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2018 Formulary List

For State, Education, and Local Government Employees

GlobalHealth, Inc. 701 NE 10th Street, Suite 300 MSTDF18 Lists Updated 11/2017 Oklahoma City, OK 73104-5403 www.GlobalHealth.com/state HELPFUL NUMBERS Plan Issuer: Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.5600 (local) 1.877.280.5600 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/state 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.5600 (local) 24/7 Nurse Help Line: 1.877.280.5600 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected]

i IMPORTANT INFORMATION This formulary applies to Members who enrolled through the State, Education, and Local Government employees Plan.

Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose Member Handbook  Tells you about your benefits. for State, Education, o What benefits are covered and how much you will pay. and Local o How they are covered (including limitations and exclusions). Government o How to use them. Employees (“Member Handbook”) Physicians and  Lists our Network of doctors, Facilities, and pharmacies. Health Providers  Tells you if a Facility is preferred or not. Directory (“Provider Directory”) Formulary Drug List  Lists we cover. for State, Education,  Tells you what Tier a drug is in. and Local  Tells you if there are any rules to getting a drug. Government Employees (“Drug Formulary” or “Formulary”)

Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.

This is an important legal document. Please keep it in a safe place.

When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary.

For specific questions about your coverage, please call the phone number printed on your Member ID card.

Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. and Drug Administration (“FDA”).

ii For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.

For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.

THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies.

iii NOTICE ABOUT NON-DISCRIMINATION

GlobalHealth, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GlobalHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

GlobalHealth:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact the Director of Compliance and Legal Services.

If you believe that GlobalHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ATTN: Director of Compliance and Legal Services, 701 NE 10th St, Ste. 300, Oklahoma City, OK 73104-5403, Fax: (405) 280-5894, or E-mail: [email protected]. You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Compliance Attorney is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Translation Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-5600 (TTY: 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-5600 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-280- 5600 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-280-5600 OR (TTY: 711)번으로 전화해 주십시오. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Language Translation Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-5600 (TTY: 711). 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة Arabic 4692-082-778-1 (ھاتف الصم والبكم برقم Burmese သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-5600 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-5600 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-5600 (TTY: 711). French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-5600 (ATS: 711). Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ ທ່ານ. ໂທຣ 1-877-280-5600 (TTY: 711). Thai เรียน: ถ ้าคุณพูดภาษาไทยคุณสามารถใชบริการช้ วยเหลือทางภาษาได่ ้ฟรี โทร 1-877-280-5600 (TTY: 711). -280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار Urdu 5600 (TTY: 711). Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-5600 (TTY: 711). اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما :توجھ Persian .با تماس بگیرید .فراھم می باشد (TTY: 711) 1-877-280-5600 TIER DESCRIPTION

0 Health Care Reform

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Specialty Drug

TYPE DESCRIPTION

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

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

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

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

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

C Custom This drug has unique restrictions.

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

This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative . If you have questions, please contact member services.

The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered.

PAGE 1 LAST UPDATED 10/2017 PS Preferred Specialty Preferred Specialty.

HCG High Cost Generic High Cost Generic.

Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share.

PAGE 2 LAST UPDATED 10/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AGENTS

ALPHA AND BETA ADRENERGIC (RESPR)

QL 2 / fill ADRENACLICK 3 PA

ADRENALIN 3

ADYPHREN 3 QL 2 / fill

ADYPHREN AMP 3 QL 2 / fill

ADYPHREN AMP II 3 QL 2 / fill

ADYPHREN II 3 QL 2 / fill

QL 2 / fill AUVI-Q 3 PA

hcl 3 ephedrine sulfate powder 3 epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 2 / fill 0.3mg/0.3 auto injct) 1 QL

epinephrine powder 3 epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1

epinephrine bitartrate powder 3 epinephrine hcl 3

epinephrine hcl/pf 1 HCG

epinephrine/pf 1 HCG

EPINEPHRINESNAP-V 3 QL 2 / fill

QL 2 / fill EPIPEN 3 PA

QL 2 / fill EPIPEN 2-PAK 3 PA

PAGE 3 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / fill EPIPEN JR 2-PAK 3 PA

QL 2 / fill EPISNAP 3 HCG

EPY 3 QL 2 / fill

QL 40/ day HYCOFENIX 3 AL At least 18 yrs old hcl 3 racepinephrine hcl 3

QL 20 / day REZIRA 3 AL At least 18 yrs old

NON-SELECT.BETA-ADRENERGIC AGONT(RESPIR) isoproterenol hcl powder 3 ISUPREL 3 SELECT.BETA-2-(RESPIR)

ADVAIR DISKUS 2 QL 2 / day

ADVAIR HFA 2 QL 0.4 / day albuterol sulfate powder 3 albuterol sulfate 5 mg/ml solution 1 LCG albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml 1 vial-neb, 4 mg tab er 12h, 4 mg tablet, 8 mg tab er 12h)

ANORO ELLIPTA 2 QL 2 / day

QL 1 / day ARCAPTA NEOHALER 3 ST

QL 0.357 / day BEVESPI AEROSPHERE 3 ST

PAGE 4 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BREO ELLIPTA 2 QL 2 / day

BROVANA 3 QL 4 / day

COMBIVENT RESPIMAT 2 QL 0.267 / day

QL 0.04 / day propionate/ xinafoate 1 AL At least 12 yrs old

FORADIL 3 QL 3 / day fumarate 3 formoterol fumarate dihydrate, micronized 3 ipratropium /albuterol sulfate 1 levalbuterol hcl 100 % powder 3 levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb) 1 HCG metaproterenol sulfate powder 3 metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1

PERFOROMIST 3 QL 120 / 30 days

PROAIR HFA 2 QL .8 / day

QL 0.07 / day PROAIR RESPICLICK 2 AL At least 12 yrs old

SEREVENT DISKUS 2 QL 2 / day

QL .144 / day STRIVERDI RESPIMAT 2 ST

SYMBICORT 2 QL 0.4 / day sulfate powder 3 terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1 LCG terbutaline sulfate 1 mg/ml vial 1

PAGE 5 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day UTIBRON NEOHALER 3 ST AL At least 18 yrs old

VENTOLIN HFA 2 QL 1.5 / day

VOSPIRE ER 3 XOPENEX 3 XOPENEX CONCENTRATE 3 ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS

CARDURA 3

QL 1 / day CARDURA XL 3 ST mesylate 100 % powder 3 doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) 1

MINIPRESS 3 hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1 prazosin hcl powder 3 hcl 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

CAFERGOT 3 D.H.E.45 3 DIBENZYLINE 3 mesylate powder 3

QL 8 / 30 days dihydroergotamine mesylate 0.5mg/spry spray/pump 1 HCG dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1

PAGE 6 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mesylates 100 % powder 3 ergoloid mesylates 1 mg tablet 1 ERGOMAR 3 tartrate 3 ergotamine tartrate/ 1 maleate 3 MIGERGOT 3

MIGRANAL 3 QL 8 / 30 days hcl 10 mg capsule 1 phenoxybenzamine hcl powder 3 mesylate powder 3 phentolamine mesylate 5 mg vial 1 phentolamine mesylate/alprostadil in bacteriostatic water 1 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

QL 1 / day hcl 1 GL Male 1 COREG 3

COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR 40 MG QL 2 / day 3 CAPSULE) ST

QL 1 / day COREG CR 80 MG CAPSULE 3 ST

QL 1 / day / hcl 1 GL Male

FLOMAX 3 QL 2 / day

QL 1 / day JALYN 3 GL Male

PAGE 7 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl powder 3 labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

QL 1 / day RAPAFLO 2 GL Male tamsulosin hcl 1 QL 2 / day

QL 1 / day UROXATRAL 3 GL Male

ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC. acetaminophen 3 acetaminophen with phosphate (120-12mg/5 solution, QL 139 / day 1 300mg/12.5 solution) AL At least 18 yrs old

QL 22 / day acetaminophen with codeine 300mg-15mg tablet 1 AL At least 18 yrs old

QL 12 / day acetaminophen with codeine 300mg-30mg tablet 1 AL At least 12 yrs old

QL 6 / day acetaminophen with codeine 300mg-60mg tablet 1 AL At least 12 yrs old

QL 10 / day acetaminophen/caff/dihydrocod 320.5-30mg capsule 1 AL At least 18 yrs old acetaminophen/caff/dihydrocod 325-30-16 tablet 1 QL 10 / day

QL 6 / day ALLZITAL 3 HCG

QL 6 / day BUPAP 3 HCG

QL 6 / day /acetaminophen 50mg-300mg tablet 3 HCG

PAGE 8 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS butalbital/acetaminophen 50mg-325mg tablet 3 QL 6 / day

QL 6 / day butalb/acetaminophen/caffeine 50-325-40 capsule 1 HCG butalbital/acetaminophen/caffeine (butalb/acetaminophen/caffeine 50-300-40 capsule, 1 QL 6 / day butalb/acetaminophen/caffeine 50-325-40 tablet) butalbital/acetaminophen/caffeine/codeine phosphate 1 QL 6 / day

QL 6 / day CAPACET 1 HCG

QL 125 / day CAPITAL W-CODEINE 3 AL At least 18 yrs old

QL 12 / day ENDOCET 1 AL At least 18 yrs old

QL 6 / day ESGIC CAPSULE 1 HCG

ESGIC 50-325-40 MG TABLET 3 QL 6 / day

FIORICET 3 QL 6 / day

FIORICET WITH CODEINE 3 QL 6 / day gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day gabapentin 100 % powder 3 gabapentin (250 mg/5ml solution, 300 mg/6ml solution) 1 QL 72 / day gabapentin 600 mg tablet 1 QL 6 / day gabapentin 800 mg tablet 1 QL 5 / day

GRALISE 30-DAY STARTER PACK 3 ST

QL 1 / day GRALISE ER 300 MG TABLET 3 ST

PAGE 9 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day GRALISE ER 600 MG TABLET 3 ST

HORIZANT ER 300 MG TABLET 3 QL 4 / day

HORIZANT ER 600 MG TABLET 3 QL 2 / day

QL 140 / day HYCET 3 AL At least 2 yrs old hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5 solution, QL 140 / day 1 hydrocodone/acetaminophen 5-217mg/10 solution, AL At least 2 yrs old hydrocodone/acetaminophen 7.5-325/15 solution)

QL 100 / day hydrocodone/acetaminophen 2.5-167/5 solution 1 AL At least 2 yrs old hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-300mg tablet, QL 13 / day 1 hydrocodone/acetaminophen 7.5-300 mg tablet, AL At least 18 yrs old hydrocodone/acetaminophen 10mg-300mg tablet) hydrocodone bitartrate/acetaminophen QL 12 / day (hydrocodone/acetaminophen 5 mg-325mg tablet, 1 hydrocodone/acetaminophen 10mg-325mg tablet) AL At least 18 yrs old

QL 20 / day hydrocodone/acetaminophen 2.5-325 mg tablet 1 AL At least 18 yrs old

QL 8 / day hydrocodone/acetaminophen 7.5-325 mg tablet 1 AL At least 18 yrs old mucate/caffeine/acetaminophen 1 isometheptene mucate//acetaminophen 1

QL 12 / day LORCET 1 AL At least 18 yrs old

QL 12 / day LORCET HD 1 AL At least 18 yrs old

QL 6 / day LORCET PLUS 1 AL At least 18 yrs old

PAGE 10 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / day LORTAB 10 MG-300 MG/15 ML ELXR 3 AL At least 2 yrs old

LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG QL 8 / day 1 TABLET) AL At least 18 yrs old

QL 6 / day MARGESIC 1 HCG

MARTEN-TAB 1 QL 6 / day

NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400 MG 9 / day CAPSULE) 3 QL

NEURONTIN 250 MG/5 ML SOLN 3 QL 72 / day

NEURONTIN 600 MG TABLET 3 QL 6 / day

NEURONTIN 800 MG TABLET 3 QL 5 / day

NODOLOR 1

QL 12 / day NORCO 3 AL At least 18 yrs old

QL 62 / day oxycodone hcl/acetaminophen 5-325/5 ml solution 1 AL At least 18 yrs old oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet, hcl/acetaminophen 5 mg-325mg tablet, QL 12 / day 1 hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen AL At least 18 yrs old 10mg-325mg tablet)

QL 3 / day oxycodone hcl/acetaminophen 10mg-300mg tablet 1 AL At least 18 yrs old

QL 7 / day oxycodone hcl/acetaminophen 5 mg-300mg tablet 1 AL At least 18 yrs old

QL 4 / day oxycodone hcl/acetaminophen 7.5-300 mg tablet 1 AL At least 18 yrs old

PAGE 11 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 12 / day PERCOCET 3 AL At least 18 yrs old

QL 3 / day PRIMLEV 10-300 MG TABLET 3 AL At least 18 yrs old

QL 7 / day PRIMLEV 5-300 MG TABLET 3 AL At least 18 yrs old

QL 4 / day PRIMLEV 7.5-300 MG TABLET 3 AL At least 18 yrs old

PRODRIN 3

TENCON 1 QL 6 / day

QL 8 / day hcl/acetaminophen 1 AL At least 18 yrs old

QL 10 / day TREZIX 3 AL At least 18 yrs old

QL 12 / day TYLENOL-CODEINE NO.3 3 AL At least 12 yrs old

QL 6 / day TYLENOL-CODEINE NO.4 3 AL At least 12 yrs old

QL 8 / day ULTRACET 3 AL At least 18 yrs old

VANATOL LQ 3

QL 20 / day VERDROCET 1 AL At least 18 yrs old

QL 8 / day VICODIN 1 AL At least 18 yrs old

QL 13 / day VICODIN ES 1 AL At least 18 yrs old

PAGE 12 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 13 / day VICODIN HP 1 AL At least 18 yrs old

QL 12 / day XARTEMIS XR 3 AL At least 18 yrs old

QL 13 / day XODOL 10-300 3 AL At least 18 yrs old

QL 13 / day XODOL 5-300 3 AL At least 18 yrs old

QL 13 / day XODOL 7.5-300 3 AL At least 18 yrs old

QL 90 / day ZAMICET 3 AL At least 2 yrs old

QL 6 / day ZEBUTAL 1 HCG

OPIATE

QL 4 / day ACTIQ 3 PA AL At least 18 yrs old alfentanil hcl 1

QL 3 / day ARYMO ER 3 PA

QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old

ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day

QL 100 / day ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 HCG

PAGE 13 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS /aspirin/codeine 200-325-16 tablet 1 QL 21 / day codeine phosphate 3

QL 6 / day codeine/butalbital/asa/caffein 30-50-325 capsule 1 AL At least 18 yrs old

QL 6 / day codeine sulfate 1 AL At least 18 yrs old

QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) 3 PA AL At least 18 yrs old

DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML AMPUL, 50 MG/ML QL 10 / day CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 ML AMPUL, 100 MG/2 3 ML AMPUL) AL At least 18 yrs old

QL 20 / day DEMEROL 25 MG/ML CARPUJECT 3 AL At least 18 yrs old

QL 7 / day DEMEROL 75 MG/ML SYRINGE 3 AL At least 18 yrs old

QL 5 / day DEMEROL 100 MG TABLET 3 AL At least 18 yrs old

QL 10 / day DEMEROL 50 MG TABLET 3 AL At least 18 yrs old

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

QL 6 / day DILAUDID 2 MG/ML AMPUL 3 AL At least 18 yrs old

QL 3 / day DILAUDID 4 MG/ML AMPUL 3 AL At least 18 yrs old

PAGE 14 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 13 / day DILAUDID 5 MG/5 ML ORAL LIQUID 3 AL At least 18 yrs old

DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML SYRINGE, 2 At least 18 yrs old MG/ML SYRINGE, 4 MG/ML SYRINGE) 3 AL

QL 6 / day DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) 3 AL At least 18 yrs old

QL 1 / day DILAUDID-HP 3 AL At least 18 yrs old

QL 3 / day DOLOPHINE HCL 3 PA

QL 0.5 / day DURAGESIC 3 PA

DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day

QL 10 / day DURAMORPH 5 MG/10 ML AMPUL 1 HCG

QL 2 / day EMBEDA 2 PA

QL 2 / day EXALGO 3 PA fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, QL 0.5 / day 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr patch 1 td72) PA

QL 0.5 / day fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr patch td72, 87.5mcg/hr patch td72) 1 PA HCG fentanyl 100 % powder 3

PAGE 15 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600 PA mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd, 1 1600 mcg lozenge hd) AL At least 18 yrs old HCG fentanyl citrate 100 % powder 3 fentanyl citrate-0.9 % nacl/pf 600mcg/30 pca vial 1 QL 19 / day fentanyl/bupivacaine/ns/pf 2-1250mcg plast. bag 1 QL 192 / day fentanyl/bupivacaine/ns/pf 4mcg/ml-.1 plast. bag 1 QL 96 / day fentanyl/bupivacaine/ns/pf 2-625mcg/1 pump resvr 1 QL 192 / day fentanyl citrate/pf 50 mcg/ml ampul 1 MED Medical Drug fentanyl citrate/pf 50 mcg/ml vial 1 MED Medical Drug fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf (fentanyl/ropivacaine/ns/pf 2-1500mcg pump resvr, 1 QL 192 / day fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 pump resvr)

QL 6 / day FIORINAL WITH CODEINE #3 3 AL At least 18 yrs old hydrocodone bitart/chlorpheniramine QL 20 / day 1 maleate/pseudoephedrine AL At least 18 yrs old hydrocodone bitartrate (100 % powder, crystals) 3 hydrocodone/ibuprofen (hydrocodone/ibuprofen 2.5-200mg QL 5 / day tablet, hydrocodone/ibuprofen 7.5-200 mg tablet, 1 hydrocodone/ibuprofen 10mg-200mg tablet) AL At least 16 yrs old

QL 6 / day hydrocodone/ibuprofen 5mg-200mg tablet 1 AL At least 16 yrs old HCG hydromorphone hcl 1 mg/ml ampul 1 QL 13 / day

QL 13 / day hydromorphone hcl 1 mg/ml liquid 1 AL At least 18 yrs old

PAGE 16 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydromorphone hcl 100 % powder 3 hydromorphone hcl 3 mg supp.rect 1 QL 4 / day

QL 50 / day hydromorphone hcl 0.5mg/.5ml syringe 1 AL At least 18 yrs old HCG

QL 13 / day hydromorphone hcl 1 mg/ml syringe 1 AL At least 18 yrs old

QL 6 / day hydromorphone hcl 2 mg/ml syringe 1 AL At least 18 yrs old MED Medical Drug

QL 3 / day hydromorphone hcl 4 mg/ml syringe 1 AL At least 18 yrs old

QL 2 / day hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32 mg tab er 24h) 1 PA HCG

QL 6 / day hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1 AL At least 18 yrs old hydromorphone hcl (2 mg/ml ampul, 2 mg/ml vial) 1 QL 6 / day

QL 1 / day hydromorphone hcl/pf 10 mg/ml ampul 1 AL At least 18 yrs old hydromorphone hcl/pf 10 mg/ml vial 1 QL 1 / day

QL 5 / day IBUDONE 10-200 MG TABLET 3 AL At least 16 yrs old

QL 6 / day IBUDONE 5-200 MG TABLET 1 AL At least 16 yrs old HCG

PAGE 17 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day ibuprofen/oxycodone hcl 1 AL At least 18 yrs old

INFUMORPH 200 MG/20 ML AMPUL 3 QL 5 / day

INFUMORPH 500 MG/20 ML AMPUL 3 QL 2 / day tartrate 100 % powder 3 AL At least 18 yrs old

QL 4 / day levorphanol tartrate 2 mg tablet 1 AL At least 18 yrs old

QL 50 / day meperidine hcl 10 mg/ml cartridge 1 AL At least 18 yrs old meperidine hcl 100 % powder 3 AL At least 18 yrs old

QL 50 / day meperidine hcl 50 mg/5 ml solution 1 AL At least 18 yrs old

QL 5 / day meperidine hcl 100 mg tablet 1 AL At least 18 yrs old

QL 10 / day meperidine hcl 50 mg tablet 1 AL At least 18 yrs old

QL 5 / day meperidine hcl/pf 100 mg/ml vial 1 AL At least 18 yrs old

QL 20 / day meperidine hcl/pf 25 mg/ml vial 1 AL At least 18 yrs old

QL 10 / day meperidine hcl/pf 50 mg/ml vial 1 AL At least 18 yrs old hcl 100 % powder 3

QL 8 / day methadone hcl 10 mg/5 ml solution 1 PA

QL 18 / day methadone hcl 5 mg/5 ml solution 1 PA

PAGE 18 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day methadone hcl (10 mg tablet, 10 mg/ml oral conc) 1 PA

QL 3 / day methadone hcl 5 mg tablet 1 PA methadone hcl 10 mg/ml vial 1 QL 2 / day

QL 2 / day METHADONE INTENSOL 1 PA

QL 2 / day METHADOSE 10 MG/ML ORAL CONC 3 PA sulfate (10 mg cap er pel, 20 mg cap er pel, 50 mg cap QL 2 / day 1 er pel, 100 mg cap er pel) PA morphine sulfate (30 mg cap er pel, 30 mg cpmp 24hr, 45 mg QL 1 / day cpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp 1 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 120 mg cpmp 24hr) PA

QL 3 / day morphine sulfate 10mg/0.7ml pen injctr 1 PA HCG morphine sulfate 100 % powder 3 PA morphine sulfate (20 mg supp.rect, 100 mg/5ml solution) 1 QL 3 / day morphine sulfate 10 mg/5 ml solution 1 QL 25 / day morphine sulfate 20 mg/5 ml solution 1 QL 13 / day morphine sulfate 10 mg supp.rect 1 QL 5 / day morphine sulfate 30 mg supp.rect 1 QL 2 / day morphine sulfate 5 mg supp.rect 1 QL 10 / day

QL 10 / day morphine sulfate 5 mg/ml syringe 1 PA

PAGE 19 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day morphine sulfate 15 mg tablet 1 AL At least 18 yrs old

QL 2 / day morphine sulfate 30 mg tablet 1 AL At least 18 yrs old morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet QL 3 / day 1 er, 100 mg tablet er, 200 mg tablet er) PA

QL 3 / day morphine sulfate 15 mg/ml vial 1 PA

QL 6 / day morphine sulfate 8 mg/ml vial 1 PA MED Medical Drug

QL 100 / day morphine sulfate/pf 0.5 mg/ml vial 1 PA HCG

QL 50 / day morphine sulfate/pf 1 mg/ml vial 1 PA

QL 3 / day MS CONTIN 3 PA

QL 6 / day NUCYNTA (50 MG TABLET, 75 MG TABLET) 3 AL At least 18 yrs old

QL 7 / day NUCYNTA 100 MG TABLET 3 AL At least 18 yrs old

QL 17 / day OPANA 1 MG/ML INJ AMPULE 3 AL At least 18 yrs old

QL 12 / day OPANA (5 MG TABLET, 10 MG TABLET) 3 AL At least 18 yrs old

PAGE 20 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day OPANA ER 3 PA AL At least 18 yrs old opium/belladonna 30-16.2 mg supp.rect 1 QL 2 / day opium/belladonna alkaloids 60-16.2 mg supp.rect 1 QL 1 / day

QL 8 / day OXAYDO 3 AL At least 18 yrs old

OXECTA 3 QL 8 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mg QL 8 / day 1 tablet, 30 mg tablet) AL At least 18 yrs old oxycodone hcl 20 mg/ml oral conc 1 QL 2 / day oxycodone hcl 100 % powder 3 oxycodone hcl 5 mg/5 ml solution 1 QL 33 / day oxycodone hcl 10mg/0.5ml syringe 1 QL 4 / day

3 / day oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab QL er 12h, 30 mg tab er 12h, 40 mg tab er 12h, 60 mg tab er 12h, 1 PA 80 mg tab er 12h) HCG oxycodone hcl 10 mg tablet 1 QL 8 / day

QL 7 / day oxycodone hcl/aspirin 1 AL At least 18 yrs old

QL 3 / day OXYCONTIN 3 PA

QL 2 / day oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg PA tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er 1 12h, 40 mg tab er 12h) AL At least 18 yrs old HCG

PAGE 21 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 12 / day oxymorphone hcl (5 mg tablet, 10 mg tablet) 1 AL At least 18 yrs old HCG

QL 30 / day /phenyleph/codeine 6.25-5-10 syrup 1 AL At least 6 yrs old

QL 5 / day REPREXAIN 10-200 MG TABLET 1 AL At least 16 yrs old

QL 5 / day REPREXAIN 2.5-200 MG TABLET 3 AL At least 16 yrs old

QL 6 / day REPREXAIN 5-200 MG TABLET 3 AL At least 16 yrs old

QL 8 / day ROXICODONE 3 AL At least 18 yrs old sufentanil citrate powder 3

QL 1 / day tramadol hcl (100 mg cpbp 25-75, 100 mg tab er 24h, 100 mg tbmp 24hr, 150 mg cpbp 25-75, 200 mg cpbp 25-75, 200 mg PA 1 tab er 24h, 200 mg tbmp 24hr, 300 mg cpbp 17-83, 300 mg tab AL At least 18 yrs old er 24h, 300 mg tbmp 24hr) HCG tramadol hcl 100 % powder 3 AL At least 18 yrs old

QL 8 / day tramadol hcl 50 mg tablet 1 AL At least 18 yrs old

QL 20 / day TUZISTRA XR 3 AL At least 18 yrs old

QL 8 / day ULTRAM 3 AL At least 18 yrs old

QL 1 / day ULTRAM ER 3 PA AL At least 18 yrs old

PAGE 22 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 5 / day VICOPROFEN 3 AL At least 16 yrs old

XYLON 10 1

QL 20 / day ZUTRIPRO 3 AL At least 18 yrs old

OPIATE PARTIAL AGONISTS

QL 2 / day BELBUCA 3 PA AL At least 18 yrs old

QL 3 / day BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3 PA

QL 2 / day BUNAVAIL 4.2-0.7 MG FILM 3 PA

BUPRENEX 3 QL 17 / day

QL 0.144 / day buprenorphine 3 PA buprenorphine hcl powder 3 buprenorphine hcl (0.3 mg/ml syringe, 0.3 mg/ml vial) 1 QL 17 / day

QL 3 / day buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1 PA

QL 3 / day buprenorphine hcl/naloxone hcl 1 PA HCG tartrate 100 % powder 3 AL At least 18 yrs old

QL 0.3 / day butorphanol tartrate 10 mg/ml spray 1 AL At least 18 yrs old

PAGE 23 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 7 / day butorphanol tartrate 1 mg/ml vial 1 AL At least 18 yrs old

QL 4 / day butorphanol tartrate 2 mg/ml vial 1 AL At least 18 yrs old

QL 0.144 / day BUTRANS 3 PA hcl (10 mg/ml ampul, 10 mg/ml vial) 1 QL 5 / day nalbuphine hcl (20 mg/ml ampul, 20 mg/ml vial) 1 QL 3 / day nalbuphine hcl 100 % powder 3

QL 12 / day hcl/naloxone hcl 1 AL At least 12 yrs old

QL 3 / day SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 PA

QL 2 / day SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 PA

TALWIN (30 MG/ML AMPUL, 30 MG/ML VIAL) 3 QL 5 / day

QL 3 / day ZUBSOLV 3 PA

ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

QL 2 / day ADIPEX-P (37.5 MG CAPSULE, 37.5 MG TABLET) 3 PA AL At least 17 yrs old

QL 3 / day BONTRIL PDM 3 PA AL At least 17 yrs old

PAGE 24 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diethylpropion hcl 100 % powder 3

QL 3 / day diethylpropion hcl 25 mg tablet 1 PA AL At least 16 yrs old

QL 1 / day diethylpropion hcl 75 mg tablet er 1 PA

QL 3 / day PA LOMAIRA 1 AL At least 17 yrs old HCG

QL 1 / day phendimetrazine tartrate 105 mg capsule er 1 PA

QL 3 / day phendimetrazine tartrate 35 mg tablet 1 PA

QL 1 / day phentermine hcl (15 mg capsule, 30 mg capsule) 1 PA phentermine hcl 100 % powder 3

QL 2 / day phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PA AL At least 17 yrs old

QL 1 / day QSYMIA 3 PA AL At least 18 yrs old

SUPRENZA ODT 3 PA

ANOREXIGENIC AGENTS, MISCELLANEOUS

QL 4 / day CONTRAVE 3 PA AL At least 18 yrs old

PAGE 25 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SELECTIVE AGONISTS

QL 2 / day BELVIQ 3 PA AL At least 18 yrs old

QL 1 / day BELVIQ XR 3 PA AL At least 18 yrs old

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

QL 2 / day 3 ST

QL 2 / day ADDERALL XR 3 ST

QL 1 / day ADZENYS XR-ODT 3 ST AL At least 6 yrs old

QL 3 / day benzphetamine hcl 25 mg tablet 1 PA AL At least 12 yrs old

QL 3 / day benzphetamine hcl 50 mg tablet 1 PA

QL 5 / day DESOXYN 3 ST

QL 5 / day DEXEDRINE SPANSULE 10 MG 3 ST

QL 4 / day DEXEDRINE SPANSULE 15 MG 3 ST

PAGE 26 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day DEXEDRINE SPANSULE 5 MG 3 ST

QL 6 / day DEXEDRINE 10 MG TABLET 1 HCG

QL 2 / day DEXEDRINE 5 MG TABLET 1 HCG sulf-saccharate/ sulf- aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h, dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg cap er 24h, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, 2 / day dextroamphetamine/amphetamine 15 mg cap er 24h, 1 QL dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg cap er 24h, dextroamphetamine/amphetamine 20 mg tablet, dextroamphetamine/amphetamine 25 mg cap er 24h, dextroamphetamine/amphetamine 30 mg cap er 24h, dextroamphetamine/amphetamine 30 mg tablet)

QL 5 / day dextroamphetamine sulfate 10 mg capsule er 1 HCG

QL 4 / day dextroamphetamine sulfate 15 mg capsule er 1 HCG

QL 60 / day dextroamphetamine sulfate 5 mg/5 ml solution 1 HCG

QL 2 / day dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet) 1 HCG

QL 6 / day dextroamphetamine sulfate 10 mg tablet 1 HCG

QL 8 / day DYANAVEL XR 3 ST AL At least 6 yrs old

PAGE 27 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day EVEKEO 3 ST hcl 1 QL 5 / day

QL 60 / day PROCENTRA 3 ST

QL 3 / day REGIMEX 3 PA AL At least 12 yrs old

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

QL 2 / day ZENZEDI (15 MG TABLET, 30 MG TABLET) 3 ST

QL 3 / day ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3 ST

QL 6 / day ZENZEDI 10 MG TABLET 1 HCG

QL 2 / day ZENZEDI 5 MG TABLET 1 HCG

QL 8 / day ZENZEDI 7.5 MG TABLET 3 ST

ANOREXIGENIC AGENTS AND STIMULANTS, MISC hcl 3 RESPIRATORY AND CNS STIMULANTS

QL 1 / day APTENSIO XR 3 ST

PAGE 28 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS caffeine 3 caffeine citrate powder 3 caffeine citrate 60 mg/3 ml solution 1 caffeine/sodium benzoate 1

CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36 MG QL 2 / day 3 TABLET) ST

QL 1 / day CONCERTA ER 54 MG TABLET 3 ST

QL 1 / day DAYTRANA 3 ST dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, QL 1 / day 15 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 1 mg cpbp 50-50, 40 mg cpbp 50-50) HCG

QL 2 / day dexmethylphenidate hcl 20 mg cpbp 50-50 1 HCG dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet) 1 QL 3 / day dexmethylphenidate hcl 10 mg tablet 1 QL 2 / day

QL 2 / day FOCALIN 3 ST

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, QL 1 / day 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG 3 CAPSULE) ST

QL 2 / day FOCALIN XR 20 MG CAPSULE 3 ST

QL 1 / day METADATE CD 3 ST

QL 3 / day METADATE ER 1 LCG

PAGE 29 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / day METHYLIN 10 MG/5 ML SOLUTION 3 ST

QL 60 / day METHYLIN 5 MG/5 ML SOLUTION 3 ST

QL 3 / day METHYLIN (2.5 MG TAB, 5 MG TABLET, 10 MG TABLET) 3 ST hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 20 QL 1 / day mg cpbp 50-50, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg 1 cpbp 30-70, 60 mg cpbp 30-70) HCG

QL 2 / day methylphenidate hcl (30 mg cpbp 30-70, 30 mg cpbp 50-50) 1 HCG methylphenidate hcl 60 mg cpbp 50-50 1 QL 1 / day methylphenidate hcl powder 3 methylphenidate hcl 10 mg/5 ml solution 1 QL 30 / day methylphenidate hcl 5 mg/5 ml solution 1 QL 60 / day methylphenidate hcl 2.5 mg tab chew 1 methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg QL 2 / day 1 tab er 24) HCG

QL 1 / day methylphenidate hcl 54 mg tab er 24 1 HCG methylphenidate hcl (10 mg tablet, 10 mg tablet er) 1 QL 5 / day methylphenidate hcl (5 mg tab chew, 5 mg tablet, 10 mg tab 3 / day chew, 20 mg tablet, 20 mg tablet er) 1 QL

QL 1 / day QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG CHEW TAB) 3 ST AL At least 6 yrs old

QL 2 / day QUILLICHEW ER 30 MG CHEW TAB 3 ST AL At least 6 yrs old

PAGE 30 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 12 / day QUILLIVANT XR 3 ST

QL 3 / day RITALIN (5 MG TABLET, 20 MG TABLET) 3 ST

QL 5 / day RITALIN 10 MG TABLET 3 ST

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, QL 1 / day 3 60 MG CAPSULE) ST

QL 2 / day RITALIN LA 30 MG CAPSULE 3 ST

WAKEFULNESS-PROMOTING AGENTS

QL 1 / day armodafinil 1 PA HCG

QL 1 / day modafinil 1 PA

QL 1 / day NUVIGIL 3 PA

QL 1 / day PROVIGIL 3 PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS albendazole 3

QL 4 / day ALBENZA 3 PA

BILTRICIDE 3 PA

PAGE 31 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EMVERM 3 PA powder 3 ivermectin 3 mg tablet 1 PA levamisole hcl 3 mebendazole 3 niclosamide 3 praziquantel 3 pyrantel pamoate 3

STROMECTOL 3 PA thiabendazole 3 ANTI-INFECTIVES (SYSTEMIC), MISC. diethylcarbamazine citrate 3 furazolidone 3 URINARY ANTI-INFECTIVES

AZUPHEN MB 1 FURADANTIN 3 HIPREX 3 HYOPHEN 1

INDIOMIN MB 1 HCG

MACROBID 3 MACRODANTIN 3 methenamine 3 methenamine hippurate 1 methenamine mandelate powder 3 methenamine mandelate (1 g tablet, 500 mg tablet) 1 methenamine/sod phosph,monobasic// 1

PAGE 32 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONUROL 3 nitrofurantoin 25 mg/5 ml oral susp 1 nitrofurantoin powder 3 nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule, 100 mg capsule) 1 nitrofurantoin macrocrystal 100 % powder 3 nitrofurantoin monohydrate/macrocrystals 1 PHOSPHASAL 1 PRIMSOL 3 PROSED-DS 3 trimethoprim 100 % powder 3 trimethoprim 100 mg tablet 1 trimethoprim, micronized 3 UR N-C 1

URELLE 1 HCG

URETRON D-S 1

QL 4 / day URIBEL 1 HCG

URIMAR-T 1 URIN D.S. 1

URO-458 1 HCG

URO-BLUE 1

URO-L 1 HCG

UROGESIC-BLUE 3 UROPHEN MB 1 UROQID- NO.2 3 URYL 1

PAGE 33 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS USTELL 1 UTA 1 UTIRA-C 1 ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC 1 QL 0.434 / day

AZASITE 3 QL 0.36/day bacitracin 500 unit/g oint. (g) 1 QL 0.434 / day bacitracin/polymyxin b sulfate 1 QL 0.434 / day

BACTROBAN NASAL 2

BESIVANCE 3 QL 0.767 / day

BLEPH-10 3 QL 5 / fill

BLEPHAMIDE 3 QL 5 / fill

BLEPHAMIDE S.O.P. 3 QL 4 / fill

CETRAXAL 3 QL 0.567 / day

CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day

CIPRO HC 3 QL 0.434 / day

CIPRODEX 2 QL 0.257 / day ciprofloxacin hcl 0.2 % droperette 1 QL 0.567 / day ciprofloxacin hcl 0.3 % drops 1 QL 0.767 / day

COLY-MYCIN S 3 QL 10 / fill

CORTISPORIN-TC 3 QL 10 / fill doxycycline hyclate 20 mg tablet 1 erythromycin base 5 mg/gram oint. (g) 1 QL 0.54 / day

PAGE 34 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLOXIN 3 QL 10 / 30 days gatifloxacin 0.5 % drops 1 QL 0.36/day gatifloxacin 100 % powder 3

GENTAK 1 QL 0.54 / day gentamicin sulfate 0.3 % drops 1 QL 2.143 / day gentamicin sulfate 0.3 % oint. (g) 1 QL 0.54 / day

ILOTYCIN 1 QL 0.54 / day levofloxacin 0.5 % drops 1 QL 0.767 / day

MAXITROL EYE DROPS 3 QL 5 / fill

MAXITROL EYE OINTMENT 3 QL 4 / fill

MOXEZA 2 QL 0.434 / day moxifloxacin hcl 0.5 % drops 1 QL 0.434 / day 100 % powder 3

NEO-POLYCIN 1 QL 0.124 / day

NEO-POLYCIN HC 1 QL 4 / fill sulfate/bacitracin /polymyxin b/hydrocortisone 1 QL 4 / fill neomycin sulfate/bacitracin/polymyxin b 1 QL 0.124 / day neomycin sulfate/polymyxin b sulfate/gramicidin d 1 QL 1.47 / day neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp, 1 QL 10 / fill neomycin/polymyxin b/hydrocort 3.5-10k-1 solution) neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1 QL 10/ fill neomycin/polymyxin b/dexametha 0.1 % drops susp 1 QL 5 / fill neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g) 1 QL 4 / fill

PAGE 35 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NEOSPORIN 3 QL 1.47 / day

OCUFLOX 3 QL 1.47 / day ofloxacin 0.3 % drops 1 QL 1.47 / day

OTIPRIO 3 OTOVEL 3

POLYCIN 1 QL 0.434 / day polymyxin b sulfate/trimethoprim 1 QL 1.47 / day

POLYTRIM 3 QL 1.47 / day

PRED-G 1% EYE DROPS 3 QL 5 / fill

PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill sulfacetamide sodium 10 % drops 1 QL 5 / fill sulfacetamide sodium 10 % oint. (g) 1 QL 4 / fill sulfacetamide sodium/ sodium phosphate 1 QL 5 / fill

TOBRADEX EYE DROPS 3 QL 5 / fill

TOBRADEX EYE OINTMENT 3 QL 4 / fill

TOBRADEX ST 3 QL 5 / fill tobramycin 0.3 % drops 1 QL 2.143 / day tobramycin/ 1 QL 5 / fill

TOBREX 0.3% EYE DROPS 3 QL 2.143 / day

TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day

VIGAMOX 2 QL 0.434 / day

ZYLET 3 QL 5 / fill

ZYMAXID 3 QL 0.36/day

PAGE 36 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIFUNGALS (EENT)

NATACYN 3 QL 0.767 / day

ANTIVIRALS (EENT) idoxuridine 3 trifluridine 1 % drops 1 trifluridine 100 % powder 3 VIROPTIC 3

ZIRGAN 3 QL 0.167 / day

EENT ANTI-INFECTIVES, MISCELLANEOUS

ACETASOL HC 1 acetic acid 2 % solution 1 acetic acid/aluminum 1 BETADINE 3 boric acid (granules, powder) 3 chlorhexidine gluconate 0.12 % mouthwash 1 hydrocortisone/acetic acid 1 PAROEX 1 PERIDEX 3 PERIOGARD 1 povidone-iodine 5 % solution 1 ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ALTABAX 3 bacitracin (5mm unit powder(ea), 65 unit/mg powder) 3 bacitracin zinc micronized 3 bacitracin, micronized 3

PAGE 37 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BACTROBAN (CREAM, OINTMENT) 3 CENTANY 3 CENTANY AT 3 CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN 100 MG VAGINAL OVULE 2

CLEOCIN T 1% GEL 3 QL 75 / 30 days

CLEOCIN T (LOION, PLEDGES, SOLUION) 3 CLINDACIN ETZ KIT 3 CLINDACIN ETZ 1% PLEDGET 1 CLINDACIN P 1 CLINDACIN PAC 3

CLINDAGEL 3 QL 75 / 30 days clindamycin phosphate 1 % foam 1 QL 1.667 / day clindamycin phosphate 1 % gel (gram) 1 QL 75 / 30 days clindamycin phosphate (1 % lotion, 1 % med. swab, 1 % solution, 2 % cream/appl) 1

QL 1.5 / day clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1 HCG clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel QL 1.667 / day 1 (gram), phos/benzoyl 1 % gel w/pump) HCG

QL 2 / day clindamycin phosphate/tretinoin 1 HCG

CLINDESSE 3

CORTISPORIN CREAM 3 QL 0.25 / day

CORTISPORIN OINTMENT 3 QL 0.5 / day

ERY 1

PAGE 38 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ERYGEL 3 QL 1 / day

QL 1.60 / day erythromycin base/benzoyl peroxide 1 HCG erythromycin base/ 2 % gel (gram) 1 QL 1 / day erythromycin base/ethyl (base/ethanol 2 % med. swab, base/ethanol 2 % solution) 1

EVOCLIN 3 QL 1.667 / day gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) 1 METROCREAM 3 METROGEL (GEL, PUMP) 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel (gram)) 1 HCG metronidazole (0.75 % gel w/appl, 1 % gel w/pump) 1 mupirocin 2 % oint. (g) 1 mupirocin 1 NEO-SYNALAR 0.5%-0.025% CREAM 3

QL 1.5 / day NEUAC GEL 1 HCG

NORITATE 3 NUVESSA 3

ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day

ONEXTON GEL PUMP 3 QL 1.967 / day

ROSADAN (CREAM, GEL) 1 HCG

ROSADAN (CREAM KIT, GEL KIT) 3 VANDAZOLE 1

PAGE 39 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) acyclovir 5 % oint. (g) 1 HCG

QL 0.167 / day DENAVIR 3 PA AL At least 12 yrs old docosanol 3

QL 0.167 / day XERESE 3 PA AL At least 6 yrs old

QL 0.167 / day ZOVIRAX 5% CREAM 2 PA AL At least 12 yrs old

QL 30 / fill ZOVIRAX 5% OINTMENT 3 PA AL At least 12 yrs old

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVAR CLEANSER 1 HCG

AVAR 9.5-5% CLEANSING PADS 3 AVAR LS (10-2% CLEANSING PADS, CLEANSER) 3 AVAR LS 10%-2% FOAM 3

AVAR-E 1 HCG

AVAR-E GREEN 1 HCG

AVAR-E LS 3 AVC 3 benzalkonium chloride 3 BP 10-1 1

PAGE 40 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbamide peroxide 3 chlorhexidine gluconate 20 % solution 3 CLARIFOAM EF 3 CLEANSING WASH 1 DERMAZENE 1 FEM PH 3 guaiacol 1 hydrocortisone acetate/iodoquinol/aloe vera 1 hydrocortisone/iodoquinol 1 iodine 3 IODOFLEX 3 IODOSORB 3

KLARON 3 QL 4 / day

LUGOL'S STRONG IODINE SOLUTION 1 mafenide acetate 3 nitrofurazone 3

OVACE 3 QL 12 / day

OVACE PLUS 10% WASH 3 QL 15.767 / day

OVACE PLUS 10% CREAM 3 QL 2 / day

OVACE PLUS 9.8% FOAM 3 QL 3.334 / day

OVACE PLUS 9.8% LOTION 3 QL 4 / day

OVACE PLUS 10% SHAMPOO 3 QL 8 / day

OVACE PLUS WASH 3 QL 12 / day (89 % liquid, 100 % crystals) 3 phenol liquid 1 PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% CLNSING CLOTH, 9.8- 4.8% CREAM, 9.8-4.8% LOTION) 3

PAGE 41 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS polyhexamethylene biguanide/gauze bandage (biguan/gauze bandage 0.2%-2"x2" sponge, biguan/gauze bandage 0.2- 3 6x6.75 sponge, biguan/gauze bandage .2-4.5x4.1 bandage) povidone-iodine 100 % powder 3 RELAGARD 3

ROSANIL 1 HCG

QL 12 / day SEB-PREV 1 HCG sulfide (2.25 % shampoo, 2.5 % lotion) 1 selenium sulfide 52 %-55.5% powder 3 SELRX 3 SILVADENE 3 silver gel (gram) 3 silver nitrate crystals 3 silver nitrate (0.5 % solution, 10 % oint. (g), 25 % solution, 50 % solution) 1 silver ,mild 3 silver sulfadiazine 1 % cream (g) 1 silver sulfadiazine 100 % powder 3 SSD 1

SSS 10-5 CREAM 1 HCG

SSS 10-5 FOAM 1

QL 12 / day sulfacetamide sodium (10 % cleanser, 10 % clnsr gel) 1 HCG sulfacetamide sodium 10 % shampoo 1 QL 8 / day sulfacetamide sodium 10 % suspension 1 QL 4 / day

PAGE 42 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfacetamide sodium/sulfur (sodium/sulfur 8 %-4 % suspension, sodium/sulfur 9 %-4 % cleanser, sodium/sulfur 9 %-4.5 % cleanser, sodium/sulfur 9.8%-4.8% cleanser, sodium/sulfur 10 %-2 % cleanser, sodium/sulfur 10 %-2 % 1 cream (g), sodium/sulfur 10 %-4 % med. pad, sodium/sulfur 10 %-5 % foam, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w) lotion, sodium/sulfur 10-5%(w/w) suspension) sulfacetamide sodium/sulfur 10-5%(w/w) cleanser 1 HCG sulfacetamide sodium/sulfur 10-5%(w/w) cream (g) 1 HCG sulfacetamide sodium/sulfur/skin cleanser comb no.23 1 sulfacetamide sodium/sulfur/ 1

SULFACLEANSE 8-4 1 HCG

SULFAMYLON (8.5% CREAM, POWDER PACKET) 3 SUMADAN 9%-4.5% WASH 3 SUMAXIN (CLEANSING PADS, WASH) 3 SUMAXIN TS 3 TERSI FOAM 3 THERMAZENE 1 3

ULESFIA 3 ST

VYTONE 3 ZENCIA 1 SCABICIDES AND PEDICULICIDES benzyl benzoate 3 crotamiton 3 ELIMITE 3

EURAX (CREAM, LOTION) 3 ST lindane (1 % lotion, 1 % shampoo) 1 malathion 1 HCG

PAGE 43 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NATROBA 3 ST

OVIDE 3 ST permethrin 5 % cream (g) 1 permethrin 92 % liquid 3

SKLICE 3 ST spinosad 1 HCG

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

ALREX 3 QL 0.5 / day

BECONASE AQ 3 QL 1.667 / day 32mcg spray/pump 1 QL 0.574 / day budesonide, micronized 3 CORTANE-B 3 DERMOTIC 3 dexamethasone sod phosphate 0.1 % drops 1 QL 10 / fill

DUREZOL 3

FLAREX 3 QL 10 / fill 25 mcg spray 1 QL .834 / day fluocinolone acetonide oil 1 HCG fluorometholone 1 QL 10 / fill 50 mcg spray susp 1 QL 0.6 / day

FML 3 QL 10 / fill

FML FORTE 3 QL 10 / fill

FML S.O.P. 3 QL 4 / fill

PAGE 44 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill

LOTEMAX 0.5% EYE DROPS 3 QL 21 / fill

LOTEMAX 0.5% EYE OINTMENT 3 QL 4 / fill

MAXIDEX 3 QL 10 / fill furoate 100 % powder 3

QL 0.567 / day mometasone furoate 50 mcg spray/pump 1 HCG

NASONEX 3 QL 0.567 / day

OMNARIS 3 QL 0.434 / day

OMNIPRED 3 QL 21 / fill

PRED FORTE 3 QL 21 / fill

PRED MILD 3 QL 21 / fill prednisolone acetate 1 QL 21 / fill prednisolone sod phosphate 1 % drops 1

QNASL 3 QL 0.3 / day

QNASL CHILDREN 3

RHINOCORT AQUA 3 QL 0.574 / day acetonide 55 mcg spray 1 QL 0.55 / day

TRIESENCE 3 QL 1 / day

VERAMYST 3 QL 0.357 / day

VEXOL 3 QL 10 / fill

ZETONNA 3 QL 0.22 / day

PAGE 45 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

QL 2 / day XIIDRA 3 PA AL At least 17 yrs old

EENT ANTI-INFLAM. AGENTS

ACULAR 3 QL 15 / 30 days

ACULAR LS 3 QL 5 / fill

ACUVAIL 2 QL 1 / day bromfenac sodium 0.09% drops 1 QL 8 / rx

BROMSITE 3 QL 15/ 180 days diclofenac sodium 0.1 % drops 1 QL 5 / fill flurbiprofen sodium 1 QL 3/ fill

ILEVRO 3 QL 4 / fill ketorolac tromethamine 0.4 % drops 1 QL 5 / fill ketorolac tromethamine 0.5 % drops 1 QL 15 / 30 days

NEVANAC 3 QL 3/ fill

OCUFEN 3 QL 3/ fill

PROLENSA 3 QL 3/ fill

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

LEUKOTRIENE MODIFIERS

ACCOLATE 3 QL 2 / day montelukast sodium powder 3

PAGE 46 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab 1 / day chew, 10 mg tablet) 1 QL SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG 1 / day TABLET CHEW, 10 MG TABLET) 3 QL zafirlukast 1 QL 2 / day

QL 4 / day zileuton 3 ST

QL 4 / day ZYFLO 3 ST

QL 4 / day ZYFLO CR 3 ST

MAST-CELL STABILIZERS

ALOCRIL 3 QL 5 / fill cromolyn sodium 20 mg/2 ml ampul-neb 1 cromolyn sodium 4 % drops 1 QL 10 / fill cromolyn sodium 20 mg/ml oral conc 1 cromolyn sodium powder 3 GASTROCROM 3 tranilast 3 ANTIANEMIA DRUGS

IRON PREPARATIONS

ACTIVE FE 3 GL Female

ATABEX EC 3 GL Female

CADEAU DHA 3 DIALYVITE 800 WITH IRON 3 DOTHELLE DHA 3

PAGE 47 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ELITE-OB 400 3 GL Female

ESCAVITE LQ 3 FEROCON 1 FEROTRINSIC 1 FERREX 150 FORTE 3 ferric sulfate 3 FERROCITE PLUS 1 ferrous fumarate 3 ferrous gluconate 3 ferrous sulfate, dried 3 FOCALGIN 90 DHA 3

FOCALGIN CA 3 GL Female

FOCALGIN DSS 3 GL Female

FOLIVANE-PLUS 3 FORTAVIT 3 FUSION PLUS 3 FUSION SPRINKLES 3 HEMATINIC PLUS 1

HEMATINIC WITH FOLIC ACID 1 HCG

HEMATRON-AF 3

HEMAX 1 HCG

HEMOCYTE PLUS 3

HEMOCYTE-F 1 HCG

ICAR-C PLUS 3

INFED 4 S

MACNATAL CN DHA 3 GL Female

PAGE 48 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAXARON FORTE 3 MULTICHEW 3 MULTIGEN FOLIC 3 MULTIGEN PLUS 3 MYKIDZ IRON FL 3

MYNATAL CAPSULE 3 GL Female

MYNATAL ADVANCE 3 GL Female

MYNATAL PLUS 3 GL Female

MYNATAL-Z 3 GL Female

NEWGEN 3 NUTRICAP 3

O-CAL FA 3 GL Female

OBSTETRIX EC 3 GL Female

GL Female OBSTETRIX ONE 1 HCG

OBTREX DHA 3 GL Female pediatric multivitamin no.45/sodium fluoride/ferrous sulfate 1

PNV 29-1 3 GL Female

PNV-DHA + DOCUSATE 3 GL Female

PNV-OMEGA 3 GL Female

POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) 3 POLYSACCHARIDE IRON FORTE 1

PRENA1 PEARL 3 GL Female

PRENA1 TRUE 3 GL Female

PRENATABS RX 3 GL Female

PAGE 49 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal no.79/iron fum/folic acid/levomefolate/dha 3 GL Female prenatal vits with calcium #74/ferrous fumarate/folic acid 3 GL Female prenatal vits with calcium no.72/ferrous fumarate/folic acid 3 prenatal vits with calcium no.74/ferrous fumarate/folic acid 3 GL Female

PREPLUS 3 GL Female

PRETAB 3 GL Female

PROFERRIN-FORTE 3 PROTECT IRON 3 PROVIDA DHA 3

PROVIDA OB 3 GL Female

R-NATAL OB 3 GL Female

RULAVITE DHA 3 TEXAVITE LQ 3 THRIVITE 19 3 THRIVITE RX 3 TL 3

TRI-TABS DHA 3 GL Female

TRICARE PRENATAL 3 GL Female

TRIFERIC 272 MG POWDER PACKET 4 S

TRINATE 3 GL Female

TRIVEEN-ONE 3 GL Female

VINATE DHA 3 GL Female

VINATE DHA RF 3 GL Female

VINATE GT 3 GL Female

PAGE 50 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VINATE II 3 GL Female

VINATE ONE 3 GL Female

VINATE ULTRA 3 GL Female

VIRT-ADVANCE 3 GL Female

VIRT-C DHA 3

VIRT-NATE 3 GL Female

VIRT-NATE DHA 3 GL Female

VIRT-PN 3 GL Female

VIRT-PN DHA 3 GL Female

VIRT-PN PLUS 3 GL Female

VITAFOL GUMMIES 3 GL Female

VITATRUE 3 GL Female

VIVA DHA 3 GL Female

VOL-TAB RX 3 GL Female

VP-CH-PNV 3 GL Female

VP- OB 3 GL Female

VP-HEME ONE 3 GL Female

VP-PNV-DHA 3

VYNATAL-FA 1 GL Female

ANTIARRHYTHMIC AGENTS

ANTIARRHYTHMICS, MISCELLANEOUS

DIGITEK 1 DIGOX 1 digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) 1

PAGE 51 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1 LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET) 2

LANOXIN PEDIATRIC 2 sulfate 100 % crystals 3 magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial) 1 CLASS IA ANTIARRHYTHMICS disopyramide phosphate 1 NORPACE 3 NORPACE CR 100 MG CAPSULE 2 NORPACE CR 150 MG CAPSULE 3 procainamide hcl powder 3 procainamide hcl (100 mg/ml vial, 500 mg/ml vial) 1 gluconate 324 mg tablet er 1 quinidine gluconate 80 mg/ml vial 1 quinidine sulfate (100 % powder, crystals) 3 quinidine sulfate (200 mg tablet, 300 mg tablet, 300 mg tablet er) 1 CLASS IB ANTIARRHYTHMICS

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2 DILANTIN-125 2 lidocaine hcl (20 mg/ml vial, 30 mg/3 ml syringe, 100mg/10ml syringe) 1 lidocaine hcl/pf 100mg/10ml syringe 1 lidocaine hcl/pf (hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial) 1 MED Medical Drug mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) 1 mexiletine hcl 100 % powder 3

PAGE 52 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHENYTEK 2 powder 3 phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1 phenytoin sodium powder 3 phenytoin sodium extended 1 XYLOCAINE 2% VIAL 3 XYLOCAINE-MPF (AMPUL, VIAL) 3 CLASS IC ANTIARRHYTHMICS flecainide acetate 1 hcl (225 mg cap er 12h, 325 mg cap er 12h, 425 mg cap er 12h) 1 HCG propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg tablet) 1 RYTHMOL 3 RYTHMOL SR 3 CLASS II ANTIARRHYTHMICS hcl (200 mg capsule, 400 mg capsule) 1 acebutolol hcl powder 3 100 % powder 3 atenolol (25 mg tablet, 50 mg tablet) 1 LCG atenolol 100 mg tablet 1 atenolol/chlorthalidone 1 BETAPACE 3 BETAPACE AF 3 hcl (10 mg tablet, 20 mg tablet) 1 fumarate 1

PAGE 53 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bisoprolol fumarate/ (bisoprolol/hydrochlorothiazide 2.5-6.25mg tablet, 1 bisoprolol/hydrochlorothiazide 10-6.25mg tablet) bisoprolol/hydrochlorothiazide 5-6.25mg tablet 1 LCG

CORGARD 3 CORZIDE 3

DUTOPROL 3 QL 2 / day

HEMANGEOL 4 S

INDERAL LA 3

INDERAL XL 3 ST

INNOPRAN XL 3 ST

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3 LOPRESSOR HCT 3 succinate 1 metoprolol tartrate 100 % powder 3 metoprolol tartrate (25 mg tablet, 50 mg tablet) 1 LCG metoprolol tartrate (37.5 mg tablet, 75 mg tablet) 1 metoprolol tartrate 100 mg tablet 1 metoprolol tartrate/hydrochlorothiazide 1 powder 3 nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1 nadolol/bendroflumethiazide 1 1 hcl powder 3

PAGE 54 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa 1 24h, 160 mg cap sa 24h) propranolol hcl/hydrochlorothiazide 1 SECTRAL 3 SORINE 1 hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1

SOTYLIZE 3 TENORETIC 100 3 TENORETIC 50 3 TENORMIN 3 maleate 100 % powder 3 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 TOPROL XL 3 ZEBETA 3 ZIAC 3 CLASS III ANTIARRHYTHMICS amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 CORDARONE 2 dofetilide 4 S

MULTAQ 3 PA

PACERONE 1

TIKOSYN 4 S

CLASS IV ANTIARRHYTHMICS powder 3

CALAN 3 QL 3 / day

PAGE 55 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CALAN SR 3 QL 1 / day

CARDIZEM 3 QL 4 / day

CARDIZEM CD (180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 3

CARDIZEM CD 120 MG CAPSULE 3 QL 1 / day

CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MG 1 / day TABLET) 3 QL

CARDIZEM LA 120 MG TABLET 3 QL 4 / day

CARDIZEM LA 180 MG TABLET 3 QL 3 / day

CARDIZEM LA 240 MG TABLET 3 QL 2 / day

CARTIA XT 1 QL 1 / day

DILT XR 120 MG CAPSULE 1 QL 1 / day

DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 hcl (60 mg cap er 12h, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 240 mg cap er 24h, 240 mg cap er deg, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa 1 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 420 mg cap sa 24h) diltiazem hcl 180 mg cap er 24h 1 QL 1 / day diltiazem hcl (120 mg cap er 24h, 120 mg cap er deg, 120 mg cap sa 24h, 180 mg cap er deg, 180 mg cap sa 24h, 300 mg tab 1 QL 1 / day er 24h, 360 mg tab er 24h, 420 mg tab er 24h) diltiazem hcl powder 3 diltiazem hcl 180 mg tab er 24h 1 QL 3 / day diltiazem hcl 240 mg tab er 24h 1 QL 2 / day diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day

MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day

MATZIM LA 180 MG TABLET 1 QL 3 / day

PAGE 56 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MATZIM LA 240 MG TABLET 1 QL 2 / day

TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day

TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 1

TIAZAC (ER 120 MG CAPSULE, ER 180 MG CAPSULE) 3 QL 1 / day

TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER 360 MG CAPSULE, ER 420 MG CAPSULE) 3 hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h 1 / day pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 1 QL 360 mg cap24h pel) verapamil hcl 100 % powder 3 verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil hcl 40 mg tablet 1

VERELAN 3 QL 1 / day

VERELAN PM 3 QL 1 / day

ANTIBACTERIALS

AMINOGLYCOSIDES amikacin 3 amikacin sulfate 1

PA BETHKIS 4 S PS gentamicin sulfate 590mcg/mg powder 3 gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial) 1 gentamicin sulfate/pf 20 mg/2 ml vial 1 kanamycin sulfate 3

PA KITABIS PAK 4 S

PAGE 57 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS neomycin sulfate powder 3 neomycin sulfate 500 mg tablet 1 paromomycin sulfate 250 mg capsule 1 paromomycin sulfate 675 mcg/mg powder 3 streptomycin sulfate powder 3 streptomycin sulfate 1 g vial 1

PA TOBI 4 S

PA TOBI PODHALER 4 S tobramycin 900 mcg/mg powder 3

PA tobramycin in 0.225 % sodium chloride 4 S tobramycin sulfate 634 mcg/mg powder 3 tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) 1

PA tobramycin/nebulizer 4 S

CHLORAMPHENICOL chloramphenicol 3 chloramphenicol palmitate 3 MACROLIDES clarithromycin 100 % powder 3 E.E.S. 200 3 E.E.S. 400 3 ERY-TAB 3 ERYPED 200 2 ERYPED 400 3

PAGE 58 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ERYTHROCIN STEARATE 3 erythromycin base 250 mg capsule dr 1 erythromycin base (250 mg tablet, 500 mg tablet) 1 HCG erythromycin ethylsuccinate 200 mg/5ml susp recon 1 erythromycin ethylsuccinate 400 mg tablet 1 HCG

PCE 3 QUINOLONES

AVELOX 3 QL 21 / fill

AVELOX ABC PACK 3 QL 5 / day

CIPRO 10% SUSPENSION 3 QL 10 / day

CIPRO 5% SUSPENSION 3 QL 7 / day

CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day

CIPRO XR 1,000 MG TABLET 3 QL 14 / 1 rx

CIPRO XR 500 MG TABLET 3 QL 28 / fill ciprofloxacin 250 mg/5ml sus mc rec 1 QL 7 / day ciprofloxacin 500 mg/5ml sus mc rec 1 QL 10 / day ciprofloxacin hcl (100 % crystals, 100 % powder) 3 ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg tablet, 2 / day 750 mg tablet) 1 QL ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr 1 QL 14 / 1 rx ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr 1 QL 28 / fill

QL 7 / day FACTIVE 3 PA

LEVAQUIN 3 QL 30 / fill levofloxacin 100 % powder 3

PAGE 59 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levofloxacin (250mg/10ml solution, 500mg/20ml solution) 1 levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill moxifloxacin hcl 100 % powder 3 moxifloxacin hcl 400 mg tablet 1 QL 21 / fill nalidixic acid 3 ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill

SULFONAMIDES (SYSTEMIC)

AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3 BACTRIM 3 BACTRIM DS 3 sulfacetamide 3 sulfacetamide sodium powder 3 sulfacetamide sodium, monohydrate 3 sulfadiazine powder 3 sulfadiazine 500 mg tablet 1 sulfadiazine sodium 3 sulfamethoxazole 3 sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, 1 sulfamethoxazole/trimethoprim 800-160 mg tablet, sulfamethoxazole/trimethoprim 800-160/20 oral susp) sulfanilamide powder 3 sulfapyridine 3 sulfasalazine powder 3 sulfasalazine (500 mg tablet, 500 mg tablet dr) 1 sulfathiazole 3 SULFATRIM 1

PAGE 60 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfisoxazole 3 TETRACYCLINES

ACTICLATE 3 ST

ADOXA 3 ST

AVIDOXY 1 demeclocycline hcl 1

QL 7/ rx DORYX DR 200 MG TABLET 3 ST

DORYX DR 50 MG TABLET 3 ST

DORYX MPC 3 ST doxycycline hyclate (50 mg capsule, 100 mg capsule, 100 mg tablet) 1 doxycycline hyclate powder 3 doxycycline hyclate (75 mg tablet, 150 mg tablet) 3 ST doxycycline hyclate (50 mg tablet dr, 75 mg tablet dr, 100 mg tablet dr, 150 mg tablet dr) 1 HCG

QL 7/ rx doxycycline hyclate 200 mg tablet dr 1 HCG doxycycline monohydrate 40 mg cap ir dr 1 QL 1 / day doxycycline monohydrate 150 mg capsule 1 QL 30 / fill doxycycline monohydrate 100 % powder 3 doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mg 1 capsule, 100 mg tablet, 150 mg tablet)

MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3 hcl powder 3

QL 1 / day minocycline hcl (90 mg tab er 24h, 135 mg tab er 24h) 1 HCG

PAGE 61 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day minocycline hcl 45 mg tab er 24h 1 HCG minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet) 1

MONDOXYNE NL 1 MONODOX 3 MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

QL 1 / day ORACEA 3 ST oxytetracycline hcl 3

PYLERA 2 QL 120 / 365 days

QL 1 / day SOLODYN 3 ST

TARGADOX 3 ST tetracycline hcl (250 mg capsule, 500 mg capsule) 1 HCG tetracycline hcl powder 3 VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3 ST ANTIBACTERIALS, MISCELLANEOUS

BACITRACINS

BACIIM 1 bacitracin 50000 unit vial 1 GLYCOPEPTIDES

VANCOCIN HCL 3 vancomycin hcl (125 mg capsule, 250 mg capsule) 1 HCG vancomycin hcl 900 mcg/mg powder 3 vancomycin hcl 125mg/2.5 syringe 1

PAGE 62 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LINCOMYCINS

CLEOCIN HCL 3 QL 4 / day

CLEOCIN PALMITATE 3 QL 70/ day

CLEOCIN PHOS 150 MG/ML VIAL 3 MED Medical Drug

CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 300 MG/2 ML VIAL, 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) 3 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg 4 / day capsule) 1 QL clindamycin hcl powder 3 clindamycin palmitate hcl 75 mg/5 ml soln recon 1 QL 70/ day clindamycin phosphate (crystals, powder) 3 clindamycin phosphate 150 mg/ml vial 1 LINCOCIN 3 lincomycin hcl 1 QL 10 / day

OXAZOLIDINONES 100 mg/5ml susp recon 1 QL 900 / rx linezolid 600 mg tablet 1 QL 2 / day

QL 6 / 30 days SIVEXTRO 200 MG TABLET 3 PA

QL 900 / rx ZYVOX 100 MG/5 ML SUSPENSION 3 PA

QL 2 / day ZYVOX 600 MG TABLET 3 PA

POLYMYXINS colistin (colistimethate na) 390mcg/mg powder 3 colistin (colistimethate na) 150 mg vial 1

PAGE 63 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS colistin sulfate 3 COLY-MYCIN M PARENTERAL 3 polymyxin b sulfate 1 polymyxin b sulfate, micronized 3 polymyxin b sulfate,micronized 3 RIFAMYCINS

MYCOBUTIN 3

PRIFTIN 3 QL 1.25 / day rifabutin 1 RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3 RIFAMATE 3 rifampin (150 mg capsule, 300 mg capsule) 1 rifampin powder 3 RIFATER 3 rifaximin 3

XIFAXAN 3 PA

ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

ANASPAZ 3 ATROPEN 3 sulfate powder 3 atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml disp syrin, 0.1 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial) 1

ATROVENT HFA 3 QL 1.29 / day

B-DONNA 1 belladonna alkaloids 3 belladonna alkaloids leaf extract 3

PAGE 64 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BENTYL 10 MG/ML AMPUL 3 BENTYL (10 MG CAPSULE, 20 MG TABLET) 3 CANTIL 3 / 1 clidinium bromide 3 CUVPOSA 3 dicyclomine hcl 100 % powder 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1 LCG dicyclomine hcl 10 mg/ml vial 1 diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine 2.5-.025mg tablet) 1

DONNATAL (ELIXIR, TABLET) 3 DUODOTE 3

ED-SPAZ 1 HCG glycopyrrolate 100 % powder 3 glycopyrrolate (1 mg tablet, 2 mg tablet) 1

QL 30 / day hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup 1 AL At least 2 yrs old

QL 6 / day hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet 1 AL At least 6 yrs old

QL 30 / day HYDROMET 1 AL At least 2 yrs old hyoscyamine sulfate powder 3 hyoscyamine sulfate (0.125 mg tab subl, 0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir) 1 hyoscyamine sulfate 0.125 mg tab rapdis 1 HCG

HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1

PAGE 65 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INCRUSE ELLIPTA 2 QL 1 / day powder 3 ipratropium bromide 0.2 mg/ml solution 1 QL 12.5 / day

LEVBID 3 LEVSIN 0.5 MG/ML AMPUL 3 LEVSIN 0.125 MG TABLET 3 LEVSIN-SL 3 LIBRAX 3 LOMOTIL 3 methscopolamine bromide powder 3 methscopolamine bromide (2.5 mg tablet, 5 mg tablet) 1 methylscopolamine nitrate 3

NULEV 1 HCG

OSCIMIN 0.125 MG TABLET 1

OSCIMIN 0.125 MG ODT 1 HCG

OSCIMIN SL 1 OSCIMIN SR 1 /hyoscyamine sulf/atropine sulf/ hb 1 PHENOHYTRO 1 powder 3 propantheline bromide 15 mg tablet 1 ROBINUL 1 MG TABLET 3 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG/5 ML VIAL, 4 MG/20 ML VIAL) 3

ROBINUL FORTE 3 scopolamine hydrobromide powder 3 scopolamine hydrobromide 0.4 mg/ml vial 1

PAGE 66 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day SEEBRI NEOHALER 3 PA AL At least 18 yrs old

SPIRIVA 2 QL 1 / day

SPIRIVA RESPIMAT 2 QL 1 / day

STIOLTO RESPIMAT 2 QL 0.134 / day

SYMAX 1 HCG

SYMAX DUOTAB 3 SYMAX-SL 1 SYMAX-SR 1

QL 6 / day TUSSIGON 1 AL At least 6 yrs old

ANTIPARKINSONIAN AGENTS benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) 1 COGENTIN 3 hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1 ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

ACD-A 3 citrate phosphate dextros soln 3 sodium citrate 4 % (3 ml) syringe 1 COUMARIN DERIVATIVES

COUMADIN 2 dicumarol 3

JANTOVEN (1 MG TABLET, 3 MG TABLET, 4 MG TABLET) 1 LCG

PAGE 67 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS JANTOVEN (2 MG TABLET, 2.5 MG TABLET, 5 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 1 sodium 100 % powder 3 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 LCG warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1 DIRECT FACTOR XA INHIBITORS

ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 4 S

ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 4 S

QL 2 / day ELIQUIS 3 PA fondaparinux sodium (2.5 mg/0.5 syringe, 7.5mg/0.6 syringe, 10mg/0.8ml syringe) 4 S fondaparinux sodium 5mg/0.4ml syringe 4 S

QL 1 / day SAVAYSA 3 PA

XARELTO STARTER PACK 2

XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day

XARELTO 15 MG TABLET 2 QL 2 / day

DIRECT THROMBIN INHIBITORS

IPRIVASK 4 S

PRADAXA 2 QL 2 / day

HEPARINS enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe, 4 S 120mg/.8ml syringe, 150 mg/ml syringe, 300mg/3ml vial)

PAGE 68 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 4 S 95,000 UNITS/3.8 ML VL) heparin sodium,porcine (5000/ml(1) cartridge, 20000/ml vial) 1 heparin sodium,porcine 180/mg powder 3 heparin sodium,porcine 10000/ml vial 1 MED Medical Drug heparin sodium,porcine/pf (sodium,porcine/pf 5000/0.5ml syringe, sodium,porcine/pf 5000/0.5ml vial) 1 heparin sodium,porcine/pf 1000/ml vial 1 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 4 S MG/3 ML VIAL)

ANTICONVULSANTS, MISCELLANEOUS

APTIOM 3 BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3

QL 20 / day BRIVIACT 10 MG/ML ORAL SOLN 3 PA

QL 4 / day BRIVIACT (10 MG TABLET, 50 MG TABLET) 3 PA

QL 2 / day BRIVIACT 100 MG TABLET 3 PA

QL 8 / day BRIVIACT 25 MG TABLET 3 PA

QL 3 / day BRIVIACT 75 MG TABLET 3 PA powder 3

PAGE 69 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tablet, 300 mg 1 cpmp 12hr) carbamazepine (100 mg tab er 12h, 200 mg tab er 12h, 400 mg tab er 12h) 1 HCG

CARBATROL 2 DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 DEPAKOTE 3 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 divalproex sodium (250 mg tab er 24h, 500 mg tab er 24h) 1 HCG divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250 mg tablet dr, 500 mg tablet dr) 1

EPITOL 1 EQUETRO 3 (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1 FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3 PA

FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day

FYCOMPA (2 MG TABLET, 2 MG-4 MG TABLET KIT, 4 MG TABLET, 1 / day 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 QL

GABITRIL (12 MG TABLET, 16 MG TABLET) 2 GABITRIL (2 MG TABLET, 4 MG TABLET) 3 KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3

KEPPRA XR 3 LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) 3

LAMICTAL (BLUE) 3 LAMICTAL (GREEN) 3

PAGE 70 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LAMICTAL (ORANGE) 3 LAMICTAL ODT 3 LAMICTAL ODT (BLUE) 3 LAMICTAL ODT (GREEN) 3 LAMICTAL ODT (ORANGE) 3 LAMICTAL XR 3 LAMICTAL XR (BLUE) 3 LAMICTAL XR (GREEN) 3 LAMICTAL XR (ORANGE) 3 100 % powder 3 lamotrigine (25 mg tab er 24, 50 mg tab er 24, 100 mg tab er 24, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) 1 HCG lamotrigine (5 mg tb chw dsp, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab rapdis, 50(42)-100 tb rd dspk, 100 mg tab rapdis, 1 100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mg tablet) levetiracetam 100 % powder 3 levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 1 mg tablet) levetiracetam 500 mg/5ml solution 1 QL 946 / 30 days

QL 2 / day LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3 PA

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, QL 3 / day 3 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) PA

QL 30 / day LYRICA 20 MG/ML ORAL SOLUTION 3 PA magnesium chloride 200 mg/ml vial 1

PAGE 71 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) 1

OXTELLAR XR 3

QL 3 / day POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET) 3 PA

QL 9 / day POTIGA 50 MG TABLET 3 PA pregabalin 3 QUDEXY XR 3 ROWEEPRA 1

QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 4 PA S

QL 3 / day SPRITAM 3 AL At least 4 yrs old

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3 TEGRETOL XR 2 tiagabine hcl 1 TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2 (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24) 1 HCG topiramate 99.7 % powder 3 topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600 MG TABLET) 3

TROKENDI XR 3 valproic acid 250 mg capsule 1

PAGE 72 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valproic acid 100 % liquid 3 valproic acid (as sodium ) 100 % powder 3 valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500mg/10ml solution) 1

QL 6 / day vigabatrin 4 PA S

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, STARTER KIT) 3

ZONEGRAN 2 (25 mg capsule, 50 mg capsule, 100 mg capsule) 1 zonisamide 100 % powder 3 (ANTICONVULSANTS)

BREVITAL SODIUM 3 MYSOLINE 3 phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 1 97.2mg tablet, 100 mg tablet) phenobarbital sodium 1 100 % powder 3 primidone (50 mg tablet, 250 mg tablet) 1 (ANTICONVULSANTS)

ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day

ATIVAN 2 MG TABLET 3 QL 5 / day

ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 ML VIAL, 40 MG/10 ML VIAL) 3 100 % powder 3 clonazepam (2 mg tab rapdis, 2 mg tablet) 1 QL 10 / day

PAGE 73 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg 3 / day tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL dipotassium 15 mg tablet 1 QL 6 / day clorazepate dipotassium 3.75 mg tablet 1 QL 24 / day clorazepate dipotassium 7.5 mg tablet 1 QL 12 / day

DIASTAT 3 QL 0.07 / day

DIASTAT ACUDIAL 3 QL 0.07 / day (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1 QL 0.07 / day diazepam 100 % powder 3 diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 5 mg/ml syringe, 5 mg/ml vial, 10 mg tablet) 1

KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day

KLONOPIN 2 MG TABLET 3 QL 10 / day (2 mg tablet, 2 mg/ml oral conc) 1 QL 5 / day lorazepam 100 % powder 3 lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day lorazepam (2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml syringe, 4 mg/ml vial) 1

LORAZEPAM INTENSOL 1 QL 5 / day

PA ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 4 S

TRANXENE T-TAB 3.75 MG 3 QL 24 / day

TRANXENE T-TAB 7.5 MG 3 QL 12 / day

VALIUM 3

PAGE 74 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYDANTOINS

CEREBYX 3 PEGANONE 3 SUCCINIMIDES

CELONTIN 3 ethosuximide 100 % powder 3 ethosuximide (250 mg capsule, 250 mg/5ml solution) 1 ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2

ANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 3 QL 1 / day benactyzine hcl 3

QL 2 / day BUPROBAN 1 HCR hcl 100 % powder 3 bupropion hcl (200 mg tab er 12h, 200 mg tablet er) 1 QL 2 / day bupropion hcl 150 mg tab er 24h 1 QL 3 / day bupropion hcl 300 mg tab er 24h 1 QL 1 / day bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl (100 mg tab er 12h, 100 mg tablet er) 1 QL 4 / day

QL 2 / day bupropion hcl (150 mg tab er 12h, 150 mg tablet er) 1 HCR

FORFIVO XL 3 QL 1 / day 100 % powder 3

PAGE 75 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 1 / day 30 mg tablet, 45 mg tab rapdis, 45 mg tablet) 1 QL mirtazapine 7.5 mg tablet 1 QL 2 / day

REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG SOLTAB, 30 1 / day MG TABLET, 45 MG SOLTAB, 45 MG TABLET) 3 QL

WELLBUTRIN 100 MG TABLET 3 QL 5 / day

WELLBUTRIN 75 MG TABLET 3 QL 6 / day

WELLBUTRIN SR (150 MG TABLET, 200 MG TABLET) 3 QL 2 / day

WELLBUTRIN SR 100 MG TABLET 3 QL 4 / day

WELLBUTRIN XL 150 MG TABLET 3 QL 3 / day

WELLBUTRIN XL 300 MG TABLET 3 QL 1 / day

ZYBAN 3 QL 2 / day

MONOAMINE OXIDASE INHIBITORS

AZILECT 3 ELDEPRYL 3

EMSAM 3 QL 1 / day

MARPLAN 3 QL 6 / day

NARDIL 3 QL 6 / day

PARNATE 3 QL 6 / day sulfate 100 % powder 3 phenelzine sulfate 15 mg tablet 1 QL 6 / day mesylate 100 % powder 3 rasagiline mesylate (0.5 mg tablet, 1 mg tablet) 1 hcl (5 mg capsule, 5 mg tablet) 1 selegiline hcl powder 3

PAGE 76 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfate 1 QL 6 / day

ZELAPAR 3 SEL.SEROTONIN,NOREPI INHIBITOR

CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3 QL 1 / day

CYMBALTA 60 MG CAPSULE 3 QL 2 / day (50 mg tab er 24, 50 mg tab er 24h, 100 mg tab QL 1 / day 1 er 24, 100 mg tab er 24h) HCG

QL 1 / day desvenlafaxine fumarate 1 HCG

QL 1 / day desvenlafaxine succinate 1 HCG hcl (20 mg capsule dr, 30 mg capsule dr) 1 QL 1 / day duloxetine hcl (40 mg capsule dr, 60 mg capsule dr) 1 QL 2 / day duloxetine hcl 100 % powder 3

EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3 QL 1 / day

EFFEXOR XR 75 MG CAPSULE 3 QL 3 / day

FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 QL 1 / day 3 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) ST

IRENKA 3 QL 2 / day

KHEDEZLA 3 QL 1 / day

PRISTIQ 3 QL 1 / day

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 QL 2 / day 3 MG TABLET, TITRATION PACK) ST hcl 75 mg cap er 24h 1 QL 3 / day

PAGE 77 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tab er 24, 75 mg tab er 24, 150 mg cap er 24h, 150 mg tab er 24, 225 mg tab er 1 QL 1 / day 24) venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet) 1 SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

BRISDELLE 3 QL 1 / day

CELEXA 3 QL 1 / day hydrobromide 10 mg/5 ml solution 1 QL 20 / day citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg QL 1 / day 1 tablet) LCG oxalate 5 mg/5 ml solution 1 QL 20 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day escitalopram oxalate 20 mg tablet 1 QL 1 / day 3 fluoxetine hcl (20 mg capsule, 20 mg tablet) 1 QL 4 / day fluoxetine hcl 10 mg capsule 1 QL 1 / day fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine hcl 90 mg capsule dr 1 QL 0.142 / day fluoxetine hcl 20 mg/5 ml solution 1 QL 20 / day fluoxetine hcl 10 mg tablet 1 QL 1.5 / day

QL 1.5 / day fluoxetine hcl 60 mg tablet 1 HCG

QL 2 / day maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 HCG fluvoxamine maleate (25 mg tablet, 50 mg tablet) 1 QL 1 / day

PAGE 78 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluvoxamine maleate 100 mg tablet 1 QL 3 / day

LEXAPRO 5 MG/5 ML SOLUTION 3 QL 20 / day

LEXAPRO (5 MG TABLET, 10 MG TABLET) 3 QL 1.5 / day

LEXAPRO 20 MG TABLET 3 QL 1 / day

QL 1 / day /fluoxetine hcl 1 AL At least 10 yrs old HCG hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 2 / day 24h) 1 QL paroxetine hcl (12.5 mg tab er 24h, 20 mg tablet, 40 mg tablet) 1 QL 1 / day paroxetine hcl 10 mg tablet 1 QL 1.5 / day paroxetine mesylate 1 QL 1 / day

PAXIL 10 MG/5 ML SUSPENSION 3 QL 42 / day

PAXIL (20 MG TABLET, 40 MG TABLET) 3 QL 1 / day

PAXIL 10 MG TABLET 3 QL 1.5 / day

PAXIL 30 MG TABLET 3 QL 2 / day

PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3 QL 2 / day

PAXIL CR 12.5 MG TABLET 3 QL 1 / day

PEXEVA 3 QL 1 / day

PROZAC 10 MG PULVULE 3

PROZAC 20 MG PULVULE 3 QL 4 / day

PROZAC 40 MG PULVULE 3 QL 2 / day

PROZAC WEEKLY 3 QL 0.15 / day

SARAFEM 10 MG TABLET 3 QL 1.5 / day

PAGE 79 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SARAFEM 20 MG TABLET 3 QL 4 / day hcl 20 mg/ml oral conc 1 QL 10 / day sertraline hcl 100 % powder 3

QL 1.5 / day sertraline hcl (25 mg tablet, 50 mg tablet) 1 LCG

QL 2 / day sertraline hcl 100 mg tablet 1 LCG

QL 1 / day SYMBYAX 3 AL At least 10 yrs old

ZOLOFT 20 MG/ML ORAL CONC 3 QL 10 / day

ZOLOFT (25 MG TABLET, 50 MG TABLET) 3 QL 1.5 / day

ZOLOFT 100 MG TABLET 3 QL 2 / day

SEROTONIN MODULATORS

QL 1 / day BRINTELLIX 3 ST hcl 100 mg tablet 1 QL 6 / day nefazodone hcl 150 mg tablet 1 QL 4 / day nefazodone hcl 200 mg tablet 1 QL 3 / day nefazodone hcl 250 mg tablet 1 QL 2.5 / day nefazodone hcl 50 mg tablet 1 QL 12 / day hcl powder 3

QL 4 / day trazodone hcl 100 mg tablet 1 LCG trazodone hcl 150 mg tablet 1 QL 2 / day trazodone hcl 300 mg tablet 1 QL 1 / day

PAGE 80 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day trazodone hcl 50 mg tablet 1 LCG

QL 1 / day TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) 3 ST

VIIBRYD 10-20 MG STARTER PACK 3

VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day

TRICYCLICS, OTHER NOREPI-RU INHIBITORS hcl powder 3 amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 1 LCG amitriptyline hcl/chlordiazepoxide 1 1 ANAFRANIL 3 hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) 1 HCG clomipramine hcl 100 % powder 3 hcl powder 3 desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 1 HCG hcl (10 mg capsule, 25 mg capsule) 1 LCG doxepin hcl (10 mg/ml oral conc, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) 1 doxepin hcl powder 3 hcl 100 % powder 3 imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG imipramine pamoate 1 HCG hcl 1 NORPRAMIN 3

PAGE 81 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl (10 mg capsule, 10 mg/5 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1 nortriptyline hcl powder 3 PAMELOR 3 /amitriptyline hcl 1 hcl 1

SILENOR 3 QL 1 / day

SURMONTIL 3 TOFRANIL 3 TOFRANIL-PM 3 maleate 1 ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS acarbose 100 mg tablet 1 QL 3 / day acarbose 25 mg tablet 1 QL 12 / day acarbose 50 mg tablet 1 QL 6 / day

GLYSET 3 QL 3 / day miglitol 1 QL 3 / day

PRECOSE 100 MG TABLET 3 QL 3 / day

PRECOSE 25 MG TABLET 3 QL 12 / day

PRECOSE 50 MG TABLET 3 QL 6 / day

AMYLINOMIMETICS

SYMLINPEN 120 2 QL 0.4 / day

SYMLINPEN 60 2 QL 0.2 / day

PAGE 82 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIDIABETIC AGENTS, MISCELLANEOUS

PA KORLYM 4 S

WELCHOL 3.75G PACKET 2 QL 1 / day

WELCHOL 625 MG TABLET 2 QL 6 / day

BIGUANIDES

ACTOPLUS MET 3 QL 3 / day

QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB 2 ST

QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB 2 ST

QL 2 / day AVANDAMET 2 PA glipizide/metformin hcl (glipizide/metformin 2.5-500 mg tablet, 4 / day glipizide/metformin 5 mg-500mg tablet) 1 QL glipizide/metformin hcl 2.5-250 mg tablet 1 QL 8 / day

GLUCOPHAGE 1,000 MG TABLET 3 QL 2.5 / day

GLUCOPHAGE 500 MG TABLET 3 QL 5 / day

GLUCOPHAGE 850 MG TABLET 3 QL 3 / day

GLUCOPHAGE XR 500 MG TAB 3 QL 5 / day

GLUCOPHAGE XR 750 MG TAB 3 QL 3 / day

GLUCOVANCE 3 QL 4 / day glyburide/metformin hcl (glyburide/metformin 2.5-500 mg 4 / day tablet, glyburide/metformin 5 mg-500mg tablet) 1 QL glyburide/metformin hcl 1.25-250mg tablet 1 QL 8 / day

PAGE 83 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day INVOKAMET 2 ST

QL 2 / day INVOKAMET XR 2 ST

QL 2 / day JANUMET 2 ST

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

QL 1 / day JANUMET XR 100-1,000 MG TABLET 2 ST

QL 2 / day JENTADUETO 2 ST

QL 1 / day JENTADUETO XR 2 ST metformin hcl 100 % powder 3

QL 5 / day metformin hcl 500 mg tab er 24h 1 C Only Glucophage ER generic covered

QL 3 / day metformin hcl 750 mg tab er 24h 1 C Only Glucophage ER generic covered

QL 2.5 / day metformin hcl 1000 mg tablet 1 LCG

QL 5 / day metformin hcl 500 mg tablet 1 LCG

QL 3 / day metformin hcl 850 mg tablet 1 LCG

QL 3 / day pioglitazone hcl/metformin hcl 1 HCG

PAGE 84 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PRANDIMET 3 QL 5 / day repaglinide/metformin hcl 1 QL 5 / day

RIOMET 3 QL 25 / day

QL 2 / day SYNJARDY 2 ST

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5- QL 2 / day 2 1,000 MG TAB) ST

QL 1 / day SYNJARDY XR 25-1,000 MG TABLET 2 ST

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

QL 1 / day GLYXAMBI 3 PA

QL 1 / day JANUVIA 2 ST

QL 1 / day TRADJENTA 2 ST

INCRETIN MIMETICS

QL 0.15 / day BYDUREON 2 ST

QL .15 / day BYDUREON PEN 2 ST

QL 0.8 / day BYETTA 10 MCG DOSE PEN INJ 2 ST

QL 0.04 / day BYETTA 5 MCG DOSE PEN INJ 2 ST

QL 0.5 / day SAXENDA 3 PA AL At least 18 yrs old

PAGE 85 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.6 / day SOLIQUA 100-33 2 PA

QL 0.08 / day TRULICITY 2 ST

QL 0.3 / day VICTOZA 2-PAK 2 ST

QL 0.3 / day VICTOZA 3-PAK 2 ST

INSULINS

AFREZZA 3 PA

HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2 HUMALOG KWIKPEN U-100 2 HUMALOG KWIKPEN U-200 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN R U-500 2 HUMULIN R U-500 KWIKPEN 2 LANTUS 2 LANTUS SOLOSTAR 2 TOUJEO SOLOSTAR 2 MEGLITINIDES nateglinide 1 QL 3 / day

PRANDIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day

PRANDIN 2 MG TABLET 3 QL 8 / day

PAGE 86 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day

STARLIX 3 QL 3 / day

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

QL 1 / day INVOKANA 2 ST

QL 1 / day JARDIANCE 2 ST

SULFONYLUREAS

AMARYL 3 chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 QL 3 / day

DIABETA 3

DUETACT 3 QL 1 / day glimepiride 1 LCG glipizide 100 % powder 3 glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mg tablet) 1 LCG

GLUCOTROL 3 GLUCOTROL XL 3 glyburide powder 3 glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG glyburide,micronized (3 mg tablet, 6 mg tablet) 1 LCG glyburide,micronized 1.5 mg tablet 1 GLYNASE 3 pioglitazone hcl/glimepiride 1 QL 1 / day

PAGE 87 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day

THIAZOLIDINEDIONES

ACTOS 3 QL 1 / day

QL 3 / day AVANDIA 2 MG TABLET 2 PA

QL 2 / day AVANDIA 4 MG TABLET 2 PA

QL 1 / day AVANDIA 8 MG TABLET 2 PA pioglitazone hcl 1 QL 1 / day

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

QL 0.15 / day AKYNZEO 4 PA S

ANZEMET (50 MG TABLET, 100 MG TABLET) 3 QL 0.15 / day granisetron hcl 1 mg tablet 1 QL 6 / 30 days

QL 24 / 30 days ondansetron 1 Max allowable- 3/day C with max of 24 / 30 days ondansetron hcl 100 % powder 3 ondansetron hcl 4 mg/5 ml solution 1 QL 20 / day

QL 24 / 30 days ondansetron hcl (4 mg tablet, 8 mg tablet) 1 Max allowable- 3/day C with max of 24 / 30 days

PAGE 88 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ondansetron hcl 24 mg tablet 1 QL 3 days ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 ml vial) 4 S ondansetron hcl/pf 4 mg/2 ml syringe 4 S

QL 0.144 / day SANCUSO 4 S

ZOFRAN 4 MG/5 ML ORAL SOLN 3 QL 20 / day

QL 24 / 30 days ZOFRAN (4 MG TABLET, 8 MG TABLET) 3 Max allowable- 3/day C with max of 24 / 30 days

QL 24 / 30 days ZOFRAN ODT 3 Max allowable- 3/day C with max of 24 / 30 days

ZUPLENZ 3 QL 24 / 30 days

ANTIEMETICS, MISCELLANEOUS aprepitant 125mg-80mg cap ds pk 1 QL 3/ fill aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day aprepitant 80 mg capsule 1 QL 0.15 / day

QL 0.67 / day CESAMET 4 PA S

QL 4 / day DICLEGIS 3 PA diphenidol hcl 3

QL 5 / day dronabinol 1 HCG

PAGE 89 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EMEND TRIPACK 3 QL 3/ fill

EMEND (40 MG CAPSULE, 125 MG CAPSULE) 3 QL 0.08 / day

EMEND 80 MG CAPSULE 3 QL 0.15 / day

QL 5 / day MARINOL 3 PA scopolamine 1

QL 13 / day SYNDROS 3 PA AL At least 18 yrs old

TRANSDERM-SCOP 2

QL 0.15 / day VARUBI 4 PA S

ANTIHISTAMINES (GI DRUGS)

ANTIVERT 3

COMPAZINE 25 MG SUPPOSITORY 1 HCG

COMPAZINE (5 MG TABLET, 10 MG TABLET) 3

COMPRO 1 HCG 50 mg/ml vial 1 hcl powder 3 meclizine hcl (12.5 mg tablet, 25 mg tablet) 1 1 HCG prochlorperazine edisylate 100 % powder 3 prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial) 1 prochlorperazine maleate powder 3 prochlorperazine maleate (5 mg tablet, 10 mg tablet) 1

PAGE 90 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TIGAN 300 MG CAPSULE 3 TIGAN 100 MG/ML VIAL 3 trimethobenzamide hcl 300 mg capsule 1 trimethobenzamide hcl 100 % powder 3 ANTIFUNGAL (SYSTEMIC)

ALLYLAMINES

LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK, 250 MG TABLET) 3 terbinafine hcl 100 % powder 3 terbinafine hcl 250 mg tablet 1 ANTIFUNGALS, MISCELLANEOUS

GRIFULVIN V 3 GRIS-PEG 3 griseofulvin powder 3 griseofulvin ultramicrosize 1 griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1 HCG

LUGOL'S SOLUTION 1 potassium iodide (100 % crystals, granules) 3 potassium iodide/iodine 1 sodium caprylate 3 SSKI 3 triacetin 1 AZOLES

CRESEMBA 186 MG CAPSULE 3 PA

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 3

QL 0.4 / day DIFLUCAN 150 MG TABLET 3 GL Female

PAGE 91 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluconazole 100 % powder 3 fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1

QL 0.4 / day fluconazole 150 mg tablet 1 LCG itraconazole 100 mg capsule 1 itraconazole powder 3 itraconazole, micronized 3 powder 3 ketoconazole 200 mg tablet 1 ketoconazole, micronized 3 NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3

ONMEL 3 PA

SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3

VFEND 40 MG/ML SUSPENSION 3 QL 20 / day

VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day voriconazole 100 % powder 3

QL 20 / day voriconazole 200 mg/5ml susp recon 1 HCG

QL 4 / day voriconazole (50 mg tablet, 200 mg tablet) 1 HCG

POLYENES amphotericin b powder 3 amphotericin b 50 mg vial 1 nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 100000/ml oral susp) 1

PAGE 92 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PYRIMIDINES

ANCOBON 3 flucytosine (250 mg capsule, 500 mg capsule) 1 flucytosine 100 % powder 3 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) naftifine hcl 1 NAFTIN (1% CREAM, 1% GEL, 2% CREAM, 2% GEL) 3 ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC

ALA-QUIN 3 clioquinol powder 3

EXODERM 1 HCG sodium thiosulfate 100 % crystals 3 TRIPLE DYE 3 undecylenic acid 3 zinc undecylenate 3 AZOLES (SKIN AND MUCOUS MEMBRANE) clotrimazole powder 3 clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) 1 clotrimazole/ dipropionate (clotrimazole/betamethasone 1 % cream (g), 1 clotrimazole/betamethasone 1 % lotion) econazole nitrate 1 % cream (g) 1 HCG econazole nitrate powder 3 ECOZA 3 ERTACZO 3 EXELDERM (CREAM, SOLUTION) 3

PAGE 93 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXTINA 3 GYNAZOLE 1 3

QL 0.54 / day JUBLIA 3 PA AL At least 18 yrs old ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) 1 LOTRISONE 3

QL 2 / day LUZU 3 PA miconazole 3 miconazole nitrate powder 3 miconazole nitrate 200 mg supp.vag 3 GL Female

NIZORAL 3 ORAVIG 3 oxiconazole nitrate 1 HCG

OXISTAT (CREAM, LOTION) 3

QL 1.5 / day TERAZOL 3 3 GL Female

TERAZOL 7 3 QL 1.5 / day

QL 1.5 / day terconazole 1 GL Female

VUSION 3 XOLEGEL 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)

MENTAX 3

PAGE 94 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 0.77% CREAM KIT 3 CICLODAN 0.77% CREAM 1

CICLODAN 8% SOLUTION 1 QL 0.22 / day ciclopirox (0.77 % gel (gram), 1 % shampoo) 1 ciclopirox 8 % solution 1 QL 0.22 / day ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1 ciclopirox olamine powder 3 CNL 8 3 LOPROX (0.77% TOPICAL SUSP, 1% SHAMPOO) 3

PENLAC 3 QL 0.22 / day

OXABOROLES

QL 0.67 / day KERYDIN 3 PA AL At least 18 yrs old

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 1 NYATA 100,000 UNIT/GM POWDER 1 nystatin (100000/g cream (g), 100000/g oint. (g), 100000/g powder) 1 nystatin (1b unit powder(ea), 2b unit powder(ea), 5b unit powder(ea), 10b unit powder(ea), 15b unit powder(ea), 100mm 3 unit powder(ea)) nystatin/ (nystatin/triamcin 100000- 0.1 cream (g), nystatin/triamcin 100000-0.1 oint. (g)) 1 HCG

NYSTOP 1 PEDIADERM AF 3

PAGE 95 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 2 QL 21 / fill

ALPHAGAN P 0.15% EYE DROPS 3 QL 21 / fill tartrate (0.15 % drops, 0.2 % drops) 1 QL 21 / fill brimonidine tartrate 100 % powder 3

COMBIGAN 2 QL 21 / fill

SIMBRINZA 3 QL 10 / fill

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

BETAGAN 3 QL 21 / fill betaxolol hcl 0.5 % drops 1 QL 21 / fill

BETIMOL 0.25% EYE DROPS 3 QL 5 / fill

BETIMOL 0.5% EYE DROPS 3 QL 21 / fill

BETOPTIC S 3 QL 21 / fill hcl 1 QL 21 / fill

COSOPT 3 QL 10/ fill

COSOPT PF 3 QL 60 / fill dorzolamide hcl/timolol maleate 1 QL 10/ fill

ISTALOL 3 QL 5 / fill hcl 1 QL 21 / fill 1 QL 5 / fill timolol maleate (0.25 % drops, 0.5 % drops) 1 QL 21 / fill timolol maleate (0.25 % sol-gel, 0.5 % sol-gel) 1 QL 5 / fill

PAGE 96 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TIMOPTIC 0.25% EYE DROPS 3 QL 5 / fill

TIMOPTIC 0.5% EYE DROPS 3 QL 10 / fill

TIMOPTIC OCUDOSE 3 QL 60 / fill

TIMOPTIC-XE 3 QL 5 / fill

CARBONIC ANHYDRASE INHIBITORS (EENT) acetazolamide 500 mg capsule er 1 HCG acetazolamide powder 3 acetazolamide (125 mg tablet, 250 mg tablet) 1 acetazolamide sodium 1

AZOPT 2 QL 21 / fill

DIAMOX SEQUELS 3 dorzolamide hcl 1 QL 10 / fill methazolamide powder 3 methazolamide (25 mg tablet, 50 mg tablet) 1 NEPTAZANE 3

TRUSOPT 3 QL 10 / fill

MIOTICS chloride 3 3

ISOPTO CARPINE 3 QL 21 / fill

MIOCHOL-E 3 MIOSTAT 3 PHOSPHOLINE IODIDE 3 hcl (1 % drops, 2 % drops, 4 % drops) 1 QL 21 / fill pilocarpine hcl powder 3

PAGE 97 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pilocarpine nitrate 3 OSMOTIC AGENTS mannitol powder 3 PROSTAGLANDIN ANALOGS bimatoprost 0.03 % drops 1 QL 10/ fill bimatoprost 0.03 % drop w/app 1 latanoprost 0.005 % drops 1 QL 3/ fill latanoprost 100 % oil 3 LATISSE 3

LUMIGAN 2 QL 10 / fill

TRAVATAN Z 2 QL 5 / fill travoprost (benzalkonium) 1 QL 5 / fill

XALATAN 3 QL 3/ fill

ANTIHEMORRHAGIC AGENTS

ANTIHEPARIN AGENTS protamine sulfate 100 % powder 3 HEMOSTATICS

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3 aminocaproic acid 3 ASTRINGYN 3 AVITENE (FLOUR, SHEET 35MMX35MM, SHEET 70MMX35MM, SHEET 70MMX70MM) 3 DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3

DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1

PAGE 98 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS desmopressin acetate powder 3 desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump) 1

ENDO-AVITENE 3 EVARREST 3 EVICEL FIBRIN 2X5 ML SEALANT 3 GELFOAM POWDER 3

QL 6/ day plus 90/ 90 day LYSTEDA 3 limit GL Female

MONSEL'S 3 OXYCEL 3

RECOTHROM (5,000 UNIT VIAL, 20,000 UNIT VIAL) 4 S

STIMATE 4 S

SYRINGE AVITENE 3 TACHOSIL 3 THROMBIN-JMI (5,000 EPIST, 5,000 SYR, 5,000 VIAL, 20,000 PUMP, 20,000 SYR, 20,000 VIAL) 3 TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT, FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) 3 tranexamic acid (98 % powder, powder) 3

QL 6 / day tranexamic acid 650 mg tablet 1 GL Female

ULTRAFOAM 3 DRUGS

FIRST GENERATION

ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old maleate 3

PAGE 99 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS maleate (4 mg tablet, 4 mg/5 ml liquid) 1 AL At least 2 yrs old chlorpheniramine maleate 3 fumarate powder 3 AL At least 2 yrs old clemastine fumarate 2.68 mg tablet 1 AL At least 2 yrs old hcl 100 % powder 3 AL At least 2 yrs old cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml At least 2 yrs old syrup) 1 AL dimenhydrinate 100 % powder 3 hcl 12.5mg/5ml elixir 1 diphenhydramine hcl powder 3 diphenhydramine hcl (50 mg/ml syringe, 50 mg/ml vial) 1 succinate 3

KARBINAL ER 3 AL At least 2 yrs old

RYVENT 3 ST hcl 3 OTHER ANTIHISTAMINES ketotifen fumarate 3 SECOND GENERATION ANTIHISTAMINES cetirizine hcl 1 mg/ml solution 1 QL 10 / day

CLARINEX 0.5 MG/ML (2.5 MG/5) 3 QL 10 / day

CLARINEX 5 MG TABLET 3 QL 1 / day

CLARINEX-D 12 HOUR 3 QL 2 / day desloratadine (2.5 mg tab rapdis, 5 mg tab rapdis, 5 mg tablet) 1 QL 1 / day fexofenadine hcl 100 % powder 3 fexofenadine hcl 180 mg tablet 1 QL 1 / day

PAGE 100 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine dihydrochloride powder 3 levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 30 / day levocetirizine dihydrochloride 5 mg tablet 1 QL 1 / day loratadine 3 loratadine, micronized 3

SEMPREX-D 3 QL 4 / day

XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day

XYZAL 5 MG TABLET 3 QL 1 / day

ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)

FIRST GENERATION ANTIHIST.(RESPIR TRACT)

AL At least 2 yrs old BROMFED DM 1 HCG brompheniramine maleate/pseudoephedrine AL At least 2 yrs old 1 hcl/ HCG

CENTERGY 1 CENTERGY DM 1

QL 10 / day hydrocodone polistirex/chlorpheniramine polistirex 1 AL At least 6 yrs old

PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML At least 2 yrs old AMPUL, 50 MG/ML VIAL) 3 AL hcl/prometh hcl 5-6.25mg/5 syrup 1 promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 At least 2 yrs old mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL promethazine hcl 100 % powder 3 AL At least 2 yrs old

PAGE 101 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 50 mg At least 2 yrs old tablet) 1 AL

AL At least 2 yrs old promethazine hcl 25 mg tablet 1 LCG promethazine hcl/codeine 1 promethazine hcl/dextromethorphan hbr 1 AL At least 2 yrs old

RESPA A.R. 3

QL 6 / day TUSSICAPS 3 AL At least 6 yrs old

QL 10 / day TUSSIONEX 3 AL At least 6 yrs old

QL 4 / day VITUZ 3 AL At least 6 yrs old

SECOND GENERATION ANTIHIST(RESPIR TRACT)

DYMISTA 2 QL 0.8 / day

ANTIHYPOGLYCEMIC AGENTS

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS 3 PROGLYCEM 3 GLYCOGENOLYTIC AGENTS

GLUCAGEN 2 GLUCAGON EMERGENCY KIT 2 glucagon hcl 1 HCG

PAGE 102 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

QL 1 / day JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) 4 PA S

QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 4 PA S

QL 0.15 / day KYNAMRO 4 PA S

LOVAZA 3 QL 4 / day powder 3

QL 2 / day niacin (750 mg tab er 24h, 1000 mg tab er 24h) 1 HCG

QL 3 / day niacin 500 mg tab er 24h 1 HCG

NIACOR 3 QL 12 / day

NIASPAN (ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL 2 / day

NIASPAN ER 500 MG TABLET 3 QL 3 / day

QL 4 / day omega-3 acid ethyl esters 1 HCG

QL 4 / day TRIKLO 1 HCG

QL 4 / day VASCEPA 3 ST

PAGE 103 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIT 3 3 BILE ACID SEQUESTRANTS cholestyramine 3 cholestyramine (with sugar) 4 g powder 1 QL 24 / day cholestyramine (with sugar) 4 g powd pack 1 QL 4 / day

QL 24 / day cholestyramine/ 4 g powder 1 HCG

QL 4 / day cholestyramine/aspartame 4 g powd pack 1 HCG

COLESTID (FLAVORED GRANULES, GRANULES, GRANULES 6 / day PACKET) 3 QL

COLESTID 1 GM TABLET 3 QL 4 / day colestipol hcl (5 g granules, 5 g packet) 1 QL 6 / day colestipol hcl 1 g tablet 1 QL 4 / day

QL 24 / day PREVALITE POWDER 1 HCG

QL 4 / day PREVALITE PACKET 1 HCG

QUESTRAN POWDER 3 QL 24 / day

QUESTRAN PACKET 3 QL 4 / day

QUESTRAN LIGHT 3 QL 24 / day

CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 1 QL 1 / day ezetimibe/simvastatin 1 QL 1 / day

VYTORIN 3 QL 1 / day

PAGE 104 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ZETIA 3 QL 1 / day

FIBRIC ACID DERIVATIVES

ANTARA 30 MG CAPSULE 3 QL 2 / day

ANTARA 90 MG CAPSULE 3 QL 1 / day

QL 1 / day fenofibrate 150 mg capsule 1 HCG

QL 2 / day fenofibrate 50 mg capsule 1 HCG fenofibrate 120 mg tablet 1 QL 1 / day fenofibrate 160 mg tablet 1 QL 1 / day fenofibrate 40 mg tablet 1 QL 2 / day fenofibrate 54 mg tablet 1 QL 2 / day fenofibrate nanocrystallized 145mg tablet 1 QL 1 / day fenofibrate nanocrystallized 48 mg tablet 1 QL 2 / day fenofibrate,micronized (67 mg capsule, 130 mg capsule, 134 1 / day mg capsule, 200 mg capsule) 1 QL fenofibrate,micronized 43 mg capsule 1 QL 2 / day fenofibric acid 105 mg tablet 1 QL 1 / day fenofibric acid 35 mg tablet 1 QL 2 / day fenofibric acid () 135 mg capsule dr 1 QL 1 / day fenofibric acid (choline) 45 mg capsule dr 1 QL 2 / day

FENOGLIDE 120 MG TABLET 3 QL 1 / day

FENOGLIDE 40 MG TABLET 3 QL 2 / day

FIBRICOR 105 MG TABLET 3 QL 1 / day

PAGE 105 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FIBRICOR 35 MG TABLET 3 QL 2 / day gemfibrozil powder 3 gemfibrozil 600 mg tablet 1 QL 2 / day

LIPOFEN 150 MG CAPSULE 3 QL 1 / day

LIPOFEN 50 MG CAPSULE 3 QL 2 / day

LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 160 MG TABLET, 1 / day 200 MG CAPSULE) 3 QL

LOFIBRA 54 MG TABLET 3 QL 2 / day

LOPID 3 QL 2 / day

TRICOR 145 MG TABLET 3 QL 1 / day

TRICOR 48 MG TABLET 3 QL 2 / day

TRIGLIDE 3 QL 1 / day

TRILIPIX DR 135 MG CAPSULE 3 QL 1 / day

TRILIPIX DR 45 MG CAPSULE 3 QL 2 / day

HMG-COA REDUCTASE INHIBITORS

ADVICOR (500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3 QL 2 / day

ADVICOR 1,000 MG-40 MG TABLET 3 QL 1 / day

ALTOPREV 3 QL 1 / day

QL 1 / day amlodipine besylate/atorvastatin calcium 1 HCG atorvastatin calcium 1 QL 1 / day

CADUET 3 QL 1 / day

CRESTOR 3 QL 1 / day fluvastatin sodium 40 mg capsule 1 QL 2 / day

PAGE 106 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluvastatin sodium (20 mg capsule, 80 mg tab er 24h) 1 QL 1 / day

LESCOL 20 MG CAPSULE 3 QL 1 / day

LESCOL 40 MG CAPSULE 3 QL 2 / day

LESCOL XL 3

LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day

LIPITOR 80 MG TABLET 3

LIVALO 3 QL 1 / day lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day lovastatin 40 mg tablet 1 QL 2 / day

PRAVACHOL 3 QL 1 / day

QL 1 / day pravastatin sodium (10 mg tablet, 20 mg tablet) 1 LCG pravastatin sodium 40 mg tablet 1 QL 1 / day pravastatin sodium 80 mg tablet 1 rosuvastatin calcium 1 QL 1 / day

SIMCOR (500-20 MG TABLET, 750-20 MG TABLET, 1,000-20 MG 2 / day TABLET) 3 QL

SIMCOR (500-40 MG TABLET, 1,000-40 MG TABLET) 3 QL 1 / day simvastatin 100 % powder 3 simvastatin (20 mg tablet, 40 mg tablet) 1 QL 1.5 / day

QL 1.5 / day simvastatin 10 mg tablet 1 LCG

QL 1 / day simvastatin 5 mg tablet 1 LCG

QL 1 / day simvastatin 80 mg tablet 1 PA

PAGE 107 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

ZOCOR 5 MG TABLET 3 QL 1 / day

QL 1 / day ZOCOR 80 MG TABLET 3 PA

PCSK9 INHIBITORS

QL 0.08 / day PA PRALUENT PEN 4 S PS

QL 0.08 / day PA PRALUENT SYRINGE 4 S PS

QL 0.13 / day PA REPATHA PUSHTRONEX 4 S PS

QL 0.08 / day PA REPATHA SURECLICK 4 S PS

QL 0.08 / day PA REPATHA SYRINGE 4 S PS

PAGE 108 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIMIGRAINE AGENTS

SELECTIVE SEROTONIN AGONISTS

QL 0.4 / day almotriptan malate 1 HCG

ALSUMA 3 QL 0.167 / day

AMERGE 3 QL 0.3 / day

AXERT 3 QL 0.4 / day

QL 0.4 / day eletriptan hbr 1 HCG

FROVA 3 QL 0.6 / day

QL 0.6 / day frovatriptan succinate 1 HCG

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 3 QL 0.167 / day ML VIAL)

IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3 QL 6 / 30 days

IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3 QL 0.3 / day

MAXALT 3 QL 0.6 / day

MAXALT MLT 3 QL 0.6 / day naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL 0.6 / day

ONZETRA XSAIL 3 ST

RELPAX 3 QL 0.4 / day rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mg tab 0.6 / day rapdis, 10 mg tablet) 1 QL sumatriptan 100 % powder 3

QL 6 / 30 days sumatriptan (5 mg spray, 20 mg spray) 1 HCG

PAGE 109 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen QL 0.167 / day injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml 1 vial) HCG sumatriptan succinate 100 % powder 3 sumatriptan succinate 6 mg/0.5ml syringe 1 QL 0.167 / day sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg 0.3 / day tablet) 1 QL

SUMAVEL DOSEPRO 3 QL 0.134 / day

QL 0.3 / day TREXIMET 3 ST

QL 0.134 / day ZEMBRACE SYMTOUCH 3 ST zolmitriptan 100 % powder 3 QL 0.2 / day zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day

QL 0.2 / day zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis) 1 HCG

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL 0.2 / day

ZOMIG ZMT 3 QL 0.2 / day

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS clofazimine 3 dapsone 98 % powder 3 dapsone (25 mg tablet, 100 mg tablet) 1 ANTITUBERCULOSIS AGENTS aminosalicylate sodium 3

PAGE 110 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aminosalicylic acid 3 BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3

CAPASTAT SULFATE 3 clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) 1 250 mg capsule 1 HCG cycloserine powder 3 ethambutol hcl 1 powder 3 isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1 isoniazid 100 mg/ml vial 1 MYAMBUTOL 3 PASER 3 pyrazinamide 100 % powder 3 pyrazinamide 500 mg tablet 1

SIRTURO 3 PA

TRECATOR 3 ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS) hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1 amantadine hcl powder 3 CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. carbidopa/levodopa/entacapone 1 COMTAN 3 entacapone 1 STALEVO 100 3

PAGE 111 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 TASMAR 3 tolcapone 1 PRECURSORS carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 1 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg-200mg tablet er)

QL 1 / day DUOPA 4 PA S levodopa 3 RYTARY 3 SINEMET 10-100 3 SINEMET 25-100 3 SINEMET 25-250 3 SINEMET CR 3 B INHIBITORS

QL 1 / day XADAGO 3 PA AL At least 18 yrs old

PAGE 112 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPROTOZOALS

AMEBICIDES

FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET) 3 FLAGYL ER 3 iodoquinol 3 metronidazole powder 3 metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1 metronidazole benzoate 3 ANTIMALARIALS atovaquone/proguanil hcl 1 PA phosphate powder 3 chloroquine phosphate (250 mg tablet, 500 mg tablet) 1 COARTEM 3 hydroxychloroquine sulfate powder 3 hydroxychloroquine sulfate 200 mg tablet 1

MALARONE 3 PA mefloquine hcl 1 PLAQUENIL 3 primaquine phosphate 1 pyrimethamine 3

QL 42 / 365 days QUALAQUIN 3 PA quinacrine hcl 3 quinine hcl dihydrate 3

QL 42 / 365 days quinine sulfate 324 mg capsule 1 PA

PAGE 113 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS quinine sulfate powder 3 ANTIPROTOZOALS, MISCELLANEOUS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3 PA antimony trichloride 3 atovaquone 1 PA

IMPAVIDO 4 S

MEPRON 3 NEBUPENT 3 PENTAM 300 3 TINDAMAX 3 tinidazole 100 % powder 3 tinidazole (250 mg tablet, 500 mg tablet) 1 ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

ADASUVE 3 AL At least 18 yrs old succinate 1 AL At least 18 yrs old molindone hcl 1 ORAP 3 pimozide 1 ATYPICAL ANTIPSYCHOTICS

QL 1 / day ABILIFY 3 AL At least 6 yrs old

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

QL 30 / day 1 mg/ml solution 1 AL At least 6 yrs old HCG

PAGE 114 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg At least 6 yrs old tablet, 20 mg tablet, 30 mg tablet) 1 AL HCG

QL 1 / day aripiprazole (10 mg tab rapdis, 15 mg tab rapdis) 1 AL At least 6 yrs old

QL 0.15 / day ARISTADA ER 1064 MG/3.9 ML SYR 3 PA AL At least 18 yrs old

QL 0.07 / day ARISTADA ER 441 MG/1.6 ML SYRN 3 PA AL At least 18 yrs old

QL 0.08 / day ARISTADA ER 662 MG/2.4 ML SYRN 3 PA AL At least 18 yrs old

QL 0.12 / day ARISTADA ER 882 MG/3.2 ML SYRN 3 PA AL At least 18 yrs old

QL 3 / day (12.5 mg tab rapdis, 25 mg tab rapdis, 50 mg tablet) 1 AL At least 18 yrs old

QL 4 / day clozapine 200 mg tablet 1 AL At least 18 yrs old

QL 18 / day clozapine 25 mg tablet 1 AL At least 18 yrs old

QL 9 / day clozapine (100 mg tab rapdis, 100 mg tablet) 1 AL At least 18 yrs old

AL At least 18 yrs old clozapine (150 mg tab rapdis, 200 mg tab rapdis) 1 HCG

PAGE 115 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 9 / day CLOZARIL 100 MG TABLET 3 AL At least 18 yrs old

QL 18 / day CLOZARIL 25 MG TABLET 3 AL At least 18 yrs old

QL 8 / rx FANAPT TITRATION PACK 3 AL At least 18 yrs old

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

FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200 MG QL 3 / day 3 ODT) AL At least 18 yrs old

QL 9 / day FAZACLO 100 MG ODT 3 AL At least 18 yrs old

QL 2 / day GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) 3 ST AL At least 18 yrs old

GEODON 20 MG/ML VIAL 3 ST

ST INVEGA 3 AL At least 12 yrs old

QL 0.0333 / day INVEGA SUSTENNA 117 MG/0.75 ML 3 PA AL At least 18 yrs old

QL 0.04 / day INVEGA SUSTENNA 156 MG/ML SYRG 3 PA AL At least 18 yrs old

QL 0.057 / day INVEGA SUSTENNA 234 MG/1.5 ML 3 PA AL At least 18 yrs old

PAGE 116 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.0111 / day INVEGA SUSTENNA 39 MG/0.25 ML 3 PA AL At least 18 yrs old

QL 0.02 / day INVEGA SUSTENNA 78 MG/0.5 ML 3 PA AL At least 18 yrs old

QL 0.0333 / day INVEGA TRINZA 273 MG/0.875 ML 3 PA AL At least 18 yrs old

QL 0.057 / day INVEGA TRINZA 410 MG/1.315 ML 3 PA AL At least 18 yrs old

QL 0.067 / day INVEGA TRINZA 546 MG/1.75 ML 3 PA AL At least 18 yrs old

QL 0.1 / day INVEGA TRINZA 819 MG/2.625 ML 3 PA AL At least 18 yrs old

QL 1 / day LATUDA 3 AL At least 13 yrs old

QL 2 / day NUPLAZID 4 PA S olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day olanzapine 10 mg tablet 1 QL 3 / day olanzapine 15 mg tablet 1 QL 2 / day olanzapine 20 mg tablet 1 QL 1 / day

PAGE 117 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS olanzapine 7.5 mg tablet 1 QL 4 / day

QL 3 / day olanzapine 10 mg tab rapdis 1 HCG

QL 2 / day olanzapine 15 mg tab rapdis 1 HCG

QL 1 / day olanzapine 20 mg tab rapdis 1 HCG

QL 6 / day olanzapine 5 mg tab rapdis 1 HCG olanzapine 10 mg vial 1

AL At least 12 yrs old 1 HCG

QL 2 / day fumarate (300 mg tab er 24h, 400 mg tab er 24h) 1 AL At least 10 yrs old HCG

QL 5 / day quetiapine fumarate 150 mg tab er 24h 1 AL At least 10 yrs old HCG

QL 4 / day quetiapine fumarate 200 mg tab er 24h 1 AL At least 10 yrs old HCG

QL 6 / day quetiapine fumarate 50 mg tab er 24h 1 AL At least 10 yrs old HCG

QL 6 / day quetiapine fumarate (25 mg tablet, 50 mg tablet) 1 AL At least 10 yrs old

QL 3 / day quetiapine fumarate 100 mg tablet 1 AL At least 10 yrs old

PAGE 118 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1.5 / day quetiapine fumarate 200 mg tablet 1 AL At least 10 yrs old

QL 1 / day quetiapine fumarate 300 mg tablet 1 AL At least 10 yrs old

QL 2 / day quetiapine fumarate 400 mg tablet 1 AL At least 10 yrs old

QL 1 / day REXULTI 3 PA AL At least 18 yrs old

QL 16/day RISPERDAL 1 MG/ML SOLUTION 3 AL At least 5 yrs old

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

QL 5 / day RISPERDAL 3 MG TABLET 3 AL At least 5 yrs old

QL 4 / day RISPERDAL 4 MG TABLET 3 AL At least 5 yrs old

QL 0.1 / day RISPERDAL CONSTA 3 PA AL At least 18 yrs old

QL 8 / day RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG ODT) 3 AL At least 5 yrs old

QL 5 / day RISPERDAL M-TAB 3 MG ODT 3 AL At least 5 yrs old

QL 4 / day RISPERDAL M-TAB 4 MG ODT 3 AL At least 5 yrs old

PAGE 119 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 16/day 1 mg/ml solution 1 AL At least 5 yrs old risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg QL 8 / day 1 tablet) AL At least 5 yrs old

QL 5 / day risperidone 3 mg tablet 1 AL At least 5 yrs old

QL 4 / day risperidone 4 mg tablet 1 AL At least 5 yrs old

QL 8 / day risperidone (0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab At least 5 yrs old rapdis, 2 mg tab rapdis) 1 AL HCG

QL 5 / day risperidone 3 mg tab rapdis 1 AL At least 5 yrs old HCG

QL 4 / day risperidone 4 mg tab rapdis 1 AL At least 5 yrs old HCG

QL 2 / day SAPHRIS 3 ST AL At least 10 yrs old

QL 6 / day SEROQUEL (25 MG TABLET, 50 MG TABLET) 3 AL At least 10 yrs old

QL 3 / day SEROQUEL 100 MG TABLET 3 AL At least 10 yrs old

QL 1.5 / day SEROQUEL 200 MG TABLET 3 AL At least 10 yrs old

QL 1 / day SEROQUEL 300 MG TABLET 3 AL At least 10 yrs old

PAGE 120 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day SEROQUEL 400 MG TABLET 3 AL At least 10 yrs old

SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old

QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2 AL At least 10 yrs old

QL 5 / day SEROQUEL XR 150 MG TABLET 2 AL At least 10 yrs old

QL 4 / day SEROQUEL XR 200 MG TABLET 2 AL At least 10 yrs old

QL 6 / day SEROQUEL XR 50 MG TABLET 2 AL At least 10 yrs old

QL 20 / day VERSACLOZ 3 AL At least 18 yrs old

QL 1 / day VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) 3 PA AL At least 18 yrs old

QL 2 / day hcl 1 AL At least 18 yrs old

QL 6 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 AL At least 13 yrs old

QL 3 / day ZYPREXA 10 MG TABLET 3 AL At least 13 yrs old

QL 2 / day ZYPREXA 15 MG TABLET 3 AL At least 13 yrs old

QL 1 / day ZYPREXA 20 MG TABLET 3 AL At least 13 yrs old

PAGE 121 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day ZYPREXA 7.5 MG TABLET 3 AL At least 13 yrs old

ZYPREXA 10 MG VIAL 3 AL At least 13 yrs old

QL 0.08 / day ZYPREXA RELPREVV 3 PA AL At least 18 yrs old

QL 3 / day ZYPREXA ZYDIS 10 MG TABLET 3 AL At least 13 yrs old

QL 2 / day ZYPREXA ZYDIS 15 MG TABLET 3 AL At least 13 yrs old

QL 1 / day ZYPREXA ZYDIS 20 MG TABLET 3 AL At least 13 yrs old

QL 6 / day ZYPREXA ZYDIS 5 MG TABLET 3 AL At least 13 yrs old

BUTYROPHENONES

HALDOL 3 HALDOL DECANOATE 100 3 HALDOL DECANOATE 50 3 powder 3 haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) 1 50 mg/ml ampul 1 haloperidol decanoate 100 % powder 3 haloperidol decanoate (50 mg/ml vial, 100 mg/ml ampul, 100 mg/ml vial) 1 haloperidol lactate 5 mg/ml ampul 1 haloperidol lactate 2 mg/ml oral conc 1

PAGE 122 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS haloperidol lactate 5 mg/ml vial 1 acepromazine maleate 3 hcl 25 mg/ml ampul 1 chlorpromazine hcl 100 % powder 3 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 HCG decanoate (2.5 %(w/w) oil, 100 % liquid) 3 fluphenazine decanoate 25 mg/ml vial 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1 fluphenazine hcl 2.5 mg/ml vial 1 perphenazine 100 % powder 3 AL At least 18 yrs old perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg At least 18 yrs old tablet) 1 AL hcl 3 hcl 100 % powder 3 thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hcl 1 thiothixene 1 ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

QL 2 / day FUZEON 4 S

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG S 4 TABLET, 150 MG TABLET, 300 MG TABLET) PS

PAGE 123 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HIV INTEGRASE INHIBITORS

GENVOYA 4 S

S ISENTRESS 100 MG POWDER PACKET 4 PS

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 S 4 MG TABLET) PS

S ISENTRESS HD 4 PS

STRIBILD 4 S

TIVICAY 4 S

TRIUMEQ 4 S

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

S ATRIPLA 4 PS

S COMPLERA 4 PS

S EDURANT 4 PS

S INTELENCE 4 PS (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 4 S

ODEFSEY 4 S

RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 4 S

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 4 S

PAGE 124 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 4 S

VIRAMUNE XR 4 S

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS sulfate (20 mg/ml solution, 300 mg tablet) 4 S abacavir sulfate/ 4 S abacavir sulfate/lamivudine/ 4 S

COMBIVIR 4 S

QL 1 / day DESCOVY 4 S 4 S

S EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4 PS

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 4 S

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 4 S

EPZICOM 4 S lamivudine 10 mg/ml solution 4 S lamivudine (150 mg tablet, 300 mg tablet) 4 S lamivudine 100 mg tablet 4 S lamivudine/zidovudine 4 S

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 4 S (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) 4 S

TRIZIVIR 4 S

S TRUVADA 4 PS

PAGE 125 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

S VIDEX 4 PS

VIDEX EC 4 S

VIREAD POWDER 4 S

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 S 4 MG TABLET) PS

ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) 4 S

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 4 S zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 4 S

HIV INHIBITORS

S APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4 PS

S CRIXIVAN 4 PS

EVOTAZ 4 S calcium 4 S

S INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4 PS

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MG TABLET) 4 S

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 4 S

S / 4 PS

NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) 4 S

PAGE 126 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PREZCOBIX 4 S

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG S 4 TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) PS

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MG S 4 CAPSULE) PS

S REYATAZ 50 MG POWDER PACKET 4 PS

QL 2 / day TECHNIVIE 4 PA S

QL 4 / day VIEKIRA PAK 4 PA S

QL 3 / day VIEKIRA XR 4 PA S

S VIRACEPT 4 PS

ANTITHROMBOTIC AGENTS

PLATELET-AGGREGATION INHIBITORS

AGGRENOX 3 QL 2 / day aspirin 100 % powder 3

QL 10 / day aspirin/caffeine/dihydrocodeine bitartrate 1 AL At least 18 yrs old

QL 2 / day aspirin/dipyridamole 1 HCG

PAGE 127 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BRILINTA 2 QL 2 / day butalbital/aspirin/caffeine 50-325-40 capsule 1 QL 6 / day cilostazol 1 QL 2 / day clopidogrel bisulfate 100 % powder 3 clopidogrel bisulfate (75 mg tablet, 300 mg tablet) 1 QL 1 / day dipyridamole 100 % powder 3 dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day

DURLAZA 3 QL 1 / day

EFFIENT 3 QL 1 / day

FIORINAL 3 QL 6 / day

LEVACET 3 PA

PERSANTINE 3 QL 4 / day

PLAVIX 3 QL 1 / day

PLETAL 3 QL 2 / day prasugrel hcl 1 QL 1 / day

QL 10 / day SYNALGOS-DC 3 AL At least 12 yrs old ticlopidine hcl 1 QL 2 / day

QL 1 / day ZONTIVITY 3 PA

PLATELET-REDUCING AGENTS

AGRYLIN 3 QL 4 / day anagrelide hcl 1 QL 4 / day

PAGE 128 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THROMBOLYTIC AGENTS

CATHFLO ACTIVASE 4 S

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ANTITOXINS AND IMMUNE GLOBULINS antivenin,latrodectus mactans 1 antivenin,micrurus fulvius 1 CROFAB 3

PA CUVITRU 4 S

PA GAMMAGARD LIQUID 4 S

PA GAMMAKED 4 S

PA GAMUNEX-C 4 S

PA HIZENTRA 4 S

HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 4 S

HYPERRAB S-D 4 S

HYPERTET S-D 4 S

PA HYQVIA 4 S

PA HYQVIA IG COMPONENT 4 S

IMOGAM RABIES-HT 4 S

PAGE 129 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NABI-HB 4 S

VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 4 S

TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 2 HCR

BOOSTRIX TDAP (SYRINGE, VIAL) 2 HCR

DAPTACEL DTAP 2 HCR

INFANRIX DTAP (SYRINGE, VIAL) 2 PEDIARIX 2

TENIVAC (SYRINGE, VIAL) 2 HCR tetanus and diphtheria toxoids, adult 1 HCR tetanus,diphtheria toxoid ped/pf 1 VACCINES

ACTHIB VACCINE WITH DILUENT 2

AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR

AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR bcg vaccine, live/pf 3 BEXSERO 2 BIOTHRAX 2

CERVARIX 2 HCR

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 2 HCR

ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) 2 HCR

EZ FLU 16-17 (FLUZON QUAD PED) 2 HCR

EZ FLU 2016-2017 (AFLURIA) 2 HCR

EZ FLU 2016-2017 (FLUVIRIN) 2 HCR

PAGE 130 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLUAD 2016-2017 2 HCR

FLUARIX QUAD 2016-2017 2 HCR

FLUBLOK 2016-2017 2 HCR

FLUCELVAX QUAD 2016-2017 2 HCR

FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL) 2 HCR

FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR

FLUZONE HIGH-DOSE 2016-2017 2 HCR

FLUZONE INTRADERM QUAD 2016-17 2 HCR

FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 2 HCR

FLUZONE QUAD PEDI 2016-2017 2 HCR

GARDASIL (SYRINGE, VIAL) 2 HCR

GARDASIL 9 (9 SYRINGE, 9 VIAL) 2 HCR

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 2 HCR

HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIES VACCINE 2 IPOL VIAL 2 IXIARO 2 KINRIX (TIP-LOK SYRINGE, VIAL) 2

M-M-R II VACCINE 2 HCR

MENACTRA 2 HCR

MENHIBRIX 2

MENOMUNE-A-C-Y-W-135 2 HCR

MENVEO A-C-Y-W-135-DIP 2 HCR

PAGE 131 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 2 HCR

PREVNAR 13 2 HCR

PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 2 HCR

ROTARIX 2 ROTATEQ 2 STAMARIL 2

THERACYS 4 S

TRUMENBA 3

TWINRIX (SYRINGE, VIAL) 2 HCR

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2 VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 2 HCR

VARIVAX VACCINE 2 HCR

VAXCHORA ACTIVE COMPONENT 2 VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2

PAGE 132 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS YF-VAX 2

ZOSTAVAX 2 HCR

ANTIULCER AGENTS AND ACID SUPPRESSANTS

HISTAMINE H2-ANTAGONISTS cimetidine powder 3 cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet, 800 mg tablet) 1 cimetidine hcl 1 famotidine 100 % powder 3 famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1 nizatidine (150mg/10ml solution, 300 mg capsule) 1 nizatidine 150 mg capsule 1 QL 2 / day

PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3 ranitidine hcl powder 3 ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg capsule, 300 mg tablet) 1 ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial) 1 ZANTAC (150 MG TABLET, 300 MG TABLET) 3 ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 1,000 MG/40 ML VIAL) 3 PROSTAGLANDINS

ARTHROTEC 50 3 ARTHROTEC 75 3 CYTOTEC 3 diclofenac sodium/misoprostol (sodium/misoprostol 50 tab ir dr, sodium/misoprostol 75 tab ir dr) 1 misoprostol 1 % powder 3 misoprostol (100 mcg tablet, 200 mcg tablet) 1

PAGE 133 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROTECTANTS

CARAFATE 1 GM/10 ML SUSP 2 CARAFATE 1 GM TABLET 3 sucralfate powder 3 sucralfate 1 g tablet 1 -PUMP INHIBITORS

QL 2 / day ACIPHEX 3 ST

ACIPHEX SPRINKLE 3 QL 1 / day

QL 1 / day DEXILANT 3 ST esomeprazole magnesium 20 mg capsule dr 1 QL 1 / day

QL 1 / day esomeprazole magnesium 40 mg capsule dr 1 HCG

QL 1 / day esomeprazole strontium 1 HCG lansoprazole 15 mg capsule dr 1 lansoprazole 30 mg capsule dr 1 QL 1 / day lansoprazole 100 % powder 3

QL 112 / 365 days lansoprazole/amoxicillin trihydrate/clarithromycin 1 HCG

NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3 QL 1 / day

NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG 2 / day PACKET, DR 20 MG PACKET, DR 40 MG PACKET) 3 QL

OMECLAMOX-PAK 3 QL 80 / 365 days omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule 1 / day dr) 1 QL

PAGE 134 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS omeprazole 100 % powder 3 omeprazole/sodium bicarbonate (omeprazole/sodium 20- 1680mg packet, omeprazole/sodium 20mg-1.1g capsule, 1 omeprazole/sodium 40-1680mg packet) omeprazole/sodium bicarbonate 40mg-1.1g capsule 1 HCG

QL 1 / day pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 LCG

PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MG QL 1 / day 3 SOLUTAB, DR 30 MG CAPSULE) ST

PREVPAC 3 QL 112 / 365 days

PRILOSEC (DR 10 MG CAPSULE, DR 20 MG CAPSULE, DR 40 MG QL 1 / day 3 CAPSULE) ST

PRILOSEC (DR 2.5 MG SUSPENSION, DR 10 MG SUSPENSION) 3 ST

PROTONIX 40 MG SUSPENSION 3 QL 1 / day

QL 1 / day PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 3 ST rabeprazole sodium 1 QL 2 / day

ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG CAPSULE) 3 ST

QL 1 / day ZEGERID 40 MG PACKET 3 ST

ANTIVIRALS (SYSTEMIC)

ADAMANTANES

FLUMADINE 3 hcl 1 ANTIVIRALS, MISCELLANEOUS

2-deoxy-d-glucose powder 3

PAGE 135 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INTERFERONS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 PA MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS 4 VIL) S

PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4 S

PA PEGASYS PROCLICK 4 S

PA PEGINTRON 4 S PS

PA PEGINTRON REDIPEN 4 S PS

PA SYLATRON 4 S

NEURAMINIDASE INHIBITORS oseltamivir phosphate 1 QL 20 / 365 days

RELENZA 3 QL 40 / 365 days

TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) 3 QL 20 / 365 days

TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 / 30 days

NUCLEOSIDES AND NUCLEOTIDES acyclovir 100 % powder 3 acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1 adefovir dipivoxil 4 S

QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 4 PA S

PAGE 136 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4 PA S cidofovir 100 % powder 3

QL 6 / day COPEGUS 4 PA S

QL 1 / day entecavir 4 S famciclovir 1 HCG

FAMVIR 3

QL 1 / day HEPSERA 4 PA S

QL 2 / day MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 4 PA S

QL 6 / day MODERIBA 200 MG TABLET 4 PA S

QL 6 / day REBETOL 200 MG CAPSULE 4 PA S

QL 30 / day REBETOL 40 MG/ML SOLUTION 4 PA S

QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 4 PA S

PAGE 137 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day RIBASPHERE 400 MG TABLET 4 PA S

QL 2 / day RIBASPHERE 600 MG TABLET 4 PA S

QL 2 / day RIBASPHERE RIBAPAK 4 PA S

QL 2 / day RIBATAB 4 PA S

QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 4 PA S ribavirin 6 g vial-neb 1

QL 2 / fill SITAVIG 3 PA AL At least 18 yrs old

QL 1 / day TYZEKA 4 PA S valacyclovir hcl 100 % powder 3 valacyclovir hcl (500 mg tablet, 1000 mg tablet) 1 HCG

VALCYTE 50 MG/ML SOLUTION 3

VALCYTE 450 MG TABLET 3 QL 4 / day valganciclovir hcl 50 mg/ml soln recon 1

PAGE 138 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valganciclovir hcl 450 mg tablet 1 QL 4 / day

VALTREX 3

QL 1 / day PA VEMLIDY 4 AL At least 18 yrs old S vidarabine 3 vidarabine monohydrate 3 VIRAZOLE 3 ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET) 3 ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

QL 1 / day AMBIEN 3 ST

QL 1 / day AMBIEN CR 3 ST

BELSOMRA 3 ST hcl 100 % powder 3 buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 1 hydrate 3 PA dichloralphenazone 3 powder 3 droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1

QL 1 / day EDLUAR 3 ST

PAGE 139 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (1 mg tablet, 2 mg tablet) 1 QL 1 / day

QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old

QL 1 / day HETLIOZ 4 PA S hcl powder 3 AL At least 2 yrs old hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg At least 2 yrs old tablet, 50 mg tablet, 50 mg/25ml solution) 1 AL hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) 1 AL At least 2 yrs old hydroxyzine pamoate (25 mg capsule, 50 mg capsule) 1 AL At least 2 yrs old hydroxyzine pamoate 100 mg capsule 1 hydroxyzine pamoate powder 3

QL 1 / day INTERMEZZO 3 ST

QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) 3 ST

QL 1 / day LUNESTA 3 MG TABLET 3 ST AL Up to 65 yrs old 1

PHENADOZ 1 AL At least 2 yrs old

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg At least 2 yrs old supp.rect) 1 AL

PROMETHEGAN 1 AL At least 2 yrs old

QL 1 / day ROZEREM 3 ST

PAGE 140 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day SONATA 3 ST 3

VISTARIL 3 AL At least 2 yrs old 1 QL 1 / day tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg 1 / day tablet, 6.25 mg tab mphase, 10 mg tablet, 12.5 mg tab mphase) 1 QL

ZOLPIMIST 3 QL 0.257 / day

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

AMYTAL SODIUM 3 butalbital 3 BUTISOL SODIUM 3 NEMBUTAL SODIUM 3 sodium 100 % powder 3 pentobarbital sodium 50 mg/ml vial 1 phenobarbital powder 3 SECONAL SODIUM 3 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 100 % powder 3 alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h) 1 QL 1 / day alprazolam 3 mg tab er 24h 1 QL 3 / day alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab 4 / day rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL alprazolam (2 mg tab er 24h, 2 mg tab rapdis, 2 mg tablet) 1 QL 5 / day

ALPRAZOLAM INTENSOL 3 QL 10 / day chlordiazepoxide hcl 10 mg capsule 1 QL 30 / day

PAGE 141 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS chlordiazepoxide hcl 25 mg capsule 1 QL 12 / day chlordiazepoxide hcl 5 mg capsule 1 QL 4 / day

DORAL 3 QL 1 / day 1 QL 1 / day hcl 1 QL 1 / day

HALCION 3 QL 2 / day 3 midazolam hcl 2 mg/ml syrup 1 midazolam hcl (2 mg/2 ml vial, 5 mg/5 ml vial, 5 mg/ml vial, 5 mg/ml(1) vial, 10 mg/10ml vial, 10 mg/2 ml vial) 1 midazolam hcl/pf (hcl/pf 2 mg/2 ml vial, hcl/pf 5 mg/5 ml vial, hcl/pf 5 mg/ml syringe, hcl/pf 5 mg/ml(1) vial, hcl/pf 10 mg/2 1 ml vial) 1 QL 4 / day 1 QL 1 / day

RESTORIL 3 QL 1 / day 1 QL 1 / day 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day

XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day

XANAX 2 MG TABLET 3 QL 5 / day

XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 1 / day

XANAX XR 2 MG TABLET 3 QL 5 / day

XANAX XR 3 MG TABLET 3 QL 3 / day

PAGE 142 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 3 HCR

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG QL 2 / day 3 TABLET) HCR nicotine polacrilex 3

NICOTROL 3 QL 16/day

NICOTROL NS 3 QL 20 / day

PARASYMPATHOMIMETIC ( AGENTS)

ARICEPT (5 MG TABLET, 10 MG TABLET) 3 AL At least 40 yrs old

ST ARICEPT 23 MG TABLET 3 AL At least 40 yrs old chloride powder 3 bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) 1 hcl 1 HCG donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, At least 40 yrs old 10 mg tablet, 23 mg tablet) 1 AL

EVOXAC 3 EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6 MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 3 AL At least 40 yrs old 13.3 MG/24HR PATCH) hbr (8 mg cap24h pel, 16 mg cap24h pel, 24 mg cap24h pel) 1 HCG galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12 mg tablet) 1 guanidine hcl 1 MESTINON 60 MG/5 ML SYRUP 2

PAGE 143 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MESTINON (60 MG TABLET, 180 MG TIMESPAN) 3 NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK) 3 ST neostigmine methylsulfate 100 % powder 3 physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine bromide 100 % powder 3 pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1 RAZADYNE 3 RAZADYNE ER 3 REGONOL 3 rivastigmine 1 AL At least 40 yrs old rivastigmine tartrate 1 AL At least 40 yrs old

SALAGEN 3 URECHOLINE 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS isometheptene mucate 3 BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ 2 QL 1 / day

BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-1-ADRENERGIC AGONISTS dopamine hcl powder 3

PAGE 144 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)

NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS

BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day

BYSTOLIC 2.5 MG TABLET 2 QL 1 / day

BYSTOLIC 20 MG TABLET 2 QL 2 / day

BYVALSON 2 QL 1 / day

BLOOD FORMATION, , THROMBOSIS

HEMATOPOIETIC AGENTS

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 4 S MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 PS MCG/1 ML SYRINGE)

PA EPOGEN 4 S

PA GRANIX 4 S

PA LEUKINE 4 S

PA MIRCERA 4 S

PA MOZOBIL 4 S

PA NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4 S PS

PAGE 145 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4 S PS

PA PROCRIT 4 S PS

PA PROMACTA 4 S

QL 90 / 30 days ZARXIO 4 PA S

HEMORRHEOLOGIC AGENTS pentoxifylline 100 % powder 3 pentoxifylline 400 mg tablet er 1 BRONCHODILATORS

XANTHINE DERIVATIVES aminophylline powder 3 dyphylline 3 ELIXOPHYLLIN 3 THEO-24 3 THEOCHRON 1 theophylline anhydrous powder 3 theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 1 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)

PAGE 146 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CALCIUM-CHANNEL BLOCKING AGENTS

DIHYDROPYRIDINES felodipine 1 QL 1 / day isradipine 1 QL 2 / day

QL 1 / day nisoldipine 1 HCG

SULAR 3 QL 1 / day

CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)

CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)

TARKA 3 QL 1 / day trandolapril/verapamil hcl 1 DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)

ADALAT CC 30 MG TABLET 3 QL 1 / day

ADALAT CC 60 MG TABLET 3 QL 2 / day

ADALAT CC 90 MG TABLET 3

AFEDITAB CR 30 MG TABLET 1 QL 1 / day

AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besylate 100 % powder 3 amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1 QL 1 / day amlodipine besylate/benazepril hcl 1 QL 1 / day

QL 1 / day amlodipine besylate/olmesartan medoxomil 1 HCG amlodipine besylate/valsartan (besylate/valsartan 5 mg-320mg tablet, besylate/valsartan 10mg-160mg tablet, 1 QL 1 / day besylate/valsartan 10mg-320mg tablet)

PAGE 147 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amlodipine besylate/valsartan 5 mg-160mg tablet 1 QL 2 / day

QL 1 / day amlodipine besylate/valsartan/hydrochlorothiazide 1 HCG

AZOR 3 QL 1 / day

CARDENE SR 30 MG CAPSULE 3 QL 2 / day

EXFORGE 3 QL 1 / day

EXFORGE HCT 3 QL 1 / day

LOTREL 3 QL 1 / day hcl (20 mg capsule, 30 mg capsule) 1 HCG

NIFEDICAL XL 1 QL 1 / day (10 mg capsule, 20 mg capsule) 1 QL 4 / day nifedipine powder 3 nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg tab er 24, 1 / day 90 mg tablet er) 1 QL nifedipine (60 mg tab er 24, 60 mg tablet er) 1 QL 2 / day nimodipine 30 mg capsule 1 nimodipine 100 % powder 3

NORVASC 3 QL 1 / day

NYMALIZE 60 MG/20 ML SOLUTION 3 QL 120 / day

PROCARDIA 3 QL 4 / day

PROCARDIA XL 3 QL 1 / day

TEKAMLO 3 QL 1 / day

PAGE 148 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

QL 2 / day CORLANOR 2 ST

RANEXA 2 QL 2 / day

CARDIOVASCULAR DRUGS

BETA-ADRENERGIC BLOCKING AGENTS

LEVATOL 3 CALCIUM-CHANNEL BLOCKING AGENTS

QL 1 / day PRESTALIA 3 ST telmisartan/amlodipine besylate 1 QL 1 / day

TWYNSTA 3 QL 1 / day

SCLEROSING AGENTS

SCLEROSOL 3 sodium tetradecyl sulfate (27 % solution, powder) 3 talc 3 VASODILATING AGENTS betahistine hcl 100 % powder 3 cyclandelate 3 nylidrin hcl 3 CENTRAL AGENTS

ANTIMANIC AGENTS carbonate 99 % powder 3

PAGE 149 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mg capsule) 1 1 LITHOBID 3 CENTRAL NERVOUS SYSTEM AGENTS, MISC. calcium 1 HCG

QL 1 / day PA ADDYI 3 GL Female AL 18 to 60 yrs old

QL 2 / day hcl 1 AL At least 6 yrs old

QL 4 / day PA AUSTEDO 4 AL At least 18 yrs old S carbidopa powder 3 carbidopa 25 mg tablet 1 flibanserin 3 flumazenil 100 % powder 3 hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er 24h) 1 guanfacine hcl (1 mg tablet, 2 mg tablet) 1 idebenone 3

QL 2 / day PA INGREZZA 40 MG CAPSULE 4 AL At least 18 yrs old S

PAGE 150 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INTUNIV 3 QL 1 / day

LODOSYN 3 hcl 100 % powder 3 AL At least 40 yrs old

QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old

AL At least 40 yrs old memantine hcl 5 mg-10 mg tab ds pk 1 HCG

QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old

QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old

NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG At least 40 yrs old TITRATION PK, 10 MG TABLET) 3 AL

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG ST 3 CAPSULE, 28 MG CAPSULE, TITRATION PACK) AL At least 40 yrs old

NUEDEXTA 2 PA

RILUTEK 3 1

QL 2 / day STRATTERA 3 AL At least 6 yrs old

TENEX 3

PA tetrabenazine 4 S

PA XENAZINE 4 S

QL 18 / day XYREM 4 PA S

PAGE 151 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OPIATE ANTAGONISTS

DEPADE 1 naloxone hcl powder 3 naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml syringe) 1 naltrexone hcl 100 % powder 3 naltrexone hcl 50 mg tablet 1 naltrexone hydrochloride dihydrate 3

NARCAN 2 MG NASAL SPRAY 3 QL 5 / 30 days

NARCAN 4 MG NASAL SPRAY 3 QL 2 / 30 days

REVIA 3

PA VIVITROL 380 MG VIAL 4 S

CEPHALOSPORINS

FIRST GENERATION CEPHALOSPORINS cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) 1 cefazolin sodium (10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial) 1 cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 1 750 mg capsule)

QL 4 / day DAXBIA 3 ST

KEFLEX 3 FOURTH GENERATION CEPHALOSPORINS cefepime hcl 1 MAXIPIME (1 VIAL, 2 VIAL) 3

PAGE 152 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SECOND GENERATION CEPHALOSPORINS cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 mg capsule) 1 cefaclor 500 mg tab er 12h 1 QL 20 / 30 days

CEFOTAN 3 cefotetan disodium (1 g vial, 2 g vial) 1 cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) 1

CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2 CEFTIN (250 MG TABLET, 500 MG TABLET) 3 cefuroxime axetil 1 cefuroxime sodium 750 mg vial 1 ZINACEF 750 MG VIAL 3 THIRD GENERATION CEPHALOSPORINS

CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1 cefditoren pivoxil 1

QL 1200 / 90 days cefixime 1 HCG cefotaxime sodium 1 cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) 1 ceftazidime 100 % powder 3 ceftazidime (1 g vial, 2 g vial, 6 g vial) 1 HCG ceftibuten (180 mg/5ml susp recon, 400 mg capsule) 1 HCG ceftriaxone sodium 100 g bulkbaginj 1 HCG ceftriaxone sodium powder 3

PAGE 153 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ceftriaxone sodium (1 g vial, 2 g vial, 10 g vial, 250 mg vial, 500 mg vial) 1

CLAFORAN (1 GM VIAL, 2 GM VIAL, 10 GM VIAL, 500 MG VIAL) 3 FORTAZ (1 GM VIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) 3 SPECTRACEF 3 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) 3 SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML 1200 / 90 days SUSPENSION) 3 QL

TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1 HCG

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS ()

AEROSPAN 2 QL 0.334 / day

ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day

ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb) 1

FLOVENT 250 MCG DISKUS 2 QL 8 / day

FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day

FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day

PULMICORT 3 QL 120 / 30 days

PULMICORT FLEXHALER 2 QL 0.07 / day

CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

QL 4 / day ORKAMBI 4 PA S

PAGE 154 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYSTIC FIBROSIS (CFTR) POTENTIATORS

QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 4 PA S

DEPIGMENTING AND PIGMENTING AGENTS

DEPIGMENTING AGENTS

ACLARO 3 ALPHAQUIN HP 1 BLANCHE 1 4 % cream (g) 1 hydroquinone (100 % crystals, powder) 3 hydroquinone microspheres 1 MELPAQUE HP 1 MELQUIN-3 3 3 monobenzone 3 TRI-LUMA 3 PIGMENTING AGENTS

8-MOP 3 methoxsalen 10 mg cap lq rap 1 methoxsalen (crystals, powder) 3 OXSORALEN 3 OXSORALEN-ULTRA 3

UVADEX 4 S

PAGE 155 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY corticotropin powder 3 CORTROSYN 3 cosyntropin 0.25 mg vial 1

PA H.P. ACTHAR 4 S

ALLERGENIC EXTRACTS (DIAGNOSTIC) allergenic extract tree pollen-american elm 3 allergenic extract, grass pollen-bermuda, standard 3 allergenic extract, grass pollen-orchard grass, standard 3 allergenic extract, mite-d.farinae-d.pteronyssinus,standard 3 allergenic extract,grass pollen-june(kentucky blue),standard 3 allergenic extract,grass pollen-redtop, standard 3 grass pollen-timothy, standard 100k/ml vial 3 QL 1 / day grass pollen-timothy, standard 10k unit/1 vial 3 allergenic extract,mite-dermatophagoides pteronyssinus, std 3 allergenic extract-acremonium strictum 3 allergenic extract-alternaria alternata 3 allergenic extract-american cockroach 3 allergenic extract-aspergillus fumigatus 3 allergenic extract-aspergillus,mixed 3 allergenic extract-aureobasidium pullulans 3 allergenic extract-botrytis cinerea 3 allergenic extract-candida albicans 3 allergenic extract-cattle epithelium 3 allergenic extract-cladosporium cladosporioides 3

PAGE 156 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-cladosporium sphaerospermum 3 allergenic extract-cockroach (american and german) 3 allergenic extract-corn smut 3 allergenic extract-cultivated crop pollen-corn 3 allergenic extract-curvularia 3 allergenic extract-dog epithelium 3 allergenic extract-drechslera sorokiniana 3 allergenic extract-epicoccum nigrum 3 allergenic extract-fire ant 3 allergenic extract-fusarium oxysporum 3 allergenic extract-german cockroach 3 allergenic extract-grass pollen-bahia 3 allergenic extract-grass pollen-johnson 3 allergenic extract-grass pollen-meadow fescue, standardized 3 allergenic extract-grass pollen-perennial rye, standard 3 allergenic extract-grass pollen-quack 3 allergenic extract-grass pollen-smooth brome 3 allergenic extract-horse epithelium 3 allergenic extract-mixed feathers, chicken, duck, goose 3 allergenic extract-mixed weed pollen-short and tall ragweed 3 allergenic extract-mosquito 3 allergenic extract-mouse epithelium 3 allergenic extract-mucor plumbeus 3 allergenic extract-penicillium notatum 3 allergenic extract-phoma herbarum 3 allergenic extract-rabbit epithelium 3 allergenic extract-rhizopus oryzae 3

PAGE 157 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-saccharomyces cerevisiae 3 allergenic extract-sweet vernal, standardized 3 allergenic extract-tree pollen-acacia 3 allergenic extract-tree pollen-alder white 3 allergenic extract-tree pollen-american beech 3 allergenic extract-tree pollen-american sycamore 3 allergenic extract-tree pollen-arizona cypress 3 allergenic extract-tree pollen-australian pine 3 allergenic extract-tree pollen-bald cypress 3 allergenic extract-tree pollen-bayberry 3 allergenic extract-tree pollen-black walnut 3 allergenic extract-tree pollen-black willow 3 allergenic extract-tree pollen-box elder 3 allergenic extract-tree pollen-eastern cottonwood 3 allergenic extract-tree pollen-elm, cedar 3 allergenic extract-tree pollen-hackberry 3 allergenic extract-tree pollen-juniper, western 3 allergenic extract-tree pollen-kapok 3 allergenic extract-tree pollen-melaleuca 3 allergenic extract-tree pollen-mesquite 3 allergenic extract-tree pollen-mountain cedar 3 allergenic extract-tree pollen-mulberry, red 3 allergenic extract-tree pollen-mulberry, white 3 allergenic extract-tree pollen-olive 3 allergenic extract-tree pollen-palm, queen 3 allergenic extract-tree pollen-pecan 3 allergenic extract-tree pollen-pepper tree, california 3

PAGE 158 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-tree pollen-pine, white 3 allergenic extract-tree pollen-privet 3 allergenic extract-tree pollen-red birch 3 allergenic extract-tree pollen-red cedar 3 allergenic extract-tree pollen-red maple 3 allergenic extract-tree pollen-red oak 3 allergenic extract-tree pollen-shagbark 3 allergenic extract-tree pollen-sweet gum 3 allergenic extract-tree pollen-virginia live oak 3 allergenic extract-tree pollen-white ash 3 allergenic extract-tree pollen-white birch 3 allergenic extract-tree pollen-white oak 3 allergenic extract-trichophyton mentagrophytes 3 allergenic extract-venom-honey bee 3 allergenic extract-venom-mixed vespid protein 3 allergenic extract-venom-wasp protein 3 allergenic extract-venom-white-faced hornet protein 3 allergenic extract-venom-yellow hornet protein 3 allergenic extract-venom-yellow jacket protein 3 allergenic extract-weed pollen-carelessweed 3 allergenic extract-weed pollen-cocklebur 3 allergenic extract-weed pollen-dog fennel 3 allergenic extract-weed pollen-english plantain 3 allergenic extract-weed pollen-giant (tall) ragweed 3 allergenic extract-weed pollen-goldenrod 3 allergenic extract-weed pollen-kochia (firebush) 3 allergenic extract-weed pollen-lambsquarters 3

PAGE 159 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-weed pollen-mugwort 3 allergenic extract-weed pollen-rough pigweed 3 allergenic extract-weed pollen-russian thistle 3 allergenic extract-weed pollen-sagebrush 3 allergenic extract-weed pollen-sheep sorrel 3 allergenic extract-weed pollen-sheep sorrel,yellow dock 3 allergenic extract-weed pollen-short ragweed 3 allergenic extract-weed pollen-spiny pigweed 3 allergenic extract-weed pollen-true marsh elder 3 allergenic extract-weed pollen-western ragweed 3 allergenic extract-weed pollen-yellow dock 3 extract 3 extract 3 avocado extract 3 banana extract 3 beef extract 3 cantaloupe extract 3 casein extract 3 cat hair standardized allergenic extract 3 chicken meat extract 3 cocoa extract 3 corn extract 3 crab extract 3 egg extract 3 egg white extract 3 mite-dermatophagoides farinae, standardized 3 oats extract 3

PAGE 160 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS orange extract 3 extract 3 pecan extract 3 pistachio nut extract 3 extract 3 rice extract 3 sesame seed extract 3 shrimp extract 3 extract 3 strawberry extract 3 CARDIAC FUNCTION

IC GREEN 3 indocyanine green 1 DRUG HYPERSENSITIVITY

PRE-PEN 3 FUNGI

CANDIN 3 SPHERUSOL 3 GALLBLADDER FUNCTION

KINEVAC 3 KIDNEY FUNCTION

INDIGO CARMINE 1 indigotindisulfonate sodium in water for injection,sterile 1 LYMPHATIC SYSTEM

LYMPHAZURIN 3

PAGE 161 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MYASTHENIA GRAVIS edrophonium chloride 3 ENLON 3 OCULAR DISORDERS

BIOGLO 1 FLUCAINE 1 FLUOR-I-STRIP AT 1 fluorescein sodium 3 FUL-GLO 1 MG OPTH STRIPS 1 FUL-GLO EYE STRIPS 3 MEMBRANEBLUE 3 proparacaine hcl/fluorescein sodium 1 PANCREATIC FUNCTION acetate (human) 3 PITUITARY FUNCTION

METOPIRONE 3 ROENTGENOGRAPHY barium sulfate 3 CONRAY 3 CYSTOGRAFIN 3 CYSTOGRAFIN-DILUTE 3 E-Z DISK 3 E-Z-CAT 3 E-Z-HD 3 E-Z-PAQUE 3 E-Z-PASTE 3 ENTERO VU 3

PAGE 162 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GASTROGRAFIN 3 ISOVUE-200 41% VIAL 3 LIQUID E-Z PAQUE 3 LIQUID POLIBAR PLUS 3 MD-76 R (R 66-10 BOTTLE, R 66-10 VIAL) 3 MD-GASTROVIEW 1 POLIBAR ACB 3 READI-CAT 2 3 SINOGRAFIN 3 SITZMARKS 3 TAGITOL 3 ULTRAVIST 3 VARIBAR HONEY 3 VARIBAR NECTAR 3 VARIBAR PUDDING 3 VARIBAR THIN HONEY 3 VARIBAR THIN LIQUID 3 VOLUMEN 3 THYROID FUNCTION protirelin 3 TUBERCULOSIS

APLISOL 3 TUBERSOL 3 DIURETICS

LOOP DIURETICS (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 bumetanide 0.25 mg/ml vial 1

PAGE 163 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEMADEX 3 EDECRIN 3 ethacrynic acid 1 powder 3 furosemide (10 mg/ml syringe, 10 mg/ml vial) 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) 1

LASIX 3 torsemide 1 OSMOTIC DIURETICS mannitol/sorbitol solution 1 HCG

POTASSIUM-SPARING DIURETICS amiloride hcl 1 amiloride hcl/hydrochlorothiazide 1 DYAZIDE 3 DYRENIUM 3 MAXZIDE 3 MAXZIDE-25 MG 3 triamterene 3 triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg tablet, 1 triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet) THIAZIDE DIURETICS chlorothiazide 1 DIURIL 3 hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 50 mg tablet) 1

PAGE 164 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydrochlorothiazide 100 % powder 3 hydrochlorothiazide 25 mg tablet 1 LCG methyclothiazide 1 MICROZIDE 3

QL 1 / day TEKTURNA HCT 3 ST trichlormethiazide 3 THIAZIDE-LIKE DIURETICS chlorthalidone 1 indapamide 1 metolazone 1 VASOPRESSIN ANTAGONISTS

QL 1 / day SAMSCA 15 MG TABLET 4 PA S

QL 2 / day SAMSCA 30 MG TABLET 4 PA S

DIURETICS (HYPOTENSIVE AGENTS)

POTASSIUM-SPARING DIURETICS (HYPOTEN)

ALDACTAZIDE 3 ALDACTONE 3 eplerenone 1 HCG

INSPRA 3 100 % powder 3 spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

PAGE 165 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS spironolactone, micronized 3 spironolactone/hydrochlorothiazide 1 THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)

ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3 QL 2 / day

ACCURETIC 20-25 MG TABLET 3 QL 1 / day

ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3 QL 1 / day

ATACAND HCT 16-12.5 MG TAB 3 QL 2 / day

AVALIDE 150-12.5 MG TABLET 3 QL 2 / day

AVALIDE 300-12.5 MG TABLET 3 QL 1 / day benazepril hcl/hydrochlorothiazide 1 QL 1 / day

BENICAR HCT 3 QL 1 / day candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 32-12.5mg tablet, 1 QL 1 / day candesartan/hydrochlorothiazid 32mg-25mg tablet) candesartan/hydrochlorothiazid 16-12.5mg tablet 1 QL 2 / day captopril/hydrochlorothiazide 1 QL 2 / day

DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3 QL 1 / day

DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB, 160-25 2 / day MG TABLET) 3 QL enalapril/hydrochlorothiazide 10 mg-25mg tablet 1 QL 2 / day enalapril/hydrochlorothiazide 5mg-12.5mg tablet 1 fosinopril sodium/hydrochlorothiazide 1 QL 2 / day

HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3 QL 1 / day

HYZAAR 50-12.5 TABLET 3 QL 2 / day irbesartan/hydrochlorothiazide 150-12.5mg tablet 1 QL 2 / day

PAGE 166 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS irbesartan/hydrochlorothiazide 300-12.5mg tablet 1 QL 1 / day lisinopril/hydrochlorothiazide 1 QL 2 / day losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 100-12.5mg tablet, 1 QL 1 / day losartan/hydrochlorothiazide 100mg-25mg tablet) losartan/hydrochlorothiazide 50-12.5 mg tablet 1 QL 2 / day

LOTENSIN HCT 3 QL 1 / day /hydrochlorothiazide 1

MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3 QL 1 / day

MICARDIS HCT 80-12.5 MG TABLET 3 QL 2 / day moexipril hcl/hydrochlorothiazide 1 QL 2 / day olmesartan medoxomil/amlodipine QL 1 / day 1 besylate/hydrochlorothiazide HCG olmesartan medoxomil/hydrochlorothiazide 1 QL 1 / day quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 10-12.5mg tablet, 1 QL 2 / day quinapril/hydrochlorothiazide 20-12.5 mg tablet) quinapril/hydrochlorothiazide 20 mg-25mg tablet 1 QL 1 / day

QL 2 / day telmisartan/hydrochlorothiazid 80-12.5mg tablet 1 HCG telmisartan/hydrochlorothiazide QL 1 / day (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, 1 telmisartan/hydrochlorothiazid 80 mg-25mg tablet) HCG

TRIBENZOR 3 QL 1 / day valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 320-12.5mg tablet, valsartan/hydrochlorothiazide 320mg- 1 QL 1 / day 25mg tablet)

PAGE 167 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, valsartan/hydrochlorothiazide 160-12.5mg 1 QL 2 / day tablet, valsartan/hydrochlorothiazide 160-25mg tablet)

VASERETIC 3 QL 2 / day

ZESTORETIC 3 QL 2 / day

THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT)

CLORPRES 3

QL 1 / day EDARBYCLOR 3 ST

DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS mesylate (2.5 mg tablet, 5 mg capsule) 1 bromocriptine mesylate powder 3 1

QL 6 / day CYCLOSET 3 PA

PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3 NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

PA APOKYN 4 S hcl 3 MIRAPEX 3

MIRAPEX ER 3 ST

NEUPRO 3 di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h, 1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg 1 HCG tab er 24h, 4.5 mg tab er 24h)

PAGE 168 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 1

REQUIP 3

REQUIP XL 3 QL 1 / day hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 1 / day 24h, 8 mg tab er 24h, 12 mg tab er 24h) 1 QL ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS chloride granules 3 K-PHOS NEUTRAL 3 K-PHOS NO.2 3 K-PHOS ORIGINAL 3 PHOSPHA 250 NEUTRAL 1 VIRT-PHOS 250 NEUTRAL 1 ALKALINIZING AGENTS /sodium citrate 1 CYTRA-2 1 CYTRA-3 3 CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1 ORACIT 3 potassium citrate 1 potassium citrate/citric acid 1100-334/5 solution 1 SHOHL'S MODIFIED 3 sodium citrate 100 % powder 3 sodium citrate dihydrate 3 sodium/potassium/potassium citrate/sodium citrate/cit ac 1

PAGE 169 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TARON-CRYSTALS 1 TRICITRASOL 3 TRICITRATES 1 UROCIT-K 3 VIRTRATE-2 1 VIRTRATE-3 1 VIRTRATE-K 1 AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 4 S

CARBAGLU 4 S

CONSTULOSE 1 ENULOSE 1 GENERLAC 1 KRISTALOSE 1 lactulose 1 LITHOSTAT 3

QL 20 / day RAVICTI 4 PA S sodium phenylbutyrate 100 % powder 3 sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 4 S

CALORIC AGENTS

ACD 1 powder 3 (100 % crystals, 100 % powder) 3 arginine hcl 3 3

PAGE 170 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl powder 3 dextrose 3 (100 % crystals, powder) 3 hcl 3 LYSIPLEX PLUS 1 3 ribose 3 3 IRRIGATING SOLUTIONS

RESECTISOL 3 REPLACEMENT PREPARATIONS

0.9 % sodium chloride 0.9 % syringe 1 0.9 % sodium chloride 0.9 % vial 1 bacteriostatic sodium chloride 1 calcium chelate 3 calcium carbonate 3 calcium citrate 3 calcium glubionate 3 calcium glucarate 3 monohydrate 3 calcium levulinate dihydrate 3 calcium phosphate 3 cardioplegic solution no.1 1 cardioplegic solution no.10 3 EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3 EFFER-K 25 MEQ TABLET EFF 1

FOLBECAL 3 GL Female

PAGE 171 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FOLGARD OS 3 HYPER-SAL 3 K EFFERVESCENT 1 K-SOL 1 K-TAB ER 3 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 25 MEQ PACKET 3 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 3 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 magnesium amino acid chelate 3 magnesium glycinate 3 chloride 100 % powder 3 manganese gluconate 3 molybdenum 3 MONOJECT 0.9% SODIUM CHLORIDE 1 MONOJECT PREFILL 0.9% FLUSH 1 MONOJECT PREFILL ADVANCED 1 NEBUSAL 3% VIAL 1 NEBUSAL 6% VIAL 3 PLEGISOL 3 potassium bicarbonate/citric acid 1

PAGE 172 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid, 1 40meq/15ml liquid) potassium chloride (granules, powder) 3 potassium chloride/potassium bicarbonate/citric acid 1 potassium citrate monohydrate (100 % granules, 100 % powder) 3 potassium phosphate, dibasic 3 potassium phosphate,monobasic 3

PRENAISSANCE NEXT 3 GL Female

PRISMASOL (B22GK 2/0, B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5, BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2) 3

PULMOSAL 1 selenomethionine 3 sodium acetate trihydrate (100 % powder, crystals, granules) 3 sodium aspartate monohydrate 3 sodium cacodylate 3 sodium chloride for inhalation 1 SYREX 1 zinc chloride 100 % powder 3 zinc picolinate 3 zinc sulfate 100 % powder 3 zinc sulfate heptahydrate 3 SALT AND SUGAR SUBSTITUTES saccharin 1 URICOSURIC AGENTS probenecid 1 QL 4 / day probenecid/ 1 QL 2 / day

PAGE 173 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day ZURAMPIC 3 PA AL At least 18 yrs old

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS ammonium lactate 12 % lotion 1 ATOPICLAIR 3 calamine 3 lactic acid 10 % lotion 1 PRUCLAIR 3 BASIC OILS AND OTHER SOLVENTS

AVO CREAM 3 BIAFINE 3 LUXAMEND 1 mineral oil 3 PRUTECT 3 SONAFINE 3 SYNERDERM 3 BASIC OINTMENTS AND PROTECTANTS ammonium lactate 12 % cream (g) 1 DEXERYL 3 ELETONE CREAM 3 lactic acid 10 % cream (g) 1 TETRIX CREAM 3 VASELINE WHITE PETROLEUM 3 XCLAIR 3

PAGE 174 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AND

ESTROGEN AGONIST-ANTAGONISTS clomiphene citrate 100 % powder 3 clomiphene citrate 50 mg tablet 1 GL Female

DUAVEE 2

EVISTA 3 QL 1 / day

OSPHENA 3 hcl 1 HCR

SEROPHENE 1 GL Female

ESTROGENS

QL 1 / day ACTIVELLA 3 GL Female

QL 0.29 / day ALORA 3 GL Female

QL 1 / day AMABELZ 1 GL Female

QL 1 / day ANGELIQ 3 GL Female

QL 0.15 / day CLIMARA 3 GL Female

QL 0.15 / day CLIMARA PRO 2 GL Female

QL 0.29 / day COMBIPATCH 3 GL Female

COVARYX 1 GL Female

PAGE 175 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COVARYX H.S. 1 GL Female

DELESTROGEN 3 GL Female

DEPO- 3 GL Female 3 DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL Female PACKET) 2 GL

EEMT 1 GL Female

EEMT H.S. 1 GL Female

ELESTRIN 3 GL Female

QL 1 / day ENJUVIA 2 GL Female

ESTRACE 0.01% CREAM 2 GL Female

QL 1 / day ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 GL Female estradiol (.025mg/24h patch tdsw, .0375mg/24 patch tdsw, QL 0.29 / day 0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hr 1 patch tdsw) GL Female estradiol (.025mg/24h patch tdwk, 0.05mg/24h patch tdwk, QL 0.15 / day 1 0.1mg/24hr patch tdwk) GL Female estradiol (.0375mg/24 patch tdwk, 0.06mg/24h patch tdwk, QL 0.15 / day 1 .075mg/24h patch tdwk) GL Female estradiol 100 % powder 3

QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female LCG estradiol 10 mcg tablet 1 GL Female

QL 1 / day estradiol 2 mg tablet 1 GL Female

PAGE 176 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 3 estradiol hemihydrate, micronized 3 estradiol micronized 3 powder 3 estradiol valerate (20 mg/ml vial, 40 mg/ml vial) 1 GL Female

QL 1 / day estradiol/norethindrone acetate 1 GL Female

QL 90 days ESTRING 2 GL Female 3 GL Female estriol micronized 3 GL Female

QL 1.667 / day ESTROGEL 3 GL Female estrogens,esterified/ 1 GL Female (100 % powder, crystals) 3

QL 1 / day (0.75 mg tablet, 1.5 mg tablet) 1 GL Female LCG

QL 1 / day estropipate 3 mg tablet 1 GL Female

QL 0.54 / day EVAMIST 3 GL Female

QL 1 / day FEMHRT 3 GL Female

QL 0.02 / day FEMRING 3 GL Female

PAGE 177 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FYAVOLV 1 GL Female

JEVANTIQUE LO 3 GL Female

QL 1 / day JINTELI 1 GL Female HCR

QL 1 / day LOPREEZA 1 GL Female

QL 1 / day MENEST (0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 3 GL Female

QL 1 / day MENEST 0.3 MG TABLET 2 GL Female

QL 0.15 / day MENOSTAR 3 GL Female

QL 1 / day MIMVEY 1 GL Female

MIMVEY LO 1

QL 0.29 / day MINIVELLE 3 GL Female norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg- 5mcg tablet) 1 HCR

QL 1 / day OGEN 3 GL Female

QL 1 / day PREFEST 3 GL Female

PREMARIN VAGINAL CREAM-APPL 2 GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, QL 1 / day 2 0.9 MG TABLET, 1.25 MG TABLET) GL Female

PAGE 178 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREMARIN 25 MG VIAL 2

QL 1 / day PREMPHASE 2 GL Female

QL 1 / day PREMPRO 2 GL Female

VAGIFEM 3 GL Female

QL 8 / 28 days VIVELLE-DOT 3 GL Female

YUVAFEM 1 GL Female

EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

ALOMIDE 3 QL 10 / fill

ASTEPRO 3 QL 2 / day hcl 0.05 % drops 1 QL 10 / fill azelastine hcl 100 % powder 3 azelastine hcl (137 mcg spray/pump, 205.5mcg spray/pump) 1 QL 2 / day

BEPREVE 3 QL 5 / fill

ELESTAT 3 QL 5 / fill

EMADINE 3 QL 5 / fill epinastine hcl 1 QL 5 / fill

QL 3 / 30 days LASTACAFT 3 ST

QL 5 / 30 days hcl 0.1 % drops 1 HCG olopatadine hcl 0.2 % drops 1 QL 3/ fill

PAGE 179 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 31 / 30 days olopatadine hcl 0.6 % spray/pump 1 HCG

PATADAY 3 QL 3/ fill

PATANASE 3 QL 31 / 30 days

PATANOL 3 QL 5 / 30 days

PAZEO 3 QL 3/ fill

EENT DRUGS, MISCELLANEOUS in sterile water/pf 1 QL 10 / 30 days hcl 1 QL 10/ fill

ATROVENT 3 QL 2 / day balanced salt irrig soln no.2 1 BSS 1 BSS PLUS 3 CELLUGEL 3

PA CYSTARAN 4 S

GELFILM 3

IOPIDINE 1% EYE DROPS 3 QL 28 / fill

IOPIDINE 0.5% EYE DROPS 3 QL 10/ fill ipratropium bromide (21 mcg spray, 42 mcg spray) 1 QL 2 / day

LACRISERT 3

QL 0.04 / day LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 4 PA S

OCUCOAT 1

PAGE 180 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOCAL (EENT)

AKTEN 3 ALCAINE 3 ALTACAINE 1 ALTAFLUOR 1 benoxinate hcl/fluorescein sodium 1 BUCALSEP (SOLUTION, SPRAY) 3 hcl 100 % crystals 3 cocaine hcl 4 % solution 1 hcl/lidocaine hcl/phenylephrine/ 1 dyclonine hcl 3 FLUROX 1 GLYDO 1 lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 40 mg/ml solution) 1 proparacaine hcl 0.5 % drops 1 proparacaine hcl 100 % powder 3 TETCAINE 1 tetracaine hcl 0.5 % drops 1 tetracaine hcl/pf 0.5 % drops 1

TETRAVISC 1 HCG

TETRAVISC FORTE 1 XYLOCAINE 4% SOLUTION 3 MYDRIATICS atropine sulfate (1 % drops, 1 % oint. (g)) 1 CYCLOGYL 3 CYCLOMYDRIL 3

PAGE 181 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1 cyclopentolate hcl 100 % powder 3 cyclopentolate hcl/tropicamide/phenylephrine hcl in water 1 HOMATROPAIRE 1 hbr 1 homatropine methylbromide 3 hydroxyamphetamine hbr 3 ISOPTO ATROPINE 3 MYDRIACYL 3 PAREMYD 3 tropicamide (0.5 % drops, 1 % drops) 1 tropicamide powder 3 VASOCONSTRICTORS

ADRENALIN CHLORIDE 3 PA naphazoline hcl 1 hcl 3 phenylephrine hcl (2.5 % drops, 10 % drops) 1 tetrahydrozoline hcl 3 TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE DROPS, 0.1% NOSE SPRAY) 3 FIRST GENERATION ANTIHISTAMINES

ETHYLENEDIAMINE DERIVATIVES pyrilamine maleate 3 hcl 3 DERIVATIVES trimeprazine tartrate 3

PAGE 182 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GASTROINTESTINAL DRUGS

ANTACIDS AND ADSORBENTS aluminum hydroxide 3 magnesium oxide 3 ANTI-INFLAMMATORY AGENTS (GI DRUGS)

GL Female alosetron hcl 1 AL At least 18 yrs old

APRISO 2 balsalazide disodium 1 CANASA 2 COLAZAL 3 DIPENTUM 3

GIAZO 3 GL Male

LIALDA 2

PA LOTRONEX 3 GL Female AL At least 18 yrs old mesalamine 4 g/60 ml enema 1 mesalamine powder 3 mesalamine 1.2 g tablet dr 1 HCG mesalamine with cleansing wipes 1 PENTASA 3 ROWASA 3 SFROWASA 3 ANTIDIARRHEA AGENTS attapulgite 3

PAGE 183 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bismuth subsalicylate 3

FULYZAQ 4 S lactobacillus acidophilus 3 hcl 2 mg capsule 1 loperamide hcl powder 3 MOTOFEN 3

MYTESI 4 S opium tincture 1 QL 5 / day paregoric 1

PA XERMELO 4 AL At least 18 yrs old S

ANTIFLATULENTS simethicone 3 CATHARTICS AND LAXATIVES

QL 2 / day AMITIZA 2 AL At least 18 yrs old aromatic cascara fluid extract 3 bisacodyl 3 COLYTE WITH PACKETS 3 docusate sodium 3

GAVILYTE-C 1 HCR

GAVILYTE-G 1 HCR

GAVILYTE-N 1 HCR

GOLYTELY PACKET 3 HCR

GOLYTELY SOLUTION 3

PAGE 184 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS karaya gum 3

MOVIPREP 3 HCR

NULYTELY WITH FLAVOR PACKS 3 OSMOPREP 3 peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 1 HCR

PEG-PREP 1 polyethylene glycol 3350 powder 3 polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 1 HCR

PREPOPIK 3 QL 2 / fill sodium chloride/nahco3/kcl/peg 420g soln recon 1 HCR sodium phosphate dibasic, heptahydrate 3 sodium phosphate,dibasic 3 sodium sulfate 3 sorbitol solution 70 % solution 1

SUPREP 3 QL 354 / fill

TRILYTE WITH FLAVOR PACKETS 1 HCR

CHOLELITHOLYTIC AGENTS

ACTIGALL 3

CHENODAL 4 S

URSO 3 URSO FORTE 3 ursodiol 100 % powder 3 ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1 DIGESTANTS

CREON 2

PAGE 185 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 pancreatin powder 3 PANCRELIPASE 5,000 1 ZENPEP 2 GI DRUGS, MISCELLANEOUS

QL 7 / day CHOLBAM 250 MG CAPSULE 4 PA S

QL 4 / day CHOLBAM 50 MG CAPSULE 4 PA S

QL 0.08 / day CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 4 PA S

QL 3/ fill CIMZIA 200 MG/ML STARTER KIT 4 PA S

ENDARI 3 ENTEREG 3

PA GATTEX 4 S powder 3

QL 0.22 / day PA HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4 S PS

QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 4 S PS

PAGE 186 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 4 S PS

QL 0.22 / day PA HUMIRA PEN 4 S PS

QL 0.22 / day PA HUMIRA PEN CROHN-UC-HS STARTER 4 S PS

QL 0.22 / day PA HUMIRA PEN PSORIASIS-UVEITIS 4 S PS

QL 1 / day LINZESS 2 ST

NUTRESTORE 3

QL 1 / day OCALIVA 4 PA S

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL) 3 PA

RELISTOR 150 MG TABLET 3 PA

RESTORA SPRINKLES 3

QL 2 / day VIBERZI 2 PA

PAGE 187 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XENICAL 3 LIPOTROPIC AGENTS choline bitartrate 3 3 PROKINETIC AGENTS metoclopramide hcl powder 3 metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet) 1 LCG metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis, 10 mg/10ml solution) 1 metoclopramide hcl (5 mg/ml vial, 10 mg/2 ml syringe) 1 METOZOLV ODT 3 REGLAN 3 GENERAL ANESTHETICS

GENERAL ANESTHETICS, MISCELLANEOUS

KETALAR 3 hcl 100 % powder 3 ketamine hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial) 1 INHALATION ANESTHETICS 3 COMPOUND 347 1 FORANE 3 1 1 SOJOURN 1 SUPRANE 3 TERRELL 1

PAGE 188 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTANE 3 GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

QL 1 / day hydrobromide 1 HCG

DETROL 3 QL 2 / day

DETROL LA 3 QL 1 / day

DITROPAN XL (10 MG TABLET, 15 MG TABLET) 3 QL 2 / day

DITROPAN XL 5 MG TABLET 3 QL 1 / day

ENABLEX 3 QL 1 / day hcl 1

QL 3.067 / day GELNIQUE 3% GEL 3 ST

QL 1 / day GELNIQUE (GEL PUMP, GEL SACHETS) 3 ST chloride powder 3 oxybutynin chloride 5 mg/5 ml syrup 1 QL 20 / day oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24) 1 QL 2 / day oxybutynin chloride 5 mg tab er 24 1 QL 1 / day oxybutynin chloride 5 mg tablet 1 QL 4 / day

QL 0.357 / day OXYTROL 3 ST

QL 1 / day tartrate (2 mg cap er 24h, 4 mg cap er 24h) 1 HCG tolterodine tartrate (1 mg tablet, 2 mg tablet) 1 QL 2 / day

PAGE 189 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TOVIAZ 3 QL 1 / day

QL 1 / day 60 mg cap er 24h 1 HCG

QL 2 / day trospium chloride 20 mg tablet 1 HCG

VESICARE 2 QL 1 / day

HCV ANTIVIRALS

HCV POLYMERASE INHIBITORS

QL 1 / day PA EPCLUSA 4 S PS

QL 1 / day PA HARVONI 4 S PS

QL 1 / day PA SOVALDI 4 S PS

HCV PROTEASE INHIBITORS

QL 1 / day OLYSIO 4 PA S

QL 1 / day ZEPATIER 4 PA S

PAGE 190 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HCV REPLICATION COMPLEX INHIBITORS

QL 1 / day DAKLINZA 4 PA S

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

A-HYDROCORT 3 A-METHAPRED 1 3 ARISTOSPAN 3 beclomethasone dipropionate 3 betamethasone acetate, micronized 3 betamethasone acetate/betamethasone sodium phosphate 1 betamethasone sodium phosphate 3 budesonide 3 mg capdr - er 1 HCG

CELESTONE 3 CORTEF 3 cortisone acetate powder 3 cortisone acetate 25 mg tablet 1 DELTASONE 1 DEPO-MEDROL 3 desoxycorticosterone acetate 3 dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 1 4 mg tablet, 6 mg tablet) dexamethasone acetate 3 dexamethasone acetate, micro 100 % powder 3 DEXAMETHASONE INTENSOL 2

PAGE 191 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dexamethasone isonicotinate 3 dexamethasone sod phosphate 100 % powder 3 dexamethasone, micronized 3 DEXPAK 3

PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL At least 5 yrs old SUSP, 30 MG TABLET, 36 MG TABLET) 4 AL S

ENTOCORT EC 3 EZ USE JOINT-TUNNEL-TRIGGER 3 FLO-PRED 3 fludrocortisone acetate powder 3 fludrocortisone acetate 0.1 mg tablet 1 flunisolide 100 % powder 3 fluticasone propionate 100 % powder 3 fluticasone propionate, micronized 3 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

QL 1 / day INTRAROSA 3 AL At least 18 yrs old

KENALOG-10 3 KENALOG-40 3 MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) 3

MEDROL 2 MG TABLET 2 methylprednisolone (4 mg tab ds pk, 4 mg tablet, 8 mg tablet, 16 mg tablet, 32 mg tablet) 1 methylprednisolone acetate 1 methylprednisolone acetate, micronized 3 methylprednisolone sodium succinate (40 mg vial, 125 mg vial) 1

PAGE 192 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylprednisolone, micronized 3 MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3 MILLIPRED DP 3 ORAPRED ODT 3 PEDIAPRED 3 prednisolone 1 prednisolone acetate, micronized 3 prednisolone sod phosphate powder 3 prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tab 1 rapdis) prednisolone, micronized 100 % powder 3 prednisone powder 3 prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg tablet, 20 1 mg tablet, 50 mg tablet)

PREDNISONE INTENSOL 2 prednisone micronized 3 RAYOS 3 SOLU-CORTEF 3 SOLU-MEDROL (40 MG VIAL, 125 MG VIAL) 3 triamcinolone 3 triamcinolone acetonide 100 % powder 3 triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial) 1 triamcinolone diacetate 3 triamcinolone diacetate, micronized 3 triamcinolone hexacetonide 3 triamcinolone hexacetonide, micronized 3

PAGE 193 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3 VERIPRED 20 3 ZODEX 6 DAY 1.5 MG TABLET 3 ANDROGENS

ANADROL-50 3 GL Male

QL 1 / day ANDRODERM 2 PA GL Male

QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 PA GL Male

PA ANDROID 3 GL Male 3

PA ANDROXY 3 GL Male (50 mg capsule, 100 mg capsule, 200 mg capsule) 1 danazol powder 3

PA DELATESTRYL 3 GL Male

DEPO- (100 MG/ML VL, 200 MG/ML) 3 GL Male fluoxymesterone 3

PA METHITEST 3 GL Male methyltestosterone 10 mg capsule 1 methyltestosterone powder 3

PAGE 194 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methyltestosterone, micronized 3 decanoate 3

QL 3 / day PA NATESTO 3 GL Male AL At least 18 yrs old

PA OXANDRIN 3 GL Male oxandrolone 100 % powder 3

PA oxandrolone (2.5 mg tablet, 10 mg tablet) 1 GL Male (dhea) 3 prasterone (dhea), micronized 100 % powder 3 stanozolol 3 stanozolol micronized 3

PA STRIANT 3 GL Male testosterone powder 3 GL Male 100 % powder 3 GL Male testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1 GL Male testosterone cypionate, micronized 3 GL Male

PA 1 GL Male testosterone micronized 3 GL Male 3 GL Male

PA TESTRED 3 GL Male

PAGE 195 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CONTRACEPTIVES

QL 1 / day ALTAVERA 1 GL Female HCR

GL Female ALYACEN 1 HCR

QL 91 days AMETHIA 1 GL Female HCR

QL 91 days AMETHIA LO 1 GL Female HCR

QL 1 / day AMETHYST 1 GL Female HCR

GL Female APRI 1 HCR

GL Female ARANELLE 1 HCR

GL Female ASHLYNA 1 HCR

QL 1 / day AUBRA 1 GL Female HCR

QL 1 / day AVIANE 1 GL Female HCR

PAGE 196 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female AZURETTE 1 HCR

GL Female BALZIVA 1 HCR

GL Female BEKYREE 1 HCR

BEYAZ 3 GL Female

GL Female BLISOVI 24 FE 1 HCR

GL Female BLISOVI FE 1 HCR

BREVICON 3 GL Female

GL Female BRIELLYN 1 HCR

GL Female CAMILA 1 HCR

QL 91 days CAMRESE 1 GL Female HCR

QL 91 days CAMRESE LO 1 GL Female HCR

GL Female CAZIANT 1 HCR

QL 1 / day CHATEAL 1 GL Female HCR

PAGE 197 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female CRYSELLE 1 HCR

GL Female CYCLAFEM 1 HCR

CYCLESSA 3 GL Female

GL Female CYRED 1 HCR

GL Female DASETTA 1 HCR

QL 91 days DAYSEE 1 GL Female HCR

GL Female DEBLITANE 1 HCR

QL 1 / day DELYLA 1 GL Female HCR

DESOGEN 3 GL Female

GL Female desogestrel-ethinyl estradiol 0.15-0.03 tablet 1 HCR

GL Female desogestrel-ethinyl estradiol/ethinyl estradiol 1 HCR

GL Female drospirenone/ethinyl estradiol/levomefolate calcium 1 HCR

GL Female ELINEST 1 HCR

PAGE 198 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day ELLA 3 GL Female HCR

GL Female EMOQUETTE 1 HCR

GL Female ENPRESSE 1 HCR

GL Female ENSKYCE 1 HCR

GL Female ERRIN 1 HCR

GL Female ESTARYLLA 1 HCR

ESTROSTEP FE 3 GL Female

GL Female ethinyl estradiol/drospirenone 1 HCR

GL Female ethynodiol diacetate-ethinyl estradiol 1 HCR

QL 1 / day FALMINA 1 GL Female HCR

QL 91 days FAYOSIM 1 GL Female HCR

FEMCON FE 3 GL Female

GL Female FEMYNOR 1 HCR

PAGE 199 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GENERESS FE 3 GL Female

GL Female GIANVI 1 HCR

GL Female GILDAGIA 1 HCR

GL Female GILDESS 1 HCR

GL Female GILDESS 24 FE 1 HCR

GL Female GILDESS FE 1 HCR

GL Female HEATHER 1 HCR

QL 91 days INTROVALE 1 GL Female HCR

GL Female ISIBLOOM 1 HCR

GL Female JENCYCLA 1 HCR

QL 91 days JOLESSA 1 GL Female HCR

GL Female JOLIVETTE 1 HCR

GL Female JULEBER 1 HCR

PAGE 200 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female JUNEL 1 HCR

GL Female JUNEL FE 1 HCR

GL Female JUNEL FE 24 1 HCR

GL Female KAITLIB FE 1 HCR

GL Female KARIVA 1 HCR

GL Female KELNOR 1-35 1 HCR

GL Female KIMIDESS 1 HCR

QL 1 / day KURVELO 1 GL Female HCR

GL Female LARIN 1 HCR

GL Female LARIN 24 FE 1 HCR

GL Female LARIN FE 1 HCR

QL 1 / day LARISSIA 1 GL Female HCR

PAGE 201 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female LAYOLIS FE 1 HCR

GL Female LEENA 1 HCR

QL 1 / day LESSINA 1 GL Female HCR

GL Female LEVONEST 1 HCR

QL 0.07 / day levonorgestrel 1 GL Female HCR

QL 91 days levonorgestrel-ethin estradiol 0.15-0.03 tablet 1 GL Female HCR

GL Female levonorgestrel-ethin estradiol 6-5-10 tablet 1 HCR

QL 1 / day levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 90-20 mcg Female tablet) 1 GL HCR

QL 91 days levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo 1 GL Female HCR

GL Female l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo 1 HCR

PAGE 202 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

91 days levonorgestrel/ethinyl estradiol and ethinyl estradiol (l- QL norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo, l- 1 GL Female norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo) HCR

QL 1 / day LEVORA-28 1 GL Female HCR

QL 1 / day LILLOW 1 GL Female HCR

GL Female LO LOESTRIN FE 3 HCR

LOESTRIN 3 GL Female

LOESTRIN FE 1-20 TABLET 3 GL Female

GL Female LOESTRIN FE 1.5-30 TABLET 3 HCR

GL Female LOMEDIA 24 FE 1 HCR

GL Female LORYNA 1 HCR

QL 91 days LOSEASONIQUE 3 GL Female

GL Female LOW-OGESTREL 1 HCR

QL 1 / day LUTERA 1 GL Female HCR

PAGE 203 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female LYZA 1 HCR

QL 1 / day MARLISSA 1 GL Female HCR

GL Female MELODETTA 24 FE 1 HCR

GL Female MIBELAS 24 FE 1 HCR

GL Female MICROGESTIN 1 HCR

GL Female MICROGESTIN 24 FE 1 HCR

GL Female MICROGESTIN FE 1 HCR

MINASTRIN 24 FE 3 GL Female

MIRCETTE 3 GL Female

MODICON 3 GL Female

GL Female MONO-LINYAH 1 HCR

GL Female MONONESSA 1 HCR

GL Female MYZILRA 1 HCR

NATAZIA 2 GL Female

GL Female NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 10-11-28 TABLET) 1 HCR

PAGE 204 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female NECON 1-50-28 TABLET 3 HCR

QL 1 / day NECON 7-7-7-28 TABLET 1 GL Female HCR

GL Female NIKKI 1 HCR

NOR-Q-D 3 GL Female

GL Female NORA-BE 1 HCR

GL Female norethindrone 0.35 mg tablet 1 HCR

GL Female norethindrone ac-eth estradiol 1mg-20mcg tablet 1 HCR norethindrone acetate-ethinyl estradiol/ferrous fumarate (tab GL Female 3 chew, tablet) HCR

GL Female norethindrone-e.estradiol-iron 1mg-20(21) tablet 1 HCR

GL Female norethindrone-ethinyl estradiol/ferrous fumarate 1 HCR

GL Female norgestimate-ethinyl estradiol 1 HCR

GL Female NORINYL 1+50 3 HCR

NORINYL 1-35 3 GL Female

GL Female NORLYDA 1 HCR

PAGE 205 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female NORLYROC 1 HCR

GL Female NORTREL 1 HCR

GL Female NUVARING 2 HCR

GL Female OCELLA 1 HCR

QL 1 / day OGESTREL 1 GL Female HCR

QL 1 / day ORSYTHIA 1 GL Female HCR

ORTHO MICRONOR 3 GL Female

ORTHO TRI-CYCLEN 3 GL Female

ORTHO TRI-CYCLEN LO 3 GL Female

ORTHO-CEPT 3 GL Female

ORTHO-CYCLEN 3 GL Female

ORTHO-NOVUM 3 GL Female

OVCON-35 3 GL Female

GL Female PHILITH 1 HCR

GL Female PIMTREA 1 HCR

PAGE 206 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female PIRMELLA 1 HCR

QL 2 / 30 days PLAN B ONE-STEP 3 GL Female

QL 1 / day PORTIA 1 GL Female HCR

GL Female PREVIFEM 1 HCR

QUARTETTE 3 GL Female

QL 91 days QUASENSE 1 GL Female HCR

GL Female RAJANI 1 HCR

GL Female RECLIPSEN 1 HCR

QL 91 days RIVELSA 1 GL Female HCR

SAFYRAL 3 GL Female

QL 91 days SEASONIQUE 3 GL Female

QL 91 days SETLAKIN 1 GL Female HCR

PAGE 207 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female SHAROBEL 1 HCR

GL Female SPRINTEC 1 HCR

QL 1 / day SRONYX 1 GL Female HCR

GL Female SYEDA 1 HCR

GL Female TARINA FE 1 HCR

GL Female TAYTULLA 3 HCR

GL Female TILIA FE 1 HCR

GL Female TRI FEMYNOR 1 HCR

GL Female TRI-ESTARYLLA 1 HCR

GL Female TRI-LEGEST FE 1 HCR

GL Female TRI-LINYAH 1 HCR

GL Female TRI-LO-ESTARYLLA 1 HCR

GL Female TRI-LO-MARZIA 1 HCR

PAGE 208 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female TRI-LO-SPRINTEC 1 HCR

TRI-NORINYL 3 GL Female

GL Female TRI-PREVIFEM 1 HCR

GL Female TRI-SPRINTEC 1 HCR

GL Female TRINESSA 1 HCR

GL Female TRINESSA LO 1 HCR

GL Female TRIVORA-28 1 HCR

GL Female VELIVET 1 HCR

GL Female VESTURA 1 HCR

QL 1 / day VIENVA 1 GL Female HCR

GL Female VIORELE 1 HCR

GL Female VYFEMLA 1 HCR

GL Female WERA 1 HCR

PAGE 209 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female WYMZYA FE 1 HCR

QL 0.12 / day XULANE 1 GL Female HCR

YASMIN 28 3 GL Female

YAZ 3 GL Female

GL Female ZARAH 1 HCR

GL Female ZENCHENT 1 HCR

GL Female ZENCHENT FE 1 HCR

GL Female ZEOSA 1 HCR

GL Female ZOVIA 1-35E 1 HCR

GL Female ZOVIA 1-50E 1 HCR

GONADOTROPINS

PA GL Female BRAVELLE 4 S PS chorionic gonadotropin, human (1mm unit powder(ea), 2mm unit powder(ea), 5mm unit powder(ea), 10mm unit powder(ea), 4 S 10000 unit vial)

PAGE 210 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA ELIGARD 4 S

FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNIT PA 4 CARTRIDG, 900 UNIT CARTRIDG) S

PA GONAL-F 4 S PS

PA GL Female GONAL-F RFF 4 S PS

PA GL Female GONAL-F RFF REDI-JECT 4 S PS

PA leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial) 4 S

LUPANETA PACK 4 S

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, PA DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 4 MG 6MO KIT) S

PA LUPRON DEPOT 3.75 MG KIT 4 S

PA LUPRON DEPO 11.25MG (LUPANETA) 4 S

PA LUPRON DEPOT 3.75MG (LUPANETA) 4 S

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG PA 4 KIT, 15 MG KIT, 30 MG 3MO KIT) S

PAGE 211 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA GL Female MENOPUR 4 S PS

PA NOVAREL 10,000 UNITS VIAL 4 S

PA OVIDREL 4 S PS

PA PREGNYL 4 S

PA SYNAREL 4 S

LEPTINS

PA MYALEPT 4 S

PARATHYROID calcitonin,salmon,synthetic 1 QL 0.13 / day

PA FORTEO 4 S

FORTICAL 3 QL 0.13 / day

MIACALCIN 200 UNIT NASAL SPRAY 3 QL 0.13 / day

MIACALCIN 400 UNIT/2 ML VIAL 4 S

PA NATPARA 4 S

QL 1.60 / day PA TYMLOS 4 AL At least 18 yrs old S

PAGE 212 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PITUITARY

DDAVP 0.01% NASAL SPRAY 3 desmopressin acetate (non-refrigerated) 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, PA MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, 4 MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG S CARTRIDGE)

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, PA 4 24 MG CARTRIDGE) S

PA NORDITROPIN FLEXPRO 4 S PS

PA NUTROPIN AQ 4 S

PA NUTROPIN AQ NUSPIN 4 S

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML PA 4 CRTG) S

PA SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 4 S

PA SAIZEN-SAIZENPREP 4 S sermorelin acetate 3

QL 1 / day SEROSTIM 4 PA S vasopressin 1

PAGE 213 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA ZOMACTON 4 S

QL 1 / day ZORBTIVE 4 PA S

PROGESTINS

AYGESTIN 3 GL Female

CRINONE 4% GEL 3 GL Female

CRINONE 8% GEL 3 GL Female

DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL) 3 GL Female

DEPO-PROVERA 400 MG/ML VIAL 3

QL 90 days DEPO-SUBQ PROVERA 104 3 GL Female HCR

GL Female ENDOMETRIN 4 S PS hydroxyprogesterone caproate 100 % powder 3

PA hydroxyprogesterone caproate 250 mg/ml vial 4 GL Female S

PA GL Female MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4 S PS

GL Female medroxyprogesterone acetate (2.5 mg tablet, 10 mg tablet) 1 LCG

PAGE 214 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS medroxyprogesterone acetate 5 mg tablet 1 GL Female

QL 0.04 / day medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml Female vial) 1 GL HCR medroxyprogesterone acetate, micronized 3 norethindrone 100 % powder 3 norethindrone acetate 1 GL Female 100 % powder 3 progesterone 50 mg/ml vial 1 GL Female progesterone, micronized (100 mg capsule, 200 mg capsule) 1 GL Female progesterone, micronized 100 % powder 3 GL Female progesterone,micronized 3 GL Female

PROMETRIUM 3 GL Female

PROVERA 3 GL Female

HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

CATAPRES 3

CATAPRES-TTS 1 3 QL 0.15 / day

CATAPRES-TTS 2 3 QL 0.4 / day

CATAPRES-TTS 3 3 QL 0.4 / day

QL 0.29 / day (0.2mg/24hr patch tdwk, 0.3mg/24hr patch tdwk) 1 HCG

QL 0.15 / day clonidine 0.1mg/24hr patch tdwk 1 HCG clonidine hcl powder 3

PAGE 215 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day clonidine hcl 0.1 mg tab er 12h 1 HCG clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG acetate 3

QL 4 / day KAPVAY 3 ST methyldopa 1 DIRECT VASODILATORS

BIDIL 3 QL 6 / day hydralazine hcl powder 3 hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hydralazine hcl 20 mg/ml vial 1 powder 3 minoxidil (2.5 mg tablet, 10 mg tablet) 1 HYPOTENSIVE AGENTS, MISCELLANEOUS sulfate 3 mecamylamine hcl 3

PA VECAMYL 4 S

PERIPHERAL ADRENERGIC INHIBITORS rauwolfia serpentina 3 reserpine 100 % powder 3 reserpine (0.1 mg tablet, 0.25 mg tablet) 1

PAGE 216 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS -REMOVING AGENTS

OTHER ION-REMOVING AGENTS

RADIOGARDASE 3 PHOSPHATE-REMOVING AGENTS

AURYXIA 3 calcium acetate 1 ELIPHOS 3 FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MG TABLET CHEW) 2 lanthanum carbonate 1 PHOSLYRA 3 RENAGEL 3 RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET) 3 RENVELA 800 MG TABLET 2 sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack, 800 mg tablet) 1 HCG

VELPHORO 3 POTASSIUM-REMOVING AGENTS

KAYEXALATE 3 KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 sodium polystyrene sulfonate 50 g/200ml enema 1 HCG sodium polystyrene sulfonate (15 g/60 ml oral susp, 30 g/120ml enema, powder) 1

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1

QL 1 / day VELTASSA 3 PA

PAGE 217 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROLIDES

ERYTHROMYCINS erythromycin base powder 3 erythromycin estolate 3 erythromycin ethylsuccinate powder 3 KETOLIDES

KETEK 3 OTHER MACROLIDES azithromycin 100 % powder 3 azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 QL 6 / 5 days

DIFICID 3 PA

ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill

ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill

ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK TABLET) 3

ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days

ZITHROMAX 500 MG TABLET 3 QL 5 / fill

ZITHROMAX 600 MG TABLET 3 QL 0.29 / day

ZITHROMAX TRI-PAK 3

ZMAX 2 QL 60 / fill

MISCELLANEOUS B-LACTAM

CARBAPENEMS

INVANZ 1 GM VIAL 3

PAGE 218 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOBACTAMS

AZACTAM 3 aztreonam 1

PA CAYSTON 4 S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

QL 1 / day AVODART 3 GL Male

QL 1 / day dutasteride 1 GL Male HCG 100 % powder 3

QL 1 / day finasteride 5 mg tablet 1 GL Male

QL 1 / day PROSCAR 3 GL Male

ALCOHOL DETERRENTS

ANTABUSE 3 disulfiram 100 % powder 3 disulfiram (250 mg tablet, 500 mg tablet) 1 ANTIDOTES amyl nitrite 1 BAL IN OIL 3 CHEMET 3 deferoxamine mesylate 1

PAGE 219 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DESFERAL 3 DESFERAL MESYLATE 3 edetate calcium disodium 200 mg/ml ampul 1 edetate calcium disodium 100 % powder 3 fomepizole 100 % liquid 3 leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1 leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vial) 4 S

MEPHYTON 2 phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml syringe, 10 mg/ml ampul) 1 pralidoxime chloride 600 mg/2ml pen injctr 1 pralidoxime chloride 100 % powder 3 PROTOPAM CHLORIDE 3 succimer 98 % powder 3

VISTOGARD 4 S

ANTIGOUT AGENTS allopurinol powder 3

QL 3 / day allopurinol 100 mg tablet 1 LCG

QL 2 / day allopurinol 300 mg tablet 1 LCG

ANAPROX 3 ANAPROX DS 3 colchicine 0.6 mg capsule 1 QL 2 / day colchicine powder 3 colchicine 0.6 mg tablet 1 QL 4 / day

PAGE 220 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COLCRYS 2 QL 4 / day

EC-NAPROSYN 3

INDOCIN 25 MG/5 ML SUSPENSION 3 QL 6 / day

INDOCIN 50 MG SUPPOSITORY 3 QL 4 / day indomethacin (50 mg capsule, 75 mg capsule er) 1 indomethacin 25 mg capsule 1 LCG

QL 2 / day MITIGARE 3 ST

NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3

NAPRELAN CR 750 MG TABLET 3 QL 1 / day

NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET) 3 naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr) 1 naproxen 500 mg tablet 1 LCG naproxen sodium (275 mg tablet, 550 mg tablet) 1 naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 1 HCG

TIVORBEX 3

QL 1 / day ULORIC 2 ST

ZYLOPRIM 100 MG TABLET 3 QL 3 / day

ZYLOPRIM 300 MG TABLET 3 QL 2 / day

BONE RESORPTION INHIBITORS

ACTONEL (5 MG TABLET, 30 MG TABLET) 3 QL 1 / day

ACTONEL 150 MG TABLET 3 QL 0.04 / day

ACTONEL 35 MG TABLET 3 QL 0.15 / day

PAGE 221 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alendronate sodium (35 mg tablet, 40 mg tablet, 70 mg tablet, .15 / day 70 mg/75ml solution) 1 QL alendronate sodium (5 mg tablet, 10 mg tablet) 1 QL 1 / day

QL 0.15 / day ATELVIA 3 ST

BINOSTO 3 QL .15 / day

BONIVA 150 MG TABLET 3 QL 0.04 / day etidronate disodium 1

FOSAMAX 3 QL .15 / day

FOSAMAX PLUS D 3 QL 0.15 / day ibandronate sodium 150 mg tablet 1 QL 0.04 / day

QL 0.04 / day risedronate sodium 150 mg tablet 1 HCG risedronate sodium 30 mg tablet 1 HCG

QL 0.15 / day risedronate sodium 35 mg tablet 1 HCG

QL 1 / day risedronate sodium 5 mg tablet 1 HCG risedronate sodium 35 mg tablet dr 1 CARIOSTATIC AGENTS

CLINPRO 5000 1 DENTA 5000 PLUS 1 DENTAGEL 1

HCR FLUOR-A-DAY 2.5 MG/ML DROPS 1 HCG

FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) 3

PAGE 222 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLUORABON 3 fluoride (sodium) powder 3 fluoride (sodium) 0.2 % solution 1 fluoride (sodium) (0.25(0.55) tab chew, 0.5 mg/ml drops, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew) 1 HCR

FLUORIDEX 1 FLUORIDEX DAILY DEFENSE 1 FLUORIDEX SENSITIVITY RELIEF 1

HCR FLUORITAB 0.125 MG/DRP DROPS 1 HCG

FLUORITAB (0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 1 HCR

FLURA-DROPS 3 HCR

LUDENT FLUORIDE 1 HCR pediatric multivitamin no.150 with sodium fluoride 1 pediatric multivitamin no.16/sodium fluoride 3 pediatric multivitamin no.2/sodium fluoride 1 POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) 3 PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS, DENTAL RINSE) 3

PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 TRI-VI-FLOR 3

PAGE 223 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMPLEMENT INHIBITORS

PA FIRAZYR 4 S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 4 PA S

ARAVA 3 AZASAN 3 azathioprine powder 3 azathioprine 50 mg tablet 1 azathioprine sodium 1 CUPRIMINE 3 cyclosporine (25 mg capsule, 100 mg capsule) 4 S cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) 4 S

DEPEN 2

QL 0.15 / day PA ENBREL 50 MG/ML SURECLICK SYR 4 S PS

QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML PA 4 SYRINGE) S PS

GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLUTION) 4 S gold sodium thiomalate 3

PAGE 224 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IMURAN 3

QL 0.1 / day PA KEVZARA 4 AL At least 18 yrs old S leflunomide 1 methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1 methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1 NEORAL (25 MG CAPSULE, 100 MG GELATIN CAPSULE, 100 MG/ML SOLUTION) 4 S

QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE) 4 PA S

QL 0.15 / day ORENCIA CLICKJECT 4 PA S

QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK) 4 PA S

QL 0.08 / day OTREXUP 3 PA penicillamine powder 3

QL .08 / day RASUVO (10 MG/0.2 ML, 12.5 MG/0.25 ML) 3 PA

RASUVO (7.5 MG/0.15 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 QL 0.08 / day MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 3 ML, 30 MG/0.6 ML) PA

RHEUMATREX 3

PAGE 225 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIDAURA 2

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 4 S

S SANDIMMUNE 100 MG/ML SOLN 4 PS

QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 4 PA S

QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE) 4 PA S

TREXALL 2

QL 4 / day XATMEP 3 PA AL Up to 18 yrs old

QL 2 / day XELJANZ 4 PA S

QL 1 / day XELJANZ XR 4 PA S

GONADOTROPIN-RELEASING HORMONE ANTAGNTS

PA GL Female CETROTIDE 4 S PS

PA FIRMAGON 120 MG VIAL 4 S

PAGE 226 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female ganirelix acetate 4 S

IMMUNOMODULATORY AGENTS

ACTIMMUNE 4 S

QL 1 / day PA AUBAGIO 4 S PS

QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLED PA 4 SYR 30 MCG KT) S PS

QL 0.15 / day PA AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4 S PS

QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) 4 PA S

QL 1 / day PA COPAXONE 4 S PS

QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 4 PA S

QL 1 / day PA GILENYA 4 S PS

PAGE 227 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day GLATOPA 4 PA S

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML SYRING 4 S PS

QL 1 / lifetime PA PLEGRIDY SYRINGE STARTER PACK 4 S PS

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML PEN 4 S PS

QL 1 / lifetime PA PLEGRIDY PEN INJ STARTER PACK 4 S PS

QL 1 / day POMALYST 4 PA S

QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 4 PA S

QL 4.2 / 365 days REBIF TITRATION PACK 4 PA S

PAGE 228 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4 PA S

QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 4 PA S

QL 1 / day REVLIMID 4 PA S

QL 2 / day PA TECFIDERA 4 S PS

QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4 PA S

QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4 PA S

QL 1 / day ZINBRYTA 4 PA S

IMMUNOSUPPRESSIVE AGENTS

QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 4 PA S

QL 30 / day ASTAGRAF XL 1 MG CAPSULE 4 PA S

PAGE 229 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day ASTAGRAF XL 5 MG CAPSULE 4 PA S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 4 S cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA cyclophosphamide 100 % powder 3 cyclosporine powder 3

QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old

QL 1 / day ENVARSUS XR 4 PA S mercaptopurine 100 % powder 3 mercaptopurine 50 mg tablet 1 mycophenolate mofetil (250 mg capsule, 500 mg tablet) 4 S mycophenolate mofetil 200 mg/ml susp recon 4 S mycophenolate sodium 4 S

MYFORTIC 4 S

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 4 S

PA PURIXAN 4 S

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) 4 S sirolimus 100 % powder 3 sirolimus (1 mg tablet, 2 mg tablet) 4 S

PAGE 230 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sirolimus 0.5 mg tablet 4 S

QL 2 / day 0.5 mg capsule 4 S

QL 8 / day tacrolimus 1 mg capsule 4 S

QL 4 / day tacrolimus 5 mg capsule 4 S tacrolimus 100 % powder 3 tacrolimus anhydrous 3 tacrolimus, micronized 3

PA ZORTRESS 4 S

OTHER MISCELLANEOUS THERAPEUTIC AGENTS hcl 3 acetylcysteine powder 3 acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1 amifampridine 3

QL 2 / day PA AMPYRA 4 S PS

PA ARCALYST 4 S beta 1,3 glucan 3 betaine hcl 3

PA BOTOX COSMETIC 4 S

PAGE 231 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 CARDIOVID PLUS 3 CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 CARNITOR SF 3

QL 2 / day CERDELGA 4 PA S chondroitin sulfate a sodium 100 % powder 3 coumarin 3

CYSTADANE 4 S

CYSTAGON 4 S cysteamine hcl 3 dalfampridine 3 DEMSER 3 dimethyl sulfoxide 99 % vial 3 edetate disodium 3 EPIFIX AMNIOTIC MEMBRANE 3 ethyl alcohol (98 % ampul, 98 % vial) 1 gamma-aminobutyric acid 3 ginkgo biloba 3 glucosamine hcl powder 3 glucosamine sulfate (dipotassium chloride) 3 glucosamine sulfate sodium cl 3 GRAFIX CORE 5CM X 5CM MATRIX 3 GRAFIX PRIME 5CM X 5CM MATRIX 3

QL 1 / day GRASTEK 3 PA

PAGE 232 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.04 / day ILARIS 150 MG/ML VIAL 4 PA S indole-3-carbinol 3

QL 4 / day KEVEYIS 4 PA S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MG PA 4 POWDER PACKET) S leucovorin calcium powder 3 levocarnitine powder 3 levocarnitine 330 mg tablet 1 levocarnitine (with sugar) 1 levocarnitine hcl 3 lycopene 3 3 NEXAVIR 3 -adenine dinucleotide, reduced, disodium 3

ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT, PA 4 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) S

ORALAIR 100 IR STARTER PACK 4 S

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG PA 4 CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S

POTABA 3 potassium perchlorate 3

PROCYSBI 4 S 3

PAGE 233 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day RAGWITEK 3 PA 3

QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 4 PA S

QL 4 / day SENSIPAR 90 MG TABLET 4 PA S squaric acid dibutylester 3 STRAVIX (STRAVI3CM 6CM, STRAVI4CM 7CM) 3 99.1 % powder 3 THIOLA 3 tiopronin 3 turmeric (95 % powder, 100 % powder) 3

S TYBOST 4 PS ubidecarenone (100 % powder, powder) 3 ubiquinol 3 VP-ZEL 3

XURIDEN 4 S

PA ZAVESCA 4 S

PROTECTIVE AGENTS

ELMIRON 3

MESNEX 400 MG TABLET 4 S pentosan polysulfate sodium 3

PAGE 234 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3 QL 2 / day

CELEBREX 100 MG CAPSULE 3 QL 3 / day

CELEBREX 400 MG CAPSULE 3 QL 1 / day celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day celecoxib 100 % powder 3 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

ANSAID 3 DAYPRO 3 diclofenac potassium 1 diclofenac sodium 1.5 % drops 1 HCG

QL 1000/ 30 days diclofenac sodium 1 % gel (gram) 1 HCG diclofenac sodium 100 % powder 3 diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) 1 diclofenac sodium, micronized 3 diflunisal 1 etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 1 24h)

FELDENE 3 fenoprofen calcium (200 mg capsule, 400 mg capsule) 1 HCG

PAGE 235 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenoprofen calcium 600 mg tablet 1 fenoprofen calcium, dihydrate 3 FENORTHO 3

FLECTOR 3 QL 2 / day flurbiprofen powder 3 flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen 100 mg/5ml oral susp 1 ibuprofen 100 % powder 3 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG indomethacin powder 3 ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel) 1 HCG ketoprofen 100 % powder 3 ketoprofen, micronized 3 ketorolac tromethamine 100 % powder 3 ketorolac tromethamine (30 mg/ml syringe, 30mg/ml(1) vial) 1 QL 20 / 23 days ketorolac tromethamine 10 mg tablet 1 QL 21 / fill ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml vial) 1 QL 40 / 23 days ketorolac tromethamine (30 mg/ml cartridge, 30 mg/ml vial, 60 20 / 30 days mg/2 ml cartridge, 60 mg/2 ml syringe, 60 mg/2 ml vial) 1 QL

KLOFENSAID II 1 HCG

LODINE 3 meclofenamate sodium (50 mg capsule, 100 mg capsule) 1 meclofenamate sodium powder 3

QL 5 / day 250 mg capsule 1 HCG mefenamic acid 100 % powder 3

PAGE 236 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS meloxicam 7.5 mg/5ml oral susp 1 QL 10 / day meloxicam 100 % powder 3

QL 1 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 LCG

MOBIC 7.5 MG/5 ML SUSPENSION 3 QL 10 / day

MOBIC (7.5 MG TABLET, 15 MG TABLET) 3 QL 1 / day nabumetone 100 % powder 3 nabumetone (500 mg tablet, 750 mg tablet) 1 nabumetone, micronized 3 NALFON 3 naproxen powder 3 naproxen sodium powder 3 oxaprozin 600 mg tablet 1 HCG

PENNSAID 2% PUMP 3 QL 3.73 / day phenylbutazone 3 piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old piroxicam 100 % powder 3

PONSTEL 3 QL 5 / day

SPRIX 3 QL 5 days sulindac powder 3 sulindac (150 mg tablet, 200 mg tablet) 1 tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mg tablet) 1

TOXICOLOGY SALIVA COLLECTION 3

QL 1 / day VIVLODEX 3 PA AL At least 18 yrs old

PAGE 237 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VOLTAREN 3 QL 1000/ 30 days

VOLTAREN-XR 3

ZIPSOR 3 QL 4 / day

SALICYLATES carisoprodol/aspirin 200-325 mg tablet 1 choline salicyl/mag salicylate 500 mg/5ml liquid 1 choline salicyl/mag salicylate powder 3 DISALCID 3 salsalate 100 % powder 3 salsalate (500 mg tablet, 750 mg tablet) 1 PENICILLINS

AMINOPENICILLINS amoxicillin 100 % powder 3 amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 400 mg/5ml susp recon) 1 LCG amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) 1 amoxicillin 775 mg tbmp 24hr 1 HCG amoxicillin/potassium clav 4:1 powder 3 amoxicillin/potassium clav 1000-62.5 tab er 12h 1 HCG

PAGE 238 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amoxicillin/potassium clavulanate (amoxicillin/potassium 200- 28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, 1 amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet) ampicillin sodium (1 g vial, 2 g vial, 10 g vial, 125 mg vial, 250 mg vial, 500 mg vial) 1 ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 g vial, sodium/sulbactam 3 g vial, sodium/sulbactam 15 g vial) 1 ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) 1

AUGMENTIN 125-31.25 MG/5 ML 2 AUGMENTIN (250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET) 3

AUGMENTIN ES-600 3 AUGMENTIN XR 3 MOXATAG 3 UNASYN 3 EXTENDED-SPECTRUM PENICILLINS ticarcillin disodium/potassium clavulanate 3 NATURAL PENICILLINS

BICILLIN C-R 3 BICILLIN L-A 3 penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) 1 LCG

PAGE 239 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PFIZERPEN 3 PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium 1 nafcillin sodium (1 g vial, 2 g vial, 10 g vial) 1 oxacillin sodium (1 g vial, 2 g vial, 10 g vial) 1 RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)

ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)

ATACAND 3 QL 1 / day

AVAPRO 3 QL 1 / day

BENICAR 3 QL 3 / day candesartan cilexetil 1 QL 1 / day

COZAAR (25 MG TABLET, 50 MG TABLET) 3 QL 2 / day

COZAAR 100 MG TABLET 3 QL 1 / day

DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3 QL 2 / day

DIOVAN 320 MG TABLET 3 QL 1 / day

QL 1 / day EDARBI 3 ST eprosartan mesylate 1 QL 1 / day irbesartan 1 QL 1 / day losartan potassium (25 mg tablet, 50 mg tablet) 1 QL 2 / day losartan potassium 100 mg tablet 1 QL 1 / day

MICARDIS 3 QL 1 / day olmesartan medoxomil 1 QL 3 / day telmisartan 1 QL 1 / day

PAGE 240 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day valsartan 320 mg tablet 1 QL 1 / day

ANGIOTENSIN-CONVERT. INHIB(HYPOTN)

ACCUPRIL 3 QL 2 / day

ACEON 3 QL 1 / day

ALTACE 3 QL 2 / day benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day captopril 100 % powder 3 captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg 4 / day tablet) 1 QL enalapril maleate 100 % powder 3 enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 2 / day mg tablet) 1 QL

EPANED (1 MG/ML ORAL SOLUTION, 1 MG/ML SOLUTION) 3 QL 5 / day fosinopril sodium 1 QL 2 / day lisinopril 100 % powder 3 lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg 1 / day tablet, 30 mg tablet) 1 QL lisinopril 40 mg tablet 1 QL 2 / day

LOTENSIN 20 MG TABLET 3 QL 4 / day

LOTENSIN 40 MG TABLET 3 QL 2 / day

MAVIK 3 QL 2 / day moexipril hcl 1 QL 1 / day

PAGE 241 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS perindopril erbumine 1 QL 1 / day

PRINIVIL 3 QL 1 / day

QBRELIS 3 QL 40/ day quinapril hcl 1 QL 2 / day ramipril 1 QL 2 / day trandolapril 1 QL 2 / day

VASOTEC 3 QL 2 / day

ZESTRIL 3 QL 1 / day

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

QL 2 / day ENTRESTO 3 PA

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS benazepril hcl 100 % powder 3 RENIN INHIBITORS

QL 1 / day TEKTURNA 3 ST

RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 4 PA S

QL 3 / day ESBRIET 801 MG TABLET 4 PA S

PAGE 242 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day OFEV 4 PA S

ANTITUSSIVES benzonatate 1 AL At least 11 yrs old dextromethorphan hbr 3

QL 60 / day FLOWTUSS 3 AL At least 18 yrs old

TESSALON PERLE 3 AL At least 11 yrs old

ZONATUSS 3 AL At least 11 yrs old

EXPECTORANTS bromhexine hcl 3 guaifenesin 3 terpin hydrate 3 MUCOLYTIC AGENTS

QL 5 / day PULMOZYME 4 PA S

PHOSPHODIESTERASE TYPE 4 INHIBITORS

QL 1 / day DALIRESP 3 PA

PULMONARY SURFACTANTS

CUROSURF 3 INFASURF 3 SURVANTA 3

PAGE 243 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VASODILATING AGENTS (RESPIRATORY TRACT)

QL 2 / day ADCIRCA 4 PA S

QL 3 / day ADEMPAS 4 PA S

QL 1 / day PA LETAIRIS 4 S PS

QL 1 / day OPSUMIT 4 PA S

QL 3 / day ORENITRAM ER 4 PA S

PA REMODULIN 4 S

QL 6 / day PA REVATIO 10 MG/ML ORAL SUSP 4 AL At least 18 yrs old S

QL 3 / day PA REVATIO 20 MG TABLET 4 AL At least 18 yrs old S

PAGE 244 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sildenafil citrate 100 % powder 3

QL 3 / day sildenafil citrate 20 mg tablet 4 PA S

QL 2 / day PA TRACLEER 4 S PS

QL 1 / day TYVASO 4 PA S

QL 1 / day TYVASO INSTITUTIONAL START KIT 4 PA S

QL 1 / day TYVASO REFILL KIT 4 PA S

QL 1 / day TYVASO STARTER KIT 4 PA S

PA UPTRAVI 200-800 TITRATION PACK 4 AL At least 18 yrs old S

QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG PA TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG 4 TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) AL At least 18 yrs old S

PAGE 245 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

AMRIX 3 carisoprodol powder 3 carisoprodol (250 mg tablet, 350 mg tablet) 1 chlorzoxazone 500 mg tablet 1 hcl 100 % powder 3 cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet) 1 FEXMID 3 LORZONE 3

METAXALL 1 HCG metaxalone 1 HCG methocarbamol 100 % powder 3 methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 100 mg/ml vial 1 PARAFON FORTE DSC 3 ROBAXIN 500 MG TABLET 3 ROBAXIN 1,000 MG/10 ML VIAL 3 ROBAXIN-750 3 SKELAXIN 3 SOMA 3 hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mg tablet, 6 mg capsule) 1 tizanidine hcl 100 % powder 3 ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, 6 MG CAPSULE) 3

PAGE 246 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3 dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule) 1 dantrolene sodium powder 3 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen 100 % powder 3 baclofen (10 mg tablet, 20 mg tablet) 1 NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide 100 % powder 3 rocuronium bromide 100 % powder 3 succinylcholine chloride 100 % powder 3 vecuronium bromide 100 % powder 3 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS citrate powder 3 orphenadrine citrate 100 mg tablet er 1 orphenadrine citrate (30 mg/ml ampul, 30 mg/ml vial) 1 SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ALA-CORT 1 ALA-SCALP 3 alclometasone dipropionate (0.05 % cream (g), 0.05 % oint. (g)) 1 amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1 ANA-LEX 2-2% CREAM 3 ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE, 2.5%-1% LOTION) 3

ANUCORT-HC 1

PAGE 247 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANUSOL-HC 2.5% CREAM 3 ANUSOL-HC 25 MG SUPPOSITORY 1 APEXICON E 3 betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g)) 1 betamethasone dipropionate powder 3 betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), betamethasone/propylene 0.05 % lotion, 1 betamethasone/propylene 0.05 % oint. (g)) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 % foam) 1 betamethasone valerate powder 3 calcipotriene/betamethasone dipropionate 1 QL 3 / day

CAPEX SHAMPOO 3 clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g), 0.05 % shampoo, 1 0.05 % solution, 0.05 % spray) clobetasol propionate powder 3 clobetasol propionate/emollient base (propionate/emoll 0.05 % cream (g), propionate/emoll 0.05 % foam) 1

CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) 3 clocortolone pivalate 0.1 % cream (g) 1 HCG

CLODAN 0.05% SHAMPOO 1 CLODERM 3 COLOCORT 1 CORMAX 1 CORTENEMA 3 CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3

PAGE 248 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3 DERMATOP (EMOLLIENT CREAM, OINTMENT) 3 DESONATE 3 desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1 HCG desonide, micronized 3 DESOWEN (CREAM, LOTION) 3 desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 % cream (g), 0.25 % oint. (g)) 1 HCG desoximetasone, micronized 3 diflorasone diacetate (0.05 % cream (g), 0.05 % oint. (g)) 1 DIPROLENE (LOTION, OINTMENT) 3 DIPROLENE AF 3 ELOCON (CREAM, LOTION, OINTMENT) 3

ENSTILAR 3 QL 2 / day

EPIFOAM 3

QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.025 % cream (g), 0.025 % oint. (g)) 1 HCG fluocinolone acetonide powder 3 fluocinolone acetonide 0.01 % solution 1 fluocinolone acetonide/shower cap 1 HCG fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % solution, 0.1 % cream (g)) 1 fluocinonide, micronized 3 fluocinonide/emollient base 1 fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1

PAGE 249 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 1 HCG

HALOG (CREAM, OINTMENT) 3 HEMMOREX-HC 1 hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. 1 (g), 100mg/60ml enema) hydrocortisone powder 3 hydrocortisone acetate powder 3 hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1 hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl 1 hydrocortisone acetate/pramoxine hcl (hydrocortisone/pramoxine 1 %-1 % cream/appl, hydrocortisone/pramoxine 2.5 %-1 % cream (g), 1 hydrocortisone/pramoxine 2.5 %-1 % cream/appl, hydrocortisone/pramoxine 2.5-1%(4g) cream/appl) hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1 hydrocortisone butyrate/emoll 0.1 % cream (g) 1 hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g)) 1 hydrocortisone/mineral oil/petrolatum,white 1 KENALOG 3 lidocaine/hydrocortisone ac 3 %-0.5 % cream/appl 1 lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream (g), lidocaine/hydrocortisone 3-2.5%(7g) gel 1 HCG w/appl)

LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 LUXIQ 3 MICORT-HC 3 mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

NOVACORT GEL 3

PAGE 250 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OLUX 3 OLUX-E 3 ORALONE 1 PANDEL 3 PRAMCORT 1 PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1% 3 OINTMENT)

PRAMOSONE E 3 prednicarbate (0.1 % cream (g), 0.1 % oint. (g)) 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3 PROCTOFOAM-HC 2 PROCTOSOL-HC 1 PROCTOZONE-HC 1 PSORCON 3 RIMSO-50 3

SANADERMRX 1 HCG

SCALACORT 1 SERNIVO 3 SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3 SYNALAR TS 3

TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) 3 QL 3 / day

TEMOVATE (CREAM, OINTMENT) 3 TEMOVATE EMOLLIENT 3 TEXACORT 3

PAGE 251 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM, 0.25% OINTMENT, 0.25% SPRAY) 3 triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.1 % paste (g), 0.147mg/g aerosol, 0.5 % cream (g), 0.5 % 1 oint. (g))

TRIANEX 1 TRIDERM 1

TRIDESILON 3 HCG

ULTRAVATE (CREAM, LOTION, OINTMENT) 3 VANOS 3

VANOXIDE-HC 3 QL 0.84 / day

VERDESO 3 ANTIPRURITICS AND LOCAL ANESTHETICS

ANACAINE 3 ANASTIA 3 CETACAINE 3 CIDALEAZE 1 dibucaine hcl 3 doxepin hcl 5 % cream (g) 1 EMLA 3 ethyl chloride 1

QL 3 / day lidocaine 5 % adh. patch 1 HCG lidocaine 5 % oint. (g) 1 lidocaine hcl (3 % cream (g), 3 % lotion, 4 % solution) 1 lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5 kit) 1 lidocaine/tetracaine 1 HCG

PAGE 252 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LIDODERM 3 QL 3 / day

LIDODEXTRAPINE 1 QL 4 / day

LIDOPIN 3% CREAM 1 LIDOPIN 3.25% CREAM 3 LIDOPRIL 1

QL 1 / day LIDORX 2 PA

LIDOTRAL 3 LIDOVEX 3 LIDTOPIC MAX 3 LP LITE PAK 1 NUMBONEX 3 PAIN EASE 3 phenazopyridine hcl 100 % powder 3 phenazopyridine hcl (100 mg tablet, 200 mg tablet) 1 PLIAGLIS 3 PONTOCAINE 3 pramoxine hcl 3 PRE-ATTACHED LTA KIT 3 PRUDOXIN 3 PYRIDIUM 3 REGENECARE 3 SPRAY AND STRETCH 3 SYNERA 3 ZONALON 3

PAGE 253 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ASTRINGENTS

DRYSOL 3 CELL STIMULANTS AND PROLIFERANTS

ATRALIN 3 QL 1.5 / day

AVITA 0.025% CREAM 1

AVITA 0.025% GEL 1 HCG

REFISSA 3 RENOVA 3 RENOVA PUMP 3 RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% CREAM, 0.1% CREAM) 3

RETIN-A MICRO 3 QL 50 / 30 days

RETIN-A MICRO PUMP 3 QL 50 / 30 days

TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3 tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g)) 1 tretinoin 0.025 % gel (gram) 1 HCG tretinoin powder 3 tretinoin microspheres (0.04 % gel (gram), 0.04 % gel w/pump, QL 1.667 / day 1 0.1 % gel (gram), 0.1 % gel w/pump) HCG tretinoin/emollient base 1 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

ALEVICYN ANTIPRURITIC SG 3 KERATOLYTIC AGENTS

ALUVEA 3 BENSAL HP 3

BENZEFOAM 3 QL 2 / day

PAGE 254 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BENZEFOAM ULTRA 3 QL 3.334 / day

BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1 benzoyl peroxide 7 % cleanser 1 BP-50% UREA 1 BPO (4% GEL, 8% GEL) 3

BPO 6% FOAMING CLOTHS 1 QL 2 / day

CEM-UREA 3 GORDO-UREA 40% OINTMENT 3 HYDRO 35 3 HYDRO 40 3 KERAFOAM 3 KERALAC 3 KERALYT 3 lactic acid 88% to 92% liquid 3 LATRIX 1

NUOX 3 QL 1.47 / day

PACNEX 1 PACNEX HP 3 PACNEX LP 3 podophyllum resin 3 potassium hydroxide pellet (g) 3 potassium hydroxide 5 % solution 1 HCG

PR BENZOYL PEROXIDE 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 RYNODERM 3 SALACYN (CREAM, LOTION) 1

PAGE 255 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SALEX 6% SHAMPOO 3 salicylic acid (6 % cream (g), 6 % crm er (g), 6 % foam, 6 % gel (gram), 6 % lotion, 6 % lotion er, 6 % shampoo, 26 % liquid, 1 27.5 % liq-film, 28.5 % sol-filmer) salicylic acid powder 3 salicylic acid/ammonium lactate/aloe vera 1 SALKERA 3 SALVAX 3 silver nitrate 10 % solution 1 silver nitrate/potassium nitrate 1 sodium hydroxide (10 % solution, 100 % pellet (g), flakes, granules) 3 sulfur 3 sulfur sublimed 3 ULTRASAL-ER 3 UMECTA (EMULSION, NAIL FILM PEN, NAIL FILM SUSP) 3 UMECTA 40% MOUSSE 1 UMECTA PD (PD EMULSION, PD SUSPENSION) 3 URAMAXIN (20% FOAM, 45% LOTION, 45% NAIL GEL, 45% UREA CREAM) 3

URAMAXIN GT 45% PRE-FILLED APP 3 URE-K 1 urea (35 % foam, 39 % cream (g), 40 % cream (g), 40 % gel (ml), 40 % lotion, 40 % nl fm susp, 45 % cream (g), 45 % gel 1 (ml), 45 % lotion, 47 % cream (g), 50 % cream (g)) urea (50 % sol/pf app, 100 % powder) 3 UREVAZ 3 UTOPIC 3 VIRASAL 3

PAGE 256 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KERATOPLASTIC AGENTS anthralin 3 coal tar (tar tar, tar 20 % solution) 3 DRITHOCREME HP 3 ZITHRANOL 3 ZITHRANOL-RR 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

ABSORICA 3 PA

QL 2 / day acitretin (17.5 mg capsule, 25 mg capsule) 1 HCG

QL 4 / day acitretin 10 mg capsule 1 HCG

ACZONE (5% GEL, 7.5% GEL PUMP) 3 QL 3 / day adapalene 0.1 % gel (gram) 1 QL 1.5 / day adapalene (0.1 % cream (g), 0.3 % gel (gram), 0.3 % gel QL 1.5 / day 1 w/pump) HCG

QL 2 / day adapalene 0.1 % lotion 1 HCG adapalene/benzoyl peroxide 3 QL 1.5 / day

QL 0.434 / day ALDARA 3 AL At least 12 yrs old

PA AMNESTEEM 1 HCG

ARTISS 3

AVAGE 3 QL 1.47 / day azelaic acid (85 % flakes, 88 % flakes, 100 % flakes, 100 % powder) 3

PAGE 257 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AZELEX 3 QL 1.667 / day

QL 2 / day calcipotriene (0.005 % cream (g), 0.005 % oint. (g)) 1 HCG calcipotriene 0.005 % solution 1 QL 2 / day

QL 2 / day CALCITRENE 1 HCG calcitriol 3 mcg/g oint. (g) 1 QL 3.334 / day camphor 3 capsaicin 3 capsaicin palmitate 3 capsicum oleoresin 3 CARAC 2

PA CLARAVIS 1 HCG collagenase clostridium histolyticum 3 CONDYLOX (GEL, TOPICAL SOLN) 3

QL 0.357 / day COSENTYX (2 SYRINGES) 4 PA S

QL 0.357 / day COSENTYX PEN 4 PA S

QL 0.357 / day COSENTYX PEN (2 PENS) 4 PA S

QL 0.357 / day COSENTYX SYRINGE 4 PA S

PAGE 258 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEBACTEROL (SOLUTION, SWABSTICK) 3 diclofenac sodium 3 % gel (gram) 1 QL 100 / 30 days

DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL 1.5 / day PUMP) 3 QL

DIFFERIN 0.1% LOTION 3 QL 1.967 / day

DOVONEX 3 QL 2 / day

QL 0.15 / day PA DUPIXENT 4 AL At least 18 yrs old S

EFUDEX 3

EPIDUO 0.1-2.5% GEL 3 QL 1.667 / day

EPIDUO 0.1-2.5% GEL PUMP 3 QL 1.5 / day

EPIDUO FORTE 3 QL 1.667 / day

QL 3.73 / day FABIOR 3 AL Up to 34 yrs old

QL 50 / 30 days FINACEA (FOAM, GEL) 3 PA finasteride 1 mg tablet 1 FLUOROPLEX 2 fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g), 5 % solution) 1

FORMADON 1 formaldehyde 1 GRANULEX 3

QL 0.434 / day imiquimod 5 % cream pack 1 AL At least 12 yrs old

PAGE 259 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS imiquimod 100 % powder 3 isotretinoin 3 LEVULAN 3 methyl aminolevulinate hcl 3

MIRVASO (GEL, GEL PUMP) 2 QL 1 / day

MUCOTROL 3

PA MYORISAN 1 HCG

PANRETIN 3

PICATO 3 ST

PODOCON-25 3 podofilox 0.5 % solution 1 PROPECIA 3

QL 2.5 / day PROTOPIC 0.03% OINTMENT 3 ST AL At least 2 yrs old

QL 2.5 / day PROTOPIC 0.1% OINTMENT 3 ST AL At least 16 yrs old

PYROGALLIC ACID 1 RECTIV 3

REGRANEX 3 QL 1 / day

RENOVO 3

QL 1.25 / day RHOFADE 3 PA

SANTYL 3 SINELEE 5%-0.05% PATCH 3

PAGE 260 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SOLARAZE 3 QL 100 / 30 days

SOOLANTRA 2 QL 1.5 / day

SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) 3 QL 2 / day

SORIATANE 10 MG CAPSULE 3 QL 4 / day

SORILUX 3 QL 2 / day

QL 100 / 30 days tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 ST HCG

QL 0.15 / day TALTZ AUTOINJECTOR 4 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (2 PACK) 4 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (3 PACK) 4 PA S

QL 0.15 / day TALTZ SYRINGE 4 PA S

QL 0.15 / day TALTZ SYRINGE (2 PACK) 4 PA S

QL 0.15 / day TALTZ SYRINGE (3 PACK) 4 PA S

PAGE 261 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA TARGRETIN 1% GEL 4 S

QL 1.47 / day tazarotene 0.1 % cream (g) 1 HCG tazarotene 100 % powder 3

TAZORAC (0.05% CREAM, 0.1% CREAM) 3 QL 2 / day

TAZORAC (0.05% GEL, 0.1% GEL) 3 QL 3.334 / day

QL 1.47 / day TOLAK 3 ST

TRI-CHLOR 3 trichloroacetic acid (25 % soln recon, 75 % soln recon) 1

QL 3 / day VALCHLOR 4 PA S

VANIQA 3

VECTICAL 3 QL 3.334 / day

VENELEX (OINTMENT, OINTMENT PACKET) 3 VEREGEN 3

PA ZENATANE 1 HCG

QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) 3 AL At least 12 yrs old

QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP 3 AL At least 12 yrs old

SUNSCREEN AGENTS zinc oxide 3

PAGE 262 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 100 PA mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 500 4 mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial) S octreotide acetate (50 mcg/ml vial, 200 mcg/ml vial, PA 4 1000mcg/ml vial) S

QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 4 PA S

QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 4 PA S

QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 4 PA S

QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 4 PA S

QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 4 PA S

QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30 MG VL) 4 PA S

QL 0.07 / day SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4 PA S

PAGE 263 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA SIGNIFOR 4 S

QL 0.1 / day SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4 PA S

QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 4 PA S

QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 4 PA S

SOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN AGONISTS

QL 2 / day EGRIFTA 4 PA S

PA INCRELEX 4 S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 4 S

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) hcl powder 3

PAGE 264 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS bupivacaine hcl/epinephrine 1 bupivacaine hcl/epinephrine bitartrate 1 bupivacaine hcl/epinephrine/pf 1 lidocaine hcl/epinephrine (hcl/epinephrine 0.5-1:200k vial, hcl/epinephrine 1%-1:100k vial, hcl/epinephrine 1.5-1:200k ampul, hcl/epinephrine 1.5-1:200k vial, hcl/epinephrine 2 %- 1 1:100k vial, hcl/epinephrine 2%-1:200k vial) lidocaine hcl/epinephrine bitartrate 1 MARCAINE-EPINEPHRINE 3 bitartrate 100 % powder 3

QL 84 / 14 days NORTHERA 4 PA S hcl 3 SENSORCAINE-EPINEPHRINE 1 SENSORC MPF 0.75%-EPI 1:200000 3 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI, SENSORCN-MPF 0.5%-EPI) 1

XYLOCAINE DENTAL-EPINEPHRINE 1 XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 1%-EPI 1:100,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000) 3

XYLOCAINE-MPF WITH EPINEPHRINE 3 ALPHA-ADRENERGIC AGONISTS hcl 1 phenylephrine hcl 100 % powder 3 phenylephrine hcl 10 mg/ml vial 1

PAGE 265 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS carbimazole 3 methimazole 100 % powder 3 methimazole (5 mg tablet, 10 mg tablet) 1 propylthiouracil 100 % powder 3 propylthiouracil 50 mg tablet 1 TAPAZOLE 3 THYROID AGENTS

ARMOUR THYROID 3 CYTOMEL 3

LEVO-T 1 HCG sodium (1 mg/g powder, 100 % powder) 3 levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcg HCG tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 1 mcg tablet, 175mcg tablet) LCG levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcg tablet, 300 mcg tablet) 1 HCG

HCG LEVOXYL (25 MCG TABLET, 100 MCG TABLET) 1 LCG

LEVOXYL (50 MCG TABLET, 75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 1 HCG MCG TABLET, 175 MCG TABLET, 200 MCG TABLET) liothyronine sodium (1 mg/g powder, 100 % powder) 3 liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1

NATURE-THROID 3 NP THYROID 1 SYNTHROID 2

PAGE 266 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROID 3 thyroid,pork 3 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3

TIROSINT 3 QL 1 / day

UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCG HCG 1 TABLET, 112 MCG TABLET) LCG

UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 1 HCG 200 MCG TABLET, 300 MCG TABLET)

WESTHROID 3 WP THYROID 3 Uncategorized

Unclassified

0.9 % sodium chloride 0.9 % syringe cp 1 HCG

2-methoxyestradiol 3 3,5-diiodothyronine 3 5hydroxytryptophan(oxitriptan) powder 3 7-oxodehydroepiandrosterone 3 7-oxodehydroepiandrosterone, micronized 3 acacia 3 acetarsol 3 acetyl hexapeptide-8 3 acetylglucosamine 3

PAGE 267 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 4 PA S

QL 1 / day AFINITOR 2.5 MG TABLET 4 PA S

PA AFINITOR DISPERZ 4 S

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR

AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR albumin, serum, bovine 3

QL 8 / day PA ALECENSA 4 AL At least 18 yrs old S alginic acid 3 ALKERAN 2 MG TABLET 3 allantoin 3 ALLFEN CDX 3 almond oil oil 3 aloe vera leaf gel extract 3 (100 % powder, powder) 3 aluminum acetate 3 aluminum chloride 3 aluminum chlorohydrate 3 aluminum sulfate 3

QL 6 / day PA ALUNBRIG 4 AL At least 18 yrs old S

PAGE 268 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS american ginseng root 3 ammonium lactate 70 % solution 3 ammonium sulfate 3 ammonium tetrathiomolybdate 3 AMVISC 3 AMVISC PLUS 3 anastrozole 100 % powder 3 anastrozole 1 mg tablet 1 anisindione 3 APLIGRAF 3 AQUORAL 3 ARIMIDEX 3 arnica flower extract 3 AROMASIN 3 arsenic trioxide 3 ashwagandha root extract 3 3 astragalus root extract 3 ATRAPRO DERMAL SPRAY 3 ATRAPRO HYDROGEL 3 AURSTAT ANTI-ITCH HYDROGEL 3 AVAILNEX 3 AVENOVA 3 azacitidine 4 S

B-PLEX PLUS 1 BEAU RX 3

PA BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 4 S

PAGE 269 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS benzocaine 3 benzocaine micronized 3 benzoic acid 3 benzoyl peroxide 65% to 82% powder 3 benzyl alcohol 3 bergamot 3 beta-glucan, (1-3) (1-4) 3 betadex 3

PA bexarotene 4 S 1 BIONECT (CREAM, GEL) 3 biotin 100 % powder 3 bismuth citrate 3 bismuth subgallate 3 bismuth tribromophenate/petrolatum,white (tribromoph/petrolatum 1"x8" bandage, tribromoph/petrolatum 2" x 2" bandage, tribromoph/petrolatum 4" x 4" bandage, 3 tribromoph/petrolatum 4"x108" bandage, tribromoph/petrolatum 5"x9" bandage) bitter melon extract 3

BLEO 15K 4 S bleomycin sulfate 4 S blood-glucose sensor 3 blood-glucose transmitter each 3 blue-green algae 3

QL 4 / day PA BOSULIF 100 MG TABLET 4 S PS

PAGE 270 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA BOSULIF 500 MG TABLET 4 S PS boswellia serrata extract 3 bromelains 3 bromfenac sodium 100 % powder 3 hcl 3 bupivacaine hcl 100 % powder 3 bupivacaine hcl/dex-water/pf 0.75 % ampul 1 bupivacaine hcl/pf (hcl/pf 2.5 mg/ml ampul, hcl/pf 5 mg/ml ampul, hcl/pf 7.5 mg/ml ampul) 1 butalbital/aspirin/caffeine 50-325-40 tablet 1 QL 6 / day

QL 4 / day CABOMETYX 20 MG TABLET 4 PA S

QL 2 / day CABOMETYX 40 MG TABLET 4 PA S

QL 1.5 / day CABOMETYX 60 MG TABLET 4 PA S calcipotriene 100 % powder 3 calcipotriene monohydrate 3 calcitriol/almond oil 3 cantharidin (100 % crystals, powder) 3 capecitabine 4 S

CAPHOSOL 3

PAGE 271 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day CAPRELSA 100 MG TABLET 4 PA S

QL 1 / day CAPRELSA 300 MG TABLET 4 PA S carbitol 3 CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) 3

CARDENE SR 45 MG CAPSULE 3 QL 2 / day

CASODEX 3 catheter (6fr-16" each, 8 fr each, 8fr-16" each, 10 fr each, 10fr- 16" each, 12 fr each, 12fr-16" each, 14 fr-16 " each, 16 fr each, 3 16fr-16" each, 18fr-16" each, 28 fr each) catheter 14 fr each 1 catheterization tray tray 3 CEDAX 90 MG/5 ML SUSPENSION 3 cellulose 3

CERAMAX 1 HCG cervical cap (cap 26mm each, cap 30mm each) 3 cervical cap 22mm each 3 HCR

CERVIDIL 3 GL Female cesium chloride 3 cetyl myristoleate (20 % powder, 40 % oil, 40 % wax) 3 cetylpyridinium chloride 3 chinese red pine bark extract 3 chlorambucil 3 chloroallyl methenamine chloride 3

PAGE 272 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 chloroprocaine hcl/pf 1 chloroxine 3 chloroxylenol 3 chlorzoxazone 250 mg tablet 1 3 chromium picolinate 3 chromium polynicotinate 3 chrysin 3 chymotrypsin 3 citric acid (100 % granules, powder) 3 clemizole hcl 3 cobalt gluconate 3 colostomy bag, non-sterile 3

QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 4 PA S

QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 4 PA S

QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 4 PA S compression stocking, knee high, regular length, medium 3 compression stocking, knee high, regular length, small 3 compression stocking,knee high,long length, large circumfer. 3 compression stocking,knee high,long length, x-large circumf. 3

PAGE 273 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS compression stocking,knee high,long length,medium circumfer. 3 compression stocking,knee high,long length,small circumferen 3 compression stocking,knee high,regular length,large circumf. 3 compression stocking,knee high,regular length,x-large circum 3 compression stocking,thigh high,long length,extra-large circ 3 compression stocking,thigh high,long length,large circumfer. 3 compression stocking,thigh high,long length,medium circumfer 3 compression stocking,thigh high,long length,small circumfer. 3 compression stocking,thigh high,long length,x-small circumf. 3 compression stocking,thigh high,reg length,x-large circumfer 3 compression stocking,thigh high,regular length,large circumf 3 compression stocking,thigh high,regular length,medium circum 3 compression stocking,thigh high,regular length,small circumf 3 compression stocking,thigh high,regular length,x-small circ. 3 compression stocking,thigh high,short length,large circumfer 3 compression stocking,thigh high,short length,medium circumf. 3 compression stocking,thigh high,short length,small circumfer 3 compressor, for nebulizer each 3 conception assistance supplies combination no.1 1

QL 2.5 / day PA COTELLIC 4 AL At least 18 yrs old S

QL 1 / day COTEMPLA XR-ODT 3 ST cream base no.134 3 3

PAGE 274 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS creatine monohydrate 3 3 cytarabine 4 S cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 100 mg/5ml vial) 4 S cytarabine/pf 20 mg/ml vial 4 S hcl 3 deanol 3 demecarium bromide 3 deoxycholic acid 3 DERMAGRAFT 3 devil's claw extract 3 maleate 1 dexpanthenol 3 diaphragms, wide seal 3 HCR dibucaine 3 dichloroacetic acid 3 diethanolamine 3 diindolylmethane 3 dimethyl sulfoxide (99 % liquid, 99.99 % liquid) 3 dimethylacetamide 3 dinitrochlorobenzene (2,4) 3 diphencyprone 3 DISCOVISC 3 drainage bag (bag each, bag 2000ml each) 3 dressing, /sodium alginate/carboxymethylcellulose 3 dressing,collagen/silver/sod alginate/carboxymethylcellulose 3

PAGE 275 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DROXIA 3 DUOVISC 3

EMCYT 4 S

EMULSION SB TOPICAL EMULSION 3 ENDOFORM (4" 5" TEMPLATE, FENESTRATED, FENESTRATED 4" 5", TEMPLATE) 3

ENTTY 3 EPICERAM 3 3

EPISIL 3 HCG

QL 1 / day ERIVEDGE 4 PA S

ERWINAZE 4 S ethoxydiglycol 3 ethyl acetate 1 ethyl oleate 3 exemestane 1

PA EXJADE 4 S

EXPAREL 3 FARESTON 2

PA FARYDAK 4 S feeder container 3 feeder container with gravity set 3 feeder container with pump set 3

PAGE 276 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FEMARA 3 PA ferric ammonium citrate 3 ferric subsulfate 3

PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 4 S fexofenadine hcl/pseudoephedrine hcl 1 QL 1 / day floxuridine 100 % powder 3 floxuridine 500 mg vial 4 S

AL At least 65 yrs old FLUAD 2017-2018 2 HCR

FLUARIX QUAD 2017-2018 2 HCR

FLUBLOK 2017-2018 2 HCR

FLUBLOK QUAD 2017-2018 2 HCR

FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 2 HCR FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 2 HCR fluorouracil 100 % powder 3 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR

AL At least 65 yrs old FLUZONE HIGH-DOSE 2017-2018 2 HCR

FLUZONE INTRADERM QUAD 2017-18 2 HCR

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 2 HCR

FLUZONE QUAD PEDI 2017-2018 2 HCR foam bandage 1

PAGE 277 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS foam/gauze bandage/lidocaine/chlorhexidine/ 3 FORMA-RAY 3 GALZIN 3 GASTROMARK 3 gauze bandage 3 gel dressing gel (gram) 3 gelatin 3 GELCLAIR 3 GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200 SPONGE) 3

GELFOAM COMPRESSED 3 GELFOAM JMI SPONGE KIT 3 GELX 3 GENADUR NAIL LACQUER 3

QL 1 / day GILOTRIF 4 PA S

QL 8 / day PA GLEEVEC 100 MG TABLET 4 S PS

QL 2 / day PA GLEEVEC 400 MG TABLET 4 S PS

GLEOSTINE 3 gluconolactone 3 3

PAGE 278 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glutaraldehyde 1 3 3 glycolic acid (70 % solution, crystals) 3 glycopyrrolate 1.5 mg tablet 1 glycosaminoglycans,mixed 3 glycyrrhizin 3 gramicidin d 3 guarana seed extract 3 HEMABATE 3

PA HEXALEN 4 S

HICON (500 MCI/0.5 ML KIT, 1,000 MCI/ML KIT) 3 phosphate 3 3 histidine hcl 3 HPR 3 HPR PLUS (CREAM, EMOLLIENT FOAM) 3 HUMALOG JUNIOR KWIKPEN 2 hyaluronate sodium (94 % powder, 100 % powder) 3 hyaluronidase, bovine 3

PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 4 S hydrazine sulfate 3 HYDREA 3 hydrocolloid dressing (4" 4" bandage, 6" 6" bandage, 8" 8" bandage) 1 hydrocolloid dressing 7"x8" bandage 3

PAGE 279 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS peroxide 3 hydroxyethyl methacrylate 3 hydroxypropyl betadex 3 hydroxyurea 500 mg capsule 1 hydroxyurea 100 % powder 3 HYGEL 3 HYLATOPIC 3 HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3 HYLENEX 3

PA HYQVIA HY COMPONENT 4 S

QL 1.25 / day IBRANCE 100 MG CAPSULE 4 PA S

QL 1 / day IBRANCE 125 MG CAPSULE 4 PA S

QL 1.667 / day IBRANCE 75 MG CAPSULE 4 PA S ichthammol 3

QL 2 / day ICLUSIG 15 MG TABLET 4 PA S

QL 1 / day ICLUSIG 45 MG TABLET 4 PA S

PAGE 280 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day IMBRUVICA 4 PA S

INDICLOR 3

QL 1 / day PA INGREZZA 80 MG CAPSULE 4 AL At least 18 yrs old S inhaler, assist devices spacer 3 inhaler,assist device,accesory each 3

QL 4 / day PA INLYTA 4 S PS inositol 3 iodoform (1" x 5yard bandage, 1/2"x5yd bandage, 1/4"x180" bandage, 2"x180" bandage) 3 iodoform 100 % powder 3 iopanoic acid 3 IPOL SINGLE DOSE SYRINGE 2

QL 1 / day IRESSA 4 PA S (100 % crystals, powder) 3 iodide 3 isopropyl myristate 3 isoproterenol hcl 0.2 mg/ml vial 1

PA JADENU 4 S

PAGE 281 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA JADENU SPRINKLE 4 S

QL 2 / day JAKAFI 4 PA S

QL 3 / day PA KISQALI 200 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI 400 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 1 / day PA KISQALI 600 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 3 / day PA KISQALI FEMARA 200 MG CO-PACK 4 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI FEMARA 400 MG CO-PACK 4 AL At least 18 yrs old S

QL 1 / day PA KISQALI FEMARA 600 MG CO-PACK 4 AL At least 18 yrs old S

PAGE 282 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS kojic acid 3 lancing device/lancets 2

QL 3 / day LENVIMA 4 PA S letrozole 100 % powder 3 letrozole 2.5 mg tablet 1 LEUKERAN 3 leuprolide acetate 100 % powder 3 lidocaine powder 3 lidocaine hcl 100 % powder 3 lidocaine hcl (5 mg/ml vial, 10 mg/ml syringe, 10 mg/ml vial, 50 mg/5 ml syringe) 1 lidocaine hcl buffered with 8.4 % sodium bicarbonate (0.9 %(3ml) syringe, 0.9 %(5ml) syringe, 0.9%(10ml) syringe, 1 % (1 ml) syringe, 1 %(0.5ml) syringe, 2 % (3 ml) syringe, 2 % (5 3 ml) syringe) lidocaine hcl/pf 10 mg/ml ampul 1 MED Medical Drug lidocaine hcl/pf (hcl/pf 10 mg/ml syringe, hcl/pf 10 mg/ml vial, hcl/pf 15 mg/ml ampul, hcl/pf 200mg/10ml syringe) 1 lomustine 1

QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 4 PA S

QL 3 / day LONSURF 20 MG-8.19 MG TABLET 4 PA S

LOUTREX 3 LUMINAL SODIUM 3

PAGE 283 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lutein 3

PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 4 S

LYSODREN 4 S maca 3 magnesium aspartate dihydrate 3 magnesium chloride crystals 3 magnesium malate 3 malic acid 3 MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL) 3 MARCAINE SPINAL AMPUL 3

MATULANE 4 S

QL 3 / day PA MAVYRET 4 AL At least 18 yrs old S PS

MAXIFED CDX 3 MAXIPHEN CD 3 MAXIPHEN CDX 3 mechlorethamine hcl 3 medical supply, miscellaneous miscell 3 MEGACE 3

MEGACE ES 3 GL Female megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1 megestrol acetate (20 mg tablet, 40 mg tablet) 1

PAGE 284 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS megestrol acetate,micronized 3

QL 4 / day MEKINIST 0.5 MG TABLET 4 PA S

QL 1 / day MEKINIST 2 MG TABLET 4 PA S melphalan 1 menadione 3 3 mepivacaine hcl/pf 1 chloride 3

QL 2 / day methadone hcl 5 mg/0.5ml syringe 1 PA

METHERGINE 1 powder 3 methotrexate 3 methylene blue/gentian violet/foam bandage 1 methylergonovine maleate (.2mg/ml(1) ampul, .2mg/ml(1) vial) 1 methylergonovine maleate 0.2 mg tablet 1 methylparaben 3 methylsulfonylmethane 3 MICROCYN 3 MICROCYN HYDROGEL 3 middle ear inflation device 1 MIFEPREX 3 milk thistle 3

PAGE 285 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mitomycin powder 3 mitotane 3 monochloroacetic acid 3 clearing device each 3 MUGARD 3

MUSTARGEN 4 S

MYLERAN 4 S nadide 3 NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL, 0.2% 200 MG/100 ML BAG, 0.2% 40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400 MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 100 MG/20 ML AMP, 0.5% 100 MG/20 ML VIAL, 0.5% 150 MG/30 ML VIAL, 0.75% 150 MG/20 ML 3 AMP, 0.75% 150 MG/20 ML VL, 1% 100 MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20 ML AMPULE, 1% 200 MG/20 ML VIAL, 2 MG/ML INFUSION BTL, 5 MG/ML INFUSION BTL, 200 MG/100 ML INF BTL) nasal exhalation resistance device 3 nebulizer each 3 nebulizer accessories (each, kit) 3 nebulizer and compressor each 3 needles, blood collection 3 needles, disposable 3 needles, filter 19gx1 1/2" dis needle 3 needles, filter 19gx1" dis needle 3

PAGE 286 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS needles, safety (18gx1 1/2" dis needle, 18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 21 g x 1" dis needle, 21gx1 1/2" dis needle, 22gx1 1/2" dis needle, 22gx1" dis needle, 23gx1 1/2" 3 dis needle, 23gx1" dis needle, 25gx1 1/2" dis needle, 25gx1" dis needle, 25gx5/8" dis needle, 26gx1/2" dis needle, 27gx1/2" dis needle, 30gx1 1/2" dis needle)

NEOSALUS (CREAM, FOAM, LOTION) 3 NEOSALUS CP 3 NESACAINE 3 NESACAINE-MPF 3 nettle leaf 3 NEUTRASAL 538 MG POWDER PACKET 3

QL 4 / day NEXAVAR 4 PA S

NILANDRON 4 S

PA nilutamide 4 S

QL 0.124 / day PA NINLARO 4 AL At least 18 yrs old S

NIVATOPIC PLUS 3

PA NOVAREL 5,000 UNIT VIAL 4 S

NUMOISYN (LIQUID, LOZENGE) 3 NUVAIL 3

NYMALIZE 30 MG/10 ML SOLUTION 3 QL 120 / day

PAGE 287 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS octanoic acid 3

QL 1 / day ODOMZO 4 PA S omega-3 fatty /dha/epa/fish oil/sunflower oil 3

ONCASPAR 4 S

ORAFATE 4 S

ORAMAGICRX 3 powder 3 ostomy kit 3 ostomy supply each 3 oxytocin powder 3 oxytocin 10 unit/ml vial 1 panax ginseng root 3 papain 3 parachlorophenol 3 peak flow meter each 3 peak flow meter/inh assit dev kit 3 pen needle, diabetic 2 pentylenetetrazol 3 phenindione 3 phenolsulfonic acid 3 phenylmercuric nitrate 3 citrate (dihydrogen) 3 phosphatidyl 3 PITOCIN 3 podofilox 100 % powder 3

PAGE 288 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1 POLOCAINE-MPF 1 polyhexam biguan/gauze bandage 0.2%-1/2x3 strip 3 polyvinyl alcohol 3 polyvinyl alcohol/gentian violet/methylene blue 3 porcine acell submucosa,meshed 3 porcine acellular small intestine submucosa, fenestrated (3 cm x7 cm sheet, 3cm x3.5cm sheet) 3 potassium aminobenzoate 100 % powder 3 (100 % powder, crystals) 3 potassium permanganate (crystals, granules) 3 potassium sorbate (crystals, powder) 3 povidone k-30 powder 3 3 pregnenolone, micronized 3

PREPIDIL 3 GL Female

PRESERA 3 prezatide copper 3 prilocaine hcl 3 procaine hcl 3 procarbazine hcl 3 3 PROMISEB 3 propyl gallate 3 propylene glycol 3

PROSTIN E2 VAGINAL SUPPOSITORY 3 GL Female

PROTHELIAL 4 S

PAGE 289 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prothrombin time/inr test meter 3 PROVISC 3 PROVOCHOLINE 3 PRUMYX 3 pump set 3 3 pyrithione zinc 3 dihydrate 3 RADIAPLEXRX 3 RADIGEL 3 RECEDO 3 red rice extract 3 resorcinol (crystals, powder) 3 retinal 3 ropivacaine hcl 3 ropivacaine hcl in 0.9 % sodium chloride/pf (ropivacae chl/pf 0.1% 400ml els pmp hr, ropivacae chl/pf 0.2% 550ml els pmp 1 hr) ropivacaine hcl/pf (hcl/pf 2 mg/ml vial, hcl/pf 5 mg/ml vial, hcl/pf 7.5 mg/ml vial, hcl/pf 10 mg/ml vial) 1

QL 2 / day PA RUBRACA (200 MG TABLET, 250 MG TABLET) 4 AL At least 18 yrs old S

QL 2 / day PA RUBRACA 300 MG TABLET 4 AL At least 18 yrs old S

QL 2 / day PA RYDAPT 4 AL At least 18 yrs old S

PAGE 290 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS s-adenosylmethionine sulfate tosylate 3 SALIVAMAX 3 SALIVATERX 3 sapropterin dihydrochloride (100 % powder, powder) 3 saw palmetto fruit 3 SEBUDERM 3 SENSORCAINE 1 SENSORCAINE WITH DEXTROSE 1 SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1 serine 3 serotonin hcl 3 silver (1" x 24" bandage, 2" x 2" bandage, 4" x 4" bandage, 4" x 5" bandage, 5"x5" bandage, 6" x 6" bandage) 3 silver (4" x 8" bandage, 4"x48" bandage, 8"x16" bandage, 16"x16" bandage) 1 silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5 %-2"x 2" bandage, sulfadiaz/foam bandage 5 %-4"x 4" bandage, sulfadiaz/foam bandage 5 %-6"x 6" bandage, 1 sulfadiaz/foam bandage 5 %-8"x 8" bandage) silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5 %-3" x3" bandage, sulfadiaz/foam bandage 5 %-5" x5" 3 bandage, sulfadiaz/foam bandage 5 %-7" x7" bandage) silver sulfate/foam bandage 3 silver sulfate/non-adherent bandage 3 silver/calcium alginate 3 silver/foam bandage 1 silver/hydrocolloid dressing 3 SILVRSTAT 3 sodium benzoate 3 sodium butyrate 3

PAGE 291 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium desoxycholate 3 sodium dichloroacetate 3 sodium iodide 3 sodium metabisulfite (100 % granules, powder) 3 sodium stearyl fumarate 3 sodium succinate 1 SOLTAMOX 3 sorbic acid 3 SP ANTIPRURITIC 3 spirometers and accessories each 3

QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 4 PA S

QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 4 PA S

QL 9 / day SPRYCEL 20 MG TABLET 4 PA S

QL 3 / day SPRYCEL 50 MG TABLET 4 PA S

QL 4 / day STIVARGA 4 PA S

PA AL Up to 18 yrs old STRENSIQ 4 S PS

PAGE 292 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SUCRAID 4 S sulfurated potash 3

QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4 S PS

QL 7 / day PA SUTENT 12.5 MG CAPSULE 4 S PS

QL 3 / day PA SUTENT 25 MG CAPSULE 4 S PS

SWABFLUSH 1 HCG

PA SYNRIBO 4 S

PA SYPRINE 4 S syring w-needl 0.5 ml,kit-tray 3 syringe with cannula, disposable, 3 ml 3 syringe with cannula, disposable, 6 ml 3 syringe with cannula,disposable 12 ml 3 syringe with needle, , safety, 0.3 ml 2 syringe with needle, insulin, safety, 0.5 ml 2 syringe with needle, insulin, safety, 1 ml 2 syringe with needle,disposable 3

PAGE 293 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe with needle,disposable, 0.5 ml 3 syringe with needle,disposable, 1 ml (syringe 1 ml 25gx1" disp syrin, syringe 1 ml 25gx5/8" disp syrin) 3 syringe with needle,disposable, 1 ml (syringe 1 ml 26gx1/2" disp syrin, syringe 1 ml 26gx3/8" disp syrin, syringe 1 ml 3 27gx0.375" disp syrin, syringe 1 ml 27gx1/2" disp syrin) syringe with needle,disposable, 6 ml 3 syringe with needle,disposable,insulin 1 ml (syringe disp syrin, syringe 28gx1/2" disp syrin, syringe 29 g x1/2" disp syrin, 2 syringe 30g x5/16" disp syrin, syringe 30gx1/2" disp syrin) syringe with needle,insulin,0.3 ml 2 syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin, ml 29 g x1/2" disp syrin, ml 30g x5/16" disp syrin, ml 30gx1/2" 2 disp syrin) syringe, disposable irrigation, 70 ml 1 syringe, disposable, 1 ml disp syrin 3 syringe, disposable, 12 ml disp syrin 3 syringe, disposable, 3 ml 3 syringe, disposable, 5 ml 3 syringe, disposable, 6 ml 3 syringe, insulin u-500 with needle, disposable, 0.5 ml 2 syringe,safety with needle,1 ml (25gx1" syringe, 25gx5/8" disp syrin, 26gx3/8" disp syrin, 27gx1/2" disp syrin) 3 syringe,safety with needle,10 ml 3 syringe,safety with needle,12 ml 3 syringe,safety with needle,3 ml (20gx1 1/2" disp syrin, 20gx1" disp syrin, 21 g x 1" disp syrin, 21gx1 1/2" disp syrin, 22gx1 1/2" disp syrin, 22gx1" disp syrin, 23gx1" disp syrin, 25gx1" 3 disp syrin, 25gx5/8" disp syrin) syringe,safety with needle,5 ml 3 TABLOID 3

QL 6 / day TAFINLAR 50 MG CAPSULE 4 PA S

PAGE 294 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day TAFINLAR 75 MG CAPSULE 4 PA S

QL 1 / day PA TAGRISSO 4 AL At least 18 yrs old S PS citrate powder 3 tamoxifen citrate (10 mg tablet, 20 mg tablet) 1 HCR

QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 4 PA S

QL 6 / day TARCEVA 25 MG TABLET 4 PA S

PA TARGRETIN 75 MG CAPSULE 4 S

QL 4 / day PA TASIGNA 4 S PS

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, PA 4 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) S

PA 4 S tetracaine 3

PAGE 295 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tetracaine hcl powder 3 tetracaine hcl/pf 10 mg/ml ampul 1 theobromine 3 thioguanine 3 thiotepa 100 % powder 3 thiotepa 15 mg vial 4 S (crystals, powder) 3 THROMBI-GEL 3 THROMBI-PAD 3 titanium dioxide 3 TL-CERMIDE 3 topical cream metered-dose device 3 tens unit each 3 transfer device, closed system (13mm each, 20mm each, 28mm each) 3

TREAGAN OTIC 3

QL 90 / 365 days tretinoin 10 mg capsule 4 S trichloroacetic acid (crystals, powder) 3 triethanolamine 3 3 trioxsalen 3 TROPAZONE 3 trypsin 3

QL 6 / day PA TYKERB 4 S PS

PAGE 296 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS unithiol (97 % powder, crystals) 3 urinary bag/catheter (bag/catheter 6 fr combo. pkg, bag/catheter 8fr-14" combo. pkg) 3 urinary bag/catheter 14 fr-16 " combo. pkg 3 urinary bag/catheterization tray 3 vacuum erection device system 3 3

VALSTAR 4 S

VAXCHORA BUFFER COMPONENT 2

VENATAL COMPLETE DHA 3 GL Female

QL 4 / day VENCLEXTA 4 PA S

QL 1.5 / day VENCLEXTA STARTING PACK 4 PA S

VIASPAN BELZER-UW 3 VISCOAT 3

VITASPIRE 3 GL Female

VITRASE 3

QL 1 / day PA VOSEVI 4 AL At least 18 yrs old S PS

QL 4 / day VOTRIENT 4 PA S

PAGE 297 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS water for inj.,bacteriostatic 1 water for inj.,bacteriostatic/methylparaben/propylparaben 1 water for injection,sterile (ampul, vial) 1 white willow bark/salicin 3

QL 2 / day XALKORI 4 PA S xanthan gum 3

QL 4 / day XELODA 4 PA S

QL 4 / day XTANDI 4 PA S

XYLOCAINE (0.5% VIAL, 1% VIAL) 3 XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1% VIAL, 1.5% AMPUL, 4% AMPUL) 3 hcl 3 yohimbine hcl 5.4 mg tablet 1 ZANABIN 3 zeaxanthin 3

QL 3 / day PA ZEJULA 4 AL At least 18 yrs old S

QL 8 / day ZELBORAF 4 PA S

PAGE 298 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zinc acetate dihydrate (100 % crystals, 100 % powder) 3 ZINGO 3 ZODEX 12 DAY 1.5 MG TABLET 3

QL 4 / day ZOLINZA 4 PA S

ZOTEX-C 3

QL 2 / day ZYDELIG 4 PA S

QL 8 / day PA ZYKADIA 4 AL At least 18 yrs old S

QL 4 / day PA ZYTIGA 250 MG TABLET 4 S PS

QL 2 / day PA ZYTIGA 500 MG TABLET 4 S PS

VASODILATING AGENTS

NITRATES AND NITRITES

DILATRATE-SR 3 QL 4 / day

QL 1.25 / day GONITRO 3 PA AL At least 18 yrs old

PAGE 299 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day ISOCHRON 1 HCG

ISORDIL 3 QL 12 / day

ISORDIL TITRADOSE 3 QL 12 / day isosorbide 3 isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 12 / day mg tablet) 1 QL

QL 4 / day isosorbide dinitrate 40 mg tablet er 1 HCG isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab 2 / day er 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1 QL

QL 1 / day MINITRAN 1 HCG

NITRO-BID 2 QL 4 / day

NITRO-DUR 3 QL 1 / day

NITRO-TIME 1 QL 4 / day nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 mg 4 / day capsule er) 1 QL nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, QL 1 / day 1 0.4mg/hr patch td24, 0.6mg/hr patch td24) HCG

QL 0.8 / day nitroglycerin 400mcg/spr spray 1 HCG nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1 QL 6 / day

NITROLINGUAL 3 QL 0.8 / day

NITROMIST 3 QL 0.3 / day

NITROSTAT 3 QL 6 / day

PAGE 300 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium nitrite granules 3 PHOSPHODIESTERASE TYPE 5 INHIBITORS

QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 2 GL Male

QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 2 GL Male

QL 0.2 / day VIAGRA 2 GL Male AL At least 18 yrs old

VASODILATING AGENTS, MISCELLANEOUS alprostadil 100 % powder 3 alprostadil 500 mcg/ml vial 1 CAVERJECT 40 MCG/2 ML AMPUL 3 CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 Male MCG KIT, 40 MCG VIAL) 3 GL

EDEX 3 GL Male hcl 100 % powder 3 isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1

MUSE 3 GL Male papaverine hcl powder 3 papaverine hcl 30 mg/ml vial 1 papaverine hcl/alprostadil in bacteriostatic water 1 PROSTIN VR PEDIATRIC 3 hcl 3

PAGE 301 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMINS

MULTIVITAMIN PREPARATIONS

ELDERCAPS 1 HCG

ELITE OB DHA 3 GL Female

ELITE-OB 3 GL Female

MATERNITY 1 GL Female

MAXINATE 3 GL Female multivitamin-minerals no.44/cholecalciferol (vit d3)/vit k1 1 HCG

MYNATAL ULTRACAPLET 3 GL Female

MYNATE 90 PLUS 3 GL Female pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) 1 HCG pediatric multivit no.22/cholecalciferol(d3)/phytonadione(k) 1 PNV-VP-U 3

PRENA1 CHEW 3 GL Female prenatal vitamins no.5/ferrous fumarate/folic acid 3 GL Female

REQ49+ 3 SUPERVITE EC 3 THERAPEUTIC W-MINERALS 1

TRIVEEN-U 3 GL Female

TRUST NATAL DHA 3 GL Female

UDAMIN SP 3 V-C FORTE 1 VIC-FORTE 1

VINATE PN CARE 3 GL Female

PAGE 302 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VINATE-M 3 GL Female

VITAMIN A

AQUASOL A 3 beta-carotene 3 ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops 1 acetate 3 vitamin a palmitate (plmitte 1.06 mm/g liquid, plmitte 1.7mm/g liquid, plmitte 18000/ml liquid) 3 VITAMIN B COMPLEX

B-12 COMPLIANCE 3 B-12 KIT 1 calcium pantothenate 3 CARDIOTEK-RX 3 cobamamide 100 % powder 3 cyanocobalamin (vitamin b-12) powder 3 cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1 cyanocobalamin/folic acid/pyridoxine 1 FOLBEE 1 FOLBEE AR 3 FOLBEE PLUS CZ 1 FOLGARD RX 3 folic acid 100 % powder 3 folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 FOLPLEX 2.2 1 hydroxocobalamin powder 3 hydroxocobalamin 1000mcg/ml vial 1

PAGE 303 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levomefolate calcium 100 % powder 3 mecobalamin 3 methyltetrahydrofolate calcium 3 methyltetrahydrofolate glucosamine 3 NASCOBAL 3 NEPHRO-VITE RX 3 NEURIN-SL 3 niacinamide 3 panthenol 3 pyridoxine hcl (vitamin b6) (100 % powder, crystals) 3 pyridoxine hcl (vitamin b6) 100 mg/ml vial 1 RENA-VITE RX 1 riboflavin (vitamin b2) 3 riboflavin 5-phosphate sodium (b2) 3 SUPERVITE 3 thiamine hcl powder 3 thiamine hcl 100 mg/ml vial 1 thiamine hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 1 VIRT-CAPS SOFTGEL 1 VIRT-GARD 1 VIRT-VITE 1

VIRT-VITE PLUS 1 HCG

VITA-RESPA 3 VP-VITE RX 1 ZOLATE 1 ascorbate sodium 3

PAGE 304 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ascorbic acid 100 % powder 3 ascorbic acid 500 mg/ml vial 1 VITAMIN D calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 calcitriol (100 % crystals, 100 % powder) 3 cholecalciferol (vitamin d3) (2400/ml liquid, 100000/g powder) 3 doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 4 S

DRISDOL 3 ergocalciferol (vitamin d2) 50000 unit capsule 1 ergocalciferol (vitamin d2) powder 3 HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 4 S paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) 4 S

RAYALDEE 4 S

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORAL SOLN) 3

PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4 S

VITAMIN E (dl-alpha tocopheryl acetate) 3 vitamin e acetate (actat50 % powdr, actat125/ml liquid) 3 vitamin e acid succinate 3 vitamin e mixed 3 ACTIVITY phytonadione (vit k1) 100 % liquid 3 3

PAGE 305 LAST UPDATED 10/2017 Index of Covered Drugs acetaminophen 8 0 acetaminophen with codeine phosphate 8 0.9 % sodium chloride 171,267 acetaminophen/caffeine/dihydrocodeine bitartrate 8 acetarsol 267 2 ACETASOL HC 37 2-deoxy-d-glucose 135 acetazolamide 97 2-methoxyestradiol 267 acetazolamide sodium 97 acetic acid 37 3 acetic acid/aluminum acetate 37 3,5-diiodothyronine 267 acetyl hexapeptide-8 267 acetylcarnitine hcl 231 5 acetylcholine chloride 97 5-hydroxy-l-tryptophan (oxitriptan) 267 acetylcysteine 231 acetylcysteine in sterile water/pf 180 7 acetylglucosamine 267 7-oxodehydroepiandrosterone 267 ACIPHEX 134 7-oxodehydroepiandrosterone, micronized 267 ACIPHEX SPRINKLE 134 acitretin 257 8 ACLARO 155 8-MOP 155 ACTEMRA 224 ACTHIB 130 A ACTICLATE 61 A-HYDROCORT 191 ACTIGALL 185 A-METHAPRED 191 ACTIMMUNE 227 abacavir sulfate 125 ACTIQ 13 abacavir sulfate/lamivudine 125 ACTIVE FE 47 abacavir sulfate/lamivudine/zidovudine 125 ACTIVELLA 175 ABILIFY 114 ACTONEL 221 ABILIFY MAINTENA 114 ACTOPLUS MET 83 ABSORICA 257 ACTOPLUS MET XR 83 acacia 267 ACTOS 88 acamprosate calcium 150 ACULAR 46 acarbose 82 ACULAR LS 46 ACCOLATE 46 ACUVAIL 46 ACCUPRIL 241 acyclovir 40,136 ACCURETIC 166 ACZONE 257 ACD 170 ADACEL TDAP 130 ACD-A 67 ADALAT CC 147 acebutolol hcl 53 adapalene 257 ACEON 241 adapalene/benzoyl peroxide 257 acepromazine maleate 123 ADASUVE 114 ADCIRCA 244 albuterol sulfate 4 ADDERALL 26 ALCAINE 181 ADDERALL XR 26 alclometasone dipropionate 247 ADDYI 150 ALDACTAZIDE 165 adefovir dipivoxil 136 ALDACTONE 165 ADEMPAS 244 ALDARA 257 adenosine 55 aldosterone 191 ADIPEX-P 24 ALECENSA 268 ADOXA 61 alendronate sodium 222 ADRENACLICK 3 ALEVICYN ANTIPRURITIC SG 254 ADRENALIN 3 alfentanil hcl 13 ADRENALIN CHLORIDE 182 alfuzosin hcl 7 ADVAIR DISKUS 4 alginic acid 268 ADVAIR HFA 4 ALINIA 114 ADVICOR 106 ALKERAN 268 ADYPHREN 3 allantoin 268 ADYPHREN AMP 3 allergenic extract tree pollen-american elm 156 ADYPHREN AMP II 3 allergenic extract, grass pollen-bermuda, standard 156 ADYPHREN II 3 allergenic extract, grass pollen-orchard grass, standard 156 ADZENYS XR-ODT 26 allergenic extract, mite-d.farinae- AEROSPAN 154 d.pteronyssinus,standard 156 AFEDITAB CR 147 allergenic extract,grass pollen-june(kentucky AFINITOR 268 blue),standard 156 AFINITOR DISPERZ 268 allergenic extract,grass pollen-redtop, standard 156 AFLURIA 2016-2017 130 allergenic extract,grass pollen-timothy,standard 156 AFLURIA 2017-2018 268 allergenic extract,mite-dermatophagoides pteronyssinus, AFLURIA QUAD 2016-2017 130 std 156 AFLURIA QUAD 2017-2018 268 allergenic extract-acremonium strictum 156 AFREZZA 86 allergenic extract-alternaria alternata 156 AGGRENOX 127 allergenic extract-american cockroach 156 AGRYLIN 128 allergenic extract-aspergillus fumigatus 156 AK-POLY-BAC 34 allergenic extract-aspergillus,mixed 156 AKTEN 181 allergenic extract-aureobasidium pullulans 156 AKYNZEO 88 allergenic extract-botrytis cinerea 156 ALA-CORT 247 allergenic extract-candida albicans 156 ALA-QUIN 93 allergenic extract-cattle epithelium 156 ALA-SCALP 247 allergenic extract-cladosporium cladosporioides 156 alanine 170 allergenic extract-cladosporium sphaerospermum 157 albendazole 31 allergenic extract-cockroach (american and german) 157 ALBENZA 31 allergenic extract-corn smut 157 albumin, serum, bovine 268 allergenic extract-cultivated crop pollen-corn 157 allergenic extract-curvularia 157 allergenic extract-tree pollen-juniper, western 158 allergenic extract-dog epithelium 157 allergenic extract-tree pollen-kapok 158 allergenic extract-drechslera sorokiniana 157 allergenic extract-tree pollen-melaleuca 158 allergenic extract-epicoccum nigrum 157 allergenic extract-tree pollen-mesquite 158 allergenic extract-fire ant 157 allergenic extract-tree pollen-mountain cedar 158 allergenic extract-fusarium oxysporum 157 allergenic extract-tree pollen-mulberry, red 158 allergenic extract-german cockroach 157 allergenic extract-tree pollen-mulberry, white 158 allergenic extract-grass pollen-bahia 157 allergenic extract-tree pollen-olive 158 allergenic extract-grass pollen-johnson 157 allergenic extract-tree pollen-palm, queen 158 allergenic extract-grass pollen-meadow fescue, allergenic extract-tree pollen-pecan 158 standardized 157 allergenic extract-tree pollen-pepper tree, california 158 allergenic extract-grass pollen-perennial rye, standard 157 allergenic extract-tree pollen-pine, white 159 allergenic extract-grass pollen-quack 157 allergenic extract-tree pollen-privet 159 allergenic extract-grass pollen-smooth brome 157 allergenic extract-tree pollen-red birch 159 allergenic extract-horse epithelium 157 allergenic extract-tree pollen-red cedar 159 allergenic extract-mixed feathers, chicken, duck, goose 157 allergenic extract-tree pollen-red maple 159 allergenic extract-mixed weed pollen-short and tall allergenic extract-tree pollen-red oak 159 ragweed 157 allergenic extract-tree pollen-shagbark hickory 159 allergenic extract-mosquito 157 allergenic extract-tree pollen-sweet gum 159 allergenic extract-mouse epithelium 157 allergenic extract-tree pollen-virginia live oak 159 allergenic extract-mucor plumbeus 157 allergenic extract-tree pollen-white ash 159 allergenic extract-penicillium notatum 157 allergenic extract-tree pollen-white birch 159 allergenic extract-phoma herbarum 157 allergenic extract-tree pollen-white oak 159 allergenic extract-rabbit epithelium 157 allergenic extract-trichophyton mentagrophytes 159 allergenic extract-rhizopus oryzae 157 allergenic extract-venom-honey bee 159 allergenic extract-saccharomyces cerevisiae 158 allergenic extract-venom-mixed vespid protein 159 allergenic extract-sweet vernal, standardized 158 allergenic extract-venom-wasp protein 159 allergenic extract-tree pollen-acacia 158 allergenic extract-venom-white-faced hornet protein 159 allergenic extract-tree pollen-alder white 158 allergenic extract-venom-yellow hornet protein 159 allergenic extract-tree pollen-american beech 158 allergenic extract-venom-yellow jacket protein 159 allergenic extract-tree pollen-american sycamore 158 allergenic extract-weed pollen-carelessweed 159 allergenic extract-tree pollen-arizona cypress 158 allergenic extract-weed pollen-cocklebur 159 allergenic extract-tree pollen-australian pine 158 allergenic extract-weed pollen-dog fennel 159 allergenic extract-tree pollen-bald cypress 158 allergenic extract-weed pollen-english plantain 159 allergenic extract-tree pollen-bayberry 158 allergenic extract-weed pollen-giant (tall) ragweed 159 allergenic extract-tree pollen-black walnut 158 allergenic extract-weed pollen-goldenrod 159 allergenic extract-tree pollen-black willow 158 allergenic extract-weed pollen-kochia (firebush) 159 allergenic extract-tree pollen-box elder 158 allergenic extract-weed pollen-lambsquarters 159 allergenic extract-tree pollen-eastern cottonwood 158 allergenic extract-weed pollen-mugwort 160 allergenic extract-tree pollen-elm, cedar 158 allergenic extract-weed pollen-rough pigweed 160 allergenic extract-tree pollen-hackberry 158 allergenic extract-weed pollen-russian thistle 160 allergenic extract-weed pollen-sagebrush 160 ALYACEN 196 allergenic extract-weed pollen-sheep sorrel 160 AMABELZ 175 allergenic extract-weed pollen-sheep sorrel,yellow amantadine hcl 111 dock 160 AMARYL 87 allergenic extract-weed pollen-short ragweed 160 AMBIEN 139 allergenic extract-weed pollen-spiny pigweed 160 AMBIEN CR 139 allergenic extract-weed pollen-true marsh elder 160 amcinonide 247 allergenic extract-weed pollen-western ragweed 160 AMERGE 109 allergenic extract-weed pollen-yellow dock 160 american ginseng root 269 ALLFEN CDX 268 AMETHIA 196 allopurinol 220 AMETHIA LO 196 ALLZITAL 8 AMETHYST 196 almond extract 160 AMICAR 98 almond oil 268 amifampridine 231 almotriptan malate 109 amikacin 57 ALOCRIL 47 amikacin sulfate 57 aloe vera leaf gel extract 268 amiloride hcl 164 ALOMIDE 179 amiloride hcl/hydrochlorothiazide 164 ALORA 175 aminocaproic acid 98 alosetron hcl 183 aminophylline 146 alpha lipoic acid 268 aminosalicylate sodium 110 ALPHAGAN P 96 aminosalicylic acid 111 ALPHAQUIN HP 155 amiodarone hcl 55 alprazolam 141 AMITIZA 184 ALPRAZOLAM INTENSOL 141 amitriptyline hcl 81 alprostadil 301 amitriptyline hcl/chlordiazepoxide 81 ALREX 44 amlodipine besylate 147 ALSUMA 109 amlodipine besylate/atorvastatin calcium 106 ALTABAX 37 amlodipine besylate/benazepril hcl 147 ALTACAINE 181 amlodipine besylate/olmesartan medoxomil 147 ALTACE 241 amlodipine besylate/valsartan 147,148 ALTAFLUOR 181 amlodipine besylate/valsartan/hydrochlorothiazide 148 ALTAVERA 196 ammonium chloride 169 ALTOPREV 106 ammonium lactate 174,269 aluminum acetate 268 ammonium sulfate 269 aluminum chloride 268 ammonium tetrathiomolybdate 269 aluminum chlorohydrate 268 AMNESTEEM 257 aluminum hydroxide 183 amoxapine 81 aluminum sulfate 268 amoxicillin 238 ALUNBRIG 268 amoxicillin/potassium clavulanate 238,239 ALUVEA 254 amphotericin b 92 ampicillin sodium 239 APLENZIN 75 ampicillin sodium/sulbactam sodium 239 APLIGRAF 269 ampicillin trihydrate 239 APLISOL 163 AMPYRA 231 APOKYN 168 AMRIX 246 apomorphine hcl 168 AMVISC 269 apple extract 160 AMVISC PLUS 269 apraclonidine hcl 180 amyl nitrite 219 aprepitant 89 AMYTAL SODIUM 141 APRI 196 ANA-LEX 247 APRISO 183 ANACAINE 252 APTENSIO XR 28 ANADROL-50 194 APTIOM 69 ANAFRANIL 81 APTIVUS 126 anagrelide hcl 128 AQUASOL A 303 ANALPRAM HC 247 AQUORAL 269 ANAPROX 220 ARANELLE 196 ANAPROX DS 220 ARANESP 145 ANASPAZ 64 ARAVA 224 ANASTIA 252 ARBINOXA 99 anastrozole 269 ARCALYST 231 ANCOBON 93 ARCAPTA NEOHALER 4 ANDRODERM 194 arginine 170 ANDROGEL 194 arginine hcl 170 ANDROID 194 ARICEPT 143 androstenedione 194 ARIMIDEX 269 ANDROXY 194 aripiprazole 114,115 ANGELIQ 175 ARISTADA 115 anisindione 269 ARISTOSPAN 191 ANORO ELLIPTA 4 ARIXTRA 68 ANSAID 235 armodafinil 31 ANTABUSE 219 ARMOUR THYROID 266 ANTARA 105 arnica flower extract 269 anthralin 257 ARNUITY ELLIPTA 154 antimony trichloride 114 AROMASIN 269 antivenin,latrodectus mactans 129 aromatic cascara fluid extract 184 antivenin,micrurus fulvius 129 arsenic trioxide 269 ANTIVERT 90 ARTHROTEC 50 133 ANUCORT-HC 247 ARTHROTEC 75 133 ANUSOL-HC 248 ARTISS 257 ANZEMET 88 ARYMO ER 13 APEXICON E 248 ASCOMP WITH CODEINE 13 ascorbate sodium 304 AUSTEDO 150 ascorbic acid 305 AUVI-Q 3 ASHLYNA 196 AVAGE 257 ashwagandha root extract 269 AVAILNEX 269 aspartic acid 269 AVALIDE 166 aspirin 127 AVANDAMET 83 aspirin/caffeine/dihydrocodeine bitartrate 127 AVANDIA 88 aspirin/dipyridamole 127 AVAPRO 240 ASTAGRAF XL 229,230 AVAR 40 ASTEPRO 179 AVAR LS 40 astragalus root extract 269 AVAR-E 40 ASTRAMORPH-PF 13 AVAR-E GREEN 40 ASTRINGYN 98 AVAR-E LS 40 ATABEX EC 47 AVC 40 ATACAND 240 AVELOX 59 ATACAND HCT 166 AVELOX ABC PACK 59 ATELVIA 222 AVENOVA 269 atenolol 53 AVIANE 196 atenolol/chlorthalidone 53 AVIDOXY 61 ATIVAN 73 AVITA 254 atomoxetine hcl 150 AVITENE 98 ATOPICLAIR 174 AVO CREAM 174 atorvastatin calcium 106 avocado extract 160 atovaquone 114 AVODART 219 atovaquone/proguanil hcl 113 AVONEX 227 ATRALIN 254 AVONEX PEN 227 ATRAPRO DERMAL SPRAY 269 AXERT 109 ATRAPRO HYDROGEL 269 AYGESTIN 214 ATRIPLA 124 azacitidine 269 ATROPEN 64 AZACTAM 219 atropine sulfate 64,181 AZASAN 224 ATROVENT 180 AZASITE 34 ATROVENT HFA 64 azathioprine 224 attapulgite 183 azathioprine sodium 224 AUBAGIO 227 azelaic acid 257 AUBRA 196 azelastine hcl 179 AUGMENTIN 239 AZELEX 258 AUGMENTIN ES-600 239 AZILECT 76 AUGMENTIN XR 239 azithromycin 218 AURSTAT 269 AZOPT 97 AURYXIA 217 AZOR 148 aztreonam 219 benactyzine hcl 75 AZULFIDINE 60 benazepril hcl 241,242 AZUPHEN MB 32 benazepril hcl/hydrochlorothiazide 166 AZURETTE 197 BENICAR 240 BENICAR HCT 166 B BENLYSTA 269 B-12 COMPLIANCE 303 benoxinate hcl/fluorescein sodium 181 B-12 KIT 303 BENSAL HP 254 B-DONNA 64 BENTYL 65 B-PLEX PLUS 269 benzalkonium chloride 40 BACIIM 62 BENZEFOAM 254 bacitracin 34,37,62 BENZEFOAM ULTRA 255 bacitracin zinc micronized 37 BENZEPRO 255 bacitracin, micronized 37 benzocaine 270 bacitracin/polymyxin b sulfate 34 benzocaine micronized 270 baclofen 247 benzoic acid 270 bacteriostatic sodium chloride 171 benzonatate 243 BACTRIM 60 benzoyl peroxide 255,270 BACTRIM DS 60 benzphetamine hcl 26 BACTROBAN 38 benztropine mesylate 67 BACTROBAN NASAL 34 benzyl alcohol 270 BAL IN OIL 219 benzyl benzoate 43 balanced salt irrig soln no.2 180 BEPREVE 179 balsalazide disodium 183 bergamot 270 BALZIVA 197 BESIVANCE 34 banana extract 160 beta 1,3 glucan 231 BANZEL 69 beta-carotene 303 BARACLUDE 136,137 beta-glucan, (1-3) (1-4) 270 barium sulfate 162 betadex 270 bcg vaccine, live/pf 130 BETADINE 37 BEAU RX 269 BETAGAN 96 beclomethasone dipropionate 191 betahistine hcl 149 BECONASE AQ 44 betaine hcl 231 beef extract 160 betamethasone acetate, micronized 191 BEKYREE 197 betamethasone acetate/betamethasone sodium BELBUCA 23 phosphate 191 belladonna alkaloids 64 betamethasone dipropionate 248 belladonna alkaloids leaf extract 64 betamethasone dipropionate/propylene glycol 248 BELSOMRA 139 betamethasone sodium phosphate 191 BELVIQ 26 betamethasone valerate 248 BELVIQ XR 26 BETAPACE 53 BETAPACE AF 53 blood-glucose transmitter 270 BETASERON 227 blue-green algae 270 betaxolol hcl 53,96 BONIVA 222 bethanechol chloride 143 BONTRIL PDM 24 BETHKIS 57 BOOSTRIX TDAP 130 BETIMOL 96 boric acid 37 BETOPTIC S 96 BOSULIF 270,271 BEVESPI AEROSPHERE 4 boswellia serrata extract 271 bexarotene 270 BOTOX COSMETIC 231 BEXSERO 130 BP 10-1 40 BEYAZ 197 BP-50% UREA 255 BIAFINE 174 BPO 255 BIAXIN 111 BRAVELLE 210 bicalutamide 270 BREO ELLIPTA 5 BICILLIN C-R 239 BREVICON 197 BICILLIN L-A 239 BREVITAL SODIUM 73 BIDIL 216 BRIELLYN 197 BILTRICIDE 31 BRILINTA 128 bimatoprost 98 brimonidine tartrate 96 BINOSTO 222 BRINTELLIX 80 BIOGLO 162 BRISDELLE 78 BIONECT 270 BRIVIACT 69 BIOTHRAX 130 bromelains 271 biotin 270 BROMFED DM 101 bisacodyl 184 bromfenac sodium 46,271 bismuth citrate 270 bromhexine hcl 243 bismuth subgallate 270 bromocriptine mesylate 168 bismuth subsalicylate 184 brompheniramine maleate 99 bismuth tribromophenate/petrolatum,white 270 brompheniramine maleate/pseudoephedrine bisoprolol fumarate 53 hcl/dextromethorphan 101 bisoprolol fumarate/hydrochlorothiazide 54 BROMSITE 46 bitter melon extract 270 BROVANA 5 BLANCHE 155 BSS 180 BLEO 15K 270 BSS PLUS 180 bleomycin sulfate 270 BUCALSEP 181 BLEPH-10 34 budesonide 44,154,191 BLEPHAMIDE 34 budesonide, micronized 44 BLEPHAMIDE S.O.P. 34 buflomedil hcl 271 BLISOVI 24 FE 197 bumetanide 163 BLISOVI FE 197 BUNAVAIL 23 blood-glucose sensor 270 BUPAP 8 BUPHENYL 170 calcipotriene 258,271 bupivacaine hcl 271 calcipotriene monohydrate 271 bupivacaine hcl/dextrose-water/pf 271 calcipotriene/betamethasone dipropionate 248 bupivacaine hcl/epinephrine 265 calcitonin,salmon,synthetic 212 bupivacaine hcl/epinephrine bitartrate 265 CALCITRENE 258 bupivacaine hcl/epinephrine/pf 265 calcitriol 258,305 bupivacaine hcl/pf 271 calcitriol/almond oil 271 BUPRENEX 23 calcium acetate 217 buprenorphine 23 calcium amino acid chelate 171 buprenorphine hcl 23 calcium carbonate 171 buprenorphine hcl/naloxone hcl 23 calcium citrate 171 BUPROBAN 75 calcium glubionate 171 bupropion hcl 75 calcium glucarate 171 buspirone hcl 139 calcium gluconate monohydrate 171 butalbital 141 calcium levulinate dihydrate 171 butalbital/acetaminophen 8,9 calcium pantothenate 303 butalbital/acetaminophen/caffeine 9 calcium phosphate 171 butalbital/acetaminophen/caffeine/codeine phosphate 9 CAMILA 197 butalbital/aspirin/caffeine 128,271 camphor 258 BUTISOL SODIUM 141 CAMRESE 197 butorphanol tartrate 23,24 CAMRESE LO 197 BUTRANS 24 CANASA 183 butylated hydroxytoluene 232 candesartan cilexetil 240 BYDUREON 85 candesartan cilexetil/hydrochlorothiazide 166 BYDUREON PEN 85 CANDIN 161 BYETTA 85 cantaloupe extract 160 BYSTOLIC 145 cantharidin 271 BYVALSON 145 CANTIL 65 CAPACET 9 C CAPASTAT SULFATE 111 cabergoline 168 capecitabine 271 CABOMETYX 271 CAPEX SHAMPOO 248 CADEAU DHA 47 CAPHOSOL 271 CADUET 106 CAPITAL W-CODEINE 9 CAFERGOT 6 CAPRELSA 272 caffeine 29 capsaicin 258 caffeine citrate 29 capsaicin palmitate 258 caffeine/sodium benzoate 29 capsicum oleoresin 258 calamine 174 captopril 241 CALAN 55 captopril/hydrochlorothiazide 166 CALAN SR 56 CARAC 258 CARAFATE 134 CAVERJECT 301 carbachol 97 CAYSTON 219 CARBAGLU 170 CAZIANT 197 carbamazepine 69,70 CEDAX 153,272 carbamide peroxide 41 cefaclor 153 CARBATROL 70 cefadroxil 152 carbidopa 150 cefazolin sodium 152 carbidopa/levodopa 112 cefdinir 153 carbidopa/levodopa/entacapone 111 cefditoren pivoxil 153 carbimazole 266 cefepime hcl 152 carbinoxamine maleate 100 cefixime 153 carbitol 272 CEFOTAN 153 CARBOCAINE 272 cefotaxime sodium 153 CARDENE SR 148,272 cefotetan disodium 153 cardioplegic solution no.1 171 cefpodoxime proxetil 153 cardioplegic solution no.10 171 cefprozil 153 CARDIOTEK-RX 303 ceftazidime 153 CARDIOVID PLUS 232 ceftibuten 153 CARDIZEM 56 CEFTIN 153 CARDIZEM CD 56 ceftriaxone sodium 153,154 CARDIZEM LA 56 cefuroxime axetil 153 CARDURA 6 cefuroxime sodium 153 CARDURA XL 6 CELEBREX 235 carisoprodol 246 celecoxib 235 carisoprodol/aspirin 238 CELESTONE 191 carisoprodol/aspirin/codeine phosphate 14 CELEXA 78 CARNITOR 232 CELLCEPT 230 CARNITOR SF 232 CELLUGEL 180 carteolol hcl 96 cellulose 272 CARTIA XT 56 CELONTIN 75 carvedilol 7 CEM-UREA 255 casein extract 160 CENTANY 38 CASODEX 272 CENTANY AT 38 cat hair standardized allergenic extract 160 CENTERGY 101 CATAPRES 215 CENTERGY DM 101 CATAPRES-TTS 1 215 cephalexin 152 CATAPRES-TTS 2 215 CERAMAX 272 CATAPRES-TTS 3 215 CERDELGA 232 catheter 272 CEREBYX 75 catheterization tray 272 CERVARIX 130 CATHFLO ACTIVASE 129 cervical cap 272 CERVIDIL 272 cholestyramine/aspartame 104 CESAMET 89 choline bitartrate 188 cesium chloride 272 choline salicylate/magnesium salicylate 238 CETACAINE 252 chondroitin sulfate a sodium 232 cetirizine hcl 100 chorionic gonadotropin, human 210 CETRAXAL 34 chromium picolinate 273 CETROTIDE 226 chromium polynicotinate 273 cetyl myristoleate 272 chrysin 273 cetylpyridinium chloride 272 chymotrypsin 273 cevimeline hcl 143 CIALIS 301 CHANTIX 143 CICLODAN 95 CHATEAL 197 ciclopirox 95 CHEMET 219 ciclopirox olamine 95 CHENODAL 185 CIDALEAZE 252 chicken meat extract 160 cidofovir 137 chinese red pine bark extract 272 cilostazol 128 139 CILOXAN 34 chlorambucil 272 cimetidine 133 chloramphenicol 58 cimetidine hcl 133 chloramphenicol palmitate 58 CIMZIA 186 chlordiazepoxide hcl 141,142 CIPRO 59 chlordiazepoxide/clidinium bromide 65 CIPRO HC 34 chlorhexidine gluconate 37,41 CIPRO XR 59 chloroallyl methenamine chloride 272 CIPRODEX 34 chlorobutanol 273 ciprofloxacin 59 chloroform 188 ciprofloxacin hcl 34,59 chloroprocaine hcl/pf 273 ciprofloxacin/ciprofloxacin hcl 59 chloroquine phosphate 113 citalopram hydrobromide 78 chlorothiazide 164 citrate phosphate dextros soln 67 chloroxine 273 citric acid 273 chloroxylenol 273 citric acid/sodium citrate 169 chlorpheniramine maleate 100 citrulline 170 chlorpromazine hcl 123 CLAFORAN 154 chlorpropamide 87 CLARAVIS 258 chlorthalidone 165 CLARIFOAM EF 41 chlorzoxazone 246,273 CLARINEX 100 CHOLBAM 186 CLARINEX-D 12 HOUR 100 cholecalciferol (vitamin d3) 305 clarithromycin 58,111 cholesterol 273 CLEANSING WASH 41 cholestyramine 104 clemastine fumarate 100 cholestyramine (with sugar) 104 clemizole hcl 273 CLEOCIN 38 COARTEM 113 CLEOCIN HCL 63 cobalt gluconate 273 CLEOCIN PALMITATE 63 cobamamide 303 CLEOCIN PHOSPHATE 63 cocaine hcl 181 CLEOCIN T 38 cocoa extract 160 clidinium bromide 65 codeine phosphate 14 CLIMARA 175 codeine phosphate/butalbital/aspirin/caffeine 14 CLIMARA PRO 175 codeine sulfate 14 CLINDACIN ETZ 38 COGENTIN 67 CLINDACIN P 38 COLAZAL 183 CLINDACIN PAC 38 colchicine 220 CLINDAGEL 38 COLCRYS 221 clindamycin hcl 63 COLESTID 104 clindamycin palmitate hcl 63 colestipol hcl 104 clindamycin phosphate 38,63 colistin (as colistimethate sodium) 63 clindamycin phosphate/benzoyl peroxide 38 colistin sulfate 64 clindamycin phosphate/tretinoin 38 collagenase clostridium histolyticum 258 CLINDESSE 38 COLOCORT 248 CLINPRO 5000 222 colostomy bag, non-sterile 273 clioquinol 93 COLY-MYCIN M PARENTERAL 64 clobetasol propionate 248 COLY-MYCIN S 34 clobetasol propionate/emollient base 248 COLYTE WITH FLAVOR PACKETS 184 CLOBEX 248 COMBIGAN 96 clocortolone pivalate 248 COMBIPATCH 175 CLODAN 248 COMBIVENT RESPIMAT 5 CLODERM 248 COMBIVIR 125 clofazimine 110 COMETRIQ 273 clomiphene citrate 175 COMPAZINE 90 clomipramine hcl 81 COMPLERA 124 clonazepam 73,74 COMPOUND 347 188 clonidine 215 compression stocking, knee high, regular length, clonidine hcl 215,216 medium 273 clopidogrel bisulfate 128 compression stocking, knee high, regular length, small 273 clorazepate dipotassium 74 compression stocking,knee high,long length, large CLORPRES 168 circumfer. 273 clotrimazole 93 compression stocking,knee high,long length, x-large clotrimazole/betamethasone dipropionate 93 circumf. 273 clozapine 115 compression stocking,knee high,long length,medium CLOZARIL 116 circumfer. 274 CNL 8 95 compression stocking,knee high,long length,small coal tar 257 circumferen 274 compression stocking,knee high,regular length,large COPEGUS 137 circumf. 274 CORDARONE 55 compression stocking,knee high,regular length,x-large COREG 7 circum 274 COREG CR 7 compression stocking,thigh high,long length,extra-large CORGARD 54 circ 274 CORLANOR 149 compression stocking,thigh high,long length,large CORMAX 248 circumfer. 274 corn extract 160 compression stocking,thigh high,long length,medium CORTANE-B 44 circumfer 274 CORTEF 191 compression stocking,thigh high,long length,small CORTENEMA 248 circumfer. 274 corticotropin 156 compression stocking,thigh high,long length,x-small CORTIFOAM 248 circumf. 274 cortisone acetate 191 compression stocking,thigh high,reg length,x-large CORTISPORIN 38 circumfer 274 CORTISPORIN-TC 34 compression stocking,thigh high,regular length,large CORTROSYN 156 circumf 274 CORZIDE 54 compression stocking,thigh high,regular length,medium COSENTYX (2 SYRINGES) 258 circum 274 COSENTYX PEN 258 compression stocking,thigh high,regular length,small COSENTYX PEN (2 PENS) 258 circumf 274 COSENTYX SYRINGE 258 compression stocking,thigh high,regular length,x-small COSOPT 96 circ. 274 COSOPT PF 96 compression stocking,thigh high,short length,large cosyntropin 156 circumfer 274 COTELLIC 274 compression stocking,thigh high,short length,medium COTEMPLA XR-ODT 274 circumf. 274 COUMADIN 67 compression stocking,thigh high,short length,small coumarin 232 circumfer 274 COVARYX 175 compressor, for nebulizer 274 COVARYX H.S. 176 COMPRO 90 COZAAR 240 COMTAN 111 crab extract 160 conception assistance supplies combination no.1 274 cream base no.134 274 CONCERTA 29 creatine 274 CONDYLOX 258 creatine monohydrate 275 CONRAY 162 creatinine 275 CONSTULOSE 170 CREON 185 CONTRAVE 25 CRESEMBA 91 CONZIP 14 CRESTOR 106 COPAXONE 227 CRINONE 214 CRIXIVAN 126 CYTOTEC 133 CROFAB 129 CYTRA-2 169 cromolyn sodium 47 CYTRA-3 169 crotamiton 43 CYTRA-K 169 CRYSELLE 198 CUPRIMINE 224 D CUROSURF 243 D.H.E.45 6 CUTIVATE 248 DAKLINZA 191 CUVITRU 129 dalfampridine 232 CUVPOSA 65 DALIRESP 243 cyanocobalamin (vitamin b-12) 303 danazol 194 cyanocobalamin/folic acid/pyridoxine 303 DANTRIUM 247 CYCLAFEM 198 dantrolene sodium 247 cyclandelate 149 dapiprazole hcl 275 CYCLESSA 198 dapsone 110 cyclobenzaprine hcl 246 DAPTACEL DTAP 130 CYCLOGYL 181 darifenacin hydrobromide 189 CYCLOMYDRIL 181 DASETTA 198 cyclopentolate hcl 182 DAXBIA 152 cyclopentolate hcl/lidocaine DAYPRO 235 hcl/phenylephrine/tropicamide 181 DAYSEE 198 cyclopentolate hcl/tropicamide/phenylephrine hcl in DAYTRANA 29 water 182 DDAVP 98,213 cyclophosphamide 230 deanol 275 cycloserine 111 DEBACTEROL 259 CYCLOSET 168 DEBLITANE 198 cyclosporine 224,230 deferoxamine mesylate 219 cyclosporine, modified 224 DELATESTRYL 194 CYMBALTA 77 DELESTROGEN 176 cyproheptadine hcl 100 DELTASONE 191 CYRED 198 DELYLA 198 CYSTADANE 232 DEMADEX 164 CYSTAGON 232 demecarium bromide 275 CYSTARAN 180 demeclocycline hcl 61 cysteamine hcl 232 DEMEROL 14 cysteine hcl 171 DEMSER 232 CYSTOGRAFIN 162 DENAVIR 40 CYSTOGRAFIN-DILUTE 162 DENTA 5000 PLUS 222 cytarabine 275 DENTAGEL 222 cytarabine/pf 275 deoxycholic acid 275 CYTOMEL 266 DEPADE 152 DEPAKENE 70 dexamethasone acetate, micronized 191 DEPAKOTE 70 DEXAMETHASONE INTENSOL 191 DEPAKOTE ER 70 dexamethasone isonicotinate 192 DEPAKOTE SPRINKLE 70 dexamethasone sod phosphate 44,192 DEPEN 224 dexamethasone, micronized 192 DEPO-ESTRADIOL 176 dexchlorpheniramine maleate 275 DEPO-MEDROL 191 DEXEDRINE 26,27 DEPO-PROVERA 214 DEXERYL 174 DEPO-SUBQ PROVERA 104 214 DEXILANT 134 DEPO-TESTOSTERONE 194 dexmethylphenidate hcl 29 DERMA-SMOOTHE-FS 249 DEXPAK 192 DERMAGRAFT 275 dexpanthenol 275 DERMATOP 249 dextroamphetamine sulf-saccharate/amphetamine sulf- DERMAZENE 41 aspartate 27 DERMOTIC 44 dextroamphetamine sulfate 27 DESCOVY 125 dextromethorphan hbr 243 DESFERAL 220 dextrose 171 DESFERAL MESYLATE 220 DIABETA 87 desipramine hcl 81 DIALYVITE 800 WITH IRON 47 desloratadine 100 DIAMOX SEQUELS 97 desmopressin acetate 98,99 diaphragms, wide seal 275 desmopressin acetate (non-refrigerated) 213 DIASTAT 74 DESOGEN 198 DIASTAT ACUDIAL 74 desogestrel-ethinyl estradiol 198 diazepam 74 desogestrel-ethinyl estradiol/ethinyl estradiol 198 diazoxide 102 DESONATE 249 DIBENZYLINE 6 desonide 249 dibucaine 275 desonide, micronized 249 dibucaine hcl 252 DESOWEN 249 dichloralphenazone 139 desoximetasone 249 dichloroacetic acid 275 desoximetasone, micronized 249 DICLEGIS 89 desoxycorticosterone acetate 191 diclofenac potassium 235 DESOXYN 26 diclofenac sodium 46,235,259 desvenlafaxine 77 diclofenac sodium, micronized 235 desvenlafaxine fumarate 77 diclofenac sodium/misoprostol 133 desvenlafaxine succinate 77 dicloxacillin sodium 240 DETROL 189 dicumarol 67 DETROL LA 189 dicyclomine hcl 65 devil's claw extract 275 didanosine 125 dexamethasone 191 diethanolamine 275 dexamethasone acetate 191 diethylcarbamazine citrate 32 diethylpropion hcl 25 DIVIGEL 176 diethylstilbestrol 176 docosanol 40 DIFFERIN 259 docusate sodium 184 DIFICID 218 dofetilide 55 diflorasone diacetate 249 DOLOPHINE HCL 15 DIFLUCAN 91 donepezil hcl 143 diflunisal 235 DONNATAL 65 DIGITEK 51 dopamine hcl 144 DIGOX 51 DORAL 142 digoxin 51,52 DORYX 61 dihydrocodeine bitartrate 14 DORYX MPC 61 dihydroergotamine mesylate 6 dorzolamide hcl 97 diindolylmethane 275 dorzolamide hcl/timolol maleate 96 DILANTIN 52 DOTHELLE DHA 47 DILANTIN-125 52 DOVONEX 259 DILATRATE-SR 299 doxazosin mesylate 6 DILAUDID 14,15 doxepin hcl 81,252 DILAUDID-HP 15 doxercalciferol 305 DILT-XR 56 doxycycline hyclate 34,61 diltiazem hcl 56 doxycycline monohydrate 61 dimenhydrinate 90,100 doxylamine succinate 100 dimethyl sulfoxide 232,275 drainage bag 275 dimethylacetamide 275 dressing, collagen/sodium dinitrochlorobenzene (2,4) 275 alginate/carboxymethylcellulose 275 DIOVAN 240 dressing,collagen/silver/sod DIOVAN HCT 166 alginate/carboxymethylcellulose 275 DIPENTUM 183 DRISDOL 305 diphencyprone 275 DRITHOCREME HP 257 diphenhydramine hcl 100 dronabinol 89 diphenidol hcl 89 droperidol 139 diphenoxylate hcl/atropine sulfate 65 drospirenone/ethinyl estradiol/levomefolate calcium 198 DIPROLENE 249 DROXIA 276 DIPROLENE AF 249 DRYSOL 254 dipyridamole 128 DUAVEE 175 DISALCID 238 DUETACT 87 DISCOVISC 275 duloxetine hcl 77 disopyramide phosphate 52 DUODOTE 65 disulfiram 219 DUOPA 112 DITROPAN XL 189 DUOVISC 276 DIURIL 164 DUPIXENT 259 divalproex sodium 70 DURAGESIC 15 DURAMORPH 15 egg white extract 160 DUREZOL 44 EGRIFTA 264 DURLAZA 128 ELDEPRYL 76 dutasteride 219 ELDERCAPS 302 dutasteride/tamsulosin hcl 7 ELESTAT 179 DUTOPROL 54 ELESTRIN 176 DYANAVEL XR 27 ELETONE 174 DYAZIDE 164 eletriptan hbr 109 dyclonine hcl 181 ELIDEL 230 DYMISTA 102 ELIGARD 211 dyphylline 146 ELIMITE 43 DYRENIUM 164 ELINEST 198 ELIPHOS 217 E ELIQUIS 68 E-Z DISK 162 ELITE OB DHA 302 E-Z-CAT 162 ELITE-OB 302 E-Z-HD 162 ELITE-OB 400 48 E-Z-PAQUE 162 ELIXOPHYLLIN 146 E-Z-PASTE 162 ELLA 199 E.E.S. 200 58 ELMIRON 234 E.E.S. 400 58 ELOCON 249 EC-NAPROSYN 221 EMADINE 179 econazole nitrate 93 EMBEDA 15 ECOZA 93 EMCYT 276 ED-SPAZ 65 EMEND 90 EDARBI 240 EMFLAZA 192 EDARBYCLOR 168 EMLA 252 EDECRIN 164 EMOQUETTE 199 edetate calcium disodium 220 EMSAM 76 edetate disodium 232 EMTRIVA 125 EDEX 301 EMULSION SB 276 EDLUAR 139 EMVERM 32 edrophonium chloride 162 ENABLEX 189 EDURANT 124 enalapril maleate 241 EEMT 176 enalapril maleate/hydrochlorothiazide 166 EEMT H.S. 176 ENBREL 224 EFFER-K 171 ENDARI 186 EFFEXOR XR 77 ENDO-AVITENE 99 EFFIENT 128 ENDOCET 9 EFUDEX 259 ENDOFORM 276 egg extract 160 ENDOMETRIN 214 ENGERIX-B ADULT 130 EPIVIR HBV 125 ENGERIX-B PEDIATRIC-ADOLESCENT 130 eplerenone 165 ENJUVIA 176 EPOGEN 145 ENLON 162 eprosartan mesylate 240 enoxaparin sodium 68 EPY 4 ENPRESSE 199 EPZICOM 125 ENSKYCE 199 EQUETRO 70 ENSTILAR 249 ergocalciferol (vitamin d2) 305 entacapone 111 ergoloid mesylates 7 entecavir 137 ERGOMAR 7 ENTEREG 186 ergotamine tartrate 7 ENTERO VU 162 ergotamine tartrate/caffeine 7 ENTOCORT EC 192 ERIVEDGE 276 ENTRESTO 242 ERRIN 199 ENTTY 276 ERTACZO 93 ENULOSE 170 ERWINAZE 276 ENVARSUS XR 230 ERY 38 EPANED 241 ERY-TAB 58 EPCLUSA 190 ERYGEL 39 ephedrine hcl 3 ERYPED 200 58 ephedrine sulfate 3 ERYPED 400 58 EPICERAM 276 ERYTHROCIN STEARATE 59 EPIDUO 259 erythromycin base 34,59,218 EPIDUO FORTE 259 erythromycin base/benzoyl peroxide 39 EPIFIX AMNIOTIC MEMBRANE 232 erythromycin base/ethyl alcohol 39 EPIFOAM 249 erythromycin estolate 218 epigallocatechin gallate 276 erythromycin ethylsuccinate 59,218 epinastine hcl 179 ESBRIET 242 epinephrine 3 ESCAVITE LQ 48 epinephrine bitartrate 3 escitalopram oxalate 78 epinephrine hcl 3 ESGIC 9 epinephrine hcl/pf 3 esomeprazole magnesium 134 epinephrine/pf 3 esomeprazole strontium 134 EPINEPHRINESNAP-V 3 ESTARYLLA 199 EPIPEN 3 estazolam 142 EPIPEN 2-PAK 3 ESTRACE 176 EPIPEN JR 2-PAK 4 estradiol 176 EPISIL 276 estradiol benzoate 177 EPISNAP 4 estradiol cypionate 177 EPITOL 70 estradiol hemihydrate, micronized 177 EPIVIR 125 estradiol micronized 177 estradiol valerate 177 EXPAREL 276 estradiol/norethindrone acetate 177 EXTAVIA 227 ESTRING 177 EXTINA 94 estriol 177 EZ FLU 16-17 (FLUZON QUAD PED) 130 estriol micronized 177 EZ FLU 2016-2017 (AFLURIA) 130 ESTROGEL 177 EZ FLU 2016-2017 (FLUVIRIN) 130 estrogens,esterified/methyltestosterone 177 EZ USE JOINT-TUNNEL-TRIGGER 192 estrone 177 ezetimibe 104 estropipate 177 ezetimibe/simvastatin 104 ESTROSTEP FE 199 eszopiclone 140 F ethacrynic acid 164 FABIOR 259 ethambutol hcl 111 FACTIVE 59 ethinyl estradiol/drospirenone 199 FALMINA 199 ethosuximide 75 famciclovir 137 ethoxydiglycol 276 famotidine 133 ethyl acetate 276 FAMVIR 137 ethyl alcohol 232 FANAPT 116 ethyl chloride 252 FARESTON 276 ethyl oleate 276 FARYDAK 276 ethynodiol diacetate-ethinyl estradiol 199 FAYOSIM 199 etidronate disodium 222 FAZACLO 116 etodolac 235 feeder container 276 EUCRISA 249 feeder container with gravity set 276 EURAX 43 feeder container with pump set 276 EVAMIST 177 felbamate 70 EVARREST 99 FELBATOL 70 EVEKEO 28 FELDENE 235 EVICEL 99 felodipine 147 EVISTA 175 FEM PH 41 EVOCLIN 39 FEMARA 277 EVOTAZ 126 FEMCON FE 199 EVOXAC 143 FEMHRT 177 EXALGO 15 FEMRING 177 EXELDERM 93 FEMYNOR 199 EXELON 143 fenofibrate 105 exemestane 276 fenofibrate nanocrystallized 105 EXFORGE 148 fenofibrate,micronized 105 EXFORGE HCT 148 fenofibric acid 105 EXJADE 276 fenofibric acid (choline) 105 EXODERM 93 FENOGLIDE 105 fenoprofen calcium 235,236 flibanserin 150 fenoprofen calcium, dihydrate 236 FLO-PRED 192 FENORTHO 236 FLOMAX 7 fentanyl 15 FLOVENT DISKUS 154 fentanyl citrate 16 FLOVENT HFA 154 fentanyl citrate in 0.9 % sodium chloride/pf 16 FLOWTUSS 243 fentanyl citrate/bupivacaine hcl in 0.9 % sodium FLOXIN 35 chloride/pf 16 floxuridine 277 fentanyl citrate/pf 16 FLUAD 2016-2017 131 fentanyl citrate/ropivacaine hcl/sodium chloride FLUAD 2017-2018 277 0.9%/pf 16 FLUARIX QUAD 2016-2017 131 FEROCON 48 FLUARIX QUAD 2017-2018 277 FEROTRINSIC 48 FLUBLOK 2016-2017 131 FERREX 150 FORTE 48 FLUBLOK 2017-2018 277 ferric ammonium citrate 277 FLUBLOK QUAD 2017-2018 277 ferric subsulfate 277 FLUCAINE 162 ferric sulfate 48 FLUCELVAX QUAD 2016-2017 131 FERRIPROX 277 FLUCELVAX QUAD 2017-2018 277 FERROCITE PLUS 48 fluconazole 92 ferrous fumarate 48 flucytosine 93 ferrous gluconate 48 fludrocortisone acetate 192 ferrous sulfate, dried 48 FLULAVAL QUAD 2016-2017 131 FETZIMA 77 FLULAVAL QUAD 2017-2018 277 FEXMID 246 FLUMADINE 135 fexofenadine hcl 100,101 flumazenil 150 fexofenadine hcl/pseudoephedrine hcl 277 flunisolide 44,192 FIBRICOR 105,106 fluocinolone acetonide 249 FINACEA 259 fluocinolone acetonide oil 44 finasteride 219,259 fluocinolone acetonide/shower cap 249 FIORICET 9 fluocinonide 249 FIORICET WITH CODEINE 9 fluocinonide, micronized 249 FIORINAL 128 fluocinonide/emollient base 249 FIORINAL WITH CODEINE #3 16 FLUOR-A-DAY 222 FIRAZYR 224 FLUOR-I-STRIP AT 162 FIRMAGON 226 FLUORABON 223 FLAGYL 113 fluorescein sodium 162 FLAGYL ER 113 fluoride (sodium) 223 FLAREX 44 FLUORIDEX 223 flavoxate hcl 189 FLUORIDEX DAILY DEFENSE 223 flecainide acetate 53 FLUORIDEX SENSITIVITY RELIEF 223 FLECTOR 236 FLUORITAB 223 fluorometholone 44 FOLBEE 303 FLUOROPLEX 259 FOLBEE AR 303 fluorouracil 259,277 FOLBEE PLUS CZ 303 fluoxetine 78 FOLGARD OS 172 fluoxetine hcl 78 FOLGARD RX 303 fluoxymesterone 194 folic acid 303 fluphenazine decanoate 123 FOLIVANE-PLUS 48 fluphenazine hcl 123 FOLLISTIM AQ 211 FLURA-DROPS 223 FOLPLEX 2.2 303 flurazepam hcl 142 fomepizole 220 flurbiprofen 236 fondaparinux sodium 68 flurbiprofen sodium 46 FORADIL 5 FLUROX 181 FORANE 188 flutamide 277 FORFIVO XL 75 fluticasone propionate 44,192,249 FORMA-RAY 278 fluticasone propionate, micronized 192 FORMADON 259 fluticasone propionate/salmeterol xinafoate 5 formaldehyde 259 fluvastatin sodium 106,107 formoterol fumarate 5 FLUVIRIN 2016-2017 131 formoterol fumarate dihydrate, micronized 5 FLUVIRIN 2017-2018 277 FORTAVIT 48 fluvoxamine maleate 78,79 FORTAZ 154 FLUZONE HIGH-DOSE 2016-2017 131 FORTEO 212 FLUZONE HIGH-DOSE 2017-2018 277 FORTICAL 212 FLUZONE INTRADERM QUAD 2016-17 131 FOSAMAX 222 FLUZONE INTRADERM QUAD 2017-18 277 FOSAMAX PLUS D 222 FLUZONE QUAD 2016-2017 131 fosamprenavir calcium 126 FLUZONE QUAD 2017-2018 277 fosinopril sodium 241 FLUZONE QUAD PEDI 2016-2017 131 fosinopril sodium/hydrochlorothiazide 166 FLUZONE QUAD PEDI 2017-2018 277 FOSRENOL 217 FML 44 FRAGMIN 69 FML FORTE 44 FROVA 109 FML S.O.P. 44 frovatriptan succinate 109 foam bandage 277 FUL-GLO 162 foam/gauze bandage/lidocaine/chlorhexidine/isopropyl FULYZAQ 184 alcohol 278 FURADANTIN 32 FOCALGIN 90 DHA 48 furazolidone 32 FOCALGIN CA 48 furosemide 164 FOCALGIN DSS 48 FUSION PLUS 48 FOCALIN 29 FUSION SPRINKLES 48 FOCALIN XR 29 FUZEON 123 FOLBECAL 171 FYAVOLV 178 FYCOMPA 70 GENVOYA 124 GEODON 116 G GIANVI 200 gabapentin 9 GIAZO 183 GABITRIL 70 GILDAGIA 200 galantamine hbr 143 GILDESS 200 GALZIN 278 GILDESS 24 FE 200 gamma-aminobutyric acid 232 GILDESS FE 200 GAMMAGARD LIQUID 129 GILENYA 227 GAMMAKED 129 GILOTRIF 278 GAMUNEX-C 129 ginkgo biloba 232 ganirelix acetate 227 GLATOPA 228 GARDASIL 131 GLEEVEC 278 GARDASIL 9 131 GLEOSTINE 278 GASTROCROM 47 glimepiride 87 GASTROGRAFIN 163 glipizide 87 GASTROMARK 278 glipizide/metformin hcl 83 gatifloxacin 35 GLUCAGEN 102 GATTEX 186 GLUCAGON EMERGENCY KIT 102 gauze bandage 278 glucagon hcl 102 GAVILYTE-C 184 gluconolactone 278 GAVILYTE-G 184 GLUCOPHAGE 83 GAVILYTE-N 184 GLUCOPHAGE XR 83 gel dressing 278 glucosamine hcl 232 gelatin 278 glucosamine sulfate (dipotassium chloride) 232 GELCLAIR 278 glucosamine sulfate sodium cl 232 GELFILM 180 GLUCOTROL 87 GELFOAM 99,278 GLUCOTROL XL 87 GELFOAM COMPRESSED 278 GLUCOVANCE 83 GELFOAM JMI 278 glutamic acid 278 GELNIQUE 189 glutamine 186 GELX 278 glutaraldehyde 279 gemfibrozil 106 glutathione 279 GENADUR 278 glyburide 87 GENERESS FE 200 glyburide,micronized 87 GENERLAC 170 glyburide/metformin hcl 83 GENGRAF 224 glycine 279 GENOTROPIN 213 glycolic acid 279 GENTAK 35 glycopyrrolate 65,279 gentamicin sulfate 35,39,57 glycosaminoglycans,mixed 279 gentamicin sulfate/pf 57 glycyrrhizin 279 GLYDO 181 haloperidol 122 GLYNASE 87 haloperidol decanoate 122 GLYSET 82 haloperidol lactate 122,123 GLYXAMBI 85 HARVONI 190 gold sodium thiomalate 224 HAVRIX 131 GOLYTELY 184 HEATHER 200 GONAL-F 211 HECTOROL 305 GONAL-F RFF 211 HEMABATE 279 GONAL-F RFF REDI-JECT 211 HEMANGEOL 54 GONITRO 299 HEMATINIC PLUS 48 GORDO-UREA 255 HEMATINIC WITH FOLIC ACID 48 GRAFIX CORE 232 HEMATRON-AF 48 GRAFIX PRIME 232 HEMAX 48 GRALISE 9,10 HEMMOREX-HC 250 gramicidin d 279 HEMOCYTE PLUS 48 granisetron hcl 88 HEMOCYTE-F 48 GRANIX 145 heparin sodium,porcine 69 GRANULEX 259 heparin sodium,porcine/pf 69 GRASTEK 232 HEPSERA 137 GRIFULVIN V 91 HETLIOZ 140 GRIS-PEG 91 HEXALEN 279 griseofulvin 91 HIBERIX 131 griseofulvin ultramicrosize 91 HICON 279 griseofulvin, microsize 91 HIPREX 32 guaiacol 41 histamine phosphate 279 guaifenesin 243 histidine 279 guanabenz acetate 216 histidine hcl 279 guanethidine sulfate 216 HIZENTRA 129 guanfacine hcl 150 HOMATROPAIRE 182 guanidine hcl 143 homatropine hbr 182 guarana seed extract 279 homatropine methylbromide 182 GYNAZOLE 1 94 HORIZANT 10 HPR 279 H HPR PLUS 279 H.P. ACTHAR 156 HUMALOG 86 HALCION 142 HUMALOG JUNIOR KWIKPEN 279 HALDOL 122 HUMALOG KWIKPEN U-100 86 HALDOL DECANOATE 100 122 HUMALOG KWIKPEN U-200 86 HALDOL DECANOATE 50 122 HUMALOG MIX 50-50 86 halobetasol propionate 250 HUMALOG MIX 50-50 KWIKPEN 86 HALOG 250 HUMALOG MIX 75-25 86 HUMALOG MIX 75-25 KWIKPEN 86 HYDROMET 65 HUMATROPE 213 hydromorphone hcl 16,17 HUMIRA 186 hydromorphone hcl/pf 17 HUMIRA PEDIATRIC CROHN'S 187 hydroquinone 155 HUMIRA PEN 187 hydroquinone microspheres 155 HUMIRA PEN CROHN-UC-HS STARTER 187 hydroxocobalamin 303 HUMIRA PEN PSORIASIS-UVEITIS 187 hydroxyamphetamine hbr 182 HUMULIN R U-500 86 hydroxychloroquine sulfate 113 HUMULIN R U-500 KWIKPEN 86 hydroxyethyl methacrylate 280 hyaluronate sodium 279 hydroxyprogesterone caproate 214 hyaluronidase, bovine 279 hydroxypropyl betadex 280 HYCAMTIN 279 hydroxyurea 280 HYCET 10 hydroxyzine hcl 140 HYCOFENIX 4 hydroxyzine pamoate 140 hydralazine hcl 216 HYGEL 280 hydrazine sulfate 279 HYLATOPIC 280 HYDREA 279 HYLATOPICPLUS 280 HYDRO 35 255 HYLENEX 280 HYDRO 40 255 HYOPHEN 32 hydrochloric acid 186 hyoscyamine sulfate 65 hydrochlorothiazide 164,165 HYOSYNE 65 hydrocodone bitart/chlorpheniramine HYPER-SAL 172 maleate/pseudoephedrine 16 HYPERHEP B S-D 129 hydrocodone bitartrate 16 HYPERRAB S-D 129 hydrocodone bitartrate/acetaminophen 10 HYPERTET S-D 129 hydrocodone bitartrate/homatropine methylbromide 65 HYQVIA 129 hydrocodone polistirex/chlorpheniramine polistirex 101 HYQVIA HY COMPONENT 280 hydrocodone/ibuprofen 16 HYQVIA IG COMPONENT 129 hydrocolloid dressing 279 HYZAAR 166 hydrocortisone 192,250 hydrocortisone acetate 250 I hydrocortisone acetate/iodoquinol/aloe vera 41 ibandronate sodium 222 hydrocortisone acetate/lidocaine hcl/aloe vera 250 IBRANCE 280 hydrocortisone acetate/pramoxine hcl 250 IBUDONE 17 hydrocortisone butyrate 250 ibuprofen 236 hydrocortisone butyrate/emollient base 250 ibuprofen/oxycodone hcl 18 hydrocortisone valerate 250 IC GREEN 161 hydrocortisone/acetic acid 37 ICAR-C PLUS 48 hydrocortisone/iodoquinol 41 ichthammol 280 hydrocortisone/mineral oil/petrolatum,white 250 ICLUSIG 280 hydrogen peroxide 280 idebenone 150 idoxuridine 37 INTRON A 136 ILARIS 233 INTROVALE 200 ILEVRO 46 INTUNIV 151 ILOTYCIN 35 INVANZ 218 IMBRUVICA 281 INVEGA 116 imipramine hcl 81 INVEGA SUSTENNA 116,117 imipramine pamoate 81 INVEGA TRINZA 117 imiquimod 259,260 INVIRASE 126 IMITREX 109 INVOKAMET 84 IMOGAM RABIES-HT 129 INVOKAMET XR 84 IMOVAX RABIES VACCINE 131 INVOKANA 87 IMPAVIDO 114 iodine 41 IMURAN 225 IODOFLEX 41 INCRELEX 264 iodoform 281 INCRUSE ELLIPTA 66 iodoquinol 113 indapamide 165 IODOSORB 41 INDERAL LA 54 iopanoic acid 281 INDERAL XL 54 IOPIDINE 180 INDICLOR 281 IPOL 131,281 INDIGO CARMINE 161 ipratropium bromide 66,180 indigotindisulfonate sodium in water for ipratropium bromide/albuterol sulfate 5 injection,sterile 161 IPRIVASK 68 INDIOMIN MB 32 irbesartan 240 INDOCIN 221 irbesartan/hydrochlorothiazide 166,167 indocyanine green 161 IRENKA 77 indole-3-carbinol 233 IRESSA 281 indomethacin 221,236 ISENTRESS 124 INFANRIX DTAP 130 ISENTRESS HD 124 INFASURF 243 ISIBLOOM 200 INFED 48 ISOCHRON 300 INFUMORPH 18 isoflurane 188 INGREZZA 150,281 isoleucine 281 inhaler, assist devices 281 isometheptene mucate 144 inhaler, assist devices, accessories 281 isometheptene mucate/caffeine/acetaminophen 10 INLYTA 281 isometheptene INNOPRAN XL 54 mucate/dichloralphenazone/acetaminophen 10 inositol 281 isoniazid 111 INSPRA 165 isopropamide iodide 281 INTELENCE 124 isopropyl myristate 281 INTERMEZZO 140 isoproterenol hcl 4,281 INTRAROSA 192 ISOPTO ATROPINE 182 ISOPTO CARPINE 97 ISORDIL 300 K ISORDIL TITRADOSE 300 K EFFERVESCENT 172 isosorbide 300 K-PHOS NEUTRAL 169 isosorbide dinitrate 300 K-PHOS NO.2 169 isosorbide mononitrate 300 K-PHOS ORIGINAL 169 isotretinoin 260 K-SOL 172 ISOVUE-200 163 K-TAB ER 172 isoxsuprine hcl 301 KAITLIB FE 201 isradipine 147 KALETRA 126 ISTALOL 96 KALYDECO 155 ISUPREL 4 kanamycin sulfate 57 itraconazole 92 KAPVAY 216 itraconazole, micronized 92 karaya gum 185 ivermectin 32 KARBINAL ER 100 IXIARO 131 KARIVA 201 KAYEXALATE 217 J KEFLEX 152 JADENU 281 KELNOR 1-35 201 JADENU SPRINKLE 282 KENALOG 250 JAKAFI 282 KENALOG-10 192 JALYN 7 KENALOG-40 192 JANTOVEN 67,68 KEPPRA 70 JANUMET 84 KEPPRA XR 70 JANUMET XR 84 KERAFOAM 255 JANUVIA 85 KERALAC 255 JARDIANCE 87 KERALYT 255 JENCYCLA 200 KERYDIN 95 JENTADUETO 84 KETALAR 188 JENTADUETO XR 84 ketamine hcl 188 JEVANTIQUE LO 178 KETEK 218 JINTELI 178 ketoconazole 92,94 JOLESSA 200 ketoconazole, micronized 92 JOLIVETTE 200 ketoprofen 236 JUBLIA 94 ketoprofen, micronized 236 JULEBER 200 ketorolac tromethamine 46,236 JUNEL 201 ketotifen fumarate 100 JUNEL FE 201 KEVEYIS 233 JUNEL FE 24 201 KEVZARA 225 JUXTAPID 103 KHEDEZLA 77 KIMIDESS 201 KINEVAC 161 LAMICTAL XR (ORANGE) 71 KINRIX 131 LAMISIL 91 KIONEX 217 lamivudine 125 KISQALI 282 lamivudine/zidovudine 125 KISQALI FEMARA CO-PACK 282 lamotrigine 71 KITABIS PAK 57 lancing device/lancets 283 KLARON 41 LANOXIN 52 KLOFENSAID II 236 LANOXIN PEDIATRIC 52 KLONOPIN 74 lansoprazole 134 KLOR-CON 172 lansoprazole/amoxicillin trihydrate/clarithromycin 134 KLOR-CON 10 172 lanthanum carbonate 217 KLOR-CON 8 172 LANTUS 86 KLOR-CON M10 172 LANTUS SOLOSTAR 86 KLOR-CON M15 172 LARIN 201 KLOR-CON M20 172 LARIN 24 FE 201 KLOR-CON SPRINKLE 172 LARIN FE 201 KLOR-CON-EF 172 LARISSIA 201 kojic acid 283 LASIX 164 KORLYM 83 LASTACAFT 179 KRISTALOSE 170 latanoprost 98 KURVELO 201 LATISSE 98 KUVAN 233 LATRIX 255 KYNAMRO 103 LATUDA 117 LAYOLIS FE 202 L LEENA 202 labetalol hcl 8 leflunomide 225 LACRISERT 180 LENVIMA 283 lactic acid 174,255 LESCOL 107 lactobacillus acidophilus 184 LESCOL XL 107 lactulose 170 LESSINA 202 LAMICTAL 70 LETAIRIS 244 LAMICTAL (BLUE) 70 letrozole 283 LAMICTAL (GREEN) 70 leucine 171 LAMICTAL (ORANGE) 71 leucovorin calcium 220,233 LAMICTAL ODT 71 LEUKERAN 283 LAMICTAL ODT (BLUE) 71 LEUKINE 145 LAMICTAL ODT (GREEN) 71 leuprolide acetate 211,283 LAMICTAL ODT (ORANGE) 71 LEVACET 128 LAMICTAL XR 71 levalbuterol hcl 5 LAMICTAL XR (BLUE) 71 levamisole hcl 32 LAMICTAL XR (GREEN) 71 LEVAQUIN 59 LEVATOL 149 LIDORX 253 LEVBID 66 LIDOTRAL 253 levetiracetam 71 LIDOVEX 253 LEVO-T 266 LIDTOPIC MAX 253 levobunolol hcl 96 LILLOW 203 levocarnitine 233 LINCOCIN 63 levocarnitine (with sugar) 233 lincomycin hcl 63 levocarnitine hcl 233 lindane 43 levocetirizine dihydrochloride 101 linezolid 63 levodopa 112 LINZESS 187 levofloxacin 35,59,60 liothyronine sodium 266 levomefolate calcium 304 LIPITOR 107 LEVONEST 202 LIPOFEN 106 levonorgestrel 202 LIQUID E-Z PAQUE 163 levonorgestrel-ethinyl estradiol 202 LIQUID POLIBAR PLUS 163 levonorgestrel/ethinyl estradiol and ethinyl lisinopril 241 estradiol 202,203 lisinopril/hydrochlorothiazide 167 LEVORA-28 203 lithium carbonate 149,150 levorphanol tartrate 18 lithium citrate 150 levothyroxine sodium 266 LITHOBID 150 LEVOXYL 266 LITHOSTAT 170 LEVSIN 66 LIVALO 107 LEVSIN-SL 66 LO LOESTRIN FE 203 LEVULAN 260 LOCOID 250 LEXAPRO 79 LODINE 236 LEXIVA 126 LODOSYN 151 LIALDA 183 LOESTRIN 203 LIBRAX 66 LOESTRIN FE 203 lidocaine 252,283 LOFIBRA 106 lidocaine hcl 52,181,252,283 LOMAIRA 25 lidocaine hcl buffered with 8.4 % sodium bicarbonate 283 LOMEDIA 24 FE 203 lidocaine hcl/epinephrine 265 LOMOTIL 66 lidocaine hcl/epinephrine bitartrate 265 lomustine 283 lidocaine hcl/hydrocortisone acetate 250 LONSURF 283 lidocaine hcl/pf 52,283 loperamide hcl 184 lidocaine/prilocaine 252 LOPID 106 lidocaine/tetracaine 252 lopinavir/ritonavir 126 LIDODERM 253 LOPREEZA 178 LIDODEXTRAPINE 253 LOPRESSOR 54 LIDOPIN 253 LOPRESSOR HCT 54 LIDOPRIL 253 LOPROX 95 loratadine 101 lycopene 233 loratadine, micronized 101 LYMPHAZURIN 161 lorazepam 74 LYNPARZA 284 LORAZEPAM INTENSOL 74 LYRICA 71 LORCET 10 lysine hcl 171 LORCET HD 10 LYSIPLEX PLUS 171 LORCET PLUS 10 LYSODREN 284 LORTAB 11 LYSTEDA 99 LORYNA 203 LYZA 204 LORZONE 246 losartan potassium 240 M losartan potassium/hydrochlorothiazide 167 M-M-R II VACCINE 131 LOSEASONIQUE 203 maca 284 LOTEMAX 45 MACNATAL CN DHA 48 LOTENSIN 241 MACROBID 32 LOTENSIN HCT 167 MACRODANTIN 32 LOTREL 148 mafenide acetate 41 LOTRISONE 94 magnesium amino acid chelate 172 LOTRONEX 183 magnesium aspartate dihydrate 284 LOUTREX 283 magnesium chloride 71,284 lovastatin 107 magnesium glycinate 172 LOVAZA 103 magnesium malate 284 LOVENOX 69 magnesium oxide 183 LOW-OGESTREL 203 magnesium sulfate 52 loxapine succinate 114 MAKENA 214 LP LITE PAK 253 MALARONE 113 LUCENTIS 180 malathion 43 LUDENT FLUORIDE 223 malic acid 284 LUGOL'S 41,91 manganese chloride 172 LUMIGAN 98 manganese gluconate 172 LUMINAL SODIUM 283 mannitol 98 LUNESTA 140 mannitol/sorbitol solution 164 LUPANETA PACK 211 maprotiline hcl 81 LUPRON DEPOT 211 MARCAINE 284 LUPRON DEPOT (LUPANETA) 211 MARCAINE SPINAL 284 LUPRON DEPOT-PED 211 MARCAINE-EPINEPHRINE 265 lutein 284 MARGESIC 11 LUTERA 203 MARINOL 90 LUXAMEND 174 MARLISSA 204 LUXIQ 250 MARPLAN 76 LUZU 94 MARTEN-TAB 11 MATERNITY 302 melphalan 285 MATULANE 284 MELQUIN-3 155 MATZIM LA 56,57 memantine hcl 151 MAVIK 241 MEMBRANEBLUE 162 MAVYRET 284 MENACTRA 131 MAXALT 109 menadione 285 MAXALT MLT 109 MENEST 178 MAXARON FORTE 49 MENHIBRIX 131 MAXIDEX 45 MENOMUNE-A-C-Y-W-135 131 MAXIFED CDX 284 MENOPUR 212 MAXINATE 302 MENOSTAR 178 MAXIPHEN CD 284 MENTAX 94 MAXIPHEN CDX 284 menthol 285 MAXIPIME 152 MENVEO A-C-Y-W-135-DIP 131 MAXITROL 35 MENVEO MENA COMPONENT 132 MAXZIDE 164 MENVEO MENCYW-135 COMPONENT 132 MAXZIDE-25 MG 164 meperidine hcl 18 MD-76 R 163 meperidine hcl/pf 18 MD-GASTROVIEW 163 MEPHYTON 220 mebendazole 32 mepivacaine hcl/pf 285 mecamylamine hcl 216 meprobamate 140 mechlorethamine hcl 284 MEPRON 114 meclizine hcl 90 mequinol 155 meclofenamate sodium 236 mercaptopurine 230 meclofenoxate hcl 28 mesalamine 183 mecobalamin 304 mesalamine with cleansing wipes 183 medical supply, miscellaneous 284 MESNEX 234 MEDROL 192 MESTINON 143,144 medroxyprogesterone acetate 214,215 METADATE CD 29 medroxyprogesterone acetate, micronized 215 METADATE ER 29 mefenamic acid 236 metaproterenol sulfate 5 mefloquine hcl 113 METAXALL 246 MEGACE 284 metaxalone 246 MEGACE ES 284 metformin hcl 84 megestrol acetate 284 methacholine chloride 285 megestrol acetate,micronized 285 methadone hcl 18,19,285 MEKINIST 285 METHADONE INTENSOL 19 melatonin 233 METHADOSE 19 MELODETTA 24 FE 204 methamphetamine hcl 28 meloxicam 237 methazolamide 97 MELPAQUE HP 155 methenamine 32 methenamine hippurate 32 metoprolol tartrate/hydrochlorothiazide 54 methenamine mandelate 32 METOZOLV ODT 188 methenamine/sod phosph,monobasic/methylene METROCREAM 39 blue/hyoscyamine 32 METROGEL 39 METHERGINE 285 METROGEL-VAGINAL 39 methimazole 266 METROLOTION 39 methionine 285 metronidazole 39,113 METHITEST 194 metronidazole benzoate 113 methocarbamol 246 mexiletine hcl 52 methotrexate 285 MIACALCIN 212 methotrexate sodium 225 MIBELAS 24 FE 204 methotrexate sodium/pf 225 MICARDIS 240 methoxsalen 155 MICARDIS HCT 167 methscopolamine bromide 66 miconazole 94 methyclothiazide 165 miconazole nitrate 94 methyl aminolevulinate hcl 260 MICORT-HC 250 methyldopa 216 MICROCYN 285 methyldopa/hydrochlorothiazide 167 MICROCYN HYDROGEL 285 methylene blue/gentian violet/foam bandage 285 MICROGESTIN 204 methylergonovine maleate 285 MICROGESTIN 24 FE 204 METHYLIN 30 MICROGESTIN FE 204 methylparaben 285 MICROZIDE 165 methylphenidate hcl 30 midazolam 142 methylprednisolone 192 midazolam hcl 142 methylprednisolone acetate 192 midazolam hcl/pf 142 methylprednisolone acetate, micronized 192 middle ear inflation device 285 methylprednisolone sodium succinate 192 midodrine hcl 265 methylprednisolone, micronized 193 MIFEPREX 285 methylscopolamine nitrate 66 MIGERGOT 7 methylsulfonylmethane 285 miglitol 82 methyltestosterone 194 MIGRANAL 7 methyltestosterone, micronized 195 milk thistle 285 methyltetrahydrofolate calcium 304 MILLIPRED 193 methyltetrahydrofolate glucosamine 304 MILLIPRED DP 193 methysergide maleate 7 MIMVEY 178 metipranolol 96 MIMVEY LO 178 metoclopramide hcl 188 MINASTRIN 24 FE 204 metolazone 165 mineral oil 174 METOPIRONE 162 MINIPRESS 6 metoprolol succinate 54 MINITRAN 300 metoprolol tartrate 54 MINIVELLE 178 MINOCIN 61 MOVIPREP 185 minocycline hcl 61,62 MOXATAG 239 minoxidil 216 MOXEZA 35 MIOCHOL-E 97 moxifloxacin hcl 35,60 MIOSTAT 97 MOZOBIL 145 MIRAPEX 168 MS CONTIN 20 MIRAPEX ER 168 MUCOTROL 260 MIRCERA 145 mucus clearing device 286 MIRCETTE 204 MUGARD 286 mirtazapine 75,76 MULTAQ 55 MIRVASO 260 MULTICHEW 49 misoprostol 133 MULTIGEN FOLIC 49 mite-dermatophagoides farinae, standardized 160 MULTIGEN PLUS 49 MITIGARE 221 multivitamin-minerals no.44/cholecalciferol (vit d3)/vit mitomycin 286 k1 302 mitotane 286 mupirocin 35,39 MOBIC 237 mupirocin calcium 39 modafinil 31 MUSE 301 MODERIBA 137 MUSTARGEN 286 MODICON 204 MYALEPT 212 moexipril hcl 241 MYAMBUTOL 111 moexipril hcl/hydrochlorothiazide 167 MYCOBUTIN 64 molindone hcl 114 mycophenolate mofetil 230 molybdenum 172 mycophenolate sodium 230 mometasone furoate 45,250 MYDRIACYL 182 MONDOXYNE NL 62 MYFORTIC 230 MONO-LINYAH 204 MYKIDZ IRON FL 49 monobenzone 155 MYLERAN 286 monochloroacetic acid 286 MYNATAL 49,302 MONODOX 62 MYNATAL ADVANCE 49 MONOJECT 0.9% SODIUM CHLORIDE 172 MYNATAL PLUS 49 MONOJECT PREFILL 172 MYNATAL-Z 49 MONOJECT PREFILL ADVANCED 172 MYNATE 90 PLUS 302 MONONESSA 204 MYORISAN 260 MONSEL'S 99 MYRBETRIQ 144 montelukast sodium 46,47 MYSOLINE 73 MONUROL 33 MYTESI 184 MORGIDOX 62 MYZILRA 204 morphine sulfate 19,20 morphine sulfate/pf 20 N MOTOFEN 184 NABI-HB 130 nabumetone 237 NEBUSAL 172 nabumetone, micronized 237 NECON 204,205 nadide 286 needles, blood collection 286 nadolol 54 needles, disposable 286 nadolol/bendroflumethiazide 54 needles, filter 286 nafcillin sodium 240 needles, safety 287 naftifine hcl 93 nefazodone hcl 80 NAFTIN 93 NEMBUTAL SODIUM 141 nalbuphine hcl 24 NEO-POLYCIN 35 NALFON 237 NEO-POLYCIN HC 35 nalidixic acid 60 NEO-SYNALAR 39 naloxone hcl 152 neomycin sulfate 58 naltrexone hcl 152 neomycin sulfate/bacitracin zinc/polymyxin naltrexone hydrochloride dihydrate 152 b/hydrocortisone 35 NAMENDA 151 neomycin sulfate/bacitracin/polymyxin b 35 NAMENDA XR 151 neomycin sulfate/polymyxin b sulfate/gramicidin d 35 NAMZARIC 144 neomycin sulfate/polymyxin b sulfate/hydrocortisone 35 195 neomycin/polymyxin b sulfate/dexamethasone 35 naphazoline hcl 182 NEORAL 225 NAPRELAN 221 NEOSALUS 287 NAPROSYN 221 NEOSALUS CP 287 naproxen 221,237 NEOSPORIN 36 naproxen sodium 221,237 neostigmine methylsulfate 144 naratriptan hcl 109 NEPHRO-VITE RX 304 NARCAN 152 NEPTAZANE 97 NARDIL 76 NESACAINE 287 NAROPIN 286 NESACAINE-MPF 287 nasal exhalation resistance device 286 nettle leaf 287 NASCOBAL 304 NEUAC 39 NASONEX 45 NEULASTA 145 NATACYN 37 NEUPOGEN 146 NATAZIA 204 NEUPRO 168 nateglinide 86 NEURIN-SL 304 NATESTO 195 NEURONTIN 11 NATPARA 212 NEUTRASAL 287 NATROBA 44 NEVANAC 46 NATURE-THROID 266 nevirapine 124 nebulizer 286 NEWGEN 49 nebulizer accessories 286 NEXAVAR 287 nebulizer and compressor 286 NEXAVIR 233 NEBUPENT 114 NEXIUM 134 niacin 103 norethindrone acetate-ethinyl estradiol/ferrous niacinamide 304 fumarate 205 NIACOR 103 norethindrone-ethinyl estradiol/ferrous fumarate 205 NIASPAN 103 norgestimate-ethinyl estradiol 205 nicardipine hcl 148 NORINYL 1+50 205 niclosamide 32 NORINYL 1-35 205 nicotinamide-adenine dinucleotide, reduced, disodium 233 NORITATE 39 nicotine polacrilex 143 NORLYDA 205 NICOTROL 143 NORLYROC 206 NICOTROL NS 143 NORPACE 52 NIFEDICAL XL 148 NORPACE CR 52 nifedipine 148 NORPRAMIN 81 NIKKI 205 NORTHERA 265 NILANDRON 287 NORTREL 206 nilutamide 287 nortriptyline hcl 82 nimodipine 148 NORVASC 148 NINLARO 287 NORVIR 126 nisoldipine 147 NOVACORT 250 NITRO-BID 300 NOVAREL 212,287 NITRO-DUR 300 NOXAFIL 92 NITRO-TIME 300 NP THYROID 266 nitrofurantoin 33 NUCYNTA 20 nitrofurantoin macrocrystal 33 NUEDEXTA 151 nitrofurantoin monohydrate/macrocrystals 33 NULEV 66 nitrofurazone 41 NULYTELY WITH FLAVOR PACKS 185 nitroglycerin 300 NUMBONEX 253 NITROLINGUAL 300 NUMOISYN 287 NITROMIST 300 NUOX 255 NITROSTAT 300 NUPLAZID 117 NIVATOPIC PLUS 287 NUTRESTORE 187 nizatidine 133 NUTRICAP 49 NIZORAL 94 NUTROPIN AQ 213 NODOLOR 11 NUTROPIN AQ NUSPIN 213 NOR-Q-D 205 NUVAIL 287 NORA-BE 205 NUVARING 206 NORCO 11 NUVESSA 39 NORDITROPIN FLEXPRO 213 NUVIGIL 31 norepinephrine bitartrate 265 NYAMYC 95 norethindrone 205,215 NYATA 95 norethindrone acetate 215 nylidrin hcl 149 norethindrone acetate-ethinyl estradiol 178,205 NYMALIZE 148,287 nystatin 92,95 ONCASPAR 288 nystatin/triamcinolone acetonide 95 ondansetron 88 NYSTOP 95 ondansetron hcl 88,89 ondansetron hcl/pf 89 O ONEXTON 39 O-CAL FA 49 ONFI 74 oats extract 160 ONMEL 92 OBSTETRIX EC 49 ONZETRA XSAIL 109 OBSTETRIX ONE 49 OPANA 20 OBTREX DHA 49 OPANA ER 21 OCALIVA 187 opium tincture 184 OCELLA 206 opium/belladonna alkaloids 21 octanoic acid 288 OPSUMIT 244 octreotide acetate 263 ORACEA 62 OCUCOAT 180 ORACIT 169 OCUFEN 46 ORAFATE 288 OCUFLOX 36 ORALAIR 233 ODEFSEY 124 ORALONE 251 ODOMZO 288 ORAMAGICRX 288 OFEV 243 orange extract 161 ofloxacin 36,60 ORAP 114 OGEN 178 ORAPRED ODT 193 OGESTREL 206 ORAVIG 94 olanzapine 117,118 ORENCIA 225 olanzapine/fluoxetine hcl 79 ORENCIA CLICKJECT 225 olmesartan medoxomil 240 ORENITRAM ER 244 olmesartan medoxomil/amlodipine ORFADIN 233 besylate/hydrochlorothiazide 167 ORKAMBI 154 olmesartan medoxomil/hydrochlorothiazide 167 ornithine 288 olopatadine hcl 179,180 orphenadrine citrate 247 OLUX 251 ORSYTHIA 206 OLUX-E 251 ORTHO MICRONOR 206 OLYSIO 190 ORTHO TRI-CYCLEN 206 OMECLAMOX-PAK 134 ORTHO TRI-CYCLEN LO 206 omega-3 acid ethyl esters 103 ORTHO-CEPT 206 omega-3 fatty acids/dha/epa/fish oil/sunflower oil 288 ORTHO-CYCLEN 206 omeprazole 134,135 ORTHO-NOVUM 206 omeprazole/sodium bicarbonate 135 OSCIMIN 66 OMNARIS 45 OSCIMIN SL 66 OMNIPRED 45 OSCIMIN SR 66 OMNITROPE 213 oseltamivir phosphate 136 OSMOPREP 185 PACNEX 255 OSPHENA 175 PACNEX HP 255 ostomy kit 288 PACNEX LP 255 ostomy supply 288 PAIN EASE 253 OTEZLA 225 paliperidone 118 OTIPRIO 36 PAMELOR 82 OTOVEL 36 panax ginseng root 288 OTREXUP 225 pancreatin 186 OVACE 41 PANCRELIPASE 5,000 186 OVACE PLUS 41 pancuronium bromide 247 OVACE PLUS WASH 41 PANDEL 251 OVCON-35 206 PANRETIN 260 OVIDE 44 panthenol 304 OVIDREL 212 pantoprazole sodium 135 oxacillin sodium 240 papain 288 OXANDRIN 195 papaverine hcl 301 oxandrolone 195 papaverine hcl/alprostadil in bacteriostatic water 301 oxaprozin 237 parachlorophenol 288 OXAYDO 21 PARAFON FORTE DSC 246 oxazepam 142 paregoric 184 oxcarbazepine 72 PAREMYD 182 OXECTA 21 paricalcitol 305 oxiconazole nitrate 94 PARLODEL 168 OXISTAT 94 PARNATE 76 OXSORALEN 155 PAROEX 37 OXSORALEN-ULTRA 155 paromomycin sulfate 58 OXTELLAR XR 72 paroxetine hcl 79 oxybutynin chloride 189 paroxetine mesylate 79 OXYCEL 99 PASER 111 oxycodone hcl 21 PATADAY 180 oxycodone hcl/acetaminophen 11 PATANASE 180 oxycodone hcl/aspirin 21 PATANOL 180 OXYCONTIN 21 PAXIL 79 oxymetazoline hcl 182 PAXIL CR 79 oxymorphone hcl 21,22 PAZEO 180 oxytetracycline hcl 62 PCE 59 oxytocin 288 peak flow meter 288 OXYTROL 189 peak flow meter/inhaler, assist devices 288 peanut extract 161 P pecan extract 161 PACERONE 55 pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit PERCOCET 12 k) 302 PERFOROMIST 5 PEDIADERM AF 95 PERIDEX 37 PEDIAPRED 193 perindopril erbumine 242 PEDIARIX 130 PERIOGARD 37 pediatric multivit permethrin 44 no.22/cholecalciferol(d3)/phytonadione(k) 302 perphenazine 123 pediatric multivit with a,c,d3 no.21/sodium fluoride 303 perphenazine/amitriptyline hcl 82 pediatric multivitamin no.150 with sodium fluoride 223 PERSANTINE 128 pediatric multivitamin no.16/sodium fluoride 223 PEXEVA 79 pediatric multivitamin no.2/sodium fluoride 223 PFIZERPEN 240 pediatric multivitamin no.45/sodium fluoride/ferrous PHENADOZ 140 sulfate 49 phenazopyridine hcl 253 PEDVAXHIB 132 phendimetrazine tartrate 25 peg 3350/sod sulf/sod bicarb/sod chloride/potassium phenelzine sulfate 76 chloride 185 PHENERGAN 101,140 PEG-PREP 185 phenindione 288 PEGANONE 75 phenobarbital 73,141 PEGASYS 136 phenobarbital sodium 73 PEGASYS PROCLICK 136 phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine PEGINTRON 136 hb 66 PEGINTRON REDIPEN 136 PHENOHYTRO 66 pen needle, diabetic 288 phenol 41 penicillamine 225 phenolsulfonic acid 288 penicillin g potassium 239 phenoxybenzamine hcl 7 penicillin g procaine 239 phentermine hcl 25 penicillin g sodium 239 phentolamine mesylate 7 penicillin v potassium 239 phentolamine mesylate/alprostadil in bacteriostatic water 7 PENLAC 95 phenylalanine 171 PENNSAID 237 phenylbutazone 237 PENTACEL 132 phenylephrine hcl 182,265 PENTACEL ACTHIB COMPONENT 132 phenylephrine hcl/promethazine hcl 101 PENTACEL DTAP-IPV COMPONENT 132 phenylmercuric nitrate 288 PENTAM 300 114 phenylpropanolamine hcl 265 PENTASA 183 phenyltoloxamine citrate (dihydrogen) 288 pentazocine hcl/naloxone hcl 24 PHENYTEK 53 pentobarbital sodium 141 phenytoin 53 pentosan polysulfate sodium 234 phenytoin sodium 53 pentoxifylline 146 phenytoin sodium extended 53 pentylenetetrazol 288 PHILITH 206 PEPCID 133 PHOSLYRA 217 PHOSPHA 250 NEUTRAL 169 POLY-VI-FLOR WITH IRON 49 PHOSPHASAL 33 POLYCIN 36 phosphatidyl serine 288 polyethylene glycol 3350 185 phosphatidylcholine 188 polyhexamethylene biguanide/gauze bandage 42,289 PHOSPHOLINE IODIDE 97 polymyxin b sulfate 64 physostigmine salicylate 144 polymyxin b sulfate, micronized 64 phytonadione (vit k1) 220,305 polymyxin b sulfate,micronized 64 PICATO 260 polymyxin b sulfate/trimethoprim 36 pilocarpine hcl 97,144 POLYSACCHARIDE IRON FORTE 49 pilocarpine nitrate 98 POLYTRIM 36 pimozide 114 polyvinyl alcohol 289 PIMTREA 206 polyvinyl alcohol/gentian violet/methylene blue 289 pindolol 54 POMALYST 228 pioglitazone hcl 88 PONSTEL 237 pioglitazone hcl/glimepiride 87 PONTOCAINE 253 pioglitazone hcl/metformin hcl 84 porcine acell submucosa,meshed 289 PIRMELLA 207 porcine acellular small intestine submucosa, piroxicam 237 fenestrated 289 pistachio nut extract 161 pork extract 161 PITOCIN 288 PORTIA 207 PLAN B ONE-STEP 207 POTABA 233 PLAQUENIL 113 potassium aminobenzoate 289 PLAVIX 128 potassium bicarbonate/citric acid 172 PLEGISOL 172 potassium bromide 289 PLEGRIDY 228 potassium chloride 173 PLEGRIDY PEN 228 potassium chloride/potassium bicarbonate/citric acid 173 PLETAL 128 potassium citrate 169 PLEXION 41 potassium citrate monohydrate 173 PLIAGLIS 253 potassium citrate/citric acid 169 PNEUMOVAX 23 132 potassium hydroxide 255 PNV 29-1 49 potassium iodide 91 PNV-DHA + DOCUSATE 49 potassium iodide/iodine 91 PNV-OMEGA 49 potassium perchlorate 233 PNV-VP-U 302 potassium permanganate 289 PODOCON-25 260 potassium phosphate, dibasic 173 podofilox 260,288 potassium phosphate,monobasic 173 podophyllum resin 255 potassium sorbate 289 POLIBAR ACB 163 POTIGA 72 POLOCAINE 289 povidone 289 POLOCAINE-MPF 289 povidone-iodine 37,42 POLY-VI-FLOR 223 PR BENZOYL PEROXIDE 255 PRADAXA 68 PRENA1 CHEW 302 pralidoxime chloride 220 PRENA1 PEARL 49 PRALUENT PEN 108 PRENA1 TRUE 49 PRALUENT SYRINGE 108 PRENAISSANCE NEXT 173 PRAMCORT 251 PRENATABS RX 49 pramipexole di-hcl 168,169 prenatal vitamins no.5/ferrous fumarate/folic acid 302 PRAMOSONE 251 prenatal vitamins no.79/iron fum/folic PRAMOSONE E 251 acid/levomefolate/dha 50 pramoxine hcl 253 prenatal vits with calcium #74/ferrous fumarate/folic PRANDIMET 85 acid 50 PRANDIN 86 prenatal vits with calcium no.72/ferrous fumarate/folic prasterone (dhea) 195 acid 50 prasterone (dhea), micronized 195 prenatal vits with calcium no.74/ferrous fumarate/folic prasugrel hcl 128 acid 50 PRAVACHOL 107 PREPIDIL 289 pravastatin sodium 107 PREPLUS 50 praziquantel 32 PREPOPIK 185 prazosin hcl 6 PRESERA 289 PRE-ATTACHED LTA KIT 253 PRESTALIA 149 PRE-PEN 161 PRETAB 50 PRECOSE 82 PREVACID 135 PRED FORTE 45 PREVALITE 104 PRED MILD 45 PREVIDENT 223 PRED-G 36 PREVIDENT 5000 223 prednicarbate 251 PREVIDENT 5000 ENAMEL PROTECT 223 prednisolone 193 PREVIDENT 5000 PLUS 223 prednisolone acetate 45 PREVIDENT 5000 SENSITIVE 223 prednisolone acetate, micronized 193 PREVIFEM 207 prednisolone sod phosphate 45,193 PREVNAR 13 132 prednisolone, micronized 193 PREVPAC 135 prednisone 193 prezatide copper 289 PREDNISONE INTENSOL 193 PREZCOBIX 127 prednisone micronized 193 PREZISTA 127 PREFEST 178 PRIFTIN 64 pregabalin 72 prilocaine hcl 289 pregnenolone 289 PRILOSEC 135 pregnenolone, micronized 289 primaquine phosphate 113 PREGNYL 212 primidone 73 PREMARIN 178,179 PRIMLEV 12 PREMPHASE 179 PRIMSOL 33 PREMPRO 179 PRINIVIL 242 PRISMASOL 173 PROMISEB 289 PRISTIQ 77 propafenone hcl 53 PROAIR HFA 5 propantheline bromide 66 PROAIR RESPICLICK 5 proparacaine hcl 181 probenecid 173 proparacaine hcl/fluorescein sodium 162 probenecid/colchicine 173 PROPECIA 260 procainamide hcl 52 propranolol hcl 54,55 procaine hcl 289 propranolol hcl/hydrochlorothiazide 55 procarbazine hcl 289 propyl gallate 289 PROCARDIA 148 propylene glycol 289 PROCARDIA XL 148 propylthiouracil 266 PROCENTRA 28 PROQUAD 132 prochlorperazine 90 PROSCAR 219 prochlorperazine edisylate 90 PROSED-DS 33 prochlorperazine maleate 90 PROSTIN E2 VAGINAL SUPPOSITORY 289 PROCORT 251 PROSTIN VR PEDIATRIC 301 PROCRIT 146 protamine sulfate 98 PROCTO-MED HC 251 PROTECT IRON 50 PROCTO-PAK 251 PROTHELIAL 289 PROCTOCORT 251 prothrombin time/inr test meter 290 PROCTOFOAM-HC 251 protirelin 163 PROCTOSOL-HC 251 PROTONIX 135 PROCTOZONE-HC 251 PROTOPAM CHLORIDE 220 PROCYSBI 233 PROTOPIC 260 PRODRIN 12 protriptyline hcl 82 PROFERRIN-FORTE 50 PROVERA 215 progesterone 215 PROVIDA DHA 50 progesterone, micronized 215 PROVIDA OB 50 progesterone,micronized 215 PROVIGIL 31 PROGLYCEM 102 PROVISC 290 PROGRAF 230 PROVOCHOLINE 290 PROLENSA 46 PROZAC 79 proline 289 PROZAC WEEKLY 79 PROMACTA 146 PRUCLAIR 174 promazine hcl 123 PRUDOXIN 253 promethazine hcl 101,102,140 PRUMYX 290 promethazine hcl/codeine 102 PRUTECT 174 promethazine hcl/dextromethorphan hbr 102 pseudoephedrine hcl 4 promethazine/phenylephrine hcl/codeine 22 PSORCON 251 PROMETHEGAN 140 PULMICORT 154 PROMETRIUM 215 PULMICORT FLEXHALER 154 PULMOSAL 173 PULMOZYME 243 R pump set 290 R-NATAL OB 50 PURIXAN 230 RABAVERT 132 PYLERA 62 rabeprazole sodium 135 pyrantel pamoate 32 racepinephrine hcl 4 pyrazinamide 111 RADIAPLEXRX 290 PYRIDIUM 253 RADIGEL 290 pyridostigmine bromide 144 RADIOGARDASE 217 pyridoxal phosphate 290 RAGWITEK 234 pyridoxine hcl (vitamin b6) 304 RAJANI 207 pyrilamine maleate 182 raloxifene hcl 175 pyrimethamine 113 ramipril 242 pyrithione zinc 290 RANEXA 149 PYROGALLIC ACID 260 ranitidine hcl 133 pyruvic acid 233 RAPAFLO 8 RAPAMUNE 230 Q rasagiline mesylate 76 QBRELIS 242 RASUVO 225 QNASL 45 rauwolfia serpentina 216 QNASL CHILDREN 45 RAVICTI 170 QSYMIA 25 RAYALDEE 305 QUADRACEL DTAP-IPV 132 RAYOS 193 QUALAQUIN 113 RAZADYNE 144 QUARTETTE 207 RAZADYNE ER 144 QUASENSE 207 REA LO 40 255 quazepam 142 READI-CAT 2 163 QUDEXY XR 72 REBETOL 137 quercetin dihydrate 290 REBIF 228 QUESTRAN 104 REBIF REBIDOSE 229 QUESTRAN LIGHT 104 RECEDO 290 quetiapine fumarate 118,119 RECLIPSEN 207 QUILLICHEW ER 30 RECOMBIVAX HB 132 QUILLIVANT XR 31 RECOTHROM 99 quinacrine hcl 113 RECTIV 260 quinapril hcl 242 red yeast rice extract 290 quinapril hcl/hydrochlorothiazide 167 REFISSA 254 quinidine gluconate 52 REGENECARE 253 quinidine sulfate 52 REGIMEX 28 quinine hcl dihydrate 113 REGLAN 188 quinine sulfate 113,114 REGONOL 144 REGRANEX 260 REXULTI 119 RELAGARD 42 REYATAZ 127 RELENZA 136 REZIRA 4 RELISTOR 187 RHEUMATREX 225 RELPAX 109 RHINOCORT AQUA 45 REMERON 76 RHOFADE 260 REMEVEN 255 RIBASPHERE 137,138 REMODULIN 244 RIBASPHERE RIBAPAK 138 RENA-VITE RX 304 RIBATAB 138 RENAGEL 217 ribavirin 138 RENOVA 254 riboflavin (vitamin b2) 304 RENOVA PUMP 254 riboflavin 5-phosphate sodium (b2) 304 RENOVO 260 ribose 171 RENVELA 217 rice extract 161 repaglinide 87 RIDAURA 226 repaglinide/metformin hcl 85 rifabutin 64 REPATHA PUSHTRONEX 108 RIFADIN 64 REPATHA SURECLICK 108 RIFAMATE 64 REPATHA SYRINGE 108 rifampin 64 REPREXAIN 22 RIFATER 64 REQ49+ 302 rifaximin 64 REQUIP 169 RILUTEK 151 REQUIP XL 169 riluzole 151 RESCRIPTOR 124 rimantadine hcl 135 RESECTISOL 171 RIMSO-50 251 reserpine 216 RIOMET 85 resorcinol 290 risedronate sodium 222 RESPA A.R. 102 RISPERDAL 119 RESTASIS 46 RISPERDAL CONSTA 119 RESTASIS MULTIDOSE 46 RISPERDAL M-TAB 119 RESTORA SPRINKLES 187 risperidone 120 RESTORIL 142 RITALIN 31 resveratrol 234 RITALIN LA 31 RETIN-A 254 rivastigmine 144 RETIN-A MICRO 254 rivastigmine tartrate 144 RETIN-A MICRO PUMP 254 RIVELSA 207 retinal 290 rizatriptan benzoate 109 RETROVIR 125 ROBAXIN 246 REVATIO 244 ROBAXIN-750 246 REVIA 152 ROBINUL 66 REVLIMID 229 ROBINUL FORTE 66 ROCALTROL 305 SAMSCA 165 rocuronium bromide 247 SANADERMRX 251 ropinirole hcl 169 SANCUSO 89 ropivacaine hcl 290 SANDIMMUNE 226 ropivacaine hcl in 0.9 % sodium chloride/pf 290 SANDOSTATIN 263 ropivacaine hcl/pf 290 SANDOSTATIN LAR DEPOT 263 ROSADAN 39 SANTYL 260 ROSANIL 42 SAPHRIS 120 rosuvastatin calcium 107 sapropterin dihydrochloride 291 ROTARIX 132 SARAFEM 79,80 ROTATEQ 132 SAVAYSA 68 ROWASA 183 SAVELLA 77 ROWEEPRA 72 saw palmetto fruit 291 ROXICODONE 22 SAXENDA 85 ROZEREM 140 SCALACORT 251 RUBRACA 290 SCLEROSOL 149 RULAVITE DHA 50 scopolamine 90 RYDAPT 290 scopolamine hydrobromide 66 RYNODERM 255 SEASONIQUE 207 RYTARY 112 SEB-PREV 42 RYTHMOL 53 SEBUDERM 291 RYTHMOL SR 53 SECONAL SODIUM 141 RYVENT 100 secretin acetate (human) 162 SECTRAL 55 S SEEBRI NEOHALER 67 s-adenosylmethionine sulfate tosylate 291 selegiline hcl 76 SABRIL 72 selenium sulfide 42 saccharin 173 selenomethionine 173 SAFYRAL 207 SELRX 42 SAIZEN 213 SELZENTRY 123 SAIZEN-SAIZENPREP 213 SEMPREX-D 101 SALACYN 255 SENSIPAR 234 SALAGEN 144 SENSORCAINE 291 SALEX 256 SENSORCAINE WITH DEXTROSE 291 salicylic acid 256 SENSORCAINE-EPINEPHRINE 265 salicylic acid/ammonium lactate/aloe vera 256 SENSORCAINE-MPF 291 SALIVAMAX 291 SENSORCAINE-MPF EPINEPHRINE 265 SALIVATERX 291 SEREVENT DISKUS 5 SALKERA 256 serine 291 salsalate 238 sermorelin acetate 213 SALVAX 256 SERNIVO 251 SEROPHENE 175 SINEMET 25-250 112 SEROQUEL 120,121 SINEMET CR 112 SEROQUEL XR 121 SINGULAIR 47 SEROSTIM 213 SINOGRAFIN 163 serotonin hcl 291 sirolimus 230,231 sertraline hcl 80 SIRTURO 111 sesame seed extract 161 SITAVIG 138 SETLAKIN 207 SITZMARKS 163 sevelamer carbonate 217 SIVEXTRO 63 sevoflurane 188 SKELAXIN 246 SF 223 SKLICE 44 SF 5000 PLUS 223 sodium acetate trihydrate 173 SFROWASA 183 sodium aspartate monohydrate 173 SHAROBEL 208 sodium benzoate 291 SHOHL'S MODIFIED 169 sodium butyrate 291 shrimp extract 161 sodium cacodylate 173 SIGNIFOR 264 sodium caprylate 91 SIGNIFOR LAR 264 sodium chloride for inhalation 173 sildenafil citrate 245 sodium chloride/sodium bicarbonate/potassium SILENOR 82 chloride/peg 185 SILVADENE 42 sodium citrate 67,169 silver 42,291 sodium citrate dihydrate 169 silver nitrate 42,256 sodium desoxycholate 292 silver nitrate/potassium nitrate 256 sodium dichloroacetate 292 silver protein,mild 42 sodium hydroxide 256 silver sulfadiazine 42 sodium iodide 292 silver sulfadiazine/foam bandage 291 sodium metabisulfite 292 silver sulfate/foam bandage 291 sodium nitrite 301 silver sulfate/non-adherent bandage 291 sodium phenylbutyrate 170 silver/calcium alginate 291 sodium phosphate dibasic, heptahydrate 185 silver/foam bandage 291 sodium phosphate,dibasic 185 silver/hydrocolloid dressing 291 sodium polystyrene sulfonate 217 SILVRSTAT 291 sodium stearyl fumarate 292 SIMBRINZA 96 sodium succinate 292 SIMCOR 107 sodium sulfate 185 simethicone 184 sodium tetradecyl sulfate 149 SIMPONI 226 sodium thiosulfate 93 simvastatin 107 sodium/potassium/potassium citrate/sodium citrate/cit SINELEE 260 ac 169 SINEMET 10-100 112 SOJOURN 188 SINEMET 25-100 112 SOLARAZE 261 SOLIQUA 100-33 86 STALEVO 100 111 SOLODYN 62 STALEVO 125 112 SOLTAMOX 292 STALEVO 150 112 SOLU-CORTEF 193 STALEVO 200 112 SOLU-MEDROL 193 STALEVO 50 112 SOMA 246 STALEVO 75 112 SOMAVERT 264 STAMARIL 132 SONAFINE 174 stanozolol 195 SONATA 141 stanozolol micronized 195 SOOLANTRA 261 STARLIX 87 sorbic acid 292 stavudine 125 sorbitol solution 185 STELARA 226 SORIATANE 261 STIMATE 99 SORILUX 261 STIOLTO RESPIMAT 67 SORINE 55 STIVARGA 292 sotalol hcl 55 STRATTERA 151 SOTYLIZE 55 STRAVIX 234 SOVALDI 190 strawberry extract 161 soybean extract 161 STRENSIQ 292 SP ANTIPRURITIC 292 streptomycin sulfate 58 SPECTRACEF 154 STRIANT 195 SPHERUSOL 161 STRIBILD 124 spinosad 44 STRIVERDI RESPIMAT 5 SPIRIVA 67 STROMECTOL 32 SPIRIVA RESPIMAT 67 SUBOXONE 24 spirometers and accessories 292 succimer 220 spironolactone 165 succinylcholine chloride 247 spironolactone, micronized 166 SUCRAID 293 spironolactone/hydrochlorothiazide 166 sucralfate 134 SPORANOX 92 sufentanil citrate 22 SPRAY AND STRETCH 253 SULAR 147 SPRINTEC 208 sulfacetamide 60 SPRITAM 72 sulfacetamide sodium 36,42,60 SPRIX 237 sulfacetamide sodium, monohydrate 60 SPRYCEL 292 sulfacetamide sodium/prednisolone sodium phosphate 36 SPS 217 sulfacetamide sodium/sulfur 43 squaric acid dibutylester 234 sulfacetamide sodium/sulfur/skin cleanser comb no.23 43 SRONYX 208 sulfacetamide sodium/sulfur/urea 43 SSD 42 SULFACLEANSE 8-4 43 SSKI 91 sulfadiazine 60 SSS 10-5 42 sulfadiazine sodium 60 sulfamethoxazole 60 SYNALAR TS 251 sulfamethoxazole/trimethoprim 60 SYNALGOS-DC 128 SULFAMYLON 43 SYNAREL 212 sulfanilamide 60 SYNDROS 90 sulfapyridine 60 SYNERA 253 sulfasalazine 60 SYNERDERM 174 sulfathiazole 60 SYNJARDY 85 SULFATRIM 60 SYNJARDY XR 85 sulfisoxazole 61 SYNRIBO 293 sulfur 256 SYNTHROID 266 sulfur sublimed 256 SYPRINE 293 sulfurated potash 293 SYREX 173 sulindac 237 syring w-needl 0.5 ml,kit-tray 293 SUMADAN 43 SYRINGE AVITENE 99 sumatriptan 109 syringe with cannula, disposable, 3 ml 293 sumatriptan succinate 110 syringe with cannula, disposable, 6 ml 293 SUMAVEL DOSEPRO 110 syringe with cannula,disposable 12 ml 293 SUMAXIN 43 syringe with needle, insulin, safety, 0.3 ml 293 SUMAXIN TS 43 syringe with needle, insulin, safety, 0.5 ml 293 SUPERVITE 304 syringe with needle, insulin, safety, 1 ml 293 SUPERVITE EC 302 syringe with needle,disposable 293 SUPRANE 188 syringe with needle,disposable, 0.5 ml 294 SUPRAX 154 syringe with needle,disposable, 1 ml 294 SUPRENZA ODT 25 syringe with needle,disposable, 6 ml 294 SUPREP 185 syringe with needle,disposable,insulin 1 ml 294 SURMONTIL 82 syringe with needle,insulin,0.3 ml 294 SURVANTA 243 syringe with needle,insulin,0.5 ml 294 SUSTIVA 124 syringe, disposable irrigation, 70 ml 294 SUTENT 293 syringe, disposable, 1 ml 294 SWABFLUSH 293 syringe, disposable, 12 ml 294 SYEDA 208 syringe, disposable, 3 ml 294 SYLATRON 136 syringe, disposable, 5 ml 294 SYMAX 67 syringe, disposable, 6 ml 294 SYMAX DUOTAB 67 syringe, insulin u-500 with needle, disposable, 0.5 ml 294 SYMAX-SL 67 syringe,safety with needle,1 ml 294 SYMAX-SR 67 syringe,safety with needle,10 ml 294 SYMBICORT 5 syringe,safety with needle,12 ml 294 SYMBYAX 80 syringe,safety with needle,3 ml 294 SYMLINPEN 120 82 syringe,safety with needle,5 ml 294 SYMLINPEN 60 82 SYNALAR 251 TEKTURNA 242 T TEKTURNA HCT 165 TABLOID 294 telmisartan 240 TACHOSIL 99 telmisartan/amlodipine besylate 149 TACLONEX 251 telmisartan/hydrochlorothiazide 167 tacrolimus 231,261 temazepam 142 tacrolimus anhydrous 231 TEMODAR 295 tacrolimus, micronized 231 TEMOVATE 251 TAFINLAR 294,295 TEMOVATE EMOLLIENT 251 TAGITOL 163 temozolomide 295 TAGRISSO 295 TENCON 12 talc 149 TENEX 151 TALTZ AUTOINJECTOR 261 TENIVAC 130 TALTZ AUTOINJECTOR (2 PACK) 261 TENORETIC 100 55 TALTZ AUTOINJECTOR (3 PACK) 261 TENORETIC 50 55 TALTZ SYRINGE 261 TENORMIN 55 TALTZ SYRINGE (2 PACK) 261 TERAZOL 3 94 TALTZ SYRINGE (3 PACK) 261 TERAZOL 7 94 TALWIN 24 terazosin hcl 6 TAMIFLU 136 terbinafine hcl 91 tamoxifen citrate 295 terbutaline sulfate 5 tamsulosin hcl 8 terconazole 94 TAPAZOLE 266 terpin hydrate 243 TARCEVA 295 TERRELL 188 TARGADOX 62 TERSI FOAM 43 TARGRETIN 262,295 TESSALON PERLE 243 TARINA FE 208 testosterone 195 TARKA 147 testosterone cypionate 195 TARON-CRYSTALS 170 testosterone cypionate, micronized 195 TASIGNA 295 testosterone enanthate 195 TASMAR 112 testosterone micronized 195 TAYTULLA 208 testosterone propionate 195 tazarotene 262 TESTRED 195 TAZICEF 154 tetanus and diphtheria toxoids, adult 130 TAZORAC 262 tetanus,diphtheria toxoid ped/pf 130 TAZTIA XT 57 TETCAINE 181 TECFIDERA 229 tetrabenazine 151 TECHNIVIE 127 tetracaine 295 TEGRETOL 72 tetracaine hcl 181,296 TEGRETOL XR 72 tetracaine hcl/pf 181,296 TEKAMLO 148 tetracycline hcl 62 tetrahydrozoline hcl 182 TIGAN 91 TETRAVISC 181 TIKOSYN 55 TETRAVISC FORTE 181 TILIA FE 208 TETRIX 174 timolol maleate 55,96 TEXACORT 251 TIMOPTIC 97 TEXAVITE LQ 50 TIMOPTIC OCUDOSE 97 THALOMID 229 TIMOPTIC-XE 97 theanine 234 TINDAMAX 114 THEO-24 146 tinidazole 114 theobromine 296 tiopronin 234 THEOCHRON 146 TIROSINT 267 theophylline anhydrous 146 TISSEEL VHSD 99 THERACYS 132 titanium dioxide 296 THERAPEUTIC VITAMIN W-MINERALS 302 TIVICAY 124 THERMAZENE 43 TIVORBEX 221 thiabendazole 32 tizanidine hcl 246 thiamine hcl 304 TL FOLATE 50 thiamine TL-CERMIDE 296 hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 304 TOBI 58 thioguanine 296 TOBI PODHALER 58 THIOLA 234 TOBRADEX 36 thioridazine hcl 123 TOBRADEX ST 36 thiotepa 296 tobramycin 36,58 thiothixene 123 tobramycin in 0.225 % sodium chloride 58 threonine 296 tobramycin sulfate 58 THRIVITE 19 50 tobramycin/dexamethasone 36 THRIVITE RX 50 tobramycin/nebulizer 58 THROMBI-GEL 296 TOBREX 36 THROMBI-PAD 296 TOFRANIL 82 THROMBIN-JMI 99 TOFRANIL-PM 82 THYROID 267 TOLAK 262 thyroid,pork 267 tolazamide 88 THYROLAR-1 267 tolazoline hcl 301 THYROLAR-1/2 267 tolbutamide 88 THYROLAR-1/4 267 tolcapone 112 THYROLAR-2 267 tolmetin sodium 237 THYROLAR-3 267 tolterodine tartrate 189 tiagabine hcl 72 TOPAMAX 72 TIAZAC 57 topical cream metered-dose device 296 ticarcillin disodium/potassium clavulanate 239 TOPICORT 252 ticlopidine hcl 128 topiramate 72 TOPROL XL 55 TRI-SPRINTEC 209 torsemide 164 TRI-TABS DHA 50 TOUJEO SOLOSTAR 86 TRI-VI-FLOR 223 TOVIAZ 190 triacetin 91 TOXICOLOGY SALIVA COLLECTION 237 triamcinolone 193 TRACLEER 245 triamcinolone acetonide 45,193,252 TRADJENTA 85 triamcinolone diacetate 193 tramadol hcl 22 triamcinolone diacetate, micronized 193 tramadol hcl/acetaminophen 12 triamcinolone hexacetonide 193 trandolapril 242 triamcinolone hexacetonide, micronized 193 trandolapril/verapamil hcl 147 triamterene 164 tranexamic acid 99 triamterene/hydrochlorothiazide 164 tranilast 47 TRIANEX 252 transcutaneous electrical nerve stimulators (tens units) 296 triazolam 142 TRANSDERM-SCOP 90 TRIBENZOR 167 transfer device, closed system 296 TRICARE PRENATAL 50 TRANXENE T-TAB 74 trichlormethiazide 165 tranylcypromine sulfate 77 trichloroacetic acid 262,296 TRAVATAN Z 98 TRICITRASOL 170 travoprost (benzalkonium) 98 TRICITRATES 170 trazodone hcl 80,81 triclosan 43 TREAGAN OTIC 296 TRICOR 106 TRECATOR 111 TRIDERM 252 TRETIN-X 254 TRIDESILON 252 tretinoin 254,296 TRIESENCE 45 tretinoin microspheres 254 triethanolamine 296 tretinoin/emollient base 254 TRIFERIC 50 TREXALL 226 trifluoperazine hcl 123 TREXIMET 110 trifluridine 37 TREZIX 12 TRIGLIDE 106 TRI FEMYNOR 208 trihexyphenidyl hcl 67 TRI-CHLOR 262 TRIKLO 103 TRI-ESTARYLLA 208 TRILEPTAL 72 TRI-LEGEST FE 208 TRILIPIX 106 TRI-LINYAH 208 trilostane 296 TRI-LO-ESTARYLLA 208 TRILYTE WITH FLAVOR PACKETS 185 TRI-LO-MARZIA 208 trimeprazine tartrate 182 TRI-LO-SPRINTEC 209 trimethobenzamide hcl 91 TRI-LUMA 155 trimethoprim 33 TRI-NORINYL 209 trimethoprim, micronized 33 TRI-PREVIFEM 209 trimipramine maleate 82 TRINATE 50 TYVASO REFILL KIT 245 TRINESSA 209 TYVASO STARTER KIT 245 TRINESSA LO 209 TYZEKA 138 TRINTELLIX 81 TYZINE 182 trioxsalen 296 tripelennamine hcl 182 U TRIPLE DYE 93 ubidecarenone 234 triprolidine hcl 100 ubiquinol 234 TRIUMEQ 124 UCERIS 194 TRIVEEN-ONE 50 UDAMIN SP 302 TRIVEEN-U 302 ULESFIA 43 TRIVORA-28 209 ULORIC 221 TRIZIVIR 125 ULTANE 189 TROKENDI XR 72 ULTRACET 12 TROPAZONE 296 ULTRAFOAM 99 tropicamide 182 ULTRAM 22 trospium chloride 190 ULTRAM ER 22 TRULICITY 86 ULTRASAL-ER 256 TRUMENBA 132 ULTRAVATE 252 TRUSOPT 97 ULTRAVIST 163 TRUST NATAL DHA 302 UMECTA 256 TRUVADA 125 UMECTA PD 256 trypsin 296 UNASYN 239 tryptophan 141 undecylenic acid 93 TUBERSOL 163 unithiol 297 turmeric 234 UNITHROID 267 TUSSICAPS 102 UPTRAVI 245 TUSSIGON 67 UR N-C 33 TUSSIONEX 102 URAMAXIN 256 TUZISTRA XR 22 URAMAXIN GT 256 TWINRIX 132 URE-K 256 TWYNSTA 149 urea 256 TYBOST 234 URECHOLINE 144 TYKERB 296 URELLE 33 TYLENOL-CODEINE NO.3 12 URETRON D-S 33 TYLENOL-CODEINE NO.4 12 UREVAZ 256 TYMLOS 212 URIBEL 33 TYPHIM VI 132 URIMAR-T 33 tyrosine 171 URIN D.S. 33 TYVASO 245 urinary bag/catheter 297 TYVASO INSTITUTIONAL START KIT 245 urinary bag/catheterization tray 297 URO-458 33 VANOXIDE-HC 252 URO-BLUE 33 VAQTA 132 URO-L 33 VARIBAR HONEY 163 UROCIT-K 170 VARIBAR NECTAR 163 UROGESIC-BLUE 33 VARIBAR PUDDING 163 UROPHEN MB 33 VARIBAR THIN HONEY 163 UROQID-ACID NO.2 33 VARIBAR THIN LIQUID 163 UROXATRAL 8 VARIVAX VACCINE 132 URSO 185 VARIZIG 130 URSO FORTE 185 VARUBI 90 ursodiol 185 VASCEPA 103 URYL 33 VASELINE WHITE PETROLEUM 174 USTELL 34 VASERETIC 168 UTA 34 vasopressin 213 UTIBRON NEOHALER 6 VASOTEC 242 UTIRA-C 34 VAXCHORA ACTIVE COMPONENT 132 UTOPIC 256 VAXCHORA BUFFER COMPONENT 297 UVADEX 155 VAXCHORA VACCINE 132 VECAMYL 216 V VECTICAL 262 V-C FORTE 302 vecuronium bromide 247 vacuum erection device system 297 VELIVET 209 VAGIFEM 179 VELPHORO 217 valacyclovir hcl 138 VELTASSA 217 VALCHLOR 262 VEMLIDY 139 VALCYTE 138 VENATAL COMPLETE DHA 297 valganciclovir hcl 138,139 VENCLEXTA 297 valine 297 VENCLEXTA STARTING PACK 297 VALIUM 74 VENELEX 262 valproic acid 72,73 venlafaxine hcl 77,78 valproic acid (as sodium salt) (valproate sodium) 73 VENTOLIN HFA 6 valsartan 241 VERAMYST 45 valsartan/hydrochlorothiazide 167,168 verapamil hcl 57 VALSTAR 297 VERDESO 252 VALTREX 139 VERDROCET 12 VANATOL LQ 12 VEREGEN 262 VANCOCIN HCL 62 VERELAN 57 vancomycin hcl 62 VERELAN PM 57 VANDAZOLE 39 VERIPRED 20 194 VANIQA 262 VERSACLOZ 121 VANOS 252 VESICARE 190 VESTURA 209 VIRT-ADVANCE 51 VEXOL 45 VIRT-C DHA 51 VFEND 92 VIRT-CAPS 304 VIAGRA 301 VIRT-GARD 304 VIASPAN BELZER-UW 297 VIRT-NATE 51 VIBERZI 187 VIRT-NATE DHA 51 VIBRAMYCIN 62 VIRT-PHOS 250 NEUTRAL 169 VIC-FORTE 302 VIRT-PN 51 VICODIN 12 VIRT-PN DHA 51 VICODIN ES 12 VIRT-PN PLUS 51 VICODIN HP 13 VIRT-VITE 304 VICOPROFEN 23 VIRT-VITE PLUS 304 VICTOZA 2-PAK 86 VIRTRATE-2 170 VICTOZA 3-PAK 86 VIRTRATE-3 170 vidarabine 139 VIRTRATE-K 170 vidarabine monohydrate 139 VISCOAT 297 VIDEX 126 VISTARIL 141 VIDEX EC 126 VISTOGARD 220 VIEKIRA PAK 127 VIT 3 104 VIEKIRA XR 127 VITA-RESPA 304 VIENVA 209 VITAFOL GUMMIES 51 vigabatrin 73 vitamin a acetate 303 VIGAMOX 36 vitamin a palmitate 303 VIIBRYD 81 vitamin e (dl-alpha tocopheryl acetate) 305 VIMPAT 73 vitamin e acetate 305 VINATE DHA 50 vitamin e acid succinate 305 VINATE DHA RF 50 vitamin e mixed 305 VINATE GT 50 vitamin k2 305 VINATE II 51 VITASPIRE 297 VINATE ONE 51 VITATRUE 51 VINATE PN CARE 302 VITRASE 297 VINATE ULTRA 51 VITUZ 102 VINATE-M 303 VIVA DHA 51 VIORELE 209 VIVELLE-DOT 179 VIRACEPT 127 VIVITROL 152 VIRAMUNE 125 VIVLODEX 237 VIRAMUNE XR 125 VIVOTIF 132 VIRASAL 256 VIVOTIF BERNA 132 VIRAZOLE 139 VOL-TAB RX 51 VIREAD 126 VOLTAREN 238 VIROPTIC 37 VOLTAREN-XR 238 VOLUMEN 163 xanthan gum 298 voriconazole 92 XARELTO 68 VOSEVI 297 XARTEMIS XR 13 VOSPIRE ER 6 XATMEP 226 VOTRIENT 297 XCLAIR 174 VP-CH-PNV 51 XELJANZ 226 VP-HEME OB 51 XELJANZ XR 226 VP-HEME ONE 51 XELODA 298 VP-PNV-DHA 51 XENAZINE 151 VP-VITE RX 304 XENICAL 188 VP-ZEL 234 XERESE 40 VRAYLAR 121 XERMELO 184 VUSION 94 XIFAXAN 64 VYFEMLA 209 XIIDRA 46 VYNATAL-FA 51 XODOL 10-300 13 VYTONE 43 XODOL 5-300 13 VYTORIN 104 XODOL 7.5-300 13 VYVANSE 28 XOLEGEL 94 XOPENEX 6 W XOPENEX CONCENTRATE 6 warfarin sodium 68 XTANDI 298 water for inj.,bacteriostatic 298 XULANE 210 water for XURIDEN 234 inj.,bacteriostatic/methylparaben/propylparaben 298 XYLOCAINE 53,181,298 water for injection,sterile 298 XYLOCAINE DENTAL-EPINEPHRINE 265 WELCHOL 83 XYLOCAINE WITH EPINEPHRINE 265 WELLBUTRIN 76 XYLOCAINE-MPF 53,298 WELLBUTRIN SR 76 XYLOCAINE-MPF WITH EPINEPHRINE 265 WELLBUTRIN XL 76 xylometazoline hcl 298 WERA 209 XYLON 10 23 WESTHROID 267 XYREM 151 white willow bark/salicin 298 XYZAL 101 WP THYROID 267 WYMZYA FE 210 Y YASMIN 28 210 X YAZ 210 XADAGO 112 YF-VAX 133 XALATAN 98 yohimbine hcl 264,298 XALKORI 298 YUVAFEM 179 XANAX 142 XANAX XR 142 zinc chloride 173 Z zinc oxide 262 zafirlukast 47 zinc picolinate 173 zaleplon 141 zinc sulfate 173 ZAMICET 13 zinc sulfate heptahydrate 173 ZANABIN 298 zinc undecylenate 93 ZANAFLEX 246 ZINGO 299 ZANTAC 133 ziprasidone hcl 121 ZARAH 210 ZIPSOR 238 ZARONTIN 75 ZIRGAN 37 ZARXIO 146 ZITHRANOL 257 ZAVESCA 234 ZITHRANOL-RR 257 zeaxanthin 298 ZITHROMAX 218 ZEBETA 55 ZITHROMAX TRI-PAK 218 ZEBUTAL 13 ZMAX 218 ZEGERID 135 ZOCOR 108 ZEJULA 298 ZODEX 194,299 ZELAPAR 77 ZOFRAN 89 ZELBORAF 298 ZOFRAN ODT 89 ZEMBRACE SYMTOUCH 110 ZOLATE 304 ZEMPLAR 305 ZOLINZA 299 ZENATANE 262 zolmitriptan 110 ZENCHENT 210 ZOLOFT 80 ZENCHENT FE 210 zolpidem tartrate 141 ZENCIA 43 ZOLPIMIST 141 ZENPEP 186 ZOMACTON 214 ZENZEDI 28 ZOMIG 110 ZEOSA 210 ZOMIG ZMT 110 ZEPATIER 190 ZONALON 253 ZERIT 126 ZONATUSS 243 ZESTORETIC 168 ZONEGRAN 73 ZESTRIL 242 zonisamide 73 ZETIA 105 ZONTIVITY 128 ZETONNA 45 ZORBTIVE 214 ZIAC 55 ZORTRESS 231 ZIAGEN 126 ZOSTAVAX 133 zidovudine 126 ZOTEX-C 299 zileuton 47 ZOVIA 1-35E 210 ZINACEF 153 ZOVIA 1-50E 210 ZINBRYTA 229 ZOVIRAX 40,139 zinc acetate dihydrate 299 ZUBSOLV 24 ZUPLENZ 89 ZURAMPIC 174 ZUTRIPRO 23 ZYBAN 76 ZYCLARA 262 ZYDELIG 299 ZYFLO 47 ZYFLO CR 47 ZYKADIA 299 ZYLET 36 ZYLOPRIM 221 ZYMAXID 36 ZYPREXA 121,122 ZYPREXA RELPREVV 122 ZYPREXA ZYDIS 122 ZYTIGA 299 ZYVOX 63

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