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Magellan Rx Precision Formulary

Welcome to Magellan Rx Management’s Precision Formulary. A formulary is a list of covered prescription drugs. The Precision Formulary excludes certain drugs in order to reduce the cost of your prescriptions. For every excluded drug there is a preferred alternative available at a lower cost. Please use this formulary drug list when you receive a prescription from your doctor. This formulary list is not intended to imply coverage and may change over time. Please refer to your plan document for detailed information about your drug benefit coverage.

The formulary is organized by categories depending on the type of medical conditions that they are used to treat. Medications are listed as Tier 1 Generic, Tier 2 Preferred Brand, Tier 3 Non-Preferred Brand, and Excluded Products. Medications listed as “Specialty Drugs” are used to treat complex medical conditions that require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may apply. Excluded products are not covered by your plan; however, a preferred alternative is available at a lower cost.

Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug’s safety and efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects appropriate Tier placement based on the drugs’ safety, efficacy and cost- effectiveness. Please note all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.

Drug exception requests must have clinical information submitted by a prescriber. For excluded drug products, members or prescribers may request a medical exception review if the prescriber feels that the formulary does not adequately cover your clinical needs. The request may be initiated by the member or the prescriber. If the request is initiated by the member using the online tool or via a telephone request to our offices, Magellan will contact your physician for the necessary clinical information to support this exception. If the request is initiated by your prescriber, he or she may submit it by fax, phone, or mail. They will be required to submit supporting clinical documentation to justify Magellan’s approval.

For the most up-to-date Formulary Drug list visit our website at magellanrx.com.

TIER DESCRIPTION

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.

Your provider is required to get prior authorization before you fill your prescription, which ensures appropriate use of the PA Prior Authorization selected drug. Without prior approval, we may not cover this drug.

In some cases, you may be required to first try certain drugs to ST Step Therapy treat your medical condition before you move up a “step” to other drug options.

GL Gender Limit This prescription drug is restricted for a single gender.

This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit.

C Custom This drug has unique restrictions.

Specialty drugs are high-cost drugs used to treat complex or rare conditions. Some examples of the diseases include; S Specialty Drug multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

PS Preferred Specialty Preferred Specialty.

PAGE 2 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ANTI-INFECTIVE AGENTS ANTHELMINTICS

QL 4 / day albendazole 1 PA QL 4 / day ALBENZA 3 PA BILTRICIDE 3 PA EMVERM 2 PA ivermectin 1 PA praziquantel 1 PA STROMECTOL 3 PA ANTIBACTERIALS

ACTICLATE 3 ST AEMCOLO 3 amikacin sulfate (500 mg/2ml vial, 1000mg/4ml vial) 1 amoxicillin (125 mg tab chew, 250 mg tab chew, 250 1 mg/5ml susp recon, 500 mg capsule, 500 mg tablet) amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 400 mg/5ml susp recon, 1 875 mg tablet)

PAGE 3 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, 1 amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h) ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial port, 10 g vial, 125 mg vial, 250 mg vial, 500 mg 1 vial) ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 g vial, sodium/sulbactam 1.5 g vial port, sodium/sulbactam 3 g vial, 1 sodium/sulbactam 3 g vial port, sodium/sulbactam 15 g vial) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg 1 capsule) QL 9 / day ARIKAYCE 3 PA S AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 3 ML, 500-125 TABLET, 875-125 TABLET) AUGMENTIN ES-600 3 AUGMENTIN XR 3 AVELOX 3 QL 21 / fill AVELOX IV 3 AVIDOXY 1

PAGE 4 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & AVYCAZ 3 AZACTAM 3 AZACTAM-ISO-OSMOTIC DEXTROSE 3 azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 500 mg tablet, 600 mg 1 tablet) azithromycin 250 mg tablet 1 QL 6 / 5 days azithromycin (500 mg vial, 500 mg vial port) 1 aztreonam 1 AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3 BACIIM 1 bacitracin 50000 unit vial 1 BACTRIM 3 BACTRIM DS 3 QL max 14 days BAXDELA 450 MG TABLET 3 PA QL max 14 days BAXDELA 300 MG VIAL 3 PA PA BETHKIS 3 S BICILLIN C-R 3 BICILLIN L-A 3 PA CAYSTON 3 S CEDAX (90 MG/5 ML SUSPENSION, 180 MG/5 ML 3 SUSPENSION, 400 MG CAPSULE)

PAGE 5 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 1 mg capsule) cefaclor 500 mg tab er 12h 1 QL 20 / 30 days cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 1 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 1 g vial port, 10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg 1 vial) cefazolin sodium in 0.9 % sodium chloride (in 0.9 % 1 g/10 ml syringe, in 0.9 % 2 g/10 ml syringe, in 0.9 % 1 2 g/100 ml plast. bag, in 0.9 % 2 g/50 ml piggyback, in 0.9 % 3 g/100 ml piggyback) cefazolin sodium/dextrose 5 % in water (sodium/d5w 2 g/100 ml plast. bag, sodium/d5w 2 1 g/50 ml piggyback, sodium/d5w 3 g/100 ml piggyback) cefazolin sodium/dextrose, iso-osmotic (sodium/dextrose,iso 1 g/50 ml froz.piggy, sodium/dextrose,iso 1 g/50 ml piggyback, 1 sodium/dextrose,iso 2 g/100 ml froz.piggy, sodium/dextrose,iso 2 g/50 ml piggyback) cefazolin sodium/water for injection,sterile 1 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp 1 recon, 300 mg capsule) cefditoren pivoxil 1 cefepime hcl (1 g vial, 2 g vial) 1 cefepime hcl in dextrose 5 % in water 1 cefepime hcl in iso-osmotic dextrose 1 cefixime 1 QL 1200 / 90 days

PAGE 6 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CEFOTAN 3 cefotaxime sodium 1 cefotetan disodium 1 cefotetan disodium in iso-osmotic dextrose 1 cefoxitin sodium 1 cefoxitin sodium/dextrose, iso-osmotic 1 cefpodoxime proxetil (50 mg/5 ml susp recon, 100 1 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 1 250 mg/5ml susp recon, 500 mg tablet) ceftazidime 1 ceftazidime in dextrose 5% and water 1 ceftibuten (180 mg/5ml susp recon, 400 mg capsule) 1 CEFTIN 2 ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial port, 10 g vial, 100 g bulkbaginj, 250 mg vial, 1 500 mg vial) ceftriaxone sodium in iso-osmotic dextrose (in 1 g/50 ml froz.piggy, in 1 g/50 ml piggyback, in 2 g/50 ml 1 froz.piggy, in 2 g/50 ml piggyback) cefuroxime axetil 1 cefuroxime sodium 1 cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg 1 capsule, 500 mg tablet, 750 mg capsule) sod succinate 1 CIPRO 10% SUSPENSION 3 QL 10 / day

PAGE 7 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CIPRO 5% SUSPENSION 3 QL 7 / day CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day CIPRO I.V. 3 CIPRO XR 1,000 MG TABLET 3 QL 14 / 1 rx CIPRO XR 500 MG TABLET 3 QL 28 / fill ciprofloxacin 250 mg/5ml sus mc rec 1 QL 7 / day ciprofloxacin 500 mg/5ml sus mc rec 1 QL 10 / day ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 750 1 QL 2 / day mg tablet) ciprofloxacin hcl 500 mg tablet 1 QL 2 / day ciprofloxacin lactate 1 ciprofloxacin lactate/dextrose 5 % in water 1 ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr 1 QL 14 / 1 rx ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr 1 QL 28 / fill CLAFORAN (1 GM ADD-VANTAGE VL, 1 GM VIAL, 2 GM ADD-VANTAGE VL, 2 GM VIAL, 10 GM VIAL, 500 3 MG VIAL) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 1 500 mg tablet) CLEOCIN HCL 3 QL 4 / day CLEOCIN PALMITATE 3 QL 70/ day CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 150 MG/ML VIAL, 300 MG/2 ML VIAL, 300 MG/2ML ADDVAN, 3 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) CLEOCIN PHOSPHATE (600 MG/4ML, 900 MG/6ML) 3

PAGE 8 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CLEOCIN PHOSPHATE IN D5W 3 hcl 1 QL 4 / day clindamycin palmitate hcl 1 QL 70/ day clindamycin phosphate (150 mg/ml vial, 300 mg/2ml 1 vial port, 600 mg/4ml vial port, 900mg/6ml vial port) clindamycin phosphate in 0.9 % sodium chloride 1 clindamycin phosphate/dextrose 5 % in water 1 colistin (as colistimethate sodium) 1 COLY-MYCIN M PARENTERAL 3 QL 1 / day COREMINO (ER 90 MG TABLET, ER 135 MG TABLET) 1 ST QL 3 / day COREMINO ER 45 MG TABLET 1 ST CUBICIN 3 CUBICIN RF 3 daptomycin 500 mg vial 1 QL 4 / day DAXBIA 3 ST demeclocycline hcl 1 sodium 250 mg capsule 1 dicloxacillin sodium 500 mg capsule 1 DIFICID 3 PA DORIBAX 3 doripenem 1 QL 7/ rx DORYX DR 200 MG TABLET 3 ST

PAGE 9 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DORYX DR 50 MG TABLET 3 ST DORYX MPC 3 ST DOXY 100 1 doxycycline hyclate (50 mg capsule, 50 mg tablet, 1 100 mg capsule, 100 mg tablet) doxycycline hyclate (75 mg tablet, 75 mg tablet dr, 1 ST 150 mg tablet, 150 mg tablet dr) doxycycline hyclate (50 mg tablet dr, 100 mg tablet 1 ST dr) QL 7/ rx doxycycline hyclate 200 mg tablet dr 1 ST doxycycline hyclate 100 mg vial 1 doxycycline monohydrate 40 mg cap ir dr 1 QL 1 / day doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 100 mg capsule, 100 1 mg tablet) doxycycline monohydrate 150 mg capsule 1 QL 30 / fill doxycycline monohydrate (75 mg capsule, 75 mg 1 tablet, 150 mg tablet) E.E.S. 200 3 E.E.S. 400 3 ERY-TAB 3 ERYPED 200 2 ERYPED 400 3 ERYTHROCIN LACTOBIONATE (1 GM ADDVANT VIAL, 3 500 MG ADDVNT VL, 500 MG VIAL) ERYTHROCIN STEARATE 3

PAGE 10 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & base (250 mg capsule dr, 250 mg 1 tablet, 500 mg tablet) erythromycin ethylsuccinate (200 mg/5ml susp 1 recon, 400 mg tablet, 400 mg/5ml susp recon) QL 7 / day FACTIVE 3 PA FORTAZ (1 GM TWISTVIAL, 1 GM VIAL, 2 GM 3 TWISTVIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) FORTAZ IN ISO-OSMOTIC DEXTROSE 3 gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial) 1 gentamicin sulfate in sodium chloride, iso-osmotic (in 60 mg/50ml piggyback, in 70 mg/50ml piggyback, in 80 mg/50ml piggyback, in 1 80mg/100ml piggyback, in 90mg/100ml piggyback, in 100mg/0.1l piggyback, in 100mg/50ml piggyback, in 120mg/0.1l piggyback) gentamicin sulfate/pf (sulfate/pf 20 mg/2 ml vial, sulfate/pf 60 mg/6 ml vial port, sulfate/pf 80 mg/8 1 ml vial port, sulfate/pf 100mg/10ml vial port) gentamicin sulf/sodium citrate 0.9 mg/3ml syringe 1 imipenem/cilastatin sodium 1 INVANZ (1 GM ADD-VANTAGE VIAL, 1 GM VIAL) 3 KEFLEX 3 KETEK 3 PA KITABIS PAK 3 S LEVAQUIN 3 QL 30 / fill levofloxacin (250mg/10ml solution, 500mg/20ml 1 solution)

PAGE 11 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & levofloxacin (250 mg tablet, 500 mg tablet, 750 mg 1 QL 30 / fill tablet) levofloxacin 25 mg/ml vial 1 levofloxacin/dextrose 5 % in water 1 LINCOCIN 3 lincomycin hcl 300 mg/ml vial 1 QL 10 / day linezolid 100 mg/5ml susp recon 1 QL 900 / rx linezolid 600 mg tablet 1 QL 2 / day linezolid in 0.9 % sodium chloride 1 linezolid in dextrose 5 % in water 1 MAXIPIME (1 GM ADD-VANTAGE VL, 1 GRAM VIAL, 2 3 GM ADD-VANTAGE VL, 2 GRAM VIAL) meropenem 1 meropenem in 0.9 % sodium chloride 1 MERREM 3 MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3 MINOCIN 100 MG VIAL 3 minocycline hcl (50 mg capsule, 75 mg capsule, 100 1 mg capsule) minocycline hcl (55 mg tab er 24h, 65 mg tab er 24h, QL 1 / day 80 mg tab er 24h, 90 mg tab er 24h, 105 mg tab er 1 24h, 115mg tab er 24h, 135 mg tab er 24h) ST QL 3 / day minocycline hcl 45 mg tab er 24h 1 ST minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg 1 tablet) QL 1 / day MINOLIRA ER 3 PA

PAGE 12 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MONDOXYNE NL (NL 50 MG CAPSULE, NL 100 MG 1 CAPSULE) MONDOXYNE NL 75 MG CAPSULE 1 MONODOX 3 ST MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1 MOXATAG 3 moxifloxacin hcl 400 mg tablet 1 QL 21 / fill moxifloxacin hcl in sodium acetate and 1 sulfate,water,iso-osm moxifloxacin hcl in sodium chloride, iso-osmotic 1 in dextrose, iso-osmotic 3 nafcillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g 1 vial port, 10 g vial) neomycin sulfate 1 NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 3 PA 150 MG-7 DAY WITH LOAD) NUZYRA 100 MG VIAL 3 ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill OKEBO 1 QL 1 / day ORACEA 3 PA oxacillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g 1 vial port, 10 g vial) oxacillin sodium in iso-osmotic dextrose 3 PCE 3 penicillin g potassium 1

PAGE 13 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & penicillin g potassium/dextrose-water 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5ml soln recon, 250 1 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) PFIZERPEN 3 piperacillin sodium/tazobactam 13.5 g vial 3 piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 g vial, sodium/tazobactam 2.25 g vial port, sodium/tazobactam 3.375 g vial, 1 sodium/tazobactam 3.375 g vial port, sodium/tazobactam 4.5 g vial, sodium/tazobactam 4.5 g vial port, sodium/tazobactam 40.5 g vial) polymyxin b sulfate 1 PRIMAXIN 3 QL 120 / 365 days PYLERA 2 PA QL 1 / day SEYSARA 3 PA QL 6 / 30 days SIVEXTRO 200 MG TABLET 3 PA QL 6 / 30 days SIVEXTRO 200 MG VIAL 3 PA QL 1 / day SOLODYN 3 PA SOLOXIDE 1 SPECTRACEF 3

PAGE 14 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & streptomycin sulfate 1 sulfadiazine 1 sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg 1 tablet, sulfamethoxazole/trimethoprim 800-160/20 oral susp) sulfamethoxazole/trimethoprim 800-160 mg tablet 1 sulfamethoxazole/trimethoprim 80-16mg/ml vial 1 sulfasalazine (500 mg tablet, 500 mg tablet dr) 1 SULFATRIM 1 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML 3 SUSPENSION) SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML 3 QL 1200 / 90 days SUSPENSION) SYNERCID 3 TARGADOX 3 ST TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 1 GM ADD-VANTAGE, 2 GRAM VIAL, 6 GRAM VIAL) TEFLARO 3 PA hcl 1 tigecycline 1 PA TOBI 3 S PA TOBI PODHALER 3 S

PAGE 15 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA tobramycin in 0.225 % sodium chloride 1 S tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 1 mg/ml vial) tobramycin sulfate/sodium chloride 1 PA tobramycin/nebulizer 1 S TYGACIL 3 UNASYN 3 VANCOCIN HCL 3 vancomycin hcl (125 mg capsule, 250 mg capsule) 1 vancomycin hcl (1 g vial, 1 g vial port, 1.25 g vial, 1.5 g vial, 5 g vial, 10 g vial, 100 g bulkbaginj, 250 mg 1 vial, 500 mg vial, 500 mg vial port, 750 mg vial, 750 mg vial port) vancomycin hcl in water for injection (peg-400, 1 nada)

PAGE 16 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & vancomycin in 0.9 % sodium chloride (vancomycin/0.9 % 1 g/100 ml plast. bag, vancomycin/0.9 % 1.25 g/150 plast. bag, vancomycin/0.9 % 1.25 g/250 plast. bag, vancomycin/0.9 % 1.5g/150ml plast. bag, vancomycin/0.9 % 1.5g/250ml plast. bag, vancomycin/0.9 % 1.5g/300ml plast. bag, vancomycin/0.9 % 1.5g/500ml plast. bag, vancomycin/0.9 % 1.75 g/500 plast. bag, vancomycin/0.9 % 1.75g/250 plast. bag, 1 vancomycin/0.9 % 1g/150ml plast. bag, vancomycin/0.9 % 1g/200ml froz.piggy, vancomycin/0.9 % 1g/250ml plast. bag, vancomycin/0.9 % 2 g/250 ml plast. bag, vancomycin/0.9 % 2 g/500 ml plast. bag, vancomycin/0.9 % 500mg/0.1l froz.piggy, vancomycin/0.9 % 750 mg/250 plast. bag, vancomycin/0.9 % 750mg/.15l froz.piggy, vancomycin/0.9 % 750mg/.15l plast. bag) vancomycin in 5 % dextrose in water (in 5 % 1 g/100 ml plast. bag, in 5 % 1.25 g/250 plast. bag, in 5 % 1.5g/250ml plast. bag, in 5 % 1.5g/500ml plast. bag, in 5 % 1.75 g/500 plast. bag, in 5 % 1g/200ml 1 froz.piggy, in 5 % 1g/250ml plast. bag, in 5 % 2 g/500 ml plast. bag, in 5 % 500mg/0.1l froz.piggy, in 5 % 750 mg/250 plast. bag, in 5 % 750mg/.15l froz.piggy) VIBATIV 3 VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML 3 ST SYRUP, 100 MG CAPSULE) XIFAXAN 3 PA ZINACEF (1.5 GM TWISTVIAL, 1.5 GM VIAL, 1.5 GRAM/50 ML, 7.5 GM VIAL, 750 MG TWISTVIAL, 750 3 MG VIAL)

PAGE 17 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK 3 TABLET) ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days ZITHROMAX 500 MG TABLET 3 QL 5 / fill ZITHROMAX 600 MG TABLET 3 QL 0.29 / day ZITHROMAX I.V. 500 MG VIAL 3 ZITHROMAX TRI-PAK 3 ZMAX 2 QL 60 / fill ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL, 3.375 GM/50 ML GALAXY, 3.375 GRAM VIAL, 3 4.5 GM/100 ML GALAXY BAG, 4.5 GRAM VIAL, 40.5 GRAM BULK VIAL) ZYVOX (200 MG/100, 600 MG/300) 3 PA QL 900 / rx ZYVOX 100 MG/5 ML SUSPENSION 3 PA QL 2 / day ZYVOX 600 MG TABLET 3 PA (SYSTEMIC)

ABELCET 3 AMBISOME 3 1 ANCOBON 3 CANCIDAS 3 acetate 1

PAGE 18 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CRESEMBA 186 MG CAPSULE 3 PA CRESEMBA 372 MG VIAL 3 PA DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 3 MG TABLET) DIFLUCAN 150 MG TABLET 3 QL 1 / day ERAXIS (WATER DILUENT) 3 (10 mg/ml susp recon, 40 mg/ml susp 1 recon, 50 mg tablet, 100 mg tablet, 200 mg tablet) fluconazole 150 mg tablet 1 QL 1 / day fluconazole in dextrose, iso-osmotic 1 fluconazole in sodium chloride, iso-osmotic (in 100mg/50ml pggybk btl, in 100mg/50ml piggyback, 1 in 200mg/0.1l pggybk btl, in 200mg/0.1l piggyback, in 400mg/0.2l pggybk btl, in 400mg/0.2l piggyback) 1 GRIS-PEG 3 ultramicrosize 1 griseofulvin, microsize 125 mg/5ml oral susp 1 griseofulvin, microsize 500 mg tablet 1 (10 mg/ml solution, 100 mg capsule) 1 200 mg tablet 1 LAMISIL 250 MG TABLET 3 MYCAMINE 3 NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG 3 TABLET) NOXAFIL 300 MG/16.7 ML VIAL 3

PAGE 19 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & (500k unit tablet, 100000/ml oral susp) 1 ONMEL 3 PA SPORANOX (10 MG/ML SOLUTION, 100 MG 3 CAPSULE) hcl 250 mg tablet 1 triacetin 1 VFEND 40 MG/ML SUSPENSION 3 QL 20 / day VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day VFEND IV 3 PA 200 mg/5ml susp recon 1 QL 20 / day voriconazole (50 mg tablet, 200 mg tablet) 1 QL 4 / day voriconazole 200 mg vial 1 PA ANTIMYCOBACTERIALS

CAPASTAT SULFATE 3 cycloserine 1 (25 mg tablet, 100 mg tablet) 1 ethambutol hcl 1 isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 1 mg tablet) isoniazid 100 mg/ml vial 1 MYAMBUTOL 3 MYCOBUTIN 3 PASER 3 PRIFTIN 3 QL 1.25 / day pyrazinamide 1

PAGE 20 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & rifabutin 1 RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3 RIFADIN IV 600 MG VIAL 3 RIFAMATE 3 rifampin (150 mg capsule, 300 mg capsule) 1 rifampin 600 mg vial 1 RIFATER 3 SIRTURO 3 PA TRECATOR 3 ANTIPROTOZOALS ALINIA (100 MG/5 ML SUSPENSION, 500 MG 3 PA TABLET) ARAKODA 3 PA 1 PA atovaquone/proguanil hcl 1 PA QL max 60 days benznidazole 2 AL 2 to 12 yrs old chloroquine phosphate 1 COARTEM 3 FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG 3 TABLET) FLAGYL ER 3 hydroxychloroquine sulfate 1 IMPAVIDO 3 S KRINTAFEL 3

PAGE 21 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MALARONE 3 PA mefloquine hcl 1 MEPRON 3 PA METRO IV 3 (250 mg tablet, 375 mg capsule, 500 1 mg tablet) metronidazole in sodium chloride 1 NEBUPENT 3 paromomycin sulfate 1 PENTAM 300 3 isethionate 1 PLAQUENIL 3 primaquine phosphate 1 QL 42 / 365 days QUALAQUIN 3 PA QL 42 / 365 days quinine sulfate 1 PA QL 1/ fill SOLOSEC 3 GL Female TINDAMAX 3 tinidazole 1 ANTIVIRALS (SYSTEMIC)

S abacavir sulfate (20 mg/ml solution, 300 mg tablet) 1 PS S abacavir sulfate/lamivudine 1 PS

PAGE 22 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & S abacavir sulfate/lamivudine/zidovudine 1 PS acyclovir (200 mg capsule, 200 mg/5ml oral susp, 1 400 mg tablet, 800 mg tablet) acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 1 mg vial) acyclovir sodium/dextrose 5 % in water 1 adefovir dipivoxil 1 S ALFERON N 3 S APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3 S S atazanavir sulfate 1 PS ATRIPLA 3 S QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 3 PA S QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3 PA S BIKTARVY 3 S cidofovir 1 S S CIMDUO 3 PS COMBIVIR 3 S COMPLERA 3 S QL 6 / day COPEGUS 3 PA S

PAGE 23 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CRIXIVAN 3 S CYTOVENE 3 S QL 1 / day DAKLINZA 3 PA S DELSTRIGO 3 S QL 1 / day DESCOVY 3 S S didanosine 1 PS EDURANT 3 S (50 mg capsule, 200 mg capsule, 600 mg S 1 tablet) PS EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3 S QL 1 / day entecavir 1 S QL 1 / day PA EPCLUSA 3 S PS EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 3 S MG TABLET) EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3 S EPZICOM 3 S EVOTAZ 3 S famciclovir 1

PAGE 24 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FLUMADINE 3 S fosamprenavir calcium 1 PS foscarnet sodium 1 FOSCAVIR 3 QL 2 / day FUZEON 3 S ganciclovir 1 S ganciclovir sodium (500 mg vial, 500mg/10ml vial) 1 S GENVOYA 3 S QL 1 / day PA HARVONI 3 S PS QL 1 / day HEPSERA 3 PA S INTELENCE 3 S INTRON A (10 MILLION UNITS VIL, 18 MILLION PA UNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLION 3 UNIT/2.5ML, 50 MILLION UNITS VIL) S INVIRASE (200 MG CAPSULE, 500 MG TABLET) 3 S ISENTRESS 100 MG POWDER PACKET 3 S ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET 3 S CHEW, 400 MG TABLET) ISENTRESS HD 3 S

PAGE 25 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day JULUCA 3 S KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG 3 S TABLET, 200-50 MG TABLET) S lamivudine 10 mg/ml solution 1 PS S lamivudine (150 mg tablet, 300 mg tablet) 1 PS lamivudine 100 mg tablet 1 S S lamivudine/zidovudine 1 PS QL 1 / day PA ledipasvir/sofosbuvir 3 S PS LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3 S S lopinavir/ 1 PS QL 3 / day PA MAVYRET 3 AL At least 18 yrs old S PS

MODERIBA (200-400 MG DOSEPACK, 400-400 MG QL 2 / day DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG 3 PA DOSEPACK) S QL 6 / day MODERIBA 200 MG TABLET 1 PA S

PAGE 26 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & (50 mg/5 ml oral susp, 100 mg tab er S 1 24h, 200 mg tablet, 400 mg tab er 24h) PS NORVIR (80 MG/ML SOLUTION, 100 MG POWDER 3 S PACKET, 100 MG SOFTGEL CAP, 100 MG TABLET) ODEFSEY 3 S QL 1 / day OLYSIO 3 PA S oseltamivir phosphate (30 mg capsule, 45 mg 1 QL 20 / 365 days capsule, 75 mg capsule) oseltamivir phosphate 6 mg/ml susp recon 1 QL 180 / 30 days

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML PA 3 VIAL) S PA PEGASYS PROCLICK 3 S PA PEGINTRON 3 S PIFELTRO 3 S PA PREVYMIS (240 MG TABLET, 480 MG TABLET) 3 AL At least 18 yrs old S PA PREVYMIS (240 MG/12 ML VIAL, 480 MG/24 ML 3 AL At least 18 yrs old VIAL) S PREZCOBIX 3 S PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 3 S 150 MG TABLET, 600 MG TABLET, 800 MG TABLET)

PAGE 27 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 30 / day REBETOL 3 PA S RELENZA 3 QL 40 / 365 days RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 3 S RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3 S RETROVIR 200 MG/20 ML VIAL 3 S REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 3 S MG CAPSULE) REYATAZ 50 MG POWDER PACKET 3 S QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1 PA S QL 3 / day RIBASPHERE 400 MG TABLET 3 PA S QL 2 / day RIBASPHERE 600 MG TABLET 3 PA S QL 2 / day RIBASPHERE RIBAPAK 3 PA S QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 1 PA S ribavirin 6 g vial-neb 1

PAGE 28 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & rimantadine hcl 1 S ritonavir 1 PS SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 3 S 75 MG TABLET, 150 MG TABLET, 300 MG TABLET) QL 2 / fill SITAVIG 3 PA AL At least 18 yrs old QL 1 / day PA sofosbuvir/velpatasvir 3 S PS QL 1 / day PA SOVALDI 3 S PS stavudine (1 mg/ml soln recon, 15 mg capsule, 20 S 1 mg capsule, 30 mg capsule, 40 mg capsule) PS STRIBILD 3 S SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 3 S MG TABLET) PA SYLATRON 3 S S SYMFI 3 PS S SYMFI LO 3 PS

PAGE 29 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SYMTUZA 3 S PA SYNAGIS 3 S TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG 3 QL 20 / 365 days CAPSULE) TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 / 30 days QL 2 / day TECHNIVIE 3 PA S S tenofovir disoproxil fumarate 1 PS TIVICAY 3 S TRIUMEQ 3 S TRIZIVIR 3 S TRUVADA 3 S valacyclovir hcl 1 VALCYTE 50 MG/ML SOLUTION 3 VALCYTE 450 MG TABLET 3 QL 4 / day valganciclovir hcl 50 mg/ml soln recon 1 valganciclovir hcl 450 mg tablet 1 QL 4 / day VALTREX 3 QL 1 / day PA VEMLIDY 3 AL At least 18 yrs old S

PAGE 30 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VIDEX 3 S VIDEX EC 3 S QL 4 / day VIEKIRA PAK 3 PA S QL 3 / day VIEKIRA XR 3 PA S VIRACEPT 3 S VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3 S VIRAMUNE XR 3 S VIRAZOLE 3 VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG 3 S TABLET, 300 MG TABLET, POWDER) QL 1 / day PA VOSEVI 3 AL At least 18 yrs old S PS XOFLUZA 3 QL 2 / fill QL 1 / day ZEPATIER 3 PA S ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG 3 S CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3 S

PAGE 31 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & zidovudine (10 mg/ml syrup, 100 mg capsule, 300 S 1 mg tablet) PS ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 3 400 MG TABLET, 800 MG TABLET) URINARY ANTI-INFECTIVES

FURADANTIN 3 HIPREX 3 MACROBID 3 MACRODANTIN 3 methenamine hippurate 1 methenamine mandelate 1 MONUROL 3 nitrofurantoin 1 nitrofurantoin macrocrystal 1 nitrofurantoin monohydrate/macrocrystals 1 PRIMSOL 3 trimethoprim 1 TRIMPEX 3 QL max 10 days URIBEL 1 QL 4 / day UROGESIC-BLUE 3 ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES

ABATUSS DMX 1 AL At least 2 yrs old ALLER-CHLOR 4 MG TABLET 1

PAGE 32 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CVS ALLERGY 25 MG CAPSULE 1 CVS ALLERGY RELIEF 25 MG CAP 1 carbinoxamine maleate 4 mg/5 ml liquid 1 AL At least 2 yrs old carbinoxamine maleate (4 mg tablet, 6 mg tablet) 1 AL At least 6 yrs old CENTERGY 1 clemastine fumarate 1 AL At least 2 yrs old CONEX SOLUTION 3 cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 1 AL At least 2 yrs old mg/10 ml syrup) diphenhydramine hcl (12.5mg/5ml elixir, 50 mg/ml 1 cartridge) diphenhydramine hcl (50 mg/ml syringe, 50 mg/ml 1 vial) diphenhydramine hcl in 0.9 % sodium chloride 1 HISTEX PD 3 HISTEX-PE 3 KARBINAL ER 3 AL At least 2 yrs old PHENADOZ 1 AL At least 2 yrs old PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 3 AL At least 2 yrs old 50 MG/ML AMPUL, 50 MG/ML VIAL) phenylephrine hcl/promethazine hcl 1 promethazine hcl (25 mg/ml ampul, 25 mg/ml vial, 1 AL At least 2 yrs old 50 mg/ml ampul, 50 mg/ml vial) promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 50 mg 1 AL At least 2 yrs old supp.rect, 50 mg tablet)

PAGE 33 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & promethazine hcl 25 mg tablet 1 AL At least 2 yrs old promethazine hcl in 0.9 % sodium chloride 1 PROMETHEGAN 1 AL At least 2 yrs old RESPA A.R. 3 RYCLORA 3 RYVENT 3 ST WAL-DRYL ALLERGY 25 MG CAPSULE 1 SECOND GENERATION ANTIHISTAMINES cetirizine hcl 1 mg/ml solution 1 QL 10 / day QL 10 / day CLARINEX 0.5 MG/ML (2.5 MG/5) 3 PA CLARINEX 5 MG TABLET 3 QL 1 / day CLARINEX-D 12 HOUR 3 QL 2 / day desloratadine 5 mg tablet 1 QL 1 / day desloratadine (2.5 mg tab rapdis, 5 mg tab rapdis) 1 QL 1 / day fexofenadine hcl 180 mg tablet 1 QL 1 / day fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 30 / day levocetirizine dihydrochloride 5 mg tablet 1 QL 1 / day SEMPREX-D 3 QL 4 / day XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day

PAGE 34 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ANTINEOPLASTIC AGENTS

PA ABRAXANE 3 S PA ADCETRIS 3 S ADRIAMYCIN (10 MG VIAL, 50 MG VIAL, 200 1 S MG/100 ML VIAL) ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 3 S 50 MG/25 ML VIAL) ADRUCIL 1 S QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG 3 PA TABLET) S QL 1 / day AFINITOR 2.5 MG TABLET 3 PA S PA AFINITOR DISPERZ 3 S QL 8 / day PA ALECENSA 3 AL At least 18 yrs old S PA ALIMTA 3 S ALKERAN 2 MG TABLET 3 ALKERAN 50 MG VIAL 3 S QL 2 / day ALUNBRIG (90 MG TABLET, 90 MG-180 MG TAB PA 3 PACK) AL At least 18 yrs old S

PAGE 35 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day PA ALUNBRIG 180 MG TABLET 3 AL At least 18 yrs old S QL 6 / day PA ALUNBRIG 30 MG TABLET 3 AL At least 18 yrs old S anastrozole 1 ARIMIDEX 3 AROMASIN 3 ARRANON 3 S trioxide 1 S PA ARZERRA 3 S PA AVASTIN 3 S azacitidine 1 S PA BELEODAQ 3 S bendamustine hcl 1 S PA bexarotene 1 S bicalutamide 1 BICNU 3 S bleomycin sulfate 1 S

PAGE 36 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BLINCYTO (35 MCG VIAL, 35MCG VIAL+STABILIZER) 3 S PA bortezomib 3 S QL 1 / day PA BOSULIF (400 MG TABLET, 500 MG TABLET) 3 S PS QL 4 / day PA BOSULIF 100 MG TABLET 3 S PS PA BRAFTOVI 3 S busulfan 3 S BUSULFEX 3 S QL 4 / day CABOMETYX 20 MG TABLET 3 PA S QL 2 / day CABOMETYX 40 MG TABLET 3 PA S QL 1.5 / day CABOMETYX 60 MG TABLET 3 PA S QL 2 / day PA CALQUENCE 3 AL At least 18 yrs old S

PAGE 37 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA CAMPATH 3 S CAMPTOSAR 3 S PA capecitabine 1 S QL 2 / day CAPRELSA 100 MG TABLET 3 PA S QL 1 / day CAPRELSA 300 MG TABLET 3 PA S CARAC 2 carboplatin (10 mg/ml vial, 150 mg vial) 1 S carmustine 1 S CASODEX 3 cisplatin 1 mg/ml vial 1 S cladribine 1 S clofarabine 1 S CLOLAR 3 S QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 3 PA S QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 3 PA S QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 3 PA S

PAGE 38 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA COPIKTRA 3 S COSMEGEN 3 S QL 2.5 / day PA COTELLIC 3 AL At least 18 yrs old S (25 mg capsule, 50 mg capsule) 1 PA PA cyclophosphamide (1 g vial, 2 g vial, 500 mg vial) 1 S PA CYRAMZA 3 S cytarabine 1 S cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 20 mg/ml vial, cytarabine/pf 100 1 S mg/5ml vial) dacarbazine 1 S DACOGEN 3 S PA DARZALEX 3 S daunorubicin hcl (5 mg/ml vial, 20 mg vial) 1 S QL 1 / day DAURISMO 3 PA S decitabine 1 S DEPOCYT 3 S

PAGE 39 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 100 / 30 days diclofenac sodium 3 % gel (gram) 1 PA DOCEFREZ 3 S (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/4 ml vial, 80 mg/8 ml vial, 160 mg/8ml vial, 1 S 160mg/16ml vial, 200mg/10ml vial) DOXIL 3 S doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml 1 S vial) doxorubicin hcl peg-liposomal 2 mg/ml vial 1 S DROXIA 3 EFUDEX 3 ELLENCE 3 S EMCYT 3 S epirubicin hcl (50 mg vial, 50 mg/25ml vial, 200 mg 1 S vial, 200mg/0.1l vial) PA ERBITUX 3 S QL 1 / day ERIVEDGE 3 PA S QL 4 / day ERLEADA 3 PA S ERWINAZE 3 S ETOPOPHOS 3 S

PAGE 40 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & etoposide 50 mg capsule 1 S etoposide 20 mg/ml vial 1 S EVOMELA 3 S exemestane 1 PA FARYDAK 3 S QL 1.25 / day FASLODEX 3 PA S FEMARA 3 PA floxuridine 1 S fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) 1 S FLUOROPLEX 2 fluorouracil (0.5 % cream (g), 2 % solution, 5 % 1 cream (g), 5 % solution) fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 1 S ml vial, 500mg/10ml vial) flutamide 1 PA FOLOTYN 3 S PA GAZYVA 3 S gemcitabine hcl 1 S GEMZAR 3 S QL 1 / day GILOTRIF 3 PA S

PAGE 41 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 8 / day PA GLEEVEC 100 MG TABLET 3 S PS QL 2 / day PA GLEEVEC 400 MG TABLET 3 S PS GLEOSTINE 3 GLIADEL 3 PA HALAVEN 3 S PA HERCEPTIN 3 S PA HEXALEN 3 S PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 3 S HYCAMTIN 4 MG VIAL 3 S HYDREA 3 hydroxyurea 1 QL 1.25 / day IBRANCE 100 MG CAPSULE 3 PA S QL 1 / day IBRANCE 125 MG CAPSULE 3 PA S

PAGE 42 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1.667 / day IBRANCE 75 MG CAPSULE 3 PA S QL 2 / day ICLUSIG 15 MG TABLET 3 PA S QL 1 / day ICLUSIG 45 MG TABLET 3 PA S IDAMYCIN PFS 3 S idarubicin hcl 1 mg/ml vial 1 S QL 1 / day PA IDHIFA 3 AL At least 18 yrs old S IFEX 3 S ifosfamide (1 g vial, 1 g/20 ml vial, 3 g vial, 3 g/60 ml 1 S vial) ifosfamide/mesna 1 S QL 8 / day PA imatinib mesylate 100 mg tablet 1 S PS QL 2 / day PA imatinib mesylate 400 mg tablet 1 S PS

PAGE 43 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 4 / day IMBRUVICA (140 MG CAPSULE, 140 MG TABLET) 3 PA S QL 8 / day IMBRUVICA 70 MG CAPSULE 3 PA S QL 2 / day IMBRUVICA 280 MG TABLET 3 PA S QL 1.47 / day IMBRUVICA 420 MG TABLET 3 PA S QL 1 / day IMBRUVICA 560 MG TABLET 3 PA S QL 4 / day PA INLYTA 3 S PS QL 1 / day IRESSA 3 PA S irinotecan hcl 1 S PA ISTODAX 3 S IXEMPRA 3 S QL 2 / day JAKAFI 3 PA S

PAGE 44 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.15 / day JEVTANA 3 PA S PA KADCYLA 3 S PA KEYTRUDA 3 S QL 1 / day PA KISQALI 200 MG DAILY DOSE 3 AL At least 18 yrs old S QL 2 / day PA KISQALI 400 MG DAILY DOSE 3 AL At least 18 yrs old S QL 3 / day PA KISQALI 600 MG DAILY DOSE 3 AL At least 18 yrs old S QL 1 / day PA KISQALI FEMARA 200 MG CO-PACK 3 AL At least 18 yrs old S QL 2 / day PA KISQALI FEMARA 400 MG CO-PACK 3 AL At least 18 yrs old S QL 3 / day PA KISQALI FEMARA 600 MG CO-PACK 3 AL At least 18 yrs old S

PAGE 45 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA KYPROLIS 3 S QL 3 / day LENVIMA 3 PA S letrozole 1 LEUKERAN 3 QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 3 PA S QL 3 / day LONSURF 20 MG-8.19 MG TABLET 3 PA S QL 1 / day LORBRENA 3 PA S PA LUMOXITI 3 S PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 3 AL At least 18 yrs old MG TABLET) S LYSODREN 3 S PA MARQIBO 3 S MATULANE 3 S QL 4 / day MEKINIST 0.5 MG TABLET 3 PA S

PAGE 46 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day MEKINIST 2 MG TABLET 3 PA S PA MEKTOVI 3 S melphalan 1 melphalan hcl 50 mg vial 1 S mercaptopurine 1 methotrexate sodium 2.5 mg tablet 1 methotrexate sodium 25 mg/ml vial 1 methotrexate sodium/pf (sodium/pf 1 g vial, 1 sodium/pf 25 mg/ml vial) mitomycin (5 mg vial, 20 mg vial, 40 mg vial) 1 S PA mitoxantrone hcl 2 mg/ml vial 1 S MUSTARGEN 3 S MUTAMYCIN 1 S MYLERAN 3 S MYLOTARG 3 S NAVELBINE 3 S QL 6 / day PA NERLYNX 3 AL At least 18 yrs old S QL 4 / day NEXAVAR 3 PA S

PAGE 47 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NILANDRON 3 S nilutamide 1 S QL 0.124 / day PA NINLARO 3 AL At least 18 yrs old S NIPENT 3 S QL 1 / day ODOMZO 3 PA S ONCASPAR 3 S ONXOL 1 S PA OPDIVO 3 S QL 0.08 / day OTREXUP 3 PA oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, 1 S 100mg/20ml vial) 6 mg/ml vial 1 S PANRETIN 3 PA PERJETA 3 S PHOTOFRIN 3 S PICATO 3 ST QL 1 / day POMALYST 3 PA S

PAGE 48 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA PROLEUKIN 3 S PA PURIXAN 3 S QL .08 / day RASUVO (10 MG/0.2 ML, 12.5 MG/0.25 ML) 3 PA RASUVO (7.5 MG/0.15 ML, 15 MG/0.3 ML, 17.5 QL 0.08 / day MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 3 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML) PA QL 1 / day REVLIMID 3 PA S PA RITUXAN 3 S PA RITUXAN HYCELA 3 S PA romidepsin 10 mg/2 ml vial 3 S QL 2 / day PA RUBRACA 3 AL At least 18 yrs old S QL 2 / day PA RYDAPT 3 AL At least 18 yrs old S SIKLOS 3 S

PAGE 49 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 100 / 30 days SOLARAZE 3 PA QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 3 PA S QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 3 PA S QL 9 / day SPRYCEL 20 MG TABLET 3 PA S QL 3 / day SPRYCEL 50 MG TABLET 3 PA S QL 4 / day STIVARGA 3 PA S QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 3 S PS QL 7 / day PA SUTENT 12.5 MG CAPSULE 3 S PS QL 3 / day PA SUTENT 25 MG CAPSULE 3 S PS

PAGE 50 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA SYLVANT 3 S PA SYNRIBO 3 S TABLOID 3 S QL 6 / day TAFINLAR 50 MG CAPSULE 3 PA S QL 4 / day TAFINLAR 75 MG CAPSULE 3 PA S QL 1 / day PA TAGRISSO 3 AL At least 18 yrs old S PA TALZENNA 3 S QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 3 PA S QL 6 / day TARCEVA 25 MG TABLET 3 PA S PA TARGRETIN (1% GEL, 75 MG CAPSULE) 3 S QL 4 / day TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 3 PA S

PAGE 51 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 6 / day TASIGNA 50 MG CAPSULE 3 PA S TAXOTERE 3 S PA TECENTRIQ 3 S TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 PA MG CAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 3 250 MG CAPSULE) S TEMODAR 100 MG VIAL 3 S PA temozolomide 1 S QL 0.29 / day temsirolimus 1 PA S teniposide 1 S thiotepa 1 S PA TIBSOVO 3 S QL 1.47 / day TOLAK 3 ST TOPOSAR 1 S topotecan hcl (4 mg vial, 4 mg/4 ml vial) 1 S QL 0.29 / day TORISEL 3 PA S

PAGE 52 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA TREANDA 3 S QL 90 / 365 days tretinoin 10 mg capsule 1 S TREXALL 2 TRISENOX (10 MG/10 ML AMPULE, 12 MG/6 ML 3 S VIAL) QL 6 / day TYKERB 3 PA S PA UNITUXIN 3 S QL 3 / day VALCHLOR 3 PA S VALSTAR 3 S PA VECTIBIX 3 S PA VELCADE 3 S QL 4 / day VENCLEXTA 3 PA S QL 1.5 / day VENCLEXTA STARTING PACK 3 PA S QL 2 / day PA VERZENIO 3 AL At least 18 yrs old S

PAGE 53 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VIDAZA 3 S vinblastine sulfate 1 S VINCASAR PFS 1 S vincristine sulfate 1 S vinorelbine tartrate 1 S QL 2 / day VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 3 PA 100 MG CAPSULE) S PA VIZIMPRO 3 S QL 4 / day VOTRIENT 3 PA S QL 2 / day XALKORI 3 PA S QL 4 / day XATMEP 3 PA AL Up to 18 yrs old QL 4 / day XELODA 3 PA S QL 3 / day XOSPATA 3 PA S QL 4 / day XTANDI 3 PA S

PAGE 54 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA YERVOY 3 S QL 4 / day YONSA 3 PA S PA ZALTRAP 3 S ZANOSAR 3 S QL 3 / day PA ZEJULA 3 AL At least 18 yrs old S QL 8 / day ZELBORAF 3 PA S ZEVALIN 3 S QL 4 / day ZOLINZA 3 PA S QL 2 / day ZYDELIG 3 PA S QL 8 / day PA ZYKADIA 3 AL At least 18 yrs old S QL 4 / day PA ZYTIGA 250 MG TABLET 3 S PS

PAGE 55 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day PA ZYTIGA 500 MG TABLET 3 S PS ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES ALLERGENIC EXTRACTS (THERAPEUTIC)

QL 1 / day GRASTEK 3 PA QL 1 / day ODACTRA 3 PA ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT PA SAMPLE KT, 300 IR STARTER PACK, 300 IR 3 SUBLINGUAL TAB) S ORALAIR 100 IR STARTER PACK 3 S QL 1 / day RAGWITEK 3 PA ANTITOXINS AND IMMUNE GLOBULINS

PA BIVIGAM 3 S PA CARIMUNE NF NANOFILTERED 3 S PA CUVITRU 3 S CYTOGAM 3 S PA FLEBOGAMMA DIF 3 S

PAGE 56 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA GAMASTAN 3 S PA GAMASTAN S-D 3 S PA GAMMAGARD LIQUID 3 S

GAMMAGARD S-D (2.5 GM VL W/ST, 5 G (IGA<1) PA 3 SOLN, 10 G (IGA<1) SOL) S PA GAMMAKED 3 S GAMMAPLEX (5 GRAM/100 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 10 GRAM/200 ML PA 3 VIAL, 20 GRAM/200 ML VIAL, 20 GRAM/400 ML S VIAL) PA GAMUNEX-C 3 S HEPAGAM B 3 S PA HIZENTRA 3 S HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 3 S HYPERRAB 3 S HYPERRAB S-D 3 S HYPERRHO S-D 3 S HYPERTET S-D 3 S PA HYQVIA 3 S

PAGE 57 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA HYQVIA IG COMPONENT 3 S IMOGAM RABIES-HT 3 S KEDRAB 3 S MICRHOGAM ULTRA-FILTERED PLUS 3 S NABI-HB 3 S PA OCTAGAM 3 S PA PANZYGA 3 S PA PRIVIGEN 3 S RHOGAM ULTRA-FILTERED PLUS 3 S RHOPHYLAC 3 S VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 3 S WINRHO SDF 3 S TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 2 BOOSTRIX TDAP (SYRINGE, VIAL) 2 DAPTACEL DTAP 2 INFANRIX DTAP (SYRINGE, VIAL) 2 TENIVAC (SYRINGE, VIAL) 2 tetanus and diphtheria toxoids, adult 1 tetanus,diphtheria toxoid ped/pf 1

PAGE 58 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VACCINES

ACTHIB VACCINE WITH DILUENT 2 AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016- 2 2017 VIAL) AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017- 2 AL At least 5 yrs old 2018 VIAL) AFLURIA 2018-2019 (2018-2019 SYRINGE, 2018- 2 AL At least 5 yrs old 2019 VIAL) AFLURIA QUAD 2016-2017 2 AFLURIA QUAD 2017-2018 VIAL 2 AL At least 18 yrs old AFLURIA QUAD 2018-2019 (2018-2019 SYRINGE, 2 AL At least 5 yrs old 2018-2019 VIAL) bcg live 3 S bcg vaccine, live/pf 3 BEXSERO 2 ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML 2 VIAL) ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 2 ML PED VL, PEDI 10 MCG/0.5 SYRN) EZ FLU 16-17 (FLUZON QUAD PED) 2 EZ FLU 2016-2017 (AFLURIA) 2 EZ FLU 2016-2017 (FLUVIRIN) 2 EZ FLU 2018-2019 (FLUCELVAX) 2 FLUAD 2016-2017 2 FLUAD 2017-2018 2 AL At least 65 yrs old FLUAD 2018-2019 2 AL At least 65 yrs old

PAGE 59 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FLUARIX QUAD 2016-2017 2 FLUARIX QUAD 2017-2018 2 AL At least 3 yrs old FLUARIX QUAD 2018-2019 2 FLUBLOK 2016-2017 2 FLUBLOK 2017-2018 2 AL At least 18 yrs old FLUBLOK QUAD 2017-2018 2 AL At least 18 yrs old FLUBLOK QUAD 2018-2019 2 AL At least 18 yrs old FLUCELVAX QUAD 2016-2017 2 FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017- 2 AL At least 4 yrs old 2018 VIAL) FLUCELVAX QUAD 2018-2019 (2018-2019 SYR, 2018- 2 AL At least 4 yrs old 2019 VIAL) FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016- 2 2017 VIAL) FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017- 2 2018 VIAL) FLULAVAL QUAD 2018-2019 (2018-2019 SYR, 2018- 2 2019 VIAL) FLUMIST QUAD 2018-2019 2 AL 2 to 49 yrs old FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016- 2 2017 VIAL) FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017- 2 AL At least 4 yrs old 2018 VIAL) FLUZONE HIGH-DOSE 2016-2017 2 FLUZONE HIGH-DOSE 2017-2018 2 AL At least 65 yrs old FLUZONE HIGH-DOSE 2018-2019 2 AL At least 65 yrs old FLUZONE INTRADERM QUAD 2016-17 2

PAGE 60 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FLUZONE INTRADERM QUAD 2017-18 2 AL 18 to 64 yrs old FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2 2016-2017 VIAL) FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2 AL At least 3 yrs old 2017-2018 VIAL) FLUZONE QUAD 2018-2019 (2018-2019 SYRINGE, 2 2018-2019 VIAL) FLUZONE QUAD PEDI 2016-2017 2 FLUZONE QUAD PEDI 2017-2018 2 AL Up to 3 yrs old FLUZONE QUAD PEDI 2018-2019 2 AL Up to 3 yrs old GARDASIL 2 GARDASIL 9 (9 SYRINGE, 9 VIAL) 2 HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML 2 VIAL) HEPLISAV-B 20 MCG/0.5 ML SYRNG 2 HEPLISAV-B 20 MCG/0.5 ML VIAL 2 HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIES VACCINE 2 IPOL (SINGLE DOSE SYRINGE, VIAL) 2 IXIARO 2 KINRIX (TIP-LOK SYRINGE, VIAL) 2 M-M-R II VACCINE 2 MENACTRA 2 MENOMUNE-A-C-Y-W-135 2 MENVEO A-C-Y-W-135-DIP 2

PAGE 61 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDIARIX 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2 PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 2 PREVNAR 13 2 PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML 2 VIAL) ROTARIX 2 ROTATEQ 2 SHINGRIX 2 AL At least 50 yrs old SHINGRIX GE ANTIGEN COMPONENT 2 AL At least 50 yrs old STAMARIL 2 TRUMENBA 3 TWINRIX (SYRINGE, VIAL) 2 TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML 2 SYRNG) VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML 2 VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)

PAGE 62 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VARIVAX VACCINE 2 VAXCHORA ACTIVE COMPONENT 2 VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2 YF-VAX 2 ZOSTAVAX 2 APPENDIX aminophylline 250mg/10ml ampul 1 AVAILNEX 3 benzalkonium chloride 17 % solution 1 CARDENE SR 3 QL 2 / day CAVERJECT 40 MCG/2 ML AMPUL 3 chlorpheniramine maleate/phenylephrine 3 hcl/dextromethorphan CORLOPAM 10 MG/ML VIAL 3 cosyntropin 0.25 mg/ml vial 1 dexchlorpheniramine maleate 6 mg tablet er 1 dihydroergotamine mesylate 1 mg/ml vial 1 PA docetaxel (20mg/2 vial, 80mg/8 vial) 1 S EPIDUO 0.1-2.5% GEL 3 QL 1.667 / day guaifenesin/dextromethorphan 3 hbr/pseudoephedrine hcl heparin sodium,porcine (100/ml (1) syringe, 200/2 1 ml syringe)

PAGE 63 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & heparin sodium,porcine (300/3 ml syringe, 500/5 ml 1 syringe) heparin sodium,porcine 10 unit/ml syringe 1 LEVACET 3 PA LUMINAL SODIUM 3 MEFOXIN 3 promethazine hcl 25 mg/ml syringe 1 AL At least 2 yrs old TEKAMLO 3 QL 1 / day yohimbine hcl 1 Z-COF I 3 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS

ANASPAZ 3 ANORO ELLIPTA 2 QL 2 / day ATROVENT HFA 3 QL 1.29 / day BENTYL 10 MG/ML AMPUL 3 BENTYL 10 MG CAPSULE 3 BEVESPI AEROSPHERE INHALER Excluded Drugs chlordiazepoxide/clidinium bromide 1 COMBIVENT RESPIMAT 2 QL 0.267 / day CUVPOSA 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 1 20 mg tablet) dicyclomine hcl 10 mg/ml vial 1

PAGE 64 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DONNATAL (ELIXIR, TABLET) 3 ED-SPAZ 1 GLYCATE 3 glycopyrrolate (0.2 mg/ml vial, 0.4mg/2ml syringe, 1 0.6mg/3ml syringe, 1 mg/5 ml syringe) glycopyrrolate (1 mg tablet, 1.5 mg tablet, 2 mg 1 tablet) glycopyrrolate in sterile water/pf (in water/pf 0.2 1 mg/ml syringe, in water/pf 0.4mg/2ml syringe) GLYRX-PF 0.2 MG/ML VIAL 3 GLYRX-PF 0.4 MG/2 ML VIAL 3 hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet, 0.125mg/ml drops, 0.375 1 mg tab er 12h, 125mcg/5ml elixir) HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML 1 ELIXIR) INCRUSE ELLIPTA 2 QL 1 / day ipratropium bromide 0.2 mg/ml solution 1 QL 12.5 / day ipratropium bromide/albuterol sulfate 1 LEVBID 3 LEVSIN 0.125 MG TABLET 3 LEVSIN-SL 3 LIBRAX 3 QL 2 / day LONHALA MAGNAIR REFILL 3 PA QL 2 / day LONHALA MAGNAIR STARTER 3 PA

PAGE 65 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & methscopolamine bromide 1 NULEV 1 OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1 OSCIMIN SL 1 OSCIMIN SR 1 /hyoscyamine sulf/atropine sulf/scopolamine hb 1 (phenobarb/hyoscy/atropine/scop 16.2 mg tablet, phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir) PHENOHYTRO TABLET 1 propantheline bromide 1 QL 1 / day QBREXZA 3 PA ROBINUL 1 MG TABLET 3 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 3 MG/5 ML VIAL, 4 MG/20 ML VIAL) ROBINUL FORTE 3 SEEBRI NEOHALER 15.6 MCG INHAL Excluded Drugs SPIRIVA 2 QL 1 / day SPIRIVA RESPIMAT 2 QL 1 / day STIOLTO RESPIMAT 2 QL 0.134 / day SYMAX 1 SYMAX DUOTAB 3 SYMAX-SL 1 SYMAX-SR 1 TUDORZA PRESSAIR 400 MCG INH Excluded Drugs

PAGE 66 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 3 CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 3 QL 2 / day 1 MG TABLET) NICOTROL 3 QL 16/day NICOTROL NS 3 QL 20 / day PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

ARICEPT 3 AL At least 40 yrs old bethanechol chloride 1 BLOXIVERZ 3 cevimeline hcl 1 donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg 1 AL At least 40 yrs old tab rapdis, 10 mg tablet, 23 mg tablet) EVOXAC 3 EXELON 3 AL At least 40 yrs old galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg 1 AL At least 40 yrs old cap24h pel, 24 mg cap24h pel) guanidine hcl 1 MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 3 MG TIMESPAN) neostigmine methylsulfate (0.5 mg/ml vial, 1 mg/ml vial, 2 mg/2 ml syringe, 4 mg/4 ml syringe, 5 mg/5 1 ml syringe) physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

PAGE 67 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & pyridostigmine bromide (60 mg tablet, 60 mg/5 ml 1 syrup) pyridostigmine bromide 180 mg tablet er 1 RAZADYNE 3 AL At least 40 yrs old RAZADYNE ER 3 AL At least 40 yrs old REGONOL 3 rivastigmine 1 AL At least 40 yrs old rivastigmine tartrate 1 AL At least 40 yrs old SALAGEN 3 URECHOLINE 3 SKELETAL MUSCLE RELAXANTS AMRIX (ER 15 MG CAPSULE, ER 30 MG CAPSULE) Excluded Drugs baclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 carisoprodol 250 mg tablet 1 carisoprodol 350 mg tablet 1 carisoprodol/aspirin 1 carisoprodol/aspirin/codeine phosphate 1 QL 21 / day chlorzoxazone 1 cyclobenzaprine hcl 10 mg tablet 1 cyclobenzaprine hcl 5 mg tablet 1 cyclobenzaprine hcl 7.5 mg tablet 1 DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3 DANTRIUM 20 MG VIAL 3 dantrolene sodium 1

PAGE 68 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FEXMID 3 LORZONE 3 METAXALL 1 metaxalone 1 methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 100 mg/ml vial 1 orphenadrine citrate 100 mg tablet er 1 orphenadrine citrate (30 mg/ml ampul, 30 mg/ml 1 vial) PARAFON FORTE DSC 3 REVONTO 1 ROBAXIN 500 MG TABLET 3 ROBAXIN 1,000 MG/10 ML VIAL 3 ROBAXIN-750 3 SKELAXIN 3 SOMA 3 tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg 1 capsule) tizanidine hcl (2 mg tablet, 4 mg tablet) 1 ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG 3 TABLET, 6 MG CAPSULE) SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS

QL 1 / day alfuzosin hcl 1 GL Male CAFERGOT 3 QL 10 / 30 days D.H.E.45 3 PA

PAGE 69 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DIBENZYLINE 3 dihydroergotamine mesylate 1 mg/ml ampul 1 PA dihydroergotamine mesylate 0.5mg/spry QL 8 / 30 days 1 spray/pump PA ergoloid mesylates 1 ERGOMAR 3 ergotamine tartrate/caffeine 1 FLOMAX 3 QL 2 / day MIGERGOT 3 QL 8 / 30 days MIGRANAL 3 PA phenoxybenzamine hcl 1 phentolamine mesylate 1 phentolamine mesylate/alprostadil in bacteriostatic 1 water QL 1 / day RAPAFLO 2 GL Male QL 1 / day silodosin 1 GL Male tamsulosin hcl (0.4 mg cap er 24h, 0.4 mg capsule) 1 QL 2 / day QL 1 / day UROXATRAL 3 GL Male SYMPATHOMIMETIC (ADRENERGIC) AGENTS

QL 2 / fill ADRENACLICK 3 PA

PAGE 70 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ADRENALIN 3 albuterol hfa 90 mcg inhaler Excluded Drugs albuterol sulfate (2 mg/5 ml syrup, 4 mg tab er 12h, 1 8 mg tab er 12h) albuterol sulfate (2 mg tablet, 4 mg tablet) 1 albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml 1 QL 18 / day vial-neb) albuterol sulfate (2.5 mg/0.5 vial-neb, 2.5 mg/3ml 1 QL 18 / day vial-neb, 5 mg/ml solution) QL 1 / day ARCAPTA NEOHALER 3 ST QL 2 / fill AUVI-Q 3 PA BROVANA 3 QL 4 / day epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto 1 QL 4 / fill injct, 0.3mg/0.3 auto injct) epinephrine (0.1 mg/ml syringe, 1 mg/ml(1) ampul) 1 epinephrine hcl in 0.9 % sodium chloride (in 0.9 % 1 0.16 mg/10 syringe, in 0.9 % 800 mcg/50 syringe) epinephrine hcl in dextrose 5 % in water (in 5 1 mg/250ml plast. bag, in 100 mcg/10 syringe) EPINEPHRINESNAP-EMS 3 QL 2 / fill EPINEPHRINESNAP-V 3 QL 2 / fill QL 4 / fill EPIPEN 3 PA QL 4 / fill EPIPEN 2-PAK 3 PA

PAGE 71 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 4 / fill EPIPEN JR 2-PAK 3 PA FORADIL 3 QL 3 / day levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml 1 vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb) levalbuterol tar hfa 45mcg inh Excluded Drugs QL 48 tablets/180 days LUCEMYRA 3 PA metaproterenol sulfate (10 mg tablet, 10 mg/5 ml 1 syrup, 20 mg tablet) midodrine hcl 1 KRO NASAL DECONGEST 30 MG TAB 1 norepinephrine bitartrate in 0.9 % sodium chloride (bit/0.9 % 0.16 mg/10 syringe, bit/0.9 % 1 15mg/250ml plast. bag) norepinephrine bitartrate in 0.9 % sodium 1 chloride/pf norepinephrine bitartrate in 5 % dextrose in water (bitartrate/d5w 0.16 mg/10 syringe, bitartrate/d5w 1 100 mcg/10 syringe) QL 84 / 14 days NORTHERA 3 PA S PERFOROMIST 3 QL 120 / 30 days phenylephrine hcl in 0.9 % sodium chloride (in 5 mg/50 ml syringe, in 10mg/250ml plast. bag, in 100 1 mcg/10 syringe, in 200mcg/2ml syringe, in 200mg/.25l plast. bag, in 1200mcg/10 syringe)

PAGE 72 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & phenylephrine hcl in dextrose 5 % in water (hcl/dextrose 5 % 20mg/500ml plast. bag, hcl/dextrose 5 % 25mg/250ml plast. bag, 1 hcl/dextrose 5 % 30mg/250ml plast. bag, hcl/dextrose 5 % 8 mg/100ml plast. bag) phenylephrine hcl in sterile water for injection 1 PROAIR HFA 2 QL 0.8 / day PROAIR RESPICLICK 2 QL 0.07 / day PROVENTIL HFA 90 MCG INHALER Excluded Drugs pseudoephedrine hcl 120 mg tablet er 1 SEREVENT DISKUS 2 QL 2 / day QL .144 / day STRIVERDI RESPIMAT 3 ST terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1 terbutaline sulfate 1 mg/ml vial 1 UTIBRON NEOHALER 27.5-15.6 MCG Excluded Drugs VENTOLIN HFA 2 QL 1.5 / day XOPENEX 3 XOPENEX CONCENTRATE 3 XOPENEX HFA 45 MCG INHALER Excluded Drugs BLOOD DERIVATIVES

ALBUMINEX 3 BLOOD FORMATION, COAGULATION, THROMBOSIS ANTIANEMIA DRUGS

FERAHEME 3 S

PAGE 73 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FEROTRINSIC 1 FERRLECIT 3 S INFED 1 S INJECTAFER 3 S IRO-PLEX CAPLET 3 POLYSACCHARIDE IRON FORTE 1 SIDEROL 3 sodium ferric gluconate complex in sucrose 1 S TRIFERIC 3 S VENOFER 3 S ANTIHEMORRHAGIC AGENTS ADVATE (200-400 UNIT VIAL, 200-400 UNITS VIAL, 401-800 UNIT VIAL, 401-800 UNITS VIAL, 801-1,200 UNIT VIAL, 801-1,200 UNITS VIAL, 1,201-1,800 UNIT PA 3 VIAL, 1,201-1,800 UNITS VIAL, 1,801-2,400 UNIT S VIAL, 2,401-3,600 UNIT VIAL, 2,401-3,600 UNITS VIAL, 3,601-4,800 UNIT VIAL) PA ADVATE H 3 S PA ADVATE L 3 S PA ADVATE M 3 S PA ADVATE SH 3 S PA ADVATE UH 3 S

PAGE 74 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA ADYNOVATE 3 S PA AFSTYLA 3 S PA ALPHANATE 3 S ALPHANINE SD 3 S PA ALPROLIX 3 S AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG 3 TABLET, 1,000 MG TABLET) aminocaproic acid (500 mg tablet, 1000 mg tablet) 1 PA BEBULIN 3 S PA BENEFIX 3 S PA COAGADEX 3 S CORIFACT 3 S PA ELOCTATE 3 S PA FEIBA NF 3 S PA FEIBA VH IMMUNO 3 S PA HELIXATE FS 3 S

PAGE 75 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 12 / day HEMLIBRA 3 PA S PA HEMOFIL M 3 S PA HUMATE-P 3 S PA IDELVION 3 S PA IXINITY 3 S KCENTRA 3 PA KOATE 3 S PA KOGENATE FS 3 S PA KOVALTRY 3 S

QL 6/ day plus 90/ 90 LYSTEDA 3 day limit GL Female MONOCLATE-P 3 S

PA MONONINE 3 S PA NOVOEIGHT 3 S PA NOVOSEVEN RT 3 S

PAGE 76 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA NUWIQ 3 S PA OBIZUR 3 S PA PROFILNINE 3 S protamine sulfate 10 mg/ml vial 1 PA RECOMBINATE 3 S PA RIXUBIS 3 S QL 6 / day tranexamic acid 650 mg tablet 1 GL Female PA TRETTEN 3 S PA VONVENDI 3 S PA WILATE 3 S PA XYNTHA 3 S PA XYNTHA SOLOFUSE 3 S ANTITHROMBOTIC AGENTS

ACTIVASE 3 S AGGRASTAT (3.75 MG/15 ML VIAL, 5 MG/100 ML IV 3 SOLN, 5 MG/100 ML VIAL, 12.5 MG/250 ML)

PAGE 77 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & AGRYLIN 3 QL 4 / day anagrelide hcl 1 QL 4 / day ANGIOMAX 3 argatroban 1 argatroban in 0.9 % sod chlor 250 mg/250 iv soln 3 argatroban in 0.9 % sodium chloride (in 0.9 % 125 1 mg/125 vial, in 0.9 % 50 mg/50ml vial) argatroban in sodium chloride, iso-osmotic 1 ARIXTRA 3 S QL 1.25 / day BEVYXXA 3 PA AL At least 18 yrs old bivalirudin (250 mg vial, 250 mg vial port) 1 bivalirudin in 0.9 % sodium chloride 1 BRILINTA 2 QL 2 / day CATHFLO ACTIVASE 3 S cilostazol 1 QL 2 / day clopidogrel bisulfate 1 QL 1 / day COUMADIN 2 EFFIENT 3 QL 1 / day ELIQUIS 5 MG STARTER PACK 2 QL 100 / 30 days ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL 2 / day enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe, 1 S 120mg/.8ml syringe, 150 mg/ml syringe, 300mg/3ml vial)

PAGE 78 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & eptifibatide 1 fondaparinux sodium 1 S FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 3 S ML, 18,000 UNITS/0.72 ML, 95,000 UNITS/3.8 ML VL) heparin sodium,porcine 5000/ml(1) cartridge 1 heparin sodium,porcine (5000/ml syringe, 20000/ml 1 vial) heparin sodium,porcine (10 unit/ml vial, 5000/ml 1 vial) heparin sodium,porcine (100/ml vial, 1000/ml vial, 1 10000/ml vial) heparin sodium,porcine in 0.45 % sodium chloride 1 heparin sodium,porcine in 0.45 % sodium chloride/pf 1

PAGE 79 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & heparin sodium,porcine in 0.9 % sodium chloride (sod,porcine/0.9 % 100/100 ml iv soln, sod,porcine/0.9 % 10k/1000ml iv soln, sod,porcine/0.9 % 2000/500ml iv soln, sod,porcine/0.9 % 250/250 ml iv soln, sod,porcine/0.9 % 2500/500ml iv soln, sod,porcine/0.9 % 25000/250 iv soln, sod,porcine/0.9 % 3000/500ml iv soln, 1 sod,porcine/0.9 % 30k/1000ml iv soln, sod,porcine/0.9 % 4000/500ml iv soln, sod,porcine/0.9 % 4k/1000 ml iv soln, sod,porcine/0.9 % 500/500 ml iv soln, sod,porcine/0.9 % 5000/5 ml syringe, sod,porcine/0.9 % 5000/500ml iv soln, sod,porcine/0.9 % 5k/1000 ml iv soln, sod,porcine/0.9 % 6k/1000 ml iv soln) heparin sodium,porcine in 0.9 % sodium chloride (sod,porcine/0.9 % 100/ml kit, sod,porcine/0.9 % 1 1k/1000 ml iv soln) heparin sodium,porcine/dextrose 5 % in water 1 heparin sodium,porcine/pf (sodium,porcine/pf 10 unit/ml syringe, sodium,porcine/pf 100/ml (1) syringe, sodium,porcine/pf 300/3 ml syringe, 1 sodium,porcine/pf 500/5 ml syringe, sodium,porcine/pf 1000/10 ml syringe, sodium,porcine/pf 1000/ml vial) heparin sodium,porcine/pf (sodium,porcine/pf 1 1 unit/ml syringe, sodium,porcine/pf 10 unit/ml vial) heparin sodium,porcine/pf (sodium,porcine/pf 100/ml (1) vial, sodium,porcine/pf 200/2 ml syringe, 1 sodium,porcine/pf 5000/0.5ml cartridge, sodium,porcine/pf 5000/0.5ml vial) INTEGRILIN 3 IPRIVASK 3 S

PAGE 80 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG 1 TABLET, 4 MG TABLET, 5 MG TABLET) JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG 1 TABLET, 10 MG TABLET) KENGREAL 3 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML 3 S SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL) PLAVIX 3 QL 1 / day PRADAXA 2 QL 2 / day prasugrel hcl 1 QL 1 / day REOPRO 3 QL 1 / day SAVAYSA 3 PA sodium citrate 4 % (4 ml) syringe 1 ticlopidine hcl 1 QL 2 / day TNKASE 50 MG KIT 3 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg 1 tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg 1 tablet) XARELTO STARTER PACK 2 QL 56 / fill XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day XARELTO (2.5 MG TABLET, 15 MG TABLET) 2 QL 2 / day QL 1 / day ZONTIVITY 3 PA

PAGE 81 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

PA TAVALISSE 3 S HEMATOPOIETIC AGENTS ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML 3 S SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML PS SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE) PA DOPTELET 3 S PA EPOGEN 3 S PA FULPHILA 3 S GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML SYRINGE, 300 MCG/ML VIAL, 480 MCG/0.8 ML PA 3 SAFE SYR, 480 MCG/0.8 ML SYRINGE, 480 MCG/1.6 S ML VIAL) PA LEUKINE 3 S PA MIRCERA 3 S PA MOZOBIL 3 S

PAGE 82 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 PA 3 MG/0.6 ML KIT) S

NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML PA 3 VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) S NIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/ML PA VIAL, 480 MCG/0.8 ML SYRING, 480 MCG/1.6 ML 3 VIAL) S PA NPLATE 3 S PA PROCRIT 3 S PROMACTA (12.5 MG SUSPEN PACKET, 12.5 MG PA TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG 3 TABLET) S PA RETACRIT 3 S PS QL 0.6 / day UDENYCA 3 PA S QL 90 / 30 days ZARXIO 3 PA S HEMORRHEOLOGIC AGENTS pentoxifylline 1

PAGE 83 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 3 QL 1 / day CARDURA XL 3 ST doxazosin mesylate 1 MINIPRESS 3 prazosin hcl 1 terazosin hcl 1 ANTILIPEMIC AGENTS

QL 1 / day ALTOPREV 3 ST besylate/atorvastatin calcium 1 QL 1 / day QL 2 / day ANTARA 30 MG CAPSULE 3 PA QL 1 / day ANTARA 90 MG CAPSULE 3 PA atorvastatin calcium (10 mg tablet, 20 mg tablet) 1 QL 1 / day atorvastatin calcium (40 mg tablet, 80 mg tablet) 1 QL 1 / day CADUET 3 QL 1 / day cholestyramine (with sugar) 4 g powder 1 QL 24 / day cholestyramine (with sugar) 4 g powd pack 1 QL 4 / day cholestyramine/aspartame 4 g powder 1 QL 24 / day cholestyramine/aspartame 4 g powd pack 1 QL 4 / day

PAGE 84 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & colesevelam hcl 3.75 g powd pack 1 QL 1 / day colesevelam hcl 625 mg tablet 1 QL 6 / day COLESTID (FLAVORED GRANULES, GRANULES, 3 QL 6 / day GRANULES PACKET) COLESTID 1 GM TABLET 3 QL 4 / day colestipol hcl (5 g granules, 5 g packet) 1 QL 6 / day colestipol hcl 1 g tablet 1 QL 4 / day QL 1 / day CRESTOR 3 ST ezetimibe 1 QL 1 / day ezetimibe/ 1 QL 1 / day fenofibrate 150 mg capsule 1 QL 1 / day fenofibrate 50 mg capsule 1 QL 2 / day fenofibrate 120 mg tablet 1 QL 1 / day fenofibrate 160 mg tablet 1 QL 1 / day fenofibrate 40 mg tablet 1 QL 2 / day fenofibrate 54 mg tablet 1 QL 2 / day fenofibrate nanocrystallized (145mg tablet, 160 mg 1 QL 1 / day tablet) fenofibrate nanocrystallized 48 mg tablet 1 QL 2 / day fenofibrate,micronized (67 mg capsule, 134 mg 1 QL 1 / day capsule, 200 mg capsule) fenofibrate,micronized 130 mg capsule 1 QL 1 / day fenofibrate,micronized 43 mg capsule 1 QL 2 / day fenofibric acid 105 mg tablet 1 QL 1 / day

PAGE 85 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fenofibric acid 35 mg tablet 1 QL 2 / day fenofibric acid (choline) 135 mg capsule dr 1 QL 1 / day fenofibric acid (choline) 45 mg capsule dr 1 QL 2 / day FENOGLIDE 120 MG TABLET 3 QL 1 / day FENOGLIDE 40 MG TABLET 3 QL 2 / day FIBRICOR 105 MG TABLET 3 QL 1 / day FIBRICOR 35 MG TABLET 3 QL 2 / day QL 10 / day FLOLIPID 20 MG/5 ML ORAL SUSP 3 ST QL 5 / day FLOLIPID 40 MG/5 ML ORAL SUSP 3 ST fluvastatin sodium 40 mg capsule 1 QL 2 / day fluvastatin sodium (20 mg capsule, 80 mg tab er 1 QL 1 / day 24h) gemfibrozil 1 QL 2 / day QL 1 / day JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG 3 PA CAPSULE, 60 MG CAPSULE) S QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 3 PA S QL 0.15 / day KYNAMRO 3 PA S QL 1 / day LESCOL 20 MG CAPSULE 3 ST

PAGE 86 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day LESCOL 40 MG CAPSULE 3 ST QL 1 / day LESCOL XL 3 ST

LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG QL 1 / day 3 TABLET) ST LIPITOR 80 MG TABLET 3 ST QL 1 / day LIPOFEN 150 MG CAPSULE 3 PA QL 2 / day LIPOFEN 50 MG CAPSULE 3 PA QL 1 / day LIVALO 2 ST LOPID 3 QL 2 / day (10 mg tablet, 20 mg tablet) 1 QL 1 / day lovastatin 40 mg tablet 1 QL 2 / day LOVAZA 3 QL 4 / day niacin (750 mg tab er 24h, 1000 mg tab er 24h) 1 QL 2 / day niacin 500 mg tab er 24h 1 QL 3 / day niacin 500 mg tablet er 1 NIACOR 3 QL 12 / day NIASPAN (ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL 2 / day NIASPAN ER 500 MG TABLET 3 QL 3 / day omega-3 acid ethyl esters 1 QL 4 / day

PAGE 87 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & omega-3 fatty acids 100 mg tab chew 1 QL 0.08 / day PA PRALUENT PEN 3 S PS QL 1 / day PRAVACHOL 3 ST pravastatin sodium (10 mg tablet, 20 mg tablet, 40 1 QL 1 / day mg tablet) pravastatin sodium 80 mg tablet 1 PREVALITE POWDER 1 QL 24 / day PREVALITE PACKET 1 QL 4 / day QUESTRAN POWDER 3 QL 24 / day QUESTRAN PACKET 3 QL 4 / day QUESTRAN LIGHT 3 QL 24 / day QL 0.13 / day PA REPATHA PUSHTRONEX 3 S PS QL 0.08 / day PA REPATHA SURECLICK 3 S PS QL 0.08 / day PA REPATHA SYRINGE 3 S PS

PAGE 88 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & rosuvastatin calcium (20 mg tablet, 40 mg tablet) 1 QL 1 / day rosuvastatin calcium (5 mg tablet, 10 mg tablet) 1 QL 1 / day simvastatin (10 mg tablet, 20 mg tablet, 40 mg 1 QL 1.5 / day tablet) simvastatin 5 mg tablet 1 QL 1 / day QL 1 / day simvastatin 80 mg tablet 1 PA THEROMEGA SPORT 1 TRICOR 145 MG TABLET 3 QL 1 / day TRICOR 48 MG TABLET 3 QL 2 / day QL 1 / day TRIGLIDE 3 PA TRIKLO 1 QL 4 / day TRILIPIX DR 135 MG CAPSULE 3 QL 1 / day TRILIPIX DR 45 MG CAPSULE 3 QL 2 / day VASCEPA 3 QL 4 / day VYTORIN 3 QL 1 / day WELCHOL 3.75G PACKET 3 QL 1 / day WELCHOL 625 MG TABLET 3 QL 6 / day ZETIA 3 QL 1 / day

ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG QL 1.5 / day 3 TABLET) ST QL 1 / day ZOCOR 5 MG TABLET 3 ST

PAGE 89 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day ZOCOR 80 MG TABLET 3 PA ST ZYPITAMAG (1 MG TABLET, 2 MG TABLET, 4 MG Excluded Drugs TABLET) BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl 1 atenolol (25 mg tablet, 50 mg tablet) 1 atenolol 100 mg tablet 1 atenolol/chlorthalidone 1 BETAPACE 3 BETAPACE AF 3 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 bisoprolol fumarate/hydrochlorothiazide 1 BREVIBLOC (100 MG/10 ML VIAL, 2,000 MG/100 ML 3 BAG, 2,500 MG/250 ML BAG) BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day BYSTOLIC 2.5 MG TABLET 2 QL 1 / day BYSTOLIC 20 MG TABLET 2 QL 2 / day BYVALSON 2 QL 1 / day 1 carvedilol phosphate (10 mg cpmp 24hr, 20 mg 1 QL 2 / day cpmp 24hr, 40 mg cpmp 24hr) carvedilol phosphate 80 mg cpmp 24hr 1 QL 1 / day

PAGE 90 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & COREG 3 CORGARD 3 CORZIDE 3 DUTOPROL 3 esmolol hcl 100mg/10ml syringe 1 esmolol hcl 100mg/10ml vial 1 esmolol hcl in sodium chloride, iso-osmotic 1 HEMANGEOL 3 S INDERAL LA 3 INDERAL XL 3 ST INNOPRAN XL 3 ST labetalol hcl 20 mg/4 ml cartridge 1 labetalol hcl (5 mg/ml vial, 20 mg/4 ml syringe, 25 1 mg/5 ml syringe, 50 mg/10ml syringe) labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg 1 tablet) labetalol in dextrose 5 % in water 1 LEVATOL 3 LOPRESSOR 5 MG/5 ML AMPUL 3 LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3 LOPRESSOR HCT 3 metoprolol succinate 1 metoprolol tartrate (25 mg tablet, 50 mg tablet) 1 metoprolol tartrate (37.5 mg tablet, 75 mg tablet) 1 metoprolol tartrate (5 mg/5 ml cartridge, 100 mg 1 tablet)

PAGE 91 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & metoprolol tartrate (5 mg/5 ml ampul, 5 mg/5 ml 1 vial) metoprolol tartrate/hydrochlorothiazide 1 nadolol 1 nadolol/bendroflumethiazide 40 mg-5 mg tablet 1 nadolol/bendroflumethiazide 80 mg-5 mg tablet 1 pindolol 1 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg 1 cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa 24h, 160 mg cap sa 24h) propranolol hcl 1 mg/ml vial 1 propranolol hcl/hydrochlorothiazide 1 SORINE 1 sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg 1 tablet, 240 mg tablet) sotalol hcl 150mg/10ml vial 1 SOTYLIZE 3 TENORETIC 100 3 TENORETIC 50 3 TENORMIN 3 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg 1 tablet) TOPROL XL 3 ZEBETA 3 ZIAC 3

PAGE 92 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CALCIUM-CHANNEL BLOCKING AGENTS

ADALAT CC 30 MG TABLET 3 QL 1 / day ADALAT CC 60 MG TABLET 3 QL 2 / day ADALAT CC 90 MG TABLET 3 AFEDITAB CR 30 MG TABLET 1 QL 1 / day AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besylate 1 QL 1 / day amlodipine besylate/benazepril hcl 1 QL 1 / day amlodipine besylate/olmesartan medoxomil 1 QL 1 / day amlodipine besylate/valsartan (besylate/valsartan 5 mg-320mg tablet, besylate/valsartan 10mg-160mg 1 QL 1 / day tablet, besylate/valsartan 10mg-320mg tablet) amlodipine besylate/valsartan 5 mg-160mg tablet 1 QL 2 / day amlodipine besylate/valsartan/hydrochlorothiazide 1 QL 1 / day AZOR 3 QL 1 / day CALAN 3 QL 3 / day CALAN SR 3 QL 1 / day CARDENE I.V. 25 MG/10 ML AMPUL 3 CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN, CARDENE-DEX 40 MG/200 ML IV, CARDENE-NACL 20 3 MG/200 ML SOLN, CARDENE-NACL 40 MG/200 ML IV) CARDIZEM 3 QL 4 / day CARDIZEM CD (300 MG CAPSULE, 360 MG CAPSULE) 3 QL 1 / day CARDIZEM CD 120 MG CAPSULE 3 QL 4 / day

PAGE 93 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CARDIZEM CD 180 MG CAPSULE 3 QL 3 / day CARDIZEM CD 240 MG CAPSULE 3 QL 2 / day CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 3 QL 1 / day MG TABLET) CARDIZEM LA 120 MG TABLET 3 QL 4 / day CARDIZEM LA 180 MG TABLET 3 QL 3 / day CARDIZEM LA 240 MG TABLET 3 QL 2 / day CARTIA XT 120 MG CAPSULE 1 QL 4 / day CARTIA XT 180 MG CAPSULE 1 QL 3 / day CARTIA XT 240 MG CAPSULE 1 QL 2 / day CARTIA XT 300 MG CAPSULE 1 QL 1 / day CLEVIPREX 3 DILT XR 120 MG CAPSULE 1 QL 1 / day DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 diltiazem hcl (120 mg cap er deg, 120 mg cap sa 24h, 180 mg cap er deg, 180 mg cap sa 24h, 300 mg cap 1 QL 1 / day er 24h, 300 mg tab er 24h, 360 mg cap er 24h, 360 mg tab er 24h, 420 mg tab er 24h) diltiazem hcl (180 mg cap er 24h, 180 mg tab er 24h) 1 QL 3 / day diltiazem hcl (60 mg cap er 12h, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 240 mg cap er deg, 1 240 mg cap sa 24h, 300 mg cap sa 24h, 360 mg cap sa 24h, 420 mg cap sa 24h) diltiazem hcl (240 mg cap er 24h, 240 mg tab er 24h) 1 QL 2 / day diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg 1 QL 4 / day cap er 24h, 120 mg tablet) diltiazem hcl 5 mg/ml vial 1

PAGE 94 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & diltiazem hcl 100 mg vial port 1 diltiazem hcl in 0.9 % sodium chloride 1 diltiazem hcl/d5w 125 mg/125 plast. bag 1 EXFORGE 3 QL 1 / day EXFORGE HCT 3 QL 1 / day 1 QL 1 / day isradipine 2.5 mg capsule 1 QL 2 / day isradipine 5 mg capsule 1 QL 4 / day LOTREL 3 QL 1 / day MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 1 QL 1 / day MG TABLET) MATZIM LA 180 MG TABLET 1 QL 3 / day MATZIM LA 240 MG TABLET 1 QL 2 / day hcl 20 mg capsule 1 nicardipine hcl 30 mg capsule 1 nicardipine hcl 2.5 mg/ml syringe 1 nicardipine hcl (25 mg/10ml ampul, 25 mg/10ml 1 vial) nicardipine hcl in 0.9 % sodium chloride (in 0.5 1 mg/5ml syringe, in 1 mg/10 ml syringe) nicardipine in 5 % dextrose in water 1 (10 mg capsule, 20 mg capsule) 1 QL 4 / day nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg 1 QL 1 / day tab er 24, 90 mg tablet er) nifedipine (60 mg tab er 24, 60 mg tablet er) 1 QL 2 / day

PAGE 95 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & nimodipine 1 1 QL 1 / day NORVASC 3 QL 1 / day NYMALIZE 3 QL 120 / day PROCARDIA 3 QL 4 / day PROCARDIA XL (30 MG TABLET, 90 MG TABLET) 3 QL 1 / day PROCARDIA XL 60 MG TABLET 3 QL 2 / day SULAR 3 QL 1 / day TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 1 MG CAPSULE) TIAZAC (ER 120 MG CAPSULE, ER 180 MG CAPSULE) 3 QL 1 / day TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, 3 ER 360 MG CAPSULE, ER 420 MG CAPSULE) verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml syringe) 1 verapamil hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet er, 180 mg cap24h pel, 180 mg 1 QL 1 / day tablet er, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct) verapamil hcl 360 mg cap24h pel 1 QL 1 / day verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil hcl 40 mg tablet 1 verapamil hcl 2.5 mg/ml vial 1 VERELAN 3 QL 1 / day VERELAN PM 3 QL 1 / day

PAGE 96 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CARDIAC DRUGS

ADENOCARD 3 adenosine 1 hcl (100 mg tablet, 200 mg tablet, 400 1 mg tablet) amiodarone hcl (50 mg/ml vial, 150 mg/3ml syringe) 1 amiodarone hcl/dextrose 5 % in water 1 QL 2 / day CORLANOR 3 ST CORVERT 3 DIGITEK 1 DIGOX 1 digoxin 50 mcg/ml solution 1 digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) 1 digoxin (125 mcg tablet, 250 mcg tablet) 1 disopyramide phosphate 1 dofetilide 1 S flecainide acetate 1 ibutilide fumarate 1 LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 2 187.5 MCG TABLET, 250 MCG TABLET) LANOXIN PEDIATRIC 2 lidocaine hcl in dextrose 5% in water/pf 1 lidocaine hcl/dextrose 5%-water/pf 1

PAGE 97 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & lidocaine hcl/pf (hcl/pf 20 mg/ml vial, hcl/pf 50 mg/5 1 ml syringe, hcl/pf 100 mg/5ml syringe) mexiletine hcl 1 MULTAQ 3 PA NEXTERONE 3 NORPACE 3 NORPACE CR 100 MG CAPSULE 2 NORPACE CR 150 MG CAPSULE 3 PACERONE 1 procainamide hcl 500 mg/ml vial 1 propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 1 425 mg cap er 12h) quinidine gluconate 324 mg tablet er 1 quinidine gluconate 80 mg/ml vial 1 quinidine sulfate 1 RANEXA 3 QL 2 / day ranolazine 1 QL 2 / day RYTHMOL SR 3 TIKOSYN 3 S XYLOCAINE IV 3 HYPOTENSIVE AGENTS

BIDIL 3 QL 6 / day CATAPRES 3 CATAPRES-TTS 1 3 QL 0.15 / day

PAGE 98 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CATAPRES-TTS 2 3 QL 0.4 / day CATAPRES-TTS 3 3 QL 0.4 / day clonidine (0.2mg/24hr patch tdwk, 0.3mg/24hr 1 QL 0.4 / day patch tdwk) clonidine 0.1mg/24hr patch tdwk 1 QL 0.15 / day clonidine hcl 0.1 mg tab er 12h 1 QL 4 / day clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg 1 tablet) CLORPRES 3 CORLOPAM 10 MG/ML AMPUL 3 guanfacine hcl (1 mg tablet, 2 mg tablet) 1 hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg 1 tablet, 100 mg tablet) hydralazine hcl 20 mg/ml vial 1 QL 4 / day KAPVAY 3 ST methyldopa 1 methyldopa/hydrochlorothiazide 1 methyldopate hcl 1 minoxidil (2.5 mg tablet, 10 mg tablet) 1 NITROPRESS 3 nitroprusside sodium 1 PA VECAMYL 3 S

PAGE 99 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ACCUPRIL 3 QL 2 / day ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG 3 QL 2 / day TABLET) ACCURETIC 20-25 MG TABLET 3 QL 1 / day ALDACTAZIDE 3 ALDACTONE 3 QL 1 / day aliskiren hemifumarate 1 ST ALTACE 3 QL 2 / day ATACAND 3 QL 1 / day ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3 QL 1 / day ATACAND HCT 16-12.5 MG TAB 3 QL 2 / day AVALIDE 150-12.5 MG TABLET 3 QL 2 / day AVALIDE 300-12.5 MG TABLET 3 QL 1 / day AVAPRO 3 QL 1 / day benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day benazepril hcl/hydrochlorothiazide 1 QL 1 / day BENICAR 3 QL 3 / day BENICAR HCT 3 QL 1 / day candesartan cilexetil 1 QL 1 / day

PAGE 100 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 32-12.5mg tablet, 1 QL 1 / day candesartan/hydrochlorothiazid 32mg-25mg tablet) candesartan/hydrochlorothiazid 16-12.5mg tablet 1 QL 2 / day captopril 1 QL 4 / day captopril/hydrochlorothiazide 1 QL 2 / day CAROSPIR 2 PA COZAAR (25 MG TABLET, 50 MG TABLET) 3 QL 2 / day COZAAR 100 MG TABLET 3 QL 1 / day DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG 3 QL 2 / day TABLET) DIOVAN 320 MG TABLET 3 QL 1 / day DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3 QL 1 / day DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG 3 QL 2 / day TAB, 160-25 MG TABLET) QL 1 / day EDARBI 3 ST QL 1 / day EDARBYCLOR 3 ST enalapril maleate 1 QL 2 / day enalapril/hydrochlorothiazide 10 mg-25mg tablet 1 QL 2 / day enalapril/hydrochlorothiazide 5mg-12.5mg tablet 1 enalaprilat dihydrate 1.25 mg/ml vial 1 ENTRESTO 3 QL 2 / day EPANED (1 MG/ML ORAL SOLUTION, 1 MG/ML 3 QL 5 / day SOLUTION)

PAGE 101 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & eplerenone 1 eprosartan mesylate 1 QL 1 / day fosinopril sodium 1 QL 2 / day fosinopril sodium/hydrochlorothiazide 1 QL 2 / day HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3 QL 1 / day HYZAAR 50-12.5 TABLET 3 QL 2 / day INSPRA 3 irbesartan 1 QL 1 / day irbesartan/hydrochlorothiazide 150-12.5mg tablet 1 QL 2 / day irbesartan/hydrochlorothiazide 300-12.5mg tablet 1 QL 1 / day lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1 QL 1 / day lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day lisinopril 40 mg tablet 1 QL 2 / day lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide 10-12.5mg tablet, 1 QL 2 / day lisinopril/hydrochlorothiazide 20-12.5 mg tablet) lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide 20 mg-25mg tablet, 1 QL 2 / day lisinopril/hydrochlorothiazide 20-25mg tablet) losartan potassium (25 mg tablet, 50 mg tablet) 1 QL 2 / day losartan potassium 100 mg tablet 1 QL 1 / day losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 100-12.5mg tablet, 1 QL 1 / day losartan/hydrochlorothiazide 100mg-25mg tablet) losartan/hydrochlorothiazide 50-12.5 mg tablet 1 QL 2 / day LOTENSIN (10 MG TABLET, 40 MG TABLET) 3 QL 2 / day

PAGE 102 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & LOTENSIN 20 MG TABLET 3 QL 4 / day LOTENSIN HCT 3 QL 1 / day MICARDIS 3 QL 1 / day MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG 3 QL 1 / day TABLET) MICARDIS HCT 80-12.5 MG TABLET 3 QL 2 / day moexipril hcl 1 QL 1 / day moexipril hcl/hydrochlorothiazide 1 QL 2 / day olmesartan medoxomil 1 QL 3 / day olmesartan medoxomil/amlodipine 1 QL 1 / day besylate/hydrochlorothiazide olmesartan medoxomil/hydrochlorothiazide 1 QL 1 / day perindopril erbumine 1 QL 1 / day QL 1 / day PRESTALIA 3 ST PRINIVIL 3 QL 1 / day QBRELIS 3 QL 40/ day quinapril hcl 1 QL 2 / day quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 10-12.5mg tablet, 1 QL 2 / day quinapril/hydrochlorothiazide 20-12.5 mg tablet) quinapril/hydrochlorothiazide 20 mg-25mg tablet 1 QL 1 / day ramipril 1 QL 2 / day 1 spironolactone/hydrochlorothiazide 1

PAGE 103 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & TARKA 3 QL 1 / day QL 1 / day TEKTURNA 3 ST QL 1 / day TEKTURNA HCT 3 ST 1 QL 1 / day telmisartan/amlodipine besylate 1 QL 1 / day telmisartan/hydrochlorothiazid 80-12.5mg tablet 1 QL 2 / day telmisartan/hydrochlorothiazide (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, 1 QL 1 / day telmisartan/hydrochlorothiazid 80 mg-25mg tablet) trandolapril 1 QL 2 / day trandolapril/verapamil hcl 1 TRIBENZOR 3 QL 1 / day TWYNSTA 3 QL 1 / day valsartan (40 mg tablet, 80 mg tablet, 160 mg 1 QL 2 / day tablet) valsartan 320 mg tablet 1 QL 1 / day valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 320-12.5mg tablet, 1 QL 1 / day valsartan/hydrochlorothiazide 320mg-25mg tablet) valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, 1 QL 2 / day valsartan/hydrochlorothiazide 160-12.5mg tablet, valsartan/hydrochlorothiazide 160-25mg tablet) VASERETIC 3 QL 2 / day VASOTEC 3 QL 2 / day

PAGE 104 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ZESTORETIC 3 QL 2 / day ZESTRIL (2.5 MG TABLET, 5 MG TABLET, 10 MG 3 QL 1 / day TABLET, 20 MG TABLET, 30 MG TABLET) ZESTRIL 40 MG TABLET 3 QL 2 / day VASODILATING AGENTS

QL 2 / day ADCIRCA 3 PA S AGGRENOX 3 QL 2 / day QL 2 / day ALYQ 1 PA S aspirin/dipyridamole 1 QL 2 / day CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, 3 GL Male IMPULSE 20 MCG KIT, 40 MCG VIAL) QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 3 GL Male QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 3 GL Male DILATRATE-SR 3 QL 4 / day dipyridamole (25 mg tablet, 50 mg tablet, 75 mg 1 QL 4 / day tablet) EDEX 3 GL Male QL 1.25 / day GONITRO 3 PA AL At least 18 yrs old

PAGE 105 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ISOCHRON 1 QL 4 / day ISORDIL 3 QL 12 / day ISORDIL TITRADOSE 3 QL 12 / day isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 1 QL 12 / day mg tablet, 30 mg tablet) isosorbide dinitrate 40 mg tablet er 1 QL 4 / day isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 1 QL 2 / day 24h) isoxsuprine hcl 10 mg tablet 1 LEVITRA (2.5 MG TABLET, 5 MG TABLET, 10 MG Excluded Drugs TABLET, 20 MG TABLET) MINITRAN 1 QL 1 / day MUSE 3 GL Male NATRECOR 3 NITRO-BID 2 QL 4 / day NITRO-DUR 3 QL 1 / day NITRO-TIME (ER 2.5 MG CAPSULE, ER 6.5 MG 1 QL 4 / day CAPSULE) nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 1 QL 4 / day mg capsule er) nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch 1 QL 1 / day td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24) nitroglycerin 400mcg/spr spray 1 QL 0.8 / day nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 1 QL 6 / day mg tab subl) nitroglycerin 50 mg/10ml vial 1

PAGE 106 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & nitroglycerin in 5 % dextrose in water 1 NITROLINGUAL 3 QL 0.8 / day NITROMIST 3 QL 0.3 / day NITROSTAT 3 QL 6 / day papaverine hcl 1 papaverine hcl/alprostadil in bacteriostatic water 1 QL 6 / day PA REVATIO 10 MG/ML ORAL SUSP 3 AL At least 18 yrs old S QL 3 / day PA REVATIO 20 MG TABLET 3 AL At least 18 yrs old S PA REVATIO 10 MG/12.5 ML VIAL 3 AL At least 18 yrs old S QL 3 / day sildenafil 20 mg tablet (pah) 1 PA S QL 0.2 / day sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg 1 GL Male tablet) AL At least 18 yrs old PA sildenafil citrate 10 mg/12.5 vial 1 AL At least 18 yrs old S STAXYN 10 MG ODT Excluded Drugs

PAGE 107 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & STENDRA (50 MG TABLET, 100 MG TABLET, 200 MG Excluded Drugs TABLET) QL 1 / day tadalafil (2.5 mg tablet, 5 mg tablet) 1 GL Male QL 0.2 / day tadalafil 10 mg tablet 1 GL Male QL 2 / day PA tadalafil 20 mg tablet 1 GL Male S QL 0.2 / day TADALAFIL 20 MG TABLET (ED/BPH) 1 GL Male QL 2 / day TADALAFIL 20 MG TABLET (PAH) 1 PA S QL 0.2 / day vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tab 1 GL Male rapdis, 10 mg tablet, 20 mg tablet) AL At least 18 yrs old VIAGRA (25 MG TABLET, 50 MG TABLET, 100 MG Excluded Drugs TABLET) CELLULAR AND GENE THERAPY CELLULAR THERAPY

QL 18 / day PROVENGE 3 PA S

PAGE 108 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS ABSTRAL (100 MCG TAB, 200 MCG TAB, 300 MCG Excluded Drugs TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB) QL 140 / day acetaminophen with codeine 120-12mg/5 solution 1 AL At least 12 yrs old QL 139 / day acetaminophen with codeine 300mg/12.5 solution 1 AL At least 12 yrs old QL 22 / day acetaminophen with codeine 300mg-15mg tablet 1 AL At least 12 yrs old QL 12 / day acetaminophen with codeine 300mg-30mg tablet 1 AL At least 12 yrs old QL 6 / day acetaminophen with codeine 300mg-60mg tablet 1 AL At least 12 yrs old acetaminophen/caffeine/dihydrocodeine bitartrate (acetaminophen/caff/dihydrocod 320.5-30mg QL 10 / day 1 capsule, acetaminophen/caff/dihydrocod 325-30-16 AL At least 18 yrs old tablet) QL 4 / day ACTIQ 3 PA AL At least 18 yrs old ALLZITAL 3 QL 12 / day ANAPROX DS 3 ANSAID 3 ARTHROTEC 50 3 ARTHROTEC 75 3 QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old

PAGE 109 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 10 / day aspirin/caffeine/dihydrocodeine bitartrate 1 AL At least 18 yrs old ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML 1 QL 50 / day VIAL) ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 1 QL 100 / day ML VIAL) QL 2 / day BELBUCA 3 PA AL At least 18 yrs old QL 3 / day BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3 PA QL 2 / day BUNAVAIL 4.2-0.7 MG FILM 3 PA BUPAP 1 QL 6 / day BUPRENEX 3 QL 17 / day QL 0.144 / day buprenorphine 1 PA buprenorphine hcl 0.3 mg/ml cartridge 1 QL 17 / day QL 3 / day buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1 PA buprenorphine hcl 0.3 mg/ml vial 1 QL 17 / day buprenorphine hcl/naloxone hcl (/naloxone 4mg- QL 2 / day 1 1mg film, /naloxone 12 mg-3 mg film) PA buprenorphine hcl/naloxone hcl (/naloxone 2 mg- 0.5mg film, /naloxone 2 mg-0.5mg tab subl, QL 3 / day 1 /naloxone 8 mg-2 mg film, /naloxone 8 mg-2 mg tab PA subl)

PAGE 110 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & butalbital/acetaminophen (butalbital/acetaminophen capsule, 1 QL 6 / day butalbital/acetaminophen tablet) butalbital/acetaminophen 50mg-325mg tablet 1 QL 6 / day butalbital/acetaminophen/caffeine (butalb/acetaminophen/caffeine 50-300-40 capsule, 1 QL 6 / day butalb/acetaminophen/caffeine 50-325-40 capsule, butalb/acetaminophen/caffeine 50-325-40 tablet) butalbital/acetaminophen/caffeine/codeine phosphate (butalbit/acetamin/caff/codeine 50-300- 1 QL 6 / day 30 capsule, butalbit/acetamin/caff/codeine 50-325- 30 capsule) butalbital/aspirin/caffeine (butalbital/aspirin/caffeine 50-325-40 capsule, 1 QL 6 / day butalbital/aspirin/caffeine 50-325-40 tablet) QL 0.3 / day butorphanol tartrate 10 mg/ml spray 1 AL At least 18 yrs old QL 7 / day butorphanol tartrate 1 mg/ml vial 1 AL At least 18 yrs old QL 4 / day butorphanol tartrate 2 mg/ml vial 1 AL At least 18 yrs old QL 0.144 / day BUTRANS 3 PA CALDOLOR 3 CAMBIA 50 MG POWDER PACKET Excluded Drugs CAPACET 1 QL 6 / day QL 125 / day CAPITAL W-CODEINE 3 AL At least 12 yrs old CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3 QL 2 / day

PAGE 111 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CELEBREX 100 MG CAPSULE 3 QL 3 / day CELEBREX 400 MG CAPSULE 3 QL 1 / day celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day choline salicylate/magnesium salicylate 1 clonidine hcl/pf 1 QL 6 / day codeine phosphate/butalbital/aspirin/caffeine 1 AL At least 18 yrs old QL 6 / day codeine sulfate 1 AL At least 18 yrs old QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 3 PA MG CAPSULE) AL At least 18 yrs old CORICIDIN HBP COLD & FLU TAB 3 DAYPRO 3 DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML QL 10 / day AMPUL, 50 MG/ML CARPUJECT, 50 MG/ML VIAL, 75 3 MG/1.5 ML AMPUL, 100 MG/2 ML AMPUL) AL At least 18 yrs old QL 20 / day DEMEROL 25 MG/ML CARPUJECT 3 AL At least 18 yrs old QL 7 / day DEMEROL 75 MG/ML CARPUJECT 3 AL At least 18 yrs old QL 5 / day DEMEROL 100 MG TABLET 3 AL At least 18 yrs old

DEMEROL (100 MG/ML AMPUL, 100 MG/ML QL 5 / day 3 CARPUJECT, 100 MG/ML VIAL) AL At least 18 yrs old

PAGE 112 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & diclofenac epolamine 1 QL 2 / day diclofenac potassium 1 diclofenac sodium 1.5 % drops 1 diclofenac sodium 1 % gel (gram) 1 QL 1000/ 30 days diclofenac sodium (50 mg tablet dr, 75 mg tablet dr, 1 100 mg tab er 24h) diclofenac sodium 25 mg tablet dr 1 diclofenac sodium/misoprostol (sodium/misoprostol 1 50 tab ir dr, sodium/misoprostol 75 tab ir dr) diflunisal 1 QL 13 / day DILAUDID 5 MG/5 ML ORAL LIQUID 3 AL At least 18 yrs old DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML 3 AL At least 18 yrs old SYRINGE, 2 MG/ML SYRINGE, 4 MG/ML SYRINGE)

DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG QL 6 / day 3 TABLET) AL At least 18 yrs old QL 3 / day DOLOPHINE HCL 3 PA DSUVIA 3 DUEXIS 800-26.6 MG TABLET Excluded Drugs DURACLON 3 QL 0.5 / day DURAGESIC 3 PA DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day QL 1 / day DURLAZA 3 PA

PAGE 113 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 10 / day DVORAH 3 AL At least 18 yrs old DYLOJECT 3 EC-NAPROSYN 3 QL 2 / day EMBEDA 2 PA

ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10- QL 12 / day 1 325 MG TABLET) AL At least 18 yrs old QL 12 / day ENDOCET 2.5-325 MG TABLET 1 AL At least 18 yrs old ESGIC CAPSULE 1 QL 6 / day ESGIC 50-325-40 MG TABLET 3 QL 6 / day etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 600 mg 1 tab er 24h) etodolac 500 mg tab er 24h 1 QL 2 / day EXALGO 3 PA FELDENE 3 fenoprofen calcium (200 mg capsule, 400 mg 1 capsule) fenoprofen calcium 600 mg tablet 1 FENORTHO 3 (12 mcg/hr patch td72, 25 mcg/hr patch QL 0.5 / day td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 1 87.5mcg/hr patch td72, 100 mcg/hr patch td72) PA fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr patch QL 0.5 / day 1 td72) PA

PAGE 114 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fentanyl citrate (200 mcg lozenge hd, 400 mcg QL 4 / day lozenge hd, 600 mcg lozenge hd, 1200 mcg lozenge 1 PA hd, 1600 mcg lozenge hd) AL At least 18 yrs old QL 4 / day fentanyl citrate 800 mcg lozenge hd 1 PA AL At least 18 yrs old fentanyl citrate-0.9 % nacl/pf 1375mcg/55 pca 1 QL 15 / day syring fentanyl citrate in 0.9 % sodium chloride/pf (% nacl/pf 5 mcg/ml plast. bag, % nacl/pf 5 mcg/ml syringe, % nacl/pf 5mcg/0.5ml syringe, % nacl/pf 5mcg/ml(1) vial, % nacl/pf 10 mcg/2ml syringe, % nacl/pf 10 mcg/ml pump resvr, % nacl/pf 15 mcg/3ml syringe, % nacl/pf 20 mcg/ml plast. bag, % 1 nacl/pf 25 mcg/2.5 syringe, % nacl/pf 50mcg/5ml syringe, % nacl/pf 300mcg/30 pca syring, % nacl/pf 500 mcg/50 pca syring, % nacl/pf 550mcg/55 pca syring, % nacl/pf 750mcg/30 pca vial, % nacl/pf 1100mcg/55 pca syring) fentanyl citrate in 0.9 % sodium chloride/pf (% nacl/pf 600mcg/30 pca syring, % nacl/pf 600mcg/30 1 QL 19 / day pca vial) fentanyl citrate-0.9 % nacl/pf 10 mcg/ml plast. bag 1 QL 38 / day fentanyl citrate in 0.9 % sodium chloride/pf (% 1 QL 38 / day nacl/pf 10 mcg/ml syringe, % nacl/pf 10 mcg/ml vial) fentanyl citrat/dextrose 5%/pf 100 mcg/10 pca 1 syring fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf (fentanyl/bupivacaine/ns/pf 1.5/1-.125 1 syringe, fentanyl/bupivacaine/ns/pf 2mcg/ml-.1 pump resvr) fentanyl citrate/pf 100mcg/2ml cartridge 1 QL 8 / day

PAGE 115 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fentanyl citrate/pf (citrate/pf 1000mcg/20 pca 1 syring, citrate/pf 1250mcg/25 pca syring) fentanyl citrate/pf (citrate/pf 100mcg/2ml syringe, 1 QL 8 / day citrate/pf 1500mcg/30 pca syring) fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 plast. bag 1 QL 192 / day FENTORA (100 MCG TABLET, 200 MCG TABLET, 400 Excluded Drugs MCG TABLET, 600 MCG TABLET, 800 MCG TABLET) FIORICET 3 QL 6 / day FIORICET WITH CODEINE 3 QL 6 / day FIORINAL 3 QL 6 / day QL 6 / day FIORINAL WITH CODEINE #3 3 AL At least 18 yrs old FLECTOR 3 QL 2 / day flurbiprofen 1 GOODY'S EX-STR POWDER PACKET 3 GRALISE 30-DAY STARTER PACK 3 ST QL 1 / day GRALISE ER 300 MG TABLET 3 ST QL 3 / day GRALISE ER 600 MG TABLET 3 ST QL 180/day HYCET 3 AL At least 2 yrs old hydrocodone bitartrate/acetaminophen QL 140 / day (hydrocodone/acetaminophen 2.5-108/5 solution, 1 hydrocodone/acetaminophen 5-217mg/10 solution) AL At least 2 yrs old hydrocodone/acetaminophen 10-325/15 solution 1 AL At least 2 yrs old

PAGE 116 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 100 / day hydrocodone/acetaminophen 2.5-167/5 solution 1 AL At least 2 yrs old QL 180/day hydrocodone/acetaminophen 7.5-325/15 solution 1 AL At least 2 yrs old hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-300mg tablet, QL 13 / day 1 hydrocodone/acetaminophen 7.5-300 mg tablet, AL At least 18 yrs old hydrocodone/acetaminophen 10mg-300mg tablet) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-325mg tablet, QL 12 / day 1 hydrocodone/acetaminophen 7.5-325 mg tablet, AL At least 18 yrs old hydrocodone/acetaminophen 10mg-325mg tablet) QL 20 / day hydrocodone/acetaminophen 2.5-325 mg tablet 1 AL At least 18 yrs old QL 5 / day hydrocodone/ibuprofen 10mg-200mg tablet 1 AL At least 16 yrs old QL 6 / day hydrocodone/ibuprofen 5mg-200mg tablet 1 AL At least 16 yrs old QL 5 / day hydrocodone/ibuprofen 7.5-200 mg tablet 1 AL At least 16 yrs old hydromorphone hcl 1 mg/ml ampul 1 QL 13 / day hydromorphone hcl 4 mg/ml ampul 1 QL 3 / day QL 3 / day hydromorphone hcl 4 mg/ml cartridge 1 AL At least 18 yrs old QL 13 / day hydromorphone hcl 1 mg/ml liquid 1 AL At least 18 yrs old hydromorphone hcl (1 mg/ml cartridge, 1 mg/ml QL 13 / day 1 syringe) AL At least 18 yrs old

PAGE 117 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & hydromorphone hcl (2 mg/ml cartridge, 2 mg/ml QL 6 / day 1 syringe) AL At least 18 yrs old QL 50 / day hydromorphone hcl 0.5mg/.5ml syringe 1 AL At least 18 yrs old hydromorphone hcl (8 mg tab er 24h, 12 mg tab er QL 2 / day 1 24h, 16 mg tab er 24h, 32 mg tab er 24h) PA hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg QL 6 / day 1 tablet) AL At least 18 yrs old hydromorphone hcl (2 mg/ml ampul, 2 mg/ml vial, 1 QL 6 / day 60 mg/30ml pca syring) hydromorphone hcl in 0.9 % sodium chloride (in 15 1 QL 25 / day mg/30ml pca syring, in 15 mg/30ml pca vial) hydromorphone hcl in 0.9 % sodium chloride (in 30 mg/30ml pca syring, in 30 mg/30ml pca vial, in 55 1 QL 13 / day mg/55ml pca syring) hydromorphone hcl in 0.9% nacl 6mg/30ml pca 1 QL 63 / day syring hydromorphone hcl in 0.9 % sodium chloride (in 2 1 QL 6 / day mg/ml plast. bag, in 100mg/50ml pump resvr) hydromorphone hcl in 0.9% nacl 0.5mg/50ml plast. 1 QL 5000 / day bag hydromorphone hcl in 0.9% nacl 1 mg/50 ml plast. 1 QL 50 / day bag hydromorphone hcl in 0.9% nacl 2 mg/50 ml plast. 1 QL 313 / day bag hydromorphone hcl in 0.9 % sodium chloride (in 0.2 mg/ml plast. bag, in 10 mg/50ml pca syring, in 10 1 QL 1 / day mg/50ml pump resvr, in 50 mg/50ml pca syring) hydromorphone hcl in 0.9 % sodium chloride (in 1 6mg/30ml pca vial, in 250 mg/250 pump resvr)

PAGE 118 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 30 mg/30ml pca syring, hcl/0.9% 1 QL 13 / day nacl/pf 30 mg/30ml pca vial, hcl/0.9% nacl/pf 55 mg/55ml pca syring) hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 0.5 mg/ml plast. bag, hcl/0.9% 1 QL 25 / day nacl/pf 15 mg/30ml pca syring) hydromorphone hcl/0.9% nacl/pf 0.2 mg/ml plast. 1 QL 63 / day bag hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 1 mg/ml plast. bag, hcl/0.9% nacl/pf 10 mg/50ml pca syring, hcl/0.9% nacl/pf 10 1 QL 1 / day mg/50ml pump resvr, hcl/0.9% nacl/pf 50 mg/50ml pca syring, hcl/0.9% nacl/pf 50 mg/50ml pump resvr) hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 20mg/100ml pump resvr, hcl/0.9% 1 QL 63 / day nacl/pf 6mg/30ml pca syring, hcl/0.9% nacl/pf 6mg/30ml pca vial) hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 1 mg/5 ml syringe, hcl/0.9% 1 nacl/pf 12mg/30ml pca syring) hydromorphone hcl in d5w/pf 0.5 mg/5ml syringe 1 hydromorphone/bupiv/0.9nacl/pf 5mcg/ml-.1 plast. 1 QL 10 / day bag hydromorphone hcl/bupivacaine hcl in 0.9% sodium chloride/pf (hydromorphone/bupiv/0.9nacl/pf 10mcg-0.1% pump resvr, 1 hydromorphone/bupiv/0.9nacl/pf 20-0.125 pump resvr) hydromorphone/bupiv/0.9nacl/pf 20mcg-0.1% pump 1 QL 3 / day resvr

PAGE 119 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & hydromorphone hcl/pf 2 mg/ml vial 1 QL 6 / day hydromorphone hcl/ropivacaine in 0.9 % sodium 1 QL 6 / day chloride/pf QL 1 / day HYSINGLA ER 2 PA IBU 1 QL 5 / day IBUDONE 10-200 MG TABLET 3 AL At least 16 yrs old QL 6 / day IBUDONE 5-200 MG TABLET 1 AL At least 16 yrs old ibuprofen (50 mg/1.25 drops susp, 100 mg/5ml oral 1 susp) ibuprofen (400 mg tablet, 600 mg tablet, 800 mg 1 tablet) ibuprofen lysine/pf 3 QL 4 / day ibuprofen/oxycodone hcl 1 AL At least 18 yrs old INDOCIN 25 MG/5 ML SUSPENSION 3 QL 6 / day INDOCIN 50 MG SUPPOSITORY 3 QL 4 / day INDOCIN I.V. 3 indomethacin (50 mg capsule, 75 mg capsule er) 1 indomethacin 25 mg capsule 1 indomethacin sodium 1 IONSYS 3 QL 1 / day isometheptene mucate/caffeine/acetaminophen 1 isometheptene 1 mucate/dichloralphenazone/acetaminophen

PAGE 120 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG Excluded Drugs CAPSULE, ER 60 MG CAPSULE, ER 80 MG CAPSULE, ER 100 MG CAPSULE, ER 200 MG CAPSULE) ketoprofen 200 mg cap24h pel 1 ketoprofen (25 mg capsule, 75 mg capsule) 1 ketoprofen 50 mg capsule 1 ketorolac tromethamine 15 mg/ml cartridge 1 QL 40 / 23 days ketorolac tromethamine 30 mg/ml cartridge 1 QL 20 / 30 days ketorolac tromethamine 30 mg/ml syringe 1 QL 20 / 23 days ketorolac tromethamine 60 mg/2 ml syringe 1 QL 20 / 30 days ketorolac tromethamine 10 mg tablet 1 QL 21 / fill ketorolac tromethamine (60 mg/2 ml cartridge, 60 1 QL 20 / 30 days mg/2 ml vial) ketorolac tromethamine 15 mg/ml vial 1 QL 40 / 23 days ketorolac tromethamine 30 mg/ml vial 1 QL 20 / 30 days ketorolac tromethamine 30mg/ml(1) vial 1 QL 20 / 23 days KLOFENSAID II 1 LAZANDA (100 MCG NASAL SPRAY, 300 MCG NASAL Excluded Drugs SPRAY, 400 MCG NASAL SPRAY) LODINE 3 QL 12 / day LORCET 1 AL At least 18 yrs old QL 12 / day LORCET HD 1 AL At least 18 yrs old QL 12 / day LORCET PLUS 1 AL At least 18 yrs old

PAGE 121 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 90 / day LORTAB 3 AL At least 2 yrs old QL 3 / day LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 3 PA QL 2 / day LYRICA CR 330 MG TABLET 3 PA MARTEN-TAB 1 QL 6 / day meclofenamate sodium 1 mefenamic acid 1 QL 5 / day meloxicam 7.5 mg/5ml oral susp 1 QL 10 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 QL 1 / day QL 50 / day meperidine hcl 10 mg/ml cartridge 1 AL At least 18 yrs old QL 50 / day meperidine hcl 50 mg/5 ml solution 1 AL At least 18 yrs old QL 5 / day meperidine hcl 100 mg tablet 1 AL At least 18 yrs old QL 10 / day meperidine hcl 50 mg tablet 1 AL At least 18 yrs old meperidine hcl in 0.9% nacl/pf 300mg/30ml pca 1 syring meperidine hcl in 0.9% nacl/pf 550mg/55ml pca 1 QL 50 / day syring QL 5 / day meperidine hcl/pf 100 mg/ml vial 1 AL At least 18 yrs old QL 20 / day meperidine hcl/pf 25 mg/ml vial 1 AL At least 18 yrs old

PAGE 122 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 10 / day meperidine hcl/pf 50 mg/ml vial 1 AL At least 18 yrs old QL 2 / day methadone hcl 10 mg/ml oral conc 1 PA QL 8 / day methadone hcl 10 mg/5 ml solution 1 PA QL 18 / day methadone hcl 5 mg/5 ml solution 1 PA QL 2 / day methadone hcl 10 mg/ml syringe 1 PA QL 3 / day methadone hcl (5 mg tablet, 10 mg tablet) 1 PA methadone hcl 10 mg/ml vial 1 QL 2 / day QL 2 / day METHADONE INTENSOL 1 PA QL 2 / day METHADOSE 10 MG/ML ORAL CONC 3 PA methyl salicylate (liquid, oil) 1 MOBIC 3 QL 1 / day QL 2 / day MORPHABOND ER 3 PA morphine sulfate (10 mg cap er pel, 20 mg cap er QL 2 / day 1 pel, 50 mg cap er pel, 100 mg cap er pel) PA QL 25 / day morphine sulfate 2 mg/ml cartridge 1 PA

PAGE 123 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & morphine sulfate (30 mg cap er pel, 30 mg cpmp QL 1 / day 24hr, 40 mg cap er pel, 45 mg cpmp 24hr, 75 mg 1 cpmp 24hr) PA morphine sulfate (60 mg cap er pel, 60 mg cpmp QL 1 / day 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 120 mg 1 cpmp 24hr) PA QL 3 / day morphine sulfate 10mg/0.7ml pen injctr 1 PA morphine sulfate 10 mg/5 ml solution 1 QL 25 / day morphine sulfate 100 mg/5ml solution 1 QL 3 / day morphine sulfate 20 mg/5 ml solution 1 QL 13 / day morphine sulfate 10 mg supp.rect 1 QL 5 / day QL 5 / day morphine sulfate 10 mg/ml syringe 1 PA QL 25 / day morphine sulfate 2 mg/ml syringe 1 PA QL 13 / day morphine sulfate 4 mg/ml syringe 1 PA QL 10 / day morphine sulfate 5 mg/ml syringe 1 PA QL 6 / day morphine sulfate 8 mg/ml syringe 1 PA QL 3 / day morphine sulfate 15 mg tablet 1 AL At least 18 yrs old QL 2 / day morphine sulfate 30 mg tablet 1 AL At least 18 yrs old morphine sulfate (15 mg tablet er, 30 mg tablet er, QL 3 / day 1 60 mg tablet er, 100 mg tablet er) PA

PAGE 124 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 3 / day morphine sulfate 200 mg tablet er 1 PA morphine sulfate (10 mg/ml cartridge, 10 mg/ml QL 5 / day 1 vial) PA QL 13 / day morphine sulfate (4 mg/ml cartridge, 4 mg/ml vial) 1 PA QL 6 / day morphine sulfate (8 mg/ml cartridge, 8 mg/ml vial) 1 PA morphine sulfate in 0.9 % nacl 300mg/30ml pca QL 5 / day 1 syring PA morphine sulfate in 0.9 % sodium chloride (in 0.9 % 1 mg/ml plast. bag, in 0.9 % 1 mg/ml(1) syringe, in 0.9 % 10 mg/10ml syringe, in 0.9 % 2 mg/2 ml syringe, in QL 50 / day 1 0.9 % 30 mg/30ml pca syring, in 0.9 % 30 mg/30ml PA pca vial, in 0.9 % 50 mg/50ml pca syring, in 0.9 % 50 mg/50ml pump resvr) morphine sulfate in 0.9 % sodium chloride (in 0.9 % 150mg/30ml pca syring, in 0.9 % 250mg/50ml pump 1 PA resvr, in 0.9 % 275mg/55ml pca syring) morphine sulfate in 0.9 % sodium chloride (in 0.9 % 10 mg/ml plast. bag, in 0.9 % 1000mg/100 pump 1 resvr) morphine sulfate in 0.9 % sodium chloride (in 0.9 % 5 QL 10 / day 1 mg/ml plast. bag, in 0.9 % 500mg/0.1l pump resvr) PA QL 100 / day morphine sulfate in 0.9 % nacl 0.5 mg/ml syringe 1 PA QL 50 / day morphine sulfate/0.9% nacl/pf 1 mg/ml plast. bag 1 PA QL 10 / day morphine sulfate/0.9% nacl/pf 5 mg/ml plast. bag 1 PA

PAGE 125 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & morphine sulfate in 0.9 % sodium chloride/pf (sulfate/0.9% nacl/pf 1 mg/ml syringe, sulfate/0.9% QL 50 / day 1 nacl/pf 2 mg/2 ml syringe, sulfate/0.9% nacl/pf 30 PA mg/30ml pca syring) QL 100 / day morphine sulfate/0.9% nacl/pf 0.5 mg/ml syringe 1 PA QL 100/ day morphine sulfate/0.9% nacl/pf 0.5mg/.5ml syringe 1 PA morphine sulfate/dextrose 5 % in water 1 PA QL 10 / day morphine sulfate/pf 150mg/30ml pca vial 1 PA morphine sulfate/pf (sulfate/pf 0.5 mg/ml vial, QL 100 / day 1 sulfate/pf 1 mg/2 ml syringe) PA morphine sulfate/pf (sulfate/pf 1 mg/ml vial, QL 50 / day 1 sulfate/pf 30 mg/30ml pca vial) PA QL 3 / day MS CONTIN 3 PA nabumetone 1 nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial) 1 QL 5 / day nalbuphine hcl (20 mg/ml ampul, 20 mg/ml vial) 1 QL 3 / day NALFON (400 MG CAPSULE, 600 MG TABLET) 3 PA QL 12 / day NALOCET 3 AL At least 18 yrs old NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3 NAPRELAN CR 750 MG TABLET 3 QL 1 / day NAPROSYN (125 MG/5 ML SUSPEN, 500 MG TABLET) 3

PAGE 126 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & naproxen 125 mg/5ml oral susp 1 naproxen (375 mg tablet, 500 mg tablet) 1 naproxen 250 mg tablet 1 naproxen (375 mg tablet dr, 500 mg tablet dr) 3 naproxen sodium (275 mg tablet, 500 mg tbmp 24hr, 1 550 mg tablet) naproxen sodium 375 mg tbmp 24hr 1 NEOPROFEN 3 NODOLOR 1 QL 12 / day NORCO 3 AL At least 18 yrs old NUCYNTA (50 MG TABLET, 75 MG TABLET, 100 MG Excluded Drugs TABLET) NUCYNTA ER (ER 100 MG TABLET, ER 150 MG Excluded Drugs TABLET, ER 200 MG TABLET, ER 250 MG TABLET) NUCYNTA ER 50 MG TABLET Excluded Drugs QL 17 / day OPANA 1 MG/ML INJ AMPULE 3 AL At least 18 yrs old QL 12 / day OPANA (5 MG TABLET, 10 MG TABLET) 3 AL At least 18 yrs old opium/belladonna alkaloids 30-16.2 mg supp.rect 1 QL 2 / day opium/belladonna alkaloids 60-16.2 mg supp.rect 1 QL 1 / day oxaprozin 600 mg tablet 1 QL 8 / day OXAYDO 3 AL At least 18 yrs old QL 8 / day oxycodone hcl 5 mg capsule 1 AL At least 18 yrs old

PAGE 127 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & oxycodone hcl 20 mg/ml oral conc 1 QL 2 / day oxycodone hcl 5 mg/5 ml solution 1 QL 33 / day oxycodone hcl 10mg/0.5ml syringe 1 QL 4 / day oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, QL 3 / day 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 1 12h, 60 mg tab er 12h, 80 mg tab er 12h) PA oxycodone hcl (5 mg tablet, 10 mg tablet, 15 mg QL 8 / day 1 tablet, 20 mg tablet, 30 mg tablet) AL At least 18 yrs old QL 62 / day oxycodone hcl/acetaminophen 5-325/5 ml solution 1 AL At least 18 yrs old oxycodone hcl/acetaminophen (hcl/acetaminophen QL 12 / day 5 mg-325mg tablet, hcl/acetaminophen 7.5-325 mg 1 tablet, hcl/acetaminophen 10mg-325mg tablet) AL At least 18 yrs old QL 3 / day oxycodone hcl/acetaminophen 10mg-300mg tablet 1 AL At least 18 yrs old QL 12 / day oxycodone hcl/acetaminophen 2.5-325 mg tablet 1 AL At least 18 yrs old QL 7 / day oxycodone hcl/acetaminophen 5 mg-300mg tablet 1 AL At least 18 yrs old QL 4 / day oxycodone hcl/acetaminophen 7.5-300 mg tablet 1 AL At least 18 yrs old QL 7 / day oxycodone hcl/aspirin 1 AL At least 18 yrs old QL 3 / day OXYCONTIN 2 PA oxymorphone hcl (5 mg tab er 12h, 10 mg tab er QL 2 / day 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab 1 PA er 12h, 40 mg tab er 12h) AL At least 18 yrs old

PAGE 128 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day oxymorphone hcl 7.5 mg tab er 12h 1 PA AL At least 18 yrs old QL 12 / day oxymorphone hcl (5 mg tablet, 10 mg tablet) 1 AL At least 18 yrs old QL 10 / day PANLOR 1 AL At least 18 yrs old PENNSAID 2% PUMP Excluded Drugs QL 12 / day pentazocine hcl/naloxone hcl 1 AL At least 12 yrs old QL 12 / day PERCOCET 3 AL At least 18 yrs old PHRENILIN FORTE 1 QL 6 / day piroxicam 1 AL Up to 75 yrs old PONSTEL 3 QL 5 / day PRIALT 3 S QL 3 / day PRIMLEV 10-300 MG TABLET 3 AL At least 18 yrs old QL 7 / day PRIMLEV 5-300 MG TABLET 3 AL At least 18 yrs old QL 4 / day PRIMLEV 7.5-300 MG TABLET 3 AL At least 18 yrs old PRODRIN 3 PROFENO 1 QL 5 / day REPREXAIN 10-200 MG TABLET 1 AL At least 16 yrs old

PAGE 129 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 5 / day REPREXAIN 2.5-200 MG TABLET 3 AL At least 16 yrs old QL 6 / day REPREXAIN 5-200 MG TABLET 3 AL At least 16 yrs old QL 8 / day ROXICODONE 3 AL At least 18 yrs old ROXYBOND (15 MG TABLET, 30 MG TABLET) 3 QL 6 / day ROXYBOND 5 MG TABLET 3 QL 8 / day salsalate 1 SPRIX 15.75 MG NASAL SPRAY Excluded Drugs QL 0.02 / day SUBLOCADE 100 MG/0.5 ML SYRING 3 PA S QL 0.057 / day SUBLOCADE 300 MG/1.5 ML SYRING 3 PA S QL 3 / day SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 PA QL 2 / day SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 PA SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCG SPRAY, 800 MCG SPRAY, 1,200 Excluded Drugs MCG SPRAY, 1,600 MCG SPRAY) sulindac 1 QL 10 / day SYNALGOS-DC 3 AL At least 12 yrs old

PAGE 130 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & TALWIN (30 MG/ML AMPUL, 30 MG/ML VIAL) 3 QL 5 / day TENCON 1 QL 6 / day TIVORBEX 3 tolmetin sodium 400 mg capsule 1 tolmetin sodium (200 mg tablet, 600 mg tablet) 1 QL 1 / day tramadol hcl (100 mg cpbp 25-75, 200 mg cpbp 25- 1 PA 75, 300 mg cpbp 17-83) AL At least 18 yrs old QL 8 / day tramadol hcl 50 mg tablet 1 AL At least 18 yrs old tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, QL 1 / day 150 mg cpbp 25-75, 200 mg tab er 24h, 200 mg 1 PA tbmp 24hr, 300 mg tab er 24h, 300 mg tbmp 24hr) AL At least 18 yrs old QL 8 / day tramadol hcl/acetaminophen 1 AL At least 18 yrs old QL 10 / day TREZIX 3 AL At least 18 yrs old QL 12 / day -CODEINE NO.3 3 AL At least 12 yrs old QL 6 / day TYLENOL-CODEINE NO.4 3 AL At least 12 yrs old QL 8 / day ULTRACET 3 AL At least 18 yrs old QL 8 / day ULTRAM 3 AL At least 18 yrs old VANATOL LQ 3

PAGE 131 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 20 / day VERDROCET 1 AL At least 18 yrs old QL 13 / day VICODIN 1 AL At least 18 yrs old QL 13 / day VICODIN ES 1 AL At least 18 yrs old QL 13 / day VICODIN HP 1 AL At least 18 yrs old VIMOVO (DR 375-20 MG TABLET, DR 500-20 MG Excluded Drugs TABLET) QL 1 / day VIVLODEX 3 PA AL At least 18 yrs old VOLTAREN 3 QL 1000/ 30 days VOLTAREN-XR 3 QL 12 / day XARTEMIS XR 3 AL At least 18 yrs old QL 13 / day XODOL 10-300 3 AL At least 18 yrs old QL 13 / day XODOL 5-300 3 AL At least 18 yrs old QL 13 / day XODOL 7.5-300 3 AL At least 18 yrs old XTAMPZA ER (ER 9 MG CAPSULE, ER 13.5 MG CAPSULE, ER 18 MG CAPSULE, ER 27 MG CAPSULE, Excluded Drugs ER 36 MG CAPSULE) XYLON 10 1

PAGE 132 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 90 / day ZAMICET 3 AL At least 2 yrs old ZEBUTAL 1 QL 6 / day QL 4 / day ZIPSOR 3 PA ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, Excluded Drugs ER 40 MG CAPSULE, ER 50 MG CAPSULE) ZORVOLEX (18 MG CAPSULE, 35 MG CAPSULE) Excluded Drugs QL 3 / day ZUBSOLV 2 PA ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG QL 3 / day TABLET, 12.5 MG TABLET, 15 MG TABLET, 20 MG 3 TABLET) ST QL 2 / day ADDERALL 30 MG TABLET 3 ST QL 2 / day ADDERALL XR 3 ST QL 2 / day ADIPEX-P (37.5 MG CAPSULE, 37.5 MG TABLET) 3 PA AL At least 17 yrs old QL 15 / day ADZENYS ER 3 ST AL At least 6 yrs old QL 1 / day ADZENYS XR-ODT 3 ST AL At least 6 yrs old

PAGE 133 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & amphetamine sulfate 1 QL 6 / day QL 1 / day APTENSIO XR 3 ST QL 1 / day armodafinil 1 PA QL 2 / day BELVIQ 3 PA AL At least 18 yrs old QL 1 / day BELVIQ XR 3 PA AL At least 18 yrs old QL 3 / day benzphetamine hcl 25 mg tablet 1 PA AL At least 12 yrs old QL 3 / day benzphetamine hcl 50 mg tablet 1 PA caffeine citrate 60 mg/3 ml solution 1

CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER QL 2 / day 3 36 MG TABLET) ST QL 1 / day CONCERTA ER 54 MG TABLET 3 ST QL 4 / day CONTRAVE 3 PA AL At least 18 yrs old QL 1 / day COTEMPLA XR-ODT 3 ST

PAGE 134 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day DAYTRANA 3 ST QL 5 / day DESOXYN 3 ST QL 5 / day DEXEDRINE SPANSULE 10 MG 3 ST QL 4 / day DEXEDRINE SPANSULE 15 MG 3 ST QL 2 / day DEXEDRINE SPANSULE 5 MG 3 ST dexmethylphenidate hcl (10 mg tablet, 20 mg cpbp 1 QL 2 / day 50-50) dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 25 mg cpbp 50-50, 1 QL 1 / day 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50) dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet) 1 QL 3 / day dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h, dextroamphetamine/amphetamine 10 mg cap er 24h, dextroamphetamine/amphetamine 15 mg cap er 1 QL 2 / day 24h, dextroamphetamine/amphetamine 20 mg cap er 24h, dextroamphetamine/amphetamine 25 mg cap er 24h, dextroamphetamine/amphetamine 30 mg cap er 24h, dextroamphetamine/amphetamine 30 mg tablet)

PAGE 135 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 1 QL 3 / day mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg tablet) dextroamphetamine sulfate 10 mg capsule er 1 QL 5 / day dextroamphetamine sulfate 15 mg capsule er 1 QL 4 / day dextroamphetamine sulfate 5 mg/5 ml solution 1 QL 60 / day dextroamphetamine sulfate (5 mg capsule er, 5 mg 1 QL 2 / day tablet) dextroamphetamine sulfate 10 mg tablet 1 QL 6 / day QL 3 / day diethylpropion hcl 25 mg tablet 1 PA AL At least 16 yrs old QL 1 / day diethylpropion hcl 75 mg tablet er 1 PA DOPRAM 3 doxapram hcl 1 QL 8 / day DYANAVEL XR 3 ST AL At least 6 yrs old QL 6 / day EVEKEO 3 ST QL 3 / day FOCALIN (2.5 MG TABLET, 5 MG TABLET) 3 ST

PAGE 136 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day FOCALIN 10 MG TABLET 3 ST FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 QL 1 / day MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 3 MG CAPSULE, 40 MG CAPSULE) ST QL 2 / day FOCALIN XR 20 MG CAPSULE 3 ST QL 3 / day LOMAIRA 1 PA AL At least 17 yrs old

METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, QL 1 / day 3 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE) ST QL 2 / day METADATE CD 30 MG CAPSULE 3 ST METADATE ER 1 QL 3 / day methamphetamine hcl 1 QL 5 / day QL 30 / day METHYLIN 10 MG/5 ML SOLUTION 3 ST QL 60 / day METHYLIN 5 MG/5 ML SOLUTION 3 ST methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70, 20 mg cpbp 50-50, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg cpbp 30-70, 1 QL 1 / day 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50- 50, 72 mg tab er 24) methylphenidate hcl 10 mg/5 ml solution 1 QL 30 / day methylphenidate hcl 5 mg/5 ml solution 1 QL 60 / day

PAGE 137 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & methylphenidate hcl 2.5 mg tab chew 1 methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 36 mg tab 1 QL 2 / day er 24) methylphenidate hcl 10 mg tablet 1 QL 5 / day methylphenidate hcl 5 mg tablet 1 QL 3 / day methylphenidate hcl (5 mg tab chew, 10 mg tab 1 QL 3 / day chew, 20 mg tablet, 20 mg tablet er) methylphenidate hcl 10 mg tablet er 1 QL 5 / day QL 1 / day modafinil 1 PA QL 1 / day MYDAYIS 3 ST QL 1 / day NUVIGIL 3 PA QL 1 / day phendimetrazine tartrate 105 mg capsule er 1 PA QL 3 / day phendimetrazine tartrate 35 mg tablet 1 PA QL 1 / day phentermine hcl (15 mg capsule, 30 mg capsule) 1 PA QL 2 / day phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PA AL At least 17 yrs old QL 60 / day PROCENTRA 3 ST QL 1 / day PROVIGIL 3 PA

PAGE 138 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day QSYMIA 3 PA AL At least 18 yrs old QL 1 / day QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG 3 ST CHEW TAB) AL At least 6 yrs old QL 2 / day QUILLICHEW ER 30 MG CHEW TAB 3 ST AL At least 6 yrs old QL 12 / day QUILLIVANT XR 3 ST QL 3 / day REGIMEX 3 PA AL At least 12 yrs old RELEXXII 1 QL 1 / day QL 3 / day RITALIN (5 MG TABLET, 20 MG TABLET) 3 ST QL 5 / day RITALIN 10 MG TABLET 3 ST

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 QL 1 / day 3 MG CAPSULE) ST QL 2 / day RITALIN LA 30 MG CAPSULE 3 ST VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG 2 QL 1 / day CAPSULE, 70 MG CAPSULE) VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 50 MG TABLET, 60 MG 2 QL 1 / day TABLET)

PAGE 139 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day ZENZEDI (15 MG TABLET, 30 MG TABLET) 3 ST QL 3 / day ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3 ST ZENZEDI 10 MG TABLET 1 QL 6 / day ZENZEDI 5 MG TABLET 1 QL 2 / day QL 8 / day ZENZEDI 7.5 MG TABLET 3 ST ANTICONVULSANTS

APTIOM 3 BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 3 400 MG TABLET) QL 20 / day BRIVIACT 10 MG/ML ORAL SOLN 3 PA QL 4 / day BRIVIACT (10 MG TABLET, 50 MG TABLET) 3 PA QL 2 / day BRIVIACT 100 MG TABLET 3 PA QL 8 / day BRIVIACT 25 MG TABLET 3 PA QL 3 / day BRIVIACT 75 MG TABLET 3 PA QL 20 / day BRIVIACT 50 MG/5 ML VIAL 3 PA

PAGE 140 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100 mg/5ml oral susp, 200 1 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) CARBATROL 3 CELONTIN 3 CEREBYX 3 PA clobazam 2.5 mg/ml oral susp 1 S clobazam (10 mg tablet, 20 mg tablet) 1 PA clonazepam (2 mg tab rapdis, 2 mg tablet) 1 QL 10 / day clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab 1 QL 3 / day rapdis, 1 mg tablet) DEPACON 3 DEPAKENE (250 MG CAPSULE, 250 MG/5 ML 3 SOLUTION) DEPAKOTE 3 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 2 MG CAPSULE) DILANTIN-125 2 divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab 1 er 24h, 500 mg tablet dr) QL 1.47 / day EPIDIOLEX 3 PA S

PAGE 141 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & EPITOL 1 EQUETRO 3 ethosuximide (250 mg capsule, 250 mg/5ml 1 solution) felbamate (400 mg tablet, 600 mg tablet, 600 1 mg/5ml oral susp) FELBATOL (400 MG TABLET, 600 MG TABLET, 600 3 PA MG/5 ML SUSP) fosphenytoin sodium 1 FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day FYCOMPA (2 MG TABLET, 2 MG-4 MG TABLET KIT, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG 3 QL 1 / day TABLET, 12 MG TABLET) gabapentin (100 mg capsule, 300 mg capsule, 400 1 QL 9 / day mg capsule) gabapentin (250 mg/5ml solution, 300 mg/6ml 1 QL 72 / day solution) gabapentin 600 mg tablet 1 QL 6 / day gabapentin 800 mg tablet 1 QL 5 / day GABITRIL 3 QL 4 / day HORIZANT ER 300 MG TABLET 3 PA QL 2 / day HORIZANT ER 600 MG TABLET 3 PA KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 3 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) KEPPRA 500 MG/5 ML VIAL 3

PAGE 142 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & KEPPRA XR 3 KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day KLONOPIN 2 MG TABLET 3 QL 10 / day LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG 3 TABLET, 200 MG TABLET) LAMICTAL (BLUE) 3 LAMICTAL (GREEN) 3 LAMICTAL (ORANGE) 3 LAMICTAL ODT 3 LAMICTAL ODT (BLUE) 3 LAMICTAL ODT (GREEN) 3 LAMICTAL ODT (ORANGE) 3 LAMICTAL XR 3 LAMICTAL XR (BLUE) 3 LAMICTAL XR (GREEN) 3 LAMICTAL XR (ORANGE) 3 lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk, 25(84)- 100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er 24, 50 mg tab rapdis, 50(42)-100 1 tb rd dspk, 100 mg tab er 24, 100 mg tab rapdis, 100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mg tab rapdis, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24) levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 750 mg tab er 1 24h, 750 mg tablet, 1000 mg tablet)

PAGE 143 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & levetiracetam 500 mg/5ml solution 1 QL 946 / 30 days levetiracetam 500 mg/5ml vial 1 levetiracetam in sodium chloride, iso-osmotic 1 LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 2 QL 2 / day LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 2 QL 3 / day MG CAPSULE) LYRICA 20 MG/ML ORAL SOLUTION 2 QL 30 / day magnesium sulfate in 0.9 % sodium chloride (in 1 g/100 ml piggyback, in 6 g/50 ml piggyback, in 1 40g/1000ml plast. bag) magnesium sulfate/dextrose 5 % in water (sulfate/d5w 40 g/500ml plast. bag, sulfate/d5w 40g/1000ml plast. bag, sulfate/d5w 5 g/100 ml 1 piggyback, sulfate/d5w 6 g/100 ml piggyback, sulfate/d5w 6 g/50 ml piggyback) MYSOLINE 3 NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 3 QL 9 / day 400 MG CAPSULE) NEURONTIN 250 MG/5 ML SOLN 3 QL 72 / day NEURONTIN 600 MG TABLET 3 QL 6 / day NEURONTIN 800 MG TABLET 3 QL 5 / day PA ONFI 2.5 MG/ML SUSPENSION 3 S ONFI (10 MG TABLET, 20 MG TABLET) 3 PA oxcarbazepine (150 mg tablet, 300 mg tablet, 300 1 mg/5ml oral susp, 600 mg tablet) OXTELLAR XR 3

PAGE 144 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PEGANONE 3 PHENYTEK 2 (50 mg tab chew, 100 mg/4ml oral susp, 1 125 mg/5ml oral susp) phenytoin sodium 1 phenytoin sodium extended 1

POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG QL 3 / day 3 TABLET) PA QL 9 / day POTIGA 50 MG TABLET 3 PA primidone 1 QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 Excluded Drugs MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) ROWEEPRA 1 ROWEEPRA XR 1 QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 3 PA S QL 3 / day SPRITAM 3 AL At least 4 yrs old SUBVENITE 1 SUBVENITE (BLUE) 1 SUBVENITE (GREEN) 1 SUBVENITE (ORANGE) 1 TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3 TEGRETOL XR 3

PAGE 145 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & tiagabine hcl 1 TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG 2 TABLET, 200 MG TABLET) topiramate 15 mg cap sprink 1 topiramate (25 mg cap spr 24, 25 mg cap sprink, 25 mg tablet, 50 mg cap spr 24, 50 mg tablet, 100 mg 1 cap spr 24, 100 mg tablet, 150 mg cap spr 24, 200 mg cap spr 24, 200 mg tablet) TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 3 MG/5 ML SUSP, 600 MG TABLET) TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, Excluded Drugs 100 MG CAPSULE, 200 MG CAPSULE) valproic acid 1 valproic acid (as sodium salt) ( sodium) 1 (250 mg/5ml solution, 500mg/10ml solution) valproic acid (as sodium salt) 500 mg/5ml vial 1 QL 6 / day PA vigabatrin 500 mg powd pack 1 S PS QL 6 / day vigabatrin 500 mg tablet 3 PA S VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 3 STARTER KIT) VIMPAT 200 MG/20 ML VIAL 3 ZARONTIN (250 MG CAPSULE, 250 MG/5 ML 2 SOLUTION)

PAGE 146 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ZONEGRAN 2 zonisamide (25 mg capsule, 100 mg capsule) 1 zonisamide 50 mg capsule 1 ANTIMANIC AGENTS lithium carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg tablet er, 450 mg tablet er, 1 600 mg capsule) lithium citrate 1 LITHOBID 3 ANTIMIGRAINE AGENTS

QL 0.0333 / day AIMOVIG 140 MG/ML AUTOINJECTOR 2 PA AL At least 18 yrs old QL 2 / 30 days AIMOVIG 70 MG/ML AUTOINJECTOR 2 PA AL At least 18 yrs old QL 2/ 30 days AIMOVIG AUTOINJECTOR (2 PACK) 2 PA AL At least 18 yrs old almotriptan malate 1 QL 0.4 / day QL 0.167 / day ALSUMA 3 ST QL 0.6 / day AMERGE 3 ST QL 0.4 / day AXERT 3 ST

PAGE 147 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & eletriptan hydrobromide 1 QL 0.4 / day QL 0.04 / day EMGALITY PEN 2 PA AL At least 18 yrs old QL 0.04 / day EMGALITY SYRINGE 2 PA AL At least 18 yrs old QL 0.6 / day FROVA 3 ST frovatriptan succinate 1 QL 0.6 / day QL 0.167 / day IMITREX 4 MG/0.5 ML CARTRIDGES 3 ST IMITREX (4 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML QL 0.167 / day CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 3 ML VIAL) ST QL 6 / 30 days IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3 ST

IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG QL 0.3 / day 3 TABLET) ST QL 0.6 / day MAXALT 3 ST QL 0.6 / day MAXALT MLT 3 ST naratriptan hcl 1 QL 0.6 / day QL 0.4 / day RELPAX 3 ST rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 1 QL 0.6 / day 10 mg tab rapdis, 10 mg tablet)

PAGE 148 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & sumatriptan 1 QL 6 / 30 days sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5ml cartridge, 6 1 QL 0.167 / day mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial) sumatriptan succinate (25 mg tablet, 50 mg tablet, 1 QL 0.3 / day 100 mg tablet) sumatriptan succinate/naproxen sodium 1 QL 0.3 / day QL 0.3 / day TREXIMET 3 ST zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg 1 QL 0.2 / day tab rapdis, 5 mg tablet) QL 0.2 / day ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 ST QL 0.2 / day ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 ST QL 0.2 / day ZOMIG ZMT 3 ST ANTIPARKINSONIAN AGENTS (CNS) amantadine hcl (50 mg/5 ml solution, 100 mg 1 capsule, 100 mg tablet) QL 2 / day APOKYN 3 PA S AZILECT 3 benztropine mesylate 2 mg/2 ml ampul 1 benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 1 mg tablet)

PAGE 149 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & benztropine mesylate 2 mg/2 ml vial 1 bromocriptine mesylate (2.5 mg tablet, 5 mg 1 capsule) cabergoline 1 carbidopa/levodopa (carbidopa/levodopa 10mg- 100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg-100mg tablet, 1 carbidopa/levodopa 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg-200mg tablet er) carbidopa/levodopa/entacapone 1 COGENTIN 3 COMTAN 3 QL 6 / day CYCLOSET 3 PA QL 1 / day DUOPA 3 PA S ELDEPRYL 3 EMSAM 3 QL 1 / day entacapone 1 QL 2 / day GOCOVRI ER 137 MG CAPSULE 3 PA S QL 1 / day GOCOVRI ER 68.5 MG CAPSULE 3 PA S

PAGE 150 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MIRAPEX 3 MIRAPEX ER 3 NEUPRO 3 QL 1 / day OSMOLEX ER 3 PA S PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3 pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.375 mg tab er 24h, 0.5 mg tablet, 0.75 mg tab er 24h, 0.75 mg tablet, 1 mg tablet, 1.5 mg tab er 24h, 1 1.5 mg tablet, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg tab er 24h, 4.5 mg tab er 24h) rasagiline mesylate 1 REQUIP 3 REQUIP XL 3 ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 1 QL 1 / day mg tab er 24h, 8 mg tab er 24h, 12 mg tab er 24h) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg 1 tablet) RYTARY 3 selegiline hcl (5 mg capsule, 5 mg tablet) 1 SINEMET 10-100 3 SINEMET 25-100 3 SINEMET 25-250 3 SINEMET CR 3 STALEVO 100 3

PAGE 151 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 TASMAR 3 tolcapone 1 trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 1 mg tablet) QL 1 / day XADAGO 3 PA AL At least 18 yrs old ZELAPAR 3 ANXIOLYTICS, SEDATIVES AND HYPNOTICS alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h) 1 QL 1 / day alprazolam 3 mg tab er 24h 1 QL 3 / day alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg 1 QL 4 / day tablet) alprazolam (2 mg tab er 24h, 2 mg tab rapdis, 2 mg 1 QL 5 / day tablet) ALPRAZOLAM INTENSOL 3 QL 10 / day QL 1 / day AMBIEN 3 ST QL 1 / day AMBIEN CR 3 ST

PAGE 152 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day ATIVAN 2 MG TABLET 3 QL 5 / day ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 3 ML VIAL, 40 MG/10 ML VIAL) BELSOMRA 3 ST buspirone hcl 1 BUTISOL SODIUM 3 chlordiazepoxide hcl 10 mg capsule 1 QL 30 / day chlordiazepoxide hcl 25 mg capsule 1 QL 12 / day chlordiazepoxide hcl 5 mg capsule 1 QL 4 / day clorazepate dipotassium 15 mg tablet 1 QL 6 / day clorazepate dipotassium 3.75 mg tablet 1 QL 24 / day clorazepate dipotassium 7.5 mg tablet 1 QL 12 / day dexmedetomidine hcl 200mcg/2ml vial 1 DIASTAT 3 QL 0.07 / day DIASTAT ACUDIAL 3 QL 0.07 / day diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1 QL 0.07 / day diazepam (5 mg/ml cartridge, 5 mg/ml syringe, 5 1 mg/ml vial) diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml 1 solution, 5 mg/ml oral conc, 10 mg tablet) DORAL 3 QL 1 / day droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1 QL 1 / day EDLUAR 3 ST

PAGE 153 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & estazolam 1 QL 1 / day eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old flurazepam hcl 1 QL 1 / day HALCION 3 QL 2 / day QL 1 / day HETLIOZ 3 PA S hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 1 AL At least 2 yrs old 25 mg tablet, 50 mg tablet, 50 mg/25ml solution) hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) 1 AL At least 2 yrs old hydroxyzine pamoate (25 mg capsule, 50 mg 1 AL At least 2 yrs old capsule) hydroxyzine pamoate 100 mg capsule 1 QL 1 / day INTERMEZZO 3 ST lorazepam (2 mg tablet, 2 mg/ml oral conc) 1 QL 5 / day lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day lorazepam (2 mg/ml cartridge, 2 mg/ml syringe, 2 1 mg/ml vial, 4 mg/ml cartridge, 4 mg/ml vial) lorazepam in 0.9 % sodium chloride 1 lorazepam in 5 % dextrose and water 1 LORAZEPAM INTENSOL 1 QL 5 / day QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) 3 ST

PAGE 154 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day LUNESTA 3 MG TABLET 3 ST AL Up to 65 yrs old meprobamate 1 midazolam hcl 2 mg/ml syrup 1 midazolam in 0.9 % sod.chlorid 55 mg/55ml syringe 1 midazolam hcl in 0.9 % sodium chloride/pf (in 0.9 % nacl/pf 2 mg/2 ml syringe, in 0.9 % nacl/pf 5 mg/5 1 ml syringe) midazolam in 5 % dextrose 1 mg/ml plast. bag 1 NEMBUTAL SODIUM 3 oxazepam 1 QL 4 / day phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg 1 tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) phenobarbital sodium 1 PRECEDEX (80 MCG/20 ML INJECT, 200 MCG/2 ML VIAL, 200 MCG/50 ML INJECT, 400 MCG/100 ML 3 INJECT) quazepam 1 QL 1 / day RESTORIL 3 QL 1 / day QL 1 / day ROZEREM 3 ST SECONAL SODIUM 3 QL 1 / day SONATA 3 ST temazepam 1 QL 1 / day

PAGE 155 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & TRANXENE T-TAB 3 QL 12 / day triazolam 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day VALIUM 3 VISTARIL 3 AL At least 2 yrs old XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG 3 QL 4 / day TABLET) XANAX 2 MG TABLET 3 QL 5 / day XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 1 / day XANAX XR 2 MG TABLET 3 QL 5 / day XANAX XR 3 MG TABLET 3 QL 3 / day zaleplon 1 QL 1 / day zolpidem tartrate (5 mg tablet, 6.25 mg tab mphase, 1 QL 1 / day 10 mg tablet, 12.5 mg tab mphase) zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl) 1 QL 1 / day ZOLPIMIST 3 QL 0.257 / day CENTRAL NERVOUS SYSTEM AGENTS, MISC. acamprosate calcium 1 QL 1 / day PA ADDYI 3 GL Female AL 18 to 60 yrs old QL 2 / day atomoxetine hcl 1 AL At least 6 yrs old carbidopa 1

PAGE 156 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & flumazenil 0.1 mg/ml vial 1 guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 1 mg tab er 24h, 4 mg tab er 24h) INTUNIV 3 QL 1 / day LODOSYN 3 memantine hcl (5 mg-10 mg tab ds pk, 7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mg cap 1 AL At least 40 yrs old spr 24) QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old NAMENDA (5 MG TABLET, 5-10 MG TITRATION PK, 3 AL At least 40 yrs old 10 MG TABLET)

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 ST 3 MG CAPSULE, 28 MG CAPSULE, TITRATION PACK) AL At least 40 yrs old NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG ST CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG 3 CAPSULE, TITRATION PACK) AL At least 40 yrs old NUEDEXTA 2 PA RILUTEK 3 riluzole 1 QL 2 / day STRATTERA 3 AL At least 6 yrs old TIGLUTIK 3 PA

PAGE 157 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 18 / day XYREM 3 PA S FIBROMYALGIA AGENTS

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG QL 2 / day 3 TABLET, 100 MG TABLET, TITRATION PACK) ST GENERAL ANESTHETICS methohexital sodium in sterile water for injection/pf 1 OPIATE ANTAGONISTS

DEPADE 1 EVZIO (0.4 MG, 2 MG) Excluded Drugs naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1 1 mg/ml syringe) naltrexone hcl 1 NARCAN 2 MG NASAL SPRAY 2 QL 5 / 30 days NARCAN 4 MG NASAL SPRAY 2 QL 2 / 30 days REVIA 3 PA VIVITROL 3 S PSYCHOTHERAPEUTIC AGENTS

QL 1 / day ABILIFY 3 AL At least 6 yrs old QL 0.04 / day ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, 3 PA ER 400 MG SYR, ER 400 MG VL) AL At least 18 yrs old

PAGE 158 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day ABILIFY MYCITE 3 PA AL At least 18 yrs old ADASUVE 3 AL At least 18 yrs old amitriptyline hcl 1 amitriptyline hcl/chlordiazepoxide 1 amoxapine 1 ANAFRANIL 3 APLENZIN 3 QL 1 / day QL 30 / day aripiprazole 1 mg/ml solution 1 AL At least 6 yrs old aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tab QL 1 / day rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 1 20 mg tablet, 30 mg tablet) AL At least 6 yrs old QL 0.15 / day ARISTADA ER 1064 MG/3.9 ML SYR 3 PA AL At least 18 yrs old QL 0.07 / day ARISTADA ER 441 MG/1.6 ML SYRN 3 PA AL At least 18 yrs old QL 0.08 / day ARISTADA ER 662 MG/2.4 ML SYRN 3 PA AL At least 18 yrs old QL 0.12 / day ARISTADA ER 882 MG/3.2 ML SYRN 3 PA AL At least 18 yrs old QL 0.08 / day ARISTADA INITIO 3 PA AL At least 18 yrs old

PAGE 159 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BRISDELLE 3 QL 1 / day bupropion hcl (300 mg tab er 24h, 450 mg tab er 1 QL 1 / day 24h) bupropion hcl 150 mg tab er 24h 1 QL 3 / day bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl (100 mg tab er 12h, 100 mg tab sr 1 QL 4 / day 12h, 100 mg tablet er) bupropion hcl (150 mg tab er 12h, 150 mg tablet er) 1 QL 2 / day bupropion hcl (150 mg tab sr 12h, 200 mg tab sr 1 QL 2 / day 12h, 200 mg tablet er) CELEXA 3 QL 1 / day hcl 25 mg/ml ampul 1 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 1 mg tablet, 100 mg tablet, 200 mg tablet) citalopram hydrobromide 10 mg/5 ml solution 1 QL 20 / day citalopram hydrobromide (10 mg tablet, 20 mg 1 QL 1 / day tablet, 40 mg tablet) clomipramine hcl 1 clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 50 QL 3 / day 1 mg tablet) AL At least 18 yrs old QL 4 / day clozapine 200 mg tablet 1 AL At least 18 yrs old QL 18 / day clozapine 25 mg tablet 1 AL At least 18 yrs old QL 9 / day clozapine (100 mg tab rapdis, 100 mg tablet) 1 AL At least 18 yrs old

PAGE 160 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & clozapine (150 mg tab rapdis, 200 mg tab rapdis) 1 AL At least 18 yrs old QL 9 / day CLOZARIL 100 MG TABLET 3 AL At least 18 yrs old QL 18 / day CLOZARIL 25 MG TABLET 3 AL At least 18 yrs old CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3 QL 1 / day CYMBALTA 60 MG CAPSULE 3 QL 2 / day desipramine hcl 1 desvenlafaxine (50 mg tab er 24, 50 mg tab er 24h, 1 QL 1 / day 100 mg tab er 24, 100 mg tab er 24h) desvenlafaxine fumarate 1 QL 1 / day desvenlafaxine succinate 1 QL 1 / day doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg 1 capsule, 100 mg capsule) doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 1 mg capsule) duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) 1 QL 1 / day duloxetine hcl (40 mg capsule dr, 60 mg capsule dr) 1 QL 2 / day EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3 QL 1 / day EFFEXOR XR 75 MG CAPSULE 3 QL 3 / day ELAVIL 3 escitalopram oxalate 5 mg/5 ml solution 1 QL 20 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day escitalopram oxalate 20 mg tablet 1 QL 1 / day QL 8 / rx FANAPT TITRATION PACK 3 ST AL At least 18 yrs old

PAGE 161 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS &

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, QL 2 / day 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG 3 ST TABLET) AL At least 18 yrs old

FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, QL 3 / day 3 200 MG ODT) AL At least 18 yrs old QL 9 / day FAZACLO 100 MG ODT 3 AL At least 18 yrs old FETZIMA (20-40 MG TITRATION PAK, ER 20 MG QL 1 / day CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, 3 ER 120 MG CAPSULE) ST fluoxetine hcl 10 mg capsule 1 QL 1 / day fluoxetine hcl 20 mg capsule 1 QL 4 / day fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine hcl 90 mg capsule dr 1 QL 0.15 / day fluoxetine hcl 20 mg/5 ml solution 1 QL 20 / day fluoxetine hcl 10 mg tablet 1 QL 1.5 / day fluoxetine hcl 20 mg tablet 1 QL 4 / day fluoxetine hcl 60 mg tablet 1 QL 1.5 / day fluphenazine decanoate 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg 1 tablet) fluphenazine hcl 2.5 mg/ml vial 1 fluvoxamine maleate (100 mg cap er 24h, 150 mg 1 QL 2 / day cap er 24h) fluvoxamine maleate (25 mg tablet, 50 mg tablet) 1 QL 1 / day

PAGE 162 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fluvoxamine maleate 100 mg tablet 1 QL 3 / day FORFIVO XL 3 QL 1 / day QL 2 / day GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG 3 ST CAPSULE, 80 MG CAPSULE) AL At least 18 yrs old GEODON 20 MG/ML VIAL 3 ST HALDOL 3 HALDOL DECANOATE 100 3 HALDOL DECANOATE 50 3 haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 1 10 mg tablet, 20 mg tablet) haloperidol 1 mg tablet 1 haloperidol decanoate (50 mg/ml ampul, 50 mg/ml 1 vial, 100 mg/ml ampul, 100 mg/ml vial) haloperidol lactate 5 mg/ml ampul 1 haloperidol lactate (2 mg/ml oral conc, 5 mg/ml 1 syringe) haloperidol lactate 5 mg/ml vial 1 imipramine hcl 1 imipramine pamoate 1 QL 8 / day INVEGA ER 1.5 MG TABLET 3 ST AL At least 12 yrs old QL 4 / day INVEGA ER 3 MG TABLET 3 ST AL At least 12 yrs old

PAGE 163 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day INVEGA ER 6 MG TABLET 3 ST AL At least 12 yrs old QL 1 / day INVEGA ER 9 MG TABLET 3 ST AL At least 12 yrs old QL 0.0333 / day INVEGA SUSTENNA 117 MG/0.75 ML 3 PA AL At least 18 yrs old QL 0.04 / day INVEGA SUSTENNA 156 MG/ML SYRG 3 PA AL At least 18 yrs old QL 0.057 / day INVEGA SUSTENNA 234 MG/1.5 ML 3 PA AL At least 18 yrs old QL 0.0111 / day INVEGA SUSTENNA 39 MG/0.25 ML 3 PA AL At least 18 yrs old QL 0.02 / day INVEGA SUSTENNA 78 MG/0.5 ML 3 PA AL At least 18 yrs old QL 0.0333 / day INVEGA TRINZA 273 MG/0.875 ML 3 PA AL At least 18 yrs old QL 0.057 / day INVEGA TRINZA 410 MG/1.315 ML 3 PA AL At least 18 yrs old

PAGE 164 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.067 / day INVEGA TRINZA 546 MG/1.75 ML 3 PA AL At least 18 yrs old QL 0.1 / day INVEGA TRINZA 819 MG/2.625 ML 3 PA AL At least 18 yrs old IRENKA 3 QL 2 / day KHEDEZLA 3 QL 1 / day QL 1 / day LATUDA 3 AL At least 10 yrs old LEXAPRO (5 MG TABLET, 10 MG TABLET) 3 QL 1.5 / day LEXAPRO 20 MG TABLET 3 QL 1 / day loxapine succinate 1 AL At least 18 yrs old maprotiline hcl 1 MARPLAN 3 QL 6 / day mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg 1 QL 1 / day tablet) mirtazapine 7.5 mg tablet 1 QL 2 / day molindone hcl 1 NARDIL 3 QL 6 / day hcl 100 mg tablet 1 QL 6 / day nefazodone hcl 150 mg tablet 1 QL 4 / day nefazodone hcl 200 mg tablet 1 QL 3 / day nefazodone hcl 250 mg tablet 1 QL 2.5 / day

PAGE 165 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & nefazodone hcl 50 mg tablet 1 QL 12 / day NORPRAMIN 3 nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg/10ml solution, 25 mg capsule, 50 mg 1 capsule, 75 mg capsule) QL 1 / day NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 3 PA S QL 2 / day NUPLAZID 17 MG TABLET 3 PA S olanzapine (15 mg tab rapdis, 15 mg tablet) 1 QL 2 / day olanzapine 7.5 mg tablet 1 QL 4 / day olanzapine (10 mg tab rapdis, 10 mg tablet) 1 QL 3 / day olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg 1 QL 6 / day tablet) olanzapine (20 mg tab rapdis, 20 mg tablet) 1 QL 1 / day olanzapine 10 mg vial 1 QL 1 / day olanzapine/fluoxetine hcl 1 AL At least 10 yrs old ORAP 3 QL 8 / day paliperidone 1.5 mg tab er 24 1 AL At least 12 yrs old QL 4 / day paliperidone 3 mg tab er 24 1 AL At least 12 yrs old QL 2 / day paliperidone 6 mg tab er 24 1 AL At least 12 yrs old

PAGE 166 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day paliperidone 9 mg tab er 24 1 AL At least 12 yrs old PAMELOR 3 PARNATE 3 QL 6 / day paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 1 QL 2 / day mg tab er 24h) paroxetine hcl (12.5 mg tab er 24h, 40 mg tablet) 1 QL 1 / day paroxetine hcl 10 mg tablet 1 QL 1.5 / day paroxetine hcl 20 mg tablet 1 QL 1 / day paroxetine mesylate 1 QL 1 / day QL 42 / day PAXIL 10 MG/5 ML SUSPENSION 3 PA PAXIL (20 MG TABLET, 40 MG TABLET) 3 QL 1 / day PAXIL 10 MG TABLET 3 QL 1.5 / day PAXIL 30 MG TABLET 3 QL 2 / day PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3 QL 2 / day PAXIL CR 12.5 MG TABLET 3 QL 1 / day perphenazine 1 AL At least 18 yrs old perphenazine/amitriptyline hcl 1 QL 0.0333 / day PERSERIS 3 PA AL At least 18 yrs old QL 1 / day PEXEVA 3 PA phenelzine sulfate 1 QL 6 / day

PAGE 167 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & pimozide 1 PRISTIQ 3 QL 1 / day protriptyline hcl 1 PROZAC 10 MG PULVULE 3 PROZAC 20 MG PULVULE 3 QL 4 / day PROZAC 40 MG PULVULE 3 QL 2 / day PROZAC WEEKLY 3 QL 0.15 / day QL 5 / day quetiapine fumarate 150 mg tab er 24h 1 AL At least 10 yrs old QL 4 / day quetiapine fumarate 200 mg tab er 24h 1 AL At least 10 yrs old quetiapine fumarate (25 mg tablet, 50 mg tab er QL 6 / day 1 24h, 50 mg tablet) AL At least 10 yrs old quetiapine fumarate (300 mg tab er 24h, 400 mg tab QL 2 / day 1 er 24h, 400 mg tablet) AL At least 10 yrs old QL 3 / day quetiapine fumarate 100 mg tablet 1 AL At least 10 yrs old QL 1.5 / day quetiapine fumarate 200 mg tablet 1 AL At least 10 yrs old QL 1 / day quetiapine fumarate 300 mg tablet 1 AL At least 10 yrs old REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG SOLTAB, 30 MG TABLET, 45 MG SOLTAB, 45 MG 3 QL 1 / day TABLET) QL 1 / day REXULTI 3 PA AL At least 18 yrs old

PAGE 168 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 16/day RISPERDAL 1 MG/ML SOLUTION 3 AL At least 5 yrs old

RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG QL 8 / day 3 TABLET, 2 MG TABLET) AL At least 5 yrs old QL 5 / day RISPERDAL 3 MG TABLET 3 AL At least 5 yrs old QL 4 / day RISPERDAL 4 MG TABLET 3 AL At least 5 yrs old QL 0.1 / day RISPERDAL CONSTA 3 PA AL At least 18 yrs old

RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG QL 8 / day 3 ODT) AL At least 5 yrs old QL 5 / day RISPERDAL M-TAB 3 MG ODT 3 AL At least 5 yrs old QL 4 / day RISPERDAL M-TAB 4 MG ODT 3 AL At least 5 yrs old QL 16/day risperidone 1 mg/ml solution 1 AL At least 5 yrs old QL 4 / day risperidone (4 mg tab rapdis, 4 mg tablet) 1 AL At least 5 yrs old risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 QL 8 / day mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg 1 tablet, 2 mg tab rapdis, 2 mg tablet) AL At least 5 yrs old QL 5 / day risperidone (3 mg tab rapdis, 3 mg tablet) 1 AL At least 5 yrs old QL 2 / day SAPHRIS 3 AL At least 10 yrs old

PAGE 169 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SARAFEM 10 MG TABLET 3 QL 1.5 / day SARAFEM 20 MG TABLET 3 QL 4 / day QL 6 / day SEROQUEL (25 MG TABLET, 50 MG TABLET) 3 AL At least 10 yrs old QL 3 / day SEROQUEL 100 MG TABLET 3 AL At least 10 yrs old QL 1.5 / day SEROQUEL 200 MG TABLET 3 AL At least 10 yrs old QL 1 / day SEROQUEL 300 MG TABLET 3 AL At least 10 yrs old QL 2 / day SEROQUEL 400 MG TABLET 3 AL At least 10 yrs old SEROQUEL XR SAMPLE KIT 3 AL At least 10 yrs old QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 3 AL At least 10 yrs old QL 5 / day SEROQUEL XR 150 MG TABLET 3 AL At least 10 yrs old QL 4 / day SEROQUEL XR 200 MG TABLET 3 AL At least 10 yrs old QL 6 / day SEROQUEL XR 50 MG TABLET 3 AL At least 10 yrs old sertraline hcl 20 mg/ml oral conc 1 QL 10 / day sertraline hcl (25 mg tablet, 50 mg tablet) 1 QL 1.5 / day sertraline hcl 100 mg tablet 1 QL 2 / day SILENOR 3 QL 1 / day

PAGE 170 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SURMONTIL 3 QL 1 / day SYMBYAX 3 AL At least 10 yrs old thioridazine hcl 1 thiothixene 1 TOFRANIL 3 tranylcypromine sulfate 1 QL 6 / day trazodone hcl 100 mg tablet 1 QL 4 / day trazodone hcl 150 mg tablet 1 QL 2 / day trazodone hcl 300 mg tablet 1 QL 1 / day trazodone hcl 50 mg tablet 1 QL 3 / day trifluoperazine hcl 1 trimipramine maleate 1 QL 1 / day TRINTELLIX 3 ST venlafaxine hcl (37.5 mg cap er 24h, 150 mg cap er 1 QL 1 / day 24h) venlafaxine hcl 75 mg cap er 24h 1 QL 3 / day venlafaxine hcl (37.5 mg tab er 24, 75 mg tab er 24, 1 QL 1 / day 150 mg tab er 24, 225 mg tab er 24) venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg 1 tablet, 100 mg tablet) venlafaxine hcl 25 mg tablet 1 QL 20 / day VERSACLOZ 3 AL At least 18 yrs old VIIBRYD 10-20 MG STARTER PACK 3

PAGE 171 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG 3 QL 1 / day TABLET) QL 1 / day VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 3 ST MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) AL At least 18 yrs old WELLBUTRIN SR (SR 150 MG TABLET, SR 200 MG 3 QL 2 / day TABLET) WELLBUTRIN SR 100 MG TABLET 3 QL 4 / day WELLBUTRIN XL 150 MG TABLET 3 QL 3 / day WELLBUTRIN XL 300 MG TABLET 3 QL 1 / day QL 2 / day ziprasidone hcl 1 AL At least 18 yrs old ZOLOFT 20 MG/ML ORAL CONC 3 QL 10 / day ZOLOFT (25 MG TABLET, 50 MG TABLET) 3 QL 1.5 / day ZOLOFT 100 MG TABLET 3 QL 2 / day ZYBAN 3 QL 2 / day QL 6 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 AL At least 13 yrs old QL 3 / day ZYPREXA 10 MG TABLET 3 AL At least 13 yrs old QL 2 / day ZYPREXA 15 MG TABLET 3 AL At least 13 yrs old QL 1 / day ZYPREXA 20 MG TABLET 3 AL At least 13 yrs old QL 4 / day ZYPREXA 7.5 MG TABLET 3 AL At least 13 yrs old

PAGE 172 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ZYPREXA 10 MG VIAL 3 AL At least 13 yrs old QL 0.08 / day ZYPREXA RELPREVV 3 PA AL At least 18 yrs old QL 3 / day ZYPREXA ZYDIS 10 MG TABLET 3 AL At least 13 yrs old QL 2 / day ZYPREXA ZYDIS 15 MG TABLET 3 AL At least 13 yrs old QL 1 / day ZYPREXA ZYDIS 20 MG TABLET 3 AL At least 13 yrs old QL 6 / day ZYPREXA ZYDIS 5 MG TABLET 3 AL At least 13 yrs old VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

QL 4 / day PA AUSTEDO 3 AL At least 18 yrs old S QL 2 / day PA INGREZZA 40 MG CAPSULE 3 AL At least 18 yrs old S QL 1 / day PA INGREZZA 80 MG CAPSULE 3 AL At least 18 yrs old S PA tetrabenazine 1 S

PAGE 173 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA XENAZINE 3 S DEVICES 2tek glucose-wrist monitor kit Excluded Drugs 2tek glucose-wrist monitor kit Excluded Drugs accu-chek aviva connect meter Excluded Drugs accu-chek aviva connect meter Excluded Drugs accu-chek aviva plus meter Excluded Drugs accu-chek aviva plus meter Excluded Drugs accu-chek combo system Excluded Drugs accu-chek compact plus kit Excluded Drugs accu-chek compact plus kit Excluded Drugs accu-chek guide me glucose mtr Excluded Drugs accu-chek guide me glucose mtr Excluded Drugs accu-chek guide monitor system Excluded Drugs accu-chek guide monitor system Excluded Drugs accu-chek nano smartview meter Excluded Drugs accu-chek nano smartview meter Excluded Drugs accu-chek voicemate system Excluded Drugs accu-chek voicemate system Excluded Drugs advocate blood glucose monitor Excluded Drugs advocate blood glucose monitor Excluded Drugs advocate duo glu-wrist monitor Excluded Drugs advocate duo glu-wrist monitor Excluded Drugs

PAGE 174 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & advocate duo meter Excluded Drugs advocate duo meter Excluded Drugs advocate redi-code duo meter Excluded Drugs advocate redi-code glu meter Excluded Drugs advocate redi-code glu meter Excluded Drugs advocate redi-code glu monitor Excluded Drugs advocate redi-code glu monitor Excluded Drugs advocate redi-code plus meter Excluded Drugs advocate redi-code plus meter Excluded Drugs agamatrix amp gluc monitor sys Excluded Drugs agamatrix amp gluc monitor sys Excluded Drugs assure platinum glucose meter Excluded Drugs assure platinum glucose meter Excluded Drugs assure prism multi meter Excluded Drugs assure prism multi meter Excluded Drugs AVENOVA 3 blade lancet, safety (0.8 each, 1.5 each) 2 blade lancet, safety 1.2 mm each 2 blood administration set (blood set blood set, blood 3 set each) blood collection set blood set 1 blood collection set (blood set 23gx3/4" each, blood 3 set 25gx3/4" blood set) blood glucose calibration control solution, high 2 blood glucose calibration control solution, normal 2

PAGE 175 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & blood glucose monitoring syst Excluded Drugs blood glucose monitoring syst Excluded Drugs blood ketone test, strips 3 blood-glucose meter each 2 blood-glucose meter kit 2 QL 10 / day blunt needle, disposable (22gx1 1/2" dis needle, 3 23gx1" dis needle) careone glucose monitoring sys Excluded Drugs careone glucose monitoring sys Excluded Drugs caresens n blood glucose syst Excluded Drugs caresens n blood glucose syst Excluded Drugs caresens n voice glucose meter Excluded Drugs caresens n voice glucose meter Excluded Drugs caresens n voice glucose sys Excluded Drugs caresens n voice glucose sys Excluded Drugs caretouch glucose monitor sys Excluded Drugs caretouch glucose monitor sys Excluded Drugs chemstrip bg diary Excluded Drugs choicedm clarus monitor system Excluded Drugs choicedm clarus monitor system Excluded Drugs clever chek blood glucose syst Excluded Drugs clever chek blood glucose syst Excluded Drugs clever choice blood glucos sys Excluded Drugs clever choice blood glucos sys Excluded Drugs clever choice glucose monitor Excluded Drugs

PAGE 176 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & clever choice glucose monitor Excluded Drugs clever choice hd glucose syst Excluded Drugs clever choice hd glucose syst Excluded Drugs clever choice micro monitor Excluded Drugs clever choice micro monitor Excluded Drugs clever choice pro glucose mtr Excluded Drugs clever choice pro glucose mtr Excluded Drugs clever choice talk glucose sys Excluded Drugs clever choice talk glucose sys Excluded Drugs contour link meter Excluded Drugs contour link meter Excluded Drugs contour meter Excluded Drugs contour meter Excluded Drugs contour meter system Excluded Drugs contour meter system Excluded Drugs contour next ez meter Excluded Drugs contour next ez meter Excluded Drugs contour next ez meter system Excluded Drugs contour next ez meter system Excluded Drugs contour next link 2.4 meter kt Excluded Drugs contour next link 2.4 meter kt Excluded Drugs contour next link meter Excluded Drugs contour next link meter Excluded Drugs contour next meter Excluded Drugs contour next meter Excluded Drugs

PAGE 177 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & contour next one meter Excluded Drugs contour next one meter Excluded Drugs control ast monitoring system Excluded Drugs cool blood glucose meter Excluded Drugs cool blood glucose meter Excluded Drugs cool blood glucose meter kit Excluded Drugs cool blood glucose meter kit Excluded Drugs cvs advanced glucose meter Excluded Drugs cvs advanced glucose meter Excluded Drugs dario blood glucose monitor Excluded Drugs dexcom g4 (ped) receiver kit Excluded Drugs dexcom g4 receiver kit Excluded Drugs dexcom g4 receiver-share (ped) Excluded Drugs dexcom g4 receiver-share kit Excluded Drugs dexcom g5 receiver kit Excluded Drugs dexcom g6 receiver Excluded Drugs dexcom receiver kit Excluded Drugs diaper/brief,infant-toddler, disposable 3 diatrue plus blood glucose sys Excluded Drugs diatrue plus blood glucose sys Excluded Drugs PA DUROLANE 3 S easy check blood glucose sys Excluded Drugs easy check blood glucose sys Excluded Drugs easy check glucose meter Excluded Drugs

PAGE 178 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & easy check glucose meter Excluded Drugs easy plus ii blood glucose sys Excluded Drugs easy plus ii blood glucose sys Excluded Drugs easy step blood glucose meter Excluded Drugs easy step blood glucose meter Excluded Drugs easy step glucose system kit Excluded Drugs easy step glucose system kit Excluded Drugs easy talk blood glucose meter Excluded Drugs easy talk blood glucose meter Excluded Drugs easy touch glucose monitor sys Excluded Drugs easy touch glucose monitor sys Excluded Drugs easy trak blood glucose meter Excluded Drugs easy trak blood glucose meter Excluded Drugs easy-touch blood glucose meter Excluded Drugs easy-touch blood glucose meter Excluded Drugs easygluco meter Excluded Drugs easygluco meter Excluded Drugs easygluco meter starter kit Excluded Drugs easygluco meter starter kit Excluded Drugs easygluco plus meter kit Excluded Drugs easygluco plus meter kit Excluded Drugs easygluco plus starter kit Excluded Drugs easygluco plus starter kit Excluded Drugs easymax l blood glucose system Excluded Drugs easymax l blood glucose system Excluded Drugs

PAGE 179 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & easymax ng blood glucose sys Excluded Drugs easymax ng blood glucose sys Excluded Drugs easymax ng glucose system kit Excluded Drugs easymax ng glucose system kit Excluded Drugs easymax v speaking glucose sys Excluded Drugs easymax v speaking glucose sys Excluded Drugs easymax v2 blood glucose sys Excluded Drugs easymax v2 blood glucose sys Excluded Drugs element compact glucose meter Excluded Drugs element compact glucose meter Excluded Drugs element compact v glucose mtr Excluded Drugs element compact v glucose mtr Excluded Drugs element plus blood glucose kit Excluded Drugs element plus blood glucose kit Excluded Drugs embrace blood glucose kit Excluded Drugs embrace blood glucose kit Excluded Drugs embrace blood glucose system Excluded Drugs embrace blood glucose system Excluded Drugs embrace evo blood glucose kit Excluded Drugs embrace evo blood glucose kit Excluded Drugs embrace pro blood glucose mtr Excluded Drugs embrace pro blood glucose mtr Excluded Drugs embrace talk blood glucose mtr Excluded Drugs embrace talk blood glucose mtr Excluded Drugs embrace talk blood glucose sys Excluded Drugs

PAGE 180 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & embrace talk blood glucose sys Excluded Drugs EPISIL 3 PA EUFLEXXA 3 S PS evencare g2 blood glucose sys Excluded Drugs evencare g2 blood glucose sys Excluded Drugs evencare g3 blood glucose sys Excluded Drugs evencare g3 blood glucose sys Excluded Drugs evencare mini monitor system Excluded Drugs evencare mini monitor system Excluded Drugs evencare monitoring system Excluded Drugs evencare monitoring system Excluded Drugs evolution blood glucose meter Excluded Drugs evolution blood glucose meter Excluded Drugs ez smart plus system kit Excluded Drugs ez smart plus system kit Excluded Drugs ez smart system kit Excluded Drugs ez smart system kit Excluded Drugs feeder container with gravity set, enfit 3 fifty50 2.0 glucose meter Excluded Drugs fifty50 2.0 glucose meter Excluded Drugs PA flash glucose scanning reader 2 AL At least 18 yrs old PA flash glucose sensor 2 AL At least 18 yrs old

PAGE 181 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fora d10 blood glucose system Excluded Drugs fora d20 blood glucose system Excluded Drugs fora d20 blood glucose system Excluded Drugs fora g20 blood glucose system Excluded Drugs fora g20 blood glucose system Excluded Drugs fora g30a blood glucose system Excluded Drugs fora g30a blood glucose system Excluded Drugs fora gd50 blood glucose system Excluded Drugs fora gd50 blood glucose system Excluded Drugs fora premium v10 glucose meter Excluded Drugs fora premium v10 glucose meter Excluded Drugs fora test n'go voice system Excluded Drugs fora test n'go voice system Excluded Drugs fora tn'g voice glucose meter Excluded Drugs fora tn'g voice glucose meter Excluded Drugs fora v10 blood glucose system Excluded Drugs fora v10 blood glucose system Excluded Drugs fora v12 blood glucose system Excluded Drugs fora v12 blood glucose system Excluded Drugs fora v20 blood glucose system Excluded Drugs fora v20 blood glucose system Excluded Drugs fora v30a blood glucose system Excluded Drugs fora v30a blood glucose system Excluded Drugs foracare gd20 glucose system Excluded Drugs foracare gd20 glucose system Excluded Drugs

PAGE 182 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & foracare gd40a glucose system Excluded Drugs foracare gd40a glucose system Excluded Drugs foracare gd40b glucose system Excluded Drugs foracare gd40b glucose system Excluded Drugs fortiscare blood glucose syst Excluded Drugs fortiscare blood glucose syst Excluded Drugs freestyle flash system kit Excluded Drugs freestyle flash system kit Excluded Drugs freestyle freedom kit Excluded Drugs freestyle freedom kit Excluded Drugs freestyle freedom lite meter Excluded Drugs freestyle freedom lite meter Excluded Drugs freestyle freedom lite nfrs Excluded Drugs freestyle freedom lite nfrs Excluded Drugs freestyle insulinx glucose sys Excluded Drugs freestyle insulinx glucose sys Excluded Drugs freestyle lite meter Excluded Drugs freestyle lite meter Excluded Drugs freestyle lite meter nfrs Excluded Drugs freestyle lite meter nfrs Excluded Drugs freestyle navigator sensor kit Excluded Drugs freestyle navigator sensor kit Excluded Drugs freestyle precision neo meter Excluded Drugs freestyle precision neo meter Excluded Drugs freestyle sidekick ii valpk Excluded Drugs

PAGE 183 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & freestyle sidekick ii valpk Excluded Drugs freestyle system kit Excluded Drugs freestyle system kit Excluded Drugs gdrive blood glucose system Excluded Drugs gdrive blood glucose system Excluded Drugs ge100 blood glucose system Excluded Drugs ge100 blood glucose system Excluded Drugs PA GEL-ONE 3 S PA GENVISC 850 3 S gloves, latex (each, package) 1 gluco navii glucose monitor kt Excluded Drugs gluco navii glucose monitor kt Excluded Drugs glucocard 01 meter kit Excluded Drugs glucocard 01 meter kit Excluded Drugs glucocard expression meter Excluded Drugs glucocard expression meter Excluded Drugs glucocard expression meter kit Excluded Drugs glucocard expression meter kit Excluded Drugs glucocard shine connex meter Excluded Drugs glucocard shine connex meter Excluded Drugs glucocard shine express meter Excluded Drugs glucocard shine express meter Excluded Drugs glucocard shine meter Excluded Drugs

PAGE 184 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & glucocard shine meter Excluded Drugs glucocard shine meter kit Excluded Drugs glucocard shine meter kit Excluded Drugs glucocard shine xl meter Excluded Drugs glucocard shine xl meter Excluded Drugs glucocard vital meter kit Excluded Drugs glucocard vital meter kit Excluded Drugs glucocom blood glucose kit Excluded Drugs glucocom blood glucose kit Excluded Drugs glucocom blood glucose meter Excluded Drugs glucocom blood glucose meter Excluded Drugs glucocom value kit Excluded Drugs glucocom value kit Excluded Drugs glucose sensor,implantable,continuous/ 3 acetate gmate smart meter kit Excluded Drugs gmate smart meter kit Excluded Drugs gmate smart starter kit Excluded Drugs gmate smart starter kit Excluded Drugs gmate voice meter monitor syst Excluded Drugs gmate voice meter monitor syst Excluded Drugs gmate voice starter kit Excluded Drugs gmate voice starter kit Excluded Drugs gnp easy touch glucose monitor Excluded Drugs

PAGE 185 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & gnp easy touch glucose monitor Excluded Drugs goodlife ac-302 glucose meter Excluded Drugs goodlife ac-302 glucose meter Excluded Drugs gs blood glucose monitor sys Excluded Drugs gs blood glucose monitor sys Excluded Drugs guardian real-time glu monitor Excluded Drugs healthpro glucose monitor syst Excluded Drugs healthpro glucose monitor syst Excluded Drugs HPR PLUS (CREAM, EMOLLIENT FOAM) 3 humana true metrix air glu mtr Excluded Drugs humana true metrix air glu mtr Excluded Drugs humana true metrix air meter Excluded Drugs humana true metrix air meter Excluded Drugs humana trueresult glucose mtr Excluded Drugs humana trueresult glucose mtr Excluded Drugs PA HYALGAN (20 MG/2 ML SYRINGE, 20 MG/2 ML VIAL) 3 S HYCLODEX 3 HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, 3 LOTION) PA HYMOVIS 3 S iglucose blood glucose monitor Excluded Drugs iglucose blood glucose monitor Excluded Drugs infinity meter kit Excluded Drugs

PAGE 186 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & infinity meter kit Excluded Drugs infinity starter kit Excluded Drugs infinity starter kit Excluded Drugs infinity voice glucose monitor Excluded Drugs infinity voice glucose monitor Excluded Drugs irrigation piercing pin set,nv 3 irrigation set irrig set 3 jazz wireless 2 meter kit Excluded Drugs jazz wireless 2 meter kit Excluded Drugs kro premium blood glucose syst Excluded Drugs kro premium blood glucose syst Excluded Drugs lancets (17 gauge each, 18 gauge each, 21 gauge each, 23 gauge each, 25 gauge each, 26 gauge each, 2 28 gauge each, 30 gauge each, 31 gauge each, 32 gauge each, 33 gauge each, each) lancing device each 2 lancing device, vacuum/lancets 2 lancing device/lancets 2 liberty blood glucose monitor Excluded Drugs liberty blood glucose monitor Excluded Drugs LIDOTREX (2% GEL, 2%-1.2%-1% GEL) 3 microdot blood glucose system Excluded Drugs microdot blood glucose system Excluded Drugs minimed 630g guardian start kt Excluded Drugs PA MONOVISC 3 S

PAGE 187 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MUCOTROL 3 myglucohealth monitoring kit Excluded Drugs myglucohealth monitoring kit Excluded Drugs needles, blood collection (blood 20gx1" dis needle, 1 blood 21 g x 1" dis needle, blood 22gx1" dis needle) needles, blood collection 20gx1 1/2" dis needle 3 needles, disposable (14gx1" dis needle, 14gx1.5" dis needle, 14gx2" dis needle, 15gx1.5" dis needle, 16 g x 1" dis needle, 16gx0.625" dis needle, 16gx1.5" dis needle, 16gx3/4" dis needle, 18gx1 1/2" dis needle, 18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 21 g x 1" dis needle, 21gx1 1/2" dis needle, 21gx2" dis 3 needle, 22gx1 1/2" dis needle, 22gx1" dis needle, 23gx1" dis needle, 23gx1/2" dis needle, 23gx3/4" dis needle, 25gx1 1/2" dis needle, 25gx1" dis needle, 25gx1.25" dis needle, 25gx2" dis needle, 25gx5/8" dis needle, 26gx1.5" dis needle, 26gx1/2" dis needle, 27gx1.25" dis needle, 27gx1.5" dis needle, 27gx1/2" dis needle, 30gx1/2" dis needle, 30gx3/4" dis needle) needles, filter (18gx3" dis needle, 19gx1 1/2" dis 3 needle, 19gx1" dis needle, 20gx1 1/2" dis needle) needles, filter 18gx1 1/2" dis needle 1 needles, insulin disposable (31gx1/4" dis needle, 2 31gx5/16" dis needle) needles, insulin disposable 29gx1/2" dis needle 2 needles, insulin disposable, safety 2 needles, reusable 3

PAGE 188 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & needles, safety (18gx1 1/2" dis needle, 18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 21 g x 1" dis needle, 21gx1 1/2" dis needle, 22gx1 1/2" dis needle, 22gx1" dis needle, 23gx1 1/2" dis needle, 3 23gx1" dis needle, 25gx1 1/2" dis needle, 25gx1" dis needle, 25gx5/8" dis needle, 26gx1/2" dis needle, 27gx1/2" dis needle, 27gx5/8" dis needle, 30gx1 1/2" dis needle, 30gx1/2" dis needle) needles, spinal-anesthetic (15gx1.5" dis needle, 16gx1.5" dis needle, 17gx1.5" dis needle, 18gx1" dis 3 needle, 19gx1 1/2" dis needle, 20gx1 1/2" dis needle, 21 g x 1" dis needle) nova max blood glucose meter Excluded Drugs nova max blood glucose meter Excluded Drugs novamax plus glu-ket ctrl soln Excluded Drugs NUMOISYN LOZENGE 3 NUVAIL 3 on call express ctrl soln pak Excluded Drugs on call express meter Excluded Drugs on call express meter Excluded Drugs on call express meter system Excluded Drugs on call express meter system Excluded Drugs on call plus meter Excluded Drugs on call plus meter Excluded Drugs on call vivid meter Excluded Drugs on call vivid meter Excluded Drugs on call vivid pal meter Excluded Drugs

PAGE 189 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & on call vivid pal meter Excluded Drugs onetouch ultra2 glucose syst 2 onetouch ultramini meter 2 onetouch verio flex startr kit 2 QL 10 / day onetouch verio flex system kit 2 onetouch verio iq meter 2 onetouch verio iq system kit 2 onetouch verio meter system 2 onetouch verio sync syst kit 2 optumrx blood glucose meter Excluded Drugs optumrx blood glucose meter Excluded Drugs optumrx blood glucose system Excluded Drugs optumrx blood glucose system Excluded Drugs ORAFATE 1 S PA ORTHOVISC 3 S PAIN EASE 3

PAGE 190 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & pen needle, diabetic (pen 29 g x1/2" dis needle, pen 29 gauge dis needle, pen 29g x 3/8" dis needle, pen 30 gx 1/3" dis needle, pen 30 gx5/16" dis needle, pen 31 g x1/3" dis needle, pen 31 g x1/4" dis needle, pen 31 g x1/6" dis needle, pen 31 gx3/16" dis needle, pen 31 gx5/16" dis needle, pen 32 gx 1/4" dis needle, pen 2 32 gx 1/5" dis needle, pen 32 gx 1/6" dis needle, pen 32 gx3/16" dis needle, pen 32 gx5/16" dis needle, pen 32gx 5/32" dis needle, pen 33 g x1/4" dis needle, pen 33 gx3/16" dis needle, pen 33 gx5/16" dis needle, pen 33 gx5/32" dis needle) pen needle, diabetic disposable, safety 2 pen needle, diabetic, safety (pen 29 g x1/2" dis needle, pen 29gx 5/16" dis needle, pen 29gx3/16" dis needle, pen 30 gx 1/3" dis needle, pen 30 gx3/16" 2 dis needle, pen 30 gx5/16" dis needle, pen 31 g x1/4" dis needle, pen 31 gx3/16" dis needle, pen 31 gx5/16" dis needle) pharmacist choice glucose sys Excluded Drugs pharmacist choice glucose sys Excluded Drugs pharmacist choice mini glu sys Excluded Drugs pharmacist choice mini glu sys Excluded Drugs precision link direct monit Excluded Drugs precision link direct monit Excluded Drugs precision xtra monitor Excluded Drugs precision xtra monitor Excluded Drugs precision xtra monitor nfrs Excluded Drugs precision xtra monitor nfrs Excluded Drugs precision xtra monitor system Excluded Drugs precision xtra monitor system Excluded Drugs

PAGE 191 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & premium blood glucose monitor Excluded Drugs premium blood glucose monitor Excluded Drugs premium blood glucose system Excluded Drugs premium blood glucose system Excluded Drugs premium v10 blood glucose mtr Excluded Drugs premium v10 blood glucose mtr Excluded Drugs presto pro blood glucose meter Excluded Drugs presto pro blood glucose meter Excluded Drugs pro voice v8 glucose monitor Excluded Drugs pro voice v8 glucose monitor Excluded Drugs pro voice v9 glucose monitor Excluded Drugs pro voice v9 glucose monitor Excluded Drugs prodigy autocode meter kit Excluded Drugs prodigy autocode meter kit Excluded Drugs prodigy autocode monitor syst Excluded Drugs prodigy autocode monitor syst Excluded Drugs prodigy pocket meter kit Excluded Drugs prodigy pocket meter kit Excluded Drugs prodigy voice meter kit Excluded Drugs prodigy voice meter kit Excluded Drugs PROTHELIAL 1 S quintet ac blood glucose meter Excluded Drugs quintet ac blood glucose meter Excluded Drugs quintet blood glucose system Excluded Drugs

PAGE 192 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & quintet blood glucose system Excluded Drugs ra blood glucose monitor Excluded Drugs ra blood glucose monitor Excluded Drugs refuah plus monitoring system Excluded Drugs refuah plus monitoring system Excluded Drugs REGENECARE 3 relion all-in-one meter kit Excluded Drugs relion all-in-one meter kit Excluded Drugs relion confirm glucose monitor Excluded Drugs relion confirm glucose monitor Excluded Drugs relion confirm system kit Excluded Drugs relion confirm system kit Excluded Drugs relion micro blood glucose sys Excluded Drugs relion micro blood glucose sys Excluded Drugs relion micro system Excluded Drugs relion micro system kit Excluded Drugs relion micro system kit Excluded Drugs relion premier blu glucose mtr Excluded Drugs relion premier blu glucose mtr Excluded Drugs relion premier voice gluco mtr Excluded Drugs relion premier voice gluco mtr Excluded Drugs relion prime blood glucose mtr Excluded Drugs relion prime blood glucose mtr Excluded Drugs relion ultima glucose meter Excluded Drugs relion ultima glucose meter Excluded Drugs

PAGE 193 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & reveal blood glucose meter Excluded Drugs reveal blood glucose meter Excluded Drugs rexall glucose monitoring sys Excluded Drugs rexall glucose monitoring sys Excluded Drugs rightest gm100 system kit Excluded Drugs rightest gm100 system kit Excluded Drugs rightest gm250s glucose meter Excluded Drugs rightest gm250s glucose meter Excluded Drugs rightest gm260 glucose meter Excluded Drugs rightest gm260 glucose meter Excluded Drugs rightest gm300 system kit Excluded Drugs rightest gm300 system kit Excluded Drugs rightest gm550 system kit Excluded Drugs rightest gm550 system kit Excluded Drugs sidekick blood glucose system Excluded Drugs SILVASORB 3 SILVRSTAT 3 smart caresens n glucose systm Excluded Drugs smart caresens n glucose systm Excluded Drugs smart sense monitoring system Excluded Drugs smart sense monitoring system Excluded Drugs smartest eject meter Excluded Drugs smartest eject meter Excluded Drugs smartest persona glucose meter Excluded Drugs smartest persona glucose meter Excluded Drugs

PAGE 194 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & smartest persona starter kit Excluded Drugs smartest persona starter kit Excluded Drugs smartest pronto glucose meter Excluded Drugs smartest pronto glucose meter Excluded Drugs smartest pronto starter kit Excluded Drugs smartest pronto starter kit Excluded Drugs smartest protege meter Excluded Drugs smartest protege meter Excluded Drugs smartest smart code meter Excluded Drugs smartest smart code meter Excluded Drugs smartest talking meter Excluded Drugs smartest talking meter Excluded Drugs SOLESTA 3 S solus v2 audible meter Excluded Drugs solus v2 audible meter Excluded Drugs solus v2 audible meter sys kit Excluded Drugs solus v2 audible meter sys kit Excluded Drugs SP ANTIPRURITIC 3 SPRAY AND STRETCH 3 PA SUPARTZ FX 3 S sure-test easyplus mini meter Excluded Drugs sure-test easyplus mini meter Excluded Drugs PA SYNVISC 3 S PS

PAGE 195 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA SYNVISC-ONE 3 S PS syringe cap, enfit,non-sterile 1 syringe,needle,insuln,sf,0.3ml 31gx15/64" disp syrin 2 syringe,needle,insuln,sf 0.5ml 31gx15/64" disp syrin 2 syringe,needle,insuln,safe,1ml 31gx15/64" disp syrin 2 syringe and needle,insulin,1ml 30gx15/64" disp syrin 2 syrge-ndl,ins 0.3 ml half mark 30gx1/2" disp syrin 2 syringe with needle,insulin 0.5 ml (half unit mark) 2 syring-needl,disp,insul,0.3 ml 30gx15/64" disp syrin 2 syringe, enfit 1 ml, non-sterile 1 syringe, enfit 1 ml, sterile 1 syringe, enfit 12 ml, non-sterile 1 syringe, enfit 12 ml, sterile 1 syringe, enfit 3 ml, sterile 1 syringe, enfit 35 ml, non-sterile 1 syringe, enfit 35 ml, sterile 1 syringe, enfit 6 ml, non-sterile 1 syringe, enfit 6 ml, sterile 1 syringe, enfit 60 ml, non-sterile 1 syringe, enfit 60 ml, sterile 1 syringe,enfit 3 ml,non-sterile 1 syringe,safety with needle,1 ml (23gx1" disp syrin, 3 27gx5/8" disp syrin)

PAGE 196 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & td gold blood glucose monitor Excluded Drugs td gold blood glucose monitor Excluded Drugs td gold voice glucose monitor Excluded Drugs td gold voice glucose monitor Excluded Drugs telcare bgm blood glucose kit Excluded Drugs telcare bgm blood glucose kit Excluded Drugs telcare blood glucose monitor Excluded Drugs telcare blood glucose monitor Excluded Drugs test n'go blood glucose system Excluded Drugs test n'go blood glucose system Excluded Drugs transfer device, closed system (13mm each, 20mm 3 each, 28mm each) PA TRIVISC 3 S true metrix air glucose meter Excluded Drugs true metrix air glucose meter Excluded Drugs true metrix blood glucose mtr Excluded Drugs true metrix blood glucose mtr Excluded Drugs true metrix go glucose meter Excluded Drugs true metrix go glucose meter Excluded Drugs true2go blood glucose system Excluded Drugs true2go blood glucose system Excluded Drugs trueresult blood glucose systm Excluded Drugs trueresult blood glucose systm Excluded Drugs truetrack blood glucose system Excluded Drugs

PAGE 197 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & truetrack blood glucose system Excluded Drugs truetrack smart system Excluded Drugs truetrack smart system Excluded Drugs ultima monitor kit Excluded Drugs ultima monitor kit Excluded Drugs ultratrak blood glucose meter Excluded Drugs ultratrak blood glucose meter Excluded Drugs ultratrak pro glucose mtr sys Excluded Drugs ultratrak pro glucose mtr sys Excluded Drugs ultratrak pro meter kit Excluded Drugs ultratrak pro meter kit Excluded Drugs ultratrak ultimate glucose mtr Excluded Drugs ultratrak ultimate glucose mtr Excluded Drugs underpads 30"x36" each 3 up & up blood monitoring syst Excluded Drugs up & up blood monitoring syst Excluded Drugs verasens blood glucose meter Excluded Drugs verasens blood glucose meter Excluded Drugs verasens meter starter kit Excluded Drugs verasens meter starter kit Excluded Drugs wavesense amp system kit Excluded Drugs wavesense amp system kit Excluded Drugs wavesense presto system kit Excluded Drugs wavesense presto system kit Excluded Drugs

PAGE 198 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY

CORTROSYN 3 cosyntropin 0.25 mg vial 1 PA H.P. ACTHAR 3 S DIABETES MELLITUS accu-chek aviva plus test strp Excluded Drugs accu-chek aviva plus test strp Excluded Drugs accu-chek compact plus strips Excluded Drugs accu-chek compact plus strips Excluded Drugs accu-chek guide test strip Excluded Drugs accu-chek guide test strip Excluded Drugs accu-chek smartview test strip Excluded Drugs accu-chek smartview test strip Excluded Drugs accutrend glucose test strip Excluded Drugs accutrend glucose test strip Excluded Drugs acura test strips Excluded Drugs acura test strips Excluded Drugs advocate redi-code test strip Excluded Drugs advocate redi-code test strip Excluded Drugs advocate redi-code+ test strip Excluded Drugs advocate redi-code+ test strip Excluded Drugs advocate test strip Excluded Drugs

PAGE 199 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & advocate test strip Excluded Drugs agamatrix amp test strips Excluded Drugs agamatrix amp test strips Excluded Drugs assure 4 test strips Excluded Drugs assure 4 test strips Excluded Drugs assure platinum test strips Excluded Drugs assure platinum test strips Excluded Drugs assure prism multi test strips Excluded Drugs assure prism multi test strips Excluded Drugs blood glucose test strip Excluded Drugs blood glucose test strip Excluded Drugs blood glucose test strips Excluded Drugs blood glucose test strips Excluded Drugs blood sugar diagnostic 2 QL 10 / day breeze 2 disc test strip Excluded Drugs breeze 2 disc test strip Excluded Drugs careone blood glucose tst strp Excluded Drugs careone blood glucose tst strp Excluded Drugs caresens n test strips Excluded Drugs caresens n test strips Excluded Drugs caretouch test strip Excluded Drugs caretouch test strip Excluded Drugs choicedm clarus test strips Excluded Drugs choicedm clarus test strips Excluded Drugs

PAGE 200 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & clever choice micro test strip Excluded Drugs clever choice micro test strip Excluded Drugs clever choice pro test strip Excluded Drugs clever choice pro test strip Excluded Drugs clever choice talk test strips Excluded Drugs clever choice talk test strips Excluded Drugs clever choice test strips Excluded Drugs clever choice test strips Excluded Drugs clever choice voice+ tst strip Excluded Drugs clever choice voice+ tst strip Excluded Drugs contour next test strip Excluded Drugs contour next test strip Excluded Drugs contour test strip Excluded Drugs contour test strip Excluded Drugs cool glucose test strip Excluded Drugs cool glucose test strip Excluded Drugs cvs advanced glucose test str Excluded Drugs cvs advanced glucose test str Excluded Drugs dario blood glucose test strip Excluded Drugs dario blood glucose test strip Excluded Drugs diatrue plus test strip Excluded Drugs diatrue plus test strip Excluded Drugs easy check glucose test strip Excluded Drugs easy check glucose test strip Excluded Drugs easy gluco g2 test strip Excluded Drugs

PAGE 201 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & easy gluco g2 test strip Excluded Drugs easy plus glucose test strip Excluded Drugs easy plus glucose test strip Excluded Drugs easy plus ii test strip Excluded Drugs easy plus ii test strip Excluded Drugs easy plus ii test strips Excluded Drugs easy plus ii test strips Excluded Drugs easy step glucose test strips Excluded Drugs easy step glucose test strips Excluded Drugs easy talk glucose test strip Excluded Drugs easy talk glucose test strip Excluded Drugs easy touch glucose test strip Excluded Drugs easy touch glucose test strip Excluded Drugs easy trak glucose test strip Excluded Drugs easy trak glucose test strip Excluded Drugs easygluco plus test strips Excluded Drugs easygluco plus test strips Excluded Drugs easygluco test strips Excluded Drugs easygluco test strips Excluded Drugs easymax 15 glucose test strip Excluded Drugs easymax 15 glucose test strip Excluded Drugs easymax glucose test strips Excluded Drugs easymax glucose test strips Excluded Drugs element compact test strips Excluded Drugs element compact test strips Excluded Drugs

PAGE 202 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & element test strips Excluded Drugs element test strips Excluded Drugs embrace evo test strips Excluded Drugs embrace evo test strips Excluded Drugs embrace glucose test strips Excluded Drugs embrace glucose test strips Excluded Drugs embrace pro test strip Excluded Drugs embrace pro test strip Excluded Drugs embrace pro test strips Excluded Drugs embrace pro test strips Excluded Drugs embrace talk test strip Excluded Drugs embrace talk test strip Excluded Drugs embrace test strips Excluded Drugs embrace test strips Excluded Drugs eq blood glucose test strip Excluded Drugs eq blood glucose test strip Excluded Drugs evencare g2 test strip Excluded Drugs evencare g2 test strip Excluded Drugs evencare g3 test strip Excluded Drugs evencare g3 test strip Excluded Drugs evencare glucose tst strips Excluded Drugs evencare glucose tst strips Excluded Drugs evencare mini glucose test str Excluded Drugs evencare mini glucose test str Excluded Drugs evencare proview test strip Excluded Drugs

PAGE 203 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & evencare proview test strip Excluded Drugs evolution test strips Excluded Drugs evolution test strips Excluded Drugs ez smart plus test strips Excluded Drugs ez smart plus test strips Excluded Drugs ez smart test strips Excluded Drugs ez smart test strips Excluded Drugs fifty50 glucose test strip Excluded Drugs fifty50 glucose test strip Excluded Drugs fora 6 connect glucose strip Excluded Drugs fora 6 connect glucose strip Excluded Drugs fora blood glucose test strip Excluded Drugs fora blood glucose test strip Excluded Drugs fora d15g glucose test strips Excluded Drugs fora d15g glucose test strips Excluded Drugs fora d20 glucose test strips Excluded Drugs fora d20 glucose test strips Excluded Drugs fora d40-g31 test strips Excluded Drugs fora d40-g31 test strips Excluded Drugs fora g20 glucose test strips Excluded Drugs fora g20 glucose test strips Excluded Drugs fora g30-premium v10 test strp Excluded Drugs fora g30-premium v10 test strp Excluded Drugs fora gd50 test strips Excluded Drugs fora gd50 test strips Excluded Drugs

PAGE 204 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fora tn'g voice test strips Excluded Drugs fora tn'g voice test strips Excluded Drugs fora v10 glucose test strip Excluded Drugs fora v10 glucose test strip Excluded Drugs fora v10-v12-d10-d20 strips Excluded Drugs fora v10-v12-d10-d20 strips Excluded Drugs fora v12 glucose test strip Excluded Drugs fora v12 glucose test strip Excluded Drugs fora v20 glucose test strips Excluded Drugs fora v20 glucose test strips Excluded Drugs fora v30a glucose test strip Excluded Drugs fora v30a glucose test strip Excluded Drugs foracare gd20 test strips Excluded Drugs foracare gd20 test strips Excluded Drugs foracare gd40 glucose strips Excluded Drugs foracare gd40 glucose strips Excluded Drugs fortiscare glucose test strips Excluded Drugs fortiscare glucose test strips Excluded Drugs freestyle insulinx strip nfrs Excluded Drugs freestyle insulinx strip nfrs Excluded Drugs freestyle insulinx test strip Excluded Drugs freestyle insulinx test strip Excluded Drugs freestyle insulinx test strips Excluded Drugs freestyle insulinx test strips Excluded Drugs freestyle lite test strip Excluded Drugs

PAGE 205 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & freestyle lite test strip Excluded Drugs freestyle lite test strip nfrs Excluded Drugs freestyle lite test strip nfrs Excluded Drugs freestyle prec neo test strips Excluded Drugs freestyle prec neo test strips Excluded Drugs freestyle test strips Excluded Drugs freestyle test strips Excluded Drugs freestyle test strips nfrs Excluded Drugs freestyle test strips nfrs Excluded Drugs g-4 test strips Excluded Drugs g-4 test strips Excluded Drugs ge100 blood glucose test strip Excluded Drugs ge100 blood glucose test strip Excluded Drugs genstrip glucose test strip Excluded Drugs genstrip glucose test strip Excluded Drugs genultimate test strip Excluded Drugs genultimate test strip Excluded Drugs ght blood glucose test strip Excluded Drugs ght blood glucose test strip Excluded Drugs gluco navii glucose test strip Excluded Drugs gluco navii glucose test strip Excluded Drugs glucocard 01 sensor plus strip Excluded Drugs glucocard 01 sensor plus strip Excluded Drugs glucocard expression test strp Excluded Drugs glucocard expression test strp Excluded Drugs

PAGE 206 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & glucocard shine test strips Excluded Drugs glucocard shine test strips Excluded Drugs glucocard vital sensor strip Excluded Drugs glucocard vital sensor strip Excluded Drugs glucocard vital test strips Excluded Drugs glucocard vital test strips Excluded Drugs glucocom glucose test strip Excluded Drugs glucocom glucose test strip Excluded Drugs gmate test strips Excluded Drugs gmate test strips Excluded Drugs gnp easy touch gluc test strip Excluded Drugs gnp easy touch gluc test strip Excluded Drugs goodlife ac-302 test strip Excluded Drugs goodlife ac-302 test strip Excluded Drugs gs blood glucose test strip Excluded Drugs gs blood glucose test strip Excluded Drugs harmony glucose test strip Excluded Drugs harmony glucose test strip Excluded Drugs healthpro glucose test strips Excluded Drugs healthpro glucose test strips Excluded Drugs humana true metrix test strip Excluded Drugs humana true metrix test strip Excluded Drugs humana truetest test strips Excluded Drugs humana truetest test strips Excluded Drugs iglucose test strip Excluded Drugs

PAGE 207 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & iglucose test strip Excluded Drugs infinity test strips Excluded Drugs infinity test strips Excluded Drugs infinity voice test strip Excluded Drugs infinity voice test strip Excluded Drugs kro premium blood glucose test Excluded Drugs kro premium blood glucose test Excluded Drugs liberty test strips Excluded Drugs liberty test strips Excluded Drugs maxima test strip Excluded Drugs maxima test strip Excluded Drugs meijer blood glucose test strp Excluded Drugs meijer blood glucose test strp Excluded Drugs microdot test strips Excluded Drugs microdot test strips Excluded Drugs microdot xtra test strips Excluded Drugs microdot xtra test strips Excluded Drugs myglucohealth test strips Excluded Drugs myglucohealth test strips Excluded Drugs neutek 2tek test strips Excluded Drugs neutek 2tek test strips Excluded Drugs nova max glucose test strip Excluded Drugs nova max glucose test strip Excluded Drugs on call express test strip Excluded Drugs on call express test strip Excluded Drugs

PAGE 208 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & on call plus test strip Excluded Drugs on call plus test strip Excluded Drugs on call vivid test strip Excluded Drugs on call vivid test strip Excluded Drugs blue test strp 2 QL 10 / day onetouch verio test strip 2 QL 10 / day optium ez test strip Excluded Drugs optium ez test strip Excluded Drugs optium test strip Excluded Drugs optium test strip Excluded Drugs optumrx test strip Excluded Drugs optumrx test strip Excluded Drugs pharmacist choice test strips Excluded Drugs pharmacist choice test strips Excluded Drugs precision pcx plus test str Excluded Drugs precision pcx plus test str Excluded Drugs precision pcx test strips Excluded Drugs precision pcx test strips Excluded Drugs precision point of care str Excluded Drugs precision point of care str Excluded Drugs precision q-i-d test strips Excluded Drugs precision q-i-d test strips Excluded Drugs precision xtra test strips Excluded Drugs precision xtra test strips Excluded Drugs

PAGE 209 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & premium blood glucose test str Excluded Drugs premium blood glucose test str Excluded Drugs premium blood glucose tst strp Excluded Drugs premium blood glucose tst strp Excluded Drugs premium v10 glucose test strip Excluded Drugs premium v10 glucose test strip Excluded Drugs pro voice v8-v9 test strip Excluded Drugs pro voice v8-v9 test strip Excluded Drugs prodigy no coding test strips Excluded Drugs prodigy no coding test strips Excluded Drugs quintet ac glucose test strips Excluded Drugs quintet ac glucose test strips Excluded Drugs quintet glucose test strips Excluded Drugs quintet glucose test strips Excluded Drugs refuah plus test strips Excluded Drugs refuah plus test strips Excluded Drugs relion confirm-micro test strp Excluded Drugs relion confirm-micro test strp Excluded Drugs relion micro test strips Excluded Drugs relion micro test strips Excluded Drugs relion premier test strip Excluded Drugs relion premier test strip Excluded Drugs relion prime test strips Excluded Drugs relion prime test strips Excluded Drugs relion ultima test strips Excluded Drugs

PAGE 210 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & relion ultima test strips Excluded Drugs reveal test strip Excluded Drugs reveal test strip Excluded Drugs rexall blood glucose test strp Excluded Drugs rexall blood glucose test strp Excluded Drugs rightest gs100 test strips Excluded Drugs rightest gs100 test strips Excluded Drugs rightest gs250s test strips Excluded Drugs rightest gs250s test strips Excluded Drugs rightest gs260 test strips Excluded Drugs rightest gs260 test strips Excluded Drugs rightest gs300 test strips Excluded Drugs rightest gs300 test strips Excluded Drugs rightest gs550 test strips Excluded Drugs rightest gs550 test strips Excluded Drugs smart sense test strips Excluded Drugs smart sense test strips Excluded Drugs smartest test strips Excluded Drugs smartest test strips Excluded Drugs solus v2 audible test strips Excluded Drugs solus v2 audible test strips Excluded Drugs sure-test easyplus mini strip Excluded Drugs sure-test easyplus mini strip Excluded Drugs td gold test strip Excluded Drugs td gold test strip Excluded Drugs

PAGE 211 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & telcare test strips Excluded Drugs telcare test strips Excluded Drugs test n'go glucose test strip Excluded Drugs test n'go glucose test strip Excluded Drugs true metrix glucose test strip Excluded Drugs true metrix glucose test strip Excluded Drugs true metrix pro test strip Excluded Drugs true metrix pro test strip Excluded Drugs truetest glucose test strip Excluded Drugs truetest glucose test strip Excluded Drugs truetest glucose test strips Excluded Drugs truetest glucose test strips Excluded Drugs truetrack glucose test strips Excluded Drugs truetrack glucose test strips Excluded Drugs ultima test strips Excluded Drugs ultima test strips Excluded Drugs ultratrak test strip Excluded Drugs ultratrak test strip Excluded Drugs ultratrak ultimate test strips Excluded Drugs ultratrak ultimate test strips Excluded Drugs unistrip1 glucose test strip Excluded Drugs unistrip1 glucose test strip Excluded Drugs up & up blood glucose tst strp Excluded Drugs up & up blood glucose tst strp Excluded Drugs v-r glucose test strip Excluded Drugs

PAGE 212 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & v-r glucose test strip Excluded Drugs verasens test strip Excluded Drugs verasens test strip Excluded Drugs wavesense jazz test strips Excluded Drugs wavesense jazz test strips Excluded Drugs wavesense presto test strips Excluded Drugs wavesense presto test strips Excluded Drugs MYASTHENIA GRAVIS

ENLON 3 ENLON-PLUS 3 PITUITARY FUNCTION

PA ACTHREL 3 S PA MACRILEN 3 S ROENTGENOGRAPHY AND OTHER IMAGING AGENTS

DOTAREM 2.5 MMOL/5 ML VIAL 3 OMNIPAQUE 12 MG/ML ORAL SOLN 3 OMNIPAQUE 9 MG/ML ORAL SOLN 3 OPTIRAY 240 (240 MG/ML) SYRN 3 READI-CAT 2 3 THYROID FUNCTION

PA THYROGEN 3 S

PAGE 213 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & URINE AND FECES CONTENTS urine acetone test,strips 3 QL 6.66 / day urine albumin test 3 urine bilirubin test 3 urine glucose test strip 3 QL 10 / day urine glucose-acet test strip 3 urine leukocyte test strips 3 urine multiple test strips 3 QL 6.66 / day urine phenaphthazine-ph test (15 feet each, strip) 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS

K-PHOS ORIGINAL 3 ALKALINIZING AGENTS

CYTRA-K CRYSTALS PACKET 1 potassium citrate 1 TARON-CRYSTALS 1 tromethamine in sterile water for injection 1 UROCIT-K 3 AMMONIA DETOXICANTS

BUPHENYL 500 MG TABLET 3 S CARBAGLU 3 S CONSTULOSE 1 ENULOSE 1

PAGE 214 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & GENERLAC 1 KRISTALOSE 1 lactulose (10 g packet, 10 g/15 ml solution, 20 g/30 1 ml solution) QL 20 / day RAVICTI 3 PA S sodium phenylbutyrate 500 mg tablet 1 S CALORIC AGENTS

BCAD 1 3 CYCLINEX-1 3 EAA 3 ELECARE 3 GLUTAREX-1 3 GLYTACTIN 15 PE BETTERMILK 3 GLYTACTIN RTD 10 PE 3 GLYTACTIN RTD 15 PE 3 HCY 1 3 HOMINEX-1 3 I-VALEX-1 3 KETONEX-1 3 LANAFLEX 3 OMEGAVEN 3 PHENYLADE GMP (POWDER, POWDER PKT) 3 PHENYLADE GMP MIX-IN POWDER 3

PAGE 215 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DIURETICS amiloride hcl 1 amiloride hcl/hydrochlorothiazide 1 bumetanide (1 mg tablet, 2 mg tablet) 1 bumetanide 0.5 mg tablet 1 chlorothiazide 1 chlorothiazide sodium 1 chlorthalidone 1 DEMADEX 3 DIURIL 3 DYAZIDE 3 DYRENIUM 3 EDECRIN 3 ethacrynic acid 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg 1 tablet, 40mg/5ml solution, 80 mg tablet) hydrochlorothiazide (12.5 mg capsule, 12.5 mg 1 tablet, 50 mg tablet) hydrochlorothiazide 25 mg tablet 1 indapamide 1 QL 1 / day JYNARQUE 15 MG TABLET 3 PA S QL 2 / day JYNARQUE (30 MG TABLET, 45 MG-15 MG TABLET, 3 PA 60 MG-30 MG TABLET, 90 MG-30 MG TABLET) S

PAGE 216 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & LASIX 3 mannitol (5 % iv soln, 10 % iv soln, 20 % iv soln, 25 % 1 vial) MAXZIDE 3 MAXZIDE-25 MG 3 methyclothiazide 1 metolazone 1 MICROZIDE 3 OSMITROL 1 QL 1 / day SAMSCA 15 MG TABLET 3 PA S QL 2 / day SAMSCA 30 MG TABLET 3 PA S SODIUM DIURIL 3 torsemide 1 triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg 1 tablet, triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg- 50mg tablet) ION-REMOVING AGENTS

AURYXIA 3 calcium acetate (667 mg capsule, 667 mg tablet) 1 ELIPHOS 3

PAGE 217 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & FOSRENOL (500 MG TABLET CHEW, 750 MG POWDER PACKET, 750 MG TABLET CHEW, 1,000 MG 3 POWDER PACK, 1,000 MG TABLET CHEW) KAYEXALATE 3 KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 lanthanum carbonate (500 mg tab chew, 750 mg tab 1 chew) lanthanum carbonate 1000 mg tab chew 1 LOKELMA 3 QL 1 / day PHOSLYRA 3 RADIOGARDASE 3 RENAGEL 3 RENVELA (0.8 GM POWDER PACKET, 2.4 GM 3 POWDER PACKET, 800 MG TABLET) sevelamer carbonate 2.4 g powd pack 1 sevelamer carbonate (0.8 g powd pack, 800 mg 1 tablet) sevelamer hcl 1 sodium polystyrene sulfonate (15 g/60 ml oral susp, 1 30 g/120ml enema, 50 g/200ml enema, powder) SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML 1 ENEMA) VELPHORO 3 VELTASSA 3 QL 1 / day IRRIGATING SOLUTIONS

RESECTISOL 3 RIMSO-50 3

PAGE 218 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & REPLACEMENT PREPARATIONS calcium gluconate in 0.9 % sodium chloride (in 1 1 g/50 ml syringe, in 2 g/50 ml syringe) calcium gluconate in sodium chloride, iso-osmotic 1 EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3 EFFER-K 25 MEQ TABLET EFF 1 K EFFERVESCENT 1 K-TAB ER 3 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 25 MEQ PACKET 3 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 3 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 potassium acetate 2 meq/ml vial 1 potassium bicarbonate/citric acid 1 potassium chloride (2 meq/ml ampul, 2 meq/ml vial) 1 potassium chloride (8 capsule er, 8 tablet er, 10 capsule er, 10 tab er prt, 10 tablet er, 20 tab er prt, 1 20 tablet er) potassium chloride (20 meq packet, 20meq/15ml 1 liquid, 40meq/15ml liquid) potassium chloride in 0.45 % sodium chloride 1

PAGE 219 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & potassium chloride in 5 % dextrose in water 1 potassium chloride in dextrose 5 % and 0.9 % sodium 1 chloride potassium chloride in dextrose 5 %-0.2 % sodium chloride (chloride/d5-0.2%nacl 10 meq/l iv soln, chloride/d5-0.2%nacl 20 meq/l iv soln, chloride/d5- 1 0.2%nacl 30 meq/l iv soln, chloride/d5-0.2%nacl 40 meq/l iv soln) potassium chloride in dextrose 5 %-0.45 % sodium chloride (chloride/d5-0.45nacl 10 meq/l iv soln, chloride/d5-0.45nacl 20 meq/l iv soln, chloride/d5- 1 0.45nacl 30 meq/l iv soln, chloride/d5-0.45nacl 40 meq/l iv soln) potassium chloride/d5-0.3%nacl 20 meq/l iv soln 1 potassium chloride in lactated ringers and 5 % 1 dextrose potassium chloride in water for injection, sterile (in 10meq/0.1l piggyback, in 10meq/50ml piggyback, in 1 20meq/0.1l piggyback, in 20meq/50ml piggyback, in 30meq/0.1l piggyback, in 40meq/0.1l piggyback) potassium chloride/lidocaine hcl in 0.9 % sodium 1 chloride potassium chloride/potassium bicarbonate/citric 1 acid potassium phos in 0.9 % nacl 30mmol/250 plast. bag 1 sodium phosphate in 0.9 % nacl 30mmol/250 plast. 1 bag sodium phosphate in 5 % dextrose in water 1 zinc chloride 1

PAGE 220 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & URICOSURIC AGENTS

QL 1 / day DUZALLO 3 PA probenecid 1 QL 4 / day probenecid/colchicine 1 QL 2 / day QL 1 / day ZURAMPIC 3 PA AL At least 18 yrs old ENZYMES

ADAGEN 3 S PA ALDURAZYME 3 S PA CEREZYME 3 S PA ELAPRASE 3 S PA ELELYSO 3 S PS ELITEK 3 S PA FABRAZYME 3 S HYLENEX 3 PA HYQVIA HY COMPONENT 3 S

PAGE 221 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA LUMIZYME 3 S PA NAGLAZYME 3 S QL 2 / day PALYNZIQ (10 MG/0.5 ML SYRINGE, 20 MG/ML 3 PA SYRINGE) S QL 8 / day PALYNZIQ 2.5 MG/0.5 ML SYRINGE 3 PA S REVCOVI 3 S PA STRENSIQ 3 S PS SUCRAID 3 S VIMIZIM 3 S VITRASE 3 PA VPRIV 3 S PA XIAFLEX 3 S EYE, EAR, NOSE AND THROAT (EENT) PREPS. ANTI-INFECTIVES (EENT) 2 % solution 1 acetic acid/aluminum acetate 1

PAGE 222 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & AZASITE 3 QL 0.36/day bacitracin 500 unit/g oint. (g) 1 QL 0.434 / day bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1 QL 0.434 / day BACTROBAN NASAL 2 PA BESIVANCE 3 QL 0.767 / day BETADINE 5% EYE SOLUTION 3 BLEPH-10 3 QL 5 / fill BLEPHAMIDE 3 QL 5 / fill BLEPHAMIDE S.O.P. 3 QL 4 / fill CETRAXAL 3 QL 0.567 / day chlorhexidine gluconate 0.12 % mouthwash 1 CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day CIPRO HC 3 QL 0.434 / day CIPRODEX 2 QL 0.257 / day ciprofloxacin hcl 0.2 % droperette 1 QL 0.567 / day ciprofloxacin hcl 0.3 % drops 1 QL 0.767 / day COLY-MYCIN S 3 QL 10 / fill doxycycline hyclate 20 mg tablet 1 erythromycin base 5 mg/gram oint. (g) 1 QL 0.54 / day FLOXIN 3 QL 10 / 30 days gatifloxacin 1 QL 0.36/day GENTAK 1 QL 0.54 / day gentamicin sulfate 0.3 % drops 1 QL 2.143 / day

PAGE 223 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & gentamicin sulfate 0.3 % oint. (g) 1 QL 0.54 / day hydrocortisone/acetic acid 1 levofloxacin 0.5 % drops 1 QL 0.767 / day MAXITROL EYE DROPS 3 QL 5 / fill MAXITROL EYE OINTMENT 3 QL 4 / fill MOXEZA 2 QL 0.434 / day moxifloxacin hcl 0.5 % drops 1 QL 0.434 / day NATACYN 3 QL 0.767 / day NEO-POLYCIN 1 QL 0.124 / day NEO-POLYCIN HC 1 QL 4 / fill neomycin sulfate/bacitracin zinc/polymyxin 1 QL 4 / fill b/hydrocortisone neomycin sulfate/bacitracin/polymyxin b 1 QL 0.124 / day neomycin sulfate/polymyxin b sulfate/gramicidin d 1 QL 1.47 / day neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin 1 QL 10 / fill b/hydrocort 3.5-10k-1 drops susp, neomycin/polymyxin b/hydrocort 3.5-10k-1 solution) neomycin/polymyxin b/hydrocort 3.5-10k-10 drops 1 QL 10/ fill susp neomycin/polymyxin b/dexametha 0.1 % drops susp 1 QL 5 / fill neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. 1 QL 4 / fill (g) NEOSPORIN EYE DROPS 3 QL 1.47 / day OCUFLOX 3 QL 1.47 / day ofloxacin 0.3 % drops 1 QL 1.47 / day

PAGE 224 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & OTIPRIO 3 OTOVEL 3 PAROEX 1 PERIDEX 3 PERIOGARD 1 POLYCIN 1 QL 0.434 / day polymyxin b sulfate/trimethoprim 1 QL 1.47 / day POLYTRIM 3 QL 1.47 / day povidone-iodine 5 % solution 1 PRED-G 1% EYE DROPS 3 QL 5 / fill PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill sulfacetamide sodium 10 % drops 1 QL 5 / fill sulfacetamide sodium 10 % oint. (g) 1 QL 4 / fill sulfacetamide sodium/ sodium 1 QL 5 / fill phosphate TOBRADEX EYE DROPS 3 QL 5 / fill TOBRADEX EYE OINTMENT 3 QL 4 / fill TOBRADEX ST 3 QL 5 / fill tobramycin 1 QL 2.143 / day tobramycin/dexamethasone 1 QL 5 / fill TOBREX 0.3% EYE DROP 3 QL 2.143 / day TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day trifluridine 1 vancomycin hcl/balanced salt solution no.2/pf 1

PAGE 225 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VIGAMOX 2 QL 0.434 / day VIROPTIC 3 ZIRGAN 3 QL 0.167 / day ZYLET 3 QL 5 / fill ZYMAXID 3 QL 0.36/day ANTI-INFLAMMATORY AGENTS (EENT)

ACULAR 3 QL 15 / 30 days ACULAR LS 3 QL 5 / fill ACUVAIL 3 QL 1 / day ALREX 3 QL 0.5 / day BECONASE AQ 3 QL 1.667 / day bromfenac sodium 1 QL 8 / rx BROMSITE 0.075% EYE DROPS Excluded Drugs budesonide 32mcg spray/pump 1 QL 0.574 / day DERMOTIC 3 dexamethasone sodium phosphate 0.1 % drops 1 QL 10 / fill diclofenac sodium 0.1 % drops 1 QL 5 / fill DUREZOL 3 QL 10 / 30 days FLAC OTIC OIL 1 FLAREX 3 QL 10 / fill flunisolide 1 QL .834 / day fluocinolone acetonide oil 1 1 QL 10 / fill

PAGE 226 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & flurbiprofen sodium 1 QL 3/ fill fluticasone propionate 50 mcg spray susp 1 QL 0.6 / day FML 3 QL 10 / fill FML FORTE 3 QL 10 / fill FML S.O.P. 3 QL 4 / fill ILEVRO 0.3% OPHTH DROPS Excluded Drugs QL max 1 per 365 days ILUVIEN 3 S ketorolac tromethamine 0.4 % drops 1 QL 5 / fill ketorolac tromethamine 0.5 % drops 1 QL 15 / 30 days LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill LOTEMAX 0.5% EYE DROPS 3 QL 21 / fill LOTEMAX 0.5% EYE OINTMENT 3 QL 4 / fill LOTEMAX SM 3 QL 10 / fill MAXIDEX 3 QL 10 / fill mometasone furoate 50 mcg spray/pump 1 QL 0.567 / day NASONEX 3 QL 0.567 / day NEVANAC 0.1% DROPTAINER Excluded Drugs OMNARIS 3 QL 0.434 / day OMNIPRED 3 QL 21 / fill QL 0.04 / day OZURDEX 3 S PRED FORTE 3 QL 21 / fill PRED MILD 3 QL 21 / fill

PAGE 227 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & prednisolone acetate 1 QL 21 / fill prednisolone sodium phosphate 1 % drops 1 QL 20 / 30 days PROLENSA 2 QL 3/ fill QNASL 3 QL 0.4 / day QNASL CHILDREN 3 QL 0.3 / day RESTASIS 2 PA RESTASIS MULTIDOSE 2 PA QL max 1 per 365 days RETISERT 3 S triamcinolone acetonide 55 mcg spray 1 QL 0.55 / day TRIESENCE 3 QL 1 / day QL 2 / day XIIDRA 2 PA AL At least 17 yrs old YUTIQ 3 S ZETONNA 3 QL 0.22 / day ANTIALLERGIC AGENTS

ALOMIDE 3 QL 10 / fill ASTEPRO 3 QL 2 / day azelastine hcl 0.05 % drops 1 QL 0.267 / day azelastine hcl (137 mcg spray/pump, 205.5 mcg 1 QL 2 / day spray/pump) QL 0.334 / day BEPREVE 3 ST

PAGE 228 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DYMISTA 2 QL 0.8 / day QL 0.286 / day ELESTAT 3 ST QL 5 / fill EMADINE 3 ST epinastine hcl 1 QL 0.286 / day ketotifen fumarate 1 QL 0.167 / day QL 3 / 30 days LASTACAFT 3 ST olopatadine hcl (0.1 % drops, 0.2 % drops) 1 QL 0.286 / day olopatadine hcl 0.6 % spray/pump 1 QL 31 / 30 days QL 0.286 / day PATADAY 3 ST PATANASE 3 QL 31 / 30 days QL 0.286 / day PATANOL 3 ST PAZEO 2 QL 0.286 / day ANTIGLAUCOMA AGENTS acetazolamide (125 mg tablet, 250 mg tablet, 500 1 mg capsule er) acetazolamide sodium 1 ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day ALPHAGAN P 0.15% EYE DROPS 3 QL 0.4 / day AZOPT 2 QL 0.334 / day BETAGAN 3 QL 0.4 / day

PAGE 229 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & betaxolol hcl 0.5 % drops 1 QL 0.54 / day BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day BETOPTIC S 3 QL 0.54 / day bimatoprost 0.03 % drops 1 QL 0.13 / day bimatoprost 0.03 % drop w/app 1 brimonidine tartrate 0.15 % drops 1 QL 0.4 / day brimonidine tartrate 0.2 % drops 1 QL 0.4 / day carteolol hcl 1 QL 0.334 / day COMBIGAN 2 QL 0.334 / day COSOPT 3 QL 0.334 / day COSOPT PF 3 QL 2 / day DIAMOX SEQUELS 3 dorzolamide hcl 1 QL 0.4 / day dorzolamide hcl/timolol maleate 1 QL 0.334 / day dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL 2 / day ISOPTO CARPINE 3 QL 0.54 / day ISTALOL 3 QL 0.286 / day latanoprost 1 QL 0.13 / day LATISSE 3 levobunolol hcl 1 QL 0.4 / day LUMIGAN 2 QL 0.13 / day methazolamide 25 mg tablet 1

PAGE 230 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & methazolamide 50 mg tablet 1 metipranolol 1 QL 0.334 / day MIOCHOL-E 3 MIOSTAT 3 NEPTAZANE 3 PHOSPHOLINE IODIDE 3 pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1 QL 0.54 / day QL 0.1 / day RHOPRESSA 3 PA SIMBRINZA 2 QL 0.4 / day timolol maleate (0.5 % drop daily, 0.5 % drops) 1 QL 0.334 / day timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % 1 QL 0.286 / day sol-gel) TIMOPTIC (DROP, DROPS) 3 QL 0.286 / day TIMOPTIC (DROP, DROPS) 3 QL 0.334 / day TIMOPTIC OCUDOSE 3 QL 2 / day TIMOPTIC-XE 3 QL 0.286 / day TRAVATAN Z 2 QL 0.167 / day TRUSOPT 3 QL 0.4 / day XALATAN 3 QL 0.13 / day ZIOPTAN 0.0015% EYE DROPS Excluded Drugs EENT DRUGS, MISCELLANEOUS apraclonidine hcl 1 QL 0.8 / day PA bevacizumab 1 S

PAGE 231 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SM COUGH DROPS 5.8 MG 1 QL 1 / day CYSTARAN 3 PA S IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day ipratropium bromide (21 mcg spray, 42 mcg spray) 1 QL 2 / day PA JETREA 2.5 MG/ML VIAL 3 S

LUCENTIS (0.3 MG VIAL, 0.3 MG/0.05 ML SYRING, QL 0.04 / day 0.3 MG/0.05 ML VIAL, 0.5 MG VIAL, 0.5 MG/0.05 ML 3 PA SYRING, 0.5 MG/0.05 ML VIAL) S QL 1 / day OXERVATE 3 PA S VISUDYNE 3 S LOCAL ANESTHETICS (EENT)

AKTEN 3 proparacaine hcl 1 TETCAINE 1 tetracaine hcl 1 tetracaine hcl/pf 0.5 % drops 1 TETRAVISC 1 MYDRIATICS atropine sulfate (1 % drops, 1 % oint. (g)) 1 HOMATROPAIRE 1

PAGE 232 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & homatropine hbr 1 OMIDRIA 3 VASOCONSTRICTORS

ADRENALIN CHLORIDE 3 PA NASAL SPRAY ORIGINAL 0.05% 1 phenylephrine hcl (2.5 % drops, 10 % drops) 1 TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE DROPS, 3 0.1% NOSE SPRAY) TOTALITY 3 GASTROINTESTINAL DRUGS ANTACIDS AND ADSORBENTS

ANTACID EX-STR 750 MG TAB CHEW 1 ANTI-INFLAMMATORY AGENTS (GI DRUGS)

GL Female alosetron hcl 1 AL At least 18 yrs old APRISO 2 ASACOL HD DR 800 MG TABLET Excluded Drugs balsalazide disodium 1 CANASA 2 COLAZAL 3 DELZICOL DR 400 MG CAPSULE Excluded Drugs DIPENTUM 250 MG CAPSULE Excluded Drugs GIAZO 3 GL Male LIALDA DR 1.2 GM TABLET Excluded Drugs

PAGE 233 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA LOTRONEX 3 GL Female AL At least 18 yrs old mesalamine (1.2 g tablet dr, 4 g/60 ml enema, 1000 1 mg supp.rect) mesalamine 800 mg dr tablet Excluded Drugs mesalamine with cleansing wipes 1 PENTASA 3 ROWASA (4 GM/60 ML ENEMA, 4 GM/60 ML 3 ENEMA KIT) SFROWASA 3 ANTIDIARRHEA AGENTS diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5- 1 .025/5 liquid, hcl/atropine 2.5-.025mg tablet) LOMOTIL 3 MYTESI 3 S opium tincture 1 QL 5 / day paregoric 1 CVS STOMACH RELIEF MAX STR LIQ 1 PA XERMELO 3 AL At least 18 yrs old S ANTIEMETICS

QL 0.15 / day AKYNZEO 300-0.5 MG CAPSULE 3 PA ANTIVERT 3

PAGE 234 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ANZEMET 3 QL 0.15 / day aprepitant 125mg-80mg cap ds pk 1 QL 3/ fill aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day aprepitant 80 mg capsule 1 QL 0.15 / day QL 2 / day BONJESTA 3 PA QL 0.67 / day CESAMET 3 PA S CINVANTI 3 S COMPAZINE 25 MG SUPPOSITORY 1 COMPAZINE (5 MG TABLET, 10 MG TABLET) 3 COMPRO 1 QL 4 / day DICLEGIS 3 PA dimenhydrinate 50 mg/ml vial 1 dronabinol 1 QL 5 / day EMEND TRIPACK 3 QL 3/ fill EMEND (40 MG CAPSULE, 125 MG CAPSULE, 125 3 QL 0.08 / day MG POWDER PACKET) EMEND 80 MG CAPSULE 3 QL 0.15 / day QL 2 / fill EMEND 150 MG VIAL 3 S granisetron hcl 1 mg tablet 1 QL 6 / 30 days granisetron hcl (1 mg/ml vial, 1 mg/ml(1) vial) 1 S

PAGE 235 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & granisetron hcl/pf 1 S QL 5 / day MARINOL 3 PA hcl (12.5 mg tablet, 25 mg tablet) 1 QL 24 / 30 days ondansetron 1 Max allowable- C 3/day with max of 24 / 30 days ondansetron hcl 4 mg/5 ml solution 1 QL 20 / day QL 24 / 30 days ondansetron hcl (4 mg tablet, 8 mg tablet) 1 Max allowable- C 3/day with max of 24 / 30 days ondansetron hcl 24 mg tablet 1 QL 3 days ondansetron hcl 2 mg/ml vial 1 S ondansetron hcl in 0.9 % sodium chloride (in 0.9 % 16 mg/50ml piggyback, in 0.9 % 8 mg/50 ml 1 S piggyback) ondansetron hcl in dextrose 5% in water 1 S ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 1 S mg/2 ml syringe, hcl/pf 4 mg/2 ml vial) prochlorperazine 1 prochlorperazine edisylate 10 mg/2 ml vial 1 prochlorperazine edisylate 5 mg/ml vial 1 prochlorperazine maleate 1 SANCUSO 3 QL 0.144 / day scopolamine 1 QL 13 / day SYNDROS 3 PA AL At least 18 yrs old

PAGE 236 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & TIGAN 300 MG CAPSULE 3 TIGAN 100 MG/ML VIAL 3 TRANSDERM-SCOP 3 trimethobenzamide hcl 1 QL 0.15 / day VARUBI 90 MG TABLET 3 PA S PA VARUBI 166.5 MG/92.5 ML VIAL 3 S ZOFRAN 4 MG/5 ML ORAL SOLN 3 QL 20 / day QL 24 / 30 days ZOFRAN (4 MG TABLET, 8 MG TABLET) 3 Max allowable- C 3/day with max of 24 / 30 days ZOFRAN 2 MG/ML VIAL 3 S QL 24 / 30 days ZOFRAN ODT 3 Max allowable- C 3/day with max of 24 / 30 days ZUPLENZ 3 QL 24 / 30 days ANTIULCER AGENTS AND ACID SUPPRESSANTS

QL 2 / day ACIPHEX 3 ST QL 1 / day ACIPHEX SPRINKLE 3 ST CARAFATE 1 GM/10 ML SUSP 2 CARAFATE 1 GM TABLET 3

PAGE 237 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & cimetidine 1 cimetidine hcl 1 CYTOTEC 3 QL 1 / day DEXILANT 3 ST esomeprazole magnesium (20 mg capsule dr, 40 mg 1 QL 1 / day capsule dr) esomeprazole sodium 1 QL 1 / day esomeprazole strontium 24.65 mg capsule dr 1 ST QL 1 / day esomeprazole strontium 49.3 mg capsule dr 1 ST famotidine 40mg/5ml oral susp 1 famotidine (20 mg tablet, 40 mg tablet) 1 famotidine (10 mg/ml vial, 20 mg/2 ml syringe) 1 famotidine in 0.9 % sodium chloride 1 famotidine in sodium chloride, iso-osmotic/pf 1 famotidine/pf 1 HEARTBURN TREATMENT 1 QL 1 / day lansoprazole 15 mg capsule dr 1 lansoprazole (15 mg tab rap dr, 30 mg capsule dr, 30 1 QL 1 / day mg tab rap dr) lansoprazole/amoxicillin trihydrate/clarithromycin 1 QL 112 / 365 days misoprostol 1 NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR QL 1 / day 10 MG PACKET, DR 20 MG CAPSULE, DR 20 MG 3 PACKET, DR 40 MG CAPSULE, DR 40 MG PACKET) ST

PAGE 238 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NEXIUM I.V. 3 nizatidine 150 mg capsule 1 QL 2 / day nizatidine 300 mg capsule 1 nizatidine 150mg/10ml solution 1 QL 80 / 365 days OMECLAMOX-PAK 3 PA (10 mg capsule dr, 20 mg capsule dr, 40 1 QL 1 / day mg capsule dr) omeprazole/sodium bicarbonate (omeprazole/sodium 20-1680mg packet, omeprazole/sodium 20mg-1.1g capsule, 1 ST omeprazole/sodium 40-1680mg packet, omeprazole/sodium 40mg-1.1g capsule) pantoprazole sodium 20 mg tablet dr 1 QL 1 / day pantoprazole sodium 40 mg tablet dr 1 QL 2 / day pantoprazole sodium 40 mg vial 1 PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML 3 ORAL SUSP)

PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 QL 1 / day 3 MG SOLUTAB, DR 30 MG CAPSULE) ST QL 112 / 365 days PREVPAC 3 PA PRILOSEC 3 ST QL 1 / day PROTONIX (DR 20 MG TABLET, 40 MG SUSPENSION) 3 ST QL 2 / day PROTONIX DR 40 MG TABLET 3 ST

PAGE 239 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PROTONIX IV 3 rabeprazole sodium 1 QL 2 / day ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 1 mg tablet, 300 mg capsule, 300 mg tablet) ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial) 1 sucralfate 1 ZANTAC (150 MG TABLET, 300 MG TABLET) 3 ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 3 1,000 MG/40 ML VIAL) ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG 3 ST CAPSULE) QL 1 / day ZEGERID 40 MG PACKET 3 ST CATHARTICS AND LAXATIVES AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) Excluded Drugs CLENPIQ 3 COLYTE WITH FLAVOR PACKETS 3 GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-N 1 GOLYTELY PACKET 3 GOLYTELY SOLUTION 3 HYDROCIL INSTANT POWDER 3 KONSYL ORIGINAL FIBER POWDER 3 MINERAL OIL (OIL ENEMA, OIL, HEAVY) 1

PAGE 240 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MIRALAX POWDER 3 MOVIPREP 3 GNP NATURAL FIBER POWDER 3 NULYTELY WITH FLAVOR PACKS 3 OSMOPREP 3 peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride (peg3350/sod sulf,bicarb,cl/kcl 236-22.74g soln recon, 1 peg3350/sod sulf,bicarb,cl/kcl 240-22.72g soln recon) PEG-PREP 1 PLENVU 3 polyethylene glycol 3350 (3350 17g powd pack, 3350 1 17g/dose powder) PREPOPIK 3 QL 2 / fill sodium chloride/sodium bicarbonate/potassium 1 chloride/peg SUPREP 3 QL 354 / fill TRILYTE WITH FLAVOR PACKETS 1 CHOLELITHOLYTIC AGENTS

ACTIGALL 3 CHENODAL 3 S URSO 3 URSO FORTE 3 ursodiol (250 mg tablet, 300 mg capsule, 500 mg 1 tablet)

PAGE 241 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DIGESTANTS

CREON 2 hydrochloric acid 1 PANCREAZE (DR 2,600 UNIT CAP, DR 4,200 UNIT CAP, DR 10,500 UNIT CAP, DR 16,800 UNIT CAP, DR Excluded Drugs 21,000 UNIT CAP) PERTZYE (DR 4,000 UNIT CAPSULE, DR 8,000 UNIT CAPSULE, DR 16,000 UNIT CAPSULE, DR 24,000 UNIT Excluded Drugs CAPSULE) VIOKACE (10,440-39,150 TB, 20,880-78,300 TB) Excluded Drugs ZENPEP 2 GI DRUGS, MISCELLANEOUS

QL 7 / day CHOLBAM 250 MG CAPSULE 3 PA S QL 4 / day CHOLBAM 50 MG CAPSULE 3 PA S ENTEREG 3 QL 2/ 30 days ENTYVIO 3 PA S PA GATTEX 3 S QL 0.22 / day PA HUMIRA(CF) PEDI CROHN 80-40 MG 3 S PS

PAGE 242 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day LINZESS 2 ST MOVANTIK (12.5 MG TABLET, 25 MG TABLET) Excluded Drugs QL 1 / day OCALIVA 3 PA S RELISTOR (12 MG/0.6 ML VIAL, 150 MG TABLET) Excluded Drugs QL 1 / day SYMPROIC 2 PA AL At least 18 yrs old TRULANCE 3 MG TABLET Excluded Drugs QL 2 / day VIBERZI 2 PA VSL#3 DS 3 XENICAL 3 PROKINETIC AGENTS metoclopramide hcl 10 mg/2 ml syringe 1 metoclopramide hcl (5 mg tablet, 5 mg/5 ml 1 solution, 10 mg tablet, 10 mg/10ml solution) metoclopramide hcl (5 mg tab rapdis, 10 mg tab 1 rapdis) metoclopramide hcl 5 mg/ml vial 1 REGLAN 3 GOLD COMPOUNDS

RIDAURA 2

PAGE 243 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & HEAVY METAL ANTAGONISTS

BAL IN OIL 3 CA-DTPA 1 CHEMET 3 CUPRIMINE 3 D-PENAMINE 2 PA deferasirox 1 S deferoxamine mesylate 1 DEPEN 2 DESFERAL 3 DESFERAL MESYLATE 3 edetate calcium disodium 1 PA EXJADE 3 S

FERRIPROX (100 MG/ML SOLUTION, 500 MG PA 3 TABLET) S GALZIN 3 PA JADENU 3 S PA JADENU SPRINKLE 3 S pentetate calcium trisodium 1 pentetate zinc trisodium 1 PA SYPRINE 3 S

PAGE 244 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA trientine hcl 1 S ZN-DTPA 1 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS

A-HYDROCORT 3 A-METHAPRED 1 ARISTOSPAN 3 betamethasone acetate and sodium phos in sterile 1 water/pf betamethasone acetate/betamethasone sodium 1 phosphate betamethasone acetate/betamethasone sodium 1 phosphate/water budesonide 3 mg capdr - er 1 PA budesonide 9 mg tabdr - er 1 PA CELESTONE 3 CORTEF 3 cortisone acetate 1 DECADRON (0.5 MG TABLET, 0.5 MG/5 ML ELIXIR, 1 0.75 MG TABLET, 4 MG TABLET, 6 MG TABLET) DELTASONE 1 DEPO-MEDROL 3

PAGE 245 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 1.5mg (21) tab ds pk, 1.5mg (35) tab ds 1 pk, 1.5mg (51) tab ds pk, 2 mg tablet, 4 mg tablet, 6 mg tablet) dexamethasone acetate and sodium phosphate in 1 sterile water dexamethasone acetate in sodium chloride, iso- 1 osmotic DEXAMETHASONE INTENSOL 2 dexamethasone sod phosphate 4 mg/ml vial 1 dexamethasone sodium phosphate (4 mg/ml 1 syringe, 4 mg/ml vial, 10 mg/ml vial) dexamethasone sodium phosphate in 0.9 % sodium 1 chloride dexamethasone sodium phosphate/pf 1 DEXPAK 3 DXEVO 3 PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 3 AL At least 5 yrs old MG/ML ORAL SUSP, 30 MG TABLET, 36 MG TABLET) S ENTOCORT EC 3 PA fludrocortisone acetate 1 HIDEX 1 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg 1 tablet) QL 1 / day INTRAROSA 3 AL At least 18 yrs old

PAGE 246 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & KENALOG-10 3 KENALOG-40 3 LOCORT 3 MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG 3 TABLET, 16 MG TABLET, 32 MG TABLET) MEDROL 2 MG TABLET 2 (4 mg tab ds pk, 4 mg tablet, 8 1 mg tablet, 16 mg tablet, 32 mg tablet) methylprednisolone acetate 1 methylprednisolone acetate in sodium chloride,iso- 1 osmotic/pf methylprednisolone acetate in sterile water for 1 injection methylprednisolone sodium succinate 1 MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3 MILLIPRED DP 3 ORAPRED ODT 3 PEDIAPRED 3 prednisolone 15 mg/5 ml solution 1 prednisolone sodium phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 ml solution, 15 mg tab 1 rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tab rapdis) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 1 10 mg tablet, 20 mg tablet, 50 mg tablet) PREDNISONE INTENSOL 3 SOLU-CORTEF 3

PAGE 247 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SOLU-MEDROL (40 MG VIAL, 125 MG VIAL, 500 MG 3 VIAL, 1,000 MG VIAL, 2,000 MG VIAL) SOLU-MEDROL 1 GRAM VIAL 3 triamcinolone acetonide (10 mg/ml vial, 40 mg/ml 1 vial) triamcinolone aceton/0.9% nacl 50 mg/ml vial 1 triamcinolone diacetate in 0.9 % sodium chloride 1 triamcinolone diacetate in 0.9 % sodium chloride/pf 1 UCERIS 2 MG RECTAL FOAM 3 UCERIS 9 MG ER TABLET 3 PA VERIPRED 20 3 ZODEX 3 ZONACORT 3 ANDROGENS

ANADROL-50 3 GL Male QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL 3 PA PCKT, 1.62%(2.5G) GEL PCKT) GL Male ANDROGEL 1% GEL PUMP Excluded Drugs ANDROGEL 1%(2.5G) GEL PACKET Excluded Drugs ANDROGEL 1%(5G) GEL PACKET Excluded Drugs PA ANDROID 3 GL Male PA ANDROXY 3 GL Male

PAGE 248 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA AVEED 3 S AXIRON 30 MG/ACTUATION SOLN Excluded Drugs COVARYX 1 GL Female COVARYX H.S. 1 GL Female danazol 1 PA DELATESTRYL 3 GL Male DEPO-TESTOSTERONE 3 GL Male EEMT 1 GL Female EEMT H.S. 1 GL Female estrogens,esterified/methyltestosterone 1 GL Female FORTESTA 10 MG GEL PUMP Excluded Drugs PA METHITEST 3 GL Male methyltestosterone 1 GL Male QL 3 / day PA NATESTO 3 GL Male AL At least 18 yrs old PA OXANDRIN 3 GL Male PA oxandrolone 1 GL Male PA STRIANT 3 GL Male

PAGE 249 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & TESTIM 1% (50MG) GEL Excluded Drugs PA TESTOPEL 3 GL Male S testosterone 50 mg (1%) gel (gram) 1 QL 300 / 30 days testosterone 12.5/1.25g gel md pmp 1 QL 10 / day testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel QL 5 / day 1 packet, 20.25/1.25 gel md pmp) GL Male QL 2.5 / day testosterone 25mg(1%) gel packet 1 GL Male testosterone 50 mg (1%) gel packet 1 QL 5 / day testosterone cypionate (100 mg/ml vial, 200 mg/ml 1 GL Male vial) testosterone enanthate 200 mg/ml vial 1 GL Male PA TESTRED 3 GL Male VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 Excluded Drugs MG/5 GEL PACKT) ANTIDIABETIC AGENTS acarbose 100 mg tablet 1 QL 3 / day acarbose 25 mg tablet 1 QL 12 / day acarbose 50 mg tablet 1 QL 6 / day ACTOPLUS MET 3 QL 3 / day QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB 2 ST

PAGE 250 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB 2 ST ACTOS 3 QL 1 / day ADLYXIN (10-20 MCG STARTER PACK, 20 MCG Excluded Drugs MAINTENANCE PK) ADMELOG 100 UNIT/ML VIAL Excluded Drugs ADMELOG SOLOSTAR 100 UNIT/ML Excluded Drugs AFREZZA 3 PA alogliptin 12.5 mg tablet Excluded Drugs alogliptin 25 mg tablet Excluded Drugs alogliptin 6.25 mg tablet Excluded Drugs alogliptin-metformin 12.5-1000 Excluded Drugs alogliptin-metformin 12.5-500 Excluded Drugs alogliptin-pioglit 12.5-15 mg Excluded Drugs alogliptin-pioglit 12.5-30 mg Excluded Drugs alogliptin-pioglit 12.5-45 mg Excluded Drugs alogliptin-pioglit 25-15 mg tb Excluded Drugs alogliptin-pioglit 25-30 mg tb Excluded Drugs alogliptin-pioglit 25-45 mg tb Excluded Drugs AMARYL 3 APIDRA 100 UNITS/ML VIAL Excluded Drugs APIDRA SOLOSTAR 100 UNITS/ML Excluded Drugs QL 2 / day AVANDAMET 2 PA QL 3 / day AVANDIA 2 MG TABLET 2 PA

PAGE 251 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day AVANDIA 4 MG TABLET 2 PA BASAGLAR 100 UNIT/ML KWIKPEN Excluded Drugs QL 0.15 / day BYDUREON 2 ST QL 0.15 / day BYDUREON BCISE 2 ST QL .15 / day BYDUREON PEN 2 ST QL 0.08 / day BYETTA 10 MCG DOSE PEN INJ 2 ST QL 0.04 / day BYETTA 5 MCG DOSE PEN INJ 2 ST chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 QL 3 / day DUETACT 3 QL 1 / day FARXIGA (5 MG TABLET, 10 MG TABLET) Excluded Drugs FIASP 100 UNIT/ML VIAL Excluded Drugs FIASP 100 UNIT/ML FLEXTOUCH Excluded Drugs glimepiride 1 glipizide (2.5 mg tab er 24, 5 mg tab er 24, 10 mg 1 tab er 24) glipizide (5 mg tablet, 10 mg tablet) 1 glipizide/metformin hcl (glipizide/metformin 2.5-500 1 QL 4 / day mg tablet, glipizide/metformin 5 mg-500mg tablet) glipizide/metformin hcl 2.5-250 mg tablet 1 QL 8 / day

PAGE 252 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & GLUCOPHAGE 1,000 MG TABLET 3 QL 2.5 / day GLUCOPHAGE 500 MG TABLET 3 QL 5 / day GLUCOPHAGE 850 MG TABLET 3 QL 3 / day GLUCOPHAGE XR 500 MG TAB 3 QL 5 / day GLUCOPHAGE XR 750 MG TAB 3 QL 3 / day GLUCOTROL 3 GLUCOTROL XL 3 GLUCOVANCE 3 QL 4 / day glyburide 1 glyburide,micronized 1 glyburide/metformin hcl (glyburide/metformin 2.5- 500 mg tablet, glyburide/metformin 5 mg-500mg 1 QL 4 / day tablet) glyburide/metformin hcl 1.25-250mg tablet 1 QL 8 / day GLYNASE 3 GLYSET 3 QL 3 / day QL 1 / day GLYXAMBI 2 ST HUMALOG (100 UNIT/ML VIAL, 100 UNITS/ML 2 CARTRIDGE) HUMALOG JUNIOR KWIKPEN 2 HUMALOG KWIKPEN U-100 2 HUMALOG KWIKPEN U-200 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2

PAGE 253 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & HUMALOG MIX 75-25 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN 70-30 2 HUMULIN 70/30 KWIKPEN 2 HUMULIN N 2 HUMULIN N KWIKPEN 2 HUMULIN R 2 HUMULIN R U-500 2 HUMULIN R U-500 KWIKPEN 2 QL 2 / day INVOKAMET 2 ST QL 2 / day INVOKAMET XR 2 ST QL 1 / day INVOKANA 2 ST QL 2 / day JANUMET 2 ST

JANUMET XR (50-1,000 MG TABLET, 50-500 MG QL 2 / day 2 TABLET) ST QL 1 / day JANUMET XR 100-1,000 MG TABLET 2 ST QL 1 / day JANUVIA 2 ST QL 1 / day JARDIANCE 2 ST QL 2 / day JENTADUETO 2 ST

PAGE 254 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day JENTADUETO XR 2.5 MG-1,000 MG 2 ST QL 1 / day JENTADUETO XR 5 MG-1,000 MG TB 2 ST KAZANO (12.5-1,000 MG TABLET, 12.5-500 MG Excluded Drugs TABLET) KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG Excluded Drugs TAB, 5-500 MG TABLET) PA KORLYM 3 S LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 100 UNIT/ML VIAL Excluded Drugs LEVEMIR FLEXTOUCH 100 UNIT/ML Excluded Drugs metformin hcl 500 mg/5ml solution 1 QL 25 / day QL 5 / day metformin hcl 500 mg tab er 24h 1 C Only Glucophage ER generic covered QL 3 / day metformin hcl 750 mg tab er 24h 1 C Only Glucophage ER generic covered metformin hcl 1000 mg tablet 1 QL 2.5 / day metformin hcl 500 mg tablet 1 QL 5 / day metformin hcl 850 mg tablet 1 QL 3 / day miglitol 1 QL 3 / day nateglinide 1 QL 3 / day NESINA (6.25 MG TABLET, 12.5 MG TABLET, 25 MG Excluded Drugs TABLET)

PAGE 255 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NOVOLIN 70-30 100 UNIT/ML VIAL Excluded Drugs NOVOLIN 70-30 (100 UNIT/ML VIAL, RELION VIAL) Excluded Drugs NOVOLIN 70-30 FLEXPEN (, RELION) Excluded Drugs NOVOLIN N 100 UNIT/ML VIAL Excluded Drugs NOVOLIN N (N 100 UNIT/ML VIAL, RELION N 100 Excluded Drugs UNIT/ML) NOVOLIN R 100 UNIT/ML VIAL Excluded Drugs NOVOLIN R (R 100 UNIT/ML VIAL, RELION R 100 Excluded Drugs UNIT/ML) NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML Excluded Drugs VIAL) NOVOLOG 100 UNIT/ML FLEXPEN Excluded Drugs NOVOLOG MIX 70-30 VIAL Excluded Drugs NOVOLOG MIX 70-30 FLEXPEN SYRN Excluded Drugs ONGLYZA (2.5 MG TABLET, 5 MG TABLET) Excluded Drugs OSENI (12.5-15 MG TABLET, 12.5-30 MG TABLET, 12.5-45 MG TABLET, 25-15 MG TABLET, 25-30 MG Excluded Drugs TABLET, 25-45 MG TABLET) QL 0.067 / day OZEMPIC 0.25-0.5 MG DOSE PEN 2 ST QL 0.124 / day OZEMPIC 1 MG DOSE PEN 2 ST pioglitazone hcl 1 QL 1 / day pioglitazone hcl/glimepiride 1 QL 1 / day pioglitazone hcl/metformin hcl 1 QL 3 / day PRANDIN 1 MG TABLET 3 QL 4 / day

PAGE 256 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PRANDIN 2 MG TABLET 3 QL 8 / day PRECOSE 100 MG TABLET 3 QL 3 / day PRECOSE 25 MG TABLET 3 QL 12 / day PRECOSE 50 MG TABLET 3 QL 6 / day QTERN 10 MG-5 MG TABLET Excluded Drugs repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day repaglinide/metformin hcl 1 QL 5 / day RIOMET 3 QL 25 / day QL 0.5 / day SAXENDA 3 PA AL At least 18 yrs old SEGLUROMET (2.5-1,000 MG TABLET, 2.5-500 MG Excluded Drugs TABLET, 7.5-1,000 MG TABLET, 7.5-500 MG TABLET) QL 0.6 / day SOLIQUA 100-33 2 PA STARLIX 3 QL 3 / day STEGLATRO (5 MG TABLET, 15 MG TABLET) Excluded Drugs STEGLUJAN (5-100 MG TABLET, 15-100 MG TABLET) Excluded Drugs QL 0.4 / day SYMLINPEN 120 2 PA QL 0.2 / day SYMLINPEN 60 2 PA QL 2 / day SYNJARDY 2 ST

PAGE 257 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG QL 2 / day 2 TABLET, 12.5-1,000 MG TAB) ST QL 1 / day SYNJARDY XR 25-1,000 MG TABLET 2 ST TANZEUM (30 MG PEN, 50 MG PEN) Excluded Drugs tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day TOUJEO MAX SOLOSTAR 2 TOUJEO SOLOSTAR 2 QL 1 / day TRADJENTA 2 ST TRESIBA 100 UNIT/ML VIAL Excluded Drugs TRESIBA FLEXTOUCH 100 UNIT/ML Excluded Drugs TRESIBA FLEXTOUCH 200 UNIT/ML Excluded Drugs QL 0.08 / day TRULICITY 2 ST QL 0.3 / day VICTOZA 2-PAK 2 ST QL 0.3 / day VICTOZA 3-PAK 2 ST XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MG TABLET, 10 MG-1,000 MG Excluded Drugs TAB, 10 MG-500 MG TABLET) QL 0.5 / day XULTOPHY 100-3.6 3 PA

PAGE 258 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ANTIHYPOGLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 PROGLYCEM 3 CONTRACEPTIVES

ALTAVERA 1 GL Female ALYACEN 1 GL Female QL 91 days AMETHIA 1 GL Female QL 91 days AMETHIA LO 1 GL Female QL 1 / day AMETHYST 1 GL Female APRI 1 GL Female ARANELLE 1 GL Female ASHLYNA 1 GL Female AUBRA 1 GL Female AUBRA EQ 1 GL Female AUROVELA 24 FE 1 GL Female AVIANE 1 GL Female AZURETTE 1 GL Female BALCOLTRA 3 GL Female BALZIVA 1 GL Female BEKYREE 1 GL Female

PAGE 259 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BLISOVI 24 FE 1 GL Female BLISOVI FE 1 GL Female BRIELLYN 1 GL Female CAMILA 1 GL Female QL 91 days CAMRESE 1 GL Female QL 91 days CAMRESE LO 1 GL Female CAZIANT 1 GL Female CHATEAL 1 GL Female CHATEAL EQ 1 GL Female CRYSELLE 1 GL Female CYCLAFEM 1 GL Female CYRED 1 GL Female CYRED EQ 1 GL Female DASETTA 1 GL Female QL 91 days DAYSEE 1 GL Female DEBLITANE 1 GL Female DELYLA 1 GL Female desogestrel-ethinyl estradiol 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol 1 GL Female drospir/eth estra/levomefol ca 3-0.02(24) tablet 1 GL Female drospir/eth estra/levomefol ca 3-0.03(21) tablet 1 GL Female

PAGE 260 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ELINEST 1 GL Female QL 1 / day ELLA 3 GL Female EMOQUETTE 1 GL Female ENPRESSE 1 GL Female ENSKYCE 1 GL Female ERRIN 1 GL Female ESTARYLLA 1 GL Female ethinyl estradiol/drospirenone 1 GL Female ethynodiol diacetate-ethinyl estradiol 1 GL Female FALMINA 1 GL Female QL 91 days FAYOSIM 1 GL Female FEMYNOR 1 GL Female GIANVI 1 GL Female GILDAGIA 1 GL Female HAILEY 24 FE 1 GL Female HEATHER 1 GL Female INCASSIA 1 GL Female QL 91 days INTROVALE 1 GL Female ISIBLOOM 1 GL Female JASMIEL 1 GL Female JENCYCLA 1 GL Female

PAGE 261 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 91 days JOLESSA 1 GL Female JOLIVETTE 1 GL Female JULEBER 1 GL Female JUNEL 1 GL Female JUNEL FE 1 GL Female JUNEL FE 24 1 GL Female KAITLIB FE 1 GL Female KARIVA 1 GL Female KELNOR 1-35 1 GL Female KELNOR 1-50 1 GL Female KIMIDESS 1 GL Female KURVELO 1 GL Female GL Female KYLEENA 3 S PS LARIN 1 GL Female LARIN 24 FE 1 GL Female LARIN FE 1 GL Female LARISSIA 1 GL Female LAYOLIS FE 1 GL Female LEENA 1 GL Female LESSINA 1 GL Female LEVONEST 1 GL Female

PAGE 262 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / 30 days levonorgestrel 1 GL Female levonorgestrel-ethinyl estradiol (0.1-0.02mg tablet, 0.15-0.03 tablet, 0.15-0.03 tbdspk 3mo, 6-5-10 1 GL Female tablet, 90-20 mcg tablet) l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 1 GL Female 3mo levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk QL 91 days 1 3mo, l-norgest/e.estradiol-e.estrad 100-20(84) GL Female tbdspk 3mo) LEVORA-28 1 GL Female LILETTA 3 S LILLOW 1 GL Female LO LOESTRIN FE 3 GL Female LOMEDIA 24 FE 1 GL Female LORYNA 1 GL Female LOW-OGESTREL 1 GL Female LUTERA 1 GL Female LYZA 1 GL Female MARLISSA 1 GL Female MELODETTA 24 FE 1 GL Female MIBELAS 24 FE 1 GL Female MICROGESTIN 1 GL Female MICROGESTIN 24 FE 1 GL Female MICROGESTIN FE 1 GL Female

PAGE 263 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & MILI 1 GL Female GL Female MIRENA 3 S PS MONO-LINYAH 1 GL Female MONONESSA 1 GL Female MYZILRA 1 GL Female NATAZIA 2 GL Female NECON (0.5-35-28 TABLET, 7-7-7-28 TABLET, 10-11- 1 GL Female 28 TABLET) NECON 1-50-28 TABLET 3 GL Female NEXPLANON 3 S NIKKI 1 GL Female NORA-BE 1 GL Female norethindrone 1 GL Female norethindrone ac-eth estradiol 1mg-20mcg tablet 1 GL Female norethindrone acetate-ethinyl estradiol/ferrous 1 GL Female fumarate (tab chew, tablet) norethindrone-e.estradiol-iron 1mg-20(21) tablet 1 GL Female norethindrone-ethinyl estradiol/ferrous fumarate 1 GL Female norgestimate-ethinyl estradiol 1 GL Female NORLYDA 1 GL Female NORLYROC 1 GL Female NORTREL 1 GL Female

PAGE 264 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NUVARING 2 GL Female OCELLA 1 GL Female OGESTREL 1 GL Female ORSYTHIA 1 GL Female PARAGARD T 380-A 3 S PHILITH 1 GL Female PIMTREA 1 GL Female PIRMELLA 1 GL Female PORTIA 1 GL Female PREVIFEM 1 GL Female QL 91 days QUASENSE 1 GL Female RAJANI 1 GL Female RECLIPSEN 1 GL Female QL 91 days RIVELSA 1 GL Female QL 91 days SETLAKIN 1 GL Female SHAROBEL 1 GL Female GL Female SKYLA 3 S PS SPRINTEC 1 GL Female SRONYX 1 GL Female

PAGE 265 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SYEDA 1 GL Female TARINA 24 FE 1 GL Female TARINA FE 1 GL Female TARINA FE 1-20 EQ 1 GL Female TAYTULLA 3 GL Female TILIA FE 1 GL Female TRI FEMYNOR 1 GL Female TRI-ESTARYLLA 1 GL Female TRI-LEGEST FE 1 GL Female TRI-LINYAH 1 GL Female TRI-LO-ESTARYLLA 1 GL Female TRI-LO-MARZIA 1 GL Female TRI-LO-SPRINTEC 1 GL Female TRI-MILI 1 GL Female TRI-PREVIFEM 1 GL Female TRI-SPRINTEC 1 GL Female TRI-VYLIBRA 1 GL Female TRI-VYLIBRA LO 1 GL Female TRINESSA 1 GL Female TRINESSA LO 1 GL Female TRIVORA-28 1 GL Female TULANA 1 GL Female TYDEMY 1 GL Female

PAGE 266 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VELIVET 1 GL Female VESTURA 1 GL Female VIENVA 1 GL Female VIORELE 1 GL Female VYFEMLA 1 GL Female VYLIBRA 1 GL Female WERA 1 GL Female WYMZYA FE 1 GL Female QL 0.12 / day XULANE 3 GL Female ZARAH 1 GL Female ZENCHENT 1 GL Female ZENCHENT FE 1 GL Female ZOVIA 1-35E 1 GL Female ZOVIA 1-50E 1 GL Female ESTROGENS AND ANTIESTROGENS

QL 1 / day ACTIVELLA 3 GL Female QL 0.29 / day ALORA 3 GL Female QL 1 / day AMABELZ 1 GL Female QL 1 / day ANGELIQ 3 GL Female

PAGE 267 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day BIJUVA 3 GL Female QL 0.15 / day CLIMARA 3 GL Female QL 0.15 / day CLIMARA PRO 2 GL Female clomiphene citrate 1 GL Female QL 0.29 / day COMBIPATCH 3 GL Female DELESTROGEN 3 GL Female DEPO-ESTRADIOL 3 GL Female DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 2 GL Female 0.75 MG GEL PACKET, 1 MG GEL PACKET) DUAVEE 2 ELESTRIN 3 GL Female QL 4 / day ESTRACE 0.01% CREAM 3 GL Female

ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG QL 1 / day 3 TABLET) GL Female QL 4 / day estradiol 0.01 % cream/appl 1 GL Female estradiol (.025mg/24h patch tdsw, .0375mg/24 QL 0.29 / day patch tdsw, 0.05mg/24h patch tdsw, .075mg/24h 1 patch tdsw, 0.1mg/24hr patch tdsw) GL Female estradiol (.025mg/24h patch tdwk, 0.05mg/24h QL 0.15 / day 1 patch tdwk, 0.1mg/24hr patch tdwk) GL Female

PAGE 268 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & estradiol (.0375mg/24 patch tdwk, 0.06mg/24h QL 0.15 / day 1 patch tdwk) GL Female QL 0.15 / day estradiol .075mg/24h patch tdwk 1 GL Female QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female QL 1 / day estradiol (2 mg tablet, 10 mcg tablet) 1 GL Female estradiol valerate 1 GL Female QL 1 / day estradiol/norethindrone acetate 1 GL Female QL 90 days ESTRING 2 GL Female QL 1.667 / day ESTROGEL 3 GL Female QL 1 / day estropipate 1 GL Female QL 0.54 / day EVAMIST 3 GL Female EVISTA 3 QL 1 / day FARESTON 3 QL 1 / day FEMHRT 3 GL Female QL 0.02 / day FEMRING 3 GL Female FYAVOLV 1 GL Female

PAGE 269 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & IMVEXXY (4 MCG MAINTENANCE PACK, 4 MCG STARTER PACK, 10 MCG MAINTENANCE PAK, 10 3 QL 1 / day MCG STARTER PACK) JEVANTIQUE LO 1 GL Female QL 1 / day JINTELI 1 GL Female QL 1 / day LOPREEZA 1 GL Female QL 1 / day MENEST (0.625 MG TABLET, 1.25 MG TABLET) 3 GL Female QL 1 / day MENEST 0.3 MG TABLET 2 GL Female QL 0.15 / day MENOSTAR 3 GL Female QL 1 / day MIMVEY 1 GL Female MIMVEY LO 1 QL 0.29 / day MINIVELLE 3 GL Female norethindrone acetate-ethinyl estradiol (0.5mg-2.5 1 tablet, 1mg-5mcg tablet) QL 1 / day OGEN 3 GL Female OSPHENA 3 QL 1 / day PREFEST 3 GL Female QL 2 / day PREMARIN VAGINAL CREAM-APPL 2 GL Female

PAGE 270 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 QL 1 / day 2 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET) GL Female PREMARIN 25 MG VIAL 2 QL 1 / day PREMPHASE 2 GL Female QL 1 / day PREMPRO 2 GL Female raloxifene hcl 1 SEROPHENE 1 GL Female SOLTAMOX 3 tamoxifen citrate 1 toremifene citrate 1 QL 1 / day VAGIFEM 3 GL Female QL 0.29 / day VIVELLE-DOT 3 GL Female QL 1 / day YUVAFEM 1 GL Female GONADOTROPINS AND ANTIGONADOTROPINS

PA BRAVELLE 3 GL Female S PA GL Female CETROTIDE 3 S PS

PAGE 271 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & chorionic gonadotropin, human 1 S PA ELIGARD 3 S PA FIRMAGON 3 S PA FOLLISTIM AQ 3 S GL Female ganirelix acetate 1 S PA GONAL-F 3 S PS PA GL Female GONAL-F RFF 3 S PS PA GL Female GONAL-F RFF REDI-JECT 3 S PS PA leuprolide acetate 1 S PA LUPRON DEPOT 3 S PA LUPRON DEPOT (LUPANETA) 3 S

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, PA 3 11.25 MG KIT, 15 MG KIT, 30 MG 3MO KIT) S

PAGE 272 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA GL Female MENOPUR 3 S PS PA NOVAREL 1 S QL 1 / day ORILISSA 150 MG TABLET 2 PA AL At least 18 yrs old QL 2 / day ORILISSA 200 MG TABLET 2 PA AL At least 18 yrs old PA OVIDREL 3 S PS PA PREGNYL 1 S PA SUPPRELIN LA 3 S PA SYNAREL 3 S PA TRELSTAR 3 S PA VANTAS 3 S PA ZOLADEX 10.8 MG IMPLANT SYRN 3 S

PAGE 273 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA ZOLADEX 3.6 MG IMPLANT SYRN 3 S PS LEPTINS

PA MYALEPT 3 S PARATHYROID AND ANTIPARATHYROID AGENTS calcitonin,salmon,synthetic 1 QL 0.13 / day PA FORTEO 3 S MIACALCIN 3 S PA NATPARA 3 S QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 3 PA S QL 4 / day SENSIPAR 90 MG TABLET 3 PA S QL 1.60 / day PA TYMLOS 3 AL At least 18 yrs old S PITUITARY DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 3 MG TABLET, 10 MCG/0.1 ML SOLUTION)

PAGE 274 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 desmopressin acetate 4 mcg/ml ampul 1 desmopressin acetate (0.1 mg tablet, 0.1 mg/ml 1 solution, 0.2 mg tablet, 10/spray spray/pump) desmopressin acetate 4 mcg/ml vial 1 desmopressin acetate (non-refrigerated) 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK PA 3 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, S MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE)

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG PA 3 CARTRIDGE, 24 MG CARTRIDGE) S QL 1 / day NOCDURNA 3 PA QL 0.1 / day NOCTIVA 3 PA PA NORDITROPIN FLEXPRO 3 S PS PA NUTROPIN AQ NUSPIN 3 S

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 PA 3 MG/1.5 ML CRTG) S

SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 PA 3 MG VIAL) S PA SAIZEN-SAIZENPREP 3 S

PAGE 275 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day SEROSTIM 3 PA S STIMATE 3 S vasopressin in 0.9 % sodium chloride 1 vasopressin in dextrose 5 % in water 1 PA ZOMACTON 3 S QL 1 / day ZORBTIVE 3 PA S PROGESTINS

AYGESTIN 3 GL Female CRINONE 4% GEL 3 GL Female QL 2.5 / day CRINONE 8% GEL 3 GL Female DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML 3 GL Female VIAL) DEPO-PROVERA 400 MG/ML VIAL 3 QL 90 days DEPO-SUBQ PROVERA 104 3 PA GL Female QL 3 / day ENDOMETRIN 2 GL Female PA GL Female hydroxyprogesterone caproate 250 mg/ml vial 1 S PS

PAGE 276 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA GL Female hydroxyprogesterone caproate/pf 1 S PS PA MAKENA (250 MG/ML VIAL, 275 MG/1.1 ML GL Female 3 AUTOINJCT, 1,250 MG/5 ML VIAL) S PS medroxyprogesterone acetate (2.5 mg tablet, 5 mg 1 GL Female tablet, 10 mg tablet) medroxyprogesterone acetate (150 mg/ml syringe, QL 0.04 / day 1 150 mg/ml vial) GL Female MEGACE ES 3 GL Female megestrol acetate (20 mg tablet, 40 mg tablet, 1 400mg/10ml oral susp, 625mg/5ml oral susp) norethindrone acetate 1 GL Female 1 GL Female progesterone, micronized 1 GL Female PROMETRIUM 3 GL Female PROVERA 3 GL Female SOMATOSTATIN AGONISTS AND ANTAGONISTS octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 100 mcg/ml ampul, 100 mcg/ml syringe, PA 1 100 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml S syringe, 500 mcg/ml vial) octreotide acetate (50 mcg/ml vial, 200 mcg/ml vial, PA 1 1000mcg/ml vial) S

PAGE 277 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 3 PA S QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 3 PA S QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 3 PA S QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 3 PA S QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 3 PA S QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 3 PA MG KT, 30 MG VL) S QL 0.07 / day SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 3 PA S PA SIGNIFOR 3 S QL 0.1 / day SIGNIFOR LAR (10 MG KIT, 10 MG VIAL, 20 MG KIT, 3 PA 20 MG VIAL, 30 MG KIT, 30 MG VIAL) S QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 3 PA S

PAGE 278 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 3 PA S QL 0.02 / day SOMATULINE DEPOT 3 PA S SOMATOTROPIN AGONISTS AND ANTAGONISTS

QL 2 / day EGRIFTA 3 PA S PA INCRELEX 3 S SOMAVERT 3 S THYROID AND ANTITHYROID AGENTS

ARMOUR THYROID 3 CYTOMEL 3 EUTHYROX 1 LEVO-T 1 sodium (25 mcg tablet, 50 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 1 mcg tablet, 150 mcg tablet, 175 mcg tablet) levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 1 200 mcg tablet, 300 mcg tablet) levothyroxine sodium (100 mcg vial, 200 mcg vial, 1 500 mcg vial) LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 1 MCG TABLET)

PAGE 279 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 1 150 MCG TABLET, 175 MCG TABLET, 200 MCG TABLET) liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 1 mcg tablet) liothyronine sodium 10 mcg/ml vial 1 methimazole 1 NATURE-THROID 3 NP THYROID 1 propylthiouracil 1 SSKI 3 SYNTHROID 2 TAPAZOLE 3 THYROID 1 thyroid,pork 1 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3 TIROSINT 3 QL 1 / day TIROSINT-SOL 3 QL 1 / day TRIOSTAT 3 UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 1 MCG TABLET, 112 MCG TABLET)

PAGE 280 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 1 175 MCG TABLET, 200 MCG TABLET, 300 MCG TABLET) WESTHROID 3 WP THYROID 3 LOCAL ANESTHETICS (PARENTERAL) lidocaine hcl 50 mg/5 ml syringe 1 lidocaine hcl buffered with 8.4 % sodium bicarbonate 3 (1.8 %(3ml) syringe, 1.8 %(5ml) syringe) lidocaine hcl in 0.9 % sodium chloride 1 lidocaine hcl in sodium chloride, iso-osmotic/pf 1 lidocaine hcl/pf (hcl/pf 40 mg/2 ml syringe, hcl/pf 1 400mg/20ml syringe) MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS

QL 1 / day AVODART 3 GL Male QL 1 / day dutasteride 1 GL Male QL 1 / day dutasteride/tamsulosin hcl 1 GL Male QL 1 / day finasteride 5 mg tablet 1 GL Male QL 1 / day JALYN 3 GL Male

PAGE 281 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day PROSCAR 3 GL Male ALCOHOL DETERRENTS

ANTABUSE 3 disulfiram 1 ANTIDOTES

DUODOTE 3 FUSILEV 3 S KHAPZORY 3 S leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg 1 tablet, 25 mg tablet) leucovorin calcium (10 mg/ml vial, 50 mg vial, 100 1 S mg vial, 200 mg vial, 350 mg vial, 500 mg vial) levoleucovorin calcium (10 mg/ml vial, 50 mg vial, 1 S 175 mg vial) methylene blue 1 % vial 1 NITHIODOTE 3 pralidoxime chloride 1 PROTOPAM CHLORIDE 3 1 VISTOGARD 3 S VORAXAZE 3 S ANTIGOUT AGENTS allopurinol 100 mg tablet 1 QL 3 / day allopurinol 300 mg tablet 1 QL 2 / day

PAGE 282 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & allopurinol sodium 1 ALOPRIM 3 colchicine 0.6 mg capsule 1 QL 2 / day colchicine 0.6 mg tablet 1 QL 4 / day COLCRYS 2 QL 4 / day QL 0.07 / day KRYSTEXXA 3 PA S QL 2 / day MITIGARE 3 ST QL 1 / day ULORIC 2 ST ZYLOPRIM 100 MG TABLET 3 QL 3 / day ZYLOPRIM 300 MG TABLET 3 QL 2 / day ANTISENSE OLIGONUCLEOTIDES

PA TEGSEDI 3 S BONE RESORPTION INHIBITORS

ACTONEL (5 MG TABLET, 30 MG TABLET) 3 QL 1 / day ACTONEL 150 MG TABLET 3 QL 0.04 / day ACTONEL 35 MG TABLET 3 QL 0.15 / day alendronate sodium (35 mg tablet, 40 mg tablet, 70 1 QL .15 / day mg tablet, 70 mg/75ml solution) alendronate sodium (5 mg tablet, 10 mg tablet) 1 QL 1 / day QL 0.15 / day ATELVIA 3 ST

PAGE 283 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BINOSTO 3 QL .15 / day BONIVA 3 MG/3 ML SYRINGE 3 S BONIVA 150 MG TABLET 3 QL 0.04 / day etidronate disodium 1 FOSAMAX 3 QL .15 / day FOSAMAX PLUS D 3 QL 0.15 / day ibandronate sodium 3 mg/3 ml syringe 1 S ibandronate sodium 150 mg tablet 1 QL 0.04 / day ibandronate sodium 3 mg/3 ml vial 1 S pamidronate disodium (30 mg vial, 30mg/10ml vial, 1 S 60 mg/10ml vial, 90 mg vial, 90 mg/10ml vial) QL 0.13 / day PROLIA 3 PA S RECLAST 3 S risedronate sodium 150 mg tablet 1 QL 0.04 / day risedronate sodium 30 mg tablet 1 risedronate sodium 35 mg tablet 1 QL 0.15 / day risedronate sodium 5 mg tablet 1 QL 1 / day risedronate sodium 35 mg tablet dr 1 QL 0.07 / day XGEVA 3 PA S zoledronic acid (4 mg vial, 4 mg/5 ml vial) 1 S zoledronic acid in mannitol and 0.9 % sodium 1 S chloride

PAGE 284 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & zoledronic acid in mannitol and water for injection (acid/mannitol-water 4 mg/100ml pggybk btl, 1 S acid/mannitol-water 5 mg/100ml pggybk btl, acid/mannitol-water 5 mg/100ml piggyback) ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML 3 S VIAL) CARBONIC ANHYDRASE INHIBITORS (MISC.)

QL 4 / day KEVEYIS 3 PA S CARIOSTATIC AGENTS

DENTA 5000 PLUS 1 DENTAGEL 1 PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER 3 PLUS, DENTAL RINSE) PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 COMPLEMENT INHIBITORS

PA BERINERT (500 UNIT KIT, 500 UNIT VIAL) 3 S PA CINRYZE 3 S

PAGE 285 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA FIRAZYR 3 S QL 1.25 / day HAEGARDA 3 PA S PA KALBITOR 3 S QL 0.87 / day RUCONEST 3 PA S PA SOLIRIS 3 S QL 0.144 / day TAKHZYRO 3 PA S DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 3 PA S QL 0.15 / day ACTEMRA (80 MG/4 ML VIAL, 200 MG/10 ML VIAL, 3 PA 400 MG/20 ML VIAL) S QL 0.15 / day ACTEMRA ACTPEN 3 PA S ARAVA 3 QL 0.08 / day PA CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 3 S PS

PAGE 286 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 3/ fill PA CIMZIA 200 MG/ML STARTER KIT 3 S PS QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 3 PA MG/ML SYRINGE) S QL 0.15 / day ENBREL MINI 3 PA S QL 0.15 / day ENBREL SURECLICK 3 PA S QL 0.22 / day HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML PA 3 SYRINGE) S PS QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 3 S PS QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 3 S PS QL 0.22 / day PA HUMIRA PEN 3 S PS

PAGE 287 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.22 / day PA HUMIRA PEN CROHN'S-UC-HS 3 S PS QL 0.22 / day PA HUMIRA PEN PSOR-UVEITS-ADOL HS 3 S PS QL 0.22 / day PA HUMIRA(CF) 3 S PS QL 0.22 / day PA HUMIRA(CF) PEDI CROHN 80MG/0.8 3 S PS QL 0.22 / day PA HUMIRA(CF) PEN 3 S PS QL 0.22 / day PA HUMIRA(CF) PEN CROHN'S-UC-HS 3 S PS QL 0.22 / day PA HUMIRA(CF) PEN PSOR-UV-ADOL HS 3 S PS

PAGE 288 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & INFLECTRA 100 MG VIAL Excluded Drugs QL 0.1 / day KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 PA ML SYRINGE, 200 MG/1.14 ML PEN INJ, 200 3 AL At least 18 yrs old MG/1.14 ML SYRINGE) S PS QL 10 / day KINERET 3 PA S leflunomide 1 OLUMIANT 2 MG TABLET Excluded Drugs QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML 3 PA SYRINGE, 125 MG/ML SYRINGE) S QL 0.15 / day ORENCIA 250 MG VIAL 3 PA S QL 0.15 / day ORENCIA CLICKJECT 3 PA S QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, PA 3 STARTER PACK) S PS QL 10 / 30 days REMICADE 3 S PS

PAGE 289 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & RENFLEXIS 100 MG VIAL Excluded Drugs QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML PA SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML 3 SYRINGE) S PS QL 0.29 / day PA SIMPONI ARIA 3 S PS QL 2 / day PA XELJANZ 3 S PS QL 1 / day PA XELJANZ XR 3 S PS IMMUNOMODULATORY AGENTS

ACTIMMUNE 3 S QL 1 / day AUBAGIO 3 PA S QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG PA 3 KT) S PS QL 0.15 / day PA AVONEX PEN 3 S PS

PAGE 290 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.5 / day PA BETASERON (0.3 MG KIT, 0.3 MG VIAL) 3 S PS QL 1 / day PA COPAXONE 20 MG/ML SYRINGE 3 S PS QL 0.434 / day PA COPAXONE 40 MG/ML SYRINGE 3 S PS QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 3 PA S QL 2 / day PA GILENYA 0.25 MG CAPSULE 3 S PS QL 1 / day PA GILENYA 0.5 MG CAPSULE 3 S PS QL 1 / day PA glatiramer acetate 20 mg/ml syringe 3 S PS QL 0.434 / day PA glatiramer acetate 40 mg/ml syringe 3 S PS

PAGE 291 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day GLATOPA 20 MG/ML SYRINGE 3 PA S QL 0.434 / day GLATOPA 40 MG/ML SYRINGE 3 PA S QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML SYRING 3 S PS QL 1 / lifetime PA PLEGRIDY SYRINGE STARTER PACK 3 S PS QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML PEN 3 S PS QL 1 / lifetime PA PLEGRIDY PEN INJ STARTER PACK 3 S PS QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML 3 PA SYRINGE) S QL 4.2 / 365 days REBIF TITRATION PACK 3 PA S

PAGE 292 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 3 PA S QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 3 PA S QL 2 / day PA TECFIDERA 3 S PS QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 3 PA S QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 3 PA S QL 0.6 / day TYSABRI 3 PA S QL 1 / day ZINBRYTA 3 PA S IMMUNOSUPPRESSIVE AGENTS

QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 3 PA S QL 30 / day ASTAGRAF XL 1 MG CAPSULE 3 PA S

PAGE 293 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 6 / day ASTAGRAF XL 5 MG CAPSULE 3 PA S ATGAM 3 S AZASAN 3 azathioprine 1 azathioprine sodium 1

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML PA 3 SYRINGE) S QL 0.25 / day BENLYSTA 120 MG VIAL 3 PA S QL 0.07 / day BENLYSTA 400 MG VIAL 3 PA S CELLCEPT (200 MG/ML ORAL SUSP, 250 MG 3 S CAPSULE, 500 MG TABLET) CELLCEPT 500 MG VIAL 3 S cyclosporine 250 mg/5ml ampul 1 S cyclosporine (25 mg capsule, 100 mg capsule) 1 S cyclosporine, modified (25 mg capsule, 50 mg 1 S capsule, 100 mg capsule, 100 mg/ml solution) QL 1 / day ENVARSUS XR 3 PA S GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 1 S MG CAPSULE, 100 MG/ML SOLUTION)

PAGE 294 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & IMURAN 3 mycophenolate mofetil (250 mg capsule, 500 mg 1 S tablet) mycophenolate mofetil 200 mg/ml susp recon 1 S mycophenolate mofetil hcl 1 S mycophenolate sodium 1 S MYFORTIC 3 S NEORAL (25 MG GELATIN CAPSULE, 100 MG 3 S GELATIN CAPSULE, 100 MG/ML SOLUTION) PA NULOJIX 3 S PROGRAF 5 MG/ML AMPULE 2 S PROGRAF (0.2 MG GRANULE PACKET, 0.5 MG CAPSULE, 1 MG CAPSULE, 1 MG GRANULE PACKET, 5 2 S MG CAPSULE) RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 3 S MG/ML ORAL SOLN, 2 MG TABLET) SANDIMMUNE 50 MG/ML AMPUL 3 S SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 3 S 100 MG/ML SOLN) SIMULECT 3 (0.5 mg tablet, 1 mg tablet, 1 mg/ml 1 S solution, 2 mg tablet) (0.5 mg capsule, 1 mg capsule, 5 mg 1 S capsule) THYMOGLOBULIN 3 PA ZORTRESS 3 S

PAGE 295 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & OTHER MISCELLANEOUS THERAPEUTIC AGENTS alpha 100 mg capsule 1 QL 2 / day AMPYRA 3 PA S PA ARCALYST 3 S bioflavonoids, citrus 3 PA BOTOX 3 S PA BOTOX COSMETIC 3 S CARNITOR (100 MG/ML ORAL SOLN, 330 MG 3 TABLET) CARNITOR 1 GM/5 ML VIAL 3 CARNITOR SF 3 QL 2 / day CERDELGA 3 PA S CYSTADANE 3 S QL 13 / day CYSTAGON 150 MG CAPSULE 3 PA S QL 40/ day CYSTAGON 50 MG CAPSULE 3 PA S

PAGE 296 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 2 / day dalfampridine 1 PA S DEMSER 3 PA DYSPORT 3 S PS PA GALAFOLD 3 S QL 0.08 / day ILARIS 3 PA S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, PA 3 500 MG POWDER PACKET) S levocarnitine 200 mg/ml vial 1 levocarnitine (with sugar) 1 melatonin 3 mg tablet 1 melatonin/pyridoxine 3mg-2mg tablet 1 melatonin/pyridoxine hcl (b6) 3 mg-10 mg tablet 1 methylene blue powder 3 MIDNITE FOR MENOPAUSE 3 MIDNITE MENOPAUSE 3 MIDNITE PM 3 PA miglustat 1 S PA MYOBLOC 3 S

PAGE 297 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NEXAVIR 3 PA NITYR 3 S

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 PA 3 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S PANHEMATIN 3 POTABA 3 QL 3 / day PROCYSBI DR 25 MG CAPSULE 3 PA S QL 1 / day PROCYSBI DR 75 MG CAPSULE 3 PA S THIOLA 3 TYBOST 3 S PA XEOMIN 3 S XURIDEN 3 S PA ZAVESCA 3 S PROTECTIVE AGENTS amifostine crystalline 1 S PA dexrazoxane hcl 1 S QL 3 / day ELMIRON 2 PA

PAGE 298 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ETHYOL 3 S mesna 100 mg/ml vial 1 S MESNEX 400 MG TABLET 3 S MESNEX 1 GRAM/10 ML VIAL 3 S PA ZINECARD 3 S OXYTOCICS

METHERGINE 1 methylergonovine maleate 0.2 mg tablet 1 MIFEPREX 3 PHARMACEUTICAL AIDS anise oil 1 DILUENT FOR ELITEK 3 ethyl acetate 1 eucalyptol 1 eucalyptus oil 100 % oil 1 lemon flavor extract 1 lemon oil 1 orange oil 1 raspberry flavor, artificial 1 sassafras 1 SHINGRIX ADJUVANT COMPONENT 2 AL At least 50 yrs old spearmint oil 1 PA stabilizer for moxetumomab pasudotox-tdfk 3 S

PAGE 299 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & RADIOACTIVE AGENTS

HICON 3 S METASTRON 3 S PA XOFIGO 3 S RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

ACCOLATE 3 QL 2 / day ADVAIR DISKUS 2 QL 2 / day ADVAIR HFA 2 QL 0.4 / day AEROSPAN 2 QL 0.334 / day AIRDUO RESPICLICK (55-14 MCG, 113-14 MCG, 232- Excluded Drugs 14 MCG) ALOCRIL 3 QL 5 / fill ALVESCO (80 MCG INHALER, 160 MCG INHALER) Excluded Drugs ARMONAIR RESPICLICK (55 MCG, 113 MCG, 232 Excluded Drugs MCG) ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day ARNUITY ELLIPTA 50 MCG INH 2 QL 4 / day ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 110 MCG #7, TWISTHALER 220 MCG #14, Excluded Drugs TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120) ASMANEX HFA (HFA 100 MCG INHALER, HFA 200 Excluded Drugs MCG INHALER)

PAGE 300 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & BREO ELLIPTA 2 QL 2 / day budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml 1 ampul-neb) budesonide 1 mg/2 ml ampul-neb 1 cromolyn sodium 20 mg/2 ml ampul-neb 1 cromolyn sodium 4 % drops 1 QL 10 / fill cromolyn sodium 20 mg/ml oral conc 1 DULERA (100 MCG/5 MCG INHALER, 200 MCG/5 Excluded Drugs MCG INHALER) QL 0.15 / day PA DUPIXENT 200 MG/1.14 ML SYRING 3 AL At least 12 yrs old S PA FASENRA 3 S FLOVENT 250 MCG DISKUS 2 QL 8 / day FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 2 QL 0.8 / day MCG INHALER) FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day fluticasone propionate/salmeterol xinafoate (propion/salmeterol 55-14 mcg aer pow ba, QL 0.04 / day 1 propion/salmeterol 113-14 mcg aer pow ba, AL At least 12 yrs old propion/salmeterol 232-14 mcg aer pow ba) fluticasone propionate/salmeterol xinafoate (propion/salmeterol 100-50 mcg blst w/dev, 1 QL 2 / day propion/salmeterol 250-50 mcg blst w/dev, propion/salmeterol 500-50 mcg blst w/dev)

PAGE 301 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & GASTROCROM 3 montelukast sodium 4 mg gran pack 1 QL 1 / day montelukast sodium (4 mg tab chew, 5 mg tab chew, 1 QL 1 / day 10 mg tablet) QL 0.04 / day PA NUCALA 3 AL At least 12 yrs old S PULMICORT 3 QL 120 / 30 days PULMICORT FLEXHALER 2 QL 0.07 / day QVAR (40 MCG ORAL INHALER, 80 MCG ORAL Excluded Drugs INHALER) QVAR REDIHALER (40 MCG, 80 MCG) Excluded Drugs SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 3 QL 1 / day MG TABLET CHEW, 10 MG TABLET) SYMBICORT 2 QL 0.4 / day TRELEGY ELLIPTA 2 QL 2 / day WIXELA INHUB 1 QL 2 / day 1 QL 2 / day QL 4 / day zileuton 1 ST QL 4 / day ZYFLO 3 ST QL 4 / day ZYFLO CR 3 ST

PAGE 302 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ANTIFIBROTIC AGENTS

QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 3 PA S QL 3 / day ESBRIET 801 MG TABLET 3 PA S QL 2 / day OFEV 3 PA S ANTITUSSIVES

ALLFEN CDX 3 benzonatate (150 mg capsule, 200 mg capsule) 1 AL At least 10 yrs old benzonatate 100 mg capsule 1 AL At least 10 yrs old BROMFED DM 1 AL At least 2 yrs old brompheniramine/pseudoephed/dm 2-30-10/5 syrup 1 AL At least 2 yrs old CENTERGY DM 1 QL 60 / day codeine phosphate/guaifenesin 10-100mg/5 liquid 1 AL At least 6 yrs old codeine phosphate/guaifenesin 20-200/10 liquid 1 CORICIDIN HBP COUGH & COLD TAB 3 DAYTIME COLD-FLU LIQUID 1 QL 60 / day FLOWTUSS 3 AL At least 18 yrs old GUAIFENESIN DAC 1

PAGE 303 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 60 / day guaifenesin/hydrocodone bitartrate 1 AL At least 18 yrs old HISTEX-DM 3 QL 40/ day HYCOFENIX 3 AL At least 18 yrs old hydrocodone bitart/chlorpheniramine QL 20 / day 1 maleate/pseudoephedrine AL At least 18 yrs old QL 30 / day hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup 1 AL At least 2 yrs old QL 6 / day hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet 1 AL At least 6 yrs old QL 10 / day hydrocodone polistirex/chlorpheniramine polistirex 1 AL At least 6 yrs old QL 30 / day HYDROMET 1 AL At least 18 yrs old LORTUSS EX 1 MAXIFED CDX 3 MAXIPHEN CD 3 MAXIPHEN CDX 3 NEOTUSS PLUS 3 NIVA-HIST DM 1 QL 60 / day OBREDON 3 AL At least 18 yrs old promethazine hcl/codeine 1 promethazine/dextromethorphan 6.25-15/5 syrup 1 AL At least 2 yrs old

PAGE 304 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 30 / day promethazine/phenylephrine hcl/codeine 1 AL At least 6 yrs old QL 20 / day REZIRA 3 AL At least 18 yrs old TESSALON PERLE 3 AL At least 11 yrs old TUSNEL CAPLET 3 TUSNEL DM PEDIATRIC DROPS 3 QL 6 / day TUSSICAPS 3 AL At least 6 yrs old QL 6 / day TUSSIGON 1 AL At least 6 yrs old QL 10 / day TUSSIONEX 3 AL At least 18 yrs old QL 2 / day TUXARIN ER 3 AL At least 18 yrs old QL 20 / day TUZISTRA XR 3 AL At least 18 yrs old QL 4 / day VITUZ 3 AL At least 6 yrs old ZODRYL DAC 50 3 ZODRYL DAC 60 3 ZODRYL DAC 80 3 ZODRYL DEC 50 3 ZODRYL DEC 60 3 ZODRYL DEC 80 3

PAGE 305 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 20 / day ZUTRIPRO 3 AL At least 18 yrs old CYSTIC FIBROSIS (CFTR) MODULATORS

QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG 3 PA GRANULES PACKET, 150 MG TABLET) S QL 2 / day ORKAMBI (100-125 MG GRANULE PKT, 150-188 MG 3 PA GRANULE PKT) S QL 4 / day ORKAMBI (100 MG TABLET, 200 MG TABLET) 3 PA S QL 2 / day SYMDEKO 3 PA S EXPECTORANTS

EXACTUSS TR 3 EXAPHEX TR 3 GILPHEX TR 3 GILTUSS TR 3 TUSNEL PEDIATRIC DROPS 3 TUSSI-PRES PEDIATRIC LIQUID 3 TUSSLIN PEDIATRIC DROPS 1 MUCOLYTIC AGENTS acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1

PAGE 306 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 5 / day PULMOZYME 3 PA S PHOSPHODIESTERASE TYPE 4 INHIBITORS

QL 1 / day DALIRESP 3 PA PULMONARY SURFACTANTS

CUROSURF 3 INFASURF 3 SURVANTA 3 RESPIRATORY TRACT AGENTS, MISCELLANEOUS

PA ARALAST NP 3 S PA GLASSIA 3 S PA PROLASTIN C 1,000 MG VIAL 3 S PA XOLAIR (75 MG/0.5 ML SYRINGE, 150 MG VIAL, 150 3 AL At least 6 yrs old MG/ML SYRINGE) S PA ZEMAIRA 3 S VASODILATING AGENTS (RESPIRATORY TRACT)

QL 3 / day ADEMPAS 3 PA S

PAGE 307 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day 1 PA S epoprostenol sodium (glycine) 1 S PA FLOLAN 3 S QL 1 / day LETAIRIS 3 PA S QL 1 / day OPSUMIT 3 PA S QL 3 / day ORENITRAM ER 3 PA S PA REMODULIN 3 S QL 2 / day TRACLEER (32 MG TABLET FOR SUSP, 62.5 MG 3 PA TABLET, 125 MG TABLET) S PA treprostinil sodium 1 S QL 1 / day TYVASO 3 PA S QL 1 / day TYVASO INSTITUTIONAL START KIT 3 PA S

PAGE 308 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day TYVASO REFILL KIT 3 PA S QL 1 / day TYVASO STARTER KIT 3 PA S PA UPTRAVI 200-800 TITRATION PACK 3 AL At least 18 yrs old S

UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 QL 2 / day MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, PA 3 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG AL At least 18 yrs old TABLET) S PA VELETRI 3 S QL 9 / day VENTAVIS 3 PA S SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE) ACANYA GEL PUMP Excluded Drugs acyclovir 5 % oint. (g) 1 AKTIPAK 3%-5% GEL POUCH Excluded Drugs ALA-QUIN 3 ALTABAX 3 PA EQ ATHLETE'S FOOT 1% CREAM 1

PAGE 309 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & AVC 3 BACTROBAN 3 BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 QL 1.667 / day BENZAMYCIN GEL Excluded Drugs CENTANY 3 PA CICLODAN 0.77% CREAM KIT 3 CICLODAN 0.77% CREAM 1 CICLODAN 8% SOLUTION 1 QL 0.22 / day (0.77 % gel (gram), 1 % shampoo) 1 ciclopirox 8 % solution 1 QL 0.22 / day ciclopirox olamine (0.77 % cream (g), 0.77 % 1 suspension) CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN 100 MG VAGINAL OVULE 2 CLEOCIN T 1% GEL 3 QL 75 / 30 days CLEOCIN T (LOION, PLEDGES, SOLUION) 3 clind ph-benzoyl pero 1.2-2.5% Excluded Drugs CLINDACIN ETZ 1% PLEDGET 1 CLINDACIN P 1 CLINDAGEL 1% GEL Excluded Drugs clindamycin phosphate 1 % foam 1 QL 1.667 / day QL 75 / 30 days clindamycin phosphate 1 % gel (gram) 1 C Generic for Cleocin T clindamycin phosphate (1 % lotion, 1 % med. swab, 1 1 % solution, 2 % cream/appl)

PAGE 310 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & clindamycin phosphate 1% gel Excluded Drugs clindamycin phos/benzoyl perox 1.2(1)%-5% gel 1 QL 1.5 / day (gram) clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram), phos/benzoyl 1 % gel 1 QL 1.667 / day w/pump) clindamycin phosphate/tretinoin 1 QL 2 / day CLINDESSE 3 (1 % cream (g), 1 % solution, 10 mg 1 troche) clotrimazole/betamethasone dip 1 %-0.05 % cream 1 (g) clotrimazole/betamethasone dip 1 %-0.05 % lotion 1 CNL 8 3 CORTISPORIN CREAM 3 QL 0.25 / day CORTISPORIN OINTMENT 3 QL 0.5 / day CROTAN 1 QL 0.167 / day DENAVIR 3 PA AL At least 12 yrs old DERMAZENE 1 DUAC 1.2-5% GEL Excluded Drugs nitrate 1 ECOZA 3 ELIMITE 3 ERTACZO 3

PAGE 311 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & ERY 1 ERYGEL 3 QL 1 / day erythromycin base in ethanol 2 % gel (gram) 1 QL 1 / day erythromycin base in ethanol (in 2 % med. swab, in 2 1 % solution) erythromycin base/benzoyl peroxide 1 QL 1.60 / day EURAX (CREAM, LOTION) 3 ST EVOCLIN 3 QL 1.667 / day EXELDERM (CREAM, SOLUTION) 3 EXODERM 1 EXTINA 3 FEM PH 3 gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) 1 GYNAZOLE 1 3 hydrocortisone/iodoquinol 1 iodine/ 5%-10% solution 1 iodine/sodium iodide (iodine/sodium tincture, 1 iodine/sodium 2 % tincture) IODOFLEX 3 IODOSORB 3 ketoconazole 2 % foam 1 ketoconazole (2 % cream (g), 2 % shampoo) 1 KLARON 3 QL 4 / day lindane 1 LOPROX (0.77% TOPICAL SUSP, 1% SHAMPOO) 3

PAGE 312 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & LOTRISONE 3 LUGOL'S STRONG IODINE SOLUTION 1 QL 2 / day 1 PA QL 2 / day LUZU 3 PA malathion 1 MENTAX 3 METROCREAM 3 METROGEL (GEL, PUMP) 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 1 % gel (gram), 1 % 1 gel w/pump) nitrate 200 mg supp.vag 3 GL Female miconazole nitrate/zinc oxide/petrolatum,white 1 mupirocin 1 mupirocin calcium 1 hcl 1 NAFTIN (1% GEL, 2% CREAM, 2% GEL) 3 NATROBA 3 ST NEO-SYNALAR 0.5%-0.025% CREAM 3 NEUAC GEL 1 QL 1.5 / day NIZORAL 3

PAGE 313 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NUVESSA 3 NYAMYC 1 nystatin (100000/g cream (g), 100000/g oint. (g), 1 100000/g powder) nystatin/triamcin 100000-0.1 cream (g) 1 nystatin/triamcin 100000-0.1 oint. (g) 1 NYSTOP 1 ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day ONEXTON GEL PUMP 3 QL 1.967 / day ORAVIG 3 OVIDE 3 ST nitrate 1 OXISTAT (CREAM, LOTION) 3 PENLAC 3 QL 0.22 / day 5 % cream (g) 1 ROSADAN (CREAM, GEL) 1 ROSADAN (CREAM KIT, GEL KIT) 3 SILVADENE 3 silver sulfadiazine 1 SKLICE 3 ST spinosad 1 SSD 1 sulfacetamide sodium 10 % suspension 1 QL 4 / day TERAZOL 7 3 QL 1.5 / day

PAGE 314 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1.5 / day terconazole (0.4 % cream/appl, 0.8 % cream/appl) 1 GL Female QL 1.5 / day terconazole 80 mg supp.vag 1 GL Female TRIPLE DYE 3 ULESFIA 3 ST VANDAZOLE 1 VELTIN 1.2%-0.025% GEL Excluded Drugs VUSION 3 XEPI 3 PA QL 0.167 / day XERESE 3 PA AL At least 6 yrs old XOLEGEL 3 ZIANA GEL Excluded Drugs QL 0.167 / day ZOVIRAX 5% CREAM 2 PA AL At least 12 yrs old QL 30 / fill ZOVIRAX 5% OINTMENT 3 PA AL At least 12 yrs old ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ALA-CORT 1 ALA-SCALP 3 alclometasone dipropionate (0.05 % cream (g), 0.05 1 % oint. (g))

PAGE 315 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & amcinonide (0.1 % cream (g), 0.1 % lotion) 1 amcinonide 0.1 % oint. (g) 1 ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%- 3 1% CRM SINGLE, 2.5%-1% LOTION) ANUCORT-HC 1 ANUSOL-HC 2.5% CREAM 3 ANUSOL-HC 25 MG SUPPOSITORY 1 APEXICON E 3 betamethasone dipropionate (0.05 % cream (g), 0.05 1 % gel (gram), 0.05 % lotion, 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), 1 betamethasone/propylene 0.05 % lotion, betamethasone/propylene 0.05 % oint. (g)) betamethasone valerate 0.12 % foam 1 betamethasone valerate (0.1 % cream (g), 0.1 % 1 lotion, 0.1 % oint. (g)) BRYHALI 3 PA CAPEX SHAMPOO 3 clobetasol propionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % shampoo, 0.05 % 1 solution) clobetasol propionate (0.05 % foam, 0.05 % lotion, 1 0.05 % spray) clobetasol propionate/emoll 0.05 % cream (g) 1 clobetasol propionate/emoll 0.05 % foam 1 CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) 3 clocortolone pivalate 0.1 % cream (g) 1

PAGE 316 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & CLODAN 0.05% SHAMPOO 1 CLODERM 3 COLOCORT 1 CORMAX 1 CORTENEMA 3 CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3 DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3 DERMATOP (EMOLLIENT CREAM, OINTMENT) 3 DESONATE 3 desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % 1 oint. (g)) DESOWEN (CREAM, LOTION) 3 desoximetasone (0.05 % cream (g), 0.05 % oint. (g)) 1 desoximetasone (0.05 % gel (gram), 0.25 % cream 1 (g), 0.25 % oint. (g), 0.25 % spray) diflorasone diacetate (0.05 % cream (g), 0.05 % oint. 1 (g)) DIPROLENE 3 DIPROLENE AF 3 ELOCON (CREAM, OINTMENT) 3 EPIFOAM 3 QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old fluocinolone acetonide (0.01 % cream (g), 0.01 % oil) 1

PAGE 317 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & fluocinolone acetonide (0.01 % solution, 0.025 % 1 cream (g), 0.025 % oint. (g)) fluocinolone acetonide/shower cap 1 fluocinonide 0.1 % cream (g) 1 fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 1 0.05 % oint. (g), 0.05 % solution) fluocinonide/emollient base 1 fluticasone propionate (0.005 % oint. (g), 0.05 % 1 cream (g)) fluticasone propionate 0.05 % lotion 1 halobetasol propionate 0.05 % foam 1 PA halobetasol propionate (0.05 % cream (g), 0.05 % 1 oint. (g)) HEMMOREX-HC 1 hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g), 2.5 % crm/pe app, 2.5 % 1 lotion, 2.5 % oint. (g), 100mg/60ml enema) hydrocortisone acetate (25 mg supp.rect, 30 mg 1 supp.rect) hydrocortisone acetate/pramoxine hcl (hydrocortisone/pramoxine 1 %-1 % cream/appl, 1 hydrocortisone/pramoxine 2.5 %-1 % cream/appl, hydrocortisone/pramoxine 2.5-1%(4g) cream/appl) hydrocortisone butyrate (0.1 % cream (g), 0.1 % 1 lotion, 0.1 % oint. (g), 0.1 % solution) hydrocortisone butyrate/emoll 0.1 % cream (g) 1 hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. 1 (g)) hydrocortisone/mineral oil/petrolatum,white 1

PAGE 318 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & IMPOYZ 3 QL 4 / day KENALOG 3 LEXETTE 3 PA lidocaine/hydrocortisone ac 3 %-0.5 % cream (g) 1 LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 LUXIQ 3 MICORT-HC 3 mometasone furoate (0.1 % cream (g), 0.1 % oint. 1 (g), 0.1 % solution) NOVACORT GEL 3 OLUX 3 OLUX-E 3 ORALONE 1 PANDEL 3 PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% 3 OINTMENT, 2.5%-1% LOTION, 2.5%-1% OINTMENT) PRAMOSONE E 3 prednicarbate (0.1 % cream (g), 0.1 % oint. (g)) 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3 PROCTOFOAM-HC 2 PROCTOSOL-HC 1 PROCTOZONE-HC 1

PAGE 319 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PSORCON 3 SANADERMRX 1 SCALACORT 1 SERNIVO 3 SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3 TEMOVATE (CREAM, OINTMENT) 3 TEMOVATE EMOLLIENT 3 TEXACORT 3 TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% 3 OINTMENT, 0.25% CREAM, 0.25% OINTMENT) triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 % cream (g), 0.1 % 1 lotion, 0.1 % oint. (g), 0.1 % paste (g), 0.147mg/g aerosol, 0.5 % cream (g), 0.5 % oint. (g)) TRIANEX 3 TRIDERM 1 TRIDESILON 3 ULTRAVATE (CREAM, LOTION, OINTMENT) 3 VANOS 3 VANOXIDE-HC 3 QL 0.84 / day VERDESO 3 ANTIPRURITICS AND LOCAL ANESTHETICS

ANACAINE 3 ANASTIA 3 QC ANTI- CREAM 1 CETACAINE 3

PAGE 320 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 49 / fill doxepin hcl 5 % cream (g) 1 PA ethyl chloride 1 hydrocortisone/lidocaine/aloe 0.55%-2.8% gel 1 w/appl LENZAPATCH 3 QL 4 / day lidocaine 5 % adh. patch 1 QL 3 / day lidocaine (4 % cream (g), 5 % oint. (g)) 1 lidocaine hcl 3 % lotion 1 lidocaine hcl (3 % cream (g), 4 % solution) 1 lidocaine/hydrocortisone ac 3 %-0.5 % cream/appl 1 lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream 1 (g), lidocaine/prilocaine 2.5 kit) lidocaine/tetracaine 1 LIDODERM 3 QL 3 / day QL 1 / day LIDODOSE 2 PA LIDOPIN 3% CREAM 1 LIDOPRIL 1 LIDTOPIC MAX 3 NUMBONEX 3 phenazopyridine hcl 1 PLIAGLIS 3 PONTOCAINE 2% SOLUTION 3 pramoxine hcl 1

PAGE 321 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PRE-ATTACHED LTA KIT 3 PRIKAAN 1 PRIKAAN LITE 1 QL 49 / fill PRUDOXIN 3 PA PYRIDIUM 3 RADIAGUARD 3 SYNERA 3 TEROCIN PATCH 3 WAL-DRYL 2%-0.1% CREAM 1 QL 49 / fill ZONALON 3 PA QL 3 / day ZTLIDO 3 PA ASTRINGENTS

DRYSOL 3 CVS MEDICATED PADS 1 XERAC AC 3 CELL STIMULANTS AND PROLIFERANTS

ALTRENO 3 QL 1.5 / day ATRALIN 3 QL 1.5 / day AVITA (CREAM, GEL) 1 KEPIVANCE 3 S REFISSA 3

PAGE 322 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & REGRANEX 3 QL 1 / day RENOVA 3 RENOVA PUMP 3 RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 3 0.05% CREAM, 0.1% CREAM) RETIN-A MICRO 3 QL 50 / 30 days RETIN-A MICRO PUMP 3 QL 50 / 30 days TRETIN-X 0.075% CREAM 3 tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 % cream (g), 0.05 % gel 1 (gram), 0.1 % cream (g)) tretinoin microspheres (0.04 % gel (gram), 0.04 % gel QL 1.667 / day 1 w/pump, 0.1 % gel (gram), 0.1 % gel w/pump) PA tretinoin/emollient base 1 DEPIGMENTING AND PIGMENTING AGENTS

BLANCHE 1 hydroquinone 4 % cream (g) 1 hydroquinone microspheres 1 methoxsalen 10 mg cap lq rap 1 OXSORALEN-ULTRA 3 TRI-LUMA 3 UVADEX 3 S DETERGENTS octoxynol 9 3 polysorbate 60 1

PAGE 323 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & polysorbate 80 solution 1 KERATOLYTIC AGENTS

BENSAL HP 3 BENZEFOAM 3 QL 2 / day BENZEFOAM ULTRA 3 QL 3.334 / day BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY 1 WASH) benzoyl peroxide 7 % cleanser 1 benzoyl peroxide 9.8 % foam 1 QL 3.334 / day benzoyl peroxide microspheres 1 BP-50% UREA 1 BPO (4% GEL, 8% GEL) 3 BPO 6% FOAMING CLOTHS 1 QL 2 / day DHS SAL 3 KERALAC 3 KERALYT 6% GEL 3 OIL-FREE 2% ACNE WASH 1 PACNEX 1 SALACYN (CREAM, LOTION) 1 SALEX 6% SHAMPOO 3 (6 % foam, 6 % gel (gram), 28.5 % sol- 1 filmer) salicylic acid (6 % cream (g), 6 % crm er (g), 6 % lotion, 6 % lotion er, 6 % shampoo, 26 % liquid, 27.5 1 % liq-film) SALIMEZ FORTE 3

PAGE 324 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SALVAX 3 silver nitrate/potassium nitrate 3 SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1 ULTRASAL-ER 3 urea (35 % foam, 39 % cream (g), 40 % lotion, 45 % 1 cream (g), 45 % gel (ml)) UTOPIC 3 VIRASAL 3 KERATOPLASTIC AGENTS coal tar 1 DRITHOCREME HP 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. acitretin (17.5 mg capsule, 25 mg capsule) 1 QL 2 / day acitretin 10 mg capsule 1 QL 4 / day QL 3 / day ACZONE (5% GEL, 7.5% GEL PUMP) 3 PA adapalene (0.1 % cream (g), 0.1 % gel (gram), 0.3 % 1 QL 1.5 / day gel (gram), 0.3 % gel w/pump) adapalene (0.1 % lotion, 0.1 % solution) 1 QL 2 / day adapalene 0.1 % med. swab 1 QL 1 / day adapalene/benzoyl peroxide 1 QL 1.5 / day QL 0.434 / day ALDARA 3 AL At least 12 yrs old AMNESTEEM 1 PA AVAGE 3 QL 1.47 / day

PAGE 325 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 50 / 30 days azelaic acid 3 PA AZELEX 3 QL 1.667 / day calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 1 QL 2 / day 0.005 % solution) QL 3 / day calcipotriene/betamethasone dipropionate 1 PA CALCITRENE 1 QL 2 / day calcitriol 3 mcg/g oint. (g) 1 QL 3.334 / day CLARAVIS 1 PA CONDYLOX (GEL, TOPICAL SOLN) 3 QL 0.357 / day PA COSENTYX (2 SYRINGES) 3 S PS QL 0.357 / day PA COSENTYX PEN 3 S PS QL 0.357 / day PA COSENTYX PEN (2 PENS) 3 S PS QL 0.357 / day PA COSENTYX SYRINGE 3 S PS

PAGE 326 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & dapsone 5 % gel (gram) 1 QL 3 / day DEBACTEROL SWABSTICK 3 DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% 3 QL 1.5 / day GEL PUMP) DIFFERIN 0.1% LOTION 3 QL 1.967 / day DOVONEX 3 QL 2 / day QL 0.15 / day PA DUPIXENT 300 MG/2 ML SYRINGE 3 AL At least 12 yrs old S QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old QL 2 / day ENSTILAR 3 PA EPIDUO 0.1-2.5% GEL PUMP 3 QL 1.5 / day EPIDUO FORTE 3 QL 1.667 / day QL 3.73 / day FABIOR 3 PA AL Up to 34 yrs old QL 50 / 30 days FINACEA (FOAM, GEL) 3 PA finasteride 1 mg tablet 1 FORMADON 1 formaldehyde 1 SM HEMORRHOIDAL SUPPOSITORY 1

PAGE 327 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 0.434 / day imiquimod 5 % cream pack 1 AL At least 12 yrs old QL 0.25 / day imiquimod 3.75 % crm md pmp 1 AL At least 12 yrs old isotretinoin 1 PA MIRVASO (GEL, GEL PUMP) 2 QL 1 / day MYORISAN 1 PA QL 2.5 / day pimecrolimus 1 ST AL At least 2 yrs old pine tar 1 PLIXDA 3 QL 1 / day PODOCON-25 3 podofilox 1 PROPECIA 3 QL 2.5 / day PROTOPIC 0.03% OINTMENT 3 ST AL At least 2 yrs old QL 2.5 / day PROTOPIC 0.1% OINTMENT 3 ST AL At least 16 yrs old PYROGALLIC ACID 1 QUTENZA 3 S RECTIV 3 QL 1.25 / day RHOFADE 3 PA

PAGE 328 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SANTYL 3 PA SILIQ 3 AL At least 18 yrs old S SOOLANTRA 2 QL 1.5 / day SORE MUSCLE RUB 1 SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) 3 QL 2 / day SORIATANE 10 MG CAPSULE 3 QL 4 / day SORILUX 3 QL 2 / day QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML PA 3 VIAL, 90 MG/ML SYRINGE) S PS QL 3.73 / day PA STELARA 130 MG/26 ML VIAL 3 S PS QL 3 / day TACLONEX OINTMENT 3 PA QL 4 / day TACLONEX 0.005%-0.064% SUSPENS 3 PA QL 100 / 30 days tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 ST TALTZ 80 MG/ML AUTOINJECTOR Excluded Drugs TALTZ 80 MG/ML AUTOINJ (2-PK) Excluded Drugs TALTZ 80 MG/ML AUTOINJ (3-PK) Excluded Drugs

PAGE 329 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & tazarotene 1 QL 1.47 / day TAZORAC (0.05% CREAM, 0.1% CREAM) 3 QL 2 / day TAZORAC (0.05% GEL, 0.1% GEL) 3 QL 3.334 / day 100 % oil 3 TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT, 3 FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) QL 0.04 / day PA TREMFYA (100 MG/ML INJECTOR, 100 MG/ML 3 AL At least 18 yrs old SYRINGE) S PS TRI-CHLOR 3 trichloroacetic acid (20 % soln recon, 25 % soln recon, 50 % soln recon, 75 % soln recon, 80 % soln 1 recon, 85 % soln recon, 90 % soln recon, 100 % soln recon) VANIQA 3 VECTICAL 3 QL 3.334 / day VENELEX OINTMENT 3 VEREGEN 3 ZENATANE 1 PA QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) 3 AL At least 12 yrs old QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP 3 AL At least 12 yrs old

PAGE 330 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & SMOOTH MUSCLE RELAXANTS GENITOURINARY SMOOTH MUSCLE RELAXANTS darifenacin hydrobromide 1 QL 1 / day DETROL 3 QL 2 / day DETROL LA 3 QL 1 / day DITROPAN XL (10 MG TABLET, 15 MG TABLET) 3 QL 2 / day DITROPAN XL 5 MG TABLET 3 QL 1 / day ENABLEX 3 QL 1 / day flavoxate hcl 1 QL 1 / day GELNIQUE (GEL PUMP, GEL SACHET, GEL SACHETS) 3 ST MYRBETRIQ 2 QL 1 / day oxybutynin chloride 5 mg/5 ml syrup 1 QL 20 / day oxybutynin chloride (10 mg tab er 24, 15 mg tab er 1 QL 2 / day 24) oxybutynin chloride 5 mg tab er 24 1 QL 1 / day oxybutynin chloride 5 mg tablet 1 QL 4 / day QL 0.357 / day OXYTROL 3 ST tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 1 QL 1 / day 24h) tolterodine tartrate (1 mg tablet, 2 mg tablet) 1 QL 2 / day TOVIAZ 3 QL 1 / day trospium chloride 60 mg cap er 24h 1 QL 1 / day

PAGE 331 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & trospium chloride 20 mg tablet 1 QL 2 / day VESICARE 2 QL 1 / day RESPIRATORY SMOOTH MUSCLE RELAXANTS aminophylline (250mg/10ml vial, 500mg/20ml 1 ampul, 500mg/20ml vial) ELIXOPHYLLIN 3 THEO-24 3 THEOCHRON 1 theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er 12h, 200 mg tab er 1 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h) theophylline in dextrose 5 % in water 1 UNCATEGORIZED onetouch ultra blue test strp 2 QL 10 / day onetouch ultra2 glucose syst 2 onetouch ultramini meter 2 onetouch verio flex startr kit 2 QL 10 / day onetouch verio flex system kit 2 onetouch verio iq meter 2 onetouch verio iq system kit 2 onetouch verio meter system 2 onetouch verio sync syst kit 2 onetouch verio test strip 2 QL 10 / day

PAGE 332 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VITAMINS MULTIVITAMIN PREPARATIONS

ATABEX EC 3 GL Female CADEAU DHA 3 ELITE OB DHA 3 GL Female ELITE-OB 400 3 GL Female FOLBECAL 3 GL Female INFUVITE PEDIATRIC 1 M.V.I. PEDIATRIC 3 MACNATAL CN DHA 3 GL Female MATERNITY 1 GL Female MVW COMPLETE FORMLTN PEDIATRIC 3 MVW COMPLETE FORMUL D3000 SFGL 3 MYNATAL (CAPSULE, ULTRACAPLET) 3 GL Female MYNATAL ADVANCE 3 GL Female MYNATAL PLUS 3 GL Female MYNATAL-Z 3 GL Female MYNATE 90 PLUS 3 GL Female NEWGEN 3 OBSTETRIX EC 3 GL Female OBSTETRIX ONE 1 GL Female OBTREX DHA (COMBO PACK, PRENATAL VITAMIN) 3 GL Female PNV-DHA PLUS 3

PAGE 333 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PNV-IRON 3 PRENA1 CHEW 3 GL Female PRENA1 PEARL 3 GL Female PRENA1 TRUE 3 GL Female PRENATABS RX 3 GL Female PRENATAL VITAMIN WITH MINERALS AND FOLIC 3 GL Female ACID GREATER THAN 0.8 MG ORAL TABLET prenatal vitamins no.5/ferrous fumarate/folic acid 3 GL Female prenatal vitamins no.79/iron fum/folic 3 GL Female acid/levomefolate/dha prenatal vits with calcium #74/ferrous 3 GL Female fumarate/folic acid prenatal vits with calcium no.74/ferrous 3 GL Female fumarate/folic acid R-NATAL OB 3 GL Female THERANATAL OVAVITE 3 THERANATAL PLUS 3 TRI-TABS DHA 3 GL Female TRINATE 3 GL Female TRIVEEN-ONE 3 GL Female TRIVEEN-U 3 GL Female TRUST NATAL DHA 3 GL Female VENATAL COMPLETE DHA 3 GL Female VINACAL B 3 GL Female VINATE DHA 3 GL Female

PAGE 334 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & VINATE DHA RF 3 GL Female VINATE GT 3 GL Female VINATE II 3 GL Female VINATE ONE 3 GL Female VINATE PN CARE 3 GL Female VINATE ULTRA 3 GL Female VINATE-M 3 GL Female VIRT-C DHA 3 VITASPIRE 3 GL Female VITATRUE 3 GL Female VIVA DHA 3 GL Female VYNATAL-FA 1 GL Female VITAMIN A

AQUASOL A 3 VITAMIN B COMPLEX

ARKALIOX 1 B-12 COMPLIANCE 3 cyanocobalamin (vitamin b-12) (1000mcg/ml vial, 1 2500 mcg tab subl) folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 hydroxocobalamin 1 levomefolate calcium 7.5 mg tablet 1 NASCOBAL 3

PAGE 335 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & NEPHRONEX-SL 1 pyridoxine hcl (vitamin b6) 100 mg/ml vial 1 thiamine hcl 100 mg/ml vial 1 UROSEX 1 ascorbic acid granules 3 ascorbic acid 500 mg/ml vial 1 VITAMIN D calcitriol 1 mcg/ml ampul 1 calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 1 mcg/ml solution) doxercalciferol (4mcg/2ml ampul, 4mcg/2ml vial) 1 S doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 1 S mcg capsule) ergocalciferol (vitamin d2) 50000 unit capsule 1 HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 3 S MCG CAPSULE) HECTOROL (2 MCG/ML VIAL, 4 MCG/2 ML VIAL) 3 S OPTIMAL D3 1 paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg 1 S capsule) paricalcitol (2 mcg/ml vial, 5 mcg/ml vial) 1 S RAYALDEE 3 S ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 3 1 MCG/ML ORAL SOLN) THERA-D SPORT 2,000 UNIT TAB 1

PAGE 336 LAST UPDATED 04/2019 PRODUCT DESCRIPTION TIER LIMITS & PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3 S

ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 PA 3 MCG/2 ML VIAL) S VITAMIN E wheat germ oil oil 1 VITAMIN K ACTIVITY

MEPHYTON 3 phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml 1 syringe, 10 mg/ml ampul) phytonadione (vit k1) 5 mg tablet 1

PAGE 337 LAST UPDATED 04/2019 Index of Covered Drugs acetazolamide sodium 229 2 acetic acid 222 2tek glucose-wrist monitor kit 174 acetic acid/aluminum acetate 222 acetylcysteine 306 A ACIPHEX 237 A-HYDROCORT 245 ACIPHEX SPRINKLE 237 A-METHAPRED 245 acitretin 325 abacavir sulfate 22 ACTEMRA 286 abacavir sulfate/lamivudine 22 ACTEMRA ACTPEN 286 abacavir sulfate/lamivudine/zidovudine 23 ACTHIB 59 ABATUSS DMX 32 ACTHREL 213 ABELCET 18 ACTICLATE 3 ABILIFY 158 ACTIGALL 241 ABILIFY MAINTENA 158 ACTIMMUNE 290 ABILIFY MYCITE 159 ACTIQ 109 ABRAXANE 35 ACTIVASE 77 ABSTRAL 109 ACTIVELLA 267 acamprosate calcium 156 ACTONEL 283 ACANYA 309 ACTOPLUS MET 250 acarbose 250 ACTOPLUS MET XR 250,251 ACCOLATE 300 ACTOS 251 accu-chek aviva connect meter 174 ACULAR 226 accu-chek aviva plus meter 174 ACULAR LS 226 accu-chek aviva plus test strp 199 acura test strips 199 accu-chek combo system 174 ACUVAIL 226 accu-chek compact plus kit 174 acyclovir 23,309 accu-chek compact plus strips 199 acyclovir sodium 23 accu-chek guide me glucose mtr 174 acyclovir sodium/dextrose 5 % in water 23 accu-chek guide monitor system 174 ACZONE 325 accu-chek guide test strip 199 ADACEL TDAP 58 accu-chek nano smartview meter 174 ADAGEN 221 accu-chek smartview test strip 199 ADALAT CC 93 accu-chek voicemate system 174 adapalene 325 ACCUPRIL 100 adapalene/benzoyl peroxide 325 ACCURETIC 100 ADASUVE 159 accutrend glucose test strip 199 ADCETRIS 35 acebutolol hcl 90 ADCIRCA 105 acetaminophen with codeine phosphate 109 ADDERALL 133 acetaminophen/caffeine/dihydrocodeine ADDERALL XR 133 bitartrate 109 ADDYI 156 acetazolamide 229 adefovir dipivoxil 23 ADEMPAS 307 AFLURIA QUAD 2016-2017 59 ADENOCARD 97 AFLURIA QUAD 2017-2018 59 adenosine 97 AFLURIA QUAD 2018-2019 59 ADIPEX-P 133 AFREZZA 251 ADLYXIN 251 AFSTYLA 75 ADMELOG 251 agamatrix amp gluc monitor sys 175 ADMELOG SOLOSTAR 251 agamatrix amp test strips 200 ADRENACLICK 70 AGGRASTAT 77 ADRENALIN 71 AGGRENOX 105 ADRENALIN CHLORIDE 233 AGRYLIN 78 ADRIAMYCIN 35 AIMOVIG AUTOINJECTOR 147 ADRUCIL 35 AIMOVIG AUTOINJECTOR (2 PACK) 147 ADVAIR DISKUS 300 AIRDUO RESPICLICK 300 ADVAIR HFA 300 AKTEN 232 ADVATE 74 AKTIPAK 309 ADVATE H 74 AKYNZEO 234 ADVATE L 74 ALA-CORT 315 ADVATE M 74 ALA-QUIN 309 ADVATE SH 74 ALA-SCALP 315 ADVATE UH 74 albendazole 3 advocate blood glucose monitor 174 ALBENZA 3 advocate duo glu-wrist monitor 174 ALBUMINEX 73 advocate duo meter 175 albuterol hfa 90 mcg inhaler 71 advocate redi-code duo meter 175 albuterol sulfate 71 advocate redi-code glu meter 175 alclometasone dipropionate 315 advocate redi-code glu monitor 175 ALDACTAZIDE 100 advocate redi-code plus meter 175 ALDACTONE 100 advocate redi-code test strip 199 ALDARA 325 advocate redi-code+ test strip 199 ALDURAZYME 221 advocate test strip 199,200 ALECENSA 35 ADYNOVATE 75 alendronate sodium 283 ADZENYS ER 133 ALFERON N 23 ADZENYS XR-ODT 133 alfuzosin hcl 69 AEMCOLO 3 ALIMTA 35 AEROSPAN 300 ALINIA 21 AFEDITAB CR 93 aliskiren hemifumarate 100 AFINITOR 35 ALKERAN 35 AFINITOR DISPERZ 35 ALLER-CHLOR 32 AFLURIA 2016-2017 59 ALLERGY 33 AFLURIA 2017-2018 59 ALLERGY RELIEF 33 AFLURIA 2018-2019 59 ALLFEN CDX 303 allopurinol 282 AMBIEN 152 allopurinol sodium 283 AMBIEN CR 152 ALLZITAL 109 AMBISOME 18 almotriptan malate 147 ambrisentan 308 ALOCRIL 300 amcinonide 316 alogliptin 12.5 mg tablet 251 AMERGE 147 alogliptin 25 mg tablet 251 AMETHIA 259 alogliptin 6.25 mg tablet 251 AMETHIA LO 259 alogliptin-metformin 12.5-1000 251 AMETHYST 259 alogliptin-metformin 12.5-500 251 AMICAR 75 alogliptin-pioglit 12.5-15 mg 251 amifostine crystalline 298 alogliptin-pioglit 12.5-30 mg 251 amikacin sulfate 3 alogliptin-pioglit 12.5-45 mg 251 amiloride hcl 216 alogliptin-pioglit 25-15 mg tb 251 amiloride hcl/hydrochlorothiazide 216 alogliptin-pioglit 25-30 mg tb 251 aminocaproic acid 75 alogliptin-pioglit 25-45 mg tb 251 aminophylline 63,332 ALOMIDE 228 amiodarone hcl 97 ALOPRIM 283 amiodarone hcl/dextrose 5 % in water 97 ALORA 267 AMITIZA 240 alosetron hcl 233 amitriptyline hcl 159 alpha lipoic acid 296 amitriptyline hcl/chlordiazepoxide 159 ALPHAGAN P 229 amlodipine besylate 93 ALPHANATE 75 amlodipine besylate/atorvastatin calcium 84 ALPHANINE SD 75 amlodipine besylate/benazepril hcl 93 alprazolam 152 amlodipine besylate/olmesartan medoxomil 93 ALPRAZOLAM INTENSOL 152 amlodipine besylate/valsartan 93 ALPROLIX 75 amlodipine ALREX 226 besylate/valsartan/hydrochlorothiazide 93 ALSUMA 147 AMNESTEEM 325 ALTABAX 309 amoxapine 159 ALTACE 100 amoxicillin 3 ALTAVERA 259 amoxicillin/potassium clavulanate 4 ALTOPREV 84 amphetamine sulfate 134 ALTRENO 322 amphotericin b 18 ALUNBRIG 35,36 ampicillin sodium 4 ALVESCO 300 ampicillin sodium/sulbactam sodium 4 ALYACEN 259 ampicillin trihydrate 4 ALYQ 105 AMPYRA 296 AMABELZ 267 AMRIX 68 amantadine hcl 149 ANACAINE 320 AMARYL 251 ANADROL-50 248 ANAFRANIL 159 ARAVA 286 anagrelide hcl 78 ARCALYST 296 ANALPRAM HC 316 ARCAPTA NEOHALER 71 ANAPROX DS 109 argatroban 78 ANASPAZ 64 argatroban in 0.9 % sodium chloride 78 ANASTIA 320 argatroban in sodium chloride, iso-osmotic 78 anastrozole 36 ARICEPT 67 ANCOBON 18 ARIKAYCE 4 ANDROGEL 248 ARIMIDEX 36 ANDROID 248 aripiprazole 159 ANDROXY 248 ARISTADA 159 ANGELIQ 267 ARISTADA INITIO 159 ANGIOMAX 78 ARISTOSPAN 245 anise oil 299 ARIXTRA 78 ANORO ELLIPTA 64 ARKALIOX 335 ANSAID 109 armodafinil 134 ANTABUSE 282 ARMONAIR RESPICLICK 300 ANTACID 233 ARMOUR THYROID 279 ANTARA 84 ARNUITY ELLIPTA 300 ANTI-ITCH 320 AROMASIN 36 ANTIVERT 234 ARRANON 36 ANUCORT-HC 316 arsenic trioxide 36 ANUSOL-HC 316 ARTHROTEC 50 109 ANZEMET 235 ARTHROTEC 75 109 APEXICON E 316 ARZERRA 36 APIDRA 251 ASACOL HD 233 APIDRA SOLOSTAR 251 ASCOMP WITH CODEINE 109 APLENZIN 159 ascorbic acid 336 APOKYN 149 ASHLYNA 259 apraclonidine hcl 231 ASMANEX 300 aprepitant 235 ASMANEX HFA 300 APRI 259 aspirin/caffeine/dihydrocodeine bitartrate 110 APRISO 233 aspirin/dipyridamole 105 APTENSIO XR 134 assure 4 test strips 200 APTIOM 140 assure platinum glucose meter 175 APTIVUS 23 assure platinum test strips 200 AQUASOL A 335 assure prism multi meter 175 ARAKODA 21 assure prism multi test strips 200 ARALAST NP 307 ASTAGRAF XL 293,294 ARANELLE 259 ASTEPRO 228 ARANESP 82 ASTRAMORPH-PF 110 ATABEX EC 333 AVIDOXY 4 ATACAND 100 AVITA 322 ATACAND HCT 100 AVODART 281 atazanavir sulfate 23 AVONEX 290 ATELVIA 283 AVONEX PEN 290 atenolol 90 AVYCAZ 5 atenolol/chlorthalidone 90 AXERT 147 ATGAM 294 AXIRON 249 ATHLETE'S FOOT 309 AYGESTIN 276 ATIVAN 153 azacitidine 36 atomoxetine hcl 156 AZACTAM 5 atorvastatin calcium 84 AZACTAM-ISO-OSMOTIC DEXTROSE 5 atovaquone 21 AZASAN 294 atovaquone/proguanil hcl 21 AZASITE 223 ATRALIN 322 azathioprine 294 ATRIPLA 23 azathioprine sodium 294 atropine sulfate 232 azelaic acid 326 ATROVENT HFA 64 azelastine hcl 228 AUBAGIO 290 AZELEX 326 AUBRA 259 AZILECT 149 AUBRA EQ 259 azithromycin 5 AUGMENTIN 4 AZOPT 229 AUGMENTIN ES-600 4 AZOR 93 AUGMENTIN XR 4 aztreonam 5 AUROVELA 24 FE 259 AZULFIDINE 5 AURYXIA 217 AZURETTE 259 AUSTEDO 173 AUVI-Q 71 B AVAGE 325 B-12 COMPLIANCE 335 AVAILNEX 63 BACIIM 5 AVALIDE 100 bacitracin 5,223 AVANDAMET 251 bacitracin/polymyxin b sulfate 223 AVANDIA 251,252 baclofen 68 AVAPRO 100 BACTRIM 5 AVASTIN 36 BACTRIM DS 5 AVC 310 BACTROBAN 310 AVEED 249 BACTROBAN NASAL 223 AVELOX 4 BAL IN OIL 244 AVELOX IV 4 BALCOLTRA 259 AVENOVA 175 balsalazide disodium 233 AVIANE 259 BALZIVA 259 BANZEL 140 betamethasone acetate and sodium phos in BARACLUDE 23 sterile water/pf 245 BASAGLAR KWIKPEN U-100 252 betamethasone acetate/betamethasone sodium BAXDELA 5 phosphate 245 BCAD 1 215 betamethasone acetate/betamethasone sodium bcg live 59 phosphate/water 245 bcg vaccine, live/pf 59 betamethasone dipropionate 316 BEBULIN 75 betamethasone dipropionate/propylene BECONASE AQ 226 glycol 316 BEKYREE 259 betamethasone valerate 316 BELBUCA 110 BETAPACE 90 BELEODAQ 36 BETAPACE AF 90 BELSOMRA 153 BETASERON 291 BELVIQ 134 betaxolol hcl 90,230 BELVIQ XR 134 bethanechol chloride 67 benazepril hcl 100 BETHKIS 5 benazepril hcl/hydrochlorothiazide 100 BETIMOL 230 bendamustine hcl 36 BETOPTIC S 230 BENEFIX 75 bevacizumab 231 BENICAR 100 BEVESPI AEROSPHERE 64 BENICAR HCT 100 BEVYXXA 78 BENLYSTA 294 bexarotene 36 BENSAL HP 324 BEXSERO 59 BENTYL 64 bicalutamide 36 BENZACLIN 310 BICILLIN C-R 5 benzalkonium chloride 63 BICILLIN L-A 5 BENZAMYCIN 310 BICNU 36 BENZEFOAM 324 BIDIL 98 BENZEFOAM ULTRA 324 BIJUVA 268 BENZEPRO 324 BIKTARVY 23 benznidazole 21 BILTRICIDE 3 benzonatate 303 bimatoprost 230 benzoyl peroxide 324 BINOSTO 284 benzoyl peroxide microspheres 324 bioflavonoids, citrus 296 benzphetamine hcl 134 bisoprolol fumarate 90 benztropine mesylate 149,150 bisoprolol fumarate/hydrochlorothiazide 90 BEPREVE 228 bivalirudin 78 BERINERT 285 bivalirudin in 0.9 % sodium chloride 78 BESIVANCE 223 BIVIGAM 56 BETADINE 223 blade lancet, safety 175 BETAGAN 229 BLANCHE 323 bleomycin sulfate 36 bromfenac sodium 226 BLEPH-10 223 bromocriptine mesylate 150 BLEPHAMIDE 223 brompheniramine maleate/pseudoephedrine BLEPHAMIDE S.O.P. 223 hcl/dextromethorphan 303 BLINCYTO 37 BROMSITE 226 BLISOVI 24 FE 260 BROVANA 71 BLISOVI FE 260 BRYHALI 316 blood administration set 175 budesonide 226,245,301 blood collection set 175 bumetanide 216 blood glucose calibration control solution, BUNAVAIL 110 high 175 BUPAP 110 blood glucose calibration control solution, BUPHENYL 214 normal 175 BUPRENEX 110 blood glucose monitoring syst 176 buprenorphine 110 blood glucose test strip 200 buprenorphine hcl 110 blood glucose test strips 200 buprenorphine hcl/naloxone hcl 110 blood ketone test, strips 176 bupropion hcl 160 blood sugar diagnostic 200 buspirone hcl 153 blood-glucose meter 176 busulfan 37 BLOXIVERZ 67 BUSULFEX 37 blunt needle, disposable 176 butalbital/acetaminophen 111 BONIVA 284 butalbital/acetaminophen/caffeine 111 BONJESTA 235 butalbital/acetaminophen/caffeine/codeine BOOSTRIX TDAP 58 phosphate 111 bortezomib 37 butalbital/aspirin/caffeine 111 BOSULIF 37 BUTISOL SODIUM 153 BOTOX 296 butorphanol tartrate 111 BOTOX COSMETIC 296 BUTRANS 111 BP-50% UREA 324 BYDUREON 252 BPO 324 BYDUREON BCISE 252 BRAFTOVI 37 BYDUREON PEN 252 BRAVELLE 271 BYETTA 252 breeze 2 disc test strip 200 BYSTOLIC 90 BREO ELLIPTA 301 BYVALSON 90 BREVIBLOC 90 BRIELLYN 260 C BRILINTA 78 CA-DTPA 244 brimonidine tartrate 230 cabergoline 150 BRISDELLE 160 CABOMETYX 37 BRIVIACT 140 CADEAU DHA 333 BROMFED DM 303 CADUET 84 CAFERGOT 69 carbinoxamine maleate 33 caffeine citrate 134 carboplatin 38 CALAN 93 CARDENE I.V. 93 CALAN SR 93 CARDENE SR 63 calcipotriene 326 CARDIZEM 93 calcipotriene/betamethasone dipropionate 326 CARDIZEM CD 93,94 calcitonin,salmon,synthetic 274 CARDIZEM LA 94 CALCITRENE 326 CARDURA 84 calcitriol 326,336 CARDURA XL 84 calcium acetate 217 careone blood glucose tst strp 200 calcium gluconate in 0.9 % sodium chloride 219 careone glucose monitoring sys 176 calcium gluconate in sodium chloride, iso- caresens n blood glucose syst 176 osmotic 219 caresens n test strips 200 CALDOLOR 111 caresens n voice glucose meter 176 CALQUENCE 37 caresens n voice glucose sys 176 CAMBIA 111 caretouch glucose monitor sys 176 CAMILA 260 caretouch test strip 200 CAMPATH 38 CARIMUNE NF NANOFILTERED 56 CAMPTOSAR 38 carisoprodol 68 CAMRESE 260 carisoprodol/aspirin 68 CAMRESE LO 260 carisoprodol/aspirin/codeine phosphate 68 CANASA 233 carmustine 38 CANCIDAS 18 CARNITOR 296 candesartan cilexetil 100 CARNITOR SF 296 candesartan cilexetil/hydrochlorothiazide 101 CAROSPIR 101 CAPACET 111 carteolol hcl 230 CAPASTAT SULFATE 20 CARTIA XT 94 capecitabine 38 carvedilol 90 CAPEX SHAMPOO 316 carvedilol phosphate 90 CAPITAL W-CODEINE 111 CASODEX 38 CAPRELSA 38 caspofungin acetate 18 captopril 101 CATAPRES 98 captopril/hydrochlorothiazide 101 CATAPRES-TTS 1 98 CARAC 38 CATAPRES-TTS 2 99 CARAFATE 237 CATAPRES-TTS 3 99 CARBAGLU 214 CATHFLO ACTIVASE 78 carbamazepine 141 CAVERJECT 63,105 CARBATROL 141 CAYSTON 5 carbidopa 156 CAZIANT 260 carbidopa/levodopa 150 CEDAX 5 carbidopa/levodopa/entacapone 150 cefaclor 6 cefadroxil 6 CESAMET 235 cefazolin sodium 6 CETACAINE 320 cefazolin sodium in 0.9 % sodium chloride 6 cetirizine hcl 34 cefazolin sodium/dextrose 5 % in water 6 CETRAXAL 223 cefazolin sodium/dextrose, iso-osmotic 6 CETROTIDE 271 cefazolin sodium/water for injection,sterile 6 cevimeline hcl 67 cefdinir 6 CHANTIX 67 cefditoren pivoxil 6 CHATEAL 260 cefepime hcl 6 CHATEAL EQ 260 cefepime hcl in dextrose 5 % in water 6 CHEMET 244 cefepime hcl in iso-osmotic dextrose 6 chemstrip bg diary 176 cefixime 6 CHENODAL 241 CEFOTAN 7 chloramphenicol sod succinate 7 cefotaxime sodium 7 chlordiazepoxide hcl 153 cefotetan disodium 7 chlordiazepoxide/clidinium bromide 64 cefotetan disodium in iso-osmotic dextrose 7 chlorhexidine gluconate 223 cefoxitin sodium 7 chloroquine phosphate 21 cefoxitin sodium/dextrose, iso-osmotic 7 chlorothiazide 216 cefpodoxime proxetil 7 chlorothiazide sodium 216 cefprozil 7 chlorpheniramine maleate/phenylephrine ceftazidime 7 hcl/dextromethorphan 63 ceftazidime in dextrose 5% and water 7 chlorpromazine hcl 160 ceftibuten 7 chlorpropamide 252 CEFTIN 7 chlorthalidone 216 ceftriaxone sodium 7 chlorzoxazone 68 ceftriaxone sodium in iso-osmotic dextrose 7 choicedm clarus monitor system 176 cefuroxime axetil 7 choicedm clarus test strips 200 cefuroxime sodium 7 CHOLBAM 242 CELEBREX 111,112 cholestyramine (with sugar) 84 celecoxib 112 cholestyramine/aspartame 84 CELESTONE 245 choline salicylate/magnesium salicylate 112 CELEXA 160 chorionic gonadotropin, human 272 CELLCEPT 294 CIALIS 105 CELONTIN 141 CICLODAN 310 CENTANY 310 ciclopirox 310 CENTERGY 33 ciclopirox olamine 310 CENTERGY DM 303 cidofovir 23 cephalexin 7 cilostazol 78 CERDELGA 296 CILOXAN 223 CEREBYX 141 CIMDUO 23 CEREZYME 221 cimetidine 238 cimetidine hcl 238 clever choice voice+ tst strip 201 CIMZIA 286,287 CLEVIPREX 94 CINRYZE 285 CLIMARA 268 CINVANTI 235 CLIMARA PRO 268 CIPRO 7,8 clind ph-benzoyl pero 1.2-2.5% 310 CIPRO HC 223 CLINDACIN ETZ 310 CIPRO I.V. 8 CLINDACIN P 310 CIPRO XR 8 CLINDAGEL 310 CIPRODEX 223 clindamycin hcl 9 ciprofloxacin 8 clindamycin palmitate hcl 9 ciprofloxacin hcl 8,223 clindamycin phosphate 9,310 ciprofloxacin lactate 8 clindamycin phosphate 1% gel 311 ciprofloxacin lactate/dextrose 5 % in water 8 clindamycin phosphate in 0.9 % sodium chloride 9 ciprofloxacin/ciprofloxacin hcl 8 clindamycin phosphate/benzoyl peroxide 311 cisplatin 38 clindamycin phosphate/dextrose 5 % in water 9 citalopram hydrobromide 160 clindamycin phosphate/tretinoin 311 cladribine 38 CLINDESSE 311 CLAFORAN 8 clobazam 141 CLARAVIS 326 clobetasol propionate 316 CLARINEX 34 clobetasol propionate/emollient base 316 CLARINEX-D 12 HOUR 34 CLOBEX 316 clarithromycin 8 clocortolone pivalate 316 clemastine fumarate 33 CLODAN 317 CLENPIQ 240 CLODERM 317 CLEOCIN 310 clofarabine 38 CLEOCIN HCL 8 CLOLAR 38 CLEOCIN PALMITATE 8 clomiphene citrate 268 CLEOCIN PHOSPHATE 8 clomipramine hcl 160 CLEOCIN PHOSPHATE IN D5W 9 clonazepam 141 CLEOCIN T 310 clonidine 99 clever chek blood glucose syst 176 clonidine hcl 99 clever choice blood glucos sys 176 clonidine hcl/pf 112 clever choice glucose monitor 176,177 clopidogrel bisulfate 78 clever choice hd glucose syst 177 clorazepate dipotassium 153 clever choice micro monitor 177 CLORPRES 99 clever choice micro test strip 201 clotrimazole 311 clever choice pro glucose mtr 177 clotrimazole/betamethasone dipropionate 311 clever choice pro test strip 201 clozapine 160,161 clever choice talk glucose sys 177 CLOZARIL 161 clever choice talk test strips 201 CNL 8 311 clever choice test strips 201 COAGADEX 75 coal tar 325 CONTRAVE 134 COARTEM 21 control ast monitoring system 178 codeine phosphate/butalbital/aspirin/caffeine112 CONZIP 112 codeine phosphate/guaifenesin 303 cool blood glucose meter 178 codeine sulfate 112 cool blood glucose meter kit 178 COGENTIN 150 cool glucose test strip 201 COLAZAL 233 COPAXONE 291 colchicine 283 COPEGUS 23 COLCRYS 283 COPIKTRA 39 colesevelam hcl 85 COREG 91 COLESTID 85 COREMINO 9 colestipol hcl 85 CORGARD 91 colistin (as colistimethate sodium) 9 CORICIDIN HBP 112,303 COLOCORT 317 CORIFACT 75 COLY-MYCIN M PARENTERAL 9 CORLANOR 97 COLY-MYCIN S 223 CORLOPAM 63,99 COLYTE WITH FLAVOR PACKETS 240 CORMAX 317 COMBIGAN 230 CORTEF 245 COMBIPATCH 268 CORTENEMA 317 COMBIVENT RESPIMAT 64 CORTIFOAM 317 COMBIVIR 23 cortisone acetate 245 COMETRIQ 38 CORTISPORIN 311 COMPAZINE 235 CORTROSYN 199 COMPLERA 23 CORVERT 97 COMPRO 235 CORZIDE 91 COMTAN 150 COSENTYX (2 SYRINGES) 326 CONCERTA 134 COSENTYX PEN 326 CONDYLOX 326 COSENTYX PEN (2 PENS) 326 CONEX 33 COSENTYX SYRINGE 326 CONSTULOSE 214 COSMEGEN 39 contour link meter 177 COSOPT 230 contour meter 177 COSOPT PF 230 contour meter system 177 cosyntropin 63,199 contour next ez meter 177 COTELLIC 39 contour next ez meter system 177 COTEMPLA XR-ODT 134 contour next link 2.4 meter kt 177 COUGH DROPS 232 contour next link meter 177 COUMADIN 78 contour next meter 177 COVARYX 249 contour next one meter 178 COVARYX H.S. 249 contour next test strip 201 COZAAR 101 contour test strip 201 CREON 242 CRESEMBA 19 CRESTOR 85 D CRINONE 276 D-PENAMINE 244 CRIXIVAN 24 D.H.E.45 69 cromolyn sodium 301 dacarbazine 39 CROTAN 311 DACOGEN 39 CRYSELLE 260 DAKLINZA 24 CUBICIN 9 dalfampridine 297 CUBICIN RF 9 DALIRESP 307 CUPRIMINE 244 danazol 249 CUROSURF 307 DANTRIUM 68 CUTIVATE 317 dantrolene sodium 68 CUVITRU 56 dapsone 20,327 CUVPOSA 64 DAPTACEL DTAP 58 cvs advanced glucose meter 178 daptomycin 9 cvs advanced glucose test str 201 darifenacin hydrobromide 331 cyanocobalamin (vitamin b-12) 335 dario blood glucose monitor 178 CYCLAFEM 260 dario blood glucose test strip 201 CYCLINEX-1 215 DARZALEX 39 cyclobenzaprine hcl 68 DASETTA 260 cyclophosphamide 39 daunorubicin hcl 39 cycloserine 20 DAURISMO 39 CYCLOSET 150 DAXBIA 9 cyclosporine 294 DAYPRO 112 cyclosporine, modified 294 DAYSEE 260 CYMBALTA 161 DAYTIME COLD-FLU 303 cyproheptadine hcl 33 DAYTRANA 135 CYRAMZA 39 DDAVP 274,275 CYRED 260 DEBACTEROL 327 CYRED EQ 260 DEBLITANE 260 CYSTADANE 296 DECADRON 245 CYSTAGON 296 decitabine 39 CYSTARAN 232 deferasirox 244 cytarabine 39 deferoxamine mesylate 244 cytarabine/pf 39 DELATESTRYL 249 CYTOGAM 56 DELESTROGEN 268 CYTOMEL 279 DELSTRIGO 24 CYTOTEC 238 DELTASONE 245 CYTOVENE 24 DELYLA 260 CYTRA-K 214 DELZICOL 233 DEMADEX 216 demeclocycline hcl 9 DETROL LA 331 DEMEROL 112 dexamethasone 246 DEMSER 297 dexamethasone acetate and sodium phosphate in DENAVIR 311 sterile water 246 DENTA 5000 PLUS 285 dexamethasone acetate in sodium chloride, iso- DENTAGEL 285 osmotic 246 DEPACON 141 DEXAMETHASONE INTENSOL 246 DEPADE 158 dexamethasone sod phosphate 246 DEPAKENE 141 dexamethasone sodium phosphate 226,246 DEPAKOTE 141 dexamethasone sodium phosphate in 0.9 % DEPAKOTE ER 141 sodium chloride 246 DEPAKOTE SPRINKLE 141 dexamethasone sodium phosphate/pf 246 DEPEN 244 dexchlorpheniramine maleate 63 DEPO-ESTRADIOL 268 dexcom g4 (ped) receiver kit 178 DEPO-MEDROL 245 dexcom g4 receiver kit 178 DEPO-PROVERA 276 dexcom g4 receiver-share (ped) 178 DEPO-SUBQ PROVERA 104 276 dexcom g4 receiver-share kit 178 DEPO-TESTOSTERONE 249 dexcom g5 receiver kit 178 DEPOCYT 39 dexcom g6 receiver 178 DERMA-SMOOTHE-FS 317 dexcom receiver kit 178 DERMATOP 317 DEXEDRINE 135 DERMAZENE 311 DEXILANT 238 DERMOTIC 226 dexmedetomidine hcl 153 DESCOVY 24 dexmethylphenidate hcl 135 DESFERAL 244 DEXPAK 246 DESFERAL MESYLATE 244 dexrazoxane hcl 298 desipramine hcl 161 dextroamphetamine sulf- desloratadine 34 saccharate/amphetamine sulf-aspartate 135,136 desmopressin acetate 275 dextroamphetamine sulfate 136 desmopressin acetate (non-refrigerated) 275 DHS SAL 324 desogestrel-ethinyl estradiol 260 DIAMOX SEQUELS 230 desogestrel-ethinyl estradiol/ethinyl estradiol 260 diaper/brief,infant-toddler, disposable 178 DESONATE 317 DIASTAT 153 desonide 317 DIASTAT ACUDIAL 153 DESOWEN 317 diatrue plus blood glucose sys 178 desoximetasone 317 diatrue plus test strip 201 DESOXYN 135 diazepam 153 desvenlafaxine 161 DIBENZYLINE 70 desvenlafaxine fumarate 161 DICLEGIS 235 desvenlafaxine succinate 161 diclofenac epolamine 113 DETROL 331 diclofenac potassium 113 diclofenac sodium 40,113,226 docetaxel 40,63 diclofenac sodium/misoprostol 113 dofetilide 97 dicloxacillin sodium 9 DOLOPHINE HCL 113 dicyclomine hcl 64 donepezil hcl 67 didanosine 24 DONNATAL 65 diethylpropion hcl 136 DOPRAM 136 DIFFERIN 327 DOPTELET 82 DIFICID 9 DORAL 153 diflorasone diacetate 317 DORIBAX 9 DIFLUCAN 19 doripenem 9 diflunisal 113 DORYX 9,10 DIGITEK 97 DORYX MPC 10 DIGOX 97 dorzolamide hcl 230 digoxin 97 dorzolamide hcl/timolol maleate 230 dihydroergotamine mesylate 63,70 dorzolamide hcl/timolol maleate/pf 230 DILANTIN 141 DOTAREM 213 DILANTIN-125 141 DOVONEX 327 DILATRATE-SR 105 doxapram hcl 136 DILAUDID 113 doxazosin mesylate 84 DILT-XR 94 doxepin hcl 161,321 diltiazem hcl 94,95 doxercalciferol 336 diltiazem hcl in 0.9 % sodium chloride 95 DOXIL 40 diltiazem hcl/dextrose 5 % in water 95 doxorubicin hcl 40 DILUENT FOR ELITEK 299 doxorubicin hcl pegylated liposomal 40 dimenhydrinate 235 DOXY 100 10 DIOVAN 101 doxycycline hyclate 10,223 DIOVAN HCT 101 doxycycline monohydrate 10 DIPENTUM 233 DRITHOCREME HP 325 diphenhydramine hcl 33 dronabinol 235 diphenhydramine hcl in 0.9 % sodium chloride 33 droperidol 153 diphenoxylate hcl/atropine sulfate 234 drospirenone/ethinyl estradiol/levomefolate DIPROLENE 317 calcium 260 DIPROLENE AF 317 DROXIA 40 dipyridamole 105 DRYSOL 322 disopyramide phosphate 97 DSUVIA 113 disulfiram 282 DUAC 311 DITROPAN XL 331 DUAVEE 268 DIURIL 216 DUETACT 252 divalproex sodium 141 DUEXIS 113 DIVIGEL 268 DULERA 301 DOCEFREZ 40 duloxetine hcl 161 DUODOTE 282 easy trak blood glucose meter 179 DUOPA 150 easy trak glucose test strip 202 DUPIXENT 301,327 easy-touch blood glucose meter 179 DURACLON 113 easygluco meter 179 DURAGESIC 113 easygluco meter starter kit 179 DURAMORPH 113 easygluco plus meter kit 179 DUREZOL 226 easygluco plus starter kit 179 DURLAZA 113 easygluco plus test strips 202 DUROLANE 178 easygluco test strips 202 dutasteride 281 easymax 15 glucose test strip 202 dutasteride/tamsulosin hcl 281 easymax glucose test strips 202 DUTOPROL 91 easymax l blood glucose system 179 DUZALLO 221 easymax ng blood glucose sys 180 DVORAH 114 easymax ng glucose system kit 180 DXEVO 246 easymax v speaking glucose sys 180 DYANAVEL XR 136 easymax v2 blood glucose sys 180 DYAZIDE 216 EC-NAPROSYN 114 DYLOJECT 114 econazole nitrate 311 DYMISTA 229 ECOZA 311 DYRENIUM 216 ED-SPAZ 65 DYSPORT 297 EDARBI 101 EDARBYCLOR 101 E EDECRIN 216 E.E.S. 200 10 edetate calcium disodium 244 E.E.S. 400 10 EDEX 105 EAA 215 EDLUAR 153 easy check blood glucose sys 178 EDURANT 24 easy check glucose meter 178,179 EEMT 249 easy check glucose test strip 201 EEMT H.S. 249 easy gluco g2 test strip 201,202 efavirenz 24 easy plus glucose test strip 202 EFFER-K 219 easy plus ii blood glucose sys 179 EFFEXOR XR 161 easy plus ii test strip 202 EFFIENT 78 easy plus ii test strips 202 EFUDEX 40 easy step blood glucose meter 179 EGRIFTA 279 easy step glucose system kit 179 ELAPRASE 221 easy step glucose test strips 202 ELAVIL 161 easy talk blood glucose meter 179 ELDEPRYL 150 easy talk glucose test strip 202 ELECARE 215 easy touch glucose monitor sys 179 ELELYSO 221 easy touch glucose test strip 202 element compact glucose meter 180 element compact test strips 202 EMOQUETTE 261 element compact v glucose mtr 180 EMSAM 150 element plus blood glucose kit 180 EMTRIVA 24 element test strips 203 EMVERM 3 ELESTAT 229 ENABLEX 331 ELESTRIN 268 enalapril maleate 101 eletriptan hydrobromide 148 enalapril maleate/hydrochlorothiazide 101 ELIDEL 327 enalaprilat dihydrate 101 ELIGARD 272 ENBREL 287 ELIMITE 311 ENBREL MINI 287 ELINEST 261 ENBREL SURECLICK 287 ELIPHOS 217 ENDOCET 114 ELIQUIS 78 ENDOMETRIN 276 ELITE OB DHA 333 ENGERIX-B ADULT 59 ELITE-OB 400 333 ENGERIX-B PEDIATRIC-ADOLESCENT 59 ELITEK 221 ENLON 213 ELIXOPHYLLIN 332 ENLON-PLUS 213 ELLA 261 enoxaparin sodium 78 ELLENCE 40 ENPRESSE 261 ELMIRON 298 ENSKYCE 261 ELOCON 317 ENSTILAR 327 ELOCTATE 75 entacapone 150 EMADINE 229 entecavir 24 EMBEDA 114 ENTEREG 242 embrace blood glucose kit 180 ENTOCORT EC 246 embrace blood glucose system 180 ENTRESTO 101 embrace evo blood glucose kit 180 ENTYVIO 242 embrace evo test strips 203 ENULOSE 214 embrace glucose test strips 203 ENVARSUS XR 294 embrace pro blood glucose mtr 180 EPANED 101 embrace pro test strip 203 EPCLUSA 24 embrace pro test strips 203 EPIDIOLEX 141 embrace talk blood glucose mtr 180 EPIDUO 63,327 embrace talk blood glucose sys 180,181 EPIDUO FORTE 327 embrace talk test strip 203 EPIFOAM 317 embrace test strips 203 epinastine hcl 229 EMCYT 40 epinephrine 71 EMEND 235 epinephrine hcl in 0.9 % sodium chloride 71 EMFLAZA 246 epinephrine hcl in dextrose 5 % in water 71 EMGALITY PEN 148 EPINEPHRINESNAP-EMS 71 EMGALITY SYRINGE 148 EPINEPHRINESNAP-V 71 EPIPEN 71 esmolol hcl 91 EPIPEN 2-PAK 71 esmolol hcl in sodium chloride, iso-osmotic 91 EPIPEN JR 2-PAK 72 esomeprazole magnesium 238 epirubicin hcl 40 esomeprazole sodium 238 EPISIL 181 esomeprazole strontium 238 EPITOL 142 ESTARYLLA 261 EPIVIR 24 estazolam 154 EPIVIR HBV 24 ESTRACE 268 eplerenone 102 estradiol 268,269 EPOGEN 82 estradiol valerate 269 epoprostenol sodium (glycine) 308 estradiol/norethindrone acetate 269 eprosartan mesylate 102 ESTRING 269 eptifibatide 79 ESTROGEL 269 EPZICOM 24 estrogens,esterified/methyltestosterone 249 eq blood glucose test strip 203 estropipate 269 EQUETRO 142 eszopiclone 154 ERAXIS (WATER DILUENT) 19 ethacrynic acid 216 ERBITUX 40 ethambutol hcl 20 ergocalciferol (vitamin d2) 336 ethinyl estradiol/drospirenone 261 ergoloid mesylates 70 ethosuximide 142 ERGOMAR 70 ethyl acetate 299 ergotamine tartrate/caffeine 70 ethyl chloride 321 ERIVEDGE 40 ethynodiol diacetate-ethinyl estradiol 261 ERLEADA 40 ETHYOL 299 ERRIN 261 etidronate disodium 284 ERTACZO 311 etodolac 114 ERWINAZE 40 ETOPOPHOS 40 ERY 312 etoposide 41 ERY-TAB 10 eucalyptol 299 ERYGEL 312 eucalyptus oil 299 ERYPED 200 10 EUCRISA 317 ERYPED 400 10 EUFLEXXA 181 ERYTHROCIN LACTOBIONATE 10 EURAX 312 ERYTHROCIN STEARATE 10 EUTHYROX 279 erythromycin base 11,223 EVAMIST 269 erythromycin base in ethanol 312 EVEKEO 136 erythromycin base/benzoyl peroxide 312 evencare g2 blood glucose sys 181 erythromycin ethylsuccinate 11 evencare g2 test strip 203 ESBRIET 303 evencare g3 blood glucose sys 181 escitalopram oxalate 161 evencare g3 test strip 203 ESGIC 114 evencare glucose tst strips 203 evencare mini glucose test str 203 famotidine 238 evencare mini monitor system 181 famotidine in 0.9 % sodium chloride 238 evencare monitoring system 181 famotidine in sodium chloride, iso-osmotic/pf 238 evencare proview test strip 203,204 famotidine/pf 238 EVISTA 269 FANAPT 161,162 EVOCLIN 312 FARESTON 269 evolution blood glucose meter 181 FARXIGA 252 evolution test strips 204 FARYDAK 41 EVOMELA 41 FASENRA 301 EVOTAZ 24 FASLODEX 41 EVOXAC 67 FAYOSIM 261 EVZIO 158 FAZACLO 162 EXACTUSS TR 306 feeder container with gravity set, enfit 181 EXALGO 114 FEIBA NF 75 EXAPHEX TR 306 FEIBA VH IMMUNO 75 EXELDERM 312 felbamate 142 EXELON 67 FELBATOL 142 exemestane 41 FELDENE 114 EXFORGE 95 felodipine 95 EXFORGE HCT 95 FEM PH 312 EXJADE 244 FEMARA 41 EXODERM 312 FEMHRT 269 EXTAVIA 291 FEMRING 269 EXTINA 312 FEMYNOR 261 EZ FLU 16-17 (FLUZON QUAD PED) 59 fenofibrate 85 EZ FLU 2016-2017 (AFLURIA) 59 fenofibrate nanocrystallized 85 EZ FLU 2016-2017 (FLUVIRIN) 59 fenofibrate,micronized 85 EZ FLU 2018-2019 (FLUCELVAX) 59 fenofibric acid 85,86 ez smart plus system kit 181 fenofibric acid (choline) 86 ez smart plus test strips 204 FENOGLIDE 86 ez smart system kit 181 fenoprofen calcium 114 ez smart test strips 204 FENORTHO 114 ezetimibe 85 fentanyl 114 ezetimibe/simvastatin 85 fentanyl citrate 115 fentanyl citrate in 0.9 % sodium chloride/pf 115 F fentanyl citrate in dextrose 5% in water/pf 115 FABIOR 327 fentanyl citrate/bupivacaine hcl in 0.9 % sodium FABRAZYME 221 chloride/pf 115 FACTIVE 11 fentanyl citrate/pf 115,116 FALMINA 261 fentanyl citrate/ropivacaine hcl/sodium chloride famciclovir 24 0.9%/pf 116 FENTORA 116 FLUAD 2018-2019 59 FERAHEME 73 FLUARIX QUAD 2016-2017 60 FEROTRINSIC 74 FLUARIX QUAD 2017-2018 60 FERRIPROX 244 FLUARIX QUAD 2018-2019 60 FERRLECIT 74 FLUBLOK 2016-2017 60 FETZIMA 162 FLUBLOK 2017-2018 60 FEXMID 69 FLUBLOK QUAD 2017-2018 60 fexofenadine hcl 34 FLUBLOK QUAD 2018-2019 60 FIASP 252 FLUCELVAX QUAD 2016-2017 60 FIASP FLEXTOUCH 252 FLUCELVAX QUAD 2017-2018 60 FIBRICOR 86 FLUCELVAX QUAD 2018-2019 60 fifty50 2.0 glucose meter 181 fluconazole 19 fifty50 glucose test strip 204 fluconazole in dextrose, iso-osmotic 19 FINACEA 327 fluconazole in sodium chloride, iso-osmotic 19 finasteride 281,327 flucytosine 19 FIORICET 116 fludarabine phosphate 41 FIORICET WITH CODEINE 116 fludrocortisone acetate 246 FIORINAL 116 FLULAVAL QUAD 2016-2017 60 FIORINAL WITH CODEINE #3 116 FLULAVAL QUAD 2017-2018 60 FIRAZYR 286 FLULAVAL QUAD 2018-2019 60 FIRMAGON 272 FLUMADINE 25 FLAC OTIC OIL 226 flumazenil 157 FLAGYL 21 FLUMIST QUAD 2018-2019 60 FLAGYL ER 21 flunisolide 226 FLAREX 226 fluocinolone acetonide 317,318 flash glucose scanning reader 181 fluocinolone acetonide oil 226 flash glucose sensor 181 fluocinolone acetonide/shower cap 318 flavoxate hcl 331 fluocinonide 318 FLEBOGAMMA DIF 56 fluocinonide/emollient base 318 flecainide acetate 97 fluorometholone 226 FLECTOR 116 FLUOROPLEX 41 FLOLAN 308 fluorouracil 41 FLOLIPID 86 fluoxetine hcl 162 FLOMAX 70 fluphenazine decanoate 162 FLOVENT DISKUS 301 fluphenazine hcl 162 FLOVENT HFA 301 flurazepam hcl 154 FLOWTUSS 303 flurbiprofen 116 FLOXIN 223 flurbiprofen sodium 227 floxuridine 41 flutamide 41 FLUAD 2016-2017 59 fluticasone propionate 227,318 FLUAD 2017-2018 59 fluticasone propionate/salmeterol xinafoate 301 fluvastatin sodium 86 fora tn'g voice test strips 205 FLUVIRIN 2016-2017 60 fora v10 blood glucose system 182 FLUVIRIN 2017-2018 60 fora v10 glucose test strip 205 fluvoxamine maleate 162,163 fora v10-v12-d10-d20 strips 205 FLUZONE HIGH-DOSE 2016-2017 60 fora v12 blood glucose system 182 FLUZONE HIGH-DOSE 2017-2018 60 fora v12 glucose test strip 205 FLUZONE HIGH-DOSE 2018-2019 60 fora v20 blood glucose system 182 FLUZONE INTRADERM QUAD 2016-17 60 fora v20 glucose test strips 205 FLUZONE INTRADERM QUAD 2017-18 61 fora v30a blood glucose system 182 FLUZONE QUAD 2016-2017 61 fora v30a glucose test strip 205 FLUZONE QUAD 2017-2018 61 foracare gd20 glucose system 182 FLUZONE QUAD 2018-2019 61 foracare gd20 test strips 205 FLUZONE QUAD PEDI 2016-2017 61 foracare gd40 glucose strips 205 FLUZONE QUAD PEDI 2017-2018 61 foracare gd40a glucose system 183 FLUZONE QUAD PEDI 2018-2019 61 foracare gd40b glucose system 183 FML 227 FORADIL 72 FML FORTE 227 FORFIVO XL 163 FML S.O.P. 227 FORMADON 327 FOCALIN 136,137 formaldehyde 327 FOCALIN XR 137 FORTAZ 11 FOLBECAL 333 FORTAZ IN ISO-OSMOTIC DEXTROSE 11 folic acid 335 FORTEO 274 FOLLISTIM AQ 272 FORTESTA 249 FOLOTYN 41 fortiscare blood glucose syst 183 fondaparinux sodium 79 fortiscare glucose test strips 205 fora 6 connect glucose strip 204 FOSAMAX 284 fora blood glucose test strip 204 FOSAMAX PLUS D 284 fora d10 blood glucose system 182 fosamprenavir calcium 25 fora d15g glucose test strips 204 foscarnet sodium 25 fora d20 blood glucose system 182 FOSCAVIR 25 fora d20 glucose test strips 204 fosinopril sodium 102 fora d40-g31 test strips 204 fosinopril sodium/hydrochlorothiazide 102 fora g20 blood glucose system 182 fosphenytoin sodium 142 fora g20 glucose test strips 204 FOSRENOL 218 fora g30-premium v10 test strp 204 FRAGMIN 79 fora g30a blood glucose system 182 freestyle flash system kit 183 fora gd50 blood glucose system 182 freestyle freedom kit 183 fora gd50 test strips 204 freestyle freedom lite meter 183 fora premium v10 glucose meter 182 freestyle freedom lite nfrs 183 fora test n'go voice system 182 freestyle insulinx glucose sys 183 fora tn'g voice glucose meter 182 freestyle insulinx strip nfrs 205 freestyle insulinx test strip 205 GARDASIL 9 61 freestyle insulinx test strips 205 GASTROCROM 302 freestyle lite meter 183 gatifloxacin 223 freestyle lite meter nfrs 183 GATTEX 242 freestyle lite test strip 205,206 GAVILYTE-C 240 freestyle lite test strip nfrs 206 GAVILYTE-G 240 freestyle navigator sensor kit 183 GAVILYTE-N 240 freestyle prec neo test strips 206 GAZYVA 41 freestyle precision neo meter 183 gdrive blood glucose system 184 freestyle sidekick ii valpk 183,184 ge100 blood glucose system 184 freestyle system kit 184 ge100 blood glucose test strip 206 freestyle test strips 206 GEL-ONE 184 freestyle test strips nfrs 206 GELNIQUE 331 FROVA 148 gemcitabine hcl 41 frovatriptan succinate 148 gemfibrozil 86 FULPHILA 82 GEMZAR 41 FURADANTIN 32 GENERLAC 215 furosemide 216 GENGRAF 294 FUSILEV 282 GENOTROPIN 275 FUZEON 25 genstrip glucose test strip 206 FYAVOLV 269 GENTAK 223 FYCOMPA 142 gentamicin sulfate 11,223,224,312 gentamicin sulfate in sodium chloride, iso- G osmotic 11 g-4 test strips 206 gentamicin sulfate/pf 11 gabapentin 142 gentamicin sulfate/sodium citrate 11 GABITRIL 142 genultimate test strip 206 GALAFOLD 297 GENVISC 850 184 galantamine hbr 67 GENVOYA 25 GALZIN 244 GEODON 163 GAMASTAN 57 ght blood glucose test strip 206 GAMASTAN S-D 57 GIANVI 261 GAMMAGARD LIQUID 57 GIAZO 233 GAMMAGARD S-D 57 GILDAGIA 261 GAMMAKED 57 GILENYA 291 GAMMAPLEX 57 GILOTRIF 41 GAMUNEX-C 57 GILPHEX TR 306 ganciclovir 25 GILTUSS TR 306 ganciclovir sodium 25 GLASSIA 307 ganirelix acetate 272 glatiramer acetate 291 GARDASIL 61 GLATOPA 292 GLEEVEC 42 GLYCATE 65 GLEOSTINE 42 glycopyrrolate 65 GLIADEL 42 glycopyrrolate in sterile water/pf 65 glimepiride 252 GLYNASE 253 glipizide 252 GLYRX-PF 65 glipizide/metformin hcl 252 GLYSET 253 gloves, latex 184 GLYTACTIN 15 PE BETTERMILK 215 GLUCAGEN 259 GLYTACTIN RTD 10 PE 215 GLUCAGON EMERGENCY KIT 259 GLYTACTIN RTD 15 PE 215 gluco navii glucose monitor kt 184 GLYXAMBI 253 gluco navii glucose test strip 206 gmate smart meter kit 185 glucocard 01 meter kit 184 gmate smart starter kit 185 glucocard 01 sensor plus strip 206 gmate test strips 207 glucocard expression meter 184 gmate voice meter monitor syst 185 glucocard expression meter kit 184 gmate voice starter kit 185 glucocard expression test strp 206 gnp easy touch gluc test strip 207 glucocard shine connex meter 184 gnp easy touch glucose monitor 185,186 glucocard shine express meter 184 GOCOVRI 150 glucocard shine meter 184,185 GOLYTELY 240 glucocard shine meter kit 185 GONAL-F 272 glucocard shine test strips 207 GONAL-F RFF 272 glucocard shine xl meter 185 GONAL-F RFF REDI-JECT 272 glucocard vital meter kit 185 GONITRO 105 glucocard vital sensor strip 207 goodlife ac-302 glucose meter 186 glucocard vital test strips 207 goodlife ac-302 test strip 207 glucocom blood glucose kit 185 GOODY'S EXTRA STRENGTH 116 glucocom blood glucose meter 185 GRALISE 116 glucocom glucose test strip 207 granisetron hcl 235 glucocom value kit 185 granisetron hcl/pf 236 GLUCOPHAGE 253 GRANIX 82 GLUCOPHAGE XR 253 GRASTEK 56 glucose GRIS-PEG 19 sensor,implantable,continuous/dexamethasone griseofulvin ultramicrosize 19 acetate 185 griseofulvin, microsize 19 GLUCOTROL 253 gs blood glucose monitor sys 186 GLUCOTROL XL 253 gs blood glucose test strip 207 GLUCOVANCE 253 GUAIFENESIN DAC 303 GLUTAREX-1 215 guaifenesin/dextromethorphan glyburide 253 hbr/pseudoephedrine hcl 63 glyburide,micronized 253 guaifenesin/hydrocodone bitartrate 304 glyburide/metformin hcl 253 guanfacine hcl 99,157 guanidine hcl 67 heparin sodium,porcine/pf 80 guardian real-time glu monitor 186 HEPLISAV-B 61 GYNAZOLE 1 312 HEPSERA 25 HERCEPTIN 42 H HETLIOZ 154 H.P. ACTHAR 199 HEXALEN 42 HAEGARDA 286 HIBERIX 61 HAILEY 24 FE 261 HICON 300 HALAVEN 42 HIDEX 246 HALCION 154 HIPREX 32 HALDOL 163 HISTEX PD 33 HALDOL DECANOATE 100 163 HISTEX-DM 304 HALDOL DECANOATE 50 163 HISTEX-PE 33 halobetasol propionate 318 HIZENTRA 57 haloperidol 163 HOMATROPAIRE 232 haloperidol decanoate 163 homatropine hbr 233 haloperidol lactate 163 HOMINEX-1 215 harmony glucose test strip 207 HORIZANT 142 HARVONI 25 HPR PLUS 186 HAVRIX 61 HUMALOG 253 HCY 1 215 HUMALOG JUNIOR KWIKPEN 253 healthpro glucose monitor syst 186 HUMALOG KWIKPEN U-100 253 healthpro glucose test strips 207 HUMALOG KWIKPEN U-200 253 HEARTBURN TREATMENT 238 HUMALOG MIX 50-50 253 HEATHER 261 HUMALOG MIX 50-50 KWIKPEN 253 HECTOROL 336 HUMALOG MIX 75-25 254 HELIXATE FS 75 HUMALOG MIX 75-25 KWIKPEN 254 HEMANGEOL 91 humana true metrix air glu mtr 186 HEMLIBRA 76 humana true metrix air meter 186 HEMMOREX-HC 318 humana true metrix test strip 207 HEMOFIL M 76 humana trueresult glucose mtr 186 HEMORRHOIDAL SUPPOSITORY 327 humana truetest test strips 207 HEPAGAM B 57 HUMATE-P 76 heparin sodium,porcine 63,64,79 HUMATROPE 275 heparin sodium,porcine in 0.45 % sodium HUMIRA 287 chloride 79 HUMIRA PEDIATRIC CROHN'S 287 heparin sodium,porcine in 0.45 % sodium HUMIRA PEN 287 chloride/pf 79 HUMIRA PEN CROHN'S-UC-HS 288 heparin sodium,porcine in 0.9 % sodium HUMIRA PEN PSOR-UVEITS-ADOL HS 288 chloride 80 HUMIRA(CF) 288 heparin sodium,porcine/dextrose 5 % in water 80 HUMIRA(CF) PEDIATRIC CROHN'S 242,288 HUMIRA(CF) PEN 288 hydromorphone hcl in 0.9 % sodium chloride 118 HUMIRA(CF) PEN CROHN'S-UC-HS 288 hydromorphone hcl in 0.9 % sodium HUMIRA(CF) PEN PSOR-UV-ADOL HS 288 chloride/pf 119 HUMULIN 70-30 254 hydromorphone hcl in dextrose 5 %-water/pf 119 HUMULIN 70/30 KWIKPEN 254 hydromorphone hcl/bupivacaine hcl in 0.9% HUMULIN N 254 sodium chloride/pf 119 HUMULIN N KWIKPEN 254 hydromorphone hcl/pf 120 HUMULIN R 254 hydromorphone hcl/ropivacaine in 0.9 % sodium HUMULIN R U-500 254 chloride/pf 120 HUMULIN R U-500 KWIKPEN 254 hydroquinone 323 HYALGAN 186 hydroquinone microspheres 323 HYCAMTIN 42 hydroxocobalamin 335 HYCET 116 hydroxychloroquine sulfate 21 HYCLODEX 186 hydroxyprogesterone caproate 276 HYCOFENIX 304 hydroxyprogesterone caproate/pf 277 hydralazine hcl 99 hydroxyurea 42 HYDREA 42 hydroxyzine hcl 154 hydrochloric acid 242 hydroxyzine pamoate 154 hydrochlorothiazide 216 HYLATOPICPLUS 186 HYDROCIL INSTANT 240 HYLENEX 221 hydrocodone bitart/chlorpheniramine HYMOVIS 186 maleate/pseudoephedrine 304 hyoscyamine sulfate 65 hydrocodone bitartrate/acetaminophen 116,117 HYOSYNE 65 hydrocodone bitartrate/homatropine HYPERHEP B S-D 57 methylbromide 304 HYPERRAB 57 hydrocodone polistirex/chlorpheniramine HYPERRAB S-D 57 polistirex 304 HYPERRHO S-D 57 hydrocodone/ibuprofen 117 HYPERTET S-D 57 hydrocortisone 246,318 HYQVIA 57 hydrocortisone acetate 318 HYQVIA HY COMPONENT 221 hydrocortisone acetate/lidocaine hcl/aloe HYQVIA IG COMPONENT 58 vera 321 HYSINGLA ER 120 hydrocortisone acetate/pramoxine hcl 318 HYZAAR 102 hydrocortisone butyrate 318 hydrocortisone butyrate/emollient base 318 I hydrocortisone valerate 318 I-VALEX-1 215 hydrocortisone/acetic acid 224 ibandronate sodium 284 hydrocortisone/iodoquinol 312 IBRANCE 42,43 hydrocortisone/mineral oil/petrolatum,white 318 IBU 120 HYDROMET 304 IBUDONE 120 hydromorphone hcl 117,118 ibuprofen 120 ibuprofen lysine/pf 120 INFED 74 ibuprofen/oxycodone hcl 120 infinity meter kit 186,187 ibutilide fumarate 97 infinity starter kit 187 ICLUSIG 43 infinity test strips 208 IDAMYCIN PFS 43 infinity voice glucose monitor 187 idarubicin hcl 43 infinity voice test strip 208 IDELVION 76 INFLECTRA 289 IDHIFA 43 INFUVITE PEDIATRIC 333 IFEX 43 INGREZZA 173 ifosfamide 43 INJECTAFER 74 ifosfamide/mesna 43 INLYTA 44 iglucose blood glucose monitor 186 INNOPRAN XL 91 iglucose test strip 207,208 INSPRA 102 ILARIS 297 INTEGRILIN 80 ILEVRO 227 INTELENCE 25 ILUVIEN 227 INTERMEZZO 154 imatinib mesylate 43 INTRAROSA 246 IMBRUVICA 44 INTRON A 25 imipenem/cilastatin sodium 11 INTROVALE 261 imipramine hcl 163 INTUNIV 157 imipramine pamoate 163 INVANZ 11 imiquimod 328 INVEGA 163,164 IMITREX 148 INVEGA SUSTENNA 164 IMOGAM RABIES-HT 58 INVEGA TRINZA 164,165 IMOVAX RABIES VACCINE 61 INVIRASE 25 IMPAVIDO 21 INVOKAMET 254 IMPOYZ 319 INVOKAMET XR 254 IMURAN 295 INVOKANA 254 IMVEXXY 270 iodine/potassium iodide 312 INCASSIA 261 iodine/sodium iodide 312 INCRELEX 279 IODOFLEX 312 INCRUSE ELLIPTA 65 IODOSORB 312 indapamide 216 IONSYS 120 INDERAL LA 91 IOPIDINE 232 INDERAL XL 91 IPOL 61 INDOCIN 120 ipratropium bromide 65,232 INDOCIN I.V. 120 ipratropium bromide/albuterol sulfate 65 indomethacin 120 IPRIVASK 80 indomethacin sodium 120 irbesartan 102 INFANRIX DTAP 58 irbesartan/hydrochlorothiazide 102 INFASURF 307 IRENKA 165 IRESSA 44 jazz wireless 2 meter kit 187 irinotecan hcl 44 JENCYCLA 261 IRO-PLEX 74 JENTADUETO 254 irrigation piercing pin set,nv 187 JENTADUETO XR 255 irrigation set 187 JETREA 232 ISENTRESS 25 JEVANTIQUE LO 270 ISENTRESS HD 25 JEVTANA 45 ISIBLOOM 261 JINTELI 270 ISOCHRON 106 JOLESSA 262 isometheptene JOLIVETTE 262 mucate/caffeine/acetaminophen 120 JULEBER 262 isometheptene JULUCA 26 mucate/dichloralphenazone/acetaminophen 120 JUNEL 262 isoniazid 20 JUNEL FE 262 ISOPTO CARPINE 230 JUNEL FE 24 262 ISORDIL 106 JUXTAPID 86 ISORDIL TITRADOSE 106 JYNARQUE 216 isosorbide dinitrate 106 isosorbide mononitrate 106 K isotretinoin 328 K EFFERVESCENT 219 isoxsuprine hcl 106 K-PHOS ORIGINAL 214 isradipine 95 K-TAB ER 219 ISTALOL 230 KADCYLA 45 ISTODAX 44 KADIAN 121 itraconazole 19 KAITLIB FE 262 ivermectin 3 KALBITOR 286 IXEMPRA 44 KALETRA 26 IXIARO 61 KALYDECO 306 IXINITY 76 KAPVAY 99 KARBINAL ER 33 J KARIVA 262 JADENU 244 KAYEXALATE 218 JADENU SPRINKLE 244 KAZANO 255 JAKAFI 44 KCENTRA 76 JALYN 281 KEDRAB 58 JANTOVEN 81 KEFLEX 11 JANUMET 254 KELNOR 1-35 262 JANUMET XR 254 KELNOR 1-50 262 JANUVIA 254 KENALOG 319 JARDIANCE 254 KENALOG-10 247 JASMIEL 261 KENALOG-40 247 KENGREAL 81 KRINTAFEL 21 KEPIVANCE 322 KRISTALOSE 215 KEPPRA 142 kro premium blood glucose syst 187 KEPPRA XR 143 kro premium blood glucose test 208 KERALAC 324 KRYSTEXXA 283 KERALYT 324 KURVELO 262 KETEK 11 KUVAN 297 ketoconazole 19,312 KYLEENA 262 KETONEX-1 215 KYNAMRO 86 ketoprofen 121 KYPROLIS 46 ketorolac tromethamine 121,227 ketotifen fumarate 229 L KEVEYIS 285 labetalol hcl 91 KEVZARA 289 labetalol in dextrose 5 % in water 91 KEYTRUDA 45 lactulose 215 KHAPZORY 282 LAMICTAL 143 KHEDEZLA 165 LAMICTAL (BLUE) 143 KIMIDESS 262 LAMICTAL (GREEN) 143 KINERET 289 LAMICTAL (ORANGE) 143 KINRIX 61 LAMICTAL ODT 143 KIONEX 218 LAMICTAL ODT (BLUE) 143 KISQALI 45 LAMICTAL ODT (GREEN) 143 KISQALI FEMARA CO-PACK 45 LAMICTAL ODT (ORANGE) 143 KITABIS PAK 11 LAMICTAL XR 143 KLARON 312 LAMICTAL XR (BLUE) 143 KLOFENSAID II 121 LAMICTAL XR (GREEN) 143 KLONOPIN 143 LAMICTAL XR (ORANGE) 143 KLOR-CON 219 LAMISIL 19 KLOR-CON 10 219 lamivudine 26 KLOR-CON 8 219 lamivudine/zidovudine 26 KLOR-CON M10 219 lamotrigine 143 KLOR-CON M15 219 LANAFLEX 215 KLOR-CON M20 219 lancets 187 KLOR-CON SPRINKLE 219 lancing device 187 KLOR-CON-EF 219 lancing device, vacuum/lancets 187 KOATE 76 lancing device/lancets 187 KOGENATE FS 76 LANOXIN 97 KOMBIGLYZE XR 255 LANOXIN PEDIATRIC 97 KONSYL 240 lansoprazole 238 KORLYM 255 lansoprazole/amoxicillin KOVALTRY 76 trihydrate/clarithromycin 238 lanthanum carbonate 218 LEVO-T 279 LANTUS 255 levobunolol hcl 230 LANTUS SOLOSTAR 255 levocarnitine 297 LARIN 262 levocarnitine (with sugar) 297 LARIN 24 FE 262 levocetirizine dihydrochloride 34 LARIN FE 262 levofloxacin 11,12,224 LARISSIA 262 levofloxacin/dextrose 5 % in water 12 LASIX 217 levoleucovorin calcium 282 LASTACAFT 229 levomefolate calcium 335 latanoprost 230 LEVONEST 262 LATISSE 230 levonorgestrel 263 LATUDA 165 levonorgestrel-ethinyl estradiol 263 LAYOLIS FE 262 levonorgestrel/ethinyl estradiol and ethinyl LAZANDA 121 estradiol 263 ledipasvir/sofosbuvir 26 LEVORA-28 263 LEENA 262 levothyroxine sodium 279 leflunomide 289 LEVOXYL 279,280 lemon flavor extract 299 LEVSIN 65 lemon oil 299 LEVSIN-SL 65 LENVIMA 46 LEXAPRO 165 LENZAPATCH 321 LEXETTE 319 LESCOL 86,87 LEXIVA 26 LESCOL XL 87 LIALDA 233 LESSINA 262 liberty blood glucose monitor 187 LETAIRIS 308 liberty test strips 208 letrozole 46 LIBRAX 65 leucovorin calcium 282 lidocaine 321 LEUKERAN 46 lidocaine hcl 281,321 LEUKINE 82 lidocaine hcl buffered with 8.4 % sodium leuprolide acetate 272 bicarbonate 281 LEVACET 64 lidocaine hcl in 0.9 % sodium chloride 281 levalbuterol hcl 72 lidocaine hcl in dextrose 5% in water/pf 97 levalbuterol tar hfa 45mcg inh 72 lidocaine hcl in sodium chloride, iso- LEVAQUIN 11 osmotic/pf 281 LEVATOL 91 lidocaine hcl/dextrose 5%-water/pf 97 LEVBID 65 lidocaine hcl/hydrocortisone acetate 319,321 LEVEMIR 255 lidocaine hcl/pf 98,281 LEVEMIR FLEXTOUCH 255 lidocaine/prilocaine 321 levetiracetam 143,144 lidocaine/tetracaine 321 levetiracetam in sodium chloride, iso-osmotic 144 LIDODERM 321 LEVITRA 106 LIDODOSE 321 LIDOPIN 321 lorazepam in 0.9 % sodium chloride 154 LIDOPRIL 321 lorazepam in 5 % dextrose and water 154 LIDOTREX 187 LORAZEPAM INTENSOL 154 LIDTOPIC MAX 321 LORBRENA 46 LILETTA 263 LORCET 121 LILLOW 263 LORCET HD 121 LINCOCIN 12 LORCET PLUS 121 lincomycin hcl 12 LORTAB 122 lindane 312 LORTUSS EX 304 linezolid 12 LORYNA 263 linezolid in 0.9 % sodium chloride 12 LORZONE 69 linezolid in dextrose 5 % in water 12 losartan potassium 102 LINZESS 243 losartan potassium/hydrochlorothiazide 102 liothyronine sodium 280 LOTEMAX 227 LIPITOR 87 LOTEMAX SM 227 LIPOFEN 87 LOTENSIN 102,103 lisinopril 102 LOTENSIN HCT 103 lisinopril/hydrochlorothiazide 102 LOTREL 95 lithium carbonate 147 LOTRISONE 313 lithium citrate 147 LOTRONEX 234 LITHOBID 147 lovastatin 87 LIVALO 87 LOVAZA 87 LO LOESTRIN FE 263 LOVENOX 81 LOCOID 319 LOW-OGESTREL 263 LOCORT 247 loxapine succinate 165 LODINE 121 LUCEMYRA 72 LODOSYN 157 LUCENTIS 232 LOKELMA 218 LUGOL'S 313 LOMAIRA 137 luliconazole 313 LOMEDIA 24 FE 263 LUMIGAN 230 LOMOTIL 234 LUMINAL SODIUM 64 LONHALA MAGNAIR REFILL 65 LUMIZYME 222 LONHALA MAGNAIR STARTER 65 LUMOXITI 46 LONSURF 46 LUNESTA 154,155 LOPID 87 LUPRON DEPOT 272 lopinavir/ritonavir 26 LUPRON DEPOT (LUPANETA) 272 LOPREEZA 270 LUPRON DEPOT-PED 272 LOPRESSOR 91 LUTERA 263 LOPRESSOR HCT 91 LUXIQ 319 LOPROX 312 LUZU 313 lorazepam 154 LYNPARZA 46 LYRICA 144 meclofenamate sodium 122 LYRICA CR 122 MEDICATED PADS 322 LYSODREN 46 MEDROL 247 LYSTEDA 76 medroxyprogesterone acetate 277 LYZA 263 mefenamic acid 122 mefloquine hcl 22 M MEFOXIN 64 M-M-R II VACCINE 61 MEGACE ES 277 M.V.I. PEDIATRIC 333 megestrol acetate 277 MACNATAL CN DHA 333 meijer blood glucose test strp 208 MACRILEN 213 MEKINIST 46,47 MACROBID 32 MEKTOVI 47 MACRODANTIN 32 melatonin 297 magnesium sulfate in 0.9 % sodium chloride 144 melatonin/pyridoxine 297 magnesium sulfate/dextrose 5 % in water 144 melatonin/pyridoxine hcl (vit b6) 297 MAKENA 277 MELODETTA 24 FE 263 MALARONE 22 meloxicam 122 malathion 313 melphalan 47 mannitol 217 melphalan hcl 47 maprotiline hcl 165 memantine hcl 157 MARINOL 236 MENACTRA 61 MARLISSA 263 MENEST 270 MARPLAN 165 MENOMUNE-A-C-Y-W-135 61 MARQIBO 46 MENOPUR 273 MARTEN-TAB 122 MENOSTAR 270 MATERNITY 333 MENTAX 313 MATULANE 46 MENVEO A-C-Y-W-135-DIP 61 MATZIM LA 95 MENVEO MENA COMPONENT 62 MAVYRET 26 MENVEO MENCYW-135 COMPONENT 62 MAXALT 148 meperidine hcl 122 MAXALT MLT 148 meperidine hcl in 0.9 % sodium chloride/pf 122 MAXIDEX 227 meperidine hcl/pf 122,123 MAXIFED CDX 304 MEPHYTON 337 maxima test strip 208 meprobamate 155 MAXIPHEN CD 304 MEPRON 22 MAXIPHEN CDX 304 mercaptopurine 47 MAXIPIME 12 meropenem 12 MAXITROL 224 meropenem in 0.9 % sodium chloride 12 MAXZIDE 217 MERREM 12 MAXZIDE-25 MG 217 mesalamine 234 meclizine hcl 236 mesalamine 800 mg dr tablet 234 mesalamine with cleansing wipes 234 methylprednisolone acetate in sterile water for mesna 299 injection 247 MESNEX 299 methylprednisolone sodium succinate 247 MESTINON 67 methyltestosterone 249 METADATE CD 137 metipranolol 231 METADATE ER 137 metoclopramide hcl 243 metaproterenol sulfate 72 metolazone 217 METASTRON 300 metoprolol succinate 91 METAXALL 69 metoprolol tartrate 91,92 metaxalone 69 metoprolol tartrate/hydrochlorothiazide 92 metformin hcl 255 METRO IV 22 methadone hcl 123 METROCREAM 313 METHADONE INTENSOL 123 METROGEL 313 METHADOSE 123 METROGEL-VAGINAL 313 methamphetamine hcl 137 METROLOTION 313 methazolamide 230,231 metronidazole 22,313 methenamine hippurate 32 metronidazole in sodium chloride 22 methenamine mandelate 32 mexiletine hcl 98 METHERGINE 299 MIACALCIN 274 methimazole 280 MIBELAS 24 FE 263 METHITEST 249 MICARDIS 103 methocarbamol 69 MICARDIS HCT 103 methohexital sodium in sterile water for miconazole nitrate 313 injection/pf 158 miconazole nitrate/zinc methotrexate sodium 47 oxide/petrolatum,white 313 methotrexate sodium/pf 47 MICORT-HC 319 methoxsalen 323 MICRHOGAM ULTRA-FILTERED PLUS 58 methscopolamine bromide 66 microdot blood glucose system 187 methyclothiazide 217 microdot test strips 208 methyl salicylate 123 microdot xtra test strips 208 methyldopa 99 MICROGESTIN 263 methyldopa/hydrochlorothiazide 99 MICROGESTIN 24 FE 263 methyldopate hcl 99 MICROGESTIN FE 263 methylene blue 282,297 MICROZIDE 217 methylergonovine maleate 299 midazolam hcl 155 METHYLIN 137 midazolam hcl in 0.9 % sodium chloride 155 methylphenidate hcl 137,138 midazolam hcl in 0.9 % sodium chloride/pf 155 methylprednisolone 247 midazolam hcl in dextrose 5% in water 155 methylprednisolone acetate 247 MIDNITE FOR MENOPAUSE 297 methylprednisolone acetate in sodium MIDNITE MENOPAUSE 297 chloride,iso-osmotic/pf 247 MIDNITE PM 297 midodrine hcl 72 MONO-LINYAH 264 MIFEPREX 299 MONOCLATE-P 76 MIGERGOT 70 MONODOX 13 miglitol 255 MONONESSA 264 miglustat 297 MONONINE 76 MIGRANAL 70 MONOVISC 187 MILI 264 montelukast sodium 302 MILLIPRED 247 MONUROL 32 MILLIPRED DP 247 MORGIDOX 13 MIMVEY 270 MORPHABOND ER 123 MIMVEY LO 270 morphine sulfate 123,124,125 MINERAL OIL 240 morphine sulfate in 0.9 % sodium chloride 125 minimed 630g guardian start kt 187 morphine sulfate in 0.9 % sodium MINIPRESS 84 chloride/pf 125,126 MINITRAN 106 morphine sulfate/dextrose 5 % in water 126 MINIVELLE 270 morphine sulfate/pf 126 MINOCIN 12 MOVANTIK 243 minocycline hcl 12 MOVIPREP 241 MINOLIRA ER 12 MOXATAG 13 minoxidil 99 MOXEZA 224 MIOCHOL-E 231 moxifloxacin hcl 13,224 MIOSTAT 231 moxifloxacin hcl in sodium acetate and MIRALAX 241 sulfate,water,iso-osm 13 MIRAPEX 151 moxifloxacin hcl in sodium chloride, iso- MIRAPEX ER 151 osmotic 13 MIRCERA 82 MOZOBIL 82 MIRENA 264 MS CONTIN 126 mirtazapine 165 MUCOTROL 188 MIRVASO 328 MULTAQ 98 misoprostol 238 mupirocin 313 MITIGARE 283 mupirocin calcium 313 mitomycin 47 MUSE 106 mitoxantrone hcl 47 MUSTARGEN 47 MOBIC 123 MUTAMYCIN 47 modafinil 138 MVW COMPLETE FORMLTN PEDIATRIC 333 MODERIBA 26 MVW COMPLETE FORMULATION D3000 333 moexipril hcl 103 MYALEPT 274 moexipril hcl/hydrochlorothiazide 103 MYAMBUTOL 20 molindone hcl 165 MYCAMINE 19 mometasone furoate 227,319 MYCOBUTIN 20 MONDOXYNE NL 13 mycophenolate mofetil 295 mycophenolate mofetil hcl 295 naproxen sodium 127 mycophenolate sodium 295 naratriptan hcl 148 MYDAYIS 138 NARCAN 158 MYFORTIC 295 NARDIL 165 myglucohealth monitoring kit 188 NASAL DECONGESTANT 72 myglucohealth test strips 208 NASAL SPRAY ORIGINAL 233 MYLERAN 47 NASCOBAL 335 MYLOTARG 47 NASONEX 227 MYNATAL 333 NATACYN 224 MYNATAL ADVANCE 333 NATAZIA 264 MYNATAL PLUS 333 nateglinide 255 MYNATAL-Z 333 NATESTO 249 MYNATE 90 PLUS 333 NATPARA 274 MYOBLOC 297 NATRECOR 106 MYORISAN 328 NATROBA 313 MYRBETRIQ 331 NATURAL FIBER 241 MYSOLINE 144 NATURE-THROID 280 MYTESI 234 NAVELBINE 47 MYZILRA 264 NEBUPENT 22 NECON 264 N needles, blood collection 188 NABI-HB 58 needles, disposable 188 nabumetone 126 needles, filter 188 nadolol 92 needles, insulin disposable 188 nadolol/bendroflumethiazide 92 needles, insulin disposable, safety 188 nafcillin in dextrose, iso-osmotic 13 needles, reusable 188 nafcillin sodium 13 needles, safety 189 naftifine hcl 313 needles, spinal-anesthetic 189 NAFTIN 313 nefazodone hcl 165,166 NAGLAZYME 222 NEMBUTAL SODIUM 155 nalbuphine hcl 126 NEO-POLYCIN 224 NALFON 126 NEO-POLYCIN HC 224 NALOCET 126 NEO-SYNALAR 313 naloxone hcl 158 neomycin sulfate 13 naltrexone hcl 158 neomycin sulfate/bacitracin zinc/polymyxin NAMENDA 157 b/hydrocortisone 224 NAMENDA XR 157 neomycin sulfate/bacitracin/polymyxin b 224 NAMZARIC 157 neomycin sulfate/polymyxin b sulfate/gramicidin NAPRELAN 126 d 224 NAPROSYN 126 neomycin sulfate/polymyxin b naproxen 127 sulfate/hydrocortisone 224 neomycin/polymyxin b nisoldipine 96 sulfate/dexamethasone 224 NITHIODOTE 282 NEOPROFEN 127 NITRO-BID 106 NEORAL 295 NITRO-DUR 106 NEOSPORIN 224 NITRO-TIME 106 neostigmine methylsulfate 67 nitrofurantoin 32 NEOTUSS PLUS 304 nitrofurantoin macrocrystal 32 NEPHRONEX-SL 336 nitrofurantoin monohydrate/macrocrystals 32 NEPTAZANE 231 nitroglycerin 106 NERLYNX 47 nitroglycerin in 5 % dextrose in water 107 NESINA 255 NITROLINGUAL 107 NEUAC 313 NITROMIST 107 NEULASTA 83 NITROPRESS 99 NEUPOGEN 83 nitroprusside sodium 99 NEUPRO 151 NITROSTAT 107 NEURONTIN 144 NITYR 298 neutek 2tek test strips 208 NIVA-HIST DM 304 NEVANAC 227 NIVESTYM 83 nevirapine 27 nizatidine 239 NEWGEN 333 NIZORAL 313 NEXAVAR 47 NOCDURNA 275 NEXAVIR 298 NOCTIVA 275 NEXIUM 238 NODOLOR 127 NEXIUM I.V. 239 NORA-BE 264 NEXPLANON 264 NORCO 127 NEXTERONE 98 NORDITROPIN FLEXPRO 275 niacin 87 norepinephrine bitartrate in 0.9 % sodium NIACOR 87 chloride 72 NIASPAN 87 norepinephrine bitartrate in 0.9 % sodium nicardipine hcl 95 chloride/pf 72 nicardipine hcl in 0.9 % sodium chloride 95 norepinephrine bitartrate in 5 % dextrose in nicardipine in 5 % dextrose in water 95 water 72 NICOTROL 67 norethindrone 264 NICOTROL NS 67 norethindrone acetate 277 nifedipine 95 norethindrone acetate-ethinyl estradiol 264,270 NIKKI 264 norethindrone acetate-ethinyl estradiol/ferrous NILANDRON 48 fumarate 264 nilutamide 48 norethindrone-ethinyl estradiol/ferrous nimodipine 96 fumarate 264 NINLARO 48 norgestimate-ethinyl estradiol 264 NIPENT 48 NORLYDA 264 NORLYROC 264 NUVIGIL 138 NORPACE 98 NUWIQ 77 NORPACE CR 98 NUZYRA 13 NORPRAMIN 166 NYAMYC 314 NORTHERA 72 NYMALIZE 96 NORTREL 264 nystatin 20,314 nortriptyline hcl 166 nystatin/triamcinolone acetonide 314 NORVASC 96 NYSTOP 314 NORVIR 27 nova max blood glucose meter 189 O nova max glucose test strip 208 OBIZUR 77 NOVACORT 319 OBREDON 304 novamax plus glu-ket ctrl soln 189 OBSTETRIX EC 333 NOVAREL 273 OBSTETRIX ONE 333 NOVOEIGHT 76 OBTREX DHA 333 NOVOLIN 70-30 256 OCALIVA 243 NOVOLIN 70-30 FLEXPEN 256 OCELLA 265 NOVOLIN N 256 OCTAGAM 58 NOVOLIN R 256 octoxynol 9 323 NOVOLOG 256 octreotide acetate 277 NOVOLOG FLEXPEN 256 OCUFLOX 224 NOVOLOG MIX 70-30 256 ODACTRA 56 NOVOLOG MIX 70-30 FLEXPEN 256 ODEFSEY 27 NOVOSEVEN RT 76 ODOMZO 48 NOXAFIL 19 OFEV 303 NP THYROID 280 ofloxacin 13,224 NPLATE 83 OGEN 270 NUCALA 302 OGESTREL 265 NUCYNTA 127 OIL-FREE ACNE WASH 324 NUCYNTA ER 127 OKEBO 13 NUEDEXTA 157 olanzapine 166 NULEV 66 olanzapine/fluoxetine hcl 166 NULOJIX 295 olmesartan medoxomil 103 NULYTELY WITH FLAVOR PACKS 241 olmesartan medoxomil/amlodipine NUMBONEX 321 besylate/hydrochlorothiazide 103 NUMOISYN 189 olmesartan medoxomil/hydrochlorothiazide 103 NUPLAZID 166 olopatadine hcl 229 NUTROPIN AQ NUSPIN 275 OLUMIANT 289 NUVAIL 189 OLUX 319 NUVARING 265 OLUX-E 319 NUVESSA 314 OLYSIO 27 OMECLAMOX-PAK 239 OPANA 127 omega-3 acid ethyl esters 87 OPDIVO 48 omega-3 fatty acids 88 opium tincture 234 OMEGAVEN 215 opium/belladonna alkaloids 127 omeprazole 239 OPSUMIT 308 omeprazole/sodium bicarbonate 239 OPTIMAL D3 336 OMIDRIA 233 OPTIRAY 240 213 OMNARIS 227 optium ez test strip 209 OMNIPAQUE 213 optium test strip 209 OMNIPRED 227 optumrx blood glucose meter 190 OMNITROPE 275 optumrx blood glucose system 190 on call express ctrl soln pak 189 optumrx test strip 209 on call express meter 189 ORACEA 13 on call express meter system 189 ORAFATE 190 on call express test strip 208 ORALAIR 56 on call plus meter 189 ORALONE 319 on call plus test strip 209 orange oil 299 on call vivid meter 189 ORAP 166 on call vivid pal meter 189,190 ORAPRED ODT 247 on call vivid test strip 209 ORAVIG 314 ONCASPAR 48 ORENCIA 289 ondansetron 236 ORENCIA CLICKJECT 289 ondansetron hcl 236 ORENITRAM ER 308 ondansetron hcl in 0.9 % sodium chloride 236 ORFADIN 298 ondansetron hcl in dextrose 5% in water 236 ORILISSA 273 ondansetron hcl/pf 236 ORKAMBI 306 onetouch ultra blue test strp 209,332 orphenadrine citrate 69 onetouch ultra2 glucose syst 190,332 ORSYTHIA 265 onetouch ultramini meter 190,332 ORTHOVISC 190 onetouch verio flex startr kit 190,332 OSCIMIN 66 onetouch verio flex system kit 190,332 OSCIMIN SL 66 onetouch verio iq meter 190,332 OSCIMIN SR 66 onetouch verio iq system kit 190,332 oseltamivir phosphate 27 onetouch verio meter system 190,332 OSENI 256 onetouch verio sync syst kit 190,332 OSMITROL 217 onetouch verio test strip 209,332 OSMOLEX ER 151 ONEXTON 314 OSMOPREP 241 ONFI 144 OSPHENA 270 ONGLYZA 256 OTEZLA 289 ONMEL 20 OTIPRIO 225 ONXOL 48 OTOVEL 225 OTREXUP 48 pantoprazole sodium 239 OVIDE 314 PANZYGA 58 OVIDREL 273 papaverine hcl 107 oxacillin sodium 13 papaverine hcl/alprostadil in bacteriostatic oxacillin sodium in iso-osmotic dextrose 13 water 107 oxaliplatin 48 PARAFON FORTE DSC 69 OXANDRIN 249 PARAGARD T 380-A 265 oxandrolone 249 paregoric 234 oxaprozin 127 paricalcitol 336 OXAYDO 127 PARLODEL 151 oxazepam 155 PARNATE 167 oxcarbazepine 144 PAROEX 225 OXERVATE 232 paromomycin sulfate 22 oxiconazole nitrate 314 paroxetine hcl 167 OXISTAT 314 paroxetine mesylate 167 OXSORALEN-ULTRA 323 PASER 20 OXTELLAR XR 144 PATADAY 229 oxybutynin chloride 331 PATANASE 229 oxycodone hcl 127,128 PATANOL 229 oxycodone hcl/acetaminophen 128 PAXIL 167 oxycodone hcl/aspirin 128 PAXIL CR 167 OXYCONTIN 128 PAZEO 229 oxymorphone hcl 128,129 PCE 13 OXYTROL 331 PEDIAPRED 247 OZEMPIC 256 PEDIARIX 62 OZURDEX 227 PEDVAXHIB 62 peg 3350/sod sulf/sod bicarb/sod P chloride/potassium chloride 241 PACERONE 98 PEG-PREP 241 paclitaxel 48 PEGANONE 145 PACNEX 324 PEGASYS 27 PAIN EASE 190 PEGASYS PROCLICK 27 paliperidone 166,167 PEGINTRON 27 PALYNZIQ 222 pen needle, diabetic 191 PAMELOR 167 pen needle, diabetic disposable, safety 191 pamidronate disodium 284 pen needle, diabetic, safety 191 PANCREAZE 242 penicillin g potassium 13 PANDEL 319 penicillin g potassium/dextrose-water 14 PANHEMATIN 298 penicillin g procaine 14 PANLOR 129 penicillin g sodium 14 PANRETIN 48 penicillin v potassium 14 PENLAC 314 phentolamine mesylate 70 PENNSAID 129 phentolamine mesylate/alprostadil in PENTACEL 62 bacteriostatic water 70 PENTACEL ACTHIB COMPONENT 62 PHENYLADE GMP 215 PENTACEL DTAP-IPV COMPONENT 62 PHENYLADE GMP MIX-IN 215 PENTAM 300 22 phenylephrine hcl 233 pentamidine isethionate 22 phenylephrine hcl in 0.9 % sodium chloride 72 PENTASA 234 phenylephrine hcl in dextrose 5 % in water 73 pentazocine hcl/naloxone hcl 129 phenylephrine hcl in sterile water for injection 73 pentetate calcium trisodium 244 phenylephrine hcl/promethazine hcl 33 pentetate zinc trisodium 244 PHENYTEK 145 pentoxifylline 83 phenytoin 145 PEPCID 239 phenytoin sodium 145 PERCOCET 129 phenytoin sodium extended 145 PERFOROMIST 72 PHILITH 265 PERIDEX 225 PHOSLYRA 218 perindopril erbumine 103 PHOSPHOLINE IODIDE 231 PERIOGARD 225 PHOTOFRIN 48 PERJETA 48 PHRENILIN FORTE 129 permethrin 314 physostigmine salicylate 67 perphenazine 167 phytonadione (vit k1) 337 perphenazine/amitriptyline hcl 167 PICATO 48 PERSERIS 167 PIFELTRO 27 PERTZYE 242 pilocarpine hcl 67,231 PEXEVA 167 pimecrolimus 328 PFIZERPEN 14 pimozide 168 pharmacist choice glucose sys 191 PIMTREA 265 pharmacist choice mini glu sys 191 pindolol 92 pharmacist choice test strips 209 pine tar 328 PHENADOZ 33 pioglitazone hcl 256 phenazopyridine hcl 321 pioglitazone hcl/glimepiride 256 phendimetrazine tartrate 138 pioglitazone hcl/metformin hcl 256 phenelzine sulfate 167 piperacillin sodium/tazobactam sodium 14 PHENERGAN 33 PIRMELLA 265 phenobarbital 155 piroxicam 129 phenobarbital sodium 155 PLAQUENIL 22 phenobarbital/hyoscyamine sulf/atropine PLAVIX 81 sulf/scopolamine hb 66 PLEGRIDY 292 PHENOHYTRO 66 PLEGRIDY PEN 292 phenoxybenzamine hcl 70 PLENVU 241 phentermine hcl 138 PLIAGLIS 321 PLIXDA 328 potassium phosphate in 0.9 % sodium PNEUMOVAX 23 62 chloride 220 PNV-DHA PLUS 333 POTIGA 145 PNV-IRON 334 povidone-iodine 225 PODOCON-25 328 PRADAXA 81 podofilox 328 pralidoxime chloride 282 POLYCIN 225 PRALUENT PEN 88 polyethylene glycol 3350 241 pramipexole di-hcl 151 polymyxin b sulfate 14 PRAMOSONE 319 polymyxin b sulfate/trimethoprim 225 PRAMOSONE E 319 POLYSACCHARIDE IRON FORTE 74 pramoxine hcl 321 polysorbate 60 323 PRANDIN 256,257 polysorbate 80 324 prasugrel hcl 81 POLYTRIM 225 PRAVACHOL 88 POMALYST 48 pravastatin sodium 88 PONSTEL 129 praziquantel 3 PONTOCAINE 321 prazosin hcl 84 PORTIA 265 PRE-ATTACHED LTA KIT 322 POTABA 298 PRECEDEX 155 potassium acetate 219 precision link direct monit 191 potassium bicarbonate/citric acid 219 precision pcx plus test str 209 potassium chloride 219 precision pcx test strips 209 potassium chloride in 0.45 % sodium chloride 219 precision point of care str 209 potassium chloride in 5 % dextrose in water 220 precision q-i-d test strips 209 potassium chloride in dextrose 5 % and 0.9 % precision xtra monitor 191 sodium chloride 220 precision xtra monitor nfrs 191 potassium chloride in dextrose 5 %-0.2 % sodium precision xtra monitor system 191 chloride 220 precision xtra test strips 209 potassium chloride in dextrose 5 %-0.45 % sodium PRECOSE 257 chloride 220 PRED FORTE 227 potassium chloride in dextrose 5% and 0.3 % PRED MILD 227 sodium chloride 220 PRED-G 225 potassium chloride in lactated ringers and 5 % prednicarbate 319 dextrose 220 prednisolone 247 potassium chloride in water for injection, prednisolone acetate 228 sterile 220 prednisolone sodium phosphate 228,247 potassium chloride/lidocaine hcl in 0.9 % sodium prednisone 247 chloride 220 PREDNISONE INTENSOL 247 potassium chloride/potassium bicarbonate/citric PREFEST 270 acid 220 PREGNYL 273 potassium citrate 214 PREMARIN 270,271 premium blood glucose monitor 192 PRIKAAN LITE 322 premium blood glucose system 192 PRILOSEC 239 premium blood glucose test str 210 primaquine phosphate 22 premium blood glucose tst strp 210 PRIMAXIN 14 premium v10 blood glucose mtr 192 primidone 145 premium v10 glucose test strip 210 PRIMLEV 129 PREMPHASE 271 PRIMSOL 32 PREMPRO 271 PRINIVIL 103 PRENA1 CHEW 334 PRISTIQ 168 PRENA1 PEARL 334 PRIVIGEN 58 PRENA1 TRUE 334 pro voice v8 glucose monitor 192 PRENATABS RX 334 pro voice v8-v9 test strip 210 PRENATAL VITAMIN WITH MINERALS AND FOLIC pro voice v9 glucose monitor 192 ACID GREATER THAN 0.8 MG ORAL TABLET 334 PROAIR HFA 73 prenatal vitamins no.5/ferrous fumarate/folic PROAIR RESPICLICK 73 acid 334 probenecid 221 prenatal vitamins no.79/iron fum/folic probenecid/colchicine 221 acid/levomefolate/dha 334 procainamide hcl 98 prenatal vits with calcium #74/ferrous PROCARDIA 96 fumarate/folic acid 334 PROCARDIA XL 96 prenatal vits with calcium no.74/ferrous PROCENTRA 138 fumarate/folic acid 334 prochlorperazine 236 PREPOPIK 241 prochlorperazine edisylate 236 PRESTALIA 103 prochlorperazine maleate 236 presto pro blood glucose meter 192 PROCORT 319 PREVACID 239 PROCRIT 83 PREVALITE 88 PROCTO-MED HC 319 PREVIDENT 285 PROCTO-PAK 319 PREVIDENT 5000 285 PROCTOCORT 319 PREVIDENT 5000 ENAMEL PROTECT 285 PROCTOFOAM-HC 319 PREVIDENT 5000 PLUS 285 PROCTOSOL-HC 319 PREVIDENT 5000 SENSITIVE 285 PROCTOZONE-HC 319 PREVIFEM 265 PROCYSBI 298 PREVNAR 13 62 prodigy autocode meter kit 192 PREVPAC 239 prodigy autocode monitor syst 192 PREVYMIS 27 prodigy no coding test strips 210 PREZCOBIX 27 prodigy pocket meter kit 192 PREZISTA 27 prodigy voice meter kit 192 PRIALT 129 PRODRIN 129 PRIFTIN 20 PROFENO 129 PRIKAAN 322 PROFILNINE 77 progesterone 277 PULMICORT 302 progesterone, micronized 277 PULMICORT FLEXHALER 302 PROGLYCEM 259 PULMOZYME 307 PROGRAF 295 PURIXAN 49 PROLASTIN C 307 PYLERA 14 PROLENSA 228 pyrazinamide 20 PROLEUKIN 49 PYRIDIUM 322 PROLIA 284 pyridostigmine bromide 68 PROMACTA 83 pyridoxine hcl (vitamin b6) 336 promethazine hcl 33,34,64 PYROGALLIC ACID 328 promethazine hcl in 0.9 % sodium chloride 34 promethazine hcl/codeine 304 Q promethazine hcl/dextromethorphan hbr 304 QBRELIS 103 promethazine/phenylephrine hcl/codeine 305 QBREXZA 66 PROMETHEGAN 34 QNASL 228 PROMETRIUM 277 QNASL CHILDREN 228 propafenone hcl 98 QSYMIA 139 propantheline bromide 66 QTERN 257 proparacaine hcl 232 QUADRACEL DTAP-IPV 62 PROPECIA 328 QUALAQUIN 22 propranolol hcl 92 QUASENSE 265 propranolol hcl/hydrochlorothiazide 92 quazepam 155 propylthiouracil 280 QUDEXY XR 145 PROQUAD 62 QUESTRAN 88 PROSCAR 282 QUESTRAN LIGHT 88 protamine sulfate 77 quetiapine fumarate 168 PROTHELIAL 192 QUILLICHEW ER 139 PROTONIX 239 QUILLIVANT XR 139 PROTONIX IV 240 quinapril hcl 103 PROTOPAM CHLORIDE 282 quinapril hcl/hydrochlorothiazide 103 PROTOPIC 328 quinidine gluconate 98 protriptyline hcl 168 quinidine sulfate 98 PROVENGE 108 quinine sulfate 22 PROVENTIL HFA 73 quintet ac blood glucose meter 192 PROVERA 277 quintet ac glucose test strips 210 PROVIGIL 138 quintet blood glucose system 192,193 PROZAC 168 quintet glucose test strips 210 PROZAC WEEKLY 168 QUTENZA 328 PRUDOXIN 322 QVAR 302 pseudoephedrine hcl 73 QVAR REDIHALER 302 PSORCON 320 RELENZA 28 R RELEXXII 139 R-NATAL OB 334 relion all-in-one meter kit 193 ra blood glucose monitor 193 relion confirm glucose monitor 193 RABAVERT 62 relion confirm system kit 193 rabeprazole sodium 240 relion confirm-micro test strp 210 RADIAGUARD 322 relion micro blood glucose sys 193 RADIOGARDASE 218 relion micro system 193 RAGWITEK 56 relion micro system kit 193 RAJANI 265 relion micro test strips 210 raloxifene hcl 271 relion premier blu glucose mtr 193 ramipril 103 relion premier test strip 210 RANEXA 98 relion premier voice gluco mtr 193 ranitidine hcl 240 relion prime blood glucose mtr 193 ranolazine 98 relion prime test strips 210 RAPAFLO 70 relion ultima glucose meter 193 RAPAMUNE 295 relion ultima test strips 210,211 rasagiline mesylate 151 RELISTOR 243 raspberry flavor, artificial 299 RELPAX 148 RASUVO 49 REMERON 168 RAVICTI 215 REMICADE 289 RAYALDEE 336 REMODULIN 308 RAZADYNE 68 RENAGEL 218 RAZADYNE ER 68 RENFLEXIS 290 READI-CAT 2 213 RENOVA 323 REBETOL 28 RENOVA PUMP 323 REBIF 292 RENVELA 218 REBIF REBIDOSE 293 REOPRO 81 RECLAST 284 repaglinide 257 RECLIPSEN 265 repaglinide/metformin hcl 257 RECOMBINATE 77 REPATHA PUSHTRONEX 88 RECOMBIVAX HB 62 REPATHA SURECLICK 88 RECTIV 328 REPATHA SYRINGE 88 REFISSA 322 REPREXAIN 129,130 refuah plus monitoring system 193 REQUIP 151 refuah plus test strips 210 REQUIP XL 151 REGENECARE 193 RESCRIPTOR 28 REGIMEX 139 RESECTISOL 218 REGLAN 243 RESPA A.R. 34 REGONOL 68 RESTASIS 228 REGRANEX 323 RESTASIS MULTIDOSE 228 RESTORIL 155 rightest gs550 test strips 211 RETACRIT 83 RILUTEK 157 RETIN-A 323 riluzole 157 RETIN-A MICRO 323 rimantadine hcl 29 RETIN-A MICRO PUMP 323 RIMSO-50 218 RETISERT 228 RIOMET 257 RETROVIR 28 risedronate sodium 284 REVATIO 107 RISPERDAL 169 REVCOVI 222 RISPERDAL CONSTA 169 reveal blood glucose meter 194 RISPERDAL M-TAB 169 reveal test strip 211 risperidone 169 REVIA 158 RITALIN 139 REVLIMID 49 RITALIN LA 139 REVONTO 69 ritonavir 29 rexall blood glucose test strp 211 RITUXAN 49 rexall glucose monitoring sys 194 RITUXAN HYCELA 49 REXULTI 168 rivastigmine 68 REYATAZ 28 rivastigmine tartrate 68 REZIRA 305 RIVELSA 265 RHOFADE 328 RIXUBIS 77 RHOGAM ULTRA-FILTERED PLUS 58 rizatriptan benzoate 148 RHOPHYLAC 58 ROBAXIN 69 RHOPRESSA 231 ROBAXIN-750 69 RIBASPHERE 28 ROBINUL 66 RIBASPHERE RIBAPAK 28 ROBINUL FORTE 66 ribavirin 28 ROCALTROL 336 RIDAURA 243 romidepsin 49 rifabutin 21 ropinirole hcl 151 RIFADIN 21 ROSADAN 314 RIFAMATE 21 rosuvastatin calcium 89 rifampin 21 ROTARIX 62 RIFATER 21 ROTATEQ 62 rightest gm100 system kit 194 ROWASA 234 rightest gm250s glucose meter 194 ROWEEPRA 145 rightest gm260 glucose meter 194 ROWEEPRA XR 145 rightest gm300 system kit 194 ROXICODONE 130 rightest gm550 system kit 194 ROXYBOND 130 rightest gs100 test strips 211 ROZEREM 155 rightest gs250s test strips 211 RUBRACA 49 rightest gs260 test strips 211 RUCONEST 286 rightest gs300 test strips 211 RYCLORA 34 RYDAPT 49 SEROQUEL 170 RYTARY 151 SEROQUEL XR 170 RYTHMOL SR 98 SEROSTIM 276 RYVENT 34 sertraline hcl 170 SETLAKIN 265 S sevelamer carbonate 218 SABRIL 145 sevelamer hcl 218 SAIZEN 275 SEYSARA 14 SAIZEN-SAIZENPREP 275 SF 285 SALACYN 324 SF 5000 PLUS 285 SALAGEN 68 SFROWASA 234 SALEX 324 SHAROBEL 265 salicylic acid 324 SHINGRIX 62 SALIMEZ FORTE 324 SHINGRIX ADJUVANT COMPONENT 299 salsalate 130 SHINGRIX GE ANTIGEN COMPONENT 62 SALVAX 325 sidekick blood glucose system 194 SAMSCA 217 SIDEROL 74 SANADERMRX 320 SIGNIFOR 278 SANCUSO 236 SIGNIFOR LAR 278,279 SANDIMMUNE 295 SIKLOS 49 SANDOSTATIN 278 sildenafil 20 mg tablet (pah) 107 SANDOSTATIN LAR DEPOT 278 sildenafil citrate 107 SANTYL 329 SILENOR 170 SAPHRIS 169 SILIQ 329 SARAFEM 170 silodosin 70 sassafras 299 SILVADENE 314 SAVAYSA 81 SILVASORB 194 SAVELLA 158 silver nitrate/potassium nitrate 325 SAXENDA 257 silver sulfadiazine 314 SCALACORT 320 SILVRSTAT 194 scopolamine 236 SIMBRINZA 231 SECONAL SODIUM 155 SIMPONI 290 SEEBRI NEOHALER 66 SIMPONI ARIA 290 SEGLUROMET 257 SIMULECT 295 selegiline hcl 151 simvastatin 89 SELZENTRY 29 SINEMET 10-100 151 SEMPREX-D 34 SINEMET 25-100 151 SENSIPAR 274 SINEMET 25-250 151 SEREVENT DISKUS 73 SINEMET CR 151 SERNIVO 320 SINGULAIR 302 SEROPHENE 271 sirolimus 295 SIRTURO 21 solus v2 audible test strips 211 SITAVIG 29 SOMA 69 SIVEXTRO 14 SOMATULINE DEPOT 279 SKELAXIN 69 SOMAVERT 279 SKLICE 314 SONATA 155 SKYLA 265 SOOLANTRA 329 smart caresens n glucose systm 194 SORE MUSCLE RUB 329 smart sense monitoring system 194 SORIATANE 329 smart sense test strips 211 SORILUX 329 smartest eject meter 194 SORINE 92 smartest persona glucose meter 194 sotalol hcl 92 smartest persona starter kit 195 SOTYLIZE 92 smartest pronto glucose meter 195 SOVALDI 29 smartest pronto starter kit 195 SP ANTIPRURITIC 195 smartest protege meter 195 spearmint oil 299 smartest smart code meter 195 SPECTRACEF 14 smartest talking meter 195 spinosad 314 smartest test strips 211 SPIRIVA 66 sodium chloride/sodium bicarbonate/potassium SPIRIVA RESPIMAT 66 chloride/peg 241 spironolactone 103 sodium citrate 81 spironolactone/hydrochlorothiazide 103 SODIUM DIURIL 217 SPORANOX 20 sodium ferric gluconate complex in sucrose 74 SPRAY AND STRETCH 195 sodium phenylbutyrate 215 SPRINTEC 265 sodium phosphate in 0.9 % sodium chloride 220 SPRITAM 145 sodium phosphate in 5 % dextrose in water 220 SPRIX 130 sodium polystyrene sulfonate 218 SPRYCEL 50 sodium thiosulfate 282 SPS 218 sofosbuvir/velpatasvir 29 SRONYX 265 SOLARAZE 50 SSD 314 SOLESTA 195 SSKI 280 SOLIQUA 100-33 257 SSS 10-5 325 SOLIRIS 286 stabilizer for moxetumomab pasudotox-tdfk 299 SOLODYN 14 STALEVO 100 151 SOLOSEC 22 STALEVO 125 152 SOLOXIDE 14 STALEVO 150 152 SOLTAMOX 271 STALEVO 200 152 SOLU-CORTEF 247 STALEVO 50 152 SOLU-MEDROL 248 STALEVO 75 152 solus v2 audible meter 195 STAMARIL 62 solus v2 audible meter sys kit 195 STARLIX 257 stavudine 29 SUPREP 241 STAXYN 107 sure-test easyplus mini meter 195 STEGLATRO 257 sure-test easyplus mini strip 211 STEGLUJAN 257 SURMONTIL 171 STELARA 329 SURVANTA 307 STENDRA 108 SUSTIVA 29 STIMATE 276 SUTENT 50 STIOLTO RESPIMAT 66 SYEDA 266 STIVARGA 50 SYLATRON 29 STOMACH RELIEF 234 SYLVANT 51 STRATTERA 157 SYMAX 66 STRENSIQ 222 SYMAX DUOTAB 66 streptomycin sulfate 15 SYMAX-SL 66 STRIANT 249 SYMAX-SR 66 STRIBILD 29 SYMBICORT 302 STRIVERDI RESPIMAT 73 SYMBYAX 171 STROMECTOL 3 SYMDEKO 306 SUBLOCADE 130 SYMFI 29 SUBOXONE 130 SYMFI LO 29 SUBSYS 130 SYMLINPEN 120 257 SUBVENITE 145 SYMLINPEN 60 257 SUBVENITE (BLUE) 145 SYMPROIC 243 SUBVENITE (GREEN) 145 SYMTUZA 30 SUBVENITE (ORANGE) 145 SYNAGIS 30 SUCRAID 222 SYNALAR 320 sucralfate 240 SYNALGOS-DC 130 SULAR 96 SYNAREL 273 sulfacetamide sodium 225,314 SYNDROS 236 sulfacetamide sodium/prednisolone sodium SYNERA 322 phosphate 225 SYNERCID 15 sulfadiazine 15 SYNJARDY 257 sulfamethoxazole/trimethoprim 15 SYNJARDY XR 258 sulfasalazine 15 SYNRIBO 51 SULFATRIM 15 SYNTHROID 280 sulindac 130 SYNVISC 195 sumatriptan 149 SYNVISC-ONE 196 sumatriptan succinate 149 SYPRINE 244 sumatriptan succinate/naproxen sodium 149 syringe cap, enfit,non-sterile 196 SUPARTZ FX 195 syringe with needle, insulin, safety, 0.3 ml 196 SUPPRELIN LA 273 syringe with needle, insulin, safety, 0.5 ml 196 SUPRAX 15 syringe with needle, insulin, safety, 1 ml 196 syringe with needle,disposable,insulin 1 ml 196 TARGADOX 15 syringe with needle,insulin 0.3 ml (half unit TARGRETIN 51 mark) 196 TARINA 24 FE 266 syringe with needle,insulin 0.5 ml (half unit TARINA FE 266 mark) 196 TARINA FE 1-20 EQ 266 syringe with needle,insulin,0.3 ml 196 TARKA 104 syringe, enfit 1 ml, non-sterile 196 TARON-CRYSTALS 214 syringe, enfit 1 ml, sterile 196 TASIGNA 51,52 syringe, enfit 12 ml, non-sterile 196 TASMAR 152 syringe, enfit 12 ml, sterile 196 TAVALISSE 82 syringe, enfit 3 ml, sterile 196 TAXOTERE 52 syringe, enfit 35 ml, non-sterile 196 TAYTULLA 266 syringe, enfit 35 ml, sterile 196 tazarotene 330 syringe, enfit 6 ml, non-sterile 196 TAZICEF 15 syringe, enfit 6 ml, sterile 196 TAZORAC 330 syringe, enfit 60 ml, non-sterile 196 TAZTIA XT 96 syringe, enfit 60 ml, sterile 196 td gold blood glucose monitor 197 syringe,enfit 3 ml,non-sterile 196 td gold test strip 211 syringe,safety with needle,1 ml 196 td gold voice glucose monitor 197 tea tree oil 330 T TECENTRIQ 52 TABLOID 51 TECFIDERA 293 TACLONEX 329 TECHNIVIE 30 tacrolimus 295,329 TEFLARO 15 tadalafil 108 TEGRETOL 145 TADALAFIL 20 MG TABLET (ED/BPH) 108 TEGRETOL XR 145 TADALAFIL 20 MG TABLET (PAH) 108 TEGSEDI 283 TAFINLAR 51 TEKAMLO 64 TAGRISSO 51 TEKTURNA 104 TAKHZYRO 286 TEKTURNA HCT 104 TALTZ AUTOINJECTOR 329 telcare bgm blood glucose kit 197 TALTZ AUTOINJECTOR (2 PACK) 329 telcare blood glucose monitor 197 TALTZ AUTOINJECTOR (3 PACK) 329 telcare test strips 212 TALWIN 131 telmisartan 104 TALZENNA 51 telmisartan/amlodipine besylate 104 TAMIFLU 30 telmisartan/hydrochlorothiazide 104 tamoxifen citrate 271 temazepam 155 tamsulosin hcl 70 TEMODAR 52 TANZEUM 258 TEMOVATE 320 TAPAZOLE 280 TEMOVATE EMOLLIENT 320 TARCEVA 51 temozolomide 52 temsirolimus 52 thiamine hcl 336 TENCON 131 THIOLA 298 teniposide 52 thioridazine hcl 171 TENIVAC 58 thiotepa 52 tenofovir disoproxil fumarate 30 thiothixene 171 TENORETIC 100 92 THYMOGLOBULIN 295 TENORETIC 50 92 THYROGEN 213 TENORMIN 92 THYROID 280 TERAZOL 7 314 thyroid,pork 280 terazosin hcl 84 THYROLAR-1 280 terbinafine hcl 20 THYROLAR-1/2 280 terbutaline sulfate 73 THYROLAR-1/4 280 terconazole 315 THYROLAR-2 280 TEROCIN 322 THYROLAR-3 280 TESSALON PERLE 305 tiagabine hcl 146 test n'go blood glucose system 197 TIAZAC 96 test n'go glucose test strip 212 TIBSOVO 52 TESTIM 250 ticlopidine hcl 81 TESTOPEL 250 TIGAN 237 testosterone 250 tigecycline 15 testosterone cypionate 250 TIGLUTIK 157 testosterone enanthate 250 TIKOSYN 98 TESTRED 250 TILIA FE 266 tetanus and diphtheria toxoids, adult 58 timolol maleate 92,231 tetanus,diphtheria toxoid ped/pf 58 TIMOPTIC 231 TETCAINE 232 TIMOPTIC OCUDOSE 231 tetrabenazine 173 TIMOPTIC-XE 231 tetracaine hcl 232 TINDAMAX 22 tetracaine hcl/pf 232 tinidazole 22 tetracycline hcl 15 TIROSINT 280 TETRAVISC 232 TIROSINT-SOL 280 TEXACORT 320 TISSEEL VHSD 330 THALOMID 293 TIVICAY 30 THEO-24 332 TIVORBEX 131 THEOCHRON 332 tizanidine hcl 69 theophylline anhydrous 332 TNKASE 81 theophylline in dextrose 5 % in water 332 TOBI 15 THERA-D 336 TOBI PODHALER 15 THERANATAL OVAVITE 334 TOBRADEX 225 THERANATAL PLUS 334 TOBRADEX ST 225 THEROMEGA SPORT 89 tobramycin 225 tobramycin in 0.225 % sodium chloride 16 TRELSTAR 273 tobramycin sulfate 16 TREMFYA 330 tobramycin sulfate/sodium chloride 16 treprostinil sodium 308 tobramycin/dexamethasone 225 TRESIBA 258 tobramycin/nebulizer 16 TRESIBA FLEXTOUCH U-100 258 TOBREX 225 TRESIBA FLEXTOUCH U-200 258 TOFRANIL 171 TRETIN-X 323 TOLAK 52 tretinoin 53,323 tolazamide 258 tretinoin microspheres 323 tolbutamide 258 tretinoin/emollient base 323 tolcapone 152 TRETTEN 77 tolmetin sodium 131 TREXALL 53 tolterodine tartrate 331 TREXIMET 149 TOPAMAX 146 TREZIX 131 TOPICORT 320 TRI FEMYNOR 266 topiramate 146 TRI-CHLOR 330 TOPOSAR 52 TRI-ESTARYLLA 266 topotecan hcl 52 TRI-LEGEST FE 266 TOPROL XL 92 TRI-LINYAH 266 toremifene citrate 271 TRI-LO-ESTARYLLA 266 TORISEL 52 TRI-LO-MARZIA 266 torsemide 217 TRI-LO-SPRINTEC 266 TOUJEO MAX SOLOSTAR 258 TRI-LUMA 323 TOUJEO SOLOSTAR 258 TRI-MILI 266 TOVIAZ 331 TRI-PREVIFEM 266 TRACLEER 308 TRI-SPRINTEC 266 TRADJENTA 258 TRI-TABS DHA 334 tramadol hcl 131 TRI-VYLIBRA 266 tramadol hcl/acetaminophen 131 TRI-VYLIBRA LO 266 trandolapril 104 triacetin 20 trandolapril/verapamil hcl 104 triamcinolone acetonide 228,248,320 tranexamic acid 77 triamcinolone acetonide in 0.9 % sodium TRANSDERM-SCOP 237 chloride 248 transfer device, closed system 197 triamcinolone diacetate in 0.9 % sodium TRANXENE T-TAB 156 chloride 248 tranylcypromine sulfate 171 triamcinolone diacetate in 0.9 % sodium TRAVATAN Z 231 chloride/pf 248 trazodone hcl 171 triamterene/hydrochlorothiazide 217 TREANDA 53 TRIANEX 320 TRECATOR 21 triazolam 156 TRELEGY ELLIPTA 302 TRIBENZOR 104 trichloroacetic acid 330 trueresult blood glucose systm 197 TRICOR 89 truetest glucose test strip 212 TRIDERM 320 truetest glucose test strips 212 TRIDESILON 320 truetrack blood glucose system 197,198 trientine hcl 245 truetrack glucose test strips 212 TRIESENCE 228 truetrack smart system 198 TRIFERIC 74 TRULANCE 243 trifluoperazine hcl 171 TRULICITY 258 trifluridine 225 TRUMENBA 62 TRIGLIDE 89 TRUSOPT 231 trihexyphenidyl hcl 152 TRUST NATAL DHA 334 TRIKLO 89 TRUVADA 30 TRILEPTAL 146 TUDORZA PRESSAIR 66 TRILIPIX 89 TULANA 266 TRILYTE WITH FLAVOR PACKETS 241 TUSNEL 305 trimethobenzamide hcl 237 TUSNEL DM PEDIATRIC 305 trimethoprim 32 TUSNEL PEDIATRIC 306 trimipramine maleate 171 TUSSI-PRES PEDIATRIC 306 TRIMPEX 32 TUSSICAPS 305 TRINATE 334 TUSSIGON 305 TRINESSA 266 TUSSIONEX 305 TRINESSA LO 266 TUSSLIN 306 TRINTELLIX 171 TUXARIN ER 305 TRIOSTAT 280 TUZISTRA XR 305 TRIPLE DYE 315 TWINRIX 62 TRISENOX 53 TWYNSTA 104 TRIUMEQ 30 TYBOST 298 TRIVEEN-ONE 334 TYDEMY 266 TRIVEEN-U 334 TYGACIL 16 TRIVISC 197 TYKERB 53 TRIVORA-28 266 TYLENOL-CODEINE NO.3 131 TRIZIVIR 30 TYLENOL-CODEINE NO.4 131 TROKENDI XR 146 TYMLOS 274 tromethamine in sterile water for injection 214 TYPHIM VI 62 trospium chloride 331,332 TYSABRI 293 true metrix air glucose meter 197 TYVASO 308 true metrix blood glucose mtr 197 TYVASO INSTITUTIONAL START KIT 308 true metrix glucose test strip 212 TYVASO REFILL KIT 309 true metrix go glucose meter 197 TYVASO STARTER KIT 309 true metrix pro test strip 212 TYZINE 233 true2go blood glucose system 197 URSO 241 U URSO FORTE 241 UCERIS 248 ursodiol 241 UDENYCA 83 UTIBRON NEOHALER 73 ULESFIA 315 UTOPIC 325 ULORIC 283 UVADEX 323 ultima monitor kit 198 ultima test strips 212 V ULTRACET 131 v-r glucose test strip 212,213 ULTRAM 131 VAGIFEM 271 ULTRASAL-ER 325 valacyclovir hcl 30 ultratrak blood glucose meter 198 VALCHLOR 53 ultratrak pro glucose mtr sys 198 VALCYTE 30 ultratrak pro meter kit 198 valganciclovir hcl 30 ultratrak test strip 212 VALIUM 156 ultratrak ultimate glucose mtr 198 valproic acid 146 ultratrak ultimate test strips 212 valproic acid (as sodium salt) (valproate ULTRAVATE 320 sodium) 146 UNASYN 16 valsartan 104 underpads 198 valsartan/hydrochlorothiazide 104 unistrip1 glucose test strip 212 VALSTAR 53 UNITHROID 280,281 VALTREX 30 UNITUXIN 53 VANATOL LQ 131 up & up blood glucose tst strp 212 VANCOCIN HCL 16 up & up blood monitoring syst 198 vancomycin hcl 16 UPTRAVI 309 vancomycin hcl in water for injection (peg-400, urea 325 nada) 16 URECHOLINE 68 vancomycin hcl/balanced salt solution no.2/pf 225 URIBEL 32 vancomycin in 0.9 % sodium chloride 17 urine acetone test,strips 214 vancomycin in 5 % dextrose in water 17 urine albumin test 214 VANDAZOLE 315 urine bilirubin test 214 VANIQA 330 urine glucose test strip 214 VANOS 320 urine glucose-acet test strip 214 VANOXIDE-HC 320 urine leukocyte test strips 214 VANTAS 273 urine multiple test strips 214 VAQTA 62 urine phenaphthazine-ph test 214 vardenafil hcl 108 UROCIT-K 214 VARIVAX VACCINE 63 UROGESIC-BLUE 32 VARIZIG 58 UROSEX 336 VARUBI 237 UROXATRAL 70 VASCEPA 89 VASERETIC 104 VIBATIV 17 vasopressin in 0.9 % sodium chloride 276 VIBERZI 243 vasopressin in dextrose 5 % in water 276 VIBRAMYCIN 17 VASOTEC 104 VICODIN 132 VAXCHORA ACTIVE COMPONENT 63 VICODIN ES 132 VAXCHORA VACCINE 63 VICODIN HP 132 VECAMYL 99 VICTOZA 2-PAK 258 VECTIBIX 53 VICTOZA 3-PAK 258 VECTICAL 330 VIDAZA 54 VELCADE 53 VIDEX 31 VELETRI 309 VIDEX EC 31 VELIVET 267 VIEKIRA PAK 31 VELPHORO 218 VIEKIRA XR 31 VELTASSA 218 VIENVA 267 VELTIN 315 vigabatrin 146 VEMLIDY 30 VIGAMOX 226 VENATAL COMPLETE DHA 334 VIIBRYD 171,172 VENCLEXTA 53 VIMIZIM 222 VENCLEXTA STARTING PACK 53 VIMOVO 132 VENELEX 330 VIMPAT 146 venlafaxine hcl 171 VINACAL B 334 VENOFER 74 VINATE DHA 334 VENTAVIS 309 VINATE DHA RF 335 VENTOLIN HFA 73 VINATE GT 335 verapamil hcl 96 VINATE II 335 verasens blood glucose meter 198 VINATE ONE 335 verasens meter starter kit 198 VINATE PN CARE 335 verasens test strip 213 VINATE ULTRA 335 VERDESO 320 VINATE-M 335 VERDROCET 132 vinblastine sulfate 54 VEREGEN 330 VINCASAR PFS 54 VERELAN 96 vincristine sulfate 54 VERELAN PM 96 vinorelbine tartrate 54 VERIPRED 20 248 VIOKACE 242 VERSACLOZ 171 VIORELE 267 VERZENIO 53 VIRACEPT 31 VESICARE 332 VIRAMUNE 31 VESTURA 267 VIRAMUNE XR 31 VFEND 20 VIRASAL 325 VFEND IV 20 VIRAZOLE 31 VIAGRA 108 VIREAD 31 VIROPTIC 226 wavesense presto system kit 198 VIRT-C DHA 335 wavesense presto test strips 213 VISINE TOTALITY 233 WELCHOL 89 VISTARIL 156 WELLBUTRIN SR 172 VISTOGARD 282 WELLBUTRIN XL 172 VISUDYNE 232 WERA 267 VITASPIRE 335 WESTHROID 281 VITATRUE 335 wheat germ oil 337 VITRAKVI 54 WILATE 77 VITRASE 222 WINRHO SDF 58 VITUZ 305 WIXELA INHUB 302 VIVA DHA 335 WP THYROID 281 VIVELLE-DOT 271 WYMZYA FE 267 VIVITROL 158 VIVLODEX 132 X VIVOTIF 63 XADAGO 152 VIVOTIF BERNA 63 XALATAN 231 VIZIMPRO 54 XALKORI 54 VOGELXO 250 XANAX 156 VOLTAREN 132 XANAX XR 156 VOLTAREN-XR 132 XARELTO 81 VONVENDI 77 XARTEMIS XR 132 VORAXAZE 282 XATMEP 54 voriconazole 20 XELJANZ 290 VOSEVI 31 XELJANZ XR 290 VOTRIENT 54 XELODA 54 VPRIV 222 XENAZINE 174 VRAYLAR 172 XENICAL 243 VSL#3 DS 243 XEOMIN 298 VUSION 315 XEPI 315 VYFEMLA 267 XERAC AC 322 VYLIBRA 267 XERESE 315 VYNATAL-FA 335 XERMELO 234 VYTORIN 89 XGEVA 284 VYVANSE 139 XIAFLEX 222 XIFAXAN 17 W XIGDUO XR 258 WAL-DRYL 34,322 XIIDRA 228 warfarin sodium 81 XODOL 10-300 132 wavesense amp system kit 198 XODOL 5-300 132 wavesense jazz test strips 213 XODOL 7.5-300 132 XOFIGO 300 ZEBETA 92 XOFLUZA 31 ZEBUTAL 133 XOLAIR 307 ZEGERID 240 XOLEGEL 315 ZEJULA 55 XOPENEX 73 ZELAPAR 152 XOPENEX CONCENTRATE 73 ZELBORAF 55 XOPENEX HFA 73 ZEMAIRA 307 XOSPATA 54 ZEMPLAR 337 XTAMPZA ER 132 ZENATANE 330 XTANDI 54 ZENCHENT 267 XULANE 267 ZENCHENT FE 267 XULTOPHY 100-3.6 258 ZENPEP 242 XURIDEN 298 ZENZEDI 140 XYLOCAINE IV 98 ZEPATIER 31 XYLON 10 132 ZERIT 31 XYNTHA 77 ZESTORETIC 105 XYNTHA SOLOFUSE 77 ZESTRIL 105 XYREM 158 ZETIA 89 XYZAL 34 ZETONNA 228 ZEVALIN 55 Y ZIAC 92 YERVOY 55 ZIAGEN 31 YF-VAX 63 ZIANA 315 yohimbine hcl 64 zidovudine 32 YONSA 55 zileuton 302 YUTIQ 228 ZINACEF 17 YUVAFEM 271 ZINBRYTA 293 zinc chloride 220 Z ZINECARD 299 Z-COF I 64 ZIOPTAN 231 zafirlukast 302 ziprasidone hcl 172 zaleplon 156 ZIPSOR 133 ZALTRAP 55 ZIRGAN 226 ZAMICET 133 ZITHROMAX 18 ZANAFLEX 69 ZITHROMAX TRI-PAK 18 ZANOSAR 55 ZMAX 18 ZANTAC 240 ZN-DTPA 245 ZARAH 267 ZOCOR 89,90 ZARONTIN 146 ZODEX 248 ZARXIO 83 ZODRYL DAC 50 305 ZAVESCA 298 ZODRYL DAC 60 305 ZODRYL DAC 80 305 ZYCLARA 330 ZODRYL DEC 50 305 ZYDELIG 55 ZODRYL DEC 60 305 ZYFLO 302 ZODRYL DEC 80 305 ZYFLO CR 302 ZOFRAN 237 ZYKADIA 55 ZOFRAN ODT 237 ZYLET 226 ZOHYDRO ER 133 ZYLOPRIM 283 ZOLADEX 273,274 ZYMAXID 226 zoledronic acid 284 ZYPITAMAG 90 zoledronic acid in mannitol and 0.9 % sodium ZYPREXA 172,173 chloride 284 ZYPREXA RELPREVV 173 zoledronic acid in mannitol and water for ZYPREXA ZYDIS 173 injection 285 ZYTIGA 55,56 ZOLINZA 55 ZYVOX 18 zolmitriptan 149 ZOLOFT 172 zolpidem tartrate 156 ZOLPIMIST 156 ZOMACTON 276 ZOMETA 285 ZOMIG 149 ZOMIG ZMT 149 ZONACORT 248 ZONALON 322 ZONEGRAN 147 zonisamide 147 ZONTIVITY 81 ZORBTIVE 276 ZORTRESS 295 ZORVOLEX 133 ZOSTAVAX 63 ZOSYN 18 ZOVIA 1-35E 267 ZOVIA 1-50E 267 ZOVIRAX 32,315 ZTLIDO 322 ZUBSOLV 133 ZUPLENZ 237 ZURAMPIC 221 ZUTRIPRO 306 ZYBAN 172