San Francisco Health Plan Healthy Workers Formulary AS OF May 17, 2017

SAN FRANCISCO HEALTH PLAN Healthy Workers Formulary

As of May 17, 2017

San Francisco Health Plan Healthy Workers Formulary AS OF May 17, 2017

San Francisco Health Plan Healthy Workers Formulary The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The P&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physicians from various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to review formulary changes based on quality of care considerations and sound pharmacoeconomic principles.

The formulary is a list of drug products designed to reflect the most appropriate, high quality and cost- effective drug therapies. The formulary is updated regularly and is subject to change without notice.

The formulary requires the continuous support of all our providers and pharmacists. Please contact us at (415) 547-7818 x 7085 option 3 or [email protected] if you have any questions regarding the formulary. The SFHP Formulary can be easily accessed online from our website at http://www.sfhp.org/providers/formulary/sfhp-formulary/.

Request for Addition or Deletion of a Drug to the Formulary SFHP providers may request evaluation of drugs for addition to or deletion from the Formulary by submitting the Formulary Modification Request Form available on our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.

Request for Non-Preferred Medications Non-preferred or non-formulary medications may be authorized when there is clinical justification for doing so. Clinicians can submit a prior authorization (PA) request in one of three different ways:

1. Online: Submit using the Online Pharmacy Prior Authorization Request Form. 2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standard and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form. 3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbal request.

The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can be accessed from our website at http://www.sfhp.org/providers/formulary/prior-authorization- requests/.

San Francisco Health Plan Healthy Workers Formulary AS OF May 17, 2017

Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent generic product is available. Dispensing of brand name medications when generic equivalent is available will be allowed only in the following cases: • Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product) • Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available) • Pharmacy is dispensing one of the following narrow therapeutic index drugs: Armour Thyroid, Coumadin, Dilantin, Synthroid

In all other cases, a prior authorization (PA) request should be submitted using the instructions above. Detailed PA criteria for brand name medication requests can be found at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf under “Brand Medication Requests” section.

Healthy Workers Formulary Exclusions The following drug classes are excluded from the Healthy Workers formulary: • Over-the-counter (OTC) medications except: o OTC insulin and diabetic testing supplies including test strips, lancets, insulin needles and , urine ketone testing strips o OTC replacement products o OTC prenatal vitamins, folic acid and fluoride preparations

Copayments The following copayments apply to Healthy Workers formulary: • $5 - generic medications • $10 - brand medications

Day Supply Policy SFHP standard day supply policy is 30 day supply for most brand medications and 90 day supply for generic medications with some exceptions. Refills are allowed when 75% of the medication has been used, except for opioid pain medications where refills are allowed when 90% of the medication has been used.

Exceptions to the 30 day supply policy for brand medications are as follows: • Up to 100 day supply is allowed for test strips, lancets, insulin syringes and urine ketone testing strips • Up to 90 day supply is allowed for select medications used for treatment of chronic conditions. Examples include but are not limited to antidiabetic medications including insulin, anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, and inhaled steroids. San Francisco Health Plan Healthy Workers Formulary AS OF May 17, 2017

Exceptions to the 90 day supply policy for generic medications are as follows: • 30 day supply only is allowed for all opiate medications except tramadol

Exceptions to the 30 and 90 days supply policy for brand and generic medications are as follows: • Up to a year supply of self-administered hormonal contraceptives (i.e. up to 364 pills, 12 vaginal rings, and 36 patches) is allowed with patient request and a valid prescription for the correct quantity. For the 12 month supply, refills are allowed only when 90% of the medication has been used.

Exceptions to the 90 day supply policy for generic medications are as follows: • 30 day supply only is allowed for all opiate medications except tramadol

Exceptions to the 30 and 90 days supply policy for brand and generic medications are as follows: • Up to a year supply of self-administered hormonal contraceptives (i.e. up to 364 pills, 12 vaginal rings, and 36 patches) is allowed with patient request and a valid prescription for the correct quantity. For the 12 month supply, refills are allowed only when 90% of the medication has been used.

Formulary Restrictions (DUR edits) Standard formulary restrictions applicable to SFHP formulary are medication quantity and age limitations. All formulary restrictions are based on FDA approved indications, standards of practice and safety and abuse potential considerations.

Step Therapy (ST) Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescription claims for preferred medications. If there are no paid prescription claims, a prior authorization (PA) request must be submitted for consideration of coverage. Visit our website at http://www.sfhp.org/providers/formulary/sfhp-formulary/ for detailed information on all active step therapy rules.

Therapeutic Interchange Policy Per American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and will only employ therapeutic interchange with prescriber’s approval. Criteria for consideration in therapeutic interchange include availability of agents within a therapeutic class, therapeutic equivalence, safety data, and costs.

Diabetic Supplies The following diabetic supplies are covered: San Francisco Health Plan Healthy Workers Formulary AS OF May 17, 2017

• Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days • Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits: o 400 per 100 days for all members o 800 per 100 days for members with gestational diabetes • Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply

Respiratory Supplies The following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days: • and assist devices • • Peak flow meters

Formulary Document Details The SFHP formulary document is listed by drug class and the following information: drug name, , drug tier, quantity limit and prior authorization or step therapy requirements. Brand products are listed in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary and will pay at the point of sale, if quantity limits and age limitations are met (see “Formulary Restrictions” above). Tier 2 drugs may require a Prior Authorization (see “Request for Non-Preferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above).

**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary and another strength of the same medication requiring a prior authorization.

Tier Drug T1= Formulary, Generic Generic drugs = lowercase T2= Formulary, Brand Notes italics T3= Formulary, Prior AL= Age Limit Authorization or Step Therapy PA= Prior Authorization Brand name drugs = T4= Specialty Pharmacy, Prior QL= Quantity Limit UPPERCASE Authorization ST= Step Therapy

Drug Tier Notes Antihistamine Drugs Ethanolamine Derivatives clemastine oral T1 First Gen. Antihist. Derivatives, Misc. cyproheptadine T1 First Generation Antihistamines clemastine oral syrup T1 cyproheptadine T1 Phenothiazine Derivatives PHENADOZ RECTAL 12.5 MG T1 AL (Min 2 Years) promethazine oral T1 AL (Min 2 Years) promethazine rectal suppository 25 mg T1 AL (Min 2 Years) PROMETHAZINE VC T1 AL (Min 2 Years) promethazine-dm T1 AL (Min 2 Years) PROMETHEGAN RECTAL SUPPOSITORY 50 T3 PA MG Piperazine Derivatives hydroxyzine hcl oral 10 mg/5 ml T1 hydroxyzine hcl oral T1 hydroxyzine pamoate T1 meclizine oral tablet 12.5 mg, 25 mg T1 Second Generation Antihistamines desloratadine oral tablet T3 PA levocetirizine oral tablet T1 QL (30 EA per 30 days)

1 Drug Tier Notes Anti-Infective Agents Adamantanes amantadine hcl oral solution T1 amantadine hcl oral tablet T1 rimantadine T1 Allylamines terbinafine hcl oral T1 QL (180 EA per 365 days) Amebicides metronidazole oral tablet T1 Aminoglycosides KITABIS PAK T3 PA neomycin T1 paromomycin T1 in 0.225 % nacl T3 PA Aminopenicillins amoxicillin oral T1 amoxicillin oral for reconstitution T1 amoxicillin oral tablet T1 amoxicillin oral tablet,chewable 125 mg, 250 mg T1 amoxicillin-pot clavulanate oral suspension for T1 AL (Max 12 Years) reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml amoxicillin-pot clavulanate oral suspension for T1 reconstitution 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet T1 amoxicillin-pot clavulanate oral tablet extended T1 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable T1 ampicillin oral capsule T1 ampicillin oral suspension for reconstitution T1 AL (Max 12 Years) AUGMENTIN ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION 125-31.25 MG/5 ML Anthelmintics ALBENZA T2 QL (4 EA per 365 days) 2 Drug Tier Notes BILTRICIDE T2 ivermectin oral T1 QL (30 EA per 365 days) Antifungals, Miscellaneous griseofulvin microsize T1 griseofulvin ultramicrosize T1 Anti-Infective Agents DESCOVY T1 TYBOST T1 Antimalarials atovaquone-proguanil T1 QL (180 EA per 365 days) chloroquine phosphate oral T1 DARAPRIM T3 PA hydroxychloroquine oral T1 mefloquine T1 primaquine T1 quinidine gluconate oral T1 quinidine sulfate T1 Antimycobacterials, Miscellaneous dapsone T1 Antiprotozoals, Miscellaneous ALINIA T2 QL (30 ML per 365 days) atovaquone T1 dapsone T1 metronidazole oral tablet T1 NEBUPENT T3 PA PENTAM T3 PA tinidazole T1 QL (30 EA per 365 days) Antituberculosis Agents ciprofloxacin T1 AL (Max 12 Years) ciprofloxacin hcl oral T1 clarithromycin oral tablet T1 QL (60 EA per 30 days) cycloserine T1

3 Drug Tier Notes ethambutol T1 isoniazid oral solution T1 AL (Max 12 Years) isoniazid oral tablet T1 levofloxacin oral solution T1 AL (Max 12 Years) levofloxacin oral tablet T1 moxifloxacin T3 PA PASER T2 PRIFTIN T2 pyrazinamide T1 rifabutin T1 rifampin oral T1 RIFATER T2 SIRTURO T3 PA TRECATOR T2 Azoles fluconazole T1 itraconazole T3 PA ketoconazole oral T1 ONMEL T3 PA voriconazole oral T3 PA Erythromycins erythromycin-sulfisoxazole T1 First Generation Cephalosporins cefadroxil oral capsule T3 PA cefadroxil oral suspension for reconstitution 250 T3 PA mg/5 ml, 500 mg/5 ml cefadroxil oral tablet T3 PA cephalexin oral capsule 250 mg, 500 mg T1 cephalexin oral suspension for reconstitution T1 Glycopeptides intravenous recon soln 1,000 mg, 5 T1 gram, 500 mg vancomycin oral capsule T3 ST; QL (40 QY per 10 DYs)

4 Drug Tier Notes Hcv Polymerase Inhibitors EPCLUSA T3 PA HARVONI T3 PA SOVALDI T3 PA VIEKIRA PAK T3 PA Hcv Protease Inhibitors TECHNIVIE T3 PA VIEKIRA PAK T3 PA ZEPATIER T3 PA Hcv Replication Complex Inhibitors DAKLINZA T3 PA EPCLUSA T3 PA HARVONI T3 PA TECHNIVIE T3 PA VIEKIRA PAK T3 PA ZEPATIER T3 PA Hiv Entry And Fusion Inhibitors FUZEON SUBCUTANEOUS RECON SOLN T3 PA SELZENTRY T2 Hiv Integrase Inhibitors GENVOYA T2 ISENTRESS T2 STRIBILD T2 TIVICAY T2 TRIUMEQ T2 VITEKTA T2 Hiv Nonnucleoside Rev.Transcrip. Inhib. ATRIPLA T2 COMPLERA T2 EDURANT T2 INTELENCE T2 nevirapine T1

5 Drug Tier Notes ODEFSEY T2 RESCRIPTOR T2 SUSTIVA T2 Hiv Nucleoside, Nucleotide Rt Inhibitors abacavir T1 abacavir-lamivudine-zidovudine T1 ATRIPLA T2 COMPLERA T2 DESCOVY T2 didanosine T1 EMTRIVA T2 EPIVIR HBV ORAL SOLUTION T2 EPZICOM T2 GENVOYA T2 lamivudine T1 lamivudine-zidovudine T1 ODEFSEY T2 stavudine T1 STRIBILD T2 TRIUMEQ T2 TRUVADA T2 VIDEX 2 GRAM PEDIATRIC T2 VIDEX 4 GRAM PEDIATRIC T2 VIREAD T2 ZIAGEN T2 zidovudine T1 Hiv Protease Inhibitors APTIVUS T2 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T2 EVOTAZ T2 INVIRASE T2 KALETRA T2 LEXIVA T2 6 Drug Tier Notes NORVIR T2 PREZCOBIX T2 PREZISTA T2 REYATAZ ORAL CAPSULE 150 MG, 200 MG, T2 300 MG REYATAZ ORAL IN PACKET T2 TECHNIVIE T3 PA VIEKIRA PAK T3 PA VIRACEPT ORAL TABLET T2 Interferons ALFERON N T3 PA INFERGEN T3 PA INTRON A T3 PA PEGASYS CONVENIENCE PACK T3 PA SYLATRON T3 PA Ketolides KETEK ORAL TABLET 400 MG T3 PA Lincomycins clindamycin hcl oral capsule 150 mg, 300 mg T1 clindamycin hcl oral capsule 75 mg T3 PA clindamycin palmitate hcl T1 AL (Max 12 Years) Macrolides ERYPED 400 T2 AL (Max 12 Years) ERY-TAB T1 ERYTHROCIN (AS STEARATE) ORAL T1 QL (120 EA per 30 days) TABLET 250 MG erythromycin ethylsuccinate oral suspension for T1 AL (Max 12 Years) reconstitution erythromycin ethylsuccinate oral tablet T1 erythromycin oral capsule,delayed release(dr/ec) T1 erythromycin oral tablet T1 QL (120 EA per 30 days) PCE T2 Monobactams

7 Drug Tier Notes CAYSTON T3 PA Natural Penicillins penicillin v potassium T1 Neuraminidase Inhibitors oseltamivir oral capsule 30 mg, 45 mg T1 AL (Max 12 Years) oseltamivir oral capsule 75 mg T1 RELENZA DISKHALER T2 QL (20 QY per 30 DYs) TAMIFLU ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION Nucleosides And Nucleotides acyclovir oral capsule T1 QL (150 QY per 30 DYs) acyclovir oral suspension 200 mg/5 ml T1 acyclovir oral tablet T1 QL (150 QY per 30 DYs) BARACLUDE ORAL SOLUTION T2 AL (Max 12 Years) entecavir T1 QL (30 EA per 30 days) famciclovir T1 REBETOL ORAL SOLUTION T3 PA ribavirin oral capsule T1 ribavirin oral tablet 200 mg T1 TYZEKA T2 QL (30 EA per 30 days) valacyclovir T1 QL (90 QY per 30 DYs) VALCYTE ORAL TABLET T3 PA valganciclovir oral recon soln T3 PA VIRAZOLE T3 PA Other Macrolides azithromycin oral packet T1 QL (2 FL per 90 DYs) azithromycin oral suspension for reconstitution T1 100 mg/5 ml azithromycin oral suspension for reconstitution T1 QL (2 FL per 90 DYs) 200 mg/5 ml azithromycin oral tablet 250 mg, 600 mg T1 QL (30 QY per 30 DYs) azithromycin oral tablet 500 mg T1 QL (15 EA per 30 days) clarithromycin oral tablet T1 QL (60 EA per 30 days) DIFICID T3 PA 8 Drug Tier Notes Oxazolidinones linezolid oral suspension for reconstitution T1 AL (Max 12 Years) linezolid oral tablet T1 Penicillinase-Resistant Penicillins dicloxacillin T1 Polyenes nystatin oral powder 50 million unit T1 nystatin oral suspension T1 nystatin oral tablet T1 Quinolones ciprofloxacin T1 AL (Max 12 Years) ciprofloxacin hcl oral T1 levofloxacin oral solution T1 AL (Max 12 Years) levofloxacin oral tablet T1 moxifloxacin T3 PA Rifamycins PRIFTIN T2 rifabutin T1 RIFAMATE T2 rifampin oral T1 RIFATER T2 XIFAXAN ORAL TABLET 200 MG T3 ST; QL (90 QY per 30 DYs) XIFAXAN ORAL TABLET 550 MG T3 ST; QL (60 QY per 30 DYs) Second Generation Cephalosporins cefaclor oral capsule T1 cefaclor oral suspension for reconstitution 125 T1 AL (Max 12 Years) mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr T1 cefprozil oral suspension for reconstitution T1 AL (Max 12 Years) cefprozil oral tablet T1 CEFTIN ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION 250 MG/5 ML

9 Drug Tier Notes cefuroxime axetil oral suspension for T1 AL (Max 12 Years) reconstitution 125 mg/5 ml cefuroxime axetil oral tablet T1 Sulfonamides (Systemic) sulfadiazine oral T1 sulfamethoxazole-trimethoprim oral T1 sulfasalazine T1 Tetracyclines doxycycline hyclate oral capsule T1 QL (60 EA per 30 days) doxycycline hyclate oral tablet 100 mg T1 QL (60 EA per 30 days) doxycycline monohydrate oral capsule 100 mg, 50 T1 QL (60 EA per 30 days) mg doxycycline monohydrate oral tablet 100 mg T1 QL (60 EA per 30 days) minocycline oral capsule 100 mg, 50 mg T1 QL (60 EA per 30 days) tetracycline T1 QL (120 QY per 30 DYs) Third Generation Cephalosporins CEDAX ORAL SUSPENSION FOR T3 PA RECONSTITUTION cefdinir oral capsule T1 QL (60 EA per 30 days) cefdinir oral suspension for reconstitution T1 AL (Max 12 Years) cefditoren pivoxil T3 PA cefixime oral suspension for reconstitution 100 T1 AL (Max 12 Years) mg/5 ml cefixime oral suspension for reconstitution 200 T1 AL (Min 12 Years) mg/5 ml cefpodoxime oral suspension for reconstitution T1 AL (Max 12 Years) cefpodoxime oral tablet 100 mg T1 QL (60 QY per 30 DYs) cefpodoxime oral tablet 200 mg T1 ceftibuten T3 PA SUPRAX ORAL CAPSULE T2 QL (28 EA per 28 days) SUPRAX ORAL TABLET,CHEWABLE T2 AL (Max 12 Years) Urinary Anti-Infectives nitrofurantoin macrocrystal T1 nitrofurantoin monohyd/m-cryst T1

10 Drug Tier Notes nitrofurantoin oral T1 trimethoprim T1 Antineoplastic Agents Antineoplastic Agents AFINITOR T3 PA AFINITOR DISPERZ T3 PA ALECENSA T3 PA ALFERON N T3 PA ALKERAN ORAL T3 PA anastrozole T1 QL (30 QY per 30 DYs) bexarotene T3 PA bicalutamide T1 BOSULIF T3 PA CABOMETYX T3 PA capecitabine T3 PA CAPRELSA T3 PA COMETRIQ T3 PA COTELLIC T3 PA cyclophosphamide oral capsule T3 PA ELIGARD T3 PA ELIGARD (3 MONTH) T3 PA ELIGARD (4 MONTH) T3 PA ELIGARD (6 MONTH) T3 PA EMCYT T3 PA ERIVEDGE T3 PA exemestane T3 PA FARESTON T3 PA FARYDAK T3 PA FIRMAGON KIT W DILUENT T3 PA flutamide T1 GILOTRIF T3 PA GLEOSTINE T3 PA HEXALEN T3 PA 11 Drug Tier Notes HYCAMTIN ORAL T3 PA hydroxyurea T1 IBRANCE T3 PA ICLUSIG T3 PA imatinib T3 PA IMBRUVICA T3 PA INLYTA T3 PA INTRON A INJECTION T3 PA IRESSA T3 PA JAKAFI T3 PA KISQALI T3 PA LENVIMA T3 PA letrozole T1 LEUKERAN T3 PA leuprolide T3 PA LONSURF T3 PA LUPRON DEPOT-PED T3 PA LUPRON DEPOT-PED (3 MONTH) T3 PA LYNPARZA T3 PA LYSODREN T3 PA MATULANE T3 PA megestrol oral suspension 400 mg/10 ml (10 ml), T1 400 mg/10 ml (40 mg/ml) megestrol oral tablet T1 MEKINIST T3 PA mercaptopurine T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days) methotrexate sodium injection T1 QL (16 ML per 28 days) methotrexate sodium oral T1 MYLERAN T3 PA NEXAVAR T3 PA NINLARO T3 PA ODOMZO T3 PA

12 Drug Tier Notes POMALYST T3 PA PURIXAN T3 PA REVLIMID T3 PA RHEUMATREX T2 RUBRACA T3 PA SOLTAMOX T3 PA SPRYCEL T3 PA STIVARGA T3 PA SUTENT T3 PA SYLATRON T3 PA SYNRIBO T3 PA TABLOID T3 PA TAFINLAR T3 PA TAGRISSO T3 PA tamoxifen T1 TARCEVA T3 PA TASIGNA T3 PA temozolomide T3 PA tretinoin (chemotherapy) T3 PA TREXALL T3 PA TYKERB T3 PA VENCLEXTA T3 PA VENCLEXTA STARTING PACK T3 PA VOTRIENT T3 PA XALKORI T3 PA XTANDI T3 PA ZELBORAF T3 PA ZOLINZA T3 PA ZYDELIG T3 PA ZYKADIA T3 PA ZYTIGA ORAL TABLET 250 MG T3 PA Antitoxins,Immune Glob,Toxoids,Vaccines Toxoids 13 Drug Tier Notes ADACEL(TDAP ADOLESN/ADULT)(PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years) BOOSTRIX TDAP T2 QL (0.5 ML per 1 fill); AL (Min 19 Years) TENIVAC (PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years) Autonomic Drugs Alpha- And Beta-Adrenergic Agonists injection auto-injector T1 QL (6 EA per 365 days) REZIRA T3 PA Alpha-Adrenergic Agonists clonidine hcl T1 clonidine patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days) clonidine weekly 0.2 mg/24 hr, T1 QL (8 EA per 28 days) 0.3 mg/24 hr KAPVAY DOSE PACK T2 AL (Min 5 Years and Max 24 Years) methyldopa T1 methyldopa-hydrochlorothiazide T1 midodrine T1 PROMETHAZINE VC T1 AL (Min 2 Years) Antimuscarinics/Antispasmodics ATROVENT HFA T2 QL (25.8 QY per 30 DYs) chlordiazepoxide-clidinium T1 COMBIVENT T2 QL (4 QY per 20 DYs) dicyclomine oral capsule T1 dicyclomine oral tablet T1 diphenoxylate-atropine T1 glycopyrrolate oral T1 hyoscyamine sulfate oral tablet T1 hyoscyamine sulfate oral tablet extended release T1 12 hr hyoscyamine sulfate sublingual T1 T1 QL (312.5 QY per 30 DYs) ipratropium-albuterol T1 QL (570 QY per 30 DYs)

14 Drug Tier Notes SPIRIVA RESPIMAT T2 QL (4 GM per 30 days) SPIRIVA WITH HANDIHALER T2 QL (30 QY per 30 DYs) TUDORZA PRESSAIR T2 QL (1 QY per 30 DYs) Antiparkinsonian Agents benztropine oral T1 trihexyphenidyl T1 Autonomic Drugs, Miscellaneous CHANTIX ORAL TABLET 0.5 MG T2 QL (360 QY per 365 DYs) CHANTIX ORAL TABLET 1 MG T2 QL (224 EA per 365 days) CHANTIX STARTING MONTH BOX T2 QL (106 QY per 365 DYs) nicotine (polacrilex) buccal gum T1 QL (360 QY per 30 DYs) nicotine (polacrilex) buccal lozenge T1 QL (360 EA per 30 days) nicotine transdermal patch 24 hour 14 mg/24 hr, T1 QL (30 QY per 30 DYs) 21 mg/24 hr, 7 mg/24 hr NICOTROL T3 PA NICOTROL NS T3 PA Centrally Acting Skeletal Muscle Relaxnt cyclobenzaprine oral tablet 10 mg, 5 mg T1 QL (90 QY per 30 DYs) methocarbamol oral T1 QL (120 EA per 30 days) tizanidine oral tablet T1 QL (90 QY per 30 DYs) Gaba-Derivative Skeletal Muscle Relaxant baclofen T1 Non-Sel. Beta-Adrenergic Blocking Agents carvedilol T1 labetalol oral T1 nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Non-Sel.Alpha-1-Adrenergic Blocking Agts doxazosin T1 prazosin oral T1 terazosin T1 15 Drug Tier Notes Non-Sel.Alpha-Adrenergic Blocking Agents phenoxybenzamine T3 PA Parasympathomimetic (Cholinergic Agents) bethanechol chloride T3 PA donepezil T1 galantamine T1 MESTINON ORAL SYRUP T2 NAMZARIC T2 pilocarpine hcl oral tablet 5 mg T1 QL (180 QY per 30 DYs) PROSTIGMIN T2 pyridostigmine bromide T1 rivastigmine T1 rivastigmine tartrate T1 Selective Alpha-1-Adrenergic Block.Agent alfuzosin T1 QL (30 EA per 30 days) carvedilol T1 labetalol oral T1 RAPAFLO T3 PA tamsulosin T1 QL (60 QY per 30 DYs) Selective Beta-2-Adrenergic Agonists ADVAIR DISKUS T2 QL (60 EA per 30 days) ADVAIR HFA T3 PA albuterol sulfate inhalation solution for T1 nebulization 1.25 mg/3 ml, 2.5 mg/0.5 ml albuterol sulfate inhalation solution for T1 QL (525 QY per 30 DYs) nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for T1 QL (100 QY per 30 DYs) nebulization 5 mg/ml albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years) albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs) BREO ELLIPTA T3 PA COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) DULERA T2 QL (13 QY per 30 DYs)

16 Drug Tier Notes ipratropium-albuterol T1 QL (570 QY per 30 DYs) levalbuterol hcl inhalation solution for T3 ST; QL (240 QY per 30 DYs) nebulization 0.31 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (360 QY per 30 DYs) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (150 QY per 30 DYs) nebulization 1.25 mg/0.5 ml levalbuterol tartrate T3 ST; QL (30 GM per 30 days) PROAIR HFA T2 QL (17 GM per 30 days) PROVENTIL HFA T3 ST; QL (13.4 GM per 30 days) SEREVENT DISKUS T3 PA SYMBICORT T2 QL (10.2 QY per 30 DYs) oral T1 VENTOLIN HFA T2 QL (36 QY per 30 DYs) Selective Beta-Adrenergic Blocking Agent acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg Blood Formation, Coagulation, Thrombosis Coumarin Derivatives warfarin T1 Direct Factor Xa Inhibitors ELIQUIS T2 QL (60 EA per 30 days) SAVAYSA T3 PA XARELTO ORAL TABLET 10 MG, 20 MG T2 QL (30 EA per 30 days) XARELTO ORAL TABLET 15 MG T2 QL (60 EA per 30 days) XARELTO ORAL TABLETS,DOSE PACK T2 QL (51 EA per 30 days) Direct Thrombin Inhibitors PRADAXA T3 PA 17 Drug Tier Notes Hematopoietic Agents ARANESP (IN POLYSORBATE) T3 PA EPOGEN INJECTION SOLUTION 10,000 T3 PA UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML NEULASTA SUBCUTANEOUS SYRINGE T3 PA PROCRIT INJECTION SOLUTION 4,000 T3 PA UNIT/ML, 40,000 UNIT/ML PROMACTA T3 PA ZARXIO T3 PA Hemorrheologic Agents pentoxifylline T1 QL (90 QY per 30 DYs) Hemostatics desmopressin ,non- T1 desmopressin oral T1 STIMATE T3 PA Heparins enoxaparin subcutaneous solution T1 QL (6 QY per 10 DYs) enoxaparin subcutaneous syringe 100 mg/ml, 150 T1 QL (20 QY per 10 DYs) mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, T1 QL (16 QY per 10 DYs) 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (6 QY per 10 DYs) enoxaparin subcutaneous syringe 40 mg/0.4 ml T1 QL (8 QY per 10 DYs) enoxaparin subcutaneous syringe 60 mg/0.6 ml T1 QL (12 QY per 10 DYs) heparin (porcine) injection cartridge T1 heparin (porcine) injection solution 10,000 T1 unit/ml, 20,000 unit/ml heparin, porcine (pf) injection solution 1,000 T1 unit/ml Iron Preparations ATABEX EC T2 QL (30 QY per 30 DYs) BAL-CARE DHA T1 QL (60 QY per 30 DYs) BAL-CARE DHA ESSENTIAL T2 QL (60 QY per 30 DYs) CAVAN-EC SOD DHA T1 QL (60 QY per 30 DYs) 18 Drug Tier Notes CENTRUM SPECIALIST PRENATAL T2 QL (60 QY per 30 DYs) CITRANATAL HARMONY T1 QL (30 QY per 30 DYs) CLASSIC PRENATAL T2 DUET DHA BALANCED ORAL COMBO T2 QL (60 QY per 30 DYs) PACK 26 MG IRON- 1 MG-278 MG DUET DHA EC-OM 3 T2 QL (60 QY per 30 DYs) DUET DHA WITH OMEGA-3 T2 QL (60 QY per 30 DYs) ELITE-OB 400 T1 QL (30 QY per 30 DYs) EXTRA-VIRT PLUS DHA T1 FOLIVANE-EC CALCIUM DHA NF T1 QL (60 EA per 30 days) FOLIVANE-OB T1 QL (30 QY per 30 DYs) FOLIVANE-PRX DHA NF T2 QL (30 QY per 30 DYs) HEMATOGEN FA T1 HEMENATAL OB T1 QL (30 QY per 30 DYs) HEMENATAL OB + DHA T1 QL (60 QY per 30 DYs) INATAL ULTRA T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs) L-METHYLFOLATE PNV DHA T1 MACNATAL CN DHA T1 QL (30 QY per 30 DYs) MARNATAL-F T2 QL (30 QY per 30 DYs) MINI PRENATAL T2 QL (30 QY per 30 DYs) MYNATAL ORAL CAPSULE T2 QL (30 QY per 30 DYs) MYNATAL-Z T1 QL (30 QY per 30 DYs) NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NATAFORT (NEW FORMULA 2011) T2 QL (30 QY per 30 DYs) NATALVIRT CA T1 QL (60 QY per 30 DYs) NATALVIT T2 QL (30 QY per 30 DYs) NATELLE ONE T1 QL (30 QY per 30 DYs) NEWGEN T1 QL (30 EA per 30 days) OB COMPLETE 400 T2 QL (30 QY per 30 DYs) OB COMPLETE ONE T2 QL (30 QY per 30 DYs) OB COMPLETE ORAL TABLET,CHEWABLE T2 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)

19 Drug Tier Notes OBSTETRIX DHA T1 QL (60 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) OBTREX T2 O-CAL FA T2 QL (30 QY per 30 DYs) O-CAL PRENATAL T2 QL (30 QY per 30 DYs) ONE A DAY WOMEN'S PRENATAL DHA T1 QL (60 QY per 30 DYs) PAIRE OB PLUS DHA T1 PERRY PRENATAL T2 QL (30 QY per 30 DYs) PNV 29-1 T1 PNV FOLIC ACID + IRON T1 PNV-OMEGA T1 QL (30 QY per 30 DYs) PR NATAL 430 T1 QL (60 QY per 30 DYs) PR NATAL 430 EC T1 QL (60 QY per 30 DYs) PRENA1 T2 QL (30 QY per 30 DYs) PRENA1 PLUS T1 QL (60 EA per 30 days) PRENAISSANCE 90 DHA T1 QL (60 EA per 30 days) PRENAISSANCE DHA HARMONY T1 QL (60 EA per 30 days) PRENATA T2 QL (30 QY per 30 DYs) PRENATAL 19 T1 QL (30 QY per 30 DYs) PRENATAL 19 (WITH DOCUSATE) T1 QL (30 QY per 30 DYs) PRENATAL DHA+COMPLETE PRENATAL T1 QL (60 QY per 30 DYs) PRENATAL FORMULA ORAL TABLET 9 MG T1 QL (30 QY per 30 DYs) IRON- 267 MCG PRENATAL LOW IRON T1 QL (30 QY per 30 DYs) PRENATAL MULTI-DHA ORAL CAPSULE 27 T1 QL (60 QY per 30 DYs) MG IRON-800 MCG-228 MG PRENATAL ORAL TABLET 28 MG IRON- 800 T1 QL (30 QY per 30 DYs) MCG PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRENATAL-1 T1 QL (30 QY per 30 DYs) PRENATE DHA T2 QL (30 QY per 30 DYs)

20 Drug Tier Notes PRENATE ELITE T2 QL (30 QY per 30 DYs) PRENATE ESSENTIAL T2 QL (30 QY per 30 DYs) PRENATE MINI T2 QL (30 QY per 30 DYs) PREQUE 10 T2 PROTECT NATAL T2 QL (60 QY per 30 DYs) PROTECT PLUS T1 PUREFE OB PLUS T2 QL (30 QY per 30 DYs) RELNATE DHA T1 QL (30 QY per 30 DYs) SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs) SE-TAN DHA T1 QL (30 QY per 30 DYs) STROVITE FORTE T2 STUART PRENATAL PLUS DHA T2 QL (60 QY per 30 DYs) TARON-BC T1 QL (90 QY per 30 DYs) TARON-C DHA T1 QL (30 QY per 30 DYs) THERANATAL COMPLETE T2 QL (60 QY per 30 DYs) TRIADVANCE T1 TRICARE PRENATAL DHA ONE T2 QL (30 QY per 30 DYs) TRIGELS-F FORTE T1 TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) TRIVEEN-TEN T1 QL (60 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VENATAL-FA T1 QL (30 QY per 30 DYs) VINACAL B T1 VINATE AZ T1 QL (30 QY per 30 DYs) VINATE II T1 VINATE ONE T1 QL (30 QY per 30 DYs) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL T2 VITAFOL GUMMIES T2 VOL-NATE T1 VP-ERA OB PLUS T1 QL (30 QY per 30 DYs)

21 Drug Tier Notes VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 ZATEAN-PN T1 QL (30 QY per 30 DYs) Platelet-Aggregation Inhibitors aspirin-dipyridamole T1 QL (60 EA per 30 days) BRILINTA T2 QL (60 EA per 30 days) butalbital-aspirin-caffeine oral capsule T3 PA cilostazol T1 QL (60 QY per 30 DYs) clopidogrel oral tablet 75 mg T1 dipyridamole oral T1 EFFIENT ORAL TABLET 10 MG T3 ST; QL (30 QY per 30 DYs) EFFIENT ORAL TABLET 5 MG T3 ST; QL (60 EA per 30 days) Platelet-Reducing Agents anagrelide T1 Thrombolytic Agents butalbital-aspirin-caffeine oral capsule T3 PA Cardiovascular Drugs Alpha-Adrenergic Blocking Agents carvedilol T1 doxazosin T1 labetalol oral T1 prazosin oral T1 terazosin T1 Alpha-Adrenergic Blocking Agt.(Hypoten) doxazosin T1 labetalol oral T1 prazosin oral T1 terazosin T1 Angiotensin Ii Receptor Antagon.(Hypotn) amlodipine-valsartan T1 QL (30 EA per 30 days) candesartan T3 ST candesartan-hydrochlorothiazid T3 ST

22 Drug Tier Notes irbesartan T1 QL (30 EA per 30 days) irbesartan-hydrochlorothiazide T1 QL (30 EA per 30 days) losartan T1 QL (30 QY per 30 DYs) losartan-hydrochlorothiazide T1 QL (30 QY per 30 DYs) telmisartan T1 valsartan oral tablet 160 mg, 80 mg T1 valsartan oral tablet 320 mg, 40 mg T1 QL (30 EA per 30 days) valsartan-hydrochlorothiazide T1 QL (30 EA per 30 days) Angiotensin Ii Receptor Antagonists amlodipine-valsartan T1 QL (30 EA per 30 days) candesartan T3 ST candesartan-hydrochlorothiazid T3 ST ENTRESTO T3 ST irbesartan T1 QL (30 EA per 30 days) irbesartan-hydrochlorothiazide T1 QL (30 EA per 30 days) losartan T1 QL (30 QY per 30 DYs) losartan-hydrochlorothiazide T1 QL (30 QY per 30 DYs) telmisartan T1 valsartan oral tablet 160 mg, 80 mg T1 valsartan oral tablet 320 mg, 40 mg T1 QL (30 EA per 30 days) valsartan-hydrochlorothiazide T1 QL (30 EA per 30 days) Angiotensin-Convert.Enzyme Inhib(Hypotn) amlodipine-benazepril T1 benazepril T1 benazepril-hydrochlorothiazide T1 captopril T1 enalapril maleate T1 enalapril-hydrochlorothiazide T1 fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 perindopril erbumine T1 quinapril T1 23 Drug Tier Notes ramipril T1 trandolapril T1 Angiotensin-Converting Enzyme Inhibitors amlodipine-benazepril T1 benazepril T1 benazepril-hydrochlorothiazide T1 captopril T1 enalapril maleate T1 enalapril-hydrochlorothiazide T1 fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 perindopril erbumine T1 quinapril T1 ramipril T1 trandolapril T1 Antiarrhythmics, Miscellaneous digoxin oral solution 50 mcg/ml T1 digoxin oral tablet T1 Antilipemic Agents, Miscellaneous niacin oral capsule, extended release 250 mg, 500 T1 mg NIACOR T1 Beta-Adrenergic Blocking Agents acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 carvedilol T1 labetalol oral T1 metoprolol succinate T1

24 Drug Tier Notes metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Beta-Adrenergic Blocking Agt.(Hypoten) acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 labetalol oral T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Bile Acid Sequestrants cholestyramine (with sugar) T1 CHOLESTYRAMINE LIGHT T1 colestipol T3 PA WELCHOL T3 PA Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem hcl oral capsule, extended release 180 T1 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 TAZTIA XT ORAL CAPSULE, EXTENDED T1 QL (30 QY per 30 DYs) RELEASE 120 MG

25 Drug Tier Notes TAZTIA XT ORAL CAPSULE, EXTENDED T1 RELEASE 240 MG verapamil oral T1 Calcium-Channel Blocking Agents, Misc. diltiazem hcl oral capsule, extended release 180 T1 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 TAZTIA XT ORAL CAPSULE, EXTENDED T1 QL (30 QY per 30 DYs) RELEASE 120 MG TAZTIA XT ORAL CAPSULE, EXTENDED T1 RELEASE 240 MG verapamil oral T1 Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide T1 Cardiac Drugs, Miscellaneous RANEXA T3 ST Cardiotonic Agents digoxin oral solution 50 mcg/ml T1 digoxin oral tablet T1 Central Alpha-Agonists clonidine hcl T1 clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days) clonidine transdermal patch weekly 0.2 mg/24 hr, T1 QL (8 EA per 28 days) 0.3 mg/24 hr guanfacine oral tablet T1 QL (45 EA per 30 days) guanfacine oral tablet extended release 24 hr T1 KAPVAY DOSE PACK T2 AL (Min 5 Years and Max 24 Years) methyldopa T1 methyldopa-hydrochlorothiazide T1 Cholesterol Absorption Inhibitors ezetimibe T3 ST

26 Drug Tier Notes Class Ia Antiarrhythmics disopyramide phosphate oral capsule T1 NORPACE CR T2 quinidine gluconate oral T1 quinidine sulfate T1 Class Ib Antiarrhythmics DILANTIN T2 QL (180 QY per 30 DYs) mexiletine T1 phenytoin oral suspension T1 phenytoin oral tablet,chewable T1 phenytoin sodium extended T1 Class Ic Antiarrhythmics flecainide T1 propafenone oral tablet T1 Class Ii Antiarrhythmics acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 carvedilol T1 labetalol oral T1 metoprolol succinate T1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 T1 mg nadolol T1 pindolol T1 propranolol oral T1 sotalol oral T1 Class Iii Antiarrhythmics amiodarone oral T1 dofetilide T1 MULTAQ T2 27 Drug Tier Notes sotalol oral T1 Class Iv Antiarrhythmics diltiazem hcl oral capsule, extended release 180 T1 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 TAZTIA XT ORAL CAPSULE, EXTENDED T1 QL (30 QY per 30 DYs) RELEASE 120 MG TAZTIA XT ORAL CAPSULE, EXTENDED T1 RELEASE 240 MG verapamil oral T1 Dihydropyridines amlodipine T1 amlodipine-benazepril T1 amlodipine-valsartan T1 QL (30 EA per 30 days) felodipine oral tablet extended release 24 hr 10 mg T1 QL (60 QY per 30 DYs) felodipine oral tablet extended release 24 hr 2.5 T1 QL (30 QY per 30 DYs) mg, 5 mg nifedipine oral capsule 10 mg T1 QL (180 EA per 30 days) nifedipine oral tablet extended release 24hr 30 mg T1 QL (30 QY per 30 DYs) nifedipine oral tablet extended release 24hr 60 mg, T1 QL (60 QY per 30 DYs) 90 mg nifedipine oral tablet extended release 30 mg, 90 T1 QL (30 QY per 30 DYs) mg nifedipine oral tablet extended release 60 mg T1 QL (60 QY per 30 DYs) Dihydropyridines (Hypotensive Agents) amlodipine T1 amlodipine-benazepril T1 amlodipine-valsartan T1 QL (30 EA per 30 days) felodipine oral tablet extended release 24 hr 10 mg T1 QL (60 QY per 30 DYs) felodipine oral tablet extended release 24 hr 2.5 T1 QL (30 QY per 30 DYs) mg, 5 mg nifedipine oral capsule 10 mg T1 QL (180 EA per 30 days)

28 Drug Tier Notes nifedipine oral tablet extended release 24hr 30 mg T1 QL (30 QY per 30 DYs) nifedipine oral tablet extended release 24hr 60 mg, T1 QL (60 QY per 30 DYs) 90 mg nifedipine oral tablet extended release 30 mg, 90 T1 QL (30 QY per 30 DYs) mg nifedipine oral tablet extended release 60 mg T1 QL (60 QY per 30 DYs) Direct Vasodilators hydralazine oral T1 minoxidil oral T1 Diuretics, Miscellaneous (Hypotensive) theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Fibric Acid Derivatives fenofibrate micronized T1 fenofibrate nanocrystallized T1 fenofibrate oral tablet 160 mg, 54 mg T1 fenofibric acid T1 fenofibric acid (choline) T1 gemfibrozil oral T1 Hmg-Coa Reductase Inhibitors atorvastatin T1 lovastatin T1 pravastatin T1 rosuvastatin T1 simvastatin T1 Hypotensive Agents, Miscellaneous acebutolol T1 carvedilol T1 doxazosin T1 phenoxybenzamine T3 PA pindolol T1 propranolol oral T1

29 Drug Tier Notes sotalol oral T1 terazosin T1 Loop Diuretics (Hypotensive Agents) bumetanide oral T1 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 T1 mg/ml) furosemide oral tablet T1 torsemide oral T1 Mineralocorticoid (Aldosterone) Antagnts eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 Mineralocorticoid(Aldoster.)Antag(Hypot) eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 Nitrates And Nitrites DILATRATE-SR T2 ISORDIL T2 isosorbide dinitrate oral T1 isosorbide mononitrate T1 NITRO-BID T2 nitroglycerin sublingual T1 Pcsk9 Inhibitors PRALUENT PEN T3 PA PRALUENT SYRINGE T3 PA REPATHA PUSHTRONEX T3 PA REPATHA SURECLICK T3 PA REPATHA SYRINGE T3 PA Peripheral Adrenergic Inhibitors reserpine T1 Phosphodiesterase Type 5 Inhibitors ADCIRCA T3 PA 30 Drug Tier Notes cilostazol T1 QL (60 QY per 30 DYs) sildenafil oral T3 PA Potassium-Sparing Diuretics (Hypoten) eplerenone T3 ST spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 Renin-Angioten.-Aldost. Sys. Inhib, Misc ENTRESTO T3 ST Thiazide Diuretics(Hypotensive Agents) benazepril-hydrochlorothiazide T1 bisoprolol-hydrochlorothiazide T1 candesartan-hydrochlorothiazid T3 ST chlorothiazide T1 DIURIL T2 AL (Max 12 Years) enalapril-hydrochlorothiazide T1 hydrochlorothiazide T1 irbesartan-hydrochlorothiazide T1 QL (30 EA per 30 days) lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 QL (30 QY per 30 DYs) methyldopa-hydrochlorothiazide T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 valsartan-hydrochlorothiazide T1 QL (30 EA per 30 days) Thiazide-Like Diuretics(Hypotensive Agt) atenolol-chlorthalidone T1 chlorthalidone oral tablet 100 mg T1 QL (30 QY per 30 DYs) chlorthalidone oral tablet 25 mg, 50 mg T1 metolazone T1

31 Drug Tier Notes Vasodilating Agents, Miscellaneous ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 T3 PA MG amlodipine T1 amlodipine-benazepril T1 amlodipine-valsartan T1 QL (30 EA per 30 days) aspirin-dipyridamole T1 QL (60 EA per 30 days) diltiazem hcl oral capsule, extended release 180 T1 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable T1 diltiazem hcl oral capsule,extended release 12 hr T1 diltiazem hcl oral capsule,extended release 24hr T1 diltiazem hcl oral tablet T1 dipyridamole oral T1 isoxsuprine T3 ST LETAIRIS T3 PA nifedipine oral capsule 10 mg T1 QL (180 EA per 30 days) nifedipine oral tablet extended release 24hr 30 mg T1 QL (30 QY per 30 DYs) nifedipine oral tablet extended release 24hr 60 mg, T1 QL (60 QY per 30 DYs) 90 mg nifedipine oral tablet extended release 30 mg, 90 T1 QL (30 QY per 30 DYs) mg nifedipine oral tablet extended release 60 mg T1 QL (60 QY per 30 DYs) OPSUMIT T3 PA REMODULIN T3 PA TAZTIA XT ORAL CAPSULE, EXTENDED T1 QL (30 QY per 30 DYs) RELEASE 120 MG TAZTIA XT ORAL CAPSULE, EXTENDED T1 RELEASE 240 MG TYVASO REFILL KIT T3 PA TYVASO STARTER KIT T3 PA UPTRAVI T3 PA VENTAVIS T3 PA verapamil oral T1 Central Nervous System Agents 32 Drug Tier Notes Adamantanes (Cns) amantadine hcl oral solution T1 amantadine hcl oral tablet T1 Amphetamine Derivatives phentermine T3 PA Amphetamines dextroamphetamine oral capsule, extended release T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) dextroamphetamine oral tablet 10 mg T1 QL (120 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) dextroamphetamine oral tablet 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) dextroamphetamine-amphetamine T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) Analgesics And Antipyretics, Misc. acetaminophen-codeine oral solution 120-12 mg/5 T1 AL (Min 12 Years) ml acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) butalbital-acetaminophen-caff oral capsule 50- T3 PA 325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- T1 40 mg CAPITAL WITH CODEINE T2 AL (Min 12 Years) gabapentin oral capsule 100 mg T1 QL (1080 QY per 30 DYs) gabapentin oral capsule 300 mg T1 QL (360 QY per 30 DYs) gabapentin oral capsule 400 mg T1 QL (270 QY per 30 DYs) gabapentin oral solution 250 mg/5 ml T1 gabapentin oral solution 250 mg/5 ml (5 ml) T1 QL (2160 QY per 30 DYs); AL (Max 12 Years) gabapentin oral tablet 600 mg T1 QL (180 QY per 30 DYs) gabapentin oral tablet 800 mg T1 QL (135 EA per 30 days) hydrocodone-acetaminophen oral tablet 10-325 T1 QL (120 QY per 30 DYs) mg, 5-325 mg, 7.5-325 mg hydrocodone-acetaminophen oral tablet 2.5-325 T1 QL (120 EA per 30 days) mg

33 Drug Tier Notes oxycodone-acetaminophen oral solution T1 oxycodone-acetaminophen oral tablet 10-325 mg, T1 QL (120 EA per 30 days) 2.5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs) tramadol-acetaminophen T1 QL (120 EA per 30 DYs) Anorexigenic Agents, Miscellaneous CONTRAVE T3 PA Anticholinergic Agents (Cns) benztropine oral T1 trihexyphenidyl T1 Anticonvulsants, Miscellaneous APTIOM T2 BANZEL T2 BRIVIACT ORAL TABLET T2 carbamazepine oral capsule, er multiphase 12 hr T1 carbamazepine oral suspension 100 mg/5 ml T1 carbamazepine oral tablet T1 carbamazepine oral tablet extended release 12 hr T1 carbamazepine oral tablet,chewable T1 divalproex oral capsule, delayed rel sprinkle T1 QL (300 QY per 30 DYs) divalproex oral tablet extended release 24 hr T1 divalproex oral tablet,delayed release (dr/ec) T1 felbamate oral tablet T1 gabapentin oral capsule 100 mg T1 QL (1080 QY per 30 DYs) gabapentin oral capsule 300 mg T1 QL (360 QY per 30 DYs) gabapentin oral capsule 400 mg T1 QL (270 QY per 30 DYs) gabapentin oral solution 250 mg/5 ml T1 gabapentin oral solution 250 mg/5 ml (5 ml) T1 QL (2160 QY per 30 DYs); AL (Max 12 Years) gabapentin oral tablet 600 mg T1 QL (180 QY per 30 DYs) gabapentin oral tablet 800 mg T1 QL (135 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG T2 lamotrigine oral tablet T1

34 Drug Tier Notes lamotrigine oral tablet, chewable dispersible T1 AL (Max 12 Years) levetiracetam oral solution 100 mg/ml T1 AL (Max 12 Years) levetiracetam oral tablet T1 levetiracetam oral tablet extended release 24 hr T1 LYRICA ORAL CAPSULE T3 PA oxcarbazepine oral suspension T1 AL (Max 12 Years) oxcarbazepine oral tablet T1 POTIGA T2 SABRIL ORAL TABLET T2 tiagabine T1 topiramate oral capsule, sprinkle T1 topiramate oral tablet T1 valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 12 Years) mg/5 ml VIMPAT ORAL SOLUTION T2 AL (Max 12 Years) VIMPAT ORAL TABLET T2 zonisamide T1 Antidepressants, Miscellaneous bupropion hcl T1 bupropion hcl ( deter) T1 mirtazapine oral tablet T1 Antimanic Agents divalproex oral capsule, delayed rel sprinkle T1 QL (300 QY per 30 DYs) divalproex oral tablet extended release 24 hr T1 divalproex oral tablet,delayed release (dr/ec) T1 lithium carbonate T1 lithium citrate oral solution 8 meq/5 ml T1 valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 12 Years) mg/5 ml Antimigraine Agents, Miscellaneous butalbital-acetaminophen-caff oral capsule 50- T3 PA 325-40 mg 35 Drug Tier Notes butalbital-acetaminophen-caff oral tablet 50-325- T1 40 mg butalbital-aspirin-caffeine oral capsule T3 PA divalproex oral capsule, delayed rel sprinkle T1 QL (300 QY per 30 DYs) divalproex oral tablet extended release 24 hr T1 divalproex oral tablet,delayed release (dr/ec) T1 propranolol oral T1 tramadol-acetaminophen T1 QL (120 EA per 30 DYs) valproic acid T1 valproic acid (as sodium salt) oral solution 250 T1 AL (Max 12 Years) mg/5 ml Antipsychotics, Miscellaneous loxapine succinate T1 pimozide T1 Anxiolytics,Sedatives,And Hypnotics,Misc buspirone oral tablet 10 mg, 5 mg, 7.5 mg T1 QL (90 QY per 30 DYs) buspirone oral tablet 15 mg T1 QL (90 EA per 30 days) buspirone oral tablet 30 mg T1 QL (60 QY per 30 DYs) eszopiclone T1 QL (30 EA per 30 days); AL (Min 16 Years) hydroxyzine hcl oral solution 10 mg/5 ml T1 hydroxyzine hcl oral tablet T1 hydroxyzine pamoate T1 PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years) promethazine oral T1 AL (Min 2 Years) promethazine rectal suppository 25 mg T1 AL (Min 2 Years) PROMETHEGAN RECTAL SUPPOSITORY 50 T3 PA MG ROZEREM T3 PA zaleplon T1 QL (30 EA per 30 days); AL (Min 16 Years) zolpidem oral tablet T1 QL (30 QY per 30 DYs); AL (Min 16 Years) zolpidem oral tablet,ext release multiphase T3 PA Atypical Antipsychotics 36 Drug Tier Notes aripiprazole oral tablet T1 clozapine oral tablet T1 NUPLAZID T3 PA olanzapine oral tablet T1 quetiapine oral tablet T1 risperidone oral solution T1 risperidone oral tablet T1 ziprasidone hcl T1 Barbiturates (Anticonvulsants) phenobarbital T1 primidone T1 Barbiturates (Anxiolytic, Sedative/Hyp) butalbital-acetaminophen-caff oral capsule 50- T3 PA 325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- T1 40 mg butalbital-aspirin-caffeine oral capsule T3 PA phenobarbital T1 Benzodiazepines (Anticonvulsants) clonazepam oral tablet T1 QL (60 QY per 30 DYs) clonazepam oral tablet,disintegrating T1 QL (90 EA per 30 days); AL (Max 12 Years) diazepam oral tablet T1 QL (120 QY per 30 DYs) diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 T1 QL (5 EA per 365 days) mg diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs) lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs) lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs) ONFI ORAL SUSPENSION T2 AL (Max 12 Years) ONFI ORAL TABLET 10 MG, 20 MG T2 Benzodiazepines (Anxiolytic,Sedativ/Hyp) chlordiazepoxide hcl T1 QL (120 QY per 30 DYs) chlordiazepoxide-clidinium T1 clonazepam oral tablet T1 QL (60 QY per 30 DYs)

37 Drug Tier Notes clonazepam oral tablet,disintegrating T1 QL (90 EA per 30 days); AL (Max 12 Years) diazepam oral tablet T1 QL (120 QY per 30 DYs) diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 T1 QL (5 EA per 365 days) mg diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs) lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs) lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs) midazolam injection solution 5 mg/ml T1 QL (5 ML per 1 fill) ONFI ORAL SUSPENSION T2 AL (Max 12 Years) ONFI ORAL TABLET 10 MG, 20 MG T2 ONFI ORAL TABLET 5 MG T3 PA oxazepam T1 QL (120 QY per 30 DYs) temazepam T1 QL (30 QY per 30 DYs) Butyrophenones haloperidol T1 haloperidol lactate oral T1 Catechol-O-Methyltransferase(Comt)Inhib. carbidopa-levodopa-entacapone oral tablet 18.75- T1 75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone T1 tolcapone T3 PA Central Nervous System Agents, Misc. acamprosate T1 QL (120 QY per 30 DYs) carbidopa T1 guanfacine oral tablet T1 QL (45 EA per 30 days) guanfacine oral tablet extended release 24 hr T1 memantine T1 NAMENDA XR T2 NAMZARIC T2 riluzole T1 STRATTERA T3 PA tetrabenazine T3 PA

38 Drug Tier Notes Cyclooxygenase-2 (Cox-2) Inhibitors celecoxib T1 Dopamine Precursors carbidopa-levodopa T1 carbidopa-levodopa-entacapone oral tablet 18.75- T1 75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg Ergot-Deriv. Dopamine Receptor Agonists bromocriptine T1 cabergoline T1 Fibromyalgia Agents duloxetine oral capsule,delayed release(dr/ec) 20 T1 mg, 30 mg, 60 mg LYRICA ORAL CAPSULE T3 PA Hydantoins DILANTIN T2 QL (180 QY per 30 DYs) PEGANONE T2 phenytoin oral suspension T1 phenytoin oral tablet,chewable T1 phenytoin sodium extended T1 Monoamine Oxidase B Inhibitors selegiline hcl T1 Monoamine Oxidase Inhibitors selegiline hcl T1 Nonergot-Deriv.Dopamine Receptor Agonist pramipexole oral tablet T1 ropinirole oral tablet T1 Opiate Agonists acetaminophen-codeine oral solution 120-12 mg/5 T1 AL (Min 12 Years) ml acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) CAPITAL WITH CODEINE T2 AL (Min 12 Years)

39 Drug Tier Notes codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) fentanyl T3 PA hydrocodone-acetaminophen oral tablet 10-325 T1 QL (120 QY per 30 DYs) mg, 5-325 mg, 7.5-325 mg hydrocodone-acetaminophen oral tablet 2.5-325 T1 QL (120 EA per 30 days) mg hydromorphone oral T3 PA hydromorphone oral tablet T1 QL (120 QY per 30 DYs) hydromorphone rectal T3 PA KADIAN ORAL CAPSULE,EXTEND.RELEASE T3 PA PELLETS 130 MG, 150 MG, 200 MG, 40 MG, 70 MG morphine concentrate oral solution T1 morphine oral capsule,extend.release pellets T3 PA morphine oral solution T1 morphine oral tablet T1 QL (120 QY per 30 DYs) morphine oral tablet extended release T1 morphine rectal T1 oxycodone oral concentrate T1 oxycodone oral solution T1 oxycodone oral tablet T1 QL (120 QY per 30 DYs) oxycodone oral tablet,oral only,ext.rel.12 hr T3 PA oxycodone-acetaminophen oral solution T1 oxycodone-acetaminophen oral tablet 10-325 mg, T1 QL (120 EA per 30 days) 2.5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs) oxycodone-aspirin T1 QL (120 QY per 30 DYs) OXYCONTIN ORAL TABLET,ORAL T3 PA ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG oxymorphone T3 PA tramadol oral tablet T1 QL (240 QY per 30 DYs) tramadol-acetaminophen T1 QL (120 EA per 30 DYs) Opiate Antagonists

40 Drug Tier Notes naloxone T1 naltrexone T1 NARCAN NASAL SPRAY,NON-AEROSOL 4 T2 MG/ACTUATION Opiate Partial Agonists BUNAVAIL T3 PA buprenorphine hcl sublingual T1 QL (120 QY per 30 DYs) buprenorphine-naloxone T1 QL (120 QY per 30 DYs) SUBOXONE T3 PA ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 T3 PA MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6- 2.1 MG Other Nonsteroidal Anti-Inflam. Agents COMFORT PAC-MELOXICAM T3 PA diclofenac potassium T3 PA diclofenac sodium oral T1 diclofenac sodium topical 1 % T1 QL (100 GM per 30 days) diclofenac-misoprostol T1 diflunisal T3 PA etodolac T1 fenoprofen oral tablet T3 PA flurbiprofen T1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 INDOCIN ORAL T2 AL (Max 12 Years) INDOCIN RECTAL T1 indomethacin oral capsule T1 ketoprofen oral capsule T3 PA ketoprofen oral capsule,ext rel. pellets 24 hr 200 T3 PA mg ketorolac oral T3 PA meclofenamate oral T3 PA mefenamic acid T3 PA meloxicam oral suspension T3 PA; AL (Max 12 Years) meloxicam oral tablet T1

41 Drug Tier Notes nabumetone T1 naproxen T1 naproxen sodium oral tablet 275 mg, 550 mg T1 oxaprozin T1 piroxicam T1 SPRIX T3 PA sulindac oral T1 tolmetin T3 PA Phenothiazines fluphenazine hcl oral tablet T1 perphenazine T1 prochlorperazine T1 prochlorperazine maleate oral T1 thioridazine T1 trifluoperazine T1 Respiratory And Cns Stimulants butalbital-acetaminophen-caff oral capsule 50- T3 PA 325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- T1 40 mg butalbital-aspirin-caffeine oral capsule T3 PA dexmethylphenidate oral tablet T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) methylphenidate oral capsule, er biphasic 30-70 T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) methylphenidate oral capsule,er biphasic 50-50 T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) methylphenidate oral solution 10 mg/5 ml T1 QL (900 QY per 30 DYs); AL (Min 5 Years and Max 12 Years) methylphenidate oral solution 5 mg/5 ml T1 QL (300 QY per 30 DYs); AL (Min 5 Years and Max 12 Years) methylphenidate oral tablet T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years) methylphenidate oral tablet extended release 10 T1 QL (60 QY per 30 DYs); AL (Min 5 mg Years and Max 18 Years)

42 Drug Tier Notes methylphenidate oral tablet extended release 20 T1 QL (90 QY per 30 DYs); AL (Min 5 mg Years and Max 18 Years) methylphenidate oral tablet extended release 24hr T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) RITALIN LA ORAL CAPSULE,ER BIPHASIC T2 QL (60 EA per 30 days); AL (Min 5 50-50 10 MG Years and Max 18 Years) Salicylates aspirin-dipyridamole T1 QL (60 EA per 30 days) butalbital-aspirin-caffeine oral capsule T3 PA choline,magnesium salicylate T1 oxycodone-aspirin T1 QL (120 QY per 30 DYs) salsalate T1 Sel.Serotonin,Norepi Reuptake Inhibitor duloxetine oral capsule,delayed release(dr/ec) 20 T1 mg, 30 mg, 60 mg venlafaxine oral capsule,extended release 24hr T1 venlafaxine oral tablet T1 Selective Serotonin Agonists naratriptan T3 ST; QL (9 EA per 30 days) rizatriptan oral tablet T1 QL (9 EA per 30 days); AL (Min 6 Years and Max 18 Years) rizatriptan oral tablet,disintegrating T1 QL (9 EA per 30 days) sumatriptan T3 PA sumatriptan succinate oral T1 QL (36 EA per 30 days); AL (Min 12 Years) Selective Serotonin Receptor Agonists BELVIQ T3 PA BELVIQ XR T3 PA Selective-Serotonin Reuptake Inhibitors citalopram T1 escitalopram oxalate oral solution T1 AL (Max 12 Years) escitalopram oxalate oral tablet T1 fluoxetine oral capsule T1 fluoxetine oral solution T1 AL (Max 12 Years)

43 Drug Tier Notes fluvoxamine oral tablet T1 paroxetine hcl oral tablet T1 sertraline oral concentrate T1 AL (Max 12 Years) sertraline oral tablet T1 Serotonin Modulators nefazodone T1 trazodone oral tablet 100 mg, 150 mg, 50 mg T1 Succinimides CELONTIN ORAL CAPSULE 300 MG T2 ethosuximide T1 Thioxanthenes thiothixene T1 Tricyclics, Other Norepi-Ru Inhibitors amitriptyline T1 clomipramine T1 desipramine oral T1 doxepin oral T1 imipramine hcl T1 nortriptyline T1 Wakefulness-Promoting Agents armodafinil T3 PA modafinil T3 PA Contraceptives (E.G. Foams, Devices) Contraceptives (E.G. Foams, Devices) CAYA CONTOURED T1 FEMCAP T1 TODAY CONTRACEPTIVE SPONGE T2 VAGINAL CONTRACEPTIVE FILM T2 VAGINAL CONTRACEPTIVE FOAM T1 VCF CONTRACEPTIVE GEL T1 WIDE-SEAL DIAPHRAGM 60 T1 WIDE-SEAL DIAPHRAGM 65 T1

44 Drug Tier Notes WIDE-SEAL DIAPHRAGM 70 T1 WIDE-SEAL DIAPHRAGM 75 T1 WIDE-SEAL DIAPHRAGM 80 T1 WIDE-SEAL DIAPHRAGM 85 T1 WIDE-SEAL DIAPHRAGM 90 T1 WIDE-SEAL DIAPHRAGM 95 T1 Devices Devices ACCU-CHEK AVIVA CONTROL SOLN T1 ACCU-CHEK AVIVA PLUS METER T1 QL (1 QY per 365 DYs) ACCU-CHEK FASTCLIX T1 ACCU-CHEK NANO T1 QL (1 QY per 365 DYs) ACCU-CHEK SMARTVIEW CONTRL SOL T1 AEROCHAMBER PLUS FLOW-VU,S MSK T1 QL (2 FL per 365 DYs) AEROECLIPSE II T1 QL (2 FL per 365 days) ASTHMAPACK CHILDREN'S T1 QL (2 EA per 365 days) BD SAFETYGLIDE ALLERGIST TRAY T1 SYRINGE 1 ML 27 X 1/2" COMPACT COMPRESSOR NEBULIZER T1 QL (2 FL per 365 days) DEXCOM G4 RECEIVER T1 EXACTA-MIX EVA CONTAINER 3,000 ML T1 FEMCAP T1 GUARDIAN RT MONITOR SYSTEM T1 GUARDIAN RT TEST PLUG DEVICE T1 MEDI-JECTOR VISION T1 NESSI SPACER T1 QL (2 FL per 365 days) OMNIPOD INSULIN REFILL T1 RESTORE FOAM DRESSING SILVER T1 TOPICAL BANDAGE 4 X 4 " RESTORE TOPICAL BANDAGE 1 X 12 " T1 SENSURA OSTOMY BASE PLATE T1 SILICONE MASK - INFANT T1 QL (2 FL per 365 days) sodium chloride inhalation solution for T1 nebulization 0.9 %, 3 %, 7 % 45 Drug Tier Notes TRUZONE PEAK FLOW METER T1 QL (2 FL per 365 days) VGO 20 T1 XEROFORM PETROLATUM OVERWRAP T1 TOPICAL BANDAGE 5 X 9 " Diagnostic Agents Adrenocortical Insufficiency ACTHAR H.P. T3 PA Diabetes Mellitus ACCU-CHEK AVIVA T1 QL (120 EA per 30 days) ACCU-CHEK AVIVA PLUS TEST STRP T1 QL (120 EA per 30 days) ACCU-CHEK SMARTVIEW TEST STRIP T1 QL (120 EA per 30 days) Drug Hypersensitivity PRE-PEN T2 Ketones KETOSTIX T1 QL (100 QY per 100 DYs) Respiratory Function ARIDOL BRONCHIAL CHALLENGE T2 Electrolytic, Caloric, And Water Balance Alkalinizing Agents potassium citrate T1 QL (120 QY per 30 DYs) Ammonia Detoxicants ENULOSE T1 lactulose oral solution 10 gram/15 ml T1 Caloric Agents GLYTACTIN 10 PE BETTERMILK T3 PA PKU 2 T3 PA PKU TRIO T3 PA Carbonic Anhydrase Inhibitors acetazolamide T1 Diuretics, Miscellaneous theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1

46 Drug Tier Notes theophylline oral tablet extended release 24 hr T1 Irrigating sodium chloride irrigation T1 Loop Diuretics bumetanide oral T1 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 T1 mg/ml) furosemide oral tablet T1 torsemide oral T1 Phosphate-Removing Agents AURYXIA T3 PA calcium acetate oral capsule T1 calcium acetate oral tablet 667 mg T1 FOSRENOL ORAL TABLET,CHEWABLE T3 PA PHOSLYRA T2 AL (Max 12 Years) RENVELA T3 PA VELPHORO T3 PA Potassium-Removing Agents SODIUM POLYSTYRENE (SORB FREE) T1 QL (240 QY per 30 DYs) sodium polystyrene sulfonate oral powder T1 VELTASSA T2 Potassium-Sparing Diuretics spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 Replacement Preparations ATABEX EC T2 QL (30 QY per 30 DYs) BAL-CARE DHA T1 QL (60 QY per 30 DYs) calcium gluconate oral tablet 45 mg (500 mg) T1 FOCALGIN-B T1 QL (60 QY per 30 DYs) FOLBECAL T1 QL (30 QY per 30 DYs)

47 Drug Tier Notes INATAL ULTRA T1 QL (30 QY per 30 DYs) KLOR-CON M15 T2 L-METHYLFOLATE PNV DHA T1 MACNATAL CN DHA T1 QL (30 QY per 30 DYs) MARNATAL-F T2 QL (30 QY per 30 DYs) MYNATAL ORAL CAPSULE T2 QL (30 QY per 30 DYs) MYNATAL-Z T1 QL (30 QY per 30 DYs) NATALVIRT CA T1 QL (60 QY per 30 DYs) NATALVIT T2 QL (30 QY per 30 DYs) NATELLE ONE T1 QL (30 QY per 30 DYs) NEWGEN T1 QL (30 EA per 30 days) OB COMPLETE ONE T2 QL (30 QY per 30 DYs) OB COMPLETE ORAL TABLET,CHEWABLE T2 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) O-CAL FA T2 QL (30 QY per 30 DYs) O-CAL PRENATAL T2 QL (30 QY per 30 DYs) ONE A DAY WOMEN'S PRENATAL DHA T1 QL (60 QY per 30 DYs) PERRY PRENATAL T2 QL (30 QY per 30 DYs) PNV 29-1 T1 PNV-OMEGA T1 QL (30 QY per 30 DYs) potassium chloride oral capsule, extended release T1 potassium chloride oral liquid T1 AL (Max 12 Years) potassium chloride oral tablet extended release T1 potassium chloride oral tablet,er particles/crystals T1 PR NATAL 430 T1 QL (60 QY per 30 DYs) PR NATAL 430 EC T1 QL (60 QY per 30 DYs) PRENAISSANCE 90 DHA T1 QL (60 EA per 30 days) PRENATAL FORMULA ORAL TABLET 9 MG T1 QL (30 QY per 30 DYs) IRON- 267 MCG PRENATAL LOW IRON T1 QL (30 QY per 30 DYs) PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs)

48 Drug Tier Notes prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PROTECT NATAL T2 QL (60 QY per 30 DYs) sodium chloride inhalation solution for T1 nebulization 0.9 %, 3 %, 7 % TARON-BC T1 QL (90 QY per 30 DYs) TRIADVANCE T1 TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VENATAL-FA T1 QL (30 QY per 30 DYs) VINATE AZ T1 QL (30 QY per 30 DYs) VINATE II T1 VINATE ONE T1 QL (30 QY per 30 DYs) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VOL-NATE T1 ZATEAN-CH T1 ZINGIBER T1 QL (60 QY per 30 DYs) Thiazide Diuretics benazepril-hydrochlorothiazide T1 bisoprolol-hydrochlorothiazide T1 candesartan-hydrochlorothiazid T3 ST chlorothiazide T1 DIURIL T2 AL (Max 12 Years) enalapril-hydrochlorothiazide T1 hydrochlorothiazide T1 irbesartan-hydrochlorothiazide T1 QL (30 EA per 30 days) lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 QL (30 QY per 30 DYs) methyldopa-hydrochlorothiazide T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5- T1 25 mg triamterene-hydrochlorothiazid oral tablet T1 49 Drug Tier Notes valsartan-hydrochlorothiazide T1 QL (30 EA per 30 days) Thiazide-Like Diuretics atenolol-chlorthalidone T1 chlorthalidone oral tablet 100 mg T1 QL (30 QY per 30 DYs) chlorthalidone oral tablet 25 mg, 50 mg T1 metolazone T1 Uricosuric Agents probenecid T1 Enzymes Enzymes PULMOZYME T3 PA Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) brimonidine T1 Antiallergic Agents azelastine nasal aerosol,spray T1 QL (30 QY per 30 DYs) azelastine ophthalmic T1 cromolyn ophthalmic T1 epinastine T3 ST olopatadine ophthalmic T3 ST Antibacterials (Eent) bacitracin ophthalmic T1 bacitracin-polymyxin b ophthalmic T1 BLEPHAMIDE T2 BLEPHAMIDE S.O.P. T2 CIPRODEX T3 ST; QL (7.5 QY per 30 DYs) ciprofloxacin hcl ophthalmic T1 doxycycline hyclate oral tablet 20 mg T1 QL (60 EA per 30 days) erythromycin ophthalmic T1 gentamicin ophthalmic T1 neomycin-bacitracin-poly-hc T1 neomycin-polymyxin b-dexameth T1

50 Drug Tier Notes neomycin-polymyxin-gramicidin T1 neomycin-polymyxin-hc T1 NEO-POLYCIN T1 ofloxacin ophthalmic T1 ofloxacin otic T1 polymyxin b sulf-trimethoprim T1 sulfacetamide sodium ophthalmic T1 sulfacetamide-prednisolone T1 TOBRADEX OPHTHALMIC OINTMENT T2 tobramycin T1 tobramycin-dexamethasone T1 ZYLET T3 PA Antivirals (Eent) trifluridine T1 ZIRGAN T2 Beta-Adrenergic Blocking Agents (Eent) betaxolol ophthalmic T1 carteolol T1 dorzolamide-timolol T1 levobunolol T1 metipranolol T1 timolol maleate ophthalmic drops T1 Carbonic Anhydrase Inhibitors (Eent) acetazolamide T1 dorzolamide T1 dorzolamide-timolol T1 methazolamide oral T1 (Eent) CIPRODEX T3 ST; QL (7.5 QY per 30 DYs) dexamethasone sodium phosphate ophthalmic T1 DUREZOL T3 ST; QL (5 QY per 30 DYs) flunisolide nasal spray,non-aerosol 25 mcg (0.025 T1 QL (25 QY per 30 DYs) %)

51 Drug Tier Notes fluorometholone T1 fluticasone nasal T1 QL (16 QY per 30 DYs) hydrocortisone-acetic acid T1 neomycin-bacitracin-poly-hc T1 neomycin-polymyxin b-dexameth T1 neomycin-polymyxin-hc ophthalmic T1 PRED MILD T2 prednisolone acetate T1 prednisolone sodium phosphate ophthalmic T1 TOBRADEX OPHTHALMIC OINTMENT T2 tobramycin-dexamethasone T1 ZYLET T3 PA Eent Anti-Infectives, Miscellaneous acetic acid otic T1 chlorhexidine gluconate mucous membrane T1 hydrocortisone-acetic acid T1 Eent Drugs, Miscellaneous IOPIDINE OPHTHALMIC DROPPERETTE T2 Eent Nonsteroidal Anti-Inflam. Agents diclofenac sodium ophthalmic T1 flurbiprofen sodium T1 ketorolac ophthalmic T1 Local Anesthetics (Eent) antipyrine-benzocaine otic drops 5.4-1.4 % T1 fluorescein-benoxinate T1 lidocaine hcl mucous membrane jelly T1 LIDOCAINE VISCOUS T1 proparacaine T1 Miotics pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % T1 PILOPINE HS T3 PA Mydriatics

52 Drug Tier Notes atropine ophthalmic ointment T1 ATROPINE-CARE T1 cyclopentolate T1 HOMATROPAIRE T1 ISOPTO HOMATROPINE OPHTHALMIC T2 DROPS 2 % PAREMYD T2 tropicamide ophthalmic T1 Prostaglandin Analogs latanoprost T1 travoprost (benzalkonium) T3 ST Vasoconstrictors naphazoline T1 Gastrointestinal Drugs 5-Ht3 Receptor Antagonists granisetron hcl oral T3 PA ondansetron hcl oral solution T3 PA ondansetron hcl oral tablet 4 mg T1 QL (180 EA per 30 days) ondansetron hcl oral tablet 8 mg T1 QL (90 EA per 30 days) ondansetron oral tablet,disintegrating 4 mg T1 QL (180 EA per 30 days) ondansetron oral tablet,disintegrating 8 mg T1 QL (90 EA per 30 days) Antidiarrhea Agents diphenoxylate-atropine T1 Antiemetics, Miscellaneous CESAMET T3 PA dronabinol T3 PA Antihistamines (Gi Drugs) meclizine oral tablet 12.5 mg, 25 mg T1 prochlorperazine T1 prochlorperazine maleate oral T1 TIGAN INTRAMUSCULAR T3 PA Anti-Inflammatory Agents (Gi Drugs)

53 Drug Tier Notes alosetron T3 PA APRISO T3 PA ASACOL HD T2 QL (180 QY per 30 DYs) balsalazide T1 QL (270 QY per 30 DYs) CANASA T2 QL (30 QY per 30 DYs) DELZICOL ORAL CAPSULE,DELAYED T2 QL (180 QY per 30 DYs) RELEASE(DR/EC) LIALDA T2 QL (120 QY per 30 DYs) LOTRONEX ORAL TABLET 1 MG T3 PA mesalamine rectal T1 QL (1800 QY per 30 DYs) PENTASA ORAL CAPSULE, EXTENDED T2 QL (360 EA per 30 days) RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED T2 QL (240 QY per 30 DYs) RELEASE 500 MG sulfasalazine T1 Cathartics And Laxatives AMITIZA T3 PA ATABEX EC T2 QL (30 QY per 30 DYs) CITRANATAL HARMONY T1 QL (30 QY per 30 DYs) COLYTE WITH FLAVOR PACKS ORAL T2 RECON SOLN 227.1-21.5-6.36 GRAM FOLIVANE-PRX DHA NF T2 QL (30 QY per 30 DYs) INATAL ULTRA T1 QL (30 QY per 30 DYs) MACNATAL CN DHA T1 QL (30 QY per 30 DYs) MOVIPREP T2 OBSTETRIX EC T2 QL (60 QY per 30 DYs) OBTREX T2 peg 3350-electrolytes T1 PEG-3350 WITH FLAVOR PACKS T1 polyethylene glycol 3350 oral T1 PRENAISSANCE 90 DHA T1 QL (60 EA per 30 days) PREPOPIK T2 PREQUE 10 T2 SUPREP BOWEL PREP KIT T2

54 Drug Tier Notes TRICARE PRENATAL DHA ONE T2 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) VIRT-SELECT T1 QL (30 QY per 30 DYs) ZATEAN-CH T1 Cholelitholytic Agents ursodiol oral capsule T1 ursodiol oral tablet 250 mg T1 Digestants CREON ORAL CAPSULE,DELAYED T2 QL (150 QY per 30 DYs) RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT ZENPEP T2 QL (150 QY per 30 DYs) Gi Drugs, Miscellaneous HUMIRA PEN T3 PA HUMIRA PEN PSORIASIS-UVEITIS T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T3 PA MG/0.4 ML, 40 MG/0.8 ML LINZESS T3 PA MOVANTIK T3 PA Histamine H2-Antagonists cimetidine T1 cimetidine hcl oral T1 famotidine oral suspension T1 famotidine oral tablet 20 mg, 40 mg T1 ranitidine hcl oral capsule T1 ranitidine hcl oral syrup T1 ranitidine hcl oral tablet 150 mg, 300 mg T1 Neurokinin-1 Receptor Antagonists aprepitant T3 PA EMEND ORAL SUSPENSION FOR T3 PA RECONSTITUTION Prokinetic Agents metoclopramide hcl oral solution T1

55 Drug Tier Notes metoclopramide hcl oral tablet T1 Prostaglandins diclofenac-misoprostol T1 misoprostol T1 Protectants CARAFATE ORAL SUSPENSION T2 AL (Max 12 Years) sucralfate oral tablet T1 Proton-Pump Inhibitors lansoprazole oral capsule,delayed release(dr/ec) T3 ST omeprazole oral capsule,delayed release(dr/ec) T1 pantoprazole oral T1 PREVACID SOLUTAB T2 AL (Max 12 Years) PROTONIX ORAL GRANULES DR FOR SUSP T3 PA IN PACKET rabeprazole T3 ST Gold Compounds Gold Compounds RIDAURA T2 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET T2 EXJADE T3 PA JADENU T3 PA Hormones And Synthetic Substitutes Adrenals ADVAIR DISKUS T2 QL (60 EA per 30 days) ADVAIR HFA T3 PA ARNUITY ELLIPTA T2 QL (60 EA per 30 days) ASMANEX HFA T2 QL (26 GM per 30 days) ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs) BREO ELLIPTA T3 PA inhalation suspension for nebulization T1 QL (120 QY per 30 DYs) 0.25 mg/2 ml 56 Drug Tier Notes budesonide inhalation suspension for nebulization T1 QL (240 QY per 30 DYs) 0.5 mg/2 ml budesonide oral T3 PA dexamethasone T1 DULERA T2 QL (13 QY per 30 DYs) EMFLAZA T3 PA FLOVENT DISKUS T2 QL (120 QY per 30 DYs) FLOVENT HFA INHALATION HFA AEROSOL T2 QL (24 QY per 30 DYs) INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL T2 QL (21.2 QY per 30 DYs) INHALER 44 MCG/ACTUATION fludrocortisone T1 hydrocortisone oral T1 MEDROL ORAL TABLET 2 MG T2 methylprednisolone T1 prednisolone oral solution 15 mg/5 ml T1 prednisolone sodium phosphate oral solution 15 T1 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL T1 prednisone oral T1 PULMICORT FLEXHALER T2 QL (2 EA per 30 days) PULMICORT INHALATION SUSPENSION T2 QL (120 QY per 30 DYs) FOR NEBULIZATION 1 MG/2 ML QVAR T2 QL (17.4 QY per 30 DYs) SYMBICORT T2 QL (10.2 QY per 30 DYs) UCERIS ORAL T3 PA Alpha-Glucosidase Inhibitors acarbose T1 Androgens ANDRODERM T3 PA ANDROGEL TRANSDERMAL GEL IN T3 PA PACKET 1 % (50 MG/5 GRAM) COVARYX T2 COVARYX H.S. T2

57 Drug Tier Notes oxandrolone T3 PA testosterone cypionate T1 QL (5 QY per 30 DYs) testosterone enanthate T1 QL (5 ML per 30 days) testosterone transdermal gel T3 PA testosterone transdermal gel in metered-dose T3 PA pump testosterone transdermal gel in packet 1 % (25 T3 PA mg/2.5gram) Antidiabetic Agents, Miscellaneous WELCHOL T3 PA Antithyroid Agents methimazole oral tablet 10 mg, 5 mg T1 propylthiouracil T1 Biguanides glipizide-metformin T1 glyburide-metformin T1 INVOKAMET T3 ST JANUMET T3 ST JANUMET XR T3 ST metformin oral tablet T1 metformin oral tablet extended release 24 hr T1 SYNJARDY T3 ST SYNJARDY XR T3 ST Contraceptives AMETHIA T1 BEYAZ T2 CAMRESE LO T1 CHATEAL T1 CRYSELLE (28) T1 CYCLAFEM 1/35 (28) T1 ELLA T2 FALMINA (28) T1 GIANVI (28) T1

58 Drug Tier Notes JOLESSA T1 JUNEL FE 1.5/30 (28) T1 JUNEL FE 1/20 (28) T1 JUNEL FE 24 T1 KELNOR 1/35 (28) T1 LEENA 28 T1 QL (30 QY per 30 DYs) levonorgestrel oral tablet 0.75 mg T1 QL (2 QY per 30 DYs) levonorgestrel-ethinyl estrad oral tablet 90-20 T1 mcg LO LOESTRIN FE T2 MIBELAS 24 FE T1 MICROGESTIN 1.5/30 (21) T1 QL (30 QY per 30 DYs) MICROGESTIN 1/20 (21) T1 QL (30 QY per 30 DYs) MONONESSA (28) T1 QL (30 QY per 30 DYs) MYZILRA T1 QL (30 QY per 30 DYs) NATAZIA T2 NECON 10/11 (28) T1 QL (30 QY per 30 DYs) NEXT CHOICE ONE DOSE T1 NORA-BE T1 QL (30 QY per 30 DYs) noreth-ethinyl estradiol-iron oral tablet,chewable T1 0.8mg-25mcg(24) and 75 mg (4) norethindrone-e.estradiol-iron oral T1 tablet,chewable norgestimate-ethinyl estradiol oral tablet T1 0.18/0.215/0.25 mg-25 mcg NORINYL 1+50 (28) T1 NORTREL 0.5/35 (28) T1 NORTREL 7/7/7 (28) T1 NUVARING T2 OGESTREL (28) T1 PHILITH T1 QUARTETTE T2 RECLIPSEN (28) T1 SAFYRAL T2

59 Drug Tier Notes SYEDA T1 TRI-LEGEST FE T1 TRI-SPRINTEC (28) T1 VELIVET TRIPHASIC REGIMEN (28) T1 VIORELE (28) T1 XULANE T1 ZENCHENT FE T1 ZOVIA 1/50E (28) T1 Dipeptidyl Peptidase-4(Dpp-4) Inhibitors GLYXAMBI T3 PA JANUMET T3 ST JANUMET XR T3 ST JANUVIA T3 ST Estrogen Agonist-Antagonists raloxifene T1 Estrogens ALORA TRANSDERMAL PATCH T1 SEMIWEEKLY 0.025 MG/24 HR CENESTIN T2 CLIMARA PRO T2 QL (4 QY per 28 DYs) COMBIPATCH T2 QL (8 QY per 28 DYs) COVARYX T2 COVARYX H.S. T2 DEPO-ESTRADIOL T1 QL (10 QY per 90 DYs) ENJUVIA T3 PA ESTRACE VAGINAL T2 estradiol oral T1 estradiol transdermal patch semiweekly 0.0375 T1 QL (24 EA per 84 days) mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly T1 QL (4 QY per 28 DYs) estradiol valerate T1 QL (10 QY per 80 DYs) ESTRASORB T3 PA ESTRING T2 QL (1 EA per 30 days) 60 Drug Tier Notes ESTROGEL T2 QL (50 GM per 30 days) MENEST ORAL TABLET 0.3 MG T3 PA MENOSTAR T2 QL (4 QY per 28 DYs) norethindrone ac-eth estradiol oral tablet 1-5 mg- T1 mcg PREMARIN ORAL T2 PREMARIN VAGINAL T2 PREMPHASE T2 PREMPRO T2 YUVAFEM T1 Glycogenolytic Agents GLUCAGON EMERGENCY KIT (HUMAN) T2 Gonadotropins ELIGARD T3 PA ELIGARD (3 MONTH) T3 PA ELIGARD (4 MONTH) T3 PA ELIGARD (6 MONTH) T3 PA leuprolide T3 PA LUPRON DEPOT-PED T3 PA LUPRON DEPOT-PED (3 MONTH) T3 PA SYNAREL T3 PA Incretin Mimetics TANZEUM T3 ST; QL (12 EA per 90 days) VICTOZA 2-PAK T3 ST; QL (27 ML per 90 days) VICTOZA 3-PAK T3 ST; QL (27 ML per 90 days) Insulins APIDRA T2 APIDRA SOLOSTAR T2 BASAGLAR KWIKPEN T2 HUMALOG T2 HUMALOG KWIKPEN SUBCUTANEOUS T2 INSULIN PEN 100 UNIT/ML HUMALOG MIX 50-50 T2

61 Drug Tier Notes HUMALOG MIX 50-50 KWIKPEN T2 HUMALOG MIX 75-25 T2 HUMALOG MIX 75-25 KWIKPEN T2 HUMULIN 70/30 T2 HUMULIN 70/30 PEN T2 HUMULIN N T2 HUMULIN N PEN T2 HUMULIN R U-100 T2 HUMULIN R U-500 (CONC) KWIKPEN T2 HUMULIN R U-500 (CONCENTRATED) T2 LEVEMIR T3 ST LEVEMIR FLEXTOUCH T3 ST NOVOLIN N T2 NOVOLIN R T2 NOVOLOG T2 NOVOLOG FLEXPEN T2 NOVOLOG MIX 70-30 T2 NOVOLOG MIX 70-30 FLEXPEN T2 NOVOLOG PENFILL T2 Meglitinides nateglinide T1 repaglinide T1 Parathyroid calcitonin (salmon) T1 FORTEO T3 PA Pituitary ACTHAR H.P. T3 PA desmopressin nasal spray,non-aerosol T1 desmopressin oral T1 HUMATROPE T3 PA SEROSTIM SUBCUTANEOUS RECON SOLN 4 T3 PA MG, 5 MG, 6 MG STIMATE T3 PA

62 Drug Tier Notes ZORBTIVE T3 PA Progestins COMBIPATCH T2 QL (8 QY per 28 DYs) CRINONE T2 ENDOMETRIN T3 PA MAKENA T3 PA medroxyprogesterone T1 norethindrone acetate T1 norethindrone ac-eth estradiol oral tablet 1-5 mg- T1 mcg progesterone micronized T1 QL (30 QY per 30 DYs) Sodium-Gluc Cotransport 2 (Sglt2) Inhib GLYXAMBI T3 PA INVOKAMET T3 ST INVOKANA T3 ST JARDIANCE T3 ST SYNJARDY T3 ST SYNJARDY XR T3 ST Somatostatin Agonists octreotide acetate injection solution 1,000 mcg/ml, T3 PA 200 mcg/ml octreotide acetate injection syringe T3 PA SOMATULINE DEPOT T3 PA Sulfonylureas glimepiride T1 glipizide T1 glipizide-metformin T1 glyburide micronized oral tablet 1.5 mg T1 glyburide oral T1 glyburide-metformin T1 Thiazolidinediones pioglitazone T1 QL (30 QY per 30 DYs) Thyroid Agents

63 Drug Tier Notes ARMOUR THYROID ORAL TABLET 120 MG, T2 180 MG, 240 MG, 300 MG levothyroxine oral T1 liothyronine oral T1 NATURE-THROID T2 NP THYROID T1 Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors dutasteride T1 finasteride oral tablet 5 mg T1 QL (30 QY per 30 DYs) Alcohol Deterrents disulfiram T1 naltrexone T1 Antidotes CHEMET T2 FOSRENOL ORAL TABLET,CHEWABLE T3 PA GLUCAGON EMERGENCY KIT (HUMAN) T2 leucovorin calcium oral T1 MEPHYTON T2 naloxone T1 NARCAN NASAL SPRAY,NON-AEROSOL 4 T2 MG/ACTUATION RENVELA T3 PA SODIUM POLYSTYRENE (SORB FREE) T1 QL (240 QY per 30 DYs) sodium polystyrene sulfonate oral powder T1 Antigout Agents allopurinol T1 colchicine oral T1 QL (60 EA per 30 days) INDOCIN ORAL T2 AL (Max 12 Years) INDOCIN RECTAL T1 indomethacin oral capsule T1 naproxen T1 naproxen sodium oral tablet 275 mg, 550 mg T1

64 Drug Tier Notes probenecid T1 ULORIC T3 PA Bone Resorption Inhibitors alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1 calcitonin (salmon) T1 ibandronate oral T1 PROLIA T3 PA raloxifene T1 SKELID T3 PA XGEVA T3 PA Cariostatic Agents DENTA 5000 PLUS T1 FLUOR-A-DAY T2 FLUORIDEX DAILY DEFENSE T1 FLURA-DROPS T1 LUDENT FLUORIDE ORAL T1 TABLET,CHEWABLE 0.25 MG FLUORID (0.55 MG), 0.5 MG FLUORIDE (1.1 MG) MULTIVITAMIN WITH FLUORIDE T1 MULTI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) TABLET,CHEWABLE 1 MG PREVIDENT 5000 BOOSTER PLUS T2 sodium fluoride dental T1 sodium fluoride oral drops T1 sodium fluoride oral tablet,chewable 0.5 mg T1 fluoride (1.1 mg), 1 mg fluoride (2.2 mg) TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Complement Inhibitors FIRAZYR T3 PA Disease-Modifying Antirheumatic Agents ACTEMRA SUBCUTANEOUS T3 PA azathioprine T1 cyclosporine modified oral capsule T1

65 Drug Tier Notes cyclosporine oral capsule T3 PA ENBREL T3 PA ENBREL SURECLICK T3 PA HUMIRA PEN T3 PA HUMIRA PEN PSORIASIS-UVEITIS T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T3 PA MG/0.4 ML, 40 MG/0.8 ML hydroxychloroquine oral T1 leflunomide T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days) methotrexate sodium injection T1 QL (16 ML per 28 days) methotrexate sodium oral T1 RHEUMATREX T2 RIDAURA T2 sulfasalazine T1 TREXALL T3 PA XELJANZ T3 PA XELJANZ XR T3 PA Gonadotropin-Releasing Hormone Antagnts FIRMAGON KIT W DILUENT SYRINGE T3 PA Immunomodulatory Agents ACTEMRA SUBCUTANEOUS T3 PA ACTIMMUNE T3 PA AVONEX (WITH ALBUMIN) T3 PA AVONEX INTRAMUSCULAR PEN INJECTOR T3 PA KIT AVONEX INTRAMUSCULAR SYRINGE KIT T3 PA azathioprine T1 COPAXONE SUBCUTANEOUS SYRINGE 40 T3 PA MG/ML cyclosporine modified oral capsule T1 cyclosporine oral capsule T3 PA ENBREL T3 PA ENBREL SURECLICK T3 PA 66 Drug Tier Notes GILENYA T3 PA GLATOPA T3 PA HUMIRA PEN T3 PA HUMIRA PEN PSORIASIS-UVEITIS T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 20 T3 PA MG/0.4 ML, 40 MG/0.8 ML hydroxychloroquine oral T1 INTRON A INJECTION T3 PA leflunomide T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days) methotrexate sodium injection T1 QL (16 ML per 28 days) methotrexate sodium oral T1 POMALYST T3 PA REVLIMID T3 PA RHEUMATREX T2 RIDAURA T2 sulfasalazine T1 TECFIDERA T3 PA TREXALL T3 PA Immunosuppressive Agents azathioprine T1 CELLCEPT ORAL SUSPENSION FOR T2 AL (Max 12 Years) RECONSTITUTION cyclophosphamide oral capsule T3 PA cyclosporine modified oral capsule T1 cyclosporine oral capsule T3 PA mercaptopurine T1 methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days) methotrexate sodium injection T1 QL (16 ML per 28 days) methotrexate sodium oral T1 mycophenolate mofetil oral capsule T1 mycophenolate mofetil oral tablet T1 mycophenolate sodium T1 PURIXAN T3 PA 67 Drug Tier Notes RAPAMUNE ORAL SOLUTION T3 PA RHEUMATREX T2 sirolimus T3 PA tacrolimus oral T1 TREXALL T3 PA ZORTRESS T3 PA Other Miscellaneous Therapeutic Agents solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days) acetylcysteine solution 200 mg/ml (20 %) T1 AMPYRA T3 PA CARNITOR (SUGAR-FREE) T2 CERDELGA T3 PA levocarnitine (with sugar) T1 ORFADIN T3 PA SENSIPAR T3 PA TYBOST T2 ZAVESCA T3 PA Protective Agents ELMIRON T2 MESNEX ORAL T3 PA Oxytocics Oxytocics methylergonovine oral T1 QL (30 QY per 30 DYs) Pharmaceutical Aids Pharmaceutical Aids KERLIX AMD TOPICAL SPONGE T1 Agents Alpha And Beta Adrenergic Agonist(Respr) epinephrine injection auto-injector T1 QL (6 EA per 365 days) EPIPEN JR 2-PAK T2 REZIRA T3 PA Anticholinergic Agents (Respir.Tract)

68 Drug Tier Notes ATROVENT HFA T2 QL (25.8 QY per 30 DYs) COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) diphenoxylate-atropine T1 ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs) ipratropium-albuterol T1 QL (570 QY per 30 DYs) SPIRIVA RESPIMAT T2 QL (4 GM per 30 days) SPIRIVA WITH HANDIHALER T2 QL (30 QY per 30 DYs) TUDORZA PRESSAIR T2 QL (1 QY per 30 DYs) Antitussives benzonatate oral capsule 100 mg, 200 mg T1 codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years) promethazine-dm T1 AL (Min 2 Years) REZIRA T3 PA (Cftr) Correctors ORKAMBI T3 PA Cystic Fibrosis (Cftr) Potentiators KALYDECO T3 PA ORKAMBI T3 PA First Generation Antihist.(Respir Tract) clemastine oral syrup T1 cyproheptadine T1 promethazine oral T1 AL (Min 2 Years) PROMETHAZINE VC T1 AL (Min 2 Years) promethazine-dm T1 AL (Min 2 Years) Leukotriene Modifiers montelukast oral granules in packet T1 AL (Max 2 Years) montelukast oral tablet T1 montelukast oral tablet,chewable T1 Mast-Cell Stabilizers cromolyn inhalation T1 cromolyn ophthalmic T1 cromolyn oral T1 69 Drug Tier Notes Mucolytic Agents acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days) acetylcysteine solution 200 mg/ml (20 %) T1 PULMOZYME T3 PA Nasal Preparations (Steroids) flunisolide nasal spray,non-aerosol 25 mcg (0.025 T1 QL (25 QY per 30 DYs) %) fluticasone nasal T1 QL (16 QY per 30 DYs) Orally Inhaled Preparations (Steroids) ADVAIR DISKUS T2 QL (60 EA per 30 days) ADVAIR HFA T3 PA ARNUITY ELLIPTA T2 QL (60 EA per 30 days) ASMANEX HFA T2 QL (26 GM per 30 days) ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs) BREO ELLIPTA T3 PA budesonide inhalation suspension for nebulization T1 QL (120 QY per 30 DYs) 0.25 mg/2 ml budesonide inhalation suspension for nebulization T1 QL (240 QY per 30 DYs) 0.5 mg/2 ml DULERA T2 QL (13 QY per 30 DYs) FLOVENT DISKUS T2 QL (120 QY per 30 DYs) FLOVENT HFA INHALATION HFA AEROSOL T2 QL (24 QY per 30 DYs) INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL T2 QL (21.2 QY per 30 DYs) INHALER 44 MCG/ACTUATION PULMICORT FLEXHALER T2 QL (2 EA per 30 days) PULMICORT INHALATION SUSPENSION T2 QL (120 QY per 30 DYs) FOR NEBULIZATION 1 MG/2 ML QVAR T2 QL (17.4 QY per 30 DYs) SYMBICORT T2 QL (10.2 QY per 30 DYs) Phosphodiesterase Type 4 Inhibitors DALIRESP T3 PA Second Generation Antihist(Respir Tract) desloratadine oral tablet T3 PA 70 Drug Tier Notes Select.Beta-2-Adrenergic Agonist(Respir) ADVAIR DISKUS T2 QL (60 EA per 30 days) ADVAIR HFA T3 PA albuterol sulfate inhalation solution for T1 nebulization 1.25 mg/3 ml, 2.5 mg/0.5 ml albuterol sulfate inhalation solution for T1 QL (525 QY per 30 DYs) nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for T1 QL (100 QY per 30 DYs) nebulization 5 mg/ml albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years) albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs) BREO ELLIPTA T3 PA COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs) DULERA T2 QL (13 QY per 30 DYs) ipratropium-albuterol T1 QL (570 QY per 30 DYs) levalbuterol hcl inhalation solution for T3 ST; QL (240 QY per 30 DYs) nebulization 0.31 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (360 QY per 30 DYs) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for T3 ST; QL (150 QY per 30 DYs) nebulization 1.25 mg/0.5 ml levalbuterol tartrate T3 ST; QL (30 GM per 30 days) PROAIR HFA T2 QL (17 GM per 30 days) PROVENTIL HFA T3 ST; QL (13.4 GM per 30 days) SEREVENT DISKUS T3 PA SYMBICORT T2 QL (10.2 QY per 30 DYs) terbutaline oral T1 VENTOLIN HFA T2 QL (36 QY per 30 DYs) Vasodilating Agents (Respiratory Tract) ADCIRCA T3 PA ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 T3 PA MG LETAIRIS T3 PA OPSUMIT T3 PA

71 Drug Tier Notes REMODULIN T3 PA sildenafil oral T3 PA TYVASO REFILL KIT T3 PA TYVASO STARTER KIT T3 PA UPTRAVI T3 PA VENTAVIS T3 PA Xanthine Derivatives theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Skin And Mucous Membrane Agents Antibacterials (Skin, Mucous Membrane) CLEOCIN VAGINAL SUPPOSITORY T2 clindamycin phosphate topical gel T1 clindamycin phosphate topical T1 clindamycin phosphate topical solution T1 clindamycin phosphate topical swab T1 clindamycin phosphate vaginal T1 erythromycin with ethanol topical gel T1 erythromycin with ethanol topical solution T1 metronidazole topical T1 QL (45 QY per 30 DYs) metronidazole topical gel 0.75 % T1 QL (45 QY per 30 DYs) metronidazole topical gel 1 % T3 ST; QL (60 QY per 30 DYs) metronidazole topical gel with pump T3 ST; QL (60 QY per 30 DYs) metronidazole topical lotion T1 QL (59 QY per 30 DYs) metronidazole vaginal T1 mupirocin T1 NORITATE T3 PA Anti-Inflammatory Agents (Skin, Mucous) ANUCORT-HC T1 betamethasone dipropionate topical lotion T1 QL (120 QY per 30 DYs) betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs) betamethasone valerate topical cream T1 QL (240 QY per 30 DYs) 72 Drug Tier Notes betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs) betamethasone, augmented topical cream T1 QL (120 QY per 30 DYs) betamethasone, augmented topical gel T1 QL (60 QY per 30 DYs) betamethasone, augmented topical lotion T1 QL (60 QY per 30 DYs) betamethasone, augmented topical ointment T1 QL (60 QY per 30 DYs) clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs) CORTIFOAM T2 desoximetasone topical cream 0.25 % T1 QL (60 QY per 30 DYs) fluocinolone topical cream 0.025 % T1 QL (240 QY per 30 DYs) fluocinonide topical gel T1 QL (240 QY per 30 DYs) fluocinonide topical ointment T1 QL (240 QY per 30 DYs) fluocinonide topical solution T1 QL (240 QY per 30 DYs) fluticasone topical cream T1 QL (60 QY per 30 DYs) halobetasol propionate topical ointment T1 QL (60 QY per 30 DYs) hydrocortisone rectal T1 hydrocortisone topical cream 1 %, 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone topical lotion 1 % T1 hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs) hydrocortisone topical ointment 1 %, 2.5 % T1 QL (240 QY per 30 DYs) mometasone topical cream T1 QL (60 QY per 30 DYs) mometasone topical ointment T1 QL (60 QY per 30 DYs) mometasone topical solution T1 QL (240 QY per 30 DYs) PROCTOFOAM HC T2 PROCTOZONE-HC T1 triamcinolone acetonide dental T1 triamcinolone acetonide topical cream 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs) triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs) triamcinolone acetonide topical ointment 0.025 %, T1 QL (240 QY per 30 DYs) 0.5 % triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 days) TRIANEX T1 QL (240 QY per 30 DYs) Antipruritics And Local Anesthetics 73 Drug Tier Notes lidocaine topical adhesive patch,medicated T1 lidocaine topical ointment T1 QL (60 QY per 30 DYs) lidocaine-prilocaine topical cream T1 phenazopyridine oral tablet 100 mg, 200 mg T1 PROCTOFOAM HC T2 Antivirals (Skin And Mucous Membrane) acyclovir topical T3 PA DENAVIR T3 PA ZOVIRAX TOPICAL CREAM T3 PA Astringents aluminum chloride T1 QL (75 ML per 30 days) Azoles (Skin And Mucous Membrane) clotrimazole mucous membrane T1 clotrimazole topical cream T1 QL (180 QY per 30 DYs) clotrimazole topical solution T1 clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs) econazole topical T1 QL (340 QY per 30 DYs) GYNAZOLE-1 T1 ketoconazole topical cream T1 ketoconazole topical T1 KETODAN T3 PA MICONAZOLE-3 VAGINAL SUPPOSITORY T1 terconazole T1 XOLEGEL T3 PA Basic And lactic acid T1 Cell Stimulants And Proliferants tretinoin topical cream T1 QL (20 QY per 30 DYs); AL (Max 30 Years) tretinoin topical gel 0.01 %, 0.025 % T1 QL (15 QY per 30 DYs); AL (Max 30 Years) Hydroxypyridones (Skin, Mucous Membrane) ciclopirox topical cream T1 QL (90 QY per 30 DYs)

74 Drug Tier Notes ciclopirox topical solution T1 QL (6.6 ML per 30 days) Keratolytic Agents benzoyl peroxide topical cleanser 4 % T1 sulfacetamide sodium-sulfur topical cleanser 10-5 T3 PA % (w/w) urea topical cream 40 % T1 QL (198.6 GM per 30 days) Local Anti-Infectives, Miscellaneous ALCOHOL PREP PADS T1 AVC VAGINAL T2 KERLIX AMD TOPICAL SPONGE T1 RELAGARD T1 selenium sulfide topical lotion T1 silver sulfadiazine T1 sulfacetamide sodium (acne) T3 PA sulfacetamide sodium topical cleanser, gel T3 PA sulfacetamide sodium-sulfur topical cleanser 10-5 T3 PA % (w/w) Pigmenting Agents methoxsalen oral T1 QL (12 EA per 28 days) Polyenes (Skin And Mucous Membrane) nystatin topical cream T1 QL (120 QY per 30 DYs) nystatin topical ointment T1 QL (120 QY per 30 DYs) nystatin topical powder T1 QL (1280 QY per 30 DYs) nystatin-triamcinolone T1 QL (480 QY per 30 DYs) Scabicides And Pediculicides malathion T3 PA permethrin topical cream T1 spinosad T3 PA Skin And Mucous Membrane Agents, Misc. acitretin T3 PA adapalene topical cream T3 ST; QL (45 QY per 30 DYs); AL (Max 30 Years) adapalene topical gel 0.1 % T3 ST; QL (45 QY per 30 DYs); AL (Max 30 Years) 75 Drug Tier Notes adapalene topical gel 0.3 % T3 PA adapalene topical gel with pump T3 PA adapalene topical lotion T3 PA AZELEX T3 PA calcipotriene topical T3 ST; QL (60 QY per 30 DYs) calcitriol topical T3 ST; QL (100 QY per 30 DYs) CLARAVIS T3 PA CONDYLOX TOPICAL GEL T2 diclofenac sodium topical gel 1 % T1 QL (100 GM per 30 days) FINACEA TOPICAL FOAM T3 PA fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs) imiquimod T1 AL (Min 12 Years) podofilox T1 SANTYL T2 QL (30 GM per 30 days) tacrolimus topical ointment 0.03 % T3 ST; QL (30 GM per 30 days) tacrolimus topical ointment 0.1 % T3 ST; QL (30 GM per 30 days); AL (Min 2 Years) Smooth Muscle Relaxants Antimuscarinics GELNIQUE TRANSDERMAL GEL IN T3 PA METERED-DOSE PUMP 100 MG/GRAM (10 %) GELNIQUE TRANSDERMAL GEL IN PACKET T3 PA oxybutynin chloride oral T1 tolterodine oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days) tolterodine oral tablet T3 ST; QL (60 EA per 30 days) trospium T3 ST; QL (30 EA per 30 days) Respiratory Smooth Muscle Relaxants theophylline oral solution T1 theophylline oral tablet extended release 12 hr T1 theophylline oral tablet extended release 24 hr T1 Vitamins Multivitamin Preparations

76 Drug Tier Notes ATABEX EC T2 QL (30 QY per 30 DYs) BAL-CARE DHA T1 QL (60 QY per 30 DYs) BAL-CARE DHA ESSENTIAL T2 QL (60 QY per 30 DYs) CAVAN-EC SOD DHA T1 QL (60 QY per 30 DYs) CENTRUM SPECIALIST PRENATAL T2 QL (60 QY per 30 DYs) CITRANATAL HARMONY T1 QL (30 QY per 30 DYs) CLASSIC PRENATAL T2 COMPLETENATE T1 QL (30 QY per 30 DYs) DUET DHA BALANCED ORAL COMBO T2 QL (60 QY per 30 DYs) PACK 26 MG IRON- 1 MG-278 MG DUET DHA EC-OM 3 T2 QL (60 QY per 30 DYs) DUET DHA WITH OMEGA-3 T2 QL (60 QY per 30 DYs) ELITE-OB T1 QL (60 QY per 30 DYs) ELITE-OB 400 T1 QL (30 QY per 30 DYs) EXTRA-VIRT PLUS DHA T1 FOCALGIN-B T1 QL (60 QY per 30 DYs) FOLBECAL T1 QL (30 QY per 30 DYs) FOLIVANE-EC CALCIUM DHA NF T1 QL (60 EA per 30 days) FOLIVANE-OB T1 QL (30 QY per 30 DYs) FOLIVANE-PRX DHA NF T2 QL (30 QY per 30 DYs) HEMENATAL OB T1 QL (30 QY per 30 DYs) HEMENATAL OB + DHA T1 QL (60 QY per 30 DYs) INATAL ULTRA T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs) L-METHYLFOLATE PNV DHA T1 MACNATAL CN DHA T1 QL (30 QY per 30 DYs) MARNATAL-F T2 QL (30 QY per 30 DYs) MINI PRENATAL T2 QL (30 QY per 30 DYs) MULTIVITAMIN WITH FLUORIDE T1 MULTI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) TABLET,CHEWABLE 1 MG MYNATAL ORAL CAPSULE T2 QL (30 QY per 30 DYs) MYNATAL ORAL TABLET T1 QL (30 QY per 30 DYs) MYNATAL-Z T1 QL (30 QY per 30 DYs) 77 Drug Tier Notes MYNATE 90 PLUS T1 QL (30 QY per 30 DYs) NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NATAFORT (NEW FORMULA 2011) T2 QL (30 QY per 30 DYs) NATALVIRT CA T1 QL (60 QY per 30 DYs) NATALVIT T2 QL (30 QY per 30 DYs) NATELLE ONE T1 QL (30 QY per 30 DYs) NEWGEN T1 QL (30 EA per 30 days) OB COMPLETE 400 T2 QL (30 QY per 30 DYs) OB COMPLETE ONE T2 QL (30 QY per 30 DYs) OB COMPLETE ORAL TABLET,CHEWABLE T2 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) OBSTETRIX DHA T1 QL (60 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) OBTREX T2 O-CAL FA T2 QL (30 QY per 30 DYs) O-CAL PRENATAL T2 QL (30 QY per 30 DYs) ONE A DAY WOMEN'S PRENATAL DHA T1 QL (60 QY per 30 DYs) PAIRE OB PLUS DHA T1 PERRY PRENATAL T2 QL (30 QY per 30 DYs) PNV 29-1 T1 PNV FOLIC ACID + IRON T1 PNV-OMEGA T1 QL (30 QY per 30 DYs) PR NATAL 430 T1 QL (60 QY per 30 DYs) PR NATAL 430 EC T1 QL (60 QY per 30 DYs) PRENA1 T2 QL (30 QY per 30 DYs) PRENA1 CHEW (QUATREFOLIC) T1 QL (30 QY per 30 DYs) PRENA1 PLUS T1 QL (60 EA per 30 days) PRENAISSANCE 90 DHA T1 QL (60 EA per 30 days) PRENAISSANCE DHA HARMONY T1 QL (60 EA per 30 days) PRENATA T2 QL (30 QY per 30 DYs) PRENATAL 19 T1 QL (30 QY per 30 DYs) PRENATAL 19 (WITH DOCUSATE) T1 QL (30 QY per 30 DYs) PRENATAL DHA+COMPLETE PRENATAL T1 QL (60 QY per 30 DYs)

78 Drug Tier Notes PRENATAL FORMULA ORAL TABLET 9 MG T1 QL (30 QY per 30 DYs) IRON- 267 MCG PRENATAL LOW IRON T1 QL (30 QY per 30 DYs) PRENATAL MULTI-DHA ORAL CAPSULE 27 T1 QL (60 QY per 30 DYs) MG IRON-800 MCG-228 MG PRENATAL ORAL TABLET 28 MG IRON- 800 T1 QL (30 QY per 30 DYs) MCG PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN ORAL TABLET T1 QL (30 QY per 30 DYs) PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRENATAL-1 T1 QL (30 QY per 30 DYs) PRENATAL-U T1 QL (30 QY per 30 DYs) PRENATE DHA T2 QL (30 QY per 30 DYs) PRENATE ELITE T2 QL (30 QY per 30 DYs) PRENATE ESSENTIAL T2 QL (30 QY per 30 DYs) PRENATE MINI T2 QL (30 QY per 30 DYs) PREQUE 10 T2 PROTECT NATAL T2 QL (60 QY per 30 DYs) PROTECT PLUS T1 PUREFE OB PLUS T2 QL (30 QY per 30 DYs) RELNATE DHA T1 QL (30 QY per 30 DYs) SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs) SE-TAN DHA T1 QL (30 QY per 30 DYs) STROVITE FORTE T2 STUART PRENATAL PLUS DHA T2 QL (60 QY per 30 DYs) TARON-BC T1 QL (90 QY per 30 DYs) TARON-C DHA T1 QL (30 QY per 30 DYs) THERANATAL COMPLETE T2 QL (60 QY per 30 DYs) TRIADVANCE T1 TRICARE PRENATAL DHA ONE T2 QL (30 QY per 30 DYs) TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs)

79 Drug Tier Notes TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) TRIVEEN-TEN T1 QL (60 QY per 30 DYs) TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VENATAL-FA T1 QL (30 QY per 30 DYs) VIC-FORTE T1 VINACAL B T1 VINATE AZ T1 QL (30 QY per 30 DYs) VINATE CALCIUM T1 QL (30 QY per 30 DYs) VINATE II T1 VINATE M T2 QL (30 QY per 30 DYs) VINATE ONE T1 QL (30 QY per 30 DYs) VINATE PN CARE T1 QL (30 QY per 30 DYs) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VOL-NATE T1 VP-ERA OB PLUS T1 QL (30 QY per 30 DYs) VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 ZATEAN-PN T1 QL (30 QY per 30 DYs) ZINGIBER T1 QL (60 QY per 30 DYs) Vitamin A TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Vitamin B Complex ATABEX EC T2 QL (30 QY per 30 DYs) BAL-CARE DHA T1 QL (60 QY per 30 DYs) BAL-CARE DHA ESSENTIAL T2 QL (60 QY per 30 DYs) CAVAN-EC SOD DHA T1 QL (60 QY per 30 DYs) CENTRUM SPECIALIST PRENATAL T2 QL (60 QY per 30 DYs) CITRANATAL HARMONY T1 QL (30 QY per 30 DYs) CLASSIC PRENATAL T2

80 Drug Tier Notes cyanocobalamin (vitamin b-12) injection T1 QL (1 QY per 30 DYs) DIALYVITE 800 T1 QL (200 QY per 90 DYs) DIALYVITE 800-ULTRA D T2 DIALYVITE ORAL TABLET 100-1 MG T2 DUET DHA BALANCED ORAL COMBO T2 QL (60 QY per 30 DYs) PACK 26 MG IRON- 1 MG-278 MG DUET DHA EC-OM 3 T2 QL (60 QY per 30 DYs) DUET DHA WITH OMEGA-3 T2 QL (60 QY per 30 DYs) ELITE-OB 400 T1 QL (30 QY per 30 DYs) EXTRA-VIRT PLUS DHA T1 FOCALGIN-B T1 QL (60 QY per 30 DYs) FOLBECAL T1 QL (30 QY per 30 DYs) folic acid oral tablet T1 FOLIVANE-EC CALCIUM DHA NF T1 QL (60 EA per 30 days) FOLIVANE-OB T1 QL (30 QY per 30 DYs) FOLIVANE-PRX DHA NF T2 QL (30 QY per 30 DYs) HEMATOGEN FA T1 HEMENATAL OB T1 QL (30 QY per 30 DYs) HEMENATAL OB + DHA T1 QL (60 QY per 30 DYs) INATAL ULTRA T1 QL (30 QY per 30 DYs) KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs) L-METHYLFOLATE PNV DHA T1 MACNATAL CN DHA T1 QL (30 QY per 30 DYs) MARNATAL-F T2 QL (30 QY per 30 DYs) MINI PRENATAL T2 QL (30 QY per 30 DYs) MYNATAL ORAL CAPSULE T2 QL (30 QY per 30 DYs) MYNATAL-Z T1 QL (30 QY per 30 DYs) MYNEPHROCAPS T1 NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs) NATAFORT (NEW FORMULA 2011) T2 QL (30 QY per 30 DYs) NATALVIRT CA T1 QL (60 QY per 30 DYs) NATALVIT T2 QL (30 QY per 30 DYs) NATELLE ONE T1 QL (30 QY per 30 DYs)

81 Drug Tier Notes NEWGEN T1 QL (30 EA per 30 days) OB COMPLETE 400 T2 QL (30 QY per 30 DYs) OB COMPLETE ONE T2 QL (30 QY per 30 DYs) OB COMPLETE ORAL TABLET,CHEWABLE T2 QL (30 QY per 30 DYs) OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs) OBSTETRIX DHA T1 QL (60 QY per 30 DYs) OBSTETRIX EC T2 QL (60 QY per 30 DYs) OBTREX T2 O-CAL FA T2 QL (30 QY per 30 DYs) O-CAL PRENATAL T2 QL (30 QY per 30 DYs) ONE A DAY WOMEN'S PRENATAL DHA T1 QL (60 QY per 30 DYs) PAIRE OB PLUS DHA T1 PERRY PRENATAL T2 QL (30 QY per 30 DYs) PNV 29-1 T1 PNV FOLIC ACID + IRON T1 PNV-OMEGA T1 QL (30 QY per 30 DYs) PR NATAL 430 T1 QL (60 QY per 30 DYs) PR NATAL 430 EC T1 QL (60 QY per 30 DYs) PRENA1 T2 QL (30 QY per 30 DYs) PRENA1 CHEW (QUATREFOLIC) T1 QL (30 QY per 30 DYs) PRENA1 PLUS T1 QL (60 EA per 30 days) PRENAISSANCE 90 DHA T1 QL (60 EA per 30 days) PRENAISSANCE DHA HARMONY T1 QL (60 EA per 30 days) PRENATA T2 QL (30 QY per 30 DYs) PRENATAL 19 T1 QL (30 QY per 30 DYs) PRENATAL 19 (WITH DOCUSATE) T1 QL (30 QY per 30 DYs) PRENATAL DHA+COMPLETE PRENATAL T1 QL (60 QY per 30 DYs) PRENATAL FORMULA ORAL TABLET 9 MG T1 QL (30 QY per 30 DYs) IRON- 267 MCG PRENATAL LOW IRON T1 QL (30 QY per 30 DYs) PRENATAL MULTI-DHA ORAL CAPSULE 27 T1 QL (60 QY per 30 DYs) MG IRON-800 MCG-228 MG PRENATAL ORAL TABLET 28 MG IRON- 800 T1 QL (30 QY per 30 DYs) MCG

82 Drug Tier Notes PRENATAL PLUS T1 QL (30 QY per 30 DYs) PRENATAL PLUS (CALCIUM CARB) T1 PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs) prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs) PRENATAL-1 T1 QL (30 QY per 30 DYs) PRENATE DHA T2 QL (30 QY per 30 DYs) PRENATE ELITE T2 QL (30 QY per 30 DYs) PRENATE ESSENTIAL T2 QL (30 QY per 30 DYs) PRENATE MINI T2 QL (30 QY per 30 DYs) PREQUE 10 T2 PROTECT NATAL T2 QL (60 QY per 30 DYs) PUREFE OB PLUS T2 QL (30 QY per 30 DYs) RELNATE DHA T1 QL (30 QY per 30 DYs) RENA-VITE RX T1 SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs) SE-TAN DHA T1 QL (30 QY per 30 DYs) STROVITE FORTE T2 STUART PRENATAL PLUS DHA T2 QL (60 QY per 30 DYs) TARON-BC T1 QL (90 QY per 30 DYs) TARON-C DHA T1 QL (30 QY per 30 DYs) THERANATAL COMPLETE T2 QL (60 QY per 30 DYs) TRIADVANCE T1 TRICARE PRENATAL DHA ONE T2 QL (30 QY per 30 DYs) TRIGELS-F FORTE T1 TRINATAL GT T1 QL (30 QY per 30 DYs) TRIVEEN-ONE T1 QL (30 QY per 30 DYs) TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs) TRIVEEN-TEN T1 QL (60 QY per 30 DYs) ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs) VENATAL-FA T1 QL (30 QY per 30 DYs) VIC-FORTE T1 VINACAL B T1 VINATE AZ T1 QL (30 QY per 30 DYs)

83 Drug Tier Notes VINATE II T1 VINATE ONE T1 QL (30 QY per 30 DYs) VIRT-SELECT T1 QL (30 QY per 30 DYs) VITAFOL GUMMIES T2 VOL-NATE T1 VP-ERA OB PLUS T1 QL (30 QY per 30 DYs) VP-HEME ONE T1 QL (30 EA per 30 days) ZATEAN-CH T1 ZATEAN-PN T1 QL (30 QY per 30 DYs) ZINGIBER T1 QL (60 QY per 30 DYs) Vitamin C DIALYVITE 800 T1 QL (200 QY per 90 DYs) DIALYVITE 800-ULTRA D T2 DIALYVITE ORAL TABLET 100-1 MG T2 HEMATOGEN FA T1 MYNEPHROCAPS T1 TRIGELS-F FORTE T1 TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML Vitamin D calcitriol oral capsule T1 calcitriol oral solution T3 PA DIALYVITE 800-ULTRA D T2 doxercalciferol oral T3 ST TRI-VITAMIN WITH FLUORIDE ORAL T1 AL (Max 12 Years) DROPS 0.25 MG FLUOR. (0.55 MG)/ML VITAMIN D2 T1 Vitamin K Activity MEPHYTON T2

84 Index

A ALFERON N ...... 7, 11 ASTHMAPACK abacavir ...... 6 alfuzosin ...... 16 CHILDREN'S ...... 45 abacavir-lamivudine- ALINIA ...... 3 ATABEX EC 18, 47, 54, 77, 80 zidovudine ...... 6 ALKERAN ...... 11 atenolol ...... 17, 24, 25, 27 acamprosate ...... 38 allopurinol ...... 64 atenolol-chlorthalidone .. 17, 24, acarbose ...... 57 ALORA ...... 60 25, 27, 31, 50 ACCU-CHEK AVIVA ...... 46 alosetron ...... 54 atorvastatin ...... 29 ACCU-CHEK AVIVA aluminum chloride ...... 74 atovaquone ...... 3 CONTROL SOLN...... 45 amantadine hcl ...... 2, 33 atovaquone-proguanil ...... 3 ACCU-CHEK AVIVA PLUS AMETHIA...... 58 ATRIPLA ...... 5, 6 METER ...... 45 amiodarone ...... 27 atropine ...... 53 ACCU-CHEK AVIVA PLUS AMITIZA ...... 54 ATROPINE-CARE ...... 53 TEST STRP ...... 46 amitriptyline ...... 44 ATROVENT HFA ...... 14, 69 ACCU-CHEK FASTCLIX .. 45 amlodipine ...... 28, 32 AUGMENTIN ...... 2 ACCU-CHEK NANO ...... 45 amlodipine-benazepril ... 23, 24, AURYXIA ...... 47 ACCU-CHEK SMARTVIEW 28, 32 AVC VAGINAL ...... 75 CONTRL SOL ...... 45 amlodipine-valsartan22, 23, 28, AVONEX ...... 66 ACCU-CHEK SMARTVIEW 32 AVONEX (WITH ALBUMIN) TEST STRIP ...... 46 amoxicillin ...... 2 ...... 66 acebutolol ..... 17, 24, 25, 27, 29 amoxicillin-pot clavulanate .... 2 azathioprine ...... 65, 66, 67 acetaminophen-codeine .. 33, 39 ampicillin ...... 2 azelastine ...... 50 acetazolamide ...... 26, 46, 51 AMPYRA ...... 68 AZELEX ...... 76 acetic acid ...... 52 anagrelide ...... 22 azithromycin ...... 8 acetylcysteine ...... 68, 70 anastrozole ...... 11 B acitretin ...... 75 ANDRODERM ...... 57 bacitracin ...... 50 ACTEMRA ...... 65, 66 ANDROGEL ...... 57 bacitracin-polymyxin b ...... 50 ACTHAR H.P...... 46, 62 antipyrine-benzocaine ...... 52 baclofen ...... 15 ACTIMMUNE ...... 66 ANUCORT-HC ...... 72 BAL-CARE DHA ... 18, 47, 77, acyclovir ...... 8, 74 APIDRA ...... 61 80 ADACEL(TDAP APIDRA SOLOSTAR ...... 61 BAL-CARE DHA ADOLESN/ADULT)(PF) 14 aprepitant ...... 55 ESSENTIAL ...... 18, 77, 80 adapalene ...... 75, 76 APRISO ...... 54 balsalazide ...... 54 ADCIRCA ...... 30, 71 APTIOM ...... 34 BANZEL ...... 34 ADEMPAS ...... 32, 71 APTIVUS ...... 6 BARACLUDE ...... 8 ADVAIR DISKUS .. 16, 56, 70, ARANESP (IN BASAGLAR KWIKPEN ..... 61 71 POLYSORBATE) ...... 18 BD SAFETYGLIDE ADVAIR HFA ... 16, 56, 70, 71 ARIDOL BRONCHIAL ALLERGIST TRAY ...... 45 AEROCHAMBER PLUS CHALLENGE ...... 46 BELVIQ ...... 43 FLOW-VU,S MSK...... 45 aripiprazole ...... 37 BELVIQ XR ...... 43 AEROECLIPSE II armodafinil ...... 44 benazepril ...... 23, 24 NEBULIZER ...... 45 ARMOUR THYROID ...... 64 benazepril-hydrochlorothiazide AFINITOR ...... 11 ARNUITY ELLIPTA ..... 56, 70 ...... 23, 24, 31, 49 AFINITOR DISPERZ ...... 11 ASACOL HD ...... 54 benzonatate ...... 69 ALBENZA ...... 2 ASMANEX HFA ...... 56, 70 benzoyl peroxide ...... 75 albuterol sulfate ...... 16, 71 ASMANEX TWISTHALER benztropine ...... 15, 34 ALCOHOL PREP PADS ..... 75 ...... 56, 70 betamethasone dipropionate . 72 ALECENSA ...... 11 aspirin-dipyridamole 22, 32, 43 betamethasone valerate ... 72, 73 alendronate ...... 65 betamethasone, augmented ... 73 85 betaxolol ...... 51 CARAFATE ...... 56 choline,magnesium salicylate bethanechol chloride ...... 16 carbamazepine ...... 34 ...... 43 bexarotene ...... 11 carbidopa ...... 38 ciclopirox ...... 74, 75 BEYAZ...... 58 carbidopa-levodopa ...... 39 cilostazol ...... 22, 31 bicalutamide ...... 11 carbidopa-levodopa- cimetidine ...... 55 BILTRICIDE ...... 3 entacapone ...... 38, 39 cimetidine hcl ...... 55 bisoprolol fumarate . 17, 24, 25, CARNITOR (SUGAR-FREE) CIPRODEX ...... 50, 51 27 ...... 68 ciprofloxacin ...... 3, 9 bisoprolol-hydrochlorothiazide carteolol ...... 51 ciprofloxacin hcl ...... 3, 9, 50 ...... 17, 24, 25, 27, 31, 49 carvedilol 15, 16, 22, 24, 27, 29 citalopram ...... 43 BLEPHAMIDE ...... 50 CAVAN-EC SOD DHA 18, 77, CITRANATAL HARMONY BLEPHAMIDE S.O.P...... 50 80 ...... 19, 54, 77, 80 BOOSTRIX TDAP ...... 14 CAYA CONTOURED ...... 44 CLARAVIS ...... 76 BOSULIF ...... 11 CAYSTON ...... 8 clarithromycin ...... 3, 8 BREO ELLIPTA 16, 56, 70, 71 CEDAX ...... 10 CLASSIC PRENATAL . 19, 77, BRILINTA ...... 22 cefaclor ...... 9 80 brimonidine ...... 50 cefadroxil ...... 4 clemastine ...... 1, 69 BRIVIACT ...... 34 cefdinir...... 10 CLEOCIN ...... 72 bromocriptine ...... 39 cefditoren pivoxil ...... 10 CLIMARA PRO ...... 60 budesonide ...... 56, 57, 70 cefixime ...... 10 clindamycin hcl ...... 7 bumetanide ...... 30, 47 cefpodoxime ...... 10 clindamycin palmitate hcl ...... 7 BUNAVAIL ...... 41 cefprozil ...... 9 clindamycin phosphate ...... 72 buprenorphine hcl ...... 41 ceftibuten ...... 10 clomipramine ...... 44 buprenorphine-naloxone...... 41 CEFTIN ...... 9 clonazepam ...... 37, 38 bupropion hcl...... 35 cefuroxime axetil ...... 10 clonidine ...... 14, 26 bupropion hcl (smoking deter) celecoxib ...... 39 clonidine hcl ...... 14, 26 ...... 35 CELLCEPT ...... 67 clopidogrel ...... 22 buspirone ...... 36 CELONTIN ...... 44 clotrimazole ...... 74 butalbital-acetaminophen-caff CENESTIN ...... 60 clotrimazole-betamethasone 73, ...... 33, 35, 36, 37, 42 CENTRUM SPECIALIST 74 butalbital-aspirin-caffeine ... 22, PRENATAL ...... 19, 77, 80 clozapine ...... 37 36, 37, 42, 43 cephalexin ...... 4 codeine sulfate ...... 40, 69 C CERDELGA ...... 68 colchicine ...... 64 cabergoline ...... 39 CESAMET ...... 53 colestipol ...... 25 CABOMETYX...... 11 CHANTIX ...... 15 COLYTE WITH FLAVOR calcipotriene ...... 76 CHANTIX STARTING PACKS ...... 54 calcitonin (salmon) ...... 62, 65 MONTH BOX ...... 15 COMBIPATCH ...... 60, 63 calcitriol ...... 76, 84 CHATEAL ...... 58 COMBIVENT RESPIMAT . 14, calcium acetate ...... 47 CHEMET...... 56, 64 16, 69, 71 calcium gluconate ...... 47 chlordiazepoxide hcl...... 37 COMETRIQ ...... 11 CAMRESE LO ...... 58 chlordiazepoxide-clidinium . 14, COMFORT PAC- CANASA ...... 54 37 MELOXICAM ...... 41 candesartan ...... 22, 23 chlorhexidine gluconate ...... 52 COMPACT COMPRESSOR candesartan-hydrochlorothiazid chloroquine phosphate ...... 3 NEBULIZER ...... 45 ...... 22, 23, 31, 49 chlorothiazide ...... 31, 49 COMPLERA ...... 5, 6 capecitabine ...... 11 chlorthalidone ...... 31, 50 COMPLETENATE ...... 77 CAPITAL WITH CODEINE cholestyramine (with sugar) . 25 CONDYLOX ...... 76 ...... 33, 39 CHOLESTYRAMINE LIGHT CONTRAVE ...... 34 CAPRELSA ...... 11 ...... 25 COPAXONE ...... 66 captopril ...... 23, 24 CORTIFOAM ...... 73

86 COTELLIC...... 11 dicyclomine ...... 14 EMFLAZA ...... 57 COVARYX ...... 57, 60 didanosine ...... 6 EMTRIVA ...... 6 COVARYX H.S...... 57, 60 DIFICID ...... 8 enalapril maleate ...... 23, 24 CREON ...... 55 diflunisal ...... 41 enalapril-hydrochlorothiazide CRINONE ...... 63 digoxin ...... 24, 26 ...... 23, 24, 31, 49 CRIXIVAN ...... 6 DILANTIN ...... 27, 39 ENBREL ...... 66 cromolyn...... 50, 69 DILATRATE-SR ...... 30 ENBREL SURECLICK ...... 66 CRYSELLE (28) ...... 58 diltiazem hcl ...... 25, 26, 28, 32 ENDOMETRIN ...... 63 cyanocobalamin (vitamin b-12) diphenoxylate-atropine .. 14, 53, ENJUVIA ...... 60 ...... 81 69 enoxaparin ...... 18 CYCLAFEM 1/35 (28) ...... 58 dipyridamole ...... 22, 32 entacapone ...... 38 cyclobenzaprine ...... 15 disopyramide phosphate ...... 27 entecavir ...... 8 cyclopentolate...... 53 disulfiram...... 64 ENTRESTO ...... 23, 31 cyclophosphamide ...... 11, 67 DIURIL ...... 31, 49 ENULOSE ...... 46 cycloserine ...... 3 divalproex ...... 34, 35, 36 EPCLUSA ...... 5 cyclosporine ...... 66, 67 dofetilide ...... 27 epinastine ...... 50 cyclosporine modified ... 65, 66, donepezil ...... 16 epinephrine ...... 14, 68 67 dorzolamide ...... 51 EPIPEN JR 2-PAK ...... 68 cyproheptadine ...... 1, 69 dorzolamide-timolol ...... 51 EPIVIR HBV ...... 6 D doxazosin ...... 15, 22, 29 eplerenone ...... 30, 31 DAKLINZA ...... 5 doxepin ...... 44 EPOGEN ...... 18 DALIRESP ...... 70 doxercalciferol ...... 84 EPZICOM ...... 6 dapsone ...... 3 doxycycline hyclate ...... 10, 50 ERIVEDGE ...... 11 DARAPRIM ...... 3 doxycycline monohydrate .... 10 ERYPED 400 ...... 7 DELZICOL ...... 54 dronabinol ...... 53 ERY-TAB ...... 7 DENAVIR ...... 74 DUET DHA BALANCED .. 19, ERYTHROCIN (AS DENTA 5000 PLUS...... 65 77, 81 STEARATE) ...... 7 DEPO-ESTRADIOL ...... 60 DUET DHA EC-OM 3 .. 19, 77, erythromycin ...... 7, 50 DESCOVY ...... 3, 6 81 erythromycin ethylsuccinate ... 7 desipramine ...... 44 DUET DHA WITH OMEGA-3 erythromycin with ethanol .... 72 desloratadine...... 1, 70 ...... 19, 77, 81 erythromycin-sulfisoxazole .... 4 desmopressin ...... 18, 62 DULERA ...... 16, 57, 70, 71 escitalopram oxalate ...... 43 desoximetasone ...... 73 duloxetine ...... 39, 43 ESTRACE ...... 60 dexamethasone ...... 57 DUREZOL ...... 51 estradiol ...... 60 dexamethasone sodium dutasteride ...... 64 estradiol valerate ...... 60 phosphate ...... 51 E ESTRASORB ...... 60 DEXCOM G4 RECEIVER .. 45 econazole ...... 74 ESTRING ...... 60 dexmethylphenidate ...... 42 EDURANT ...... 5 ESTROGEL ...... 61 dextroamphetamine ...... 33 EFFIENT ...... 22 eszopiclone ...... 36 dextroamphetamine- ELIGARD ...... 11, 61 ethambutol ...... 4 amphetamine ...... 33 ELIGARD (3 MONTH) . 11, 61 ethosuximide ...... 44 DIALYVITE ...... 81, 84 ELIGARD (4 MONTH) . 11, 61 etodolac ...... 41 DIALYVITE 800 ...... 81, 84 ELIGARD (6 MONTH) . 11, 61 EVOTAZ ...... 6 DIALYVITE 800-ULTRA D ELIQUIS ...... 17 EXACTA-MIX EVA ...... 81, 84 ELITE-OB ...... 77 CONTAINER ...... 45 diazepam...... 37, 38 ELITE-OB 400 ...... 19, 77, 81 exemestane ...... 11 diclofenac potassium ...... 41 ELLA ...... 58 EXJADE ...... 56 diclofenac sodium .... 41, 52, 76 ELMIRON ...... 68 EXTRA-VIRT PLUS DHA . 19, diclofenac-misoprostol ... 41, 56 EMCYT ...... 11 77, 81 dicloxacillin ...... 9 EMEND ...... 55 ezetimibe ...... 26

87 F FOLIVANE-PRX DHA NF 19, heparin (porcine) ...... 18 FALMINA (28) ...... 58 54, 77, 81 heparin, porcine (pf) ...... 18 famciclovir ...... 8 FORTEO ...... 62 HEXALEN ...... 11 famotidine...... 55 fosinopril ...... 23, 24 HOMATROPAIRE ...... 53 FARESTON ...... 11 FOSRENOL ...... 47, 64 HUMALOG ...... 61 FARYDAK...... 11 furosemide ...... 30, 47 HUMALOG KWIKPEN ...... 61 felbamate ...... 34 FUZEON ...... 5 HUMALOG MIX 50-50 ...... 61 felodipine ...... 28 G HUMALOG MIX 50-50 FEMCAP ...... 44, 45 gabapentin ...... 33, 34 KWIKPEN ...... 62 fenofibrate ...... 29 GABITRIL ...... 34 HUMALOG MIX 75-25 ...... 62 fenofibrate micronized ...... 29 galantamine ...... 16 HUMALOG MIX 75-25 fenofibrate nanocrystallized . 29 GELNIQUE ...... 76 KWIKPEN ...... 62 fenofibric acid ...... 29 gemfibrozil ...... 29 HUMATROPE ...... 62 fenofibric acid (choline) ...... 29 gentamicin ...... 50 HUMIRA ...... 55, 66, 67 fenoprofen ...... 41 GENVOYA ...... 5, 6 HUMIRA PEN ...... 55, 66, 67 fentanyl ...... 40 GIANVI (28) ...... 58 HUMIRA PEN PSORIASIS- FINACEA...... 76 GILENYA ...... 67 UVEITIS ...... 55, 66, 67 finasteride ...... 64 GILOTRIF ...... 11 HUMULIN 70/30 ...... 62 FIRAZYR ...... 65 GLATOPA ...... 67 HUMULIN 70/30 PEN ...... 62 FIRMAGON KIT W GLEOSTINE ...... 11 HUMULIN N ...... 62 DILUENT SYRINGE 11, 66 glimepiride...... 63 HUMULIN N PEN ...... 62 flecainide ...... 27 glipizide ...... 63 HUMULIN R U-100 ...... 62 FLOVENT DISKUS ...... 57, 70 glipizide-metformin ...... 58, 63 HUMULIN R U-500 (CONC) FLOVENT HFA ...... 57, 70 GLUCAGON EMERGENCY KWIKPEN ...... 62 fluconazole ...... 4 KIT (HUMAN)...... 61, 64 HUMULIN R U-500 fludrocortisone ...... 57 glyburide ...... 63 (CONCENTRATED) ...... 62 flunisolide ...... 51, 70 glyburide micronized ...... 63 HYCAMTIN ...... 12 fluocinolone ...... 73 glyburide-metformin ...... 58, 63 hydralazine ...... 29 fluocinonide ...... 73 glycopyrrolate ...... 14 hydrochlorothiazide ...... 31, 49 FLUOR-A-DAY...... 65 GLYTACTIN 10 PE hydrocodone-acetaminophen fluorescein-benoxinate ...... 52 BETTERMILK ...... 46 ...... 33, 40 FLUORIDEX DAILY GLYXAMBI ...... 60, 63 hydrocortisone ...... 57, 73 DEFENSE ...... 65 granisetron hcl ...... 53 hydrocortisone-acetic acid .... 52 fluorometholone ...... 52 griseofulvin microsize ...... 3 hydromorphone ...... 40 fluorouracil ...... 76 griseofulvin ultramicrosize ..... 3 hydroxychloroquine .... 3, 66, 67 fluoxetine ...... 43 guanfacine ...... 26, 38 hydroxyurea ...... 12 fluphenazine hcl ...... 42 GUARDIAN RT MONITOR hydroxyzine hcl ...... 1, 36 FLURA-DROPS ...... 65 SYSTEM ...... 45 hydroxyzine pamoate ...... 1, 36 flurbiprofen...... 41 GUARDIAN RT TEST PLUG hyoscyamine sulfate ...... 14 flurbiprofen sodium ...... 52 DEVICE ...... 45 I flutamide...... 11 GYNAZOLE-1 ...... 74 ibandronate ...... 65 fluticasone ...... 52, 70, 73 H IBRANCE ...... 12 fluvoxamine ...... 44 halobetasol propionate ...... 73 ibuprofen ...... 41 FOCALGIN-B ...... 47, 77, 81 haloperidol ...... 38 ICLUSIG ...... 12 FOLBECAL ...... 47, 77, 81 haloperidol lactate ...... 38 imatinib ...... 12 folic acid ...... 81 HARVONI...... 5 IMBRUVICA ...... 12 FOLIVANE-EC CALCIUM HEMATOGEN FA... 19, 81, 84 imipramine hcl ...... 44 DHA NF ...... 19, 77, 81 HEMENATAL OB... 19, 77, 81 imiquimod ...... 76 FOLIVANE-OB ...... 19, 77, 81 HEMENATAL OB + DHA . 19, INATAL ULTRA .... 19, 48, 54, 77, 81 77, 81

88 INDOCIN ...... 41, 64 KISQALI ...... 12 LONSURF ...... 12 indomethacin ...... 41, 64 KITABIS PAK ...... 2 lorazepam ...... 37, 38 INFERGEN ...... 7 KLOR-CON M15 ...... 48 losartan ...... 23 INLYTA ...... 12 KPN ...... 19, 77, 81 losartan-hydrochlorothiazide INTELENCE ...... 5 L ...... 23, 31, 49 INTRON A ...... 7, 12, 67 labetalol .. 15, 16, 22, 24, 25, 27 LOTRONEX ...... 54 INVIRASE ...... 6 lactic acid ...... 74 lovastatin ...... 29 INVOKAMET ...... 58, 63 lactulose ...... 46 loxapine succinate ...... 36 INVOKANA ...... 63 lamivudine ...... 6 LUDENT FLUORIDE ...... 65 IOPIDINE...... 52 lamivudine-zidovudine ...... 6 LUPRON DEPOT-PED . 12, 61 ipratropium bromide ...... 14, 69 lamotrigine...... 34, 35 LUPRON DEPOT-PED (3 ipratropium-albuterol .... 14, 17, lansoprazole ...... 56 MONTH) ...... 12, 61 69, 71 latanoprost ...... 53 LYNPARZA ...... 12 irbesartan ...... 23 LEENA 28 ...... 59 LYRICA ...... 35, 39 irbesartan-hydrochlorothiazide leflunomide ...... 66, 67 LYSODREN ...... 12 ...... 23, 31, 49 LENVIMA...... 12 M IRESSA ...... 12 LETAIRIS ...... 32, 71 MACNATAL CN DHA 19, 48, ISENTRESS ...... 5 letrozole ...... 12 54, 77, 81 isoniazid ...... 4 leucovorin calcium ...... 64 MAKENA ...... 63 ISOPTO HOMATROPINE .. 53 LEUKERAN ...... 12 malathion ...... 75 ISORDIL ...... 30 leuprolide ...... 12, 61 MARNATAL-F .. 19, 48, 77, 81 isosorbide dinitrate ...... 30 levalbuterol hcl ...... 17, 71 MATULANE ...... 12 isosorbide mononitrate ...... 30 levalbuterol tartrate...... 17, 71 meclizine ...... 1, 53 isoxsuprine ...... 32 LEVEMIR ...... 62 meclofenamate ...... 41 itraconazole ...... 4 LEVEMIR FLEXTOUCH ... 62 MEDI-JECTOR VISION ..... 45 ivermectin ...... 3 levetiracetam ...... 35 MEDROL ...... 57 J levobunolol ...... 51 medroxyprogesterone ...... 63 JADENU ...... 56 levocarnitine (with sugar) ..... 68 mefenamic acid ...... 41 JAKAFI ...... 12 levocetirizine ...... 1 mefloquine ...... 3 JANUMET ...... 58, 60 levofloxacin ...... 4, 9 megestrol ...... 12 JANUMET XR ...... 58, 60 levonorgestrel ...... 59 MEKINIST ...... 12 JANUVIA...... 60 levonorgestrel-ethinyl estrad 59 meloxicam ...... 41 JARDIANCE ...... 63 levothyroxine ...... 64 memantine ...... 38 JOLESSA ...... 59 LEXIVA ...... 6 MENEST ...... 61 JUNEL FE 1.5/30 (28) ...... 59 LIALDA ...... 54 MENOSTAR ...... 61 JUNEL FE 1/20 (28) ...... 59 lidocaine ...... 74 MEPHYTON ...... 64, 84 JUNEL FE 24 ...... 59 lidocaine hcl ...... 52 mercaptopurine ...... 12, 67 K LIDOCAINE VISCOUS ...... 52 mesalamine ...... 54 KADIAN ...... 40 lidocaine-prilocaine ...... 74 MESNEX ...... 68 KALETRA ...... 6 linezolid ...... 9 MESTINON ...... 16 KALYDECO ...... 69 LINZESS ...... 55 metformin ...... 58 KAPVAY DOSE PACK 14, 26 liothyronine ...... 64 methazolamide ...... 51 KELNOR 1/35 (28) ...... 59 lisinopril...... 23, 24 methimazole ...... 58 KERLIX AMD ...... 68, 75 lisinopril-hydrochlorothiazide methocarbamol ...... 15 KETEK ...... 7 ...... 23, 24, 31, 49 methotrexate sodium 12, 66, 67 ketoconazole ...... 4, 74 lithium carbonate ...... 35 methotrexate sodium (pf) .... 12, KETODAN...... 74 lithium citrate ...... 35 66, 67 ketoprofen...... 41 L-METHYLFOLATE PNV methoxsalen ...... 75 ketorolac ...... 41, 52 DHA ...... 19, 48, 77, 81 methyldopa ...... 14, 26 KETOSTIX ...... 46 LO LOESTRIN FE ...... 59

89 methyldopa- N NITRO-BID ...... 30 hydrochlorothiazide ... 14, 26, nabumetone ...... 42 nitrofurantoin ...... 11 31, 49 nadolol ...... 15, 25, 27 nitrofurantoin macrocrystal .. 10 methylergonovine ...... 68 naloxone ...... 41, 64 nitrofurantoin monohyd/m- methylphenidate ...... 42, 43 naltrexone ...... 41, 64 cryst ...... 10 methylprednisolone ...... 57 NAMENDA XR ...... 38 nitroglycerin ...... 30 metipranolol ...... 51 NAMZARIC ...... 16, 38 NORA-BE ...... 59 metoclopramide hcl ...... 55, 56 naphazoline ...... 53 noreth-ethinyl estradiol-iron . 59 metolazone ...... 31, 50 naproxen ...... 42, 64 norethindrone acetate ...... 63 metoprolol succinate 17, 24, 25, naproxen sodium ...... 42, 64 norethindrone ac-eth estradiol 27 naratriptan ...... 43 ...... 61, 63 metoprolol tartrate .... 17, 25, 27 NARCAN ...... 41, 64 norethindrone-e.estradiol-iron metronidazole ...... 2, 3, 72 NATACHEW (FE BIS- ...... 59 mexiletine ...... 27 GLYCINATE) ...... 19, 78, 81 norgestimate-ethinyl estradiol MIBELAS 24 FE ...... 59 NATAFORT (NEW ...... 59 MICONAZOLE-3 ...... 74 FORMULA 2011) 19, 78, 81 NORINYL 1+50 (28) ...... 59 MICROGESTIN 1.5/30 (21) 59 NATALVIRT CA.... 19, 48, 78, NORITATE ...... 72 MICROGESTIN 1/20 (21) ... 59 81 NORPACE CR ...... 27 midazolam ...... 38 NATALVIT ...... 19, 48, 78, 81 NORTREL 0.5/35 (28) ...... 59 midodrine ...... 14 NATAZIA ...... 59 NORTREL 7/7/7 (28) ...... 59 MINI PRENATAL ... 19, 77, 81 nateglinide ...... 62 nortriptyline ...... 44 minocycline ...... 10 NATELLE ONE . 19, 48, 78, 81 NORVIR ...... 7 minoxidil ...... 29 NATURE-THROID ...... 64 NOVOLIN N ...... 62 mirtazapine ...... 35 NEBUPENT ...... 3 NOVOLIN R ...... 62 misoprostol ...... 56 NECON 10/11 (28) ...... 59 NOVOLOG ...... 62 modafinil ...... 44 nefazodone...... 44 NOVOLOG FLEXPEN ...... 62 mometasone ...... 73 neomycin ...... 2 NOVOLOG MIX 70-30 ...... 62 MONONESSA (28) ...... 59 neomycin-bacitracin-poly-hc NOVOLOG MIX 70-30 montelukast ...... 69 ...... 50, 52 FLEXPEN ...... 62 morphine...... 40 neomycin-polymyxin b- NOVOLOG PENFILL ...... 62 morphine concentrate ...... 40 dexameth ...... 50, 52 NP THYROID ...... 64 MOVANTIK ...... 55 neomycin-polymyxin- NUPLAZID ...... 37 MOVIPREP ...... 54 gramicidin ...... 51 NUVARING ...... 59 moxifloxacin...... 4, 9 neomycin-polymyxin-hc 51, 52 nystatin ...... 9, 75 MULTAQ ...... 27 NEO-POLYCIN ...... 51 nystatin-triamcinolone ...... 75 MULTIVITAMIN WITH NESSI SPACER ...... 45 O FLUORIDE ...... 65, 77 NEULASTA ...... 18 OB COMPLETE 19, 48, 78, 82 MULTI-VITAMIN WITH nevirapine ...... 5 OB COMPLETE 400 19, 78, 82 FLUORIDE ...... 65 NEWGEN ...... 19, 48, 78, 82 OB COMPLETE ONE .. 19, 48, MULTI-VITAMIN WITH NEXAVAR ...... 12 78, 82 FLUORIDE ...... 77 NEXT CHOICE ONE DOSE OB COMPLETE PREMIER mupirocin ...... 72 ...... 59 ...... 19, 48, 78, 82 mycophenolate mofetil ...... 67 niacin ...... 24 OBSTETRIX DHA .. 20, 78, 82 mycophenolate sodium ...... 67 NIACOR ...... 24 OBSTETRIX EC 20, 54, 78, 82 MYLERAN ...... 12 nicotine ...... 15 OBTREX ...... 20, 54, 78, 82 MYNATAL ...... 19, 48, 77, 81 nicotine (polacrilex) ...... 15 O-CAL FA ...... 20, 48, 78, 82 MYNATAL-Z .... 19, 48, 77, 81 NICOTROL ...... 15 O-CAL PRENATAL ..... 20, 48, MYNATE 90 PLUS ...... 78 NICOTROL NS ...... 15 78, 82 MYNEPHROCAPS ...... 81, 84 nifedipine ...... 28, 29, 32 octreotide acetate ...... 63 MYZILRA ...... 59 NINLARO ...... 12 ODEFSEY ...... 6

90 ODOMZO ...... 12 permethrin ...... 75 PREMARIN ...... 61 ofloxacin ...... 51 perphenazine ...... 42 PREMPHASE ...... 61 OGESTREL (28) ...... 59 PERRY PRENATAL .... 20, 48, PREMPRO ...... 61 olanzapine...... 37 78, 82 PRENA1 ...... 20, 78, 82 olopatadine ...... 50 PHENADOZ ...... 1, 36 PRENA1 CHEW omeprazole ...... 56 phenazopyridine ...... 74 (QUATREFOLIC) ...... 78, 82 OMNIPOD INSULIN REFILL phenobarbital ...... 37 PRENA1 PLUS ...... 20, 78, 82 ...... 45 phenoxybenzamine ...... 16, 29 PRENAISSANCE 90 DHA . 20, ondansetron ...... 53 phentermine ...... 33 48, 54, 78, 82 ondansetron hcl ...... 53 phenytoin ...... 27, 39 PRENAISSANCE DHA ONE A DAY WOMEN'S phenytoin sodium extended . 27, HARMONY ...... 20, 78, 82 PRENATAL DHA .... 20, 48, 39 PRENATA ...... 20, 78, 82 78, 82 PHILITH ...... 59 PRENATAL ...... 20, 79, 82 ONFI...... 37, 38 PHOSLYRA ...... 47 PRENATAL 19 ...... 20, 78, 82 ONMEL ...... 4 pilocarpine hcl ...... 16, 52 PRENATAL 19 (WITH OPSUMIT ...... 32, 71 PILOPINE HS ...... 52 DOCUSATE) ...... 20, 78, 82 ORFADIN ...... 68 pimozide ...... 36 PRENATAL ORKAMBI ...... 69 pindolol ...... 15, 25, 27, 29 DHA+COMPLETE oseltamivir ...... 8 pioglitazone ...... 63 PRENATAL ...... 20, 78, 82 oxandrolone ...... 58 piroxicam ...... 42 PRENATAL FORMULA .... 20, oxaprozin ...... 42 PKU 2 ...... 46 48, 79, 82 oxazepam ...... 38 PKU TRIO ...... 46 PRENATAL LOW IRON ... 20, oxcarbazepine ...... 35 PNV 29-1 ...... 20, 48, 78, 82 48, 79, 82 oxybutynin chloride...... 76 PNV FOLIC ACID + IRON 20, PRENATAL MULTI-DHA . 20, oxycodone ...... 40 78, 82 79, 82 oxycodone-acetaminophen .. 34, PNV-OMEGA .... 20, 48, 78, 82 PRENATAL PLUS . 20, 48, 79, 40 podofilox ...... 76 83 oxycodone-aspirin ...... 40, 43 polyethylene glycol 3350 ..... 54 PRENATAL PLUS OXYCONTIN ...... 40 polymyxin b sulf-trimethoprim (CALCIUM CARB) .. 20, 48, oxymorphone ...... 40 ...... 51 79, 83 P POMALYST ...... 13, 67 PRENATAL VITAMIN ...... 79 PAIRE OB PLUS DHA 20, 78, potassium chloride ...... 48 PRENATAL VITAMIN WITH 82 potassium citrate ...... 46 MINERALS .... 20, 48, 79, 83 pantoprazole ...... 56 POTIGA ...... 35 prenatal vits96-iron fum-folic PAREMYD ...... 53 PR NATAL 430.. 20, 48, 78, 82 ...... 20, 49, 79, 83 paromomycin ...... 2 PR NATAL 430 EC 20, 48, 78, PRENATAL-1 ...... 20, 79, 83 paroxetine hcl ...... 44 82 PRENATAL-U ...... 79 PASER ...... 4 PRADAXA ...... 17 PRENATE DHA ...... 20, 79, 83 PCE...... 7 PRALUENT PEN...... 30 PRENATE ELITE .... 21, 79, 83 peg 3350-electrolytes ...... 54 PRALUENT SYRINGE ...... 30 PRENATE ESSENTIAL ..... 21, PEG-3350 WITH FLAVOR pramipexole ...... 39 79, 83 PACKS ...... 54 pravastatin ...... 29 PRENATE MINI ...... 21, 79, 83 PEGANONE ...... 39 prazosin ...... 15, 22 PRE-PEN ...... 46 PEGASYS CONVENIENCE PRED MILD...... 52 PREPOPIK ...... 54 PACK ...... 7 prednisolone ...... 57 PREQUE 10 ...... 21, 54, 79, 83 penicillin v potassium...... 8 prednisolone acetate ...... 52 PREVACID SOLUTAB ...... 56 PENTAM ...... 3 prednisolone sodium phosphate PREVIDENT 5000 BOOSTER PENTASA ...... 54 ...... 52, 57 PLUS ...... 65 pentoxifylline ...... 18 prednisone ...... 57 PREZCOBIX ...... 7 perindopril erbumine ...... 23, 24 PREDNISONE INTENSOL. 57 PREZISTA ...... 7

91 PRIFTIN ...... 4, 9 RAPAMUNE...... 68 SENSIPAR ...... 68 primaquine ...... 3 REBETOL ...... 8 SENSURA OSTOMY BASE primidone ...... 37 RECLIPSEN (28) ...... 59 PLATE ...... 45 PROAIR HFA ...... 17, 71 RELAGARD ...... 75 SEREVENT DISKUS .... 17, 71 probenecid ...... 50, 65 RELENZA DISKHALER ...... 8 SEROSTIM ...... 62 prochlorperazine ...... 42, 53 RELNATE DHA ...... 21, 79, 83 sertraline ...... 44 prochlorperazine maleate 42, 53 REMODULIN ...... 32, 72 SE-TAN DHA ...... 21, 79, 83 PROCRIT ...... 18 RENA-VITE RX ...... 83 sildenafil ...... 31, 72 PROCTOFOAM HC ...... 73, 74 RENVELA ...... 47, 64 SILICONE MASK - INFANT PROCTOZONE-HC...... 73 repaglinide ...... 62 ...... 45 progesterone micronized ...... 63 REPATHA PUSHTRONEX 30 silver sulfadiazine ...... 75 PROLIA ...... 65 REPATHA SURECLICK .... 30 simvastatin ...... 29 PROMACTA ...... 18 REPATHA SYRINGE ...... 30 sirolimus ...... 68 promethazine ...... 1, 36, 69 RESCRIPTOR ...... 6 SIRTURO ...... 4 PROMETHAZINE VC ... 1, 14, reserpine ...... 30 SKELID ...... 65 69 RESTORE ...... 45 sodium chloride ...... 45, 47, 49 promethazine-dm ...... 1, 69 RESTORE FOAM sodium fluoride ...... 65 PROMETHEGAN ...... 1, 36 DRESSING SILVER ...... 45 SODIUM POLYSTYRENE propafenone ...... 27 REVLIMID ...... 13, 67 (SORB FREE) ...... 47, 64 proparacaine ...... 52 REYATAZ ...... 7 sodium polystyrene sulfonate propranolol ... 15, 25, 27, 29, 36 REZIRA...... 14, 68, 69 ...... 47, 64 propylthiouracil ...... 58 RHEUMATREX 13, 66, 67, 68 SOLTAMOX ...... 13 PROSTIGMIN ...... 16 ribavirin ...... 8 SOMATULINE DEPOT ...... 63 PROTECT NATAL. 21, 49, 79, RIDAURA ...... 56, 66, 67 sotalol ...... 15, 25, 27, 28, 30 83 rifabutin ...... 4, 9 SOVALDI ...... 5 PROTECT PLUS ...... 21, 79 RIFAMATE...... 9 spinosad ...... 75 PROTONIX ...... 56 rifampin ...... 4, 9 SPIRIVA RESPIMAT .... 15, 69 PROVENTIL HFA ...... 17, 71 RIFATER ...... 4, 9 SPIRIVA WITH PULMICORT ...... 57, 70 riluzole ...... 38 HANDIHALER ...... 15, 69 PULMICORT FLEXHALER rimantadine ...... 2 spironolactone ...... 30, 31, 47 ...... 57, 70 risperidone ...... 37 spironolacton-hydrochlorothiaz PULMOZYME...... 50, 70 RITALIN LA ...... 43 ...... 30, 31, 47, 49 PUREFE OB PLUS .. 21, 79, 83 rivastigmine ...... 16 SPRIX ...... 42 PURIXAN ...... 13, 67 rivastigmine tartrate ...... 16 SPRYCEL ...... 13 pyrazinamide ...... 4 rizatriptan...... 43 stavudine ...... 6 pyridostigmine bromide ...... 16 ropinirole ...... 39 STIMATE ...... 18, 62 Q rosuvastatin ...... 29 STIVARGA ...... 13 QUARTETTE ...... 59 ROZEREM ...... 36 STRATTERA ...... 38 quetiapine ...... 37 RUBRACA ...... 13 STRIBILD ...... 5, 6 quinapril ...... 23, 24 S STROVITE FORTE . 21, 79, 83 quinidine gluconate ...... 3, 27 SABRIL ...... 35 STUART PRENATAL PLUS quinidine sulfate ...... 3, 27 SAFYRAL ...... 59 DHA ...... 21, 79, 83 QVAR...... 57, 70 salsalate ...... 43 SUBOXONE ...... 41 R SANTYL ...... 76 sucralfate ...... 56 rabeprazole ...... 56 SAVAYSA ...... 17 sulfacetamide sodium ..... 51, 75 raloxifene ...... 60, 65 SELECT-OB (FOLIC ACID) sulfacetamide sodium (acne) 75 ramipril ...... 24 ...... 21, 79, 83 sulfacetamide sodium-sulfur 75 RANEXA ...... 26 selegiline hcl ...... 39 sulfacetamide-prednisolone .. 51 ranitidine hcl ...... 55 selenium sulfide ...... 75 sulfadiazine ...... 10 RAPAFLO ...... 16 SELZENTRY ...... 5

92 sulfamethoxazole-trimethoprim thioridazine ...... 42 TRI-VITAMIN WITH ...... 10 thiothixene ...... 44 FLUORIDE ...... 65, 80, 84 sulfasalazine ...... 10, 54, 66, 67 tiagabine ...... 35 tropicamide ...... 53 sulindac...... 42 TIGAN...... 53 trospium ...... 76 sumatriptan ...... 43 timolol maleate ...... 51 TRUVADA ...... 6 sumatriptan succinate ...... 43 tinidazole ...... 3 TRUZONE PEAK FLOW SUPRAX ...... 10 TIVICAY...... 5 METER ...... 46 SUPREP BOWEL PREP KIT tizanidine ...... 15 TUDORZA PRESSAIR . 15, 69 ...... 54 TOBRADEX ...... 51, 52 TYBOST ...... 3, 68 SUSTIVA ...... 6 tobramycin ...... 51 TYKERB ...... 13 SUTENT...... 13 tobramycin in 0.225 % nacl .... 2 TYVASO REFILL KIT .. 32, 72 SYEDA...... 60 tobramycin-dexamethasone . 51, TYVASO STARTER KIT .. 32, SYLATRON...... 7, 13 52 72 SYMBICORT..... 17, 57, 70, 71 TODAY CONTRACEPTIVE TYZEKA ...... 8 SYNAREL ...... 61 SPONGE ...... 44 U SYNJARDY ...... 58, 63 tolcapone ...... 38 UCERIS ...... 57 SYNJARDY XR ...... 58, 63 tolmetin ...... 42 ULORIC ...... 65 SYNRIBO ...... 13 tolterodine ...... 76 ULTIMATECARE ONE NF T topiramate ...... 35 ...... 21, 49, 80, 83 TABLOID ...... 13 torsemide ...... 30, 47 UPTRAVI ...... 32, 72 tacrolimus ...... 68, 76 tramadol ...... 40 urea ...... 75 TAFINLAR ...... 13 tramadol-acetaminophen34, 36, ursodiol ...... 55 TAGRISSO ...... 13 40 V TAMIFLU ...... 8 trandolapril ...... 24 VAGINAL tamoxifen ...... 13 travoprost (benzalkonium) ... 53 CONTRACEPTIVE FILM tamsulosin...... 16 trazodone ...... 44 ...... 44 TANZEUM ...... 61 TRECATOR ...... 4 VAGINAL TARCEVA ...... 13 tretinoin ...... 74 CONTRACEPTIVE FOAM TARON-BC ...... 21, 49, 79, 83 tretinoin (chemotherapy) ...... 13 ...... 44 TARON-C DHA ...... 21, 79, 83 TREXALL ...... 13, 66, 67, 68 valacyclovir ...... 8 TASIGNA ...... 13 TRIADVANCE .. 21, 49, 79, 83 VALCYTE ...... 8 TAZTIA XT ...... 25, 26, 28, 32 triamcinolone acetonide ...... 73 valganciclovir ...... 8 TECFIDERA ...... 67 triamterene-hydrochlorothiazid valproic acid ...... 35, 36 TECHNIVIE...... 5, 7 ...... 31, 47, 49 valproic acid (as sodium salt) telmisartan ...... 23 TRIANEX ...... 73 ...... 35, 36 temazepam ...... 38 TRICARE PRENATAL DHA valsartan ...... 23 temozolomide ...... 13 ONE ...... 21, 55, 79, 83 valsartan-hydrochlorothiazide TENIVAC (PF) ...... 14 trifluoperazine ...... 42 ...... 23, 31, 50 terazosin ...... 15, 22, 30 trifluridine ...... 51 vancomycin ...... 4 terbinafine hcl ...... 2 TRIGELS-F FORTE 21, 83, 84 VCF CONTRACEPTIVE GEL terbutaline ...... 17, 71 trihexyphenidyl ...... 15, 34 ...... 44 terconazole ...... 74 TRI-LEGEST FE ...... 60 VELIVET TRIPHASIC testosterone ...... 58 trimethoprim ...... 11 REGIMEN (28) ...... 60 testosterone cypionate ...... 58 TRINATAL GT ...... 21, 79, 83 VELPHORO ...... 47 testosterone enanthate ...... 58 TRI-SPRINTEC (28) ...... 60 VELTASSA ...... 47 tetrabenazine...... 38 TRIUMEQ ...... 5, 6 VENATAL-FA ... 21, 49, 80, 83 tetracycline ...... 10 TRIVEEN-ONE . 21, 49, 79, 83 VENCLEXTA ...... 13 theophylline .. 29, 46, 47, 72, 76 TRIVEEN-PRX RNF .... 21, 49, VENCLEXTA STARTING THERANATAL COMPLETE 55, 80, 83 PACK ...... 13 ...... 21, 79, 83 TRIVEEN-TEN ...... 21, 80, 83 venlafaxine ...... 43

93 VENTAVIS ...... 32, 72 VOTRIENT ...... 13 XULANE ...... 60 VENTOLIN HFA ...... 17, 71 VP-ERA OB PLUS .. 21, 80, 84 Y verapamil ...... 26, 28, 32 VP-HEME ONE ...... 22, 80, 84 YUVAFEM ...... 61 VGO 20 ...... 46 W Z VIC-FORTE ...... 80, 83 warfarin ...... 17 zaleplon ...... 36 VICTOZA 2-PAK ...... 61 WELCHOL ...... 25, 58 ZARXIO ...... 18 VICTOZA 3-PAK ...... 61 WIDE-SEAL DIAPHRAGM ZATEAN-CH .... 22, 49, 55, 80, VIDEX 2 GRAM PEDIATRIC 60 ...... 44 84 ...... 6 WIDE-SEAL DIAPHRAGM ZATEAN-PN ...... 22, 80, 84 VIDEX 4 GRAM PEDIATRIC 65 ...... 44 ZAVESCA ...... 68 ...... 6 WIDE-SEAL DIAPHRAGM ZELBORAF ...... 13 VIEKIRA PAK ...... 5, 7 70 ...... 45 ZENCHENT FE ...... 60 VIMPAT...... 35 WIDE-SEAL DIAPHRAGM ZENPEP ...... 55 VINACAL B ...... 21, 80, 83 75 ...... 45 ZEPATIER ...... 5 VINATE AZ ...... 21, 49, 80, 83 WIDE-SEAL DIAPHRAGM ZIAGEN ...... 6 VINATE CALCIUM...... 80 80 ...... 45 zidovudine ...... 6 VINATE II ...... 21, 49, 80, 84 WIDE-SEAL DIAPHRAGM ZINGIBER ...... 49, 80, 84 VINATE M ...... 80 85 ...... 45 ziprasidone hcl ...... 37 VINATE ONE .... 21, 49, 80, 84 WIDE-SEAL DIAPHRAGM ZIRGAN ...... 51 VINATE PN CARE ...... 80 90 ...... 45 ZOLINZA ...... 13 VIORELE (28) ...... 60 WIDE-SEAL DIAPHRAGM zolpidem ...... 36 VIRACEPT ...... 7 95 ...... 45 zonisamide ...... 35 VIRAZOLE ...... 8 X ZORBTIVE ...... 63 VIREAD ...... 6 XALKORI ...... 13 ZORTRESS ...... 68 VIRT-SELECT.. 21, 49, 55, 80, XARELTO ...... 17 ZOVIA 1/50E (28) ...... 60 84 XELJANZ ...... 66 ZOVIRAX ...... 74 VITAFOL ...... 21 XELJANZ XR ...... 66 ZUBSOLV ...... 41 VITAFOL GUMMIES .. 21, 49, XEROFORM PETROLATUM ZYDELIG ...... 13 80, 84 OVERWRAP...... 46 ZYKADIA ...... 13 VITAMIN D2 ...... 84 XGEVA ...... 65 ZYLET ...... 51, 52 VITEKTA...... 5 XIFAXAN ...... 9 ZYTIGA ...... 13 VOL-NATE ...... 21, 49, 80, 84 XOLEGEL...... 74 voriconazole ...... 4 XTANDI ...... 13

94