Effective July 1, 2017

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on the back of your ID card.

Visit your plan’s member website listed on your ID card. • Locate a participating retail pharmacy by zip code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

OptumRx Select Standard 1

Your Formulary

This Formulary includes medications from your plan’s complete pharmacy benefit coverage list. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit our website, your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents Receptor Antagonist ...... 20 Antidepressants : Antidepressants, Other ...... 20 Go to your plan’s member website for complete and up-to- Antidepressants : Monoamine Oxidase Inhibitors ...... 20 date drug information ...... 2 Antidepressants : SSRIs/SNRIs (Selective Serotonin What is a Formulary? ...... 6 Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake How do I use my Formulary?...... 6 Inhibitors) ...... 21 What are tiers? ...... 7 Antidepressants : Tricyclics ...... 21 Why are some medications excluded from coverage?8 Antiemetics : Antiemetics, Other ...... 21 What if I don’t agree with a decision about an Antiemetics : Emetogenic Therapy Adjuncts ...... 22 excluded medication? ...... 8 Antifungals ...... 22 Should I talk to my doctor about OTC medications? .. 8 Antigout Agents ...... 23 What is the difference between brand-name and Antihistamine Drugs : First Generation Antihistamines ...... 23 generic medications? ...... 8 Antimigraine Agents : ...... 23 Is it a generic or brand-name drug? ...... 8 Antimigraine Agents : Ergot Alkaloids ...... 23 What if my doctor writes a brand-name prescription? . 8 Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Are you taking a specialty medication? ...... 9 Agonists ...... 23 How do I get updated information about my Antimyasthenic Agents ...... 24 pharmacy benefit? ...... 9 Antimyasthenic Agents : Parasympathomimetics ...... 24 Analgesics ...... 10 Antimycobacterials : Antimycobacterials, Other ...... 24 Analgesics : Nonsteroidal Anti-inflammatory Drugs ...... 10 Antimycobacterials : Antituberculars ...... 24 Analgesics : Opioid Analgesics, Long-acting ...... 11 Antineoplastic Agents ...... 24 Analgesics : Opioid Analgesics, Short-acting ...... 11 Antineoplastics : ...... 24 Anesthetics : Local Anesthetics ...... 12 Antineoplastics : Alkylating Agents ...... 24 Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Antineoplastics : Antiandrogens ...... 24 Deterrents/Anti-craving ...... 13 Antineoplastics : Antiangiogenic Agents...... 25 Anti-Addiction/Substance Abuse Treatment Agents : Opioid Antineoplastics : Antiestrogens/Modifiers ...... 25 Dependence Treatments ...... 13 Antineoplastics : Antimetabolites ...... 25 Anti-Addiction/Substance Abuse Treatment Agents : Opioid Antineoplastics ...... 25 Reversal Agents ...... 13 Antineoplastics : Antineoplastics, Other ...... 25 Anti-Addiction/Substance Abuse Treatment Agents : Antineoplastics : Aromatase Inhibitors, 3rd Generation ...... 25 Smoking Cessation Agents ...... 13 Antineoplastics : Enzyme Inhibitors ...... 25 Anti-infective Agents : Antibacterials ...... 13 Antineoplastics : Molecular Target Inhibitors ...... 25 Anti-infective Agents : Antivirals ...... 13 Antineoplastics : Monoclonal Antibodies ...... 26 Anti-inflammatory Agents : Nonsteroidal Anti-inflammatory Antineoplastics : Retinoids ...... 26 Drugs ...... 13 Antiparasitics : Anthelmintics ...... 26 Antibacterials : Aminoglycosides ...... 14 Antiparasitics : Antiprotozoals ...... 26 Antibacterials : Antibacterials, Other ...... 14 Antiparasitics : Pediculicides/Scabicides ...... 26 Antibacterials : Beta-lactam, Cephalosporins ...... 15 Antiparkinson Agents : Anticholinergics ...... 26 Antibacterials : Beta-lactam, Other ...... 16 Antiparkinson Agents : Antiparkinson Agents, Other ...... 26 Antibacterials : Beta-lactam, Penicillins ...... 16 Antiparkinson Agents : Dopamine Agonists ...... 26 Antibacterials : Macrolides ...... 17 Antiparkinson Agents : Dopamine Precursors/L- Amino Acid Antibacterials : Quinolones ...... 17 Decarboxylase Inhibitors ...... 27 Antibacterials : Sulfonamides ...... 17 Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Antibacterials : Tetracyclines ...... 18 Inhibitors ...... 27 Anticonvulsants : Anticonvulsants, Other...... 18 Antipsychotics : 1st Generation/Typical ...... 27 Anticonvulsants : Calcium Channel Modifying Agents ...... 18 Antipsychotics : 2nd Generation/Atypical ...... 27 Anticonvulsants : Gamma-aminobutyric Acid (GABA) Antipsychotics : Treatment-Resistant ...... 27 Augmenting Agents ...... 18 Antispasticity Agents ...... 27 Anticonvulsants : Glutamate Reducing Agents ...... 19 Antitoxins, Immune Globulins, Toxoids, and Vaccines : Anticonvulsants : Sodium Channel Agents ...... 19 Antitoxins and Immune Globulins ...... 28 Antidementia Agents : Antidementia Agents, Other ...... 20 Antivirals : ...... 28 Antidementia Agents : Cholinesterase Inhibitors ...... 20 Antivirals : Anti-cytomegalovirus (CMV) Agents ...... 28 Antidementia Agents : N-methyl-D-aspartate (NMDA) Antivirals : Anti-hepatitis B (HBV) Agents ...... 28

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Antivirals : Anti-hepatitis C (HCV) Agents ...... 28 Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) ..... 28 Inhibitors ...... 37 Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Cardiovascular Agents : Dyslipidemics, Other ...... 37 Transcriptase Inhibitors (NNRTI) ...... 28 Cardiovascular Agents : Vasodilators, Direct-acting Arterial 38 Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Cardiovascular Agents : Vasodilators, Direct-acting Reverse Transcriptase Inhibitors (NRTI) ...... 28 Arterial/Venous ...... 38 Antivirals : Anti-HIV Agents, Other ...... 29 Cardiovascular Drugs : beta-Adrenergic Blocking Agents ... 38 Antivirals : Anti-HIV Agents, Protease Inhibitors ...... 29 Cardiovascular Drugs : Calcium-Channel Blocking Agents . 38 Antivirals : Anti-influenza Agents ...... 29 Cardiovascular Drugs : Cardiac Drugs ...... 38 Antivirals : Antiherpetic Agents ...... 29 Cardiovascular Drugs : Vasodilating Agents ...... 38 Anxiolytics : Anxiolytics, Other ...... 29 Central Nervous System Agents : Analgesics and Anxiolytics : Benzodiazepines ...... 29 Antipyretics ...... 38 Autonomic Drugs : Anticholinergic Agents ...... 30 Central Nervous System Agents : Anorexigenic Agents and Autonomic Drugs : Parasympathomimetic (Cholinergic) Respiratory and CNS Stimulants ...... 39 Agents ...... 30 Central Nervous System Agents : Anticonvulsants ...... 39 Autonomic Drugs : Skeletal Muscle Relaxants ...... 30 Central Nervous System Agents : Anxiolytics, Sedatives, and Autonomic Drugs : Sympathomimetic (Adrenergic) Agents . 30 Hypnotics ...... 39 Bipolar Agents : Bipolar Agents, Other ...... 30 Central Nervous System Agents : Attention Deficit Bipolar Agents : Mood Stabilizers ...... 30 Hyperactivity Disorder Agents, Amphetamines ...... 39 Blood Formation,Coagulation & Thrombosis : Antianemia Central Nervous System Agents : Attention Deficit Drugs ...... 30 Hyperactivity Disorder Agents, Non-amphetamines ...... 39 Blood Formation,Coagulation & Thrombosis : Antithrombotic Central Nervous System Agents ...... 39 Agents ...... 30 Central Nervous System Agents : Central Nervous System Blood Formation,Coagulation & Thrombosis : Hematopoietic Agents, Misc ...... 39 Agents ...... 30 Central Nervous System Agents : Central Nervous System, Blood Glucose Regulators : Antidiabetic Agents ...... 30 Other ...... 39 Blood Glucose Regulators : Glycemic Agents ...... 31 Central Nervous System Agents : Fibromyalgia Agents ...... 40 Blood Glucose Regulators : Insulins ...... 31 Central Nervous System Agents : Multiple Sclerosis Agents Blood Products/Modifiers/Volume Expanders : ...... 40 Anticoagulants ...... 32 Central Nervous System Agents : Opiate Antagonists ...... 40 Blood Products/Modifiers/Volume Expanders : Blood Dental and Oral Agents ...... 40 Formation Modifiers ...... 32 Dermatological Agents ...... 40 Blood Products/Modifiers/Volume Expanders ...... 32 Devices ...... 43 Blood Products/Modifiers/Volume Expanders : Coagulants 32 Electrolytic, Caloric, and Water Balance : Replacement Blood Products/Modifiers/Volume Expanders : Platelet Preparations ...... 43 Modifying Agents ...... 33 Electrolytic, Caloric, and Water Balance : Uricosuric Agents Cardiovascular Agents : Alpha-adrenergic Agonists ...... 33 ...... 43 Cardiovascular Agents : Alpha-adrenergic Blocking Agents 33 Enzyme Replacement/Modifiers ...... 43 Cardiovascular Agents : Angiotensin II Receptor Antagonists Eye, Ear, Nose & Throat Preparations : Anti-infectives ...... 44 ...... 33 Eye, Ear, Nose & Throat Preparations : Anti-inflammatory Cardiovascular Agents : Angiotensin-converting Enzyme Agents ...... 44 (ACE) Inhibitors ...... 34 Eye, Ear, Nose & Throat Preparations : EENT Drugs, Cardiovascular Agents : Antiarrhythmics ...... 34 Miscellaneous...... 44 Cardiovascular Agents : Beta-adrenergic Blocking Agents . 35 Gastrointestinal Agents : Antispasmodics, Gastrointestinal 44 Cardiovascular Agents : Calcium Channel Blocking Agents 35 Gastrointestinal Agents ...... 44 Cardiovascular Agents ...... 36 Gastrointestinal Agents : Gastrointestinal Agents, Other .... 44 Cardiovascular Agents : Cardiovascular Agents, Other ...... 36 Gastrointestinal Agents : Histamine2 (H2) Receptor Cardiovascular Agents : Diuretics, Carbonic Anhydrase Antagonists ...... 45 Inhibitors ...... 36 Gastrointestinal Agents : Irritable Bowel Syndrome Agents 45 Cardiovascular Agents : Diuretics, Loop ...... 37 Gastrointestinal Agents : Laxatives ...... 45 Cardiovascular Agents : Diuretics, Potassium-sparing ...... 37 Gastrointestinal Agents : Protectants ...... 45 Cardiovascular Agents : Diuretics, Thiazide ...... 37 Gastrointestinal Agents : Proton Pump Inhibitors ...... 45 Cardiovascular Agents : Dyslipidemics, Fibric Acid Gastrointestinal Drugs : Antiemetics ...... 46 Derivatives ...... 37 Gastrointestinal Drugs : Digestants ...... 46

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Gastrointestinal Drugs : GI Drugs, Miscellaneous ...... 46 Miscellaneous Therapeutic Agents : Other Miscellaneous Genitourinary Agents : Antispasmodics, Urinary ...... 46 Therapeutic Agents ...... 59 Genitourinary Agents : Benign Prostatic Hypertrophy Agents Multiple Classifications ...... 59 ...... 46 Ophthalmic Agents : Ophthalmic Prostaglandin and Genitourinary Agents : Genitourinary Agents, Other ...... 46 Prostamide Analogs ...... 60 Genitourinary Agents : Phosphate Binders ...... 46 Ophthalmic Agents : Ophthalmic Agents, Other ...... 60 Hormonal Agents, Stimulant/Replacement/Modifying Ophthalmic Agents : Ophthalmic Anti-allergy Agents ...... 60 (Adrenal) : ...... 46 Ophthalmic Agents : Ophthalmic Anti-inflammatories ...... 61 Hormonal Agents, Stimulant/Replacement/Modifying Ophthalmic Agents : Ophthalmic Antiglaucoma Agents ...... 61 (Adrenal) ...... 46 Otic Agents ...... 61 Hormonal Agents, Stimulant/Replacement/Modifying Oxytocics ...... 61 (Pituitary) ...... 47 Respiratory Tract Agents : Expectorants ...... 62 Hormonal Agents, Stimulant/Replacement/Modifying Respiratory Tract/Pulmonary Agents : Anti-inflammatories, (Prostaglandins) ...... 47 Inhaled Corticosteroids ...... 62 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Antihistamines ...... 62 Hormones/Modifiers) : Anabolic Steroids ...... 48 Respiratory Tract/Pulmonary Agents : Antileukotrienes ...... 62 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Bronchodilators, Hormones/Modifiers) : Androgens ...... 48 Anticholinergic ...... 63 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Bronchodilators, Hormones/Modifiers) : Estrogens ...... 48 Sympathomimetic ...... 63 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Agents Hormones/Modifiers) ...... 49 ...... 63 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Mast Cell Stabilizers 63 Hormones/Modifiers) : Progesterone Agonists/Antagonists. 49 Respiratory Tract/Pulmonary Agents : Phosphodiesterase Hormonal Agents, Stimulant/Replacement/Modifying (Sex Inhibitors, Airways Disease ...... 63 Hormones/Modifiers) : Progestins...... 49 Respiratory Tract/Pulmonary Agents : Pulmonary Hormonal Agents, Stimulant/Replacement/Modifying (Sex Antihypertensives ...... 63 Hormones/Modifiers) : Selective Estrogen Receptor Respiratory Tract/Pulmonary Agents : Respiratory Tract Modifying Agents ...... 49 Agents, Other ...... 64 Hormonal Agents, Stimulant/Replacement/Modifying Skeletal Muscle Relaxants ...... 64 (Thyroid) ...... 49 Skin and Mucous Membrane Preparations : Anti-infectives 64 Hormonal Agents, Suppressant (Adrenal) ...... 49 Skin and Mucous Membrane Preparations : Anti- Hormonal Agents, Suppressant (Parathyroid) ...... 49 inflammatory Agents ...... 64 Hormonal Agents, Suppressant (Pituitary) ...... 49 Skin and Mucous Membrane Preparations : Cell Stimulants Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents and Proliferants ...... 64 ...... 50 Skin and Mucous Membrane Preparations : Skin and Mucous Hormones and Synthetic Substitutes : Adrenals ...... 50 Membrane Agents, Misc ...... 64 Hormones and Synthetic Substitutes : Antidiabetic Agents . 50 Sleep Disorder Agents : GABA Receptor Modulators ...... 65 Hormones and Synthetic Substitutes : Pituitary ...... 50 Sleep Disorder Agents : Sleep Disorders, Other ...... 65 Immunological Agents : Immune Suppressants ...... 50 Therapeutic Nutrients/Minerals/Electrolytes : ...... 65 Immunological Agents : Immunizing Agents, Passive ...... 51 Therapeutic Nutrients/Minerals/Electrolytes : Immunological Agents : Immunomodulators ...... 51 Electrolyte/Mineral Modifiers ...... 65 Immunological Agents : Vaccines ...... 51 Therapeutic Nutrients/Minerals/Electrolytes : Inflammatory Bowel Disease Agents : Aminosalicylates ..... 51 Electrolyte/Mineral Replacement ...... 65 Inflammatory Bowel Disease Agents : Glucocorticoids ...... 51 Therapeutic Nutrients/Minerals/Electrolytes ...... 66 Inflammatory Bowel Disease Agents : Sulfonamides ...... 51 Therapeutic Nutrients/Minerals/Electrolytes : Vitamins ...... 66 Local Anesthetics ...... 51 Vitamins : Multivitamin Preparations ...... 67 Metabolic Bone Disease Agents ...... 51 Vitamins : Vitamin A ...... 68 Miscellaneous Therapeutic Agents : ...... 52 Vitamins : Vitamin B Complex ...... 68 Miscellaneous Therapeutic Agents : Antidotes ...... 52 Vitamins : Vitamin D ...... 68 Miscellaneous Therapeutic Agents : Cariostatic Agents ...... 52 Index of Covered Drugs ...... 69 Miscellaneous Therapeutic Agents : Disease-modifying Nondiscrimination Notice and Access to Communication Antirheumatic Drugs ...... 52 Services ...... 101 Miscellaneous Therapeutic Agents ...... 52 Multi-language Interpreter Services ...... 102

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Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Formulary.

What is a Formulary? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on your ID card for more information.

How do I use my Formulary?

When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lower-cost, commonly Use Tier 1 drugs for $ Lowest Cost used generic drugs. the lowest out-of- Some low-cost brands pocket costs. may be included.

Tier 2 Many common brand- Use Tier 2 drugs, instead $$ Mid-range name drugs, called of Tier 3, to help reduce Cost preferred brands. your out-of-pocket costs.

Tier 3 Mostly higher-cost Many Tier 3 drugs have $$$ Highest Cost brand drugs, also lower-cost options in Tier known as non- 1 or 2. Ask your doctor if preferred brands. they could work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website, or call the toll-free member phone number on your ID card for more information about your benefit plan.

When does the Formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card.

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Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Clobex) and generic drugs in plain type (for example, clobetasol).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit your plan’s member website to make sure.

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Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications.

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on your ID card for more current information. When you register at our website and open an account, you can use the website’s helpful tools and features to: • Look up the price of drugs covered by your plan • Find lower-cost options • Refill and renew mail service prescriptions • View your order status and claims history

• View your benefits in real time

More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on your ID card. Or visit your plan’s member website.

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Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Analgesics Ibudone (10mg-200mg Tablet) 3 Bupap (Tablet) 3 Ibuprofen (100mg/5ml Suspension, 1 Butalbital/Acetaminophen (300mg- 1 400mg Tablet, 600mg Tablet, 50mg Tablet, 50mg-325mg Tablet) 800mg Tablet) Gralise (Tablet) 3 Ibuprofen Comfort Pac (Kit) 3 Gralise Starter Pack 3 IC 400 (Kit) 3 Ofirmev (Injection) 3 IC 800 (Kit) 3 Prialt (Injection) 2 Indocin (25mg/5ml Suspension) 3 Vanatol LQ (Oral Solution) 3 Indocin (50mg Suppository) 2 Indomethacin (25mg Capsule, 50mg 1 Analgesics : Nonsteroidal Anti-inflammatory Drugs Capsule) 3 Anaprox DS (Tablet) Indomethacin ER (Capsule 1 Arthrotec 50 (Tablet Delayed- 3 Extended-Release) Release) Ketoprofen (Capsule Immediate- 1 Arthrotec 75 (Tablet Delayed- 3 Release) Release) Ketoprofen ER (Capsule Extended- 1 Butalbital/Acetaminophen/Caffeine 1 Release 24 Hour) (325mg-50mg-40mg Tablet, 50mg- Ketorocaine-L (Injection) 3 300mg-40mg Capsule) Ketorocaine-LM (Injection) 3 Butalbital/Aspirin/Caffeine 1 (Capsule) Ketorolac Tromethamine (10mg 1 Tablet) Cambia (Packet) 3 Lodine (Tablet) 3 CapXib Kit (Kit) 3 Meclofenamate Sodium (100mg 1 3 Celebrex (Capsule) Capsule, 50mg Capsule) Celecoxib (Capsule) 1 Mefenamic Acid (250mg Capsule) 1 2 Choline Magnesium Trisalicylate Meloxicam (Tablet) 1 (1000mg Tablet) Meloxicam Comfort Pac (Kit) 3 Choline Magnesium Trisalicylate 1 (500mg/5ml Liquid) Mobic (Tablet) 3 Daypro (Tablet) 3 Nabumetone (Tablet) 1 Diclofenac Potassium (Tablet) 1 Nalfon (Capsule) 3 Diclofenac Sodium DR (Tablet 1 Naprelan (Tablet Extended- 3 Delayed-Release) Release 24 Hour) Diclofenac Sodium ER (Tablet 1 Naprosyn (125mg/5ml Suspension, 3 Extended-Release 24 Hour) 500mg Tablet) Diclofenac Sodium/Misoprostol 1 Naproxen (125mg/5ml Suspension, 1 (Tablet Delayed-Release) 250mg Tablet, 375mg Tablet, 500mg Tablet) Diflunisal (Tablet) 1 Naproxen Comfort Pac (Kit) 3 EC-Naprosyn (Tablet Delayed- 3 Release) Naproxen Sodium (275mg Tablet, 1 550mg Tablet) Esgic (Tablet) 3 Naproxen Sodium CR (Tablet 1 Etodolac (200mg Capsule, 300mg 1 Extended-Release 24 Hour) Capsule, 400mg Tablet, 500mg Tablet) Naproxen Sodium ER (Tablet 1 Extended-Release 24 Hour) Etodolac ER (Tablet Extended- 1 Release 24 Hour) Oxaprozin (Tablet) 1 Feldene (Capsule) 3 Oxycodone/Ibuprofen (Tablet) 1 Fenoprofen Calcium (200mg 1 Piroxicam (10mg Capsule, 20mg 1 Capsule, 400mg Capsule, 600mg Capsule) Tablet) Ponstel (Capsule) 3 Fenortho (Capsule) 3 Reprexain (5mg-200mg Tablet) 3 Fioricet (Capsule) 3 Salsalate (500mg Tablet, 750mg 1 Fiorinal (Capsule) 3 Tablet) Flanax Pain Relief Kit (Kit) 3 Sprix (Nasal Solution) 3 Flector (Patch) 3 Sulindac (150mg Tablet, 200mg 1 Tablet) Flurbiprofen (100mg Tablet, 50mg 1 Tablet) Tolmetin Sodium (200mg Tablet, 1 600mg Tablet, 400mg Capsule) Hydrocodone/Ibuprofen (Tablet) 1 Zorvolex (Capsule) 3

Bold type = Brand-name drug 10 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Analgesics : Opioid Analgesics, Long-acting 300mg Tablet Extended-Release 24 Belbuca (Film) 3 Hour, 150mg Capsule Extended- Release 24 Hour) Bunavail (Film) 3 Xartemis XR (Tablet Extended- 3 Buprenex (Injection) 3 Release) Buprenorphine HCl (0.3mg/ml 1 Xtampza ER (Capsule Extended- 3 Solution, 2mg Tablet Sublingual, Release 12 Hour Abuse-Deterrent) 8mg Tablet Sublingual) Zohydro ER (Capsule Extended- 3 Buprenorphine HCl/Naloxone HCl 1 Release 12 Hour Abuse-Deterrent) (Tablet Sublingual) Butrans (Patch Weekly) 3 Analgesics : Opioid Analgesics, Short-acting Dolophine (Tablet) 3 Abstral (Tablet Sublingual) 3 Duragesic (Patch 72 Hour) 3 Acetaminophen/Caffeine/Dihydroco 1 deine (Capsule) Embeda (Capsule Extended- 2 Release) Acetaminophen/Codeine 1 (120mg/5ml-12mg/5ml Oral Fentanyl (Patch 72 Hour) 1 Solution, 300mg-15mg Tablet, Hydromorphone HCl ER (Tablet 1 300mg-30mg Tablet, 300mg-60mg Extended-Release 24 Hour Abuse- Tablet) Deterrent) Actiq (Lollipop) 3 Infumorph 200 (Injection) 3 Alfentanil (Injection) 1 Infumorph 500 (Injection) 3 Alfentanil HCl (Injection) 3 Levorphanol Tartrate (Tablet) 3 Aspirin-Caffeine-Dihydrocodeine 1 Methadone HCl (10mg Tablet, 5mg 1 (Capsule) Tablet, 10mg/5ml Oral Solution, 5mg/5ml Oral Solution, 10mg/ml Butalbital/Acetaminophen/Caffeine/ 1 Concentrate, 40mg Tablet Soluble) Codeine (Capsule) Butalbital/Aspirin/Caffeine/Codeine 1 Methadone HCl (10mg/ml 3 (Capsule) Injection) Butorphanol Tartrate (10mg/ml 1 Methadose (10mg/ml 3 Nasal Solution, 1mg/ml Injection, Concentrate) 2mg/ml Injection) Methadose Sugar-Free 3 3 (Concentrate) Capital/Codeine (Suspension) Codeine Sulfate (Tablet) 1 Morphine Sulfate (10mg/0.7ml 3 Injection) Demerol (100mg Tablet, 3 Morphine Sulfate (30mg 2 100mg/2ml Injection, 100mg/ml Suppository) Injection, 25mg/0.5ml Injection, 25mg/ml Injection, 50mg/ml Morphine Sulfate ER (Capsule 1 Injection, 75mg/1.5ml Injection, Extended-Release 24 Hour, Tablet 75mg/ml Injection) Extended-Release) Dilaudid (1mg/ml Liquid, 1mg/ml 3 3 MS Contin (Tablet Extended- Solution, 2mg/ml Solution, Release) 4mg/ml Solution, 2mg Tablet, 4mg Nucynta ER (Tablet Extended- 3 Tablet, 8mg Tablet) Release 12 Hour) Fentanyl Citrate Oral Transmucosal 1 Opana ER (Tablet Extended- 2 (Lollipop) Release 12 Hour Abuse-Deterrent) Fentanyl Citrate/NaCl (Injection) 3 2 Oxycodone HCl ER (80mg Tablet Fentanyl Citrate/Sodium Chloride 3 Extended-Release 12 Hour Abuse- (1mg/100ml-0.9% Injection, Deterrent) 2mg/100ml-0.9% Injection) Oxycodone HCl Tablet Extended- 3 Fentora (Tablet) 3 Release 12 Hour Abuse-Deterrent (10mg, 15mg, 20mg, 30mg, 40mg, Fioricet/Codeine (Capsule) 3 60mg) Fiorinal/Codeine #3 (Capsule) 3 OxyContin (Tablet Extended- 2 Hycet (Oral Solution) 3 Release 12 Hour Abuse-Deterrent) Hydrocodone 1 Oxymorphone HCl ER (Tablet 1 Bitartrate/Acetaminophen (300mg- Extended-Release 12 Hour) 10mg Tablet, 300mg-5mg Tablet, 300mg-7.5mg Tablet, 325mg-2.5mg Suboxone (Film) 2 Tablet, 325mg/15ml-10mg/15ml Tramadol HCl ER (100mg Tablet 1 Oral Solution, 325mg/15ml- Extended-Release 24 Hour, 200mg 7.5mg/15ml Oral Solution) Tablet Extended-Release 24 Hour,

Bold type = Brand-name drug 11 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Hydrocodone/Acetaminophen 1 5mg Tablet, 5mg Capsule, 5mg/5ml (Tablet) Oral Solution) Hydromorphone HCl (1mg/ml 1 Oxycodone/Acetaminophen (2.5mg- 1 Injection, 2mg/ml Injection, 4mg/ml 325mg Tablet, 325mg-10mg Tablet, Injection, 500mg/50ml Injection, 325mg-5mg Tablet, 325mg-7.5mg 1mg/ml Liquid, 2mg Tablet, 4mg Tablet) Tablet, 8mg Tablet) Oxycodone/Acetaminophen 3 Hydromorphone HCl/ Sodium 3 (325mg/5ml-5mg/5ml Oral Chloride (Solution) Solution) Hydromorphone HCl/Sodium 1 Oxycodone/Aspirin (Tablet) 1 Chloride (10mg/50ml-0.9% Oxymorphone HCl (Tablet 1 Injection, 15mg/30ml-0.9% Immediate-Release) Injection) Pentazocine/Naloxone HCl (Tablet) 1 Hydromorphone HCl/Sodium 3 Percocet (Tablet) 3 Chloride (10mg/50ml-0.9% Primlev (Tablet) 3 Solution, 50mg/100ml-0.9% 3 Solution, 40mg/100ml-0.9% Roxicodone (Tablet) Injection, 5mg/25ml-0.9% Subsys (Liquid) 3 Solution Prefilled Syringe) Synalgos-DC (Capsule) 3 Lazanda (Nasal Solution) 3 Talwin (Injection) 3 Lortab (300mg/15ml-10mg/15ml 3 Tramadol HCl (Tablet Immediate- 1 Elixir) Release) Meperidine HCl (100mg Tablet, 1 Tramadol HCl/Acetaminophen 1 50mg Tablet, 100mg/ml Injection, (Tablet) 10mg/ml Injection, 25mg/ml Trezix (Capsule) 3 Injection, 50mg/ml Injection, Tylenol/Codeine #3 (Tablet) 3 50mg/5ml Oral Solution) Tylenol/Codeine #4 (Tablet) 3 Meperidine HCl/Sodium Chloride 1 Ultiva (Injection) 3 (1000mg/100ml-0.9% Injection, Ultracet (Tablet) 3 500mg/50ml-0.9% Injection) Ultram (Tablet) 3 Morphine Sulfate (0.5mg/ml 1 Injection, 100mg/5ml Oral Solution, Xodol (Tablet) 3 10mg/5ml Oral Solution, 20mg/5ml Zamicet (Oral Solution) 3 Oral Solution, 10mg/ml Injection, Anesthetics : Local Anesthetics 1mg/ml Injection, 4mg/ml Injection, Akten (Gel) 3 8mg/ml Injection, 15mg Tablet, BD Pudendal/Local Block Tray 3 30mg Tablet) 1% Lidocaine (Kit) Morphine Sulfate (10mg/ml 3 Bupivacaine HCl (Injection) 1 Injection, 150mg/30ml Injection, Bupivacaine HCl/Sodium 3 15mg/ml Injection, 2mg/ml Chloride (0.1%-0.9% Injection, Injection, 4mg/ml Injection, 0.125%-0.9% Injection, 0.2%- 8mg/ml Injection, 5mg/ml 0.9% Injection, 0.25%-0.9% Injection) Injection) Morphine Sulfate/Sodium Chloride 1 Bupivacaine/Epinephrine (0.25%- 1 (0.5mg/ml-0.9% Injection, 1:200000 Injection) 50mg/50ml-0.9% Injection) Carbocaine (Injection) 3 Morphine Sulfate/Sodium 3 Chloride (50mg/50ml-0.9% Durasafe Spinal/Epidural 3 Injection, 50mg/50ml-0.9% Tray/1% Xylocaine/20gx36"close Solution) Cath (Kit) Nalbuphine HCl (Injection) 1 Durasafe Spinal/Epidural 3 Tray/1% Xylocaine/20gx36"open Norco (325mg-10mg Tablet, 3 Cath (Kit) 325mg-7.5mg Tablet, 325mg-5mg Tablet) Dyural-40 (Injection) 3 Nucynta (Tablet) 3 Dyural-80 (Injection) 3 Opana (Tablet Immediate- 3 Dyural-LM (Injection) 3 Release, 1mg/ml Injection) Epifoam (Foam) 3 Oxaydo (Tablet Abuse-Deterrent) 3 Ethyl Chloride (Aerosol) 3 Oxycodone HCl (100mg/5ml 1 Exparel (Suspension) 3 Concentrate, 10mg Tablet, 15mg Gebauers Pain Ease (0-0 Aerosol) 3 Tablet, 20mg Tablet, 30mg Tablet, IV Infusion CPI (Kit) 3

Bold type = Brand-name drug 12 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Lidocaine (3% Cream, 5% 1 Antabuse (Tablet) 3 Ointment, 5% Patch) Disulfiram (Tablet) 1 Lidocaine HCl (0.5% Injection, 1% 1 Naltrexone HCl (Tablet) 1 Injection, 1.5% Injection, 2% Vivitrol (Injection) 3 Injection, 4% Injection, 2% Gel, 4% External Solution) Anti-Addiction/Substance Abuse Treatment Agents : Lidocaine HCl (Gel) 1 Opioid Dependence Treatments Lidocaine HCl/Dextrose 3 Zubsolv (1.4mg-0.36mg Tablet 2 (Injection) Sublingual, 11.4mg-2.9mg Tablet Lidocaine Viscous (Solution) 1 Sublingual, 2.9mg-0.71mg Tablet Sublingual, 5.7mg-1.4mg Tablet Lidocaine/Epinephrine (Injection) 1 Sublingual, 8.6mg-2.1mg Tablet Lidocaine/Prilocaine (2.5%-2.5% 1 Sublingual) Cream, 2.5%-2.5% Kit) Lidoderm (Patch) 3 Anti-Addiction/Substance Abuse Treatment Agents : Marcaine (Injection) 3 Opioid Reversal Agents Marcaine/Epinephrine (0.25%- 3 Evzio (0.4mg/0.4ml Injection) 3 1:200000 Injection) Naloxone HCl (Injection) 1 Marlido-25 (Injection) 3 Narcan (Liquid) 2 Monoject Bone Marrow Biopsy 3 Anti-Addiction/Substance Abuse Treatment Agents : Prepping Tray (Kit) Smoking Cessation Agents Monoject Bone Marrow Biopsy 3 Bupropion HCl (Tablet) 1 Tray/Sternal-Iliac Needle 16g Bupropion HCl XL (Tablet 1 (Kit) Extended-Release 24 Hour) Naropin (Injection) 3 Wellbutrin SR (Tablet Extended- 3 Nesacaine (Injection) 3 Release 12 Hour) Nesacaine-Mpf (Injection) 3 Wellbutrin XL (Tablet Extended- 3 Pliaglis (Cream) 3 Release 24 Hour) Pramosone (1%-1% Cream) 2 Anti-infective Agents : Antibacterials Pramosone (1%-1% Lotion, 3 Cefazolin Sodium/Dextrose 3 2.5%-1% Lotion) (2gm/50ml-5% Injection) Readysharp-A (Injection) 3 Cefazolin/Sodium Chloride 3 Readysharp-K (Injection) 3 (3gm/100ml-0.9% Solution) Readysharp-P40 (Injection) 3 Ofloxacin (300mg Tablet) 1 Readysharp-P80 (Injection) 3 Piperacillin/Tazobactam (12gm- 3 Ropivacaine (Injection) 1 1.5gm Solution) Ropivacaine HCl (Injection) 1 Vancomycin HCl + Syrspendsf 3 Ropivacaine HCl/Sodium 3 Ph4 (Suspension) Chloride (0.1%-0.9% Solution, Vancomycin HCl/Dextrose (5%- 3 0.2%-0.9% Solution) 1.25gm/250ml Solution, 5%- Sensorcaine-Mpf/Epinephrine 3 1.5gm/500ml Solution, 5%- (Injection) 1.75gm/500ml Solution) Synera (Patch) 3 Vancomycin HCl/Dextrose (5%- 1 Turkel Paracentesis Procedure 3 1.5gm/250ml Injection) Tray/8french (Kit) Vancomycin HCl/Sodium Chloride 1 Vitrase (Injection) 3 (0.9%-1.5gm/500ml Injection) Xerese (Cream) 3 Vancomycin HCl/Sodium 3 Xylocaine (0.5% Injection, 1% 3 Chloride (0.9%-1.75gm/300ml Injection, 2% Injection, 4% Solution, 0.9%-2.5gm/500ml External Solution) Solution, 0.9%-2gm/250ml Solution, 0.9%-2gm/500ml Xylocaine-MPF (Injection) 3 Solution) Xylocaine-Mpf/Epinephrine 3 Vancomycin HCl/Sodium 3 (Injection) Chloride (Solution) Xylocaine/Epinephrine (Injection) 3 Anti-infective Agents : Antivirals Anti-Addiction/Substance Abuse Treatment Agents : Selzentry (25mg Tablet, 75mg 2 Alcohol Deterrents/Anti-craving Tablet) Acamprosate Calcium DR (Tablet 1 Vemlidy (Tablet) 3 Delayed-Release) Anti-inflammatory Agents : Nonsteroidal Anti-

Bold type = Brand-name drug 13 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits inflammatory Drugs Arzol Silver Nitrate App Licators 2 Diclofenac Sodium (3% Gel) 1 Bacitracin (50000unit Injection, 1 Dyloject (Injection) 3 500unit/gm Ophthalmic Ointment) Bacitracin/Polymyxin B 1 Antibacterials : Aminoglycosides (Ophthalmic Ointment) Amikacin Sulfate (1gm/4ml 1 Bactroban (Cream) 3 Injection, 500mg/2ml Injection) Bactroban Nasal (Ointment) 3 Gentamicin Sulfate (0.1% Cream, 1 0.1% Ointment, 0.3% Ophthalmic Benzalkonium Chloride (0 3 Ointment, 0.3% Ophthalmic External Solution, 50% External Solution, 10mg/ml Injection, Solution) 40mg/ml Injection) Betadine Ophthalmic Prep 3 Gentamicin Sulfate/0.9% Sodium 1 (Ophthalmic Solution) Chloride (0.8mg/ml-0.9% Injection, Bucalsep (600mg/30ml- 3 1.2mg/ml-0.9% Injection, 1mg/ml- 30mg/30ml-45mg/30ml- 0.9% Injection) 30mg/30ml External Solution, Gentamicin Sulfate/0.9% Sodium 3 600mg/30ml-30mg/30ml- Chloride (0.9mg/ml Injection, 45mg/30ml-30mg/30ml Liquid) 1.4mg/ml Injection, 2mg/ml-0.9% Centany (Ointment) 2 Injection) Centany AT (Kit) 3 Isotonic Gentamicin (Injection) 1 Chloramphenicol Sodium 3 Kitabis Pak (Nebulized Solution) 3 Succinate (Injection) Neomycin Sulfate (Tablet) 1 Cleocin (100mg Suppository) 2 Neomycin/Polymyxin/Gramicidin 1 Cleocin (150mg Capsule, 300mg 3 (Ophthalmic Solution) Capsule, 75mg Capsule, 2% Neosporin (Ophthalmic Solution) 3 Cream) Paromomycin Sulfate (Capsule) 1 Cleocin in D5W (Injection) 3 Pred-G (Suspension) 3 Cleocin Pediatric Granules (Oral 3 Solution) Pred-G S.O.P. (Ointment) 3 Cleocin Phosphate (150mg/ml 3 Prednisolone/Moxifloxacin 3 Injection, 300mg/2ml Injection, (Ophthalmic Solution) 600mg/4ml Injection, 900mg/6ml Streptomycin Sulfate (1gm 3 Injection, 9gm/60ml Injection) Injection) Clindamycin HCl (Capsule 1 TOBI (Nebulized Solution) 3 Immediate-Release) TOBI Podhaler (Capsule) 3 Clindamycin Palmitate HCl (Oral 1 Tobradex (0.3%-0.1% 3 Solution) Ophthalmic Ointment, 0.3%- Clindamycin Phosphate (2% Cream, 1 0.1% Ophthalmic Suspension) 300mg/2ml Injection, 600mg/4ml Tobradex ST (Ophthalmic 3 Injection, 9000mg/60ml Injection, Suspension) 900mg/6ml Injection) Tobramycin (300mg/5ml Nebulized 1 Clindamycin Phosphate in D5W 1 Solution) (Injection) Tobramycin (300mg/5ml 3 Clindesse (Cream) 3 Nebulized Solution) Colistimethate Sodium (Injection) 1 Tobramycin Sulfate (0.3% 1 Coly-Mycin M (Injection) 3 Ophthalmic Solution, 1.2gm Cubicin (Injection) 3 Injection, 1.2gm/30ml Injection, 10mg/ml Injection, 80mg/2ml Cubicin RF (Injection) 3 Injection) Dalvance (Injection) 3 Tobramycin/Dexamethasone 1 Daptomycin (Solution) 1 (Ophthalmic Suspension) First-Vancomycin 25 (Oral 3 Tobrex (0.3% Ophthalmic 3 Solution) Ointment, 0.3% Ophthalmic First-Vancomycin 50 (Oral 3 Solution) Solution) Zylet (Suspension) 3 Flagyl (250mg Tablet, 500mg 3 Antibacterials : Antibacterials, Other Tablet, 375mg Capsule) Furadantin (Suspension) 3 Alcoh-Glove Contoured Wipe 3 Glutaraldehyde (External 3 Alcoh-Wipe 12" X 12" 3 Solution) Altabax (Ointment) 3 Hiprex (Tablet) 3

Bold type = Brand-name drug 14 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Hydrogen Peroxide (30% Does 3 Silver Nitrate (10% Ointment) 3 Not Apply Solution) Silver Sulfadiazine (Cream) 1 Impavido (Capsule) 3 Sivextro (200mg Injection, 200mg 3 Iodine Tincture (2% Tincture) 3 Tablet) Lincocin (Injection) 3 Sulfamylon (5% Packet, 85mg/gm 3 Lincomycin HCl (Injection) 1 Cream) Linezolid (100mg/5ml Suspension, 1 Synercid (Injection) 3 600mg Tablet, 600mg/300ml Trimethoprim (100mg Tablet) 1 Injection) Trimethoprim Sulfate/Polymyxin B 1 Macrobid (Capsule) 3 Sulfate (Ophthalmic Solution) Macrodantin (Capsule) 3 Tygacil (Injection) 3 Maxitrol (0.1% Ointment, 0.1% 3 Vancocin HCl (Capsule) 3 Suspension) Vancomycin (Injection) 1 Methenamine Hippurate (Tablet) 1 Vancomycin HCl (0.9%-1gm/200ml 1 Metro IV (Injection) 3 Injection, 1000mg Injection, 10gm MetroCream (Cream) 3 Injection, 5000mg Injection, 125mg MetroGel (Gel) 3 Capsule, 250mg Capsule) MetroGel-Vaginal (Gel) 3 Vancomycin HCl in Dextrose 3 MetroLotion (Lotion) 3 (Injection) 3 Metronidazole (0.75% Cream, 1 Vancomycin HCl/Dextrose (5%- 0.75% Gel, 1% Gel, 0.75% Lotion, 1gm/100ml Injection) 250mg Tablet, 500mg Tablet, Vancomycin HCl/Dextrose (5%- 1 375mg Capsule) 1gm/250ml Injection, 5%- Metronidazole in NaCl 0.79% 1 2gm/500ml Injection) (Injection) Vancomycin HCl/Sodium 3 Metronidazole Vaginal (Gel) 1 Chloride (0.9%-1.25gm/250ml Injection, 0.9%-1.5gm/250ml 3 Monurol (Packet) Injection, 0.9%-1gm/250ml Mupirocin (2% Cream, 2% 1 Solution) Ointment) Vancomycin HCl/Sodium Chloride 1 Neomycin/Bacitracin/Polymyxin 1 (0.9%-1.5gm/150ml Injection, (Ointment) 0.9%-1gm/150ml Injection, 0.9%- Neomycin/Polymyxin/Bacitracin/Hy 1 750mg/150ml Injection) drocortisone (Ointment) Vibativ (Injection) 3 Neomycin/Polymyxin/Dexamethaso 1 Xifaxan (Tablet) 3 ne (0.1% Ophthalmic Suspension, Zyvox (100mg/5ml Suspension, 3 0.1%-3.5mg/gm-10000unit/gm 600mg Tablet, 600mg/300ml Ointment) Injection) Neomycin/Polymyxin/Hydrocortiso 1 ne (1% Ophthalmic Suspension) Antibacterials : Beta-lactam, Cephalosporins Nitrofurantoin (Suspension) 1 Avycaz (Injection) 3 Nitrofurantoin Macrocrystals 1 Cedax (180mg/5ml Suspension, 3 (Capsule) 400mg Capsule) Nitrofurantoin Monohydrate (100mg 1 Cefaclor (125mg/5ml Suspension) 2 Capsule) Cefaclor (Capsule Immediate- 1 Noritate (Cream) 3 Release, Oral Suspension) Orbactiv (Injection) 3 Cefaclor ER (Tablet Extended- 1 Release 12 Hour) Polymyxin B Sulfate (500000unit 1 Injection) Cefadroxil (1gm Tablet, 250mg/5ml 1 Suspension, 500mg/5ml Suspension, Polymyxin B Sulfate/Trimethoprim 1 500mg Capsule) Sulfate (Ophthalmic Solution) Cefazolin (Injection) 3 Polytrim (Ophthalmic Solution) 3 Cefazolin Sodium (100gm 3 Primsol (Oral Solution) 3 Injection, 300gm Injection, Relagard (Gel) 3 1gm/50ml Injection) Silvadene (Cream) 3 Cefazolin Sodium (10gm Injection, 1 Silver Nitrate (0.5% External 2 1gm Injection, 20gm Injection, Solution, 10% External Solution, 500mg Injection) 25% External Solution, 50% Cefazolin Sodium/Dextrose (1gm- 3 External Solution) 4% Injection, 2gm-3% Injection)

Bold type = Brand-name drug 15 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Cefazolin Sodium/Sodium Chloride 1 Teflaro (Injection) 3 (Injection) Zerbaxa (Injection) 3 Cefazolin/D5W (Injection) 1 Zinacef (Injection) 3 Cefazolin/Dextrose (Injection) 1 Antibacterials : Beta-lactam, Other Cefazolin/Sodium Chloride 1 Azactam (Injection) 3 (2gm/100ml-0.9% Injection) Azactam in Iso-Osmotic Dextrose 3 Cefdinir (125mg/5ml Suspension, 1 (Injection) 250mg/5ml Suspension, 300mg Aztreonam (Injection) 1 Capsule) Cayston (Inhalation Solution) 3 Cefditoren Pivoxil (Tablet) 3 Cefotan (Injection) 3 Cefepime (1gm Injection, 2gm 1 Injection) Cefotetan (1gm Injection, 2gm 1 Injection) Cefepime (1gm/50ml Injection, 3 2gm/100ml Injection) Cefotetan (Injection) 3 Cefepime/Dextrose (Injection) 3 Doribax (Injection) 3 Cefixime (Suspension) 1 Doripenem (Injection) 3 Cefotaxime Sodium (Injection) 1 Imipenem/Cilastatin (Injection) 1 Cefotetan/Dextrose (Injection) 3 Invanz (Injection) 3 Cefoxitin Sodium (10gm Injection, 1 Meropenem (Injection) 1 1gm Injection, 2gm Injection) Meropenem/Sodium Chloride 1 Cefoxitin Sodium (1gm-4% 3 (Injection) Injection, 2gm-2.2% Injection) Merrem (Injection) 3 Cefpodoxime Proxetil (100mg 1 Primaxin IV (Injection) 3 Tablet, 200mg Tablet, 100mg/5ml Antibacterials : Beta-lactam, Penicillins Suspension, 50mg/5ml Suspension) Amoxicillin (125mg Tablet 1 Cefprozil (125mg/5ml Suspension, 1 Chewable, 250mg Tablet Chewable, 250mg/5ml Suspension, 250mg 125mg/5ml Suspension, 200mg/5ml Tablet, 500mg Tablet) Suspension, 250mg/5ml Suspension, Ceftazidime (Injection) 1 400mg/5ml Suspension, 250mg Ceftazidime/Dextrose (Injection) 3 Capsule, 500mg Capsule, 500mg Ceftibuten (180mg/5ml 3 Tablet, 875mg Tablet) Suspension, 400mg Capsule) Amoxicillin/Clavulanate Potassium 1 Ceftin (Suspension) 3 (Tablet Chewable, Tablet Immediate-Release, Oral Ceftriaxone in Iso-Osmotic 1 Suspension) Dextrose (Injection) Amoxicillin/Clavulanate Potassium 1 Ceftriaxone Sodium (100gm 1 ER (Tablet Extended-Release 12 Injection, 1gm Injection, 250mg Hour) Injection, 500mg Injection, 10gm Injection, 2gm Solution) Ampicillin (125mg/5ml Suspension, 1 250mg/5ml Suspension, 250mg Ceftriaxone/Dextrose (Injection) 3 Capsule, 500mg Capsule) Cefuroxime Axetil (Tablet) 1 Ampicillin Sodium (10gm Injection, 1 Cefuroxime Sodium (Injection) 1 1gm Injection, 250mg Injection, Cephalexin (125mg/5ml 1 2gm Injection, 500mg Injection) Suspension, 250mg/5ml Suspension, Ampicillin Sodium (125mg 3 250mg Capsule, 500mg Capsule, Injection, 1gm Injection) 750mg Capsule, 250mg Tablet, Ampicillin-Sulbactam (10gm-5gm 1 500mg Tablet) Injection, 1gm-0.5gm Injection, Fortaz (Injection) 3 2gm-1gm Injection) Keflex (Capsule) 3 Augmentin (125mg/5ml- 3 Maxipime (Injection) 3 31.25mg/5ml Suspension, Spectracef (Tablet) 3 250mg/5ml-62.5mg/5ml Suprax (100mg Tablet Chewable, 3 Suspension, 500mg-125mg Tablet, 200mg Tablet Chewable, 875mg-125mg Tablet) 100mg/5ml Suspension, Augmentin ES-600 (Suspension) 3 200mg/5ml Suspension, Augmentin XR (Tablet Extended- 3 500mg/5ml Suspension, 400mg Release 12 Hour) Capsule) Bactocill in Dextrose (Injection) 3 Tazicef (1gm/50ml-4.4% 3 Bicillin C-R (Injection) 3 Injection)

Bold type = Brand-name drug 16 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Bicillin L-A (Injection) 3 Suspension, 200mg/5ml Dicloxacillin Sodium (Capsule) 1 Suspension, 250mg Tablet, 500mg Moxatag (Tablet Extended- 3 Tablet, 600mg Tablet, 500mg Release 24 Hour) Injection) Nafcillin (Injection) 1 Zithromax (1gm Packet) 2 Nafcillin Sodium (10gm Injection, 1 Zithromax Tri-Pak (Tablet) 3 1gm Injection, 2gm Injection) Zithromax Z-Pak (Tablet) 3 Nafcillin Sodium (1gm Injection, 3 Zmax (Suspension) 3 2gm Injection) Antibacterials : Quinolones Oxacillin Sodium (Injection) 1 Avelox (Tablet, Injection) 3 Penicillin G Potassium (Injection) 1 Avelox ABC Pack (Tablet) 3 Penicillin G Potassium in Iso- 3 Besivance (Suspension) 3 Osmotic Dextrose (Injection) Cetraxal (Otic Solution) 3 Penicillin G Procaine (Injection) 3 Ciloxan (0.3% Ointment, 0.3% 3 Penicillin G Sodium (Injection) 3 Ophthalmic Solution) Penicillin V Potassium (125mg/5ml 1 Cipro (250mg Tablet, 500mg 3 Oral Solution, 250mg/5ml Oral Tablet, 500mg/5ml Suspension, Solution, 250mg Tablet, 500mg 5gm/100ml Suspension) Tablet) Cipro I.V. in D5W (Injection) 3 Pfizerpen-G (Injection) 3 Cipro XR (Tablet Extended- 3 Piperacillin/Tazobactam (2gm- 1 Release 24 Hour) 0.25gm Injection, 3gm-0.375gm Ciprofloxacin (0.2% Otic 3 Injection, 4gm-0.5gm Injection, Solution) 36gm-4.5gm Solution) Ciprofloxacin (250mg/5ml 1 Unasyn (Injection) 3 Suspension, 500mg/5ml Unasyn Bulk Pack (Injection) 3 Suspension) Zosyn (Injection) 3 Ciprofloxacin ER (Tablet Extended- 1 Antibacterials : Macrolides Release 24 Hour) Azasite (Ophthalmic Solution) 3 Ciprofloxacin HCl (0.3% 1 Azithromycin (100mg/5ml 1 Ophthalmic Solution, Tablet Suspension, 200mg/5ml Suspension, Immediate-Release) 1gm Packet, 250mg Tablet, 500mg Ciprofloxacin I.V. in D5W 1 Tablet, 600mg Tablet, 500mg (Injection) Injection) Factive (Tablet) 3 Biaxin (250mg Tablet, 500mg 3 Floxin Otic (Otic Solution) 3 Tablet, 250mg/5ml Suspension) Gatifloxacin (Ophthalmic Solution) 1 Clarithromycin (125mg/5ml 1 Levaquin (Tablet) 3 Suspension, 250mg/5ml Suspension, Levofloxacin (0.5% Ophthalmic 1 250mg Tablet, 500mg Tablet) Solution, 250mg Tablet, 500mg Clarithromycin ER (Tablet 1 Tablet, 750mg Tablet, 25mg/ml Extended-Release 24 Hour) Injection, 25mg/ml Oral Solution) Dificid (Tablet) 3 Levofloxacin in D5W (Injection) 1 E.E.S. Granules (Suspension) 3 Moxeza (Ophthalmic Solution) 2 Ery-Tab (Tablet Delayed-Release) 3 Moxifloxacin HCl (400mg Tablet, 1 EryPed 200 (Suspension) 3 400mg/250ml Injection) EryPed 400 (Suspension) 3 Ocuflox (Ophthalmic Solution) 3 Erythrocin Lactobionate 3 Ofloxacin (0.3% Ophthalmic 1 (Injection) Solution, 0.3% Otic Solution, Erythrocin Stearate (Tablet) 3 400mg Tablet) Erythromycin (250mg Capsule 1 Vigamox (Ophthalmic Solution) 2 Delayed-Release, 5mg/gm Zymaxid (Ophthalmic Solution) 3 Ointment) Antibacterials : Sulfonamides Erythromycin Base (Tablet) 1 AVC (Cream) 3 Erythromycin Ethylsuccinate 1 Bactrim (Tablet) 3 (200mg/5ml Suspension, 400mg Bactrim DS (Tablet) 3 Tablet) Bleph-10 (Ophthalmic Solution) 3 PCE (Tablet Delayed-Release) 3 Blephamide (Suspension) 3 Zithromax (100mg/5ml 3 Blephamide S.O.P. (Ointment) 3

Bold type = Brand-name drug 17 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Sodium Sulfacetamide (Ophthalmic 1 Targadox (Tablet) 3 Solution) Tetracycline HCl (Capsule) 1 Sulfacetamide Sodium (10% 2 Vibramycin (100mg Capsule, 3 Ophthalmic Ointment) 25mg/5ml Suspension, 50mg/5ml Sulfacetamide Sodium (10% 1 Syrup) Ophthalmic Solution) Anticonvulsants : Anticonvulsants, Other Sulfacetamide Sodium/Prednisolone 1 Aptiom (Tablet) 3 Sodium Phosphate (Ophthalmic BRIVIACT (100mg Tablet, 10mg 3 Solution) Tablet, 25mg Tablet, 50mg Tablet, Sulfadiazine (500mg Tablet) 1 75mg Tablet, 10mg/ml Oral Sulfamethoxazole/Trimethoprim 1 Solution, 50mg/5ml Injection) (200mg/5ml-40mg/5ml Suspension, Fycompa (0.5mg/ml Suspension, 3 400mg-80mg Tablet) 10mg Tablet, 12mg Tablet, 2mg Sulfamethoxazole/Trimethoprim 3 Tablet, 4mg Tablet, 6mg Tablet, (400mg/5ml-80mg/5ml Injection) 8mg Tablet) Sulfamethoxazole/Trimethoprim DS 1 Keppra (1000mg Tablet, 250mg 3 (Tablet) Tablet, 500mg Tablet, 750mg Antibacterials : Tetracyclines Tablet, 100mg/ml Oral Solution, Acticlate (Tablet) 3 500mg/5ml Injection) Adoxa (100mg Tablet, 50mg 3 Keppra XR (Tablet Extended- 3 Tablet, 75mg Tablet, 150mg Release 24 Hour) Capsule) Levetiracetam (1000mg/100ml- 3 Adoxa Pak 1/100 (Tablet) 3 750mg/100ml Injection, 1500mg/100ml-540mg/100ml Adoxa Pak 1/150 (Tablet) 3 Injection, 500mg/100ml- 3 Adoxa Pak 2/100 (Tablet) 820mg/100ml Injection) Avidoxy DK (Kit) 3 Levetiracetam (Tablet Immediate- 1 Demeclocycline HCl (150mg 1 Release, Oral Solution, Injection) Tablet, 300mg Tablet) Levetiracetam ER (Tablet Extended- 1 Doryx (Tablet Delayed-Release) 3 Release 24 Hour) Doryx MPC (Tablet Delayed- 3 Magnesium Sulfate in D5W (5%- 1 Release) 10mg/ml Injection) Doxycycline (25mg/5ml 1 Magnesium Sulfate in D5W (5%- 3 Suspension) 10mg/ml Injection) Doxycycline Hyclate (100mg 1 Magnesium Sulfate/Dextrose (5%- 3 Capsule, 50mg Capsule, 100mg 2gm/50ml Injection, 5%- Injection, 100mg Tablet, 20mg 3gm/50ml Injection) Tablet) Magnesium Sulfate/Sodium 3 Doxycycline Hyclate DR (Tablet 1 Chloride (2gm/50ml-0.9% Delayed-Release) Injection, 40gm/L-0.9% Injection) Doxycycline Monohydrate (100mg 1 Potiga (Tablet) 3 Capsule, 150mg Capsule, 50mg Capsule, 75mg Capsule, 100mg Anticonvulsants : Calcium Channel Modifying Tablet, 150mg Tablet, 50mg Tablet, Agents 75mg Tablet) Celontin (Capsule) 3 Minocin (100mg Capsule, 50mg 3 Ethosuximide (250mg Capsule, 1 Capsule, 75mg Capsule, 100mg 250mg/5ml Oral Solution) Injection) Lyrica (100mg Capsule, 150mg 2 Minocycline HCl (100mg Capsule, 1 Capsule, 200mg Capsule, 225mg 50mg Capsule, 75mg Capsule, Capsule, 25mg Capsule, 300mg 100mg Tablet, 50mg Tablet, 75mg Capsule, 50mg Capsule, 75mg Tablet) Capsule) Minocycline HCl ER (Tablet 1 Lyrica (20mg/ml Oral Solution) 3 Extended-Release 24 Hour) Zarontin (250mg Capsule, 3 Monodox (Capsule) 3 250mg/5ml Oral Solution) Morgidox 1x100mg (0-100mg-Kit) 3 Zonegran (Capsule) 3 Morgidox 1x50mg Kit (Kit) 3 Zonisamide (Capsule) 1 Morgidox 2x100mg (0-100mg-Kit) 3 Anticonvulsants : Gamma-aminobutyric Acid (GABA) Solodyn (Tablet Extended-Release 3 Augmenting Agents 24 Hour)

Bold type = Brand-name drug 18 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Ativan (0.5mg Tablet, 1mg Tablet, 3 Tablet, 600mg/5ml Suspension) 2mg Tablet) Felbatol (400mg Tablet, 600mg 3 Clonazepam (Tablet Immediate- 1 Tablet, 600mg/5ml Suspension) Release) Lamictal (Tablet) 3 Clonazepam ODT (Tablet 1 Lamictal Chewable Dispersible 3 Dispersible) (Tablet Chewable) Clorazepate Dipotassium (Tablet) 1 Lamictal ODT (Kit, 100mg Tablet 3 Depacon (Injection) 3 Dispersible, 200mg Tablet Depakene (250mg Capsule, 3 Dispersible, 25mg Tablet 250mg/5ml Syrup) Dispersible, 50mg Tablet Depakote (Tablet Delayed- 3 Dispersible) Release) Lamictal Starter (Blue Kit) 3 Depakote ER (Tablet Extended- 3 Lamictal Starter (Green Kit) 3 Release 24 Hour) Lamictal Starter (Orange Kit) 3 Depakote Sprinkles (Capsule 3 Lamictal XR (100mg Tablet 3 Sprinkle Delayed-Release) Extended-Release 24 Hour, 200mg Diastat AcuDial (Gel) 2 Tablet Extended-Release 24 Hour, Diastat Pediatric (Gel) 2 250mg Tablet Extended-Release Diazepam (10mg Gel, 2.5mg Gel, 1 24 Hour, 25mg Tablet Extended- 20mg Gel, 10mg Tablet, 2mg Release 24 Hour, 300mg Tablet Tablet, 5mg Tablet, 1mg/ml Oral Extended-Release 24 Hour, 50mg Solution, 5mg/ml Concentrate) Tablet Extended-Release 24 Hour) Lamotrigine (Tablet Immediate- 1 Diazepam (5mg/ml Injection) 3 Release, Tablet Chewable) Divalproex Sodium (Capsule 1 Sprinkle Delayed-Release) Lamotrigine ER (100mg Tablet 1 Extended-Release 24 Hour, 200mg Divalproex Sodium DR (Tablet 1 Tablet Extended-Release 24 Hour, Delayed-Release) 25mg Tablet Extended-Release 24 Divalproex Sodium ER (Tablet 1 Hour, 300mg Tablet Extended- Extended-Release 24 Hour) Release 24 Hour, 50mg Tablet Gabitril (Tablet) 3 Extended-Release 24 Hour, 250mg Gene-Xene Tab 15mg (Tablet) 1 Tablet Extended-Release 24 Hour) Gene-Xene Tab 3.75mg (Tablet) 1 Lamotrigine ODT (Tablet 1 Gene-Xene Tab 7.5mg (Tablet) 1 Dispersible) Klonopin (Tablet) 3 Lamotrigine Titration (Kit) 1 Lorazepam (0.5mg Tablet, 1mg 1 Qudexy XR (Capsule Extended- 3 Tablet, 2mg Tablet) Release 24 Hour Sprinkle) Mysoline (Tablet) 3 Topamax (Tablet) 3 Onfi (10mg Tablet, 20mg Tablet, 3 Topamax Sprinkle (Capsule 3 2.5mg/ml Suspension) Sprinkle) Phenobarbital (100mg Tablet, 15mg 1 Topiramate (Tablet Immediate- 1 Tablet, 16.2mg Tablet, 30mg Tablet, Release, Capsule Sprinkle 32.4mg Tablet, 60mg Tablet, Immediate-Release) 64.8mg Tablet, 97.2mg Tablet, Topiramate ER (Capsule 3 20mg/5ml Elixir, 20mg/5ml Oral Extended-Release 24 Hour Solution) Sprinkle) Primidone (Tablet) 1 Trokendi XR (Capsule Extended- 3 Sabril (500mg Packet, 500mg 3 Release 24 Hour) Tablet) Anticonvulsants : Sodium Channel Agents Tiagabine HCl (Tablet) 1 Banzel (200mg Tablet, 400mg 3 Tranxene T (Tablet) 3 Tablet, 40mg/ml Suspension) Valium (Tablet) 3 Carbamazepine (100mg Tablet 1 Valproate Sodium (100mg/ml 1 Chewable, 100mg/5ml Suspension, Injection) 200mg Tablet) Valproic Acid (250mg Capsule, 1 Carbamazepine Extended-Release 1 250mg/5ml Oral Solution, 12 Hour (Capsule, Tablet) 250mg/5ml Syrup) Carbatrol (Capsule Extended- 3 Anticonvulsants : Glutamate Reducing Agents Release 12 Hour) Felbamate (400mg Tablet, 600mg 1 Cerebyx (Injection) 3

Bold type = Brand-name drug 19 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Dilantin (Capsule) 3 (NMDA) Receptor Antagonist Dilantin INFATABS (Tablet 3 Memantine HCl (10mg Tablet, 5mg 1 Chewable) Tablet, 2mg/ml Oral Solution) Dilantin-125 (Suspension) 3 Memantine HCl Titration Pak 1 Equetro (Capsule Extended- 3 (Tablet) Release 12 Hour) Namenda (10mg Tablet, 5mg 3 Fosphenytoin Sodium (Injection) 1 Tablet, 10mg/5ml Oral Solution) Oxcarbazepine (150mg Tablet, 1 Namenda Titration Pak (Tablet) 3 300mg Tablet, 600mg Tablet, Namenda XR (Capsule Extended- 2 60mg/ml Suspension) Release 24 Hour) Oxtellar XR (Tablet Extended- 3 Namenda XR Titration Pack 2 Release 24 Hour) (Capsule Extended-Release 24 Peganone (Tablet) 3 Hour) Phenytek (Capsule) 3 Antidepressants : Antidepressants, Other Phenytoin (125mg/5ml Suspension, 1 Abilify (Tablet) 3 50mg Tablet Chewable) Aplenzin (Tablet Extended- 3 Phenytoin Sodium (50mg/ml 1 Release 24 Hour) Injection) Aripiprazole (10mg Tablet, 15mg 1 Phenytoin Sodium Extended 1 Tablet, 20mg Tablet, 2mg Tablet, (Capsule) 30mg Tablet, 5mg Tablet, 1mg/ml Tegretol (100mg/5ml Suspension, 3 Oral Solution) 200mg Tablet) Bupropion HCl ER (Tablet 1 Tegretol-XR (Tablet Extended- 3 Extended-Release 12 Hour) Release 12 Hour) Bupropion HCl SR (Tablet 1 Trileptal (150mg Tablet, 300mg 3 Extended-Release 12 Hour) Tablet, 600mg Tablet, 300mg/5ml Forfivo XL (Tablet Extended- 2 Suspension) Release 24 Hour) Vimpat (Tablet, Oral Solution, 3 Maprotiline HCl (Tablet) 1 Injection) Mirtazapine (Tablet) 1 Vraylar (Capsule Therapy Pack, 3 Mirtazapine ODT (Tablet 1 1.5mg Capsule, 3mg Capsule, Dispersible) 4.5mg Capsule, 6mg Capsule) Nefazodone HCl (Tablet) 1 Antidementia Agents : Antidementia Agents, Other Quetiapine Fumarate (Tablet) 1 Ergoloid Mesylates (Tablet) 1 Quetiapine Fumarate ER (Tablet 1 Namzaric (10mg-21mg Capsule 2 Extended-Release 24 Hour) Extended-Release 24 Hour, 10mg- Remeron (Tablet) 3 7mg Capsule Extended-Release 24 Remeron Soltab (Tablet 3 Hour) Dispersible) Antidementia Agents : Cholinesterase Inhibitors Seroquel (Tablet) 3 Aricept (Tablet) 3 Seroquel XR (150mg Tablet 2 Donepezil HCl (10mg Tablet 1 Extended-Release 24 Hour, 200mg Dispersible, 5mg Tablet Dispersible, Tablet Extended-Release 24 Hour, 10mg Tablet, 23mg Tablet, 5mg 300mg Tablet Extended-Release Tablet) 24 Hour, 50mg Tablet Extended- Exelon (Patch 24 Hour) 3 Release 24 Hour) Galantamine HBr (12mg Tablet, 1 Seroquel XR (400mg Tablet 3 4mg Tablet, 8mg Tablet, 4mg/ml Extended-Release 24 Hour) Oral Solution) Trazodone HCl (100mg Tablet, 1 Galantamine HBr ER (Capsule 1 150mg Tablet, 300mg Tablet, 50mg Extended-Release 24 Hour) Tablet) Razadyne (Tablet) 3 Trintellix (Tablet) 3 Razadyne ER (Capsule Extended- 3 Antidepressants : Monoamine Oxidase Inhibitors Release 24 Hour) Emsam (Patch 24 Hour) 3 Rivastigmine Tartrate (Capsule 1 Marplan (Tablet) 3 Immediate-Release) Nardil (Tablet) 3 Rivastigmine Transdermal System 1 Parnate (Tablet) 3 (Patch 24 Hour) Phenelzine Sulfate (Tablet) 1 Antidementia Agents : N-methyl-D-aspartate Zelapar (Tablet Dispersible) 3

Bold type = Brand-name drug 20 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Antidepressants : SSRIs/SNRIs (Selective Serotonin Prozac (Capsule) 3 Reuptake Inhibitors/Serotonin and Norepinephrine Prozac Weekly (Capsule Delayed- 3 Release) Reuptake Inhibitors) Sarafem (Tablet) 3 Brisdelle (Capsule) 3 Sertraline HCl (100mg Tablet, 25mg 1 Celexa (Tablet) 3 Tablet, 50mg Tablet, 20mg/ml Citalopram HBr (10mg Tablet, 1 Concentrate) 20mg Tablet, 40mg Tablet, Venlafaxine HCl (Tablet Immediate- 1 10mg/5ml Oral Solution) Release) Cymbalta (Capsule Delayed- 3 Venlafaxine HCl Extended-Release 1 Release) 24 Hour (Capsule, Tablet) Desvenlafaxine ER (100mg Tablet 1 Viibryd (Tablet) 3 Extended-Release 24 Hour, 25mg Viibryd Starter Pack (Kit) 3 Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Zoloft (100mg Tablet, 25mg 3 Hour) Tablet, 50mg Tablet, 20mg/ml Concentrate) Desvenlafaxine ER (100mg Tablet 3 Extended-Release 24 Hour, 50mg Antidepressants : Tricyclics Tablet Extended-Release 24 Hour) Amitriptyline HCl (100mg Tablet, 1 Duloxetine HCl (20mg Capsule 1 10mg Tablet, 150mg Tablet, 25mg Delayed-Release, 30mg Capsule Tablet, 50mg Tablet, 75mg Tablet) Delayed-Release, 60mg Capsule Amoxapine (Tablet) 1 Delayed-Release) Anafranil (Capsule) 3 Duloxetine HCl (40mg Capsule 3 Chlordiazepoxide/Amitriptyline 1 Delayed-Release) (Tablet) Effexor XR (Capsule Extended- 3 Clomipramine HCl (Capsule) 1 Release 24 Hour) Desipramine HCl (100mg Tablet, 1 Escitalopram Oxalate (10mg Tablet, 1 10mg Tablet, 150mg Tablet, 25mg 20mg Tablet, 5mg Tablet, 5mg/5ml Tablet, 50mg Tablet, 75mg Tablet) Oral Solution) Doxepin HCl (100mg Capsule, 1 Fetzima (Capsule Extended- 3 10mg Capsule, 150mg Capsule, Release 24 Hour) 25mg Capsule, 50mg Capsule, 75mg Fetzima Titration Pack (Capsule 3 Capsule, 10mg/ml Concentrate) Extended-Release 24 Hour Elavil (Tablet) 3 Therapy Pack) Imipramine HCl (10mg Tablet, 1 Fluoxetine (Capsule) 1 25mg Tablet, 50mg Tablet) Fluoxetine DR (Capsule Delayed- 1 Imipramine Pamoate (Capsule) 1 Release) Norpramin (Tablet) 3 Fluoxetine HCl (10mg Tablet, 20mg 1 Nortriptyline HCl (10mg Capsule, 1 Tablet, 60mg Tablet, 20mg/5ml Oral 25mg Capsule, 50mg Capsule, 75mg Solution, 40mg Capsule) Capsule, 10mg/5ml Oral Solution) Fluvoxamine Maleate (Tablet) 1 Pamelor (Capsule) 3 Fluvoxamine Maleate ER (Capsule 1 Perphenazine/Amitriptyline (10mg- 1 Extended-Release 24 Hour) 2mg Tablet, 25mg-2mg Tablet, Khedezla (Tablet Extended- 3 25mg-4mg Tablet) Release 24 Hour) Perphenazine/Amitriptyline 2 Lexapro (10mg Tablet, 20mg 3 (10mg-4mg Tablet, 50mg-4mg Tablet, 5mg Tablet, 5mg/5ml Oral Tablet) Solution) Protriptyline HCl (Tablet) 1 Paroxetine HCl (Tablet) 1 Surmontil (Capsule) 3 Paroxetine HCl ER (Tablet 1 Tofranil (Tablet) 3 Extended-Release 24 Hour) Trimipramine Maleate (100mg 1 Paxil (10mg Tablet, 20mg Tablet, 3 Capsule, 25mg Capsule, 50mg 30mg Tablet, 40mg Tablet) Capsule) Paxil (10mg/5ml Suspension) 2 Antiemetics : Antiemetics, Other Paxil CR (Tablet Extended- 3 Akynzeo (Capsule) 3 Release 24 Hour) Chlorpromazine HCl (100mg 1 Pexeva (Tablet) 3 Tablet, 10mg Tablet, 200mg Tablet, Pristiq (Tablet Extended-Release 3 25mg Tablet, 50mg Tablet) 24 Hour)

Bold type = Brand-name drug 21 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Diclegis (Tablet Delayed-Release) 3 Dispersible) Dimenhydrinate (50mg/ml 3 Sancuso (Patch) 3 Injection) Tigan (100mg/ml Injection, 300mg 3 Diphenhydramine HCl (12.5mg/5ml 1 Capsule) Elixir, 50mg/ml Injection) Trimethobenzamide HCl (Capsule) 1 Droperidol (2.5mg/ml Injection) 1 Varubi (Tablet) 3 Hydroxyzine HCl (10mg Tablet, 1 Zofran (4mg Tablet, 8mg Tablet, 3 25mg Tablet, 50mg Tablet, 4mg/5ml Oral Solution) 10mg/5ml Syrup, 50mg/ml Zofran ODT (Tablet Dispersible) 3 Injection) Hydroxyzine Pamoate (100mg 1 Antifungals Capsule, 25mg Capsule, 50mg Abelcet (Injection) 3 Capsule) Ala-Quin (Cream) 2 Metoclopramide HCl (10mg Tablet, 1 AmBisome (Injection) 3 5mg Tablet, 5mg/5ml Oral Solution) Amphotericin B (50mg Injection) 3 Metoclopramide ODT (10mg 3 Ancobon (Capsule) 3 Tablet Dispersible) Cancidas (Injection) 3 Metoclopramide ODT (5mg Tablet 1 Ciclodan Cream Kit (Kit) 3 Dispersible) Ciclodan Solution Kit (Kit) 3 Perphenazine (Tablet) 1 Ciclopirox (0.77% Gel, 0.77% 1 Phenergan (50mg/ml Injection) 3 Suspension, 1% Shampoo) Prochlorperazine (Suppository) 1 Ciclopirox Nail Lacquer (External 1 Prochlorperazine Edisylate 1 Solution) (Injection) Ciclopirox Olamine (0.77% Cream) 1 Prochlorperazine Maleate (10mg 1 Clotrimazole (1% Cream, 1% 1 Tablet, 5mg Tablet) External Solution, 10mg Lozenge, Promethazine HCl (12.5mg 1 10mg Troche) Suppository, 25mg Suppository, Clotrimazole/Betamethasone 1 50mg Suppository, 12.5mg Tablet, Dipropionate (0.05%-1% Cream, 25mg Tablet, 50mg Tablet, 50mg/ml 1%-0.05% Lotion) Injection, 6.25mg/5ml Oral Cresemba (186mg Capsule, 372mg 3 Solution) Injection) Promethazine HCl Plain (Syrup) 1 Diflucan (100mg Tablet, 150mg 3 Reglan (Tablet) 3 Tablet, 200mg Tablet, 50mg Transderm-Scop (Patch 72 Hour) 3 Tablet, 10mg/ml Suspension, Vistaril (Capsule) 3 40mg/ml Suspension) Antiemetics : Emetogenic Therapy Adjuncts Econazole Nitrate (1% Cream) 1 3 Aloxi (Injection) 2 Ecoza (Foam) 3 Anzemet (Tablet) 3 Eraxis (Injection) Aprepitant (Capsule) 1 Ertaczo (Cream) 3 3 Cesamet (Capsule) 3 Exelderm (1% Cream, 1% External Solution) Dronabinol (Capsule) 1 Exoderm (Lotion) 2 Emend (Capsule, 40mg Capsule, 3 3 125mg Capsule, 80mg Capsule, Extina (Foam) 125mg Suspension, 150mg First-Metronidazole 100 3 Injection) (Suspension) Granisetron HCl (0.1mg/ml 1 First-Metronidazole 50 3 Injection, 1mg/ml Injection, (Suspension) 4mg/4ml Injection, 1mg Tablet) Fluconazole (100mg Tablet, 150mg 1 Marinol (Capsule) 3 Tablet, 200mg Tablet, 50mg Tablet, Meclizine HCl (12.5mg Tablet, 1 10mg/ml Suspension, 40mg/ml 25mg Tablet) Suspension) Ondansetron HCl (24mg Tablet, 1 Fluconazole in Dextrose (Injection) 1 4mg Tablet, 8mg Tablet, 40mg/20ml Fluconazole in NaCl 3 Injection, 4mg/2ml Injection, (100mg/50ml-0.9% Injection) 4mg/5ml Oral Solution) Fluconazole in NaCl 1 Ondansetron HCl/Sodium Chloride 1 (200mg/100ml-0.9% Injection, (Injection) 400mg/200ml-0.9% Injection) Ondansetron ODT (Tablet 1 Flucytosine (Capsule) 1

Bold type = Brand-name drug 22 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits GRIS-PEG (Tablet) 3 Xolegel (Gel) 3 Griseofulvin Microsize (125mg/5ml 1 Xolegel Corepak (Kit) 3 Suspension, 500mg Tablet) Xolegel Duo/Head & Shoulders 3 Griseofulvin Ultramicrosize (Tablet) 1 (Kit) Gynazole-1 (Cream) 3 Xolegel Duo/Xolex (Kit) 3 Halotin (Cream) 3 Antigout Agents Itraconazole (Capsule) 1 Allopurinol (Tablet) 1 Jublia (External Solution) 3 Allopurinol Sodium (Injection) 1 Kerr Triple Dye (Swab) 3 Aloprim (Injection) 3 Kerydin (External Solution) 3 Colchicine (0.6mg Capsule) 3 Ketoconazole (2% Cream, 2% 1 Colchicine (0.6mg Tablet) 2 Foam, 2% Shampoo, 200mg Tablet) Colcrys (Tablet) 2 Ketodan Kit (Kit) 3 Krystexxa (Injection) 3 Lamisil (Tablet) 3 Mitigare (Capsule) 3 Loprox (0.77% Cream, 0.77% 3 Probenecid (Tablet) 1 Suspension, 0.77%-0-Kit) Probenecid/Colchicine (Tablet) 1 Loprox Shampoo 3 Uloric (Tablet) 2 Lotrisone (Cream) 3 Zyloprim (Tablet) 3 Luzu (Cream) 3 Mentax (Cream) 3 Antihistamine Drugs : First Generation Mycamine (Injection) 3 Antihistamines Naftifine HCl (Cream) 1 Dologesic (Tablet) 2 Naftifine HCl (Cream) 1 Antimigraine Agents : Naftin (1% Gel, 2% Gel, 2% 3 Treximet (60mg-10mg Tablet) 3 Cream) Antimigraine Agents : Ergot Alkaloids Natacyn (Suspension) 2 Cafergot (Tablet) 3 Nizoral (Shampoo) 3 D.h.e. 45 (Injection) 3 Noxafil (100mg Tablet Delayed- 3 Dihydroergotamine Mesylate 1 Release, 300mg/16.7ml Injection, (1mg/ml Injection, 4mg/ml Nasal 40mg/ml Suspension) Solution) Nystatin (100000unit/gm Cream, 1 Ergomar (Tablet Sublingual) 3 100000unit/gm Ointment, Ergotamine Tartrate/Caffeine 1 100000unit/gm Powder, (Tablet) 100000unit/ml Suspension, Migergot (Suppository) 3 500000unit Tablet) Migranal (Nasal Solution) 3 Nystatin/Triamcinolone 1 (100000unit/gm-0.1% Ointment, Antimigraine Agents : Serotonin (5-HT) 1b/1d 100000unit/gm-1mg/gm Cream) Receptor Agonists ONMEL (Tablet) 3 Almotriptan Malate (Tablet) 1 Oxiconazole Nitrate (Cream) 1 Amerge (Tablet) 3 Oxistat (1% Cream, 1% Lotion) 3 Axert (Tablet) 3 Penlac Nail Lacquer (External 3 Frova (Tablet) 3 Solution) Frovatriptan Succinate (Tablet) 1 Sporanox (100mg Capsule, 3 Imitrex (100mg Tablet, 25mg 3 10mg/ml Oral Solution) Tablet, 50mg Tablet, 20mg/act Sporanox Pulsepak (Capsule) 3 Nasal Solution, 5mg/act Nasal Terazol 7 (Cream) 3 Solution, 6mg/0.5ml Injection) Terbinafine HCl (Tablet) 1 Imitrex Statdose System 3 Terconazole (0.4% Cream, 0.8% 1 (Injection) Cream, 80mg Suppository) Maxalt (Tablet) 3 Triple Dye (Liquid) 3 Maxalt-MLT (Tablet Dispersible) 3 Vfend (200mg Tablet, 50mg 3 Naratriptan HCl (Tablet) 1 Tablet, 40mg/ml Suspension) Onzetra Xsail (Exhaler Powder) 3 Vfend IV (Injection) 3 Relpax (Tablet) 3 Voriconazole (200mg Injection, 1 Rizatriptan Benzoate (Tablet) 1 200mg Tablet, 50mg Tablet, Rizatriptan Benzoate ODT (Tablet 1 40mg/ml Suspension) Dispersible) Vusion (Ointment) 3

Bold type = Brand-name drug 23 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Sumatriptan (Nasal Solution) 1 Trecator (Tablet) 3 Sumatriptan Succinate (100mg 1 Antineoplastic Agents Tablet, 25mg Tablet, 50mg Tablet, Campath (Injection) 2 4mg/0.5ml Injection, 6mg/0.5ml Imlygic (Suspension) 3 Injection) Lartruvo (190mg/19ml Solution, 3 Sumavel DosePro (Injection) 3 500mg/50ml Injection) Treximet (500mg-85mg Tablet) 3 Rubraca (Tablet) 3 Zembrace Symtouch (Injection) 3 Zolmitriptan (Tablet) 1 Antineoplastics : 3 Zolmitriptan ODT (Tablet 1 Kisqali (Tablet) Dispersible) Antineoplastics : Alkylating Agents Zomig (2.5mg Nasal Solution, 5mg 3 Alkeran (2mg Tablet) 2 Nasal Solution, 2.5mg Tablet, 5mg Alkeran (50mg Injection) 3 Tablet) Bendeka (Injection) 3 Zomig ZMT (Tablet Dispersible) 3 BiCNU (Injection) 2 Antimyasthenic Agents Busulfex (Injection) 2 Enlon (Injection) 3 Carboplatin (Injection) 1 Antimyasthenic Agents : Parasympathomimetics Cisplatin (100mg/100ml Injection, 1 Bloxiverz (Injection) 3 50mg/50ml Injection) Guanidine HCl (Tablet) 1 Cisplatin (200mg/200ml Injection) 3 Mestinon (60mg Tablet) 3 Cyclophosphamide (1gm Injection, 1 2gm Injection, 500mg Injection) Mestinon (60mg/5ml Syrup) 2 Cyclophosphamide (25mg 3 Mestinon Timespan (Tablet 3 Capsule, 50mg Capsule) Extended-Release) Dacarbazine (100mg Injection) 3 Neostigmine Methylsulfate 1 (10mg/10ml Injection, 5mg/10ml Dacarbazine (200mg Injection) 1 Injection) Doxorubicin HCl (Injection) 1 Neostigmine Methylsulfate 3 Evomela (Injection) 3 (10mg/10ml Injection, 5mg/10ml Gleostine (Capsule) 3 Injection, 5mg/5ml Injection) Gliadel Wafer (Wafer) 3 Pyridostigmine Bromide (Tablet) 1 Hexalen (Capsule) 2 Pyridostigmine Bromide ER (Tablet 1 Ifex (Injection) 3 Extended-Release) Ifosfamide (1gm Injection, 1 Regonol (Injection) 3 1gm/20ml Injection, 3gm/60ml Antimycobacterials : Antimycobacterials, Other Injection) Dapsone (Tablet) 1 Ifosfamide (3gm Injection) 3 Mycobutin (Capsule) 3 Leukeran (Tablet) 2 Rifabutin (Capsule) 1 Matulane (Capsule) 2 Antimycobacterials : Antituberculars Melphalan HCl (Injection) 1 Mitoxantrone HCl (Injection) 1 Capastat Sulfate (Injection) 3 Mustargen (Injection) 2 Cycloserine (Capsule) 3 Myleran (Tablet) 2 Ethambutol HCl (100mg Tablet, 1 400mg Tablet) Temodar (100mg Capsule, 140mg 3 Capsule, 180mg Capsule, 20mg Isoniazid (100mg Tablet, 300mg 1 Capsule, 250mg Capsule, 5mg Tablet, 50mg/5ml Syrup) Capsule) Isoniazid (100mg/ml Injection) 3 Temodar (100mg Injection) 2 Myambutol (Tablet) 3 Temozolomide (Capsule) 1 Paser (Packet) 3 Thiotepa (Injection) 1 Priftin (Tablet) 3 Treanda (Injection) 2 Pyrazinamide (Tablet) 1 Yondelis (Injection) 3 Rifadin (150mg Capsule, 300mg 3 Zanosar (Injection) 2 Capsule, 600mg Injection) Rifamate (Capsule) 3 Antineoplastics : Antiandrogens Rifampin (150mg Capsule, 300mg 1 Bicalutamide (Tablet) 1 Capsule, 600mg Injection) Casodex (Tablet) 3 Rifater (Tablet) 3 Flutamide (Capsule) 1 Sirturo (Tablet) 3 Nilandron (Tablet) 3

Bold type = Brand-name drug 24 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Nilutamide (Tablet) 1 Ibrance (Capsule) 3 Xtandi (Capsule) 3 Intron A (Injection) 3 Antineoplastics : Antiangiogenic Agents Jakafi (Tablet) 2 Caprelsa (Tablet) 2 Leucovorin Calcium (10mg Tablet, 1 Pomalyst (Capsule) 3 15mg Tablet, 25mg Tablet, 5mg Tablet) Revlimid (Capsule) 3 Levoleucovorin (175mg/17.5ml 1 Thalomid (Capsule) 2 Injection, 250mg/25ml Injection) Antineoplastics : Antiestrogens/Modifiers Lynparza (Capsule) 3 Emcyt (Capsule) 2 Marqibo (Injection) 3 Fareston (Tablet) 2 Mesna (Injection) 1 Faslodex (Injection) 2 Mesnex (100mg/ml Injection) 3 Soltamox (Oral Solution) 3 Navelbine (Injection) 3 Tamoxifen Citrate (Tablet) 1 Ninlaro (Capsule) 3 Antineoplastics : Antimetabolites Odomzo (Capsule) 3 Arranon (Injection) 2 Paclitaxel (100mg/16.7ml Injection, 1 Capecitabine (Tablet) 1 300mg/50ml Injection, 30mg/5ml Cladribine (Injection) 1 Injection) Clolar (Injection) 2 Paclitaxel (150mg/25ml Injection) 3 Cytarabine Aqueous (Injection) 1 Portrazza (Injection) 3 Droxia (Capsule) 3 Sylatron (Injection) 3 Elitek (Injection) 3 Taxotere (Injection) 3 Floxuridine (Injection) 1 Teniposide (Injection) 3 Fluorouracil (1gm/20ml Injection, 1 Venclexta (Tablet) 3 2.5gm/50ml Injection, 500mg/10ml Venclexta Starting Pack (Tablet 3 Injection, 5gm/100ml Injection, 5% Therapy Pack) Cream) Vinblastine Sulfate (Injection) 3 Folotyn (Injection) 2 Vinorelbine Tartrate (Injection) 1 Gemcitabine (Injection) 1 Zolinza (Capsule) 2 Gemzar (Injection) 3 Zytiga (Tablet) 3 Hydrea (Capsule) 3 Antineoplastics : Aromatase Inhibitors, 3rd Hydroxyurea (Capsule) 1 Generation Lonsurf (Tablet) 3 Anastrozole (Tablet) 1 Mercaptopurine (Tablet) 1 Arimidex (Tablet) 3 Nipent (Injection) 3 Aromasin (Tablet) 3 3 Purixan (Suspension) Exemestane (Tablet) 1 Tabloid (Tablet) 2 Femara (Tablet) 3 Xeloda (Tablet) 3 Letrozole (Tablet) 1 Antineoplastics Antineoplastics : Enzyme Inhibitors Xofigo (Injection) 2 Etopophos (Injection) 3 Antineoplastics : Antineoplastics, Other Etoposide (100mg/5ml Injection, 1 Alferon N (Injection) 2 1gm/50ml Injection, 500mg/25ml Beleodaq (Injection) 3 Injection) Cosmegen (Injection) 3 Etoposide (50mg Capsule) 2 Cotellic (Tablet) 3 Hycamtin (0.25mg Capsule, 1mg 3 Dacogen (Injection) 3 Capsule, 4mg Solution) Decitabine (Injection) 1 Kyprolis (30mg Injection) 2 Docetaxel (160mg/16ml Injection, 3 Topotecan HCl (Injection) 1 160mg/8ml Injection, 20mg/2ml Zydelig (Tablet) 3 Injection, 20mg/ml Injection, Antineoplastics : Molecular Target Inhibitors 80mg/4ml Injection, 80mg/8ml Afinitor (Tablet) 2 Injection) Afinitor Disperz (Tablet Soluble) 3 Docetaxel (20mg/ml Injection, 1 80mg/4ml Injection) Alecensa (Capsule) 3 Docetaxel (Non-Alcohol Formula) 3 Bosulif (Tablet) 3 (Injection) Cabometyx (Tablet) 3 Farydak (Capsule) 3 Cometriq (Kit) 3

Bold type = Brand-name drug 25 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Erivedge (Capsule) 2 Stromectol (Tablet) 3 Gilotrif (Tablet) 3 Antiparasitics : Antiprotozoals Gleevec (Tablet) 3 Alinia (100mg/5ml Suspension, 2 Iclusig (Tablet) 3 500mg Tablet) Imatinib Mesylate (Tablet) 1 Atovaquone (Suspension) 1 Imbruvica (Capsule) 3 Atovaquone/Proguanil HCl (Tablet) 1 Inlyta (Tablet) 3 Chloroquine Phosphate (250mg 1 Iressa (Tablet) 3 Tablet, 500mg Tablet) Lenvima (Capsule Therapy Pack) 3 Coartem (Tablet) 3 Mekinist (Tablet) 2 DARAPRIM (Tablet) 2 Nexavar (Tablet) 2 Hydroxychloroquine Sulfate 1 Sprycel (Tablet) 2 (Tablet) Stivarga (Tablet) 3 Malarone (Tablet) 3 Sutent (Capsule) 3 Mefloquine HCl (Tablet) 1 Tafinlar (Capsule) 2 Mepron (Suspension) 3 Tarceva (Tablet) 3 Nebupent (Inhalation Solution) 2 Tasigna (Capsule) 3 Neutrexin (Injection) 3 Tykerb (Tablet) 2 Pentam 300 (Injection) 3 Votrient (Tablet) 3 Plaquenil (Tablet) 3 Xalkori (Capsule) 2 Primaquine Phosphate (Tablet) 1 Zelboraf (Tablet) 3 Qualaquin (Capsule) 3 Zykadia (Capsule) 3 Quinine Sulfate (324mg Capsule) 1 Antineoplastics : Monoclonal Antibodies Tindamax (Tablet) 3 Tinidazole (Tablet) 1 Adcetris (Injection) 2 Arzerra (Injection) 2 Antiparasitics : Pediculicides/Scabicides Avastin (Injection) 2 Elimite (Cream) 3 Blincyto (Injection) 3 Eurax (10% Cream, 10% Lotion) 2 Cyramza (Injection) 3 Lindane (Shampoo) 1 Darzalex (Injection) 3 Malathion (Lotion) 1 Empliciti (Injection) 3 Natroba (Suspension) 3 Erbitux (Injection) 2 Ovide (Lotion) 3 Gazyva (Injection) 3 Permethrin (Cream) 1 Herceptin (Injection) 2 Sklice (Lotion) 3 Keytruda (Injection) 3 Spinosad (Suspension) 3 Opdivo (Injection) 3 Sulfurated Lime (External 3 Perjeta (Injection) 2 Solution) Rituxan (Injection) 3 Ulesfia (Lotion) 3 Sylvant (Injection) 3 Antiparkinson Agents : Anticholinergics Tagrisso (Tablet) 3 Benztropine Mesylate (0.5mg 1 Tecentriq (Injection) 3 Tablet, 1mg Tablet, 2mg Tablet, 1mg/ml Injection) Unituxin (Injection) 3 Cogentin (Injection) 3 Vectibix (Injection) 3 Trihexyphenidyl HCl (0.4mg/ml 1 Yervoy (Injection) 2 Elixir, 2mg Tablet, 5mg Tablet) Zevalin Y-90 (Injection) 3 Antiparkinson Agents : Antiparkinson Agents, Other Antineoplastics : Retinoids Amantadine HCl (100mg Capsule, 1 Bexarotene (Capsule) 1 100mg Tablet, 50mg/5ml Syrup) Panretin (Gel) 3 Comtan (Tablet) 3 Targretin (1% Gel, 75mg 3 Entacapone (Tablet) 1 Capsule) Tasmar (Tablet) 3 Tretinoin (10mg Capsule) 1 Tolcapone (Tablet) 1 Antiparasitics : Anthelmintics Antiparkinson Agents : Dopamine Agonists Albenza (Tablet) 3 Apokyn (Injection) 2 Biltricide (Tablet) 2 Mirapex (Tablet) 3 Emverm (Tablet Chewable) 3 Mirapex ER (Tablet Extended- 3 Ivermectin (Tablet) 1 Release 24 Hour)

Bold type = Brand-name drug 26 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Neupro (Patch 24 Hour) 3 Loxapine Succinate (Capsule) 1 Pramipexole Dihydrochloride 1 Molindone HCl (Tablet) 1 (Tablet Immediate-Release) Orap (Tablet) 3 Pramipexole Dihydrochloride ER 1 Pimozide (Tablet) 1 (Tablet Extended-Release 24 Hour) Thioridazine HCl (Tablet) 1 Requip (Tablet) 3 Thiothixene (Capsule) 1 Requip XL (Tablet Extended- 3 Trifluoperazine HCl (Tablet) 1 Release 24 Hour) Ropinirole ER (Tablet Extended- 1 Antipsychotics : 2nd Generation/Atypical Release 24 Hour) Aristada (Injection) 3 Ropinirole HCl (Tablet) 1 Fanapt (Tablet) 3 3 Antiparkinson Agents : Dopamine Precursors/L- Fanapt Titration Pack (Tablet) Geodon (20mg Capsule, 40mg 3 Amino Acid Decarboxylase Inhibitors Capsule, 60mg Capsule, 80mg Carbidopa (Tablet) 1 Capsule) Carbidopa/Levodopa (Tablet 1 Invega (Tablet Extended-Release 3 Immediate-Release) 24 Hour) Carbidopa/Levodopa ER (Tablet 1 Invega Sustenna (Injection) 3 Extended-Release) Invega Trinza (Injection) 3 Carbidopa/Levodopa/Entacapone 1 Latuda (Tablet) 3 (Tablet) Nuplazid (Tablet) 3 Duopa (Suspension) 3 Olanzapine (Tablet Immediate- 1 Lodosyn (Tablet) 3 Release) Sinemet (Tablet) 3 Olanzapine ODT (Tablet 1 Sinemet CR (Tablet Extended- 3 Dispersible) Release) Paliperidone ER (Tablet Extended- 1 Stalevo 100 (Tablet) 3 Release 24 Hour) Stalevo 125 (Tablet) 3 Rexulti (Tablet) 3 Stalevo 150 (Tablet) 3 Risperdal (0.25mg Tablet, 0.5mg 3 Stalevo 200 (Tablet) 3 Tablet, 1mg Tablet, 2mg Tablet, Stalevo 50 (Tablet) 3 3mg Tablet, 4mg Tablet, 1mg/ml Stalevo 75 (Tablet) 3 Oral Solution) Antiparkinson Agents : Monoamine Oxidase B Risperdal M-Tab (Tablet 3 Dispersible) (MAO-B) Inhibitors Risperidone (0.25mg Tablet, 0.5mg 1 Azilect (Tablet) 3 Tablet, 1mg Tablet, 2mg Tablet, Eldepryl (Capsule) 3 3mg Tablet, 4mg Tablet, 1mg/ml Rasagiline Mesylate (Tablet) 1 Oral Solution) Selegiline HCl (5mg Capsule, 5mg 1 Risperidone ODT (Tablet 1 Tablet) Dispersible) Antipsychotics : 1st Generation/Typical Saphris (10mg Tablet Sublingual) 2 Adasuve (Aerosol Powder) 3 Ziprasidone HCl (Capsule) 1 Fluphenazine Decanoate (Injection) 1 Zyprexa (10mg Tablet, 15mg 3 Fluphenazine HCl (10mg Tablet, 1 Tablet, 2.5mg Tablet, 20mg 1mg Tablet, 2.5mg Tablet, 5mg Tablet, 5mg Tablet, 7.5mg Tablet) Tablet) Zyprexa Zydis (Tablet 3 Fluphenazine HCl (2.5mg/5ml 2 Dispersible) Elixir, 5mg/ml Concentrate) Antipsychotics : Treatment-Resistant Fluphenazine HCl (2.5mg/ml 3 Clozapine (Tablet Immediate- 1 Injection) Release) Haldol (Injection) 3 Clozapine ODT (Tablet Dispersible) 1 Haldol Decanoate 100 (Injection) 3 Clozaril (Tablet) 3 Haldol Decanoate 50 (Injection) 3 Fazaclo (Tablet Dispersible) 3 Haloperidol (0.5mg Tablet, 10mg 1 Versacloz (Suspension) 3 Tablet, 1mg Tablet, 20mg Tablet, Antispasticity Agents 2mg Tablet, 5mg Tablet, 2mg/ml Baclofen (10mg Tablet, 20mg 1 Concentrate) Tablet) Haloperidol Decanoate (Injection) 1 Cyproheptadine HCl (2mg/5ml 1 Haloperidol Lactate (Injection) 1

Bold type = Brand-name drug 27 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Syrup, 4mg Tablet) Olysio (Capsule) 3 Dantrium (Capsule) 3 Peg intron Redipen (Injection) 3 Dantrolene Sodium (Capsule) 1 PegIntron (Injection) 3 Gabapentin (100mg Capsule, 300mg 1 Rebetol (200mg Capsule, 40mg/ml 3 Capsule, 400mg Capsule, Oral Solution) 250mg/5ml Oral Solution, 600mg Ribasphere Ribapak (Tablet) 3 Tablet, 800mg Tablet) Ribavirin (200mg Capsule, 200mg 1 Gablofen (Injection) 3 Tablet) Lioresal Intrathecal (Injection) 2 Sovaldi (Tablet) 2 Neurontin (100mg Capsule, 3 Technivie (Tablet) 3 300mg Capsule, 400mg Capsule, Viekira Pak (Tablet Therapy 3 250mg/5ml Oral Solution, 600mg Pack) Tablet, 800mg Tablet) Viekira XR (Tablet Extended- 3 Tizanidine Comfort Pac 3 Release 24 Hour) Tizanidine HCl (2mg Capsule, 4mg 1 Zepatier (Tablet) 2 Capsule, 6mg Capsule, 2mg Tablet, 4mg Tablet) Antivirals : Anti-HIV Agents, Integrase Inhibitors Zanaflex (2mg Capsule, 4mg 3 (INSTI) Capsule, 6mg Capsule, 4mg Atripla (Tablet) 2 Tablet) Genvoya (Tablet) 2 Antitoxins, Immune Globulins, Toxoids, and Isentress (100mg Packet, 100mg 2 Vaccines : Antitoxins and Immune Globulins Tablet Chewable, 25mg Tablet Chewable, 400mg Tablet) Cuvitru (8gm/40ml Injection) 3 Tivicay (Tablet) 2 Zinplava (Injection) 3 Antivirals : Anti-HIV Agents, Non-nucleoside Antivirals : Rapivab (Injection) 3 Reverse Transcriptase Inhibitors (NNRTI) Complera (Tablet) 2 Antivirals : Anti-cytomegalovirus (CMV) Agents Edurant (Tablet) 2 Cidofovir (Injection) 1 Intelence (Tablet) 2 Cytovene (Injection) 3 Nevirapine (200mg Tablet, 1 Ganciclovir (Injection) 1 50mg/5ml Suspension) Valcyte (450mg Tablet, 50mg/ml 3 Nevirapine ER (Tablet Extended- 1 Oral Solution) Release 24 Hour) Valganciclovir (Tablet) 1 Odefsey (Tablet) 2 Valganciclovir Hydrochlorde (Oral 1 Rescriptor (Tablet) 2 Solution) Stribild (Tablet) 2 Zirgan (Gel) 3 Sustiva (200mg Capsule, 50mg 2 Antivirals : Anti-hepatitis B (HBV) Agents Capsule, 600mg Tablet) Adefovir Dipivoxil (Tablet) 1 Viramune (200mg Tablet) 3 Baraclude (0.05mg/ml Oral 3 Viramune (50mg/5ml Suspension) 2 Solution, 0.5mg Tablet, 1mg Viramune XR (Tablet Extended- 3 Tablet) Release 24 Hour) Entecavir (Tablet) 1 Antivirals : Anti-HIV Agents, Nucleoside and Epivir HBV (100mg Tablet) 3 Epivir HBV (5mg/ml Oral 2 Nucleotide Reverse Transcriptase Inhibitors (NRTI) Solution) Abacavir (Tablet) 1 Hepsera (Tablet) 3 Abacavir 1 Sulfate/Lamivudine/Zidovudine Lamivudine (100mg Tablet) 1 (Tablet) Antivirals : Anti-hepatitis C (HCV) Agents Abacavir/Lamivudine (Tablet) 1 Copegus (Tablet) 3 Combivir (Tablet) 3 Daklinza (Tablet) 3 Descovy (Tablet) 2 Epclusa (Tablet) 2 Didanosine (Capsule Delayed- 1 Harvoni (Tablet) 2 Release) Moderiba 3 Emtriva (10mg/ml Oral Solution, 2 Moderiba 1200 Dose Pack 3 200mg Capsule) (Tablet) Epivir (10mg/ml Oral Solution, 3 Moderiba 800 Dose Pack (Tablet) 3 150mg Tablet, 300mg Tablet)

Bold type = Brand-name drug 28 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Epzicom (Tablet) 3 Oseltamivir Phosphate (Capsule) 1 Lamivudine (10mg/ml Oral 1 Relenza Diskhaler (Aerosol 3 Solution, 150mg Tablet, 300mg Powder) Tablet) Rimantadine HCl (Tablet) 1 Lamivudine/Zidovudine (Tablet) 1 Tamiflu (30mg Capsule, 45mg 3 Retrovir (100mg Capsule, 3 Capsule, 75mg Capsule, 6mg/ml 50mg/5ml Syrup) Suspension) Retrovir IV Infusion (Solution) 2 Antivirals : Antiherpetic Agents Stavudine (Capsule) 1 Acyclovir (200mg Capsule, 1 Triumeq (Tablet) 2 200mg/5ml Suspension, 400mg Trizivir (Tablet) 3 Tablet, 800mg Tablet, 5% Truvada (Tablet) 2 Ointment) Videx EC (Capsule Delayed- 3 Acyclovir Sodium (Injection) 1 Release) Denavir (Cream) 3 Videx Pediatric (Oral Solution) 2 Famciclovir (Tablet) 1 Viread (150mg Tablet, 200mg 2 Sitavig (Tablet) 3 Tablet, 250mg Tablet, 300mg Trifluridine (Ophthalmic Solution) 1 Tablet, 40mg/gm Powder) Valacyclovir HCl (Tablet) 1 Zerit (15mg Capsule, 20mg 3 Valtrex (Tablet) 3 Capsule, 30mg Capsule, 40mg Viroptic (Ophthalmic Solution) 3 Capsule) Zovirax (200mg Capsule, 3 Zerit (1mg/ml Oral Solution) 2 200mg/5ml Suspension, 400mg Ziagen (20mg/ml Oral Solution) 2 Tablet, 5% Ointment, 800mg Ziagen (300mg Tablet) 3 Tablet) Zidovudine (100mg Capsule, 300mg 1 Zovirax (5% Cream) 2 Tablet, 50mg/5ml Syrup) Anxiolytics : Anxiolytics, Other Antivirals : Anti-HIV Agents, Other Buspirone HCl (Tablet) 1 Fuzeon (Injection) 2 Dexmedetomidine HCl (Injection) 1 Selzentry (150mg Tablet, 300mg 2 Meprobamate (Tablet) 1 Tablet) Precedex (Injection) 3 2 Tybost (Tablet) Anxiolytics : Benzodiazepines Antivirals : Anti-HIV Agents, Protease Inhibitors Alprazolam (Tablet Immediate- 1 Aptivus (100mg/ml Oral Solution, 2 Release) 250mg Capsule) Alprazolam ER (Tablet Extended- 1 Crixivan (Capsule) 2 Release 24 Hour) Evotaz (Tablet) 2 Alprazolam Intensol (1mg/ml 3 Invirase (200mg Capsule, 500mg 2 Concentrate) Tablet) Alprazolam ODT (Tablet 1 Kaletra (100mg-25mg Tablet, 2 Dispersible) 200mg-50mg Tablet) Ativan (2mg/ml Injection, 4mg/ml 3 Kaletra (400mg-100mg/5ml Oral 3 Injection) Solution) Chlordiazepoxide HCl (Capsule) 1 Lexiva (50mg/ml Suspension, 2 Doral (Tablet) 3 700mg Tablet) Estazolam (Tablet) 1 Lopinavir/Ritonavir (Solution) 1 Flurazepam HCl (Capsule) 1 Norvir (100mg Capsule, 100mg 2 Halcion (Tablet) 3 Tablet, 80mg/ml Oral Solution) Lorazepam (20mg/10ml Injection, 1 Prezcobix (Tablet) 2 4mg/ml Injection, 2mg/ml Prezista (100mg/ml Suspension, 2 Concentrate) 150mg Tablet, 600mg Tablet, Lorazepam/Dextrose (5%- 3 75mg Tablet, 800mg Tablet) 100mg/100ml Injection) Reyataz (150mg Capsule, 200mg 2 Oxazepam (Capsule) 1 Capsule, 300mg Capsule, 50mg Quazepam (Tablet) 1 Packet) Restoril (Capsule) 3 Viracept (Tablet) 2 Temazepam (Capsule) 1 Antivirals : Anti-influenza Agents Triazolam (Tablet) 1 Flumadine (Tablet) 3 Xanax (Tablet) 3

Bold type = Brand-name drug 29 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Xanax XR (Tablet Extended- 3 Lithium (Oral Solution) 1 Release 24 Hour) Lithium Carbonate (150mg 3 Autonomic Drugs : Anticholinergic Agents Capsule, 600mg Capsule) Atropine Sulfate (2mg/5ml 3 Lithium Carbonate (300mg Capsule, 1 Solution Prefilled Syringe) 600mg Capsule, 300mg Tablet) Bevespi Aerosphere (Aerosol) 3 Lithium Carbonate ER (Tablet 1 Glycopyrrolate (0.4mg/2ml 3 Extended-Release) Solution Prefilled Syringe) Lithobid (Tablet Extended- 3 Seebri Neohaler (Capsule) 3 Release) Symax Duotab (Tablet Extended- 2 Blood Formation,Coagulation & Thrombosis : Release) Antianemia Drugs Autonomic Drugs : Parasympathomimetic Feriva 21/7 (Tablet) 3 (Cholinergic) Agents Ferro-Plex Hematinic (Tablet) 3 Neostigmine Methylsulfate 3 Ferrotrin (Capsule) 3 (3mg/3ml Solution Prefilled Focalgin DSS (Tablet) 3 Syringe) Folitab 500 (Tablet Extended- 2 Autonomic Drugs : Skeletal Muscle Relaxants Release) Cisatracurium Besylate 3 Folivane-Plus (Capsule) 3 (10mg/5ml Solution Prefilled Fusion Plus (Capsule) 3 Syringe) Hemocyte Plus (Capsule) 3 Mivacron (Injection) 3 Hemocyte-F (Elixir) 3 Autonomic Drugs : Sympathomimetic (Adrenergic) ICAR-C Plus (Tablet) 3 Agents Integra Plus (210mg-300mcg-7mg- 3 10mcg-62.5mg-1000mcg-20mg- Ephedrine Sulfate (50mg/ml 3 62.5mg-25mg-5mg-5mg Capsule) Solution) Is 24/6 3 Norepinephrine 3 Bitartrate/Dextrose (5%- Niferex (Tablet) 3 8mg/250ml Injection) Nufera (Tablet) 3 Norepinephrine 3 Protectiron (Tablet) 3 Bitartrate/Sodium Chloride Renatabs with Iron 3 (16mg/250ml-0.9% Solution, Triferic (272mg Packet) 3 16mg/500ml-0.9% Solution, Blood Formation,Coagulation & Thrombosis : 4mg/250ml-0.9% Injection) Norepinephrine/Dextrose 3 Antithrombotic Agents (Solution) Heparin Sodium/NaCl 0.45% 3 Norepinephrine/Sodium Chloride 3 (100unit/ml-0.45% Injection) (0.8mg/50ml-0.9% Solution Heparin Sodium/Sodium Chloride 1 Prefilled Syringe) (2000unit/500ml-0.9% Solution) Phenylephrine HCl/Dextrose (5%- 3 Yosprala (Tablet Delayed- 3 20mg/250ml Solution) Release) Phenylephrine HCl/Sodium 3 Blood Formation,Coagulation & Thrombosis : Chloride (0.4mg/10ml-0.9% Hematopoietic Agents Injection, 100mcg/10ml-0.9% Mircera (150mcg/0.3ml Injection, 3 Injection, 1mg/10ml-0.9% 30mcg/0.3ml Injection) Injection, 20mg/50ml-0.9% Injection, 25mg/250ml-0.9% Blood Glucose Regulators : Antidiabetic Agents Solution, 40mg/250ml-0.9% Acarbose (Tablet) 1 Solution, 80mg/250ml-0.9% Actoplus Met (Tablet) 3 Solution, 80mg/500ml-0.9% Actos (Tablet) 3 Solution) Alogliptin (Tablet) 3 Phenylephrine HCl/Sodium 1 Alogliptin/Metformin HCl 3 Chloride (50mg/250ml-0.9% (Tablet) Solution) Alogliptin/Pioglitazone (Tablet) 3 Utibron Neohaler (Capsule) 3 Amaryl (Tablet) 3 Bipolar Agents : Bipolar Agents, Other Avandia (Tablet) 3 Olanzapine/Fluoxetine (Capsule) 1 Bydureon Pen (Injection) 2 Symbyax (Capsule) 3 Bydureon Vial (Injection) 2 Bipolar Agents : Mood Stabilizers Byetta (Injection) 2

Bold type = Brand-name drug 30 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Chlorpropamide (Tablet) 1 Prandin (Tablet) 3 Cycloset (Tablet) 3 Precose (Tablet) 3 Duetact (Tablet) 3 Repaglinide (Tablet) 1 Farxiga (Tablet) 3 Repaglinide/Metformin HCl 1 Fortamet (Tablet Extended- 3 (Tablet) Release 24 Hour) Riomet (Oral Solution) 3 Glimepiride (Tablet) 1 Starlix (Tablet) 3 Glipizide (Tablet Immediate- 1 SymlinPen 120 (Injection) 3 Release) SymlinPen 60 (Injection) 3 Glipizide ER (Tablet Extended- 1 Synjardy (Tablet), Synjardy XR 2 Release 24 Hour) (Tablet) Glipizide/Metformin HCl (Tablet) 1 Tanzeum (Injection) 3 Glucophage (Tablet) 3 Tolazamide (Tablet) 1 Glucophage XR (Tablet 3 Tolbutamide (Tablet) 1 Extended-Release 24 Hour) Tradjenta (Tablet) 2 Glucotrol (Tablet) 3 Tranylcypromine Sulfate (Tablet) 1 Glucotrol XL (Tablet Extended- 3 Trulicity (Injection) 2 Release 24 Hour) Victoza (Injection) 2 3 Glucovance (Tablet) Welchol (3.75gm Packet, 625mg 2 Glumetza (Tablet Extended- 3 Tablet) Release 24 Hour) Xigduo XR (Tablet Extended- 3 Glyburide (1.25mg Tablet, 2.5mg 1 Release 24 Hour) Tablet, 5mg Tablet) Glyburide Micronized (Tablet) 1 Blood Glucose Regulators : Glycemic Agents Dextrose 30% (Injection) 3 Glyburide/Metformin HCl (Tablet) 1 Dextrose 70% (70% Injection) 1 Glynase (Tablet) 3 GlucaGen HypoKit (Injection) 2 Glyset (Tablet) 3 Glucagon Emergency Kit 2 Glyxambi (Tablet) 3 (Injection) Invokamet (Tablet) 2 Proglycem (Suspension) 2 Invokamet XR (Tablet Extended- 2 Release 24 Hour) Blood Glucose Regulators : Insulins Invokana (Tablet) 2 Afrezza (Powder) 3 Janumet (Tablet) 2 Apidra (Injection) 3 Janumet XR (Tablet Extended- 2 Apidra SoloStar (Injection) 3 Release 24 Hour) Basaglar KwikPen (Injection) 3 Januvia (Tablet) 2 Humalog (Injection) 2 Jardiance (Tablet) 2 Humalog KwikPen (Injection) 2 Jentadueto (Tablet) 2 Humalog Mix 50/50 (Injection) 2 Kazano (Tablet) 3 Humalog Mix 50/50 KwikPen 2 Kombiglyze XR (Tablet 3 (Injection) Extended-Release 24 Hour) Humalog Mix 75/25 (Injection) 2 Metformin HCl (Tablet Immediate- 1 Humalog Mix 75/25 KwikPen 2 Release) (Injection) Metformin HCl ER (Tablet 1 Humulin 70/30 (Injection) 2 Extended-Release 24 Hour) Humulin 70/30 KwikPen 2 (Generic Fortamet, Generic (Injection) Glucophage XR) Humulin N (Injection) 2 Miglitol (Tablet) 1 Humulin N KwikPen (Injection) 2 Nateglinide (Tablet) 1 Humulin R (Injection) 2 Nesina (Tablet) 3 Humulin R U-500 (Concentrated) 2 Onglyza (Tablet) 3 (Injection) Oseni (Tablet) 3 Lantus (Injection) 2 Pioglitazone HCl (Tablet) 1 Lantus SoloStar (Injection) 2 Pioglitazone HCl/Glimepiride 1 Levemir (Injection) 2 (Tablet) Levemir FlexTouch (Injection) 2 Pioglitazone HCl/Metformin HCl 1 Novolin 70/30 (Injection) 2 (Tablet) Novolin 70/30 Relion (Injection) 2

Bold type = Brand-name drug 31 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Novolin N (Injection) 2 4000unit/L-0.9% Injection, Novolin N Relion (Injection) 2 50unit/50ml-0.45% Injection) Novolin R (Injection) 2 Heparin Sodium/Sodium Chloride 3 Novolin R Relion (Injection) 2 0.9% (Injection) NovoLog (Injection) 2 Heparin Sodium/Sodium Chloride 1 0.9% Premix (Injection) NovoLog FlexPen (Injection) 2 3 NovoLog Mix 70/30 (Injection) 2 Iprivask (Injection) 3 NovoLog Mix 70/30 Prefilled 2 Lovenox (100mg/ml Injection, FlexPen (Injection) 120mg/0.8ml Injection, 150mg/ml Injection, 30mg/0.3ml Injection, 2 NovoLog PenFill (Injection) 40mg/0.4ml Injection, 60mg/0.6ml Toujeo SoloStar (Injection) 2 Injection, 80mg/0.8ml Injection, Tresiba FlexTouch (Injection) 3 300mg/3ml Injection) Blood Products/Modifiers/Volume Expanders : Pradaxa (Capsule) 2 Anticoagulants Savaysa (Tablet) 3 Activase (Injection) 3 Tnkase (Injection) 3 Angiomax (Injection) 3 Warfarin Sodium (Tablet) 1 Argatroban (125mg/125ml-0.9% 3 Xarelto (Tablet) 2 Injection, 250mg/250ml-0.9% Xarelto Starter Pack (Tablet 2 Injection, 50mg/50ml Injection) Therapy Pack) Argatroban (250mg/2.5ml Injection) 1 Blood Products/Modifiers/Volume Expanders : Arixtra (Injection) 3 Blood Formation Modifiers Bivalirudin (Injection) 1 Agrylin (Capsule) 3 Cathflo Activase (Injection) 3 Anagrelide HCl (Capsule) 1 Coumadin (Tablet) 3 Aranesp Albumin Free (Injection) 2 Eliquis (Tablet) 3 Epogen (Injection) 3 Enoxaparin Sodium (100mg/ml 1 Falessa (Tablet) 3 Injection, 120mg/0.8ml Injection, Granix (Injection) 2 150mg/ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, Leukine (Injection) 3 60mg/0.6ml Injection, 80mg/0.8ml Mircera (100mcg/0.3ml Injection, 3 Injection, 300mg/3ml Injection) 200mcg/0.3ml Injection, Fondaparinux Sodium (Injection) 1 50mcg/0.3ml Injection, 75mcg/0.3ml Injection) Fragmin (Injection) 3 Mozobil (Injection) 2 Heparin Lock Flush (Injection) 1 Neulasta (Injection) 3 Heparin Sodium (10000unit/10ml 1 3 Injection, 3000unit/3ml Injection, Neulasta Onpro Kit (Injection) 5000unit/5ml Injection, Neupogen (Injection) 2 10000unit/ml Injection, 1000unit/ml Nplate (Injection) 2 Injection, 20000unit/ml Injection, Procrit (Injection) 2 5000unit/0.5ml Injection, Promacta (Tablet) 3 5000unit/ml Injection) Zarxio (Injection) 2 Heparin Sodium Lock Flush (Kit) 1 Blood Products/Modifiers/Volume Expanders Heparin Sodium/D5W (5%- 3 Hespan (Injection) 3 100unit/ml Injection, 5%- 50unit/ml Injection) Hetastarch 6%/NaCl (Injection) 1 Heparin Sodium/D5W (5%- 1 LMD 10% Dextrose 5% 3 40unit/ml Injection, 5%-50unit/ml (Injection) Injection) LMD 10% Sodium Chloride 0.9% 3 Heparin Sodium/NaCl 0.45% 3 (Injection) (50unit/ml-0.45% Injection) Voluven (Injection) 3 Heparin Sodium/NaCl 0.9% 1 Blood Products/Modifiers/Volume Expanders : (Injection) Coagulants Heparin Sodium/Sodium Ch Loride 1 Advate (Injection) 2 (Injection) Alphanate/Von Willebrand Factor 2 Heparin Sodium/Sodium Chloride 1 Complex/Human (250unit (20unit/20ml-0.9% Injection, Injection) 25000unit/250ml-0.45% Injection, Alphanine SD (Injection) 2 30000unit/L-0.9% Injection, Amicar (0.25gm/ml Oral Solution, 3

Bold type = Brand-name drug 32 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits 1000mg Tablet, 500mg Tablet) Cilostazol (Tablet) 1 Aminocaproic Acid (Injection) 3 Clopidogrel (Tablet) 1 Bebulin (Injection) 2 Dipyridamole (25mg Tablet, 50mg 1 Benefix (Injection) 2 Tablet, 75mg Tablet) Brilinta (90mg Tablet) 2 Effient (Tablet) 2 Corifact (Injection) 2 Eptifibatide (Injection) 1 Cyklokapron (Injection) 3 Integrilin (Injection) 3 Evithrom (External Solution) 3 Plavix (Tablet) 3 Feiba (Injection) 2 Reopro (Injection) 3 Gelfilm Op (Film) 3 Zontivity (Tablet) 3 Helixate FS (Injection) 3 Cardiovascular Agents : Alpha-adrenergic Agonists Hemofil M (1700unit Injection) 2 Catapres (Tablet) 3 Humate-P (Injection) 2 Catapres-TTS-1 (Patch Weekly) 3 Injectafer (Injection) 3 Catapres-TTS-2 (Patch Weekly) 3 Ixinity (Injection) 3 Catapres-TTS-3 (Patch Weekly) 3 Koate (Solution) 2 Clonidine HCl (0.1mg Tablet, 1 Koate-Dvi (Injection) 2 0.2mg Tablet, 0.3mg Tablet, Kogenate FS (Injection) 3 0.1mg/24hr Patch Weekly, Kogenate FS Bio-Set (Injection) 3 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly) Kovaltry (Injection) 3 Clorpres (Tablet) 3 Lysteda (Tablet) 3 Guanfacine HCl (Tablet Immediate- 1 Monoclate-P (Injection) 2 Release) Mononine (Injection) 2 Methyldopa (Tablet) 1 Novoeight (Injection) 3 Methyldopa/Hydrochlorothiazide 1 Novoseven (Solution) 2 (Tablet) Novoseven RT (Injection) 2 Methyldopate HCl (Injection) 3 Nuwiq (Injection) 3 Midodrine HCl (Tablet) 1 Profilnine (Injection) 2 Phenylephrine HCl (10mg/ml 1 Protamine Sulfate (Injection) 3 Injection) Recombinate (Injection) 2 Phenylephrine HCl/Dextrose (5%- 3 Recothrom (Solution) 3 50mg/500ml Injection) Riastap (Injection) 2 Phenylephrine HCl/Sodium 3 Thrombin-JMI Diluent (External 3 Chloride (0.5mg/5ml-0.9% Solution) Injection, 0.8mg/10ml-0.9% Thrombin-JMI Epistaxis (Kit) 3 Injection, 10mg/250ml-0.9% Thrombin-JMI Syringe Spray Kit 3 Injection, 200mcg/5ml-0.9% (Kit) Injection, 5mg/50ml-0.9% Injection) Thrombin-JMI w/Dil Spray Pump 3 Actuator (Kit) Vazculep (Injection) 3 Thrombogen (10000unit Kit, 3 Cardiovascular Agents : Alpha-adrenergic Blocking 10000unit Solution, 1000unit Agents Solution) Cardura (Tablet) 3 Tranexamic Acid (1000mg/10ml 1 Dibenzyline (Capsule) 3 Injection, 650mg Tablet) Doxazosin (Tablet) 1 Xyntha (Injection) 3 Doxazosin Mesylate (Tablet) 1 Xyntha Solofuse (Injection) 3 Minipress (Capsule) 3 Blood Products/Modifiers/Volume Expanders : Phenoxybenzamine HCl (Capsule) 1 Platelet Modifying Agents Phentolamine Mesylate (Injection) 3 Aggrastat (0.9%-12.5mg/250ml 3 Prazosin HCl (1mg Capsule, 2mg 1 Injection, 0.9%-5mg/100ml Capsule, 5mg Capsule) Injection) Terazosin HCl (Capsule) 1 Aggrenox (Capsule Extended- 3 Cardiovascular Agents : Angiotensin II Receptor Release 12 Hour) Aspirin/Dipyridamole (Capsule 1 Antagonists Extended-Release 12 Hour) Amlodipine Besylate/Valsartan 1 (Tablet) Brilinta (60mg Tablet) 2 Amlodipine/Olmesartan Medoxomil 1

Bold type = Brand-name drug 33 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits (Tablet) Benazepril HCl (Tablet) 1 Amlodipine/Valsartan/Hydrochlorot 1 Benazepril 1 hiazide (Tablet) HCl/Hydrochlorothiazide (Tablet) Atacand (Tablet) 3 Captopril (Tablet) 1 Atacand HCT (Tablet) 3 Captopril/Hydrochlorothiazide 1 Avalide (Tablet) 3 (Tablet) Avapro (Tablet) 3 Enalapril Maleate (Tablet) 1 Azor (Tablet) 3 Enalapril 1 Benicar (Tablet) 3 Maleate/Hydrochlorothiazide (Tablet) Benicar HCT (Tablet) 3 Enalaprilat (Injection) 1 Candesartan Cilexetil (Tablet) 1 Candesartan 1 Epaned (Oral Solution) 3 Cilexetil/Hydrochlorothiazide Fosinopril Sodium (Tablet) 1 (Tablet) Fosinopril 1 Cozaar (Tablet) 3 Sodium/Hydrochlorothiazide (Tablet) Diovan (Tablet) 3 Lisinopril (Tablet) 1 Diovan HCT (Tablet) 3 Lisinopril/Hydrochlorothiazide 1 Edarbi (Tablet) 3 (Tablet) Edarbyclor (Tablet) 3 Lotensin (Tablet) 3 Entresto (Tablet) 3 Lotensin HCT (Tablet) 3 Eprosartan Mesylate (Tablet) 1 Lotrel (Capsule) 3 Exforge (Tablet) 3 Mavik (Tablet) 3 Exforge HCT (Tablet) 3 Moexipril HCl (Tablet) 1 Hyzaar (Tablet) 3 Moexipril/Hydrochlorothiazide 1 Irbesartan (Tablet) 1 (Tablet) Irbesartan/Hydrochlorothiazide 1 Perindopril Erbumine (Tablet) 1 (Tablet) Prestalia (Tablet) 3 Losartan Potassium (Tablet) 1 Prinivil (Tablet) 3 Losartan 1 Quinapril HCl (Tablet) 1 Potassium/Hydrochlorothiazide (Tablet) Quinapril/Hydrochlorothiazide 1 (Tablet) Micardis (Tablet) 3 Ramipril (Capsule) 1 Micardis HCT (Tablet) 3 Olmesartan Medoxomil (Tablet) 1 Tarka (Tablet Extended-Release) 3 Olmesartan 1 Trandolapril (Tablet) 1 Medoxomil/Amlodipine/Hydrochlor Trandolapril/Verapamil HCl ER 1 othiazide (Tablet) (Tablet Extended-Release) Olmesartan 1 Vaseretic (Tablet) 3 Medoxomil/Hydrochlorothiazide Vasotec (Tablet) 3 (Tablet) Zestoretic (Tablet) 3 Telmisartan (Tablet) 1 Zestril (Tablet) 3 Telmisartan/Amlodipine (Tablet) 1 Cardiovascular Agents : Antiarrhythmics Telmisartan/Hydrochlorothiazide 1 Adenocard (Injection) 3 (Tablet) Adenosine (12mg/4ml Injection, 1 Tribenzor (Tablet) 3 6mg/2ml Injection) Twynsta (Tablet) 3 Amiodarone HCl (100mg Tablet, 1 Valsartan (Tablet) 1 200mg Tablet, 400mg Tablet, Valsartan/Hydrochlorothiazide 1 50mg/ml Injection) (Tablet) Amiodarone HCl/Dextrose 1 Cardiovascular Agents : Angiotensin-converting (Injection) Enzyme (ACE) Inhibitors Betapace (120mg Tablet, 160mg 3 Tablet, 80mg Tablet) Accupril (Tablet) 3 Betapace AF (120mg Tablet, 3 3 Accuretic (Tablet) 160mg Tablet, 80mg Tablet) Aceon (Tablet) 3 Cardizem (Tablet) 3 3 Altace (Capsule) Corvert (Injection) 3 Amlodipine Besylate/Benazepril 1 Diltiazem HCl (Tablet Immediate- 1 HCl (Capsule)

Bold type = Brand-name drug 34 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Release) DUTOPROL (Tablet Extended- 3 Diltiazem HCl ER (Capsule 1 Release 24 Hour) Extended-Release 24 Hour) Esmolol HCl (Injection) 1 Disopyramide Phosphate (Capsule) 1 Hemangeol (Oral Solution) 3 Dofetilide (Capsule) 1 Inderal LA (Capsule Extended- 3 Flecainide Acetate (Tablet) 1 Release 24 Hour) Ibutilide Fumarate (Injection) 1 Inderal XL (Capsule Extended- 3 Lidocaine HCl (10mg/ml 3 Release 24 Hour) Injection) Innopran XL (Capsule Extended- 3 Lidocaine HCl (20mg/ml Injection) 1 Release 24 Hour) Lidocaine HCl in D5W (Injection) 1 Labetalol HCl (100mg Tablet, 1 200mg Tablet, 300mg Tablet, Mexiletine HCl (Capsule) 1 5mg/ml Solution) Multaq (Tablet) 3 Lopressor (Tablet) 3 Nexterone (Injection) 3 Lopressor HCT (Tablet) 3 Norpace (Capsule) 3 Metoprolol Succinate ER (Tablet 1 Norpace CR (Capsule Extended- 2 Extended-Release 24 Hour) Release 12 Hour) Metoprolol Succinate 3 3 Procainamide HCl (100mg/ml ER/Hydrochlorothiazide (Tablet Injection, 500mg/ml Injection) Extended-Release 24 Hour) Propafenone HCl (Tablet) 1 Metoprolol Tartrate (100mg Tablet, 1 Propafenone HCl ER (Capsule 1 25mg Tablet, 37.5mg Tablet, 50mg Extended-Release 12 Hour) Tablet, 75mg Tablet, 5mg/5ml Quinidine Gluconate (Injection) 3 Injection, 5mg/5ml Solution) Quinidine Gluconate CR (Tablet 1 Metoprolol/Hydrochlorothiazide 1 Extended-Release) (Tablet) Quinidine Gluconate ER (Tablet 1 Nadolol (20mg Tablet, 40mg Tablet, 1 Extended-Release) 80mg Tablet) Quinidine Sulfate (Tablet) 1 Nadolol/Bendroflumethiazide 1 Rythmol SR (Capsule Extended- 3 (Tablet) Release 12 Hour) Pindolol (Tablet) 1 Sotalol HCl (AF) (Tablet) 1 Propranolol HCl (Tablet Immediate- 1 Sotalol HCl (Injection) 3 Release, 1mg/ml Injection, Oral Sotalol HCl (Tablet) 1 Solution) Tiazac (Capsule Extended-Release 3 Propranolol HCl (Tablet) 1 24 Hour) Propranolol HCl ER (Capsule 1 Tikosyn (Capsule) 3 Extended-Release 24 Hour) Cardiovascular Agents : Beta-adrenergic Blocking Propranolol/Hydrochlorothiazide 1 (Tablet) Agents Sotylize (Oral Solution) 3 Acebutolol HCl (200mg Capsule, 1 Tenoretic 100 (Tablet) 3 400mg Capsule) Tenoretic 50 (Tablet) 3 Atenolol (100mg Tablet, 25mg 1 Tablet, 50mg Tablet) Tenormin (Tablet) 3 Atenolol/Chlorthalidone (Tablet) 1 Timolol Maleate (10mg Tablet, 1 20mg Tablet, 5mg Tablet) Betaxolol HCl (10mg Tablet, 20mg 1 Tablet) Toprol XL (Tablet Extended- 3 Release 24 Hour) Bisoprolol Fumarate (Tablet) 1 Zebeta (Tablet) 3 Bisoprolol 1 Fumarate/Hydrochlorothiazide Ziac (Tablet) 3 (Tablet) Cardiovascular Agents : Calcium Channel Blocking Brevibloc (Injection) 3 Agents Bystolic (Tablet) 2 Adalat CC (30mg Tablet 3 Carvedilol (Tablet) 1 Extended-Release 24 Hour, 60mg Coreg (Tablet) 3 Tablet Extended-Release 24 Hour, Coreg CR (Capsule Extended- 3 90mg Tablet Extended-Release 24 Release 24 Hour) Hour) Corgard (Tablet) 3 Amlodipine Besylate (Tablet) 1 Corzide (Tablet) 3 Amlodipine Besylate/Atorvastatin 1

Bold type = Brand-name drug 35 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Calcium (Tablet) 4mg/500ml Injection, 5%- Caduet (Tablet) 3 4mg/250ml Solution) Calan (Tablet) 3 Norepinephrine 3 Calan SR (Tablet Extended- 3 Bitartrate/Sodium Chloride Release) (0.08mg/10ml-0.9% Injection) Cardene IV (20mg/200ml-0.86% 3 Norepinephrine/Sodium Chloride 3 Injection) (0.16mg/10ml-0.9% Injection, Cardizem CD (Capsule Extended- 3 8mg/250ml-0.9% Solution) Release 24 Hour) Cardiovascular Agents : Cardiovascular Agents, Cardizem LA (Tablet Extended- 3 Other Release 24 Hour) Asclera (Injection) 3 Cleviprex (Injection) 3 Corlanor (Tablet) 3 Diltiazem CD (Capsule Extended- 1 Demser (Capsule) 3 Release 24 Hour) Digoxin (0.05mg/ml Oral Solution, 1 Diltiazem HCl CD (Capsule 1 0.25mg/ml Injection, 125mcg Extended-Release 24 Hour) Tablet, 250mcg Tablet) Diltiazem HCl ER (Capsule 1 Dobutamine HCl (Injection) 1 Extended-Release 24 Hour, Tablet Dobutamine HCl/D5W (Injection) 1 Extended-Release 24 Hour) Dopamine HCl (160mg/ml 3 Felodipine ER (Tablet Extended- 1 Injection) Release 24 Hour) Dopamine HCl (40mg/ml Injection, 1 Isradipine (Capsule) 1 80mg/ml Injection) Nicardipine HCl (2.5mg/ml 1 Dopamine/D5W (Injection) 1 Injection, 20mg Capsule, 30mg Ethamolin (Injection) 3 Capsule) Lanoxin (0.25mg/ml Injection, 2 Nifedipine (10mg Capsule, 20mg 1 125mcg Tablet, 187.5mcg Tablet, Capsule) 250mcg Tablet, 62.5mcg Tablet) Nifedipine ER (Tablet Extended- 1 Lanoxin Pediatric (Injection) 3 Release 24 Hour) Mannitol (Injection) 1 Nimodipine (Capsule) 1 Milrinone in Dextrose (5%- 1 Nisoldipine ER (Tablet Extended- 1 20mg/100ml Injection, 5%- Release 24 Hour) 40mg/200ml Solution) Norvasc (Tablet) 3 Milrinone Lactate (Injection) 1 Nymalize (Oral Solution) 3 Natrecor (Injection) 3 Procardia (Capsule) 3 Northera (Capsule) 3 Procardia XL (Tablet Extended- 3 Osmitrol Viaflex (10% Injection, 3 Release 24 Hour) 5% Injection) Sular (Tablet Extended-Release 3 Pentoxifylline ER (Tablet Extended- 1 24 Hour) Release) Verapamil HCl (Tablet Immediate- 1 Praluent (Injection) 2 Release, 2.5mg/ml Injection) Ranexa (Tablet Extended-Release 2 Verapamil HCl Extended-Release 1 12 Hour) 24 Hour (100mg Capsule, 120mg Capsule, 180mg Capsule, 200mg Repatha (Injection) 3 Capsule, 240mg Capsule, 300mg Repatha Pushtronex System 3 Capsule, 120mg Tablet, 180mg (Injection) Tablet, 240mg Tablet) Repatha SureClick (Injection) 3 Verapamil HCl SR (Capsule 1 Sotradecol (Injection) 3 Extended-Release 24 Hour) Tekturna (Tablet) 2 Verelan (Capsule Extended- 3 Varithena (Injection) 3 Release 24 Hour) Vecamyl (Tablet) 3 Verelan PM (Capsule Extended- 3 Cardiovascular Agents : Diuretics, Carbonic Release 24 Hour) Anhydrase Inhibitors Cardiovascular Agents Acetazolamide (Tablet Immediate- 1 Levophed (Injection) 3 Release) Norepinephrine Bitartrate (Injection) 1 Dorzolamide HCl (Ophthalmic 1 Norepinephrine 3 Solution) Bitartrate/Dextrose (5%- Methazolamide (Tablet) 1 4mg/250ml Injection, 5%-

Bold type = Brand-name drug 36 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Neptazane (Tablet) 3 Fenofibrate (120mg Tablet, 145mg 1 Trusopt (Ophthalmic Solution) 3 Tablet, 160mg Tablet, 40mg Tablet, 48mg Tablet, 54mg Tablet, 130mg Cardiovascular Agents : Diuretics, Loop Capsule, 150mg Capsule, 43mg Bumetanide (0.25mg/ml Injection, 1 Capsule, 50mg Capsule) 0.5mg Tablet, 1mg Tablet, 2mg Fenofibrate Micronized (Capsule) 1 Tablet) Fenofibric Acid (Tablet) 1 Bumex (Tablet) 3 Fenofibric Acid DR (Capsule 1 Demadex (Tablet) 3 Delayed-Release) Edecrin (Tablet) 3 Fenoglide (Tablet) 3 Ethacrynate Sodium (Injection) 1 Fibricor (Tablet) 2 Ethacrynic Acid (Tablet) 1 Gemfibrozil (600mg Tablet) 1 Furosemide (10mg/ml Injection, 1 Lipofen (Capsule) 2 10mg/ml Oral Solution, 8mg/ml Oral Solution, 20mg Tablet, 40mg Lofibra (134mg Capsule, 200mg 3 Tablet, 80mg Tablet) Capsule, 67mg Capsule, 160mg Tablet, 54mg Tablet) Lasix (Tablet) 3 Lopid (Tablet) 3 Sodium Edecrin (Injection) 3 Tricor (Tablet) 3 Torsemide (Tablet) 1 Triglide (Tablet) 3 Cardiovascular Agents : Diuretics, Potassium-sparing Trilipix (Capsule Delayed- 3 Aldactazide (Tablet) 3 Release) Aldactone (Tablet) 3 Cardiovascular Agents : Dyslipidemics, HMG CoA Amiloride HCl (5mg Tablet) 1 Amiloride/Hydrochlorothiazide 1 Reductase Inhibitors (Tablet) Altoprev (Tablet Extended- 3 Release 24 Hour) Dyazide (Capsule) 3 Atorvastatin Calcium (Tablet) 1 Dyrenium (Capsule) 3 Crestor (Tablet) 3 Eplerenone (Tablet) 1 Fluvastatin (Capsule) 1 Inspra (Tablet) 3 Fluvastatin Sodium ER (Tablet 1 Maxzide (Tablet) 3 Extended-Release 24 Hour) Spironolactone (100mg Tablet, 1 Lescol XL (Tablet Extended- 3 25mg Tablet, 50mg Tablet) Release 24 Hour) Spironolactone/Hydrochlorothiazide 1 Lipitor (Tablet) 3 (Tablet) Livalo (Tablet) 3 Triamterene/Hydrochlorothiazide 1 (25mg-37.5mg Tablet, 50mg-75mg Lovastatin (Tablet) 1 Tablet, 37.5mg-25mg Capsule, Mevacor (Tablet) 3 50mg-25mg Capsule) Pravachol (Tablet) 3 Cardiovascular Agents : Diuretics, Thiazide Pravastatin Sodium (Tablet) 1 Chlorothiazide (Tablet) 1 Rosuvastatin Calcium (Tablet) 1 Chlorothiazide Sodium (Injection) 1 Simvastatin (Tablet) 1 Chlorthalidone (100mg Tablet) 2 Zocor (Tablet) 3 Chlorthalidone (25mg Tablet, 50mg 1 Cardiovascular Agents : Dyslipidemics, Other Tablet) Cholestyramine (Powder) 1 Diuril (Suspension) 3 Cholestyramine Light (Powder) 1 Hydrochlorothiazide (12.5mg 1 Colestid (1gm Tablet, 5gm 3 Capsule, 12.5mg Tablet, 25mg Granules, 5gm Packet) Tablet, 50mg Tablet) Colestid Flavored (5gm Granules, 3 Indapamide (Tablet) 1 5gm/7.5gm Packet) Methyclothiazide (5mg Tablet) 1 Colestipol HCl (1gm Tablet, 5gm 1 Metolazone (Tablet) 1 Packet) Microzide (Capsule) 3 Ezetimibe (Tablet) 1 Sodium Diuril (Injection) 3 Juxtapid (Capsule) 3 Tekturna HCT (Tablet) 2 Kynamro (Solution Prefilled 3 Cardiovascular Agents : Dyslipidemics, Fibric Acid Syringe) 3 Derivatives Lovaza (Capsule) Niacin ER (Tablet Extended- 1 3 Antara (Capsule) Release)

Bold type = Brand-name drug 37 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Niacor (Tablet) 2 Nitropress (Injection) 3 Niaspan (Tablet Extended- 3 Nitrostat (Tablet Sublingual) 3 Release) Rectiv (Ointment) 3 Omega-3-Acid Ethyl Esters 1 Sodium Nitroprusside (Injection) 1 (Capsule) Cardiovascular Drugs : beta-Adrenergic Blocking Questran (Packet) 3 Questran Light (Powder) 3 Agents Byvalson (Tablet) 3 Vascepa (Capsule) 2 Metoprolol Tartrate (5mg/5ml 3 Vytorin (Tablet) 2 Solution Prefilled Syringe) Zetia (Tablet) 3 Cardiovascular Drugs : Calcium-Channel Blocking Cardiovascular Agents : Vasodilators, Direct-acting Agents Arterial Cardene IV (40mg/200ml-0.83% 3 Corlopam (Injection) 3 Injection) Hydralazine HCl (100mg Tablet, 1 Diltiazem HCl/Dextrose (5%- 3 10mg Tablet, 25mg Tablet, 50mg 100mg/100ml Solution, 5%- Tablet, 20mg/ml Injection) 250mg/250ml Solution) Minoxidil (Tablet) 1 Diltiazem HCl/Sodium Chloride 3 Cardiovascular Agents : Vasodilators, Direct-acting (125mg/125ml-0.9% Solution) Arterial/Venous Nicardipine HCl/Sodium Chloride 3 BiDil (Tablet) 3 (Solution) Dilatrate SR (Capsule Extended- 3 Cardiovascular Drugs : Cardiac Drugs Release) Adenosine (60mg/20ml Injection, 3 Isordil Titradose (Tablet) 3 90mg/30ml Solution Prefilled Isosorbide Dinitrate (Tablet 1 Syringe) Immediate-Release) Cardiovascular Drugs : Vasodilating Agents Isosorbide Dinitrate ER (Tablet 1 Gonitro (Packet) 3 Extended-Release) Central Nervous System Agents : Analgesics and Isosorbide Mononitrate (Tablet 1 Immediate-Release) Antipyretics Isosorbide Mononitrate ER (Tablet 1 Arymo ER (Tablet Extended- 3 Extended-Release 24 Hour) Release Abuse-Deterrent) Nitro-Bid (Ointment) 3 Fentanyl Citrate/Sodium Chloride 3 (1.25mg/250ml-0.9% Injection, Nitro-Dur (Patch 24 Hour) 3 2.5mg/250ml-0.9% Injection) Nitroglycerin (0.3mg Tablet 1 Hydromorphone HCl/Sodium 1 Sublingual, 0.4mg Tablet Chloride (10mg/25ml-0.9% Solution Sublingual, 0.6mg Tablet Prefilled Syringe, 1mg/5ml-0.9% Sublingual) Solution Prefilled Syringe, Nitroglycerin (5mg/ml Injection) 3 3mg/30ml-0.9% Solution Prefilled Nitroglycerin ER (2.5mg Capsule 1 Syringe, 15mg/50ml-0.9% Injection) Extended-Release, 6.5mg Capsule Hydromorphone HCl/Sodium 3 Extended-Release, 9mg Capsule Chloride (Prefilled Syringe, Extended-Release) Injection Solution) Nitroglycerin in 5% Dextrose 1 Hydromorphone HCl/Sodium 3 (Injection) Chloride (Solution Prefilled Nitroglycerin in Dextrose 5% (5%- 1 Syringe) 100mcg/ml Injection) Ilaris (150mg/ml Solution) 3 Nitroglycerin in Dextrose 5% 3 Meperidine HCl/Sodium Chloride 3 (5%-100mcg/ml Injection, 5%- (300mg/30ml-0.9% Solution) 200mcg/ml Injection, 5%- Morphine Sulfate/Dextrose 3 400mcg/ml Injection) (Solution) Nitroglycerin Lingual 1 Morphine Sulfate/Sodium 3 (0.4mg/sprayTranslingual Solution, Chloride (150mg/150ml-0.9% 400mcg/spray Aerosol Solution) Solution, 250mg/50ml-0.9% Nitroglycerin Transdermal (Patch 24 1 Solution, 500mg/100ml-0.9% Hour) Solution, 500mg/250ml-0.9% Nitrolingual Pumpspray 3 Solution, 275mg/55ml-0.9% (Translingual Solution) Solution Prefilled Syringe) NitroMist (Aerosol Solution) 3 Tivorbex (Capsule) 3

Bold type = Brand-name drug 38 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Vivlodex (Capsule) 3 Extended-Release 12 Hour) Zubsolv (0.7mg-0.18mg Tablet 2 Concerta (Tablet Extended- 3 Sublingual) Release) Central Nervous System Agents : Anorexigenic Daytrana (Patch) 3 Agents and Respiratory and CNS Stimulants Dexmethylphenidate HCl (Tablet 1 Immediate-Release) Vyvanse (10mg Tablet Chewable, 2 20mg Tablet Chewable, 30mg Dexmethylphenidate HCl Capsule 1 Tablet Chewable, 40mg Tablet Extended-Release 24 Hour (10mg, Chewable, 50mg Tablet 15mg, 20mg, 30mg, 40mg, 5mg, Chewable, 60mg Tablet 25mg, 35mg) Chewable) Focalin (Tablet) 3 Central Nervous System Agents : Anticonvulsants Focalin XR (Capsule Extended- 3 Release 24 Hour) Lamictal XR (Kit) 3 Guanfacine ER (Tablet Extended- 1 Central Nervous System Agents : Anxiolytics, Release 24 Hour) Sedatives, and Hypnotics Intuniv (Tablet Extended-Release 3 Lorazepam/Sodium Chloride 3 24 Hour) (100mg/100ml-0.9% Solution) Kapvay (Tablet Extended-Release 3 Central Nervous System Agents : Attention Deficit 12 Hour) Hyperactivity Disorder Agents, Amphetamines Metadate CD (Capsule Extended- 3 Release) Adderall (Tablet) 3 Methylin (10mg Tablet Chewable, 3 Adderall XR (Capsule Extended- 3 2.5mg Tablet Chewable, 5mg Release 24 Hour) Tablet Chewable, 10mg/5ml Oral Adzenys XR-ODT (Tablet 3 Solution, 5mg/5ml Oral Solution) Extended-Release Dispersible) Methylphenidate HCl (Tablet 1 Amphetamine/Dextroamphetamine 1 Immediate-Release, Tablet (1.875mg-1.875mg-1.875mg- Chewable, Oral Solution) 1.875mg Tablet, 10mg Tablet, Methylphenidate HCl CD (Capsule 1 12.5mg Tablet, 15mg Tablet, 20mg Extended-Release) Tablet, 30mg Tablet, 5mg Tablet, 10mg Capsule ER, 15mg Capsule Methylphenidate HCl ER (Tablet, 1 ER, 20mg Capsule ER, 25mg Capsule) Capsule ER, 30mg Capsule ER, Methylphenidate HCl SR (Tablet 1 5mg Capsule ER) Extended-Release) Desoxyn (Tablet) 3 Quillivant XR (Suspension) 3 Dexedrine (10mg Capsule 3 Ritalin (Tablet) 3 Extended-Release 24 Hour, 15mg Ritalin LA (Capsule Extended- 3 Capsule Extended-Release 24 Release 24 Hour) Hour, 5mg Capsule Extended- Strattera (Capsule) 2 Release 24 Hour) Central Nervous System Agents Dextroamphetamine Sulfate (10mg 1 Dopram (Injection) 3 Tablet, 5mg Tablet, 5mg/5ml Oral Solution) Central Nervous System Agents : Central Nervous Dextroamphetamine Sulfate ER 1 System Agents, Misc (Capsule Extended-Release 24 Addyi (Tablet) 3 Hour) Namzaric (10mg-Capsule 2 Evekeo (Tablet) 3 Extended-Release 24 Hour Methamphetamine HCl (Tablet) 1 Therapy Pack) ProCentra (Oral Solution) 3 Central Nervous System Agents : Central Nervous Vyvanse (10mg Capsule, 20mg 2 System, Other Capsule, 30mg Capsule, 40mg Cafcit (Injection) 3 Capsule, 50mg Capsule, 60mg Caffeine Citrate (20mg/ml Oral 1 Capsule, 70mg Capsule) Solution, 60mg/3ml Injection) Zenzedi (15mg Tablet, 2.5mg 3 Flumazenil (Injection) 1 Tablet, 20mg Tablet, 30mg Tablet, 7.5mg Tablet) Hetlioz (Capsule) 3 Horizant (Tablet Extended- 3 Central Nervous System Agents : Attention Deficit Release) Hyperactivity Disorder Agents, Non-amphetamines Levacet (Tablet) 3 Clonidine HCl ER (Tablet 1

Bold type = Brand-name drug 39 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Namzaric (10mg-14mg Capsule 2 Oral Rinse (Kit) Extended-Release 24 Hour, 10mg- Q-Care Q4 Oral 3 28mg Capsule Extended-Release Cleansing/Suctioning System/Chg 24 Hour) Oral Rinse (Kit) Nuedexta (Capsule) 3 Salagen (Tablet) 3 Rilutek (Tablet) 3 Salivamax (Packet) 3 Riluzole (Tablet) 1 Salivate Rx (Packet) 3 Tetrabenazine (Tablet) 1 Triamcinolone Acetonide (0.1% 1 Xenazine (Tablet) 3 Paste) Central Nervous System Agents : Fibromyalgia Triamcinolone in Orabase (Paste) 1 Agents Dermatological Agents Savella (Tablet) 3 Absorica (10mg Capsule, 20mg 3 Savella Titration Pack 3 Capsule, 30mg Capsule, 40mg Capsule) Central Nervous System Agents : Multiple Sclerosis Acanya (Gel) 3 Agents Acitretin (Capsule) 1 Ampyra (Tablet Extended-Release 2 Aclovate (Cream) 3 12 Hour) Aczone (Gel) 3 Aubagio (Tablet) 3 Adapalene (0.1% Cream, 0.1% Gel, 1 Avonex (Injection) 2 0.3% Gel) Avonex Pen (Injection) 2 Adapalene (0.1% Lotion) 3 Betaseron (Injection) 2 Adapalene Pump (Gel) 1 Copaxone (Injection) 2 Ala Scalp (Lotion) 3 Extavia (Injection) 3 Alclometasone Dipropionate (0.05% 1 Gilenya (Capsule) 3 Cream, 0.05% Ointment) Glatopa (Injection) 1 Aldara (Cream) 3 Rebif (Injection) 3 Alevicyn Antipruritic SG (Liquid) 3 Rebif Rebidose Titration Pack 3 Amcinonide (0.1% Cream, 0.1% 1 (Injection) Lotion, 0.1% Ointment) Rebif Titration Pack (Injection) 3 Ammonium Lactate (12% Cream, 1 Tecfidera (Capsule Delayed- 2 12% Lotion) Release) Analpram-HC (2.5%-1% Lotion) 3 Tecfidera Starter Pack 2 Anusol-HC (Cream) 3 Central Nervous System Agents : Opiate Antagonists Artiss (External Solution) 3 Evzio (2mg/0.4ml Injection) 3 Atopiclair (Cream) 3 Dental and Oral Agents Atralin (Gel) 3 Aquoral (Solution) 3 Augmented Betamethasone 1 Caphosol (Solution) 3 Dipropionate (0.05% Cream, 0.05% Gel, 0.05% Lotion, 0.05% Cevimeline HCl (Capsule) 1 Ointment) Chlorhexidine Gluconate (0.12% 1 Avenova (Solution) 3 Solution) Avenova/Neutrox (Solution) 3 Chlorhexidine Gluconate (20% 3 Solution) Azelex (Cream) 3 Evoxac (Capsule) 3 Benzac AC Wash (Liquid) 3 Gel-Kam Oral Care Rinse 3 BenzaClin (Gel) 3 (Concentrate) BenzaClin with Pump (Gel) 3 Kepivance (Injection) 2 Benzamycin (Gel) 3 Neutrasal (Packet) 3 Benzefoam (Foam) 3 Numoisyn (0-0-0-0-0-0-0-0 Liquid, 3 Benzefoam Ultra (Foam) 3 0-0-0-0-0-0-0-0-0.3gm Lozenge) Benziq (Gel) 3 Peridex (Solution) 3 Benziq LS (Gel) 3 Pilocarpine HCl (5mg Tablet, 7.5mg 1 Benziq Wash (Liquid) 3 Tablet) Benzoin Compound Tincture (0 1 Prevident 5000 Enamel Protect 2 Tincture) (Paste) Benzoyl Peroxide (9.8% Foam) 1 Q-Care Q2 Oral 3 Betamethasone Dipropionate 1 Cleansing/Suctioning System/Chg (0.05% Cream, 0.05% Lotion,

Bold type = Brand-name drug 40 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits 0.05% Ointment) Desonide (0.05% Cream, 0.05% 1 Betamethasone Valerate (0.1% 1 Lotion, 0.05% Ointment) Cream, 0.1% Lotion, 0.1% DesOwen (0.05% Cream, 0.05% 3 Ointment, 0.12% Foam) Lotion) Calcipotriene (0.005% Cream, 1 Desoximetasone (0.05% Cream, 1 0.005% External Solution, 0.005% 0.25% Cream, 0.05% Gel, 0.05% Ointment) Ointment, 0.25% Ointment) Calcipotriene/Betamethasone 1 Diclofenac Sodium (1% Gel, 1.5% 1 Dipropionate (Ointment) Transdermal Solution) Calcitriol (3mcg/gm Ointment) 1 Differin (0.1% Cream, 0.1% Gel, 3 Capex (Shampoo) 3 0.3% Gel, 0.1% Lotion) Carac (Cream) 3 Diflorasone Diacetate (0.05% 1 Cleocin-T (1% External Solution, 3 Cream, 0.05% Ointment) 1% Gel, 1% Lotion, 1% Swab) Diprolene (0.05% Lotion, 0.05% 3 Clindacin ETZ (Kit) 3 Ointment) Clindacin PAC (Kit) 3 Diprolene AF (Cream) 3 Clindagel (Gel) 2 Dovonex (Cream) 3 Clindamycin Phosphate (1% 1 Doxepin HCl (Cream) 1 External Solution, 1% Foam, 1% Doxycycline (40mg Capsule 1 Gel, 1% Lotion, 1% Swab) Delayed-Release) Clindamycin Phosphate/Tretinoin 1 Dritho-Creme HP (Cream) 2 (Gel) Drysol (External Solution) 2 Clindamycin/Benzoyl Peroxide 1 Duac (Gel) 3 (Gel) Efudex (Cream) 3 Clobetasol Propionate (0.05% 1 Eletone (Cream) 3 Cream, 0.05% External Solution, Eletone Twinpack (Cream) 3 0.05% Foam, 0.05% Gel, 0.05% Elidel (Cream) 2 Liquid, 0.05% Lotion, 0.05% Ointment, 0.05% Shampoo) Elocon (0.1% Cream, 0.1% 3 Lotion, 0.1% Ointment) Clobex (0.05% Liquid, 0.05% 3 3 Lotion, 0.05% Shampoo) Epiduo (Gel) 3 Clocortolone Pivalate (Cream) 3 Epiduo Forte (Gel) Episone Cre (Cream) 1 Clodan Kit (Kit) 3 3 Cloderm (Cream) 3 Erygel (Gel) Erythromycin (2% External 1 Cloderm Pump (Cream) 3 Solution, 2% Gel, 2% Pad) Coal Tar (External Solution) 3 Erythromycin/Benzoyl Peroxide 1 3 Condylox (0.5% External (Gel) Solution, 0.5% Gel) Eucrisa (Ointment) 3 Copasil (Gel) 3 Evicel (Kit) 3 Cordran (0.05% Cream, 0.05% 3 3 Lotion, 0.05% Ointment, Evoclin (Foam) 4mcg/SQCM Tape) Excilon AMD Antimicrobialdrain 3 Cortisporin (0.5%-0.5% Cream, 3 Sponges 4"x4" 6 Ply 1%-0.5% Ointment) Fabior (Foam) 3 Cosentyx (Injection) 3 Finacea (15% Foam, 15% Gel) 3 Cosentyx Sensoready Pen 3 Fluocinolone Acetonide (Cream, 1 (Injection) External Solution, Oil, Ointment) DermacinRx Clorhexacin (Kit) 3 Fluocinolone Acetonide Ear Drops 1 (Oil) DermacinRx Surgical Pharmapak 3 (Kit) Fluocinonide (Cream, Cream, 1 External Solution, Gel, Ointment) Dermasorb HC (Kit) 3 Fluocinonide-E (Cream) 1 Dermasorb TA (Kit) 3 3 Dermatop (0.1% Cream, 0.1% 3 Fluoroplex (Cream) Ointment) Fluorouracil (External Solution, 1 External Solution) DermaweRx Surgical Plus Pak 3 (Kit) Flurandrenolide (Cream, Lotion, 1 Ointment) DermOtic (Oil) 3 Fluticasone Propionate (Ointment, 1 Desonate (Gel) 3 Cream, Lotion)

Bold type = Brand-name drug 41 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Halobetasol Propionate (0.05% 1 Onexton (Gel) 3 Cream, 0.05% Ointment) Oracea (Capsule Delayed-Release) 3 Halog (0.1% Cream, 0.1% 3 Orafate (Paste) 3 Ointment) Ovace Plus Wash (10% Liquid) 3 Hydrocortisone (1% Cream, 2.5% 1 Oxsoralen Ultra (Capsule) 3 Cream, 1% Ointment, 2.5% Pandel (Cream) 3 Ointment, 2.5% Cream, 2.5% Lotion) Picato (Gel) 3 Hydrocortisone Butyrate (0.1% 1 Podofilox (External Solution) 1 Cream, 0.1% External Solution, PR Cream (Kit) 3 0.1% Ointment) Prednicarbate (0.1% Cream, 0.1% 1 Hydrocortisone in Absorbase 1 Ointment) (Ointment) Presera (Foam) 3 Hydrocortisone Valerate (0.2% 1 Proctofoam HC (Foam) 2 Cream, 0.2% Ointment) Promiseb (Cream) 3 Imiquimod (Cream) 1 Promiseb Complete (Kit) 3 Kenalog (Aerosol Solution) 3 Prothelial (Paste) 3 Keralyt (6% Gel) 3 Protopic (Ointment) 3 Klaron (Lotion) 3 Pruclair (Cream) 3 Lac-Hydrin (12% Cream, 12% 3 PRUDOXIN (Cream) 3 Lotion) Prumyx (Cream) 3 Lactic Acid (10% Lotion) 1 Pyrogallic Acid (Ointment) 3 Lactic Acid E (10%-3500unit/30gm 1 Qutenza (Kit) 3 Cream) Recedo (Gel) 3 Lactic Acid with Vitamin E (Cream) 1 Recura (Cream) 3 Latrix XM (Emulsion) 3 Retin-A (0.01% Gel, 0.025% Gel, 3 Levulan Kerastick (External 3 0.025% Cream, 0.05% Cream, Solution) 0.1% Cream) Lidocaine HCl-Hydrocortisone 3 Retin-A Micro (Gel) 3 Acetate with Aloe (0.55%-2.8% Retin-A Micro Pump (0.04% Gel, 3 Gel) 0.1% Gel) Lidocaine HCl/Hydrocortisone 1 Retin-A Micro Pump (0.08% Gel) 2 Acetate (0.5%-3% Cream, 0.5%-3% Riax (Foam) 3 Kit, 1%-3% Kit, 2%-2% Kit, 2.5%- 3% Kit) Salicylic Acid (6% Cream, 6% Gel, 1 6% Lotion) Locoid (0.1% Cream, 0.1% 3 External Solution, 0.1% Lotion, Salicylic Acid Cream (Kit) 1 0.1% Ointment) Salicylic Acid Lotion (Kit) 1 Locoid Lipocream (Cream) 3 Salvax Duo Plus (Kit) 3 Luxiq (Foam) 3 Santyl (Ointment) 3 MB Hydrogel (Kit) 3 Scalacort DK (Kit) 3 Medrox-Rx (Ointment) 3 Sebuderm (Gel) 3 Methoxsalen (10mg Capsule) 1 Selenium Sulfide (Lotion) 1 Mirvaso (Gel) 2 Sernivo (Emulsion) 3 Mometasone Furoate (0.1% External 1 Sodium Sulfacetamide/Sulfur (10%- 1 Solution) 4% Pad) Neo-Synalar (Cream) 3 Sodium Sulfacetamide/Sulfur 2 Neo-Synalar Kit (Kit) 3 (10%-5% Lotion) Neosalus (0-0 Cream, 0-0 Lotion, 3 Sodium Sulfacetamide/Sulfur 1 0-0-0 Foam) Cleanser (9.8%-4.8% Liquid) Neosalus CP (Cream) 3 Solaraze (Gel) 3 Neuac Kit (Kit) 3 Soolantra (Cream) 2 Nivatopic Plus (Cream) 3 Soriatane (Capsule) 3 Nusrugepak Surgical 3 Sorilux (Foam) 3 Prep/Carepak (Kit) Stelara (45mg/0.5ml Injection, 2 Nuvail (External Solution) 3 90mg/ml Injection) Olux (Foam) 3 Sulfacetamide Sodium (10% Lotion, 1 10% Suspension) Olux-E (Foam) 3 Sulfacetamide Sodium/Sulfur 1

Bold type = Brand-name drug 42 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Sulfoam (Shampoo) 3 Veregen (Ointment) 3 Synalar (0.01% External Solution, 3 Voltaren (Gel) 3 0.025% Cream, 0.025% Westcort (Ointment) 3 Ointment) Xeralux (Cream) 3 Synalar TS (Kit) 3 Zacare 4% Kit (Kit) 3 Synerderm (Emulsion) 3 Zacare 8% Kit (Kit) 3 Taclonex (0.064%-0.005% 3 Ziana (Gel) 3 Ointment, 0.064%-0.005% Zonalon (Cream) 3 Suspension) Zyclara (Cream) 3 Tacrolimus (0.03% Ointment, 0.1% 1 Ointment) Zyclara Pump (Cream) 3 Taltz (Injection) 3 Devices Tazorac (0.05% Cream, 0.1% 3 Insulin Syringes, Needles 2 Cream, 0.05% Gel, 0.1% Gel) Tena Cls+ Md Brf 1 Telfa AMD Antimicrobial Island 3 Vanishpoint Insulin 2 Dressing 4"x5" Syringe/1ml/29g X 5/16" Telfa AMD Antimicrobial Island 3 Electrolytic, Caloric, and Water Balance : Dressing4"x8" Replacement Preparations 3 Telfa AMD Antimicrobial Non- Calcium Gluconate/Dextrose 3 Adherent Pad 3"x8" (1gm/100ml-5% Injection, Temovate (0.05% Cream, 0.05% 3 2gm/100ml-5% Injection) External Solution, 0.05% Gel, Calcium Gluconate/Sodium 3 0.05% Ointment) Chloride (1gm/50ml-0.9% Temovate E (Cream) 3 Solution, 3gm/100ml-0.9% Tetrix (Cream) 3 Injection) Texacort (External Solution) 3 Klor-Con/25 (Packet) 2 Tisseel (External Solution) 3 Magnesium Sulfate in D5W (5%- 3 Tisseel VH (Kit) 3 1gm/50ml Solution, 5%- Tolak (Cream) 3 2gm/100ml Solution) Topicort (0.05% Cream) 2 Magnesium Sulfate/Dextrose (0- 3 Topicort (0.05% Gel, 0.05% 3 10gm/250ml Solution, 5%- Ointment, 0.25% Ointment, 40gm/500ml Solution, 5%- 0.25% Cream, 0.25% Liquid) 4gm/100ml Solution) Tretin-X (Cream) 2 Magnesium Sulfate/Lactated 3 Tretinoin (0.01% Gel, 0.05% Gel, 1 Ringers 0.025% Cream, 0.05% Cream, 0.1% Magnesium Sulfate/Lactated 1 Cream, 0.025% Gel) Ringers (100mg/500ml- 20gm/500ml-150mg/500ml- Tretinoin Microsphere (Gel) 1 3gm/500ml-1.55gm/500ml Solution) Tretinoin Microsphere Pump (Gel) 1 Magnesium Sulfate/Sodium 3 Triamcinolone Acetonide (0.025% 1 Chloride (10gm/100ml-0.9% Cream, 0.1% Cream, 0.5% Cream, Solution, 1gm/50ml-0.9% 0.025% Lotion, 0.1% Lotion, Solution, 6gm/150ml-0.9% 0.025% Ointment, 0.1% Ointment, Solution, 6gm/50ml-0.9% 0.5% Ointment, 0.147mg/gm Solution) Aerosol Solution) Magnesium Sulfate/Sodium 1 Trianex (Ointment) 3 Chloride (4gm/100ml-0.9% Tridesilon (Cream) 3 Solution) Ultravate (0.05% Cream, 0.05% 3 Potassium Chloride (0 Granules) 2 Lotion, 0.05% Ointment) Sodium Phosphate/Sodium 3 Uramaxin (45% Gel) 3 Chloride (0.9%-7.5MMOL/100ml Urea (40% Cream, 45% Lotion) 1 Solution) Urea Topical (Suspension) 1 Electrolytic, Caloric, and Water Balance : Uricosuric Uvadex (Injection) 3 Agents Valchlor (Gel) 3 Zurampic (Tablet) 3 Vanos (Cream) 3 Vectical (Ointment) 3 Enzyme Replacement/Modifiers Adagen (Injection) 2 Veltin (Gel) 3 Aldurazyme (Injection) 2 Verdeso (Foam) 3

Bold type = Brand-name drug 43 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Buphenyl (3gm/tsp Powder, 3 Atropine Sulfate (0.1mg/ml 1 500mg Tablet) Injection, 0.4mg/ml Injection, Cerdelga (Capsule) 3 1mg/ml Injection, 1mg/2.5ml Cerezyme (Injection) 2 Solution Prefilled Syringe) Creon (Capsule Delayed-Release) 2 Bentyl (10mg Capsule, 10mg/ml 3 Cystadane (Powder) 3 Injection) Chlordiazepoxide HCl/Clidinium 1 Cystagon (Capsule) 3 Bromide (5mg-2.5mg Capsule) Elaprase (Injection) 2 Cuvposa (Oral Solution) 3 Elelyso (Injection) 3 Dicyclomine HCl (10mg Capsule, 1 Fabrazyme (Injection) 2 10mg/5ml Oral Solution, 10mg/ml Kanuma (Injection) 3 Injection, 20mg Tablet) Kuvan (100mg Packet, 500mg 2 Entyvio (Injection) 3 Packet, 100mg Tablet Soluble) Glycopyrrolate (0.4mg/2ml 1 Lumizyme (Injection) 2 Injection, 1mg/5ml Injection, Naglazyme (Injection) 2 4mg/20ml Injection, 1mg Tablet, Orfadin (10mg Capsule, 20mg 3 2mg Tablet) Capsule, 2mg Capsule, 5mg Hyoscyamine Sulfate (0.125mg 1 Capsule, 4mg/ml Suspension) Tablet Dispersible) Pancreaze (24600unit-4200unit- 3 Librax (Capsule) 3 14200unit Capsule Delayed- Methscopolamine Bromide (Tablet) 1 Release, 61500unit-10500unit- Pamine (Tablet) 3 35500unit Capsule Delayed- 3 Release, 83900unit-21000unit- Pamine Forte (Tablet) 54700unit Capsule Delayed- Pamine FQ (Kit) 3 Release, 98400unit-16800unit- Propantheline Bromide (15mg 1 56800unit Capsule Delayed- Tablet) Release) Robinul (0.2mg/ml Injection, 1mg 3 Pertzye (Capsule Delayed- 3 Tablet) Release) Robinul Forte (Tablet) 3 RAVICTI (Liquid) 3 Gastrointestinal Agents Sodium Phenylbutyrate (Powder) 1 Trulance (Tablet) 3 Strensiq (Injection) 3 Gastrointestinal Agents : Gastrointestinal Agents, 3 Sucraid (Oral Solution) Other Vimizim (Injection) 3 Actigall (Capsule) 3 Viokace (Tablet) 3 Calcium Disodium Versenate 3 3 VPRIV (Injection) (Injection) Xiaflex (Injection) 2 Cascara Sagrada (1gm/ml Fluid 3 Zavesca (Capsule) 3 Extract) Zenpep (Capsule Delayed- 2 Chenodal (Tablet) 3 Release) Cholbam (Capsule) 3 Eye, Ear, Nose & Throat Preparations : Anti- Cromolyn Sodium (100mg/5ml 1 infectives Concentrate) Cefuroxime Sodium/Sodium 3 Diphenoxylate/Atropine (2.5mg- 1 Chloride (Solution) 0.025mg Tablet, 2.5mg- Eye, Ear, Nose & Throat Preparations : Anti- 0.025mg/5ml Liquid) Ed Cyte F (Tablet) 3 inflammatory Agents Entereg (Capsule) 3 Xiidra (Ophthalmic Solution) 2 Gastrocrom (Concentrate) 3 Eye, Ear, Nose & Throat Preparations : EENT Drugs, Lansoprazole/Amoxicillin/Clarithro 1 Miscellaneous mycin (Therapy Pack) Lucentis (0.5mg/0.05ml Solution 3 Lomotil (Tablet) 3 Prefilled Syringe) Loperamide HCl (2mg Capsule) 1 Gastrointestinal Agents : Antispasmodics, Movantik (Tablet) 3 Gastrointestinal Mytesi (Tablet Delayed-Release) 3 Atropen (Injection) 3 NutreStore (Packet) 3 Atropine Sulfate (0.05mg/ml 3 Ocaliva (Tablet) 3 Injection, 0.8mg/2ml Injection) Omeclamox-Pak (Therapy Pack) 2

Bold type = Brand-name drug 44 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits OsmoPrep (Tablet) 3 Solution) Paregoric (Tincture) 2 PEG-3350/Electrolytes (Oral 1 Prevpac (Therapy Pack) 3 Solution) Pylera (Capsule) 2 PEG-3350/NaCl/Na 1 Relistor (12mg/0.6ml Injection, 2 Bicarbonate/KCl (Oral Solution) 8mg/0.4ml Injection) Polyethylene Glycol 3350 Powder 1 Restora Rx (Capsule) 3 Prepopik (Packet) 3 Rezyst IM (Tablet Chewable) 3 Suprep Bowel Prep (Oral 3 Sodium Bicarbonate (Powder) 3 Solution) Urso (Tablet) 3 Gastrointestinal Agents : Protectants Ursodiol (250mg Tablet, 500mg 1 Carafate (1gm Tablet, 1gm/10ml 3 Tablet, 300mg Capsule) Suspension) VSL#3 DS (Packet) 3 Cytotec (Tablet) 3 Gastrointestinal Agents : Histamine2 (H2) Receptor Misoprostol (Tablet) 1 Antagonists Sucralfate (1gm Tablet) 1 Cimetidine (200mg Tablet, 300mg 1 Gastrointestinal Agents : Proton Pump Inhibitors Tablet, 400mg Tablet, 800mg Aciphex (Tablet Delayed-Release) 3 Tablet) Aciphex Sprinkle (Capsule 3 Cimetidine HCl (Oral Solution) 1 Sprinkle) Famotidine (200mg/20ml Injection, 1 Dexilant (Capsule Delayed- 2 20mg/2ml Injection, 40mg/4ml Release) Injection, 20mg Tablet, 40mg Esomeprazole Magnesium (Capsule 1 Tablet, 40mg/5ml Suspension) Delayed-Release) Famotidine Premixed (Injection) 3 Esomeprazole Sodium (20mg 3 Nizatidine (150mg Capsule, 300mg 1 Injection) Capsule, 15mg/ml Oral Solution) Esomeprazole Sodium (40mg 1 Pepcid (20mg Tablet, 40mg 3 Injection) Tablet, 40mg/5ml Suspension) Esomeprazole Strontium (Capsule 3 Ranitidine HCl (150mg Capsule, 1 Delayed-Release) 300mg Capsule, 150mg Tablet, First-Lansoprazole (Suspension) 3 300mg Tablet, 150mg/6ml Injection, First-Omeprazole (Suspension) 3 50mg/2ml Injection, 15mg/ml Lansoprazole (Capsule Delayed- 1 Syrup, 75mg/5ml Syrup) Release) Zantac (150mg Tablet, 300mg 3 Nexium (10mg Packet, 2.5mg 3 Tablet, 25mg/ml Injection, Packet, 20mg Packet, 40mg 50mg/2ml Solution) Packet, 5mg Packet, 20mg Gastrointestinal Agents : Irritable Bowel Syndrome Capsule Delayed-Release, 40mg Agents Capsule Delayed-Release) Alosetron HCl (Tablet) 1 Nexium I.V. (Injection) 3 Amitiza (Capsule) 2 Omeprazole (10mg Capsule 1 Delayed-Release, 20mg Capsule Gattex (Injection) 3 Delayed-Release, 40mg Capsule Linzess (145mcg Capsule, 290mcg 2 Delayed-Release) Capsule) Omeprazole + Syrspend SF Alka 3 Lotronex (Tablet) 3 (Suspension) Viberzi (Tablet) 3 Omeprazole/Sodium Bicarbonate 1 Gastrointestinal Agents : Laxatives (20mg-1100mg Capsule, 40mg- CoLyte-Flavor Packs (Oral 3 1100mg Capsule, 20mg-1680mg Solution) Packet, 40mg-1680mg Packet) GoLYTELY (Oral Solution) 3 Pantoprazole Sodium (20mg Tablet 1 Kristalose (Packet) 3 Delayed-Release, 40mg Tablet Lactulose (Oral Solution) 1 Delayed-Release, 40mg Injection) Mineral Oil Heavy (0 Oil) 1 Prevacid (Capsule Delayed- 3 Release) MoviPrep (Oral Solution) 3 Prevacid SoluTab (Tablet 3 NuLYTELY/Flavor Packs (Oral 3 Dispersible) Solution) Prilosec (Packet) 3 PCP 100 (Kit) 3 Protonix (20mg Tablet Delayed- 3 PEG 3350/Electrolytes (Oral 1 Release, 40mg Tablet Delayed-

Bold type = Brand-name drug 45 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Release, 40mg Injection, 40mg Flomax (Capsule) 3 Packet) Jalyn (Capsule) 3 Rabeprazole Sodium (Tablet 1 Proscar (Tablet) 3 Delayed-Release) Rapaflo (Capsule) 2 Zegerid (20mg-1100mg Capsule, 3 Tamsulosin HCl (Capsule) 1 40mg-1100mg Capsule, 20mg- Uroxatral (Tablet Extended- 3 1680mg Packet, 40mg-1680mg Release 24 Hour) Packet) Genitourinary Agents : Genitourinary Agents, Other Gastrointestinal Drugs : Antiemetics Bethanechol Chloride (Tablet) 1 Sustol (Injection) 3 Cialis (10mg Tablet, 20mg Tablet) 2 Gastrointestinal Drugs : Digestants Cuprimine (Capsule) 3 Pancreaze (10850unit-2600unit- 3 Depen Titratabs (Tablet) 2 6200unit Capsule Delayed- Elmiron (Capsule) 2 Release) Levitra (Tablet) 3 Gastrointestinal Drugs : GI Drugs, Miscellaneous Lithostat (Tablet) 3 Linzess (72mcg Capsule) 2 Stendra (Tablet) 3 Relistor (150mg Tablet) 3 Thiola (Tablet) 3 Genitourinary Agents : Antispasmodics, Urinary Urecholine (Tablet) 3 Darifenacin HBr ER (Tablet 1 Viagra (Tablet) 2 Extended-Release 24 Hour) Genitourinary Agents : Phosphate Binders Detrol (Tablet) 3 Auryxia (Tablet) 3 Detrol LA (Capsule Extended- 3 Release 24 Hour) Calcium Acetate (667mg Capsule, 1 667mg Tablet) Ditropan XL (Tablet Extended- 3 Release 24 Hour) Eliphos (Tablet) 3 Enablex (Tablet Extended-Release 3 Fosrenol (1000mg Packet, 750mg 3 24 Hour) Packet, 1000mg Tablet Chewable, 500mg Tablet Chewable, 750mg Flavoxate HCl (Tablet) 1 Tablet Chewable) Gelnique (Gel) 3 Phoslyra (Oral Solution) 3 Myrbetriq (Tablet Extended- 3 Renagel (Tablet) 3 Release 24 Hour) Renvela (0.8gm Packet, 2.4gm 2 Oxybutynin Chloride (5mg Tablet, 1 Packet, 800mg Tablet) 5mg/5ml Syrup) Velphoro (Tablet Chewable) 3 Oxybutynin Chloride ER (Tablet 1 Extended-Release 24 Hour) Hormonal Agents, Oxytrol (Patch Twice Weekly) 3 Stimulant/Replacement/Modifying (Adrenal) : Tolterodine Tartrate (Tablet) 1 Methylprednisolone Pf (Injection) 3 Tolterodine Tartrate ER (Capsule 1 Triamcinolone Pf (Injection) 3 Extended-Release 24 Hour) Hormonal Agents, Toviaz (Tablet Extended-Release 3 Stimulant/Replacement/Modifying (Adrenal) 24 Hour) Analpram-HC (1%-1% Cream) 3 Trospium Chloride (Tablet) 1 Betamethasone Sodium 1 Trospium Chloride ER (Capsule 1 Phosphate/Betamethasone Acetate Extended-Release 24 Hour) (Injection) Vesicare (Tablet) 2 Celestone-Soluspan (Injection) 3 Genitourinary Agents : Benign Prostatic Cortef (Tablet) 3 Hypertrophy Agents Cortenema (Enema) 3 Alfuzosin HCl ER (Tablet 1 Cortisone Acetate (25mg Tablet) 2 Extended-Release 24 Hour) Depo-Medrol (Injection) 3 Avodart (Capsule) 3 Dexamethasone (0.5mg Tablet, 1 Cardura XL (Tablet Extended- 3 0.75mg Tablet, 1.5mg Tablet, 1mg Release 24 Hour) Tablet, 2mg Tablet, 4mg Tablet, Cialis (2.5mg Tablet, 5mg Tablet) 2 6mg Tablet, 0.5mg/5ml Elixir, Dutasteride (Capsule) 1 0.5mg/5ml Oral Solution) Dutasteride/Tamsulosin HCl 1 Dexamethasone Intensol (1mg/ml 3 (Capsule) Concentrate) Finasteride (5mg Tablet) 1 Dexamethasone Sodium Phosphate 1

Bold type = Brand-name drug 46 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits (120mg/30ml Injection, 20mg/5ml Prednisone Intensol (5mg/ml 2 Solution) Concentrate) Dexlido (Injection) 3 Triamcinolone (Injection) 1 DexPak 10 Day (Tablet Therapy 3 Uceris (2mg/act Foam, 9mg Tablet 3 Pack) Extended-Release 24 Hour) DexPak 13 Day (Tablet Therapy 3 Veripred 20 (Oral Solution) 3 Pack) Hormonal Agents, DexPak 6 Day (Tablet Therapy 3 Stimulant/Replacement/Modifying (Pituitary) Pack) Bravelle (Injection) 3 Doubledex (Injection) 3 Chorionic Gonadotropin (Injection) 1 Dyural-L (Injection) 3 DDAVP (0.01% Nasal Solution, 3 Emflaza (18mg Tablet, 30mg 3 0.1mg Tablet, 0.2mg Tablet, Tablet, 36mg Tablet, 6mg Tablet, 4mcg/ml Injection) 22.75mg/ml Suspension) Desmopressin Acetate (0.01% Nasal 1 Fludrocortisone Acetate (0.1mg 1 Solution, 0.1mg/ml Nasal Solution, Tablet) 0.1mg Tablet, 0.2mg Tablet, Hydrocort Enema 100mg (Enema) 1 4mcg/ml Injection) Hydrocortisone (10mg Tablet, 20mg 1 Egrifta (Injection) 3 Tablet, 5mg Tablet) Follistim AQ (300unit/0.36ml 3 Interarticular Joint Kit (Kit) 3 Injection, 600unit/0.72ml Kenalog-10 (Injection) 3 Injection, 900unit/1.08ml Kenalog-40 (Injection) 3 Injection, 75unit/0.5ml Injection) LT Injection Kit (Injection) 3 Genotropin (12mg Injection, 5mg 3 Marbeta-L (Injection) 3 Injection) Mardex-25 (Injection) 3 Genotropin Miniquick (Injection) 3 Medrol (16mg Tablet, 32mg 3 Gonal-F (Injection) 2 Tablet, 4mg Tablet, 8mg Tablet) Gonal-F RFf (Injection) 2 Medrol (2mg Tablet) 2 Gonal-F RFf Rediject (Injection) 2 Methylprednisolone (16mg Tablet, 1 H.P. Acthar (Injection) 2 32mg Tablet, 4mg Tablet, 8mg Humatrope (Injection) 3 Tablet) Humatrope Combo Pack 3 Methylprednisolone Acetate 1 (Injection) (40mg/ml Injection, 80mg/ml Increlex (Injection) 2 Injection) Norditropin FlexPro (Injection) 2 Methylprednisolone/Lidocaine 3 Nutropin AQ (Injection) 2 (Injection) Omnitrope (Injection) 3 Millipred (10mg/5ml Oral 3 Solution) Ovidrel (Injection) 3 Millipred (5mg Tablet) 2 Oxytocin (Injection) 1 Millipred DP (Tablet Therapy 3 Oxytocin/Sodium Chloride 3 Pack) (20unit/L-0.9% Injection) Mometasone Furoate (0.1% Cream, 1 Pitocin (Injection) 3 0.1% Ointment) Saizen (Injection) 3 Orapred ODT (Tablet 3 Serostim (Injection) 2 Dispersible) Stimate (Nasal Solution) 3 Pediapred (Oral Solution) 3 Vaprisol (Injection) 3 Prednisolone (15mg/5ml Oral 1 Vasopressin/Sodium Chloride 3 Solution, 15mg/5ml Syrup) (0.9%-40unit/100ml Injection, Prednisolone Sodium Phosphate 1 0.9%-50unit/50ml Injection) (10mg/5ml Solution, 20mg/5ml Vasostrict (Injection) 3 Solution, 25mg/5ml Oral Solution, Zomacton (Injection) 3 5mg/5ml Oral Solution) Zorbtive (Injection) 3 Prednisolone Sodium Phosphate 1 Hormonal Agents, ODT (Tablet Dispersible) Prednisone (10mg Tablet, 1mg 1 Stimulant/Replacement/Modifying (Prostaglandins) Tablet, 2.5mg Tablet, 20mg Tablet, Alprostadil (Injection) 1 50mg Tablet, 5mg Tablet) Korlym (Tablet) 3 Prednisone (5mg/5ml Oral 2 Muse (Pellet) 3 Solution) Prostin VR Pediatric (Injection) 3

Bold type = Brand-name drug 47 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Hormonal Agents, (Tablet) Stimulant/Replacement/Modifying (Sex Drospirenone/Ethinyl 1 Estradiol/Levomefolate Calcium Hormones/Modifiers) : Anabolic Steroids (Tablet) Anadrol-50 (Tablet) 3 Elestrin (Gel) 3 Oxandrin (Tablet) 3 Estrace (0.1mg/gm Cream, 0.5mg 3 Oxandrolone (Tablet) 1 Tablet, 1mg Tablet, 2mg Tablet) Hormonal Agents, Estradiol (0.025mg/24hr Patch 1 Stimulant/Replacement/Modifying (Sex Weekly, 0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Hormones/Modifiers) : Androgens Weekly, 0.075mg/24hr Patch Androderm (Patch 24 Hour) 2 Weekly, 37.5mcg/24hr Patch AndroGel (25mg/2.5gm Gel, 3 Weekly, 0.1mg/24hr Patch Weekly, 50mg/5gm Gel) 0.5mg Tablet, 1mg Tablet, 2mg AndroGel (40.5mg/2.5gm Gel) 2 Tablet) Android (Capsule) 3 Estradiol Valerate (Injection) 1 Androxy (Tablet) 2 Estradiol/Norethindrone Acetate 1 Axiron (Transdermal Solution) 3 (Tablet) Danazol (100mg Capsule, 200mg 1 Estring (Ring) 3 Capsule, 50mg Capsule) Estrogel (Gel) 3 Depo-Testosterone (Injection) 3 Estropipate (Tablet) 1 Fortesta (Gel) 3 Estrostep Fe (Tablet) 3 Methyltestosterone (10mg Capsule) 1 Ethynodiol Diacetate/Ethinyl 1 Natesto (Gel) 3 Estradiol (Tablet) Striant 3 Evamist (Transdermal Solution) 3 Testim (Gel) 3 Femcon Fe (Tablet Chewable) 3 Testopel (Pellet) 3 Femhrt Low Dose (Tablet) 3 Testosterone (100mg Pellet, 3 Femring (Ring) 3 200mg Pellet, 87.5mg Pellet) Generess Fe (Tablet Chewable) 3 Testosterone (25mg/2.5gm Gel, 1 Levonorgestrel and Ethinyl 1 50mg/5gm Gel) Estradiol (Tablet) Testosterone Cypionate (Injection) 1 Levonorgestrel/Ethinyl Estradiol 1 Testosterone Enanthate (Injection) 1 (Tablet) Testosterone Pump (Gel) 1 Lo Loestrin Fe (Tablet) 3 Testred (Capsule) 3 Loestrin 1.5/30-21 (Tablet) 3 Vogelxo (Gel) 3 Loestrin 1/20-21 (Tablet) 3 Vogelxo Pump (Gel) 3 Loestrin Fe 1.5/30 (Tablet) 3 Hormonal Agents, Loestrin Fe 1/20 (Tablet) 3 Stimulant/Replacement/Modifying (Sex LoSeasonique (Tablet) 3 Menest (Tablet) 2 Hormones/Modifiers) : Estrogens Menostar (Patch Weekly) 3 Activella (Tablet) 3 Minastrin 24 Fe (Tablet 3 Alora (Patch Twice Weekly) 3 Chewable) Angeliq (Tablet) 3 Minivelle (Patch Twice Weekly) 3 Beyaz (Tablet) 3 Mircette (Tablet) 3 Brevicon-28 (Tablet) 3 Natazia (Tablet) 2 Climara (Patch Weekly) 3 Necon 10/11-28 (Tablet) 2 Climara Pro (Patch Weekly) 2 Norethindrone Acetate/Ethinyl 1 Combipatch (Patch Twice 3 Estradiol (Tablet) Weekly) Norethindrone Acetate/Ethinyl 1 Cyclessa (Tablet) 3 Estradiol/Ferrous Fumarate (Tablet) Delestrogen (Injection) 3 Norethindrone/Ethinyl 1 Depo-Estradiol (Injection) 3 Estradiol/Ferrous Fumarate (Tablet Desogen (Tablet) 3 Chewable) Desogestrel/Ethinyl Estradiol 1 Norgestimate/Ethinyl Estradiol (0- 1 (Tablet) Tablet, 35mcg-0.25mg Tablet) Divigel (Gel) 3 Norinyl 1+35 (Tablet) 3 Drospirenone/Ethinyl Estradiol 1 Nuvaring 3

Bold type = Brand-name drug 48 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Ortho Tri-Cyclen (Tablet) 3 Hormonal Agents, Ortho Tri-Cyclen Lo (Tablet) 3 Stimulant/Replacement/Modifying (Sex Ortho-Cyclen (Tablet) 3 Hormones/Modifiers) : Selective Estrogen Receptor Ortho-Novum 1/35 (Tablet) 3 Ortho-Novum 7/7/7 (Tablet) 3 Modifying Agents Clomiphene Citrate (50mg Tablet) 1 Ovcon-35 (Tablet) 3 Evista (Tablet) 3 Prefest (Tablet) 3 Osphena (Tablet) 3 Premarin (0.3mg Tablet, 0.45mg 2 Tablet, 0.625mg Tablet, 0.9mg Raloxifene HCl (Tablet) 1 Tablet, 1.25mg Tablet, Hormonal Agents, 0.625mg/gm Cream) Stimulant/Replacement/Modifying (Thyroid) Premarin (25mg Injection) 3 Armour Thyroid (Tablet) 3 Premphase (Tablet) 2 Cytomel (Tablet) 3 Prempro (Tablet) 2 Levothyroxine Sodium (100mcg 3 Safyral (Tablet) 3 Injection, 200mcg Injection, Seasonique (Tablet) 3 500mcg Injection) Tri-Norinyl 28 (Tablet) 3 Levothyroxine Sodium (100mcg 1 Vagifem (Tablet) 3 Tablet, 112mcg Tablet, 125mcg Vivelle-Dot (Patch Twice Weekly) 3 Tablet, 137mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Yasmin 28 (Tablet) 3 Tablet, 25mcg Tablet, 300mcg Yaz (Tablet) 3 Tablet, 50mcg Tablet, 75mcg Hormonal Agents, Tablet, 88mcg Tablet) Stimulant/Replacement/Modifying (Sex Liothyronine Sodium (10mcg/ml 1 Hormones/Modifiers) Injection, 25mcg Tablet, 50mcg Tablet, 5mcg Tablet) Taytulla (Capsule) 3 Nature-Throid (Tablet) 3 Hormonal Agents, Nature-Throid Nt-2.5 (Tablet) 3 Stimulant/Replacement/Modifying (Sex Synthroid (Tablet) 3 Hormones/Modifiers) : Progesterone Thyrolar (Tablet) 3 Agonists/Antagonists Tirosint (Capsule) 3 Ella (Tablet) 3 Triostat (Injection) 3 Hormonal Agents, Westhroid (Tablet) 3 Stimulant/Replacement/Modifying (Sex WP Thyroid (Tablet) 3 Hormones/Modifiers) : Progestins Hormonal Agents, Suppressant (Adrenal) Aygestin (Tablet) 3 Lysodren (Tablet) 2 Crinone (Gel) 3 Hormonal Agents, Suppressant (Parathyroid) Depo-Provera (Injection) 3 Sensipar (Tablet) 3 Endometrin (Insert) 3 Hormonal Agents, Suppressant (Pituitary) Hydroxyprogesterone Caproate 1 Bromocriptine Mesylate (2.5mg 1 (Injection) Tablet, 5mg Capsule) Makena (Injection) 2 Cabergoline (Tablet) 1 Medroxyprogesterone Acetate 1 Cetrotide (Injection) 2 (Tablet) Eligard (Injection) 3 Megace ES (Suspension) 3 Firmagon (Injection) 3 Megace Oral (Suspension) 3 Ganirelix Acetate (Injection) 3 Megestrol Acetate (20mg Tablet, 1 Leuprolide Acetate (Injection) 1 40mg Tablet, 40mg/ml Suspension, Lupaneta Pack (Kit) 3 40mg/ml Suspension, 625mg/5ml Lupron Depot (11.25mg Injection, 3 Suspension) 3.75mg Injection) Norethindrone (Tablet) 1 Lupron Depot (22.5mg Injection, 2 Norethindrone Acetate (5mg Tablet) 1 30mg Injection, 45mg Injection, Ortho Micronor (Tablet) 3 7.5mg Injection) Progesterone (100mg Capsule, 1 Lupron Depot-PED (11.25mg 3 200mg Capsule, 50mg/ml Injection) Injection) Prometrium (Capsule) 3 Lupron Depot-PED (15mg 2 Provera (Tablet) 3 Injection, 30mg Injection, 7.5mg

Bold type = Brand-name drug 49 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Injection) Azasan (Tablet) 3 Menopur (Injection) 3 Azathioprine (100mg Injection, 1 Octreotide Acetate (Injection) 1 50mg Tablet) Parlodel (2.5mg Tablet, 5mg 3 Benlysta (Injection) 3 Capsule) Cellcept (200mg/ml Suspension, 3 Sandostatin (Injection) 3 250mg Capsule, 500mg Tablet) Sandostatin LAR Depot 3 Cellcept Intravenous (Injection) 3 (Injection) Cimzia (Injection) 2 Signifor (Injection) 3 Cimzia Starter Kit (Injection) 2 Signifor LAR (Injection) 3 Cyclosporine (100mg Capsule, 1 Somatuline Depot (Injection) 3 25mg Capsule, 50mg/ml Injection) Somavert (Injection) 3 Cyclosporine Modified (100mg 1 Supprelin LA (Injection) 2 Capsule, 25mg Capsule, 50mg Capsule, 100mg/ml Oral Solution) Synarel (Nasal Solution) 2 3 Trelstar (Injection) 3 Enbrel (25mg Injection) Envarsus XR (Tablet Extended- 3 Trelstar Mixject (11.25mg 3 Suspension, 3.75mg Suspension, Release 24 Hour) 22.5mg Injection) Humira (20mg/0.4ml Injection, 2 Vantas (Injection) 3 40mg/0.8ml Injection) Humira Pediatric Crohns Disease 2 Zoladex (10.8mg Injection) 3 Starter Pack (Injection) Zoladex (3.6mg Injection) 2 Humira Pen (Injection) 2 Hormonal Agents, Suppressant (Thyroid) : Humira Pen Crohns Disease 2 Antithyroid Agents Starter Pack (Injection) Methimazole (10mg Tablet, 5mg 1 Humira Pen-Psoriasis Starter 2 Tablet) (Injection) Propylthiouracil (Tablet) 1 Imuran (Tablet) 3 Tapazole (Tablet) 3 Methotrexate (2.5mg Tablet) 1 Hormones and Synthetic Substitutes : Adrenals Methotrexate Sodium (Injection) 1 Dexamethasone Sodium Phosphate 1 Mycophenolate Mofetil (200mg/ml 1 (10mg/ml Injection) Suspension, 250mg Capsule, 500mg Dexamethasone Sodium 3 Injection, 500mg Tablet) Phosphate/Sodium Chloride Mycophenolic Acid DR (Tablet 1 (Solution) Delayed-Release) Dmt Suik (Kit) 3 Myfortic (Tablet Delayed-Release) 3 Prednisone (10mg Tablet Therapy 1 Neoral (100mg Capsule, 25mg 3 Pack, 5mg Tablet Therapy Pack) Capsule, 100mg/ml Oral Solution) Zonacort 11 Day (Tablet Therapy 3 Nulojix (Injection) 3 Pack) Orencia (125mg/ml Injection, 3 Zonacort 7 Day (Tablet Therapy 3 250mg Injection) Pack) Orencia Clickject (Injection) 3 Hormones and Synthetic Substitutes : Antidiabetic Otrexup (Injection) 3 Agents Prograf (0.5mg Capsule, 1mg 3 Capsule, 5mg Capsule, 5mg/ml Actoplus Met XR (Tablet 3 Injection) Extended-Release 24 Hour) Rapamune (0.5mg Tablet, 1mg 3 Adlyxin (Injection) 3 Tablet, 2mg Tablet, 1mg/ml Oral Adlyxin Starter Pack (Injection) 3 Solution) Jentadueto XR (Tablet Extended- 2 Rasuvo (Injection) 2 Release 24 Hour) Remicade (Injection) 2 Soliqua 100/33 (Injection) 3 Sandimmune (100mg Capsule, 3 Xultophy (Solution Pen injector) 3 25mg Capsule, 50mg/ml Injection) Hormones and Synthetic Substitutes : Pituitary Sandimmune (100mg/ml Oral 2 Vasopressin/Sodium Chloride 3 Solution) (0.9%-60unit/100ml Solution) Simponi (Injection) 2 Immunological Agents : Immune Suppressants Simponi Aria (Injection) 2 Astagraf XL (Capsule Extended- 3 Sirolimus (Tablet) 1 Release 24 Hour) Tacrolimus (0.5mg Capsule, 1mg 1

Bold type = Brand-name drug 50 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Capsule, 5mg Capsule) Xeljanz XR (Tablet Extended- 3 Torisel (Injection) 2 Release 24 Hour) Trexall (Tablet) 3 Immunological Agents : Vaccines Zortress (Tablet) 3 Hyqvia (Injection) 3 Immunological Agents : Immunizing Agents, Passive Theracys (Injection) 2 Atgam (Injection) 2 Inflammatory Bowel Disease Agents : BIVIGAM (Injection) 2 Aminosalicylates Carimune Nanofiltered (Injection) 2 Apriso (Capsule Extended-Release 2 Cuvitru (1gm/5ml Injection, 3 24 Hour) 2gm/10ml Injection, 4gm/20ml Asacol HD (Tablet Delayed- 3 Injection) Release) Cytogam (Injection) 2 Balsalazide Disodium (Capsule) 1 Flebogamma DIF (Injection) 2 Canasa (Suppository) 2 Gamastan S/D (Injection) 2 Colazal (Capsule) 3 Gammagard Liquid (Injection) 2 Delzicol (Capsule Delayed- 3 Gammagard S/D IGA Less Than 2 Release) 1 mcg/ml (Injection) Dipentum (Capsule) 3 Gammaked (Injection) 2 Lialda (Tablet Delayed-Release) 2 Gammaplex (Injection) 2 Mesalamine (4gm Enema, 4gm Kit) 1 Gamunex-C (Injection) 2 Mesalamine DR (Tablet Delayed- 3 Hizentra (Injection) 2 Release) Hyperrab S/D (Injection) 2 Pentasa (Capsule Extended- 3 Hyperrho S/D (Injection) 2 Release) Hyperrho S/D Mini-Dose 2 Rowasa (Kit) 3 (Injection) sfRowasa (Enema) 2 Imogam Rabies-HT (Injection) 2 Inflammatory Bowel Disease Agents : Micrhogam Ultra-Filtered Plus 2 Glucocorticoids (Injection) Budesonide (3mg Capsule Delayed- 1 Octagam (Injection) 2 Release) 2 Privigen (Injection) Cortifoam (Foam) 3 2 Rhogam Ultra-Filtered Plus Entocort EC (Capsule Delayed- 3 (Injection) Release) Rhophylac (Injection) 2 Inflammatory Bowel Disease Agents : Sulfonamides Thymoglobulin (Injection) 3 Azulfidine (Tablet) 3 WinRho SDF (Injection) 2 Azulfidine EN-Tabs (Tablet 3 Immunological Agents : Immunomodulators Delayed-Release) Actemra (162mg/0.9ml Injection, 3 Sulfasalazine (500mg Tablet, 500mg 1 200mg/10ml Injection, Tablet Delayed-Release) 400mg/20ml Injection, 80mg/4ml Injection) Local Anesthetics Actimmune (Injection) 2 Articadent Dental (Injection) 3 Arava (Tablet) 3 Bupivacaine/Epinephrine (0.5%- 1 1:200000 Injection) Arcalyst (Injection) 3 Lidocaine HCl (Solution Prefilled 3 Hylira (0.1% Lotion, 0.2% Gel) 3 Syringe) Ilaris (180mg Injection) 2 Marcaine/Epinephrine (0.5%- 3 Leflunomide (Tablet) 1 1:200000 Injection) Lemtrada (Injection) 3 Metabolic Bone Disease Agents Otezla (Tablet Therapy Pack, 3 Actonel (Tablet) 3 30mg Tablet) Alendronate Sodium (10mg Tablet, 1 Provenge (Injection) 2 35mg Tablet, 40mg Tablet, 5mg Ridaura (Capsule) 3 Tablet, 70mg Tablet) Simulect (Injection) 3 Alendronate Sodium (70mg/75ml 2 Sodium Hyaluronate (Gel) 1 Oral Solution) Stelara (130mg/26ml Injection) 2 Atelvia (Tablet Delayed-Release) 3 Synagis (Injection) 2 Binosto (Tablet Effervescent) 3 Xeljanz (Tablet) 3 Boniva (150mg Tablet, 3mg/3ml 3

Bold type = Brand-name drug 51 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Injection) Florical (364mg-8.3mg Capsule, 2 Calcitonin-Salmon (Nasal Solution) 1 364mg-8.3mg Tablet) Calcitriol (0.25mcg Capsule, 0.5mcg 1 Floriva (Liquid) 2 Capsule, 1mcg/ml Injection, Fluor-A-Day (Tablet Chewable) 2 1mcg/ml Oral Solution) Fluorabon (Oral Solution) 2 Doxercalciferol (0.5mcg Capsule, 1 Flura-Drops (Oral Solution) 2 1mcg Capsule, 2.5mcg Capsule, Monocal (Tablet) 2 4mcg/2ml Injection) Nafrinse Daily/Neutral (Solution) 3 Etidronate Disodium (Tablet) 1 Nafrinse Weekly (Solution) 3 Forteo (Injection) 2 Miscellaneous Therapeutic Agents : Disease- Fosamax (Tablet) 3 Fosamax Plus D (Tablet) 3 modifying Antirheumatic Drugs Hectorol (0.5mcg Capsule, 1mcg 3 Inflectra (Injection) 3 Capsule, 2.5mcg Capsule, Miscellaneous Therapeutic Agents 2mcg/ml Injection, 4mcg/2ml 1st Choice Lancets Thin 2 Injection) 1st Tier Unifine Pentips 2 Ibandronate Sodium (150mg Tablet, 1 29gx12mm 3mg/3ml Injection) 1st Tier Unifine Pentips 31gx6mm 2 Miacalcin (200unit/act Nasal 3 1st Tier Unifine Pentips 31gx8mm 2 Solution, 200unit/ml Injection) 3ml Glass Syringe Kit/1ml Na 3 Pamidronate Disodium (30mg 1 Hep/Swab/Prep/Cap/Ndl Injection, 30mg/10ml Injection, St/Label/Drap (Kit) 90mg Injection, 90mg/10ml 5ml Glass Syringe Kit/1ml Na 3 Injection) Hep/Swab/Prep/Cap/Ndl Pamidronate Disodium (6mg/ml 3 St/Label/Drap (Kit) Injection) Accu-Chek Aviva 2 Paricalcitol (1mcg Capsule, 2mcg 1 Accu-Chek Aviva Connect (Kit) 2 Capsule, 4mcg Capsule, 2mcg/ml Injection, 5mcg/ml Injection) Accu-Chek Aviva Plus (Kit, Strip) 2 2 Prolia (Injection) 2 Accu-Chek Compact Plus (Strip) Accu-Chek Compact Plus Care 2 Reclast (Injection) 3 Kit (Kit) Risedronate Sodium (Tablet) 1 Accu-Chek Compact Test Drum 2 Risedronate Sodium DR (Tablet 1 (Strip) Delayed-Release) Accu-Chek Fastclix Lancet Device 2 3 Rocaltrol (0.25mcg Capsule, Kit (Kit) 0.5mcg Capsule, 1mcg/ml Oral Accu-Chek Fastclix Lancets 2 Solution) 2 Xgeva (Injection) 2 Accu-Chek Guide (Kit, Strip) 2 Zemplar (1mcg Capsule, 2mcg 3 Accu-Chek Multiclix Lancet Capsule, 2mcg/ml Injection, Device Kit (Kit) 5mcg/ml Injection) Accu-Chek Multiclix Lancets 2 Zoledronic Acid (4mg/100ml 3 Accu-Chek Nano Smartview (Kit) 2 Injection) Accu-Chek Safe-T-Pro Lancets 2 Zoledronic Acid (4mg/5ml 1 Accu-Chek Safe-T-Pro Pluslancets 2 Injection, 5mg/100ml Injection) Accu-Chek Smartview Strips 2 Zometa (Injection) 3 (Strip) Miscellaneous Therapeutic Agents : Accu-Chek Soft Touch Lancets 2 Aggrastat (3.75mg/15ml Injection) 3 Accu-Chek Softclix Lancet Device 2 Kit (Kit) Amphadase (Injection) 3 Accu-Chek Softclix Lancets 2 Cyanokit (Injection) 3 Accutrend Glucose (Strip) 2 Ryanodex (Injection) 3 Active 1st Blood Lancets 30g/Easy 2 Thyrogen (Injection) 2 Twist Cap Xermelo (Tablet) 3 Advocate Insulin Pen Needles 2 Miscellaneous Therapeutic Agents : Antidotes Advocate Lancets 2 Levoleucovorin (175mg Solution) 3 Advocate Lancets 30g 2 Miscellaneous Therapeutic Agents : Cariostatic Advocate Safety Lancets 26g 2 Agents AeroChamber Mini Aerosol 2 Chamber (Device)

Bold type = Brand-name drug 52 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits AeroChamber MV 2 BD Autoshield 29g X 3/16" 2 AeroChamber Plus Flow Vu 2 BD Autoshield 29g X 5/16" 2 AeroChamber Plus Flow-Vu 2 BD Autoshield Duo 30g X 3/16" 2 AeroChamber Plus Flow- 2 Bd insul Syr Mis Lo Dose 2 Vu/Large Mask BD Lancet Ultrafine 30g 2 AeroChamber Plus Flow- 2 BD Lancet Ultrafine 33g 2 Vu/Mask BD Microtainer Lancets 2 AeroChamber Plus Flow- 2 Benzoin Tincture (0 Tincture) 3 Vu/Medium Mask Betalido (Injection) 3 AeroChamber Plus Flow- 2 Boric Acid (0 Granules) 3 Vu/Small Mask BreatheRite 2 AeroChamber Z-Stat 2 2 Plus/Medium Mask BreatheRite Collapsible Spacer w/ Neonate Mask AeroChamber/FlowSignal 2 BreatheRite Rigid Spacer w/Mask 2 Aerovent Plus Holding 2 2 Chamber/Collapsible (Device) BreatheRite w/Large Mask 2 AF Lancets Super Thin 2 BreatheRite w/Medium Mask 2 Agamatrix Ultra-Thin Lancets 2 BreatheRite w/Small Mask 33g Bridion (200mg/2ml Injection, 3 Amino PM Rms (Capsule) 3 500mg/5ml Injection) 2 Ammonul (Injection) 3 Bullseye Safety Lancets 3 Antizol (Injection) 3 Cardiovid Plus (Capsule) 2 App Slim RMS (Capsule) 3 Careone Lancet Thin 2 Arial Chamber (Device) 2 Careone Lancet Ultra Thin 2 Arnica Flower (Tincture) 3 Caretouch Pen Needles 31 G X 6 Mm Assure Haemolance Plus High 2 2 Flow 18g Caretouch Pen Needles 31gx 5mm 2 Assure Haemolance Plus Low 2 Caretouch Pen Needles 31gx 8mm Flow 25g Caretouch Pen Needles 32gx 4mm 2 Assure Haemolance Plus Micro 2 Caretouch Twist Lancets 30g 2 Flow 28g Carnitor (1gm/10ml Oral 3 Assure Haemolance Plus Normal 2 Solution, 200mg/ml Injection, Flow 21g 330mg Tablet) Assure Haemolance Plus Pediatric 2 Carnitor SF (Oral Solution) 3 Blade Citrus Bergamot (Powder) 3 Assure Lance Lancets 2 Cleanlet Lancets 28g 2 Assure Lance Lancets 21g 2 Clever Chek Lancets Ultrathin 2 Assure Lance Plus Safety Lancets 2 Clever Chek Lancets Ultrathin 2 25g 30g Assure Lance Plus Safety Lancets 2 Clever Choice Anti-Static Valved 2 30g Holding Chamber/Adult Large Assure Lancets 2 (Device) Astamed Myo (Capsule) 3 Clever Choice Anti-Static Valved 2 At Last Lancets 2 Holding Chamber/Medium (Device) Aurora Lancet Super Thin 30g 2 Clever Choice Anti-Static Valved 2 Aurora Lancet Thin 23g 2 Holding Chamber/Small (Device) 2 Aurora Pen Needles 29gx12mm Clever Choice Comfort EZ Insulin 2 Aurora Pen Needles 31g X 6mm 2 Pen Needles 31gx8mm Aurora Pen Needles 31g X 8mm 2 Clever Choice Comfort EZ Pen 2 Autolet Platforms 2 Needles 29gx12mm Availnex (Tablet Chewable) 3 Clever Choice Comfort EZ Pen 2 Bacteriostatic Water for 3 Needles 31gx5mm Injection/Benzyl Alcohol Clever Choice Comfort EZ Pen 2 (Injection) Needles 31gx6mm Bayer Microlet Lancets 2 Clever Choice Comfort EZ Pen 2 BD 3ml LL Syringe/Prefill Lith 3 Needles 32gx4mm Hep/Tip Cap/Ndl Stop/Safetycone Clever Choice Comfort EZ Pen 2 (Kit) Needles 32gx8mm

Bold type = Brand-name drug 53 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Clever Choice Comfort EZ Pen 2 Easivent/Mask-Large 2 Needles 33gx4mm Easivent/Mask-Medium 2 Clever Choice Comfort EZ Pen 2 Easivent/Mask-Small 2 Needles 33gx5mm Easy Touch Insulin Syringe/U- 2 Clever Choice Comfort EZ Pen 2 100/1ml/31g X 5/16" Needles 33gx6mm Easy Touch Lancets 26g/Pressure 2 Clever Choice Comfort EZ Pen 2 Activated Needles 33gx8mm Easy Touch Lancets 28g/Pressure 2 Coaguchek Lancets 2 Activated Comfort Lancets 2 Easy Touch Lancets 30g/Pressure 2 Compact Space Chamber/Anti- 2 Activated Static (Device) Easy Touch Lancets 32g/Pressure 2 Compact Space Chamber/Anti- 2 Activated Static/Large Mask (Device) Easy Touch Lancets 33g/Twist 2 Compact Space Chamber/Anti- 2 Easy Touch Pen Needles 29gx1/2" 2 Static/Medium Mask (Device) Easy Touch Pen Needles 31gx1/4" 2 Compact Space Chamber/Anti- 2 Easy Touch Pen Needles 2 Static/Small Mask (Device) 31gx5/16" Deferoxamine Mesylate (Injection) 1 Easy Touch Pen Needles 2 Delivery Fee ( ) 1 32gx5/32" Deplin 15 (Capsule) 3 Easy Touch Pen Needles/31g X 2 Deplin 7.5 (Capsule) 3 3/16" Desferal (Injection) 3 Easy Touch Safety 2 Dexcom G4 Plat Ped 3 Lancets21g/Pressure Activated Dexcom G4 Platinum 3 Easy Touch Safety 2 Dexcom G5 Kit 3 Lancets23g/Pressure Activated (Receiver/Transmit) Easytest II Lancets 2 Dexlido-M (Injection) 3 Easytest Lancets 2 Diastar Easy Test II Lancets 30g 2 Elfolate (Tablet) 3 Diastar Easy Test Lancets30g 2 Eligen B12 (Tablet) 3 Diastix (Strip) 2 Embrace Lancets Ultra Thin 30g 2 Digifab (Injection) 3 Enteragam (Packet) 3 DrCaps Size 0 Clear (Capsule) 3 Erecaid Classic (Kit) 3 DrCaps Size 00 Clear (Capsule) 3 Erecaid Esteem (Kit) 3 DrCaps Size 1 Clear (Capsule) 3 Eros-CTD (Device) 3 Drihep Arterial Line Sampling 3 Euflexxa (Injection) 2 Syr/3ml Ll/5ml Waste Syr/2-Cap Excel Comfort Point Insulin Pen 2 (Kit) Needles 31g X 4mm DriHep Plus 3ml LL Prefilled 3 Exel Comfort Point Insulin Pen 2 Syringe/Tip Cap/Ndl Needles 29g X 12mm Stop/Safetycone (Kit) Exel Comfort Point Insulin Pen 2 Droplet Lancets Ultra Thin 30g 2 Needles 31g X 8mm Drug Mart On-The-Go Lancets 2 Exel Comfort Point Insulin 2 Gentle 30g Syringe/0.3ml/29g X 1/2" Drug Mart Unilet Lancets Ultra 2 Exel Comfort Point Insulin 2 Thin 28g Syringe/0.3ml/30g X 5/16" Duodote (Injection) 3 EZ Smart Blood Glucose Lancets 2 E-Z Ject Lancets 2 EZ-Lets Lancets 21g 2 E-Z Ject Lancets 21g 2 EZ-Lets Lancets 23g 2 E-Z Ject Lancets Color 2 EZ-Lets Lancets 26g Super-Soft 2 E-Z Ject Lancets Super Thin 30g 2 EZ-Lets Lancets 28g Ultra-Soft 2 E-Z Ject Lancets Thin 26g 2 EZ-Lets Lancets 30g 2 E-Z Spacer (Device) 2 Ferriprox (100mg/ml Oral 3 E-Z Spacer the Body Guards Pack 2 Solution, 500mg Tablet) (Device) Fifty50 Pen Needles 31g X3/16" 2 E-Zject Lancets Micro-Thin 33g 2 (5mm) Easivent 2 Fifty50 Pen Needles 31g X5/16" 2 (8mm)

Bold type = Brand-name drug 54 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Fifty50 Pen Needles 31gx5mm 2 InspiraChamber/Soother 2 Fifty50 Pen Needles/31gx8mm 2 Mask/InspiraMask/Small (Device) Fifty50 Pen Needles/32gx4mm 2 Inspirease Bags 2 Fifty50 Safety Seal Lancets 30g 2 Inspirease Drug Delivery System 2 Fifty50 Unilet Lancets 33g 2 Inspirease Mouthpiece 2 Fine 30 2 Inspirease Reservoir Bags 2 Fingerstix Lancets 2 Insulin Syringe/0.5ml/27g X 1/2" 2 Flavor Blend (Suspension) 3 Insulin Syringe/U-100/1ml/28g X 2 Flexichamber (Device) 2 1/2" Flexichamber Child Mask/Large 2 Insulin Syringes, Needles 2 Flexichamber Child Mask/Small 2 Insulin Syringes/0.5ml/27gx1/2" 2 Fomepizole (Injection) 1 Insulin Syringes/1ml/30gx1/2" 2 Fora Lancets 2 Insupen Sensitive 32gx8mm 2 FreeStyle Unistick II Lancets 2 Insupen Ultrafin 29gx12mm 2 G5/G4 Kit Sensor 3 Insupen Ultrafin 30gx8mm 2 Galaxtra (Powder) 3 Insupen Ultrafin 31gx6mm 2 Gel-One (Prefilled Syringe) 3 Insupen Ultrafin 31gx8mm 2 Gelsyn-3 (Injection) 3 Intralipid (30gm/100ml Injection) 3 Gentle-Let GP Lancets 2 Kalbitor (Injection) 3 Gentle-Let Lancets General 2 L-Methylfolate (Tablet) 1 Purpose Style/Medium Point L-Methylfolate Calcium (Tablet) 3 Gentle-Let Platforms 2.4mm 2 Lancet Transporter Case 2 Genvisc 850 (Solution Prefilled 3 Lancets 2 Syringe) Lancets 26g Twist Top 2 GlucoCom Lancets 28g 2 Lancets 28g 2 GlucoCom Lancets 30g 2 Lancets 31g Twist Top 2 GlucoCom Lancets 33g 2 Lancets Thin 2 Glucosource Lancets 2 Lancets Ultra Fine 2 Glycolic Acid 70% High Purity 3 Lancets Ultra Thin 2 Glycophos (Injection) 3 Leader Unifine Pentips 2 Gmate Lancets 30g 2 Plus/Short/31gx5/16" H-E-B in Control Pen Needles 2 Leader Unifine 2 31gx6mm Pentips/Mini/31gx3/16" H-E-B in Control Pen Needles 2 Leader Unifine 2 31gx8mm Pentips/Nano/32gx5/32" H-E-B Incontrol Pen Needles 2 Lecithin (0 Granules) 3 29gx12mm Levocarnitine (1gm/10ml Oral 1 Haemolance 2 Solution, 200mg/ml Injection, Haemolance Low Flow Lancets 2 330mg Tablet) Haemolance Plus 2 Liberty Medical Lancets 30g 2 Haemolance Plus High Flow 2 Lifescan Unistik 2 Deep 2 Penetration Haemolance Plus Low Flow 2 Lifescan Unistik II Lancets 2 Haemolance Plus Max Flow 2 3 Haemolance Plus Pediatric Flow 2 Limbrel (Capsule) Limbrel250 (Capsule) 3 HSA Sterile Diluent (Injection) 3 Limbrel500 (Capsule) 3 Hy-Vee Lancets 2 3 Hyalgan (Injection) 3 Liquihep BD 3ml Prefil Syr/Swab/Gauze/Cap/Ndl 3 Hylenex (Injection) Stop/Lbl/Ndls (Kit) 3 Hymovis (Injection) Liquihep II BD 3ml LL 3 In Touch Sterile Lancets 30g 2 Syringe/Ll/Swab/Gz/Cap/Ndl InspiraChamber/Anti-Static 2 St/Safetycone (Kit) Valved/Mouthpiece (Device) LiteAire (Device) 2 InspiraChamber/Large (Device) 2 LiteTouch Lancets Micro Thin 2 InspiraChamber/Soother 2 33g Mask/InspiraMask/Medium LiteTouch Pen Needles 2 (Device) 29gx12.7mm

Bold type = Brand-name drug 55 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits LiteTouch Pen Needles 31gx8mm 2 Neoke MCT70 (Powder) 3 Short Neoke RA Lipoic (Powder) 3 Live Better Lancet Super Thin 2 Nexavir (Injection) 3 30g Nicomide (Tablet) 3 Live Better Lancet Ultra Thin 28g 2 Nithiodote (Injection) 3 Lozibase S 3 Nova Safety Lancets 23g 2 Marbeta-25 (Injection) 3 Nova Safety Lancets 28g 2 Mask Vortex/Baby Whirl 2 Nova Sureflex Lancets 2 Duckling Novofine Pen Needles 3 Mask Vortex/Child/Frog 2 Novotwist 3 2 Mask Vortex/Spinner the Duck On Call Lancets 2 Mask Vortex/Toddler/Lady Bug 2 On Call Plus Lancets 2 Medisense Thin Lancets 2 Onetouch Club Lancets Fine Point 2 2 Medlance Plus Extra Lancets 21g Onetouch Combo Pack 2 2 Medlance Plus Lancets Onetouch Delica Lancets Extra 2 Medlance Plus Lite Lancets 25g 2 Fine 33g Medlance Plus Special Lancets 2 Onetouch Delica Lancets Fine 30g 2 0.8mm Onetouch Suresoft Lancing 2 Medlance Plus SuperLite 30g 2 Device/21g Medlance Plus SuperLite 2 Onetouch Ultra 2 (Kit) 2 30g/Comfort Max Onetouch Ultra Blue (Strip) 2 2 Medlance Plus Universal Lancets Onetouch Ultra Mini (Kit) 2 21g Onetouch Ultralink System (Hex) 2 2 Medlance/Extra (Kit) 2 Medlance/Lite Onetouch Ultrasoft Lancets 2 Medlance/Universal 2 Onetouch Verio (Kit) 2 Meijer Lancets Universal 30g 2 Onetouch Verio Flex Bloodglucose 2 Meijer Super Thin Lancets 2 Monitoring System (Kit) Metastron (Injection) 3 Onetouch Verio Iq Blood Glucose 2 Methylergonovine Maleate 1 Monitoring System (Kit) (Injection) Onetouch Verio Sync 2 Microchamber 2 Bloodglucose Monitoring System Microlet Lancets 2 (Kit) Microspacer 2 Onetouch Verio Test Strips (Strip) 2 Microtainer Safety Flow 2 OptiChamber Advantage 2 Lancet/Sterile/Single-Use OptiChamber Advantage/Large 2 Mitosol (Kit) 3 Mask Monoject Insulin Syringe/1ml 2 OptiChamber Advantage/Medium 2 Monoject Insulin 2 Face Mask Syringe/Softpack/1ml/27g X 1/2" OptiChamber Advantage/Small 2 Monoject Insulin 2 Face Mask Syringe/Softpack/U-100/0.5ml/28g OptiChamber Diamond 2 X 1/2" OptiChamber Diamond/Large 2 Monoject Ultra Comfort Insulin 2 Face Mask (Device) Syringe/1ml/30g X 5/16" OptiChamber Diamond/Medium 2 Monojector End Caps 2 Face Mask Monolet Lancets 2 OptiChamber Diamond/Small 2 Monolet Opd Lancets 2 Face Mask Monolettor Safety Lancets 2 OptiChamber Face Mask/Small 2 Monovisc (Injection) 3 Optihaler MDI Drug Delivery 2 Myalept (Injection) 3 System (Device) MyGlucoHealth MGH Softlance 2 Ora-Blend (0-0-0-0-0-0 3 Lancets 30g Suspension) Myobloc (Injection) 3 Ora-Blend SF (0-0-0-0-0 3 N-Acetyl-L-Cysteine (Capsule) 1 Suspension) 3 Natpara (Injection) 3 Ora-Plus (0-0-0-0 Liquid) ORA-Sweet (5%-4%-54% Syrup) 3 Neoke Alcar (Powder) 3

Bold type = Brand-name drug 56 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits ORA-Sweet SF (9%-10% Syrup) 3 (Kit) Oral Mix Flavored Suspending 3 Prodigy Safety Lancets 2 Vehicle (Liquid) Prodigy Twist Top Lancets 2 Oral Mix SF (Liquid) 3 Propylene Glycol (0 External 3 Oral Suspend (Liquid) 3 Solution) Oral Syrup Flavored Vehicle 3 Protopam Chloride (Injection) 3 (Liquid) Provayblue (Injection) 3 Oral Syrup SF (Liquid) 3 PSS Select GP Lancets 2 Orthovisc (Injection) 3 PSS Select Platforms 2 Panda Mask Large 2 PSS Select Safety Lancets 2 Panda Mask Medium 2 Purified Water (0 Liquid) 3 Panda Mask Small 2 PX Lancets Ultra Thin 2 PC Unifine Pentips 29g X 1/2" 2 QC Lancets Super Thin 2 PC Unifine Pentips 31g X 6mm 2 QC Lancets Ultra Thin 2 Ultra Short Quadramet (Solution) 3 Pediatric Panda Mask 2 Quinzyme (Tablet Dispersible) 3 Pen Needles 29gx1/2" 2 Radiogardase (Capsule) 3 Pen Needles 30gx5/16" 2 Relion Lancets Micro-Thin33g 2 Pen Needles 30gx5mm 2 Relion Lancets Standard 21g 2 Pen Needles 30gx8mm 2 Relion Lancets Thin 26g 2 Pen Needles 31gx6mm (1/4") 2 Relion Lancets Ultra-Thin30g 2 Penlet II Replacement Caps-Deep 2 Relion Pen Needles 29gx12mm 2 Pentetate Calcium Trisodium 3 Relion Pen Needles 31gx6mm 2 (Combination Solution) Relion Pen Needles 31gx8mm 2 3 Pentetate Zinc Trisodium Relion Pen Needles 32gx4mm 2 (Combination Solution) Relion Thin Lancets 2 Pentips 29gx12mm 2 Relion Ultra Thin Lancets 2 Pentips 31gx5mm 2 Relion Ultra Thin Plus Lancets 2 Pentips 31gx6mm 2 32g 2 Pentips 31gx8mm Rightest GD-L500 Alternate Site 2 Pentips 32gx4mm 2 Adapter Perfect Lancets 30g 2 Rightest GL300 Lancets 2 Perfect Pressure Activated Safety 2 RiteFlo (Device) 2 Lancets 28g Saccharin Sodium (0 Granules, 0 3 Ph 12 Sterile Diluent Forflolan 3 Powder) (Injection) Safe-T-Lance Low Flow 25g 2 Pharmacist Choice Ultra Thin 2 Safe-T-Lance Normal Flow 21g 2 Lancets Safe-T-Lance Plus Safety Lancet 2 Pharmacist Choice Ultra Thin 2 High Flow Lancets 28g Safe-T-Lance Plus Safety Lancet 2 Pharmacist Choice Ultra Thin 2 Low Flow Lancets 30g Safe-T-Lance Plus Safety Lancet 2 Pharmacist Choice Ultra Thin 2 Normal Flow Lancets 31g Safety Lancets 2 Pharmacist Choice Ultra Thin 2 2 Lancets 33g Safety Lancets 21g 2 Pharmacy Couniter Lancets 2 Safety Lancets 28g 2 Pocket Chamber (Device) 2 Safety Let Lancets 2 Pocket Spacer (Device) 2 Safety Seal Lancets 28g 2 Pralidoxime Chloride (Injection) 3 Safety Seal Lancets 30g 2 Precision Thin Lancets 2 Shopko Unifine Pentips Pen Needles/Mini/31gx5mm Precision Ultra Lancet 2 Single-Let 2 Preset 1ml LS Syr/Prefilllyophil 3 2 Lith Hep/Tip Cap/Safetycone Smart Sense Color Lancets (Kit) Universal 33g 2 Preset 3ml Ll Syr/Prefilllyoph 3 Smart Sense Standard Lancets Lith Hep/Cap/Prep/Gz/Sftycone Universal 21g Smart Sense Super Thin Lancets 2

Bold type = Brand-name drug 57 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Universal 30g X 1/2" Smart Sense Thin Lancets 2 Ulticare Insulin Syringe/U- 2 Universal 26g 100/0.3ml/30g X 1/2" Smartest Lancets 28g 2 Ulticare Insulin Syringe/U- 2 Smoflipid (Injection) 3 100/0.3ml/31g X 5/16" Sodium Nitrite (Injection) 3 Ulticare Insulin Syringe/U- 2 Sodium Phenylacetate/Sodium 1 100/0.5ml/31g X 5/16" Benzoate (Injection) Ulticare Micro Pen Needles/32g X 2 Sodium Phosphate/Sodium 3 4mm Chloride (0.9%-15MMOL/250ml Ulticare Pen Needles/29g X 2 Injection) 12.7mm Sodium Thiosulfate (25% 3 Ulticare Thin Lancets 30g 2 Injection) Ulticare U-100 Insulin 2 Solus V2 Pressure Activated 2 Syringes/0.3ml/31g X1/4" Safety Lancets 28g Ulticare U-100 Insulin 2 Solus V2 Twist Lancets 30g 2 Syringes/0.5ml/31g X 1/4" Sterilance PA 2 Ulticare U-100 Insulin 2 Sterilance Tl 2 Syringes/1ml/31g X 1/4" Sterile Diluent for Epoprostenol 1 Ultiguard Insulin Syringe/U- 2 Sodium (Injection) 100/0.5ml/30g X 5/16" Sterile Diluent for Remodoulin 3 Ultilet Classic Lancets 2 (Solution) Ultilet Insulin 2 Supartz (Injection) 3 Syringe/Short/1ml/31g X 5/16" Supartz Fx (Injection) 3 Ultilet Lancets 2 Sure-Fine Pen Needles 29gx1/2" 2 Ultilet Lancets 33g 2 12.7mm Ultilet Pen Needle 32gx4mm/Short 2 Sure-Fine Pen Needles 31gx3/16" 2 Ultilet Safety Lancets 23g 2 5mm Ultilet Short Pen Needles 2 Sure-Fine Pen Needles 31gx5/16" 2 31gx5/16" 8mm Ultilet Short Pen 2 Sure-Lance Lancets 26g 2 Needles31gx3/16" Sure-Lance Thin Lancets 28g 2 Ultra-Thin II Auto Lancet 2 Sure-Touch Lancets Universal 2 Ultra-Thin II Lancets 28g 2 Surelite Lancets 2 Ultra-Thin II Lancets 30g 2 Suspension Vehicle (Suspension) 3 Ultra-Thin II Pen Needles 2 Synvisc (Injection) 2 29gx1/2" Synvisc One (Injection) 2 Ultra-Thin II Safety Autolancets 2 26g Techlite Ast Lancets 2 Ultralance 2 TechLite Lancets 2 2 Techlite Lancets 30g 2 Unifine Pentips 32gx4mm 2 Techlite Pen Needles/31g X 5mm 2 Unilet ComforTouch Lancet Unilet Excelite 2 Techlite Pen Needles/32g X 8mm 2 Unilet Excelite II 2 Thinlets GP Lancets 2 2 Thinlets Lancet 2 Unilet G.P. Lancet Unilet G.P. SuperLite Lancet 2 Travel Lancets Advanced 28g 2 Unilet GP 28 Ultra Thin 2 TruePlus Lancets 26g 2 2 TruePlus Lancets 28g 2 Unilet Lancet 2 TruePlus Lancets 30g 2 Unilet Lancets Micro-Thin33g Unilet Lancets Super-Thin30g 2 TruePlus Lancets 33g 2 Unilet SuperLite Lancet 2 Trueplus Lancets 33g Micro Thin 2 2 Ulticare Insulin Safety 2 Unistik 1 Syringe/0.5ml/29g X 1/2" Unistik 2 2 Ulticare Insulin Safety 2 Unistik 2 Comfort 2 Syringe/1ml/29g X 1/2" Unistik 2 Extra 2 Ulticare Insulin Syringe/0.3ml/29g 2 Unistik 2 Neonatal 2 X 1/2" Unistik 2 Normal 2 Ulticare Insulin Syringe/0.5ml/28g 2 Unistik 2 Super 2

Bold type = Brand-name drug 58 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Unistik 3 2 Aripiprazole ODT (Tablet 1 Unistik 3 Comfort 2 Dispersible) Unistik 3 Extra 2 Azacitidine (Injection) 1 Unistik 3 Extra Single Use Safety 2 Berinert (Injection) 2 Lancets/21g Bethkis (Nebulized Solution) 2 Unistik 3 Gentle 2 Bleomycin Sulfate (Injection) 1 Unistik 3 Neonatal 2 Caldolor (Injection) 3 Unistik 3 Normal 2 Camptosar (Injection) 3 Unistik CZT Comfort 2 Chlorpromazine HCl (25mg/ml 3 Unistik CZT Normal 2 Injection, 50mg/2ml Injection) Unistik Safety Lancets 28g 2 Cinryze (Injection) 2 Unistik Safety Lancets 30g 2 Daunorubicin HCl (Injection) 1 Unistik Touch Safety Lancets 21g 2 DermacinRx Therazole Pak 3 Unistik Touch Safety Lancets 23g 2 (Therapy Pack) Unistik Touch Safety Lancets 28g 2 Dexamethasone Sodium Phosphate 1 (4mg/ml Solution) Unistik Touch Safety Lancets 30g 2 Dexrazoxane (Injection) 1 Universal 1 Lancets Thin 26g 2 Dextrose 10% (Injection) 1 Universal 1 Lancets Ultra Thin 2 30g Dextrose 20% (Injection) 3 Universal 1 Lancets/33g/Micro- 2 Dextrose 25% (Injection) 3 Thin Dextrose 40% (Injection) 3 Valumark Lancet Ultra Thin 28g 2 Dextrose 5% (Injection) 1 Vanishpoint Insulin 2 Dextrose 50% (50% Injection) 1 Syringe/0.5ml/30g X 5/16" Diazepam (10mg/2ml Injection) 3 Vanishpoint Insulin 2 Diltiazem HCl (100mg Injection) 3 Syringe/1ml/30g X 5/16" Diltiazem HCl (125mg/25ml 1 Vida Mia Unifine Pentips 2 Injection, 25mg/5ml Injection, 32gx4mm 50mg/10ml Injection) Vida Mia Unifine Pentips Original 2 Diltiazem HCl/Dextrose (5%- 1 29gx12mm 125mg/125ml Injection) Vida Mia Unipfine Pentipsshort 2 Diltiazem HCl/Sodium Chloride 1 31gx8mm (100mg/100ml-0.9% Injection) Vistogard (Packet) 3 Docetaxel (20mg/0.5ml Injection, 1 Vitalet Pro Lancets 2 80mg/2ml Injection) Vitalet Pro Plus Lancets 2 Doxil (Injection) 3 Voraxaze (Injection) 3 Duavee (Tablet) 2 Vortex Valved Holding Chamber 2 Dysport (Injection) 3 (Device) Ellence (Injection) 3 W&F Lancets 26g 2 Enbrel (25mg/0.5ml Injection, 3 W&F Lancets Colored 21g 2 50mg/ml Injection) Walgreens Lancets 2 Enbrel SureClick (Injection) 3 Walgreens Thin Lancets 2 Epirubicin HCl (Injection) 1 Walgreens Ultra Thin Lancets 2 Erwinaze (Injection) 3 WatchHaler (Device) 2 Ethyol (Injection) 3 Xeomin (100unit Injection, 50unit 3 Firazyr (Injection) 2 Injection) Fludarabine Phosphate (Injection) 1 Xuriden (Packet) 3 Foscavir (Injection) 3 Miscellaneous Therapeutic Agents : Other Fusilev (Injection) 3 Miscellaneous Therapeutic Agents Geodon (20mg Injection) 3 Exondys 51 (Injection) 3 Halaven (Injection) 2 2 Multiple Classifications Humira (10mg/0.2ml Injection) Hydroxyzine HCl (25mg/ml 3 Abilify Maintena (Injection) 3 Injection) 2 Abraxane (Injection) Ibuprofen Lysine (Injection) 1 Acetazolamide Sodium (Solution) 1 Idamycin PFS (Injection) 3 2 Alimta (Injection) Idarubicin HCl (Injection) 1 Amifostine (Injection) 1 Indomethacin (1mg Solution) 1

Bold type = Brand-name drug 59 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Intron A w/Diluent (Injection) 3 Solu-Medrol (Injection) 3 Ipratropium Bromide/Albuterol 1 Synribo (Injection) 3 Sulfate (Inhalation Solution) Tice BCG (Injection) 2 Irinotecan (40mg/2ml Injection) 1 Triamcinolone Acetonide Pf 3 Irinotecan (500mg/25ml Injection) 3 (Injection) Irinotecan HCl (Injection) 1 Trisenox (Injection) 2 Istodax (Injection) 2 Tysabri (Injection) 3 Istodax (Overfill) (Injection) 2 Velcade (Injection) 2 Ixempra Kit (Injection) 2 Vidaza (Injection) 3 Jevtana (Injection) 2 Vincristine Sulfate (Injection) 1 Kadcyla (Injection) 3 Xeomin (200unit Injection) 3 Ketorolac Tromethamine (15mg/ml 1 Zaltrap (Injection) 2 Injection, 30mg/ml Injection, Zinbryta (Injection) 3 30mg/ml Injection) Zinecard (Injection) 3 Kineret (Injection) 3 Zyprexa (10mg Injection) 3 Kyprolis (60mg Injection) 2 Zyprexa Relprevv (Injection) 3 Leucovorin Calcium (100mg 1 Injection, 200mg Injection, 350mg Ophthalmic Agents : Ophthalmic Prostaglandin and Injection, 50mg Injection) Prostamide Analogs Leucovorin Calcium (500mg 3 Bimatoprost (Ophthalmic Solution) 1 Injection) Latanoprost (Ophthalmic Solution) 1 Levoleucovorin (50mg Injection) 1 Lumigan (Ophthalmic Solution) 2 Mesnex (400mg Tablet) 3 Rescula (Ophthalmic Solution) 3 Methylprednisolone Sodium 1 Travatan Z (Ophthalmic Solution) 2 Succinate (Injection) Xalatan (Ophthalmic Solution) 3 Metoclopramide HCl (5mg/ml 1 Zioptan (Ophthalmic Solution) 3 Injection) Ophthalmic Agents : Ophthalmic Agents, Other Mitomycin (Injection) 1 Atropine Sulfate (1% Ointment) 2 Neoprofen (Injection) 3 Atropine Sulfate (1% Ophthalmic 1 Nucala (Injection) 3 Solution) Olanzapine (10mg Injection) 1 Cyclogyl (Ophthalmic Solution) 3 Oncaspar (Injection) 2 Cyclomydril (Ophthalmic 3 Onivyde (Injection) 3 Solution) Oxaliplatin (IV Solution 1 Cyclopentolate HCl (Ophthalmic 1 100mg/20ml) Solution) Oxytocin/Dextrose (5%-10unit/L 3 Cyclopentolate HCl (Ophthalmic 1 Injection, 5%-20unit/L Injection) Solution) Oxytocin/Lactated Ringers 3 Cystaran (Ophthalmic Solution) 3 (0.1gm/500ml-30unit/500ml- Lacrisert (Insert) 3 0.15gm/500ml-3gm/500ml- Lucentis (0.3mg/0.05ml Injection, 2 1.55gm/500ml Injection) 0.5mg/0.05ml Injection) Pegasys (Injection) 2 Phenylephrine HCl (10% 1 Pegasys ProClick (Injection) 2 Ophthalmic Solution, 2.5% Phenergan (25mg/ml Injection) 3 Ophthalmic Solution) Photofrin (Injection) 3 Procysbi (Capsule Delayed- 3 Plegridy (Injection) 3 Release) Plegridy Starter Pack (Injection) 3 Proparacaine HCl (Ophthalmic 1 Proleukin (Injection) 2 Solution) Promethazine HCl (25mg/ml 1 Restasis (Emulsion) 2 Injection) Restasis Multidose (Emulsion) 2 Pulmozyme (Inhalation Solution) 2 Tetracaine HCl (0.5% Ophthalmic 1 Rebif Rebidose (Injection) 3 Solution) Risperdal Consta (Injection) 3 Visudyne (Injection) 3 Saphris (2.5mg Tablet Sublingual, 2 Ophthalmic Agents : Ophthalmic Anti-allergy Agents 5mg Tablet Sublingual) Alocril (Ophthalmic Solution) 3 Soliris (Injection) 2 Alomide (Ophthalmic Solution) 3 Solu-Cortef (Injection) 3 Azelastine HCl (0.05% Ophthalmic 1

Bold type = Brand-name drug 60 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Solution) Solution) Bepreve (Ophthalmic Solution) 3 Apraclonidine (Ophthalmic 1 Cromolyn Sodium (4% Ophthalmic 1 Solution) Solution) Azopt (Suspension) 2 Elestat (Ophthalmic Solution) 3 Betagan (Ophthalmic Solution) 3 Emadine (Ophthalmic Solution) 3 Betaxolol HCl (0.5% Ophthalmic 1 Epinastine HCl (Ophthalmic 1 Solution) Solution) Betimol (Ophthalmic Solution) 3 Lastacaft (Ophthalmic Solution) 3 Betoptic-S (Suspension) 2 Olopatadine HCl (0.1% Ophthalmic 1 Brimonidine Tartrate (Ophthalmic 1 Solution) Solution) Pataday (Ophthalmic Solution) 2 Carteolol HCl (Ophthalmic 1 Patanol (Ophthalmic Solution) 3 Solution) Pazeo (Ophthalmic Solution) 2 Combigan (Ophthalmic Solution) 2 Ophthalmic Agents : Ophthalmic Anti- Cosopt (Ophthalmic Solution) 3 inflammatories Cosopt PF (Ophthalmic Solution) 3 Diamox (Capsule Extended- 3 Acular (Ophthalmic Solution) 3 Release 12 Hour) Acular LS (Ophthalmic Solution) 3 Dorzolamide HCl/Timolol Maleate 1 Acuvail (Ophthalmic Solution) 3 (Ophthalmic Solution) Alrex (Suspension) 3 Iopidine (Ophthalmic Solution) 3 Bromfenac (Ophthalmic Solution) 1 Isopto Carpine (Ophthalmic 3 Bromsite (Ophthalmic Solution) 3 Solution) Dexamethasone Sodium Phosphate 1 Istalol (Ophthalmic Solution) 3 (0.1% Ophthalmic Solution) Keveyis (Tablet) 3 Diclofenac Sodium (0.1% 1 Levobunolol HCl (Ophthalmic 1 Ophthalmic Solution) Solution) Durezol (Emulsion) 3 Metipranolol (Ophthalmic Solution) 1 Flarex (Suspension) 3 Phospholine Iodide (Ophthalmic 2 Fluorometholone (Ophthalmic 1 Solution) Suspension) Pilocarpine HCl (1% Ophthalmic 1 Flurbiprofen Sodium (Ophthalmic 1 Solution, 2% Ophthalmic Solution, Solution) 4% Ophthalmic Solution) FML (Ointment) 2 Simbrinza (Suspension) 2 FML Forte (Suspension) 2 Timolol Maleate (0.25% 1 FML Liquifilm (Suspension) 3 Ophthalmic Solution, 0.5% Ilevro (Suspension) 3 Ophthalmic Solution) Ketorolac Tromethamine (0.4% 1 Timolol Maleate Ophthalmic Gel 1 Ophthalmic Solution, 0.5% Forming (Solution) Ophthalmic Solution) Timoptic (Ophthalmic Solution) 3 Lotemax (0.5% Gel, 0.5% 3 Timoptic Ocudose (Ophthalmic 2 Ointment, 0.5% Suspension) Solution) Maxidex (Suspension) 3 Timoptic-XE (Gel Form Solution) 3 Nevanac (Suspension) 3 Otic Agents Ocufen (Ophthalmic Solution) 3 Acetic Acid (Otic Solution) 1 Omnipred (Suspension) 3 Acetic Acid/Aluminum Acetate 1 Pred Forte (Suspension) 3 (Otic Solution) Pred Mild (Suspension) 2 Cipro HC (Suspension) 3 Prednisolone Acetate (Suspension) 1 Ciprodex (Otic Suspension) 2 Prednisolone Sodium Phosphate 1 Coly-Mycin S (Suspension) 3 (1% Ophthalmic Solution) Hydrocortisone/Acetic Acid (Otic 1 Prolensa (Ophthalmic Solution) 3 Solution) Ophthalmic Agents : Ophthalmic Antiglaucoma Neomycin/Polymyxin/Hydrocortiso 1 Agents ne (1% Otic Solution, 1% Otic Suspension) Acetazolamide ER (Capsule 1 Extended-Release 12 Hour) Pramotic (Liquid) 2 Alphagan P (Ophthalmic 2 Oxytocics

Bold type = Brand-name drug 61 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Oxytocin/Dextrose (5%-40unit/L 3 Symbicort (Aerosol) 2 Solution) Triamcinolone Acetonide 1 Oxytocin/Dextrose/Lactated 3 (55mcg/act Aerosol) Ringers (Solution) Zetonna (Aerosol Solution) 3 Oxytocin/Lactated Ringers 3 Respiratory Tract/Pulmonary Agents : Oxytocin/Sodium Chloride 3 Antihistamines (20unit/L-0.45% Solution, 30unit/L-0.9% Solution, 60unit/L- Astepro (Nasal Solution) 3 0.9% Solution) Azelastine HCl (0.1% Nasal 1 Oxytocin/Sodium Chloride 1 Solution, 0.15% Nasal Solution) (30unit/500ml-0.9% Solution) Bromphen/Pseudoephedrine 1 HCl/Dextromethorphan HBr (Syrup) Respiratory Tract Agents : Expectorants Brompheniramine Tannate 3 Mucinex Maximum Strength 2 (Tablet Chewable) (1200mg Tablet Extended-Release Carbinoxamine Maleate (4mg 1 12 Hour) Tablet, 4mg/5ml Oral Solution) Respiratory Tract/Pulmonary Agents : Anti- Cetirizine HCl (1mg/ml Syrup) 1 inflammatories, Inhaled Corticosteroids Clarinex (0.5mg/ml Syrup, 5mg 3 Advair Diskus (Aerosol Powder) 2 Tablet) Advair HFA (Aerosol) 2 Clemastine Fumarate (2.68mg 2 Aerospan (Aerosol Solution) 3 Tablet) Alvesco (Aerosol Solution) 3 Desloratadine (Tablet) 1 Arnuity Ellipta (Aerosol Powder) 2 Desloratadine ODT (Tablet 1 Asmanex HFA (Aerosol) 3 Dispersible) Asmanex Twisthaler 120 Metered 3 Dymista (Suspension) 2 Doses (Aerosol Powder) Hydrocodone 1 Asmanex Twisthaler 14 Metered 3 Bitartrate/Chlorpheniramine Doses (Aerosol Powder) Maleate/PSE (Oral Solution) Asmanex Twisthaler 30 Metered 3 Hydrocodone 1 Doses (Aerosol Powder) Polistirex/Chlorpheniramine Asmanex Twisthaler 60 Metered 3 Polistirex (Suspension Extended- Doses (Aerosol Powder) Release) Asmanex Twisthaler 7 Metered 3 Karbinal ER (Suspension 3 Doses (Aerosol Powder) Extended-Release) Beconase AQ (Suspension) 3 Levocetirizine Dihydrochloride 1 (2.5mg/5ml Oral Solution, 5mg Breo Ellipta (Aerosol Powder) 2 Tablet) Budesonide (0.25mg/2ml 1 Olopatadine HCl (0.6% Nasal 1 Suspension, 0.5mg/2ml Suspension, Solution) 1mg/2ml Suspension, 32mcg/act Suspension) Patanase (Nasal Solution) 3 Dulera (Aerosol) 3 Promethazine/Phenylephrine 1 (Syrup) Flovent Diskus (Aerosol Powder) 2 Tussionex Pennkinetic Extended- 3 Flovent HFA (Aerosol) 2 Release (Suspension Extended- Flunisolide (Nasal Solution) 1 Release) Fluticasone Propionate (50mcg/act 1 Xyzal (2.5mg/5ml Oral Solution, 3 Suspension) 5mg Tablet) Mometasone Furoate (50mcg/act 1 Zutripro (Oral Solution) 3 Suspension) Nasonex (Suspension) 2 Respiratory Tract/Pulmonary Agents : Omnaris (Suspension) 3 Antileukotrienes Pulmicort (Suspension) 3 Accolate (Tablet) 3 Pulmicort Flexhaler (Aerosol 2 Montelukast Sodium (10mg Tablet, 1 Powder) 4mg Packet, 4mg Tablet Chewable, 5mg Tablet Chewable) Qnasl (Aerosol Solution) 3 3 Qnasl Childrens (Aerosol 3 Singulair (10mg Tablet, 4mg Solution) Packet, 4mg Tablet Chewable, 5mg Tablet Chewable) QVAR (Aerosol Solution) 2 Zafirlukast (Tablet) 1 Rhinocort Aqua (Suspension) 3 Zyflo (Tablet) 3

Bold type = Brand-name drug 62 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Zyflo CR (Tablet Extended- 3 Powder) Release 12 Hour) Proventil HFA (Aerosol Solution) 3 Respiratory Tract/Pulmonary Agents : Serevent Diskus (Aerosol Powder) 2 Bronchodilators, Anticholinergic Striverdi Respimat (Aerosol 3 Anoro Ellipta (Aerosol Powder) 2 Solution) Atrovent HFA (Aerosol Solution) 3 Terbutaline Sulfate (1mg/ml 1 Injection, 2.5mg Tablet, 5mg Combivent Respimat (Aerosol 2 Tablet) Solution) Ventolin HFA (Aerosol Solution) 2 Incruse Ellipta (Aerosol Powder) 2 Vospire ER (Tablet Extended- 3 Ipratropium Bromide (0.02% 1 Release 12 Hour) Inhalation Solution, 0.03% Nasal Solution, 0.06% Nasal Solution) Xopenex (Nebulized Solution) 3 Spiriva HandiHaler (Capsule) 2 Xopenex Concentrate (Nebulized 3 Solution) Spiriva Respimat (Aerosol 2 Solution) Xopenex HFA (Aerosol) 3 Tudorza Pressair (Aerosol 3 Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Powder) Agents Respiratory Tract/Pulmonary Agents : Kalydeco (150mg Tablet, 50mg 3 Bronchodilators, Sympathomimetic Packet, 75mg Packet) Adrenaclick (Injection) 3 Orkambi (Tablet) 3 Adrenalin (0.1% Nasal Solution, 3 Respiratory Tract/Pulmonary Agents : Mast Cell 1mg/ml Injection, 30mg/30ml Stabilizers Injection) Cromolyn Sodium (20mg/2ml 1 Albuterol Sulfate (Nebulized 1 Nebulized Solution) Solution, Tablet, Syrup) Respiratory Tract/Pulmonary Agents : Albuterol Sulfate ER (Tablet 1 Extended-Release 12 Hour) Phosphodiesterase Inhibitors, Airways Disease Arcapta Neohaler (Capsule) 3 Aminophylline (Injection) 1 Auvi-Q (Solution Auto injector) 3 Daliresp (Tablet) 3 Brovana (Nebulized Solution) 3 Elixophyllin (Elixir) 2 Ephedrine Sulfate (250mg/5ml 3 Theo-24 (Capsule Extended- 3 Injection) Release 24 Hour) Ephedrine Sulfate/Sodium 3 Theophylline (Oral Solution) 1 Chloride (100mg/10ml-0.9% Theophylline CR (Tablet Extended- 1 Injection, 10mg/ml-0.9% Release 12 Hour) Injection, 25mg/5ml-0.9% Theophylline ER (Tablet Extended- 1 Injection, 50mg/5ml-0.9% Release 12 Hour, Tablet Extended- Injection) Release 24 Hou) Epinephrine (0.15mg/0.15ml 3 Theophylline/D5W (Injection) 3 Solution Auto injector, Respiratory Tract/Pulmonary Agents : Pulmonary 0.3mg/0.3ml Solution Auto injector) (authorized generic Epi- Antihypertensives Pen made by Mylan) Adcirca (Tablet) 3 Epinephrine (0.15mg/0.3ml 2 Adempas (Tablet) 2 Injection, 0.3mg/0.3ml Injection) Epoprostenol Sodium (Injection) 1 Epinephrine HCl (1mg/ml 3 Flolan (Injection) 3 Injection) Letairis (Tablet) 2 EpiPen (Injection) 3 Opsumit (Tablet) 2 Isuprel (Injection) 3 Orenitram (Tablet Extended- 3 Levalbuterol (Nebulized Solution) 1 Release) Levalbuterol Tartrate HFA 3 Remodulin (Injection) 2 (Aerosol) Revatio (10mg/12.5ml Injection, 3 Metaproterenol Sulfate (10mg 1 10mg/ml Suspension, 20mg Tablet, 20mg Tablet, 10mg/5ml Tablet) Syrup) Sildenafil (10mg/12.5ml Injection, 1 Perforomist (Nebulized Solution) 3 20mg Tablet) ProAir HFA (Aerosol Solution) 2 Tracleer (Tablet) 2 ProAir RespiClick (Aerosol 2 Tyvaso (Inhalation Solution) 3

Bold type = Brand-name drug 63 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Tyvaso Refill (Inhalation 3 Carisoprodol (250mg Tablet, 350mg 1 Solution) Tablet) Tyvaso Starter (Inhalation 3 Carisoprodol/Aspirin (Tablet) 1 Solution) Carisoprodol/Aspirin/Codeine 1 Uptravi (Tablet) 3 (Tablet) Veletri (Injection) 2 Chlorzoxazone (Tablet) 1 Ventavis (Inhalation Solution) 3 Cisatracurium Besylate (Injection) 1 Respiratory Tract/Pulmonary Agents : Respiratory Cyclobenzaprine HCl (10mg Tablet, 1 Tract Agents, Other 5mg Tablet, 7.5mg Tablet) Dantrium IV (Injection) 3 Acetadote (Injection) 3 Fexmid (Tablet) 3 Acetylcysteine (10% Inhalation 1 Solution, 20% Inhalation Solution, Lorzone (Tablet) 3 200mg/ml Injection) Metaxalone (Tablet) 1 Aralast NP (Injection) 3 Methocarbamol (Injection, Tablet) 1 Benzonatate (Capsule) 1 Nimbex (Injection) 3 Cetylev (Tablet Effervescent) 3 Orphenadrine Citrate (30mg/ml 1 Cinqair (Injection) 3 Injection) Curosurf (Suspension) 3 Orphenadrine Citrate ER (Tablet 1 Extended-Release 12 Hour) Esbriet (Capsule) 3 Pancuronium Bromide (Injection) 1 Exactuss (Liquid) 3 Parafon Forte DSC (Tablet) 3 Giltuss (Liquid) 3 Quelicin (Injection) 3 Glassia (Injection) 3 Robaxin (Injection, 500mg Tablet) 3 Hydrocodone 1 Bitartrate/Homatropine Robaxin-750 (Tablet) 3 Methylbromide (1.5mg-5mg Tablet, Rocuronium Bromide (100mg/10ml 1 1.5mg/5ml-5mg/5ml Syrup) Injection, 50mg/5ml Injection) Hyper-Sal (Nebulized Solution) 3 Rocuronium Bromide (50mg/5ml 3 Hypersal (Nebulized Solution) 3 Injection) Infasurf (Suspension) 3 Skelaxin (Tablet) 3 Iodine Strong (5%-10% Oral 3 Soma (Tablet) 3 Solution) Succinylcholine Chloride 3 Lugols (Solution) 3 (100mg/5ml Injection, 200mg/10ml Injection) Nebusal (6% Nebulized Solution) 3 Vecuronium Bromide (10mg 1 Ofev (Capsule) 3 Injection, 20mg Injection) Prolastin-C (Injection) 3 Vecuronium Bromide/Sodium 3 Promethazine-DM (Syrup) 1 Chloride (Injection) Promethazine/Codeine (Syrup) 1 Skin and Mucous Membrane Preparations : Anti- Promethazine/Phenylephrine/Codein 1 e (Syrup) infectives Rezira (Oral Solution) 3 Rosadan Kit (Kit) 3 Ribavirin (6gm Solution) 1 Skin and Mucous Membrane Preparations : Anti- Sodium Chloride (Nebulized 1 inflammatory Agents Solution) Synalar Cream Kit (Kit) 3 SSKI (Oral Solution) 2 Ultravate X (Kit) 3 Stiolto Respimat (Aerosol 2 Skin and Mucous Membrane Preparations : Cell Solution) Survanta Intratracheal 3 Stimulants and Proliferants (Suspension) Retinoic Acid (Powder) 2 Tessalon Perles (Capsule) 3 Retinoic Acid-All Trans (Powder) 2 Tyzine Pediatric Nasal Drops 3 Tretinoin (Powder) 2 (Nasal Solution) Skin and Mucous Membrane Preparations : Skin and Virazole (Inhalation Solution) 3 Mucous Membrane Agents, Misc Xolair (Injection) 2 Absorica (25mg Capsule, 35mg 3 Zemaira (Injection) 3 Capsule) Skeletal Muscle Relaxants Rhofade (Cream) 3 Anectine (Injection) 3 Scarlet Red Dressing 3 Atracurium Besylate (Injection) 1

Bold type = Brand-name drug 64 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Sleep Disorder Agents : GABA Receptor Modulators Aminosyn-HBC (Injection) 3 Ambien (Tablet) 3 Aminosyn-PF (Injection) 3 Ambien CR (Tablet Extended- 3 Aminosyn-RF (Injection) 3 Release) Axona (Packet) 3 Edluar (Tablet Sublingual) 3 Calcifol (Wafer) 3 Eszopiclone (Tablet) 1 Calcium Chloride (10% Injection) 1 Intermezzo (Tablet Sublingual) 3 Calcium Gluconate/Sodium 3 Lunesta (Tablet) 3 Chloride (1gm/100ml-0.9% Sonata (Capsule) 3 Injection, 2gm/100ml-0.9% Injection, 2gm/50ml-0.9% Zaleplon (Capsule) 1 Injection) Zolpidem Tartrate (Tablet 1 Camino Pro Bettermilk/Glytactin 3 Sublingual, Tablet) (Packet) Zolpidem Tartrate ER (Tablet 1 Camino Pro Complete/Glytactin 3 Extended-Release) (Bar) Zolpimist (Oral Solution) 3 Camino Pro Swirl (Packet) 3 Sleep Disorder Agents : Sleep Disorders, Other Chromium Chloride (Injection) 1 Armodafinil (Tablet) 1 Clinimix/Dextrose (Injection) 3 Belsomra (Tablet) 3 Copper Trace Metal (Injection) 3 Butisol Sodium (Tablet) 3 Corvite 150 (Tablet) 3 Modafinil (Tablet) 1 Cytra-3 (Syrup) 2 Nembutal Sodium (Injection) 3 Effervescent Potassium/Chloride 1 Nuvigil (Tablet) 3 (Tablet Effervescent) Provigil (Tablet) 3 Ferrlecit (Injection) 3 Rozerem (Tablet) 3 Fluoride (0.5mg Tablet Chewable) 1 Seconal Sodium (Capsule) 3 Folivane-F (Capsule) 3 Silenor (Tablet) 3 Fosteum Plus (Capsule) 3 Tryptophan (500mg Capsule) 3 Fovex (Capsule) 3 Xyrem (Oral Solution) 3 FreAmine HBC 6.9% (Injection) 3 Therapeutic Nutrients/Minerals/Electrolytes : FreAmine III (Injection) 3 Feraheme (Injection) 3 Gabadone (Capsule) 3 Kabiven (Injection) 3 Galzin (Capsule) 3 Therapeutic Nutrients/Minerals/Electrolytes : Glytactin Bettermilk 15 (Packet) 3 Electrolyte/Mineral Modifiers Glytactin Bettermilk De-Lite 3 (Packet) Carbaglu (Tablet) 2 Glytactin Build 10pe (Packet) 3 Chemet (Capsule) 3 Glytactin Complete 10pe (Bar) 3 Exjade (Tablet Soluble) 3 Glytactin Restore 5 (Packet) 3 Jadenu (Tablet) 3 Glytactin Restore Lite 10PE 3 Kayexalate (Powder) 3 (Packet) Samsca (Tablet) 2 Hematron-Af (Tablet) 3 Sodium Acetate (2meq/ml Injection) 1 HepatAmine (Injection) 3 Sodium Bicarbonate (7.5% 1 Hextend (Injection) 3 Injection) Hypertensa (Capsule) 3 Sodium Lactate (Injection) 3 Infed (Injection) 3 Sodium Polystyrene Sulfonate 1 (Powder, Suspension) Integra F (40mg-62.5mg- 3 1000mcg-3mg-62.5mg Capsule) Syprine (Capsule) 3 K-Tab (10meq Tablet Extended- 3 Veltassa (Packet) 3 Release) Zinc Trace Metal (Injection) 3 K-Tab (20meq Tablet Extended- 2 Therapeutic Nutrients/Minerals/Electrolytes : Release, 8meq Tablet Extended- Electrolyte/Mineral Replacement Release) Aminosyn (Injection) 3 Klor-Con M15 (Tablet Extended- 3 Aminosyn 7%/Electrolytes 3 Release) (Injection) Lipichol 540 (Capsule) 3 Aminosyn II (Injection) 3 Lister-V (Capsule) 3 Aminosyn M (Injection) 3 Lozi-Flur (Lozenge) 2

Bold type = Brand-name drug 65 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Lukaid GLA (Emulsion) 3 Injection) Luride (Oral Solution) 3 Sodium Chloride 0.45% (Injection) 1 Macutek (Tablet Dispersible) 3 Sodium Chloride Bacteriostatic 1 Magnesium Chloride (200mg/ml 1 (0.9% Injection) Injection) Sodium Chloride 3 Magnesium Sulfate (20gm/500ml 3 Bacteriostatic/Benzyl Alcohol Injection, 2gm/50ml Injection, (Injection) 40gm/1000ml Injection, Sodium Chloride Flush (Injection) 1 4gm/100ml Injection, 4gm/50ml Sodium Ferric Gluconate 1 Injection) Complex/Sucrose (Injection) Manganese Trace Metal 3 Sodium Fluoride (0.25mg Tablet 1 (Injection) Chewable, 1.1mg Tablet Chewable, Micro-K (Capsule Extended- 3 1mg Tablet Chewable, 0.5mg/ml Release) Solution, 1mg Tablet) Multigen (Tablet) 3 Sodium Fluoride (0.5mg Tablet) 2 Multigen Folic (Tablet) 3 Sodium Phosphate (3MMOLE/ml 1 Multigen Plus (Tablet) 3 Injection) Nafrinse Daily/Acidulated 3 Sulfzix (500mcg-0-0-Capsule) 3 (Solution) Theramine (Capsule) 3 Nephramine (Injection) 3 Theramine Plus (Packet) 3 Neurepa (Capsule) 3 Travasol (Injection) 3 Nicaprin (Tablet) 3 Trepadone (Capsule) 3 Normal Saline Flush (Solution) 1 Trophamine (Injection) 3 Percura (Capsule) 3 Tylactin Restore 5PE (Packet) 3 Perikabiven (Injection) 3 Urocit-K (Tablet Extended- 3 Potassium Acetate (2meq/ml 1 Release) Injection) Vasculera (Tablet) 3 Potassium Acetate (2meq/ml 3 Venofer (Injection) 3 Injection, 4meq/ml Injection) Visbiome (Packet) 3 Potassium Chloride (10meq/50ml 3 Therapeutic Nutrients/Minerals/Electrolytes Injection) Krisgel 100 (Gel) 3 Potassium Chloride CR (Tablet 1 Plo Gel - Mediflo Kit (Kit) 3 Extended-Release) Sodium Citrate (Injection) 3 Potassium Chloride ER (10meq 1 Capsule Extended-Release, 8meq Sulfzix (500mcg/0.25gm-0-0-0 3 Capsule Extended-Release, 10meq Powder) Tablet Extended-Release, 20meq Therapeutic Nutrients/Minerals/Electrolytes : Tablet Extended-Release, 8meq Vitamins Tablet Extended-Release) Aquasol A Parenteral (Injection) 3 Potassium Chloride SR (Tablet 1 Atabex Prenatal (Tablet 2 Extended-Release) Chewable) Potassium Citrate ER (Tablet 1 B-6 Folic Acid (Capsule) 3 Extended-Release) Cerefolin Nac (Tablet) 3 Premasol (Injection) 3 Cod Liver Oil (0 Oil) 3 Prismasol (Injection) 3 Corvite (Tablet) 3 Procalamine (Injection) 3 Cyanocobalamin (1000mcg/ml 1 Proferrin-Forte (Tablet) 3 Injection) 3 Prosol (Injection) Floriva Plus (Oral Solution) 2 3 Proteolin (Tablet) Folbee Plus Cz (Tablet) 2 3 Pulmona (Capsule) Folbic RF (Tablet) 3 Saline Flush (Injection) 1 Folcaps Omega 3 (Capsule) 2 3 Saline/Phenol (Injection) Folgard Rx (Tablet) 3 Sentra AM (Capsule) 3 Folic Acid (1mg Tablet) 1 3 Sentra PM (Capsule) Folic Acid (5mg/ml Injection) 3 Shohls Solution Modified (Oral 3 Folic Acid/Vitamin B-6/Vitamin B- 1 Solution) 12 (Tablet) Sodium Chloride (2.5meq/ml 1 Foltanx (Tablet) 3 Injection, 3% Injection, 5% Foltanx RF (Capsule) 3

Bold type = Brand-name drug 66 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Foltx (Tablet) 3 Thiamine HCl (100mg/ml Injection) 1 Fortavit (Capsule) 3 Triveen-Duo DHA 3 Fosteum (Capsule) 3 Vascazen (Capsule) 3 Healthy Mama Be Well Rounded 2 Vayacog (Capsule) 3 (Therapy Pack) Vayarin (Capsule) 3 Hydroxocobalamin (Injection) 3 Vayarol (Capsule) 3 Infuvite (Injection) 3 Vinate Care (Tablet Chewable) 2 Infuvite Pediatric (Injection) 3 Vitamin C 222mg (Injection) 1 L-Methyl-B6-B12 (Tablet) 3 Vitamin D (50000unit Capsule) 1 L-Methylfolate Ca/P-5-P/Me-Cbl 1 Vitamin K1 (10mg/ml Injection) 3 (Capsule) Vitamin K1 (1mg/0.5ml Injection) 1 Lmthf/Pyridoxine 1 Vitaroca Plus (Tablet) 3 HCl/Cyanocobalamin (Tablet) Wheat Germ (Oil) 3 3 M.V.I. Adult (Injection) Your Life Multi Prenatal 2 M.V.I.-12 without Vitamin K 3 (Capsule) (Injection) Zatean-PN DHA (Capsule) 3 Mephyton (Tablet) 2 Vitamins : Multivitamin Preparations Metafolbic Plus (Tablet) 3 Adrenal C Formula (Tablet) 3 Metafolbic Plus RF (Tablet) 3 Atabex EC (Tablet Delayed- 2 Metanx (Capsule) 3 Release) Methionine/Inositol/Choline/Cyan 3 Bal-Care DHA 2 ocobalamin (Injection) Citranatal B-Calm 2 Mission Prenatal (Tablet) 2 Citranatal Rx (Tablet) 2 NascoBAL (Nasal Solution) 3 Clinical Nutrients Prenatal 2 Nephro-Vite Rx (Tablet) 3 Formula (Tablet) Nephrocaps (Capsule) 3 Concept DHA (Capsule) 2 Niacin (Powder) 3 Concept Ob (Capsule) 2 Nicadan (Tablet) 3 Duet DHA 400 2 Nicadan Zx (Tablet) 3 Duet DHA Balanced 2 Nicazel (Tablet) 3 Enbrace HR (Capsule) 2 Nicazel Forte (Tablet) 3 Escavite (Tablet Chewable) 2 Niva-Plus (Tablet) 2 Escavite D (Tablet Chewable) 2 Nutricap (Tablet) 3 Focalgin 90 DHA 3 O-Cal Fa (Tablet) 2 Focalgin Ca 3 OB Complete (Tablet) 2 Folgard Os (Tablet) 3 Obtrex (Tablet) 2 Folivane-Ob (Capsule) 2 One A Day Womens 2 M.V.I. Pediatric (Injection) 3 Prenatal/DHA Marnatal-F (Capsule) 2 One A Day Womens Prenatal1 2 (Capsule) Mteryti (Tablet Therapy Pack) 2 One-A-Day Womens Prenatal 2 Mteryti Folic 5 (Tablet Therapy 2 Pack) Phytonadione (Injection) 1 MyKidz Iron Fl (Suspension) 2 PKU Easy Microtabs (Tablet 3 Delayed-Release) Mynatal (Capsule) 2 Prenatal Vitamin (Tablet) 2 Natachew (Tablet Chewable) 2 Prenatal Vitamins (120mg- 2 Natalvit (Tablet) 2 4000unit-200mg-400unit-8mcg- Natelle One (Capsule) 2 28mg-800mcg-20mg-2.6mg-1.7mg- Neevo DHA (Capsule) 2 1.8mg-30unit-25mg Tablet) Nestabs (Tablet) 2 Protect Plus (Capsule) 3 Nestabs DHA 2 Pyridoxine HCl (100mg/ml 1 Newgen (Tablet) 2 Injection) Nexa Plus (Capsule) 3 Req 49+ (Tablet) 3 Nutrivit (Liquid) 3 Right Step Prenatal (Tablet) 2 O-Cal Prenatal (Tablet) 2 Siderol (Tablet) 3 OB Complete Gold (Capsule) 3 Theranatal Core Nutrition 2 OB Complete One (Capsule) 2 (Tablet) OB Complete Petite (Capsule) 2

Bold type = Brand-name drug 67 [Plain type = Generic drug]

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits OB Complete Premier (Tablet) 2 Cerefolin (Tablet) 3 OB Complete/DHA (Capsule) 2 Cyfolex (Capsule) 3 Obstetrix DHA 2 Elfolate Plus (Tablet) 3 Obstetrix One (Capsule) 3 Metafolbic (Tablet) 3 Obtrex DHA 2 Podiapn (Capsule) 3 Poly-Vi-Flor (Tablet 2 Pre-Folic (Tablet) 3 Chewable,Suspension) Vitamins : Vitamin D Poly-Vi-Flor Fs (Strip) 2 Rayaldee (Capsule Extended- 3 Poly-Vi-Flor/Iron (Tablet 2 Release) Chewable, Suspension) PreferaOB (Tablet) 2 Prenata (Tablet Chewable) 2 Prenate AM (Tablet) 2 Prenate Elite (Tablet) 2 Prenate Essential (Capsule) 2 Prenate Star (Tablet) 2 Primacare (Capsule) 2 Provida OB (Capsule) 2 Quflora Fe (Tablet Chewable) 3 R-Natal OB (Capsule) 3 Renatabs (Tablet) 3 Select-OB (Tablet Chewable) 2 Strovite Forte (Syrup) 3 Supervite (Liquid) 3 Support-500 (Capsule) 3 Synagex (Capsule) 3 Synatek (Capsule) 3 Taron-BC 2 Taron-C DHA (Capsule) 2 Tl G-Fol Os (Tablet) 3 Tri-Vi-Flor (Suspension) 2 Tricare Prenatal (Tablet 2 Chewable) Tricare Prenatal Compleat 2 Tricare Prenatal DHA One 2 (Capsule) Udamin Sp (Tablet) 3 Vinate DHA RF (Capsule) 2 Vita-Pren (Tablet) 2 Vitafol Gummies (Tablet 2 Chewable) Vitafol-Nano (Tablet) 2 Vitamedmd One Rx/Quatrefolic 3 (Capsule) Vitamedmd Redichew Rx (Tablet 2 Chewable) Vitapearl (Capsule Extended- 2 Release) Viva DHA (Capsule) 2 Zatean-PN Plus (Capsule) 2 Vitamins : Vitamin A Vitamin A (Capsule) 2 Vitamins : Vitamin B Complex Abaneu-Sl (Tablet Sublingual) 3 Cardiotek-Rx (Tablet) 3 Cenfol (Tablet) 3

Bold type = Brand-name drug 68 [Plain type = Generic drug]

Index of Covered Drugs

Accutrend Glucose (Strip) ...... 52 Adasuve (Aerosol Powder) ...... 27 1 Acebutolol HCl (200mg Capsule, 400mg Adcetris (Injection) ...... 26 Capsule) ...... 35 Adcirca (Tablet) ...... 63 1st Choice Lancets Thin ...... 52 Aceon (Tablet) ...... 34 Adderall (Tablet) ...... 39 1st Tier Unifine Pentips 29gx12mm ...... 52 Acetadote (Injection) ...... 64 Adderall XR (Capsule Extended-Release 24 1st Tier Unifine Pentips 31gx6mm ...... 52 Acetaminophen/Caffeine/Dihydrocodeine Hour) ...... 39 1st Tier Unifine Pentips 31gx8mm ...... 52 (Capsule) ...... 11 Addyi (Tablet)...... 39 Acetaminophen/Codeine (120mg/5ml- Adefovir Dipivoxil (Tablet) ...... 28 3 12mg/5ml Oral Solution, 300mg-15mg Adempas (Tablet) ...... 63 3ml Glass Syringe Kit/1ml Na Tablet, 300mg-30mg Tablet, 300mg-60mg Adenocard (Injection) ...... 34 Hep/Swab/Prep/Cap/Ndl St/Label/Drap Tablet) ...... 11 Adenosine (12mg/4ml Injection, 6mg/2ml (Kit) ...... 52 Acetazolamide (Tablet Immediate-Release) 36 Injection) ...... 34 Acetazolamide ER (Capsule Extended-Release Adenosine (60mg/20ml Injection, 5 12 Hour) ...... 61 90mg/30ml Solution Prefilled Syringe) . 38 Acetazolamide Sodium (Solution) ...... 59 Adlyxin (Injection) ...... 50 5ml Glass Syringe Kit/1ml Na Acetic Acid (Otic Solution) ...... 61 Adlyxin Starter Pack (Injection) ...... 50 Hep/Swab/Prep/Cap/Ndl St/Label/Drap Acetic Acid/Aluminum Acetate (Otic Solution) Adoxa (100mg Tablet, 50mg Tablet, 75mg (Kit) ...... 52 ...... 61 Tablet, 150mg Capsule) ...... 18 Acetylcysteine (10% Inhalation Solution, 20% Adoxa Pak 1/100 (Tablet) ...... 18 A Inhalation Solution, 200mg/ml Injection) Adoxa Pak 1/150 (Tablet) ...... 18 ...... 64 Adoxa Pak 2/100 (Tablet) ...... 18 Abacavir (Tablet) ...... 28 Aciphex (Tablet Delayed-Release) ...... 45 Adrenaclick (Injection) ...... 63 Abacavir Sulfate/Lamivudine/Zidovudine Aciphex Sprinkle (Capsule Sprinkle) ...... 45 Adrenal C Formula (Tablet) ...... 67 (Tablet) ...... 28 Acitretin (Capsule) ...... 40 Adrenalin (0.1% Nasal Solution, 1mg/ml Abacavir/Lamivudine (Tablet) ...... 28 Aclovate (Cream) ...... 40 Injection, 30mg/30ml Injection) ...... 63 Abaneu-Sl (Tablet Sublingual) ...... 68 Actemra (162mg/0.9ml Injection, Advair Diskus (Aerosol Powder) ...... 62 Abelcet (Injection) ...... 22 200mg/10ml Injection, 400mg/20ml Advair HFA (Aerosol) ...... 62 Abilify (Tablet) ...... 20 Injection, 80mg/4ml Injection)...... 51 Advate (Injection) ...... 32 Abilify Maintena (Injection)...... 59 Acticlate (Tablet) ...... 18 Advocate Insulin Pen Needles ...... 52 Abraxane (Injection) ...... 59 Actigall (Capsule) ...... 44 Advocate Lancets ...... 52 Absorica (10mg Capsule, 20mg Capsule, Actimmune (Injection) ...... 51 Advocate Lancets 30g ...... 52 30mg Capsule, 40mg Capsule) ...... 40 Actiq (Lollipop) ...... 11 Advocate Safety Lancets 26g ...... 52 Absorica (25mg Capsule, 35mg Capsule) .... 64 Activase (Injection) ...... 32 Adzenys XR-ODT (Tablet Extended-Release Abstral (Tablet Sublingual) ...... 11 Active 1st Blood Lancets 30g/Easy Twist Cap Dispersible) ...... 39 Acamprosate Calcium DR (Tablet Delayed- ...... 52 AeroChamber Mini Aerosol Chamber Release) ...... 13 Activella (Tablet) ...... 48 (Device) ...... 52 Acanya (Gel) ...... 40 Actonel (Tablet) ...... 51 AeroChamber MV ...... 53 Acarbose (Tablet) ...... 30 Actoplus Met (Tablet) ...... 30 AeroChamber Plus Flow Vu ...... 53 Accolate (Tablet) ...... 62 Actoplus Met XR (Tablet Extended-Release AeroChamber Plus Flow-Vu ...... 53 Accu-Chek Aviva ...... 52 24 Hour) ...... 50 AeroChamber Plus Flow-Vu/Large Mask.... 53 Accu-Chek Aviva Connect (Kit) ...... 52 Actos (Tablet) ...... 30 AeroChamber Plus Flow-Vu/Mask ...... 53 Accu-Chek Aviva Plus (Kit, Strip) ...... 52 Acular (Ophthalmic Solution) ...... 61 AeroChamber Plus Flow-Vu/Medium Mask Accu-Chek Compact Plus (Strip) ...... 52 Acular LS (Ophthalmic Solution) ...... 61 ...... 53 Accu-Chek Compact Plus Care Kit (Kit) ...... 52 Acuvail (Ophthalmic Solution) ...... 61 AeroChamber Plus Flow-Vu/Small Mask ... 53 Accu-Chek Compact Test Drum (Strip) ...... 52 Acyclovir (200mg Capsule, 200mg/5ml AeroChamber Z-Stat Plus/Medium Mask .. 53 Accu-Chek Fastclix Lancet Device Kit (Kit) .. 52 Suspension, 400mg Tablet, 800mg Tablet, AeroChamber/FlowSignal ...... 53 Accu-Chek Fastclix Lancets ...... 52 5% Ointment) ...... 29 Aerospan (Aerosol Solution)...... 62 Accu-Chek Guide (Kit, Strip) ...... 52 Acyclovir Sodium (Injection) ...... 29 Aerovent Plus Holding Chamber/Collapsible Accu-Chek Multiclix Lancet Device Kit (Kit) 52 Aczone (Gel) ...... 40 (Device) ...... 53 Accu-Chek Multiclix Lancets ...... 52 Adagen (Injection) ...... 43 AF Lancets Super Thin ...... 53 Accu-Chek Nano Smartview (Kit)...... 52 Adalat CC (30mg Tablet Extended-Release 24 Afinitor (Tablet) ...... 25 Accu-Chek Safe-T-Pro Lancets ...... 52 Hour, 60mg Tablet Extended-Release 24 Afinitor Disperz (Tablet Soluble) ...... 25 Accu-Chek Safe-T-Pro Pluslancets ...... 52 Hour, 90mg Tablet Extended-Release 24 Afrezza (Powder)...... 31 Accu-Chek Smartview Strips (Strip) ...... 52 Hour) ...... 35 Agamatrix Ultra-Thin Lancets 33g ...... 53 Accu-Chek Soft Touch Lancets ...... 52 Adapalene (0.1% Cream, 0.1% Gel, 0.3% Gel) Aggrastat (0.9%-12.5mg/250ml Injection, Accu-Chek Softclix Lancet Device Kit (Kit) .. 52 ...... 40 0.9%-5mg/100ml Injection) ...... 33 Accu-Chek Softclix Lancets ...... 52 Adapalene (0.1% Lotion) ...... 40 Aggrastat (3.75mg/15ml Injection) ...... 52 Accupril (Tablet) ...... 34 Adapalene Pump (Gel) ...... 40 Aggrenox (Capsule Extended-Release 12 Accuretic (Tablet) ...... 34 69

Hour) ...... 33 Altace (Capsule) ...... 34 Amoxicillin/Clavulanate Potassium ER (Tablet Agrylin (Capsule) ...... 32 Altoprev (Tablet Extended-Release 24 Hour) Extended-Release 12 Hour) ...... 16 Akten (Gel) ...... 12 ...... 37 Amphadase (Injection)...... 52 Akynzeo (Capsule)...... 21 Alvesco (Aerosol Solution) ...... 62 Amphetamine/Dextroamphetamine Ala Scalp (Lotion) ...... 40 Amantadine HCl (100mg Capsule, 100mg (1.875mg-1.875mg-1.875mg-1.875mg Ala-Quin (Cream) ...... 22 Tablet, 50mg/5ml Syrup)...... 26 Tablet, 10mg Tablet, 12.5mg Tablet, 15mg Albenza (Tablet) ...... 26 Amaryl (Tablet) ...... 30 Tablet, 20mg Tablet, 30mg Tablet, 5mg Albuterol Sulfate (Nebulized Solution, Tablet, Ambien (Tablet) ...... 65 Tablet, 10mg Capsule ER, 15mg Capsule Syrup) ...... 63 Ambien CR (Tablet Extended-Release) ...... 65 ER, 20mg Capsule ER, 25mg Capsule ER, Albuterol Sulfate ER (Tablet Extended- AmBisome (Injection) ...... 22 30mg Capsule ER, 5mg Capsule ER) ...... 39 Release 12 Hour) ...... 63 Amcinonide (0.1% Cream, 0.1% Lotion, 0.1% Amphotericin B (50mg Injection) ...... 22 Alclometasone Dipropionate (0.05% Cream, Ointment) ...... 40 Ampicillin (125mg/5ml Suspension, 0.05% Ointment) ...... 40 Amerge (Tablet) ...... 23 250mg/5ml Suspension, 250mg Capsule, Alcoh-Glove Contoured Wipe ...... 14 Amicar (0.25gm/ml Oral Solution, 1000mg 500mg Capsule) ...... 16 Alcoh-Wipe 12" X 12" ...... 14 Tablet, 500mg Tablet)...... 32 Ampicillin Sodium (10gm Injection, 1gm Aldactazide (Tablet) ...... 37 Amifostine (Injection) ...... 59 Injection, 250mg Injection, 2gm Injection, Aldactone (Tablet) ...... 37 Amikacin Sulfate (1gm/4ml Injection, 500mg Injection) ...... 16 Aldara (Cream) ...... 40 500mg/2ml Injection) ...... 14 Ampicillin Sodium (125mg Injection, 1gm Aldurazyme (Injection) ...... 43 Amiloride HCl (5mg Tablet) ...... 37 Injection) ...... 16 Alecensa (Capsule) ...... 25 Amiloride/Hydrochlorothiazide (Tablet) ..... 37 Ampicillin-Sulbactam (10gm-5gm Injection, Alendronate Sodium (10mg Tablet, 35mg Amino PM Rms (Capsule) ...... 53 1gm-0.5gm Injection, 2gm-1gm Injection) Tablet, 40mg Tablet, 5mg Tablet, 70mg Aminocaproic Acid (Injection) ...... 33 ...... 16 Tablet)...... 51 Aminophylline (Injection) ...... 63 Ampyra (Tablet Extended-Release 12 Hour) Alendronate Sodium (70mg/75ml Oral Aminosyn (Injection) ...... 65 ...... 40 Solution) ...... 51 Aminosyn 7%/Electrolytes (Injection) ...... 65 Anadrol-50 (Tablet) ...... 48 Alevicyn Antipruritic SG (Liquid) ...... 40 Aminosyn II (Injection) ...... 65 Anafranil (Capsule) ...... 21 Alfentanil (Injection) ...... 11 Aminosyn M (Injection) ...... 65 Anagrelide HCl (Capsule) ...... 32 Alfentanil HCl (Injection) ...... 11 Aminosyn-HBC (Injection) ...... 65 Analpram-HC (1%-1% Cream) ...... 46 Alferon N (Injection) ...... 25 Aminosyn-PF (Injection) ...... 65 Analpram-HC (2.5%-1% Lotion) ...... 40 Alfuzosin HCl ER (Tablet Extended-Release 24 Aminosyn-RF (Injection) ...... 65 Anaprox DS (Tablet) ...... 10 Hour) ...... 46 Amiodarone HCl (100mg Tablet, 200mg Anastrozole (Tablet) ...... 25 Alimta (Injection) ...... 59 Tablet, 400mg Tablet, 50mg/ml Injection) Ancobon (Capsule) ...... 22 Alinia (100mg/5ml Suspension, 500mg ...... 34 Androderm (Patch 24 Hour) ...... 48 Tablet) ...... 26 Amiodarone HCl/Dextrose (Injection) ...... 34 AndroGel (25mg/2.5gm Gel, 50mg/5gm Gel) Alkeran (2mg Tablet) ...... 24 Amitiza (Capsule) ...... 45 ...... 48 Alkeran (50mg Injection) ...... 24 Amitriptyline HCl (100mg Tablet, 10mg AndroGel (40.5mg/2.5gm Gel) ...... 48 Allopurinol (Tablet) ...... 23 Tablet, 150mg Tablet, 25mg Tablet, 50mg Android (Capsule) ...... 48 Allopurinol Sodium (Injection) ...... 23 Tablet, 75mg Tablet) ...... 21 Androxy (Tablet) ...... 48 Almotriptan Malate (Tablet) ...... 23 Amlodipine Besylate (Tablet) ...... 35 Anectine (Injection) ...... 64 Alocril (Ophthalmic Solution) ...... 60 Amlodipine Besylate/Atorvastatin Calcium Angeliq (Tablet) ...... 48 Alogliptin (Tablet) ...... 30 (Tablet) ...... 35 Angiomax (Injection) ...... 32 Alogliptin/Metformin HCl (Tablet) ...... 30 Amlodipine Besylate/Benazepril HCl (Capsule) Anoro Ellipta (Aerosol Powder) ...... 63 Alogliptin/Pioglitazone (Tablet) ...... 30 ...... 34 Antabuse (Tablet) ...... 13 Alomide (Ophthalmic Solution) ...... 60 Amlodipine Besylate/Valsartan (Tablet) ..... 33 Antara (Capsule) ...... 37 Aloprim (Injection) ...... 23 Amlodipine/Olmesartan Medoxomil (Tablet) Antizol (Injection) ...... 53 Alora (Patch Twice Weekly) ...... 48 ...... 33 Anusol-HC (Cream) ...... 40 Alosetron HCl (Tablet) ...... 45 Amlodipine/Valsartan/Hydrochlorothiazide Anzemet (Tablet) ...... 22 Aloxi (Injection) ...... 22 (Tablet) ...... 34 Apidra (Injection) ...... 31 Alphagan P (Ophthalmic Solution) ...... 61 Ammonium Lactate (12% Cream, 12% Lotion) Apidra SoloStar (Injection) ...... 31 Alphanate/Von Willebrand Factor ...... 40 Aplenzin (Tablet Extended-Release 24 Hour) Complex/Human (250unit Injection) ..... 32 Ammonul (Injection) ...... 53 ...... 20 Alphanine SD (Injection) ...... 32 Amoxapine (Tablet) ...... 21 Apokyn (Injection) ...... 26 Alprazolam (Tablet Immediate-Release) ..... 29 Amoxicillin (125mg Tablet Chewable, 250mg App Slim RMS (Capsule) ...... 53 Alprazolam ER (Tablet Extended-Release 24 Tablet Chewable, 125mg/5ml Suspension, Apraclonidine (Ophthalmic Solution) ...... 61 Hour) ...... 29 200mg/5ml Suspension, 250mg/5ml Aprepitant (Capsule)...... 22 Alprazolam Intensol (1mg/ml Concentrate) Suspension, 400mg/5ml Suspension, Apriso (Capsule Extended-Release 24 Hour) ...... 29 250mg Capsule, 500mg Capsule, 500mg ...... 51 Alprazolam ODT (Tablet Dispersible) ...... 29 Tablet, 875mg Tablet) ...... 16 Aptiom (Tablet) ...... 18 Alprostadil (Injection) ...... 47 Amoxicillin/Clavulanate Potassium (Tablet Aptivus (100mg/ml Oral Solution, 250mg Alrex (Suspension) ...... 61 Chewable, Tablet Immediate-Release, Oral Capsule) ...... 29 Altabax (Ointment) ...... 14 Suspension) ...... 16 Aquasol A Parenteral (Injection) ...... 66 70

Aquoral (Solution)...... 40 Astamed Myo (Capsule) ...... 53 Avenova (Solution) ...... 40 Aralast NP (Injection) ...... 64 Astepro (Nasal Solution) ...... 62 Avenova/Neutrox (Solution) ...... 40 Aranesp Albumin Free (Injection) ...... 32 At Last Lancets ...... 53 Avidoxy DK (Kit) ...... 18 Arava (Tablet) ...... 51 Atabex EC (Tablet Delayed-Release) ...... 67 Avodart (Capsule) ...... 46 Arcalyst (Injection) ...... 51 Atabex Prenatal (Tablet Chewable) ...... 66 Avonex (Injection) ...... 40 Arcapta Neohaler (Capsule) ...... 63 Atacand (Tablet) ...... 34 Avonex Pen (Injection)...... 40 Argatroban (125mg/125ml-0.9% Injection, Atacand HCT (Tablet) ...... 34 Avycaz (Injection) ...... 15 250mg/250ml-0.9% Injection, 50mg/50ml Atelvia (Tablet Delayed-Release) ...... 51 Axert (Tablet) ...... 23 Injection) ...... 32 Atenolol (100mg Tablet, 25mg Tablet, 50mg Axiron (Transdermal Solution) ...... 48 Argatroban (250mg/2.5ml Injection) ...... 32 Tablet) ...... 35 Axona (Packet) ...... 65 Arial Chamber (Device) ...... 53 Atenolol/Chlorthalidone (Tablet) ...... 35 Aygestin (Tablet) ...... 49 Aricept (Tablet) ...... 20 Atgam (Injection) ...... 51 Azacitidine (Injection) ...... 59 Arimidex (Tablet) ...... 25 Ativan (0.5mg Tablet, 1mg Tablet, 2mg Azactam (Injection) ...... 16 Aripiprazole (10mg Tablet, 15mg Tablet, Tablet) ...... 19 Azactam in Iso-Osmotic Dextrose (Injection) 20mg Tablet, 2mg Tablet, 30mg Tablet, Ativan (2mg/ml Injection, 4mg/ml Injection) ...... 16 5mg Tablet, 1mg/ml Oral Solution) ...... 20 ...... 29 Azasan (Tablet) ...... 50 Aripiprazole ODT (Tablet Dispersible) ...... 59 Atopiclair (Cream) ...... 40 Azasite (Ophthalmic Solution) ...... 17 Aristada (Injection) ...... 27 Atorvastatin Calcium (Tablet) ...... 37 Azathioprine (100mg Injection, 50mg Tablet) Arixtra (Injection) ...... 32 Atovaquone (Suspension) ...... 26 ...... 50 Armodafinil (Tablet) ...... 65 Atovaquone/Proguanil HCl (Tablet) ...... 26 Azelastine HCl (0.05% Ophthalmic Solution)60 Armour Thyroid (Tablet) ...... 49 Atracurium Besylate (Injection) ...... 64 Azelastine HCl (0.1% Nasal Solution, 0.15% Arnica Flower (Tincture) ...... 53 Atralin (Gel) ...... 40 Nasal Solution) ...... 62 Arnuity Ellipta (Aerosol Powder) ...... 62 Atripla (Tablet) ...... 28 Azelex (Cream) ...... 40 Aromasin (Tablet) ...... 25 Atropen (Injection) ...... 44 Azilect (Tablet) ...... 27 Arranon (Injection) ...... 25 Atropine Sulfate (0.05mg/ml Injection, Azithromycin (100mg/5ml Suspension, Arthrotec 50 (Tablet Delayed-Release) ...... 10 0.8mg/2ml Injection) ...... 44 200mg/5ml Suspension, 1gm Packet, Arthrotec 75 (Tablet Delayed-Release) ...... 10 Atropine Sulfate (0.1mg/ml Injection, 250mg Tablet, 500mg Tablet, 600mg Articadent Dental (Injection) ...... 51 0.4mg/ml Injection, 1mg/ml Injection, Tablet, 500mg Injection) ...... 17 Artiss (External Solution) ...... 40 1mg/2.5ml Solution Prefilled Syringe) ... 44 Azopt (Suspension) ...... 61 Arymo ER (Tablet Extended-Release Abuse- Atropine Sulfate (1% Ointment) ...... 60 Azor (Tablet) ...... 34 Deterrent) ...... 38 Atropine Sulfate (1% Ophthalmic Solution) 60 Aztreonam (Injection) ...... 16 Arzerra (Injection) ...... 26 Atropine Sulfate (2mg/5ml Solution Prefilled Azulfidine (Tablet)...... 51 Arzol Silver Nitrate App Licators ...... 14 Syringe) ...... 30 Azulfidine EN-Tabs (Tablet Delayed-Release) Asacol HD (Tablet Delayed-Release) ...... 51 Atrovent HFA (Aerosol Solution) ...... 63 ...... 51 Asclera (Injection) ...... 36 Aubagio (Tablet) ...... 40 Asmanex HFA (Aerosol) ...... 62 Augmented Betamethasone Dipropionate B Asmanex Twisthaler 120 Metered Doses (0.05% Cream, 0.05% Gel, 0.05% Lotion, (Aerosol Powder) ...... 62 0.05% Ointment) ...... 40 B-6 Folic Acid (Capsule) ...... 66 Asmanex Twisthaler 14 Metered Doses Augmentin (125mg/5ml-31.25mg/5ml Bacitracin (50000unit Injection, 500unit/gm (Aerosol Powder) ...... 62 Suspension, 250mg/5ml-62.5mg/5ml Ophthalmic Ointment) ...... 14 Asmanex Twisthaler 30 Metered Doses Suspension, 500mg-125mg Tablet, Bacitracin/Polymyxin B (Ophthalmic (Aerosol Powder) ...... 62 875mg-125mg Tablet) ...... 16 Ointment) ...... 14 Asmanex Twisthaler 60 Metered Doses Augmentin ES-600 (Suspension) ...... 16 Baclofen (10mg Tablet, 20mg Tablet) ...... 27 (Aerosol Powder) ...... 62 Augmentin XR (Tablet Extended-Release 12 Bacteriostatic Water for Injection/Benzyl Asmanex Twisthaler 7 Metered Doses Hour) ...... 16 Alcohol (Injection) ...... 53 (Aerosol Powder) ...... 62 Aurora Lancet Super Thin 30g ...... 53 Bactocill in Dextrose (Injection) ...... 16 Aspirin/Dipyridamole (Capsule Extended- Aurora Lancet Thin 23g ...... 53 Bactrim (Tablet) ...... 17 Release 12 Hour) ...... 33 Aurora Pen Needles 29gx12mm...... 53 Bactrim DS (Tablet) ...... 17 Aspirin-Caffeine-Dihydrocodeine (Capsule) 11 Aurora Pen Needles 31g X 6mm ...... 53 Bactroban (Cream) ...... 14 Assure Haemolance Plus High Flow 18g ..... 53 Aurora Pen Needles 31g X 8mm ...... 53 Bactroban Nasal (Ointment) ...... 14 Assure Haemolance Plus Low Flow 25g ..... 53 Auryxia (Tablet) ...... 46 Bal-Care DHA ...... 67 Assure Haemolance Plus Micro Flow 28g ... 53 Autolet Platforms ...... 53 Balsalazide Disodium (Capsule) ...... 51 Assure Haemolance Plus Normal Flow 21g 53 Auvi-Q (Solution Auto injector) ...... 63 Banzel (200mg Tablet, 400mg Tablet, Assure Haemolance Plus Pediatric Blade ... 53 Availnex (Tablet Chewable) ...... 53 40mg/ml Suspension) ...... 19 Assure Lance Lancets ...... 53 Avalide (Tablet) ...... 34 Baraclude (0.05mg/ml Oral Solution, 0.5mg Assure Lance Lancets 21g ...... 53 Avandia (Tablet) ...... 30 Tablet, 1mg Tablet) ...... 28 Assure Lance Plus Safety Lancets 25g ...... 53 Avapro (Tablet) ...... 34 Basaglar KwikPen (Injection) ...... 31 Assure Lance Plus Safety Lancets 30g ...... 53 Avastin (Injection) ...... 26 Bayer Microlet Lancets ...... 53 Assure Lancets ...... 53 AVC (Cream) ...... 17 BD 3ml LL Syringe/Prefill Lith Hep/Tip Astagraf XL (Capsule Extended-Release 24 Avelox (Tablet, Injection) ...... 17 Cap/Ndl Stop/Safetycone (Kit) ...... 53 Hour) ...... 50 Avelox ABC Pack (Tablet) ...... 17 BD Autoshield 29g X 3/16" ...... 53 71

BD Autoshield 29g X 5/16" ...... 53 Bethkis (Nebulized Solution) ...... 59 Bucalsep (600mg/30ml-30mg/30ml- BD Autoshield Duo 30g X 3/16"...... 53 Betimol (Ophthalmic Solution) ...... 61 45mg/30ml-30mg/30ml External Bd insul Syr Mis Lo Dose ...... 53 Betoptic-S (Suspension) ...... 61 Solution, 600mg/30ml-30mg/30ml- BD Lancet Ultrafine 30g ...... 53 Bevespi Aerosphere (Aerosol)...... 30 45mg/30ml-30mg/30ml Liquid) ...... 14 BD Lancet Ultrafine 33g ...... 53 Bexarotene (Capsule) ...... 26 Budesonide (0.25mg/2ml Suspension, BD Microtainer Lancets ...... 53 Beyaz (Tablet) ...... 48 0.5mg/2ml Suspension, 1mg/2ml BD Pudendal/Local Block Tray 1% Lidocaine Biaxin (250mg Tablet, 500mg Tablet, Suspension, 32mcg/act Suspension) ...... 62 (Kit) ...... 12 250mg/5ml Suspension) ...... 17 Budesonide (3mg Capsule Delayed-Release) Bebulin (Injection) ...... 33 Bicalutamide (Tablet) ...... 24 ...... 51 Beconase AQ (Suspension) ...... 62 Bicillin C-R (Injection) ...... 16 Bullseye Safety Lancets ...... 53 Belbuca (Film) ...... 11 Bicillin L-A (Injection) ...... 17 Bumetanide (0.25mg/ml Injection, 0.5mg Beleodaq (Injection) ...... 25 BiCNU (Injection) ...... 24 Tablet, 1mg Tablet, 2mg Tablet) ...... 37 Belsomra (Tablet)...... 65 BiDil (Tablet) ...... 38 Bumex (Tablet) ...... 37 Benazepril HCl (Tablet) ...... 34 Biltricide (Tablet) ...... 26 Bunavail (Film) ...... 11 Benazepril HCl/Hydrochlorothiazide (Tablet) Bimatoprost (Ophthalmic Solution) ...... 60 Bupap (Tablet) ...... 10 ...... 34 Binosto (Tablet Effervescent) ...... 51 Buphenyl (3gm/tsp Powder, 500mg Tablet) Bendeka (Injection) ...... 24 Bisoprolol Fumarate (Tablet) ...... 35 ...... 44 Benefix (Injection)...... 33 Bisoprolol Fumarate/Hydrochlorothiazide Bupivacaine HCl (Injection) ...... 12 Benicar (Tablet) ...... 34 (Tablet) ...... 35 Bupivacaine HCl/Sodium Chloride (0.1%- Benicar HCT (Tablet) ...... 34 Bivalirudin (Injection) ...... 32 0.9% Injection, 0.125%-0.9% Injection, Benlysta (Injection) ...... 50 BIVIGAM (Injection) ...... 51 0.2%-0.9% Injection, 0.25%-0.9% Bentyl (10mg Capsule, 10mg/ml Injection) 44 Bleomycin Sulfate (Injection) ...... 59 Injection) ...... 12 Benzac AC Wash (Liquid) ...... 40 Bleph-10 (Ophthalmic Solution) ...... 17 Bupivacaine/Epinephrine (0.25%-1 BenzaClin (Gel) ...... 40 Blephamide (Suspension) ...... 17 200000 Injection) ...... 12 BenzaClin with Pump (Gel) ...... 40 Blephamide S.O.P. (Ointment) ...... 17 Bupivacaine/Epinephrine (0.5%-1 Benzalkonium Chloride (0 External Solution, Blincyto (Injection) ...... 26 200000 Injection) ...... 51 50% External Solution) ...... 14 Bloxiverz (Injection) ...... 24 Buprenex (Injection) ...... 11 Benzamycin (Gel) ...... 40 Boniva (150mg Tablet, 3mg/3ml Injection) 51 Buprenorphine HCl (0.3mg/ml Solution, 2mg Benzefoam (Foam) ...... 40 Boric Acid (0 Granules) ...... 53 Tablet Sublingual, 8mg Tablet Sublingual) Benzefoam Ultra (Foam) ...... 40 Bosulif (Tablet) ...... 25 ...... 11 Benziq (Gel) ...... 40 Bravelle (Injection) ...... 47 Buprenorphine HCl/Naloxone HCl (Tablet Benziq LS (Gel) ...... 40 BreatheRite ...... 53 Sublingual) ...... 11 Benziq Wash (Liquid) ...... 40 BreatheRite Collapsible Spacer w/ Neonate Bupropion HCl (Tablet) ...... 13 Benzoin Compound Tincture (0 Tincture).... 40 Mask ...... 53 Bupropion HCl ER (Tablet Extended-Release Benzoin Tincture (0 Tincture) ...... 53 BreatheRite Rigid Spacer w/Mask ...... 53 12 Hour) ...... 20 Benzonatate (Capsule) ...... 64 BreatheRite w/Large Mask ...... 53 Bupropion HCl SR (Tablet Extended-Release Benzoyl Peroxide (9.8% Foam) ...... 40 BreatheRite w/Medium Mask ...... 53 12 Hour) ...... 20 Benztropine Mesylate (0.5mg Tablet, 1mg BreatheRite w/Small Mask ...... 53 Bupropion HCl XL (Tablet Extended-Release Tablet, 2mg Tablet, 1mg/ml Injection) ... 26 Breo Ellipta (Aerosol Powder) ...... 62 24 Hour) ...... 13 Bepreve (Ophthalmic Solution) ...... 61 Brevibloc (Injection) ...... 35 Buspirone HCl (Tablet) ...... 29 Berinert (Injection) ...... 59 Brevicon-28 (Tablet) ...... 48 Busulfex (Injection) ...... 24 Besivance (Suspension) ...... 17 Bridion (200mg/2ml Injection, 500mg/5ml Butalbital/Acetaminophen (300mg-50mg Betadine Ophthalmic Prep (Ophthalmic Injection) ...... 53 Tablet, 50mg-325mg Tablet) ...... 10 Solution) ...... 14 Brilinta (60mg Tablet)...... 33 Butalbital/Acetaminophen/Caffeine (325mg- Betagan (Ophthalmic Solution) ...... 61 Brilinta (90mg Tablet)...... 33 50mg-40mg Tablet, 50mg-300mg-40mg Betalido (Injection) ...... 53 Brimonidine Tartrate (Ophthalmic Solution) Capsule) ...... 10 Betamethasone Dipropionate (0.05% Cream, ...... 61 Butalbital/Acetaminophen/Caffeine/Codeine 0.05% Lotion, 0.05% Ointment) ...... 40 Brisdelle (Capsule) ...... 21 (Capsule) ...... 11 Betamethasone Sodium BRIVIACT (100mg Tablet, 10mg Tablet, 25mg Butalbital/Aspirin/Caffeine (Capsule) ...... 10 Phosphate/Betamethasone Acetate Tablet, 50mg Tablet, 75mg Tablet, Butalbital/Aspirin/Caffeine/Codeine (Capsule) (Injection) ...... 46 10mg/ml Oral Solution, 50mg/5ml ...... 11 Betamethasone Valerate (0.1% Cream, 0.1% Injection) ...... 18 Butisol Sodium (Tablet) ...... 65 Lotion, 0.1% Ointment, 0.12% Foam) ..... 41 Bromfenac (Ophthalmic Solution) ...... 61 Butorphanol Tartrate (10mg/ml Nasal Betapace (120mg Tablet, 160mg Tablet, Bromocriptine Mesylate (2.5mg Tablet, 5mg Solution, 1mg/ml Injection, 2mg/ml 80mg Tablet) ...... 34 Capsule) ...... 49 Injection) ...... 11 Betapace AF (120mg Tablet, 160mg Tablet, Bromphen/Pseudoephedrine Butrans (Patch Weekly) ...... 11 80mg Tablet) ...... 34 HCl/Dextromethorphan HBr (Syrup) ...... 62 Bydureon Pen (Injection) ...... 30 Betaseron (Injection) ...... 40 Brompheniramine Tannate (Tablet Bydureon Vial (Injection) ...... 30 Betaxolol HCl (0.5% Ophthalmic Solution) .. 61 Chewable) ...... 62 Byetta (Injection) ...... 30 Betaxolol HCl (10mg Tablet, 20mg Tablet) .. 35 Bromsite (Ophthalmic Solution) ...... 61 Bystolic (Tablet) ...... 35 Bethanechol Chloride (Tablet) ...... 46 Brovana (Nebulized Solution) ...... 63 Byvalson (Tablet) ...... 38 72

C Carbamazepine Extended-Release 12 Hour Cefazolin Sodium (100gm Injection, 300gm (Capsule, Tablet)...... 19 Injection, 1gm/50ml Injection) ...... 15 Cabergoline (Tablet) ...... 49 Carbatrol (Capsule Extended-Release 12 Cefazolin Sodium (10gm Injection, 1gm Cabometyx (Tablet) ...... 25 Hour) ...... 19 Injection, 20gm Injection, 500mg Injection) Caduet (Tablet) ...... 36 Carbidopa (Tablet) ...... 27 ...... 15 Cafcit (Injection) ...... 39 Carbidopa/Levodopa (Tablet Immediate- Cefazolin Sodium/Dextrose (1gm-4% Cafergot (Tablet) ...... 23 Release) ...... 27 Injection, 2gm-3% Injection) ...... 15 Caffeine Citrate (20mg/ml Oral Solution, Carbidopa/Levodopa ER (Tablet Extended- Cefazolin Sodium/Dextrose (2gm/50ml-5% 60mg/3ml Injection) ...... 39 Release) ...... 27 Injection) ...... 13 Calan (Tablet) ...... 36 Carbidopa/Levodopa/Entacapone (Tablet) . 27 Cefazolin Sodium/Sodium Chloride (Injection) Calan SR (Tablet Extended-Release) ...... 36 Carbinoxamine Maleate (4mg Tablet, ...... 16 Calcifol (Wafer) ...... 65 4mg/5ml Oral Solution) ...... 62 Cefazolin/D5W (Injection) ...... 16 Calcipotriene (0.005% Cream, 0.005% Carbocaine (Injection) ...... 12 Cefazolin/Dextrose (Injection) ...... 16 External Solution, 0.005% Ointment) ..... 41 Carboplatin (Injection) ...... 24 Cefazolin/Sodium Chloride (2gm/100ml-0.9% Calcipotriene/Betamethasone Dipropionate Cardene IV (20mg/200ml-0.86% Injection) 36 Injection) ...... 16 (Ointment) ...... 41 Cardene IV (40mg/200ml-0.83% Injection) 38 Cefazolin/Sodium Chloride (3gm/100ml- Calcitonin-Salmon (Nasal Solution) ...... 52 Cardiotek-Rx (Tablet) ...... 68 0.9% Solution) ...... 13 Calcitriol (0.25mcg Capsule, 0.5mcg Capsule, Cardiovid Plus (Capsule) ...... 53 Cefdinir (125mg/5ml Suspension, 250mg/5ml 1mcg/ml Injection, 1mcg/ml Oral Solution) Cardizem (Tablet) ...... 34 Suspension, 300mg Capsule) ...... 16 ...... 52 Cardizem CD (Capsule Extended-Release 24 Cefditoren Pivoxil (Tablet) ...... 16 Calcitriol (3mcg/gm Ointment) ...... 41 Hour) ...... 36 Cefepime (1gm Injection, 2gm Injection) .... 16 Calcium Acetate (667mg Capsule, 667mg Cardizem LA (Tablet Extended-Release 24 Cefepime (1gm/50ml Injection, 2gm/100ml Tablet)...... 46 Hour) ...... 36 Injection) ...... 16 Calcium Chloride (10% Injection)...... 65 Cardura (Tablet) ...... 33 Cefepime/Dextrose (Injection) ...... 16 Calcium Disodium Versenate (Injection) .... 44 Cardura XL (Tablet Extended-Release 24 Cefixime (Suspension) ...... 16 Calcium Gluconate/Dextrose (1gm/100ml- Hour) ...... 46 Cefotan (Injection) ...... 16 5% Injection, 2gm/100ml-5% Injection) 43 Careone Lancet Thin ...... 53 Cefotaxime Sodium (Injection) ...... 16 Calcium Gluconate/Sodium Chloride Careone Lancet Ultra Thin ...... 53 Cefotetan (1gm Injection, 2gm Injection) .... 16 (1gm/100ml-0.9% Injection, 2gm/100ml- Caretouch Pen Needles 31 G X 6 Mm ...... 53 Cefotetan (Injection) ...... 16 0.9% Injection, 2gm/50ml-0.9% Injection) Caretouch Pen Needles 31gx 5mm ...... 53 Cefotetan/Dextrose (Injection) ...... 16 ...... 65 Caretouch Pen Needles 31gx 8mm ...... 53 Cefoxitin Sodium (10gm Injection, 1gm Calcium Gluconate/Sodium Chloride Caretouch Pen Needles 32gx 4mm ...... 53 Injection, 2gm Injection) ...... 16 (1gm/50ml-0.9% Solution, 3gm/100ml- Caretouch Twist Lancets 30g ...... 53 Cefoxitin Sodium (1gm-4% Injection, 2gm- 0.9% Injection) ...... 43 Carimune Nanofiltered (Injection) ...... 51 2.2% Injection) ...... 16 Caldolor (Injection) ...... 59 Carisoprodol (250mg Tablet, 350mg Tablet)64 Cefpodoxime Proxetil (100mg Tablet, 200mg Cambia (Packet) ...... 10 Carisoprodol/Aspirin (Tablet) ...... 64 Tablet, 100mg/5ml Suspension, 50mg/5ml Camino Pro Bettermilk/Glytactin (Packet) . 65 Carisoprodol/Aspirin/Codeine (Tablet) ...... 64 Suspension) ...... 16 Camino Pro Complete/Glytactin (Bar)...... 65 Carnitor (1gm/10ml Oral Solution, Cefprozil (125mg/5ml Suspension, Camino Pro Swirl (Packet) ...... 65 200mg/ml Injection, 330mg Tablet) ...... 53 250mg/5ml Suspension, 250mg Tablet, Campath (Injection) ...... 24 Carnitor SF (Oral Solution) ...... 53 500mg Tablet) ...... 16 Camptosar (Injection) ...... 59 Carteolol HCl (Ophthalmic Solution) ...... 61 Ceftazidime (Injection) ...... 16 Canasa (Suppository) ...... 51 Carvedilol (Tablet) ...... 35 Ceftazidime/Dextrose (Injection) ...... 16 Cancidas (Injection) ...... 22 Cascara Sagrada (1gm/ml Fluid Extract) .... 44 Ceftibuten (180mg/5ml Suspension, 400mg Candesartan Cilexetil (Tablet) ...... 34 Casodex (Tablet) ...... 24 Capsule) ...... 16 Candesartan Cilexetil/Hydrochlorothiazide Catapres (Tablet) ...... 33 Ceftin (Suspension) ...... 16 (Tablet) ...... 34 Catapres-TTS-1 (Patch Weekly) ...... 33 Ceftriaxone in Iso-Osmotic Dextrose Capastat Sulfate (Injection) ...... 24 Catapres-TTS-2 (Patch Weekly) ...... 33 (Injection) ...... 16 Capecitabine (Tablet) ...... 25 Catapres-TTS-3 (Patch Weekly) ...... 33 Ceftriaxone Sodium (100gm Injection, 1gm Capex (Shampoo) ...... 41 Cathflo Activase (Injection) ...... 32 Injection, 250mg Injection, 500mg Caphosol (Solution) ...... 40 Cayston (Inhalation Solution) ...... 16 Injection, 10gm Injection, 2gm Solution) 16 Capital/Codeine (Suspension) ...... 11 Cedax (180mg/5ml Suspension, 400mg Ceftriaxone/Dextrose (Injection) ...... 16 Caprelsa (Tablet) ...... 25 Capsule) ...... 15 Cefuroxime Axetil (Tablet) ...... 16 Captopril (Tablet)...... 34 Cefaclor (125mg/5ml Suspension) ...... 15 Cefuroxime Sodium (Injection) ...... 16 Captopril/Hydrochlorothiazide (Tablet) ...... 34 Cefaclor (Capsule Immediate-Release, Oral Cefuroxime Sodium/Sodium Chloride CapXib Kit (Kit) ...... 10 Suspension) ...... 15 (Solution) ...... 44 Carac (Cream) ...... 41 Cefaclor ER (Tablet Extended-Release 12 Celebrex (Capsule) ...... 10 Carafate (1gm Tablet, 1gm/10ml Hour) ...... 15 Celecoxib (Capsule) ...... 10 Suspension) ...... 45 Cefadroxil (1gm Tablet, 250mg/5ml Celestone-Soluspan (Injection) ...... 46 Carbaglu (Tablet) ...... 65 Suspension, 500mg/5ml Suspension, Celexa (Tablet) ...... 21 Carbamazepine (100mg Tablet Chewable, 500mg Capsule) ...... 15 Cellcept (200mg/ml Suspension, 250mg 100mg/5ml Suspension, 200mg Tablet) . 19 Cefazolin (Injection) ...... 15 Capsule, 500mg Tablet) ...... 50 73

Cellcept Intravenous (Injection) ...... 50 Cilostazol (Tablet) ...... 33 Clever Choice Anti-Static Valved Holding Celontin (Capsule) ...... 18 Ciloxan (0.3% Ointment, 0.3% Ophthalmic Chamber/Medium (Device) ...... 53 Cenfol (Tablet) ...... 68 Solution) ...... 17 Clever Choice Anti-Static Valved Holding Centany (Ointment) ...... 14 Cimetidine (200mg Tablet, 300mg Tablet, Chamber/Small (Device) ...... 53 Centany AT (Kit) ...... 14 400mg Tablet, 800mg Tablet) ...... 45 Clever Choice Comfort EZ Insulin Pen Cephalexin (125mg/5ml Suspension, Cimetidine HCl (Oral Solution) ...... 45 Needles 31gx8mm ...... 53 250mg/5ml Suspension, 250mg Capsule, Cimzia (Injection) ...... 50 Clever Choice Comfort EZ Pen Needles 500mg Capsule, 750mg Capsule, 250mg Cimzia Starter Kit (Injection) ...... 50 29gx12mm ...... 53 Tablet, 500mg Tablet) ...... 16 Cinqair (Injection) ...... 64 Clever Choice Comfort EZ Pen Needles Cerdelga (Capsule) ...... 44 Cinryze (Injection) ...... 59 31gx5mm ...... 53 Cerebyx (Injection) ...... 19 Cipro (250mg Tablet, 500mg Tablet, Clever Choice Comfort EZ Pen Needles Cerefolin (Tablet) ...... 68 500mg/5ml Suspension, 5gm/100ml 31gx6mm ...... 53 Cerefolin Nac (Tablet) ...... 66 Suspension)...... 17 Clever Choice Comfort EZ Pen Needles Cerezyme (Injection) ...... 44 Cipro HC (Suspension) ...... 61 32gx4mm ...... 53 Cesamet (Capsule) ...... 22 Cipro I.V. in D5W (Injection) ...... 17 Clever Choice Comfort EZ Pen Needles Cetirizine HCl (1mg/ml Syrup) ...... 62 Cipro XR (Tablet Extended-Release 24 Hour) 32gx8mm ...... 53 Cetraxal (Otic Solution)...... 17 ...... 17 Clever Choice Comfort EZ Pen Needles Cetrotide (Injection) ...... 49 Ciprodex (Otic Suspension) ...... 61 33gx4mm ...... 54 Cetylev (Tablet Effervescent)...... 64 Ciprofloxacin (0.2% Otic Solution) ...... 17 Clever Choice Comfort EZ Pen Needles Cevimeline HCl (Capsule) ...... 40 Ciprofloxacin (250mg/5ml Suspension, 33gx5mm ...... 54 Chemet (Capsule) ...... 65 500mg/5ml Suspension) ...... 17 Clever Choice Comfort EZ Pen Needles Chenodal (Tablet) ...... 44 Ciprofloxacin ER (Tablet Extended-Release 24 33gx6mm ...... 54 Chloramphenicol Sodium Succinate Hour) ...... 17 Clever Choice Comfort EZ Pen Needles (Injection) ...... 14 Ciprofloxacin HCl (0.3% Ophthalmic Solution, 33gx8mm ...... 54 Chlordiazepoxide HCl (Capsule) ...... 29 Tablet Immediate-Release) ...... 17 Cleviprex (Injection) ...... 36 Chlordiazepoxide HCl/Clidinium Bromide Ciprofloxacin I.V. in D5W (Injection) ...... 17 Climara (Patch Weekly) ...... 48 (5mg-2.5mg Capsule) ...... 44 Cisatracurium Besylate (10mg/5ml Solution Climara Pro (Patch Weekly) ...... 48 Chlordiazepoxide/Amitriptyline (Tablet) ..... 21 Prefilled Syringe) ...... 30 Clindacin ETZ (Kit) ...... 41 Chlorhexidine Gluconate (0.12% Solution) .. 40 Cisatracurium Besylate (Injection) ...... 64 Clindacin PAC (Kit) ...... 41 Chlorhexidine Gluconate (20% Solution) ... 40 Cisplatin (100mg/100ml Injection, Clindagel (Gel) ...... 41 Chloroquine Phosphate (250mg Tablet, 50mg/50ml Injection) ...... 24 Clindamycin HCl (Capsule Immediate-Release) 500mg Tablet) ...... 26 Cisplatin (200mg/200ml Injection) ...... 24 ...... 14 Chlorothiazide (Tablet) ...... 37 Citalopram HBr (10mg Tablet, 20mg Tablet, Clindamycin Palmitate HCl (Oral Solution) .. 14 Chlorothiazide Sodium (Injection) ...... 37 40mg Tablet, 10mg/5ml Oral Solution) .. 21 Clindamycin Phosphate (1% External Solution, Chlorpromazine HCl (100mg Tablet, 10mg Citranatal B-Calm ...... 67 1% Foam, 1% Gel, 1% Lotion, 1% Swab) . 41 Tablet, 200mg Tablet, 25mg Tablet, 50mg Citranatal Rx (Tablet) ...... 67 Clindamycin Phosphate (2% Cream, Tablet)...... 21 Citrus Bergamot (Powder) ...... 53 300mg/2ml Injection, 600mg/4ml Chlorpromazine HCl (25mg/ml Injection, Cladribine (Injection) ...... 25 Injection, 9000mg/60ml Injection, 50mg/2ml Injection) ...... 59 Clarinex (0.5mg/ml Syrup, 5mg Tablet) ..... 62 900mg/6ml Injection) ...... 14 Chlorpropamide (Tablet) ...... 31 Clarithromycin (125mg/5ml Suspension, Clindamycin Phosphate in D5W (Injection) . 14 Chlorthalidone (100mg Tablet)...... 37 250mg/5ml Suspension, 250mg Tablet, Clindamycin Phosphate/Tretinoin (Gel) ...... 41 Chlorthalidone (25mg Tablet, 50mg Tablet) 37 500mg Tablet) ...... 17 Clindamycin/Benzoyl Peroxide (Gel) ...... 41 Chlorzoxazone (Tablet) ...... 64 Clarithromycin ER (Tablet Extended-Release Clindesse (Cream) ...... 14 Cholbam (Capsule) ...... 44 24 Hour) ...... 17 Clinical Nutrients Prenatal Formula (Tablet) Cholestyramine (Powder) ...... 37 Cleanlet Lancets 28g ...... 53 ...... 67 Cholestyramine Light (Powder) ...... 37 Clemastine Fumarate (2.68mg Tablet)...... 62 Clinimix/Dextrose (Injection) ...... 65 Choline Magnesium Trisalicylate (1000mg Cleocin (100mg Suppository) ...... 14 Clobetasol Propionate (0.05% Cream, 0.05% Tablet) ...... 10 Cleocin (150mg Capsule, 300mg Capsule, External Solution, 0.05% Foam, 0.05% Gel, Choline Magnesium Trisalicylate (500mg/5ml 75mg Capsule, 2% Cream) ...... 14 0.05% Liquid, 0.05% Lotion, 0.05% Liquid) ...... 10 Cleocin in D5W (Injection) ...... 14 Ointment, 0.05% Shampoo) ...... 41 Chorionic Gonadotropin (Injection) ...... 47 Cleocin Pediatric Granules (Oral Solution) 14 Clobex (0.05% Liquid, 0.05% Lotion, 0.05% Chromium Chloride (Injection) ...... 65 Cleocin Phosphate (150mg/ml Injection, Shampoo) ...... 41 Cialis (10mg Tablet, 20mg Tablet) ...... 46 300mg/2ml Injection, 600mg/4ml Clocortolone Pivalate (Cream) ...... 41 Cialis (2.5mg Tablet, 5mg Tablet) ...... 46 Injection, 900mg/6ml Injection, Clodan Kit (Kit) ...... 41 Ciclodan Cream Kit (Kit) ...... 22 9gm/60ml Injection) ...... 14 Cloderm (Cream) ...... 41 Ciclodan Solution Kit (Kit) ...... 22 Cleocin-T (1% External Solution, 1% Gel, 1% Cloderm Pump (Cream) ...... 41 Ciclopirox (0.77% Gel, 0.77% Suspension, 1% Lotion, 1% Swab) ...... 41 Clolar (Injection) ...... 25 Shampoo) ...... 22 Clever Chek Lancets Ultrathin ...... 53 Clomiphene Citrate (50mg Tablet) ...... 49 Ciclopirox Nail Lacquer (External Solution) . 22 Clever Chek Lancets Ultrathin 30g ...... 53 Clomipramine HCl (Capsule) ...... 21 Ciclopirox Olamine (0.77% Cream) ...... 22 Clever Choice Anti-Static Valved Holding Clonazepam (Tablet Immediate-Release) .... 19 Cidofovir (Injection) ...... 28 Chamber/Adult Large (Device) ...... 53 Clonazepam ODT (Tablet Dispersible) ...... 19 74

Clonidine HCl (0.1mg Tablet, 0.2mg Tablet, Ointment, 4mcg/SQCM Tape) ...... 41 50mg/ml Injection) ...... 50 0.3mg Tablet, 0.1mg/24hr Patch Weekly, Coreg (Tablet) ...... 35 Cyclosporine Modified (100mg Capsule, 25mg 0.2mg/24hr Patch Weekly, 0.3mg/24hr Coreg CR (Capsule Extended-Release 24 Capsule, 50mg Capsule, 100mg/ml Oral Patch Weekly) ...... 33 Hour) ...... 35 Solution) ...... 50 Clonidine HCl ER (Tablet Extended-Release 12 Corgard (Tablet)...... 35 Cyfolex (Capsule) ...... 68 Hour) ...... 39 Corifact (Injection) ...... 33 Cyklokapron (Injection) ...... 33 Clopidogrel (Tablet) ...... 33 Corlanor (Tablet) ...... 36 Cymbalta (Capsule Delayed-Release) ...... 21 Clorazepate Dipotassium (Tablet) ...... 19 Corlopam (Injection) ...... 38 Cyproheptadine HCl (2mg/5ml Syrup, 4mg Clorpres (Tablet) ...... 33 Cortef (Tablet) ...... 46 Tablet) ...... 27 Clotrimazole (1% Cream, 1% External Cortenema (Enema) ...... 46 Cyramza (Injection) ...... 26 Solution, 10mg Lozenge, 10mg Troche).. 22 Cortifoam (Foam) ...... 51 Cystadane (Powder) ...... 44 Clotrimazole/Betamethasone Dipropionate Cortisone Acetate (25mg Tablet) ...... 46 Cystagon (Capsule) ...... 44 (0.05%-1% Cream, 1%-0.05% Lotion) ..... 22 Cortisporin (0.5%-0.5% Cream, 1%-0.5% Cystaran (Ophthalmic Solution) ...... 60 Clozapine (Tablet Immediate-Release) ...... 27 Ointment) ...... 41 Cytarabine Aqueous (Injection) ...... 25 Clozapine ODT (Tablet Dispersible) ...... 27 Corvert (Injection) ...... 34 Cytogam (Injection) ...... 51 Clozaril (Tablet) ...... 27 Corvite (Tablet) ...... 66 Cytomel (Tablet) ...... 49 Coaguchek Lancets ...... 54 Corvite 150 (Tablet) ...... 65 Cytotec (Tablet)...... 45 Coal Tar (External Solution) ...... 41 Corzide (Tablet) ...... 35 Cytovene (Injection)...... 28 Coartem (Tablet) ...... 26 Cosentyx (Injection) ...... 41 Cytra-3 (Syrup) ...... 65 Cod Liver Oil (0 Oil) ...... 66 Cosentyx Sensoready Pen (Injection) ...... 41 Codeine Sulfate (Tablet) ...... 11 Cosmegen (Injection) ...... 25 D Cogentin (Injection) ...... 26 Cosopt (Ophthalmic Solution) ...... 61 Colazal (Capsule) ...... 51 Cosopt PF (Ophthalmic Solution) ...... 61 D.h.e. 45 (Injection) ...... 23 Colchicine (0.6mg Capsule) ...... 23 Cotellic (Tablet) ...... 25 Dacarbazine (100mg Injection) ...... 24 Colchicine (0.6mg Tablet) ...... 23 Coumadin (Tablet) ...... 32 Dacarbazine (200mg Injection) ...... 24 Colcrys (Tablet) ...... 23 Cozaar (Tablet) ...... 34 Dacogen (Injection) ...... 25 Colestid (1gm Tablet, 5gm Granules, 5gm Creon (Capsule Delayed-Release) ...... 44 Daklinza (Tablet) ...... 28 Packet) ...... 37 Cresemba (186mg Capsule, 372mg Injection) Daliresp (Tablet)...... 63 Colestid Flavored (5gm Granules, ...... 22 Dalvance (Injection) ...... 14 5gm/7.5gm Packet) ...... 37 Crestor (Tablet)...... 37 Danazol (100mg Capsule, 200mg Capsule, Colestipol HCl (1gm Tablet, 5gm Packet) ..... 37 Crinone (Gel)...... 49 50mg Capsule) ...... 48 Colistimethate Sodium (Injection) ...... 14 Crixivan (Capsule) ...... 29 Dantrium (Capsule) ...... 28 Coly-Mycin M (Injection) ...... 14 Cromolyn Sodium (100mg/5ml Concentrate) Dantrium IV (Injection) ...... 64 Coly-Mycin S (Suspension) ...... 61 ...... 44 Dantrolene Sodium (Capsule) ...... 28 CoLyte-Flavor Packs (Oral Solution) ...... 45 Cromolyn Sodium (20mg/2ml Nebulized Dapsone (Tablet) ...... 24 Combigan (Ophthalmic Solution) ...... 61 Solution) ...... 63 Daptomycin (Solution) ...... 14 Combipatch (Patch Twice Weekly) ...... 48 Cromolyn Sodium (4% Ophthalmic Solution) DARAPRIM (Tablet) ...... 26 Combivent Respimat (Aerosol Solution) .... 63 ...... 61 Darifenacin HBr ER (Tablet Extended-Release Combivir (Tablet) ...... 28 Cubicin (Injection) ...... 14 24 Hour) ...... 46 Cometriq (Kit)...... 25 Cubicin RF (Injection) ...... 14 Darzalex (Injection) ...... 26 Comfort Lancets ...... 54 Cuprimine (Capsule) ...... 46 Daunorubicin HCl (Injection) ...... 59 Compact Space Chamber/Anti-Static Curosurf (Suspension) ...... 64 Daypro (Tablet) ...... 10 (Device) ...... 54 Cuvitru (1gm/5ml Injection, 2gm/10ml Daytrana (Patch) ...... 39 Compact Space Chamber/Anti-Static/Large Injection, 4gm/20ml Injection)...... 51 DDAVP (0.01% Nasal Solution, 0.1mg Tablet, Mask (Device) ...... 54 Cuvitru (8gm/40ml Injection) ...... 28 0.2mg Tablet, 4mcg/ml Injection) ...... 47 Compact Space Chamber/Anti- Cuvposa (Oral Solution) ...... 44 Decitabine (Injection) ...... 25 Static/Medium Mask (Device) ...... 54 Cyanocobalamin (1000mcg/ml Injection) ... 66 Deferoxamine Mesylate (Injection) ...... 54 Compact Space Chamber/Anti-Static/Small Cyanokit (Injection) ...... 52 Delestrogen (Injection) ...... 48 Mask (Device) ...... 54 Cyclessa (Tablet) ...... 48 Delivery Fee ( ) ...... 54 Complera (Tablet) ...... 28 Cyclobenzaprine HCl (10mg Tablet, 5mg Delzicol (Capsule Delayed-Release) ...... 51 Comtan (Tablet) ...... 26 Tablet, 7.5mg Tablet) ...... 64 Demadex (Tablet) ...... 37 Concept DHA (Capsule) ...... 67 Cyclogyl (Ophthalmic Solution) ...... 60 Demeclocycline HCl (150mg Tablet, 300mg Concept Ob (Capsule) ...... 67 Cyclomydril (Ophthalmic Solution) ...... 60 Tablet) ...... 18 Concerta (Tablet Extended-Release) ...... 39 Cyclopentolate HCl (Ophthalmic Solution).. 60 Demerol (100mg Tablet, 100mg/2ml Condylox (0.5% External Solution, 0.5% Gel) Cyclophosphamide (1gm Injection, 2gm Injection, 100mg/ml Injection, ...... 41 Injection, 500mg Injection) ...... 24 25mg/0.5ml Injection, 25mg/ml Injection, Copasil (Gel) ...... 41 Cyclophosphamide (25mg Capsule, 50mg 50mg/ml Injection, 75mg/1.5ml Injection, Copaxone (Injection) ...... 40 Capsule) ...... 24 75mg/ml Injection) ...... 11 Copegus (Tablet) ...... 28 Cycloserine (Capsule) ...... 24 Demser (Capsule) ...... 36 Copper Trace Metal (Injection) ...... 65 Cycloset (Tablet) ...... 31 Denavir (Cream) ...... 29 Cordran (0.05% Cream, 0.05% Lotion, 0.05% Cyclosporine (100mg Capsule, 25mg Capsule, Depacon (Injection) ...... 19 75

Depakene (250mg Capsule, 250mg/5ml Dexamethasone Sodium Phosphate Diclofenac Sodium (3% Gel)...... 14 Syrup) ...... 19 (10mg/ml Injection) ...... 50 Diclofenac Sodium DR (Tablet Delayed- Depakote (Tablet Delayed-Release) ...... 19 Dexamethasone Sodium Phosphate Release) ...... 10 Depakote ER (Tablet Extended-Release 24 (120mg/30ml Injection, 20mg/5ml Diclofenac Sodium ER (Tablet Extended- Hour) ...... 19 Solution) ...... 46 Release 24 Hour) ...... 10 Depakote Sprinkles (Capsule Sprinkle Dexamethasone Sodium Phosphate (4mg/ml Diclofenac Sodium/Misoprostol (Tablet Delayed-Release) ...... 19 Solution) ...... 59 Delayed-Release) ...... 10 Depen Titratabs (Tablet) ...... 46 Dexamethasone Sodium Phosphate/Sodium Dicloxacillin Sodium (Capsule) ...... 17 Deplin 15 (Capsule) ...... 54 Chloride (Solution)...... 50 Dicyclomine HCl (10mg Capsule, 10mg/5ml Deplin 7.5 (Capsule) ...... 54 Dexcom G4 Plat Ped ...... 54 Oral Solution, 10mg/ml Injection, 20mg Depo-Estradiol (Injection) ...... 48 Dexcom G4 Platinum ...... 54 Tablet) ...... 44 Depo-Medrol (Injection) ...... 46 Dexcom G5 Kit (Receiver/Transmit) ...... 54 Didanosine (Capsule Delayed-Release) ...... 28 Depo-Provera (Injection) ...... 49 Dexedrine (10mg Capsule Extended-Release Differin (0.1% Cream, 0.1% Gel, 0.3% Gel, Depo-Testosterone (Injection) ...... 48 24 Hour, 15mg Capsule Extended-Release 0.1% Lotion) ...... 41 DermacinRx Clorhexacin (Kit) ...... 41 24 Hour, 5mg Capsule Extended-Release Dificid (Tablet) ...... 17 DermacinRx Surgical Pharmapak (Kit) ...... 41 24 Hour) ...... 39 Diflorasone Diacetate (0.05% Cream, 0.05% DermacinRx Therazole Pak (Therapy Pack) 59 Dexilant (Capsule Delayed-Release) ...... 45 Ointment) ...... 41 Dermasorb HC (Kit) ...... 41 Dexlido (Injection) ...... 47 Diflucan (100mg Tablet, 150mg Tablet, Dermasorb TA (Kit) ...... 41 Dexlido-M (Injection) ...... 54 200mg Tablet, 50mg Tablet, 10mg/ml Dermatop (0.1% Cream, 0.1% Ointment) ... 41 Dexmedetomidine HCl (Injection) ...... 29 Suspension, 40mg/ml Suspension) ...... 22 DermaweRx Surgical Plus Pak (Kit) ...... 41 Dexmethylphenidate HCl (Tablet Immediate- Diflunisal (Tablet) ...... 10 DermOtic (Oil) ...... 41 Release) ...... 39 Digifab (Injection) ...... 54 Descovy (Tablet) ...... 28 Dexmethylphenidate HCl Capsule Extended- Digoxin (0.05mg/ml Oral Solution, 0.25mg/ml Desferal (Injection) ...... 54 Release 24 Hour (10mg, 15mg, 20mg, Injection, 125mcg Tablet, 250mcg Tablet) Desipramine HCl (100mg Tablet, 10mg Tablet, 30mg, 40mg, 5mg, 25mg, 35mg)...... 39 ...... 36 150mg Tablet, 25mg Tablet, 50mg Tablet, DexPak 10 Day (Tablet Therapy Pack) ...... 47 Dihydroergotamine Mesylate (1mg/ml 75mg Tablet) ...... 21 DexPak 13 Day (Tablet Therapy Pack) ...... 47 Injection, 4mg/ml Nasal Solution) ...... 23 Desloratadine (Tablet) ...... 62 DexPak 6 Day (Tablet Therapy Pack) ...... 47 Dilantin (Capsule) ...... 20 Desloratadine ODT (Tablet Dispersible) ...... 62 Dexrazoxane (Injection) ...... 59 Dilantin INFATABS (Tablet Chewable) ...... 20 Desmopressin Acetate (0.01% Nasal Solution, Dextroamphetamine Sulfate (10mg Tablet, Dilantin-125 (Suspension) ...... 20 0.1mg/ml Nasal Solution, 0.1mg Tablet, 5mg Tablet, 5mg/5ml Oral Solution) ...... 39 Dilatrate SR (Capsule Extended-Release) ... 38 0.2mg Tablet, 4mcg/ml Injection)...... 47 Dextroamphetamine Sulfate ER (Capsule Dilaudid (1mg/ml Liquid, 1mg/ml Solution, Desogen (Tablet) ...... 48 Extended-Release 24 Hour) ...... 39 2mg/ml Solution, 4mg/ml Solution, 2mg Desogestrel/Ethinyl Estradiol (Tablet) ...... 48 Dextrose 10% (Injection) ...... 59 Tablet, 4mg Tablet, 8mg Tablet) ...... 11 Desonate (Gel) ...... 41 Dextrose 20% (Injection) ...... 59 Diltiazem CD (Capsule Extended-Release 24 Desonide (0.05% Cream, 0.05% Lotion, 0.05% Dextrose 25% (Injection) ...... 59 Hour) ...... 36 Ointment) ...... 41 Dextrose 30% (Injection) ...... 31 Diltiazem HCl (100mg Injection) ...... 59 DesOwen (0.05% Cream, 0.05% Lotion) ..... 41 Dextrose 40% (Injection) ...... 59 Diltiazem HCl (125mg/25ml Injection, Desoximetasone (0.05% Cream, 0.25% Dextrose 5% (Injection) ...... 59 25mg/5ml Injection, 50mg/10ml Injection) Cream, 0.05% Gel, 0.05% Ointment, 0.25% Dextrose 50% (50% Injection) ...... 59 ...... 59 Ointment) ...... 41 Dextrose 70% (70% Injection) ...... 31 Diltiazem HCl (Tablet Immediate-Release) .. 34 Desoxyn (Tablet) ...... 39 Diamox (Capsule Extended-Release 12 Hour) Diltiazem HCl CD (Capsule Extended-Release Desvenlafaxine ER (100mg Tablet Extended- ...... 61 24 Hour) ...... 36 Release 24 Hour, 25mg Tablet Extended- Diastar Easy Test II Lancets 30g ...... 54 Diltiazem HCl ER (Capsule Extended-Release Release 24 Hour, 50mg Tablet Extended- Diastar Easy Test Lancets30g ...... 54 24 Hour) ...... 35 Release 24 Hour) ...... 21 Diastat AcuDial (Gel) ...... 19 Diltiazem HCl ER (Capsule Extended-Release Desvenlafaxine ER (100mg Tablet Extended- Diastat Pediatric (Gel) ...... 19 24 Hour, Tablet Extended-Release 24 Release 24 Hour, 50mg Tablet Extended- Diastix (Strip) ...... 54 Hour) ...... 36 Release 24 Hour) ...... 21 Diazepam (10mg Gel, 2.5mg Gel, 20mg Gel, Diltiazem HCl/Dextrose (5%-100mg/100ml Detrol (Tablet) ...... 46 10mg Tablet, 2mg Tablet, 5mg Tablet, Solution, 5%-250mg/250ml Solution) ... 38 Detrol LA (Capsule Extended-Release 24 1mg/ml Oral Solution, 5mg/ml Diltiazem HCl/Dextrose (5%-125mg/125ml Hour) ...... 46 Concentrate) ...... 19 Injection) ...... 59 Dexamethasone (0.5mg Tablet, 0.75mg Diazepam (10mg/2ml Injection) ...... 59 Diltiazem HCl/Sodium Chloride Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Diazepam (5mg/ml Injection) ...... 19 (100mg/100ml-0.9% Injection) ...... 59 Tablet, 4mg Tablet, 6mg Tablet, Dibenzyline (Capsule) ...... 33 Diltiazem HCl/Sodium Chloride 0.5mg/5ml Elixir, 0.5mg/5ml Oral Solution) Diclegis (Tablet Delayed-Release) ...... 22 (125mg/125ml-0.9% Solution) ...... 38 ...... 46 Diclofenac Potassium (Tablet)...... 10 Dimenhydrinate (50mg/ml Injection) ...... 22 Dexamethasone Intensol (1mg/ml Diclofenac Sodium (0.1% Ophthalmic Diovan (Tablet) ...... 34 Concentrate) ...... 46 Solution) ...... 61 Diovan HCT (Tablet) ...... 34 Dexamethasone Sodium Phosphate (0.1% Diclofenac Sodium (1% Gel, 1.5% Dipentum (Capsule) ...... 51 Ophthalmic Solution) ...... 61 Transdermal Solution) ...... 41 Diphenhydramine HCl (12.5mg/5ml Elixir, 76

50mg/ml Injection) ...... 22 Capsule, 2.5mcg Capsule, 4mcg/2ml Dysport (Injection) ...... 59 Diphenoxylate/Atropine (2.5mg-0.025mg Injection) ...... 52 Dyural-40 (Injection) ...... 12 Tablet, 2.5mg-0.025mg/5ml Liquid) ...... 44 Doxil (Injection) ...... 59 Dyural-80 (Injection) ...... 12 Diprolene (0.05% Lotion, 0.05% Ointment) 41 Doxorubicin HCl (Injection) ...... 24 Dyural-L (Injection) ...... 47 Diprolene AF (Cream) ...... 41 Doxycycline (25mg/5ml Suspension) ...... 18 Dyural-LM (Injection) ...... 12 Dipyridamole (25mg Tablet, 50mg Tablet, Doxycycline (40mg Capsule Delayed-Release) 75mg Tablet) ...... 33 ...... 41 E Disopyramide Phosphate (Capsule) ...... 35 Doxycycline Hyclate (100mg Capsule, 50mg Disulfiram (Tablet) ...... 13 Capsule, 100mg Injection, 100mg Tablet, E.E.S. Granules (Suspension) ...... 17 Ditropan XL (Tablet Extended-Release 24 20mg Tablet) ...... 18 Easivent ...... 54 Hour) ...... 46 Doxycycline Hyclate DR (Tablet Delayed- Easivent/Mask-Large ...... 54 Diuril (Suspension) ...... 37 Release) ...... 18 Easivent/Mask-Medium ...... 54 Divalproex Sodium (Capsule Sprinkle Delayed- Doxycycline Monohydrate (100mg Capsule, Easivent/Mask-Small ...... 54 Release) ...... 19 150mg Capsule, 50mg Capsule, 75mg Easy Touch Insulin Syringe/U-100/1ml/31g X Divalproex Sodium DR (Tablet Delayed- Capsule, 100mg Tablet, 150mg Tablet, 5/16" ...... 54 Release) ...... 19 50mg Tablet, 75mg Tablet) ...... 18 Easy Touch Lancets 26g/Pressure Activated Divalproex Sodium ER (Tablet Extended- DrCaps Size 0 Clear (Capsule) ...... 54 ...... 54 Release 24 Hour) ...... 19 DrCaps Size 00 Clear (Capsule) ...... 54 Easy Touch Lancets 28g/Pressure Activated Divigel (Gel) ...... 48 DrCaps Size 1 Clear (Capsule) ...... 54 ...... 54 Dmt Suik (Kit) ...... 50 Drihep Arterial Line Sampling Syr/3ml Ll/5ml Easy Touch Lancets 30g/Pressure Activated Dobutamine HCl (Injection) ...... 36 Waste Syr/2-Cap (Kit) ...... 54 ...... 54 Dobutamine HCl/D5W (Injection)...... 36 DriHep Plus 3ml LL Prefilled Syringe/Tip Easy Touch Lancets 32g/Pressure Activated Docetaxel (160mg/16ml Injection, Cap/Ndl Stop/Safetycone (Kit) ...... 54 ...... 54 160mg/8ml Injection, 20mg/2ml Dritho-Creme HP (Cream) ...... 41 Easy Touch Lancets 33g/Twist ...... 54 Injection, 20mg/ml Injection, 80mg/4ml Dronabinol (Capsule) ...... 22 Easy Touch Pen Needles 29gx1/2" ...... 54 Injection, 80mg/8ml Injection) ...... 25 Droperidol (2.5mg/ml Injection) ...... 22 Easy Touch Pen Needles 31gx1/4" ...... 54 Docetaxel (20mg/0.5ml Injection, 80mg/2ml Droplet Lancets Ultra Thin 30g...... 54 Easy Touch Pen Needles 31gx5/16" ...... 54 Injection) ...... 59 Drospirenone/Ethinyl Estradiol (Tablet) ..... 48 Easy Touch Pen Needles 32gx5/32" ...... 54 Docetaxel (20mg/ml Injection, 80mg/4ml Drospirenone/Ethinyl Estradiol/Levomefolate Easy Touch Pen Needles/31g X 3/16" ...... 54 Injection) ...... 25 Calcium (Tablet) ...... 48 Easy Touch Safety Lancets21g/Pressure Docetaxel (Non-Alcohol Formula) (Injection) Droxia (Capsule) ...... 25 Activated ...... 54 ...... 25 Drug Mart On-The-Go Lancets Gentle 30g . 54 Easy Touch Safety Lancets23g/Pressure Dofetilide (Capsule) ...... 35 Drug Mart Unilet Lancets Ultra Thin 28g ... 54 Activated ...... 54 Dologesic (Tablet) ...... 23 Drysol (External Solution) ...... 41 Easytest II Lancets ...... 54 Dolophine (Tablet) ...... 11 Duac (Gel) ...... 41 Easytest Lancets ...... 54 Donepezil HCl (10mg Tablet Dispersible, 5mg Duavee (Tablet) ...... 59 EC-Naprosyn (Tablet Delayed-Release) ...... 10 Tablet Dispersible, 10mg Tablet, 23mg Duet DHA 400 ...... 67 Econazole Nitrate (1% Cream) ...... 22 Tablet, 5mg Tablet) ...... 20 Duet DHA Balanced ...... 67 Ecoza (Foam) ...... 22 Dopamine HCl (160mg/ml Injection) ...... 36 Duetact (Tablet)...... 31 Ed Cyte F (Tablet) ...... 44 Dopamine HCl (40mg/ml Injection, 80mg/ml Dulera (Aerosol) ...... 62 Edarbi (Tablet)...... 34 Injection) ...... 36 Duloxetine HCl (20mg Capsule Delayed- Edarbyclor (Tablet) ...... 34 Dopamine/D5W (Injection) ...... 36 Release, 30mg Capsule Delayed-Release, Edecrin (Tablet) ...... 37 Dopram (Injection) ...... 39 60mg Capsule Delayed-Release) ...... 21 Edluar (Tablet Sublingual)...... 65 Doral (Tablet) ...... 29 Duloxetine HCl (40mg Capsule Delayed- Edurant (Tablet) ...... 28 Doribax (Injection) ...... 16 Release) ...... 21 Effervescent Potassium/Chloride (Tablet Doripenem (Injection) ...... 16 Duodote (Injection) ...... 54 Effervescent) ...... 65 Doryx (Tablet Delayed-Release) ...... 18 Duopa (Suspension) ...... 27 Effexor XR (Capsule Extended-Release 24 Doryx MPC (Tablet Delayed-Release) ...... 18 Duragesic (Patch 72 Hour) ...... 11 Hour) ...... 21 Dorzolamide HCl (Ophthalmic Solution) ...... 36 Durasafe Spinal/Epidural Tray/1% Effient (Tablet) ...... 33 Dorzolamide HCl/Timolol Maleate Xylocaine/20gx36"close Cath (Kit) ...... 12 Efudex (Cream) ...... 41 (Ophthalmic Solution) ...... 61 Durasafe Spinal/Epidural Tray/1% Egrifta (Injection) ...... 47 Doubledex (Injection) ...... 47 Xylocaine/20gx36"open Cath (Kit) ...... 12 Elaprase (Injection) ...... 44 Dovonex (Cream) ...... 41 Durezol (Emulsion) ...... 61 Elavil (Tablet) ...... 21 Doxazosin (Tablet) ...... 33 Dutasteride (Capsule) ...... 46 Eldepryl (Capsule) ...... 27 Doxazosin Mesylate (Tablet) ...... 33 Dutasteride/Tamsulosin HCl (Capsule) ...... 46 Elelyso (Injection)...... 44 Doxepin HCl (100mg Capsule, 10mg Capsule, DUTOPROL (Tablet Extended-Release 24 Elestat (Ophthalmic Solution) ...... 61 150mg Capsule, 25mg Capsule, 50mg Hour) ...... 35 Elestrin (Gel)...... 48 Capsule, 75mg Capsule, 10mg/ml Dyazide (Capsule) ...... 37 Eletone (Cream) ...... 41 Concentrate) ...... 21 Dyloject (Injection) ...... 14 Eletone Twinpack (Cream) ...... 41 Doxepin HCl (Cream) ...... 41 Dymista (Suspension) ...... 62 Elfolate (Tablet) ...... 54 Doxercalciferol (0.5mcg Capsule, 1mcg Dyrenium (Capsule) ...... 37 Elfolate Plus (Tablet) ...... 68 77

Elidel (Cream) ...... 41 (100mg/10ml-0.9% Injection, 10mg/ml- Esmolol HCl (Injection) ...... 35 Eligard (Injection) ...... 49 0.9% Injection, 25mg/5ml-0.9% Injection, Esomeprazole Magnesium (Capsule Delayed- Eligen B12 (Tablet) ...... 54 50mg/5ml-0.9% Injection) ...... 63 Release) ...... 45 Elimite (Cream) ...... 26 Epiduo (Gel) ...... 41 Esomeprazole Sodium (20mg Injection) ..... 45 Eliphos (Tablet) ...... 46 Epiduo Forte (Gel) ...... 41 Esomeprazole Sodium (40mg Injection) ...... 45 Eliquis (Tablet) ...... 32 Epifoam (Foam) ...... 12 Esomeprazole Strontium (Capsule Delayed- Elitek (Injection) ...... 25 Epinastine HCl (Ophthalmic Solution) ...... 61 Release) ...... 45 Elixophyllin (Elixir) ...... 63 Epinephrine (0.15mg/0.15ml Solution Auto Estazolam (Tablet) ...... 29 Ella (Tablet) ...... 49 injector, 0.3mg/0.3ml Solution Auto Estrace (0.1mg/gm Cream, 0.5mg Tablet, Ellence (Injection) ...... 59 injector) (authorized generic Epi-Pen 1mg Tablet, 2mg Tablet) ...... 48 Elmiron (Capsule) ...... 46 made by Mylan) ...... 63 Estradiol (0.025mg/24hr Patch Weekly, Elocon (0.1% Cream, 0.1% Lotion, 0.1% Epinephrine (0.15mg/0.3ml Injection, 0.05mg/24hr Patch Weekly, 0.06mg/24hr Ointment) ...... 41 0.3mg/0.3ml Injection) ...... 63 Patch Weekly, 0.075mg/24hr Patch Emadine (Ophthalmic Solution) ...... 61 Epinephrine HCl (1mg/ml Injection) ...... 63 Weekly, 37.5mcg/24hr Patch Weekly, Embeda (Capsule Extended-Release) ...... 11 EpiPen (Injection) ...... 63 0.1mg/24hr Patch Weekly, 0.5mg Tablet, Embrace Lancets Ultra Thin 30g ...... 54 Epirubicin HCl (Injection) ...... 59 1mg Tablet, 2mg Tablet) ...... 48 Emcyt (Capsule) ...... 25 Episone Cre (Cream) ...... 41 Estradiol Valerate (Injection) ...... 48 Emend (Capsule, 40mg Capsule, 125mg Epivir (10mg/ml Oral Solution, 150mg Estradiol/Norethindrone Acetate (Tablet)... 48 Capsule, 80mg Capsule, 125mg Tablet, 300mg Tablet)...... 28 Estring (Ring) ...... 48 Suspension, 150mg Injection) ...... 22 Epivir HBV (100mg Tablet) ...... 28 Estrogel (Gel) ...... 48 Emflaza (18mg Tablet, 30mg Tablet, 36mg Epivir HBV (5mg/ml Oral Solution) ...... 28 Estropipate (Tablet) ...... 48 Tablet, 6mg Tablet, 22.75mg/ml Eplerenone (Tablet) ...... 37 Estrostep Fe (Tablet) ...... 48 Suspension) ...... 47 Epogen (Injection) ...... 32 Eszopiclone (Tablet)...... 65 Empliciti (Injection) ...... 26 Epoprostenol Sodium (Injection) ...... 63 Ethacrynate Sodium (Injection) ...... 37 Emsam (Patch 24 Hour) ...... 20 Eprosartan Mesylate (Tablet) ...... 34 Ethacrynic Acid (Tablet) ...... 37 Emtriva (10mg/ml Oral Solution, 200mg Eptifibatide (Injection) ...... 33 Ethambutol HCl (100mg Tablet, 400mg Capsule) ...... 28 Epzicom (Tablet) ...... 29 Tablet) ...... 24 Emverm (Tablet Chewable) ...... 26 Equetro (Capsule Extended-Release 12 Hour) Ethamolin (Injection) ...... 36 Enablex (Tablet Extended-Release 24 Hour) ...... 20 Ethosuximide (250mg Capsule, 250mg/5ml ...... 46 Eraxis (Injection) ...... 22 Oral Solution) ...... 18 Enalapril Maleate (Tablet) ...... 34 Erbitux (Injection) ...... 26 Ethyl Chloride (Aerosol) ...... 12 Enalapril Maleate/Hydrochlorothiazide Erecaid Classic (Kit) ...... 54 Ethynodiol Diacetate/Ethinyl Estradiol (Tablet) ...... 34 Erecaid Esteem (Kit) ...... 54 (Tablet) ...... 48 Enalaprilat (Injection) ...... 34 Ergoloid Mesylates (Tablet) ...... 20 Ethyol (Injection) ...... 59 Enbrace HR (Capsule) ...... 67 Ergomar (Tablet Sublingual) ...... 23 Etidronate Disodium (Tablet) ...... 52 Enbrel (25mg Injection) ...... 50 Ergotamine Tartrate/Caffeine (Tablet) ...... 23 Etodolac (200mg Capsule, 300mg Capsule, Enbrel (25mg/0.5ml Injection, 50mg/ml Erivedge (Capsule) ...... 26 400mg Tablet, 500mg Tablet) ...... 10 Injection) ...... 59 Eros-CTD (Device) ...... 54 Etodolac ER (Tablet Extended-Release 24 Enbrel SureClick (Injection)...... 59 Ertaczo (Cream) ...... 22 Hour) ...... 10 Endometrin (Insert) ...... 49 Erwinaze (Injection)...... 59 Etopophos (Injection) ...... 25 Enlon (Injection) ...... 24 Erygel (Gel) ...... 41 Etoposide (100mg/5ml Injection, 1gm/50ml Enoxaparin Sodium (100mg/ml Injection, EryPed 200 (Suspension) ...... 17 Injection, 500mg/25ml Injection) ...... 25 120mg/0.8ml Injection, 150mg/ml EryPed 400 (Suspension) ...... 17 Etoposide (50mg Capsule) ...... 25 Injection, 30mg/0.3ml Injection, Ery-Tab (Tablet Delayed-Release) ...... 17 Eucrisa (Ointment) ...... 41 40mg/0.4ml Injection, 60mg/0.6ml Erythrocin Lactobionate (Injection) ...... 17 Euflexxa (Injection) ...... 54 Injection, 80mg/0.8ml Injection, Erythrocin Stearate (Tablet) ...... 17 Eurax (10% Cream, 10% Lotion) ...... 26 300mg/3ml Injection) ...... 32 Erythromycin (2% External Solution, 2% Gel, Evamist (Transdermal Solution) ...... 48 Entacapone (Tablet) ...... 26 2% Pad) ...... 41 Evekeo (Tablet) ...... 39 Entecavir (Tablet) ...... 28 Erythromycin (250mg Capsule Delayed- Evicel (Kit) ...... 41 Enteragam (Packet)...... 54 Release, 5mg/gm Ointment) ...... 17 Evista (Tablet) ...... 49 Entereg (Capsule) ...... 44 Erythromycin Base (Tablet) ...... 17 Evithrom (External Solution) ...... 33 Entocort EC (Capsule Delayed-Release) ..... 51 Erythromycin Ethylsuccinate (200mg/5ml Evoclin (Foam) ...... 41 Entresto (Tablet) ...... 34 Suspension, 400mg Tablet) ...... 17 Evomela (Injection) ...... 24 Entyvio (Injection) ...... 44 Erythromycin/Benzoyl Peroxide (Gel) ...... 41 Evotaz (Tablet) ...... 29 Envarsus XR (Tablet Extended-Release 24 Esbriet (Capsule) ...... 64 Evoxac (Capsule) ...... 40 Hour) ...... 50 Escavite (Tablet Chewable) ...... 67 Evzio (0.4mg/0.4ml Injection)...... 13 Epaned (Oral Solution)...... 34 Escavite D (Tablet Chewable) ...... 67 Evzio (2mg/0.4ml Injection) ...... 40 Epclusa (Tablet) ...... 28 Escitalopram Oxalate (10mg Tablet, 20mg Exactuss (Liquid) ...... 64 Ephedrine Sulfate (250mg/5ml Injection) .. 63 Tablet, 5mg Tablet, 5mg/5ml Oral Excel Comfort Point Insulin Pen Needles 31g Ephedrine Sulfate (50mg/ml Solution) ...... 30 Solution) ...... 21 X 4mm ...... 54 Ephedrine Sulfate/Sodium Chloride Esgic (Tablet) ...... 10 Excilon AMD Antimicrobialdrain Sponges 78

4"x4" 6 Ply ...... 41 Feldene (Capsule) ...... 10 First-Metronidazole 100 (Suspension) ...... 22 Exel Comfort Point Insulin Pen Needles 29g X Felodipine ER (Tablet Extended-Release 24 First-Metronidazole 50 (Suspension) ...... 22 12mm ...... 54 Hour) ...... 36 First-Omeprazole (Suspension) ...... 45 Exel Comfort Point Insulin Pen Needles 31g X Femara (Tablet) ...... 25 First-Vancomycin 25 (Oral Solution) ...... 14 8mm ...... 54 Femcon Fe (Tablet Chewable) ...... 48 First-Vancomycin 50 (Oral Solution) ...... 14 Exel Comfort Point Insulin Femhrt Low Dose (Tablet) ...... 48 Flagyl (250mg Tablet, 500mg Tablet, 375mg Syringe/0.3ml/29g X 1/2" ...... 54 Femring (Ring) ...... 48 Capsule) ...... 14 Exel Comfort Point Insulin Fenofibrate (120mg Tablet, 145mg Tablet, Flanax Pain Relief Kit (Kit)...... 10 Syringe/0.3ml/30g X 5/16" ...... 54 160mg Tablet, 40mg Tablet, 48mg Tablet, Flarex (Suspension) ...... 61 Exelderm (1% Cream, 1% External Solution) 54mg Tablet, 130mg Capsule, 150mg Flavor Blend (Suspension) ...... 55 ...... 22 Capsule, 43mg Capsule, 50mg Capsule) . 37 Flavoxate HCl (Tablet) ...... 46 Exelon (Patch 24 Hour) ...... 20 Fenofibrate Micronized (Capsule) ...... 37 Flebogamma DIF (Injection) ...... 51 Exemestane (Tablet) ...... 25 Fenofibric Acid (Tablet) ...... 37 Flecainide Acetate (Tablet) ...... 35 Exforge (Tablet) ...... 34 Fenofibric Acid DR (Capsule Delayed-Release) Flector (Patch) ...... 10 Exforge HCT (Tablet) ...... 34 ...... 37 Flexichamber (Device) ...... 55 Exjade (Tablet Soluble) ...... 65 Fenoglide (Tablet)...... 37 Flexichamber Child Mask/Large ...... 55 Exoderm (Lotion) ...... 22 Fenoprofen Calcium (200mg Capsule, 400mg Flexichamber Child Mask/Small ...... 55 Exondys 51 (Injection) ...... 59 Capsule, 600mg Tablet) ...... 10 Flolan (Injection) ...... 63 Exparel (Suspension)...... 12 Fenortho (Capsule) ...... 10 Flomax (Capsule) ...... 46 Extavia (Injection) ...... 40 Fentanyl (Patch 72 Hour) ...... 11 Florical (364mg-8.3mg Capsule, 364mg- Extina (Foam) ...... 22 Fentanyl Citrate Oral Transmucosal (Lollipop) 8.3mg Tablet) ...... 52 E-Z Ject Lancets ...... 54 ...... 11 Floriva (Liquid) ...... 52 E-Z Ject Lancets 21g ...... 54 Fentanyl Citrate/NaCl (Injection) ...... 11 Floriva Plus (Oral Solution) ...... 66 E-Z Ject Lancets Color ...... 54 Fentanyl Citrate/Sodium Chloride Flovent Diskus (Aerosol Powder) ...... 62 E-Z Ject Lancets Super Thin 30g ...... 54 (1.25mg/250ml-0.9% Injection, Flovent HFA (Aerosol) ...... 62 E-Z Ject Lancets Thin 26g ...... 54 2.5mg/250ml-0.9% Injection) ...... 38 Floxin Otic (Otic Solution) ...... 17 EZ Smart Blood Glucose Lancets ...... 54 Fentanyl Citrate/Sodium Chloride Floxuridine (Injection) ...... 25 E-Z Spacer (Device) ...... 54 (1mg/100ml-0.9% Injection, 2mg/100ml- Fluconazole (100mg Tablet, 150mg Tablet, E-Z Spacer the Body Guards Pack (Device) . 54 0.9% Injection) ...... 11 200mg Tablet, 50mg Tablet, 10mg/ml Ezetimibe (Tablet) ...... 37 Fentora (Tablet) ...... 11 Suspension, 40mg/ml Suspension) ...... 22 E-Zject Lancets Micro-Thin 33g ...... 54 Feraheme (Injection) ...... 65 Fluconazole in Dextrose (Injection) ...... 22 EZ-Lets Lancets 21g ...... 54 Feriva 21/7 (Tablet) ...... 30 Fluconazole in NaCl (100mg/50ml-0.9% EZ-Lets Lancets 23g ...... 54 Ferriprox (100mg/ml Oral Solution, 500mg Injection) ...... 22 EZ-Lets Lancets 26g Super-Soft ...... 54 Tablet) ...... 54 Fluconazole in NaCl (200mg/100ml-0.9% EZ-Lets Lancets 28g Ultra-Soft ...... 54 Ferrlecit (Injection) ...... 65 Injection, 400mg/200ml-0.9% Injection) 22 EZ-Lets Lancets 30g ...... 54 Ferro-Plex Hematinic (Tablet) ...... 30 Flucytosine (Capsule) ...... 22 Ferrotrin (Capsule) ...... 30 Fludarabine Phosphate (Injection) ...... 59 F Fetzima (Capsule Extended-Release 24 Hour) Fludrocortisone Acetate (0.1mg Tablet) ...... 47 ...... 21 Flumadine (Tablet) ...... 29 Fabior (Foam) ...... 41 Fetzima Titration Pack (Capsule Extended- Flumazenil (Injection) ...... 39 Fabrazyme (Injection) ...... 44 Release 24 Hour Therapy Pack) ...... 21 Flunisolide (Nasal Solution) ...... 62 Factive (Tablet) ...... 17 Fexmid (Tablet)...... 64 Fluocinolone Acetonide (Cream, External Falessa (Tablet) ...... 32 Fibricor (Tablet) ...... 37 Solution, Oil, Ointment) ...... 41 Famciclovir (Tablet) ...... 29 Fifty50 Pen Needles 31g X3/16" (5mm) ..... 54 Fluocinolone Acetonide Ear Drops (Oil) ...... 41 Famotidine (200mg/20ml Injection, Fifty50 Pen Needles 31g X5/16" (8mm) ..... 54 Fluocinonide (Cream, Cream, External 20mg/2ml Injection, 40mg/4ml Injection, Fifty50 Pen Needles 31gx5mm ...... 55 Solution, Gel, Ointment) ...... 41 20mg Tablet, 40mg Tablet, 40mg/5ml Fifty50 Pen Needles/31gx8mm ...... 55 Fluocinonide-E (Cream) ...... 41 Suspension) ...... 45 Fifty50 Pen Needles/32gx4mm ...... 55 Fluorabon (Oral Solution) ...... 52 Famotidine Premixed (Injection) ...... 45 Fifty50 Safety Seal Lancets 30g ...... 55 Fluor-A-Day (Tablet Chewable) ...... 52 Fanapt (Tablet) ...... 27 Fifty50 Unilet Lancets 33g ...... 55 Fluoride (0.5mg Tablet Chewable)...... 65 Fanapt Titration Pack (Tablet) ...... 27 Finacea (15% Foam, 15% Gel) ...... 41 Fluorometholone (Ophthalmic Suspension) 61 Fareston (Tablet) ...... 25 Finasteride (5mg Tablet) ...... 46 Fluoroplex (Cream) ...... 41 Farxiga (Tablet) ...... 31 Fine 30 ...... 55 Fluorouracil (1gm/20ml Injection, Farydak (Capsule) ...... 25 Fingerstix Lancets ...... 55 2.5gm/50ml Injection, 500mg/10ml Faslodex (Injection)...... 25 Fioricet (Capsule) ...... 10 Injection, 5gm/100ml Injection, 5% Cream) Fazaclo (Tablet Dispersible) ...... 27 Fioricet/Codeine (Capsule) ...... 11 ...... 25 Feiba (Injection) ...... 33 Fiorinal (Capsule) ...... 10 Fluorouracil (External Solution, External Felbamate (400mg Tablet, 600mg Tablet, Fiorinal/Codeine #3 (Capsule) ...... 11 Solution) ...... 41 600mg/5ml Suspension) ...... 19 Firazyr (Injection) ...... 59 Fluoxetine (Capsule) ...... 21 Felbatol (400mg Tablet, 600mg Tablet, Firmagon (Injection) ...... 49 Fluoxetine DR (Capsule Delayed-Release) ... 21 600mg/5ml Suspension) ...... 19 First-Lansoprazole (Suspension) ...... 45 Fluoxetine HCl (10mg Tablet, 20mg Tablet, 79

60mg Tablet, 20mg/5ml Oral Solution, Fortaz (Injection) ...... 16 Gebauers Pain Ease (0-0 Aerosol) ...... 12 40mg Capsule) ...... 21 Forteo (Injection) ...... 52 Gelfilm Op (Film) ...... 33 Fluphenazine Decanoate (Injection) ...... 27 Fortesta (Gel) ...... 48 Gel-Kam Oral Care Rinse (Concentrate) ..... 40 Fluphenazine HCl (10mg Tablet, 1mg Tablet, Fosamax (Tablet) ...... 52 Gelnique (Gel) ...... 46 2.5mg Tablet, 5mg Tablet) ...... 27 Fosamax Plus D (Tablet) ...... 52 Gel-One (Prefilled Syringe) ...... 55 Fluphenazine HCl (2.5mg/5ml Elixir, 5mg/ml Foscavir (Injection) ...... 59 Gelsyn-3 (Injection) ...... 55 Concentrate) ...... 27 Fosinopril Sodium (Tablet) ...... 34 Gemcitabine (Injection) ...... 25 Fluphenazine HCl (2.5mg/ml Injection) ...... 27 Fosinopril Sodium/Hydrochlorothiazide Gemfibrozil (600mg Tablet) ...... 37 Flura-Drops (Oral Solution) ...... 52 (Tablet) ...... 34 Gemzar (Injection) ...... 25 Flurandrenolide (Cream, Lotion, Ointment) 41 Fosphenytoin Sodium (Injection) ...... 20 Generess Fe (Tablet Chewable) ...... 48 Flurazepam HCl (Capsule) ...... 29 Fosrenol (1000mg Packet, 750mg Packet, Gene-Xene Tab 15mg (Tablet) ...... 19 Flurbiprofen (100mg Tablet, 50mg Tablet).. 10 1000mg Tablet Chewable, 500mg Tablet Gene-Xene Tab 3.75mg (Tablet) ...... 19 Flurbiprofen Sodium (Ophthalmic Solution) 61 Chewable, 750mg Tablet Chewable) ..... 46 Gene-Xene Tab 7.5mg (Tablet) ...... 19 Flutamide (Capsule) ...... 24 Fosteum (Capsule) ...... 67 Genotropin (12mg Injection, 5mg Injection) Fluticasone Propionate (50mcg/act Fosteum Plus (Capsule) ...... 65 ...... 47 Suspension) ...... 62 Fovex (Capsule) ...... 65 Genotropin Miniquick (Injection) ...... 47 Fluticasone Propionate (Ointment, Cream, Fragmin (Injection) ...... 32 Gentamicin Sulfate (0.1% Cream, 0.1% Lotion) ...... 41 FreAmine HBC 6.9% (Injection) ...... 65 Ointment, 0.3% Ophthalmic Ointment, Fluvastatin (Capsule) ...... 37 FreAmine III (Injection) ...... 65 0.3% Ophthalmic Solution, 10mg/ml Fluvastatin Sodium ER (Tablet Extended- FreeStyle Unistick II Lancets ...... 55 Injection, 40mg/ml Injection) ...... 14 Release 24 Hour) ...... 37 Frova (Tablet) ...... 23 Gentamicin Sulfate/0.9% Sodium Chloride Fluvoxamine Maleate (Tablet) ...... 21 Frovatriptan Succinate (Tablet) ...... 23 (0.8mg/ml-0.9% Injection, 1.2mg/ml-0.9% Fluvoxamine Maleate ER (Capsule Extended- Furadantin (Suspension) ...... 14 Injection, 1mg/ml-0.9% Injection) ...... 14 Release 24 Hour) ...... 21 Furosemide (10mg/ml Injection, 10mg/ml Gentamicin Sulfate/0.9% Sodium Chloride FML (Ointment)...... 61 Oral Solution, 8mg/ml Oral Solution, 20mg (0.9mg/ml Injection, 1.4mg/ml Injection, FML Forte (Suspension) ...... 61 Tablet, 40mg Tablet, 80mg Tablet) ...... 37 2mg/ml-0.9% Injection) ...... 14 FML Liquifilm (Suspension) ...... 61 Fusilev (Injection) ...... 59 Gentle-Let GP Lancets ...... 55 Focalgin 90 DHA ...... 67 Fusion Plus (Capsule) ...... 30 Gentle-Let Lancets General Purpose Focalgin Ca ...... 67 Fuzeon (Injection) ...... 29 Style/Medium Point ...... 55 Focalgin DSS (Tablet) ...... 30 Fycompa (0.5mg/ml Suspension, 10mg Gentle-Let Platforms 2.4mm ...... 55 Focalin (Tablet) ...... 39 Tablet, 12mg Tablet, 2mg Tablet, 4mg Genvisc 850 (Solution Prefilled Syringe) .... 55 Focalin XR (Capsule Extended-Release 24 Tablet, 6mg Tablet, 8mg Tablet) ...... 18 Genvoya (Tablet) ...... 28 Hour) ...... 39 Geodon (20mg Capsule, 40mg Capsule, 60mg Folbee Plus Cz (Tablet) ...... 66 G Capsule, 80mg Capsule) ...... 27 Folbic RF (Tablet) ...... 66 Geodon (20mg Injection) ...... 59 Folcaps Omega 3 (Capsule) ...... 66 G5/G4 Kit Sensor ...... 55 Gilenya (Capsule) ...... 40 Folgard Os (Tablet)...... 67 Gabadone (Capsule) ...... 65 Gilotrif (Tablet) ...... 26 Folgard Rx (Tablet) ...... 66 Gabapentin (100mg Capsule, 300mg Capsule, Giltuss (Liquid) ...... 64 Folic Acid (1mg Tablet) ...... 66 400mg Capsule, 250mg/5ml Oral Solution, Glassia (Injection) ...... 64 Folic Acid (5mg/ml Injection) ...... 66 600mg Tablet, 800mg Tablet) ...... 28 Glatopa (Injection) ...... 40 Folic Acid/Vitamin B-6/Vitamin B-12 (Tablet) Gabitril (Tablet) ...... 19 Gleevec (Tablet) ...... 26 ...... 66 Gablofen (Injection) ...... 28 Gleostine (Capsule) ...... 24 Folitab 500 (Tablet Extended-Release)...... 30 Galantamine HBr (12mg Tablet, 4mg Tablet, Gliadel Wafer (Wafer) ...... 24 Folivane-F (Capsule) ...... 65 8mg Tablet, 4mg/ml Oral Solution) ...... 20 Glimepiride (Tablet) ...... 31 Folivane-Ob (Capsule) ...... 67 Galantamine HBr ER (Capsule Extended- Glipizide (Tablet Immediate-Release) ...... 31 Folivane-Plus (Capsule) ...... 30 Release 24 Hour) ...... 20 Glipizide ER (Tablet Extended-Release 24 Follistim AQ (300unit/0.36ml Injection, Galaxtra (Powder) ...... 55 Hour) ...... 31 600unit/0.72ml Injection, 900unit/1.08ml Galzin (Capsule) ...... 65 Glipizide/Metformin HCl (Tablet) ...... 31 Injection, 75unit/0.5ml Injection) ...... 47 Gamastan S/D (Injection) ...... 51 GlucaGen HypoKit (Injection) ...... 31 Folotyn (Injection) ...... 25 Gammagard Liquid (Injection) ...... 51 Glucagon Emergency Kit (Injection) ...... 31 Foltanx (Tablet) ...... 66 Gammagard S/D IGA Less Than 1 mcg/ml GlucoCom Lancets 28g ...... 55 Foltanx RF (Capsule) ...... 66 (Injection) ...... 51 GlucoCom Lancets 30g ...... 55 Foltx (Tablet) ...... 67 Gammaked (Injection) ...... 51 GlucoCom Lancets 33g ...... 55 Fomepizole (Injection) ...... 55 Gammaplex (Injection) ...... 51 Glucophage (Tablet) ...... 31 Fondaparinux Sodium (Injection) ...... 32 Gamunex-C (Injection) ...... 51 Glucophage XR (Tablet Extended-Release 24 Fora Lancets ...... 55 Ganciclovir (Injection) ...... 28 Hour) ...... 31 Forfivo XL (Tablet Extended-Release 24 Ganirelix Acetate (Injection) ...... 49 Glucosource Lancets ...... 55 Hour) ...... 20 Gastrocrom (Concentrate) ...... 44 Glucotrol (Tablet) ...... 31 Fortamet (Tablet Extended-Release 24 Hour) Gatifloxacin (Ophthalmic Solution) ...... 17 Glucotrol XL (Tablet Extended-Release 24 ...... 31 Gattex (Injection) ...... 45 Hour) ...... 31 Fortavit (Capsule) ...... 67 Gazyva (Injection) ...... 26 Glucovance (Tablet) ...... 31 80

Glumetza (Tablet Extended-Release 24 Hour) Halobetasol Propionate (0.05% Cream, 0.05% Hexalen (Capsule) ...... 24 ...... 31 Ointment) ...... 42 Hextend (Injection) ...... 65 Glutaraldehyde (External Solution) ...... 14 Halog (0.1% Cream, 0.1% Ointment) ...... 42 Hiprex (Tablet) ...... 14 Glyburide (1.25mg Tablet, 2.5mg Tablet, 5mg Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg Hizentra (Injection) ...... 51 Tablet)...... 31 Tablet, 20mg Tablet, 2mg Tablet, 5mg Horizant (Tablet Extended-Release) ...... 39 Glyburide Micronized (Tablet) ...... 31 Tablet, 2mg/ml Concentrate) ...... 27 HSA Sterile Diluent (Injection) ...... 55 Glyburide/Metformin HCl (Tablet) ...... 31 Haloperidol Decanoate (Injection) ...... 27 Humalog (Injection) ...... 31 Glycolic Acid 70% High Purity ...... 55 Haloperidol Lactate (Injection)...... 27 Humalog KwikPen (Injection) ...... 31 Glycophos (Injection) ...... 55 Halotin (Cream) ...... 23 Humalog Mix 50/50 (Injection) ...... 31 Glycopyrrolate (0.4mg/2ml Injection, Harvoni (Tablet)...... 28 Humalog Mix 50/50 KwikPen (Injection) ... 31 1mg/5ml Injection, 4mg/20ml Injection, Healthy Mama Be Well Rounded (Therapy Humalog Mix 75/25 (Injection) ...... 31 1mg Tablet, 2mg Tablet) ...... 44 Pack) ...... 67 Humalog Mix 75/25 KwikPen (Injection) ... 31 Glycopyrrolate (0.4mg/2ml Solution Prefilled H-E-B in Control Pen Needles 31gx6mm .... 55 Humate-P (Injection)...... 33 Syringe) ...... 30 H-E-B in Control Pen Needles 31gx8mm .... 55 Humatrope (Injection) ...... 47 Glynase (Tablet) ...... 31 H-E-B Incontrol Pen Needles 29gx12mm ... 55 Humatrope Combo Pack (Injection) ...... 47 Glyset (Tablet) ...... 31 Hectorol (0.5mcg Capsule, 1mcg Capsule, Humira (10mg/0.2ml Injection) ...... 59 Glytactin Bettermilk 15 (Packet) ...... 65 2.5mcg Capsule, 2mcg/ml Injection, Humira (20mg/0.4ml Injection, 40mg/0.8ml Glytactin Bettermilk De-Lite (Packet) ...... 65 4mcg/2ml Injection) ...... 52 Injection) ...... 50 Glytactin Build 10pe (Packet) ...... 65 Helixate FS (Injection) ...... 33 Humira Pediatric Crohns Disease Starter Glytactin Complete 10pe (Bar) ...... 65 Hemangeol (Oral Solution) ...... 35 Pack (Injection) ...... 50 Glytactin Restore 5 (Packet) ...... 65 Hematron-Af (Tablet) ...... 65 Humira Pen (Injection) ...... 50 Glytactin Restore Lite 10PE (Packet) ...... 65 Hemocyte Plus (Capsule) ...... 30 Humira Pen Crohns Disease Starter Pack Glyxambi (Tablet)...... 31 Hemocyte-F (Elixir) ...... 30 (Injection) ...... 50 Gmate Lancets 30g ...... 55 Hemofil M (1700unit Injection) ...... 33 Humira Pen-Psoriasis Starter (Injection) .... 50 GoLYTELY (Oral Solution) ...... 45 Heparin Lock Flush (Injection) ...... 32 Humulin 70/30 (Injection) ...... 31 Gonal-F (Injection) ...... 47 Heparin Sodium (10000unit/10ml Injection, Humulin 70/30 KwikPen (Injection) ...... 31 Gonal-F RFf (Injection) ...... 47 3000unit/3ml Injection, 5000unit/5ml Humulin N (Injection) ...... 31 Gonal-F RFf Rediject (Injection) ...... 47 Injection, 10000unit/ml Injection, Humulin N KwikPen (Injection) ...... 31 Gonitro (Packet) ...... 38 1000unit/ml Injection, 20000unit/ml Humulin R (Injection) ...... 31 Gralise (Tablet) ...... 10 Injection, 5000unit/0.5ml Injection, Humulin R U-500 (Concentrated) (Injection) Gralise Starter Pack...... 10 5000unit/ml Injection) ...... 32 ...... 31 Granisetron HCl (0.1mg/ml Injection, 1mg/ml Heparin Sodium Lock Flush (Kit) ...... 32 Hyalgan (Injection) ...... 55 Injection, 4mg/4ml Injection, 1mg Tablet) Heparin Sodium/D5W (5%-100unit/ml Hycamtin (0.25mg Capsule, 1mg Capsule, ...... 22 Injection, 5%-50unit/ml Injection) ...... 32 4mg Solution) ...... 25 Granix (Injection) ...... 32 Heparin Sodium/D5W (5%-40unit/ml Hycet (Oral Solution) ...... 11 Griseofulvin Microsize (125mg/5ml Injection, 5%-50unit/ml Injection) ...... 32 Hydralazine HCl (100mg Tablet, 10mg Tablet, Suspension, 500mg Tablet) ...... 23 Heparin Sodium/NaCl 0.45% (100unit/ml- 25mg Tablet, 50mg Tablet, 20mg/ml Griseofulvin Ultramicrosize (Tablet) ...... 23 0.45% Injection) ...... 30 Injection) ...... 38 GRIS-PEG (Tablet)...... 23 Heparin Sodium/NaCl 0.45% (50unit/ml- Hydrea (Capsule) ...... 25 Guanfacine ER (Tablet Extended-Release 24 0.45% Injection) ...... 32 Hydrochlorothiazide (12.5mg Capsule, Hour) ...... 39 Heparin Sodium/NaCl 0.9% (Injection) ...... 32 12.5mg Tablet, 25mg Tablet, 50mg Tablet) Guanfacine HCl (Tablet Immediate-Release) Heparin Sodium/Sodium Ch Loride (Injection) ...... 37 ...... 33 ...... 32 Hydrocodone Bitartrate/Acetaminophen Guanidine HCl (Tablet) ...... 24 Heparin Sodium/Sodium Chloride (300mg-10mg Tablet, 300mg-5mg Tablet, Gynazole-1 (Cream) ...... 23 (2000unit/500ml-0.9% Solution) ...... 30 300mg-7.5mg Tablet, 325mg-2.5mg Heparin Sodium/Sodium Chloride Tablet, 325mg/15ml-10mg/15ml Oral H (20unit/20ml-0.9% Injection, Solution, 325mg/15ml-7.5mg/15ml Oral 25000unit/250ml-0.45% Injection, Solution) ...... 11 H.P. Acthar (Injection) ...... 47 30000unit/L-0.9% Injection, 4000unit/L- Hydrocodone Bitartrate/Chlorpheniramine Haemolance ...... 55 0.9% Injection, 50unit/50ml-0.45% Maleate/PSE (Oral Solution) ...... 62 Haemolance Low Flow Lancets ...... 55 Injection) ...... 32 Hydrocodone Bitartrate/Homatropine Haemolance Plus...... 55 Heparin Sodium/Sodium Chloride 0.9% Methylbromide (1.5mg-5mg Tablet, Haemolance Plus High Flow ...... 55 (Injection) ...... 32 1.5mg/5ml-5mg/5ml Syrup) ...... 64 Haemolance Plus Low Flow ...... 55 Heparin Sodium/Sodium Chloride 0.9% Hydrocodone Polistirex/Chlorpheniramine Haemolance Plus Max Flow ...... 55 Premix (Injection) ...... 32 Polistirex (Suspension Extended-Release) Haemolance Plus Pediatric Flow ...... 55 HepatAmine (Injection) ...... 65 ...... 62 Halaven (Injection)...... 59 Hepsera (Tablet) ...... 28 Hydrocodone/Acetaminophen (Tablet)...... 12 Halcion (Tablet) ...... 29 Herceptin (Injection) ...... 26 Hydrocodone/Ibuprofen (Tablet) ...... 10 Haldol (Injection) ...... 27 Hespan (Injection) ...... 32 Hydrocort Enema 100mg (Enema) ...... 47 Haldol Decanoate 100 (Injection) ...... 27 Hetastarch 6%/NaCl (Injection) ...... 32 Hydrocortisone (1% Cream, 2.5% Cream, 1% Haldol Decanoate 50 (Injection) ...... 27 Hetlioz (Capsule)...... 39 Ointment, 2.5% Ointment, 2.5% Cream, 81

2.5% Lotion) ...... 42 I Injectafer (Injection) ...... 33 Hydrocortisone (10mg Tablet, 20mg Tablet, Inlyta (Tablet) ...... 26 Ibandronate Sodium (150mg Tablet, 3mg/3ml 5mg Tablet) ...... 47 Innopran XL (Capsule Extended-Release 24 Injection) ...... 52 Hydrocortisone Butyrate (0.1% Cream, 0.1% Hour) ...... 35 Ibrance (Capsule) ...... 25 External Solution, 0.1% Ointment) ...... 42 InspiraChamber/Anti-Static Ibudone (10mg-200mg Tablet)...... 10 Hydrocortisone in Absorbase (Ointment).... 42 Valved/Mouthpiece (Device) ...... 55 Ibuprofen (100mg/5ml Suspension, 400mg Hydrocortisone Valerate (0.2% Cream, 0.2% InspiraChamber/Large (Device) ...... 55 Tablet, 600mg Tablet, 800mg Tablet) .... 10 Ointment) ...... 42 InspiraChamber/Soother Ibuprofen Comfort Pac (Kit) ...... 10 Hydrocortisone/Acetic Acid (Otic Solution) . 61 Mask/InspiraMask/Medium (Device) ... 55 Ibuprofen Lysine (Injection) ...... 59 Hydrogen Peroxide (30% Does Not Apply InspiraChamber/Soother Ibutilide Fumarate (Injection) ...... 35 Solution) ...... 15 Mask/InspiraMask/Small (Device) ...... 55 IC 400 (Kit) ...... 10 Hydromorphone HCl (1mg/ml Injection, Inspirease Bags ...... 55 IC 800 (Kit) ...... 10 2mg/ml Injection, 4mg/ml Injection, Inspirease Drug Delivery System ...... 55 ICAR-C Plus (Tablet) ...... 30 500mg/50ml Injection, 1mg/ml Liquid, Inspirease Mouthpiece ...... 55 Iclusig (Tablet) ...... 26 2mg Tablet, 4mg Tablet, 8mg Tablet) ..... 12 Inspirease Reservoir Bags ...... 55 Idamycin PFS (Injection) ...... 59 Hydromorphone HCl ER (Tablet Extended- Inspra (Tablet) ...... 37 Idarubicin HCl (Injection) ...... 59 Release 24 Hour Abuse-Deterrent) ...... 11 Insulin Syringe/0.5ml/27g X 1/2" ...... 55 Ifex (Injection) ...... 24 Hydromorphone HCl/ Sodium Chloride Insulin Syringe/U-100/1ml/28g X 1/2" ...... 55 Ifosfamide (1gm Injection, 1gm/20ml (Solution) ...... 12 Insulin Syringes, Needles ...... 43, 55 Injection, 3gm/60ml Injection) ...... 24 Hydromorphone HCl/Sodium Chloride Insulin Syringes/0.5ml/27gx1/2" ...... 55 Ifosfamide (3gm Injection) ...... 24 (10mg/25ml-0.9% Solution Prefilled Insulin Syringes/1ml/30gx1/2"...... 55 Ilaris (150mg/ml Solution) ...... 38 Syringe, 1mg/5ml-0.9% Solution Prefilled Insupen Sensitive 32gx8mm ...... 55 Ilaris (180mg Injection)...... 51 Syringe, 3mg/30ml-0.9% Solution Prefilled Insupen Ultrafin 29gx12mm ...... 55 Ilevro (Suspension) ...... 61 Syringe, 15mg/50ml-0.9% Injection) ...... 38 Insupen Ultrafin 30gx8mm ...... 55 Imatinib Mesylate (Tablet) ...... 26 Hydromorphone HCl/Sodium Chloride Insupen Ultrafin 31gx6mm ...... 55 Imbruvica (Capsule) ...... 26 (10mg/50ml-0.9% Injection, 15mg/30ml- Insupen Ultrafin 31gx8mm ...... 55 Imipenem/Cilastatin (Injection) ...... 16 0.9% Injection) ...... 12 Integra F (40mg-62.5mg-1000mcg-3mg- Imipramine HCl (10mg Tablet, 25mg Tablet, Hydromorphone HCl/Sodium Chloride 62.5mg Capsule) ...... 65 50mg Tablet) ...... 21 (10mg/50ml-0.9% Solution, 50mg/100ml- Integra Plus (210mg-300mcg-7mg-10mcg- Imipramine Pamoate (Capsule) ...... 21 0.9% Solution, 40mg/100ml-0.9% 62.5mg-1000mcg-20mg-62.5mg-25mg- Imiquimod (Cream) ...... 42 Injection, 5mg/25ml-0.9% Solution 5mg-5mg Capsule)...... 30 Imitrex (100mg Tablet, 25mg Tablet, 50mg Prefilled Syringe) ...... 12 Integrilin (Injection) ...... 33 Tablet, 20mg/act Nasal Solution, 5mg/act Hydromorphone HCl/Sodium Chloride Intelence (Tablet) ...... 28 Nasal Solution, 6mg/0.5ml Injection) ... 23 (Prefilled Syringe, Injection Solution) .... 38 Interarticular Joint Kit (Kit) ...... 47 Imitrex Statdose System (Injection) ...... 23 Hydromorphone HCl/Sodium Chloride Intermezzo (Tablet Sublingual) ...... 65 Imlygic (Suspension) ...... 24 (Solution Prefilled Syringe) ...... 38 Intralipid (30gm/100ml Injection) ...... 55 Imogam Rabies-HT (Injection) ...... 51 Hydroxocobalamin (Injection) ...... 67 Intron A (Injection) ...... 25 Impavido (Capsule) ...... 15 Hydroxychloroquine Sulfate (Tablet) ...... 26 Intron A w/Diluent (Injection) ...... 60 Imuran (Tablet) ...... 50 Hydroxyprogesterone Caproate (Injection) . 49 Intuniv (Tablet Extended-Release 24 Hour)39 In Touch Sterile Lancets 30g ...... 55 Hydroxyurea (Capsule) ...... 25 Invanz (Injection) ...... 16 Increlex (Injection) ...... 47 Hydroxyzine HCl (10mg Tablet, 25mg Tablet, Invega (Tablet Extended-Release 24 Hour) 27 Incruse Ellipta (Aerosol Powder) ...... 63 50mg Tablet, 10mg/5ml Syrup, 50mg/ml Invega Sustenna (Injection) ...... 27 Indapamide (Tablet) ...... 37 Injection) ...... 22 Invega Trinza (Injection) ...... 27 Inderal LA (Capsule Extended-Release 24 Hydroxyzine HCl (25mg/ml Injection) ...... 59 Invirase (200mg Capsule, 500mg Tablet) ... 29 Hour) ...... 35 Hydroxyzine Pamoate (100mg Capsule, 25mg Invokamet (Tablet) ...... 31 Inderal XL (Capsule Extended-Release 24 Capsule, 50mg Capsule) ...... 22 Invokamet XR (Tablet Extended-Release 24 Hour) ...... 35 Hylenex (Injection) ...... 55 Hour) ...... 31 Indocin (25mg/5ml Suspension) ...... 10 Hylira (0.1% Lotion, 0.2% Gel) ...... 51 Invokana (Tablet) ...... 31 Indocin (50mg Suppository) ...... 10 Hymovis (Injection) ...... 55 Iodine Strong (5%-10% Oral Solution) ...... 64 Indomethacin (1mg Solution) ...... 59 Hyoscyamine Sulfate (0.125mg Tablet Iodine Tincture (2% Tincture) ...... 15 Indomethacin (25mg Capsule, 50mg Capsule) Dispersible) ...... 44 Iopidine (Ophthalmic Solution) ...... 61 ...... 10 Hyperrab S/D (Injection) ...... 51 Ipratropium Bromide (0.02% Inhalation Indomethacin ER (Capsule Extended-Release) Hyperrho S/D (Injection) ...... 51 Solution, 0.03% Nasal Solution, 0.06% ...... 10 Hyperrho S/D Mini-Dose (Injection) ...... 51 Nasal Solution) ...... 63 Infasurf (Suspension)...... 64 Hypersal (Nebulized Solution) ...... 64 Ipratropium Bromide/Albuterol Sulfate Infed (Injection) ...... 65 Hyper-Sal (Nebulized Solution) ...... 64 (Inhalation Solution) ...... 60 Inflectra (Injection) ...... 52 Hypertensa (Capsule) ...... 65 Iprivask (Injection) ...... 32 Infumorph 200 (Injection) ...... 11 Hyqvia (Injection) ...... 51 Irbesartan (Tablet) ...... 34 Infumorph 500 (Injection) ...... 11 Hy-Vee Lancets...... 55 Irbesartan/Hydrochlorothiazide (Tablet) ..... 34 Infuvite (Injection) ...... 67 Hyzaar (Tablet) ...... 34 Iressa (Tablet) ...... 26 Infuvite Pediatric (Injection) ...... 67 Irinotecan (40mg/2ml Injection)...... 60 82

Irinotecan (500mg/25ml Injection) ...... 60 Karbinal ER (Suspension Extended-Release) L Irinotecan HCl (Injection) ...... 60 ...... 62 Labetalol HCl (100mg Tablet, 200mg Tablet, Is 24/6 ...... 30 Kayexalate (Powder) ...... 65 300mg Tablet, 5mg/ml Solution) ...... 35 Isentress (100mg Packet, 100mg Tablet Kazano (Tablet) ...... 31 Lac-Hydrin (12% Cream, 12% Lotion) ...... 42 Chewable, 25mg Tablet Chewable, 400mg Keflex (Capsule) ...... 16 Lacrisert (Insert) ...... 60 Tablet) ...... 28 Kenalog (Aerosol Solution)...... 42 Lactic Acid (10% Lotion) ...... 42 Isoniazid (100mg Tablet, 300mg Tablet, Kenalog-10 (Injection) ...... 47 Lactic Acid E (10%-3500unit/30gm Cream) . 42 50mg/5ml Syrup) ...... 24 Kenalog-40 (Injection) ...... 47 Lactic Acid with Vitamin E (Cream) ...... 42 Isoniazid (100mg/ml Injection) ...... 24 Kepivance (Injection) ...... 40 Lactulose (Oral Solution) ...... 45 Isopto Carpine (Ophthalmic Solution) ...... 61 Keppra (1000mg Tablet, 250mg Tablet, Lamictal (Tablet) ...... 19 Isordil Titradose (Tablet) ...... 38 500mg Tablet, 750mg Tablet, 100mg/ml Lamictal Chewable Dispersible (Tablet Isosorbide Dinitrate (Tablet Immediate- Oral Solution, 500mg/5ml Injection) .... 18 Chewable) ...... 19 Release) ...... 38 Keppra XR (Tablet Extended-Release 24 Lamictal ODT (Kit, 100mg Tablet Dispersible, Isosorbide Dinitrate ER (Tablet Extended- Hour) ...... 18 200mg Tablet Dispersible, 25mg Tablet Release) ...... 38 Keralyt (6% Gel) ...... 42 Dispersible, 50mg Tablet Dispersible) ... 19 Isosorbide Mononitrate (Tablet Immediate- Kerr Triple Dye (Swab) ...... 23 Lamictal Starter (Blue Kit) ...... 19 Release) ...... 38 Kerydin (External Solution) ...... 23 Lamictal Starter (Green Kit) ...... 19 Isosorbide Mononitrate ER (Tablet Extended- Ketoconazole (2% Cream, 2% Foam, 2% Lamictal Starter (Orange Kit) ...... 19 Release 24 Hour) ...... 38 Shampoo, 200mg Tablet) ...... 23 Lamictal XR (100mg Tablet Extended- Isotonic Gentamicin (Injection) ...... 14 Ketodan Kit (Kit) ...... 23 Release 24 Hour, 200mg Tablet Extended- Isradipine (Capsule) ...... 36 Ketoprofen (Capsule Immediate-Release) .. 10 Release 24 Hour, 250mg Tablet Extended- Istalol (Ophthalmic Solution) ...... 61 Ketoprofen ER (Capsule Extended-Release 24 Release 24 Hour, 25mg Tablet Extended- Istodax (Injection) ...... 60 Hour) ...... 10 Release 24 Hour, 300mg Tablet Extended- Istodax (Overfill) (Injection) ...... 60 Ketorocaine-L (Injection) ...... 10 Release 24 Hour, 50mg Tablet Extended- Isuprel (Injection) ...... 63 Ketorocaine-LM (Injection) ...... 10 Release 24 Hour) ...... 19 Itraconazole (Capsule) ...... 23 Ketorolac Tromethamine (0.4% Ophthalmic Lamictal XR (Kit) ...... 39 IV Infusion CPI (Kit) ...... 12 Solution, 0.5% Ophthalmic Solution) ..... 61 Lamisil (Tablet) ...... 23 Ivermectin (Tablet) ...... 26 Ketorolac Tromethamine (10mg Tablet) ..... 10 Lamivudine (100mg Tablet) ...... 28 Ixempra Kit (Injection) ...... 60 Ketorolac Tromethamine (15mg/ml Injection, Lamivudine (10mg/ml Oral Solution, 150mg Ixinity (Injection) ...... 33 30mg/ml Injection, 30mg/ml Injection) . 60 Tablet, 300mg Tablet) ...... 29 Keveyis (Tablet) ...... 61 Lamivudine/Zidovudine (Tablet)...... 29 J Keytruda (Injection) ...... 26 Lamotrigine (Tablet Immediate-Release, Khedezla (Tablet Extended-Release 24 Hour) Tablet Chewable) ...... 19 Jadenu (Tablet) ...... 65 ...... 21 Lamotrigine ER (100mg Tablet Extended- Jakafi (Tablet) ...... 25 Kineret (Injection) ...... 60 Release 24 Hour, 200mg Tablet Extended- Jalyn (Capsule) ...... 46 Kisqali (Tablet) ...... 24 Release 24 Hour, 25mg Tablet Extended- Janumet (Tablet) ...... 31 Kitabis Pak (Nebulized Solution) ...... 14 Release 24 Hour, 300mg Tablet Extended- Janumet XR (Tablet Extended-Release 24 Klaron (Lotion) ...... 42 Release 24 Hour, 50mg Tablet Extended- Hour) ...... 31 Klonopin (Tablet) ...... 19 Release 24 Hour, 250mg Tablet Extended- Januvia (Tablet) ...... 31 Klor-Con M15 (Tablet Extended-Release) .. 65 Release 24 Hour) ...... 19 Jardiance (Tablet) ...... 31 Klor-Con/25 (Packet) ...... 43 Lamotrigine ODT (Tablet Dispersible) ...... 19 Jentadueto (Tablet) ...... 31 Koate (Solution) ...... 33 Lamotrigine Titration (Kit) ...... 19 Jentadueto XR (Tablet Extended-Release 24 Koate-Dvi (Injection) ...... 33 Lancet Transporter Case ...... 55 Hour) ...... 50 Kogenate FS (Injection) ...... 33 Lancets ...... 55 Jevtana (Injection) ...... 60 Kogenate FS Bio-Set (Injection) ...... 33 Lancets 26g Twist Top ...... 55 Jublia (External Solution) ...... 23 Kombiglyze XR (Tablet Extended-Release 24 Lancets 28g ...... 55 Juxtapid (Capsule) ...... 37 Hour) ...... 31 Lancets 31g Twist Top ...... 55 Korlym (Tablet) ...... 47 Lancets Thin ...... 55 K Kovaltry (Injection) ...... 33 Lancets Ultra Fine ...... 55 Krisgel 100 (Gel)...... 66 Kabiven (Injection) ...... 65 Lancets Ultra Thin ...... 55 Kristalose (Packet) ...... 45 Kadcyla (Injection) ...... 60 Lanoxin (0.25mg/ml Injection, 125mcg Krystexxa (Injection) ...... 23 Kalbitor (Injection) ...... 55 Tablet, 187.5mcg Tablet, 250mcg Tablet, K-Tab (10meq Tablet Extended-Release) ... 65 Kaletra (100mg-25mg Tablet, 200mg-50mg 62.5mcg Tablet) ...... 36 K-Tab (20meq Tablet Extended-Release, Tablet) ...... 29 Lanoxin Pediatric (Injection) ...... 36 8meq Tablet Extended-Release) ...... 65 Kaletra (400mg-100mg/5ml Oral Solution) 29 Lansoprazole (Capsule Delayed-Release) .... 45 Kuvan (100mg Packet, 500mg Packet, 100mg Kalydeco (150mg Tablet, 50mg Packet, 75mg Lansoprazole/Amoxicillin/Clarithromycin Tablet Soluble) ...... 44 Packet) ...... 63 (Therapy Pack) ...... 44 Kynamro (Solution Prefilled Syringe) ...... 37 Kanuma (Injection) ...... 44 Lantus (Injection) ...... 31 Kyprolis (30mg Injection) ...... 25 Kapvay (Tablet Extended-Release 12 Hour) Lantus SoloStar (Injection) ...... 31 Kyprolis (60mg Injection) ...... 60 ...... 39 Lartruvo (190mg/19ml Solution,

83

500mg/50ml Injection) ...... 24 Levorphanol Tartrate (Tablet) ...... 11 Syringe/Ll/Swab/Gz/Cap/Ndl Lasix (Tablet) ...... 37 Levothyroxine Sodium (100mcg Injection, St/Safetycone (Kit) ...... 55 Lastacaft (Ophthalmic Solution) ...... 61 200mcg Injection, 500mcg Injection) .... 49 Lisinopril (Tablet) ...... 34 Latanoprost (Ophthalmic Solution) ...... 60 Levothyroxine Sodium (100mcg Tablet, Lisinopril/Hydrochlorothiazide (Tablet) ...... 34 Latrix XM (Emulsion) ...... 42 112mcg Tablet, 125mcg Tablet, 137mcg Lister-V (Capsule) ...... 65 Latuda (Tablet) ...... 27 Tablet, 150mcg Tablet, 175mcg Tablet, LiteAire (Device) ...... 55 Lazanda (Nasal Solution) ...... 12 200mcg Tablet, 25mcg Tablet, 300mcg LiteTouch Lancets Micro Thin 33g ...... 55 Leader Unifine Pentips Tablet, 50mcg Tablet, 75mcg Tablet, LiteTouch Pen Needles 29gx12.7mm ...... 55 Plus/Short/31gx5/16" ...... 55 88mcg Tablet) ...... 49 LiteTouch Pen Needles 31gx8mm Short ..... 56 Leader Unifine Pentips/Mini/31gx3/16" ... 55 Levulan Kerastick (External Solution) ...... 42 Lithium (Oral Solution) ...... 30 Leader Unifine Pentips/Nano/32gx5/32" .. 55 Lexapro (10mg Tablet, 20mg Tablet, 5mg Lithium Carbonate (150mg Capsule, 600mg Lecithin (0 Granules) ...... 55 Tablet, 5mg/5ml Oral Solution) ...... 21 Capsule) ...... 30 Leflunomide (Tablet) ...... 51 Lexiva (50mg/ml Suspension, 700mg Tablet) Lithium Carbonate (300mg Capsule, 600mg Lemtrada (Injection) ...... 51 ...... 29 Capsule, 300mg Tablet) ...... 30 Lenvima (Capsule Therapy Pack) ...... 26 Lialda (Tablet Delayed-Release) ...... 51 Lithium Carbonate ER (Tablet Extended- Lescol XL (Tablet Extended-Release 24 Hour) Liberty Medical Lancets 30g ...... 55 Release) ...... 30 ...... 37 Librax (Capsule) ...... 44 Lithobid (Tablet Extended-Release) ...... 30 Letairis (Tablet) ...... 63 Lidocaine (3% Cream, 5% Ointment, 5% Lithostat (Tablet) ...... 46 Letrozole (Tablet) ...... 25 Patch) ...... 13 Livalo (Tablet) ...... 37 Leucovorin Calcium (100mg Injection, 200mg Lidocaine HCl (0.5% Injection, 1% Injection, Live Better Lancet Super Thin 30g ...... 56 Injection, 350mg Injection, 50mg Injection) 1.5% Injection, 2% Injection, 4% Injection, Live Better Lancet Ultra Thin 28g ...... 56 ...... 60 2% Gel, 4% External Solution) ...... 13 LMD 10% Dextrose 5% (Injection) ...... 32 Leucovorin Calcium (10mg Tablet, 15mg Lidocaine HCl (10mg/ml Injection)...... 35 LMD 10% Sodium Chloride 0.9% (Injection) Tablet, 25mg Tablet, 5mg Tablet) ...... 25 Lidocaine HCl (20mg/ml Injection) ...... 35 ...... 32 Leucovorin Calcium (500mg Injection) ...... 60 Lidocaine HCl (Gel) ...... 13 L-Methyl-B6-B12 (Tablet) ...... 67 Leukeran (Tablet) ...... 24 Lidocaine HCl (Solution Prefilled Syringe).. 51 L-Methylfolate (Tablet) ...... 55 Leukine (Injection) ...... 32 Lidocaine HCl in D5W (Injection)...... 35 L-Methylfolate Ca/P-5-P/Me-Cbl (Capsule) . 67 Leuprolide Acetate (Injection) ...... 49 Lidocaine HCl/Dextrose (Injection) ...... 13 L-Methylfolate Calcium (Tablet) ...... 55 Levacet (Tablet) ...... 39 Lidocaine HCl/Hydrocortisone Acetate (0.5%- Lmthf/Pyridoxine HCl/Cyanocobalamin Levalbuterol (Nebulized Solution) ...... 63 3% Cream, 0.5%-3% Kit, 1%-3% Kit, 2%-2% (Tablet) ...... 67 Levalbuterol Tartrate HFA (Aerosol) ...... 63 Kit, 2.5%-3% Kit) ...... 42 Lo Loestrin Fe (Tablet) ...... 48 Levaquin (Tablet) ...... 17 Lidocaine HCl-Hydrocortisone Acetate with Locoid (0.1% Cream, 0.1% External Solution, Levemir (Injection) ...... 31 Aloe (0.55%-2.8% Gel) ...... 42 0.1% Lotion, 0.1% Ointment) ...... 42 Levemir FlexTouch (Injection) ...... 31 Lidocaine Viscous (Solution) ...... 13 Locoid Lipocream (Cream) ...... 42 Levetiracetam (1000mg/100ml- Lidocaine/Epinephrine (Injection) ...... 13 Lodine (Tablet) ...... 10 750mg/100ml Injection, 1500mg/100ml- Lidocaine/Prilocaine (2.5%-2.5% Cream, Lodosyn (Tablet) ...... 27 540mg/100ml Injection, 500mg/100ml- 2.5%-2.5% Kit) ...... 13 Loestrin 1.5/30-21 (Tablet) ...... 48 820mg/100ml Injection) ...... 18 Lidoderm (Patch) ...... 13 Loestrin 1/20-21 (Tablet) ...... 48 Levetiracetam (Tablet Immediate-Release, Lifescan Unistik 2 Deep Penetration ...... 55 Loestrin Fe 1.5/30 (Tablet) ...... 48 Oral Solution, Injection) ...... 18 Lifescan Unistik II Lancets ...... 55 Loestrin Fe 1/20 (Tablet) ...... 48 Levetiracetam ER (Tablet Extended-Release Limbrel (Capsule) ...... 55 Lofibra (134mg Capsule, 200mg Capsule, 24 Hour) ...... 18 Limbrel250 (Capsule) ...... 55 67mg Capsule, 160mg Tablet, 54mg Levitra (Tablet) ...... 46 Limbrel500 (Capsule) ...... 55 Tablet) ...... 37 Levobunolol HCl (Ophthalmic Solution) ...... 61 Lincocin (Injection) ...... 15 Lomotil (Tablet)...... 44 Levocarnitine (1gm/10ml Oral Solution, Lincomycin HCl (Injection) ...... 15 Lonsurf (Tablet) ...... 25 200mg/ml Injection, 330mg Tablet) ...... 55 Lindane (Shampoo) ...... 26 Loperamide HCl (2mg Capsule) ...... 44 Levocetirizine Dihydrochloride (2.5mg/5ml Linezolid (100mg/5ml Suspension, 600mg Lopid (Tablet) ...... 37 Oral Solution, 5mg Tablet) ...... 62 Tablet, 600mg/300ml Injection) ...... 15 Lopinavir/Ritonavir (Solution) ...... 29 Levofloxacin (0.5% Ophthalmic Solution, Linzess (145mcg Capsule, 290mcg Capsule)45 Lopressor (Tablet) ...... 35 250mg Tablet, 500mg Tablet, 750mg Linzess (72mcg Capsule) ...... 46 Lopressor HCT (Tablet) ...... 35 Tablet, 25mg/ml Injection, 25mg/ml Oral Lioresal Intrathecal (Injection) ...... 28 Loprox (0.77% Cream, 0.77% Suspension, Solution) ...... 17 Liothyronine Sodium (10mcg/ml Injection, 0.77%-0-Kit) ...... 23 Levofloxacin in D5W (Injection) ...... 17 25mcg Tablet, 50mcg Tablet, 5mcg Tablet) Loprox Shampoo ...... 23 Levoleucovorin (175mg Solution) ...... 52 ...... 49 Lorazepam (0.5mg Tablet, 1mg Tablet, 2mg Levoleucovorin (175mg/17.5ml Injection, Lipichol 540 (Capsule)...... 65 Tablet) ...... 19 250mg/25ml Injection) ...... 25 Lipitor (Tablet) ...... 37 Lorazepam (20mg/10ml Injection, 4mg/ml Levoleucovorin (50mg Injection) ...... 60 Lipofen (Capsule) ...... 37 Injection, 2mg/ml Concentrate) ...... 29 Levonorgestrel and Ethinyl Estradiol (Tablet) Liquihep BD 3ml Prefil Lorazepam/Dextrose (5%-100mg/100ml ...... 48 Syr/Swab/Gauze/Cap/Ndl Stop/Lbl/Ndls Injection) ...... 29 Levonorgestrel/Ethinyl Estradiol (Tablet) .... 48 (Kit) ...... 55 Lorazepam/Sodium Chloride (100mg/100ml- Levophed (Injection) ...... 36 Liquihep II BD 3ml LL 0.9% Solution) ...... 39 84

Lortab (300mg/15ml-10mg/15ml Elixir) ..... 12 Macrodantin (Capsule) ...... 15 Maxzide (Tablet) ...... 37 Lorzone (Tablet) ...... 64 Macutek (Tablet Dispersible) ...... 66 MB Hydrogel (Kit) ...... 42 Losartan Potassium (Tablet) ...... 34 Magnesium Chloride (200mg/ml Injection) 66 Meclizine HCl (12.5mg Tablet, 25mg Tablet) Losartan Potassium/Hydrochlorothiazide Magnesium Sulfate (20gm/500ml Injection, ...... 22 (Tablet) ...... 34 2gm/50ml Injection, 40gm/1000ml Meclofenamate Sodium (100mg Capsule, LoSeasonique (Tablet) ...... 48 Injection, 4gm/100ml Injection, 50mg Capsule) ...... 10 Lotemax (0.5% Gel, 0.5% Ointment, 0.5% 4gm/50ml Injection) ...... 66 Medisense Thin Lancets ...... 56 Suspension) ...... 61 Magnesium Sulfate in D5W (5%-10mg/ml Medlance Plus Extra Lancets 21g ...... 56 Lotensin (Tablet) ...... 34 Injection) ...... 18 Medlance Plus Lancets ...... 56 Lotensin HCT (Tablet) ...... 34 Magnesium Sulfate in D5W (5%-1gm/50ml Medlance Plus Lite Lancets 25g ...... 56 Lotrel (Capsule) ...... 34 Solution, 5%-2gm/100ml Solution) ...... 43 Medlance Plus Special Lancets 0.8mm ...... 56 Lotrisone (Cream) ...... 23 Magnesium Sulfate/Dextrose (0- Medlance Plus SuperLite 30g ...... 56 Lotronex (Tablet) ...... 45 10gm/250ml Solution, 5%-40gm/500ml Medlance Plus SuperLite 30g/Comfort Max Lovastatin (Tablet) ...... 37 Solution, 5%-4gm/100ml Solution) ...... 43 ...... 56 Lovaza (Capsule) ...... 37 Magnesium Sulfate/Dextrose (5%-2gm/50ml Medlance Plus Universal Lancets 21g ...... 56 Lovenox (100mg/ml Injection, 120mg/0.8ml Injection, 5%-3gm/50ml Injection) ...... 18 Medlance/Extra ...... 56 Injection, 150mg/ml Injection, Magnesium Sulfate/Lactated Ringers ...... 43 Medlance/Lite ...... 56 30mg/0.3ml Injection, 40mg/0.4ml Magnesium Sulfate/Lactated Ringers Medlance/Universal ...... 56 Injection, 60mg/0.6ml Injection, (100mg/500ml-20gm/500ml- Medrol (16mg Tablet, 32mg Tablet, 4mg 80mg/0.8ml Injection, 300mg/3ml 150mg/500ml-3gm/500ml-1.55gm/500ml Tablet, 8mg Tablet) ...... 47 Injection) ...... 32 Solution) ...... 43 Medrol (2mg Tablet) ...... 47 Loxapine Succinate (Capsule) ...... 27 Magnesium Sulfate/Sodium Chloride Medrox-Rx (Ointment) ...... 42 Lozibase S ...... 56 (10gm/100ml-0.9% Solution, 1gm/50ml- Medroxyprogesterone Acetate (Tablet) ...... 49 Lozi-Flur (Lozenge) ...... 65 0.9% Solution, 6gm/150ml-0.9% Solution, Mefenamic Acid (250mg Capsule) ...... 10 LT Injection Kit (Injection) ...... 47 6gm/50ml-0.9% Solution) ...... 43 Mefloquine HCl (Tablet) ...... 26 Lucentis (0.3mg/0.05ml Injection, Magnesium Sulfate/Sodium Chloride Megace ES (Suspension) ...... 49 0.5mg/0.05ml Injection) ...... 60 (2gm/50ml-0.9% Injection, 40gm/L-0.9% Megace Oral (Suspension) ...... 49 Lucentis (0.5mg/0.05ml Solution Prefilled Injection) ...... 18 Megestrol Acetate (20mg Tablet, 40mg Syringe) ...... 44 Magnesium Sulfate/Sodium Chloride Tablet, 40mg/ml Suspension, 40mg/ml Lugols (Solution) ...... 64 (4gm/100ml-0.9% Solution) ...... 43 Suspension, 625mg/5ml Suspension) ..... 49 Lukaid GLA (Emulsion) ...... 66 Makena (Injection) ...... 49 Meijer Lancets Universal 30g ...... 56 Lumigan (Ophthalmic Solution) ...... 60 Malarone (Tablet)...... 26 Meijer Super Thin Lancets ...... 56 Lumizyme (Injection) ...... 44 Malathion (Lotion) ...... 26 Mekinist (Tablet) ...... 26 Lunesta (Tablet) ...... 65 Manganese Trace Metal (Injection) ...... 66 Meloxicam (Tablet) ...... 10 Lupaneta Pack (Kit) ...... 49 Mannitol (Injection) ...... 36 Meloxicam Comfort Pac (Kit) ...... 10 Lupron Depot (11.25mg Injection, 3.75mg Maprotiline HCl (Tablet)...... 20 Melphalan HCl (Injection) ...... 24 Injection) ...... 49 Marbeta-25 (Injection) ...... 56 Memantine HCl (10mg Tablet, 5mg Tablet, Lupron Depot (22.5mg Injection, 30mg Marbeta-L (Injection) ...... 47 2mg/ml Oral Solution) ...... 20 Injection, 45mg Injection, 7.5mg Marcaine (Injection) ...... 13 Memantine HCl Titration Pak (Tablet) ...... 20 Injection) ...... 49 Marcaine/Epinephrine (0.25%-1 Menest (Tablet) ...... 48 Lupron Depot-PED (11.25mg Injection) ...... 49 200000 Injection) ...... 13 Menopur (Injection) ...... 50 Lupron Depot-PED (15mg Injection, 30mg Marcaine/Epinephrine (0.5%-1 Menostar (Patch Weekly) ...... 48 Injection, 7.5mg Injection) ...... 49 200000 Injection) ...... 51 Mentax (Cream) ...... 23 Luride (Oral Solution) ...... 66 Mardex-25 (Injection) ...... 47 Meperidine HCl (100mg Tablet, 50mg Tablet, Luxiq (Foam) ...... 42 Marinol (Capsule) ...... 22 100mg/ml Injection, 10mg/ml Injection, Luzu (Cream) ...... 23 Marlido-25 (Injection) ...... 13 25mg/ml Injection, 50mg/ml Injection, Lynparza (Capsule) ...... 25 Marnatal-F (Capsule) ...... 67 50mg/5ml Oral Solution) ...... 12 Lyrica (100mg Capsule, 150mg Capsule, Marplan (Tablet)...... 20 Meperidine HCl/Sodium Chloride 200mg Capsule, 225mg Capsule, 25mg Marqibo (Injection) ...... 25 (1000mg/100ml-0.9% Injection, Capsule, 300mg Capsule, 50mg Capsule, Mask Vortex/Baby Whirl Duckling ...... 56 500mg/50ml-0.9% Injection) ...... 12 75mg Capsule) ...... 18 Mask Vortex/Child/Frog ...... 56 Meperidine HCl/Sodium Chloride Lyrica (20mg/ml Oral Solution) ...... 18 Mask Vortex/Spinner the Duck ...... 56 (300mg/30ml-0.9% Solution) ...... 38 Lysodren (Tablet) ...... 49 Mask Vortex/Toddler/Lady Bug ...... 56 Mephyton (Tablet) ...... 67 Lysteda (Tablet) ...... 33 Matulane (Capsule) ...... 24 Meprobamate (Tablet) ...... 29 Mavik (Tablet) ...... 34 Mepron (Suspension) ...... 26 M Maxalt (Tablet) ...... 23 Mercaptopurine (Tablet) ...... 25 Maxalt-MLT (Tablet Dispersible) ...... 23 Meropenem (Injection) ...... 16 M.V.I. Adult (Injection) ...... 67 Maxidex (Suspension) ...... 61 Meropenem/Sodium Chloride (Injection) ... 16 M.V.I. Pediatric (Injection) ...... 67 Maxipime (Injection) ...... 16 Merrem (Injection) ...... 16 M.V.I.-12 without Vitamin K (Injection) ..... 67 Maxitrol (0.1% Ointment, 0.1% Suspension) Mesalamine (4gm Enema, 4gm Kit) ...... 51 Macrobid (Capsule) ...... 15 ...... 15 Mesalamine DR (Tablet Delayed-Release) ... 51 85

Mesna (Injection) ...... 25 (Injection) ...... 60 Minivelle (Patch Twice Weekly) ...... 48 Mesnex (100mg/ml Injection) ...... 25 Methylprednisolone/Lidocaine (Injection) 47 Minocin (100mg Capsule, 50mg Capsule, Mesnex (400mg Tablet) ...... 60 Methyltestosterone (10mg Capsule) ...... 48 75mg Capsule, 100mg Injection)...... 18 Mestinon (60mg Tablet) ...... 24 Metipranolol (Ophthalmic Solution) ...... 61 Minocycline HCl (100mg Capsule, 50mg Mestinon (60mg/5ml Syrup) ...... 24 Metoclopramide HCl (10mg Tablet, 5mg Capsule, 75mg Capsule, 100mg Tablet, Mestinon Timespan (Tablet Extended- Tablet, 5mg/5ml Oral Solution) ...... 22 50mg Tablet, 75mg Tablet) ...... 18 Release) ...... 24 Metoclopramide HCl (5mg/ml Injection) .... 60 Minocycline HCl ER (Tablet Extended-Release Metadate CD (Capsule Extended-Release) . 39 Metoclopramide ODT (10mg Tablet 24 Hour) ...... 18 Metafolbic (Tablet) ...... 68 Dispersible) ...... 22 Minoxidil (Tablet) ...... 38 Metafolbic Plus (Tablet) ...... 67 Metoclopramide ODT (5mg Tablet Mirapex (Tablet) ...... 26 Metafolbic Plus RF (Tablet)...... 67 Dispersible) ...... 22 Mirapex ER (Tablet Extended-Release 24 Metanx (Capsule) ...... 67 Metolazone (Tablet) ...... 37 Hour) ...... 26 Metaproterenol Sulfate (10mg Tablet, 20mg Metoprolol Succinate ER (Tablet Extended- Mircera (100mcg/0.3ml Injection, Tablet, 10mg/5ml Syrup) ...... 63 Release 24 Hour) ...... 35 200mcg/0.3ml Injection, 50mcg/0.3ml Metastron (Injection)...... 56 Metoprolol Succinate Injection, 75mcg/0.3ml Injection) ...... 32 Metaxalone (Tablet) ...... 64 ER/Hydrochlorothiazide (Tablet Mircera (150mcg/0.3ml Injection, Metformin HCl (Tablet Immediate-Release) 31 Extended-Release 24 Hour) ...... 35 30mcg/0.3ml Injection) ...... 30 Metformin HCl ER (Tablet Extended-Release Metoprolol Tartrate (100mg Tablet, 25mg Mircette (Tablet) ...... 48 24 Hour) (Generic Fortamet, Generic Tablet, 37.5mg Tablet, 50mg Tablet, 75mg Mirtazapine (Tablet) ...... 20 Glucophage XR) ...... 31 Tablet, 5mg/5ml Injection, 5mg/5ml Mirtazapine ODT (Tablet Dispersible)...... 20 Methadone HCl (10mg Tablet, 5mg Tablet, Solution) ...... 35 Mirvaso (Gel)...... 42 10mg/5ml Oral Solution, 5mg/5ml Oral Metoprolol Tartrate (5mg/5ml Solution Misoprostol (Tablet) ...... 45 Solution, 10mg/ml Concentrate, 40mg Prefilled Syringe) ...... 38 Mission Prenatal (Tablet) ...... 67 Tablet Soluble) ...... 11 Metoprolol/Hydrochlorothiazide (Tablet) .. 35 Mitigare (Capsule) ...... 23 Methadone HCl (10mg/ml Injection) ...... 11 Metro IV (Injection) ...... 15 Mitomycin (Injection) ...... 60 Methadose (10mg/ml Concentrate) ...... 11 MetroCream (Cream) ...... 15 Mitosol (Kit) ...... 56 Methadose Sugar-Free (Concentrate) ...... 11 MetroGel (Gel)...... 15 Mitoxantrone HCl (Injection) ...... 24 Methamphetamine HCl (Tablet) ...... 39 MetroGel-Vaginal (Gel) ...... 15 Mivacron (Injection) ...... 30 Methazolamide (Tablet) ...... 36 MetroLotion (Lotion) ...... 15 Mobic (Tablet) ...... 10 Methenamine Hippurate (Tablet) ...... 15 Metronidazole (0.75% Cream, 0.75% Gel, 1% Modafinil (Tablet) ...... 65 Methimazole (10mg Tablet, 5mg Tablet) .... 50 Gel, 0.75% Lotion, 250mg Tablet, 500mg Moderiba ...... 28 Methionine/Inositol/Choline/Cyanocobalam Tablet, 375mg Capsule) ...... 15 Moderiba 1200 Dose Pack (Tablet) ...... 28 in (Injection) ...... 67 Metronidazole in NaCl 0.79% (Injection) .... 15 Moderiba 800 Dose Pack (Tablet) ...... 28 Methocarbamol (Injection, Tablet) ...... 64 Metronidazole Vaginal (Gel) ...... 15 Moexipril HCl (Tablet) ...... 34 Methotrexate (2.5mg Tablet) ...... 50 Mevacor (Tablet) ...... 37 Moexipril/Hydrochlorothiazide (Tablet) ...... 34 Methotrexate Sodium (Injection) ...... 50 Mexiletine HCl (Capsule) ...... 35 Molindone HCl (Tablet) ...... 27 Methoxsalen (10mg Capsule) ...... 42 Miacalcin (200unit/act Nasal Solution, Mometasone Furoate (0.1% Cream, 0.1% Methscopolamine Bromide (Tablet) ...... 44 200unit/ml Injection) ...... 52 Ointment) ...... 47 Methyclothiazide (5mg Tablet) ...... 37 Micardis (Tablet) ...... 34 Mometasone Furoate (0.1% External Methyldopa (Tablet) ...... 33 Micardis HCT (Tablet) ...... 34 Solution) ...... 42 Methyldopa/Hydrochlorothiazide (Tablet).. 33 Micrhogam Ultra-Filtered Plus (Injection) . 51 Mometasone Furoate (50mcg/act Methyldopate HCl (Injection) ...... 33 Microchamber ...... 56 Suspension) ...... 62 Methylergonovine Maleate (Injection)...... 56 Micro-K (Capsule Extended-Release) ...... 66 Monocal (Tablet) ...... 52 Methylin (10mg Tablet Chewable, 2.5mg Microlet Lancets ...... 56 Monoclate-P (Injection) ...... 33 Tablet Chewable, 5mg Tablet Chewable, Microspacer ...... 56 Monodox (Capsule) ...... 18 10mg/5ml Oral Solution, 5mg/5ml Oral Microtainer Safety Flow Monoject Bone Marrow Biopsy Prepping Solution) ...... 39 Lancet/Sterile/Single-Use ...... 56 Tray (Kit) ...... 13 Methylphenidate HCl (Tablet Immediate- Microzide (Capsule) ...... 37 Monoject Bone Marrow Biopsy Release, Tablet Chewable, Oral Solution) Midodrine HCl (Tablet) ...... 33 Tray/Sternal-Iliac Needle 16g (Kit) ...... 13 ...... 39 Migergot (Suppository) ...... 23 Monoject Insulin Syringe/1ml ...... 56 Methylphenidate HCl CD (Capsule Extended- Miglitol (Tablet)...... 31 Monoject Insulin Syringe/Softpack/1ml/27g Release) ...... 39 Migranal (Nasal Solution)...... 23 X 1/2" ...... 56 Methylphenidate HCl ER (Tablet, Capsule) .. 39 Millipred (10mg/5ml Oral Solution) ...... 47 Monoject Insulin Syringe/Softpack/U- Methylphenidate HCl SR (Tablet Extended- Millipred (5mg Tablet)...... 47 100/0.5ml/28g X 1/2" ...... 56 Release) ...... 39 Millipred DP (Tablet Therapy Pack) ...... 47 Monoject Ultra Comfort Insulin Methylprednisolone (16mg Tablet, 32mg Milrinone in Dextrose (5%-20mg/100ml Syringe/1ml/30g X 5/16" ...... 56 Tablet, 4mg Tablet, 8mg Tablet) ...... 47 Injection, 5%-40mg/200ml Solution) ..... 36 Monojector End Caps ...... 56 Methylprednisolone Acetate (40mg/ml Milrinone Lactate (Injection) ...... 36 Monolet Lancets ...... 56 Injection, 80mg/ml Injection) ...... 47 Minastrin 24 Fe (Tablet Chewable) ...... 48 Monolet Opd Lancets...... 56 Methylprednisolone Pf (Injection) ...... 46 Mineral Oil Heavy (0 Oil) ...... 45 Monolettor Safety Lancets ...... 56 Methylprednisolone Sodium Succinate Minipress (Capsule) ...... 33 Mononine (Injection) ...... 33 86

Monovisc (Injection) ...... 56 Mycobutin (Capsule) ...... 24 Naproxen Comfort Pac (Kit) ...... 10 Montelukast Sodium (10mg Tablet, 4mg Mycophenolate Mofetil (200mg/ml Naproxen Sodium (275mg Tablet, 550mg Packet, 4mg Tablet Chewable, 5mg Tablet Suspension, 250mg Capsule, 500mg Tablet) ...... 10 Chewable) ...... 62 Injection, 500mg Tablet) ...... 50 Naproxen Sodium CR (Tablet Extended- Monurol (Packet) ...... 15 Mycophenolic Acid DR (Tablet Delayed- Release 24 Hour) ...... 10 Morgidox 1x100mg (0-100mg-Kit) ...... 18 Release) ...... 50 Naproxen Sodium ER (Tablet Extended- Morgidox 1x50mg Kit (Kit) ...... 18 Myfortic (Tablet Delayed-Release) ...... 50 Release 24 Hour) ...... 10 Morgidox 2x100mg (0-100mg-Kit) ...... 18 MyGlucoHealth MGH Softlance Lancets 30g Naratriptan HCl (Tablet) ...... 23 Morphine Sulfate (0.5mg/ml Injection, ...... 56 Narcan (Liquid) ...... 13 100mg/5ml Oral Solution, 10mg/5ml Oral MyKidz Iron Fl (Suspension) ...... 67 Nardil (Tablet) ...... 20 Solution, 20mg/5ml Oral Solution, Myleran (Tablet) ...... 24 Naropin (Injection) ...... 13 10mg/ml Injection, 1mg/ml Injection, Mynatal (Capsule) ...... 67 NascoBAL (Nasal Solution) ...... 67 4mg/ml Injection, 8mg/ml Injection, 15mg Myobloc (Injection) ...... 56 Nasonex (Suspension) ...... 62 Tablet, 30mg Tablet) ...... 12 Myrbetriq (Tablet Extended-Release 24 Natachew (Tablet Chewable) ...... 67 Morphine Sulfate (10mg/0.7ml Injection) . 11 Hour) ...... 46 Natacyn (Suspension) ...... 23 Morphine Sulfate (10mg/ml Injection, Mysoline (Tablet) ...... 19 Natalvit (Tablet) ...... 67 150mg/30ml Injection, 15mg/ml Mytesi (Tablet Delayed-Release) ...... 44 Natazia (Tablet) ...... 48 Injection, 2mg/ml Injection, 4mg/ml Nateglinide (Tablet) ...... 31 Injection, 8mg/ml Injection, 5mg/ml N Natelle One (Capsule) ...... 67 Injection) ...... 12 Natesto (Gel) ...... 48 Morphine Sulfate (30mg Suppository) ...... 11 Nabumetone (Tablet) ...... 10 Natpara (Injection) ...... 56 Morphine Sulfate ER (Capsule Extended- N-Acetyl-L-Cysteine (Capsule) ...... 56 Natrecor (Injection) ...... 36 Release 24 Hour, Tablet Extended- Nadolol (20mg Tablet, 40mg Tablet, 80mg Natroba (Suspension) ...... 26 Release) ...... 11 Tablet) ...... 35 Nature-Throid (Tablet) ...... 49 Morphine Sulfate/Dextrose (Solution) ...... 38 Nadolol/Bendroflumethiazide (Tablet) ...... 35 Nature-Throid Nt-2.5 (Tablet)...... 49 Morphine Sulfate/Sodium Chloride Nafcillin (Injection) ...... 17 Navelbine (Injection) ...... 25 (0.5mg/ml-0.9% Injection, 50mg/50ml- Nafcillin Sodium (10gm Injection, 1gm Nebupent (Inhalation Solution) ...... 26 0.9% Injection) ...... 12 Injection, 2gm Injection) ...... 17 Nebusal (6% Nebulized Solution) ...... 64 Morphine Sulfate/Sodium Chloride Nafcillin Sodium (1gm Injection, 2gm Necon 10/11-28 (Tablet) ...... 48 (150mg/150ml-0.9% Solution, Injection) ...... 17 Neevo DHA (Capsule) ...... 67 250mg/50ml-0.9% Solution, Nafrinse Daily/Acidulated (Solution) ...... 66 Nefazodone HCl (Tablet)...... 20 500mg/100ml-0.9% Solution, Nafrinse Daily/Neutral (Solution) ...... 52 Nembutal Sodium (Injection) ...... 65 500mg/250ml-0.9% Solution, Nafrinse Weekly (Solution) ...... 52 Neoke Alcar (Powder) ...... 56 275mg/55ml-0.9% Solution Prefilled Naftifine HCl (Cream) ...... 23 Neoke MCT70 (Powder) ...... 56 Syringe) ...... 38 Naftin (1% Gel, 2% Gel, 2% Cream) ...... 23 Neoke RA Lipoic (Powder) ...... 56 Morphine Sulfate/Sodium Chloride Naglazyme (Injection) ...... 44 Neomycin Sulfate (Tablet) ...... 14 (50mg/50ml-0.9% Injection, 50mg/50ml- Nalbuphine HCl (Injection) ...... 12 Neomycin/Bacitracin/Polymyxin (Ointment) 0.9% Solution) ...... 12 Nalfon (Capsule) ...... 10 ...... 15 Movantik (Tablet) ...... 44 Naloxone HCl (Injection) ...... 13 Neomycin/Polymyxin/Bacitracin/Hydrocortis MoviPrep (Oral Solution) ...... 45 Naltrexone HCl (Tablet) ...... 13 one (Ointment) ...... 15 Moxatag (Tablet Extended-Release 24 Hour) Namenda (10mg Tablet, 5mg Tablet, Neomycin/Polymyxin/Dexamethasone (0.1% ...... 17 10mg/5ml Oral Solution) ...... 20 Ophthalmic Suspension, 0.1%-3.5mg/gm- Moxeza (Ophthalmic Solution) ...... 17 Namenda Titration Pak (Tablet) ...... 20 10000unit/gm Ointment) ...... 15 Moxifloxacin HCl (400mg Tablet, Namenda XR (Capsule Extended-Release 24 Neomycin/Polymyxin/Gramicidin 400mg/250ml Injection) ...... 17 Hour) ...... 20 (Ophthalmic Solution) ...... 14 Mozobil (Injection) ...... 32 Namenda XR Titration Pack (Capsule Neomycin/Polymyxin/Hydrocortisone (1% MS Contin (Tablet Extended-Release) ...... 11 Extended-Release 24 Hour) ...... 20 Ophthalmic Suspension) ...... 15 Mteryti (Tablet Therapy Pack) ...... 67 Namzaric (10mg-14mg Capsule Extended- Neomycin/Polymyxin/Hydrocortisone (1% Mteryti Folic 5 (Tablet Therapy Pack) ...... 67 Release 24 Hour, 10mg-28mg Capsule Otic Solution, 1% Otic Suspension) ...... 61 Mucinex Maximum Strength (1200mg Tablet Extended-Release 24 Hour) ...... 40 Neoprofen (Injection) ...... 60 Extended-Release 12 Hour) ...... 62 Namzaric (10mg-21mg Capsule Extended- Neoral (100mg Capsule, 25mg Capsule, Multaq (Tablet) ...... 35 Release 24 Hour, 10mg-7mg Capsule 100mg/ml Oral Solution) ...... 50 Multigen (Tablet) ...... 66 Extended-Release 24 Hour) ...... 20 Neosalus (0-0 Cream, 0-0 Lotion, 0-0-0 Multigen Folic (Tablet) ...... 66 Namzaric (10mg-Capsule Extended-Release Foam)...... 42 Multigen Plus (Tablet) ...... 66 24 Hour Therapy Pack) ...... 39 Neosalus CP (Cream) ...... 42 Mupirocin (2% Cream, 2% Ointment) ...... 15 Naprelan (Tablet Extended-Release 24 Hour) Neosporin (Ophthalmic Solution) ...... 14 Muse (Pellet) ...... 47 ...... 10 Neostigmine Methylsulfate (10mg/10ml Mustargen (Injection) ...... 24 Naprosyn (125mg/5ml Suspension, 500mg Injection, 5mg/10ml Injection) ...... 24 Myalept (Injection) ...... 56 Tablet) ...... 10 Neostigmine Methylsulfate (10mg/10ml Myambutol (Tablet) ...... 24 Naproxen (125mg/5ml Suspension, 250mg Injection, 5mg/10ml Injection, 5mg/5ml Mycamine (Injection) ...... 23 Tablet, 375mg Tablet, 500mg Tablet) .... 10 Injection) ...... 24 87

Neostigmine Methylsulfate (3mg/3ml Ninlaro (Capsule) ...... 25 Norethindrone Acetate (5mg Tablet) ...... 49 Solution Prefilled Syringe) ...... 30 Nipent (Injection) ...... 25 Norethindrone Acetate/Ethinyl Estradiol Neo-Synalar (Cream) ...... 42 Nisoldipine ER (Tablet Extended-Release 24 (Tablet) ...... 48 Neo-Synalar Kit (Kit) ...... 42 Hour) ...... 36 Norethindrone Acetate/Ethinyl Nephramine (Injection) ...... 66 Nithiodote (Injection) ...... 56 Estradiol/Ferrous Fumarate (Tablet) ...... 48 Nephrocaps (Capsule) ...... 67 Nitro-Bid (Ointment) ...... 38 Norethindrone/Ethinyl Estradiol/Ferrous Nephro-Vite Rx (Tablet) ...... 67 Nitro-Dur (Patch 24 Hour) ...... 38 Fumarate (Tablet Chewable) ...... 48 Neptazane (Tablet) ...... 37 Nitrofurantoin (Suspension) ...... 15 Norgestimate/Ethinyl Estradiol (0-Tablet, Nesacaine (Injection) ...... 13 Nitrofurantoin Macrocrystals (Capsule) ...... 15 35mcg-0.25mg Tablet) ...... 48 Nesacaine-Mpf (Injection) ...... 13 Nitrofurantoin Monohydrate (100mg Norinyl 1+35 (Tablet) ...... 48 Nesina (Tablet) ...... 31 Capsule) ...... 15 Noritate (Cream) ...... 15 Nestabs (Tablet) ...... 67 Nitroglycerin (0.3mg Tablet Sublingual, 0.4mg Normal Saline Flush (Solution) ...... 66 Nestabs DHA ...... 67 Tablet Sublingual, 0.6mg Tablet Norpace (Capsule) ...... 35 Neuac Kit (Kit) ...... 42 Sublingual)...... 38 Norpace CR (Capsule Extended-Release 12 Neulasta (Injection) ...... 32 Nitroglycerin (5mg/ml Injection) ...... 38 Hour) ...... 35 Neulasta Onpro Kit (Injection) ...... 32 Nitroglycerin ER (2.5mg Capsule Extended- Norpramin (Tablet) ...... 21 Neupogen (Injection) ...... 32 Release, 6.5mg Capsule Extended-Release, Northera (Capsule) ...... 36 Neupro (Patch 24 Hour) ...... 27 9mg Capsule Extended-Release) ...... 38 Nortriptyline HCl (10mg Capsule, 25mg Neurepa (Capsule) ...... 66 Nitroglycerin in 5% Dextrose (Injection) ..... 38 Capsule, 50mg Capsule, 75mg Capsule, Neurontin (100mg Capsule, 300mg Capsule, Nitroglycerin in Dextrose 5% (5%-100mcg/ml 10mg/5ml Oral Solution) ...... 21 400mg Capsule, 250mg/5ml Oral Injection) ...... 38 Norvasc (Tablet) ...... 36 Solution, 600mg Tablet, 800mg Tablet) 28 Nitroglycerin in Dextrose 5% (5%-100mcg/ml Norvir (100mg Capsule, 100mg Tablet, Neutrasal (Packet) ...... 40 Injection, 5%-200mcg/ml Injection, 5%- 80mg/ml Oral Solution) ...... 29 Neutrexin (Injection)...... 26 400mcg/ml Injection) ...... 38 Nova Safety Lancets 23g ...... 56 Nevanac (Suspension) ...... 61 Nitroglycerin Lingual Nova Safety Lancets 28g ...... 56 Nevirapine (200mg Tablet, 50mg/5ml (0.4mg/sprayTranslingual Solution, Nova Sureflex Lancets ...... 56 Suspension) ...... 28 400mcg/spray Aerosol Solution) ...... 38 Novoeight (Injection) ...... 33 Nevirapine ER (Tablet Extended-Release 24 Nitroglycerin Transdermal (Patch 24 Hour) 38 Novofine Pen Needles ...... 56 Hour) ...... 28 Nitrolingual Pumpspray (Translingual Novolin 70/30 (Injection) ...... 31 Newgen (Tablet) ...... 67 Solution) ...... 38 Novolin 70/30 Relion (Injection) ...... 31 Nexa Plus (Capsule) ...... 67 NitroMist (Aerosol Solution) ...... 38 Novolin N (Injection) ...... 32 Nexavar (Tablet) ...... 26 Nitropress (Injection) ...... 38 Novolin N Relion (Injection) ...... 32 Nexavir (Injection) ...... 56 Nitrostat (Tablet Sublingual) ...... 38 Novolin R (Injection) ...... 32 Nexium (10mg Packet, 2.5mg Packet, 20mg Niva-Plus (Tablet) ...... 67 Novolin R Relion (Injection) ...... 32 Packet, 40mg Packet, 5mg Packet, 20mg Nivatopic Plus (Cream) ...... 42 NovoLog (Injection) ...... 32 Capsule Delayed-Release, 40mg Capsule Nizatidine (150mg Capsule, 300mg Capsule, NovoLog FlexPen (Injection) ...... 32 Delayed-Release) ...... 45 15mg/ml Oral Solution) ...... 45 NovoLog Mix 70/30 (Injection) ...... 32 Nexium I.V. (Injection) ...... 45 Nizoral (Shampoo) ...... 23 NovoLog Mix 70/30 Prefilled FlexPen Nexterone (Injection) ...... 35 Norco (325mg-10mg Tablet, 325mg-7.5mg (Injection) ...... 32 Niacin (Powder) ...... 67 Tablet, 325mg-5mg Tablet) ...... 12 NovoLog PenFill (Injection) ...... 32 Niacin ER (Tablet Extended-Release) ...... 37 Norditropin FlexPro (Injection) ...... 47 Novoseven (Solution) ...... 33 Niacor (Tablet) ...... 38 Norepinephrine Bitartrate (Injection) ...... 36 Novoseven RT (Injection) ...... 33 Niaspan (Tablet Extended-Release) ...... 38 Norepinephrine Bitartrate/Dextrose (5%- Novotwist ...... 56 Nicadan (Tablet) ...... 67 4mg/250ml Injection, 5%-4mg/500ml Noxafil (100mg Tablet Delayed-Release, Nicadan Zx (Tablet) ...... 67 Injection, 5%-4mg/250ml Solution) ...... 36 300mg/16.7ml Injection, 40mg/ml Nicaprin (Tablet) ...... 66 Norepinephrine Bitartrate/Dextrose (5%- Suspension) ...... 23 Nicardipine HCl (2.5mg/ml Injection, 20mg 8mg/250ml Injection) ...... 30 Nplate (Injection) ...... 32 Capsule, 30mg Capsule) ...... 36 Norepinephrine Bitartrate/Sodium Chloride Nucala (Injection) ...... 60 Nicardipine HCl/Sodium Chloride (Solution) (0.08mg/10ml-0.9% Injection) ...... 36 Nucynta (Tablet) ...... 12 ...... 38 Norepinephrine Bitartrate/Sodium Chloride Nucynta ER (Tablet Extended-Release 12 Nicazel (Tablet) ...... 67 (16mg/250ml-0.9% Solution, Hour) ...... 11 Nicazel Forte (Tablet) ...... 67 16mg/500ml-0.9% Solution, 4mg/250ml- Nuedexta (Capsule) ...... 40 Nicomide (Tablet) ...... 56 0.9% Injection) ...... 30 Nufera (Tablet) ...... 30 Nifedipine (10mg Capsule, 20mg Capsule) .. 36 Norepinephrine/Dextrose (Solution) ...... 30 Nulojix (Injection) ...... 50 Nifedipine ER (Tablet Extended-Release 24 Norepinephrine/Sodium Chloride NuLYTELY/Flavor Packs (Oral Solution) ...... 45 Hour) ...... 36 (0.16mg/10ml-0.9% Injection, Numoisyn (0-0-0-0-0-0-0-0 Liquid, 0-0-0-0-0- Niferex (Tablet) ...... 30 8mg/250ml-0.9% Solution) ...... 36 0-0-0-0.3gm Lozenge) ...... 40 Nilandron (Tablet) ...... 24 Norepinephrine/Sodium Chloride Nuplazid (Tablet) ...... 27 Nilutamide (Tablet)...... 25 (0.8mg/50ml-0.9% Solution Prefilled Nusrugepak Surgical Prep/Carepak (Kit) .... 42 Nimbex (Injection) ...... 64 Syringe) ...... 30 NutreStore (Packet) ...... 44 Nimodipine (Capsule) ...... 36 Norethindrone (Tablet) ...... 49 Nutricap (Tablet) ...... 67 88

Nutrivit (Liquid) ...... 67 Capsule Delayed-Release) ...... 45 (Device) ...... 56 Nutropin AQ (Injection) ...... 47 Omeprazole + Syrspend SF Alka (Suspension) OptiChamber Diamond/Medium Face Mask Nuvail (External Solution) ...... 42 ...... 45 ...... 56 Nuvaring ...... 48 Omeprazole/Sodium Bicarbonate (20mg- OptiChamber Diamond/Small Face Mask .. 56 Nuvigil (Tablet) ...... 65 1100mg Capsule, 40mg-1100mg Capsule, OptiChamber Face Mask/Small ...... 56 Nuwiq (Injection) ...... 33 20mg-1680mg Packet, 40mg-1680mg Optihaler MDI Drug Delivery System Nymalize (Oral Solution) ...... 36 Packet) ...... 45 (Device) ...... 56 Nystatin (100000unit/gm Cream, Omnaris (Suspension) ...... 62 Ora-Blend (0-0-0-0-0-0 Suspension) ...... 56 100000unit/gm Ointment, 100000unit/gm Omnipred (Suspension) ...... 61 Ora-Blend SF (0-0-0-0-0 Suspension) ...... 56 Powder, 100000unit/ml Suspension, Omnitrope (Injection) ...... 47 Oracea (Capsule Delayed-Release) ...... 42 500000unit Tablet) ...... 23 On Call Lancets ...... 56 Orafate (Paste) ...... 42 Nystatin/Triamcinolone (100000unit/gm- On Call Plus Lancets ...... 56 Oral Mix Flavored Suspending Vehicle 0.1% Ointment, 100000unit/gm-1mg/gm Oncaspar (Injection) ...... 60 (Liquid) ...... 57 Cream) ...... 23 Ondansetron HCl (24mg Tablet, 4mg Tablet, Oral Mix SF (Liquid) ...... 57 8mg Tablet, 40mg/20ml Injection, Oral Suspend (Liquid) ...... 57 O 4mg/2ml Injection, 4mg/5ml Oral Oral Syrup Flavored Vehicle (Liquid) ...... 57 Solution) ...... 22 Oral Syrup SF (Liquid)...... 57 OB Complete (Tablet) ...... 67 Ondansetron HCl/Sodium Chloride (Injection) Orap (Tablet) ...... 27 OB Complete Gold (Capsule) ...... 67 ...... 22 Ora-Plus (0-0-0-0 Liquid) ...... 56 OB Complete One (Capsule) ...... 67 Ondansetron ODT (Tablet Dispersible) ...... 22 Orapred ODT (Tablet Dispersible) ...... 47 OB Complete Petite (Capsule) ...... 67 One A Day Womens Prenatal/DHA ...... 67 ORA-Sweet (5%-4%-54% Syrup) ...... 56 OB Complete Premier (Tablet) ...... 68 One A Day Womens Prenatal1 (Capsule)... 67 ORA-Sweet SF (9%-10% Syrup) ...... 57 OB Complete/DHA (Capsule) ...... 68 One-A-Day Womens Prenatal ...... 67 Orbactiv (Injection) ...... 15 Obstetrix DHA ...... 68 Onetouch Club Lancets Fine Point ...... 56 Orencia (125mg/ml Injection, 250mg Obstetrix One (Capsule)...... 68 Onetouch Combo Pack ...... 56 Injection) ...... 50 Obtrex (Tablet) ...... 67 Onetouch Delica Lancets Extra Fine 33g .... 56 Orencia Clickject (Injection) ...... 50 Obtrex DHA ...... 68 Onetouch Delica Lancets Fine 30g ...... 56 Orenitram (Tablet Extended-Release) ...... 63 O-Cal Fa (Tablet) ...... 67 Onetouch Suresoft Lancing Device/21g ..... 56 Orfadin (10mg Capsule, 20mg Capsule, 2mg O-Cal Prenatal (Tablet) ...... 67 Onetouch Ultra 2 (Kit) ...... 56 Capsule, 5mg Capsule, 4mg/ml Ocaliva (Tablet) ...... 44 Onetouch Ultra Blue (Strip) ...... 56 Suspension) ...... 44 Octagam (Injection) ...... 51 Onetouch Ultra Mini (Kit) ...... 56 Orkambi (Tablet) ...... 63 Octreotide Acetate (Injection) ...... 50 Onetouch Ultralink System (Hex) (Kit) ...... 56 Orphenadrine Citrate (30mg/ml Injection) .. 64 Ocufen (Ophthalmic Solution) ...... 61 Onetouch Ultrasoft Lancets ...... 56 Orphenadrine Citrate ER (Tablet Extended- Ocuflox (Ophthalmic Solution) ...... 17 Onetouch Verio (Kit) ...... 56 Release 12 Hour) ...... 64 Odefsey (Tablet) ...... 28 Onetouch Verio Flex Bloodglucose Ortho Micronor (Tablet) ...... 49 Odomzo (Capsule) ...... 25 Monitoring System (Kit) ...... 56 Ortho Tri-Cyclen (Tablet) ...... 49 Ofev (Capsule) ...... 64 Onetouch Verio Iq Blood Glucose Monitoring Ortho Tri-Cyclen Lo (Tablet)...... 49 Ofirmev (Injection)...... 10 System (Kit) ...... 56 Ortho-Cyclen (Tablet) ...... 49 Ofloxacin (0.3% Ophthalmic Solution, 0.3% Onetouch Verio Sync Bloodglucose Ortho-Novum 1/35 (Tablet) ...... 49 Otic Solution, 400mg Tablet) ...... 17 Monitoring System (Kit) ...... 56 Ortho-Novum 7/7/7 (Tablet) ...... 49 Ofloxacin (300mg Tablet) ...... 13 Onetouch Verio Test Strips (Strip) ...... 56 Orthovisc (Injection) ...... 57 Olanzapine (10mg Injection) ...... 60 Onexton (Gel) ...... 42 Oseltamivir Phosphate (Capsule)...... 29 Olanzapine (Tablet Immediate-Release) ..... 27 Onfi (10mg Tablet, 20mg Tablet, 2.5mg/ml Oseni (Tablet) ...... 31 Olanzapine ODT (Tablet Dispersible) ...... 27 Suspension)...... 19 Osmitrol Viaflex (10% Injection, 5% Olanzapine/Fluoxetine (Capsule) ...... 30 Onglyza (Tablet) ...... 31 Injection) ...... 36 Olmesartan Medoxomil (Tablet) ...... 34 Onivyde (Injection) ...... 60 OsmoPrep (Tablet) ...... 45 Olmesartan ONMEL (Tablet) ...... 23 Osphena (Tablet) ...... 49 Medoxomil/Amlodipine/Hydrochlorothiazi Onzetra Xsail (Exhaler Powder) ...... 23 Otezla (Tablet Therapy Pack, 30mg Tablet) 51 de (Tablet) ...... 34 Opana (Tablet Immediate-Release, 1mg/ml Otrexup (Injection) ...... 50 Olmesartan Medoxomil/Hydrochlorothiazide Injection) ...... 12 Ovace Plus Wash (10% Liquid) ...... 42 (Tablet) ...... 34 Opana ER (Tablet Extended-Release 12 Hour Ovcon-35 (Tablet) ...... 49 Olopatadine HCl (0.1% Ophthalmic Solution) Abuse-Deterrent) ...... 11 Ovide (Lotion) ...... 26 ...... 61 Opdivo (Injection)...... 26 Ovidrel (Injection) ...... 47 Olopatadine HCl (0.6% Nasal Solution)...... 62 Opsumit (Tablet) ...... 63 Oxacillin Sodium (Injection) ...... 17 Olux (Foam) ...... 42 OptiChamber Advantage ...... 56 Oxaliplatin (IV Solution 100mg/20ml) ...... 60 Olux-E (Foam) ...... 42 OptiChamber Advantage/Large Mask ...... 56 Oxandrin (Tablet) ...... 48 Olysio (Capsule) ...... 28 OptiChamber Advantage/Medium Face Oxandrolone (Tablet) ...... 48 Omeclamox-Pak (Therapy Pack) ...... 44 Mask ...... 56 Oxaprozin (Tablet) ...... 10 Omega-3-Acid Ethyl Esters (Capsule) ...... 38 OptiChamber Advantage/Small Face Mask 56 Oxaydo (Tablet Abuse-Deterrent) ...... 12 Omeprazole (10mg Capsule Delayed-Release, OptiChamber Diamond ...... 56 Oxazepam (Capsule) ...... 29 20mg Capsule Delayed-Release, 40mg OptiChamber Diamond/Large Face Mask Oxcarbazepine (150mg Tablet, 300mg Tablet, 89

600mg Tablet, 60mg/ml Suspension) ..... 20 30mg/10ml Injection, 90mg Injection, Pen Needles 30gx5/16" ...... 57 Oxiconazole Nitrate (Cream) ...... 23 90mg/10ml Injection) ...... 52 Pen Needles 30gx5mm ...... 57 Oxistat (1% Cream, 1% Lotion) ...... 23 Pamidronate Disodium (6mg/ml Injection) 52 Pen Needles 30gx8mm ...... 57 Oxsoralen Ultra (Capsule) ...... 42 Pamine (Tablet) ...... 44 Pen Needles 31gx6mm (1/4") ...... 57 Oxtellar XR (Tablet Extended-Release 24 Pamine Forte (Tablet)...... 44 Penicillin G Potassium (Injection) ...... 17 Hour) ...... 20 Pamine FQ (Kit) ...... 44 Penicillin G Potassium in Iso-Osmotic Oxybutynin Chloride (5mg Tablet, 5mg/5ml Pancreaze (10850unit-2600unit-6200unit Dextrose (Injection) ...... 17 Syrup) ...... 46 Capsule Delayed-Release) ...... 46 Penicillin G Procaine (Injection)...... 17 Oxybutynin Chloride ER (Tablet Extended- Pancreaze (24600unit-4200unit-14200unit Penicillin G Sodium (Injection) ...... 17 Release 24 Hour) ...... 46 Capsule Delayed-Release, 61500unit- Penicillin V Potassium (125mg/5ml Oral Oxycodone HCl (100mg/5ml Concentrate, 10500unit-35500unit Capsule Delayed- Solution, 250mg/5ml Oral Solution, 250mg 10mg Tablet, 15mg Tablet, 20mg Tablet, Release, 83900unit-21000unit-54700unit Tablet, 500mg Tablet) ...... 17 30mg Tablet, 5mg Tablet, 5mg Capsule, Capsule Delayed-Release, 98400unit- Penlac Nail Lacquer (External Solution) ..... 23 5mg/5ml Oral Solution) ...... 12 16800unit-56800unit Capsule Delayed- Penlet II Replacement Caps-Deep ...... 57 Oxycodone HCl ER (80mg Tablet Extended- Release) ...... 44 Pentam 300 (Injection) ...... 26 Release 12 Hour Abuse-Deterrent) ...... 11 Pancuronium Bromide (Injection) ...... 64 Pentasa (Capsule Extended-Release) ...... 51 Oxycodone HCl Tablet Extended-Release 12 Panda Mask Large ...... 57 Pentazocine/Naloxone HCl (Tablet) ...... 12 Hour Abuse-Deterrent (10mg, 15mg, Panda Mask Medium ...... 57 Pentetate Calcium Trisodium (Combination 20mg, 30mg, 40mg, 60mg) ...... 11 Panda Mask Small ...... 57 Solution) ...... 57 Oxycodone/Acetaminophen (2.5mg-325mg Pandel (Cream) ...... 42 Pentetate Zinc Trisodium (Combination Tablet, 325mg-10mg Tablet, 325mg-5mg Panretin (Gel) ...... 26 Solution) ...... 57 Tablet, 325mg-7.5mg Tablet) ...... 12 Pantoprazole Sodium (20mg Tablet Delayed- Pentips 29gx12mm ...... 57 Oxycodone/Acetaminophen (325mg/5ml- Release, 40mg Tablet Delayed-Release, Pentips 31gx5mm ...... 57 5mg/5ml Oral Solution) ...... 12 40mg Injection) ...... 45 Pentips 31gx6mm ...... 57 Oxycodone/Aspirin (Tablet)...... 12 Parafon Forte DSC (Tablet) ...... 64 Pentips 31gx8mm ...... 57 Oxycodone/Ibuprofen (Tablet) ...... 10 Paregoric (Tincture) ...... 45 Pentips 32gx4mm ...... 57 OxyContin (Tablet Extended-Release 12 Paricalcitol (1mcg Capsule, 2mcg Capsule, Pentoxifylline ER (Tablet Extended-Release) Hour Abuse-Deterrent) ...... 11 4mcg Capsule, 2mcg/ml Injection, ...... 36 Oxymorphone HCl (Tablet Immediate- 5mcg/ml Injection) ...... 52 Pepcid (20mg Tablet, 40mg Tablet, Release) ...... 12 Parlodel (2.5mg Tablet, 5mg Capsule) ...... 50 40mg/5ml Suspension) ...... 45 Oxymorphone HCl ER (Tablet Extended- Parnate (Tablet) ...... 20 Percocet (Tablet) ...... 12 Release 12 Hour) ...... 11 Paromomycin Sulfate (Capsule) ...... 14 Percura (Capsule) ...... 66 Oxytocin (Injection) ...... 47 Paroxetine HCl (Tablet) ...... 21 Perfect Lancets 30g ...... 57 Oxytocin/Dextrose (5%-10unit/L Injection, Paroxetine HCl ER (Tablet Extended-Release Perfect Pressure Activated Safety Lancets 5%-20unit/L Injection) ...... 60 24 Hour) ...... 21 28g ...... 57 Oxytocin/Dextrose (5%-40unit/L Solution) 62 Paser (Packet) ...... 24 Perforomist (Nebulized Solution) ...... 63 Oxytocin/Dextrose/Lactated Ringers Pataday (Ophthalmic Solution) ...... 61 Peridex (Solution) ...... 40 (Solution) ...... 62 Patanase (Nasal Solution) ...... 62 Perikabiven (Injection) ...... 66 Oxytocin/Lactated Ringers ...... 62 Patanol (Ophthalmic Solution)...... 61 Perindopril Erbumine (Tablet) ...... 34 Oxytocin/Lactated Ringers (0.1gm/500ml- Paxil (10mg Tablet, 20mg Tablet, 30mg Perjeta (Injection) ...... 26 30unit/500ml-0.15gm/500ml- Tablet, 40mg Tablet)...... 21 Permethrin (Cream) ...... 26 3gm/500ml-1.55gm/500ml Injection) ... 60 Paxil (10mg/5ml Suspension) ...... 21 Perphenazine (Tablet) ...... 22 Oxytocin/Sodium Chloride (20unit/L-0.45% Paxil CR (Tablet Extended-Release 24 Hour) Perphenazine/Amitriptyline (10mg-2mg Solution, 30unit/L-0.9% Solution, ...... 21 Tablet, 25mg-2mg Tablet, 25mg-4mg 60unit/L-0.9% Solution) ...... 62 Pazeo (Ophthalmic Solution) ...... 61 Tablet) ...... 21 Oxytocin/Sodium Chloride (20unit/L-0.9% PC Unifine Pentips 29g X 1/2" ...... 57 Perphenazine/Amitriptyline (10mg-4mg Injection) ...... 47 PC Unifine Pentips 31g X 6mm Ultra Short 57 Tablet, 50mg-4mg Tablet) ...... 21 Oxytocin/Sodium Chloride (30unit/500ml- PCE (Tablet Delayed-Release) ...... 17 Pertzye (Capsule Delayed-Release) ...... 44 0.9% Solution) ...... 62 PCP 100 (Kit) ...... 45 Pexeva (Tablet) ...... 21 Oxytrol (Patch Twice Weekly) ...... 46 Pediapred (Oral Solution)...... 47 Pfizerpen-G (Injection) ...... 17 Pediatric Panda Mask ...... 57 Ph 12 Sterile Diluent Forflolan (Injection) .. 57 P PEG 3350/Electrolytes (Oral Solution) ...... 45 Pharmacist Choice Ultra Thin Lancets ...... 57 Peg intron Redipen (Injection) ...... 28 Pharmacist Choice Ultra Thin Lancets 28g . 57 Paclitaxel (100mg/16.7ml Injection, PEG-3350/Electrolytes (Oral Solution) ...... 45 Pharmacist Choice Ultra Thin Lancets 30g . 57 300mg/50ml Injection, 30mg/5ml PEG-3350/NaCl/Na Bicarbonate/KCl (Oral Pharmacist Choice Ultra Thin Lancets 31g . 57 Injection) ...... 25 Solution) ...... 45 Pharmacist Choice Ultra Thin Lancets 33g . 57 Paclitaxel (150mg/25ml Injection) ...... 25 Peganone (Tablet) ...... 20 Pharmacy Couniter Lancets ...... 57 Paliperidone ER (Tablet Extended-Release 24 Pegasys (Injection) ...... 60 Phenelzine Sulfate (Tablet) ...... 20 Hour) ...... 27 Pegasys ProClick (Injection) ...... 60 Phenergan (25mg/ml Injection) ...... 60 Pamelor (Capsule) ...... 21 PegIntron (Injection) ...... 28 Phenergan (50mg/ml Injection) ...... 22 Pamidronate Disodium (30mg Injection, Pen Needles 29gx1/2" ...... 57 Phenobarbital (100mg Tablet, 15mg Tablet, 90

16.2mg Tablet, 30mg Tablet, 32.4mg Plo Gel - Mediflo Kit (Kit)...... 66 Prednicarbate (0.1% Cream, 0.1% Ointment) Tablet, 60mg Tablet, 64.8mg Tablet, Pocket Chamber (Device) ...... 57 ...... 42 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Pocket Spacer (Device) ...... 57 Prednisolone (15mg/5ml Oral Solution, Oral Solution) ...... 19 Podiapn (Capsule)...... 68 15mg/5ml Syrup) ...... 47 Phenoxybenzamine HCl (Capsule) ...... 33 Podofilox (External Solution) ...... 42 Prednisolone Acetate (Suspension) ...... 61 Phentolamine Mesylate (Injection) ...... 33 Polyethylene Glycol 3350 Powder ...... 45 Prednisolone Sodium Phosphate (1% Phenylephrine HCl (10% Ophthalmic Solution, Polymyxin B Sulfate (500000unit Injection) 15 Ophthalmic Solution) ...... 61 2.5% Ophthalmic Solution) ...... 60 Polymyxin B Sulfate/Trimethoprim Sulfate Prednisolone Sodium Phosphate (10mg/5ml Phenylephrine HCl (10mg/ml Injection) ...... 33 (Ophthalmic Solution) ...... 15 Solution, 20mg/5ml Solution, 25mg/5ml Phenylephrine HCl/Dextrose (5%- Polytrim (Ophthalmic Solution) ...... 15 Oral Solution, 5mg/5ml Oral Solution) ... 47 20mg/250ml Solution) ...... 30 Poly-Vi-Flor (Tablet Chewable,Suspension) 68 Prednisolone Sodium Phosphate ODT (Tablet Phenylephrine HCl/Dextrose (5%- Poly-Vi-Flor Fs (Strip) ...... 68 Dispersible) ...... 47 50mg/500ml Injection) ...... 33 Poly-Vi-Flor/Iron (Tablet Chewable, Prednisolone/Moxifloxacin (Ophthalmic Phenylephrine HCl/Sodium Chloride Suspension)...... 68 Solution) ...... 14 (0.4mg/10ml-0.9% Injection, Pomalyst (Capsule) ...... 25 Prednisone (10mg Tablet Therapy Pack, 5mg 100mcg/10ml-0.9% Injection, 1mg/10ml- Ponstel (Capsule) ...... 10 Tablet Therapy Pack) ...... 50 0.9% Injection, 20mg/50ml-0.9% Portrazza (Injection) ...... 25 Prednisone (10mg Tablet, 1mg Tablet, 2.5mg Injection, 25mg/250ml-0.9% Solution, Potassium Acetate (2meq/ml Injection) ..... 66 Tablet, 20mg Tablet, 50mg Tablet, 5mg 40mg/250ml-0.9% Solution, 80mg/250ml- Potassium Acetate (2meq/ml Injection, Tablet) ...... 47 0.9% Solution, 80mg/500ml-0.9% 4meq/ml Injection) ...... 66 Prednisone (5mg/5ml Oral Solution) ...... 47 Solution) ...... 30 Potassium Chloride (0 Granules) ...... 43 Prednisone Intensol (5mg/ml Concentrate) Phenylephrine HCl/Sodium Chloride Potassium Chloride (10meq/50ml Injection) ...... 47 (0.5mg/5ml-0.9% Injection, 0.8mg/10ml- ...... 66 PreferaOB (Tablet) ...... 68 0.9% Injection, 10mg/250ml-0.9% Potassium Chloride CR (Tablet Extended- Prefest (Tablet) ...... 49 Injection, 200mcg/5ml-0.9% Injection, Release) ...... 66 Pre-Folic (Tablet) ...... 68 5mg/50ml-0.9% Injection) ...... 33 Potassium Chloride ER (10meq Capsule Premarin (0.3mg Tablet, 0.45mg Tablet, Phenylephrine HCl/Sodium Chloride Extended-Release, 8meq Capsule 0.625mg Tablet, 0.9mg Tablet, 1.25mg (50mg/250ml-0.9% Solution) ...... 30 Extended-Release, 10meq Tablet Tablet, 0.625mg/gm Cream) ...... 49 Phenytek (Capsule) ...... 20 Extended-Release, 20meq Tablet Premarin (25mg Injection) ...... 49 Phenytoin (125mg/5ml Suspension, 50mg Extended-Release, 8meq Tablet Extended- Premasol (Injection) ...... 66 Tablet Chewable) ...... 20 Release) ...... 66 Premphase (Tablet)...... 49 Phenytoin Sodium (50mg/ml Injection) ...... 20 Potassium Chloride SR (Tablet Extended- Prempro (Tablet) ...... 49 Phenytoin Sodium Extended (Capsule) ...... 20 Release) ...... 66 Prenata (Tablet Chewable) ...... 68 Phoslyra (Oral Solution) ...... 46 Potassium Citrate ER (Tablet Extended- Prenatal Vitamin (Tablet) ...... 67 Phospholine Iodide (Ophthalmic Solution) 61 Release) ...... 66 Prenatal Vitamins (120mg-4000unit-200mg- Photofrin (Injection) ...... 60 Potiga (Tablet) ...... 18 400unit-8mcg-28mg-800mcg-20mg- Phytonadione (Injection) ...... 67 PR Cream (Kit) ...... 42 2.6mg-1.7mg-1.8mg-30unit-25mg Tablet) Picato (Gel) ...... 42 Pradaxa (Capsule) ...... 32 ...... 67 Pilocarpine HCl (1% Ophthalmic Solution, 2% Pralidoxime Chloride (Injection) ...... 57 Prenate AM (Tablet) ...... 68 Ophthalmic Solution, 4% Ophthalmic Praluent (Injection) ...... 36 Prenate Elite (Tablet) ...... 68 Solution) ...... 61 Pramipexole Dihydrochloride (Tablet Prenate Essential (Capsule) ...... 68 Pilocarpine HCl (5mg Tablet, 7.5mg Tablet) 40 Immediate-Release) ...... 27 Prenate Star (Tablet) ...... 68 Pimozide (Tablet) ...... 27 Pramipexole Dihydrochloride ER (Tablet Prepopik (Packet) ...... 45 Pindolol (Tablet) ...... 35 Extended-Release 24 Hour) ...... 27 Presera (Foam) ...... 42 Pioglitazone HCl (Tablet) ...... 31 Pramosone (1%-1% Cream) ...... 13 Preset 1ml LS Syr/Prefilllyophil Lith Hep/Tip Pioglitazone HCl/Glimepiride (Tablet) ...... 31 Pramosone (1%-1% Lotion, 2.5%-1% Lotion) Cap/Safetycone (Kit) ...... 57 Pioglitazone HCl/Metformin HCl (Tablet) .... 31 ...... 13 Preset 3ml Ll Syr/Prefilllyoph Lith Piperacillin/Tazobactam (12gm-1.5gm Pramotic (Liquid) ...... 61 Hep/Cap/Prep/Gz/Sftycone (Kit)...... 57 Solution) ...... 13 Prandin (Tablet) ...... 31 Prestalia (Tablet) ...... 34 Piperacillin/Tazobactam (2gm-0.25gm Pravachol (Tablet) ...... 37 Prevacid (Capsule Delayed-Release) ...... 45 Injection, 3gm-0.375gm Injection, 4gm- Pravastatin Sodium (Tablet) ...... 37 Prevacid SoluTab (Tablet Dispersible) ...... 45 0.5gm Injection, 36gm-4.5gm Solution) . 17 Prazosin HCl (1mg Capsule, 2mg Capsule, 5mg Prevident 5000 Enamel Protect (Paste) ...... 40 Piroxicam (10mg Capsule, 20mg Capsule) ... 10 Capsule) ...... 33 Prevpac (Therapy Pack) ...... 45 Pitocin (Injection) ...... 47 Precedex (Injection) ...... 29 Prezcobix (Tablet) ...... 29 PKU Easy Microtabs (Tablet Delayed- Precision Thin Lancets ...... 57 Prezista (100mg/ml Suspension, 150mg Release) ...... 67 Precision Ultra Lancet ...... 57 Tablet, 600mg Tablet, 75mg Tablet, Plaquenil (Tablet) ...... 26 Precose (Tablet) ...... 31 800mg Tablet) ...... 29 Plavix (Tablet) ...... 33 Pred Forte (Suspension) ...... 61 Prialt (Injection) ...... 10 Plegridy (Injection) ...... 60 Pred Mild (Suspension) ...... 61 Priftin (Tablet) ...... 24 Plegridy Starter Pack (Injection) ...... 60 Pred-G (Suspension) ...... 14 Prilosec (Packet) ...... 45 Pliaglis (Cream) ...... 13 Pred-G S.O.P. (Ointment) ...... 14 Primacare (Capsule) ...... 68 91

Primaquine Phosphate (Tablet) ...... 26 Propranolol HCl (Tablet Immediate-Release, Quadramet (Solution) ...... 57 Primaxin IV (Injection) ...... 16 1mg/ml Injection, Oral Solution) ...... 35 Qualaquin (Capsule)...... 26 Primidone (Tablet) ...... 19 Propranolol HCl (Tablet)...... 35 Quazepam (Tablet) ...... 29 Primlev (Tablet) ...... 12 Propranolol HCl ER (Capsule Extended- Qudexy XR (Capsule Extended-Release 24 Primsol (Oral Solution) ...... 15 Release 24 Hour) ...... 35 Hour Sprinkle) ...... 19 Prinivil (Tablet) ...... 34 Propranolol/Hydrochlorothiazide (Tablet) .. 35 Quelicin (Injection) ...... 64 Prismasol (Injection) ...... 66 Propylene Glycol (0 External Solution) ...... 57 Questran (Packet) ...... 38 Pristiq (Tablet Extended-Release 24 Hour) 21 Propylthiouracil (Tablet) ...... 50 Questran Light (Powder)...... 38 Privigen (Injection) ...... 51 Proscar (Tablet) ...... 46 Quetiapine Fumarate (Tablet) ...... 20 ProAir HFA (Aerosol Solution) ...... 63 Prosol (Injection) ...... 66 Quetiapine Fumarate ER (Tablet Extended- ProAir RespiClick (Aerosol Powder) ...... 63 Prostin VR Pediatric (Injection) ...... 47 Release 24 Hour) ...... 20 Probenecid (Tablet) ...... 23 Protamine Sulfate (Injection) ...... 33 Quflora Fe (Tablet Chewable) ...... 68 Probenecid/Colchicine (Tablet) ...... 23 Protect Plus (Capsule) ...... 67 Quillivant XR (Suspension) ...... 39 Procainamide HCl (100mg/ml Injection, Protectiron (Tablet) ...... 30 Quinapril HCl (Tablet) ...... 34 500mg/ml Injection) ...... 35 Proteolin (Tablet) ...... 66 Quinapril/Hydrochlorothiazide (Tablet) ...... 34 Procalamine (Injection) ...... 66 Prothelial (Paste) ...... 42 Quinidine Gluconate (Injection) ...... 35 Procardia (Capsule) ...... 36 Protonix (20mg Tablet Delayed-Release, Quinidine Gluconate CR (Tablet Extended- Procardia XL (Tablet Extended-Release 24 40mg Tablet Delayed-Release, 40mg Release) ...... 35 Hour) ...... 36 Injection, 40mg Packet) ...... 45 Quinidine Gluconate ER (Tablet Extended- ProCentra (Oral Solution) ...... 39 Protopam Chloride (Injection) ...... 57 Release) ...... 35 Prochlorperazine (Suppository) ...... 22 Protopic (Ointment) ...... 42 Quinidine Sulfate (Tablet) ...... 35 Prochlorperazine Edisylate (Injection) ...... 22 Protriptyline HCl (Tablet) ...... 21 Quinine Sulfate (324mg Capsule) ...... 26 Prochlorperazine Maleate (10mg Tablet, 5mg Provayblue (Injection) ...... 57 Quinzyme (Tablet Dispersible) ...... 57 Tablet)...... 22 Provenge (Injection) ...... 51 Qutenza (Kit) ...... 42 Procrit (Injection) ...... 32 Proventil HFA (Aerosol Solution) ...... 63 QVAR (Aerosol Solution) ...... 62 Proctofoam HC (Foam) ...... 42 Provera (Tablet) ...... 49 Procysbi (Capsule Delayed-Release)...... 60 Provida OB (Capsule) ...... 68 R Prodigy Safety Lancets ...... 57 Provigil (Tablet) ...... 65 Prodigy Twist Top Lancets ...... 57 Prozac (Capsule) ...... 21 Rabeprazole Sodium (Tablet Delayed- Proferrin-Forte (Tablet) ...... 66 Prozac Weekly (Capsule Delayed-Release) 21 Release) ...... 46 Profilnine (Injection) ...... 33 Pruclair (Cream) ...... 42 Radiogardase (Capsule) ...... 57 Progesterone (100mg Capsule, 200mg PRUDOXIN (Cream) ...... 42 Raloxifene HCl (Tablet) ...... 49 Capsule, 50mg/ml Injection) ...... 49 Prumyx (Cream) ...... 42 Ramipril (Capsule) ...... 34 Proglycem (Suspension)...... 31 PSS Select GP Lancets ...... 57 Ranexa (Tablet Extended-Release 12 Hour) Prograf (0.5mg Capsule, 1mg Capsule, 5mg PSS Select Platforms ...... 57 ...... 36 Capsule, 5mg/ml Injection) ...... 50 PSS Select Safety Lancets ...... 57 Ranitidine HCl (150mg Capsule, 300mg Prolastin-C (Injection) ...... 64 Pulmicort (Suspension) ...... 62 Capsule, 150mg Tablet, 300mg Tablet, Prolensa (Ophthalmic Solution) ...... 61 Pulmicort Flexhaler (Aerosol Powder) ...... 62 150mg/6ml Injection, 50mg/2ml Injection, Proleukin (Injection) ...... 60 Pulmona (Capsule) ...... 66 15mg/ml Syrup, 75mg/5ml Syrup)...... 45 Prolia (Injection) ...... 52 Pulmozyme (Inhalation Solution) ...... 60 Rapaflo (Capsule) ...... 46 Promacta (Tablet) ...... 32 Purified Water (0 Liquid) ...... 57 Rapamune (0.5mg Tablet, 1mg Tablet, 2mg Promethazine HCl (12.5mg Suppository, Purixan (Suspension) ...... 25 Tablet, 1mg/ml Oral Solution) ...... 50 25mg Suppository, 50mg Suppository, PX Lancets Ultra Thin ...... 57 Rapivab (Injection) ...... 28 12.5mg Tablet, 25mg Tablet, 50mg Tablet, Pylera (Capsule) ...... 45 Rasagiline Mesylate (Tablet) ...... 27 50mg/ml Injection, 6.25mg/5ml Oral Pyrazinamide (Tablet) ...... 24 Rasuvo (Injection) ...... 50 Solution) ...... 22 Pyridostigmine Bromide (Tablet) ...... 24 RAVICTI (Liquid) ...... 44 Promethazine HCl (25mg/ml Injection) ...... 60 Pyridostigmine Bromide ER (Tablet Extended- Rayaldee (Capsule Extended-Release) ...... 68 Promethazine HCl Plain (Syrup) ...... 22 Release) ...... 24 Razadyne (Tablet) ...... 20 Promethazine/Codeine (Syrup) ...... 64 Pyridoxine HCl (100mg/ml Injection) ...... 67 Razadyne ER (Capsule Extended-Release 24 Promethazine/Phenylephrine (Syrup) ...... 62 Pyrogallic Acid (Ointment) ...... 42 Hour) ...... 20 Promethazine/Phenylephrine/Codeine Readysharp-A (Injection) ...... 13 Readysharp-K (Injection) ...... 13 (Syrup) ...... 64 Q Promethazine-DM (Syrup) ...... 64 Readysharp-P40 (Injection) ...... 13 Prometrium (Capsule) ...... 49 QC Lancets Super Thin ...... 57 Readysharp-P80 (Injection) ...... 13 Promiseb (Cream) ...... 42 QC Lancets Ultra Thin ...... 57 Rebetol (200mg Capsule, 40mg/ml Oral Promiseb Complete (Kit)...... 42 Q-Care Q2 Oral Cleansing/Suctioning Solution) ...... 28 Propafenone HCl (Tablet) ...... 35 System/Chg Oral Rinse (Kit) ...... 40 Rebif (Injection) ...... 40 Propafenone HCl ER (Capsule Extended- Q-Care Q4 Oral Cleansing/Suctioning Rebif Rebidose (Injection) ...... 60 Release 12 Hour) ...... 35 System/Chg Oral Rinse (Kit) ...... 40 Rebif Rebidose Titration Pack (Injection) ... 40 Propantheline Bromide (15mg Tablet) ...... 44 Qnasl (Aerosol Solution) ...... 62 Rebif Titration Pack (Injection) ...... 40 Proparacaine HCl (Ophthalmic Solution) ..... 60 Qnasl Childrens (Aerosol Solution) ...... 62 Recedo (Gel) ...... 42 92

Reclast (Injection) ...... 52 Suspension, 20mg Tablet) ...... 63 1mcg/ml Oral Solution) ...... 52 Recombinate (Injection) ...... 33 Revlimid (Capsule) ...... 25 Rocuronium Bromide (100mg/10ml Injection, Recothrom (Solution) ...... 33 Rexulti (Tablet) ...... 27 50mg/5ml Injection) ...... 64 Rectiv (Ointment) ...... 38 Reyataz (150mg Capsule, 200mg Capsule, Rocuronium Bromide (50mg/5ml Injection) Recura (Cream) ...... 42 300mg Capsule, 50mg Packet) ...... 29 ...... 64 Reglan (Tablet) ...... 22 Rezira (Oral Solution) ...... 64 Ropinirole ER (Tablet Extended-Release 24 Regonol (Injection) ...... 24 Rezyst IM (Tablet Chewable) ...... 45 Hour) ...... 27 Relagard (Gel) ...... 15 Rhinocort Aqua (Suspension) ...... 62 Ropinirole HCl (Tablet) ...... 27 Relenza Diskhaler (Aerosol Powder) ...... 29 Rhofade (Cream) ...... 64 Ropivacaine (Injection) ...... 13 Relion Lancets Micro-Thin33g ...... 57 Rhogam Ultra-Filtered Plus (Injection) ...... 51 Ropivacaine HCl (Injection) ...... 13 Relion Lancets Standard 21g ...... 57 Rhophylac (Injection) ...... 51 Ropivacaine HCl/Sodium Chloride (0.1%- Relion Lancets Thin 26g ...... 57 Riastap (Injection) ...... 33 0.9% Solution, 0.2%-0.9% Solution) ...... 13 Relion Lancets Ultra-Thin30g ...... 57 Riax (Foam) ...... 42 Rosadan Kit (Kit) ...... 64 Relion Pen Needles 29gx12mm ...... 57 Ribasphere Ribapak (Tablet) ...... 28 Rosuvastatin Calcium (Tablet) ...... 37 Relion Pen Needles 31gx6mm ...... 57 Ribavirin (200mg Capsule, 200mg Tablet) .. 28 Rowasa (Kit) ...... 51 Relion Pen Needles 31gx8mm ...... 57 Ribavirin (6gm Solution) ...... 64 Roxicodone (Tablet) ...... 12 Relion Pen Needles 32gx4mm ...... 57 Ridaura (Capsule) ...... 51 Rozerem (Tablet) ...... 65 Relion Thin Lancets ...... 57 Rifabutin (Capsule) ...... 24 Rubraca (Tablet) ...... 24 Relion Ultra Thin Lancets ...... 57 Rifadin (150mg Capsule, 300mg Capsule, Ryanodex (Injection) ...... 52 Relion Ultra Thin Plus Lancets 32g ...... 57 600mg Injection) ...... 24 Rythmol SR (Capsule Extended-Release 12 Relistor (12mg/0.6ml Injection, 8mg/0.4ml Rifamate (Capsule) ...... 24 Hour) ...... 35 Injection) ...... 45 Rifampin (150mg Capsule, 300mg Capsule, Relistor (150mg Tablet) ...... 46 600mg Injection) ...... 24 S Relpax (Tablet) ...... 23 Rifater (Tablet) ...... 24 Remeron (Tablet) ...... 20 Right Step Prenatal (Tablet) ...... 67 Sabril (500mg Packet, 500mg Tablet) ...... 19 Remeron Soltab (Tablet Dispersible)...... 20 Rightest GD-L500 Alternate Site Adapter .. 57 Saccharin Sodium (0 Granules, 0 Powder) . 57 Remicade (Injection) ...... 50 Rightest GL300 Lancets ...... 57 Safe-T-Lance Low Flow 25g ...... 57 Remodulin (Injection) ...... 63 Rilutek (Tablet) ...... 40 Safe-T-Lance Normal Flow 21g ...... 57 Renagel (Tablet) ...... 46 Riluzole (Tablet) ...... 40 Safe-T-Lance Plus Safety Lancet High Flow 57 Renatabs (Tablet) ...... 68 Rimantadine HCl (Tablet) ...... 29 Safe-T-Lance Plus Safety Lancet Low Flow . 57 Renatabs with Iron ...... 30 Riomet (Oral Solution) ...... 31 Safe-T-Lance Plus Safety Lancet Normal Flow Renvela (0.8gm Packet, 2.4gm Packet, Risedronate Sodium (Tablet) ...... 52 ...... 57 800mg Tablet) ...... 46 Risedronate Sodium DR (Tablet Delayed- Safety Lancets ...... 57 Reopro (Injection) ...... 33 Release) ...... 52 Safety Lancets 21g ...... 57 Repaglinide (Tablet)...... 31 Risperdal (0.25mg Tablet, 0.5mg Tablet, 1mg Safety Lancets 28g ...... 57 Repaglinide/Metformin HCl (Tablet) ...... 31 Tablet, 2mg Tablet, 3mg Tablet, 4mg Safety Let Lancets ...... 57 Repatha (Injection) ...... 36 Tablet, 1mg/ml Oral Solution) ...... 27 Safety Seal Lancets 28g ...... 57 Repatha Pushtronex System (Injection) ..... 36 Risperdal Consta (Injection) ...... 60 Safety Seal Lancets 30g ...... 57 Repatha SureClick (Injection) ...... 36 Risperdal M-Tab (Tablet Dispersible)...... 27 Safyral (Tablet) ...... 49 Reprexain (5mg-200mg Tablet) ...... 10 Risperidone (0.25mg Tablet, 0.5mg Tablet, Saizen (Injection) ...... 47 Req 49+ (Tablet) ...... 67 1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Salagen (Tablet) ...... 40 Requip (Tablet) ...... 27 Tablet, 1mg/ml Oral Solution) ...... 27 Salicylic Acid (6% Cream, 6% Gel, 6% Lotion) Requip XL (Tablet Extended-Release 24 Risperidone ODT (Tablet Dispersible) ...... 27 ...... 42 Hour) ...... 27 Ritalin (Tablet) ...... 39 Salicylic Acid Cream (Kit) ...... 42 Rescriptor (Tablet) ...... 28 Ritalin LA (Capsule Extended-Release 24 Salicylic Acid Lotion (Kit) ...... 42 Rescula (Ophthalmic Solution) ...... 60 Hour) ...... 39 Saline Flush (Injection)...... 66 Restasis (Emulsion) ...... 60 RiteFlo (Device) ...... 57 Saline/Phenol (Injection) ...... 66 Restasis Multidose (Emulsion) ...... 60 Rituxan (Injection) ...... 26 Salivamax (Packet) ...... 40 Restora Rx (Capsule) ...... 45 Rivastigmine Tartrate (Capsule Immediate- Salivate Rx (Packet)...... 40 Restoril (Capsule) ...... 29 Release) ...... 20 Salsalate (500mg Tablet, 750mg Tablet) ..... 10 Retin-A (0.01% Gel, 0.025% Gel, 0.025% Rivastigmine Transdermal System (Patch 24 Salvax Duo Plus (Kit) ...... 42 Cream, 0.05% Cream, 0.1% Cream) ...... 42 Hour) ...... 20 Samsca (Tablet) ...... 65 Retin-A Micro (Gel) ...... 42 Rizatriptan Benzoate (Tablet) ...... 23 Sancuso (Patch) ...... 22 Retin-A Micro Pump (0.04% Gel, 0.1% Gel) 42 Rizatriptan Benzoate ODT (Tablet Dispersible) Sandimmune (100mg Capsule, 25mg Retin-A Micro Pump (0.08% Gel) ...... 42 ...... 23 Capsule, 50mg/ml Injection) ...... 50 Retinoic Acid (Powder) ...... 64 R-Natal OB (Capsule) ...... 68 Sandimmune (100mg/ml Oral Solution) .... 50 Retinoic Acid-All Trans (Powder) ...... 64 Robaxin (Injection, 500mg Tablet) ...... 64 Sandostatin (Injection) ...... 50 Retrovir (100mg Capsule, 50mg/5ml Syrup) Robaxin-750 (Tablet) ...... 64 Sandostatin LAR Depot (Injection) ...... 50 ...... 29 Robinul (0.2mg/ml Injection, 1mg Tablet) . 44 Santyl (Ointment) ...... 42 Retrovir IV Infusion (Solution) ...... 29 Robinul Forte (Tablet) ...... 44 Saphris (10mg Tablet Sublingual) ...... 27 Revatio (10mg/12.5ml Injection, 10mg/ml Rocaltrol (0.25mcg Capsule, 0.5mcg Capsule, Saphris (2.5mg Tablet Sublingual, 5mg 93

Tablet Sublingual) ...... 60 Sirturo (Tablet) ...... 24 Solodyn (Tablet Extended-Release 24 Hour) Sarafem (Tablet) ...... 21 Sitavig (Tablet) ...... 29 ...... 18 Savaysa (Tablet) ...... 32 Sivextro (200mg Injection, 200mg Tablet) . 15 Soltamox (Oral Solution) ...... 25 Savella (Tablet) ...... 40 Skelaxin (Tablet) ...... 64 Solu-Cortef (Injection) ...... 60 Savella Titration Pack ...... 40 Sklice (Lotion) ...... 26 Solu-Medrol (Injection) ...... 60 Scalacort DK (Kit) ...... 42 Smart Sense Color Lancets Universal 33g .. 57 Solus V2 Pressure Activated Safety Lancets Scarlet Red Dressing ...... 64 Smart Sense Standard Lancets Universal 21g 28g ...... 58 Seasonique (Tablet) ...... 49 ...... 57 Solus V2 Twist Lancets 30g ...... 58 Sebuderm (Gel) ...... 42 Smart Sense Super Thin Lancets Universal Soma (Tablet) ...... 64 Seconal Sodium (Capsule)...... 65 30g ...... 57 Somatuline Depot (Injection) ...... 50 Seebri Neohaler (Capsule) ...... 30 Smart Sense Thin Lancets Universal 26g .... 58 Somavert (Injection) ...... 50 Select-OB (Tablet Chewable) ...... 68 Smartest Lancets 28g ...... 58 Sonata (Capsule) ...... 65 Selegiline HCl (5mg Capsule, 5mg Tablet) ... 27 Smoflipid (Injection) ...... 58 Soolantra (Cream) ...... 42 Selenium Sulfide (Lotion)...... 42 Sodium Acetate (2meq/ml Injection) ...... 65 Soriatane (Capsule) ...... 42 Selzentry (150mg Tablet, 300mg Tablet) .... 29 Sodium Bicarbonate (7.5% Injection) ...... 65 Sorilux (Foam) ...... 42 Selzentry (25mg Tablet, 75mg Tablet) ...... 13 Sodium Bicarbonate (Powder) ...... 45 Sotalol HCl (AF) (Tablet) ...... 35 Sensipar (Tablet) ...... 49 Sodium Chloride (2.5meq/ml Injection, 3% Sotalol HCl (Injection) ...... 35 Sensorcaine-Mpf/Epinephrine (Injection) .. 13 Injection, 5% Injection) ...... 66 Sotalol HCl (Tablet) ...... 35 Sentra AM (Capsule) ...... 66 Sodium Chloride (Nebulized Solution) ...... 64 Sotradecol (Injection) ...... 36 Sentra PM (Capsule) ...... 66 Sodium Chloride 0.45% (Injection) ...... 66 Sotylize (Oral Solution) ...... 35 Serevent Diskus (Aerosol Powder) ...... 63 Sodium Chloride Bacteriostatic (0.9% Sovaldi (Tablet) ...... 28 Sernivo (Emulsion) ...... 42 Injection) ...... 66 Spectracef (Tablet) ...... 16 Seroquel (Tablet) ...... 20 Sodium Chloride Bacteriostatic/Benzyl Spinosad (Suspension) ...... 26 Seroquel XR (150mg Tablet Extended- Alcohol (Injection) ...... 66 Spiriva HandiHaler (Capsule) ...... 63 Release 24 Hour, 200mg Tablet Extended- Sodium Chloride Flush (Injection) ...... 66 Spiriva Respimat (Aerosol Solution) ...... 63 Release 24 Hour, 300mg Tablet Extended- Sodium Citrate (Injection) ...... 66 Spironolactone (100mg Tablet, 25mg Tablet, Release 24 Hour, 50mg Tablet Extended- Sodium Diuril (Injection) ...... 37 50mg Tablet) ...... 37 Release 24 Hour) ...... 20 Sodium Edecrin (Injection) ...... 37 Spironolactone/Hydrochlorothiazide (Tablet) Seroquel XR (400mg Tablet Extended- Sodium Ferric Gluconate Complex/Sucrose ...... 37 Release 24 Hour) ...... 20 (Injection) ...... 66 Sporanox (100mg Capsule, 10mg/ml Oral Serostim (Injection) ...... 47 Sodium Fluoride (0.25mg Tablet Chewable, Solution) ...... 23 Sertraline HCl (100mg Tablet, 25mg Tablet, 1.1mg Tablet Chewable, 1mg Tablet Sporanox Pulsepak (Capsule) ...... 23 50mg Tablet, 20mg/ml Concentrate) ..... 21 Chewable, 0.5mg/ml Solution, 1mg Tablet) Sprix (Nasal Solution) ...... 10 sfRowasa (Enema)...... 51 ...... 66 Sprycel (Tablet) ...... 26 Shohls Solution Modified (Oral Solution) ... 66 Sodium Fluoride (0.5mg Tablet) ...... 66 SSKI (Oral Solution) ...... 64 Shopko Unifine Pentips Pen Sodium Hyaluronate (Gel) ...... 51 Stalevo 100 (Tablet) ...... 27 Needles/Mini/31gx5mm ...... 57 Sodium Lactate (Injection) ...... 65 Stalevo 125 (Tablet) ...... 27 Siderol (Tablet) ...... 67 Sodium Nitrite (Injection) ...... 58 Stalevo 150 (Tablet) ...... 27 Signifor (Injection) ...... 50 Sodium Nitroprusside (Injection) ...... 38 Stalevo 200 (Tablet) ...... 27 Signifor LAR (Injection) ...... 50 Sodium Phenylacetate/Sodium Benzoate Stalevo 50 (Tablet) ...... 27 Sildenafil (10mg/12.5ml Injection, 20mg (Injection) ...... 58 Stalevo 75 (Tablet) ...... 27 Tablet)...... 63 Sodium Phenylbutyrate (Powder) ...... 44 Starlix (Tablet) ...... 31 Silenor (Tablet) ...... 65 Sodium Phosphate (3MMOLE/ml Injection) 66 Stavudine (Capsule) ...... 29 Silvadene (Cream) ...... 15 Sodium Phosphate/Sodium Chloride (0.9%- Stelara (130mg/26ml Injection) ...... 51 Silver Nitrate (0.5% External Solution, 10% 15MMOL/250ml Injection) ...... 58 Stelara (45mg/0.5ml Injection, 90mg/ml External Solution, 25% External Solution, Sodium Phosphate/Sodium Chloride (0.9%- Injection) ...... 42 50% External Solution) ...... 15 7.5MMOL/100ml Solution) ...... 43 Stendra (Tablet) ...... 46 Silver Nitrate (10% Ointment) ...... 15 Sodium Polystyrene Sulfonate (Powder, Sterilance PA ...... 58 Silver Sulfadiazine (Cream) ...... 15 Suspension) ...... 65 Sterilance Tl ...... 58 Simbrinza (Suspension)...... 61 Sodium Sulfacetamide (Ophthalmic Solution) Sterile Diluent for Epoprostenol Sodium Simponi (Injection)...... 50 ...... 18 (Injection) ...... 58 Simponi Aria (Injection) ...... 50 Sodium Sulfacetamide/Sulfur (10%-4% Pad) Sterile Diluent for Remodoulin (Solution) .. 58 Simulect (Injection) ...... 51 ...... 42 Stimate (Nasal Solution) ...... 47 Simvastatin (Tablet) ...... 37 Sodium Sulfacetamide/Sulfur (10%-5% Stiolto Respimat (Aerosol Solution) ...... 64 Sinemet (Tablet) ...... 27 Lotion) ...... 42 Stivarga (Tablet) ...... 26 Sinemet CR (Tablet Extended-Release) ...... 27 Sodium Sulfacetamide/Sulfur Cleanser (9.8%- Strattera (Capsule) ...... 39 Single-Let ...... 57 4.8% Liquid) ...... 42 Strensiq (Injection)...... 44 Singulair (10mg Tablet, 4mg Packet, 4mg Sodium Thiosulfate (25% Injection) ...... 58 Streptomycin Sulfate (1gm Injection)...... 14 Tablet Chewable, 5mg Tablet Chewable) Solaraze (Gel)...... 42 Striant ...... 48 ...... 62 Soliqua 100/33 (Injection) ...... 50 Stribild (Tablet) ...... 28 Sirolimus (Tablet)...... 50 Soliris (Injection)...... 60 Striverdi Respimat (Aerosol Solution) ...... 63 94

Stromectol (Tablet) ...... 26 Sustol (Injection) ...... 46 Tecfidera (Capsule Delayed-Release) ...... 40 Strovite Forte (Syrup) ...... 68 Sutent (Capsule) ...... 26 Tecfidera Starter Pack ...... 40 Suboxone (Film) ...... 11 Sylatron (Injection) ...... 25 Techlite Ast Lancets ...... 58 Subsys (Liquid) ...... 12 Sylvant (Injection) ...... 26 TechLite Lancets ...... 58 Succinylcholine Chloride (100mg/5ml Symax Duotab (Tablet Extended-Release) 30 Techlite Lancets 30g ...... 58 Injection, 200mg/10ml Injection) ...... 64 Symbicort (Aerosol) ...... 62 Techlite Pen Needles/31g X 5mm...... 58 Sucraid (Oral Solution) ...... 44 Symbyax (Capsule) ...... 30 Techlite Pen Needles/32g X 8mm...... 58 Sucralfate (1gm Tablet) ...... 45 SymlinPen 120 (Injection) ...... 31 Technivie (Tablet) ...... 28 Sular (Tablet Extended-Release 24 Hour) .. 36 SymlinPen 60 (Injection) ...... 31 Teflaro (Injection) ...... 16 Sulfacetamide Sodium (10% Lotion, 10% Synagex (Capsule)...... 68 Tegretol (100mg/5ml Suspension, 200mg Suspension) ...... 42 Synagis (Injection) ...... 51 Tablet) ...... 20 Sulfacetamide Sodium (10% Ophthalmic Synalar (0.01% External Solution, 0.025% Tegretol-XR (Tablet Extended-Release 12 Ointment) ...... 18 Cream, 0.025% Ointment) ...... 43 Hour) ...... 20 Sulfacetamide Sodium (10% Ophthalmic Synalar Cream Kit (Kit) ...... 64 Tekturna (Tablet) ...... 36 Solution) ...... 18 Synalar TS (Kit) ...... 43 Tekturna HCT (Tablet) ...... 37 Sulfacetamide Sodium/Prednisolone Sodium Synalgos-DC (Capsule) ...... 12 Telfa AMD Antimicrobial Island Dressing Phosphate (Ophthalmic Solution) ...... 18 Synarel (Nasal Solution) ...... 50 4"x5" ...... 43 Sulfacetamide Sodium/Sulfur ...... 42 Synatek (Capsule) ...... 68 Telfa AMD Antimicrobial Island Sulfadiazine (500mg Tablet) ...... 18 Synera (Patch) ...... 13 Dressing4"x8" ...... 43 Sulfamethoxazole/Trimethoprim Synercid (Injection) ...... 15 Telfa AMD Antimicrobial Non-Adherent Pad (200mg/5ml-40mg/5ml Suspension, Synerderm (Emulsion) ...... 43 3"x8" ...... 43 400mg-80mg Tablet) ...... 18 Synjardy (Tablet), Synjardy XR (Tablet) ..... 31 Telmisartan (Tablet) ...... 34 Sulfamethoxazole/Trimethoprim Synribo (Injection) ...... 60 Telmisartan/Amlodipine (Tablet) ...... 34 (400mg/5ml-80mg/5ml Injection) ...... 18 Synthroid (Tablet)...... 49 Telmisartan/Hydrochlorothiazide (Tablet) .. 34 Sulfamethoxazole/Trimethoprim DS (Tablet) Synvisc (Injection) ...... 58 Temazepam (Capsule) ...... 29 ...... 18 Synvisc One (Injection) ...... 58 Temodar (100mg Capsule, 140mg Capsule, Sulfamylon (5% Packet, 85mg/gm Cream) . 15 Syprine (Capsule) ...... 65 180mg Capsule, 20mg Capsule, 250mg Sulfasalazine (500mg Tablet, 500mg Tablet Capsule, 5mg Capsule) ...... 24 Delayed-Release) ...... 51 T Temodar (100mg Injection) ...... 24 Sulfoam (Shampoo) ...... 43 Temovate (0.05% Cream, 0.05% External Sulfurated Lime (External Solution) ...... 26 Tabloid (Tablet) ...... 25 Solution, 0.05% Gel, 0.05% Ointment) .. 43 Sulfzix (500mcg/0.25gm-0-0-0 Powder) ..... 66 Taclonex (0.064%-0.005% Ointment, 0.064%- Temovate E (Cream) ...... 43 Sulfzix (500mcg-0-0-Capsule)...... 66 0.005% Suspension) ...... 43 Temozolomide (Capsule) ...... 24 Sulindac (150mg Tablet, 200mg Tablet) ...... 10 Tacrolimus (0.03% Ointment, 0.1% Ointment) Tena Cls+ Md Brf ...... 43 Sumatriptan (Nasal Solution)...... 24 ...... 43 Teniposide (Injection) ...... 25 Sumatriptan Succinate (100mg Tablet, 25mg Tacrolimus (0.5mg Capsule, 1mg Capsule, Tenoretic 100 (Tablet)...... 35 Tablet, 50mg Tablet, 4mg/0.5ml Injection, 5mg Capsule) ...... 50 Tenoretic 50 (Tablet)...... 35 6mg/0.5ml Injection) ...... 24 Tafinlar (Capsule) ...... 26 Tenormin (Tablet) ...... 35 Sumavel DosePro (Injection) ...... 24 Tagrisso (Tablet) ...... 26 Terazol 7 (Cream) ...... 23 Supartz (Injection) ...... 58 Taltz (Injection) ...... 43 Terazosin HCl (Capsule) ...... 33 Supartz Fx (Injection) ...... 58 Talwin (Injection)...... 12 Terbinafine HCl (Tablet) ...... 23 Supervite (Liquid) ...... 68 Tamiflu (30mg Capsule, 45mg Capsule, 75mg Terbutaline Sulfate (1mg/ml Injection, 2.5mg Support-500 (Capsule) ...... 68 Capsule, 6mg/ml Suspension) ...... 29 Tablet, 5mg Tablet) ...... 63 Supprelin LA (Injection) ...... 50 Tamoxifen Citrate (Tablet) ...... 25 Terconazole (0.4% Cream, 0.8% Cream, 80mg Suprax (100mg Tablet Chewable, 200mg Tamsulosin HCl (Capsule) ...... 46 Suppository)...... 23 Tablet Chewable, 100mg/5ml Suspension, Tanzeum (Injection)...... 31 Tessalon Perles (Capsule) ...... 64 200mg/5ml Suspension, 500mg/5ml Tapazole (Tablet) ...... 50 Testim (Gel) ...... 48 Suspension, 400mg Capsule) ...... 16 Tarceva (Tablet) ...... 26 Testopel (Pellet) ...... 48 Suprep Bowel Prep (Oral Solution) ...... 45 Targadox (Tablet) ...... 18 Testosterone (100mg Pellet, 200mg Pellet, Sure-Fine Pen Needles 29gx1/2" 12.7mm .. 58 Targretin (1% Gel, 75mg Capsule) ...... 26 87.5mg Pellet) ...... 48 Sure-Fine Pen Needles 31gx3/16" 5mm ..... 58 Tarka (Tablet Extended-Release) ...... 34 Testosterone (25mg/2.5gm Gel, 50mg/5gm Sure-Fine Pen Needles 31gx5/16" 8mm ..... 58 Taron-BC ...... 68 Gel) ...... 48 Sure-Lance Lancets 26g ...... 58 Taron-C DHA (Capsule) ...... 68 Testosterone Cypionate (Injection) ...... 48 Sure-Lance Thin Lancets 28g ...... 58 Tasigna (Capsule) ...... 26 Testosterone Enanthate (Injection) ...... 48 Surelite Lancets ...... 58 Tasmar (Tablet) ...... 26 Testosterone Pump (Gel) ...... 48 Sure-Touch Lancets Universal ...... 58 Taxotere (Injection) ...... 25 Testred (Capsule) ...... 48 Surmontil (Capsule) ...... 21 Taytulla (Capsule) ...... 49 Tetrabenazine (Tablet) ...... 40 Survanta Intratracheal (Suspension) ...... 64 Tazicef (1gm/50ml-4.4% Injection) ...... 16 Tetracaine HCl (0.5% Ophthalmic Solution) 60 Suspension Vehicle (Suspension) ...... 58 Tazorac (0.05% Cream, 0.1% Cream, 0.05% Tetracycline HCl (Capsule) ...... 18 Sustiva (200mg Capsule, 50mg Capsule, Gel, 0.1% Gel) ...... 43 Tetrix (Cream) ...... 43 600mg Tablet) ...... 28 Tecentriq (Injection) ...... 26 Texacort (External Solution) ...... 43 95

Thalomid (Capsule) ...... 25 0.3%-0.1% Ophthalmic Suspension)...... 14 Trecator (Tablet) ...... 24 Theo-24 (Capsule Extended-Release 24 Hour) Tobradex ST (Ophthalmic Suspension) ...... 14 Trelstar (Injection) ...... 50 ...... 63 Tobramycin (300mg/5ml Nebulized Solution) Trelstar Mixject (11.25mg Suspension, Theophylline (Oral Solution) ...... 63 ...... 14 3.75mg Suspension, 22.5mg Injection) .. 50 Theophylline CR (Tablet Extended-Release 12 Tobramycin Sulfate (0.3% Ophthalmic Trepadone (Capsule) ...... 66 Hour) ...... 63 Solution, 1.2gm Injection, 1.2gm/30ml Tresiba FlexTouch (Injection)...... 32 Theophylline ER (Tablet Extended-Release 12 Injection, 10mg/ml Injection, 80mg/2ml Tretinoin (0.01% Gel, 0.05% Gel, 0.025% Hour, Tablet Extended-Release 24 Hou) . 63 Injection) ...... 14 Cream, 0.05% Cream, 0.1% Cream, 0.025% Theophylline/D5W (Injection) ...... 63 Tobramycin/Dexamethasone (Ophthalmic Gel) ...... 43 Theracys (Injection) ...... 51 Suspension) ...... 14 Tretinoin (10mg Capsule) ...... 26 Theramine (Capsule) ...... 66 Tobrex (0.3% Ophthalmic Ointment, 0.3% Tretinoin (Powder) ...... 64 Theramine Plus (Packet) ...... 66 Ophthalmic Solution) ...... 14 Tretinoin Microsphere (Gel) ...... 43 Theranatal Core Nutrition (Tablet) ...... 67 Tofranil (Tablet) ...... 21 Tretinoin Microsphere Pump (Gel) ...... 43 Thiamine HCl (100mg/ml Injection) ...... 67 Tolak (Cream) ...... 43 Tretin-X (Cream)...... 43 Thinlets GP Lancets ...... 58 Tolazamide (Tablet) ...... 31 Trexall (Tablet) ...... 51 Thinlets Lancet ...... 58 Tolbutamide (Tablet) ...... 31 Treximet (500mg-85mg Tablet) ...... 24 Thiola (Tablet) ...... 46 Tolcapone (Tablet) ...... 26 Treximet (60mg-10mg Tablet) ...... 23 Thioridazine HCl (Tablet) ...... 27 Tolmetin Sodium (200mg Tablet, 600mg Trezix (Capsule) ...... 12 Thiotepa (Injection) ...... 24 Tablet, 400mg Capsule) ...... 10 Triamcinolone (Injection) ...... 47 Thiothixene (Capsule) ...... 27 Tolterodine Tartrate (Tablet) ...... 46 Triamcinolone Acetonide (0.025% Cream, Thrombin-JMI Diluent (External Solution) . 33 Tolterodine Tartrate ER (Capsule Extended- 0.1% Cream, 0.5% Cream, 0.025% Lotion, Thrombin-JMI Epistaxis (Kit) ...... 33 Release 24 Hour) ...... 46 0.1% Lotion, 0.025% Ointment, 0.1% Thrombin-JMI Syringe Spray Kit (Kit) ...... 33 Topamax (Tablet) ...... 19 Ointment, 0.5% Ointment, 0.147mg/gm Thrombin-JMI w/Dil Spray Pump Actuator Topamax Sprinkle (Capsule Sprinkle) ...... 19 Aerosol Solution) ...... 43 (Kit) ...... 33 Topicort (0.05% Cream) ...... 43 Triamcinolone Acetonide (0.1% Paste) ...... 40 Thrombogen (10000unit Kit, 10000unit Topicort (0.05% Gel, 0.05% Ointment, 0.25% Triamcinolone Acetonide (55mcg/act Solution, 1000unit Solution) ...... 33 Ointment, 0.25% Cream, 0.25% Liquid) 43 Aerosol) ...... 62 Thymoglobulin (Injection) ...... 51 Topiramate (Tablet Immediate-Release, Triamcinolone Acetonide Pf (Injection)...... 60 Thyrogen (Injection) ...... 52 Capsule Sprinkle Immediate-Release) .... 19 Triamcinolone in Orabase (Paste)...... 40 Thyrolar (Tablet) ...... 49 Topiramate ER (Capsule Extended-Release Triamcinolone Pf (Injection) ...... 46 Tiagabine HCl (Tablet) ...... 19 24 Hour Sprinkle) ...... 19 Triamterene/Hydrochlorothiazide (25mg- Tiazac (Capsule Extended-Release 24 Hour) Topotecan HCl (Injection) ...... 25 37.5mg Tablet, 50mg-75mg Tablet, ...... 35 Toprol XL (Tablet Extended-Release 24 Hour) 37.5mg-25mg Capsule, 50mg-25mg Tice BCG (Injection) ...... 60 ...... 35 Capsule) ...... 37 Tigan (100mg/ml Injection, 300mg Capsule) Torisel (Injection) ...... 51 Trianex (Ointment) ...... 43 ...... 22 Torsemide (Tablet) ...... 37 Triazolam (Tablet) ...... 29 Tikosyn (Capsule) ...... 35 Toujeo SoloStar (Injection)...... 32 Tribenzor (Tablet) ...... 34 Timolol Maleate (0.25% Ophthalmic Solution, Toviaz (Tablet Extended-Release 24 Hour) 46 Tricare Prenatal (Tablet Chewable) ...... 68 0.5% Ophthalmic Solution) ...... 61 Tracleer (Tablet) ...... 63 Tricare Prenatal Compleat ...... 68 Timolol Maleate (10mg Tablet, 20mg Tablet, Tradjenta (Tablet) ...... 31 Tricare Prenatal DHA One (Capsule)...... 68 5mg Tablet) ...... 35 Tramadol HCl (Tablet Immediate-Release) . 12 Tricor (Tablet) ...... 37 Timolol Maleate Ophthalmic Gel Forming Tramadol HCl ER (100mg Tablet Extended- Tridesilon (Cream)...... 43 (Solution) ...... 61 Release 24 Hour, 200mg Tablet Extended- Triferic (272mg Packet) ...... 30 Timoptic (Ophthalmic Solution) ...... 61 Release 24 Hour, 300mg Tablet Extended- Trifluoperazine HCl (Tablet) ...... 27 Timoptic Ocudose (Ophthalmic Solution) .. 61 Release 24 Hour, 150mg Capsule Trifluridine (Ophthalmic Solution) ...... 29 Timoptic-XE (Gel Form Solution) ...... 61 Extended-Release 24 Hour) ...... 11 Triglide (Tablet) ...... 37 Tindamax (Tablet) ...... 26 Tramadol HCl/Acetaminophen (Tablet) ...... 12 Trihexyphenidyl HCl (0.4mg/ml Elixir, 2mg Tinidazole (Tablet) ...... 26 Trandolapril (Tablet) ...... 34 Tablet, 5mg Tablet) ...... 26 Tirosint (Capsule) ...... 49 Trandolapril/Verapamil HCl ER (Tablet Trileptal (150mg Tablet, 300mg Tablet, Tisseel (External Solution) ...... 43 Extended-Release) ...... 34 600mg Tablet, 300mg/5ml Suspension) 20 Tisseel VH (Kit) ...... 43 Tranexamic Acid (1000mg/10ml Injection, Trilipix (Capsule Delayed-Release) ...... 37 Tivicay (Tablet) ...... 28 650mg Tablet) ...... 33 Trimethobenzamide HCl (Capsule) ...... 22 Tivorbex (Capsule) ...... 38 Transderm-Scop (Patch 72 Hour) ...... 22 Trimethoprim (100mg Tablet) ...... 15 Tizanidine Comfort Pac ...... 28 Tranxene T (Tablet) ...... 19 Trimethoprim Sulfate/Polymyxin B Sulfate Tizanidine HCl (2mg Capsule, 4mg Capsule, Tranylcypromine Sulfate (Tablet) ...... 31 (Ophthalmic Solution) ...... 15 6mg Capsule, 2mg Tablet, 4mg Tablet) .. 28 Travasol (Injection) ...... 66 Trimipramine Maleate (100mg Capsule, 25mg Tl G-Fol Os (Tablet) ...... 68 Travatan Z (Ophthalmic Solution) ...... 60 Capsule, 50mg Capsule) ...... 21 Tnkase (Injection) ...... 32 Travel Lancets Advanced 28g ...... 58 Tri-Norinyl 28 (Tablet)...... 49 TOBI (Nebulized Solution) ...... 14 Trazodone HCl (100mg Tablet, 150mg Tablet, Trintellix (Tablet) ...... 20 TOBI Podhaler (Capsule) ...... 14 300mg Tablet, 50mg Tablet) ...... 20 Triostat (Injection) ...... 49 Tobradex (0.3%-0.1% Ophthalmic Ointment, Treanda (Injection) ...... 24 Triple Dye (Liquid) ...... 23 96

Trisenox (Injection) ...... 60 Ulticare Thin Lancets 30g ...... 58 Unistik Safety Lancets 30g ...... 59 Triumeq (Tablet) ...... 29 Ulticare U-100 Insulin Syringes/0.3ml/31g Unistik Touch Safety Lancets 21g ...... 59 Triveen-Duo DHA ...... 67 X1/4" ...... 58 Unistik Touch Safety Lancets 23g ...... 59 Tri-Vi-Flor (Suspension) ...... 68 Ulticare U-100 Insulin Syringes/0.5ml/31g X Unistik Touch Safety Lancets 28g ...... 59 Trizivir (Tablet) ...... 29 1/4" ...... 58 Unistik Touch Safety Lancets 30g ...... 59 Trokendi XR (Capsule Extended-Release 24 Ulticare U-100 Insulin Syringes/1ml/31g X Unituxin (Injection) ...... 26 Hour) ...... 19 1/4" ...... 58 Universal 1 Lancets Thin 26g ...... 59 Trophamine (Injection) ...... 66 Ultiguard Insulin Syringe/U-100/0.5ml/30g X Universal 1 Lancets Ultra Thin 30g ...... 59 Trospium Chloride (Tablet) ...... 46 5/16" ...... 58 Universal 1 Lancets/33g/Micro-Thin ...... 59 Trospium Chloride ER (Capsule Extended- Ultilet Classic Lancets ...... 58 Uptravi (Tablet) ...... 64 Release 24 Hour) ...... 46 Ultilet Insulin Syringe/Short/1ml/31g X Uramaxin (45% Gel) ...... 43 TruePlus Lancets 26g ...... 58 5/16" ...... 58 Urea (40% Cream, 45% Lotion) ...... 43 TruePlus Lancets 28g ...... 58 Ultilet Lancets ...... 58 Urea Topical (Suspension) ...... 43 TruePlus Lancets 30g ...... 58 Ultilet Lancets 33g ...... 58 Urecholine (Tablet) ...... 46 TruePlus Lancets 33g ...... 58 Ultilet Pen Needle 32gx4mm/Short ...... 58 Urocit-K (Tablet Extended-Release) ...... 66 Trueplus Lancets 33g Micro Thin ...... 58 Ultilet Safety Lancets 23g ...... 58 Uroxatral (Tablet Extended-Release 24 Hour) Trulance (Tablet) ...... 44 Ultilet Short Pen Needles 31gx5/16" ...... 58 ...... 46 Trulicity (Injection) ...... 31 Ultilet Short Pen Needles31gx3/16" ...... 58 Urso (Tablet) ...... 45 Trusopt (Ophthalmic Solution) ...... 37 Ultiva (Injection) ...... 12 Ursodiol (250mg Tablet, 500mg Tablet, Truvada (Tablet) ...... 29 Ultracet (Tablet) ...... 12 300mg Capsule) ...... 45 Tryptophan (500mg Capsule) ...... 65 Ultralance ...... 58 Utibron Neohaler (Capsule) ...... 30 Tudorza Pressair (Aerosol Powder) ...... 63 Ultram (Tablet) ...... 12 Uvadex (Injection) ...... 43 Turkel Paracentesis Procedure Tray/8french Ultra-Thin II Auto Lancet ...... 58 (Kit) ...... 13 Ultra-Thin II Lancets 28g...... 58 V Tussionex Pennkinetic Extended-Release Ultra-Thin II Lancets 30g...... 58 (Suspension Extended-Release)...... 62 Ultra-Thin II Pen Needles 29gx1/2" ...... 58 Vagifem (Tablet) ...... 49 Twynsta (Tablet) ...... 34 Ultra-Thin II Safety Autolancets 26g ...... 58 Valacyclovir HCl (Tablet) ...... 29 Tybost (Tablet) ...... 29 Ultravate (0.05% Cream, 0.05% Lotion, Valchlor (Gel) ...... 43 Tygacil (Injection) ...... 15 0.05% Ointment) ...... 43 Valcyte (450mg Tablet, 50mg/ml Oral Tykerb (Tablet) ...... 26 Ultravate X (Kit) ...... 64 Solution) ...... 28 Tylactin Restore 5PE (Packet) ...... 66 Unasyn (Injection) ...... 17 Valganciclovir (Tablet) ...... 28 Tylenol/Codeine #3 (Tablet) ...... 12 Unasyn Bulk Pack (Injection) ...... 17 Valganciclovir Hydrochlorde (Oral Solution) 28 Tylenol/Codeine #4 (Tablet) ...... 12 Unifine Pentips 32gx4mm ...... 58 Valium (Tablet) ...... 19 Tysabri (Injection) ...... 60 Unilet ComforTouch Lancet ...... 58 Valproate Sodium (100mg/ml Injection) ..... 19 Tyvaso (Inhalation Solution) ...... 63 Unilet Excelite ...... 58 Valproic Acid (250mg Capsule, 250mg/5ml Tyvaso Refill (Inhalation Solution) ...... 64 Unilet Excelite II ...... 58 Oral Solution, 250mg/5ml Syrup) ...... 19 Tyvaso Starter (Inhalation Solution) ...... 64 Unilet G.P. Lancet ...... 58 Valsartan (Tablet) ...... 34 Tyzine Pediatric Nasal Drops (Nasal Solution) Unilet G.P. SuperLite Lancet ...... 58 Valsartan/Hydrochlorothiazide (Tablet) ...... 34 ...... 64 Unilet GP 28 Ultra Thin...... 58 Valtrex (Tablet) ...... 29 Unilet Lancet...... 58 Valumark Lancet Ultra Thin 28g ...... 59 Vanatol LQ (Oral Solution) ...... 10 U Unilet Lancets Micro-Thin33g ...... 58 Unilet Lancets Super-Thin30g ...... 58 Vancocin HCl (Capsule) ...... 15 Uceris (2mg/act Foam, 9mg Tablet Unilet SuperLite Lancet ...... 58 Vancomycin (Injection) ...... 15 Extended-Release 24 Hour) ...... 47 Unistik 1 ...... 58 Vancomycin HCl (0.9%-1gm/200ml Injection, Udamin Sp (Tablet) ...... 68 Unistik 2 ...... 58 1000mg Injection, 10gm Injection, 5000mg Ulesfia (Lotion) ...... 26 Unistik 2 Comfort ...... 58 Injection, 125mg Capsule, 250mg Capsule) Uloric (Tablet) ...... 23 Unistik 2 Extra ...... 58 ...... 15 Ulticare Insulin Safety Syringe/0.5ml/29g X Unistik 2 Neonatal ...... 58 Vancomycin HCl + Syrspendsf Ph4 1/2" ...... 58 Unistik 2 Normal ...... 58 (Suspension) ...... 13 Ulticare Insulin Safety Syringe/1ml/29g X Unistik 2 Super ...... 58 Vancomycin HCl in Dextrose (Injection) ..... 15 1/2" ...... 58 Unistik 3 ...... 59 Vancomycin HCl/Dextrose (5%- Ulticare Insulin Syringe/0.3ml/29g X 1/2" . 58 Unistik 3 Comfort ...... 59 1.25gm/250ml Solution, 5%-1.5gm/500ml Ulticare Insulin Syringe/0.5ml/28g X 1/2" . 58 Unistik 3 Extra ...... 59 Solution, 5%-1.75gm/500ml Solution) .. 13 Ulticare Insulin Syringe/U-100/0.3ml/30g X Unistik 3 Extra Single Use Safety Lancets/21g Vancomycin HCl/Dextrose (5%-1.5gm/250ml 1/2" ...... 58 ...... 59 Injection) ...... 13 Ulticare Insulin Syringe/U-100/0.3ml/31g X Unistik 3 Gentle ...... 59 Vancomycin HCl/Dextrose (5%-1gm/100ml 5/16" ...... 58 Unistik 3 Neonatal ...... 59 Injection) ...... 15 Ulticare Insulin Syringe/U-100/0.5ml/31g X Unistik 3 Normal ...... 59 Vancomycin HCl/Dextrose (5%-1gm/250ml 5/16" ...... 58 Unistik CZT Comfort ...... 59 Injection, 5%-2gm/500ml Injection) ...... 15 Ulticare Micro Pen Needles/32g X 4mm .... 58 Unistik CZT Normal ...... 59 Vancomycin HCl/Sodium Chloride (0.9%- Ulticare Pen Needles/29g X 12.7mm...... 58 Unistik Safety Lancets 28g...... 59 1.25gm/250ml Injection, 0.9%- 97

1.5gm/250ml Injection, 0.9%-1gm/250ml Ventolin HFA (Aerosol Solution) ...... 63 Vistogard (Packet) ...... 59 Solution) ...... 15 Verapamil HCl (Tablet Immediate-Release, Visudyne (Injection) ...... 60 Vancomycin HCl/Sodium Chloride (0.9%- 2.5mg/ml Injection) ...... 36 Vitafol Gummies (Tablet Chewable) ...... 68 1.5gm/150ml Injection, 0.9%-1gm/150ml Verapamil HCl Extended-Release 24 Hour Vitafol-Nano (Tablet) ...... 68 Injection, 0.9%-750mg/150ml Injection) 15 (100mg Capsule, 120mg Capsule, 180mg Vitalet Pro Lancets ...... 59 Vancomycin HCl/Sodium Chloride (0.9%- Capsule, 200mg Capsule, 240mg Capsule, Vitalet Pro Plus Lancets ...... 59 1.5gm/500ml Injection) ...... 13 300mg Capsule, 120mg Tablet, 180mg Vitamedmd One Rx/Quatrefolic (Capsule) 68 Vancomycin HCl/Sodium Chloride (0.9%- Tablet, 240mg Tablet) ...... 36 Vitamedmd Redichew Rx (Tablet Chewable) 1.75gm/300ml Solution, 0.9%- Verapamil HCl SR (Capsule Extended-Release ...... 68 2.5gm/500ml Solution, 0.9%-2gm/250ml 24 Hour) ...... 36 Vitamin A (Capsule) ...... 68 Solution, 0.9%-2gm/500ml Solution) .... 13 Verdeso (Foam) ...... 43 Vitamin C 222mg (Injection) ...... 67 Vancomycin HCl/Sodium Chloride (Solution) Veregen (Ointment) ...... 43 Vitamin D (50000unit Capsule) ...... 67 ...... 13 Verelan (Capsule Extended-Release 24 Hour) Vitamin K1 (10mg/ml Injection) ...... 67 Vanishpoint Insulin Syringe/0.5ml/30g X ...... 36 Vitamin K1 (1mg/0.5ml Injection) ...... 67 5/16" ...... 59 Verelan PM (Capsule Extended-Release 24 Vitapearl (Capsule Extended-Release) ...... 68 Vanishpoint Insulin Syringe/1ml/29g X 5/16" Hour) ...... 36 Vita-Pren (Tablet)...... 68 ...... 43 Veripred 20 (Oral Solution) ...... 47 Vitaroca Plus (Tablet) ...... 67 Vanishpoint Insulin Syringe/1ml/30g X 5/16" Versacloz (Suspension) ...... 27 Vitrase (Injection) ...... 13 ...... 59 Vesicare (Tablet) ...... 46 Viva DHA (Capsule) ...... 68 Vanos (Cream)...... 43 Vfend (200mg Tablet, 50mg Tablet, 40mg/ml Vivelle-Dot (Patch Twice Weekly) ...... 49 Vantas (Injection) ...... 50 Suspension)...... 23 Vivitrol (Injection) ...... 13 Vaprisol (Injection) ...... 47 Vfend IV (Injection) ...... 23 Vivlodex (Capsule) ...... 39 Varithena (Injection) ...... 36 Viagra (Tablet) ...... 46 Vogelxo (Gel) ...... 48 Varubi (Tablet) ...... 22 Vibativ (Injection) ...... 15 Vogelxo Pump (Gel) ...... 48 Vascazen (Capsule) ...... 67 Viberzi (Tablet) ...... 45 Voltaren (Gel) ...... 43 Vascepa (Capsule) ...... 38 Vibramycin (100mg Capsule, 25mg/5ml Voluven (Injection) ...... 32 Vasculera (Tablet) ...... 66 Suspension, 50mg/5ml Syrup) ...... 18 Voraxaze (Injection) ...... 59 Vaseretic (Tablet) ...... 34 Victoza (Injection) ...... 31 Voriconazole (200mg Injection, 200mg Vasopressin/Sodium Chloride (0.9%- Vida Mia Unifine Pentips 32gx4mm...... 59 Tablet, 50mg Tablet, 40mg/ml Suspension) 40unit/100ml Injection, 0.9%- Vida Mia Unifine Pentips Original 29gx12mm ...... 23 50unit/50ml Injection) ...... 47 ...... 59 Vortex Valved Holding Chamber (Device) .. 59 Vasopressin/Sodium Chloride (0.9%- Vida Mia Unipfine Pentipsshort 31gx8mm 59 Vospire ER (Tablet Extended-Release 12 60unit/100ml Solution) ...... 50 Vidaza (Injection)...... 60 Hour) ...... 63 Vasostrict (Injection) ...... 47 Videx EC (Capsule Delayed-Release) ...... 29 Votrient (Tablet) ...... 26 Vasotec (Tablet) ...... 34 Videx Pediatric (Oral Solution) ...... 29 VPRIV (Injection) ...... 44 Vayacog (Capsule) ...... 67 Viekira Pak (Tablet Therapy Pack) ...... 28 Vraylar (Capsule Therapy Pack, 1.5mg Vayarin (Capsule) ...... 67 Viekira XR (Tablet Extended-Release 24 Capsule, 3mg Capsule, 4.5mg Capsule, Vayarol (Capsule) ...... 67 Hour) ...... 28 6mg Capsule) ...... 20 Vazculep (Injection) ...... 33 Vigamox (Ophthalmic Solution) ...... 17 VSL#3 DS (Packet) ...... 45 Vecamyl (Tablet) ...... 36 Viibryd (Tablet) ...... 21 Vusion (Ointment) ...... 23 Vectibix (Injection) ...... 26 Viibryd Starter Pack (Kit) ...... 21 Vytorin (Tablet) ...... 38 Vectical (Ointment) ...... 43 Vimizim (Injection) ...... 44 Vyvanse (10mg Capsule, 20mg Capsule, Vecuronium Bromide (10mg Injection, 20mg Vimpat (Tablet, Oral Solution, Injection) ... 20 30mg Capsule, 40mg Capsule, 50mg Injection) ...... 64 Vinate Care (Tablet Chewable) ...... 67 Capsule, 60mg Capsule, 70mg Capsule) 39 Vecuronium Bromide/Sodium Chloride Vinate DHA RF (Capsule) ...... 68 Vyvanse (10mg Tablet Chewable, 20mg (Injection) ...... 64 Vinblastine Sulfate (Injection)...... 25 Tablet Chewable, 30mg Tablet Chewable, Velcade (Injection) ...... 60 Vincristine Sulfate (Injection) ...... 60 40mg Tablet Chewable, 50mg Tablet Veletri (Injection) ...... 64 Vinorelbine Tartrate (Injection) ...... 25 Chewable, 60mg Tablet Chewable) ...... 39 Velphoro (Tablet Chewable) ...... 46 Viokace (Tablet)...... 44 Veltassa (Packet) ...... 65 Viracept (Tablet) ...... 29 W Veltin (Gel) ...... 43 Viramune (200mg Tablet) ...... 28 Vemlidy (Tablet) ...... 13 Viramune (50mg/5ml Suspension) ...... 28 W&F Lancets 26g...... 59 Venclexta (Tablet) ...... 25 Viramune XR (Tablet Extended-Release 24 W&F Lancets Colored 21g ...... 59 Venclexta Starting Pack (Tablet Therapy Hour) ...... 28 Walgreens Lancets ...... 59 Pack) ...... 25 Virazole (Inhalation Solution) ...... 64 Walgreens Thin Lancets ...... 59 Venlafaxine HCl (Tablet Immediate-Release) Viread (150mg Tablet, 200mg Tablet, 250mg Walgreens Ultra Thin Lancets ...... 59 ...... 21 Tablet, 300mg Tablet, 40mg/gm Powder) Warfarin Sodium (Tablet) ...... 32 Venlafaxine HCl Extended-Release 24 Hour ...... 29 WatchHaler (Device) ...... 59 (Capsule, Tablet) ...... 21 Viroptic (Ophthalmic Solution) ...... 29 Welchol (3.75gm Packet, 625mg Tablet) .... 31 Venofer (Injection) ...... 66 Visbiome (Packet) ...... 66 Wellbutrin SR (Tablet Extended-Release 12 Ventavis (Inhalation Solution) ...... 64 Vistaril (Capsule) ...... 22 Hour) ...... 13 98

Wellbutrin XL (Tablet Extended-Release 24 Y Zinecard (Injection) ...... 60 Hour) ...... 13 Zinplava (Injection) ...... 28 Yasmin 28 (Tablet) ...... 49 Westcort (Ointment) ...... 43 Zioptan (Ophthalmic Solution) ...... 60 Yaz (Tablet) ...... 49 Westhroid (Tablet) ...... 49 Ziprasidone HCl (Capsule) ...... 27 Yervoy (Injection) ...... 26 Wheat Germ (Oil) ...... 67 Zirgan (Gel) ...... 28 Yondelis (Injection) ...... 24 WinRho SDF (Injection) ...... 51 Zithromax (100mg/5ml Suspension, Yosprala (Tablet Delayed-Release) ...... 30 WP Thyroid (Tablet) ...... 49 200mg/5ml Suspension, 250mg Tablet, Your Life Multi Prenatal (Capsule) ...... 67 500mg Tablet, 600mg Tablet, 500mg X Injection) ...... 17 Z Zithromax (1gm Packet) ...... 17 Xalatan (Ophthalmic Solution) ...... 60 Zacare 4% Kit (Kit) ...... 43 Zithromax Tri-Pak (Tablet) ...... 17 Xalkori (Capsule) ...... 26 Zacare 8% Kit (Kit) ...... 43 Zithromax Z-Pak (Tablet) ...... 17 Xanax (Tablet) ...... 29 Zafirlukast (Tablet) ...... 62 Zmax (Suspension) ...... 17 Xanax XR (Tablet Extended-Release 24 Hour) Zaleplon (Capsule) ...... 65 Zocor (Tablet) ...... 37 ...... 30 Zaltrap (Injection) ...... 60 Zofran (4mg Tablet, 8mg Tablet, 4mg/5ml Xarelto (Tablet) ...... 32 Zamicet (Oral Solution) ...... 12 Oral Solution) ...... 22 Xarelto Starter Pack (Tablet Therapy Pack) 32 Zanaflex (2mg Capsule, 4mg Capsule, 6mg Zofran ODT (Tablet Dispersible) ...... 22 Xartemis XR (Tablet Extended-Release) ..... 11 Capsule, 4mg Tablet) ...... 28 Zohydro ER (Capsule Extended-Release 12 Xeljanz (Tablet) ...... 51 Zanosar (Injection) ...... 24 Hour Abuse-Deterrent) ...... 11 Xeljanz XR (Tablet Extended-Release 24 Zantac (150mg Tablet, 300mg Tablet, Zoladex (10.8mg Injection) ...... 50 Hour) ...... 51 25mg/ml Injection, 50mg/2ml Solution) Zoladex (3.6mg Injection) ...... 50 Xeloda (Tablet) ...... 25 ...... 45 Zoledronic Acid (4mg/100ml Injection) ...... 52 Xenazine (Tablet) ...... 40 Zarontin (250mg Capsule, 250mg/5ml Oral Zoledronic Acid (4mg/5ml Injection, Xeomin (100unit Injection, 50unit Injection) Solution) ...... 18 5mg/100ml Injection) ...... 52 ...... 59 Zarxio (Injection) ...... 32 Zolinza (Capsule) ...... 25 Xeomin (200unit Injection) ...... 60 Zatean-PN DHA (Capsule) ...... 67 Zolmitriptan (Tablet) ...... 24 Xeralux (Cream) ...... 43 Zatean-PN Plus (Capsule) ...... 68 Zolmitriptan ODT (Tablet Dispersible) ...... 24 Xerese (Cream)...... 13 Zavesca (Capsule) ...... 44 Zoloft (100mg Tablet, 25mg Tablet, 50mg Xermelo (Tablet) ...... 52 Zebeta (Tablet) ...... 35 Tablet, 20mg/ml Concentrate) ...... 21 Xgeva (Injection) ...... 52 Zegerid (20mg-1100mg Capsule, 40mg- Zolpidem Tartrate (Tablet Sublingual, Tablet) Xiaflex (Injection) ...... 44 1100mg Capsule, 20mg-1680mg Packet, ...... 65 Xifaxan (Tablet) ...... 15 40mg-1680mg Packet) ...... 46 Zolpidem Tartrate ER (Tablet Extended- Xigduo XR (Tablet Extended-Release 24 Zelapar (Tablet Dispersible) ...... 20 Release) ...... 65 Hour) ...... 31 Zelboraf (Tablet) ...... 26 Zolpimist (Oral Solution) ...... 65 Xiidra (Ophthalmic Solution) ...... 44 Zemaira (Injection) ...... 64 Zomacton (Injection)...... 47 Xodol (Tablet) ...... 12 Zembrace Symtouch (Injection) ...... 24 Zometa (Injection) ...... 52 Xofigo (Injection) ...... 25 Zemplar (1mcg Capsule, 2mcg Capsule, Zomig (2.5mg Nasal Solution, 5mg Nasal Xolair (Injection) ...... 64 2mcg/ml Injection, 5mcg/ml Injection) 52 Solution, 2.5mg Tablet, 5mg Tablet) ..... 24 Xolegel (Gel) ...... 23 Zenpep (Capsule Delayed-Release) ...... 44 Zomig ZMT (Tablet Dispersible) ...... 24 Xolegel Corepak (Kit) ...... 23 Zenzedi (15mg Tablet, 2.5mg Tablet, 20mg Zonacort 11 Day (Tablet Therapy Pack) ..... 50 Xolegel Duo/Head & Shoulders (Kit) ...... 23 Tablet, 30mg Tablet, 7.5mg Tablet) ...... 39 Zonacort 7 Day (Tablet Therapy Pack) ...... 50 Xolegel Duo/Xolex (Kit) ...... 23 Zepatier (Tablet) ...... 28 Zonalon (Cream) ...... 43 Xopenex (Nebulized Solution) ...... 63 Zerbaxa (Injection) ...... 16 Zonegran (Capsule) ...... 18 Xopenex Concentrate (Nebulized Solution) Zerit (15mg Capsule, 20mg Capsule, 30mg Zonisamide (Capsule) ...... 18 ...... 63 Capsule, 40mg Capsule) ...... 29 Zontivity (Tablet) ...... 33 Xopenex HFA (Aerosol) ...... 63 Zerit (1mg/ml Oral Solution) ...... 29 Zorbtive (Injection) ...... 47 Xtampza ER (Capsule Extended-Release 12 Zestoretic (Tablet) ...... 34 Zortress (Tablet) ...... 51 Hour Abuse-Deterrent) ...... 11 Zestril (Tablet) ...... 34 Zorvolex (Capsule) ...... 10 Xtandi (Capsule) ...... 25 Zetia (Tablet) ...... 38 Zosyn (Injection) ...... 17 Xultophy (Solution Pen injector) ...... 50 Zetonna (Aerosol Solution) ...... 62 Zovirax (200mg Capsule, 200mg/5ml Xuriden (Packet) ...... 59 Zevalin Y-90 (Injection)...... 26 Suspension, 400mg Tablet, 5% Ointment, Xylocaine (0.5% Injection, 1% Injection, 2% Ziac (Tablet) ...... 35 800mg Tablet) ...... 29 Injection, 4% External Solution) ...... 13 Ziagen (20mg/ml Oral Solution) ...... 29 Zovirax (5% Cream) ...... 29 Xylocaine/Epinephrine (Injection) ...... 13 Ziagen (300mg Tablet) ...... 29 Zubsolv (0.7mg-0.18mg Tablet Sublingual) 39 Xylocaine-MPF (Injection) ...... 13 Ziana (Gel) ...... 43 Zubsolv (1.4mg-0.36mg Tablet Sublingual, Xylocaine-Mpf/Epinephrine (Injection) ..... 13 Zidovudine (100mg Capsule, 300mg Tablet, 11.4mg-2.9mg Tablet Sublingual, 2.9mg- Xyntha (Injection) ...... 33 50mg/5ml Syrup)...... 29 0.71mg Tablet Sublingual, 5.7mg-1.4mg Xyntha Solofuse (Injection) ...... 33 Zinacef (Injection) ...... 16 Tablet Sublingual, 8.6mg-2.1mg Tablet Xyrem (Oral Solution) ...... 65 Zinbryta (Injection) ...... 60 Sublingual)...... 13 Xyzal (2.5mg/5ml Oral Solution, 5mg Tablet) Zinc Trace Metal (Injection) ...... 65 Zurampic (Tablet) ...... 43 ...... 62 Zutripro (Oral Solution) ...... 62 99

Zyclara (Cream) ...... 43 Zylet (Suspension) ...... 14 Zyprexa Relprevv (Injection) ...... 60 Zyclara Pump (Cream)...... 43 Zyloprim (Tablet) ...... 23 Zyprexa Zydis (Tablet Dispersible) ...... 27 Zydelig (Tablet) ...... 25 Zymaxid (Ophthalmic Solution) ...... 17 Zytiga (Tablet) ...... 25 Zyflo (Tablet) ...... 62 Zyprexa (10mg Injection) ...... 60 Zyvox (100mg/5ml Suspension, 600mg Zyflo CR (Tablet Extended-Release 12 Hour) Zyprexa (10mg Tablet, 15mg Tablet, 2.5mg Tablet, 600mg/300ml Injection) ...... 15 ...... 63 Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Zykadia (Capsule) ...... 26 Tablet) ...... 27

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Nondiscrimination Notice and Access to Communication Services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344 Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

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

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

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Multi-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

تنبيه: إذا كنت تتحدث العربية )Arabic(، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على معرّف العضوية.

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação.

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

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注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけま す。健康保険証に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی )Farsi( است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا با شماره تلفن رايگانی که روی کارت شناسايی شما قيد شده تماس بگيريد.

दी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नन:श쥍ु क उपल녍ध हℂ। कृ पया अपनेﴂ 鵍यान दᴂ: यदद आप ह पहचान पत्र पर सचू ीबद्ध टोल-फ्री फोन नंबर पर कॉल करᴂ।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

(Khmer) ចំ㮶ប់讶រម្មណ 㟈 បបើសិន诒នកនិ架យ徶羶ខ្មមរ បស玶ជំនួយ徶羶បោយឥតគិតថ្លៃ គឺ掶នសំ殶ប់诒នក។ សូម្ទូរស័寒ទបៅបេមឥតគិតថ្លៃ ខ្ែេ掶នបៅបេើ诒តដសញ្ញាណប័ណណរបស់诒នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dęę́ '́ t'áá jíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

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OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com. All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ©2017 OptumRx, Inc. Select Standard

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