2018 Essential Health Benefits Base Formulary

Effective January 1, 2018

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 Version 1 Last Updated August 18, 2017 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. Your formulary utilizes a Pharmacy and Therapeutics Committee made up of practicing physicians, pharmacists, and nurses to help ensure that your formulary is medically sound and that it supports patient health. This committee reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

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 your plan’s member website. 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.

What is a Formulary? This document is a list of 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. 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 the back of 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 common 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 the back of your ID card.

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Table of Contents Antiemetics : Antiemetics, Other ...... 22 Antiemetics : Emetogenic Therapy Adjuncts ...... 22 What are tiers? ...... 6 Antifungals ...... 22 Programs and Limits ...... 7 Antigout Agents ...... 23 Analgesics ...... 10 Antimigraine Agents : Ergot Alkaloids ...... 23 Analgesics : Nonsteroidal Anti-inflammatory Drugs ...... 10 Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Agonists ...... 23 Analgesics : Opioid Analgesics, Long-acting ...... 12 Antimyasthenic Agents : Parasympathomimetics ...... 23 Analgesics : Opioid Analgesics, Short-acting ...... 12 Antimycobacterials : Antimycobacterials, Other ...... 24 Anesthetics ...... 13 Antimycobacterials : Antituberculars ...... 24 Anesthetics : Local Anesthetics...... 13 Antineoplastics : Alkylating Agents ...... 24 Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Deterrents/Anti-craving ...... 14 Antineoplastics : Antiandrogens ...... 24 Anti-Addiction/Substance Abuse Treatment Agents : Opioid Antineoplastics : Antiangiogenic Agents ...... 24 Dependence Treatments ...... 14 Antineoplastics : Antiestrogens/Modifiers ...... 24 Anti-Addiction/Substance Abuse Treatment Agents : Smoking Antineoplastics : Antimetabolites ...... 24 Cessation Agents ...... 14 Antineoplastics : Antineoplastics, Other...... 25 Antibacterials : Aminoglycosides ...... 15 Antineoplastics : Aromatase Inhibitors, 3rd Generation ...... 26 Antibacterials : Antibacterials, Other ...... 16 Antineoplastics : Enzyme Inhibitors ...... 26 Antibacterials : Beta-lactam, Cephalosporins ...... 17 Antineoplastics : Molecular Target Inhibitors ...... 26 Antibacterials : Beta-lactam, Other...... 17 Antineoplastics : Monoclonal Antibody/Antibody-Drug Conjugate Antibacterials : Beta-lactam, Penicillins ...... 17 ...... 26 Antibacterials : Macrolides ...... 18 Antineoplastics : Retinoids ...... 26 Antibacterials : Quinolones ...... 18 Antiparasitics : Anthelmintics ...... 26 Antibacterials : Sulfonamides ...... 18 Antiparasitics : Antiprotozoals ...... 26 Antibacterials : Tetracyclines ...... 19 Antiparasitics : Pediculicides/Scabicides ...... 27 Anticonvulsants : Anticonvulsants, Other ...... 19 Antiparkinson Agents : Anticholinergics ...... 27 Anticonvulsants : Calcium Channel Modifying Agents ...... 19 Antiparkinson Agents : Antiparkinson Agents, Other ...... 27 Anticonvulsants : Gamma-aminobutyric Acid (GABA) Antiparkinson Agents : Dopamine Agonists ...... 27 Augmenting Agents ...... 19 Antiparkinson Agents : Dopamine Precursors/L-Amino Acid Anticonvulsants : Glutamate Reducing Agents ...... 20 Decarboxylase Inhibitors ...... 27 Anticonvulsants : Sodium Channel Agents ...... 20 Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Antidementia Agents : Cholinesterase Inhibitors ...... 20 Inhibitors ...... 27 Antidementia Agents : N-methyl-D-aspartate (NMDA) Receptor Antipsychotics : 1st Generation/Typical ...... 27 Antagonist ...... 20 Antipsychotics : 2nd Generation/Atypical ...... 27 Antidepressants : Antidepressants, Other ...... 21 Antipsychotics : Treatment-Resistant ...... 28 Antidepressants : Monoamine Oxidase Inhibitors ...... 21 Antivirals : Anti-cytomegalovirus (CMV) Agents ...... 28 Antidepressants : SSRIs/SNRIs (Selective Serotonin Reuptake Antivirals : Anti-hepatitis B (HBV) Agents ...... 28 Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)..21 Antidepressants : Tricyclics ...... 21 3 Antivirals : Anti-hepatitis C (HCV) Agents, Direct Acting Agents Cardiovascular Agents : Diuretics, Thiazide ...... 36 ...... 28 Cardiovascular Agents : Dyslipidemics, Fibric Acid Derivatives36 Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) ...... 29 Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Inhibitors ...... 36 Transcriptase Inhibitors (NNRTI) ...... 29 Cardiovascular Agents : Dyslipidemics, Other ...... 36 Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Reverse Cardiovascular Agents : Vasodilators, Direct-acting Arterial ..... 37 Transcriptase Inhibitors (NRTI) ...... 29 Cardiovascular Agents : Vasodilators, Direct-acting Antivirals : Anti-HIV Agents, Other ...... 29 Arterial/Venous ...... 37 Antivirals : Anti-HIV Agents, Protease Inhibitors ...... 29 Central Nervous System Agents : Attention Deficit Hyperactivity Antivirals : Anti-influenza Agents ...... 29 Disorder Agents, Amphetamines ...... 37 Antivirals : Antiherpetic Agents...... 30 Central Nervous System Agents : Attention Deficit Hyperactivity Antivirals ...... 30 Disorder Agents, Non-amphetamines ...... 37 Anxiolytics : Anxiolytics, Other ...... 30 Central Nervous System Agents : Central Nervous System, Other ...... 38 Anxiolytics : Benzodiazepines ...... 30 Central Nervous System Agents : Fibromyalgia Agents ...... 38 Bipolar Agents : Mood Stabilizers ...... 30 Central Nervous System Agents : Multiple Sclerosis Agents .... 38 Blood Glucose Regulators : Antidiabetic Agents ...... 30 Dental and Oral Agents ...... 38 Blood Glucose Regulators : Glycemic Agents ...... 31 Dermatological Agents ...... 39 Blood Glucose Regulators : Insulins ...... 31 Electrolytes/Minerals/Metals/Vitamins : Electrolyte/Mineral Blood Products/Modifiers/Volume Expanders : Anticoagulants 31 Replacement ...... 40 Blood Products/Modifiers/Volume Expanders : Blood Formation Electrolytes/Minerals/Metals/Vitamins : Electrolyte/Mineral/Metal Modifiers ...... 32 Modifiers ...... 42 Blood Products/Modifiers/Volume Expanders ...... 32 Electrolytes/Minerals/Metals/Vitamins ...... 42 Blood Products/Modifiers/Volume Expanders : Hemostasis Electrolytes/Minerals/Metals/Vitamins : Vitamins ...... 42 Agents ...... 32 Gastrointestinal Agents : Antispasmodics, Gastrointestinal ...... 46 Blood Products/Modifiers/Volume Expanders : Platelet Modifying Agents ...... 33 Gastrointestinal Agents : Gastrointestinal Agents, Other ...... 47 Cardiovascular Agents : Alpha-adrenergic Agonists ...... 33 Gastrointestinal Agents : Histamine2 (H2) Receptor Antagonists ...... 47 Cardiovascular Agents : Alpha-adrenergic Blocking Agents ..... 33 Gastrointestinal Agents : Irritable Bowel Syndrome Agents...... 47 Cardiovascular Agents : Angiotensin II Receptor Antagonists ..33 Gastrointestinal Agents : Laxatives ...... 47 Cardiovascular Agents : Angiotensin-converting Enzyme (ACE) Inhibitors ...... 33 Gastrointestinal Agents : Protectants ...... 48 Cardiovascular Agents : Antiarrhythmics ...... 33 Gastrointestinal Agents : Proton Pump Inhibitors ...... 48 Cardiovascular Agents : Beta-adrenergic Blocking Agents ...... 34 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ...... 48 Cardiovascular Agents : Calcium Channel Blocking Agents ..... 34 Genitourinary Agents : Antispasmodics, Urinary ...... 49 Cardiovascular Agents : Cardiovascular Agents, Other ...... 35 Genitourinary Agents : Benign Prostatic Hypertrophy Agents .. 49 Cardiovascular Agents : Diuretics, Carbonic Anhydrase Inhibitors ...... 36 Genitourinary Agents : Genitourinary Agents, Other ...... 49 Cardiovascular Agents : Diuretics, Loop ...... 36 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)50 Cardiovascular Agents : Diuretics, Potassium-sparing ...... 36 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ...... 51 4 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Phosphodiesterase Hormones/Modifiers) : Androgens ...... 51 Inhibitors, Airways Disease ...... 66 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Pulmonary Hormones/Modifiers) : Estrogens ...... 52 Antihypertensives ...... 66 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Respiratory Tract/Pulmonary Agents : Respiratory Tract Agents, Hormones/Modifiers) : Progesterone Agonists/Antagonists ...... 54 Other ...... 67 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Skeletal Muscle Relaxants ...... 68 Hormones/Modifiers) : Progestins ...... 54 Sleep Disorder Agents : GABA Receptor Modulators ...... 68 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Sleep Disorder Agents : Sleep Disorders, Other ...... 68 Hormones/Modifiers) : Selective Estrogen Receptor Modifying Agents ...... 54 Index of Covered Drugs ...... 69 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)54 Hormonal Agents, Suppressant (Adrenal) ...... 55 Hormonal Agents, Suppressant (Pituitary) ...... 55 Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents.55 Immunological Agents : Angioedema Agents ...... 55 Immunological Agents : Immune Suppressants ...... 55 Immunological Agents : Immunizing Agents, Passive ...... 56 Immunological Agents : Immunomodulators ...... 56 Immunological Agents : Vaccines ...... 56 Inflammatory Bowel Disease Agents : Aminosalicylates ...... 57 Inflammatory Bowel Disease Agents : Glucocorticoids ...... 57 Inflammatory Bowel Disease Agents : Sulfonamides ...... 57 Metabolic Bone Disease Agents ...... 57 Miscellaneous Therapeutic Agents ...... 58 Ophthalmic Agents : Ophthalmic Agents, Other ...... 63 Ophthalmic Agents : Ophthalmic Anti-allergy Agents ...... 63 Ophthalmic Agents : Ophthalmic Anti-inflammatories ...... 64 Ophthalmic Agents : Ophthalmic Antiglaucoma Agents ...... 64 Ophthalmic Agents : Ophthalmic Prostaglandin and Prostamide Analogs ...... 64 Otic Agents ...... 64 Respiratory Tract/Pulmonary Agents : Anti-inflammatories, Inhaled Corticosteroids ...... 65 Respiratory Tract/Pulmonary Agents : Antihistamines ...... 65 Respiratory Tract/Pulmonary Agents : Antileukotrienes ...... 65 Respiratory Tract/Pulmonary Agents : Bronchodilators, Anticholinergic ...... 65 Respiratory Tract/Pulmonary Agents : Bronchodilators, Sympathomimetic ...... 66 5

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. Generally, medications in a lower tier cost less than medications in higher tiers. If your medication is placed in a higher tier, look to see if there is a lower cost option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes

Tier 1 Generic drugs with the same active ingredient as the brand name versions but at lower cost.

Tier 2 Preferred brand name drugs that will generally have a lower co-payments than non-preferred brand name drugs.

Tier 3 Non-preferred drugs generally have higher co- payments than preferred brand name drugs.

Tier 4 Specialty drugs generally have the highest co- payment and cost. These drugs are sometimes used to treat complex and chronic conditions and my require special monitoring or handling.

Refer to your enrollment and plan materials – visit your plan’s member website, or call the toll-free member phone number of the back of 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 nonformulary tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 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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Programs and Limits Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

Prior Authorization – Your doctor is required to provide additional PA information to determine coverage.

Step Therapy – Trial of lower cost medication(s) is required before ST a higher-cost medication is covered.

Quantity Limits – Amount of medication covered per copayment QL or in a specific time period.

AR Age Restrictions – Some restrictions may apply based on patient age.

Preventive drugs – May have coverage and no co-payments when health care reform requirements are met. PV PV* - Available at $0 if prior authorization is approved. ST* - Available at $0 if step criteria is met or coverage exception is approved. If criteria are not met, copays will apply per plan benefit.

OptumRx’s formulary uses medical and utilization management functions to determine whether a prescription is medically necessary. These industry recognized and accepted management functions include but are not limited to quantity limits, step therapy, and prior authorization and help OptumRx and its clients determine whether the medication was prescribed in accordance with generally accepted medical practice standards, is clinically appropriate, and confirm that the prescribed medication is not more costly than an alternative product that is as likely to produce therapeutically equivalent results. As recommended by the United States Department of Labor, OptumRx’s reasonable medical and utilization management functions apply to ACA preventive drugs.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call 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, Lamictal) and generic drugs in plain type (for example, lamotrigine).

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® at 1-888-702-8423 and have your prescriptions delivered right to your home or office.

Is home delivery available? Convenient home delivery service is available through OptumRx Home Delivery. Call the toll-free member phone number on the back of your ID card. Customer Service is available 24 hours a day, 7 days a week.

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 the back of your ID card for more current information. When you register on 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 • Sign up for text reminders to take and refill your medicine • 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 the back of your ID card. Or visit your plan’s member website.

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Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Analgesics Bayer Low Dose (Tablet 1 PV Butalbital/Acetaminophen 1 Delayed-Release) (Tablet) Celecoxib (Capsule) 1 QL Butalbital/Acetaminophen/Caffein 1 Childrens Aspirin (Tablet 1 PV e (325mg-50mg-40mg Tablet, Chewable) 50mg-300mg-40mg Capsule) Childrens Aspirin Low Strength 1 PV Butalbital/Aspirin/Caffeine 1 (Tablet Chewable) (Capsule) CVS Aspirin (325mg Tablet, 1 PV Capacet (Capsule) 1 325mg Tablet Delayed-Release) Esgic (325mg-50mg-40mg 1 CVS Enteric Aspirin (Tablet 1 PV Capsule) Delayed-Release) Marten-Tab (Tablet) 1 Diclofenac Potassium (Tablet) 1 Prialt (Injection) 4 Diclofenac Sodium (1.5% 1 PA Zebutal (Capsule) 1 Transdermal Solution) Analgesics : Nonsteroidal Anti-inflammatory Diclofenac Sodium DR (Tablet 1 Drugs Delayed-Release) Aspir-81 (Tablet Delayed- 1 PV Diclofenac Sodium ER (Tablet 1 Release) Extended-Release 24 Hour) Aspir-Low (Tablet Delayed- 1 PV Diclofenac Sodium/Misoprostol 1 Release) (Tablet Delayed-Release) Aspirin (81mg Tablet Delayed- 1 PV Diflunisal (Tablet) 1 Release) Ecotrin (Tablet Delayed-Release) 1 PV Aspirin 81 (Tablet Delayed- 1 PV Ecotrin Low Strength (Tablet 1 PV Release) Delayed-Release) Aspirin 81 Low Dose (Tablet 1 PV Ecpirin (Tablet Delayed-Release) 1 PV Chewable) EQ Aspirin (325mg Tablet, 1 PV Aspirin Adult Low Dose (Tablet 1 PV 325mg Tablet Delayed-Release) Delayed-Release) EQ Childrens Aspirin (Tablet 1 PV Aspirin Childrens (Tablet 1 PV Chewable) Chewable) EQL Aspirin (Tablet) 1 PV Aspirin EC (Tablet Delayed- 1 PV EQL Aspirin EC (Tablet Delayed- 1 PV Release) Release) Aspirin EC Low Dose (Tablet 1 PV EQL Aspirin Low Dose (Tablet 1 PV Delayed-Release) Chewable) Aspirin Low Dose (Tablet 1 PV Etodolac (200mg Capsule, 1 Chewable) 300mg Capsule, 400mg Tablet, Aspirtab (Tablet Delayed- 1 PV 500mg Tablet) Release) Etodolac ER (Tablet Extended- 1 Bayer Advanced Aspirin Regular 1 PV Release 24 Hour) Strength (Tablet) Fenoprofen Calcium (400mg 3 Bayer Aspirin EC Low Dose 1 PV Capsule) (Tablet Delayed-Release) Fenoprofen Calcium (600mg 1 Bayer Aspirin Regimen (Tablet 1 PV Tablet) Delayed-Release) Fenortho (Capsule) 3 Bayer Chewable Low Dose 1 PV Flurbiprofen (100mg Tablet, 1 (Tablet Chewable) 50mg Tablet)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 10 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits GNP Adult Aspirin Low Strength 1 PV Nabumetone (Tablet) 1 (Tablet Chewable) Nalfon (Capsule) 3 GNP Aspirin (325mg Tablet, 1 PV Naprelan (750mg Tablet 3 325mg Tablet Delayed-Release, Extended-Release 24 Hour) 81mg Tablet Delayed-Release) Naproxen (125mg/5ml 1 GNP Aspirin Low Dose (Tablet 1 PV Suspension, 250mg Tablet, Delayed-Release) 375mg Tablet, 500mg Tablet) Goodsense Aspirin (Tablet) 1 PV Naproxen DR (Tablet Delayed- 1 Goodsense Aspirin Adult Low 1 PV Release) Strength (Tablet Chewable) Naproxen Sodium (275mg 1 HM Aspirin (325mg Tablet, 81mg 1 PV Tablet, 550mg Tablet) Tablet Chewable) Naproxen Sodium CR (Tablet 1 Ibuprofen (100mg/5ml 1 Extended-Release 24 Hour) Suspension, 400mg Tablet, Naproxen Sodium ER (Tablet 1 600mg Tablet, 800mg Tablet) Extended-Release 24 Hour) Indomethacin (1mg Injection, 1 Norwich Aspirin (Tablet) 1 PV 25mg Capsule, 50mg Capsule) Oxaprozin (Tablet) 1 Indomethacin ER (Capsule 1 Piroxicam (10mg Capsule, 20mg 1 Extended-Release) Capsule) Ketoprofen (50mg Capsule, 1 PX Aspirin (325mg Tablet, 81mg 1 PV 75mg Capsule Immediate- Tablet Chewable) Release) PX Enteric Aspirin (Tablet 1 PV Ketoprofen ER (Capsule 1 Delayed-Release) Extended-Release 24 Hour) QC Aspirin (325mg Tablet, 1 PV Ketorolac Tromethamine (10mg 1 QL 325mg Tablet Delayed-Release) Tablet) QC Childrens Aspirin (Tablet 1 PV Ketorolac Tromethamine 1 Chewable) (15mg/ml Injection, 30mg/ml QC Enteric Aspirin (Tablet 1 PV Injection, 30mg/ml Injection) Delayed-Release) 1 PA Klofensaid II (Transdermal RA Aspirin (Tablet) 1 PV Solution) RA Aspirin Adult Low Strength 1 PV 1 PV KLS Aspirin EC (Tablet Delayed- (Tablet Chewable) Release) RA Aspirin EC (Tablet Delayed- 1 PV KLS Aspirin Low Dose (Tablet 1 PV Release) Delayed-Release) RA Childrens Aspirin (Tablet 1 PV KP Aspirin (Tablet Delayed- 1 PV Chewable) Release) Salsalate (Tablet) 1 Meclofenamate Sodium (100mg 1 SB Aspirin (Tablet) 1 PV Capsule, 50mg Capsule) SB Aspirin EC (Tablet Delayed- 1 PV Mefenamic Acid (250mg 1 Release) Capsule) SB Childrens Aspirin (Tablet 1 PV Meijer Aspirin EC (Tablet 1 PV Chewable) Delayed-Release) SM Aspirin (Tablet) 1 PV Meloxicam (Tablet) 1 SM Aspirin Adult Low Strength 1 PV Miniprin Low Dose (Tablet 1 PV (Tablet Chewable) Delayed-Release)

Mm Aspirin (Tablet) 1 PV Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 11 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits SM Aspirin EC Low Strength 1 PV Oxycodone HCl ER (Tablet 3 QL (Tablet Delayed-Release) Extended-Release 12 Hour SM Aspirin Enteric Coated 1 PV Abuse-Deterrent) (Tablet Delayed-Release) OxyContin (Tablet Extended- 2 QL SM Childrens Aspirin (Tablet 1 PV Release 12 Hour Abuse- Chewable) Deterrent) Sprix (Nasal Solution) 3 PA,QL Oxymorphone HCl ER (Tablet 1 QL St Joseph Low Dose Aspirin 1 PV Extended-Release 12 Hour) (Tablet Chewable) Tramadol HCl ER (150mg 1 PA,QL Sulindac (150mg Tablet, 200mg 1 Capsule Extended-Release 24 Tablet) Hour) TGT Aspirin (325mg Tablet, 1 PV Tramadol HCl ER (Tablet 1 QL,ST 81mg Tablet Chewable, 81mg Extended-Release 24 Hour Tablet Delayed-Release) Generic Ultram ER) TGT Aspirin Low Dose (Tablet 1 PV Analgesics : Opioid Analgesics, Short-acting Delayed-Release) Acetaminophen/Caffeine/Dihydro 1 QL TGT Childrens Aspirin (Tablet 1 PV codeine (Capsule) Chewable) Acetaminophen/Codeine 1 QL Tolmetin Sodium (200mg Tablet, 1 (Solution, 300mg-15mg Tablet, 600mg Tablet, 400mg Capsule) 300mg-30mg Tablet, 300mg- 60mg Tablet) Analgesics : Opioid Analgesics, Long-acting Embeda (Capsule Extended- 2 QL Alfentanil (Injection) 1 Release) Ascomp/Codeine (Capsule) 1 Fentanyl (Patch 72 Hour) 1 QL Aspirin-Caffeine-Dihydrocodeine 1 QL Hydromorphone HCl ER (Tablet 1 QL (Capsule) Extended-Release 24 Hour Butalbital/Acetaminophen/Caffein 1 Abuse-Deterrent) e/Codeine (Capsule) Hysingla ER (Tablet Extended- 3 QL,ST Butalbital/Aspirin/Caffeine/Codei 1 Release 24 Hour Abuse- ne (Capsule) Deterrent) Butorphanol Tartrate (10mg/ml 1 Methadone HCl (10mg Tablet, 1 Nasal Solution, 1mg/ml Injection, 5mg Tablet, 10mg/5ml Oral 2mg/ml Injection) Solution, 5mg/5ml Oral Solution, Codeine Sulfate (Tablet) 1 QL 10mg/ml Concentrate, 40mg Duramorph (Injection) 1 Tablet Soluble) Endocet (Tablet) 1 QL Methadose (40mg Tablet 1 Fentanyl Citrate Oral 1 PA,QL Soluble) Transmucosal (Lollipop) Morphine Sulfate ER (Capsule 1 QL Hydrocodone 1 QL Extended-Release 24 Hour, Bitartrate/Acetaminophen Tablet Extended-Release) (300mg-10mg Tablet, 300mg- Nucynta ER (Tablet Extended- 3 QL,ST 5mg Tablet, 300mg-7.5mg Release 12 Hour) Tablet, 325mg-2.5mg Tablet, Opana ER (Tablet Extended- 3 QL 325mg/15ml-7.5mg/15ml Oral Release 12 Hour Abuse- Solution) Deterrent) Hydrocodone/Acetaminophen 1 QL (Tablet) Hydrocodone/Ibuprofen (Tablet) 1 QL

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 12 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Hydromorphone HCl (10mg/ml 1 Nucynta (Tablet) 3 QL Injection, 1mg/ml Injection, Oxaydo (5mg Tablet Abuse- 3 QL 2mg/ml Injection, 4mg/ml Deterrent) Injection, 500mg/50ml Injection, Oxycodone HCl (100mg/5ml 1 QL 50mg/5ml Injection) Concentrate, 10mg Tablet, 15mg Hydromorphone HCl (1mg/ml 1 QL Tablet, 20mg Tablet, 30mg Liquid, 2mg Tablet, 4mg Tablet, Tablet, 5mg Tablet, 5mg 8mg Tablet) Capsule, 5mg/5ml Oral Solution) Hydromorphone HCl/ Sodium 1 Oxycodone/Acetaminophen 1 QL Chloride (Injection) (325mg-10mg Tablet, 325mg- Hydromorphone HCl/Sodium 1 2.5mg Tablet, 325mg-5mg Chloride (10mg/25ml-0.9% Tablet, 325mg-7.5mg Tablet) Injection, 15mg/30ml-0.9% Oxycodone/Aspirin (Tablet) 1 QL Injection, 15mg/50ml-0.9% Oxycodone/Ibuprofen (Tablet) 1 QL Injection, 1mg/5ml-0.9% Oxymorphone HCl (Tablet 1 QL Injection, 3mg/30ml-0.9% Immediate-Release) Injection, 5mg/25ml-0.9% Pentazocine/Naloxone HCl 1 QL Injection) (Tablet) Hydromorphone/Sodium 1 Tramadol HCl (Immediate- 1 Chloride (Injection) Release Tablet) Ibudone (5mg-200mg Tablet) 1 QL Tramadol HCl/Acetaminophen 1 Lorcet (Tablet) 1 QL (Tablet) Lorcet HD (Tablet) 1 QL Verdrocet (Tablet) 1 QL Lorcet Plus (Tablet) 1 QL Vicodin (Tablet) 1 QL Meperidine HCl (100mg Tablet, 1 QL Vicodin ES (Tablet) 1 QL 50mg Tablet, 50mg/5ml Oral Vicodin HP (Tablet) 1 QL Solution) Xylon (Tablet) 1 QL Meperidine HCl (100mg/ml 1 Injection, 10mg/ml Injection, Anesthetics 25mg/ml Injection, 50mg/ml Cisatracurium Besylate 1 Injection) (10mg/5ml Injection, 200mg/20ml Injection) Meperidine HCl/Sodium Chloride 1 (1000mg/100ml-0.9% Injection, Ropivacaine (Injection) 1 500mg/50ml-0.9% Injection) Ropivacaine HCl (Injection) 1 Morphine Sulfate (0.5mg/ml 1 Vecuronium Bromide (10mg 1 Injection, 10mg/ml Injection, Injection, 20mg Injection) 1mg/ml Injection, 4mg/ml Anesthetics : Local Anesthetics Injection, 8mg/ml Injection) Anodyne Lpt (Kit) 1 Morphine Sulfate (100mg/5ml 1 QL Bupivacaine HCl (Injection) 1 Oral Solution, 10mg/5ml Oral Bupivacaine Spinal (Injection) 1 Solution, 20mg/5ml Oral Bupivacaine/Dextrose Spinal 1 Solution, 20mg/ml Oral Solution, (Injection) 15mg Tablet, 30mg Tablet) Bupivacaine/Epinephrine 1 Morphine Sulfate/Sodium 1 (Injection) Chloride (0.5mg/ml-0.9% DermacinRx Prizopak (Kit) 1 Injection) Glydo (Gel) 1 Nalbuphine HCl (Injection) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 13 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Lidocaine (3% Cream, 5% 1 Butrans (Patch Weekly) 3 QL Ointment, 5% Patch) Naloxone HCl (Injection) 1 Lidocaine HCl (0.5% Injection, 1 Narcan (Liquid) 2 1.5% Injection, 4% Injection, 1% Suboxone (Film) 2 QL Solution, 2% Solution, 2% Gel, Anti-Addiction/Substance Abuse Treatment 4% External Solution) Agents : Smoking Cessation Agents Lidocaine HCl (Gel) 1 Bupropion HCl SR (150mg 1 QL,PV Lidocaine Pak (Ointment) 1 Tablet Extended-Release 12 Lidocaine Viscous (Solution) 1 Hour) Lidocaine/Epinephrine (Injection) 1 Chantix (Tablet) 3 QL,ST*,PV Lidocaine/Prilocaine (2.5%-2.5% 1 Chantix Continuing Month Pak 3 QL,ST*,PV Cream, 2.5%-2.5% Kit) (Tablet) Lidopril (Kit) 1 Chantix Starting Month Pak 3 QL,ST*,PV Livixil Pak (Kit) 1 (Tablet) Polocaine (Injection) 1 CVS Nicotine (Patch 24 Hour) 1 QL,PV Polocaine-Mpf (Injection) 1 CVS Nicotine Polacrilex (2mg 1 QL,PV Relador Pak (Kit) 1 Gum, 4mg Gum, 2mg Lozenge, Ropivacaine HCl/Sodium 1 4mg Lozenge) Chloride (0.1%-0.9% Injection) CVS Nicotine Transdermal 1 QL,PV Sensorcaine (Injection) 1 System (Patch 24 Hour) Sensorcaine-MPF (Injection) 1 CVS NTS Step 1 (Patch 24 1 QL,PV Hour) Sensorcaine-MPF Spinal 1 (Injection) EQ Nicotine (14mg/24hr Patch 1 QL,PV Sensorcaine-Mpf/Epinephrine 1 24 Hour, 21mg/24hr Patch 24 (0.5%-1:200000 Injection) Hour, 7mg/24hr Patch 24 Hour, 4mg Lozenge) Sensorcaine/Epinephrine 1 (Injection) EQ Nicotine Gum Refill (Gum) 1 QL,PV EQ Nicotine Gum Starter (Gum) 1 QL,PV Synera (Patch) 3 EQ Nicotine Polacrilex (2mg 1 QL,PV Xylocaine Dental (Injection) 1 Gum, 4mg Gum, 2mg Lozenge, Anti-Addiction/Substance Abuse Treatment 4mg Lozenge) Agents : Alcohol Deterrents/Anti-craving EQL Nicotine (Lozenge) 1 QL,PV Acamprosate Calcium DR 1 1 QL,PV (Tablet Delayed-Release) EQL Nicotine Polacrilex (2mg Gum, 4mg Gum, 2mg Lozenge, Disulfiram (Tablet) 1 4mg Lozenge) Naltrexone HCl (Tablet) 1 GNP Nicotine Mini Lozenge 1 QL,PV Vivitrol (Injection) 4 PA (Lozenge) Anti-Addiction/Substance Abuse Treatment GNP Nicotine Polacrilex (2mg 1 QL,PV Agents : Opioid Dependence Treatments Gum, 4mg Gum, 2mg Lozenge, Buprenorphine (Patch Weekly) 3 QL 4mg Lozenge) Buprenorphine HCl (0.3mg/ml 1 GNP Nicotine Transdermal 1 QL,PV Injection) System (Patch 24 Hour) Buprenorphine HCl (2mg Tablet 1 QL Goodsense Nicotine Gum (Gum) 1 QL,PV Sublingual, 8mg Tablet HM Nicotine Polacrilex (2mg 1 QL,PV Sublingual) Gum, 4mg Gum, 2mg Lozenge, Buprenorphine HCl/Naloxone 1 QL 4mg Lozenge) HCl (Tablet Sublingual) Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 14 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits HM Nicotine Transdermal 1 QL,PV SM Nicotine (2mg Lozenge, 4mg 1 QL,PV System (Patch 24 Hour) Gum) HM Nicotine Transdermal 1 QL,PV SM Nicotine Polacrilex (2mg 1 QL,PV System (Patch 24 Hour) Gum, 4mg Gum, 4mg Lozenge) KLS Quit2 (2mg Gum, 2mg 1 QL,PV SM Nicotine Transdermal 1 QL,PV Lozenge) System (Patch 24 Hour) KLS Quit4 (4mg Gum, 4mg 1 QL,PV SR Nicotine Gum (Gum) 1 QL,PV Lozenge) SW Nicotine Polacrilex (2mg 1 QL,PV NICOrelief (Gum) 1 QL,PV Gum, 4mg Gum, 2mg Lozenge, Nicotine (14mg/24hr Patch 24 1 QL,PV 4mg Lozenge) Hour, 21mg/24hr Patch 24 Hour, TGT Nicotine Gum (Gum) 1 QL,PV 7mg/24hr Patch 24 Hour, 2mg TGT Nicotine Polacrilex (2mg 1 QL,PV Gum, 2mg Lozenge, 4mg Gum, 4mg Gum, 2mg Lozenge, Lozenge) 4mg Lozenge) Nicotine Mini Lozenge (Lozenge) 1 QL,PV TGT Nicotine Step One (Patch 1 QL,PV Nicotine Polacrilex (2mg Gum, 1 QL,PV 24 Hour) 4mg Gum, 2mg Lozenge, 4mg TGT Nicotine Step Three (Patch 1 QL,PV Lozenge, 4mg Lozenge) 24 Hour) Nicotine Polacrilex Refill (Gum) 1 QL,PV TGT Nicotine Step Two (Patch 1 QL,PV Nicotine Polacrilex Starter Kit 1 QL,PV 24 Hour) (Gum) Thrive (Gum) 1 QL,PV Nicotine Step 1 (Patch 24 Hour) 1 QL,PV Antibacterials : Aminoglycosides Nicotine Step 2 (Patch 24 Hour) 1 QL,PV Amikacin Sulfate (1gm/4ml 1 Nicotine Step 3 (Patch 24 Hour) 1 QL,PV Injection, 500mg/2ml Injection) Nicotine Transdermal System 1 QL,PV Bethkis (Nebulized Solution) 4 (14mg/24hr Patch 24 Hour, Gentak (Ophthalmic Ointment) 1 21mg/24hr Patch 24 Hour, Gentamicin Sulfate (0.1% 1 7mg/24hr Patch 24 Hour) Cream, 0.1% Ointment, 0.3% Nicotine Transdermal System 3 QL,PV Ophthalmic Solution, 10mg/ml (Kit) Injection, 40mg/ml Injection) Nicotrol Inhaler (Inhaler) 3 QL,ST*,PV Gentamicin Sulfate/0.9% Sodium 1 Nicotrol NS (Nasal Solution) 3 QL,ST*,PV Chloride (0.8mg/ml-0.9% PX Stop Smoking Aid (2mg 1 QL,PV Injection, 1.2mg/ml-0.9% Gum, 4mg Gum, 2mg Lozenge, Injection, 1mg/ml-0.9% Injection) 2mg Lozenge, 4mg Lozenge) Isotonic Gentamicin (Injection) 1 QC Nicotine Polacrilex (Gum) 1 QL,PV Neomycin Sulfate (Tablet) 1 RA Nicotine (14mg/24hr Patch 1 QL,PV Paromomycin Sulfate (Capsule) 1 24 Hour, 21mg/24hr Patch 24 Streptomycin Sulfate (1gm 3 Hour, 2mg Gum, 4mg Gum, 4mg Injection) Gum) Tobradex (Ophthalmic 3 RA Nicotine Gum (Gum) 1 QL,PV Ointment) RA Nicotine Polacrilex (2mg 1 QL,PV Tobramycin (300mg/5ml 4 ST Gum, 2mg Lozenge, 4mg Nebulized Solution) Lozenge) Tobramycin Sulfate (0.3% 1 RA Nicotine Transdermal System 1 QL,PV Ophthalmic Solution, 1.2gm (Patch 24 Hour) Injection, 1.2gm/30ml Injection,

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 15 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits 10mg/ml Injection, 80mg/2ml Lotion, 250mg Tablet, 500mg Injection) Tablet, 375mg Capsule) Tobrex (0.3% Ophthalmic 3 Metronidazole in NaCl 0.79% 1 Ointment) (Injection) Antibacterials : Antibacterials, Other Metronidazole Vaginal (Gel) 1 Altabax (Ointment) 3 Microclens Wipes 3 BACiiM (Injection) 1 Monurol (Packet) 3 Bacitracin (50000unit Injection, 1 Mupirocin (2% Cream, 2% 1 500unit/gm Ophthalmic Ointment) Ointment) Neomycin/Polymyxin B Sulfates 1 Bactroban Nasal (Ointment) 3 (Irrigation Solution) Clindacin ETZ Pledgets (Swab) 1 Nitrofurantoin (Suspension) 1 Clindacin-P (Swab) 1 Nitrofurantoin Macrocrystals 1 Clindamycin HCl (150mg 1 (Capsule) Capsule, 300mg Capsule, 75mg Nitrofurantoin Monohydrate 1 Capsule Immediate-Release) (100mg Capsule) Clindamycin Palmitate HCl (Oral 1 Polymyxin B Sulfate (500000unit 1 Solution) Injection) Clindamycin Phosphate Add- 1 Primsol (Oral Solution) 3 Vantage (Injection) Rosadan (0.75% Cream, 0.75% 1 Clindamycin Phosphate (1% 1 Gel) External Solution, 1% Foam, 1% Sivextro (200mg Tablet) 3 QL Gel, 1% Lotion, 1% Swab, 2% Sulfamylon (85mg/gm Cream) 3 Cream, 300mg/2ml Injection, Tinidazole (Tablet) 1 600mg/4ml Injection, Trimethoprim (Tablet) 1 9000mg/60ml Injection, Uni-Solve Wipes 3 900mg/6ml Injection) Vancomycin (Injection) 1 Clindamycin Phosphate in D5W 1 (Injection) Vancomycin HCl (1000mg 1 Colistimethate Sodium (Injection) 1 Injection, 10gm Injection, 5000mg Injection, 750mg Daptomycin (Injection) 1 Injection, 1000mg Solution, Debacterol (Solution) 3 125mg Capsule, 250mg Doribax (500mg Injection) 3 Capsule) Doripenem (500mg Injection) 3 Vancomycin HCl/Dextrose (5%- 1 IV Prep Wipes 3 1.5gm/250ml Injection, 5%- Lincomycin HCl (Injection) 1 1gm/250ml Injection, 5%- Linezolid (100mg/5ml 1 QL 2gm/500ml Injection) Suspension, 600mg Tablet) Vancomycin HCl/Sodium 1 Linezolid (600mg/300ml 1 Chloride (0.9%-1.5gm/150ml Injection) Injection, 0.9%-1.5gm/250ml Methenamine Hippurate (Tablet) 1 Injection, 0.9%-1.5gm/500ml Methenamine Mandelate (0.5gm 1 Injection, 0.9%-1gm/150ml Injection, 0.9%-1gm/250ml Tablet) Injection) Metronidazole (0.75% Cream, 1 Vandazole (Gel) 1 0.75% Gel, 1% Gel, 0.75% Xifaxan (Tablet) 3 PA

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 16 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Zyvox (200mg/100ml Injection) 3 Suspension, 250mg Tablet, Antibacterials : Beta-lactam, Cephalosporins 500mg Tablet) Cedax (180mg/5ml 3 Ceftazidime (Injection) 1 Suspension, 400mg Capsule) Ceftin (Suspension) 3 Cefaclor (250mg Capsule 1 Ceftriaxone in Iso-Osmotic 1 Immediate-Release, 500mg Dextrose (Injection) Capsule Immediate-Release, Ceftriaxone Sodium (100gm 1 250mg/5ml Suspension, Injection, 1gm Injection, 250mg 375mg/5ml Suspension) Injection, 2gm Injection, 500mg Cefaclor ER (Tablet Extended- 1 Injection, 10gm Injection) Release 12 Hour) Cefuroxime Axetil (Tablet) 1 Cefadroxil (1gm Tablet, 1 Cefuroxime Sodium (Injection) 1 250mg/5ml Suspension, Cephalexin (125mg/5ml 1 500mg/5ml Suspension, 500mg Suspension, 250mg/5ml Capsule) Suspension, 250mg Capsule, Cefazolin Sodium (10gm 1 500mg Capsule, 750mg Injection, 1gm Injection, 20gm Capsule, 250mg Tablet, 500mg Injection, 500mg Injection) Tablet) Cefazolin Sodium/Sodium 1 Maxipime (2gm Injection) 3 Chloride (2gm/50ml-0.9% Tazicef (1gm Injection, 2gm 1 Injection) Injection, 6gm Injection) Cefazolin/D5W (Injection) 1 Antibacterials : Beta-lactam, Other Cefazolin/Dextrose (Injection) 1 Azactam in Iso-Osmotic 3 Cefazolin/Sodium Chloride 1 Dextrose (1gm-0 Injection) (2gm/100ml-0.9% Injection) Aztreonam (Injection) 1 Cefdinir (125mg/5ml Suspension, 1 Imipenem/Cilastatin (Injection) 1 250mg/5ml Suspension, 300mg Invanz (Injection) 3 Capsule) Meropenem (Injection) 1 Cefditoren Pivoxil (Tablet) 3 Meropenem/Sodium Chloride 1 Cefepime (1gm Injection, 2gm 1 (Injection) Injection) Antibacterials : Beta-lactam, Penicillins Cefixime (Suspension) 1 Amoxicillin (125mg Tablet 1 Cefotaxime Sodium (Injection) 1 Chewable, 250mg Tablet Cefotetan (10gm Injection) 3 Chewable, 125mg/5ml Cefotetan (1gm Injection, 2gm 1 Suspension, 200mg/5ml Injection) Suspension, 250mg/5ml Cefotetan/Dextrose (Injection) 3 Suspension, 400mg/5ml Cefoxitin Sodium (10gm 1 Suspension, 250mg Capsule, Injection, 1gm Injection, 2gm 500mg Capsule, 500mg Tablet, Injection) 875mg Tablet) Cefpodoxime Proxetil (100mg 1 Amoxicillin/Clavulanate 1 Tablet, 200mg Tablet, Potassium (Tablet Chewable, 100mg/5ml Suspension, Suspension, Tablet, Tablet 50mg/5ml Suspension) Immediate-Release) Cefprozil (125mg/5ml 1 Amoxicillin/Clavulanate 1 Potassium ER (Tablet Extended- Suspension, 250mg/5ml Release 12 Hour)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 17 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Ampicillin (Capsule) 1 250mg Capsule Delayed- Ampicillin Sodium (10gm 1 Release, 5mg/gm Ointment) Injection, 1gm Injection, 250mg Erythromycin Base (Tablet) 1 Injection, 2gm Injection, 500mg Erythromycin Ethylsuccinate 1 Injection) (200mg/5ml Suspension, 400mg Ampicillin-Sulbactam (10gm-5gm 1 Tablet) Injection, 1gm-0.5gm Injection, PCE (500mg Tablet Delayed- 3 2gm-1gm Injection) Release) Augmentin (125mg/5ml- 3 Zithromax (1gm Packet) 2 31.25mg/5ml Suspension) Antibacterials : Quinolones Bicillin L-A (Injection) 3 Avelox (0 Injection) 3 Dicloxacillin Sodium (Capsule) 1 Besivance (Suspension) 3 Moxatag (Tablet Extended- 3 Ciloxan (0.3% Ointment) 3 Release 24 Hour) Ciprofloxacin (250mg/5ml 1 Nafcillin (Injection) 1 Suspension, 500mg/5ml Nafcillin Sodium (10gm Injection, 1 Suspension) 1gm Injection, 2gm Injection) Ciprofloxacin ER (Tablet 1 Oxacillin Sodium (Injection) 1 Extended-Release 24 Hour) Penicillin G Potassium (Injection) 1 Ciprofloxacin HCl (0.3% 1 Penicillin V Potassium 1 Ophthalmic Solution, 100mg (125mg/5ml Oral Solution, Tablet, 250mg Tablet, 500mg 250mg/5ml Oral Solution, 250mg Tablet, 750mg Tablet) Tablet, 500mg Tablet) Ciprofloxacin I.V. in D5W 1 Piperacillin/Tazobactam (2gm- 1 (Injection) 0.25gm Injection, 36gm-4.5gm Factive (Tablet) 3 Injection, 3gm-0.375gm Injection, Gatifloxacin (Ophthalmic 1 4gm-0.5gm Injection) Solution) Antibacterials : Macrolides Levofloxacin (0.5% Ophthalmic 1 Azasite (Ophthalmic Solution) 3 Solution, 250mg Tablet, 500mg Azithromycin (100mg/5ml 1 Tablet, 750mg Tablet, 25mg/ml Suspension, 200mg/5ml Injection, 25mg/ml Oral Solution) Suspension, 250mg Tablet, Levofloxacin in D5W (Injection) 1 500mg Tablet, 600mg Tablet, Levofloxacin/Dextrose (Injection) 1 500mg Injection) Moxeza (Ophthalmic Solution) 2 Clarithromycin (125mg/5ml 1 Moxifloxacin HCl (0.5% Solution, 1 Suspension, 250mg/5ml 400mg Tablet, 400mg/250ml Suspension, 250mg Tablet, Injection) 500mg Tablet) Ofloxacin (0.3% Ophthalmic 1 Clarithromycin ER (Tablet 1 Solution, 0.3% Otic Solution, Extended-Release 24 Hour) 300mg Tablet, 400mg Tablet) Dificid (Tablet) 3 Antibacterials : Sulfonamides E.E.S. 400 (Tablet) 1 Silver Sulfadiazine (Cream) 1 Ery 1 Sodium Sulfacetamide 1 Ery-Tab (333mg Tablet 3 (Ophthalmic Solution) Delayed-Release) SSD (Cream) 1 Erythromycin (2% External 1 Solution, 2% Gel, 2% Pad,

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 18 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Sulfacetamide Sodium (10% 1 BRIVIACT (100mg Tablet, 3 Ophthalmic Solution) 10mg Tablet, 25mg Tablet, Sulfadiazine (500mg Tablet) 1 50mg Tablet, 75mg Tablet, Sulfamethoxazole/Trimethopri 1 10mg/ml Oral Solution) m (200mg/5ml-40mg/5ml Fycompa (0.5mg/ml 3 Suspension, 400mg-80mg Suspension, 10mg Tablet, Tablet) 12mg Tablet, 2mg Tablet, 4mg Sulfamethoxazole/Trimethoprim 1 Tablet, 6mg Tablet, 8mg DS (Tablet) Tablet) Sulfatrim Pediatric (Suspension) 1 Levetiracetam (1000mg Tablet, 1 Antibacterials : Tetracyclines 250mg Tablet, 500mg Tablet, 750mg Tablet, 1000mg/100ml- Avidoxy (Tablet) 1 750mg/100ml Injection, Demeclocycline HCl (150mg 1 1500mg/100ml-540mg/100ml Tablet, 300mg Tablet) Injection, 500mg/100ml- Doxy 100 (Injection) 1 820mg/100ml Injection, Doxycycline (25mg/5ml 1 500mg/5ml Injection, 100mg/ml Suspension, 40mg Capsule Oral Solution, 500mg/5ml Oral Delayed-Release) Solution) Doxycycline Hyclate (100mg 1 Levetiracetam ER (Tablet 1 Capsule, 50mg Capsule, 100mg Extended-Release 24 Hour) Injection, 100mg Tablet, 20mg Roweepra (Tablet) 1 Tablet, 150mg Tablet, 75mg Anticonvulsants : Calcium Channel Modifying Tablet) Agents Doxycycline Hyclate DR (Tablet 1 Celontin (Capsule) 3 Delayed-Release) Ethosuximide (250mg Capsule, 1 Doxycycline Monohydrate 1 250mg/5ml Oral Solution) (100mg Capsule, 150mg Zonisamide (Capsule) 1 Capsule, 50mg Capsule, 75mg Capsule, 100mg Tablet, 150mg Anticonvulsants : Gamma-aminobutyric Acid Tablet, 50mg Tablet, 75mg (GABA) Augmenting Agents Tablet) Divalproex Sodium (Capsule 1 Minocycline HCl (100mg 1 Sprinkle Delayed-Release) Capsule, 50mg Capsule, 75mg Divalproex Sodium DR (Tablet 1 Capsule, 100mg Tablet, 50mg Delayed-Release) Tablet, 75mg Tablet) Divalproex Sodium ER (Tablet 1 Minocycline HCl ER (Tablet 1 Extended-Release 24 Hour) Extended-Release 24 Hour) Gabapentin (100mg Capsule, 1 Mondoxyne NL (Capsule) 1 300mg Capsule, 400mg Morgidox 1x100mg (100mg 1 Capsule, 250mg/5ml Oral Capsule) Solution, 300mg/6ml Oral Solution, 600mg Tablet, 800mg Morgidox 1x50mg (Capsule) 1 Tablet) Morgidox 2x100mg (100mg 1 Gabitril (12mg Tablet, 16mg 3 Capsule) Tablet) Oracea (Capsule Delayed- 3 Gralise (Tablet) 3 QL,ST Release) Gralise Starter Pack 3 QL,ST Tetracycline HCl (Capsule) 1

Anticonvulsants : Anticonvulsants, Other

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 19 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Onfi (10mg Tablet, 20mg 3 PA Carbamazepine (100mg Tablet 1 Tablet, 2.5mg/ml Suspension) Chewable, 100mg/5ml Pentobarbital Sodium (50mg/ml 1 Suspension, 200mg Tablet) Injection) Carbamazepine ER (Capsule 1 Phenobarbital (100mg Tablet, 1 Extended-Release 12 Hour, 15mg Tablet, 16.2mg Tablet, Tablet Extended-Release 12 30mg Tablet, 32.4mg Tablet, Hour) 60mg Tablet, 64.8mg Tablet, Dilantin (30mg Capsule) 3 97.2mg Tablet, 20mg/5ml Elixir, Epitol (Tablet) 1 20mg/5ml Oral Solution) Fosphenytoin Sodium (Injection) 1 Primidone (Tablet) 1 Oxcarbazepine (150mg Tablet, 1 Sabril (500mg Packet) 4 PA 300mg Tablet, 600mg Tablet, Tiagabine HCl (Tablet) 1 60mg/ml Suspension) Valproate Sodium (100mg/ml 1 Peganone (Tablet) 3 Injection) Phenytoin (125mg/5ml 1 Valproic Acid (250mg Capsule, 1 Suspension, 50mg Tablet 250mg/5ml Oral Solution) Chewable) Anticonvulsants : Glutamate Reducing Phenytoin Sodium (50mg/ml 1 Agents Injection) Felbamate (400mg Tablet, 1 Phenytoin Sodium Extended 1 600mg Tablet, 600mg/5ml (Capsule) Suspension) Vimpat (100mg Tablet, 150mg 3 Lamotrigine (100mg Tablet 1 Tablet, 200mg Tablet, 50mg Immediate-Release, 25mg Tablet Tablet, 10mg/ml Oral Solution) Immediate-Release, 150mg Antidementia Agents : Cholinesterase Tablet, 200mg Tablet, 25mg Inhibitors Tablet Chewable, 5mg Tablet Donepezil HCl (10mg Tablet 1 Chewable) Dispersible, 5mg Tablet Lamotrigine ER (Tablet 1 Dispersible, 10mg Tablet, 23mg Extended-Release 24 Hour) Tablet, 5mg Tablet) Lamotrigine ODT (Tablet 1 Galantamine HBr (12mg Tablet, 1 Dispersible) 4mg Tablet, 8mg Tablet, 4mg/ml Lamotrigine Titration (Kit) 1 Oral Solution) Topiramate (100mg Tablet, 1 Galantamine HBr ER (Capsule 1 200mg Tablet, 25mg Tablet, Extended-Release 24 Hour) 50mg Tablet, 15mg Capsule Rivastigmine Tartrate (Capsule 1 Sprinkle, 25mg Capsule Immediate-Release) Sprinkle) Rivastigmine Transdermal 1 Topiramate ER (Capsule 3 System (Patch 24 Hour) Extended-Release 24 Hour Antidementia Agents : N-methyl-D-aspartate Sprinkle) (NMDA) Receptor Antagonist Anticonvulsants : Sodium Channel Agents Memantine HCl (10mg Tablet, 1 Aptiom (Tablet) 3 5mg Tablet, 2mg/ml Oral Banzel (200mg Tablet, 400mg 3 Solution) Tablet, 40mg/ml Suspension) Memantine HCl Titration Pak 1 (Tablet)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 20 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Namenda XR (Capsule 2 QL Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) Extended-Release 24 Hour) Namenda XR Titration Pack 2 QL Escitalopram Oxalate (10mg 1 (Capsule Extended-Release 24 Tablet, 20mg Tablet, 5mg Tablet, Hour) 5mg/5ml Oral Solution) Antidepressants : Antidepressants, Other Fetzima (Capsule Extended- 3 QL,ST Aplenzin (Tablet Extended- 3 QL,ST Release 24 Hour) Release 24 Hour) Fluoxetine (Capsule) 1 Bupropion HCl (Tablet) 1 Fluoxetine DR (Capsule 1 QL Bupropion HCl ER (Tablet 1 QL Delayed-Release) Extended-Release 12 Hour) Fluoxetine HCl (10mg Tablet, 1 Bupropion HCl SR (100mg 1 QL 20mg Tablet, 60mg Tablet, Tablet Extended-Release 12 20mg/5ml Oral Solution, 40mg Hour, 150mg Tablet Extended- Capsule) Release 12 Hour, 200mg Tablet Fluvoxamine Maleate (Tablet) 1 Extended-Release 12 Hour) Fluvoxamine Maleate ER 1 QL Bupropion HCl XL (Tablet 1 QL (Capsule Extended-Release 24 Extended-Release 24 Hour) Hour) Chlordiazepoxide/Amitriptyline 1 Maprotiline HCl (Tablet) 1 (Tablet) Nefazodone HCl (Tablet) 1 Mirtazapine (Tablet) 1 Paroxetine HCl (Tablet) 1 Mirtazapine ODT (Tablet 1 Paroxetine HCl ER (Tablet 1 Dispersible) Extended-Release 24 Hour) Olanzapine/Fluoxetine (25mg- 1 Paxil (10mg/5ml Suspension) 2 12mg Capsule, 50mg-12mg Sertraline HCl (100mg Tablet, 1 Capsule, 50mg-6mg Capsule) 25mg Tablet, 50mg Tablet, Olanzapine/Fluoxetine (25mg- 1 QL 20mg/ml Concentrate) 3mg Capsule, 25mg-6mg Trazodone HCl (Tablet) 1 Capsule) Trintellix (Tablet) 3 QL,ST Perphenazine/Amitriptyline 1 Venlafaxine HCl (Tablet 1 (10mg-2mg Tablet, 25mg-2mg Immediate-Release) Tablet, 25mg-4mg Tablet) Venlafaxine HCl ER (Capsule 1 Antidepressants : Monoamine Oxidase Extended-Release 24 Hour, Inhibitors Tablet Extended-Release 24 Emsam (Patch 24 Hour) 3 QL Hour) Marplan (Tablet) 3 Viibryd (Tablet) 3 QL,ST Phenelzine Sulfate (Tablet) 1 Viibryd Starter Pack (Kit) 3 QL,ST Tranylcypromine Sulfate (Tablet) 1 Antidepressants : Tricyclics Antidepressants : SSRIs/SNRIs (Selective Amitriptyline HCl (100mg Tablet, 1 Serotonin Reuptake Inhibitors/Serotonin and 10mg Tablet, 150mg Tablet, Norepinephrine Reuptake Inhibitors) 25mg Tablet, 50mg Tablet, 75mg Citalopram HBr (10mg Tablet, 1 Tablet) 20mg Tablet, 40mg Tablet, Amoxapine (Tablet) 1 10mg/5ml Oral Solution) Clomipramine HCl (Capsule) 1 Desvenlafaxine ER (100mg 3 QL Desipramine HCl (100mg Tablet, 1 Tablet Extended-Release 24 10mg Tablet, 150mg Tablet, Hour, 25mg Tablet Extended-

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 21 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits 25mg Tablet, 50mg Tablet, 75mg Dronabinol (Capsule) 1 PA,QL Tablet) Granisetron HCl (0.1mg/ml 1 Doxepin HCl (100mg Capsule, 1 Injection, 1mg/ml Injection, 10mg Capsule, 150mg Capsule, 4mg/4ml Injection) 25mg Capsule, 50mg Capsule, Granisetron HCl (1mg Tablet) 1 QL 75mg Capsule, 10mg/ml Ondansetron HCl (24mg Tablet, 1 Concentrate) 4mg Tablet, 8mg Tablet, Imipramine HCl (10mg Tablet, 1 4mg/2ml Injection) 25mg Tablet, 50mg Tablet) Ondansetron HCl (40mg/20ml 1 QL Imipramine Pamoate (Capsule) 1 Injection, 4mg/5ml Oral Solution) Nortriptyline HCl (10mg Capsule, 1 Ondansetron HCl/Sodium 1 25mg Capsule, 50mg Capsule, Chloride (Injection) 75mg Capsule, 10mg/5ml Oral Ondansetron ODT (Tablet 1 QL Solution) Dispersible) Protriptyline HCl (Tablet) 1 Sancuso (Patch) 3 QL Trimipramine Maleate (100mg 1 Varubi (Tablet) 3 QL Capsule, 25mg Capsule, 50mg Antifungals Capsule) Abelcet (Injection) 3 Antiemetics : Antiemetics, Other AmBisome (Injection) 3 Akynzeo (Capsule) 3 QL Amphotericin B (50mg 3 Compro (Suppository) 1 Injection) Droperidol (2.5mg/ml Injection) 1 Bio-Statin (Powder) 1 Meclizine HCl (12.5mg Tablet, 1 Ciclodan (0.77% Cream, 8% 1 25mg Tablet) External Solution) Metoclopramide HCl (10mg 1 Ciclopirox (0.77% Gel, 0.77% 1 Tablet, 5mg Tablet, 10mg/10ml Suspension, 1% Shampoo) Oral Solution, 5mg/5ml Oral Ciclopirox Nail Lacquer (External 1 Solution, 5mg/ml Injection) Solution) Metoclopramide ODT (5mg 1 Ciclopirox Olamine (0.77% 1 Tablet Dispersible) Cream) Perphenazine (16mg Tablet, 1 Clotrimazole (1% Cream, 1% 1 4mg Tablet, 2mg Tablet, 8mg External Solution, 10mg Tablet) Lozenge, 10mg Troche) Prochlorperazine (Suppository) 1 Cresemba (186mg Capsule, 3 Prochlorperazine Edisylate 1 372mg Injection) (Injection) Econazole Nitrate (1% Cream) 1 Prochlorperazine Maleate 1 Eraxis (50mg Injection) 3 (Tablet) Ertaczo (Cream) 3 Transderm-Scop (Patch 72 3 Hour) Exelderm (1% Cream, 1% 3 External Solution) Trimethobenzamide HCl 1 (Capsule) Fluconazole (100mg Tablet, 1 150mg Tablet, 200mg Tablet, Antiemetics : Emetogenic Therapy Adjuncts 50mg Tablet, 10mg/ml Aloxi (Injection) 2 Suspension, 40mg/ml Anzemet (Tablet) 3 QL Suspension) Aprepitant (Capsule) 1 QL Cesamet (Capsule) 3 PA,QL Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 22 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Fluconazole in Dextrose 1 Voriconazole (200mg Injection, 1 (Injection) 200mg Tablet, 50mg Tablet, Fluconazole in NaCl 1 40mg/ml Suspension) (200mg/100ml-0.9% Injection, Xolegel (Gel) 3 400mg/200ml-0.9% Injection) Antigout Agents Flucytosine (Capsule) 1 Allopurinol (Tablet) 1 Griseofulvin Microsize 1 Allopurinol Sodium (Injection) 1 (125mg/5ml Suspension, 500mg Colchicine (0.6mg Tablet) 3 Tablet) (Generic Colcrys) Griseofulvin Ultramicrosize 1 Colcrys (Tablet) 2 (Tablet) Probenecid (Tablet) 1 Gynazole-1 (Cream) 3 Probenecid/Colchicine (Tablet) 1 Itraconazole (Capsule) 1 PA Uloric (Tablet) 2 ST Jublia (External Solution) 3 PA Zurampic (Tablet) 3 ST Kerydin (External Solution) 3 PA Antimigraine Agents : Ergot Alkaloids Ketoconazole (2% Cream, 2% 1 Dihydroergotamine Mesylate 1 Foam, 2% Shampoo, 200mg (1mg/ml Injection) Tablet) Dihydroergotamine Mesylate 1 QL Ketodan (Foam) 1 (4mg/ml Nasal Solution) Mentax (Cream) 3 Ergotamine Tartrate/Caffeine 1 Miconazole 3 (Suppository) 1 (Tablet) Mycamine (Injection) 3 Antimigraine Agents : Serotonin (5-HT) 1b/1d Naftifine HCl (Cream) 1 Receptor Agonists Natacyn (Suspension) 2 Almotriptan Malate (Tablet) 1 QL Noxafil (100mg Tablet Delayed- 3 Frovatriptan Succinate (Tablet) 1 QL Release) Naratriptan HCl (Tablet) 1 QL Nyamyc (Powder) 1 Relpax (Tablet) 3 QL Nyata (Powder) 1 Rizatriptan Benzoate (Tablet) 1 QL Nystatin (100000unit/gm Cream, 1 Rizatriptan Benzoate ODT 1 QL 100000unit/gm Ointment, (Tablet Dispersible) 100000unit/gm Powder, Sumatriptan (Nasal Solution) 1 QL 100000unit/ml Suspension, Sumatriptan Succinate (100mg 1 QL 500000unit Tablet) Tablet, 25mg Tablet, 50mg 1 Nystatin/Triamcinolone Tablet, 4mg/0.5ml Injection, (100000unit/gm-0.1% Ointment, 6mg/0.5ml Injection) 100000unit/gm-1mg/gm Cream) Zolmitriptan (Tablet) 1 QL Nystop (Powder) 1 Zolmitriptan ODT (Tablet 1 QL Oravig (Tablet) 3 Dispersible) Oxiconazole Nitrate (Cream) 1 Zomig (2.5mg Nasal Solution, 3 QL Oxistat (1% Lotion) 3 5mg Nasal Solution) Soliris (Injection) 4 PA Antimyasthenic Agents : Terbinafine HCl (Tablet) 1 QL Parasympathomimetics Terconazole (0.4% Cream, 0.8% 1 Guanidine HCl (Tablet) 1 Cream, 80mg Suppository) Mestinon (60mg/5ml Syrup) 2

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 23 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Neostigmine Methylsulfate 1 Melphalan (Tablet) 1 (10mg/10ml Injection, 5mg/10ml Melphalan HCl (Injection) 4 Injection) Mustargen (Injection) 4 Pyridostigmine Bromide (Tablet) 1 Myleran (Tablet) 4 Pyridostigmine Bromide ER 1 Temodar (100mg Injection) 4 (Tablet Extended-Release) Temozolomide (Capsule) 4 PA Antimycobacterials : Antimycobacterials, Treanda (Injection) 4 Other Zanosar (Injection) 4 Dapsone (Tablet) 1 Antineoplastics : Antiandrogens Rifabutin (Capsule) 1 Bicalutamide (Tablet) 1 Antimycobacterials : Antituberculars Flutamide (Capsule) 1 Capastat Sulfate (Injection) 3 Nilutamide (Tablet) 4 Cycloserine (Capsule) 3 Xtandi (Capsule) 4 PA Ethambutol HCl (100mg Tablet, 1 Zytiga (Tablet) 4 PA 400mg Tablet) Antineoplastics : Antiangiogenic Agents Isoniazid (100mg Tablet, 300mg 1 Pomalyst (Capsule) 4 PA Tablet, 50mg/5ml Syrup) Revlimid (Capsule) 4 PA Paser (Packet) 3 Thalomid (Capsule) 4 PA Priftin (Tablet) 3 Antineoplastics : Antiestrogens/Modifiers Pyrazinamide (Tablet) 1 Emcyt (Capsule) 2 Rifampin (150mg Capsule, 1 300mg Capsule, 600mg Fareston (Tablet) 2 Injection) Faslodex (Injection) 4 Rifater (Tablet) 3 Soltamox (Oral Solution) 3 Sirturo (Tablet) 3 Tamoxifen Citrate (Tablet) 1 PV* Trecator (Tablet) 3 Antineoplastics : Antimetabolites Antineoplastics : Alkylating Agents Adrucil (Injection) 4 BiCNU (Injection) 4 Alimta (Injection) 4 Busulfan (Injection) 4 Capecitabine (Tablet) 4 PA Cyclophosphamide (1gm 1 Cladribine (Injection) 4 Injection, 2gm Injection, 500mg Clofarabine (Injection) 4 Injection) Clolar (Injection) 4 Cyclophosphamide (25mg 3 Cytarabine Aqueous (Injection) 4 Capsule, 50mg Capsule) Depocyt (Injection) 4 Dacarbazine (100mg Injection) 4 Droxia (Capsule) 3 Dacarbazine (200mg Injection) 4 Elitek (Injection) 3 Gleostine (Capsule) 4 Floxuridine (Injection) 4 Hexalen (Capsule) 4 Fluorouracil (1gm/20ml Injection, 4 Ifex (3gm Injection) 4 2.5gm/50ml Injection, Ifosfamide (1gm Injection, 4 500mg/10ml Injection, 1gm/20ml Injection, 3gm/60ml 5gm/100ml Injection) Injection) Folotyn (Injection) 4 PA Ifosfamide (3gm Injection) 4 Gemcitabine (Injection) 4 Leukeran (Tablet) 4 Hydroxyurea (Capsule) 1 Matulane (Capsule) 4 Lonsurf (Tablet) 4 PA,QL

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 24 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Mercaptopurine (Tablet) 4 Leucovorin Calcium (100mg 1 Nipent (Injection) 4 Injection, 200mg Injection, Tabloid (Tablet) 4 350mg Injection, 50mg Injection, Antineoplastics : Antineoplastics, Other 10mg Tablet, 15mg Tablet, 25mg Tablet, 5mg Tablet) Abraxane (Injection) 4 Levoleucovorin (175mg 4 Adriamycin (Injection) 4 Injection, 250mg/25ml Arranon (Injection) 4 Injection) Azacitidine (Injection) 4 Levoleucovorin (175mg/17.5ml 4 Bleomycin Sulfate (Injection) 4 Injection, 50mg Injection) Camptosar (300mg/15ml 4 Lipodox 50 (Injection) 4 Injection) Marqibo (Injection) 4 Carboplatin (Injection) 4 Mesna (Injection) 4 Cisplatin (100mg/100ml Injection, 4 Mesnex (400mg Tablet) 4 50mg/50ml Injection) Mitomycin (20mg Injection, 40mg 4 Cisplatin (200mg/200ml 4 Injection) Injection) Mitomycin (5mg Injection) 4 Daunorubicin HCl (Injection) 4 Mitoxantrone HCl (Injection) 4 PA Decitabine (Injection) 4 PA Ninlaro (Capsule) 4 PA,QL Dexrazoxane (Injection) 4 Oncaspar (Injection) 4 Docetaxel (160mg/16ml 4 Onivyde (Injection) 4 Injection, 160mg/8ml Injection, 200mg/10ml Injection, Oxaliplatin (IV Solution 4 20mg/0.5ml Injection, 100mg/20ml) 20mg/2ml Injection, 80mg/2ml Paclitaxel (100mg/16.7ml 4 Injection, 80mg/8ml Injection) Injection, 300mg/50ml Injection, 30mg/5ml Injection) Docetaxel (20mg/ml Injection, 4 80mg/4ml Injection) Paclitaxel (150mg/25ml 4 Injection) Docetaxel (Non-Alcohol 4 Formula) (Injection) Proleukin (Injection) 4 Doxorubicin HCl (Injection) 4 Synribo (Injection) 4 PA Epirubicin HCl (Injection) 4 Teniposide (Injection) 4 Erwinaze (Injection) 4 Tepadina (Injection) 4 Ethyol (Injection) 4 Thiotepa (Injection) 4 Farydak (Capsule) 4 PA,QL Trisenox (Injection) 4 Fludarabine Phosphate 4 Velcade (Injection) 4 PA (Injection) Venclexta (Tablet) 4 PA Halaven (Injection) 4 PA Venclexta Starting Pack 4 PA Idarubicin HCl (Injection) 4 (Tablet Therapy Pack) Irinotecan (40mg/2ml Injection) 4 Vinblastine Sulfate (Injection) 4 Irinotecan (500mg/25ml 4 Vincasar PFS (Injection) 4 Injection) Vincristine Sulfate (Injection) 4 Irinotecan HCl (Injection) 4 Vinorelbine Tartrate (Injection) 4 Istodax (Overfill) (Injection) 4 PA Zaltrap (Injection) 4 PA Ixempra Kit (Injection) 4 Zolinza (Capsule) 4 PA Zykadia (Capsule) 4 PA Jevtana (Injection) 4 PA

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 25 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Antineoplastics : Aromatase Inhibitors, 3rd Nexavar (Tablet) 4 PA Generation Sprycel (Tablet) 4 PA Anastrozole (Tablet) 1 Stivarga (Tablet) 4 PA Exemestane (Tablet) 1 Sutent (Capsule) 4 PA Letrozole (Tablet) 1 Tafinlar (Capsule) 4 PA Antineoplastics : Enzyme Inhibitors Tarceva (Tablet) 4 PA,QL Etoposide (100mg/5ml Injection, 4 Tasigna (Capsule) 4 PA 1gm/50ml Injection, 500mg/25ml Tykerb (Tablet) 4 PA Injection) Votrient (Tablet) 4 PA Etoposide (50mg Capsule) 4 Xalkori (Capsule) 4 PA Hycamtin (0.25mg Capsule, 4 Zelboraf (Tablet) 4 PA 1mg Capsule) Antineoplastics : Monoclonal Kyprolis (Injection) 4 PA Antibody/Antibody-Drug Conjugate Lynparza (Capsule) 4 PA Adcetris (Injection) 4 PA Rubraca (Tablet) 4 PA,QL Arzerra (Injection) 4 PA Toposar (Injection) 4 Avastin (Injection) 4 Topotecan HCl (4mg Injection) 4 Bavencio (Injection) 4 PA Topotecan HCl (4mg/4ml 4 Blincyto (Injection) 4 PA Injection) Darzalex (Injection) 4 PA Zydelig (Tablet) 4 PA Empliciti (Injection) 4 PA Antineoplastics : Molecular Target Inhibitors Erbitux (Injection) 4 PA Afinitor (Tablet) 4 PA,QL Gazyva (Injection) 4 PA Afinitor Disperz (Tablet 4 PA Herceptin (Injection) 4 PA Soluble) Kadcyla (Injection) 4 PA Bosulif (Tablet) 4 PA Lartruvo (Injection) 4 PA Cabometyx (Tablet) 4 PA Opdivo (Injection) 4 PA Caprelsa (100mg Tablet) 4 PA,QL Perjeta (Injection) 4 PA Caprelsa (300mg Tablet) 4 PA Rituxan (Injection) 4 PA Cometriq (Kit) 4 PA Tagrisso (Tablet) 4 PA,QL Cotellic (Tablet) 4 PA,QL Tecentriq (Injection) 4 PA Erivedge (Capsule) 4 PA Unituxin (Injection) 4 Gilotrif (Tablet) 4 PA,QL Yervoy (Injection) 4 PA Ibrance (Capsule) 4 PA Iclusig (15mg Tablet) 4 PA,QL Antineoplastics : Retinoids Bexarotene (Capsule) 4 PA Iclusig (45mg Tablet) 4 PA Panretin (Gel) 3 Imatinib Mesylate (Tablet) 4 PA Targretin (1% Gel) 3 PA Imbruvica (Capsule) 4 PA Tretinoin (10mg Capsule) 4 Inlyta (Tablet) 4 PA Jakafi (10mg Tablet) 4 PA,QL Antiparasitics : Anthelmintics Albenza (Tablet) 3 Jakafi (15mg Tablet, 20mg 4 PA Tablet, 25mg Tablet, 5mg Biltricide (Tablet) 2 Tablet) Ivermectin (Tablet) 1 Lenvima (Capsule Therapy 4 PA Sklice (Lotion) 3 Pack) Antiparasitics : Antiprotozoals Mekinist (Tablet) 4 PA

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 26 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Alinia (100mg/5ml Suspension, 2 Pramipexole Dihydrochloride ER 1 500mg Tablet) (Tablet Extended-Release 24 Atovaquone (Suspension) 1 Hour) Atovaquone/Proguanil HCl 1 Ropinirole ER (Tablet Extended- 1 (Tablet) Release 24 Hour) Chloroquine Phosphate (250mg 1 Ropinirole HCl (Tablet) 1 Tablet, 500mg Tablet) Antiparkinson Agents : Dopamine Coartem (Tablet) 3 Precursors/L-Amino Acid Decarboxylase DARAPRIM (Tablet) 4 PA Inhibitors Hydroxychloroquine Sulfate 1 Carbidopa (Tablet) 1 (Tablet) Carbidopa/Levodopa (10mg- 1 Impavido (Capsule) 3 100mg Tablet Immediate- Mefloquine HCl (Tablet) 1 Release, 25mg-100mg Tablet, 25mg-250mg Tablet) Nebupent (Inhalation Solution) 2 Carbidopa/Levodopa ER (Tablet 1 Primaquine Phosphate (Tablet) 1 Extended-Release) Quinine Sulfate (324mg Capsule) 1 PA Carbidopa/Levodopa/Entacapon 1 Antiparasitics : Pediculicides/Scabicides e (Tablet) Eurax (10% Cream, 10% 2 Lotion) Antiparkinson Agents : Monoamine Oxidase Lindane (Shampoo) 1 B (MAO-B) Inhibitors Rasagiline Mesylate (Tablet) 1 Malathion (Lotion) 1 Selegiline HCl (5mg Capsule, 1 Permethrin (Cream) 1 5mg Tablet) Spinosad (Suspension) 3 Antipsychotics : 1st Generation/Typical Ulesfia (Lotion) 3 Chlorpromazine HCl (100mg 1 Antiparkinson Agents : Anticholinergics Tablet, 10mg Tablet, 200mg Benztropine Mesylate (0.5mg 1 Tablet, 25mg Tablet, 50mg Tablet, 1mg Tablet, 2mg Tablet, Tablet) 1mg/ml Injection) Fluphenazine Decanoate 1 Trihexyphenidyl HCl (0.4mg/ml 1 (Injection) Elixir, 2mg Tablet, 5mg Tablet) Fluphenazine HCl (10mg Tablet, 1 Antiparkinson Agents : Antiparkinson 1mg Tablet, 2.5mg Tablet, 5mg Agents, Other Tablet) Amantadine HCl (100mg 1 Haloperidol (0.5mg Tablet, 10mg 1 Capsule, 100mg Tablet, Tablet, 1mg Tablet, 20mg Tablet, 50mg/5ml Syrup) 2mg Tablet, 5mg Tablet, 2mg/ml Entacapone (Tablet) 1 Concentrate) Tolcapone (Tablet) 1 Haloperidol Decanoate 1 Antiparkinson Agents : Dopamine Agonists (Injection) Apokyn (Injection) 4 PA,QL Haloperidol Lactate (Injection) 1 Bromocriptine Mesylate (2.5mg 1 Loxapine Succinate (Capsule) 1 Tablet, 5mg Capsule) Pimozide (Tablet) 1 Neupro (Patch 24 Hour) 3 Thioridazine HCl (Tablet) 1 Pramipexole Dihydrochloride 1 Thiothixene (Capsule) 1 (Tablet) Trifluoperazine HCl (Tablet) 1 Antipsychotics : 2nd Generation/Atypical

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 27 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Abilify Maintena (Injection) 3 Antivirals : Anti-cytomegalovirus (CMV) Aripiprazole (10mg Tablet, 15mg 1 QL Agents Tablet, 20mg Tablet, 2mg Tablet, Cidofovir (Injection) 1 30mg Tablet, 5mg Tablet, Ganciclovir (Injection) 1 1mg/ml Oral Solution) Valganciclovir (Tablet) 1 Aripiprazole ODT (Tablet 1 QL Valganciclovir Hydrochlorde 1 Dispersible) (Oral Solution) Clozapine ODT (100mg Tablet 1 QL Zirgan (Gel) 3 Dispersible, 12.5mg Tablet Antivirals : Anti-hepatitis B (HBV) Agents Dispersible, 25mg Tablet Adefovir Dipivoxil (Tablet) 4 Dispersible) Baraclude (0.05mg/ml Oral 4 QL Fanapt (Tablet) 3 QL,ST Solution) Fanapt Titration Pack (Tablet) 3 QL,ST Entecavir (Tablet) 4 QL Fazaclo (12.5mg Tablet 3 QL Epivir HBV (5mg/ml Oral 4 Dispersible, 150mg Tablet Solution) Dispersible, 200mg Tablet Dispersible) Lamivudine (100mg Tablet) 4 Geodon (20mg Solution) 3 Antivirals : Anti-hepatitis C (HCV) Agents, Invega Sustenna (Injection) 3 Direct Acting Agents Alferon N (Injection) 4 Invega Trinza (Injection) 3 Daklinza (Tablet) 4 PA,QL Latuda (Tablet) 3 QL,ST Epclusa (Tablet) 4 PA,QL Olanzapine (10mg Injection) 1 Harvoni (Tablet) 4 PA,QL Olanzapine (10mg Tablet, 15mg 1 QL Tablet, 2.5mg Tablet, 20mg Intron A (Injection) 4 PA Tablet, 5mg Tablet, 7.5mg Intron A w/Diluent (Injection) 4 PA Tablet) Moderiba (200mg Tablet) 4 Olanzapine ODT (Tablet 1 QL Moderiba 1200 Dose Pack 4 Dispersible) (Tablet) Paliperidone ER (Tablet 1 QL Moderiba 800 Dose Pack 4 Extended-Release 24 Hour) (Tablet) Quetiapine Fumarate (Tablet) 1 QL Olysio (Capsule) 4 PA,QL Quetiapine Fumarate ER (Tablet 1 QL Pegasys (Injection) 4 PA Extended-Release 24 Hour) Pegasys ProClick (Injection) 4 PA Rexulti (Tablet) 3 QL PegIntron (Injection) 4 PA Risperdal Consta (Injection) 3 Rebetol (40mg/ml Oral 4 Risperidone (0.25mg Tablet, 1 QL Solution) 0.5mg Tablet, 1mg Tablet, 2mg Ribasphere (200mg Capsule, 4 Tablet, 3mg Tablet, 4mg Tablet, 200mg Tablet) 1mg/ml Oral Solution) Ribasphere (400mg Tablet, 4 Risperidone ODT (Tablet 1 QL 600mg Tablet) Dispersible) Ribasphere Ribapak (Tablet) 4 Saphris (Tablet Sublingual) 2 QL Ribavirin (200mg Capsule, 4 Ziprasidone HCl (Capsule) 1 QL 200mg Tablet) Zyprexa Relprevv (Injection) 3 Sovaldi (Tablet) 4 PA,QL Antipsychotics : Treatment-Resistant Sylatron (Injection) 4 PA Clozapine (Tablet) 1 QL Technivie (Tablet) 4 PA,QL

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 28 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Viekira Pak (Tablet Therapy 4 PA,QL Stavudine (Capsule) 1 Pack) Triumeq (Tablet) 2 Zepatier (Tablet) 4 PA,QL Truvada (Tablet) 2 Antivirals : Anti-HIV Agents, Integrase Tybost (Tablet) 2 Inhibitors (INSTI) Videx Pediatric (Oral Solution) 2 Evotaz (Tablet) 2 Viread (150mg Tablet, 200mg 2 Isentress (100mg Packet, 2 Tablet, 250mg Tablet, 300mg 100mg Tablet Chewable, 25mg Tablet, 40mg/gm Powder) Tablet Chewable, 400mg Zerit (1mg/ml Oral Solution) 2 Tablet) Ziagen (20mg/ml Oral Solution) 2 Isentress HD (Tablet) 2 Zidovudine (100mg Capsule, 1 Prezcobix (Tablet) 2 300mg Tablet, 50mg/5ml Syrup) Stribild (Tablet) 2 Antivirals : Anti-HIV Agents, Other Tivicay (Tablet) 2 Fuzeon (Injection) 2 QL Antivirals : Anti-HIV Agents, Non-nucleoside Selzentry (150mg Tablet, 25mg 2 PA Reverse Transcriptase Inhibitors (NNRTI) Tablet, 300mg Tablet, 75mg Atripla (Tablet) 2 Tablet) Complera (Tablet) 2 Antivirals : Anti-HIV Agents, Protease Edurant (Tablet) 2 Inhibitors Intelence (Tablet) 2 Aptivus (100mg/ml Oral 2 Nevirapine (Tablet) 1 Solution, 250mg Capsule) Nevirapine ER (Tablet Extended- 1 Crixivan (Capsule) 2 Release 24 Hour) Invirase (200mg Capsule, 2 Odefsey (Tablet) 2 500mg Tablet) Rescriptor (Tablet) 2 Kaletra (100mg-25mg Tablet, 2 200mg-50mg Tablet) Sustiva (200mg Capsule, 50mg 2 Capsule, 600mg Tablet) Lexiva (50mg/ml Suspension, 2 700mg Tablet) Viramune (50mg/5ml 2 Suspension) Lopinavir/Ritonavir (Oral 1 Antivirals : Anti-HIV Agents, Nucleoside and Solution) Nucleotide Reverse Transcriptase Inhibitors Norvir (100mg Capsule, 100mg 2 Tablet, 80mg/ml Oral Solution) (NRTI) Abacavir (Tablet) 1 Prezista (100mg/ml 2 Suspension, 150mg Tablet, Abacavir 1 600mg Tablet, 75mg Tablet, Sulfate/Lamivudine/Zidovudine 800mg Tablet) (Tablet) Reyataz (150mg Capsule, 2 Abacavir/Lamivudine (Tablet) 1 200mg Capsule, 300mg Didanosine (Capsule Delayed- 1 Capsule, 50mg Packet) Release) Viracept (Tablet) 2 Emtriva (10mg/ml Oral 2 Solution, 200mg Capsule) Antivirals : Anti-influenza Agents Flumist Quadrivalent 2 PV Lamivudine (10mg/ml Oral 1 (Suspension) Solution, 150mg Tablet, 300mg Tablet) Oseltamivir Phosphate (Capsule) 1 QL Relenza Diskhaler (Aerosol 3 QL Lamivudine/Zidovudine (Tablet) 1 Powder) Retrovir IV Infusion (Injection) 2

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 29 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Rimantadine HCl (Tablet) 1 Estazolam (Tablet) 1 QL Tamiflu (6mg/ml Suspension) 3 QL Gene-Xene Tab 15mg (Tablet) 1 QL Antivirals : Antiherpetic Agents Gene-Xene Tab 3.75mg (Tablet) 1 QL Acyclovir (200mg Capsule, 1 Gene-Xene Tab 7.5mg (Tablet) 1 QL 200mg/5ml Suspension, 400mg Lorazepam (0.5mg Tablet, 1mg 1 QL Tablet, 800mg Tablet, 5% Tablet, 2mg Tablet) Ointment) Lorazepam (2mg/ml Injection, 1 Acyclovir Sodium (Injection) 1 4mg/ml Injection) Denavir (Cream) 3 Lorazepam Intensol (2mg/ml 1 QL Famciclovir (Tablet) 1 Concentrate) Trifluridine (Ophthalmic Solution) 1 Oxazepam (Capsule) 1 QL Valacyclovir HCl (Tablet) 1 QL Quazepam (Tablet) 1 QL Zovirax (5% Cream) 2 Triazolam (Tablet) 1 QL Antivirals Bipolar Agents : Mood Stabilizers Ribavirin (6gm Inhalation 4 Lithium Carbonate (150mg 1 Solution) Capsule, 300mg Capsule, Anxiolytics : Anxiolytics, Other 600mg Capsule, 300mg Tablet) Buspirone HCl (Tablet) 1 Lithium Carbonate ER (Tablet 1 Hydroxyzine HCl (10mg Tablet, 1 Extended-Release) 25mg Tablet, 50mg Tablet, Blood Glucose Regulators : Antidiabetic 10mg/5ml Syrup, 50mg/ml Agents Injection) Acarbose (Tablet) 1 Hydroxyzine Pamoate (100mg 1 Actoplus Met XR (Tablet 3 ST Capsule, 25mg Capsule, 50mg Extended-Release 24 Hour) Capsule) Alogliptin (Tablet) 3 QL,ST Meprobamate (Tablet) 1 Avandia (Tablet) 3 ST Anxiolytics : Benzodiazepines Bydureon Pen (Injection) 2 QL,ST Alprazolam (Tablet) 1 QL Bydureon Vial (Injection) 2 QL,ST Alprazolam ER (Tablet 1 QL Byetta (Injection) 2 QL,ST Extended-Release 24 Hour) Chlorpropamide (Tablet) 1 PA Alprazolam ODT (Tablet 1 Cycloset (Tablet) 3 ST Dispersible) Farxiga (Tablet) 3 ST Alprazolam XR (Tablet 1 QL Glimepiride (Tablet) 1 Extended-Release 24 Hour) Glipizide (10mg Tablet 1 Chlordiazepoxide HCl (Capsule) 1 QL Immediate-Release, 5mg Tablet) Clonazepam (Tablet Immediate- 1 QL Glipizide ER (Tablet Extended- 1 Release) Release 24 Hour) Clonazepam ODT (Tablet 1 QL Glipizide XL (Tablet Extended- 1 Dispersible) Release 24 Hour) Clorazepate Dipotassium 1 QL Glipizide/Metformin HCl (Tablet) 1 (Tablet) Glyburide (1.25mg Tablet, 2.5mg 1 Diazepam (10mg Tablet, 2mg 1 Tablet, 5mg Tablet) Tablet, 5mg Tablet, 1mg/ml Oral Glyburide Micronized (Tablet) 1 Solution, 5mg/ml Injection) Glyburide/Metformin HCl (Tablet) 1 Diazepam Intensol (5mg/ml 1 Invokamet (Tablet) 2 ST Concentrate)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 30 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement

Tier s & Limits Tier s & Limits Invokamet XR (Tablet 2 ST Glucagon Emergency Kit 2 Extended-Release 24 Hour) (Injection) Invokana (Tablet) 2 ST Proglycem (Suspension) 2 Janumet (Tablet, 1000mg- 2 ST Blood Glucose Regulators : Insulins 50mg Tablet) Apidra (Injection) 3 ST

Janumet XR (Tablet Extended- 2 ST Apidra SoloStar (Injection) 3 ST

Release 24 Hour, 500mg-50mg Humalog (Injection) 2 Tablet Extended-Release 24 Humalog KwikPen (Injection) 2 Hour) Humalog Mix 50/50 (Injection) 2 Januvia (Tablet) 2 ST Humalog Mix 50/50 KwikPen 2 Jardiance (Tablet) 3 ST (Injection) Jentadueto (Tablet) 2 ST Humalog Mix 75/25 (Injection) 2 Jentadueto XR (Tablet 2 ST Humalog Mix 75/25 KwikPen 2 Extended-Release 24 Hour) (Injection) 3 ST Kombiglyze XR (Tablet Humulin 70/30 (Injection) 2 Extended-Release 24 Hour) Humulin 70/30 KwikPen 2 Metformin HCl (Immediate 1 (Injection) Release Tablet) Humulin N (Injection) 2 Metformin HCl ER (Tablet 1 Humulin N KwikPen (Injection) 2 Extended-Release 24 Hour Humulin R (Injection) 2 Generic Fortamet, Tablet 2 Extended-Release 24 Hour Humulin R U-500 Generic Glucophage XR) (Concentrated) (Injection) Miglitol (Tablet) 1 Lantus (Injection) 2 Nateglinide (Tablet) 1 Lantus SoloStar (Solution Pen 2 Onglyza (Tablet) 3 ST injector) Levemir (Injection) 3 Pioglitazone HCl (Tablet) 1 Levemir FlexTouch (Injection) 3 Pioglitazone HCl/Glimepiride 1 Novolin 70/30 (Injection) 3 (Tablet) Pioglitazone HCl/Metformin HCl 1 Novolin 70/30 Relion 3 (Tablet) (Injection) Repaglinide (Tablet) 1 Novolin N (Injection) 3 Riomet (Oral Solution) 3 Novolin N Relion (Injection) 3 SymlinPen 120 (Injection) 3 PA Novolin R (Injection) 3

SymlinPen 60 (Injection) 3 PA Novolin R Relion (Injection) 3

NovoLog (Injection) 3 Synjardy (Tablet) 2 ST Synjardy XR (Tablet Extended- 2 ST NovoLog FlexPen (Injection) 3 Release 24 Hour) NovoLog Mix 70/30 (Injection) 3 Tanzeum (Injection) 3 QL,ST NovoLog Mix 70/30 Prefilled 3 Tolazamide (Tablet) 1 FlexPen (Injection)

Tolbutamide (Tablet) 1 NovoLog PenFill (Injection) 3 Toujeo SoloStar (Injection) 2 Tradjenta (Tablet) 2 ST Trulicity (Injection) 2 QL,ST Blood Products/Modifiers/Volume Expanders Victoza (Injection) 2 QL,ST : Anticoagulants Blood Glucose Regulators : Glycemic Agents GlucaGen HypoKit (Injection) 2 Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 31 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Alphanate/Von Willebrand 4 Sash Kit for Flushing Vascular 1 Factor Complex/Human Access Devices (Kit) (Injection) Thrombate III (Injection) 4 Bivalirudin (Injection) 1 Thrombate III w/20 Ml Sterile 4 Ceprotin (Injection) 4 Water (Injection) Corifact (Injection) 4 Tretten (Injection) 4 Eliquis (Tablet) 3 QL Warfarin Sodium (Tablet) 1 Enoxaparin Sodium (100mg/ml 1 QL Xarelto (Tablet) 2 QL Injection, 120mg/0.8ml Injection, Xarelto Starter Pack (Tablet 2 QL 150mg/ml Injection, 30mg/0.3ml Therapy Pack) Injection, 40mg/0.4ml Injection, Blood Products/Modifiers/Volume Expanders 60mg/0.6ml Injection, : Blood Formation Modifiers 80mg/0.8ml Injection, 300mg/3ml Anagrelide HCl (Capsule) 1 Injection) Aranesp Albumin Free 4 PA Fondaparinux Sodium (Injection) 1 QL (Injection) Fragmin (Injection) 3 QL Eloctate (Injection) 4 Heparin Lock Flush (Injection) 1 Mircera (Injection) 4 PA Heparin Sodium (10000unit/10ml 1 Mozobil (Injection) 4 PA,QL Injection, 3000unit/3ml Injection, Neulasta (Injection) 4 PA 5000unit/5ml Injection, 10000unit/ml Injection, Neulasta Onpro Kit (Injection) 4 PA 1000unit/ml Injection, Neupogen (Injection) 4 PA 20000unit/ml Injection, Nplate (Injection) 4 PA 5000unit/0.5ml Injection, Procrit (Injection) 4 PA 5000unit/ml Injection) Promacta (Tablet) 4 PA Heparin Sodium Lock Flush (Kit) 1 Blood Products/Modifiers/Volume Expanders Heparin Sodium/D5W (5%- 1 Argatroban (125mg/125ml- 3 40unit/ml Injection, 5%-50unit/ml 0.9% Injection, 250mg/250ml- Injection) 0.9% Injection) Heparin Sodium/NaCl 0.9% 1 Argatroban (250mg/2.5ml 1 (Injection) Injection) Heparin Sodium/Sodium Ch 1 Hetastarch 6%/NaCl (Injection) 1 Loride (Injection) Vonvendi (Injection) 4 Heparin Sodium/Sodium 1 Blood Products/Modifiers/Volume Expanders Chloride (2000unit/500ml-0.9% : Hemostasis Agents Injection, 20unit/20ml-0.9% Benefix (Injection) 4 Injection, 25000unit/250ml- Coagadex (Injection) 4 0.45% Injection, 30000unit/L- 0.9% Injection, 4000unit/L-0.9% Helixate FS (Injection) 4 Injection, 50unit/50ml-0.45% Hemofil M (Injection) 4 Injection) Idelvion (Injection) 4 Heparin Sodium/Sodium 1 Koate (Injection) 4 Chloride 0.9% Premix (Injection) Koate-Dvi (Injection) 4 Humate-P (Injection) 4 Kogenate FS (Injection) 4 Jantoven (Tablet) 1 Kogenate FS Bio-Set 4 Pradaxa (Capsule) 2 QL (Injection) Monoclate-P (Injection) 4 Riastap (Injection) 4

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 32 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Recombinate (Injection) 4 Eprosartan Mesylate (Tablet) 1 Rixubis (Injection) 4 Irbesartan (Tablet) 1 Tranexamic Acid (1000mg/10ml 1 Losartan Potassium (Tablet) 1 Injection, 650mg Tablet) Olmesartan Medoxomil (Tablet) 1 Blood Products/Modifiers/Volume Expanders Telmisartan (Tablet) 1 : Platelet Modifying Agents Valsartan (Tablet) 1 Aggrastat (0.9%-12.5mg/250ml 3 Cardiovascular Agents : Angiotensin- Injection, 0.9%-5mg/100ml converting Enzyme (ACE) Inhibitors Injection) Benazepril HCl (Tablet) 1 Aspirin/Dipyridamole (Capsule 1 Captopril (Tablet) 1 Extended-Release 12 Hour) Enalapril Maleate (Tablet) 1 Brilinta (Tablet) 2 Enalaprilat (Injection) 1 Cilostazol (Tablet) 1 Fosinopril Sodium (Tablet) 1 Clopidogrel (Tablet) 1 Lisinopril (Tablet) 1 Dipyridamole (25mg Tablet, 1 Moexipril HCl (Tablet) 1 50mg Tablet, 75mg Tablet) Perindopril Erbumine (Tablet) 1 Effient (Tablet) 2 Quinapril HCl (Tablet) 1 Eptifibatide (Injection) 1 Ramipril (Capsule) 1 Zontivity (Tablet) 3 Trandolapril (Tablet) 1 Cardiovascular Agents : Alpha-adrenergic Agonists Cardiovascular Agents : Antiarrhythmics Amiodarone HCl (100mg Tablet, 1 Clonidine HCl (0.1mg Tablet, 1 200mg Tablet, 400mg Tablet, 0.2mg Tablet, 0.3mg Tablet, 150mg/3ml Injection, 50mg/ml 0.1mg/24hr Patch Weekly, Injection) 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly) Amiodarone HCl/Dextrose 1 (150mg/100ml-5% Injection, Ephedrine Sulfate (50mg/ml 1 900mg/500ml-5% Injection) Injection) Disopyramide Phosphate 1 Guanfacine HCl (1mg Tablet, 1 (Capsule) 2mg Tablet Immediate-Release) Dofetilide (Capsule) 1 Methyldopa (Tablet) 1 Flecainide Acetate (Tablet) 1 Midodrine HCl (Tablet) 1 Ibutilide Fumarate (Injection) 1 Phenylephrine HCl (10mg/ml 1 Injection) Lidocaine HCl (10mg/ml 1 Injection, 20mg/ml Injection) Cardiovascular Agents : Alpha-adrenergic Lidocaine HCl in D5W (Injection) 1 Blocking Agents Mexiletine HCl (Capsule) 1 Doxazosin (Tablet) 1 Multaq (Tablet) 3 Doxazosin Mesylate (Tablet) 1 Nexterone (150mg/100ml- 3 Phenoxybenzamine HCl 1 (Capsule) 42.1mg/ml Injection) Norpace CR (100mg Capsule 2 Prazosin HCl (1mg Capsule, 1 2mg Capsule, 5mg Capsule) Extended-Release 12 Hour) Pacerone (Tablet) 1 Cardiovascular Agents : Angiotensin II Receptor Antagonists Procainamide HCl (500mg/ml 1 Injection) Candesartan Cilexetil (Tablet) 1 Propafenone HCl (Tablet) 1 Edarbi (Tablet) 3 ST

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 33 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Propafenone HCl ER (Capsule 1 Timolol Maleate (10mg Tablet, 1 Extended-Release 12 Hour) 20mg Tablet, 5mg Tablet) Quinidine Gluconate CR (Tablet 1 Cardiovascular Agents : Calcium Channel Extended-Release) Blocking Agents Quinidine Gluconate ER (Tablet 1 Afeditab CR (Tablet Extended- 1 Extended-Release) Release 24 Hour) Quinidine Sulfate (Tablet) 1 Amlodipine Besylate (Tablet) 1 Sorine (Tablet) 1 Cardizem LA (120mg Tablet 3 Sotalol HCl (AF) (Tablet) 1 Extended-Release 24 Hour) Sotalol HCl (Tablet) 1 Cartia XT (Capsule Extended- 1 Cardiovascular Agents : Beta-adrenergic Release 24 Hour) Blocking Agents Dilt-XR (Capsule Extended- 1 Acebutolol HCl (200mg Capsule, 1 Release 24 Hour) 400mg Capsule) Diltiazem CD (Capsule 1 Atenolol (100mg Tablet, 25mg 1 Extended-Release 24 Hour) Tablet, 50mg Tablet) Diltiazem HCl (120mg Tablet, 1 Betaxolol HCl (10mg Tablet, 1 30mg Tablet, 60mg Tablet, 90mg 20mg Tablet) Tablet, 125mg/25ml Injection, Bisoprolol Fumarate (Tablet) 1 25mg/5ml Injection, 50mg/10ml Injection) Bystolic (Tablet) 2 Diltiazem HCl CD (Capsule 1 Carvedilol (Tablet) 1 Extended-Release 24 Hour) Coreg CR (Capsule Extended- 3 ST Diltiazem HCl ER (Capsule 1 Release 24 Hour) Extended-Release 24 Hour, Esmolol HCl (Injection) 1 Tablet Extended-Release 24 Labetalol HCl (100mg Tablet, 1 Hour, Capsule Extended- 200mg Tablet, 300mg Tablet, Release 12 Hour) 5mg/ml Injection) Diltiazem HCl/Dextrose (5%- 1 Metoprolol Succinate ER (Tablet 1 125mg/125ml Injection) Extended-Release 24 Hour) Diltiazem HCl/Sodium Chloride 1 Metoprolol Tartrate (100mg 1 (100mg/100ml-0.9% Injection) Tablet, 25mg Tablet, 37.5mg Felodipine ER (Tablet Extended- 1 Tablet, 50mg Tablet, 75mg Release 24 Hour) Tablet, 5mg/5ml Injection) Isradipine (Capsule) 1 Nadolol (20mg Tablet, 40mg 1 Matzim LA (Tablet Extended- 1 Tablet, 80mg Tablet) Release 24 Hour) Pindolol (Tablet) 1 Nicardipine HCl (2.5mg/ml 1 Propranolol HCl (10mg Tablet 1 Injection, 20mg Capsule, 30mg Immediate-Release, 40mg Tablet Capsule) Immediate-Release, 1mg/ml Nifedipine (10mg Capsule, 20mg 1 Injection, 20mg Tablet, 80mg Capsule) Tablet, 20mg/5ml Oral Solution, 40mg/5ml Oral Solution) Nifedipine ER (Tablet Extended- 1 Release 24 Hour) Propranolol HCl (Tablet) 1 Nimodipine (Capsule) 1 Propranolol HCl ER (Capsule 1 1 Extended-Release 24 Hour) Nisoldipine ER (Tablet Extended- Release 24 Hour)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 34 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Taztia XT (Capsule Extended- 1 Dopamine/D5W (Injection) 1 Release 24 Hour) Enalapril 1 Verapamil HCl (120mg Tablet, 1 Maleate/Hydrochlorothiazide 40mg Tablet, 80mg Tablet, (Tablet) 2.5mg/ml Injection) Fosinopril 1 Verapamil HCl ER (Capsule 1 Sodium/Hydrochlorothiazide Extended-Release 24 Hour, (Tablet) Tablet Extended-Release) Ibuprofen Lysine (Injection) 1 Verapamil HCl SR (Capsule 1 Irbesartan/Hydrochlorothiazide 1 Extended-Release 24 Hour) (Tablet) Cardiovascular Agents : Cardiovascular Lisinopril/Hydrochlorothiazide 1 Agents, Other (Tablet) Amiloride/Hydrochlorothiazide 1 Losartan 1 (Tablet) Potassium/Hydrochlorothiazide Amlodipine Besylate/Atorvastatin 1 (Tablet) Calcium (Tablet) Methyldopa/Hydrochlorothiazide 1 Amlodipine Besylate/Benazepril 1 (Tablet) HCl (Capsule) Metoprolol/Hydrochlorothiazide 1 Amlodipine Besylate/Valsartan 1 (Tablet) (Tablet) Milrinone in Dextrose (Injection) 1 Amlodipine/Olmesartan 1 Milrinone Lactate (Injection) 1 Medoxomil (Tablet) Moexipril/Hydrochlorothiazide 1 Amlodipine/Valsartan/Hydrochlor 1 (Tablet) othiazide (Tablet) Nadolol/Bendroflumethiazide 1 Atenolol/Chlorthalidone (Tablet) 1 (Tablet) Benazepril 1 Norepinephrine Bitartrate 1 HCl/Hydrochlorothiazide (Tablet) (Injection) Bisoprolol 1 Olmesartan 1 Fumarate/Hydrochlorothiazide Medoxomil/Amlodipine/Hydrochl (Tablet) orothiazide (Tablet) Byvalson (Tablet) 2 Olmesartan 1 Candesartan 1 Medoxomil/Hydrochlorothiazide Cilexetil/Hydrochlorothiazide (Tablet) (Tablet) Pentoxifylline ER (Tablet 1 Captopril/Hydrochlorothiazide 1 Extended-Release) (Tablet) Phenylephrine HCl/Sodium 1 Demser (Capsule) 3 Chloride (50mg/250ml-0.9% Digitek (Tablet) 1 Injection) Digox (Tablet) 1 Propranolol/Hydrochlorothiazide 1 Digoxin (0.05mg/ml Oral 1 (Tablet) Solution, 0.25mg/ml Injection, Quinapril/Hydrochlorothiazide 1 125mcg Tablet, 250mcg Tablet) (Tablet) Dobutamine HCl (Injection) 1 Ranexa (Tablet Extended- 2 ST Release 12 Hour) Dobutamine HCl/D5W (Injection) 1 Spironolactone/Hydrochlorothiazi 1 Dopamine HCl (40mg/ml 1 de (Tablet) Injection, 80mg/ml Injection) Tekturna (Tablet) 2 ST

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 35 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Telmisartan/Amlodipine (Tablet) 1 Hydrochlorothiazide (12.5mg 1 Telmisartan/Hydrochlorothiazide 1 Capsule, 12.5mg Tablet, 25mg (Tablet) Tablet, 50mg Tablet) Trandolapril/Verapamil HCl ER 1 Indapamide (Tablet) 1 (Tablet Extended-Release) Methyclothiazide (5mg Tablet) 1 Triamterene/Hydrochlorothiazide 1 Metolazone (Tablet) 1 (25mg-37.5mg Tablet, 50mg- Cardiovascular Agents : Dyslipidemics, Fibric 75mg Tablet, 37.5mg-25mg Acid Derivatives Capsule, 50mg-25mg Capsule) Fenofibrate (120mg Tablet, 1 Valsartan/Hydrochlorothiazide 1 145mg Tablet, 40mg Tablet, (Tablet) 48mg Tablet, 54mg Tablet, Vecamyl (Tablet) 3 130mg Capsule, 150mg Cardiovascular Agents : Diuretics, Carbonic Capsule, 43mg Capsule, 50mg Anhydrase Inhibitors Capsule) Acetazolamide (125mg Tablet, 1 Fenofibrate (160mg Tablet) 1 250mg Tablet Immediate- Fenofibrate Micronized (Capsule) 1 Release) Fenofibric Acid (Tablet) 1 Acetazolamide ER (Capsule 1 Fenofibric Acid DR (Capsule 1 Extended-Release 12 Hour) Delayed-Release) Acetazolamide Sodium 1 Fibricor (35mg Tablet) 2 ST (Injection) Gemfibrozil (600mg Tablet) 1 Keveyis (Tablet) 4 PA,QL Triglide (Tablet) 3 ST Cardiovascular Agents : Diuretics, Loop Cardiovascular Agents : Dyslipidemics, HMG Bumetanide (0.25mg/ml 1 CoA Reductase Inhibitors Injection, 0.5mg Tablet, 1mg Atorvastatin Calcium (10mg, 1 QL,PV* Tablet, 2mg Tablet) 20mg Tablet) 1 Ethacrynate Sodium (Injection) Atorvastatin Calcium (40mg, 1 QL Ethacrynic Acid (Tablet) 1 80mg Tablet) Furosemide (10mg/ml Injection, 1 Fluvastatin (Capsule) 1 QL 10mg/ml Oral Solution, 8mg/ml Fluvastatin Sodium ER (Tablet 1 QL Oral Solution, 20mg Tablet, Extended-Release 24 Hour) 40mg Tablet, 80mg Tablet) Livalo (Tablet) 3 QL,ST Torsemide (Tablet) 1 Lovastatin (Tablet) 1 PV Cardiovascular Agents : Diuretics, Pravastatin Sodium (Tablet) 1 Potassium-sparing Rosuvastatin Calcium (Tablet) 1 Amiloride HCl (5mg Tablet) 1 Simvastatin (10mg Tablet, 20mg 1 QL,PV* Dyrenium (0-100mg Capsule) 3 Tablet, 40mg Tablet, 5mg Tablet) Eplerenone (Tablet) 1 Simvastatin (80mg Tablet) 1 PA,QL Spironolactone (100mg Tablet, 1 Cardiovascular Agents : Dyslipidemics, Other 25mg Tablet, 50mg Tablet) Cholestyramine (Powder) 1 Cardiovascular Agents : Diuretics, Thiazide Cholestyramine Light (Powder) 1 Chlorothiazide (Tablet) 1 Colestipol HCl (1gm Tablet, 5gm 1 Chlorothiazide Sodium (Injection) 1 Packet) Chlorthalidone (Tablet) 1 Ezetimibe (Tablet) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 36 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Ezetimibe/Simvastatin (10mg- 1 Nitroglycerin in 5% Dextrose 1 10mg Tablet, 10mg-20mg Tablet, (Injection) 10mg-40mg Tablet) Nitroglycerin in Dextrose 5% 1 Ezetimibe/Simvastatin (10mg- 1 PA (5%-100mcg/ml Injection) 80mg Tablet) Nitroglycerin Lingual 1 Juxtapid (Capsule) 4 PA,QL (Translingual Solution) Niacin ER (Tablet Extended- 1 Nitroglycerin Transdermal (Patch 1 Release) 24 Hour) Omega-3-Acid Ethyl Esters 1 NitroMist (Aerosol Solution) 3 (Capsule) (Generic Lovaza) Rectiv (Ointment) 3 Praluent (Injection) 4 PA,QL Sodium Nitroprusside (Injection) 1 Prevalite (4gm Packet, 4gm/dose 1 Central Nervous System Agents : Attention Powder) Deficit Hyperactivity Disorder Agents, Repatha (Injection) 4 PA,QL Amphetamines Repatha Pushtronex System 4 PA,QL Amphetamine/Dextroamphetami 1 QL, PA (Injection) ne (Tablet, Capsule Extended- Repatha SureClick (Injection) 4 PA,QL Release 24 Hour) Welchol (3.75gm Packet, 2 Dextroamphetamine Sulfate 1 QL, PA 625mg Tablet) (10mg Tablet, 5mg Tablet, Cardiovascular Agents : Vasodilators, Direct- 5mg/5ml Oral Solution) acting Arterial Dextroamphetamine Sulfate ER 1 QL, PA Hydralazine HCl (100mg Tablet, 1 (Capsule Extended-Release 24 10mg Tablet, 25mg Tablet, 50mg Hour) Tablet, 20mg/ml Injection) Methamphetamine HCl (Tablet) 1 QL, PA Minoxidil (Tablet) 1 Vyvanse (Capsule, Tablet 2 QL, PA Cardiovascular Agents : Vasodilators, Direct- Chewable) acting Arterial/Venous Zenzedi (10mg Tablet, 5mg 1 QL, PA Dilatrate SR (Capsule 3 Tablet) Extended-Release) Central Nervous System Agents : Attention Isosorbide Dinitrate (Tablet) 1 Deficit Hyperactivity Disorder Agents, Non- Isosorbide Dinitrate ER (Tablet 1 amphetamines Extended-Release) Atomoxetine (Capsule) 1 QL Isosorbide Mononitrate (Tablet) 1 Clonidine HCl ER (Tablet 1 Isosorbide Mononitrate ER 1 Extended-Release 12 Hour) (Tablet Extended-Release 24 Daytrana (Patch) 3 QL,ST, PA Hour) Dexmethylphenidate HCl (Tablet 1 QL, PA Minitran (Patch 24 Hour) 1 Immediate-Release) Nitro-Bid (Ointment) 3 Dexmethylphenidate HCl ER 1 QL, PA Nitro-Time (6.5mg Capsule 1 (Capsule Extended-Release 24 Extended-Release) Hour) Nitroglycerin (0.3mg Tablet 1 Guanfacine ER (Tablet 1 Sublingual, 0.4mg Tablet Extended-Release 24 Hour) Sublingual, 0.6mg Tablet Metadate ER (Tablet Extended- 1 QL, PA Sublingual) Release) Nitroglycerin ER (Capsule 1 Extended-Release)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 37 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Methylphenidate HCl (Tablet 1 QL, PA Lyrica (20mg/ml Oral Solution) 3 QL Chewable, Immediate-Release Savella (Tablet) 3 QL,ST Tablet, Oral Solution) Central Nervous System Agents : Multiple Methylphenidate HCl CD 1 QL, PA Sclerosis Agents (Capsule Extended-Release) Ampyra (Tablet Extended- 4 PA,QL Methylphenidate HCl ER (La) 1 QL, PA Release 12 Hour) (Capsule Extended-Release 24 Aubagio (Tablet) 4 PA,QL Hour) Avonex (Injection) 4 PA,QL Methylphenidate HCl ER 1 QL, PA Avonex Pen (Injection) 4 PA,QL (Tablet Extended-Release, Betaseron (Injection) 4 PA,QL Capsule Extended-Release 24 Copaxone (Injection) 4 PA,QL QuillivantHour) XR (Suspension) 3 QL,ST, PA Gilenya (Capsule) 4 PA,QL Central Nervous System Agents : Central Glatopa (Injection) 4 PA,QL Nervous System, Other Lemtrada (Injection) 4 PA Caffeine Citrate (20mg/ml Oral 1 Solution, 60mg/3ml Oral Plegridy (Injection) 4 PA,QL Solution, 60mg/3ml Injection) Plegridy Starter Pack 4 PA,QL Duraxin (Capsule) 1 (Injection) Hetlioz (Capsule) 4 PA,QL Tecfidera (Capsule Delayed- 4 PA,QL Horizant (Tablet Extended- 3 PA,QL Release) Release) Tecfidera Starter Pack 4 PA,QL Namzaric (10mg-14mg Capsule 2 QL Tysabri (Injection) 4 PA,QL Extended-Release 24 Hour, Dental and Oral Agents 10mg-28mg Capsule Cavarest (Gel) 1 Extended-Release 24 Hour) Cevimeline HCl (Capsule) 1 Nuedexta (Capsule) 3 PA Chlorhexidine Gluconate (0.12% 1 Pancuronium Bromide (Injection) 1 Solution) Phendimetrazine Tartrate 1 PA Clinpro 5000 (Paste) 1 (Tablet) Denta 5000 Plus (Cream) 1 Riluzole (Tablet) 1 PA,QL Dentagel (Gel) 1 Rocuronium Bromide 1 Fluoridex (Paste) 1 (100mg/10ml Injection, 50mg/5ml Karigel (Gel) 1 Injection) Karigel-N (Gel) 1 Tetrabenazine (Tablet) 4 PA Kepivance (Injection) 4 Central Nervous System Agents : Neutragard Advanced (Gel) 1 Fibromyalgia Agents Neutral Sodium Fluoride 1 1 QL Duloxetine HCl (20mg Capsule (Solution) Delayed-Release, 30mg Capsule Oralone (Paste) 1 Delayed-Release, 60mg Capsule Paroex (Solution) 1 Delayed-Release) Periogard (Solution) 1 Duloxetine HCl (40mg Capsule 3 QL Delayed-Release) Phos-Flur (Gel) 1 Lyrica (100mg Capsule, 150mg 2 QL Pilocarpine HCl (5mg Tablet, 1 Capsule, 200mg Capsule, 7.5mg Tablet) 225mg Capsule, 25mg Prevident Rinse (Solution) 1 Capsule, 300mg Capsule, SF (Gel) 1 50mg Capsule, 75mg Capsule) SF 5000 Plus (Cream) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 38 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Topex Topical Anesthetic 1 Finacea (15% Foam, 15% Gel) 3 ST (Aerosol) Fluoroplex (Cream) 3 Triamcinolone Acetonide (0.1% 1 Fluorouracil (0.5% Cream) 2 Paste) Fluorouracil (2% External 4 Triamcinolone in Orabase 1 Solution, 5% External Solution) (Paste) Fluorouracil (5% Cream) 1 Dermatological Agents Imiquimod (Cream) 1 Acitretin (Capsule) 1 Lactic Acid (Lotion) 1 Adapalene (0.1% Cream, 0.1% 1 PA Lactic Acid E (Cream) 1 Gel, 0.3% Gel) Lactic Acid with Vitamin E 1 Adapalene Pump (Gel) 1 PA (Cream) Ammonium Lactate (12% Cream, 1 Methoxsalen (10mg Capsule) 1 12% Lotion) Mirvaso (Gel) 2 Amnesteem (Capsule) 1 PA Myorisan (Capsule) 1 PA Avita (0.025% Cream, 0.025% 1 PA Neo-Synalar (Cream) 3 Gel) Neuac (Gel) 1 Azelex (Cream) 3 Picato (Gel) 3 ST Calcipotriene (0.005% Cream, 1 Podofilox (External Solution) 1 0.005% External Solution, 0.005% Ointment) Regranex (Gel) 3 PA Calcipotriene/Betamethasone 1 QL Salacyn (6% Cream, 6% Lotion) 1 Dipropionate (Ointment) Salicylic Acid (27.5% Liquid, 6% 1 Calcitrene (Ointment) 1 Cream, 6% Gel, 6% Lotion, 6% Shampoo) Claravis (Capsule) 1 PA Salicylic Acid Cream (Kit) 1 Clindamycin Phosphate/Tretinoin 1 (Gel) Salicylic Acid Lotion (Kit) 1 Santyl (Ointment) 3 Clindamycin/Benzoyl Peroxide 1 (Gel) Selenium Sulfide (0-2.25%- 1 Shampoo, 2.5% Lotion) Clotrimazole/Betamethasone 1 Dipropionate (0.05%-1% Cream, Stelara (45mg/0.5ml Injection, 4 PA 1%-0.05% Lotion) 90mg/ml Injection) Condylox (Gel) 3 Sulfacetamide Sodium (10% 1 Lotion, 10% Suspension) Cortisporin (0.5%-0.5% Cream, 3 1%-0.5% Ointment) Taclonex (0.064%-0.005% 3 QL Cosentyx (Injection) 4 PA Suspension) Cosentyx Sensoready Pen 4 PA Tacrolimus (0.03% Ointment, 1 (Injection) 0.1% Ointment) Diclofenac Sodium (1% Gel, 3% 1 QL Tazarotene (Cream) 1 Gel) Tazorac (0.05% Cream, 0.05% 3 Gel, 0.1% Gel) Doxepin HCl (Cream) 1 Dupixent (Injection) 4 PA,QL Tretinoin (0.01% Gel, 0.025% 1 PA Gel, 0.05% Gel, 0.025% Cream, Elidel (Cream) 2 ST 0.05% Cream, 0.1% Cream) Epiduo (Gel) 3 Tretinoin Microsphere (Gel) 1 PA Epiduo Forte (Gel) 3 Tretinoin Microsphere Pump 1 PA Erythromycin/Benzoyl Peroxide 1 (Gel) (Gel)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 39 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Uvadex (Injection) 3 Dextrose 5%/NaCl 0.2% 1 Vectical (Ointment) 2 (Injection) Veregen (Ointment) 3 Dextrose 5%/NaCl 0.33% 1 Zenatane (Capsule) 1 PA (Injection) Electrolytes/Minerals/Metals/Vitamins : Dextrose 5%/NaCl 0.45% 1 Electrolyte/Mineral Replacement (Injection) Advate (2000unit Injection, 4 Dextrose 5%/NaCl 0.9% 1 3000unit Injection, 4000unit (Injection) Injection) Dextrose 50% (Injection) 1 Albuked 25 (Injection) 1 Dextrose 70% (Injection) 1 Albuked 5 (Injection) 1 Easygel (Gel) 1 Albumin Human (Injection) 1 Effer-K (25meq Tablet 1 Albumin-Zlb (Injection) 1 Effervescent) Albuminar-25 (Injection) 1 Effervescent Potassium/Chloride 1 (Tablet Effervescent) Albuminar-5 (Injection) 1 Ferocon (Capsule) 1 Alburx (Injection) 1 Ferotrinsic (Capsule) 1 Albutein (Injection) 1 Ferrocite Plus (Tablet) 1 Alphanine SD (1000unit 4 Injection, 1500unit Injection) Flexbumin (Injection) 1 Aminoam Rms (Capsule) 1 Fluoridex Daily Renewal 1 (Concentrate) Aminorelief Rms (Capsule) 1 Fluoridex Sensitivity Relief/Sls 1 Aminosyn 8.5%/Electrolytes 1 Free (Paste) (Injection) Foltrin (Capsule) 1 Aminosyn II 8.5%/Electrolytes 1 (Injection) Hematinic Plus 1 Vitamins/Minerals (Tablet) Argyle Sterile Saline 100ml 1 (Solution) Hematogen (Capsule) 1 AV-Phos 250 Neutral (Tablet) 1 Hematogen Forte (Capsule) 1 BD Posiflush (Solution) 1 Hemocyte-Plus (Tablet) 1 Bebulin (Injection) 4 Iferex 150 Forte (Capsule) 1 Buminate (Injection) 1 Intralipid (20gm/100ml Injection) 1 Calcium Chloride (Injection) 1 Isolyte-S (Injection) 3 Carbaglu (Tablet) 4 K-Effervescent (Tablet 3 Effervescent) Chromagen (Capsule) 1 K-Prime (Tablet Effervescent) 1 Chromium Chloride (Injection) 1 K-Tan Plus (Capsule) 1 Clinisol SF 15% (Injection) 1 K-Vescent (Tablet Effervescent) 1 Corvita (Tablet) 1 KCl 0.075%/D5W/NaCl 0.45% 1 Corvita 150 (Tablet) 1 (Injection) Curity Sterile Saline (Solution) 1 KCl 0.15%/D5W/NaCl 0.2% 1 Dextrose 10% (Injection) 1 (Injection) Dextrose 2.5%/NaCl 0.45% 1 KCl 0.15%/D5W/NaCl 0.45% 1 (Injection) (Injection) Dextrose 5% (Injection) 1 KCl 0.15%/D5W/NaCl 0.9% 1 Dextrose 5%/Lactated Ringers 1 (Injection) (Injection)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 40 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits KCl 0.3%/D5W/NaCl 0.45% 1 2.03meq/ml-1.25meq/ml (Injection) Injection) Kedbumin (Injection) 1 Obizur (Injection) 4 Klor-Con 10 (Tablet Extended- 1 OsmoPrep (Tablet) 3 Release) Phospha 250 Neutral (Tablet) 1 Klor-Con 8 (Tablet Extended- 1 Phospho-Trin 250 Neutral 1 Release) (Tablet) Klor-Con M10 (Tablet Extended- 1 Physiolyte (Irrigation Solution) 1 Release) Physiosol Irrigation (Solution) 1 Klor-Con M15 (Tablet 3 Plasbumin-25 (Injection) 1 Extended-Release) Plasbumin-5 (Injection) 1 Klor-Con M20 (Tablet Extended- 1 Plasma-Lyte A (Injection) 3 Release) Plasma-Lyte-148 (Injection) 3 Klor-Con Sprinkle (Capsule 1 Plenamine (Injection) 1 Extended-Release) Poly-Iron 150 Forte (Capsule) 1 Klor-Con/Ef (Tablet Effervescent) 1 Polysaccharide Iron Forte 1 Lactated Ringers (Injection) 1 (Capsule) Lactated Ringers Irrigation 1 Potassium Acetate (2meq/ml 1 (Solution) Injection) Levocarnitine (1gm/10ml Oral 1 Potassium Chloride (10% Oral 1 Solution, 330mg Tablet) Solution, 20% Oral Solution, 1 Magnesium Chloride (200mg/ml 10meq/100ml Injection, Injection) 20meq/50ml Injection, 2meq/ml Magnesium Sulfate (20gm/500ml 1 Injection, 40meq/100ml Injection, Injection, 2gm/50ml Injection, 20meq Packet) 40gm/1000ml Injection, Potassium Chloride 0.15% 1 4gm/100ml Injection, 4gm/50ml D5W/NaCl 0.33% (Injection) Injection, 50% Injection) Potassium Chloride 0.15% 1 Magnesium Sulfate in D5W (5%- 1 D5W/NaCl 0.45% (Injection) 1gm/100ml Injection) Potassium Chloride 0.22% 1 Magnesium Sulfate/Lactated 1 D5W/NaCl 0.45% (Injection) Ringers (100mg/500ml- Potassium Chloride 1 20gm/500ml-150mg/500ml- 0.224%D5W/NaCl 0.45% Viaflex 3gm/500ml-1.55gm/500ml (Injection) Injection) Potassium Chloride CR (Tablet 1 Magnesium Sulfate/Sodium 1 Extended-Release) Chloride (4gm/100ml-0.9% Potassium Chloride ER (10meq 1 Injection) Capsule Extended-Release, Monoject Pharma Grade Flush 1 8meq Capsule Extended- Syringe (Solution) Release, 10meq Tablet Mononine (Injection) 4 Extended-Release, 20meq Normal Saline Flush (Solution) 1 Tablet Extended-Release, 8meq Nutrilipid (Injection) 1 Tablet Extended-Release) Nutrilyte (2.03meq/ml- 1 Potassium Chloride SR (Tablet 1 0.25meq/ml-1.68meq/ml- Extended-Release) 0.25meq/ml-0.4meq/ml- Potassium Chloride/Dextrose 1 (5%-20meq/L Injection) Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 41 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement

Tier s & Limits Tier s & Limits Potassium Chloride/Lidocaine 1 Xyntha Solofuse (Injection) 4 HCl (Injection) Electrolytes/Minerals/Metals/Vitamins : Potassium Chloride/Sodium 1 Electrolyte/Mineral/Metal Modifiers Chloride (20meq/L-0.9% Chemet (Capsule) 3 Injection, 40meq/L-0.9% Exjade (Tablet Soluble) 3 PA

Injection) Ferriprox (500mg Tablet) 4 PA

Potassium Citrate ER (Tablet 1 Jadenu (Tablet) 3 PA Extended-Release) Kionex (Powder, 15gm/60ml 1 Premasol (6% Injection) 1 Suspension) Profilnine (Injection) 4 Samsca (Tablet) 4 QL PureVitamin Dualfe Plus 1 Sodium Acetate (Injection) 1 (Capsule) Sodium Bicarbonate (7.5% 1

Ringers Injection 1 Injection, 8.4% Injection) Ringers Irrigation (Solution) 1 Sodium Bicarbonate Partial Fill 1 Saline Flush (Injection) 1 (Injection) Saline Flush Zr/Sterile Field 1 Sodium Polystyrene Sulfonate 1 (Injection) (Powder, 15gm/60ml Se-Tan Plus (Capsule) 1 Suspension, 30gm/120ml Sodium Chloride 0.9% (Irrigation 1 Suspension, 50gm/200ml Solution) Suspension) Sodium Chloride (2.5meq/ml 1 SPS (Suspension) 1 Injection, 3% Injection, 4meq/ml Syprine (Capsule) 4 PA Injection, 5% Injection) Electrolytes/Minerals/Metals/Vitamins Sodium Chloride 0.45% 1 1 PV Fluor-A-Day (Oral Solution) (Injection) Fluoride (Tablet Chewable) 1 PV 1 Sodium Chloride Flush (Injection) Fluoritab (0.125mg/drop Oral 1 PV Sodium Citrate/Citric Acid (0 Oral 1 Solution, 0.25mg Tablet Solution) Chewable, 0.5mg Tablet Sodium Ferric Gluconate 1 Chewable, 1mg Tablet Complex/Sucrose (Injection) Chewable) Sodium Phosphate (142mg/ml- 1 Flura-Drops (0.125mg/drop Oral 1 PV 276mg/ml Injection) Solution)

Swabflush Saline Flush 1 Karidium (Oral Solution) 1 PV

(Injection) 1 PV Ludent (Tablet Chewable) Taron-Crystals (Packet) 1 Nafrinse (Tablet Chewable) 1 PV Tis-U-Sol (Irrigation Solution) 1 Nafrinse Drops (Oral Solution) 1 PV TL Icon (Capsule) 1 Sodium Fluoride (0.25mg Tablet 1 PV Tl-Hem 150 (Tablet) 1 Chewable, 0.5mg Tablet TPN Electrolytes (Injection) 1 Chewable, 1mg Tablet Tricon (Capsule) 1 Chewable, 0.5mg/ml Oral

Trigels-F Forte (Capsule) 1 Solution, 1mg Tablet)

Virt-Phos 250 Neutral (Tablet) 1 Electrolytes/Minerals/Metals/Vitamins :

Virtrate-2 (Oral Solution) 1 Vitamins Advate (1000unit Injection, Virtrate-3 (Oral Solution) 1 4 1500unit Injection, 250unit Virtrate-K (Oral Solution) 1 Injection, 500unit Injection) Xyntha (Injection) 4 Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 42 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Airavite (Tablet) 1 CVS Vitamin D Childrens 1 PV Alphanine SD (500unit 4 Gummies (Tablet Chewable) Injection) CVS Vitamin D3 Drops/Infants 3 PV Atabex Prenatal (Tablet 3 PV (Liquid) Chewable) Cyanocobalamin (1000mcg/ml 1 AV-Vite FB (Tablet) 1 Injection) B-Plex (Tablet) 1 D 1000 (1000unit Capsule, 1 PV B-Plex Plus (Tablet) 1 1000unit Tablet Chewable) Baby Super Daily D3 (Liquid) 3 PV D 10000 (Capsule) 1 PV Baby Vitamin D3 Drops 3 PV D 2000 (Tablet) 1 PV (Liquid) D 400 (400unit Tablet, 400unit 1 PV Bio-D-Mulsion (Liquid) 1 PV Tablet Chewable) Bio-D-Mulsion Forte (Liquid) 1 PV D-Vita (Liquid) 1 PV Biocel (Tablet) 1 D2000 Ultra Strength (Capsule) 1 PV BP Folinatal Plus B (Tablet) 1 D3 (1000unit Capsule, 2000unit 1 PV Capsule, 400unit Capsule, BP Multinatal Plus (50mg-0- 1 1000unit Tablet, 2000unit Tablet) 250mg-0-6mcg-2mg-40mg-1mg- 50mg-2mg-3.5unit-15mg Tablet D3 2000 (Tablet) 1 PV Chewable, 60mg-0-200mg-0- D3 Adult (Tablet Chewable) 1 PV 2mg-12mcg-30mg-1mg-100mg- D3 Dots (Tablet Dispersible) 3 PV 20mg-50mg-3.4mg-3mg-30unit- D3 High Potency (Tablet) 1 PV 15mg Tablet) D3 Kids (Tablet Chewable) 1 PV BP Vit 3 (Capsule) 1 D3 Maximum Strength (5000unit 1 PV Bprotected Pedia D-Vite (Liquid) 1 PV Capsule, 5000unit/ml Liquid) Brainstrong Prenatal 3 PV D3 Super Strength (Capsule) 1 PV Cadeau DHA (Capsule) 3 PV D3-1000 (Capsule) 1 PV Calcidol (Oral Solution) 1 PV D3-50 (Capsule) 1 PV Calciferol (Oral Solution) 1 PV Ddrops (Liquid) 3 PV Centrum Specialist Prenatal 3 PV Ddrops Booster (Liquid) 3 PV Choline Magnesium Trisalicylate 1 Decara (25000unit Capsule) 3 PV (Liquid) Decara (50000unit Capsule) 1 PV Classic Prenatal (Tablet) 1 PV Delta D3 (Tablet) 1 PV Co-Natal FA (Tablet) 1 Dialyvite (Tablet) 1 Complete Natal DHA 1 Dialyvite Vitamin D 5000 1 PV Completenate (Tablet Chewable) 1 (Capsule) Corvite Free (Tablet) 1 Dialyvite Vitamin D3 Max 1 PV CVS D3 (1000unit Capsule, 1 PV (Tablet) 2000unit Capsule, 400unit Elite-Ob (Tablet) 1 Capsule, 5000unit Capsule, Enfamil Expecta 3 PV 1000unit Tablet Chewable) EQL Prenatal Formula (Tablet) 1 PV 1 PV CVS Prenatal (Tablet) EQL Vitamin D3 (Capsule) 1 PV CVS Prenatal 3 PV EQL Vitamin D3 Gummies 1 PV Gummy/DHA/Folic Acid (Tablet (Tablet Chewable) Chewable) Ergocalciferol (8000unit/ml Oral 1 PV CVS Prenatal Multi+DHA 3 PV Solution) (Capsule)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 43 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits FA-8 (0.8mg Capsule, 800mcg 1 PV Multi-Vit/Fluoride (Oral Solution) 1 Tablet) Multi-Vit/Iron/Fluoride (Oral 1 Fabb (Tablet) 1 Solution) Feiba (Injection) 4 Multi-Vitamin/Fluoride Drops 1 Folbee (Tablet) 1 (Oral Solution) Folbee Plus (Tablet) 1 Multi-Vitamin/Fluoride/Iron (Oral 1 Folic Acid (1mg Tablet, 400mcg 1 Solution) Tablet, 800mcg Capsule) Multivitamin with Fluoride (Oral 1 Folic Acid/Vitamin B-6/Vitamin B- 1 Solution, Tablet Chewable) 12 (Tablet) Mvc-Fluoride (Tablet Chewable) 1 Folplex 2.2 (Tablet) 1 Mynatal Advance (Tablet) 1 GNP D 1000 (Capsule) 1 PV Mynatal Plus (Tablet) 1 GNP D 2000 (Tablet Chewable) 1 PV Mynatal Ultracaplet (Tablet) 1 GNP Daily Prenatal 3 PV Mynatal-Z (Tablet) 1 GNP Prenatal (Tablet) 3 PV Mynate 90 Plus (Tablet 1 GNP Vitamin D (Tablet) 1 PV Extended-Release) GNP Vitamin D Super Strength 1 PV Mynephron (Capsule) 1 (Tablet) NascoBAL (Nasal Solution) 3 GNP Vitamin D3 Extra Strength 1 PV Nat-Rul Prenatal Vitamins 3 PV (Tablet) (Tablet) Goodsense Prenatal Vitamins 3 PV Nat-Rul Vitamin D (Tablet) 1 PV (Tablet) Natural Vitamin D-3 (Tablet) 1 PV Healthy Kids Vitamin D3 (Tablet 1 PV Nephronex (Tablet) 1 Chewable) Novoseven (Solution) 4 Healthy Mama Be Well 3 PV Novoseven RT (Injection) 4 Rounded (Therapy Pack) Nufol (Tablet) 1 Hematinic/Folic Acid (Tablet) 1 Nutrifac ZX (Tablet) 1 Hemocyte-F (Tablet) 1 Obstetrix EC (Tablet) 1 HM One Daily Prenatal Combo 3 PV One A Day Womens 3 PV HM Prenatal (Tablet) 3 PV Prenatal/DHA HM Vitamin D (Tablet) 1 PV One A Day Womens Prenatal1 3 PV HM Vitamin D3 (Capsule) 1 PV (Capsule) Inatal Advance (Tablet) 1 One-A-Day Womens Prenatal 3 PV Inatal GT (Tablet) 1 Optimal D3 M (Capsule) 3 PV Just D (Liquid) 1 PV Optimal-D Pack (Capsule) 1 PV KP Folic Acid (Tablet) 1 PV Opurity Vitamin D (Tablet 1 PV KP Prenatal Multivitamins 3 PV Chewable) (Tablet) PA Prenatal Formula (Tablet) 3 PV KP Vitamin D (1000unit Capsule, 1 PV PA Vitamin D-3 (Capsule) 1 PV 2000unit Capsule, 400unit Tablet PA Vitamin D-3 Gummy (Tablet 1 PV Chewable) Chewable) Lysiplex Plus (Tablet) 1 Perry Prenatal (Capsule) 1 PV M-Vit (Tablet) 1 Phytonadione (Injection) 1 Mephyton (Tablet) 2 PR Natal 430 EC 1 Multi Prenatal (Tablet) 1 PV Pre-Natal Formula (Tablet) 1 PV

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 44 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Prenatabs Rx (Tablet) 1 1.7mg-1.8mg-30unit-25mg Prenatal (100mg-0-0-263mg- 1 PV Tablet) 400unit-4mcg-27mg-0.8mg- Prenatal-U (Capsule) 1 18mg-2.6mg-1.7mg-1.5mg- Prenatal/Omega-3/Folic 3 PV 11unit-4000unit-25mg Tablet, Acid/Iron (Capsule) 120mg-4000unit-200mg-400unit- Pronutrients Vitamin D3 1 PV 8mcg-0-0-0-28mg-800mcg- (Capsule) 20mg-2.6mg-1.7mg-0-1.8mg- PX Prenatal Multivitamins 1 PV 30unit-25mg Tablet) (Tablet) Prenatal (120mg-0-200mg- 3 PV Pyridoxine HCl (100mg/ml 1 400unit-8mcg-28mg-800mcg- Injection) 20mg-2.6mg-1.7mg-1.8mg- QC Prenatal (Tablet) 3 PV 30unit-4000unit-25mg Tablet, Quflora Pediatric (Oral Solution, 1 120mg-4000unit-200mg- Tablet Chewable) 400unit-8mcg-28mg-800mcg- 20mg-2.6mg-1.7mg-1.8mg- RA One Daily 3 PV 30unit-25mg Tablet) RA Prenatal (Tablet) 1 PV Prenatal 19 (100mg-1000unit- 1 RA Prenatal Formula/Folic 3 PV 200mg-7mg-12mcg-25mg-29mg- Acid (Tablet) 1mg-6mg-20mg-3mg-3mg- RA Vitamin D-3 (1000unit Tablet, 1 PV 400unit-30unit-20mg Tablet 2000unit Capsule) Chewable, 100mg-200mg- Rena-Vite Rx (Tablet) 1 400unit-12mcg-25mg-29mg- Renal Caps (Capsule) 1 1mg-15mg-7mg-20mg-3mg-3mg- Reno Caps (Capsule) 1 1000unit-30unit-20mg Tablet) Replesta (Wafer) 3 PV Prenatal and Iron (Tablet) 1 PV Replesta Childrens (Wafer) 3 PV Prenatal Complete (Tablet) 3 PV Replesta Nx (Wafer) 3 PV Prenatal Formula (Capsule) 3 PV Right Step Prenatal (Tablet) 3 PV Prenatal Forte (Tablet) 1 PV Se-Natal 19 (1000unit-100mg- 1 Prenatal Low Iron (Tablet) 1 PV 200mg-7mg-400unit-12mcg- Prenatal Multi + DHA (Capsule) 3 PV 29mg-1mg-15mg-20mg-3mg- Prenatal Multi +DHA (Capsule) 3 PV 3mg-30unit-20mg Tablet Prenatal Multivitamin (Tablet) 3 PV Chewable, 100mg-1000unit- Prenatal Multivitamin + DHA 3 PV 200mg-7mg-400unit-12mcg- Prenatal Multivitamin Plus 3 PV 25mg-29mg-1mg-15mg-20mg- DHA (Capsule) 3mg-3mg-30unit-20mg Tablet) Prenatal One Daily (Tablet) 3 PV Similac Prenatal Early Shield 3 PV Prenatal Vitamin/Iron (Tablet) 3 PV SM Folic Acid (Tablet) 1 PV Prenatal Vitamins (100mg- 1 PV SM One Daily Prenatal 3 PV 200mg-4mcg-800mcg-27mg- SM Prenatal Vitamins (Tablet) 3 PV 18mg-2.6mg-1.7mg-1.84mg- SM Vitamin D (Tablet) 1 PV 4000unit-400unit-11unit-25mg SM Vitamin D3 Maximum 3 PV Tablet) Strength (Capsule) Prenatal Vitamins (120mg- 3 PV Stuart One (Capsule) 3 PV 4000unit-200mg-400unit-8mcg- Super Daily D3 3 PV 28mg-800mcg-20mg-2.6mg- (1000unit/0.03ml Liquid)

Taron-Prex (Capsule) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 45 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Thera-D 2000 (Tablet) 1 PV 1200unit/15ml Liquid, 3000unit Thera-D 4000 (Tablet) 3 PV Tablet, 5000unit Tablet Thiamine HCl (100mg/ml 1 Dispersible) Injection) Vitamin D3 (2000unit Tablet, 1 PV TL Gard Rx (Tablet) 1 2000unit Tablet Chewable, 5000unit Tablet Chewable, Tri-Vit/Fluoride (Oral Solution) 1 400unit Capsule, 400unit/ml Tri-Vitamin/Fluoride (Oral 1 Liquid, 5000unit/ml Liquid, Solution) 5000unit Capsule, 5000unit 1 Tricare (Tablet) Tablet) 1 Trinatal Rx 1 (Tablet) Vitamin D3 Gummies (Tablet 1 PV Trinate (Tablet) 1 Chewable) Triphrocaps (Capsule) 1 Vitamin D3 Ultra Potency 1 PV Ultimatecare One (Capsule) 1 (Tablet) UltimateCare ONE NF (Capsule) 1 Vitamin K1 (1mg/0.5ml Injection) 1 Upspringbaby Vitamin D3 3 PV Vitamins A/C/D/Fluoride (Oral 1 (Liquid) Solution) Urosex (Tablet) 1 Vol-Care Rx (Tablet) 1 V-C Forte (Capsule) 1 VP-Vite Rx (Tablet) 1 Vic-Forte (Capsule) 1 Wellesse Vitamin D3 (Liquid) 3 PV Vinate II (Tablet) 1 YL Folic Acid (Tablet) 1 PV Vinate M (Tablet) 1 Your Life Multi Prenatal 3 PV Vinate One (Tablet) 1 (Capsule) Virt-Caps (Capsule) 1 Gastrointestinal Agents : Antispasmodics, Virt-Gard (Tablet) 1 Gastrointestinal Virt-Vite (Tablet) 1 Atropen (0.5mg/0.7ml 3 Virt-Vite Plus (Tablet) 1 Injection) Vita S Forte (Tablet) 1 Atropine Sulfate (1mg/10ml 1 Injection, 1mg/ml Injection, Vita-Min (Capsule) 1 8mg/20ml Injection) Vitacel (Tablet) 1 Chlordiazepoxide HCl/Clidinium 1 Vitajoy Daily D Gummies (Tablet 1 PV Bromide (Capsule) Chewable) Cuvposa (Oral Solution) 3 Vitamax Pediatric (Oral Solution) 1 Dicyclomine HCl (10mg Capsule, 1 Vitamelts Vitamin D (Tablet 3 PV 10mg/5ml Oral Solution, Dispersible) 10mg/ml Injection, 20mg Tablet) Vitamin D (2000unit Tablet, 1 PV Glycopyrrolate (0.4mg/2ml 1 400unit Capsule, 400unit Tablet, Injection, 1mg/5ml Injection, 400unit/ml Liquid, 50000unit 4mg/20ml Injection, 1mg Tablet, Capsule) 2mg Tablet) Vitamin D-1000 (Tablet) 1 PV Hyoscyamine Sulfate (0.125mg 1 1 PV Vitamin D-3 (1000unit Capsule, Tablet Dispersible, 0.125mg 1000unit Tablet, 400unit Tablet, Tablet Sublingual, 0.125mg/5ml 2000unit Tablet) Elixir, 0.125mg/ml Oral Solution) Vitamin D2 (Tablet) 3 PV Hyosyne (0.125mg/5ml Elixir, 1 Vitamin D3 (10000unit Tablet, 3 PV 0.125mg/ml Oral Solution) 1000unit/spray Liquid,

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 46 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Methscopolamine Bromide 1 75mg/5ml Syrup, 150mg/6ml (Tablet) Injection, 50mg/2ml Injection) Nulev (Tablet Dispersible) 1 Gastrointestinal Agents : Irritable Bowel Oscimin (0.125mg Tablet, 1 Syndrome Agents 0.125mg Tablet Sublingual) Alosetron HCl (Tablet) 1 PA Propantheline Bromide (15mg 1 Amitiza (Capsule) 2 QL,ST Tablet) Linzess (Capsule) 2 QL,ST Symax-SR (Tablet Extended- 1 Gastrointestinal Agents : Laxatives Release 12 Hour) Alophen (Tablet Delayed- 1 PV Gastrointestinal Agents : Gastrointestinal Release) Agents, Other Bisacodyl EC (Tablet Delayed- 1 PV Cromolyn Sodium (100mg/5ml 1 Release) Concentrate) Carters Little Pills (Tablet 1 PV Diphenoxylate/Atropine (2.5mg- 1 Delayed-Release) 0.025mg Tablet, 2.5mg- Citroma (Oral Solution) 1 PV 0.025mg/5ml Liquid) ClearLax (Powder) 1 PV Gattex (Injection) 4 PA Constulose (Oral Solution) 1 Lansoprazole/Amoxicillin/Clarithr 1 Correct (Tablet Delayed- 1 PV omycin (Therapy Pack) Release) Loperamide HCl (2mg Capsule) 1 Correctol (Tablet Delayed- 1 PV Motofen (Tablet) 3 Release) Ocaliva (Tablet) 4 PA,QL CVS Purelax (Powder) 1 PV Omeclamox-Pak (Therapy 2 Ducodyl (Tablet Delayed- 1 PV Pack) Release) Pylera (Capsule) 2 Dulcolax Balance (Powder) 1 PV Relistor (12mg/0.6ml Injection, 3 PA,QL Enulose (Oral Solution) 1 8mg/0.4ml Injection, 150mg EQ ClearLax (Powder) 1 PV Tablet) EQL ClearLax (Powder) 1 PV Ursodiol (250mg Tablet, 500mg 1 EQL Gentle Laxative (Tablet 1 PV Tablet, 300mg Capsule) Delayed-Release) Gastrointestinal Agents : Histamine2 (H2) EQL Laxative (Tablet Delayed- 1 PV Receptor Antagonists Release) Cimetidine (200mg Tablet, 1 Ex-Lax Ultra (Tablet Delayed- 1 PV 300mg Tablet, 400mg Tablet, Release) 800mg Tablet) Feenamint (Tablet Delayed- 1 PV Cimetidine HCl (Oral Solution) 1 Release) Famotidine (200mg/20ml 1 Fleet Laxative (Tablet Delayed- 1 PV Injection, 20mg/2ml Injection, Release) 40mg/4ml Injection, 20mg Tablet, GaviLAX (Powder) 1 PV 40mg Tablet, 40mg/5ml Suspension) GaviLyte-C (Oral Solution) 1 QL,PV GaviLyte-G (Oral Solution) 1 QL,PV Nizatidine (Capsule) 1 GaviLyte-H (Kit) 1 Ranitidine HCl (150mg Capsule, 1 300mg Capsule, 150mg Tablet, GaviLyte-N/Flavor Pack (Oral 1 QL,PV 300mg Tablet, 150mg/10ml Solution) Syrup, 15mg/ml Syrup, Generlac (Oral Solution) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 47 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Gentle Laxative (Tablet Delayed- 1 PV SM ClearLax (Powder) 1 PV Release) SM Gentle Laxative (Tablet 1 PV Gentlelax (Powder) 1 PV Delayed-Release) Glycolax (Powder) 1 PV Smooth Lax (Powder) 1 PV GNP Bisa-Lax (Tablet Delayed- 1 PV Stimulant Laxative (Tablet 1 PV Release) Delayed-Release) GNP ClearLax (Powder) 1 PV Suprep Bowel Prep Kit (Oral 3 GNP Womens Laxative (Tablet 1 PV Solution) Delayed-Release) SW ClearLax (Powder) 1 PV Goodsense Magnesium Citrate 1 PV TGT Powderlax (Powder) 1 PV (Solution) TriLyte (Oral Solution) 1 QL,PV HM ClearLax (Powder) 1 PV Veracolate (Tablet Delayed- 1 PV HM Laxative (Tablet Delayed- 1 PV Release) Release) Womans Laxative (Tablet 1 PV KLS LaxaClear (Powder) 1 PV Delayed-Release) KP Bisacodyl (Tablet Delayed- 1 PV Womens Laxative (Tablet 1 PV Release) Delayed-Release) Lactulose (Oral Solution) 1 Gastrointestinal Agents : Protectants Laxative (Tablet Delayed- 1 PV Carafate (1gm/10ml 3 Release) Suspension) Laxative Feminine (Tablet 1 PV Misoprostol (Tablet) 1 Delayed-Release) Sucralfate (1gm Tablet) 1 Magnesium Citrate (Oral 1 PV Gastrointestinal Agents : Proton Pump Solution) Inhibitors Mineral Oil Heavy (0 Oil) 1 Dexilant (Capsule Delayed- 2 QL MoviPrep (Oral Solution) 3 Release) PEG 3350 (Powder) RX 1 PV Esomeprazole Magnesium 1 QL PEG 3350/Electrolytes (Oral 1 QL,PV (Capsule Delayed-Release) Solution) (Generic Nexium) PEG-3350/Electrolytes (Oral 1 QL,PV Esomeprazole Sodium (40mg 1 Solution) (Generic GoLYTELY) Injection) PEG-3350/NaCl/Na 1 QL,PV Lansoprazole (Capsule Delayed- 1 QL Bicarbonate/KCl (Oral Solution) Release) (Generic NuLYTELY) Omeprazole (Capsule Delayed- 1 QL Peg-Prep (Kit) 1 Release) Pegylax (Powder) 1 PV Omeprazole/Sodium Bicarbonate 1 QL Polyethylene Glycol 3350 1 (20mg-1100mg Capsule, 40mg- (Packet, Powder) 1100mg Capsule, 20mg-1680mg Packet, 40mg-1680mg Packet) Prepopik (Packet) 3 1 QL QC Gentle Laxative (Tablet 1 PV Pantoprazole Sodium (20mg Delayed-Release) Tablet Delayed-Release, 40mg Tablet Delayed-Release, 40mg QC Natura-Lax (Powder) 1 PV Injection) RA Laxative (Powder, 5mg 1 PV Rabeprazole Sodium (Tablet 1 QL Tablet Delayed-Release) Delayed-Release) SB Bisacodyl Laxative EC 1 PV Genetic or Enzyme Disorder: Replacement, (Tablet Delayed-Release)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 48 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Modifiers, Treatment Toviaz (Tablet Extended- 3 Aldurazyme (Injection) 4 PA Release 24 Hour) Buphenyl (500mg Tablet) 4 Trospium Chloride (Tablet) 1 Cerdelga (Capsule) 4 PA Trospium Chloride ER (Capsule 1 Cerezyme (Injection) 4 PA Extended-Release 24 Hour) Creon (Capsule Delayed- 2 Vesicare (Tablet) 2 Release) Genitourinary Agents : Benign Prostatic Cystadane (Powder) 4 Hypertrophy Agents Cystagon (Capsule) 4 Alfuzosin HCl ER (Tablet 1 Elaprase (Injection) 4 PA Extended-Release 24 Hour) Elelyso (Injection) 4 PA Cardura XL (4mg Tablet 3 ST Extended-Release 24 Hour) Fabrazyme (Injection) 4 PA 2 QL,PA Kuvan (100mg Packet, 500mg 4 PA Cialis (2.5mg Tablet, 5mg Packet, 100mg Tablet Soluble) Tablet) Lumizyme (Injection) 4 PA Dutasteride (Capsule) 1 1 Naglazyme (Injection) 4 PA Dutasteride/Tamsulosin HCl (Capsule) Orfadin (10mg Capsule, 20mg 4 Finasteride (5mg Tablet) 1 Capsule, 2mg Capsule, 5mg Capsule) Rapaflo (Capsule) 2 RAVICTI (Liquid) 4 PA Tamsulosin HCl (Capsule) 1 Sodium Phenylbutyrate (Powder) 4 Terazosin HCl (Capsule) 1 Strensiq (Injection) 4 PA Genitourinary Agents : Genitourinary Agents, Sucraid (Oral Solution) 4 Other Vimizim (Injection) 4 PA Acetic Acid 0.25% (Irrigation 1 Solution) VPRIV (Injection) 4 PA Alprostadil (Injection) 1 Zavesca (Capsule) 4 PA Aminoacetic Acid (Irrigation 1 Zenpep (Capsule Delayed- 2 Solution) Release) Bethanechol Chloride (Tablet) 1 Genitourinary Agents : Antispasmodics, Calcium Acetate (667mg 1 Urinary Capsule, 667mg Tablet) Darifenacin HBr ER (Tablet 1 Cuprimine (Capsule) 4 PA Extended-Release 24 Hour) Depen Titratabs (Tablet) 2 Flavoxate HCl (Tablet) 1 Elmiron (Capsule) 2 Gelnique (Gel) 3 Encare (Suppository) 3 QL,PV Gelnique Pump (Gel) 3 Fosrenol (1000mg Packet, 3 Myrbetriq (Tablet Extended- 2 Release 24 Hour) 750mg Packet, 1000mg Tablet Chewable, 500mg Tablet Oxybutynin Chloride (5mg 1 Chewable, 750mg Tablet Tablet, 5mg/5ml Syrup) Chewable) Oxybutynin Chloride ER (Tablet 1 Glycine (1.5% Irrigation Solution) 1 Extended-Release 24 Hour) Options Gynol II Vaginal 3 QL,PV Tolterodine Tartrate (Tablet) 1 Contraceptive (Gel) Tolterodine Tartrate ER (Capsule 1 Phenazo (Tablet) 1 Extended-Release 24 Hour) Phenazopyridine HCl (100mg 1

Tablet, 200mg Tablet)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 49 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Phoslyra (Oral Solution) 3 Cormax Scalp Application 1 Renagel (Tablet) 3 (External Solution) Renvela (2.4gm Packet, 800mg 2 Cortisone Acetate (25mg 2 Tablet) Tablet) Sevelamer Carbonate (Packet) 1 Deltasone (Tablet) 1 Shur-Seal (Gel) 3 QL,PV Depo-Medrol (20mg/ml 3 VCF Vaginal Contraceptive 3 QL,PV Injection) Film (Film) Desonide (0.05% Cream, 0.05% 1 VCF Vaginal Contraceptive 3 QL,PV Lotion, 0.05% Ointment) Foam (Foam) Desoximetasone (0.05% Cream, 1 VCF Vaginal Contraceptive Gel 1 QL,PV 0.25% Cream, 0.05% Gel, 0.05% (Gel) Ointment, 0.25% Ointment) Velphoro (Tablet Chewable) 3 Dexamethasone (0.5mg Tablet, 1 0.75mg Tablet, 1.5mg Tablet, Hormonal Agents, 1mg Tablet, 2mg Tablet, 4mg Stimulant/Replacement/Modifying (Adrenal) Tablet, 6mg Tablet, 0.5mg/5ml Ala-Cort (Cream) 1 Elixir, 0.5mg/5ml Oral Solution) Alclometasone Dipropionate 1 Dexamethasone Intensol 3 (0.05% Cream, 0.05% Ointment) (1mg/ml Concentrate) Amcinonide (0.1% Cream, 0.1% 1 Dexamethasone Sodium 1 Lotion, 0.1% Ointment) Phosphate (10mg/ml Injection, Ana-Lex (Kit) 1 120mg/30ml Injection, 20mg/5ml ApexiCon E (Cream) 1 Injection, 4mg/ml Injection) Augmented Betamethasone 1 DexPak 10 Day (Tablet 3 Dipropionate (0.05% Cream, Therapy Pack) 0.05% Gel, 0.05% Lotion, 0.05% DexPak 13 Day (Tablet 3 Ointment) Therapy Pack) Betamethasone Dipropionate 1 DexPak 6 Day (Tablet Therapy 3 (0.05% Cream, 0.05% Lotion, Pack) 0.05% Ointment) Diflorasone Diacetate (0.05% 1 Betamethasone Sodium 1 Cream, 0.05% Ointment) Phosphate/Betamethasone Fludrocortisone Acetate (0.1mg 1 Acetate (Injection) Tablet) Betamethasone Valerate (0.1% 1 Fluocinolone Acetonide (0.01% 1 Cream, 0.1% Lotion, 0.1% Cream, 0.025% Cream, 0.01% Ointment, 0.12% Foam) External Solution, 0.025% Capex (Shampoo) 3 Ointment) Clobetasol Propionate (0.05% 1 Fluocinolone Acetonide Body 1 Cream, 0.05% External Solution, (Oil) 0.05% Foam, 0.05% Gel, 0.05% Fluocinolone Acetonide Scalp 1 Liquid, 0.05% Lotion, 0.05% (Oil) Ointment, 0.05% Shampoo) Fluocinonide (0.05% Cream, 1 Clobetasol Propionate Emollient 1 0.1% Cream, 0.05% External (Cream) Solution, 0.05% Gel, 0.05% Clocortolone Pivalate (Cream) 3 Ointment) Clodan (Shampoo) 1 Fluocinonide Emulsified Base 1 Cordran (4mcg/sqcm Tape) 3 (Cream)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 50 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Fluocinonide-E (Cream) 1 Prednisolone Sodium Phosphate 1 Flurandrenolide (0.05% Cream, 1 ODT (Tablet Dispersible) 0.05% Lotion, 0.05% Ointment) Prednisone (10mg Tablet 1 Fluticasone Propionate (0.005% 1 Therapy Pack, 5mg Tablet Ointment, 0.05% Cream, 0.05% Therapy Pack, 10mg Tablet, 1mg Lotion) Tablet, 2.5mg Tablet, 20mg Halobetasol Propionate (0.05% 1 Tablet, 50mg Tablet, 5mg Tablet) Cream, 0.05% Ointment) Prednisone Intensol (5mg/ml 2 Halog (0.1% Cream, 0.1% 3 Concentrate) Ointment) Scalacort (Lotion) 1 Hydrocortisone (1% Cream, 1 Solu-Cortef (1000mg Injection) 3 2.5% Cream, 1% Ointment, 2.5% Texacort (External Solution) 3 Ointment, 10mg Tablet, 20mg Triamcinolone Acetonide 1 Tablet, 5mg Tablet, 2.5% Lotion) (0.025% Cream, 0.1% Cream, Hydrocortisone 1% in Absorbase 1 0.5% Cream, 0.025% Lotion, (Ointment) 0.1% Lotion, 0.025% Ointment, Hydrocortisone Butyrate (0.1% 1 0.1% Ointment, 0.5% Ointment, Cream, 0.1% External Solution, 0.147mg/gm Aerosol Solution) 0.1% Ointment) Triderm (Cream) 1 Hydrocortisone Valerate (0.2% 1 Hormonal Agents, Cream, 0.2% Ointment) Stimulant/Replacement/Modifying (Pituitary) Lidocaine HCl/Hydrocortisone 1 Chorionic Gonadotropin 4 PA Acetate (0.5%-3% Cream, 0.5%- (Injection) 3% Kit, 1%-3% Kit, 2%-2% Kit, Desmopressin Acetate (0.01% 1 2.5%-3% Kit) Nasal Solution, 0.1mg Tablet, Locoid (0.1% Lotion) 3 0.2mg Tablet, 4mcg/ml Injection) Methylprednisolone (16mg 1 H.P. Acthar (Injection) 4 PA Tablet, 32mg Tablet, 4mg Tablet, Increlex (Injection) 4 PA 8mg Tablet) Lupron Depot-Ped (3-Month) 4 PA,QL Methylprednisolone Acetate 1 (Injection) (40mg/ml Injection, 80mg/ml Norditropin FlexPro (Injection) 4 PA Injection) Novarel (Injection) 4 PA Methylprednisolone Sodium 1 Nutropin AQ (Injection) 4 PA Succinate (Injection) Oxytocin (Injection) 1 Mometasone Furoate (0.1% 1 Pregnyl w/Diluent Benzyl 4 PA Cream, 0.1% External Solution, Alcohol/NaCl (Injection) 0.1% Ointment) Supprelin LA (Injection) 4 PA,QL Nolix (Lotion) 1 Prednicarbate (0.1% Cream, 1 Hormonal Agents, 0.1% Ointment) Stimulant/Replacement/Modifying (Sex Prednisolone (15mg/5ml Oral 1 Hormones/Modifiers) : Androgens Solution, 15mg/5ml Syrup) Anadrol-50 (Tablet) 3 PA AndroGel (40.5mg/2.5gm Gel) 2 PA Prednisolone Sodium Phosphate 1 (10mg/5ml Oral Solution, Androxy (Tablet) 3 PA 20mg/5ml Oral Solution, Danazol (100mg Capsule, 1 25mg/5ml Oral Solution, 200mg Capsule, 50mg Capsule) 5mg/5ml Oral Solution) Methitest (Tablet) 3 PA

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 51 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Methyltestosterone (10mg 1 PA Drospirenone/Ethinyl Estradiol 1 PV Capsule) (Tablet) Oxandrolone (Tablet) 1 PA,QL Drospirenone/Ethinyl 1 PV Striant 3 PA Estradiol/Levomefolate Calcium Testosterone (30mg/act Solution) 1 PA (Tablet) Testosterone Cypionate 1 PA Duavee (Tablet) 2 (Injection) Elinest (Tablet) 1 PV Testosterone Enanthate 1 PA Emoquette (Tablet) 1 PV (Injection) Enpresse-28 (Tablet) 1 PV Hormonal Agents, Enskyce (Tablet) 1 PV Stimulant/Replacement/Modifying (Sex Estarylla (Tablet) 1 PV Hormones/Modifiers) : Estrogens Estrace (0.1mg/gm Cream) 3 Altavera (Tablet) 1 PV Estradiol (0.025mg/24hr Patch 1 Alyacen 1/35 (Tablet) 1 PV Weekly, 0.05mg/24hr Patch Alyacen 7/7/7 (Tablet) 1 PV Weekly, 0.06mg/24hr Patch Amabelz (Tablet) 1 Weekly, 0.075mg/24hr Patch Amethia (Tablet) 1 QL,PV Weekly, 0.1mg/24hr Patch Weekly, 37.5mcg/24hr Patch Amethia Lo (Tablet) 1 QL,PV Weekly, 0.5mg Tablet, 1mg Apri (Tablet) 1 PV Tablet, 2mg Tablet) Aranelle (Tablet) 1 PV Estradiol Valerate (Injection) 1 Ashlyna (Tablet) 1 QL,PV Estradiol/Norethindrone Acetate 1 Aubra (Tablet) 1 PV (Tablet) Aviane (Tablet) 1 PV Estropipate (Tablet) 1 Azurette (Tablet) 1 PV Ethynodiol Diacetate/Ethinyl 1 PV Balziva (Tablet) 1 PV Estradiol (Tablet) Bekyree (Tablet) 1 PV Evamist (Solution) 3 Blisovi 24 Fe (Tablet) 1 PV Falmina (Tablet) 1 PV Blisovi Fe 1.5/30 (Tablet) 1 PV Fayosim (Tablet) 1 QL,PV Blisovi Fe 1/20 (Tablet) 1 PV Femynor (Tablet) 1 PV Briellyn (Tablet) 1 PV Fyavolv (Tablet) 1 Camrese (Tablet) 1 QL,PV Gianvi (Tablet) 1 PV Camrese Lo (Tablet) 1 QL,PV Gildagia (Tablet) 1 PV Caziant (Tablet) 1 PV Introvale (Tablet) 1 QL,PV Chateal (Tablet) 1 PV Isibloom (Tablet) 1 PV Combipatch (Patch Twice 3 Jevantique Lo (Tablet) 1 Weekly) Jinteli (Tablet) 1 Cryselle-28 (Tablet) 1 PV Jolessa (Tablet) 1 QL,PV Cyclafem (Tablet) 1 PV Juleber (Tablet) 1 PV Cyred (Tablet) 1 PV Junel 1.5/30 (Tablet) 1 PV Dasetta 1/35 (Tablet) 1 PV Junel 1/20 (Tablet) 1 PV Dasetta 7/7/7 (Tablet) 1 PV Junel Fe 1.5/30 (Tablet) 1 PV Daysee (Tablet) 1 QL,PV Junel Fe 1/20 (Tablet) 1 PV Delyla (Tablet) 1 PV Junel Fe 24 (Tablet) 1 PV Desogestrel/Ethinyl Estradiol 1 PV Kaitlib Fe (Tablet Chewable) 1 PV (Tablet)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 52 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Kariva (Tablet) 1 PV Nexplanon (Injection) 4 PV Kelnor 1/35 (Tablet) 1 PV Nikki (Tablet) 1 PV Kimidess (Tablet) 1 PV Norethindrone & Ethinyl Estradiol 1 PV Kurvelo (Tablet) 1 PV Ferrous Fumarate (Tablet LARIN 1.5/30 (Tablet) 1 PV Chewable) LARIN 1/20 (Tablet) 1 PV Norethindrone Acetate/Ethinyl 1 LARIN 24 Fe (Tablet) 1 PV Estradiol (Tablet) 1 PV LARIN Fe 1.5/30 (Tablet) 1 PV Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate LARIN Fe 1/20 (Tablet) 1 PV (20mcg-75mg-1mg Tablet, Larissia (Tablet) 1 PV 20mcg-75mg-1mg Tablet Layolis Fe (Tablet Chewable) 1 PV Chewable) Leena (Tablet) 1 PV Norethindrone/Ethinyl 1 PV Lessina (Tablet) 1 PV Estradiol/Ferrous Fumarate Levonest (Tablet) 1 PV (Tablet Chewable) Levonorgestrel and Ethinyl 1 PV Norgestimate/Ethinyl Estradiol 1 PV Estradiol (Tablet) (Tablet) Levonorgestrel/Ethinyl Estradiol 1 PV Nortrel 0.5/35 (28) (Tablet) 1 PV (0-Tablet, 20mcg-0.1mg Tablet) Nortrel 1/35 (Tablet) 1 PV Levonorgestrel/Ethinyl Estradiol 1 QL,PV Nortrel 7/7/7 (Tablet) 1 PV (0.03mg-0.15mg Tablet) NuvaRing (Ring) 2 PV Levora 0.15/30-28 (Tablet) 1 PV Ocella (Tablet) 1 PV Lo Loestrin Fe (Tablet) 3 Ogestrel (Tablet) 1 PV Lomedia 24 Fe (Tablet) 1 PV Orsythia (Tablet) 1 PV Lopreeza (Tablet) 1 Philith (Tablet) 1 PV Loryna (Tablet) 1 PV Pimtrea (Tablet) 1 PV Low-Ogestrel (Tablet) 1 PV Pirmella 1/35 (Tablet) 1 PV Lutera (Tablet) 1 PV Pirmella 7/7/7 (Tablet) 1 PV Marlissa (Tablet) 1 PV Portia-28 (Tablet) 1 PV Menest (Tablet) 2 Premarin (0.3mg Tablet, 2 Mibelas 24 Fe (Tablet Chewable) 1 PV 0.45mg Tablet, 0.625mg Tablet, Microgestin 1.5/30 (Tablet) 1 PV 0.9mg Tablet, 1.25mg Tablet) Microgestin 1/20 (Tablet) 1 PV Premphase (Tablet) 2 Microgestin 24 Fe (Tablet) 1 PV Prempro (Tablet) 2 Microgestin Fe (Tablet) 1 PV Previfem (Tablet) 1 PV Microgestin Fe 1.5/30 (Tablet) 1 PV Quasense (Tablet) 1 QL,PV Mimvey (Tablet) 1 Rajani (Tablet) 1 PV Mimvey Lo (Tablet) 1 Reclipsen (Tablet) 1 PV Mono-Linyah (Tablet) 1 PV Rivelsa (Tablet) 1 QL,PV MonoNessa (Tablet) 1 PV Setlakin (Tablet) 1 QL,PV Myzilra (Tablet) 1 PV Sprintec 28 (Tablet) 1 PV Natazia (Tablet) 2 PV Sronyx (Tablet) 1 PV Necon 0.5/35-28 (Tablet) 1 PV Syeda (Tablet) 1 PV Necon 1/50-28 (Tablet) 1 PV Tarina Fe 1/20 (Tablet) 1 PV Necon 7/7/7 (Tablet) 1 PV Tilia Fe (Tablet) 1 PV

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 53 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Tri Femynor (Tablet) 1 PV Heather (Tablet) 1 PV Tri-Estarylla (Tablet) 1 PV Jencycla (Tablet) 1 PV Tri-Legest Fe (Tablet) 1 PV Jolivette (Tablet) 1 PV Tri-Linyah (Tablet) 1 PV Kyleena (IUD) 4 PV Tri-Lo-Estarylla (Tablet) 1 PV Levonorgestrel (Tablet) 1 PV Tri-Lo-Marzia (Tablet) 1 PV Liletta (IUD) 4 PV Tri-Lo-Sprintec (Tablet) 1 PV Lyza (Tablet) 1 PV Tri-Previfem (Tablet) 1 PV Medroxyprogesterone Acetate 1 Tri-Sprintec (Tablet) 1 PV (10mg Tablet, 2.5mg Tablet, 5mg Trinessa (Tablet) 1 PV Tablet) Trinessa Lo (Tablet) 1 PV Medroxyprogesterone Acetate 1 QL,PV (150mg/ml Injection) Trivora-28 (Tablet) 1 PV Megestrol Acetate (20mg Tablet, 1 Velivet (Tablet) 1 PV 40mg Tablet, 400mg/10ml Vestura (Tablet) 1 PV Suspension, 40mg/ml Vienva (Tablet) 1 PV Suspension, 625mg/5ml Viorele (Tablet) 1 PV Suspension) Vyfemla (Tablet) 1 PV Mirena (IUD) 3 PV Wera (Tablet) 1 PV My Way (Tablet) 1 PV WYMZYA Fe (Tablet Chewable) 1 PV Next Choice One Dose (Tablet) 1 PV Xulane (Patch Weekly) 1 PV Nora-BE (Tablet) 1 PV Yuvafem (Tablet) 1 Norethindrone (Tablet) 1 PV Zarah (Tablet) 1 PV Norethindrone Acetate (5mg 1 Zenchent (Tablet) 1 PV Tablet) Zenchent Fe (Tablet Chewable) 1 PV Norlyda (Tablet) 1 PV Zovia 1/35E (Tablet) 1 PV Norlyroc (Tablet) 1 PV Zovia 1/50E (Tablet) 1 PV Opcicon One-Step (Tablet) 1 PV Hormonal Agents, Option 2 (Tablet) 1 PV Stimulant/Replacement/Modifying (Sex Progesterone (100mg Capsule, 1 Hormones/Modifiers) : Progesterone 200mg Capsule, 50mg/ml Agonists/Antagonists Injection) Makena (Injection) 4 PA React (Tablet) 1 PV Hormonal Agents, Sharobel (Tablet) 1 PV Stimulant/Replacement/Modifying (Sex Skyla (IUD) 3 PV Hormones/Modifiers) : Progestins Take Action (Tablet) 1 PV Aftera (Tablet) 1 PV Hormonal Agents, Camila (Tablet) 1 PV Stimulant/Replacement/Modifying (Sex Deblitane (Tablet) 1 PV Hormones/Modifiers) : Selective Estrogen Depo-Provera (Injection) 3 Receptor Modifying Agents Depo-SubQ Provera104 3 QL Osphena (Tablet) 3 (Injection) Raloxifene HCl (Tablet) 1 PV* Econtra EZ (Tablet) 1 PV Hormonal Agents, Ella (Tablet) 3 PV Stimulant/Replacement/Modifying (Thyroid) Errin (Tablet) 1 PV Armour Thyroid (180mg 3 Fallback Solo (Tablet) 1 PV Tablet, 240mg Tablet, 300mg Tablet) Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 54 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Levo-T (Tablet) 1 Methimazole (10mg Tablet, 5mg 1 Levothyroxine Sodium (100mcg 1 Tablet) Tablet, 112mcg Tablet, 125mcg Propylthiouracil (Tablet) 1 Tablet, 137mcg Tablet, 150mcg Immunological Agents : Angioedema Agents Tablet, 175mcg Tablet, 200mcg Berinert (Injection) 4 PA Tablet, 25mcg Tablet, 300mcg Cinryze (Injection) 4 PA Tablet, 50mcg Tablet, 75mcg Firazyr (Injection) 4 PA Tablet, 88mcg Tablet) Immunological Agents : Immune Levoxyl (Tablet) 1 Suppressants Liothyronine Sodium (10mcg/ml 1 Azasan (Tablet) 3 Injection, 25mcg Tablet, 50mcg 1 Tablet, 5mcg Tablet) Azathioprine (100mg Injection, 50mg Tablet) NP Thyroid (Tablet) 1 Cimzia (Injection) 4 PA NP Thyroid 15 (Tablet) 1 Cimzia Starter Kit (Injection) 4 PA NP Thyroid 60 (Tablet) 1 Cyclosporine (100mg Capsule, 1 NP Thyroid 90 (Tablet) 1 25mg Capsule, 50mg/ml Thyrolar (Tablet) 3 Injection) Unithroid (Tablet) 1 Cyclosporine Modified (100mg 1 Unithroid Direct (Tablet) 1 Capsule, 25mg Capsule, 50mg WP Thyroid (Tablet) 3 Capsule, 100mg/ml Oral Hormonal Agents, Suppressant (Adrenal) Solution) Lysodren (Tablet) 2 Enbrel (Injection) 4 PA Hormonal Agents, Suppressant (Pituitary) Enbrel SureClick (Injection) 4 PA Cabergoline (Tablet) 1 Gengraf (100mg Capsule, 25mg 1 Leuprolide Acetate (Injection) 4 PA Capsule, 50mg Capsule, Lupaneta Pack (Kit) 4 PA,QL 100mg/ml Oral Solution) Lupron Depot (1-Month) 4 PA,QL Humira (Injection) 4 PA (Injection) Humira Pediatric Crohns 4 PA Lupron Depot (3-Month) 4 PA,QL Disease Starter Pack (Injection) (Injection) Lupron Depot (4-Month) 4 PA,QL Humira Pen (Injection) 4 PA (Injection) Humira Pen Crohns Disease 4 PA Lupron Depot (6-Month) 4 PA,QL Starter Pack (Injection) (Injection) Humira Pen-Psoriasis Starter 4 PA Lupron Depot-Ped (1-Month) 4 PA,QL (Injection) (Injection) Kineret (Injection) 4 PA Octreotide Acetate (Injection) 4 PA Methotrexate (2.5mg Tablet) 1 Sandostatin LAR Depot 4 PA Methotrexate Sodium (Injection) 1 (Injection) Mycophenolate Mofetil 1 Signifor (Injection) 4 PA,QL (200mg/ml Suspension, 250mg Somatuline Depot (Injection) 4 PA Capsule, 500mg Injection, Somavert (Injection) 4 PA 500mg Tablet) Mycophenolic Acid DR (Tablet 1 Synarel (Nasal Solution) 2 Delayed-Release) Zoladex (3.6mg Injection) 4 QL Orencia (125mg/ml Injection, 4 PA Hormonal Agents, Suppressant (Thyroid) : 50mg/0.4ml Injection, Antithyroid Agents

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 55 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits 87.5mg/0.7ml Injection, 250mg Micrhogam Ultra-Filtered Plus 4 Injection) (Injection) Orencia Clickject (Injection) 4 PA Nabi-Hb (Injection) 4 Prograf (5mg/ml Injection) 3 Octagam (Injection) 4 PA Rapamune (1mg/ml Oral 3 Privigen (Injection) 4 PA Solution) Rhogam Ultra-Filtered Plus 4 Remicade (Injection) 4 PA (Injection) Sandimmune (100mg/ml Oral 2 Rhophylac (Injection) 4 Solution) Thymoglobulin (Injection) 3 Simponi (Injection) 4 PA WinRho SDF (Injection) 4 Simponi Aria (Injection) 4 PA Immunological Agents : Immunomodulators Sirolimus (Tablet) 1 Actemra (162mg/0.9ml 4 PA,QL Stelara (130mg/26ml Injection) 4 PA Injection) Tacrolimus (0.5mg Capsule, 1mg 1 Actemra (200mg/10ml 4 PA Capsule, 5mg Capsule) Injection, 400mg/20ml Torisel (Injection) 4 Injection, 80mg/4ml Injection) Trexall (Tablet) 3 Actimmune (Injection) 4 Xeljanz (Tablet) 4 PA Arcalyst (Injection) 4 PA Zortress (Tablet) 3 PA Hyqvia (Injection) 4 PA Immunological Agents : Immunizing Agents, Ilaris (Injection) 4 PA,QL Passive Leflunomide (Tablet) 1 Atgam (Injection) 4 Ridaura (Capsule) 3 BIVIGAM (Injection) 4 PA Simulect (20mg Injection) 3 Carimune Nanofiltered 4 PA Synagis (Injection) 4 PA (Injection) Taltz (Injection) 4 PA Cuvitru (1gm/5ml Injection, 4 PA Immunological Agents : Vaccines 2gm/10ml Injection, 4gm/20ml ActHIB (Injection) 2 PV Injection) Adacel (Injection) 2 PV Cytogam (Injection) 4 PA Afluria 2016-2017 (Injection) 2 PV Flebogamma DIF (Injection) 4 PA Afluria PF 2016-2017 2 PV Gamastan S/D (Injection) 4 PA (Injection) Gammagard Liquid (Injection) 4 PA Afluria Quadrivalent 2016-2017 2 PV Gammagard S/D IGA Less 4 PA (Injection) Than 1 mcg/ml (Injection) Bexsero (Injection) 2 PV Gammaked (Injection) 4 PA Boostrix (Injection) 2 PV Gammaplex (Injection) 4 PA Daptacel (Injection) 2 PV Gamunex-C (Injection) 4 PA Diphtheria/Tetanus Toxoids 2 PV Hepagam B (Injection) 4 Adsorbed Pediatric (Injection) Hizentra (Injection) 4 PA Engerix-B (Injection) 2 PV Hyperhep B S/D (Injection) 4 Fluad 2016-2017 (Injection) 2 PV Hyperrab S/D (Injection) 4 Fluarix Quadrivalent 2017-2018 2 PV Hyperrho S/D (Injection) 4 (Suspension Prefilled Syringe) Hyperrho S/D Mini-Dose 4 Flublok 2017-2018 (Solution) 2 PV (Injection) Imogam Rabies-HT (Injection) 4

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 56 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Flublok Quadrivalent 2017- 2 PV Inflammatory Bowel Disease Agents : 2018 (Solution Prefilled Aminosalicylates Syringe) Apriso (Capsule Extended- 2 QL Flucelvax Quadrivalent 2016- 2 PV Release 24 Hour) 2017 (Injection) Balsalazide Disodium (Capsule) 1 Flulaval Quadrivalent 2017- 2 PV Canasa (Suppository) 2 2018 (Suspension) Dipentum (Capsule) 3 Fluvirin 2016-2017 (Injection) 2 PV Mesalamine (4gm Enema, 4gm 1 Fluzone High-Dose Pf 2017- 2 PV Kit) 2018 (Suspension Prefilled Mesalamine DR (1.2 gm Tablet 1 Syringe) Delayed-Release, generic Lialda) Fluzone Quadrivalent 2017- 2 PV Pentasa (Capsule Extended- 3 2018 (Suspension Prefilled Release) Syringe) Inflammatory Bowel Disease Agents : Gardasil (Injection) 2 PV Glucocorticoids Gardasil 9 (Injection) 2 PV Budesonide (3mg Capsule 1 Havrix (Injection) 2 PV Delayed-Release) Hiberix (Injection) 2 PV Colocort (Enema) 1 Infanrix (Injection) 2 PV Cortifoam (Foam) 3 IPOL Inactivated IPV (Injection) 2 PV Hydrocort Enema 100mg 1 Kinrix (Injection) 2 PV (Enema) M-M-R II (Injection) 2 PV Hydrocortisone (2.5% Cream) 1 Medical Provider Single Use 2 PV Procto-Med HC (Cream) 1 EZ Flu Shot (Injection) Procto-Pak (Cream) 1 Menactra (Injection) 2 PV Proctosol HC (Cream) 1 MENHIBRIX (Injection) 2 PV Proctozone-HC (Cream) 1 Menveo (Injection) 2 PV Inflammatory Bowel Disease Agents : Pediarix (Injection) 2 PV Sulfonamides Pedvax HIB (Injection) 2 PV Sulfasalazine (500mg Tablet, 1 Pentacel (Injection) 2 PV 500mg Tablet Delayed-Release) Pneumovax 23 (Injection) 2 PV Metabolic Bone Disease Agents Prevnar 13 (Injection) 2 PV Alendronate Sodium (10mg 1 ProQuad (Injection) 2 PV Tablet, 40mg Tablet, 5mg Tablet) Quadracel (Injection) 2 PV Alendronate Sodium (35mg 1 QL Recombivax HB (Injection) 2 PV Tablet, 70mg Tablet) Rotarix (Suspension) 2 PV Alendronate Sodium 2 (70mg/75ml Oral Solution) RotaTeq (Oral Solution) 2 PV Calcitonin-Salmon (Nasal 1 QL Tenivac (Injection) 2 PV Solution) Tetanus/Diphtheria Toxoids- 2 PV Calcitriol (0.25mcg Capsule, 1 Adsorbed (Injection) 0.5mcg Capsule, 1mcg/ml Trumenba (Injection) 2 PV Injection, 1mcg/ml Oral Solution) Twinrix (Injection) 2 PV Doxercalciferol (0.5mcg Capsule, 1 VAQTA (Injection) 2 PV 1mcg Capsule, 2.5mcg Capsule, Varivax (Injection) 2 PV 4mcg/2ml Injection) Zostavax (Injection) 2 PV Etidronate Disodium (Tablet) 1

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 57 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Forteo (Injection) 4 PA,QL Argyle Sterile Water 100ml 1 Fosamax Plus D (Tablet) 3 QL (Solution) Hectorol (2mcg/ml Injection) 3 Asilnasal Rms (Capsule) 1 Ibandronate Sodium (150mg 1 QL Assure Haemolance Plus High 2 Tablet, 3mg/3ml Injection) Flow 18g Miacalcin (Injection) 3 Assure Haemolance Plus Low 2 Pamidronate Disodium (30mg 4 Flow 25g Injection, 30mg/10ml Injection, Assure Haemolance Plus 2 90mg Injection, 90mg/10ml Micro Flow 28g Injection) Assure Haemolance Plus 2 Pamidronate Disodium 4 Normal Flow 21g (6mg/ml Injection) Assure Haemolance Plus 2 Paricalcitol (1mcg Capsule, 1 Pediatric Blade 2mcg Capsule, 4mcg Capsule, Aurora Lancet Super Thin 30g 2 2mcg/ml Injection, 5mcg/ml Aurora Lancet Thin 23g 2 Injection) AuroRA Pen Needles 2 Prolia (Injection) 4 PA,QL Autopen (Device) 3 Rayaldee (Capsule Extended- 3 BD Autoshield 29g X 3/16" 2 Release) BD Autoshield 29g X 5/16" 2 Risedronate Sodium (150mg 1 QL BD Autoshield Duo 30g X 3/16" 2 Tablet, 35mg Tablet) BD insul Syr Mis Lo Dose 2 Risedronate Sodium (30mg 1 BD Lancet Ultrafine 30g 2 Tablet, 5mg Tablet) BD Lancet Ultrafine 33g 2 Risedronate Sodium DR (Tablet 1 QL BD Pen 3 Delayed-Release) Xgeva (Injection) 4 PA BD Pen Mini 3 BD Swabs Single Use 3 Zoledronic Acid (4mg/100ml 4 Injection) BD Swabs Single Use Butterfly 3 Zoledronic Acid (4mg/5ml 4 Benzonatate (Capsule) 1 Injection, 5mg/100ml Injection) Botox (Injection) 4 PA Zometa (4mg/100ml Injection) 4 Carefine Pen Needle 32gx4mm 3 Miscellaneous Therapeutic Agents Carefine Pen Needles 3 Accu-Chek Fastclix Lancet 2 Careone Lancet Thin 2 Device Kit (Kit) Careone Lancet Ultra Thin 2 Accu-Chek Multiclix Lancet 2 Caretouch Alcohol Prep Pads 3 Device Kit (Kit) Caretouch Pen Needles 2 Accu-Chek Softclix Lancet 2 Caya (Diaphragm) 3 QL,PV Device Kit (Kit) Cerovel (Lotion) 1 Addyi (Tablet) 3 PA Chek-Stix Control (Strip) 3 Adenosine (Injection) 1 Chemstrip 10 MD (Strip) 3 Advocate Insulin Pen Needles 2 Chemstrip 2 GP Strips (Strip) 3 Alcoh-Glove Contoured Wipe 3 Chemstrip 5 OB (Strip) 3 Alcoh-Wipe 12" X 12" 3 Chemstrip 7 (Strip) 3 Alcohol Prep Pads 3 Chemstrip 9 Strips (Strip) 3 Alcohol Swabs 3 Chemstrip UGK (Strip) 3 Alcohol Swabstick 3 Chemstrip-10 with SG (Strip) 3

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 58 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Chemstrip-K (Strip) 3 Excel Comfort Point Insulin 2 Clever Choice Comfort EZ 2 Pen Needles Insulin Pen Needles Exel Comfort Point Insulin 2 Clickfine Pen Needle 2 Syringe/0.3ml/29g X 1/2" 32gx5/32" Exel Comfort Point Insulin 2 Clickfine Pen Needles 2 Syringe/0.3ml/30g X 5/16" Combistix (Strip) 3 FC Female Condom 3 QL,PV Curity Alcohol Prep 3 FC2 Female Condom 3 QL,PV Pads/Medium 2 Ply Femcap (Device) 3 QL,PV Curity Alcohol Swabs 3 Fifty50 Alcohol Prep Pads 3 CVS Ketone Care (Strip) 3 Fifty50 Pen Needles 2 CVS Prep Pads 3 Fine 30 2 Deferoxamine Mesylate 1 Flexichamber Child 2 (Injection) Mask/Large Dexmedetomidine HCl (Injection) 1 Flexichamber Child 2 Diascreen 10 3 Mask/Small Diascreen 1B 3 Flumazenil (Injection) 1 Diascreen 1G (Strip) 3 Fomepizole (Injection) 1 Diascreen 1K 3 Global Alcohol Prep Ease 3 Diascreen 2GK (Strip) 3 Pads Diascreen 2GP 3 GNP Alcohol Swabs 3 Diascreen 3 3 H-E-B in Control Pen Needles 2 Diascreen 4NL 3 H-E-B Incontrol Alcohol Prep 3 Pads Diascreen 4OBL 3 Haemolance 2 Diascreen 4PH 3 Haemolance Plus 2 Diascreen 5 3 Haemolance Plus High Flow 2 Diascreen 6 3 Haemolance Plus Low Flow 2 Diascreen 7 3 Haemolance Plus Max Flow 2 Diascreen 8 3 Haemolance Plus Pediatric 2 Diascreen 9 3 Flow Diascreen Liquid Urine 3 Hema-Combistix (Strip) 3 Controls Humapen Luxura HD (Device) 3 Droplet Pen Needles 2 In Touch Diabetes 3 Duane Reade Lancet Alternate 2 Management Software Site 26g Inspirease Reservoir Bags 2 Duane Reade Lancet Ultra Thin 2 28g Insulin Syringe/0.5ml/27g X 2 1/2" Easy Comfort Pen Needles 2 Insulin Syringe/U-100/1ml/28g 2 Easy Touch 32gx5mm 2 X 1/2" Easy Touch 32gx6mm 2 Insulin Syringes, Needles 2 Easy Touch Alcohol Prep 3 Insupen 33gx4mm 2 Pads/Medium 2 EQL Alcohol Swabs 3 Insupen Pen Needles 32g X4mm Ergoloid Mesylates (Tablet) 1 Insupen Sensitive 32gx6mm 2

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 59 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Insupen Sensitive 32gx8mm 2 Monoject Insulin 2 Insupen Ultrafin 29gx12mm 2 Syringe/Softpack/1ml/27g X Insupen Ultrafin 30gx8mm 2 1/2" Insupen Ultrafin 31gx6mm 2 Monoject Insulin 2 Insupen Ultrafin 31gx8mm 2 Syringe/Softpack/U- 100/0.5ml/28g X 1/2" J-Tip Kit w/Vial Adapters (Kit) 3 Multistix (Strip) 3 Kanuma (Injection) 4 PA Multistix 10 Sg (Strip) 3 Keto-Diastix (Strip) 3 Multistix 5 (Strip) 3 Ketocare (Strip) 3 Multistix 7 (Strip) 3 Ketone Test Strips (Strip) 3 Multistix 8 SG (Strip) 3 Ketostix (Strip) 3 Multistix 9 (Strip) 3 Labstix (Strip) 3 Multistix 9 SG (Strip) 3 Lancets 2 Myalept (Injection) 4 PA Leader Super Thin Lancet 2 N-Acetyl-L-Cysteine (Capsule) 1 Lifescan Unistik 2 Deep 2 QL Nebusal (3% Nebulized Solution) 1 Penetration Novofine 30gx8mm 3 LiteTouch Pen Needles 2 Novofine 32gx6mm 3 Live Better Lancet Super Thin 2 30g Novofine Autocover 30gx8mm 3 Live Better Lancet Ultra Thin 2 Novofine Plus 32gx4mm 3 28g NovoPen Echo (Device) 3 Mannitol (Injection) 1 Novotwist 32gx5mm 3 Mask Vortex/Baby Whirl 2 Omniflex Diaphragm 3 QL,PV Duckling (Diaphragm) Mask Vortex/Child/Frog 2 Onetouch Combo Pack 2 Mask Vortex/Spinner the Duck 2 Onetouch Suresoft Lancing 2 Mask Vortex/Toddler/Lady Bug 2 Device/21g Medichoice Safety Lancet 2 Onetouch Ultra 2 (Kit) 2 Normal Onetouch Ultra Blue (Strip) 2 Medlance Plus SuperLite 30g 2 Onetouch Ultra Control (In 3 Medlance Plus SuperLite 2 Vitro Solution) 30g/Comfort Max Onetouch Ultra Mini (Kit) 2 Medlance/Extra 2 Onetouch Ultralink System 2 Medlance/Lite 2 (Hex) (Kit) Medlance/Universal 2 Onetouch Verio (Kit) 2 Meijer Alcohol Swabs Extra- 3 Onetouch Verio Control 3 Thick Solution High (Solution) Meijer Pen Needles 31g X 6mm 2 Onetouch Verio Flex 2 Bloodglucose Monitoring Methergine (Tablet) 1 System (Kit) Methylergonovine Maleate 1 Onetouch Verio Iq Blood 2 (Injection) Glucose Monitoring System Microtainer Safety Flow 2 (Kit) Lancet/Sterile/Single-Use Onetouch Verio Mid Control 3 Monoject Insulin Syringe/1ml 2 Solution (Solution)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 60 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Onetouch Verio Sync 2 Safe-T-Lance Low Flow 25g 2 Bloodglucose Monitoring Safe-T-Lance Normal Flow 21g 2 System (Kit) Safe-T-Lance Plus Safety 2 Onetouch Verio Test Strips 2 Lancet High Flow (Strip) Safe-T-Lance Plus Safety 2 Ortho-CS 250 (Injection) 1 Lancet Low Flow Osmitrol Viaflex (15% Injection, 1 Safe-T-Lance Plus Safety 2 20% Injection) Lancet Normal Flow Oxytocin/Sodium Chloride 1 Safety Insulin Syringes 2 (30unit/500ml-0.9% Injection) 1ml/27gx1/2" Panda Mask Large 2 Safety Insulin Syringes 2 Panda Mask Medium 2 1ml/30gx1/2" Panda Mask Small 2 Saps Care Alcohol Prep Pads 3 Paragard Intrauterine Copper 4 PV Saps Health Alcohol Prep 3 Contraceptive T380a (IUD) Pads Pediatric Panda Mask 2 SB Alcohol Prep Pads 3 Pen Needles 30gx5/16" 2 Sensipar (Tablet) 3 PA Pen Needles 30gx5mm 2 Side Button Safety Lancet21g 2 Pen Needles 30gx8mm 2 Single-Let 2 Penlet II Automatic Blood 3 SM Alcohol Prep Pads 3 Sampler (Kit) Sodium Chloride (0.9% 1 Penlet II Replacement Caps- 2 Nebulized Solution, 10% Deep Nebulized Solution, 3% Pentips 2 Nebulized Solution, 7% Phentermine HCl (15mg 1 PA Nebulized Solution) Capsule) Sodium Chloride Bacteriostatic 1 Precision Ultra Lancet 2 (Injection) Pressure Activated 2 Sodium Hyaluronate (Gel) 1 Safetylancet 21g Sodium Phenylacetate/Sodium 1 Pro Comfort Alcohol Prep 3 Benzoate (Injection) Pads Spinraza (Injection) 4 PA Pro Comfort Pen Needles 2 Sterilance Tl 2 Pulmosal (Nebulized Solution) 1 Sterile Diluent for Epoprostenol 1 PX Mini Pen Needles 31gx5mm 2 Sodium (Injection) QC Alcohol Swabs 3 Sterile Water for Injection 1 RA Alcohol Swabs 3 Sterile Water Irrigation (Solution) 1 RA Pen Needles 31g X 5mm 2 Super Daily D3 3 PV 3/16" (2000UT/0.028ml Liquid) Rea Lo 40 (40% Cream) 1 Sure Comfort Alcohol Prep 3 Pads Reality Swabs 3 Relion Ketone (Strip) 3 Sure Comfort Insulin 2 Syringes/0.5ml/31g X 6mm Relion Ketone Test Strips 3 2 (Strip) Sure Comfort Insulin Syringes/U-100/1ml/31gx6mm Relion Pen Needles 2 Sure Comfort Pen Needles 2 Remeven (Cream) 1 Sure-Fine Pen Needles 2

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 61 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Surestep Glucose Control (In 3 Ulticare U-100 Insulin 2 Vitro Solution) Syringes/1ml/31g X 1/4" Surestep Glucose Control 3 Ultiguard Insulin Syringe/U- 2 Solution (In Vitro Solution) 100/0.5ml/30g X 5/16" Surestep Pro High 3 Ultiguard Insulin Syringe/U- 2 Glucosecontrol (Liquid) 100/1ml/30g X 5/16" Surestep Pro Linearity Kit (Kit) 3 Ultilet Alcohol Swabs 3 Surestep Pro Low Glucose 3 Ultilet Insulin 2 Control (Liquid) Syringe/0.3ml/30g X 8mm Surestep Pro Normal Glucose 3 Ultilet Insulin 2 Control (Liquid) Syringe/0.3ml/31g X 8mm Techlite Pen Needles 2 Ultilet Insulin 2 TGT Lancet Alternate Site 2 Syringe/Short/0.5ml/31g X TGT Lancet Micro Thin 33g 2 5/16" TGT Lancet Super Thin 30g 2 Ultilet Insulin Syringe/U- 2 100/0.5ml/30g X 1/2" TGT Lancet Thin 23g 2 TGT Lancet Thin 26g 2 Ultilet Insulin Syringe/U- 2 100/0.5ml/31gx6mm TGT Lancet Ultra Thin 28g 2 Ultilet Insulin Syringe/U- 2 Thinlets Lancet 2 100/1ml/30g X 1/2" Today Sponge 3 QL,PV Ultilet Pen Needle 29gx12.7mm 2 Todays Health Mini Pen 2 Ultilet Pen Needle 31gx5mm 2 Needles Ultilet Pen Needle 31gx8mm 2 Ulticare Alcohol Swabs 3 Ultilet Pen Needle 32gx4mm 2 Ulticare Insulin Safety 2 Ultilet Pen Needle 2 Syringe/0.5ml/29g X 1/2" 32gx4mm/Short Ulticare Insulin Safety 2 Ultilet Short Pen 2 Syringe/1ml/29g X 1/2" Needles31gx3/16" Ulticare Insulin 2 Ultilet U-100 Insulin 2 Syringe/0.3ml/29g X 1/2" Syringes/1ml/31g X 6mm Ulticare Insulin 2 Ultra-Thin II Auto Lancet 2 Syringe/0.5ml/28g X 1/2" Ultra-Thin II Pen Needles 2 Ulticare Insulin Syringe/U- 2 100/0.3ml/30g X 1/2" 29gx1/2" Unilet ComforTouch Lancet 2 Ulticare Insulin Syringe/U- 2 100/0.3ml/31g X 5/16" Unilet Excelite 2 Ulticare Insulin Syringe/U- 2 Unilet Excelite II 2 100/0.5ml/31g X 5/16" Unilet G.P. Lancet 2 Ulticare Insulin Syringe/U- 2 Unilet G.P. SuperLite Lancet 2 100/1ml/31g X 5/16" Unilet GP 28 Ultra Thin 2 Ulticare Pen Needles/29g X 2 Unilet Lancet 2 12.7mm Unilet SuperLite Lancet 2 Ulticare U-100 Insulin 2 Unistik 3 Gentle 2 Syringes/0.3ml/31g X1/4" Urea (40% Cream, 50% Cream, 1 Ulticare U-100 Insulin 2 45% Lotion) Syringes/0.5ml/31g X 1/4" Urea Nail Gel (Gel) 1

Urea Topical (Suspension) 1 Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 62 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Urea-C40 (Lotion) 1 Neomycin/Polymyxin/Dexametha 1 Urin-Tek (Kit) 3 sone (0.1% Ophthalmic Uristix (Strip) 3 Suspension, 0.1%-3.5mg/gm- 10000unit/gm Ointment) Uristix 4 (Strip) 3 Neomycin/Polymyxin/Gramicidin 1 Valumark Lancet Ultra Thin 2 (Ophthalmic Solution) 28g Neomycin/Polymyxin/Hydrocortis 1 Vanishpoint Insulin 2 one (1% Ophthalmic Syringe/0.5ml/30g X 5/16" Suspension) Vanishpoint Insulin 2 Phenylephrine HCl (10% 1 Syringe/1ml/29g X 5/16" Ophthalmic Solution, 2.5% Vanishpoint Insulin 2 Ophthalmic Solution) Syringe/1ml/30g X 5/16" Polycin (Ointment) 1 Veltassa (Packet) 3 Polymyxin B 1 Vitamin C 222mg (Injection) 1 Sulfate/Trimethoprim Sulfate Webcol Alcohol Prep Large 1 3 (Ophthalmic Solution) Ply Proparacaine HCl (Ophthalmic 1 Webcol Alcohol Prep Medium 3 Solution) 2 Ply Restasis (Emulsion) 2 PA,QL Wide-Seal Silicone Diaphragm 3 QL,PV Restasis Multidose (Emulsion) 2 PA,QL Kit Sulfacetamide 1 Xiaflex (Injection) 4 PA Sodium/Prednisolone Sodium Ophthalmic Agents : Ophthalmic Agents, Phosphate (Ophthalmic Solution) Other Tetcaine (Ophthalmic Solution) 1 Altacaine (Ophthalmic Solution) 1 Tetracaine HCl (Ophthalmic 1 Altafrin (Ophthalmic Solution) 1 Solution) Atropine Sulfate (1% Ophthalmic 1 Tetravisc (Ophthalmic Solution) 1 Solution) Tobradex ST (Ophthalmic 3 Bacitracin/Polymyxin B 1 Suspension) (Ophthalmic Ointment) Tobramycin/Dexamethasone 1 Cyclopentolate HCl (Ophthalmic 1 (Ophthalmic Suspension) Solution) Trimethoprim Sulfate/Polymyxin 1 Cystaran (Ophthalmic 4 PA,QL B Sulfate (Ophthalmic Solution) Solution) Tropicamide (0.5% Ophthalmic 1 Homatropaire (Ophthalmic 1 Solution) Solution) Xiidra (Ophthalmic Solution) 2 PA Homatropine HBr (Ophthalmic 1 Ophthalmic Agents : Ophthalmic Anti-allergy Solution) Agents Lacrisert (Insert) 3 Alocril (Ophthalmic Solution) 3 Lastacaft (Ophthalmic 3 ST Alomide (Ophthalmic Solution) 3 Solution) Azelastine HCl (0.05% 1 Neo-Polycin (Ointment) 1 Ophthalmic Solution) Neo-Polycin HC (Ointment) 1 Bepreve (Ophthalmic Solution) 3 ST Neomycin/Bacitracin/Polymyxin 1 Cromolyn Sodium (4% 1 (Ointment) Ophthalmic Solution) Neomycin/Polymyxin/Bacitracin/ 1

Hydrocortisone (Ointment)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 63 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Emadine (Ophthalmic 3 Azopt (Suspension) 2 Solution) Betaxolol HCl (0.5% Ophthalmic 1 Epinastine HCl (Ophthalmic 1 Solution) Solution) Betimol (Ophthalmic Solution) 3 Olopatadine HCl (0.1% 1 Brimonidine Tartrate (Ophthalmic 1 Ophthalmic Solution) Solution) Olopatadine HCl (Ophthalmic 1 Carteolol HCl (Ophthalmic 1 Solution) Solution) Pazeo (Ophthalmic Solution) 2 Combigan (Ophthalmic 2 Ophthalmic Agents : Ophthalmic Anti- Solution) inflammatories Dorzolamide HCl (Ophthalmic 1 Acuvail (Ophthalmic Solution) 3 Solution) Alrex (Suspension) 3 Dorzolamide HCl/Timolol 1 Bromfenac (0.09% Ophthalmic 1 QL Maleate (Ophthalmic Solution) Solution) Iopidine (1% Ophthalmic 3 Dexamethasone Sodium 1 Solution) Phosphate (0.1% Ophthalmic Levobunolol HCl (Ophthalmic 1 Solution) Solution) Diclofenac Sodium (0.1% 1 Methazolamide (25mg Tablet, 1 Ophthalmic Solution) 50mg Tablet) Durezol (Emulsion) 3 Metipranolol (Ophthalmic 1 Flarex (Suspension) 3 Solution) Fluorometholone (Ophthalmic 1 Phospholine Iodide 2 Suspension) (Ophthalmic Solution) Flurbiprofen Sodium (Ophthalmic 1 Pilocarpine HCl (1% Ophthalmic 1 Solution) Solution, 2% Ophthalmic FML (Ointment) 2 Solution, 4% Ophthalmic Ilevro (Suspension) 3 QL Solution) Simbrinza (Suspension) 2 Ketorolac Tromethamine (0.4% 1 Ophthalmic Solution, 0.5% Timolol Maleate (0.25% 1 Ophthalmic Solution) Ophthalmic Solution, 0.5% Ophthalmic Solution) Lotemax (0.5% Gel, 0.5% 3 QL Ointment) Timolol Maleate Ophthalmic Gel 1 Forming (Solution) Lotemax (0.5% Suspension) 3 Nevanac (Suspension) 3 QL Ophthalmic Agents : Ophthalmic Pred Mild (Suspension) 2 Prostaglandin and Prostamide Analogs Latanoprost (Ophthalmic 1 QL Prednisolone Acetate 1 Solution) (Suspension) Lumigan (Ophthalmic 2 QL Prednisolone Sodium Phosphate 1 Solution) (1% Ophthalmic Solution) Travatan Z (Ophthalmic 2 QL Ophthalmic Agents : Ophthalmic Solution) Antiglaucoma Agents Zioptan (Ophthalmic Solution) 3 QL Alphagan P (0.1% Ophthalmic 2 Solution) Otic Agents Acetasol HC (Otic Solution) 1 Apraclonidine (Ophthalmic 1 Acetic Acid (Otic Solution) 1 Solution)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 64 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Acetic Acid/Aluminum Acetate 1 Carbinoxamine Maleate (4mg 1 (Otic Solution) Tablet, 4mg/5ml Oral Solution) Cipro HC (Suspension) 3 Cetirizine HCl (Syrup) 1 Ciprodex (Otic Suspension) 2 Clarinex (0.5mg/ml Syrup) 3 Coly-Mycin S (Suspension) 3 Cyproheptadine HCl (2mg/5ml 1 Fluocinolone Acetonide (0.01% 1 Syrup, 4mg Tablet) Oil) Desloratadine (Tablet) 1 Fluocinolone Acetonide Ear 1 Desloratadine ODT (Tablet 1 Drops (Oil) Dispersible) Hydrocortisone/Acetic Acid (Otic 1 Diphenhydramine HCl 1 Solution) (12.5mg/5ml Elixir, 12.5mg/5ml Neomycin/Polymyxin/Hydrocortis 1 Liquid, 50mg/ml Injection) one (1% Otic Solution, 1% Otic Levocetirizine Dihydrochloride 1 Suspension) (2.5mg/5ml Oral Solution, 5mg Otovel (Otic Solution) 3 Tablet) Respiratory Tract/Pulmonary Agents : Anti- Olopatadine HCl (0.6% Nasal 1 QL inflammatories, Inhaled Corticosteroids Solution) Arnuity Ellipta (Aerosol 2 QL Pharbedryl (Capsule) 1 Powder) Phenadoz (Suppository) 1 Beconase AQ (Suspension) 3 QL Phenergan (12.5mg Suppository, 1 Budesonide (0.25mg/2ml 1 QL 25mg Suppository, 50mg Suspension, 0.5mg/2ml Suppository) Suspension, 1mg/2ml Promethazine HCl (12.5mg 1 Suspension) Suppository, 25mg Suppository, Budesonide Nasal Spray 1 QL 50mg Suppository, 12.5mg (Suspension) Tablet, 25mg Tablet, 50mg Flovent Diskus (Aerosol 2 QL Tablet, 25mg/ml Injection, Powder) 50mg/ml Injection, 6.25mg/5ml Oral Solution) Flovent HFA (Aerosol) 2 QL Promethazine HCl Plain (Syrup) 1 Flunisolide (Nasal Solution) 1 QL Promethegan (Suppository) 1 Fluticasone Propionate 1 (50mcg/act Suspension) Respiratory Tract/Pulmonary Agents : Mometasone Furoate (50mcg/act 1 QL Antileukotrienes Suspension) Montelukast Sodium (10mg 1 Omnaris (Suspension) 3 QL Tablet, 4mg Packet, 4mg Tablet Chewable, 5mg Tablet Pulmicort Flexhaler (Aerosol 2 QL Chewable) Powder) Zafirlukast (Tablet) 1 Triamcinolone Acetonide 1 1 ST (55mcg/act Aerosol) Zileuton ER (Tablet Extended- Release 12 Hour) Respiratory Tract/Pulmonary Agents : Antihistamines Respiratory Tract/Pulmonary Agents : Azelastine HCl (0.1% Nasal 1 QL Bronchodilators, Anticholinergic Atrovent HFA (Aerosol 3 QL Solution, 0.15% Nasal Solution) Solution) Bpm (Tablet Extended-Release 1 Incruse Ellipta (Aerosol 2 QL 12 Hour) Powder)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 65 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Ipratropium Bromide (0.02% 1 QL Respiratory Tract/Pulmonary Agents : Inhalation Solution) Phosphodiesterase Inhibitors, Airways Ipratropium Bromide (0.03% 1 Disease Nasal Solution, 0.06% Nasal Aminophylline (Injection) 1 Solution) Daliresp (Tablet) 3 PA Spiriva HandiHaler (Capsule) 2 QL Difil-G Forte (Liquid) 1 Spiriva Respimat (Aerosol 2 QL Elixophyllin (Elixir) 2 Solution) Theo-24 (Capsule Extended- 3 Respiratory Tract/Pulmonary Agents : Release 24 Hour) Bronchodilators, Sympathomimetic Theochron (Tablet Extended- 1 Albuterol Sulfate (0.083% 1 QL Release 12 Hour) Nebulized Solution, 0.5% Theophylline (Oral Solution) 1 Nebulized Solution, 0.63mg/3ml Theophylline CR (Tablet 1 Nebulized Solution, 1.25mg/3ml Extended-Release 12 Hour) Nebulized Solution) Theophylline ER (100mg Tablet 1 Albuterol Sulfate (2mg Tablet, 1 Extended-Release 12 Hour, 4mg Tablet, 2mg/5ml Syrup) 200mg Tablet Extended-Release Albuterol Sulfate ER (Tablet 1 12 Hour, 300mg Tablet Extended-Release 12 Hour) Extended-Release 12 Hour, Arcapta Neohaler (Capsule) 3 QL,ST 450mg Tablet Extended-Release Brovana (Nebulized Solution) 3 QL 12 Hour, 400mg Tablet Epinephrine (0.15mg/0.3ml 2 Extended-Release 24 Hour, Injection, 0.3mg/0.3ml 600mg Tablet Extended-Release Injection) (Authorized Generic 24 Hour) for EpiPen made by Mylan) Respiratory Tract/Pulmonary Agents : Epinephrine HCl (0.1mg/ml 3 Pulmonary Antihypertensives Injection) Adcirca (Tablet) 4 PA,QL Epinephrine HCl (1mg/ml 1 Adempas (Tablet) 4 PA,QL Injection) Epoprostenol Sodium (Injection) 4 PA Levalbuterol (Nebulized Solution) 1 QL Letairis (Tablet) 4 PA,QL Metaproterenol Sulfate (10mg 1 Opsumit (Tablet) 4 PA,QL Tablet, 20mg Tablet, 10mg/5ml Orenitram (Tablet Extended- 4 PA Syrup) Release) Perforomist (Nebulized 3 QL Remodulin (Injection) 4 PA Solution) Sildenafil (10mg/12.5ml Injection, 4 PA,QL ProAir HFA (Aerosol Solution) 2 QL 20mg Tablet) ProAir RespiClick (Aerosol 2 QL Tracleer (Tablet) 4 PA,QL Powder) Tyvaso (Inhalation Solution) 4 PA,QL Serevent Diskus (Aerosol 2 QL Tyvaso Refill (Inhalation 4 PA,QL Powder) Solution) Striverdi Respimat (Aerosol 3 QL,ST Tyvaso Starter (Inhalation 4 PA,QL Solution) Solution) Terbutaline Sulfate (1mg/ml 1 Uptravi (Tablet Therapy Pack, 4 PA,QL Injection, 2.5mg Tablet, 5mg 1000mcg Tablet, 1200mcg Tablet) Tablet, 1400mcg Tablet, Ventolin HFA (Aerosol 2 QL 1600mcg Tablet, 200mcg Solution)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 66 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Tablet, 400mcg Tablet, 600mcg Clever Choice Anti-Static 2 Tablet, 800mcg Tablet) Valved Holding Chamber/Adult Veletri (Injection) 4 PA Large (Device) Ventavis (Inhalation Solution) 4 PA,QL Clever Choice Anti-Static 2 Respiratory Tract/Pulmonary Agents : Valved Holding Respiratory Tract Agents, Other Chamber/Medium (Device) Acetylcysteine (10% Inhalation 1 Clever Choice Anti-Static 2 Solution, 20% Inhalation Valved Holding Chamber/Small Solution, 200mg/ml Injection) (Device) Advair Diskus (Aerosol 2 QL Combivent Respimat (Aerosol 2 QL Powder) Solution) Advair HFA (Aerosol) 2 QL Compact Space Chamber/Anti- 2 Static (Device) AeroChamber Mini Aerosol 2 Chamber (Device) Compact Space Chamber/Anti- 2 Static/Large Mask (Device) AeroChamber MV 2 AeroChamber Plus Flow Vu 2 Compact Space Chamber/Anti- 2 Static/Medium Mask (Device) AeroChamber Plus Flow-Vu 2 Cromolyn Sodium (20mg/2ml 1 AeroChamber Plus Flow- 2 Nebulized Solution) Vu/Large Mask Dymista (Suspension) 2 QL AeroChamber Plus Flow- 2 E-Z Spacer (Device) 2 Vu/Mask E-Z Spacer the Body Guards 2 AeroChamber Plus Flow- 2 Vu/Medium Mask Pack (Device) Easivent 2 AeroChamber Plus Flow- 2 Vu/Small Mask Easivent/Mask-Large 2 AeroChamber Z-Stat 2 Easivent/Mask-Medium 2 Plus/Medium Mask Easivent/Mask-Small 2 AeroChamber/FlowSignal 2 Esbriet (Capsule) 4 PA Aerovent Plus Holding 2 Flexichamber (Device) 2 Chamber/Collapsible (Device) Glassia (Injection) 4 PA Anoro Ellipta (Aerosol Powder) 2 QL Hydrocodone 1 Aralast NP (Injection) 4 PA Bitartrate/Homatropine Arial Chamber (Device) 2 Methylbromide (1.5mg-5mg Bevespi Aerosphere (Aerosol) 3 QL,ST Tablet, 1.5mg/5ml-5mg/5ml Syrup) BreatheRite 2 Hydromet (Syrup) 1 BreatheRite Collapsible 2 InspiraChamber/Anti-Static 2 Spacer w/ Neonate Mask Valved/Mouthpiece (Device) BreatheRite Rigid Spacer 2 InspiraChamber/Large (Device) 2 w/Mask BreatheRite w/Large Mask 2 InspiraChamber/Soother 2 Mask/InspiraMask/Medium BreatheRite w/Medium Mask 2 (Device) BreatheRite w/Small Mask 2 InspiraChamber/Soother 2 Breo Ellipta (Aerosol Powder) 2 QL Mask/InspiraMask/Small Cayston (Inhalation Solution) 4 PA (Device)

Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 67 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Drug Name Drug Requirement Drug Name Drug Requirement Tier s & Limits Tier s & Limits Inspirease Drug Delivery 2 Vortex Valved Holding 2 System Chamber (Device) Ipratropium Bromide/Albuterol 1 QL WatchHaler (Device) 2 Sulfate (Inhalation Solution) Xolair (Injection) 4 PA Kalydeco (150mg Tablet, 50mg 4 PA Zemaira (Injection) 4 PA Packet, 75mg Packet) Skeletal Muscle Relaxants LiteAire (Device) 2 Atracurium Besylate (Injection) 1 Microchamber 2 Baclofen (10mg Tablet, 20mg 1 Microspacer 2 Tablet) Nucala (Injection) 4 PA,QL Carisoprodol (250mg Tablet, 1 Ofev (Capsule) 4 PA 350mg Tablet) OptiChamber Advantage 2 Chlorzoxazone (Tablet) 1 OptiChamber Advantage/Large 2 Cyclobenzaprine HCl (Tablet) 1 Mask Dantrolene Sodium (Capsule) 1 OptiChamber 2 Metaxall (Tablet) 1 Advantage/Medium Face Mask Metaxalone (Tablet) 1 OptiChamber Advantage/Small 2 Methocarbamol (1000mg/10ml 1 Face Mask Injection, 500mg Tablet, 750mg OptiChamber Diamond 2 Tablet) OptiChamber Diamond/Large 2 Orphenadrine Citrate (30mg/ml 1 Face Mask (Device) Injection) OptiChamber 2 Orphenadrine Citrate ER (Tablet 1 Diamond/Medium Face Mask Extended-Release 12 Hour) OptiChamber Diamond/Small 2 Revonto (Injection) 1 Face Mask Tizanidine HCl (2mg Capsule, 1 OptiChamber Face Mask/Small 2 4mg Capsule, 6mg Capsule, Optihaler MDI Drug Delivery 2 2mg Tablet, 4mg Tablet) System (Device) Sleep Disorder Agents : GABA Receptor Orkambi (125mg-100mg 4 PA,QL Modulators Tablet) Eszopiclone (Tablet) 1 QL Pocket Chamber (Device) 2 Flurazepam HCl (Capsule) 1 PA,QL Pocket Spacer (Device) 2 Temazepam (Capsule) 1 QL Prolastin-C (Injection) 4 PA Zaleplon (Capsule) 1 QL Pulmozyme (Inhalation 4 PA Zolpidem Tartrate (1.75mg 1 QL Solution) Tablet Sublingual, 3.5mg Tablet RiteFlo (Device) 2 Sublingual, 10mg Tablet, 5mg SSKI (Oral Solution) 3 Tablet) Stiolto Respimat (Aerosol 2 QL Zolpidem Tartrate ER (Tablet 1 QL Solution) Extended-Release) Symbicort (Aerosol) 2 QL Sleep Disorder Agents : Sleep Disorders, Tussigon (Tablet) 1 Other Tuzistra XR (Suspension 3 Armodafinil (Tablet) 1 PA,QL Extended-Release) Belsomra (Tablet) 3 QL,ST Valved Holding Chamber 2 Modafinil (Tablet) 1 PA,QL (Device) Rozerem (Tablet) 3 QL Vituz (Oral Solution) 3 Xyrem (Oral Solution) 4 PA,QL Bold type = Brand-name drug PA Prior Authorization QL Quantity Limits 68 [Plain type = Generic drug] ST Step Therapy OptumRx Effective 1/1/18

Index of Covered Drugs

Adapalene (0.1% Cream, 0.1% Gel, 0.3% Gel) Albuminar-5 (Injection) ...... 40 A ...... 39 Albumin-Zlb (Injection) ...... 40 Adapalene Pump (Gel) ...... 39 Alburx (Injection) ...... 40 Abacavir (Tablet) ...... 29 Adcetris (Injection) ...... 26 Albutein (Injection) ...... 40 Abacavir Sulfate/Lamivudine/Zidovudine Adcirca (Tablet) ...... 66 Albuterol Sulfate (0.083% Nebulized Solution, (Tablet) ...... 29 Addyi (Tablet) ...... 58 0.5% Nebulized Solution, 0.63mg/3ml Abacavir/Lamivudine (Tablet) ...... 29 Adefovir Dipivoxil (Tablet) ...... 28 Nebulized Solution, 1.25mg/3ml Nebulized Abelcet (Injection) ...... 22 Adempas (Tablet) ...... 66 Solution) ...... 66 Abilify Maintena (Injection) ...... 28 Adenosine (Injection) ...... 58 Albuterol Sulfate (2mg Tablet, 4mg Tablet, Abraxane (Injection) ...... 25 Adriamycin (Injection) ...... 25 2mg/5ml Syrup) ...... 66 Acamprosate Calcium DR (Tablet Delayed- Adrucil (Injection) ...... 24 Albuterol Sulfate ER (Tablet Extended- Release) ...... 14 Advair Diskus (Aerosol Powder) ...... 67 Release 12 Hour) ...... 66 Acarbose (Tablet) ...... 30 Advair HFA (Aerosol) ...... 67 Alclometasone Dipropionate (0.05% Cream, Accu-Chek Fastclix Lancet Device Kit (Kit) .. 58 Advate (1000unit Injection, 1500unit 0.05% Ointment)...... 50 Accu-Chek Multiclix Lancet Device Kit (Kit) 58 Injection, 250unit Injection, 500unit Alcoh-Glove Contoured Wipe ...... 58 Accu-Chek Softclix Lancet Device Kit (Kit) .. 58 Injection) ...... 42 Alcohol Prep Pads ...... 58 Acebutolol HCl (200mg Capsule, 400mg Advate (2000unit Injection, 3000unit Alcohol Swabs ...... 58 Capsule) ...... 34 Injection, 4000unit Injection) ...... 40 Alcohol Swabstick ...... 58 Acetaminophen/Caffeine/Dihydrocodeine Advocate Insulin Pen Needles ...... 58 Alcoh-Wipe 12" X 12" ...... 58 (Capsule) ...... 12 AeroChamber Mini Aerosol Chamber Aldurazyme (Injection) ...... 49 Acetaminophen/Codeine (Solution, 300mg- (Device) ...... 67 Alendronate Sodium (10mg Tablet, 40mg 15mg Tablet, 300mg-30mg Tablet, 300mg- AeroChamber MV ...... 67 Tablet, 5mg Tablet) ...... 57 60mg Tablet) ...... 12 AeroChamber Plus Flow Vu ...... 67 Alendronate Sodium (35mg Tablet, 70mg Acetasol HC (Otic Solution) ...... 64 AeroChamber Plus Flow-Vu ...... 67 Tablet) ...... 57 Acetazolamide (125mg Tablet, 250mg Tablet AeroChamber Plus Flow-Vu/Large Mask ... 67 Alendronate Sodium (70mg/75ml Oral Immediate-Release) ...... 36 AeroChamber Plus Flow-Vu/Mask ...... 67 Solution) ...... 57 Acetazolamide ER (Capsule Extended-Release AeroChamber Plus Flow-Vu/Medium Mask Alfentanil (Injection) ...... 12 12 Hour) ...... 36 ...... 67 Alferon N (Injection) ...... 28 Acetazolamide Sodium (Injection) ...... 36 AeroChamber Plus Flow-Vu/Small Mask ... 67 Alfuzosin HCl ER (Tablet Extended-Release 24 Acetic Acid (Otic Solution) ...... 64 AeroChamber Z-Stat Plus/Medium Mask.. 67 Hour) ...... 49 Acetic Acid 0.25% (Irrigation Solution) ...... 49 AeroChamber/FlowSignal ...... 67 Alimta (Injection) ...... 24 Acetic Acid/Aluminum Acetate (Otic Solution) Aerovent Plus Holding Chamber/Collapsible Alinia (100mg/5ml Suspension, 500mg ...... 65 (Device) ...... 67 Tablet) ...... 27 Acetylcysteine (10% Inhalation Solution, 20% Afeditab CR (Tablet Extended-Release 24 Allopurinol (Tablet) ...... 23 Inhalation Solution, 200mg/ml Injection) Hour) ...... 34 Allopurinol Sodium (Injection) ...... 23 ...... 67 Afinitor (Tablet) ...... 26 Almotriptan Malate (Tablet) ...... 23 Acitretin (Capsule) ...... 39 Afinitor Disperz (Tablet Soluble) ...... 26 Alocril (Ophthalmic Solution) ...... 63 Actemra (162mg/0.9ml Injection) ...... 56 Afluria 2016-2017 (Injection) ...... 56 Alogliptin (Tablet) ...... 30 Actemra (200mg/10ml Injection, Afluria PF 2016-2017 (Injection) ...... 56 Alomide (Ophthalmic Solution) ...... 63 400mg/20ml Injection, 80mg/4ml Afluria Quadrivalent 2016-2017 (Injection)56 Alophen (Tablet Delayed-Release) ...... 47 Injection) ...... 56 Aftera (Tablet) ...... 54 Alosetron HCl (Tablet) ...... 47 ActHIB (Injection) ...... 56 Aggrastat (0.9%-12.5mg/250ml Injection, Aloxi (Injection) ...... 22 Actimmune (Injection) ...... 56 0.9%-5mg/100ml Injection) ...... 33 Alphagan P (0.1% Ophthalmic Solution)..... 64 Actoplus Met XR (Tablet Extended-Release Airavite (Tablet) ...... 43 Alphanate/Von Willebrand Factor 24 Hour) ...... 30 Akynzeo (Capsule) ...... 22 Complex/Human (Injection) ...... 32 Acuvail (Ophthalmic Solution) ...... 64 Ala-Cort (Cream) ...... 50 Alphanine SD (1000unit Injection, 1500unit Acyclovir (200mg Capsule, 200mg/5ml Albenza (Tablet) ...... 26 Injection) ...... 40 Suspension, 400mg Tablet, 800mg Tablet, Albuked 25 (Injection) ...... 40 Alphanine SD (500unit Injection)...... 43 5% Ointment) ...... 30 Albuked 5 (Injection) ...... 40 Alprazolam (Tablet) ...... 30 Acyclovir Sodium (Injection) ...... 30 Albumin Human (Injection) ...... 40 Alprazolam ER (Tablet Extended-Release 24 Adacel (Injection) ...... 56 Albuminar-25 (Injection) ...... 40 Hour) ...... 30

6 9

Alprazolam ODT (Tablet Dispersible) ...... 30 200mg/5ml Suspension, 250mg/5ml Arial Chamber (Device) ...... 67 Alprazolam XR (Tablet Extended-Release 24 Suspension, 400mg/5ml Suspension, Aripiprazole (10mg Tablet, 15mg Tablet, Hour) ...... 30 250mg Capsule, 500mg Capsule, 500mg 20mg Tablet, 2mg Tablet, 30mg Tablet, Alprostadil (Injection) ...... 49 Tablet, 875mg Tablet) ...... 17 5mg Tablet, 1mg/ml Oral Solution) ...... 28 Alrex (Suspension) ...... 64 Amoxicillin/Clavulanate Potassium (Tablet Aripiprazole ODT (Tablet Dispersible) ...... 28 Altabax (Ointment) ...... 16 Chewable, Suspension, Tablet, Tablet Armodafinil (Tablet)...... 68 Altacaine (Ophthalmic Solution) ...... 63 Immediate-Release) ...... 17 Armour Thyroid (180mg Tablet, 240mg Altafrin (Ophthalmic Solution) ...... 63 Amoxicillin/Clavulanate Potassium ER (Tablet Tablet, 300mg Tablet) ...... 54 Altavera (Tablet) ...... 52 Extended-Release 12 Hour) ...... 17 Arnuity Ellipta (Aerosol Powder) ...... 65 Alyacen 1/35 (Tablet) ...... 52 Amphetamine/Dextroamphetamine (Tablet, Arranon (Injection) ...... 25 Alyacen 7/7/7 (Tablet) ...... 52 Capsule Extended-Release 24 Hour) ...... 37 Arzerra (Injection) ...... 26 Amabelz (Tablet) ...... 52 Amphotericin B (50mg Injection) ...... 22 Ascomp/Codeine (Capsule) ...... 12 Amantadine HCl (100mg Capsule, 100mg Ampicillin (Capsule) ...... 18 Ashlyna (Tablet) ...... 52 Tablet, 50mg/5ml Syrup) ...... 27 Ampicillin Sodium (10gm Injection, 1gm Asilnasal Rms (Capsule) ...... 58 AmBisome (Injection) ...... 22 Injection, 250mg Injection, 2gm Injection, Aspir-81 (Tablet Delayed-Release) ...... 10 Amcinonide (0.1% Cream, 0.1% Lotion, 0.1% 500mg Injection) ...... 18 Aspirin (81mg Tablet Delayed-Release) ...... 10 Ointment) ...... 50 Ampicillin-Sulbactam (10gm-5gm Injection, Aspirin 81 (Tablet Delayed-Release) ...... 10 Amethia (Tablet) ...... 52 1gm-0.5gm Injection, 2gm-1gm Injection) Aspirin 81 Low Dose (Tablet Chewable) ...... 10 Amethia Lo (Tablet) ...... 52 ...... 18 Aspirin Adult Low Dose (Tablet Delayed- Amikacin Sulfate (1gm/4ml Injection, Ampyra (Tablet Extended-Release 12 Hour) Release) ...... 10 500mg/2ml Injection) ...... 15 ...... 38 Aspirin Childrens (Tablet Chewable) ...... 10 Amiloride HCl (5mg Tablet) ...... 36 Anadrol-50 (Tablet) ...... 51 Aspirin EC (Tablet Delayed-Release) ...... 10 Amiloride/Hydrochlorothiazide (Tablet)...... 35 Anagrelide HCl (Capsule) ...... 32 Aspirin EC Low Dose (Tablet Delayed-Release) Aminoacetic Acid (Irrigation Solution) ...... 49 Ana-Lex (Kit) ...... 50 ...... 10 Aminoam Rms (Capsule) ...... 40 Anastrozole (Tablet) ...... 26 Aspirin Low Dose (Tablet Chewable) ...... 10 Aminophylline (Injection) ...... 66 AndroGel (40.5mg/2.5gm Gel) ...... 51 Aspirin/Dipyridamole (Capsule Extended- Aminorelief Rms (Capsule) ...... 40 Androxy (Tablet) ...... 51 Release 12 Hour) ...... 33 Aminosyn 8.5%/Electrolytes (Injection) ...... 40 Anodyne Lpt (Kit) ...... 13 Aspirin-Caffeine-Dihydrocodeine (Capsule) 12 Aminosyn II 8.5%/Electrolytes (Injection) .... 40 Anoro Ellipta (Aerosol Powder)...... 67 Aspir-Low (Tablet Delayed-Release) ...... 10 Amiodarone HCl (100mg Tablet, 200mg Anzemet (Tablet) ...... 22 Aspirtab (Tablet Delayed-Release) ...... 10 Tablet, 400mg Tablet, 150mg/3ml ApexiCon E (Cream) ...... 50 Assure Haemolance Plus High Flow 18g ..... 58 Injection, 50mg/ml Injection) ...... 33 Apidra (Injection)...... 31 Assure Haemolance Plus Low Flow 25g ...... 58 Amiodarone HCl/Dextrose (150mg/100ml-5% Apidra SoloStar (Injection) ...... 31 Assure Haemolance Plus Micro Flow 28g...58 Injection, 900mg/500ml-5% Injection) ... 33 Aplenzin (Tablet Extended-Release 24 Hour) Assure Haemolance Plus Normal Flow 21g 58 Amitiza (Capsule) ...... 47 21 Assure Haemolance Plus Pediatric Blade ...58 Amitriptyline HCl (100mg Tablet, 10mg Apokyn (Injection) ...... 27 Atabex Prenatal (Tablet Chewable) ...... 43 Tablet, 150mg Tablet, 25mg Tablet, 50mg Apraclonidine (Ophthalmic Solution) ...... 64 Atenolol (100mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) ...... 21 Aprepitant (Capsule) ...... 22 Tablet) ...... 34 Amlodipine Besylate (Tablet) ...... 34 Apri (Tablet) ...... 52 Atenolol/Chlorthalidone (Tablet) ...... 35 Amlodipine Besylate/Atorvastatin Calcium Apriso (Capsule Extended-Release 24 Hour) Atgam (Injection) ...... 56 (Tablet) ...... 35 ...... 57 Atomoxetine (Capsule) ...... 37 Amlodipine Besylate/Benazepril HCl (Capsule) Aptiom (Tablet) ...... 20 Atorvastatin Calcium (10mg, 20mg Tablet) .36 ...... 35 Aptivus (100mg/ml Oral Solution, 250mg Atorvastatin Calcium (40mg, 80mg Tablet) .36 Amlodipine Besylate/Valsartan (Tablet) ...... 35 Capsule) ...... 29 Atovaquone (Suspension) ...... 27 Amlodipine/Olmesartan Medoxomil (Tablet) Aralast NP (Injection) ...... 67 Atovaquone/Proguanil HCl (Tablet) ...... 27 ...... 35 Aranelle (Tablet) ...... 52 Atracurium Besylate (Injection) ...... 68 Amlodipine/Valsartan/Hydrochlorothiazide Aranesp Albumin Free (Injection) ...... 32 Atripla (Tablet) ...... 29 (Tablet) ...... 35 Arcalyst (Injection) ...... 56 Atropen (0.5mg/0.7ml Injection) ...... 46 Ammonium Lactate (12% Cream, 12% Lotion) Arcapta Neohaler (Capsule) ...... 66 Atropine Sulfate (1% Ophthalmic Solution).63 ...... 39 Argatroban (125mg/125ml-0.9% Injection, Atropine Sulfate (1mg/10ml Injection, Amnesteem (Capsule) ...... 39 250mg/250ml-0.9% Injection) ...... 32 1mg/ml Injection, 8mg/20ml Injection)..46 Amoxapine (Tablet) ...... 21 Argatroban (250mg/2.5ml Injection) ...... 32 Atrovent HFA (Aerosol Solution) ...... 65 Amoxicillin (125mg Tablet Chewable, 250mg Argyle Sterile Saline 100ml (Solution) ...... 40 Aubagio (Tablet) ...... 38 Tablet Chewable, 125mg/5ml Suspension, Argyle Sterile Water 100ml (Solution)...... 58 Aubra (Tablet) ...... 52 7 9

Augmented Betamethasone Dipropionate Bavencio (Injection) ...... 26 Biltricide (Tablet) ...... 26 (0.05% Cream, 0.05% Gel, 0.05% Lotion, Bayer Advanced Aspirin Regular Strength Biocel (Tablet) ...... 43 0.05% Ointment) ...... 50 (Tablet) ...... 10 Bio-D-Mulsion (Liquid) ...... 43 Augmentin (125mg/5ml-31.25mg/5ml Bayer Aspirin EC Low Dose (Tablet Delayed- Bio-D-Mulsion Forte (Liquid) ...... 43 Suspension) ...... 18 Release) ...... 10 Bio-Statin (Powder) ...... 22 Aurora Lancet Super Thin 30g ...... 58 Bayer Aspirin Regimen (Tablet Delayed- Bisacodyl EC (Tablet Delayed-Release) ...... 47 Aurora Lancet Thin 23g ...... 58 Release) ...... 10 Bisoprolol Fumarate (Tablet) ...... 34 AuroRA Pen Needles ...... 58 Bayer Chewable Low Dose (Tablet Chewable) Bisoprolol Fumarate/Hydrochlorothiazide Autopen (Device) ...... 58 ...... 10 (Tablet) ...... 35 Avandia (Tablet) ...... 30 Bayer Low Dose (Tablet Delayed-Release).. 10 Bivalirudin (Injection) ...... 32 Avastin (Injection) ...... 26 BD Autoshield 29g X 3/16" ...... 58 BIVIGAM (Injection) ...... 56 Avelox (0 Injection) ...... 18 BD Autoshield 29g X 5/16" ...... 58 Bleomycin Sulfate (Injection) ...... 25 Aviane (Tablet) ...... 52 BD Autoshield Duo 30g X 3/16" ...... 58 Blincyto (Injection) ...... 26 Avidoxy (Tablet) ...... 19 BD insul Syr Mis Lo Dose ...... 58 Blisovi 24 Fe (Tablet) ...... 52 Avita (0.025% Cream, 0.025% Gel) ...... 39 BD Lancet Ultrafine 30g ...... 58 Blisovi Fe 1.5/30 (Tablet) ...... 52 Avonex (Injection) ...... 38 BD Lancet Ultrafine 33g ...... 58 Blisovi Fe 1/20 (Tablet) ...... 52 Avonex Pen (Injection) ...... 38 BD Pen ...... 58 Boostrix (Injection) ...... 56 AV-Phos 250 Neutral (Tablet) ...... 40 BD Pen Mini ...... 58 Bosulif (Tablet) ...... 26 AV-Vite FB (Tablet) ...... 43 BD Posiflush (Solution) ...... 40 Botox (Injection) ...... 58 Azacitidine (Injection) ...... 25 BD Swabs Single Use ...... 58 BP Folinatal Plus B (Tablet) ...... 43 Azactam in Iso-Osmotic Dextrose (1gm-0 BD Swabs Single Use Butterfly ...... 58 BP Multinatal Plus (50mg-0-250mg-0-6mcg- Injection) ...... 17 Bebulin (Injection) ...... 40 2mg-40mg-1mg-50mg-2mg-3.5unit-15mg Azasan (Tablet) ...... 55 Beconase AQ (Suspension) ...... 65 Tablet Chewable, 60mg-0-200mg-0-2mg- Azasite (Ophthalmic Solution) ...... 18 Bekyree (Tablet) ...... 52 12mcg-30mg-1mg-100mg-20mg-50mg- Azathioprine (100mg Injection, 50mg Tablet) Belsomra (Tablet) ...... 68 3.4mg-3mg-30unit-15mg Tablet) ...... 43 ...... 55 Benazepril HCl (Tablet) ...... 33 BP Vit 3 (Capsule)...... 43 Azelastine HCl (0.05% Ophthalmic Solution)63 Benazepril HCl/Hydrochlorothiazide (Tablet) B-Plex (Tablet) ...... 43 Azelastine HCl (0.1% Nasal Solution, 0.15% ...... 35 B-Plex Plus (Tablet) ...... 43 Nasal Solution) ...... 65 Benefix (Injection) ...... 32 Bpm (Tablet Extended-Release 12 Hour) ..... 65 Azelex (Cream) ...... 39 Benzonatate (Capsule) ...... 58 Bprotected Pedia D-Vite (Liquid) ...... 43 Azithromycin (100mg/5ml Suspension, Benztropine Mesylate (0.5mg Tablet, 1mg Brainstrong Prenatal ...... 43 200mg/5ml Suspension, 250mg Tablet, Tablet, 2mg Tablet, 1mg/ml Injection)... 27 BreatheRite ...... 67 500mg Tablet, 600mg Tablet, 500mg Bepreve (Ophthalmic Solution) ...... 63 BreatheRite Collapsible Spacer w/ Neonate Injection) ...... 18 Berinert (Injection) ...... 55 Mask ...... 67 Azopt (Suspension) ...... 64 Besivance (Suspension) ...... 18 BreatheRite Rigid Spacer w/Mask ...... 67 Aztreonam (Injection) ...... 17 Betamethasone Dipropionate (0.05% Cream, BreatheRite w/Large Mask ...... 67 Azurette (Tablet) ...... 52 0.05% Lotion, 0.05% Ointment) ...... 50 BreatheRite w/Medium Mask ...... 67 Betamethasone Sodium BreatheRite w/Small Mask ...... 67 B Phosphate/Betamethasone Acetate Breo Ellipta (Aerosol Powder) ...... 67 (Injection) ...... 50 Briellyn (Tablet) ...... 52 Baby Super Daily D3 (Liquid) ...... 43 Betamethasone Valerate (0.1% Cream, 0.1% Brilinta (Tablet) ...... 33 Baby Vitamin D3 Drops (Liquid)...... 43 Lotion, 0.1% Ointment, 0.12% Foam)..... 50 Brimonidine Tartrate (Ophthalmic Solution) BACiiM (Injection) ...... 16 Betaseron (Injection) ...... 38 ...... 64 Bacitracin (50000unit Injection, 500unit/gm Betaxolol HCl (0.5% Ophthalmic Solution) .. 64 BRIVIACT (100mg Tablet, 10mg Tablet, 25mg Ophthalmic Ointment) ...... 16 Betaxolol HCl (10mg Tablet, 20mg Tablet).. 34 Tablet, 50mg Tablet, 75mg Tablet, Bacitracin/Polymyxin B (Ophthalmic Bethanechol Chloride (Tablet) ...... 49 10mg/ml Oral Solution) ...... 19 Ointment) ...... 63 Bethkis (Nebulized Solution) ...... 15 Bromfenac (0.09% Ophthalmic Solution) .... 64 Baclofen (10mg Tablet, 20mg Tablet) ...... 68 Betimol (Ophthalmic Solution) ...... 64 Bromocriptine Mesylate (2.5mg Tablet, 5mg Bactroban Nasal (Ointment) ...... 16 Bevespi Aerosphere (Aerosol) ...... 67 Capsule) ...... 27 Balsalazide Disodium (Capsule) ...... 57 Bexarotene (Capsule) ...... 26 Brovana (Nebulized Solution) ...... 66 Balziva (Tablet) ...... 52 Bexsero (Injection) ...... 56 Budesonide (0.25mg/2ml Suspension, Banzel (200mg Tablet, 400mg Tablet, Bicalutamide (Tablet) ...... 24 0.5mg/2ml Suspension, 1mg/2ml 40mg/ml Suspension) ...... 20 Bicillin L-A (Injection)...... 18 Suspension) ...... 65 Baraclude (0.05mg/ml Oral Solution) ...... 28 BiCNU (Injection) ...... 24 71

Budesonide (3mg Capsule Delayed-Release) Caffeine Citrate (20mg/ml Oral Solution, Carefine Pen Needle 32gx4mm ...... 58 ...... 57 60mg/3ml Oral Solution, 60mg/3ml Carefine Pen Needles ...... 58 Budesonide Nasal Spray (Suspension) ...... 65 Injection) ...... 38 Careone Lancet Thin ...... 58 Bumetanide (0.25mg/ml Injection, 0.5mg Calcidol (Oral Solution) ...... 43 Careone Lancet Ultra Thin ...... 58 Tablet, 1mg Tablet, 2mg Tablet) ...... 36 Calciferol (Oral Solution) ...... 43 Caretouch Alcohol Prep Pads ...... 58 Buminate (Injection) ...... 40 Calcipotriene (0.005% Cream, 0.005% Caretouch Pen Needles ...... 58 Buphenyl (500mg Tablet) ...... 49 External Solution, 0.005% Ointment) ..... 39 Carimune Nanofiltered (Injection) ...... 56 Bupivacaine HCl (Injection) ...... 13 Calcipotriene/Betamethasone Dipropionate Carisoprodol (250mg Tablet, 350mg Tablet)68 Bupivacaine Spinal (Injection)...... 13 (Ointment) ...... 39 Carteolol HCl (Ophthalmic Solution) ...... 64 Bupivacaine/Dextrose Spinal (Injection) ...... 13 Calcitonin-Salmon (Nasal Solution) ...... 57 Carters Little Pills (Tablet Delayed-Release) 47 Bupivacaine/Epinephrine (Injection) ...... 13 Calcitrene (Ointment) ...... 39 Cartia XT (Capsule Extended-Release 24 Hour) Buprenorphine (Patch Weekly) ...... 14 Calcitriol (0.25mcg Capsule, 0.5mcg Capsule, ...... 34 Buprenorphine HCl (0.3mg/ml Injection) .... 14 1mcg/ml Injection, 1mcg/ml Oral Solution) Carvedilol (Tablet) ...... 34 Buprenorphine HCl (2mg Tablet Sublingual, ...... 57 Cavarest (Gel) ...... 38 8mg Tablet Sublingual) ...... 14 Calcium Acetate (667mg Capsule, 667mg Caya (Diaphragm) ...... 58 Buprenorphine HCl/Naloxone HCl (Tablet Tablet) ...... 49 Cayston (Inhalation Solution) ...... 67 Sublingual) ...... 14 Calcium Chloride (Injection) ...... 40 Caziant (Tablet) ...... 52 Bupropion HCl (Tablet) ...... 21 Camila (Tablet) ...... 54 Cedax (180mg/5ml Suspension, 400mg Bupropion HCl ER (Tablet Extended-Release Camptosar (300mg/15ml Injection) ...... 25 Capsule) ...... 17 12 Hour) ...... 21 Camrese (Tablet) ...... 52 Cefaclor (250mg Capsule Immediate-Release, Bupropion HCl SR (100mg Tablet Extended- Camrese Lo (Tablet) ...... 52 500mg Capsule Immediate-Release, Release 12 Hour, 150mg Tablet Extended- Canasa (Suppository) ...... 57 250mg/5ml Suspension, 375mg/5ml Release 12 Hour, 200mg Tablet Extended- Candesartan Cilexetil (Tablet) ...... 33 Suspension) ...... 17 Release 12 Hour)...... 21 Candesartan Cilexetil/Hydrochlorothiazide Cefaclor ER (Tablet Extended-Release 12 Bupropion HCl SR (150mg Tablet Extended- (Tablet) ...... 35 Hour) ...... 17 Release 12 Hour)...... 14 Capacet (Capsule) ...... 10 Cefadroxil (1gm Tablet, 250mg/5ml Bupropion HCl XL (Tablet Extended-Release Capastat Sulfate (Injection) ...... 24 Suspension, 500mg/5ml Suspension, 24 Hour) ...... 21 Capecitabine (Tablet) ...... 24 500mg Capsule) ...... 17 Buspirone HCl (Tablet) ...... 30 Capex (Shampoo) ...... 50 Cefazolin Sodium (10gm Injection, 1gm Busulfan (Injection) ...... 24 Caprelsa (100mg Tablet) ...... 26 Injection, 20gm Injection, 500mg Injection) Butalbital/Acetaminophen (Tablet) ...... 10 Caprelsa (300mg Tablet) ...... 26 ...... 17 Butalbital/Acetaminophen/Caffeine (325mg- Captopril (Tablet) ...... 33 Cefazolin Sodium/Sodium Chloride 50mg-40mg Tablet, 50mg-300mg-40mg Captopril/Hydrochlorothiazide (Tablet) ...... 35 (2gm/50ml-0.9% Injection) ...... 17 Capsule) ...... 10 Carafate (1gm/10ml Suspension)...... 48 Cefazolin/D5W (Injection) ...... 17 Butalbital/Acetaminophen/Caffeine/Codeine Carbaglu (Tablet) ...... 40 Cefazolin/Dextrose (Injection) ...... 17 (Capsule) ...... 12 Carbamazepine (100mg Tablet Chewable, Cefazolin/Sodium Chloride (2gm/100ml-0.9% Butalbital/Aspirin/Caffeine (Capsule) ...... 10 100mg/5ml Suspension, 200mg Tablet). 20 Injection) ...... 17 Butalbital/Aspirin/Caffeine/Codeine (Capsule) Carbamazepine ER (Capsule Extended- Cefdinir (125mg/5ml Suspension, 250mg/5ml ...... 12 Release 12 Hour, Tablet Extended-Release Suspension, 300mg Capsule) ...... 17 Butorphanol Tartrate (10mg/ml Nasal 12 Hour) ...... 20 Cefditoren Pivoxil (Tablet) ...... 17 Solution, 1mg/ml Injection, 2mg/ml Carbidopa (Tablet) ...... 27 Cefepime (1gm Injection, 2gm Injection) .... 17 Injection) ...... 12 Carbidopa/Levodopa (10mg-100mg Tablet Cefixime (Suspension) ...... 17 Butrans (Patch Weekly) ...... 14 Immediate-Release, 25mg-100mg Tablet, Cefotaxime Sodium (Injection) ...... 17 Bydureon Pen (Injection) ...... 30 25mg-250mg Tablet) ...... 27 Cefotetan (10gm Injection) ...... 17 Bydureon Vial (Injection) ...... 30 Carbidopa/Levodopa ER (Tablet Extended- Cefotetan (1gm Injection, 2gm Injection) .... 17 Byetta (Injection) ...... 30 Release) ...... 27 Cefotetan/Dextrose (Injection) ...... 17 Bystolic (Tablet) ...... 34 Carbidopa/Levodopa/Entacapone (Tablet). 27 Cefoxitin Sodium (10gm Injection, 1gm Byvalson (Tablet) ...... 35 Carbinoxamine Maleate (4mg Tablet, Injection, 2gm Injection) ...... 17 4mg/5ml Oral Solution) ...... 65 Cefpodoxime Proxetil (100mg Tablet, 200mg C Carboplatin (Injection) ...... 25 Tablet, 100mg/5ml Suspension, 50mg/5ml Cardizem LA (120mg Tablet Extended- Suspension) ...... 17 Cabergoline (Tablet) ...... 55 Release 24 Hour)...... 34 Cefprozil (125mg/5ml Suspension, Cabometyx (Tablet)...... 26 Cardura XL (4mg Tablet Extended-Release 24 250mg/5ml Suspension, 250mg Tablet, Cadeau DHA (Capsule) ...... 43 Hour) ...... 49 500mg Tablet) ...... 17 72

Ceftazidime (Injection) ...... 17 Chlorzoxazone (Tablet) ...... 68 Clever Choice Anti-Static Valved Holding Ceftin (Suspension) ...... 17 Cholestyramine (Powder) ...... 36 Chamber/Medium (Device) ...... 67 Ceftriaxone in Iso-Osmotic Dextrose Cholestyramine Light (Powder) ...... 36 Clever Choice Anti-Static Valved Holding (Injection) ...... 17 Choline Magnesium Trisalicylate (Liquid) ... 43 Chamber/Small (Device) ...... 67 Ceftriaxone Sodium (100gm Injection, 1gm Chorionic Gonadotropin (Injection) ...... 51 Clever Choice Comfort EZ Insulin Pen Injection, 250mg Injection, 2gm Injection, Chromagen (Capsule) ...... 40 Needles ...... 59 500mg Injection, 10gm Injection) ...... 17 Chromium Chloride (Injection) ...... 40 Clickfine Pen Needle 32gx5/32" ...... 59 Cefuroxime Axetil (Tablet) ...... 17 Cialis (2.5mg Tablet, 5mg Tablet) ...... 49 Clickfine Pen Needles ...... 59 Cefuroxime Sodium (Injection) ...... 17 Ciclodan (0.77% Cream, 8% External Solution) Clindacin ETZ Pledgets (Swab) ...... 16 Celecoxib (Capsule) ...... 10 ...... 22 Clindacin-P (Swab) ...... 16 Celontin (Capsule) ...... 19 Ciclopirox (0.77% Gel, 0.77% Suspension, 1% Clindamycin HCl (150mg Capsule, 300mg Centrum Specialist Prenatal ...... 43 Shampoo) ...... 22 Capsule, 75mg Capsule Immediate- Cephalexin (125mg/5ml Suspension, Ciclopirox Nail Lacquer (External Solution) . 22 Release) ...... 16 250mg/5ml Suspension, 250mg Capsule, Ciclopirox Olamine (0.77% Cream) ...... 22 Clindamycin Palmitate HCl (Oral Solution) ..16 500mg Capsule, 750mg Capsule, 250mg Cidofovir (Injection) ...... 28 Clindamycin Phosphate Add-Vantage Tablet, 500mg Tablet) ...... 17 Cilostazol (Tablet)...... 33 (Injection) ...... 16 Ceprotin (Injection) ...... 32 Ciloxan (0.3% Ointment) ...... 18 Clindamycin Phosphate (1% External Solution, Cerdelga (Capsule) ...... 49 Cimetidine (200mg Tablet, 300mg Tablet, 1% Foam, 1% Gel, 1% Lotion, 1% Swab, 2% Cerezyme (Injection) ...... 49 400mg Tablet, 800mg Tablet) ...... 47 Cream, 300mg/2ml Injection, 600mg/4ml Cerovel (Lotion) ...... 58 Cimetidine HCl (Oral Solution) ...... 47 Injection, 9000mg/60ml Injection, Cesamet (Capsule) ...... 22 Cimzia (Injection) ...... 55 900mg/6ml Injection) ...... 16 Cetirizine HCl (Syrup) ...... 65 Cimzia Starter Kit (Injection) ...... 55 Clindamycin Phosphate in D5W (Injection) .16 Cevimeline HCl (Capsule) ...... 38 Cinryze (Injection) ...... 55 Clindamycin Phosphate/Tretinoin (Gel) ...... 39 Chantix (Tablet) ...... 14 Cipro HC (Suspension) ...... 65 Clindamycin/Benzoyl Peroxide (Gel)...... 39 Chantix Continuing Month Pak (Tablet) ..... 14 Ciprodex (Otic Suspension) ...... 65 Clinisol SF 15% (Injection) ...... 40 Chantix Starting Month Pak (Tablet) ...... 14 Ciprofloxacin (250mg/5ml Suspension, Clinpro 5000 (Paste) ...... 38 Chateal (Tablet) ...... 52 500mg/5ml Suspension) ...... 18 Clobetasol Propionate (0.05% Cream, 0.05% Chek-Stix Control (Strip) ...... 58 Ciprofloxacin ER (Tablet Extended-Release 24 External Solution, 0.05% Foam, 0.05% Gel, Chemet (Capsule) ...... 42 Hour) ...... 18 0.05% Liquid, 0.05% Lotion, 0.05% Chemstrip 10 MD (Strip) ...... 58 Ciprofloxacin HCl (0.3% Ophthalmic Solution, Ointment, 0.05% Shampoo)...... 50 Chemstrip 2 GP Strips (Strip) ...... 58 100mg Tablet, 250mg Tablet, 500mg Clobetasol Propionate Emollient (Cream) ...50 Chemstrip 5 OB (Strip) ...... 58 Tablet, 750mg Tablet) ...... 18 Clocortolone Pivalate (Cream) ...... 50 Chemstrip 7 (Strip) ...... 58 Ciprofloxacin I.V. in D5W (Injection) ...... 18 Clodan (Shampoo) ...... 50 Chemstrip 9 Strips (Strip) ...... 58 Cisatracurium Besylate (10mg/5ml Injection, Clofarabine (Injection) ...... 24 Chemstrip UGK (Strip) ...... 58 200mg/20ml Injection) ...... 13 Clolar (Injection) ...... 24 Chemstrip-10 with SG (Strip) ...... 58 Cisplatin (100mg/100ml Injection, Clomipramine HCl (Capsule) ...... 21 Chemstrip-K (Strip) ...... 59 50mg/50ml Injection) ...... 25 Clonazepam (Tablet Immediate-Release) .... 30 Childrens Aspirin (Tablet Chewable) ...... 10 Cisplatin (200mg/200ml Injection) ...... 25 Clonazepam ODT (Tablet Dispersible) ...... 30 Childrens Aspirin Low Strength (Tablet Citalopram HBr (10mg Tablet, 20mg Tablet, Clonidine HCl (0.1mg Tablet, 0.2mg Tablet, Chewable) ...... 10 40mg Tablet, 10mg/5ml Oral Solution).. 21 0.3mg Tablet, 0.1mg/24hr Patch Weekly, Chlordiazepoxide HCl (Capsule) ...... 30 Citroma (Oral Solution) ...... 47 0.2mg/24hr Patch Weekly, 0.3mg/24hr Chlordiazepoxide HCl/Clidinium Bromide Cladribine (Injection) ...... 24 Patch Weekly) ...... 33 (Capsule) ...... 46 Claravis (Capsule) ...... 39 Clonidine HCl ER (Tablet Extended-Release 12 Chlordiazepoxide/Amitriptyline (Tablet) ..... 21 Clarinex (0.5mg/ml Syrup) ...... 65 Hour) ...... 37 Chlorhexidine Gluconate (0.12% Solution).. 38 Clarithromycin (125mg/5ml Suspension, Clopidogrel (Tablet) ...... 33 Chloroquine Phosphate (250mg Tablet, 250mg/5ml Suspension, 250mg Tablet, Clorazepate Dipotassium (Tablet)...... 30 500mg Tablet) ...... 27 500mg Tablet) ...... 18 Clotrimazole (1% Cream, 1% External Chlorothiazide (Tablet) ...... 36 Clarithromycin ER (Tablet Extended-Release Solution, 10mg Lozenge, 10mg Troche)..22 Chlorothiazide Sodium (Injection) ...... 36 24 Hour) ...... 18 Clotrimazole/Betamethasone Dipropionate Chlorpromazine HCl (100mg Tablet, 10mg Classic Prenatal (Tablet) ...... 43 (0.05%-1% Cream, 1%-0.05% Lotion) ...... 39 Tablet, 200mg Tablet, 25mg Tablet, 50mg ClearLax (Powder) ...... 47 Clozapine (Tablet) ...... 28 Tablet)...... 27 Clever Choice Anti-Static Valved Holding Clozapine ODT (100mg Tablet Dispersible, Chlorpropamide (Tablet) ...... 30 Chamber/Adult Large (Device) ...... 67 12.5mg Tablet Dispersible, 25mg Tablet Chlorthalidone (Tablet)...... 36 Dispersible) ...... 28 73

Coagadex (Injection) ...... 32 Cromolyn Sodium (20mg/2ml Nebulized Cystagon (Capsule) ...... 49 Coartem (Tablet) ...... 27 Solution) ...... 67 Cystaran (Ophthalmic Solution) ...... 63 Codeine Sulfate (Tablet) ...... 12 Cromolyn Sodium (4% Ophthalmic Solution) Cytarabine Aqueous (Injection) ...... 24 Colchicine (0.6mg Tablet) (Generic Colcrys) ...... 63 Cytogam (Injection)...... 56 ...... 23 Cryselle-28 (Tablet) ...... 52 Colcrys (Tablet) ...... 23 Cuprimine (Capsule) ...... 49 D Colestipol HCl (1gm Tablet, 5gm Packet) ..... 36 Curity Alcohol Prep Pads/Medium 2 Ply .... 59 Colistimethate Sodium (Injection) ...... 16 Curity Alcohol Swabs ...... 59 D 1000 (1000unit Capsule, 1000unit Tablet Colocort (Enema) ...... 57 Curity Sterile Saline (Solution) ...... 40 Chewable) ...... 43 Coly-Mycin S (Suspension) ...... 65 Cuvitru (1gm/5ml Injection, 2gm/10ml D 10000 (Capsule) ...... 43 Combigan (Ophthalmic Solution) ...... 64 Injection, 4gm/20ml Injection) ...... 56 D 2000 (Tablet) ...... 43 Combipatch (Patch Twice Weekly) ...... 52 Cuvposa (Oral Solution) ...... 46 D 400 (400unit Tablet, 400unit Tablet Combistix (Strip) ...... 59 CVS Aspirin (325mg Tablet, 325mg Tablet Chewable) ...... 43 Combivent Respimat (Aerosol Solution) .... 67 Delayed-Release)...... 10 D2000 Ultra Strength (Capsule) ...... 43 Cometriq (Kit) ...... 26 CVS D3 (1000unit Capsule, 2000unit Capsule, D3 (1000unit Capsule, 2000unit Capsule, Compact Space Chamber/Anti-Static 400unit Capsule, 5000unit Capsule, 400unit Capsule, 1000unit Tablet, (Device) ...... 67 1000unit Tablet Chewable) ...... 43 2000unit Tablet) ...... 43 Compact Space Chamber/Anti-Static/Large CVS Enteric Aspirin (Tablet Delayed-Release) D3 2000 (Tablet) ...... 43 Mask (Device) ...... 67 ...... 10 D3 Adult (Tablet Chewable) ...... 43 Compact Space Chamber/Anti- CVS Ketone Care (Strip) ...... 59 D3 Dots (Tablet Dispersible) ...... 43 Static/Medium Mask (Device) ...... 67 CVS Nicotine (Patch 24 Hour) ...... 14 D3 High Potency (Tablet) ...... 43 Complera (Tablet) ...... 29 CVS Nicotine Polacrilex (2mg Gum, 4mg Gum, D3 Kids (Tablet Chewable) ...... 43 Complete Natal DHA ...... 43 2mg Lozenge, 4mg Lozenge) ...... 14 D3 Maximum Strength (5000unit Capsule, Completenate (Tablet Chewable) ...... 43 CVS Nicotine Transdermal System (Patch 24 5000unit/ml Liquid) ...... 43 Compro (Suppository) ...... 22 Hour) ...... 14 D3 Super Strength (Capsule) ...... 43 Co-Natal FA (Tablet) ...... 43 CVS NTS Step 1 (Patch 24 Hour) ...... 14 D3-1000 (Capsule) ...... 43 Condylox (Gel) ...... 39 CVS Prenatal (Tablet) ...... 43 D3-50 (Capsule) ...... 43 Constulose (Oral Solution) ...... 47 CVS Prenatal Gummy/DHA/Folic Acid (Tablet Dacarbazine (100mg Injection) ...... 24 Copaxone (Injection) ...... 38 Chewable) ...... 43 Dacarbazine (200mg Injection) ...... 24 Cordran (4mcg/sqcm Tape) ...... 50 CVS Prenatal Multi+DHA (Capsule) ...... 43 Daklinza (Tablet) ...... 28 Coreg CR (Capsule Extended-Release 24 CVS Prep Pads ...... 59 Daliresp (Tablet) ...... 66 Hour) ...... 34 CVS Purelax (Powder) ...... 47 Danazol (100mg Capsule, 200mg Capsule, Corifact (Injection) ...... 32 CVS Vitamin D Childrens Gummies (Tablet 50mg Capsule) ...... 51 Cormax Scalp Application (External Solution) Chewable) ...... 43 Dantrolene Sodium (Capsule) ...... 68 ...... 50 CVS Vitamin D3 Drops/Infants (Liquid) ...... 43 Dapsone (Tablet) ...... 24 Correct (Tablet Delayed-Release) ...... 47 Cyanocobalamin (1000mcg/ml Injection) ... 43 Daptacel (Injection) ...... 56 Correctol (Tablet Delayed-Release) ...... 47 Cyclafem (Tablet) ...... 52 Daptomycin (Injection) ...... 16 Cortifoam (Foam) ...... 57 Cyclobenzaprine HCl (Tablet) ...... 68 DARAPRIM (Tablet) ...... 27 Cortisone Acetate (25mg Tablet) ...... 50 Cyclopentolate HCl (Ophthalmic Solution).. 63 Darifenacin HBr ER (Tablet Extended-Release Cortisporin (0.5%-0.5% Cream, 1%-0.5% Cyclophosphamide (1gm Injection, 2gm 24 Hour) ...... 49 Ointment) ...... 39 Injection, 500mg Injection) ...... 24 Darzalex (Injection) ...... 26 Corvita (Tablet) ...... 40 Cyclophosphamide (25mg Capsule, 50mg Dasetta 1/35 (Tablet) ...... 52 Corvita 150 (Tablet) ...... 40 Capsule) ...... 24 Dasetta 7/7/7 (Tablet) ...... 52 Corvite Free (Tablet) ...... 43 Cycloserine (Capsule) ...... 24 Daunorubicin HCl (Injection)...... 25 Cosentyx (Injection) ...... 39 Cycloset (Tablet) ...... 30 Daysee (Tablet) ...... 52 Cosentyx Sensoready Pen (Injection) ...... 39 Cyclosporine (100mg Capsule, 25mg Capsule, Daytrana (Patch) ...... 37 Cotellic (Tablet) ...... 26 50mg/ml Injection) ...... 55 Ddrops (Liquid) ...... 43 Creon (Capsule Delayed-Release) ...... 49 Cyclosporine Modified (100mg Capsule, 25mg Ddrops Booster (Liquid) ...... 43 Cresemba (186mg Capsule, 372mg Injection) Capsule, 50mg Capsule, 100mg/ml Oral Debacterol (Solution) ...... 16 ...... 22 Solution) ...... 55 Deblitane (Tablet) ...... 54 Crixivan (Capsule) ...... 29 Cyproheptadine HCl (2mg/5ml Syrup, 4mg Decara (25000unit Capsule) ...... 43 Cromolyn Sodium (100mg/5ml Concentrate) Tablet) ...... 65 Decara (50000unit Capsule) ...... 43 ...... 47 Cyred (Tablet)...... 52 Decitabine (Injection) ...... 25 Cystadane (Powder) ...... 49 Deferoxamine Mesylate (Injection) ...... 59 74

Delta D3 (Tablet) ...... 43 DexPak 6 Day (Tablet Therapy Pack) ...... 50 Dicyclomine HCl (10mg Capsule, 10mg/5ml Deltasone (Tablet) ...... 50 Dexrazoxane (Injection) ...... 25 Oral Solution, 10mg/ml Injection, 20mg Delyla (Tablet) ...... 52 Dextroamphetamine Sulfate (10mg Tablet, Tablet) ...... 46 Demeclocycline HCl (150mg Tablet, 300mg 5mg Tablet, 5mg/5ml Oral Solution) ...... 37 Didanosine (Capsule Delayed-Release) ...... 29 Tablet)...... 19 Dextroamphetamine Sulfate ER (Capsule Dificid (Tablet) ...... 18 Demser (Capsule) ...... 35 Extended-Release 24 Hour) ...... 37 Difil-G Forte (Liquid) ...... 66 Denavir (Cream) ...... 30 Dextrose 10% (Injection) ...... 40 Diflorasone Diacetate (0.05% Cream, 0.05% Denta 5000 Plus (Cream) ...... 38 Dextrose 2.5%/NaCl 0.45% (Injection) ...... 40 Ointment) ...... 50 Dentagel (Gel) ...... 38 Dextrose 5% (Injection) ...... 40 Diflunisal (Tablet)...... 10 Depen Titratabs (Tablet) ...... 49 Dextrose 5%/Lactated Ringers (Injection)... 40 Digitek (Tablet) ...... 35 Depocyt (Injection) ...... 24 Dextrose 5%/NaCl 0.2% (Injection) ...... 40 Digox (Tablet) ...... 35 Depo-Medrol (20mg/ml Injection) ...... 50 Dextrose 5%/NaCl 0.33% (Injection) ...... 40 Digoxin (0.05mg/ml Oral Solution, 0.25mg/ml Depo-Provera (Injection) ...... 54 Dextrose 5%/NaCl 0.45% (Injection) ...... 40 Injection, 125mcg Tablet, 250mcg Tablet) Depo-SubQ Provera104 (Injection)...... 54 Dextrose 5%/NaCl 0.9% (Injection) ...... 40 ...... 35 DermacinRx Prizopak (Kit) ...... 13 Dextrose 50% (Injection) ...... 40 Dihydroergotamine Mesylate (1mg/ml Desipramine HCl (100mg Tablet, 10mg Tablet, Dextrose 70% (Injection) ...... 40 Injection) ...... 23 150mg Tablet, 25mg Tablet, 50mg Tablet, Dialyvite (Tablet) ...... 43 Dihydroergotamine Mesylate (4mg/ml Nasal 75mg Tablet) ...... 21 Dialyvite Vitamin D 5000 (Capsule) ...... 43 Solution) ...... 23 Desloratadine (Tablet) ...... 65 Dialyvite Vitamin D3 Max (Tablet) ...... 43 Dilantin (30mg Capsule) ...... 20 Desloratadine ODT (Tablet Dispersible) ...... 65 Diascreen 10 ...... 59 Dilatrate SR (Capsule Extended-Release) ...37 Desmopressin Acetate (0.01% Nasal Solution, Diascreen 1B ...... 59 Diltiazem CD (Capsule Extended-Release 24 0.1mg Tablet, 0.2mg Tablet, 4mcg/ml Diascreen 1G (Strip) ...... 59 Hour) ...... 34 Injection) ...... 51 Diascreen 1K ...... 59 Diltiazem HCl (120mg Tablet, 30mg Tablet, Desogestrel/Ethinyl Estradiol (Tablet) ...... 52 Diascreen 2GK (Strip) ...... 59 60mg Tablet, 90mg Tablet, 125mg/25ml Desonide (0.05% Cream, 0.05% Lotion, 0.05% Diascreen 2GP ...... 59 Injection, 25mg/5ml Injection, 50mg/10ml Ointment) ...... 50 Diascreen 3 ...... 59 Injection) ...... 34 Desoximetasone (0.05% Cream, 0.25% Diascreen 4NL ...... 59 Diltiazem HCl CD (Capsule Extended-Release Cream, 0.05% Gel, 0.05% Ointment, 0.25% Diascreen 4OBL ...... 59 24 Hour) ...... 34 Ointment) ...... 50 Diascreen 4PH ...... 59 Diltiazem HCl ER (Capsule Extended-Release Desvenlafaxine ER (100mg Tablet Extended- Diascreen 5 ...... 59 24 Hour, Tablet Extended-Release 24 Release 24 Hour, 25mg Tablet Extended- Diascreen 6 ...... 59 Hour, Capsule Extended-Release 12 Hour) Release 24 Hour, 50mg Tablet Extended- Diascreen 7 ...... 59 ...... 34 Release 24 Hour) ...... 21 Diascreen 8 ...... 59 Diltiazem HCl/Dextrose (5%-125mg/125ml Dexamethasone (0.5mg Tablet, 0.75mg Diascreen 9 ...... 59 Injection) ...... 34 Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Diascreen Liquid Urine Controls ...... 59 Diltiazem HCl/Sodium Chloride Tablet, 4mg Tablet, 6mg Tablet, Diazepam (10mg Tablet, 2mg Tablet, 5mg (100mg/100ml-0.9% Injection) ...... 34 0.5mg/5ml Elixir, 0.5mg/5ml Oral Solution) Tablet, 1mg/ml Oral Solution, 5mg/ml Dilt-XR (Capsule Extended-Release 24 Hour) ...... 50 Injection) ...... 30 ...... 34 Dexamethasone Intensol (1mg/ml Diazepam Intensol (5mg/ml Concentrate) .. 30 Dipentum (Capsule) ...... 57 Concentrate) ...... 50 Diclofenac Potassium (Tablet) ...... 10 Diphenhydramine HCl (12.5mg/5ml Elixir, Dexamethasone Sodium Phosphate (0.1% Diclofenac Sodium (0.1% Ophthalmic 12.5mg/5ml Liquid, 50mg/ml Injection) .65 Ophthalmic Solution) ...... 64 Solution) ...... 64 Diphenoxylate/Atropine (2.5mg-0.025mg Dexamethasone Sodium Phosphate Diclofenac Sodium (1% Gel, 3% Gel) ...... 39 Tablet, 2.5mg-0.025mg/5ml Liquid) ...... 47 (10mg/ml Injection, 120mg/30ml Diclofenac Sodium (1.5% Transdermal Diphtheria/Tetanus Toxoids Adsorbed Injection, 20mg/5ml Injection, 4mg/ml Solution) ...... 10 Pediatric (Injection) ...... 56 Injection) ...... 50 Diclofenac Sodium DR (Tablet Delayed- Dipyridamole (25mg Tablet, 50mg Tablet, Dexilant (Capsule Delayed-Release) ...... 48 Release) ...... 10 75mg Tablet) ...... 33 Dexmedetomidine HCl (Injection) ...... 59 Diclofenac Sodium ER (Tablet Extended- Disopyramide Phosphate (Capsule) ...... 33 Dexmethylphenidate HCl (Tablet Immediate- Release 24 Hour) ...... 10 Disulfiram (Tablet) ...... 14 Release) ...... 37 Diclofenac Sodium/Misoprostol (Tablet Divalproex Sodium (Capsule Sprinkle Delayed- Dexmethylphenidate HCl ER (Capsule Delayed-Release)...... 10 Release) ...... 19 Extended-Release 24 Hour) ...... 37 Dicloxacillin Sodium (Capsule) ...... 18 Divalproex Sodium DR (Tablet Delayed- DexPak 10 Day (Tablet Therapy Pack) ...... 50 Release) ...... 19 DexPak 13 Day (Tablet Therapy Pack) ...... 50 75

Divalproex Sodium ER (Tablet Extended- Drospirenone/Ethinyl Estradiol/Levomefolate Elixophyllin (Elixir) ...... 66 Release 24 Hour)...... 19 Calcium (Tablet) ...... 52 Ella (Tablet) ...... 54 Dobutamine HCl (Injection) ...... 35 Droxia (Capsule) ...... 24 Elmiron (Capsule) ...... 49 Dobutamine HCl/D5W (Injection) ...... 35 Duane Reade Lancet Alternate Site 26g..... 59 Eloctate (Injection) ...... 32 Docetaxel (160mg/16ml Injection, Duane Reade Lancet Ultra Thin 28g ...... 59 Emadine (Ophthalmic Solution) ...... 64 160mg/8ml Injection, 200mg/10ml Duavee (Tablet) ...... 52 Embeda (Capsule Extended-Release) ...... 12 Injection, 20mg/0.5ml Injection, Ducodyl (Tablet Delayed-Release) ...... 47 Emcyt (Capsule)...... 24 20mg/2ml Injection, 80mg/2ml Injection, Dulcolax Balance (Powder)...... 47 Emoquette (Tablet) ...... 52 80mg/8ml Injection) ...... 25 Duloxetine HCl (20mg Capsule Delayed- Empliciti (Injection) ...... 26 Docetaxel (20mg/ml Injection, 80mg/4ml Release, 30mg Capsule Delayed-Release, Emsam (Patch 24 Hour) ...... 21 Injection) ...... 25 60mg Capsule Delayed-Release) ...... 38 Emtriva (10mg/ml Oral Solution, 200mg Docetaxel (Non-Alcohol Formula) (Injection) Duloxetine HCl (40mg Capsule Delayed- Capsule) ...... 29 ...... 25 Release) ...... 38 Enalapril Maleate (Tablet) ...... 33 Dofetilide (Capsule) ...... 33 Dupixent (Injection) ...... 39 Enalapril Maleate/Hydrochlorothiazide Donepezil HCl (10mg Tablet Dispersible, 5mg Duramorph (Injection) ...... 12 (Tablet) ...... 35 Tablet Dispersible, 10mg Tablet, 23mg Duraxin (Capsule) ...... 38 Enalaprilat (Injection) ...... 33 Tablet, 5mg Tablet) ...... 20 Durezol (Emulsion) ...... 64 Enbrel (Injection) ...... 55 Dopamine HCl (40mg/ml Injection, 80mg/ml Dutasteride (Capsule)...... 49 Enbrel SureClick (Injection) ...... 55 Injection) ...... 35 Dutasteride/Tamsulosin HCl (Capsule) ...... 49 Encare (Suppository) ...... 49 Dopamine/D5W (Injection) ...... 35 D-Vita (Liquid) ...... 43 Endocet (Tablet) ...... 12 Doribax (500mg Injection) ...... 16 Dymista (Suspension) ...... 67 Enfamil Expecta ...... 43 Doripenem (500mg Injection) ...... 16 Dyrenium (0-100mg Capsule) ...... 36 Engerix-B (Injection) ...... 56 Dorzolamide HCl (Ophthalmic Solution) ...... 64 Enoxaparin Sodium (100mg/ml Injection, Dorzolamide HCl/Timolol Maleate E 120mg/0.8ml Injection, 150mg/ml (Ophthalmic Solution) ...... 64 Injection, 30mg/0.3ml Injection, Doxazosin (Tablet) ...... 33 E.E.S. 400 (Tablet) ...... 18 40mg/0.4ml Injection, 60mg/0.6ml Doxazosin Mesylate (Tablet) ...... 33 Easivent ...... 67 Injection, 80mg/0.8ml Injection, Doxepin HCl (100mg Capsule, 10mg Capsule, Easivent/Mask-Large ...... 67 300mg/3ml Injection) ...... 32 150mg Capsule, 25mg Capsule, 50mg Easivent/Mask-Medium ...... 67 Enpresse-28 (Tablet) ...... 52 Capsule, 75mg Capsule, 10mg/ml Easivent/Mask-Small ...... 67 Enskyce (Tablet) ...... 52 Concentrate) ...... 22 Easy Comfort Pen Needles ...... 59 Entacapone (Tablet) ...... 27 Doxepin HCl (Cream) ...... 39 Easy Touch 32gx5mm ...... 59 Entecavir (Tablet) ...... 28 Doxercalciferol (0.5mcg Capsule, 1mcg Easy Touch 32gx6mm ...... 59 Enulose (Oral Solution) ...... 47 Capsule, 2.5mcg Capsule, 4mcg/2ml Easy Touch Alcohol Prep Pads/Medium .... 59 Epclusa (Tablet) ...... 28 Injection) ...... 57 Easygel (Gel) ...... 40 Ephedrine Sulfate (50mg/ml Injection) ...... 33 Doxorubicin HCl (Injection) ...... 25 Econazole Nitrate (1% Cream) ...... 22 Epiduo (Gel)...... 39 Doxy 100 (Injection)...... 19 Econtra EZ (Tablet) ...... 54 Epiduo Forte (Gel) ...... 39 Doxycycline (25mg/5ml Suspension, 40mg Ecotrin (Tablet Delayed-Release) ...... 10 Epinastine HCl (Ophthalmic Solution) ...... 64 Capsule Delayed-Release) ...... 19 Ecotrin Low Strength (Tablet Delayed- Epinephrine (0.15mg/0.3ml Injection, Doxycycline Hyclate (100mg Capsule, 50mg Release) ...... 10 0.3mg/0.3ml Injection) (Authorized Capsule, 100mg Injection, 100mg Tablet, Ecpirin (Tablet Delayed-Release)...... 10 Generic for EpiPen made by Mylan) ...... 66 20mg Tablet, 150mg Tablet, 75mg Tablet) Edarbi (Tablet) ...... 33 Epinephrine HCl (0.1mg/ml Injection) ...... 66 ...... 19 Edurant (Tablet)...... 29 Epinephrine HCl (1mg/ml Injection) ...... 66 Doxycycline Hyclate DR (Tablet Delayed- Effer-K (25meq Tablet Effervescent) ...... 40 Epirubicin HCl (Injection) ...... 25 Release) ...... 19 Effervescent Potassium/Chloride (Tablet Epitol (Tablet) ...... 20 Doxycycline Monohydrate (100mg Capsule, Effervescent) ...... 40 Epivir HBV (5mg/ml Oral Solution) ...... 28 150mg Capsule, 50mg Capsule, 75mg Effient (Tablet) ...... 33 Eplerenone (Tablet) ...... 36 Capsule, 100mg Tablet, 150mg Tablet, Elaprase (Injection) ...... 49 Epoprostenol Sodium (Injection) ...... 66 50mg Tablet, 75mg Tablet) ...... 19 Elelyso (Injection) ...... 49 Eprosartan Mesylate (Tablet) ...... 33 Dronabinol (Capsule) ...... 22 Elidel (Cream) ...... 39 Eptifibatide (Injection) ...... 33 Droperidol (2.5mg/ml Injection) ...... 22 Elinest (Tablet) ...... 52 EQ Aspirin (325mg Tablet, 325mg Tablet Droplet Pen Needles ...... 59 Eliquis (Tablet) ...... 32 Delayed-Release) ...... 10 Drospirenone/Ethinyl Estradiol (Tablet) ...... 52 Elitek (Injection) ...... 24 EQ Childrens Aspirin (Tablet Chewable) ...... 10 Elite-Ob (Tablet) ...... 43 EQ ClearLax (Powder) ...... 47 76

EQ Nicotine (14mg/24hr Patch 24 Hour, Patch Weekly, 0.075mg/24hr Patch Famotidine (200mg/20ml Injection, 21mg/24hr Patch 24 Hour, 7mg/24hr Weekly, 0.1mg/24hr Patch Weekly, 20mg/2ml Injection, 40mg/4ml Injection, Patch 24 Hour, 4mg Lozenge) ...... 14 37.5mcg/24hr Patch Weekly, 0.5mg 20mg Tablet, 40mg Tablet, 40mg/5ml EQ Nicotine Gum Refill (Gum) ...... 14 Tablet, 1mg Tablet, 2mg Tablet) ...... 52 Suspension) ...... 47 EQ Nicotine Gum Starter (Gum) ...... 14 Estradiol Valerate (Injection) ...... 52 Fanapt (Tablet) ...... 28 EQ Nicotine Polacrilex (2mg Gum, 4mg Gum, Estradiol/Norethindrone Acetate (Tablet) .. 52 Fanapt Titration Pack (Tablet) ...... 28 2mg Lozenge, 4mg Lozenge) ...... 14 Estropipate (Tablet) ...... 52 Fareston (Tablet) ...... 24 EQL Alcohol Swabs ...... 59 Eszopiclone (Tablet) ...... 68 Farxiga (Tablet) ...... 30 EQL Aspirin (Tablet) ...... 10 Ethacrynate Sodium (Injection) ...... 36 Farydak (Capsule) ...... 25 EQL Aspirin EC (Tablet Delayed-Release) ..... 10 Ethacrynic Acid (Tablet) ...... 36 Faslodex (Injection) ...... 24 EQL Aspirin Low Dose (Tablet Chewable) .... 10 Ethambutol HCl (100mg Tablet, 400mg Fayosim (Tablet) ...... 52 EQL ClearLax (Powder) ...... 47 Tablet) ...... 24 Fazaclo (12.5mg Tablet Dispersible, 150mg EQL Gentle Laxative (Tablet Delayed-Release) Ethosuximide (250mg Capsule, 250mg/5ml Tablet Dispersible, 200mg Tablet ...... 47 Oral Solution) ...... 19 Dispersible) ...... 28 EQL Laxative (Tablet Delayed-Release) ...... 47 Ethynodiol Diacetate/Ethinyl Estradiol FC Female Condom ...... 59 EQL Nicotine (Lozenge) ...... 14 (Tablet) ...... 52 FC2 Female Condom ...... 59 EQL Nicotine Polacrilex (2mg Gum, 4mg Gum, Ethyol (Injection) ...... 25 Feenamint (Tablet Delayed-Release) ...... 47 2mg Lozenge, 4mg Lozenge) ...... 14 Etidronate Disodium (Tablet) ...... 57 Feiba (Injection) ...... 44 EQL Prenatal Formula (Tablet) ...... 43 Etodolac (200mg Capsule, 300mg Capsule, Felbamate (400mg Tablet, 600mg Tablet, EQL Vitamin D3 (Capsule) ...... 43 400mg Tablet, 500mg Tablet) ...... 10 600mg/5ml Suspension) ...... 20 EQL Vitamin D3 Gummies (Tablet Chewable) Etodolac ER (Tablet Extended-Release 24 Felodipine ER (Tablet Extended-Release 24 ...... 43 Hour) ...... 10 Hour) ...... 34 Eraxis (50mg Injection) ...... 22 Etoposide (100mg/5ml Injection, 1gm/50ml Femcap (Device) ...... 59 Erbitux (Injection) ...... 26 Injection, 500mg/25ml Injection) ...... 26 Femynor (Tablet) ...... 52 Ergocalciferol (8000unit/ml Oral Solution).. 43 Etoposide (50mg Capsule) ...... 26 Fenofibrate (120mg Tablet, 145mg Tablet, Ergoloid Mesylates (Tablet) ...... 59 Eurax (10% Cream, 10% Lotion) ...... 27 40mg Tablet, 48mg Tablet, 54mg Tablet, Ergotamine Tartrate/Caffeine (Tablet) ...... 23 Evamist (Solution) ...... 52 130mg Capsule, 150mg Capsule, 43mg Erivedge (Capsule) ...... 26 Evotaz (Tablet) ...... 29 Capsule, 50mg Capsule) ...... 36 Errin (Tablet) ...... 54 Excel Comfort Point Insulin Pen Needles... 59 Fenofibrate (160mg Tablet) ...... 36 Ertaczo (Cream) ...... 22 Exel Comfort Point Insulin Fenofibrate Micronized (Capsule) ...... 36 Erwinaze (Injection) ...... 25 Syringe/0.3ml/29g X 1/2" ...... 59 Fenofibric Acid (Tablet) ...... 36 Ery...... 18 Exel Comfort Point Insulin Fenofibric Acid DR (Capsule Delayed-Release) Ery-Tab (333mg Tablet Delayed-Release) .. 18 Syringe/0.3ml/30g X 5/16" ...... 59 ...... 36 Erythromycin (2% External Solution, 2% Gel, Exelderm (1% Cream, 1% External Solution) Fenoprofen Calcium (400mg Capsule) ...... 10 2% Pad, 250mg Capsule Delayed-Release, ...... 22 Fenoprofen Calcium (600mg Tablet) ...... 10 5mg/gm Ointment) ...... 18 Exemestane (Tablet) ...... 26 Fenortho (Capsule)...... 10 Erythromycin Base (Tablet) ...... 18 Exjade (Tablet Soluble) ...... 42 Fentanyl (Patch 72 Hour) ...... 12 Erythromycin Ethylsuccinate (200mg/5ml Ex-Lax Ultra (Tablet Delayed-Release) ...... 47 Fentanyl Citrate Oral Transmucosal (Lollipop) Suspension, 400mg Tablet) ...... 18 E-Z Spacer (Device) ...... 67 ...... 12 Erythromycin/Benzoyl Peroxide (Gel)...... 39 E-Z Spacer the Body Guards Pack (Device) 67 Ferocon (Capsule) ...... 40 Esbriet (Capsule) ...... 67 Ezetimibe (Tablet) ...... 36 Ferotrinsic (Capsule) ...... 40 Escitalopram Oxalate (10mg Tablet, 20mg Ezetimibe/Simvastatin (10mg-10mg Tablet, Ferriprox (500mg Tablet) ...... 42 Tablet, 5mg Tablet, 5mg/5ml Oral 10mg-20mg Tablet, 10mg-40mg Tablet) 37 Ferrocite Plus (Tablet)...... 40 Solution) ...... 21 Ezetimibe/Simvastatin (10mg-80mg Tablet)37 Fetzima (Capsule Extended-Release 24 Hour) Esgic (325mg-50mg-40mg Capsule) ...... 10 ...... 21 Esmolol HCl (Injection) ...... 34 F Fibricor (35mg Tablet) ...... 36 Esomeprazole Magnesium (Capsule Delayed- Fifty50 Alcohol Prep Pads ...... 59 Release) (Generic Nexium) ...... 48 FA-8 (0.8mg Capsule, 800mcg Tablet) ...... 44 Fifty50 Pen Needles ...... 59 Esomeprazole Sodium (40mg Injection) ...... 48 Fabb (Tablet) ...... 44 Finacea (15% Foam, 15% Gel) ...... 39 Estarylla (Tablet) ...... 52 Fabrazyme (Injection) ...... 49 Finasteride (5mg Tablet) ...... 49 Estazolam (Tablet) ...... 30 Factive (Tablet) ...... 18 Fine 30 ...... 59 Estrace (0.1mg/gm Cream) ...... 52 Fallback Solo (Tablet) ...... 54 Firazyr (Injection) ...... 55 Estradiol (0.025mg/24hr Patch Weekly, Falmina (Tablet) ...... 52 Flarex (Suspension) ...... 64 0.05mg/24hr Patch Weekly, 0.06mg/24hr Famciclovir (Tablet) ...... 30 Flavoxate HCl (Tablet) ...... 49 77

Flebogamma DIF (Injection) ...... 56 Fluorouracil (0.5% Cream) ...... 39 Fosphenytoin Sodium (Injection) ...... 20 Flecainide Acetate (Tablet) ...... 33 Fluorouracil (1gm/20ml Injection, Fosrenol (1000mg Packet, 750mg Packet, Fleet Laxative (Tablet Delayed-Release) ...... 47 2.5gm/50ml Injection, 500mg/10ml 1000mg Tablet Chewable, 500mg Tablet Flexbumin (Injection) ...... 40 Injection, 5gm/100ml Injection) ...... 24 Chewable, 750mg Tablet Chewable) ..... 49 Flexichamber (Device) ...... 67 Fluorouracil (2% External Solution, 5% Fragmin (Injection) ...... 32 Flexichamber Child Mask/Large ...... 59 External Solution) ...... 39 Frovatriptan Succinate (Tablet) ...... 23 Flexichamber Child Mask/Small ...... 59 Fluorouracil (5% Cream) ...... 39 Furosemide (10mg/ml Injection, 10mg/ml Flovent Diskus (Aerosol Powder) ...... 65 Fluoxetine (Capsule) ...... 21 Oral Solution, 8mg/ml Oral Solution, 20mg Flovent HFA (Aerosol) ...... 65 Fluoxetine DR (Capsule Delayed-Release)... 21 Tablet, 40mg Tablet, 80mg Tablet) ...... 36 Floxuridine (Injection)...... 24 Fluoxetine HCl (10mg Tablet, 20mg Tablet, Fuzeon (Injection) ...... 29 Fluad 2016-2017 (Injection) ...... 56 60mg Tablet, 20mg/5ml Oral Solution, Fyavolv (Tablet) ...... 52 Fluarix Quadrivalent 2017-2018 (Suspension 40mg Capsule) ...... 21 Fycompa (0.5mg/ml Suspension, 10mg Prefilled Syringe) ...... 56 Fluphenazine Decanoate (Injection) ...... 27 Tablet, 12mg Tablet, 2mg Tablet, 4mg Flublok 2017-2018 (Solution) ...... 56 Fluphenazine HCl (10mg Tablet, 1mg Tablet, Tablet, 6mg Tablet, 8mg Tablet) ...... 19 Flublok Quadrivalent 2017-2018 (Solution 2.5mg Tablet, 5mg Tablet) ...... 27 Prefilled Syringe) ...... 57 Flura-Drops (0.125mg/drop Oral Solution) . 42 G Flucelvax Quadrivalent 2016-2017 (Injection) Flurandrenolide (0.05% Cream, 0.05% Lotion, ...... 57 0.05% Ointment) ...... 51 Gabapentin (100mg Capsule, 300mg Capsule, Fluconazole (100mg Tablet, 150mg Tablet, Flurazepam HCl (Capsule) ...... 68 400mg Capsule, 250mg/5ml Oral Solution, 200mg Tablet, 50mg Tablet, 10mg/ml Flurbiprofen (100mg Tablet, 50mg Tablet) . 10 300mg/6ml Oral Solution, 600mg Tablet, Suspension, 40mg/ml Suspension) ...... 22 Flurbiprofen Sodium (Ophthalmic Solution) 64 800mg Tablet) ...... 19 Fluconazole in Dextrose (Injection) ...... 23 Flutamide (Capsule) ...... 24 Gabitril (12mg Tablet, 16mg Tablet) ...... 19 Fluconazole in NaCl (200mg/100ml-0.9% Fluticasone Propionate (0.005% Ointment, Galantamine HBr (12mg Tablet, 4mg Tablet, Injection, 400mg/200ml-0.9% Injection) 23 0.05% Cream, 0.05% Lotion) ...... 51 8mg Tablet, 4mg/ml Oral Solution) ...... 20 Flucytosine (Capsule) ...... 23 Fluticasone Propionate (50mcg/act Galantamine HBr ER (Capsule Extended- Fludarabine Phosphate (Injection) ...... 25 Suspension) ...... 65 Release 24 Hour) ...... 20 Fludrocortisone Acetate (0.1mg Tablet) ...... 50 Fluvastatin (Capsule) ...... 36 Gamastan S/D (Injection) ...... 56 Flulaval Quadrivalent 2017-2018 Fluvastatin Sodium ER (Tablet Extended- Gammagard Liquid (Injection) ...... 56 (Suspension) ...... 57 Release 24 Hour) ...... 36 Gammagard S/D IGA Less Than 1 mcg/ml Flumazenil (Injection) ...... 59 Fluvirin 2016-2017 (Injection) ...... 57 (Injection) ...... 56 Flumist Quadrivalent (Suspension) ...... 29 Fluvoxamine Maleate (Tablet) ...... 21 Gammaked (Injection) ...... 56 Flunisolide (Nasal Solution) ...... 65 Fluvoxamine Maleate ER (Capsule Extended- Gammaplex (Injection) ...... 56 Fluocinolone Acetonide (0.01% Cream, Release 24 Hour) ...... 21 Gamunex-C (Injection) ...... 56 0.025% Cream, 0.01% External Solution, Fluzone High-Dose Pf 2017-2018 (Suspension Ganciclovir (Injection) ...... 28 0.025% Ointment) ...... 50 Prefilled Syringe) ...... 57 Gardasil (Injection)...... 57 Fluocinolone Acetonide (0.01% Oil) ...... 65 Fluzone Quadrivalent 2017-2018 Gardasil 9 (Injection) ...... 57 Fluocinolone Acetonide Body (Oil) ...... 50 (Suspension Prefilled Syringe) ...... 57 Gatifloxacin (Ophthalmic Solution) ...... 18 Fluocinolone Acetonide Ear Drops (Oil) ...... 65 FML (Ointment) ...... 64 Gattex (Injection) ...... 47 Fluocinolone Acetonide Scalp (Oil) ...... 50 Folbee (Tablet) ...... 44 GaviLAX (Powder) ...... 47 Fluocinonide (0.05% Cream, 0.1% Cream, Folbee Plus (Tablet) ...... 44 GaviLyte-C (Oral Solution) ...... 47 0.05% External Solution, 0.05% Gel, 0.05% Folic Acid (1mg Tablet, 400mcg Tablet, GaviLyte-G (Oral Solution) ...... 47 Ointment) ...... 50 800mcg Capsule) ...... 44 GaviLyte-H (Kit) ...... 47 Fluocinonide Emulsified Base (Cream)...... 50 Folic Acid/Vitamin B-6/Vitamin B-12 (Tablet) GaviLyte-N/Flavor Pack (Oral Solution) ...... 47 Fluocinonide-E (Cream) ...... 51 ...... 44 Gazyva (Injection) ...... 26 Fluor-A-Day (Oral Solution) ...... 42 Folotyn (Injection) ...... 24 Gelnique (Gel) ...... 49 Fluoride (Tablet Chewable) ...... 42 Folplex 2.2 (Tablet) ...... 44 Gelnique Pump (Gel) ...... 49 Fluoridex (Paste) ...... 38 Foltrin (Capsule) ...... 40 Gemcitabine (Injection) ...... 24 Fluoridex Daily Renewal (Concentrate) ...... 40 Fomepizole (Injection) ...... 59 Gemfibrozil (600mg Tablet) ...... 36 Fluoridex Sensitivity Relief/Sls Free (Paste). 40 Fondaparinux Sodium (Injection) ...... 32 Generlac (Oral Solution) ...... 47 Fluoritab (0.125mg/drop Oral Solution, Forteo (Injection) ...... 58 Gene-Xene Tab 15mg (Tablet) ...... 30 0.25mg Tablet Chewable, 0.5mg Tablet Fosamax Plus D (Tablet) ...... 58 Gene-Xene Tab 3.75mg (Tablet) ...... 30 Chewable, 1mg Tablet Chewable) ...... 42 Fosinopril Sodium (Tablet) ...... 33 Gene-Xene Tab 7.5mg (Tablet) ...... 30 Fluorometholone (Ophthalmic Suspension) 64 Fosinopril Sodium/Hydrochlorothiazide Gengraf (100mg Capsule, 25mg Capsule, Fluoroplex (Cream) ...... 39 (Tablet) ...... 35 50mg Capsule, 100mg/ml Oral Solution) 55 78

Gentak (Ophthalmic Ointment) ...... 15 GNP Nicotine Transdermal System (Patch 24 H-E-B Incontrol Alcohol Prep Pads...... 59 Gentamicin Sulfate (0.1% Cream, 0.1% Hour) ...... 14 Hectorol (2mcg/ml Injection) ...... 58 Ointment, 0.3% Ophthalmic Solution, GNP Prenatal (Tablet) ...... 44 Helixate FS (Injection) ...... 32 10mg/ml Injection, 40mg/ml Injection).. 15 GNP Vitamin D (Tablet) ...... 44 Hema-Combistix (Strip) ...... 59 Gentamicin Sulfate/0.9% Sodium Chloride GNP Vitamin D Super Strength (Tablet) ...... 44 Hematinic Plus Vitamins/Minerals (Tablet) .40 (0.8mg/ml-0.9% Injection, 1.2mg/ml-0.9% GNP Vitamin D3 Extra Strength (Tablet) ..... 44 Hematinic/Folic Acid (Tablet) ...... 44 Injection, 1mg/ml-0.9% Injection) ...... 15 GNP Womens Laxative (Tablet Delayed- Hematogen (Capsule) ...... 40 Gentle Laxative (Tablet Delayed-Release) ... 48 Release) ...... 48 Hematogen Forte (Capsule) ...... 40 Gentlelax (Powder) ...... 48 Goodsense Aspirin (Tablet) ...... 11 Hemocyte-F (Tablet) ...... 44 Geodon (20mg Solution) ...... 28 Goodsense Aspirin Adult Low Strength Hemocyte-Plus (Tablet) ...... 40 Gianvi (Tablet) ...... 52 (Tablet Chewable) ...... 11 Hemofil M (Injection) ...... 32 Gildagia (Tablet) ...... 52 Goodsense Magnesium Citrate (Solution) .. 48 Hepagam B (Injection) ...... 56 Gilenya (Capsule) ...... 38 Goodsense Nicotine Gum (Gum) ...... 14 Heparin Lock Flush (Injection) ...... 32 Gilotrif (Tablet) ...... 26 Goodsense Prenatal Vitamins (Tablet) ...... 44 Heparin Sodium (10000unit/10ml Injection, Glassia (Injection) ...... 67 Gralise (Tablet) ...... 19 3000unit/3ml Injection, 5000unit/5ml Glatopa (Injection) ...... 38 Gralise Starter Pack ...... 19 Injection, 10000unit/ml Injection, Gleostine (Capsule) ...... 24 Granisetron HCl (0.1mg/ml Injection, 1mg/ml 1000unit/ml Injection, 20000unit/ml Glimepiride (Tablet) ...... 30 Injection, 4mg/4ml Injection) ...... 22 Injection, 5000unit/0.5ml Injection, Glipizide (10mg Tablet Immediate-Release, Granisetron HCl (1mg Tablet)...... 22 5000unit/ml Injection) ...... 32 5mg Tablet) ...... 30 Griseofulvin Microsize (125mg/5ml Heparin Sodium Lock Flush (Kit) ...... 32 Glipizide ER (Tablet Extended-Release 24 Suspension, 500mg Tablet) ...... 23 Heparin Sodium/D5W (5%-40unit/ml Hour) ...... 30 Griseofulvin Ultramicrosize (Tablet) ...... 23 Injection, 5%-50unit/ml Injection) ...... 32 Glipizide XL (Tablet Extended-Release 24 Guanfacine ER (Tablet Extended-Release 24 Heparin Sodium/NaCl 0.9% (Injection) ...... 32 Hour) ...... 30 Hour) ...... 37 Heparin Sodium/Sodium Ch Loride (Injection) Glipizide/Metformin HCl (Tablet) ...... 30 Guanfacine HCl (1mg Tablet, 2mg Tablet ...... 32 Global Alcohol Prep Ease Pads ...... 59 Immediate-Release) ...... 33 Heparin Sodium/Sodium Chloride GlucaGen HypoKit (Injection) ...... 31 Guanidine HCl (Tablet) ...... 23 (2000unit/500ml-0.9% Injection, Glucagon Emergency Kit (Injection) ...... 31 Gynazole-1 (Cream) ...... 23 20unit/20ml-0.9% Injection, Glyburide (1.25mg Tablet, 2.5mg Tablet, 5mg 25000unit/250ml-0.45% Injection, Tablet)...... 30 H 30000unit/L-0.9% Injection, 4000unit/L- Glyburide Micronized (Tablet) ...... 30 0.9% Injection, 50unit/50ml-0.45% Glyburide/Metformin HCl (Tablet) ...... 30 H.P. Acthar (Injection) ...... 51 Injection) ...... 32 Glycine (1.5% Irrigation Solution) ...... 49 Haemolance ...... 59 Heparin Sodium/Sodium Chloride 0.9% Glycolax (Powder) ...... 48 Haemolance Plus ...... 59 Premix (Injection) ...... 32 Glycopyrrolate (0.4mg/2ml Injection, Haemolance Plus High Flow ...... 59 Herceptin (Injection) ...... 26 1mg/5ml Injection, 4mg/20ml Injection, Haemolance Plus Low Flow ...... 59 Hetastarch 6%/NaCl (Injection) ...... 32 1mg Tablet, 2mg Tablet) ...... 46 Haemolance Plus Max Flow ...... 59 Hetlioz (Capsule) ...... 38 Glydo (Gel) ...... 13 Haemolance Plus Pediatric Flow ...... 59 Hexalen (Capsule) ...... 24 GNP Adult Aspirin Low Strength (Tablet Halaven (Injection) ...... 25 Hiberix (Injection) ...... 57 Chewable) ...... 11 Halobetasol Propionate (0.05% Cream, 0.05% Hizentra (Injection) ...... 56 GNP Alcohol Swabs ...... 59 Ointment) ...... 51 HM Aspirin (325mg Tablet, 81mg Tablet GNP Aspirin (325mg Tablet, 325mg Tablet Halog (0.1% Cream, 0.1% Ointment)...... 51 Chewable) ...... 11 Delayed-Release, 81mg Tablet Delayed- Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg HM ClearLax (Powder) ...... 48 Release) ...... 11 Tablet, 20mg Tablet, 2mg Tablet, 5mg HM Laxative (Tablet Delayed-Release) ...... 48 GNP Aspirin Low Dose (Tablet Delayed- Tablet, 2mg/ml Concentrate) ...... 27 HM Nicotine Polacrilex (2mg Gum, 4mg Gum, Release) ...... 11 Haloperidol Decanoate (Injection) ...... 27 2mg Lozenge, 4mg Lozenge) ...... 14 GNP Bisa-Lax (Tablet Delayed-Release) ...... 48 Haloperidol Lactate (Injection) ...... 27 HM Nicotine Transdermal System (Patch 24 GNP ClearLax (Powder) ...... 48 Harvoni (Tablet)...... 28 Hour) ...... 15 GNP D 1000 (Capsule) ...... 44 Havrix (Injection) ...... 57 HM Nicotine Transdermal System (Patch 24 GNP D 2000 (Tablet Chewable) ...... 44 Healthy Kids Vitamin D3 (Tablet Chewable) 44 Hour) ...... 15 GNP Daily Prenatal ...... 44 Healthy Mama Be Well Rounded (Therapy HM One Daily Prenatal Combo ...... 44 GNP Nicotine Mini Lozenge (Lozenge) ...... 14 Pack) ...... 44 HM Prenatal (Tablet) ...... 44 GNP Nicotine Polacrilex (2mg Gum, 4mg Heather (Tablet) ...... 54 HM Vitamin D (Tablet) ...... 44 Gum, 2mg Lozenge, 4mg Lozenge) ...... 14 H-E-B in Control Pen Needles ...... 59 HM Vitamin D3 (Capsule) ...... 44 79

Homatropaire (Ophthalmic Solution) ...... 63 Hydromet (Syrup)...... 67 Ifex (3gm Injection) ...... 24 Homatropine HBr (Ophthalmic Solution) .... 63 Hydromorphone HCl (10mg/ml Injection, Ifosfamide (1gm Injection, 1gm/20ml Horizant (Tablet Extended-Release) ...... 38 1mg/ml Injection, 2mg/ml Injection, Injection, 3gm/60ml Injection) ...... 24 Humalog (Injection) ...... 31 4mg/ml Injection, 500mg/50ml Injection, Ifosfamide (3gm Injection) ...... 24 Humalog KwikPen (Injection) ...... 31 50mg/5ml Injection) ...... 13 Ilaris (Injection) ...... 56 Humalog Mix 50/50 (Injection)...... 31 Hydromorphone HCl (1mg/ml Liquid, 2mg Ilevro (Suspension) ...... 64 Humalog Mix 50/50 KwikPen (Injection) ... 31 Tablet, 4mg Tablet, 8mg Tablet) ...... 13 Imatinib Mesylate (Tablet) ...... 26 Humalog Mix 75/25 (Injection) ...... 31 Hydromorphone HCl ER (Tablet Extended- Imbruvica (Capsule) ...... 26 Humalog Mix 75/25 KwikPen (Injection) ... 31 Release 24 Hour Abuse-Deterrent) ...... 12 Imipenem/Cilastatin (Injection) ...... 17 Humapen Luxura HD (Device) ...... 59 Hydromorphone HCl/ Sodium Chloride Imipramine HCl (10mg Tablet, 25mg Tablet, Humate-P (Injection) ...... 32 (Injection) ...... 13 50mg Tablet) ...... 22 Humira (Injection) ...... 55 Hydromorphone HCl/Sodium Chloride Imipramine Pamoate (Capsule) ...... 22 Humira Pediatric Crohns Disease Starter (10mg/25ml-0.9% Injection, 15mg/30ml- Imiquimod (Cream) ...... 39 Pack (Injection)...... 55 0.9% Injection, 15mg/50ml-0.9% Injection, Imogam Rabies-HT (Injection) ...... 56 Humira Pen (Injection) ...... 55 1mg/5ml-0.9% Injection, 3mg/30ml-0.9% Impavido (Capsule) ...... 27 Humira Pen Crohns Disease Starter Pack Injection, 5mg/25ml-0.9% Injection) ...... 13 In Touch Diabetes Management Software.59 (Injection) ...... 55 Hydromorphone/Sodium Chloride (Injection) Inatal Advance (Tablet) ...... 44 Humira Pen-Psoriasis Starter (Injection) .... 55 ...... 13 Inatal GT (Tablet) ...... 44 Humulin 70/30 (Injection) ...... 31 Hydroxychloroquine Sulfate (Tablet) ...... 27 Increlex (Injection) ...... 51 Humulin 70/30 KwikPen (Injection) ...... 31 Hydroxyurea (Capsule) ...... 24 Incruse Ellipta (Aerosol Powder) ...... 65 Humulin N (Injection) ...... 31 Hydroxyzine HCl (10mg Tablet, 25mg Tablet, Indapamide (Tablet) ...... 36 Humulin N KwikPen (Injection) ...... 31 50mg Tablet, 10mg/5ml Syrup, 50mg/ml Indomethacin (1mg Injection, 25mg Capsule, Humulin R (Injection) ...... 31 Injection) ...... 30 50mg Capsule) ...... 11 Humulin R U-500 (Concentrated) (Injection) Hydroxyzine Pamoate (100mg Capsule, 25mg Indomethacin ER (Capsule Extended-Release) ...... 31 Capsule, 50mg Capsule) ...... 30 ...... 11 Hycamtin (0.25mg Capsule, 1mg Capsule) . 26 Hyoscyamine Sulfate (0.125mg Tablet Infanrix (Injection) ...... 57 Hydralazine HCl (100mg Tablet, 10mg Tablet, Dispersible, 0.125mg Tablet Sublingual, Inlyta (Tablet) ...... 26 25mg Tablet, 50mg Tablet, 20mg/ml 0.125mg/5ml Elixir, 0.125mg/ml Oral InspiraChamber/Anti-Static Injection) ...... 37 Solution) ...... 46 Valved/Mouthpiece (Device) ...... 67 Hydrochlorothiazide (12.5mg Capsule, Hyosyne (0.125mg/5ml Elixir, 0.125mg/ml InspiraChamber/Large (Device) ...... 67 12.5mg Tablet, 25mg Tablet, 50mg Tablet) Oral Solution) ...... 46 InspiraChamber/Soother ...... 36 Hyperhep B S/D (Injection) ...... 56 Mask/InspiraMask/Medium (Device) ...67 Hydrocodone Bitartrate/Acetaminophen Hyperrab S/D (Injection) ...... 56 InspiraChamber/Soother (300mg-10mg Tablet, 300mg-5mg Tablet, Hyperrho S/D (Injection) ...... 56 Mask/InspiraMask/Small (Device) ...... 67 300mg-7.5mg Tablet, 325mg-2.5mg Hyperrho S/D Mini-Dose (Injection) ...... 56 Inspirease Drug Delivery System ...... 68 Tablet, 325mg/15ml-7.5mg/15ml Oral Hyqvia (Injection) ...... 56 Inspirease Reservoir Bags ...... 59 Solution) ...... 12 Hysingla ER (Tablet Extended-Release 24 Insulin Syringe/0.5ml/27g X 1/2" ...... 59 Hydrocodone Bitartrate/Homatropine Hour Abuse-Deterrent) ...... 12 Insulin Syringe/U-100/1ml/28g X 1/2" ...... 59 Methylbromide (1.5mg-5mg Tablet, Insulin Syringes, Needles ...... 59 1.5mg/5ml-5mg/5ml Syrup) ...... 67 I Insupen 33gx4mm ...... 59 Hydrocodone/Acetaminophen (Tablet) ...... 12 Insupen Pen Needles 32g X4mm ...... 59 Hydrocodone/Ibuprofen (Tablet) ...... 12 Ibandronate Sodium (150mg Tablet, 3mg/3ml Insupen Sensitive 32gx6mm ...... 59 Hydrocort Enema 100mg (Enema) ...... 57 Injection) ...... 58 Insupen Sensitive 32gx8mm ...... 60 Hydrocortisone (1% Cream, 2.5% Cream, 1% Ibrance (Capsule) ...... 26 Insupen Ultrafin 29gx12mm ...... 60 Ointment, 2.5% Ointment, 10mg Tablet, Ibudone (5mg-200mg Tablet) ...... 13 Insupen Ultrafin 30gx8mm ...... 60 20mg Tablet, 5mg Tablet, 2.5% Lotion) .. 51 Ibuprofen (100mg/5ml Suspension, 400mg Insupen Ultrafin 31gx6mm ...... 60 Hydrocortisone (2.5% Cream) ...... 57 Tablet, 600mg Tablet, 800mg Tablet) .... 11 Insupen Ultrafin 31gx8mm ...... 60 Hydrocortisone 1% in Absorbase (Ointment) Ibuprofen Lysine (Injection) ...... 35 Intelence (Tablet) ...... 29 ...... 51 Ibutilide Fumarate (Injection) ...... 33 Intralipid (20gm/100ml Injection) ...... 40 Hydrocortisone Butyrate (0.1% Cream, 0.1% Iclusig (15mg Tablet) ...... 26 Intron A (Injection) ...... 28 External Solution, 0.1% Ointment) ...... 51 Iclusig (45mg Tablet) ...... 26 Intron A w/Diluent (Injection) ...... 28 Hydrocortisone Valerate (0.2% Cream, 0.2% Idarubicin HCl (Injection)...... 25 Introvale (Tablet) ...... 52 Ointment) ...... 51 Idelvion (Injection) ...... 32 Invanz (Injection) ...... 17 Hydrocortisone/Acetic Acid (Otic Solution). 65 Iferex 150 Forte (Capsule) ...... 40 Invega Sustenna (Injection) ...... 28 80

Invega Trinza (Injection) ...... 28 Jencycla (Tablet) ...... 54 Ketorolac Tromethamine (0.4% Ophthalmic Invirase (200mg Capsule, 500mg Tablet) ... 29 Jentadueto (Tablet) ...... 31 Solution, 0.5% Ophthalmic Solution) ...... 64 Invokamet (Tablet) ...... 30 Jentadueto XR (Tablet Extended-Release 24 Ketorolac Tromethamine (10mg Tablet) ..... 11 Invokamet XR (Tablet Extended-Release 24 Hour) ...... 31 Ketorolac Tromethamine (15mg/ml Injection, Hour) ...... 31 Jevantique Lo (Tablet) ...... 52 30mg/ml Injection, 30mg/ml Injection)..11 Invokana (Tablet) ...... 31 Jevtana (Injection) ...... 25 Ketostix (Strip) ...... 60 Iopidine (1% Ophthalmic Solution) ...... 64 Jinteli (Tablet) ...... 52 Keveyis (Tablet) ...... 36 IPOL Inactivated IPV (Injection) ...... 57 Jolessa (Tablet) ...... 52 Kimidess (Tablet) ...... 53 Ipratropium Bromide (0.02% Inhalation Jolivette (Tablet) ...... 54 Kineret (Injection) ...... 55 Solution) ...... 66 J-Tip Kit w/Vial Adapters (Kit) ...... 60 Kinrix (Injection)...... 57 Ipratropium Bromide (0.03% Nasal Solution, Jublia (External Solution) ...... 23 Kionex (Powder, 15gm/60ml Suspension)...42 0.06% Nasal Solution) ...... 66 Juleber (Tablet) ...... 52 Klofensaid II (Transdermal Solution) ...... 11 Ipratropium Bromide/Albuterol Sulfate Junel 1.5/30 (Tablet) ...... 52 Klor-Con 10 (Tablet Extended-Release) ...... 41 (Inhalation Solution) ...... 68 Junel 1/20 (Tablet) ...... 52 Klor-Con 8 (Tablet Extended-Release) ...... 41 Irbesartan (Tablet) ...... 33 Junel Fe 1.5/30 (Tablet) ...... 52 Klor-Con M10 (Tablet Extended-Release) .... 41 Irbesartan/Hydrochlorothiazide (Tablet) ..... 35 Junel Fe 1/20 (Tablet) ...... 52 Klor-Con M15 (Tablet Extended-Release) ..41 Irinotecan (40mg/2ml Injection)...... 25 Junel Fe 24 (Tablet) ...... 52 Klor-Con M20 (Tablet Extended-Release) .... 41 Irinotecan (500mg/25ml Injection) ...... 25 Just D (Liquid) ...... 44 Klor-Con Sprinkle (Capsule Extended-Release) Irinotecan HCl (Injection) ...... 25 Juxtapid (Capsule) ...... 37 ...... 41 Isentress (100mg Packet, 100mg Tablet Klor-Con/Ef (Tablet Effervescent) ...... 41 Chewable, 25mg Tablet Chewable, 400mg K KLS Aspirin EC (Tablet Delayed-Release) ...... 11 Tablet) ...... 29 KLS Aspirin Low Dose (Tablet Delayed- Isentress HD (Tablet) ...... 29 Kadcyla (Injection) ...... 26 Release) ...... 11 Isibloom (Tablet)...... 52 Kaitlib Fe (Tablet Chewable) ...... 52 KLS LaxaClear (Powder) ...... 48 Isolyte-S (Injection) ...... 40 Kaletra (100mg-25mg Tablet, 200mg-50mg KLS Quit2 (2mg Gum, 2mg Lozenge) ...... 15 Isoniazid (100mg Tablet, 300mg Tablet, Tablet) ...... 29 KLS Quit4 (4mg Gum, 4mg Lozenge) ...... 15 50mg/5ml Syrup) ...... 24 Kalydeco (150mg Tablet, 50mg Packet, 75mg Koate (Injection) ...... 32 Isosorbide Dinitrate (Tablet) ...... 37 Packet) ...... 68 Koate-Dvi (Injection) ...... 32 Isosorbide Dinitrate ER (Tablet Extended- Kanuma (Injection) ...... 60 Kogenate FS (Injection) ...... 32 Release) ...... 37 Karidium (Oral Solution) ...... 42 Kogenate FS Bio-Set (Injection) ...... 32 Isosorbide Mononitrate (Tablet) ...... 37 Karigel (Gel) ...... 38 Kombiglyze XR (Tablet Extended-Release 24 Isosorbide Mononitrate ER (Tablet Extended- Karigel-N (Gel) ...... 38 Hour) ...... 31 Release 24 Hour)...... 37 Kariva (Tablet) ...... 53 KP Aspirin (Tablet Delayed-Release) ...... 11 Isotonic Gentamicin (Injection) ...... 15 KCl 0.075%/D5W/NaCl 0.45% (Injection) .... 40 KP Bisacodyl (Tablet Delayed-Release) ...... 48 Isradipine (Capsule) ...... 34 KCl 0.15%/D5W/NaCl 0.2% (Injection) ...... 40 KP Folic Acid (Tablet) ...... 44 Istodax (Overfill) (Injection)...... 25 KCl 0.15%/D5W/NaCl 0.45% (Injection) ...... 40 KP Prenatal Multivitamins (Tablet) ...... 44 Itraconazole (Capsule) ...... 23 KCl 0.15%/D5W/NaCl 0.9% (Injection) ...... 40 KP Vitamin D (1000unit Capsule, 2000unit IV Prep Wipes ...... 16 KCl 0.3%/D5W/NaCl 0.45% (Injection) ...... 41 Capsule, 400unit Tablet Chewable) ...... 44 Ivermectin (Tablet) ...... 26 Kedbumin (Injection)...... 41 K-Prime (Tablet Effervescent) ...... 40 Ixempra Kit (Injection) ...... 25 K-Effervescent (Tablet Effervescent) ...... 40 K-Tan Plus (Capsule) ...... 40 Kelnor 1/35 (Tablet) ...... 53 Kurvelo (Tablet) ...... 53 J Kepivance (Injection) ...... 38 Kuvan (100mg Packet, 500mg Packet, 100mg Kerydin (External Solution) ...... 23 Tablet Soluble) ...... 49 Jadenu (Tablet) ...... 42 Ketocare (Strip) ...... 60 K-Vescent (Tablet Effervescent)...... 40 Jakafi (10mg Tablet) ...... 26 Ketoconazole (2% Cream, 2% Foam, 2% Kyleena (IUD) ...... 54 Jakafi (15mg Tablet, 20mg Tablet, 25mg Shampoo, 200mg Tablet) ...... 23 Kyprolis (Injection) ...... 26 Tablet, 5mg Tablet) ...... 26 Ketodan (Foam)...... 23 Jantoven (Tablet) ...... 32 Keto-Diastix (Strip) ...... 60 L Janumet (Tablet, 1000mg-50mg Tablet) .... 31 Ketone Test Strips (Strip) ...... 60 Janumet XR (Tablet Extended-Release 24 Ketoprofen (50mg Capsule, 75mg Capsule Labetalol HCl (100mg Tablet, 200mg Tablet, Hour, 500mg-50mg Tablet Extended- Immediate-Release) ...... 11 300mg Tablet, 5mg/ml Injection) ...... 34 Release 24 Hour) ...... 31 Ketoprofen ER (Capsule Extended-Release 24 Labstix (Strip) ...... 60 Januvia (Tablet) ...... 31 Hour) ...... 11 Lacrisert (Insert) ...... 63 Jardiance (Tablet)...... 31 Lactated Ringers (Injection) ...... 41 81

Lactated Ringers Irrigation (Solution) ...... 41 Levetiracetam (1000mg Tablet, 250mg Lidocaine HCl/Hydrocortisone Acetate (0.5%- Lactic Acid (Lotion) ...... 39 Tablet, 500mg Tablet, 750mg Tablet, 3% Cream, 0.5%-3% Kit, 1%-3% Kit, 2%-2% Lactic Acid E (Cream) ...... 39 1000mg/100ml-750mg/100ml Injection, Kit, 2.5%-3% Kit)...... 51 Lactic Acid with Vitamin E (Cream) ...... 39 1500mg/100ml-540mg/100ml Injection, Lidocaine Pak (Ointment) ...... 14 Lactulose (Oral Solution) ...... 48 500mg/100ml-820mg/100ml Injection, Lidocaine Viscous (Solution) ...... 14 Lamivudine (100mg Tablet) ...... 28 500mg/5ml Injection, 100mg/ml Oral Lidocaine/Epinephrine (Injection) ...... 14 Lamivudine (10mg/ml Oral Solution, 150mg Solution, 500mg/5ml Oral Solution) ...... 19 Lidocaine/Prilocaine (2.5%-2.5% Cream, Tablet, 300mg Tablet) ...... 29 Levetiracetam ER (Tablet Extended-Release 2.5%-2.5% Kit) ...... 14 Lamivudine/Zidovudine (Tablet)...... 29 24 Hour) ...... 19 Lidopril (Kit) ...... 14 Lamotrigine (100mg Tablet Immediate- Levobunolol HCl (Ophthalmic Solution) ...... 64 Lifescan Unistik 2 Deep Penetration...... 60 Release, 25mg Tablet Immediate-Release, Levocarnitine (1gm/10ml Oral Solution, Liletta (IUD) ...... 54 150mg Tablet, 200mg Tablet, 25mg Tablet 330mg Tablet) ...... 41 Lincomycin HCl (Injection) ...... 16 Chewable, 5mg Tablet Chewable) ...... 20 Levocetirizine Dihydrochloride (2.5mg/5ml Lindane (Shampoo) ...... 27 Lamotrigine ER (Tablet Extended-Release 24 Oral Solution, 5mg Tablet) ...... 65 Linezolid (100mg/5ml Suspension, 600mg Hour) ...... 20 Levofloxacin (0.5% Ophthalmic Solution, Tablet) ...... 16 Lamotrigine ODT (Tablet Dispersible) ...... 20 250mg Tablet, 500mg Tablet, 750mg Linezolid (600mg/300ml Injection) ...... 16 Lamotrigine Titration (Kit) ...... 20 Tablet, 25mg/ml Injection, 25mg/ml Oral Linzess (Capsule) ...... 47 Lancets ...... 60 Solution) ...... 18 Liothyronine Sodium (10mcg/ml Injection, Lansoprazole (Capsule Delayed-Release) .... 48 Levofloxacin in D5W (Injection) ...... 18 25mcg Tablet, 50mcg Tablet, 5mcg Tablet) Lansoprazole/Amoxicillin/Clarithromycin Levofloxacin/Dextrose (Injection) ...... 18 ...... 55 (Therapy Pack) ...... 47 Levoleucovorin (175mg Injection, Lipodox 50 (Injection) ...... 25 Lantus (Injection) ...... 31 250mg/25ml Injection) ...... 25 Lisinopril (Tablet) ...... 33 Lantus SoloStar (Solution Pen injector) ...... 31 Levoleucovorin (175mg/17.5ml Injection, Lisinopril/Hydrochlorothiazide (Tablet) ...... 35 LARIN 1.5/30 (Tablet) ...... 53 50mg Injection) ...... 25 LiteAire (Device) ...... 68 LARIN 1/20 (Tablet) ...... 53 Levonest (Tablet) ...... 53 LiteTouch Pen Needles ...... 60 LARIN 24 Fe (Tablet) ...... 53 Levonorgestrel (Tablet) ...... 54 Lithium Carbonate (150mg Capsule, 300mg LARIN Fe 1.5/30 (Tablet) ...... 53 Levonorgestrel and Ethinyl Estradiol (Tablet) Capsule, 600mg Capsule, 300mg Tablet) 30 LARIN Fe 1/20 (Tablet) ...... 53 ...... 53 Lithium Carbonate ER (Tablet Extended- Larissia (Tablet) ...... 53 Levonorgestrel/Ethinyl Estradiol (0.03mg- Release) ...... 30 Lartruvo (Injection) ...... 26 0.15mg Tablet) ...... 53 Livalo (Tablet) ...... 36 Lastacaft (Ophthalmic Solution) ...... 63 Levonorgestrel/Ethinyl Estradiol (0-Tablet, Live Better Lancet Super Thin 30g ...... 60 Latanoprost (Ophthalmic Solution) ...... 64 20mcg-0.1mg Tablet) ...... 53 Live Better Lancet Ultra Thin 28g ...... 60 Latuda (Tablet) ...... 28 Levora 0.15/30-28 (Tablet) ...... 53 Livixil Pak (Kit) ...... 14 Laxative (Tablet Delayed-Release) ...... 48 Levo-T (Tablet) ...... 55 Lo Loestrin Fe (Tablet) ...... 53 Laxative Feminine (Tablet Delayed-Release) Levothyroxine Sodium (100mcg Tablet, Locoid (0.1% Lotion)...... 51 ...... 48 112mcg Tablet, 125mcg Tablet, 137mcg Lomedia 24 Fe (Tablet) ...... 53 Layolis Fe (Tablet Chewable) ...... 53 Tablet, 150mcg Tablet, 175mcg Tablet, Lonsurf (Tablet) ...... 24 Leader Super Thin Lancet...... 60 200mcg Tablet, 25mcg Tablet, 300mcg Loperamide HCl (2mg Capsule)...... 47 Leena (Tablet) ...... 53 Tablet, 50mcg Tablet, 75mcg Tablet, Lopinavir/Ritonavir (Oral Solution) ...... 29 Leflunomide (Tablet) ...... 56 88mcg Tablet)...... 55 Lopreeza (Tablet) ...... 53 Lemtrada (Injection) ...... 38 Levoxyl (Tablet) ...... 55 Lorazepam (0.5mg Tablet, 1mg Tablet, 2mg Lenvima (Capsule Therapy Pack) ...... 26 Lexiva (50mg/ml Suspension, 700mg Tablet) Tablet) ...... 30 Lessina (Tablet) ...... 53 ...... 29 Lorazepam (2mg/ml Injection, 4mg/ml Letairis (Tablet) ...... 66 Lidocaine (3% Cream, 5% Ointment, 5% Injection) ...... 30 Letrozole (Tablet) ...... 26 Patch) ...... 14 Lorazepam Intensol (2mg/ml Concentrate).30 Leucovorin Calcium (100mg Injection, 200mg Lidocaine HCl (0.5% Injection, 1.5% Injection, Lorcet (Tablet) ...... 13 Injection, 350mg Injection, 50mg Injection, 4% Injection, 1% Solution, 2% Solution, 2% Lorcet HD (Tablet)...... 13 10mg Tablet, 15mg Tablet, 25mg Tablet, Gel, 4% External Solution) ...... 14 Lorcet Plus (Tablet) ...... 13 5mg Tablet) ...... 25 Lidocaine HCl (10mg/ml Injection, 20mg/ml Loryna (Tablet) ...... 53 Leukeran (Tablet) ...... 24 Injection) ...... 33 Losartan Potassium (Tablet) ...... 33 Leuprolide Acetate (Injection) ...... 55 Lidocaine HCl (Gel) ...... 14 Losartan Potassium/Hydrochlorothiazide Levalbuterol (Nebulized Solution) ...... 66 Lidocaine HCl in D5W (Injection) ...... 33 (Tablet) ...... 35 Levemir (Injection) ...... 31 Lotemax (0.5% Gel, 0.5% Ointment) ...... 64 Levemir FlexTouch (Injection) ...... 31 Lotemax (0.5% Suspension) ...... 64 82

Lovastatin (Tablet) ...... 36 Matzim LA (Tablet Extended-Release 24 Mesalamine DR (1.2 gm Tablet Delayed- Low-Ogestrel (Tablet) ...... 53 Hour) ...... 34 Release, generic Lialda) ...... 57 Loxapine Succinate (Capsule) ...... 27 Maxipime (2gm Injection) ...... 17 Mesna (Injection) ...... 25 Ludent (Tablet Chewable) ...... 42 Meclizine HCl (12.5mg Tablet, 25mg Tablet) Mesnex (400mg Tablet) ...... 25 Lumigan (Ophthalmic Solution) ...... 64 ...... 22 Mestinon (60mg/5ml Syrup) ...... 23 Lumizyme (Injection) ...... 49 Meclofenamate Sodium (100mg Capsule, Metadate ER (Tablet Extended-Release) ..... 37 Lupaneta Pack (Kit) ...... 55 50mg Capsule) ...... 11 Metaproterenol Sulfate (10mg Tablet, 20mg Lupron Depot (1-Month) (Injection) ...... 55 Medical Provider Single Use EZ Flu Shot Tablet, 10mg/5ml Syrup) ...... 66 Lupron Depot (3-Month) (Injection) ...... 55 (Injection) ...... 57 Metaxall (Tablet) ...... 68 Lupron Depot (4-Month) (Injection) ...... 55 Medichoice Safety Lancet Normal ...... 60 Metaxalone (Tablet) ...... 68 Lupron Depot (6-Month) (Injection) ...... 55 Medlance Plus SuperLite 30g ...... 60 Metformin HCl (Immediate Release Tablet) 31 Lupron Depot-Ped (1-Month) (Injection) ... 55 Medlance Plus SuperLite 30g/Comfort Max Metformin HCl ER (Tablet Extended-Release Lupron Depot-Ped (3-Month) (Injection) ... 51 ...... 60 24 Hour Generic Fortamet, Tablet Lutera (Tablet) ...... 53 Medlance/Extra ...... 60 Extended-Release 24 Hour Generic Lynparza (Capsule) ...... 26 Medlance/Lite ...... 60 Glucophage XR)...... 31 Lyrica (100mg Capsule, 150mg Capsule, Medlance/Universal ...... 60 Methadone HCl (10mg Tablet, 5mg Tablet, 200mg Capsule, 225mg Capsule, 25mg Medroxyprogesterone Acetate (10mg Tablet, 10mg/5ml Oral Solution, 5mg/5ml Oral Capsule, 300mg Capsule, 50mg Capsule, 2.5mg Tablet, 5mg Tablet) ...... 54 Solution, 10mg/ml Concentrate, 40mg 75mg Capsule) ...... 38 Medroxyprogesterone Acetate (150mg/ml Tablet Soluble) ...... 12 Lyrica (20mg/ml Oral Solution) ...... 38 Injection) ...... 54 Methadose (40mg Tablet Soluble) ...... 12 Lysiplex Plus (Tablet) ...... 44 Mefenamic Acid (250mg Capsule) ...... 11 Methamphetamine HCl (Tablet) ...... 37 Lysodren (Tablet) ...... 55 Mefloquine HCl (Tablet) ...... 27 Methazolamide (25mg Tablet, 50mg Tablet) Lyza (Tablet) ...... 54 Megestrol Acetate (20mg Tablet, 40mg ...... 64 Tablet, 400mg/10ml Suspension, 40mg/ml Methenamine Hippurate (Tablet) ...... 16 M Suspension, 625mg/5ml Suspension)..... 54 Methenamine Mandelate (0.5gm Tablet) ...16 Meijer Alcohol Swabs Extra-Thick ...... 60 Methergine (Tablet) ...... 60 Magnesium Chloride (200mg/ml Injection). 41 Meijer Aspirin EC (Tablet Delayed-Release) 11 Methimazole (10mg Tablet, 5mg Tablet)..... 55 Magnesium Citrate (Oral Solution) ...... 48 Meijer Pen Needles 31g X 6mm ...... 60 Methitest (Tablet) ...... 51 Magnesium Sulfate (20gm/500ml Injection, Mekinist (Tablet) ...... 26 Methocarbamol (1000mg/10ml Injection, 2gm/50ml Injection, 40gm/1000ml Meloxicam (Tablet) ...... 11 500mg Tablet, 750mg Tablet) ...... 68 Injection, 4gm/100ml Injection, 4gm/50ml Melphalan (Tablet) ...... 24 Methotrexate (2.5mg Tablet) ...... 55 Injection, 50% Injection) ...... 41 Melphalan HCl (Injection) ...... 24 Methotrexate Sodium (Injection) ...... 55 Magnesium Sulfate in D5W (5%-1gm/100ml Memantine HCl (10mg Tablet, 5mg Tablet, Methoxsalen (10mg Capsule) ...... 39 Injection) ...... 41 2mg/ml Oral Solution) ...... 20 Methscopolamine Bromide (Tablet) ...... 47 Magnesium Sulfate/Lactated Ringers Memantine HCl Titration Pak (Tablet)...... 20 Methyclothiazide (5mg Tablet) ...... 36 (100mg/500ml-20gm/500ml- Menactra (Injection) ...... 57 Methyldopa (Tablet) ...... 33 150mg/500ml-3gm/500ml-1.55gm/500ml Menest (Tablet) ...... 53 Methyldopa/Hydrochlorothiazide (Tablet)..35 Injection) ...... 41 MENHIBRIX (Injection) ...... 57 Methylergonovine Maleate (Injection) ...... 60 Magnesium Sulfate/Sodium Chloride Mentax (Cream)...... 23 Methylphenidate HCl (Tablet Chewable, (4gm/100ml-0.9% Injection) ...... 41 Menveo (Injection) ...... 57 Immediate-Release Tablet, Oral Solution) Makena (Injection) ...... 54 Meperidine HCl (100mg Tablet, 50mg Tablet, ...... 38 Malathion (Lotion) ...... 27 50mg/5ml Oral Solution) ...... 13 Methylphenidate HCl CD (Capsule Extended- Mannitol (Injection) ...... 60 Meperidine HCl (100mg/ml Injection, Release) ...... 38 Maprotiline HCl (Tablet) ...... 21 10mg/ml Injection, 25mg/ml Injection, Methylphenidate HCl ER (La) (Capsule Marlissa (Tablet) ...... 53 50mg/ml Injection) ...... 13 Extended-Release 24 Hour) ...... 38 Marplan (Tablet) ...... 21 Meperidine HCl/Sodium Chloride Methylphenidate HCl ER (Tablet Extended- Marqibo (Injection) ...... 25 (1000mg/100ml-0.9% Injection, Release, Capsule Extended-Release 24 Marten-Tab (Tablet) ...... 10 500mg/50ml-0.9% Injection) ...... 13 Hour) ...... 38 Mask Vortex/Baby Whirl Duckling ...... 60 Mephyton (Tablet) ...... 44 Methylprednisolone (16mg Tablet, 32mg Mask Vortex/Child/Frog ...... 60 Meprobamate (Tablet) ...... 30 Tablet, 4mg Tablet, 8mg Tablet) ...... 51 Mask Vortex/Spinner the Duck ...... 60 Mercaptopurine (Tablet) ...... 25 Methylprednisolone Acetate (40mg/ml Mask Vortex/Toddler/Lady Bug ...... 60 Meropenem (Injection) ...... 17 Injection, 80mg/ml Injection) ...... 51 Matulane (Capsule) ...... 24 Meropenem/Sodium Chloride (Injection)... 17 Methylprednisolone Sodium Succinate Mesalamine (4gm Enema, 4gm Kit) ...... 57 (Injection) ...... 51 83

Methyltestosterone (10mg Capsule) ...... 52 Mirvaso (Gel) ...... 39 Moxifloxacin HCl (0.5% Solution, 400mg Metipranolol (Ophthalmic Solution) ...... 64 Misoprostol (Tablet)...... 48 Tablet, 400mg/250ml Injection) ...... 18 Metoclopramide HCl (10mg Tablet, 5mg Mitomycin (20mg Injection, 40mg Injection) Mozobil (Injection) ...... 32 Tablet, 10mg/10ml Oral Solution, 5mg/5ml ...... 25 Multaq (Tablet) ...... 33 Oral Solution, 5mg/ml Injection) ...... 22 Mitomycin (5mg Injection) ...... 25 Multi Prenatal (Tablet) ...... 44 Metoclopramide ODT (5mg Tablet Mitoxantrone HCl (Injection) ...... 25 Multistix (Strip) ...... 60 Dispersible) ...... 22 Mm Aspirin (Tablet) ...... 11 Multistix 10 Sg (Strip)...... 60 Metolazone (Tablet) ...... 36 M-M-R II (Injection) ...... 57 Multistix 5 (Strip) ...... 60 Metoprolol Succinate ER (Tablet Extended- Modafinil (Tablet) ...... 68 Multistix 7 (Strip) ...... 60 Release 24 Hour)...... 34 Moderiba (200mg Tablet) ...... 28 Multistix 8 SG (Strip) ...... 60 Metoprolol Tartrate (100mg Tablet, 25mg Moderiba 1200 Dose Pack (Tablet) ...... 28 Multistix 9 (Strip) ...... 60 Tablet, 37.5mg Tablet, 50mg Tablet, 75mg Moderiba 800 Dose Pack (Tablet) ...... 28 Multistix 9 SG (Strip) ...... 60 Tablet, 5mg/5ml Injection) ...... 34 Moexipril HCl (Tablet) ...... 33 Multi-Vit/Fluoride (Oral Solution) ...... 44 Metoprolol/Hydrochlorothiazide (Tablet) ... 35 Moexipril/Hydrochlorothiazide (Tablet) ..... 35 Multi-Vit/Iron/Fluoride (Oral Solution) ...... 44 Metronidazole (0.75% Cream, 0.75% Gel, 1% Mometasone Furoate (0.1% Cream, 0.1% Multivitamin with Fluoride (Oral Solution, Gel, 0.75% Lotion, 250mg Tablet, 500mg External Solution, 0.1% Ointment) ...... 51 Tablet Chewable) ...... 44 Tablet, 375mg Capsule) ...... 16 Mometasone Furoate (50mcg/act Multi-Vitamin/Fluoride Drops (Oral Solution) Metronidazole in NaCl 0.79% (Injection) ..... 16 Suspension) ...... 65 ...... 44 Metronidazole Vaginal (Gel) ...... 16 Mondoxyne NL (Capsule) ...... 19 Multi-Vitamin/Fluoride/Iron (Oral Solution)44 Mexiletine HCl (Capsule) ...... 33 Monoclate-P (Injection) ...... 32 Mupirocin (2% Cream, 2% Ointment) ...... 16 Miacalcin (Injection) ...... 58 Monoject Insulin Syringe/1ml ...... 60 Mustargen (Injection) ...... 24 Mibelas 24 Fe (Tablet Chewable)...... 53 Monoject Insulin Syringe/Softpack/1ml/27g Mvc-Fluoride (Tablet Chewable) ...... 44 Miconazole 3 (Suppository) ...... 23 X 1/2" ...... 60 M-Vit (Tablet) ...... 44 Micrhogam Ultra-Filtered Plus (Injection) . 56 Monoject Insulin Syringe/Softpack/U- My Way (Tablet) ...... 54 Microchamber ...... 68 100/0.5ml/28g X 1/2" ...... 60 Myalept (Injection) ...... 60 Microclens Wipes ...... 16 Monoject Pharma Grade Flush Syringe Mycamine (Injection) ...... 23 Microgestin 1.5/30 (Tablet) ...... 53 (Solution) ...... 41 Mycophenolate Mofetil (200mg/ml Microgestin 1/20 (Tablet) ...... 53 Mono-Linyah (Tablet) ...... 53 Suspension, 250mg Capsule, 500mg Microgestin 24 Fe (Tablet) ...... 53 MonoNessa (Tablet) ...... 53 Injection, 500mg Tablet) ...... 55 Microgestin Fe (Tablet) ...... 53 Mononine (Injection) ...... 41 Mycophenolic Acid DR (Tablet Delayed- Microgestin Fe 1.5/30 (Tablet) ...... 53 Montelukast Sodium (10mg Tablet, 4mg Release) ...... 55 Microspacer ...... 68 Packet, 4mg Tablet Chewable, 5mg Tablet Myleran (Tablet) ...... 24 Microtainer Safety Flow Chewable) ...... 65 Mynatal Advance (Tablet)...... 44 Lancet/Sterile/Single-Use ...... 60 Monurol (Packet) ...... 16 Mynatal Plus (Tablet) ...... 44 Midodrine HCl (Tablet) ...... 33 Morgidox 1x100mg (100mg Capsule) ...... 19 Mynatal Ultracaplet (Tablet) ...... 44 Miglitol (Tablet) ...... 31 Morgidox 1x50mg (Capsule) ...... 19 Mynatal-Z (Tablet) ...... 44 Milrinone in Dextrose (Injection) ...... 35 Morgidox 2x100mg (100mg Capsule) ...... 19 Mynate 90 Plus (Tablet Extended-Release) .44 Milrinone Lactate (Injection) ...... 35 Morphine Sulfate (0.5mg/ml Injection, Mynephron (Capsule) ...... 44 Mimvey (Tablet) ...... 53 10mg/ml Injection, 1mg/ml Injection, Myorisan (Capsule) ...... 39 Mimvey Lo (Tablet) ...... 53 4mg/ml Injection, 8mg/ml Injection) ..... 13 Myrbetriq (Tablet Extended-Release 24 Mineral Oil Heavy (0 Oil) ...... 48 Morphine Sulfate (100mg/5ml Oral Solution, Hour) ...... 49 Miniprin Low Dose (Tablet Delayed-Release) 10mg/5ml Oral Solution, 20mg/5ml Oral Myzilra (Tablet) ...... 53 ...... 11 Solution, 20mg/ml Oral Solution, 15mg Minitran (Patch 24 Hour) ...... 37 Tablet, 30mg Tablet) ...... 13 N Minocycline HCl (100mg Capsule, 50mg Morphine Sulfate ER (Capsule Extended- Capsule, 75mg Capsule, 100mg Tablet, Release 24 Hour, Tablet Extended- Nabi-Hb (Injection)...... 56 50mg Tablet, 75mg Tablet) ...... 19 Release) ...... 12 Nabumetone (Tablet) ...... 11 Minocycline HCl ER (Tablet Extended-Release Morphine Sulfate/Sodium Chloride N-Acetyl-L-Cysteine (Capsule) ...... 60 24 Hour) ...... 19 (0.5mg/ml-0.9% Injection) ...... 13 Nadolol (20mg Tablet, 40mg Tablet, 80mg Minoxidil (Tablet) ...... 37 Motofen (Tablet) ...... 47 Tablet) ...... 34 Mircera (Injection) ...... 32 MoviPrep (Oral Solution) ...... 48 Nadolol/Bendroflumethiazide (Tablet) ...... 35 Mirena (IUD) ...... 54 Moxatag (Tablet Extended-Release 24 Hour) Nafcillin (Injection) ...... 18 Mirtazapine (Tablet) ...... 21 ...... 18 Nafcillin Sodium (10gm Injection, 1gm Mirtazapine ODT (Tablet Dispersible) ...... 21 Moxeza (Ophthalmic Solution) ...... 18 Injection, 2gm Injection) ...... 18 84

Nafrinse (Tablet Chewable) ...... 42 Neomycin/Polymyxin/Hydrocortisone (1% Nimodipine (Capsule) ...... 34 Nafrinse Drops (Oral Solution) ...... 42 Ophthalmic Suspension) ...... 63 Ninlaro (Capsule) ...... 25 Naftifine HCl (Cream) ...... 23 Neomycin/Polymyxin/Hydrocortisone (1% Nipent (Injection) ...... 25 Naglazyme (Injection) ...... 49 Otic Solution, 1% Otic Suspension) ...... 65 Nisoldipine ER (Tablet Extended-Release 24 Nalbuphine HCl (Injection)...... 13 Neo-Polycin (Ointment) ...... 63 Hour) ...... 34 Nalfon (Capsule)...... 11 Neo-Polycin HC (Ointment) ...... 63 Nitro-Bid (Ointment)...... 37 Naloxone HCl (Injection) ...... 14 Neostigmine Methylsulfate (10mg/10ml Nitrofurantoin (Suspension) ...... 16 Naltrexone HCl (Tablet) ...... 14 Injection, 5mg/10ml Injection) ...... 24 Nitrofurantoin Macrocrystals (Capsule) ...... 16 Namenda XR (Capsule Extended-Release 24 Neo-Synalar (Cream) ...... 39 Nitrofurantoin Monohydrate (100mg Hour) ...... 21 Nephronex (Tablet) ...... 44 Capsule) ...... 16 Namenda XR Titration Pack (Capsule Neuac (Gel) ...... 39 Nitroglycerin (0.3mg Tablet Sublingual, 0.4mg Extended-Release 24 Hour) ...... 21 Neulasta (Injection) ...... 32 Tablet Sublingual, 0.6mg Tablet Namzaric (10mg-14mg Capsule Extended- Neulasta Onpro Kit (Injection) ...... 32 Sublingual) ...... 37 Release 24 Hour, 10mg-28mg Capsule Neupogen (Injection)...... 32 Nitroglycerin ER (Capsule Extended-Release) Extended-Release 24 Hour) ...... 38 Neupro (Patch 24 Hour) ...... 27 ...... 37 Naprelan (750mg Tablet Extended-Release Neutragard Advanced (Gel)...... 38 Nitroglycerin in 5% Dextrose (Injection) ...... 37 24 Hour) ...... 11 Neutral Sodium Fluoride (Solution) ...... 38 Nitroglycerin in Dextrose 5% (5%-100mcg/ml Naproxen (125mg/5ml Suspension, 250mg Nevanac (Suspension) ...... 64 Injection) ...... 37 Tablet, 375mg Tablet, 500mg Tablet) ..... 11 Nevirapine (Tablet) ...... 29 Nitroglycerin Lingual (Translingual Solution) Naproxen DR (Tablet Delayed-Release) ...... 11 Nevirapine ER (Tablet Extended-Release 24 ...... 37 Naproxen Sodium (275mg Tablet, 550mg Hour) ...... 29 Nitroglycerin Transdermal (Patch 24 Hour).37 Tablet)...... 11 Nexavar (Tablet) ...... 26 NitroMist (Aerosol Solution) ...... 37 Naproxen Sodium CR (Tablet Extended- Nexplanon (Injection) ...... 53 Nitro-Time (6.5mg Capsule Extended- Release 24 Hour)...... 11 Next Choice One Dose (Tablet) ...... 54 Release) ...... 37 Naproxen Sodium ER (Tablet Extended- Nexterone (150mg/100ml-42.1mg/ml Nizatidine (Capsule) ...... 47 Release 24 Hour)...... 11 Injection) ...... 33 Nolix (Lotion) ...... 51 Naratriptan HCl (Tablet) ...... 23 Niacin ER (Tablet Extended-Release) ...... 37 Nora-BE (Tablet) ...... 54 Narcan (Liquid) ...... 14 Nicardipine HCl (2.5mg/ml Injection, 20mg Norditropin FlexPro (Injection) ...... 51 NascoBAL (Nasal Solution)...... 44 Capsule, 30mg Capsule) ...... 34 Norepinephrine Bitartrate (Injection) ...... 35 Natacyn (Suspension) ...... 23 NICOrelief (Gum) ...... 15 Norethindrone & Ethinyl Estradiol Ferrous Natazia (Tablet) ...... 53 Nicotine (14mg/24hr Patch 24 Hour, Fumarate (Tablet Chewable) ...... 53 Nateglinide (Tablet) ...... 31 21mg/24hr Patch 24 Hour, 7mg/24hr Norethindrone (Tablet) ...... 54 Nat-Rul Prenatal Vitamins (Tablet) ...... 44 Patch 24 Hour, 2mg Gum, 2mg Lozenge, Norethindrone Acetate (5mg Tablet) ...... 54 Nat-Rul Vitamin D (Tablet) ...... 44 4mg Lozenge) ...... 15 Norethindrone Acetate/Ethinyl Estradiol Natural Vitamin D-3 (Tablet) ...... 44 Nicotine Mini Lozenge (Lozenge) ...... 15 (Tablet) ...... 53 Nebupent (Inhalation Solution) ...... 27 Nicotine Polacrilex (2mg Gum, 4mg Gum, Norethindrone Acetate/Ethinyl Nebusal (3% Nebulized Solution) ...... 60 2mg Lozenge, 4mg Lozenge, 4mg Lozenge) Estradiol/Ferrous Fumarate (20mcg-75mg- Necon 0.5/35-28 (Tablet) ...... 53 ...... 15 1mg Tablet, 20mcg-75mg-1mg Tablet Necon 1/50-28 (Tablet) ...... 53 Nicotine Polacrilex Refill (Gum)...... 15 Chewable) ...... 53 Necon 7/7/7 (Tablet) ...... 53 Nicotine Polacrilex Starter Kit (Gum) ...... 15 Norethindrone/Ethinyl Estradiol/Ferrous Nefazodone HCl (Tablet)...... 21 Nicotine Step 1 (Patch 24 Hour) ...... 15 Fumarate (Tablet Chewable) ...... 53 Neomycin Sulfate (Tablet) ...... 15 Nicotine Step 2 (Patch 24 Hour) ...... 15 Norgestimate/Ethinyl Estradiol (Tablet) ...... 53 Neomycin/Bacitracin/Polymyxin (Ointment) Nicotine Step 3 (Patch 24 Hour) ...... 15 Norlyda (Tablet) ...... 54 ...... 63 Nicotine Transdermal System (14mg/24hr Norlyroc (Tablet)...... 54 Neomycin/Polymyxin B Sulfates (Irrigation Patch 24 Hour, 21mg/24hr Patch 24 Hour, Normal Saline Flush (Solution) ...... 41 Solution) ...... 16 7mg/24hr Patch 24 Hour)...... 15 Norpace CR (100mg Capsule Extended- Neomycin/Polymyxin/Bacitracin/Hydrocortis Nicotine Transdermal System (Kit) ...... 15 Release 12 Hour) ...... 33 one (Ointment) ...... 63 Nicotrol Inhaler (Inhaler) ...... 15 Nortrel 0.5/35 (28) (Tablet) ...... 53 Neomycin/Polymyxin/Dexamethasone (0.1% Nicotrol NS (Nasal Solution) ...... 15 Nortrel 1/35 (Tablet) ...... 53 Ophthalmic Suspension, 0.1%-3.5mg/gm- Nifedipine (10mg Capsule, 20mg Capsule) . 34 Nortrel 7/7/7 (Tablet) ...... 53 10000unit/gm Ointment) ...... 63 Nifedipine ER (Tablet Extended-Release 24 Nortriptyline HCl (10mg Capsule, 25mg Neomycin/Polymyxin/Gramicidin Hour) ...... 34 Capsule, 50mg Capsule, 75mg Capsule, (Ophthalmic Solution) ...... 63 Nikki (Tablet) ...... 53 10mg/5ml Oral Solution) ...... 22 Nilutamide (Tablet) ...... 24 85

Norvir (100mg Capsule, 100mg Tablet, O One A Day Womens Prenatal1 (Capsule) ...44 80mg/ml Oral Solution) ...... 29 One-A-Day Womens Prenatal ...... 44 Norwich Aspirin (Tablet) ...... 11 Obizur (Injection) ...... 41 Onetouch Combo Pack ...... 60 Novarel (Injection) ...... 51 Obstetrix EC (Tablet) ...... 44 Onetouch Suresoft Lancing Device/21g ..... 60 Novofine 30gx8mm ...... 60 Ocaliva (Tablet) ...... 47 Onetouch Ultra 2 (Kit) ...... 60 Novofine 32gx6mm ...... 60 Ocella (Tablet) ...... 53 Onetouch Ultra Blue (Strip) ...... 60 Novofine Autocover 30gx8mm ...... 60 Octagam (Injection) ...... 56 Onetouch Ultra Control (In Vitro Solution) 60 Novofine Plus 32gx4mm ...... 60 Octreotide Acetate (Injection) ...... 55 Onetouch Ultra Mini (Kit) ...... 60 Novolin 70/30 (Injection) ...... 31 Odefsey (Tablet) ...... 29 Onetouch Ultralink System (Hex) (Kit) ...... 60 Novolin 70/30 Relion (Injection) ...... 31 Ofev (Capsule) ...... 68 Onetouch Verio (Kit) ...... 60 Novolin N (Injection) ...... 31 Ofloxacin (0.3% Ophthalmic Solution, 0.3% Onetouch Verio Control Solution High Novolin N Relion (Injection) ...... 31 Otic Solution, 300mg Tablet, 400mg (Solution) ...... 60 Novolin R (Injection) ...... 31 Tablet) ...... 18 Onetouch Verio Flex Bloodglucose Novolin R Relion (Injection) ...... 31 Ogestrel (Tablet) ...... 53 Monitoring System (Kit) ...... 60 NovoLog (Injection) ...... 31 Olanzapine (10mg Injection) ...... 28 Onetouch Verio Iq Blood Glucose Monitoring NovoLog FlexPen (Injection) ...... 31 Olanzapine (10mg Tablet, 15mg Tablet, System (Kit) ...... 60 NovoLog Mix 70/30 (Injection) ...... 31 2.5mg Tablet, 20mg Tablet, 5mg Tablet, Onetouch Verio Mid Control Solution NovoLog Mix 70/30 Prefilled FlexPen 7.5mg Tablet) ...... 28 (Solution) ...... 60 (Injection) ...... 31 Olanzapine ODT (Tablet Dispersible)...... 28 Onetouch Verio Sync Bloodglucose NovoLog PenFill (Injection) ...... 31 Olanzapine/Fluoxetine (25mg-12mg Capsule, Monitoring System (Kit) ...... 61 NovoPen Echo (Device) ...... 60 50mg-12mg Capsule, 50mg-6mg Capsule) Onetouch Verio Test Strips (Strip) ...... 61 Novoseven (Solution) ...... 44 ...... 21 Onfi (10mg Tablet, 20mg Tablet, 2.5mg/ml Novoseven RT (Injection) ...... 44 Olanzapine/Fluoxetine (25mg-3mg Capsule, Suspension) ...... 20 Novotwist 32gx5mm ...... 60 25mg-6mg Capsule) ...... 21 Onglyza (Tablet) ...... 31 Noxafil (100mg Tablet Delayed-Release) ... 23 Olmesartan Medoxomil (Tablet) ...... 33 Onivyde (Injection) ...... 25 NP Thyroid (Tablet) ...... 55 Olmesartan Opana ER (Tablet Extended-Release 12 Hour NP Thyroid 15 (Tablet) ...... 55 Medoxomil/Amlodipine/Hydrochlorothiazi Abuse-Deterrent) ...... 12 NP Thyroid 60 (Tablet) ...... 55 de (Tablet) ...... 35 Opcicon One-Step (Tablet) ...... 54 NP Thyroid 90 (Tablet) ...... 55 Olmesartan Medoxomil/Hydrochlorothiazide Opdivo (Injection) ...... 26 Nplate (Injection) ...... 32 (Tablet) ...... 35 Opsumit (Tablet) ...... 66 Nucala (Injection) ...... 68 Olopatadine HCl (0.1% Ophthalmic Solution) OptiChamber Advantage ...... 68 Nucynta (Tablet) ...... 13 ...... 64 OptiChamber Advantage/Large Mask ...... 68 Nucynta ER (Tablet Extended-Release 12 Olopatadine HCl (0.6% Nasal Solution) ...... 65 OptiChamber Advantage/Medium Face Hour) ...... 12 Olopatadine HCl (Ophthalmic Solution) ...... 64 Mask ...... 68 Nuedexta (Capsule) ...... 38 Olysio (Capsule) ...... 28 OptiChamber Advantage/Small Face Mask68 Nufol (Tablet)...... 44 Omeclamox-Pak (Therapy Pack) ...... 47 OptiChamber Diamond ...... 68 Nulev (Tablet Dispersible)...... 47 Omega-3-Acid Ethyl Esters (Capsule) (Generic OptiChamber Diamond/Large Face Mask Nutrifac ZX (Tablet) ...... 44 Lovaza) ...... 37 (Device) ...... 68 Nutrilipid (Injection) ...... 41 Omeprazole (Capsule Delayed-Release) ..... 48 OptiChamber Diamond/Medium Face Mask Nutrilyte (2.03meq/ml-0.25meq/ml- Omeprazole/Sodium Bicarbonate (20mg- ...... 68 1.68meq/ml-0.25meq/ml-0.4meq/ml- 1100mg Capsule, 40mg-1100mg Capsule, OptiChamber Diamond/Small Face Mask ..68 2.03meq/ml-1.25meq/ml Injection) ...... 41 20mg-1680mg Packet, 40mg-1680mg OptiChamber Face Mask/Small ...... 68 Nutropin AQ (Injection) ...... 51 Packet) ...... 48 Optihaler MDI Drug Delivery System NuvaRing (Ring) ...... 53 Omnaris (Suspension) ...... 65 (Device) ...... 68 Nyamyc (Powder) ...... 23 Omniflex Diaphragm (Diaphragm) ...... 60 Optimal D3 M (Capsule) ...... 44 Nyata (Powder) ...... 23 Oncaspar (Injection) ...... 25 Optimal-D Pack (Capsule) ...... 44 Nystatin (100000unit/gm Cream, Ondansetron HCl (24mg Tablet, 4mg Tablet, Option 2 (Tablet) ...... 54 100000unit/gm Ointment, 100000unit/gm 8mg Tablet, 4mg/2ml Injection) ...... 22 Options Gynol II Vaginal Contraceptive (Gel) Powder, 100000unit/ml Suspension, Ondansetron HCl (40mg/20ml Injection, ...... 49 500000unit Tablet) ...... 23 4mg/5ml Oral Solution) ...... 22 Opurity Vitamin D (Tablet Chewable) ...... 44 Nystatin/Triamcinolone (100000unit/gm- Ondansetron HCl/Sodium Chloride (Injection) Oracea (Capsule Delayed-Release) ...... 19 0.1% Ointment, 100000unit/gm-1mg/gm ...... 22 Oralone (Paste) ...... 38 Cream) ...... 23 Ondansetron ODT (Tablet Dispersible) ...... 22 Oravig (Tablet) ...... 23 Nystop (Powder) ...... 23 One A Day Womens Prenatal/DHA ...... 44 86

Orencia (125mg/ml Injection, 50mg/0.4ml Oxytocin/Sodium Chloride (30unit/500ml- Peg-Prep (Kit) ...... 48 Injection, 87.5mg/0.7ml Injection, 250mg 0.9% Injection) ...... 61 Pegylax (Powder) ...... 48 Injection) ...... 55 Pen Needles 30gx5/16" ...... 61 Orencia Clickject (Injection) ...... 56 P Pen Needles 30gx5mm ...... 61 Orenitram (Tablet Extended-Release) ...... 66 Pen Needles 30gx8mm ...... 61 Orfadin (10mg Capsule, 20mg Capsule, 2mg PA Prenatal Formula (Tablet) ...... 44 Penicillin G Potassium (Injection) ...... 18 Capsule, 5mg Capsule) ...... 49 PA Vitamin D-3 (Capsule) ...... 44 Penicillin V Potassium (125mg/5ml Oral Orkambi (125mg-100mg Tablet)...... 68 PA Vitamin D-3 Gummy (Tablet Chewable) 44 Solution, 250mg/5ml Oral Solution, 250mg Orphenadrine Citrate (30mg/ml Injection).. 68 Pacerone (Tablet) ...... 33 Tablet, 500mg Tablet) ...... 18 Orphenadrine Citrate ER (Tablet Extended- Paclitaxel (100mg/16.7ml Injection, Penlet II Automatic Blood Sampler (Kit) ..... 61 Release 12 Hour)...... 68 300mg/50ml Injection, 30mg/5ml Penlet II Replacement Caps-Deep ...... 61 Orsythia (Tablet) ...... 53 Injection) ...... 25 Pentacel (Injection) ...... 57 Ortho-CS 250 (Injection) ...... 61 Paclitaxel (150mg/25ml Injection) ...... 25 Pentasa (Capsule Extended-Release) ...... 57 Oscimin (0.125mg Tablet, 0.125mg Tablet Paliperidone ER (Tablet Extended-Release 24 Pentazocine/Naloxone HCl (Tablet) ...... 13 Sublingual) ...... 47 Hour) ...... 28 Pentips ...... 61 Oseltamivir Phosphate (Capsule)...... 29 Pamidronate Disodium (30mg Injection, Pentobarbital Sodium (50mg/ml Injection) .20 Osmitrol Viaflex (15% Injection, 20% 30mg/10ml Injection, 90mg Injection, Pentoxifylline ER (Tablet Extended-Release) Injection) ...... 61 90mg/10ml Injection) ...... 58 ...... 35 OsmoPrep (Tablet) ...... 41 Pamidronate Disodium (6mg/ml Injection)58 Perforomist (Nebulized Solution) ...... 66 Osphena (Tablet) ...... 54 Pancuronium Bromide (Injection) ...... 38 Perindopril Erbumine (Tablet) ...... 33 Otovel (Otic Solution) ...... 65 Panda Mask Large ...... 61 Periogard (Solution) ...... 38 Oxacillin Sodium (Injection) ...... 18 Panda Mask Medium ...... 61 Perjeta (Injection) ...... 26 Oxaliplatin (IV Solution 100mg/20ml) ...... 25 Panda Mask Small ...... 61 Permethrin (Cream) ...... 27 Oxandrolone (Tablet)...... 52 Panretin (Gel) ...... 26 Perphenazine (16mg Tablet, 4mg Tablet, 2mg Oxaprozin (Tablet) ...... 11 Pantoprazole Sodium (20mg Tablet Delayed- Tablet, 8mg Tablet) ...... 22 Oxaydo (5mg Tablet Abuse-Deterrent) ...... 13 Release, 40mg Tablet Delayed-Release, Perphenazine/Amitriptyline (10mg-2mg Oxazepam (Capsule) ...... 30 40mg Injection) ...... 48 Tablet, 25mg-2mg Tablet, 25mg-4mg Oxcarbazepine (150mg Tablet, 300mg Tablet, Paragard Intrauterine Copper Contraceptive Tablet) ...... 21 600mg Tablet, 60mg/ml Suspension) ..... 20 T380a (IUD) ...... 61 Perry Prenatal (Capsule) ...... 44 Oxiconazole Nitrate (Cream) ...... 23 Paricalcitol (1mcg Capsule, 2mcg Capsule, Pharbedryl (Capsule) ...... 65 Oxistat (1% Lotion)...... 23 4mcg Capsule, 2mcg/ml Injection, Phenadoz (Suppository)...... 65 Oxybutynin Chloride (5mg Tablet, 5mg/5ml 5mcg/ml Injection) ...... 58 Phenazo (Tablet) ...... 49 Syrup) ...... 49 Paroex (Solution) ...... 38 Phenazopyridine HCl (100mg Tablet, 200mg Oxybutynin Chloride ER (Tablet Extended- Paromomycin Sulfate (Capsule) ...... 15 Tablet) ...... 49 Release 24 Hour)...... 49 Paroxetine HCl (Tablet) ...... 21 Phendimetrazine Tartrate (Tablet) ...... 38 Oxycodone HCl (100mg/5ml Concentrate, Paroxetine HCl ER (Tablet Extended-Release Phenelzine Sulfate (Tablet) ...... 21 10mg Tablet, 15mg Tablet, 20mg Tablet, 24 Hour) ...... 21 Phenergan (12.5mg Suppository, 25mg 30mg Tablet, 5mg Tablet, 5mg Capsule, Paser (Packet) ...... 24 Suppository, 50mg Suppository) ...... 65 5mg/5ml Oral Solution) ...... 13 Paxil (10mg/5ml Suspension) ...... 21 Phenobarbital (100mg Tablet, 15mg Tablet, Oxycodone HCl ER (Tablet Extended-Release Pazeo (Ophthalmic Solution) ...... 64 16.2mg Tablet, 30mg Tablet, 32.4mg 12 Hour Abuse-Deterrent) ...... 12 PCE (500mg Tablet Delayed-Release) ...... 18 Tablet, 60mg Tablet, 64.8mg Tablet, Oxycodone/Acetaminophen (325mg-10mg Pediarix (Injection) ...... 57 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Tablet, 325mg-2.5mg Tablet, 325mg-5mg Pediatric Panda Mask ...... 61 Oral Solution) ...... 20 Tablet, 325mg-7.5mg Tablet)...... 13 Pedvax HIB (Injection) ...... 57 Phenoxybenzamine HCl (Capsule) ...... 33 Oxycodone/Aspirin (Tablet) ...... 13 PEG 3350 (Powder) RX ...... 48 Phentermine HCl (15mg Capsule) ...... 61 Oxycodone/Ibuprofen (Tablet) ...... 13 PEG 3350/Electrolytes (Oral Solution) ...... 48 Phenylephrine HCl (10% Ophthalmic Solution, OxyContin (Tablet Extended-Release 12 PEG-3350/Electrolytes (Oral Solution) 2.5% Ophthalmic Solution) ...... 63 Hour Abuse-Deterrent) ...... 12 (Generic GoLYTELY) ...... 48 Phenylephrine HCl (10mg/ml Injection) ...... 33 Oxymorphone HCl (Tablet Immediate- PEG-3350/NaCl/Na Bicarbonate/KCl (Oral Phenylephrine HCl/Sodium Chloride Release) ...... 13 Solution) (Generic NuLYTELY) ...... 48 (50mg/250ml-0.9% Injection) ...... 35 Oxymorphone HCl ER (Tablet Extended- Peganone (Tablet) ...... 20 Phenytoin (125mg/5ml Suspension, 50mg Release 12 Hour)...... 12 Pegasys (Injection)...... 28 Tablet Chewable) ...... 20 Oxytocin (Injection) ...... 51 Pegasys ProClick (Injection)...... 28 Phenytoin Sodium (50mg/ml Injection) ...... 20 PegIntron (Injection) ...... 28 Phenytoin Sodium Extended (Capsule) ...... 20 87

Philith (Tablet) ...... 53 Potassium Chloride 0.15% D5W/NaCl 0.33% Tablet, 2.5mg Tablet, 20mg Tablet, 50mg Phos-Flur (Gel) ...... 38 (Injection) ...... 41 Tablet, 5mg Tablet) ...... 51 Phoslyra (Oral Solution) ...... 50 Potassium Chloride 0.15% D5W/NaCl 0.45% Prednisone Intensol (5mg/ml Concentrate) Phospha 250 Neutral (Tablet) ...... 41 (Injection) ...... 41 ...... 51 Phospholine Iodide (Ophthalmic Solution) 64 Potassium Chloride 0.22% D5W/NaCl 0.45% Pregnyl w/Diluent Benzyl Alcohol/NaCl Phospho-Trin 250 Neutral (Tablet) ...... 41 (Injection) ...... 41 (Injection) ...... 51 Physiolyte (Irrigation Solution) ...... 41 Potassium Chloride 0.224%D5W/NaCl 0.45% Premarin (0.3mg Tablet, 0.45mg Tablet, Physiosol Irrigation (Solution)...... 41 Viaflex (Injection) ...... 41 0.625mg Tablet, 0.9mg Tablet, 1.25mg Phytonadione (Injection) ...... 44 Potassium Chloride CR (Tablet Extended- Tablet) ...... 53 Picato (Gel) ...... 39 Release) ...... 41 Premasol (6% Injection) ...... 42 Pilocarpine HCl (1% Ophthalmic Solution, 2% Potassium Chloride ER (10meq Capsule Premphase (Tablet)...... 53 Ophthalmic Solution, 4% Ophthalmic Extended-Release, 8meq Capsule Prempro (Tablet) ...... 53 Solution) ...... 64 Extended-Release, 10meq Tablet Prenatabs Rx (Tablet) ...... 45 Pilocarpine HCl (5mg Tablet, 7.5mg Tablet) 38 Extended-Release, 20meq Tablet Prenatal (100mg-0-0-263mg-400unit-4mcg- Pimozide (Tablet) ...... 27 Extended-Release, 8meq Tablet Extended- 27mg-0.8mg-18mg-2.6mg-1.7mg-1.5mg- Pimtrea (Tablet) ...... 53 Release) ...... 41 11unit-4000unit-25mg Tablet, 120mg- Pindolol (Tablet) ...... 34 Potassium Chloride SR (Tablet Extended- 4000unit-200mg-400unit-8mcg-0-0-0- Pioglitazone HCl (Tablet) ...... 31 Release) ...... 41 28mg-800mcg-20mg-2.6mg-1.7mg-0- Pioglitazone HCl/Glimepiride (Tablet) ...... 31 Potassium Chloride/Dextrose (5%-20meq/L 1.8mg-30unit-25mg Tablet) ...... 45 Pioglitazone HCl/Metformin HCl (Tablet) .... 31 Injection) ...... 41 Prenatal (120mg-0-200mg-400unit-8mcg- Piperacillin/Tazobactam (2gm-0.25gm Potassium Chloride/Lidocaine HCl (Injection) 28mg-800mcg-20mg-2.6mg-1.7mg-1.8mg- Injection, 36gm-4.5gm Injection, 3gm- ...... 42 30unit-4000unit-25mg Tablet, 120mg- 0.375gm Injection, 4gm-0.5gm Injection) Potassium Chloride/Sodium Chloride 4000unit-200mg-400unit-8mcg-28mg- ...... 18 (20meq/L-0.9% Injection, 40meq/L-0.9% 800mcg-20mg-2.6mg-1.7mg-1.8mg- Pirmella 1/35 (Tablet) ...... 53 Injection) ...... 42 30unit-25mg Tablet) ...... 45 Pirmella 7/7/7 (Tablet) ...... 53 Potassium Citrate ER (Tablet Extended- Prenatal 19 (100mg-1000unit-200mg-7mg- Piroxicam (10mg Capsule, 20mg Capsule) ... 11 Release) ...... 42 12mcg-25mg-29mg-1mg-6mg-20mg-3mg- Plasbumin-25 (Injection)...... 41 PR Natal 430 EC ...... 44 3mg-400unit-30unit-20mg Tablet Plasbumin-5 (Injection)...... 41 Pradaxa (Capsule) ...... 32 Chewable, 100mg-200mg-400unit-12mcg- Plasma-Lyte A (Injection) ...... 41 Praluent (Injection) ...... 37 25mg-29mg-1mg-15mg-7mg-20mg-3mg- Plasma-Lyte-148 (Injection) ...... 41 Pramipexole Dihydrochloride (Tablet) ...... 27 3mg-1000unit-30unit-20mg Tablet) ...... 45 Plegridy (Injection) ...... 38 Pramipexole Dihydrochloride ER (Tablet Prenatal and Iron (Tablet) ...... 45 Plegridy Starter Pack (Injection) ...... 38 Extended-Release 24 Hour) ...... 27 Prenatal Complete (Tablet) ...... 45 Plenamine (Injection) ...... 41 Pravastatin Sodium (Tablet) ...... 36 Prenatal Formula (Capsule) ...... 45 Pneumovax 23 (Injection) ...... 57 Prazosin HCl (1mg Capsule, 2mg Capsule, 5mg Pre-Natal Formula (Tablet) ...... 44 Pocket Chamber (Device) ...... 68 Capsule) ...... 33 Prenatal Forte (Tablet) ...... 45 Pocket Spacer (Device) ...... 68 Precision Ultra Lancet...... 61 Prenatal Low Iron (Tablet) ...... 45 Podofilox (External Solution) ...... 39 Pred Mild (Suspension) ...... 64 Prenatal Multi + DHA (Capsule) ...... 45 Polocaine (Injection) ...... 14 Prednicarbate (0.1% Cream, 0.1% Ointment) Prenatal Multi +DHA (Capsule) ...... 45 Polocaine-Mpf (Injection) ...... 14 ...... 51 Prenatal Multivitamin (Tablet) ...... 45 Polycin (Ointment) ...... 63 Prednisolone (15mg/5ml Oral Solution, Prenatal Multivitamin + DHA...... 45 Polyethylene Glycol 3350 (Packet, Powder) 48 15mg/5ml Syrup)...... 51 Prenatal Multivitamin Plus DHA (Capsule).45 Poly-Iron 150 Forte (Capsule) ...... 41 Prednisolone Acetate (Suspension) ...... 64 Prenatal One Daily (Tablet) ...... 45 Polymyxin B Sulfate (500000unit Injection). 16 Prednisolone Sodium Phosphate (1% Prenatal Vitamin/Iron (Tablet) ...... 45 Polymyxin B Sulfate/Trimethoprim Sulfate Ophthalmic Solution) ...... 64 Prenatal Vitamins (100mg-200mg-4mcg- (Ophthalmic Solution) ...... 63 Prednisolone Sodium Phosphate (10mg/5ml 800mcg-27mg-18mg-2.6mg-1.7mg- Polysaccharide Iron Forte (Capsule) ...... 41 Oral Solution, 20mg/5ml Oral Solution, 1.84mg-4000unit-400unit-11unit-25mg Pomalyst (Capsule) ...... 24 25mg/5ml Oral Solution, 5mg/5ml Oral Tablet)...... 45 Portia-28 (Tablet) ...... 53 Solution) ...... 51 Prenatal Vitamins (120mg-4000unit-200mg- Potassium Acetate (2meq/ml Injection) ...... 41 Prednisolone Sodium Phosphate ODT (Tablet 400unit-8mcg-28mg-800mcg-20mg- Potassium Chloride (10% Oral Solution, 20% Dispersible) ...... 51 2.6mg-1.7mg-1.8mg-30unit-25mg Tablet) Oral Solution, 10meq/100ml Injection, Prednisone (10mg Tablet Therapy Pack, 5mg ...... 45 20meq/50ml Injection, 2meq/ml Injection, Tablet Therapy Pack, 10mg Tablet, 1mg Prenatal/Omega-3/Folic Acid/Iron (Capsule) 40meq/100ml Injection, 20meq Packet) 41 ...... 45 88

Prenatal-U (Capsule) ...... 45 Propranolol HCl (10mg Tablet Immediate- Quinapril/Hydrochlorothiazide (Tablet) ...... 35 Prepopik (Packet) ...... 48 Release, 40mg Tablet Immediate-Release, Quinidine Gluconate CR (Tablet Extended- Pressure Activated Safetylancet 21g ...... 61 1mg/ml Injection, 20mg Tablet, 80mg Release) ...... 34 Prevalite (4gm Packet, 4gm/dose Powder) . 37 Tablet, 20mg/5ml Oral Solution, 40mg/5ml Quinidine Gluconate ER (Tablet Extended- Prevident Rinse (Solution) ...... 38 Oral Solution) ...... 34 Release) ...... 34 Previfem (Tablet) ...... 53 Propranolol HCl (Tablet) ...... 34 Quinidine Sulfate (Tablet) ...... 34 Prevnar 13 (Injection) ...... 57 Propranolol HCl ER (Capsule Extended- Quinine Sulfate (324mg Capsule) ...... 27 Prezcobix (Tablet) ...... 29 Release 24 Hour) ...... 34 Prezista (100mg/ml Suspension, 150mg Propranolol/Hydrochlorothiazide (Tablet).. 35 R Tablet, 600mg Tablet, 75mg Tablet, Propylthiouracil (Tablet) ...... 55 800mg Tablet) ...... 29 ProQuad (Injection) ...... 57 RA Alcohol Swabs ...... 61 Prialt (Injection) ...... 10 Protriptyline HCl (Tablet) ...... 22 RA Aspirin (Tablet) ...... 11 Priftin (Tablet) ...... 24 Pulmicort Flexhaler (Aerosol Powder) ...... 65 RA Aspirin Adult Low Strength (Tablet Primaquine Phosphate (Tablet) ...... 27 Pulmosal (Nebulized Solution) ...... 61 Chewable) ...... 11 Primidone (Tablet) ...... 20 Pulmozyme (Inhalation Solution)...... 68 RA Aspirin EC (Tablet Delayed-Release) ...... 11 Primsol (Oral Solution)...... 16 PureVitamin Dualfe Plus (Capsule) ...... 42 RA Childrens Aspirin (Tablet Chewable) ...... 11 Privigen (Injection) ...... 56 PX Aspirin (325mg Tablet, 81mg Tablet RA Laxative (Powder, 5mg Tablet Delayed- Pro Comfort Alcohol Prep Pads ...... 61 Chewable) ...... 11 Release) ...... 48 Pro Comfort Pen Needles ...... 61 PX Enteric Aspirin (Tablet Delayed-Release) 11 RA Nicotine (14mg/24hr Patch 24 Hour, ProAir HFA (Aerosol Solution) ...... 66 PX Mini Pen Needles 31gx5mm ...... 61 21mg/24hr Patch 24 Hour, 2mg Gum, 4mg ProAir RespiClick (Aerosol Powder)...... 66 PX Prenatal Multivitamins (Tablet) ...... 45 Gum, 4mg Gum) ...... 15 Probenecid (Tablet) ...... 23 PX Stop Smoking Aid (2mg Gum, 4mg Gum, RA Nicotine Gum (Gum) ...... 15 Probenecid/Colchicine (Tablet) ...... 23 2mg Lozenge, 2mg Lozenge, 4mg Lozenge) RA Nicotine Polacrilex (2mg Gum, 2mg Procainamide HCl (500mg/ml Injection) ...... 33 ...... 15 Lozenge, 4mg Lozenge) ...... 15 Prochlorperazine (Suppository) ...... 22 Pylera (Capsule) ...... 47 RA Nicotine Transdermal System (Patch 24 Prochlorperazine Edisylate (Injection) ...... 22 Pyrazinamide (Tablet) ...... 24 Hour) ...... 15 Prochlorperazine Maleate (Tablet) ...... 22 Pyridostigmine Bromide (Tablet) ...... 24 RA One Daily ...... 45 Procrit (Injection) ...... 32 Pyridostigmine Bromide ER (Tablet Extended- RA Pen Needles 31g X 5mm 3/16"...... 61 Procto-Med HC (Cream) ...... 57 Release) ...... 24 RA Prenatal (Tablet) ...... 45 Procto-Pak (Cream) ...... 57 Pyridoxine HCl (100mg/ml Injection) ...... 45 RA Prenatal Formula/Folic Acid (Tablet) .... 45 Proctosol HC (Cream) ...... 57 RA Vitamin D-3 (1000unit Tablet, 2000unit Proctozone-HC (Cream) ...... 57 Q Capsule) ...... 45 Profilnine (Injection) ...... 42 Rabeprazole Sodium (Tablet Delayed- Progesterone (100mg Capsule, 200mg QC Alcohol Swabs ...... 61 Release) ...... 48 Capsule, 50mg/ml Injection) ...... 54 QC Aspirin (325mg Tablet, 325mg Tablet Rajani (Tablet)...... 53 Proglycem (Suspension) ...... 31 Delayed-Release)...... 11 Raloxifene HCl (Tablet) ...... 54 Prograf (5mg/ml Injection) ...... 56 QC Childrens Aspirin (Tablet Chewable) ...... 11 Ramipril (Capsule)...... 33 Prolastin-C (Injection) ...... 68 QC Enteric Aspirin (Tablet Delayed-Release) Ranexa (Tablet Extended-Release 12 Hour) Proleukin (Injection) ...... 25 ...... 11 ...... 35 Prolia (Injection) ...... 58 QC Gentle Laxative (Tablet Delayed-Release) Ranitidine HCl (150mg Capsule, 300mg Promacta (Tablet) ...... 32 ...... 48 Capsule, 150mg Tablet, 300mg Tablet, Promethazine HCl (12.5mg Suppository, QC Natura-Lax (Powder) ...... 48 150mg/10ml Syrup, 15mg/ml Syrup, 25mg Suppository, 50mg Suppository, QC Nicotine Polacrilex (Gum) ...... 15 75mg/5ml Syrup, 150mg/6ml Injection, 12.5mg Tablet, 25mg Tablet, 50mg Tablet, QC Prenatal (Tablet) ...... 45 50mg/2ml Injection) ...... 47 25mg/ml Injection, 50mg/ml Injection, Quadracel (Injection) ...... 57 Rapaflo (Capsule) ...... 49 6.25mg/5ml Oral Solution) ...... 65 Quasense (Tablet) ...... 53 Rapamune (1mg/ml Oral Solution) ...... 56 Promethazine HCl Plain (Syrup) ...... 65 Quazepam (Tablet) ...... 30 Rasagiline Mesylate (Tablet) ...... 27 Promethegan (Suppository) ...... 65 Quetiapine Fumarate (Tablet) ...... 28 RAVICTI (Liquid) ...... 49 Pronutrients Vitamin D3 (Capsule) ...... 45 Quetiapine Fumarate ER (Tablet Extended- Rayaldee (Capsule Extended-Release) ...... 58 Propafenone HCl (Tablet) ...... 33 Release 24 Hour) ...... 28 Rea Lo 40 (40% Cream) ...... 61 Propafenone HCl ER (Capsule Extended- Quflora Pediatric (Oral Solution, Tablet React (Tablet) ...... 54 Release 12 Hour)...... 34 Chewable) ...... 45 Reality Swabs ...... 61 Propantheline Bromide (15mg Tablet) ...... 47 Quillivant XR (Suspension) ...... 38 Rebetol (40mg/ml Oral Solution) ...... 28 Proparacaine HCl (Ophthalmic Solution) ..... 63 Quinapril HCl (Tablet) ...... 33 Reclipsen (Tablet) ...... 53 89

Recombinate (Injection) ...... 33 Riomet (Oral Solution) ...... 31 Salicylic Acid Cream (Kit)...... 39 Recombivax HB (Injection) ...... 57 Risedronate Sodium (150mg Tablet, 35mg Salicylic Acid Lotion (Kit) ...... 39 Rectiv (Ointment) ...... 37 Tablet) ...... 58 Saline Flush (Injection) ...... 42 Regranex (Gel)...... 39 Risedronate Sodium (30mg Tablet, 5mg Saline Flush Zr/Sterile Field (Injection) ...... 42 Relador Pak (Kit) ...... 14 Tablet) ...... 58 Salsalate (Tablet) ...... 11 Relenza Diskhaler (Aerosol Powder) ...... 29 Risedronate Sodium DR (Tablet Delayed- Samsca (Tablet) ...... 42 Relion Ketone (Strip) ...... 61 Release) ...... 58 Sancuso (Patch) ...... 22 Relion Ketone Test Strips (Strip) ...... 61 Risperdal Consta (Injection) ...... 28 Sandimmune (100mg/ml Oral Solution) .... 56 Relion Pen Needles ...... 61 Risperidone (0.25mg Tablet, 0.5mg Tablet, Sandostatin LAR Depot (Injection) ...... 55 Relistor (12mg/0.6ml Injection, 8mg/0.4ml 1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Santyl (Ointment) ...... 39 Injection, 150mg Tablet) ...... 47 Tablet, 1mg/ml Oral Solution) ...... 28 Saphris (Tablet Sublingual) ...... 28 Relpax (Tablet) ...... 23 Risperidone ODT (Tablet Dispersible) ...... 28 Saps Care Alcohol Prep Pads ...... 61 Remeven (Cream) ...... 61 RiteFlo (Device) ...... 68 Saps Health Alcohol Prep Pads ...... 61 Remicade (Injection) ...... 56 Rituxan (Injection) ...... 26 Sash Kit for Flushing Vascular Access Devices Remodulin (Injection) ...... 66 Rivastigmine Tartrate (Capsule Immediate- (Kit) ...... 32 Renagel (Tablet) ...... 50 Release) ...... 20 Savella (Tablet) ...... 38 Renal Caps (Capsule) ...... 45 Rivastigmine Transdermal System (Patch 24 SB Alcohol Prep Pads ...... 61 Rena-Vite Rx (Tablet) ...... 45 Hour) ...... 20 SB Aspirin (Tablet) ...... 11 Reno Caps (Capsule) ...... 45 Rivelsa (Tablet) ...... 53 SB Aspirin EC (Tablet Delayed-Release) ...... 11 Renvela (2.4gm Packet, 800mg Tablet) ...... 50 Rixubis (Injection) ...... 33 SB Bisacodyl Laxative EC (Tablet Delayed- Repaglinide (Tablet) ...... 31 Rizatriptan Benzoate (Tablet) ...... 23 Release) ...... 48 Repatha (Injection) ...... 37 Rizatriptan Benzoate ODT (Tablet Dispersible) SB Childrens Aspirin (Tablet Chewable) ...... 11 Repatha Pushtronex System (Injection) ..... 37 ...... 23 Scalacort (Lotion) ...... 51 Repatha SureClick (Injection) ...... 37 Rocuronium Bromide (100mg/10ml Injection, Selegiline HCl (5mg Capsule, 5mg Tablet) ...27 Replesta (Wafer) ...... 45 50mg/5ml Injection) ...... 38 Selenium Sulfide (0-2.25%-Shampoo, 2.5% Replesta Childrens (Wafer) ...... 45 Ropinirole ER (Tablet Extended-Release 24 Lotion)...... 39 Replesta Nx (Wafer) ...... 45 Hour) ...... 27 Selzentry (150mg Tablet, 25mg Tablet, Rescriptor (Tablet) ...... 29 Ropinirole HCl (Tablet) ...... 27 300mg Tablet, 75mg Tablet) ...... 29 Restasis (Emulsion) ...... 63 Ropivacaine (Injection)...... 13 Se-Natal 19 (1000unit-100mg-200mg-7mg- Restasis Multidose (Emulsion)...... 63 Ropivacaine HCl (Injection) ...... 13 400unit-12mcg-29mg-1mg-15mg-20mg- Retrovir IV Infusion (Injection) ...... 29 Ropivacaine HCl/Sodium Chloride (0.1%-0.9% 3mg-3mg-30unit-20mg Tablet Chewable, Revlimid (Capsule) ...... 24 Injection) ...... 14 100mg-1000unit-200mg-7mg-400unit- Revonto (Injection) ...... 68 Rosadan (0.75% Cream, 0.75% Gel) ...... 16 12mcg-25mg-29mg-1mg-15mg-20mg- Rexulti (Tablet) ...... 28 Rosuvastatin Calcium (Tablet) ...... 36 3mg-3mg-30unit-20mg Tablet) ...... 45 Reyataz (150mg Capsule, 200mg Capsule, Rotarix (Suspension) ...... 57 Sensipar (Tablet) ...... 61 300mg Capsule, 50mg Packet) ...... 29 RotaTeq (Oral Solution) ...... 57 Sensorcaine (Injection) ...... 14 Rhogam Ultra-Filtered Plus (Injection) ...... 56 Roweepra (Tablet)...... 19 Sensorcaine/Epinephrine (Injection) ...... 14 Rhophylac (Injection) ...... 56 Rozerem (Tablet) ...... 68 Sensorcaine-MPF (Injection) ...... 14 Riastap (Injection) ...... 32 Rubraca (Tablet) ...... 26 Sensorcaine-MPF Spinal (Injection) ...... 14 Ribasphere (200mg Capsule, 200mg Tablet)28 Sensorcaine-Mpf/Epinephrine (0.5%-1 Ribasphere (400mg Tablet, 600mg Tablet) 28 S 200000 Injection) ...... 14 Ribasphere Ribapak (Tablet)...... 28 Serevent Diskus (Aerosol Powder) ...... 66 Ribavirin (200mg Capsule, 200mg Tablet) ... 28 Sabril (500mg Packet) ...... 20 Sertraline HCl (100mg Tablet, 25mg Tablet, Ribavirin (6gm Inhalation Solution) ...... 30 Safe-T-Lance Low Flow 25g ...... 61 50mg Tablet, 20mg/ml Concentrate) ...... 21 Ridaura (Capsule) ...... 56 Safe-T-Lance Normal Flow 21g ...... 61 Se-Tan Plus (Capsule) ...... 42 Rifabutin (Capsule) ...... 24 Safe-T-Lance Plus Safety Lancet High Flow 61 Setlakin (Tablet) ...... 53 Rifampin (150mg Capsule, 300mg Capsule, Safe-T-Lance Plus Safety Lancet Low Flow. 61 Sevelamer Carbonate (Packet) ...... 50 600mg Injection) ...... 24 Safe-T-Lance Plus Safety Lancet Normal Flow SF (Gel) ...... 38 Rifater (Tablet) ...... 24 ...... 61 SF 5000 Plus (Cream) ...... 38 Right Step Prenatal (Tablet)...... 45 Safety Insulin Syringes 1ml/27gx1/2" ...... 61 Sharobel (Tablet) ...... 54 Riluzole (Tablet) ...... 38 Safety Insulin Syringes 1ml/30gx1/2" ...... 61 Shur-Seal (Gel) ...... 50 Rimantadine HCl (Tablet) ...... 30 Salacyn (6% Cream, 6% Lotion) ...... 39 Side Button Safety Lancet21g ...... 61 Ringers Injection ...... 42 Salicylic Acid (27.5% Liquid, 6% Cream, 6% Signifor (Injection) ...... 55 Ringers Irrigation (Solution) ...... 42 Gel, 6% Lotion, 6% Shampoo) ...... 39 90

Sildenafil (10mg/12.5ml Injection, 20mg Sodium Chloride Flush (Injection) ...... 42 Sterile Water for Injection ...... 61 Tablet)...... 66 Sodium Citrate/Citric Acid (0 Oral Solution) 42 Sterile Water Irrigation (Solution) ...... 61 Silver Sulfadiazine (Cream) ...... 18 Sodium Ferric Gluconate Complex/Sucrose Stimulant Laxative (Tablet Delayed-Release) Simbrinza (Suspension) ...... 64 (Injection) ...... 42 ...... 48 Similac Prenatal Early Shield...... 45 Sodium Fluoride (0.25mg Tablet Chewable, Stiolto Respimat (Aerosol Solution) ...... 68 Simponi (Injection) ...... 56 0.5mg Tablet Chewable, 1mg Tablet Stivarga (Tablet) ...... 26 Simponi Aria (Injection) ...... 56 Chewable, 0.5mg/ml Oral Solution, 1mg Strensiq (Injection) ...... 49 Simulect (20mg Injection) ...... 56 Tablet) ...... 42 Streptomycin Sulfate (1gm Injection) ...... 15 Simvastatin (10mg Tablet, 20mg Tablet, 40mg Sodium Hyaluronate (Gel) ...... 61 Striant ...... 52 Tablet, 5mg Tablet) ...... 36 Sodium Nitroprusside (Injection) ...... 37 Stribild (Tablet) ...... 29 Simvastatin (80mg Tablet) ...... 36 Sodium Phenylacetate/Sodium Benzoate Striverdi Respimat (Aerosol Solution) ...... 66 Single-Let ...... 61 (Injection) ...... 61 Stuart One (Capsule) ...... 45 Sirolimus (Tablet) ...... 56 Sodium Phenylbutyrate (Powder) ...... 49 Suboxone (Film) ...... 14 Sirturo (Tablet) ...... 24 Sodium Phosphate (142mg/ml-276mg/ml Sucraid (Oral Solution) ...... 49 Sivextro (200mg Tablet) ...... 16 Injection) ...... 42 Sucralfate (1gm Tablet) ...... 48 Sklice (Lotion) ...... 26 Sodium Polystyrene Sulfonate (Powder, Sulfacetamide Sodium (10% Lotion, 10% Skyla (IUD) ...... 54 15gm/60ml Suspension, 30gm/120ml Suspension) ...... 39 SM Alcohol Prep Pads ...... 61 Suspension, 50gm/200ml Suspension) .. 42 Sulfacetamide Sodium (10% Ophthalmic SM Aspirin (Tablet) ...... 11 Sodium Sulfacetamide (Ophthalmic Solution) Solution) ...... 19 SM Aspirin Adult Low Strength (Tablet ...... 18 Sulfacetamide Sodium/Prednisolone Sodium Chewable) ...... 11 Soliris (Injection) ...... 23 Phosphate (Ophthalmic Solution) ...... 63 SM Aspirin EC Low Strength (Tablet Delayed- Soltamox (Oral Solution) ...... 24 Sulfadiazine (500mg Tablet) ...... 19 Release) ...... 12 Solu-Cortef (1000mg Injection) ...... 51 Sulfamethoxazole/Trimethoprim SM Aspirin Enteric Coated (Tablet Delayed- Somatuline Depot (Injection) ...... 55 (200mg/5ml-40mg/5ml Suspension, Release) ...... 12 Somavert (Injection) ...... 55 400mg-80mg Tablet) ...... 19 SM Childrens Aspirin (Tablet Chewable) ...... 12 Sorine (Tablet) ...... 34 Sulfamethoxazole/Trimethoprim DS (Tablet) SM ClearLax (Powder) ...... 48 Sotalol HCl (AF) (Tablet) ...... 34 ...... 19 SM Folic Acid (Tablet) ...... 45 Sotalol HCl (Tablet)...... 34 Sulfamylon (85mg/gm Cream) ...... 16 SM Gentle Laxative (Tablet Delayed-Release) Sovaldi (Tablet) ...... 28 Sulfasalazine (500mg Tablet, 500mg Tablet ...... 48 Spinosad (Suspension) ...... 27 Delayed-Release) ...... 57 SM Nicotine (2mg Lozenge, 4mg Gum) ...... 15 Spinraza (Injection)...... 61 Sulfatrim Pediatric (Suspension) ...... 19 SM Nicotine Polacrilex (2mg Gum, 4mg Gum, Spiriva HandiHaler (Capsule) ...... 66 Sulindac (150mg Tablet, 200mg Tablet) ...... 12 4mg Lozenge) ...... 15 Spiriva Respimat (Aerosol Solution) ...... 66 Sumatriptan (Nasal Solution) ...... 23 SM Nicotine Transdermal System (Patch 24 Spironolactone (100mg Tablet, 25mg Tablet, Sumatriptan Succinate (100mg Tablet, 25mg Hour) ...... 15 50mg Tablet) ...... 36 Tablet, 50mg Tablet, 4mg/0.5ml Injection, SM One Daily Prenatal ...... 45 Spironolactone/Hydrochlorothiazide (Tablet) 6mg/0.5ml Injection) ...... 23 SM Prenatal Vitamins (Tablet) ...... 45 ...... 35 Super Daily D3 (1000unit/0.03ml Liquid) ...45 SM Vitamin D (Tablet)...... 45 Sprintec 28 (Tablet) ...... 53 Super Daily D3 (2000UT/0.028ml Liquid) ...61 SM Vitamin D3 Maximum Strength (Capsule) Sprix (Nasal Solution) ...... 12 Supprelin LA (Injection) ...... 51 ...... 45 Sprycel (Tablet) ...... 26 Suprep Bowel Prep Kit (Oral Solution) ...... 48 Smooth Lax (Powder) ...... 48 SPS (Suspension) ...... 42 Sure Comfort Alcohol Prep Pads ...... 61 Sodium Acetate (Injection) ...... 42 SR Nicotine Gum (Gum) ...... 15 Sure Comfort Insulin Syringes/0.5ml/31g X Sodium Bicarbonate (7.5% Injection, 8.4% Sronyx (Tablet) ...... 53 6mm ...... 61 Injection) ...... 42 SSD (Cream) ...... 18 Sure Comfort Insulin Syringes/U- Sodium Bicarbonate Partial Fill (Injection) .. 42 SSKI (Oral Solution) ...... 68 100/1ml/31gx6mm ...... 61 Sodium Chloride 0.9% (Irrigation Solution) 42 St Joseph Low Dose Aspirin (Tablet Chewable) Sure Comfort Pen Needles ...... 61 Sodium Chloride (0.9% Nebulized Solution, ...... 12 Sure-Fine Pen Needles ...... 61 10% Nebulized Solution, 3% Nebulized Stavudine (Capsule) ...... 29 Surestep Glucose Control (In Vitro Solution) Solution, 7% Nebulized Solution) ...... 61 Stelara (130mg/26ml Injection) ...... 56 ...... 62 Sodium Chloride (2.5meq/ml Injection, 3% Stelara (45mg/0.5ml Injection, 90mg/ml Surestep Glucose Control Solution (In Vitro Injection, 4meq/ml Injection, 5% Injection) Injection) ...... 39 Solution) ...... 62 ...... 42 Sterilance Tl ...... 61 Surestep Pro High Glucosecontrol (Liquid) 62 Sodium Chloride 0.45% (Injection) ...... 42 Sterile Diluent for Epoprostenol Sodium Surestep Pro Linearity Kit (Kit) ...... 62 Sodium Chloride Bacteriostatic (Injection) .. 61 (Injection) ...... 61 Surestep Pro Low Glucose Control (Liquid) 62 91

Surestep Pro Normal Glucose Control Tecentriq (Injection) ...... 26 Theochron (Tablet Extended-Release 12 (Liquid) ...... 62 Tecfidera (Capsule Delayed-Release) ...... 38 Hour) ...... 66 Sustiva (200mg Capsule, 50mg Capsule, Tecfidera Starter Pack ...... 38 Theophylline (Oral Solution) ...... 66 600mg Tablet) ...... 29 Techlite Pen Needles ...... 62 Theophylline CR (Tablet Extended-Release 12 Sutent (Capsule) ...... 26 Technivie (Tablet) ...... 28 Hour) ...... 66 SW ClearLax (Powder) ...... 48 Tekturna (Tablet) ...... 35 Theophylline ER (100mg Tablet Extended- SW Nicotine Polacrilex (2mg Gum, 4mg Gum, Telmisartan (Tablet) ...... 33 Release 12 Hour, 200mg Tablet Extended- 2mg Lozenge, 4mg Lozenge) ...... 15 Telmisartan/Amlodipine (Tablet) ...... 36 Release 12 Hour, 300mg Tablet Extended- Swabflush Saline Flush (Injection) ...... 42 Telmisartan/Hydrochlorothiazide (Tablet).. 36 Release 12 Hour, 450mg Tablet Extended- Syeda (Tablet) ...... 53 Temazepam (Capsule) ...... 68 Release 12 Hour, 400mg Tablet Extended- Sylatron (Injection) ...... 28 Temodar (100mg Injection) ...... 24 Release 24 Hour, 600mg Tablet Extended- Symax-SR (Tablet Extended-Release 12 Hour) Temozolomide (Capsule)...... 24 Release 24 Hour) ...... 66 ...... 47 Teniposide (Injection)...... 25 Thera-D 2000 (Tablet) ...... 46 Symbicort (Aerosol) ...... 68 Tenivac (Injection) ...... 57 Thera-D 4000 (Tablet) ...... 46 SymlinPen 120 (Injection) ...... 31 Tepadina (Injection) ...... 25 Thiamine HCl (100mg/ml Injection) ...... 46 SymlinPen 60 (Injection) ...... 31 Terazosin HCl (Capsule) ...... 49 Thinlets Lancet ...... 62 Synagis (Injection) ...... 56 Terbinafine HCl (Tablet) ...... 23 Thioridazine HCl (Tablet) ...... 27 Synarel (Nasal Solution) ...... 55 Terbutaline Sulfate (1mg/ml Injection, 2.5mg Thiotepa (Injection) ...... 25 Synera (Patch) ...... 14 Tablet, 5mg Tablet) ...... 66 Thiothixene (Capsule) ...... 27 Synjardy (Tablet) ...... 31 Terconazole (0.4% Cream, 0.8% Cream, 80mg Thrive (Gum) ...... 15 Synjardy XR (Tablet Extended-Release 24 Suppository) ...... 23 Thrombate III (Injection) ...... 32 Hour) ...... 31 Testosterone (30mg/act Solution) ...... 52 Thrombate III w/20 Ml Sterile Water Synribo (Injection) ...... 25 Testosterone Cypionate (Injection) ...... 52 (Injection) ...... 32 Syprine (Capsule) ...... 42 Testosterone Enanthate (Injection) ...... 52 Thymoglobulin (Injection) ...... 56 Tetanus/Diphtheria Toxoids-Adsorbed Thyrolar (Tablet) ...... 55 T (Injection) ...... 57 Tiagabine HCl (Tablet) ...... 20 Tetcaine (Ophthalmic Solution) ...... 63 Tilia Fe (Tablet) ...... 53 Tabloid (Tablet) ...... 25 Tetrabenazine (Tablet) ...... 38 Timolol Maleate (0.25% Ophthalmic Solution, Taclonex (0.064%-0.005% Suspension) ...... 39 Tetracaine HCl (Ophthalmic Solution) ...... 63 0.5% Ophthalmic Solution) ...... 64 Tacrolimus (0.03% Ointment, 0.1% Ointment) Tetracycline HCl (Capsule) ...... 19 Timolol Maleate (10mg Tablet, 20mg Tablet, ...... 39 Tetravisc (Ophthalmic Solution) ...... 63 5mg Tablet) ...... 34 Tacrolimus (0.5mg Capsule, 1mg Capsule, Texacort (External Solution) ...... 51 Timolol Maleate Ophthalmic Gel Forming 5mg Capsule) ...... 56 TGT Aspirin (325mg Tablet, 81mg Tablet (Solution) ...... 64 Tafinlar (Capsule) ...... 26 Chewable, 81mg Tablet Delayed-Release) Tinidazole (Tablet) ...... 16 Tagrisso (Tablet)...... 26 ...... 12 Tis-U-Sol (Irrigation Solution)...... 42 Take Action (Tablet)...... 54 TGT Aspirin Low Dose (Tablet Delayed- Tivicay (Tablet) ...... 29 Taltz (Injection) ...... 56 Release) ...... 12 Tizanidine HCl (2mg Capsule, 4mg Capsule, Tamiflu (6mg/ml Suspension)...... 30 TGT Childrens Aspirin (Tablet Chewable) .... 12 6mg Capsule, 2mg Tablet, 4mg Tablet) ..68 Tamoxifen Citrate (Tablet) ...... 24 TGT Lancet Alternate Site ...... 62 TL Gard Rx (Tablet) ...... 46 Tamsulosin HCl (Capsule) ...... 49 TGT Lancet Micro Thin 33g ...... 62 TL Icon (Capsule) ...... 42 Tanzeum (Injection) ...... 31 TGT Lancet Super Thin 30g ...... 62 Tl-Hem 150 (Tablet) ...... 42 Tarceva (Tablet) ...... 26 TGT Lancet Thin 23g ...... 62 Tobradex (Ophthalmic Ointment) ...... 15 Targretin (1% Gel) ...... 26 TGT Lancet Thin 26g ...... 62 Tobradex ST (Ophthalmic Suspension) ...... 63 Tarina Fe 1/20 (Tablet) ...... 53 TGT Lancet Ultra Thin 28g ...... 62 Tobramycin (300mg/5ml Nebulized Solution) Taron-Crystals (Packet) ...... 42 TGT Nicotine Gum (Gum) ...... 15 ...... 15 Taron-Prex (Capsule) ...... 45 TGT Nicotine Polacrilex (2mg Gum, 4mg Gum, Tobramycin Sulfate (0.3% Ophthalmic Tasigna (Capsule) ...... 26 2mg Lozenge, 4mg Lozenge) ...... 15 Solution, 1.2gm Injection, 1.2gm/30ml Tazarotene (Cream) ...... 39 TGT Nicotine Step One (Patch 24 Hour) ...... 15 Injection, 10mg/ml Injection, 80mg/2ml Tazicef (1gm Injection, 2gm Injection, 6gm TGT Nicotine Step Three (Patch 24 Hour) ... 15 Injection) ...... 15 Injection) ...... 17 TGT Nicotine Step Two (Patch 24 Hour) ...... 15 Tobramycin/Dexamethasone (Ophthalmic Tazorac (0.05% Cream, 0.05% Gel, 0.1% Gel) TGT Powderlax (Powder) ...... 48 Suspension) ...... 63 ...... 39 Thalomid (Capsule) ...... 24 Tobrex (0.3% Ophthalmic Ointment) ...... 16 Taztia XT (Capsule Extended-Release 24 Hour) Theo-24 (Capsule Extended-Release 24 Hour) Today Sponge ...... 62 ...... 35 ...... 66 Todays Health Mini Pen Needles ...... 62 92

Tolazamide (Tablet) ...... 31 Ointment, 0.5% Ointment, 0.147mg/gm Tuzistra XR (Suspension Extended-Release) Tolbutamide (Tablet) ...... 31 Aerosol Solution) ...... 51 ...... 68 Tolcapone (Tablet) ...... 27 Triamcinolone Acetonide (0.1% Paste) ...... 39 Twinrix (Injection) ...... 57 Tolmetin Sodium (200mg Tablet, 600mg Triamcinolone Acetonide (55mcg/act Tybost (Tablet) ...... 29 Tablet, 400mg Capsule) ...... 12 Aerosol) ...... 65 Tykerb (Tablet) ...... 26 Tolterodine Tartrate (Tablet) ...... 49 Triamcinolone in Orabase (Paste) ...... 39 Tysabri (Injection) ...... 38 Tolterodine Tartrate ER (Capsule Extended- Triamterene/Hydrochlorothiazide (25mg- Tyvaso (Inhalation Solution) ...... 66 Release 24 Hour)...... 49 37.5mg Tablet, 50mg-75mg Tablet, Tyvaso Refill (Inhalation Solution) ...... 66 Topex Topical Anesthetic (Aerosol) ...... 39 37.5mg-25mg Capsule, 50mg-25mg Tyvaso Starter (Inhalation Solution) ...... 66 Topiramate (100mg Tablet, 200mg Tablet, Capsule) ...... 36 25mg Tablet, 50mg Tablet, 15mg Capsule Triazolam (Tablet) ...... 30 U Sprinkle, 25mg Capsule Sprinkle) ...... 20 Tricare (Tablet) ...... 46 Topiramate ER (Capsule Extended-Release Tricon (Capsule) ...... 42 Ulesfia (Lotion) ...... 27 24 Hour Sprinkle) ...... 20 Triderm (Cream) ...... 51 Uloric (Tablet) ...... 23 Toposar (Injection) ...... 26 Tri-Estarylla (Tablet) ...... 54 Ulticare Alcohol Swabs ...... 62 Topotecan HCl (4mg Injection) ...... 26 Trifluoperazine HCl (Tablet) ...... 27 Ulticare Insulin Safety Syringe/0.5ml/29g X Topotecan HCl (4mg/4ml Injection) ...... 26 Trifluridine (Ophthalmic Solution) ...... 30 1/2" ...... 62 Torisel (Injection) ...... 56 Trigels-F Forte (Capsule) ...... 42 Ulticare Insulin Safety Syringe/1ml/29g X Torsemide (Tablet) ...... 36 Triglide (Tablet) ...... 36 1/2" ...... 62 Toujeo SoloStar (Injection) ...... 31 Trihexyphenidyl HCl (0.4mg/ml Elixir, 2mg Ulticare Insulin Syringe/0.3ml/29g X 1/2" .62 Toviaz (Tablet Extended-Release 24 Hour) 49 Tablet, 5mg Tablet) ...... 27 Ulticare Insulin Syringe/0.5ml/28g X 1/2" .62 TPN Electrolytes (Injection) ...... 42 Tri-Legest Fe (Tablet) ...... 54 Ulticare Insulin Syringe/U-100/0.3ml/30g X Tracleer (Tablet) ...... 66 Tri-Linyah (Tablet) ...... 54 1/2" ...... 62 Tradjenta (Tablet) ...... 31 Tri-Lo-Estarylla (Tablet) ...... 54 Ulticare Insulin Syringe/U-100/0.3ml/31g X Tramadol HCl (Immediate-Release Tablet).. 13 Tri-Lo-Marzia (Tablet) ...... 54 5/16" ...... 62 Tramadol HCl ER (150mg Capsule Extended- Tri-Lo-Sprintec (Tablet) ...... 54 Ulticare Insulin Syringe/U-100/0.5ml/31g X Release 24 Hour)...... 12 TriLyte (Oral Solution) ...... 48 5/16" ...... 62 Tramadol HCl ER (Tablet Extended-Release 24 Trimethobenzamide HCl (Capsule) ...... 22 Ulticare Insulin Syringe/U-100/1ml/31g X Hour Generic Ultram ER) ...... 12 Trimethoprim (Tablet)...... 16 5/16" ...... 62 Tramadol HCl/Acetaminophen (Tablet) ...... 13 Trimethoprim Sulfate/Polymyxin B Sulfate Ulticare Pen Needles/29g X 12.7mm ...... 62 Trandolapril (Tablet) ...... 33 (Ophthalmic Solution) ...... 63 Ulticare U-100 Insulin Syringes/0.3ml/31g Trandolapril/Verapamil HCl ER (Tablet Trimipramine Maleate (100mg Capsule, 25mg X1/4" ...... 62 Extended-Release) ...... 36 Capsule, 50mg Capsule) ...... 22 Ulticare U-100 Insulin Syringes/0.5ml/31g X Tranexamic Acid (1000mg/10ml Injection, Trinatal Rx 1 (Tablet) ...... 46 1/4" ...... 62 650mg Tablet) ...... 33 Trinate (Tablet) ...... 46 Ulticare U-100 Insulin Syringes/1ml/31g X Transderm-Scop (Patch 72 Hour) ...... 22 Trinessa (Tablet) ...... 54 1/4" ...... 62 Tranylcypromine Sulfate (Tablet) ...... 21 Trinessa Lo (Tablet) ...... 54 Ultiguard Insulin Syringe/U-100/0.5ml/30g X Travatan Z (Ophthalmic Solution) ...... 64 Trintellix (Tablet) ...... 21 5/16" ...... 62 Trazodone HCl (Tablet) ...... 21 Triphrocaps (Capsule) ...... 46 Ultiguard Insulin Syringe/U-100/1ml/30g X Treanda (Injection) ...... 24 Tri-Previfem (Tablet) ...... 54 5/16" ...... 62 Trecator (Tablet) ...... 24 Trisenox (Injection) ...... 25 Ultilet Alcohol Swabs ...... 62 Tretinoin (0.01% Gel, 0.025% Gel, 0.05% Gel, Tri-Sprintec (Tablet) ...... 54 Ultilet Insulin Syringe/0.3ml/30g X 8mm...62 0.025% Cream, 0.05% Cream, 0.1% Cream) Triumeq (Tablet) ...... 29 Ultilet Insulin Syringe/0.3ml/31g X 8mm...62 ...... 39 Tri-Vit/Fluoride (Oral Solution) ...... 46 Ultilet Insulin Syringe/Short/0.5ml/31g X Tretinoin (10mg Capsule) ...... 26 Tri-Vitamin/Fluoride (Oral Solution) ...... 46 5/16" ...... 62 Tretinoin Microsphere (Gel) ...... 39 Trivora-28 (Tablet) ...... 54 Ultilet Insulin Syringe/U-100/0.5ml/30g X Tretinoin Microsphere Pump (Gel) ...... 39 Tropicamide (0.5% Ophthalmic Solution) ... 63 1/2" ...... 62 Tretten (Injection) ...... 32 Trospium Chloride (Tablet) ...... 49 Ultilet Insulin Syringe/U- Trexall (Tablet) ...... 56 Trospium Chloride ER (Capsule Extended- 100/0.5ml/31gx6mm ...... 62 Tri Femynor (Tablet) ...... 54 Release 24 Hour) ...... 49 Ultilet Insulin Syringe/U-100/1ml/30g X 1/2" Triamcinolone Acetonide (0.025% Cream, Trulicity (Injection) ...... 31 ...... 62 0.1% Cream, 0.5% Cream, 0.025% Lotion, Trumenba (Injection) ...... 57 Ultilet Pen Needle 29gx12.7mm ...... 62 0.1% Lotion, 0.025% Ointment, 0.1% Truvada (Tablet) ...... 29 Ultilet Pen Needle 31gx5mm ...... 62 Tussigon (Tablet) ...... 68 Ultilet Pen Needle 31gx8mm ...... 62 93

Ultilet Pen Needle 32gx4mm ...... 62 Injection, 1000mg Solution, 125mg Vic-Forte (Capsule) ...... 46 Ultilet Pen Needle 32gx4mm/Short ...... 62 Capsule, 250mg Capsule) ...... 16 Vicodin (Tablet) ...... 13 Ultilet Short Pen Needles31gx3/16" ...... 62 Vancomycin HCl/Dextrose (5%-1.5gm/250ml Vicodin ES (Tablet) ...... 13 Ultilet U-100 Insulin Syringes/1ml/31g X Injection, 5%-1gm/250ml Injection, 5%- Vicodin HP (Tablet) ...... 13 6mm ...... 62 2gm/500ml Injection) ...... 16 Victoza (Injection) ...... 31 Ultimatecare One (Capsule) ...... 46 Vancomycin HCl/Sodium Chloride (0.9%- Videx Pediatric (Oral Solution) ...... 29 UltimateCare ONE NF (Capsule) ...... 46 1.5gm/150ml Injection, 0.9%- Viekira Pak (Tablet Therapy Pack) ...... 29 Ultra-Thin II Auto Lancet ...... 62 1.5gm/250ml Injection, 0.9%- Vienva (Tablet)...... 54 Ultra-Thin II Pen Needles 29gx1/2" ...... 62 1.5gm/500ml Injection, 0.9%-1gm/150ml Viibryd (Tablet) ...... 21 Unilet ComforTouch Lancet ...... 62 Injection, 0.9%-1gm/250ml Injection) .... 16 Viibryd Starter Pack (Kit) ...... 21 Unilet Excelite ...... 62 Vandazole (Gel) ...... 16 Vimizim (Injection) ...... 49 Unilet Excelite II ...... 62 Vanishpoint Insulin Syringe/0.5ml/30g X Vimpat (100mg Tablet, 150mg Tablet, 200mg Unilet G.P. Lancet ...... 62 5/16" ...... 63 Tablet, 50mg Tablet, 10mg/ml Oral Unilet G.P. SuperLite Lancet ...... 62 Vanishpoint Insulin Syringe/1ml/29g X 5/16" Solution) ...... 20 Unilet GP 28 Ultra Thin ...... 62 ...... 63 Vinate II (Tablet) ...... 46 Unilet Lancet ...... 62 Vanishpoint Insulin Syringe/1ml/30g X 5/16" Vinate M (Tablet) ...... 46 Unilet SuperLite Lancet ...... 62 ...... 63 Vinate One (Tablet)...... 46 Uni-Solve Wipes ...... 16 VAQTA (Injection) ...... 57 Vinblastine Sulfate (Injection) ...... 25 Unistik 3 Gentle ...... 62 Varivax (Injection) ...... 57 Vincasar PFS (Injection) ...... 25 Unithroid (Tablet) ...... 55 Varubi (Tablet) ...... 22 Vincristine Sulfate (Injection) ...... 25 Unithroid Direct (Tablet) ...... 55 V-C Forte (Capsule) ...... 46 Vinorelbine Tartrate (Injection) ...... 25 Unituxin (Injection) ...... 26 VCF Vaginal Contraceptive Film (Film) ...... 50 Viorele (Tablet) ...... 54 Upspringbaby Vitamin D3 (Liquid) ...... 46 VCF Vaginal Contraceptive Foam (Foam)... 50 Viracept (Tablet) ...... 29 Uptravi (Tablet Therapy Pack, 1000mcg VCF Vaginal Contraceptive Gel (Gel) ...... 50 Viramune (50mg/5ml Suspension) ...... 29 Tablet, 1200mcg Tablet, 1400mcg Tablet, Vecamyl (Tablet) ...... 36 Viread (150mg Tablet, 200mg Tablet, 250mg 1600mcg Tablet, 200mcg Tablet, 400mcg Vectical (Ointment) ...... 40 Tablet, 300mg Tablet, 40mg/gm Powder) Tablet, 600mcg Tablet, 800mcg Tablet) 66 Vecuronium Bromide (10mg Injection, 20mg ...... 29 Urea (40% Cream, 50% Cream, 45% Lotion) 62 Injection) ...... 13 Virt-Caps (Capsule) ...... 46 Urea Nail Gel (Gel) ...... 62 Velcade (Injection) ...... 25 Virt-Gard (Tablet)...... 46 Urea Topical (Suspension) ...... 62 Veletri (Injection) ...... 67 Virt-Phos 250 Neutral (Tablet) ...... 42 Urea-C40 (Lotion) ...... 63 Velivet (Tablet) ...... 54 Virtrate-2 (Oral Solution) ...... 42 Urin-Tek (Kit) ...... 63 Velphoro (Tablet Chewable) ...... 50 Virtrate-3 (Oral Solution) ...... 42 Uristix (Strip) ...... 63 Veltassa (Packet) ...... 63 Virtrate-K (Oral Solution) ...... 42 Uristix 4 (Strip) ...... 63 Venclexta (Tablet) ...... 25 Virt-Vite (Tablet) ...... 46 Urosex (Tablet) ...... 46 Venclexta Starting Pack (Tablet Therapy Virt-Vite Plus (Tablet)...... 46 Ursodiol (250mg Tablet, 500mg Tablet, Pack) ...... 25 Vita S Forte (Tablet) ...... 46 300mg Capsule) ...... 47 Venlafaxine HCl (Tablet Immediate-Release) Vitacel (Tablet) ...... 46 Uvadex (Injection) ...... 40 ...... 21 Vitajoy Daily D Gummies (Tablet Chewable)46 Venlafaxine HCl ER (Capsule Extended- Vitamax Pediatric (Oral Solution) ...... 46 V Release 24 Hour, Tablet Extended-Release Vitamelts Vitamin D (Tablet Dispersible) ...46 24 Hour) ...... 21 Vita-Min (Capsule) ...... 46 Valacyclovir HCl (Tablet) ...... 30 Ventavis (Inhalation Solution) ...... 67 Vitamin C 222mg (Injection) ...... 63 Valganciclovir (Tablet) ...... 28 Ventolin HFA (Aerosol Solution) ...... 66 Vitamin D (2000unit Tablet, 400unit Capsule, Valganciclovir Hydrochlorde (Oral Solution) 28 Veracolate (Tablet Delayed-Release) ...... 48 400unit Tablet, 400unit/ml Liquid, Valproate Sodium (100mg/ml Injection) ..... 20 Verapamil HCl (120mg Tablet, 40mg Tablet, 50000unit Capsule) ...... 46 Valproic Acid (250mg Capsule, 250mg/5ml 80mg Tablet, 2.5mg/ml Injection) ...... 35 Vitamin D-1000 (Tablet) ...... 46 Oral Solution) ...... 20 Verapamil HCl ER (Capsule Extended-Release Vitamin D2 (Tablet) ...... 46 Valsartan (Tablet) ...... 33 24 Hour, Tablet Extended-Release) ...... 35 Vitamin D3 (10000unit Tablet, Valsartan/Hydrochlorothiazide (Tablet) ...... 36 Verapamil HCl SR (Capsule Extended-Release 1000unit/spray Liquid, 1200unit/15ml Valumark Lancet Ultra Thin 28g ...... 63 24 Hour) ...... 35 Liquid, 3000unit Tablet, 5000unit Tablet Valved Holding Chamber (Device) ...... 68 Verdrocet (Tablet) ...... 13 Dispersible) ...... 46 Vancomycin (Injection) ...... 16 Veregen (Ointment) ...... 40 Vitamin D-3 (1000unit Capsule, 1000unit Vancomycin HCl (1000mg Injection, 10gm Vesicare (Tablet) ...... 49 Tablet, 400unit Tablet, 2000unit Tablet) 46 Injection, 5000mg Injection, 750mg Vestura (Tablet) ...... 54 94

Vitamin D3 (2000unit Tablet, 2000unit Tablet X Zenpep (Capsule Delayed-Release) ...... 49 Chewable, 5000unit Tablet Chewable, Zenzedi (10mg Tablet, 5mg Tablet) ...... 37 400unit Capsule, 400unit/ml Liquid, Xalkori (Capsule) ...... 26 Zepatier (Tablet) ...... 29 5000unit/ml Liquid, 5000unit Capsule, Xarelto (Tablet)...... 32 Zerit (1mg/ml Oral Solution) ...... 29 5000unit Tablet) ...... 46 Xarelto Starter Pack (Tablet Therapy Pack) 32 Ziagen (20mg/ml Oral Solution) ...... 29 Vitamin D3 Gummies (Tablet Chewable) ..... 46 Xeljanz (Tablet) ...... 56 Zidovudine (100mg Capsule, 300mg Tablet, Vitamin D3 Ultra Potency (Tablet) ...... 46 Xgeva (Injection) ...... 58 50mg/5ml Syrup) ...... 29 Vitamin K1 (1mg/0.5ml Injection) ...... 46 Xiaflex (Injection) ...... 63 Zileuton ER (Tablet Extended-Release 12 Vitamins A/C/D/Fluoride (Oral Solution) ..... 46 Xifaxan (Tablet) ...... 16 Hour) ...... 65 Vituz (Oral Solution) ...... 68 Xiidra (Ophthalmic Solution) ...... 63 Zioptan (Ophthalmic Solution) ...... 64 Vivitrol (Injection) ...... 14 Xolair (Injection) ...... 68 Ziprasidone HCl (Capsule) ...... 28 Vol-Care Rx (Tablet) ...... 46 Xolegel (Gel) ...... 23 Zirgan (Gel) ...... 28 Vonvendi (Injection) ...... 32 Xtandi (Capsule) ...... 24 Zithromax (1gm Packet) ...... 18 Voriconazole (200mg Injection, 200mg Xulane (Patch Weekly) ...... 54 Zoladex (3.6mg Injection) ...... 55 Tablet, 50mg Tablet, 40mg/ml Suspension) Xylocaine Dental (Injection) ...... 14 Zoledronic Acid (4mg/100ml Injection) ...... 58 ...... 23 Xylon (Tablet) ...... 13 Zoledronic Acid (4mg/5ml Injection, Vortex Valved Holding Chamber (Device) .. 68 Xyntha (Injection) ...... 42 5mg/100ml Injection) ...... 58 Votrient (Tablet) ...... 26 Xyntha Solofuse (Injection) ...... 42 Zolinza (Capsule) ...... 25 VPRIV (Injection) ...... 49 Xyrem (Oral Solution) ...... 68 Zolmitriptan (Tablet)...... 23 VP-Vite Rx (Tablet) ...... 46 Zolmitriptan ODT (Tablet Dispersible) ...... 23 Vyfemla (Tablet) ...... 54 Y Zolpidem Tartrate (1.75mg Tablet Sublingual, Vyvanse (Capsule, Tablet Chewable) ...... 37 3.5mg Tablet Sublingual, 10mg Tablet, Yervoy (Injection) ...... 26 5mg Tablet) ...... 68 W YL Folic Acid (Tablet) ...... 46 Zolpidem Tartrate ER (Tablet Extended- Your Life Multi Prenatal (Capsule) ...... 46 Release) ...... 68 Warfarin Sodium (Tablet) ...... 32 Yuvafem (Tablet) ...... 54 Zometa (4mg/100ml Injection) ...... 58 WatchHaler (Device) ...... 68 Zomig (2.5mg Nasal Solution, 5mg Nasal Webcol Alcohol Prep Large 1 Ply ...... 63 Z Solution) ...... 23 Webcol Alcohol Prep Medium 2 Ply ...... 63 Zonisamide (Capsule) ...... 19 Zafirlukast (Tablet) ...... 65 Welchol (3.75gm Packet, 625mg Tablet) .... 37 Zontivity (Tablet) ...... 33 Zaleplon (Capsule) ...... 68 Wellesse Vitamin D3 (Liquid)...... 46 Zortress (Tablet) ...... 56 Zaltrap (Injection) ...... 25 Wera (Tablet) ...... 54 Zostavax (Injection) ...... 57 Zanosar (Injection) ...... 24 Wide-Seal Silicone Diaphragm Kit ...... 63 Zovia 1/35E (Tablet)...... 54 Zarah (Tablet) ...... 54 WinRho SDF (Injection) ...... 56 Zovia 1/50E (Tablet)...... 54 Zavesca (Capsule) ...... 49 Womans Laxative (Tablet Delayed-Release) 48 Zovirax (5% Cream) ...... 30 Zebutal (Capsule) ...... 10 Womens Laxative (Tablet Delayed-Release)48 Zurampic (Tablet) ...... 23 Zelboraf (Tablet) ...... 26 WP Thyroid (Tablet) ...... 55 Zydelig (Tablet) ...... 26 Zemaira (Injection) ...... 68 WYMZYA Fe (Tablet Chewable) ...... 54 Zykadia (Capsule) ...... 25 Zenatane (Capsule) ...... 40 Zyprexa Relprevv (Injection) ...... 28 Zenchent (Tablet) ...... 54 Zytiga (Tablet) ...... 24 Zenchent Fe (Tablet Chewable) ...... 54 Zyvox (200mg/100ml Injection) ...... 17

95

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.

optumrx.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. © 2016 Optum, Inc. All rights reserved. ORX284511_161212

96

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: اذإ كنت د حتتث العربية )Arabic( إ، فن خدامت ال سمادعة اللوغية الاجمنية مت حاة لك. الاجرء الاات صل ى لع رقم الاهتف الجماي ن الجومدو ل عى مع رف وض عالية. 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. 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。

هجو ت: اگر زبان شام فارسی )Farsi( سات، دخت ام دادما زبانی هب روط اراي گن در خاتيار شام می دشا ب. ف طل ا ب شامره ف لتن ن ا گ يا ری هک وریا کرت شناسايی شام د يق شده تامس د ير ي گب. ध् य् न द्् : यद द आप ह दी (Hindi) ब् लत् ह् , आपक भ ष सह् यत स् ब् ए,् नन:श् लक उपल녍ध ह।्् क् पय् अपन् पहच् न पत्र पर स ् बद्ध ट ल-फ्र् फ न न बर 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.

ច 㮶 ប讶រម ្មណ បបសនអ្ កនយ យ徶 羶ខ្ មរម (Khmer)បស玶ជំន យ徶羶បេ យឥតគិតថ ្ លៃ គ 掶ន ស 殶បំ អ ្ នក។ ស មទូរស ព្ ទបេ បេ មឥតគិតថ ្ លៃ ខ្PAKDAAR:ែ េ 掶ន Nuបេ saritaemបេ េ អ្ ត tiស Ilocano⟒ញ ណបណណ (Ilocano)របស អនក។ , 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'dę́ ę́ ' 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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