSTEM 265 INFINITY CONTROL SOLUTION ibutilide fumarate 22 NORMAL 205 ICAR-C PLUS 169 IMLYGIC 61

Index 53 INFINITY VOICE 150 INSULIN SYRINGE/0.5ML/28G INSULIN INFINITY VOICE LEVEL 2 205 X 1/2" 243 SYRINGES/0.5ML/31GX5/16" INSULIN SYRINGE/0.5ML/30G 244 INFLAMMATION REDUCTION X 1/2" 243 INSULIN PACK 5 INSULIN SYRINGE/0.5ML/30G SYRINGES/1ML/27GX/1/2" INFLATHERM 5 X 5/16" 243 244 INFLECTRA 161 INSULIN SYRINGE/0.5ML/31G INSULIN INFUGEM 53 X 5/16" 243 SYRINGES/1ML/27GX1/2" 244 INSULIN SYRINGE/1ML/28G X INSULIN INFUMORPH 200 10 1/2" 243 SYRINGES/1ML/28GX1/2" 244 INFUMORPH 500 10 INSULIN SYRINGE/1ML/29G X INSULIN INFUVITE ADULT 280 1/2" 243 SYRINGES/1ML/29GX1/2" 244 INFUVITE PEDIATRIC 282 INSULIN SYRINGE/1ML/30G X INSULIN 5/16" 243 SYRINGES/1ML/30GX1/2" 244 INGREZZA 328 INSULIN SYRINGE/NEEDLE INSULIN INJECTAFER 170 0.3ML/30G X 5/16" 243 SYRINGES/1ML/31GX5/16" INLYTA 54 INSULIN SYRINGE/NEEDLE 244 0.3ML/31G X 5/16" 243 INSUPEN 29G X 12MM 244 INNOPRAN XL 71 INSULIN SYRINGE/NEEDLE INOSITOL 91 0.5ML/29G X 1/2" 243 INSUPEN 31G X 5MM 244 INOSITOL INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 244 HEXANICOTINATE 91 0.5ML/30G X 5/16" 244 INSUPEN 32G X 4MM 244 INOVA 121 INSULIN SYRINGE/NEEDLE INSUPEN 33GX4MM 244 0.5ML/31G X 5/16" 244 INOVA 4/1 ACNE CONTROL INSUPEN PEN NEEDLES 32G THERAPY 121 INSULIN SYRINGE/NEEDLE 1ML/29G X 1/2" 244 X4MM 244 INOVA 8/2 ACNE CONTROL INSUPEN SENSITIVE THERAPY 121 INSULIN SYRINGE/NEEDLE 1ML/30G X 5/16" 244 32GX6MM 244 INQOVI 57 INSULIN SYRINGE/NEEDLE INSUPEN SENSITIVE INREBIC 58 1ML/31G X 5/16" 244 32GX8MM 244 INSUPEN ULTRAFIN INSPRA 50 INSULIN SYRINGE/U- 100/0.3ML/29G X 1/2" 244 29GX12MM 244 INSULIN ASPART PENFILL 36 INSUPEN ULTRAFIN INSULIN ASPART INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 244 30GX8MM 244 PROTAMINE/INSULIN INSULIN SYRINGE/U- INSUPEN ULTRAFIN ASPART 36 100/1ML/29G X 1/2" 244 31GX6MM 245 INSULIN ASPART INSULIN SYRINGE/U- INSUPEN ULTRAFIN PROTAMINE/INSULIN ASPART 100/1ML/30G X 5/16" 244 31GX8MM 245 FLEXPEN 36 INSULIN SYRINGE/U- INTEGRA F 169 INSULIN LISPRO 36 100/1ML/31G X 5/16" 244 INTEGRA PLUS 169 INSULIN LISPRO JUNIOR INSULIN SYRINGES INTELENCE 67 KWIKPEN 36 0.3ML/31G X 1/4" 244 INSULIN LISPRO KWIKPEN 36 INSULIN SYRINGES INTERMEZZO 171 INSULIN LISPRO 0.5ML/31G X 1/4" 244 INTRALIPID 292 PROTAMINE/INSULIN LISPRO INSULIN INTRAROSA 338 KWIKPEN 36 SYRINGES/0.5ML/27GX1/2" INTRASITE GEL INSULIN SYRINGE 1ML/31G 244 APPLIPAK 144 X1/4" 243 INSULIN INTRON A 59 INSULIN SYRINGE/0.3ML/29G X SYRINGES/0.5ML/28GX1/2" 1" 243 244 INTUNIV 2 INSULIN SYRINGE/0.3ML/29G X INSULIN INULOSE BLOOD SUGAR 1/2" 243 SYRINGES/0.5ML/29GX1/2" SUPPORT 287 INSULIN SYRINGE/0.3ML/30G X 244 INVANZ 17 5/16" 243 INSULIN INVEGA 63 INSULIN SYRINGE/0.3ML/31G X SYRINGES/0.5ML/30GX5/16" INVEGA SUSTENNA 63 5/16" 243 244 INSULIN SYRINGE/0.5ML/27G X INSULIN INVEGA TRINZA 63 1/2" 243 SYRINGES/0.5ML/31GX INVELTYS 299 5/16" 244 INVIRASE 67

Index 54 INVOKAMET 34 ISOLYTE-S PH 7.4 267 J & J GAUZE 4"X4" 12 PLY187 INVOKAMET XR 34 ISOMETHEPTENE J & J GAUZE 4"X4" 8 PLY 187 INVOKANA 37 MUCATE 91 J & J GAUZE SPONGES 12-PLY ISONIAZID 52 IODINE 91 4" X 4" 187 isoniazid 52 J & J GAUZE SPONGES 16-PLY IODINE RESUBLIMED 91 ISOPROPAMIDE IODIDE334 4" X 4" 187 IODINE STRONG 91 J & J GAUZE SPONGES 8- ISOPROPANOL 107 iodine strong (lugol's) 268 PLY4" X 4" 187 ISOPROPYL ALCOHOL 107 J & J NON-STICK PADS iodine strong (lugol's) (bulk) 91 isopropyl alcohol 107 100LARGE 187 IODINE TINCTURE 65 ISOPROPYL ALCOHOL JADENU 39 IODINE TINCTURE MILD 65 WIPES 141 JADENU SPRINKLE 39 IODOFORM 110 ISOPROPYL MYRISTATE 91 JAKAFI 58 IODOQUINOL 3 ISOPROPYL JALYN 164 PALMITATE 107 IONOSOL-MB/DEXTROSE JANUMET 34 5% 267 isoproterenol hcl 25 JANUMET XR 34 IONSYS 10 ISOPROTERENOL HCL 91 IOPANOIC ACID 91 ISOPROTERENOL JANUVIA 35 IOPIDINE 297 HYDROCHLORIDE/SODIUM JARDIANCE 37 CHLORIDE 25 IPAMORELIN ACETATE 155 JASMINE FRAGRANCE 91 ISOPTO ATROPINE 296 IPOL INACTIVATED IPV 338 JATENZO 15 ISOPTO CARPINE 296 IPRATROPIUM BROMIDE 22 JELENE 322 ISORDIL TITRADOSE 20 ipratropium bromide 22 JELMYTO 57 ISOSORBIDE 91 ipratropium bromide (nasal)290 JEMPERLI 54 isosorbide dinitrate 20 IPRATROPIUM BROMIDE JENLIVA MONOHYDRATE 22 isosorbide mononitrate 20 PRENATAL/POSTNATAL 283 ipratropium-albuterol 25 ISOTRETINOIN 91 JENTADUETO 34 irbesartan 47 isotretinoin 121,122 JENTADUETO XR 34 irbesartan-hydrochlorothiazide ISOXSUPRINE HCL 91 JETREA 301 49 isradipine 73 JEVTANA 61 IRESSA 55 ISTALOL 295 JIVI 165 irinotecan hcl 61 ISTODAX (OVERFILL) 58 JOBST IT STAYS/ROLL- ON 139 iron combinations 169 ISTURISA 154 iron polysaccharide complex-vit JOJOBA OIL 91 b12-folic acid 169 ISUPREL 25 JORNAY PM 2 iron w/ vitamins 277 ITHOXIA 122 JTT PHYSICIANS KIT 115 iron-docusate-b12-folic acid-vit c- itraconazole 42 JUBLIA 126 vit e-copper-biotin 169 ITRACONAZOLE 91 JULUCA 67 iron-folic acid-vitamin c-vitamin ivermectin 16 b6-vitamin b12-zinc 169 JUNIPER TAR 107 iron-vitamin c-vitamin b12-folic IVERMECTIN 141,142 JUXTAPID 46 acid 169 ivermectin (pediculicide) 141 JYNARQUE 158 IROSPAN 24/6 169 ivermectin (rosacea) 141 K-PHOS 269 irrigation solutions, IVERMECTIN/METRONIDAZO physiological 272 LE/NIACINAMIDE 141 K-PHOS NEUTRAL 269 IS 24/6 169 IXEMPRA KIT 61 K-PHOS NO 2 163 ISENTRESS 67 IXIARO 338 K-TAB 269 ISENTRESS HD 67 IXINITY 165 K.B.G.L. IN TERODERM CREAM 124 isoflurane 163 J & J ADHESIVE LARGE 187 KABIVEN 292 ISOLYTE-P/DEXTROSE J & J GAUZE 2"X2" 8 5% 267 PLY 187 KADCYLA 54 ISOLYTE-S 268 KADIAN 10

Index 55 KAHLUA FLAVOR 307 KENDALL HYDROGEL KERLIX AMD KALBITOR 166 IMPREGNATED GAUZE ANTIMICROBIALSUPER 4"X8" 144 SPONGES 187 KALETRA 67 KENDALL HYDROGEL KERLIX BANDAGE ROLL 2- KALYDECO 330 WOUND DRESSING 3" 1/4"X9' 6PLY 187 KAMDOY 139 DISK 144 KERLIX BANDAGE ROLL 3- KENDALL HYDROGEL 7/16"X3-3/16' 6PLY 187 KANAMYCIN SULFATE 91 WOUND DRESSING 4-3/4" KERLIX BANDAGE ROLL 4- KANJINTI 54 DISK 144 1/2"X4-1/8YD 6PLY 187 KANUMA 157 KENDALL HYDROPHILIC KERLIX BANDAGE ROLL 4- KAOLIN 39 FOAM DRESSING 4"X8" 187 1/2"X9.3' 8PLY 187 KENDALL HYDROPHILIC KERLIX BANDAGE ROLL/6 KAOLIN COLLOIDAL 39 FOAMDRESSING 2"X2" 187 PLY/MEDIUM 187 KAPSPARGO SPRINKLE 71 KENDALL HYDROPHILIC KERLIX GAUZE ROLL LARGE KAPVAY 2 FOAMDRESSING 4"X4" 187 4.5"X 4.1YD 6 PLY 187 KENDALL HYDROPHILIC KERLIX GAUZE ROLL KARAYA GUM 319 FOAMDRESSING 6"X6" 187 MEDIUM3.4"X3.6YD 6 PLY187 KARBINAL ER 43 KENDALL HYDROPHILIC KERLIX GAUZE ROLL SMALL KATERZIA 73 FOAMPLUS DRESSING 2.25"X 3YD 6 PLY 187 KAZANO 34 2"X2" 187 KERLIX SPONGES 4" X 4" 12 PLY 187 KCL 0.15%/D5W/NACL KENDALL ZINC CALCIUM ALGINATE DRESSING KERLIX SPONGES 4" X 4" 16 0.225% 268 PLY 187 KCL 0.3%/D5W/NACL 2"X2" 144 KENDALL ZINC CALCIUM KERLIX SUPER SPONGES 0.9% 268 ALGINATE DRESSING MEDIUM 6"X6-3/4" 187 KEDRAB 303 4"X4" 144 KERLIX SUPER SPONGES KEFLEX 76 KENDALL ZINC CALCIUM MEDIUM 6"X6.75" 187 KELARX 142 ALGINATE DRESSING KERLIX X-RAY DETECTABLE PACKING SPONGE 4- KENALOG 133 4"X8" 144 KENDALL ZINC CALCIUM 1/2"X22" 187 KENALOG-10 115 ALGINATE DRESSING ROPE KERLIX X-RAY DETECTABLE KENALOG-40 115 12" 144 SPONGES EXTRA LARGE 1- KENALOG-80 115 KEPIVANCE 60 5/8" 187 KENDALL ALGINATE KEPPRA 28 KERYDIN 126 HYDROCOLLOID DRESSING KEPPRA XR 28 KESIMPTA 328 4"X4" 144 KERAGEL 144 KETALAR 163 KENDALL ALGINATE KETAMINE HCL 92 HYDROCOLLOID DRESSING KERAGELT 144 4"X5" 144 KERALAC 134 ketamine hcl 163 KETAMINE KENDALL ALGINATE KERALYT 135 HYDROCOLLOID DRESSING HYDROCHLORIDE 163 6"X6" 144 KERALYT SCALP 136 KETAMINE KENDALL ALGINATE KERAMATRIX REPLICINE HYDROCHLORIDE/ROPIVACAI HYDROCOLLOID DRESSING 10CMX10CM 144 NE 6"X7" 144 KERAMATRIX REPLICINE HYDROCHLORIDE/KETOROLA KENDALL ALGINATE 5CMX5CM 145 C T 5 HYDROCOLLOID DRESSING KERASAL FUNGAL NAIL KETAMINE 8"X8" 144 RENEWAL 139 HYDROCHLORIDE/SODIUM KENDALL AMORPHOUS KERASAL MULTI-PURPOSE CHLORIDE 163 HYDROGEL WOUND NAIL REPAIR 139 ketoconazole 42 KERLIX AMD DRESSING 144 KETOCONAZOLE 110 KENDALL HYDROGEL ANTIMICROBIALBANDAGE IMPREGNATED GAUZE ROLL 4-1/2"X12.3YD 6 ketoconazole (topical) 126 2"X2" 144 PLY 187 KETODAN KIT 126 KENDALL HYDROGEL KERLIX AMD KETONE 150 ANTIMICROBIALBANDAGE IMPREGNATED GAUZE KETONE TEST STRIPS 150 4"X4" 144 ROLL/6 PLY/4.5"X4- 1/8YD 187 KETOPHENE RAPIDPAQ 124

Index 56 ketoprofen 5 KISQALI FEMARA 200 KROGER HEALTHPRO KETOPROFEN 92 DOSE 57 GLUCOSECONTROL KISQALI FEMARA 400 SOLUTION/HIGH/LOW 206 KETOPROFEN DOSE 57 KROGER HEALTHPRO MICRONIZED 92 KISQALI FEMARA 600 GLUCOSETEST STRIPS 150 KETOPROFEN ULTRA DOSE 57 KROGER HEALTHPRO TWIST MICRONIZED 92 KITABIS PAK 3 LANCETS/26G 206 KETOROCAINE-L 6 KIVIK 139 KROGER INSULIN KETOROCAINE-LM 6 SYRINGE/0.3ML/29G X KIWI FRAGRANCE 92 KETOROLAC 2% GEL 124 1/2" 245 KLARITY-A 297 KROGER INSULIN ketorolac tromethamine 6 KLARITY-B 299 SYRINGE/0.3ML/30G X KETOROLAC 5/16" 245 TROMETHAMINE 6 KLARITY-L 299 KROGER INSULIN ketorolac tromethamine 6 KLARON 122 SYRINGE/0.3ML/31G X KETOROLAC KLING FLUFF 187 5/16" 245 TROMETHAMINE 6 KLING FLUFF SPONGE KROGER INSULIN ketorolac tromethamine 6 6X6.75 187 SYRINGE/0.5ML/29G X KETOROLAC KLISYRI 127 1/2" 245 KROGER INSULIN TROMETHAMINE 92 KLONOPIN 27 ketorolac tromethamine SYRINGE/0.5ML/30G X (ophth) 301 KMART VALU PLUS INSULIN 5/16" 245 KETOROLAC SYRINGE/0.3ML/30G 245 KROGER INSULIN TROMETHAMINE/BUPIVACAIN KMART VALU PLUS INSULIN SYRINGE/0.5ML/31G X E SYRINGE/0.5ML/29G 245 5/16" 245 HYDROCHLORIDE/KETAMINE KMART VALU PLUS INSULIN KROGER INSULIN SYRINGE/0.5ML/30G 245 SYRINGE/1ML/29G X 1/2" 245 HY 6 KMART VALU PLUS INSULIN KETOSTIX 150 KROGER INSULIN SYRINGE/1ML/29G 245 SYRINGE/1ML/30G X KETOTIFEN FUMARATE 92 KMART VALU PLUS INSULIN 5/16" 245 KETOTIFEN HYDROGEN SYRINGE/1ML/30G 245 KROGER INSULIN FUMARATE 92 KOATE 165 SYRINGE/1ML/31G X KEVEYIS 153 KOATE-DVI 165 5/16" 245 KEVZARA 4 KOGENATE FS 165 KROGER LANCETS 206 KEYTRUDA 54 KOJIC ACID 110 KROGER LANCETS 21G 206 KHAPZORY 60 KOMBIGLYZE XR 34 KROGER LANCETS MICRO KHEDEZLA 33 THIN33G 206 KORLYM 35 KROGER LANCETS SUPER KIMYRSA 18 KOSELUGO 58 THIN 206 KINERET 4 KOSHER PRENATAL PLUS KROGER LANCETS THIN 206 KINETIN 92 IRON 283 KROGER LANCETS THIN KINNEY LANCETS 205 KOVALTRY 165 26G 206 KRINTAFEL 51 KROGER LANCETS KINNEY THIN LANCETS 205 ULTRATHIN30G 206 KINRAY INSULIN SYRINGE KRIS-ESTER 236 322 KROGER LANCING PREFERRED PLUS/0.3ML/31G KRISGEL 100 322 DEVICE 206 X 5/16" 245 KRISTALOSE 173 KROGER PEN NEEDLES 29G KINRAY INSULIN SYRINGE KROGER AUTOLET LANCING X12MM 245 PREFERRED PLUS/0.5ML/31G DEVICE 205 KROGER PEN NEEDLES 31G X 5/16" 245 KROGER BLOOD GLUCOSE X8MM 245 KINRAY INSULIN SYRINGE MONITORING KIT 206 KROGER PEN NEEDLES PREFERRED PLUS/1ML/31G X KROGER BLOOD GLUCOSE 31GX1/4" 245 5/16" 245 TESTSTRIPS 150 KROGER PEN NEEDLES/31G KINRAY INSULIN KROGER HEALTHPRO X1/4" 245 SYRINGE/0.5ML/29G X BLOOD GLUCOSE KROGER PEN NEEDLES/31G 1/2" 245 MONITORING SYSTEM 206 X3/16" 245 KINRIX 333 KROGER PEN NEEDLES/31G KISQALI 58 X5/16" 245

Index 57 KROGER PEN NEEDLES/32G L-LEUCINE 294 LACTOSE X5/32" 245 L-LYSINE HCL 92 MONOHYDRATE 319 KROGER PEN NEEDLES/33G LACTOSE MONOHYDRATE X5/32" 245 L-LYSINE SPRAYDRIED 319 KROGER PREMIUM BLOOD HYDROCHLORIDE 294 L-LYSINE LACTULOSE 173 GLUCOSE MONITORING lactulose 173 KIT 206 MONOHYDROCHLORIDE 92 KROGER PREMIUM BLOOD L-MENTHOL 110 lactulose (encephalopathy) 162 GLUCOSE TEST STRIPS 150 L-METHIONINE 294 LAMICTAL 28 KROGER TEST STRIPS 150 L-METHYLFOLATE LAMICTAL CHEWABLE KRYSTEXXA 165 CALCIUM 92 DISPERSIBLE 28 L-ORNITHINE KUDZU ROOT 92 LAMICTAL ODT 28 HYDROCHLORIDE 96 LAMICTAL STARTER/NOT KUVAN 157 L-PHENYLALANINE 294 TAKING CARBAMAZEPINE 28 KYLEENA 113 L-PROLINE 295 LAMICTAL STARTER/TAKING KYMRIAH 55 L-SELENOMETHIONINE 92 CARBAMAZEPINE/NOT TAKING KYNMOBI 62 VALPROATE 28 L-SELENOMETHIONINE LAMICTAL STARTER/TAKING KYPROLIS 58 BLEND 92 VALPROATE 28 L-5- L-SERINE 100 LAMICTAL XR 28,29 METHYLTETRAHYDROFOLICA L-THREONINE 295 lamivudine 67 CID CALCIUM 92 L-TRYPTOPHAN 295 L-ALANINE 294 lamivudine (hbv) 69 L-TYROSINE 295 L-ARGININE 294 lamivudine-zidovudine 67 L-VALINE 295 L-ARGININE BASE 294 lamotrigine 29 L.E.T. 137 L-ARGININE HCL 80 LAMOTRIGINE 92 labetalol hcl 70 L-ARGININE LAMPIT 17 HYDROCHLORIDE 294 LABETALOL HCL 92 LANCET DEVICE L-ASPARAGINE LABETALOL ADJUSTABLE 206 MONOHYDRATE 106 HYDROCHLORIDE 70 LANCET DEVICE WITH L-ASPARTIC ACID 110 LABETALOL EJECTOR 206 L-ASPARTIC ACID SODIUM HYDROCHLORIDE/DEXTROS LANCETS 206 MONOHYDRATE 100 E 70 LANCETS 26G TWIST L-ASPARTIC ACID SODIUM LABETALOL TOP 206 SALT 100 HYDROCHLORIDE/SODIUM CHLORIDE 70 LANCETS 28G 206 L-CARNITINE 92 LAC-HYDRIN 135 LANCETS 30G 206 L-CARNOSINE 85 LAC-HYDRIN TWELVE 135 LANCETS 30G TWIST L-CITRULLINE 85 TOP 206 LACRISERT 295 L-CYSTEINE 85 LANCETS 30G/TWIST LACTASE 5000 92 TOP 206 L-CYSTEINE HCL LANCETS 31G TWIST MONOHYDRATE 85 lactated ringer's 268 lactated ringer's TOP 206 L-CYSTINE 294 LANCETS 33G EXTRA (irrigation) 272 L-GLUTAMIC ACID 294 FINE 206 LACTIC ACID 77,135 L-GLUTAMIC ACID HCL 153 LANCETS 33G UNIVERSAL lactic acid (ammonium DESIGN 206 L-GLUTAMIC ACID lactate) 135 LANCETS MICRO THIN MONOSODIUM 93 LACTIC ACID E 135 33G 206 L-GLUTAMINE 294 LACTIC ACID RACEMIC 77 LANCETS SAFETY SEAL L-HISTIDINE 294 LACTIC 21G 206 L-HISTIDINE ACID/NIACINAMIDE 141 LANCETS SAFETY SEAL MONOHYDROCHLORIDE 294 lactobacillus 38 26G 206 L-HISTIDINE LANCETS SAFETY SEAL MONOHYDROCHLORIDE LACTOSE 319 28G 206 MONOHYDRATE 294 LACTOSE ANHYDROUS 319 LANCETS SAFETY SEAL L-ISOLEUCINE 294 LACTOSE HYDROUS 319 30G 206

Index 58 LANCETS SUPER THIN LEADER ADVANCED LEMON EXTRACT 307 28G 206 LANCING DEVICE 206 LEMON FLAVOR 307 LANCETS THIN 206 LEADER INSULIN LEMONADE FLAVOR 307 LANCETS TWIST TOP 206 SYRINGE/0.3ML/29G X 1/2" 245 LEMTRADA 328 LANCETS ULTRA FINE 206 LEADER INSULIN LENVIMA 10 MG DAILY LANCETS ULTRA THIN 206 SYRINGE/0.3ML/30G X DOSE 54 LANCETS ULTRA THIN 5/16" 245 LENVIMA 12MG DAILY 30G 206 LEADER INSULIN DOSE 54 LANCETSBULLSEYE SYRINGE/0.3ML/31G X LENVIMA 14 MG DAILY SAFETY 206 5/16" 245 DOSE 54 LANCING DEVICE 206 LEADER INSULIN LENVIMA 18 MG DAILY LANCING DEVICE SYRINGE/0.5ML/28G X DOSE 54 ADJUSTABLE 206 1/2" 246 LENVIMA 20 MG DAILY LANOLIN 322 LEADER INSULIN DOSE 54 SYRINGE/0.5ML/29G X LENVIMA 24 MG DAILY lanolin 322 1/2" 246 DOSE 54 LANOLIN ALCOHOL 322 LEADER INSULIN LENVIMA 4 MG DAILY LANOLIN ANHYDROUS 322 SYRINGE/0.5ML/30G X DOSE 54 LANOLIN ANHYDROUS- 5/16" 246 LENVIMA 8 MG DAILY GRX 322 LEADER INSULIN DOSE 54 SYRINGE/0.5ML/31G X LANOXIN 73 LESCOL XL 45 5/16" 246 LETAIRIS 75 LANOXIN PEDIATRIC 73 LEADER INSULIN LANSOPRAZOLE 92 SYRINGE/1ML/28G X letrozole 56 lansoprazole 335 1/2" 246 LETROZOLE 92 LEADER INSULIN lanthanum carbonate 162 LETS KIT 173 SYRINGE/1ML/29G X LEUCINE 295 LANTUS 36 1/2" 246 LANTUS SOLOSTAR 36 LEADER INSULIN leucovorin calcium 60 LANZO 206 SYRINGE/1ML/30G X LEUCOVORIN CALCIUM 92 5/16" 246 LEUKERAN 52 lapatinib ditosylate 58 LEADER INSULIN LARTRUVO 56 SYRINGE/1ML/31G X LEUKINE 167 LASIX 153 5/16" 246 LEUKOSTRIP 1/2"X4" 187 LEADER UNIFINE PENTIPS LASTACAFT 301 LEUKOSTRIP 1/4"X3" 187 PLUS/MINI/31GX3/16" 246 LEUKOSTRIP 1/4"X4" 188 LATANOPROST 92 LEADER UNIFINE PENTIPS latanoprost 301 PLUS/SHORT/31GX5/16" LEUKOSTRIP 1/8"X1-1/2" 188 LATUDA 63 246 leuprolide acetate 56 LEADER UNIFINE LAURETH-9 LEUPROLIDE ACETATE 92 PENTIPS/MINI/31GX3/16" LEUPROLIDE POLIDOCANOL 92 246 LAURIC ACID 92 ACETATE/BUPIVACAINE LEADER UNIFINE HYDROCHLORIDE 56 LAVARE WOUND WASH 145 PENTIPS/NANO/32GX5/32" levalbuterol hcl 25 LAVENDER OIL 107 246 LEVALBUTEROL HCL 92 LAVENDER OIL LEADER UNIFINE FRAGRANCE 107 PENTIPS/PLUS/32GX5/32" levalbuterol tartrate 25 LAVENDER OIL NATURAL 107 246 LEVAMISOLE HCL 56 100 LECITHIN LEVAQUIN 160 LAXATIVE FORMULA 273 LECITHIN ISOPROPYL LAZANDA 10 PALMITATE 319 LEVATIO PATCH 137 LDO PLUS 137 LECITHIN ORGANOGEL 322 LEVBID 334 LDR BLOOD GLUCOSE LECITHIN SOYA 100 LEVEMIR 36 TRUETEST KIT 206 LEDIPASVIR/SOFOSBUVIR LEVEMIR FLEXTOUCH 36 LEAD ACETATE 69 LEVETIRACETAM 29 TRIHYDRATE 110 leflunomide 7 LEAD TETROXIDE 92 levetiracetam 29 LEFLUNOMIDE 92

Index 59 LEVETIRACETAM 92 LIALDA 161 LIDOCAINE levetiracetam in sodium LIBERTY BLOOD GLUCOSE HYDROCHLORIDE/EPINEPHRI chloride 29 METER 206 NE 298 LEVICYN 139 LIBERTY CONTROL LIDOCAINE HYDROCHLORIDE/EPINEPHRI LEVICYN DERMAL SOLUTION HIGH 207 SPRAY 145 LIBERTY CONTROL NE/TETRACAINE HYDROCHLORIDE 137 LEVIGOLT 137 SOLUTIONNORMAL 207 LIBERTY GLUCOSE LIDOCAINE levobunolol hcl 295 CONTROL MID 207 HYDROCHLORIDE/PHENYLEP LEVOCARNITINE 92 LIBERTY GLUCOSE HRINE HYDROCHLORIDE 298 levocarnitine (metabolic CONTROL NORMAL 207 LIDOCAINE modifiers) 157 LIBERTY MEDICAL LANCETS HYDROCHLORIDE/SODIUM levocetirizine dihydrochloride43 30G 207 BICARBONATE 173 LIBERTY MINI LANCING LIDOCAINE LEVOCETIRIZINE HYDROCHLORIDE/SODIUM DIHYDROCHLORIDE 92 DEVICE 207 LIBERTY NEXT GENERATION CHLORIDE 173 LEVODOPA 62 BLOOD GLUCOSE lidocaine in d5w 22 levofloxacin 160 MONITOR 207 lidocaine w/ epinephrine 173 levofloxacin (ophth) 297 LIBERTY NEXT GENERATION lidocaine-hydrocortisone LEVOFLOXACIN BLOOD GLUCOSE TEST acetate 133 HEMIHYDRATE 92 STRIPS 150 lidocaine-hydrocortisone acetate levofloxacin in d5w 160 LIBERTY TEST STRIPS 150 (rectal) 16 levoleucovorin calcium 60 LIBRAX 334 lidocaine-menthol 137 LEVOMEFOLATE CALCIUM92 LIBTAYO 54 lidocaine-prilocaine 137 levonorgestrel & eth LICART 124 LIDOCAINE-PRILOCAINE- estradiol 112 LICORICE CREAM BASE 322 levonorgestrel (emergency DEGLYCYRRHIZINATED 93 lidocaine-transparent oc) 113 LICORICE FLAVOR 307 dressing 137 levonorgestrel-eth estradiol LICORICE ROOT 110 LIDOCAINE/TETRACAINE 137 (triphasic) 112 LIDOCIDEX I 115 levonorgestrel-ethinyl estradiol LIDO GB-300 329 (91-day) 112 LIDOCAINE 16,93 LIDOCILONE I 115 levonorgestrel-ethinyl estradiol lidocaine 137 LIDODERM 138 (continuous) 112 LIDOCAINE AND LIDODOSE 138 LEVOPHED 341 TETRACAINECREAM 137 LIDODOSE PEDIATRIC BULK levorphanol tartrate 10 LIDOCAINE BASE 93 PACK 138 LEVORPHANOL LIDOCAINE HCL 21,93 LIDOLOG KIT 115 TARTRATE 92 lidocaine hcl 137 LIDOMAR 173 LEVOTHYROXINE SODIUM 92 lidocaine hcl (cardiac) 21 LIDOMARK 1/5 175 levothyroxine sodium 332 lidocaine hcl (local LIDOMARK 2/5 175 LEVOTHYROXINE anesth.) 175 LIDOPIN 138 SODIUM 332 lidocaine hcl (mouth- LIDOPURE PATCH 138 levothyroxine sodium 332 throat) 275 LEVOTHYROXINE LIDOCAINE HCL LIDORX 138 SODIUM 332 MONOHYDRATE 93 LIDOSTREAM 138 levothyroxine sodium 332 LIDOCAINE HCL- LIDOTHOL 138 LEVOTHYROXINE SODIUM HYDROCORTISONE LIDOTIN 329 (T4) 92 ACETATE WITH ALOE 16 LIDOTRAL 138 LEVSIN 334 LIDOCAINE LIDOTREX 145 LEVSIN/SL 334 HCL/DEXTROSE 175 LIDOCAINE LIDOVEX 138 LEVULAN KERASTICK 127 HYDROCHLORIDE 137,175 LIDOVIX 6 LEXAPRO 32 LIDOCAINE LIDTOPIC MAX 138 LEXETTE 133 HYDROCHLORIDE/DEXTROS E 22 LIFEMS NALOXONE 40 LEXIVA 67

Index 60 LIFESCAN UNISTIK 2 DEEP LIPOTRIAD VISION LITETOUCH INSULIN PENETRATION 207 SUPPORTPLUS 287 SYRINGE/U-100/1ML/28G X LIFESCAN UNISTIK II LIPOTRIAD VISIONARY 287 1/2" 246 LANCETS 207 LIPOZYME 323 LITETOUCH INSULIN LILETTA 113 SYRINGE/U-100/1ML/29G X LIPRITIN 329 LIME FLAVOR 307 1/2" 246 LIPRITIN II 329 LITETOUCH INSULIN LIME OIL 107 LIQUIGEL COMPLEX 319 SYRINGE/U-100/1ML/30G X LIMONENE 93 LIQUIVIDA HYDRATION 5/16" 246 LINCOCIN 19 KIT 270 LITETOUCH INSULIN lincomycin hcl 19 lisinopril 47 SYRINGE/U-100/1ML/31G X 5/16" 247 LINCOMYCIN HCL 93 LISINOPRIL 93 LITETOUCH LANCETS MICRO lindane 142 lisinopril & THIN 33G 207 linezolid 19 hydrochlorothiazide 49 LITETOUCH PEN NEEDLES LISSAMINE GREEN B 306 29GX12.7MM 247 linezolid in sodium chloride 19 LITE TOUCH LANCETS 207 LITETOUCH PEN NEEDLES LINOLEIC ACID 93 LITE TOUCH LANCING 31G X 6MM 247 LITETOUCH PEN NEEDLES LINSEED OIL RAW 107 PEN 207 LINZESS 162 LITETOUCH INSULIN PEN 31G X 6MM/ULTRA NEEDLES/32G X SHORT 247 LIORESAL INTRATHECAL 288 LITETOUCH PEN NEEDLES 4MM/MINI 246 LIOTHYRONINE 93 31GX8MM SHORT 247 LITETOUCH INSULIN LITETOUCH PEN LIOTHYRONINE SODIUM 93 SYRINGE/0.3ML/29G X NEEDLES/31G X 3/16" 247 liothyronine sodium 332 1/2" 246 LITETOUCH PEN LIOTHYRONINE SODIUM LITETOUCH INSULIN NEEDLES/31G X SYRINGE/0.3ML/30G X (T3) 93 5MM/MINI 247 LIP BALM BASE 322 5/16" 246 LITETOUCH PEN LITETOUCH INSULIN NEEDLES/31G X LIPACTIVE INCA INCHI WO 91 SYRINGE/0.3ML/31G X 8MM/SHORT 247 LIPIDSHIELD PLUS 287 5/16" 246 LITHIUM 63 LIPITOR 45 LITETOUCH INSULIN lithium carbonate 63 LIPMAX 319 SYRINGE/0.5ML/30G X 5/16" 246 LITHIUM CARBONATE 63 LIPO 292 LITETOUCH INSULIN lithium carbonate 63 LIPO CREAM BASE 323 SYRINGE/0.5ML/31G X LITHIUM CITRATE LIPO-B 169 5/16" 246 LITETOUCH INSULIN TETRAHYDRATE 93 LIPO-C 292 SYRINGE/1ML/30G X LITHOBID 63 LIPOBASE 323 5/16" 246 LITHOSTAT 164 LIPOCREAM BASE 323 LITETOUCH INSULIN LIVALO 45 LIPOFEN 45 SYRINGE/U-100/0.3ML/30G X LIVE BETTER ADVANCED 5/16" 246 LIPOFOAM RX 323 LANCING DEVICE 207 LITETOUCH INSULIN LIVE BETTER LANCET LIPOGEL CR BASE 323 SYRINGE/U-100/0.3ML/31G X SUPERTHIN 30G 207 LIPOIC ACID 80 5/16" 246 LIVE BETTER LANCET LIPOIC ACID/DL-ALPHA (DL- LITETOUCH INSULIN ULTRATHIN 28G 207 THIOCTIC ACID) 80 SYRINGE/U-100/0.5ML/28G X LIVER CONCENTRATE 307 1/2" 246 LIPOLAYER 323 LITETOUCH INSULIN LIVER FLAVOR 307 LIPOPEN ABSORPTION SYRINGE/U-100/0.5ML/29G X LMR PLUS 138 ENHANCING BASE 323 1/2" 246 LO LOESTRIN FE 112 LIPOPEN ANHYDROUS 323 LITETOUCH INSULIN LIPOPEN ULTRA BASE 323 SYRINGE/U-100/0.5ML/30G X LOCOID 133 LIPOSOMAL HEAVY 323 5/16" 246 LOCOID LIPOCREAM 133 LITETOUCH INSULIN LIPOSOMAL REGULAR 323 LOCUST BEAN GUM 85 SYRINGE/U-100/0.5ML/31G X LODINE 6 LIPOTRIAD VISION 5/16" 246 SUPPORT 287 LODOSYN 61

Index 61 LOKELMA 274 LOXORAL BASE 319 LYSTEDA 170 LOLLIBASE 319 LOYON 139 LYUMJEV 37 LOLLIPOP BASE 319 LOZIBASE 316 LYUMJEV KWIKPEN 36 LOMOTIL 39 LOZIBASE S 316 M-M-R II 338 LONGS INSULIN lubiprostone 161 M-NATAL PLUS 283 SYRINGE/0.5ML/31G X LUBRAJEL NP 323 M.V.I. ADULT 280 5/16" 247 LONGS LANCETS LUCEMYRA 327 M.V.I. PEDIATRIC 282 STANDARD 207 LUCENTIS 296 MACA ROOT 93 LONGS LANCETS THIN 207 LUGOLS STRONG MACADAMIA NUT OIL 107 LONGS LANCETS ULTRA IODINE 65 MACI 288 THIN 207 luliconazole 126 MACROBID 19 LONHALA MAGNAIR REFILL LUMAKRAS 58 KIT 22 MACRODANTIN 20 LUMIGAN 301 LONHALA MAGNAIR STARTER MACUGEN 296 LUMINEUX CLEAN/FRESH KIT 22 MAFENIDE ACETATE 93 LONSURF 57 TOOTHPASTE 227 LUMINEUX KIDS mafenide acetate 129 LOPERAMIDE HCL 39 TOOTHPASTE 227 MAGELLAN INSULIN SAFETY loperamide hcl 39 LUMINEUX SENSITIVITY SYRINGE/U-100/0.3ML/29G X LOPID 45 TOOTHPASTE 227 1/2" 247 LUMINEUX WHITENING lopinavir-ritonavir 67 MAGELLAN INSULIN SAFETY TOOTHPASTE 227 SYRINGE/U-100/0.3ML/30G X LOPRESSOR 71 LUMIZYME 157 5/16" 247 LOPRESSOR HCT 49 LUMOXITI 54 MAGELLAN INSULIN SAFETY LOPROX 126 LUNESTA 171 SYRINGE/U-100/0.5ML/29G X 1/2" 247 LOPROX KIT 126 LUPANETA PACK 156 MAGELLAN INSULIN SAFETY LOPROX SHAMPOO 126 LUPKYNIS 272 SYRINGE/U-100/0.5ML/30G X LORATADINE 93 LUPRON DEPOT (1- 5/16" 247 lorazepam 21 MONTH) 56 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X LORAZEPAM 93 LUPRON DEPOT (3- MONTH) 56 1/2" 247 LORBRENA 58 LUPRON DEPOT (4- MAGELLAN INSULIN SAFETY LORTAB 13 MONTH) 56 SYRINGE/U-100/1ML/30G X losartan potassium 47 LUPRON DEPOT (6- 5/16" 247 MONTH) 56 MAGNASWEET 110 80 LOSARTAN POTASSIUM 93 LUPRON DEPOT-PED (1- losartan potassium & MAGNASWEET 135 80 MONTH) 156 MAGNESIUM ALUMINUM hydrochlorothiazide 49 LUPRON DEPOT-PED (3- LOSEASONIQUE 112 SILICATE 93 MONTH) 156 MAGNESIUM AMINO ACID LOTEMAX 299 LUTATHERA 59 CHELLATE 20% 93 LOTEMAX SM 299 LUTEIN 93 MAGNESIUM ASCORBATE 93 LOTENSIN 47 LUXAMEND 145 MAGNESIUM BISGLYCINATE LOTENSIN HCT 49 LUXIQ 133 CHELATE 93 MAGNESIUM BISGLYCINATE loteprednol etabonate 299 LUXTURNA 298 DIHYDRATE 93 LOTREL 49 LUZU 126 MAGNESIUM CARBONATE LOTRIMIN ULTRA 126 LYDEXA 138 HEAVY 268 LOTRISONE 126 LYDIA PINKHAM 273 MAGNESIUM CARBONATE LIGHT 268 LOTRONEX 162 LYNPARZA 58 MAGNESIUM CHLORIDE 269 lovastatin 45 LYRICA 29 magnesium chloride 269 LOVAZA 44 LYRICA CR 329 MAGNESIUM CHLORIDE LOVENOX 26 LYSINE HCL 93 HEXAHYDRATE 268 loxapine succinate 64 LYSODREN 56 MAGNESIUM CITRATE 93

Index 62 MAGNESIUM CITRATE mannitol 153 MAXICOMFORT INSULIN TRIBASIC 93 MAPLE FLAVOR 308 SYRINGES 27G X 1/2" 247 MAGNESIUM GLUCONATE 93 MAXIDEX 299 maprotiline hcl 31 MAGNESIUM GLYCINATE 93 MAR-COF CG MAXIPIME 77 MAGNESIUM HYDROXIDE 93 EXPECTORANT 118 MAXITROL 299 MAGNESIUM MALATE 94 MARATHON MEDICAL MAXZIDE 153 MAGNESIUM OXIDE PENTIPS29GX12MM 247 MAXZIDE-25 153 MARATHON MEDICAL HEAVY 16 MAYZENT 328 MAGNESIUM OXIDE LIGHT 16 PENTIPS31GX5MM 247 MARATHON MEDICAL MAYZENT STARTER MAGNESIUM PHOSPHATE PENTIPS31GX8MM 247 PACK 328 DIBASIC TRIHYDRATE 94 MARATHON MEDICAL MB HYDROGEL 139 MAGNESIUM SALICYLATE 94 PENTIPS32GX4MM 247 MEBENDAZOLE 16 MAGNESIUM STEARATE 319 MARBETA-25 115 MECAMYLAMINE HCL 94 MAGNESIUM SULFATE 173 MARBETA-L 115 MECHLORETHAMINE HCL 94 magnesium sulfate 269 MARCAINE 175 MECLIZINE HCL 41 MAGNESIUM SULFATE 269 MARCAINE SPINAL 175 meclizine hcl 41 magnesium sulfate 269 MARCAINE/EPINEPHRINE MECLIZINE HCL MAGNESIUM SULFATE 269 173 MONOHYDRATE 41 MAGNESIUM SULFATE MARDEX-25 115 meclofenamate sodium 6 HEPTAHYDRATE 173 MARGENZA 54 MECLOFENAMATE SODIUM 6 MAGNESIUM SULFATE IN MARINOL 41 D5W 269 MECLOFENOXATE magnesium sulfate in MARLIDO KIT 173 HYDROCHLORIDE 94 dextrose 269 MARLIDO-25 174 MEDI-DERM 136 MAGNESIUM MARNATAL-F 283 MEDI-DERM-RX 136 SULFATE/DEXTROSE 269 MARPLAN 31 MEDI-DERM/L 138 MAGNESIUM SULFATE/LACTATED MARQIBO 61 MEDI-DERM/L-RX 138 RINGERS 269 MARSHMALLOW ARTIFICIAL MEDI-PATCH RX 138 MAGNESIUM FLAVOR 308 MEDI-PATCH/LIDOCAINE 138 MARSHMALLOW SULFATE/SODIUMCHLORIDE MEDI-RDT BASE 319 269 FLAVOR 308 MAGNESIUM TRISILICATE 16 MARVONA SUIK 174 MEDI-RDT KIT 319 MAGNESIUM TRISILICATE MAS CARE-PAK 115 MEDI-RDT KIT (MULTIDOSE) 319 HYDRATE 16 MATULANE 60 MAKENA 326 MEDIBASE C 323 MAVENCLAD 328 MEDIC INSULIN MALARONE 50 MAVYRET 69 SYRINGE/0.3ML/30G X malathion 142 MAXALT 265 5/16" 247 MEDIC INSULIN MALEIC ACID 94 MAXALT-MLT 266 MALIC ACID 94 SYRINGE/0.5ML/30G X MAXFE 169 5/16" 247 MALTODEXTRIN 94 MAXI-COMFORT INSULIN MEDICHOICE PRE-SET MANDELIC ACID 94 SYRINGE/U- SAFETY LANCET DUAL manganese chloride 269 100/0.5ML/28GX1/2" 247 USE 207 MANGANESE CHLORIDE MAXI-COMFORT INSULIN MEDICHOICE PRE-SET TETRAHYDRATE 94 SYRINGE/U- SAFETY LANCET LOW 100/1ML/28GX1/2" 247 FLOW 207 MANGANESE GLUCONATE94 MAXI-COMFORT SAFETY MEDICHOICE PRE-SET MANGANESE SULFATE 94 PEN NEEDLE/29G X SAFETY LANCET MEDIUM manganese sulfate 269 3/16" 247 FLOW 207 MANGO FLAVOR 308 MAXI-COMFORT SAFETY MEDICHOICE PRE-SET PEN NEEDLE/29G X SAFETY LANCET MODERATE MANGO FLAVOR 5/16" 247 SWEETENED 308 FLOW 207 MAXICOMFORT II PEN MEDICHOICE SAFETY MANNITOL 110 NEEDLES/31G X 1/4" 247 LANCETEXTRA 207

Index 63 MEDICHOICE SAFETY MEDLANCE PLUS MEIJER LANCETS LANCETNORMAL 207 UNIVERSAL LANCETS UNIVERSAL30G 208 MEDICINE SHOPPE PEN 21G 208 MEIJER LANCETS NEEDLES 29G X 12MM 247 MEDLANCE PLUS/LITE UNIVERSAL33G 208 MEDICINE SHOPPE PEN 25G 208 MEIJER PEN NEEDLES 29G NEEDLES 31G X 6MM 247 MEDLANCE/EXTRA 208 X12MM 248 MEDICINE SHOPPE PEN MEDLANCE/LITE 208 MEIJER PEN NEEDLES 31G NEEDLES 31G X 8MM 248 X6MM 248 MEDICOOLS DIASOX 220 MEDLANCE/UNIVERSAL208 MEIJER PEN NEEDLES 31G MEDPURA ALCOHOL MEDIDERM 323 X8MM 248 PADS 141 MEIJER PREMIUM BLOOD MEDIHOL BASE 323 MEDROL 115 GLUCOSE MONITORING MEDIHONEY CALCIUM MEDROL DOSEPAK 115 KIT 208 ALGINATE DRESSING MEIJER PREMIUM BLOOD 4"X5" 145 MEDROLOAN II SUIK 115 GLUCOSE TEST STRIPS 150 MEDIHONEY CALCIUM MEDROLOAN SUIK 115 MEIJER SUPER THIN ALGINATE MEDROX-RX 136 LANCETS 208 DRESSING/2"X2" 145 MEDROXYPROGESTERONE MEIJER TRUE2GO BLOOD MEDIHONEY WOUND & BURN ACETATE 94 GLUCOSE MONITORING DRESSING 3/4"X12" 145 medroxyprogesterone SYSTEM 208 MEDIHONEY acetate 326 MEIJER TRUERESULT BLOOD WOUND/BURNDRESSING 145 medroxyprogesterone acetate GLUCOSE MONITORING MEDIHONEY (contraceptive) 113 SYSTEM 208 WOUND/BURNDRESSING MEDROXYPROGESTERONE MEIJER TRUETEST BLOOD 4"X5" 145 ACETATE MICRONIZED 94 GLUCOSE TEST STRIPS 150 MEDIPORE + PAD SOFT MEDROXYPROGESTERONE MEIJER TRUETRACK BLOOD CLOTH ADHESIVE WOUND ACETATE YAM 94 GLUCOSE MONITORING DRESSING 6"X6" 188 MEDROXYPROGESTERONE KIT 208 MEDISENSE GLUCOSE MICRONIZED 94 MEIJER TRUETRACK BLOOD KETONECONTROL SOLUTION mefenamic acid 6 GLUCOSE TEST STRIPS 150 1-LOW,1-MED,1 HIGH 207 MEKINIST 58 MEDISENSE GLUCOSE MEFENAMIC ACID 6 MEKTOVI 58 KETONECONTROL SOLUTION mefloquine hcl 51 MELATONIN 110 1-NORMAL 207 MEGACE ES 326 MEDISENSE HIGH/LOW meloxicam 6 MEGESTROL ACETATE 56 CONTROL SOLUTION 207 MELOXICAM 94 MEDISENSE HIGH/MID/LOW megestrol acetate 56 CONTROL SOLUTION 207 megestrol acetate melphalan 53 MEDISENSE MID CONTROL (appetite) 326 melphalan hcl 52 SOLUTION 207 MEGLUMINE 94 memantine hcl 327 MEDISENSE THIN MEIJER ALCOHOL SWABS MEMANTINE LANCETS 207 EXTRA-THICK 226 HYDROCHLORIDE 94 MEDIUM CHAIN MEIJER BLOOD GLUCOSE MEMBRANEBLUE 300 TRIGLYCERIDES 94 MONITORING KIT 208 MEDLANCE PLUS EXTRA MEMORY WORK/SPORT MEIJER BLOOD GLUCOSE INSOLES 220 LANCETS 21G 207 TESTSTRIPS 150 MEDLANCE PLUS MEIJER COLOR LANCETS MENACTRA 337 LANCETS 207 UNIVERSAL 33G 208 MENADIONE 94 MEDLANCE PLUS LANCETS MEIJER ESSENTIAL BLOOD MENADIONE SODIUM LITE 25G 207 GLUCOSE MONITORING BISULFITE 110 MEDLANCE PLUS LITE SYSTEM 208 MENEST 159 LANCETS 25G 207 MEIJER ESSENTIAL BLOOD MENOPUR 155 MEDLANCE PLUS SPECIAL GLUCOSE TEST LANCETS 0.8MM 207 STRIPS 150 MENOSTAR 159 MEDLANCE PLUS SUPERLITE MENQUADFI 337 30G 207 MEIJER LANCETS 208 MEDLANCE PLUS SUPERLITE MEIJER LANCETS THIN 208 MENTAX 126 30G/COMFORT MAX 207 MEIJER LANCETS MENTHOL 110 UNIVERSAL21G 208 MENTHOL-L 110

Index 64 MENVEO 337 METHADOSE SUGAR- METHYL ALCOHOL 107 MEPERIDINE HCL 10 FREE 11 METHYL FOLATE 94 methamphetamine hcl 1 meperidine hcl 10,11 METHYL METHACRYLATE METHANESULFONIC MEPHYTON 342 CROSSPOLYMER 94 ACID 94 METHYL SALICYLATE 136 MEPIVACAINE HCL 175 METHANOL 107 METHYL SULFONE 94 mepivacaine hcl 175 METHAZOLAMIDE 153 METHYL-GUARD 287 meprobamate 21 methazolamide 153 METHYL-GUARD PLUS 287 MEPRON 17 METHENAMINE 110 METHYLCELLULOSE 319 MEPSEVII 157 methenamine hippurate 20 METHYLCOBALAMIN 94,167 MEQUINOL 94 methenamine mandelate 20 methyldopa 48 mercaptopurine 53 METHENAMINE methyldopa & MERCAPTOPURINE 94 MANDELATE 110 methenamine-hyosc-methylene hydrochlorothiazide 49 MERCAPTOPURINE METHYLENE BLUE 110 MONOHYDRATE 94 blue-benzoic acid-phenyl sal 17 methylene blue (antidote) 40 meropenem 18 methenamine-hyosc-methylene METHYLENE BLUE MEROPENEM/SODIUM blue-sod phos-phenyl sal 17 TRIHYDRATE 110 CHLORIDE 18 methenamine-hyoscamine- METHYLENE CHLORIDE 94 MERREM 18 methylene blue-sodium methylergonovine maleate 302 mesalamine 161 phosphate 17 METHYLIN 2 MESALAMINE 161 METHIMAZOLE 332 methimazole 332 METHYLMETHACRYLATE mesalamine 161 CROSSPOLYMER (310) 94 mesalamine w/ cleanser 161 METHIONINE 295 METHYLPARABEN 305 mesna 60 METHIONINE/INOSITOL/CHO METHYLPARABEN LINE/CYANOCOBALAMIN MESNEX 60 SODIUM 305 169 methylphenidate hcl 2 MESTINON 51 METHITEST 15 MESTINON TIMESPAN 51 METHYLPHENIDATE HCL 94 METHOCARBAMOL 94 METHYLPHENIDATE METABO-STYLE 273 methocarbamol 288 HYDROCHLORIDE ER 2 METACRESOL ACETATE 94 METHOCEL E4M 91 METHYLPREDNISOLONE 116 METAPROTERENOL METHOCEL E4M methylprednisolone 116 SULFATE 25 PREMIUM 91 METHYLPREDNISOLONE METAXALL CP 289 METHOCEL E4M PREMIUM ACETATE 115,116 metaxalone 288 CR 91 METHOCEL K100 methylprednisolone acetate116 METER BUFFER PH 10 318 PREMIUM 91 METHYLPREDNISOLONE METER BUFFER PH 4 318 METHOCEL K100M ACETATE/BUPIVACAINE METER BUFFER PH 7 318 PREMIUM 91 HYDROCHLORIDE 116 methylprednisolone sod metformin hcl 35 METHOHEXITAL SODIUM 163 succ 116 METFORMIN HCL 94 METHOTREXATE 4 METHYLPREDNISOLONE/LIDO METHACHOLINE CAINE 116 CHLORIDE 94 methotrexate sodium 53 METHYLSULFONYLMETHANE METHACRYLIC ACID METHOXSALEN 141 94 COPOLYMER TYPE A 94 methoxsalen rapid 128 methyltestosterone 15 methadone hcl 11 METHOXYAMINE METHYLTESTOSTERONE 15 METHADONE HCL 11 HYDROCHLORIDE 94 METHYLTETRAHYDROFOLATE methadone hcl 11 METHOXYETHANOL 94 CALCIUM 95 METHADONE METHSCOPOLAMINE METHYSERGIDE HYDROCHLORIDE/SODIUM BROMIDE 94 MALEATE 95 CHLORIDE 11 methscopolamine METOCLOPRAMIDE HCL 161 METHADOSE 11 bromide 334 metoclopramide hcl 161 METHSCOPOLAMINE NITRATE 94

Index 65 METOCLOPRAMIDE HCL MICRHOGAM ULTRA- MIL ADREGEN 287 MONOHYDRATE 161 FILTEREDPLUS 303 MILK THISTLE 95 METOCLOPRAMIDE MICROCRYSTALLINE HYDROCHLORIDE 161 CELLULOSE NF 101 85 MILLIPRED 116 METOCLOPRAMIDE ODT 161 MICROCRYSTALLINE MILLIPRED DP 116 metolazone 154 CELLULOSE NF 105 85 milrinone lactate 74 metoprolol & MICROCYN 145 milrinone lactate in dextrose 74 hydrochlorothiazide 49 MICROCYN SKIN AND WOUND HYDROGEL 145 MIMYX 139 metoprolol succinate 71 MINASTRIN 24 FE 112 METOPROLOL SUCCINATE MICRODERM BASE 323 ER/HYDROCHLOROTHIAZIDE MICRODOT BLOOD MINERAL OIL 173 49 GLUCOSE MONITORING mineral oil 173 METOPROLOL TARTRATE 71 SYSTEM 208 MINERAL OIL HEAVY 173 MICRODOT CONTROL metoprolol tartrate 71 SOLUTIONHIGH/LOW 208 MINERAL OIL LIGHT 173 METROCREAM 141 MICRODOT PEN MINI LANCING DEVICE 208 METROGEL 141 NEEDLE/31G X 6 MM 248 MINIPRESS 48 MICRODOT PEN METROGEL-VAGINAL 339 NEEDLE/32G X 4 MM 248 MINIVELLE 159 METROLOTION 141 MICRODOT PEN MINOCIN 331 metronidazole 17 NEEDLE/33G X 4 MM 248 minocycline hcl 331 METRONIDAZOLE 17 MICRODOT TEST MINOCYCLINE HCL 331 STRIPS 150 metronidazole 17 MICRODOT XTRA TEST minocycline hcl 331 METRONIDAZOLE 95 STRIPS 150 MINOLIRA 331 metronidazole (topical) 141 MICROLET LANCETS 208 minoxidil 50 METRONIDAZOLE MICROLET NEXT 208 MINOXIDIL 110 BENZOATE 95 MICROPLEGIA MSA/MSG 74 MINT CHOCOLATE CHIP METRONIDAZOLE MICROSOME BASE 323 FLAVOR 308 BENZOATE/SYRSPEND SF MIOCHOL-E 296 PH4 17 MICROTAINER SAFETY metronidazole in nacl 17 FLOW MIOSTAT 296 LANCET/STERILE/SINGLE- MIRAPEX 62 metronidazole vaginal 339 USE 208 MIRAPEX ER 62 metyrosine 47 MICROVIX LP 138 MIRASORB SPONGES 2" X mexiletine hcl 22 MIDAZOLAM 95,172 2" 188 MEXILETINE midazolam hcl 171 MIRASORB SPONGES 4" X HYDROCHLORIDE 95 MIDAZOLAM 4" 188 MG PLUS PROTEIN 287 HYDROCHLORIDE 171 MIRCERA 167 MG217 PSORIASIS MULTI- MIDAZOLAM MIRCETTE 112 SYMTOM 136 HYDROCHLORIDE/SODIUM MI PASTE 227 CHLORIDE 171 MIRENA 113 MI PASTE PLUS 227 MIDAZOLAM/KETAMINE mirtazapine 31 HYDROCHLORIDE/ONDANSE MIACALCIN 154 MIRTAZAPINE 95 TRON MIRVASO 141 MIC/L-CARNITINE 292 HYDROCHLORIDE 171 micafungin sodium 41 MIDAZOLAM/SODIUM misc natural products 273 MICARDIS 47 CHLORIDE 172 MISEFLEX-C 273 MIDAZOLAM/SYRSPEND SF MICARDIS HCT 49 MISOPROSTOL 95 PH4 172 misoprostol 336 MICONAZOLE 42 midodrine hcl 341 MISOPROSTOL-HPMC 95 MICONAZOLE NITRATE 126 miglitol 34 MITIGARE 165 miconazole nitrate vaginal 339 miglustat 166 mitomycin 57 miconazole-zinc oxide-white MIGRAINE PACK 265 petrolatum 126 MITOMYCIN 95,297 MIGRANAL 265 MICORT-HC 133 MITOSOL 297 MIGRANOW 265

Index 66 MITOTANE 95 MONOJECT BONE MARROW MONOJECT INSULIN mitoxantrone hcl 57 BIOPSY TRAY/BIOP ASPIR SYRINGEREGULAR LUER NEEDLE 11GX4" 175 TIP/SOFTPACK/1ML 249 MKO MELT DOSE PACK 171 MONOJECT BONE MARROW MONOJECT ULTRA COMFORT MLK F1 KIT 116 BIOPSY TRAY/BIOP ASPIR INSULIN SYRINGE/0.3ML/29G X MLK F2 KIT 116 NEEDLE 8GX4" 175 1/2" 249 MONOJECT BONE MARROW MONOJECT ULTRA COMFORT MLK F3 KIT 116 BIOPSY TRAY/STERNAL- INSULIN SYRINGE/0.3ML/30G X MLK F4 KIT 116 ILIAC NEEDLE 16G 175 5/16" 249 MM BIOTIN/KERATIN 287 MONOJECT INSULIN MONOJECT ULTRA COMFORT MM EASY TOUCH BLOOD SYRINGE/1ML 248 INSULIN SYRINGE/0.3ML/31G X GLUCOSE METER 208 MONOJECT INSULIN 5/16" 249 MM EASY TOUCH GLUCOSE SYRINGE/1ML/31G X MONOJECT ULTRA COMFORT TEST STRIPS 150 5/16" 248 INSULIN SYRINGE/0.5ML/28G X MM INSULIN SYRINGE/U- MONOJECT INSULIN 1/2" 249 100/0.3ML/30G X 5/16" 248 SYRINGE/DETACH MONOJECT ULTRA COMFORT MM INSULIN SYRINGE/U- NEEDLE/1ML/25G X 5/8" 248 INSULIN SYRINGE/0.5ML/29G X 100/0.3ML/31G X 5/16" 248 MONOJECT INSULIN 1/2" 249 MM INSULIN SYRINGE/U- SYRINGE/DETACH MONOJECT ULTRA COMFORT 100/1/2ML/30G X 5/16" 248 NEEDLE/1ML/27G X 1/2" 248 INSULIN SYRINGE/0.5ML/30G X MM INSULIN SYRINGE/U- MONOJECT INSULIN 5/16" 249 100/1/2ML/31G X 5/16" 248 SYRINGE/PERM MONOJECT ULTRA COMFORT MM INSULIN SYRINGE/U- NEEDLE/1ML/28G X 1/2" 248 INSULIN SYRINGE/0.5ML/31G X 100/1ML/30G X 5/16" 248 MONOJECT INSULIN 5/16" 249 MM INSULIN SYRINGE/U- SYRINGE/PERM NEEDLE/U- MONOJECT ULTRA COMFORT 100/1ML/31G X 5/16" 248 100/0.5ML/28G X 1/2" 248 INSULIN SYRINGE/1ML/28G X MM LANCING DEVICE 208 MONOJECT INSULIN 1/2" 249 MM PEN NEEDLES 31G X SYRINGE/SAFETY/PERM MONOJECT ULTRA COMFORT 1/4" 248 NEEDLE/0.3ML/29G X INSULIN SYRINGE/1ML/29G X MM PEN NEEDLES 31G X 1/2" 248 1/2" 249 3/16" 248 MONOJECT INSULIN MONOLET LANCETS 208 MM PEN NEEDLES 31G X SYRINGE/SAFETY/PERM MONOLET OPD LANCETS208 NEEDLE/0.3ML/29GX1/2" 5/16" 248 MONOLETTOR SAFETY MM PEN NEEDLES 32G X 248 MONOJECT INSULIN LANCETS 208 5/32" 248 MONONINE 165 MM TWIST LANCETS 208 SYRINGE/SAFETY/PERM NEEDLE/0.5ML/29G X MONSELS FERRIC MOBIC 6 1/2" 248 SUBSULFATE 170 modafinil 2 MONOJECT INSULIN montelukast sodium 23 moexipril hcl 47 SYRINGE/SAFETY/PERM MONTELUKAST SODIUM 95 MOI-STIR 275 NEEDLE/1ML/29G X 1/2" 248 MORANTEL TARTRATE 95 MONOJECT INSULIN MOLASSES FLAVOR 308 SYRINGE/SOFTPACK/1ML/27 MORGIDOX 1X100MG 331 MOLESKIN FOAM G X 1/2" 248 MORGIDOX 1X50MG KIT 331 PADDING 188 MONOJECT INSULIN MORGIDOX 2X100MG 331 molindone hcl 64 SYRINGE/SOFTPACK/U- MORPHABOND ER 11 MOLYBDENUM 95 100/0.5ML/28G X 1/2" 248 MONOJECT INSULIN morphine sulfate 11 MOMETASONE FUROATE 95 SYRINGE/U-100/0.3ML/30G X MORPHINE SULFATE 11 mometasone furoate 133 5/16" 249 morphine sulfate 11 mometasone furoate MONOJECT INSULIN (nasal) 290 SYRINGE/U-100/0.5ML/30G X MORPHINE SULFATE 11 MONISTAT SOOTHING CARE 5/16" 249 morphine sulfate 11 ITCH RELIEF 133 MONOJECT INSULIN MORPHINE SULFATE 11 MONJUVI 54 SYRINGE/U-100/1ML/28G X morphine sulfate 11 MONOBENZONE 95 1/2" 249 MONOJECT INSULIN MORPHINE SULFATE 11 MONOETHANOLAMINE 95 SYRINGE/U-100/1ML/30G X morphine sulfate 11 MONOFERRIC 170 5/16" 249

Index 67 morphine sulfate beads 11 MULTIBASE 323 MYGLUCOHEALTH BLOOD morphine sulfate for continuous MULTIGEN 169 GLUCOSE TEST 150 MYGLUCOHEALTH CONTROL microinfusion 11 MULTIGEN FOLIC 169 MORPHINE LOW/NORMAL/HIGH 208 SULFATE/DEXTROSE 11 MULTIGEN PLUS 169 MYGLUCOHEALTH MGH MORPHINE SULFATE/SODIUM multiple vitamin 280 SOFTLANCE LANCETS CHLORIDE 11 multiple vitamins w/ 30G 209 MOTEGRITY 160 minerals 278,279 MYLERAN 53 MOTOFEN 39 multiple vitamins w/ minerals & MYLOTARG 54 folic acid 278 MOUTH KOTE 276 MYNATAL 283 MULTITRACE-4 270 MYNATAL ADVANCE 283 MOUTH KOTE REMINT 275 MULTITRACE-4 MOVANTIK 162 NEONATAL 270 MYNATAL PLUS 283 MOVIPREP 172 MULTITRACE-4 MYNATAL ULTRACAPLET 283 MOXEZA 297 PEDIATRIC 270 MYNATAL-Z 283 MULTITRACE-5 270 MOXIFLOXACIN 297 MYNATE 90 PLUS 283 MULTIVITAMIN + MYOBLOC 291 MOXIFLOXACIN HCL 95 FLUORIDE 280 moxifloxacin hcl 160 MULTIVITAMIN WITH MYRBETRIQ 337 moxifloxacin hcl (ophth) 297 FLUORIDE 277 MYRJ 53 326 moxifloxacin hcl in sodium MULTIVITAMIN/FLUORIDE MYSOLINE 29 277 chloride 160 MYTESI 38 MUPIROCIN 95 MOXIFLOXACIN MYXREDLIN 37 HYDROCHLORIDE 160 mupirocin 125 MOXIFLOXACIN mupirocin calcium N-ACETYL-L-CARNOSINE 95 HYDROCHLORIDE/SODIUM (topical) 125 N-ACETYL-L-CYSTEINE 119 CHLORIDE 297 MURI-LUBE 173 NABI-HB 303 MOXISYLYTE HCL 95 MVASI 54 nabumetone 6 MOZOBIL 170 MX-SOL 316 NABUMETONE 95 MPD SAFETY LANCET 21G/1.8MM 208 MX-SOL BLEND 316 NADH 95 MPD SAFETY LANCET MX-SOL BLEND SF 316 NADOLOL 71 28G/1.8MM 208 MX-SOL SF 316 nadolol 72 MPD SAFETY LANCET MX-SOL SUSPEND 316 NAFCILLIN 304 30G/1.8MM 208 MPD SAFETY LANCETS MYALEPT 157 nafcillin sodium 304 23G/1.8MM 208 MYAMBUTOL 52 NAFCILLIN SODIUM 304 MS CONTIN 12 MYCAMINE 41 naftifine hcl 126 MS INSULIN MYCAPSSA 158 NAFTIFINE SYRINGE/0.3ML/31G X MYCO NAIL 126 HYDROCHLORIDE 126 5/16" 249 NAFTIN 126 MS INSULIN MYCO-NAIL 126 NAGLAZYME 157 SYRINGE/0.5ML/31G X MYCOBUTIN 52 5/16" 249 MYCOPHENOLATE NAIL SCRUB 139 MS INSULIN SYRINGE/1ML/31G MOFETIL 95 nalbuphine hcl 14 X 5/16" 249 mycophenolate mofetil 272 NALBUPHINE HCL 95 MTX SUPPORT 169 mycophenolate mofetil NALFON 6 MUCOLOX 319 hcl 272 NALOCET 13 MUCOSITISRX 276 mycophenolate sodium 272 naloxone hcl 40 MULPLETA 167 MYDAYIS 1 NALOXONE HCL 95 MULTAQ 22 MYFEMBREE 159 NALOXONE HCL MULTI-LANCET DEVICE 208 MYFORTIC 272 DIHYDRATE 95 MULTI-SPECIALTY KIT 116 MYGLUCOHEALTH BLOOD NALOXONE HYDROCHLORIDE MULTI-VITE 278 GLUCOSE MONITORING DIHYDRATE 95 SYSTEM 208 NALTREXONE 40

Index 68 naltrexone hcl 40 NATURAL MIXED NESACAINE 176 NALTREXONE HCL 95 TOCOPHEROLS30% 103 NESACAINE-MPF 176 NATURE-THROID 332 NALTREXONE NESINA 35 NATURE-THROID NT- HYDROCHLORIDE 95 NESTABS 283 NALTREXONE 2.5 332 HYDROCHLORIDEDIHYDRATE NAVELBINE 61 NESTABS DHA 283 95 NAYZILAM 27 NESTABS ONE 283 NAMENDA 327 NEBUPENT 17 NETTLE LEAF 95 NAMENDA TITRATION NEBUSAL 119 NEUAC KIT 122 PAK 327 NEULASTA 167 NAMENDA XR 327 NEEVO DHA 283 NAMENDA XR TITRATION nefazodone hcl 32 NEULASTA ONPRO KIT 167 PACK 327 NEMBUTAL SODIUM 171 NEUPOGEN 167 NAMZARIC 327 NEO-SYNALAR 125 NEUPRO 62 NANDROLONE NEO-SYNALAR KIT 125 NEURAPTINE 124 DECANOATE 95 NEURIN-SL 169 NANDROLONE NEOCERA 139 DECANOATE/TESTOSTERONE NEOKE ALCAR 295 NEURONTIN 29 CYPIONATE/TESTOSTERONE NEOKE MCT70 292 NEUTEK 2TEK CONTROL SOLUTIONS 209 ENA 15 NEOKE RA LIPOIC 3 NAPHAZOLINE HCL 95 NEUTEK 2TEK TEST neomycin sulfate 3 STRIPS 150 NAPRELAN 6 NEOMYCIN SULFATE 125 NEUTRASAL 276 NAPRO 15% COMPOUNDING neomycin-bacitracin zn- KIT 124 NEVANAC 301 polymyxin 297 nevirapine 67 NAPROSYN 6 neomycin-polymy- NAPROXEN 6 dexameth 299 NEW LIFE HAIR 287 naproxen 6 neomycin-polymyxin-gramicidin NEXA PLUS 283 297 NEXAVAR 58 NAPROXEN COMFORT PAC 6 neomycin-polymyxin-hc NAPROXEN SODIUM 6 (ophth) 299 NEXAVIR 274 naproxen sodium 6 neomycin-polymyxin-hc NEXCARE ABSOLUTE (otic) 302 WATERPROOF PAD 188 naproxen-esomeprazole NEXCARE ABSOLUTE magnesium 6 neomycin/polymyxin b gu 164 WATERPROOF PREMIUM naratriptan hcl 266 NEONATAL 19 283 ADHESIVE PAD 2- NARCAN 40 NEONATAL COMPLETE 283 3/8"X45" 188 NARDIL 32 NEONATAL FE 283 NEXCARE ACTIVE BRIGHTS NAROPIN 175 BANDAGES ASSORTED 188 NEONATAL PLUS 283 NEXCARE ACTIVE SPORT NASCOBAL 167 NEONATAL/DHA 283 FOAM BANDAGES 1-1/8" X NASONEX 290 NEOPROFEN 6 3" 188 NATACHEW 283 NEORAL 272 NEXCARE ACTIVE SPORT FOAM BANDAGES NATACYN 297 NEOSALUS 139 ASSORTED 188 NATALVIT 283 NEOSALUS CP 139 NEXCARE ACTIVE SPORT NATAPRES 106 neostigmine methylsulfate 51 FOAM BANDAGES NATAZIA 112 NEOSTIGMINE KNEE/ELBOW 188 NEXCARE ADHESIVE nateglinide 37 METHYLSULFATE 51,95 NEOTUSS PLUS 118 DRESSING/PAD WATERPROOF NATELLE ONE 283 6" X 6" 188 NEOVITE 279 NATESTO 15 NEXCARE COMFORT FABRIC NEPAFENAC 95 NATPARA 154 BANDAGES 3/4" X 3" 188 NEPHPLEX RX 277 NEXCARE COMFORT FABRIC NATROBA 142 BANDAGES ASSORTED 188 NEPHRAMINE 295 NATURAL BITTERNESS 319 NEXCARE COMFORT FABRIC NEPHRON FA 169 NATURAL CARAMEL 308 BANDAGES NERLYNX 58 KNEE/ELBOW 188

Index 69 NEXCARE HEAVY DUTY NEXLIZET 44 NICOTINE POLACRILEX 95 CLEAR& TOUGH BANDAGES NEXPLANON 113 nicotine polacrilex 329 ASSORTED 188 NEXCARE HEAVY DUTY NEXTERONE 22 NICOTINE TARTRATE 96 CLEAR& TOUGH BANDAGES NEXTOL SF 319 NICOTINE TRANSDERMAL KNEE/ELBOW 188 NEXTSTELLIS 112 SYSTEM 329 NEXCARE HEAVY DUTY NICOTROL INHALER 330 NIACIN 342 FLEXIBLE FABRIC BANDAGES NICOTROL NS 330 niacin (antihyperlipidemic) 46 1-1/8"X3" 188 nifedipine 73 NEXCARE HEAVY DUTY NIACINAMIDE 342 FLEXIBLE FABRIC BANDAGES niacinamide w/ zinc-copper- NIFEREX 169 ASSORTED 188 methylfolate-se-cr 288 NILANDRON 56 NEXCARE HEAVY DUTY NIACINAMIDE/SPIRONOLACT nilutamide 56 FLEXIBLE FABRIC BANDAGES ONE 122 NIMBEX 291 KNEE/ELBOW 188 NIACINAMIDE/SPIRONOLACT NEXCARE NON-STICK PADS ONE/TRETINOIN 122 nimodipine 73 3"X 4" 188 NIACINAMIDE/SULFACETAMI NIMODIPINE 96 NEXCARE PREMIUM DE SODIUM NINLARO 58 ADHESIVEGAUZE PAD 6" X MONOHYDRATE 122 6" 188 NIACINAMIDE/TACROLIMUS NIPENT 60 NEXCARE SOFT 'N FLEX MONOHYDRATE 135 NIPRIDE RTU 50 BANDAGES 188 NIACINAMIDE/TAZAROTENE nisoldipine 73 NEXCARE TATTOO 122 nitazoxanide 17 WATERPROOF BANDAGES 1- NIACINAMIDE/TRETINOIN 1/16" X 2-1/4" 188 122 NITHIODOTE 39 NEXCARE TATTOO NIACINAMIDE/TRIAMCINOLO nitisinone 157 WATERPROOF NE ACETONIDE 133 NITRIC ACID 77 BANDAGES/EINSTEINS 1- NIAOULI 107 1/16"X2-1/4" 188 NITRO-BID 20 NEXCARE TATTOO NIASPAN 46 NITRO-DUR 20 WATERPROOF NICADAN 279 nitrofurantoin 20 BANDAGES/NEMO 1-1/16" X 2- nicardipine hcl 73 NITROFURANTOIN 96 1/4" 188 NICARDIPINE NEXCARE TATTOO NITROFURANTOIN HYDROCHLORIDE 73 ANHYDROUS 96 WATERPROOF NICARDIPINE BANDAGES/POOH 1-1/16" X 2- HYDROCHLORIDE/SODIUM nitrofurantoin macrocrystal 20 1/4" 188 CHLORIDE 73 nitrofurantoin monohyd NEXCARE TATTOO NICAZEL FORTE 279 macro 20 WATERPROOF NITROFURANTOIN NICE DISTILLED MONOHYDRATE 96 BANDAGES/PRINCESS 1-1/16" WATER 316 X 2-1/4" 189 NICE PURE BAKING NITROFURAZONE 129 NEXCARE WATERPROOF SODA 100 nitroglycerin 20 BANDAGES 189 NEXCARE WATERPROOF NICLOSAMIDE 95 NITROGLYCERIN 20 BANDAGES 1-1/16" X 2- NICODERM CQ 329 nitroglycerin 20 1/4" 189 NICOMIDE 288 nitroglycerin in d5w 20 NEXCARE WATERPROOF NICORETTE 329 NITROLINGUAL BANDAGES ASSORTED 189 NICORETTE MINI 329 PUMPSPRAY 20 NEXCARE WATERPROOF NITROMIST 20 BANDAGES NICORETTE STARTER KNEE/ELBOW 189 KIT 329 NITROPRESS 50 NEXIUM 335 NICOTINAMIDE 342 nitroprusside sodium 50 NEXIUM 24HR 335 NICOTINAMIDE ADENINE NITROSTAT 20 DINUCLEOTIDE 95 NITYR 157 NEXIUM 24HR CLEAR NICOTINAMIDE ADENINE MINIS 335 DINUCLEOTIDE (NAD) 95 NIVA-PLUS 283 NEXIUM I.V. 335 NICOTINAMIDE RIBOSIDE NIVATOPIC PLUS 140 NEXLETOL 43 CHLORIDE 95 NIVESTYM 167 nicotine 329

Index 70 nizatidine 334 NORMOSOL-M IN D5W 268 NOVOLIN N FLEXPEN 37 NIZORAL 126 NORMOSOL-M/D5W 268 NOVOLIN N FLEXPEN NOCDURNA 158 NORMOSOL-R 268 RELION 37 NOVOLIN N RELION 37 NOCTIVA 158 NORMOSOL-R IN D5W 268 NOVOLIN R 37 NON-STICK PADS 3"X4" 189 NORMOSOL-R/5% NOVOLIN R FLEXPEN 37 NOPIOID-LMC KIT 289 DEXTROSE 268 NORPACE 21 NOVOLIN R FLEXPEN NOPIOID-TC KIT 289 NORPACE CR 21 RELION 37 NORCO 14 NOVOLIN R RELION 37 NORPRAMIN 33 NORDITROPIN FLEXPRO 155 NOVOLOG FLEXPEN norelgestromin-ethinyl NORTHERA 340 RELION 37 estradiol 113 nortriptyline hcl 33 NOVOLOG FLEXPEN NOREPHINEPHRINE NORTRIPTYLINE HCL 33 SOPN 37 BITARTRATE/SODIUM nortriptyline hcl 33 NOVOLOG MIX 70/30 37 CHLORIDE 341 NOVOLOG MIX 70/30 NOREPINEPHRINE NORVASC 73 PREFILLED FLEXPEN 37 BITARTRATE 96 NORVIR 67 NOVOLOG MIX 70/30 norepinephrine bitartrate 341 NORWEGIAN COD LIVER PREFILLED FLEXPEN NOREPINEPHRINE OIL 288 RELION 37 BITARTRATE/DEXTROSE 341 NOURIANZ 61 NOVOLOG MIX 70/30 NOREPINEPHRINE NOURILITE 323 PREFILLED FLEXPEN BITARTRATE/SODIUM SUPN 37 CHLORIDE 341 NOURISIL 100 NOVOLOG MIX 70/30 NOREPINEPHRINE/DEXTROSE NOURIVAN ANTIOX CREAM RELION 37 341 BASE 323 NOVOLOG MIX 70/30 SUSP37 NOVA MAX BLOOD NOREPINEPHRINE/SODIUM NOVOLOG PENFILL 37 CHLORIDE 341 GLUCOSE MONITORING NOVOLOG PENFILL SOCT 37 norethin acet & estrad-fe 112 SYSTEM 209 NOVA MAX GLUCOSE TEST NOVOLOG RELION 37 NORETHINDRONE 96 STRIPS 150 NOVOLOG SOLN 37 norethindrone & eth NOVA MAX PLUS GLU/KET estradiol 112 CONTROL SOLUTION- NOVOSEVEN RT 165 norethindrone & ethinyl estradiol- MID 209 NOVOTWIST PEN NEEDLE fe 112 NOVA SAFETY LANCETS 32GX 5MM 249 norethindrone 23G 209 NOXAFIL 42 (contraceptive) 113 NOVA SAFETY LANCETS NOZIN NASAL SANITIZER 290 norethindrone acet & eth 28G 209 estra 112 NP #2 DRUG PREPARATION NOVA SUREFLEX KIT 124 NORETHINDRONE LANCETS 209 ACETATE 326 NOVA SUREFLEX LANCING NPLATE 167 norethindrone acetate 327 DEVICE 209 NU GAUZE 4PLY 4"X4" 189 norethindrone acetate-ethinyl NOVAFILM 323 NU GAUZE GENERAL-USE estradiol 159 NOVAREL 155 SPONGES 4"X4" 4 PLY 189 norethindrone acetate-ethinyl NU GAUZE PACKING STRIPS NOVOFINE AUTOCOVER PEN PLAIN 1/2" X 5 YDS 189 estradiol-fe 112 NEEDLE 30G X 8MM 249 norethindrone-eth estradiol NU GAUZE UTERINE NOVOFINE PEN NEEDLE 32G PACKINGSTRIPS IODOFORM (triphasic) 112 X 4MM 249 NORGESIC FORTE 289 8" X 10 YDS 189 NOVOFINE PLUS PEN NU-GEL COLLAGEN WOUND norgestimate-ethinyl NEEDLE32G X 4MM 249 estradiol 112 DRESSING 145 NOVOLIN 70/30 37 NUBEQA 56 norgestimate-ethinyl estradiol NOVOLIN 70/30 (triphasic) 112 FLEXPEN 37 NUCALA 22 norgestrel & ethinyl NOVOLIN 70/30 FLEXPEN NUCARACLINPAK 122 estradiol 112 RELION 37 NUCARARXPAK 122 NORITATE 141 NOVOLIN 70/30 RELION 37 NUCORT 133 NORMOSOL -R 268 NOVOLIN N 37 NUCYNTA 12

Index 71 NUCYNTA ER 12 nystatin-triamcinolone 126 olmesartan medoxomil 47 NUDERMRXPAK 120 128 NYVEPRIA 167 OLMESARTAN NUDERMRXPAK 60 128 O-CAL FA 283 MEDOXOMIL 96 olmesartan medoxomil- NUDROXIPAK 6 O-CAL PRENATAL 283 amlodipine-hydrochlorothiazide NUDROXIPAK DSDR-50 6 OB COMPLETE 283 49 NUDROXIPAK DSDR-75 6 OB COMPLETE ONE 283 olmesartan medoxomil- hydrochlorothiazide 49 NUDROXIPAK E-400 6 OB COMPLETE PETITE 283 olopatadine hcl 301 NUDROXIPAK I-800 6 OB COMPLETE olopatadine hcl (nasal) 290 NUDROXIPAK M-15 6 PREMIER 283 OB COMPLETE/DHA 283 OLUMIANT 4 NUDROXIPAK N-500 6 OBIZUR 165 OLUX 133 NUEDEXTA 329 OBSTETRIX DHA 283 OLUX-E 133 NUFERA 169 OBSTETRIX EC 283 OMECLAMOX-PAK 336 NULIBRY 157 OBSTETRIX ONE 283 OMEGA-3 RX COMPLETE 44 NULOJIX 272 OBTREX 283 omega-3-acid ethyl esters 44 NULYTELY 172 OBTREX DHA 283 OMEGA-3/D-3 WELLNESS NULYTELY/FLAVOR PACK 44 OCALIVA 160 PACKS 172 OMEGAVEN 292 NUMBRINO 290 OCCLUVAN 323 OMEPRAZOLE 96 NUMOISYN 276 OCREVUS 328 omeprazole 336 NUPLAZID 63 OCTAGAM 303 OMEPRAZOLE + SYRSPEND NURTEC 265 OCTINOXATE 96 SFALKA 335 NUSURGEPAK SURGICAL octreotide acetate 158 omeprazole-sodium PREP/CAREPAK 141 OCTYL STEARATE 96 bicarbonate 336 NUTRASEB 129 OMIDRIA 300 OCUFLOX 297 NUTRICAP 280 OMNARIS 290 OCUVEL 280 NUTRIDOX 331 OMNI-BIOTIC AB 10 38 ODEFSEY 67 NUTRILIPID 292 OMNI-BIOTIC HETOX 38 ODOMZO 55 NUTRIVIT 277 ODOR CONTROL INSOLES OMNIBASE 323 NUTROPIN AQ NUSPIN MENS/WOMENS 220 OMNIPOD 5 PACK 209 10 155 ODOR EATERS ULTRA OMNIPOD DASH 5 PACK 209 NUTROPIN AQ NUSPIN COMFORT 220 OMNIPOD DASH SYSTEM 209 20 156 OFEV 330 NUTROPIN AQ NUSPIN 5 156 OMNIPOD STARTER KIT 209 OFIRMEV 8 NUVAIL 140 OMNITROPE 156 ofloxacin 160 NUVAKAAN II 138 ON CALL EXPRESS BLOOD ofloxacin (ophth) 297 GLUCOSE METER 209 NUVARING 113 ofloxacin (otic) 302 ON CALL EXPRESS BLOOD NUVESSA 339 OGIVRI 54 GLUCOSE MONITORING NUVIGIL 3 SYSTEM 209 OIL-ALMOND SWEET 107 NUWIQ 165 ON CALL EXPRESS BLOOD OIL-COCONUT 107 GLUCOSE TEST STRIPS 150 NUZYRA 331 OINTMENT BASE ON CALL EXPRESS GLUCOSE NYLIDRIN EMULSIFYING 323 CONTROL SOLUTION 209 HYDROCHLORIDE 75 olanzapine 64 ON CALL LANCETS 209 NYMALIZE 73 olanzapine-fluoxetine hcl 328 ON CALL LANCING nystatin 42 OLEABASE DEVICE 209 NYSTATIN 96 PLASTICIZED 323 ON CALL PLUS BLOOD GLUCOSE METER 209 nystatin (mouth-throat) 275 OLEIC ACID 319 ON CALL PLUS BLOOD nystatin (topical) 126 OLINVYK 12 GLUCOSE MONITORING NYSTATIN FOREIGN 96 OLIVE OIL 107 SYSTEM 209

Index 72 ON CALL PLUS BLOOD ONETOUCH ULTRALINK OPTIUMEZ TEST STRIPS 151 GLUCOSE TEST 150 SYSTEM (DEC) 210 OPTUMRX BLOOD GLUCOSE ON CALL PLUS GLUCOSE ONETOUCH ULTRALINK METER 210 CONTROL LEVEL 1/2 209 SYSTEM (HEX) 210 OPTUMRX BLOOD GLUCOSE ON CALL PLUS LANCETS 209 ONETOUCH ULTRASOFT MONITORING SYSTEM 210 ON CALL PLUS LANCING LANCETS 210 OPTUMRX BLOOD GLUCOSE DEVICE 209 ONETOUCH VERIO 210 TEST 151 ON CALL VIVID BLOOD ONETOUCH VERIO OPTUMRX GLUCOSE GLUCOSE METER 209 CONTROL SOLUTION CONTROL LEVEL 1/2 210 ON CALL VIVID BLOOD HIGH 210 OPURITY B12/FOLIC GLUCOSE MONITORING ONETOUCH VERIO FLEX ACID 169 SYSTEM 209 BLOOD GLUCOSE ORA-BLEND 316 ON CALL VIVID BLOOD MONITORING SYSTEM 210 ORA-BLEND SF 316 GLUCOSE TEST 151 ONETOUCH VERIO IQ ON CALL VIVID BLOOD BLOOD GLUCOSE ORA-PLUS 316 GLUCOSE TEST STRIPS 151 MONITORING SYSTEM 210 ORA-SWEET 316 ON CALL VIVID GLUCOSE ONETOUCH VERIO MID ORA-SWEET SF 316 CONTROL LEVEL 1/2 209 CONTROL SOLUTION 210 ON CALL VIVID PAL BLOOD ONETOUCH VERIO ORABLOC 174 GLUCOSE METER 209 REFLECT 210 ORACEA 141 ONCASPAR 59 ONETOUCH VERIO SYNC ORACIT 163 ondansetron 40 BLOODGLUCOSE ORAFATE 276 MONITORING SYSTEM 210 ORAL MIX FLAVORED ondansetron hcl 40 ONETOUCH VERIO TEST SUSPENDING VEHICLE 316 ONDANSETRON HCL 96 STRIPS 151 ORAL MIX SF 316 ONDANSETRON HCL ONEVITE 280 ORAL RELIEF SPRAY FOR DIHYDRATE 96 ONEXTON 122 ONE A DAY PRENATAL 283 DRYMOUTH & ONFI 27 DISCOMFORT 276 ONE DROP BLOOD GLUCOSE MONITORING SYSTEM 209 ONGENTYS 61 ORAL SUSPEND 316 ONE DROP BLOOD GLUCOSE ONGLYZA 35 ORAL SUSPENDING TEST STRIPS 151 ONIVYDE 61 COMPOUNDPLUS 316 ONE VITE WOMENS ORAL SYRUP FLAVORED PRENATALVITAMIN PLUS 283 ONPATTRO 330 VEHICLE 316 ONETOUCH CLUB LANCETS ONTRUZANT 54 ORAL SYRUP SF 316 FINE POINT 209 ONUREG 53 ORANGE CONCENTRATE 308 ONETOUCH DELICA LANCETS ONYCHO-MED 127 ORANGE CREAM EXTRA FINE 33G 209 ONZDEOXIA 122 FLAVOR 308 ONETOUCH DELICA LANCETS ORANGE FLAVOR 308 FINE 30G 209 ONZETRA XSAIL 266 ORANGE OIL FLAVOR 308 ONETOUCH DELICA LANCING OPANA 12 DEVICE 209 ORAPRED ODT 116 OPDIVO 54 ONETOUCH DELICA PLUS ORAVIG 275 LANCETS EXTRA FINE ophthalmic irrigation solution - 33G 209 intraocular 301 ORBACTIV 18 ONETOUCH DELICA PLUS opium tincture 39 ORENCIA 7 LANCETS FINE 30G 209 OPSUMIT 75 ORENCIA CLICKJECT 7 ONETOUCH DELICA PLUS OPTIFOAM 189 ORENITRAM 75 LANCING DEVICE 210 ONETOUCH DELICA SAFETY OPTIONS CONCEPTROL ORFADIN 157 LACING DEVICE 210 VAGINAL ORGANIC COCONUT OIL 107 CONTRACEPTIVE 339 ONETOUCH FINEPOINT ORGOVYX 56 LANCETS 210 OPTIONS GYNOL II VAGINALCONTRACEPTIVE ORIAHNN 159 ONETOUCH ULTRA 151 339 ORIGANUM 96 ONETOUCH ULTRA 2 210 OPTIUM BLOOD GLUCOSE ONETOUCH ULTRA MONITORING SYSTEM 210 ORILISSA 155 CONTROL 210 OPTIUM TEST STRIPS 151 ORKAMBI 330 ONETOUCH ULTRA MINI 210 ORLISTAT 96

Index 73 ORMECA 127 OXALIC ACID OXYTROL 337 ORNITHINE DIHYDRATE 77 OZEMPIC 35 oxaliplatin 53 HYDROCHLORIDE 96 OZOBAX 289 ORPHENADRINE OXANDROLONE 96 OZURDEX 299 CITRATE 289 oxaprozin 6 orphenadrine citrate 289 P-CARE 100MX 174 OXAYDO 12 orphenadrine w/ aspirin & P-CARE D40 116 oxazepam 21 caff 289 P-CARE D40G 116 OXBRYTA 166 ORTHO DF 169 P-CARE D40MX 116 oxcarbazepine 29 ORTHO MICRONOR 113 P-CARE D80 116 OXERVATE 298 ORTHO TRI-CYCLEN LO 112 P-CARE D80G 116 OXIANUJO 135 ORTHO-FOLIC 169 P-CARE D80MX 116 OXIATAR 122 ORTHO-NOVUM 1/35 112 P-CARE K40 116 OXIAVARRY 122 ORTHO-NOVUM 7/7/7 112 P-CARE K40G 116 OXIAZAR 122 ORTHODIET 273 P-CARE K40MX 116 oxiconazole nitrate 127 ORTIKOS 116 P-CARE K80 116 OXISTAT 127 oseltamivir phosphate 70 P-CARE K80G 116 OSELTAMIVIR OXLUMO 164 P-CARE K80MX 116 PHOSPHATE 96 OXSORALEN ULTRA 128 P-CARE M 175 OSENI 34 OXTELLAR XR 29 P-CARE MG 174 OSMOLEX ER 62 OXYBENZONE 110 P-CARE X 175 OSMOPREP 173 OXYBUTININ CHLORIDE 96 P-SILOXAN DS 323 OSPHENA 156 OXYBUTYNIN CHLORIDE 96 OSTEO BI-FLEX ADVANCED paclitaxel 61 oxybutynin chloride 337 DOUBLE STRENGTH WITH PADCEV 55 oxycodone hcl 12 JOINT SHIELD 273 PAINGO KFT 138 OSTEO BI-FLEX ADVANCED OXYCODONE HCL 12 paliperidone 63 TRIPLE STRENGTH 273 oxycodone hcl 12 OSTEO BI-FLEX ADVANCED PALMAROSA OIL 96 OXYCODONE WITH JOINT SHIELD 273 PALMERS COCOA BUTTER OSTEO BI-FLEX JOINT HEALTH HYDROCHLORIDE/ACETAMI NOPHEN 14 FORMULA SCAR SERUM 142 TRIPLE STRENGTH 273 PALMITAMIDE MEA OSTEO BI-FLEX JOINT SHIELD oxycodone w/ 14 (PMEA) 96 FORMULA WITH 5-LOXIN 273 acetaminophen PALMITOYL PENTAPEPTIDE- OSTEO BI-FLEX TRIPLE oxycodone-aspirin 14 3 96 STRENGTH WITH 5- oxycodone-ibuprofen 14 PALMITOYL TRIPEPTIDE-3 96 LOXIN 273 OXYCODONE/ACETAMINOPH palonosetron hcl 40 OSTEO BI-FLEX/5-LOXIN EN 14 PALONOSETRON ADVANCED JOINT CARE 273 OXYCONTIN 12 OTEZLA 7 HYDROCHLORIDE 40 OXYMETAZOLINE HCL 96 PALYNZIQ 157 OTIPRIO 302 oxymorphone hcl 12 PAMELOR 33 OTOVEL 302 OXYTETRACYCLINE pamidronate disodium 154 OTREXUP 4 DIHYDRATE 96 PAMIDRONATE OVACE PLUS 129 OXYTETRACYCLINE HCL 331 DISODIUM 154 OVACE PLUS WASH 129 OXYTOCIN 96 pamidronate disodium 154 OVACE WASH 129 oxytocin 302 PANCREATIN 96 OVEEZA 169 OXYTOCIN ACETATE 96 PANCREAZE 152 OVIDE 142 OXYTOCIN/DEXTROSE 302 pancuronium bromide 291 OVIDREL 155 OXYTOCIN/LACTATED PANDEL 133 OXACILLIN SODIUM 304 RINGERS 302 PANOXYL 122 oxacillin sodium 305 OXYTOCIN/SODIUM PANRETIN 127 CHLORIDE 302

Index 74 PANTETHINE PLUS 273 PC UNIFINE PENTIPS 31G PCCA NATATROCHE PANTHENOL 96 X6MM ULTRA SHORT 249 BASE 316 PC UNIFINE PENTIPS 31G PCCA OCCLUSADERM 324 PANTOPRAZOLE SODIUM 96 X8MM SHORT 249 PCCA PERME8 pantoprazole sodium 336 PCCA ACACIA SYRUP ANHYDROUS 324 PANTOPRAZOLE SODIUM BASE 316 PCCA PLASTICIZED SESQUIHYDRATE 96 PCCA ALADERM BASE 323 BASE 324 PANZYGA 303 PCCA ANHYDROUS PCCA PLURONIC F127 PAPAIN 96 BASE 323 BASE 324 PCCA ANHYDROUS PAPAVERINE HCL 75 PCCA POLOXAMER 407 324 LIPODERM BASE 323 PCCA POLYGLYCOL papaverine hcl 75 PCCA BASE 7542 323 TROCHE 316 PAPAVERINE PCCA BIOPEPTIDE PCCA POLYPEG BASE 324 HYDROCHLORIDE 75 BASE 323 PCCA PRACAMAC BASE 316 PARA-AMINOBENZOIC PCCA CANNIDEX 2.0 ACID 342 CUSTOMBASE 323 PCCA PRACASIL TM-PLUS PARACHLOROPHENOL 96 PCCA CANNIDEX CUSTOM BASE 324 PARADIGM LINK BLOOD BASE 323 PCCA RAPID DISSOLVE GLUCOSE MONITOR 210 TABLET POWDER BASE 320 PCCA COBASE #1 323 PCCA SORBITOL LOLLIPOP PARAFFIN 319 PCCA COSMETIC HRT BASE 320 PARAFORMALDEHYDE 97 BASE 323 PCCA SPIRA-WASH BASE324 PCCA CUSTOM LIPO- PARAGARD INTRAUTERINE PCCA SWEET-SF 316 COPPER CONTRACEPTIVE MAX 323 PCCA SWEETNESS T380A 113 PCCA CUSTOM ENHANCER 308 paregoric 39 NATATROCHE HMP BASE 316 PCCA SYRUP VEHICLE 316 parenteral electrolytes 268 PCCA CUSTOM RDT PCCA T3 SODIUM paricalcitol 157 POWDER 320 DILUTION 93 PARLODEL 62 PCCA CUSTOM TROCHE PCCA T4 SODIUM BASE 316 PARNATE 32 DILUTION 93 PCCA DMAE COMPLEX 87 PCCA VANISHING CREAM paromomycin sulfate 3 PCCA ELLAGE 323 LIGHT 324 PAROMOMYCIN SULFATE 97 PCCA EMOLLIENT CREAM PCCA VANISHING paroxetine hcl 32 BASE 323 CREAM/LOTION BASE 324 paroxetine mesylate PCCA EMULSIFIX-205 PCCA VANPEN BASE 324 (vasomotor) 330 BASE 320 PCCA W06 ANHYDROUS PARSABIV 157 PCCA FIXED OIL BASE 316 TOPICAL 324 PCCA WAV CUSTOM PASER 52 PCCA GELATIN BASE 323 BASE 324 PASSION FRUIT FLAVOR 308 PCCA LECITHIN ISOPROPYL PCCA XYLIFOS BASE 320 PALMITATE 320 PASSION FRUIT FLAVOR PCCA-PLUS 316 SWEETENED 308 PCCA LIPODERM BASE 323 172 PATADAY 301 PCCA LIPODERM CUSTOM PCP 100 PATADAY EXTRA BASE 323 PEACH FLAVOR 308 STRENGTH 301 PCCA LIPODERM HMW 323 PEANUT BUTTER PATANASE 290 PCCA LIPOSOMIC BASE FOR FLAVOR 308 107 PATANOL 301 DRY SKIN 323 PEANUT OIL PCCA LIPOSOMIC BASE FOR PEANUTS BANDAGES 189 PAXIL 32 NORMAL SKIN 323 PECTIN 39 PAXIL CR 32 PCCA LIPOSOMIC BASE FOR ped multivitamins w/fl & PAZEO 301 OILY SKIN 323 PCCA LIPOSOMIC BASE FOR iron 282 PC LANCETS SUPER THIN PEDIAPRED 116 30G 210 SENSITIVE SKIN 324 PC UNIFINE PENTIPS 29G PCCA LOXASPERSE PEDIARIX 333 X1/2" 249 BASE 320 pediatric multiple vitamin w/ PC UNIFINE PENTIPS 31G PCCA MVC BASE 324 minerals & c 282 X5MM MINI 249 PCCA NATACREAM 324 pediatric multivitamins w/fl 281

Index 75 pediatric vitamins acd w/ PEN NEEDLES/29G X pentobarbital sodium 171 fluoride 281 1/2" 250 PENTOSAN POLYSULFATE PEDIZOLPAK 127 PEN NEEDLES/31G X SODIUM 97 PEDVAX HIB 337 1/4" 250 PENTOSAN POLYSULFATE PEN NEEDLES/31G X PEG 324 SODIUM DR 164 3/16" 250 PENTOXIFYLLINE 97 PEG 300 324 PEN NEEDLES/31G X peg 3350-kcl-nacl-na sulfate-na 5/16" 250 pentoxifylline 166 ascorbate-ascorbic acid 172 PEN NEEDLES/31G X PENTYLENE GLYCOL 97 peg 3350-kcl-sod bicarb-sod 6MM 250 PENTYLENETETRAZOLE 97 PEN NEEDLES/32G X chloride-sod sulfate 173 PEPAXTO 53 peg 3350-potassium chloride-sod 5/32" 250 bicarbonate-sod chloride 173 PENCREAM 324 PEPCID 334 PEG 400 MONOSTEARATE 97 PENDERM 324 PEPCID AC 334 PEG OINTMENT BASE 324 PENICILLAMINE 97 PEPCID AC MAXIMUM STRENGTH 334 PEG TROCHE BASE 316 penicillamine 271 PEPPERMINT FLAVOR 308 PEG-40 CASTOR OIL 97 penicillin g potassium 304 PEPPERMINT OIL 107 PEGANONE 31 PENICILLIN G POTASSIUM IN PEPSIN 152 PEGASYS 69 ISO-OSMOTIC DEXTROSE 304 PERCOCET 14 PEGASYS PROCLICK 69 PENICILLIN G PERFECT LANCETS 30G 210 PEGINTRON 69 PROCAINE 304 PERFECT PRESSURE PEMAZYRE 58 penicillin g sodium 304 ACTIVATED SAFETY LANCETS PEN NEEDLES 29G X penicillin v potassium 304 28G 210 12MM 249 PENLAC NAIL PERFLUORODECALIN 97 PEN NEEDLES 29GX1/2" 249 LACQUER 127 PERFORMAX SALT PEN NEEDLES PENLEN 140 SUPPORTIVEBASE 324 29GX12MM 249 PENNSAID 124 PERFOROMIST 25 PEN NEEDLES 30GX5/16" 249 PENNYROYAL OIL 97 PERGOLIDE MESYLATE 97 PEN NEEDLES 30GX5MM 249 PENSOMAL CREAM 324 PERIDEX 275 PEN NEEDLES 30GX8MM 249 PENTACEL 333 PERIDIN-C 277 PEN NEEDLES 31G X 1/4" PERIKABIVEN 292 SHORT 250 PENTAM 300 17 PEN NEEDLES 31G X pentamidine isethionate 17 perindopril erbumine 47 3/16" 250 PENTAPHENE BASE 324 peritoneal dialysis solutions 274 PEN NEEDLES 31G X PERJETA 54 5MM 250 PENTASA 161 PEN NEEDLES 31G X pentazocine w/ naloxone 14 permethrin 142 6MM 250 PENTETATE CALCIUM PERMETHRIN TECHNICAL 97 PEN NEEDLES 31G X TRISODIUM 39 perphenazine 64 8MM 250 PENTETATE ZINC PERPHENAZINE 97 PEN NEEDLES 31GX5/16" 250 TRISODIUM 39 PEN NEEDLES 31GX6MM PENTICAN 329 perphenazine-amitriptyline 328 (1/4") 250 PENTIPS 29G X 12MM 250 PERSERIS 63 PEN NEEDLES 31GX8MM 250 PENTIPS 29GX12MM 250 PERTZYE 152 PEN NEEDLES 31GX8MM PENTIPS 31G X 5MM 250 PERUVIAN BALSAM 108 (5/16") 250 PETROLATUM 324 PEN NEEDLES 32G X PENTIPS 31G X 8MM 250 4MM 250 PENTIPS 31GX5MM 250 PETROLATUM WHITE 324 PEN NEEDLES 32G X PENTIPS 31GX6MM 250 PETROLEUM JELLY 324 5MM 250 PENTIPS 31GX8MM 250 PETROLEUM JELLYBABY 324 PEN NEEDLES 32G X PEUCEDANUM OSTRUTHIUM 6MM 250 PENTIPS 32G X 4MM 250 EXTRACT 97 PEN NEEDLES 32GX4MM 250 PENTIPS 32GX4MM 250 PEXEVA 32 PEN NEEDLES 33G X PENTOBARBITAL 5/32" 250 SODIUM 171

Index 76 PF-LIDOCAINE phenobarbital 171 PHLAG SPRAY 140 HYDROCHLORIDE 175 PHENOBARBITAL PHLEXY-10 295 PFCB 324 SODIUM 171 PHOSLYRA 162 PH 10 BUFFER 318 phenobarbital sodium 171 PHOSPHATIDYLCHOLINE 97 PH 12 STERILE DILUENT PHENOL 65,274 PHOSPHATIDYLSERINE 100 FORFLOLAN 316 PHENOLSULFONIC ACID 97 PH 4 BUFFER 318 PHOSPHOLINE IODIDE 296 phenoxybenzamine hcl 47 PHOSPHORIC ACID 77 PH 7 BUFFER 318 PHENOXYBENZAMINE PHARMABASE HCL 97 PHOTOFRIN 60 ANTIOXIDANT 324 PHENOXYETHANOL 97 PHOTREXA VISCOUS 298 PHARMABASE PHENTERMINE PHOTREXA/PHOTREXA COSMETIC 324 VISCOUS KIT 298 PHARMABASE COSMETIC HYDROCHLORIDE 97 NATURAL 324 phentolamine mesylate 47 PHOXILLUM B22K4/0 271 PHARMABASE HEAVY 324 PHENTOLAMINE PHOXILLUM BK4/2.5 271 MESYLATE 97 PHARMABASE LIGHT 324 PHYSICIANS EZ USE B-12 PHENYL SALICYLATE 97 COMPLIANCE KIT 167 PHARMABASE VAGINAL PHENYLBUTAZONE 6 PHYSICIANS EZ USE JOINT MOISTURIZING 324 TUNNEL AND TRIGGER 116 PHARMACIST CHOICE PHENYLEPHRINE HCL 290 PHYSICIANS EZ USE M- ALCOHOL PRED PADS 226 phenylephrine hcl PRED 116 PHARMACIST CHOICE (mydriatic) 296 PHYSOSTIGMINE ALCOHOLPREP PADS 226 phenylephrine hcl SALICYLATE 40 PHARMACIST CHOICE (pressors) 341 PHYTIC ACID IN WATER 97 AUTOCODE BLOOD GLUCOSE PHENYLEPHRINE MONITORING SYSTEM 210 HYDROCHLORIDE 296,341 PHYTOBASE 324 PHARMACIST CHOICE PHENYLEPHRINE PHYTONADIONE 97 AUTOCODE BLOOD GLUCOSE HYDROCHLORIDE/DEXTROS phytonadione 342 TEST STRIPS 151 E 341 PHARMACIST CHOICE MINI PHENYLEPHRINE PICATO 127 BLOOD GLUCOSE HYDROCHLORIDE/SODIUM PIFELTRO 67 MONITORING SYSTEM 210 CHLORIDE 341 PILOCARPINE HCL 110 PHARMACIST CHOICE NO phenylephrine w/ dm-gg 118 CODING BLOOD GLUCOSE pilocarpine hcl 296 PHENYLETHYL pilocarpine hcl (oral) 276 TEST STRIPS 151 ALCOHOL 97 PHARMACIST CHOICE ULTRA PHENYLETHYLAMINE PILOCARPINE NITRATE 110 THIN LANCETS 210 HCL 97 pimecrolimus 135 PHARMACIST CHOICE ULTRA PHENYLMERCURIC PIMOBENDAN 97 THIN LANCETS 28G 210 ACETATE 110 PHARMACIST CHOICE ULTRA PHENYLMERCURIC pimozide 329 THIN LANCETS 30G 210 NITRATE 110 PINA COLADA FLAVOR 308 PHARMACIST CHOICE ULTRA PHENYLPROPANOLAMINE THIN LANCETS 31G 210 pindolol 72 HYDROCHLORIDE USP 290 PINE BARK EXTRACT 97 PHARMACIST CHOICE ULTRA PHENYLTOLOXAMINE THIN LANCETS 33G 210 DIHYDROGEN CITRATE 97 PINE NEEDLE OIL 97 PHARMACY COUNTER PINE OIL 107 LANCETS 210 PHENYTEK 31 PHENAZOPYRIDINE HCL 164 phenytoin 31 PINE TAR 107 phenazopyridine hcl 164 PHENYTOIN 97 PINEAPPA 273 phenelzine sulfate 32 PHENYTOIN SODIUM 31 PINEAPPLE EXTRACT 97 PHENELZINE SULFATE 97 phenytoin sodium 31 PINEAPPLE FLAVOR 308 PHENERGAN 43 phenytoin sodium PINENE (L-ALPHA) 93 extended 31 pioglitazone hcl 36 PHENINDIONE 97 PHEODOYO 127 PHENIRAMINE MALEATE 97 pioglitazone hcl-glimepiride 34 PHESGO 57 pioglitazone hcl-metformin phenobarbital 171 PHEXXI 339 hcl 34 PHENOBARBITAL 171 PHEYO 127 PIP LANCETS/28G 210

Index 77 PIP LANCETS/30G 211 PMX-1184 SILICONE 100 POLYETHYLENE GLYCOL piperacillin sodium-tazobactam PNA-HRT BASE 325 1450 325 POLYETHYLENE GLYCOL sodium 304 PNEUMOVAX 23 337 PIPERAZINE CITRATE 16 1500 325 PNEUMOVAX 23/1 POLYETHYLENE GLYCOL PIPERINE 97 DOSE 337 300 325 PIQRAY 200MG DAILY PNV TABS 20-1 283 POLYETHYLENE GLYCOL DOSE 58 PNV TABS 29-1 283 3350 325 PIQRAY 250MG DAILY POLYETHYLENE GLYCOL DOSE 58 PNV-DHA+DOCUSATE 283 400 325 PIQRAY 300MG DAILY PNV-OMEGA 283 POLYETHYLENE GLYCOL DOSE 58 POCKETCHEM EZ BLOOD 4500 325 PIRACETAM 97 GLUCOSE MONITORING POLYETHYLENE GLYCOL piroxicam 7 SYSTEM 211 600 106 POCKETCHEM EZ BLOOD POLYETHYLENE GLYCOL PIROXICAM 7 GLUCOSE TEST 8000 325 PITOCIN 302 STRIPS 151 POLYETHYLENE GLYCOL PLAN B ONE-STEP 113 POCKETCHEM EZ CONTROL 8000BASE E 325 PLAQUENIL 51 LEVEL 1 211 POLYETHYLENE GLYCOL POD-CARE 100C 116 BLEND 325 PLASMA-LYTE A 268 POLYETHYLENE GLYCOL POD-CARE 100CG 116 PLASMA-LYTE-148 268 NF 325 POD-CARE 100CMX 116 PLASTIBASE 324 POLYHEXAMETHYLENE PLASTIC ADHESIVE POD-CARE 100K 116 BIGUANIDE 97 BANDAGES 3/4" 189 POD-CARE 100KG 116 POLYMAC PROGEL 325 PLASTIC BANDAGES 3/4" 189 POD-CARE 100KMX 116 POLYMATRIX POWDER 320 PLASTICIZED BASE 324 PODOCON 25 IN BENZOIN POLYMEM FILM DOT 189 PLAVIX 166 TINCTURE 136 POLYMEM NON-ADHESIVE PODOFILOX 97 PAD 189 PLEGISOL 74 podofilox 136 POLYMYXIN B SULFATE 19 PLEGRIDY 328 polymyxin b sulfate 19 PLEGRIDY STARTER PODOPHYLLUM RESIN 136 PACK 328 POGO AUTOMATIC BLOOD polymyxin b-trimethoprim 297 PLENVU 173 GLUCOSE MONITORING POLYOX WSR-301 106 SYSTEM 211 PLEXION 122 POLYOXYL 40 STEARATE326 POINT OF CARE KM 116 PLEXION CLEANSER 122 POLYOXYL LAURYL POINT OF CARE L.2 116 PLEXION CLEANSING ETHER 275 POLYPEG SUPPOSITORY CLOTHS 122 POINT OF CARE L.5 116 BASE 320 PLIAGLIS 138 POINT OF CARE LM DEP 2 116 POLYSORBATE 20 107 PLIXDA 122 POINT OF CARE LM-2.2 174 POLYSORBATE 40 107 PLO GEL - MEDIFLO 30 PRE- MIXED 324 POINT OF CARE LM-2.5 174 POLYSORBATE 60 107 PLO GEL - MEDIFLO KIT 324 POLIVY 55 POLYSORBATE 80 107 PLO GEL - MEDIFLO PRE- POLOX 320 POLYTRIM 297 MIXED 324 POLOXAMER 188 320 POLYVINYL ALCOHOL 97 PLO TRANSDERMAL POLYVINYLPYRROLIDONE K- CREAM 324 POLOXAMER 407 320 POLY-VI-FLOR 281 30 97 PLO20 BASE 324 POLYVINYLPYRROLIDONE K- PLO20 FLOWABLE 324 POLY-VI-FLOR FS 281 90 97 PLO20 NON-FLOWABLE 324 POLY-VI-FLOR/IRON 282 POMALYST 56 PLURONIC 320 POLYACRYLATE POMEGRANATE SEED 98 CROSSPOLYMER-6 97 PONAZURIL 98 PLURONIC F127 320 POLYBASE 325 PLURONIC L64 320 POLYETHYLENE GLYCOL PONVORY 328 PMS FORMULA 1000 325 PONVORY 14-DAY STARTER INDOLPLEX 273 PACK 328

Index 78 PORTRAZZA 55 POTASSIUM CITRATE PRAMOXINE HCL 138 posaconazole 42 MONOHYDRATE 163 PRANDIN 37 potassium citrate-citric pot & sod citrates w/citric acid 163 PRASTERA 4 ac 163 POTASSIUM GLUCONATE prasugrel hcl 166 pot phosphate monobasic w/ sod ANHYDROUS 110 PRAVACHOL 45 phosphate dibasic & POTASSIUM monobasic 269 HYDROXIDE 77 pravastatin sodium 46 POTASH SULFURATED PRAXBIND 40 LUMP 110 POTASSIUM IODIDE 98 praziquantel 16 POTASSIUM ACETATE 98 POTASSIUM METABISULFITE 98 PRAZIQUANTEL 98 potassium acetate 269 POTASSIUM NITRATE 110 prazosin hcl 48 POTASSIUM ALUM 110 POTASSIUM PRAZOSIN POTASSIUM ASPARTATE 98 PERCHLORATE 110 HYDROCHLORIDE 48 POTASSIUM AZELAOYL POTASSIUM PRE & POST SX POUCH 141 DIGLYCINATE 98 PERMANGANATE 98 PRECEDEX 172 POTASSIUM BENZOATE 98 POTASSIUM PHOSPHATE PRECISION GLUCOSE POTASSIUM DIBASIC 98 POTASSIUM PHOSPHATE CONTROL 211 BICARBONATE 269 DIBASIC ANHYDROUS 98 PRECISION GLUCOSE potassium bicarbonate 269 POTASSIUM PHOSPHATE CONTROLSOLUTION (TRI- POTASSIUM MONOBASIC 98 LEVEL/HI/LO/NORMAL) 211 BITARTRATE 110 potassium phosphates 269 PRECISION GLUCOSE POTASSIUM BROMIDE 110 POTASSIUM KETONECONTROL SOLUTION POTASSIUM PHOSPHATES 269 1-LOW, 1-HIGH 211 CARBONATE 110 POTASSIUM SODIUM PRECISION potassium chloride 269 TARTRATE 98 GLUCOSE/KETONECONTROL POTASSIUM CHLORIDE 270 POTASSIUM SORBATE 305 SOLUTIONS 1-HI 1-LO 211 PRECISION LINK 211 potassium chloride 270 POTASSIUM SULFATE 98 PRECISION PCX 151 POTELIGEO 55 POTASSIUM CHLORIDE 270 PRECISION PCX PLUS TEST potassium chloride 270 POVIDONE 98 STRIPS 151 potassium chloride in POVIDONE IODINE 297 PRECISION POINT OF CARE dextrose 268 POVIDONE K-30 98 TEST STRIPS 151 potassium chloride in dextrose & PRECISION QID sodium chloride 268 POVIDONE-IODINE 98 MONITOR 211 potassium chloride in nacl 268 POWDER SCENT PRECISION QID TEST potassium chloride FRAGRANCE 98 STRIPS 151 microencapsulated crystals POWER-V 274 PRECISION SOF-TACT er 270 PR BENZOYL MONITOR 211 POTASSIUM PEROXIDE 122 PRECISION SOF-TACT TEST CHLORIDE/DEXTROSE 268 PR CREAM 140 STRIPS 151 POTASSIUM PR NATAL 400 284 PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X CHLORIDE/DEXTROSE/LACTA PR NATAL 400 EC 284 TED RINGERS 268 5/16" 250 POTASSIUM PR NATAL 430 284 PRECISION SURE-DOSE CHLORIDE/LIDOCAINE PR NATAL 430 EC 284 INSULIN SYRINGE/0.5ML/28G X 1/2" 250 HYDROCHLORIDE/SODIUM PRADAXA 27 CHLORIDE 268 PRECISION SURE-DOSE PRALIDOXIME INSULIN SYRINGE/0.5ML/29G X POTASSIUM CHLORIDE 40 CHLORIDE/SODIUM 1/2" 250 PRALINES AND CREAM PRECISION SURE-DOSE CHLORIDE 268 FLAVOR 308 POTASSIUM INSULIN SYRINGE/0.5ML/30G X CHLORIDE/SODIUMCHLORIDE PRALUENT 46 3/8" 250 268 pramipexole PRECISION SURE-DOSE POTASSIUM CITRATE 163 dihydrochloride 62 INSULIN SYRINGE/1ML/28G X 250 potassium citrate PRAMOTIC 302 1/2" (alkalinizer) 163 PRAMOX GEL 138

Index 79 PRECISION SURE-DOSE PREDNISOLONE SODIUM PREFERRED PLUS UNIFINE PLUSINSULIN PHOSPHATE/GATIFLOXACIN/ PENTIPS 31G X 8MM SYRINGE/0.3ML/29G X BROMFENAC 299 SHORT 251 1/2" 250 PREDNISOLONE SODIUM PREFERRED PLUS UNIFINE PRECISION SURE-DOSE PHOSPHATE/MOXIFLOXACIN PENTIPS 32GX4MM 251 PLUSINSULIN 299 PREFERRED PLUS UNIFINE SYRINGE/1ML/29G X 1/2" 250 PREDNISOLONE SODIUM PENTIPS/MINI/31GX5MM 251 PRECISION THINS GP PHOSPHATE/MOXIFLOXACIN PREFEST 159 LANCET 211 /BROMFENAC 299 pregabalin 29 PRECISION XTRA 211 PREDNISOLONE- PREGABALIN 98 PRECISION XTRA BLOOD GATIFLOXACIN 299 GLUCOSE TEST STRIPS 151 PREDNISOLONE/BROMFENA pregabalin (once-daily) 329 PRECISION XTRA C 299 PREGEN DHA 284 PREDNISOLONE/GATIFLOXA MONITOR 211 PREGENNA 284 PRECOSE 34 CIN/BROMFENAC 300 PREDNISOLONEUSP, PREGNENOLONE 110 PRED FORTE 299 MICRONIZED PREGNENOLONE PRED MILD 299 ANHYDROUS 117 MICRONIZED 110 PRED-G 299 PREDNISONE 117 PREGNYL W/DILUENT BENZYLALCOHOL/NACL 155 PRED-G S.O.P. 299 prednisone 117 PREMARIN 160,339 prednicarbate 133 PREDNISONE INTENSOL 117 PREMASOL 295 PREDNISOLONE 116 PREFERRED PLUS INSULIN PREMESISRX 284 prednisolone 117 SYRINGE/U-100/0.3ML/29G X PREMIUM BLOOD GLUCOSE PREDNISOLONE 1/2" 250 TEST STRIPS 151 ACETATE 116 PREFERRED PLUS INSULIN PREMIUM SCAR PATCH 138 prednisolone acetate SYRINGE/U-100/0.3ML/30G X (ophth) 299 5/16" 250 PREMPHASE 159 PREDNISOLONE ACETATE P- PREFERRED PLUS INSULIN PREMPRO 159 F 299 SYRINGE/U-100/0.5ML/28G X PRENA 1 TRUE 284 PREDNISOLONE 1/2" 251 PRENA1 CHEW 284 ACETATE/MOXIFLOXACIN PREFERRED PLUS INSULIN 299 SYRINGE/U-100/0.5ML/29G X PRENA1 PEARL 284 PREDNISOLONE 1/2" 251 PRENAISSANCE 284 ACETATE/MOXIFLOXACIN/BRO PREFERRED PLUS INSULIN PRENAISSANCE PLUS 284 MFENAC 299 SYRINGE/U-100/0.5ML/30G X PREDNISOLONE 5/16" 251 PRENARA 284 ACETATE/MOXIFLOXACIN/NEP PREFERRED PLUS INSULIN PRENATABS FA 284 AFENAC 299 SYRINGE/U-100/1ML/28G X PRENATAL 284 PREDNISOLONE 1/2" 251 PRENATAL + COMPLETE ACETATE/NEPAFENAC 299 PREFERRED PLUS INSULIN MULTI/DHA/CHOLINE/FOLATE PREDNISOLONE SYRINGE/U-100/1ML/29G X 284 ANHYDROUS 116 1/2" 251 PRENATAL + DHA 284 PREDNISOLONE SODIUM PREFERRED PLUS INSULIN PHOSPHATE 117 SYRINGE/U-100/1ML/30G X PRENATAL 19 284 prednisolone sodium 5/16" 251 PRENATAL ADULT phosphate 117 PREFERRED PLUS LANCETS GUMMY/DHA/FOLIC ACID 284 PREDNISOLONE SODIUM COLORED 21G 211 PRENATAL PLUS IRON 284 PHOSPHATE 299 PREFERRED PLUS LANCETS prenatal vit w/ docusate-iron PREDNISOLONE SODIUM SUPER THIN 30G 211 carbonyl-folic acid 284 PHOSPHATE, USP 117 PREFERRED PLUS LANCETS prenatal vit w/ ferrous fumarate- PREDNISOLONE SODIUM THIN 26G 211 folic acid 284 PHOSPHATE/BROMFENAC PREFERRED PLUS UNIFINE prenatal vit w/ ferrous fumarate-l 299 PENTIPS 29G X 12MM 251 methylfolate-folic acid 284 PREDNISOLONE SODIUM PREFERRED PLUS UNIFINE prenatal vit w/ iron carbonyl-folic PHOSPHATE/GATIFLOXACIN PENTIPS 31G X 6MM ULTRA acid 284,285 299 SHORT 251 PRENATAL VITAMINS PLUS LOW IRON 285

Index 80 prenatal without a w/ fe fumarate- PRIALT 8 PRO COMFORT INSULIN l methylfolate-fa-dha 285 PRIFTIN 52 SYRINGES/0.5ML/30G X PRENATAL-U 285 1/2" 251 PRILO PATCH 138 PRENATE 285 PRO COMFORT INSULIN PRILO PATCH II 138 SYRINGES/0.5ML/30G X PRENATE AM 285 PRILOCAINE 98 5/16" 251 PRENATE DHA 285 PRO COMFORT INSULIN PRILOCAINE HCL 98 PRENATE ELITE 285 SYRINGES/0.5ML/31G X PRILOCAINE HCLUSP 98 5/16" 251 PRENATE ENHANCE 285 PRILOCAINE PRO COMFORT INSULIN PRENATE ESSENTIAL 285 HYDROCHLORIDE 98 SYRINGES/1ML/30G X PRENATE MINI 285 PRILOHEAL PLUS 30 138 1/2" 251 PRENATE PIXIE 285 PRILOPENTIN 329 PRO COMFORT INSULIN SYRINGES/1ML/30G X PRENATE RESTORE 285 PRILOSEC 336 5/16" 251 PRENATRIX 285 PRILOVIXIL 138 PRO COMFORT INSULIN PRENATRYL 285 PRIMACARE 285 SYRINGES/1ML/31G X PRENATVITE COMPLETE 285 PRIMACOL THIN DRESSING 5/16" 251 PRO COMFORT LANCETS PRENATVITE PLUS 285 4"X4" 145 PRIMACOL THIN DRESSING 30G 211 PRENATVITE RX 285 6"X6" 145 PRO COMFORT LANCETS PREPIV SUPPLY 138 PRIMAPORE 11-3/4"X4" 189 31G 211 PRO COMFORT PEN PREPLUS 285 PRIMAPORE 13-3/4"X4" 189 NEEDLES/31G X 8MM 251 PREPOPIK 173 PRIMAPORE 2-7/8"X2" 189 PRO COMFORT PEN PRESERA 140 PRIMAPORE 4"X3-1/8" 189 NEEDLES/32G X 4MM 251 PRO COMFORT PEN PRESSURE ACTIVATED PRIMAPORE 6"X3-1/8" 189 SAFETYLANCET 21G 211 NEEDLES/32G X 5MM 251 PRIMAPORE 8"X4" 189 PRESTALIA 49 PRO COMFORT PEN primaquine phosphate 51 NEEDLES/32G X 6MM 251 PRETAB 285 PRIMAQUINE PRO HERS RX 287 PRETOMANID 52 PHOSPHATE 51 PRO HIS RX 287 PREVACID 336 PRIMAXIN IV 18 PRO NUTRIENTS FRUIT & PREVACID 24HR 336 primidone 29 VEGGIE 274 PREVACID SOLUTAB 336 PRIMIDONE 98 PRO NUTRIENTS PROBIOTIC 38 PREVALON 220 PRIMLEV 14 PRO PCOS RX 287 PREVALON FOOT/LEG PRIMSOL 17 STABILIZER WEDGE 220 PRO VOICE V8 BLOOD PREVALON PRESSURE PRINIVIL 47 GLUCOSE MONITORING RELIEVING HEEL PRISMASOL B22GK 4/0 271 SYSTEM 211 PROTECTOR 220 PRO VOICE V8/V9 BLOOD PRISMASOL BGK 0/2.5 271 GLUCOSE TEST STRIPS 151 PREVALON PRESSURE PRISMASOL BGK 2/0 271 RELIEVING HEEL PRO VOICE V9 BLOOD PROTECTOR/PETITE 220 PRISMASOL BGK 2/3.5 271 GLUCOSE MONITORING PREVALON PRESSURE PRISMASOL BGK SYSTEM 211 RELIEVING HEEL 4/0/1.2 271 PRO-C-DURE 5 KIT 117 PROTECTOR/WEDGE 220 PRISMASOL BGK 4/2.5 271 PRO-C-DURE 6 KIT 117 PREVENT SAFETY PEN PRISMASOL BK 0/0/1.2 271 PROAIR DIGIHALER 25 NEEDLES 31GX1/4" 251 PREVENT SAFETY PEN PRISTIQ 33 PROAIR HFA 25 NEEDLES 31GX5/16" 251 PRIVIGEN 303 PROAIR RESPICLICK 25 PREVIDOLRX ANALGESIC PRIZOPAK II 138 probenecid 165 PAK 7 PRIZOTRAL 138 PROBICHEW 38 PREVNAR 13 337 PRIZOTRAL II 138 PROBIOMAX PLUS DF 38 PREVYMIS 68 PRO COMFORT ALCOHOL PROBIOTIC 38 PREZCOBIX 67 PADS 226 PROBIOTIC + PREZISTA 67 COLOSTRUM 38

Index 81 PROBIOTIC GOLD EXTRA PRODIGY VOICE BLOOD PROPANTHELINE STRENGTH 38 GLUCOSE METER KIT 212 BROMIDE 334 PROBUPHINE IMPLANT PROFILNINE 165 propantheline bromide 334 KIT 14 PROFILNINE SD 165 PROPARACAINE HCL 99 PROCAINAMIDE HCL 21 PROFLAVINE proparacaine hcl 298 procainamide hcl 21 HEMISULFATE 98 PROPIONIC ACID 99 PROCAINE HCL 176 PROFOOT PLANTAR propofol 163 PROCALAMINE 295 FASCIITIS 220 PROGESTERONE 98 propranolol & PROCARBAZINE HCL 98 hydrochlorothiazide 49 progesterone 327 PROCARDIA 73 propranolol hcl 72 PROGESTERONE 10% PROCARDIA XL 73 KIT 327 PROPRANOLOL HCL 72 prochlorperazine 65 PROGESTERONE propranolol hcl 72 prochlorperazine edisylate 64 COMPOUNDINGKIT 327 PROPYL GALLATE 99 PROGESTERONE PROCHLORPERAZINE PROPYLENE GLYCOL 99 EDISYLATE 98 CONCENTRATE 98 PROGESTERONE PROPYLENE GLYCOL PROCHLORPERAZINE MONOSTEARATE 99 MALEATE 65 MICRONIZED 98 PROGESTERONE PROPYLPARABEN 305 prochlorperazine maleate 65 MICRONIZED (SOY) 98 PROPYLPARABEN PROCRIT 167 PROGESTERONE SODIUM 305 PROCTOCORT 16 MICRONIZED (YAM) 98 PROPYLTHIOURACIL 99 PROCTOFOAM HC 16 PROGESTERONE propylthiouracil 332 MICRONIZED PREMIUM 98 PROCYSBI 164 PROGESTERONE PROQUAD 338 PRODIGY AUTOCODE BLOOD MILLED 98 PROSCAR 164 GLUCOSE MONITORING PROGESTERONE ULTRA PROSOL 295 SYSTEM 211 MICRONIZED 98 PRODIGY AUTOCODE BLOOD PROGESTERONE PROSTAGLANDIN E1 110 GLUCOSE WETTABLE 99 PROSTAGLANDIN E2 87 MONITORING/TALKING 211 PROGESTERONE WETTABLE PROSTIN VR PEDIATRIC 275 PRODIGY CONTROL (YAM) 99 PROTAMINE SULFATE 99 SOLUTIONHIGH 211 PROGLYCEM 35 PROTEXA 134 PRODIGY CONTROL PROGRAF 272 SOLUTIONLOW 211 PROTHELIAL 276 PROLASTIN-C 330 PRODIGY INSULIN SYRING/U- PROTONIX 336 100/0.3ML/31G X 5/16" 251 PROLATE 14 PROTOPAM CHLORIDE 40 PRODIGY INSULIN PROLENSA 301 SYRINGE/1/2ML/31G X PROTOPIC 135 PROLEUKIN 60 5/16" 251 protriptyline hcl 33 PRODIGY INSULIN PROLIA 154 PROVAYBLUE 40 SYRINGE/1ML/28G X 1/2" 251 PROMACTA 167 PROVENGE 55 PRODIGY LANCING PROMAZINE HCL 99 DEVICE 211 promethazine & PROVENTIL HFA 25 PRODIGY NO CODING BLOOD PROVERA 327 GLUCOSE 211 phenylephrine 118 PRODIGY NO CODING BLOOD promethazine hcl 43 PROVIDA DHA 285 GLUCOSE TEST STRIPS 151 PROMETHAZINE HCL 99 PROVIDA OB 285 PRODIGY POCKET BLOOD promethazine w/codeine 118 PROVIGIL 3 GLUCOSE METER KIT 211 PRODIGY PRESSURE promethazine-dm 118 PROVISC 300 ACTIVATED SAFETY promethazine-phenylephrine- PROXI-STRIP 1/4" X 4" 189 LANCETS 211 codeine 118 PROXI-STRIPS 1/2"X4" 189 PRODIGY SAFETY PROMETRIUM 327 PROZAC 32 LANCETS 211 PROMISEB 129 PRUCLAIR 140 PRODIGY TWIST TOP propafenone hcl 22 LANCETS 212 PRUDOXIN 128 PROPANEDIOL 99 PRUMYX 140

Index 82 pseudoephed-bromphen- PX PEN NEEDLE QC LANCETS ULTRA dm 118 31GX8MM 252 THIN 212 pseudoephed-cpm w/ PX PURIFIED WATER 316 QC NON-ADHERENT PADS hydrocod 118 PX SHORTLENGTH PEN 3"X4" 189 PSEUDOEPHEDRINE HCL290 NEEDLES/31GX8MM 252 QC PEN NEEDLES 29G X PSORCON 133 PX SUPERSTRIP 1" X 3" 189 12MM 252 QC PEN NEEDLES 31G X PSS SELECT GP PYCNOGENOL 6MM 252 LANCETS 212 COMPLEX 274 QC PEN NEEDLES 31G X PSS SELECT SAFETY PYLERA 336 8MM 252 LANCETS 212 PYRANTEL PAMOATE 99 QC SENSITIVE EXTREME 227 PSYLLIUM HUSK 99 pyrazinamide 52 PTS PANELS GLUCOSE QC STERILE PADS 189 TEST 151 PYRAZINAMIDE 99 QC SWEET OIL 107 PULLULAN 99 PYRIDIUM 164 QC UNIFINE PENTIPS PULMICORT 23 pyridostigmine bromide 51 32GX4MM 252 QC UNILET LANCETS PULMICORT FLEXHALER 23 PYRIDOSTIGMINE BROMIDE 99 28G/ULTRA THIN 212 PULMOZYME 330 PYRIDOXAL-5-PHOSPHATE QC UNILET LANCETS PUMICE (FLOUR) 110 342 33G/MICRO THIN 212 PUMICE STONE 220 PYRIDOXAL-5-PHOSPHATE QDOLO 12 PUMPKIN FLAVOR 308 MONOHYDRATE 99 QELBREE 2 PURE COMFORT ALCOHOL PYRIDOXINE HCL 342 QINLOCK 58 PREPPADS 226 pyridoxine hcl 342 QMIIZ ODT 7 PURE COMFORT LANCETS PYRIDOXINE QNASL 290 30G 212 HYDROCHLORIDE 342 QNASL CHILDRENS 290 PURE COMFORT PEN NEEDLE PYRILAMINE MALEATE 43 QTERN 34 32G X6MM 251 pyrimethamine 51 PURE COMFORT PEN NEEDLE QUADRACEL 333 PYRIMETHAMINE 99 32G X8MM 251 QUADRAMET 59 PURE COMFORT PEN PYRIMETHAMINE/LEUCOVO NEEDLE/32G X 5MM 251 RIN 50 QUALAQUIN 51 PURE COMFORT PEN PYROGALLIC ACID 136 QUARTETTE 112 NEEDLE/32G X4MM 251 PYROGALLOL 110 QUATERNIUM-15 99 PURIFIED WATER 316 PYRUVIC ACID 110 quazepam 172 PURIXAN 53 Q-DERM 325 QUDEXY XR 29 PUSH BUTTON SAFETY LANCETS 21G 212 QBRELIS 47 QUELICIN 290 PUSH BUTTON SAFETY QBREXZA 141 QUERCETIN DIHYDRATE 99 LANCETS 28G 212 QC ADVANCED LANCING QUESTRAN 44 PX ADVANCED LANCING DEVICE 212 QUESTRAN LIGHT 44 DEVICE 212 QC ALCOHOL SWABS 226 quetiapine fumarate 64 PX EXTRA SHORT PEN QC ALL PURPOSE NEEDLES 31GX6MM 252 DRESSINGS4"X4" 189 QUFLORA FE 277 PX INSULIN SYRINGE/U- QC BORDER ISLAND GAUZE QUFLORA FE PEDIATRIC 282 100/0.5ML/30G X 1/2" 252 PAD 2"X2" 189 QUFLORA GUMMIES 281 PX LANCET AUTO QC BORIC ACID 110 INJECTOR 212 QUFLORA PEDIATRIC 281 PX LANCETS MICROTHIN QC CASTOR OIL 107 QUICKTEK 212 33G 212 QC COD LIVER OIL 288 QUICKTEK CONTROL PX LANCETS ULTRA QC GLUCOSAMINE & SOLUTION 212 THIN 212 CHONDROITIN TRIPLE QUICKTEK TEST STRIPS 151 PX LANCETS ULTRA THIN STRENGTH/MSM 274 QUIHOXVAR 127 28G 212 QC IODIDES TINCTURE 65 PX MINI PEN NEEDLES QUILLICHEW ER 3 QC IODINE TINCTURE 65 31GX5MM 252 QUILLIVANT XR 3 PX PEN NEEDLE QC LANCETS SUPER 29GX12MM 252 THIN 212

Index 83 QUINACRINE RA E-ZJECT LANCETS THIN raloxifene hcl 156 DIHYDROCHLORIDE 51 26G 212 ramelteon 172 QUINACRINE RA E-ZJECT LANCETS THIN DIHYDROCHLORIDE 28G 212 ramipril 47 DIHYDRATE 51 RA E-ZJECT LANCETS RANEXA 20 QUINACRINE HCL 51 ULTRATHIN 30G 212 RANITIDINE HCL 99 quinapril hcl 47 RA EAR CARE 287 ranitidine hcl 335 quinapril-hydrochlorothiazide RA ESTROPLUS MAX RANITIDINE 49 STRENGTH 274 HYDROCHLORIDE 99 quinidine gluconate 21 RA FIRST AID FLEXIBLE FABRIC ADHESIVE ranolazine 20 quinidine sulfate 21 BANDAGE 189 RAPAFLO 164 QUINIDINE SULFATE RA FIRST AID IODINE 65 RAPAMUNE 272 DIHYDRATE 110 RA FIRST AID NON-STICK RAPESEED OIL 99 QUININE HCL 99 PADS 189 RAPIVAB 70 quinine sulfate 51 RA GAUZE BANDAGE 189 rasagiline mesylate 63 QUININE SULFATE 51 RA GEL TOE QUININE SULFATE SEPARATORS 220 RASAGILINE MESYLATE 99 DIHYDRATE 51 RA INSULIN RASPBERRY QUINIXIL 133 SYRINGE/0.5ML/29G X CONCENTRATE 308 1/2" 252 RASPBERRY FLAVOR 308 QUINIZARIN GREEN SS 306 RA INSULIN RASPBERRY FLAVOR QUINOSONE 133 SYRINGE/1ML/29G X ARTIFICIAL 308 QUINTET AC BLOOD 1/2" 252 RASPBERRY SYRUP 316 GLUCOSEMONITORING RA INSULIN SYRINGE/U- SYSTEM 212 100/0.5ML/30G X 5/16" 252 RASUVO 4 QUINTET AC BLOOD RA INSULIN SYRINGE/U- RAUWOLFIA SERPENTINA 99 GLUCOSETEST STRIPS 151 100/1 ML/30G X 5/16" 252 RAVICTI 157 QUINTET BLOOD GLUCOSE RA ISOPROPYL ALCOHOL RAY-TEC X-RAY MONITORING SYSTEM 212 WIPES 141 DETECTABLESPONGES 4" X 4" QUINTET BLOOD GLUCOSE RA PEN NEEDLES 31G X 16 PLY 189 TEST STRIPS 151 5MM3/16" 252 RAY-TEC X-RAY QUINTET GLUCOSE RA PEN NEEDLES 31G X DETECTABLESPONGES 8" X 4" CONTROL/HIGH/NORMAL 8MM5/16" 252 12 PLY 190 212 RA PETROLEUM JELLY 325 RAY-TEC X-RAY QUTENZA 138 RA PLANTAR FASCIITIS DETECTABLESPONGES 8" X 4" QUZYTTIR 43 ARCH SLEEVE 220 16 PLY 190 QVAR REDIHALER 23 RA SHEER ADHESIVE RAYALDEE 157 LARGE 189 R-NATAL OB 285 RA STERILE PADS RAYOS 117 R.N.A. - 180 274 2"X2" 189 RAZADYNE 327 RA ADHESIVE RA STERILE PADS RAZADYNE ER 327 BANDAGES 189 4"X4" 189 RDT BASE 320 RA ADHESIVE BANDAGES RABAVERT 338 RDT-PLUS 320 FLEXIBLE FOAM 189 rabeprazole sodium 336 RA ALCOHOL SWABS 226 RE:IIMMUNE 38 RABEPRAZOLE SODIUM DR READYLANCE SAFETY RA BANDAGES/EXTRA LONG SPRINKLE 336 FABRIC/HEAVY DUTY 189 LANCETS/21G/2.2MM 212 RACEPINEPHRINE HCL 99 READYLANCE SAFETY RA BORIC ACID 110 RADIACARE POST LANCETS/23G/1.8MM 212 RA COD LIVER OIL 288 HEALING 145 READYLANCE SAFETY RA CONFORMED RADIADRES GEL LANCETS/26G/1.8MM 212 BANDAGE 189 SHEET 145 READYLANCE SAFETY RA CUSHION INSOLES RADIAGEL 145 LANCETS/28G/1.8MM 212 WOMENS 220 RADIAPLEXRX 145 READYLANCE SAFETY RA DRY MOUTH 276 RADICAVA 290 LANCETS/30G/1.6MM 212 RA E-ZJECT LANCETS READYSHARP ANESTHETICS 28G 212 RADIOGARDASE 40 +BETAMETHASONE 117

Index 84 READYSHARP ANESTHETICS REFUAH PLUS BLOOD RELION INSULIN SYRINGE/U- +DEXAMETHASONE 117 GLUCOSEMONITORING 100/1ML/31G X 5/16" 252 READYSHARP ANESTHETICS SYSTEM 212 RELION KETONE TEST +KETOROLAC 7 REFUAH PLUS BLOOD STRIPS 151 READYSHARP ANESTHETICS GLUCOSETEST STRIPS 151 RELION LANCETS MICRO- +METHYLPREDNISOLONE REFUAH PLUS GLUCOSE THIN33G 213 80 117 CONTROL SOLUTION 212 RELION LANCETS THIN READYSHARP REGEN-COV 303 26G 213 BETAMETHASONE 117 REGENECARE 145 RELION LANCETS ULTRA- READYSHARP THIN30G 213 DEXAMETHASONE 117 REGENT ALCOHOL 316 RELION LANCING READYSHARP KETOROLAC 7 REGIOCIT 27 DEVICE 213 READYSHARP REGLAN 161 RELION MICRO BLOOD GLUCOSE MONITORING LIDOCAINE 175 REGONOL 51 READYSHARP-A 174 SYSTEM 213 REGRANEX 145 RELION MINI PEN NEEDLES READYSHARP-K 117 RELAFEN DS 7 31GX6MM 252 REAL HEAL-I 138 RELAX & SLEEP 274 RELION PEN NEEDLES REALITY INSULIN SYRINGE/U- 29GX12MM 252 RELEASE NON-ADHERING RELION PEN NEEDLES 31G 100/0.5ML/28G X 1/2" 252 DRESSING 4" X 3" 190 REALITY INSULIN SYRINGE/U- X6MM 252 100/0.5ML/29G X 1/2" 252 RELENZA DISKHALER 70 RELION PEN NEEDLES 31G REALITY INSULIN SYRINGE/U- RELEXXII 3 X8MM 252 100/1ML/28G X 1/2" 252 RELIAMED SELF-ADHESIVE RELION PEN NEEDLES REALITY INSULIN SYRINGE/U- DRESSING RETENTION 31GX5/16" 252 100/1ML/29G X 1/2" 252 SHEET 190 RELION PEN NEEDLES REALITY LANCETS 212 RELION 2-IN-1 LANCET 31GX6MM 252 RELION PEN NEEDLES REALITY SWABS 226 DEVICES 30G 212 RELION 2-IN-1 LANCING 31GX8MM 253 REALITY TRIGGER DEVICE 25G 212 RELION PEN NEEDLES 32G LANCETS 212 RELION 2-IN-1 LANCING X4MM 253 REBIF 328 DEVICE 30G 212 RELION PEN NEEDLES 32G REBIF REBIDOSE 328 RELION ALCOHOL X5/32" 253 REBIF REBIDOSE SWABS 226 RELION PEN NEEDLES TITRATIONPACK 328 RELION ALL-IN-ONE 32GX4MM 253 REBIF TITRATION PACK 328 COMPACTBLOOD GLUCOSE RELION PEN NEEDLES/31G TESTING SYSTEM 213 X1/4" 253 REBLOZYL 167 RELION BLOOD GLUCOSE RELION PREMIER BLOOD RECARBRIO 18 TESTSTRIPS 151 GLUCOSE TEST STRIPS 151 RECEDO 142 RELION CONFIRM BLOOD RELION PREMIER BLU BLOOD GLUCOSE MONITORING RECK 174 GLUCOSE MONITORING SYSTEM 213 SYSTEM 213 RECLAST 154 RELION CONFIRM/MICRO RELION PREMIER CLASSIC RECOMBINATE 165 TEST STRIPS 151 BLOOD GLUCOSE RECOMBIVAX HB 338 RELION INSULIN SYRINGE MONITORING SYSTEM 213 0.5ML/31G X 15/64" 252 RELION PREMIER COMPACT RECOTHROM 170 RELION INSULIN SYRINGE BLOOD GLUCOSE RECOTHROM SPRAY KIT 170 1ML/31GX15/64" 252 MONITORING SYSTEM 213 RECOTHROM/SPRAY RELION INSULIN SYRINGE/U- RELION PREMIER VOICE APPLICATOR KIT 170 100/0.3ML/31G X 15/64" 252 BLOOD GLUCOSE RECTIV 16 RELION INSULIN SYRINGE/U- MONITORING SYSTEM 213 RELION PRIME BLOOD RECURA 127 100/0.3ML/31G X 5/16" 252 RELION INSULIN SYRINGE/U- GLUCOSE MONITORING RED YEAST RICE 99 100/0.5ML/29G X 1/2" 252 SYSTEM 213 RED YEAST RICE RELION INSULIN SYRINGE/U- RELION PRIME BLOOD EXTRACT 99 100/0.5ML/31G X 5/16" 252 GLUCOSE TEST STRIPS 151 REDITREX 4 RELION INSULIN SYRINGE/U- RELION SHORT PEN 100/1ML/31G X 15/64" 252 NEEDLES31GX8MM 253

Index 85 RELION TRUE METRIX AIR REQUIP XL 62 RETROVIR IV INFUSION 67 BLOOD GLUCOSE RESCRIPTOR 67 REVATIO 75 METER/BLUETOOTH 213 RELION TRUE METRIX RESERPINE 48 REVCOVI 157 BLOODGLUCOSE TEST RESORCINOL 110 REVEAL BLOOD GLUCOSE STRIPS 151 resorcinol-sulfur 122 MONITOR 213 RELION ULTIMA BLOOD REVEAL BLOOD GLUCOSE GLUCOSE MONITORING RESTASIS 298 TEST 151 SYSTEM 213 RESTASIS MULTIDOSE 298 REVESTA 169 RELION ULTIMA BLOOD RESTORA RX 39 REVITADERM WOUND GLUCOSE TEST STRIPS 151 RESTORE 38 CARE 145 RELION ULTRA THIN RESTORE CONTACT REVLIMID 271 LANCETS/30G 213 LAYER/NON-ADHERENT REXALL BLOOD GLUCOSE RELION ULTRA THIN MONITORING SYSTEM 213 LANCETS30G 213 2"X2" 190 RESTORE DUO ABSORBENT REXALL BLOOD GLUCOSE RELION ULTRA THIN PLUS TEST STRIPS 151 LANCETS 32G 213 DRESSING 4"X5" 190 RESTORE FOAM DRESSING REXALL LANCETS ULTRA RELION ULTRA THIN PLUS THIN 213 LANCETS 33G 213 BORDERED 4"X4" 190 RESTORE FOAM DRESSING REXAPHENAC 124 RELISTOR 162 BORDERED 6"X6" 190 REXASIL PATCH/VITAMIN E RELNATE DHA 285 RESTORE FOAM DRESSING KIT 145 RELPAX 266 NON-BORDERED 4"X4" 190 REXULTI 65 RELTONE 160 RESTORE FOAM DRESSING NON-BORDERED 6"X6" 190 REYATAZ 67 REMDESIVIR 70 RESTORE HYDROGEL REYVOW 266 REMEDIENT 280 DRESSING 145 REZAMID 122 REMERON 31 RESTORE LITE FOAM RHEOSPRAY 316 DRESSING NON-BORDERED REMERON SOLTAB 31 4"X5" 190 RHOFADE 141 REMESENSE 227 RESTORE LITE FOAM RHOGAM ULTRA-FILTERED REMICADE 161 DRESSING NON-BORDERED PLUS 303 RHOPHYLAC 303 remifentanil hcl 12 6"X6" 190 RESTORE ODOR RHOPRESSA 298 REMIGEN CREAM 140 ABSORBING DRESSING RIABNI 55 REMODULIN 75 4"X4" 190 REMOVE ADHESIVE RESTORE TRIO ABSORBENT RIASTAP 165 REMOVER 140 DRESSING 4"X5" 190 RIAX 122 RENACIDIN 164 RESTORIL 172 RIBASPHERE 69 RENAGEL 162 RESVERATROL 99 RIBASPHERE RIBAPAK 69 RENATABS 277 RESVERATROL 98% 99 ribavirin 70 RENATABS WITH IRON 277 RESVERATROL 98+% 99 RIBAVIRIN 99 RENEWCREAM HRT 325 RETACRIT 167 ribavirin (hepatitis c) 69 RENFLEXIS 161 RETAINE VISION 287 RIBOFLAVIN 99 RENOVAGE 103 RETEVMO 58 RIBOFLAVIN-5-PHOSPHATE RENOVO 138 RETIN-A 122 SODIUM 99 RIBOFLAVIN-5-PHOSPHATE RENVELA 162 RETIN-A MICRO 122 SODIUM ANHYDROUS 99 repaglinide 37 RETIN-A MICRO PUMP 122 RIBOSE (D) 87 repaglinide-metformin hcl 34 RETINALDEHYDE 99 RIDAURA 4 REPATHA 46 RETINOIC ACID 122 rifabutin 52 REPATHA PUSHTRONEX RETINOIC ACID-ALL RIFADIN 52 SYSTEM 46 TRANS 122 RIFAMATE 51 REPATHA SURECLICK 46 RETINOL MOLECULAR FILM 105 rifampin 52 REPHRESH PRO-B 38 RETISERT 300 RIFAMPIN 99 REQ 49+ 280 RETROVIR 67

Index 86 RIFAMPIN/SYRSPEND SF ROAOXIA 127 RUXIENCE 55 PH4 52 ROBAXIN 289 RUZURGI 51 RIFATER 51 ROBAXIN-750 289 RYANODEX 289 RIFAXIMIN 99 ROCALTROL 157 RYBELSUS 35 RIGHTEST GC300 HIGH CONTROL 213 ROCKLATAN 298 RYBREVANT 55 RIGHTEST GC300 NORMAL ROCURONIUM BROMIDE 99 RYDAPT 58 CONTROL 213 rocuronium bromide 291 RYLAZE 59 RIGHTEST GD500 LANCING ROCURONIUM RYTARY 62 DEVICE 213 BROMIDE 291 RIGHTEST GL300 RYTHMOL SR 22 ROMIDEPSIN 58 LANCETS 213 RYVENT 43 RONIDAZOLE 99 RIGHTEST GM100 BLOOD SA3 DERM 325 GLUCOSE MONITORING ROOT BEER FLAVOR 308 SABRIL 30 SYSTEM 213 ROPIDEX 117 RIGHTEST GM300 BLOOD SACCHARIN CALCIUM 100 GLUCOSE MONITORING ropinirole hydrochloride 62 SAFE-T-LANCE LOW FLOW SYSTEM 213 ropivacaine hcl 175 25G 213 RIGHTEST GM550 BLOOD ROPIVACAINE SAFE-T-LANCE NORMAL GLUCOSE MONITORING HYDROCHLORIDE 100,175 FLOW21G 213 SYSTEM 213 ROPIVACAINE SAFE-T-LANCE PLUS RIGHTEST GS100 BLOOD HYDROCHLORIDE/CLONIDIN SAFETYLANCET HIGH GLUCOSE TEST STRIPS 151 E FLOW 213 RIGHTEST GS300 BLOOD HYDROCHLORIDE/KETOROL SAFE-T-LANCE PLUS GLUCOSE TEST STRIPS 152 AC 174 SAFETYLANCET LOW RIGHTEST GS550 BLOOD ROPIVACAINE FLOW 213 GLUCOSE TEST STRIPS 152 HYDROCHLORIDE/SODIUM SAFE-T-LANCE PLUS RIGHTEST GT333 BLOOD CHLORIDE 175 SAFETYLANCET NORMAL GLUCOSE MONITORING ROSADAN KIT 141 FLOW 214 SYSTEM 213 ROSE BENGAL B 100 SAFESNAP INSULIN RILUTEK 290 SYRINGE/0.3ML/30G X ROSE OIL 108 riluzole 290 5/16" 253 ROSEMARY OIL 108 SAFESNAP INSULIN rimantadine hydrochloride 70 ROSIN LUMP 111 SYRINGE/0.5ML/29G X RIMSO-50 164 1/2" 253 rosuvastatin calcium 46 ringer's 268 SAFESNAP INSULIN ROSZET 44 ringer's irrigation 272 SYRINGE/0.5ML/30G X ROTARIX 338 5/16" 253 RINVOQ 4 ROTATEQ 338 SAFESNAP INSULIN RIOMET 35 SYRINGE/1ML/28G X 1/2" 253 ROWASA 162 RIOMET ER 35 SAFESNAP INSULIN ROXICODONE 12 risedronate sodium 155 SYRINGE/1ML/29G X 1/2" 253 ROXYBOND 12 SAFETY INSULIN SYRINGES RISPERDAL 63 0.5ML/29GX1/2" 253 ROZEREM 172 RISPERDAL CONSTA 63 SAFETY INSULIN SYRINGES ROZLYTREK 58 risperidone 63 0.5ML/30GX5/16" 253 RTD WOUND CARE SAFETY INSULIN SYRINGES RITALIN 3 DRESSING2" X 2" 145 1ML/27GX1/2" 253 RITALIN LA 3 RTD WOUND CARE SAFETY INSULIN SYRINGES ritonavir 67 DRESSING4" X 4" 145 1ML/29GX1/2" 253 RTD WOUND CARE SAFETY INSULIN SYRINGES RITUXAN 55 DRESSING4" X 5" 145 1ML/30GX1/2" 253 RITUXAN HYCELA 57 RUBIDIUM CHLORIDE 100 SAFETY LANCET rivastigmine 327 RUBRACA 58 21G/PRESSURE rivastigmine tartrate 328 ACTIVATED 214 rufinamide 29 SAFETY LANCET RIXUBIS 165 RUKOBIA 67 23G/PRESSURE rizatriptan benzoate 266 RUTIN 100 ACTIVATED 214

Index 87 SAFETY LANCET SANTYL 135 scopolamine 41 28G/PRESSURE SAPHRIS 64 SCOPOLAMINE HBR 334 ACTIVATED 214 SAFETY LANCET sapropterin SE-NATAL 19 285 30G/PRESSURE dihydrochloride 157 SEASONAL IC 274 ACTIVATED 214 SAPS CARE ALCOHOL PREP PADS 226 SEASONIQUE 113 SAFETY LANCETS 214 SAPS HEALTH ALCOHOL SEBUDERM 140 SAFETY LANCETS 21G 214 PREPPADS 226 SECONAL SODIUM 171 SAFETY LANCETS 28G 214 SAPS HEALTH CARE ALCOHOLPREP PADS 226 SECRETIN-MANNITOL 100 SAFETY LET LANCETS 214 SAPS HEALTH CARE TWIST SECUADO 64 SAFETY SEAL LANCETS TOP LANCETS 214 SECURESAFE SAFETY 28G 214 SAPS HEALTH TWIST TOP INSULIN SYRINGES/U- SAFETY SEAL LANCETS LANCETS 30G 214 100/0.5ML/29GX1/2" 253 30G 214 SAPSCARE TWIST TOP SECURESAFE SAFETY SAFFLOWER OIL 108 LANCETS 30G 214 INSULIN SYRINGES/U- SAFYRAL 112 SARAFEM 329 100/1ML/29GX1/2" 253 SAGE LEAF 100 SARCLISA 55 SECURESAFE SAFETY PEN NEEDLES/30G X 5/16" 253 SAIZEN 156 308 SARDINE FLAVOR SEEBRI NEOHALER 22 SAIZENPREP 108 SASSAFRAS OIL SEGLUROMET 34 RECONSTITUTIONKIT 156 SAVAYSA 26 SALAGEN 276 SELECT-LITE LANCING SAVELLA 328 DEVICE 214 SALEX 136 SAVELLA TITRATION SELECT-OB 285 SALEX CREAM 136 PACK 328 SELECT-OB+DHA 285 SALEX LOTION 136 SAW PALMETTO selegiline hcl 63 SALICYLIC ACID 100 BERRY 100 SB ALCOHOL PREP SELEGILINE HCL 63 salicylic acid 136 PADS 226 selenious acid 270 salicylic acid w/ cleanser 136 SB INSULIN SYRINGE/U- SELENIOUS ACID 270 SALICYLIC 100/0.5ML/29G X 1/2" 253 ACID/SULFACETAMIDE SB INSULIN SYRINGE/U- SELENIUM SULFIDE 100 SODIUM MONOHYDRATE 122 100/0.5ML/30G X 5/16" 253 selenium sulfide 129 SALIMEZ 136 SB INSULIN SYRINGE/U- SELENIUM YEAST 100 100/1ML/29G X 1/2" 253 SALIMEZ FORTE 136 SB INSULIN SYRINGE/U- SELRX 129 SALINE/PHENOL 316 100/1ML/30G X 5/16" 253 SELZENTRY 67 SALIVAMAX 276 SB INSULIN SYRINGE/U- SEMGLEE 37 100/1ML/31G X 5/16" 253 salsalate 8 SEMPREX-D 118 SB LANCETS THIN 214 SALSALATE 100 SB LANCETS ULTRA SENNA 100 SALT DURABLE CREAM 325 THIN 214 SENSIPAR 157 SALT STABLE LS SCALACORT DK 133 SENSITIVE TOOTHPASTE ADVANCED 325 SCAR CARE BASE EXTRA WHITENING/FLUORIDE SALTSTABLE LO 325 ENHANCED 325 MAX ST 227 SALVAX 136 SCAR CARE CREAM 325 SENSITIVE TOOTHPASTE/FLUORIDE/MAXI SALVAX DUO PLUS 136 scar treatment products 142 MUM STRENGTH 227 SAMSCA 158 SCARCIN GEL 142 SENSODYNE MAXIMUM SANARE ADVANCED SCAR SCARCIN ROLL-ON 142 STRENGTH 227 THERAPY 325 SENSODYNE MAXIMUM SCARLET RED 100 SANARE SCAR THERAPY 325 STRENGTH/FLUORIDE 227 SCARSILK GEL 142 SANCUSO 40 SENSODYNE PRONAMEL 227 SCARZEN SKIN REPAIR 133 SANDIMMUNE 272 SENSODYNE PRONAMEL SCENESSE 141 FRESHBREATH 227 SANDOSTATIN 158 SCLEROSOL SENSORCAINE- SANDOSTATIN LAR INTRAPLEURAL 330 MPF/EPINEPHRINE 174 DEPOT 158

Index 88 SEPICALM VG 105 SHOPKO UNIFINE PENTIPS SILIQ 128 SEPINEO P 600 320 PEN silodosin 164 NEEDLES/SHORT/31GX8MM SERAQUA 316 253 SILOSOME SEREVENT DISKUS 25 SHOPKO UNIFINE PENTIPS TRANSDERMAL 325 SILPROTEX PLUS 325 SERMORELIN ACETATE 100 PLUS PEN SILVADENE 129 SERNIVO 133 NEEDLES/MICRO/REMOVR/3 2GX4MM 253 SILVER NITRATE 129 SEROQUEL 64 SHOPKO UNIFINE PENTIPS silver nitrate-potassium SEROQUEL XR 64 PLUS PEN nitrate 129 SEROSTIM 156 NEEDLES/MINI/REMOVER/31 SILVER PROTEIN MILD 66 GX5MM 254 SEROTONIN HCL 100 SHOPKO UNIFINE PENTIPS SILVER SULFADIAZINE 101 sertraline hcl 32 PLUS PEN silver sulfadiazine 129 SERTRALINE HCL 100 NEEDLES/REMOVER/29GX12 SIMBRINZA 297 SESAME OIL 108 MM 254 SHOPKO UNIFINE PENTIPS SIMETHICONE 160 sevelamer carbonate 162 PLUS PEN SIMILAC PROBIOTIC TRI- sevelamer hcl 162 NEEDLES/SHORT/REMOVR/3 BLEND 38 1GX8MM 254 SIMPLE DIAGNOSTICS sevoflurane 163 LANCING DEVICE 214 SEYSARA 331 SHOPKO UNILET LANCETS SUPER THIN 30G 214 SIMPLE SYRUP 316 SFROWASA 162 SHOPKO UNILET LANCETS SIMPLGEL 30 325 SHARK CARTILAGE 100 ULTRA THIN 28G 214 SIMPONI 4 SHEA BUTTER 320 SHOWER FRESH FRAGRANCE 100 SIMPONI ARIA 4 SHEA BUTTER ORGANIC 320 SHRIMP FLAVOR 308 SIMULECT 272 SHEER ADHESIVE SIMVASTATIN 46 BANDAGES 190 SHUR-SEAL 339 SHEER ADHESIVE BANDAGES SIBERIAN GINSENG 100 simvastatin 46 3/4" X 3" 190 SIDE BUTTON SAFETY SIMVASTATIN 101 SHEER BANDAGES 190 LANCET21G 214 SINCALIDE IN MANNITOL 101 SHEER BANDAGES 3/4" 190 SIDEKICK BLOOD GLUCOSE SINEMET 62 SYSTEM 214 SHEER SINEMET CR 62 BANDAGES/ASSORTED 190 SIDEROL 280 SHEER BANDAGES/EX- SIGNIFOR 158 SINGLE-LET 214 LARGE 190 SIGNIFOR LAR 158 SINGULAIR 23 SHINGRIX 338 SIKLOS 166 SINUVA 290 SHOE HORN SILA III 133 SIROLIMUS 101 DELUXE/CHROME FINISH220 sirolimus 272 SHOPKO ALCOHOL SILDENAFIL CITRATE 100 SWABS 226 sildenafil citrate (pulmonary SIRTURO 52 SHOPKO AUTOLET LANCING hypertension) 75 SITAVIG 69 DEVICE 214 SILENOR 171 SIVEXTRO 19 SHOPKO ON-THE-GO SILICA GEL 111 COMFORTLANCETS 30G 214 SKELAXIN 289 SHOPKO UNIFINE PENTIPS SILICA GEL SKIN PROTECTANT PEN ULTRAMICRONIZED 111 PETROLATUM 325 NEEDLES/MICRO/32GX4MM SILICON DIOXIDE 111 SKINTEGRITY 253 SILICON DIOXIDE (SYLOID HYDROGEL 145 SHOPKO UNIFINE PENTIPS 244 FP) 111 SKLICE 142 PEN NEEDLES/MINI/31GX5MM SILICONE BLEND SKYADERM-LP 138 CUSTOM 101 253 SKYLA 113 SHOPKO UNIFINE PENTIPS SILICONE ELASTOMER PEN BLEND 101 SKYRIZI 128 NEEDLES/ORIGINAL/29GX12M SILICONE FLUID 556 101 SKYRIZI PEN 128 M 253 silicone-vitamin e 145 SKYY DERM 325 SILIPAC 142 SLEEP TONITE 274

Index 89 SLEEP-N-HEEL NIGHT SM ISOPROPYL ALCOHOL SMARTEST PRONTO CONDITIONING HEEL RUBBING 108 STARTERKIT 215 SLEEVES 220 SM MICRO THIN LANCETS SMARTEST PROTEGE BLOOD SLEEP-N-HEEL+ NIGHT 33G 214 GLUCOSE MONITORING CONDITIONING HEEL SM ROLLED GAUZE SYSTEM 215 SLEEVES 220 BANDAGE 2"X4.1YD 191 SMARTEST PROTEGE SLYND 113 SM ROLLED GAUZE STARTERKIT 215 SM ADHESIVE PADS BANDAGE 3"X4.1YD 191 SMOFLIPID 292 2"X3" 190 SM STERILE PADS 191 SOCK AID DELUXE SM ADHESIVE PADS SM STERILE PADS MOLDED 220 3"X4" 190 2"X2" 191 sod benzoate & sod SM ALCOHOL PREP SM STRONG STRIPS 191 phenylacetate 157 PADS 226 SM STURDY STRIP FABRIC SODIUM 4- SM BANDAGE ROLL BANDAGES 1"X3" 191 AMINOSALICYLATEDIHYDRAT 4.5"X144" 190 SM SWEET OIL 108 E 80 SM BANDAGES CLEAR SM TRUEDRAW LANCING SODIUM ACETATE 266 SPOTS 190 sodium acetate 266 SM BANDAGES FABRIC DEVICE 214 SMART DIABETES VANTAGE 3/4" 190 SODIUM ACETATE SM BANDAGES FABRIC LANCING DEVICE 214 ANHYDROUS 266 SMART SENSE COLOR EXTRALARGE 190 SODIUM ACETATE SM BANDAGES FABRIC LANCETS UNIVERSAL TRIHYDRATE 101 KNUCKLE/FINGERTIP 190 33G 214 SODIUM ALGINATE 101 SMART SENSE PREMIUM SODIUM ASCORBATE 342 SM BANDAGES FOAM 190 BLOODGLUCOSE SM BANDAGES FOAM EXTRA MONITORING SYSTEM 214 SODIUM BENZOATE 320 LARGE 190 SMART SENSE PREMIUM SODIUM SM BANDAGES PLASTIC 190 BLOODGLUCOSE BICARBONATE 16,266 SM BANDAGES SHEER 190 STRIPS 152 sodium bicarbonate 266 SM BANDAGES SHEER EXTRA SMART SENSE STANDARD SODIUM LARGE 190 LANCETS UNIVERSAL BICARBONATE/DEXTROSE SM BANDAGES STRONG 21G 214 267 STRIPS 1" 190 SMART SENSE SUPER THIN SODIUM BISULFITE 101 SM BANDAGES LANCETS UNIVERSAL SODIUM BITARTRATE WATERSHIELD 190 30G 214 MONOHYDRATE 101 SMART SENSE THIN SM SODIUM BORATE 77 BANDAGES/ANTIBACTERIAL LANCETSUNIVERSAL 26G 214 SODIUM BORATE 190 DECAHYDRATE 77 SM SMART SENSE VALUE BANDAGES/CLEAR/ASSORTED BLOOD GLUCOSE SODIUM BROMIDE 111 190 STRIPS 152 SODIUM BUTYRATE 111 SM SMART SENSE VALUE SODIUM CACODYLATE 111 BLOODGLUCOSE BANDAGES/FLEXIBLE/ASSORT SODIUM CAPRATE 101 191 MONITORING SYSTEM 214 ED SODIUM CAPYRLATE FOOD SM BENZOIN TINCTURE 141 SMARTEST BLOOD GLUCOSE TEST GRADE 101 SM BORIC ACID 111 STRIPS 152 SODIUM CARBONATE SM GAUZE PADS 2"X2" 191 SMARTEST CONTROL ANHYDROUS 78 SM GAUZE PADS 4"X4" 191 SOLUTIONMEDIUM 214 SODIUM CARBONATE SMARTEST EJECT BLOOD MONOHYDRATE 78 SM GLUCOSAMINE SODIUM CHONDROITIN COMPLEX GLUCOSE MONITORING SYSTEM 214 CARBOXYMETHYLCELLULOSE TRIPLE STRENGTH 274 MEDIUM VISCOSITY 111 SM HYPO-ALLERGENIC SMARTEST EJECT STARTER BANDAGES 191 KIT 215 SODIUM CHLORIDE 270 SM IODIDES TINCTURE 65 SMARTEST LANCETS sodium chloride 270 28G 215 SM IODINE TINCTURE 65 sodium chloride (gu SMARTEST PERSONA irrigant) 164 SM ISOPROPYL STARTERKIT 215 ALCOHOL 108 sodium chloride (inhalant) 119

Index 90 sodium chloride flush 270 SODIUM PERBORATE SODIUM SODIUM CHLORIDE/SODIUM MONOHYDRATE 111 SULFACETAMIDE/SULFUR BICARBONATE 111 SODIUM PERBORATE CLEANSER IN UREA 122 SODIUM CHLORITE 101 TETRAHYDRATE 111 SODIUM SULFATE 111 SODIUM SODIUM SULFITE 111 SODIUM CITRATE 26 PHENYLBUTYRATE 101 SODIUM SULFITE SODIUM CITRATE sodium phenylbutyrate 157 ANHYDROUS 163 ANHYDROUS 111 SODIUM PHOSPHATE SODIUM TARTRATE SODIUM CITRATE DIBASIC 101 DIHYDRATE 101 DIHYDRATE 102 SODIUM PHOSPHATE SODIUM TETRADECYL SODIUM CITRATE LOCK DIBASICANHYDROUS 101 FLUSH 26 SULFATE 102 SODIUM PHOSPHATE sodium tetradecyl sulfate 275 SODIUM DIBASICDIHYDRATE 101 CITRATE/GENTAMICIN 27 SODIUM PHOSPHATE SODIUM THIOSULFATE 40 SODIUM COCOYL DIBASICDRIED 101 sodium thiosulfate 40 GLUTAMATE 101 SODIUM PHOSPHATE SODIUM THIOSULFATE SODIUM DIBASICHEPTAHYDRATE DEHYDROACETATE 101 PENTAHYDRATE 320 102 SODIUM VALPROATE 105 SODIUM SODIUM PHOSPHATE DEOXYCHOLATE 101 SODIUM-L-ASCORBYL-2- MONOBASIC 102 PHOSPHATE DIHYDRATE 102 SODIUM DIACETATE 101 SODIUM PHOSPHATE SODIUM SOF-SET ADHESIVE MONOBASIC PATCH 191 DICHLOROACETATE 101 ANHYDROUS 102 SODIUM DIURIL 154 SODIUM PHOSPHATE SOF-WICK 4"X4" 191 SODIUM EDECRIN 153 TRIBASIC 102 SOF-WIK 191 sodium ferric gluconate complex SODIUM SOFOSBUVIR/VELPATASVIR in sucrose 170 PHOSPHATE/DEXTROSE 26 69 9 SOFT FOAM TOE SODIUM FLUORIDE 101 SODIUM SEPARATORSMEDIUM 220 sodium fluoride 268 PHOSPHATE/SODIUM SOLARAVIX 127 SODIUM CHLORIDE 269 SOLARTEK GLUCOSE FLUOROPHOSPHATE 101 sodium phosphates (sodium CONTROLSOLUTIONS 215 SODIUM GLUCONATE 101 phosphate dibasic & solifenacin succinate 337 SODIUM HYALURONATE 91 monobasic) 269 SODIUM SOLIQUA 100/33 34 SODIUM HYALURONATE SOLIRIS 166 (INJECTION GRADE) 91 PHOSPHATES/DEXTROSE 269 SODIUM HYDROXIDE 78 SOLODYN 331 sodium polystyrene SOLOSEC 3 SODIUM IODIDE 101 sulfonate 274 SODIUM IODIDE I-131 332 SODIUM PROPIONATE 102 SOLOSITE 145 SODIUM L-ASPARTATE 101 SODIUM PYROPHOSPHATE SOLTAMOX 56 SODIUM LACTATE 101 ANHYDROUS 106 SOLU-CORTEF 117 SODIUM PYRROLIDONE SOLU-MEDROL 117 SODIUM LAURETH CARBOXYLATE 102 SULFATE 101 SOLUS V2 AUDIBLE BLOOD SODIUM LAURYL SODIUM SALICYLATE 8 GLUCOSE MANAGEMENT SULFATE 320 SODIUM SELENITE 102 SYSTEM 215 SODIUM METABISULFITE 101 SODIUM STEARATE 102 SOLUS V2 AUDIBLE TEST152 SODIUM METABISULFITE SODIUM STEARYL SOLUS V2 CONTROL ANHYDROUS 101 FUMARATE 102 HIGH 215 SODIUM MOLYBDATE 101 SODIUM SUCCINATE 102 SOLUS V2 CONTROL SODIUM SODIUM SULFACETAMIDE LOW 215 MONOFLUOROPHOSPHATE WASH 129 SOLUS V2 LANCING 101 SODIUM DEVICE 215 SOLUS V2 PRESSURE SODIUM NITRATE ACS 101 SULFACETAMIDE/SULFUR 122 ACTIVATED SAFETY LANCETS SODIUM NITRITE 40 28G 215 SODIUM OLEATE 101 SOLUS V2 TWIST LANCETS 30G 215

Index 91 SOLYDRA 316 SPENCO ARCH SUPPORT SPENCO GEL INSOLES SIZE SOMA 289 INSOLES SIZE 12/13 12/13 MENS 221 MENS 220 SPENCO GEL INSOLES SIZE SOMATULINE DEPOT 158 SPENCO ARCH SUPPORT 14/15 221 SOMAVERT 155 INSOLES SIZE 8/9 SPENCO GEL INSOLES SIZE SOOLANTRA 141 MENS 220 14/15 MENS 221 SPENCO COMFORT INSOLES SPENCO GEL INSOLES SIZE SOOTHEE 138 SIZE 10/11 MENS 220 3/4 221 SORBIC ACID 305 SPENCO COMFORT INSOLES SPENCO GEL INSOLES SIZE SORBITAN SIZE 12/13 MENS 220 5/6 221 MONOLAURATE 102 SPENCO COMFORT INSOLES SPENCO GEL INSOLES SIZE SORBITAN SIZE 14/15 MENS 220 6/7-7/8 221 MONOOLEATE 102 SPENCO COMFORT INSOLES SPENCO GEL INSOLES SIZE SORBITAN SIZE 8/9 MENS 220 8/9 MENS 221 MONOPALMITATE 102 SPENCO FOR HER INSOLES SPENCO GEL INSOLES SIZE SORBITAN MONOPALMITATE SIZE 11/12 220 8/9-9/10 221 BASE I 102 SPENCO FOR HER INSOLES SPENCO IRONMAN GEL SORBITAN SIZE 11/12 TOTAL INSOLES LARGE 221 MONOSTEARATE 102 SUPPORT 220 SPENCO IRONMAN GEL SORBITOL 164,317 SPENCO FOR HER INSOLES INSOLES SMALL 221 SORBITOL CANDY BASE 320 SIZE 3/4 220 SPENCO IRONMAN PLUS SPENCO FOR HER INSOLES INSOLES LARGE 221 SORBITOL HARD CANDY SIZE 3/4 TOTAL SPENCO IRONMAN PLUS BASE-GRAPE 320 SUPPORT 221 INSOLES SMALL 221 SORBITOL-MANNITOL 164 SPENCO FOR HER INSOLES SPENCO KIDS COMFORT SORBITOL/MANNITOL SIZE 5/6 221 INSOLES SIZE 3 TO 4-1/2 221 IRRIGATION 164 SPENCO FOR HER INSOLES SPENCO KIDS COMFORT SORESPOT BLISTER & SKIN SIZE 5/6 TOTAL INSOLES SIZE 5 TO 6-1/2 221 PROTECTION SUPPORT 221 SPENCO KIDS COMFORT BANDAGES 191 SPENCO FOR HER INSOLES INSOLES SIZE 7/8 221 SORIATANE 128 SIZE 7/8 221 SPENCO KIDS POLYSORB SORILUX 128 SPENCO FOR HER INSOLES INSOLES SIZE 3 TO 4-1/2 221 SPENCO KIDS POLYSORB SOSWEET 317 SIZE 7/8 TOTAL SUPPORT 221 INSOLES SIZE 5 TO 6-1/2 221 sotalol hcl 72 SPENCO FOR HER INSOLES SPENCO KIDS POLYSORB sotalol hcl (afib/afl) 72 SIZE 9/10 221 INSOLES SIZE 7/8 221 SOTALOL SPENCO FOR HER INSOLES SPENCO POLYSORB INSOLES HYDROCHLORIDE 72 SIZE 9/10 TOTAL SIZE 10/11-11/12 CROSS- SOTRADECOL 275 SUPPORT 221 TRAINER 221 SPENCO GEL ARCH SPENCO POLYSORB INSOLES SOTROVIMAB 303 INSOLES SIZE LARGE 221 SIZE 10/11-11/12 HEAVY SOTYLIZE 72 SPENCO GEL ARCH DUTY 221 SOVALDI 69 INSOLES SIZE MEDIUM 221 SPENCO POLYSORB INSOLES SOYABEAN CASEIN DIGEST SPENCO GEL ARCH SIZE 10/11-11/12 HIKER 221 INSOLES SIZE SMALL 221 SPENCO POLYSORB INSOLES MEDIUM 102 SIZE 10/11-11/12 TOTAL SOYBEAN OIL 108 SPENCO GEL BALL OF FOOT ONE SIZE 221 SUPPORT 222 SPAN 80 102 SPENCO GEL HEEL CUP SPENCO POLYSORB INSOLES SPEARMINT 108 SIZEMEDIUM/LARGE 221 SIZE 10/11-11/12 WALKER- SPEARMINT FLAVOR 308 SPENCO GEL HEEL CUP RUNNER 222 SIZESMALL/MEDIUM 221 SPENCO POLYSORB INSOLES SPEARMINT OIL 108 SPENCO GEL HEEL INSOLES SIZE 12/13 CROSS- specialty vitamins products 287 ONE SIZE 221 TRAINER 222 SPENCO ADHESIVE KNIT SPENCO GEL INSOLES SIZE SPENCO POLYSORB INSOLES 3"X5" 191 10/11 MENS 221 SIZE 12/13 HEAVY DUTY 222 SPENCO ARCH SUPPORT SPENCO GEL INSOLES SIZE SPENCO POLYSORB INSOLES INSOLES SIZE 10/11 10/11-11/12 221 SIZE 12/13 HIKER 222 MENS 220 SPENCO GEL INSOLES SIZE 12/13 221

Index 92 SPENCO POLYSORB INSOLES SPENCO POLYSORB SPENCO RX ARCH INSOLES SIZE 12/13 TOTAL INSOLES SIZE 8/9-9/10 SIZE 14/15 223 SUPPORT 222 HEAVY DUTY 222 SPENCO RX ARCH INSOLES SPENCO POLYSORB INSOLES SPENCO POLYSORB SIZE 3/4 223 SIZE 12/13 WALKER- INSOLES SIZE 8/9-9/10 SPENCO RX ARCH INSOLES RUNNER 222 HIKER 222 SIZE 5/6 223 SPENCO POLYSORB INSOLES SPENCO POLYSORB SPENCO RX ARCH INSOLES SIZE 14/15 CROSS- INSOLES SIZE 8/9-9/10 SIZE 6/7-7/8 223 TRAINER 222 TOTAL SUPPORT 222 SPENCO RX ARCH INSOLES SPENCO POLYSORB INSOLES SPENCO POLYSORB SIZE 8/9-9/10 223 SIZE 14/15 HEAVY DUTY 222 INSOLES SIZE 8/9-9/10 SPENCO RX ARTHRITIS SPENCO POLYSORB INSOLES WALKER-RUNNER 222 FOOTCRADLES SIZE 10 SIZE 14/15 HIKER 222 SPENCO POLYSORB OS MENS 223 SPENCO POLYSORB INSOLES INSOLES SIZE 10/11-11/12 SPENCO RX ARTHRITIS SIZE 14/15 TOTAL BACKPACKER 223 FOOTCRADLES SIZE 11 SUPPORT 222 SPENCO POLYSORB OS MENS 223 SPENCO POLYSORB INSOLES INSOLES SIZE 10/11-11/12 SPENCO RX ARTHRITIS SIZE 14/15 WALKER- DAY HIKER 223 FOOTCRADLES SIZE 12 RUNNER 222 SPENCO POLYSORB OS MENS 223 SPENCO POLYSORB INSOLES INSOLES SIZE 12/13 SPENCO RX ARTHRITIS SIZE 3/4 CROSS- BACKPACKER 223 FOOTCRADLES SIZE 6 TRAINER 222 SPENCO POLYSORB OS WOMENS 223 SPENCO POLYSORB INSOLES INSOLES SIZE 12/13 DAY SPENCO RX ARTHRITIS SIZE 3/4 HIKER 222 HIKER 223 FOOTCRADLES SIZE 7 SPENCO POLYSORB INSOLES SPENCO POLYSORB OS WOMENS 223 SIZE 3/4 TOTAL INSOLES SIZE 14/15 SPENCO RX ARTHRITIS SUPPORT 222 BACKPACKER 223 FOOTCRADLES SIZE 8 SPENCO POLYSORB INSOLES SPENCO POLYSORB OS WOMENS 223 SIZE 3/4 WALKER- INSOLES SIZE 14/15 DAY SPENCO RX ARTHRITIS RUNNER 222 HIKER 223 FOOTCRADLES SIZE 9 SPENCO POLYSORB INSOLES SPENCO POLYSORB OS MENS 223 SIZE 5/6 CROSS- INSOLES SIZE 3/4 SPENCO RX ARTHRITIS TRAINER 222 BACKPACKER 223 FOOTCRADLES SIZE 9 SPENCO POLYSORB INSOLES SPENCO POLYSORB OS WOMENS 223 SIZE 5/6 HEAVY DUTY 222 INSOLES SIZE 3/4 DAY SPENCO RX BALL OF FOOT SPENCO POLYSORB INSOLES HIKER 223 LARGE 223 SIZE 5/6 HIKER 222 SPENCO POLYSORB OS SPENCO RX BALL OF FOOT SPENCO POLYSORB INSOLES INSOLES SIZE 5/6 MEDIUM 223 SIZE 5/6 TOTAL BACKPACKER 223 SPENCO RX BALL OF FOOT SUPPORT 222 SPENCO POLYSORB OS SMALL 223 SPENCO POLYSORB INSOLES INSOLES SIZE 5/6 DAY SPENCO RX DIABETIC SIZE 5/6 WALKER- HIKER 223 SUPPORT SIZE 10 MENS 224 RUNNER 222 SPENCO POLYSORB OS SPENCO RX DIABETIC SPENCO POLYSORB INSOLES INSOLES SIZE 6/7-7/8 SUPPORT SIZE 11 MENS 224 SIZE 6/7-7/8 CROSS- BACKPACKER 223 SPENCO RX DIABETIC TRAINER 222 SPENCO POLYSORB OS SUPPORT SIZE 12 MENS 224 SPENCO POLYSORB INSOLES INSOLES SIZE 6/7-7/8 DAY SPENCO RX DIABETIC SIZE 6/7-7/8 HEAVY DUTY222 HIKER 223 SUPPORT SIZE 6 SPENCO POLYSORB INSOLES SPENCO POLYSORB OS WOMENS 224 SIZE 6/7-7/8 HIKER 222 INSOLES SIZE 8/9-9/10 SPENCO RX DIABETIC SPENCO POLYSORB INSOLES BACKPACKER 223 SUPPORT SIZE 7 SIZE 6/7-7/8 TOTAL SPENCO POLYSORB OS WOMENS 224 SUPPORT 222 INSOLES SIZE 8/9-9/10 DAY SPENCO RX DIABETIC SPENCO POLYSORB INSOLES HIKER 223 SUPPORT SIZE 8 SIZE 6/7-7/8 WALKER- SPENCO RX ARCH INSOLES WOMENS 224 RUNNER 222 SIZE 10/11-11/12 223 SPENCO RX DIABETIC SPENCO POLYSORB INSOLES SPENCO RX ARCH INSOLES SUPPORT SIZE 9 MENS 224 SIZE 8/9-9/10 CROSS- SIZE 12/13 223 TRAINER 222

Index 93 SPENCO RX DIABETIC SPENCO RX ORTHOTIC STARCH 111 SUPPORT SIZE 9 ARCH SUPPORTS SIZE 8/9- STARLIX 37 WOMENS 224 9/10 224 SPENCO RX HEEL INSOLES SPENCO RX ORTHOTIC stavudine 67 SIZE 10/11-11/12 224 ARCH SUPPORTS SIZE 8/9- STAVUDINE 67 SPENCO RX HEEL INSOLES 9/10 THINSOLE 225 STEARIC ACID 320 SIZE 12/13 224 SPENCO SLIM FIT INSOLES STEARIC ACID TRIPLE SPENCO RX HEEL INSOLES SIZE 10/11 MENS 225 PRESSED 320 SIZE 5/6 224 SPENCO SLIM FIT INSOLES SPENCO RX HEEL INSOLES SIZE 12/13 MENS 225 STEARYL ALCOHOL 320 SIZE 6/7-7/8 224 SPENCO SLIM FIT INSOLES STEGLATRO 37 SPENCO RX HEEL INSOLES SIZE 14/15 MENS 225 STEGLUJAN 34 SIZE 8/9-9/10 224 SPENCO SLIM FIT INSOLES STELARA 128 SPENCO RX INSOLES SIZE SIZE 8/9 MENS 225 10/11-11/12 224 SPG SUPPOSI-BASE 320 STERA BASE 325 STERI-STRIP 1 7/8" X SPENCO RX INSOLES SIZE spinosad 142 12/13 224 1/2"/DRESSING 2 3/8" X 1 SPENCO RX INSOLES SIZE SPINRAZA 291 7/8" 191 14/15 224 SPIRIVA HANDIHALER 22 STERI-STRIP 1" X 5" 191 SPENCO RX INSOLES SIZE SPIRIVA RESPIMAT 22 STERI-STRIP 1/2" X 2" 191 3/4 224 SPENCO RX INSOLES SIZE SPIRONOLACTONE 153 STERI-STRIP 1/2" X 4 " 191 5/6 224 spironolactone 154 STERI-STRIP 1/4" X 1 1/2" 191 SPENCO RX INSOLES SIZE 6/7- spironolactone & STERI-STRIP 1/4" X 3" 191 7/8 224 hydrochlorothiazide 153 STERI-STRIP 1/4" X 4" 191 SPENCO RX INSOLES SIZE 8/9- SPIRULINA 102 STERI-STRIP 1/8" X 3" 191 9/10 224 SPORANOX 42 SPENCO RX ORTHOTIC ARCH STERILANCE TL 215 SUPPORTS SIZE 10/11- SPORANOX PULSEPAK 42 STERILE BANDAGE ROLL 11/12 224 SPORT & WORK CUSHION 2.25"X3YD 191 SPENCO RX ORTHOTIC ARCH INSOLES MENS SIZE 7- STERILE DILUENT FOR SUPPORTS SIZE 10/11-11/12 13 225 FLOLAN 317 THINSOLE 224 SPRAVATO 56MG DOSE 32 STERILE DILUENT FOR SPENCO RX ORTHOTIC ARCH SPRAVATO 84MG DOSE 32 TREPROSTINIL SUPPORTS SIZE 12/13 224 SPRITAM 29 INJECTION 317 SPENCO RX ORTHOTIC ARCH STERILE GAUZE PADS SUPPORTS SIZE 12/13 SPRIX 7 2"X2" 191 THINSOLE 224 SPRYCEL 58 STERILE PADS 2"X2" 191 SPENCO RX ORTHOTIC ARCH SQUALANE 102 SUPPORTS SIZE 14/15 224 STERILE PADS 4"X4" 191 SPENCO RX ORTHOTIC ARCH SQUARIC ACID 102 STERILE TALC POWDER 330 SUPPORTS SIZE 14/15 SQUARIC ACID IN STERILE TOPICAL L.E.T. THINSOLE 224 BUTANOL 102 GEL 138 SPENCO RX ORTHOTIC ARCH SSKI 119 STERITALC 330 SUPPORTS SIZE 3/4 224 ST JOHNS WORT 102 STEVIA EXTRACT 102 SPENCO RX ORTHOTIC ARCH SUPPORTS SIZE 3/4 STALEVO 100 62 STEVIA GLYCERITE LIQUID THINSOLE 224 STALEVO 125 62 EXTRACT 308 SPENCO RX ORTHOTIC ARCH STEVIA POWDER STALEVO 150 62 EXTRACT 102 SUPPORTS SIZE 5/6 224 STALEVO 200 62 SPENCO RX ORTHOTIC ARCH STEVIOL GLYCOSIDES 102 SUPPORTS SIZE 5/6 STALEVO 50 63 STEVIOSIDE 102 THINSOLE 224 STALEVO 75 63 STIMATE 158 SPENCO RX ORTHOTIC ARCH STAMARIL 338 SUPPORTS SIZE 6/7-7/8 224 STIMULEN 145 STANNOUS CHLORIDE STIOLTO RESPIMAT 25 SPENCO RX ORTHOTIC ARCH DIHYDRATE 102 SUPPORTS SIZE 6/7-7/8 STIVARGA 58 THINSOLE 224 STANNOUS FLUORIDE 111 STANOZOLOL 102 STRATA CTX 140

Index 94 STRATA GRT 145 SULFACETAMIDE SUMAXIN 123 STRATA MARK 140 SODIUM 129 SUMAXIN CP KIT 123 sulfacetamide sodium STRATA XRT 140 (acne) 122 SUMAXIN WASH 123 STRATTERA 2 sulfacetamide sodium SUN BURNT PLUS PAIN STRAWBERRY FLAVOR 308 (ophth) 297 RELIEF 138 sulfacetamide sodium w/ sunitinib malate 58 STRENSIQ 157 sulfur 123 SUNOSI 2 STREPTOMYCIN SULFATE 3 sulfacetamide sodium-sulfur in SUPER SYNERSWEET streptomycin sulfate 3 urea vehicle 123 FLAVOR 308 sulfacetamide sodium-sulfur w/ STRETCH GAUZE SUPER THIN LANCETS 215 BANDAGE 191 skin cleanser 123 SULFADIAZINE 330 SUPEROXIDE STRIANT 15 DISMUTASE 103 STRIBILD 68 SULFADIAZINE SODIUM330 SUPERVITE 277 STRIVERDI RESPIMAT 25 SULFADIMETHOXINE 103 SUPPORT 280 STROMECTOL 16 SULFAMERAZINE 103 SUPPORT-500 287 STRONTIUM CHLORIDE 102 SULFAMETHOXAZOLE 330 SUPPOSI-PLEX R36 320 SULFAMETHOXAZOLE STRONTIUM CHLORIDE SR- SUPPOSI-PLEX V33 320 89 59 MICRO 330 SUPPOSI-PURE 320 STRONTIUM NITRATE 111 sulfamethoxazole-trimethoprim 17 SUPPOSIBLEND 320 STROVITE FORTE 280 SULFAMYLON 129 SUPPOSITORY BLEND 320 STROVITE ONE 280 SULFANILAMIDE 111 SUPPRELIN LA 156 SUBLOCADE 14 SULFAPYRIDINE 330 SUPRANE 163 SUBOXONE 14 SULFASALAZINE 162 SUPRAX 77 SUBSYS 12 sulfasalazine 162 SUPREME II HIGH/LOW SUCCIMER DMSA 102 SULFATHIAZOLE 330 CONTROL SOLUTION 215 SUCCINIC ACID 102 SULFISOXIZOLE 330 SUPREME TEST STRIPS 152 SUCCINYLCHOLINE SULFOSALICYLIC ACID SUPREP BOWEL PREP CHLORIDE 102,291 DIHYDRATE 103 KIT 173 succinylcholine chloride 291 SULFUR 103 SURE COMFORT ALCOHOL SUCCINYLCHOLINE PREP PADS 226 SULFUR SURE COMFORT INSULIN CHLORIDE 291 PRECIPITATED 103 SUCCINYLCHOLINE SYRINGE/U-100/0.3ML/29G X CHLORIDEDIHYDRATE 102 SULFUR SUBLIMED 103 1/2" 254 SUCRAID 152 SULFURATED LIME 142 SURE COMFORT INSULIN SULFURIC ACID 78 SYRINGE/U-100/0.3ML/30G X SUCRALFATE 335 1/2" 254 sucralfate 335 SULINDAC 7 SURE COMFORT INSULIN SUCROSE 111 sulindac 7 SYRINGE/U-100/0.3ML/30G X SUCROSE SULPHAN BLUE 306 5/16" 254 CONFECTIONERS 111 SULPIRIDE 103 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X SUCROSE SUMADAN KIT 123 OCTAACETATE 102 5/16 254 SUCROSE POWDERED SUMADAN WASH 123 SURE COMFORT INSULIN CONFECTIONERS 111 SUMADAN XLT 123 SYRINGE/U-100/0.3ML/31G X sufentanil citrate 12 SUMANSETRON 265 5/16" 254 SURE COMFORT INSULIN SUFENTANIL CITRATE 12,102 SUMATRIPTAN 103 SYRINGE/U- SULAR 73 sumatriptan 266 100/0.3ML/31GX1/4" 254 sulconazole nitrate 127 SUMATRIPTAN SURE COMFORT INSULIN SULFACETAMIDE 102 SUCCINATE 103 SYRINGE/U-100/0.5ML/28G X sumatriptan succinate 266 1/2" 254 sulfacetamide sod- SURE COMFORT INSULIN prednisolone 300 sumatriptan-naproxen sodium 265 SYRINGE/U-100/0.5ML/29G X sulfacetamide sodium 129 1/2" 254

Index 95 SURE COMFORT INSULIN SURE EDGE BLOOD SURE-TEST EASYPLUS MINI SYRINGE/U-100/0.5ML/30G X GLUCOSE MONITORING BLOOD GLUCOSE TEST 1/2" 254 SYSTEM 215 STRIPS 152 SURE COMFORT INSULIN SURE EDGE BLOOD SURE-TEST EASYPLUS MINI SYRINGE/U-100/0.5ML/30G X GLUCOSE TEST SELF MONITORING BLOOD 5/16" 254 STRIPS 152 GLUCOSE METER 215 SURE COMFORT INSULIN SURE RESULT O3D3 SURE-TOUCH LANCETS SYRINGE/U-100/0.5ML/31G X SYSTEM 44 UNIVERSAL 215 5/16 254 SURE-FINE PEN NEEDLES SURECHEK BLOOD GLUCOSE SURE COMFORT INSULIN 29GX1/2" 12.7MM 255 MONITORING SYSTEM 215 SYRINGE/U-100/1ML/28G X SURE-FINE PEN NEEDLES SURECHEK BLOOD GLUCOSE 1/2" 254 31GX3/16" 5MM 255 MONITORING SYSTEM SURE COMFORT INSULIN SURE-FINE PEN NEEDLES STARTER KIT 215 SYRINGE/U-100/1ML/29G X 31GX5/16" 8MM 255 SURECHEK BLOOD GLUCOSE 1/2" 254 SURE-JECT INSULIN TEST STRIPS 152 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X SURELITE LANCETS 215 SYRINGE/U-100/1ML/30G X 1/2" 255 SURESEAL 191 1/2" 254 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X SURESEAL EXTRA SURE COMFORT INSULIN 191 SYRINGE/U-100/1ML/30G X 5/16" 255 LARGE 5/16" 254 SURE-JECT INSULIN SURESEAL LARGE 191 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X SURESTEP GLUCOSE SYRINGE/U-100/1ML/31G X 5/16" 255 CONTROL 215 5/16" 254 SURE-JECT INSULIN SURESTEP GLUCOSE SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X CONTROLSOLUTION 215 SYRINGES/0.5ML/31G X 1/2" 255 SURESTEP PRO HIGH 6MM 254 SURE-JECT INSULIN GLUCOSECONTROL 215 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X SURESTEP PRO LOW SYRINGES/U- 1/2" 255 GLUCOSECONTROL 215 100/1ML/31GX6MM 254 SURE-JECT INSULIN SURESTEP PRO NORMAL SURE COMFORT LANCETS SYRINGE/U-100/0.5ML/30G X GLUCOSE CONTROL 216 18G 215 5/16" 255 SURGICAL GAUZE SURE COMFORT LANCETS SURE-JECT INSULIN SPONGE 191 21G 215 SYRINGE/U-100/0.5ML/31G X SURVANTA SURE COMFORT LANCETS 5/16" 255 INTRATRACHEAL 330 23G 215 SURE-JECT INSULIN SUSPENDIT 325 SURE COMFORT LANCETS SYRINGE/U-100/1ML/28G X SUSPENDRX WITH BITTER- 28G 215 1/2" 255 BLOC/SWEETENED 317 SURE COMFORT LANCETS SURE-JECT INSULIN SUSPENDRX WITH BITTER- 30G 215 SYRINGE/U-100/1ML/29G X BLOC/UNSWEETENED 317 SURE COMFORT LANCING 1/2" 255 SUSPENSION VEHICLE 317 PEN 215 SURE-JECT INSULIN SUSTIVA 68 SURE COMFORT PEN SYRINGE/U-100/1ML/30G X NEEDLES29GX1/2" 5/16" 255 SUSTOL 40 12.7MM 254 SURE-JECT INSULIN SUTAB 173 SURE COMFORT PEN SYRINGE/U-100/1ML/31G X SUTENT 58 NEEDLES30GX5/16" 5/16" 255 SUVICORT 140 SHORT 254 SURE-LANCE FLAT SURE COMFORT PEN LANCETS 215 SWEET CORN FLAVOR NEEDLES31GX3/16" SURE-LANCE LANCETS CONCENTRATE 308 (5MM) 254 26G 215 SWEET OIL 108 SURE COMFORT PEN SURE-LANCE THIN LANCETS SWEETENING NEEDLES31GX5/16" 28G 215 ENHANCER 308 (8MM) 254 SURE-LANCE ULTRA THIN SWEETENING SURE COMFORT PEN LANCETS 215 ENHANCER/FLAVORX 308 NEEDLES32GX5/32" 254 SURE-PEN 215 SWEETENING SUSPENDING SURE COMFORT PEN SURE-PREP ALCOHOL PREP COMPOUND 317 NEEDLES32GX6MM 254 PADS 226 SX1 MEDICATED POST- OPERATIVE SYSTEM 138

Index 96 SYLATRON 60 TACHOSIL 170 TAXOTERE 61 SYLVANT 272 TACLONEX 133 TAYTULLA 113 SYMAX DUOTAB 334 TACROLIMUS 103 TAZAROTENE 103 SYMBICORT 25 tacrolimus 272 tazarotene 128 SYMBYAX 328 tacrolimus (topical) 135 TAZICEF 77 SYMDEKO 330 TACROLIMUS TAZORAC 128 SYMFI 68 MONOHYDRATE 103 TAZVERIK 59 tadalafil 74 SYMFI LO 68 TDC MAX CREAM 325 TADALAFIL 103 SYMJEPI 340 TDM SOLUTION 317 tadalafil (pulmonary SYMLINPEN 120 34 hypertension) 75 TDVAX 333 SYMLINPEN 60 34 TAFINLAR 59 TEA COCOYL GLUTAMINE 103 SYMPAZAN 27 TAGAMET HB 335 TEA TREE OIL 103 SYMPROIC 162 TAGRISSO 55 TEABERRY FLAVOR 308 SYMTUZA 68 TAI DOC CONTROL 216 TECENTRIQ 55 SYN-AKE 87 TAKHZYRO 166 TECFIDERA 328 SYNAGIS 303 TALC 111 TECFIDERA STARTER SYNALAR 133 TALICIA 336 PACK 328 SYNALAR CREAM KIT 133 TALIVA 169 TECHLITE AST LANCETS 216 SYNALAR OINTMENT KIT 133 TALTZ 128 TECHLITE INSULIN SYRINGEU- SYNALAR TS 133 TALZENNA 59 100/0.3ML/29G X 1/2" 255 TECHLITE INSULIN SYRINGEU- SYNAPRYN FUSEPAQ 12 TAMIFLU 70 100/0.3ML/30G X 1/2" 255 SYNAPSIN 320 tamoxifen citrate 56 TECHLITE INSULIN SYRINGEU- SYNAREL 156 TAMOXIFEN CITRATE 103 100/0.3ML/30G X 5/16" 255 SYNDROS 41 TAMOXIFEN CITRATE TECHLITE INSULIN SYRINGEU- MICRONIZED 103 100/0.3ML/31G X 15/64" 255 SYNERA 138 TECHLITE INSULIN SYRINGEU- SYNERCID 19 tamsulosin hcl 164 100/0.3ML/31G X 5/16" 255 SYNERDERM 140 TANGERINE FLAVOR 308 TECHLITE INSULIN SYRINGEU- TANGERINE FLAVOR 100/0.5ML/29G X 1/2" 255 SYNERTROPIN 287 SWEETENED 308 TECHLITE INSULIN SYRINGEU- SYNJARDY 34 TANNIC ACID 141 100/0.5ML/30G X 1/2" 255 SYNJARDY XR 34 TAPAZOLE 332 TECHLITE INSULIN SYRINGEU- 100/0.5ML/30G X 5/16" 255 SYNRIBO 60 TARCEVA 55 TECHLITE INSULIN SYRINGEU- SYNTHAMIN 17 295 TARDEOXIA 123 100/0.5ML/31G X 15/64" 255 SYNTHROID 332 TARDIMAXIA 123 TECHLITE INSULIN SYRINGEU- SYNVEXIA TC 138 100/0.5ML/31G X 5/16" 255 TARGRETIN 60,127 TECHLITE INSULIN SYRINGEU- SYPRINE 271 TARKA 49 100/1ML/29G X 1/2" 255 SYRPALTA 317 TARON FORTE 169 TECHLITE INSULIN SYRINGEU- SYRSPEND SF 317 100/1ML/30G X 1/2" 256 TARON-BC 285 TECHLITE INSULIN SYRINGEU- SYRSPEND SF ALKA 317 TARON-C DHA 285 100/1ML/30G X 5/16" 256 SYRSPEND SF PH4 317 TARON-PREX 285 TECHLITE INSULIN SYRINGEU- SYRUP NF 317 TAROXIA 123 100/1ML/31G X 15/64" 256 SYRUP VEHICLE 317 TECHLITE INSULIN SYRINGEU- TARTARIC ACID 78 100/1ML/31G X 5/16" 256 SYRUP VEHICLE SF 317 TASIGNA 59 TECHLITE LANCETS 216 TABLOID 53 TASMAR 61 TECHLITE LANCETS 30G 216 TABRADOL FUSEPAQ 289 TASOPROL 134 TECHLITE PEN NEEDLES 29GX TABRADOL RAPIDPAQ 289 TAURINE 295 10MM 256 TABRECTA 59 TECHLITE PEN NEEDLES 29GX tavaborole 127 12 MM 256

Index 97 TECHLITE PEN NEEDLES 31GX TEGADERM HYDROGEL TENDEROL UNDERCAST 5MM 256 WOUND FILLER 146 PADDING 3"X4 YD 192 TECHLITE PEN NEEDLES/31GX TEGRETOL 29 TENDEROL UNDERCAST 5MM 256 TEGRETOL-XR 29 PADDING 4"X4 YD 192 TECHLITE PEN NEEDLES/31GX TENDEROL UNDERCAST 6 MM 256 TEGSEDI 330 PADDING 6"X4 YD 192 TECHLITE PEN NEEDLES/31GX TEKTURNA 50 TENIPOSIDE 61 8MM 256 TEKTURNA HCT 49 TENIVAC 333 TECHLITE PEN NEEDLES/32GX TELCARE BLOOD GLUCOSE tenofovir disoproxil fumarate 68 4MM 256 MONITORING SYSTEM 216 TECHLITE PEN NEEDLES/32GX TELCARE BLOOD GLUCOSE TENORETIC 100 50 6MM 256 TEST STRIPS 152 TENORETIC 50 50 TECHLITE PEN NEEDLES/32GX TELCARE GLUCOSE TENORMIN 71 8MM 256 CONTROL SOLUTION LEVEL TECHNA 20 SF TROCHE TEPADINA 53 1/2 216 BASEWITH BITTER-BLOC 317 TELFA ADHESIVE DRESSING TEPEZZA 156 TECHNA NATURAL SF 3"X4" 191 TEPMETKO 59 TROCHEBASE WITH BITTER- TELFA AMD ADHESIVE terazosin hcl 48 BLOC 317 BANDAGE 2"X3.75" 191 TEFLARO 77 TELFA AMD ANTIMICROBIAL terbinafine hcl 42 TEGADERM CONTACT ISLAND DRESSING TERBINAFINE HCL 103 LAYER/NON-ADHERENT 4"X5" 192 TERBUTALINE SULFATE 25 3"X4" 191 TELFA AMD ANTIMICROBIAL terbutaline sulfate 25 TEGADERM CONTACT ISLAND LAYER/NON-ADHERENT DRESSING4"X8" 192 terconazole vaginal 339 3"X8" 191 TELFA AMD ANTIMICROBIAL TERIPARATIDE 155 TEGADERM FILM NON-ADHERENT PAD TERODERM 325 TRANSPARENT DRESS/FRAME 3"X8" 192 STYLE 1-3/4"X1-3/4" 191 TELFA ISLAND DRESSING TERODERM-PLUS 325 TEGADERM FOAM DRESSING 4"X10" 192 TERPIN HYDRATE 119 2"X2" 191 TELFA ISLAND DRESSING TERPIN HYDRATE TEGADERM FOAM DRESSING 4"X14" 192 MONOHYDRATE 119 4"X4" 191 TELFA ISLAND DRESSING TESSALON PERLES 118 TEGADERM FOAM DRESSING 4"X5" 192 TESTIM 15 4"X8" 191 TELFA ISLAND DRESSING TEGADERM FOAM DRESSING 4"X8" 192 TESTONE CIK 15 ROLL 4"X24" 191 TELFA NON-ADHERENT TESTOPEL 15 TEGADERM HYDROCOLLIOD DRESSING 3"X4" 192 testosterone 15 THIN DRESSING 5- TELFA NON-ADHERENT PAD 1/8"X6" 145 3"X8" 192 TESTOSTERONE 15 TEGADERM HYDROCOLLOID TELFA NON-ADHERENT PAD testosterone 15 DRESSING 4"X4" 145 PREPACK 8"X3" 192 TESTOSTERONE 103 TEGADERM HYDROCOLLOID TELFA NON-ADHERENT TESTOSTERONE DRESSING 4"X4-3/4" 145 PADS PREPACK 3"X4" 192 COMPOUNDINGKIT 15 TEGADERM HYDROCOLLOID telmisartan 47 TESTOSTERONE DRESSING 5-1/8"X6" 145 CONCENTRATE 103 TEGADERM HYDROCOLLOID telmisartan-amlodipine 49 telmisartan-hydrochlorothiazide TESTOSTERONE DRESSING 6"X6" 145 CYPIONATE 15 TEGADERM HYDROCOLLOID 49,50 DRESSING 6-3/4"X6-3/8" 146 temazepam 172 testosterone cypionate 15 TEGADERM HYDROCOLLOID TEMIXYS 68 TESTOSTERONE CYPIONATE 103 DRESSING 6-3/4"X8" 146 TEMODAR 53 TEGADERM HYDROCOLLOID TESTOSTERONE THIN DRESSING 4"X4" 146 TEMOVATE 134 CYPIONATE/TESTOSTERONE TEGADERM HYDROCOLLOID temozolomide 53 PROPIONATE 15 TESTOSTERONE THIN DRESSING 4"X4-3/4"146 temsirolimus 59 TEGADERM HYDROCOLLOID ENANTHATE 15 TENDEROL UNDERCAST testosterone enanthate 15 THIN DRESSING 6-3/4"X8"146 PADDING 2"X4 YD 192

Index 98 TESTOSTERONE THALOMID 271 THYMOL 111 MICRONIZED 103 THAM 267 THYMOL IODIDE 111 TESTOSTERONE MICRONIZED (SOY) 103 THE LIQUILIFT TRACE THYMOL IODIDE TESTOSTERONE MICRONIZED KIT 270 PURIFIED 111 (YAM) 103 THEANINE 104 THYMUS 104 TESTOSTERONE MICRONIZED THEO-24 25 THYQUIDITY 332 SOY 103 THEOBROMINE 104 THYROID 104,332 TESTOSTERONE MICRONIZED YAM 103 theophylline 25 thyroid 332 TESTOSTERONE NON- THEOPHYLLINE THYROID PORCINE 332 MICRONIZED SOY 103 ANHYDROUS 111 tiagabine hcl 30 THEOPHYLLINE TESTOSTERONE TIAZAC 73 PROPIONATE 15 ETHYLENEDIAMINE EP 25 TETANUS/DIPHTHERIA THEOPHYLLINE/D5W 25 TIBSOVO 59 TOXOIDS-ADSORBED THERABETIC EYE TICARCILLIN ADULT 333 HEALTH 287 DISODIUM/CLAVULANATE tetrabenazine 328 THERAGAUZE 192 POTASSIUM 104 TETRACAINE 103 THERAHONEY 146 TICE BCG 60 TETRACAINE HCL 103 THERANATAL CORE TIGAN 41 tetracaine hcl 176 NUTRITION 285 tigecycline 331 THIABENDAZOLE 16 tetracaine hcl (ophth) 298 TIGECYCLINE 331 THIAMINE HCL 342 TETRACYCLINE HCL 125 TIGHTENING BASE 325 thiamine hcl 342 tetracycline hcl 331 TIGLUTIK 290 THIAMINE TIKOSYN 22 TETRACYCLINE MONONITRATE 342 HYDROCHLORIDE 125 TIMOLOL MALEATE 72 THIMEROSAL 66 TETRAHYDRO-L-BIOPTERIN timolol maleate 72 DIHYDROCHLORIDE 103 THINLETS GP LANCETS216 timolol maleate (ophth) 295 TETRAHYDROBIOPTERIN THIOGUANINE 104 TIMOLOL/BRIMONIDE/DORZOL DIHYDROCHLORIDE 103 THIOLA 164 TETRAHYDROBIOPTERIN AMIDE 295 HYDROCHLORIDE 103 THIOLA EC 164 TIMOLOL/BRIMONIDINE/DORZ TETRAHYDROCURCUMINOIDS thioridazine hcl 65 OLAMIDE/LATANOPROST (THC) 103 THIORIDAZINE HCL 104 295 TETRAHYDROZOLINE TIMOLOL/DORZOLAMIDE/LATA THIOSALICYLIC ACID NOPROST 295 HCL 103 SODIUMSALT 103 TETRIX 140 TIMOLOL/LATANOPROST thiotepa 53 295 134 TEXACORT THIOTEPA 104 TIMOPTIC 296 226 TGT ALCOHOL SWABS thiothixene 65 TIMOPTIC OCUDOSE 295 TGT BLOOD GLUCOSE METER MONITORING SYSTEM 216 THREONINE 295 TIMOPTIC-XE 296 TGT BLOOD GLUCOSE THRIVITE 19 280 tinidazole 17 MONITORING SYSTEM 216 THRIVITE RX 285 TINIDAZOLE 111 TGT BLOOD GLUCOSE THROMBIN-JMI TINOGARD TL 81 MONITORING SYSTEM DILUENT 170 PREMIUM 216 THROMBIN-JMI TIOPRONIN 104 TGT BLOOD GLUCOSE TEST EPISTAXIS 170 tiopronin 164 STRIPS 152 THROMBIN-JMI SYRINGE TIROSINT 332 TGT BLOOD GLUCOSE TEST SPRAY KIT 170 TIROSINT-SOL 333 STRIPS PREMIUM 152 THROMBIN-JMI W/DIL TGT LANCET MICRO THIN SPRAYPUMP TISSEEL 170 33G 216 ACTUATOR 170 TITANIUM DIOXIDE 104 TGT LANCET THIN 26G 216 THROMBOGEN 170 TIVICAY 68 TGT LANCET ULTRA THIN THUM 140 30G 216 TIVICAY PD 68 TGT LANCING DEVICE 216 THYMOGLOBULIN 272 TIVORBEX 7

Index 99 TIZANIDINE COMFORT tolterodine tartrate 337 TOPROL XL 71 PAC 289 TOLTRAZURIL 104 toremifene citrate 56 TIZANIDINE HCL 104 TOLU BALSAM 104 TORISEL 59 tizanidine hcl 289 TOLUIDINE BLUE O 104 TORONOVA II SUIK 7 TL FOLATE 285 tolvaptan 158 TORONOVA SUIK 7 TL G-FOL OS 277 TOMMY GEL 325 torsemide 153 TL-CARE DHA 285 TOPAMAX 30 TOSYMRA 266 TL-FLUORIVITE 282 TOPAMAX SPRINKLE 30 TOTAL MEMORY & FOCUS TL-SELECT 285 TOPCARE CLICKFINE FORMULA 274 TOBI 3 UNIVERSAL PEN EEDLES TOTECT 60 TOBI PODHALER 3 31GX1/4" 256 TOUJEO MAX SOLOSTAR 37 TOBRADEX 300 TOPCARE CLICKFINE TOUJEO SOLOSTAR 37 UNIVERSAL PEN EEDLES TOBRADEX ST 300 31GX5/16" 256 TOVET KIT 134 tobramycin 3 TOPCARE LANCETS MICRO- TOVIAZ 337 TOBRAMYCIN 104 THIN 33G 216 TPN ELECTROLYTES 268 TOPCARE ULTRA COMFORT TRACE ELEMENTS tobramycin (ophth) 297 INSULIN SYRINGE/0.3ML/30G TOBRAMYCIN SULFATE 3 4/PEDIATRIC 270 X 5/16" 256 trace minerals (cr-cu-mn-se- tobramycin sulfate 3 TOPCARE ULTRA COMFORT zn) 270 tobramycin- INSULIN SYRINGE/0.3ML/31G trace minerals (cr-cu-mn- dexamethasone 300 X 5/16" 256 zn) 270 TOBREX 297 TOPCARE ULTRA COMFORT TRACLEER 75 INSULIN SYRINGE/0.5ML/30G TOCOPHERYL ACID TRADJENTA 35 SUCCINATED-ALPHA 105 X 5/16" 256 TOPCARE ULTRA COMFORT TRAGACANTH 320 TOCOTRIENOLS 104 INSULIN SYRINGE/0.5ML/31G TRALEMENT 270 TODAY SPONGE 339 X 5/16" 256 TODAYS HEALTH ADVANCED TOPCARE ULTRA COMFORT tramadol hcl 12 LANCING DEVICE 216 INSULIN SYRINGE/1ML/30G X TRAMADOL HCL 104 TODAYS HEALTH MINI PEN 5/16" 256 TRAMADOL NEEDLES 31G X 1/4" 256 TOPCARE ULTRA COMFORT HYDROCHLORIDE 104 TODAYS HEALTH ORIGINAL INSULIN SYRINGE/1ML/31G X tramadol-acetaminophen 14 PEN NEEDLES 29G X 1/2" 256 5/16" 256 trandolapril 47 TODAYS HEALTH SHORT PEN TOPCARE ULTRA COMFORT NEEDLES 31G X 5/16" 256 INSULIN SYRINGE/U- trandolapril-verapamil hcl 50 TODAYS HEALTH SUPER 100/0.3ML/29G X 1/2" 256 TRANEXAMIC ACID 104 THINLANCETS 30G 216 TOPCARE ULTRA COMFORT tranexamic acid 170 TODAYS HEALTH ULTRA INSULIN SYRINGE/U- TRANEXAMIC ACID/SODIUM THINLANCETS 28G 216 100/0.5ML/29G X 1/2" 256 CHLORIDE 170 TOENAIL CLIPPER 225 TOPCARE ULTRA COMFORT TRANILAST 104 TOENAIL CLIPPER/FILE INSULIN SYRINGE/U- DELUXE 225 100/1ML/29G X 1/2" 256 TRANSDERM SCOP 41 TOENAIL NIPPER 225 TOPICORT 134 TRANSDERM-SCOP 41 TOFACITINIB CITRATE 104 TOPIDEX 117 TRANSDERMAL PAIN BASE 325 topiramate 30 TOFRANIL 33 TRANXENE T 21 TOPIRAMATE 104 TOLAK 127 tranylcypromine sulfate 32 TOLAZOLINE topotecan hcl 61 TRAVASOL 295 HYDROCHLORIDE 104 TOPOTECAN HCL 61 TRAVATAN Z 301 tolbutamide 38 topotecan hcl 61 TRAVEL LANCETS 30G 216 tolcapone 61 TOPPER DRESSING tolmetin sodium 7 SPONGES 192 TRAVEL LANCETS ADVANCED 28G 216 TOLNAFTATE 127 TOPPER DRESSING SPONGES 4"X4" 192 travoprost 301 TOLSURA 42 TRAZIMERA 54

Index 100 TRAZODONE HCL 32 TRIAMCINOLONEUSP, TRINATAL RX 1 285 trazodone hcl 32 MICRONIZED 104 TRINAZ 286 TRIAMSIL COMBIPAK 134 TREANDA 53 TRINTELLIX 32 TRIAMSIL MULTIPAK 134 TRECATOR 52 TRIOSTAT 333 triamterene 154 TRELEGY ELLIPTA 25 TRIOXSALEN 104 TRIAMTERENE 154 TRELSTAR MIXJECT 56 TRIPELENNAMINE HCL 43 triamterene & TREMFYA 128 hydrochlorothiazide 153 TRIPLE COMPLEX FORMULA 3KIT 124 treprostinil 75 TRIANEX 134 TRIPLE PMB 300 TRESIBA 37 triazolam 172 TRIPLE PMK 300 TRESIBA FLEXTOUCH 37 TRIBENZOR 50 TRIPROLIDINE HCL 104 tretinoin 123 TRICARE 285 TRIPTODUR 156 TRETINOIN 123 TRICARE PRENATAL DHA TRETINOIN (ALL-TRANS ONE 285 TRISENOX 60 RETINOIC ACID) 123 TRICHLORMETHIAZIDE 104 TRISODIUM tretinoin (chemotherapy) 60 TRICHLOROACETIC CITRATE/CRRT 271 TRISTART DHA 286 tretinoin microsphere 123 ACID 104 TRISTART FREE 286 TRETTEN 165 TRICITRASOL 27 TRISTART ONE 286 TREXALL 54 TRICLOSAN 104 TRITON X-100 96 TREXIMET 265 TRICOR 45 TRIUMEQ 68 TRI-AMINO 295 TRIDESILON 134 TRIVEEN-DUO DHA 286 TRI-CHLOR 129 trientine hcl 271 TRIXYLITRAL 125 TRI-TABS DHA 285 TRIESENCE 300 TRIETHANOLAMINE LAURYL TRIZIVIR 68 TRI-VI-FLOR 281 SULFATE 104 TROCHE BASE 317 TRI-VI-FLORO 282 TRIETHYL CITRATE 104 TROCHE BASE NS 317 TRIACETIN 104 TRIFERIC 170 TROCHE BASE SF WITH TRIAMCINOLONE 104 trifluoperazine hcl 65 BITTER BLOC 317 triamcinolone acetonide 117 trifluridine 297 TROCHIBASE 317 TRIAMCINOLONE TRIGLIDE 45 TROCHIBASE S CLASSIC 317 ACETONIDE 117,134 triamcinolone acetonide trihexyphenidyl hcl 61 TRODELVY 61 (mouth) 275 TRIJARDY XR 34 TROGARZO 68 triamcinolone acetonide TRIKAFTA 330 TROKENDI XR 30 (topical) 134 TROLAMINE 305 TRIAMCINOLONE ACETONIDE TRILEPTAL 30 PF 117 TRILIPIX 45 TROMETHAMINE 104 triamcinolone acetonide- TRILOAN II SUIK 118 TROPHAMINE 295 dimethicone-silicone 134 TRILOAN SUIK 118 TROPICAL PUNCH TRIAMCINOLONE FLAVOR 308 TRILOCICLO 134 ACETONIDE/BUPIVACAINE TROPICAMIDE 296 HYDROCHLORIDE 117 TRILOSTANE 104 TROPICAMIDE/CYCLOPENTOL TRIAMCINOLONE TRIMEPRAZINE ATE ACETONIDEUSP, TARTRATE 104 HYDROCHLORIDE/PHENYLEP MICRONIZED 134 trimethobenzamide hcl 41 HRINE HYDRO 296 TRIAMCINOLONE TRIMETHOBENZAMIDE TROPICAMIDE/CYCLOPENTOL DIACETATE 117 HCL 104 ATE/PHENYLEPHRINE 296 TRIAMCINOLONE DIACETATE TRIMETHOPRIM 17 TROPICAMIDE/CYCLOPENTOL MICRONIZED 117 ATE/PHENYLEPHRINE/KETOR TRIAMCINOLONE trimethoprim 17 OLAC 296 HEXACETONIDE 104 trimipramine maleate 33 TROPICAMIDE/CYCLOPENTOL TRIAMCINOLONE/MOXIFLOXA TRIMIPRAMINE ATE/PHENYLEPHRINE/KETOR CIN HCL 300 MALEATE 34 OLAC/PROPARCA 296 TRIMO-SAN 339

Index 101 TROPICAMIDE/PHENYLEPHRIN TRUE COMFORT TWIST TOP TRUEPLUS INSULIN E 296 LANCETS 30G 216 SYRINGE/U-100/0.3ML/31G X TROPICAMIDE/PROPARACAIN TRUE FOCUS BLOOD 5/16" 257 E/PHENYLEPHRINE/KETOROL GLUCOSESELF MONITORING TRUEPLUS INSULIN AC 296 METER 216 SYRINGE/U-100/0.5ML/28G X TROPOLONE 104 TRUE FOCUS SELF 1/2" 257 trospium chloride 337 MONITORING BLOOD TRUEPLUS INSULIN TRUE COMFORT ALCOHOL GLUCOSE TEST SYRINGE/U-100/0.5ML/29G X STRIPS 152 1/2" 257 PREP PADS 226 TRUEPLUS INSULIN TRUE COMFORT INSULIN TRUE METRIX 216 SYRINGE/0.5ML/31G X TRUE METRIX AIR BLOOD SYRINGE/U-100/0.5ML/30G X GLUCOSE 5/16" 258 5/16" 256 TRUEPLUS INSULIN TRUE COMFORT INSULIN METER/BLUETOOTH 216 TRUE METRIX AIR BLOOD SYRINGE/U-100/0.5ML/31G X SYRINGE/1ML/31G X 5/16" 258 5/16" 257 GLUCOSE METER/BLUETOOTH TRUEPLUS INSULIN TRUE COMFORT PEN SYRINGE/U-100/1ML/28G X NEEDLES31G X 5MM 257 SMART 216 TRUE METRIX AIR 1/2" 258 TRUE COMFORT PEN TRUEPLUS INSULIN NEEDLES31G X 6MM 257 W/BLUETOOTH SMART 216 TRUE COMFORT PEN TRUE METRIX BLOOD SYRINGE/U-100/1ML/29G X NEEDLES32G X 4MM 257 GLUCOSEMETER 216 1/2" 258 TRUE COMFORT PRO TRUE METRIX BLOOD TRUEPLUS INSULIN ALCOHOLPREP PADS 226 GLUCOSETEST STRIPS 152 SYRINGE/U-100/1ML/30G X TRUE COMFORT PRO TRUE METRIX CONTROL 5/16" 258 INSULINSYRINGE/0.5ML/30G X SOLUTION LEVEL 1 216 TRUEPLUS INSULIN 5/16" 257 TRUE METRIX CONTROL SYRINGE/U-100/1ML/31G X TRUE COMFORT PRO SOLUTION LEVEL 2 216 5/16" 258 INSULINSYRINGE/0.5ML/31G X TRUE METRIX CONTROL TRUEPLUS LANCETS 5/16" 257 SOLUTION LEVEL 3 216 26G 216 TRUE COMFORT PRO TRUE METRIX GO BLOOD TRUEPLUS LANCETS GLUCOSE METER 216 28G 216 INSULINSYRINGE/1ML/30G X TRUEPLUS LANCETS 28G 5/16" 257 TRUE METRIX PRO TRUE COMFORT PRO GLUCOSE TEST SUPER THIN 217 INSULINSYRINGE/1ML/31G X STRIPS 152 TRUEPLUS LANCETS TRUE METRIX SELF 30G 217 5/16" 257 TRUEPLUS LANCETS 30G TRUE COMFORT PRO MONITORING BLOOD GLUCOSE STRIPS 152 ULTRA THIN 217 INSULINSYRINGE/U- TRUEPLUS LANCETS 100/0.5ML/30G X 1/2" 257 TRUECONTROL GLUCOSE CONTROL LEVEL 0 216 33G 217 TRUE COMFORT PRO TRUEPLUS LANCETS 33G INSULINSYRINGE/U- TRUECONTROL GLUCOSE CONTROL LEVEL 1 216 MICRO THIN 217 100/1ML/30G X 1/2" 257 TRUEPLUS PEN NEEDLES TRUE COMFORT PRO PEN TRUEDRAW LANCING DEVICE 216 29GX12MM 258 NEEDLES 31G X 5MM 257 TRUEPLUS PEN NEEDLES TRUE COMFORT PRO PEN TRUEPLUS 5-BEVEL PEN NEEDLES 29GX12.7MM 257 31GX5MM 258 NEEDLES 31G X 6MM 257 TRUEPLUS PEN NEEDLES TRUE COMFORT PRO PEN TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 257 31GX6MM 258 NEEDLES 31G X 8MM 257 TRUEPLUS PEN NEEDLES TRUE COMFORT PRO PEN TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 257 31GX8MM 258 NEEDLES 32G X 4MM 257 TRUEPLUS PEN NEEDLES TRUE COMFORT PRO PEN TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 257 32GX4MM 258 NEEDLES 32G X 5MM 257 TRUEPLUS SAFETY LANCETS TRUE COMFORT PRO PEN TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 257 28G 217 NEEDLES 32G X 6MM 257 TRUERESULT BLOOD TRUE COMFORT PRO PEN TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X GLUCOSEMONITORING NEEDLES 33G X 4MM 257 SYSTEM/NO CODING 217 TRUE COMFORT PRO PEN 1/2" 257 NEEDLES 33G X 5MM 257 TRUEPLUS INSULIN TRUETEST STRIPS 152 TRUE COMFORT PRO PEN SYRINGE/U-100/0.3ML/30G X NEEDLES 33G X 6MM 257 5/16" 257

Index 102 TRUETRACK BLOOD TYVASO 75 ULTICARE INSULIN GLUCOSE MONITORING TYVASO REFILL 75 SYRINGE/1ML/30G X 1/2" 258 SYSTEM 217 ULTICARE INSULIN TRUETRACK BLOOD TYVASO STARTER 75 SYRINGE/1ML/30G X GLUCOSE TEST 152 U-BASE 325 5/16" 258 TRUETRACK SMART U-MILD SHAMPOO 317 ULTICARE INSULIN SYSTEM 217 SYRINGE/SHORT/0.3ML/30G X UBIDECARENONE 111 TRUETRACK TEST 152 5/16" 258 UBIQUINOL 105 TRULANCE 160 ULTICARE INSULIN UBRELVY 265 SYRINGE/SHORT/0.3ML/31G X TRULICITY 35 UCARE POLYMER JR- 5/16" 258 TRUMENBA 337 400 320 ULTICARE INSULIN TRUSELTIQ 59 UCERIS 16,118 SYRINGE/SHORT/0.5ML/30G X 5/16" 258 TRUSOPT 301 UDAMIN SP 280 ULTICARE INSULIN TRUVADA 68 UDENYCA 167 SYRINGE/SHORT/0.5ML/31G X TRUXIMA 55 UKONIQ 59 5/16" 258 TRYPAN BLUE 306 ULESFIA 142 ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X TRYPSIN 104 ULORIC 165 5/16" 258 TRYPTOPHAN 295 ULTANE 163 ULTICARE INSULIN TUDORZA PRESSAIR 22 ULTI-LANCE AUTOMATIC/ SYRINGE/SHORT/1ML/31G X TUKYSA 54 CLEAR TIP 217 5/16" 258 ULTICARE ALCOHOL ULTICARE INSULIN TUNA FLAVOR 308 SWABS 226 SYRINGE/U-100/0.3ML/30G X TUNA TYPE FLAVOR OS 309 ULTICARE INSULIN SAFETY 1/2" 259 TURALIO 59 SYRINGE/0.5ML/29G X ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X TURMERIC 104 1/2" 258 ULTICARE INSULIN SAFETY 5/16" 259 TURMERIC ROOT 104 SYRINGE/1ML/29G X ULTICARE INSULIN TURPENTINE SPIRITS 136 1/2" 258 SYRINGE/U-100/0.5ML/30G X TUSSICAPS 118 ULTICARE INSULIN 1/2" 259 SYRINGE/0.3ML/29G X ULTICARE INSULIN TUSSLIN PEDIATRIC 118 1/2" 258 SYRINGE/U-100/0.5ML/31G X TUTTI FRUTTI ULTICARE INSULIN 5/16" 259 CONCENTRATE 309 SYRINGE/0.3ML/30G X ULTICARE INSULIN TUTTI FRUTTI FLAVOR 309 1/2" 258 SYRINGE/U-100/1ML/30G X TUTTI-FRUTTI FLAVOR 309 ULTICARE INSULIN 1/2" 259 TUXARIN ER 118 SYRINGE/0.3ML/30G X ULTICARE INSULIN 5/16" 258 SYRINGE/U-100/1ML/31G X TUZISTRA XR 118 ULTICARE INSULIN 5/16" 259 TWINRIX 338 SYRINGE/0.5ML/28G X ULTICARE INSULIN TWIRLA 113 1/2" 258 SYRINGEULTRAFINE U- 100/0.3ML/31G X 5/16" 259 TWYNSTA 50 ULTICARE INSULIN SYRINGE/0.5ML/29G X ULTICARE INSULIN TYBLUME 113 1/2" 258 SYRINGEULTRAFINE U- TYBOST 68 ULTICARE INSULIN 100/0.5ML/31G X 5/16" 259 TYGACIL 331 SYRINGE/0.5ML/30G X ULTICARE INSULIN 1/2" 258 SYRINGEULTRAFINE U- TYKERB 59 ULTICARE INSULIN 100/1ML/31G X 5/16" 259 TYLENOL/CODEINE #3 14 SYRINGE/0.5ML/30G X ULTICARE MICRO PEN TYLENOL/CODEINE #4 14 5/16" 258 NEEDLES 31G X 8MM 259 ULTICARE MICRO PEN TYLOSIN TARTRATE 104 ULTICARE INSULIN SYRINGE/1ML/28G X NEEDLES 32G X 4MM 259 TYLOXAPOL 104 1/2" 258 ULTICARE MICRO PEN TYMLOS 155 ULTICARE INSULIN NEEDLES/31G X 1/4" 259 TYPHIM VI 337 SYRINGE/1ML/29G X ULTICARE MICRO PEN NEEDLES/31G X 5/16" 259 TYSABRI 329 1/2" 258

Index 103 ULTICARE MICRO PEN ULTIGUARD SAFEPACK ULTILET INSULIN NEEDLES/32G X 4MM 259 INSULIN SYRINGE/0.3ML/31G SYRINGE/SHORT/0.3ML/30G X ULTICARE MICRO PEN X 5/16"/SHARPS 260 12.7MM 261 NEEDLES/32G X 5/32" 259 ULTIGUARD SAFEPACK ULTILET INSULIN ULTICARE MINI PEN NEEDLES INSULIN SYRINGE/0.5ML/30G SYRINGE/SHORT/0.3ML/30G X 31GX6MM 259 X 1/2"/SHARPS C 260 5/16" 261 ULTICARE MINI PEN NEEDLES ULTIGUARD SAFEPACK MINI ULTILET INSULIN ULTI-FINE IV 259 PEN NEEDLE/31G X SYRINGE/SHORT/0.3ML/31G X ULTICARE MINI PEN 3/16"/SHARPS CONTAI 260 5/16" 261 NEEDLES/31G X 6MM 259 ULTIGUARD SAFEPACK PEN ULTILET INSULIN ULTICARE MINI PEN NEEDLE/29G X 1/2"/SHARPS SYRINGE/SHORT/0.5ML/30G X NEEDLES/32G X 1/4" 259 CONTAINER 260 5/16" 261 ULTICARE MINI PEN ULTIGUARD ULTILET INSULIN NEEDLES31GX6MM 259 SAFEPACK/MICROPEN SYRINGE/SHORT/0.5ML/31G X ULTICARE MINI SAFETY NEEDLE/32G X 5/32" 260 5/16" 261 PENNEEDLES 30G X ULTIGUARD ULTILET INSULIN 3/16" 259 SAFEPACK/MICROPEN SYRINGE/SHORT/1ML/30G X ULTICARE ORIGINAL PEN NEEDLE/32G X 5/32"/SHARPS 5/16" 261 NEEDLES ULTI-FINE 259 CONTA 260 ULTILET INSULIN ULTICARE PEN NEEDLES ULTIGUARD SAFEPACK/MINI SYRINGE/SHORT/1ML/31G X 31GX 5MM/MINI 259 PEN NEEDLE/31G X 5/16" 261 ULTICARE PEN 1/4"/SHARPS CONTAIN 260 ULTILET INSULIN SYRINGE/U- NEEDLES/29GX 12.7MM 259 ULTIGUARD SAFEPACK/MINI 100/0.5ML/30G X 1/2" 261 ULTICARE SHORT PEN PEN NEEDLE/31G X ULTILET INSULIN SYRINGE/U- NEEDLES 31GX8MM 259 3/16"/SHARPS CONTAI 260 100/0.5ML/31GX6MM 261 ULTICARE SHORT PEN ULTIGUARD SAFEPACK/MINI ULTILET INSULIN SYRINGE/U- NEEDLES ULTI-FINE IV 259 PEN NEEDLE/32G X 100/1ML/30G X 1/2" 261 ULTICARE SHORT PEN 1/4"/SHARPS CONTAIN 260 ULTILET LANCETS 217 NEEDLES/31G X 8MM 259 ULTIGUARD ULTILET LANCETS 33G 217 ULTICARE SHORT SAFETY SAFEPACK/SHORTPEN PEN NEEDLES 30G X ULTILET PEN NEEDLE NEEDLE/31G X 5/16"/SHARPS 29GX12.7MM 261 5/16" 259 CONTA 260 ULTICARE U-100 INSULIN ULTILET PEN NEEDLE ULTIGUARD 31GX5MM 261 SYRINGES/0.3ML/31G X SAFEPACK/SYRINGE/NEEDL 1/4" 259 ULTILET PEN NEEDLE E/31G X 5/16"/SHARPS 31GX8MM 261 ULTICARE U-100 INSULIN CONTAIN 260 SYRINGES/0.3ML/31G ULTILET PEN NEEDLE ULTILET ALCOHOL 32GX4MM 261 X1/4" 260 SWABS 226 ULTICARE U-100 INSULIN ULTILET PEN NEEDLE ULTILET CLASSIC 32GX4MM/SHORT 261 SYRINGES/0.5ML/31G X LANCETS 217 1/4" 260 ULTILET SAFETY LANCETS ULTILET INSULIN SYRINGE 21G X 2.2MM 217 ULTICARE U-100 INSULIN 31X6MM 260 SYRINGES/1ML/31G X ULTILET SAFETY LANCETS ULTILET INSULIN 23G 217 1/4" 260 SYRINGE/0.3ML/30G X ULTIGUARD SAFEPACK ULTILET SHORT PEN 8MM 260 NEEDLES 31GX5/16" 261 INSULIN SYRINGE 0.3ML/30G X ULTILET INSULIN 1/2"/SHARPS C 260 ULTILET SHORT PEN SYRINGE/0.3ML/31G X NEEDLES31GX3/16" 261 ULTIGUARD SAFEPACK 8MM 260 INSULIN SYRINGE 1/2ML 30G X ULTILET U-100 INSULIN ULTILET INSULIN SYRINGES/1ML/31G X 1/2"/SHARPS C 260 SYRINGE/0.5ML/30G X ULTIGUARD SAFEPACK 6MM 261 8MM 260 ULTIMA 217 INSULIN SYRINGE 1ML 30G X ULTILET INSULIN 1/2"/SHARPS CON 260 SYRINGE/1ML/30G X ULTIMATECARE ONE 286 ULTIGUARD SAFEPACK 8MM 261 ULTIVA 12 INSULIN SYRINGE 1ML 31G X ULTILET INSULIN ULTRA COMFORT INSULIN 5/16"/SHARPS CO 260 SYRINGE/1ML/31G X SYRINGE/U-100/0.3ML/30G X ULTIGUARD SAFEPACK 8MM 261 5/16" 261 INSULIN SYRINGE/0.3ML/30G X ULTRA FLO INSULIN PEN 1/2"/SHARPS C 260 NEEDLE 31GX5MM 261

Index 104 ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN ULTRA-THIN II PEN NEEDLES NEEDLE 32GX4MM 261 SYRINGE/U-100/0.3ML/31G X 29GX1/2" 263 ULTRA FLO INSULIN PEN 5/16" 262 ULTRA-THIN II PEN NEEDLE 33GX4MM 261 ULTRA-COMFORT INSULIN NEEDLES/SHORT/31GX5/16" ULTRA FLO INSULIN PEN SYRINGE/U-100/0.5ML/28G X 263 NEEDLES 261 1/2" 262 ULTRABAG/DIANEAL LOW ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN CALCIUM/1.5% NEELE 31GX8MM 261 SYRINGE/U-100/0.5ML/29G X DEXTROSE 274 ULTRA FLO INSULIN SYRINGE 1/2" 262 ULTRABAG/DIANEAL LOW 0.3ML/29G X 1/2" 261 ULTRA-COMFORT INSULIN CALCIUM/2.5% ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/0.5ML/30G X DEXTROSE 274 0.3ML/30GX1/2" 261 5/16" 262 ULTRABAG/DIANEAL LOW ULTRA FLO INSULIN SYRINGE ULTRA-COMFORT INSULIN CALCIUM/4.25% 0.3ML/30GX5/16" 261 SYRINGE/U-100/0.5ML/31G X DEXTROSE 274 ULTRA FLO INSULIN SYRINGE 5/16" 262 ULTRABAG/DIANEAL PD- 0.3ML/31GX5/16" 261 ULTRA-COMFORT INSULIN 2/1.5% DEXTROSE 274 ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/28G X ULTRABAG/DIANEAL PD- 0.5ML/29GX1/2" 261 1/2" 262 2/2.5% DEXTROSE 274 ULTRA FLO INSULIN SYRINGE ULTRA-COMFORT INSULIN ULTRABAG/DIANEAL PD- 0.5ML/30GX1/2" 261 SYRINGE/U-100/1ML/29G X 2/4.25% DEXTROSE 274 ULTRA FLO INSULIN SYRINGE 1/2" 262 ULTRACARE INSULIN 0.5ML/30GX5/16" 261 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/30G X 5/16" 263 0.5ML/31GX5/16" 262 5/16" 262 ULTRACARE INSULIN ULTRA FLO INSULIN SYRINGE ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 1/2 UNIT/0.3ML/30GX1/2" 262 SYRINGE/U-100/1ML/31G X 5/16" 263 ULTRA FLO INSULIN SYRINGE 5/16" 262 ULTRACARE INSULIN 1/2 UNIT/0.3ML/30GX5/16" ULTRA-THIN II AUTO SYRINGE/U-100/0.5ML/30G X 262 LANCET 217 1/2" 263 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN ULTRACARE INSULIN 1/2 UNIT/0.3ML/31GX5/16" SYRINGE SHORT/U- SYRINGE/U-100/0.5ML/30G X 262 100/0.3ML/30GX5/16" 262 5/16" 263 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN ULTRACARE INSULIN 1M/29GX1/2" 262 SYRINGE SHORT/U- SYRINGE/U-100/0.5ML/31G X ULTRA FLO INSULIN SYRINGE 100/0.3ML/31GX5/16" 262 5/16" 263 1ML/30GX1/2" 262 ULTRA-THIN II INSULIN ULTRACARE INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- SYRINGE/U-100/1ML/30G X 1ML/30GX5/16" 262 100/0.5ML/30GX5/16" 262 1/2" 263 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN ULTRACARE INSULIN 1ML/31GX5/16" 262 SYRINGE SHORT/U- SYRINGE/U-100/1ML/30G X ULTRA THIN LANCETS 100/0.5ML/31GX5/16" 262 5/16" 263 31G 217 ULTRA-THIN II INSULIN ULTRACARE INSULIN ULTRA THIN PEN NEEDLES SYRINGE SHORT/U- SYRINGE/U-100/1ML/31G X 32G X 4MM 262 100/1ML/30GX5/16" 262 5/16" 263 ULTRA TRAK PRO BLOOD ULTRA-THIN II INSULIN ULTRACARE PEN GLUCOSE MONITORING SYRINGE SHORT/U- NEEDLES/31G X 1/4" 263 SYSTEM 217 100/1ML/31GX5/16" 262 ULTRACARE PEN ULTRA-CARE ALCOHOL PREP ULTRA-THIN II INSULIN NEEDLES/31G X 3/16" 263 PADS 227 SYRINGE/U- ULTRACARE PEN ULTRA-CARE LANCETS 100/0.5ML/29GX1/2" 263 NEEDLES/31G X 5/16" 263 30G 217 ULTRA-THIN II INSULIN ULTRACARE PEN ULTRA-COMFORT INSULIN SYRINGE/U- NEEDLES/32G X 1/14" 263 SYRINGE/U-100/0.3ML/29G X 100/1ML/29GX1/2" 263 ULTRACARE PEN 1/2" 262 ULTRA-THIN II LANCETS NEEDLES/32G X 3/16" 263 ULTRA-COMFORT INSULIN 28G 217 ULTRACARE PEN SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II LANCETS NEEDLES/32G X 5/32" 263 5/16" 262 30G 217 ULTRACARE PEN ULTRA-THIN II MINI PEN NEEDLES/33G X 5/32" 263 NEEEDLES/31GX3/16" 263 ULTRACET 14

Index 105 ULTRADERM 325 UNIFINE PENTIPS/30G X UNIVERSAL 1 ULTRAM 12 3/16" 264 LANCETS/33G/MICRO-THIN UNIFINE SAFECONTROL PEN 218 ULTRASAL-ER 136 NEEDLE/30G X 3/16" 264 UNIVERSAL WATER GEL 325 ULTRATRAK ACTIVE 217 UNIFINE SAFECONTROL PEN UPLIZNA 272 NEEDLE/30G X 5/16" 264 ULTRATRAK PRO 217 UPNEEQ 301 ULTRATRAK PRO CONTROL UNILET COMFORTOUCH SOLUTION 2 LEVELS 217 LANCET 217 UPSPRING HE NATAL 287 ULTRATRAK PRO NORMAL UNILET EXCELITE 217 UPTRAVI 75 CONTROL 217 UNILET EXCELITE II 217 URAMAXIN 134 ULTRATRAK PRO TEST UNILET G.P. LANCET 217 UREA 105 STRIPS 152 UNILET G.P. SUPERLITE urea 134 ULTRATRAK ULTIMATE LANCET 217 CONTROL SOLUTION 2 UNILET GP 28 ULTRA UREA 134 LEVELS 217 THIN 217 urea 135 ULTRATRAK ULTIMATE MONITOR 217 UNILET LANCET 217 urea in lactic acid vehicle 135 ULTRATRAK ULTIMATE TEST UNILET LANCETS MICRO- UREA PEROXIDE 85 STRIPS 152 THIN33G 217 URECHOLINE 337 ULTRAVATE 134 UNILET LANCETS SUPER- THIN30G 217 URESOL 135 UNASYN 304 UNILET LANCETS ULTRA- UREVAZ 135 UNASYN BULK PACK 304 THIN 28G 217 URIDINE 105 UNILET SUPERLITE UNDECYLENIC ACID 108 URIMAR-T 17 UNIFINE PEN NEEDLE/32G LANCET 217 UNISPEND ANHYDROUS URINOZINC PLUS 274 X4MM 263 UNIFINE PENTIPS SWEETENED 317 UROCIT-K 10 163 UNISPEND ANHYDROUS 29GX12MM 263 UNSWEETENED 317 UROCIT-K 15 163 UNIFINE PENTIPS 31G X UROCIT-K 5 163 3/16" 263 UNISTIK 3 GENTLE 217 UNIFINE PENTIPS UNISTIK PRO SAFETY UROGESIC-BLUE 17 31GX5MM 263 LANCET 21G 218 UROXATRAL 164 UNIFINE PENTIPS UNISTIK PRO SAFETY URSO 250 160 31GX6MM 263 LANCET 25G 218 UNIFINE PENTIPS UNISTIK PRO SAFETY URSO FORTE 160 31GX8MM 263 LANCET 28G 218 URSODIOL 105,160 UNIFINE PENTIPS UNISTIK SAFETY LANCETS ursodiol 160 32GX4MM 263 28G 218 URSODIOL/SYRSPEND SF UNIFINE PENTIPS UNISTIK SAFETY LANCETS PH4 160 30G 218 32GX6MM 263 UTIBRON NEOHALER 25 UNIFINE PENTIPS UNISTIK TOUCH SAFETY 33GX4MM 263 LANCETS 21G 218 UTOPIC 135 UNIFINE PENTIPS PLUS UNISTIK TOUCH SAFETY UVADEX 60 29GX12MM 263 LANCETS 23G 218 V-GO 20 218 UNIFINE PENTIPS PLUS UNISTIK TOUCH SAFETY 31GX5MM 263 LANCETS 28G 218 V-GO 30 218 UNIFINE PENTIPS PLUS UNISTIK TOUCH SAFETY V-GO 40 218 31GX6MM 263 LANCETS 30G 218 V-MAX 326 UNISTRIP CONTROL UNIFINE PENTIPS PLUS VABOMERE 18 31GX8MM 263 SOLUTIONHIGH 218 UNIFINE PENTIPS PLUS UNISTRIP CONTROL VAGIFEM 339 32GX4MM 263 SOLUTIONLOW 218 valacyclovir hcl 69 UNIFINE PENTIPS PLUS 33GX UNISTRIP1 GENERIC 152 VALACYCLOVIR HCL 105 5/32" 264 UNITUXIN 55 VALACYCLOVIR UNIFINE PENTIPS PLUS UNIVERSAL 1 LANCETS HYDROCHLORIDE 105 33GX4MM 264 THIN26G 218 UNIFINE PENTIPS PLUS/30GX VALCHLOR 127 UNIVERSAL 1 LANCETS VALCYTE 69 3/16" 264 ULTRA THIN 30G 218 VALERIAN ROOT 105

Index 106 valganciclovir hcl 69 VALULINE SHORT LEG VANILLA FLAVOR 309 VALINE 295 WALKER/LOW VANILLIN 105 TOP/MEDIUM 225 VALIUM 21 VALULINE SHORT LEG VANILLIN FLAVOR 309 valproate sodium 31 WALKER/LOW VANISH-PEN 326 VALPROATE SODIUM 105 TOP/SMALL 225 VANISHING CREAM 326 VALULINE SHORT LEG VANISHING CREAM valproic acid 31 WALKER/MEDIUM 225 VALPROIC ACID 105 BOTANICALBASE 326 VALULINE SHORT LEG VANISHPOINT INSULIN valrubicin 57 WALKER/SMALL 225 SYRINGE/0.5ML/30G X valsartan 47 VALULINE SHORT LEG 1/2" 264 valsartan-hydrochlorothiazide WALKER/STANDARD VANISHPOINT INSULIN TOP/MEDIUM 225 SYRINGE/0.5ML/30G X 50 VALULINE SHORT LEG VALSTAR 57 3/16" 264 WALKER/STANDARD VANISHPOINT INSULIN VALTOCO 27 TOP/SMALL 225 SYRINGE/0.5ML/30G X VALTREX 69 VALULINE SHORT LEG 5/16" 264 VALUE HEALTH INSULIN WALKER/STANDARD/LARGE VANISHPOINT INSULIN SYRINGE/U-100/0.5ML/29G X 225 SYRINGE/1ML/29G X 1/2" 264 1/2" 264 VALULINE SHORT LEG VANISHPOINT INSULIN VALUE HEALTH INSULIN WALKER/XLARGE 225 SYRINGE/1ML/29G X SYRINGE/U-100/1ML/29G X VALULINE SHORT LEG 5/16" 264 1/2" 264 WALKER/XSMALL 225 VANISHPOINT INSULIN VALUE PLUS LANCETS VALUMARK LANCET SUPER SYRINGE/1ML/30G X STANDARD 21G 218 THIN 30G 218 3/16" 264 VALUE PLUS LANCETS VALUMARK LANCET ULTRA VANISHPOINT INSULIN SUPERTHIN 30G 218 THIN 28G 218 SYRINGE/1ML/30G X VALUMARK PEN NEEDLES VALUE PLUS LANCETS THIN 5/16" 264 29GX12MM 264 26G 218 VANOS 134 VALUE PLUS LANCING VALUMARK PEN NEEDLES DEVICE 218 31GX 6MM 264 VANTAS 56 VALULINE PNEUMATIC VALUMARK PEN NEEDLES VAPRISOL 158 SHORTLEG WALKER/LOW 31GX 8MM 264 VAQTA 338 TOP/LARGE 225 VANADIUM 105 VARDENAFIL VALULINE PNEUMATIC VANADYL SULFATE HYDROCHLORIDE 105 SHORTLEG WALKER/LOW HYDRATE 105 VARDIMAXIA 123 TOP/MEDIUM 225 VANCOCIN 18 VARITHENA 275 VALULINE PNEUMATIC VANCOCIN HCL 18 SHORTLEG WALKER/LOW VARIVAX 338 VANCOMYCIN 18 TOP/SMALL 225 VARIZIG 303 vancomycin hcl 18 VALULINE PNEUMATIC VAROPHEN 125 SHORTLEG VANCOMYCIN HCL 18 VAROXIA 123 WALKER/STANDARD vancomycin hcl 18 TOP/LARGE 225 VARUBI 41 VANCOMYCIN HCL 105 VALULINE PNEUMATIC VASCEPA 44 SHORTLEG VANCOMYCIN HCL + WALKER/STANDARD SYRSPENDSF PH4 18 VASERETIC 50 TOP/MEDIUM 225 VANCOMYCIN VASHE SKIN/WOUND/BURN VALULINE PNEUMATIC HYDROCHLORIDE 105,298 CLEANSING 146 SHORTLEG VANCOMYCIN VASHE WOUND WALKER/STANDARD HYDROCHLORIDE/DEXTROS THERAPY 146 TOP/SMALL 225 E 18 VASOPRESSIN/DEXTROSE VALULINE SHORT LEG VANCOMYCIN 158 WALKER/LARGE 225 HYDROCHLORIDE/SODIUM VASOPRESSIN/SODIUM VALULINE SHORT LEG CHLORIDE 18 CHLORIDE 158 WALKER/LOW VANIBASE 326 VASOSTRICT 158 TOP/LARGE 225 VANILLA BUTTERNUT VASOTEC 47 FLAVOR 309 VAXCHORA 337

Index 107 VAXELIS 333 VERAPAMIL HCL 73 VIDA MIA UNIFINE VAZCULEP 341 verapamil hcl 73 PENTIPSORIGINAL 29GX12MM 264 VCF VAGINAL VERASENS BLOOD VIDA MIA UNILET LANCETS CONTRACEPTIVE FILM 339 GLUCOSE MONITORING SUPER THIN 30G 218 VCF VAGINAL SYSTEM 218 VIDA MIA UNILET LANCETS CONTRACEPTIVE FOAM 339 VERASENS BLOOD ULTRA THIN 28G 218 VCF VAGINAL GLUCOSE MONITORING VIDA MIA UNIPFINE CONTRACEPTIVEGEL 339 SYSTEM METER KIT 218 PENTIPSSHORT VECAMYL 50 VERASENS BLOOD 31GX8MM 264 VECTIBIX 55 GLUCOSE TEST STRIPS 152 VIDARABINE 105 VECTICAL 128 VERASENS GLUCOSE VIDAZA 54 VECURONIUM BROMIDE 105 CONTROLLEVEL 1 218 VIDEX EC 68 vecuronium bromide 291 VERDESO 134 VIDEXPEDIATRIC 68 VECURONIUM BROMIDE 291 VEREGEN 123 VIEKIRA PAK 69 VEGETABLE CAPSULE #0 VERELAN 73 vigabatrin 30 GREEN 318 VERELAN PM 73 VEGETABLE CAPSULE #0 VIGAMOX 298 WHITE 318 VERQUVO 75 VIIBRYD 32 VEGETABLE CAPSULE #00 VERSABASE 326 VIIBRYD STARTER PACK 32 WHITE 318 VERSABASE FOAM 326 VEGETABLE CAPSULE #1 VILTEPSO 291 WHITE 318 VERSABASE HRT 326 VIMIZIM 157 VEGETABLE CAPSULE #2 VERSACLOZ 64 VIMOVO 7 WHITE 318 VERSAFREE 317 VIMPAT 30 VEGETABLE CAPSULE #3 VERSAPLUS 317 WHITE 318 VINATE DHA RF 286 VEGETABLE CAPSULE #4 VERSAPRO 326 VINATE II 286 WHITE 318 VERSAPRO ANHYDROUS VINATE ONE 286 VEINPUNCTURE PX1 BASE 326 PHLEBOTOMY SYSTEM 138 VERSAPRO SHAMPOO 317 vinblastine sulfate 61 VEKLURY 70 VERSATILE CREAM vincristine sulfate 61 VELCADE 59 BASE 326 vinorelbine tartrate 61 VERSATILE RICH CREAM VINPOCETINE 105 VELETRI 75 BASE 326 VIOKACE 152 VELPHORO 162 VERSIGEL 326 VIRACEPT 68 VELTASSA 274 VERZENIO 59 VIRAMUNE 68 VELTIN 123 VESICARE 337 VIRAMUNE XR 68 VEMLIDY 69 VESICARE LS 337 VIRASAL 136 VENA-BAL DHA 286 VEXASYN 146 VIRAZOLE 70 VENCLEXTA 55 VFEND 42 VIREAD 68 VENCLEXTA STARTING VFEND IV 42 PACK 55 VIRT-C DHA 286 VIBATIV 18 VENELEX 146 VIRT-FEFA PLUS 169 VIBERZI 162 VENEXA 280 VIRT-NATE DHA 286 VENEXA FE 280 VIBRAMYCIN 332 VICTORIAS SECRET VIRT-PN DHA 286 venlafaxine hcl 33 VANILLALACE 106 VIRT-PN PLUS 286 VENNGEL ONE 125 VICTOZA 35 VISBIOME 38 VENOFER 170 VIDA MIA AUTOLET VISBIOME PROBIOTIC HIGH VENTAVIS 75 LANCINGDEVICE 218 POTENCY 38 VENTOLIN HFA 25 VIDA MIA UNIFINE VISIONBLUE 300 PENTIPS32GX4MM 264 VENTRIXYL 280 VISTA ADVANCED VIDA MIA UNIFINE CAROTENOIID FORMULA 287 verapamil hcl 73 PENTIPSMINI 31GX6MM264 VISTARIL 21

Index 108 VISTOGARD 40 VITRANOL 280 VSL#3 JUNIOR 38 VISUDYNE 298 VITRANOL FE 280 VUMERITY 329 VITA-RX DIABETIC VITRASE 271 VUSION 127 VITAMIN 287 VITREXATE 280 VYEPTI 265 VITAFOL FE+ 286 VITREXATE FE 280 VYNDAMAX 75 VITAFOL GUMMIES 286 VITREXYL 280 VYNDAQEL 75 VITAFOL STRIPS 286 VITREXYL/IRON 280 VYONDYS 53 291 VITAFOL ULTRA 286 VIVA DHA 286 VYTORIN 44 VITAFOL-NANO 286 VIVAGUARD INO BLOOD VYVANSE 1 VITAFOL-OB 286 GLUCOSE METER 218 VYXEOS 57 VITAFOL-OB+DHA 286 VIVAGUARD INO BLOOD VYZULTA 301 VITAFOL-ONE 286 GLUCOSE TEST STRIPS 152 WA-001 EXPERIMENTAL VITAL-D RX 277 VIVAGUARD INO CONTROL SOILSURFACTANT 108 VITALET PRO LANCETS 218 SOLUTION 218 WABANA 274 VITALET PRO PLUS VIVAGUARD LANCETS 218 WAKIX 2 LANCETS 218 VIVAGUARD LANCING WALGREENS ADVANCED VITAMEDMD ONE DEVICE 218 TRAVELLANCETS 28G 218 RX/QUATREFOLIC 286 VIVELLE-DOT 160 WALGREENS COMFORT VITAMEDMD REDICHEW VIVITROL 40 ASSUREDLANCETS MICRO RX 286 THIN/33G 218 VITAMEZ 169 VIVLODEX 7 WALGREENS COMFORT VITAMIN A 105 VIVOTIF 337 ASSUREDLANCETS SUPER VITAMIN A ACETATE 105 VIZIMPRO 55 THIN/28G 218 WALGREENS LANCETS 218 VITAMIN A PALMITATE 105 VOCAL POINT BLOOD GLUCOSE MONITORING WALGREENS THIN VITAMIN B SYSTEM 218 LANCETS 219 COMPLEX/HYDROXOCOBALA VOCAL POINT BLOOD WALGREENS ULTRA THIN MIN 276 GLUCOSE TEST LANCETS 219 VITAMIN B12/FOLIC ACID 169 STRIPS 152 warfarin sodium 26 VITAMIN D3 85,342 VOGELXO 16 WARFARIN SODIUM VITAMIN D3 IMMUNE VOGELXO PUMP 16 CLATHRATEFORM 26 HEALTH 342 WATER BASE GEL 326 VITAMIN DEFICIENCY VOL-NATE 286 VOL-PLUS 286 water for inject, bacteriostatic INJECTABLE SYSTEM- benzyl alcohol 317 B12 167 VOL-TAB RX 286 water for injection, sterile 317 VITAMIN E 105 VOLTAREN 125 water for irrigation, sterile 272 VITAMIN E ACETATE 105,342 VORAXAZE 60 WATERMELON FLAVOR 309 VITAMIN E SUCCINATE 105 voriconazole 42 WATERSHIELD WATER- VITAMIN K2 95 VORICONAZOLE 105 RESISTANT BANDAGES 192 VITAMIN/IRON MASKING VOSEVI 69 WAVESENSE AMP 219 AGENT FLAVOR 309 WAVESENSE KEYNOTE 219 VITAMINS FOR THE HAIR 287 VOTRIENT 59 VP DERMABASE 326 WAVESENSE KEYNOTE PRO VITAPEARL 286 METER 219 VITAROCA PLUS 280 VP FC KIT 125 WAVESENSE PRESTO TEST VITATHELY/GINGER 286 VP GKL KIT 125 STRIPS 152 VITATROCHE PLUS BASE SF VP INSULIN SYRINGE/U- WAX PARAFFIN BEADS 320 WITH BITTER-BLOC 317 100/0.3ML/29G X 1/2" 264 WEBCOL ALCOHOL PREP VITATRUE 286 VP-PNV-DHA 286 LARGE 1 PLY 227 VPRIV 166 WEBCOL ALCOHOL PREP VITAXYME 280 LARGE 2 PLY 227 VITAZYME 280 VRAYLAR 63 WEBCOL ALCOHOL PREP VITRAKVI 59 VSL#3 38 MEDIUM 2 PLY 227 VSL#3 DS 38

Index 109 WEGMANS UNIFINE PENTIPS XALKORI 59 XEROFORM OCCLUSIVE PLUS 32GX4MM 264 XANAX 21 PETROLATUM GAUZE WEGMANS UNIFINE PENTIPS STRIP/OVERWRAP 5"X9" 146 PLUS/MINI/31GX5MM 264 XANAX XR 21 XEROFORM OCCLUSIVE WEGMANS UNIFINE PENTIPS XANTHAN GUM 321 PETROLTUM GAUZE PATCH PLUS/SHORT/31GX8MM 264 XARACOLL 175 2"X2" 146 WEGMANS UNIFINE PENTIPS XEROFORM OCCLUSIVE PLUS/ULTRA XARELTO 26 PETROLTUM GAUZE PATCH SHORT/31GX6MM 264 XARELTO STARTER 4"X4" 146 WELCHOL 44 PACK 26 XEROSTOMIA RELIEF XATMEP 54 WELLBUTRIN SR 31 SPRAY 276 XCEL 100 326 XGEVA 155 WELLBUTRIN XL 31 XCOPRI 30 XHANCE 290 WESTAB PLUS 286 XELJANZ 4 XIAFLEX 271 WESTGEL DHA 286 XELJANZ XR 4 XIFAXAN 17 WESTHROID 333 XELODA 54 XIGDUO XR 34 WHEAT GERM 342 WHEY PROTEIN ISOLATE XELPROS 301 XIIDRA 298 INSTANIZED 105 XEMATOP BASE 326 XIMINO 332 WHITE BEES WAX 320 XEMBIFY 303 XOFIGO 59 WHITE KIDNEY BEAN XENAZINE 328 XOFLUZA 70 EXTRACT 105 XENLETA 19 XOLAIR 22 white petrolatum 326 XEOMIN 291 XOLEGEL 127 WHITE PETROLATUM 326 XEPI 125 XOLEGEL COREPAK 127 WHITE WAX 320 XERAC AC 141 XOLEGEL DUO/HEAD & WHITE WAX PASTILLES 320 XERALUX 140 SHOULDERS 127 WHITE WILLOW BARK 105 XOLEGEL DUO/XOLEX 127 XERAVA 331 WILATE 166 XOPENEX 25 XERESE 129 WILD CHERRY FLAVOR 309 XOPENEX CONCENTRATE 25 XERMELO 162 WILD CHERRY SD N&A XOPENEX HFA 25 FLAVOR CONCENTRATE 309 XEROFORM NON- WILEY BASIC ELEMENTS OCCLUSIVE OIL EMULSION XOSPATA 59 BHRTBASE 326 GAUZE STRIP 5"X9" 146 XPOVIO 57 XEROFORM NON- WILZIN 270 XPOVIO 100 MG ONCE OCCLUSIVE OIL EMULSION WEEKLY 56 WINLEVI 123 PATCH 2"X2" 146 XPOVIO 40 MG ONCE WINRHO SDF 303 XEROFORM NON- WEEKLY 56 WITCH HAZEL 91 OCCLUSIVE OIL EMULSION XPOVIO 40 MG TWICE STRIP/OVERWRAP WITEPSOL 320 WEEKLY 56 1"X8" 146 XPOVIO 60 MG ONCE WITEPSOL H15 320 XEROFORM NON- WEEKLY 56 WITEPSOL H15 BASE F 320 OCCLUSIVE ROLL 146 XPOVIO 60 MG TWICE WOUND CARE CREAM 326 XEROFORM OCCLUSIVE WEEKLY 56 PETROLATUM GAUZE ROLL XPOVIO 80 MG ONCE WOUND GEL 146 4"X9' 146 WEEKLY 56 WOUND GEL SPRAY 146 XEROFORM OCCLUSIVE XPOVIO 80 MG TWICE WOUND TREATMENT KIT 192 PETROLATUM GAUZE STRIP WEEKLY 56 1"X8" 146 XRYLIX 125 WP THYROID 333 XEROFORM OCCLUSIVE WPR PLUS WOUND HEALING PETROLATUM GAUZE STRIP XTAMPZA ER 12 SYSTEM 138 5"X9" 146 XTANDI 56 WYNZORA 134 XEROFORM OCCLUSIVE XULTOPHY 100/3.6 34 XADAGO 63 PETROLATUM GAUZE XURIDEN 157 STRIP/OVERWRAP XALATAN 301 XYLAZINE 1"X8" 146 XALIX 136 HYDROCHLORIDE 105

Index 110 XYLITOL 105 ZARONTIN 31 ZINC CHLORIDE 106 XYLITOL NF 105 ZARXIO 167,168 zinc chloride 270 XYLOCAINE 175 ZATEAN-PN DHA 286 ZINC CITRATE XYLOCAINE-MPF 175 ZATEAN-PN PLUS 286 DIHYDRATE 106 ZINC GLUCONATE 106 XYLOCAINE- ZAVESCA 166 ZINC MONOMETHIONINE 106 MPF/EPINEPHRINE 174 ZCORT 7-DAY 118 XYLOCAINE/EPINEPHRINE ZINC OXIDE 106 ZEAXANTHIN 106 174 ZINC PICOLINATE 106 XYLOMETAZOLINE HCL 105 ZEGALOGUE 35 ZINC PYRITHIONE 99 XYLOMETAZOLINE ZEGERID 336 ZINC SULFATE 270 HYDROCHLORIDE 105 ZEGERID OTC 336 zinc sulfate 270 XYNTHA 166 ZEJULA 59 XYNTHA SOLOFUSE 166 ZINC SULFATE ZELAPAR 63 GRANULAR 270 XYOSTED 16 ZELBORAF 59 ZINC SULFATE XYREM 327 ZELNORM 162 HEPTAHYDRATE 270 ZINC SULFATE XYWAV 327 ZEMAIRA 330 XYZAL ALLERGY 24HR 43 MONOHYDRATE 270 ZEMBRACE ZINC UNDECYLENATE 106 XYZAL ALLERGY 24HR SYMTOUCH 266 CHILDRENS 43 ZEMDRI 3 ZINECARD 60 YASMIN 28 113 ZEMPLAR 157 ZINGO 175 YAZ 113 ZENEVIX 138 ZINPLAVA 303 YEAST EXTRACT 105 ZENPEP 153 ZIOPTAN 301 YELLOW PETROLATUM 326 ZEPATIER 69 ziprasidone hcl 63 YELLOW WAX 321 ZEPOSIA 329 ziprasidone mesylate 63 YERVOY 55 ZEPOSIA 7-DAY STARTER ZIPSOR 7 YESCARTA 55 PACK 329 ZIRABEV 54 YF-VAX 338 ZEPOSIA STARTER KIT 329 ZIRCONIUM OXIDE 106 YLANG-YLANG OIL ZEPZELCA 53 ZIRGAN 298 FRAGRANCE 85 ZERBAXA 76 ZITHRANOL 128 YOHIMBINE HCL 105 ZERVIATE 301 ZITHROMAX 176 YONDELIS 53 ZESTORETIC 50 ZITHROMAX TRI-PAK 176 YONSA 56 ZESTRIL 47 ZITHROMAX Z-PAK 176 YOSPRALA 166 ZETIA 46 ZOCOR 46 YUPELRI 22 ZETONNA 290 ZOE SCRIPTS YUTIQ 300 ZEVALIN Y-90 55 IDEALBASE 326 ZACARE 4% KIT 123 ZEVRX PEN NEEDLES 31G X ZOFRAN 40 ZACARE 8% KIT 123 6MM 264 ZOKINVY 275 ZACLIR CLEANSING 123 ZEVRX STERILE ALCOHOL ZOLADEX 56 PREP PADS 227 zafirlukast 23 zoledronic acid 155 ZIAC 50 zaleplon 172 ZOLEDRONIC ACID 155 ZIAGEN 68 ZALTRAP 54 zoledronic acid 155 ZIANA 123 ZALVIT 286 ZOLEDRONIC ACID 155 zidovudine 68 ZANABIN ANTIPRURITIC ZOLGENSMA 10.1-10.5 HYDROGEL 146 ZIEXTENZO 168 KG 291 ZANAFLEX 289 ZILACAINE PATCH 138 ZOLGENSMA 10.6-11.0 ZANOSAR 53 zileuton 23 KG 291 ZOLGENSMA 11.1-11.5 ZANTAC 335 ZILRETTA 118 KG 291 ZANTAC 150 MAXIMUM ZILXI 141 ZOLGENSMA 11.6-12.0 STRENGTH 335 ZINC ACETATE 106 KG 291

Index 111 ZOLGENSMA 12.1-12.5 ZYCLARA 135 KG 291 ZYCLARA PUMP 135 ZOLGENSMA 12.6-13.0 KG 291 ZYDELIG 59 ZOLGENSMA 13.1-13.5 ZYFLO 23 KG 291 ZYKADIA 59 ZOLGENSMA 2.6-3.0 KG 291 ZYLET 300 ZOLGENSMA 3.1-3.5 KG 291 ZYLOPRIM 165 ZOLGENSMA 3.6-4.0 KG 291 ZYMAXID 298 ZOLGENSMA 4.1-4.5 KG 291 ZYNLONTA 55 ZOLGENSMA 4.6-5.0 KG 291 ZYNRELEF 7 ZOLGENSMA 5.1-5.5 KG 291 ZYPITAMAG 46 ZOLGENSMA 5.6-6.0 KG 291 ZYPREXA 64 ZOLGENSMA 6.1-6.5 KG 291 ZYPREXA RELPREVV 64 ZOLGENSMA 6.6-7.0 KG 291 ZYPREXA ZYDIS 64 ZOLGENSMA 7.1-7.5 KG 291 ZYTIGA 56 ZOLGENSMA 7.6-8.0 KG 291 ZYVANA 280 ZOLGENSMA 8.1-8.5 KG 292 ZYVOX 19 ZOLGENSMA 8.6-9.0 KG 292 ZOLGENSMA 9.1-9.5 KG 292 ZOLGENSMA 9.6-10.0 KG 292 ZOLINZA 59 ZOLMITRIPTAN 106 zolmitriptan 266 ZOLOFT 32 ZOLPAK 127 zolpidem tartrate 172 ZOLPIMIST 172 ZOMACTON 156 ZOMIG 266 ZOMIG ZMT 266 ZONALON 128 ZONEGRAN 30 zonisamide 30 ZONISAMIDE 106 ZONTIVITY 166 ZORBTIVE 156 ZORTRESS 272 ZORVOLEX 7 ZOSIL 326 ZOSTAVAX 338 ZOSYN 304 ZOVIRAX 70,129 ZTLIDO 139 ZUBSOLV 14 ZULRESSO 31 ZUPLENZ 40

Index 112