Comprehensive PREFERRED DRUG LIST

MHS Indiana Effective

HIP BASIC HIP STATE BASIC HOOSIER CARE CONNECT HOOSIER HEALTHWISE Pharmacy Program MHS Health Plan (MHS) is committed to providing appropriate, high-quality, and cost- effective drug therapy to all MHS members. MHS works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. MHS covers prescription medications and certain over-the-counter (OTC) medications when ordered by an Indiana Medicaid enrolled MHS practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. For the most current information about the MHS Pharmacy Program you may call Member Services at (877) 647-4848 (TTY/TTD (800) 743-3333) or visit the MHS website www.mhsindiana.com.

Preferred Drug List The MHS Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs that members can receive at retail pharmacies. The MHS PDL is continually evaluated by the MHS Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians, pharmacists, and specialists.

Pharmacy Benefit Manager Envolve Pharmacy Solutions (EPS) is our Pharmacy Benefit Manager. MHS works with EPS to process all pharmacy claims for prescribed drugs. Some drugs on the MHS PDL require PA, and EPS is responsible for administering this process.

Specialty Drugs Certain medications are only covered when supplied by MHS’ specialty pharmacy provider. AcariaHealth is our specialty pharmacy provider. A medical provider can obtain specialty medications through Acaria Health. Acaria Health will ship these medications to the medical provider’s office. Some selected medications are also available through the medical benefit upon administration within the medical provider’s office for providers who choose to inventory these medications for office administration. Billing instructions for this situation can be found in the provider handbook. The MHS Pharmacy Director and MHS Medical Director oversee the clinical review of these medications and AcariaHealth provides members with the following services:  Deliver drugs to the member’s home or provider’s office  Provide staff pharmacists who can help 24 hours a day, seven days a week to answer member questions and offer help with drugs  Give information, materials, and ongoing support to help members take the drug(s) to appropriately manage their health condition(s) These drugs are not usually available at retail pharmacies. Additional information about the drugs that AcariaHealth provides is in the Biopharmaceutical Pharmacy Program document located on the MHS website at www.mhsindiana.com.

Mental Health Drugs In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic drugs are considered as being preferred and do not require prior authorizations. If such a mental health drug is not listed on the PDL it is still considered preferred. Although considered preferred and no prior authorization is required, mental health drugs may be subject to utilizations edits such as quantity and age limits, duplicate therapy edits and other authorization requirements.

Dispensing Limits Drugs may be dispensed up to a maximum of 30 days supply for each new prescription or refill. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be refilled for 30 days supply, non-controlled-substance PDL drugs. A total of 88% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs.

Appropriate Use and Safety Edits Member health and safety is a priority for MHS. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on the Food and Drug Administration (FDA) recommendations and promote safe and effective medication utilization. A primary example of these recommendations would be limiting the number of fills each month to one medication in the same therapy classes. Additional information about the drugs that are part of the these edits can be found in the Appropriate Use and Safety Edits document located on the MHS website at www.mhsindiana.com.

Prior Authorizations Some medications listed on the MHS PDL may require PA. The information should be submitted by the practitioner or pharmacist to EPS on the Medication Prior Authorization Form. This document is located on the MHS website at www.mhsindiana.com. The completed form and all clinicals to support the request should be faxed to Envolve Pharmacy Solutions at (866) 399-0929. MHS will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the MHS P&T Committee. If the request is approved, EPS notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy Some medications listed on the MHS PDL may require specific medications to be used before the member can receive the step therapy medication. If MHS has a record that the required medication was tried first, the step therapy medications are automatically covered. If MHS does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If MHS does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits MHS may limit how much of a medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a larger amount, a PA may be requested. If MHS does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits Some medications on the MHS PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. MHS requires:

. Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or

. Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or . Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist or physician using the criteria established by the MHS P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call EPS at (855) 772-7125 for a prescription override to submit the 72 hour medication supply for payment.

Exclusions The following drug categories are not part of the MHS PDL and are not covered by the 72 hour emergency supply policy:

. Drugs that are considered experimental

. Drug Efficacy Study and Implementation (DESI) drugs

. Drugs prescribed for weight loss (with the exception of Orlistat)

. Drugs prescribed for infertility

. Drugs prescribed for erectile dysfunction

. Drugs prescribed for cosmetic purposes or hair growth

. Cough and cold preparations, minus those covered by OTC program

. Infusion therapy and supplies

. Immunizations and vaccines (except flu vaccine)

. Physician administered drugs that are not listed in the PDL, Specialty Drug Benefit, or the Physician Administered Drug Prior Authorization List

. Hepatitis C Agents* Effective September 1, 2016 all drugs used in the treatment of Hepatitis C will be provided by the Office of Medicaid Policy and Planning (OMPP) through the FFS pharmacy benefit. Any member of MHS who is presently treated with a Hepatitis C agent prior to September 1, 2016 will continue to get their medication with no interruption. Any MHS member requesting a Hepatitis C agent after September 1, 2016 will need to have their physician send the prior authorization (PA) request to: o Optum Clinical Call Center o Phone: 855-577-6317 o Fax: 855-577-6384

Newly Approved Products MHS reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If MHS does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications The MHS OTC list covers a variety of medications. A list of covered OTC medications can be found in the Over-the-Counter Medications program document. These OTCs are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. A list of covered OTC medications in the Over-the-Counter Pharmacy Program is also located on the MHS website at www.mhsindiana.com.

Tobacco Cessation Medications The following types of tobacco cessation medications will be covered by MHS: generic nicotine replacement products (gum, lozenges, and patches), Bupropion SR 150mg (Zyban), Commit lozenges, Nicoderm, Nicorette, Nicotine gum, and Nicotine patches. Varenicline is also allowed with a PA. A prescription will be required for all tobacco cessation medications. MHS authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines, and manufacturers’ recommendations.

Generic Drugs When generic drugs are available, the brand-name drug will not be covered without prior MHS authorization. Generic drugs have the same active ingredient, work the same as brand-name drugs, and have lower copayments. If the member or their practitioner feels a brand-name drug is medically necessary, the practitioner can request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If MHS does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process.

Drug Efficacy Study and Implementation Drugs Drug Efficacy Study and Implementation (DESI) products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by MHS.

Filling a Prescription A member can have prescriptions filled at an MHS network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting MHS Member Services or by visiting www.mhsindiana.com. At the pharmacy the member will need to provide the pharmacist with the prescription and their MHS ID card.

Ordering, Prescribing and Referring (OPR) Provider Requirements To ensure compliance with Indiana Medicaid and the Center for Medicaid and Medicare Services (CMS) regulations, MHS and EPS edit pharmacy claims for the presence of a participating Medicaid provider or an enrolled ordering, prescribing, or referring (OPR) provider. All pharmacy claims must contain the NPI of the prescribing provider. All prescriptions written by a non-registered or non-OPR prescriber will result in a claim denial.

Pharmacies will be notified through claim transactions if the submitted prescribing provider is not enrolled with the Department of Community Health (DCH) as a participating provider or an ordering, prescribing or rendering provider. Pharmacies will also receive a claims message if their own store NPI is not enrolled in Indiana Medicaid.

Copayments (Copays) The table below lists the copayment for the drugs according to the actual cost of the prescription. Copayments are not required for pregnant women, family planning supplies, members in the hospital or a nursing home, or Native Americans.

Plan Type Generic /Preferred Drug Non-Preferred Drug HIP State Basic $4.00 $8.00 HIP Basic $4.00 $8.00 HIP Plus, State Plus No Cost No Cost HCC $3.00 $3.00

Generic, Single Source Multiple Source Brand Plan Type Brand, Compound Medications Medications HHW - Package A No Cost No Cost Standard Plan HHW - Package C $3.00 $10.00 CHIP

Contact Information

MHS Member & Provider Services Phone: (877) 647-4848 Fax: (866) 714-7993 TTY/TDD: (800) 743-3333

Envolve Pharmacy Solutions Prior Phone: (855) 772-7125 Authorizations Fax: (866) 399-0929

Specialty Medication Prior Authorization Fax Fax: (855) 678-6976

CVS Pharmacy Help Desk Phone: (800) 311-0557- HIP (800) 378-0779 – HCC (800) 378-0815 - HHW

AcariaHealth Specialty Medication Shipping Phone: (855) 535-1815 Questions Preferred Drug List Abbreviations Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

Abbreviation Term What it means

Tier 1 Drug Tier 1 Tier 1 drugs are preferred generic drugs. These will have the lowest plan copay if your plan has copays.

Tier 2 Drug Tier 2 Tier 2 drugs are preferred brand drugs. These will have the highest plan copay if your plan has copays.

AL Age Limit Some drugs are only covered for certain ages.

PA Prior Your doctor must ask for approval from Authorization MHS before some drugs will be covered.

QL Quantity Limit Some drugs are only covered for a certain amount.

NP Non-preferred These drugs are on formulary that may still need to meet prior authorization/class criteria before they will be covered.

RX/OTC Prescription and These drugs are made in both prescription OTC form and Over-the-counter (OTC) form.

SP Specialty Drug Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific pharmacy.

ST Step Therapy In some cases, you must first try certain drugs before MHS covers another drug for your medical condition. For example, if Drug A and Drug B both treat your medical condition, MHS may not cover Drug B unless you try Drug A first.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(3 ea daily); OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine tabs AL(At least 3 ADHD, Sleep and Eating Disorders 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- Amphetamines 2.5mg, 7.5mg-7.5mg- ADDERALL TABS (Use QL(3 ea daily); 7.5mg-7.5mg, 1.25mg- Amphetamine- NP AL(At least 3 1.25mg-1.25mg-1.25mg, 1 Dextroamphetamine) yrs old) 3.75mg-3.75mg-3.75mg- ADDERALL XR CP24 QL(1 ea daily); 3.75mg, 1.875mg- 2.5MG-2.5MG-2.5MG- AL(At least 6 1.875mg-1.875mg- 2.5MG, 1.25MG-1.25MG- yrs old) 1.875mg, 3.125mg- 1.25MG-1.25MG, 3.75MG- NP 3.125mg-3.125mg- 3.75MG-3.75MG-3.75MG 3.125mg (Use Amphetamine- DESOXYN TABS (Use NP AL(At least 6 Dextroamphetamine) Methamphetamine HCl) yrs old) ADDERALL XR CP24 QL(2 ea daily); DEXEDRINE CP24 (Use QL(2 ea daily); 5MG-5MG-5MG-5MG, AL(At least 6 Dextroamphetamine NP AL(At least 6 7.5MG-7.5MG-7.5MG- yrs old) Sulfate) yrs old) 7.5MG, 6.25MG-6.25MG- NP QL(2 ea daily); 6.25MG-6.25MG (Use dextroamphetamine sulfate 1 AL(At least 6 cp24 5 mg, 10 mg, 15 mg Amphetamine- yrs old) Dextroamphetamine) QL(40 ml QL(16 ml dextroamphetamine sulfate 1 daily); AL(At soln 5 mg/5ml ADZENYS ER SUER 2 daily); AL(At least 3 yrs old) least 6 yrs old) QL(4 ea daily); QL(1 ea daily); dextroamphetamine sulfate 1 AL(At least 3 tabs 10 mg ADZENYS XR-ODT TBED 2 AL(At least 6 yrs old) yrs old) QL(1 ea daily); QL(6 ea daily); dextroamphetamine sulfate 1 AL(At least 3 amphetamine sulfate tabs 1 AL(At least 3 tabs 5 mg 10 mg yrs old) yrs old) QL(8 ml daily); QL(1 ea daily); DYANAVEL XR SUER 2 AL(At least 6 amphetamine sulfate tabs 1 AL(At least 3 5 mg yrs old) yrs old) QL(6 ea daily); amphetamine- QL(1 ea daily); EVEKEO TABS 10 MG NP AL(At least 3 (Use Amphetamine Sulfate) dextroamphetamine cp24 AL(At least 6 yrs old) 2.5mg-2.5mg-2.5mg- 1 yrs old) 2.5mg, 1.25mg-1.25mg- QL(1 ea daily); EVEKEO TABS 5 MG (Use NP AL(At least 3 1.25mg-1.25mg, 3.75mg- Amphetamine Sulfate) 3.75mg-3.75mg-3.75mg yrs old) AL(At least 6 amphetamine- QL(2 ea daily); methamphetamine hcl tabs 1 dextroamphetamine cp24 AL(At least 6 yrs old) QL(1 ea daily); 5mg-5mg-5mg-5mg, 1 yrs old) 7.5mg-7.5mg-7.5mg- MYDAYIS CP24 2 AL(At least 18 7.5mg, 6.25mg-6.25mg- yrs old) 6.25mg-6.25mg PROCENTRA SOLN (Use QL(40 ml Dextroamphetamine NP daily); AL(At Sulfate) least 3 yrs old)

MHS Indiana Preferred Drug List Updated December 1, 2018

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); CONCERTA TBCR 18 MG, QL(1 ea daily); VYVANSE CAPS 2 AL(At least 6 27 MG (Use NP AL(At least 6 yrs old) Methylphenidate HCl) yrs old) QL(1 ea daily); CONCERTA TBCR 36 MG, QL(2 ea daily); VYVANSE CHEW 2 AL(At least 6 54 MG (Use NP AL(At least 6 yrs old) Methylphenidate HCl) yrs old) QL(1 ea daily); COTEMPLA XR-ODT QL(2 ea daily); ZENZEDI TABS 15 MG, 2 AL(At least 3 2 AL(At least 6 2.5 MG TBED 17.3 MG, 25.9 MG yrs old) yrs old) QL(2 ea daily); COTEMPLA XR-ODT QL(1 ea daily); ZENZEDI TABS 20 MG, 30 2 AL(At least 3 2 AL(At least 6 MG, 7.5 MG TBED 8.6 MG yrs old) yrs old) Analeptics QL(1 ea daily); 2 Use QL(45 ml per DAYTRANA PTCH AL(At least 6 CAFCIT SOLN ( NP yrs old) Caffeine Citrate) fill retail) dexmethylphenidate hcl QL(1 ea daily); 1 QL(45 ml per caffeine citrate soln fill retail) cp24 5 mg, 10 mg, 15 mg, 1 AL(At least 6 20 mg, 25 mg, 30 mg, 35 yrs old) DOPRAM SOLN 2 mg, 40 mg QL(4 ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) dexmethylphenidate hcl 1 AL(At least 3 tabs 10 mg yrs old) atomoxetine hcl caps 10 1 QL(2 ea daily) mg, 18 mg, 25 mg, 40 mg QL(2 ea daily); dexmethylphenidate hcl 1 AL(At least 3 atomoxetine hcl caps 60 1 QL(1 ea daily) tabs 5 mg, 2.5 mg mg, 80 mg, 100 mg yrs old) clonidine hcl (adhd) tb12 1 QL(4 ea daily) FOCALIN TABS 10 MG QL(4 ea daily); (Use Dexmethylphenidate NP AL(At least 3 HCl) yrs old) guanfacine hcl (adhd) tb24 1 QL(1 ea daily) FOCALIN TABS 5 MG, 2.5 QL(2 ea daily); INTUNIV TB24 (Use NP QL(1 ea daily) MG (Use NP AL(At least 3 Guanfacine HCl (ADHD)) Dexmethylphenidate HCl) yrs old) KAPVAY TB12 (Use NP QL(4 ea daily) QL(1 ea daily); Clonidine HCl (ADHD)) FOCALIN XR CP24 (Use NP Dexmethylphenidate HCl) AL(At least 6 STRATTERA CAPS 10 QL(2 ea daily) yrs old) MG, 18 MG, 25 MG, 40 MG NP QL(1 ea daily); (Use Atomoxetine HCl) METADATE CD CPCR NP AL(At least 6 (Use Methylphenidate HCl) STRATTERA CAPS 60 QL(1 ea daily) yrs old) MG, 80 MG, 100 MG (Use NP METHYLIN CHEW 5 MG, QL(3 ea daily); Atomoxetine HCl) 10 MG, 2.5 MG (Use NP AL(At least 3 Methylphenidate HCl) yrs old) Stimulants - Misc. QL(1 ea daily); METHYLIN SOLN 10 QL(30 ml APTENSIO XR CP24 2 AL(At least 6 MG/5ML (Use NP daily); AL(At yrs old) Methylphenidate HCl) least 3 yrs old) METHYLIN SOLN 5 QL(60 ml armodafinil tabs 150 mg, 1 QL(1 ea daily) 200 mg, 250 mg MG/5ML (Use NP daily); AL(At Methylphenidate HCl) least 3 yrs old) armodafinil tabs 50 mg 1 QL(2 ea daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea daily); PROVIGIL TABS 100 MG NP QL(1 ea daily) methylphenidate hcl chew 1 AL(At least 3 ) 5 mg, 10 mg, 2.5 mg (Use Modafinil yrs old) PROVIGIL TABS 200 MG NP QL(2 ea daily) QL(1 ea daily); (Use Modafinil) methylphenidate hcl cp24 1 AL(At least 6 10 mg, 20 mg, 40 mg QL(1 ea daily); yrs old) QUILLICHEW ER CHER 2 20 MG, 40 MG AL(At least 6 QL(2 ea daily); yrs old) methylphenidate hcl cp24 1 AL(At least 6 30 mg QL(2 ea daily); yrs old) QUILLICHEW ER CHER 2 30 MG AL(At least 6 methylphenidate hcl cpcr QL(1 ea daily); yrs old) 10 mg, 20 mg, 30 mg, 40 1 AL(At least 6 QL(12 ml mg, 50 mg, 60 mg yrs old) QUILLIVANT XR SUSR 2 daily); AL(At QL(30 ml least 6 yrs old) methylphenidate hcl soln 1 daily); AL(At 10 mg/5ml RITALIN LA CP24 10 MG, QL(1 ea daily); least 3 yrs old) 20 MG, 40 MG (Use NP AL(At least 6 QL(60 ml Methylphenidate HCl) yrs old) methylphenidate hcl soln 5 1 daily); AL(At mg/5ml QL(2 ea daily); least 3 yrs old) RITALIN LA CP24 30 MG NP AL(At least 6 (Use Methylphenidate HCl) QL(3 ea daily); yrs old) methylphenidate hcl tabs 5 1 AL(At least 3 mg, 10 mg, 20 mg QL(3 ea daily); yrs old) RITALIN TABS (Use NP Methylphenidate HCl) AL(At least 3 QL(3 ea daily); yrs old) methylphenidate hcl tbcr 10 1 AL(At least 6 mg, 20 mg yrs old) ALLERGENIC EXTRACTS/BIOLOGICALS MISC QL(1 ea daily); Allergenic Extracts methylphenidate hcl tbcr 18 1 AL(At least 6 mg, 27 mg, 72 mg yrs old) QL(1 ea daily); ORALAIR ADULT SAMPLE 2 AL(At least 10 QL(2 ea daily); KIT SUBL yrs old - Up to methylphenidate hcl tbcr 36 1 AL(At least 6 mg, 54 mg 65 yrs old) yrs old) QL(1 ea daily); METHYLPHENIDATE QL(1 ea daily); ORALAIR ADULT 2 AL(At least 10 HYDROCHLORIDE ER 2 AL(At least 6 STARTER PACK SUBL yrs old - Up to (LA) CP24 yrs old) 65 yrs old) METHYLPHENIDATE QL(1 ea daily); QL(3 ea daily); HYDROCHLORIDE ER 2 AL(At least 6 ORALAIR 2 AL(At least 10 TB24 18 MG, 27 MG yrs old) CHILDREN/ADOLESCENT yrs old - Up to S STARTER PACK SUBL METHYLPHENIDATE QL(2 ea daily); 65 yrs old) HYDROCHLORIDE ER 2 AL(At least 6 QL(1 ea daily); TB24 36 MG, 54 MG yrs old) AL(At least 10 ORALAIR SUBL 2 modafinil tabs 100 mg 1 QL(1 ea daily) yrs old - Up to 65 yrs old) QL(2 ea daily) modafinil tabs 200 mg 1 ALTERNATIVE MEDICINES NUVIGIL TABS 150 MG, QL(1 ea daily) Alternative Medicine - M's 200 MG, 250 MG (Use NP Armodafinil) CVS MELATONIN CHEW 2 NUVIGIL TABS 50 MG NP QL(2 ea daily) (Use Armodafinil) MHS Indiana Preferred Drug List Updated December 1, 2018

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MELATONIN CAPS OR 1 2 Anti-TNF-alpha - Monoclonal Antibodies MG, 2.5 MG HUMIRA PEDIATRIC PA; SP melatonin caps or 3 mg, 5 1 CROHNS DISEASE 2 mg, 10 mg STARTER PACK PSKT 40 melatonin chew or 2.5 mg 1 MG/0.8ML HUMIRA PEN PNKT 40 2 PA; SP melatonin liqd or 1 mg/ml, 1 MG/0.8ML 5 mg/15ml HUMIRA PEN-CD/UC/HS PA; SP MELATONIN LIQD OR 5 STARTER PNKT 40 2 MG/ML, 1 MG/4ML, 2.5 2 MG/0.8ML MG/10ML HUMIRA PEN-PS/UV 2 PA; SP melatonin tabs or 1 mg, 10 1 STARTER PNKT mg, 300 mcg HUMIRA PSKT 10 PA; SP MELATONIN TABS OR 2 MG/0.2ML, 20 MG/0.4ML, 2 200 MCG 40 MG/0.8ML melatonin tabs or 3 mg, 5 1 QL(1 ea daily) PA; SP mg SIMPONI ARIA SOLN 2 SLEEP SOUNDLY LIQD 2 SIMPONI SOAJ 2 PA; SP

AMINOGLYCOSIDES - Drugs to Treat Bacterial SIMPONI SOSY 2 PA; SP Infections Aminoglycosides Antirheumatic - Enzyme Inhibitors PA; SP BETHKIS NEBU 2 PA; SP XELJANZ TABS 5 MG 2 PA; SP KITABIS PAK NEBU 2 PA; SP XELJANZ XR TB24 2 Antirheumatic Antimetabolites neomycin sulfate tabs 1 OTREXUP SOAJ 2 PA; SP TOBI NEBU (Use NP PA; SP Tobramycin) RASUVO SOAJ 2 PA; SP TOBI PODHALER CAPS 2 PA; SP Interleukin-1 Blockers PA; SP TOBRAMYCIN NEBU 2 ARCALYST SOLR 2 PA; SP PA; SP tobramycin nebu 1 Interleukin-1 Receptor Antagonist (IL-1Ra) TOBRAMYCIN SULFATE PA KINERET SOSY 2 PA; SP SOLN 10 MG/ML, 40 2 MG/ML Interleukin-6 Receptor Inhibitors tobramycin sulfate soln 40 PA ACTEMRA SOLN 2 PA; SP mg/ml, 80 mg/2ml, 1.2 1 gm/30ml ACTEMRA SOSY 2 PA; SP tobramycin sulfate solr 1.2 1 PA gm Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANALGESICS - ANTI-INFLAMMATORY - Drugs ADVIL TABS (Use NP to Treat Pain, Swelling, Muscle and Joint Ibuprofen) Conditions MHS Indiana Preferred Drug List Updated December 1, 2018

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALEVE ARTHRITIS TABS NP QL(2 ea daily) INFANTS ADVIL SUSP NP (Use Naproxen Sodium) (Use Ibuprofen) ALEVE TABS (Use NP QL(2 ea daily) ketoprofen caps 50 mg, 75 1 Naproxen Sodium) mg ANAPROX DS TABS (Use NP KETOPROFEN CAPS 50 2 Naproxen Sodium) MG, 75 MG CELEBREX CAPS (Use NP PA; QL(2 ea KETOPROFEN ER CP24 2 Celecoxib) daily) PA; QL(2 ea QL(0.67 ea celecoxib caps 1 daily) ketorolac tromethamine 1 daily); AL(At tabs or 10 mg least 17 yrs CHILDRENS ADVIL SUSP NP RX/OTC (Use Ibuprofen) old) LODINE TABS (Use CHILDRENS MOTRIN NP RX/OTC NP SUSP (Use Ibuprofen) Etodolac) meloxicam tabs 1 DAYPRO TABS (Use NP Oxaprozin) MOBIC TABS (Use NP diclofenac potassium tabs 1 Meloxicam) MOTRIN INFANTS diclofenac sodium tb24 or 1 100 mg DROPS SUSP (Use NP Ibuprofen) diclofenac sodium tbec or 1 25 mg, 50 mg, 75 mg nabumetone tabs 1 EC-NAPROSYN TBEC QL(2 ea daily) NP NAPROSYN SUSP (Use NP (Use Naproxen) Naproxen) etodolac caps 1 NAPROSYN TABS (Use NP Naproxen) etodolac tabs 1 naproxen sodium tabs 220 1 QL(2 ea daily) mg etodolac tb24 1 naproxen sodium tabs 275 1 mg, 550 mg FELDENE CAPS (Use NP Piroxicam) naproxen susp 125 mg/5ml 1 flurbiprofen tabs 1 naproxen tabs 250 mg, 375 1 mg, 500 mg ibuprofen chew 100 mg 1 naproxen tbec 375 mg, 500 1 QL(2 ea daily) mg ibuprofen susp 100 mg/5ml 1 RX/OTC oxaprozin tabs 1 ibuprofen susp 40 mg/ml, 1 50 mg/1.25ml piroxicam caps 1 ibuprofen tabs 200 mg, 400 1 mg, 600 mg, 800 mg sulindac tabs 1 indomethacin caps 1 Phosphodiesterase 4 (PDE4) Inhibitors indomethacin cpcr 1 OTEZLA TABS 2 PA; SP

MHS Indiana Preferred Drug List Updated December 1, 2018

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OTEZLA TBPK 2 PA; SP acetaminophen caps or 1 500 mg Pyrimidine Synthesis Inhibitors acetaminophen chew or 80 1 mg, 160 mg ARAVA TABS (Use NP QL(1 ea daily) Leflunomide) acetaminophen liqd or 160 1 mg/5ml leflunomide tabs 1 QL(1 ea daily) acetaminophen soln or 160 Selective Costimulation Modulators mg/5ml, 650 mg/20.3ml, 1 325 mg/10.15ml ORENCIA CLICKJECT 2 PA; SP SOAJ acetaminophen supp re 1 QL(0.4 ea 120 mg, 325 mg, 650 mg daily) ORENCIA SOLR 2 PA; SP acetaminophen susp or 1 QL(240 ml per 160 mg/5ml, 80 mg/2.5ml fill retail) ORENCIA SOSY 2 PA; SP acetaminophen tabs or 325 1 mg, 500 mg Soluble Tumor Necrosis Factor Receptor Agents PA; SP FEVERALL INFANTS 2 ENBREL SOLR 2 SUPP TYLENOL CHILDRENS ENBREL SOSY 2 PA; SP CHEWABLES/PAIN + NP FEVER CHEW (Use ENBREL SURECLICK 2 PA; SP SOAJ Acetaminophen) TYLENOL CHILDRENS QL(240 ml per ANALGESICS - NonNarcotic - Drugs to Treat SUSP (Use NP fill retail) Pain, Muscle and Joint Conditions Acetaminophen) Analgesic Combinations TYLENOL EXTRA STRENGTH TABS (Use NP butalbital-acetaminophen 1 tabs 325mg-50mg Acetaminophen) butalbital-acetaminophen- QL(4 ea daily) TYLENOL INFANTS QL(240 ml per caffeine caps 325mg- 1 PAIN+FEVER SUSP (Use NP fill retail) 50mg-40mg Acetaminophen) butalbital-acetaminophen- QL(4 ea daily) TYLENOL INFANTS SUSP NP QL(240 ml per caffeine tabs 325mg-50mg- 1 (Use Acetaminophen) fill retail) 40mg TYLENOL TABS (Use NP Acetaminophen) butalbital-aspirin-caffeine 1 QL(4 ea daily) caps Analgesics-Peptide Channel Blockers BUTALBITAL/ASPIRIN/CA 2 QL(4 ea daily) PA; SP FFEINE TABS PRIALT SOLN 2 ESGIC TABS (Use QL(4 ea daily) Salicylates Butalbital-Acetaminophen- NP Caffeine) aspirin buffered (cal carb- 1 mag carb-mag oxide) tabs FIORINAL CAPS (Use NP QL(4 ea daily) Butalbital-Aspirin-Caffeine) aspirin chew or 81 mg $0 PV TENCON TABS 2 ASPIRIN SUPP RE 300 2 QL(0.4 ea MG, 600 MG daily) Analgesics Other aspirin supp re 300 mg, 1 QL(0.4 ea 600 mg daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aspirin tabs or 325 mg $0 PV hydromorphone hcl tabs or 1 QL(4 ea daily) 8 mg aspirin tbec or 81 mg, 324 PV $0 MEPERIDINE HCL SOLN 2 mg, 325 mg OR 50 MG/5ML BUFFERIN TABS (Use meperidine hcl tabs or 100 1 QL(6 ea daily) Aspirin Buffered (Cal Carb- NP mg Mag Carb-Mag Oxide)) meperidine hcl tabs or 50 1 QL(12 ea daily) diflunisal tabs 1 mg methadone hcl tabs or 5 1 PA DISALCID TABS (Use NP mg, 10 mg Salsalate) morphine sulfate soln or 10 1 QL(30 ml daily) ECOTRIN REGULAR PV mg/5ml STRENGTH TBEC (Use NP Aspirin) morphine sulfate soln or 20 1 QL(15 ml daily) mg/5ml salsalate tabs 1 morphine sulfate soln or 20 1 QL(240 ml per mg/ml, 100 mg/5ml fill retail) ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions MORPHINE SULFATE 2 QL(6 ea daily) SUPP RE 10 MG Opioid Agonists MORPHINE SULFATE 2 QL(3 ea daily) codeine sulfate tabs 15 mg, 1 AL(At least 12 SUPP RE 20 MG 30 mg, 60 mg yrs old) MORPHINE SULFATE 2 QL(2 ea daily) CODEINE SULFATE TABS AL(At least 12 SUPP RE 30 MG 15 MG, 30 MG, 60 MG NP yrs old) MORPHINE SULFATE 2 QL(12 ea daily) (Use Codeine Sulfate) SUPP RE 5 MG DEMEROL TABS OR 100 QL(6 ea daily) NP MORPHINE SULFATE 2 QL(6 ea daily) MG (Use Meperidine HCl) TABS OR 15 MG, 30 MG DILAUDID TABS OR 2 MG NP QL(8 ea daily) morphine sulfate tbcr or 15 QL(3 ea daily) (Use Hydromorphone HCl) mg, 30 mg, 60 mg, 100 mg, 1 DILAUDID TABS OR 4 MG NP 200 mg (Use Hydromorphone HCl) MS CONTIN TBCR (Use NP QL(3 ea daily) DILAUDID TABS OR 8 MG NP QL(4 ea daily) Morphine Sulfate) (Use Hydromorphone HCl) NUCYNTA ER TB12 2 PA DOLOPHINE TABS (Use NP PA Methadone HCl) NUCYNTA TABS 2 PA DURAGESIC PT72 (Use NP QL(0.34 ea Fentanyl) daily) oxycodone hcl caps 5 mg 1 QL(8 ea daily) fentanyl pt72 12 mcg/hr, 25 QL(0.34 ea mcg/hr, 50 mcg/hr, 75 1 daily) oxycodone hcl conc 100 1 QL(120 ml per mcg/hr, 100 mcg/hr mg/5ml fill retail) oxycodone hcl soln 5 QL(30 ml daily) HYDROMORPHONE HCL 2 QL(2 ea daily) 1 SUPP RE 3 MG mg/5ml oxycodone hcl tabs 10 mg, QL(6 ea daily) hydromorphone hcl tabs or 1 QL(8 ea daily) 1 2 mg 15 mg, 20 mg, 30 mg QL(8 ea daily) hydromorphone hcl tabs or 1 oxycodone hcl tabs 5 mg 1 4 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROXICODONE TABS 15 QL(6 ea daily) NORCO TABS 10MG- QL(6 ea daily) MG, 30 MG (Use NP 325MG (Use Hydrocodone- NP Oxycodone HCl) Acetaminophen) ROXICODONE TABS 5 NP QL(8 ea daily) NORCO TABS 5MG- QL(12 ea daily) MG (Use Oxycodone HCl) 325MG (Use Hydrocodone- NP QL(8 ea daily); Acetaminophen) tramadol hcl tabs 50 mg 1 AL(At least 18 NORCO TABS 7.5MG- QL(8 ea daily) yrs old) 325MG (Use Hydrocodone- NP QL(8 ea daily); Acetaminophen) ULTRAM TABS (Use NP QL(6 ea daily) Tramadol HCl) AL(At least 18 oxycodone w/ yrs old) acetaminophen tabs 10mg- 1 325mg, 7.5mg-325mg Opioid Combinations oxycodone w/ QL(8 ea daily) QL(167 ml 1 daily); AL(At acetaminophen tabs 5mg- acetaminophen w/ codeine 1 325mg soln 120mg/5ml-12mg/5ml least 12 yrs old) oxycodone-aspirin tabs 1 QL(6 ea daily) QL(13 ea acetaminophen w/ codeine OXYCODONE/ACETAMIN QL(16.67 ml 1 daily); AL(At 2 tabs 300mg-15mg, 300mg- least 12 yrs OPHEN SOLN daily) 30mg old) PERCOCET TABS 10MG- QL(6 ea daily) QL(7 ea daily); 325MG, 7.5MG-325MG NP acetaminophen w/ codeine 1 AL(At least 12 (Use Oxycodone w/ tabs 300mg-60mg yrs old) Acetaminophen) butalbital-acetaminophen- QL(4 ea daily); PERCOCET TABS 5MG- QL(8 ea daily) caffeine w/ codeine caps 1 AL(At least 12 325MG (Use Oxycodone w/ NP 325mg-50mg-40mg-30mg yrs old) Acetaminophen) QL(8 ea daily); QL(4 ea daily); tramadol-acetaminophen butalbital-aspirin-caffeine 1 AL(At least 12 1 AL(At least 18 w/cod caps tabs yrs old) yrs old) FIORINAL/CODEINE #3 QL(4 ea daily); TYLENOL/CODEINE #3 QL(13 ea CAPS (Use Butalbital- NP AL(At least 12 TABS (Use Acetaminophen NP daily); AL(At Aspirin-Caffeine w/Cod) yrs old) w/ Codeine) least 12 yrs old) hydrocodone- QL(180 ml acetaminophen soln daily) TYLENOL/CODEINE #4 QL(7 ea daily); 2.5mg/5ml-108mg/5ml, 1 TABS (Use Acetaminophen NP AL(At least 12 5mg/10ml-217mg/10ml, w/ Codeine) yrs old) 7.5mg/15ml-325mg/15ml QL(8 ea daily); ULTRACET TABS (Use NP hydrocodone- QL(6 ea daily) Tramadol-Acetaminophen) AL(At least 18 acetaminophen tabs 10mg- 1 yrs old) 325mg Opioid Partial Agonists hydrocodone- QL(12 ea daily) buprenorphine hcl subl sl 2 1 QL(3 ea daily) acetaminophen tabs 5mg- 1 mg, 8 mg 325mg buprenorphine hcl- 1 QL(3 ea daily) hydrocodone- QL(8 ea daily) naloxone hcl dihydrate subl acetaminophen tabs 1 7.5mg-325mg ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Androgens MHS Indiana Preferred Drug List Updated December 1, 2018

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANDRODERM PT24 2 QL(1 ea daily) Antacid Combinations alum & mag hydrox- ANDROXY TABS 2 simethicone chew 200mg- 1 25mg-200mg QL(4 ea daily) danazol caps 200 mg 1 alum & mag hydrox- QL(24 ml daily) simethicone liqd danazol caps 50 mg, 100 1 QL(2 ea daily) 1 mg 200mg/5ml-20mg/5ml- 200mg/5ml DEPO-TESTOSTERONE QL(0.134 ml SOLN 200 MG/ML (Use NP daily) alum & mag hydrox- Testosterone Cypionate) simethicone liqd 1 400mg/5ml-40mg/5ml- METHITEST TABS 2 400mg/5ml alum & mag hydrox- QL(24 ml daily) TESTOSTERONE QL(0.134 ml simethicone susp CYPIONATE SOLN 200 2 daily) 200mg/5ml-20mg/5ml- MG/ML 200mg/5ml, 200mg/5ml- 1 testosterone cypionate soln 1 QL(0.134 ml 200mg/5ml-20mg/5ml- 200 mg/ml daily) 20mg/5ml-200mg/5ml- ANORECTAL AGENTS - Rectal Drugs to Treat 200mg/5ml Pain, Swelling and Itching alum & mag hydrox- simethicone susp Intrarectal Steroids 400mg/5ml-40mg/5ml- CORTENEMA ENEM (Use 400mg/5ml, 400mg/5ml- 1 Hydrocortisone NP 400mg/5ml-40mg/5ml- (Intrarectal)) 40mg/5ml-400mg/5ml- 400mg/5ml hydrocortisone (intrarectal) 1 enem GELUSIL CHEW (Use Rectal Combinations Alum & Mag Hydrox- NP Simethicone) phenylephrine in hard fat 1 supp HYVEE ADVANCED ANTACID MAXIMUM phenylephrine-cocoa butter 1 STRENGTH SUSP (Use NP supp 88.44%-0.25% Alum & Mag Hydrox- phenylephrine-shark liver QL(1 gm daily) Simethicone) oil-mineral oil-petrolatum 1 oint Antacids - Aluminum Salts ALUMINUM HYDROXIDE 2 Rectal Local Anesthetics SUSP OR QL(1 gm daily) dibucaine (rectal) oint 1 Antacids - Bicarbonate sodium bicarbonate QL(16.54 ea NUPERCAINAL OINT (Use NP QL(1 gm daily) 1 Dibucaine (Rectal)) (antacid) tabs daily) Rectal Steroids Antacids - Calcium Salts calcium carbonate (antacid) ANUSOL-HC CREA (Use NP Hydrocortisone (Rectal)) chew 500 mg, 750 mg, 1 1000 mg hydrocortisone (rectal) crea 1 2.5 % calcium carbonate (antacid) 1 QL(16.67 ml susp 1250 mg/5ml daily) ANTACIDS

MHS Indiana Preferred Drug List Updated December 1, 2018

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUMS CHEW (Use metronidazole tabs or 250 1 Calcium Carbonate NP mg, 500 mg (Antacid)) trimethoprim tabs 1 TUMS CHEWY BITES CHEW (Use Calcium NP Anti-infective Misc. - Combinations Carbonate (Antacid)) BACTRIM DS TABS (Use TUMS E-X 750 CHEW Sulfamethoxazole- NP (Use Calcium Carbonate NP Trimethoprim) (Antacid)) BACTRIM TABS (Use TUMS EXTRA STRENGTH Sulfamethoxazole- NP 750 CHEW (Use Calcium NP Trimethoprim) Carbonate (Antacid)) sulfamethoxazole- TUMS KIDS CHEW (Use trimethoprim susp or 1 Calcium Carbonate NP 40mg/5ml-200mg/5ml (Antacid)) sulfamethoxazole- TUMS LASTING EFFECTS trimethoprim tabs or 80mg- 1 CHEW (Use Calcium NP 400mg, 160mg-800mg Carbonate (Antacid)) TUMS SMOOTHIES Glycopeptides QL(300 ml per CHEW (Use Calcium NP FIRVANQ SOLR 2 Carbonate (Antacid)) fill retail) TUMS ULTRA 1000 CHEW VANCOCIN HCL CAPS QL(4 ea daily) (Use Calcium Carbonate NP 125 MG (Use Vancomycin NP (Antacid)) HCl) Antacids - Magnesium Salts VANCOCIN HCL CAPS QL(8 ea daily) 250 MG (Use Vancomycin NP magnesium oxide tabs 400 1 HCl) mg vancomycin hcl caps or 1 QL(4 ea daily) ANTHELMINTICS - Drugs to Treat Worm 125 mg Infections vancomycin hcl caps or 1 QL(8 ea daily) Anthelmintics 250 mg vancomycin hcl solr iv 1 QL(14 ea per EMVERM CHEW 2 QL(1 ea per 14 1 days retail) gm, 1000 mg fill retail) ANTI-INFECTIVE AGENTS - MISC. - Drugs to vancomycin hcl solr iv 500 1 QL(0.467 ea Treat Bacterial Infections mg daily) Anti-infective Agents - Misc. Leprostatics dapsone tabs 1 FIRST-METRONIDAZOLE 2 QL(150 ml per 100 SUSR fill retail) Lincosamides FIRST-METRONIDAZOLE 2 QL(150 ml per 50 SUSR fill retail) CLEOCIN CAPS OR 150 FLAGYL TABS 250 MG, MG, 300 MG (Use NP 500 MG (Use NP Clindamycin HCl) Metronidazole) CLEOCIN PEDIATRIC QL(300 ml per METRONIDAZOLE QL(150 ml per GRANULES SOLR (Use NP fill retail) BENZOATE/SYRSPEND 2 fill retail) Clindamycin Palmitate SF PH4 SUSR Hydrochloride)

MHS Indiana Preferred Drug List Updated December 1, 2018

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin hcl caps 150 1 droperidol soln ij 1 mg, 300 mg HYDROXYZINE HCL clindamycin palmitate 1 QL(300 ml per 2 hydrochloride solr fill retail) SOLN IM 25 MG/ML Oxazolidinones hydroxyzine hcl soln im 50 1 mg/ml PA; QL(6 ea SIVEXTRO TABS OR 2 per fill retail) hydroxyzine hcl syrp or 10 1 QL(100 ml mg/5ml daily) ANTIANGINAL AGENTS - Drugs to Treat Chest hydroxyzine hcl tabs or 10 1 QL(4 ea daily) Pain mg, 25 mg Nitrates hydroxyzine hcl tabs or 50 1 QL(8 ea daily) ISORDIL TITRADOSE mg TABS 5 MG (Use NP HYDROXYZINE QL(4 ea daily) Isosorbide Dinitrate) PAMOATE CAPS OR 100 2 MG ISOSORBIDE DINITRATE 2 ER TBCR hydroxyzine pamoate caps 1 QL(4 ea daily) or 25 mg, 50 mg isosorbide dinitrate tabs 1 HYDROXYZINE 2 isosorbide mononitrate 1 QL(2 ea daily) PAMOATE POWD XX tabs 10 mg, 20 mg meprobamate tabs 1 QL(4 ea daily) isosorbide mononitrate 1 QL(1 ea daily) tb24 30 mg, 60 mg, 120 mg VISTARIL CAPS (Use NP QL(4 ea daily) Hydroxyzine Pamoate) NITRO-BID OINT 2 Benzodiazepines NITRO-DUR PT24 0.1 ALPRAZOLAM INTENSOL QL(4 ml daily) MG/HR, 0.2 MG/HR, 0.4 NP 2 MG/HR, 0.6 MG/HR (Use CONC Nitroglycerin) alprazolam tabs or 0.25 1 QL(4 ea daily) mg, 0.5 mg, 1 mg, 2 mg nitroglycerin cpcr or 9 mg, 1 2.5 mg, 6.5 mg alprazolam tb24 or 0.5 mg, 1 QL(1 ea daily) nitroglycerin pt24 td 0.1 1 mg, 2 mg, 3 mg mg/hr, 0.2 mg/hr, 0.4 1 alprazolam tbdp or 0.25 1 QL(4 ea daily) mg/hr, 0.6 mg/hr mg, 0.5 mg, 1 mg, 2 mg ATIVAN SOLN IJ 2 nitroglycerin subl sl 0.3 mg, 1 0.4 mg, 0.6 mg MG/ML, 4 MG/ML (Use NP Lorazepam) NITROSTAT SUBL (Use NP Nitroglycerin) ATIVAN TABS OR 0.5 MG, QL(4 ea daily) 1 MG, 2 MG (Use NP ANTIANXIETY AGENTS - Drugs to Treat Anxiety Lorazepam) QL(4 ea daily) Antianxiety Agents - Misc. chlordiazepoxide hcl caps 1 buspirone hcl tabs or 30 QL(2 ea daily) 1 clorazepate dipotassium 1 QL(4 ea daily) mg tabs buspirone hcl tabs or 5 mg, 1 QL(3 ea daily) QL(8 ml daily) 10 mg, 15 mg, 7.5 mg diazepam conc or 5 mg/ml 1 DROPERIDOL POWD XX 2 DIAZEPAM SOLN IJ 5 2 MG/ML

MHS Indiana Preferred Drug List Updated December 1, 2018

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIAZEPAM SOLN OR 5 2 Antiarrhythmics Type III MG/5ML amiodarone hcl tabs or 200 1 diazepam tabs or 2 mg, 5 1 QL(4 ea daily) mg mg, 10 mg dofetilide caps 1 lorazepam conc or 2 mg/ml 1 TIKOSYN CAPS (Use NP lorazepam soln ij 2 mg/ml, 1 Dofetilide) 4 mg/ml, 20 mg/10ml ANTIASTHMATIC AND BRONCHODILATOR lorazepam tabs or 0.5 mg, 1 QL(4 ea daily) AGENTS - Drugs to Treat Lung Conditions 1 mg, 2 mg Anti-Inflammatory Agents oxazepam caps 10 mg, 15 1 QL(4 ea daily) mg, 30 mg cromolyn sodium nebu 1 QL(8 ml daily) OXAZEPAM CAPS 30 MG 2 QL(4 ea daily) Antiasthmatic - Monoclonal Antibodies TRANXENE T TABS (Use NP QL(4 ea daily) PA; SP Clorazepate Dipotassium) NUCALA SOLR 2 VALIUM TABS (Use NP QL(4 ea daily) XOLAIR SOLR 150 MG 2 PA; SP Diazepam) XANAX TABS (Use NP QL(4 ea daily) Bronchodilators - Anticholinergics Alprazolam) QL(0.86 gm ATROVENT HFA AERS 2 XANAX XR TB24 (Use NP QL(1 ea daily) daily) Alprazolam) INCRUSE ELLIPTA AEPB 2 ANTIARRHYTHMICS - Drugs to treat abnormal QL(12.5 ml heart rhythms ipratropium bromide soln 1 daily) Antiarrhythmics Type I-A SPIRIVA HANDIHALER 2 disopyramide phosphate 1 CAPS caps TUDORZA PRESSAIR 2 QL(0.034 ea NORPACE CAPS (Use 2 AEPB daily) Disopyramide Phosphate) Leukotriene Modulators NORPACE CR CP12 150 2 MG montelukast sodium chew 1 QL(1 ea daily) quinidine gluconate tbcr or 1 324 mg montelukast sodium pack 1 QL(1 ea daily) QUINIDINE SULFATE 2 TABS montelukast sodium tabs 1 QL(1 ea daily) Antiarrhythmics Type I-B SINGULAIR CHEW (Use NP QL(1 ea daily) Montelukast Sodium) mexiletine hcl caps 1 SINGULAIR PACK (Use NP QL(1 ea daily) Antiarrhythmics Type I-C Montelukast Sodium) SINGULAIR TABS (Use NP QL(1 ea daily) flecainide acetate tabs 1 Montelukast Sodium) propafenone hcl tabs 150 1 Steroid Inhalants mg, 225 mg, 300 mg QL(0.6 gm AEROSPAN AERS 2 RYTHMOL TABS (Use 2 daily) Propafenone HCl)

MHS Indiana Preferred Drug List Updated December 1, 2018

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(120 ml per METAPROTERENOL budesonide (inhalation) 2 1 fill retail); SULFATE TABS 10 MG, susp 0.25 mg/2ml, 0.5 AL(Up to 8 yrs 20 MG mg/2ml old ) SEREVENT DISKUS 2 QL(2 ml daily); AEPB budesonide (inhalation) 1 AL(Up to 8 yrs susp 1 mg/2ml SYMBICORT AERO 2 QL(11 gm per old ) fill retail) QL(2 ea daily) FLOVENT DISKUS AEPB 2 terbutaline sulfate tabs or 5 1 mg, 2.5 mg FLOVENT HFA AERO 110 2 QL(0.4 gm Limit 2 per MCG/ACT, 220 MCG/ACT daily) month;QL(36 VENTOLIN HFA AERS 2 FLOVENT HFA AERO 44 2 QL(0.367 gm gm per 30 days MCG/ACT daily) retail) PULMICORT FLEXHALER 2 QL(1 ea per fill Limit 2 per AEPB retail) month;QL(16 VENTOLIN HFA AERS 2 PULMICORT SUSP 0.25 QL(120 ml per gm per 30 days retail) MG/2ML, 0.5 MG/2ML NP fill retail); (Use Budesonide AL(Up to 8 yrs VOSPIRE ER TB12 (Use NP (Inhalation)) old ) Albuterol Sulfate) PULMICORT SUSP 1 QL(2 ml daily); Xanthines MG/2ML (Use Budesonide NP AL(Up to 8 yrs (Inhalation)) old ) ELIXOPHYLLIN ELIX 2 Sympathomimetics THEO-24 CP24 2 ALBUTEROL SULFATE 2 ER TB12 theophylline soln 80 1 QL(475 ml per mg/15ml fill retail) albuterol sulfate nebu in 1 0.5 % theophylline tb12 100 mg, 1 albuterol sulfate nebu in QL(12.5 ml 200 mg, 300 mg, 450 mg 0.63 mg/3ml, 0.083 %, 1.25 1 daily) theophylline tb24 400 mg, 1 mg/3ml 600 mg albuterol sulfate syrp or 2 1 mg/5ml ANTICOAGULANTS - Blood Thinners albuterol sulfate tabs or 2 1 Coumarin Anticoagulants mg, 4 mg COUMADIN TABS (Use 2 albuterol sulfate tb12 or 4 1 Warfarin Sodium) mg, 8 mg warfarin sodium tabs 1 COMBIVENT RESPIMAT 2 QL(0.134 gm AERS daily) Direct Factor Xa Inhibitors QL(13 gm per DULERA AERO 2 ELIQUIS STARTER PACK 2 QL(4 ea daily) fill retail) TABS QL(12 ml daily) ipratropium-albuterol soln 1 ELIQUIS TABS 2 QL(4 ea daily) METAPROTERENOL QL(30 ml daily) QL(1 ea SULFATE SYRP 10 2 XARELTO TABS 10 MG 2 daily,35 ea per MG/5ML 180 days retail)

MHS Indiana Preferred Drug List Updated December 1, 2018

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XARELTO TABS 15 MG 2 QL(2 ea daily) KLONOPIN TABS (Use NP QL(3 ea daily) Clonazepam) QL(1 ea daily) XARELTO TABS 20 MG 2 ONFI SUSP 2.5 MG/ML NP QL(32 ml daily) (Use Clobazam) Heparins And Heparinoid-Like Agents ONFI TABS 10 MG (Use NP QL(8 ea daily) Clobazam) ARIXTRA SOLN (Use NP PA; SP Fondaparinux Sodium) ONFI TABS 20 MG (Use NP QL(4 ea daily) Clobazam) enoxaparin sodium soln 1 Anticonvulsants - Misc. fondaparinux sodium soln 1 PA; SP carbamazepine chew or 1 100 mg FRAGMIN SOLN 2 PA; SP carbamazepine cp12 or 1 100 mg, 200 mg, 300 mg heparin sodium (porcine) 1 lock flush soln 10 unit/ml CARBAMAZEPINE POWD 2 XX heparin sodium (porcine) 1 soln carbamazepine susp or 1 100 mg/5ml LOVENOX SOLN (Use NP Enoxaparin Sodium) carbamazepine tabs or 200 1 mg ANTICONVULSANTS - Drugs to Treat Seizures carbamazepine tb12 or 100 1 Anticonvulsants - Benzodiazepines mg, 200 mg, 400 mg QL(32 ml daily) CARBATROL CP12 (Use 2 clobazam susp 2.5 mg/ml 1 Carbamazepine) clobazam tabs 10 mg 1 QL(8 ea daily) gabapentin caps 1 clobazam tabs 20 mg 1 QL(4 ea daily) gabapentin soln 1 clonazepam tabs 1 QL(3 ea daily) gabapentin tabs 1 QL(3 ea daily) KEPPRA SOLN (Use NP clonazepam tbdp 1 Levetiracetam) QL(1 ea per fill KEPPRA TABS (Use NP DIASTAT ACUDIAL GEL 2 retail); AL(Up to Levetiracetam) 21 yrs old ) KEPPRA XR TB24 (Use NP QL(1 ea per fill Levetiracetam) DIASTAT PEDIATRIC GEL 2 retail); AL(Up to LAMICTAL CHEWABLE 21 yrs old ) DISPERSIBLE CHEW (Use NP QL(1 ea per fill Lamotrigine) diazepam (anticonvulsant) 2 retail); AL(Up to gel 21 yrs old ) LAMICTAL ODT KIT 2 QL(1 ea per fill LAMICTAL ODT TBDP 25 DIAZEPAM GEL RE 20 2 retail); AL(Up to MG, 2.5 MG MG, 50 MG, 100 MG, 200 NP 21 yrs old ) MG (Use Lamotrigine) QL(1 ea per fill LAMICTAL STARTER/NOT DIAZEPAM RECTAL GEL 2 retail); AL(Up to GEL TAKING NP 21 yrs old ) CARBAMAZEPINE KIT (Use Lamotrigine) MHS Indiana Preferred Drug List Updated December 1, 2018

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL LYRICA CAPS 225 MG, 2 QL(2 ea daily) STARTER/TAKING 300 MG CARBAMAZEPINE/NOT NP LYRICA CAPS 25 MG, 50 QL(3 ea daily) TAKING VALPROATE KIT MG, 75 MG, 100 MG, 150 2 (Use Lamotrigine) MG, 200 MG LAMICTAL LYRICA SOLN 20 MG/ML 2 QL(30 ml daily) STARTER/TAKING NP VALPROATE KIT (Use MYSOLINE TABS (Use NP Lamotrigine) Primidone) LAMICTAL TABS (Use NP NEURONTIN CAPS (Use NP Lamotrigine) Gabapentin) LAMICTAL XR KIT 2 NEURONTIN SOLN (Use NP Gabapentin) LAMICTAL XR TB24 25 NEURONTIN TABS (Use MG, 50 MG, 100 MG, 200 NP NP MG, 250 MG, 300 MG (Use Gabapentin) Lamotrigine) oxcarbazepine susp 1 lamotrigine chew 1 oxcarbazepine tabs 1 lamotrigine kit 1 OXTELLAR XR TB24 2 lamotrigine tabs 1 primidone tabs 1 lamotrigine tb24 1 QUDEXY XR CS24 2 QL(2 ea daily) lamotrigine tbdp 1 TEGRETOL SUSP (Use 2 Carbamazepine) levetiracetam in sodium 1 chloride soln TEGRETOL TABS (Use 2 Carbamazepine) levetiracetam soln iv 500 1 mg/5ml TEGRETOL-XR TB12 (Use 2 LEVETIRACETAM SOLN Carbamazepine) IV 500MG/100ML- TOPAMAX SPRINKLE NP 820MG/100ML, CPSP (Use Topiramate) 1000MG/100ML- TOPAMAX TABS (Use NP 750MG/100ML, NP Topiramate) 1500MG/100ML- 540MG/100ML (Use topiramate cpsp 1 Levetiracetam in Sodium QL(2 ea daily) Chloride) TOPIRAMATE ER CS24 2 levetiracetam soln or 100 1 mg/ml, 500 mg/5ml topiramate tabs 1 levetiracetam tabs or 250 TRILEPTAL SUSP (Use NP mg, 500 mg, 750 mg, 1000 1 Oxcarbazepine) mg TRILEPTAL TABS (Use NP levetiracetam tb24 or 500 1 Oxcarbazepine) mg, 750 mg TROKENDI XR CP24 2 QL(2 ea daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIMPAT SOLN IV 200 2 ethosuximide soln 1 MG/20ML ZARONTIN CAPS (Use ZONEGRAN CAPS (Use NP 2 Zonisamide) Ethosuximide) ZARONTIN SOLN (Use 2 zonisamide caps 1 Ethosuximide) Carbamates Valproic Acid felbamate susp 1 DEPACON SOLN (Use 2 Valproate Sodium) felbamate tabs 1 DEPAKENE CAPS 250 MG 2 (Use Valproic Acid) FELBATOL SUSP (Use NP DEPAKENE SOLN 250 Felbamate) MG/5ML (Use Valproate NP FELBATOL TABS (Use NP Sodium) Felbamate) DEPAKOTE ER TB24 (Use 2 GABA Modulators Divalproex Sodium) DEPAKOTE SPRINKLES GABITRIL TABS (Use NP Tiagabine HCl) CSDR (Use Divalproex 2 Sodium) SABRIL PACK (Use NP PA; SP Vigabatrin) DEPAKOTE TBEC (Use 2 Divalproex Sodium) SABRIL TABS 2 PA; SP divalproex sodium csdr 1 tiagabine hcl tabs 1 divalproex sodium tb24 1 vigabatrin pack 1 PA; SP divalproex sodium tbec 1 Hydantoins valproate sodium soln iv 1 DILANTIN CAPS 100 MG 100 mg/ml, 500 mg/5ml (Use Phenytoin Sodium 2 Extended) valproate sodium soln or 1 250 mg/5ml DILANTIN CAPS 30 MG 2 valproic acid caps 1 DILANTIN INFATABS 2 CHEW (Use Phenytoin) ANTIDEPRESSANTS - Drugs to Treat Depression DILANTIN-125 SUSP (Use 2 Phenytoin) Alpha-2 Receptor Antagonists (Tetracyclics) phenytoin chew 1 mirtazapine tabs 1 QL(1 ea daily) phenytoin sodium extended 1 QL(1 ea daily) caps 100 mg mirtazapine tbdp 1 phenytoin susp 1 REMERON SOLTAB TBDP NP QL(1 ea daily) (Use Mirtazapine) Succinimides REMERON TABS (Use NP QL(1 ea daily) Mirtazapine) ethosuximide caps 1 Antidepressants - Misc.

MHS Indiana Preferred Drug List Updated December 1, 2018

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) APLENZIN TB24 2 FLUOXETINE DR CPDR 2 QL(0.143 ea daily) bupropion hcl tabs or 75 QL(4 ea daily) 1 fluoxetine hcl caps or 10 1 QL(1 ea daily) mg, 100 mg mg bupropion hcl tb12 or 100 QL(2 ea daily) 1 fluoxetine hcl caps or 20 1 QL(4 ea daily) mg, 150 mg, 200 mg mg bupropion hcl tb24 or 150 QL(1 ea daily) 1 fluoxetine hcl caps or 40 1 QL(2 ea daily) mg, 300 mg mg BUPROPION QL(1 ea daily) fluoxetine hcl soln or 20 1 QL(20 ml daily) HYDROCHLORIDE ER 2 mg/5ml TB24 QL(1.5 ea fluoxetine hcl tabs or 10 mg 1 FORFIVO XL TB24 2 QL(1 ea daily) daily) fluoxetine hcl tabs or 20 mg 1 QL(4 ea daily) MAPROTILINE HCL TABS 2 QL(3 ea daily) fluoxetine hcl tabs or 60 mg 1 QL(1 ea daily) WELLBUTRIN SR TB12 NP QL(2 ea daily) (Use Bupropion HCl) FLUOXETINE 2 QL(1 ea daily) WELLBUTRIN XL TB24 NP QL(1 ea daily) HYDROCHLORIDE TABS (Use Bupropion HCl) FLUOXETINE QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) HYDROCHLORIDE TABS NP (Use Fluoxetine HCl) EMSAM PT24 2 QL(1 ea daily) fluvoxamine maleate cp24 1 QL(2 ea daily) 100 mg, 150 mg MARPLAN TABS 2 QL(3 ea daily) fluvoxamine maleate tabs 1 QL(3 ea daily) NARDIL TABS (Use NP QL(6 ea daily) 100 mg Phenelzine Sulfate) fluvoxamine maleate tabs 1 QL(1 ea daily) PARNATE TABS (Use NP QL(6 ea daily) 25 mg, 50 mg Tranylcypromine Sulfate) LEXAPRO SOLN 5 QL(20 ml daily) phenelzine sulfate tabs or 1 QL(6 ea daily) MG/5ML (Use Escitalopram NP Oxalate) tranylcypromine sulfate QL(6 ea daily) 1 LEXAPRO TABS 20 MG NP QL(1.5 ea tabs (Use Escitalopram Oxalate) daily) Selective Serotonin Reuptake Inhibitors (SSRIs) LEXAPRO TABS 5 MG, 10 QL(1 ea daily) MG (Use Escitalopram NP CELEXA TABS (Use NP QL(1 ea daily) Citalopram Hydrobromide) Oxalate) citalopram hydrobromide QL(20 ml daily) QL(1 ea daily); 1 paroxetine hcl tabs 10 mg, 1 AL(At least 18 soln 10 mg/5ml 20 mg yrs old) citalopram hydrobromide 1 QL(1 ea daily) tabs 10 mg, 20 mg, 40 mg QL(2 ea daily); paroxetine hcl tabs 30 mg, 1 AL(At least 18 40 mg escitalopram oxalate soln 5 1 QL(20 ml daily) yrs old) mg/5ml QL(1 ea daily); escitalopram oxalate tabs QL(1.5 ea paroxetine hcl tb24 25 mg, 1 AL(At least 18 1 12.5 mg, 37.5 mg 20 mg daily) yrs old) escitalopram oxalate tabs 5 1 QL(1 ea daily) QL(1 ea daily); mg, 10 mg PAXIL CR TB24 (Use NP AL(At least 18 Paroxetine HCl) yrs old)

MHS Indiana Preferred Drug List Updated December 1, 2018

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(40 ml TRINTELLIX TABS 2 QL(1 ea daily) 2 daily); AL(At PAXIL SUSP 10 MG/5ML least 18 yrs VIIBRYD STARTER PACK 2 old) KIT QL(1 ea daily); VIIBRYD TABS 2 QL(1 ea daily) PAXIL TABS 10 MG, 20 NP AL(At least 18 MG (Use Paroxetine HCl) yrs old) Serotonin-Norepinephrine Reuptake Inhibitors QL(2 ea daily); CYMBALTA CPEP (Use QL(2 ea daily) PAXIL TABS 30 MG, 40 NP AL(At least 18 NP MG (Use Paroxetine HCl) Duloxetine HCl) yrs old) DESVENLAFAXINE ER 2 QL(2 ea daily) QL(1 ea daily); TB24 100 MG PEXEVA TABS 2 AL(At least 18 yrs old) DESVENLAFAXINE ER 2 QL(1 ea daily) TB24 50 MG PROZAC CAPS 10 MG NP QL(1 ea daily) (Use Fluoxetine HCl) desvenlafaxine succinate 1 QL(2 ea daily) tb24 100 mg PROZAC CAPS 20 MG NP QL(4 ea daily) (Use Fluoxetine HCl) desvenlafaxine succinate 1 QL(1 ea daily) tb24 25 mg, 50 mg PROZAC CAPS 40 MG NP QL(2 ea daily) (Use Fluoxetine HCl) duloxetine hcl cpep 1 QL(2 ea daily) PROZAC WEEKLY CPDR QL(0.143 ea NP EFFEXOR XR CP24 150 NP QL(2 ea daily) (Use Fluoxetine HCl) daily) MG (Use Venlafaxine HCl) sertraline hcl conc or 20 QL(10 ml daily) 1 EFFEXOR XR CP24 37.5 NP QL(1 ea daily) mg/ml MG (Use Venlafaxine HCl) sertraline hcl tabs or 100 QL(3 ea daily) 1 EFFEXOR XR CP24 75 NP QL(3 ea daily) mg MG (Use Venlafaxine HCl) sertraline hcl tabs or 25 1 QL(2 ea daily) QL(1 ea daily) mg, 50 mg FETZIMA CP24 2 ZOLOFT CONC 20 MG/ML QL(10 ml daily) NP FETZIMA TITRATION 2 QL(1 ea daily) (Use Sertraline HCl) PACK C4PK ZOLOFT TABS 100 MG NP QL(3 ea daily) QL(2 ea daily) (Use Sertraline HCl) KHEDEZLA TB24 100 MG 2 ZOLOFT TABS 25 MG, 50 NP QL(2 ea daily) QL(1 ea daily) MG (Use Sertraline HCl) KHEDEZLA TB24 50 MG 2 Serotonin Modulators PRISTIQ TB24 100 MG QL(2 ea daily) (Use Desvenlafaxine NP NEFAZODONE HCL TABS 2 QL(2 ea daily) Succinate) 100 MG, 150 MG PRISTIQ TB24 25 MG, 50 QL(1 ea daily) nefazodone hcl tabs 50 1 QL(2 ea daily) MG (Use Desvenlafaxine NP mg, 250 mg Succinate) NEFAZODONE QL(2 ea daily) 2 venlafaxine hcl cp24 150 1 QL(2 ea daily) HYDROCHLORIDE TABS mg TRAZODONE HCL POWD 2 venlafaxine hcl cp24 37.5 1 QL(1 ea daily) XX mg trazodone hcl tabs or 100 1 QL(3 ea daily) QL(3 ea daily) mg, 150 mg venlafaxine hcl cp24 75 mg 1 trazodone hcl tabs or 50 1 QL(2 ea daily) mg, 300 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits venlafaxine hcl tabs 25 mg, QL(3 ea daily) DOXEPIN 50 mg, 75 mg, 100 mg, 1 HYDROCHLORIDE POWD 2 37.5 mg XX venlafaxine hcl tb24 150 1 QL(2 ea daily) ELAVIL TABS (Use NP QL(3 ea daily) mg Amitriptyline HCl) venlafaxine hcl tb24 225 1 QL(1 ea daily) IMIPRAMINE HCL POWD 2 mg, 37.5 mg XX venlafaxine hcl tb24 75 mg 1 QL(3 ea daily) imipramine hcl tabs or 10 1 QL(2 ea daily) mg Tricyclic Agents imipramine hcl tabs or 25 1 QL(1 ea daily) mg amitriptyline hcl tabs 1 QL(3 ea daily) imipramine hcl tabs or 50 1 QL(6 ea daily) mg AMOXAPINE TABS 25 2 QL(2 ea daily) MG, 150 MG imipramine pamoate caps 1 QL(3 ea daily) 100 mg AMOXAPINE TABS 50 2 QL(4 ea daily) MG, 100 MG imipramine pamoate caps 1 QL(2 ea daily) 125 mg, 150 mg ANAFRANIL CAPS 25 MG NP QL(2 ea daily) (Use Clomipramine HCl) imipramine pamoate caps 1 QL(1 ea daily) 75 mg ANAFRANIL CAPS 50 MG NP QL(5 ea daily) (Use Clomipramine HCl) NORPRAMIN TABS 10 MG NP QL(4 ea daily) (Use Desipramine HCl) ANAFRANIL CAPS 75 MG NP QL(3 ea daily) (Use Clomipramine HCl) NORPRAMIN TABS 25 MG NP QL(2 ea daily) (Use Desipramine HCl) clomipramine hcl caps 25 1 QL(2 ea daily) mg nortriptyline hcl caps or 10 1 QL(4 ea daily) mg, 25 mg clomipramine hcl caps 50 1 QL(5 ea daily) mg nortriptyline hcl caps or 50 1 QL(3 ea daily) mg clomipramine hcl caps 75 1 QL(3 ea daily) mg nortriptyline hcl caps or 75 1 QL(2 ea daily) mg DESIPRAMINE HCL 2 POWD XX NORTRIPTYLINE HCL 2 POWD XX desipramine hcl tabs or 10 1 QL(4 ea daily) mg nortriptyline hcl soln or 10 1 QL(20 ml daily) mg/5ml desipramine hcl tabs or 1 QL(3 ea daily) 100 mg NORTRIPTYLINE HCL 2 QL(20 ml daily) SOLN OR 10 MG/5ML desipramine hcl tabs or 25 1 QL(2 ea daily) mg, 50 mg, 75 mg, 150 mg PAMELOR CAPS 10 MG, QL(4 ea daily) QL(4 ea daily) 25 MG (Use Nortriptyline NP doxepin hcl caps or 10 mg 1 HCl) doxepin hcl caps or 25 mg, QL(2 ea daily) PAMELOR CAPS 50 MG NP QL(3 ea daily) 50 mg, 75 mg, 100 mg, 150 1 (Use Nortriptyline HCl) mg PAMELOR CAPS 75 MG NP QL(2 ea daily) doxepin hcl conc or 10 1 QL(30 ml daily) (Use Nortriptyline HCl) mg/ml protriptyline hcl tabs 1 QL(4 ea daily) DOXEPIN HCL POWD XX 2

MHS Indiana Preferred Drug List Updated December 1, 2018

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURMONTIL CAPS 100 QL(3 ea daily) pioglitazone hcl-metformin 1 QL(2 ea daily) MG (Use Trimipramine NP hcl tabs Maleate) ST; QL(2 ea SEGLUROMET TABS 2 SURMONTIL CAPS 25 QL(1 ea daily) daily) MG, 50 MG (Use NP Trimipramine Maleate) Biguanides GLUCOPHAGE TABS 500 NP QL(5 ea daily) TOFRANIL TABS 10 MG NP QL(2 ea daily) Use Metformin HCl) (Use Imipramine HCl) MG ( GLUCOPHAGE TABS 850 TOFRANIL TABS 25 MG NP QL(1 ea daily) NP ) MG, 1000 MG (Use (Use Imipramine HCl Metformin HCl) TOFRANIL TABS 50 MG NP QL(6 ea daily) GLUCOPHAGE XR TB24 QL(4 ea daily) (Use Imipramine HCl) 500 MG (Use Metformin NP trimipramine maleate caps 1 QL(3 ea daily) HCl) or 100 mg GLUCOPHAGE XR TB24 QL(3 ea daily) trimipramine maleate caps 1 QL(1 ea daily) 750 MG (Use Metformin NP or 25 mg, 50 mg HCl) TRIMIPRAMINE MALEATE 2 QL(5 ea daily) POWD XX metformin hcl tabs 500 mg 1 ANTIDIABETICS - Drugs to Regulate Blood metformin hcl tabs 850 mg, 1 Sugar 1000 mg Antidiabetic - Amylin Analogs metformin hcl tb24 500 mg 1 QL(4 ea daily) SYMLINPEN 120 SOPN 2 QL(0.36 ml QL(3 ea daily) daily) metformin hcl tb24 750 mg 1 SYMLINPEN 60 SOPN 2 QL(0.2 ml Diabetic Other daily) CVS GLUCOSE CHEW 4 2 QL(1.67 ea Antidiabetic Combinations GM daily) ACTOPLUS MET TABS QL(2 ea daily) DEX4 QUICK DISSOLVE 2 QL(1.67 ea (Use Pioglitazone HCl- NP GLUCOSE CHEW daily) Metformin HCl) GLUCAGEN HYPOKIT 2 QL(1 ea per fill alogliptin-metformin hcl 1 QL(1 ea daily) SOLR retail) tabs GLUCAGON 2 QL(1 ea per fill alogliptin-pioglitazone tabs 1 QL(1 ea daily) EMERGENCY KIT KIT retail) QL(1.67 ea GLUCOSE CHEW 4 GM 2 glipizide-metformin hcl tabs 1 daily) GNP GLUCOSE CHEW 4 QL(1.67 ea GLUCOVANCE TABS (Use NP 2 Glyburide-Metformin) GM daily) GNP QUICK DISSOLVE 2 QL(1.67 ea glyburide-metformin tabs 1 GLUCOSE CHEW daily) QL(2 ea daily); LEADER QUICK QL(1.67 ea JENTADUETO TABS 2 AL(At least 18 DISSOLVE GLUCOSE 2 daily) yrs old) CHEW SM GLUCOSE CHEW 4 QL(1.67 ea KAZANO TABS (Use NF 2 Alogliptin-Metformin HCl) GM daily) WALGREENS GLUCOSE QL(1.67 ea OSENI TABS (Use NF 2 Alogliptin-Pioglitazone) CHEW 4 GM daily) MHS Indiana Preferred Drug List Updated December 1, 2018

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HUMALOG MIX 75/25 2 QL(1 ml daily) KWIKPEN SUPN alogliptin benzoate tabs 1 QL(1 ea daily) HUMALOG MIX 75/25 2 QL(1.34 ml SUSP daily) NESINA TABS (Use NF Alogliptin Benzoate) HUMULIN 70/30 KWIKPEN 2 QL(1 ml daily) QL(1 ea daily); SUPN QL(1.34 ml TRADJENTA TABS 2 AL(At least 18 HUMULIN 70/30 SUSP 2 yrs old) daily) Incretin Mimetic Agents (GLP-1 Receptor HUMULIN N KWIKPEN 2 QL(1 ml daily) SUPN PA; Limit 4 per 28 HUMULIN N SUSP 2 QL(1.34 ml daily) BYDUREON PEN PEN 2 days;QL(0.143 ea daily); AL(At HUMULIN R SOLN 2 QL(1.34 ml least 18 yrs daily) old) NOVOLIN 70/30 FLEXPEN 2 QL(1 ml daily) BYDUREON SRER 2 PA RELION SUPN NOVOLIN 70/30 FLEXPEN 2 QL(1 ml daily) PA; Limit 2.4ml SUPN per NOVOLIN 70/30 RELION 2 QL(1.34 ml BYETTA SOPN 10 2 month;QL(0.08 SUSP daily) MCG/0.04ML ml daily); AL(At QL(1.34 ml least 18 yrs NOVOLIN 70/30 SUSP 2 old) daily) PA; Limit 1.2ml NOVOLIN N RELION 2 QL(1.34 ml per SUSP daily) BYETTA SOPN 5 month;QL(0.04 2 NOVOLIN N SUSP 2 QL(1.34 ml MCG/0.02ML ml daily); AL(At daily) least 18 yrs NOVOLIN R RELION 2 QL(1.34 ml old) SOLN daily) PA; QL(0.3 ml VICTOZA SOPN 2 NOVOLIN R SOLN 2 QL(1.34 ml daily) daily) Insulin Sensitizing Agents NOVOLOG MIX 70/30 QL(1 ml daily) PREFILLED FLEXPEN 2 ACTOS TABS (Use NP QL(1 ea daily) Pioglitazone HCl) SUPN QL(1 ea daily) NOVOLOG MIX 70/30 2 QL(1.34 ml pioglitazone hcl tabs 1 SUSP daily) Insulin Meglitinide Analogues ADMELOG SOLN 2 QL(1 ml daily) nateglinide tabs 1 QL(3 ea daily) STARLIX TABS (Use QL(3 ea daily) ADMELOG SOLOSTAR 2 QL(1 ml daily) NP SOPN Nateglinide) BASAGLAR KWIKPEN 2 QL(1 ml daily) Sodium-Glucose Co-Transporter 2 (SGLT2) SOPN PA; QL(1 ea JARDIANCE TABS 2 HUMALOG MIX 50/50 2 QL(1 ml daily) daily) KWIKPEN SUPN ST; QL(1 ea STEGLATRO TABS 2 HUMALOG MIX 50/50 2 QL(1.34 ml daily) SUSP daily) MHS Indiana Preferred Drug List Updated December 1, 2018

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Sulfonylureas PEPTO-BISMOL TO-GO CHEW (Use Bismuth NP AMARYL TABS 1 MG, 2 NP QL(4 ea daily) Subsalicylate) MG (Use Glimepiride) Antiperistaltic Agents AMARYL TABS 4 MG (Use NP QL(2 ea daily) Glimepiride) diphenoxylate w/ atropine 1 tabs glimepiride tabs 1 mg, 2 1 QL(4 ea daily) mg DIPHENOXYLATE/ATROP 2 INE LIQD glimepiride tabs 4 mg 1 QL(2 ea daily) IMODIUM A-D CAPS 2 MG NP QL(8 ea daily); glipizide tabs 1 (Use Loperamide HCl) RX/OTC IMODIUM A-D TABS 2 MG NP QL(8 ea daily) glipizide tb24 1 (Use Loperamide HCl) LOMOTIL TABS (Use NP GLUCOTROL TABS (Use NP Diphenoxylate w/ Atropine) Glipizide) QL(8 ea daily); loperamide hcl caps 2 mg 1 GLUCOTROL XL TB24 NP RX/OTC (Use Glipizide) loperamide hcl liqd 1 1 QL(40 ml daily) glyburide micronized tabs 1 mg/5ml loperamide hcl tabs 2 mg 1 QL(8 ea daily) glyburide tabs 1

GLYNASE TABS (Use NP ANTIDOTES AND SPECIFIC ANTAGONISTS Glyburide Micronized) Antidotes - Chelating Agents ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea CHEMET CAPS 2 Antidiarrheal/Probiotic Agents - Misc. EXJADE TBSO 2 PA; SP bismuth subsalicylate chew 1 262 mg JADENU SPRINKLE PACK 2 PA bismuth subsalicylate susp 1 525 mg/15ml JADENU TABS 2 PA; SP bismuth subsalicylate tabs 1 262 mg Antidotes and Specific Antagonists PEPTO BISMOL TABS deferoxamine mesylate solr 1 PA; SP (Use Bismuth NP Subsalicylate) DESFERAL SOLR (Use NP PA; SP PEPTO-BISMOL CHEW Deferoxamine Mesylate) 262 MG (Use Bismuth NP Opioid Antagonists Subsalicylate) naloxone hcl soln 0.4 1 QL(2 ml per 90 PEPTO-BISMOL mg/ml days retail) INSTACOOL CHEW (Use NP Bismuth Subsalicylate) naltrexone hcl tabs 1 PEPTO-BISMOL MAX STRENGTH SUSP (Use NP NARCAN LIQD 2 Bismuth Subsalicylate) VIVITROL SUSR 2

MHS Indiana Preferred Drug List Updated December 1, 2018

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIEMETICS - Drugs to Treat Nausea and nystatin tabs 1 QL(6 ea daily) Vomiting QL(1 ea 5-HT3 Receptor Antagonists terbinafine hcl tabs 1 daily,90 ea per ondansetron hcl soln ij 4 1 120 days retail) mg/2ml, 40 mg/20ml Imidazole-Related Antifungals ondansetron hcl soln or 4 1 QL(2 ml daily) mg/5ml DIFLUCAN SUSR 10 QL(70 ml per MG/ML, 40 MG/ML (Use NP fill retail) ondansetron hcl tabs or 24 1 QL(1 ea per 14 Fluconazole) mg days retail) DIFLUCAN TABS 100 MG, NP ondansetron hcl tabs or 4 1 QL(2 ea daily) 200 MG (Use Fluconazole) mg, 8 mg DIFLUCAN TABS 150 MG NP QL(2 ea per fill ONDANSETRON 2 (Use Fluconazole) retail) HYDROCHLORIDE SOLN DIFLUCAN TABS 50 MG NP QL(3 ea per 14 ondansetron tbdp 1 QL(2 ea daily) (Use Fluconazole) days retail) fluconazole susr 10 mg/ml, 1 QL(70 ml per ZOFRAN ODT TBDP (Use NP QL(2 ea daily) 40 mg/ml fill retail) Ondansetron) fluconazole tabs 100 mg, 1 ZOFRAN SOLN 4 MG/5ML NP QL(2 ml daily) 200 mg (Use Ondansetron HCl) QL(2 ea per fill fluconazole tabs 150 mg 1 ZOFRAN TABS 4 MG, 8 QL(2 ea daily) retail) MG (Use Ondansetron NP QL(3 ea per 14 HCl) fluconazole tabs 50 mg 1 days retail) Antiemetics - Anticholinergic PA; QL(1 ea itraconazole caps 100 mg 1 dimenhydrinate tabs or 50 1 QL(24 ea per daily) mg fill retail) SPORANOX CAPS 100 NP PA; QL(1 ea DRAMAMINE TABS (Use NP QL(24 ea per MG (Use Itraconazole) daily) Dimenhydrinate) fill retail) SPORANOX PULSEPAK NP PA; QL(1 ea meclizine hcl chew 25 mg 1 CAPS (Use Itraconazole) daily) ANTIHISTAMINES - Drugs to Treat Allergies meclizine hcl tabs 25 mg, 1 RX/OTC 12.5 mg Antihistamines - Alkylamines ANTIFUNGALS - Drugs to Treat Fungal Infections CHLOR-TRIMETON SYRP 2 MG/5ML (Use NP Antifungals Chlorpheniramine Maleate) GRIS-PEG TABS (Use NP CHLOR-TRIMETON TABS QL(120 ea per Griseofulvin Ultramicrosize) 4 MG (Use NP fill retail) griseofulvin microsize susp 1 Chlorpheniramine Maleate) chlorpheniramine maleate 1 griseofulvin microsize tabs 1 syrp 2 mg/5ml chlorpheniramine maleate QL(120 ea per griseofulvin ultramicrosize 1 1 tabs tabs 4 mg fill retail) QL(1 ea RYCLORA SYRP 2 LAMISIL TABS (Use NP Terbinafine HCl) daily,90 ea per 120 days retail) Antihistamines - Ethanolamines

MHS Indiana Preferred Drug List Updated December 1, 2018

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENADRYL ALLERGY QL(4 ea daily) CLARITIN REDITABS QL(1 ea daily) CAPS (Use NP TBDP 10 MG (Use NP Diphenhydramine HCl) Loratadine) BENADRYL ALLERGY QL(240 ml per CLARITIN SYRP 5 NP QL(240 ml per CHILDRENS LIQD 12.5 NP fill retail) MG/5ML (Use Loratadine) fill retail) MG/5ML (Use CLARITIN TABS 10 MG NP QL(1 ea daily) Diphenhydramine HCl) (Use Loratadine) BENADRYL ALLERGY QL(4 ea daily) fexofenadine hcl tabs 180 1 QL(1 ea daily) TABS (Use NP mg Diphenhydramine HCl) fexofenadine hcl tabs 60 1 QL(2 ea daily) clemastine fumarate tabs 1 QL(2 ea daily) mg 1.34 mg levocetirizine 1 RX/OTC diphenhydramine hcl caps 1 QL(4 ea daily) dihydrochloride tabs 5 mg or 25 mg QL(240 ml per loratadine soln 5 mg/5ml 1 diphenhydramine hcl caps 1 QL(4 ea daily); fill retail) or 50 mg RX/OTC QL(240 ml per loratadine syrp 5 mg/5ml 1 diphenhydramine hcl liqd or QL(240 ml per fill retail) 25 mg/10ml, 50 mg/20ml, 1 fill retail) 12.5 mg/5ml loratadine tabs 10 mg 1 QL(1 ea daily) diphenhydramine hcl tabs 1 QL(4 ea daily) QL(1 ea daily) or 25 mg loratadine tbdp 10 mg 1 QL(240 ml per SILPHEN COUGH SYRP 2 XYZAL ALLERGY 24HR RX/OTC fill retail) TABS (Use Levocetirizine NP TAVIST ALLERGY TABS QL(2 ea daily) Dihydrochloride) (Use Clemastine NP XYZAL TABS 5 MG (Use RX/OTC Fumarate) Levocetirizine NP Antihistamines - Non-Sedating Dihydrochloride) ALLEGRA ALLERGY QL(1 ea daily) ZYRTEC ALLERGY TABS NP QL(1 ea daily) TABS 180 MG (Use NP (Use Cetirizine HCl) Fexofenadine HCl) ZYRTEC CHILDRENS QL(240 ml per ALLEGRA ALLERGY QL(2 ea daily) ALLERGY SOLN (Use NP fill retail); TABS 60 MG (Use NP Cetirizine HCl) RX/OTC Fexofenadine HCl) Antihistamines - Phenothiazines cetirizine hcl chew 5 mg, QL(1 ea daily) 1 promethazine hcl soln or 1 AL(At least 2 10 mg 6.25 mg/5ml yrs old) QL(240 ml per cetirizine hcl soln 1 mg/ml, QL(12 ea per 1 fill retail); promethazine hcl supp re 1 fill retail); AL(At 5 mg/5ml 25 mg, 12.5 mg RX/OTC least 2 yrs old) QL(240 ml per promethazine hcl syrp or AL(At least 2 cetirizine hcl syrp 1 mg/ml, 1 fill retail); 1 5 mg/5ml 6.25 mg/5ml yrs old) RX/OTC promethazine hcl tabs or 1 AL(At least 2 cetirizine hcl tabs 5 mg, 10 1 QL(1 ea daily) 25 mg, 50 mg, 12.5 mg yrs old) mg Antihistamines - Piperidines CLARITIN ALLERGY QL(240 ml per CHILDRENS SYRP (Use NP fill retail) cyproheptadine hcl syrp or 1 Loratadine) 2 mg/5ml

MHS Indiana Preferred Drug List Updated December 1, 2018

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyproheptadine hcl tabs or 1 fenofibrate micronized caps 1 QL(2 ea daily) 4 mg 67 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High FENOFIBRATE TABS 160 2 QL(1 ea daily) Cholesterol MG QL(1 ea daily) Antihyperlipidemics - Combinations fenofibrate tabs 160 mg 1 PA; QL(1 ea ezetimibe-simvastatin tabs $0 QL(3 ea daily) daily); PV fenofibrate tabs 54 mg 1 VYTORIN TABS (Use NP PA; QL(1 ea QL(2 ea daily) Ezetimibe-Simvastatin) daily); PV gemfibrozil tabs 1 Antihyperlipidemics - Misc. LOFIBRA CAPS (Use NP QL(1 ea daily) Fenofibrate Micronized) KYNAMRO SOSY 2 PA; SP LOFIBRA TABS (Use NP QL(1 ea daily) LOVAZA CAPS (Use Fenofibrate) Omega-3-acid Ethyl NP LOPID TABS (Use NP QL(2 ea daily) Esters) Gemfibrozil) QL(1 ea daily) omega-3-acid ethyl esters 1 TRIGLIDE TABS 2 caps Bile Acid Sequestrants HMG CoA Reductase Inhibitors $0 copay for cholestyramine light pack 1 Generic only, atorvastatin calcium tabs 1 age 40 to cholestyramine light powd 1 75;QL(1 ea daily); PV cholestyramine pack 1 ST; $0 copay for Generic cholestyramine powd 1 CRESTOR TABS (Use NP Rosuvastatin Calcium) only, age 40 to COLESTID FLAVORED 75;QL(1 ea GRAN 5 GM (Use NP daily) Colestipol HCl) $0 copay for COLESTID GRAN 5 GM Generic only, NP LIPITOR TABS (Use NP (Use Colestipol HCl) ) age 40 to Atorvastatin Calcium 75;QL(1 ea COLESTID TABS 1 GM NP daily); PV (Use Colestipol HCl) $0 copay for colestipol hcl gran 5 gm 1 Generic only, lovastatin tabs 10 mg, 20 1 age 40 to mg colestipol hcl tabs 1 gm 1 75;QL(1 ea daily); PV QUESTRAN LIGHT POWD NP ) $0 copay for (Use Cholestyramine Light Generic only, QUESTRAN PACK (Use NP lovastatin tabs 40 mg 1 age 40 to Cholestyramine) 75;QL(2 ea daily); PV QUESTRAN POWD (Use NP Cholestyramine) Fibric Acid Derivatives fenofibrate micronized caps 1 QL(1 ea daily) 134 mg, 200 mg MHS Indiana Preferred Drug List Updated December 1, 2018

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits $0 copay for ANTIHYPERTENSIVES - Drugs to Treat High Generic only, Blood Pressure MEVACOR TABS (Use NP ) age 40 to Lovastatin 75;QL(2 ea ACE Inhibitors daily); PV ACCUPRIL TABS (Use NP $0 copay for Quinapril HCl) Generic only, ALTACE CAPS (Use QL(2 ea daily) PRAVACHOL TABS (Use NP NP Pravastatin Sodium) age 40 to Ramipril) 75;QL(1 ea QL(2 ea daily) daily); PV benazepril hcl tabs 40 mg 1 $0 copay for benazepril hcl tabs 5 mg, 1 QL(1 ea daily) Generic only, 10 mg, 20 mg pravastatin sodium tabs 1 age 40 to QL(3 ea daily) 75;QL(1 ea captopril tabs 1 daily); PV QL(2 ea daily) ST; $0 copay enalapril maleate tabs 1 for Generic rosuvastatin calcium tabs 1 only, age 40 to EPANED SOLR 2 75;QL(1 ea QL(1 ea daily) daily) fosinopril sodium tabs 1 $0 copay for Generic only, lisinopril tabs 1 simvastatin tabs 1 age 40 to LOTENSIN TABS 10 MG, QL(1 ea daily) 75;QL(1 ea 20 MG (Use Benazepril NP daily); PV HCl) $0 copay for LOTENSIN TABS 40 MG NP QL(2 ea daily) Generic only, (Use Benazepril HCl) ZOCOR TABS (Use NP Simvastatin) age 40 to 75;QL(1 ea MAVIK TABS (Use NP QL(1 ea daily) daily); PV Trandolapril) PRINIVIL TABS (Use NP Nicotinic Acid Derivatives Lisinopril) niacin (antihyperlipidemic) 1 tbcr quinapril hcl tabs 1 NIACOR TABS 2 ramipril caps 1 QL(2 ea daily) NIASPAN TBCR (Use NP trandolapril tabs 1 mg, 2 1 QL(1 ea daily) Niacin (Antihyperlipidemic)) mg Proprotein Convertase Subtilisin/Kexin Type 9 trandolapril tabs 4 mg 1 QL(2 ea daily) PRALUENT SOPN 2 PA; SP VASOTEC TABS (Use NP QL(2 ea daily) Enalapril Maleate) PRALUENT SOSY 2 PA; SP ZESTRIL TABS (Use NP Lisinopril) REPATHA PUSHTRONEX 2 PA; SP SYSTEM SOCT Angiotensin II Receptor Antagonists PA; SP REPATHA SOSY 2 ATACAND TABS (Use NP Candesartan Cilexetil) REPATHA SURECLICK 2 PA; SP SOAJ

MHS Indiana Preferred Drug List Updated December 1, 2018

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVAPRO TABS (Use NP QL(1 ea daily) prazosin hcl caps 1 Irbesartan) PRAZOSIN BENICAR TABS (Use NP ST 2 Olmesartan Medoxomil) HYDROCHLORIDE POWD TENEX TABS (Use NP candesartan cilexetil tabs 1 Guanfacine HCl) COZAAR TABS (Use NP QL(1 ea daily) terazosin hcl caps 1 Losartan Potassium) DIOVAN TABS (Use NP QL(1 ea daily) Antihypertensive Combinations Valsartan) ACCURETIC TABS 10MG- QL(3 ea daily) irbesartan tabs 1 QL(1 ea daily) 12.5MG (Use Quinapril- NP Hydrochlorothiazide) losartan potassium tabs 1 QL(1 ea daily) ACCURETIC TABS 20MG- QL(4 ea daily) 12.5MG (Use Quinapril- NP MICARDIS TABS (Use NP QL(1 ea daily) Hydrochlorothiazide) Telmisartan) ACCURETIC TABS 20MG- QL(2 ea daily) olmesartan medoxomil tabs 1 ST 25MG (Use Quinapril- NP Hydrochlorothiazide) QL(1 ea daily) telmisartan tabs 1 amlodipine besylate- 1 QL(1 ea daily) benazepril hcl caps valsartan tabs 1 QL(1 ea daily) amlodipine besylate- 1 ST olmesartan medoxomil tabs Antiadrenergic Antihypertensives amlodipine besylate- 1 ST CARDURA TABS (Use NP valsartan tabs Doxazosin Mesylate) amlodipine-valsartan- 1 ST CATAPRES TABS 0.1 MG, QL(10 ea daily) hydrochlorothiazide tabs 0.2 MG (Use Clonidine NP ATACAND HCT TABS HCl) (Use Candesartan Cilexetil- NP CATAPRES TABS 0.3 MG NP QL(8 ea daily) Hydrochlorothiazide) (Use Clonidine HCl) atenolol & chlorthalidone 1 QL(2 ea daily) CLONIDINE HCL POWD 2 tabs XX AVALIDE TABS (Use QL(1 ea daily) clonidine hcl tabs or 0.1 1 QL(10 ea daily) Irbesartan- NP mg, 0.2 mg Hydrochlorothiazide) clonidine hcl tabs or 0.3 mg 1 QL(8 ea daily) AZOR TABS (Use ST Amlodipine Besylate- NP CLONIDINE 2 Olmesartan Medoxomil) HYDROCHLORIDE POWD benazepril & 1 QL(1 ea daily) doxazosin mesylate tabs or 1 hydrochlorothiazide tabs 1 mg, 2 mg, 4 mg, 8 mg BENICAR HCT TABS (Use ST guanfacine hcl tabs 1 Olmesartan Medoxomil- NP Hydrochlorothiazide) methyldopa tabs 1 bisoprolol & 1 QL(1 ea daily) hydrochlorothiazide tabs MINIPRESS CAPS (Use NP Prazosin HCl) candesartan cilexetil- 1 hydrochlorothiazide tabs

MHS Indiana Preferred Drug List Updated December 1, 2018

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPTOPRIL/HYDROCHL QL(2 ea daily) METOPROLOL QL(1 ea daily) OROTHIAZIDE TABS 2 SUCCINATE 2 25MG-15MG, 25MG- ER/HYDROCHLOROTHIA 25MG, 50MG-15MG ZIDE TB24 CAPTOPRIL/HYDROCHL QL(3 ea daily) METOPROLOL/HYDROCH 2 QL(1 ea daily) OROTHIAZIDE TABS 2 LOROTHIAZIDE TABS 50MG-25MG MICARDIS HCT TABS QL(1 ea daily) DIOVAN HCT TABS (Use QL(1 ea daily) (Use Telmisartan- NP Valsartan- NP Hydrochlorothiazide) Hydrochlorothiazide) olmesartan medoxomil- ST DUTOPROL TB24 2 QL(1 ea daily) amlodipine- 1 hydrochlorothiazide tabs enalapril maleate & QL(2 ea daily) 1 olmesartan medoxomil- 1 ST hydrochlorothiazide tabs hydrochlorothiazide tabs EXFORGE HCT TABS ST PROPRANOLOL/HYDROC 2 QL(2 ea daily) (Use Amlodipine-Valsartan- NP HLOROTHIAZIDE TABS Hydrochlorothiazide) quinapril- QL(3 ea daily) EXFORGE TABS (Use ST hydrochlorothiazide tabs 1 Amlodipine Besylate- NP 10mg-12.5mg Valsartan) quinapril- QL(4 ea daily) fosinopril sodium & 1 QL(1 ea daily) hydrochlorothiazide tabs 1 hydrochlorothiazide tabs 20mg-12.5mg HYZAAR TABS (Use QL(1 ea daily) quinapril- QL(2 ea daily) Losartan Potassium & NP hydrochlorothiazide tabs 1 Hydrochlorothiazide) 20mg-25mg irbesartan- 1 QL(1 ea daily) TARKA TBCR (Use hydrochlorothiazide tabs Trandolapril-Verapamil NP HCl) lisinopril & 1 hydrochlorothiazide tabs telmisartan-amlodipine tabs 1 LOPRESSOR HCT TABS QL(2 ea daily) (Use Metoprolol & NP telmisartan- 1 QL(1 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs losartan potassium & 1 QL(1 ea daily) TENORETIC 100 TABS QL(2 ea daily) hydrochlorothiazide tabs (Use Atenolol & NP LOTENSIN HCT TABS QL(1 ea daily) Chlorthalidone) (Use Benazepril & NP TENORETIC 50 TABS QL(2 ea daily) Hydrochlorothiazide) (Use Atenolol & NP LOTREL CAPS (Use QL(1 ea daily) Chlorthalidone) Amlodipine Besylate- NP trandolapril-verapamil hcl 1 Benazepril HCl) tbcr metoprolol & QL(1 ea daily) TRANDOLAPRIL/VERAPA 2 hydrochlorothiazide tabs 1 MIL HCL ER TBCR 100mg-50mg TRIBENZOR TABS (Use ST metoprolol & QL(2 ea daily) Olmesartan Medoxomil- NP hydrochlorothiazide tabs 1 Amlodipine- 50mg-25mg, 100mg-25mg Hydrochlorothiazide)

MHS Indiana Preferred Drug List Updated December 1, 2018

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TWYNSTA TABS (Use NP Antimyasthenic/Cholinergic Agents Telmisartan-Amlodipine) MESTINON TABS 60 MG valsartan- 1 QL(1 ea daily) (Use Pyridostigmine NP hydrochlorothiazide tabs Bromide) VASERETIC TABS (Use QL(2 ea daily) MESTINON TIMESPAN Enalapril Maleate & NP TBCR (Use Pyridostigmine NP Hydrochlorothiazide) Bromide) ZESTORETIC TABS (Use pyridostigmine bromide 1 Lisinopril & NP tabs Hydrochlorothiazide) pyridostigmine bromide tbcr 1 ZIAC TABS (Use Bisoprolol NP QL(1 ea daily) & Hydrochlorothiazide) ANTIMYCOBACTERIAL AGENTS - Drugs to Antihypertensives - Misc. Treat Tuberculosis (Bacterial Infections) VECAMYL TABS 2 PA; SP Antimycobacterial Agents Vasodilators ethambutol hcl tabs 1 hydralazine hcl tabs or 10 1 ISONIAZID SYRP OR 50 2 mg, 25 mg, 50 mg, 100 mg MG/5ML QL(10 ea daily) minoxidil tabs 10 mg 1 isoniazid tabs or 100 mg, 1 300 mg QL(3 ea daily) minoxidil tabs 2.5 mg 1 MYAMBUTOL TABS (Use NP Ethambutol HCl) ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) pyrazinamide tabs 1 Antimalarial Combinations RIFADIN CAPS OR 150 NP QL(24 ea per MG, 300 MG (Use COARTEM TABS 2 Rifampin) fill retail) rifampin caps or 150 mg, 1 Antimalarials 300 mg CHLOROQUINE PHOSPHATE TABS 250 2 TRECATOR TABS 2 MG ANTINEOPLASTICS AND ADJUNCTIVE chloroquine phosphate 1 QL(1 ea daily) THERAPIES - Drugs to Treat Cancer tabs 500 mg Alkylating Agents hydroxychloroquine sulfate 1 tabs ALKERAN SOLR IV 50 MG NP PA; SP (Use Melphalan HCl) MEFLOQUINE HCL TABS 2 ALKERAN TABS OR 2 MG NP (Use Melphalan) mefloquine hcl tabs 1 BENDAMUSTINE 2 PA; SP PLAQUENIL TABS (Use HYDROCHLORIDE SOLN Hydroxychloroquine NP PA; SP Sulfate) BENDEKA SOLN 2 PRIMAQUINE 2 LEUKERAN TABS 2 PHOSPHATE TABS PA; SP ANTIMYASTHENIC/CHOLINERGIC AGENTS melphalan hcl solr 1

MHS Indiana Preferred Drug List Updated December 1, 2018

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits melphalan tabs 1 Antineoplastic - Antibodies ADCETRIS SOLR 2 PA; SP MYLERAN TABS 2 PA; SP TEMODAR CAPS OR 5 PA ARZERRA CONC 2 MG, 20 MG, 100 MG, 140 NP PA; SP MG, 180 MG, 250 MG (Use ERBITUX SOLN 2 Temozolomide) HERCEPTIN SOLR 2 PA; SP TEMODAR SOLR IV 100 2 PA MG KADCYLA SOLR 2 PA; SP temozolomide caps 1 PA PERJETA SOLN 2 PA; SP TREANDA SOLR 2 PA; SP RITUXAN SOLN 2 PA; SP Antimetabolites PA; SP azacitidine susr 1 PA; SP VECTIBIX SOLN 2 PA; SP capecitabine tabs 1 PA; SP YERVOY SOLN 2 Antineoplastic - Hedgehog Pathway Inhibitors DACOGEN SOLR (Use NP PA; SP Decitabine) ERIVEDGE CAPS 2 PA; SP decitabine solr 1 PA; SP ODOMZO CAPS 2 PA; SP mercaptopurine tabs 1 Antineoplastic - Hormonal and Related Agents methotrexate sodium soln ij PA; SP 1 gm/40ml, 50 mg/2ml, 200 1 abiraterone acetate tabs 1 mg/8ml, 250 mg/10ml METHOTREXATE anastrozole tabs 1 SODIUM SOLN IJ 250 2 ARIMIDEX TABS (Use NP MG/10ML Anastrozole) methotrexate sodium tabs 1 AROMASIN TABS (Use NP PA; SP or 2.5 mg Exemestane) PURIXAN SUSP 2 bicalutamide tabs 1 QL(1 ea daily) PA; SP TABLOID TABS 2 CASODEX TABS (Use NP QL(1 ea daily) Bicalutamide) TREXALL TABS 2 DEPO-PROVERA SUSP 2 VIDAZA SUSR (Use NP PA; SP Azacitidine) ELIGARD KIT 2 PA; SP XELODA TABS (Use NP PA; SP PA; SP Capecitabine) EMCYT CAPS 2 Antineoplastic - Angiogenesis Inhibitors ERLEADA TABS 2 PA; SP AVASTIN SOLN 2 PA; SP exemestane tabs 1 PA; SP ZALTRAP SOLN 2 PA; SP

MHS Indiana Preferred Drug List Updated December 1, 2018

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FARESTON TABS 2 PA Antineoplastic - Immunomodulators POMALYST CAPS 2 PA; SP FEMARA TABS (Use NP Letrozole) Antineoplastic Antibiotics FIRMAGON SOLR 2 PA; SP mitoxantrone hcl conc 1 PA; SP flutamide caps 1 VALSTAR SOLN 2 PA; SP PA; Limit 5ml per Antineoplastic Enzyme Inhibitors HYDROXYPROGESTERO 2 month;QL(0.16 PA; SP NE CAPROATE SOLN 7 ml daily); AFINITOR DISPERZ TBSO 2 1.25 GM/5ML AL(At least 16 PA; SP yrs old) AFINITOR TABS 2 letrozole tabs 1 BOSULIF TABS 100 MG, 2 PA; SP 500 MG PA; SP leuprolide acetate kit 1 BRAFTOVI CAPS 2 PA LUPRON DEPOT (1- 2 PA; SP PA; SP MONTH) KIT COTELLIC TABS 2 LUPRON DEPOT (3- 2 PA; SP PA; SP MONTH) KIT FARYDAK CAPS 2 PA; SP LUPRON DEPOT (4- 2 PA; SP GILOTRIF TABS 2 MONTH) KIT GLEEVEC TABS (Use PA; SP LUPRON DEPOT (6- 2 PA; SP NP MONTH) KIT Imatinib Mesylate) PA; SP LYSODREN TABS 2 PA; SP IBRANCE CAPS 2 PA; SP MEGACE ORAL SUSP NP ICLUSIG TABS 2 (Use Megestrol Acetate) PA; SP megestrol acetate susp 1 imatinib mesylate tabs 1 PA; SP megestrol acetate tabs 1 INLYTA TABS 2 PV ISTODAX (OVERFILL) 2 PA; SP tamoxifen citrate tabs $0 SOLR PA; SP TRELSTAR MIXJECT 2 PA; SP JAKAFI TABS 2 SUSR PA TRELSTAR SUSR 2 PA; SP KYPROLIS SOLR 60 MG 2 PA; SP VANTAS KIT 2 PA; SP MEKINIST TABS 2 PA XTANDI CAPS 2 PA; SP MEKTOVI TABS 2 PA; SP ZOLADEX IMPL 2 PA; SP NEXAVAR TABS 2 NINLARO CAPS 2 PA; SP ZYTIGA TABS (Use NP PA; SP Abiraterone Acetate)

MHS Indiana Preferred Drug List Updated December 1, 2018

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROMIDEPSIN SOLR 2 PA; SP INTRON A W/DILUENT 2 PA; SP SOLR PA; SP SPRYCEL TABS 2 MATULANE CAPS 2 PA; SP PA; SP STIVARGA TABS 2 PROLEUKIN SOLR 2 PA; SP PA; SP SUTENT CAPS 2 SYLATRON KIT 2 PA; SP PA; SP TAFINLAR CAPS 2 SYNRIBO SOLR 2 PA; SP PA; SP TARCEVA TABS 2 TARGRETIN CAPS OR 75 NP PA; SP MG (Use Bexarotene) TASIGNA CAPS 150 MG, PA; SP 2 tretinoin (chemotherapy) 1 PA; SP 200 MG caps PA; SP temsirolimus soln 1 Chemotherapy Adjuncts PA TORISEL SOLN (Use NP PA; SP KEPIVANCE SOLR 2 Temsirolimus) Chemotherapy Rescue/Antidote Agents TYKERB TABS 2 PA; SP FUSILEV SOLR (Use NP PA; SP VELCADE SOLR 2 PA; SP Levoleucovorin Calcium) LEUCOVORIN CALCIUM 2 VOTRIENT TABS 2 PA; SP TABS OR 10 MG, 15 MG leucovorin calcium tabs or 1 XALKORI CAPS 2 PA; SP 5 mg, 25 mg PA; SP ZELBORAF TABS 2 PA; SP levoleucovorin calcium soln 1 PA; SP ZOLINZA CAPS 2 PA; SP levoleucovorin calcium solr 1 PA; SP LEVOLEUCOVORIN SOLN PA; SP ZYKADIA CAPS 2 250 MG/25ML (Use NP Levoleucovorin Calcium) Antineoplastic Enzymes mesna soln 1 PA; SP ONCASPAR SOLN 2 PA; SP MESNEX SOLN IV 100 NP PA; SP Antineoplastics Misc. MG/ML (Use Mesna) PA; SP ACTIMMUNE SOLN 2 MESNEX TABS OR 400 2 PA; SP MG bexarotene caps 1 PA; SP Mitotic Inhibitors ETOPOSIDE CAPS OR 50 PA HYDREA CAPS (Use NP 2 Hydroxyurea) MG etoposide soln iv 100 1 PA hydroxyurea caps 1 mg/5ml PA; SP INTRON A SOLN 2 PA; SP HALAVEN SOLN 2 PA; SP INTRON A SOLR 2 PA; SP IXEMPRA KIT SOLR 2

MHS Indiana Preferred Drug List Updated December 1, 2018

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JEVTANA SOLN 2 PA; SP carbidopa-levodopa tabs 10mg-100mg, 25mg- 1 Topoisomerase I Inhibitors 100mg, 25mg-250mg carbidopa-levodopa tbcr HYCAMTIN CAPS OR 0.25 2 PA; SP MG, 1 MG 25mg-100mg, 50mg- 1 200mg HYCAMTIN SOLR IV 4 MG NP PA; SP (Use Topotecan HCl) MIRAPEX TABS (Use QL(3 ea daily); Pramipexole NP AL(At least 18 topotecan hcl soln 4 1 PA; SP Dihydrochloride) yrs old) mg/4ml PARLODEL CAPS (Use NP TOPOTECAN HCL SOLN 2 PA; SP Bromocriptine Mesylate) 4 MG/4ML PARLODEL TABS (Use NP TOPOTECAN HCL SOLN PA; SP Bromocriptine Mesylate) 4 MG/4ML (Use Topotecan NP HCl) pramipexole QL(3 ea daily); dihydrochloride tabs 0.125 1 AL(At least 18 topotecan hcl solr 4 mg 1 PA; SP mg, 0.25 mg, 0.75 mg, 0.5 yrs old) mg, 1 mg, 1.5 mg ANTIPARKINSON AND RELATED THERAPY REQUIP TABS 0.25 MG, 3 QL(6 ea daily) AGENTS - Drugs to Treat Parkinson's Disease MG, 4 MG (Use Ropinirole NP Antiparkinson Adjuvants Hydrochloride) REQUIP TABS 0.5 MG, 1 QL(3 ea daily) carbidopa tabs 1 MG, 2 MG, 5 MG (Use NP Ropinirole Hydrochloride) LODOSYN TABS (Use NP Carbidopa) ropinirole hydrochloride 1 QL(6 ea daily) Antiparkinson Anticholinergics tabs 0.25 mg, 3 mg, 4 mg ropinirole hydrochloride QL(3 ea daily) benztropine mesylate soln 1 tabs 0.5 mg, 1 mg, 2 mg, 5 1 mg benztropine mesylate tabs 1 SINEMET CR TBCR (Use NP Carbidopa-Levodopa) COGENTIN SOLN (Use NP Benztropine Mesylate) SINEMET TABS (Use NP Carbidopa-Levodopa) trihexyphenidyl hcl elix 0.4 1 QL(16.67 ml mg/ml daily) Antiparkinson Monoamine Oxidase Inhibitors trihexyphenidyl hcl tabs 2 1 ELDEPRYL CAPS (Use NP mg, 5 mg Selegiline HCl) Antiparkinson Dopaminergics selegiline hcl caps or 1 amantadine hcl caps 100 1 mg SELEGILINE HCL POWD 2 XX amantadine hcl syrp 50 1 mg/5ml selegiline hcl tabs or 1 bromocriptine mesylate 1 caps ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to Treat Mood Disorders bromocriptine mesylate 1 tabs Antimanic Agents lithium carbonate caps or 1 150 mg, 300 mg, 600 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITHIUM CARBONATE QL(2 ea daily); ziprasidone hcl caps 20 1 AL(At least 18 CAPS OR 150 MG, 600 2 mg, 40 mg MG (Use Lithium yrs old) Carbonate) QL(3 ea daily); ziprasidone hcl caps 60 1 AL(At least 18 LITHIUM CARBONATE 2 mg, 80 mg POWD XX yrs old) lithium carbonate tabs or 1 Benzisoxazoles 300 mg QL(2 ea daily); lithium carbonate tbcr or 1 FANAPT TABS 2 AL(At least 18 300 mg, 450 mg yrs old) LITHIUM SOLN 2 QL(2 ea daily); FANAPT TITRATION 2 AL(At least 18 PACK TABS LITHOBID TBCR (Use 2 yrs old) Lithium Carbonate) Limit 1 syringe Antipsychotics - Misc. each QL(4 ea daily) INVEGA SUSTENNA 2 month;QL(0.02 EQUETRO CP12 100 MG 2 SUSP 117 MG/0.75ML 7 ml daily); QL(8 ea daily) AL(At least 18 EQUETRO CP12 200 MG 2 yrs old) QL(5 ea daily) Limit 1 syringe EQUETRO CP12 300 MG 2 each GEODON CAPS OR 20 QL(2 ea daily); INVEGA SUSTENNA 2 month;QL(0.03 MG, 40 MG (Use NP AL(At least 18 SUSP 156 MG/ML 6 ml daily); Ziprasidone HCl) yrs old) AL(At least 18 yrs old) GEODON CAPS OR 60 QL(3 ea daily); MG, 80 MG (Use NP AL(At least 18 Limit 1 syringe Ziprasidone HCl) yrs old) each INVEGA SUSTENNA month;QL(0.05 AL(At least 18 2 GEODON SOLR IM 20 MG 2 SUSP 234 MG/1.5ML 4 ml daily); yrs old) AL(At least 18 QL(1 ea daily); yrs old) LATUDA TABS 20 MG, 40 2 AL(At least 10 MG, 60 MG, 120 MG Limit 1 syringe yrs old) each QL(2 ea daily); INVEGA SUSTENNA 2 month;QL(0.00 LATUDA TABS 80 MG 2 AL(At least 10 SUSP 39 MG/0.25ML 9 ml daily); yrs old) AL(At least 18 PA; QL(2 ea yrs old) NUPLAZID TABS 17 MG 2 daily) Limit 1 syringe QL(2 ea daily); each VRAYLAR CAPS 1.5 MG 2 AL(At least 18 INVEGA SUSTENNA 2 month;QL(0.01 yrs old) SUSP 78 MG/0.5ML 8 ml daily); QL(1 ea daily); AL(At least 18 VRAYLAR CAPS 3 MG, 6 2 yrs old) MG, 4.5 MG AL(At least 18 yrs old) INVEGA TB24 3 MG, 9 QL(1 ea daily) QL(1 ea MG, 1.5 MG (Use NP VRAYLAR CPPK 2 daily,28 day(s) Paliperidone) limit) INVEGA TB24 6 MG (Use NP QL(2 ea daily) Paliperidone)

MHS Indiana Preferred Drug List Updated December 1, 2018

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 syringe haloperidol tabs or 0.5 mg, QL(3 ea daily) every 3 1 mg, 2 mg, 5 mg, 10 mg, 1 INVEGA TRINZA SUSP 2 months;AL(At 20 mg least 18 yrs old) Dibenzapines QL(3 ea daily); paliperidone tb24 3 mg, 9 1 QL(1 ea daily) 2 mg, 1.5 mg CLOZAPINE ODT TBDP AL(At least 18 yrs old) QL(2 ea daily) paliperidone tb24 6 mg 1 QL(6 ea daily); clozapine tabs 100 mg 1 AL(At least 18 QL(0.072 ea yrs old) RISPERDAL CONSTA 2 daily); AL(At SUSR least 18 yrs QL(3 ea daily); clozapine tabs 25 mg, 50 1 AL(At least 18 old) mg, 200 mg yrs old) RISPERDAL M-TAB TBDP NP QL(2 ea daily) (Use Risperidone) QL(6 ea daily); clozapine tbdp 100 mg 1 AL(At least 18 RISPERDAL SOLN 1 NP QL(8 ml daily) yrs old) MG/ML (Use Risperidone) QL(3 ea daily); RISPERDAL TABS 0.25 QL(2 ea daily) clozapine tbdp 25 mg, 12.5 1 AL(At least 18 mg MG, 0.5 MG, 1 MG, 2 MG, NP yrs old) 3 MG, 4 MG (Use Risperidone) QL(6 ea daily); CLOZARIL TABS 100 MG 2 (Use Clozapine) AL(At least 18 RISPERIDONE ODT TBDP 2 QL(2 ea daily) yrs old) QL(8 ml daily) QL(3 ea daily); risperidone soln 1 mg/ml 1 CLOZARIL TABS 25 MG 2 AL(At least 18 (Use Clozapine) risperidone tabs 0.25 mg, QL(2 ea daily) yrs old) 0.5 mg, 1 mg, 2 mg, 3 mg, 1 QL(6 ea daily); FAZACLO TBDP 100 MG 2 AL(At least 18 4 mg (Use Clozapine) risperidone tbdp 0.25 mg, QL(2 ea daily) yrs old) 0.5 mg, 1 mg, 2 mg, 3 mg, 1 QL(3 ea daily); FAZACLO TBDP 12.5 MG NP AL(At least 18 4 mg (Use Clozapine) yrs old) Butyrophenones QL(3 ea daily); HALDOL DECANOATE AL(At least 18 FAZACLO TBDP 150 MG, 2 200 MG AL(At least 18 100 SOLN (Use NP yrs old) yrs old) Haloperidol Decanoate) QL(3 ea daily); HALDOL DECANOATE 50 AL(At least 18 FAZACLO TBDP 25 MG 2 (Use Clozapine) AL(At least 18 SOLN (Use Haloperidol NP yrs old) yrs old) Decanoate) QL(4 ea daily); HALDOL SOLN (Use NP loxapine succinate caps 1 AL(At least 18 Haloperidol Lactate) yrs old) AL(At least 18 haloperidol decanoate soln 1 yrs old) olanzapine solr im 10 mg 1 haloperidol lactate conc 1 olanzapine tabs or 10 mg, 1 QL(2 ea daily) 15 mg haloperidol lactate soln 1 olanzapine tabs or 20 mg 1 QL(3 ea daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine tabs or 5 mg, 1 QL(1 ea daily) QL(0.072 ea 2.5 mg, 7.5 mg ZYPREXA RELPREVV 2 daily); AL(At SUSR 210 MG, 300 MG least 18 yrs olanzapine tbdp or 10 mg, 1 QL(2 ea daily) 15 mg old) QL(0.036 ea olanzapine tbdp or 20 mg 1 QL(3 ea daily) ZYPREXA RELPREVV 2 daily); AL(At QL(1 ea daily) SUSR 405 MG least 18 yrs olanzapine tbdp or 5 mg 1 old) quetiapine fumarate tabs QL(3 ea daily) ZYPREXA SOLR IM 10 NP 25 mg, 50 mg, 100 mg, 200 1 MG (Use Olanzapine) mg ZYPREXA TABS OR 10 QL(2 ea daily) MG, 15 MG (Use NP quetiapine fumarate tabs 1 QL(4 ea daily) 300 mg, 400 mg Olanzapine) ZYPREXA TABS OR 20 QL(3 ea daily) quetiapine fumarate tb24 1 QL(1 ea daily) NP 150 mg, 200 mg MG (Use Olanzapine) ZYPREXA TABS OR 5 QL(1 ea daily) quetiapine fumarate tb24 1 QL(3 ea daily) 300 mg MG, 2.5 MG, 7.5 MG (Use NP Olanzapine) quetiapine fumarate tb24 1 QL(4 ea daily) 400 mg ZYPREXA ZYDIS TBDP 10 QL(2 ea daily) MG, 15 MG (Use NP quetiapine fumarate tb24 1 QL(2 ea daily) 50 mg Olanzapine) QL(2 ea daily) ZYPREXA ZYDIS TBDP 20 NP QL(3 ea daily) SAPHRIS SUBL 2 MG (Use Olanzapine) SEROQUEL TABS 25 MG, QL(3 ea daily) ZYPREXA ZYDIS TBDP 5 NP QL(1 ea daily) 50 MG, 100 MG, 200 MG NP MG (Use Olanzapine) (Use Quetiapine Fumarate) Dihydroindolones SEROQUEL TABS 300 QL(4 ea daily) MOLINDONE QL(9 ea daily) MG, 400 MG (Use NP HYDROCHLORIDE TABS 2 Quetiapine Fumarate) 25 MG SEROQUEL XR TB24 150 QL(1 ea daily) MOLINDONE QL(4 ea daily) MG, 200 MG (Use NP HYDROCHLORIDE TABS 2 Quetiapine Fumarate) 5 MG, 10 MG SEROQUEL XR TB24 300 QL(3 ea daily) MG (Use Quetiapine NP Phenothiazines Fumarate) CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50 2 SEROQUEL XR TB24 400 QL(4 ea daily) MG/2ML MG (Use Quetiapine NP Fumarate) chlorpromazine hcl tabs or QL(4 ea daily) 10 mg, 25 mg, 50 mg, 100 1 SEROQUEL XR TB24 50 QL(2 ea daily) mg, 200 mg MG (Use Quetiapine NP Fumarate) fluphenazine decanoate 1 AL(At least 18 soln yrs old) QL(12 ml FLUPHENAZINE HCL AL(At least 18 2 daily); AL(At 2 VERSACLOZ SUSP least 18 yrs CONC OR 5 MG/ML yrs old) old) FLUPHENAZINE HCL 2 AL(At least 18 ELIX OR 2.5 MG/5ML yrs old)

MHS Indiana Preferred Drug List Updated December 1, 2018

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUPHENAZINE HCL AL(At least 18 QL(1.5 ea 2 aripiprazole tabs 5 mg 1 SOLN IJ 2.5 MG/ML yrs old) daily) QL(4 ea daily); aripiprazole tbdp 10 mg, 15 1 QL(2 ea daily) fluphenazine hcl tabs or 1 1 AL(At least 18 mg mg, 5 mg, 10 mg, 2.5 mg yrs old) QL(2.4 ml per QL(4 ea daily); 180 days perphenazine tabs 1 AL(At least 18 ARISTADA INITIO PRSY 2 retail); AL(At yrs old) least 18 yrs old) prochlorperazine edisylate 1 soln QL(4 ml per 56 ARISTADA PRSY 1064 days retail); PROCHLORPERAZINE 2 2 MALEATE POWD XX MG/3.9ML AL(At least 18 yrs old) prochlorperazine maleate 1 tabs or 5 mg, 10 mg Limit 1 syringe each prochlorperazine supp 1 ARISTADA PRSY 441 2 month;QL(0.05 MG/1.6ML 7 ml daily); thioridazine hcl tabs 1 QL(4 ea daily) AL(At least 18 yrs old) trifluoperazine hcl tabs 1 1 QL(2 ea daily) mg, 2 mg, 5 mg Limit 1 syringe each trifluoperazine hcl tabs 10 QL(4 ea daily) 1 ARISTADA PRSY 662 2 month;QL(0.08 mg MG/2.4ML 6 ml daily); Quinolinone Derivatives AL(At least 18 QL(0.36 ea yrs old) daily,1 ea per Limit 1 syringe ABILIFY MAINTENA PRSY 2 28 days retail); each AL(At least 18 ARISTADA PRSY 882 2 month;QL(0.11 yrs old) MG/3.2ML 43 ml daily); QL(0.36 ea AL(At least 18 daily,1 ea per yrs old) ABILIFY MAINTENA SRER 2 28 days retail); QL(1 ea daily); AL(At least 18 REXULTI TABS 2 AL(At least 18 yrs old) yrs old) ABILIFY TABS 2 MG, 10 QL(1 ea daily) Thioxanthenes MG, 15 MG, 30 MG (Use NP QL(3 ea daily) Aripiprazole) thiothixene caps 1 ABILIFY TABS 20 MG (Use NP QL(2 ea daily) Aripiprazole) ANTISEPTICS & DISINFECTANTS ABILIFY TABS 5 MG (Use NP QL(1.5 ea Antiseptics & Disinfectants Aripiprazole) daily) formaldehyde soln 10%, 10 1 QL(90 ml per aripiprazole soln 1 mg/ml 1 QL(30 ml daily) % fill retail) Chlorine Antiseptics aripiprazole tabs 2 mg, 10 1 QL(1 ea daily) mg, 15 mg, 30 mg chlorhexidine gluconate 1 liqd 4 % aripiprazole tabs 20 mg 1 QL(2 ea daily) dakin's solution soln 1

MHS Indiana Preferred Drug List Updated December 1, 2018

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DAKINS SOLUTION FULL CRIXIVAN CAPS 200 MG 2 QL(9 ea daily) STRENGTH SOLN (Use NP Dakin's Solution) CRIXIVAN CAPS 400 MG 2 QL(6 ea daily) DAKINS SOLUTION HALF STRENGTH SOLN (Use NP DESCOVY TABS 2 QL(1 ea daily) Dakin's Solution) DAKINS SOLUTION didanosine cpdr 1 QL(1 ea daily) QUARTER STRENGTH NP SOLN (Use Dakin's EDURANT TABS 2 QL(1 ea daily) Solution) QL(1 ea daily) HIBICLENS LIQD (Use NP efavirenz caps 200 mg 1 Chlorhexidine Gluconate) QL(2 ea daily) Iodine Antiseptics efavirenz caps 50 mg 1 BETADINE SOLN 10 % NP efavirenz tabs 600 mg 1 QL(1 ea daily) (Use Povidone-Iodine) QL(1 ea daily) povidone-iodine soln 10 % 1 EMTRIVA CAPS 200 MG 2 EMTRIVA SOLN 10 2 QL(24 ml daily) ANTIVIRALS - Drugs to Treat Viral Infections MG/ML Antiretrovirals EPIVIR SOLN 10 MG/ML NP QL(30 ml daily) (Use Lamivudine) abacavir sulfate soln 20 1 QL(30 ml daily) mg/ml EPIVIR TABS 150 MG NP QL(2 ea daily) (Use Lamivudine) abacavir sulfate tabs 300 1 QL(2 ea daily) mg EPIVIR TABS 300 MG NP QL(1 ea daily) (Use Lamivudine) abacavir sulfate-lamivudine 1 QL(1 ea daily) tabs EPZICOM TABS (Use QL(1 ea daily) Abacavir Sulfate- NP abacavir sulfate- 1 QL(2 ea daily) Lamivudine) lamivudine-zidovudine tabs EVOTAZ TABS 2 QL(1 ea daily) APTIVUS CAPS 250 MG 2 QL(4 ea daily) fosamprenavir calcium tabs 1 QL(4 ea daily) APTIVUS SOLN 100 2 QL(10 ml daily) MG/ML FUZEON SOLR 2 PA atazanavir sulfate caps 150 1 QL(2 ea daily) mg, 200 mg GENVOYA TABS 2 QL(1 ea daily) atazanavir sulfate caps 300 1 mg INTELENCE TABS 200 2 QL(2 ea daily) ATRIPLA TABS 2 QL(1 ea daily) MG INTELENCE TABS 25 MG, 2 QL(4 ea daily) BIKTARVY TABS 2 QL(1 ea daily) 100 MG INVIRASE CAPS 200 MG 2 QL(10 ea daily) CIMDUO TABS 2 QL(1 ea daily) INVIRASE TABS 500 MG 2 QL(4 ea daily) COMBIVIR TABS (Use NP QL(2 ea daily) Lamivudine-Zidovudine) ISENTRESS CHEW 100 2 QL(6 ea daily) COMPLERA TABS 2 ST; QL(1 ea MG daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISENTRESS CHEW 25 MG 2 QL(12 ea daily) PREZCOBIX TABS 2 QL(1 ea daily)

ISENTRESS HD TABS 2 QL(2 ea daily) PREZISTA SUSP 100 2 QL(12 ml daily) MG/ML ISENTRESS PACK 100 2 QL(2 ea daily) QL(3 ea daily) MG PREZISTA TABS 150 MG 2 ISENTRESS TABS 400 2 QL(2 ea daily) PREZISTA TABS 75 MG, 2 QL(2 ea daily) MG 600 MG JULUCA TABS 2 QL(1 ea daily) PREZISTA TABS 800 MG 2 QL(1 ea daily)

KALETRA SOLN QL(16 ml daily) RESCRIPTOR TABS 100 2 QL(12 ea daily) 400MG/5ML-100MG/5ML NP MG (Use Lopinavir-Ritonavir) RESCRIPTOR TABS 200 2 QL(6 ea daily) KALETRA TABS 100MG- 2 QL(4 ea daily) MG 25MG RETROVIR CAPS 100 MG NP QL(6 ea daily) KALETRA TABS 200MG- 2 QL(6 ea daily) (Use Zidovudine) 50MG RETROVIR IV INFUSION 2 PA lamivudine soln 10 mg/ml 1 QL(30 ml daily) SOLN RETROVIR SYRP 50 NP QL(60 ml daily) lamivudine tabs 150 mg 1 QL(2 ea daily) MG/5ML (Use Zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) lamivudine tabs 300 mg 1 QL(1 ea daily) 200 MG (Use Atazanavir NP Sulfate) lamivudine-zidovudine tabs 1 QL(2 ea daily) REYATAZ CAPS 300 MG NP (Use Atazanavir Sulfate) LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily) REYATAZ PACK 50 MG 2 QL(6 ea daily) LEXIVA TABS 700 MG QL(4 ea daily) (Use Fosamprenavir NP ritonavir tabs 1 QL(12 ea daily) Calcium) QL(16 ml daily) SELZENTRY SOLN 20 2 QL(35 ml daily) lopinavir-ritonavir soln 1 MG/ML QL(40 ml daily) SELZENTRY TABS 25 2 QL(2 ea daily) nevirapine susp 50 mg/5ml 1 MG, 75 MG, 150 MG nevirapine tabs 200 mg 1 QL(2 ea daily) SELZENTRY TABS 300 2 QL(4 ea daily) MG QL(3 ea daily) nevirapine tb24 100 mg 1 stavudine caps 1 QL(2 ea daily) QL(1 ea daily) nevirapine tb24 400 mg 1 STRIBILD TABS 2 ST; QL(1 ea daily) QL(12 ea daily) NORVIR CAPS 100 MG 2 SUSTIVA CAPS 200 MG NP QL(1 ea daily) (Use Efavirenz) NORVIR SOLN 80 MG/ML 2 QL(15 ml daily) SUSTIVA CAPS 50 MG NP QL(2 ea daily) (Use Efavirenz) NORVIR TABS 100 MG NP QL(12 ea daily) (Use Ritonavir) SUSTIVA TABS 600 MG NP QL(1 ea daily) (Use Efavirenz) ODEFSEY TABS 2 QL(1 ea daily) SYMFI LO TABS 2 QL(1 ea daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYMFI TABS 2 QL(1 ea daily) ZERIT CAPS 15 MG, 20 QL(2 ea daily) MG, 30 MG, 40 MG (Use NP Stavudine) tenofovir disoproxil 1 QL(1 ea daily) fumarate tabs ZERIT SOLR 1 MG/ML 2 QL(80 ml daily) TIVICAY TABS 10 MG, 25 2 MG ZIAGEN SOLN 20 MG/ML NP QL(30 ml daily) (Use Abacavir Sulfate) TIVICAY TABS 50 MG 2 QL(2 ea daily) ZIAGEN TABS 300 MG NP QL(2 ea daily) QL(1 ea daily); (Use Abacavir Sulfate) TRIUMEQ TABS 2 AL(At least 18 QL(6 ea daily) yrs old) zidovudine caps 100 mg 1 TRIZIVIR TABS (Use QL(2 ea daily) zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) Abacavir Sulfate- NP Lamivudine-Zidovudine) zidovudine tabs 300 mg 1 QL(2 ea daily) TRUVADA TABS 2 QL(1 ea daily) CMV Agents QL(1 ea daily); VALCYTE TABS 450 MG NP QL(2 ea daily) TYBOST TABS 2 AL(At least 18 (Use Valganciclovir HCl) yrs old) valganciclovir hcl tabs 450 1 QL(2 ea daily) VIDEX EC CPDR 125 MG 2 QL(1 ea daily) mg VIDEX EC CPDR 200 MG, QL(1 ea daily) Hepatitis Agents 250 MG, 400 MG (Use NP adefovir dipivoxil tabs 1 PA Didanosine) QL(20 ml daily) BARACLUDE TABS 0.5 NP PA VIDEXPEDIATRIC SOLR 2 MG, 1 MG (Use Entecavir) VIRACEPT TABS 250 MG 2 QL(9 ea daily) COPEGUS TABS (Use CO PA Ribavirin (Hepatitis C)) QL(4 ea daily) VIRACEPT TABS 625 MG 2 DAKLINZA TABS CO PA VIRAMUNE SUSP 50 NP QL(40 ml daily) PA MG/5ML (Use Nevirapine) entecavir tabs 1 VIRAMUNE TABS 200 MG NP QL(2 ea daily) EPCLUSA TABS CO (Use Nevirapine) VIRAMUNE XR TB24 100 NP QL(3 ea daily) HARVONI TABS CO MG (Use Nevirapine) HEPSERA TABS (Use PA VIRAMUNE XR TB24 400 NP QL(1 ea daily) NP MG (Use Nevirapine) Adefovir Dipivoxil) QL(8 gm daily) LEDIPASVIR/SOFOSBUVI CO VIREAD POWD 40 MG/GM 2 R TABS MODERIBA 1200 DOSE PA VIREAD TABS 150 MG, 2 QL(1 ea daily) CO 200 MG, 250 MG PACK TABS VIREAD TABS 300 MG QL(1 ea daily) MODERIBA 800 DOSE CO PA (Use Tenofovir Disoproxil NP PACK TABS ) Fumarate OLYSIO CAPS CO PA QL(1 ea daily); VITEKTA TABS 2 AL(At least 18 PEG-INTRON REDIPEN CO PA yrs old) KIT MHS Indiana Preferred Drug List Updated December 1, 2018

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGASYS PROCLICK CO PA valacyclovir hcl tabs 1 gm, 1 QL(42 ea per SOLN 1000 mg 21 days retail) PEGASYS SOLN CO PA valacyclovir hcl tabs 500 1 QL(2 ea daily) mg PA PEGINTRON KIT CO VALTREX TABS 1 GM NP QL(42 ea per (Use Valacyclovir HCl) 21 days retail) REBETOL CAPS 200 MG PA VALTREX TABS 500 MG NP QL(2 ea daily) (Use Ribavirin (Hepatitis CO (Use Valacyclovir HCl) C)) ZOVIRAX CAPS OR 200 NP QL(1.67 ea REBETOL SOLN 40 CO PA MG (Use Acyclovir) daily) MG/ML ZOVIRAX SUSP OR 200 NP QL(13.34 ml RIBASPHERE RIBAPAK CO PA MG/5ML (Use Acyclovir) daily) TABS 400 MG, 600 MG ZOVIRAX TABS OR 400 NP QL(3 ea daily) RIBASPHERE TABS 400 CO PA MG (Use Acyclovir) MG, 600 MG ZOVIRAX TABS OR 800 NP QL(1.67 ea ribavirin (hepatitis c) caps CO PA MG (Use Acyclovir) daily) Influenza Agents ribavirin (hepatitis c) tabs CO PA oseltamivir phosphate caps 1 QL(20 ea per or 30 mg 30 days retail) SOFOSBUVIR/VELPATAS CO VIR TABS oseltamivir phosphate caps 1 QL(10 ea per SOVALDI TABS CO PA or 45 mg, 75 mg 30 days retail) oseltamivir phosphate susr 1 QL(120 ml per TECHNIVIE TABS CO or 6 mg/ml 30 days retail) RELENZA DISKHALER 2 AL(At least 6 VIEKIRA PAK TBPK CO AEPB yrs old) TAMIFLU CAPS 30 MG QL(20 ea per VIEKIRA XR TB24 CO (Use Oseltamivir NP 30 days retail) Phosphate) VOSEVI TABS CO TAMIFLU CAPS 45 MG, 75 QL(10 ea per MG (Use Oseltamivir NP 30 days retail) ZEPATIER TABS CO Phosphate) Herpes Agents TAMIFLU SUSR 6 MG/ML QL(120 ml per (Use Oseltamivir NP 30 days retail) QL(1.67 ea acyclovir caps 200 mg 1 Phosphate) daily) QL(13.34 ml BETA BLOCKERS - Drugs to Treat High Blood acyclovir susp 200 mg/5ml 1 daily) Pressure Alpha-Beta Blockers acyclovir tabs 400 mg 1 QL(3 ea daily) carvedilol phosphate cp24 1 QL(1 ea daily) QL(1.67 ea acyclovir tabs 800 mg 1 daily) carvedilol tabs 12.5 mg, 1 QL(2 ea daily) 6.25 mg, 3.125 mg famciclovir tabs 1 carvedilol tabs 25 mg 1 QL(4 ea daily) FAMVIR TABS (Use NP Famciclovir) COREG CR CP24 (Use NP QL(1 ea daily) Carvedilol Phosphate)

MHS Indiana Preferred Drug List Updated December 1, 2018

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COREG TABS 12.5 MG, QL(2 ea daily) BETAPACE TABS (Use NP 6.25 MG, 3.125 MG (Use NP Sotalol HCl) Carvedilol) CORGARD TABS (Use NP QL(2 ea daily) COREG TABS 25 MG (Use NP QL(4 ea daily) Nadolol) Carvedilol) HEMANGEOL SOLN 2 PA labetalol hcl tabs or 100 mg 1 QL(3 ea daily) INDERAL LA CP24 (Use NP labetalol hcl tabs or 200 mg 1 QL(6 ea daily) Propranolol HCl) INDERAL XL CP24 2 labetalol hcl tabs or 300 mg 1 QL(8 ea daily) INNOPRAN XL CP24 2 Beta Blockers Cardio-Selective QL(2 ea daily) acebutolol hcl caps 1 nadolol tabs 1 atenolol tabs 1 QL(2 ea daily) pindolol tabs 1 QL(1 ea daily) propranolol hcl cp24 or 60 bisoprolol fumarate tabs 1 mg, 80 mg, 120 mg, 160 1 LOPRESSOR TABS 100 QL(4.5 ea mg MG (Use Metoprolol NP daily) PROPRANOLOL HCL 2 Tartrate) POWD XX LOPRESSOR TABS 50 QL(4 ea daily) propranolol hcl soln iv 1 1 MG (Use Metoprolol NP mg/ml Tartrate) PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40 2 metoprolol succinate tb24 1 QL(2 ea daily) 200 mg MG/5ML propranolol hcl tabs or 10 metoprolol succinate tb24 1 QL(4 ea daily) 25 mg, 50 mg, 100 mg mg, 20 mg, 40 mg, 60 mg, 1 80 mg metoprolol tartrate tabs or 1 QL(4.5 ea 100 mg daily) sotalol hcl (afib/afl) tabs 1 QL(2 ea daily) metoprolol tartrate tabs or 1 QL(4 ea daily) 25 mg, 50 mg sotalol hcl tabs 1 SECTRAL CAPS (Use NP Acebutolol HCl) TIMOLOL MALEATE TABS 2 TENORMIN TABS (Use NP QL(2 ea daily) Atenolol) CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure TOPROL XL TB24 200 MG NP QL(2 ea daily) (Use Metoprolol Succinate) Calcium Channel Blockers TOPROL XL TB24 25 MG, QL(4 ea daily) ADALAT CC TB24 30 MG, NP QL(1 ea daily) 50 MG, 100 MG (Use NP 90 MG (Use Nifedipine) Metoprolol Succinate) ADALAT CC TB24 60 MG NP QL(2 ea daily) (Use Nifedipine) ZEBETA TABS (Use NP QL(1 ea daily) Bisoprolol Fumarate) amlodipine besylate tabs 1 QL(1 ea daily) Beta Blockers Non-Selective CALAN SR TBCR (Use NP QL(2 ea daily) BETAPACE AF TABS (Use NP QL(2 ea daily) Verapamil HCl) Sotalol HCl (AFIB/AFL))

MHS Indiana Preferred Drug List Updated December 1, 2018

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALAN TABS (Use NP QL(3 ea daily) PROCARDIA XL TB24 30 QL(1 ea daily) Verapamil HCl) MG, 90 MG (Use NP CARDIZEM CD CP24 120 QL(1 ea daily) Nifedipine) MG, 180 MG, 300 MG (Use NP PROCARDIA XL TB24 60 NP QL(2 ea daily) Diltiazem HCl Coated MG (Use Nifedipine) Beads) TIAZAC CP24 120 MG, QL(1 ea daily) CARDIZEM CD CP24 240 QL(2 ea daily) 180 MG, 300 MG, 360 MG, NP MG (Use Diltiazem HCl NP 420 MG (Use Diltiazem HCl Coated Beads) Extended Release Beads) CARDIZEM TABS (Use NP QL(3 ea daily) TIAZAC CP24 240 MG QL(2 ea daily) Diltiazem HCl) (Use Diltiazem HCl NP diltiazem hcl coated beads QL(1 ea daily) Extended Release Beads) cp24 120 mg, 180 mg, 300 1 verapamil hcl cp24 or 100 1 QL(2 ea daily) mg mg, 200 mg diltiazem hcl coated beads 1 QL(2 ea daily) verapamil hcl cp24 or 120 QL(1 ea daily) cp24 240 mg mg, 180 mg, 240 mg, 300 1 mg diltiazem hcl cp12 or 60 1 QL(2 ea daily) mg, 90 mg, 120 mg VERAPAMIL HCL SR 2 QL(1 ea daily) CP24 diltiazem hcl cp24 or 120 1 QL(1 ea daily) mg, 180 mg verapamil hcl tabs or 40 1 QL(3 ea daily) mg, 80 mg, 120 mg diltiazem hcl cp24 or 240 1 QL(2 ea daily) mg verapamil hcl tbcr or 120 1 QL(2 ea daily) diltiazem hcl extended QL(1 ea daily) mg, 180 mg, 240 mg release beads cp24 120 1 VERELAN CP24 120 MG, QL(1 ea daily) mg, 180 mg, 300 mg, 360 180 MG, 240 MG (Use NP mg, 420 mg Verapamil HCl) diltiazem hcl extended QL(2 ea daily) VERELAN CP24 360 MG 2 QL(1 ea daily) release beads cp24 240 1 mg VERELAN PM CP24 100 QL(2 ea daily) MG, 200 MG (Use NP diltiazem hcl tabs or 30 mg, 1 QL(3 ea daily) 60 mg, 90 mg, 120 mg Verapamil HCl) QL(1 ea daily) VERELAN PM CP24 300 NP QL(1 ea daily) felodipine tb24 1 MG (Use Verapamil HCl) nicardipine hcl caps or 20 1 CARDIOTONICS - Drugs to Treat Heart Failure mg, 30 mg and Abnormal Heart Rhythm nifedipine caps 10 mg, 20 QL(4 ea daily) 1 Cardiac Glycosides mg DIGOXIN SOLN OR 0.05 2 nifedipine tb24 30 mg, 90 1 QL(1 ea daily) MG/ML mg digoxin tabs or 0.125 mg, nifedipine tb24 60 mg 1 QL(2 ea daily) 0.25 mg, 125 mcg, 250 1 mcg NORVASC TABS (Use NP QL(1 ea daily) Amlodipine Besylate) LANOXIN TABS OR 125 MCG, 250 MCG (Use 2 PROCARDIA CAPS (Use NP QL(4 ea daily) Digoxin) Nifedipine) CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions

MHS Indiana Preferred Drug List Updated December 1, 2018

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Peripheral Vasodilators sildenafil citrate (pulmonary 1 PA; SP hypertension) tabs isoxsuprine hcl tabs 10 mg 1 tadalafil (pulmonary 1 PA; SP hypertension) tabs ISOXSUPRINE HCL TABS 2 20 MG Pulmonary Hypertension - Sol Guanylate Cyclase Prostaglandin Vasodilators ADEMPAS TABS 2 PA; SP epoprostenol sodium solr 1 PA; SP CEPHALOSPORINS - Drugs to Treat Bacterial Infections FLOLAN SOLR (Use NP PA; SP Epoprostenol Sodium) Cephalosporins - 1st Generation PA; SP ORENITRAM TBCR 2 cefadroxil caps 1 PA; SP REMODULIN SOLN 2 cefadroxil susr 1 PA; SP TYVASO REFILL SOLN 2 cefadroxil tabs 1 TYVASO SOLN 2 PA; SP cephalexin caps 250 mg, 1 500 mg TYVASO STARTER SOLN 2 PA; SP cephalexin susr 125 1 mg/5ml, 250 mg/5ml VELETRI SOLR 2 PA; SP KEFLEX CAPS 250 MG, NP 500 MG (Use Cephalexin) VENTAVIS SOLN 2 PA; SP Cephalosporins - 2nd Generation Pulmonary Hypertension - Endothelin Receptor cefaclor caps 250 mg, 500 1 LETAIRIS TABS 2 PA; SP mg CEFACLOR SUSR 125 OPSUMIT TABS 2 PA; SP MG/5ML, 250 MG/5ML, 2 375 MG/5ML PA; SP TRACLEER TABS 2 cefprozil susr 125 mg/5ml, 1 AL(Up to 12 yrs 250 mg/5ml old ) Pulmonary Hypertension - Phosphodiesterase cefprozil tabs 250 mg, 500 1 QL(20 ea per ADCIRCA TABS (Use PA; SP mg fill retail) Tadalafil (Pulmonary NP CEFTIN SUSR 2 AL(Up to 12 yrs Hypertension)) old ) REVATIO SOLN IV 10 PA; SP QL(20 ea per cefuroxime axetil tabs 1 MG/12.5ML (Use Sildenafil NP fill retail) Citrate (Pulmonary Hypertension)) Cephalosporins - 3rd Generation QL(20 ea per REVATIO SUSR OR 10 2 PA; SP cefdinir caps 300 mg 1 MG/ML fill retail) REVATIO TABS OR 20 PA; SP cefdinir susr 125 mg/5ml, 1 MG (Use Sildenafil Citrate NP 250 mg/5ml (Pulmonary Hypertension)) ceftriaxone sodium solr ij 1 1 QL(3 ea per fill gm, 250 mg, 500 mg retail) sildenafil citrate (pulmonary 1 PA; SP hypertension) soln ceftriaxone sodium solr iv 1 1 QL(3 ea per fill gm retail)

MHS Indiana Preferred Drug List Updated December 1, 2018

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHEMICALS CONTRACEPTIVES - Drugs to Prevent Pregnancy Bulk Chemicals - A's Combination Contraceptives - Oral ALPRAZOLAM POWD XX 2 BREVICON-28 TABS (Use PV Norethindrone & Eth NP ARGININE HCL POWD 2 RX/OTC Estradiol) RX/OTC CYCLESSA TABS (Use PV L-ARGININE HCL POWD 2 Desogestrel-Ethinyl NP Estradiol (Triphasic)) Bulk Chemicals - B's DESOGEN TABS (Use PV BUPROPION HCL POWD 2 Desogestrel & Ethinyl NP XX Estradiol) BUPROPION 2 desogestrel & ethinyl $0 PV HYDROCHLORIDE POWD estradiol tabs BUSPIRONE HCL POWD 2 desogestrel-ethinyl $0 PV XX estradiol (biphasic) tabs Bulk Chemicals - C's desogestrel-ethinyl $0 PV estradiol (triphasic) tabs CYPROHEPTADINE HCL 2 POWD XX drospirenone-ethinyl $0 QL(1 ea daily); estradiol tabs 3mg-0.02mg PV Bulk Chemicals - D's drospirenone-ethinyl $0 PV DIAZEPAM POWD XX 2 estradiol tabs 3mg-0.03mg ESTROSTEP FE TABS Bulk Chemicals - F's (Use Norethindrone NP FLUOXETINE HCL POWD 2 Acetate-Ethinyl Estradiol- XX Fe) Bulk Chemicals - H's ethynodiol diacet & eth $0 PV estrad tabs HALOPERIDOL POWD XX 2 FEMCON FE CHEW (Use Norethindrone & Ethinyl NP HYDROXYZINE HCL 2 POWD XX Estradiol-Fe) Bulk Chemicals - L's GENERESS FE CHEW (Use Norethindrone & NP LORAZEPAM POWD XX 2 Ethinyl Estradiol-Fe) levonorgestrel & eth $0 PV Bulk Chemicals - P's estradiol tabs PHENELZINE SULFATE 2 levonorgestrel-eth estradiol $0 PV POWD XX (triphasic) tabs Bulk Chemicals - S's levonorgestrel-ethinyl $0 QL(1 ea daily); estradiol (91-day) tabs PV SERTRALINE HCL POWD 2 XX LOESTRIN 1.5/30-21 PV Bulk Chemicals - V's TABS (Use Norethindrone NP Acet & Eth Estra) SODIUM VALPROATE 2 POWD LOESTRIN 1/20-21 TABS PV (Use Norethindrone Acet & NP VALPROATE SODIUM 2 Eth Estra) POWD XX MHS Indiana Preferred Drug List Updated December 1, 2018

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOESTRIN FE 1.5/30 PV ORTHO-CYCLEN TABS PV TABS (Use Norethin Acet & NP (Use Norgestimate-Ethinyl NP Estrad-Fe) Estradiol) LOESTRIN FE 1/20 TABS PV ORTHO-NOVUM 1/35 PV (Use Norethin Acet & NP TABS (Use Norethindrone NP Estrad-Fe) & Eth Estradiol) MIRCETTE TABS (Use PV ORTHO-NOVUM 7/7/7 PV Desogestrel-Ethinyl NP TABS (Use Norethindrone- NP Estradiol (Biphasic)) Eth Estradiol (Triphasic)) NECON 1/50-28 TABS $0 PV OVCON-35 TABS (Use PV Norethindrone & Eth NP NECON 10/11-28 TABS $0 PV Estradiol) SEASONIQUE TABS (Use QL(1 ea daily); norethin acet & estrad-fe PV Levonorgestrel-Ethinyl NP PV tabs 75mg-20mcg-1mg, $0 Estradiol (91-Day)) 75mg-30mcg-1.5mg TRI-NORINYL 28 TABS PV norethindrone & eth $0 PV (Use Norethindrone-Eth NP estradiol tabs Estradiol (Triphasic)) norethindrone & ethinyl $0 YASMIN 28 TABS (Use PV estradiol-fe chew Drospirenone-Ethinyl NP Estradiol) norethindrone acet & eth $0 PV estra tabs YAZ TABS (Use QL(1 ea daily); Drospirenone-Ethinyl NP PV norethindrone acetate- $0 ethinyl estradiol-fe tabs Estradiol) norethindrone-eth estradiol $0 PV Combination Contraceptives - Transdermal (triphasic) tabs QL(0.11 ea XULANE PTWK $0 norgestimate-ethinyl $0 PV daily); PV estradiol (triphasic) tabs Combination Contraceptives - Vaginal norgestimate-ethinyl $0 PV estradiol tabs NUVARING RING $0 QL(1 ea per fill retail); PV norgestrel & ethinyl $0 QL(2 ea daily); estradiol tabs PV Emergency Contraceptives NORINYL 1+35 TABS (Use PV QL(4 ea per Norethindrone & Eth NP ELLA TABS $0 365 days Estradiol) retail); PV PV levonorgestrel (emergency $0 QL(1 ea per 21 OGESTREL TABS $0 oc) tabs days retail); PV ORTHO TRI-CYCLEN LO PV PLAN B ONE-STEP TABS QL(1 ea per 21 (Use Levonorgestrel NP days retail); PV TABS (Use Norgestimate- NP Ethinyl Estradiol (Emergency OC)) (Triphasic)) Progestin Contraceptives - IUD ORTHO TRI-CYCLEN PV KYLEENA IUD $0 SP TABS (Use Norgestimate- NP Ethinyl Estradiol (Triphasic)) LILETTA IUD $0 SP

MIRENA IUD $0 SP

MHS Indiana Preferred Drug List Updated December 1, 2018

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SKYLA IUD $0 SP; PV dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg, 1 Progestin Contraceptives - Implants 1.5 mg SP; PV DEXAMETHASONE TABS 2 NEXPLANON IMPL $0 1 MG, 2 MG Progestin Contraceptives - Injectable hydrocortisone tabs 1 DEPO-PROVERA QL(1 ml per fill MEDROL DOSEPAK TBPK NP CONTRACEPTIVE SUSP NP retail); PV (Use Methylprednisolone) (Use Medroxyprogesterone Acetate (Contraceptive)) MEDROL TABS 4 MG, 8 MG (Use NP DEPO-PROVERA QL(1 ml per fill Methylprednisolone) CONTRACEPTIVE SUSY NP retail); PV (Use Medroxyprogesterone methylprednisolone tabs or 1 Acetate (Contraceptive)) 4 mg, 8 mg methylprednisolone tbpk or DEPO-SUBQ PROVERA $0 QL(1 ml per fill 1 104 SUSY retail); PV 4 mg medroxyprogesterone QL(1 ml per fill MILLIPRED TABS 5 MG 2 acetate (contraceptive) $0 retail); PV susp PEDIAPRED SOLN (Use medroxyprogesterone QL(1 ml per fill Prednisolone Sodium NP acetate (contraceptive) $0 retail); PV Phosphate) susy prednisolone sodium QL(240 ml per phosphate soln or 15 1 fill retail) Progestin Contraceptives - Oral mg/5ml NOR-QD TABS (Use PV prednisolone sodium QL(150 ml per Norethindrone NP phosphate soln or 20 1 fill retail) (Contraceptive)) mg/5ml norethindrone $0 PV prednisolone sodium (contraceptive) tabs phosphate soln or 5 1 ORTHO MICRONOR PV mg/5ml TABS (Use Norethindrone NP (Contraceptive)) PREDNISOLONE SOLN 2 CORTICOSTEROIDS - Steroid Hormone Drugs to prednisolone soln 1 Treat Systemic Swelling Conditions Glucocorticosteroids prednisolone syrp 1 CORTEF TABS (Use NP PREDNISONE INTENSOL 2 Hydrocortisone) CONC CORTISONE ACETATE 2 PREDNISONE SOLN 5 2 TABS MG/5ML dexamethasone elix 0.5 1 prednisone tabs 1 mg, 5 1 mg/5ml mg, 10 mg, 20 mg, 2.5 mg dexamethasone sodium QL(5 ml daily) PREDNISONE TABS 50 2 phosphate soln ij 4 mg/ml, 1 MG 20 mg/5ml, 120 mg/30ml PREDNISONE TBPK 5 2 DEXAMETHASONE SOLN 2 MG, 10 MG 0.5 MG/5ML

MHS Indiana Preferred Drug List Updated December 1, 2018

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VERIPRED 20 SOLN (Use QL(150 ml per cetirizine-pseudoephedrine 1 QL(2 ea daily) Prednisolone Sodium NP fill retail) tb12 Phosphate) CHERACOL PLUS LIQD QL(240 ml per Mineralocorticoids (Use Dextromethorphan- NP fill retail) Guaifenesin) fludrocortisone acetate 1 tabs CHERACOL-D COUGH QL(240 ml per LIQD (Use NP fill retail) COUGH/COLD/ALLERGY - Drugs to Treat Dextromethorphan- Cough, Cold and Allergy Symptoms Guaifenesin) Antitussives CLARITIN-D 12 HOUR QL(2 ea daily) AL(At least 10 TB12 (Use Loratadine & NP benzonatate caps 100 mg 1 yrs old) Pseudoephedrine) QL(30 ea per CLARITIN-D 24 HOUR QL(1 ea daily) TB24 (Use Loratadine & NP 1 fill retail); AL(At benzonatate caps 200 mg least 10 yrs Pseudoephedrine) old) CLEAR COUGH PM DELSYM COUGH MULTI-SYMPTOM LIQD (Use Dextromethorphan- NP CHILDRENS SUER (Use NP Dextromethorphan Doxylamine- Polistirex) Acetaminophen) DELSYM SUER (Use DAY TIME MULTI- Dextromethorphan NP SYMPTOM COLD/FLU Polistirex) RELIEF CAPS (Use NP Dextromethorphan- dextromethorphan 1 Phenylephrine- polistirex suer Acetaminophen) hydrocodone w/ AL(At least 18 dextromethorphan- homatropine syrp 5mg/5ml- 1 yrs old) doxylamine-acetaminophen 1.5mg/5ml liqd 6.25mg/15ml- TESSALON PERLES NP AL(At least 10 15mg/15ml-500mg/15ml, CAPS (Use Benzonatate) yrs old) 12.5mg/30ml-30mg/30ml- 1 Cough/Cold/Allergy Combinations 1000mg/30ml, 6.25mg/15ml-6.25mg/15ml- ADVIL COLD & SINUS 15mg/15ml-15mg/15ml- TABS (Use NP 500mg/15ml-500mg/15ml- Pseudoephedrine- 10% Ibuprofen) dextromethorphan- QL(240 ml per brompheniramine & QL(120 ml per guaifenesin liqd 10mg/5ml- fill retail) phenyleph elix 1mg/5ml- fill retail) 100mg/5ml, 10mg/5ml- 2.5mg/5ml, 1mg/5ml- 1 200mg/5ml, 20mg/10ml- 1mg/5ml-2.5mg/5ml- 200mg/10ml, 20mg/10ml- 1 2.5mg/5ml 400mg/10ml, 15mg/7.5ml- brompheniramine & 1 QL(120 ml per 150mg/7.5ml, 10mg/5ml- pseudoeph elix fill retail) 10mg/5ml-100mg/5ml- 100mg/5ml brompheniramine & 1 QL(120 ml per pseudoeph liqd fill retail) dextromethorphan- guaifenesin liqd 5mg/5ml- BROTAPP DM LIQD 2 QL(240 ml per 1 fill retail) 100mg/5ml, 20mg/20ml- 400mg/20ml

MHS Indiana Preferred Drug List Updated December 1, 2018

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- QL(240 ml per MUCINEX D TB12 (Use QL(210 ea per guaifenesin soln 10mg/5ml- 1 fill retail) Pseudoephedrine- NP fill retail) 100mg/5ml, 20mg/10ml- Guaifenesin) 200mg/10ml MUCINEX DM TB12 (Use QL(2 ea dextromethorphan- QL(240 ml per Dextromethorphan- NP daily,210 ea guaifenesin syrp fill retail) Guaifenesin) per fill retail) 10mg/5ml-100mg/5ml, 1 phenylephrine-chlorphen- QL(240 ml per 10mg/5ml-10mg/5ml- dm liqd 15mg/5ml- 1 fill retail) 100mg/5ml-100mg/5ml 4mg/5ml-10mg/5ml dextromethorphan- QL(240 ml per phenylephrine-dm liqd 1 guaifenesin tabs 20mg- 1 fill retail) 400mg, 20mg-20mg- QL(240 ml per 400mg-400mg phenylephrine-dm soln 1 fill retail) dextromethorphan- QL(2 ea guaifenesin tb12 30mg- 1 daily,210 ea QL(240 ml per 600mg per fill retail) promethazine & 1 6 days retail); phenylephrine soln AL(At least 2 dextromethorphan- yrs old) phenylephrine- QL(240 ml per acetaminophen caps 1 10mg-325mg-5mg, 10mg- promethazine w/codeine 1 fill retail); AL(At 10mg-325mg-325mg-5mg- soln least 18 yrs 5mg old) DIMETAPP COLD & QL(120 ml per QL(240 ml per ALLERGY ELIX 1MG/5ML- fill retail) promethazine w/codeine 1 fill retail); AL(At 2.5MG/5ML (Use NP syrp least 18 yrs Brompheniramine & old) Phenyleph) QL(240 ml per promethazine-dm syrp 1 fill retail); AL(At ED BRON GP LIQD 2 QL(240 ml per 6 days retail) least 2 yrs old) QL(240 ml per guaifenesin-codeine liqd 1 100mg/5ml-10mg/5ml PROMETHAZINE/PHENYL 2 6 days retail); EPHRINE SYRP AL(At least 2 guaifenesin-codeine soln 1 yrs old) 100mg/5ml-10mg/5ml pseudoephed-bromphen- 1 QL(240 ml per guaifenesin-codeine syrp 1 dm elix fill retail) 100mg/5ml-10mg/5ml pseudoephed-bromphen- QL(240 ml per QL(240 ml per 1 LOHIST-D LIQD 2 dm syrp fill retail) fill retail) pseudoephedrine w/ 1 QL(240 ml per loratadine & QL(2 ea daily) codeine-gg soln 6 days retail) pseudoephedrine tb12 1 5mg-120mg pseudoephedrine- 1 QL(240 ml per chlorphen-dm liqd fill retail) loratadine & QL(1 ea daily) pseudoephedrine- pseudoephedrine tb24 1 10mg-240mg, 10mg-10mg- guaifenesin tb12 120mg- 1 240mg-240mg 1200mg MUCINEX D MAXIMUM pseudoephedrine- QL(210 ea per guaifenesin tb12 60mg- 1 fill retail) STRENGTH TB12 (Use NP Pseudoephedrine- 600mg Guaifenesin)

MHS Indiana Preferred Drug List Updated December 1, 2018

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pseudoephedrine-ibuprofen 1 HYPERSAL NEBU 7 % tabs (Use Sodium Chloride NP ROBITUSSIN PEAK COLD QL(240 ml per (Inhalant)) COUGH+ CHEST fill retail) sodium chloride (inhalant) 1 CONGESTION DM MAX NP nebu 0.9 %, 3 %, 7 %, 10 STRENGTH LIQD (Use % Dextromethorphan- Guaifenesin) Mucolytics ROBITUSSIN PEAK COLD QL(240 ml per acetylcysteine soln 1 DM SYRP (Use NP fill retail) Dextromethorphan- DERMATOLOGICALS - Drugs to Treat Skin Guaifenesin) Conditions TRIAMINIC COLD & QL(240 ml per Acne Products COUGH DAY TIME 2 fill retail) ACNE MEDICATION 10 2 CHILDRENS SOLN LOTN TRIAMINIC COLD & QL(240 ml per ACNE MEDICATION 5 2 COUGH DAY TIME 2 fill retail) LOTN CHILDRENS SYRP BENZAC AC WASH LIQD NP RX/OTC ZYRTEC-D QL(2 ea daily) (Use Benzoyl Peroxide) ALLERGY/CONGESTION NP TB12 (Use Cetirizine- BENZOYL PEROXIDE 2 Pseudoephedrine) CLEANSER LOTN 6 % benzoyl peroxide crea 10 1 Expectorants % guaifenesin liqd 100 QL(240 ml per RX/OTC mg/5ml, 200 mg/10ml, 400 1 6 days retail) benzoyl peroxide gel 10 % 1 mg/20ml BENZOYL PEROXIDE 2 guaifenesin soln 100 QL(240 ml per GEL 2.5 % mg/5ml, 200 mg/10ml, 300 1 6 days retail) mg/15ml benzoyl peroxide gel 5 % 1 guaifenesin syrp 100 1 QL(240 ml per mg/5ml, 200 mg/10ml 6 days retail) benzoyl peroxide liqd 4 % 1 guaifenesin tb12 1200 mg 1 benzoyl peroxide liqd 5 %, 1 RX/OTC 10 % QL(2 ea guaifenesin tb12 600 mg 1 daily,40 ea per benzoyl peroxide lotn 6 % 1 fill retail) CLEAN & CLEAR MUCINEX MAXIMUM ADVANTAGE 3-IN-1 2 STRENGTH TB12 (Use NP EXFOLIATING CLEANSER Guaifenesin) LOTN QL(2 ea CLEOCIN-T GEL (Use MUCINEX TB12 (Use NP Guaifenesin) daily,40 ea per Clindamycin Phosphate NF fill retail) (Topical)) Misc. Respiratory Inhalants CLEOCIN-T LOTN (Use Clindamycin Phosphate NP HYPER-SAL NEBU (Use NP Sodium Chloride (Inhalant)) (Topical)) CLEOCIN-T SOLN (Use Clindamycin Phosphate NP (Topical)) MHS Indiana Preferred Drug List Updated December 1, 2018

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate 1 QL(15 gm per (topical) gel 1 fill retail); tretinoin gel 0.01 % AL(Up to 35 yrs clindamycin phosphate 1 (topical) lotn old ) AL(Up to 35 yrs clindamycin phosphate 1 tretinoin gel 0.025 % 1 (topical) soln old ) Anti-inflammatory Agents - Topical DESQUAM-X WASH LIQD NP RX/OTC (Use Benzoyl Peroxide) diclofenac sodium (topical) 1 QL(6.68 gm gel 1 % daily) ERYGEL GEL (Use NP Erythromycin (Acne Aid)) VOLTAREN GEL (Use QL(6.68 gm erythromycin (acne aid) gel 1 Diclofenac Sodium NP daily) (Topical)) erythromycin (acne aid) 1 Antibiotics - Topical soln BACIGUENT OINT (Use NP QL(2 ea daily); Bacitracin (Topical)) isotretinoin caps 10 mg, 20 1 AL(At least 12 mg, 40 mg yrs old) bacitracin (topical) oint 1 KLARON LOTN (Use QL(120 ml per QL(30 gm per bacitracin zinc oint 1 Sulfacetamide Sodium NP fill retail) fill retail) (Acne)) PANOXYL-4 CREAMY bacitracin-polymyxin b oint 1 WASH LIQD (Use Benzoyl NP Peroxide) BACTROBAN CREA (Use Mupirocin Calcium NP QL(20 gm per (Topical)) RETIN-A CREA 0.025 %, fill retail); 0.05 %, 0.1 % (Use NP 1 package / Tretinoin) AL(Up to 35 yrs old ) 2 claim;QL(30 CENTANY OINT gm per fill QL(15 gm per retail) RETIN-A GEL 0.01 % (Use NP fill retail); Tretinoin) AL(Up to 35 yrs 1 package / old ) gentamicin sulfate (topical) 1 claim;QL(30 crea gm per fill RETIN-A GEL 0.025 % NP AL(Up to 35 yrs retail) (Use Tretinoin) old ) 1 package / 1 package / SODIUM gentamicin sulfate (topical) 1 claim;QL(30 SULFACETAMIDE/SULFU 2 claim;QL(60 oint gm per fill R LOTN gm per fill retail) retail) mupirocin calcium (topical) 1 package / 1 SODIUM crea 2 claim;QL(30 SULFACETAMIDE/SULFU gm per fill 1 package / R SUSP retail) 1 claim;QL(30 mupirocin oint gm per fill sulfacetamide sodium 1 QL(120 ml per retail) (acne) lotn fill retail) neomycin-bacitracin- 1 QL(1 gm daily) QL(20 gm per polymyxin oint tretinoin crea 0.025 %, 0.05 1 fill retail); %, 0.1 % AL(Up to 35 yrs neomycin-polymyxin w/ 1 QL(0.5 gm old ) pramoxine crea daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOSPORIN ORIGINAL QL(1 gm daily) NIZORAL SHAM (Use NP QL(4 ml daily) OINT (Use Neomycin- NP Ketoconazole (Topical)) Bacitracin-Polymyxin) 1 package / NEOSPORIN PLUS PAIN QL(0.5 gm claim;QL(30 nystatin (topical) crea 1 RELIEF MAXIMUM daily) gm per fill STRENGTH CREA (Use NP retail) Neomycin-Polymyxin w/ Pramoxine) nystatin (topical) oint 1 POLYSPORIN OINT (Use NP nystatin (topical) powd 1 Bacitracin-Polymyxin B) Antifungals - Topical nystatin-triamcinolone crea 1 RX/OTC clotrimazole (topical) crea 1 nystatin-triamcinolone oint 1 RX/OTC clotrimazole (topical) soln 1 terbinafine hcl (topical) crea 1 clotrimazole w/ QL(1.5 gm 1 TINACTIN CREA (Use NP QL(30 gm per betamethasone crea daily) Tolnaftate) fill retail) clotrimazole w/ QL(1 ml daily) 1 TINACTIN JOCK ITCH NP QL(30 gm per betamethasone lotn CREA (Use Tolnaftate) fill retail) QL(30 gm per QL(30 gm per econazole nitrate crea 1 tolnaftate crea 1 fill retail) fill retail) ketoconazole (topical) crea 1 Antihistamines-Topical diphenhydramine hcl ketoconazole (topical) 1 QL(4 ml daily) 1 sham (topical) crea LAMISIL AT CREA (Use NP ITCH RELIEF CREA 2 Terbinafine HCl (Topical)) LAMISIL AT JOCK ITCH Antineoplastic or Premalignant Lesion Agents - CREA (Use Terbinafine NP HCl (Topical)) CARAC CREA 2 LOTRIMIN AF CREA 1 % RX/OTC EFUDEX CREA (Use NP QL(40 gm per (Use Clotrimazole NP Fluorouracil (Topical)) fill retail) (Topical)) QL(40 gm per fluorouracil (topical) crea 1 LOTRIMIN AF FOR HER RX/OTC fill retail) CREA (Use Clotrimazole NP FLUOROURACIL CREA 2 (Topical)) EX 0.5 % LOTRIMIN AF JOCK ITCH RX/OTC FLUOROURACIL SOLN 2 QL(10 ml per CREA (Use Clotrimazole NP EX 2 %, 5 % fill retail) (Topical)) PA; SP LOTRISONE CREA (Use QL(1.5 gm TARGRETIN GEL EX 1 % 2 Clotrimazole w/ NP daily) Betamethasone) Antipruritics - Topical MICATIN CREA (Use QL(1.5 ml camphor & menthol lotn 1 Miconazole Nitrate NP daily) 0.5%-0.5% (Topical)) SARNA LOTN (Use NP Camphor & Menthol) miconazole nitrate (topical) 1 QL(1.5 ml crea daily) Antipsoriatics

MHS Indiana Preferred Drug List Updated December 1, 2018

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcipotriene crea 1 QL(2 gm daily) sulfacetamide sodium liqd 1 ex calcipotriene soln 1 QL(2 ml daily) Antivirals - Topical

COSENTYX 2 PA; SP ABREVA CREA 2 SENSOREADY PEN SOAJ acyclovir topical oint 1 QL(1 gm daily) COSENTYX SOSY 2 PA; SP ZOVIRAX CREA EX 5 % 2 DOVONEX CREA (Use NP QL(2 gm daily) Calcipotriene) ZOVIRAX OINT EX 5 % NP QL(1 gm daily) STELARA SOSY 2 PA; SP (Use Acyclovir Topical) QL(2 gm daily); Burn Products tazarotene crea 1 AL(Up to 21 yrs SILVADENE CREA (Use NP old ) Silver Sulfadiazine) QL(2 gm daily); silver sulfadiazine crea 1 TAZORAC CREA 0.05 % 2 AL(Up to 21 yrs old ) Corticosteroids - Topical QL(2 gm daily); betamethasone 1 rtl pack lmt TAZORAC CREA 0.1 % NP 1 ) AL(Up to 21 yrs dipropionate (topical) crea per fill, (Use Tazarotene old ) betamethasone QL(2 gm daily); dipropionate augmented 1 TAZORAC GEL 0.05 %, 2 0.1 % AL(Up to 21 yrs crea old ) betamethasone valerate 1 Antiseborrheic Products crea 0.1 % OVACE PLUS WASH LIQD betamethasone valerate 1 (Use Sulfacetamide NP lotn 0.1 % Sodium) betamethasone valerate 1 OVACE WASH LIQD (Use NP oint 0.1 % Sulfacetamide Sodium) clobetasol propionate crea 1 selenium sulfide lotn 1 % 1 clobetasol propionate 1 QL(120 ml per selenium sulfide lotn 2.5 % 1 emollient base crea fill retail) clobetasol propionate gel 1 selenium sulfide sham 1 % 1 clobetasol propionate oint 1 SELSUN BLUE DAILY NP LOTN (Use Selenium clobetasol propionate soln 1 Sulfide) 1 rtl pack lmt SELSUN BLUE LOTN (Use NP desonide crea 1 Selenium Sulfide) per fill, 1 rtl pack lmt SELSUN BLUE desonide oint 1 MEDICATED LOTN (Use NP per fill, Selenium Sulfide) DESOWEN CREA (Use NP 1 rtl pack lmt SELSUN BLUE Desonide) per fill, MOISTURIZING LOTN NP (Use Selenium Sulfide)

MHS Indiana Preferred Drug List Updated December 1, 2018

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIPROLENE AF CREA MONISTAT SOOTHING RX/OTC (Use Betamethasone NP CARE ITCH RELIEF CREA NP Dipropionate Augmented) (Use Hydrocortisone (Topical)) ELOCON CREA (Use NP Mometasone Furoate) TEMOVATE CREA (Use NP Clobetasol Propionate) ELOCON OINT (Use NP Mometasone Furoate) TEMOVATE E CREA (Use Clobetasol Propionate NP EPIFOAM FOAM 2 Emollient Base) fluocinonide crea 0.05 % 1 TEMOVATE OINT (Use NP Clobetasol Propionate) fluocinonide emulsified 1 triamcinolone acetonide 1 QL(4 gm daily) base crea (topical) crea 0.025 % fluocinonide gel 0.05 % 1 triamcinolone acetonide 1 (topical) crea 0.1 %, 0.5 % fluocinonide oint 0.05 % 1 triamcinolone acetonide (topical) lotn 0.025 %, 0.1 1 fluocinonide soln 0.05 % 1 % triamcinolone acetonide fluticasone propionate crea 1 (topical) oint 0.025 %, 0.1 1 0.05 % %, 0.5 % fluticasone propionate oint 1 TRIDESILON CREA (Use NP 1 rtl pack lmt 0.005 % Desonide) per fill, hydrocortisone (topical) 1 crea 0.5 % Diaper Rash Products hydrocortisone (topical) 1 RX/OTC diaper rash products oint 1 crea 1%, 1 % Emollient/Keratolytic Agents hydrocortisone (topical) 1 QL(4 gm daily) crea 2.5 % urea crea 40 % 1 RX/OTC hydrocortisone (topical) 1 lotn 1 %, 2.5 % urea lotn 40 % 1 hydrocortisone (topical) 1 oint 0.5 %, 2.5 % Emollients A + D PERSONAL CARE hydrocortisone (topical) 1 QL(2 gm daily); 2 oint 1 % RX/OTC LOTION LOTN hydrocortisone butyrate 1 ALBOLENE CREA 2 soln ALOE AFTERSUN hydrocortisone-aloe vera 1 2 crea 1% LOTION LOTN AMLACTIN CERAPEUTIC LOCOID SOLN (Use NP 2 Hydrocortisone Butyrate) LOTN mometasone furoate crea 1 AMLACTIN ULTRA CREA 2 AQUA GLYCOLIC FACE 2 mometasone furoate oint 1 CREAM CREA AQUA GLYCOLIC HAND & 2 mometasone furoate soln 1 BODYLOTION LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AQUA LACTEN LOTN 2 AVEENO POSITIVELY RADIANTOVERNIGHT 2 AQUADERM HYDRATING FACIAL TREATMENT/MOISTURIZ 2 MOISTURI CREA ER LOTN AVEENO STRESS RELIEF 2 AQUAMED LOTN 2 MOISTURIZING LOTN BASLE CREA 2 AQUAPHILIC OINT 2 BETA CARE CREA 2 AQUAPHOR ADVANCED 2 THERAPY OINT BETA CARE LOTN 2 AQUAPHOR OINT 2 BETA XMA CREA 2 AVEENO ACTIVE NATURALS DAILY 2 BOUDREAUXS BABY MOISTURIZING BODY BUTT SMOOTH DRY SKIN 2 YOGURT LOTN OINT AVEENO ACTIVE CAM LOTN 2 NATURALS DAILY 2 MOISTURIZING BODY CERAVE AM SPF 30 2 YOGURT/APRICO LOTN LOTN AVEENO ACTIVE CERAVE CREA 2 NATURALS SKIN RELIEF 2 MOISTURE REPAIR CREA CERAVE LOTN 2 AVEENO DAILY CERAVE PM LOTN 2 MOISTURIZINGSPF 15 2 LOTN CERAVE RENEWING SA 2 CREA AVEENO INTENSE 2 RELIEF HAND CREA CERAVE SA RENEWING 2 AVEENO POSITIVELY LOTN AGELESSFIRMING BODY 2 CETAPHIL CREA 2 LOTN AVEENO POSITIVELY CETAPHIL DAILY ADVANCE ULTRA 2 AGELESSSKIN 2 STRENGTHENING BODY HYDRATING LOTN CREAM CREA CETAPHIL DAILY FACIAL 2 AVEENO POSITIVELY MOISTURIZER LOTN AGELESSSKIN 2 CETAPHIL STRENGTHENING HAND DERMACONTROL 2 CREAM CREA MOISTURIZER/SPF 30 AVEENO POSITIVELY LOTN NOURISHING 24-HOUR 2 CETAPHIL ULTRA-HYDRATING MOISTURIZING CREA NP CREA (Use Emollient) AVEENO POSITIVELY 2 CETAPHIL 2 RADIANT LOTN MOISTURIZING LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CETAPHIL 2 DIABETIDERM LOTN 2 RESTORADERM LOTN CETAPHIL THERAPEUTIC 2 DMAE CREA 2 HAND CREA CLN FACIAL DML FORTE CREA 2 MOISTURIZER 2 NOURISHING LOTN DROXY CREAM CREA 2 COCOA BUTTER HAND & 2 BODYLOTION LOTN ELON SKIN REPAIR 2 SYSTEM CREA COCOA BUTTER LOTN 2 EMOLLIA-CREME CREA 2 COCONUT OIL BEAUTY 2 CREA EMOLLIA-LOTION LOTN 2 CVS DAILY ULTRA 2 MOISTURELOTION LOTN emollient crea 1 CVS MOISTURIZING 2 CREAM CREA emollient lotn 1 DAILY CONDITIONING 2 emollient oint 1 TREATMENT OINT DERMABASEOIL IN 2 EPILYT LOTN 2 WATER CREA EQ THERAPEUTIC DRY 2 DERMAIDE ALOE CREA 2 SKIN CREA DERMAL THERAPY EQ THERAPEUTIC EXTRA STRENGTH BODY 2 MOISTURIZING CREAM 2 LOTION LOTN CREA DERMAL THERAPY FACE EQL ADVANCED CAREMOISTURIZING 2 RECOVERY SKIN CARE 2 LOTION LOTN LOTN EQL MOISTURIZING DERMAL THERAPY FOOT 2 2 MASSAGE LOTN CREAM CREA DERMAL THERAPY HAND EQL ULTRA ELBOW & KNEE CREAM 2 MOISTURIZING DAILY 2 LOTN LOTION LOTN DERMAL THERAPY HEEL 2 EUCERIN BABY LOTN 2 CARE LOTN DERMEND EUCERIN CALMING MOISTURIZING BRUISE 2 DAILY MOISTURIZER NP FORMULA CREA CREA (Use Emollient) EUCERIN DAILY DHEA CREA EX 1% 2 PROTECTION/SPF 30 2 LOTN DIABETIDERM CREA 2 EUCERIN INTENSIVE 2 REPAIR LOTN DIABETIDERM FOOT 2 REJUVENATING CREA EUCERIN INTENSIVE 2 REPAIRHAND CREA DIABETIDERM HAND & 2 BODY LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCERIN LOTN 2 GOLD BOND ULTIMATE 2 HEALING CREA EUCERIN ORIGINAL GOLD BOND ULTIMATE 2 HEALINGSOOTHING 2 HEALING LOTN REPAIR LOTN GOLD BOND ULTIMATE 2 EUCERIN PLUS CREA 2 HEALING OINT GOLD BOND ULTIMATE 2 EUCERIN PLUS LOTN INTENSIVE REPAIR NP CREA (Use Emollient) GOLD BOND ULTIMATE 2 OVERNIGHT LOTN EUCERIN PLUS LOTN 2 GOLD BOND ULTIMATE 2 EUCERIN PROTECTION LOTN PROFESSIONAL REPAIR 2 GOLD BOND ULTIMATE 2 RICH FEEL LOTN RESTORING LOTN EUCERIN SKIN CALMING GOLD BOND ULTIMATE DAILY MOISTURIZING NP SHEERRIBBONS 2 CREA (Use Emollient) PEARLRADIANCE LOTN EUCERIN SMOOTHING GOLD BOND ULTIMATE REPAIRADVANCED 2 SHEERRIBBONS 2 FORMULA LOTN SILKSOFTNESS LOTN GOLD BOND ULTIMATE FORMULA 405 2 2 ENRICHED EYE CREA SOFTENING LOTN GOLD BOND ULTIMATE FORMULA 405 FACE 2 2 CREAM CREA SOOTHING CREA FORMULA 405 LIGHT GOLD BOND ULTIMATE 2 TEXTURED 2 SOOTHING LOTN MOISTURIZER CREA GRX VITAMIN E LOTN 2 FORMULA 405 2 MOISTURIZING LOTN HYDRASYN25 CREA 2 GENTLE CREA 2 HYDRAZONE LOTION 2 LOTN glycerin (topical) liqd 1 HYDRO-LAN CREA 2 GNP ADVANCED 2 RECOVERY LOTN J & J BURN CREAM CREA 2 GOLD BOND MEDICATED BODYLOTION EXTRA 2 KERADAN CREA 2 STRENGTH LOTN KERI ADVANCED GOLD BOND MEDICATED 2 BODYLOTION LOTN MOISTURE THERAPY 2 LOTN GOLD BOND ULTIMATE DIABETICS DRY SKIN 2 KERI BASIC ESSENTIALS 2 RELIEF LOTN LOTN GOLD BOND ULTIMATE KERI LONG LASTING 2 DIABETICS' DRY RELIEF 2 CREA LOTN KERI NOURISHING SHEA 2 BUTTER LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERI ORIGINAL LOTN 2 LUBRIDERM INTENSE 2 SKIN REPAIR LOTN KERI OVERNIGHT LOTN 2 LUBRIDERM LOTN 2 KERI RENEWAL MILK 2 LUBRIDERM MENS 3-IN-1 2 BODY LOTN LOTN KERI RENEWAL SKIN 2 LUBRIDERM SERIOUSLY 2 FIRMING LOTN SENSITIVE LOTN KERI RENEWAL LUBRIDERM SKIN STRETCH MARK 2 NOURISHINGWITH SHEA 2 MINIMIZER LOTN AND COCOA BUTTERS LOTN KERI SENSITIVE SKIN 2 LOTN LUBRISOFT LOTN 2 LAC-HYDRIN CREA (Use RX/OTC Lactic Acid (Ammonium NP MAXAM LOTN 2 Lactate)) LAC-HYDRIN LOTN (Use RX/OTC MEDELA TENDER CARE 2 Lactic Acid (Ammonium NP LANOLIN CREA Lactate)) MEDERMA AG FACE 2 LAC-HYDRIN TWELVE RX/OTC CREAM CREA LOTN (Use Lactic Acid NP MEDERMA AG HAND & 2 (Ammonium Lactate)) BODY LOTION LOTN lactic acid (ammonium RX/OTC 1 MEDERMA STRETCH 2 lactate) crea 12 % MARKS THERAPY CREA lactic acid (ammonium RX/OTC 1 MOISTURIZING CREAM 2 lactate) lotn 12 % CREA LACTINOL HX CREA 2 MOTHERS FRIEND CREA 2

LADY ESTHER 4 MOTHERS FRIEND LOTN 2 PURPOSE FACE CREAM 2 CREA MSM SKIN LOTION LOTN 2 LANAPHILIC OINT 2 NEUTROGENA BODY LIGHT SESAME 2 2 LANOLOR CREA FORMULA LOTN LEADER FINGER CREAM 2 NEUTROGENA HAND 2 CREA CREA LUBRIDERM ADVANCED 2 NEUTROGENA THERAPY LOTN HAND/NORWEGIANFOR 2 LUBRIDERM DAILY MULA/FAST ABSORBING MOISTURE/NORMAL TO 2 CREA DRY SKIN LOTN NEUTROGENA HEALTHY 2 LUBRIDERM DAILY SKIN CREA MOISTURESHEA + 2 NEUTROGENA HEALTHY 2 CALMING LAVENDER SKIN FACE SPF 15 LOTN JASMINE LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUTROGENA PETROLATUM OINT 2 MOISTURE SENSITIVE 2 SKIN LOTN PRETTY FEET & HANDS 2 NISEKO HYDRATING CREA FACIAL MOISTURIZER 2 RA ADVANCED HEALING 2 CREA OINT NIVEA CREA 2 RA DAYLOGIC HEALING DRY SKIN THERAPY 2 NIVEA EXTRA ENRICHED 2 LOTN LOTION LOTN RA GENTLE SKIN CREAM 2 NIVEA EXTRA ENRICHED 2 CREA LOTN RA RENEWAL DRY SKIN 2 NIVEA GENTLE BODY 2 THERAPY LOTN EXFOLIATOR LOTN RADIAGUARD 2 NIVEA LIGHT CREA 2 ADVANCED LOTN RESTA CREA 2 NIVEA LIGHT LOTN 2 RESTA LITE LOTN 2 NIVEA LOTN 2 RISABAL-PH CREA 2 NIVEA ORIGINAL LOTN 2 ROC DEEP WRINKLE 2 NIVEA ORIGINAL 2 SERUM LOTN MOISTURE LOTN ROC MULTI CORREXION NIVEA SOFT CREA 2 5 IN1 RESTORING EYE 2 CREAM CREA NIVEA VISAGE CREA 2 ROC MULTI CORREXION 5 IN1 RESTORING NIGHT 2 NIVEA VISAGE INNER CREAM CREA BEAUTY NIGHTTIME 2 RENEWAL CREA ROC RETINOL 2 CORREXION CREA NIVEA VISAGE LOTN 2 ROC RETINOL 2 CORREXION MAX CREA NUTRADERM ADVANCED 2 FORMULA LOTN ROC RETINOL CORREXION NIGHT 2 NUTRADERM CREA CREA 2.5%-2.5%-2.5%-2.5%- 2 2.5%-2.5% ROC RETINOL CORREXION SENSITIVE 2 NUTRADERM LOTN 2.5%- 2 EYE CREA 2.5%-2.5%-2.5%-2.5% ROC RETINOL OINTMENT BASE OINT 2 CORREXION SENSITIVE 2 NIGHT CREA PEN-KERA CREA 2 ROSE MILK LOTN 2 PENTRAVAN CREA 2 SKIN REPAIR LOTN 2 PENTRAVAN PLUS CREA 2

MHS Indiana Preferred Drug List Updated December 1, 2018

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOOTHE & COOL ALDARA CREA (Use NP QL(48 ea per MOISTURIZING BODY 2 Imiquimod) 180 days retail) LOTION WITH ALOE QL(48 ea per imiquimod crea 1 LOTN 180 days retail) SOOTHE & COOL SKIN CREAMWITH ALOE & 2 Immunosuppressive Agents - Topical VITAMINS A, D & E CREA PA; QL(1 gm ELIDEL CREA 2 daily); AL(At SORBOLENE CREA 2 least 2 yrs old) SPECIAL CARE CREAM PA; QL(1 gm 2 PROTOPIC OINT 0.03 % NP daily); AL(At CREA (Use Tacrolimus (Topical)) least 2 yrs old) ST IVES SWISS FORMULA 24HOUR 2 PA; QL(1 gm MOISTURE LOTN PROTOPIC OINT 0.1 % NP daily); AL(At (Use Tacrolimus (Topical)) least 16 yrs STUDIO 35 EXTRA old) MOISTURIZING LOTION 2 LOTN PA; QL(1 gm tacrolimus (topical) oint 1 daily); AL(At 0.03 % STUDIO 35 least 2 yrs old) MOISTURIZING SKIN 2 CREA PA; QL(1 gm tacrolimus (topical) oint 0.1 1 daily); AL(At THERABETIC SKIN CARE 2 % least 16 yrs LOTN old) THERAPEUTIC 2 MOISTURIZING CREA Keratolytic/Antimitotic Agents CONDYLOX SOLN (Use THERAPLEX 2 NP HYDROLOTION LOTN Podofilox) UDDERLY SMOOTH 2 podofilox soln 1 CREA Local Anesthetics - Topical UDDERLY SMOOTH 2 EXTRA CARE CREA ARTHRITIS PAIN 2 RELIEVING CREA UDDERLY SMOOTH 2 EXTRA CARE20 CREA capsaicin crea 0.025 % 1 QL(2 ml daily) VANICREAM CREA 2 capsaicin crea 0.1 % 1 VANICREAM LITE LOTN 2 CAPZASIN-HP CREA (Use NP Capsaicin) VELVACHOL CREA 2 dibucaine oint 1 QL(1 gm daily) VITAMIN E WITH 2 PANTHENOL CREA Limit 30gms lidocaine crea 4 % 1 per month;QL(1 Vitamins A & D (Topical) F gm daily) RX/OTC WIBI LOTN 2 lidocaine hcl crea ex 3 % 1 QL(30 ml per ZIMS CRACK CREME 2 DAYTIME CREA lidocaine hcl gel ex 2 % 1 fill retail); RX/OTC Immunomodulating Agents - Topical

MHS Indiana Preferred Drug List Updated December 1, 2018

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lidocaine ptch 5 % 1 QL(3 ea daily) EUCERIN CREA (Use Skin NP RX/OTC Protectants, Misc.) QL(30 gm per lidocaine-prilocaine crea 1 FORMULA 405 FACIAL & 2 fill retail) BODYCLEANSING LOTN LIDODERM PTCH (Use QL(3 ea daily) NP GENTLE SKIN CLEANSER 2 Lidocaine) LOTN Limit 30gms RX/OTC LMX 4 CREA (Use NP HYDROCERIN CREA 2 Lidocaine) per month;QL(1 gm daily) MOISTURE GUARD CREA 2 Misc. Topical 4-N-1 CREA 2 NEUTRAPHOR CREA 2 ALOE VESTA DAILY NEUTRAPHORUS REX 2 MOISTURIZER LOTN (Use NP CREA Dimethicone (Topical)) NIVEA MOISTURIZING 2 ALOE VESTA SKIN BODY WASH 2 IN 1 LOTN NIVEA MOISTURIZING CONDITIONER LOTN NP 2 (Use Dimethicone BODY WASH LOTN (Topical)) NIVEA TOUCH OF SMOOTHNESS ANTI-BACTERIAL HAND 2 2 LOTION LOTN MOISTURIZING BODY WASH LOTN AQUANIL SKIN 2 CLEANSER LOTN NIVEA VISAGE GENTLE 2 AVEENO POSITIVELY CLEANSING LOTN RADIANTCLEANSER 2 OCUSOFT HAND SOAP 2 LOTN LOTN PROSHIELD PLUS SKIN BASIS FACIAL 2 RX/OTC 2 MOISTURIZER CREA PROTECTANT CREA RX/OTC REMEDY CLEANSING 2 BASIS OVERNIGHT CREA 2 BODY LOTION LOTN BAZA CLEANSE & 2 REMEDY DIMETHICONE PROTECT LOTN MOISTURE BARRIER 2 CREA CARRINGTON MOISTURE 2 RX/OTC BARRIER CREA REMEDY NUTRASHIELD 2 CREA CARRINGTON MOISTURE 2 RX/OTC BARRIER/ZINC CREA REMEDY SKIN REPAIR 2 CREA COOL BOTTOMS CREA 2 SECURA DIMETHICONE 2 corn starch powd 1 PROTECTANT CREA SENSI-CARE 2 RX/OTC DIABETIDERM 2 MOISTURIZING CREA CLEANSING LOTN skin protectants, misc. crea 1 RX/OTC dimethicone (topical) crea 1 2 % SM SKIN CLEANSER GENTLE/SENSITIVE SKIN 2 dimethicone (topical) lotn 1 1 %, 3 % LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SORBIDON HYDRATE 2 RX/OTC 1 package / CREA claim;QL(60 permethrin crea 5 % 1 SUMMERS EVE gm per fill FEMININE POWD (Use NP retail) Corn Starch) permethrin liqd 1 % 1 THERASEAL HAND PROTECTION LOTN (Use NP permethrin lotn 1 % 1 QL(4 ml daily) Dimethicone (Topical)) pyrethrins-piperonyl 1 TOPICLEAR LOTN 2 butoxide liqd 0.33%-4% pyrethrins-piperonyl zinc oxide (topical) oint 20 1 % butoxide sham 0.3%- 1 0.33%-4%, 0.33%-4% Rosacea Agents pyrethrins-piperonyl METROCREAM CREA QL(1.5 gm butoxide-permethrin-nit 1 (Use Metronidazole NP daily) remover kit (Topical)) RID COMPLETE LICE METROLOTION LOTN ELIMINATION KIT (Use (Use Metronidazole NP Pyrethrins-Piperonyl NP (Topical)) Butoxide-Permethrin-Nit metronidazole (topical) 1 QL(1.5 gm Remover) crea 0.75 % daily) RID LIQD (Use Pyrethrins- NP metronidazole (topical) gel 1 QL(1.5 gm Piperonyl Butoxide) 0.75 % daily) AL(At least 1 SPINOSAD SUSP 2 metronidazole (topical) lotn 1 yrs old) 0.75 % Sunscreens Scabicides & Pediculicides ANTHELIOS 60 MELT-IN 2 crotamiton lotn 1 SUNSCREEN LOTN AVEENO ABSOLUTELY 1 package / AGELESSLEAVE-ON DAY 2 ELIMITE CREA (Use NP claim;QL(60 MASK SPF 30 LOTN ) Permethrin gm per fill AVEENO ACTIVE retail) NATURALS 2 EURAX CREA 2 QL(2 gm daily) PROTECT+HYDRATE/SP F 30 LOTN EURAX LOTN (Use NP AVEENO BABY Crotamiton) CONTINUOUS 2 QL(59 ml per malathion lotn 1 PROTECTION LOTN fill retail) AVEENO NATURAL AL(At least 1 NATROBA SUSP 2 PROTECTIONSPF 50 2 yrs old) LOTN NIX CREME RINSE LIQD NP AVEENO POSITIVELY (Use Permethrin) RADIANTDAILY 2 MOISTURIZER SPF15 OVIDE LOTN (Use NP QL(59 ml per Malathion) fill retail) LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVEENO POSITIVELY CERAVE 2 RADIANTDAILY 2 SUNSCREEN/FACE LOTN MOISTURIZER SPF30 CHANTAL SUN SCREEN 2 LOTN SPF 30 LOTN AVEENO POSITIVELY COTZ LOTN 2 RADIANTTINTED 2 MOISTURIZER SPF30 DIABETIDERM FAIR/LIGHT LOTN SUNSCREEN SPF15 2 AVEENO POSITIVELY LOTN RADIANTTINTED 2 MOISTURIZER SPF30 FACE COTZ LOTN 2 MEDIUM LOTN HUGGIES LITTLE AVEENO PROTECT + 2 SWIMMERS SPF50 LOTN 2 HYDRATESPF 50 LOTN 1%-5%-0.8%-7.5%-5% AVEENO PROTECT + 2 KERI AGE DEFY & 2 HYDRATESPF 70 LOTN PROTECT LOTN AVEENO SMART LUBRIDERM DAILY ESSENTIALS DAILY MOISTURE/SUNSCREEN 2 NOURISHING 2 SPF 15 LOTN MOISTURIZER SPF30 NEUTROGENA AGE LOTN SHIELD FACE AVEENO ULTRA- SUNBLOCK WITH 2 CALMING DAILY 2 HELIOPLEX SPF110 MOISTURIZER SPF15 LOTN LOTN NEUTROGENA AGE AVEENO ULTRA- SHIELD FACE 2 CALMING DAILY 2 SUNBLOCK WITH MOISTURIZER SPF30 HELIOPLEX SPF70 LOTN LOTN NEUTROGENA COOLDRY BULL FROG SPORTWITH HELIOPLEX 2 SUPERBLOCK SPF50 2 SPF 30 LOTN LOTN NEUTROGENA HEALTHY BULL FROG ULTIMATE DEFENSE DAILY 2 SHEERPROTECTION 2 MOISTURIZER FACE SUNBLOCK SPF 30 PURESCREEN LOTN LOTN NEUTROGENA MEN SPF 2 BULL FROG ULTIMATE 20 LOTN SHEERPROTECTION 2 NEUTROGENA SUNBLOCK SPF 30 LOTN MOISTURE 2 BULL FROG WATER SPF15UNTINTED LOTN ARMOR SPORT FACE 2 NEUTROGENA SPORT SPF 30 LOTN FACE SUNBLOCK WITH 2 CERAVE SUNSCREEN 2 HELIOPLEX SPF70 LOTN FACE/SPF50 LOTN NEUTROGENA ULTRA CERAVE SHEER DRY-TOUCH SPF 2 SUNSCREEN/BODY 2 45 LOTN LOTN

MHS Indiana Preferred Drug List Updated December 1, 2018

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUTROGENA ULTRA sunscreens lotn 4%-5%, SHEER DRY-TOUCH 2 9.1 %, 5%-10%, 1%-0.5%, WITH HELIOPLEX SPF 5.5%-8%, 4.9%-4.7%, 100 LOTN 7.5%-4.5%, 7.5%-3%-5%, NEUTROGENA ULTRA 2%-1%-1%-4%, 3%-7%- 4%-13%, 2%-7.5%-6%-3%, SHEER DRY-TOUCH 2 WITH HELIOPLEX SPF 55 5%-7.5%-4%-9%, 5%-9%- LOTN 7.5%-6%, 2%-5%-2%-2%- 2%, 2%-5%-4%-5%-8%, NEUTROGENA ULTRA 2%-2%-4%-5%-13%, 2%- 1 SHEER DRY-TOUCH 2 2%-5%-2%-10%, 2%-5%- WITH HELIOPLEX SPF 70 2%-2%-10%, 2%-5%-2%- LOTN 4%-13%, 3%-5%-6%-5%- NIVEA HAND THERAPY 2 13%, 3%-7%-4%-5%-13%, LOTN 3%-10%-6%-5%-15%, 5%- 2%-7.5%-6%-8%, 5%-3%- NIVEA VISAGE UV CARE 2 DAILY FACIAL LOTN 7.5%-6%-9%, 2%-2%-2%- 5%-10.5%, 2%-5%-7.5%- PRE SUN KIDS LOTN 2 6%-12%, 2%-5%-1%-7.5%- PURE & FREE BABY 6%-15% TOTAL BLOCK SPF 60 SUNSCREEN BROAD 2 2 SPECTRUM SPF 50 COVERUP LOTN PURESCREEN LOTN TOTAL BLOCK SPF 65 2 PURE & FREE BABY CLEAR LOTN SUNSCREEN BROAD 2 WATER BABIES SPF 30 NP SPECTRUM SPF 60+ LOTN (Use Sunscreens) LOTN Tar Products RA RX SUNCARE ADVANCED 2 coal tar extract sham 0.5 % 1 PROTECTION SPF50 LOTN DHS TAR GEL SHAM (Use NP Coal Tar Extract) ROC MULTI CORREXION DHS TAR SHAM (Use Coal 5 IN1 DAILY 2 NP MOISTURIZER SPF 30 Tar Extract) LOTN NEUTROGENA T/GEL ROC RETINOL SHAM (Use Coal Tar NP CORREXION SPF30 2 Extract) LOTN NEUTROGENA T/GEL SHADE SUNBLOCK SPF STUBBORN ITCH NP 45 LOTN (Use NP CONTROL SHAM (Use Sunscreens) Coal Tar Extract) SHADE UVAGUARD SPF DIAGNOSTIC PRODUCTS 15 LOTN (Use NP Sunscreens) Diagnostic Drugs SOLBAR AVO LOTN 2 CORTROSYN SOLR (Use NP PA; SP Cosyntropin) SOLBAR PF SPF15 LOTN 2 PA; SP 7.5%-6% cosyntropin solr 1

MHS Indiana Preferred Drug List Updated December 1, 2018

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCAGEN DIAGNOSTIC 2 QL(1 ea per fill INSULIN SOLR retail) USERS PA; SP LIMITED TO THYROGEN SOLR 2 150 PER 30 FREESTYLE INSULINX DAYS, NON- Diagnostic Tests BLOODGLUCOSE TEST 2 STRIPS STRP INSULIN INSULIN USERS USERS LIMITED TO LIMITED TO 100 PER 90 150 PER 30 DAYS;RX/OTC ACCU-CHEK AVIVA PLUS 2 DAYS, NON- INSULIN STRP VI INSULIN USERS USERS LIMITED TO LIMITED TO 150 PER 30 100 PER 90 FREESTYLE INSULINX BLOODGLUCOSE TEST 2 DAYS, NON- DAYS;RX/OTC INSULIN STRP INSULIN USERS USERS LIMITED TO LIMITED TO 100 PER 90 150 PER 30 DAYS;RX/OTC ACCU-CHEK GUIDE 2 DAYS, NON- INSULIN STRP VI INSULIN USERS USERS LIMITED TO LIMITED TO 150 PER 30 100 PER 90 FREESTYLE LITE TEST 2 DAYS, NON- DAYS;RX/OTC STRIPS STRP INSULIN INSULIN USERS USERS LIMITED TO LIMITED TO 100 PER 90 150 PER 30 DAYS;RX/OTC ACCU-CHEK SMARTVIEW 2 DAYS, NON- INSULIN STRIPS STRP INSULIN USERS USERS LIMITED TO LIMITED TO 150 PER 30 100 PER 90 FREESTYLE TEST 2 DAYS, NON- DAYS;RX/OTC STRIPS STRP INSULIN CHEK-STIX COMBO PAK USERS URINALYSIS CONTROL 2 LIMITED TO STRP 100 PER 90 DAYS;RX/OTC CHEK-STIX CONTROL 2 STRP KETOCARE STRP 2 CHEMSTRIP-K STRP 2 KETONE TEST STRIPS 2 STRP KETOSTIX STRP 2

RELION KETONE STRP 2

RELION KETONE TEST 2 STRIPS STRP

MHS Indiana Preferred Drug List Updated December 1, 2018

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN LISTER-V CAPS 2 PA USERS LIMITED TO MACUZIN CAPS 2 PA 150 PER 30 TRUE METRIX BLOOD 2 DAYS, NON- PA GLUCOSETEST STRIPS INSULIN METHAVER CAPS 2 STRP USERS PA LIMITED TO METHAZEL CAPS 2 100 PER 90 PA DAYS;RX/OTC NEUREPA CAPS 2 DIETARY PRODUCTS/DIETARY MANAGEMENT OMNIQUIN CAPS 2 PA PRODUCTS PA Dietary Management Products PERCURA CAPS 2 PA DEPLIN 15 CAPS 2 PULMONA CAPS 2 PA PA DEPLIN 7.5 CAPS 2 RHEUMATE CAPS 2 PA PA ELFOLATE TABS 2 RIBOZEL CAPS 2 PA PA ENLYTE CAPS 2 SENTRA AM CAPS 2 PA PA FOSTEUM PLUS CAPS 2 SENTRA PM CAPS 2 PA FOVEX CAPS 2 PA SODIUM PA POLYSULTHIONATE/FOLI 2 GABADONE CAPS 2 PA C ACID CAPS SULFZIX CAPS 2 PA HYPERTENSA CAPS 2 PA T-SUPPORT MAX CAPS 2 PA L-METHYLFOLATE CA/S- 2 PA ALGAL CAPS THERAMINE CAPS 2 PA L-METHYLFOLATE 2 PA CALCIUM TABS TL-ICARE CAPS 2 PA L-METHYLFOLATE 2 PA FORMULA 15 CAPS TREPADONE CAPS 2 PA L-METHYLFOLATE 2 PA FORMULA 7.5 CAPS VAYARIN PLUS CAPS 2 PA L-METHYLFOLATE 2 PA FORTE CAPS ZAVITROL CAPS 2 PA PA L-METHYLFOLATE TABS 2 DIGESTIVE AIDS - Drugs to Treat Low Digestive LEVOMEFOLATE PA Enzymes CALCIUM ALGAL 2 Digestive Enzymes POWDER CAPS LEXAZIN CAPS 2 PA

LIPICHOL 540 CAPS 2 PA

MHS Indiana Preferred Drug List Updated December 1, 2018

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CREON CPEP MAXZIDE-25 TABS (Use QL(2 ea daily) 19000UNIT-6000UNIT- Triamterene & NP 30000UNIT, 38000UNIT- 2 Hydrochlorothiazide) 12000UNIT-60000UNIT, spironolactone & 1 76000UNIT-24000UNIT- hydrochlorothiazide tabs 120000UNIT triamterene & PANCREAZE CPEP hydrochlorothiazide caps 1 14200UNIT-4200UNIT- 37.5mg-25mg 24600UNIT, 35500UNIT- 10500UNIT-61500UNIT, 2 triamterene & QL(2 ea daily) 54700UNIT-21000UNIT- hydrochlorothiazide tabs 1 83900UNIT, 56800UNIT- 37.5mg-25mg 16800UNIT-98400UNIT triamterene & ZENPEP CPEP hydrochlorothiazide tabs 1 17000UNIT-5000UNIT- 75mg-50mg 24000UNIT, 63000UNIT- TRIAMTERENE/HYDROC 2 20000UNIT-84000UNIT, 2 HLOROTHIAZIDE CAPS 79000UNIT-25000UNIT- Loop Diuretics 105000UNIT, 126000UNIT- 40000UNIT-168000UNIT bumetanide tabs or 0.5 mg, 1 1 mg, 2 mg DIURETICS - Drugs to Treat Heart, Circulation BUMEX TABS (Use NP Conditions and Blood Pressure Bumetanide) Carbonic Anhydrase Inhibitors DEMADEX TABS 10 MG NP QL(1 ea daily) (Use Torsemide) acetazolamide cp12 1 DEMADEX TABS 20 MG NP acetazolamide tabs 1 (Use Torsemide) furosemide soln ij 10 mg/ml 1 DIAMOX CP12 (Use NP Acetazolamide) furosemide soln or 10 1 methazolamide tabs 1 mg/ml FUROSEMIDE SOLN OR 8 2 NEPTAZANE TABS (Use NP MG/ML Methazolamide) furosemide tabs or 20 mg, 1 Diuretic Combinations 40 mg, 80 mg ALDACTAZIDE TABS LASIX TABS (Use NP Furosemide) 25MG-25MG (Use NP Spironolactone & Hydrochlorothiazide) torsemide tabs 20 mg 1 amiloride & QL(1 ea daily) 1 torsemide tabs 5 mg, 10 1 QL(1 ea daily) hydrochlorothiazide tabs mg, 100 mg DYAZIDE CAPS (Use Potassium Sparing Diuretics Triamterene & NP Hydrochlorothiazide) ALDACTONE TABS (Use NP Spironolactone) MAXZIDE TABS (Use Triamterene & NP amiloride hcl tabs 1 QL(4 ea daily) Hydrochlorothiazide) spironolactone tabs 1

MHS Indiana Preferred Drug List Updated December 1, 2018

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Thiazides and Thiazide-Like Diuretics ibandronate sodium soln iv 1 PA; SP 3 mg/3ml CHLOROTHIAZIDE TABS 2 QL(2 ea daily) 250 MG MIACALCIN SOLN IJ 200 2 QL(2 ml per fill UNIT/ML retail) QL(4 ea daily) chlorothiazide tabs 500 mg 1 MIACALCIN SOLN NA 200 UNIT/ACT (Use Calcitonin NP chlorthalidone tabs 1 (Salmon)) pamidronate disodium soln 1 PA; SP hydrochlorothiazide caps 1 30 mg/10ml, 90 mg/10ml hydrochlorothiazide tabs 1 PAMIDRONATE PA; SP DISODIUM SOLN 6 2 indapamide tabs 1 MG/ML PAMIDRONATE PA; SP metolazone tabs 1 DISODIUM SOLR 30 MG, 2 90 MG MICROZIDE CAPS (Use NP PA; SP Hydrochlorothiazide) PROLIA SOLN 2 ENDOCRINE AND METABOLIC AGENTS - RECLAST SOLN (Use NP PA; SP MISC. - Drugs to Treat Bone Disease and Zoledronic Acid) Regulate Hormones risedronate sodium tabs 35 1 PA; QL(0.143 Bone Density Regulators mg ea daily) risedronate sodium tabs 5 PA; QL(1 ea ACTONEL TABS 35 MG NP PA; QL(0.143 1 (Use Risedronate Sodium) ea daily) mg, 30 mg daily) ACTONEL TABS 5 MG, 30 PA; QL(1 ea risedronate sodium tbec 35 1 PA; QL(0.143 MG (Use Risedronate NP daily) mg ea daily) Sodium) XGEVA SOLN 2 PA; SP ALENDRONATE SODIUM 2 QL(10 ml daily) SOLN 70 MG/75ML zoledronic acid conc 4 1 PA; SP mg/5ml alendronate sodium tabs 1 QL(0.15 ea 35 mg, 70 mg daily) ZOLEDRONIC ACID SOLN 2 PA; SP 4 MG/100ML ALENDRONATE SODIUM 2 QL(1 ea daily) TABS 40 MG zoledronic acid soln 5 1 PA; SP mg/100ml alendronate sodium tabs 5 1 QL(1 ea daily) mg, 10 mg ZOLEDRONIC ACID SOLR 2 PA; SP 4 MG ATELVIA TBEC (Use NP PA; QL(0.143 Risedronate Sodium) ea daily) ZOMETA CONC 4 PA; SP NP BONIVA SOLN IV 3 PA; SP MG/5ML (Use Zoledronic Acid) MG/3ML (Use Ibandronate NP Sodium) ZOMETA SOLN 4 2 PA; SP MG/100ML calcitonin (salmon) soln 1 Corticotropin ETIDRONATE DISODIUM 2 PA; SP TABS H.P. ACTHAR GEL 2 FORTEO SOLN 2 PA; SP Fertility Regulators CHORIONIC 2 PA FOSAMAX TABS (Use NP QL(0.15 ea GONADOTROPIN SOLR Alendronate Sodium) daily) MHS Indiana Preferred Drug List Updated December 1, 2018

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVAREL SOLR 10000 2 PA EVISTA TABS (Use NP QL(1 ea daily); UNIT Raloxifene HCl) PV QL(1 ea daily); PREGNYL W/DILUENT PA raloxifene hcl tabs $0 BENZYLALCOHOL/NACL 2 PV SOLR Insulin-Like Growth Factors (Somatomedins) Growth Hormone Receptor Antagonists INCRELEX SOLN 2 PA; SP SOMAVERT SOLR 2 PA; SP LHRH/GnRH Agonist Analog Pituitary Growth Hormone Releasing Hormones (GHRH) LUPANETA PACK KIT 2 PA; SP EGRIFTA SOLR 2 PA; SP LUPRON DEPOT-PED (1- 2 PA; SP Growth Hormones MONTH) KIT LUPRON DEPOT-PED (3- PA; SP GENOTROPIN MINIQUICK 2 PA 2 SOLR MONTH) KIT PA; SP GENOTROPIN SOLR 2 PA SUPPRELIN LA KIT 2 PA; SP HUMATROPE COMBO 2 PA SYNAREL SOLN 2 PACK SOLR Metabolic Modifiers HUMATROPE SOLR 2 PA ALDURAZYME SOLN 2 PA; SP NORDITROPIN FLEXPRO 2 PA SOLN BUPHENYL POWD (Use NP PA; SP Sodium Phenylbutyrate) NUTROPIN AQ NUSPIN 2 PA 10 SOLN BUPHENYL TABS (Use NP PA; SP Sodium Phenylbutyrate) NUTROPIN AQ NUSPIN 2 PA 20 SOLN calcitriol caps or 0.25 mcg, 1 0.5 mcg NUTROPIN AQ NUSPIN 5 2 PA SOLN CARBAGLU TABS 2 PA; SP PA OMNITROPE SOLN 2 CARNITOR SF SOLN (Use QL(30 ml daily) PA Levocarnitine (Metabolic NP OMNITROPE SOLR 2 Modifiers)) SAIZEN CLICK.EASY 2 PA; SP CARNITOR SOLN OR 1 QL(30 ml daily) SOLR GM/10ML (Use NP PA; SP Levocarnitine (Metabolic SAIZEN SOLR 2 Modifiers)) SAIZENPREP PA; SP CARNITOR TABS OR 330 QL(3 ea daily); RECONSTITUTIONKIT 2 MG (Use Levocarnitine NP RX/OTC SOLR (Metabolic Modifiers)) SEROSTIM SOLR 2 PA; SP CYSTADANE POWD 2 PA; SP

ZOMACTON SOLR 2 PA ELAPRASE SOLN 2 PA; SP

ZORBTIVE SOLR 2 PA; SP FABRAZYME SOLR 2 PA; SP Hormone Receptor Modulators KUVAN PACK 2 PA; SP

MHS Indiana Preferred Drug List Updated December 1, 2018

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KUVAN TBSO 2 PA; SP desmopressin acetate 1 PA; QL(5 ml spray soln per fill retail) levocarnitine (metabolic QL(30 ml daily) 1 desmopressin acetate tabs 1 QL(6 ea daily) modifiers) soln 1 gm/10ml or 0.1 mg, 0.2 mg levocarnitine (metabolic 1 QL(3 ea daily); PA; SP modifiers) tabs 330 mg RX/OTC STIMATE SOLN 2 LUMIZYME SOLR 2 PA; SP Somatostatic Agents octreotide acetate soln 1 PA; SP MYALEPT SOLR 2 PA; SP SANDOSTATIN LAR 2 PA; SP NAGLAZYME SOLN 2 PA; SP DEPOT KIT SANDOSTATIN SOLN PA; SP paricalcitol soln iv 2 1 PA; SP NP mcg/ml, 5 mcg/ml (Use Octreotide Acetate) PA; SP RAVICTI LIQD 2 PA; SP SIGNIFOR SOLN 2 ROCALTROL CAPS 0.25 SOMATULINE DEPOT 2 PA; SP MCG, 0.5 MCG (Use NP SOLN Calcitriol) Vasopressin Receptor Antagonists PA; SP SENSIPAR TABS 2 JYNARQUE TBPK 2 PA sodium phenylbutyrate PA; SP 1 2 PA powd SAMSCA TABS sodium phenylbutyrate tabs 1 PA; SP ESTROGENS - Hormone Replacement/Modifying Drugs PA; SP VIMIZIM SOLN 2 Estrogen Combinations ZEMPLAR SOLN IV 2 PA; SP ACTIVELLA TABS (Use QL(1 ea daily) MCG/ML, 5 MCG/ML (Use NP Estradiol & Norethindrone NP Paricalcitol) Acetate) Posterior Pituitary Hormones Limit 8 patches 2 per DDAVP SOLN IJ 4 PA; SP COMBIPATCH PTTW month;QL(0.29 MCG/ML (Use NP ea daily) Desmopressin Acetate) estradiol & norethindrone 1 QL(1 ea daily) DDAVP SOLN NA 0.01 % 2 QL(5 ml per fill acetate tabs retail) FEMHRT LOW DOSE DDAVP SOLN NA 0.01 % PA; QL(5 ml TABS (Use Norethindrone NP (Use Desmopressin NP per fill retail) Acetate-Ethinyl Estradiol) Acetate Spray) norethindrone acetate- $0 DDAVP TABS OR 0.1 MG, QL(6 ea daily) ethinyl estradiol tabs 0.2 MG (Use NP Desmopressin Acetate) PREMPRO TABS 2 desmopressin acetate soln 1 PA; SP ij 4 mcg/ml Estrogens QL(0.286 ea desmopressin acetate 1 QL(5 ml per fill ALORA PTTW 2 spray refrigerated soln retail) daily) CLIMARA PTWK (Use NP QL(0.143 ea Estradiol) daily) MHS Indiana Preferred Drug List Updated December 1, 2018

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESTRACE TABS OR 0.5 QL(1 ea NP LEVAQUIN TABS (Use NP MG, 1 MG, 2 MG (Use Levofloxacin) daily,14 ea per Estradiol) fill retail) estradiol pttw td 0.025 QL(0.286 ea QL(1 ea 1 daily) levofloxacin tabs or 250 1 daily,14 ea per mg/24hr, 0.075 mg/24hr, mg, 500 mg, 750 mg 0.05 mg/24hr, 0.1 mg/24hr fill retail) estradiol pttw td 0.0375 1 OFLOXACIN TABS 300 2 QL(56 ea per mg/24hr MG fill retail) QL(0.143 ea QL(56 ea per estradiol ptwk td 0.025 ofloxacin tabs 400 mg 1 mg/24hr, 0.075 mg/24hr, daily) fill retail) 0.05 mg/24hr, 0.06 1 mg/24hr, 0.1 mg/24hr, 37.5 GASTROINTESTINAL AGENTS - MISC. - mcg/24hr Miscellaneous Gastrointestinal Drugs Antiflatulents estradiol tabs or 0.5 mg, 1 1 mg, 2 mg GAS-X CHEW (Use NP Simethicone) ESTROPIPATE TABS 0.75 2 QL(1 ea daily) MG MYLICON INFANTS GAS QL(1 ml daily) MINIVELLE PTTW 0.025 QL(0.286 ea RELIEF SUSP (Use NP MG/24HR, 0.075 daily) Simethicone) MG/24HR, 0.05 MG/24HR, NP MYLICON SUSP (Use NP QL(1 ml daily) 0.1 MG/24HR (Use Simethicone) Estradiol) simethicone chew 80 mg 1 MINIVELLE PTTW 0.0375 NP MG/24HR (Use Estradiol) simethicone susp 20 1 QL(1 ml daily) PREMARIN TABS OR QL(1 ea daily) mg/0.3ml, 40 mg/0.6ml 0.625 MG, 0.45 MG, 0.3 2 Bile Acid Synthesis Disorder Agents MG, 0.9 MG, 1.25 MG CHOLBAM CAPS 2 PA; QL(5 ea VIVELLE-DOT PTTW QL(0.286 ea daily); SP 0.025 MG/24HR, 0.075 daily) MG/24HR, 0.05 MG/24HR, NP Farnesoid X Receptor (FXR) Agonists 0.1 MG/24HR (Use PA; SP Estradiol) OCALIVA TABS 2 VIVELLE-DOT PTTW Gallstone Solubilizing Agents 0.0375 MG/24HR (Use NP ACTIGALL CAPS (Use NP Estradiol) Ursodiol) FLUOROQUINOLONES - Drugs to Treat Bacterial URSO 250 TABS (Use NP QL(7 ea daily) Infections Ursodiol) Fluoroquinolones ursodiol caps 300 mg 1 CIPRO TABS 250 MG, 500 MG (Use Ciprofloxacin NP ursodiol tabs 250 mg 1 QL(7 ea daily) HCl) Gastrointestinal Stimulants CIPROFLOXACIN HCL 2 QL(6 ea per fill TABS 100 MG retail) metoclopramide hcl soln or 1 5 mg/5ml, 10 mg/10ml ciprofloxacin hcl tabs 250 1 mg, 500 mg, 750 mg metoclopramide hcl tabs or 1 5 mg, 10 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REGLAN TABS (Use NP potassium citrate Metoclopramide HCl) (alkalinizer) tbcr 540 mg, 1 1080 mg Inflammatory Bowel Agents sodium citrate & citric acid 1 QL(16.67 ml AZULFIDINE EN-TABS NP daily); RX/OTC TBEC (Use Sulfasalazine) soln UROCIT-K 10 TBCR (Use AZULFIDINE TABS (Use NP NP ) Potassium Citrate Sulfasalazine (Alkalinizer)) QL(9 ea daily) balsalazide disodium caps 1 UROCIT-K 5 TBCR (Use Potassium Citrate NP CIMZIA KIT 2 PA; SP (Alkalinizer)) Cystinosis Agents CIMZIA STARTER KIT KIT 2 PA; SP CYSTAGON CAPS 2 PA; SP COLAZAL CAPS (Use NP QL(9 ea daily) Balsalazide Disodium) PROCYSBI CPDR 2 PA; SP ENTYVIO SOLR 2 PA; SP Genitourinary Irrigants LIALDA TBEC (Use NP sodium chloride (gu 1 Mesalamine) irrigant) soln QL(60 ml daily) mesalamine enem re 4 gm 1 Interstitial Cystitis Agents QL(3 ea daily) mesalamine tbec or 1.2 gm 1 ELMIRON CAPS 2 mesalamine tbec or 800 1 QL(3 ea daily) Prostatic Hypertrophy Agents mg finasteride tabs 1 QL(1 ea daily) REMICADE SOLR 2 PA; SP FLOMAX CAPS (Use NP QL(2 ea daily) SFROWASA ENEM 2 Tamsulosin HCl) PROSCAR TABS (Use NP QL(1 ea daily) sulfasalazine tabs 1 Finasteride) tamsulosin hcl caps 1 QL(2 ea daily) sulfasalazine tbec 1 Urinary Analgesics Intestinal Acidifiers phenazopyridine hcl tabs 1 lactulose (encephalopathy) 1 95 mg, 100 mg, 200 mg soln PYRIDIUM TABS (Use NP Phosphate Binder Agents Phenazopyridine HCl) calcium acetate (phosphate 1 binder) caps GOUT AGENTS - Drugs to Treat Gout Short Bowel Syndrome (SBS) Agents Gout Agent Combinations GATTEX KIT 2 PA; SP colchicine w/ probenecid 1 tabs GENITOURINARY AGENTS - MISCELLANEOUS Gout Agents - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System allopurinol tabs 1 Alkalinizers MHS Indiana Preferred Drug List Updated December 1, 2018

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COLCHICINE TABS 2 QL(6 ea per fill HEMOFIL M SOLR CO retail) QL(6 ea per fill colchicine tabs 2 HUMATE-P SOLR CO retail) IDELVION SOLR 250 COLCRYS TABS 2 QL(6 ea per fill retail) UNIT, 500 UNIT, 1000 CO UNIT, 2000 UNIT KRYSTEXXA SOLN 2 PA; SP IXINITY SOLR CO ZYLOPRIM TABS (Use NP Allopurinol) KCENTRA KIT CO Uricosurics KOATE SOLR CO probenecid tabs 1 KOATE-DVI SOLR CO HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders KOGENATE FS BIO-SET CO KIT Antihemophilic Products KOGENATE FS KIT CO ADVATE SOLR CO KOVALTRY SOLR CO ADYNOVATE SOLR CO MONOCLATE-P KIT CO AFSTYLA KIT CO ALPHANATE/VON MONONINE SOLR CO WILLEBRANDFACTOR CO COMPLEX/HUMAN SOLR NOVOEIGHT SOLR CO ALPHANINE SD SOLR CO NOVOSEVEN RT SOLR CO

ALPROLIX SOLR CO OBIZUR SOLR CO

BEBULIN SOLR CO PROFILNINE SD SOLR CO

BENEFIX KIT CO PROFILNINE SOLR CO

COAGADEX SOLR CO REBINYN SOLR CO

CORIFACT KIT CO RECOMBINATE SOLR CO

ELOCTATE SOLR CO RIASTAP SOLR CO

FEIBA SOLR CO RIXUBIS SOLR CO

FIBRYGA SOLR CO TRETTEN SOLR CO

HELIXATE FS KIT CO VONVENDI SOLR CO

HEMLIBRA SOLN CO WILATE KIT CO

MHS Indiana Preferred Drug List Updated December 1, 2018

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XYNTHA KIT CO dipyridamole tabs or 25 1 mg, 50 mg, 75 mg XYNTHA SOLOFUSE KIT CO EFFIENT TABS (Use NP QL(1 ea daily) Prasugrel HCl) Bradykinin B2 Receptor Antagonists PLAVIX TABS 75 MG (Use NP QL(1 ea daily) Clopidogrel Bisulfate) FIRAZYR SOLN 2 PA; SP prasugrel hcl tabs 1 QL(1 ea daily) Complement Inhibitors HEMATOPOIETIC AGENTS - Drugs to Treat 2 PA; SP BERINERT KIT Blood Disorders CINRYZE SOLR 2 PA; SP Agents for Gaucher Disease CERDELGA CAPS 2 PA; SP RUCONEST SOLR 2 PA; SP CEREZYME SOLR 2 PA; SP SOLIRIS SOLN 2 PA; SP PA; SP Hemataologic - Tyrosine Kinase Inhibitors miglustat caps 1 PA TAVALISSE TABS 2 VPRIV SOLR 2 PA; SP

Hematorheologic Agents ZAVESCA CAPS (Use NP PA; SP Miglustat) pentoxifylline tbcr 1 Agents for Sickle Cell Anemia Human Protein C DROXIA CAPS 2 CEPROTIN SOLR 2 PA; SP Cobalamins Plasma Kallikrein Inhibitors B-12 CAPS 1000 MCG 2 KALBITOR SOLN 2 PA; SP cyanocobalamin liqd or 1 Plasma Proteins 1000 mcg/15ml PA; SP cyanocobalamin soln ij 1 QL(10 ml per THROMBATE III SOLR 2 1000 mcg/ml 270 days retail) cyanocobalamin subl sl THROMBATE III W/10 ML 2 PA; SP 1 STERILE WATER SOLR 1000 mcg cyanocobalamin tabs or THROMBATE III W/20 ML 2 PA; SP 1 STERILE WATER SOLR 1000 mcg Platelet Aggregation Inhibitors Folic Acid/Folates RX/OTC; PV AGRYLIN CAPS (Use NP folic acid tabs or 1 mg $0 Anagrelide HCl) folic acid tabs or 400 mcg, $0 QL(1 ea daily); anagrelide hcl caps 1 800 mcg PV BRILINTA TABS 2 QL(2 ea daily) Hematopoietic Growth Factors ARANESP ALBUMIN 2 PA; SP cilostazol tabs 1 QL(2 ea daily) FREE SOLN ARANESP ALBUMIN 2 PA; SP clopidogrel bisulfate tabs 1 QL(1 ea daily) FREE SOSY 75 mg MHS Indiana Preferred Drug List Updated December 1, 2018

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPOGEN SOLN 2 PA; SP QL(3.4 ml ferrous sulfate soln 15 $0 daily); AL(Up to mg/ml LEUKINE SOLR 2 PA; SP 18 yrs old ); PV ferrous sulfate tabs 65 mg, $0 PV MIRCERA SOSY 50 PA; SP 325 mg MCG/0.3ML, 75 FERROUS SULFATE 2 MCG/0.3ML, 100 2 TBEC 324 MG MCG/0.3ML, 200 MCG/0.3ML ferrous sulfate tbec 325 mg $0 PV NEULASTA ONPRO KIT PA; SP 2 HEMOCYTE TABS (Use NP PSKT Ferrous Fumarate) NEULASTA SOSY 2 PA; SP IRON CHEWS PEDIATRIC 2 CHEW NPLATE SOLR 2 PA; SP NOVAFERRUM 2 PROCRIT SOLN 2000 PA; SP PEDIATRIC DROPS LIQD UNIT/ML, 3000 UNIT/ML, polysaccharide iron 1 QL(1 ea daily) 4000 UNIT/ML, 10000 2 complex caps UNIT/ML, 20000 UNIT/ML, Stem Cell Mobilizers 40000 UNIT/ML MOZOBIL SOLN 2 PA; SP PROMACTA TABS 2 PA; SP PA; SP HEMOSTATICS - Drugs to Stop Bleeding/Treat ZARXIO SOSY 2 Blood Disorders Hematopoietic Mixtures Hemostatics - Systemic QL(24 ea per ferrous fumarate-fa-b QL(1 ea daily) AMICAR TABS 500 MG 2 complex-c-zn-mg-mn-cu 1 fill retail) tabs QL(30 ea per 5 LYSTEDA TABS (Use NP days retail); NOVAFERRUM 125 LIQD 2 Tranexamic Acid) AL(At least 12 yrs old) Iron QL(30 ea per 5 FE GLUCONATE TABS 2 tranexamic acid tabs or 650 1 days retail); mg AL(At least 12 QL(3.4 ml yrs old) FER-IN-SOL SOLN (Use NP Ferrous Sulfate) daily); AL(Up to 18 yrs old ); PV HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS FERRETTS TABS 2 QL(2 ea daily) Antihistamine Hypnotics ferrous fumarate tabs 324 1 diphenhydramine hcl 1 mg (sleep) caps 25 mg, 50 mg ferrous gluconate tabs 27 1 diphenhydramine hcl 1 mg, 240 mg, 324 mg (sleep) liqd 50 mg/30ml FERROUS GLUCONATE 2 diphenhydramine hcl 1 TABS 324 MG (sleep) tabs 25 mg, 50 mg ferrous sulfate elix 220 PV $0 doxylamine succinate 1 mg/5ml (sleep) tabs FERROUS SULFATE LIQD 2 220 MG/5ML MHS Indiana Preferred Drug List Updated December 1, 2018

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NYTOL MAXIMUM AMBIEN CR TBCR (Use NP QL(1 ea daily) STRENGTH TABS (Use NP Zolpidem Tartrate) Diphenhydramine HCl AMBIEN TABS (Use NP QL(1 ea daily) (Sleep)) Zolpidem Tartrate) UNISOM SLEEPGELS CHLORAL HYDRATE 2 CAPS (Use NP CRYS Diphenhydramine HCl (Sleep)) dexmedetomidine hcl soln 1 200 mcg/2ml UNISOM SLEEPTABS TABS (Use Doxylamine NP EDLUAR SUBL 2 QL(1 ea daily) Succinate (Sleep)) QL(1 ea daily) ZZZQUIL CAPS (Use estazolam tabs 1 Diphenhydramine HCl NP QL(1 ea daily) (Sleep)) eszopiclone tabs 1 ZZZQUIL LIQD (Use QL(1 ea daily) Diphenhydramine HCl NP FLURAZEPAM HCL CAPS 2 (Sleep)) HALCION TABS (Use NP QL(1 ea daily) Barbiturate Hypnotics Triazolam) INTERMEZZO SUBL (Use NP QL(1 ea daily) AMYTAL SODIUM SOLR 2 Zolpidem Tartrate) NEMBUTAL SODIUM LUNESTA TABS (Use NP QL(1 ea daily) SOLN (Use Pentobarbital NP Eszopiclone) Sodium) midazolam hcl soln 1 PENTOBARBITAL 2 SODIUM POWD XX midazolam hcl syrp 1 pentobarbital sodium soln ij 1 PRECEDEX SOLN 200 MCG/2ML (Use NP phenobarbital elix or 20 1 mg/5ml Dexmedetomidine HCl) RESTORIL CAPS (Use QL(1 ea daily) PHENOBARBITAL POWD 2 NP XX Temazepam) SONATA CAPS (Use QL(2 ea daily) PHENOBARBITAL 2 NP SODIUM POWD Zaleplon) QL(1 ea daily) PHENOBARBITAL 2 temazepam caps 1 SODIUM SOLN QL(1 ea daily) phenobarbital soln or 20 1 triazolam tabs 1 mg/5ml QL(2 ea daily) phenobarbital tabs or 15 zaleplon caps 1 mg, 30 mg, 60 mg, 100 mg, 1 16.2 mg, 32.4 mg, 64.8 mg, zolpidem tartrate subl 1 QL(1 ea daily) 97.2 mg zolpidem tartrate tabs 1 QL(1 ea daily) SECONAL SODIUM CAPS 2 zolpidem tartrate tbcr 1 QL(1 ea daily) Hypnotics - Tricyclic Agents SILENOR TABS 2 QL(1 ea daily) ZOLPIMIST SOLN 2 QL(2 ml daily) Non-Barbiturate Hypnotics Orexin Receptor Antagonists MHS Indiana Preferred Drug List Updated December 1, 2018

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BELSOMRA TABS 2 QL(1 ea daily) NULYTELY/FLAVOR PACKS SOLR (Use PEG Selective Melatonin Receptor Agonists 3350-Potassium Chloride- NP Sod Bicarbonate-Sod HETLIOZ CAPS 2 PA; QL(1 ea Chloride) daily); SP peg 3350-kcl-sod bicarb- PV ROZEREM TABS 2 QL(1 ea daily) sod chloride-sod sulfate $0 solr 236gm-22.74gm- LAXATIVES - Bowel Treatment Drugs 5.86gm-2.97gm-6.74gm peg 3350-kcl-sod bicarb- Bulk Laxatives sod chloride-sod sulfate 1 calcium polycarbophil tabs 1 QL(10 ea daily) solr 240gm-22.72gm- 5.84gm-2.98gm-6.72gm EVAC POWD (Use NP peg 3350-potassium Psyllium) chloride-sod bicarbonate- 1 sod chloride solr FIBERCON TABS (Use NP QL(10 ea daily) Calcium Polycarbophil) sennosides-docusate 1 QL(4 ea daily) sodium tabs KONSYL DAILY FIBER 2 PACK 100 % SENOKOT S TABS (Use QL(4 ea daily) KONSYL DAILY FIBER Sennosides-Docusate NP POWD 100 % (Use NP Sodium) Psyllium) Laxatives - Miscellaneous KONSYL ORIGINAL glycerin (laxative) supp 1 1 FORMULADAILY FIBER NP gm, 2 gm, 1.2 gm, 2.1 gm POWD (Use Psyllium) GLYCERIN ADULT SUPP NP METAMUCIL CAPS 0.52 NP (Use Glycerin (Laxative)) GM (Use Psyllium) lactulose soln 10 gm/15ml, 1 METAMUCIL ORIGINAL 20 gm/30ml TEXTURE POWD (Use NP Psyllium) MIRALAX POWD (Use NP QL(34 gm Polyethylene Glycol 3350) daily); RX/OTC METAMUCIL POWD 48.57 NP % (Use Psyllium) PEDIA-LAX SUPP RE 1 GM (Use Glycerin NP psyllium caps 0.52 gm, 520 1 (Laxative)) mg PEDIA-LAX SUPP RE 2.8 2 psyllium powd 33 %, 100 GM %, 28.3 %, 30.9 %, 58.6 %, 1 48.57 % polyethylene glycol 3350 1 QL(34 gm powd or daily); RX/OTC Laxative Combinations SORBITOL SOLN OR 70 2 COLYTE-FLAVOR PACKS % SOLR (Use PEG 3350- NP KCl-Sod Bicarb-Sod Saline Laxatives Chloride-Sod Sulfate) FLEET ENEMA ENEM NP GOLYTELY SOLR 236GM- PV (Use Sodium Phosphates) 22.74GM-5.86GM-2.97GM- FLEET ENEMA SIX PACK 6.74GM (Use PEG 3350- NP ENEM (Use Sodium NP KCl-Sod Bicarb-Sod Phosphates) Chloride-Sod Sulfate)

MHS Indiana Preferred Drug List Updated December 1, 2018

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLEET PEDIATRIC ENEM NP docusate sodium liqd or 50 1 (Use Sodium Phosphates) mg/5ml, 150 mg/15ml magnesium citrate soln docusate sodium syrp or 60 1 1.745gm/30ml, 1.745 1 mg/15ml gm/30ml, docusate sodium tabs or 1 magnesium hydroxide susp 1 QL(32 ml daily) 100 mg MACROLIDES - Drugs to Treat Bacterial MILK OF MAGNESIA 2 Infections CONCENTRATE SUSP sodium phosphates enem Azithromycin re 16gm/133ml-6gm/133ml, azithromycin susr or 100 1 mg/5ml, 200 mg/5ml 19gm/118ml-7gm/118ml, 1 9.5gm/59ml-3.5gm/59ml, azithromycin tabs or 250 1 QL(6 ea per fill 19gm/118ml-19gm/118ml- mg retail) 7gm/118ml-7gm/118ml azithromycin tabs or 500 1 QL(4 ea daily) Stimulant Laxatives mg QL(12 ea per azithromycin tabs or 600 QL(0.286 ea bisacodyl supp re 10 mg 1 1 fill retail) mg daily) bisacodyl tbec or 5 mg 1 QL(1 ea daily) ZITHROMAX SUSR OR 100 MG/5ML, 200 MG/5ML NP (Use Azithromycin) DULCOLAX SUPP RE 10 NP QL(12 ea per MG (Use Bisacodyl) fill retail) ZITHROMAX TABS OR NP QL(6 ea per fill 250 MG (Use Azithromycin) retail) DULCOLAX TBEC OR 5 NP QL(1 ea daily) MG (Use Bisacodyl) ZITHROMAX TABS OR NP QL(4 ea daily) 500 MG (Use Azithromycin) EX-LAX TABS (Use NP Sennosides) ZITHROMAX TABS OR NP QL(0.286 ea 600 MG (Use Azithromycin) daily) SENNA SYRP 2 ZITHROMAX TRI-PAK NP QL(4 ea daily) sennosides liqd 8.8 mg/5ml 1 TABS (Use Azithromycin) ZITHROMAX Z-PAK TABS NP QL(6 ea per fill sennosides syrp 8.8 1 (Use Azithromycin) retail) mg/5ml Clarithromycin sennosides tabs 15 mg, 8.6 1 mg, 17.2 mg BIAXIN SUSR 250 MG/5ML (Use NP SENOKOT TABS (Use NP Sennosides) Clarithromycin) BIAXIN TABS 250 MG, 500 QL(28 ea per SENOKOT XTRA TABS NP NP (Use Sennosides) MG (Use Clarithromycin) fill retail) CLARITHROMYCIN SUSR 2 Surfactant Laxatives 125 MG/5ML, 250 MG/5ML COLACE CAPS (Use QL(3 ea daily) NP clarithromycin susr 125 1 Docusate Sodium) mg/5ml, 250 mg/5ml docusate calcium caps 1 clarithromycin tabs 250 mg, 1 QL(28 ea per 500 mg fill retail) docusate sodium caps or QL(3 ea daily) QL(14 ea per 1 clarithromycin tb24 500 mg 1 100 mg, 250 mg fill retail) Erythromycins MHS Indiana Preferred Drug List Updated December 1, 2018

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits E.E.S. GRANULES SUSR BIOGUARD GAUZE RX/OTC (Use Erythromycin NP SPONGE 2"X2" 8 PLY 2 Ethylsuccinate) PADS ERY-TAB TBEC 2 BIOGUARD GAUZE RX/OTC SPONGES 4"X4" 12 PLY 2 ERYPED 200 SUSR (Use PADS Erythromycin NP BORDERED GAUZE 2 RX/OTC Ethylsuccinate) PADS ERYPED 400 SUSR 2 CARRASMART FOAM 2 RX/OTC PADS erythromycin base cpep 1 RX/OTC 250 mg CARRASMART PADS XX 2 erythromycin base tabs 1 COPA ISLAND RX/OTC 250 mg BORDERED FOAM 2 erythromycin DRESSING 4"X4" PADS ethylsuccinate susr 200 1 COPA PLUS RX/OTC mg/5ml HYDROPHILIC FOAM 2 PCE TBEC 333 MG 2 DRESSING 4"X4" PADS COVRSITE COVER 2 RX/OTC MEDICAL DEVICES AND SUPPLIES DRESSING PADS COVRSITE PLUS RX/OTC Bandages-Dressings-Tape COMPOSITE DRESSING 2 PADS ALLEVYN PLUS CAVITY 2 RX/OTC PADS CUREX ALL-PURPOSE RX/OTC RX/OTC SPONGES 4"X4" 4 PLY 2 ALLEVYN THIN PADS 2 PADS CURITY ALL PURPOSE RX/OTC AMD FOAM DRESSING 2 RX/OTC 4"X4" PADS SPONGES 2"X2" 4PLY 2 AMD FOAM RX/OTC PADS DRESSING/TOPSHEET 2 CURITY ALL PURPOSE 2 RX/OTC 4"X4" PADS SPONGES 2"X2" PADS CURITY ALL PURPOSE BAND-AID GAUZE PADS 2 RX/OTC LARGE4" X 4" PADS SPONGES 3"X3" 4PLY 2 PADS BAND-AID GAUZE PADS 2 MEDIUM 3" X 3" PADS CURITY ALL PURPOSE 2 RX/OTC SPONGES 4 PLY PADS BAND-AID GAUZE PADS 2 RX/OTC SMALL2" X 2" PADS CURITY ALL PURPOSE RX/OTC BAND-AID MIRASORB RX/OTC SPONGES 4"X4" 4PLY 2 GAUZE SPONGES 2 PADS LARGE 4" X 4" PADS CURITY ALL PURPOSE RX/OTC BIATAIN ADHESIVE RX/OTC SPONGES 4"X4" 2 FOAM DRESSING 4"X4" 2 4PLY/SOFT POUCH PADS PADS CURITY ALL PURPOSE 2 RX/OTC SPONGES 4"X4" PADS BIATAIN FOAM 2 RX/OTC DRESSING 4"X4" PADS

MHS Indiana Preferred Drug List Updated December 1, 2018

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY AMD RX/OTC CURITY RX/OTC ANTIMICROBIALGAUZE 2 SPONGES/CELLULOSEFI 2 SPONGES 2"X2" 8 PLY LLED/2"X2" PADS PADS CURITY RX/OTC CURITY AMD RX/OTC SPONGES/CELLULOSEFI 2 ANTIMICROBIALGAUZE 2 LLED/4"X4" PADS SPONGES 4"X4" 12 PLY CVS GAUZE PAD 3"X3" 2 PADS PADS CURITY COVER SPONGE RX/OTC 2 CVS GAUZE PADS 2"X2" 2 RX/OTC 4"X4" PADS 12-PLY PADS CURITY COVER 2 CVS GAUZE PADS 4"X4" 2 RX/OTC SPONGES 3"X3" PADS 12-PLY PADS CURITY COVER 2 RX/OTC CVS GAUZE PADS RX/OTC SPONGES 4"X4" PADS STERILE 4"X4" 12-PLY 2 CURITY DRESSING RX/OTC PADS SPONGES 4"X4" 6 PLY 2 DERMACEA DRAIN 2 RX/OTC PADS SPONGES 4"X4" PADS CURITY GAUZE PADS 2 RX/OTC DERMACEA GAUZE RX/OTC 2"X2" 12 PLY PADS SPONGE 2"X2" 12 PLY 2 CURITY GAUZE PADS 2 RX/OTC PADS 2"X2" PADS DERMACEA GAUZE RX/OTC CURITY GAUZE PADS 2 SPONGE 2"X2" 8 PLY 2 3"X3" PADS PADS CURITY GAUZE PADS 2 RX/OTC DERMACEA GAUZE 4"X4" 12 PLY PADS SPONGE 3"X3" 12 PLY 2 PADS CURITY GAUZE SPONGE 2 RX/OTC 2"X2" 8 PLY PADS DERMACEA GAUZE SPONGE 3"X3" 8 PLY 2 CURITY GAUZE SPONGE 2 RX/OTC 2"X2"12 PLY PADS PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE 2 3"X3" 12 PLY PADS SPONGE 4"X4" 12 PLY 2 PADS CURITY GAUZE SPONGE 2 RX/OTC 4"X4" 12 PLY PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 16 PLY 2 CURITY GAUZE SPONGE 2 RX/OTC PADS 4"X4" 16 PLY PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE 2 RX/OTC SPONGE 4"X4" 8 PLY 2 4"X4" 8 PLY PADS PADS CURITY GAUZE SPONGE RX/OTC 2 DERMACEA I.V. DRAIN 2 RX/OTC 4"X4"16 PLY PADS SPONGES 2"X2" PADS CURITY GAUZE RX/OTC DERMACEA I.V. DRAIN 2 RX/OTC SPONGES 4"X4" 12 PLY 2 SPONGES 4"X4" PADS PADS DERMACEA I.V. 2 RX/OTC CURITY GAUZE RX/OTC SPONGES 2"X2" PADS SPONGES 4"X4" 8 PLY 2 PADS DERMACEA NON-WOVEN RX/OTC SPONGES 2"X2" 4 PLY 2 CURITY NON-ADHERENT 2 PADS STRIPS 3"X3" PADS MHS Indiana Preferred Drug List Updated December 1, 2018

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA NON-WOVEN EXCILON AMD RX/OTC 2 SPONGES 3"X3" 4 PLY ANTIMICROBIALNON- 2 PADS WOVEN SPONGES 4"X4" DERMACEA NON-WOVEN RX/OTC 6 PLY PADS 2 SPONGES 4"X4" 4 PLY EXCILON DRAIN 2 RX/OTC PADS SPONGE 4"X4" PADS DERMACEA NON-WOVEN RX/OTC EXCILON DRAIN RX/OTC SPONGES 4"X4" 6 PLY 2 SPONGES 4"X4" 6 PLY 2 PADS PADS DERMACEA TYPE VII RX/OTC EXCILON I.V. SPONGES 2 RX/OTC GAUZE 2"X2" 12 PLY 2 2"X2" 6 PLY PADS PADS GAUZE DRESSING 4"X4" 2 RX/OTC DERMACEA TYPE VII 2 RX/OTC PADS GAUZE 2"X2" 8 PLY PADS GAUZE PADS 2"X2" PADS 2 RX/OTC DERMACEA TYPE VII 2 GAUZE 3"X3" 12 PLY GAUZE PADS 3"X3" PADS 2 PADS DERMACEA TYPE VII GAUZE PADS 4"X4" 12 2 RX/OTC GAUZE 3"X3" 12PLY 2 PLY PADS PADS GAUZE PADS 4"X4" PADS 2 RX/OTC DERMACEA TYPE VII RX/OTC GAUZE 4"X4" 12 PLY 2 GAUZE SPONGE TYPE RX/OTC PADS VII MEDI-PAK 2"X2" 8PLY 2 DERMACEA TYPE VII RX/OTC PADS GAUZE 4"X4" 16 PLY 2 GAUZE SPONGES 4"X4" 2 RX/OTC PADS 12 PLY PADS GNP STERILE PADS DERMACEA TYPE VII 2 RX/OTC 2 GAUZE 4"X4" 8 PLY PADS 3"X3" PADS DERMACEA X-RAY RX/OTC HM STERILE PADS 2"X2" 2 RX/OTC SPONGES 4"X4" 16 PLY 2 PADS PADS HM STERILE PADS PADS 2 RX/OTC DERMALEVIN ADHESIVE RX/OTC FOAMDRESSING 4"X4" 2 HYDROCELL ADHESIVE 2 RX/OTC PADS DRESSING 4"X4" PADS RX/OTC DRYMAX EXTRA PADS 2 HYDROCELL DRESSING 2 RX/OTC 4"X4" PADS EQL GAUZE PADS RX/OTC 2 J & J GAUZE 2"X2" 8 PLY 2 RX/OTC 2"X2"/SMALL PADS PADS EQL GAUZE PADS RX/OTC 2 J & J GAUZE 4"X4" 12 PLY 2 RX/OTC 4"X4"/LARGE PADS PADS EQL GAUZE STERILE 2 J & J GAUZE 4"X4" 8 PLY 2 RX/OTC PADS 3"X3" PADS PADS EXCILON AMD RX/OTC J & J GAUZE SPONGES 2 RX/OTC ANTIMICROBIALDRAIN 2 12-PLY 4" X 4" MISC SPONGES 4"X4" 6 PLY PADS J & J GAUZE SPONGES 2 RX/OTC 16-PLY 4" X 4" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits J & J GAUZE SPONGES 2 RX/OTC QC STERILE PADS PADS 2 RX/OTC 8-PLY4" X 4" MISC KENDALL HYDROPHILIC RX/OTC RA ALL PURPOSE 2 RX/OTC FOAMDRESSING 2"X2" 2 DRESSINGS4"X4" PADS PADS RA DRESSING SPONGES 2 RX/OTC KENDALL HYDROPHILIC 4"X4" PADS FOAMDRESSING 3"X3" 2 RA GAUZE SPONGES 2 RX/OTC PADS 4"X4" PADS KENDALL HYDROPHILIC RX/OTC RA STERILE PADS 2"X2" 2 RX/OTC FOAMDRESSING 4"X4" 2 PADS PADS RA STERILE PADS 3"X3" 2 KENDALL HYDROPHILIC RX/OTC PADS FOAMPLUS DRESSING 2 RA STERILE PADS 4"X4" 2 RX/OTC 2"X2" PADS PADS KENDALL HYDROPHILIC RAY-TEC X-RAY RX/OTC FOAMPLUS DRESSING 2 DETECTABLESPONGES 2 3"X3" PADS 4" X 4" 16 PLY MISC KERLIX SPONGES 4" X 4" 2 RX/OTC RESTORE CONTACT RX/OTC 12 PLY PADS LAYER/NON-ADHERENT 2 KERLIX SPONGES 4" X 4" 2 RX/OTC 2"X2" PADS 16 PLY PADS RESTORE FOAM RX/OTC MIRASORB SPONGES 2" 2 RX/OTC DRESSING BORDERED 2 X 2" MISC 4"X4" PADS MIRASORB SPONGES 4" 2 RX/OTC RESTORE FOAM RX/OTC X 4" MISC DRESSING NON- 2 BORDERED 4"X4" PADS NU GAUZE 4PLY 4"X4" 2 RX/OTC PADS RESTORE ODOR RX/OTC NU GAUZE GENERAL- RX/OTC ABSORBING DRESSING 2 USE SPONGES 4"X4" 4 2 4"X4" PADS PLY MISC RESTORE TRIO RX/OTC ABSORBENT DRESSING 2 OPTIFOAM PADS 2 3"X3" PADS POLYMEM DRESSING/3" 2 SM GAUZE PADS 2"X2" 2 RX/OTC X 3" PADS PADS POLYMEM DRESSING/4" 2 RX/OTC SM GAUZE PADS 3"X3" 2 X 4" PADS PADS POLYMEM FILM DOT 2 RX/OTC SM GAUZE PADS 4"X4" 2 RX/OTC PADS PADS POLYMEM NON- 2 RX/OTC SM STERILE PADS 2"X2" 2 RX/OTC ADHESIVE PAD PADS PADS QC ALL PURPOSE 2 RX/OTC SM STERILE PADS PADS 2 RX/OTC DRESSINGS4"X4" PADS RX/OTC QC BORDER ISLAND 2 RX/OTC SOF-WICK 4"X4" PADS 2 GAUZE PAD 2"X2" PADS STERILE GAUZE PADS 2 RX/OTC QC STERILE PADS PADS 2 2"X2" PADS

MHS Indiana Preferred Drug List Updated December 1, 2018

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STERILE GAUZE PADS 2 ELEXA STIMULATING $0 QL(1.2 ea 3"X3" PADS MISC daily); PV STERILE PADS 2"X2" 2 RX/OTC ELEXA ULTRA SENSITIVE $0 QL(1.2 ea PADS MISC daily); PV STERILE PADS 3"X3" 2 EXTRA SENSITIVE $0 QL(1.2 ea PADS SPERMICIDAL DEVI daily); PV STERILE PADS 4"X4" 2 RX/OTC FANTASY LUBRICATED $0 QL(1.2 ea PADS MISC daily); PV SURGICAL GAUZE 2 RX/OTC FANTASY QL(1.2 ea SPONGE PADS LUBRICATED/SPERMICID $0 daily); PV E MISC TEGADERM FOAM 2 RX/OTC DRESSING 2"X2" PADS HIGH SENSATION $0 QL(1.2 ea SPERMICIDAL DEVI daily); PV TEGADERM FOAM 2 RX/OTC DRESSING 4"X4" PADS INTENSE SENSATION $0 QL(1.2 ea DEVI daily); PV THERAGAUZE PADS 2 RX/OTC KAMELEON LUBRICATED $0 QL(1.2 ea MISC daily); PV TOPPER DRESSING 2 RX/OTC SPONGES 4"X4" MISC QL(1.2 ea KIMONO COLORS DEVI $0 VERSIVA XC 3" X 3" daily); PV FOAM 2 KIMONO LUBRICATED $0 QL(1.2 ea DRESSING/HYDROFIBER MISC daily); PV TECHNOLOGY PADS KIMONO MICRO THIN QL(1.2 ea VERSIVA XC 4" X 4" RX/OTC PLUS SPERMICIDE $0 daily); PV FOAM 2 LUBRICATED MISC DRESSING/HYDROFIBER KIMONO PLUS QL(1.2 ea TECHNOLOGY PADS SPERMICIDE $0 daily); PV VISTEC X-RAY RX/OTC LUBRICATED MISC DETECTABLE SPONGES 2 KIMONO PLUS QL(1.2 ea 4"X4" 16 PLY PADS SPERMICIDE/LUBRICATE $0 daily); PV Contraceptives D MISC KIMONO PS LUBRICATED QL(1.2 ea AIMSCO LUBRICATED $0 QL(1.2 ea $0 MISC daily); PV MISC daily); PV ATLAS COLORED QL(1.2 ea KIMONO PS PLUS QL(1.2 ea LUBRICATEDCONDOM $0 daily); PV SPERMICIDE/LUBRICATE $0 daily); PV DEVI D MISC KIMONO SENSATION QL(1.2 ea ATLAS LUBRICATED $0 QL(1.2 ea $0 CONDOM DEVI daily); PV LUBRICATED MISC daily); PV ATLAS LUBRICATED QL(1.2 ea KIMONO SENSATION QL(1.2 ea CONDOM/SPERMICIDE $0 daily); PV PLUS SPERMICIDE $0 daily); PV DEVI LUBRICATED MISC QL(1.2 ea CLASS ACT LUBRICATED $0 QL(1.2 ea KIMONO SPECIAL DEVI $0 MISC daily); PV daily); PV QL(1.2 ea DUREX EXTRA $0 QL(1.2 ea MAXX LUBRICATED MISC $0 SENSITIVE DEVI daily); PV daily); PV MAXX PLUS SPERMICIDE QL(1.2 ea ELEXA NATURAL FEEL $0 QL(1.2 ea $0 MISC daily); PV LUBRICATED MISC daily); PV

MHS Indiana Preferred Drug List Updated December 1, 2018

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMIUM CONDOMS QL(1.2 ea $0 TROJAN-ENZ $0 QL(1.2 ea LUBRICATED MISC daily); PV LUBRICATED MISC daily); PV REALITY LATEX QL(1.2 ea TROJAN-ENZ $0 QL(1.2 ea CONDOMS/LUBRICATED $0 daily); PV W/SPERMICIDAL MISC daily); PV MISC TRUSTEX COLOR $0 QL(1.2 ea REALITY LATEX/ULTRA $0 QL(1.2 ea CONDOMS + LUBE MISC daily); PV TEXTURED DEVI daily); PV TRUSTEX LUBRICATED $0 QL(1.2 ea REALITY LATEX/ULTRA $0 QL(1.2 ea EXTRALARGE MISC daily); PV THIN DEVI daily); PV TRUSTEX LUBRICATED $0 QL(1.2 ea TROJAN EXTENDED QL(1.2 ea EXTRASTRENGTH MISC daily); PV PLEASURE/LUBRICATED $0 daily); PV TRUSTEX LUBRICATED $0 QL(1.2 ea DEVI MISC daily); PV QL(1.2 ea TROJAN MAGNUM MISC $0 TRUSTEX QL(1.2 ea daily); PV LUBRICATED/RIBBED/ST $0 daily); PV TROJAN MAGNUM WARM $0 QL(1.2 ea UDDED MISC SENSATIONS DEVI daily); PV TRUSTEX QL(1.2 ea TROJAN MAGNUM XL $0 QL(1.2 ea LUBRICATED/SPERMICID $0 daily); PV LUBRICATED DEVI daily); PV E EXTRA LARGE MISC TROJAN PLEASURE QL(1.2 ea TRUSTEX QL(1.2 ea $0 MESH/SPERMICIDAL daily); PV LUBRICATED/SPERMICID $0 daily); PV DEVI E EXTRA STRENGTH MISC TROJAN RIBBED $0 QL(1.2 ea W/SPERMICIDAL MISC daily); PV TRUSTEX QL(1.2 ea TROJAN SHARED QL(1.2 ea LUBRICATED/SPERMICID $0 daily); PV SENSATION/LUBRICATE $0 daily); PV E MISC D DEVI TRUSTEX NATURAL QL(1.2 ea CONDOMS daily); PV TROJAN SUPRAS $0 QL(1.2 ea $0 SPERMICIDAL DEVI daily); PV +LUBE/LUBRICATED MISC TROJAN TWISTED $0 QL(1.2 ea PLEASURE DEVI daily); PV TRUSTEX WITH QL(1.2 ea NONOXYNOL- $0 daily); PV TROJAN ULTRA QL(1.2 ea 9/RIBBED/STUDDED PLEASURE/LUBRICATED $0 daily); PV MISC DEVI TRUSTEX/RIA $0 QL(1.2 ea TROJAN VERY QL(1.2 ea LUBRICATED MISC daily); PV SENSITIVE LUBRICATED $0 daily); PV MISC TRUSTEX/RIA QL(1.2 ea LUBRICATED $0 daily); PV TROJAN VERY QL(1.2 ea SPERMICIDE MISC SENSITIVE SPERMICIDAL $0 daily); PV LUBRICANT MISC TRUSTEX/RIA QL(1.2 ea LUBRICATED/SPERMICID $0 daily); PV TROJAN VERY THIN $0 QL(1.2 ea E MISC LUBRICATED MISC daily); PV ULTIMATE FEELING DEVI $0 QL(1.2 ea TROJAN VERY THIN QL(1.2 ea daily); PV SPERMICIDAL $0 daily); PV LUBRICANT MISC Diabetic Supplies 1ST TIER UNILET QL(6.85 ea TROJAN-ENZ LUBRICANT $0 QL(1.2 ea MISC daily); PV COMFORTOUCH 2 daily) LANCETS 28G MISC MHS Indiana Preferred Drug List Updated December 1, 2018

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNILET QL(6.85 ea ASSURE COMFORT QL(6.85 ea COMFORTOUCH 2 daily) LANCETS ULTRA THIN 2 daily) LANCETS 30G MISC 28G MISC ACCU-CHEK FASTCLIX 2 QL(6.85 ea ASSURE HAEMOLANCE QL(6.85 ea LANCETS MISC daily) PLUS HIGH FLOW 18G 2 daily) MISC ACCU-CHEK MULTICLIX 2 QL(6.85 ea LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.85 ea PLUS LOW FLOW 25G 2 daily) ACCU-CHEK SAFE-T-PRO 2 QL(6.85 ea LANCETS MISC daily) MISC ASSURE HAEMOLANCE QL(6.85 ea ACCU-CHEK SAFE-T-PRO 2 QL(6.85 ea PLUSLANCETS MISC daily) PLUS MICRO FLOW 28G 2 daily) MISC ACCU-CHEK SOFT 2 QL(6.85 ea TOUCH LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.85 ea PLUS NORMAL FLOW 2 daily) ACCU-CHEK SOFTCLIX 2 QL(6.85 ea 21G MISC LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.85 ea ACTI-LANCE LANCETS 2 QL(6.85 ea PLUS PEDIATRIC BLADE 2 daily) 28G MISC daily) MISC ACTI-LANCE LITE QL(6.85 ea ASSURE LANCE 2 QL(6.85 ea SAFETY LANCETS 28G 2 daily) LANCETS 21G MISC daily) MISC ASSURE LANCE 2 QL(6.85 ea ACTI-LANCE SPECIAL QL(6.85 ea LANCETS MISC daily) SAFETY LANCETS 17G 2 daily) MISC ASSURE LANCE PLUS QL(6.85 ea SAFETYLANCETS 25G 2 daily) ACTI-LANCE SPECIAL QL(6.85 ea MISC SAFETYLANCETS 17G 2 daily) MISC ASSURE LANCE PLUS QL(6.85 ea SAFETYLANCETS 30G 2 daily) ACTI-LANCE UNIVERSAL QL(6.85 ea MISC SAFETY LANCETS 23G 2 daily) MISC ASSURE LANCETS MISC 2 QL(6.85 ea daily) ACTIVE 1ST BLOOD QL(6.85 ea QL(6.85 ea LANCETS30G/EASY 2 daily) AT LAST LANCETS MISC 2 TWIST CAP MISC daily) AURORA LANCET SUPER QL(6.85 ea ADVANCED MOBILE 2 QL(6.85 ea 2 LANCET 30G MISC daily) THIN30G MISC daily) AURORA LANCET THIN QL(6.85 ea ADVOCATE LANCETS 2 QL(6.85 ea 2 30G MISC daily) 23G MISC daily) BAYER MICROLET QL(6.85 ea ADVOCATE LANCETS 2 QL(6.85 ea 2 MISC daily) LANCETS MISC daily) BD LANCET ULTRAFINE QL(6.85 ea ADVOCATE SAFETY 2 QL(6.85 ea 2 LANCETS 26G MISC daily) 30G MISC daily) BD LANCET ULTRAFINE QL(6.85 ea ADVOCATE SAFETY 2 QL(6.85 ea 2 LANCETS MISC daily) 33G MISC daily) BD MICROTAINER QL(6.85 ea AGAMATRIX ULTRA-THIN 2 QL(6.85 ea 2 LANCETS 33G MISC daily) LANCETS MISC daily) BULLSEYE MINI SAFETY QL(6.85 ea AQUALANCE LANCETS 2 QL(6.85 ea 2 ULTRA THIN 30G MISC daily) LANCETS MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BULLSEYE SAFETY 2 QL(6.85 ea CVS LANCETS THIN 26G 2 QL(6.85 ea LANCETS MISC daily) MISC daily) CAREONE LANCET THIN 2 QL(6.85 ea CVS LANCETS ULTRA 2 QL(6.85 ea MISC daily) THIN 30G MISC daily) CAREONE LANCET 2 QL(6.85 ea CVS LANCETS ULTRA- 2 QL(6.85 ea ULTRA THIN MISC daily) THIN 30G MISC daily) CARETOUCH TWIST 2 QL(6.85 ea CVS ULTRA THIN 2 QL(6.85 ea LANCETS 28G MISC daily) LANCETS MISC daily) CARETOUCH TWIST QL(6.85 ea 2 DROPLET LANCETS 2 QL(6.85 ea LANCETS 30G MISC daily) ULTRA THIN 30G MISC daily) CARETOUCH TWIST 2 QL(6.85 ea DRUG MART LANCETS 2 QL(6.85 ea LANCETS 33G MISC daily) THIN MISC daily) CLEANLET LANCETS 28G 2 QL(6.85 ea DRUG MART ON-THE-GO QL(6.85 ea MISC daily) LANCETS GENTLE 30G 2 daily) MISC CLEVER CHEK LANCETS 2 QL(6.85 ea ULTRATHIN 30G MISC daily) DRUG MART UNILET QL(6.85 ea LANCETSSUPER THIN 2 daily) CLEVER CHEK LANCETS 2 QL(6.85 ea ULTRATHIN MISC daily) 30G MISC CLEVER CHOICE QL(6.85 ea DRUG MART UNILET QL(6.85 ea COMFORT EZLANCETS 2 daily) LANCETSULTRA THIN 2 daily) 21G MISC 28G MISC CLEVER CHOICE QL(6.85 ea DRUG MART UNILET QL(6.85 ea COMFORT EZLANCETS 2 daily) MICRO THIN LANCETS 2 daily) 23G MISC 33G MISC CLEVER CHOICE QL(6.85 ea E-Z JECT LANCETS 21G 2 QL(6.85 ea COMFORT EZLANCETS 2 daily) MISC daily) 28G MISC E-Z JECT LANCETS 2 QL(6.85 ea COLOR MISC daily) COAGUCHEK LANCETS 2 QL(6.85 ea MISC daily) QL(6.85 ea E-Z JECT LANCETS MISC 2 COMFORT ASSURED QL(6.85 ea daily) 2 LANCETS MICRO THIN daily) E-Z JECT LANCETS 2 QL(6.85 ea 33G MISC SUPER THIN 30G MISC daily) COMFORT ASSURED QL(6.85 ea E-Z JECT LANCETS THIN 2 QL(6.85 ea LANCETS SUPER THIN 2 daily) 26G MISC daily) 28G MISC E-ZJECT LANCETS 2 QL(6.85 ea COMFORT LANCETS 2 QL(6.85 ea MICRO-THIN 33G MISC daily) MISC daily) EASY COMFORT QL(6.85 ea QL(6.85 ea LANCETS 30G/PULL TOP 2 daily) CVS LANCETS 21G MISC 2 daily) MISC CVS LANCETS MICRO 2 QL(6.85 ea EASY COMFORT QL(6.85 ea THIN 33G MISC daily) LANCETS 30G/THIN TOP 2 daily) MISC CVS LANCETS MICRO- 2 QL(6.85 ea THIN 33G MISC daily) EASY COMFORT 2 QL(6.85 ea LANCETS MISC daily) CVS LANCETS ORIGINAL 2 QL(6.85 ea MISC daily) EASY COMFORT QL(6.85 ea LANCETS TWIST TOP 2 daily) MISC MHS Indiana Preferred Drug List Updated December 1, 2018

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea 21G/PRESSURE 2 daily) LANCETS26G/BUTTON 2 daily) ACTIVATED MISC ACTIVATED MISC EASY TOUCH LANCETS QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea 23G/PRESSURE 2 daily) LANCETS26G/PRESSURE 2 daily) ACTIVATED MISC ACTIVATED MISC EASY TOUCH LANCETS QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea 26G/PRESSURE 2 daily) LANCETS28G/BUTTON 2 daily) ACTIVATED MISC ACTIVATED MISC EASY TOUCH LANCETS 2 QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea 26G/PULL-TOP MISC daily) LANCETS28G/PRESSURE 2 daily) ACTIVATED MISC EASY TOUCH LANCETS 2 QL(6.85 ea 26G/TWIST MISC daily) EASY TWIST & CAP 2 QL(6.85 ea EASY TOUCH LANCETS QL(6.85 ea LANCETS MISC daily) 2 28G/PRESSURE daily) EASYTEST II LANCETS 2 QL(6.85 ea ACTIVATED MISC MISC daily) EASY TOUCH LANCETS 2 QL(6.85 ea EASYTEST LANCETS 2 QL(6.85 ea 28G/PULL-TOP MISC daily) MISC daily) EASY TOUCH LANCETS 2 QL(6.85 ea EMBRACE LANCETS 2 QL(6.85 ea 28G/TWIST MISC daily) ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS QL(6.85 ea EQL COLOR LANCETS 2 QL(6.85 ea 30G/BUTTON-ACTIVATED 2 daily) 21G MISC daily) MISC EQL COLOR LANCETS 2 QL(6.85 ea EASY TOUCH LANCETS QL(6.85 ea MICRO THIN 33G MISC daily) 30G/PRESSURE 2 daily) EQL SUPER THIN 2 QL(6.85 ea ACTIVATED MISC LANCETS 30G MISC daily) EASY TOUCH LANCETS QL(6.85 ea 2 EQL THIN LANCETS 26G 2 QL(6.85 ea 30G/PULL-TOP MISC daily) MISC daily) EASY TOUCH LANCETS 2 QL(6.85 ea EZ SMART BLOOD QL(6.85 ea 30G/TWIST MISC daily) GLUCOSE LANCETS 2 daily) EASY TOUCH LANCETS QL(6.85 ea MISC 32G/PRESSURE 2 daily) EZ-LETS LANCETS 21G 2 QL(6.85 ea ACTIVATED MISC MISC daily) EASY TOUCH LANCETS QL(6.85 ea 2 EZ-LETS LANCETS 23G 2 QL(6.85 ea 32G/PULL-TOP MISC daily) MISC daily) EASY TOUCH LANCETS QL(6.85 ea 2 EZ-LETS LANCETS 26G 2 QL(6.85 ea 32G/TWIST MISC daily) SUPER-SOFT MISC daily) EASY TOUCH LANCETS QL(6.85 ea 2 EZ-LETS LANCETS 28G 2 QL(6.85 ea 33G/TWIST MISC daily) ULTRA-SOFT MISC daily) EASY TOUCH SAFETY QL(6.85 ea EZ-LETS LANCETS 30G 2 QL(6.85 ea LANCETS21G/PRESSURE 2 daily) MISC daily) ACTIVATED MISC FIFTY50 SAFETY SEAL 2 QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea LANCETS 30G MISC daily) LANCETS23G/PRESSURE 2 daily) ACTIVATED MISC FIFTY50 SAFETY SEAL 2 QL(6.85 ea LANCETS 32G MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIFTY50 UNILET QL(6.85 ea 2 GNP LANCETS 21G MISC 2 QL(6.85 ea LANCETS 33G MISC daily) daily) QL(6.85 ea GNP LANCETS MICRO QL(6.85 ea FINE 30 MISC 2 2 daily) THIN 33G MISC daily) FINGERSTIX LANCETS QL(6.85 ea 2 GNP LANCETS MISC 2 QL(6.85 ea MISC daily) daily) QL(6.85 ea GNP LANCETS SUPER QL(6.85 ea FORA LANCETS MISC 2 2 daily) THIN 30G MISC daily) FREDS PHARMACY QL(6.85 ea GNP LANCETS THIN 26G 2 QL(6.85 ea UNILET LANCETS SUPER 2 daily) MISC daily) THIN 30G MISC GNP LANCETS THIN 2 QL(6.85 ea FREDS PHARMACY QL(6.85 ea MISC daily) UNILET LANCETS ULTRA 2 daily) GNP MICRO THIN 2 QL(6.85 ea THIN 28G MISC LANCETS 33G MISC daily) FREESTYLE LANCETS QL(6.85 ea 2 GNP SUPER THIN 2 QL(6.85 ea MISC daily) LANCETS/30G MISC daily) FREESTYLE UNISTICK II 2 QL(6.85 ea GOODSENSE COLOR QL(6.85 ea LANCETS MISC daily) LANCETS MICRO-THIN 2 daily) GENTEEL BUTTERFLY 2 QL(6.85 ea 33G UNIVERSAL MISC TOUCH LANCETS MISC daily) GOODSENSE LANCETS 2 QL(6.85 ea GENTLE-LET GP 2 QL(6.85 ea MICRO-THIN 33G MISC daily) LANCETS MISC daily) GOODSENSE LANCETS QL(6.85 ea GENTLE-LET LANCETS QL(6.85 ea MICRO-THIN 33G 2 daily) GENERAL PURPOSE 2 daily) UNIVERSAL MISC STYLE/FINE POINT MISC GOODSENSE LANCETS QL(6.85 ea GENTLE-LET LANCETS QL(6.85 ea ULTRA-THIN 26G 2 daily) GENERAL PURPOSE 2 daily) UNIVERSAL MISC STYLE/MEDIUM POINT GOODSENSE LANCETS 2 QL(6.85 ea MISC ULTRA-THIN 30G MISC daily) GENTLE-LET LANCETS QL(6.85 ea GOODSENSE LANCETS QL(6.85 ea SAFETY STYLE/FINE 2 daily) ULTRA-THIN 30G 2 daily) POINT MISC UNIVERSAL MISC GENTLE-LET LANCETS QL(6.85 ea H-E-B INCONTROL QL(6.85 ea SAFETY STYLE/MEDIUM 2 daily) LANCETS MICRO THIN 2 daily) POINT MISC 33G MISC GLOBAL INJECT EASE 2 QL(6.85 ea H-E-B INCONTROL QL(6.85 ea LANCETS 28G MISC daily) LANCETS SUPER THIN 2 daily) GLOBAL INJECT EASE 2 QL(6.85 ea 30G MISC LANCETS 30G MISC daily) H-E-B INCONTROL QL(6.85 ea GLUCOCOM LANCETS 2 QL(6.85 ea LANCETS ULTRA THIN 2 daily) 28G MISC daily) 28G MISC GLUCOCOM LANCETS 2 QL(6.85 ea HAEMOLANCE LOW 2 QL(6.85 ea 30G MISC daily) FLOW LANCETS MISC daily) GLUCOCOM LANCETS QL(6.85 ea 2 HAEMOLANCE MISC 2 QL(6.85 ea 33G MISC daily) daily) GLUCOSOURCE 2 QL(6.85 ea HAEMOLANCE PLUS 2 QL(6.85 ea LANCETS MISC daily) HIGH FLOW MISC daily) MHS Indiana Preferred Drug List Updated December 1, 2018

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HAEMOLANCE PLUS 2 QL(6.85 ea LANCETS 30G/TWIST 2 QL(6.85 ea LOW FLOW MISC daily) TOP MISC daily) HAEMOLANCE PLUS 2 QL(6.85 ea LANCETS 31G TWIST 2 QL(6.85 ea MAX FLOW MISC daily) TOP MISC daily) HAEMOLANCE PLUS 2 QL(6.85 ea LANCETS 33G QL(6.85 ea MISC daily) UNIVERSAL DESIGN 2 daily) MISC HAEMOLANCE PLUS 2 QL(6.85 ea PEDIATRIC FLOW MISC daily) LANCETS MICRO THIN 2 QL(6.85 ea 33G MISC daily) HEALTHWISE LANCETS 2 QL(6.85 ea 30G MISC daily) QL(6.85 ea LANCETS MISC 2 HEALTHY ACCENTS QL(6.85 ea daily) 2 UNILET LANCETS SUPER daily) LANCETS SAFETY SEAL 2 QL(6.85 ea THIN 30G MISC 21G MISC daily) QL(6.85 ea LANCETS SAFETY SEAL QL(6.85 ea HY-VEE LANCETS MISC 2 2 daily) 26G MISC daily) HY-VEE THIN LANCETS 2 QL(6.85 ea LANCETS SAFETY SEAL 2 QL(6.85 ea MISC daily) 28G MISC daily) IN TOUCH STERILE 2 QL(6.85 ea LANCETS SAFETY SEAL 2 QL(6.85 ea LANCETS30G MISC daily) 30G MISC daily) QL(6.85 ea LANCETS SUPER THIN QL(6.85 ea KINNEY LANCETS MISC 2 2 daily) 28G MISC daily) KINNEY THIN LANCETS QL(6.85 ea 2 LANCETS THIN MISC 2 QL(6.85 ea MISC daily) daily) KROGER LANCETS 21G 2 QL(6.85 ea LANCETS TWIST TOP 2 QL(6.85 ea MISC daily) MISC daily) KROGER LANCETS 2 QL(6.85 ea LANCETS ULTRA FINE 2 QL(6.85 ea MICRO THIN33G MISC daily) MISC daily) QL(6.85 ea LANCETS ULTRA THIN QL(6.85 ea KROGER LANCETS MISC 2 2 daily) 30G MISC daily) KROGER LANCETS 2 QL(6.85 ea LANCETS ULTRA THIN 2 QL(6.85 ea SUPER THIN MISC daily) MISC daily) KROGER LANCETS THIN 2 QL(6.85 ea LANCETSBULLSEYE 2 QL(6.85 ea 26G MISC daily) SAFETY MISC daily) KROGER LANCETS THIN 2 QL(6.85 ea LIBERTY MEDICAL 2 QL(6.85 ea MISC daily) LANCETS 30G MISC daily) KROGER LANCETS 2 QL(6.85 ea LIFESCAN UNISTIK 2 QL(6.85 ea ULTRATHIN30G MISC daily) DEEP PENETRATION 2 daily) MISC LANCETS 26G TWIST 2 QL(6.85 ea TOP MISC daily) LIFESCAN UNISTIK II 2 QL(6.85 ea QL(6.85 ea LANCETS MISC daily) LANCETS 28G MISC 2 daily) LITE TOUCH LANCETS 2 QL(6.85 ea MISC daily) 2 QL(6.85 ea LANCETS 30G MISC QL(6.85 ea daily) LITETOUCH LANCETS 2 MICRO THIN 33G MISC daily) LANCETS 30G TWIST 2 QL(6.85 ea TOP MISC daily) LIVE BETTER LANCET 2 QL(6.85 ea SUPERTHIN 30G MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIVE BETTER LANCET QL(6.85 ea 2 MEDLANCE PLUS/LITE 2 QL(6.85 ea ULTRATHIN 28G MISC daily) 25G MISC daily) LONGS LANCETS QL(6.85 ea 2 MEDLANCE/EXTRA MISC 2 QL(6.85 ea STANDARD MISC daily) daily) LONGS LANCETS THIN QL(6.85 ea 2 MEDLANCE/LITE MISC 2 QL(6.85 ea MISC daily) daily) LONGS LANCETS ULTRA QL(6.85 ea 2 MEDLANCE/UNIVERSAL 2 QL(6.85 ea THIN MISC daily) MISC daily) MEDICHOICE PRE-SET QL(6.85 ea MEIJER COLOR QL(6.85 ea SAFETY LANCET DUAL 2 daily) LANCETS UNIVERSAL 2 daily) USE MISC 33G MISC MEDICHOICE PRE-SET QL(6.85 ea MEIJER LANCETS MISC 2 QL(6.85 ea SAFETY LANCET LOW 2 daily) daily) FLOW MISC MEIJER LANCETS THIN 2 QL(6.85 ea MEDICHOICE PRE-SET QL(6.85 ea MISC daily) SAFETY LANCET 2 daily) MEIJER LANCETS 2 QL(6.85 ea MEDIUM FLOW MISC UNIVERSAL21G MISC daily) MEDICHOICE PRE-SET QL(6.85 ea MEIJER LANCETS 2 QL(6.85 ea SAFETY LANCET 2 daily) UNIVERSAL30G MISC daily) MODERATE FLOW MISC MEIJER LANCETS 2 QL(6.85 ea MEDICHOICE SAFETY 2 QL(6.85 ea UNIVERSAL33G MISC daily) LANCETEXTRA MISC daily) MEIJER SUPER THIN 2 QL(6.85 ea MEDICHOICE SAFETY 2 QL(6.85 ea LANCETS MISC daily) LANCETNORMAL MISC daily) MICROLET LANCETS 2 QL(6.85 ea MEDISENSE THIN 2 QL(6.85 ea MISC daily) LANCETS MISC daily) MICROTAINER SAFETY QL(6.85 ea MEDLANCE PLUS EXTRA QL(6.85 ea 2 FLOW 2 daily) LANCETS 21G MISC daily) LANCET/STERILE/SINGL MEDLANCE PLUS 2 QL(6.85 ea E-USE MISC LANCETS LITE 25G MISC daily) MM TWIST LANCETS 2 QL(6.85 ea MEDLANCE PLUS 2 QL(6.85 ea MISC daily) LANCETS MISC daily) MONOLET LANCETS 2 QL(6.85 ea MEDLANCE PLUS LITE 2 QL(6.85 ea MISC daily) LANCETS 25G MISC daily) MONOLET OPD LANCETS 2 QL(6.85 ea MEDLANCE PLUS QL(6.85 ea MISC daily) SPECIAL LANCETS 2 daily) MONOLETTOR SAFETY 2 QL(6.85 ea 0.8MM MISC LANCETS MISC daily) MEDLANCE PLUS QL(6.85 ea 2 MPD SAFETY LANCET 2 QL(6.85 ea SUPERLITE 30G MISC daily) 21G/1.8MM MISC daily) MEDLANCE PLUS QL(6.85 ea MPD SAFETY LANCET 2 QL(6.85 ea SUPERLITE 2 daily) 28G/1.8MM MISC daily) 30G/COMFORT MAX MISC MPD SAFETY LANCET 2 QL(6.85 ea 30G/1.8MM MISC daily) MEDLANCE PLUS QL(6.85 ea UNIVERSAL LANCETS 2 daily) MPD SAFETY LANCETS 2 QL(6.85 ea 21G MISC 23G/1.8MM MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYGLUCOHEALTH MGH QL(6.85 ea PHARMACIST CHOICE QL(6.85 ea SOFTLANCE LANCETS 2 daily) ULTRA THIN LANCETS 2 daily) 30G MISC 33G MISC NETGROUP LANCETS 2 QL(6.85 ea PHARMACIST CHOICE QL(6.85 ea MISC daily) ULTRA THIN LANCETS 2 daily) MISC NOVA SAFETY LANCETS 2 QL(6.85 ea 23G MISC daily) PHARMACY COUNTER 2 QL(6.85 ea LANCETS MISC daily) NOVA SAFETY LANCETS 2 QL(6.85 ea 28G MISC daily) PRECISION THIN 2 QL(6.85 ea LANCETS MISC daily) NOVA SUREFLEX 2 QL(6.85 ea LANCETS MISC daily) PRECISION THINS GP 2 QL(6.85 ea LANCET MISC daily) 2 QL(6.85 ea ON CALL LANCETS MISC daily) PRECISION ULTRA 2 QL(6.85 ea LANCET MISC daily) ON CALL PLUS LANCETS 2 QL(6.85 ea MISC daily) PREFERRED PLUS QL(6.85 ea ONETOUCH CLUB QL(6.85 ea LANCETS COLORED 21G 2 daily) LANCETS FINE POINT 2 daily) MISC MISC PREFERRED PLUS QL(6.85 ea LANCETS SUPER THIN 2 daily) ONETOUCH COMBO 2 QL(6.85 ea PACK MISC daily) 30G MISC ONETOUCH DELICA QL(6.85 ea PREFERRED PLUS 2 QL(6.85 ea LANCETS EXTRA FINE 2 daily) LANCETS THIN 26G MISC daily) 33G MISC PRESSURE ACTIVATED QL(6.85 ea SAFETYLANCET 21G 2 daily) ONETOUCH DELICA 2 QL(6.85 ea LANCETS FINE 30G MISC daily) MISC PRO COMFORT QL(6.85 ea ONETOUCH FINEPOINT 2 QL(6.85 ea 2 LANCETS MISC daily) LANCETS 30G MISC daily) PRO COMFORT QL(6.85 ea ONETOUCH ULTRASOFT 2 QL(6.85 ea 2 LANCETS MISC daily) LANCETS 31G MISC daily) PRODIGY PRESSURE QL(6.85 ea PC LANCETS SUPER 2 QL(6.85 ea THIN 30G MISC daily) ACTIVATED SAFETY 2 daily) LANCETS MISC PERFECT LANCETS 30G 2 QL(6.85 ea MISC daily) PRODIGY SAFETY 2 QL(6.85 ea LANCETS MISC daily) PERFECT PRESSURE QL(6.85 ea ACTIVATED SAFETY 2 daily) PRODIGY TWIST TOP 2 QL(6.85 ea LANCETS 28G MISC LANCETS MISC daily) PHARMACIST CHOICE QL(6.85 ea PSS SELECT GP 2 QL(6.85 ea ULTRA THIN LANCETS 2 daily) LANCETS MISC daily) 28G MISC PSS SELECT SAFETY 2 QL(6.85 ea PHARMACIST CHOICE QL(6.85 ea LANCETS MISC daily) 2 ULTRA THIN LANCETS daily) PUSH BUTTON SAFETY 2 QL(6.85 ea 30G MISC LANCETS 21G MISC daily) PHARMACIST CHOICE QL(6.85 ea PUSH BUTTON SAFETY 2 QL(6.85 ea ULTRA THIN LANCETS 2 daily) LANCETS 28G MISC daily) 31G MISC PX LANCETS ULTRA 2 QL(6.85 ea THIN 28G MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX LANCETS ULTRA 2 QL(6.85 ea RELION LANCETS 2 QL(6.85 ea THIN MISC daily) ULTRA-THIN30G MISC daily) QC LANCETS SUPER 2 QL(6.85 ea RELION ULTRA THIN 2 QL(6.85 ea THIN MISC daily) LANCETS30G MISC daily) QC LANCETS ULTRA 2 QL(6.85 ea RELION ULTRA THIN QL(6.85 ea THIN MISC daily) PLUS LANCETS 32G 2 daily) MISC QC UNILET LANCETS 2 QL(6.85 ea 28G/ULTRA THIN MISC daily) RELION ULTRA THIN QL(6.85 ea PLUS LANCETS 33G 2 daily) QC UNILET LANCETS 2 QL(6.85 ea 33G/MICRO THIN MISC daily) MISC RA E-ZJECT COLOR QL(6.85 ea REXALL LANCETS ULTRA 2 QL(6.85 ea LANCETSMICRO-THIN 2 daily) THIN MISC daily) 33G MISC RIGHTEST GL300 2 QL(6.85 ea LANCETS MISC daily) RA E-ZJECT LANCETS 2 QL(6.85 ea 28G MISC daily) SAFE-T-LANCE LOW 2 QL(6.85 ea FLOW 25G MISC daily) RA E-ZJECT LANCETS 2 QL(6.85 ea THIN 26G MISC daily) SAFE-T-LANCE NORMAL 2 QL(6.85 ea FLOW21G MISC daily) RA E-ZJECT LANCETS 2 QL(6.85 ea THIN 28G MISC daily) SAFE-T-LANCE PLUS QL(6.85 ea SAFETYLANCET HIGH 2 daily) RA E-ZJECT LANCETS 2 QL(6.85 ea ULTRATHIN 30G MISC daily) FLOW MISC READYLANCE SAFETY QL(6.85 ea SAFE-T-LANCE PLUS QL(6.85 ea LANCETS/21G/2.2MM 2 daily) SAFETYLANCET LOW 2 daily) MISC FLOW MISC READYLANCE SAFETY QL(6.85 ea SAFE-T-LANCE PLUS QL(6.85 ea LANCETS/23G/1.8MM 2 daily) SAFETYLANCET 2 daily) MISC NORMAL FLOW MISC READYLANCE SAFETY QL(6.85 ea SAFETY LANCET QL(6.85 ea LANCETS/26G/1.8MM 2 daily) 21G/PRESSURE 2 daily) MISC ACTIVATED MISC READYLANCE SAFETY QL(6.85 ea SAFETY LANCET QL(6.85 ea LANCETS/28G/1.8MM 2 daily) 28G/PRESSURE 2 daily) MISC ACTIVATED MISC READYLANCE SAFETY QL(6.85 ea SAFETY LANCETS 21G 2 QL(6.85 ea LANCETS/30G/1.6MM 2 daily) MISC daily) MISC SAFETY LANCETS 28G 2 QL(6.85 ea MISC daily) 2 QL(6.85 ea REALITY LANCETS MISC daily) SAFETY LANCETS MISC 2 QL(6.85 ea daily) REALITY TRIGGER 2 QL(6.85 ea LANCETS MISC daily) SAFETY LET LANCETS 2 QL(6.85 ea MISC daily) RELION LANCETS 2 QL(6.85 ea MICRO-THIN33G MISC daily) SAFETY SEAL LANCETS 2 QL(6.85 ea 28G MISC daily) RELION LANCETS 2 QL(6.85 ea STANDARD 21G MISC daily) SAFETY SEAL LANCETS 2 QL(6.85 ea 30G MISC daily) RELION LANCETS THIN 2 QL(6.85 ea 26G MISC daily) SAPS HEALTH TWIST 2 QL(6.85 ea TOP LANCETS 30G MISC daily) MHS Indiana Preferred Drug List Updated December 1, 2018

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAPSCARE TWIST TOP QL(6.85 ea 2 SURE COMFORT 2 QL(6.85 ea LANCETS 30G MISC daily) LANCETS 21G MISC daily) QL(6.85 ea SURE COMFORT QL(6.85 ea SB LANCETS THIN MISC 2 2 daily) LANCETS 23G MISC daily) SB LANCETS ULTRA QL(6.85 ea 2 SURE COMFORT 2 QL(6.85 ea THIN MISC daily) LANCETS 28G MISC daily) SHOPKO ON-THE-GO QL(6.85 ea SURE COMFORT 2 QL(6.85 ea COMFORTLANCETS 30G 2 daily) LANCETS 30G MISC daily) MISC SURE-LANCE FLAT 2 QL(6.85 ea SHOPKO UNILET QL(6.85 ea LANCETS MISC daily) LANCETS SUPER THIN 2 daily) SURE-LANCE LANCETS 2 QL(6.85 ea 30G MISC 26G MISC daily) SHOPKO UNILET QL(6.85 ea SURE-LANCE THIN 2 QL(6.85 ea LANCETS ULTRA THIN 2 daily) LANCETS 28G MISC daily) 28G MISC SURE-LANCE ULTRA 2 QL(6.85 ea SIDE BUTTON SAFETY 2 QL(6.85 ea THIN LANCETS MISC daily) LANCET21G MISC daily) SURE-TOUCH LANCETS 2 QL(6.85 ea SINGLE-LET MISC 2 QL(6.85 ea UNIVERSAL MISC daily) daily) SURELITE LANCETS 2 QL(6.85 ea SM MICRO THIN 2 QL(6.85 ea MISC daily) LANCETS 33G MISC daily) TECHLITE AST LANCETS 2 QL(6.85 ea SMART SENSE COLOR QL(6.85 ea MISC daily) LANCETS UNIVERSAL 2 daily) 33G MISC TECHLITE LANCETS 30G 2 QL(6.85 ea MISC daily) SMART SENSE QL(6.85 ea STANDARD LANCETS 2 daily) TECHLITE LANCETS 2 QL(6.85 ea UNIVERSAL 21G MISC MISC daily) SMART SENSE SUPER QL(6.85 ea TGT LANCET MICRO 2 QL(6.85 ea THIN LANCETS 2 daily) THIN 33G MISC daily) UNIVERSAL 30G MISC TGT LANCET THIN 26G 2 QL(6.85 ea SMART SENSE THIN QL(6.85 ea MISC daily) LANCETSUNIVERSAL 2 daily) TGT LANCET ULTRA 2 QL(6.85 ea 26G MISC THIN 30G MISC daily) THINLETS GP LANCETS QL(6.85 ea SMARTEST LANCETS 2 QL(6.85 ea 2 28G MISC daily) MISC daily) QL(6.85 ea SOLUS V2 PRESSURE QL(6.85 ea THINLETS LANCET MISC 2 ACTIVATED SAFETY 2 daily) daily) LANCETS 28G MISC TODAYS HEALTH SUPER 2 QL(6.85 ea THINLANCETS 30G MISC daily) SOLUS V2 TWIST 2 QL(6.85 ea LANCETS 30G MISC daily) TODAYS HEALTH ULTRA 2 QL(6.85 ea THINLANCETS 28G MISC daily) STERILANCE TL MISC 2 QL(6.85 ea daily) TOPCARE LANCETS 2 QL(6.85 ea MICRO-THIN 33G MISC daily) SUPER THIN LANCETS 2 QL(6.85 ea MISC daily) TRAVEL LANCETS 30G 2 QL(6.85 ea MISC daily) SURE COMFORT 2 QL(6.85 ea LANCETS 18G MISC daily) TRAVEL LANCETS 2 QL(6.85 ea ADVANCED 28G MISC daily) MHS Indiana Preferred Drug List Updated December 1, 2018

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT TWIST 2 QL(6.85 ea ULTRA-THIN II LANCETS 2 QL(6.85 ea TOP LANCETS 30G MISC daily) 28G MISC daily) TRUE METRIX CONTROL ULTRA-THIN II LANCETS 2 QL(6.85 ea SOLUTION LEVEL 1 2 30G MISC daily) SOLN ULTRA-THIN II SAFETY QL(6.85 ea TRUE METRIX CONTROL AUTOLANCETS 26G 2 daily) SOLUTION LEVEL 2 2 MISC SOLN UNILET COMFORTOUCH 2 QL(6.85 ea TRUE METRIX CONTROL LANCET MISC daily) SOLUTION LEVEL 3 2 QL(6.85 ea UNILET EXCELITE II MISC 2 SOLN daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET EXCELITE MISC 2 QL(6.85 ea 26G MISC daily) daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET G.P. LANCET 2 QL(6.85 ea 28G MISC daily) MISC daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET G.P. SUPERLITE 2 QL(6.85 ea 28G SUPER THIN MISC daily) LANCET MISC daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET GP 28 ULTRA 2 QL(6.85 ea 30G MISC daily) THIN MISC daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET LANCET MISC 2 QL(6.85 ea 30G ULTRA THIN MISC daily) daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET LANCETS 2 QL(6.85 ea 33G MICRO THIN MISC daily) MICRO-THIN33G MISC daily) TRUEPLUS LANCETS QL(6.85 ea 2 UNILET LANCETS 2 QL(6.85 ea 33G MISC daily) SUPER-THIN30G MISC daily) TRUEPLUS SAFETY QL(6.85 ea 2 UNILET LANCETS 2 QL(6.85 ea LANCETS 28G MISC daily) ULTRA-THIN 28G MISC daily) ULTICARE THIN QL(6.85 ea 2 UNILET SUPERLITE 2 QL(6.85 ea LANCETS 30G MISC daily) LANCET MISC daily) ULTILET CLASSIC QL(6.85 ea 2 UNISTIK 3 GENTLE MISC 2 QL(6.85 ea LANCETS MISC daily) daily) ULTILET LANCETS 33G QL(6.85 ea 2 UNISTIK PRO SAFETY 2 QL(6.85 ea MISC daily) LANCET 21G MISC daily) QL(6.85 ea ULTILET LANCETS MISC 2 UNISTIK PRO SAFETY 2 QL(6.85 ea daily) LANCET 25G MISC daily) ULTILET SAFETY QL(6.85 ea UNISTIK PRO SAFETY 2 QL(6.85 ea LANCETS 21G X 2.2MM 2 daily) LANCET 28G MISC daily) MISC UNISTIK SAFETY 2 QL(6.85 ea ULTILET SAFETY 2 QL(6.85 ea LANCETS 28G MISC daily) LANCETS 23G MISC daily) UNISTIK SAFETY 2 QL(6.85 ea ULTRA THIN LANCETS 2 QL(6.85 ea LANCETS 30G MISC daily) 31G MISC daily) UNISTIK TOUCH SAFETY 2 QL(6.85 ea ULTRA-CARE LANCETS 2 QL(6.85 ea LANCETS 21G MISC daily) 30G MISC daily) UNISTIK TOUCH SAFETY 2 QL(6.85 ea ULTRA-THIN II AUTO 2 QL(6.85 ea LANCETS 23G MISC daily) LANCET MISC daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNISTIK TOUCH SAFETY 2 QL(6.85 ea WALGREENS THIN 2 QL(6.85 ea LANCETS 28G MISC daily) LANCETS MISC daily) UNISTIK TOUCH SAFETY 2 QL(6.85 ea WALGREENS ULTRA 2 QL(6.85 ea LANCETS 30G MISC daily) THIN LANCETS MISC daily) UNIVERSAL 1 LANCETS 2 QL(6.85 ea Misc. Devices THIN26G MISC daily) ALCOHOL PREP PADS 2 QL(13.34 ea UNIVERSAL 1 LANCETS 2 QL(6.85 ea PADS daily); RX/OTC ULTRA THIN 30G MISC daily) ALCOHOL PREPS PADS 2 QL(13.34 ea UNIVERSAL 1 QL(6.85 ea daily); RX/OTC LANCETS/33G/MICRO- 2 daily) QL(13.34 ea THIN MISC ALCOHOL SWABS PADS 2 daily); RX/OTC VALUE PLUS LANCETS QL(6.85 ea 2 ALCOHOL SWABSTICK QL(13.34 ea STANDARD 21G MISC daily) 2 PADS daily); RX/OTC VALUE PLUS LANCETS QL(6.85 ea 2 QL(13.34 ea SUPERTHIN 30G MISC daily) ALCOHOL WIPES PADS 2 daily); RX/OTC VALUE PLUS LANCETS QL(6.85 ea 2 APLICARE ALCOHOL QL(13.34 ea THIN 26G MISC daily) 2 SWABSTICK PADS daily); RX/OTC VALUMARK LANCET QL(6.85 ea 2 BD SWABS SINGLE USE QL(13.34 ea SUPER THIN 30G MISC daily) 2 PADS daily); RX/OTC VALUMARK LANCET QL(6.85 ea 2 CURITY ALCOHOL QL(13.34 ea ULTRA THIN 28G MISC daily) PREPS/MEDIUM 2 PLY 2 daily); RX/OTC VIDA MIA UNILET QL(6.85 ea PADS LANCETS SUPER THIN 2 daily) CURITY ALCOHOL QL(13.34 ea 30G MISC 2 SWABS PADS daily); RX/OTC VIDA MIA UNILET QL(6.85 ea LANCETS ULTRA THIN 2 daily) CVS ALCOHOL PREP 2 QL(13.34 ea SWABS PADS daily); RX/OTC 28G MISC VITALET PRO LANCETS QL(6.85 ea 2 QL(13.34 ea 2 CVS PREP PADS PADS daily); RX/OTC MISC daily) VITALET PRO PLUS QL(6.85 ea EASY TOUCH ALCOHOL QL(13.34 ea 2 PREP PADS/MEDIUM 2 daily); RX/OTC LANCETS MISC daily) PADS QL(6.85 ea W&F LANCETS 26G MISC 2 FIFTY50 ALCOHOL PREP QL(13.34 ea daily) 2 PADS PADS daily); RX/OTC W&F LANCETS QL(6.85 ea 2 GNP ALCOHOL SWABS QL(13.34 ea COLORED 21G MISC daily) 2 PADS daily); RX/OTC WALGREENS ADVANCED QL(6.85 ea TRAVELLANCETS 28G 2 daily) HM STERILE ALCOHOL 2 QL(13.34 ea PREP PADS PADS daily); RX/OTC MISC MEIJER ALCOHOL QL(13.34 ea WALGREENS COMFORT QL(6.85 ea 2 ASSUREDLANCETS 2 daily) SWABS EXTRA-THICK daily); RX/OTC PADS MICRO THIN/33G MISC WALGREENS COMFORT QL(6.85 ea PRO COMFORT 2 QL(13.34 ea ALCOHOL PADS PADS daily); RX/OTC ASSUREDLANCETS 2 daily) SUPER THIN/28G MISC QC ALCOHOL SWABS 2 QL(13.34 ea PADS daily); RX/OTC WALGREENS LANCETS 2 QL(6.85 ea MISC daily) RA ALCOHOL SWABS 2 QL(13.34 ea PADS daily); RX/OTC MHS Indiana Preferred Drug List Updated December 1, 2018

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION ALCOHOL 2 QL(13.34 ea ADVOCATE INSULIN PEN QL(5 ea daily); SWABS PADS daily); RX/OTC NEEDLES 29GX12.7MM 2 RX/OTC MISC SB ALCOHOL PREP 2 QL(13.34 ea PADS PADS daily); RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC SHOPKO ALCOHOL 2 QL(13.34 ea SWABS PADS daily); RX/OTC MISC ADVOCATE INSULIN PEN QL(5 ea daily); SM ALCOHOL PREP 2 QL(13.34 ea PADS PADS daily); RX/OTC NEEDLES 31GX8MM 2 RX/OTC MISC TGT ALCOHOL SWABS 2 QL(13.34 ea PADS daily); RX/OTC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC WEBCOL ALCOHOL QL(13.34 ea 100/0.3ML/29GX1/2" MISC PREP LARGE 1 PLY 2 daily); RX/OTC PADS ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC WEBCOL ALCOHOL QL(13.34 ea 100/0.3ML/30GX5/16" PREP LARGE 2 PLY 2 daily); RX/OTC MISC PADS ADVOCATE INSULIN QL(5 ea daily) WEBCOL ALCOHOL QL(13.34 ea SYRINGE/U- 2 PREP MEDIUM 2 PLY 2 daily); RX/OTC 100/0.3ML/31GX5/16" PADS MISC Parenteral Therapy Supplies ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC PENTIPS/MINI/31GX5MM 2 RX/OTC 100/0.5ML/29GX1/2" MISC MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC PENTIPS29GX12MM 2 RX/OTC 100/0.5ML/30GX5/16" MISC MISC ADVOCATE INSULIN QL(5 ea daily) 1ST TIER UNIFINE 2 QL(5 ea daily); PENTIPS31GX6MM MISC RX/OTC SYRINGE/U- 2 100/0.5ML/31GX5/16" 1ST TIER UNIFINE 2 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC SYRINGE/U- 2 RX/OTC 100/1ML/29GX1/2" MISC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS 31GX8MM 2 RX/OTC ADVOCATE INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC 100/1ML/30GX5/16" MISC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS 32GX4MM 2 RX/OTC ADVOCATE INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 100/1ML/31GX5/16" MISC 1ST TIER UNIFINE QL(5 ea daily); PENTIPSPLUS/MINI/31GX 2 RX/OTC ANTI-STICK INSULIN QL(5 ea daily); 5MM MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPSPLUS/ORIGINAL/ 2 RX/OTC 29GX12MM MISC ANTI-STICK INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); 100/0.5ML/29G X 1/2" PENTIPSPLUS/ULTRA 2 RX/OTC MISC SHORT/31GX6MM MISC MHS Indiana Preferred Drug List Updated December 1, 2018

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTI-STICK INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); 2 SYRINGE/U-100/1ML/29G RX/OTC MICROFINE/U- 2 RX/OTC X 1/2" MISC 100/0.5ML/28G X 1/2" ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.5ML/29G X 1/2" MICROFINE/U- 2 RX/OTC MISC 100/1ML/28G X 1/2" MISC ASSURE ID INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); SAFETYSYRINGE/U- 2 RX/OTC SAFETYGLIDE/0.5ML/29G 2 RX/OTC 100/1ML/29G X 1/2" MISC X 1/2" MISC ASSURE ID SAFETY PEN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); NEEDLES 30G X 5/16" 2 SAFETYGLIDE/1ML/29G X 2 RX/OTC MISC 1/2" MISC AURORA PEN NEEDLES 2 QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) 29GX12MM MISC RX/OTC ULTRA-FINE/0.3ML/31G X 2 8MM MISC AURORA PEN NEEDLES 2 QL(5 ea daily); 31G X6MM MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.5ML/31G X 2 AURORA PEN NEEDLES 2 QL(5 ea daily); 31G X8MM MISC RX/OTC 8MM MISC BD INSULIN SYRINGE QL(5 ea daily) AURORA UNIFINE 2 QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC ULTRA-FINE/1/2 2 UNIT/0.3ML/31G X 8MM AURORA UNIFINE QL(5 ea daily); MISC PENTIPS/MINI/31GX3/16" 2 RX/OTC MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/1ML/30G X 2 AUTOJECT 2 MISC 2 PA; RX/OTC 12.7MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.3ML/31G 2 ULTRA-FINE/1ML/31G X 2 X 5/16" MISC 8MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.5ML/31G 2 ULTRAFINE HALF- 2 X 5/16" MISC UNIT/0.3ML/31G X 5/16" MISC B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/1ML/31G X 2 BD INSULIN SYRINGE QL(5 ea daily) 5/16" MISC ULTRAFINE/0.3ML/31G X 2 5/16" MISC BD LO-DOSE INSULIN QL(5 ea daily); SYRINGE MICROFINE 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) IV/0.5ML/28G X 1/2" MISC ULTRAFINE/0.5ML/31G X 2 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 2 RX/OTC 100/0.5ML/28G X 1/2" ULTRAFINE/1ML/30G X 2 MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); MICROFINE IV/U- 2 RX/OTC ULTRAFINE/U- 2 RX/OTC 100/1ML/28G X 1/2" MISC 100/0.3ML/29G X 1/2" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily); ULTRAFINE/U- 2 RX/OTC NEEDLE/NANO/ULTRA- 2 RX/OTC 100/0.3ML/31G X 15/64" FINE/32G X 4MM MISC MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) NEEDLE/ORIGINAL/ULTR 2 RX/OTC ULTRAFINE/U- 2 A-FINE/29G X 12.7MM 100/0.3ML/31G X 5/16" MISC MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/SHORT/ULTRA- 2 RX/OTC ULTRAFINE/U- 2 RX/OTC FINE/31G X 8MM MISC 100/0.5ML/29G X 1/2" BD SAFETY-GLIDE QL(5 ea daily); MISC INSULIN 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/0.5ML/29G X ULTRAFINE/U- 2 1/2" MISC 100/0.5ML/31G X 5/16" BD SAFETY-LOK INSULIN QL(5 ea daily); MISC SYRINGE/PERM 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/UF/1ML/29G X ULTRAFINE/U- 2 RX/OTC 1/2" MISC 100/1ML/29G X 1/2" MISC BD SAFETYGLIDE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) INSULIN 2 RX/OTC ULTRAFINE/U- 2 SYRINGE/0.3ML/29G X 100/1ML/30G X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily); ULTRAFINE/U- 2 INSULIN 2 RX/OTC 100/1ML/31G X 5/16" SYRINGE/0.3ML/31G X MISC 15/64" MISC BD INSULIN QL(5 ea daily); BD SAFETYGLIDE QL(5 ea daily) 2 SYRINGE/0.3ML/29G X RX/OTC INSULIN 2 12.7MM MISC SYRINGE/0.3ML/31G X BD INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X 2 RX/OTC BD SAFETYGLIDE QL(5 ea daily); 12.7MM MISC INSULIN 2 RX/OTC BD INSULIN QL(5 ea daily); SYSYRINGE/0.5ML/30G X SYRINGE/1ML/29G X 2 RX/OTC 5/16" MISC 12.7MM MISC BD VEO INSULIN QL(5 ea daily); SYRINGE ULTRA- RX/OTC BD INSULIN SYRINGE/U- 2 QL(5 ea daily); 2 100/1ML/28G X 1/2" MISC RX/OTC AFINE/0.3ML/31G X 6MM MISC BD INTEGRA INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G 2 RX/OTC BD VEO INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE ULTRA- 2 RX/OTC FINE/0.3ML/31G X 6MM BD PEN QL(5 ea daily) MISC NEEDLE/MICRO/ULTRA- 2 FINE/32G X 6MM MISC BD VEO INSULIN QL(5 ea daily); SYRINGE ULTRA- 2 RX/OTC BD PEN QL(5 ea daily); FINE/1/2 UNIT/0.3ML/31G NEEDLE/MINI/ULTRA- 2 RX/OTC X 6MM MISC FINE/31G X 5MM MISC CAREFINE PEN NEEDLE 2 QL(5 ea daily); 32GX4MM MISC RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREFINE PEN 2 QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC PENTIPS PLUS PEN 2 RX/OTC CAREFINE PEN QL(5 ea daily) NEEDLES 31GX5MM NEEDLES 30GX5/16" 2 MISC MISC CAREONE UNIFINE QL(5 ea daily); CAREFINE PEN QL(5 ea daily); PENTIPS PLUS PEN 2 RX/OTC NEEDLES 31GX6MM 2 RX/OTC NEEDLES 31GX6MM MISC MISC CAREFINE PEN QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC PENTIPS PLUS PEN 2 RX/OTC MISC NEEDLES 31GX8MM MISC CAREFINE PEN QL(5 ea daily); NEEDLES 32GX5MM 2 RX/OTC CAREONE UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 2 RX/OTC NEEDLES 32GX4MM CAREFINE PEN QL(5 ea daily) MISC NEEDLES 32GX6MM 2 MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 31G X 6 MM 2 RX/OTC CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/31G X 2 5/16" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 31GX 5MM 2 RX/OTC CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/31G X 2 5/16" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 31GX 8MM 2 RX/OTC CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/1ML/30G X 2 1/2" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 32GX 4MM 2 RX/OTC CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/1ML/31GX5/16 2 " MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 32GX 5MM 2 RX/OTC CAREONE UNIFINE QL(5 ea daily); MISC PENTIPS 29GX12MM 2 RX/OTC MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE 2 QL(5 ea daily); PEN NEEDLES 31GX8MM PENTIPS 31GX5MM MISC RX/OTC MISC CAREONE UNIFINE 2 QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS 31GX6MM MISC RX/OTC COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE 2 QL(5 ea daily); SYRINGE/0.3ML/29G X PENTIPS 31GX8MM MISC RX/OTC 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PEN NEEDLES 2 RX/OTC COMFORT EZINSULIN 2 RX/OTC 32GX4MM MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS PLUS PEN 2 RX/OTC CLEVER CHOICE QL(5 ea daily) NEEDLES 29GX12MM COMFORT EZINSULIN 2 MISC SYRINGE/0.3ML/31G X 5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 RX/OTC SYRINGE/0.5ML/28G X NEEDLES 31GX8MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 RX/OTC SYRINGE/0.5ML/29G X NEEDLES 32GX4MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 RX/OTC COMFORT EZPEN 2 SYRINGE/0.5ML/30G X NEEDLES 32GX6MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN NEEDLE 2 QL(5 ea daily); COMFORT EZINSULIN 2 32GX5/32" MISC RX/OTC SYRINGE/0.5ML/31G X CLICKFINE PEN NEEDLE QL(5 ea daily); 5/16" MISC UNIVERSAL/31GX1/4" 2 RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 2 CLICKFINE PEN NEEDLE QL(5 ea daily); SYRINGE/1.0ML/30G X UNIVERSAL/31GX5/16" 2 RX/OTC 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN 2 QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC NEEDLES/31GX1/4" MISC RX/OTC SYRINGE/1ML/28G X 1/2" MISC CLICKFINE PEN QL(5 ea daily); NEEDLES/31GX5/16" 2 RX/OTC CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" CLICKFINE UNIVERSAL QL(5 ea daily); MISC PEN NEEDLES 31GX5/16" 2 RX/OTC MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC SYRINGE/1ML/30G X INSULIN SYRINGE 2 RX/OTC 5/16" MISC 0.3ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); INSULIN RX/OTC COMFORT EZINSULIN 2 2 SYRINGE/U- SYRINGE/0.3ML/30G X 100/1ML/31GX5/16" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) INSULIN COMFORT EZPEN 2 RX/OTC 2 NEEDLES 29GX12MM SYRINGE/0.3ML/31G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); INSULIN RX/OTC COMFORT EZPEN 2 RX/OTC 2 NEEDLES 31GX5MM SYRINGE/0.5ML/29G X MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); INSULIN RX/OTC COMFORT EZPEN 2 RX/OTC 2 NEEDLES 31GX6MM SYRINGE/0.5ML/30G X MISC 5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) INSULIN 2 SYRINGE U-100/1ML/30G 2 SYRINGE/0.5ML/31G X X 1/2" MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); SYRINGE U-100/1ML/30G 2 RX/OTC INSULIN 2 RX/OTC X 5/16" MISC SYRINGE/1ML/29G X 1/2" DROPLET INSULIN QL(5 ea daily) MISC SYRINGE U-100/1ML/31G 2 COMFORT ASSIST QL(5 ea daily); X 5/16" MISC INSULIN RX/OTC 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); SYRINGE/1ML/30G X 29GX12MM MISC RX/OTC 5/16" MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) 31GX5MM MISC RX/OTC INSULIN 2 SYRINGE/1ML/31G X DROPLET PEN NEEDLES 2 QL(5 ea daily); 5/16" MISC 31GX6MM MISC RX/OTC CORNWALL METAL PA; RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily); PIPETTINGHOLDER (FOR 2 31GX8MM MISC RX/OTC 1240S) MISC DROPLET PEN NEEDLES 2 QL(5 ea daily) CORNWALL METAL PA; RX/OTC 32G X 1/4" MISC PIPETTINGHOLDER (FOR 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); 1250S) MISC 32G X 3/16" MISC RX/OTC CORNWALL METAL PA; RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily); PIPETTINGHOLDER (FOR 2 32G X 5/32" MISC RX/OTC 1260S) MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); CORNWALL METAL PA; RX/OTC 32GX4MM MISC RX/OTC PIPETTINGHOLDER (FOR 2 DROPLET PEN NEEDLES 2 QL(5 ea daily) 1270S) MISC 32GX6MM MISC DROPLET INSULIN QL(5 ea daily) DRUG MART UNIFINE 2 QL(5 ea daily); SYRINGE U-100/0.3/31G 2 PENTIPS 31GX5MM MISC RX/OTC X 5/16" MISC DRUG MART UNIFINE QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); PENTIPS29G X 12MM 2 RX/OTC SYRINGE U- 2 RX/OTC MISC 100/0.3ML/30G X 5/16" DRUG MART UNIFINE 2 QL(5 ea daily); MISC PENTIPS31GX6MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily); DRUG MART UNIFINE 2 QL(5 ea daily); SYRINGE U- 2 RX/OTC PENTIPS31GX8MM MISC RX/OTC 100/0.3ML/31G X 15/64" MISC DRUG MART UNIFINE 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily); DRUG MART UNIFINE QL(5 ea daily); SYRINGE U- 2 RX/OTC 100/0.5ML/30G X 5/16" PENTIPSPLUS 32GX4MM 2 RX/OTC MISC MISC DROPLET INSULIN QL(5 ea daily) EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE U- 2 100/0.5ML/31G X 5/16" 5/16" MISC MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 5/16" MISC MHS Indiana Preferred Drug List Updated December 1, 2018

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY COMFORT INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC 5/16" MISC 1/2" MISC EASY COMFORT INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 SYRINGE/1ML/30G X 2 RX/OTC X 1/2" MISC 5/16" MISC EASY COMFORT PEN 2 QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLES31GX1/4" MISC RX/OTC SYRINGE/SAFETY/U- 2 RX/OTC EASY COMFORT PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES31GX3/16" 2 RX/OTC MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY COMFORT PEN QL(5 ea daily); SYRINGE/SAFETY/U- 2 RX/OTC NEEDLES31GX5/16" 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC EASY COMFORT PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLES32GX5/32" 2 RX/OTC SYRINGE/SAFETY/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH 32GX5MM 2 QL(5 ea daily); MISC RX/OTC SYRINGE/SAFETY/U- 2 100/1ML/30G X 1/2" MISC EASY TOUCH 32GX6MM 2 QL(5 ea daily) MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); 100/0.5ML/28G X 1/2" SAFETY INSULIN 2 RX/OTC MISC SYRINGE 1ML/29GX1/2" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U- 2 EASY TOUCH FLIPLOCK QL(5 ea daily) 100/0.5ML/31G X 5/16" SAFETY INSULIN 2 MISC SYRINGE 1ML/30GX1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); X 1/2" MISC SAFETY INSULIN 2 RX/OTC SYRINGE 1ML/30GX5/16" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC EASY TOUCH FLIPLOCK QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) SAFETY INSULIN 2 SYRINGE 1ML/31GX5/16" SYRINGE/U-100/1ML/30G 2 MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/U-100/1ML/31G 2 5/16" MISC X 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 NEEDLE 30G X 5/16" 2 5/16" MISC MISC EASY TOUCH PEN 2 QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH PEN 2 QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) NEEDLES 31GX1/4" MISC RX/OTC SYRINGE/U- 2 EASY TOUCH PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEDLES 31GX5/16" 2 RX/OTC MISC MISC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC EASY TOUCH PEN 2 QL(5 ea daily) NEEDLES 32GX1/4" MISC X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); NEEDLES 32GX3/16" 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC MISC X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) NEEDLES 32GX5/32" 2 RX/OTC SYRINGE/U-100/1ML/31G 2 MISC X 5/16" MISC EASY TOUCH PEN QL(5 ea daily); EQL INSULIN QL(5 ea daily); NEEDLES/31G X 3/16" 2 RX/OTC SYRINGE/0.3ML/29G X 2 RX/OTC MISC 1/2" MISC EASY TOUCH QL(5 ea daily); EQL INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC SHEATHLOCK SAFETY 2 RX/OTC INSULIN SYRINGE 5/16" MISC 1ML/29GX1/2" MISC EQL INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily); SYRINGE/0.3ML/31G X 2 5/16" MISC SHEATHLOCK SAFETY 2 RX/OTC INSULIN SYRINGE EQL INSULIN QL(5 ea daily); 1ML/30GX5/16" MISC SYRINGE/0.5ML/29G X 2 RX/OTC EASY TOUCH QL(5 ea daily) 1/2" MISC SHEATHLOCK SAFETY 2 EQL INSULIN QL(5 ea daily); INSULIN SYRINGE SYRINGE/0.5ML/30G X 2 RX/OTC 1ML/31GX5/16" MISC 5/16" MISC EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily) SHEATHLOCK SAFETY 2 SYRINGE/0.5ML/31G X 2 SYRINGE 1ML/30GX1/2" 5/16" MISC MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/0.3ML/31G X 2 MISC 5/16" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC 5/16" MISC 1/2" MISC EQL INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC 29G X 12MM MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 2 RX/OTC SYRINGE/U- 2 RX/OTC 31G X 6MM MISC 100/0.5ML/28G X 1/2" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

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

MHS Indiana Preferred Drug List Updated December 1, 2018

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL EASE INJECT QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily) PEN NEEDLES 32GX4MM 2 RX/OTC INSULIN SYRINGE/U- 2 MISC 100/1ML/30G X 1/2" MISC GLOBAL EASE INJECT QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); 2 PEN NEEEDLES RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 31GX5MM MISC 100/1ML/30G X 5/16" GLOBAL EASY GLIDE QL(5 ea daily) MISC INSULINSYRINGE/U- 2 GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/31G X 5/16" INSULIN SYRINGE/U- 2 MISC 100/1ML/31G X 5/16" GLOBAL EASY GLIDE QL(5 ea daily); MISC PEN NEEDLES 32GX4MM 2 RX/OTC GLOBAL INSULIN QL(5 ea daily); MISC SYRINGES/U- 2 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30GX5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/31G X 5/16" MISC INSULIN SYRINGE/U- 2 100/0.3ML/31G X 5/16" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.5ML/30G X 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 GLOBAL INJECT EASE QL(5 ea daily); 100/0.5ML/31G X 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/30G 2 GLOBAL INJECT EASE QL(5 ea daily); X 1/2" MISC INSULIN SYRINGE/U- 2 RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U-100/1ML/30G 2 RX/OTC MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U-100/1ML/31G 2 100/0.5ML/31G X 5/16" X 5/16" MISC MISC GNP CLICKFINE PEN QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); NEEDLEUNIVERSAL/31G 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC X5/16" MISC 100/1ML/28G X 1/2" MISC GNP CLICKFINE QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); UNIVERSAL PEN 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC NEEDLES 31GX1/4" MISC 100/1ML/29G X 1/2" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP CLICKFINE QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) UNIVERSAL PEN 2 RX/OTC INSULIN 2 NEEDLES 31GX5/16" SYRINGE/0.3ML/31G X MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); 2 SYRINGE/0.3ML/29G X RX/OTC INSULIN 2 RX/OTC 1/2" MISC SYRINGE/0.5ML/28G X GNP INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/30G X 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 2 RX/OTC GNP INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X SYRINGE/0.3ML/31G X 2 1/2" MISC 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 2 RX/OTC SYRINGE/0.5ML/28G X 2 RX/OTC SYRINGE/0.5ML/30G X 1/2" MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) SYRINGE/0.5ML/29G X 2 RX/OTC INSULIN 2 1/2" MISC SYRINGE/0.5ML/31G X 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 2 RX/OTC SYRINGE/1ML/28G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); INSULIN 2 RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/1ML/30G X MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) SYRINGE/1ML/30G X 2 RX/OTC INSULIN 2 5/16" MISC SYRINGE/1ML/31G X GNP INSULIN QL(5 ea daily) 5/16" SHORT MISC SYRINGE/1ML/31G X 2 H-E-B IN CONTROL PEN QL(5 ea daily); 5/16" MISC NEEDLES 31GX5MM 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN 2 RX/OTC H-E-B IN CONTROL PEN QL(5 ea daily); SYRINGE/0.3ML/29G X NEEDLES 31GX6MM 2 RX/OTC 1/2" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily); INSULIN 2 RX/OTC NEEDLES 31GX8MM 2 RX/OTC SYRINGE/0.3ML/30G X MISC 5/16" SHORT MISC H-E-B IN CONTROL PEN QL(5 ea daily); NEEDLES/NANO/32GX4M 2 RX/OTC M MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL QL(5 ea daily); HUMATROPEN FOR 2 PA; RX/OTC UNIFINEPENTIPS PLUS 2 RX/OTC 12MG DEVI 31GX5MM MISC HUMATROPEN FOR 2 PA; RX/OTC H-E-B IN CONTROL QL(5 ea daily); 24MG DEVI UNIFINEPENTIPS PLUS 2 RX/OTC HUMATROPEN FOR 6MG 2 PA; RX/OTC 32GX4MM MISC DEVI H-E-B INCONTROL PEN QL(5 ea daily); INJECT-EASE PA; RX/OTC NEEDLES 29GX12MM 2 RX/OTC AUTOMATIC INJECTOR 2 MISC MISC HEALTHWISE MINI PEN QL(5 ea daily); PA; RX/OTC NEEDLES 31GX6MM 2 RX/OTC INJECT-EASE MISC 2 MISC INSULIN QL(5 ea daily); HEALTHWISE PEN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC NEEDLES 29GX12MM 2 RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC PEN NEEDLES 31GX8MM 2 RX/OTC 5/16" MISC MISC INSULIN QL(5 ea daily) HEALTHWISE UNIFINE QL(5 ea daily); SYRINGE/0.3ML/31G X 2 PENTIPS PEN NEEDLES 2 RX/OTC 5/16" MISC 32GX4MM MISC INSULIN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); SYRINGE/0.5ML/28G X 2 RX/OTC UNIFINE PENTIPS PEN 2 RX/OTC 1/2" MISC NEEDLES 29GX12MM INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 2 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 5/16" MISC UNIFINE PENTIPS PEN 2 RX/OTC INSULIN QL(5 ea daily) NEEDLES 31GX5MM SYRINGE/0.5ML/31G X 2 MISC 5/16" MISC HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily); UNIFINE PENTIPS PEN 2 RX/OTC SYRINGE/1ML/28G X 1/2" 2 RX/OTC NEEDLES 31GX6MM MISC MISC INSULIN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 31GX8MM MISC INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 5/16" MISC UNIFINE PENTIPS PEN 2 RX/OTC NEEDLES 32GX4MM INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 2 RX/OTC 0.3ML/30G X 5/16" MISC HM ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 2 INSULIN QL(5 ea daily) MISC SYRINGE/NEEDLE 2 0.3ML/31G X 5/16" MISC HM ULTICARE INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/U- 2 100/0.3ML/31G X 5/16" SYRINGE/NEEDLE 2 RX/OTC MISC 0.5ML/29G X 1/2" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 2 RX/OTC SYRINGES/0.5ML/31GX5/ 2 0.5ML/30G X 5/16" MISC 16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 2 SYRINGES/1ML/28GX1/2" 2 RX/OTC 0.5ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 2 RX/OTC SYRINGES/1ML/29GX1/2" 2 RX/OTC 1ML/29G X 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 2 RX/OTC SYRINGES/1ML/30GX1/2" 2 1ML/30G X 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/NEEDLE 2 SYRINGES/1ML/31GX5/16 2 1ML/31G X 5/16" MISC " MISC INSULIN SYRINGE/U- QL(5 ea daily); INSUPEN 29G X 12MM 2 QL(5 ea daily); 100/0.3ML/29G X 1/2" 2 RX/OTC MISC RX/OTC MISC INSUPEN 31G X 5MM 2 QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); MISC RX/OTC 100/0.5ML/28G X 1/2" 2 RX/OTC INSUPEN 31G X 8MM 2 QL(5 ea daily); MISC MISC RX/OTC INSULIN SYRINGE/U- QL(5 ea daily); INSUPEN 32G X 4MM 2 QL(5 ea daily); 100/0.5ML/29G X 1/2" 2 RX/OTC MISC RX/OTC MISC INSUPEN PEN NEEDLES 2 QL(5 ea daily); INSULIN SYRINGE/U- 2 QL(5 ea daily); 32G X4MM MISC RX/OTC 100/1ML/28G X 1/2" MISC RX/OTC INSUPEN SENSITIVE 2 QL(5 ea daily) INSULIN SYRINGE/U- 2 QL(5 ea daily); 32GX6MM MISC 100/1ML/29G X 1/2" MISC RX/OTC INSUPEN ULTRAFIN 2 QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); 29GX12MM MISC RX/OTC 100/1ML/30G X 5/16" 2 RX/OTC MISC INSUPEN ULTRAFIN 2 QL(5 ea daily) 30GX8MM MISC INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/31G X 5/16" 2 INSUPEN ULTRAFIN 2 QL(5 ea daily); MISC 31GX6MM MISC RX/OTC INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 2 QL(5 ea daily); SYRINGES/0.5ML/28GX1/ 2 RX/OTC 31GX8MM MISC RX/OTC 2" MISC J-TIP KIT W/VIAL 2 PA INSULIN QL(5 ea daily); ADAPTERS KIT SYRINGES/0.5ML/29GX1/ 2 RX/OTC KINRAY INSULIN QL(5 ea daily) 2" MISC SYRINGE PREFERRED 2 INSULIN QL(5 ea daily); PLUS/0.3ML/31G X 5/16" SYRINGES/0.5ML/30GX5/ 2 RX/OTC MISC 16" MISC KINRAY INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE PREFERRED 2 SYRINGES/0.5ML/31GX 2 PLUS/0.5ML/31G X 5/16" 5/16" MISC MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINRAY INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily) SYRINGE PREFERRED 2 SYRINGE/0.3ML/31G X 2 PLUS/1ML/31G X 5/16" 5/16" MISC MISC LEADER INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC 1/2" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/0.3ML/29G X 2 RX/OTC 1/2" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 SYRINGE/0.3ML/31G X 2 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 2 RX/OTC SYRINGE/0.5ML/31G X 2 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/1ML/29G X 1/2" 2 RX/OTC 5/16" MISC MISC LEADER UNIFINE QL(5 ea daily); KROGER INSULIN QL(5 ea daily); PENTIPS 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC PLUS/MINI/31GX3/16" 5/16" MISC MISC KROGER INSULIN QL(5 ea daily) LEADER UNIFINE QL(5 ea daily); SYRINGE/1ML/31G X 2 PENTIPS 2 RX/OTC 5/16" MISC PLUS/SHORT/31GX5/16" MISC KROGER PEN NEEDLES 2 QL(5 ea daily); 29G X12MM MISC RX/OTC LEADER UNIFINE QL(5 ea daily); PENTIPS/MINI/31GX3/16" 2 RX/OTC KROGER PEN NEEDLES 2 QL(5 ea daily); 31G X8MM MISC RX/OTC MISC LEADER UNIFINE QL(5 ea daily); KROGER PEN NEEDLES 2 QL(5 ea daily); 31GX1/4" MISC RX/OTC PENTIPS/NANO/32GX5/32 2 RX/OTC " MISC LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC LEADER UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS/PLUS/32GX5/32" 2 RX/OTC MISC LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC LITE TOUCH PEN QL(5 ea daily); 5/16" MISC NEEDLES/31G X 3/16" 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

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

MHS Indiana Preferred Drug List Updated December 1, 2018

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICINE SHOPPE PEN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 2 NEEDLES 31G X 6MM RX/OTC SYRINGE/PERM 2 RX/OTC MISC NEEDLE/U-100/0.5ML/28G MEDICINE SHOPPE PEN QL(5 ea daily); X 1/2" MISC NEEDLES 31G X 8MM 2 RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/PERM 2 RX/OTC NEEDLE/0.3ML/29G X 1/2" MEIJER PEN NEEDLES 2 QL(5 ea daily); 29G X12MM MISC RX/OTC MISC MONOJECT INSULIN QL(5 ea daily); MEIJER PEN NEEDLES 2 QL(5 ea daily); 31G X6MM MISC RX/OTC SYRINGE/SAFETY/PERM 2 RX/OTC NEEDLE/0.3ML/29GX1/2" MEIJER PEN NEEDLES 2 QL(5 ea daily); MISC 31G X8MM MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/SAFETY/PERM 2 RX/OTC 100/0.3ML/30G X 5/16" 2 RX/OTC NEEDLE/0.5ML/29G X 1/2" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" 2 SYRINGE/SAFETY/PERM 2 RX/OTC MISC NEEDLE/1ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/1/2ML/30G X 5/16" 2 RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SOFTPACK/U- 2 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/0.5ML/28G X 1/2" 100/1/2ML/31G X 5/16" 2 MISC MISC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" 2 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 2 SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/28G X 1/2" MISC MM PEN NEEDLES 31G X 2 QL(5 ea daily); 1/4" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC MM PEN NEEDLES 31G X 2 QL(5 ea daily); 2 3/16" MISC RX/OTC 100/0.5ML/30G X 5/16" MISC MM PEN NEEDLES 31G X 2 QL(5 ea daily); 5/16" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC MM PEN NEEDLES 32G X 2 QL(5 ea daily); 5/32" MISC RX/OTC X 1/2" MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/U-100/1ML/30G 2 RX/OTC 5/16" MISC X 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); COMFORT INSULIN RX/OTC SYRINGE/PERM 2 RX/OTC 2 NEEDLE/1ML/28G X 1/2" SYRINGE/0.3ML/29G X MISC 1/2" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); COMFORT INSULIN 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/0.3ML/30G X 100/1ML/29G X 1/2" MISC 5/16" MISC MS INSULIN QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily) SYRINGE/0.3ML/31G X 2 COMFORT INSULIN 2 5/16" MISC SYRINGE/0.3ML/31G X MS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X 2 MONOJECT ULTRA QL(5 ea daily); 5/16" MISC COMFORT INSULIN 2 RX/OTC MS INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X SYRINGE/1ML/31G X 2 1/2" MISC 5/16" MISC MONOJECT ULTRA QL(5 ea daily); NORDIPEN 5 INJECTION 2 PA; RX/OTC COMFORT INSULIN 2 RX/OTC DEVICE MISC SYRINGE/0.5ML/29G X 1/2" MISC NORDIPEN DELIVERY 2 PA; RX/OTC SYSTEM MISC MONOJECT ULTRA QL(5 ea daily); NOVOFINE 30GX8MM QL(5 ea daily) COMFORT INSULIN 2 RX/OTC 2 SYRINGE/0.5ML/30G X MISC 5/16" MISC NOVOFINE 32GX6MM 2 QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily) MISC NOVOFINE AUTOCOVER QL(5 ea daily) COMFORT INSULIN 2 2 SYRINGE/0.5ML/31G X 30GX8MM MISC 5/16" MISC NOVOFINE PLUS 2 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 32GX4MM MISC RX/OTC COMFORT INSULIN RX/OTC 2 OMNITROPE PEN 10 2 PA; RX/OTC SYRINGE/1ML/28G X 1/2" INJECTION DEVICE MISC MISC OMNITROPE PEN 5 2 PA; RX/OTC MONOJECT ULTRA QL(5 ea daily); INJECTION DEVICE MISC COMFORT INSULIN RX/OTC 2 PC UNIFINE PENTIPS 2 QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 29G X1/2" MISC RX/OTC MISC PC UNIFINE PENTIPS 2 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 31G X5MM MINI MISC RX/OTC COMFORT INSULIN 2 RX/OTC SYRINGE/1ML/30G X PC UNIFINE PENTIPS QL(5 ea daily); 5/16" MISC 31G X6MM ULTRA 2 RX/OTC SHORT MISC MOORE MED MONOJECT QL(5 ea daily); PC UNIFINE PENTIPS QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC 2 100/0.5ML/28G X 1/2" 31G X8MM SHORT MISC RX/OTC MISC PEN NEEDLES 29G X 2 QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); 12MM MISC RX/OTC PEN NEEDLES 29GX1/2" QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC 2 100/0.5ML/29G X 1/2" MISC RX/OTC MISC PEN NEEDLES 30GX5/16" 2 QL(5 ea daily) MOORE MED MONOJECT QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC PEN NEEDLES 30GX8MM 2 QL(5 ea daily) 100/1ML/28G X 1/2" MISC MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES 31G X 1/4" 2 QL(5 ea daily); PLASTIC ADAPTER FOR PA; RX/OTC SHORT MISC RX/OTC BUSHINJECTOR B-D 2 PLASTIPAK MISC PEN NEEDLES 31G X 2 QL(5 ea daily); 3/16" MISC RX/OTC PLASTIC ADAPTER FOR 2 PA BUSHINJECTOR MISC PEN NEEDLES 31G X 2 QL(5 ea daily); 5MM MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); INSULIN RX/OTC PEN NEEDLES 31G X 2 QL(5 ea daily); 2 6MM MISC RX/OTC SYRINGE/0.3ML/30G X 5/16" MISC PEN NEEDLES 31G X 2 QL(5 ea daily); 8MM MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily); INSULIN 2 RX/OTC PEN NEEDLES 31GX5/16" 2 QL(5 ea daily); SYRINGE/0.5ML/28G X MISC RX/OTC 1/2" MISC PEN NEEDLES 31GX6MM 2 QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); (1/4") MISC RX/OTC INSULIN 2 RX/OTC PEN NEEDLES 31GX8MM 2 QL(5 ea daily); SYRINGE/0.5ML/29G X (5/16") MISC RX/OTC 1/2" MISC PEN NEEDLES 31GX8MM 2 QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); MISC RX/OTC INSULIN 2 RX/OTC SYRINGE/1ML/28G X 1/2" PEN NEEDLES 32G X 2 QL(5 ea daily); 4MM MISC RX/OTC MISC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 32G X 2 QL(5 ea daily); 5MM MISC RX/OTC PLUSINSULIN 2 RX/OTC SYRINGE/0.3ML/29G X PEN NEEDLES 32G X 2 QL(5 ea daily) 6MM MISC 1/2" MISC PRECISION SURE-DOSE QL(5 ea daily); PEN NEEDLES 32GX4MM 2 QL(5 ea daily); MISC RX/OTC PLUSINSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" PENTIPS 29G X 12MM 2 QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 29GX12MM QL(5 ea daily); 2 INSULIN SYRINGE/U- 2 RX/OTC MISC RX/OTC 100/0.3ML/29G X 1/2" PENTIPS 31G X 5MM 2 QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 31G X 8MM QL(5 ea daily); 2 INSULIN SYRINGE/U- 2 RX/OTC MISC RX/OTC 100/0.3ML/30G X 5/16" QL(5 ea daily); MISC PENTIPS 31GX5MM MISC 2 RX/OTC PREFERRED PLUS QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC PENTIPS 31GX6MM MISC 2 QL(5 ea daily); 2 RX/OTC 100/0.5ML/28G X 1/2" MISC PENTIPS 31GX8MM MISC 2 QL(5 ea daily); RX/OTC PREFERRED PLUS QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC PENTIPS 32G X 4MM 2 QL(5 ea daily); 2 MISC RX/OTC 100/0.5ML/29G X 1/2" MISC PENTIPS 32GX4MM MISC 2 QL(5 ea daily); RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC NEEDLES/31G X 8MM 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC PRO COMFORT PEN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); NEEDLES/32G X 4MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/28G X 1/2" MISC PRO COMFORT PEN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); NEEDLES/32G X 5MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC PRO COMFORT PEN QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); NEEDLES/32G X 6MM 2 INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/30G X 5/16" PRODIGY INSULIN QL(5 ea daily) MISC SYRING/U-100/0.3ML/31G 2 PREFERRED PLUS QL(5 ea daily); X 5/16" MISC UNIFINE PENTIPS 29G X 2 RX/OTC PRODIGY INSULIN QL(5 ea daily) 12MM MISC SYRINGE/1/2ML/31G X 2 PREFERRED PLUS QL(5 ea daily); 5/16" MISC UNIFINE PENTIPS 31G X 2 RX/OTC PRODIGY INSULIN QL(5 ea daily); 6MM ULTRA SHORT SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC MISC PREFERRED PLUS QL(5 ea daily); PX EXTRA SHORT PEN QL(5 ea daily); UNIFINE PENTIPS 31G X 2 RX/OTC NEEDLES 31GX6MM 2 RX/OTC 8MM SHORT MISC MISC PREFERRED PLUS QL(5 ea daily); PX INSULIN SYRINGE/U- QL(5 ea daily) UNIFINE PENTIPS 2 RX/OTC 100/0.3ML/31G X 5/16" 2 32GX4MM MISC MISC PREFERRED PLUS QL(5 ea daily); PX INSULIN SYRINGE/U- QL(5 ea daily) UNIFINE 2 RX/OTC 100/0.5ML/31G X 5/16" 2 PENTIPS/MINI/31GX5MM MISC MISC PX INSULIN SYRINGE/U- 2 QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGES/0.5ML/30G X 2 RX/OTC 5/16" MISC PX INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/31G X 5/16" 2 PRO COMFORT INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/31G X 2 5/16" MISC PX MINI PEN NEEDLES 2 QL(5 ea daily); 31GX5MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) SYRINGES/1ML/30G X 2 PX PEN NEEDLE 2 QL(5 ea daily); 1/2" MISC 29GX12MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily); PX PEN NEEDLE 2 QL(5 ea daily); SYRINGES/1ML/30G X 2 RX/OTC 31GX8MM MISC RX/OTC 5/16" MISC PX SHORTLENGTH PEN QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) NEEDLES/31GX8MM 2 RX/OTC SYRINGES/1ML/31G X 2 MISC 5/16" MISC QC PEN NEEDLES 29G X 2 QL(5 ea daily); 12MM MISC RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QC PEN NEEDLES 31G X 2 QL(5 ea daily); RELION INSULIN QL(5 ea daily); 6MM MISC RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/31G X 15/64" QC PEN NEEDLES 31G X 2 QL(5 ea daily); 8MM MISC RX/OTC MISC RELION INSULIN QL(5 ea daily) QC UNIFINE PENTIPS 2 QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE/U- 2 100/0.3ML/31G X 5/16" RA INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 2 RX/OTC 1/2" MISC RELION INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC RA INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); RA INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC RA INSULIN SYRINGE/U- QL(5 ea daily); RELION INSULIN QL(5 ea daily) 100/1 ML/30G X 5/16" 2 RX/OTC SYRINGE/U- 2 MISC 100/0.5ML/31G X 5/16" RA PEN NEEDLES 31G X 2 QL(5 ea daily); MISC 5MM3/16" MISC RX/OTC RELION INSULIN QL(5 ea daily); RA PEN NEEDLES 31G X 2 QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC 8MM5/16" MISC RX/OTC X 5/16" MISC REALITY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGE/U- 2 RX/OTC SYRINGE/U-100/1ML/31G 2 100/0.5ML/28G X 1/2" X 5/16" MISC MISC RELION MINI PEN QL(5 ea daily); REALITY INSULIN QL(5 ea daily); NEEDLES 31GX6MM 2 RX/OTC SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/29G X 1/2" RELION PEN NEEDLES 2 QL(5 ea daily); MISC 29GX12MM MISC RX/OTC REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES 2 QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC 31GX6MM MISC RX/OTC X 1/2" MISC RELION PEN NEEDLES 2 QL(5 ea daily); REALITY INSULIN QL(5 ea daily); 31GX8MM MISC RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC RELION PEN NEEDLES 2 QL(5 ea daily); 32GX4MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SYRINGE/U-00/1ML/29G 2 RX/OTC RELION SHORT PEN 2 QL(5 ea daily); X 1/2" MISC NEEDLES31GX8MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" 5/16" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC 1/2" MISC SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC MHS Indiana Preferred Drug List Updated December 1, 2018

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFESNAP INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 2 RX/OTC PENTIPS PEN 2 RX/OTC MISC NEEDLES/ORIGINAL/29G SAFESNAP INSULIN QL(5 ea daily); X12MM MISC SYRINGE/1ML/29G X 1/2" 2 RX/OTC SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PEN 2 RX/OTC SAFETY INSULIN QL(5 ea daily); NEEDLES/SHORT/31GX8 SYRINGES 2 RX/OTC MM MISC 0.5ML/29GX1/2" MISC SHOPKO UNIFINE QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); PENTIPS PLUS PEN 2 RX/OTC SYRINGES 2 RX/OTC NEEDLES/MICRO/REMOV 0.5ML/30GX5/16" MISC R/32GX4MM MISC SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGES 1ML/29GX1/2" 2 RX/OTC PENTIPS PLUS PEN 2 RX/OTC MISC NEEDLES/MINI/REMOVE R/31GX5MM MISC SAFETY INSULIN QL(5 ea daily) SYRINGES 1ML/30GX1/2" 2 SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 2 RX/OTC NEEDLES/REMOVER/29G SB INSULIN SYRINGE/U- QL(5 ea daily); X12MM MISC 100/0.5ML/29G X 1/2" 2 RX/OTC MISC SHOPKO UNIFINE QL(5 ea daily); PENTIPS PLUS PEN 2 RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/SHORT/REMO 100/0.5ML/30G X 5/16" 2 RX/OTC VR/31GX8MM MISC MISC SM INSULIN QL(5 ea daily) SB INSULIN SYRINGE/U- 2 QL(5 ea daily); SYRINGE/1ML/31G X 2 100/1ML/29G X 1/2" MISC RX/OTC 5/16" MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily); 100/1ML/30G X 5/16" 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/29G X 1/2" SB INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 2 SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC SCHNUCKS INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGEULTI-FINE/U- 2 RX/OTC MISC 100/0.5ML/29G X 1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 SCHNUCKS INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16 SYRINGEULTI-FINE/U- 2 RX/OTC MISC 100/0.5ML/30G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 SHOPKO UNIFINE QL(5 ea daily); 100/0.3ML/31G X 5/16" PENTIPS PEN 2 RX/OTC MISC NEEDLES/MICRO/32GX4 SURE COMFORT QL(5 ea daily); MM MISC INSULIN SYRINGE/U- 2 RX/OTC SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/28G X 1/2" PENTIPS PEN 2 RX/OTC MISC NEEDLES/MINI/31GX5MM MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE-FINE PEN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC NEEDLES 29GX1/2" 2 RX/OTC 100/0.5ML/29G X 1/2" 12.7MM MISC MISC SURE-FINE PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily); NEEDLES 31GX3/16" 5MM 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/30G X 5/16" SURE-FINE PEN QL(5 ea daily); MISC NEEDLES 31GX5/16" 8MM 2 RX/OTC SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 2 SURE-JECT INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16 SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/29G X 1/2" SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC SURE-JECT INSULIN QL(5 ea daily); 100/1ML/28G X 1/2" MISC SYRINGE/U- 2 RX/OTC SURE COMFORT QL(5 ea daily); 100/0.3ML/30G X 5/16" INSULIN SYRINGE/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC SURE-JECT INSULIN QL(5 ea daily) SURE COMFORT QL(5 ea daily) SYRINGE/U- 2 INSULIN SYRINGE/U- 2 100/0.3ML/31G X 5/16" 100/1ML/30G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 SYRINGE/U- 2 RX/OTC 100/1ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); 2 NEEDLES29GX1/2" RX/OTC SYRINGE/U- 2 RX/OTC 12.7MM MISC 100/0.5ML/30G X 5/16" SURE COMFORT PEN QL(5 ea daily) MISC NEEDLES30GX5/16" 2 SURE-JECT INSULIN QL(5 ea daily) SHORT MISC SYRINGE/U- 2 SURE COMFORT PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEDLES31GX3/16" 2 RX/OTC MISC (5MM) MISC SURE-JECT INSULIN QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC NEEDLES31GX5/16" 2 RX/OTC X 1/2" MISC (8MM) MISC SURE-JECT INSULIN QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/29G 2 RX/OTC NEEDLES32GX5/32" 2 RX/OTC X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC SURE COMFORT PEN 2 QL(5 ea daily) NEEDLES32GX6MM MISC X 5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

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

MHS Indiana Preferred Drug List Updated December 1, 2018

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily); COMFORT INSULIN 2 RX/OTC NEEDLES32G X 4MM 2 RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) NEEDLES 29GX12.7MM 2 RX/OTC COMFORT INSULIN 2 MISC SYRINGE/1ML/31G X TRUEPLUS 5-BEVEL PEN QL(5 ea daily); 5/16" MISC NEEDLES 32GX4MM 2 RX/OTC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" 100/0.3ML/29G X 1/2" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); COMFORT INSULIN RX/OTC SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 100/0.3ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- 2 COMFORT INSULIN 2 RX/OTC 100/0.3ML/31G X 5/16" SYRINGE/U-100/1ML/29G MISC X 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" 100/0.3ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" 100/0.5ML/28G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCO INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/U-100/1ML/28G 2 RX/OTC 100/0.5ML/31G X 5/16" X 1/2" MISC MISC TOPCO INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G 2 RX/OTC SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC X 1/2" MISC TRUE COMFORT INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 2 SYRINGE/U-100/1ML/29G 2 RX/OTC 5/16" MISC X 1/2" MISC TRUE COMFORT INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 2 SYRINGE/U-100/1ML/30G 2 RX/OTC 5/16" MISC X 5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 2 SYRINGE/1ML/30G X 1/2" 2 X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 29GX12MM 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC MISC 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC SYRINGE/SHORT/0.3ML/3 2 RX/OTC MISC 0G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 31GX6MM 2 RX/OTC SYRINGE/SHORT/0.3ML/3 2 MISC 1G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC SYRINGE/SHORT/0.5ML/3 2 RX/OTC MISC 0G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 32GX4MM 2 RX/OTC SYRINGE/SHORT/0.5ML/3 2 MISC 1G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SAFETY 2 RX/OTC SYRINGE/SHORT/1ML/30 2 RX/OTC SYRINGE/0.5ML/29G X G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/31 2 SAFETY 2 RX/OTC G X 5/16" MISC SYRINGE/1ML/29G X 1/2" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC ULTICARE INSULIN QL(5 ea daily); 100/0.3ML/29G X 1/2" SYRINGE/0.3ML/29G X 2 RX/OTC MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC 100/0.3ML/30G X 5/16" 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X 2 RX/OTC SYRINGE/U- 2 1/2" MISC 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 2 RX/OTC ULTICARE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 2 RX/OTC ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC SYRINGE/1ML/28G X 1/2" 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/U- 2 MISC 100/0.5ML/31G X 5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE ORIGINAL QL(5 ea daily); SYRINGE/U-100/1ML/29G 2 RX/OTC PEN NEEDLES ULTI-FINE 2 RX/OTC X 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE PEN NEEDLES 2 QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 31GX 5MM/MINI MISC RX/OTC X 1/2" MISC ULTICARE PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES/29GX 12.7MM 2 RX/OTC SYRINGE/U-100/1ML/30G 2 RX/OTC MISC X 5/16" MISC ULTICARE SHORT PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 31GX8MM 2 RX/OTC SYRINGE/U-100/1ML/31G 2 MISC X 5/16" MISC ULTICARE SHORT PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES ULTI-FINE IV 2 RX/OTC SYRINGEULTRAFINE U- 2 MISC 100/0.3ML/31G X 5/16" ULTICARE SHORT PEN QL(5 ea daily); MISC NEEDLES/31G X 8MM 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) MISC SYRINGEULTRAFINE U- 2 ULTILET INSULIN 2 QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE 31X6MM MISC RX/OTC MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGEULTRAFINE U- 2 8MM MISC 100/1ML/31G X 5/16" MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 ULTICARE MICRO PEN QL(5 ea daily); 8MM MISC NEEDLES 31G X 8MM 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC ULTICARE MICRO PEN QL(5 ea daily); 8MM MISC NEEDLES 32G X 4MM 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC ULTICARE MICRO PEN QL(5 ea daily); 8MM MISC NEEDLES/32G X 4MM 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 2 ULTICARE MICRO PEN QL(5 ea daily); 8MM MISC NEEDLES/32G X 5/32" 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 2 RX/OTC ULTICARE MINI PEN QL(5 ea daily); 0G X 5/16" MISC NEEDLES 31GX6MM 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 2 ULTICARE MINI PEN QL(5 ea daily); 1G X 5/16" MISC NEEDLES ULTI-FINE IV 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 2 RX/OTC ULTICARE MINI PEN QL(5 ea daily); 0G X 5/16" MISC NEEDLES/31G X 6MM 2 RX/OTC MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/SHORT/0.5ML/3 2 ULTICARE MINI PEN 2 QL(5 ea daily); 1G X 5/16" MISC NEEDLES31GX6MM MISC RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); 2 SYRINGE/SHORT/1ML/30 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC G X 5/16" MISC 100/0.5ML/29G X 1/2" ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/1ML/31 2 ULTRA-COMFORT QL(5 ea daily); G X 5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/U-100/1ML/30G 2 MISC X 1/2" MISC ULTRA-COMFORT QL(5 ea daily) INSULIN SYRINGE/U- ULTILET PEN NEEDLE 2 QL(5 ea daily); 2 29GX12.7MM MISC RX/OTC 100/0.5ML/31G X 5/16" MISC ULTILET PEN NEEDLE 2 QL(5 ea daily); 31GX5MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC ULTILET PEN NEEDLE 2 QL(5 ea daily); 100/1ML/28G X 1/2" MISC 31GX8MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily); ULTILET PEN NEEDLE 2 QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC 32GX4MM MISC RX/OTC 100/1ML/29G X 1/2" MISC ULTILET PEN NEEDLE 2 QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); 32GX4MM/SHORT MISC RX/OTC INSULIN SYRINGE/U- 2 RX/OTC ULTILET SHORT PEN QL(5 ea daily); 100/1ML/30G X 5/16" NEEDLES 31GX5/16" 2 RX/OTC MISC MISC ULTRA-COMFORT QL(5 ea daily) ULTILET SHORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 2 NEEDLES31GX3/16" 2 RX/OTC 100/1ML/31G X 5/16" MISC MISC ULTRA COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC 2 SYRINGE SHORT/U- 2 RX/OTC 100/0.3ML/30G X 5/16" 100/0.3ML/30GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) INSULIN SYRINGE/U- RX/OTC 2 SYRINGE SHORT/U- 2 100/0.3ML/29G X 1/2" 100/0.3ML/31GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC 2 SYRINGE SHORT/U- 2 RX/OTC 100/0.3ML/30G X 5/16" 100/0.5ML/30GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE SHORT/U- 2 100/0.3ML/31G X 5/16" 100/0.5ML/31GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE SHORT/U- 2 RX/OTC 100/0.5ML/28G X 1/2" 100/1ML/30GX5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- 2 100/1ML/31GX5/16" MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily); UNIFINE PENTIPS 2 QL(5 ea daily); SYRINGE/U- 2 RX/OTC 29GX12MM MISC RX/OTC 100/0.3ML/29GX1/2" MISC UNIFINE PENTIPS 31G X 2 QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); 3/16" MISC RX/OTC SYRINGE/U- 2 RX/OTC UNIFINE PENTIPS 2 QL(5 ea daily); 100/0.5ML/29GX1/2" MISC 31GX5MM MISC RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); UNIFINE PENTIPS 2 QL(5 ea daily); SYRINGE/U- 2 RX/OTC 31GX6MM MISC RX/OTC 100/1ML/29GX1/2" MISC UNIFINE PENTIPS 2 QL(5 ea daily); ULTRA-THIN II MINI PEN QL(5 ea daily); 31GX8MM MISC RX/OTC NEEEDLES/31GX3/16" 2 RX/OTC MISC UNIFINE PENTIPS 2 QL(5 ea daily); 32GX4MM MISC RX/OTC ULTRA-THIN II PEN 2 QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC UNIFINE PENTIPS 2 QL(5 ea daily) 32GX6MM MISC ULTRA-THIN II PEN QL(5 ea daily); NEEDLES/SHORT/31GX5/ 2 RX/OTC UNIFINE PENTIPS PLUS 2 QL(5 ea daily); 16" MISC 29GX12MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS 2 QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" UNIFINE PENTIPS PLUS 2 QL(5 ea daily); MISC 31GX6MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily) UNIFINE PENTIPS PLUS 2 QL(5 ea daily); 31GX8MM MISC RX/OTC SYRINGE/U- 2 100/0.3ML/31G X 5/16" UNIFINE PENTIPS PLUS 2 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); V-R MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC 2 SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC ULTRACARE INSULIN QL(5 ea daily) V-R MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/U- 2 RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC ULTRACARE INSULIN QL(5 ea daily) V-R MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 SYRINGE/U- 2 RX/OTC X 1/2" MISC 100/0.5ML/29G X 1/2" ULTRACARE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 2 RX/OTC V-R MONOJECT INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U-100/1ML/28G 2 RX/OTC ULTRACARE INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/U-100/1ML/31G 2 V-R MONOJECT INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U-100/1ML/29G 2 RX/OTC ULTRACARE PEN QL(5 ea daily) X 1/2" MISC NEEDLES/32G X 1/14" 2 VALUE HEALTH INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC ULTRACARE PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES/32G X 5/32" 2 RX/OTC MISC MISC

MHS Indiana Preferred Drug List Updated December 1, 2018

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALUE HEALTH INSULIN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily); SYRINGE/U-100/1ML/29G 2 RX/OTC PENTIPS PLUS/ULTRA 2 RX/OTC X 1/2" MISC SHORT/31GX6MM MISC VALUMARK PEN QL(5 ea daily); Respiratory Therapy Supplies NEEDLES 29GX12MM 2 RX/OTC AEROCHAMBER MINI QL(2 ea per MISC AEROSOLCHAMBER 2 360 days VALUMARK PEN QL(5 ea daily); DEVI retail); RX/OTC NEEDLES 31GX 6MM 2 RX/OTC MISC QL(2 ea per AEROCHAMBER MV 2 MISC 360 days VALUMARK PEN QL(5 ea daily); retail); RX/OTC NEEDLES 31GX 8MM 2 RX/OTC MISC QL(2 ea per AEROCHAMBER PLUS 2 FLOW VU MISC 360 days VANISHPOINT INSULIN QL(5 ea daily); retail); RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC QL(2 ea per AEROCHAMBER PLUS 2 FLOW-VU MISC 360 days VANISHPOINT INSULIN QL(5 ea daily); retail); RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC AEROCHAMBER PLUS QL(2 ea per FLOW-VU/LARGE MASK 2 360 days VANISHPOINT INSULIN QL(5 ea daily); MISC retail); RX/OTC SYRINGE/1ML/30G X 2 RX/OTC 5/16" MISC QL(2 ea per AEROCHAMBER PLUS 2 360 days FLOW-VU/MASK MISC VIDA MIA UNIFINE 2 QL(5 ea daily); retail); RX/OTC PENTIPS32GX4MM MISC RX/OTC AEROCHAMBER PLUS QL(2 ea per VIDA MIA UNIFINE QL(5 ea daily); FLOW-VU/MEDIUM MASK 2 360 days PENTIPSMINI 31GX6MM 2 RX/OTC MISC retail); RX/OTC MISC AEROCHAMBER PLUS QL(2 ea per VIDA MIA UNIFINE QL(5 ea daily); FLOW-VU/SMALL MASK 2 360 days PENTIPSORIGINAL 2 RX/OTC MISC retail); RX/OTC 29GX12MM MISC AEROCHAMBER Z-STAT QL(2 ea per VIDA MIA UNIPFINE QL(5 ea daily); PLUS VALVED HOLDING 2 360 days PENTIPSSHORT 2 RX/OTC CHAMBER W/FLOW VU retail); RX/OTC 31GX8MM MISC MISC VP INSULIN SYRINGE/U- QL(5 ea daily); QL(2 ea per 100/0.3ML/29G X 1/2" 2 RX/OTC AEROCHAMBER Z-STAT 2 PLUS/FLOWSIGNAL MISC 360 days MISC retail); RX/OTC WEGMANS UNIFINE QL(5 ea daily); QL(2 ea per PENTIPS PLUS 32GX4MM 2 RX/OTC AEROCHAMBER Z-STAT 2 PLUS/LARGE MASK MISC 360 days MISC retail); RX/OTC WEGMANS UNIFINE QL(5 ea daily); AEROCHAMBER Z-STAT QL(2 ea per PENTIPS 2 RX/OTC PLUS/MEDIUM MASK 2 360 days PLUS/MINI/31GX5MM MISC retail); RX/OTC MISC QL(2 ea per WEGMANS UNIFINE QL(5 ea daily); AEROCHAMBER Z-STAT 2 360 days PLUS/SMALL MASK MISC PENTIPS 2 RX/OTC retail); RX/OTC PLUS/SHORT/31GX8MM QL(2 ea per MISC AEROCHAMBER/FLOWSI 2 GNAL MISC 360 days retail); RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AEROVENT PLUS QL(2 ea per CLEVER CHOICE ANTI- QL(2 ea per HOLDING 2 360 days STATICVALVED 360 days CHAMBER/COLLAPSIBLE retail); RX/OTC HOLDING 2 retail); RX/OTC DEVI CHAMBER/ADULT LARGE QL(2 ea per DEVI ARIAL CHAMBER DEVI 2 360 days CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED 2 360 days QL(2 ea per HOLDING retail); RX/OTC BREATHE EASE/LARGE 2 CHAMBER/MEDIUM DEVI MASK DEVI 360 days retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED 2 360 days BREATHE EASE/MEDIUM 2 HOLDING retail); RX/OTC MASK DEVI 360 days retail); RX/OTC CHAMBER/SMALL DEVI QL(2 ea per COMPACT SPACE QL(2 ea per BREATHE EASE/SMALL 2 CHAMBER/ANTI-STATIC 2 360 days MASK DEVI 360 days retail); RX/OTC DEVI retail); RX/OTC BREATHERITE QL(2 ea per COMPACT SPACE QL(2 ea per COLLAPSIBLEADULT 2 360 days CHAMBER/ANTI- 2 360 days SPACER W/MASK MISC retail); RX/OTC STATIC/LARGE MASK retail); RX/OTC DEVI BREATHERITE QL(2 ea per COLLAPSIBLECHILD 2 360 days COMPACT SPACE QL(2 ea per SPACER W/MASK MISC retail); RX/OTC CHAMBER/ANTI- 2 360 days STATIC/MEDIUM MASK retail); RX/OTC BREATHERITE QL(2 ea per DEVI COLLAPSIBLEINFANT 2 360 days SPACER W/MASK MISC retail); RX/OTC COMPACT SPACE QL(2 ea per CHAMBER/ANTI- 2 360 days BREATHERITE QL(2 ea per STATIC/SMALL MASK retail); RX/OTC COLLAPSIBLESMALL 2 360 days DEVI CHILD SPACER W/MASK retail); RX/OTC MISC QL(2 ea per E-Z SPACER DEVI 2 360 days BREATHERITE QL(2 ea per retail); RX/OTC COLLAPSIBLESPACER 2 360 days W/ NEONATE MASK MISC retail); RX/OTC QL(2 ea per E-Z SPACER THE BODY 2 GUARDS PACK DEVI 360 days QL(2 ea per retail); RX/OTC BREATHERITE MISC 2 360 days retail); RX/OTC QL(2 ea per EASIVENT MISC 2 360 days QL(2 ea per retail); RX/OTC BREATHERITE RIGID 2 SPACERW/MASK MISC 360 days retail); RX/OTC QL(2 ea per EASIVENT/MASK-LARGE 2 MISC 360 days QL(2 ea per retail); RX/OTC BREATHERITE W/LARGE 2 MASK MISC 360 days retail); RX/OTC QL(2 ea per EASIVENT/MASK- 2 MEDIUM MISC 360 days QL(2 ea per retail); RX/OTC BREATHERITE 2 W/MEDIUM MASK MISC 360 days retail); RX/OTC QL(2 ea per EASIVENT/MASK-SMALL 2 MISC 360 days QL(2 ea per retail); RX/OTC BREATHERITE W/SMALL 2 MASK MISC 360 days retail); RX/OTC

MHS Indiana Preferred Drug List Updated December 1, 2018

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea per OPTICHAMBER QL(2 ea per FLEXICHAMBER DEVI 2 360 days DIAMOND/SMALLFACE 2 360 days retail); RX/OTC MASK MISC retail); RX/OTC INSPIRACHAMBER/ANTI- QL(2 ea per QL(2 ea per STATIC 360 days OPTICHAMBER FACE 2 2 MASK/LARGE MISC 360 days VALVED/MOUTHPIECE retail); RX/OTC retail); RX/OTC DEVI QL(2 ea per OPTICHAMBER FACE 2 INSPIRACHAMBER/LARG QL(2 ea per 360 days 2 360 days MASK/MEDIUM MISC retail); RX/OTC E DEVI retail); RX/OTC QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per OPTICHAMBER FACE 2 MASK/SMALL MISC 360 days HERMASK/INSPIRAMASK 2 360 days retail); RX/OTC /MEDIUM DEVI retail); RX/OTC QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per OPTIHALER MDI DRUG 2 DELIVERY SYSTEM DEVI 360 days HERMASK/INSPIRAMASK 2 360 days retail); RX/OTC /SMALL DEVI retail); RX/OTC QL(2 ea per 2 INSPIREASE DRUG QL(2 ea per OPTIHALER MISC 360 days 2 360 days retail); RX/OTC DELIVERYSYSTEM MISC retail); RX/OTC QL(2 ea per INSPIREASE RESERVOIR 2 QL(3 ea per POCKET CHAMBER DEVI 2 360 days BAGS MISC 180 days retail) retail); RX/OTC QL(2 ea per QL(2 ea per LITEAIRE DEVI 2 360 days POCKET SPACER DEVI 2 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per PRO COMFORT INHALER QL(2 ea per MICROCHAMBER MISC 2 360 days SPACER CHAMBER 2 360 days retail); RX/OTC ADULT MISC retail); RX/OTC QL(2 ea per PRO COMFORT INHALER QL(2 ea per MICROSPACER MISC 2 360 days SPACER CHAMBER 2 360 days retail); RX/OTC CHILD MISC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(2 ea per ADVANTAGE/LARGE 2 360 days RITEFLO DEVI 2 360 days MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(2 ea per ADVANTAGE/MEDIUM 2 360 days VALVED HOLDING 2 CHAMBER DEVI 360 days FACE MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per VORTEX VALVED QL(2 ea per ADVANTAGE/SMALL 2 360 days HOLDING CHAMBER 2 360 days FACE MASK MISC retail); RX/OTC DEVI retail); RX/OTC OPTICHAMBER QL(2 ea per QL(2 ea per 2 360 days WATCHHALER DEVI 2 360 days DIAMOND MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per MIGRAINE PRODUCTS - Drugs to Treat Migraine DIAMOND/LARGEFACE 2 360 days Headaches MASK DEVI retail); RX/OTC Migraine Products OPTICHAMBER QL(2 ea per DIAMOND/MEDIUM FACE 2 360 days MASK MISC retail); RX/OTC MHS Indiana Preferred Drug List Updated December 1, 2018

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits D.H.E. 45 SOLN (Use QL(0.4 ea NP rizatriptan benzoate tabs 5 1 daily); AL(At Dihydroergotamine mg, 10 mg Mesylate) least 6 yrs old) dihydroergotamine 1 rizatriptan benzoate tbdp 5 1 QL(0.4 ea mesylate soln ij 1 mg/ml mg, 10 mg daily) dihydroergotamine 2 QL(0.2 ea mesylate soln na 4 mg/ml 1 daily); AL(At sumatriptan soln least 12 yrs MIGRANAL SOLN 2 old) Serotonin Agonists QL(0.067 ml sumatriptan succinate soaj 1 daily); AL(At QL(0.6 ea sc 6 mg/0.5ml least 12 yrs AMERGE TABS (Use NP daily); AL(At old) Naratriptan HCl) least 18 yrs old) QL(0.067 ml daily,30 day(s) sumatriptan succinate soct eletriptan hydrobromide 1 QL(0.2 ea 1 limit); AL(At tabs daily) sc 6 mg/0.5ml least 12 yrs QL(0.2 ea IMITREX SOLN NA 5 old) MG/ACT, 20 MG/ACT ( NP daily); AL(At QL(0.083 ml Use least 12 yrs Sumatriptan) sumatriptan succinate soln 1 daily); AL(At old) sc 6 mg/0.5ml least 12 yrs QL(0.083 ml IMITREX SOLN SC 6 old) NP daily); AL(At QL(0.067 ml MG/0.5ML (Use least 12 yrs SUMATRIPTAN Sumatriptan Succinate) 2 daily); AL(At old) SUCCINATE SOSY SC 6 least 12 yrs QL(0.067 ml MG/0.5ML IMITREX STATDOSE old) daily,30 day(s) QL(0.6 ea REFILL SOCT 6 MG/0.5ML NP limit); AL(At (Use Sumatriptan sumatriptan succinate tabs 1 daily); AL(At Succinate) least 12 yrs or 25 mg, 50 mg, 100 mg least 12 yrs old) old) IMITREX STATDOSE QL(0.067 ml QL(0.2 ea zolmitriptan tabs 1 SYSTEM SOAJ 6 NP daily); AL(At daily) MG/0.5ML (Use least 12 yrs QL(0.2 ea Sumatriptan Succinate) old) zolmitriptan tbdp 1 daily) QL(0.6 ea IMITREX TABS OR 25 MG, daily); AL(At QL(0.2 ea 50 MG, 100 MG (Use NP daily); AL(At Sumatriptan Succinate) least 12 yrs ZOMIG SOLN NA 5 MG 2 old) least 12 yrs old) QL(0.4 ea MAXALT TABS (Use NP ZOMIG TABS OR 5 MG, QL(0.2 ea Rizatriptan Benzoate) daily); AL(At NP least 6 yrs old) 2.5 MG (Use Zolmitriptan) daily) ZOMIG ZMT TBDP (Use QL(0.2 ea MAXALT-MLT TBDP (Use NP QL(0.4 ea NP Rizatriptan Benzoate) daily) Zolmitriptan) daily) QL(0.6 ea MINERALS & ELECTROLYTES daily); AL(At naratriptan hcl tabs 1 least 18 yrs Calcium old) CAL-CITRATE PLUS 2 RELPAX TABS (Use NP QL(0.2 ea VITAMIND TABS Eletriptan Hydrobromide) daily) MHS Indiana Preferred Drug List Updated December 1, 2018

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCET CREAMY BITES 2 calcium tabs 500 mg 1 CHEW CALCI-CHEW CHEW 2 Calcium w/ Vitamin D F CALTRATE 600+D TABS QL(2 ea daily) calcium carbonate tabs 500 1 mg, 1250 mg (Use Calcium Carbonate- NP calcium carbonate- Cholecalciferol) CITRACAL + D3 cholecalciferol chew 1 500mg-100unit, 500mg- MAXIMUM TABS (Use NP 400unit Calcium Citrate-Vitamin D) calcium carbonate- CITRACAL MAXIMUM cholecalciferol tabs 500mg- TABS (Use Calcium NP 200unit, 500mg-400unit, 1 Citrate-Vitamin D) 600mg-200unit, 500mg- CITRACAL 500mg-400unit-400unit PETITES/VITAMIND TABS NP calcium carbonate- QL(2 ea daily) (Use Calcium Citrate- cholecalciferol tabs 600mg- Vitamin D) 1 400unit, 600mg-800unit, MAGNEBIND 200 TABS 2 600mg-600mg-800unit- 400unit MAGNEBIND 300 TABS 2 Calcium Carbonate-Vitamin F D 500 oyster shell tabs 1 Calcium Carbonate-Vitamin F QL D 600 PARVA-CAL TABS 2 calcium carbonate-vitamin 1 d caps UPCAL D PACK 2 calcium carbonate-vitamin 1 d chew UPCAL D POWD 2 calcium carbonate-vitamin 1 Electrolyte Mixtures d tabs CERASPORT EX1 SOLN 2 CALCIUM CHEW 500 MG 2 CERASPORT SOLN calcium citrate tabs 200 1 4MEQ/L-18MEQ/L- 2 mg, 950 mg 20MEQ/L-6MEQ/L CALCIUM CITRATE W/D 2 ENFAMIL ENFALYTE 2 TABS SOLN CALCIUM CITRATE 2 EQUALYTE SOLN (Use NP W/VITAMIN D TABS Oral Electrolytes) calcium citrate-vitamin d 1 HYDRALYTE FREEZER 2 chew POPS SOLN calcium citrate-vitamin d 1 HYDRALYTE SOLN tabs 270MG/250ML- CALCIUM 210MG/250ML, 45MEQ/L- 2 CITRATE/VITAMIN D3 2 45MEQ/L-20MEQ/L- LIQD 90MEQ/L-16GM/L CALCIUM PLUS VITAMIN 2 D CAPS oral electrolytes soln 1

MHS Indiana Preferred Drug List Updated December 1, 2018

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEDIALYTE ADVANCED K-PHOS NEUTRAL TABS QL(8 ea daily) CARE SOLN (Use Oral NP (Use Pot Phosphate Electrolytes) Monobasic w/ Sod NP PEDIALYTE FREEZER Phosphate Dibasic & POPS SOLN (Use Oral NP Monobasic) Electrolytes) pot phosphate monobasic QL(8 ea daily) PEDIALYTE SINGLES w/ sod phosphate dibasic & 1 SOLN (Use Oral NP monobasic tabs Electrolytes) Potassium PEDIALYTE SOLN K-TAB TBCR 10 MEQ (Use NP 20MEQ/L-45MEQ/L- Potassium Chloride) 35MEQ/L-5GM/L-20GM/L, 20MEQ/L-45MEQ/L- K-TAB TBCR 8 MEQ 2 35MEQ/L-30MEQ/L- 25GM/L, 35MEQ/L- KLOR-CON M15 TBCR 2 45MEQ/L-7.8MG/L- 20MEQ/L-25GM/L, MICRO-K CPCR 10 MEQ NP 4.7MEQ/237ML- NP (Use Potassium Chloride) 10.6MEQ/237ML- MICRO-K CPCR 8 MEQ NP QL(1 ea daily) 8.3MEQ/237ML, (Use Potassium Chloride) 2.1MEQ/59ML- 2.7MEQ/59ML- potassium bicarbonate tbef 1 0.5MG/59ML- potassium chloride cpcr or 1 1.2MEQ/59ML- 10 meq 1.5GM/59ML (Use Oral Electrolytes) potassium chloride cpcr or 1 QL(1 ea daily) 8 meq Fluoride POTASSIUM CHLORIDE 2 LURIDE SOLN (Use NP AL(Up to 15 yrs ER TBCR 8 MEQ Sodium Fluoride) old ); PV potassium chloride sodium fluoride chew 0.25 AL(Up to 15 yrs microencapsulated crystals 1 mg, 0.5 mg, 1 mg, 1.1 mg, $0 old ); PV er tbcr 2.2 mg potassium chloride pack or 1 sodium fluoride soln 0.5 $0 AL(Up to 15 yrs 20 meq mg/ml old ); PV potassium chloride soln or 1 Magnesium 10 %, 20 % potassium chloride tbcr or 8 1 MAGDELAY TBEC 2 meq, 10 meq MAGNEBIND 400 TABS 2 Sodium magnesium oxide (mg sodium chloride flush soln 1 supplement) tabs 400 mg, 1 241.3 mg sodium chloride soln ij 0.9 1 % MAGOX 400 TABS (Use Magnesium Oxide (Mg NP SODIUM CHLORIDE 2 Supplement)) SOLN IJ 0.9 % sodium chloride soln iv 0.9 1 Phosphate %

MHS Indiana Preferred Drug List Updated December 1, 2018

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM CHLORIDE 2 cyclosporine modified (for 1 SOLN IV 0.9 % microemulsion) soln Zinc CYCLOSPORINE 2 MODIFIED CAPS COLD-EEZE LOZG MT NP (Use Zinc Gluconate) CYCLOSPORINE MODIFIED CAPS (Use NP zinc gluconate lozg mt 13.3 1 Cyclosporine Modified (For mg Microemulsion)) QL(3.34 ea zinc sulfate caps or 220 mg 1 cyclosporine soln iv 50 PA; SP daily) 1 mg/ml MISCELLANEOUS THERAPEUTIC CLASSES IMURAN TABS (Use NP Azathioprine) Chelating Agents mycophenolate mofetil 1 DEPEN TITRATABS TABS 2 caps mycophenolate mofetil hcl 1 PA; SP SYPRINE CAPS (Use NP PA; SP solr Trientine HCl) mycophenolate mofetil susr 1 trientine hcl caps 1 PA; SP Enzymes mycophenolate mofetil tabs 1 XIAFLEX SOLR 2 PA; SP mycophenolate sodium 1 tbec Immunomodulators MYFORTIC TBEC (Use NP Mycophenolate Sodium) REVLIMID CAPS 2 PA; SP NEORAL CAPS (Use PA; SP Cyclosporine Modified (For NP THALOMID CAPS 2 Microemulsion)) Immunosuppressive Agents NEORAL SOLN (Use Cyclosporine Modified (For NP AZASAN TABS 2 Microemulsion)) PA; SP azathioprine tabs or 50 mg 1 NULOJIX SOLR 2 PROGRAF CAPS OR 0.5 CELLCEPT CAPS (Use NP Mycophenolate Mofetil) MG, 1 MG, 5 MG (Use NP Tacrolimus) CELLCEPT PA; SP PROGRAF SOLN IV 5 PA; SP INTRAVENOUS SOLR NP 2 (Use Mycophenolate MG/ML Mofetil HCl) RAPAMUNE SOLN 1 2 MG/ML CELLCEPT SUSR (Use NP Mycophenolate Mofetil) RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use NP CELLCEPT TABS (Use NP Mycophenolate Mofetil) Sirolimus) SANDIMMUNE CAPS OR cyclosporine caps or 25 1 mg, 100 mg 25 MG, 100 MG (Use 2 Cyclosporine) cyclosporine modified (for 1 microemulsion) caps

MHS Indiana Preferred Drug List Updated December 1, 2018

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SANDIMMUNE SOLN IV PA; SP sodium fluoride (dental) 1 QL(2 gm daily) 50 MG/ML (Use 2 crea dt 1.1 % Cyclosporine) sodium fluoride (dental) gel 1 QL(2 ml daily) sirolimus tabs 1 dt 1.1 % THERA-FLUR-N GEL (Use NP QL(2 ml daily) tacrolimus caps 1 Sodium Fluoride (Dental)) Steroids - Mouth/Throat ZORTRESS TABS 0.25 2 PA MG, 0.75 MG, 0.5 MG triamcinolone acetonide 1 (mouth) pste Potassium Removing Agents KAYEXALATE POWD (Use Throat Products - Misc. Sodium Polystyrene NP pilocarpine hcl (oral) tabs 5 1 QL(6 ea daily) Sulfonate) mg SALAGEN TABS 5 MG QL(6 ea daily) sodium polystyrene 1 sulfonate powd or (Use Pilocarpine HCl NP sodium polystyrene (Oral)) sulfonate susp or 15 1 MULTIVITAMINS gm/60ml Systemic Lupus Erythematosus Agents B-Complex Vitamins PA; SP B-Complex Vitamin F QL BENLYSTA SOLR 2 Cap/Tab MOUTH/THROAT/DENTAL AGENTS B-Complex w/ Folic Acid b-complex w/ c & folic acid QL(1 ea daily); Anesthetics Topical Oral caps 1.5mg-5mg-20mg- RX/OTC 1.7mg-6mcg-1mg-150mcg- lidocaine hcl (mouth-throat) 1 QL(100 ml per 1 soln fill retail) 10mg-100mg, 5mg-1.7mg- 6mcg-20mg-1.5mg-1mg- Anti-infectives - Throat 150mcg-10mg-100mg nystatin (mouth-throat) 1 NEPHROCAPS CAPS QL(1 ea daily); susp (Use B-Complex w/ C & NP RX/OTC Antiseptics - Mouth/Throat Folic Acid) chlorhexidine gluconate 1 Multiple Vitamins w/ Iron (mouth-throat) soln Multiple Vitamins w/ Iron F QL PERIDEX SOLN (Use Chlorhexidine Gluconate NP Multiple Vitamins w/ Minerals (Mouth-Throat)) ICAPS LUTEIN & 2 Dental Products ZEAXANTHIN TBEC PREVIDENT 5000 DRY QL(2 ml daily) Multiple Vitamins w/ F MOUTH GEL (Use Sodium NP Minerals Fluoride (Dental)) Multiple Vitamins w/ F PREVIDENT 5000 PLUS QL(2 gm daily) Minerals & Folic Acid CREA (Use Sodium NP multiple vitamins w/ 1 Fluoride (Dental)) minerals tbef PREVIDENT FLUORIDE QL(2 ml daily) GEL (Use Sodium Fluoride NP Multivitamins (Dental)) Multiple Vitamin F QL

MHS Indiana Preferred Drug List Updated December 1, 2018

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Ped MV w/ Fluoride EQL PRENATAL 2 FORMULA TABS Pediatric Multivitamins w/Fl F 0.25MG, 1MG GNP PRENATAL TABS 2 Pediatric Multivitamins w/Fl F AL/QL 0.5MG, Soln GOODSENSE PRENATAL 2 VITAMINS TABS Pediatric Vitamins ACD w/ F AL/QL Fluoride HM PRENATAL TABS 2 Ped MV w/ Iron INATAL GT TABS 2 Pediatric Multiple Vitamins F w/ Iron Chew KP PRENATAL 2 MULTIVITAMINS TABS Pediatric Multiple Vitamins F QL w/ Iron Drops KPN PRENATAL TABS 2 Ped Multi Vitamins w/Fl & FE M-NATAL PLUS TABS 2 RX/OTC Ped Multivitamins w/Fl & F AL/QL Iron M-VIT TABS 2 RX/OTC Pediatric Vitamins ACD F Fluoride & Iron MULTI PRENATAL TABS 2 Ped Multiple Vitamins w/ Minerals MYNATAL ADVANCE Pediatric Multiple Vitamin AL 2 F TABS w/ Minerals & C Drops MYNATAL PLUS TABS 2 Pediatric Multiple Vitamin F w/ Minerals Chew MYNATAL ULTRACAPLET 2 Pediatric Multiple Vitamins TABS Pediatric Multiple Vitamin F QL MYNATAL-Z TABS 2 w/ C QL(1 ea daily) Pediatric Multiple Vitamin F QL MYNATE 90 PLUS TBCR 2 w/ C & FA NAT-RUL PRENATAL 2 Pediatric Multiple Vitamins F VITAMINS TABS Pediatric Vitamins NATALVIT TABS 2 QL Pediatric Vitamins ADC F NEONATAL PLUS TABS 2 RX/OTC Prenatal Vitamins NEONATAL VITAMIN 2 TABS CLASSIC PRENATAL 2 TABS NIVA-PLUS TABS 2 RX/OTC CO-NATAL FA TABS 2 NUTRICION PORVIDA 2 COMPLETENATE CHEW 2 TABS RX/OTC CVS PRENATAL O-CAL FA TABS 2 GUMMY/DHA/FOLIC ACID 2 CHEW O-CAL PRENATAL TABS 2 CVS PRENATAL TABS 2 PERRY PRENATAL CAPS 2

MHS Indiana Preferred Drug List Updated December 1, 2018

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PNV FERROUS QL(1 ea daily) PRENATAL TABS 11UNIT- FUMARATE/DOCUSATE/F 2 263MG-25MG-1.5MG- OLIC ACID TABS 27MG-4000UNIT-18MG- 1.7MG-4MCG-400UNIT- PNV FOLIC ACID + IRON 2 RX/OTC MULTIVITAMIN TABS 0.8MG-2.6MG-100MG, 30UNIT-4000UNIT-25MG- PNV PRENATAL PLUS 2 RX/OTC 1.8MG-200MG-28MG- MULTIVITAMIN TABS 20MG-1.7MG-8MCG- PRE-NATAL FORMULA 2 400UNIT-0.8MG-2.6MG- TABS 120MG, 30UNIT-25MG- PRENATABS FA TABS 2 1.8MG-200MG-28MG- 20MG-1.7MG-4000UNIT- PRENATAL 19 CHEW 8MCG-400UNIT-800MCG- 30UNIT-1000UNIT-20MG- 2.6MG-120MG, 30UNIT- 3MG-200MG-29MG-7MG- 4000UNIT-25MG-1.8MG- 15MG-3MG-12MCG- 200MG-28MG-20MG- 2 1.7MG-8MCG-400UNIT- 400UNIT-1MG-20MG- 2 100MG, 1000UNIT- 800MCG-2.6MG-120MG, 400UNIT-20MG-25MG- 4000UNIT-30UNIT-200MG- 3MG-200MG-29MG-7MG- 25MG-1.8MG-28MG- 6MG-3MG-12MCG-1MG- 20MG-1.7MG-8MCG- 30UNIT-20MG-100MG 400UNIT-800MCG-2.6MG- PRENATAL 19 TABS QL(1 ea daily) 120MG, 4000UNIT- 1000UNIT-30UNIT-20MG- 30UNIT-25MG-1.8MG- 25MG-3MG-200MG-29MG- 200MG-28MG-20MG- 15MG-3MG-7MG-12MCG- 1.7MG-8MCG-400UNIT- 400UNIT-20MG-1MG- 800MCG-2.6MG-120MG, 100MG, 30UNIT- 2 160MG-11UNIT-200MG- 1000UNIT-20MG-25MG- 25MG-1.84MG-27MG- 3MG-200MG-29MG-7MG- 4000UNIT-18MG-1.7MG- 15MG-3MG-12MCG- 4MCG-400UNIT-800MCG- 400UNIT-1MG-20MG- 2.6MG-100MG 100MG PRENATAL TABS 22MG- RX/OTC 2MG-25MG-1.84MG- PRENATAL AND IRON 2 TABS 200MG-27MG-4000UNIT- 2 20MG-3MG-12MCG- PRENATAL FORMULA 2 400UNIT-1MG-10MG- CAPS 120MG PRENATAL FORTE TABS 2 PRENATAL TABS 4000UNIT-200MG-11UNIT- PRENATAL LOW IRON 2 27MG-25MG-1.84MG- 2 TABS 18MG-1.7MG-4MCG- 400UNIT-0.8MG-2.6MG- Prenatal Multivit-Min w/Fe- F FA 100MG PRENATAL VITAMIN & PRENATAL 2 2 MULTIVITAMIN TABS MINERAL TABS PRENATAL VITAMIN PRENATAL ONE DAILY 2 2 TABS TABS PRENATAL PLUS TABS 2 RX/OTC PRENATAL 2 VITAMIN/IRON TABS

MHS Indiana Preferred Drug List Updated December 1, 2018

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL VITAMINS 2 RX/OTC VIRT-VITE GT TABS 2 PLUS LOW IRON TABS PRENATAL VITAMINS 2 VITAFOL-OB TABS 2 TABS RX/OTC PREPLUS TABS 2 RX/OTC VOL-PLUS TABS 2 Vitamins w/ Lipotropics PRETAB TABS 2 Vitamins w/ Lipotropics F QL PX PRENATAL 2 MULTIVITAMINS TABS MUSCULOSKELETAL THERAPY AGENTS - QC PRENATAL TABS 2 Drugs to Treat Spasms RA PRENATAL Central Muscle Relaxants FORMULA/FOLICACID 2 baclofen tabs or 10 mg, 20 1 TABS mg CHLORZOXAZONE TABS 2 RA PRENATAL TABS 2 500 MG cyclobenzaprine hcl tabs 5 QL(3 ea daily) RIGHT STEP PRENATAL 2 1 TABS mg, 10 mg SE-NATAL 19 CHEW cyclobenzaprine hcl tabs 1 QL(4 ea daily) 30UNIT-1000UNIT- 7.5 mg 100MG-20MG-3MG- 2 FEXMID TABS (Use NP QL(4 ea daily) 200MG-29MG-7MG-15MG- Cyclobenzaprine HCl) 3MG-12MCG-400UNIT- 1MG-20MG methocarbamol tabs or 500 1 mg, 750 mg SE-NATAL 19 TABS QL(1 ea daily) 30UNIT-1000UNIT-20MG- orphenadrine citrate tb12 or 1 100 mg 25MG-200MG-29MG-7MG- 2 15MG-3MG-12MCG- PARAFON FORTE DSC NP 400UNIT-3MG-20MG- TABS (Use Chlorzoxazone) 1MG-100MG ROBAXIN TABS OR 500 NP MG (Use Methocarbamol) SM PRENATAL VITAMINS 2 TABS ROBAXIN-750 TABS (Use NP Methocarbamol) THERANATAL CORE 2 RX/OTC NUTRITION TABS tizanidine hcl tabs 2 mg, 4 1 mg THRIVITE 19 TABS 2 QL(1 ea daily) ZANAFLEX TABS 4 MG NP TRIADVANCE TABS 2 (Use Tizanidine HCl) Viscosupplements TRICARE TABS 2 RX/OTC EUFLEXXA SOSY 2 PA TRINATAL GT TABS 2 HYALGAN SOLN 2 PA TRINATAL RX 1 TABS 2 HYALGAN SOSY 2 PA VINATE ONE TABS 2 MONOVISC SOSY 2 PA; SP VIRT-ADVANCE TABS 2

MHS Indiana Preferred Drug List Updated December 1, 2018

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHOVISC SOSY 2 PA; SP QL(17 ml per fill retail,17 ml SYNVISC ONE SOSY 2 PA; SP per fill mail); NASACORT ALLERGY 2 AL(At least 2 24HR AERO PA; SP yrs old - Up to SYNVISC SOSY 2 999 yrs old); NASAL AGENTS - SYSTEMIC AND TOPICAL - RX/OTC Drugs to treat the Nose or Sinus QL(17 ml per fill retail,17 ml Nasal Agents - Misc. NASACORT ALLERGY per fill mail); 24HR AERO (Use OCEAN NASAL SPRAY 2 AL(At least 2 NP Triamcinolone Acetonide SOLN (Use Saline) )) yrs old - Up to (Nasal 999 yrs old); saline soln 0.65%-0.002%, 1 0.65 %, 0.65% RX/OTC QL(17 ml per Nasal Antiallergy fill retail,17 ml NASACORT ALLERGY ASTEPRO SOLN (Use NP per fill mail); Azelastine HCl) 24HR CHILDRENS AERO 2 AL(At least 2 (Use Triamcinolone azelastine hcl soln 1 )) yrs old - Up to Acetonide (Nasal 999 yrs old); RX/OTC cromolyn sodium (nasal) 1 QL(0.867 ml aers daily) RHINOCORT AQUA SUSP NP QL(0.6 ml (Use Budesonide (Nasal)) daily); RX/OTC NASALCROM AERS (Use NP QL(0.867 ml Cromolyn Sodium (Nasal)) daily) QL(17 ml per Nasal Anticholinergics triamcinolone acetonide 1 fill retail); AL(At (nasal) aero least 2 yrs old); ipratropium bromide (nasal) 1 QL(1 ml daily) RX/OTC soln 0.03 % QL(17 ml per ipratropium bromide (nasal) 1 QL(0.5 ml fill retail,17 ml soln 0.06 % daily) per fill mail); triamcinolone acetonide 1 AL(At least 2 Nasal Steroids (nasal) aero QL(0.6 ml yrs old - Up to budesonide (nasal) susp 1 daily); RX/OTC 999 yrs old); RX/OTC FLONASE ALLERGY QL(16 ml per Sympathomimetic Decongestants RELIEF CHILDRENS NP fill retail); SUSP (Use Fluticasone RX/OTC NASAL DECONGESTANT 2 Propionate (Nasal)) LIQD FLONASE ALLERGY QL(16 ml per NASAL DECONGESTANT 2 RELIEF SUSP (Use NP fill retail); SYRP Fluticasone Propionate RX/OTC phenylephrine hcl (oral) 1 QL(24 ea per (Nasal)) tabs fill retail) QL(0.834 ml FLUNISOLIDE SOLN 2 pseudoephedrine hcl liqd 1 daily) 15 mg/5ml QL(16 ml per pseudoephedrine hcl tabs fluticasone propionate 1 fill retail); 1 (nasal) susp 30 mg, 60 mg RX/OTC pseudoephedrine hcl tb12 1 QL(2 ea daily) 120 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUDAFED CHILDRENS omega-3 fatty acids caps QL(6 ea daily) LIQD (Use NP 1000mg, 1200mg, 1000 Pseudoephedrine HCl) mg, 1200 mg, 180mg- SUDAFED CONGESTION 120mg, 1200mg-2unit, TABS (Use NP 300mg-1000mg, 350mg- Pseudoephedrine HCl) 1000mg, 360mg-1200mg, 600mg-1000mg, 600mg- SUDAFED NASAL 1200mg, 180mg-120mg- DECONGESTANT 5unit, 300mg-180mg- MAXIMUM STRENGTH NP 120mg, 300mg-200mg- TABS (Use 1unit, 1000mg-180mg- Pseudoephedrine HCl) 120mg, 160mg-1000mg- SUDAFED PE QL(24 ea per 100mg, 180mg-1000mg- CONGESTION TABS (Use NP fill retail) 120mg, 180mg-1200mg- Phenylephrine HCl (Oral)) 144mg, 216mg-1200mg- NEUROMUSCULAR AGENTS - Drugs to 144mg, 270mg-1000mg- Relax/Paralyze Muscles 180mg, 300mg-1000mg- 1unit, 300mg-1000mg- Muscular Dystrophy Agents 200mg, 300mg-1unit- 1000mg, 336mg-1200mg- EXONDYS 51 SOLN CO 276mg, 350mg-1000mg- Neuromuscular Blocking Agent - Neurotoxins 250mg, 400mg-1000mg- 300mg, 500mg-1000mg- BOTOX SOLR 2 PA; SP 250mg, 180mg-120mg- 1.8unit, 300mg-180mg- 1 DYSPORT SOLR 2 PA; SP 1gm-120mg, 1000mg- 180mg-120mg-1mg, MYOBLOC SOLN 2 PA; SP 210mg-1000mg-75mg- 90mg, 60mg-180mg- XEOMIN SOLR 2 PA; SP 1200mg-120mg, 60mg- 360mg-1200mg-300mg, Spinal Muscular Atrophy Agents (SMA) 1000mg-180mg-120mg- 1unit, 100mg-300mg- SPINRAZA SOLN CO 1000mg-200mg, 180mg- 1000mg-120mg-1unit, NUTRIENTS 180mg-1unit-1000mg- 120mg, 300mg-1000mg- Lipotropics 200mg-1unit, 300mg- PA 180mg-1000mg-120mg, INOSITOL TABS 500 MG 2 360mg-216mg-1200mg- PA 144mg, 600mg-324mg- inositol tabs 650 mg 1 1200mg-216mg, 700mg- PA 350mg-1000mg-250mg, INOSITOL-5 TABS 2 900mg-455mg-1000mg- 360mg, 100mg-1000mg- Misc. Nutritional Substances 500mg-10unit, 216mg- 1200mg-144mg-15unit, 300mg-1000mg-1000mg- 1unit, 340mg-180mg-1unit- 1000mg-120mg Proteins

MHS Indiana Preferred Drug List Updated December 1, 2018

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits arginine caps 500 mg 1 white petrolatum-mineral oil 1 oint ARGININE TABS 500 MG 2 Beta-blockers - Ophthalmic BETAGAN SOLN (Use QL(0.5 ml arginine tabs 500 mg, 1000 1 NP mg Levobunolol HCl) daily) RX/OTC 1 package / L-ARGININE BASE POWD 2 betaxolol hcl (ophth) soln 1 claim;QL(10 ml per fill retail) L-ARGININE POWD OR 2 Limit 15mls per RX/OTC carteolol hcl (ophth) soln 1 month;QL(0.5 L-ARGININE POWD XX 2 ml daily) Limit 15mls per L-TRYPTOPHAN POWD 2 RX/OTC XX CARTEOLOL HCL SOLN 2 month;QL(0.5 ml daily) L-TRYPTOPHAN TABS 2 OR COSOPT SOLN (Use QL(0.34 ml Dorzolamide HCl-Timolol NP daily) PURE L-CITRULLINE 2 CAPS Maleate) RX/OTC dorzolamide hcl-timolol QL(0.34 ml TRYPTOPHAN POWD XX 2 maleate soln 2%-0.5%, 1 daily) 22.3mg/ml-6.8mg/ml OPHTHALMIC AGENTS - Drugs to Treat the Eye DORZOLAMIDE QL(0.34 ml HCL/TIMOLOL MALEATE 2 daily) Artificial Tears and Lubricants SOLN QL(4 gm per fill artificial tear ointment oint 1 QL(0.5 ml retail) levobunolol hcl soln 1 daily) artificial tear solution soln 1 1 package / timolol maleate (ophth) soln 1 claim;QL(10 ml 0.25 % carboxymethylcellulose 1 per fill retail) sodium (ophth) soln 0.5 % 1 package / GENTEAL MILD TO timolol maleate (ophth) soln 1 claim;QL(15 ml 0.5 % MODERATE SOLN (Use NP per fill retail) Hypromellose (Ophth)) 1 package / hypromellose (ophth) soln 1 TIMOPTIC OCUDOSE 2 SOLN claim;QL(60 ea per fill retail) QL(1 ml daily) polyvinyl alcohol soln 1 TIMOPTIC SOLN 0.25 % 1 package / (Use Timolol Maleate NP claim;QL(10 ml polyvinyl alcohol-povidone 1 (ophth) soln 0.6%-1.4% (Ophth)) per fill retail) TIMOPTIC SOLN 0.5 % 1 package / REFRESH SOLN 2 (Use Timolol Maleate NP claim;QL(15 ml (Ophth)) per fill retail) REFRESH TEARS SOLN Cycloplegic Mydriatics (Use NP Carboxymethylcellulose ATROPINE SULFATE 2 Sodium (Ophth)) SOLN OP 1 % TEARS NATURALE PM CYCLOGYL SOLN (Use NP OINT (Use White NP Cyclopentolate HCl) Petrolatum-Mineral Oil) cyclopentolate hcl soln 1

MHS Indiana Preferred Drug List Updated December 1, 2018

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOPTO ATROPINE SOLN 2 gentamicin sulfate (ophth) 1 QL(4 gm per fill oint retail) MYDRIACYL SOLN (Use NP gentamicin sulfate (ophth) 1 Tropicamide) soln tropicamide soln 1 moxifloxacin hcl (ophth) 1 QL(3 ml per fill soln retail) Miotics neomycin-bacitracin zn- 1 QL(4 gm per fill polymyxin oint retail) ISOPTO CARPINE SOLN NP (Use Pilocarpine HCl) neomycin-polymyxin- 1 gramicidin soln pilocarpine hcl soln 1 NEOSPORIN SOLN (Use Ophthalmic - Angiogenesis Inhibitors Neomycin-Polymyxin- NP PA; SP Gramicidin) EYLEA SOLN 2 1 package / OCUFLOX SOLN (Use NP LUCENTIS SOLN 0.3 PA; SP Ofloxacin (Ophth)) claim;QL(10 ml MG/0.05ML, 0.5 2 per fill retail) MG/0.05ML 1 package / PA; SP ofloxacin (ophth) soln 1 claim;QL(10 ml MACUGEN SOLN 2 per fill retail) Ophthalmic Adrenergic Agents polymyxin b-trimethoprim 1 QL(0.34 ml soln daily) apraclonidine hcl soln 1 POLYTRIM SOLN (Use NP QL(0.34 ml Polymyxin B-Trimethoprim) daily) brimonidine tartrate soln 1 0.2 % sulfacetamide sodium 1 QL(15 ml per (ophth) soln fill retail) IOPIDINE SOLN 0.5 % NP (Use Apraclonidine HCl) SULFACETAMIDE 2 QL(0.134 gm SODIUM OINT OP daily) 2 IOPIDINE SOLN 1 % QL(0.167 ml tobramycin (ophth) soln 1 Ophthalmic Anti-infectives daily) 2 BACITRACIN OINT OP 2 QL(0.134 gm TOBREX OINT 500 UNIT/GM daily) TOBREX SOLN (Use NP QL(0.167 ml bacitracin-polymyxin b 1 QL(0.134 gm Tobramycin (Ophth)) daily) (ophth) oint daily) QL(0.267 ml trifluridine soln 1 BLEPH-10 SOLN (Use QL(15 ml per daily) Sulfacetamide Sodium NP fill retail) (Ophth)) VIGAMOX SOLN (Use NP QL(3 ml per fill Moxifloxacin HCl (Ophth)) retail) CILOXAN OINT 2 VIROPTIC SOLN (Use NP QL(0.267 ml Trifluridine) daily) CILOXAN SOLN (Use NP Ciprofloxacin HCl (Ophth)) Ophthalmic Decongestants ciprofloxacin hcl (ophth) 1 naphazoline w/ soln pheniramine soln 0.025%- 1 0.3% erythromycin (ophth) oint 1 NAPHCON-A SOLN (Use QL(4 gm per fill NP GENTAK OINT 2 Naphazoline w/ retail) Pheniramine)

MHS Indiana Preferred Drug List Updated December 1, 2018

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phenylephrine hcl (ophth) 1 QL(0.167 ml neomycin-polymy- QL(5 ml per fill soln 2.5 % daily) dexameth susp 1 retail) 10000unit/ml-3.5mg/ml- tetrahydrozoline hcl (ophth) 1 soln 0.1% VISINE SOLN (Use NEOMYCIN/POLYMYXIN/ QL(0.5 ml Tetrahydrozoline HCl NP HYDROCORTISONE 2 daily) (Ophth)) SUSP OMNIPRED SUSP (Use 1 package / Ophthalmic Gene Therapy Prednisolone Acetate NP claim;QL(15 ml LUXTURNA SUSP CO (Ophth)) per fill retail) PRED FORTE SUSP (Use 1 package / Ophthalmic Local Anesthetics Prednisolone Acetate NP claim;QL(15 ml tetracaine hcl (ophth) soln 1 (Ophth)) per fill retail) QL(0.34 ml PRED MILD SUSP 2 Ophthalmic Photodynamic Therapy Agents daily) VISUDYNE SOLR 2 PA; SP PRED-G SUSP 2 Ophthalmic Steroids 1 package / prednisolone acetate 1 claim;QL(15 ml (ophth) susp BLEPHAMIDE S.O.P. 2 per fill retail) OINT 1 package / 1 rtl pack lmt PREDNISOLONE 2 ACETATE P-F SUSP claim;QL(15 ml BLEPHAMIDE SUSP 2 amt,31 rtl pack per fill retail) lmt day(s), PREDNISOLONE SODIUM DEXAMETHASONE PHOSPHATE SOLN OP 1 2 SODIUM PHOSPHATE 2 % SOLN OP 0.1 % sulfacetamide sod- 1 QL(0.34 ml fluorometholone (ophth) 1 prednisolone soln daily) susp TOBRADEX OINT 2 QL(0.134 gm FML LIQUIFILM SUSP daily) (Use Fluorometholone NP (Ophth)) TOBRADEX SUSP (Use Tobramycin- NP FML OINT 2 QL(0.134 gm Dexamethasone) daily) tobramycin- 1 MAXITROL OINT QL(4 gm per fill dexamethasone susp 10000UNIT/GM- retail) 3.5MG/GM-0.1% (Use NP Ophthalmics - Misc. Neomycin-Polymy- ACULAR LS SOLN (Use Dexameth) Ketorolac Tromethamine NP MAXITROL SUSP QL(5 ml per fill (Ophth)) 10000UNIT/ML-3.5MG/ML- NP retail) ACULAR SOLN (Use 1 package / 0.1% (Use Neomycin- Ketorolac Tromethamine NP claim;QL(10 ml Polymy-Dexameth) (Ophth)) per fill retail) neomycin-polymy- QL(4 gm per fill QL(0.167 ml ALOCRIL SOLN 2 dexameth oint 1 retail) daily) 10000unit/gm-3.5mg/gm- ALOMIDE SOLN 2 QL(0.34 ml 0.1% daily)

MHS Indiana Preferred Drug List Updated December 1, 2018

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ml per fill azelastine hcl (ophth) soln 1 DEBROX SOLN (Use NP QL(0.5 ml retail) Carbamide Peroxide (Otic)) daily) AZOPT SUSP 2 Otic Anti-infectives FLOXIN OTIC SOLN (Use NP QL(10 ml per QL(10 ml per Ofloxacin (Otic)) 30 days retail) fill retail,1 ml cromolyn sodium (ophth) QL(10 ml per 1 per fill mail,1 ofloxacin (otic) soln 1 soln claims per fill 30 days retail) retail) Otic Combinations diclofenac sodium (ophth) 1 QL(0.1 ml QL(7.5 ml per soln daily) CIPRODEX SUSP 2 fill retail)1 rtl MAX fill,30 rtl DORZOLAMIDE HCL 2 QL(0.34 ml SOLN daily) day(s) supply, QL(0.34 ml CORTANE-B-OTIC SOLN dorzolamide hcl soln 1 daily) (Use Pramoxine-HC- NP QL(0.167 ml Chloroxylenol) flurbiprofen sodium soln 1 daily) neomycin-polymyxin-hc 1 QL(10 ml per (otic) soln fill retail) ketorolac tromethamine 1 (ophth) soln 0.4 % neomycin-polymyxin-hc 1 1 package / (otic) susp ketorolac tromethamine 1 claim;QL(10 ml OTICIN HC NR SOLN (Use (ophth) soln 0.5 % per fill retail) Pramoxine-HC- NP Chloroxylenol) ketotifen fumarate (ophth) 1 soln pramoxine-hc-chloroxylenol 1 soln OCUFEN SOLN (Use NP QL(0.167 ml Flurbiprofen Sodium) daily) Otic Steroids TRUSOPT SOLN (Use NP QL(0.34 ml DERMOTIC OIL (Use Dorzolamide HCl) daily) Fluocinolone Acetonide NP ZADITOR SOLN (Use (Otic)) Ketotifen Fumarate NP fluocinolone acetonide 1 (Ophth)) (otic) oil Prostaglandins - Ophthalmic hydrocortisone w/acetic 1 QL(10 ml per QL(3 ml per fill acid soln fill retail) latanoprost soln 1 retail) OXYTOCICS - Drugs to Prevent/Control Uterine QL(3 ml per fill Bleeding LATANOPROST SOLN 2 retail) Oxytocics XALATAN SOLN (Use QL(3 ml per fill NP methylergonovine maleate 1 Latanoprost) retail) tabs or 0.2 mg OTIC AGENTS - Drugs to Treat the Ear PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune Otic Agents - Miscellaneous System QL(0.5 ml acetic acid (otic) soln 1 daily) Immune Serums BIVIGAM SOLN 2 PA carbamide peroxide (otic) 1 QL(0.5 ml soln daily) CARIMUNE 2 PA NANOFILTERED SOLR MHS Indiana Preferred Drug List Updated December 1, 2018

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CUVITRU SOLN 2 PA; SP Passive Immunizing Agents - Combinations HYQVIA KIT 2 PA; SP CYTOGAM INJ 2 PA; SP

FLEBOGAMMA DIF SOLN 2 PA PENICILLINS - Drugs to Treat Bacterial Infections Aminopenicillins GAMASTAN INJ 2 PA; SP amoxicillin caps 250 mg, 1 500 mg GAMASTAN S/D INJ 2 PA; SP AMOXICILLIN CHEW 125 2 GAMMAGARD LIQUID 2 PA MG, 250 MG SOLN amoxicillin susr 125 GAMMAGARD S/D IGA PA mg/5ml, 200 mg/5ml, 250 1 LESS THAN 1MCG/ML 2 mg/5ml, 400 mg/5ml SOLR amoxicillin tabs 875 mg 1 GAMMAKED SOLN 2 PA ampicillin caps 250 mg, 1 GAMMAPLEX SOLN 2 PA 500 mg AMPICILLIN CAPS 500 2 GAMUNEX-C SOLN 2 PA MG AMPICILLIN SUSR 125 2 HEPAGAM B SOLN 2 PA; SP MG/5ML, 250 MG/5ML Natural Penicillins HIZENTRA SOLN 2 PA; SP penicillin v potassium solr 1 HYPERHEP B S/D SOLN 2 PA; SP 125 mg/5ml, 250 mg/5ml PENICILLIN V HYPERRHO S/D MINI- 2 PA POTASSIUM SOLR 125 2 DOSE SOSY MG/5ML, 250 MG/5ML PA HYPERRHO S/D SOSY 2 penicillin v potassium tabs 1 250 mg, 500 mg MICRHOGAM ULTRA- 2 PA FILTEREDPLUS SOSY Penicillin Combinations PA; SP amoxicillin & pot NABI-HB SOLN 2 clavulanate susr PA 400mg/5ml-57mg/5ml, 1 OCTAGAM SOLN 2 200mg/5ml-28.5mg/5ml, 250mg/5ml-62.5mg/5ml, PRIVIGEN SOLN 2 PA 600mg/5ml-42.9mg/5ml amoxicillin & pot QL(30 ea per RHOGAM ULTRA- 2 PA FILTERED PLUS SOSY clavulanate tabs 250mg- 1 fill retail) 125mg, 500mg-125mg PA RHOPHYLAC SOSY 2 amoxicillin & pot QL(20 ea per PA clavulanate tabs 875mg- 1 fill retail) WINRHO SDF SOLN 2 125mg amoxicillin & pot QL(2 ea daily) Monoclonal Antibodies clavulanate tb12 1000mg- 1 SYNAGIS SOLN 2 PA; SP 62.5mg

MHS Indiana Preferred Drug List Updated December 1, 2018

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMOXICILLIN/CLAVULAN 2 QL(20 ea per FLAVOR SWEET-SF 2 RX/OTC ATE POTASSIUM CHEW fill retail) SYRP AUGMENTIN ES-600 glycine diluent soln 1 PA; SP SUSR (Use Amoxicillin & NP Pot Clavulanate) GRAPE SYRUP SYRP 2 RX/OTC AUGMENTIN SUSR 2 125MG/5ML-31.25MG/5ML MX-SOL BLEND SF SUSP 2 RX/OTC AUGMENTIN SUSR RX/OTC 250MG/5ML-62.5MG/5ML NP MX-SOL BLEND SUSP 2 (Use Amoxicillin & Pot Clavulanate) MX-SOL SF SYRP 2 RX/OTC AUGMENTIN TABS QL(30 ea per RX/OTC 500MG-125MG (Use NP fill retail) MX-SOL SUSPEND SUSP 2 Amoxicillin & Pot Clavulanate) MX-SOL SYRP 2 RX/OTC AUGMENTIN TABS QL(20 ea per ORA-BLEND SF SUSP 2 RX/OTC 875MG-125MG (Use NP fill retail) Amoxicillin & Pot Clavulanate) ORA-BLEND SUSP 2 RX/OTC AUGMENTIN XR TB12 QL(2 ea daily) RX/OTC (Use Amoxicillin & Pot NP ORA-PLUS LIQD 2 Clavulanate) ORA-SWEET SF SYRP 2 RX/OTC Penicillinase-Resistant Penicillins RX/OTC dicloxacillin sodium caps 1 ORA-SWEET SYRP 2 ORAL MIX FLAVORED RX/OTC PHARMACEUTICAL ADJUVANTS SUSPENDING VEHICLE 2 SUSP Internal Vehicle Ingredients/Agents ORAL MIX SF SUSP 2 RX/OTC SIMPLYTHICK EASY MIX 2 QL(1816 ml per GEL fill retail) ORAL SUSPEND LIQD 2 RX/OTC SIMPLYTHICK GEL 2 QL(1816 ml per fill retail) ORAL SUSPENDING 2 RX/OTC starch-maltodextrin 1 COMPOUNDPLUS SUSP (thickening) powd ORAL SYRUP FLAVORED 2 RX/OTC THICK-IT ORIGINAL VEHICLE SYRP POWD (Use Starch- NP RX/OTC Maltodextrin (Thickening)) ORAL SYRUP SF SYRP 2 Liquid Vehicles PCCA SWEET-SF SYRP 2 RX/OTC BLENDED SUSPENDING 2 RX/OTC COMPOUND SUSP PCCA SYRUP VEHICLE 2 RX/OTC SYRP FLAVOR BLEND SUSP 2 RX/OTC PCCA-PLUS SUSP 2 RX/OTC RX/OTC FLAVOR PLUS LIQD 2 PH 12 STERILE DILUENT PA; SP RX/OTC FORFLOLAN SOLN (Use NP FLAVOR SWEET SYRP 2 Glycine Diluent)

MHS Indiana Preferred Drug List Updated December 1, 2018

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIMPLE SYRUP SYRP 2 RX/OTC MAKENA OIL IM 250 QL(5 ml per fill MG/ML (Use NP retail,21 ml per SOLVATECH PLUS SUSP 2 RX/OTC Hydroxyprogesterone 180 days Caproate) retail); SP SOLVATECH SWEET SF 2 RX/OTC QL(5.5 ml per SYRP MAKENA SOAJ SC 275 2 fill retail,21 ml MG/1.1ML per 180 days SORBITOL SOLN XX 70 2 RX/OTC %, retail); SP STERILE DILUENT FOR PA; SP medroxyprogesterone 1 FLOLAN SOLN (Use NP acetate tabs Glycine Diluent) norethindrone acetate tabs $0 PV STERILE DILUENT FOR 2 PA; SP REMODOULIN SOLN progesterone micronized 1 QL(1 ea daily) caps 100 mg SUSPENDOL-S LIQD 2 progesterone micronized 1 QL(0.67 ea caps 200 mg daily) SUSPENSION VEHICLE 2 RX/OTC SUSP PROMETRIUM CAPS 100 QL(1 ea daily) SWEETENING RX/OTC MG (Use Progesterone NP SUSPENDING 2 Micronized) COMPOUND SYRP PROMETRIUM CAPS 200 QL(0.67 ea RX/OTC MG (Use Progesterone NP daily) SYRPALTA SYRP 2 Micronized) SYRSPEND SF LIQD 2 RX/OTC PROVERA TABS (Use Medroxyprogesterone 2 SYRUP NF SYRP 2 RX/OTC Acetate) PSYCHOTHERAPEUTIC AND NEUROLOGICAL SYRUP VEHICLE SF 2 RX/OTC AGENTS - MISC. - Drugs to Treat Mental and SYRP Emotional Conditions RX/OTC SYRUP VEHICLE SYRP 2 Agents for Chemical Dependency RX/OTC ANTABUSE TABS 250 MG NP VERSAFREE SYRP 2 (Use Disulfiram) VERSAPLUS SYRP 2 RX/OTC disulfiram tabs 250 mg 1 Semi Solid Vehicles Anti-Cataplectic Agents QL(18 ml POLYETHYLENE GLYCOL 2 QL(34 gm XYREM SOLN 2 3350 POWD XX daily); RX/OTC daily); SP PROGESTINS - Hormone Replacement/Modifying Antidementia Agents Drugs ARICEPT TABS (Use NP QL(1 ea daily) Progestins Donepezil Hydrochloride) donepezil hydrochloride QL(1 ea daily) AYGESTIN TABS (Use NP PV 1 Norethindrone Acetate) tabs QL(5 ml per fill donepezil hydrochloride 1 QL(1 ea daily) tbdp hydroxyprogesterone 1 retail,21 ml per caproate oil 250 mg/ml 180 days EXELON CAPS OR 1.5 QL(2 ea daily) retail); SP MG (Use Rivastigmine NP Tartrate)

MHS Indiana Preferred Drug List Updated December 1, 2018

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXELON PT24 TD 4.6 QL(1 ea daily) QL(1 ea daily); olanzapine-fluoxetine hcl 1 AL(At least 18 MG/24HR, 9.5 MG/24HR, NP caps 13.3 MG/24HR (Use yrs old) Rivastigmine) PERPHENAZINE/AMITRIP 2 galantamine hydrobromide 1 QL(1 ea daily) TYLINE TABS cp24 8 mg, 16 mg, 24 mg QL(1 ea daily); SYMBYAX CAPS (Use NP GALANTAMINE QL(6 ml daily) Olanzapine-Fluoxetine HCl) AL(At least 18 HYDROBROMIDE SOLN 4 2 yrs old) MG/ML Fibromyalgia Agents galantamine hydrobromide 1 QL(2 ea daily) tabs 4 mg, 8 mg, 12 mg SAVELLA TABS 2 memantine hcl cp24 7 mg, QL(1 ea daily) 1 SAVELLA TITRATION 2 14 mg, 21 mg, 28 mg PACK MISC memantine hcl soln 2 1 QL(10 ml daily) mg/ml Movement Disorder Drug Therapy tetrabenazine tabs 1 PA; SP memantine hcl tabs 5 mg, 1 QL(2 ea daily) 10 mg, XENAZINE TABS (Use NP PA; SP NAMENDA SOLN 10 QL(10 ml daily) Tetrabenazine) MG/5ML (Use Memantine NP HCl) Multiple Sclerosis Agents AMPYRA TB12 (Use PA; SP NAMENDA TABS 5 MG, 10 NP QL(2 ea daily) NP MG (Use Memantine HCl) Dalfampridine) NAMENDA TITRATION QL(2 ea daily) AUBAGIO TABS 2 PA; SP PAK TABS (Use NP Memantine HCl) AVONEX KIT 2 PA; SP NAMENDA XR CP24 (Use NP QL(1 ea daily) Memantine HCl) AVONEX PEN AJKT 2 PA; SP NAMENDA XR TITRATION 2 QL(1 ea daily) PACK CP24 AVONEX PSKT 2 PA; SP QL(1 ea daily) NAMZARIC C4PK 2 BETASERON KIT 2 PA; SP QL(1 ea daily) NAMZARIC CP24 2 COPAXONE SOSY (Use NP PA; SP Glatiramer Acetate) RAZADYNE ER CP24 (Use QL(1 ea daily) Galantamine NP dalfampridine tb12 1 PA; SP Hydrobromide) PA; SP RAZADYNE TABS (Use QL(2 ea daily) GILENYA CAPS 0.5 MG 2 Galantamine NP PA; SP Hydrobromide) glatiramer acetate sosy 1 QL(1 ea daily) rivastigmine pt24 1 LEMTRADA SOLN 2 PA; SP QL(2 ea daily) rivastigmine tartrate caps 1 PLEGRIDY SOPN 2 PA; SP

Combination Psychotherapeutics PLEGRIDY SOSY 2 PA; SP CHLORDIAZEPOXIDE/AMI 2 TRIPTYLINE TABS PLEGRIDY STARTER 2 PA; SP PACK SOPN

MHS Indiana Preferred Drug List Updated December 1, 2018

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEGRIDY STARTER 2 PA; SP bupropion hcl (smoking $0 QL(2 ea daily); PACK SOSY deterrent) tb12 PV REBIF REBIDOSE SOAJ 2 PA; SP CHANTIX CONTINUING $0 QL(2 ea daily); MONTHPAK TABS PV REBIF REBIDOSE PA; SP 2 CHANTIX STARTING $0 QL(2 ea daily); TITRATIONPACK SOAJ MONTH PAK TABS PV PA; SP REBIF SOSY 2 CHANTIX TABS $0 QL(2 ea daily); PV REBIF TITRATION PACK PA; SP 2 NICODERM CQ PT24 (Use NP QL(1 ea daily); SOSY Nicotine) PV TECFIDERA CPDR 2 PA; SP NICORETTE GUM 2 MG, 4 QL(24 ea MG (Use Nicotine NP daily); PV TECFIDERA STARTER 2 PA; SP Polacrilex) PACK MISC NICORETTE LOZG 2 MG, QL(20 ea TYSABRI CONC 2 PA; SP 4 MG (Use Nicotine NP daily); PV Polacrilex) ZINBRYTA SOSY 2 PA; SP NICORETTE MINI LOZG NP QL(20 ea (Use Nicotine Polacrilex) daily); PV Premenstrual Dysphoric Disorder (PMDD) Agents NICORETTE STARTER QL(24 ea FLUOXETINE CAPS 10 2 QL(1 ea daily) KIT GUM (Use Nicotine NP daily); PV MG Polacrilex) FLUOXETINE CAPS 20 QL(4 ea daily) 2 nicotine polacrilex gum 2 $0 QL(24 ea MG mg, 4 mg daily); PV fluoxetine hcl (pmdd) tabs QL(1.5 ea 1 nicotine polacrilex lozg 2 $0 QL(20 ea 10 mg daily) mg, 4 mg daily); PV fluoxetine hcl (pmdd) tabs QL(4 ea daily) QL(1 ea daily); 1 nicotine pt24 $0 20 mg PV SARAFEM TABS 10 MG QL(1.5 ea NICOTINE PV (Use Fluoxetine HCl NP daily) TRANSDERMAL SYSTEM $0 (PMDD)) KIT SARAFEM TABS 20 MG QL(4 ea daily) NICOTROL INHALER $0 QL(16.8 ea (Use Fluoxetine HCl NP INHA daily); PV (PMDD)) QL(4 ml daily); NICOTROL NS SOLN $0 Psychotherapeutic and Neurological Agents - PV ZYBAN TB12 (Use QL(2 ea daily); ERGOLOID MESYLATES 2 QL(3 ea daily) TABS Bupropion HCl (Smoking NP PV Deterrent)) ORAP TABS 1 MG (Use NP QL(10 ea daily) Pimozide) RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions ORAP TABS 2 MG (Use NP QL(5 ea daily) Pimozide) Alpha-Proteinase Inhibitor (Human) QL(10 ea daily) pimozide tabs 1 mg 1 ARALAST NP SOLR 2 PA; SP QL(5 ea daily) pimozide tabs 2 mg 1 GLASSIA SOLN 2 PA; SP Smoking Deterrents PROLASTIN-C SOLR 1000 2 PA; SP MG

MHS Indiana Preferred Drug List Updated December 1, 2018

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZEMAIRA SOLR 2 PA; SP VIBRAMYCIN CAPS 100 MG (Use Doxycycline NP Cystic Fibrosis Agents Hyclate) KALYDECO PACK CO THYROID AGENTS - Drugs to Regulate Thyroid Hormones KALYDECO TABS CO Antithyroid Agents methimazole tabs 1 ORKAMBI TABS 100MG- CO 125MG, 200MG-125MG propylthiouracil tabs 1 PULMOZYME SOLN 2 PA; SP TAPAZOLE TABS (Use NP SYMDEKO TBPK CO Methimazole) Pulmonary Fibrosis Agents Thyroid Hormones PA; SP ARMOUR THYROID TABS NP ESBRIET CAPS 2 120 MG (Use Thyroid) ARMOUR THYROID TABS TETRACYCLINES - Drugs to Treat Bacterial 15 MG, 30 MG, 60 MG, 90 2 Infections MG (Use Thyroid) Tetracyclines ARMOUR THYROID TABS 2 ADOXA PAK 1/100 TABS 180 MG, 240 MG, 300 MG (Use Doxycycline NP CYTOMEL TABS (Use NP (Monohydrate)) Liothyronine Sodium) ADOXA PAK 2/100 TABS levothyroxine sodium tabs (Use Doxycycline NP or 25 mcg, 50 mcg, 75 (Monohydrate)) mcg, 88 mcg, 100 mcg, 1 ADOXA TABS 50 MG, 100 112 mcg, 125 mcg, 137 MG (Use Doxycycline NP mcg, 150 mcg, 175 mcg, (Monohydrate)) 200 mcg, 300 mcg liothyronine sodium tabs or doxycycline (monohydrate) 1 1 caps 50 mg, 100 mg 5 mcg, 25 mcg, 50 mcg SYNTHROID TABS (Use doxycycline (monohydrate) 1 2 tabs 50 mg, 100 mg Levothyroxine Sodium) doxycycline hyclate caps or 1 thyroid tabs 1 50 mg, 100 mg doxycycline hyclate tabs or 1 THYROLAR-1 TABS 2 100 mg MINOCIN CAPS OR 50 THYROLAR-1/2 TABS 2 MG, 75 MG, 100 MG (Use NP Minocycline HCl) THYROLAR-1/4 TABS 2 minocycline hcl caps 50 1 mg, 75 mg, 100 mg THYROLAR-2 TABS 2 MONODOX CAPS 100 MG (Use Doxycycline NP THYROLAR-3 TABS 2 (Monohydrate)) TOXOIDS Toxoid Combinations MHS Indiana Preferred Drug List Updated December 1, 2018

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hyoscyamine sulfate tb12 QL(4 ea daily) ADACEL SUSP $0 AL(At least 19 1 yrs old) or 0.375 mg hyoscyamine sulfate tbdp BOOSTRIX SUSP $0 AL(At least 19 1 yrs old) or 0.125 mg DIPHTHERIA/TETANUS AL(At least 19 LEVBID TB12 (Use NP QL(4 ea daily) TOXOIDS ADSORBED $0 yrs old) Hyoscyamine Sulfate) PEDIATRIC SUSP ROBINUL FORTE TABS NP QL(4 ea daily) (Use Glycopyrrolate) INFANRIX SUSP $0 AL(At least 19 yrs old) ROBINUL TABS OR 1 MG NP QL(4 ea daily) AL(At least 19 (Use Glycopyrrolate) KINRIX SUSP $0 yrs old) H-2 Antagonists PEDIARIX SUSP $0 AL(At least 19 yrs old) CIMETIDINE HCL SOLN 2 PENTACEL SUSR $0 AL(At least 19 RX/OTC yrs old) cimetidine tabs 200 mg 1 AL(At least 19 QUADRACEL SUSP $0 cimetidine tabs 300 mg, 1 yrs old) 400 mg, 800 mg AL(At least 19 TENIVAC INJ $0 famotidine susr or 40 1 yrs old) mg/5ml TETANUS/DIPHTHERIA AL(At least 19 famotidine tabs or 10 mg, 1 TOXOIDS-ADSORBED $0 yrs old) 40 mg SUSP famotidine tabs or 20 mg 1 RX/OTC ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions PEPCID AC MAXIMUM RX/OTC STRENGTH TABS (Use NP Antispasmodics Famotidine) BENTYL CAPS OR 10 MG NP PEPCID AC TABS (Use NP (Use Dicyclomine HCl) Famotidine) BENTYL TABS OR 20 MG NP PEPCID SUSR 40 MG/5ML NP (Use Dicyclomine HCl) (Use Famotidine) dicyclomine hcl caps or 10 1 PEPCID TABS 20 MG (Use NP RX/OTC mg Famotidine) dicyclomine hcl soln or 10 QL(16.54 ml 1 PEPCID TABS 40 MG (Use NP mg/5ml daily) Famotidine) dicyclomine hcl tabs or 20 1 ranitidine hcl caps or 150 1 QL(2 ea daily) mg mg glycopyrrolate tabs or 1 QL(4 ea daily) 1 ranitidine hcl caps or 300 1 QL(1 ea daily) mg, 2 mg mg hyoscyamine sulfate elix or 1 ranitidine hcl syrp or 15 QL(40 ml daily) 0.125 mg/5ml mg/ml, 75 mg/5ml, 150 1 hyoscyamine sulfate soln 1 mg/10ml or 0.125 mg/ml ranitidine hcl tabs or 150 1 RX/OTC hyoscyamine sulfate subl sl 1 mg 0.125 mg ranitidine hcl tabs or 300 1 hyoscyamine sulfate tabs 1 mg or 0.125 mg

MHS Indiana Preferred Drug List Updated December 1, 2018

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl tabs or 75 mg 1 QL(2 ea daily) KLS OMEPRAZOLE TBEC 2 QL(1 ea daily) TAGAMET HB TABS ( QL(2 ea daily); Use NP RX/OTC lansoprazole cpdr 15 mg 1 Cimetidine) RX/OTC ZANTAC 150 MAXIMUM RX/OTC lansoprazole cpdr 30 mg 1 QL(2 ea daily) STRENGTH TABS (Use NP Ranitidine HCl) lansoprazole tbdp 15 mg, 1 ST 30 mg ZANTAC 75 TABS (Use NP QL(2 ea daily) Ranitidine HCl) NEXIUM 24HR CLEAR QL(1 ea daily); MINIS CPDR (Use 2 RX/OTC ZANTAC TABS OR 150 NP RX/OTC MG (Use Ranitidine HCl) Esomeprazole Magnesium) NEXIUM 24HR CPDR (Use QL(1 ea daily); ZANTAC TABS OR 300 NP 2 MG (Use Ranitidine HCl) Esomeprazole Magnesium) RX/OTC Misc. Anti-Ulcer NEXIUM CPDR 40 MG ST (Use Esomeprazole NP CARAFATE SUSP 1 2 QL(420 ml per Magnesium) GM/10ML fill retail) NEXIUM PACK 10 MG 2 PA CARAFATE TABS 1 GM NP QL(4 ea daily) (Use Sucralfate) NEXIUM PACK 5 MG, 20 2 ST sucralfate tabs 1 QL(4 ea daily) MG, 40 MG, 2.5 MG OMEPRAZOLE + QL(300 ml per Proton Pump Inhibitors SYRSPEND SFALKA 2 fill retail) SUSP ACIPHEX SPRINKLE 2 ST CPSP omeprazole cpdr 10 mg 1 PA ACIPHEX TBEC (Use ST NP QL(2 ea daily); Rabeprazole Sodium) omeprazole cpdr 20 mg 1 RX/OTC CVS OMEPRAZOLE TBEC 2 QL(1 ea daily) omeprazole cpdr 40 mg 1 QL(2 ea daily) DEXILANT CPDR 2 ST omeprazole magnesium 1 PA cpdr EQ OMEPRAZOLE TBEC 2 QL(1 ea daily) OMEPRAZOLE TBEC 20 2 QL(1 ea daily) EQL OMEPRAZOLE TBEC 2 QL(1 ea daily) MG pantoprazole sodium tbec 1 QL(1 ea daily) esomeprazole magnesium 1 ST or 20 mg cpdr 40 mg pantoprazole sodium tbec 1 QL(2 ea daily) ESOMEPRAZOLE ST or 40 mg STRONTIUM CPDR 49.3 2 PREVACID 24HR CPDR NP QL(2 ea daily); MG, 24.65 MG (Use Lansoprazole) RX/OTC FIRST-LANSOPRAZOLE QL(300 ml per 2 PREVACID CPDR 15 MG NP QL(2 ea daily); SUSP fill retail) (Use Lansoprazole) RX/OTC FIRST-OMEPRAZOLE QL(300 ml per 2 PREVACID CPDR 30 MG NP QL(2 ea daily) SUSP fill retail) (Use Lansoprazole) GNP OMEPRAZOLE QL(1 ea daily) 2 PREVACID SOLUTAB NP ST TBEC TBDP (Use Lansoprazole) HM OMEPRAZOLE TBEC 2 QL(1 ea daily) PRILOSEC CPDR 10 MG NP PA (Use Omeprazole)

MHS Indiana Preferred Drug List Updated December 1, 2018

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRILOSEC CPDR 20 MG NP QL(2 ea daily); MACROBID CAPS (Use (Use Omeprazole) RX/OTC Nitrofurantoin Monohyd NP Macro) PRILOSEC CPDR 40 MG NP QL(2 ea daily) (Use Omeprazole) MACRODANTIN CAPS 50 MG, 100 MG (Use NP PRILOSEC PACK 10 MG, 2 PA 2.5 MG Nitrofurantoin Macrocrystal) methenamine mandelate PROTONIX PACK OR 40 2 ST 1 MG tabs PROTONIX TBEC OR 20 QL(1 ea daily) nitrofurantoin macrocrystal 1 MG (Use Pantoprazole NP caps 50 mg, 100 mg Sodium) nitrofurantoin monohyd 1 PROTONIX TBEC OR 40 QL(2 ea daily) macro caps MG (Use Pantoprazole NP nitrofurantoin susp 1 QL(40 ml daily) Sodium) PX OMEPRAZOLE TBEC 2 QL(1 ea daily) URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms QL(1 ea daily) RA OMEPRAZOLE TBEC 2 Urinary Antispasmodic - Antimuscarinics ST DETROL LA CP24 (Use NP QL(1 ea daily) rabeprazole sodium tbec 1 Tolterodine Tartrate) QL(1 ea daily) DETROL TABS (Use NP QL(2 ea daily) SB OMEPRAZOLE TBEC 2 Tolterodine Tartrate) QL(1 ea daily) SM OMEPRAZOLE TBEC 2 DITROPAN XL TB24 (Use NP QL(2 ea daily) Oxybutynin Chloride) QL(1 ea daily) SW OMEPRAZOLE TBEC 2 oxybutynin chloride syrp 5 1 QL(16 ml daily) mg/5ml TGT OMEPRAZOLE TBEC 2 QL(1 ea daily) oxybutynin chloride tabs 5 1 QL(3 ea daily) mg Ulcer Drugs - Prostaglandins oxybutynin chloride tb24 5 1 QL(2 ea daily) CYTOTEC TABS (Use NP mg, 10 mg, 15 mg Misoprostol) tolterodine tartrate cp24 2 1 QL(1 ea daily) misoprostol tabs 1 mg, 4 mg tolterodine tartrate tabs 1 1 QL(2 ea daily) URINARY ANTI-INFECTIVES - Drugs to Treat mg, 2 mg Bladder/Kidney Infections trospium chloride tabs 20 1 QL(2 ea daily) Urinary Anti-infective Combinations mg methenamine-hyosc- Urinary Antispasmodics - Cholinergic Agonists methylene blue-sod phos- bethanechol chloride tabs 1 phenyl sal tabs 40.8mg- 1 0.12mg-36.2mg-81.6mg- URECHOLINE TABS (Use NP 10.8mg, 40.8mg-36.2mg- Bethanechol Chloride) 0.12mg-81.6mg-10.8mg Urinary Antispasmodics - Direct Muscle Relaxants Urinary Anti-infectives flavoxate hcl tabs 1 FURADANTIN SUSP (Use NP QL(40 ml daily) Nitrofurantoin) VACCINES

MHS Indiana Preferred Drug List Updated December 1, 2018

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 19 Bacterial Vaccines GARDASIL 9 SUSP $0 QL(4 ea per yrs old) AL(At least 19 999 days GARDASIL 9 SUSY $0 ACTHIB SOLR $0 retail); AL(At yrs old) least 19 yrs GARDASIL SUSP $0 AL(At least 19 old) yrs old) AL(At least 19 BEXSERO SUSY $0 QL(2 ml per yrs old) 999 days QL(4 ea per HAVRIX SUSP $0 retail); AL(At 999 days least 19 yrs HIBERIX SOLR $0 retail); AL(At old) least 19 yrs QL(2 ea per old) 999 days M-M-R II INJ $0 retail); AL(At MENACTRA INJ $0 AL(At least 19 yrs old) least 19 yrs AL(At least 19 old) MENVEO SOLR $0 yrs old) QL(4 ml per 999 days QL(3 ml per $0 999 days RECOMBIVAX HB SUSP retail); AL(At least 19 yrs PEDVAX HIB SUSP $0 retail); AL(At least 19 yrs old) old) QL (1 ea per AL(At least 19 Seasonal Influenza $0 180 days); AL: PNEUMOVAX 23 INJ $0 Vaccine At least 19 yrs yrs old) old PNEUMOVAX 23/1 DOSE $0 AL(At least 19 INJ yrs old) QL(2 ea per 999 days AL(At least 19 PREVNAR 13 SUSP $0 SHINGRIX SUSR 2 retail); AL(At yrs old) least 50 yrs AL(At least 19 old) TRUMENBA SUSY $0 yrs old) QL(4 ml per Viral Vaccines 999 days TWINRIX SUSP $0 retail); AL(At QL(4 ml per least 19 yrs 999 days old) ENGERIX-B INJ $0 retail); AL(At least 19 yrs QL(2 ml per old) 999 days VAQTA SUSP $0 retail); AL(At QL(4 ml per least 19 yrs 999 days old) ENGERIX-B SUSP $0 retail); AL(At least 19 yrs QL(2 ea per old) 999 days VARIVAX INJ $0 retail); AL(At 1 rtl MAX least 19 yrs fill,180 rtl old) FLUMIST $0 day(s) supply,; QUADRIVALENT SUSP AL(At least 19 yrs old)

MHS Indiana Preferred Drug List Updated December 1, 2018

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea per MONISTAT 3 999 days COMBINATION PACK KIT NP ZOSTAVAX SUSR $0 retail); AL(At (Use Miconazole Nitrate least 50 yrs Vaginal) old) MONISTAT 3 CREA (Use NP QL(1.5 gm VAGINAL PRODUCTS - Drugs to Treat Vaginal Miconazole Nitrate Vaginal) daily) Infections and Low Hormones MONISTAT 7 SIMPLY QL(1.5 gm CURE CREA (Use NP daily) Vaginal Anti-infectives Miconazole Nitrate Vaginal) CLEOCIN CREA VA 2 % (Use Clindamycin NP TERAZOL 7 CREA (Use NP Phosphate Vaginal) Terconazole Vaginal) TERCONAZOLE CREA 2 clindamycin phosphate 1 vaginal crea terconazole vaginal crea 1 clotrimazole vaginal crea 1 1 QL(1.5 gm % daily) terconazole vaginal supp 1 clotrimazole vaginal crea 2 1 QL(1 gm daily) % tioconazole vaginal oint 1 GYNAZOLE-1 CREA 2 VAGISTAT-1 OINT (Use NP Tioconazole Vaginal) GYNE-LOTRIMIN 3 CREA NP QL(1 gm daily) (Use Clotrimazole Vaginal) Vaginal Estrogens GYNE-LOTRIMIN CREA NP QL(1.5 gm ESTRACE CREA VA 0.1 QL(1.5 gm (Use Clotrimazole Vaginal) daily) MG/GM (Use Estradiol NP daily) Limit 70gms Vaginal) METROGEL-VAGINAL per GEL (Use Metronidazole NP estradiol vaginal crea 0.1 1 QL(1.5 gm Vaginal) month;QL(2.34 mg/gm daily) gm daily) PREMARIN CREA VA 2 Limit 70gms 0.625 MG/GM 1 per metronidazole vaginal gel month;QL(2.34 VASOPRESSORS - Drugs to Treat Heart and gm daily) Circulation Conditions MICONAZOLE 3 SUPP 2 Anaphylaxis Therapy Agents epinephrine (anaphylaxis) 1 QL(4 ea per miconazole nitrate vaginal 1 QL(1.5 gm soaj 350 days retail) crea 2 %, 4 % daily) Vasopressors miconazole nitrate vaginal 1 kit midodrine hcl tabs 1 miconazole nitrate vaginal 1 QL(0.234 ea supp 100 mg daily) VITAMINS MONISTAT 1 COMBO PACK KIT (Use NP Oil Soluble Vitamins Miconazole Nitrate Vaginal) AQUA-E LIQD 20UNIT 2 MONISTAT 1 DAY OR cholecalciferol caps 1000 QL(100 ea per NIGHT COMBO PACK KIT NP 1 (Use Miconazole Nitrate unit fill retail) Vaginal) cholecalciferol caps 2000 1 unit MHS Indiana Preferred Drug List Updated December 1, 2018

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholecalciferol caps 400 $0 PV ascorbic acid tabs or QL(3.34 ea unit 500mg, 1000mg, 250 mg, daily) 500 mg, 1000 mg, 10mg- cholecalciferol caps 5000 1 QL(2 ea daily) 1 unit 500mg, 37mg-500mg, 37mg-1000mg, 14mg- Limit 4 per 28 25mg-500mg cholecalciferol caps 50000 1 days;QL(0.286 unit ea daily) ascorbic acid tbcr or 1500 1 mg cholecalciferol chew 1000 1 unit biotin caps or 5 mg, 5000 1 mcg cholecalciferol chew 400 $0 PV unit niacin cpcr 1 cholecalciferol liqd 400 $0 PV unit/ml niacin tabs 1 cholecalciferol tabs 1000 1 unit niacin tbcr 1 cholecalciferol tabs 400 $0 PV unit NIACIN TR TBCR 2 pyridoxine hcl tabs or 25 D-VI-SOL LIQD (Use NP PV Cholecalciferol) mg, 50 mg, 100 mg, 250 1 mg, 500 mg DRISDOL CAPS (Use NP PV Ergocalciferol) RIBOFLAVIN CAPS 50 MG 2 ergocalciferol caps $0 PV riboflavin tabs 50 mg, 100 1 QL(3.34 ea mg daily) ergocalciferol soln $0 PV SLO-NIACIN TBCR (Use NP Niacin) MEPHYTON TABS (Use NP Phytonadione) thiamine hcl tabs or 50 mg, 1 QL(3.34 ea 100 mg, 250 mg daily) phytonadione tabs or 5 mg 1 QL(3.34 ea thiamine mononitrate tabs 1 Vitamin A Cap/Tab F daily) VITAMIN C POWD 2 Vitamin E Cap F QL VITAMIN C SYRP 500 2 Vitamin E Liquid/Soln F MG/5ML Water Soluble Vitamins ASCOCID POWD 2 ascorbic acid chew or QL(3.34 ea 500mg, 500 mg, 7.5mg- 1 daily) 500mg ASCORBIC ACID POWD 2 OR

MHS Indiana Preferred Drug List Updated December 1, 2018

152 Index 1ST TIER UNIFINE ACCUPRIL 26 ADOXA PAK 2/100 146 PENTIPS/MINI/31GX5MM 96 ACCURETIC 27 ADVANCED MOBILE LANCET 1ST TIER UNIFINE acebutolol hcl 42 30G 85 PENTIPS29GX12MM 96 ADVATE 73 1ST TIER UNIFINE acetaminophen 6 ADVIL 4 PENTIPS31GX6MM 96 acetaminophen w/ codeine 8 1ST TIER UNIFINE ADVIL COLD & SINUS 48 acetazolamide 67 PENTIPS31GX8MM 96 ADVOCATE INSULIN PEN 1ST TIER UNIFINE acetic acid (otic) 140 NEEDLES 29GX12.7MM 96 PENTIPS32GX4MM 96 acetylcysteine 50 ADVOCATE INSULIN PEN 1ST TIER UNIFINE ACIPHEX 148 NEEDLES 31GX5MM 96 PENTIPSPLUS 31GX8MM 96 ADVOCATE INSULIN PEN 1ST TIER UNIFINE ACIPHEX SPRINKLE 148 NEEDLES 31GX8MM 96 PENTIPSPLUS 32GX4MM 96 ACNE MEDICATION 10 50 ADVOCATE INSULIN 1ST TIER UNIFINE ACNE MEDICATION 5 50 SYRINGE/U- PENTIPSPLUS/MINI/31GX5MM ACTEMRA 4 100/0.3ML/29GX1/2" 96 96 ADVOCATE INSULIN 1ST TIER UNIFINE ACTHIB 150 SYRINGE/U- PENTIPSPLUS/ORIGINAL/29GX ACTI-LANCE LANCETS 100/0.3ML/30GX5/16" 96 12MM 96 28G 85 ADVOCATE INSULIN 1ST TIER UNIFINE ACTI-LANCE LITE SAFETY SYRINGE/U- PENTIPSPLUS/ULTRA LANCETS 28G 85 100/0.3ML/31GX5/16" 96 SHORT/31GX6MM 96 ACTI-LANCE SPECIAL ADVOCATE INSULIN 1ST TIER UNILET SAFETY LANCETS 17G 85 SYRINGE/U- COMFORTOUCH LANCETS ACTI-LANCE SPECIAL 100/0.5ML/29GX1/2" 96 28G 84 SAFETYLANCETS 17G 85 ADVOCATE INSULIN 1ST TIER UNILET ACTI-LANCE UNIVERSAL SYRINGE/U- COMFORTOUCH LANCETS SAFETY LANCETS 23G 85 100/0.5ML/30GX5/16" 96 30G 85 ACTIGALL 71 ADVOCATE INSULIN 4-N-1 61 ACTIMMUNE 32 SYRINGE/U- A + D PERSONAL CARE ACTIVE 1ST BLOOD 100/0.5ML/31GX5/16" 96 LOTION 54 LANCETS30G/EASY TWIST ADVOCATE INSULIN abacavir sulfate 38 CAP 85 SYRINGE/U-100/1ML/29GX1/2" ACTIVELLA 70 96 abacavir sulfate-lamivudine 38 ADVOCATE INSULIN abacavir sulfate-lamivudine- ACTONEL 68 SYRINGE/U-100/1ML/30GX5/16" zidovudine 38 ACTOPLUS MET 20 96 37 ABILIFY ACTOS 21 ADVOCATE INSULIN 37 SYRINGE/U-100/1ML/31GX5/16" ABILIFY MAINTENA ACULAR 139 30 96 abiraterone acetate ACULAR LS 139 53 ADVOCATE LANCETS 85 ABREVA acyclovir 41 65 ADVOCATE LANCETS 30G 85 ACCU-CHEK AVIVA PLUS acyclovir topical 53 ACCU-CHEK FASTCLIX ADVOCATE SAFETY LANCETS 85 ADACEL 147 LANCETS 85 ADALAT CC 42 ADVOCATE SAFETY LANCETS ACCU-CHEK GUIDE 65 26G 85 ACCU-CHEK MULTICLIX ADCETRIS 30 ADYNOVATE 73 LANCETS 85 ADCIRCA 44 ACCU-CHEK SAFE-T-PRO ADZENYS ER 1 LANCETS 85 ADDERALL 1 ADZENYS XR-ODT 1 ACCU-CHEK SAFE-T-PRO ADDERALL XR 1 AEROCHAMBER MINI PLUSLANCETS 85 adefovir dipivoxil 40 AEROSOLCHAMBER 124 ACCU-CHEK SMARTVIEW ADEMPAS 44 AEROCHAMBER MV 124 STRIPS 65 ADMELOG 21 AEROCHAMBER PLUS FLOW ACCU-CHEK SOFT TOUCH VU 124 LANCETS 85 ADMELOG SOLOSTAR 21 AEROCHAMBER PLUS FLOW- ACCU-CHEK SOFTCLIX ADOXA 146 VU 124 LANCETS 85 ADOXA PAK 1/100 146

Index 1 AEROCHAMBER PLUS FLOW- ALLEVYN THIN 79 amlodipine-valsartan- VU/LARGE MASK 124 allopurinol 72 hydrochlorothiazide 27 AEROCHAMBER PLUS FLOW- AMOXAPINE 19 ALOCRIL 139 VU/MASK 124 amoxicillin 141 AEROCHAMBER PLUS FLOW- ALOE AFTERSUN VU/MEDIUM MASK 124 LOTION 54 AMOXICILLIN 141 AEROCHAMBER PLUS FLOW- ALOE VESTA DAILY amoxicillin 141 VU/SMALL MASK 124 MOISTURIZER 61 amoxicillin & pot AEROCHAMBER Z-STAT PLUS ALOE VESTA SKIN clavulanate 141 VALVED HOLDING CHAMBER CONDITIONER 61 AMOXICILLIN/CLAVULANATE W/FLOW VU 124 alogliptin benzoate 21 POTASSIUM 142 AEROCHAMBER Z-STAT alogliptin-metformin hcl 20 amphetamine sulfate 1 PLUS/FLOWSIGNAL 124 alogliptin-pioglitazone 20 amphetamine- AEROCHAMBER Z-STAT dextroamphetamine 1 PLUS/LARGE MASK 124 ALOMIDE 139 ampicillin 141 AEROCHAMBER Z-STAT ALORA 70 PLUS/MEDIUM MASK 124 ALPHANATE/VON AMPICILLIN 141 AEROCHAMBER Z-STAT WILLEBRANDFACTOR AMPYRA 144 PLUS/SMALL MASK 124 COMPLEX/HUMAN 73 AMYTAL SODIUM 76 AEROCHAMBER/FLOWSIGNAL ALPHANINE SD 73 124 ANAFRANIL 19 AEROSPAN 12 alprazolam 11 anagrelide hcl 74 AEROVENT PLUS HOLDING ALPRAZOLAM 45 ANAPROX DS 5 CHAMBER/COLLAPSIBLE 125 ALPRAZOLAM INTENSOL11 anastrozole 30 AFINITOR 31 ALPROLIX 73 ANDRODERM 9 AFINITOR DISPERZ 31 ALTACE 26 ANDROXY 9 AFSTYLA 73 alum & mag hydrox- ANTABUSE 143 9 AGAMATRIX ULTRA-THIN simethicone ANTHELIOS 60 MELT-IN LANCETS 33G 85 ALUMINUM HYDROXIDE 9 SUNSCREEN 62 AGRYLIN 74 amantadine hcl 33 ANTI-BACTERIAL HAND AIMSCO LUBRICATED 83 AMARYL 22 LOTION 61 ALBOLENE 54 AMBIEN 76 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X albuterol sulfate 13 AMBIEN CR 76 1/2" 96 ALBUTEROL SULFATE ER 13 AMD FOAM DRESSING ANTI-STICK INSULIN ALCOHOL PREP PADS 95 4"X4" 79 SYRINGE/U-100/0.5ML/29G X AMD FOAM ALCOHOL PREPS 95 1/2" 96 DRESSING/TOPSHEET ANTI-STICK INSULIN ALCOHOL SWABS 95 4"X4" 79 SYRINGE/U-100/1ML/29G X ALCOHOL SWABSTICK 95 AMERGE 127 1/2" 97 ALCOHOL WIPES 95 AMICAR 75 ANUSOL-HC 9 ALDACTAZIDE 67 amiloride & APLENZIN 17 ALDACTONE 67 hydrochlorothiazide 67 APLICARE ALCOHOL amiloride hcl 67 ALDARA 60 SWABSTICK 95 amiodarone hcl 12 apraclonidine hcl 138 ALDURAZYME 69 amitriptyline hcl 19 APTENSIO XR 2 ALENDRONATE SODIUM 68 AMLACTIN CERAPEUTIC 54 APTIVUS 38 alendronate sodium 68 AMLACTIN ULTRA 54 AQUA GLYCOLIC FACE ALENDRONATE SODIUM 68 CREAM 54 amlodipine besylate 42 alendronate sodium 68 AQUA GLYCOLIC HAND & amlodipine besylate-benazepril ALEVE 5 BODYLOTION 54 hcl 27 AQUA LACTEN 55 ALEVE ARTHRITIS 5 amlodipine besylate-olmesartan AQUA-E 151 ALKERAN 29 medoxomil 27 amlodipine besylate- AQUADERM ALLEGRA ALLERGY 24 valsartan 27 TREATMENT/MOISTURIZER ALLEVYN PLUS CAVITY 79 55

Index 2 AQUALANCE LANCETS ULTRA ASSURE HAEMOLANCE AURORA UNIFINE THIN 30G 85 PLUS PEDIATRIC BLADE 85 PENTIPS/32GX5/32" 97 AQUAMED 55 ASSURE ID INSULIN AURORA UNIFINE AQUANIL SKIN CLEANSER 61 SAFETYSYRINGE/U- PENTIPS/MINI/31GX3/16" 97 100/0.5ML/29G X 1/2" 97 AUTOJECT 2 97 AQUAPHILIC 55 ASSURE ID INSULIN AVALIDE 27 AQUAPHOR 55 SAFETYSYRINGE/U- AQUAPHOR ADVANCED 100/1ML/29G X 1/2" 97 AVAPRO 27 THERAPY 55 ASSURE ID SAFETY PEN AVASTIN 30 ARALAST NP 145 NEEDLES 30G X 5/16" 97 AVEENO ABSOLUTELY ASSURE LANCE ARANESP ALBUMIN FREE 74 AGELESSLEAVE-ON DAY LANCETS 85 MASK SPF 30 62 ARAVA 6 ASSURE LANCE LANCETS AVEENO ACTIVE NATURALS ARCALYST 4 21G 85 DAILY MOISTURIZING BODY arginine 137 ASSURE LANCE PLUS YOGURT 55 SAFETYLANCETS 25G 85 AVEENO ACTIVE NATURALS ARGININE 137 ASSURE LANCE PLUS DAILY MOISTURIZING BODY arginine 137 SAFETYLANCETS 30G 85 YOGURT/APRICO 55 ARGININE HCL 45 ASSURE LANCETS 85 AVEENO ACTIVE NATURALS ARIAL CHAMBER 125 ASTEPRO 135 PROTECT+HYDRATE/SPF 30 62 ARICEPT 143 AT LAST LANCETS 85 AVEENO ACTIVE NATURALS ARIMIDEX 30 ATACAND 26 SKIN RELIEF MOISTURE aripiprazole 37 ATACAND HCT 27 REPAIR 55 ARISTADA 37 atazanavir sulfate 38 AVEENO BABY CONTINUOUS PROTECTION 62 ARISTADA INITIO 37 ATELVIA 68 AVEENO DAILY ARIXTRA 14 atenolol 42 MOISTURIZINGSPF 15 55 armodafinil 2 atenolol & chlorthalidone 27 AVEENO INTENSE RELIEF HAND 55 ARMOUR THYROID 146 ATIVAN 11 AVEENO NATURAL AROMASIN 30 ATLAS COLORED PROTECTIONSPF 50 62 ARTHRITIS PAIN LUBRICATEDCONDOM 83 AVEENO POSITIVELY RELIEVING 60 ATLAS LUBRICATED AGELESSFIRMING BODY 55 CONDOM 83 AVEENO POSITIVELY artificial tear ointment 137 ATLAS LUBRICATED artificial tear solution 137 AGELESSSKIN CONDOM/SPERMICIDE 83 STRENGTHENING BODY ARZERRA 30 atomoxetine hcl 2 CREAM 55 ASCOCID 152 atorvastatin calcium 25 AVEENO POSITIVELY ascorbic acid 152 ATRIPLA 38 AGELESSSKIN STRENGTHENING HAND ASCORBIC ACID 152 ATROPINE SULFATE 137 CREAM 55 ascorbic acid 152 ATROVENT HFA 12 AVEENO POSITIVELY aspirin 6 AUBAGIO 144 NOURISHING 24-HOUR ULTRA- ASPIRIN 6 AUGMENTIN 142 HYDRATING 55 AVEENO POSITIVELY aspirin 6,7 AUGMENTIN ES-600 142 RADIANT 55 aspirin buffered (cal carb-mag AUGMENTIN XR 142 AVEENO POSITIVELY carb-mag oxide) 6 AURORA LANCET SUPER RADIANTCLEANSER 61 ASSURE COMFORT LANCETS THIN30G 85 AVEENO POSITIVELY ULTRA THIN 28G 85 AURORA LANCET THIN RADIANTDAILY MOISTURIZER ASSURE HAEMOLANCE PLUS 23G 85 SPF15 62 HIGH FLOW 18G 85 AURORA PEN NEEDLES AVEENO POSITIVELY ASSURE HAEMOLANCE PLUS 29GX12MM 97 RADIANTDAILY MOISTURIZER LOW FLOW 25G 85 AURORA PEN NEEDLES 31G SPF30 63 ASSURE HAEMOLANCE PLUS X6MM 97 AVEENO POSITIVELY MICRO FLOW 28G 85 AURORA PEN NEEDLES 31G RADIANTOVERNIGHT ASSURE HAEMOLANCE PLUS X8MM 97 HYDRATING FACIAL NORMAL FLOW 21G 85 MOISTURI 55

Index 3 AVEENO POSITIVELY bacitracin-polymyxin b 51 BD INSULIN SYRINGE ULTRA- RADIANTTINTED bacitracin-polymyxin b FINE/1ML/30G X 12.7MM 97 MOISTURIZER SPF30 (ophth) 138 BD INSULIN SYRINGE ULTRA- FAIR/LIGHT 63 baclofen 134 FINE/1ML/31G X 8MM 97 AVEENO POSITIVELY BD INSULIN SYRINGE RADIANTTINTED BACTRIM 10 ULTRAFINE HALF- MOISTURIZER SPF30 BACTRIM DS 10 UNIT/0.3ML/31G X 5/16" 97 MEDIUM 63 BACTROBAN 51 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X AVEENO PROTECT + balsalazide disodium 72 HYDRATESPF 50 63 5/16" 97 AVEENO PROTECT + BAND-AID GAUZE PADS BD INSULIN SYRINGE HYDRATESPF 70 63 LARGE4" X 4" 79 ULTRAFINE/0.5ML/31G X AVEENO SMART ESSENTIALS BAND-AID GAUZE PADS 5/16" 97 DAILY NOURISHING MEDIUM 3" X 3" 79 BD INSULIN SYRINGE MOISTURIZER SPF30 63 BAND-AID GAUZE PADS ULTRAFINE/1ML/30G X AVEENO STRESS RELIEF SMALL2" X 2" 79 1/2" 97 MOISTURIZING 55 BAND-AID MIRASORB GAUZE BD INSULIN SYRINGE AVEENO ULTRA-CALMING SPONGES LARGE 4" X 4" 79 ULTRAFINE/U-100/0.3ML/29G X DAILY MOISTURIZER BARACLUDE 40 1/2" 97 SPF15 63 BASAGLAR KWIKPEN 21 BD INSULIN SYRINGE AVEENO ULTRA-CALMING BASIS FACIAL ULTRAFINE/U-100/0.3ML/31G X DAILY MOISTURIZER MOISTURIZER 61 15/64" 98 SPF30 63 BASIS OVERNIGHT 61 BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/31G X AVONEX 144 BASLE 55 AVONEX PEN 144 5/16" 98 BAYER MICROLET BD INSULIN SYRINGE AYGESTIN 143 LANCETS 85 ULTRAFINE/U-100/0.5ML/29G X azacitidine 30 BAZA CLEANSE & 1/2" 98 PROTECT 61 AZASAN 130 BD INSULIN SYRINGE BD LO-DOSE INSULIN ULTRAFINE/U-100/0.5ML/31G X azathioprine 130 SYRINGE MICROFINE 5/16" 98 azelastine hcl 135 IV/0.5ML/28G X 1/2" 97 BD INSULIN SYRINGE azelastine hcl (ophth) 140 BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X MICROFINE IV/U- azithromycin 78 1/2" 98 100/0.5ML/28G X 1/2" 97 BD INSULIN SYRINGE AZOPT 140 BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/30G X AZOR 27 MICROFINE IV/U- 1/2" 98 100/1ML/28G X 1/2" 97 BD INSULIN SYRINGE AZULFIDINE 72 BD INSULIN SYRINGE AZULFIDINE EN-TABS 72 ULTRAFINE/U-100/1ML/31G X MICROFINE/U-100/0.5ML/28G 5/16" 98 B-12 74 X 1/2" 97 BD INSULIN B-Complex Vitamin BD INSULIN SYRINGE SYRINGE/0.3ML/29G X Cap/Tab 131 MICROFINE/U-100/1ML/28G X 12.7MM 98 b-complex w/ c & folic acid 131 1/2" 97 BD INSULIN BD INSULIN SYRINGE B-D INSULIN SYRINGE SYRINGE/0.5ML/29G X ULTRAFINE II/0.3ML/31G X SAFETYGLIDE/0.5ML/29G X 12.7MM 98 1/2" 97 BD INSULIN SYRINGE/1ML/29G 5/16" 97 BD INSULIN SYRINGE B-D INSULIN SYRINGE X 12.7MM 98 ULTRAFINE II/0.5ML/31G X SAFETYGLIDE/1ML/29G X BD INSULIN SYRINGE/U- 1/2" 97 100/1ML/28G X 1/2" 98 5/16" 97 BD INSULIN SYRINGE B-D INSULIN SYRINGE BD INTEGRA INSULIN ULTRAFINE II/1ML/31G X ULTRA-FINE/0.3ML/31G X SYRINGE/U-100/1ML/29G X 8MM 97 1/2" 98 5/16" 97 BD INSULIN SYRINGE BACIGUENT 51 BD LANCET ULTRAFINE ULTRA-FINE/0.5ML/31G X 30G 85 BACITRACIN 138 8MM 97 BD LANCET ULTRAFINE bacitracin (topical) 51 BD INSULIN SYRINGE 33G 85 bacitracin zinc 51 ULTRA-FINE/1/2 BD MICROTAINER UNIT/0.3ML/31G X 8MM 97 LANCETS 85

Index 4 BD PEN BENTYL 147 BONIVA 68 NEEDLE/MICRO/ULTRA- BENZAC AC WASH 50 BOOSTRIX 147 FINE/32G X 6MM 98 BD PEN NEEDLE/MINI/ULTRA- benzonatate 48 BORDERED GAUZE 79 FINE/31G X 5MM 98 benzoyl peroxide 50 BOSULIF 31 BD PEN BENZOYL PEROXIDE 50 BOTOX 136 NEEDLE/NANO/ULTRA- benzoyl peroxide 50 BOUDREAUXS BABY BUTT FINE/32G X 4MM 98 SMOOTH DRY SKIN 55 BD PEN BENZOYL PEROXIDE NEEDLE/ORIGINAL/ULTRA- CLEANSER 50 BRAFTOVI 31 FINE/29G X 12.7MM 98 benztropine mesylate 33 BREATHE EASE/LARGE BD PEN BERINERT 74 MASK 125 BREATHE EASE/MEDIUM NEEDLE/SHORT/ULTRA- BETA CARE 55 FINE/31G X 8MM 98 MASK 125 BD SAFETY-GLIDE INSULIN BETA XMA 55 BREATHE EASE/SMALL SYRINGE/0.5ML/29G X 1/2" 98 BETADINE 38 MASK 125 BD SAFETY-LOK INSULIN BETAGAN 137 BREATHERITE 125 SYRINGE/PERM betamethasone dipropionate BREATHERITE NEEDLE/UF/1ML/29G X (topical) 53 COLLAPSIBLEADULT SPACER 1/2" 98 betamethasone dipropionate W/MASK 125 BD SAFETYGLIDE INSULIN augmented 53 BREATHERITE COLLAPSIBLECHILD SPACER SYRINGE/0.3ML/29G X 1/2" 98 betamethasone valerate 53 BD SAFETYGLIDE INSULIN W/MASK 125 SYRINGE/0.3ML/31G X BETAPACE 42 BREATHERITE 15/64" 98 BETAPACE AF 42 COLLAPSIBLEINFANT SPACER BD SAFETYGLIDE INSULIN BETASERON 144 W/MASK 125 SYRINGE/0.3ML/31G X BREATHERITE 5/16" 98 betaxolol hcl (ophth) 137 COLLAPSIBLESMALL CHILD BD SAFETYGLIDE INSULIN bethanechol chloride 149 SPACER W/MASK 125 SYSYRINGE/0.5ML/30G X BETHKIS 4 BREATHERITE 5/16" 98 bexarotene 32 COLLAPSIBLESPACER W/ 95 NEONATE MASK 125 BD SWABS SINGLE USE BEXSERO 150 BD VEO INSULIN SYRINGE BREATHERITE RIGID BIATAIN ADHESIVE FOAM SPACERW/MASK 125 ULTRA-AFINE/0.3ML/31G X DRESSING 4"X4" 79 6MM 98 BREATHERITE W/LARGE BIATAIN FOAM DRESSING MASK 125 BD VEO INSULIN SYRINGE 4"X4" 79 ULTRA-FINE/0.3ML/31G X BREATHERITE W/MEDIUM 6MM 98 BIAXIN 78 MASK 125 BD VEO INSULIN SYRINGE bicalutamide 30 BREATHERITE W/SMALL MASK 125 ULTRA-FINE/1/2 BIKTARVY 38 BREVICON-28 45 UNIT/0.3ML/31G X 6MM 98 BIOGUARD GAUZE SPONGE BEBULIN 73 2"X2" 8 PLY 79 BRILINTA 74 BELSOMRA 77 BIOGUARD GAUZE brimonidine tartrate 138 BENADRYL ALLERGY 24 SPONGES 4"X4" 12 PLY 79 bromocriptine mesylate 33 BENADRYL ALLERGY biotin 152 brompheniramine & CHILDRENS 24 bisacodyl 78 phenyleph 48 benazepril & bismuth subsalicylate 22 brompheniramine & hydrochlorothiazide 27 bisoprolol & pseudoeph 48 benazepril hcl 26 hydrochlorothiazide 27 BROTAPP DM 48 BENDAMUSTINE bisoprolol fumarate 42 budesonide (inhalation) 13 HYDROCHLORIDE 29 BIVIGAM 140 budesonide (nasal) 135 BENDEKA 29 BLENDED SUSPENDING BUFFERIN 7 BENEFIX 73 COMPOUND 142 BULL FROG SUPERBLOCK BENICAR 27 BLEPH-10 138 SPF50 63 BENICAR HCT 27 BLEPHAMIDE 139 BULL FROG ULTIMATE SHEERPROTECTION FACE BENLYSTA 131 BLEPHAMIDE S.O.P. 139 SUNBLOCK SPF 30 63

Index 5 BULL FROG ULTIMATE calcium acetate (phosphate CAREFINE PEN NEEDLE SHEERPROTECTION binder) 72 32GX4MM 98 SUNBLOCK SPF 30 63 calcium carbonate 128 CAREFINE PEN NEEDLES BULL FROG WATER ARMOR calcium carbonate (antacid) 9 29GX1/2" 99 SPORT FACE SPF 30 63 CAREFINE PEN NEEDLES BULLSEYE MINI SAFETY calcium carbonate- 30GX5/16" 99 LANCETS 85 cholecalciferol 128 CAREFINE PEN NEEDLES BULLSEYE SAFETY calcium carbonate-vitamin 31GX6MM 99 LANCETS 86 d 128 CAREFINE PEN NEEDLES Calcium Carbonate-Vitamin D 31GX8MM 99 bumetanide 67 500 128 BUMEX 67 CAREFINE PEN NEEDLES Calcium Carbonate-Vitamin D 32GX5MM 99 BUPHENYL 69 600 128 CAREFINE PEN NEEDLES buprenorphine hcl 8 calcium citrate 128 32GX6MM 99 buprenorphine hcl-naloxone hcl CALCIUM CITRATE W/D 128 CAREONE INSULIN dihydrate 8 CALCIUM CITRATE SYRINGES/0.3ML/31G X bupropion hcl 17 W/VITAMIN D 128 5/16" 99 calcium citrate-vitamin d 128 CAREONE INSULIN BUPROPION HCL 45 SYRINGES/0.5ML/31G X bupropion hcl (smoking CALCIUM CITRATE/VITAMIN D3 128 5/16" 99 deterrent) 145 CAREONE INSULIN BUPROPION CALCIUM PLUS VITAMIN D 128 SYRINGES/1ML/30G X 1/2" 99 HYDROCHLORIDE 45 CAREONE INSULIN BUPROPION calcium polycarbophil 77 SYRINGES/1ML/31GX5/16" 99 HYDROCHLORIDE ER 17 Calcium w/ Vitamin D 128 CAREONE LANCET THIN 86 buspirone hcl 11 CALTRATE 600+D 128 CAREONE LANCET ULTRA BUSPIRONE HCL 45 CAM 55 THIN 86 butalbital-acetaminophen 6 camphor & menthol 52 CAREONE UNIFINE PENTIPS 29GX12MM 99 butalbital-acetaminophen- candesartan cilexetil 27 caffeine 6 CAREONE UNIFINE PENTIPS butalbital-acetaminophen- candesartan cilexetil- 31GX5MM 99 caffeine w/ codeine 8 hydrochlorothiazide 27 CAREONE UNIFINE PENTIPS butalbital-aspirin-caffeine 6 capecitabine 30 31GX6MM 99 capsaicin 60 CAREONE UNIFINE PENTIPS butalbital-aspirin-caffeine 31GX8MM 99 w/cod 8 captopril 26 CAREONE UNIFINE PENTIPS BUTALBITAL/ASPIRIN/CAFFEIN CAPTOPRIL/HYDROCHLORO PEN NEEDLES 32GX4MM 99 E 6 THIAZIDE 28 CAREONE UNIFINE PENTIPS BYDUREON 21 CAPZASIN-HP 60 PLUS PEN NEEDLES BYDUREON PEN 21 CARAC 52 29GX12MM 99 BYETTA 21 CARAFATE 148 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES CAFCIT 2 CARBAGLU 69 31GX5MM 99 caffeine citrate 2 carbamazepine 14 CAREONE UNIFINE PENTIPS CAL-CITRATE PLUS CARBAMAZEPINE 14 PLUS PEN NEEDLES VITAMIND 127 carbamazepine 14 31GX6MM 99 CALAN 43 CAREONE UNIFINE PENTIPS carbamide peroxide (otic) 140 CALAN SR 42 PLUS PEN NEEDLES CARBATROL 14 31GX8MM 99 CALCET CREAMY BITES 128 carbidopa 33 CAREONE UNIFINE PENTIPS CALCI-CHEW 128 PLUS PEN NEEDLES carbidopa-levodopa 33 calcipotriene 53 32GX4MM 99 carboxymethylcellulose sodium calcitonin (salmon) 68 CARETOUCH PEN NEEDLES (ophth) 137 31G X 6 MM 99 calcitriol 69 CARDIZEM 43 CARETOUCH PEN NEEDLES CALCIUM 128 CARDIZEM CD 43 31GX 5MM 99 calcium 128 CARDURA 27 CARETOUCH PEN NEEDLES 31GX 8MM 99

Index 6 CARETOUCH PEN NEEDLES CERAVE SUNSCREEN CHLORPROMAZINE HCL 36 32GX 4MM 99 FACE/SPF50 63 chlorpromazine hcl 36 CARETOUCH PEN NEEDLES CERAVE 32GX 5MM 99 SUNSCREEN/BODY 63 chlorthalidone 68 CARETOUCH TWIST LANCETS CERAVE CHLORZOXAZONE 134 28G 86 SUNSCREEN/FACE 63 CHOLBAM 71 CARETOUCH TWIST LANCETS CERDELGA 74 cholecalciferol 151,152 30G 86 CEREZYME 74 CARETOUCH TWIST LANCETS cholestyramine 25 33G 86 CETAPHIL 55 cholestyramine light 25 CARIMUNE CETAPHIL DAILY ADVANCE CHORIONIC NANOFILTERED 140 ULTRA HYDRATING 55 GONADOTROPIN 68 CARNITOR 69 CETAPHIL DAILY FACIAL MOISTURIZER 55 cilostazol 74 CARNITOR SF 69 CETAPHIL DERMACONTROL CILOXAN 138 CARRASMART 79 MOISTURIZER/SPF 30 55 CIMDUO 38 CARRASMART FOAM 79 CETAPHIL cimetidine 147 MOISTURIZING 55 CARRINGTON MOISTURE CIMETIDINE HCL 147 BARRIER 61 CETAPHIL CARRINGTON MOISTURE RESTORADERM 56 CIMZIA 72 BARRIER/ZINC 61 CETAPHIL THERAPEUTIC CIMZIA STARTER KIT 72 HAND 56 CARTEOLOL HCL 137 CINRYZE 74 cetirizine hcl 24 carteolol hcl (ophth) 137 cetirizine-pseudoephedrine CIPRO 71 carvedilol 41 48 CIPRODEX 140 carvedilol phosphate 41 CHANTAL SUN SCREEN SPF CIPROFLOXACIN HCL 71 CASODEX 30 30 63 ciprofloxacin hcl 71 CATAPRES 27 CHANTIX 145 CHANTIX CONTINUING ciprofloxacin hcl (ophth) 138 cefaclor 44 MONTHPAK 145 citalopram hydrobromide 17 CEFACLOR 44 CHANTIX STARTING MONTH CITRACAL + D3 cefadroxil 44 PAK 145 MAXIMUM 128 cefdinir 44 CHEK-STIX COMBO PAK CITRACAL MAXIMUM 128 URINALYSIS CONTROL 65 CITRACAL cefprozil 44 CHEK-STIX CONTROL 65 PETITES/VITAMIND 128 CEFTIN 44 CHEMET 22 CLARITHROMYCIN 78 ceftriaxone sodium 44 CHEMSTRIP-K 65 clarithromycin 78 cefuroxime axetil 44 CHERACOL PLUS 48 CLARITIN 24 CELEBREX 5 CHERACOL-D COUGH 48 CLARITIN ALLERGY celecoxib 5 CHILDRENS ADVIL 5 CHILDRENS 24 CLARITIN REDITABS 24 CELEXA 17 CHILDRENS MOTRIN 5 CLARITIN-D 12 HOUR 48 CELLCEPT 130 CHLOR-TRIMETON 23 CELLCEPT CLARITIN-D 24 HOUR 48 CHLORAL HYDRATE 76 INTRAVENOUS 130 CLASS ACT LUBRICATED 83 chlordiazepoxide hcl 11 CENTANY 51 CLASSIC PRENATAL 132 cephalexin 44 CHLORDIAZEPOXIDE/AMITRI PTYLINE 144 CLEAN & CLEAR ADVANTAGE CEPROTIN 74 chlorhexidine gluconate 37 3-IN-1 EXFOLIATING CLEANSER 50 CERASPORT 128 chlorhexidine gluconate CLEANLET LANCETS 28G 86 CERASPORT EX1 128 (mouth-throat) 131 CLEAR COUGH PM MULTI- CERAVE 55 CHLOROQUINE PHOSPHATE 29 SYMPTOM 48 CERAVE AM SPF 30 55 chloroquine phosphate 29 clemastine fumarate 24 CERAVE PM 55 CHLOROTHIAZIDE 68 CLEOCIN 10,151 CERAVE RENEWING SA 55 chlorothiazide 68 CLEOCIN PEDIATRIC CERAVE SA RENEWING 55 GRANULES 10 chlorpheniramine maleate 23

Index 7 CLEOCIN-T 50 CLEVER CHOICE COMFORT clonidine hcl (adhd) 2 CLEVER CHEK LANCETS EZINSULIN SYRINGE/U- CLONIDINE ULTRATHIN 86 100/1ML/31GX5/16" 100 HYDROCHLORIDE 27 CLEVER CHEK LANCETS CLEVER CHOICE COMFORT clopidogrel bisulfate 74 EZLANCETS 21G 86 ULTRATHIN 30G 86 clorazepate dipotassium 11 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT STATICVALVED HOLDING EZLANCETS 23G 86 clotrimazole (topical) 52 CHAMBER/ADULT LARGE 125 CLEVER CHOICE COMFORT clotrimazole vaginal 151 CLEVER CHOICE ANTI- EZLANCETS 28G 86 clotrimazole w/ STATICVALVED HOLDING CLEVER CHOICE COMFORT betamethasone 52 EZPEN NEEDLES CHAMBER/MEDIUM 125 clozapine 35 CLEVER CHOICE ANTI- 29GX12MM 100 STATICVALVED HOLDING CLEVER CHOICE COMFORT CLOZAPINE ODT 35 CHAMBER/SMALL 125 EZPEN NEEDLES CLOZARIL 35 CLEVER CHOICE COMFORT 31GX5MM 100 CO-NATAL FA 132 CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES COAGADEX 73 31GX8MM 99 EZPEN NEEDLES CLEVER CHOICE COMFORT 31GX6MM 100 COAGUCHEK LANCETS 86 EZINSULIN CLEVER CHOICE COMFORT coal tar extract 64 SYRINGE/0.3ML/29G X 1/2" 99 EZPEN NEEDLES COARTEM 29 31GX8MM 100 CLEVER CHOICE COMFORT COCOA BUTTER 56 EZINSULIN CLEVER CHOICE COMFORT SYRINGE/0.3ML/30G X EZPEN NEEDLES COCOA BUTTER HAND & 5/16" 99 32GX4MM 100 BODYLOTION 56 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT COCONUT OIL BEAUTY 56 EZINSULIN EZPEN NEEDLES codeine sulfate 7 32GX6MM 100 SYRINGE/0.3ML/31G X CODEINE SULFATE 7 5/16" 99 CLICKFINE PEN NEEDLE CLEVER CHOICE COMFORT 32GX5/32" 100 COGENTIN 33 EZINSULIN CLICKFINE PEN NEEDLE COLACE 78 SYRINGE/0.5ML/28G X UNIVERSAL/31GX1/4" 100 COLAZAL 72 CLICKFINE PEN NEEDLE 1/2" 100 COLCHICINE 73 CLEVER CHOICE COMFORT UNIVERSAL/31GX5/16" 100 EZINSULIN CLICKFINE PEN colchicine 73 SYRINGE/0.5ML/29G X NEEDLES/31GX1/4" 100 colchicine w/ probenecid 72 CLICKFINE PEN 1/2" 100 COLCRYS 73 CLEVER CHOICE COMFORT NEEDLES/31GX5/16" 100 CLICKFINE UNIVERSAL PEN COLD-EEZE 130 EZINSULIN NEEDLES 31GX5/16" 100 SYRINGE/0.5ML/30G X COLESTID 25 5/16" 100 CLIMARA 70 COLESTID FLAVORED 25 CLEVER CHOICE COMFORT clindamycin hcl 11 colestipol hcl 25 EZINSULIN clindamycin palmitate COLYTE-FLAVOR PACKS 77 SYRINGE/0.5ML/31G X hydrochloride 11 5/16" 100 clindamycin phosphate COMBIPATCH 70 CLEVER CHOICE COMFORT (topical) 51 COMBIVENT RESPIMAT 13 EZINSULIN clindamycin phosphate COMBIVIR 38 SYRINGE/1.0ML/30G X vaginal 151 COMFORT ASSIST INSULIN 1/2" 100 CLN FACIAL MOISTURIZER SYRINGE 0.3ML/29G X CLEVER CHOICE COMFORT NOURISHING 56 1/2" 100 EZINSULIN SYRINGE/1ML/28G clobazam 14 COMFORT ASSIST INSULIN X 1/2" 100 clobetasol propionate 53 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT clobetasol propionate emollient 5/16" 100 EZINSULIN SYRINGE/1ML/29G base 53 COMFORT ASSIST INSULIN X 1/2" 100 SYRINGE/0.3ML/31G X CLEVER CHOICE COMFORT clomipramine hcl 19 clonazepam 14 5/16" 100 EZINSULIN SYRINGE/1ML/30G COMFORT ASSIST INSULIN X 5/16" 100 CLONIDINE HCL 27 SYRINGE/0.5ML/29G X clonidine hcl 27 1/2" 100

Index 8 COMFORT ASSIST INSULIN CORNWALL METAL CURITY AMD SYRINGE/0.5ML/30G X PIPETTINGHOLDER (FOR ANTIMICROBIALGAUZE 5/16" 100 1260S) 101 SPONGES 2"X2" 8 PLY 80 COMFORT ASSIST INSULIN CORNWALL METAL CURITY AMD SYRINGE/0.5ML/31G X PIPETTINGHOLDER (FOR ANTIMICROBIALGAUZE 5/16" 101 1270S) 101 SPONGES 4"X4" 12 PLY 80 COMFORT ASSIST INSULIN CORTANE-B-OTIC 140 CURITY COVER SPONGE SYRINGE/1ML/29G X 1/2" 101 CORTEF 47 4"X4" 80 COMFORT ASSIST INSULIN CURITY COVER SPONGES SYRINGE/1ML/30G X CORTENEMA 9 3"X3" 80 5/16" 101 CORTISONE ACETATE 47 CURITY COVER SPONGES COMFORT ASSIST INSULIN CORTROSYN 64 4"X4" 80 SYRINGE/1ML/31G X CURITY DRESSING SPONGES 5/16" 101 COSENTYX 53 4"X4" 6 PLY 80 COMFORT ASSURED COSENTYX SENSOREADY CURITY GAUZE PADS LANCETS MICRO THIN PEN 53 2"X2" 80 33G 86 COSOPT 137 CURITY GAUZE PADS 2"X2" 12 COMFORT ASSURED cosyntropin 64 PLY 80 LANCETS SUPER THIN COTELLIC 31 CURITY GAUZE PADS 28G 86 3"X3" 80 COTEMPLA XR-ODT 2 COMFORT LANCETS 86 CURITY GAUZE PADS 4"X4" 12 COMPACT SPACE COTZ 63 PLY 80 CHAMBER/ANTI-STATIC 125 COUMADIN 13 CURITY GAUZE SPONGE 2"X2" COMPACT SPACE COVRSITE COVER 8 PLY 80 CURITY GAUZE SPONGE CHAMBER/ANTI- DRESSING 79 STATIC/LARGE MASK 125 COVRSITE PLUS 2"X2"12 PLY 80 CURITY GAUZE SPONGE 3"X3" COMPACT SPACE COMPOSITE DRESSING 79 CHAMBER/ANTI- 12 PLY 80 COZAAR 27 CURITY GAUZE SPONGE 4"X4" STATIC/MEDIUM MASK 125 CREON 67 COMPACT SPACE 12 PLY 80 CHAMBER/ANTI-STATIC/SMALL CRESTOR 25 CURITY GAUZE SPONGE 4"X4" 16 PLY 80 MASK 125 CRIXIVAN 38 CURITY GAUZE SPONGE 4"X4" COMPLERA 38 cromolyn sodium 12 8 PLY 80 COMPLETENATE 132 cromolyn sodium (nasal) 135 CURITY GAUZE SPONGE CONCERTA 2 cromolyn sodium (ophth) 140 4"X4"16 PLY 80 CURITY GAUZE SPONGES CONDYLOX 60 crotamiton 62 4"X4" 12 PLY 80 COOL BOTTOMS 61 CUREX ALL-PURPOSE CURITY GAUZE SPONGES COPA ISLAND BORDERED SPONGES 4"X4" 4 PLY 79 4"X4" 8 PLY 80 FOAM DRESSING 4"X4" 79 CURITY ALCOHOL CURITY NON-ADHERENT COPA PLUS HYDROPHILIC PREPS/MEDIUM 2 PLY 95 STRIPS 3"X3" 80 FOAM DRESSING 4"X4" 79 CURITY ALCOHOL CURITY COPAXONE 144 SWABS 95 SPONGES/CELLULOSEFILLED/ CURITY ALL PURPOSE COPEGUS 40 2"X2" 80 SPONGES 2"X2" 79 CURITY COREG 42 CURITY ALL PURPOSE SPONGES/CELLULOSEFILLED/ COREG CR 41 SPONGES 2"X2" 4PLY 79 4"X4" 80 CORGARD 42 CURITY ALL PURPOSE CUVITRU 141 SPONGES 3"X3" 4PLY 79 CORIFACT 73 CURITY ALL PURPOSE CVS ALCOHOL PREP SPONGES 4 PLY 79 SWABS 95 corn starch 61 CVS DAILY ULTRA CORNWALL METAL CURITY ALL PURPOSE SPONGES 4"X4" 79 MOISTURELOTION 56 PIPETTINGHOLDER (FOR CVS GAUZE PAD 3"X3" 80 1240S) 101 CURITY ALL PURPOSE CORNWALL METAL SPONGES 4"X4" 4PLY 79 CVS GAUZE PADS 2"X2" 12- PIPETTINGHOLDER (FOR CURITY ALL PURPOSE PLY 80 1250S) 101 SPONGES 4"X4" 4PLY/SOFT CVS GAUZE PADS 4"X4" 12- POUCH 79 PLY 80

Index 9 CVS GAUZE PADS STERILE DAKINS SOLUTION DERMACEA I.V. DRAIN 4"X4" 12-PLY 80 QUARTER STRENGTH 38 SPONGES 4"X4" 80 CVS GLUCOSE 20 DAKLINZA 40 DERMACEA I.V. SPONGES CVS LANCETS 21G 86 dalfampridine 144 2"X2" 80 DERMACEA NON-WOVEN CVS LANCETS MICRO THIN danazol 9 SPONGES 2"X2" 4 PLY 80 33G 86 dapsone 10 DERMACEA NON-WOVEN CVS LANCETS MICRO-THIN SPONGES 3"X3" 4 PLY 81 33G 86 DAY TIME MULTI-SYMPTOM COLD/FLU RELIEF 48 DERMACEA NON-WOVEN CVS LANCETS ORIGINAL 86 DAYPRO 5 SPONGES 4"X4" 4 PLY 81 CVS LANCETS THIN 26G 86 DERMACEA NON-WOVEN DAYTRANA 2 CVS LANCETS ULTRA THIN SPONGES 4"X4" 6 PLY 81 30G 86 DDAVP 70 DERMACEA TYPE VII GAUZE CVS LANCETS ULTRA-THIN DEBROX 140 2"X2" 12 PLY 81 30G 86 decitabine 30 DERMACEA TYPE VII GAUZE 2"X2" 8 PLY 81 CVS MELATONIN 3 deferoxamine mesylate 22 CVS MOISTURIZING DERMACEA TYPE VII GAUZE CREAM 56 DELSYM 48 3"X3" 12 PLY 81 DERMACEA TYPE VII GAUZE CVS OMEPRAZOLE 148 DELSYM COUGH CHILDRENS 48 3"X3" 12PLY 81 CVS PRENATAL 132 DEMADEX 67 DERMACEA TYPE VII GAUZE CVS PRENATAL 4"X4" 12 PLY 81 GUMMY/DHA/FOLIC ACID 132 DEMEROL 7 DERMACEA TYPE VII GAUZE CVS PREP PADS 95 DEPACON 16 4"X4" 16 PLY 81 CVS ULTRA THIN DEPAKENE 16 DERMACEA TYPE VII GAUZE LANCETS 86 DEPAKOTE 16 4"X4" 8 PLY 81 cyanocobalamin 74 DERMACEA X-RAY SPONGES DEPAKOTE ER 16 4"X4" 16 PLY 81 CYCLESSA 45 DEPAKOTE SPRINKLES 16 DERMAIDE ALOE 56 cyclobenzaprine hcl 134 DEPEN TITRATABS 130 DERMAL THERAPY EXTRA CYCLOGYL 137 DEPLIN 15 66 STRENGTH BODY LOTION 56 cyclopentolate hcl 137 DERMAL THERAPY FACE DEPLIN 7.5 66 CAREMOISTURIZING cyclosporine 130 DEPO-PROVERA 30 LOTION 56 CYCLOSPORINE DEPO-PROVERA DERMAL THERAPY FOOT MODIFIED 130 CONTRACEPTIVE 47 MASSAGE 56 cyclosporine modified (for DEPO-SUBQ PROVERA DERMAL THERAPY HAND microemulsion) 130 104 47 ELBOW & KNEE CREAM 56 CYMBALTA 18 DEPO-TESTOSTERONE 9 DERMAL THERAPY HEEL cyproheptadine hcl 24,25 DERMABASEOIL IN CARE 56 CYPROHEPTADINE HCL 45 WATER 56 DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" 81 CYSTADANE 69 DERMACEA DRAIN SPONGES 4"X4" 80 DERMEND MOISTURIZING CYSTAGON 72 DERMACEA GAUZE SPONGE BRUISE FORMULA 56 CYTOGAM 141 2"X2" 12 PLY 80 DERMOTIC 140 CYTOMEL 146 DERMACEA GAUZE SPONGE DESCOVY 38 2"X2" 8 PLY 80 DESFERAL 22 CYTOTEC 149 DERMACEA GAUZE SPONGE D-VI-SOL 152 3"X3" 12 PLY 80 DESIPRAMINE HCL 19 D.H.E. 45 127 DERMACEA GAUZE SPONGE desipramine hcl 19 DACOGEN 30 3"X3" 8 PLY 80 desmopressin acetate 70 DERMACEA GAUZE SPONGE DAILY CONDITIONING 4"X4" 12 PLY 80 desmopressin acetate spray 70 TREATMENT 56 DERMACEA GAUZE SPONGE desmopressin acetate spray dakin's solution 37 4"X4" 16 PLY 80 refrigerated 70 DAKINS SOLUTION FULL DERMACEA GAUZE SPONGE DESOGEN 45 STRENGTH 38 4"X4" 8 PLY 80 desogestrel & ethinyl DAKINS SOLUTION HALF DERMACEA I.V. DRAIN estradiol 45 STRENGTH 38 SPONGES 2"X2" 80

Index 10 desogestrel-ethinyl estradiol DIAZEPAM 11,12 disulfiram 143 (biphasic) 45 diazepam 12 DITROPAN XL 149 desogestrel-ethinyl estradiol (triphasic) 45 DIAZEPAM 14,45 divalproex sodium 16 desonide 53 diazepam (anticonvulsant) 14 DMAE 56 DESOWEN 53 DIAZEPAM RECTAL GEL 14 DML FORTE 56 DESOXYN 1 dibucaine 60 docusate calcium 78 DESQUAM-X WASH 51 dibucaine (rectal) 9 docusate sodium 78 DESVENLAFAXINE ER 18 diclofenac potassium 5 dofetilide 12 desvenlafaxine succinate 18 diclofenac sodium 5 DOLOPHINE 7 DETROL 149 diclofenac sodium (ophth)140 donepezil hydrochloride 143 DETROL LA 149 diclofenac sodium (topical) 51 DOPRAM 2 DEX4 QUICK DISSOLVE dicloxacillin sodium 142 DORZOLAMIDE HCL 140 GLUCOSE 20 dicyclomine hcl 147 dorzolamide hcl 140 dexamethasone 47 didanosine 38 dorzolamide hcl-timolol DEXAMETHASONE 47 DIFLUCAN 23 maleate 137 dexamethasone 47 DORZOLAMIDE HCL/TIMOLOL diflunisal 7 MALEATE 137 DEXAMETHASONE 47 DIGOXIN 43 DOVONEX 53 dexamethasone sodium phosphate 47 digoxin 43 doxazosin mesylate 27 DEXAMETHASONE SODIUM dihydroergotamine doxepin hcl 19 mesylate 127 PHOSPHATE 139 DOXEPIN HCL 19 DILANTIN 16 DEXEDRINE 1 DOXEPIN DEXILANT 148 DILANTIN INFATABS 16 HYDROCHLORIDE 19 dexmedetomidine hcl 76 DILANTIN-125 16 doxycycline (monohydrate) 146 dexmethylphenidate hcl 2 DILAUDID 7 doxycycline hyclate 146 dextroamphetamine sulfate 1 diltiazem hcl 43 doxylamine succinate (sleep) 75 dextromethorphan polistirex 48 diltiazem hcl coated beads 43 DRAMAMINE 23 dextromethorphan-doxylamine- diltiazem hcl extended release acetaminophen 48 beads 43 DRISDOL 152 dextromethorphan-guaifenesin dimenhydrinate 23 DROPERIDOL 11 48,49 DIMETAPP COLD & droperidol 11 dextromethorphan- ALLERGY 49 DROPLET INSULIN SYRINGE phenylephrine-acetaminophen dimethicone (topical) 61 U-100/0.3/31G X 5/16" 101 49 DIOVAN 27 DROPLET INSULIN SYRINGE DHEA 56 DIOVAN HCT 28 U-100/0.3ML/30G X 5/16" 101 DHS TAR 64 DROPLET INSULIN SYRINGE diphenhydramine hcl 24 DHS TAR GEL 64 U-100/0.3ML/31G X 15/64" 101 diphenhydramine hcl DROPLET INSULIN SYRINGE DIABETIDERM 56 (sleep) 75 U-100/0.5ML/30G X 5/16" 101 DIABETIDERM CLEANSING61 diphenhydramine hcl DROPLET INSULIN SYRINGE DIABETIDERM FOOT (topical) 52 U-100/0.5ML/31G X 5/16" 101 REJUVENATING 56 diphenoxylate w/ atropine 22 DROPLET INSULIN SYRINGE DIABETIDERM HAND & DIPHENOXYLATE/ATROPINE U-100/1ML/30G X 1/2" 101 BODY 56 22 DROPLET INSULIN SYRINGE DIABETIDERM SUNSCREEN DIPHTHERIA/TETANUS U-100/1ML/30G X 5/16" 101 SPF15 63 TOXOIDS ADSORBED DROPLET INSULIN SYRINGE DIAMOX 67 PEDIATRIC 147 U-100/1ML/31G X 5/16" 101 diaper rash products 54 DIPROLENE AF 54 DROPLET LANCETS ULTRA THIN 30G 86 DIASTAT ACUDIAL 14 dipyridamole 74 DROPLET PEN NEEDLES DIASTAT PEDIATRIC 14 DISALCID 7 29GX12MM 101 diazepam 11 disopyramide phosphate 12 DROPLET PEN NEEDLES 31GX5MM 101

Index 11 DROPLET PEN NEEDLES E-Z JECT LANCETS SUPER EASY TOUCH FLIPLOCK 31GX6MM 101 THIN 30G 86 SAFETY INSULIN SYRINGE DROPLET PEN NEEDLES E-Z JECT LANCETS THIN 1ML/30GX1/2" 102 31GX8MM 101 26G 86 EASY TOUCH FLIPLOCK DROPLET PEN NEEDLES 32G E-Z SPACER 125 SAFETY INSULIN SYRINGE X 1/4" 101 E-Z SPACER THE BODY 1ML/30GX5/16" 102 DROPLET PEN NEEDLES 32G GUARDS PACK 125 EASY TOUCH FLIPLOCK X 3/16" 101 E-ZJECT LANCETS MICRO- SAFETY INSULIN SYRINGE DROPLET PEN NEEDLES 32G THIN 33G 86 1ML/31GX5/16" 102 X 5/32" 101 E.E.S. GRANULES 79 EASY TOUCH INSULIN DROPLET PEN NEEDLES SYRINGE/0.3ML/30G X 32GX4MM 101 EASIVENT 125 5/16" 102 DROPLET PEN NEEDLES EASIVENT/MASK-LARGE EASY TOUCH INSULIN 32GX6MM 101 125 SYRINGE/0.3ML/31G X drospirenone-ethinyl EASIVENT/MASK-MEDIUM 5/16" 102 estradiol 45 125 EASY TOUCH INSULIN DROXIA 74 EASIVENT/MASK-SMALL SYRINGE/0.5ML/29G X 125 1/2" 102 DROXY CREAM 56 EASY COMFORT INSULIN DRUG MART LANCETS EASY TOUCH INSULIN SYRINGE/0.5ML/30G X SYRINGE/0.5ML/30G X THIN 86 5/16" 101 DRUG MART ON-THE-GO 5/16" 102 EASY COMFORT INSULIN EASY TOUCH INSULIN LANCETS GENTLE 30G 86 SYRINGE/0.5ML/31G X DRUG MART UNIFINE PENTIPS SYRINGE/1ML/30G X 5/16" 101 5/16" 102 31GX5MM 101 EASY COMFORT INSULIN DRUG MART UNIFINE EASY TOUCH INSULIN SYRINGE/1ML/30G X SYRINGE/SAFETY/U- PENTIPS29G X 12MM 101 5/16" 102 DRUG MART UNIFINE 100/0.5ML/29G X 1/2" 102 EASY COMFORT INSULIN EASY TOUCH INSULIN PENTIPS31GX6MM 101 SYRINGE/1ML/31G X DRUG MART UNIFINE SYRINGE/SAFETY/U- 5/16" 102 100/0.5ML/30G X 5/16" 102 PENTIPS31GX8MM 101 EASY COMFORT INSULIN DRUG MART UNIFINE EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/SAFETY/U- PENTIPS32GX4MM 101 1/2" 102 DRUG MART UNIFINE 100/1ML/29G X 1/2" 102 EASY COMFORT EASY TOUCH INSULIN PENTIPSPLUS 32GX4MM 101 LANCETS 86 DRUG MART UNILET SYRINGE/SAFETY/U- EASY COMFORT LANCETS 100/1ML/30G X 1/2" 102 LANCETSSUPER THIN 30G86 30G/PULL TOP 86 DRUG MART UNILET EASY TOUCH INSULIN EASY COMFORT LANCETS SYRINGE/U-100/0.5ML/28G X LANCETSULTRA THIN 28G 86 30G/THIN TOP 86 DRUG MART UNILET MICRO 1/2" 102 EASY COMFORT LANCETS EASY TOUCH INSULIN THIN LANCETS 33G 86 TWIST TOP 86 DRYMAX EXTRA 81 SYRINGE/U-100/0.5ML/31G X EASY COMFORT PEN 5/16" 102 DULCOLAX 78 NEEDLES31GX1/4" 102 EASY TOUCH INSULIN DULERA 13 EASY COMFORT PEN SYRINGE/U-100/1ML/28G X NEEDLES31GX3/16" 102 1/2" 102 duloxetine hcl 18 EASY COMFORT PEN DURAGESIC 7 EASY TOUCH INSULIN NEEDLES31GX5/16" 102 SYRINGE/U-100/1ML/29G X DUREX EXTRA SENSITIVE 83 EASY COMFORT PEN 1/2" 102 DUTOPROL 28 NEEDLES32GX5/32" 102 EASY TOUCH INSULIN EASY TOUCH DYANAVEL XR 1 SYRINGE/U-100/1ML/30G X 32GX5MM 102 1/2" 102 DYAZIDE 67 EASY TOUCH EASY TOUCH INSULIN DYSPORT 136 32GX6MM 102 EASY TOUCH ALCOHOL SYRINGE/U-100/1ML/31G X E-Z JECT LANCETS 86 PREP PADS/MEDIUM 95 5/16" 102 E-Z JECT LANCETS 21G 86 EASY TOUCH FLIPLOCK EASY TOUCH LANCETS E-Z JECT LANCETS SAFETY INSULIN SYRINGE 21G/PRESSURE COLOR 86 1ML/29GX1/2" 102 ACTIVATED 87

Index 12 EASY TOUCH LANCETS EASY TOUCH SAFETY ELIQUIS STARTER PACK 13 23G/PRESSURE LANCETS26G/BUTTON ELITE-THIN INSULIN ACTIVATED 87 ACTIVATED 87 SYRINGE/0.3ML/31G X EASY TOUCH LANCETS EASY TOUCH SAFETY 5/16" 103 26G/PRESSURE LANCETS26G/PRESSURE ELITE-THIN INSULIN ACTIVATED 87 ACTIVATED 87 SYRINGE/0.5ML/29G X EASY TOUCH LANCETS EASY TOUCH SAFETY 1/2" 103 26G/PULL-TOP 87 LANCETS28G/BUTTON ELITE-THIN INSULIN EASY TOUCH LANCETS ACTIVATED 87 SYRINGE/0.5ML/30G X 26G/TWIST 87 EASY TOUCH SAFETY 5/16" 103 EASY TOUCH LANCETS LANCETS28G/PRESSURE ELITE-THIN INSULIN 28G/PRESSURE ACTIVATED 87 SYRINGE/1ML/30G X ACTIVATED 87 EASY TOUCH SHEATHLOCK 5/16" 103 EASY TOUCH LANCETS SAFETY INSULIN SYRINGE ELITE-THIN INSULIN 28G/PULL-TOP 87 1ML/29GX1/2" 103 SYRINGE/U-100/0.5ML/28G X EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 1/2" 103 28G/TWIST 87 SAFETY INSULIN SYRINGE ELITE-THIN INSULIN EASY TOUCH LANCETS 1ML/30GX5/16" 103 SYRINGE/U-100/0.5ML/31G X 30G/BUTTON-ACTIVATED 87 EASY TOUCH SHEATHLOCK 5/16" 103 EASY TOUCH LANCETS SAFETY INSULIN SYRINGE ELITE-THIN INSULIN 30G/PRESSURE 1ML/31GX5/16" 103 SYRINGE/U-100/1ML/28G X ACTIVATED 87 EASY TOUCH SHEATHLOCK 1/2" 103 EASY TOUCH LANCETS SAFETY SYRINGE ELITE-THIN INSULIN 30G/PULL-TOP 87 1ML/30GX1/2" 103 SYRINGE/U-100/1ML/29G X EASY TOUCH LANCETS EASY TWIST & CAP 1/2" 103 30G/TWIST 87 LANCETS 87 ELITE-THIN INSULIN EASY TOUCH LANCETS EASYTEST II LANCETS 87 SYRINGE/U-100/1ML/31G X 32G/PRESSURE 5/16" 103 ACTIVATED 87 EASYTEST LANCETS 87 EASY TOUCH LANCETS EC-NAPROSYN 5 ELIXOPHYLLIN 13 32G/PULL-TOP 87 econazole nitrate 52 ELLA 46 EASY TOUCH LANCETS ECOTRIN REGULAR ELMIRON 72 32G/TWIST 87 STRENGTH 7 ELOCON 54 EASY TOUCH LANCETS ED BRON GP 49 33G/TWIST 87 ELOCTATE 73 EASY TOUCH PEN NEEDLE EDLUAR 76 ELON SKIN REPAIR 30G X 5/16" 102 EDURANT 38 SYSTEM 56 EASY TOUCH PEN NEEDLES efavirenz 38 EMBRACE LANCETS ULTRA 29GX1/2" 102 THIN 30G 87 EASY TOUCH PEN NEEDLES EFFEXOR XR 18 EMCYT 30 31GX1/4" 103 EFFIENT 74 EMOLLIA-CREME 56 EASY TOUCH PEN NEEDLES EFUDEX 52 EMOLLIA-LOTION 56 31GX5/16" 103 EGRIFTA 69 EASY TOUCH PEN NEEDLES emollient 56 32GX1/4" 103 ELAPRASE 69 EMSAM 17 EASY TOUCH PEN NEEDLES ELAVIL 19 EMTRIVA 38 32GX3/16" 103 ELDEPRYL 33 EASY TOUCH PEN NEEDLES EMVERM 10 32GX5/32" 103 eletriptan hydrobromide 127 enalapril maleate 26 EASY TOUCH PEN ELEXA NATURAL FEEL 83 enalapril maleate & NEEDLES/31G X 3/16" 103 ELEXA STIMULATING 83 hydrochlorothiazide 28 EASY TOUCH SAFETY ELEXA ULTRA ENBREL 6 LANCETS21G/PRESSURE SENSITIVE 83 ENBREL SURECLICK 6 ACTIVATED 87 ELFOLATE 66 EASY TOUCH SAFETY ENFAMIL ENFALYTE 128 LANCETS23G/PRESSURE ELIDEL 60 ENGERIX-B 150 ACTIVATED 87 ELIGARD 30 ENLYTE 66 ELIMITE 62 enoxaparin sodium 14 ELIQUIS 13

Index 13 entecavir 40 EQL OMEPRAZOLE 148 EUCERIN BABY 56 ENTYVIO 72 EQL PRENATAL EUCERIN CALMING DAILY EPANED 26 FORMULA 132 MOISTURIZER 56 EQL SUPER THIN LANCETS EUCERIN DAILY EPCLUSA 40 30G 87 PROTECTION/SPF 30 56 EPIFOAM 54 EQL THIN LANCETS 26G 87 EUCERIN INTENSIVE EPILYT 56 EQL ULTRA MOISTURIZING REPAIR 56 EUCERIN INTENSIVE epinephrine (anaphylaxis) 151 DAILY LOTION 56 EQUALYTE 128 REPAIRHAND 56 EPIVIR 38 EUCERIN ORIGINAL EPOGEN 75 EQUETRO 34 HEALINGSOOTHING epoprostenol sodium 44 ERBITUX 30 REPAIR 57 EUCERIN PLUS 57 EPZICOM 38 ergocalciferol 152 ERGOLOID EUCERIN PLUS INTENSIVE EQ OMEPRAZOLE 148 MESYLATES 145 REPAIR 57 EQ THERAPEUTIC DRY ERIVEDGE 30 EUCERIN PROFESSIONAL SKIN 56 REPAIR RICH FEEL 57 EQ THERAPEUTIC ERLEADA 30 EUCERIN SKIN CALMING MOISTURIZING CREAM 56 ERY-TAB 79 DAILY MOISTURIZING 57 EQL ADVANCED RECOVERY ERYGEL 51 EUCERIN SMOOTHING SKIN CARE 56 ERYPED 200 79 REPAIRADVANCED EQL COLOR LANCETS 21G87 FORMULA 57 EQL COLOR LANCETS MICRO ERYPED 400 79 EUFLEXXA 134 THIN 33G 87 erythromycin (acne aid) 51 EURAX 62 EQL GAUZE PADS erythromycin (ophth) 138 EVAC 77 2"X2"/SMALL 81 erythromycin base 79 EQL GAUZE PADS EVEKEO 1 4"X4"/LARGE 81 erythromycin ethylsuccinate 79 EVISTA 69 EQL GAUZE STERILE PADS EVOTAZ 38 3"X3" 81 ESBRIET 146 EQL INSULIN escitalopram oxalate 17 EX-LAX 78 SYRINGE/0.3ML/29G X ESGIC 6 EXCILON AMD 1/2" 103 esomeprazole ANTIMICROBIALDRAIN SPONGES 4"X4" 6 PLY 81 EQL INSULIN magnesium 148 SYRINGE/0.3ML/30G X ESOMEPRAZOLE EXCILON AMD ANTIMICROBIALNON-WOVEN 5/16" 103 STRONTIUM 148 EQL INSULIN SPONGES 4"X4" 6 PLY 81 SYRINGE/0.3ML/31G X estazolam 76 EXCILON DRAIN SPONGE 5/16" 103 ESTRACE 71,151 4"X4" 81 EQL INSULIN estradiol 71 EXCILON DRAIN SPONGES SYRINGE/0.5ML/29G X estradiol & norethindrone 4"X4" 6 PLY 81 1/2" 103 acetate 70 EXCILON I.V. SPONGES 2"X2" 6 EQL INSULIN estradiol vaginal 151 PLY 81 SYRINGE/0.5ML/30G X EXEL COMFORT POINT 5/16" 103 ESTROPIPATE 71 INSULIN PEN NEEDLES 29G X EQL INSULIN ESTROSTEP FE 45 12MM 103 SYRINGE/0.5ML/31G X eszopiclone 76 EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 5/16" 103 ethambutol hcl 29 EQL INSULIN 6MM 103 SYRINGE/1ML/29G X 1/2" 103 ethosuximide 16 EXEL COMFORT POINT EQL INSULIN ethynodiol diacet & eth INSULIN PEN NEEDLES 31G X SYRINGE/1ML/30G X estrad 45 8MM 104 5/16" 103 ETIDRONATE DISODIUM 68 EXEL COMFORT POINT EQL INSULIN etodolac 5 INSULIN SYRINGE/0.3ML/29G X SYRINGE/1ML/31G X 1/2" 104 5/16" 103 ETOPOSIDE 32 EXEL COMFORT POINT EQL MOISTURIZING etoposide 32 INSULIN SYRINGE/0.3ML/30G X CREAM 56 EUCERIN 57 5/16" 104

Index 14 EXEL COMFORT POINT FEIBA 73 FIFTY50 SUPERIOR INSULIN SYRINGE/0.5ML/28G X felbamate 16 COMFORTINSULIN 1/2" 104 SYRINGE/0.3ML/31G X EXEL COMFORT POINT FELBATOL 16 5/16" 104 INSULIN SYRINGE/0.5ML/29G X FELDENE 5 FIFTY50 SUPERIOR 1/2" 104 felodipine 43 COMFORTINSULIN EXEL COMFORT POINT FEMARA 31 SYRINGE/0.5ML/31G X INSULIN SYRINGE/0.5ML/30G X 5/16" 104 5/16" 104 FEMCON FE 45 FIFTY50 SUPERIOR EXEL COMFORT POINT FEMHRT LOW DOSE 70 COMFORTINSULIN INSULIN SYRINGE/1ML/28G X FENOFIBRATE 25 SYRINGE/1ML/31G X 1/2" 104 5/16" 104 EXEL COMFORT POINT fenofibrate 25 FIFTY50 UNILET LANCETS INSULIN SYRINGE/1ML/29G X fenofibrate micronized 25 33G 88 1/2" 104 fentanyl 7 finasteride 72 EXEL COMFORT POINT FER-IN-SOL 75 FINE 30 88 INSULIN SYRINGE/1ML/30G X 5/16" 104 FERRETTS 75 FINGERSTIX LANCETS 88 EXELON 143,144 ferrous fumarate 75 FIORINAL 6 exemestane 30 ferrous fumarate-fa-b complex- FIORINAL/CODEINE #3 8 c-zn-mg-mn-cu 75 EXFORGE 28 FIRAZYR 74 ferrous gluconate 75 EXFORGE HCT 28 FIRMAGON 31 FERROUS GLUCONATE 75 EXJADE 22 FIRST-LANSOPRAZOLE 148 ferrous sulfate 75 EXONDYS 51 136 FIRST-METRONIDAZOLE FERROUS SULFATE 75 EXTRA SENSITIVE 100 10 SPERMICIDAL 83 ferrous sulfate 75 FIRST-METRONIDAZOLE 50 10 EYLEA 138 FERROUS SULFATE 75 FIRST-OMEPRAZOLE 148 EZ SMART BLOOD GLUCOSE ferrous sulfate 75 FIRVANQ 10 LANCETS 87 FETZIMA 18 EZ-LETS LANCETS 21G 87 FETZIMA TITRATION FLAGYL 10 EZ-LETS LANCETS 23G 87 PACK 18 FLAVOR BLEND 142 EZ-LETS LANCETS 26G FEVERALL INFANTS 6 FLAVOR PLUS 142 SUPER-SOFT 87 FEXMID 134 FLAVOR SWEET 142 EZ-LETS LANCETS 28G ULTRA-SOFT 87 fexofenadine hcl 24 FLAVOR SWEET-SF 142 EZ-LETS LANCETS 30G 87 FIBERCON 77 flavoxate hcl 149 ezetimibe-simvastatin 25 FIBRYGA 73 FLEBOGAMMA DIF 141 FABRAZYME 69 FIFTY50 ALCOHOL PREP flecainide acetate 12 PADS 95 FLEET ENEMA 77 FACE COTZ 63 FIFTY50 PEN NEEDLES 31G famciclovir 41 X3/16" (5MM) 104 FLEET ENEMA SIX PACK 77 famotidine 147 FIFTY50 PEN NEEDLES 31G FLEET PEDIATRIC 78 X5/16" (8MM) 104 FLEXICHAMBER 126 FAMVIR 41 FIFTY50 PEN NEEDLES FANAPT 34 31GX5MM 104 FLOLAN 44 FANAPT TITRATION PACK 34 FIFTY50 PEN FLOMAX 72 FANTASY LUBRICATED 83 NEEDLES/31GX8MM 104 FLONASE ALLERGY FIFTY50 PEN RELIEF 135 FANTASY NEEDLES/32GX4MM 104 FLONASE ALLERGY RELIEF LUBRICATED/SPERMICIDE FIFTY50 PEN CHILDRENS 135 83 NEEDLES/32GX6MM 104 FLOVENT DISKUS 13 FARESTON 31 FIFTY50 SAFETY SEAL FLOVENT HFA 13 FARYDAK 31 LANCETS 30G 87 FLOXIN OTIC 140 FAZACLO 35 FIFTY50 SAFETY SEAL LANCETS 32G 87 fluconazole 23 FE GLUCONATE 75 fludrocortisone acetate 48

Index 15 FLUMIST QUADRIVALENT150 fosinopril sodium & GALANTAMINE FLUNISOLIDE 135 hydrochlorothiazide 28 HYDROBROMIDE 144 fluocinolone acetonide FOSTEUM PLUS 66 galantamine hydrobromide 144 (otic) 140 FOVEX 66 GAMASTAN 141 fluocinonide 54 FRAGMIN 14 GAMASTAN S/D 141 fluocinonide emulsified base 54 FREDS PHARMACY UNIFINE GAMMAGARD LIQUID 141 fluorometholone (ophth) 139 PENTIPS PEN NEEDLES GAMMAGARD S/D IGA LESS 32GX4MM 104 FLUOROURACIL 52 THAN 1MCG/ML 141 FREDS PHARMACY UNIFINE GAMMAKED 141 fluorouracil (topical) 52 PENTIPS PLUS GAMMAPLEX 141 FLUOXETINE 145 31GX5MM 104 FREDS PHARMACY UNIFINE GAMUNEX-C 141 FLUOXETINE DR 17 PENTIPS PLUS GARDASIL 150 fluoxetine hcl 17 31GX8MM 104 GARDASIL 9 150 FLUOXETINE HCL 45 FREDS PHARMACY UNILET GAS-X 71 fluoxetine hcl (pmdd) 145 LANCETS SUPER THIN FLUOXETINE 30G 88 GATTEX 72 HYDROCHLORIDE 17 FREDS PHARMACY UNILET GAUZE DRESSING 4"X4" 81 LANCETS ULTRA THIN fluphenazine decanoate 36 28G 88 GAUZE PADS 2"X2" 81 FLUPHENAZINE HCL 36,37 FREESTYLE INSULINX GAUZE PADS 3"X3" 81 fluphenazine hcl 37 BLOODGLUCOSE TEST 65 GAUZE PADS 4"X4" 81 FLURAZEPAM HCL 76 FREESTYLE INSULINX GAUZE PADS 4"X4" 12 PLY 81 BLOODGLUCOSE TEST flurbiprofen 5 STRIPS 65 GAUZE SPONGE TYPE VII flurbiprofen sodium 140 MEDI-PAK 2"X2" 8PLY 81 FREESTYLE LANCETS 88 GAUZE SPONGES 4"X4" 12 flutamide 31 FREESTYLE LITE TEST PLY 81 fluticasone propionate 54 STRIPS 65 GELUSIL 9 FREESTYLE PRECISION fluticasone propionate gemfibrozil 25 (nasal) 135 INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 104 GENERESS FE 45 fluvoxamine maleate 17 FREESTYLE PRECISION GENOTROPIN 69 FML 139 INSULIN SYRINGE/U- GENOTROPIN MINIQUICK 69 FML LIQUIFILM 139 100/0.5ML/31G X 5/16" 104 GENTAK 138 FOCALIN 2 FREESTYLE PRECISION INSULIN SYRINGE/U- gentamicin sulfate (ophth) 138 FOCALIN XR 2 100/1ML/31G X 5/16" 104 gentamicin sulfate (topical) 51 folic acid 74 FREESTYLE PRECISION GENTEAL MILD TO fondaparinux sodium 14 INSULIN SYRINGES/U- MODERATE 137 FORA LANCETS 88 100/1ML/30G X 5/16" 104 GENTEEL BUTTERFLY TOUCH FREESTYLE TEST LANCETS 88 FORFIVO XL 17 STRIPS 65 formaldehyde 37 FREESTYLE UNISTICK II GENTLE 57 FORMULA 405 ENRICHED LANCETS 88 GENTLE SKIN CLEANSER 61 EYE 57 FURADANTIN 149 GENTLE-LET GP LANCETS 88 FORMULA 405 FACE furosemide 67 GENTLE-LET LANCETS CREAM 57 FUROSEMIDE 67 GENERAL PURPOSE FORMULA 405 FACIAL & STYLE/FINE POINT 88 BODYCLEANSING 61 furosemide 67 GENTLE-LET LANCETS FORMULA 405 LIGHT FUSILEV 32 GENERAL PURPOSE TEXTURED MOISTURIZER 57 FUZEON 38 STYLE/MEDIUM POINT 88 FORMULA 405 GABADONE 66 GENTLE-LET LANCETS MOISTURIZING 57 SAFETY STYLE/FINE FORTEO 68 gabapentin 14 POINT 88 FOSAMAX 68 GABITRIL 16 GENTLE-LET LANCETS fosamprenavir calcium 38 galantamine SAFETY STYLE/MEDIUM hydrobromide 144 POINT 88 fosinopril sodium 26

Index 16 GENVOYA 38 GLOBAL INJECT EASE GLYCERIN ADULT 77 GEODON 34 INSULIN SYRINGE/U- glycine diluent 142 100/1ML/31G X 5/16" 105 GILENYA 144 GLOBAL INJECT EASE glycopyrrolate 147 GILOTRIF 31 LANCETS 28G 88 GLYNASE 22 GLASSIA 145 GLOBAL INJECT EASE GNP ADVANCED LANCETS 30G 88 glatiramer acetate 144 RECOVERY 57 GLOBAL INSULIN GNP ALCOHOL SWABS 95 GLEEVEC 31 SYRINGES/U- GNP CLICKFINE PEN glimepiride 22 100/0.3ML/30GX5/16" 105 NEEDLEUNIVERSAL/31GX5/16" glipizide 22 GLUCAGEN 105 DIAGNOSTIC 65 GNP CLICKFINE UNIVERSAL glipizide-metformin hcl 20 GLUCAGEN HYPOKIT 20 GLOBAL EASE INJECT PEN PEN NEEDLES 31GX1/4" 105 GLUCAGON EMERGENCY GNP CLICKFINE UNIVERSAL NEEDLES 29GX12MM 104 KIT 20 GLOBAL EASE INJECT PEN PEN NEEDLES 31GX5/16" 106 GLUCOCOM LANCETS GNP GLUCOSE 20 NEEDLES 31GX8MM 104 28G 88 GLOBAL EASE INJECT PEN GNP INSULIN GLUCOCOM LANCETS SYRINGE/0.3ML/29G X NEEDLES 32GX4MM 105 30G 88 GLOBAL EASE INJECT PEN 1/2" 106 GLUCOCOM LANCETS GNP INSULIN NEEEDLES 31GX5MM 105 33G 88 GLOBAL EASY GLIDE SYRINGE/0.3ML/30G X INSULINSYRINGE/U- GLUCOPHAGE 20 5/16" 106 100/0.3ML/31G X 5/16" 105 GLUCOPHAGE XR 20 GNP INSULIN GLOBAL EASY GLIDE PEN GLUCOPRO INSULIN SYRINGE/0.3ML/31G X NEEDLES 32GX4MM 105 SYRINGE/U-100/0.3ML/30G X 5/16" 106 GLOBAL INJECT EASE INSULIN 5/16" 105 GNP INSULIN SYRINGE/U-100/0.3ML/29G X GLUCOPRO INSULIN SYRINGE/0.5ML/28G X 1/2" 105 SYRINGE/U-100/0.3ML/31G X 1/2" 106 GLOBAL INJECT EASE INSULIN 5/16" 105 GNP INSULIN SYRINGE/U-100/0.3ML/30G X GLUCOPRO INSULIN SYRINGE/0.5ML/29G X 5/16" 105 SYRINGE/U-100/0.5ML/30G X 1/2" 106 GLOBAL INJECT EASE INSULIN 5/16" 105 GNP INSULIN SYRINGE/U-100/0.3ML/31G X GLUCOPRO INSULIN SYRINGE/0.5ML/30G X 5/16" 105 SYRINGE/U-100/0.5ML/31G X 5/16" 106 GLOBAL INJECT EASE INSULIN 5/16" 105 GNP INSULIN SYRINGE/U-100/0.5ML/28G X GLUCOPRO INSULIN SYRINGE/0.5ML/31G X 1/2" 105 SYRINGE/U-100/1ML/30G X 5/16" 106 GLOBAL INJECT EASE INSULIN 1/2" 105 GNP INSULIN SYRINGE/U-100/0.5ML/29G X GLUCOPRO INSULIN SYRINGE/1ML/28G X 1/2" 106 1/2" 105 SYRINGE/U-100/1ML/30G X GNP INSULIN GLOBAL INJECT EASE INSULIN 5/16" 105 SYRINGE/1ML/29G X 1/2" 106 SYRINGE/U-100/0.5ML/30G X GLUCOPRO INSULIN GNP INSULIN 5/16" 105 SYRINGE/U-100/1ML/31G X SYRINGE/1ML/30G X GLOBAL INJECT EASE INSULIN 5/16" 105 5/16" 106 SYRINGE/U-100/0.5ML/31G X GLUCOSE 20 GNP INSULIN 5/16" 105 GLUCOSOURCE SYRINGE/1ML/31G X GLOBAL INJECT EASE INSULIN LANCETS 88 5/16" 106 SYRINGE/U-100/1ML/28G X GLUCOTROL 22 GNP LANCETS 88 1/2" 105 GLUCOTROL XL 22 GNP LANCETS 21G 88 GLOBAL INJECT EASE INSULIN GNP LANCETS MICRO THIN SYRINGE/U-100/1ML/29G X GLUCOVANCE 20 33G 88 1/2" 105 glyburide 22 GNP LANCETS SUPER THIN GLOBAL INJECT EASE INSULIN 30G 88 SYRINGE/U-100/1ML/30G X glyburide micronized 22 1/2" 105 glyburide-metformin 20 GNP LANCETS THIN 88 GLOBAL INJECT EASE INSULIN glycerin (laxative) 77 GNP LANCETS THIN 26G 88 SYRINGE/U-100/1ML/30G X glycerin (topical) 57 GNP MICRO THIN LANCETS 5/16" 105 33G 88

Index 17 GNP OMEPRAZOLE 148 GOLD BOND ULTIMATE H-E-B IN CONTROL GNP PRENATAL 132 RESTORING 57 UNIFINEPENTIPS PLUS GOLD BOND ULTIMATE 32GX4MM 107 GNP QUICK DISSOLVE SHEERRIBBONS H-E-B INCONTROL LANCETS GLUCOSE 20 PEARLRADIANCE 57 MICRO THIN 33G 88 GNP STERILE PADS 3"X3" 81 GOLD BOND ULTIMATE H-E-B INCONTROL LANCETS GNP SUPER THIN SHEERRIBBONS SUPER THIN 30G 88 LANCETS/30G 88 SILKSOFTNESS 57 H-E-B INCONTROL LANCETS GNP ULTRA COMFORT GOLD BOND ULTIMATE ULTRA THIN 28G 88 INSULIN SYRINGE/0.3ML/29G X SOFTENING 57 H-E-B INCONTROL PEN 1/2" 106 GOLD BOND ULTIMATE NEEDLES 29GX12MM 107 GNP ULTRA COMFORT SOOTHING 57 H.P. ACTHAR 68 INSULIN SYRINGE/0.3ML/30G X GOLYTELY 77 5/16" SHORT 106 HAEMOLANCE 88 GOODSENSE COLOR HAEMOLANCE LOW FLOW GNP ULTRA COMFORT LANCETS MICRO-THIN 33G INSULIN SYRINGE/0.3ML/31G X LANCETS 88 UNIVERSAL 88 HAEMOLANCE PLUS 89 5/16" SHORT 106 GOODSENSE LANCETS HAEMOLANCE PLUS HIGH GNP ULTRA COMFORT MICRO-THIN 33G 88 INSULIN SYRINGE/0.5ML/28G X GOODSENSE LANCETS FLOW 88 HAEMOLANCE PLUS LOW 1/2" 106 MICRO-THIN 33G GNP ULTRA COMFORT FLOW 89 UNIVERSAL 88 HAEMOLANCE PLUS MAX INSULIN SYRINGE/0.5ML/29G X GOODSENSE LANCETS FLOW 89 1/2" 106 ULTRA-THIN 26G GNP ULTRA COMFORT HAEMOLANCE PLUS UNIVERSAL 88 PEDIATRIC FLOW 89 INSULIN SYRINGE/0.5ML/30G X GOODSENSE LANCETS 5/16" SHORT 106 ULTRA-THIN 30G 88 HALAVEN 32 GNP ULTRA COMFORT GOODSENSE LANCETS HALCION 76 INSULIN SYRINGE/0.5ML/31G X ULTRA-THIN 30G 5/16" SHORT 106 HALDOL 35 UNIVERSAL 88 HALDOL DECANOATE 100 35 GNP ULTRA COMFORT GOODSENSE PRENATAL INSULIN SYRINGE/1ML/28G X VITAMINS 132 HALDOL DECANOATE 50 35 1/2" 106 haloperidol 35 GNP ULTRA COMFORT GRAPE SYRUP 142 INSULIN SYRINGE/1ML/29G X GRIS-PEG 23 HALOPERIDOL 45 1/2" 106 griseofulvin microsize 23 haloperidol decanoate 35 GNP ULTRA COMFORT griseofulvin ultramicrosize 23 haloperidol lactate 35 INSULIN SYRINGE/1ML/30G X HARVONI 40 5/16" SHORT 106 GRX VITAMIN E 57 GNP ULTRA COMFORT guaifenesin 50 HAVRIX 150 INSULIN SYRINGE/1ML/31G X guaifenesin-codeine 49 HEALTHWISE LANCETS 30G 89 5/16" SHORT 106 guanfacine hcl 27 GOLD BOND MEDICATED HEALTHWISE MINI PEN BODYLOTION 57 guanfacine hcl (adhd) 2 NEEDLES 31GX6MM 107 GOLD BOND MEDICATED GYNAZOLE-1 151 HEALTHWISE PEN NEEDLES BODYLOTION EXTRA GYNE-LOTRIMIN 151 29GX12MM 107 STRENGTH 57 HEALTHWISE SHORT PEN GYNE-LOTRIMIN 3 151 GOLD BOND ULTIMATE 57 NEEDLES 31GX8MM 107 H-E-B IN CONTROL PEN HEALTHWISE UNIFINE GOLD BOND ULTIMATE NEEDLES 31GX5MM 106 DIABETICS DRY SKIN PENTIPS PEN NEEDLES H-E-B IN CONTROL PEN 32GX4MM 107 RELIEF 57 NEEDLES 31GX6MM 106 HEALTHY ACCENTS UNIFINE GOLD BOND ULTIMATE H-E-B IN CONTROL PEN DIABETICS' DRY RELIEF 57 PENTIPS PEN NEEDLES NEEDLES 31GX8MM 106 29GX12MM 107 GOLD BOND ULTIMATE H-E-B IN CONTROL PEN HEALING 57 HEALTHY ACCENTS UNIFINE NEEDLES/NANO/32GX4MM PENTIPS PEN NEEDLES GOLD BOND ULTIMATE 106 OVERNIGHT 57 31GX5MM 107 H-E-B IN CONTROL HEALTHY ACCENTS UNIFINE GOLD BOND ULTIMATE UNIFINEPENTIPS PLUS PROTECTION 57 PENTIPS PEN NEEDLES 31GX5MM 107 31GX6MM 107

Index 18 HEALTHY ACCENTS UNIFINE HUMATROPEN FOR hydroxyprogesterone PENTIPS PEN NEEDLES 6MG 107 caproate 143 31GX8MM 107 HUMIRA 4 hydroxyurea 32 HEALTHY ACCENTS UNIFINE HUMIRA PEDIATRIC CROHNS HYDROXYZINE HCL 11 PENTIPS PEN NEEDLES DISEASE STARTER PACK 4 hydroxyzine hcl 11 32GX4MM 107 HUMIRA PEN 4 HEALTHY ACCENTS UNILET HYDROXYZINE HCL 45 LANCETS SUPER THIN HUMIRA PEN-CD/UC/HS STARTER 4 HYDROXYZINE PAMOATE 11 30G 89 HUMIRA PEN-PS/UV hydroxyzine pamoate 11 HELIXATE FS 73 STARTER 4 HYDROXYZINE PAMOATE 11 HEMANGEOL 42 HUMULIN 70/30 21 hyoscyamine sulfate 147 HEMLIBRA 73 HUMULIN 70/30 HYPER-SAL 50 HEMOCYTE 75 KWIKPEN 21 HYPERHEP B S/D 141 HEMOFIL M 73 HUMULIN N 21 HYPERRHO S/D 141 HEPAGAM B 141 HUMULIN N KWIKPEN 21 HUMULIN R 21 HYPERRHO S/D MINI- heparin sodium (porcine) 14 DOSE 141 heparin sodium (porcine) lock HY-VEE LANCETS 89 HYPERSAL 50 flush 14 HY-VEE THIN LANCETS 89 HYPERTENSA 66 HEPSERA 40 HYALGAN 134 hypromellose (ophth) 137 HERCEPTIN 30 HYCAMTIN 33 HYQVIA 141 HETLIOZ 77 hydralazine hcl 29 HYVEE ADVANCED ANTACID HIBERIX 150 HYDRALYTE 128 MAXIMUM STRENGTH 9 HIBICLENS 38 HYDRALYTE FREEZER HYZAAR 28 HIGH SENSATION POPS 128 ibandronate sodium 68 SPERMICIDAL 83 HYDRASYN25 57 IBRANCE 31 HIZENTRA 141 HYDRAZONE LOTION 57 ibuprofen 5 HM OMEPRAZOLE 148 HYDREA 32 ICAPS LUTEIN & HM PRENATAL 132 HYDRO-LAN 57 ZEAXANTHIN 131 HM STERILE ALCOHOL PREP HYDROCELL ADHESIVE ICLUSIG 31 PADS 95 DRESSING 4"X4" 81 IDELVION 73 HM STERILE PADS 81 HYDROCELL DRESSING imatinib mesylate 31 HM STERILE PADS 2"X2" 81 4"X4" 81 HM ULTICARE INSULIN HYDROCERIN 61 IMIPRAMINE HCL 19 SYRINGE/1ML/30G X 1/2" 107 hydrochlorothiazide 68 imipramine hcl 19 HM ULTICARE INSULIN hydrocodone w/ imipramine pamoate 19 SYRINGE/U-100/0.3ML/31G X homatropine 48 imiquimod 60 5/16" 107 hydrocodone- IMITREX 127 HUGGIES LITTLE SWIMMERS acetaminophen 8 IMITREX STATDOSE SPF50 63 hydrocortisone 47 HUMALOG MIX 50/50 21 REFILL 127 hydrocortisone (intrarectal) 9 IMITREX STATDOSE HUMALOG MIX 50/50 SYSTEM 127 KWIKPEN 21 hydrocortisone (rectal) 9 IMODIUM A-D 22 HUMALOG MIX 75/25 21 hydrocortisone (topical) 54 HUMALOG MIX 75/25 hydrocortisone butyrate 54 IMURAN 130 KWIKPEN 21 hydrocortisone w/acetic IN TOUCH STERILE HUMATE-P 73 acid 140 LANCETS30G 89 INATAL GT 132 HUMATROPE 69 hydrocortisone-aloe vera 54 HUMATROPE COMBO HYDROMORPHONE HCL 7 INCRELEX 69 PACK 69 hydromorphone hcl 7 INCRUSE ELLIPTA 12 HUMATROPEN FOR hydroxychloroquine sulfate 29 indapamide 68 12MG 107 HUMATROPEN FOR HYDROXYPROGESTERONE INDERAL LA 42 24MG 107 CAPROATE 31 INDERAL XL 42

Index 19 indomethacin 5 INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN INFANRIX 147 1ML/30G X 5/16" 108 31GX6MM 108 INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN INFANTS ADVIL 5 1ML/31G X 5/16" 108 31GX8MM 108 INJECT-EASE 107 INSULIN SYRINGE/U- INTELENCE 38 INJECT-EASE AUTOMATIC 100/0.3ML/29G X 1/2" 108 INTENSE SENSATION 83 INJECTOR 107 INSULIN SYRINGE/U- INTERMEZZO 76 INLYTA 31 100/0.5ML/28G X 1/2" 108 INSULIN SYRINGE/U- INTRON A 32 INNOPRAN XL 42 100/0.5ML/29G X 1/2" 108 INTRON A W/DILUENT 32 INOSITOL 136 INSULIN SYRINGE/U- INTUNIV 2 inositol 136 100/1ML/28G X 1/2" 108 INVEGA 34 INOSITOL-5 136 INSULIN SYRINGE/U- 100/1ML/29G X 1/2" 108 INSPIRACHAMBER/ANTI- INVEGA SUSTENNA 34 INSULIN SYRINGE/U- INVEGA TRINZA 35 STATIC 100/1ML/30G X 5/16" 108 VALVED/MOUTHPIECE 126 INSULIN SYRINGE/U- INVIRASE 38 INSPIRACHAMBER/LARGE 100/1ML/31G X 5/16" 108 IOPIDINE 138 126 INSULIN ipratropium bromide 12 INSPIRACHAMBER/SOOTHER SYRINGES/0.5ML/28GX1/2" MASK/INSPIRAMASK/MEDIUM 108 ipratropium bromide (nasal)135 126 INSULIN ipratropium-albuterol 13 INSPIRACHAMBER/SOOTHER SYRINGES/0.5ML/29GX1/2" MASK/INSPIRAMASK/SMALL irbesartan 27 108 irbesartan-hydrochlorothiazide 126 INSULIN INSPIREASE DRUG 28 SYRINGES/0.5ML/30GX5/16" IRON CHEWS PEDIATRIC 75 DELIVERYSYSTEM 126 108 INSPIREASE RESERVOIR INSULIN ISENTRESS 38,39 BAGS 126 SYRINGES/0.5ML/31GX ISENTRESS HD 39 INSULIN SYRINGE/0.3ML/29G X 5/16" 108 ISONIAZID 29 1/2" 107 INSULIN INSULIN SYRINGE/0.3ML/30G X SYRINGES/0.5ML/31GX5/16" isoniazid 29 5/16" 107 108 ISOPTO ATROPINE 138 INSULIN SYRINGE/0.3ML/31G X INSULIN 5/16" 107 ISOPTO CARPINE 138 SYRINGES/1ML/28GX1/2" ISORDIL TITRADOSE 11 INSULIN SYRINGE/0.5ML/28G X 108 1/2" 107 INSULIN isosorbide dinitrate 11 INSULIN SYRINGE/0.5ML/30G X SYRINGES/1ML/29GX1/2" ISOSORBIDE DINITRATE 5/16" 107 ER 11 INSULIN SYRINGE/0.5ML/31G X 108 INSULIN isosorbide mononitrate 11 5/16" 107 INSULIN SYRINGE/1ML/28G X SYRINGES/1ML/30GX1/2" isotretinoin 51 1/2" 107 108 isoxsuprine hcl 44 INSULIN INSULIN SYRINGE/1ML/29G X ISOXSUPRINE HCL 44 1/2" 107 SYRINGES/1ML/31GX5/16" INSULIN SYRINGE/1ML/30G X 108 ISTODAX (OVERFILL) 31 5/16" 107 INSUPEN 29G X 12MM 108 ITCH RELIEF 52 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 5MM 108 itraconazole 23 0.3ML/30G X 5/16" 107 INSUPEN 31G X 8MM 108 IXEMPRA KIT 32 INSULIN SYRINGE/NEEDLE 0.3ML/31G X 5/16" 107 INSUPEN 32G X 4MM 108 IXINITY 73 INSULIN SYRINGE/NEEDLE INSUPEN PEN NEEDLES 32G J & J BURN CREAM 57 X4MM 108 0.5ML/29G X 1/2" 107 J & J GAUZE 2"X2" 8 PLY 81 INSULIN SYRINGE/NEEDLE INSUPEN SENSITIVE 0.5ML/30G X 5/16" 108 32GX6MM 108 J & J GAUZE 4"X4" 12 PLY 81 INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN J & J GAUZE 4"X4" 8 PLY 81 0.5ML/31G X 5/16" 108 29GX12MM 108 J & J GAUZE SPONGES 12-PLY INSULIN SYRINGE/NEEDLE INSUPEN ULTRAFIN 4" X 4" 81 1ML/29G X 1/2" 108 30GX8MM 108 J & J GAUZE SPONGES 16-PLY 4" X 4" 81

Index 20 J & J GAUZE SPONGES 8- KERI RENEWAL MILK KINRAY INSULIN SYRINGE PLY4" X 4" 82 BODY 58 PREFERRED PLUS/1ML/31G X J-TIP KIT W/VIAL KERI RENEWAL SKIN 5/16" 109 ADAPTERS 108 FIRMING 58 KINRAY INSULIN JADENU 22 KERI RENEWAL STRETCH SYRINGE/0.5ML/29G X JADENU SPRINKLE 22 MARK MINIMIZER 58 1/2" 109 KERI SENSITIVE SKIN 58 KINRIX 147 JAKAFI 31 KERLIX SPONGES 4" X 4" 12 KITABIS PAK 4 JARDIANCE 21 PLY 82 KLARON 51 JENTADUETO 20 KERLIX SPONGES 4" X 4" 16 KLONOPIN 14 JEVTANA 33 PLY 82 KLOR-CON M15 129 JULUCA 39 KETOCARE 65 KLS OMEPRAZOLE 148 JYNARQUE 70 ketoconazole (topical) 52 KOATE 73 K-PHOS NEUTRAL 129 KETONE TEST STRIPS 65 KOATE-DVI 73 K-TAB 129 ketoprofen 5 KOGENATE FS 73 KADCYLA 30 KETOPROFEN 5 KOGENATE FS BIO-SET 73 KALBITOR 74 KETOPROFEN ER 5 KONSYL DAILY FIBER 77 KALETRA 39 ketorolac tromethamine 5 ketorolac tromethamine KONSYL ORIGINAL KALYDECO 146 (ophth) 140 FORMULADAILY FIBER 77 KAMELEON LUBRICATED 83 KETOSTIX 65 KOVALTRY 73 KAPVAY 2 ketotifen fumarate (ophth)140 KP PRENATAL KAYEXALATE 131 KHEDEZLA 18 MULTIVITAMINS 132 KAZANO 20 KPN PRENATAL 132 KIMONO COLORS 83 KROGER INSULIN KCENTRA 73 KIMONO LUBRICATED 83 SYRINGE/0.3ML/29G X KEFLEX 44 KIMONO MICRO THIN PLUS 1/2" 109 KENDALL HYDROPHILIC SPERMICIDE KROGER INSULIN FOAMDRESSING 2"X2" 82 LUBRICATED 83 SYRINGE/0.3ML/30G X KENDALL HYDROPHILIC KIMONO PLUS SPERMICIDE 5/16" 109 FOAMDRESSING 3"X3" 82 LUBRICATED 83 KROGER INSULIN KENDALL HYDROPHILIC KIMONO PLUS SYRINGE/0.3ML/31G X FOAMDRESSING 4"X4" 82 SPERMICIDE/LUBRICATED 5/16" 109 KENDALL HYDROPHILIC 83 KROGER INSULIN FOAMPLUS DRESSING KIMONO PS SYRINGE/0.5ML/29G X 2"X2" 82 LUBRICATED 83 1/2" 109 KENDALL HYDROPHILIC KIMONO PS PLUS KROGER INSULIN FOAMPLUS DRESSING SPERMICIDE/LUBRICATED SYRINGE/0.5ML/30G X 3"X3" 82 83 5/16" 109 KEPIVANCE 32 KIMONO SENSATION KROGER INSULIN KEPPRA 14 LUBRICATED 83 SYRINGE/0.5ML/31G X KIMONO SENSATION PLUS 5/16" 109 KEPPRA XR 14 SPERMICIDE KROGER INSULIN KERADAN 57 LUBRICATED 83 SYRINGE/1ML/29G X 1/2" 109 KERI ADVANCED MOISTURE KIMONO SPECIAL 83 KROGER INSULIN THERAPY 57 KINERET 4 SYRINGE/1ML/30G X KERI AGE DEFY & 5/16" 109 PROTECT 63 KINNEY LANCETS 89 KROGER INSULIN KERI BASIC ESSENTIALS 57 KINNEY THIN LANCETS 89 SYRINGE/1ML/31G X KERI LONG LASTING 57 KINRAY INSULIN SYRINGE 5/16" 109 PREFERRED KERI NOURISHING SHEA KROGER LANCETS 89 PLUS/0.3ML/31G X 5/16" 108 KROGER LANCETS 21G 89 BUTTER 57 KINRAY INSULIN SYRINGE KERI ORIGINAL 58 PREFERRED KROGER LANCETS MICRO KERI OVERNIGHT 58 PLUS/0.5ML/31G X 5/16" 108 THIN33G 89 KROGER LANCETS SUPER THIN 89

Index 21 KROGER LANCETS THIN 89 LAMISIL AT 52 LEADER INSULIN KROGER LANCETS THIN LAMISIL AT JOCK ITCH 52 SYRINGE/0.3ML/31G X 5/16" 109 26G 89 lamivudine 39 KROGER LANCETS LEADER INSULIN ULTRATHIN30G 89 lamivudine-zidovudine 39 SYRINGE/0.5ML/28G X KROGER PEN NEEDLES 29G lamotrigine 15 1/2" 109 LEADER INSULIN X12MM 109 LANAPHILIC 58 KROGER PEN NEEDLES 31G SYRINGE/0.5ML/29G X X8MM 109 LANCETS 89 1/2" 109 KROGER PEN NEEDLES LANCETS 26G TWIST LEADER INSULIN 31GX1/4" 109 TOP 89 SYRINGE/0.5ML/30G X KRYSTEXXA 73 LANCETS 28G 89 5/16" 109 LANCETS 30G 89 LEADER INSULIN KUVAN 69 SYRINGE/0.5ML/31G X KYLEENA 46 LANCETS 30G TWIST TOP 89 5/16" 109 KYNAMRO 25 LANCETS 30G/TWIST LEADER INSULIN KYPROLIS 31 TOP 89 SYRINGE/1ML/28G X 1/2" 109 LEADER INSULIN L-ARGININE 137 LANCETS 31G TWIST TOP 89 SYRINGE/1ML/29G X 1/2" 109 L-ARGININE BASE 137 LANCETS 33G UNIVERSAL LEADER INSULIN L-ARGININE HCL 45 DESIGN 89 SYRINGE/1ML/30G X LANCETS MICRO THIN 5/16" 109 L-METHYLFOLATE 66 LEADER INSULIN L-METHYLFOLATE CA/S- 33G 89 LANCETS SAFETY SEAL SYRINGE/1ML/31G X ALGAL 66 5/16" 109 L-METHYLFOLATE 21G 89 LANCETS SAFETY SEAL LEADER QUICK DISSOLVE CALCIUM 66 GLUCOSE 20 L-METHYLFOLATE FORMULA 26G 89 LANCETS SAFETY SEAL LEADER UNIFINE PENTIPS 15 66 PLUS/MINI/31GX3/16" 109 L-METHYLFOLATE FORMULA 28G 89 LANCETS SAFETY SEAL LEADER UNIFINE PENTIPS 7.5 66 PLUS/SHORT/31GX5/16" 109 L-METHYLFOLATE FORTE 66 30G 89 LANCETS SUPER THIN LEADER UNIFINE L-TRYPTOPHAN 137 28G 89 PENTIPS/MINI/31GX3/16" 109 labetalol hcl 42 LEADER UNIFINE LANCETS THIN 89 PENTIPS/NANO/32GX5/32" LAC-HYDRIN 58 LANCETS TWIST TOP 89 109 LAC-HYDRIN TWELVE 58 LANCETS ULTRA FINE 89 LEADER UNIFINE lactic acid (ammonium LANCETS ULTRA THIN 89 PENTIPS/PLUS/32GX5/32" lactate) 58 LANCETS ULTRA THIN 109 LEDIPASVIR/SOFOSBUVIR LACTINOL HX 58 30G 89 lactulose 77 LANCETSBULLSEYE 40 leflunomide 6 lactulose (encephalopathy) 72 SAFETY 89 LADY ESTHER 4 PURPOSE LANOLOR 58 LEMTRADA 144 FACE CREAM 58 LANOXIN 43 LETAIRIS 44 LAMICTAL 15 lansoprazole 148 letrozole 31 LAMICTAL CHEWABLE LASIX 67 LEUCOVORIN CALCIUM 32 DISPERSIBLE 14 latanoprost 140 leucovorin calcium 32 LAMICTAL ODT 14 LEUKERAN 29 LAMICTAL STARTER/NOT LATANOPROST 140 TAKING CARBAMAZEPINE 14 LATUDA 34 LEUKINE 75 LAMICTAL STARTER/TAKING LEADER FINGER CREAM 58 leuprolide acetate 31 CARBAMAZEPINE/NOT TAKING LEADER INSULIN LEVAQUIN 71 VALPROATE 15 SYRINGE/0.3ML/29G X LEVBID 147 LAMICTAL STARTER/TAKING 1/2" 109 VALPROATE 15 LEADER INSULIN levetiracetam 15 LAMICTAL XR 15 SYRINGE/0.3ML/30G X LEVETIRACETAM 15 LAMISIL 23 5/16" 109 levetiracetam 15

Index 22 levetiracetam in sodium LITETOUCH INSULIN LONGS INSULIN chloride 15 SYRINGE/0.3ML/31G X SYRINGE/0.5ML/31G X levobunolol hcl 137 5/16" 110 5/16" 110 levocarnitine (metabolic LITETOUCH INSULIN LONGS LANCETS modifiers) 70 SYRINGE/0.5ML/30G X STANDARD 90 levocetirizine dihydrochloride24 5/16" 110 LONGS LANCETS THIN 90 LITETOUCH INSULIN levofloxacin 71 LONGS LANCETS ULTRA SYRINGE/0.5ML/31G X THIN 90 LEVOLEUCOVORIN 32 5/16" 110 loperamide hcl 22 LITETOUCH INSULIN levoleucovorin calcium 32 LOPID 25 LEVOMEFOLATE CALCIUM SYRINGE/1ML/30G X ALGAL POWDER 66 5/16" 110 lopinavir-ritonavir 39 levonorgestrel & eth LITETOUCH INSULIN LOPRESSOR 42 estradiol 45 SYRINGE/U-100/0.5ML/28G X LOPRESSOR HCT 28 1/2" 110 levonorgestrel (emergency loratadine 24 oc) 46 LITETOUCH INSULIN levonorgestrel-eth estradiol SYRINGE/U-100/0.5ML/29G X loratadine & (triphasic) 45 1/2" 110 pseudoephedrine 49 levonorgestrel-ethinyl estradiol LITETOUCH INSULIN lorazepam 12 (91-day) 45 SYRINGE/U-100/1ML/28G X LORAZEPAM 45 levothyroxine sodium 146 1/2" 110 LITETOUCH INSULIN losartan potassium 27 LEXAPRO 17 SYRINGE/U-100/1ML/29G X losartan potassium & LEXAZIN 66 1/2" 110 hydrochlorothiazide 28 LEXIVA 39 LITETOUCH INSULIN LOTENSIN 26 LIALDA 72 SYRINGE/U-100/1ML/31G X LOTENSIN HCT 28 5/16" 110 LOTREL 28 LIBERTY MEDICAL LANCETS LITETOUCH LANCETS MICRO 30G 89 THIN 33G 89 LOTRIMIN AF 52 lidocaine 60,61 LITETOUCH PEN NEEDLES LOTRIMIN AF FOR HER 52 lidocaine hcl 60 29GX12.7MM 110 LOTRIMIN AF JOCK ITCH 52 lidocaine hcl (mouth-throat) 131 LITETOUCH PEN NEEDLES 31G X 6MM 110 LOTRISONE 52 lidocaine-prilocaine 61 LITETOUCH PEN NEEDLES lovastatin 25 LIDODERM 61 31GX8MM SHORT 110 LOVAZA 25 LIFESCAN UNISTIK 2 DEEP LITHIUM 34 LOVENOX 14 PENETRATION 89 lithium carbonate 33 LIFESCAN UNISTIK II loxapine succinate 35 LANCETS 89 LITHIUM CARBONATE 34 LUBRIDERM 58 LILETTA 46 lithium carbonate 34 LUBRIDERM ADVANCED liothyronine sodium 146 LITHOBID 34 THERAPY 58 LUBRIDERM DAILY LIPICHOL 540 66 LIVE BETTER LANCET SUPERTHIN 30G 89 MOISTURE/NORMAL TO DRY LIPITOR 25 LIVE BETTER LANCET SKIN 58 lisinopril 26 ULTRATHIN 28G 90 LUBRIDERM DAILY lisinopril & LMX 4 61 MOISTURE/SUNSCREEN SPF 15 63 hydrochlorothiazide 28 LOCOID 54 LISTER-V 66 LUBRIDERM DAILY LODINE 5 MOISTURESHEA + CALMING LITE TOUCH LANCETS 89 LODOSYN 33 LAVENDER JASMINE 58 LITE TOUCH PEN LUBRIDERM INTENSE SKIN NEEDLES/31G X 3/16" 109 LOESTRIN 1.5/30-21 45 REPAIR 58 LITEAIRE 126 LOESTRIN 1/20-21 45 LUBRIDERM MENS 3-IN-1 58 LITETOUCH INSULIN LOESTRIN FE 1.5/30 46 LUBRIDERM SERIOUSLY SYRINGE/0.3ML/29G X LOESTRIN FE 1/20 46 SENSITIVE 58 1/2" 110 LOFIBRA 25 LUBRIDERM SKIN LITETOUCH INSULIN NOURISHINGWITH SHEA AND SYRINGE/0.3ML/30G X LOHIST-D 49 COCOA BUTTERS 58 5/16" 110 LOMOTIL 22

Index 23 LUBRISOFT 58 magnesium oxide 10 MEDICHOICE PRE-SET LUCENTIS 138 magnesium oxide (mg SAFETY LANCET MEDIUM FLOW 90 LUMIZYME 70 supplement) 129 MAGOX 400 129 MEDICHOICE PRE-SET LUNESTA 76 SAFETY LANCET MODERATE MAKENA 143 LUPANETA PACK 69 FLOW 90 LUPRON DEPOT (1- malathion 62 MEDICHOICE SAFETY MONTH) 31 MAPROTILINE HCL 17 LANCETEXTRA 90 LUPRON DEPOT (3- MARATHON MEDICAL MEDICHOICE SAFETY MONTH) 31 PENTIPS29GX12MM 110 LANCETNORMAL 90 LUPRON DEPOT (4- MARATHON MEDICAL MEDICINE SHOPPE PEN MONTH) 31 PENTIPS31GX5MM 110 NEEDLES 29G X 12MM 110 LUPRON DEPOT (6- MARATHON MEDICAL MEDICINE SHOPPE PEN MONTH) 31 PENTIPS31GX8MM 110 NEEDLES 31G X 6MM 111 LUPRON DEPOT-PED (1- MARATHON MEDICAL MEDICINE SHOPPE PEN MONTH) 69 PENTIPS32GX4MM 110 NEEDLES 31G X 8MM 111 MEDISENSE THIN LUPRON DEPOT-PED (3- MARPLAN 17 MONTH) 69 LANCETS 90 MATULANE 32 MEDLANCE PLUS EXTRA LURIDE 129 MAVIK 26 LANCETS 21G 90 LUXTURNA 139 MAXALT 127 MEDLANCE PLUS LYRICA 15 LANCETS 90 MAXALT-MLT 127 LYSODREN 31 MEDLANCE PLUS LANCETS MAXAM 58 LITE 25G 90 LYSTEDA 75 MAXI-COMFORT INSULIN MEDLANCE PLUS LITE M-M-R II 150 SYRINGE/U- LANCETS 25G 90 M-NATAL PLUS 132 100/0.5ML/28GX1/2" 110 MEDLANCE PLUS SPECIAL LANCETS 0.8MM 90 M-VIT 132 MAXI-COMFORT INSULIN SYRINGE/U- MEDLANCE PLUS SUPERLITE MACROBID 149 100/1ML/28GX1/2" 110 30G 90 MACRODANTIN 149 MAXITROL 139 MEDLANCE PLUS SUPERLITE MACUGEN 138 30G/COMFORT MAX 90 MAXX LUBRICATED 83 MEDLANCE PLUS UNIVERSAL MACUZIN 66 MAXX PLUS SPERMICIDE LANCETS 21G 90 MAGDELAY 129 LUBRICATED 83 MEDLANCE PLUS/LITE MAGELLAN INSULIN SAFETY MAXZIDE 67 25G 90 SYRINGE/U-100/0.3ML/29G X MAXZIDE-25 67 MEDLANCE/EXTRA 90 1/2" 110 meclizine hcl 23 MEDLANCE/LITE 90 MAGELLAN INSULIN SAFETY MEDELA TENDER CARE SYRINGE/U-100/0.3ML/30G X MEDLANCE/UNIVERSAL 90 LANOLIN 58 MEDROL 47 5/16" 110 MEDERMA AG FACE MAGELLAN INSULIN SAFETY CREAM 58 MEDROL DOSEPAK 47 SYRINGE/U-100/0.5ML/29G X MEDERMA AG HAND & BODY medroxyprogesterone 1/2" 110 LOTION 58 acetate 143 MAGELLAN INSULIN SAFETY MEDERMA STRETCH MARKS medroxyprogesterone acetate SYRINGE/U-100/0.5ML/30G X THERAPY 58 (contraceptive) 47 5/16" 110 MEDIC INSULIN MEFLOQUINE HCL 29 MAGELLAN INSULIN SAFETY SYRINGE/0.3ML/30G X mefloquine hcl 29 SYRINGE/U-100/1ML/29G X 5/16" 110 1/2" 110 MEDIC INSULIN MEGACE ORAL 31 MAGELLAN INSULIN SAFETY SYRINGE/0.5ML/30G X megestrol acetate 31 SYRINGE/U-100/1ML/30G X 5/16" 110 MEIJER ALCOHOL SWABS 5/16" 110 MEDICHOICE PRE-SET EXTRA-THICK 95 MAGNEBIND 200 128 SAFETY LANCET DUAL MEIJER COLOR LANCETS MAGNEBIND 300 128 USE 90 UNIVERSAL 33G 90 MAGNEBIND 400 129 MEDICHOICE PRE-SET MEIJER LANCETS 90 SAFETY LANCET LOW MEIJER LANCETS THIN 90 magnesium citrate 78 FLOW 90 magnesium hydroxide 78

Index 24 MEIJER LANCETS methenamine mandelate 149 MICRHOGAM ULTRA- UNIVERSAL21G 90 methenamine-hyosc-methylene FILTEREDPLUS 141 MEIJER LANCETS blue-sod phos-phenyl sal 149 MICRO-K 129 UNIVERSAL30G 90 methimazole 146 MICROCHAMBER 126 MEIJER LANCETS UNIVERSAL33G 90 METHITEST 9 MICROLET LANCETS 90 MEIJER PEN NEEDLES 29G methocarbamol 134 MICROSPACER 126 X12MM 111 methotrexate sodium 30 MICROTAINER SAFETY FLOW MEIJER PEN NEEDLES 31G METHOTREXATE LANCET/STERILE/SINGLE-USE X6MM 111 SODIUM 30 90 MEIJER PEN NEEDLES 31G MICROZIDE 68 X8MM 111 methotrexate sodium 30 MEIJER SUPER THIN methyldopa 27 midazolam hcl 76 LANCETS 90 methylergonovine midodrine hcl 151 MEKINIST 31 maleate 140 miglustat 74 MEKTOVI 31 METHYLIN 2 MIGRANAL 127 MELATONIN 4 methylphenidate hcl 3 MILK OF MAGNESIA melatonin 4 METHYLPHENIDATE CONCENTRATE 78 HYDROCHLORIDE ER 3 MILLIPRED 47 MELATONIN 4 METHYLPHENIDATE MINIPRESS 27 melatonin 4 HYDROCHLORIDE ER (LA)3 MINIVELLE 71 MELATONIN 4 methylprednisolone 47 MINOCIN 146 melatonin 4 metoclopramide hcl 71 minocycline hcl 146 meloxicam 5 metolazone 68 minoxidil 29 melphalan 30 metoprolol & hydrochlorothiazide 28 MIRALAX 77 melphalan hcl 29 metoprolol succinate 42 MIRAPEX 33 memantine hcl 144 METOPROLOL SUCCINATE MIRASORB SPONGES 2" X MENACTRA 150 ER/HYDROCHLOROTHIAZIDE 2" 82 MENVEO 150 28 MIRASORB SPONGES 4" X MEPERIDINE HCL 7 metoprolol tartrate 42 4" 82 meperidine hcl 7 METOPROLOL/HYDROCHLO MIRCERA 75 ROTHIAZIDE 28 MEPHYTON 152 MIRCETTE 46 METROCREAM 62 MIRENA 46 meprobamate 11 METROGEL-VAGINAL 151 mercaptopurine 30 mirtazapine 16 METROLOTION 62 misoprostol 149 mesalamine 72 metronidazole 10 mesna 32 mitoxantrone hcl 31 metronidazole (topical) 62 MM INSULIN SYRINGE/U- MESNEX 32 METRONIDAZOLE 100/0.3ML/30G X 5/16" 111 MESTINON 29 BENZOATE/SYRSPEND SF MM INSULIN SYRINGE/U- MESTINON TIMESPAN 29 PH4 10 100/0.3ML/31G X 5/16" 111 METADATE CD 2 metronidazole vaginal 151 MM INSULIN SYRINGE/U- MEVACOR 26 100/1/2ML/30G X 5/16" 111 METAMUCIL 77 MM INSULIN SYRINGE/U- METAMUCIL ORIGINAL mexiletine hcl 12 100/1/2ML/31G X 5/16" 111 TEXTURE 77 MIACALCIN 68 MM INSULIN SYRINGE/U- METAPROTERENOL MICARDIS 27 100/1ML/30G X 5/16" 111 SULFATE 13 MICARDIS HCT 28 MM INSULIN SYRINGE/U- metformin hcl 20 100/1ML/31G X 5/16" 111 MICATIN 52 methadone hcl 7 MM PEN NEEDLES 31G X MICONAZOLE 3 151 1/4" 111 methamphetamine hcl 1 miconazole nitrate (topical)52 MM PEN NEEDLES 31G X METHAVER 66 miconazole nitrate 3/16" 111 MM PEN NEEDLES 31G X METHAZEL 66 vaginal 151 methazolamide 67 5/16" 111

Index 25 MM PEN NEEDLES 32G X MONOJECT INSULIN MOORE MED MONOJECT 5/32" 111 SYRINGE/U-100/0.5ML/30G X INSULIN SYRINGE/U- MM TWIST LANCETS 90 5/16" 111 100/0.5ML/28G X 1/2" 112 MOBIC 5 MONOJECT INSULIN MOORE MED MONOJECT SYRINGE/U-100/1ML/28G X INSULIN SYRINGE/U- modafinil 3 1/2" 111 100/0.5ML/29G X 1/2" 112 MODERIBA 1200 DOSE MONOJECT INSULIN MOORE MED MONOJECT PACK 40 SYRINGE/U-100/1ML/30G X INSULIN SYRINGE/U- MODERIBA 800 DOSE 5/16" 111 100/1ML/28G X 1/2" 112 PACK 40 MONOJECT ULTRA MOORE MED MONOJECT MOISTURE GUARD 61 COMFORT INSULIN INSULIN SYRINGE/U- MOISTURIZING CREAM 58 SYRINGE/0.3ML/29G X 100/1ML/29G X 1/2" 112 MOLINDONE 1/2" 111 morphine sulfate 7 HYDROCHLORIDE 36 MONOJECT ULTRA MORPHINE SULFATE 7 mometasone furoate 54 COMFORT INSULIN SYRINGE/0.3ML/30G X morphine sulfate 7 MONISTAT 1 COMBO 5/16" 112 MOTHERS FRIEND 58 PACK 151 MONOJECT ULTRA MONISTAT 1 DAY OR NIGHT MOTRIN INFANTS DROPS 5 151 COMFORT INSULIN moxifloxacin hcl (ophth) 138 COMBO PACK SYRINGE/0.3ML/31G X MONISTAT 3 151 5/16" 112 MOZOBIL 75 MONISTAT 3 COMBINATION MONOJECT ULTRA MPD SAFETY LANCET PACK 151 COMFORT INSULIN 21G/1.8MM 90 MONISTAT 7 SIMPLY SYRINGE/0.5ML/28G X MPD SAFETY LANCET CURE 151 1/2" 112 28G/1.8MM 90 MONISTAT SOOTHING CARE MONOJECT ULTRA MPD SAFETY LANCET ITCH RELIEF 54 COMFORT INSULIN 30G/1.8MM 90 MONOCLATE-P 73 SYRINGE/0.5ML/29G X MPD SAFETY LANCETS MONODOX 146 1/2" 112 23G/1.8MM 90 MONOJECT INSULIN MONOJECT ULTRA MS CONTIN 7 SYRINGE/1ML/31G X COMFORT INSULIN MS INSULIN 5/16" 111 SYRINGE/0.5ML/30G X SYRINGE/0.3ML/31G X MONOJECT INSULIN 5/16" 112 5/16" 112 SYRINGE/PERM MONOJECT ULTRA MS INSULIN NEEDLE/1ML/28G X 1/2" 111 COMFORT INSULIN SYRINGE/0.5ML/31G X MONOJECT INSULIN SYRINGE/0.5ML/31G X 5/16" 112 SYRINGE/PERM NEEDLE/U- 5/16" 112 MS INSULIN SYRINGE/1ML/31G 100/0.5ML/28G X 1/2" 111 MONOJECT ULTRA X 5/16" 112 MONOJECT INSULIN COMFORT INSULIN MSM SKIN LOTION 58 SYRINGE/SAFETY/PERM SYRINGE/1ML/28G X MUCINEX 50 NEEDLE/0.3ML/29G X 1/2" 111 1/2" 112 MONOJECT INSULIN MONOJECT ULTRA MUCINEX D 49 SYRINGE/SAFETY/PERM COMFORT INSULIN MUCINEX D MAXIMUM NEEDLE/0.3ML/29GX1/2" 111 SYRINGE/1ML/29G X STRENGTH 49 MONOJECT INSULIN 1/2" 112 MUCINEX DM 49 SYRINGE/SAFETY/PERM MONOJECT ULTRA MUCINEX MAXIMUM NEEDLE/0.5ML/29G X 1/2" 111 COMFORT INSULIN STRENGTH 50 MONOJECT INSULIN SYRINGE/1ML/30G X MULTI PRENATAL 132 SYRINGE/SAFETY/PERM 5/16" 112 Multiple Vitamin 131 NEEDLE/1ML/29G X 1/2" 111 MONOLET LANCETS 90 MONOJECT INSULIN Multiple Vitamins w/ Iron 131 MONOLET OPD Multiple Vitamins w/ SYRINGE/SOFTPACK/U- LANCETS 90 100/0.5ML/28G X 1/2" 111 Minerals 131 MONOLETTOR SAFETY multiple vitamins w/ MONOJECT INSULIN LANCETS 90 minerals 131 SYRINGE/U-100/0.3ML/30G X MONONINE 73 5/16" 111 Multiple Vitamins w/ Minerals & MONOJECT INSULIN MONOVISC 134 Folic Acid 131 SYRINGE/U-100/0.5ML/28G X montelukast sodium 12 mupirocin 51 1/2" 111

Index 26 mupirocin calcium (topical) 51 NARCAN 22 NEUTRAPHOR 61 MX-SOL 142 NARDIL 17 NEUTRAPHORUS REX 61 MX-SOL BLEND 142 NASACORT ALLERGY NEUTROGENA AGE SHIELD MX-SOL BLEND SF 142 24HR 135 FACE SUNBLOCK WITH NASACORT ALLERGY 24HR HELIOPLEX SPF110 63 MX-SOL SF 142 CHILDRENS 135 NEUTROGENA AGE SHIELD MX-SOL SUSPEND 142 NASAL FACE SUNBLOCK WITH MYALEPT 70 DECONGESTANT 135 HELIOPLEX SPF70 63 NEUTROGENA BODY LIGHT MYAMBUTOL 29 NASALCROM 135 NAT-RUL PRENATAL SESAME FORMULA 58 mycophenolate mofetil 130 VITAMINS 132 NEUTROGENA COOLDRY mycophenolate mofetil hcl 130 NATALVIT 132 SPORTWITH HELIOPLEX SPF 30 63 mycophenolate sodium 130 nateglinide 21 NEUTROGENA HAND 58 MYDAYIS 1 NATROBA 62 NEUTROGENA MYDRIACYL 138 NECON 1/50-28 46 HAND/NORWEGIANFORMULA/ MYFORTIC 130 NECON 10/11-28 46 FAST ABSORBING 58 MYGLUCOHEALTH MGH NEFAZODONE HCL 18 NEUTROGENA HEALTHY SOFTLANCE LANCETS DEFENSE DAILY 30G 91 nefazodone hcl 18 MOISTURIZER MYLERAN 30 NEFAZODONE PURESCREEN 63 HYDROCHLORIDE 18 MYLICON 71 NEUTROGENA HEALTHY NEMBUTAL SODIUM 76 SKIN 58 MYLICON INFANTS GAS neomycin sulfate 4 NEUTROGENA HEALTHY SKIN RELIEF 71 FACE SPF 15 58 MYNATAL ADVANCE 132 neomycin-bacitracin zn- polymyxin 138 NEUTROGENA MEN SPF MYNATAL PLUS 132 neomycin-bacitracin-polymyxin 20 63 MYNATAL ULTRACAPLET 132 51 NEUTROGENA MOISTURE SENSITIVE SKIN 59 MYNATAL-Z 132 neomycin-polymy- dexameth 139 NEUTROGENA MOISTURE MYNATE 90 PLUS 132 neomycin-polymyxin w/ SPF15UNTINTED 63 MYOBLOC 136 pramoxine 51 NEUTROGENA SPORT FACE MYSOLINE 15 neomycin-polymyxin-gramicidin SUNBLOCK WITH HELIOPLEX SPF70 63 NABI-HB 141 138 neomycin-polymyxin-hc NEUTROGENA T/GEL 64 nabumetone 5 (otic) 140 NEUTROGENA T/GEL nadolol 42 NEOMYCIN/POLYMYXIN/HYD STUBBORN ITCH NAGLAZYME 70 ROCORTISONE 139 CONTROL 64 NEONATAL PLUS 132 NEUTROGENA ULTRA SHEER naloxone hcl 22 DRY-TOUCH SPF 45 63 naltrexone hcl 22 NEONATAL VITAMIN 132 NEUTROGENA ULTRA SHEER NAMENDA 144 NEORAL 130 DRY-TOUCH WITH HELIOPLEX NAMENDA TITRATION NEOSPORIN 138 SPF 100 64 PAK 144 NEOSPORIN ORIGINAL 52 NEUTROGENA ULTRA SHEER NAMENDA XR 144 NEOSPORIN PLUS PAIN DRY-TOUCH WITH HELIOPLEX SPF 55 64 NAMENDA XR TITRATION RELIEF MAXIMUM NEUTROGENA ULTRA SHEER STRENGTH 52 PACK 144 DRY-TOUCH WITH HELIOPLEX NAMZARIC 144 NEPHROCAPS 131 SPF 70 64 naphazoline w/ NEPTAZANE 67 nevirapine 39 pheniramine 138 NESINA 21 NEXAVAR 31 NAPHCON-A 138 NETGROUP LANCETS 91 NEXIUM 148 NAPROSYN 5 NEULASTA 75 NEXIUM 24HR 148 naproxen 5 NEULASTA ONPRO KIT 75 NEXIUM 24HR CLEAR naproxen sodium 5 NEUREPA 66 MINIS 148 naratriptan hcl 127 NEURONTIN 15 NEXPLANON 47

Index 27 niacin 152 NIVEA VISAGE GENTLE NOVAFERRUM 125 75 niacin (antihyperlipidemic) 26 CLEANSING 61 NOVAFERRUM PEDIATRIC NIVEA VISAGE INNER NIACIN TR 152 DROPS 75 BEAUTY NIGHTTIME NOVAREL 69 NIACOR 26 RENEWAL 59 NOVOEIGHT 73 NIASPAN 26 NIVEA VISAGE UV CARE DAILY FACIAL 64 NOVOFINE 30GX8MM 112 nicardipine hcl 43 NIX CREME RINSE 62 NOVOFINE 32GX6MM 112 NICODERM CQ 145 NIZORAL 52 NOVOFINE AUTOCOVER NICORETTE 145 NOR-QD 47 30GX8MM 112 NICORETTE MINI 145 NOVOFINE PLUS NORCO 8 NICORETTE STARTER 32GX4MM 112 KIT 145 NORDIPEN 5 INJECTION NOVOLIN 70/30 21 DEVICE 112 nicotine 145 NORDIPEN DELIVERY NOVOLIN 70/30 FLEXPEN 21 nicotine polacrilex 145 SYSTEM 112 NOVOLIN 70/30 FLEXPEN NICOTINE TRANSDERMAL NORDITROPIN FLEXPRO 69 RELION 21 SYSTEM 145 norethin acet & estrad-fe 46 NOVOLIN 70/30 RELION 21 NICOTROL INHALER 145 norethindrone & eth NOVOLIN N 21 NICOTROL NS 145 estradiol 46 NOVOLIN N RELION 21 nifedipine 43 norethindrone & ethinyl NOVOLIN R 21 NINLARO 31 estradiol-fe 46 norethindrone NOVOLIN R RELION 21 NISEKO HYDRATING FACIAL (contraceptive) 47 NOVOLOG MIX 70/30 21 MOISTURIZER 59 norethindrone acet & eth NOVOLOG MIX 70/30 NITRO-BID 11 estra 46 PREFILLED FLEXPEN 21 NITRO-DUR 11 norethindrone acetate 143 NOVOSEVEN RT 73 nitrofurantoin 149 norethindrone acetate-ethinyl NPLATE 75 nitrofurantoin macrocrystal 149 estradiol 70 NU GAUZE 4PLY 4"X4" 82 norethindrone acetate-ethinyl nitrofurantoin monohyd NU GAUZE GENERAL-USE macro 149 estradiol-fe 46 norethindrone-eth estradiol SPONGES 4"X4" 4 PLY 82 nitroglycerin 11 (triphasic) 46 NUCALA 12 NITROSTAT 11 norgestimate-ethinyl NUCYNTA 7 NIVA-PLUS 132 estradiol 46 NUCYNTA ER 7 NIVEA 59 norgestimate-ethinyl estradiol (triphasic) 46 NULOJIX 130 NIVEA EXTRA ENRICHED 59 norgestrel & ethinyl NULYTELY/FLAVOR NIVEA EXTRA ENRICHED estradiol 46 PACKS 77 LOTION 59 NORINYL 1+35 46 NUPERCAINAL 9 NIVEA GENTLE BODY NUPLAZID 34 EXFOLIATOR 59 NORPACE 12 NUTRADERM 59 NIVEA HAND THERAPY 64 NORPACE CR 12 NORPRAMIN 19 NUTRADERM ADVANCED NIVEA LIGHT 59 FORMULA 59 NIVEA MOISTURIZING BODY nortriptyline hcl 19 NUTRICION PORVIDA 132 WASH 61 NORTRIPTYLINE HCL 19 NUTROPIN AQ NUSPIN 10 69 NIVEA MOISTURIZING BODY nortriptyline hcl 19 WASH 2 IN 1 61 NUTROPIN AQ NUSPIN 20 69 NIVEA ORIGINAL 59 NORTRIPTYLINE HCL 19 NUTROPIN AQ NUSPIN 5 69 NIVEA ORIGINAL NORVASC 43 NUVARING 46 MOISTURE 59 NORVIR 39 NUVIGIL 3 NIVEA SOFT 59 NOVA SAFETY LANCETS nystatin 23 NIVEA TOUCH OF 23G 91 SMOOTHNESS MOISTURIZING NOVA SAFETY LANCETS nystatin (mouth-throat) 131 BODY WASH 61 28G 91 nystatin (topical) 52 NIVEA VISAGE 59 NOVA SUREFLEX nystatin-triamcinolone 52 LANCETS 91

Index 28 NYTOL MAXIMUM ONDANSETRON ORAL SUSPEND 142 STRENGTH 76 HYDROCHLORIDE 23 ORAL SUSPENDING O-CAL FA 132 ONETOUCH CLUB LANCETS COMPOUNDPLUS 142 O-CAL PRENATAL 132 FINE POINT 91 ORAL SYRUP FLAVORED ONETOUCH COMBO OBIZUR 73 VEHICLE 142 PACK 91 ORAL SYRUP SF 142 OCALIVA 71 ONETOUCH DELICA ORALAIR 3 OCEAN NASAL SPRAY 135 LANCETS EXTRA FINE 33G 91 ORALAIR ADULT SAMPLE OCTAGAM 141 ONETOUCH DELICA KIT 3 octreotide acetate 70 LANCETS FINE 30G 91 ORALAIR ADULT STARTER OCUFEN 140 ONETOUCH FINEPOINT PACK 3 ORALAIR OCUFLOX 138 LANCETS 91 ONETOUCH ULTRASOFT CHILDREN/ADOLESCENTS OCUSOFT HAND SOAP 61 LANCETS 91 STARTER PACK 3 ODEFSEY 39 ONFI 14 ORAP 145 ODOMZO 30 OPSUMIT 44 ORENCIA 6 OFLOXACIN 71 OPTICHAMBER ORENCIA CLICKJECT 6 ofloxacin 71 ADVANTAGE/LARGE ORENITRAM 44 MASK 126 ofloxacin (ophth) 138 OPTICHAMBER ORKAMBI 146 ofloxacin (otic) 140 ADVANTAGE/MEDIUM FACE orphenadrine citrate 134 OGESTREL 46 MASK 126 ORTHO MICRONOR 47 OINTMENT BASE 59 OPTICHAMBER ORTHO TRI-CYCLEN 46 ADVANTAGE/SMALL FACE olanzapine 35,36 MASK 126 ORTHO TRI-CYCLEN LO 46 olanzapine-fluoxetine hcl 144 OPTICHAMBER ORTHO-CYCLEN 46 olmesartan medoxomil 27 DIAMOND 126 ORTHO-NOVUM 1/35 46 olmesartan medoxomil- OPTICHAMBER DIAMOND/LARGEFACE ORTHO-NOVUM 7/7/7 46 amlodipine-hydrochlorothiazide ORTHOVISC 135 28 MASK 126 olmesartan medoxomil- OPTICHAMBER oseltamivir phosphate 41 hydrochlorothiazide 28 DIAMOND/MEDIUM FACE OSENI 20 MASK 126 OLYSIO 40 OPTICHAMBER OTEZLA 5 omega-3 fatty acids 136 DIAMOND/SMALLFACE OTICIN HC NR 140 omega-3-acid ethyl esters 25 MASK 126 OTREXUP 4 omeprazole 148 OPTICHAMBER FACE OVACE PLUS WASH 53 MASK/LARGE 126 OMEPRAZOLE 148 OPTICHAMBER FACE OVACE WASH 53 OMEPRAZOLE + SYRSPEND MASK/MEDIUM 126 OVCON-35 46 SFALKA 148 OPTICHAMBER FACE OVIDE 62 omeprazole magnesium 148 MASK/SMALL 126 oxaprozin 5 OMNIPRED 139 OPTIFOAM 82 oxazepam 12 OMNIQUIN 66 OPTIHALER 126 OXAZEPAM 12 OMNITROPE 69 OPTIHALER MDI DRUG OMNITROPE PEN 10 DELIVERY SYSTEM 126 oxcarbazepine 15 INJECTION DEVICE 112 ORA-BLEND 142 OXTELLAR XR 15 OMNITROPE PEN 5 INJECTION ORA-BLEND SF 142 oxybutynin chloride 149 DEVICE 112 ORA-PLUS 142 oxycodone hcl 7 ON CALL LANCETS 91 ORA-SWEET 142 oxycodone w/ acetaminophen 8 ON CALL PLUS LANCETS 91 ORA-SWEET SF 142 oxycodone-aspirin 8 ONCASPAR 32 oral electrolytes 128 OXYCODONE/ACETAMINOPHE ondansetron 23 ORAL MIX FLAVORED N 8 ondansetron hcl 23 SUSPENDING VEHICLE 142 oyster shell 128 ORAL MIX SF 142 paliperidone 35

Index 29 PAMELOR 19 Pediatric Multivitamins w/Fl penicillin v potassium 141 pamidronate disodium 68 0.25MG, 1MG 132 PENTACEL 147 Pediatric Multivitamins w/Fl PAMIDRONATE DISODIUM 68 0.5MG, Soln 132 PENTIPS 29G X 12MM 113 PANCREAZE 67 Pediatric Vitamins ACD PENTIPS 29GX12MM 113 PANOXYL-4 CREAMY Fluoride & Iron 132 PENTIPS 31G X 5MM 113 Pediatric Vitamins ACD w/ WASH 51 PENTIPS 31G X 8MM 113 pantoprazole sodium 148 Fluoride 132 PENTIPS 31GX5MM 113 PARAFON FORTE DSC 134 Pediatric Vitamins ADC 132 PENTIPS 31GX6MM 113 paricalcitol 70 PEDVAX HIB 150 peg 3350-kcl-sod bicarb-sod PENTIPS 31GX8MM 113 PARLODEL 33 chloride-sod sulfate 77 PENTIPS 32G X 4MM 113 PARNATE 17 peg 3350-potassium chloride- PENTIPS 32GX4MM 113 paroxetine hcl 17 sod bicarbonate-sod PENTOBARBITAL SODIUM 76 PARVA-CAL 128 chloride 77 PEG-INTRON REDIPEN 40 pentobarbital sodium 76 PAXIL 18 PEGASYS 41 pentoxifylline 74 PAXIL CR 17 PENTRAVAN 59 PC LANCETS SUPER THIN PEGASYS PROCLICK 41 30G 91 PEGINTRON 41 PENTRAVAN PLUS 59 PC UNIFINE PENTIPS 29G PEN NEEDLES 29G X PEPCID 147 X1/2" 112 12MM 112 PEPCID AC 147 PC UNIFINE PENTIPS 31G PEN NEEDLES PEPCID AC MAXIMUM X5MM MINI 112 29GX1/2" 112 STRENGTH 147 PC UNIFINE PENTIPS 31G PEN NEEDLES X6MM ULTRA SHORT 112 30GX5/16" 112 PEPTO BISMOL 22 PC UNIFINE PENTIPS 31G PEN NEEDLES PEPTO-BISMOL 22 X8MM SHORT 112 30GX8MM 112 PEPTO-BISMOL PCCA SWEET-SF 142 PEN NEEDLES 31G X 1/4" INSTACOOL 22 PCCA SYRUP VEHICLE 142 SHORT 113 PEPTO-BISMOL MAX PEN NEEDLES 31G X STRENGTH 22 PCCA-PLUS 142 3/16" 113 PEPTO-BISMOL TO-GO 22 PCE 79 PEN NEEDLES 31G X PERCOCET 8 Ped Multivitamins w/Fl & 5MM 113 Iron 132 PEN NEEDLES 31G X PERCURA 66 PEDIA-LAX 77 6MM 113 PERFECT LANCETS 30G 91 PEN NEEDLES 31G X PEDIALYTE 129 PERFECT PRESSURE 8MM 113 ACTIVATED SAFETY LANCETS PEDIALYTE ADVANCED PEN NEEDLES 28G 91 CARE 129 31GX5/16" 113 PERIDEX 131 PEDIALYTE FREEZER PEN NEEDLES 31GX6MM POPS 129 (1/4") 113 PERJETA 30 PEDIALYTE SINGLES 129 PEN NEEDLES permethrin 62 PEDIAPRED 47 31GX8MM 113 perphenazine 37 PEDIARIX 147 PEN NEEDLES 31GX8MM PERPHENAZINE/AMITRIPTYLIN (5/16") 113 E 144 Pediatric Multiple Vitamin w/ PEN NEEDLES 32G X C 132 4MM 113 PERRY PRENATAL 132 Pediatric Multiple Vitamin w/ C & PEN NEEDLES 32G X PETROLATUM 59 FA 132 5MM 113 PEXEVA 18 Pediatric Multiple Vitamin w/ PEN NEEDLES 32G X Minerals & C Drops 132 PH 12 STERILE DILUENT 6MM 113 FORFLOLAN 142 Pediatric Multiple Vitamin w/ PEN NEEDLES Minerals Chew 132 PHARMACIST CHOICE ULTRA 32GX4MM 113 THIN LANCETS 91 Pediatric Multiple Vitamins 132 PEN-KERA 59 PHARMACIST CHOICE ULTRA Pediatric Multiple Vitamins w/ Iron THIN LANCETS 28G 91 Chew 132 penicillin v potassium 141 PENICILLIN V PHARMACIST CHOICE ULTRA Pediatric Multiple Vitamins w/ Iron THIN LANCETS 30G 91 Drops 132 POTASSIUM 141

Index 30 PHARMACIST CHOICE ULTRA PNV PRENATAL PLUS PRECISION SURE-DOSE THIN LANCETS 31G 91 MULTIVITAMIN 133 INSULIN SYRINGE/0.3ML/30G X PHARMACIST CHOICE ULTRA POCKET CHAMBER 126 5/16" 113 THIN LANCETS 33G 91 POCKET SPACER 126 PRECISION SURE-DOSE PHARMACY COUNTER INSULIN SYRINGE/0.5ML/28G X LANCETS 91 podofilox 60 1/2" 113 phenazopyridine hcl 72 polyethylene glycol 3350 77 PRECISION SURE-DOSE phenelzine sulfate 17 POLYETHYLENE GLYCOL INSULIN SYRINGE/0.5ML/29G X 3350 143 1/2" 113 PHENELZINE SULFATE 45 POLYMEM DRESSING/3" X PRECISION SURE-DOSE phenobarbital 76 3" 82 INSULIN SYRINGE/1ML/28G X PHENOBARBITAL 76 POLYMEM DRESSING/4" X 1/2" 113 phenobarbital 76 4" 82 PRECISION SURE-DOSE POLYMEM FILM DOT 82 PLUSINSULIN PHENOBARBITAL SODIUM 76 POLYMEM NON-ADHESIVE SYRINGE/0.3ML/29G X phenylephrine hcl (ophth) 139 PAD 82 1/2" 113 phenylephrine hcl (oral) 135 polymyxin b-trimethoprim 138 PRECISION SURE-DOSE polysaccharide iron PLUSINSULIN phenylephrine in hard fat 9 SYRINGE/1ML/29G X 1/2" 113 phenylephrine-chlorphen-dm complex 75 PRECISION THIN 49 POLYSPORIN 52 LANCETS 91 phenylephrine-cocoa butter 9 POLYTRIM 138 PRECISION THINS GP phenylephrine-dm 49 polyvinyl alcohol 137 LANCET 91 phenylephrine-shark liver oil- polyvinyl alcohol-povidone PRECISION ULTRA mineral oil-petrolatum 9 (ophth) 137 LANCET 91 phenytoin 16 POMALYST 31 PRED FORTE 139 phenytoin sodium extended 16 pot phosphate monobasic w/ PRED MILD 139 phytonadione 152 sod phosphate dibasic & PRED-G 139 monobasic 129 pilocarpine hcl 138 PREDNISOLONE 47 potassium bicarbonate 129 pilocarpine hcl (oral) 131 prednisolone 47 potassium chloride 129 pimozide 145 prednisolone acetate POTASSIUM CHLORIDE (ophth) 139 pindolol 42 ER 129 PREDNISOLONE ACETATE P- pioglitazone hcl 21 potassium chloride F 139 pioglitazone hcl-metformin microencapsulated crystals prednisolone sodium hcl 20 er 129 phosphate 47 piroxicam 5 potassium citrate PREDNISOLONE SODIUM (alkalinizer) 72 PHOSPHATE 139 PLAN B ONE-STEP 46 povidone-iodine 38 PREDNISONE 47 PLAQUENIL 29 PRALUENT 26 prednisone 47 PLASTIC ADAPTER FOR pramipexole PREDNISONE 47 BUSHINJECTOR 113 dihydrochloride 33 PLASTIC ADAPTER FOR pramoxine-hc-chloroxylenol PREDNISONE INTENSOL 47 BUSHINJECTOR B-D 140 PREFERRED PLUS INSULIN PLASTIPAK 113 prasugrel hcl 74 SYRINGE/U-100/0.3ML/29G X PLAVIX 74 1/2" 113 PRAVACHOL 26 PLEGRIDY 144 PREFERRED PLUS INSULIN PLEGRIDY STARTER pravastatin sodium 26 SYRINGE/U-100/0.3ML/30G X PACK 144 prazosin hcl 27 5/16" 113 PREFERRED PLUS INSULIN PNEUMOVAX 23 150 PRAZOSIN HYDROCHLORIDE 27 SYRINGE/U-100/0.5ML/28G X PNEUMOVAX 23/1 DOSE 150 1/2" 113 PNV FERROUS PRE SUN KIDS 64 PREFERRED PLUS INSULIN FUMARATE/DOCUSATE/FOLIC PRE-NATAL FORMULA 133 SYRINGE/U-100/0.5ML/29G X ACID 133 PRECEDEX 76 1/2" 113 PNV FOLIC ACID + IRON MULTIVITAMIN 133

Index 31 PREFERRED PLUS INSULIN PRENATAL VITAMINS PLUS PRO COMFORT PEN SYRINGE/U-100/0.5ML/30G X LOW IRON 134 NEEDLES/32G X 4MM 114 5/16" 114 PREPLUS 134 PRO COMFORT PEN PREFERRED PLUS INSULIN PRESSURE ACTIVATED NEEDLES/32G X 5MM 114 SYRINGE/U-100/1ML/28G X SAFETYLANCET 21G 91 PRO COMFORT PEN 1/2" 114 PRETAB 134 NEEDLES/32G X 6MM 114 PREFERRED PLUS INSULIN probenecid 73 PRETTY FEET & HANDS 59 SYRINGE/U-100/1ML/29G X PROCARDIA 43 1/2" 114 PREVACID 148 PROCARDIA XL 43 PREFERRED PLUS INSULIN PREVACID 24HR 148 PROCENTRA 1 SYRINGE/U-100/1ML/30G X PREVACID SOLUTAB 148 5/16" 114 PREVIDENT 5000 DRY prochlorperazine 37 PREFERRED PLUS LANCETS prochlorperazine edisylate 37 COLORED 21G 91 MOUTH 131 PREFERRED PLUS LANCETS PREVIDENT 5000 PLUS 131 PROCHLORPERAZINE SUPER THIN 30G 91 PREVIDENT FLUORIDE 131 MALEATE 37 prochlorperazine maleate 37 PREFERRED PLUS LANCETS PREVNAR 13 150 THIN 26G 91 PROCRIT 75 PREZCOBIX 39 PREFERRED PLUS UNIFINE PROCYSBI 72 PREZISTA 39 PENTIPS 29G X 12MM 114 PRODIGY INSULIN SYRING/U- PREFERRED PLUS UNIFINE PRIALT 6 100/0.3ML/31G X 5/16" 114 PENTIPS 31G X 6MM ULTRA PRILOSEC 148,149 PRODIGY INSULIN SHORT 114 SYRINGE/1/2ML/31G X PREFERRED PLUS UNIFINE PRIMAQUINE 5/16" 114 PENTIPS 31G X 8MM PHOSPHATE 29 primidone 15 PRODIGY INSULIN SHORT 114 SYRINGE/1ML/28G X 1/2" 114 PREFERRED PLUS UNIFINE PRINIVIL 26 PRODIGY PRESSURE PENTIPS 32GX4MM 114 PRISTIQ 18 ACTIVATED SAFETY PREFERRED PLUS UNIFINE PRIVIGEN 141 LANCETS 91 PENTIPS/MINI/31GX5MM 114 PRODIGY SAFETY PREGNYL W/DILUENT PRO COMFORT ALCOHOL PADS 95 LANCETS 91 BENZYLALCOHOL/NACL 69 PRODIGY TWIST TOP PREMARIN 71,151 PRO COMFORT INHALER SPACER CHAMBER LANCETS 91 PREMIUM CONDOMS ADULT 126 PROFILNINE 73 LUBRICATED 84 PRO COMFORT INHALER PROFILNINE SD 73 PREMPRO 70 SPACER CHAMBER progesterone micronized 143 PRENATABS FA 133 CHILD 126 PROGRAF 130 PRENATAL 133 PRO COMFORT INSULIN PROLASTIN-C 145 PRENATAL 19 133 SYRINGES/0.5ML/30G X 5/16" 114 PROLEUKIN 32 PRENATAL AND IRON 133 PRO COMFORT INSULIN PROLIA 68 PRENATAL FORMULA 133 SYRINGES/0.5ML/31G X PROMACTA 75 PRENATAL FORTE 133 5/16" 114 PRO COMFORT INSULIN promethazine & PRENATAL LOW IRON 133 SYRINGES/1ML/30G X phenylephrine 49 Prenatal Multivit-Min w/Fe- 1/2" 114 promethazine hcl 24 FA 133 PRO COMFORT INSULIN promethazine w/codeine 49 PRENATAL SYRINGES/1ML/30G X MULTIVITAMIN 133 5/16" 114 promethazine-dm 49 PRENATAL ONE DAILY 133 PRO COMFORT INSULIN PROMETHAZINE/PHENYLEPHR PRENATAL PLUS 133 SYRINGES/1ML/31G X INE 49 PROMETRIUM 143 PRENATAL VITAMIN 133 5/16" 114 PRO COMFORT LANCETS PRENATAL VITAMIN & propafenone hcl 12 30G 91 propranolol hcl 42 MINERAL 133 PRO COMFORT LANCETS PRENATAL 31G 91 PROPRANOLOL HCL 42 VITAMIN/IRON 133 PRO COMFORT PEN propranolol hcl 42 PRENATAL VITAMINS 134 NEEDLES/31G X 8MM 114 PROPRANOLOL HCL 42

Index 32 propranolol hcl 42 PX INSULIN SYRINGE/U- quinapril hcl 26 PROPRANOLOL/HYDROCHLOR 100/1ML/31G X 5/16" 114 quinapril-hydrochlorothiazide OTHIAZIDE 28 PX LANCETS ULTRA 28 propylthiouracil 146 THIN 92 quinidine gluconate 12 PX LANCETS ULTRA THIN PROSCAR 72 28G 91 QUINIDINE SULFATE 12 PROSHIELD PLUS SKIN PX MINI PEN NEEDLES RA ADVANCED HEALING 59 PROTECTANT 61 31GX5MM 114 RA ALCOHOL SWABS 95 PROTONIX 149 PX OMEPRAZOLE 149 RA ALL PURPOSE PROTOPIC 60 PX PEN NEEDLE DRESSINGS4"X4" 82 protriptyline hcl 19 29GX12MM 114 RA DAYLOGIC HEALING DRY PX PEN NEEDLE PROVERA 143 SKIN THERAPY 59 31GX8MM 114 RA DRESSING SPONGES PROVIGIL 3 PX PRENATAL 4"X4" 82 PROZAC 18 MULTIVITAMINS 134 RA E-ZJECT COLOR PROZAC WEEKLY 18 PX SHORTLENGTH PEN LANCETSMICRO-THIN 33G 92 NEEDLES/31GX8MM 114 pseudoephed-bromphen-dm 49 RA E-ZJECT LANCETS 28G92 pyrazinamide 29 RA E-ZJECT LANCETS THIN pseudoephedrine hcl 135 pyrethrins-piperonyl 26G 92 pseudoephedrine w/ codeine- butoxide 62 RA E-ZJECT LANCETS THIN gg 49 pyrethrins-piperonyl butoxide- 28G 92 pseudoephedrine-chlorphen-dm permethrin-nit remover 62 RA E-ZJECT LANCETS 49 PYRIDIUM 72 ULTRATHIN 30G 92 pseudoephedrine-guaifenesin pyridostigmine bromide 29 RA GAUZE SPONGES 49 4"X4" 82 pyridoxine hcl 152 pseudoephedrine-ibuprofen 50 RA GENTLE SKIN CREAM 59 PSS SELECT GP LANCETS 91 QC ALCOHOL SWABS 95 RA INSULIN PSS SELECT SAFETY QC ALL PURPOSE SYRINGE/0.5ML/29G X LANCETS 91 DRESSINGS4"X4" 82 1/2" 115 psyllium 77 QC BORDER ISLAND GAUZE RA INSULIN SYRINGE/1ML/29G PAD 2"X2" 82 PULMICORT 13 X 1/2" 115 QC LANCETS SUPER RA INSULIN SYRINGE/U- PULMICORT FLEXHALER 13 THIN 92 100/0.5ML/30G X 5/16" 115 PULMONA 66 QC LANCETS ULTRA RA INSULIN SYRINGE/U-100/1 THIN 92 PULMOZYME 146 ML/30G X 5/16" 115 QC PEN NEEDLES 29G X RA OMEPRAZOLE 149 PURE & FREE BABY 12MM 114 SUNSCREEN BROAD QC PEN NEEDLES 31G X RA PEN NEEDLES 31G X SPECTRUM SPF 50 6MM 115 5MM3/16" 115 PURESCREEN 64 QC PEN NEEDLES 31G X RA PEN NEEDLES 31G X PURE & FREE BABY 8MM 115 8MM5/16" 115 SUNSCREEN BROAD QC PRENATAL 134 RA PRENATAL 134 SPECTRUM SPF 60+ 64 RA PRENATAL QC STERILE PADS 82 PURE L-CITRULLINE 137 FORMULA/FOLICACID 134 QC UNIFINE PENTIPS PURIXAN 30 RA RENEWAL DRY SKIN 32GX4MM 115 THERAPY 59 PUSH BUTTON SAFETY QC UNILET LANCETS RA RX SUNCARE ADVANCED LANCETS 21G 91 28G/ULTRA THIN 92 PROTECTION SPF50 64 PUSH BUTTON SAFETY QC UNILET LANCETS RA STERILE PADS 2"X2" 82 LANCETS 28G 91 33G/MICRO THIN 92 PX EXTRA SHORT PEN QUADRACEL 147 RA STERILE PADS 3"X3" 82 NEEDLES 31GX6MM 114 QUDEXY XR 15 RA STERILE PADS 4"X4" 82 PX INSULIN SYRINGE/U- rabeprazole sodium 149 100/0.3ML/31G X 5/16" 114 QUESTRAN 25 PX INSULIN SYRINGE/U- QUESTRAN LIGHT 25 RADIAGUARD ADVANCED 59 100/0.5ML/31G X 5/16" 114 quetiapine fumarate 36 raloxifene hcl 69 PX INSULIN SYRINGE/U- ramipril 26 100/1ML/30G X 1/2" 114 QUILLICHEW ER 3 QUILLIVANT XR 3 ranitidine hcl 147,148

Index 33 RAPAMUNE 130 RELION INSULIN SYRINGE/U- REPATHA PUSHTRONEX RASUVO 4 100/0.3ML/30G X 5/16" 115 SYSTEM 26 RELION INSULIN SYRINGE/U- REPATHA SURECLICK 26 RAVICTI 70 100/0.3ML/31G X 15/64" 115 REQUIP 33 RAY-TEC X-RAY RELION INSULIN SYRINGE/U- DETECTABLESPONGES 4" X 4" 100/0.3ML/31G X 5/16" 115 RESCRIPTOR 39 16 PLY 82 RELION INSULIN SYRINGE/U- RESTA 59 RAZADYNE 144 100/0.5ML/29G X 1/2" 115 RESTA LITE 59 RAZADYNE ER 144 RELION INSULIN SYRINGE/U- RESTORE CONTACT READYLANCE SAFETY 100/0.5ML/30G X 5/16" 115 LAYER/NON-ADHERENT RELION INSULIN SYRINGE/U- LANCETS/21G/2.2MM 92 2"X2" 82 READYLANCE SAFETY 100/0.5ML/31G X 5/16" 115 RESTORE FOAM DRESSING RELION INSULIN SYRINGE/U- LANCETS/23G/1.8MM 92 BORDERED 4"X4" 82 READYLANCE SAFETY 100/1ML/30G X 5/16" 115 RESTORE FOAM DRESSING RELION INSULIN SYRINGE/U- LANCETS/26G/1.8MM 92 NON-BORDERED 4"X4" 82 READYLANCE SAFETY 100/1ML/31G X 5/16" 115 RESTORE ODOR ABSORBING LANCETS/28G/1.8MM 92 RELION KETONE 65 DRESSING 4"X4" 82 READYLANCE SAFETY RELION KETONE TEST RESTORE TRIO ABSORBENT LANCETS/30G/1.6MM 92 STRIPS 65 DRESSING 3"X3" 82 REALITY INSULIN SYRINGE/U- RELION LANCETS MICRO- RESTORIL 76 THIN33G 92 100/0.5ML/28G X 1/2" 115 RETIN-A 51 REALITY INSULIN SYRINGE/U- RELION LANCETS 100/0.5ML/29G X 1/2" 115 STANDARD 21G 92 RETROVIR 39 REALITY INSULIN SYRINGE/U- RELION LANCETS THIN RETROVIR IV INFUSION 39 100/1ML/28G X 1/2" 115 26G 92 REVATIO 44 REALITY INSULIN SYRINGE/U- RELION LANCETS ULTRA- 100/1ML/29G X 1/2" 115 THIN30G 92 REVLIMID 130 REALITY LANCETS 92 RELION MINI PEN NEEDLES REXALL LANCETS ULTRA THIN 92 REALITY LATEX 31GX6MM 115 RELION PEN NEEDLES CONDOMS/LUBRICATED 84 REXULTI 37 REALITY LATEX/ULTRA 29GX12MM 115 REYATAZ 39 RELION PEN NEEDLES TEXTURED 84 RHEUMATE 66 REALITY LATEX/ULTRA 31GX6MM 115 RELION PEN NEEDLES RHINOCORT AQUA 135 THIN 84 REALITY TRIGGER 31GX8MM 115 RHOGAM ULTRA-FILTERED RELION PEN NEEDLES LANCETS 92 PLUS 141 32GX4MM 115 RHOPHYLAC 141 REBETOL 41 RELION SHORT PEN REBIF 145 NEEDLES31GX8MM 115 RIASTAP 73 REBIF REBIDOSE 145 RELION ULTRA THIN RIBASPHERE 41 REBIF REBIDOSE LANCETS30G 92 RIBASPHERE RIBAPAK 41 TITRATIONPACK 145 RELION ULTRA THIN PLUS ribavirin (hepatitis c) 41 LANCETS 32G 92 REBIF TITRATION PACK 145 RELION ULTRA THIN PLUS RIBOFLAVIN 152 REBINYN 73 LANCETS 33G 92 riboflavin 152 RECLAST 68 RELPAX 127 RIBOZEL 66 RECOMBINATE 73 REMEDY CLEANSING BODY RID 62 RECOMBIVAX HB 150 LOTION 61 RID COMPLETE LICE REMEDY DIMETHICONE ELIMINATION 62 REFRESH 137 MOISTURE BARRIER 61 RIFADIN 29 REFRESH TEARS 137 REMEDY NUTRASHIELD 61 rifampin 29 REGLAN 72 REMEDY SKIN REPAIR 61 RIGHT STEP PRENATAL 134 RELENZA DISKHALER 41 REMERON 16 RIGHTEST GL300 RELION ALCOHOL SWABS 96 REMERON SOLTAB 16 LANCETS 92 RELION INSULIN SYRINGE/U- REMICADE 72 RISABAL-PH 59 00/1ML/29G X 1/2" 115 RELION INSULIN SYRINGE/U- REMODULIN 44 risedronate sodium 68 100/0.3ML/29G X 1/2" 115 REPATHA 26 RISPERDAL 35

Index 34 RISPERDAL CONSTA 35 RYCLORA 23 SALAGEN 131 RISPERDAL M-TAB 35 RYTHMOL 12 saline 135 risperidone 35 SABRIL 16 salsalate 7 RISPERIDONE ODT 35 SAFE-T-LANCE LOW FLOW SAMSCA 70 RITALIN 3 25G 92 SANDIMMUNE 130,131 SAFE-T-LANCE NORMAL RITALIN LA 3 FLOW21G 92 SANDOSTATIN 70 RITEFLO 126 SAFE-T-LANCE PLUS SANDOSTATIN LAR ritonavir 39 SAFETYLANCET HIGH DEPOT 70 FLOW 92 SAPHRIS 36 RITUXAN 30 SAFE-T-LANCE PLUS SAPS HEALTH TWIST TOP rivastigmine 144 SAFETYLANCET LOW LANCETS 30G 92 rivastigmine tartrate 144 FLOW 92 SAPSCARE TWIST TOP RIXUBIS 73 SAFE-T-LANCE PLUS LANCETS 30G 93 SAFETYLANCET NORMAL SARAFEM 145 rizatriptan benzoate 127 FLOW 92 ROBAXIN 134 SAFESNAP INSULIN SARNA 52 ROBAXIN-750 134 SYRINGE/0.3ML/30G X SAVELLA 144 5/16" 115 SAVELLA TITRATION ROBINUL 147 SAFESNAP INSULIN PACK 144 ROBINUL FORTE 147 SYRINGE/0.5ML/29G X SB ALCOHOL PREP PADS 96 ROBITUSSIN PEAK COLD 1/2" 115 SB INSULIN SYRINGE/U- COUGH+ CHEST CONGESTION SAFESNAP INSULIN 100/0.5ML/29G X 1/2" 116 DM MAX STRENGTH 50 SYRINGE/0.5ML/30G X SB INSULIN SYRINGE/U- ROBITUSSIN PEAK COLD 5/16" 115 100/0.5ML/30G X 5/16" 116 DM 50 SAFESNAP INSULIN SB INSULIN SYRINGE/U- ROC DEEP WRINKLE SYRINGE/1ML/28G X 100/1ML/29G X 1/2" 116 SERUM 59 1/2" 116 SB INSULIN SYRINGE/U- ROC MULTI CORREXION 5 IN1 SAFESNAP INSULIN 100/1ML/30G X 5/16" 116 DAILY MOISTURIZER SPF SYRINGE/1ML/29G X SB INSULIN SYRINGE/U- 30 64 1/2" 116 100/1ML/31G X 5/16" 116 ROC MULTI CORREXION 5 IN1 SAFETY INSULIN SYRINGES SB LANCETS THIN 93 RESTORING EYE CREAM 59 0.5ML/29GX1/2" 116 ROC MULTI CORREXION 5 IN1 SAFETY INSULIN SYRINGES SB LANCETS ULTRA THIN 93 RESTORING NIGHT 0.5ML/30GX5/16" 116 SB OMEPRAZOLE 149 CREAM 59 SAFETY INSULIN SYRINGES SCHNUCKS INSULIN ROC RETINOL 1ML/29GX1/2" 116 SYRINGEULTI-FINE/U- CORREXION 59 SAFETY INSULIN SYRINGES 100/0.5ML/29G X 1/2" 116 ROC RETINOL CORREXION 1ML/30GX1/2" 116 SCHNUCKS INSULIN MAX 59 SAFETY LANCET SYRINGEULTI-FINE/U- ROC RETINOL CORREXION 21G/PRESSURE 100/0.5ML/30G X 5/16" 116 NIGHT 59 ACTIVATED 92 SE-NATAL 19 134 ROC RETINOL CORREXION SAFETY LANCET Seasonal Influenza SENSITIVE EYE 59 28G/PRESSURE Vaccine 150 ROC RETINOL CORREXION ACTIVATED 92 SEASONIQUE 46 SENSITIVE NIGHT 59 SAFETY LANCETS 92 ROC RETINOL CORREXION SECONAL SODIUM 76 SAFETY LANCETS 21G 92 SPF30 64 SECTRAL 42 ROCALTROL 70 SAFETY LANCETS 28G 92 SECURA DIMETHICONE ROMIDEPSIN 32 SAFETY LET LANCETS 92 PROTECTANT 61 ropinirole hydrochloride 33 SAFETY SEAL LANCETS SEGLUROMET 20 28G 92 selegiline hcl 33 ROSE MILK 59 SAFETY SEAL LANCETS rosuvastatin calcium 26 30G 92 SELEGILINE HCL 33 ROXICODONE 8 SAIZEN 69 selenium sulfide 53 ROZEREM 77 SAIZEN CLICK.EASY 69 SELSUN BLUE 53 RUCONEST 74 SAIZENPREP SELSUN BLUE DAILY 53 RECONSTITUTIONKIT 69

Index 35 SELSUN BLUE SHOPKO UNIFINE PENTIPS SM INSULIN SYRINGE/1ML/31G MEDICATED 53 PLUS PEN X 5/16" 116 SELSUN BLUE NEEDLES/MINI/REMOVER/31 SM MICRO THIN LANCETS MOISTURIZING 53 GX5MM 116 33G 93 SELZENTRY 39 SHOPKO UNIFINE PENTIPS SM OMEPRAZOLE 149 SENNA 78 PLUS PEN SM PRENATAL VITAMINS 134 NEEDLES/REMOVER/29GX12 sennosides 78 SM SKIN CLEANSER MM 116 GENTLE/SENSITIVE SKIN 61 sennosides-docusate SHOPKO UNIFINE PENTIPS sodium 77 PLUS PEN SM STERILE PADS 82 SENOKOT 78 NEEDLES/SHORT/REMOVR/3 SM STERILE PADS 2"X2" 82 SENOKOT S 77 1GX8MM 116 SMART SENSE COLOR SENOKOT XTRA 78 SHOPKO UNILET LANCETS LANCETS UNIVERSAL 33G 93 SUPER THIN 30G 93 SMART SENSE STANDARD SENSI-CARE SHOPKO UNILET LANCETS LANCETS UNIVERSAL 21G 93 MOISTURIZING 61 ULTRA THIN 28G 93 SMART SENSE SUPER THIN SENSIPAR 70 SIDE BUTTON SAFETY LANCETS UNIVERSAL 30G 93 SENTRA AM 66 LANCET21G 93 SMART SENSE THIN SENTRA PM 66 SIGNIFOR 70 LANCETSUNIVERSAL 26G 93 SEREVENT DISKUS 13 sildenafil citrate (pulmonary SMARTEST LANCETS 28G 93 hypertension) 44 SEROQUEL 36 sodium bicarbonate (antacid) 9 SILENOR 76 SEROQUEL XR 36 sodium chloride 129 SILPHEN COUGH 24 SEROSTIM 69 SODIUM CHLORIDE 129 SILVADENE 53 sertraline hcl 18 sodium chloride (gu irrigant) 72 silver sulfadiazine 53 SERTRALINE HCL 45 sodium chloride (inhalant) 50 simethicone 71 SFROWASA 72 sodium chloride flush 129 SIMPLE SYRUP 143 SHADE SUNBLOCK SPF 4564 sodium citrate & citric acid 72 SIMPLYTHICK 142 SHADE UVAGUARD SPF sodium fluoride 129 15 64 SIMPLYTHICK EASY sodium fluoride (dental) 131 MIX 142 SHINGRIX 150 SIMPONI 4 sodium phenylbutyrate 70 SHOPKO ALCOHOL SIMPONI ARIA 4 sodium phosphates 78 SWABS 96 sodium polystyrene SHOPKO ON-THE-GO simvastatin 26 sulfonate 131 COMFORTLANCETS 30G 93 SINEMET 33 SODIUM SHOPKO UNIFINE PENTIPS POLYSULTHIONATE/FOLIC PEN SINEMET CR 33 SINGLE-LET 93 ACID 66 NEEDLES/MICRO/32GX4MM SODIUM 116 SINGULAIR 12 SULFACETAMIDE/SULFUR SHOPKO UNIFINE PENTIPS sirolimus 131 51 PEN NEEDLES/MINI/31GX5MM 116 SIVEXTRO 11 SODIUM VALPROATE 45 SHOPKO UNIFINE PENTIPS skin protectants, misc. 61 SOF-WICK 4"X4" 82 PEN SKIN REPAIR 59 SOFOSBUVIR/VELPATASVIR 41 NEEDLES/ORIGINAL/29GX12M SKYLA 47 M 116 SOLBAR AVO 64 SLEEP SOUNDLY 4 SHOPKO UNIFINE PENTIPS SOLBAR PF SPF15 64 PEN SLO-NIACIN 152 SOLIRIS 74 NEEDLES/SHORT/31GX8MM SM ALCOHOL PREP 116 PADS 96 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS SHOPKO UNIFINE PENTIPS SM GAUZE PADS 2"X2" 82 PLUS PEN 28G 93 NEEDLES/MICRO/REMOVR/32 SM GAUZE PADS 3"X3" 82 SOLUS V2 TWIST LANCETS GX4MM 116 SM GAUZE PADS 4"X4" 82 30G 93 SM GLUCOSE 20 SOLVATECH PLUS 143 SOLVATECH SWEET SF 143

Index 36 SOMATULINE DEPOT 70 STUDIO 35 MOISTURIZING SURE COMFORT INSULIN SOMAVERT 69 SKIN 60 SYRINGE/U-100/0.5ML/31G X sucralfate 148 5/16 117 SONATA 76 SURE COMFORT INSULIN SOOTHE & COOL SUDAFED CHILDRENS 136 SUDAFED SYRINGE/U-100/1ML/28G X MOISTURIZING BODY LOTION 1/2" 117 WITH ALOE 60 CONGESTION 136 SURE COMFORT INSULIN SOOTHE & COOL SKIN SUDAFED NASAL DECONGESTANT MAXIMUM SYRINGE/U-100/1ML/29G X CREAMWITH ALOE & 1/2" 117 VITAMINS A, D & E 60 STRENGTH 136 SUDAFED PE SURE COMFORT INSULIN SORBIDON HYDRATE 62 SYRINGE/U-100/1ML/30G X CONGESTION 136 SORBITOL 77,143 sulfacetamide sod- 1/2" 117 139 SURE COMFORT INSULIN SORBOLENE 60 prednisolone SYRINGE/U-100/1ML/30G X sotalol hcl 42 sulfacetamide sodium 53 5/16" 117 sotalol hcl (afib/afl) 42 SULFACETAMIDE SURE COMFORT INSULIN SODIUM 138 SOVALDI 41 SYRINGE/U-100/1ML/31G X sulfacetamide sodium 5/16" 117 SPECIAL CARE CREAM 60 (acne) 51 SURE COMFORT LANCETS SPINOSAD 62 sulfacetamide sodium 18G 93 SPINRAZA 136 (ophth) 138 SURE COMFORT LANCETS sulfamethoxazole-trimethoprim 21G 93 SPIRIVA HANDIHALER 12 10 SURE COMFORT LANCETS spironolactone 67 sulfasalazine 72 23G 93 spironolactone & SULFZIX 66 SURE COMFORT LANCETS hydrochlorothiazide 67 sulindac 5 28G 93 SPORANOX 23 SURE COMFORT LANCETS sumatriptan 127 SPORANOX PULSEPAK 23 30G 93 sumatriptan succinate 127 SURE COMFORT PEN SPRYCEL 32 SUMATRIPTAN NEEDLES29GX1/2" ST IVES SWISS FORMULA SUCCINATE 127 12.7MM 117 24HOUR MOISTURE 60 sumatriptan succinate 127 SURE COMFORT PEN starch-maltodextrin NEEDLES30GX5/16" (thickening) 142 SUMMERS EVE FEMININE 62 SHORT 117 STARLIX 21 SURE COMFORT PEN sunscreens 64 stavudine 39 NEEDLES31GX3/16" SUPER THIN LANCETS 93 STEGLATRO 21 (5MM) 117 SUPPRELIN LA 69 SURE COMFORT PEN STELARA 53 SURE COMFORT INSULIN NEEDLES31GX5/16" STERILANCE TL 93 SYRINGE/U-100/0.3ML/29G X (8MM) 117 STERILE DILUENT FOR 1/2" 116 SURE COMFORT PEN FLOLAN 143 SURE COMFORT INSULIN NEEDLES32GX5/32" 117 STERILE DILUENT FOR SYRINGE/U-100/0.3ML/30G X SURE COMFORT PEN REMODOULIN 143 5/16" 116 NEEDLES32GX6MM 117 STERILE GAUZE PADS SURE COMFORT INSULIN SURE-FINE PEN NEEDLES 2"X2" 82 SYRINGE/U-100/0.3ML/31G X 29GX1/2" 12.7MM 117 STERILE GAUZE PADS 5/16 116 SURE-FINE PEN NEEDLES 3"X3" 83 SURE COMFORT INSULIN 31GX3/16" 5MM 117 STERILE PADS 2"X2" 83 SYRINGE/U-100/0.3ML/31G X SURE-FINE PEN NEEDLES 31GX5/16" 8MM 117 STERILE PADS 3"X3" 83 5/16" 116 SURE COMFORT INSULIN SURE-JECT INSULIN STERILE PADS 4"X4" 83 SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.3ML/29G X STIMATE 70 1/2" 116 1/2" 117 STIVARGA 32 SURE COMFORT INSULIN SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X STRATTERA 2 SYRINGE/U-100/0.5ML/29G X 1/2" 117 5/16" 117 STRIBILD 39 SURE COMFORT INSULIN SURE-JECT INSULIN STUDIO 35 EXTRA SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/31G X MOISTURIZING LOTION 60 5/16" 117 5/16" 117

Index 37 SURE-JECT INSULIN SYNAREL 69 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/28G X SYNRIBO 32 100/0.5ML/29G X 1/2" 118 1/2" 117 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN SYNTHROID 146 100/0.5ML/30G X 5/16" 118 SYRINGE/U-100/0.5ML/29G X SYNVISC 135 TECHLITE INSULIN SYRINGEU- 1/2" 117 SYNVISC ONE 135 100/0.5ML/31G X 5/16" 118 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/30G X SYPRINE 130 100/1ML/29G X 1/2" 118 5/16" 117 SYRPALTA 143 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN SYRSPEND SF 143 100/1ML/30G X 1/2" 118 SYRINGE/U-100/0.5ML/31G X SYRUP NF 143 TECHLITE INSULIN SYRINGEU- 5/16" 117 100/1ML/30G X 5/16" 118 SURE-JECT INSULIN SYRUP VEHICLE 143 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/28G X SYRUP VEHICLE SF 143 100/1ML/31G X 5/16" 118 1/2" 117 T-SUPPORT MAX 66 TECHLITE LANCETS 93 SURE-JECT INSULIN TABLOID 30 TECHLITE LANCETS 30G 93 SYRINGE/U-100/1ML/29G X tacrolimus 131 TECHLITE PEN NEEDLES 29GX 1/2" 117 12 MM 118 SURE-JECT INSULIN tacrolimus (topical) 60 TECHLITE PEN NEEDLES 31GX SYRINGE/U-100/1ML/30G X tadalafil (pulmonary 5MM 118 5/16" 117 hypertension) 44 TECHLITE PEN NEEDLES/31GX SURE-JECT INSULIN TAFINLAR 32 5MM 118 SYRINGE/U-100/1ML/31G X TAGAMET HB 148 TECHLITE PEN NEEDLES/31GX 5/16" 118 6 MM 118 SURE-LANCE FLAT TAMIFLU 41 TECHLITE PEN NEEDLES/31GX LANCETS 93 tamoxifen citrate 31 8MM 118 SURE-LANCE LANCETS tamsulosin hcl 72 TECHLITE PEN NEEDLES/32GX 26G 93 TAPAZOLE 146 4MM 118 SURE-LANCE THIN LANCETS TECHLITE PEN NEEDLES/32GX 28G 93 TARCEVA 32 6MM 118 SURE-LANCE ULTRA THIN TARGRETIN 32,52 TECHNIVIE 41 LANCETS 93 SURE-TOUCH LANCETS TARKA 28 TEGADERM FOAM DRESSING UNIVERSAL 93 TASIGNA 32 2"X2" 83 TEGADERM FOAM DRESSING SURELITE LANCETS 93 TAVALISSE 74 4"X4" 83 SURGICAL GAUZE TAVIST ALLERGY 24 TEGRETOL 15 SPONGE 83 tazarotene 53 SURMONTIL 20 TEGRETOL-XR 15 TAZORAC 53 SUSPENDOL-S 143 telmisartan 27 TEARS NATURALE PM 137 SUSPENSION VEHICLE 143 telmisartan-amlodipine 28 TECFIDERA 145 telmisartan-hydrochlorothiazide SUSTIVA 39 TECFIDERA STARTER 28 SUTENT 32 PACK 145 temazepam 76 SW OMEPRAZOLE 149 TECHLITE AST LANCETS 93 TEMODAR 30 SWEETENING SUSPENDING TECHLITE INSULIN TEMOVATE 54 COMPOUND 143 SYRINGEU-100/0.3ML/29G X SYLATRON 32 1/2" 118 TEMOVATE E 54 SYMBICORT 13 TECHLITE INSULIN temozolomide 30 SYRINGEU-100/0.3ML/30G X temsirolimus 32 SYMBYAX 144 5/16" 118 SYMDEKO 146 TECHLITE INSULIN TENCON 6 SYMFI 40 SYRINGEU-100/0.3ML/31G X TENEX 27 SYMFI LO 39 15/64" 118 TENIVAC 147 TECHLITE INSULIN tenofovir disoproxil fumarate 40 SYMLINPEN 120 20 SYRINGEU-100/0.3ML/31G X SYMLINPEN 60 20 5/16" 118 TENORETIC 100 28 SYNAGIS 141 TENORETIC 50 28 TENORMIN 42

Index 38 TERAZOL 7 151 THROMBATE III W/20 ML TOPCARE CLICKFINE terazosin hcl 27 STERILE WATER 74 UNIVERSAL PEN EEDLES THYROGEN 65 31GX1/4" 118 terbinafine hcl 23 thyroid 146 TOPCARE CLICKFINE terbinafine hcl (topical) 52 UNIVERSAL PEN EEDLES THYROLAR-1 146 terbutaline sulfate 13 31GX5/16" 118 THYROLAR-1/2 146 TOPCARE LANCETS MICRO- TERCONAZOLE 151 THYROLAR-1/4 146 THIN 33G 93 terconazole vaginal 151 TOPCARE ULTRA COMFORT THYROLAR-2 146 TESSALON PERLES 48 INSULIN SYRINGE/0.3ML/30G X TESTOSTERONE THYROLAR-3 146 5/16" 118 CYPIONATE 9 tiagabine hcl 16 TOPCARE ULTRA COMFORT testosterone cypionate 9 TIAZAC 43 INSULIN SYRINGE/0.3ML/31G X TETANUS/DIPHTHERIA 5/16" 118 TIKOSYN 12 TOPCARE ULTRA COMFORT TOXOIDS-ADSORBED 147 TIMOLOL MALEATE 42 INSULIN SYRINGE/0.5ML/30G X tetrabenazine 144 timolol maleate (ophth) 137 5/16" 118 tetracaine hcl (ophth) 139 TIMOPTIC 137 TOPCARE ULTRA COMFORT tetrahydrozoline hcl (ophth) 139 INSULIN SYRINGE/0.5ML/31G X TIMOPTIC OCUDOSE 137 TGT ALCOHOL SWABS 96 5/16" 118 TINACTIN 52 TOPCARE ULTRA COMFORT TGT LANCET MICRO THIN TINACTIN JOCK ITCH 52 INSULIN SYRINGE/1ML/30G X 33G 93 5/16" 119 TGT LANCET THIN 26G 93 tioconazole vaginal 151 TOPCARE ULTRA COMFORT TGT LANCET ULTRA THIN TIVICAY 40 INSULIN SYRINGE/1ML/31G X 30G 93 tizanidine hcl 134 5/16" 119 TGT OMEPRAZOLE 149 TL-ICARE 66 TOPCARE ULTRA COMFORT THALOMID 130 INSULIN SYRINGE/U- TOBI 4 100/0.3ML/29G X 1/2" 119 THEO-24 13 TOBI PODHALER 4 TOPCARE ULTRA COMFORT theophylline 13 TOBRADEX 139 INSULIN SYRINGE/U- THERA-FLUR-N 131 TOBRAMYCIN 4 100/0.5ML/29G X 1/2" 119 THERABETIC SKIN CARE 60 TOPCARE ULTRA COMFORT tobramycin 4 INSULIN SYRINGE/U- THERAGAUZE 83 tobramycin (ophth) 138 100/1ML/29G X 1/2" 119 THERAMINE 66 TOBRAMYCIN SULFATE 4 TOPCO INSULIN SYRINGE/U- THERANATAL CORE 100/0.3ML/29G X 1/2" 119 NUTRITION 134 tobramycin sulfate 4 TOPCO INSULIN SYRINGE/U- THERAPEUTIC tobramycin- 100/0.5ML/28G X 1/2" 119 MOISTURIZING 60 dexamethasone 139 TOPCO INSULIN SYRINGE/U- THERAPLEX TOBREX 138 100/0.5ML/29G X 1/2" 119 HYDROLOTION 60 TODAYS HEALTH MINI PEN TOPCO INSULIN SYRINGE/U- THERASEAL HAND NEEDLES 31G X 1/4" 118 100/1ML/28G X 1/2" 119 PROTECTION 62 TODAYS HEALTH ORIGINAL TOPCO INSULIN SYRINGE/U- thiamine hcl 152 PEN NEEDLES 29G X 100/1ML/29G X 1/2" 119 thiamine mononitrate 152 1/2" 118 TOPICLEAR 62 TODAYS HEALTH SHORT topiramate 15 THICK-IT ORIGINAL 142 PEN NEEDLES 31G X THINLETS GP LANCETS 93 5/16" 118 TOPIRAMATE ER 15 THINLETS LANCET 93 TODAYS HEALTH SUPER topotecan hcl 33 thioridazine hcl 37 THINLANCETS 30G 93 TOPOTECAN HCL 33 TODAYS HEALTH ULTRA topotecan hcl 33 thiothixene 37 THINLANCETS 28G 93 THRIVITE 19 134 TOPPER DRESSING SPONGES TOFRANIL 20 4"X4" 83 THROMBATE III 74 tolnaftate 52 TOPROL XL 42 THROMBATE III W/10 ML tolterodine tartrate 149 STERILE WATER 74 TORISEL 32 TOPAMAX 15 torsemide 67 TOPAMAX SPRINKLE 15

Index 39 TOTAL BLOCK SPF 60 TRIGLIDE 25 TRUE COMFORT INSULIN COVERUP 64 trihexyphenidyl hcl 33 SYRINGE/0.5ML/31G X TOTAL BLOCK SPF 65 5/16" 119 CLEAR 64 TRILEPTAL 15 TRUE COMFORT INSULIN TRACLEER 44 trimethoprim 10 SYRINGE/1ML/31G X TRADJENTA 21 trimipramine maleate 20 5/16" 119 TRUE COMFORT PEN tramadol hcl 8 TRIMIPRAMINE MALEATE 20 NEEDLES32G X 4MM 119 tramadol-acetaminophen 8 TRUE COMFORT TWIST TOP TRINATAL GT 134 trandolapril 26 LANCETS 30G 94 TRINATAL RX 1 134 TRUE METRIX BLOOD trandolapril-verapamil hcl 28 TRINTELLIX 18 GLUCOSETEST STRIPS 66 TRANDOLAPRIL/VERAPAMIL TRIUMEQ 40 TRUE METRIX CONTROL HCL ER 28 SOLUTION LEVEL 1 94 tranexamic acid 75 TRIZIVIR 40 TRUE METRIX CONTROL TRANXENE T 12 TROJAN EXTENDED SOLUTION LEVEL 2 94 PLEASURE/LUBRICATED tranylcypromine sulfate 17 TRUE METRIX CONTROL 84 SOLUTION LEVEL 3 94 TRAVEL LANCETS 30G 93 TROJAN MAGNUM 84 TRUEPLUS 5-BEVEL PEN TRAVEL LANCETS ADVANCED TROJAN MAGNUM WARM NEEDLES 29GX12.7MM 119 28G 93 SENSATIONS 84 TRUEPLUS 5-BEVEL PEN TRAZODONE HCL 18 TROJAN MAGNUM XL NEEDLES 32GX4MM 119 trazodone hcl 18 LUBRICATED 84 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X TREANDA 30 TROJAN PLEASURE MESH/SPERMICIDAL 84 1/2" 119 TRECATOR 29 TROJAN RIBBED TRUEPLUS INSULIN TRELSTAR 31 W/SPERMICIDAL 84 SYRINGE/U-100/0.3ML/30G X TRELSTAR MIXJECT 31 TROJAN SHARED 5/16" 119 SENSATION/LUBRICATED TRUEPLUS INSULIN TREPADONE 66 84 SYRINGE/U-100/0.3ML/31G X tretinoin 51 TROJAN SUPRAS 5/16" 119 tretinoin (chemotherapy) 32 SPERMICIDAL 84 TRUEPLUS INSULIN TRETTEN 73 TROJAN TWISTED SYRINGE/U-100/0.5ML/28G X PLEASURE 84 1/2" 119 TREXALL 30 TROJAN ULTRA TRUEPLUS INSULIN TRI-NORINYL 28 46 PLEASURE/LUBRICATED SYRINGE/U-100/0.5ML/29G X TRIADVANCE 134 84 1/2" 119 triamcinolone acetonide TROJAN VERY SENSITIVE TRUEPLUS INSULIN (mouth) 131 LUBRICATED 84 SYRINGE/U-100/0.5ML/30G X triamcinolone acetonide TROJAN VERY SENSITIVE 5/16" 119 (nasal) 135 SPERMICIDAL TRUEPLUS INSULIN triamcinolone acetonide LUBRICANT 84 SYRINGE/U-100/0.5ML/31G X (topical) 54 TROJAN VERY THIN 5/16" 119 TRIAMINIC COLD & COUGH LUBRICATED 84 TRUEPLUS INSULIN DAY TIME CHILDRENS 50 TROJAN VERY THIN SYRINGE/U-100/1ML/28G X triamterene & SPERMICIDAL 1/2" 119 hydrochlorothiazide 67 LUBRICANT 84 TRUEPLUS INSULIN TRIAMTERENE/HYDROCHLOR TROJAN-ENZ SYRINGE/U-100/1ML/29G X OTHIAZIDE 67 LUBRICANT 84 1/2" 119 triazolam 76 TROJAN-ENZ TRUEPLUS INSULIN LUBRICATED 84 SYRINGE/U-100/1ML/30G X TRIBENZOR 28 TROJAN-ENZ 5/16" 119 TRICARE 134 W/SPERMICIDAL 84 TRUEPLUS INSULIN TRIDESILON 54 TROKENDI XR 15 SYRINGE/U-100/1ML/31G X 5/16" 120 trientine hcl 130 tropicamide 138 TRUEPLUS LANCETS 26G 94 trifluoperazine hcl 37 trospium chloride 149 TRUEPLUS LANCETS 28G 94 trifluridine 138

Index 40 TRUEPLUS LANCETS 28G TUMS CHEWY BITES 10 ULTICARE INSULIN SUPER THIN 94 TUMS E-X 750 10 SYRINGE/0.5ML/30G X 5/16" 120 TRUEPLUS LANCETS 30G 94 TUMS EXTRA STRENGTH TRUEPLUS LANCETS 30G ULTICARE INSULIN 750 10 SYRINGE/1ML/28G X 1/2" 120 ULTRA THIN 94 TUMS KIDS 10 TRUEPLUS LANCETS 33G 94 ULTICARE INSULIN TUMS LASTING SYRINGE/1ML/29G X 1/2" 120 TRUEPLUS LANCETS 33G EFFECTS 10 ULTICARE INSULIN MICRO THIN 94 TUMS SMOOTHIES 10 SYRINGE/1ML/30G X 1/2" 120 TRUEPLUS PEN NEEDLES TUMS ULTRA 1000 10 ULTICARE INSULIN 29GX12MM 120 SYRINGE/1ML/30G X TRUEPLUS PEN NEEDLES TWINRIX 150 5/16" 120 31GX5MM 120 TWYNSTA 29 ULTICARE INSULIN TRUEPLUS PEN NEEDLES SYRINGE/SHORT/0.3ML/30G X 31GX6MM 120 TYBOST 40 TRUEPLUS PEN NEEDLES TYKERB 32 5/16" 120 ULTICARE INSULIN 31GX8MM 120 TYLENOL 6 SYRINGE/SHORT/0.3ML/31G X TRUEPLUS PEN NEEDLES TYLENOL CHILDRENS 6 32GX4MM 120 5/16" 120 TRUEPLUS SAFETY LANCETS TYLENOL CHILDRENS ULTICARE INSULIN 28G 94 CHEWABLES/PAIN + SYRINGE/SHORT/0.5ML/30G X FEVER 6 5/16" 120 TRUMENBA 150 TYLENOL EXTRA ULTICARE INSULIN TRUSOPT 140 STRENGTH 6 SYRINGE/SHORT/0.5ML/31G X TRUSTEX COLOR CONDOMS + TYLENOL INFANTS 6 5/16" 120 LUBE 84 TYLENOL INFANTS ULTICARE INSULIN TRUSTEX LUBRICATED 84 PAIN+FEVER 6 SYRINGE/SHORT/1ML/30G X TRUSTEX LUBRICATED TYLENOL/CODEINE #3 8 5/16" 120 EXTRALARGE 84 ULTICARE INSULIN TRUSTEX LUBRICATED TYLENOL/CODEINE #4 8 SYRINGE/SHORT/1ML/31G X EXTRASTRENGTH 84 TYSABRI 145 5/16" 120 TRUSTEX TYVASO 44 ULTICARE INSULIN SYRINGE/U-100/0.3ML/29G X LUBRICATED/RIBBED/STUDDE TYVASO REFILL 44 D 84 1/2" 120 TRUSTEX TYVASO STARTER 44 ULTICARE INSULIN LUBRICATED/SPERMICIDE UDDERLY SMOOTH 60 SYRINGE/U-100/0.3ML/30G X 84 UDDERLY SMOOTH EXTRA 5/16" 120 TRUSTEX CARE 60 ULTICARE INSULIN LUBRICATED/SPERMICIDE UDDERLY SMOOTH EXTRA SYRINGE/U-100/0.3ML/31G X EXTRA LARGE 84 CARE20 60 5/16" 120 TRUSTEX ULTICARE INSULIN SAFETY ULTICARE INSULIN LUBRICATED/SPERMICIDE SYRINGE/0.5ML/29G X SYRINGE/U-100/0.5ML/29G X EXTRA STRENGTH 84 1/2" 120 1/2" 120 TRUSTEX NATURAL ULTICARE INSULIN SAFETY ULTICARE INSULIN CONDOMS SYRINGE/1ML/29G X SYRINGE/U-100/0.5ML/30G X +LUBE/LUBRICATED 84 1/2" 120 5/16" 120 TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN ULTICARE INSULIN 9/RIBBED/STUDDED 84 SYRINGE/0.3ML/29G X SYRINGE/U-100/0.5ML/31G X TRUSTEX/RIA 1/2" 120 5/16" 120 LUBRICATED 84 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX/RIA LUBRICATED SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/29G X SPERMICIDE 84 5/16" 120 1/2" 121 TRUSTEX/RIA ULTICARE INSULIN ULTICARE INSULIN LUBRICATED/SPERMICIDE SYRINGE/0.5ML/28G X SYRINGE/U-100/1ML/30G X 84 1/2" 120 1/2" 121 TRUVADA 40 ULTICARE INSULIN ULTICARE INSULIN SYRINGE/U-100/1ML/30G X TRYPTOPHAN 137 SYRINGE/0.5ML/29G X 1/2" 120 5/16" 121 TUDORZA PRESSAIR 12 TUMS 10

Index 41 ULTICARE INSULIN ULTILET INSULIN ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X SYRINGE/SHORT/0.3ML/30G SYRINGE/U-100/0.5ML/28G X 5/16" 121 X 5/16" 121 1/2" 122 ULTICARE INSULIN ULTILET INSULIN ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- SYRINGE/SHORT/0.3ML/31G SYRINGE/U-100/0.5ML/29G X 100/0.3ML/31G X 5/16" 121 X 5/16" 121 1/2" 122 ULTICARE INSULIN ULTILET INSULIN ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/30G SYRINGE/U-100/0.5ML/30G X 100/0.5ML/31G X 5/16" 121 X 5/16" 121 5/16" 122 ULTICARE INSULIN ULTILET INSULIN ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/31G SYRINGE/U-100/0.5ML/31G X 100/1ML/31G X 5/16" 121 X 5/16" 121 5/16" 122 ULTICARE MICRO PEN ULTILET INSULIN ULTRA-COMFORT INSULIN NEEDLES 31G X 8MM 121 SYRINGE/SHORT/1ML/30G X SYRINGE/U-100/1ML/28G X ULTICARE MICRO PEN 5/16" 122 1/2" 122 NEEDLES 32G X 4MM 121 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE MICRO PEN SYRINGE/SHORT/1ML/31G X SYRINGE/U-100/1ML/29G X NEEDLES/32G X 4MM 121 5/16" 122 1/2" 122 ULTICARE MICRO PEN ULTILET INSULIN ULTRA-COMFORT INSULIN NEEDLES/32G X 5/32" 121 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X ULTICARE MINI PEN NEEDLES 1/2" 122 5/16" 122 31GX6MM 121 ULTILET LANCETS 94 ULTRA-COMFORT INSULIN ULTICARE MINI PEN NEEDLES ULTILET LANCETS 33G 94 SYRINGE/U-100/1ML/31G X ULTI-FINE IV 121 5/16" 122 ULTICARE MINI PEN ULTILET PEN NEEDLE ULTRA-THIN II AUTO NEEDLES/31G X 6MM 121 29GX12.7MM 122 LANCET 94 ULTICARE MINI PEN ULTILET PEN NEEDLE ULTRA-THIN II INSULIN NEEDLES31GX6MM 121 31GX5MM 122 SYRINGE SHORT/U- ULTILET PEN NEEDLE ULTICARE ORIGINAL PEN 100/0.3ML/30GX5/16" 122 NEEDLES ULTI-FINE 121 31GX8MM 122 ULTRA-THIN II INSULIN ULTICARE PEN NEEDLES ULTILET PEN NEEDLE SYRINGE SHORT/U- 31GX 5MM/MINI 121 32GX4MM 122 ULTILET PEN NEEDLE 100/0.3ML/31GX5/16" 122 ULTICARE PEN ULTRA-THIN II INSULIN NEEDLES/29GX 12.7MM 121 32GX4MM/SHORT 122 SYRINGE SHORT/U- ULTICARE SHORT PEN ULTILET SAFETY LANCETS 21G X 2.2MM 94 100/0.5ML/30GX5/16" 122 NEEDLES 31GX8MM 121 ULTRA-THIN II INSULIN ULTICARE SHORT PEN ULTILET SAFETY LANCETS 23G 94 SYRINGE SHORT/U- NEEDLES ULTI-FINE IV 121 100/0.5ML/31GX5/16" 122 ULTICARE SHORT PEN ULTILET SHORT PEN NEEDLES 31GX5/16" 122 ULTRA-THIN II INSULIN NEEDLES/31G X 8MM 121 SYRINGE SHORT/U- ULTICARE THIN LANCETS ULTILET SHORT PEN NEEDLES31GX3/16" 122 100/1ML/30GX5/16" 122 30G 94 ULTRA-THIN II INSULIN ULTILET CLASSIC ULTIMATE FEELING 84 SYRINGE SHORT/U- LANCETS 94 ULTRA COMFORT INSULIN 100/1ML/31GX5/16" 122 ULTILET INSULIN SYRINGE SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II INSULIN 31X6MM 121 5/16" 122 SYRINGE/U- ULTILET INSULIN ULTRA THIN LANCETS 100/0.3ML/29GX1/2" 123 SYRINGE/0.3ML/30G X 31G 94 ULTRA-THIN II INSULIN 8MM 121 ULTRA-CARE LANCETS SYRINGE/U- ULTILET INSULIN 30G 94 100/0.5ML/29GX1/2" 123 SYRINGE/0.3ML/31G X ULTRA-COMFORT INSULIN ULTRA-THIN II INSULIN 8MM 121 SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/1ML/29GX1/2" ULTILET INSULIN 1/2" 122 123 SYRINGE/0.5ML/30G X ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS 8MM 121 SYRINGE/U-100/0.3ML/30G X 28G 94 ULTILET INSULIN 5/16" 122 ULTRA-THIN II LANCETS SYRINGE/1ML/30G X 8MM121 ULTRA-COMFORT INSULIN 30G 94 ULTILET INSULIN SYRINGE/U-100/0.3ML/31G X ULTRA-THIN II MINI PEN SYRINGE/1ML/31G X 8MM121 5/16" 122 NEEEDLES/31GX3/16" 123

Index 42 ULTRA-THIN II PEN NEEDLES UNILET COMFORTOUCH V-R MONOJECT INSULIN 29GX1/2" 123 LANCET 94 SYRINGE/U-100/0.3ML/29G X ULTRA-THIN II PEN UNILET EXCELITE 94 1/2" 123 NEEDLES/SHORT/31GX5/16" UNILET EXCELITE II 94 V-R MONOJECT INSULIN 123 SYRINGE/U-100/0.5ML/28G X ULTRA-THIN II SAFETY UNILET G.P. LANCET 94 1/2" 123 AUTOLANCETS 26G 94 UNILET G.P. SUPERLITE V-R MONOJECT INSULIN ULTRACARE INSULIN LANCET 94 SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.3ML/30G X UNILET GP 28 ULTRA 1/2" 123 5/16" 123 THIN 94 V-R MONOJECT INSULIN ULTRACARE INSULIN UNILET LANCET 94 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.3ML/31G X UNILET LANCETS MICRO- 1/2" 123 5/16" 123 THIN33G 94 V-R MONOJECT INSULIN ULTRACARE INSULIN UNILET LANCETS SUPER- SYRINGE/U-100/1ML/29G X SYRINGE/U-100/0.5ML/30G X THIN30G 94 1/2" 123 5/16" 123 UNILET LANCETS ULTRA- VAGISTAT-1 151 ULTRACARE INSULIN THIN 28G 94 valacyclovir hcl 41 SYRINGE/U-100/0.5ML/31G X UNILET SUPERLITE 5/16" 123 LANCET 94 VALCYTE 40 ULTRACARE INSULIN UNISOM SLEEPGELS 76 valganciclovir hcl 40 SYRINGE/U-100/1ML/30G X UNISOM SLEEPTABS 76 VALIUM 12 1/2" 123 ULTRACARE INSULIN UNISTIK 3 GENTLE 94 valproate sodium 16 SYRINGE/U-100/1ML/30G X UNISTIK PRO SAFETY VALPROATE SODIUM 45 5/16" 123 LANCET 21G 94 valproic acid 16 ULTRACARE INSULIN UNISTIK PRO SAFETY LANCET 25G 94 valsartan 27 SYRINGE/U-100/1ML/31G X valsartan-hydrochlorothiazide 5/16" 123 UNISTIK PRO SAFETY ULTRACARE PEN LANCET 28G 94 29 NEEDLES/32G X 1/14" 123 UNISTIK SAFETY LANCETS VALSTAR 31 ULTRACARE PEN 28G 94 VALTREX 41 NEEDLES/32G X 5/32" 123 UNISTIK SAFETY LANCETS VALUE HEALTH INSULIN ULTRACET 8 30G 94 SYRINGE/U-100/0.5ML/29G X UNISTIK TOUCH SAFETY 1/2" 123 ULTRAM 8 LANCETS 21G 94 UNIFINE PENTIPS VALUE HEALTH INSULIN UNISTIK TOUCH SAFETY SYRINGE/U-100/1ML/29G X 29GX12MM 123 LANCETS 23G 94 UNIFINE PENTIPS 31G X 1/2" 124 UNISTIK TOUCH SAFETY VALUE PLUS LANCETS 3/16" 123 LANCETS 28G 95 UNIFINE PENTIPS STANDARD 21G 95 UNISTIK TOUCH SAFETY VALUE PLUS LANCETS 31GX5MM 123 LANCETS 30G 95 UNIFINE PENTIPS SUPERTHIN 30G 95 UNIVERSAL 1 LANCETS VALUE PLUS LANCETS THIN 31GX6MM 123 THIN26G 95 UNIFINE PENTIPS 26G 95 UNIVERSAL 1 LANCETS VALUMARK LANCET SUPER 31GX8MM 123 ULTRA THIN 30G 95 UNIFINE PENTIPS THIN 30G 95 UNIVERSAL 1 VALUMARK LANCET ULTRA 32GX4MM 123 LANCETS/33G/MICRO-THIN UNIFINE PENTIPS THIN 28G 95 95 VALUMARK PEN NEEDLES 32GX6MM 123 UPCAL D 128 UNIFINE PENTIPS PLUS 29GX12MM 124 29GX12MM 123 urea 54 VALUMARK PEN NEEDLES UNIFINE PENTIPS PLUS URECHOLINE 149 31GX 6MM 124 VALUMARK PEN NEEDLES 31GX5MM 123 UROCIT-K 10 72 UNIFINE PENTIPS PLUS 31GX 8MM 124 31GX6MM 123 UROCIT-K 5 72 VALVED HOLDING UNIFINE PENTIPS PLUS URSO 250 71 CHAMBER 126 31GX8MM 123 ursodiol 71 VANCOCIN HCL 10 UNIFINE PENTIPS PLUS vancomycin hcl 10 32GX4MM 123 VANICREAM 60

Index 43 VANICREAM LITE 60 VIDA MIA UNIPFINE VOSPIRE ER 13 VANISHPOINT INSULIN PENTIPSSHORT VOTRIENT 32 124 SYRINGE/0.5ML/30G X 31GX8MM VP INSULIN SYRINGE/U- 5/16" 124 VIDAZA 30 100/0.3ML/29G X 1/2" 124 VANISHPOINT INSULIN VIDEX EC 40 VPRIV 74 SYRINGE/1ML/29G X 1/2" 124 VIDEXPEDIATRIC 40 VANISHPOINT INSULIN VRAYLAR 34 SYRINGE/1ML/30G X VIEKIRA PAK 41 VYTORIN 25 5/16" 124 VIEKIRA XR 41 VYVANSE 2 VANTAS 31 vigabatrin 16 W&F LANCETS 26G 95 VAQTA 150 VIGAMOX 138 W&F LANCETS COLORED VARIVAX 150 VIIBRYD 18 21G 95 VASERETIC 29 VIIBRYD STARTER PACK 18 WALGREENS ADVANCED TRAVELLANCETS 28G 95 VASOTEC 26 VIMIZIM 70 WALGREENS COMFORT VAYARIN PLUS 66 VIMPAT 16 ASSUREDLANCETS MICRO VECAMYL 29 VINATE ONE 134 THIN/33G 95 VECTIBIX 30 WALGREENS COMFORT VIRACEPT 40 ASSUREDLANCETS SUPER VELCADE 32 VIRAMUNE 40 THIN/28G 95 VELETRI 44 VIRAMUNE XR 40 WALGREENS GLUCOSE 20 VELVACHOL 60 VIREAD 40 WALGREENS LANCETS 95 venlafaxine hcl 18,19 VIROPTIC 138 WALGREENS THIN VENTAVIS 44 VIRT-ADVANCE 134 LANCETS 95 WALGREENS ULTRA THIN VENTOLIN HFA 13 VIRT-VITE GT 134 LANCETS 95 verapamil hcl 43 VISINE 139 warfarin sodium 13 VERAPAMIL HCL SR 43 VISTARIL 11 WATCHHALER 126 VERELAN 43 VISTEC X-RAY DETECTABLE WATER BABIES SPF 30 64 VERELAN PM 43 SPONGES 4"X4" 16 PLY 83 WEBCOL ALCOHOL PREP VERIPRED 20 48 VISUDYNE 139 LARGE 1 PLY 96 VERSACLOZ 36 VITAFOL-OB 134 WEBCOL ALCOHOL PREP LARGE 2 PLY 96 VERSAFREE 143 VITALET PRO LANCETS 95 VITALET PRO PLUS WEBCOL ALCOHOL PREP VERSAPLUS 143 LANCETS 95 MEDIUM 2 PLY 96 WEGMANS UNIFINE PENTIPS VERSIVA XC 3" X 3" FOAM Vitamin A Cap/Tab 152 DRESSING/HYDROFIBER PLUS 32GX4MM 124 TECHNOLOGY 83 VITAMIN C 152 WEGMANS UNIFINE PENTIPS VERSIVA XC 4" X 4" FOAM Vitamin E Cap 152 PLUS/MINI/31GX5MM 124 DRESSING/HYDROFIBER Vitamin E Liquid/Soln 152 WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MM 124 TECHNOLOGY 83 VITAMIN E WITH VIBRAMYCIN 146 WEGMANS UNIFINE PENTIPS PANTHENOL 60 PLUS/ULTRA VICTOZA 21 Vitamins A & D (Topical) 60 SHORT/31GX6MM 124 VIDA MIA UNIFINE Vitamins w/ Lipotropics 134 WELLBUTRIN SR 17 PENTIPS32GX4MM 124 VIDA MIA UNIFINE VITEKTA 40 WELLBUTRIN XL 17 PENTIPSMINI 31GX6MM 124 VIVELLE-DOT 71 white petrolatum-mineral oil 137 VIDA MIA UNIFINE VIVITROL 22 WIBI 60 PENTIPSORIGINAL VOL-PLUS 134 WILATE 73 29GX12MM 124 VIDA MIA UNILET LANCETS VOLTAREN 51 WINRHO SDF 141 SUPER THIN 30G 95 VONVENDI 73 XALATAN 140 VIDA MIA UNILET LANCETS VORTEX VALVED HOLDING XALKORI 32 ULTRA THIN 28G 95 CHAMBER 126 XANAX 12 VOSEVI 41 XANAX XR 12

Index 44 XARELTO 13,14 zinc gluconate 130 XELJANZ 4 zinc oxide (topical) 62 XELJANZ XR 4 zinc sulfate 130 XELODA 30 ziprasidone hcl 34 XENAZINE 144 ZITHROMAX 78 XEOMIN 136 ZITHROMAX TRI-PAK 78 XGEVA 68 ZITHROMAX Z-PAK 78 XIAFLEX 130 ZOCOR 26 XOLAIR 12 ZOFRAN 23 XTANDI 31 ZOFRAN ODT 23 XULANE 46 ZOLADEX 31 XYNTHA 74 zoledronic acid 68 XYNTHA SOLOFUSE 74 ZOLEDRONIC ACID 68 XYREM 143 zoledronic acid 68 XYZAL 24 ZOLEDRONIC ACID 68 XYZAL ALLERGY 24HR 24 ZOLINZA 32 YASMIN 28 46 zolmitriptan 127 YAZ 46 ZOLOFT 18 YERVOY 30 zolpidem tartrate 76 ZADITOR 140 ZOLPIMIST 76 zaleplon 76 ZOMACTON 69 ZALTRAP 30 ZOMETA 68 ZANAFLEX 134 ZOMIG 127 ZANTAC 148 ZOMIG ZMT 127 ZANTAC 150 MAXIMUM ZONEGRAN 16 STRENGTH 148 zonisamide 16 ZANTAC 75 148 ZORBTIVE 69 ZARONTIN 16 ZORTRESS 131 ZARXIO 75 ZOSTAVAX 151 ZAVESCA 74 ZOVIRAX 41,53 ZAVITROL 66 ZYBAN 145 ZEBETA 42 ZYKADIA 32 ZELBORAF 32 ZYLOPRIM 73 ZEMAIRA 146 ZYPREXA 36 ZEMPLAR 70 ZYPREXA RELPREVV 36 ZENPEP 67 ZYPREXA ZYDIS 36 ZENZEDI 2 ZYRTEC ALLERGY 24 ZEPATIER 41 ZYRTEC CHILDRENS ZERIT 40 ALLERGY 24 ZESTORETIC 29 ZYRTEC-D ZESTRIL 26 ALLERGY/CONGESTION 50 ZYTIGA 31 ZIAC 29 ZZZQUIL 76 ZIAGEN 40 zidovudine 40 ZIMS CRACK CREME DAYTIME 60 ZINBRYTA 145

Index 45