VIRGINIA PREMIER HEALTH PLAN

MEDICAID FORMULARY

PLEASE NOTE: Check your benefit materials for the specific drugs covered and the copayments for your prescription drug program. For specific questions about your coverage, please call the phone number printed on your ID card. The list may not be all- inclusive. THIS LIST IS SUBJECT TO CHANGE.

For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you. CURRENT AS OF 9/1/2021

Requirements/Limits AGE = Age limit requirement Custom = Drug has unique restrictions OTC = Over the Counter PA = Prior Authorization required QL = Quantity Level Limit lowercase italics = Generic Formulary SP = Specialty Drug. Preferred Specialty drugs Pharmacy will be listed if applicable UPPERCASE = Brand name Formulary Formulary Status ST = Step Therapy may apply to some or all drugs Formulary = Covered strengths of the drug Drug Name Formulary Status Requirements/Limits 1st relief spray external liquid 4-1 % Formulary OTC 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 Formulary OTC; QL (200 EA per 30 days) mm , 31g x 8 mm , 32g x 4 mm 1st tier unilet comfortouch Formulary OTC; QL (150 EA per 30 days) 50+ adult eye health oral capsule Formulary OTC A & D ZINC OXIDE EXTERNAL CREAM Formulary OTC a thru z advanced oral tablet Formulary OTC a thru z advantage oral tablet Formulary OTC a thru z select oral tablet chewable Formulary OTC A+D CRACKED SKIN RELIEF EXTERNAL CREAM 2- Formulary OTC 0.13 % a1c test at-home in vitro kit Formulary OTC a-25 oral capsule 25000 unit Formulary OTC sulfate oral solution 20 mg/ml Formulary abacavir sulfate oral tablet 300 mg Formulary abacavir sulfate- oral tablet 600-300 mg Formulary abacavir-lamivudine- oral tablet 300-150-300 Formulary mg ABANATUSS PED ORAL LIQUID 15-0.5-6.25 MG/ML, Formulary OTC 60-2-25 MG/5ML ABATRACE ORAL CAPSULE Formulary OTC ABATREX ORAL TABLET 8-200-4-100-600 MG Formulary OTC ABATRON AF ORAL TABLET 150-1 MG Formulary OTC ABATRON ORAL LIQUID Formulary OTC ABATUSS DMX ORAL LIQUID 30-1-15 MG/5ML Formulary OTC ABILIFY MAINTENA INTRAMUSCULAR PREFILLED Formulary AGE (Min 18 Years) SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR Formulary AGE (Min 18 Years) SUSPENSION RECONSTITUTED ER 300 MG, 400 MG abiraterone acetate oral tablet 250 mg Formulary ABRAXANE INTRAVENOUS SUSPENSION Formulary RECONSTITUTED 100 MG ABREVA EXTERNAL CREAM 10 % Formulary OTC acamprosate calcium oral tablet delayed release 333 mg Formulary acarbose oral tablet 100 mg, 25 mg, 50 mg Formulary ACCU-CHEK FASTCLIX LANCET KIT Formulary OTC

1 Drug Name Formulary Status Requirements/Limits ACCU-CHEK SOFT TOUCH LANCETS Formulary OTC; QL (150 EA per 30 days) ACCU-CHEK SOFTCLIX LANCETS Formulary OTC; QL (150 EA per 30 days) ACCUTANE ORAL CAPSULE 20 MG, 30 MG, 40 MG Formulary ACCUTREND CHOLESTEROL CONTROL IN VITRO Formulary OTC SOLUTION ACCUTREND CHOLESTEROL IN VITRO STRIP Formulary OTC ACCUTREND PLUS DEVICE Formulary OTC ACE AEROSOL CLOUD ENHANCER Formulary QL (2 EA per 365 days) ACE KNEE BRACE W/STABILIZERS Formulary OTC acebutolol hcl oral capsule 200 mg, 400 mg Formulary ACEROLA C 500 ORAL WAFER 500 MG Formulary OTC ACETA-GESIC ORAL TABLET 12.5-325 MG Formulary OTC acetaminophen oral liquid 160 mg/5ml Formulary OTC acetaminophen oral solution 160 mg/5ml Formulary OTC acetaminophen oral tablet 325 mg Formulary OTC acetaminophen-codeine #2 oral tablet 300-15 mg Formulary PA; QL (280 EA per 7 days) acetaminophen-codeine #3 oral tablet 300-30 mg Formulary PA; QL (140 EA per 7 days) acetaminophen-codeine #4 oral tablet 300-60 mg Formulary PA; QL (70 EA per 7 days) acetaminophen-codeine oral solution 120-12 mg/5ml Formulary PA; QL (1750 ML per 7 days) ACETASOL HC OTIC SOLUTION 2-1 % Formulary acetazolamide er oral capsule extended release 12 hour 500 Formulary mg acetazolamide oral tablet 250 mg Formulary acetic acid irrigation solution 0.25 % Formulary acetic acid otic solution 2 % Formulary acetylcysteine inhalation solution 10 %, 20 % Formulary ACID GONE ORAL SUSPENSION 95-358 MG/15ML Formulary OTC acid reducer maximum strength oral tablet 20 mg Formulary OTC acidophilus oral capsule Formulary OTC acidophilus probiotic oral tablet 10 mg Formulary OTC acidophilus/bifidus oral tablet chewable Formulary OTC acidophilus/citrus pectin oral tablet Formulary OTC acidophilus/pectin oral capsule Formulary OTC acitretin oral capsule 10 mg, 17.5 mg, 25 mg Formulary PA; QL (68 EA per 34 days) acne medication 10 external gel 10 % Formulary OTC; AGE (Max 18 Years) acne medication 10 external lotion 10 % Formulary OTC; AGE (Max 18 Years) acne medication 5 external gel 5 % Formulary AGE (Max 18 Years) acne medication 5 external lotion 5 % Formulary OTC; AGE (Max 18 Years) acne treatment external bar 10 % Formulary OTC; AGE (Max 18 Years) ACNEFREE ACNE CLEARING SYSTEM EXTERNAL Formulary OTC KIT 2.5 & 3.7 % ACNEFREE SEVERE CLEARING SYST EXTERNAL Formulary OTC KIT 2.5 & 10 % ACT TOTAL CARE MOUTH/THROAT SOLUTION 0.05 Formulary OTC %

2 Drug Name Formulary Status Requirements/Limits ACTHIB INTRAMUSCULAR SOLUTION Formulary AGE (Min 19 Years) RECONSTITUTED ACTICARNITINE SF ORAL SOLUTION 1 GM/10ML Formulary OTC ACTICON ORAL SOLUTION 1-30 MG/5ML Formulary OTC ACTICON ORAL TABLET 2-60 MG Formulary OTC actidom dmx oral liquid 10-30-200 mg/5ml Formulary OTC ACTIDOSE WITH SORBITOL ORAL LIQUID 50 Formulary OTC GM/240ML actidose-aqua oral liquid 15 gm/72ml Formulary OTC ACTIFLOVIT EAR HEALTH ORAL TABLET Formulary OTC ACTIFOAM COLLAGEN SPONGE EXTERNAL Formulary acti-lance lite lancets 28g Formulary OTC; QL (150 EA per 30 days) acti-lance special lancets 17g Formulary OTC; QL (150 EA per 30 days) acti-lance universal 23g Formulary OTC; QL (150 EA per 30 days) ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 Formulary UNIT/0.5ML ACTINEL ORAL LIQUID 30-15-200 MG/5ML Formulary OTC ACTISEP MOUTH/THROAT SOLUTION 2-0.5-0.1 % Formulary OTC ACTITROM ORAL CAPSULE Formulary OTC ACTIVE Q MAXIMUM STRENGTH ORAL CAPSULE Formulary OTC 300 MG ACTIVE Q ORAL SYRUP 100 MG/5ML Formulary OTC ACTIVE-Q EXTRA STRENGTH ORAL CAPSULE 200 Formulary OTC MG ACTIVE-Q ORAL CAPSULE 200-30 MG Formulary OTC ACTIVITE EC ORAL TABLET 1 MG Formulary OTC ACTIVON ARTHRITIS ULTRA ST EXTERNAL STICK Formulary OTC 0.028-4.574 % acyclovir external ointment 5 % Formulary acyclovir oral capsule 200 mg Formulary acyclovir oral suspension 200 mg/5ml Formulary acyclovir oral tablet 400 mg, 800 mg Formulary ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 Formulary LF-MCG/0.5 ADAGEN INTRAMUSCULAR SOLUTION 250 Formulary PA UNIT/ML adapalene external cream 0.1 % Formulary AGE (Max 18 Years) adapalene external gel 0.1 %, 0.3 % Formulary AGE (Max 18 Years) ADDERALL XR ORAL CAPSULE EXTENDED QL (30 EA per 30 days); AGE (Min 4 Formulary RELEASE 24 HOUR 10 MG, 15 MG, 5 MG Years and Max 17 Years) ADDERALL XR ORAL CAPSULE EXTENDED QL (60 EA per 30 days); AGE (Min 4 Formulary RELEASE 24 HOUR 20 MG, 25 MG, 30 MG Years and Max 17 Years) adefovir dipivoxil oral tablet 10 mg Formulary adhesive bandages sheer Formulary OTC adjustable lancing device Formulary OTC; QL (1 EA per 365 days) ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 100 UNIT/ML 3 Drug Name Formulary Status Requirements/Limits ADMELOG SUBCUTANEOUS SOLUTION 100 Formulary UNIT/ML ADRENAL C FORMULA ORAL TABLET Formulary ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 Formulary MG/30ML ADRUCIL INTRAVENOUS SOLUTION 2.5 GM/50ML, 5 Formulary GM/100ML, 500 MG/10ML adult gummy oral tablet chewable Formulary OTC adult mask device Formulary QL (2 EA per 365 days) adult wash cloths with aloe external 3 % Formulary OTC adult-lock weekly pill remind Formulary OTC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 Formulary MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 Formulary MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT advanced acne wash external liquid extended release 4.4 % Formulary OTC ADVANCED CALCIUM/D/MAGNESIUM ORAL Formulary OTC TABLET advanced hand sanitizer external liquid 70 % Formulary OTC ADVIL ALLERGY & CONGESTION ORAL TABLET 4- Formulary OTC 10-200 MG ADVIL ALLERGY SINUS ORAL TABLET 2-30-200 MG Formulary OTC ADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE Formulary OTC 30-200 MG ADVIL COLD/SINUS ORAL TABLET 30-200 MG Formulary OTC ADVIL ORAL CAPSULE 200 MG Formulary OTC ADVIL ORAL TABLET 200 MG Formulary OTC ADVIL PM ORAL CAPSULE 200-25 MG Formulary OTC ADVIL PM ORAL TABLET 200-38 MG Formulary OTC ADVIL SINUS CONGESTION & PAIN ORAL TABLET Formulary OTC 10-200 MG ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML ADVOCATE INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML ADVOCATE INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML ADVOCATE INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML AEROCHAMBER PLUS FLO-VU Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Formulary QL (2 EA per 365 days) AFEDITAB CR ORAL TABLET EXTENDED RELEASE Formulary 24 HOUR 30 MG, 60 MG AFLURIA INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years)

4 Drug Name Formulary Status Requirements/Limits AFLURIA PRESERVATIVE FREE INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION PREFILLED SYRINGE 0.5 ML AFREZZA INHALATION POWDER 12 UNIT, 8 UNIT Formulary AFRIN CHILDRENS NASAL SOLUTION 0.25 % Formulary OTC AFRIN MENTHOL SPRAY NASAL SOLUTION 0.05 % Formulary OTC AFTERA ORAL TABLET 1.5 MG Formulary OTC; QL (2 EA per 34 days) AGAMATRIX ULTRA-THIN LANCETS Formulary OTC; QL (150 EA per 30 days) AHIST ORAL TABLET 25 MG Formulary OTC aimsco lubricated Formulary OTC AIRAVITE ORAL TABLET 2.5-25-1 MG Formulary AIRBORNE ORAL LOZENGE Formulary OTC AIRS DISPOSABLE NEBULIZER Formulary OTC; QL (2 EA per 365 days) AIRS DISPOSABLE NEBULIZER KIT Formulary QL (2 EA per 365 days) AIRZONE PEAK FLOW METER DEVICE Formulary OTC; QL (2 EA per 365 days) AJOVY SUBCUTANEOUS SOLUTION AUTO- Formulary ST; AGE (Min 18 Years) INJECTOR 225 MG/1.5ML AJOVY SUBCUTANEOUS SOLUTION PREFILLED Formulary ST; AGE (Min 18 Years) SYRINGE 225 MG/1.5ML ak-poly-bac ophthalmic ointment 500-10000 unit/gm Formulary AL12 EXTERNAL LOTION 12 % Formulary OTC ALA SEB EXTERNAL SHAMPOO 2-2 % Formulary OTC ALA SEB T EXTERNAL SHAMPOO 1-2-2 % Formulary OTC ALAHIST DM ORAL LIQUID 7.5-2-15 MG/5ML Formulary OTC ALA-HIST IR ORAL TABLET 2 MG Formulary OTC ALA-HIST PE ORAL TABLET 2-10 MG Formulary OTC alanine 1000 oral packet 1000 mg Formulary OTC ALAWAY CHILDRENS ALLERGY OPHTHALMIC Formulary OTC SOLUTION 0.025 % ALAWAY OPHTHALMIC SOLUTION 0.025 % Formulary OTC alba-lybe nr oral liquid 325-10-50 mg/5ml Formulary OTC oral tablet 200 mg Formulary ALBOLENE EXTERNAL CREAM Formulary OTC; QL (454 GM per 34 days) ALBUKED 25 INTRAVENOUS SOLUTION 25 % Formulary ALBUKED 5 INTRAVENOUS SOLUTION 5 % Formulary albumin human intravenous solution 25 %, 5 % Formulary albumin-zlb intravenous solution 25 %, 5 % Formulary alburx intravenous solution 5 % Formulary ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 % Formulary albuterol sulfate er oral tablet extended release 12 hour 4 Formulary mg, 8 mg albuterol sulfate hfa inhalation aerosol solution 108 (90 Formulary base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 Formulary mg/3ml albuterol sulfate oral syrup 2 mg/5ml Formulary 5 Drug Name Formulary Status Requirements/Limits albuterol sulfate oral tablet 2 mg, 4 mg Formulary alcohol (rubbing) solution 70 % Formulary OTC alcohol prep pad 70 % Formulary OTC alcohol prep pad 70 % 70 % Formulary OTC alcohol swabs pad Formulary OTC alcohol swabs pad 70 % 70 % Formulary OTC alcohol wipes pad 70 % 70 % Formulary OTC alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, Formulary 70 mg aler-cap oral capsule 25 mg Formulary OTC aler-dryl oral tablet 50 mg Formulary OTC alertness aid oral tablet 200 mg Formulary OTC alevazol external ointment 1 % Formulary OTC ALEVE ORAL CAPSULE 220 MG Formulary OTC ALEVE ORAL TABLET 220 MG Formulary OTC ALFERON N INJECTION SOLUTION 5000000 Formulary PA UNIT/ML alfuzosin hcl er oral tablet extended release 24 hour 10 mg Formulary alga oral capsule 0.225-2000 mg-unit Formulary OTC ALGAL-900 DHA ORAL CAPSULE 300 MG Formulary OTC ALIMTA INTRAVENOUS SOLUTION Formulary RECONSTITUTED 100 MG, 500 MG ALIVE MULTI-VITAMIN CHILDRENS ORAL TABLET Formulary OTC CHEWABLE 60 MG ALIVIO EXTERNAL PATCH 0.03-5 % Formulary OTC alka-aid oral tablet 180-360 mg Formulary OTC ALKA-SELTZER HEARTBURN + GAS ORAL TABLET Formulary OTC CHEWABLE 750-80 MG ALKA-SELTZER ORAL TABLET EFFERVESCENT Formulary OTC 325-1000-1916 MG all day allergy childrens oral solution 5 mg/5ml Formulary OTC all day pain relief oral tablet 220 mg Formulary OTC ALL-DRY SIZE 3 Formulary OTC ALLEGRA ALLERGY CHILDRENS ORAL Formulary OTC SUSPENSION 30 MG/5ML ALLEGRA ALLERGY CHILDRENS ORAL TABLET Formulary OTC DISPERSIBLE 30 MG ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG Formulary OTC ALLEGRA-D ALLERGY & CONGESTION ORAL Formulary OTC TABLET EXTENDED RELEASE 12 HOUR 60-120 MG ALLEGRA-D ALLERGY & CONGESTION ORAL Formulary OTC TABLET EXTENDED RELEASE 24 HOUR 180-240 MG aller-ease oral tablet 60 mg Formulary OTC; QL (68 EA per 34 days) allergy childrens oral liquid 12.5 mg/5ml Formulary OTC allergy eye ophthalmic solution 0.025-0.3 % Formulary OTC allergy multi-symptom day/nght oral Formulary OTC

6 Drug Name Formulary Status Requirements/Limits allergy relief oral tablet 5 mg Formulary OTC allergy spray 24 hour aerosol 55 mcg/act nasal 55 mcg/act Formulary OTC ALLEVYN PLUS CAVITY PAD 6"X8" Formulary OTC ALLI ORAL CAPSULE 60 MG Formulary OTC allopurinol oral tablet 100 mg, 300 mg Formulary ALMACONE ORAL TABLET CHEWABLE 200-200-25 Formulary OTC MG ALOCANE PLUS EXTERNAL GEL 4-0.13 % Formulary OTC ALOE GRANDE EXTERNAL CREAM 100000-1500 Formulary OTC UNIT/GM ALOE GRANDE EXTERNAL LOTION 10000-1500 Formulary OTC UNIT/30ML aloe vera external cream 72 % Formulary OTC aloe vera external gel 99.5 % Formulary OTC aloe vera moisturizing external gel 99.5 % Formulary OTC ALOE VESTA 2-N-1 PROTECTIVE EXTERNAL Formulary OTC OINTMENT ALOE VESTA CLEAR ANTIFUNGAL EXTERNAL Formulary OTC OINTMENT 2 % ALOE VESTA MULTI PURPOSE EXTERNAL FOAM Formulary OTC ALOE VESTA PROTECTIVE EXTERNAL OINTMENT Formulary OTC ALOE VESTA SKIN PROTECTANT EXTERNAL Formulary OTC AEROSOL 36 % aloe/lidocaine pain reliever external gel 0.5 % Formulary OTC alosetron hcl oral tablet 0.5 mg, 1 mg Formulary PA alp high3 oral capsule delayed release 600 mg Formulary OTC ALPAWASH EXTERNAL OINTMENT Formulary ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 Formulary % alpha-lipoic acid oral capsule 100 mg Formulary OTC alpha-lipoic acid oral tablet 200 mg Formulary OTC ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 Formulary UNIT, 1500 UNIT, 250 UNIT, 500 UNIT ALPHANINE SD INTRAVENOUS SOLUTION Formulary RECONSTITUTED 1000 UNIT, 500 UNIT alph-e oral capsule 400 unit Formulary OTC alph-e-mixed 1000 oral capsule 1000 unit Formulary OTC alph-e-mixed oral capsule 200 unit Formulary OTC alprazolam er oral tablet extended release 24 hour 0.5 mg, Formulary QL (170 EA per 30 days) 1 mg, 2 mg alprazolam er oral tablet extended release 24 hour 3 mg Formulary QL (170 EA per 34 days) ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 Formulary QL (170 ML per 34 days) MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Formulary QL (170 EA per 34 days) alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 Formulary QL (170 EA per 34 days) mg

7 Drug Name Formulary Status Requirements/Limits ALTACAINE OPHTHALMIC SOLUTION 0.5 % Formulary ALTAFLUOR OPHTHALMIC SOLUTION 0.25-0.4 % Formulary ALTAVERA ORAL TABLET 0.15-30 MG-MCG Formulary QL (28 EA per 28 days) aluminum acetate external solution Formulary OTC aluminum bottle seal Formulary OTC aluminum hydroxide gel oral suspension 320 mg/5ml Formulary OTC ALWAYS MAXI MAXIMUM PROTECTION PAD Formulary OTC alyacen 1/35 oral tablet 1-35 mg-mcg Formulary QL (28 EA per 28 days) alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg Formulary QL (28 EA per 28 days) ALYQ ORAL TABLET 20 MG Formulary PA; AGE (Min 18 Years) amantadine hcl oral capsule 100 mg Formulary amantadine hcl oral syrup 50 mg/5ml Formulary amantadine hcl oral tablet 100 mg Formulary ambi 12.5cpd/100gfn/30pse oral liquid 30-12.5-100 mg/5ml Formulary OTC ambi 12.5cpd/1dcpm/30pse oral liquid 30-1-12.5 mg/5ml Formulary OTC ambi 40pse/400gfn oral tablet 40-400 mg Formulary OTC ambi 60pse/400gfn oral tablet 60-400 mg Formulary OTC ambi 60pse/4cpm oral tablet 60-4 mg Formulary OTC AMBI FADE EXTERNAL CREAM 2 % Formulary OTC ambrisentan oral tablet 10 mg, 5 mg Formulary AGE (Min 18 Years) amcinonide external cream 0.1 % Formulary AMERICERIN EXTERNAL CREAM Formulary OTC AMERIWASH EXTERNAL LOTION Formulary OTC AMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MG Formulary QL (91 EA per 91 days) AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG Formulary QL (91 EA per 91 days) AMETHYST ORAL TABLET 90-20 MCG Formulary QL (28 EA per 28 days) amiloride hcl oral tablet 5 mg Formulary amiloride-hydrochlorothiazide oral tablet 5-50 mg Formulary aminoacetic acid irrigation solution 1.5 % Formulary aminocaproic acid intravenous solution 250 mg/ml Formulary AMINORELIEFRMS ORAL CAPSULE Formulary amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Formulary AMITIZA ORAL CAPSULE 24 MCG, 8 MCG Formulary PA; AGE (Min 18 Years) amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Formulary 50 mg, 75 mg amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10- Formulary 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg Formulary amlodipine besylate-valsartan oral tablet 10-160 mg, 10- Formulary 320 mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, Formulary 10-40 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5- Formulary 20 mg, 5-40 mg

8 Drug Name Formulary Status Requirements/Limits amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- Formulary ST 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ammonia aromatic inhalation inhaler Formulary OTC ammonia aromatic inhalation spirit Formulary OTC ammonium lactate external cream 12 % Formulary AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG Formulary oral capsule 250 mg, 500 mg Formulary amoxicillin oral suspension reconstituted 125 mg/5ml, 200 Formulary mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg Formulary amoxicillin oral tablet chewable 125 mg, 250 mg Formulary amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600- Formulary 42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500- Formulary 125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 Formulary mg, 400-57 mg amphetamine- oral tablet 10 mg, 12.5 Formulary AGE (Min 4 Years and Max 17 Years) mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg ampicillin oral capsule 500 mg Formulary ANA-LEX RECTAL KIT 2-2 % Formulary ANASEPT ANTIMICROBIAL EXTERNAL GEL 0.057 % Formulary OTC ANASEPT EXTERNAL LIQUID 0.057 % Formulary OTC anastrozole oral tablet 1 mg Formulary ANBESOL MAXIMUM STRENGTH MOUTH/THROAT Formulary OTC LIQUID 20 % ANBESOL MOUTH/THROAT GEL 10 % Formulary OTC ANBESOL MOUTH/THROAT LIQUID 10 % Formulary OTC ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 Formulary AGE (Min 18 Years) MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL 20.25 Formulary AGE (Min 18 Years) MG/ACT (1.62%) ANECREAM EXTERNAL CREAM 4 % Formulary OTC animal chews oral tablet chewable Formulary OTC ANORO ELLIPTA INHALATION AEROSOL POWDER Formulary BREATH ACTIVATED 62.5-25 MCG/INH antacid anti-gas max strength oral suspension 400-400-40 Formulary OTC mg/5ml antacid anti-gas oral suspension 200-200-20 mg/5ml Formulary OTC antacid extra strength oral tablet chewable 675-135 mg Formulary OTC antacid multi-symptom oral tablet chewable 675-135-60 mg Formulary OTC antacid oral tablet chewable 500 mg Formulary OTC antacid soft chews oral tablet chewable 1177 mg Formulary OTC ANTARA ORAL CAPSULE 30 MG, 90 MG Formulary anthelios 50 mineral external liquid Formulary OTC anti-allergy oral tablet 100-100-50 mg Formulary OTC

9 Drug Name Formulary Status Requirements/Limits antibacterial liquid soap external liquid 0.15 % Formulary OTC anti-diarrheal oral liquid 1 mg/5ml Formulary OTC anti-diarrheal oral tablet 2 mg Formulary OTC antifungal external aerosol 1 % Formulary OTC antifungal external cream 2 % Formulary OTC anti-fungal external powder 1 % Formulary OTC anti-itch external cream 1-0.1 % Formulary OTC anti-itch external lotion 0.5-0.5 % Formulary OTC ANTI-ITCH INTENSIVE HEALING EXTERNAL Formulary OTC LOTION 1 % antioxidant formula sg oral capsule extended release Formulary OTC anti-oxidant oral tablet Formulary OTC antiseptic external aerosol 4.5-0.05-40.5 % Formulary OTC ANTISEPTIC HAND RINSE EXTERNAL GEL 62 % Formulary OTC antiseptic skin cleanser external solution 4 % Formulary OTC antiseptic wound/skin cleanser external liquid 0.1 % Formulary OTC ANUSOL-HC RECTAL CREAM 2.5 % Formulary AO-SEPT CONTACT LENS HOLDER Formulary OTC APETIGEN ORAL ELIXIR Formulary OTC APETIGEN-PLUS ORAL SOLUTION Formulary OTC APETIGEN-PLUS ORAL TABLET Formulary OTC ap-hist dm oral liquid 7.5-4-15 mg/5ml Formulary OTC APLIGRAF EXTERNAL DISK Formulary apothesar external cream Formulary apraclonidine hcl ophthalmic solution 0.5 % Formulary aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg Formulary QL (1 EA per 34 days) aprepitant oral capsule 80 mg Formulary QL (2 EA per 34 days) APRI ORAL TABLET 0.15-30 MG-MCG Formulary QL (28 EA per 28 days) APRISO ORAL CAPSULE EXTENDED RELEASE 24 Formulary HOUR 0.375 GM APTIVUS ORAL CAPSULE 250 MG Formulary APTIVUS ORAL SOLUTION 100 MG/ML Formulary AQUA CARE EXTERNAL LOTION 10 % Formulary OTC aquabase external ointment Formulary OTC AQUADEKS ORAL LIQUID Formulary OTC AQUAFRESH DR SEUSS EXTRA SOFT Formulary OTC aquanaz oral tablet 10-15-400 mg Formulary OTC AQUAPHILIC EXTERNAL OINTMENT Formulary OTC AQUAPHILIC/CARBAMIDE EXTERNAL OINTMENT Formulary OTC 10 %, 20 % AQUASONIC 100 EXTERNAL GEL Formulary OTC AQUEOUS SELENIUM ORAL LIQUID 95 MCG/DROP Formulary OTC aqueous vitamin e oral solution 15 mg/0.67ml, 15 Formulary OTC unit/0.3ml AQUORAL MOUTH/THROAT SOLUTION Formulary 10 Drug Name Formulary Status Requirements/Limits ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG Formulary QL (28 EA per 28 days) ARCALYST SUBCUTANEOUS SOLUTION Formulary PA RECONSTITUTED 220 MG ARCAPTA NEOHALER INHALATION CAPSULE 75 Formulary MCG arctic relief pain relieving external gel 0.2-3.5 % Formulary OTC arformoterol tartrate inhalation nebulization solution 15 Formulary mcg/2ml ARGIMENT AT ORAL PACKET Formulary OTC arginine oral packet 500 mg Formulary OTC arginine2000 oral packet 2000 mg Formulary OTC ARGYLE STERILE SALINE IRRIGATION SOLUTION Formulary 0.9 % ARGYLE STERILE WATER IRRIGATION SOLUTION Formulary aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, Formulary AGE (Min 18 Years) 5 mg ARISTADA INITIO INTRAMUSCULAR PREFILLED Formulary AGE (Min 18 Years) SYRINGE 675 MG/2.4ML ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 Formulary AGE (Min 18 Years) MG/3.2ML arkaliox oral capsule 200 mg Formulary OTC ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, Formulary 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG arnica external tincture 20 % Formulary OTC arnicare arthritis oral tablet dispersible Formulary OTC ARRANON INTRAVENOUS SOLUTION 5 MG/ML Formulary arthritis pain relieving external cream 0.075 % Formulary OTC artificial tears ophthalmic solution 1 %, 1-0.3 %, 1.4 % Formulary OTC ARZERRA INTRAVENOUS CONCENTRATE 100 Formulary MG/5ML, 1000 MG/50ML ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 Formulary % asafetida tincture Formulary OTC ascocid-iso-ph oral powder effervescent Formulary OTC ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG Formulary PA ascorbic acid oral tablet 1000 mg, 500 mg Formulary OTC ascorbic acid oral tablet chewable 250 mg Formulary OTC ASCRIPTIN ORAL TABLET 325 MG Formulary OTC asepto oral thermometer kit Formulary OTC ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 Formulary MCG/INH ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 Formulary MCG/INH aspartate mg & k oral capsule 90-90 mg Formulary OTC

11 Drug Name Formulary Status Requirements/Limits ASPERCREME W/LIDOCAINE EXTERNAL CREAM 4 Formulary OTC % aspirin 81 oral tablet delayed release 81 mg Formulary OTC aspirin oral tablet 325 mg Formulary OTC aspirin oral tablet chewable 81 mg Formulary OTC aspirin oral tablet delayed release 325 mg Formulary OTC aspirin rectal suppository 300 mg, 600 mg Formulary OTC aspirin-dipyridamole er oral capsule extended release 12 Formulary hour 25-200 mg aspirtab maximum strength oral tablet 500 mg Formulary OTC ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Formulary (OTC) 29G X 1/2" 0.5 ML ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML Formulary 29G X 1/2" 1 ML ASSURE LANCETS Formulary OTC; QL (150 EA per 30 days) ASTHMAPACK FOR CHILDREN KIT Formulary OTC; QL (2 EA per 365 days) atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg Formulary atenolol oral tablet 100 mg, 25 mg, 50 mg Formulary atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg Formulary athletes foot maximum strength external ointment Formulary OTC atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, Formulary QL (30 EA per 30 days) 40 mg, 60 mg, 80 mg ATOPICLAIR EXTERNAL CREAM Formulary atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 Formulary mg atovaquone oral suspension 750 mg/5ml Formulary atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 Formulary mg ATRAC-TAIN EXTERNAL CREAM 10 % Formulary OTC ATRAC-TAIN EXTERNAL LOTION 5 % Formulary OTC ATROVENT HFA INHALATION AEROSOL Formulary SOLUTION 17 MCG/ACT atuss da oral liquid 30-2-12.5 mg/5ml Formulary OTC AUBRA ORAL TABLET 0.1-20 MG-MCG Formulary QL (28 EA per 28 days) auraphene-b otic solution 6.5 % Formulary OTC aurora lancet super thin 30g Formulary OTC; QL (150 EA per 30 days) aurora lancet thin 23g Formulary OTC; QL (150 EA per 30 days) AUROVELA FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary AUTOJECT 2 Formulary OTC; QL (1 EA per 365 days) AUTOLET PLATFORMS Formulary OTC autopen device Formulary OTC; QL (1 EA per 365 days) avalin external patch 4-1 % Formulary OTC AVAR CLEANSER EXTERNAL EMULSION 10-5 % Formulary AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % Formulary AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, Formulary PA 400 MG/16ML

12 Drug Name Formulary Status Requirements/Limits AVEENO BABY GENTLE CONDITION EXTERNAL Formulary OTC SHAMPOO AVEENO BABY SOOTHING WASH EXTERNAL Formulary OTC LIQUID AVEENO INTENSE RELIEF EXTERNAL CREAM 1.3 % Formulary OTC AVEENO POSITIVELY RADIANT WASH EXTERNAL Formulary OTC LIQUID AVENOVA/NEUTROX EXTERNAL SOLUTION 0.01 % Formulary AVERTEAX MOUTH/THROAT OINTMENT 1 % Formulary OTC AVITENE EXTERNAL PAD Formulary AVITENE FLOUR EXTERNAL POWDER Formulary AVO CREAM EXTERNAL EMULSION Formulary AVONEX INTRAMUSCULAR KIT 30 MCG Formulary AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR Formulary KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED Formulary SYRINGE KIT 30 MCG/0.5ML av-phos 250 neutral oral tablet 155-852-130 mg Formulary axillary block needle 22g x 1" , 25g x 1" Formulary OTC AXSAIN EXTERNAL CREAM 0.25 % Formulary OTC AYR SALINE NASAL DROPS NASAL SOLUTION 0.65 Formulary OTC % AYR SALINE NASAL GEL NASAL SWAB Formulary OTC AYR SALINE NASAL NASAL GEL Formulary OTC AYR SALINE NASAL NO-DRIP NASAL GEL Formulary OTC AYR SALINE NASAL RINSE NASAL PACKET 1.57 Formulary OTC GM azacitidine injection suspension reconstituted 100 mg Formulary azathioprine oral tablet 50 mg Formulary azec oral capsule Formulary OTC azelastine hcl nasal solution 0.1 %, 0.15 % Formulary azithromycin oral packet 1 gm Formulary azithromycin oral suspension reconstituted 100 mg/5ml, Formulary 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Formulary azithromycin tablet 250 mg oral 250 mg Formulary azithromycin tablet 500 mg oral 500 mg Formulary AZOPT OPHTHALMIC SUSPENSION 1 % Formulary AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Formulary QL (28 EA per 28 days) b complete oral tablet Formulary OTC b complex formula 1 oral tablet Formulary OTC b complex oral capsule Formulary OTC b complex oral tablet Formulary OTC b complex-folic acid oral tablet 500-5-200 mcg-mg-mcg Formulary OTC b-1 oral tablet 100 mg, 250 mg Formulary OTC b-100 cr oral tablet extended release Formulary OTC 13 Drug Name Formulary Status Requirements/Limits b-12 oral tablet 2000 mcg, 250 mcg Formulary OTC b-12 sublingual tablet sublingual 1000 mcg, 2500 mcg, Formulary OTC 5000 mcg b-12 tr oral tablet extended release 2000 mcg Formulary OTC b-2 oral tablet 100 mg Formulary OTC B-2-400 ORAL CAPSULE 400 MG Formulary OTC b-6 oral tablet 250 mg, 50 mg, 500 mg Formulary OTC BABY ANBESOL MOUTH/THROAT GEL 7.5 % Formulary OTC baby lotion external lotion Formulary OTC baby super daily d3 oral liquid 400 ut/0.028ml Formulary OTC baby teething pain medicine mouth/throat gel 7.5 % Formulary OTC baby thermometer Formulary OTC baciim intramuscular solution reconstituted 50000 unit Formulary bacitracin ophthalmic ointment 500 unit/gm Formulary bacitracin zinc external ointment 500 unit/gm Formulary bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % Formulary back pain-off oral tablet 250-50-290 mg Formulary OTC baclofen oral tablet 10 mg, 20 mg, 5 mg Formulary BACTROBAN NASAL NASAL OINTMENT 2 % Formulary balamine dm oral syrup 5-2-10 mg/5ml Formulary OTC balanced b-50 complex oral capsule Formulary OTC balanced b-50 oral tablet extended release Formulary OTC BAL-CARE DHA ORAL 27-1 & 430 MG Formulary BALNEOL EXTERNAL LOTION Formulary OTC balsalazide disodium oral capsule 750 mg Formulary BALZIVA ORAL TABLET 0.4-35 MG-MCG Formulary QL (28 EA per 28 days) BAND-AID SURGIPAD SURGICAL PAD 5"X9" Formulary OTC BANOPHEN ORAL CAPSULE 50 MG Formulary OTC BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE Formulary QL (2 EA per 30 days) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE Formulary QL (2 EA per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML Formulary BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION Formulary QL (30 ML per 30 days) PEN-INJECTOR 100 UNIT/ML BAYER BACK & BODY ORAL TABLET 500-32.5 MG Formulary OTC BAYER BREEZE 2 CONTROL LIQUID HIGH IN VITRO Formulary OTC; QL (100 EA per 30 days) HIGH BAYER BREEZE 2 CONTROL LIQUID LOW IN VITRO Formulary OTC; QL (100 EA per 30 days) LOW BAYER BREEZE 2 CONTROL LIQUID NORMAL IN Formulary OTC; QL (100 EA per 30 days) VITRO NORMAL BAYER BREEZE 2 SYSTEM KIT W/DEVICE Formulary OTC; QL (1 EA per 365 days) W/DEVICE BAYER BREEZE 2 TEST DISK IN VITRO Formulary OTC; QL (150 EA per 30 days) BAYER CONTOUR LINK MONITOR KIT W/DEVICE Formulary OTC; QL (1 EA per 365 days) W/DEVICE BAYER CONTOUR MONITOR DEVICE Formulary OTC; QL (1 EA per 365 days) 14 Drug Name Formulary Status Requirements/Limits BAYER WOMENS ORAL TABLET 81-777 MG Formulary OTC BAZA CLEANSE & PROTECT EXTERNAL LOTION 2 Formulary OTC % BC FAST PAIN RELIEF ARTHRITIS ORAL PACKET Formulary OTC 742-222-38 MG BC FAST PAIN RELIEF ORAL PACKET 650-195-33.3 Formulary OTC MG b-caro-t oral capsule 15 mg Formulary OTC b-complex high potency oral tablet extended release Formulary OTC BD ALLERGY SYRINGE 28G X 1/2" 1 ML Formulary OTC BD AUTOSHIELD 29G X 5MM , 29G X 8MM Formulary OTC BD AUTOSHIELD DUO 30G X 5 MM Formulary OTC BD BLUNT FILTER NEEDLE 18G X 1-1/2" Formulary OTC BD DISP NEEDLE 22G X 3/4" , 23G X 1-1/4" , 27G X 1- Formulary OTC 1/4" , 30G X 1" BD DISP NEEDLE TW 18G X 1" Formulary OTC BD DISP NEEDLES 16G X 1-1/2" , 19G X 1" , 20G X 1" , Formulary OTC 21G X 1-1/2" , 25G X 7/8" , 27G X 1/2" , 30G X 1/2" BD ECLIPSE NEEDLE 22G X 1-1/2" , 23G X 1" , 25G X Formulary OTC 1-1/2" , 25G X 5/8" BD ECLIPSE SYRINGE 25G X 5/8" 1 ML, 30G X 1/2" 1 Formulary OTC ML BD HYPODERMIC NEEDLE 23G X 1-1/2" , 26G X 5/8" Formulary OTC BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML BD INSULIN SYRINGE 25G X 1" 1 ML 25G X 1" 1 ML Formulary OTC BD INSULIN SYRINGE 25G X 5/8" 1 ML 25G X 5/8" 1 Formulary OTC ML BD INSULIN SYRINGE 26G X 1/2" 1 ML 26G X 1/2" 1 Formulary OTC ML BD INSULIN SYRINGE 27.5G X 5/8" 2 ML 27.5G X 5/8" Formulary OTC 2 ML BD INSULIN SYRINGE 27G X 1/2" 1 ML 27G X 1/2" 1 Formulary OTC ML BD INSULIN SYRINGE 29G X 1/2" 1 ML 29G X 1/2" 1 Formulary OTC ML BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML Formulary OTC 27G X 5/8" 1 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML Formulary OTC 28G X 1/2" 0.5 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML Formulary OTC 28G X 1/2" 1 ML

15 Drug Name Formulary Status Requirements/Limits BD INSULIN SYRINGE U/F 1/2UNIT 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML 30G X Formulary OTC 1/2" 0.3 ML BD INSULIN SYRINGE U/F 30G X 1/2" 0.5 ML 30G X Formulary OTC 1/2" 0.5 ML BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML 30G X Formulary OTC 1/2" 1 ML BD INSULIN SYRINGE U/F 31G X 5/16" 0.3 ML 31G X Formulary OTC 5/16" 0.3 ML BD INSULIN SYRINGE U/F 31G X 5/16" 0.5 ML 31G X Formulary OTC 5/16" 0.5 ML BD INSULIN SYRINGE U/F 31G X 5/16" 1 ML 31G X Formulary OTC 5/16" 1 ML BD INSULIN SYRINGE U-100 1 ML U-100 1 ML Formulary OTC BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML 31G Formulary X 6MM 0.5 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML Formulary OTC 29G X 1/2" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML Formulary OTC 30G X 1/2" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.5 ML Formulary OTC 30G X 1/2" 0.5 ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 Formulary OTC ML 31G X 5/16" 0.5 ML BD LANCET ULTRAFINE 30G Formulary OTC; QL (150 EA per 30 days) BD LANCET ULTRAFINE 33G Formulary OTC; QL (150 EA per 30 days) BD LUER-LOK SYRINGE 18G X 1-1/2" 3 ML, 20G X 1" 1 ML, 20G X 1" 10 ML, 20G X 1" 3 ML, 20G X 1" 5 ML, 20G X 1-1/2" 10 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 5 ML, 21G X 1" 10 ML, 21G X 1" 3 ML, 21G X 1" 5 ML, Formulary OTC 21G X 1-1/2" 3 ML, 22G X 1" 10 ML, 22G X 1" 3 ML, 22G X 1" 5 ML, 22G X 1-1/2" 5 ML, 23G X 1-1/2" 3 ML, 23G X 1-1/4" 10 ML, 25G X 1" 3 ML, 25G X 1-1/2" 3 ML, 25G X 5/8" 3 ML BD LUER-LOK SYRINGE 23G X 1" 3 ML Formulary BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM Formulary OTC BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 Formulary OTC ML 29G X 1/2" 0.3 ML BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 Formulary OTC ML 29G X 1/2" 0.5 ML BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 Formulary OTC ML 30G X 5/16" 0.5 ML BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" Formulary 0.3 ML 31G X 15/64" 0.3 ML BD SAFETYGLIDE INSULIN SYRINGE 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML

16 Drug Name Formulary Status Requirements/Limits BD SAFETYGLIDE NEEDLE 27G X 5/8" Formulary OTC BD SAFETYGLIDE SYRINGE/NEEDLE 27G X 5/8" 1 Formulary OTC ML BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML BD SHARPS COLLECTOR Formulary OTC BD SWAB SINGLE USE REGULAR PAD Formulary OTC BD SWABS SINGLE USE BUTTERFLY PAD Formulary OTC BD SYRINGE 50 ML Formulary OTC BD SYRINGE/NEEDLE SLIP TIP 26G X 5/8" 1 ML Formulary OTC BD TB SYRINGE 21G X 1" 1 ML, 27G X 1/2" 0.5 ML Formulary OTC BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 Formulary OTC ML 31G X 15/64" 0.3 ML BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML Formulary OTC 31G X 15/64" 0.3 ML BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.5 ML Formulary OTC 31G X 15/64" 0.5 ML BD VEO INSULIN SYRINGE U/F 31G X 15/64" 1 ML Formulary OTC 31G X 15/64" 1 ML BEBULIN INTRAVENOUS SOLUTION Formulary RECONSTITUTED 200-1200 UNIT bec/zinc oral tablet Formulary OTC bee pollen oral capsule 580 mg Formulary OTC bee pollen oral tablet chewable 500 mg Formulary OTC BEELITH ORAL TABLET 362-20 MG Formulary OTC BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 Formulary PA; QL (68 EA per 34 days) MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG belladonna alkaloids-opium rectal suppository 16.2-60 mg Formulary belladonna-opium rectal suppository 16.2-30 mg Formulary BENADRYL ALLERGY CHILDRENS ORAL LIQUID Formulary OTC 12.5 MG/5ML BENADRYL ALLERGY CHILDRENS ORAL TABLET Formulary OTC CHEWABLE 12.5 MG BENADRYL ALLERGY CON ULTRATABS ORAL Formulary OTC TABLET 25-10 MG BENADRYL ALLERGY ORAL TABLET 25 MG Formulary OTC BENADRYL ALLERGY ULTRATABS ORAL TABLET Formulary OTC 25 MG BENADRYL ITCH RELIEF EXTERNAL STICK 2-0.1 % Formulary OTC BENADRYL ITCH STOPPING EXTERNAL CREAM 1- Formulary OTC 0.1 % BENADRYL-D ALLERGY/SINUS CHILD ORAL Formulary OTC SOLUTION 12.5-5 MG/5ML benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg Formulary benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Formulary 12.5 mg, 20-25 mg, 5-6.25 mg BENEFIBER FOR CHILDREN ORAL POWDER Formulary OTC BENEFIBER ON THE GO ORAL PACKET Formulary OTC 17 Drug Name Formulary Status Requirements/Limits BENEFIBER ORAL POWDER Formulary OTC BENEFIBER PLUS B VITS & FA ORAL TABLET Formulary OTC BENEFIBER PLUS CALCIUM ORAL POWDER Formulary OTC BENEFIBER PLUS CALCIUM ORAL TABLET Formulary OTC CHEWABLE BENEFIBER PLUS HEART HEALTH ORAL POWDER Formulary OTC benfotiamine multi-b oral capsule Formulary OTC benzalkonium chloride external concentrate 50 % Formulary OTC benzalkonium chloride external solution 50 % Formulary BENZEDREX NASAL INHALER Formulary OTC BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 % Formulary BENZEPRO EXTERNAL FOAM 5.3 % Formulary BENZEPRO SHORT CONTACT EXTERNAL FOAM 9.8 Formulary % BENZODENT MOUTH/THROAT CREAM 20 % Formulary OTC benzoin external tincture Formulary benzonatate oral capsule 100 mg, 150 mg, 200 mg Formulary AGE (Min 6 Years) BENZ-O-STHETIC MOUTH/THROAT SWAB 20 % Formulary OTC benzoyl peroxide cleanser external lotion 6 % Formulary benzoyl peroxide external gel 2.5 % Formulary OTC; AGE (Max 18 Years) benzoyl peroxide wash external liquid 10 % Formulary AGE (Max 18 Years) benzoyl peroxide wash external liquid 5 % Formulary OTC; AGE (Max 18 Years) benzoyl peroxide-erythromycin external gel 5-3 % Formulary benzphetamine hcl oral tablet 50 mg Formulary PA benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg Formulary BERINERT INTRAVENOUS KIT 500 UNIT Formulary PA; QL (8 EA per 30 days) BERRI-FREEZ PAIN RELIEVING EXTERNAL GEL 4.5 Formulary OTC % BERRI-FREEZ PAIN RELIEVING EXTERNAL LIQUID Formulary OTC 10 % BERRI-FREEZ PLUS EXTERNAL GEL 0.2-4-8 % Formulary OTC BETA CARE BETATAR GEL EXTERNAL SHAMPOO Formulary OTC 2.5 % beta carotene provitamin a oral capsule 25000 unit Formulary OTC BETADINE EXTERNAL SOLUTION 10 %, 5 % Formulary OTC BETADINE SURGICAL SCRUB EXTERNAL Formulary OTC SOLUTION 7.5 % BETADINE SWABSTICKS EXTERNAL SWAB 10 % Formulary OTC betaine hcl oral tablet 300 mg Formulary OTC betamethasone dipropionate aug external cream 0.05 % Formulary betamethasone dipropionate aug external lotion 0.05 % Formulary betamethasone dipropionate aug external ointment 0.05 % Formulary betamethasone dipropionate external cream 0.05 % Formulary betamethasone dipropionate external lotion 0.05 % Formulary betamethasone dipropionate external ointment 0.05 % Formulary

18 Drug Name Formulary Status Requirements/Limits betamethasone valerate external cream 0.1 % Formulary betamethasone valerate external lotion 0.1 % Formulary betamethasone valerate external ointment 0.1 % Formulary BETAQUIK ORAL EMULSION Formulary OTC BETASERON SUBCUTANEOUS KIT 0.3 MG Formulary betaxolol hcl ophthalmic solution 0.5 % Formulary betaxolol hcl oral tablet 10 mg, 20 mg Formulary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Formulary BETHKIS INHALATION NEBULIZATION SOLUTION QL (280 ML per 28 days); AGE (Min 6 Formulary 300 MG/4ML Years) BEVESPI AEROSPHERE INHALATION AEROSOL 9- Formulary 4.8 MCG/ACT bexarotene oral capsule 75 mg Formulary PA BIATAIN HEEL ADH FOAM DRESSING PAD Formulary OTC 19CMX20CM BIATAIN SACRAL FOAM DRESSING PAD 9"X9" Formulary OTC bicalutamide oral tablet 50 mg Formulary BICARSIM FORTE ORAL TABLET 125 MG Formulary OTC BICARSIM ORAL TABLET 80 MG Formulary OTC BICNU INTRAVENOUS SOLUTION RECONSTITUTED Formulary 100 MG BIKTARVY ORAL TABLET 50-200-25 MG Formulary QL (30 EA per 30 days) biobron sf oral syrup 10-15-350 mg/5ml Formulary OTC biocotron oral liquid 10-100 mg/5ml Formulary OTC biodesp dm oral syrup 5-15-100 mg/5ml Formulary OTC BIO-FLAX ORAL CAPSULE 1000 MG Formulary OTC BIOFLONEX ORAL TABLET 250-650 MG Formulary OTC BIOFREEZE EXTERNAL AEROSOL 10.5 % Formulary OTC BIOGAIA GASTRUS ORAL TABLET CHEWABLE Formulary OTC biogtuss oral liquid 10-28-388 mg/5ml Formulary OTC BIOGUARD NON-ADHERENT DRESSING PAD 3"X8" Formulary BIOLLE GEL TEARS OPHTHALMIC GEL 1 % Formulary OTC bionatuss dxp oral liquid 10-2-20 mg/5ml Formulary OTC BIOPATCH PROTECTIVE DISK/CHG EXTERNAL Formulary OTC (DRESSING) biopetit oral elixir Formulary OTC BIORX SPONIX ANTI-FUNGAL EXTERNAL Formulary OTC SOLUTION 22 % BIORX SPONIX ARTHR & MUSC EXTERNAL Formulary OTC SOLUTION 4-10-0.035 % biospec dmx oral liquid 15-25 mg/5ml Formulary OTC biotalan clear oral liquid Formulary OTC BIO-THERM PAIN RELIEVING EXTERNAL LOTION Formulary OTC 0.002-10-20 % biotin forte oral tablet 3 mg Formulary OTC biotin oral capsule 10 mg, 2500 mcg Formulary OTC 19 Drug Name Formulary Status Requirements/Limits biotin oral tablet 1000 mcg, 10000 mcg, 300 mcg, 800 mcg Formulary OTC biotin plus keratin oral tablet 10000-100 mcg-mg Formulary OTC biotuss oral liquid 10-15-300 mg/5ml Formulary biovol oral syrup Formulary OTC bisacodyl ec oral tablet delayed release 5 mg Formulary OTC bismatrol maximum strength oral suspension 525 mg/15ml Formulary OTC bismatrol oral tablet chewable 262 mg Formulary OTC bisoprolol fumarate oral tablet 10 mg, 5 mg Formulary bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- Formulary 6.25 mg, 5-6.25 mg bite/itch external lotion 1-2 % Formulary OTC BI-ZETS/BENZOTROCHES MOUTH/THROAT Formulary OTC LOZENGE 15 MG bleomycin sulfate injection solution reconstituted 15 unit, Formulary 30 unit BLINK TEARS OPHTHALMIC GEL 0.25 % Formulary OTC BLINK TEARS OPHTHALMIC SOLUTION 0.25 % Formulary OTC BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24) Formulary BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG Formulary blood pressure monitor/wrist kit Formulary OTC BOIL EASE MAXIMUM STRENGTH EXTERNAL Formulary OTC OINTMENT 20 % BONE DENSITY ORAL TABLET 300-200 MG-UNIT Formulary OTC BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5- Formulary 18.5 borage oral capsule 1000-240-378 mg Formulary OTC boric acid external granules Formulary boron oral capsule 3 mg Formulary OTC boron oral tablet 6 mg Formulary OTC BOTOX INJECTION SOLUTION RECONSTITUTED Formulary PA 100 UNIT, 200 UNIT BOUDREAUXS BABY KISSES EXTERNAL Formulary OTC OINTMENT BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT Formulary OTC 16 %, 40 % BOUDREAUXS RASH PREVENTOR EXTERNAL Formulary OTC LIQUID 10 % bp 10-1 external emulsion 10-1 % Formulary QL (170.1 GM per 30 days) bp cleansing wash external emulsion 10-4 % Formulary bp wash external liquid 2.5 % Formulary BPROTECTED MULTI-VITE ORAL LIQUID Formulary OTC BPROTECTED PEDIA IRON ORAL SOLUTION 75 (15 Formulary OTC FE) MG/ML BPROTECTED PEDIA POLY-VITE ORAL SOLUTION , Formulary OTC 35 MG/ML BRAINSTRONG PRENATAL ORAL 33-0.8 & 350 MG Formulary OTC 20 Drug Name Formulary Status Requirements/Limits BRASIVOL EXTERNAL PASTE Formulary OTC BRAUN NO TOUCH + FOREHEAD Formulary OTC BREEZE 2 TEST DISK IN VITRO Formulary OTC; QL (150 EA per 30 days) BREVIBLOC IN NACL INTRAVENOUS SOLUTION Formulary 2000 MG/100ML, 2500 MG/250ML brewers yeast oral tablet Formulary OTC BRILINTA ORAL TABLET 60 MG, 90 MG Formulary brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % Formulary brinzolamide ophthalmic suspension 1 % Formulary BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML Formulary brohist d oral tablet 4-10 mg Formulary OTC bromi-lotion external lotion Formulary OTC bromocriptine mesylate oral capsule 5 mg Formulary bromocriptine mesylate oral tablet 2.5 mg Formulary bronchial asthma relief oral tablet 12.5-200 mg Formulary OTC BRONKAID ORAL TABLET 25-400 MG Formulary OTC bronkids oral liquid 1.5-0.6-2.75 mg/ml, 10-4-10 mg/5ml Formulary OTC brontuss dx oral liquid 10-20-200 mg/5ml Formulary OTC brotapp dm oral liquid 15-1-5 mg/5ml Formulary OTC btrex oral tablet extended release 8-200-4-100-600 mg Formulary OTC BUCKLEYS CHEST CONGESTION ORAL LIQUID 100 Formulary OTC MG/5ML BUCKLEYS COUGH ORAL LIQUID 12.5 MG/5ML Formulary OTC budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, Formulary 1 mg/2ml budesonide oral capsule delayed release particles 3 mg Formulary budesonide suspension 32 mcg/act nasal (otc) 32 mcg/act Formulary BUFFERIN EXTRA STRENGTH ORAL TABLET 500 Formulary OTC MG BUFFERIN LOW DOSE ORAL TABLET 81 MG Formulary OTC BUFFERIN ORAL TABLET 325 MG Formulary OTC BULL FROG WATER ARMOR SPORT EXTERNAL Formulary OTC GEL bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Formulary BUPHENYL ORAL TABLET 500 MG Formulary buprenorphine hcl injection solution 0.3 mg/ml Formulary PA PA; QL (360 EA per 30 days); AGE (Min buprenorphine hcl sublingual tablet sublingual 2 mg Formulary 16 Years) PA; QL (90 EA per 30 days); AGE (Min buprenorphine hcl sublingual tablet sublingual 8 mg Formulary 16 Years) buprenorphine transdermal patch weekly 10 mcg/hr, 5 Formulary PA; QL (8 EA per 28 days) mcg/hr, 7.5 mcg/hr buprenorphine transdermal patch weekly 15 mcg/hr, 20 Formulary PA; QL (4 EA per 28 days) mcg/hr hcl er (smoking det) oral tablet extended release Formulary 12 hour 150 mg

21 Drug Name Formulary Status Requirements/Limits bupropion hcl er (sr) oral tablet extended release 12 hour Formulary 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour Formulary 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg Formulary burn relief/lidocaine/aloe external gel 0.5 % Formulary OTC buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 Formulary mg busulfan intravenous solution 6 mg/ml Formulary butalbital-acetaminophen oral tablet 50-325 mg Formulary butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- Formulary PA; QL (140 EA per 7 days) 325-40-30 mg butalbital-apap-caffeine oral tablet 50-325-40 mg Formulary butalbital-aspirin-caffeine oral capsule 50-325-40 mg Formulary butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml Formulary butorphanol tartrate nasal solution 10 mg/ml Formulary PA; QL (5 ML per 34 days) BUTRANS TRANSDERMAL PATCH WEEKLY 10 Formulary PA; QL (8 EA per 28 days) MCG/HR, 5 MCG/HR, 7.5 MCG/HR BUTRANS TRANSDERMAL PATCH WEEKLY 15 Formulary PA; QL (4 EA per 28 days) MCG/HR, 20 MCG/HR BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG Formulary BYDUREON SUBCUTANEOUS SUSPENSION Formulary RECONSTITUTED ER 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 5 MCG/0.02ML c-1500/rose hips sr oral tablet extended release 1500 mg Formulary OTC c1500/rose hips/bioflavonoid oral tablet extended release Formulary OTC cabenuva intramuscular suspension extended release 400 & Formulary PA 600 mg/2ml, 600 & 900 mg/3ml cabergoline oral tablet 0.5 mg Formulary QL (10 EA per 34 days) cadeau dha oral capsule 29-0.4-0.8-375 mg Formulary OTC caffeine citrate oral solution 20 mg/ml Formulary cal/mag oral tablet 200-100 mg Formulary OTC CALADRYL CLEAR EXTERNAL LOTION 1-0.1 % Formulary OTC CALADRYL EXTERNAL LOTION 1-8 % Formulary OTC CALAGEL MAXIMUM STRENGTH EXTERNAL GEL Formulary OTC CALAGESIC EXTERNAL LOTION 1-8 % Formulary OTC calahist clear external lotion 1-0.1 % Formulary OTC calamine external lotion , 8-8 % Formulary OTC calamine phenolated external lotion Formulary OTC calamine-zinc oxide external lotion Formulary OTC calamine-zinc oxide external suspension 8-8 % Formulary OTC CAL-CARB FORTE ORAL TABLET 1250 (500 CA) MG Formulary OTC CALCET PETITES ORAL TABLET 200-250 MG-UNIT Formulary OTC

22 Drug Name Formulary Status Requirements/Limits CALCI-CHEW ORAL TABLET CHEWABLE 1250 (500 Formulary OTC CA) MG calci-max oral capsule Formulary OTC calcipotriene external cream 0.005 % Formulary calcipotriene external ointment 0.005 % Formulary calcipotriene external solution 0.005 % Formulary calcitonin (salmon) nasal solution 200 unit/act Formulary cal-citrate oral capsule 150 mg Formulary OTC CALCITRATE ORAL TABLET 950 MG Formulary OTC calcitriol oral capsule 0.25 mcg, 0.5 mcg Formulary calcitriol oral solution 1 mcg/ml Formulary calcium + d3 oral tablet 600-800 mg-unit Formulary OTC calcium 1200 oral tablet chewable 1200-1000 mg-unit Formulary OTC calcium 500 + d3 oral tablet 500-600 mg-unit Formulary OTC calcium 600 + d oral tablet 600-200 mg-unit Formulary OTC calcium 600 oral tablet 1500 (600 ca) mg Formulary OTC calcium 600+d3 oral tablet 600-400 mg-unit Formulary OTC calcium 600+d3 plus minerals oral tablet 600-800 mg-unit Formulary OTC calcium acetate (phos binder) oral capsule 667 mg Formulary calcium acetate (phos binder) oral tablet 667 mg Formulary calcium acetate oral tablet 668 (169 ca) mg Formulary OTC calcium ascorbate oral tablet 500 mg Formulary OTC calcium aspartate oral tablet 75 mg Formulary OTC calcium carbonate antacid oral tablet 648 mg Formulary OTC calcium carbonate oral powder 800 mg/2gm Formulary OTC calcium carbonate oral tablet 1500 (600 ca) mg, 600 mg Formulary OTC calcium carbonate-vitamin d oral capsule 600-200 mg-unit Formulary OTC calcium carbonate-vitamin d oral tablet 600-400 mg-unit Formulary OTC calcium citrate + d3 oral tablet 250-200 mg-unit Formulary OTC calcium citrate malate-vit d oral tablet 250-100 mg-unit Formulary OTC calcium citrate oral tablet 1040 mg, 200 mg, 250 mg Formulary OTC calcium citrate plus oral tablet Formulary OTC calcium citrate-vitamin d oral tablet 200-125 mg-unit Formulary OTC calcium citrate-vitamin d3 oral liquid 1000-400 Formulary OTC calcium citrate-vitamin d3 oral tablet 315-250 mg-unit Formulary OTC calcium gluconate oral tablet 500 mg Formulary OTC calcium gummies oral tablet chewable 250-100-500 mg- Formulary OTC unit calcium high potency/vitamin d oral tablet 600-200 mg-unit Formulary OTC calcium lactate oral tablet 100 mg, 648 mg Formulary OTC calcium oral tablet 500 mg, 500-125 mg-unit Formulary OTC calcium oral tablet chewable 500-100 mg-unit, 600-400 Formulary OTC mg-unit calcium oyster shell oral tablet 500 mg Formulary OTC

23 Drug Name Formulary Status Requirements/Limits calcium pantothenate oral tablet 100 mg, 200 mg, 500 mg Formulary OTC calcium plus vitamin d3 oral capsule 600-500 mg-unit Formulary OTC calcium soft chews oral tablet chewable 500-1000-40 mg- Formulary OTC unt-mcg, 500-500-40 mg-unt-mcg calcium-magnesium-zinc oral tablet 333-133-5 mg Formulary OTC calcium-vitamin d oral tablet 600-200 mg-unit Formulary OTC calcium-vitamin d3 oral tablet 600-125 mg-unit Formulary OTC calcium-vitamin d-minerals oral tablet chewable 600-400 Formulary OTC mg-unit, 600-800 mg-unit calendula external lotion Formulary OTC calendula external ointment Formulary OTC cal-glu oral capsule 500 mg Formulary OTC cal-lac oral capsule 500 mg Formulary OTC calmag thins oral tablet 200-50 mg Formulary OTC cal-mint oral tablet chewable 260 mg Formulary OTC CALMOL-4 RECTAL SUPPOSITORY 76-10 % Formulary OTC calna oral tablet Formulary OTC CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT Formulary OTC CALTRATE 600+D PLUS MINERALS ORAL TABLET Formulary OTC 600-800 MG-UNIT CALTRATE 600+D PLUS MINERALS ORAL TABLET Formulary OTC CHEWABLE 600-800 MG-UNIT CALTRATE 600+D3 SOFT ORAL TABLET Formulary OTC CHEWABLE 600-800 MG-UNIT CALTRATE GUMMY BITES ORAL TABLET Formulary OTC CHEWABLE 250-400 MG-UNIT CALTRATE MINIS PLUS MINERALS ORAL TABLET Formulary OTC 300-800 MG-UNIT CAMILA ORAL TABLET 0.35 MG Formulary QL (28 EA per 28 days) CAMPHO-PHENIQUE EXTERNAL GEL 10.8-4.7 % Formulary OTC CAMPHO-PHENIQUE EXTERNAL LIQUID 10.8-4.7 % Formulary OTC CAMPHOTREX EXTERNAL GEL 10-4 % Formulary OTC candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Formulary candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 Formulary mg CANKAID MOUTH/THROAT SOLUTION 10 % Formulary OTC capcof oral syrup 5-2-10 mg/5ml Formulary OTC capecitabine oral tablet 150 mg, 500 mg Formulary PA capmist dm oral tablet 60-15-400 mg Formulary OTC capron dm oral liquid 7.5-7.5 mg/5ml Formulary OTC capron dmt oral tablet 30-30 mg Formulary OTC capsaicin external cream 0.025 %, 0.1 % Formulary OTC capsaicin hot patch external pad 0.025 % Formulary OTC CAPSIDERM EXTERNAL PATCH 0.0375-5 % Formulary OTC capsule 1 clear veggie capsule Formulary OTC captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Formulary 24 Drug Name Formulary Status Requirements/Limits CAPZASIN-HP EXTERNAL CREAM 0.1 % Formulary OTC CARBAGLU ORAL TABLET 200 MG Formulary carbamazepine er oral capsule extended release 12 hour Formulary 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 Formulary mg, 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml Formulary carbamazepine oral tablet 200 mg Formulary carbamazepine oral tablet chewable 100 mg Formulary CARBAPHEN CH ORAL SUSPENSION 10-4-24 Formulary OTC MG/5ML CARBAPHEN PED CH ORAL SUSPENSION 2.5-1.25-8 Formulary OTC MG/ML carbidopa-levodopa er oral tablet extended release 25-100 Formulary mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25- Formulary 250 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25- Formulary 100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg Formulary carbinoxamine maleate oral solution 4 mg/5ml Formulary carbinoxamine maleate oral tablet 4 mg Formulary CARBOHOL 940 GEL Formulary CARBZERO ORAL EMULSION Formulary OTC CARDENZ ORAL TABLET Formulary OTC CAREFINE PEN NEEDLES 32G X 5 MM , 32G X 6 MM Formulary OTC careone insulin syringe 30g x 1/2" 0.3 ml 30g x 1/2" 0.3 ml Formulary OTC careone insulin syringe 30g x 1/2" 0.5 ml 30g x 1/2" 0.5 ml Formulary OTC careone insulin syringe 30g x 1/2" 1 ml 30g x 1/2" 1 ml Formulary OTC careone insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 Formulary OTC ml careone insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 Formulary OTC ml careone insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC CAREONE LANCET SUPER THIN 30G Formulary OTC; QL (150 EA per 30 days) careone lancet thin 23g Formulary OTC; QL (150 EA per 30 days) CA-REZZ EXTERNAL LIQUID 0.25 % Formulary OTC ca-rezz gentle external liquid 0.2 % Formulary OTC ca-rezz norisc external cream 0.2 % Formulary OTC CARRACOLLOID 4"X4" EXTERNAL PAD Formulary OTC CARRASMART EXTERNAL GEL Formulary OTC CARRASORB H EXTERNAL Formulary OTC CARRASYN V WOUND DRESSING EXTERNAL GEL Formulary OTC CARRINGTON DERMAL WOUND EXTERNAL GEL Formulary OTC carteolol hcl ophthalmic solution 1 % Formulary

25 Drug Name Formulary Status Requirements/Limits CARTIA XT ORAL CAPSULE EXTENDED RELEASE Formulary 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Formulary cascara sagrada oral capsule 450 mg Formulary OTC castellani paint modified external liquid 1.5 % Formulary OTC CASTIVA COOLING EXTERNAL LOTION 5-14 % Formulary OTC CASTIVA WARMING EXTERNAL LOTION 0.035 % Formulary OTC castor oil stimulant laxative oral oil 100 % Formulary OTC CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY Formulary 0.1 MG/24HR CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY Formulary 0.2 MG/24HR CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY Formulary 0.3 MG/24HR CAVAREST DENTAL GEL 1.1 % Formulary CAVILON EMOLLIENT EXTERNAL CREAM Formulary OTC CAVILON FOOT & DRY SKIN EXTERNAL CREAM Formulary OTC CAVILON NO STING BARRIER FILM EXTERNAL Formulary OTC LIQUID CAVILON ONE-STEP SKIN CARE EXTERNAL Formulary OTC LOTION CAVILON SKIN CLEANSER EXTERNAL LIQUID Formulary OTC CAYA VAGINAL DIAPHRAGM Formulary CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG Formulary QL (28 EA per 28 days) cefaclor oral capsule 250 mg, 500 mg Formulary cefaclor oral suspension reconstituted 125 mg/5ml Formulary cefadroxil oral capsule 500 mg Formulary cefadroxil oral suspension reconstituted 250 mg/5ml, 500 Formulary mg/5ml cefadroxil oral tablet 1 gm Formulary cefdinir oral capsule 300 mg Formulary cefdinir oral suspension reconstituted 125 mg/5ml, 250 Formulary mg/5ml cefpodoxime proxetil oral suspension reconstituted 100 Formulary QL (200 ML per 34 days) mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg Formulary QL (28 EA per 34 days) cefprozil oral suspension reconstituted 125 mg/5ml, 250 Formulary mg/5ml cefprozil oral tablet 250 mg, 500 mg Formulary ceftriaxone sodium in dextrose intravenous solution 20 Formulary mg/ml, 40 mg/ml ceftriaxone sodium injection solution reconstituted 1 gm, 2 Formulary gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 10 Formulary gm, 2 gm ceftriaxone sodium-dextrose intravenous solution Formulary reconstituted 1-3.74 gm-%, 2-2.22 gm-% axetil oral tablet 250 mg, 500 mg Formulary 26 Drug Name Formulary Status Requirements/Limits CELACYN EXTERNAL GEL Formulary celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg Formulary ST celery seed oil Formulary OTC CELONTIN ORAL CAPSULE 300 MG Formulary CENTRATEX ORAL CAPSULE 106-1 MG Formulary centravites adults oral tablet Formulary OTC CENTRUM FLAVOR BURST DRINK ORAL PACKET Formulary OTC CENTRUM ORAL LIQUID Formulary OTC CENTRUM SPECIALIST PRENATAL ORAL 27-0.8 & Formulary OTC 200 MG CEO-TWO RECTAL SUPPOSITORY Formulary OTC CEPACOL EXTRA STRENGTH MOUTH/THROAT Formulary OTC LOZENGE 15-2.6 MG CEPACOL SORE THROAT & COUGH Formulary OTC MOUTH/THROAT LOZENGE 5-7.5 MG CEPACOL SORE THROAT EX ST MOUTH/THROAT Formulary OTC LOZENGE 15-3.6 MG CEPACOL SORE THROAT MOUTH/THROAT Formulary OTC LOZENGE 15-2.6 MG CEPASTAT MOUTH/THROAT LOZENGE 5-6-10 MG Formulary OTC cephalexin oral capsule 250 mg, 500 mg Formulary cephalexin oral suspension reconstituted 125 mg/5ml, 250 Formulary mg/5ml CERACADE EMULSION EXTERNAL Formulary CERALYTE 70 ORAL PACKET Formulary OTC CERAVE BABY EXTERNAL LOTION 1 % Formulary OTC CERAVE ITCH RELIEF EXTERNAL CREAM 1 % Formulary OTC CERAVE SUNSCREEN SPF50 EXTERNAL LOTION Formulary OTC CEROVEL EXTERNAL LOTION 40 % Formulary CESIUM 1000 ORAL CAPSULE 1000 MG Formulary OTC cesium 500 oral capsule 500 mg Formulary OTC cesium oral tablet 100 mg Formulary OTC CETACAINE EXTERNAL LIQUID 2-2-14 % Formulary CETAPHIL GENTLE CLEANSING EXTERNAL BAR Formulary OTC cetirizine hcl oral tablet 5 mg Formulary OTC CETRAXAL OTIC SOLUTION 0.2 % Formulary CHANTIX CONTINUING MONTH PAK ORAL Formulary TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG Formulary CHANTIX STARTING MONTH PAK ORAL TABLET Formulary 0.5 MG X 11 & 1 MG X 42 CHAP-EX TROPICALS EXTERNAL STICK Formulary OTC CHAR-FLO WITH SORBITOL ORAL SUSPENSION 25- Formulary OTC 48 GM/120ML chelated calcium oral tablet 200 mg Formulary OTC chelated magnesium oral tablet 100 mg Formulary OTC

27 Drug Name Formulary Status Requirements/Limits chelated zinc oral tablet 50 mg Formulary OTC CHEMSTRIP CALIBRATION IN VITRO STRIP Formulary OTC CHEMSTRIP UGK IN VITRO STRIP Formulary OTC CHENODAL ORAL TABLET 250 MG Formulary PA CHERACOL-D COUGH ORAL LIQUID 10-100 MG/5ML Formulary OTC cherry concentrate oral concentrate Formulary OTC cherry oral syrup Formulary chest rub external ointment 4.8-1.2-2.6 % Formulary OTC CHEW Q ORAL TABLET CHEWABLE 100 MG, 30 MG, Formulary OTC 600 MG chewable iron oral tablet chewable 30-10-25 mg Formulary OTC CHIGG AWAY EXTERNAL LOTION 5-10 % Formulary OTC childrens aspirin free oral elixir 80 mg/2.5ml Formulary OTC CHILDRENS MOTRIN ORAL SUSPENSION 100 Formulary OTC MG/5ML childrens pain reliever oral tablet chewable 80 mg Formulary OTC childrens plus multi-sympt cld oral suspension 2.5-1-5-160 Formulary OTC mg/5ml childrens silfedrine oral liquid 15 mg/5ml Formulary OTC CHILDRENS SOOTHE ORAL TABLET CHEWABLE Formulary OTC 400 MG chlo hist oral solution 12.5-1 mg/5ml Formulary OTC CHLO TUSS ORAL LIQUID 30-1-12.5 MG/5ML Formulary OTC chlophed oral liquid 5-12.5-100 mg/5ml Formulary OTC CHLORASEPTIC MOUTH/THROAT LOZENGE 6-10 Formulary OTC MG chlordiazepoxide hcl oral capsule 10 mg, 5 mg Formulary QL (170 EA per 34 days) chlordiazepoxide hcl oral capsule 25 mg Formulary QL (170 EA per 30 days) chlorella oral capsule Formulary OTC chlorhexidine gluconate cloth external pad 2 % Formulary OTC chlorhexidine gluconate external liquid 2 %, 4 % Formulary OTC chlorhexidine gluconate mouth/throat solution 0.12 % Formulary chlorophyll oral tablet 3-0.6 mg Formulary OTC chloroquine phosphate oral tablet 250 mg, 500 mg Formulary chlorothiazide oral tablet 250 mg, 500 mg Formulary CHLORPHEN SR ORAL TABLET EXTENDED Formulary OTC RELEASE 12 MG chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml Formulary AGE (Min 18 Years) chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 Formulary AGE (Min 18 Years) mg, 50 mg chlorthalidone oral tablet 25 mg, 50 mg Formulary CHLOR-TRIMETON ALLERGY ORAL TABLET Formulary OTC EXTENDED RELEASE 12 MG CHLOR-TRIMETON ORAL SYRUP 2 MG/5ML Formulary OTC CHLOR-TRIMETON ORAL TABLET 4 MG Formulary OTC chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg Formulary 28 Drug Name Formulary Status Requirements/Limits chocolated laxative oral tablet chewable 15 mg Formulary OTC cholesterol acetate powder Formulary OTC cholestyramine light oral packet 4 gm Formulary cholestyramine light oral powder 4 gm/dose Formulary cholestyramine oral packet 4 gm Formulary cholestyramine oral powder 4 gm/dose Formulary choline citrate oral tablet 650 mg Formulary OTC choline oral capsule 648 mg Formulary OTC choline sr oral tablet extended release 300 mg Formulary OTC choline-mag trisalicylate oral liquid 500 mg/5ml Formulary CHONDROITIN SULFATE COMPLEX ORAL Formulary OTC CAPSULE 400-60-2.5 MG CHROMACAPS ORAL CAPSULE 1 MG Formulary OTC chromium aspartate oral tablet 1000 mcg Formulary OTC chromium gtf oral tablet 200 mcg Formulary OTC chromium oral tablet 1000 mcg, 400 mcg Formulary OTC chromium picolate oral tablet 1000 mcg Formulary OTC chromium picolinate oral capsule 200 mcg Formulary OTC chromium picolinate oral tablet 200 mcg, 400 mcg Formulary OTC CICLODAN EXTERNAL CREAM 0.77 % Formulary CICLODAN EXTERNAL SOLUTION 8 % Formulary PA ciclopirox external gel 0.77 % Formulary PA ciclopirox external shampoo 1 % Formulary ciclopirox external solution 8 % Formulary PA ciclopirox olamine external suspension 0.77 % Formulary ciclopirox treatment external kit 8 % Formulary cilostazol oral tablet 100 mg, 50 mg Formulary oral tablet 300 mg, 400 mg, 800 mg Formulary cinnamon oral capsule 500 mg Formulary OTC CINRYZE INTRAVENOUS SOLUTION Formulary PA; QL (20 EA per 34 days) RECONSTITUTED 500 UNIT CIPRO ORAL SUSPENSION RECONSTITUTED 500 Formulary MG/5ML (10%) CIPRODEX OTIC SUSPENSION 0.3-0.1 % Formulary ciprofloxacin hcl ophthalmic solution 0.3 % Formulary ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 Formulary mg ciprofloxacin hcl otic solution 0.2 % Formulary ciprofloxacin oral suspension reconstituted 500 mg/5ml Formulary (10%) ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % Formulary cisplatin intravenous solution 50 mg/50ml Formulary citalopram hydrobromide oral solution 10 mg/5ml Formulary citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg Formulary CITRA PH ORAL SOLUTION 2.7 GM/30ML Formulary OTC

29 Drug Name Formulary Status Requirements/Limits CITRANATAL 90 DHA ORAL 90-1 & 300 MG Formulary CITRANATAL ASSURE ORAL 35-1 & 300 MG Formulary CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG Formulary CITRANATAL DHA ORAL 27-1 & 250 MG Formulary CITRANATAL HARMONY ORAL CAPSULE 27-1-260 Formulary MG CITRANATAL RX ORAL TABLET 27-1 MG Formulary CITRUCEL ORAL POWDER Formulary OTC CITRUCEL ORAL TABLET 500 MG Formulary OTC CITRULLINE 1000 ORAL PACKET 1 GM Formulary OTC CITRULLINE200 ORAL PACKET 200 MG Formulary OTC cladribine intravenous solution 10 mg/10ml Formulary CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 Formulary MG clarithromycin er oral tablet extended release 24 hour 500 Formulary mg clarithromycin oral suspension reconstituted 125 mg/5ml, Formulary 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg Formulary CLARITIN CHILDRENS ORAL TABLET CHEWABLE 5 Formulary OTC MG CLARITIN ORAL CAPSULE 10 MG Formulary OTC CLARITIN ORAL SYRUP 5 MG/5ML Formulary OTC CLARITIN ORAL TABLET 10 MG Formulary OTC CLARITIN REDITABS ORAL TABLET DISPERSIBLE Formulary OTC 10 MG, 5 MG CLARITIN-D 12 HOUR ORAL TABLET EXTENDED Formulary OTC RELEASE 12 HOUR 5-120 MG CLARITIN-D 24 HOUR ORAL TABLET EXTENDED Formulary OTC RELEASE 24 HOUR 10-240 MG classic prenatal oral tablet 28-0.8 mg Formulary OTC CLEAN & CLEAR ACNE CLEANSER EXTERNAL Formulary OTC FOAM 2 % CLEAN & CLEAR ACNE CLEANSER EXTERNAL Formulary OTC LIQUID 2 % CLEAN & CLEAR ADVANTAGE MARK EXTERNAL Formulary OTC GEL 2 % CLEAN SIGHTS SOLUTION Formulary OTC CLEAN ZING MOUTH/THROAT LIQUID 0.06 % Formulary OTC CLEANLET LANCETS 28G Formulary OTC; QL (150 EA per 30 days) CLEAR EYES REDNESS RELIEF OPHTHALMIC Formulary OTC SOLUTION 0.012-0.2 % clear zinc spf 50 external lotion Formulary OTC CLEARASIL DAILY CLEAN EXTERNAL LIQUID 1 % Formulary OTC CLEARASIL DAILY CLEAR ACNE EXTERNAL Formulary OTC CREAM 10 % CLEARCANAL EAR WAX REMOVAL OTIC KIT 6.5 % Formulary OTC

30 Drug Name Formulary Status Requirements/Limits CLEARLAX ORAL POWDER 17 GM/SCOOP Formulary OTC CLEARLIFE ALLERGY RELIEF NASAL LIQUID Formulary OTC clemastine fumarate oral tablet 2.68 mg Formulary CLEOCIN VAGINAL SUPPOSITORY 100 MG Formulary CLERZ PLUS SOLUTION Formulary OTC CLEVER CHOICE BP MONITOR/WRIST DEVICE Formulary OTC clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Formulary clindamycin palmitate hcl oral solution reconstituted 75 Formulary mg/5ml clindamycin phos-benzoyl perox external gel 1.2-5 % Formulary clindamycin phos-benzoyl perox external gel 1-5 % Formulary AGE (Max 18 Years) clindamycin phosphate external foam 1 % Formulary AGE (Max 18 Years) clindamycin phosphate external lotion 1 % Formulary AGE (Max 18 Years) clindamycin phosphate external solution 1 % Formulary AGE (Max 18 Years) clindamycin phosphate swab 1 % external 1 % Formulary AGE (Max 18 Years) clindamycin phosphate vaginal cream 2 % Formulary CLINDESSE VAGINAL CREAM 2 % Formulary clobazam oral suspension 2.5 mg/ml Formulary PA clobazam oral tablet 10 mg, 20 mg Formulary PA; AGE (Min 2 Years) clobetasol propionate e external cream 0.05 % Formulary clobetasol propionate emulsion external foam 0.05 % Formulary clobetasol propionate external cream 0.05 % Formulary clobetasol propionate external foam 0.05 % Formulary clobetasol propionate external gel 0.05 % Formulary clobetasol propionate external ointment 0.05 % Formulary clobetasol propionate external solution 0.05 % Formulary clofarabine intravenous solution 1 mg/ml Formulary clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg Formulary clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Formulary clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 Formulary QL (170 EA per 34 days) mg, 1 mg, 2 mg clonidine hcl (analgesia) epidural solution 100 mcg/ml Formulary clonidine hcl er oral tablet extended release 12 hour 0.1 mg Formulary clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Formulary clopidogrel bisulfate oral tablet 300 mg, 75 mg Formulary clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg Formulary QL (170 EA per 30 days) clotrimazole 3 vaginal cream 2 % Formulary OTC clotrimazole anti-fungal external cream 1 % Formulary clotrimazole external cream 1 % Formulary clotrimazole mouth/throat lozenge 10 mg Formulary clotrimazole solution 1 % external (otc) 1 % Formulary clotrimazole vaginal cream 1 % Formulary OTC clotrimazole-betamethasone external cream 1-0.05 % Formulary clotrimazole-betamethasone external lotion 1-0.05 % Formulary

31 Drug Name Formulary Status Requirements/Limits clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg Formulary AGE (Min 18 Years) clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, Formulary AGE (Min 18 Years) 200 mg, 25 mg co q-10 oral capsule 150 mg, 200 mg Formulary OTC COAGUCHEK XS PLUS SYSTEM KIT Formulary OTC COAGUCHEK XS PT TEST IN VITRO STRIP Formulary OTC COARTEM ORAL TABLET 20-120 MG Formulary COATS ALOE EXTERNAL CREAM 0.5 % Formulary OTC COATS ALOE EXTERNAL GEL 0.5 % Formulary OTC COATS ALOE EXTERNAL LOTION 0.5 % Formulary OTC COATS ALOE JUICE DRINK ORAL LIQUID Formulary OTC COATS ALOE LINIMENT EXTERNAL LOTION 10 % Formulary OTC cocoa butter skin external cream Formulary OTC cod liver oil oral capsule Formulary OTC cod liver oil oral oil Formulary codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Formulary PA; QL (180 EA per 7 days) coditussin ac oral liquid 200-10 mg/5ml Formulary OTC coditussin dac oral liquid 30-10-200 mg/5ml Formulary OTC coenzyme q10 oral capsule 100 mg Formulary OTC coenzyme q-10 oral capsule 60 mg Formulary OTC coenzyme q10 oral liquid 30 mg/5ml Formulary OTC coenzyme q10 oral tablet 100 mg, 25 mg Formulary OTC coenzyme q10 oral tablet chewable 60 mg Formulary OTC coenzyme q10-levocarnitine oral capsule 30-250 mg Formulary OTC co-enzyme q10-vitamin e oral wafer 200-400 mg-unit Formulary OTC cola syrup oral syrup Formulary OTC COLACE ORAL CAPSULE 100 MG Formulary OTC colchicine oral tablet 0.6 mg Formulary colchicine-probenecid oral tablet 0.5-500 mg Formulary cold & cough childrens oral liquid 2.5-1-5 mg/5ml Formulary OTC cold & cough day/night child oral 2.5-5 &2.5-6.25 mg/5ml Formulary OTC cold remedy oral tablet dispersible Formulary OTC cold sore treatment external gel 10.8-4.7 % Formulary OTC cold sore treatment external liquid Formulary OTC cold therapy pain relief external gel 3.1 % Formulary OTC COLD-EEZE MOUTH/THROAT LOZENGE 13.3 MG Formulary OTC colestipol hcl oral packet 5 gm Formulary colestipol hcl oral tablet 1 gm Formulary collodion flexible external liquid Formulary COLOCORT RECTAL ENEMA 100 MG/60ML Formulary COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % Formulary COMBIVENT RESPIMAT INHALATION AEROSOL Formulary SOLUTION 20-100 MCG/ACT

32 Drug Name Formulary Status Requirements/Limits COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 Formulary OTC ML 29G X 1/2" 0.3 ML COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.5 Formulary OTC ML 29G X 1/2" 0.5 ML COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 Formulary OTC ML 29G X 1/2" 1 ML COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 0.3 Formulary OTC ML 30G X 5/16" 0.3 ML COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 0.5 Formulary OTC ML 30G X 5/16" 0.5 ML COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 1 Formulary OTC ML 30G X 5/16" 1 ML COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.5 Formulary OTC ML 31G X 5/16" 0.5 ML COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 1 Formulary OTC ML 31G X 5/16" 1 ML comfort assured lancets 28g Formulary OTC; QL (150 EA per 30 days) comfort assured lancets 33g Formulary OTC; QL (150 EA per 30 days) COMFORT CLEAN/COMFORT SHIELD EXTERNAL 3 Formulary OTC % COMFORT EZ PEN NEEDLES 32G X 8 MM Formulary OTC COMPAT STAY-PUT NJ DOUBLE LUME Formulary OTC COMPLERA ORAL TABLET 200-25-300 MG Formulary complete lice treatment combination kit 0.33-4-0.5 % Formulary OTC complete natal dha oral 29-1-200 & 250 mg Formulary completenate oral tablet chewable 29-1 mg Formulary COMPOUND W MAXIMUM STRENGTH EXTERNAL Formulary OTC GEL 17 % COMPOUND W ONE STEP INVISIBLE EXTERNAL Formulary OTC STRIP 40 % compoz oral capsule 50 mg Formulary OTC COMPRO RECTAL SUPPOSITORY 25 MG Formulary COMTREX COLD & COUGH MAX ST ORAL TABLET Formulary OTC 10-5-325 MG COMTREX COLD/COUGH DAY/NITE MS ORAL 5-2- Formulary OTC 10-325 MG COMTREX DEEP CHEST COLD ORAL TABLET 325- Formulary OTC 200 MG CO-NATAL FA ORAL TABLET Formulary CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG Formulary CONCEPT OB ORAL CAPSULE 130-92.4-1 MG Formulary CONCEPTIONXR MOTILITY SUPPORT ORAL Formulary OTC CONCERTA ORAL TABLET EXTENDED RELEASE 18 Formulary AGE (Min 4 Years and Max 17 Years) MG, 27 MG, 36 MG, 54 MG condoms Formulary OTC constulose oral solution 10 gm/15ml Formulary

33 Drug Name Formulary Status Requirements/Limits CONTAC COLD+FLU MAX ST ORAL TABLET 5-500 Formulary OTC MG CONTOUR BLOOD GLUCOSE SYSTEM KIT Formulary OTC; QL (150 EA per 30 days) W/DEVICE W/DEVICE CONTOUR CONTROL LIQUID HIGH IN VITRO HIGH Formulary OTC; QL (100 EA per 30 days) CONTOUR CONTROL LIQUID LOW IN VITRO LOW Formulary OTC; QL (100 EA per 30 days) CONTOUR CONTROL LIQUID NORMAL IN VITRO Formulary OTC; QL (100 EA per 30 days) NORMAL CONTOUR MONITOR DEVICE Formulary OTC; QL (1 EA per 365 days) CONTOUR MONITOR KIT W/DEVICE W/DEVICE Formulary OTC; QL (1 EA per 365 days) CONTOUR NEXT CONTROL SOLUTION LOW IN Formulary OTC; QL (100 EA per 30 days) VITRO LOW CONTOUR NEXT CONTROL SOLUTION NORMAL IN Formulary OTC; QL (100 EA per 30 days) VITRO NORMAL CONTOUR NEXT EZ KIT W/DEVICE W/DEVICE Formulary OTC; QL (1 EA per 365 days) CONTOUR NEXT LINK KIT W/DEVICE W/DEVICE Formulary OTC; QL (1 EA per 365 days) CONTOUR NEXT MONITOR KIT W/DEVICE Formulary OTC; QL (1 EA per 365 days) W/DEVICE CONTOUR NEXT ONE KIT Formulary OTC; QL (1 EA per 365 days) CONTOUR NEXT TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) CONTOUR TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) control denture adhesive cream Formulary OTC control syringe disposable 10 ml Formulary OTC convex eye protector Formulary OTC cool n heat ex st external patch 5 % Formulary OTC cool n heat maximum strength external liquid 16 % Formulary OTC COPAXONE SUBCUTANEOUS SOLUTION Formulary PREFILLED SYRINGE 20 MG/ML COPPERMIN ORAL TABLET 5 MG Formulary OTC co-q 10 omega-3 fish oil oral capsule Formulary OTC coq10 oral capsule 30 mg Formulary OTC coq-10 oral capsule 50 mg Formulary OTC coq10 oral powder 50 gm Formulary OTC coral calcium oral capsule 185-50-100 mg-mg-unit, 200- Formulary OTC 100-100 mg-unit CORICIDIN HBP COLD/FLU ORAL TABLET 2-325 MG Formulary OTC CORICIDIN HBP COUGH/COLD ORAL TABLET 4-30 Formulary OTC MG CORICIDIN HBP DAY/NIGHT COLD ORAL 10-20 &15- Formulary OTC 200-2 MG CORICIDIN HBP NIGHTTIME COLD ORAL LIQUID Formulary OTC 15-6.25-500 MG/15ML CORIFACT INTRAVENOUS KIT 1000-1600 UNIT Formulary corn oil oral oil Formulary OTC CORN REMOVER WATERPROOF EXTERNAL PAD 40 Formulary OTC % corn/callus remover external solution 12.6 % Formulary OTC

34 Drug Name Formulary Status Requirements/Limits CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 Formulary OTC MG CORTIC-ND OTIC SOLUTION 10-10-1 MG/ML Formulary CORTIFOAM RECTAL FOAM 10 % Formulary cortisone acetate oral tablet 25 mg Formulary CORTIZONE-10/ALOE EXTERNAL CREAM 1 % Formulary OTC CORVITA 150 ORAL TABLET 150-1.25 MG Formulary COSAMIN ASU FOR JOINT HEALTH ORAL CAPSULE Formulary OTC COSAMIN VERDE FOR JOINT HEALTH ORAL Formulary OTC TABLET COTTONTAILS DIAPER RASH CREAMY EXTERNAL Formulary OTC OINTMENT 10 % cough & chest congestion dm oral liquid 5-100 mg/5ml Formulary OTC cough & cold oral tablet 4-30 mg Formulary OTC cough drops mouth/throat lozenge 10 mg, 3.1 mg, 5 mg, 5.4 Formulary OTC mg, 6.5 mg, 7.5 mg, 7.6 mg, 8 mg, 9.1 mg cough relief oral liquid 15 mg/5ml Formulary OTC coughtab oral tablet 200 mg Formulary OTC cramp tabs oral tablet 325-25 mg Formulary OTC cranberry oral capsule 250 mg Formulary OTC cream base with liposome external cream Formulary creatine oral powder Formulary OTC creatine5000 oral packet 5000 mg Formulary OTC CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, Formulary PA 3000-9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT CR-GTF ORAL CAPSULE 200 MCG Formulary OTC CRITIC-AID CLEAR AF EXTERNAL OINTMENT 2 % Formulary OTC CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Formulary cromolyn sodium inhalation nebulization solution 20 Formulary mg/2ml cromolyn sodium nasal aerosol solution 5.2 mg/act Formulary OTC cromolyn sodium ophthalmic solution 4 % Formulary cromolyn sodium oral concentrate 100 mg/5ml Formulary CROTAN EXTERNAL LOTION 10 % Formulary ST CR-PLUS ORAL TABLET 500 MCG Formulary OTC CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG Formulary QL (28 EA per 28 days) cu-25 oral capsule 25 mg Formulary OTC cu-5 oral capsule 5 mg Formulary OTC CULTURELLE GENTLE-GO KIDS ORAL PACKET Formulary OTC CULTURELLE KIDS ORAL PACKET Formulary OTC CURAD GERM SHIELD EXTERNAL GEL Formulary OTC CURAFIL WOUND DRESSING EXTERNAL GEL Formulary OTC CURASOL WOUND DRESSING EXTERNAL GEL Formulary OTC CURITY ALCOHOL PREPS PAD 70 % 70 % Formulary OTC CURITY ALCOHOL SWABS PAD Formulary OTC 35 Drug Name Formulary Status Requirements/Limits CURITY GAUZE SPONGE PAD 2"X2" Formulary OTC CURITY MESH GAUZE BNDG 4"X30' Formulary OTC CURITY NURSING PAD Formulary OTC CURX ANTIMICROBIAL EXTERNAL GEL 0.13 % Formulary OTC CUTINOVA HYDRO 2"X2-3/8" EXTERNAL Formulary OTC cvs acetaminophen oral capsule 325 mg Formulary OTC cvs adhesive gauze pad 2-3/8"x4" Formulary OTC cvs aftersun aloe/lidocaine external gel 0.5 % Formulary OTC CVS AIRSHIELD ORAL TABLET EFFERVESCENT Formulary OTC cvs alcohol prep pads pad 70 % 70 % Formulary OTC cvs allergy relief childrens oral tablet dispersible 12.5 mg Formulary OTC cvs allergy relief d oral tablet extended release 12 hour 60- Formulary OTC; QL (68 EA per 34 days) 120 mg cvs allergy relief oral tablet 5 mg Formulary OTC cvs all-purpose skin protect external ointment Formulary OTC cvs antacid childrens oral liquid 400 mg/5ml Formulary OTC cvs anti-diarrheal oral capsule 2 mg Formulary OTC cvs anti-diarrheal oral suspension 262 mg/15ml Formulary OTC cvs anti-itch sensitive external lotion 1 % Formulary OTC cvs astringent solution external packet Formulary OTC cvs b complex plus c oral tablet Formulary OTC cvs baby safety swabs swab Formulary OTC cvs backache relief oral tablet 500 mg Formulary OTC cvs beta carotene oral capsule 15 mg Formulary OTC cvs calcium 600 plus oral tablet chewable Formulary OTC cvs calcium oral tablet chewable 250-400 mg-unit Formulary OTC cvs cherry menthol drops mouth/throat lozenge Formulary OTC cvs chest rub medicated external ointment 4.7-1.2-2.6 % Formulary OTC cvs cleansing eyelid wipes external pad Formulary OTC cvs cleansing skin external cream Formulary OTC cvs cold & sinus relief oral capsule 30-200 mg Formulary OTC cvs cold remedy oral tablet dispersible Formulary OTC cvs corn/callus remover external kit 17 % Formulary OTC cvs creamy acne face wash external liquid 4 % Formulary OTC; AGE (Max 18 Years) cvs d3 oral capsule 25 mcg (1000 ut) Formulary OTC cvs dairy relief ex st oral tablet 4500 unit Formulary OTC cvs daytime/nighttime cold/flu oral (liquid) Formulary OTC cvs daytime/nighttime cough oral liquid therapy pack 6.25- Formulary OTC 15 & 15 mg/15ml cvs diabetes health support oral Formulary OTC cvs digestive probiotic oral capsule Formulary OTC cvs diuretic maximum strength oral capsule 50 mg Formulary OTC cvs e oil oral oil 100 unt/0.25ml Formulary OTC cvs early result pregnancy in vitro diagnostic test Formulary OTC

36 Drug Name Formulary Status Requirements/Limits cvs easy fiber/calcium oral tablet chewable Formulary OTC cvs enema disposable rectal enema 19-7 gm/118ml Formulary OTC cvs ethyl alcohol solution 70 % Formulary OTC cvs eye pad Formulary OTC cvs fiber gummies oral tablet chewable 2 gm Formulary OTC cvs gas relief extra strength oral tablet chewable 125 mg Formulary OTC cvs gas relief oral tablet chewable 80 mg Formulary OTC cvs gauze sterile pad 4"x4" Formulary OTC cvs gluco-chondroit plus uc-ii oral tablet 125-100-10 mg Formulary OTC cvs glucosamine-chondroitin oral tablet chewable 750-600 Formulary OTC mg cvs glucosamine-chondroit-msm oral tablet 375-300-250 Formulary OTC mg cvs glucose bits oral tablet chewable 1 gm Formulary OTC cvs glucose shot oral liquid Formulary OTC cvs glycerin adult rectal suppository 2.1 gm Formulary OTC cvs hair regrowth for women external foam 5 % Formulary OTC cvs hand wash advanced antibac external solution 2 % Formulary OTC cvs heartburn relief ex st oral suspension 254-237.5 mg/5ml Formulary OTC cvs heatwraps/back/hip Formulary OTC cvs hemorrhoidal rectal suppository 0.25-88.44 % Formulary OTC cvs hot steam inhalation liquid 6.2 % Formulary OTC cvs hydrocolloid pads pad Formulary OTC cvs inner ear plus oral tablet Formulary OTC cvs instant food thickener oral powder Formulary OTC cvs iron oral tablet 325 (65 fe) mg Formulary OTC cvs isopropyl alcohol wipes external 70 % Formulary OTC cvs itch relief external gel 2 % Formulary OTC cvs lancets 21g Formulary OTC; QL (150 EA per 30 days) cvs lancets micro thin 33g Formulary OTC; QL (150 EA per 30 days) cvs lancets original Formulary OTC; QL (150 EA per 30 days) cvs lancets thin 26g Formulary OTC; QL (150 EA per 30 days) cvs lancets ultra thin 30g Formulary OTC; QL (150 EA per 30 days) cvs lancets ultra-thin 30g Formulary OTC; QL (150 EA per 30 days) cvs laxative dietary supplemnt oral tablet 500 mg Formulary OTC CVS LICE SOLUTION 3-STEP COMBINATION KIT Formulary OTC cvs l-lysine oral tablet 500 mg Formulary OTC cvs lubricant drops ophthalmic gel 0.25-0.3 % Formulary OTC cvs magnesium citrate oral capsule 125 mg Formulary OTC cvs manuka honey wound external gel Formulary OTC cvs melatonin extra strength oral liquid 5 mg/15ml Formulary OTC cvs melatonin oral tablet chewable 5 mg Formulary OTC cvs melatonin sublingual tablet sublingual 5 mg Formulary OTC cvs miconazole 1 combo pack vaginal kit 1200 & 2 mg & % Formulary OTC

37 Drug Name Formulary Status Requirements/Limits cvs miconazole 3 combo pack vaginal kit 200 & 2 mg-% Formulary OTC (9gm) cvs mineral oil enema rectal enema Formulary OTC cvs mineral oil oral oil Formulary OTC cvs mini enema kids rectal enema 100 mg/5ml Formulary OTC cvs multi-purpose external ointment 15.5-53.4 % Formulary OTC cvs nasal allergy spray aerosol 55 mcg/act nasal 55 Formulary OTC mcg/act cvs nasal decongestant inhalation inhaler 50 mg Formulary OTC cvs nasal decongestant oral capsule 30 mg Formulary OTC cvs nasal mist nasal aerosol solution 3 % Formulary OTC cvs natural fiber supplement oral packet 58.6 % Formulary OTC cvs natural fish oil oral capsule 1000 mg Formulary OTC cvs nerve pain relief external ointment Formulary OTC cvs non-drying sinus pe oral tablet 5-200 mg Formulary OTC cvs omeprazole oral tablet delayed release 20 mg Formulary OTC cvs oral pain reliever mouth/throat cream 20 % Formulary OTC cvs pain relief external cream 4 % Formulary OTC cvs phosphate saline laxative oral solution 2.7-7.2 gm/15ml Formulary OTC cvs potassium gluconate oral tablet 2 meq Formulary OTC cvs prenatal gummy oral tablet chewable 0.4-113.5 mg Formulary OTC cvs prenatal oral tablet 28-0.8 mg Formulary OTC cvs prep pad 70 % 70 % Formulary OTC cvs protective external powder 81-15 % Formulary OTC cvs saline wound wash external solution 0.9 % Formulary OTC cvs selenium oral tablet 200 mcg Formulary OTC cvs silver external gel Formulary OTC cvs sinus relief day/night oral Formulary OTC cvs sinus relief day/night oral tablet therapy pack 5-200- Formulary OTC 325 & 5-25-325mg cvs skin relief external lotion 1.3 % Formulary OTC cvs sore muscle rub external gel 2.5 % Formulary OTC cvs sore throat max strength mouth/throat lozenge 15-2.6 Formulary OTC mg cvs sore throat relief pops mouth/throat lozenge on a handle Formulary OTC 20 mg cvs steam inhaler Formulary OTC cvs stool softener oral capsule 50 mg Formulary OTC cvs stuffy nose & cold child oral liquid 2.5-100 mg/5ml Formulary OTC cvs super cranberry urinary oral capsule 140-100 mg Formulary OTC cvs tension headache oral capsule 500-65 mg Formulary OTC cvs therapeutic dandruff external shampoo 1 % Formulary OTC cvs therapeutic external shampoo 0.5 % Formulary OTC cvs triacting cough/runny nose oral liquid 1-5 mg/5ml Formulary OTC cvs triple magnesium complex oral capsule 400 mg Formulary OTC

38 Drug Name Formulary Status Requirements/Limits cvs ultra thin lancets Formulary OTC; QL (150 EA per 30 days) cvs vaporizer warm steam Formulary OTC cvs wound wash advanced external liquid Formulary OTC cvs yogurt+calcium gummies oral tablet chewable 250-100 Formulary OTC mg-unit cvs zinc oxide diaper external cream 1-10 % Formulary OTC cyanocobalamin injection solution 1000 mcg/ml Formulary cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg Formulary CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % Formulary cyclopentolate hcl ophthalmic solution 1 % Formulary cyclophosphamide injection solution reconstituted 1 gm, 2 Formulary gm, 500 mg cyclophosphamide oral capsule 25 mg, 50 mg Formulary cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg Formulary cyclosporine modified oral solution 100 mg/ml Formulary cyclosporine oral capsule 100 mg, 25 mg Formulary cyproheptadine hcl oral syrup 2 mg/5ml Formulary cyproheptadine hcl oral tablet 4 mg Formulary CYSTADANE ORAL POWDER Formulary PA CYSTAGON ORAL CAPSULE 150 MG, 50 MG Formulary CYSTECH ORAL CAPSULE 500 MG Formulary OTC cystine oral packet 500 mg Formulary OTC cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml Formulary CYTO-Q MAX ORAL LIQUID 100 MG/ML Formulary OTC cytra k crystals oral packet 3300-1002 mg Formulary d 1000 oral tablet 25 mcg (1000 ut) Formulary OTC d 2000 oral tablet 50 mcg (2000 ut) Formulary OTC dacarbazine intravenous solution reconstituted 100 mg, 200 Formulary mg daily care skin protectant external ointment 30 % Formulary OTC daily ovulation predictor in vitro strip Formulary OTC daily vite multivitamin/iron oral tablet Formulary OTC dairy relief oral tablet 3000 unit Formulary OTC dakins (1/2 strength) external solution 0.25 % Formulary OTC dakins (1/4 strength) external solution 0.125 % Formulary OTC dakins external solution 0.4-0.5 % Formulary OTC DAKRINA OPHTHALMIC SOLUTION 2.7-2 % Formulary OTC danazol oral capsule 100 mg, 200 mg, 50 mg Formulary dandruff shampoo external lotion 1 % Formulary OTC dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg Formulary dapsone oral tablet 100 mg, 25 mg Formulary daunorubicin hcl intravenous injectable 5 mg/ml Formulary daunorubicin hcl intravenous solution 20 mg/4ml Formulary day time multi-sympt cold/flu oral capsule 10-5-325 mg Formulary OTC

39 Drug Name Formulary Status Requirements/Limits DAYTIME COLD MEDICINE ORAL LIQUID 325-15 Formulary OTC MG/15ML daytime cough oral liquid 15 mg/15ml Formulary OTC daytime severe cold & flu oral liquid 5-10-200-325 Formulary OTC mg/15ml DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 QL (30 EA per 30 days); AGE (Min 4 Formulary MG/9HR, 20 MG/9HR, 30 MG/9HR Years and Max 17 Years) DDROPS ORAL LIQUID 2000 UT/0.028ML Formulary OTC DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % Formulary DECARA ORAL CAPSULE 625 MCG (25000 UT) Formulary OTC decitabine intravenous solution reconstituted 50 mg Formulary DECONEX DMX ORAL TABLET 10-17.5-385 MG Formulary OTC DECONEX IR ORAL TABLET 10-385 MG Formulary OTC deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg Formulary PA del clens external gel Formulary OTC DELBASE COMPOUNDING EXTERNAL OINTMENT Formulary OTC DELSYM COUGH CHILDRENS ORAL SUSPENSION Formulary OTC EXTENDED RELEASE 30 MG/5ML DELTUSS DP ORAL LIQUID 1-30 MG/5ML Formulary OTC DELZICOL ORAL CAPSULE DELAYED RELEASE 400 Formulary MG demeclocycline hcl oral tablet 150 mg, 300 mg Formulary DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 25 MG/ML, 50 MG/ML, 75 Formulary MG/1.5ML, 75 MG/ML DEMSER ORAL CAPSULE 250 MG Formulary DENDRACIN NEURODENDRAXCIN EXTERNAL Formulary OTC LOTION 0.0375-10-30 % DENTAPAINE MOUTH/THROAT GEL 20 % Formulary OTC DEPACON INTRAVENOUS SOLUTION 100 MG/ML Formulary DEPO-PROVERA INTRAMUSCULAR SUSPENSION Formulary 400 MG/ML DEQUASINE ORAL TABLET Formulary OTC DERMA CIDOL 2000 EXTERNAL LIQUID 0.5 % Formulary OTC dermacloud external cream Formulary OTC DERMAGESIC EXTERNAL CREAM 1-0.4-0.4 % Formulary OTC DERMAGESIC EXTERNAL LIQUID 1-0.4-0.4 % Formulary OTC DERMAGRAN EXTERNAL GEL Formulary OTC DERMAL THERAPY FINGER CARE EXTERNAL Formulary OTC LOTION 20 % DERMAL WOUND CLEANSER EXTERNAL LIQUID Formulary OTC 0.13 % DERMAMED EXTERNAL OINTMENT Formulary OTC DERMAPLEX EXTERNAL GEL Formulary OTC DERMAREST PSORIASIS EXTERNAL GEL 3 % Formulary OTC DERMASTAT EXTERNAL FOAM 65 % Formulary OTC DERMASYN EXTERNAL GEL Formulary OTC 40 Drug Name Formulary Status Requirements/Limits DERMAZENE EXTERNAL CREAM 1-1 % Formulary DERMOPLAST EXTERNAL AEROSOL 20-0.5 % Formulary OTC DESCOVY ORAL TABLET 200-25 MG Formulary DESENEX FOOT/SNEAKER SPRAY EXTERNAL Formulary OTC AEROSOL DESGEN DM ORAL SYRUP 5-15-100 MG/5ML Formulary OTC DESGEN DM ORAL TABLET 30-10-200 MG Formulary OTC desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, Formulary 50 mg, 75 mg DESITIN MAXIMUM STRENGTH EXTERNAL PASTE Formulary OTC 40 % desmopressin ace spray refrig nasal solution 0.01 % Formulary desmopressin acetate oral tablet 0.1 mg, 0.2 mg Formulary desmopressin acetate spray nasal solution 0.01 % Formulary desonide external cream 0.05 % Formulary desonide external lotion 0.05 % Formulary desonide external ointment 0.05 % Formulary despec dm-g oral syrup 5-10-100 mg/5ml Formulary OTC desvenlafaxine succinate er oral tablet extended release 24 Formulary ST hour 100 mg, 25 mg, 50 mg DEVROM ORAL TABLET CHEWABLE 200 MG Formulary OTC DEWEES CARMINATIVE ORAL LIQUID 6-250 Formulary OTC DEXAMETHASONE INTENSOL ORAL Formulary CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml Formulary dexamethasone oral solution 0.5 mg/5ml Formulary dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 Formulary mg, 4 mg, 6 mg dexamethasone sodium phosphate ophthalmic solution 0.1 Formulary % dexrazoxane intravenous solution reconstituted 250 mg, 500 Formulary mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg Formulary AGE (Min 4 Years and Max 17 Years) dhea oral capsule 50 mg Formulary OTC dhea oral tablet 25 mg Formulary OTC DHS ZINC EXTERNAL SHAMPOO 2 % Formulary OTC DIAB DAILY CARE EXTERNAL GEL Formulary OTC DIABETIC BASICS HEALTHY FOOT EXTERNAL Formulary OTC LOTION 0.13 % DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 Formulary OTC MG/5ML DIABETIC TUSSIN COLD/FLU ORAL CAPSULE 325-4- Formulary OTC 15 MG DIABETIC TUSSIN NIGHT COLD/FLU ORAL LIQUID Formulary OTC 10-12.5-325 MG/5ML diabet-x daily prevention external cream 0.3 % Formulary OTC

41 Drug Name Formulary Status Requirements/Limits DIADERM FOOT REJUVENATING EXTERNAL Formulary OTC CREAM DIALYVITE 800 ORAL WAFER 0.8 MG Formulary OTC DIALYVITE 800 PLUS D ORAL WAFER 800 MCG Formulary OTC DIALYVITE 800/IRON ORAL TABLET 29-0.8 MG Formulary OTC DIALYVITE ORAL TABLET Formulary DIALYVITE/ZINC ORAL TABLET Formulary diaper rash external cream 10 % Formulary OTC diaper rash external paste 40 % Formulary OTC DIASTIX IN VITRO STRIP Formulary OTC DIAZEPAM INTENSOL ORAL CONCENTRATE 5 Formulary QL (136 ML per 34 days) MG/ML diazepam oral solution 1 mg/ml Formulary QL (136 EA per 34 days) diazepam oral solution 5 mg/5ml Formulary QL (136 ML per 34 days) diazepam oral tablet 10 mg Formulary QL (136 EA per 34 days) diazepam oral tablet 2 mg, 5 mg Formulary QL (136 EA per 30 days) diazepam rectal gel 10 mg, 2.5 mg, 20 mg Formulary AGE (Min 2 Years) diazoxide oral suspension 50 mg/ml Formulary dibucaine external ointment 1 % Formulary OTC diclofenac potassium oral tablet 50 mg Formulary diclofenac sodium er oral tablet extended release 24 hour Formulary 100 mg diclofenac sodium external gel 1 % Formulary diclofenac sodium ophthalmic solution 0.1 % Formulary diclofenac sodium oral tablet delayed release 25 mg, 50 mg, Formulary 75 mg dicloxacillin sodium oral capsule 250 mg, 500 mg Formulary dicyclomine hcl oral capsule 10 mg Formulary dicyclomine hcl oral solution 10 mg/5ml Formulary dicyclomine hcl oral tablet 20 mg Formulary DI-DAK-SOL EXTERNAL SOLUTION 0.0125 % Formulary OTC didanosine oral capsule delayed release 200 mg, 250 mg, Formulary 400 mg dieters super tea oral Formulary OTC dietex forte oral capsule Formulary OTC diethylpropion hcl er oral tablet extended release 24 hour Formulary PA 75 mg diethylpropion hcl oral tablet 25 mg Formulary PA DIFFERIN GEL 0.1 % EXTERNAL (OTC) 0.1 % Formulary AGE (Max 18 Years) diflunisal oral tablet 500 mg Formulary digestive enzyme ultra oral capsule Formulary OTC DIGITEK ORAL TABLET 125 MCG, 250 MCG Formulary oral solution 0.05 mg/ml Formulary DILANTIN ORAL CAPSULE 30 MG Formulary DILAUDID INJECTION SOLUTION 1 MG/ML, 2 Formulary MG/ML, 4 MG/ML 42 Drug Name Formulary Status Requirements/Limits diltiazem hcl er beads oral capsule extended release 24 Formulary hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release Formulary 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release Formulary 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 Formulary mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 Formulary mg, 180 mg, 240 mg diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, Formulary 50 mg/10ml diltiazem hcl intravenous solution reconstituted 100 mg Formulary diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg Formulary dilt-xr oral capsule extended release 24 hour 120 mg, 180 Formulary mg, 240 mg dimenhydrinate oral tablet 50 mg Formulary OTC DIMETAPP COLD/ALLERGY ORAL ELIXIR 1-2.5 Formulary OTC MG/5ML DIMETAPP DM COLD/COUGH ORAL LIQUID 2.5-1-5 Formulary OTC MG/5ML DIMETAPP LONG ACT COUGH/COLD ORAL SYRUP Formulary OTC 1-7.5 MG/5ML dimethyl fumarate oral capsule delayed release 120 mg, Formulary 240 mg dimethyl fumarate starter pack oral 120 & 240 mg Formulary diphenhydramine hcl (sleep) oral tablet 50 mg Formulary OTC diphenhydramine hcl oral capsule 50 mg Formulary diphenhydramine hcl oral tablet 25 mg Formulary OTC diphenoxylate-atropine oral tablet 2.5-0.025 mg Formulary diphtheria-tetanus toxoids dt intramuscular suspension 25-5 Formulary AGE (Min 19 Years) lfu/0.5ml dipyridamole oral tablet 25 mg, 50 mg, 75 mg Formulary disulfiram oral tablet 250 mg, 500 mg Formulary divalproex sodium er oral tablet extended release 24 hour Formulary 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle Formulary 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 Formulary mg, 500 mg dl-pa-500 oral capsule 500 mg Formulary OTC DML EXTERNAL LOTION Formulary OTC DOANS PILLS ORAL TABLET 325 MG Formulary OTC DOANS PM EXTRA STRENGTH ORAL TABLET 580- Formulary OTC 25 MG DOC OMEGA ORAL PACKET 200 MG Formulary OTC docetaxel intravenous concentrate 160 mg/8ml, 20 Formulary mg/0.5ml, 20 mg/ml, 80 mg/2ml, 80 mg/4ml

43 Drug Name Formulary Status Requirements/Limits docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 Formulary mg/8ml docosanol external cream 10 % Formulary OTC docusate sodium oral liquid 50 mg/5ml Formulary OTC docusate sodium oral tablet 100 mg Formulary OTC DOCUSOL KIDS RECTAL ENEMA 100 MG/5ML Formulary OTC DOCUSOL PLUS MINI-ENEMA RECTAL ENEMA 20- Formulary OTC 283 MG dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Formulary DOLOGEN ORAL TABLET 1-325 MG Formulary OTC dologesic-df oral tablet 1-500 mg Formulary OTC dolorex oral tablet 25-325 mg Formulary OTC DOMEBORO EXTERNAL PACKET Formulary OTC dometuss-da/children oral liquid 1-2.5 mg/5ml Formulary OTC donepezil hcl oral tablet 10 mg, 5 mg Formulary donepezil hcl oral tablet 23 mg Formulary QL (30 EA per 30 days) donepezil hcl oral tablet dispersible 10 mg, 5 mg Formulary dorzolamide hcl ophthalmic solution 2 % Formulary dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 Formulary mg/ml DOUBLE-TUSSIN DM ORAL LIQUID 20-300 MG/5ML Formulary OTC DOVATO ORAL TABLET 50-300 MG Formulary QL (30 EA per 30 days) DOVER IRRIGATION TRAY KIT Formulary OTC doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg Formulary QL (34 EA per 34 days) doxazosin mesylate oral tablet 8 mg Formulary QL (68 EA per 34 days) doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 Formulary mg doxepin hcl oral concentrate 10 mg/ml Formulary doxorubicin hcl intravenous solution 2 mg/ml Formulary doxorubicin hcl intravenous solution reconstituted 10 mg, Formulary 50 mg doxycycline hyclate oral capsule 100 mg, 50 mg Formulary doxycycline hyclate oral tablet 100 mg, 20 mg Formulary doxycycline monohydrate oral capsule 100 mg, 50 mg Formulary doxycycline monohydrate oral suspension reconstituted 25 Formulary mg/5ml doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg Formulary DR BOLDTS HINEY HEALER EXTERNAL CREAM Formulary OTC DR SMITHS DIAPER EXTERNAL OINTMENT 10 % Formulary OTC DR SMITHS DIAPER RASH EXTERNAL AEROSOL 10 Formulary OTC % DR SMITHS RASH + SKIN EXTERNAL OINTMENT Formulary OTC 16-57 % DRAMAMINE ORAL TABLET 50 MG Formulary OTC DRAMAMINE ORAL TABLET CHEWABLE 50 MG Formulary OTC DRITHO-CREME HP EXTERNAL CREAM 1 % Formulary 44 Drug Name Formulary Status Requirements/Limits DRIXORAL COLD/ALLERGY ORAL TABLET Formulary OTC EXTENDED RELEASE 12 HOUR 6-120 MG DRIXORAL COUGH/SORE THROAT ORAL CAPSULE Formulary OTC 325-15 MG dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Formulary PA DROPLET LANCETS ULTRA THIN 30G Formulary OTC; QL (150 EA per 30 days) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 Formulary QL (28 EA per 28 days) mg DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG Formulary drug mart lancets thin 26g Formulary OTC; QL (150 EA per 30 days) DRUG MART UNILET LANCETS 28G Formulary OTC; QL (150 EA per 30 days) DRUG MART UNILET LANCETS 30G Formulary OTC; QL (150 EA per 30 days) dry skin treatment adv therapy external ointment Formulary OTC drymax extra pad 8"x8" Formulary OTC DRYSOL EXTERNAL SOLUTION 20 % Formulary DULCOLAX MILK OF MAGNESIA ORAL Formulary OTC SUSPENSION 400 MG/5ML DULCOLAX ORAL TABLET DELAYED RELEASE 5 Formulary OTC MG DULCOLAX RECTAL SUPPOSITORY 10 MG Formulary OTC DULERA INHALATION AEROSOL 100-5 MCG/ACT, Formulary 200-5 MCG/ACT, 50-5 MCG/ACT duloxetine hcl oral capsule delayed release particles 20 mg, Formulary 30 mg, 60 mg DUOFILM EXTERNAL SOLUTION 17 % Formulary OTC DURAFLEX COMFORT EXTERNAL GEL Formulary OTC DURAFLU ORAL TABLET 60-20-200-325 MG Formulary OTC DURAPROXIN ES TRANSDERMAL PATCH 3-1.25-10 Formulary OTC % DURAPROXIN TRANSDERMAL PATCH 1.25-3 % Formulary OTC DURASAFE SPINAL/EPIDURAL KIT Formulary DURATION SPRAY NASAL SOLUTION 0.05 % Formulary OTC DURAVENT DM ORAL TABLET 10-15-395 MG Formulary OTC DURAVENT PE ORAL TABLET 10-395 MG Formulary OTC DUREZOL OPHTHALMIC EMULSION 0.05 % Formulary oral capsule 0.5 mg Formulary dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg Formulary D-VI-SOL ORAL LIQUID 400 UNIT/ML Formulary OTC d-xylose powder Formulary DY-O-DERM VITILIGO STAIN EXTERNAL Formulary OTC SOLUTION 6.55 % E.E.S. GRANULES ORAL SUSPENSION Formulary RECONSTITUTED 200 MG/5ML ear wax cleansing otic kit 6.5 % Formulary OTC EASIVENT Formulary QL (2 EA per 365 days) EASIVENT MASK LARGE Formulary QL (2 EA per 365 days)

45 Drug Name Formulary Status Requirements/Limits EASIVENT MASK MEDIUM Formulary QL (2 EA per 365 days) EASIVENT MASK SMALL Formulary QL (2 EA per 365 days) easy fiber oral powder Formulary OTC EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % Formulary OTC 70 % EASY TOUCH ALLERGY SYRINGE 26G X 3/8" 1 ML, Formulary OTC 27G X 1/2" 1 ML EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 Formulary OTC ML 29G X 1/2" 1 ML EASY TOUCH FLIPLOCK INSULIN SY 30G X 1/2" 1 Formulary OTC ML 30G X 1/2" 1 ML EASY TOUCH FLIPLOCK INSULIN SY 30G X 5/16" 1 Formulary OTC ML 30G X 5/16" 1 ML EASY TOUCH FLIPLOCK INSULIN SY 31G X 5/16" 1 Formulary OTC ML 31G X 5/16" 1 ML EASY TOUCH FLURINGE 25G X 1" 1 ML Formulary OTC EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 Formulary OTC ML 29G X 1/2" 0.5 ML EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML EASY TOUCH INSULIN SAFETY SYR 30G X 1/2" 1 ML Formulary OTC 30G X 1/2" 1 ML EASY TOUCH INSULIN SAFETY SYR 30G X 5/16" 0.5 Formulary OTC ML 30G X 5/16" 0.5 ML EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML Formulary OTC 27G X 1/2" 0.5 ML EASY TOUCH INSULIN SYRINGE 27G X 1/2" 1 ML Formulary OTC 27G X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML Formulary OTC 28G X 1/2" 0.5 ML EASY TOUCH INSULIN SYRINGE 28G X 1/2" 1 ML Formulary OTC 28G X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML EASY TOUCH INSULIN SYRINGE 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 30G X 1/2" 0.3 ML Formulary OTC 30G X 1/2" 0.3 ML EASY TOUCH INSULIN SYRINGE 30G X 1/2" 0.5 ML Formulary OTC 30G X 1/2" 0.5 ML EASY TOUCH INSULIN SYRINGE 30G X 1/2" 1 ML Formulary OTC 30G X 1/2" 1 ML EASY TOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML EASY TOUCH INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML EASY TOUCH INSULIN SYRINGE 30G X 5/16" 1 ML Formulary OTC 30G X 5/16" 1 ML EASY TOUCH INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML

46 Drug Name Formulary Status Requirements/Limits EASY TOUCH INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML EASY TOUCH INSULIN SYRINGE 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML EASY TOUCH LANCETS 26G Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 28G Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 28G/TWIST Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 30G Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 30G/TWIST Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 32G Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 32G/TWIST Formulary OTC; QL (150 EA per 30 days) EASY TOUCH LANCETS 33G/TWIST Formulary OTC; QL (150 EA per 30 days) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 Formulary OTC ML 29G X 1/2" 1 ML EASY TOUCH SHEATHLOCK SYRINGE 30G X 1/2" 1 Formulary OTC ML 30G X 1/2" 1 ML EASY TOUCH SHEATHLOCK SYRINGE 30G X 5/16" 1 Formulary OTC ML 30G X 5/16" 1 ML EASY TOUCH SHEATHLOCK SYRINGE 31G X 5/16" 1 Formulary OTC ML 31G X 5/16" 1 ML EASY TWIST & CAP LANCETS Formulary OTC; QL (150 EA per 30 days) EASYGEL DENTAL GEL 0.4 % Formulary ecee plus oral tablet Formulary OTC econazole nitrate external cream 1 % Formulary ECOTRIN MAXIMUM STRENGTH ORAL TABLET Formulary OTC DELAYED RELEASE 500 MG ECOTRIN ORAL TABLET DELAYED RELEASE 325 Formulary OTC MG e-cream complex external cream Formulary OTC ed a-hist dm oral tablet 10-4-10 mg Formulary OTC ED A-HIST ORAL LIQUID 4-10 MG/5ML Formulary OTC ed bron gp oral liquid 5-100 mg/5ml Formulary OTC ED CHLORPED D ORAL LIQUID 2-5 MG/ML Formulary OTC ED CHLORPED ORAL LIQUID 2 MG/ML Formulary OTC ed-spaz oral tablet dispersible 0.125 mg Formulary EDURANT ORAL TABLET 25 MG Formulary efavirenz oral capsule 200 mg, 50 mg Formulary efavirenz oral tablet 600 mg Formulary efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg Formulary EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ Formulary effervescent pain relief oral tablet effervescent 325 mg Formulary OTC effervescent pot chloride oral tablet effervescent 25 meq Formulary EGRIFTA SUBCUTANEOUS SOLUTION Formulary PA RECONSTITUTED 1 MG ELDERTONIC ORAL ELIXIR Formulary OTC eletriptan hydrobromide oral tablet 20 mg, 40 mg Formulary ST; QL (6 EA per 34 days)

47 Drug Name Formulary Status Requirements/Limits ELIDEL EXTERNAL CREAM 1 % Formulary PA; AGE (Min 2 Years) ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 Formulary PA; QL (1 EA per 90 days) MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG Formulary elite ca/mg oral tablet 100-50 mg Formulary OTC elite calcium oral tablet 150 mg Formulary OTC ELITE ZINC ORAL CAPSULE 15 MG Formulary OTC ELITEK INTRAVENOUS SOLUTION Formulary RECONSTITUTED 1.5 MG, 7.5 MG ELITE-OB ORAL TABLET 50-1.25 MG Formulary elite-thin insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC elite-thin insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC elite-thin insulin syringe 28g x 5/16" 0.5 ml 28g x 5/16" 0.5 Formulary OTC ml elite-thin insulin syringe 28g x 5/16" 1 ml 28g x 5/16" 1 ml Formulary OTC elite-thin insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC elite-thin insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC elite-thin insulin syringe 29g x 5/16" 0.5 ml 29g x 5/16" 0.5 Formulary OTC ml elite-thin insulin syringe 29g x 5/16" 1 ml 29g x 5/16" 1 ml Formulary OTC elite-thin insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 Formulary OTC ml elite-thin insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC elite-thin insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 Formulary OTC ml elite-thin insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 Formulary OTC ml elite-thin insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML Formulary ELIXSURE COUGH ORAL GEL 7.5 MG/5ML Formulary OTC ELIXSURE FEVER/PAIN ORAL GEL 160 MG/5ML Formulary OTC ELLA ORAL TABLET 30 MG Formulary ELLURA ORAL CAPSULE 200 MG Formulary OTC ELMIRON ORAL CAPSULE 100 MG Formulary PA ELTA DERMAL EXTERNAL GEL Formulary OTC ELURYNG VAGINAL RING 0.12-0.015 MG/24HR Formulary QL (1 EA per 28 days) EMCYT ORAL CAPSULE 140 MG Formulary EMETROL ORAL SOLUTION 1.87-1.87-21.5 Formulary OTC EMGALITY SUBCUTANEOUS SOLUTION AUTO- Formulary ST; AGE (Min 18 Years) INJECTOR 120 MG/ML EMGALITY SUBCUTANEOUS SOLUTION Formulary ST; AGE (Min 18 Years) PREFILLED SYRINGE 120 MG/ML EMJOI TENS DEVICE Formulary empty capsule size 1 clear capsule Formulary emtricitabine oral capsule 200 mg Formulary emtricitabine-tenofovir df oral tablet 200-300 mg Formulary

48 Drug Name Formulary Status Requirements/Limits EMTRIVA ORAL SOLUTION 10 MG/ML Formulary EMULSION SB EMULSION EXTERNAL Formulary enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Formulary enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 Formulary mg ENBREL MINI SUBCUTANEOUS SOLUTION Formulary CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML Formulary AGE (Min 2 Years) ENBREL SUBCUTANEOUS SOLUTION PREFILLED Formulary AGE (Min 2 Years) SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION Formulary AGE (Min 2 Years) RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION Formulary AGE (Min 2 Years) AUTO-INJECTOR 50 MG/ML ENDOXCIN EXTERNAL PATCH 4-1 % Formulary OTC ENDUR-ACIN ORAL TABLET EXTENDED RELEASE Formulary OTC 500 MG ENEMEEZ MINI RECTAL ENEMA 283 MG/5ML Formulary OTC ENFAMIL ENFALYTE ORAL SOLUTION Formulary OTC ENFAMIL EXPECTA ORAL 28-0.8 & 200 MG Formulary OTC ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, Formulary AGE (Min 19 Years) 20 MCG/ML ENLITE GLUCOSE SENSOR Formulary enoxaparin sodium injection solution 300 mg/3ml Formulary enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 Formulary mg/0.6ml, 80 mg/0.8ml ENPRESSE-28 ORAL TABLET 50-30/75-40/ 125-30 Formulary QL (28 EA per 28 days) MCG entecavir oral tablet 0.5 mg, 1 mg Formulary ENTEX T ORAL TABLET 60-375 MG Formulary OTC ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97- Formulary QL (68 EA per 34 days) 103 MG ENTSOL NASAL NASAL SOLUTION 3 % Formulary OTC enulose oral solution 10 gm/15ml Formulary e-oil external oil 30000 unit Formulary OTC epa/gla oral capsule Formulary OTC EPANED ORAL SOLUTION 1 MG/ML Formulary AGE (Max 12 Years) ephedrine hcl oral tablet 25 mg Formulary OTC EPIDIOLEX ORAL SOLUTION 100 MG/ML Formulary PA epidural needle 18g x 2" , 18g x 4" Formulary OTC epinastine hcl ophthalmic solution 0.05 % Formulary epinephrine injection solution 30 mg/30ml Formulary epinephrine injection solution auto-injector 0.15 mg/0.3ml, Formulary 0.3 mg/0.3ml epinephrine injection solution prefilled syringe 1 mg/10ml Formulary epinephrine pf injection solution 1 mg/ml Formulary

49 Drug Name Formulary Status Requirements/Limits epinephrine pf injection solution prefilled syringe 1 Formulary mg/10ml epinephrine solution auto-injector 0.15 mg/0.15ml injection Formulary 0.15 mg/0.15ml epinephrine solution auto-injector 0.3 mg/0.3ml injection Formulary 0.3 mg/0.3ml EPIPEN 2-PAK SOLUTION AUTO-INJECTOR 0.3 Formulary MG/0.3ML INJECTION 0.3 MG/0.3ML EPIPEN JR 2-PAK SOLUTION AUTO-INJECTOR 0.15 Formulary MG/0.3ML INJECTION 0.15 MG/0.3ML epirubicin hcl intravenous solution 200 mg/100ml, 50 Formulary mg/25ml EPISORB TRANSDERMAL Formulary OTC EPITOL ORAL TABLET 200 MG Formulary EPIVIR HBV ORAL SOLUTION 5 MG/ML Formulary eplerenone oral tablet 25 mg, 50 mg Formulary EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 Formulary UNIT/ML eprosartan mesylate oral tablet 600 mg Formulary ST epsom salt oral granules Formulary OTC eq allergy relief childrens oral elixir 12.5 mg/5ml Formulary OTC eq allergy relief childrens oral liquid 12.5 mg/5ml Formulary OTC eq allergy relief oral tablet 10 mg Formulary OTC eq allergy/sinus headache oral tablet 12.5-30-500 mg Formulary OTC eq aspirin oral tablet delayed release 500 mg Formulary OTC EQ BABY CHEST RUB EXTERNAL CREAM Formulary OTC eq calcium citrate+d3 petites oral tablet 200-250 mg-unit Formulary OTC eq cough sugar free mouth/throat lozenge 5.8 mg Formulary OTC eq cryogenic wart removal sys external aerosol Formulary OTC eq daily fiber oral capsule 400 mg Formulary OTC eq dairy digestive fast acting oral tablet 9000 unit Formulary OTC eq dairy digestive fast acting oral tablet chewable 9000 unit Formulary OTC eq feminine wash sensitive vaginal liquid Formulary OTC eq ibuprofen pm oral tablet 200-38 mg Formulary OTC EQ MUCUS ER ORAL TABLET EXTENDED RELEASE Formulary OTC 12 HOUR 600 MG eq multi-symptom cold children oral liquid 2.5-5-100 mg/ml Formulary OTC eq omeprazole oral tablet delayed release 20 mg Formulary OTC eq pain relief/rapid burst oral liquid 500 mg/15ml Formulary OTC eq sinus relief max st oral tablet 30-500 mg Formulary OTC eq tioconazole 1 vaginal ointment 6.5 % Formulary OTC eql 2 in 1 probiotic oral tablet Formulary OTC eql advanced relief ophthalmic solution 0.05-0.1-1-1 % Formulary OTC eql alcohol swabs pad 70 % 70 % Formulary OTC eql aller-ease oral tablet 180 mg Formulary OTC; QL (34 EA per 34 days)

50 Drug Name Formulary Status Requirements/Limits eql allergy oral tablet 4 mg Formulary OTC eql aloe vera after sun external gel Formulary OTC eql antacid ultra strength oral tablet chewable 1000 mg Formulary OTC eql antibacterial hand soap external liquid 0.13 % Formulary OTC eql anti-nausea oral solution 1.87-1.87-21.5 Formulary OTC eql biotin oral capsule 5000 mcg Formulary OTC eql color lancets 21g Formulary OTC; QL (150 EA per 30 days) eql color lancets micro 33g Formulary OTC; QL (150 EA per 30 days) eql congestion relief oral tablet 10-200 mg Formulary OTC eql denture brush/pick Formulary OTC eql denture cleanser tablet effervescent Formulary OTC eql digestive enzymes oral tablet Formulary OTC eql ear drops otic solution Formulary OTC eql effervescent cold relief oral tablet effervescent 2-7.8- Formulary OTC 325 mg eql ethyl alcohol (rubbing) solution 70 % Formulary OTC eql everyday clean external shampoo 1 % Formulary OTC eql eye drops ac ophthalmic solution 0.05-0.25 % Formulary OTC eql fiber therapy oral powder 48.57 % Formulary OTC eql gas prevention oral capsule Formulary OTC eql gentle skin cleanser external liquid Formulary OTC eql insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC eql insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC eql insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC eql insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC eql insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC eql insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC eql insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC eql insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC eql insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC eql lutein oral capsule 20 mg Formulary OTC eql mouthwash/gargle mouth/throat liquid Formulary OTC eql mucus-dm oral tablet extended release 12 hour 30-600 Formulary OTC mg eql multi-purpose solution Formulary OTC eql omega 3 fish oil oral capsule delayed release 1200 mg Formulary OTC eql omeprazole oral tablet delayed release 20 mg Formulary OTC eql one daily womens oral tablet Formulary OTC eql redness relief ophthalmic solution 0.012-0.2 % Formulary OTC eql scalp relief max strength external liquid 3 % Formulary OTC eql super thin lancets 30g Formulary OTC; QL (150 EA per 30 days) eql thin lancets 26g Formulary OTC; QL (150 EA per 30 days) eql ultra protection spf50 external aerosol Formulary OTC eql vitamin d3 oral capsule 10 mcg (400 unit) Formulary OTC

51 Drug Name Formulary Status Requirements/Limits eql wet cleansing towelettes external Formulary OTC eql zinc cold relief mouth/throat lozenge Formulary OTC EQUALACTIN ORAL TABLET CHEWABLE 625 MG Formulary OTC ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, Formulary PA 200 MG/100ML ergocalciferol oral capsule 1.25 mg (50000 ut) Formulary ergocalciferol oral solution 8000 unit/ml Formulary OTC ergoloid mesylates oral tablet 1 mg Formulary ery external pad 2 % Formulary erythromycin base oral capsule delayed release particles Formulary 250 mg erythromycin ethylsuccinate oral suspension reconstituted Formulary 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg Formulary erythromycin external gel 2 % Formulary erythromycin external solution 2 % Formulary AGE (Max 18 Years) erythromycin ophthalmic ointment 5 mg/gm Formulary escavite lq oral liquid 0.25-6 mg/ml Formulary escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Formulary esmolol hcl intravenous solution 100 mg/10ml Formulary esomeprazole magnesium oral capsule delayed release 20 Formulary QL (30 EA per 30 days) mg, 40 mg ESOTERICA FADE NIGHTTIME EXTERNAL CREAM Formulary OTC 2 % ESOTERICA SENSITIVE SKIN EXTERNAL CREAM Formulary OTC 1.5 % ESTARYLLA ORAL TABLET 0.25-35 MG-MCG Formulary QL (28 EA per 28 days) estazolam oral tablet 1 mg, 2 mg Formulary estradiol oral tablet 0.5 mg, 1 mg, 2 mg Formulary estradiol transdermal patch twice weekly 0.025 mg/24hr, Formulary QL (8 EA per 34 days) 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr estradiol transdermal patch twice weekly 0.1 mg/24hr Formulary QL (8 EA per 28 days) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 Formulary QL (5 EA per 34 days) mg/24hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml Formulary estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 Formulary mg estropipate oral tablet 0.75 mg Formulary eszopiclone oral tablet 1 mg, 2 mg, 3 mg Formulary QL (30 EA per 30 days) ethambutol hcl oral tablet 100 mg, 400 mg Formulary ethosuximide oral capsule 250 mg Formulary ethosuximide oral solution 250 mg/5ml Formulary ethyl alcohol (rubbing) solution 70 % Formulary OTC ethyl alcohol external solution 95 % Formulary OTC ethyl chloride external aerosol Formulary

52 Drug Name Formulary Status Requirements/Limits etidronate disodium oral tablet 200 mg, 400 mg Formulary etodolac er oral tablet extended release 24 hour 400 mg, Formulary 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg Formulary etodolac oral tablet 400 mg, 500 mg Formulary ETOPOPHOS INTRAVENOUS SOLUTION Formulary RECONSTITUTED 100 MG etoposide intravenous solution 1 gm/50ml, 100 mg/5ml Formulary etoposide oral capsule 50 mg Formulary etravirine oral tablet 100 mg, 200 mg Formulary eucalyptus oil external oil Formulary OTC EUCERIN ECZEMA RELIEF EXTERNAL CREAM 1 % Formulary OTC EUCERIN EXTERNAL CREAM Formulary OTC EUCERIN ORIGINAL HEALING EXTERNAL LOTION Formulary OTC EUFLEXXA INTRA-ARTICULAR SOLUTION Formulary PA PREFILLED SYRINGE 20 MG/2ML EURAX EXTERNAL CREAM 10 % Formulary ST EVAC-U-GEN ORAL TABLET 8.6 MG Formulary OTC evening primrose oil oral capsule 1000 mg, 500 mg Formulary OTC everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg Formulary EXACTECH R-S-G TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) EXACTECH TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) EXACTUSS TR ORAL TABLET 10-28-388 MG Formulary OTC EXAPHEN CH ORAL TABLET 10-3.5-24 MG Formulary OTC EXAPHEN ORAL TABLET 3.5-10 MG Formulary OTC EXAPHEX TR ORAL TABLET 10-388 MG Formulary OTC EXCEDRIN PM ORAL TABLET 500-38 MG Formulary OTC EXCEDRIN TENSION HEADACHE ORAL TABLET Formulary OTC 500-65 MG EXCEL AP EXTERNAL SWAB 7.5-72 % Formulary OTC EXCEL-GEL EXTERNAL GEL Formulary OTC EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 Formulary OTC ML 28G X 1/2" 0.5 ML EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 1 Formulary OTC ML 28G X 1/2" 1 ML EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.3 Formulary OTC ML 29G X 1/2" 0.3 ML EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.5 Formulary OTC ML 29G X 1/2" 0.5 ML EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 1 Formulary OTC ML 29G X 1/2" 1 ML EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 0.3 Formulary OTC ML 30G X 5/16" 0.3 ML EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 0.5 Formulary OTC ML 30G X 5/16" 0.5 ML EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 1 Formulary OTC ML 30G X 5/16" 1 ML

53 Drug Name Formulary Status Requirements/Limits EXELON TRANSDERMAL PATCH 24 HOUR 13.3 Formulary MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR exemestane oral tablet 25 mg Formulary EXFOLIX EXFOLIATING FOOT SOAP EXTERNAL Formulary OTC BAR EX-LAX MAXIMUM STRENGTH ORAL TABLET 25 Formulary OTC MG EX-LAX ORAL TABLET 15 MG Formulary OTC EX-LAX ORAL TABLET CHEWABLE 15 MG Formulary OTC exoten-c pain relief external lotion 0.001-10-20 %, 0.025- Formulary OTC 10-20 % exotic-hc otic solution 10-10-1 mg/ml Formulary EXTRESS-30 ORAL CAPSULE EXTENDED RELEASE Formulary OTC eye allergy relief ophthalmic solution 0.027-0.315 % Formulary OTC eye drops ophthalmic solution 0.012-0.2 % Formulary OTC eye itch relief ophthalmic solution 0.025 % Formulary OTC EYE STREAM OPHTHALMIC SOLUTION Formulary OTC E-Z JECT LANCET MICRO-THIN 33G Formulary OTC; QL (150 EA per 30 days) E-Z JECT LANCET SUPER THIN 30G Formulary OTC; QL (150 EA per 30 days) E-Z JECT LANCETS Formulary OTC; QL (150 EA per 30 days) E-Z JECT LANCETS 21G Formulary OTC; QL (150 EA per 30 days) E-Z JECT LANCETS THIN 26G Formulary OTC; QL (150 EA per 30 days) EZ SMART BLOOD GLUCOSE LANCETS Formulary OTC; QL (150 EA per 30 days) ezetimibe oral tablet 10 mg Formulary ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10- Formulary ST 40 mg, 10-80 mg EZFE 200 ORAL CAPSULE 434.8 (200 FE) MG Formulary OTC E-Z-GAS II ORAL PACKET 2.21-1.53-0.04 GM Formulary OTC EZ-LETS LANCETS 21G Formulary OTC; QL (150 EA per 30 days) EZ-LETS LANCETS 23G Formulary OTC; QL (150 EA per 30 days) EZ-LETS LANCETS 28G Formulary OTC; QL (150 EA per 30 days) fabb oral tablet 2.2-25-1 mg Formulary famciclovir oral tablet 125 mg, 250 mg, 500 mg Formulary famotidine oral suspension reconstituted 40 mg/5ml Formulary famotidine oral tablet 10 mg Formulary OTC famotidine oral tablet 20 mg, 40 mg Formulary FARESTON ORAL TABLET 60 MG Formulary FARXIGA ORAL TABLET 10 MG, 5 MG Formulary PA; AGE (Min 18 Years) FAST FREEZE PRO STYLE THERAPY EXTERNAL Formulary OTC GEL 3.5 % FAST FREEZE PRO STYLE THERAPY EXTERNAL Formulary OTC LIQUID 3.5 % fast-heat heating pad pad Formulary OTC father johns medicine oral syrup 10 mg/5ml Formulary OTC fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg Formulary FAYOSIM ORAL TABLET 42-21-21-7 DAYS Formulary QL (91 EA per 91 days) 54 Drug Name Formulary Status Requirements/Limits FC FEMALE CONDOM Formulary OTC febuxostat oral tablet 40 mg, 80 mg Formulary QL (34 EA per 34 days) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED Formulary , 1000 UNIT, 2500 UNIT, 500 UNIT felbamate oral suspension 600 mg/5ml Formulary felbamate oral tablet 400 mg, 600 mg Formulary felodipine er oral tablet extended release 24 hour 10 mg, Formulary 2.5 mg, 5 mg FEM PH VAGINAL GEL 0.9-0.025 % Formulary FEMINEASE VAGINAL CREAM Formulary OTC fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Formulary fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg Formulary fenofibric acid oral capsule delayed release 135 mg, 45 mg Formulary fenofibric acid tablet 105 mg oral 105 mg Formulary fenofibric acid tablet 35 mg oral 35 mg Formulary fenoprofen calcium capsule 200 mg oral 200 mg Formulary fentanyl citrate (pf) injection solution cartridge 100 Formulary mcg/2ml fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 Formulary PA; QL (120 EA per 30 days) mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, Formulary PA; QL (10 EA per 34 days) 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FER-IN-SOL ORAL SOLUTION 75 (15 FE) MG/ML Formulary OTC ferocon oral capsule Formulary ferraplus 90 oral tablet 90-1 mg Formulary ferretts chewable iron oral tablet chewable 18 mg Formulary OTC ferretts ips oral solution 40 mg/15ml Formulary OTC ferretts oral tablet 325 (106 fe) mg Formulary OTC FERREX 150 FORTE PLUS ORAL CAPSULE 50-100 Formulary OTC MG FERREX 150 ORAL CAPSULE 150 MG Formulary OTC FERREX 28 ORAL Formulary OTC FERRIMIN 150 ORAL TABLET 150 MG Formulary OTC FERROCITE ORAL TABLET 324 MG Formulary OTC FERROCITE PLUS ORAL TABLET 106-1 MG Formulary ferrous gluconate oral tablet 324 (37.5 fe) mg, 324 (38 fe) Formulary OTC mg ferrous sulfate er oral tablet extended release 140 (45 fe) Formulary OTC mg ferrous sulfate oral elixir 220 (44 fe) mg/5ml Formulary OTC ferrous sulfate oral liquid 220 (44 fe) mg/5ml Formulary OTC ferrous sulfate oral syrup 300 (60 fe) mg/5ml Formulary OTC ferrous sulfate oral tablet delayed release 324 (65 fe) mg, Formulary OTC 325 (65 fe) mg FEVERALL INFANTS RECTAL SUPPOSITORY 80 MG Formulary OTC

55 Drug Name Formulary Status Requirements/Limits FEVERALL JUNIOR STRENGTH RECTAL Formulary OTC SUPPOSITORY 325 MG fiber laxative oral tablet 625 mg Formulary OTC fiber oral powder Formulary OTC FIBERCON ORAL TABLET 625 MG Formulary OTC FIBEREX F15 ORAL LIQUID 15 GM/30ML Formulary OTC FIFTY50 ALCOHOL PREP PAD 70 % 70 % Formulary OTC FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.5 Formulary OTC ML 31G X 5/16" 0.5 ML FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML filter needle 18g x 1-1/2" Formulary finasteride oral tablet 5 mg Formulary FINE 30 Formulary OTC; QL (150 EA per 30 days) first aid antibiotic external ointment 4 % Formulary OTC first aid antiseptic external ointment 10 % Formulary OTC first aid antiseptic spray external aerosol 20-0.13 % Formulary OTC FIRVANQ ORAL SOLUTION RECONSTITUTED 25 Formulary MG/ML, 50 MG/ML fish oil + d3 oral capsule 1000-1000 mg-unit Formulary OTC fish oil adult gummies oral tablet chewable 113.5 mg Formulary OTC fish oil oral capsule 1200 mg, 500 mg, 600 mg Formulary OTC fish oil oral capsule delayed release 1000 mg Formulary OTC fish oil-flax oil-borage oil oral capsule Formulary OTC flavoxate hcl oral tablet 100 mg Formulary flecainide acetate oral tablet 100 mg, 150 mg, 50 mg Formulary FLEET BISACODYL RECTAL ENEMA 10 MG/30ML Formulary OTC FLEET LIQUID GLYCERIN SUPP RECTAL ENEMA 5.4 Formulary OTC GM/DOSE FLEET NATURALS CLEANSING ENEMA RECTAL Formulary OTC ENEMA FLEET OIL RECTAL ENEMA Formulary OTC FLEET PEDIATRIC RECTAL ENEMA 3.5-9.5 GM/59ML Formulary OTC FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 % Formulary FLEXICHAMBER CHILD MASK/LARGE Formulary FLEXICHAMBER DEVICE Formulary QL (2 EA per 365 days) FLINTSTONES TODDLER ORAL TABLET Formulary OTC CHEWABLE 40 MG FLOGEN ORAL TABLET 250-650 MG Formulary OTC FLONASE ALLERGY RELIEF SUSPENSION 50 Formulary OTC MCG/ACT NASAL 50 MCG/ACT FLONASE SENSIMIST NASAL SUSPENSION 27.5 Formulary OTC MCG/SPRAY FLORA ASSIST ORAL PACKET Formulary OTC

56 Drug Name Formulary Status Requirements/Limits FLORANEX ORAL PACKET Formulary OTC FLORASTOR KIDS ORAL PACKET 250 MG Formulary OTC FLORASTOR ORAL CAPSULE 250 MG Formulary OTC FLORICAL ORAL CAPSULE 8.3-364 MG Formulary OTC FLORICAL ORAL TABLET 8.3-364 MG Formulary OTC FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 Formulary MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 Formulary MCG/ACT, 220 MCG/ACT, 44 MCG/ACT flow-eze vented needle Formulary OTC floxuridine injection solution reconstituted 0.5 gm Formulary flu hbp oral tablet 15-500-2 mg Formulary OTC FLUCAINE OPHTHALMIC SOLUTION 0.25-0.5 % Formulary FLUCELVAX QUADRIVALENT INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION PREFILLED SYRINGE 0.5 ML fluconazole oral suspension reconstituted 10 mg/ml, 40 Formulary mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Formulary fludarabine phosphate intravenous solution 50 mg/2ml Formulary fludarabine phosphate intravenous solution reconstituted 50 Formulary mg fludrocortisone acetate oral tablet 0.1 mg Formulary flunisolide nasal solution 25 mcg/act (0.025%) Formulary QL (3 ML per 34 days) fluocinolone acetonide body external oil 0.01 % Formulary fluocinolone acetonide external cream 0.01 %, 0.025 % Formulary fluocinolone acetonide external ointment 0.025 % Formulary fluocinolone acetonide external solution 0.01 % Formulary fluocinolone acetonide otic oil 0.01 % Formulary fluocinolone acetonide scalp external oil 0.01 % Formulary fluocinonide external cream 0.05 %, 0.1 % Formulary fluocinonide external gel 0.05 % Formulary fluocinonide external ointment 0.05 % Formulary fluoride mouth rinse mouth/throat solution 0.0221 (0.01 f) Formulary OTC % fluorometholone ophthalmic suspension 0.1 % Formulary fluorouracil external cream 5 % Formulary fluorouracil external solution 2 %, 5 % Formulary fluorouracil intravenous solution 1 gm/20ml Formulary fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg Formulary fluoxetine hcl oral solution 20 mg/5ml Formulary fluoxetine hcl oral tablet 10 mg Formulary QL (34 EA per 34 days) fluphenazine decanoate injection solution 25 mg/ml Formulary AGE (Min 18 Years) fluphenazine hcl injection solution 2.5 mg/ml Formulary AGE (Min 18 Years) fluphenazine hcl oral concentrate 5 mg/ml Formulary AGE (Min 18 Years) fluphenazine hcl oral elixir 2.5 mg/5ml Formulary AGE (Min 18 Years) 57 Drug Name Formulary Status Requirements/Limits fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg Formulary AGE (Min 18 Years) flurazepam hcl oral capsule 15 mg, 30 mg Formulary QL (68 EA per 34 days) flurbiprofen oral tablet 100 mg, 50 mg Formulary flurbiprofen sodium ophthalmic solution 0.03 % Formulary flutamide oral capsule 125 mg Formulary propionate external cream 0.05 % Formulary fluticasone propionate external ointment 0.005 % Formulary fluticasone propionate nasal suspension 50 mcg/act Formulary FLUVIRIN INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg Formulary FLUZONE HIGH-DOSE INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG Formulary AGE (Min 4 Years and Max 17 Years) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE QL (30 EA per 30 days); AGE (Min 4 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 Formulary Years and Max 17 Years) MG, 40 MG, 5 MG FOILLE EXTERNAL OINTMENT 5-0.1 % Formulary OTC FOLET DHA ORAL THERAPY PACK 38-1 & 350 MG Formulary FOLGARD ORAL TABLET Formulary OTC FOLGARD OS ORAL TABLET 500-1.1 MG Formulary FOLIC + B12 ORAL TABLET 800-1000 MCG Formulary OTC folic acid oral capsule 0.8 mg, 20 mg, 5 mg Formulary OTC folic acid oral tablet 1 mg Formulary folic acid oral tablet 400 mcg, 800 mcg Formulary OTC folinic-plus oral tablet 4-50-2 mg Formulary OTC FOLITAB 500 ORAL TABLET EXTENDED RELEASE Formulary OTC 105-500-0.8 MG FOLIVANE-F ORAL CAPSULE 125-1 MG Formulary FOLIVANE-PLUS ORAL CAPSULE Formulary FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML Formulary FORA D40 GLUCOSE/PRESSURE DEVICE Formulary OTC FORA LANCETS Formulary OTC; QL (150 EA per 30 days) FORADIL AEROLIZER INHALATION CAPSULE 12 Formulary MCG FORMADON EXTERNAL SOLUTION 10 % Formulary formaldehyde external solution 37 % Formulary FORMA-RAY EXTERNAL SOLUTION 20 % Formulary formoterol fumarate inhalation nebulization solution 20 Formulary QL (120 ML per 30 days) mcg/2ml FORTEO SUBCUTANEOUS SOLUTION 600 Formulary PA; QL (2.4 ML per 28 days) MCG/2.4ML fosamprenavir calcium oral tablet 700 mg Formulary

58 Drug Name Formulary Status Requirements/Limits fosfomycin tromethamine oral packet 3 gm Formulary QL (3 EA per 30 days) fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg Formulary fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg Formulary fosphenytoin sodium injection solution 100 mg pe/2ml, 500 Formulary mg pe/10ml freds pharmacy unilet lanc 28g Formulary OTC; QL (150 EA per 30 days) FREE & CLEAR EXTERNAL LIQUID Formulary OTC FREE & CLEAR EXTERNAL SHAMPOO Formulary OTC FREESTYLE CONTROL SOLUTION LIQUID IN VITRO Formulary OTC; QL (100 EA per 30 days) FREESTYLE FLASH SYSTEM KIT Formulary OTC; QL (1 EA per 365 days) FREESTYLE FREEDOM KIT Formulary OTC; QL (1 EA per 365 days) FREESTYLE FREEDOM LITE KIT W/DEVICE Formulary OTC; QL (1 EA per 365 days) W/DEVICE FREESTYLE INSULINX SYSTEM KIT W/DEVICE Formulary OTC; QL (1 EA per 365 days) W/DEVICE FREESTYLE INSULINX TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) FREESTYLE LANCETS Formulary OTC; QL (150 EA per 30 days) FREESTYLE LIBRE 14 DAY READER DEVICE Formulary FREESTYLE LIBRE 14 DAY SENSOR Formulary FREESTYLE LIBRE 2 READER SYSTM DEVICE Formulary FREESTYLE LIBRE 2 SENSOR SYSTM Formulary FREESTYLE LIBRE READER DEVICE Formulary QL (1 EA per 365 days) FREESTYLE LIBRE SENSOR SYSTEM Formulary QL (3 EA per 30 days) FREESTYLE LITE TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML FREESTYLE PRECISION INS SYR 30G X 5/16" 1 ML Formulary OTC 30G X 5/16" 1 ML FREESTYLE PRECISION INS SYR 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML FREESTYLE PRECISION INS SYR 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML FREESTYLE PRECISION NEO SYSTEM KIT Formulary OTC; QL (1 EA per 365 days) W/DEVICE FREESTYLE PRECISION NEO TEST IN VITRO STRIP Formulary OTC; QL (150 EA per 30 days) FREESTYLE SIDEKICK II KIT Formulary OTC; QL (1 EA per 365 days) FREESTYLE SYSTEM KIT Formulary OTC; QL (1 EA per 365 days) FREESTYLE TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) fruit c oral tablet chewable 100 mg Formulary OTC fulvestrant intramuscular solution 250 mg/5ml Formulary FUNGI-NAIL EXTERNAL SOLUTION 25 % Formulary OTC FUNGI-NAIL TOE & FOOT EXTERNAL OINTMENT 5- Formulary OTC 20 % FUNGOID TINCTURE EXTERNAL KIT 2 % Formulary OTC FUNGOID TINCTURE EXTERNAL SOLUTION 2 % Formulary OTC FUNGOID-D EXTERNAL CREAM 1 % Formulary OTC

59 Drug Name Formulary Status Requirements/Limits furosemide oral solution 10 mg/ml Formulary furosemide oral tablet 20 mg, 40 mg, 80 mg Formulary FUSION ORAL CAPSULE 65-65-25-30 MG Formulary OTC FUZEON SUBCUTANEOUS SOLUTION Formulary PA RECONSTITUTED 90 MG FYAVOLV ORAL TABLET 1-5 MG-MCG Formulary gabapentin oral capsule 100 mg, 300 mg, 400 mg Formulary gabapentin oral solution 250 mg/5ml Formulary gabapentin oral tablet 600 mg, 800 mg Formulary GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG Formulary galantamine hydrobromide er oral capsule extended release Formulary 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml Formulary galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg Formulary GARDASIL 9 INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) GARDASIL 9 INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) PREFILLED SYRINGE garlic/epa oral capsule 60-90-250 mg Formulary OTC garlic-lecithin oral capsule 192-650 mg Formulary OTC garlic-parsley oral tablet 100-175 mg Formulary OTC gas relief oral liquid 40 mg/0.6ml Formulary OTC GASTROCROM ORAL CONCENTRATE 100 MG/5ML Formulary GAS-X CHILDRENS ORAL STRIP 40 MG Formulary OTC GAS-X EXTRA STRENGTH ORAL STRIP 62.5 MG Formulary OTC GAS-X EXTRA STRENGTH ORAL TABLET Formulary OTC CHEWABLE 125 MG GAS-X ORAL TABLET CHEWABLE 80 MG Formulary OTC GAS-X PREVENTION ORAL CAPSULE Formulary OTC GAS-X WITH MAALOX EX ST ORAL TABLET Formulary OTC CHEWABLE 500-125 MG GAVILYTE-C ORAL SOLUTION RECONSTITUTED Formulary 240 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED Formulary 236 GM GAVILYTE-N WITH FLAVOR PACK ORAL Formulary SOLUTION RECONSTITUTED 420 GM GAVISCON EXTRA STRENGTH ORAL SUSPENSION Formulary OTC 254-237.5 MG/5ML GAVISCON EXTRA STRENGTH ORAL TABLET Formulary OTC CHEWABLE 160-105 MG GAVISCON ORAL SUSPENSION 95-358 MG/15ML Formulary OTC GAVISCON ORAL TABLET CHEWABLE 80-14.2 MG Formulary OTC G-BUCAL-C MOUTH/THROAT SOLUTION 0.15-0.1 % Formulary OTC G-DOLOGEN ORAL TABLET 2-650 MG Formulary OTC ge-150 oral capsule 150 mg Formulary OTC GEBAUERS INSTANT ICE EXTERNAL AEROSOL Formulary OTC

60 Drug Name Formulary Status Requirements/Limits gelatin oral capsule 650 mg Formulary OTC GELFOAM SPONGE EXTERNAL 12-7 MM Formulary GELFOAM SPONGE SIZE 100 EXTERNAL Formulary GEL-KAM DENTAL GEL 0.4 % Formulary OTC GELONASAL NASAL SOLUTION Formulary OTC GELUSIL ORAL TABLET CHEWABLE 200-200-25 MG Formulary OTC gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 Formulary gm/52.6ml, 200 mg/5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 Formulary gm, 200 mg gemfibrozil oral tablet 600 mg Formulary GENCONTUSS ORAL LIQUID 5-2-10 MG/5ML Formulary OTC GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 0.2 MG SUBCUTANEOUS 0.2 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 0.4 MG SUBCUTANEOUS 0.4 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 0.6 MG SUBCUTANEOUS 0.6 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 0.8 MG SUBCUTANEOUS 0.8 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 1 MG SUBCUTANEOUS 1 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 1.2 MG SUBCUTANEOUS 1.2 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 1.4 MG SUBCUTANEOUS 1.4 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 1.6 MG SUBCUTANEOUS 1.6 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 1.8 MG SUBCUTANEOUS 1.8 MG GENOTROPIN MINIQUICK SOLUTION Formulary PA RECONSTITUTED 2 MG SUBCUTANEOUS 2 MG GENOTROPIN SOLUTION RECONSTITUTED 12 MG Formulary PA SUBCUTANEOUS 12 MG GENOTROPIN SOLUTION RECONSTITUTED 5 MG Formulary PA SUBCUTANEOUS 5 MG gentamicin sulfate external cream 0.1 % Formulary gentamicin sulfate external ointment 0.1 % Formulary gentamicin sulfate ophthalmic solution 0.3 % Formulary GENTEAL MILD OPHTHALMIC SOLUTION 0.2 % Formulary OTC GENTEAL MILD TO MODERATE OPHTHALMIC Formulary OTC SOLUTION 0.3 % GENTEAL OPHTHALMIC GEL 0.25-0.3 % Formulary OTC GENTEAL TEARS PF OPHTHALMIC SOLUTION 0.1- Formulary OTC 0.3 % gentian violet external solution 1 %, 2 % Formulary OTC gentle laxative rectal suppository 10 mg Formulary OTC GENTLE RAIN EXTERNAL LIQUID 0.3 % Formulary OTC

61 Drug Name Formulary Status Requirements/Limits gentle skin cleanser external lotion Formulary OTC GENTLE-LET GP LANCETS Formulary OTC; QL (150 EA per 30 days) GENTLE-LET LANCETS Formulary OTC; QL (150 EA per 30 days) GENVOYA ORAL TABLET 150-150-200-10 MG Formulary geravine oral elixir Formulary OTC geriatric vitamin oral liquid 100-1-10 Formulary OTC gerisilk bath oil external oil Formulary OTC GERMBLOC HEALTH EXTERNAL FOAM 0.1 % Formulary OTC GILTUSS COUGH & COLD ORAL LIQUID 10-29-390 Formulary OTC MG/5ML ginger root oral capsule 500 mg Formulary OTC ginseng oral capsule 250 mg, 50 mg Formulary OTC gla-45 oral capsule 45 mg Formulary OTC glass syringe 3 ml kit Formulary glatiramer acetate subcutaneous solution prefilled syringe Formulary 20 mg/ml, 40 mg/ml glen pe oral liquid 16-5 mg/5ml Formulary OTC glenmax peb dm forte oral liquid 10-4-20 mg/5ml Formulary OTC glenmax peb dm oral liquid 5-2-10 mg/5ml Formulary OTC; AGE (Min 2 Years) glenmax peb oral liquid 4-10 mg/5ml Formulary OTC glentuss oral liquid 30-6.25-15 mg/5ml Formulary OTC g-levocarnitine s/f oral solution 1 gm/10ml Formulary OTC glimepiride oral tablet 1 mg, 2 mg, 4 mg Formulary glipizide er oral tablet extended release 24 hour 10 mg, 2.5 Formulary mg, 5 mg glipizide oral tablet 10 mg, 5 mg Formulary glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 Formulary mg, 5 mg glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, Formulary 5-500 mg global inject ease insulin syr 29g x 1/2" 1 ml 29g x 1/2" 1 Formulary OTC ml global inject ease insulin syr 30g x 1/2" 1 ml 30g x 1/2" 1 Formulary OTC ml global insulin syringes 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 Formulary OTC ml GLUCAGEN HYPOKIT INJECTION SOLUTION Formulary QL (2 EA per 34 days) RECONSTITUTED 1 MG glucagon emergency injection kit 1 mg Formulary QL (2 EA per 34 days) GLUCOCOM AUTOLINK TELEMONITOR Formulary OTC GLUCOCOM LANCETS 28G Formulary OTC; QL (150 EA per 30 days) GLUCOCOM LANCETS 30G Formulary OTC; QL (150 EA per 30 days) GLUCOCOM LANCETS 33G Formulary OTC; QL (150 EA per 30 days) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML Formulary OTC 30G X 1/2" 0.3 ML GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.5 ML Formulary OTC 30G X 1/2" 0.5 ML 62 Drug Name Formulary Status Requirements/Limits GLUCOPRO INSULIN SYRINGE 30G X 1/2" 1 ML 30G Formulary OTC X 1/2" 1 ML GLUCOPRO INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML GLUCOPRO INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML GLUCOPRO INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML GLUCOPRO INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML GLUCOPRO INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML GLUCOPRO INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML glucosamine chond complex/msm oral tablet Formulary OTC glucosamine chondroitin complx oral capsule 500-250 mg Formulary OTC glucosamine complex/vitamin d3 oral tablet Formulary OTC glucosamine hcl oral tablet 1500 mg Formulary OTC glucosamine sulfate oral capsule 1000 mg, 500 mg Formulary OTC glucosamine sulfate oral tablet 1000 mg Formulary OTC glucosamine-chondroitin oral capsule 250-200 mg, 500-400 Formulary OTC mg glucosamine-chondroitin oral liquid 1500-1200 mg/30ml Formulary OTC glucosamine-chondroitin oral tablet 500-400 mg, 750-600 Formulary OTC mg glucosamine-chondroitin-msm oral tablet 400-333.3-200 Formulary OTC mg, 500-400-167 mg glucosamine-chondroitin-vit d3 oral packet 1500-1200-800 Formulary OTC mg-mg-unit glucosamine-msm oral liquid 1500-500 mg/30ml Formulary OTC GLUCOSE NURSETTE ORAL SOLUTION 5 % Formulary OTC glucose oral gel 40 % Formulary OTC glucose oral liquid 15 gm/59ml Formulary OTC glucose oral tablet chewable 4 gm, 4-6 gm-mg Formulary OTC glutamine oral capsule 500 mg Formulary OTC glutathione oral tablet 50 mg Formulary OTC glutol oral liquid Formulary OTC glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Formulary glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Formulary glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, Formulary 5-500 mg glycerin (adult) rectal suppository 2 gm Formulary OTC glycerin (infants & children) rectal suppository 1 gm, 1.2 Formulary OTC gm glycerin external liquid Formulary OTC glycine500 oral packet 500 mg Formulary OTC glycolic acid solution 70 % Formulary

63 Drug Name Formulary Status Requirements/Limits glycopyrrolate oral tablet 1 mg, 2 mg Formulary GLYDO EXTERNAL GEL 2 % Formulary GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG Formulary ST; AGE (Min 18 Years) g-myco nail external solution Formulary OTC gnp 24 hour nasal allergy aerosol 55 mcg/act nasal 55 Formulary OTC mcg/act gnp 4x probiotic oral tablet Formulary OTC gnp advanced eye health oral capsule 250-2.5-0.5 mg Formulary OTC gnp alcohol denatured solution Formulary OTC gnp alcohol swabs pad 70 % 70 % Formulary OTC gnp allergy & sinus headache oral tablet 25-10-650 mg Formulary OTC gnp animal shapes plus iron oral tablet chewable 15 mg Formulary OTC gnp b-50 complex oral tablet extended release Formulary OTC gnp b-complex plus vitamin c oral tablet Formulary OTC gnp calamine external lotion 8-8 % Formulary OTC gnp calcium 600 plus d/mineral oral tablet 600-400 mg-unit Formulary OTC gnp calcium plus 600 +d oral tablet 600-200 mg-unit Formulary OTC gnp capsaicin external liquid 0.15 % Formulary OTC gnp childrens chewables/ex c oral tablet chewable Formulary OTC gnp coq-10 & fish oil oral capsule 120-180-50-30 Formulary OTC gnp ethyl alcohol solution 70 % Formulary OTC gnp fish oil oral capsule 435 mg Formulary OTC gnp gentian violet external solution 1 % Formulary OTC gnp glycerin/rose water external solution 10 % Formulary OTC gnp headache relief extra str oral tablet 250-250-65 mg Formulary OTC gnp insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC gnp insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC gnp insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC gnp insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC gnp insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC gnp insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC gnp insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC gnp insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC gnp insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC gnp insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC gnp insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC gnp iodides external tincture Formulary OTC gnp iodine external tincture Formulary OTC gnp isopropyl alcohol wipes 70 % external 70 % Formulary OTC gnp lancets Formulary OTC; QL (150 EA per 30 days) gnp lancets 21g Formulary OTC; QL (150 EA per 30 days) gnp lancets micro thin 33g Formulary OTC; QL (150 EA per 30 days) gnp lancets super thin 30g Formulary OTC; QL (150 EA per 30 days) gnp lancets thin 26g Formulary OTC; QL (150 EA per 30 days)

64 Drug Name Formulary Status Requirements/Limits gnp lice egg remover external gel Formulary OTC gnp liquid bandage external liquid 0.75-0.2 % Formulary OTC gnp l-lysine oral tablet 600 mg Formulary OTC gnp micro thin lancets 33g Formulary OTC; QL (150 EA per 30 days) gnp niacin oral tablet 250 mg Formulary OTC gnp omeprazole oral tablet delayed release 20 mg Formulary OTC gnp pain relief/benzocaine external pad 6-70 % Formulary OTC gnp potassium oral tablet 99 mg Formulary OTC gnp shampoo & body wash external liquid Formulary OTC gnp sinus wash refill nasal packet 2300-700 mg Formulary OTC gnp super thin lancets 30g Formulary OTC; QL (150 EA per 30 days) gnp terbinafine hydrochloride external cream 1 % Formulary OTC gnp ultra com insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" Formulary OTC 0.5 ml gnp ultra com insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 Formulary OTC ml gnp ultra com insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" Formulary OTC 0.3 ml gnp ultra com insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" Formulary OTC 0.5 ml gnp ultra com insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 Formulary OTC ml gnp ultra com insulin syringe 30g x 5/16" 0.3 ml 30g x Formulary OTC 5/16" 0.3 ml gnp ultra com insulin syringe 30g x 5/16" 0.5 ml 30g x Formulary OTC 5/16" 0.5 ml gnp ultra com insulin syringe 30g x 5/16" 1 ml 30g x 5/16" Formulary OTC 1 ml gnp ultra com insulin syringe 31g x 5/16" 0.3 ml 31g x Formulary OTC 5/16" 0.3 ml gnp ultra com insulin syringe 31g x 5/16" 0.5 ml 31g x Formulary OTC 5/16" 0.5 ml gnp ultra com insulin syringe 31g x 5/16" 1 ml 31g x 5/16" Formulary OTC 1 ml gnp urinary pain relief oral tablet 97.5 mg Formulary OTC gnp vitamin d super strength oral tablet 125 mcg (5000 ut) Formulary OTC gnp vitamin d-400 oral tablet 90-400 mg-unit Formulary OTC GOLD BOND MULTI-SYMPTOM EXTERNAL CREAM Formulary OTC 4 % GOLD BOND RAPID RELIEF EXTERNAL CREAM 1-1 Formulary OTC % GOLD BOND ULTIMATE EXTERNAL LOTION Formulary OTC GONIOSOL OPHTHALMIC SOLUTION 2.5 % Formulary OTC GONIOTAIRE OPHTHALMIC SOLUTION 2.5 % Formulary OTC GONIOVISC OPHTHALMIC SOLUTION 2 % Formulary OTC GOOD START 5% GLUCOSE WATER ORAL Formulary OTC SOLUTION 5 % goodsense all day allergy oral tablet 10 mg Formulary OTC 65 Drug Name Formulary Status Requirements/Limits goodsense cough dm oral suspension extended release 30 Formulary OTC mg/5ml goodsense eye drops ophthalmic solution 0.05 % Formulary OTC goodsense flu/cold/cough/night oral packet 25-10-650 mg Formulary OTC goodsense flu/cold/daytime oral packet 20-10-500 mg Formulary OTC goodsense ibuprofen childrens oral suspension 100 mg/5ml Formulary OTC goodsense ibuprofen infants oral suspension 50 mg/1.25ml Formulary OTC goodsense ibuprofen oral tablet 200 mg Formulary OTC goodsense lancets 30g Formulary OTC; QL (150 EA per 30 days) goodsense lancets 33g Formulary OTC; QL (150 EA per 30 days) goodsense lubricant eye drops ophthalmic solution 0.4-0.3 Formulary OTC % goodsense miconazole 1 vaginal kit 1200 & 2 mg & % Formulary OTC goodsense nicotine mouth/throat gum 4 mg Formulary OTC goodsense nighttime cold & flu oral liquid 5-6.25-10-325 Formulary OTC mg/15ml goodsense redness relief plus ophthalmic solution 0.5-0.03 Formulary OTC % goodsense sinus congest/pain oral 2-5-325 & 5-325 mg Formulary OTC goodsense sleeptime oral liquid 50 mg/30ml Formulary OTC goodsense sore throat spray mouth/throat liquid 1.4 % Formulary OTC gordomatic external crystals Formulary OTC GORDONS NO 5 EXTERNAL AEROSOL POWDER Formulary OTC gordons urea external ointment 22 % Formulary OTC GORDONS-VITE A EXTERNAL CREAM 100000 Formulary OTC UNIT/GM GORDONS-VITE A EXTERNAL LOTION 100000 UNIT Formulary OTC GORDO-POOL CONCENTRATE Formulary OTC GRANDPAS OATMEAL SOAP EXTERNAL BAR Formulary OTC GRANDPAS THYLOX SOAP EXTERNAL BAR 3 % Formulary OTC GRANIX SUBCUTANEOUS SOLUTION PREFILLED Formulary PA SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML green soap external tincture Formulary OTC griseofulvin microsize oral suspension 125 mg/5ml Formulary griseofulvin microsize oral tablet 500 mg Formulary grx wound external gel Formulary OTC G-TRON PED ORAL LIQUID 10-15-350 MG/5ML Formulary OTC G-TUSICOF ORAL LIQUID 10-20-400 MG/5ML Formulary OTC guaifenesin oral tablet 400 mg Formulary OTC guaifenesin-codeine oral solution 100-10 mg/5ml Formulary OTC; AGE (Min 6 Years) guanfacine hcl er oral tablet extended release 24 hour 1 Formulary mg, 2 mg, 3 mg, 4 mg guanfacine hcl oral tablet 1 mg, 2 mg Formulary guanidine hcl oral tablet 125 mg Formulary gumsol mouth/throat liquid 5-0.1 % Formulary OTC GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % Formulary OTC 66 Drug Name Formulary Status Requirements/Limits GYNE-LOTRIMIN VAGINAL CREAM 1 % Formulary OTC H2Q ORAL POWDER 200 MG/GM Formulary OTC HAILEY FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary halobetasol propionate external cream 0.05 % Formulary haloperidol decanoate intramuscular solution 100 mg/ml, Formulary AGE (Min 18 Years) 50 mg/ml haloperidol lactate injection solution 5 mg/ml Formulary haloperidol lactate oral concentrate 2 mg/ml Formulary AGE (Min 18 Years) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 Formulary AGE (Min 18 Years) mg hand wipes external 0.13 % Formulary OTC HARD NAILS ORAL CAPSULE 2.5 MG Formulary OTC HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL Formulary AGE (Min 19 Years) U/ML, 720 EL U/0.5ML HC DERMAPAX EXTERNAL LIQUID 0.5-0.5 % Formulary OTC H-CHLOR 12 EXTERNAL SOLUTION 0.125 % Formulary OTC H-CHLOR 6 EXTERNAL SOLUTION 0.062 % Formulary OTC headache relief pm oral tablet 500-38 mg Formulary OTC healthy accents unilet lancets Formulary OTC; QL (150 EA per 30 days) hearing aid batteries Formulary OTC heartburn antacid ex st oral tablet chewable 160-105 mg Formulary OTC heartburn treatment 24 hour oral capsule delayed release Formulary OTC; QL (34 EA per 34 days) 15 mg h-e-b incontrol alcohol pad Formulary OTC h-e-b incontrol lancets 28g Formulary OTC; QL (150 EA per 30 days) h-e-b incontrol lancets 30g Formulary OTC; QL (150 EA per 30 days) h-e-b incontrol lancets 33g Formulary OTC; QL (150 EA per 30 days) HEET TRIPLE ACTION EXTERNAL LIQUID Formulary OTC hematinic/folic acid oral tablet 324-1 mg Formulary HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG Formulary HEMATOGEN ORAL CAPSULE Formulary HEMOCYTE ORAL TABLET 324 (106 FE) MG Formulary OTC hemorrhoidal cooling rectal gel 0.25-50 % Formulary OTC hemorrhoidal max st/aloe rectal cream 1-0.25-14.4-15 % Formulary OTC hemorrhoidal rectal suppository 0.25-3-85.5 %, 0.25-85.39 Formulary OTC %, 0.25-88.44 % heparin (porcine) in nacl injection solution 100-0.45 Formulary unit/ml-%, 2-0.9 unit/ml-%, 50-0.45 unit/ml-% heparin sodium (porcine) injection solution 1000 unit/ml, Formulary 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 Formulary unit/0.5ml HERCEPTIN INTRAVENOUS SOLUTION Formulary RECONSTITUTED 440 MG hetastarch-nacl intravenous solution 6-0.9 % Formulary HETLIOZ LQ ORAL SUSPENSION 4 MG/ML Formulary PA

67 Drug Name Formulary Status Requirements/Limits HEXALEN ORAL CAPSULE 50 MG Formulary HIBICLENS EXTERNAL LIQUID 4 % Formulary OTC high potency iron oral tablet 27 mg Formulary OTC histaflex oral tablet 325-25 mg Formulary OTC HISTEX ORAL SYRUP 2.5 MG/5ML Formulary OTC HISTEX ORAL TABLET CHEWABLE 1.25 MG Formulary OTC HISTEX PD ORAL LIQUID 0.938 MG/ML Formulary OTC HISTEX PDX ORAL LIQUID 1.25 MG/ML Formulary OTC HISTEX-AC ORAL SYRUP 10-2.5-10 MG/5ML Formulary OTC HISTEX-DM ORAL SYRUP 10-2.5-20 MG/5ML Formulary OTC HISTEX-PE ORAL SYRUP 2.5-10 MG/5ML Formulary OTC hm calamine external lotion 8-8 % Formulary OTC hm clear fiber oral powder Formulary OTC hm ethyl rubbing alcohol solution 70 % Formulary OTC hm iodides external tincture Formulary OTC hm iodine external tincture Formulary OTC hm iron oral tablet 200 (65 fe) mg Formulary OTC hm melatonin quick dissolve oral tablet dispersible 10 mg Formulary OTC hm nighttime sleep aid oral tablet 25 mg Formulary OTC hm omeprazole oral tablet delayed release 20 mg Formulary OTC hm probiotic digestive health oral capsule Formulary OTC hm rolled gauze bandage Formulary OTC HM SALONPAS PAIN RELIEF EXTERNAL PATCH 1.2- Formulary OTC 5.7-6.3 % hm severe cold/cough/flu oral packet 20-10-650 mg Formulary OTC hm super vitamin b12 oral tablet chewable 2500 mcg Formulary OTC hm vitamin b12 oral tablet extended release 1000 mcg Formulary OTC hm z-sleep oral capsule 25 mg Formulary OTC HOLD MOUTH/THROAT LOZENGE 5 MG Formulary OTC HOMATROPAIRE OPHTHALMIC SOLUTION 5 % Formulary HONEY BEARS W/IRON-ZINC ORAL TABLET Formulary OTC CHEWABLE 30-200-3 HPR PLUS HYDROGEL EXTERNAL KIT Formulary huber needle 19g x 1-1/4" , 19g x 3/4" , 20g x 1-1/4" , 20g x Formulary OTC 3/4" , 22g x 1-1/4" HUGGIES NATURAL CARE WIPES Formulary OTC HUMALOG JUNIOR KWIKPEN SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 Formulary UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML SUBCUTANEOUS Formulary (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS Formulary SUSPENSION (50-50) 100 UNIT/ML

68 Drug Name Formulary Status Requirements/Limits HUMALOG MIX 75/25 KWIKPEN SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML SUBCUTANEOUS Formulary (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS Formulary SUSPENSION (75-25) 100 UNIT/ML HUMALOG SOLUTION CARTRIDGE 100 UNIT/ML Formulary SUBCUTANEOUS 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 Formulary UNIT/ML HUMAN ALBUMIN GRIFOLS INTRAVENOUS Formulary SOLUTION 25 % HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- Formulary 1200 UNIT humidifier Formulary OTC; QL (2 EA per 365 days) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 Formulary AGE (Min 2 Years) MG/0.8ML HUMIRA PEDIATRIC CROHNS START SP; QL (2 EA per 28 days); AGE (Min 2 SUBCUTANEOUS PREFILLED SYRINGE KIT 80 Formulary Years) MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT SP; QL (2 EA per 28 days); AGE (Min 2 Formulary 40 MG/0.4ML, 40 MG/0.8ML Years) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS SP; QL (2 EA per 28 days); AGE (Min 2 Formulary PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML Years) HUMIRA PEN-PS/UV/ADOL HS START SP; QL (2 EA per 28 days); AGE (Min 2 SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, Formulary Years) 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE SP; QL (2 EA per 28 days); AGE (Min 2 KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 Formulary Years) MG/0.4ML, 40 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE Formulary AGE (Min 2 Years) KIT 40 MG/0.8ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- Formulary OTC 30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 Formulary OTC UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML Formulary OTC HUMULIN R U-500 (CONCENTRATED) Formulary SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SOLUTION PEN- INJECTOR 500 UNIT/ML SUBCUTANEOUS 500 Formulary UNIT/ML HURRICAINE MOUTH/THROAT AEROSOL 20 % Formulary OTC HURRICAINE MOUTH/THROAT SOLUTION 20 % Formulary OTC HURRICAINE MOUTH/THROAT SWAB 20 % Formulary OTC

69 Drug Name Formulary Status Requirements/Limits HURRICAINE ONE MOUTH/THROAT SOLUTION 20 Formulary OTC % HURRIVIEW DENTAL SWAB 1.5 % Formulary OTC HURRIVIEW II DENTAL SWAB Formulary OTC HYALGAN INTRA-ARTICULAR SOLUTION 20 Formulary PA MG/2ML HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG Formulary hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg Formulary HYDROCELL ADHESIVE DRESSING PAD 6"X6" Formulary OTC hydrocerin external cream Formulary OTC hydrocerin external lotion Formulary OTC hydrochlorothiazide oral capsule 12.5 mg Formulary hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg Formulary hydrocod polst-cpm polst er oral suspension extended Formulary AGE (Min 6 Years) release 10-8 mg/5ml hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml Formulary PA; QL (1260 ML per 7 days) hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 Formulary PA; QL (63 EA per 7 days) mg hydrocodone-acetaminophen oral tablet 2.5-325 mg Formulary PA; QL (252 EA per 7 days) hydrocodone-acetaminophen oral tablet 5-300 mg, 5-325 Formulary PA; QL (126 EA per 7 days) mg hydrocodone-acetaminophen oral tablet 7.5-300 mg, 7.5- Formulary PA; QL (84 EA per 7 days) 325 mg hydrocodone-homatropine oral syrup 5-1.5 mg/5ml Formulary AGE (Min 6 Years) hydrocodone-homatropine oral tablet 5-1.5 mg Formulary hydrocodone-ibuprofen oral tablet 10-200 mg Formulary PA; QL (63 EA per 7 days) hydrocodone-ibuprofen oral tablet 5-200 mg Formulary PA; QL (126 EA per 7 days) hydrocodone-ibuprofen oral tablet 7.5-200 mg Formulary PA; QL (84 EA per 7 days) hydrocortisone ace-pramoxine rectal cream 1-1 % Formulary hydrocortisone butyrate external cream 0.1 % Formulary hydrocortisone butyrate external ointment 0.1 % Formulary hydrocortisone butyrate external solution 0.1 % Formulary hydrocortisone external cream 0.5 % Formulary OTC hydrocortisone external cream 1 %, 2.5 % Formulary hydrocortisone external lotion 2.5 % Formulary hydrocortisone external ointment 0.5 % Formulary OTC hydrocortisone external ointment 1 %, 2.5 % Formulary hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Formulary hydrocortisone rectal cream 1 % Formulary hydrocortisone valerate external cream 0.2 % Formulary hydrocortisone valerate external ointment 0.2 % Formulary HYDROGEL EXTERNAL GEL Formulary OTC hydromet oral syrup 5-1.5 mg/5ml Formulary AGE (Min 6 Years) hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 Formulary mg/ml hydromorphone hcl oral tablet 2 mg Formulary PA; QL (79 EA per 7 days) 70 Drug Name Formulary Status Requirements/Limits hydromorphone hcl oral tablet 4 mg Formulary PA; QL (39 EA per 7 days) hydromorphone hcl oral tablet 8 mg Formulary PA; QL (20 EA per 7 days) hydromorphone hcl pf injection solution 10 mg/ml Formulary hydrophilic external ointment Formulary OTC hydrophilic petrolatum external ointment Formulary OTC hydroxychloroquine sulfate oral tablet 200 mg Formulary hydroxyurea oral capsule 500 mg Formulary hydroxyzine hcl intramuscular solution 50 mg/ml Formulary hydroxyzine hcl oral syrup 10 mg/5ml Formulary hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Formulary hydroxyzine pamoate oral capsule 25 mg, 50 mg Formulary HYLATOPIC PLUS EXTERNAL LOTION Formulary HYOPHEN ORAL TABLET 81.6 MG Formulary hyoscyamine sulfate er oral tablet extended release 12 hour Formulary 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml Formulary hyoscyamine sulfate oral solution 0.125 mg/ml Formulary hyoscyamine sulfate oral tablet 0.125 mg Formulary hyoscyamine sulfate sl sublingual tablet sublingual 0.125 Formulary mg HYPERCARE EXTERNAL SOLUTION 15 % Formulary OTC HYPERRHO S/D INTRAMUSCULAR SOLUTION Formulary PREFILLED SYRINGE 1500 UNIT, 250 UNIT hypodermic needle 21g x 1-1/4" , 25g x 3/4" , 26g x 3/8" Formulary OTC HYPOTEARS OPHTHALMIC SOLUTION 1-1 % Formulary OTC HYSEPT EXTERNAL SOLUTION 0.25 %, 0.5 % Formulary OTC HYVEE ADVANCED ANTACID ORAL SUSPENSION Formulary OTC 400-400-40 MG/5ML HY-VEE LANCETS Formulary OTC; QL (150 EA per 30 days) hy-vee thin lancets Formulary OTC; QL (150 EA per 30 days) ibandronate sodium intravenous solution 3 mg/3ml Formulary PA; QL (1 ML per 90 days) ibandronate sodium oral tablet 150 mg Formulary ibuprofen 100 junior strength oral tablet chewable 100 mg Formulary OTC ibuprofen oral capsule 200 mg Formulary OTC ibuprofen oral tablet 400 mg, 600 mg, 800 mg Formulary ibuprofen pm oral capsule 200-25 mg Formulary OTC ICAR ORAL SUSPENSION 15 MG/1.25ML Formulary OTC ICAR-C ORAL TABLET 100-250 MG Formulary OTC icatibant acetate subcutaneous solution 30 mg/3ml Formulary PA; QL (24 ML per 14 days) ice blue external gel 2 % Formulary OTC ICY HOT EXTERNAL STICK 10-30 % Formulary OTC ICY HOT LIDOCAINE PLUS MENTHOL EXTERNAL Formulary OTC CREAM 4-1 % ICY HOT LIDOCAINE PLUS MENTHOL EXTERNAL Formulary OTC PATCH 4-1 %

71 Drug Name Formulary Status Requirements/Limits idarubicin hcl intravenous solution 10 mg/10ml, 20 Formulary mg/20ml, 5 mg/5ml IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 Formulary GM ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml Formulary ifosfamide intravenous solution reconstituted 1 gm Formulary imatinib mesylate oral tablet 100 mg, 400 mg Formulary PA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Formulary imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, Formulary 75 mg imiquimod external cream 3.75 % Formulary imiquimod external cream 5 % Formulary QL (12 EA per 34 days) imiquimod pump external cream 3.75 % Formulary IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT Formulary immune support oral tablet chewable Formulary OTC IMODIUM A-D ORAL CAPSULE 2 MG Formulary OTC IMODIUM A-D ORAL LIQUID 1 MG/7.5ML Formulary OTC IMODIUM A-D ORAL TABLET 2 MG Formulary OTC IMODIUM MULTI-SYMPTOM RELIEF ORAL TABLET Formulary OTC 2-125 MG IMOVAX RABIES INTRAMUSCULAR INJECTABLE Formulary AGE (Min 19 Years) 2.5 UNIT/ML IMPROVUE OPHTHALMIC SOLUTION PREFILLED Formulary OTC SYRINGE 1.7 % indapamide oral tablet 1.25 mg, 2.5 mg Formulary indomethacin er oral capsule extended release 75 mg Formulary indomethacin oral capsule 25 mg, 50 mg Formulary INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10 Formulary infants gas relief oral suspension 40 mg/0.6ml Formulary OTC INFED INJECTION SOLUTION 50 MG/ML Formulary INFUMORPH 200 INJECTION SOLUTION 200 Formulary MG/20ML (10 MG/ML) INFUMORPH 500 INJECTION SOLUTION 500 Formulary MG/20ML (25 MG/ML) inositol oral tablet 500 mg, 650 mg Formulary OTC INOSITOL-5 ORAL TABLET 324 MG Formulary OTC INSPIRACHAMBER/LARGE DEVICE Formulary QL (2 EA per 365 days) INSPIRACHAMBER/MEDIUM DEVICE Formulary QL (2 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE DEVICE Formulary QL (2 EA per 365 days) INSPIRACHAMBER/SMALL DEVICE Formulary QL (2 EA per 365 days) INSPIREASE Formulary QL (2 EA per 365 days) INSTACLEAN EXTERNAL LIQUID Formulary OTC INSTA-GLUCOSE ORAL GEL 77.4 % Formulary OTC instant ear-dry otic liquid 95-5 % Formulary OTC instant hand sanitizer external liquid 62 % Formulary OTC INSTAT EXTERNAL PAD Formulary 72 Drug Name Formulary Status Requirements/Limits INSUFLON 25G X 0.71" Formulary insulin asp prot & asp flexpen suspension pen-injector (70- Formulary 30) 100 unit/ml subcutaneous (70-30) 100 unit/ml insulin aspart flexpen solution pen-injector 100 unit/ml Formulary subcutaneous 100 unit/ml insulin aspart penfill solution cartridge 100 unit/ml Formulary subcutaneous 100 unit/ml insulin aspart prot & aspart suspension (70-30) 100 unit/ml Formulary subcutaneous (70-30) 100 unit/ml insulin aspart subcutaneous solution 100 unit/ml Formulary insulin lispro (1 unit dial) subcutaneous solution pen- Formulary injector 100 unit/ml insulin lispro junior kwikpen subcutaneous solution pen- Formulary injector 100 unit/ml insulin lispro prot & lispro subcutaneous suspension pen- Formulary injector (75-25) 100 unit/ml insulin lispro subcutaneous solution 100 unit/ml Formulary insulin syringe 27g x 1/2" 0.5 ml 27g x 1/2" 0.5 ml Formulary OTC insulin syringe 27g x 1/2" 1 ml 27g x 1/2" 1 ml Formulary OTC insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC insulin syringe 30g x 1/2" 1 ml 30g x 1/2" 1 ml Formulary OTC insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC insulin syringe/needle 27g x 1/2" 0.5 ml 27g x 1/2" 0.5 ml Formulary OTC insulin syringe/needle 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC insulin syringe/needle 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC INSUPEN ULTRAFIN 30G X 8 MM Formulary OTC INTEGRA ORAL CAPSULE 62.5-62.5-40-3 MG Formulary OTC intense cough reliever ex st oral liquid 20-300 mg/5ml Formulary OTC INTERDRY AG TEXTILE 10"X144" EXTERNAL Formulary OTC SHEET INTRASITE GEL APPLIPAK EXTERNAL GEL Formulary OTC INTRON A INJECTION SOLUTION 10000000 Formulary PA UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED Formulary PA 10000000 UNIT, 18000000 UNIT, 50000000 UNIT INTROVALE ORAL TABLET 0.15-0.03 MG Formulary QL (91 EA per 91 days)

73 Drug Name Formulary Status Requirements/Limits INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, Formulary AGE (Min 18 Years) 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 Formulary AGE (Min 18 Years) MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML INVIRASE ORAL CAPSULE 200 MG Formulary INVIRASE ORAL TABLET 500 MG Formulary INVOKAMET ORAL TABLET 150-1000 MG, 150-500 Formulary ST; AGE (Min 18 Years) MG, 50-1000 MG, 50-500 MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 Formulary ST; AGE (Min 18 Years) MG, 50-500 MG INVOKANA ORAL TABLET 100 MG, 300 MG Formulary PA; AGE (Min 18 Years) iodides tincture external tincture Formulary OTC iodine external tincture , 2 % Formulary OTC iodine strong external tincture 6.9-5 % Formulary OTC iodine strong oral solution 5 % Formulary iodine tincture external tincture Formulary OTC iodine tincture external tincture 2 % Formulary IONIL EXTERNAL SHAMPOO 2-0.2 % Formulary OTC IONIL-T EXTERNAL SHAMPOO 1 % Formulary OTC IONSYS TRANSDERMAL PATCH 40 MCG/ACT Formulary PA IPOL INJECTION INJECTABLE Formulary AGE (Min 19 Years) ipratropium bromide inhalation solution 0.02 % Formulary ipratropium bromide nasal solution 0.03 % Formulary QL (60 ML per 34 days) ipratropium bromide nasal solution 0.06 % Formulary QL (30 ML per 34 days) ipratropium-albuterol inhalation solution 0.5-2.5 (3) Formulary mg/3ml irbesartan oral tablet 150 mg, 300 mg, 75 mg Formulary irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, Formulary 300-12.5 mg irinotecan hcl intravenous solution 100 mg/5ml, 300 Formulary mg/15ml, 40 mg/2ml, 500 mg/25ml IROFOL ORAL LIQUID 100-1000-15 MG-MCG/5ML Formulary OTC IROFOL ORAL TABLET 150-0.025-1 MG Formulary OTC iron (ferrous sulfate) oral tablet extended release 142 (45 Formulary OTC fe) mg iron 100 plus oral tablet 100-250-0.025-1 mg Formulary OTC iron 100/c oral tablet 100-250 mg Formulary OTC iron 21/7 oral Formulary OTC iron 27 oral tablet 240 (27 fe) mg Formulary OTC iron chews pediatric oral tablet chewable 15 mg Formulary OTC iron slow release oral tablet extended release 143 (45 fe) Formulary OTC mg irrigating eyewash ophthalmic solution Formulary OTC

74 Drug Name Formulary Status Requirements/Limits ISENTRESS HD ORAL TABLET 600 MG Formulary ISENTRESS ORAL TABLET 400 MG Formulary ISOLEUCINE 1000 ORAL PACKET 1 GM Formulary OTC isoleucine oral packet 50 mg Formulary OTC isoniazid oral syrup 50 mg/5ml Formulary isoniazid oral tablet 100 mg, 300 mg Formulary isopropyl alcohol (rubbing) solution 70 % Formulary OTC isopropyl alcohol solution 50 % Formulary OTC isopropyl alcohol solution 70 % Formulary isopropyl alcohol wipes 70 % external 70 % Formulary OTC ISOPTO TEARS OPHTHALMIC SOLUTION 0.5 % Formulary OTC isosorbide dinitrate er oral tablet extended release 40 mg Formulary isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg Formulary isosorbide mononitrate er oral tablet extended release 24 Formulary hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg Formulary isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg Formulary isradipine oral capsule 2.5 mg, 5 mg Formulary itch relief external cream 2 % Formulary OTC ITCH-X EXTERNAL GEL 1-10 % Formulary OTC ITCH-X EXTERNAL SOLUTION 1-10 % Formulary OTC itraconazole oral capsule 100 mg Formulary QL (34 EA per 34 days) itraconazole oral solution 10 mg/ml Formulary IVAREST MEDICATED POISON IVY EXTERNAL Formulary OTC LIQUID 1 % IVAREST POISON IVY ITCH EXTERNAL CREAM 2- Formulary OTC 14-10.5 % ivermectin oral tablet 3 mg Formulary ivy wash poison ivy cleanser external lotion 1 % Formulary OTC IXEMPRA KIT INTRAVENOUS SOLUTION Formulary RECONSTITUTED 15 MG, 45 MG IXIARO INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) J & J ALL-PURPOSE FIRST AID COMBINATION KIT Formulary OTC J & J DENTAL FLOSS FOR KIDS Formulary OTC JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 Formulary MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG JANUMET ORAL TABLET 50-1000 MG, 50-500 MG Formulary ST; AGE (Min 18 Years) JANUMET XR ORAL TABLET EXTENDED RELEASE Formulary ST; AGE (Min 18 Years) 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Formulary ST; AGE (Min 18 Years) JARDIANCE ORAL TABLET 10 MG, 25 MG Formulary ST; AGE (Min 18 Years) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 Formulary ST; AGE (Min 18 Years) MG, 2.5-850 MG jessners external solution Formulary OTC jock itch spray external aerosol powder 1 % Formulary OTC

75 Drug Name Formulary Status Requirements/Limits JOHNSONS BABY CORNSTARCH EXTERNAL Formulary OTC POWDER JOHNSONS BABY OIL GEL EXTERNAL GEL Formulary OTC JOHNSONS BABY POWDER EXTERNAL POWDER Formulary OTC JULUCA ORAL TABLET 50-25 MG Formulary JUNEL 1/20 ORAL TABLET 1-20 MG-MCG Formulary JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary k 100 oral tablet 100 mcg Formulary OTC k-99 oral capsule 595 mg Formulary OTC KAITLIB FE ORAL TABLET CHEWABLE 0.8-25 MG- Formulary MCG KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML Formulary PA; QL (6 ML per 34 days) KANGAROO ENTRIFLUSH PUMP SET Formulary KANGAROO JOEY PUMP SET Formulary KANK-A MOUTH PAIN MOUTH/THROAT SOLUTION Formulary OTC 20 % KANK-A SOFTBRUSH MOUTH/THROAT GEL 20-0.1 Formulary OTC % KAOPECTATE ORAL TABLET 262 MG Formulary OTC KARBOZYME ORAL TABLET DELAYED RELEASE Formulary OTC 167-173-346 MG K-BICARB ORAL CAPSULE 99 MG Formulary OTC kedbumin intravenous solution 25 % Formulary KELNOR 1/35 ORAL TABLET 1-35 MG-MCG Formulary QL (28 EA per 28 days) kelp oral tablet 150 mcg Formulary OTC kelp-b6-lecithin-vinegar oral capsule 5-0.75-200-50 mg Formulary OTC KENALOG INJECTION SUSPENSION 10 MG/ML Formulary KENDALL ALGINATE DRESS 8"X8" EXTERNAL PAD Formulary OTC KENDALL ANTIMICROBIAL BANDAGE EXTERNAL Formulary OTC KENDALL CA ALGINATE 6"X10" EXTERNAL Formulary OTC KENDALL HYDROPHILIC FOAM DRESS PAD 4"X8" , Formulary OTC 5"X5" KENDALL TRANSPARENT FILM DRESS Formulary OTC KEPIVANCE INTRAVENOUS SOLUTION Formulary RECONSTITUTED 6.25 MG KERAMATRIX REPLICINE 10CMX10CM EXTERNAL Formulary SHEET KERASAL EXTERNAL OINTMENT 5-10 % Formulary OTC KERR TRIPLE DYE SWABS EXTERNAL SWAB Formulary OTC KESIMPTA SUBCUTANEOUS SOLUTION AUTO- Formulary PA INJECTOR 20 MG/0.4ML ketoconazole external cream 2 % Formulary ketoconazole external foam 2 % Formulary ketoconazole external shampoo 2 % Formulary ketoconazole oral tablet 200 mg Formulary

76 Drug Name Formulary Status Requirements/Limits ketorolac tromethamine injection solution 15 mg/ml, 30 Formulary mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml Formulary ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % Formulary ketorolac tromethamine oral tablet 10 mg Formulary QL (20 EA per 34 days) KETOSTIX IN VITRO STRIP Formulary OTC ketotifen fumarate ophthalmic solution 0.025 % Formulary kettle neti pot sinus wash nasal kit 2300-700 mg Formulary OTC KEY OMEGA ORAL PACKET 200-100 MG Formulary OTC k-iii oral solution reconstituted 33.3-33.3-33.3 % Formulary OTC KINERASE EXTERNAL CREAM 0.1 %, 0.125 % Formulary OTC KINERASE EXTERNAL LOTION 0.1 % Formulary OTC kinney lancets Formulary OTC; QL (150 EA per 30 days) kinney thin lancets Formulary OTC kinray insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC kinray insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC kinray insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC kinray insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC KINRIX INTRAMUSCULAR SUSPENSION Formulary KIONEX ORAL SUSPENSION 15 GM/60ML Formulary AGE (Min 19 Years) KITABIS PAK NEBULIZATION SOLUTION 300 QL (280 ML per 28 days); AGE (Min 6 Formulary MG/5ML INHALATION 300 MG/5ML Years) KLOR-CON 10 ORAL TABLET EXTENDED RELEASE Formulary 10 MEQ KLOR-CON M15 ORAL TABLET EXTENDED Formulary RELEASE 15 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 Formulary MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED Formulary RELEASE 10 MEQ, 8 MEQ KLS ALLER-CORT AEROSOL 55 MCG/ACT NASAL 55 Formulary OTC MCG/ACT kls cold & flu ms day/night oral tablet therapy pack Formulary OTC kls esomeprazole magnesium oral capsule delayed release Formulary OTC 20 mg kls omeprazole oral tablet delayed release 20 mg Formulary OTC K-MAG ASPARTATE ORAL TABLET 250-250 MG Formulary OTC K-MAG ORAL CAPSULE 40-40 MG Formulary OTC K-MAG-70 ORAL CAPSULE 70-70 MG Formulary OTC kmart valu insulin syringe 29g u-100 0.5 ml u-100 0.5 ml Formulary OTC kmart valu insulin syringe 29g u-100 1 ml u-100 1 ml Formulary OTC kmart valu insulin syringe 30g u-100 0.3 ml u-100 0.3 ml Formulary OTC kmart valu insulin syringe 30g u-100 0.5 ml u-100 0.5 ml Formulary OTC kmart valu insulin syringe 30g u-100 1 ml u-100 1 ml Formulary OTC konsyl daily fiber oral packet 100 % Formulary OTC konsyl daily fiber oral powder 100 % Formulary OTC 77 Drug Name Formulary Status Requirements/Limits KONSYL ORAL PACKET 28.3 %, 60.3 % Formulary OTC KONSYL ORAL POWDER 60.3 %, 71.67 % Formulary OTC KONSYL-D ORAL POWDER 52.3 % Formulary OTC korean ginseng oral capsule 350 mg Formulary OTC kp hydrocortisone-aloe external cream 0.5 % Formulary OTC kp ketotifen fumarate ophthalmic solution 0.025 % Formulary OTC kp mag-oxide magnesium oral tablet 200 mg Formulary OTC kp silicone scar therapy gel strip Formulary OTC K-PHOS NO 2 ORAL TABLET 305-700 MG Formulary K-PHOS ORAL TABLET 500 MG Formulary kpn prenatal oral tablet 0.1 mg Formulary OTC krill oil oral capsule 300 mg Formulary OTC KROGER HEALTHPRO LANCET 26G Formulary OTC; QL (150 EA per 30 days) kroger insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC kroger insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC kroger insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC kroger insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC kroger insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC kroger insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC kroger insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC kroger insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC kroger insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC kroger lancets Formulary OTC; QL (150 EA per 30 days) kroger lancets 21g Formulary OTC; QL (150 EA per 30 days) kroger lancets micro thin 33g Formulary OTC; QL (150 EA per 30 days) kroger lancets super thin Formulary OTC; QL (150 EA per 30 days) kroger lancets thin Formulary OTC; QL (150 EA per 30 days) kroger lancets thin 26g Formulary OTC; QL (150 EA per 30 days) kroger lancets ultrathin 30g Formulary OTC; QL (150 EA per 30 days) KT TAPE PRO TAPE Formulary OTC K-TAN PLUS ORAL CAPSULE 162-115.2-1 MG Formulary KWAN LOONG PAIN RELIEVING EXTERNAL OIL Formulary OTC KYLEENA INTRAUTERINE INTRAUTERINE DEVICE Formulary 19.5 MG labetalol hcl intravenous solution 5 mg/ml Formulary labetalol hcl oral tablet 100 mg, 200 mg, 300 mg Formulary LAC-HYDRIN FIVE EXTERNAL LOTION 5 % Formulary OTC LAC-HYDRIN TWELVE EXTERNAL LOTION 12 % Formulary OTC lactated ringers irrigation solution Formulary lactic acid e external cream 10-3500 %-unt/30gm Formulary lactic acid external lotion 10 % Formulary lacto-bifidus-600 oral capsule Formulary OTC LAMISIL ADVANCED EXTERNAL GEL 1 % Formulary OTC LAMISIL AT EXTERNAL CREAM 1 % Formulary OTC

78 Drug Name Formulary Status Requirements/Limits LAMISIL AT EXTERNAL POWDER Formulary OTC LAMISIL AT SPRAY EXTERNAL SOLUTION 1 % Formulary OTC LAMISILK PROTECT EXTERNAL LIQUID Formulary OTC lamivudine oral solution 10 mg/ml Formulary lamivudine oral tablet 100 mg, 150 mg, 300 mg Formulary lamivudine-zidovudine oral tablet 150-300 mg Formulary er oral tablet extended release 24 hour 100 mg, Formulary 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg Formulary lamotrigine oral tablet chewable 25 mg, 5 mg Formulary LANACANE ANTI-BACTERIAL EXTERNAL Formulary OTC AEROSOL 20-0.2 % LANACANE MAXIMUM STRENGTH EXTERNAL Formulary OTC CREAM 20-0.2 % lancets Formulary OTC; QL (150 EA per 30 days) lancets 28g Formulary OTC; QL (150 EA per 30 days) lancets 30g Formulary OTC; QL (150 EA per 30 days) lancets micro thin 33g Formulary OTC; QL (150 EA per 30 days) lancets super thin 28g Formulary OTC; QL (150 EA per 30 days) lancets thin Formulary OTC; QL (150 EA per 30 days) LANCETS ULTRA THIN Formulary OTC; QL (150 EA per 30 days) lancets ultra thin 30g Formulary OTC; QL (150 EA per 30 days) lanolin anhydrous external ointment Formulary lanolin external ointment Formulary OTC lanolin hydrous-grx external ointment 72 % Formulary OTC lansoprazole oral capsule delayed release 15 mg Formulary lansoprazole oral capsule delayed release 30 mg Formulary QL (34 EA per 34 days) lansoprazole oral tablet dispersible 15 mg, 30 mg Formulary PA LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML Formulary l-arginine oral capsule 500 mg Formulary OTC l-arginine oral tablet 1000 mg Formulary OTC LARIN 1/20 ORAL TABLET 1-20 MG-MCG Formulary LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary latanoprost ophthalmic solution 0.005 % Formulary LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 Formulary AGE (Min 18 Years) MG, 80 MG laxative oral tablet 25 mg Formulary OTC laxative pills oral tablet 15 mg Formulary OTC LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 Formulary PA; QL (120 EA per 30 days) MCG/ACT l-carnitine oral capsule 250 mg, 500 mg Formulary OTC l-carnitine oral tablet 250 mg, 500 mg Formulary OTC leader insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC

79 Drug Name Formulary Status Requirements/Limits leader insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC leader insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC leader insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC leader insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC leader insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC leader insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC leader insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC leader insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC leader insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC lecithin-kelp-b6-cider vinegar oral capsule 200-0.075-5-50 Formulary OTC mg leflunomide oral tablet 10 mg, 20 mg Formulary lemon-glycerin mouth/throat swab Formulary OTC LENZAPATCH EXTERNAL PATCH 4-1 % Formulary letrozole oral tablet 2.5 mg Formulary leucine oral packet 100 mg Formulary OTC leucovorin calcium injection solution reconstituted 100 mg, Formulary 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg Formulary LEUKERAN ORAL TABLET 2 MG Formulary leuprolide acetate injection kit 1 mg/0.2ml Formulary PA levalbuterol hcl inhalation nebulization solution 0.31 Formulary PA mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act Formulary LEVEMIR FLEXTOUCH SOLUTION PEN-INJECTOR Formulary 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML Formulary levetiracetam er oral tablet extended release 24 hour 500 Formulary mg, 750 mg levetiracetam in nacl intravenous solution 1000 mg/100ml, Formulary 1500 mg/100ml, 500 mg/100ml levetiracetam intravenous solution 500 mg/5ml Formulary levetiracetam oral solution 100 mg/ml Formulary levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg Formulary levobunolol hcl ophthalmic solution 0.5 % Formulary levocarnitine (dietary) oral tablet 330 mg Formulary OTC levocarnitine fumarate oral capsule 250 mg Formulary OTC levocarnitine oral solution 1 gm/10ml Formulary levocarnitine oral tablet 330 mg Formulary levocarnitine-b5-taurine oral liquid 1000-10-150 mg/15ml Formulary OTC levocetirizine dihydrochloride oral solution 2.5 mg/5ml Formulary levocetirizine dihydrochloride oral tablet 5 mg Formulary levofloxacin intravenous solution 25 mg/ml Formulary levofloxacin ophthalmic solution 0.5 % Formulary levofloxacin oral solution 25 mg/ml Formulary

80 Drug Name Formulary Status Requirements/Limits levofloxacin oral tablet 250 mg, 500 mg, 750 mg Formulary levoleucovorin calcium intravenous solution reconstituted Formulary 50 mg LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 Formulary MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG LEXIVA ORAL SUSPENSION 50 MG/ML Formulary l-glutamine oral capsule 500 mg Formulary OTC l-glutamine oral tablet 500 mg Formulary OTC LICE B GONE CAP SATURATED EXTERNAL KIT Formulary OTC LICE B GONE EXTERNAL SHAMPOO Formulary OTC lice cure external solution Formulary OTC lice killing maximum strength external shampoo 0.33-4 % Formulary OTC LICEFREEE EXTERNAL SOLUTION Formulary OTC LICEMD COMPLETE EXTERNAL KIT 0.33-4 % Formulary OTC LICIDE TREATMENT COMBINATION KIT Formulary OTC lidocaine external cream 5 % Formulary OTC; QL (60 GM per 30 days) lidocaine external ointment 5 % Formulary ST; QL (30 GM per 34 days) lidocaine external patch 5 % Formulary QL (90 EA per 30 days) lidocaine hcl external solution 4 % Formulary lidocaine hcl mouth/throat solution 4 % Formulary lidocaine viscous mouth/throat solution 2 % Formulary lidocaine-hydrocortisone ace rectal cream 3-0.5 % Formulary lidocaine-hydrocortisone ace rectal kit 3-1 %, 3-2.5 % Formulary lidocaine-menthol external gel 4-1 % Formulary OTC lidocaine-prilocaine external cream 2.5-2.5 % Formulary lidocaine-transparent dressing external kit 4 % Formulary OTC LIDOPATCH PAIN RELIEF EXTERNAL PATCH 3.99- Formulary OTC 1.25 % LIDOPRO TRANSDERMAL PATCH 4-4-5 % Formulary OTC LIDOZENGEL EXTERNAL GEL 4-1 % Formulary OTC LILETTA (52 MG) INTRAUTERINE INTRAUTERINE Formulary DEVICE 18.6 MCG/DAY, 19.5 MCG/DAY limencin external patch 4-4 % Formulary OTC lindane external shampoo 1 % Formulary ST; QL (60 ML per 30 days) linezolid oral suspension reconstituted 100 mg/5ml Formulary PA linezolid oral tablet 600 mg Formulary PA LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 Formulary PA; AGE (Min 18 Years) MCG liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg Formulary lip balm external ointment Formulary OTC lip balm external stick Formulary OTC LIP MEDEX EXTERNAL OINTMENT Formulary OTC lipochol nr oral capsule Formulary OTC lipochol plus oral tablet Formulary OTC

81 Drug Name Formulary Status Requirements/Limits LIPO-GEL ORAL CAPSULE 100-30 MG-UNIT Formulary OTC lipoic acid oral capsule 150 mg Formulary OTC LIPOTRIAD ORAL TABLET Formulary OTC LIPOTRIAD VISIONARY ORAL CAPSULE Formulary OTC LIQ-10 ORAL SYRUP 100-1 MG-UNT/5ML, 50-15 Formulary OTC LIQSORB ORAL LIQUID 100 MG/ML Formulary OTC LIQUACEL ORAL LIQUID Formulary OTC LIQUIMAT EXTERNAL LOTION 5 % Formulary OTC lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 Formulary mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Formulary 12.5 mg, 20-25 mg LISTERINE NATURALS ANTISEPTIC Formulary OTC MOUTH/THROAT LIQUID lite touch lancets Formulary OTC; QL (150 EA per 30 days) LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML Formulary OTC 28G X 1/2" 0.5 ML LITETOUCH INSULIN SYRINGE 28G X 1/2" 1 ML 28G Formulary OTC X 1/2" 1 ML LITETOUCH INSULIN SYRINGE 29G X 1/2" 0.3 ML Formulary OTC 29G X 1/2" 0.3 ML LITETOUCH INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML LITETOUCH INSULIN SYRINGE 29G X 1/2" 1 ML 29G Formulary OTC X 1/2" 1 ML LITETOUCH INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML LITETOUCH INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML LITETOUCH INSULIN SYRINGE 30G X 5/16" 1 ML Formulary OTC 30G X 5/16" 1 ML LITETOUCH INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML LITETOUCH INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML LITETOUCH INSULIN SYRINGE 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML LITETOUCH LANCETS Formulary OTC; QL (150 EA per 30 days) lithium carbonate er oral tablet extended release 300 mg, Formulary 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg Formulary lithium carbonate oral tablet 300 mg Formulary lithium oral solution 8 meq/5ml Formulary LITTLE COLDS COUGH FORMULA ORAL LIQUID 7.5 Formulary OTC MG/ML LITTLE COLDS DECONGESTANT ORAL LIQUID 2.5 Formulary OTC MG/ML LITTLE REMEDIES POISON TREAT ORAL Formulary OTC SUSPENSION RECONSTITUTED 15 GM/120ML 82 Drug Name Formulary Status Requirements/Limits LITTLE TUMMYS LAXATIVE ORAL LIQUID 8.8 Formulary OTC MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG Formulary ST live better lancet super thin Formulary OTC; QL (150 EA per 30 days) live better lancet ultra thin Formulary OTC; QL (150 EA per 30 days) liver extract oral tablet 455 mg Formulary OTC liver oral capsule 500 mg Formulary OTC l-lysine hcl oral capsule 500 mg Formulary OTC l-lysine hcl oral tablet 1000 mg Formulary OTC l-lysine oral capsule 500 mg Formulary OTC l-lysine oral tablet 1000 mg, 500 mg Formulary OTC LMX 4 EXTERNAL CREAM 4 % Formulary OTC LMX 4 PLUS EXTERNAL KIT 4 % Formulary OTC LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 Formulary QL (28 EA per 28 days) MCG local anesthesia needle 20g x 4" , 22 x 4" , 22g x 3" Formulary OTC LODRANE D ORAL CAPSULE 4-60 MG Formulary OTC LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Formulary LOHIST-D ORAL LIQUID 2-30 MG/5ML Formulary OTC lohist-dm oral syrup 5-2-10 mg/5ml Formulary OTC; AGE (Min 2 Years) longs insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC longs lancets thin Formulary OTC; QL (150 EA per 30 days) loperamide hcl oral suspension 1 mg/7.5ml Formulary OTC lopinavir-ritonavir oral solution 400-100 mg/5ml Formulary lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg Formulary loratadine childrens oral solution 5 mg/5ml Formulary OTC loratadine oral capsule 10 mg Formulary OTC LORAZEPAM INTENSOL ORAL CONCENTRATE 2 Formulary QL (170 ML per 30 days) MG/ML lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Formulary QL (170 EA per 30 days) LORTUSS DM ORAL LIQUID 30-6.25-15 MG/5ML Formulary OTC LORTUSS EX ORAL LIQUID 30-10-100 MG/5ML Formulary OTC LORTUSS LQ ORAL LIQUID 6.25-30 MG/5ML Formulary OTC losartan potassium oral tablet 100 mg, 25 mg, 50 mg Formulary losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 Formulary mg, 50-12.5 mg LOTRIMIN AF EXTERNAL AEROSOL 2 % Formulary OTC LOTRIMIN AF EXTERNAL CREAM 1 % Formulary OTC LOTRIMIN ULTRA EXTERNAL CREAM 1 % Formulary OTC lovastatin oral tablet 10 mg, 20 mg, 40 mg Formulary loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg Formulary AGE (Min 18 Years) LOZIBASE S Formulary l-phenylalanine oral tablet 500 mg Formulary OTC l-tyrosine oral capsule 500 mg Formulary OTC l-tyrosine oral tablet 500 mg Formulary OTC 83 Drug Name Formulary Status Requirements/Limits lubiprostone oral capsule 24 mcg, 8 mcg Formulary PA; AGE (Min 18 Years) lubricant drops/dual-action ophthalmic solution 0.5-0.9 % Formulary OTC lubricant eye drops ophthalmic solution 0.4-0.3 % Formulary OTC LUBRISKIN EXTERNAL LOTION Formulary OTC LUCENTIS INTRAVITREAL SOLUTION 0.5 Formulary PA; QL (0.05 ML per 28 days) MG/0.05ML LUDENS COUGH DROPS MOUTH/THROAT Formulary OTC LOZENGE 3-60 MG LUDENS THROAT DROPS MOUTH/THROAT LOZENGE 1 MG, 1.6 MG, 1.7 MG, 2.4 MG, 2.5 MG, 2.8 Formulary OTC MG, 4 MG LUPKYNIS ORAL CAPSULE 7.9 MG Formulary PA; QL (180 EA per 30 days) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT Formulary PA; QL (1 EA per 90 days) 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT Formulary PA; QL (1 EA per 90 days) 11.25 MG, 22.5 MG LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Formulary PA; QL (1 EA per 90 days) 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT Formulary PA; QL (1 EA per 90 days) 45 MG LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR Formulary PA; QL (1 EA per 90 days) KIT 11.25 MG, 15 MG, 7.5 MG LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR Formulary PA; QL (1 EA per 90 days) KIT 11.25 MG (PED), 30 MG (PED) lutein oral capsule 15-0.7 mg, 40 mg, 6 mg Formulary OTC lutein oral tablet 10 mg, 20 mg, 6 mg Formulary OTC LUVENA FEMININE WIPES EXTERNAL 1 % Formulary OTC LYCELLE EXTERNAL GEL Formulary OTC lysine4000 oral packet 4000 mg Formulary OTC LYSODREN ORAL TABLET 500 MG Formulary M2 C ORAL CAPSULE EXTENDED RELEASE 500 MG Formulary OTC MAALOX ADVANCED MAX ST ORAL TABLET Formulary OTC CHEWABLE 1000-60 MG MAALOX JUNIOR PLUS ANTIGAS ORAL TABLET Formulary OTC CHEWABLE 400-24 MG MAALOX ORAL TABLET CHEWABLE 600 MG Formulary OTC MACUGEN INTRAOCULAR SOLUTION 0.3 MG Formulary MAG-200 ORAL TABLET 200 MG Formulary OTC mag-al oral liquid 200-200 mg/5ml Formulary OTC magdelay oral tablet delayed release 70 mg Formulary OTC MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 Formulary ML 29G X 1/2" 0.3 ML MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 Formulary ML 29G X 1/2" 0.5 ML MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML Formulary 29G X 1/2" 1 ML MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 Formulary ML 30G X 5/16" 0.3 ML

84 Drug Name Formulary Status Requirements/Limits MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.5 Formulary ML 30G X 5/16" 0.5 ML MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML Formulary 30G X 5/16" 1 ML MAGIC3 INTERMITTENT CATHETER Formulary OTC MAGIMIN ORAL TABLET 80 MG Formulary OTC magnacaps oral capsule 100 mg Formulary OTC MAGNEBIND 200 ORAL TABLET 450-200 MG Formulary OTC MAGNEBIND 300 ORAL TABLET 250-300 MG Formulary OTC magnesium aspartate oral tablet 65 mg Formulary OTC magnesium carbonate oral powder 250 mg/gm Formulary OTC magnesium chloride oral tablet delayed release 64 mg Formulary OTC magnesium chloride-calcium oral tablet 64-112 mg Formulary OTC magnesium citrate oral solution 1.745 gm/30ml Formulary OTC magnesium fizz-plus oral powder effervescent 300-500 Formulary OTC mg/6.1gm magnesium gluconate oral tablet 27.5 mg Formulary OTC magnesium oral capsule 300 mg Formulary OTC magnesium oral tablet 200 mg, 250 mg, 30 mg Formulary OTC magnesium oxide -mg supplement oral tablet 250 mg Formulary OTC magnesium oxide oral capsule 500 mg Formulary OTC magnesium oxide oral powder Formulary OTC magnesium oxide oral tablet 400 (240 mg) mg, 400 (241.3 Formulary OTC mg) mg, 400 mg, 420 mg, 500 mg magnesium sulfate oral capsule 70 mg Formulary OTC magnum-75 oral tablet extended release Formulary OTC MAGONATE ORAL TABLET 500 (27 MG) MG Formulary OTC mag-sr plus calcium oral tablet delayed release 64-106 mg Formulary OTC MAG-TAB SR ORAL TABLET EXTENDED RELEASE Formulary OTC 84 MG (7MEQ) MAKENA SUBCUTANEOUS SOLUTION AUTO- Formulary INJECTOR 275 MG/1.1ML malathion external lotion 0.5 % Formulary ST manganese aspartate oral tablet 93 mg Formulary OTC manganese gluconate oral tablet 50 mg Formulary OTC manganese oral tablet 15 mg Formulary OTC MANGIMIN ORAL TABLET 10 MG Formulary OTC MAOX ORAL TABLET 420 MG Formulary OTC MAPAP HEADACHE PLUS ORAL TABLET 500-250 Formulary OTC MG MAR-COF BP ORAL LIQUID 30-2-7.5 MG/5ML Formulary OTC MAR-COF CG EXPECTORANT ORAL LIQUID 225-7.5 Formulary OTC MG/5ML MASTISOL ADHESIVE EXTERNAL LIQUID Formulary OTC MATULANE ORAL CAPSULE 50 MG Formulary MAVYRET ORAL TABLET 100-40 MG Formulary PA; AGE (Min 12 Years) 85 Drug Name Formulary Status Requirements/Limits MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 Formulary OTC ML 28G X 1/2" 0.5 ML MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 1 ML Formulary OTC 28G X 1/2" 1 ML MAXIMUM D3 ORAL CAPSULE 10000 UNIT Formulary OTC ME-500 ORAL CAPSULE 500 MG Formulary OTC mecholyl external ointment 0.25 % Formulary OTC meclizine hcl oral tablet 12.5 mg, 25 mg Formulary MEDADYNE ORAL PAIN RELIEF MOUTH/THROAT Formulary OTC LIQUID 10-0.13-70 % MEDERMA AG FACIAL CLEANSER EXTERNAL Formulary OTC LIQUID MEDERMA EXTERNAL GEL Formulary OTC MEDERMA PM EXTERNAL CREAM 2 % Formulary OTC medic insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" 0.3 ml Formulary OTC medic insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC medicated body external powder Formulary OTC medicated douche vaginal solution 0.3 % Formulary OTC medicated wipes external pad 50 % Formulary OTC MEDICONE RECTAL SUPPOSITORY 0.25 % Formulary OTC MEDI-DERM/L-RX EXTERNAL CREAM 2-0.035-5-20 Formulary % MEDI-DERM-RX EXTERNAL CREAM 0.035-5-20 % Formulary MEDI-FIRST ANTISEPTIC CLEANER EXTERNAL GEL Formulary OTC 66.5 % MEDI-FIRST/LIDOCAINE EXTERNAL CREAM 0.5- Formulary OTC 0.13 % MEDIHONEY WOUND/BURN DRESSING EXTERNAL Formulary GEL MEDIHONEY WOUND/BURN DRESSING EXTERNAL Formulary PASTE medi-laxx oral capsule 8.6-50 mg Formulary OTC MEDI-LYTE ORAL TABLET 18-9-40 MG Formulary OTC medi-patch-lidocaine external patch 0.5-0.035-5-20 % Formulary OTC MEDIPLAST EXTERNAL 40 % Formulary OTC MEDIPORE + PAD ADHESIVE DRESS PAD 2"X2-3/4" , Formulary OTC 3-1/2"X10" , 3-1/2"X13-3/4" MEDISENSE GLUCOSE KETONE CONTR LIQUID IN Formulary OTC; QL (100 EA per 30 days) VITRO MEDISENSE HI/MID/LOW CONTROL LIQUID IN Formulary OTC; QL (100 EA per 30 days) VITRO MEDISENSE HIGH/LOW CONTROL LIQUID IN VITRO Formulary OTC; QL (100 EA per 30 days) MEDISENSE MID CONTROL LIQUID IN VITRO Formulary OTC; QL (100 EA per 30 days) MEDISENSE THIN LANCETS Formulary OTC; QL (150 EA per 30 days) medi-tussin dm double strength oral liquid 30-200 mg/5ml Formulary OTC MEDROX EXTERNAL OINTMENT 0.0375-5-20 % Formulary OTC MEDROX EXTERNAL PATCH 0.0375-5-20 % Formulary OTC

86 Drug Name Formulary Status Requirements/Limits medroxyprogesterone acetate intramuscular suspension 150 Formulary QL (1 ML per 90 days) mg/ml medroxyprogesterone acetate intramuscular suspension Formulary prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 Formulary mg mefenamic acid oral capsule 250 mg Formulary mefloquine hcl oral tablet 250 mg Formulary mega coq10 oral capsule 400 mg Formulary OTC MEGA MULTIVITAMIN ORAL POWDER Formulary OTC megestrol acetate oral suspension 40 mg/ml Formulary megestrol acetate oral tablet 20 mg, 40 mg Formulary meijer alcohol swabs pad 70 % 70 % Formulary OTC MEIJER LANCETS Formulary OTC; QL (150 EA per 30 days) MEIJER LANCETS THIN Formulary OTC; QL (150 EA per 30 days) MEIJER LANCETS UNIVERSAL 21G Formulary OTC; QL (150 EA per 30 days) MEIJER LANCETS UNIVERSAL 33G Formulary OTC; QL (150 EA per 30 days) MEIJER SUPER THIN LANCETS Formulary OTC; QL (150 EA per 30 days) melatonin er oral tablet extended release 3 mg Formulary OTC melatonin oral capsule 1 mg, 10 mg, 3 mg, 5 mg Formulary OTC melatonin oral tablet 1 mg, 10 mg, 3 mg, 300 mcg, 5 mg Formulary OTC melatonin oral tablet dispersible 5 mg Formulary OTC melatonin sublingual tablet sublingual 10 mg Formulary OTC melatonin tr oral tablet extended release 1 mg Formulary OTC melatonin-pyridoxine oral tablet 1-10 mg Formulary OTC MELLOW-TONE ORAL STRIP Formulary OTC meloxicam oral tablet 15 mg, 7.5 mg Formulary melphalan hcl intravenous solution reconstituted 50 mg Formulary melphalan oral tablet 2 mg Formulary memantine hcl er oral capsule extended release 24 hour 14 Formulary mg, 21 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml Formulary memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 Formulary mg MENACTRA INTRAMUSCULAR INJECTABLE Formulary AGE (Min 19 Years) mencaps external patch 0.0225-4.5 % Formulary OTC m-end dmx oral liquid 20-0.667-10 mg/5ml Formulary OTC M-END PE ORAL LIQUID 3.33-1.33-6.33 MG/5ML Formulary OTC MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG Formulary menstrual pain relief oral tablet 500-25-15 mg Formulary OTC menstrual relief max strength oral tablet 500-60-15 mg Formulary OTC MENVEO INTRAMUSCULAR SOLUTION Formulary AGE (Min 19 Years) RECONSTITUTED meperidine hcl injection solution 10 mg/ml, 100 mg/ml, 25 Formulary mg/ml, 50 mg/ml mercaptopurine oral tablet 50 mg Formulary 87 Drug Name Formulary Status Requirements/Limits mesalamine er oral capsule extended release 24 hour 0.375 Formulary gm mesalamine oral tablet delayed release 1.2 gm Formulary mesalamine rectal enema 4 gm Formulary mesalamine rectal suppository 1000 mg Formulary mesalamine-cleanser rectal kit 4 gm Formulary mesna intravenous solution 100 mg/ml Formulary MESNEX ORAL TABLET 400 MG Formulary MESTINON ORAL SYRUP 60 MG/5ML Formulary METAMUCIL MULTIHEALTH FIBER ORAL PACKET Formulary OTC 58.12 % METAMUCIL MULTIHEALTH FIBER ORAL POWDER Formulary OTC 63 % METAMUCIL ORAL CAPSULE 0.52 GM Formulary OTC METAMUCIL ORAL POWDER 48.57 % Formulary OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 Formulary OTC % metaproterenol sulfate oral syrup 10 mg/5ml Formulary METAXALL ORAL TABLET 800 MG Formulary ST metformin hcl er oral tablet extended release 24 hour 500 Formulary AGE (Min 10 Years) mg, 750 mg metformin hcl oral solution 500 mg/5ml Formulary ST; AGE (Min 10 Years) metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Formulary AGE (Min 10 Years) METHADONE HCL INTENSOL ORAL Formulary PA; QL (90 ML per 30 days) CONCENTRATE 10 MG/ML methadone hcl oral solution 10 mg/5ml Formulary PA; QL (450 ML per 30 days) methadone hcl oral solution 5 mg/5ml Formulary PA; QL (900 ML per 30 days) methadone hcl oral tablet 10 mg Formulary PA; QL (90 EA per 30 days) methadone hcl oral tablet 5 mg Formulary PA; QL (180 EA per 30 days) methadone hcl oral tablet soluble 40 mg Formulary PA; QL (22.5 EA per 30 days) methazolamide oral tablet 25 mg, 50 mg Formulary methenamine hippurate oral tablet 1 gm Formulary methenamine mandelate oral tablet 1 gm Formulary methimazole oral tablet 10 mg, 5 mg Formulary methionine oral packet 100 mg Formulary OTC methionine oral tablet 500 mg Formulary OTC methitest oral tablet 10 mg Formulary methocarbamol injection solution 1000 mg/10ml Formulary methocarbamol oral tablet 500 mg, 750 mg Formulary methotrexate oral tablet 2.5 mg Formulary methotrexate sodium (pf) injection solution 1 gm/40ml, 250 Formulary mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 Formulary mg/2ml methotrexate sodium injection solution reconstituted 1 gm Formulary methyl salicylate external liquid Formulary 88 Drug Name Formulary Status Requirements/Limits methyl salicylate external oil Formulary OTC methyldopa oral tablet 250 mg, 500 mg Formulary methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Formulary AGE (Min 4 Years and Max 17 Years) methylprednisolone acetate injection suspension 40 mg/ml, Formulary 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Formulary methylprednisolone oral tablet therapy pack 4 mg Formulary methylprednisolone sodium succ injection solution Formulary reconstituted 1000 mg, 125 mg, 40 mg metipranolol ophthalmic solution 0.3 % Formulary metoclopramide hcl oral solution 5 mg/5ml Formulary metoclopramide hcl oral tablet 10 mg, 5 mg Formulary metolazone oral tablet 10 mg, 2.5 mg, 5 mg Formulary metoprolol succinate er oral tablet extended release 24 Formulary hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml Formulary metoprolol tartrate intravenous solution cartridge 5 mg/5ml Formulary metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 Formulary mg, 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- Formulary 50 mg, 50-25 mg METRO INTRAVENOUS SOLUTION 500-0.74 Formulary MG/100ML-% METROCREAM EXTERNAL CREAM 0.75 % Formulary METROGEL EXTERNAL GEL 1 % Formulary METROLOTION EXTERNAL LOTION 0.75 % Formulary metronidazole external cream 0.75 % Formulary metronidazole external gel 0.75 % Formulary metronidazole external lotion 0.75 % Formulary metronidazole in nacl intravenous solution 500-0.79 Formulary mg/100ml-% metronidazole oral capsule 375 mg Formulary metronidazole oral tablet 250 mg, 500 mg Formulary metronidazole vaginal gel 0.75 % Formulary mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg Formulary MEXSANA EXTERNAL POWDER 10.8 % Formulary OTC MG/TAURINE FORTE ORAL CAPSULE Formulary OTC MI PASTE PLUS DENTAL PASTE Formulary MIBELAS 24 FE ORAL TABLET CHEWABLE 1-20 MG- Formulary PA; QL (28 EA per 28 days) MCG(24) MICATIN EXTERNAL CREAM 2 % Formulary OTC miconazole 3 vaginal cream 4 % Formulary OTC miconazole 7 vaginal suppository 100 mg Formulary OTC miconazole nitrate vaginal cream 2 % Formulary OTC; QL (45 GM per 34 days) microfiber cleaning cloths Formulary OTC MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG Formulary 89 Drug Name Formulary Status Requirements/Limits MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG- Formulary MCG MICROKLENZ EXTERNAL LIQUID 0.1 % Formulary OTC midazolam hcl oral syrup 2 mg/ml Formulary midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg Formulary MIDOL CAFFEINE FREE ORAL TABLET 500-25 MG Formulary OTC MIDOL COMPLETE ORAL TABLET 500-60-15 MG Formulary OTC MIGERGOT RECTAL SUPPOSITORY 2-100 MG Formulary miglitol oral tablet 100 mg, 50 mg Formulary miglustat oral capsule 100 mg Formulary MIL-A-MULSION ORAL EMULSION 10-15000 Formulary OTC UNIT/DROP MILCO-ZYME ORAL TABLET Formulary OTC milk of magnesia concentrate oral suspension 2400 Formulary OTC mg/10ml MILLGUARD ORAL TABLET 800-10-115 MCG-MG- Formulary OTC MCG MILTAB #1 ORAL TABLET Formulary OTC mineral oil light external oil 100 % Formulary OTC mineral oil-hydrophil petrolat external ointment Formulary OTC MINIMED GUARDIAN LINK 3 Formulary MINIMED PRO-SET INFUSION 42" Formulary MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 Formulary MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR minocycline hcl oral capsule 100 mg, 50 mg, 75 mg Formulary minocycline hcl oral tablet 100 mg, 50 mg, 75 mg Formulary minoxidil for women external solution 2 % Formulary OTC minoxidil oral tablet 10 mg, 2.5 mg Formulary MIRALAX ORAL PACKET 17 GM Formulary OTC MIRALAX ORAL POWDER 17 GM/SCOOP Formulary OTC MIRENA (52 MG) INTRAUTERINE INTRAUTERINE Formulary QL (1 EA per 365 days) DEVICE 20 MCG/24HR mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg Formulary mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg Formulary misoprostol oral tablet 100 mcg, 200 mcg Formulary mitomycin intravenous solution reconstituted 20 mg, 40 mg, Formulary 5 mg mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 Formulary mg/12.5ml, 30 mg/15ml M-M-R II SUBCUTANEOUS INJECTABLE Formulary AGE (Min 19 Years) mn-50 oral capsule 16.67 mg Formulary OTC moexipril hcl oral tablet 15 mg, 7.5 mg Formulary moisture barrier external ointment , 0.44-20.6 % Formulary OTC MOISTURE GUARD EXTERNAL CREAM 5 % Formulary OTC MOISTUREL EXTERNAL LOTION 3 % Formulary OTC moisturizing skin protectant external cream 8 % Formulary OTC 90 Drug Name Formulary Status Requirements/Limits molybdenum oral capsule 30 mcg Formulary OTC mometasone furoate external cream 0.1 % Formulary mometasone furoate external ointment 0.1 % Formulary mometasone furoate external solution 0.1 % Formulary mometasone furoate nasal suspension 50 mcg/act Formulary QL (17 GM per 30 days) MONOCAL ORAL TABLET 625-22.75 MG Formulary OTC MONOJECT ALLERGIST TRAY KIT 28G X 1/2" 1 ML Formulary MONOJECT BLUNTIP CANNULA 21G X 1" Formulary MONOJECT HYPODERMIC NEEDLE 14G X 1-1/2" , 14G X 2" , 16G X 3/4" , 16G X 5/8" , 21G X 2" , 25G X 1- Formulary 1/4" , 25G X 2" , 26G X 1-1/2" , 26G X 1/2" , 27G X 1-1/2" , 30G X 3/4" MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML 25G Formulary OTC X 5/8" 1 ML MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML Formulary (OTC) 27G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML (RX) Formulary 27G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Formulary (OTC) 28G X 1/2" 0.5 ML MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Formulary (RX) 28G X 1/2" 0.5 ML MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML Formulary (OTC) 28G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML (RX) Formulary 28G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Formulary 29G X 1/2" 0.3 ML MONOJECT INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary 29G X 1/2" 0.5 ML MONOJECT INSULIN SYRINGE 29G X 1/2" 1 ML (RX) Formulary 29G X 1/2" 1 ML MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary 30G X 5/16" 0.3 ML MONOJECT INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary (RX) 30G X 5/16" 0.5 ML MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML Formulary (OTC) 30G X 5/16" 1 ML MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML Formulary (RX) 30G X 5/16" 1 ML MONOJECT INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML MONOJECT INSULIN SYRINGE U-100 1 ML U-100 1 Formulary ML MONOJECT LIFESHIELD SYRINGE 18G X 1" 3 ML Formulary MONOJECT MAGELLAN SAFETY NDL 21G X 5/8" , Formulary 23G X 5/8" MONOJECT MAGELLAN SYRINGE 20G X 1-1/2" 12 Formulary ML, 21G X 1" 12 ML, 21G X 1-1/2" 12 ML

91 Drug Name Formulary Status Requirements/Limits MONOJECT SYRINGE 18G X 1" 12 ML, 20G X 3/4" 3 Formulary ML, 21G X 1-1/2" 6 ML MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" Formulary 0.5 ML (OTC) 28G X 1/2" 0.5 ML MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" Formulary 0.5 ML (RX) 28G X 1/2" 0.5 ML MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" Formulary 1 ML (OTC) 28G X 1/2" 1 ML MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" Formulary 1 ML (RX) 28G X 1/2" 1 ML MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" Formulary OTC 0.3 ML 29G X 1/2" 0.3 ML MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" Formulary OTC 0.5 ML 29G X 1/2" 0.5 ML MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" Formulary OTC 1 ML 29G X 1/2" 1 ML MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" Formulary 0.3 ML (OTC) 30G X 5/16" 0.3 ML MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" Formulary 0.3 ML (RX) 30G X 5/16" 0.3 ML MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" Formulary 0.5 ML (OTC) 30G X 5/16" 0.5 ML MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" Formulary 0.5 ML (RX) 30G X 5/16" 0.5 ML MONOJECT ULTRA COMFORT SYRINGE 31G X 5/16" Formulary OTC 0.3 ML 31G X 5/16" 0.3 ML MONOJECT ULTRA COMFORT SYRINGE 31G X 5/16" Formulary OTC 0.5 ML 31G X 5/16" 0.5 ML MONOLET LANCETS Formulary OTC; QL (150 EA per 30 days) MONOLET OPD LANCETS Formulary OTC; QL (150 EA per 30 days) MONONINE INTRAVENOUS SOLUTION Formulary RECONSTITUTED 1000 UNIT MONOVISC INTRA-ARTICULAR SOLUTION Formulary PA PREFILLED SYRINGE 88 MG/4ML montelukast sodium oral packet 4 mg Formulary montelukast sodium oral tablet 10 mg Formulary montelukast sodium oral tablet chewable 4 mg, 5 mg Formulary MORPHABOND ER ORAL TABLET ER 12 HOUR Formulary PA ABUSE-DETERRENT 60 MG morphine sulfate (concentrate) oral solution 100 mg/5ml Formulary PA; QL (32 ML per 7 days) morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml Formulary morphine sulfate (pf) intravenous solution 10 mg/ml, 2 Formulary mg/ml, 4 mg/ml, 8 mg/ml morphine sulfate er beads oral capsule extended release 24 Formulary PA hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral tablet extended release 100 mg Formulary PA; QL (34 EA per 34 days) morphine sulfate er oral tablet extended release 15 mg Formulary PA; QL (204 EA per 34 days) morphine sulfate er oral tablet extended release 200 mg Formulary PA; QL (15.3 EA per 34 days) morphine sulfate er oral tablet extended release 30 mg Formulary PA; QL (102 EA per 34 days)

92 Drug Name Formulary Status Requirements/Limits morphine sulfate er oral tablet extended release 60 mg Formulary PA; QL (47 EA per 34 days) morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 Formulary mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate intravenous solution 1 mg/ml, 150 Formulary mg/30ml, 25 mg/ml, 50 mg/ml morphine sulfate oral solution 10 mg/5ml Formulary PA; QL (315 ML per 7 days) morphine sulfate oral solution 20 mg/5ml Formulary PA; QL (158 ML per 7 days) morphine sulfate oral tablet 15 mg Formulary PA; QL (42 EA per 7 days) morphine sulfate oral tablet 30 mg Formulary PA; QL (21 EA per 7 days) morphine sulfate rectal suppository 30 mg Formulary MOTRIN INFANTS DROPS ORAL SUSPENSION 50 Formulary OTC MG/1.25ML mouth rinse mouth/throat liquid 0.07 % Formulary OTC MOVANTIK ORAL TABLET 12.5 MG, 25 MG Formulary PA; AGE (Min 18 Years) moxifloxacin hcl ophthalmic solution 0.5 % Formulary moxifloxacin hcl oral tablet 400 mg Formulary MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML Formulary ms insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" 0.3 ml Formulary OTC ms insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" 0.5 ml Formulary OTC ms insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC MUCINEX COUGH CHILDRENS ORAL LIQUID 5-100 Formulary OTC MG/5ML MUCINEX COUGH FOR KIDS ORAL PACKET 5-100 Formulary OTC MG MUCINEX D MAX STRENGTH ORAL TABLET Formulary OTC EXTENDED RELEASE 12 HOUR 120-1200 MG MUCINEX D ORAL TABLET EXTENDED RELEASE 12 Formulary OTC HOUR 60-600 MG MUCINEX DM MAXIMUM STRENGTH ORAL Formulary OTC TABLET EXTENDED RELEASE 12 HOUR 60-1200 MG MUCINEX DM ORAL TABLET EXTENDED RELEASE Formulary OTC 12 HOUR 30-600 MG MUCINEX FAST-MAX COLD & SINUS ORAL LIQUID Formulary OTC 10-650-400 MG/20ML MUCINEX FAST-MAX COLD & SINUS ORAL Formulary OTC TABLET 5-325-200 MG MUCINEX FAST-MAX COLD FLU ORAL LIQUID 5- Formulary OTC 10-200-325 MG/10ML MUCINEX FAST-MAX CONGEST COUGH ORAL Formulary OTC LIQUID 2.5-5-100 MG/5ML MUCINEX FAST-MAX CONGEST COUGH ORAL Formulary OTC TABLET 5-10-200 MG MUCINEX FAST-MAX DAY/NIGHT M/S ORAL Formulary OTC (TABLET) MUCINEX FAST-MAX DAY/NIGHT ORAL Formulary OTC MUCINEX FAST-MAX DAY/NIGHT ORAL CAPSULE Formulary OTC THERAPY PACK MUCINEX FAST-MAX DAY/NIGHT TAB ORAL Formulary OTC

93 Drug Name Formulary Status Requirements/Limits MUCINEX FAST-MAX ORAL CAPSULE 5-10-200-325 Formulary OTC MG MUCINEX FOR KIDS ORAL PACKET 100 MG Formulary OTC MUCINEX MAXIMUM STRENGTH ORAL TABLET Formulary OTC EXTENDED RELEASE 12 HOUR 1200 MG MUCINEX ORAL TABLET EXTENDED RELEASE 12 Formulary OTC HOUR 600 MG MUCINEX SINUS-MAX CONGESTION ORAL TABLET Formulary OTC 5-325-200 MG MUCINEX SINUS-MAX DAY/NIGHT ORAL LIQUID Formulary OTC MUCINEX SINUS-MAX DAY/NIGHT ORAL LIQUID Formulary OTC THERAPY PACK MUCINEX SINUS-MAX DAY/NIGHT ORAL TABLET Formulary OTC THERAPY PACK 5-200-325 & 5- 12.5-325MG MUCINEX SINUS-MAX PRESS & PAIN ORAL Formulary OTC TABLET 5-325-200 MG MUCINEX STUFFY NOSE/COLD CHILD ORAL Formulary OTC LIQUID 2.5-100 MG/5ML mucus relief cold/sinus max st oral liquid 10-650-400 Formulary OTC mg/20ml mucus relief d oral tablet extended release 12 hour 60-600 Formulary OTC mg mucus relief er oral tablet extended release 12 hour 1200 Formulary OTC mg mucus relief pe oral tablet 10-400 mg Formulary OTC mucus-dm max oral tablet extended release 12 hour 60- Formulary OTC 1200 mg multi-delyn/iron oral liquid Formulary OTC multi-draw needle 20g x 1" , 21g x 1" , 22g x 1" Formulary MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG Formulary MULTIGEN ORAL TABLET 70 MG Formulary MULTIGEN PLUS ORAL TABLET 50-101-1 MG Formulary multi-minerals oral tablet Formulary OTC multi-purpose cold compress Formulary OTC multi-symptom cold plus child oral liquid 2.5-5-100 mg/5ml Formulary OTC multi-vit/fluoride oral solution 0.25 mg/ml Formulary multivitamin gummies childrens oral tablet chewable Formulary OTC multivitamins/fluoride oral tablet chewable 0.5 mg Formulary mupirocin external ointment 2 % Formulary MURO 128 OPHTHALMIC OINTMENT 5 % Formulary OTC MURO 128 OPHTHALMIC SOLUTION 2 %, 5 % Formulary OTC muscle rub ultra strength external cream 4-10-30 % Formulary OTC MUSTARGEN INJECTION SOLUTION Formulary RECONSTITUTED 10 MG M-VIT ORAL TABLET Formulary QL (34 EA per 34 days) MYCOCIDE CX CALLUS EXFOLIATOR EXTERNAL Formulary OTC CREAM 12-0.1 % mycophenolate mofetil oral capsule 250 mg Formulary 94 Drug Name Formulary Status Requirements/Limits mycophenolate mofetil oral suspension reconstituted 200 Formulary mg/ml mycophenolate mofetil oral tablet 500 mg Formulary mycophenolate sodium oral tablet delayed release 180 mg, Formulary 360 mg MYGLUCOHEALTH LANCETS 30G Formulary OTC; QL (150 EA per 30 days) MYLANTA ORAL SUSPENSION 200-200-20 MG/5ML Formulary OTC MYLERAN ORAL TABLET 2 MG Formulary MYNATAL ORAL CAPSULE Formulary mynate 90 plus oral tablet extended release Formulary mynephrocaps oral capsule 1 mg Formulary MYOBLOC INTRAMUSCULAR SOLUTION 10000 Formulary PA UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, Formulary 40 MG nabumetone oral tablet 500 mg, 750 mg Formulary nac oral capsule 600 mg Formulary OTC NAIL SCRUB EXTERNAL LIQUID Formulary OTC NAIL-EX ORAL TABLET 2.5 MG Formulary OTC nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml Formulary naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml Formulary naloxone hcl injection solution cartridge 0.4 mg/ml Formulary naloxone hcl injection solution prefilled syringe 2 mg/2ml Formulary naltrexone hcl oral tablet 50 mg Formulary NAMENDA XR TITRATION PACK ORAL CAPSULE Formulary EXTENDED RELEASE 24 HOUR 7 & 14 & 21 NAMZARIC ORAL CAPSULE EXTENDED RELEASE Formulary 24 HOUR 14-10 MG NAPHCON-A OPHTHALMIC SOLUTION 0.025-0.3 % Formulary OTC naproxen dr oral tablet delayed release 375 mg, 500 mg Formulary naproxen oral suspension 125 mg/5ml Formulary naproxen oral tablet 250 mg, 375 mg, 500 mg Formulary naproxen sodium oral capsule 220 mg Formulary OTC hcl oral tablet 1 mg, 2.5 mg Formulary ST NARCAN NASAL LIQUID 4 MG/0.1ML Formulary NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT Formulary OTC NASAL 55 MCG/ACT NASACORT ALLERGY 24HR CHILDREN AEROSOL Formulary OTC 55 MCG/ACT NASAL 55 MCG/ACT nasal allergy 24 hour aerosol 55 mcg/act nasal 55 mcg/act Formulary OTC nasal aspirator Formulary OTC nasal decongestant oral liquid 30 mg/5ml Formulary OTC nasal decongestant oral syrup 30 mg/5ml Formulary OTC nasal decongestant spray nasal solution 0.05 % Formulary OTC NASAL EASE ALLERGY RELIEVER NASAL POWDER Formulary OTC

95 Drug Name Formulary Status Requirements/Limits NASALCROM NASAL AEROSOL SOLUTION 5.2 Formulary OTC MG/ACT NASOGEL NASAL GEL Formulary OTC NASONEB NEBULIZER STARTER Formulary OTC; QL (2 EA per 365 days) NASOPEN PE ORAL LIQUID 50-10 MG/15ML Formulary OTC NATACYN OPHTHALMIC SUSPENSION 5 % Formulary nateglinide oral tablet 120 mg, 60 mg Formulary NATROBA EXTERNAL SUSPENSION 0.9 % Formulary natural fiber laxative oral powder 28.3 % Formulary OTC natural vitamin e moisturizing external gel Formulary OTC NATURAL WHEY ORAL POWDER Formulary OTC NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG Formulary QL (28 EA per 28 days) neomycin sulfate oral tablet 500 mg Formulary neomycin-bacitracin zn-polymyx ophthalmic ointment 5- Formulary 400-10000 neomycin-polymyxin b gu irrigation solution 40-200000 Formulary neomycin-polymyxin-dexameth ophthalmic ointment 3.5- Formulary 10000-0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- Formulary 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- Formulary 10000-.025 neomycin-polymyxin-hc otic solution 3.5-10000-1 Formulary neomycin-polymyxin-hc otic suspension 3.5-10000-1 Formulary NEOSPORIN + PAIN RELIEF MAX ST EXTERNAL Formulary OTC OINTMENT 1 % NEOSPORIN ORIGINAL EXTERNAL OINTMENT 3.5- Formulary OTC 400-5000 NEOSPORIN PLUS MAX ST EXTERNAL OINTMENT 4 Formulary OTC % NEOSPORIN PLUS PAIN RELIEF MS EXTERNAL Formulary OTC CREAM 3.5-10000-10 NEOSTRATA FACIAL CLEANSER EXTERNAL Formulary OTC LIQUID 0.3 % NEOTUSS-D ORAL LIQUID 7.5-30-200 MG/5ML Formulary OTC NEPHRONEX ORAL LIQUID 0.9 MG/5ML Formulary OTC NEPHRO-VITE ORAL TABLET 0.8 MG Formulary OTC NEULASTA SUBCUTANEOUS SOLUTION Formulary PA; QL (2 ML per 34 days) PREFILLED SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 Formulary PA MCG/1.6ML NEUPOGEN INJECTION SOLUTION PREFILLED Formulary PA SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML NEURO-K-250 T.D. ORAL CAPSULE 250 MG Formulary OTC neuromax external gel 20 % Formulary OTC NEUROPEN KIT Formulary OTC NEUROTIPS Formulary OTC

96 Drug Name Formulary Status Requirements/Limits NEUTROGENA BODY EXTERNAL OIL Formulary OTC NEUTROGENA CLEAR PORE EXTERNAL LIQUID 3.5 Formulary OTC % NEUTROGENA T/GEL EXTERNAL SHAMPOO 4 % Formulary OTC NEUTROGENA T/GEL STUBBORN ITCH EXTERNAL Formulary OTC SHAMPOO 0.5 % nevirapine er oral tablet extended release 24 hour 100 mg, Formulary 400 mg nevirapine oral suspension 50 mg/5ml Formulary nevirapine oral tablet 200 mg Formulary NEW DIGNITY ODOR ELIMINATOR EXTERNAL Formulary OTC SOLUTION NEW IMAGE SKIN BARRIER/FLANGE WAFER Formulary OTC NEW IMAGE SKIN/FLANGE/TAPE Formulary OTC new terocin external lotion 0.025-10-25 % Formulary OTC NEXAFED ORAL TABLET ABUSE-DETERRENT 30 Formulary OTC MG NEXAFED SINUS PRESSURE + PAIN ORAL TABLET Formulary OTC 30-325 MG NEXAVAR ORAL TABLET 200 MG Formulary PA NEXCARE PREMIUM ADHESIVE GAUZE PAD 3- Formulary OTC 1/2"X6" , 3-1/2"X8" NEXIUM 24HR CAPSULE DELAYED RELEASE 20 MG Formulary OTC; QL (68 EA per 34 days) ORAL 20 MG NEXIUM 24HR TABLET DELAYED RELEASE 20 MG Formulary OTC; QL (68 EA per 34 days) ORAL 20 MG NEXPLANON SUBCUTANEOUS IMPLANT 68 MG Formulary niacin er (antihyperlipidemic) oral tablet extended release Formulary 1000 mg, 500 mg, 750 mg niacin er oral capsule extended release 250 mg, 500 mg Formulary OTC niacin er oral tablet extended release 1000 mg, 250 mg, 750 Formulary OTC mg niacin flush free oral capsule 400-100 mg, 500 mg Formulary OTC niacin oral tablet 100 mg, 50 mg, 500 mg Formulary OTC niacinamide oral tablet 100 mg, 500 mg Formulary OTC nicardipine hcl intravenous solution 2.5 mg/ml Formulary nicardipine hcl oral capsule 20 mg, 30 mg Formulary NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 Formulary OTC MG/24HR, 21 MG/24HR, 7 MG/24HR MOUTH/THROAT GUM 2 MG, 4 MG Formulary OTC NICORETTE MOUTH/THROAT LOZENGE 2 MG, 4 MG Formulary OTC nicotine polacrilex mouth/throat gum 2 mg Formulary OTC nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg Formulary OTC nicotine step 1 transdermal patch 24 hour 21 mg/24hr Formulary OTC nicotine step 2 transdermal patch 24 hour 14 mg/24hr Formulary OTC nicotine step 3 transdermal patch 24 hour 7 mg/24hr Formulary OTC nicotine transdermal kit 21-14-7 mg/24hr Formulary OTC

97 Drug Name Formulary Status Requirements/Limits NICOTROL INHALATION INHALER 10 MG Formulary NIFEDICAL XL ORAL TABLET EXTENDED RELEASE Formulary 24 HOUR 60 MG nifedipine er oral tablet extended release 24 hour 30 mg, 60 Formulary mg, 90 mg nifedipine er osmotic release oral tablet extended release Formulary 24 hour 30 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg Formulary nilutamide oral tablet 150 mg Formulary nimodipine oral capsule 30 mg Formulary NINJACOF ORAL LIQUID 12.5-12.5 MG/5ML Formulary OTC NINJACOF-A ORAL LIQUID 12.5-12.5-160 MG/5ML Formulary OTC NINJACOF-XG ORAL LIQUID 200-8 MG/5ML Formulary OTC NIPENT INTRAVENOUS SOLUTION Formulary RECONSTITUTED 10 MG NISEKO SUNSCREEN SPF 25 EXTERNAL CREAM Formulary OTC nisoldipine er oral tablet extended release 24 hour 17 mg, Formulary 25.5 mg, 34 mg, 8.5 mg NITEBITE ORAL BAR Formulary OTC nite-time cold/flu relief oral liquid 5-6.25-15-500 mg/15ml Formulary OTC NITRO-BID TRANSDERMAL OINTMENT 2 % Formulary nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg Formulary nitrofurantoin monohyd macro oral capsule 100 mg Formulary nitrofurantoin oral suspension 25 mg/5ml Formulary nitroglycerin er oral capsule extended release 2.5 mg, 6.5 Formulary mg, 9 mg nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, Formulary 0.6 mg NIVANEX DMX ORAL TABLET 10-15-380 MG Formulary OTC NIX CREME RINSE EXTERNAL LIQUID 1 % Formulary OTC nizatidine oral capsule 150 mg, 300 mg Formulary nizatidine oral solution 15 mg/ml Formulary NIZORAL A-D EXTERNAL SHAMPOO 1 % Formulary OTC NOBLE FORMULA EXTERNAL SHAMPOO 2 % Formulary OTC NOBLE FORMULA HC EXTERNAL SOLUTION 1 % Formulary OTC nohist-lq oral liquid 4-10 mg/5ml Formulary OTC NOKOR ADMIX NEEDLE 18G X 1-1/2" Formulary OTC non-stick pad 2"x3" Formulary OTC NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR Formulary PA 10 MG/1.5ML SUBCUTANEOUS 10 MG/1.5ML NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR Formulary PA 15 MG/1.5ML SUBCUTANEOUS 15 MG/1.5ML NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR Formulary PA 30 MG/3ML SUBCUTANEOUS 30 MG/3ML NORDITROPIN FLEXPRO SOLUTION PEN-INJECTOR Formulary PA 5 MG/1.5ML SUBCUTANEOUS 5 MG/1.5ML NOREL AD ORAL TABLET 4-10-325 MG Formulary OTC 98 Drug Name Formulary Status Requirements/Limits NOREL CS ORAL LIQUID 10-4-12.5 MG/5ML Formulary OTC norethin ace-eth estrad-fe oral tablet 1.5-30 mg-mcg Formulary norethindrone acetate oral tablet 5 mg Formulary norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg Formulary norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 Formulary QL (28 EA per 28 days) mg-35 mcg NORMLSHIELD EXTERNAL CREAM 4.5 % Formulary OTC nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg Formulary NORVIR ORAL CAPSULE 100 MG Formulary NORVIR ORAL SOLUTION 80 MG/ML Formulary NO-STING SKIN-PREP EXTERNAL Formulary OTC NOVA SUREFLEX LANCETS Formulary OTC; QL (150 EA per 30 days) NOVAFERRUM 125 ORAL LIQUID 125-100 MG- Formulary OTC UNT/5ML NOVAFERRUM 50 ORAL CAPSULE 50 MG Formulary OTC NOVAFERRUM ORAL LIQUID 125 MG/5ML Formulary OTC NOVAFERRUM PEDIATRIC DROPS ORAL LIQUID 15 Formulary OTC MG/ML NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NOVOLIN N FLEXPEN RELION SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR 100 UNIT/ML NOVOLIN N FLEXPEN SUBCUTANEOUS Formulary OTC SUSPENSION PEN-INJECTOR 100 UNIT/ML NOVOLOG 70/30 FLEXPEN RELION SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML Formulary SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLOG FLEXPEN RELION SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 Formulary UNIT/ML NOVOLOG FLEXPEN SOLUTION PEN-INJECTOR 100 Formulary UNIT/ML SUBCUTANEOUS 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS Formulary (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 RELION SUSPENSION (70-30) Formulary 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS Formulary SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SOLUTION CARTRIDGE 100 Formulary UNIT/ML SUBCUTANEOUS 100 UNIT/ML NOVOLOG RELION SOLUTION 100 UNIT/ML Formulary SUBCUTANEOUS 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 Formulary UNIT/ML NOVOPEN ECHO DEVICE Formulary NOXICARE EXTERNAL CREAM Formulary OTC

99 Drug Name Formulary Status Requirements/Limits np thyroid oral tablet 30 mg, 60 mg, 90 mg Formulary NPLATE SUBCUTANEOUS SOLUTION Formulary PA RECONSTITUTED 250 MCG, 500 MCG NUEDEXTA ORAL CAPSULE 20-10 MG Formulary PA NUFERA ORAL TABLET Formulary NU-GEL EXTERNAL GEL Formulary OTC NULIDO EXTERNAL GEL 4-1 % Formulary OTC NU-MAG ORAL TABLET DELAYED RELEASE 71.5- Formulary OTC 119 MG NUPERCAINAL RECTAL OINTMENT 1 % Formulary OTC NUTRA/PRO CHOCOLATE ORAL PACKET Formulary OTC NUTRATEAR OPHTHALMIC SOLUTION 0.6 % Formulary OTC NUTR-E-SOL ORAL LIQUID 400 UNIT/15ML Formulary OTC NUVESSA VAGINAL GEL 1.3 % Formulary NYAMYC EXTERNAL POWDER 100000 UNIT/GM Formulary NYMALIZE ORAL SOLUTION 30 MG/10ML, 60 Formulary MG/20ML nystatin external cream 100000 unit/gm Formulary nystatin external ointment 100000 unit/gm Formulary nystatin external powder 100000 unit/gm Formulary nystatin mouth/throat suspension 100000 unit/ml Formulary nystatin oral tablet 500000 unit Formulary nystatin-triamcinolone external cream 100000-0.1 unit/gm- Formulary % nystatin-triamcinolone external ointment 100000-0.1 Formulary unit/gm-% NYSTOP EXTERNAL POWDER 100000 UNIT/GM Formulary NYTOL MAXIMUM STRENGTH ORAL TABLET 50 Formulary OTC MG OASIS MOISTURIZING MOUTHWASH Formulary OTC MOUTH/THROAT LIQUID OBSTETRIX DHA ORAL 29-1 & 387 MG Formulary OBSTETRIX EC ORAL TABLET 29-1 MG Formulary OC8 EXTERNAL GEL 7 % Formulary OTC OCEAN BLUE MINICAPS D/OMEGA3 ORAL Formulary OTC CAPSULE 350-1000 MG-UNIT OCEAN BLUE MINICAPS OMEGA-3 ORAL CAPSULE Formulary OTC 350 MG OCEAN BLUE OPTIMAL HEALTH ORAL CAPSULE Formulary OTC 250 MG OCEAN COMPLETE SINUS RINSE NASAL AEROSOL Formulary OTC SOLUTION OCEAN NASAL SPRAY NASAL SOLUTION 0.65 % Formulary OTC oceanic selenium oral tablet 50 mcg Formulary OTC OCUSOFT LID SCRUB COMPLIANCE KIT Formulary OTC ODEFSEY ORAL TABLET 200-25-25 MG Formulary

100 Drug Name Formulary Status Requirements/Limits ODOR EATERS ANTIFUNGAL EXTERNAL POWDER Formulary OTC 1 % odor spray liquid Formulary OTC OFF ACTIVE EXTERNAL AEROSOL 15 % Formulary OTC OFF FAMILYCARE CLEAN FEEL EXTERNAL LIQUID Formulary OTC 5 % ofloxacin ophthalmic solution 0.3 % Formulary ofloxacin oral tablet 400 mg Formulary QL (68 EA per 34 days) ofloxacin otic solution 0.3 % Formulary OGESTREL ORAL TABLET 0.5-50 MG-MCG Formulary olanzapine intramuscular solution reconstituted 10 mg Formulary AGE (Min 18 Years) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, Formulary AGE (Min 18 Years) 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 Formulary AGE (Min 18 Years) mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg Formulary olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 Formulary mg, 40-25 mg olopatadine hcl nasal solution 0.6 % Formulary olopatadine hcl ophthalmic solution 0.1 %, 0.2 % Formulary omega dha oral tablet chewable Formulary OTC OMEGA POWER ORAL CAPSULE 1050 MG Formulary OTC omega-3 fish oil ex st oral capsule 880 mg Formulary OTC omega-3 fish oil oral capsule 300 mg Formulary OTC omega-3 fish oil-vitamin d3 oral capsule 1200-1000 mg- Formulary OTC unit OMEGA-3 IQ ORAL TABLET CHEWABLE 240 MG Formulary OTC omega-3 oral capsule 1400 mg Formulary OTC omega-3-acid ethyl esters oral capsule 1 gm Formulary PA omeprazole magnesium oral capsule delayed release 20.6 Formulary OTC (20 base) mg omeprazole magnesium oral tablet delayed release 20 mg Formulary OTC omeprazole oral capsule delayed release 10 mg, 20 mg, 40 Formulary mg omeprazole oral tablet delayed release 20 mg Formulary OTC omeprazole-sodium bicarbonate capsule 20-1100 mg oral Formulary QL (34 EA per 34 days) (otc) 20-1100 mg OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM Formulary ONCASPAR INJECTION SOLUTION 750 UNIT/ML Formulary hcl oral solution 4 mg/5ml Formulary QL (150 ML per 30 days) ondansetron hcl oral tablet 24 mg Formulary QL (1 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg Formulary QL (15 EA per 34 days) ondansetron oral tablet dispersible 4 mg, 8 mg Formulary QL (15 EA per 34 days) one step pregnancy in vitro diagnostic test Formulary OTC ONE-A-DAY ADULT VITACRAVES+DHA ORAL Formulary OTC TABLET CHEWABLE

101 Drug Name Formulary Status Requirements/Limits ONE-A-DAY WOMENS 50+ ADVANTAGE ORAL Formulary OTC TABLET ONETOUCH DELICA LANCETS 30G Formulary OTC; QL (150 EA per 30 days) ONETOUCH DELICA LANCETS 33G Formulary OTC; QL (150 EA per 30 days) ONETOUCH FINEPOINT LANCETS Formulary OTC; QL (150 EA per 30 days) ONETOUCH PING METER REMOTE SUPPLIES Formulary OTC ONETOUCH ULTRASOFT LANCETS Formulary OTC; QL (150 EA per 30 days) ONEXTON EXTERNAL GEL 1.2-3.75 % Formulary AGE (Max 19 Years) opium oral tincture 10 mg/ml (1%) Formulary OPSUMIT ORAL TABLET 10 MG Formulary PA OPTIONS CONCEPTROL VAGINAL GEL 4 % Formulary OTC OPTIONS GYNOL II CONTRACEPTIVE VAGINAL Formulary OTC GEL 3 % OPTIUM BLOOD GLUCOSE MONITOR KIT Formulary OTC; QL (1 EA per 365 days) W/DEVICE W/DEVICE OPTIUM GLUCOSE MONITOR SYSTEM DEVICE Formulary OTC; QL (150 EA per 30 days) OPTIUM TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) OPTIUMEZ TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) ORA-FILM MOUTH/THROAT STRIP 6 % Formulary OTC oral analgesic max st mouth/throat gel 20 % Formulary OTC oral anesthetic mouth/throat paste 20 % Formulary OTC oral electrolytes oral solution Formulary OTC ORAL SWAB PETITE MOUTH/THROAT SWAB Formulary OTC oral syringe bottle adapter Formulary OTC ORALONE MOUTH/THROAT PASTE 0.1 % Formulary ORAMAGIC PLUS MOUTH/THROAT SUSPENSION Formulary OTC RECONSTITUTED 10 % ORAZINC ORAL CAPSULE 220 (50 ZN) MG Formulary OTC ORAZINC ORAL TABLET 110 MG Formulary OTC ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG Formulary ORILISSA ORAL TABLET 150 MG, 200 MG Formulary PA ornithine oral capsule 500 mg Formulary OTC orphenadrine citrate er oral tablet extended release 12 hour Formulary 100 mg orphenadrine citrate injection solution 30 mg/ml Formulary ORTHOVISC INTRA-ARTICULAR SOLUTION Formulary PA PREFILLED SYRINGE 30 MG/2ML OS-CAL EXTRA D3 ORAL TABLET 500-600 MG-UNIT Formulary OTC OS-CAL ORAL TABLET CHEWABLE 500-600 MG- Formulary OTC UNIT OS-CAL ULTRA ORAL TABLET 600 MG Formulary OTC oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Formulary oseltamivir phosphate oral suspension reconstituted 6 Formulary mg/ml OSTEO-PORETICAL ORAL TABLET 600-1000 MG- Formulary OTC UNIT

102 Drug Name Formulary Status Requirements/Limits ostomy protective powder Formulary OTC ovulation predictor in vitro kit Formulary OTC oxaliplatin intravenous solution 100 mg/20ml, 50 mg/10ml Formulary oxaliplatin intravenous solution reconstituted 100 mg Formulary oxandrolone oral tablet 10 mg, 2.5 mg Formulary oxaprozin oral tablet 600 mg Formulary oxazepam oral capsule 10 mg, 15 mg, 30 mg Formulary QL (136 EA per 34 days) oxcarbazepine oral suspension 300 mg/5ml Formulary oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Formulary oxybutynin chloride er oral tablet extended release 24 hour Formulary 10 mg, 15 mg oxybutynin chloride er oral tablet extended release 24 hour Formulary QL (34 EA per 34 days) 5 mg oxybutynin chloride oral syrup 5 mg/5ml Formulary oxybutynin chloride oral tablet 5 mg Formulary oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 Formulary PA; QL (68 EA per 34 days) mg, 20 mg, 40 mg oxycodone hcl er oral tablet er 12 hour abuse-deterrent 15 Formulary PA; QL (102 EA per 34 days) mg, 30 mg, 60 mg, 80 mg oxycodone hcl oral capsule 5 mg Formulary PA; QL (84 EA per 7 days) oxycodone hcl oral concentrate 10 mg/0.5ml, 100 mg/5ml Formulary PA oxycodone hcl oral solution 5 mg/5ml Formulary PA; QL (420 ML per 7 days) oxycodone hcl oral tablet 10 mg Formulary PA; QL (42 EA per 7 days) oxycodone hcl oral tablet 15 mg Formulary PA; QL (28 EA per 7 days) oxycodone hcl oral tablet 20 mg Formulary PA; QL (21 EA per 7 days) oxycodone hcl oral tablet 30 mg Formulary PA; QL (14 EA per 7 days) oxycodone hcl oral tablet 5 mg Formulary PA; QL (84 EA per 7 days) oxycodone-acetaminophen oral tablet 10-325 mg Formulary PA; QL (42 EA per 7 days) oxycodone-acetaminophen oral tablet 2.5-325 mg Formulary PA; QL (168 EA per 7 days) oxycodone-acetaminophen oral tablet 5-325 mg Formulary PA; QL (84 EA per 7 days) oxycodone-acetaminophen oral tablet 7.5-325 mg Formulary PA; QL (56 EA per 7 days) oxycodone-ibuprofen oral tablet 5-400 mg Formulary PA OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- Formulary PA; QL (68 EA per 34 days) DETERRENT 10 MG, 20 MG, 40 MG OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- Formulary PA; QL (102 EA per 34 days) DETERRENT 15 MG, 30 MG, 60 MG, 80 MG oxymorphone hcl er oral tablet extended release 12 hour 10 Formulary PA; QL (68 EA per 34 days) mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone hcl er oral tablet extended release 12 hour 30 Formulary PA; QL (102 EA per 34 days) mg oxymorphone hcl er oral tablet extended release 12 hour 40 Formulary PA; QL (34 EA per 34 days) mg oxymorphone hcl oral tablet 10 mg Formulary PA; QL (90 EA per 30 days) oxymorphone hcl oral tablet 5 mg Formulary PA; QL (180 EA per 30 days) OXYTROL FOR WOMEN TRANSDERMAL PATCH Formulary OTC TWICE WEEKLY 3.9 MG/24HR

103 Drug Name Formulary Status Requirements/Limits OXYZAL WET DRESSING EXTERNAL SOLUTION Formulary OTC 1:2000 oyster calcium + d oral tablet 250-125 mg-unit Formulary OTC oyster calcium/d3 oral tablet 500-200 mg-unit Formulary OTC oyster shell calcium 250+d oral tablet 250-125 mg-unit Formulary OTC oyster shell calcium 500+d oral tablet chewable 500-400 Formulary OTC mg-unit oyster shell calcium oral tablet 500-400 mg-unit Formulary OTC oyster shell calcium plus d oral tablet 500-125 mg-unit Formulary OTC oyster shell calcium/d oral tablet 250-250 mg-unit, 500-200 Formulary OTC mg-unit oyster shell calcium/d3 oral tablet 500-400 mg-unit Formulary OTC P & S EXTERNAL LIQUID Formulary OTC P & S EXTERNAL SHAMPOO 2 % Formulary OTC p-1000 oral capsule 500 mg Formulary OTC PA CLA ORAL CAPSULE 1000 MG Formulary OTC pa fish oil/vit d3 triple st oral capsule delayed release 900- Formulary OTC 1000 mg-unit pa glucosamine-chondroitin oral capsule 166.7-133.3 mg Formulary OTC pa prenatal formula oral tablet 9-0.5 mg Formulary OTC pa probiotic complex oral tablet Formulary OTC paclitaxel intravenous concentrate 100 mg/16.7ml, 150 Formulary mg/25ml, 30 mg/5ml, 300 mg/50ml pain & fever childrens oral tablet chewable 160 mg Formulary OTC pain relief day & night ex st oral 25-500 & 500 mg Formulary OTC pain relief oral tablet Formulary OTC pain relief roll-on external liquid 4 % Formulary OTC pain reliever extra strength oral tablet 500 mg Formulary OTC pain reliever pm ex st oral tablet 25-500 mg Formulary OTC pain reliever pm oral tablet 25-500 mg Formulary OTC pain reliever/fever reducer rectal suppository 120 mg Formulary OTC pain relieving + lidocaine cream 4 % external 4 % Formulary OTC pain relieving external gel 3.5 % Formulary OTC PALADIN EXTERNAL OINTMENT Formulary OTC pamidronate disodium intravenous solution 30 mg/10ml, 6 Formulary PA mg/ml, 90 mg/10ml pamidronate disodium intravenous solution reconstituted 30 Formulary PA mg, 90 mg pancreatin oral tablet 325 mg Formulary OTC PANCREAZE ORAL CAPSULE DELAYED RELEASE Formulary PARTICLES 4200-14200 UNIT PANOXYL EXTERNAL LIQUID 2.5 % Formulary OTC PANOXYL WASH EXTERNAL LIQUID 10 % Formulary OTC; AGE (Max 18 Years) PANOXYL-4 CREAMY WASH EXTERNAL LIQUID 4 Formulary OTC; AGE (Max 18 Years) % panto-250 oral capsule 250 mg Formulary OTC

104 Drug Name Formulary Status Requirements/Limits pantoprazole sodium oral tablet delayed release 20 mg, 40 Formulary mg pantothenic acid oral tablet 500 mg Formulary OTC papaya enzyme oral tablet chewable Formulary OTC PARAGARD INTRAUTERINE COPPER Formulary INTRAUTERINE INTRAUTERINE DEVICE paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml Formulary PA paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg Formulary PA MOUTH/THROAT PASTE 0.454 % Formulary OTC paromomycin sulfate oral capsule 250 mg Formulary hcl er oral tablet extended release 24 hour 12.5 Formulary QL (68 EA per 34 days) mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Formulary parvenzyme digestive enzyme oral tablet Formulary OTC PATADAY SOLUTION 0.1 % OPHTHALMIC 0.1 % Formulary OTC PATADAY SOLUTION 0.2 % OPHTHALMIC (OTC) 0.2 Formulary % PAZEO OPHTHALMIC SOLUTION 0.7 % Formulary pc lancets super thin 30g Formulary OTC; QL (150 EA per 30 days) PECGEN DMX ORAL LIQUID 10-187 MG/5ML, 15-125 Formulary OTC MG/5ML PEDIACARE CHILDRENS LONG-ACT ORAL LIQUID Formulary OTC 7.5 MG/5ML PEDIACARE CHILDRENS MULTI-SYMP ORAL Formulary OTC LIQUID 2.5-5 MG/5ML PEDIACARE MULTI-SYMPTOM ORAL LIQUID 2.5-1- Formulary OTC 5-160 MG/5ML PEDIACLEAR ALLERGY CHILDRENS ORAL LIQUID Formulary OTC 0.313 MG/ML PEDIA-LAX FIBER GUMMIES ORAL TABLET Formulary OTC CHEWABLE PEDIA-LAX ORAL LIQUID 50 MG/15ML Formulary OTC PEDIA-LAX ORAL TABLET CHEWABLE 400 MG Formulary OTC PEDIA-LAX RECTAL SUPPOSITORY 1 GM, 2.8 GM Formulary OTC PEDIALYTE ADVANCED CARE ORAL SOLUTION Formulary OTC PEDIARIX INTRAMUSCULAR SUSPENSION Formulary PEDIAVENT ORAL SYRUP 2 MG/5ML Formulary OTC PEDIAVENT ORAL TABLET CHEWABLE 1 MG Formulary OTC PEDIAVIT ORAL LIQUID Formulary OTC PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 Formulary AGE (Min 19 Years) MCG/0.5ML PEGANONE ORAL TABLET 250 MG Formulary PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML Formulary penicillamine oral tablet 250 mg Formulary PA penicillin g potassium injection solution reconstituted Formulary 20000000 unit, 5000000 unit

105 Drug Name Formulary Status Requirements/Limits penicillin v potassium oral solution reconstituted 125 Formulary mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg Formulary PENTACEL INTRAMUSCULAR SUSPENSION Formulary RECONSTITUTED pentamidine isethionate inhalation solution reconstituted Formulary 300 mg PENTASA ORAL CAPSULE EXTENDED RELEASE 250 Formulary MG, 500 MG pentoxifylline er oral tablet extended release 400 mg Formulary PENTRAX GOLD EXTERNAL SHAMPOO 4 % Formulary OTC PEPCID AC MAXIMUM STRENGTH ORAL TABLET Formulary OTC 20 MG PEPCID AC ORAL TABLET 10 MG Formulary OTC PEPTO-BISMOL MAX STRENGTH ORAL Formulary OTC SUSPENSION 525 MG/15ML PEPTO-BISMOL ORAL SUSPENSION 262 MG/15ML Formulary OTC PEPTO-BISMOL ORAL TABLET 262 MG Formulary OTC PEPTO-BISMOL TO-GO ORAL TABLET CHEWABLE Formulary OTC 262 MG PERFORM ATOMIC HEAT EXTERNAL CREAM 0.034- Formulary OTC 10 % PERFORM ATOMIC HEAT EXTERNAL LIQUID 0.034- Formulary OTC 10 % PERFORM PAIN RELIEVING EXTERNAL LIQUID 10.4 Formulary OTC % PERFORM PAIN RELIEVING ROLL-ON EXTERNAL Formulary OTC LIQUID 3.1 % PERIDIN-C ORAL TABLET 200-50-150 MG Formulary OTC perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Formulary PERIOMED MOUTH/THROAT CONCENTRATE 0.63 % Formulary OTC permethrin external cream 5 % Formulary PERNOX EXTERNAL LOTION 1.5-2 % Formulary OTC PEROXYL EXTERNAL SOLUTION 1.5-6 % Formulary OTC PEROXYL MOUTH/THROAT SOLUTION 1.5 % Formulary OTC PEROXYL SPOT TREATMENT MOUTH/THROAT GEL Formulary OTC 1.5 % perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Formulary AGE (Min 18 Years) perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- Formulary AGE (Min 18 Years) 10 mg, 4-25 mg, 4-50 mg PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG Formulary OTC petroleum jelly external aerosol Formulary OTC petroleum jelly external ointment Formulary OTC PHARMABASE BARRIER EXTERNAL OINTMENT Formulary OTC 9.38 % PHARMACY COUNTER LANCETS Formulary OTC; QL (150 EA per 30 days) PHAZYME MAXIMUM STRENGTH ORAL CAPSULE Formulary OTC 250 MG 106 Drug Name Formulary Status Requirements/Limits PHAZYME ULTRA STRENGTH ORAL CAPSULE 180 Formulary OTC MG PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Formulary AGE (Min 2 Years) PHENAZO ORAL TABLET 200 MG Formulary phenazopyridine hcl oral tablet 100 mg Formulary phenelzine sulfate oral tablet 15 mg Formulary phenobarbital oral elixir 20 mg/5ml Formulary phenobarbital oral solution 20 mg/5ml Formulary phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, Formulary 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenol external liquid Formulary OTC PHENOL EZ SWABS EXTERNAL SWAB 89 % Formulary OTC phenoxybenzamine hcl oral capsule 10 mg Formulary phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg Formulary PA phentermine hcl oral tablet 37.5 mg Formulary PA phenylalanine oral packet 50 mg Formulary OTC PHENYTOIN INFATABS ORAL TABLET CHEWABLE Formulary 50 MG phenytoin oral suspension 125 mg/5ml Formulary phenytoin oral tablet chewable 50 mg Formulary phenytoin sodium extended oral capsule 100 mg, 200 mg, Formulary 300 mg phenytoin sodium injection solution 50 mg/ml Formulary PHLEXY-10 ORAL TABLET Formulary OTC PHOS-FLUR ORTHO DEFENSE MOUTH/THROAT Formulary OTC SOLUTION 0.044 % phos-nak oral packet 280-160-250 mg Formulary OTC PHOSPHASAL ORAL TABLET 81.6 MG Formulary phosphatidyl choline oral tablet 65 mg Formulary OTC PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION Formulary RECONSTITUTED 0.125 % PHOTOFRIN INTRAVENOUS SOLUTION Formulary RECONSTITUTED 75 MG phytonadione oral tablet 5 mg Formulary PHYTOPLEX Z-GUARD EXTERNAL PASTE 57-17 % Formulary OTC PIFELTRO ORAL TABLET 100 MG Formulary QL (30 EA per 30 days) pilocarpine hcl oral tablet 5 mg, 7.5 mg Formulary pimecrolimus external cream 1 % Formulary PA; AGE (Min 2 Years) pindolol oral tablet 10 mg, 5 mg Formulary pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Formulary pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg Formulary ST; QL (34 EA per 34 days) pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15- Formulary 850 mg piroxicam oral capsule 10 mg, 20 mg Formulary PLAN B ONE-STEP ORAL TABLET 1.5 MG Formulary OTC; QL (2 EA per 34 days) PLASBUMIN-25 INTRAVENOUS SOLUTION 25 % Formulary 107 Drug Name Formulary Status Requirements/Limits PLASBUMIN-5 INTRAVENOUS SOLUTION 5 % Formulary PLIAGEL GEL 0.5-0.5-0.25 % Formulary OTC PLO ULTRAMAX EXTERNAL GEL Formulary OTC PNEUMOVAX 23 INJECTION INJECTABLE 25 Formulary AGE (Min 19 Years) MCG/0.5ML pnv-dha oral capsule 27-0.6-0.4-300 mg Formulary pnv-omega oral capsule 28-0.6-0.4-340 mg Formulary pnv-select oral tablet 27-0.6-0.4 mg Formulary podofilox external solution 0.5 % Formulary poison ivy wash fast acting external Formulary OTC POLAR FREEZE EXTERNAL GEL 3.5-0.8 % Formulary OTC POLAR FROST EXTERNAL GEL 4 % Formulary OTC poly bacitracin external ointment 500-10000 unit/gm Formulary OTC POLY HIST FORTE ORAL TABLET 7.5-10 MG Formulary OTC poly-hist dm oral liquid 5-25-10 mg/5ml Formulary OTC poly-hist pd oral liquid 6.25-6.25 mg/ml Formulary OTC polymyxin b-trimethoprim ophthalmic solution 10000-0.1 Formulary unit/ml-% POLYSPORIN EXTERNAL OINTMENT 500-10000 Formulary OTC UNIT/GM poly-tussin ac oral liquid 10-4-10 mg/5ml Formulary OTC POLY-VENT DM ORAL TABLET 60-20-380 MG Formulary OTC POLY-VENT IR ORAL TABLET 60-380 MG Formulary OTC POLY-VI-SOL ORAL SOLUTION Formulary OTC POLY-VI-SOL/IRON ORAL SOLUTION Formulary OTC poly-vite pediatric oral solution Formulary OTC potassimin oral tablet 75 mg Formulary OTC potassium chloride crys er oral tablet extended release 10 Formulary meq, 20 meq potassium citrate er oral tablet extended release 10 meq Formulary (1080 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml Formulary potassium gluconate oral tablet 2 meq, 2.5 meq, 595 (99 k) Formulary OTC mg potassium iodide (antidote) oral solution 65 mg/ml Formulary OTC povidone-iodine external ointment 10 % Formulary OTC povidone-iodine external solution 10 % Formulary OTC povidone-iodine external swab 7.5 % Formulary OTC povidone-iodine paint sponge external swab 10 % Formulary OTC povidone-iodine prep external pad 10 % Formulary OTC povidone-iodine scrub sponge external 10 % Formulary OTC power oral care system mouth/throat kit Formulary OTC PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR) Formulary PR NATAL 400 ORAL 29-1-200 & 400 MG Formulary PR NATAL 430 EC ORAL 29-1-200 & 430 MG (DR) Formulary

108 Drug Name Formulary Status Requirements/Limits PR NATAL 430 ORAL 29-1-200 & 430 MG Formulary PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG Formulary PRALUENT SOLUTION AUTO-INJECTOR 150 MG/ML Formulary PA SUBCUTANEOUS 150 MG/ML PRALUENT SOLUTION AUTO-INJECTOR 75 MG/ML Formulary PA SUBCUTANEOUS 75 MG/ML PRALUENT SUBCUTANEOUS SOLUTION PEN- Formulary PA INJECTOR 150 MG/ML, 75 MG/ML PRAMEGEL EXTERNAL GEL 1 % Formulary OTC pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, Formulary 0.5 mg, 0.75 mg, 1 mg, 1.5 mg PRAMOX EXTERNAL GEL 1 % Formulary pramoxine hcl rectal foam 1 % Formulary OTC prasugrel hcl oral tablet 10 mg, 5 mg Formulary pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg Formulary prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Formulary PRECISION GLUCOSE CONTROL LIQUID IN VITRO Formulary OTC; QL (100 EA per 30 days) PRECISION GLUCOSE CONTROL SOLN SOLUTION Formulary OTC; QL (150 EA per 30 days) IN VITRO PRECISION GLUCOSE KETONE CONTR LIQUID IN Formulary OTC; QL (100 EA per 30 days) VITRO PRECISION GLUCOSE/KETONE CONTR LIQUID IN Formulary OTC; QL (100 EA per 30 days) VITRO PRECISION LINK KIT Formulary OTC; QL (1 EA per 365 days) PRECISION PCX PLUS TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) PRECISION PCX STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) PRECISION POINT OF CARE TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) PRECISION QID MONITOR DEVICE Formulary OTC; QL (1 EA per 365 days) PRECISION QID MONITOR DEVICE Formulary OTC; QL (150 EA per 30 days) PRECISION QID TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) PRECISION SOF-TACT MONITOR DEVICE Formulary OTC; QL (1 EA per 365 days) PRECISION SOF-TACT TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML Formulary OTC 29G X 1/2" 0.3 ML PRECISION SUREDOSE PLUS SYR 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML Formulary OTC 28G X 1/2" 0.5 ML PRECISION SURE-DOSE SYRINGE 28G X 1/2" 1 ML Formulary OTC 28G X 1/2" 1 ML PRECISION SURE-DOSE SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML Formulary OTC 30G X 3/8" 0.5 ML PRECISION THINS GP LANCETS Formulary OTC; QL (150 EA per 30 days) PRECISION XTRA BLOOD GLUCOSE STRIP IN Formulary OTC; QL (150 EA per 30 days) VITRO PRECISION XTRA DEVICE Formulary OTC; QL (1 EA per 365 days) 109 Drug Name Formulary Status Requirements/Limits PRECISION XTRA DEVICE Formulary OTC; QL (150 EA per 30 days) PRECISION XTRA KETONE STRIP IN VITRO Formulary OTC; QL (100 EA per 30 days) PRECISION XTRA KIT Formulary OTC; QL (1 EA per 365 days) PRECISION XTRA MONITOR DEVICE Formulary OTC; QL (1 EA per 365 days) PRED MILD OPHTHALMIC SUSPENSION 0.12 % Formulary prednicarbate external cream 0.1 % Formulary prednicarbate external ointment 0.1 % Formulary prednisolone acetate ophthalmic suspension 1 % Formulary prednisolone oral solution 15 mg/5ml Formulary prednisolone sodium phosphate oral solution 15 mg/5ml, 20 Formulary mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml PREDNISONE INTENSOL ORAL CONCENTRATE 5 Formulary MG/ML prednisone oral solution 5 mg/5ml Formulary prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, Formulary 50 mg prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), Formulary 5 mg (21), 5 mg (48) preferred plus insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" Formulary OTC 0.5 ml preferred plus insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 Formulary OTC ml preferred plus insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" Formulary OTC 0.3 ml preferred plus insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" Formulary OTC 0.5 ml preferred plus insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 Formulary OTC ml preferred plus insulin syringe 30g x 5/16" 0.3 ml 30g x Formulary OTC 5/16" 0.3 ml preferred plus insulin syringe 30g x 5/16" 0.5 ml 30g x Formulary OTC 5/16" 0.5 ml preferred plus insulin syringe 30g x 5/16" 1 ml 30g x 5/16" Formulary OTC 1 ml preferred plus lancets colored Formulary OTC; QL (150 EA per 30 days) preferred plus lancets thin Formulary OTC; QL (150 EA per 30 days) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, Formulary 25 mg, 300 mg, 50 mg, 75 mg PREGNITUDE ORAL PACKET 2000-200 MG-MCG Formulary OTC PREMARIN VAGINAL CREAM 0.625 MG/GM Formulary PREMIER UROSTOMY POUCH Formulary OTC PREMPHASE ORAL TABLET 0.625-5 MG Formulary PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, Formulary 0.625-2.5 MG, 0.625-5 MG prenatal formula a-free oral tablet 9-0.267 mg Formulary OTC prenatal formula oral capsule 28-0.8-235 mg Formulary OTC prenatal low iron oral tablet 27-0.8 mg Formulary OTC prenatal multi +dha oral capsule 27-0.8-200 mg Formulary OTC 110 Drug Name Formulary Status Requirements/Limits prenatal multivitamin plus dha oral capsule 27-0.8-250 mg Formulary OTC prenatal oral tablet 27-0.8 mg Formulary prenatal oral tablet 28-0.8 mg, 6.75-0.2 mg Formulary OTC PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG Formulary prep protective skin barrier external pad 0.5 % Formulary OTC PREPARATION H RECTAL CREAM 1-0.25-14.4-15 %, Formulary OTC 5-14.4 % PREPARATION H RECTAL GEL 0.25-50 % Formulary OTC PREPARATION H RECTAL OINTMENT 0.25-14-74.9 % Formulary OTC PREPARATION H TOTABLES RECTAL CREAM 1- Formulary OTC 0.25-14.4-15 % pres gen pediatric oral liquid 2.5-5-75 mg/5ml Formulary OTC PRESGEN B ORAL LIQUID 10-4-20 MG/5ML Formulary OTC PRETZ NASAL SOLUTION Formulary OTC PREVACARE ANTIMICROBIAL EXTERNAL GEL 60 Formulary OTC % PREVACARE EXTRA PROTECTIVE EXTERNAL Formulary OTC OINTMENT PREVACARE PERSONAL PROTECT EXTERNAL Formulary OTC CREAM PREVACARE TOTAL SKIN CARE EXTERNAL Formulary OTC SOLUTION PREVACID 24HR ORAL CAPSULE DELAYED Formulary OTC RELEASE 15 MG PREVALITE ORAL PACKET 4 GM Formulary PREVALITE ORAL POWDER 4 GM/DOSE Formulary PREVIDENT MOUTH/THROAT SOLUTION 0.2 % Formulary PREVNAR 13 INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) PREZCOBIX ORAL TABLET 800-150 MG Formulary PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, Formulary 800 MG PRIFTIN ORAL TABLET 150 MG Formulary PRILOSEC OTC ORAL TABLET DELAYED RELEASE Formulary OTC 20 MG PRIMATENE ASTHMA ORAL TABLET 12.5-200 MG Formulary OTC primidone oral tablet 250 mg, 50 mg Formulary PRO NUTRIENTS OMEGA 3 ORAL CAPSULE Formulary OTC DELAYED RELEASE 332.5 MG PROAIR HFA INHALATION AEROSOL SOLUTION Formulary 108 (90 BASE) MCG/ACT probenecid oral tablet 500 mg Formulary PROBIOMAX PLUS DF ORAL PACKET Formulary OTC probiotic digestive support oral capsule Formulary OTC probiotic oral capsule 250 mg Formulary OTC probiotic oral tablet delayed release Formulary OTC probiotic-prebiotic oral capsule 1-250 billion-mg Formulary OTC PROCARE PLUS UNDERWEAR MEDIUM Formulary OTC 111 Drug Name Formulary Status Requirements/Limits PRO-CEPTION VAGINAL KIT Formulary OTC prochlorperazine maleate oral tablet 10 mg, 5 mg Formulary prochlorperazine rectal suppository 25 mg Formulary PROCOMYCIN EXTERNAL CREAM 4 % Formulary OTC PROCTOCORT RECTAL CREAM 1 % Formulary PROCTOFOAM RECTAL FOAM 1 % Formulary OTC PROCTOSOL HC RECTAL CREAM 2.5 % Formulary PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML 28G X Formulary OTC 1/2" 1 ML PRODIGY INSULIN SYRINGE 31G X 5/16" 0.3 ML 31G Formulary OTC X 5/16" 0.3 ML PRODIGY INSULIN SYRINGE 31G X 5/16" 0.5 ML 31G Formulary OTC X 5/16" 0.5 ML PRODIGY NO CODING BLOOD GLUC STRIP IN Formulary PA; OTC; QL (150 EA per 30 days) VITRO PRODIGY TWIST TOP LANCETS 28G Formulary OTC; QL (150 EA per 30 days) PROFE ORAL CAPSULE 391.3 (180 FE) MG Formulary OTC PROFERRIN ES ORAL TABLET 12 MG Formulary OTC PROFERRIN-FORTE ORAL TABLET 12-1 MG Formulary OTC PROFILNINE SD INTRAVENOUS SOLUTION Formulary RECONSTITUTED 500 UNIT progesterone intramuscular oil 50 mg/ml Formulary progesterone micronized oral capsule 100 mg, 200 mg Formulary progesterone oral capsule 100 mg, 200 mg Formulary PROLENSA OPHTHALMIC SOLUTION 0.07 % Formulary PROLIDA EXTERNAL PATCH 4-1 % Formulary OTC PROMACTA ORAL TABLET 12.5 MG Formulary PA; QL (240 EA per 30 days) PROMACTA ORAL TABLET 25 MG Formulary PA; QL (120 EA per 30 days) PROMACTA ORAL TABLET 50 MG Formulary PA; QL (60 EA per 30 days) PROMACTA ORAL TABLET 75 MG Formulary PA; QL (30 EA per 30 days) promethazine hcl oral syrup 6.25 mg/5ml Formulary AGE (Min 2 Years) promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg Formulary AGE (Min 2 Years) promethazine hcl rectal suppository 12.5 mg, 50 mg Formulary AGE (Min 2 Years) promethazine hcl rectal suppository 25 mg Formulary promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml Formulary AGE (Min 6 Years) promethazine-codeine oral syrup 6.25-10 mg/5ml Formulary AGE (Min 6 Years) promethazine-dm oral syrup 6.25-15 mg/5ml Formulary AGE (Min 6 Years) PROMETHEGAN RECTAL SUPPOSITORY 25 MG Formulary PROMETHEGAN RECTAL SUPPOSITORY 50 MG Formulary AGE (Min 2 Years) PROMOLAXIN ORAL TABLET 100 MG Formulary OTC PRONUTRIENTS CALCIUM+D3 ORAL TABLET 600- Formulary OTC 800 MG-UNIT PRONUTRIENTS SUPER B COMPLEX ORAL TABLET Formulary OTC propafenone hcl er oral capsule extended release 12 hour Formulary 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg Formulary 112 Drug Name Formulary Status Requirements/Limits propranolol hcl er oral capsule extended release 24 hour Formulary 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml Formulary propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml Formulary propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 Formulary mg propranolol-hctz oral tablet 40-25 mg, 80-25 mg Formulary propylene glycol external solution Formulary propylthiouracil oral tablet 50 mg Formulary PRO-RED AC ORAL SYRUP 5-1-9 MG/5ML Formulary OTC PROSHIELD SKIN CARE EXTERNAL KIT Formulary OTC protein oral powder 80 % Formulary OTC protein oral tablet 975 mg Formulary OTC PROTEINEX ORAL LIQUID Formulary OTC PROTEINEX P100 ORAL LIQUID Formulary OTC protriptyline hcl oral tablet 10 mg, 5 mg Formulary PROVENT SLEEP APNEA THERAPY Formulary PROVIDA DHA ORAL CAPSULE 16-16-1.25-110 MG Formulary PROVIEW KIT Formulary OTC pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml Formulary pseudoephedrine hcl er oral tablet extended release 12 hour Formulary OTC 120 mg pseudoephedrine hcl oral syrup 30 mg/5ml Formulary OTC pseudoephedrine hcl oral tablet 30 mg Formulary OTC pseudoephedrine hcl oral tablet 60 mg Formulary psorcon external cream 0.05 % Formulary PSS SELECT GP LANCETS Formulary OTC; QL (150 EA per 30 days) PSS SELECT SAFETY LANCETS Formulary OTC; QL (150 EA per 30 days) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 Formulary MCG/ACT PULMOZYME INHALATION SOLUTION 1 MG/ML Formulary PURACYN PLUS DUO-CARE EXTERNAL LIQUID Formulary OTC PURE & GENTLE LUBRICANT OPHTHALMIC Formulary OTC SOLUTION 3 MG/ML pure l-citrulline oral capsule 600 mg Formulary OTC pure l-citrulline oral powder Formulary OTC purefe ob plus oral capsule 162-115.2-1 mg Formulary purified water oral liquid Formulary PURILON EXTERNAL GEL Formulary OTC px allergy relief d oral tablet extended release 12 hour 5- Formulary OTC 120 mg px allergy sinus pe oral tablet 2-5-325 mg Formulary OTC px antacid extra strength oral tablet chewable 750 mg Formulary OTC px artificial tears ophthalmic solution 5-6 mg/ml Formulary OTC px daytime cold oral tablet 10-5-325 mg Formulary OTC 113 Drug Name Formulary Status Requirements/Limits px daytime multi-symptom oral capsule 30-325-15 mg Formulary OTC px gas relief extra strength oral capsule 125 mg Formulary OTC px ibuprofen cold & sinus oral tablet 30-200 mg Formulary OTC px insulin syringe 30g x 1/2" 0.5 ml 30g x 1/2" 0.5 ml Formulary OTC px lancets ultra thin Formulary OTC; QL (150 EA per 30 days) px minoxidil for men external solution 5 % Formulary OTC px nasal four nasal solution 1 % Formulary OTC px nitetime multi-symptom oral capsule 30-6.25-15-325 mg Formulary OTC px omeprazole oral tablet delayed release 20 mg Formulary OTC PYLERA ORAL CAPSULE 140-125-125 MG Formulary pyrazinamide oral tablet 500 mg Formulary pyridostigmine bromide er oral tablet extended release 180 Formulary mg pyridostigmine bromide oral tablet 60 mg Formulary pyridoxine hcl oral tablet 25 mg Formulary OTC PYRIDOXINE/MINERALS ORAL CAPSULE 100-99-200 Formulary OTC MG pyrilamine-phenylephrine oral tablet 25-10 mg Formulary OTC pyrimethamine oral tablet 25 mg Formulary PA qc alcohol swabs pad 70 % 70 % Formulary OTC qc arthritis external cream 10 % Formulary OTC qc calamine external lotion Formulary OTC qc iodides external tincture Formulary OTC qc iodine tincture external tincture Formulary OTC qc lancets super thin 30g Formulary OTC; QL (150 EA per 30 days) qc lancets ultra thin Formulary OTC; QL (150 EA per 30 days) QC MEDIFIN PE ORAL TABLET 10-400 MG Formulary OTC qc natural vegetable oral powder 95 % Formulary OTC qc non-adherent pad 3"x4" Formulary OTC qc unilet lancets 28g Formulary OTC; QL (150 EA per 30 days) qc unilet lancets micro thin Formulary OTC; QL (150 EA per 30 days) Q-GEL ORAL CAPSULE 15 MG Formulary OTC quercetin oral tablet 250 mg, 50 mg Formulary OTC quetiapine fumarate er oral tablet extended release 24 hour QL (30 EA per 30 days); AGE (Min 18 Formulary 150 mg, 200 mg Years) quetiapine fumarate er oral tablet extended release 24 hour Formulary AGE (Min 18 Years) 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 Formulary AGE (Min 18 Years) mg, 400 mg, 50 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg Formulary quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Formulary 12.5 mg, 20-25 mg quinidine gluconate er oral tablet extended release 324 mg Formulary quinidine sulfate oral tablet 200 mg, 300 mg Formulary quinine sulfate oral capsule 324 mg Formulary

114 Drug Name Formulary Status Requirements/Limits ra 8 hour pain relief oral tablet extended release 650 mg Formulary OTC ra acetaminophen flu cold oral tablet 30-500-15 mg Formulary OTC ra acid reducer plus antacid oral tablet chewable 10-800- Formulary OTC 165 mg ra acne maximum external pad 2 % Formulary OTC ra advanced eye health oral capsule 250-2.5-0.5 mg, 500-5- Formulary OTC 1 mg ra alcohol swabs pad 70 % 70 % Formulary OTC ra anorectal external cream 5 % Formulary OTC ra antifungal pen external liquid 25 % Formulary OTC ra b-12 mouth/throat lozenge 1000-400 mcg Formulary OTC ra back & body pain relief oral tablet 500-32.5 mg Formulary OTC ra b-complex/vitamin c cr oral tablet extended release Formulary OTC ra ca/mg/zn/cu oral tablet Formulary OTC ra calamine external lotion 6.971-6.971 % Formulary OTC ra calamine external suspension 8-8 % Formulary OTC ra calcium hi-cal/vitamin d oral tablet 250-125 mg-unit, Formulary OTC 500-125 mg-unit, 500-200 mg-unit ra calcium high potency oral tablet 600 mg Formulary OTC ra calcium oral tablet 500 mg Formulary OTC ra calcium-boron oral tablet 500-1.5 mg Formulary OTC ra cold remedy multi-symptom oral tablet dispersible Formulary OTC ra cold therapy gel external gel 4 % Formulary OTC ra cold/sinus max oral tablet 5-325-200 mg Formulary OTC ra corn cushions small pad Formulary OTC ra corn removers ultra thin external pad 40 % Formulary OTC ra dark tanning external oil Formulary OTC ra day/night/cold/flu relief oral Formulary OTC ra daytime cold/flu relief oral liquid 10-5-325 mg/15ml Formulary OTC ra ear wax cleansing system otic kit 6.5 % Formulary OTC ra ethyl alcohol solution 70 % Formulary OTC RA E-ZJECT COLOR LANCETS 33G Formulary OTC; QL (150 EA per 30 days) RA E-ZJECT LANCETS 28G Formulary OTC; QL (150 EA per 30 days) RA E-ZJECT LANCETS THIN 26G Formulary OTC; QL (150 EA per 30 days) RA E-ZJECT LANCETS THIN 28G Formulary OTC; QL (150 EA per 30 days) RA E-ZJECT LANCETS ULTRA THIN Formulary OTC; QL (150 EA per 30 days) ra feminine care douche vaginal solution Formulary OTC ra fever reducer/pain reliever oral suspension 160 mg/5ml Formulary OTC ra fiber weight management oral tablet chewable Formulary OTC ra first aid iodine external tincture Formulary OTC ra first aid non-stick pad Formulary OTC ra first aid saline wound wash external liquid 0.13 % Formulary OTC RA FISH OIL EXTRA STRENGTH ORAL CAPSULE 870 Formulary OTC MG ra fish oil oral capsule 900 mg Formulary OTC 115 Drug Name Formulary Status Requirements/Limits ra fish oil oral capsule delayed release 1400 mg Formulary OTC ra foaming hand soap refill external liquid 0.6 % Formulary OTC ra gel toe separator Formulary OTC ra glucosamine-chondroitin oral capsule 166.7-133.3 mg Formulary OTC ra glucosamine-chondroitin-d3 oral tablet 750-600-500 mg- Formulary OTC mg-unit ra glucosamine-chondroit-msm oral tablet , 500-400-300 Formulary OTC mg ra hot & cold lidocaine external patch 4-1 % Formulary OTC ra hot/cold gel sleeve Formulary OTC ra hydrogen peroxide external solution 3 % Formulary OTC ra insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC ra insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC ra insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC ra insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC ra intimacy gels/him/her external gel Formulary OTC ra isopropyl alcohol wipes external 70 % Formulary OTC ra lice solution combination kit 0.5-0.33-4 % Formulary OTC RA LOTION EXTERNAL LOTION Formulary OTC ra lubricant eye drops ophthalmic solution 0.6 % Formulary OTC ra lutein oral capsule 20-1 mg Formulary OTC RA LYCOPENE ORAL CAPSULE 15 MG Formulary OTC ra melatonin sublingual tablet sublingual 1 mg Formulary OTC ra miconazole 3 combo pack vaginal kit 200 & 2 mg-% Formulary OTC (9gm) ra mouth pain anesthetic mouth/throat liquid 20 % Formulary OTC ra mucus relief d max strength oral tablet extended release Formulary OTC 12 hour 120-1200 mg ra multihealth fiber oral powder 58.6 % Formulary OTC ra nasal strip/drug free/large strip Formulary OTC ra nighttime cold/flu relief oral liquid 30-12.5-650 mg/30ml Formulary OTC ra oatmeal moisturizing external lotion 1.6 % Formulary OTC ra omega 3-6-9 oral capsule Formulary OTC ra omeprazole oral tablet delayed release 20 mg Formulary OTC ra omeprazole-sodium bicarb capsule 20-1100 mg oral 20- Formulary OTC; QL (34 EA per 34 days) 1100 mg ra oyster shell calcium/d oral tablet 250-125 mg-unit, 500- Formulary OTC 200 mg-unit ra pain relief external cream 4 % Formulary OTC ra personal lubricant external liquid Formulary OTC ra prenatal oral tablet 28-0.8 mg Formulary OTC ra probiotic complex oral tablet Formulary OTC ra probiotic digestive care oral tablet Formulary OTC ra probiotic gummies oral tablet chewable Formulary OTC RA RENEWAL ACNE TREATMENT EXTERNAL GEL Formulary OTC 10 % 116 Drug Name Formulary Status Requirements/Limits RA RENEWAL SHOWER & BATH EXTERNAL OIL Formulary OTC ra saline nasal spray nasal solution 0.65 % Formulary OTC ra saline wound wash external solution 0.9 % Formulary OTC ra sensitive anti-itch external lotion 1 % Formulary OTC ra severe cold/night cold&flu oral Formulary OTC ra severe congestion/cold max oral tablet 5-10-200-325 mg Formulary OTC ra shower & bath body external powder Formulary OTC ra silky lubricant moisturizer vaginal gel Formulary OTC ra sinus wash nasal relief nasal packet 1685-515 mg Formulary OTC ra sinus wash neti pot nasal packet 1685-515 mg Formulary OTC ra slow release iron oral tablet extended release 45 mg Formulary OTC ra stay awake oral tablet 100 mg Formulary OTC ra sterile saline nasal mist nasal solution 0.9 % Formulary OTC ra triple antibiotic external aerosol 3.5-400-5000 Formulary OTC RA TUGABOOS BABY EXTERNAL OIL Formulary OTC ra vaginal infection screening in vitro kit Formulary OTC ra vitamin b-12 oral liquid 1000 mcg/ml Formulary OTC ra vitamin c oral tablet chewable 300 mg Formulary OTC ra yeast relief plus oral tablet Formulary OTC rabano yodado oral liquid Formulary OTC RABAVERT INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) RECONSTITUTED rabeprazole sodium oral tablet delayed release 20 mg Formulary RADIACARE POST HEALING EXTERNAL CREAM Formulary OTC raloxifene hcl oral tablet 60 mg Formulary ramelteon oral tablet 8 mg Formulary ST; QL (30 EA per 30 days) ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Formulary hcl oral syrup 75 mg/5ml Formulary ranitidine hcl oral tablet 150 mg, 300 mg Formulary ranitidine hcl oral tablet 75 mg Formulary OTC RASH AWAY EXTERNAL AEROSOL 33 % Formulary OTC RASH RELIEF EXTERNAL LIQUID 20-25 % Formulary OTC raspberry syrup oral syrup Formulary reality insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml Formulary OTC reality insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC reality insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC reality insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC reality lancets Formulary OTC; QL (150 EA per 30 days) reality swabs pad Formulary OTC reality trigger lancets Formulary OTC; QL (150 EA per 30 days) REA-LO EXTERNAL CREAM 30 % Formulary OTC REBETOL ORAL CAPSULE 200 MG Formulary PA REBETOL ORAL SOLUTION 40 MG/ML Formulary PA

117 Drug Name Formulary Status Requirements/Limits RECOMBIVAX HB INJECTION SUSPENSION 10 Formulary AGE (Min 19 Years) MCG/ML, 40 MCG/ML, 5 MCG/0.5ML RECTICARE EXTERNAL CREAM 5 % Formulary OTC red cross cotton sterile Formulary OTC REDNESS RELIEF OPHTHALMIC SOLUTION 0.012- Formulary OTC 0.25 % reeses pinworm medicine oral tablet 180 mg Formulary OTC REFENESEN CHEST CONG/PAIN RLF ORAL TABLET Formulary OTC 650-400 MG REFENESEN CHST CONG/PAIN PE ORAL TABLET Formulary OTC 10-650-400 MG REFRESH LACRI-LUBE OPHTHALMIC OINTMENT Formulary OTC REFRESH OPHTHALMIC SOLUTION 1.4-0.6 % Formulary OTC REFRESH OPTIVE MEGA-3 OPHTHALMIC Formulary OTC SOLUTION 0.5-1-0.5 % REFRESH OPTIVE OPHTHALMIC GEL 1-0.9 % Formulary OTC REFRESH OPTIVE OPHTHALMIC SOLUTION 0.5-0.9 Formulary OTC % REFRESH OPTIVE SENSITIVE OPHTHALMIC Formulary OTC SOLUTION 0.5-0.9 % REFRESH P.M. OPHTHALMIC OINTMENT Formulary OTC REFRESH TEARS OPHTHALMIC SOLUTION 0.5 % Formulary OTC REGENECARE HA EXTERNAL LIQUID 2 % Formulary OTC REGRANEX EXTERNAL GEL 0.01 % Formulary PA; QL (15 GM per 34 days) relagesic oral tablet 29-500 mg Formulary OTC relcof c oral solution 100-6.3 mg/5ml Formulary OTC; AGE (Min 6 Years) RELIADERM EXTERNAL CREAM 0.035-10-25 % Formulary OTC RELIEF PAIN RELIEVING EXTERNAL CREAM 3 % Formulary OTC RELION ALCOHOL SWABS PAD Formulary OTC RELION ALCOHOL SWABS PAD 70 % 70 % Formulary OTC RELION ALL-IN-ONE DEVICE Formulary OTC RELION BLOOD GLUCOSE TEST STRIP IN VITRO Formulary OTC; QL (150 EA per 30 days) RELION GLUCOSE SHOT ORAL LIQUID Formulary OTC RELI-ON INSULIN SYRINGE 29G 0.3 ML 29G 0.3 ML Formulary OTC RELI-ON INSULIN SYRINGE 29G 0.5 ML 29G 0.5 ML Formulary OTC RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML 29G X Formulary OTC 1/2" 0.3 ML RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML 29G X Formulary OTC 1/2" 0.5 ML RELION INSULIN SYRINGE 29G X 1/2" 1 ML 29G X Formulary OTC 1/2" 1 ML RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML 29G X Formulary OTC 1/2" 1 ML RELI-ON INSULIN SYRINGE 30G 0.3 ML 30G 0.3 ML Formulary OTC RELI-ON INSULIN SYRINGE 30G 0.5 ML 30G 0.5 ML Formulary OTC RELI-ON INSULIN SYRINGE 30G 1 ML 30G 1 ML Formulary OTC

118 Drug Name Formulary Status Requirements/Limits RELION INSULIN SYRINGE 30G X 5/16" 0.3 ML 30G X Formulary OTC 5/16" 0.3 ML RELION INSULIN SYRINGE 30G X 5/16" 0.5 ML 30G X Formulary OTC 5/16" 0.5 ML RELION INSULIN SYRINGE 30G X 5/16" 1 ML 30G X Formulary OTC 5/16" 1 ML RELION INSULIN SYRINGE 31G X 15/64" 0.3 ML 31G Formulary OTC X 15/64" 0.3 ML RELION INSULIN SYRINGE 31G X 15/64" 0.5 ML 31G Formulary OTC X 15/64" 0.5 ML RELION INSULIN SYRINGE 31G X 15/64" 1 ML 31G X Formulary OTC 15/64" 1 ML RELION INSULIN SYRINGE 31G X 5/16" 0.3 ML 31G X Formulary OTC 5/16" 0.3 ML RELION INSULIN SYRINGE 31G X 5/16" 0.5 ML 31G X Formulary OTC 5/16" 0.5 ML RELION INSULIN SYRINGE 31G X 5/16" 1 ML 31G X Formulary OTC 5/16" 1 ML RELION LANCETS MICRO-THIN 33G Formulary OTC; QL (150 EA per 30 days) RELION LANCETS STANDARD 21G Formulary OTC; QL (150 EA per 30 days) RELION LANCETS THIN 26G Formulary OTC; QL (150 EA per 30 days) RELION LANCETS ULTRA-THIN 30G Formulary OTC; QL (150 EA per 30 days) RELION ULTRA THIN LANCETS 30G Formulary OTC; QL (150 EA per 30 days) RELION ULTRA THIN PLUS LANCETS Formulary OTC; QL (150 EA per 30 days) RELISTOR ORAL TABLET 150 MG Formulary PA; QL (90 EA per 30 days) RELISTOR SUBCUTANEOUS SOLUTION 12 Formulary PA MG/0.6ML REMEDY ANTIMICROBIAL CLEANSER EXTERNAL Formulary OTC LIQUID 0.12 % REMEDY CALAZIME EXTERNAL PASTE 0.4-20.5 % Formulary OTC REMEDY CLEANSING BODY EXTERNAL LOTION Formulary OTC 1.5 % REMEDY PHYTOPLEX ANTIFUNGAL EXTERNAL Formulary OTC POWDER 2 % REMEDY SKIN REPAIR EXTERNAL CREAM 1.5 % Formulary OTC REMOVE ADHESIVE REMOVER WIPES EXTERNAL Formulary OTC RENACIDIN IRRIGATION SOLUTION Formulary renal vitamin oral tablet 0.8 mg Formulary OTC RENFLEXIS INTRAVENOUS SOLUTION Formulary RECONSTITUTED 100 MG renuu nl external patch 2-30 % Formulary repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Formulary REPATHA SOLUTION PREFILLED SYRINGE 140 Formulary PA MG/ML SUBCUTANEOUS 140 MG/ML REPATHA SURECLICK SOLUTION AUTO-INJECTOR Formulary PA 140 MG/ML SUBCUTANEOUS 140 MG/ML REPLACE SR ORAL TABLET EXTENDED RELEASE Formulary OTC RESCON ORAL TABLET 2-60 MG Formulary OTC

119 Drug Name Formulary Status Requirements/Limits RESCRIPTOR ORAL TABLET 100 MG, 200 MG Formulary RESOURCE THICKENUP WATER ORAL LIQUID Formulary OTC RESPAIRE-30 ORAL CAPSULE 30-150 MG Formulary OTC RESTASIS OPHTHALMIC EMULSION 0.05 % Formulary PA; QL (60 EA per 30 days) RESTORE CLEANSER & MOISTURIZER EXTERNAL Formulary OTC LIQUID 2 % RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 Formulary UNIT/ML RETAINE PM OPHTHALMIC OINTMENT Formulary OTC RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % Formulary AGE (Max 18 Years) RETIN-A EXTERNAL GEL 0.01 %, 0.025 % Formulary AGE (Max 18 Years) REVEAL COLON DISEASE IN VITRO DIAGNOSTIC Formulary OTC TEST REVEAL DNA PATERNITY TEST IN VITRO KIT Formulary OTC REVEAL GET PREGNANT QUICK IN VITRO KIT Formulary OTC REVEAL MULTI-DRUG TESTING CUP IN VITRO Formulary OTC REVEAL URINARY TRACT IN VITRO STRIP Formulary OTC REVITADERM WOUND CARE EXTERNAL GEL Formulary OTC REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 Formulary PA MG, 25 MG, 5 MG REVONTO INTRAVENOUS SOLUTION Formulary RECONSTITUTED 20 MG REXALL LANCETS ULTRA THIN 30G Formulary OTC; QL (150 EA per 30 days) REZAMID EXTERNAL LOTION 2-5 % Formulary OTC RHINARIS NASAL SOLUTION 0.2 % Formulary OTC RHINASE NASAL GEL Formulary OTC RHINASE NASAL SOLUTION Formulary OTC RHOPRESSA OPHTHALMIC SOLUTION 0.02 % Formulary RIASTAP INTRAVENOUS SOLUTION Formulary RECONSTITUTED RIAX EXTERNAL FOAM 5.5 %, 9.5 % Formulary OTC; AGE (Max 19 Years) RIBASPHERE ORAL TABLET 400 MG, 600 MG Formulary PA riboflavin oral capsule 50 mg Formulary OTC RICOLA CHERRY HONEY HERB MOUTH/THROAT Formulary OTC LOZENGE 2 MG RICOLA HERB MOUTH/THROAT LOZENGE 1.1 MG, Formulary OTC 2.6 MG RICOLA LEMON MINT MOUTH/THROAT LOZENGE Formulary OTC 1.5 MG RICOLA W/ECHINACEA MOUTH/THROAT LOZENGE Formulary OTC 3.5 MG RIDAURA ORAL CAPSULE 3 MG Formulary rifabutin oral capsule 150 mg Formulary rifampin oral capsule 150 mg, 300 mg Formulary RIGHTEST GL300 LANCETS Formulary OTC; QL (150 EA per 30 days) riluzole oral tablet 50 mg Formulary 120 Drug Name Formulary Status Requirements/Limits ringers irrigation irrigation solution Formulary RISAMINE EXTERNAL OINTMENT 0.44-20.625 % Formulary OTC RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 Formulary AGE (Min 18 Years) MG, 50 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, Formulary AGE (Min 18 Years) 37.5 MG, 50 MG risperidone oral solution 1 mg/ml Formulary AGE (Min 18 Years) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 Formulary AGE (Min 18 Years) mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 Formulary AGE (Min 18 Years) mg, 3 mg, 4 mg ritonavir oral tablet 100 mg Formulary RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, Formulary PA 500 MG/50ML rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 Formulary mg rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 Formulary mg/24hr, 9.5 mg/24hr rixubis intravenous solution reconstituted 1000 unit, 2000 Formulary unit, 250 unit, 3000 unit, 500 unit rizatriptan benzoate oral tablet 10 mg, 5 mg Formulary ST; QL (12 EA per 34 days) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg Formulary QL (12 EA per 34 days) ROBATHOL EXTERNAL OIL Formulary OTC ROBITUSSIN CHILD COUGH/COLD CF ORAL LIQUID Formulary OTC 2.5-5-50 MG/5ML ROBITUSSIN COUGH+CHEST CONG DM ORAL Formulary OTC CAPSULE 10-200 MG ROBITUSSIN DAY/NIGHT VALUE PAK ORAL Formulary OTC ROBITUSSIN LINGERING COUGHGELS ORAL Formulary OTC CAPSULE 15 MG ROBITUSSIN MULTI-SYMPTOM MAX ORAL LIQUID Formulary OTC 5-10-200 MG/5ML ROBITUSSIN NIGHTTIME COUGH DM ORAL LIQUID Formulary OTC 12.5-30 MG/10ML ROBITUSSIN NIGHTTIME COUGH ORAL LIQUID 1- Formulary OTC 7.5 MG/5ML ROBITUSSIN PK COLD DAY/NGHT DM ORAL Formulary OTC ROBITUSSIN PK COLD DAY/NGHT MS ORAL Formulary OTC ROBITUSSIN SEVERE NIGHTTIME ORAL LIQUID Formulary OTC 12.5-5-325 MG/10ML ROBITUSSIN TO GO COUGH/COLD CF ORAL LIQUID Formulary OTC 5-10-100 MG/5ML ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % Formulary ROLAIDS ORAL TABLET CHEWABLE 550-110 MG Formulary OTC hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 Formulary mg, 4 mg, 5 mg rose water external liquid Formulary OTC

121 Drug Name Formulary Status Requirements/Limits rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Formulary ROTARIX ORAL SUSPENSION RECONSTITUTED Formulary AGE (Min 19 Years) ROTATEQ ORAL SOLUTION Formulary AGE (Min 19 Years) rotex external cream 0.038-4-35 % Formulary OTC rufinamide oral suspension 40 mg/ml Formulary PA rufinamide oral tablet 200 mg, 400 mg Formulary PA ru-hist d oral tablet 4-10 mg Formulary OTC rutin oral tablet 50 mg Formulary OTC rydex g oral tablet 38.5-398 mg Formulary OTC rymed oral tablet 2-10 mg Formulary OTC rynex pse oral liquid 1-15 mg/5ml Formulary OTC SAFE TUSSIN PM ORAL LIQUID 3.125-7.5 MG/5ML Formulary OTC SAFELET IV CATHETER Formulary OTC safety insulin syringes 27g x 1/2" 1 ml 27g x 1/2" 1 ml Formulary OTC safety insulin syringes 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC safety insulin syringes 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC safety insulin syringes 30g x 1/2" 1 ml 30g x 1/2" 1 ml Formulary OTC safety insulin syringes 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC SAFETY SEAL LANCETS Formulary OTC; QL (150 EA per 30 days) SAFETY-GARD NEEDLE 18G Formulary OTC SAFETY-LOK SYRINGE 21G X 1-1/2" 10 ML, 21G X 1- Formulary OTC 1/2" 5 ML SAF-GEL EXTERNAL GEL Formulary OTC SALEM SUMP TUBE 12FR Formulary salicylic acid external foam 6 % Formulary salicylic acid external gel 6 % Formulary salicylic acid wart remover external liquid 27.5 % Formulary salicylic acid-cleanser external kit 6 % (lotion) Formulary saline nasal gel Formulary OTC saline solution Formulary OTC SALMON ORAL CAPSULE 200 MG Formulary OTC SAM-E COMPLETE ORAL TABLET DELAYED Formulary OTC RELEASE 200 MG sam-e oral tablet delayed release 400 mg Formulary OTC sam-g.l.a. oral capsule 100-150-40 mg Formulary OTC SAMSCA ORAL TABLET 15 MG Formulary PA; QL (34 EA per 34 days) SAMSCA ORAL TABLET 30 MG Formulary PA; QL (68 EA per 34 days) SANTYL EXTERNAL OINTMENT 250 UNIT/GM Formulary QL (60 GM per 34 days) sapropterin dihydrochloride oral tablet 100 mg Formulary PA sapropterin dihydrochloride oral tablet soluble 100 mg Formulary PA SARNA EXTERNAL LOTION 0.5-0.5 % Formulary OTC SASTID SOAP EXTERNAL BAR 3-5 % Formulary OTC SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Formulary PA; QL (68 EA per 34 days) MG

122 Drug Name Formulary Status Requirements/Limits SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 Formulary PA; QL (55 EA per 30 days) MG sb alcohol prep pad 70 % 70 % Formulary OTC sb bacitracin external ointment 500 unit/gm Formulary OTC sb cold & flu hbp oral tablet 2-325 mg Formulary OTC sb fib lax orange oral powder 30 % Formulary OTC sb insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml Formulary OTC sb insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC sb insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" 0.5 ml Formulary OTC sb insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 ml Formulary OTC sb insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 ml Formulary OTC sb lancets thin Formulary OTC; QL (150 EA per 30 days) sb lancets ultra thin Formulary OTC; QL (150 EA per 30 days) sb lice treatment external liquid 0.3-3 %, 1 % Formulary OTC sb omeprazole oral tablet delayed release 20 mg Formulary OTC sb stool softener oral capsule 240 mg Formulary OTC scarcin external cream Formulary OTC SCYTERA EXTERNAL FOAM 2 % Formulary OTC se-100 oral capsule 100 mcg Formulary OTC SEBUDERM EXTERNAL GEL Formulary SEBULEX EXTERNAL SHAMPOO 2-2 % Formulary OTC SECONAL ORAL CAPSULE 100 MG Formulary SECURA EPC SKIN CARE STARTER EXTERNAL KIT Formulary OTC 0.13 & 30.6 % SECURA EXTRA PROTECTIVE EXTERNAL CREAM Formulary OTC 30.6 % SECURA MOISTURIZING CLEANSER EXTERNAL Formulary OTC LIQUID 0.13 % SECURA PERSONAL CLEANSER EXTERNAL LIQUID Formulary OTC 0.13 % SECURA TOTAL BODY CLEANSER EXTERNAL Formulary OTC FOAM 0.13 % SECURA TWO-STEP EXTERNAL KIT 0.13 & 10 % Formulary OTC SELECT-OB ORAL TABLET CHEWABLE 29-1 MG Formulary selegiline hcl oral capsule 5 mg Formulary selegiline hcl oral tablet 5 mg Formulary selenicaps-200 oral capsule 200 mcg Formulary OTC selenimin oral tablet 125 mcg Formulary OTC selenium er oral tablet extended release 200 mcg Formulary OTC selenium sulfide external lotion 2.5 % Formulary SELSUN BLUE DEEP CLEANSING EXTERNAL Formulary OTC SHAMPOO 3 % SELZENTRY ORAL TABLET 150 MG, 300 MG Formulary senna leaves oral leaves Formulary OTC senna oral capsule 8.6 mg Formulary OTC senna oral syrup 176 mg/5ml Formulary OTC 123 Drug Name Formulary Status Requirements/Limits senna oral syrup 8.8 mg/5ml Formulary senna oral tablet 8.6 mg Formulary OTC SENNA PROMPT ORAL CAPSULE 9-500 MG Formulary OTC senna s oral tablet 8.6-50 mg Formulary OTC SENOKOT EXTRA STRENGTH ORAL TABLET 17.2 Formulary OTC MG SENOKOT S ORAL TABLET 8.6-50 MG Formulary OTC SENSI-CARE BODY EXTERNAL CREAM 1-30 % Formulary OTC SENSI-CARE PERINEAL/SKIN EXTERNAL LIQUID Formulary OTC SENSI-CARE PROTECTIVE BARRIER EXTERNAL Formulary OTC OINTMENT 49-15 % SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG Formulary PA SENSITIVE EYES ENZYME CLEANER TABLET Formulary OTC EFFERVESCENT MAXIMUM STRENGTH DENTAL GEL Formulary OTC SE-PLUS PROTEIN ORAL TABLET 200 MCG Formulary OTC SEREVENT DISKUS INHALATION AEROSOL Formulary POWDER BREATH ACTIVATED 50 MCG/DOSE sertraline hcl oral concentrate 20 mg/ml Formulary sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Formulary sevelamer carbonate oral packet 0.8 gm, 2.4 gm Formulary sevelamer carbonate oral tablet 800 mg Formulary sevelamer hcl oral tablet 800 mg Formulary severe cold & flu day/night oral liquid therapy pack Formulary OTC shampoo & body wash rinse-free external foam Formulary OTC SHAMROCK LATEX EXAM GLOVES Formulary OTC SHINGRIX INTRAMUSCULAR SUSPENSION Formulary RECONSTITUTED 50 MCG SHOPKO ALCOHOL SWABS PAD 70 % 70 % Formulary OTC SHOPKO UNILET LANCETS 30G Formulary OTC; QL (150 EA per 30 days) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % Formulary OTC silace oral syrup 60 mg/15ml Formulary OTC sildenafil citrate oral suspension reconstituted 10 mg/ml Formulary PA; AGE (Min 18 Years) sildenafil citrate oral tablet 20 mg Formulary PA; AGE (Min 18 Years) silver nitrate external ointment 10 % Formulary silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % Formulary silver sulfadiazine external cream 1 % Formulary SIMILAC STERILIZED WATER ORAL LIQUID Formulary OTC simple syrup oral syrup Formulary simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg Formulary SINADRIN PE COMPLETE SINUS REL ORAL TABLET Formulary OTC 2-10-650 MG sinus & cold-d oral tablet extended release 12 hour 120- Formulary OTC 220 mg sinus & congestion day/night oral Formulary OTC sinus congestion/pain daytime oral tablet 5-325 mg Formulary OTC 124 Drug Name Formulary Status Requirements/Limits sinus relief sublingual tablet sublingual Formulary OTC sirolimus oral solution 1 mg/ml Formulary sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Formulary siterol external patch 3.99-1 % Formulary OTC skin protectant external cream 12 % Formulary OTC skin tag remover external liquid Formulary OTC SKINTEGRITY HYDROGEL EXTERNAL GEL Formulary OTC SKYLA INTRAUTERINE INTRAUTERINE DEVICE Formulary 13.5 MG sleep aid oral tablet 25 mg Formulary OTC SLEEP-N-HEEL EXTERNAL KIT 20 % Formulary OTC SLO-NIACIN ORAL TABLET EXTENDED RELEASE Formulary OTC 500 MG, 750 MG SLOW FE ORAL TABLET EXTENDED RELEASE 142 Formulary OTC (45 FE) MG slow iron oral tablet extended release 160 (50 fe) mg Formulary OTC slow magnesium/calcium oral tablet delayed release 70-117 Formulary OTC mg slow release iron oral tablet extended release 47.5 mg Formulary OTC sm alcohol prep pad Formulary OTC sm alcohol prep pad 70 % 70 % Formulary OTC sm allergy relief oral tablet 1.34 mg Formulary OTC sm b super vitamin complex oral tablet Formulary OTC sm biotin oral tablet 5000 mcg Formulary OTC sm calamine external lotion Formulary OTC sm chest congestion relief dm oral tablet 20-400 mg Formulary OTC SM CORAL CALCIUM ORAL TABLET 1000 (390 CA) Formulary OTC MG sm cosmetic puffs jumbo Formulary OTC sm cough drops mouth/throat lozenge 7 mg Formulary OTC sm daytime cold & cough child oral solution 2.5-5 mg/5ml Formulary OTC sm dental rinse anti-plaque mouth/throat liquid Formulary OTC sm ethyl alcohol (rubbing) solution 70 % Formulary OTC sm foaming antacid oral tablet chewable 80-20 mg Formulary OTC sm fruit coolers mouth/throat lozenge 7 mg Formulary OTC sm glucosamine hcl-msm oral tablet 750-750 mg Formulary OTC SM GLUCOSAMINE/CALCIUM + D ORAL TABLET Formulary OTC 500-333-250 MG-MG-UNIT sm hemorrhoidal rectal ointment 0.25-14-74.9 % Formulary OTC sm ibuprofen jr oral tablet 100 mg Formulary OTC sm iodides external tincture Formulary OTC sm iodine tincture external tincture Formulary OTC sm lancets 33g Formulary OTC; QL (150 EA per 30 days) sm medicated chest rub external ointment 4.73-1.2-2.6 % Formulary OTC sm melatonin oral tablet dispersible 5 mg Formulary OTC

125 Drug Name Formulary Status Requirements/Limits sm natural herb cough drops mouth/throat lozenge 4.8 mg Formulary OTC sm omega-3-6-9 fatty acids oral capsule Formulary OTC sm omeprazole oral tablet delayed release 20 mg Formulary OTC sm one daily prenatal oral 28-0.8 & 440 mg Formulary OTC sm pain relief/menthol external gel Formulary OTC sm prenatal vitamins oral tablet 28-0.8 mg Formulary OTC sm slow release iron oral tablet extended release 143 (45 Formulary OTC fe) mg sm vitamin b1 oral tablet 100 mg Formulary OTC SMART SENSE COLOR LANCETS 33G Formulary OTC; QL (150 EA per 30 days) SMART SENSE STANDARD LANCETS Formulary OTC; QL (150 EA per 30 days) SMART SENSE SUPER THIN LANCETS Formulary OTC; QL (150 EA per 30 days) SMART SENSE THIN LANCETS 26G Formulary OTC; QL (150 EA per 30 days) smoothfit cuff Formulary OTC sod citrate-citric acid oral solution 500-334 mg/5ml Formulary sodium bicarbonate oral powder Formulary sodium bicarbonate oral tablet 325 mg, 650 mg Formulary OTC sodium chloride (hypertonic) ophthalmic ointment 5 % Formulary OTC sodium chloride (hypertonic) ophthalmic solution 5 % Formulary OTC sodium chloride inhalation nebulization solution 0.9 %, 3 Formulary %, 7 % sodium chloride oral solution 4 meq/ml Formulary OTC sodium chloride oral tablet 1 gm Formulary OTC sodium fluoride mouth/throat solution 0.2 % Formulary sodium fluoride oral solution 1.1 (0.5 f) mg/ml Formulary sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 Formulary (0.5 f) mg, 2.2 (1 f) mg sodium polystyrene sulfonate oral suspension 15 gm/60ml Formulary sodium polystyrene sulfonate rectal suspension 30 Formulary gm/120ml sofosbuvir-velpatasvir oral tablet 400-100 mg Formulary PA; AGE (Min 18 Years) solifenacin succinate oral tablet 10 mg, 5 mg Formulary SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML Formulary PA SOLOSITE WOUND GEL EXTERNAL GEL Formulary OTC solvatech plus oral suspension Formulary SOMBRA COOL THERAPY EXTERNAL GEL 6 % Formulary OTC SOMBRA WARM THERAPY EXTERNAL GEL 3-3 % Formulary OTC SOOTHE & COOL INZO BARRIER EXTERNAL Formulary OTC CREAM 5-5 % SOOTHE XP XTRA PROTECTION OPHTHALMIC Formulary OTC SOLUTION sorbitol oral solution 70 % Formulary OTC sorbitol rectal solution 70 % Formulary OTC sorbutuss nr oral liquid 15-150-127.5 mg/7.5ml Formulary OTC sore throat lozenges mouth/throat lozenge 6-10 mg Formulary OTC

126 Drug Name Formulary Status Requirements/Limits sore throat mouth/throat lozenge 15-3.6 mg Formulary OTC SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 Formulary MG sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Formulary sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg Formulary soya lecithin oral capsule 1200 mg Formulary OTC spinosad external suspension 0.9 % Formulary SPIRIVA HANDIHALER INHALATION CAPSULE 18 Formulary MCG spironolactone oral tablet 100 mg, 25 mg, 50 mg Formulary spironolactone-hctz oral tablet 25-25 mg Formulary sportbalm external lotion Formulary OTC SPORTSCREME EXTERNAL CREAM 10 % Formulary OTC spot acne treatment external cream 2.5 % Formulary OTC SPRAYZOIN EXTERNAL LIQUID Formulary OTC SPS ORAL SUSPENSION 15 GM/60ML Formulary stahist ad oral liquid 25-60 mg/5ml Formulary OTC stahist ad oral tablet 25-60 mg Formulary OTC STALEVO 100 ORAL TABLET 25-100-200 MG Formulary STALEVO 125 ORAL TABLET 31.25-125-200 MG Formulary STALEVO 150 ORAL TABLET 37.5-150-200 MG Formulary STALEVO 200 ORAL TABLET 50-200-200 MG Formulary STALEVO 75 ORAL TABLET 18.75-75-200 MG Formulary STANBACK HEADACHE POWDERS ORAL PACKET Formulary OTC 650-200-32 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg Formulary STERILANCE TL Formulary OTC; QL (150 EA per 30 days) STERILE LUBRICANT OPHTHALMIC LIQUID 0.7 % Formulary OTC sterile pad 3"x3" Formulary OTC STERI-STRIP COMPOUND BENZOIN EXTERNAL Formulary OTC TINCTURE STERI-TAMP SEALS BOTTLES/VIALS Formulary OTC STERI-TAMP SEALS/BAGS Formulary OTC STERI-TAMP SEALS/SYRINGES Formulary OTC STIMATE NASAL SOLUTION 1.5 MG/ML Formulary STIMEX INSULATED NEEDLE 22G X 2-1/8" , 22G X 4- Formulary OTC 1/4" STIMULEN EXTERNAL GEL Formulary OTC STIOLTO RESPIMAT INHALATION AEROSOL Formulary SOLUTION 2.5-2.5 MCG/ACT STOMAHESIVE MOLDABLE ADHESIVE STRIP Formulary OTC STOMAHESIVE PASTE PASTE Formulary OTC STRIANT BUCCAL 30 MG Formulary STRIBILD ORAL TABLET 150-150-200-300 MG Formulary STRIDEX ESSENTIAL EXTERNAL PAD 1 % Formulary OTC

127 Drug Name Formulary Status Requirements/Limits STRI-DEX SENSITIVE SKIN EXTERNAL PAD 0.5 % Formulary OTC STUART ONE ORAL CAPSULE 27-0.8-200 MG Formulary OTC SUBLOCADE SUBCUTANEOUS SOLUTION Formulary PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML QL (60 EA per 30 days); AGE (Min 16 SUBOXONE SUBLINGUAL FILM 12-3 MG Formulary Years) QL (360 EA per 30 days); AGE (Min 16 SUBOXONE SUBLINGUAL FILM 2-0.5 MG Formulary Years) QL (180 EA per 30 days); AGE (Min 16 SUBOXONE SUBLINGUAL FILM 4-1 MG Formulary Years) QL (90 EA per 30 days); AGE (Min 16 SUBOXONE SUBLINGUAL FILM 8-2 MG Formulary Years) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 Formulary PA; QL (120 EA per 30 days) MCG, 800 MCG sucralfate oral suspension 1 gm/10ml Formulary sucralfate oral tablet 1 gm Formulary SUDAFED 24 HOUR ORAL TABLET EXTENDED Formulary OTC RELEASE 24 HOUR 240 MG SUDAFED CHILDRENS ORAL LIQUID 15 MG/5ML Formulary OTC SUDAFED ORAL TABLET 30 MG Formulary OTC SUDAFED PE CHILDRENS ORAL SOLUTION 2.5 Formulary OTC MG/5ML SUDAFED PE COLD & COUGH CHILD ORAL Formulary OTC SOLUTION 2.5-5 MG/5ML SUDAFED PE DAY & NIGHT ORAL 25-10 & 10 MG Formulary OTC SUDAFED PE MAXIMUM STRENGTH ORAL TABLET Formulary OTC 10 MG SUDAFED PRESSURE+PAIN 12 HR ORAL TABLET Formulary OTC EXTENDED RELEASE 12 HOUR 120-220 MG sulfacetamide sodium (acne) external lotion 10 % Formulary sulfacetamide sodium ophthalmic ointment 10 % Formulary sulfacetamide sodium ophthalmic solution 10 % Formulary sulfacetamide sodium-sulfur external liquid 9-4 % Formulary sulfacetamide sodium-sulfur external lotion 10-5 % Formulary sulfacetamide sodium-sulfur external pad 10-4 % Formulary sulfacetamide sodium-sulfur external suspension 8-4 % Formulary sulfacetamide-prednisolone ophthalmic solution 10-0.23 % Formulary sulfadiazine oral tablet 500 mg Formulary sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- Formulary 160 mg SULFAMYLON EXTERNAL CREAM 85 MG/GM Formulary SULFAMYLON EXTERNAL PACKET 5 % Formulary sulfasalazine oral tablet 500 mg Formulary sulfasalazine oral tablet delayed release 500 mg Formulary sulfo-lo external bar 5 % Formulary OTC sulfur external bar 10 % Formulary OTC

128 Drug Name Formulary Status Requirements/Limits sulindac oral tablet 150 mg, 200 mg Formulary nasal solution 20 mg/act, 5 mg/act Formulary sumatriptan succinate oral tablet 100 mg Formulary ST; QL (9 EA per 34 days) sumatriptan succinate oral tablet 25 mg, 50 mg Formulary ST; QL (18 EA per 34 days) sumatriptan succinate refill subcutaneous solution cartridge Formulary 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml Formulary sumatriptan succinate subcutaneous solution auto-injector Formulary 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled Formulary syringe 6 mg/0.5ml SUMMERS EVE DEODORANT ULTRA EXTERNAL Formulary OTC AEROSOL super b-50 complex oral capsule Formulary OTC super c-500 complex oral tablet extended release Formulary OTC super cal/mag oral tablet 333.333-166.667 mg Formulary OTC super moleskin pad Formulary OTC SUPER OMEGA-3 ORAL CAPSULE Formulary OTC super thin lancets Formulary OTC; QL (150 EA per 30 days) supposibase f powder Formulary OTC SUPPRELIN LA SUBCUTANEOUS KIT 50 MG Formulary PA SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5- Formulary 3.13-1.6 GM/177ML supress a pediatric oral liquid 5-1-10 mg/ml Formulary OTC supress dm pediatric oral liquid 5-50 mg/ml Formulary OTC SUPRESS-PE PEDIATRIC ORAL LIQUID 2.5-50 Formulary OTC MG/ML sure comfort alcohol prep pad 70 % 70 % Formulary OTC sure comfort insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" Formulary OTC 0.5 ml sure comfort insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml Formulary OTC sure comfort insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" Formulary OTC 0.3 ml sure comfort insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" Formulary OTC 0.5 ml sure comfort insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC sure comfort insulin syringe 30g x 1/2" 0.3 ml 30g x 1/2" Formulary OTC 0.3 ml sure comfort insulin syringe 30g x 1/2" 0.5 ml 30g x 1/2" Formulary OTC 0.5 ml sure comfort insulin syringe 30g x 1/2" 1 ml 30g x 1/2" 1 ml Formulary OTC sure comfort insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" Formulary OTC 0.3 ml sure comfort insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" Formulary OTC 0.5 ml sure comfort insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 Formulary OTC ml

129 Drug Name Formulary Status Requirements/Limits sure comfort insulin syringe 31g x 1/4" 0.3 ml 31g x 1/4" Formulary OTC 0.3 ml sure comfort insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" Formulary OTC 0.3 ml sure comfort insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" Formulary OTC 0.5 ml sure comfort insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 Formulary OTC ml sure comfort lancets 28g Formulary OTC; QL (150 EA per 30 days) sure comfort lancets 30g Formulary OTC; QL (150 EA per 30 days) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML 28G Formulary OTC X 1/2" 0.5 ML SURE-JECT INSULIN SYRINGE 28G X 1/2" 1 ML 28G Formulary OTC X 1/2" 1 ML SURE-JECT INSULIN SYRINGE 29G X 1/2" 0.3 ML 29G Formulary OTC X 1/2" 0.3 ML SURE-JECT INSULIN SYRINGE 29G X 1/2" 0.5 ML 29G Formulary OTC X 1/2" 0.5 ML SURE-JECT INSULIN SYRINGE 29G X 1/2" 1 ML 29G Formulary OTC X 1/2" 1 ML SURE-JECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML SURE-JECT INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML SURE-JECT INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML SURE-JECT INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML SURE-JECT INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML SURE-JECT INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML SURE-LANCE ULTRA THIN LANCETS Formulary OTC; QL (150 EA per 30 days) SURELITE LANCETS Formulary OTC; QL (150 EA per 30 days) SUSPENDOL-S LIQUID Formulary OTC SUTENT ORAL CAPSULE 12.5 MG, 50 MG Formulary PA SWEEN EXTERNAL CREAM Formulary OTC SWEEN PREP EXTERNAL SOLUTION Formulary OTC SWIM EAR OTIC LIQUID 95 % Formulary OTC swimmers instant ear dry otic liquid 95 % Formulary OTC SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 Formulary MCG, 600 MCG SYMBICORT INHALATION AEROSOL 160-4.5 Formulary MCG/ACT, 80-4.5 MCG/ACT sympathetic nerve needle 19g x 5" , 20g x 5" Formulary OTC SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, Formulary PA 50 MG/0.5ML SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 Formulary ST; AGE (Min 18 Years) MG, 5-1000 MG, 5-500 MG

130 Drug Name Formulary Status Requirements/Limits SYNVISC INTRA-ARTICULAR SOLUTION Formulary PA PREFILLED SYRINGE 16 MG/2ML SYNVISC ONE INTRA-ARTICULAR SOLUTION Formulary PA PREFILLED SYRINGE 48 MG/6ML syringe 10-12 ml 12 ml Formulary OTC syringe 20-25 ml 25 ml Formulary OTC syringe 20g x 1" 12 ml, 20g x 1" 6 ml, 21g x 1" 6 ml, 21g x 1-1/4" 6 ml, 22g x 1" 12 ml, 22g x 1" 6 ml, 22g x 1-1/2" 6 Formulary OTC ml, 22g x 1-1/4" 6 ml, 22g x 3/4" 3 ml, 27g x 1-1/4" 3 ml syringe 2-3 ml 3 ml Formulary OTC syringe 30-35 ml 35 ml Formulary OTC syringe 50-60 ml 60 ml Formulary OTC syringe 5-6 ml 6 ml Formulary OTC syringe luer slip 1 ml Formulary syringe luer slip 26g x 3/8" 1 ml, 27g x 1/2" 1 ml Formulary OTC syringe precisedose dispenser Formulary SYRSPEND SF ORAL LIQUID Formulary SYRSPEND SF PH4 ORAL SUSPENSION Formulary RECONSTITUTED syrup nf oral syrup 85 % Formulary OTC SYSTANE BALANCE OPHTHALMIC SOLUTION 0.6 % Formulary OTC SYSTANE LID WIPES EXTERNAL PAD Formulary OTC SYSTANE OPHTHALMIC GEL 0.4-0.3 % Formulary OTC SYSTANE OPHTHALMIC SOLUTION 0.4-0.3 % Formulary OTC SYSTANE OVERNIGHT THERAPY OPHTHALMIC Formulary OTC GEL 0.3 % SYSTANE PRESERVATIVE FREE OPHTHALMIC Formulary OTC SOLUTION 0.4-0.3 % SYSTANE ULTRA OPHTHALMIC SOLUTION 0.4-0.3 Formulary OTC % SYSTANE ULTRA PF OPHTHALMIC SOLUTION 0.4- Formulary OTC 0.3 % TABLOID ORAL TABLET 40 MG Formulary tacrolimus external ointment 0.03 %, 0.1 % Formulary PA tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Formulary tadalafil (pah) oral tablet 20 mg Formulary PA; AGE (Min 18 Years) tamoxifen citrate oral tablet 10 mg, 20 mg Formulary tamsulosin hcl oral capsule 0.4 mg Formulary TANDEM ORAL CAPSULE 162-115.2 MG Formulary OTC tangerine oil Formulary OTC TARGRETIN EXTERNAL GEL 1 % Formulary taron forte oral capsule Formulary TARON-PREX ORAL CAPSULE 30-1.2-265 MG Formulary TARSUM EXTERNAL SHAMPOO 10-5 % Formulary OTC taurine oral capsule 500 mg Formulary OTC tazarotene external cream 0.1 % Formulary PA

131 Drug Name Formulary Status Requirements/Limits TAZORAC EXTERNAL CREAM 0.05 % Formulary PA TAZORAC EXTERNAL GEL 0.05 %, 0.1 % Formulary PA TAZTIA XT ORAL CAPSULE EXTENDED RELEASE Formulary 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG tb syringe 1 ml Formulary tdm solution external solution Formulary TEAR FLO OPHTHALMIC STRIP Formulary OTC TEARS NATURALE PM OPHTHALMIC OINTMENT 3- Formulary OTC 94 % TECFIDERA ORAL 120 & 240 MG Formulary TECFIDERA ORAL CAPSULE DELAYED RELEASE Formulary 120 MG, 240 MG TECHLITE AST LANCETS Formulary OTC; QL (150 EA per 30 days) TECHLITE LANCETS Formulary OTC; QL (150 EA per 30 days) TECHLITE LANCETS 30G Formulary OTC; QL (150 EA per 30 days) TECNU FIRST AID EXTERNAL GEL 0.2-2.5 % Formulary OTC TEGADERM CONTACT LAYER PAD 8"X10" Formulary OTC TEGADERM FOAM ADHESIVE PAD 2-3/4"X2-3/4" , 2- 3/4"X3" , 4"X4-1/2" , 5-5/8"X5-5/8" , 5-5/8"X6-1/8" , 7- Formulary OTC 1/2"X8-3/4" TEGADERM HYDROGEL WOUND FILLER Formulary OTC EXTERNAL GEL telmisartan oral tablet 20 mg, 40 mg, 80 mg Formulary telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 Formulary mg temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg Formulary temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, Formulary 250 mg, 5 mg temsirolimus intravenous solution 25 mg/ml Formulary tenofovir disoproxil fumarate oral tablet 300 mg Formulary terazosin hcl oral capsule 1 mg, 2 mg, 5 mg Formulary QL (34 EA per 34 days) terazosin hcl oral capsule 10 mg Formulary QL (68 EA per 34 days) terbinafine hcl oral tablet 250 mg Formulary terbutaline sulfate oral tablet 2.5 mg, 5 mg Formulary terconazole vaginal cream 0.4 % Formulary QL (45 GM per 30 days) terconazole vaginal cream 0.8 % Formulary QL (20 GM per 30 days) terconazole vaginal suppository 80 mg Formulary QL (3 EA per 30 days) terocin external lotion 2.5-0.025-10-25 % Formulary OTC terocin external patch 4-4 % Formulary OTC teroderm-plus external cream Formulary TESTOPEL IMPLANT PELLET 75 MG Formulary testosterone cypionate intramuscular solution 100 mg/ml, Formulary 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml Formulary testosterone transdermal gel 12.5 mg/act (1%), 20.25 Formulary AGE (Min 18 Years) mg/act (1.62%)

132 Drug Name Formulary Status Requirements/Limits testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 Formulary mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) tetanus-diphtheria toxoids td intramuscular suspension 2-2 Formulary AGE (Min 19 Years) lf/0.5ml tetrabenazine oral tablet 12.5 mg, 25 mg Formulary PA tetracycline hcl oral capsule 250 mg, 500 mg Formulary TETRA-FORMULA CGH/SORE THROAT Formulary OTC MOUTH/THROAT LOZENGE 10-15 MG tgt alcohol swabs pad 70 % 70 % Formulary OTC tgt first aid cleansing external liquid 2.5-0.13 % Formulary OTC tgt lancet micro thin 33g Formulary OTC; QL (150 EA per 30 days) tgt lancet thin 26g Formulary OTC; QL (150 EA per 30 days) tgt lancet ultra thin 30g Formulary OTC; QL (150 EA per 30 days) tgt lubricant eye drops ophthalmic solution 0.95 % Formulary OTC tgt lubricant redness reliever ophthalmic solution 0.03-0.5 Formulary OTC % tgt omeprazole oral tablet delayed release 20 mg Formulary OTC THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 Formulary PA MG, 50 MG THE ITCH ERASER EXTERNAL SOLUTION 2 % Formulary OTC THEOCHRON ORAL TABLET EXTENDED RELEASE Formulary 12 HOUR 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 hour 450 mg Formulary theophylline er oral tablet extended release 24 hour 400 Formulary mg, 600 mg THERACOF PLUS COUGH/COLD REL ORAL LIQUID Formulary OTC 5-10-100-325 MG/5ML THERACYS INTRAVESICAL SUSPENSION Formulary RECONSTITUTED 81 MG/VIAL THERA-D 4000 ORAL TABLET 100 MCG (4000 UT) Formulary OTC THERAFLU COLD & COUGH ORAL PACKET 10-20-20 Formulary OTC MG THERAFLU EXPRESSMAX ORAL LIQUID 12.5-5-325 Formulary OTC MG/15ML THERAFLU SEVERE COLD & COUGH ORAL PACKET Formulary OTC THERAFLU SEVERE COLD DAYTIME ORAL TABLET Formulary OTC 15-5-325 MG THERAFLU SEVERE COLD NIGHTTIME ORAL Formulary OTC PACKET 25-10-500 MG THERAFLU SEVERE COLD NIGHTTIME ORAL Formulary OTC TABLET 5-2-10-325 MG THERAFLU SEVERE COLD ORAL PACKET 20-10-500 Formulary OTC MG THERAFLU SEVERE COLD/CGH NIGHT ORAL Formulary OTC PACKET 25-10-650 MG THERAFLU WARMING RELIEF SINUS ORAL LIQUID Formulary OTC 12.5-5-325 MG/15ML THERA-GESIC EXTERNAL CREAM 0.5-15 % Formulary OTC

133 Drug Name Formulary Status Requirements/Limits THERANATAL COMPLETE ORAL 27-1 & 300 MG Formulary OTC THERANATAL OVAVITE ORAL THERAPY PACK 18- Formulary OTC 1 & 125 MG THERAPLEX T EXTERNAL SHAMPOO 1 % Formulary OTC THERASEAL HAND PROTECTION EXTERNAL Formulary OTC LOTION 1 % THERATEARS NUTRITION ORAL CAPSULE Formulary OTC THERATEARS OPHTHALMIC GEL 1 % Formulary OTC THERATEARS OPHTHALMIC SOLUTION 0.25 % Formulary OTC thiamine oral capsule 50 mg Formulary OTC THINLETS GP LANCETS Formulary OTC; QL (150 EA per 30 days) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg Formulary AGE (Min 18 Years) thiotepa injection solution reconstituted 15 mg Formulary thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Formulary AGE (Min 18 Years) THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG) Formulary THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG Formulary (MCG) THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG Formulary (MCG) THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG) Formulary THYROLAR-3 ORAL TABLET 180 (37.5-150) MG Formulary (MCG) tiagabine hcl oral tablet 2 mg, 4 mg Formulary ticlopidine hcl oral tablet 250 mg Formulary TIGER BALM LINIMENT EXTERNAL LIQUID 16-28 % Formulary OTC TIGER BALM MUSCLE RUB EXTERNAL CREAM 3-5- Formulary OTC 15 % TIGER BALM NECK & SHOULDER RUB EXTERNAL Formulary OTC CREAM 10-11 % TIGER BALM PAIN RELIEVING EXTERNAL PATCH Formulary OTC 80-24-16 MG TIGER BALM PAIN RELIEVING LG EXTERNAL Formulary OTC PATCH 70-230 MG TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG Formulary QL (28 EA per 28 days) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 Formulary % timolol maleate ophthalmic solution 0.25 %, 0.5 % Formulary timolol maleate oral tablet 10 mg, 20 mg, 5 mg Formulary TINACTIN EXTERNAL AEROSOL 1 % Formulary OTC TINACTIN EXTERNAL AEROSOL POWDER 1 % Formulary OTC TINACTIN JOCK ITCH EXTERNAL CREAM 1 % Formulary OTC TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Formulary tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg Formulary tizanidine hcl oral tablet 2 mg, 4 mg Formulary TN DICKINSONS WITCH HAZEL EXTERNAL PAD Formulary OTC ST; QL (56 EA per 28 days); AGE (Min 6 TOBI PODHALER INHALATION CAPSULE 28 MG Formulary Years) 134 Drug Name Formulary Status Requirements/Limits TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % Formulary TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % Formulary tobramycin ophthalmic solution 0.3 % Formulary tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 Formulary % TODAY SPONGE VAGINAL 1000 MG Formulary OTC todays health thin lancets 28g Formulary OTC; QL (150 EA per 30 days) todays health thin lancets 30g Formulary OTC; QL (150 EA per 30 days) tolazamide oral tablet 250 mg, 500 mg Formulary tolbutamide oral tablet 500 mg Formulary tolmetin sodium oral capsule 400 mg Formulary tolnaftate external cream 1 % Formulary OTC tolnaftate external powder 1 % Formulary OTC tolnaftate external solution 1 % Formulary OTC tolterodine tartrate er oral capsule extended release 24 Formulary QL (30 EA per 30 days) hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg Formulary QL (60 EA per 30 days) toomey syringe 70 ml Formulary topcare lancets micro-thin 33g Formulary OTC; QL (150 EA per 30 days) topcare ultra comfort ins syr 29g x 1/2" 0.3 ml 29g x 1/2" Formulary OTC 0.3 ml topcare ultra comfort ins syr 29g x 1/2" 0.5 ml 29g x 1/2" Formulary OTC 0.5 ml topcare ultra comfort ins syr 29g x 1/2" 1 ml 29g x 1/2" 1 Formulary OTC ml topcare ultra comfort ins syr 30g x 5/16" 0.3 ml 30g x 5/16" Formulary OTC 0.3 ml topcare ultra comfort ins syr 30g x 5/16" 0.5 ml 30g x 5/16" Formulary OTC 0.5 ml topcare ultra comfort ins syr 30g x 5/16" 1 ml 30g x 5/16" 1 Formulary OTC ml topcare ultra comfort ins syr 31g x 5/16" 0.3 ml 31g x 5/16" Formulary OTC 0.3 ml topcare ultra comfort ins syr 31g x 5/16" 0.5 ml 31g x 5/16" Formulary OTC 0.5 ml topcare ultra comfort ins syr 31g x 5/16" 1 ml 31g x 5/16" 1 Formulary OTC ml TOPICAINE 5 EXTERNAL GEL 5 % Formulary OTC topiramate oral capsule sprinkle 15 mg, 25 mg Formulary topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Formulary topotecan hcl intravenous solution 4 mg/4ml Formulary topotecan hcl intravenous solution reconstituted 4 mg Formulary torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Formulary TOVIAZ ORAL TABLET EXTENDED RELEASE 24 Formulary HOUR 4 MG, 8 MG TRACLEER ORAL TABLET 125 MG, 62.5 MG Formulary TRADJENTA ORAL TABLET 5 MG Formulary ST; AGE (Min 18 Years)

135 Drug Name Formulary Status Requirements/Limits tramadol hcl er (biphasic) oral tablet extended release 24 Formulary PA; QL (34 EA per 34 days) hour 100 mg, 200 mg tramadol hcl er oral tablet extended release 24 hour 100 Formulary PA; QL (34 EA per 34 days) mg, 200 mg, 300 mg tramadol hcl oral tablet 50 mg Formulary PA; QL (126 EA per 7 days) tramadol-acetaminophen oral tablet 37.5-325 mg Formulary PA trandolapril oral tablet 1 mg, 2 mg, 4 mg Formulary tranexamic acid oral tablet 650 mg Formulary QL (30 EA per 30 days) TRANQUILITY BRIEFS KIT Formulary OTC TRANSANOSIL EXTERNAL LOTION 0.025-10-30 % Formulary OTC transderm-iq external ointment 4-0.0375-10-20 % Formulary OTC sulfate oral tablet 10 mg Formulary TRANZAREL EXTERNAL GEL 4 % Formulary TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % Formulary travel sickness oral tablet chewable 25 mg Formulary OTC travoprost (bak free) ophthalmic solution 0.004 % Formulary trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg Formulary TREANDA INTRAVENOUS SOLUTION Formulary RECONSTITUTED 100 MG, 25 MG T-RELIEF PAIN ARNICA + 12 EXTERNAL OINTMENT Formulary OTC T-RELIEF PAIN RELIEF EXTERNAL CREAM Formulary OTC TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, Formulary PA 3.75 MG treprostinil solution 100 mg/20ml injection 100 mg/20ml Formulary PA treprostinil solution 20 mg/20ml injection 20 mg/20ml Formulary PA treprostinil solution 200 mg/20ml injection 200 mg/20ml Formulary PA treprostinil solution 50 mg/20ml injection 50 mg/20ml Formulary PA tretinoin external cream 0.025 %, 0.05 %, 0.1 % Formulary AGE (Max 18 Years) tretinoin external gel 0.01 %, 0.025 % Formulary AGE (Max 18 Years) tretinoin oral capsule 10 mg Formulary TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 Formulary MG triamcinolone acetonide aerosol 55 mcg/act nasal (otc) 55 Formulary mcg/act triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 Formulary % triamcinolone acetonide external lotion 0.025 %, 0.1 % Formulary triamcinolone acetonide external ointment 0.025 %, 0.05 %, Formulary 0.1 %, 0.5 % triamcinolone acetonide injection suspension 40 mg/ml Formulary TRIAMINIC CHEST/NASAL CONGEST ORAL LIQUID Formulary OTC 2.5-50 MG/5ML TRIAMINIC COLD & ALLERGY ORAL SYRUP 1-2.5 Formulary OTC MG/5ML TRIAMINIC COLD/COUGH DAY TIME ORAL SYRUP Formulary OTC 2.5-5 MG/5ML

136 Drug Name Formulary Status Requirements/Limits TRIAMINIC COLD/COUGH ORAL 2.5-5 &2.5-6.25 Formulary OTC MG/5ML TRIAMINIC COUGH/RUNNY NOSE ORAL TABLET Formulary OTC CHEWABLE 1-5 MG TRIAMINIC COUGH/SORE THROAT ORAL TABLET Formulary OTC CHEWABLE 160-5 MG TRIAMINIC FEVER REDUCER ORAL SYRUP 160 Formulary OTC MG/5ML TRIAMINIC FLU/COUGH/FEVER ORAL LIQUID 7.5- Formulary OTC 160-1 MG/5ML TRIAMINIC LONG ACTING COUGH ORAL LIQUID Formulary OTC 7.5 MG/5ML TRIAMINIC LONG ACTING COUGH ORAL STRIP 7.5 Formulary OTC MG TRIAMINIC NIGHT TIME COLD/CGH ORAL SYRUP Formulary OTC 6.25-2.5 MG/5ML TRIAMINIC SORE THROAT MOUTH/THROAT Formulary OTC SOLUTION 0.5 % triamino oral tablet Formulary OTC triamterene-hctz oral capsule 37.5-25 mg Formulary triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg Formulary triazolam oral tablet 0.125 mg, 0.25 mg Formulary QL (34 EA per 34 days) tri-buffered aspirin oral tablet 325 mg Formulary OTC tricitrates oral solution 550-500-334 mg/5ml Formulary trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg Formulary AGE (Min 18 Years) trifluridine ophthalmic solution 1 % Formulary trihexyphenidyl hcl oral elixir 0.4 mg/ml Formulary trihexyphenidyl hcl oral tablet 2 mg, 5 mg Formulary TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG- Formulary 25 MCG trimethobenzamide hcl oral capsule 300 mg Formulary trimethoprim oral tablet 100 mg Formulary trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg Formulary TRINATE ORAL TABLET Formulary triple antibiotic external ointment 3.5-400-5000 Formulary OTC TRIPLE FLEX ORAL TABLET 750-400-375 MG Formulary OTC triple helix collagen external powder Formulary OTC TRIPLE PASTE EXTERNAL OINTMENT 12.8 % Formulary OTC triprolidine hcl oral liquid 0.313 mg/ml, 0.625 mg/ml Formulary OTC TRISPEC PSE PEDIATRIC ORAL LIQUID 30-10-187 Formulary OTC MG/5ML TRIUMEQ ORAL TABLET 600-50-300 MG Formulary TRI-VI-SOL ORAL SOLUTION 750-400-35 UNIT- Formulary OTC MG/ML TROCAINE THROAT MOUTH/THROAT LOZENGE 10 Formulary OTC MG TROCAL COUGH SUPPRESSANT MOUTH/THROAT Formulary OTC LOZENGE 7.5 MG 137 Drug Name Formulary Status Requirements/Limits trochibase s flakes Formulary OTC TROGARZO INTRAVENOUS SOLUTION 200 Formulary PA MG/1.33ML TROMBONEX-D ORAL CAPSULE Formulary OTC trospium chloride oral tablet 20 mg Formulary TRUEPLUS GLUCOSE ORAL GEL Formulary OTC TRUEPLUS GLUCOSE ORAL TABLET CHEWABLE Formulary OTC TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML 28G Formulary OTC X 1/2" 0.5 ML TRUEPLUS INSULIN SYRINGE 28G X 1/2" 1 ML 28G Formulary OTC X 1/2" 1 ML TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.3 ML 29G Formulary OTC X 1/2" 0.3 ML TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.5 ML 29G Formulary OTC X 1/2" 0.5 ML TRUEPLUS INSULIN SYRINGE 29G X 1/2" 1 ML 29G Formulary OTC X 1/2" 1 ML TRUEPLUS INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML TRUEPLUS INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML TRUEPLUS INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML TRUEPLUS INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML TRUEPLUS INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML TRUEPLUS INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML TRUEPLUS LANCETS 26G Formulary OTC; QL (150 EA per 30 days) TRUEPLUS LANCETS 28G Formulary OTC; QL (150 EA per 30 days) TRUEPLUS LANCETS 30G Formulary OTC; QL (150 EA per 30 days) TRUEPLUS LANCETS 33G Formulary OTC; QL (150 EA per 30 days) TRU-FIT ICE/HEAT ANKLE/GEL PAK PAD Formulary OTC TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 Formulary MG/0.5ML, 4.5 MG/0.5ML trymine cg oral liquid 225-7.5 mg/5ml Formulary OTC E-X 750 ORAL TABLET CHEWABLE 750 MG Formulary OTC TUMS LASTING EFFECTS ORAL TABLET Formulary OTC CHEWABLE 500 MG TUMS ULTRA 1000 ORAL TABLET CHEWABLE 1000 Formulary OTC MG tuohy epidural needle tw 14g x 3" , 17g x 3-1/2" , 20g x 3- Formulary OTC 1/2" TUSICOF ORAL TABLET 10-20-400 MG Formulary OTC TUSNEL C ORAL SYRUP 30-10-100 MG/5ML Formulary OTC TUSNEL PEDIATRIC ORAL LIQUID 15-5-50 MG/5ML, Formulary OTC; AGE (Min 6 Years) 7.5-50 MG/ML 138 Drug Name Formulary Status Requirements/Limits TUSNEL-DM PEDIATRIC ORAL LIQUID 7.5-2.5-25 Formulary OTC MG/ML tussin cf max multi-symptom oral liquid 5-10-200 mg/5ml Formulary OTC tussin cough dm oral syrup 100-10 mg/5ml Formulary OTC tussin cough long-acting oral syrup 15 mg/5ml Formulary OTC tussin dm max oral liquid 10-200 mg/5ml Formulary OTC TUSSI-PRES ORAL LIQUID 5-10-200 MG/5ML Formulary OTC TUSSI-PRES PE PEDIATRIC ORAL LIQUID 2.5-100 Formulary OTC MG/5ML TUSSI-PRES PEDIATRIC ORAL LIQUID 2.5-5-75 Formulary OTC MG/5ML TUSSLIN PEDIATRIC ORAL LIQUID 2.5-7.5-88 Formulary OTC MG/ML TWINRIX INTRAMUSCULAR SUSPENSION 720-20 Formulary AGE (Min 19 Years) TYLENOL CHILDRENS PLUS MS COLD ORAL Formulary OTC SUSPENSION 2.5-1-5-160 MG/5ML TYLENOL COLD & HEAD ORAL TABLET 5-325-200 Formulary OTC MG TYLENOL COLD MAX ORAL LIQUID 10-5-325 Formulary OTC MG/15ML TYLENOL COLD MULTI-SYMPTOM ORAL LIQUID 5- Formulary OTC 6.25-10-325 MG/15ML TYLENOL COLD/FLU SEVERE ORAL TABLET 5-10- Formulary OTC 200-325 MG TYLENOL COLD/FLU SEVERE ORAL TABLET Formulary OTC THERAPY PACK TYLENOL EXTRA STRENGTH ORAL TABLET 500 Formulary OTC MG TYLENOL INFANTS ORAL SUSPENSION 160 Formulary OTC MG/5ML TYLENOL ORAL CAPSULE 325 MG Formulary OTC TYLENOL ORAL TABLET 325 MG Formulary OTC TYLENOL PM EXTRA STRENGTH ORAL TABLET Formulary OTC 500-25 MG TYLENOL SINUS SEVERE ORAL TABLET 5-325-200 Formulary OTC MG TYLENOL WARMING COUGH/CONGEST ORAL Formulary OTC LIQUID 5-10-200-325 MG/15ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 Formulary AGE (Min 19 Years) MCG/0.5ML tyrosine oral packet 1000 mg Formulary OTC TYVASO REFILL INHALATION SOLUTION 0.6 Formulary PA MG/ML UBRELVY ORAL TABLET 100 MG, 50 MG Formulary ST ULCEREASE MOUTH/THROAT LIQUID 0.6 % Formulary OTC ULCEREASE MOUTH/THROAT SOLUTION 0.6-1.5 % Formulary OTC ULTICARE ALCOHOL SWABS PAD Formulary OTC ULTICARE ALCOHOL SWABS PAD 70 % 70 % Formulary OTC

139 Drug Name Formulary Status Requirements/Limits ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Formulary 29G X 1/2" 0.5 ML ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML Formulary 29G X 1/2" 1 ML ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML 28G Formulary OTC X 1/2" 0.5 ML ULTICARE INSULIN SYRINGE 28G X 1/2" 1 ML 28G X Formulary OTC 1/2" 1 ML ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML 29G Formulary OTC X 1/2" 0.3 ML ULTICARE INSULIN SYRINGE 29G X 1/2" 0.5 ML 29G Formulary OTC X 1/2" 0.5 ML ULTICARE INSULIN SYRINGE 29G X 1/2" 1 ML 29G X Formulary OTC 1/2" 1 ML ULTICARE INSULIN SYRINGE 30G X 1/2" 0.3 ML 30G Formulary OTC X 1/2" 0.3 ML ULTICARE INSULIN SYRINGE 30G X 1/2" 0.5 ML 30G Formulary OTC X 1/2" 0.5 ML ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML 30G X Formulary OTC 1/2" 1 ML ULTICARE INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML ULTICARE INSULIN SYRINGE 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML ULTICARE INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML ULTICARE INSULIN SYRINGE 31G X 1/4" 0.3 ML 31G Formulary OTC X 1/4" 0.3 ML ULTICARE INSULIN SYRINGE 31G X 1/4" 0.5 ML 31G Formulary OTC X 1/4" 0.5 ML ULTICARE INSULIN SYRINGE 31G X 1/4" 1 ML 31G X Formulary OTC 1/4" 1 ML ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML ULTICARE INSULIN SYRINGE 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML ULTICARE INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML ULTICARE SYRINGE 22G X 1-1/2" 3 ML Formulary OTC ULTICARE TUBERCULIN SAFETY SYR 25G X 1" 1 Formulary OTC ML, 25G X 5/8" 1 ML ultilet alcohol swabs pad Formulary OTC ULTILET CLASSIC LANCETS Formulary OTC; QL (150 EA per 30 days) ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML 30G X Formulary OTC 1/2" 0.5 ML ULTILET INSULIN SYRINGE 30G X 1/2" 1 ML 30G X Formulary OTC 1/2" 1 ML ULTILET INSULIN SYRINGE 30G X 5/16" 0.3 ML 30G Formulary OTC X 5/16" 0.3 ML

140 Drug Name Formulary Status Requirements/Limits ULTILET INSULIN SYRINGE 30G X 5/16" 0.5 ML 30G Formulary OTC X 5/16" 0.5 ML ULTILET INSULIN SYRINGE 30G X 5/16" 1 ML 30G X Formulary OTC 5/16" 1 ML ULTILET INSULIN SYRINGE 31G X 1/4" 0.3 ML 31G X Formulary OTC 1/4" 0.3 ML ULTILET INSULIN SYRINGE 31G X 1/4" 1 ML 31G X Formulary OTC 1/4" 1 ML ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML Formulary (OTC) 31G X 15/64" 0.3 ML ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML Formulary (RX) 31G X 15/64" 0.3 ML ULTILET INSULIN SYRINGE 31G X 15/64" 0.5 ML 31G Formulary OTC X 15/64" 0.5 ML ULTILET INSULIN SYRINGE 31G X 5/16" 0.3 ML 31G Formulary OTC X 5/16" 0.3 ML ULTILET INSULIN SYRINGE 31G X 5/16" 1 ML 31G X Formulary OTC 5/16" 1 ML ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 Formulary OTC ML 30G X 1/2" 0.3 ML ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.3 Formulary OTC ML 30G X 5/16" 0.3 ML ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 0.5 Formulary OTC ML 30G X 5/16" 0.5 ML ULTILET INSULIN SYRINGE SHORT 30G X 5/16" 1 Formulary OTC ML 30G X 5/16" 1 ML ULTILET INSULIN SYRINGE SHORT 31G X 5/16" 0.3 Formulary OTC ML 31G X 5/16" 0.3 ML ULTILET INSULIN SYRINGE SHORT 31G X 5/16" 0.5 Formulary OTC ML 31G X 5/16" 0.5 ML ULTILET INSULIN SYRINGE SHORT 31G X 5/16" 1 Formulary OTC ML 31G X 5/16" 1 ML ULTILET LANCETS Formulary OTC; QL (150 EA per 30 days) ultra comfort insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" Formulary OTC 0.3 ml ULTRA FRESH OPHTHALMIC SOLUTION 0.5 % Formulary OTC ULTRA FRESH PM OPHTHALMIC OINTMENT Formulary OTC ULTRA MEGA GOLD ORAL TABLET EXTENDED Formulary OTC RELEASE ULTRA MIDE 25 EXTERNAL LOTION 25 % Formulary OTC ultracin external lotion 0.025-10-28 % Formulary OTC ULTRACIN M EXTERNAL GEL 5 % Formulary OTC ULTRACIN T EXTERNAL LOTION 10 % Formulary OTC ULTRACIN-M EXTERNAL GEL 10 % Formulary OTC ultra-comfort insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" Formulary OTC 0.5 ml ultra-comfort insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 Formulary OTC ml ultra-comfort insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" Formulary OTC 0.3 ml 141 Drug Name Formulary Status Requirements/Limits ultra-comfort insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" Formulary OTC 0.5 ml ultra-comfort insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 Formulary OTC ml ultra-comfort insulin syringe 30g x 5/16" 0.3 ml 30g x 5/16" Formulary OTC 0.3 ml ultra-comfort insulin syringe 30g x 5/16" 0.5 ml 30g x 5/16" Formulary OTC 0.5 ml ultra-comfort insulin syringe 30g x 5/16" 1 ml 30g x 5/16" 1 Formulary OTC ml ultra-comfort insulin syringe 31g x 5/16" 0.3 ml 31g x 5/16" Formulary OTC 0.3 ml ultra-comfort insulin syringe 31g x 5/16" 0.5 ml 31g x 5/16" Formulary OTC 0.5 ml ultra-comfort insulin syringe 31g x 5/16" 1 ml 31g x 5/16" 1 Formulary OTC ml ultrasone external cream Formulary OTC ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.5 ML Formulary OTC 30G X 5/16" 0.5 ML ULTRA-THIN II INS SYR SHORT 30G X 5/16" 1 ML Formulary OTC 30G X 5/16" 1 ML ULTRA-THIN II INS SYR SHORT 31G X 5/16" 0.3 ML Formulary OTC 31G X 5/16" 0.3 ML ULTRA-THIN II INS SYR SHORT 31G X 5/16" 0.5 ML Formulary OTC 31G X 5/16" 0.5 ML ULTRA-THIN II INS SYR SHORT 31G X 5/16" 1 ML Formulary OTC 31G X 5/16" 1 ML ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.3 ML Formulary OTC 29G X 1/2" 0.3 ML ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 1 ML Formulary OTC 29G X 1/2" 1 ML ULTRA-THIN II LANCETS Formulary OTC; QL (150 EA per 30 days) UMCKA ELDERBERRY COLD+FLU ORAL SYRUP Formulary OTC UMCKA FASTACTIVES COLD+FLU ORAL PACKET Formulary OTC UMECTA MOUSSE EXTERNAL FOAM 40 % Formulary UNDELENIC EXTERNAL TINCTURE Formulary OTC unibase external cream Formulary OTC UNILET COMFORTOUCH LANCET Formulary OTC; QL (150 EA per 30 days) UNILET EXCELITE Formulary OTC; QL (150 EA per 30 days) UNILET EXCELITE II Formulary OTC; QL (150 EA per 30 days) UNILET G.P. LANCET Formulary OTC; QL (150 EA per 30 days) UNILET G.P. SUPERLITE LANCET Formulary OTC; QL (150 EA per 30 days) UNILET GP 28 ULTRA THIN Formulary OTC; QL (150 EA per 30 days) UNILET LANCET Formulary OTC; QL (150 EA per 30 days)

142 Drug Name Formulary Status Requirements/Limits UNILET MICRO-THIN 33G Formulary OTC; QL (150 EA per 30 days) UNILET SUPERLITE LANCET Formulary OTC; QL (150 EA per 30 days) UNILET SUPER-THIN 30G Formulary OTC; QL (150 EA per 30 days) UNILET ULTRA-THIN 28G Formulary OTC; QL (150 EA per 30 days) UNI-SOLVE EXTERNAL PAD Formulary OTC UNIVERSAL 1 LANCETS THIN 26G Formulary OTC; QL (150 EA per 30 days) UNIVERSAL 1 LANCETS THIN 33G Formulary OTC; QL (150 EA per 30 days) UNIVERSAL 1 LANCETS ULTRA THIN Formulary OTC; QL (150 EA per 30 days) universal ph in vitro strip Formulary OTC urea 20 intensive hydrating external cream 20 % Formulary OTC urea external cream 40 %, 45 % Formulary urea external lotion 40 % Formulary urea hydrating external foam 35 % Formulary urea nail external gel 45 % Formulary urea nail external stick 50 % Formulary urinary pain relief oral tablet 95 mg Formulary OTC URO-MAG ORAL CAPSULE 140 MG Formulary OTC ursodiol oral capsule 300 mg Formulary ursodiol oral tablet 250 mg, 500 mg Formulary USTELL ORAL CAPSULE 120 MG Formulary vagicaine external cream 20-3 % Formulary OTC vagicaine vaginal cream 20-3 % Formulary OTC VAGIFEM VAGINAL TABLET 10 MCG Formulary VAGISIL EXTERNAL CREAM 5-2 % Formulary OTC valacyclovir hcl oral tablet 1 gm, 500 mg Formulary valerian oral capsule 500 mg Formulary OTC valerian root oral capsule 450 mg Formulary OTC valganciclovir hcl oral solution reconstituted 50 mg/ml Formulary valganciclovir hcl oral tablet 450 mg Formulary VALINE 1000 ORAL PACKET 1 GM Formulary OTC valine oral packet 50 mg Formulary OTC valproate sodium intravenous solution 100 mg/ml, 500 Formulary mg/5ml valproate sodium oral solution 250 mg/5ml Formulary valproic acid oral capsule 250 mg Formulary valproic acid oral solution 250 mg/5ml Formulary valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Formulary QL (34 EA per 34 days) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, Formulary 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VALSTAR INTRAVESICAL SOLUTION 40 MG/ML Formulary VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML Formulary PA VALTOCO 15 MG DOSE NASAL LIQUID THERAPY Formulary PA PACK 7.5 MG/0.1ML VALTOCO 20 MG DOSE NASAL LIQUID THERAPY Formulary PA PACK 10 MG/0.1ML 143 Drug Name Formulary Status Requirements/Limits VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML Formulary PA value health insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 Formulary OTC ml value health insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml Formulary OTC value plus lancet standard 21g Formulary OTC; QL (150 EA per 30 days) value plus lancets super thin Formulary OTC; QL (150 EA per 30 days) value plus lancets thin 26g Formulary OTC; QL (150 EA per 30 days) valumark lancet super thin 30g Formulary OTC; QL (150 EA per 30 days) valumark lancet ultra thin 28g Formulary OTC; QL (150 EA per 30 days) VAMOUSSE LICE TREATMENT EXTERNAL FOAM Formulary OTC VANACHOL ORAL CAPSULE Formulary OTC VANACOF AC ORAL LIQUID 12.5-25 MG/30ML Formulary OTC VANACOF DM ORAL LIQUID 10-18-200 MG/15ML Formulary OTC VANACOF ORAL LIQUID 30-1-12.5 MG/5ML Formulary OTC VANACOF-8 ORAL LIQUID 25-50 MG/15ML Formulary OTC vanadium oral capsule 7.5 mg Formulary OTC VANATAB AC ORAL TABLET 12.5-25 MG Formulary OTC VANATAB DM ORAL TABLET 5-9-198 MG Formulary OTC vancomycin hcl in dextrose intravenous solution 1-5 Formulary gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-% vancomycin hcl in dextrose intravenous solution 1-5 Formulary gm/250ml-% vancomycin hcl in nacl intravenous solution 1-0.9 Formulary gm/200ml-%, 500-0.9 mg/100ml-%, 750-0.9 mg/150ml-% vancomycin hcl intravenous solution reconstituted 10 gm, Formulary 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral capsule 125 mg, 250 mg Formulary VANDAZOLE VAGINAL GEL 0.75 % Formulary VANICREAM DIAPER RASH EXTERNAL OINTMENT Formulary OTC 1.1-40 % VANIPLY EXTERNAL OINTMENT 1 % Formulary OTC VANISHPOINT SAFETY SYRINGE 25G X 1-1/2" 10 ML, 25G X 1-1/2" 5 ML, 27G X 1-1/2" 10 ML, 27G X 1- Formulary OTC 1/2" 5 ML VANTAS SUBCUTANEOUS KIT 50 MG Formulary PA VAPOR PATCH EXTERNAL PATCH Formulary OTC VAQTA INTRAMUSCULAR SUSPENSION 25 Formulary AGE (Min 19 Years) UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 Formulary AGE (Min 19 Years) PFU/0.5ML VASHE WOUND THERAPY EXTERNAL SOLUTION Formulary OTC VASOCLEAR-A OPHTHALMIC SOLUTION 0.02-0.25 Formulary OTC % VASOFLEX D1 ORAL TABLET 900-100 MG Formulary OTC VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 Formulary OTC %

144 Drug Name Formulary Status Requirements/Limits VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM Formulary OTC 12.5 % VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % Formulary OTC VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, Formulary 400 MG/20ML VELCADE INJECTION SOLUTION RECONSTITUTED Formulary 3.5 MG venaliv oral tablet 900-100-100 mg Formulary OTC VENIA EXTERNAL PATCH 4-4 % Formulary OTC venlafaxine hcl er oral capsule extended release 24 hour Formulary 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 Formulary ST mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, Formulary 75 mg VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 Formulary MCG/ML VENTOLIN HFA INHALATION AEROSOL SOLUTION Formulary 108 (90 BASE) MCG/ACT verapamil hcl er oral capsule extended release 24 hour 100 Formulary mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 Formulary mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml Formulary verapamil hcl oral tablet 120 mg, 40 mg, 80 mg Formulary VERELAN PM ORAL CAPSULE EXTENDED Formulary RELEASE 24 HOUR 200 MG VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG Formulary PA VERSAPLUS ORAL SYRUP Formulary VERSIVA XC PAD 5-1/2"X5-1/2" Formulary OTC VIBERZI ORAL TABLET 100 MG, 75 MG Formulary PA VIBRAMYCIN ORAL SYRUP 50 MG/5ML Formulary VICKS DAYQUIL MUCUS CONTROL DM ORAL Formulary OTC LIQUID 10-200 MG/15ML VICKS NYQUIL CHILDRENS CLD/CGH ORAL Formulary OTC LIQUID 2-15 MG/15ML VICKS NYQUIL COLD & FLU NIGHT ORAL LIQUID Formulary OTC 15-6.25-325 MG/15ML, 30-650-4 MG/30ML VICKS NYQUIL COUGH ORAL LIQUID 12.5-30 Formulary OTC MG/30ML VICKS NYQUIL SEVERE COLD & FLU ORAL Formulary OTC TABLET 5-6.25-10-325 MG VICKS SINEX DAYQUIL/NYQUIL ORAL Formulary OTC VICKS VAPO STEAM INHALATION LIQUID 6.2 % Formulary OTC VICKS VAPODROPS MOUTH/THROAT LOZENGE 1.7 Formulary OTC MG, 3.3 MG VICKS VAPOINHALER INHALATION INHALER Formulary OTC VICKS VAPORUB EXTERNAL OINTMENT 4.73-1.2-2.6 Formulary OTC % 145 Drug Name Formulary Status Requirements/Limits VICODIN ES ORAL TABLET 7.5-300 MG Formulary PA; QL (84 EA per 7 days) VICODIN HP ORAL TABLET 10-300 MG Formulary PA; QL (63 EA per 7 days) VICODIN ORAL TABLET 5-300 MG Formulary PA; QL (126 EA per 7 days) VICTOZA SUBCUTANEOUS SOLUTION PEN- Formulary INJECTOR 18 MG/3ML VIDA MIA UNILET LANCETS 28G Formulary OTC; QL (150 EA per 30 days) VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 Formulary GM vigabatrin oral packet 500 mg Formulary PA vigabatrin oral tablet 500 mg Formulary PA VIIBRYD ORAL TABLET 10 MG Formulary PA; QL (68 EA per 34 days) VIIBRYD ORAL TABLET 20 MG, 40 MG Formulary PA; QL (34 EA per 34 days) VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML Formulary VIMPAT ORAL SOLUTION 10 MG/ML Formulary VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 Formulary MG VINATE M ORAL TABLET 27-1 MG Formulary vinblastine sulfate intravenous solution 1 mg/ml Formulary VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML Formulary VINCE DENTAL POWDER Formulary OTC vinorelbine tartrate intravenous solution 10 mg/ml, 50 Formulary mg/5ml VIRACEPT ORAL TABLET 250 MG, 625 MG Formulary virtussin dac oral solution 30-10-100 mg/5ml Formulary OTC VISI-FLOW IRRIGATION STARTER KIT Formulary OTC vita-c oral crystals Formulary OTC VITA-CALCIUM ORAL WAFER 333-133 MG-UNIT Formulary OTC VITADYE EXTERNAL LOTION 5 % Formulary OTC VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG Formulary VITALINE BIOTIN FORTE/ZINC ORAL TABLET 0.8 Formulary OTC MG VITALINE COQ10 ORAL TABLET 200 MG, 60 MG Formulary OTC VITA-MAG ORAL TABLET 133-5-10 MG Formulary OTC VITAMAX ORAL TABLET CHEWABLE 60 MG Formulary OTC VITAMELTS ENERGY VITAMIN B-12 ORAL TABLET Formulary OTC DISPERSIBLE 1500 MCG vitamin a & d oral capsule 5000-400 unit Formulary OTC vitamin a & d oral tablet 10000-400 unit Formulary OTC VITAMIN A FISH ORAL CAPSULE 7500 UNIT Formulary OTC vitamin a oral capsule 10000 unit, 8000 unit Formulary OTC vitamin a palmitate oral tablet 10000 unit, 15000 unit Formulary OTC vitamin a wrinkle treatment external gel Formulary OTC vitamin a-beta carotene oral tablet 10000-1000 unit, Formulary OTC 15000-10000 unit vitamin b complex-c oral capsule Formulary OTC vitamin b-1 oral tablet 50 mg Formulary OTC 146 Drug Name Formulary Status Requirements/Limits vitamin b-12 oral liquid 1000 mcg/15ml Formulary OTC vitamin b-12 oral lozenge 50 mcg, 500 mcg Formulary OTC vitamin b-12 oral tablet 100 mcg, 1000 mcg, 500 mcg Formulary OTC vitamin b12 sublingual liquid 3000 mcg/ml Formulary OTC vitamin b-12 sublingual tablet sublingual 500 mcg Formulary OTC vitamin b-2 oral tablet 25 mg, 50 mg Formulary OTC vitamin b-6 er oral tablet extended release 200 mg Formulary OTC vitamin b-6 oral tablet 100 mg Formulary OTC vitamin c (calcium ascorbate) oral solution reconstituted Formulary OTC vitamin c drops mouth/throat lozenge 60 mg Formulary OTC vitamin c gummies oral tablet chewable 125 mg Formulary OTC vitamin c oral liquid , 500 mg/5ml Formulary OTC vitamin c oral powder Formulary OTC vitamin c oral tablet 100 mg, 250 mg Formulary OTC vitamin c oral tablet chewable Formulary OTC vitamin c plus wild rose hips oral tablet chewable 500 mg Formulary OTC vitamin c-rose hips er oral tablet extended release 1000 mg, Formulary OTC 500 mg vitamin d2 oral tablet 50 mcg (2000 ut) Formulary OTC vitamin d3 oral capsule 1.25 mg (50000 ut), 125 mcg (5000 Formulary OTC ut), 250 mcg (10000 ut), 50 mcg (2000 ut) vitamin d3 oral liquid 5000 unit/ml Formulary OTC vitamin d3 oral tablet 1.25 mg (50000 ut) Formulary OTC vitamin d3 oral tablet chewable 10 mcg (400 unit), 25 mcg Formulary OTC (1000 ut) vitamin d-400 oral tablet 10 mcg (400 unit) Formulary OTC VITAMIN E & C BEAUTY LOTION EXTERNAL Formulary OTC LOTION VITAMIN E & K BEAUTIFUL SKIN EXTERNAL OIL Formulary OTC vitamin e beauty external oil 24000 unit/52ml Formulary OTC vitamin e external cream Formulary OTC vitamin e external liquid 24000 unit Formulary OTC vitamin e oral capsule 100 unit Formulary OTC vitamin e oral tablet 400 unit Formulary OTC vitamin e/selenium oral capsule 400-50 unit-mcg Formulary OTC vitamins acd-fluoride oral solution 0.25 mg/ml Formulary VITAMINS E & A BEAUTY OIL EXTERNAL OIL 1000- Formulary OTC 14000 UNIT/52ML VITAMINS E & D BEAUTY OIL EXTERNAL OIL 400- Formulary OTC 14000 UNIT/52ML VITA-RAY EXTERNAL CREAM 10-200000-3000 Formulary OTC VITONIC ORAL LIQUID Formulary OTC VIVA DROPS OPHTHALMIC SOLUTION 1 % Formulary OTC viva external patch 2.5-4-2 % Formulary OTC VIVABEN ORAL CAPSULE Formulary OTC

147 Drug Name Formulary Status Requirements/Limits VIVITROL INTRAMUSCULAR SUSPENSION Formulary RECONSTITUTED 380 MG VIVOTIF ORAL CAPSULE DELAYED RELEASE Formulary AGE (Min 19 Years) vocabria oral tablet 30 mg Formulary voriconazole oral suspension reconstituted 40 mg/ml Formulary PA voriconazole oral tablet 200 mg, 50 mg Formulary PA vp insulin syringe 29g x 1/2" 0.3 ml 29g x 1/2" 0.3 ml Formulary OTC VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 QL (30 EA per 30 days); AGE (Min 4 Formulary MG, 50 MG, 60 MG, 70 MG Years and Max 17 Years) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 Formulary AGE (Min 4 Years and Max 17 Years) MG, 30 MG, 40 MG, 50 MG, 60 MG WAL-DRYL ANTI-ITCH EXTERNAL LIQUID 2-0.1 % Formulary OTC WAL-DRYL EXTERNAL CREAM 2-0.1 % Formulary OTC WAL-DRYL PE ALLERGY & SINUS ORAL TABLET Formulary OTC 25-10 MG WAL-FEX D ALLERGY & CONGESTION ORAL Formulary OTC TABLET EXTENDED RELEASE 24 HOUR 180-240 MG WAL-FLU COLD & SORE THROAT ORAL PACKET Formulary OTC 20-10-325 MG WAL-FLU SEV COLD/CGH DAY/NIGHT ORAL Formulary OTC PACKET WALGREENS LANCETS Formulary OTC; QL (150 EA per 30 days) walgreens lancets micro thin Formulary OTC; QL (150 EA per 30 days) walgreens lancets super thin Formulary OTC; QL (150 EA per 30 days) WALGREENS THIN LANCETS Formulary OTC; QL (150 EA per 30 days) WALGREENS ULTRA THIN LANCETS Formulary OTC; QL (150 EA per 30 days) WAL-ITIN D ORAL TABLET EXTENDED RELEASE 12 Formulary OTC HOUR 5-120 MG WAL-PHED PE DAYTIME/NIGHTTIME ORAL Formulary OTC WAL-SLEEP Z LIQUID SHOTS ORAL LIQUID 50 Formulary OTC MG/50ML WAL-SLEEP Z ORAL TABLET DISPERSIBLE 25 MG Formulary OTC wal-tap cold/allergy oral liquid 2-5 mg/10ml Formulary OTC WAL-TUSSIN CF MAX ORAL LIQUID 5-10-200-325 Formulary OTC MG/10ML wal-tussin cough relief oral tablet chewable 7.5 mg Formulary OTC WAL-ZYR CHILDRENS ORAL TABLET CHEWABLE Formulary OTC 10 MG, 5 MG WAL-ZYR ORAL CAPSULE 10 MG Formulary OTC warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 Formulary mg, 4 mg, 5 mg, 6 mg, 7.5 mg wart remover maximum strength external gel 17 % Formulary OTC wart remover maximum strength external liquid 17 % Formulary OTC WATCHHALER DEVICE Formulary QL (2 EA per 365 days) water tabs oral tablet Formulary OTC wax for braces wax Formulary OTC WEBCOL ALCOHOL PREP LARGE PAD 70 % 70 % Formulary OTC

148 Drug Name Formulary Status Requirements/Limits WEBCOL ALCOHOL PREP MEDIUM PAD 70 % 70 % Formulary OTC wee care oral suspension 15 mg/1.25ml Formulary OTC wegmans complete prenatal+dha oral 28-0.975 & 200 mg Formulary OTC WEISS EPIDURAL NEEDLE 20G X 2" Formulary OTC WEISS EPIDURAL NEEDLE TW 17G X 5" , 18G X 3- Formulary OTC 1/2" , 18G X 5" WELLMIND MENTAL FOCUS ORAL TABLET Formulary OTC CHEWABLE WHITE PED ARTERIAL NEEDLE 19G X 1-1/2" , 20G X Formulary OTC 1-1/2" white petrolatum external ointment Formulary WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM Formulary 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM Formulary 2 % WINGS MATERNITY PANTS 2X-3X Formulary OTC WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, Formulary 5000 UNIT/4.4ML witch hazel external liquid Formulary OTC witch hazel external solution 86 % Formulary OTC wound gel external gel Formulary OTC wound gel spray external gel Formulary OTC WYMZYA FE ORAL TABLET CHEWABLE 0.4-35 MG- Formulary QL (28 EA per 28 days) MCG XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 Formulary MG XARELTO STARTER PACK ORAL TABLET THERAPY Formulary PACK 15 & 20 MG XEOMIN INTRAMUSCULAR SOLUTION Formulary PA RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT XERAC AC EXTERNAL SOLUTION 6.25 % Formulary XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL Formulary XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML Formulary XIAFLEX INJECTION SOLUTION RECONSTITUTED Formulary PA 0.9 MG XIFAXAN ORAL TABLET 200 MG, 550 MG Formulary PA 149 Drug Name Formulary Status Requirements/Limits XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 Formulary ST; AGE (Min 18 Years) MG, 5-500 MG XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY Formulary QL (2 EA per 180 days) PACK 2 X 20 MG XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY Formulary QL (2 EA per 180 days) PACK 2 X 40 MG XOLAIR SUBCUTANEOUS SOLUTION PREFILLED Formulary PA; QL (2 EA per 28 days) SYRINGE 150 MG/ML, 75 MG/0.5ML XOLAIR SUBCUTANEOUS SOLUTION Formulary PA; QL (2 EA per 28 days) RECONSTITUTED 150 MG xolido external cream 2 % Formulary OTC X-SEB T PEARL EXTERNAL SHAMPOO 10 % Formulary OTC XTRA-CARE EXTERNAL LOTION Formulary OTC XULANE TRANSDERMAL PATCH WEEKLY 150-35 Formulary MCG/24HR XYREM ORAL SOLUTION 500 MG/ML Formulary PA; QL (540 ML per 30 days) YES FOR WOMEN EXTERNAL GEL Formulary OTC YF-VAX SUBCUTANEOUS INJECTABLE Formulary AGE (Min 19 Years) YUVAFEM VAGINAL TABLET 10 MCG Formulary ZADITOR OPHTHALMIC SOLUTION 0.025 % Formulary OTC ZAFEMY TRANSDERMAL PATCH WEEKLY 150-35 Formulary MCG/24HR zafirlukast oral tablet 10 mg, 20 mg Formulary zaleplon oral capsule 10 mg Formulary QL (68 EA per 34 days) zaleplon oral capsule 5 mg Formulary QL (34 EA per 34 days) ZANOSAR INTRAVENOUS SOLUTION Formulary RECONSTITUTED 1 GM ZANTAC 150 MAXIMUM STRENGTH ORAL TABLET Formulary OTC 150 MG ZANTAC 75 ORAL TABLET 75 MG Formulary OTC Z-BUM EXTERNAL CREAM 22.5 % Formulary OTC ZEASORB EXTERNAL POWDER Formulary OTC ZEGERID OTC CAPSULE 20-1100 MG ORAL 20-1100 Formulary OTC; QL (34 EA per 34 days) MG ZELBORAF ORAL TABLET 240 MG Formulary ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, Formulary 40 MG ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 10000-32000 UNIT, 15000- 47000 UNIT, 15000-51000 UNIT, 20000-63000 UNIT, Formulary PA 20000-68000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT, 5000-24000 UNIT ZEPHREX-D ORAL TABLET ABUSE-DETERRENT 30 Formulary OTC MG ZE-PLUS ORAL CAPSULE Formulary OTC ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML Formulary ZICAM ALLERGY RELIEF NASAL GEL Formulary OTC 150 Drug Name Formulary Status Requirements/Limits ZICAM COLD REMEDY ORAL TABLET DISPERSIBLE Formulary OTC zidovudine oral capsule 100 mg Formulary zidovudine oral syrup 50 mg/5ml Formulary zidovudine oral tablet 300 mg Formulary ZIKS ARTHRITIS PAIN RELIEF EXTERNAL CREAM Formulary OTC 0.025-1-12 % ZILACTIN MOUTH/THROAT GEL 10 % Formulary OTC ZILACTIN-B MOUTH/THROAT GEL 10 % Formulary OTC ZIMS MAX-FREEZE EXTERNAL GEL 3.7 % Formulary OTC zinc + vitamin c mouth/throat lozenge 20-120 mg Formulary OTC ZINC 15 ORAL TABLET 66 MG Formulary OTC zinc aspartate oral tablet 40 mg Formulary OTC zinc gluconate oral tablet 15 mg, 50 mg Formulary OTC zinc methionate oral capsule 50 mg Formulary OTC zinc mouth/throat lozenge 10 mg Formulary OTC zinc oral tablet 100 mg, 30 mg Formulary OTC zinc oxide external ointment 20 % Formulary OTC zinc oxide external paste 25 % Formulary OTC zinc sulfate oral tablet 220 (50 zn) mg Formulary OTC zinc-c-b6 mouth/throat lozenge 12-60-0.5 mg, 15-60-5 mg Formulary OTC zincolate oral capsule 10-20 mg Formulary OTC ZINC-OXYDE PLUS EXTERNAL OINTMENT 0.44-20 Formulary OTC % zinc-vitamin c oral tablet dispersible 15-60 mg Formulary OTC ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Formulary AGE (Min 18 Years) ZITHROMAX ORAL PACKET 1 GM Formulary QL (8 EA per 34 days) ZITHROMAX ORAL SUSPENSION RECONSTITUTED Formulary 100 MG/5ML zn-50 oral capsule 50 mg Formulary OTC ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG Formulary PA; QL (1 EA per 90 days) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Formulary PA zoledronic acid intravenous concentrate 4 mg/5ml Formulary PA zoledronic acid intravenous solution 4 mg/100ml, 5 Formulary PA mg/100ml ZOLINZA ORAL CAPSULE 100 MG Formulary PA zolmitriptan nasal solution 2.5 mg Formulary ST zolmitriptan nasal solution 5 mg Formulary ST; QL (36 EA per 34 days) zolmitriptan oral tablet 2.5 mg, 5 mg Formulary ST; QL (6 EA per 34 days) zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Formulary ST; QL (6 EA per 34 days) zolpidem tartrate er oral tablet extended release 12.5 mg, Formulary QL (30 EA per 30 days) 6.25 mg zolpidem tartrate oral tablet 10 mg, 5 mg Formulary ZOMIG NASAL SOLUTION 2.5 MG Formulary ST ZOMIG NASAL SOLUTION 5 MG Formulary ST; QL (36 EA per 34 days) zonisamide oral capsule 100 mg, 25 mg, 50 mg Formulary

151 Drug Name Formulary Status Requirements/Limits ZOSTAVAX SUBCUTANEOUS SUSPENSION Formulary AGE (Min 19 Years) RECONSTITUTED 19400 UNT/0.65ML ZOSTRIX HOT & COLD THERAPY EXTERNAL KIT Formulary OTC 0.025 & 4 % ZOSTRIX HP EXTERNAL CREAM 0.1 % Formulary OTC ZOSTRIX-HP EXTERNAL STICK 0.075 % Formulary OTC ZOVIRAX EXTERNAL CREAM 5 % Formulary QL (5 GM per 34 days) Z-TUSS AC ORAL LIQUID 2-9 MG/5ML Formulary OTC ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % Formulary ZYNCOF ORAL SYRUP 20-400 MG/5ML Formulary OTC ZYRTEC ALLERGY ORAL CAPSULE 10 MG Formulary OTC ZYRTEC ALLERGY ORAL TABLET 10 MG Formulary OTC ZYRTEC ALLERGY ORAL TABLET DISPERSIBLE 10 Formulary OTC MG ZYRTEC-D ALLERGY & CONGESTION ORAL Formulary OTC TABLET EXTENDED RELEASE 12 HOUR 5-120 MG ZZZQUIL ORAL LIQUID 50 MG/30ML Formulary OTC

152 Index 1st relief spray...... 1 acne medication 5...... 2 AEROCHAMBER PLUS FLO-VU...... 4 1st tier unifine pentips...... 1 acne treatment...... 2 AEROCHAMBER PLUS FLO-VU 1st tier unilet comfortouch...... 1 ACNEFREE ACNE CLEARING LARGE...... 4 50+ adult eye health...... 1 SYSTEM...... 2 AEROCHAMBER PLUS FLO-VU A & D ZINC OXIDE...... 1 ACNEFREE SEVERE CLEARING SMALL...... 4 a thru z advanced...... 1 SYST...... 2 AEROCHAMBER PLUS FLO-VU a thru z advantage...... 1 ACT TOTAL CARE...... 2 W/MASK...... 4 a thru z select...... 1 ACTHIB...... 3 AFEDITAB CR...... 4 A+D CRACKED SKIN RELIEF...... 1 ACTICARNITINE SF...... 3 AFLURIA...... 4 a1c test at-home...... 1 ACTICON...... 3 AFLURIA PRESERVATIVE FREE...... 5 a-25...... 1 actidom dmx...... 3 AFREZZA...... 5 abacavir sulfate...... 1 ACTIDOSE WITH SORBITOL...... 3 AFRIN CHILDRENS...... 5 abacavir sulfate-lamivudine...... 1 actidose-aqua...... 3 AFRIN MENTHOL SPRAY...... 5 abacavir-lamivudine-zidovudine...... 1 ACTIFLOVIT EAR HEALTH...... 3 AFTERA...... 5 ABANATUSS PED...... 1 ACTIFOAM COLLAGEN SPONGE...... 3 AGAMATRIX ULTRA-THIN ABATRACE...... 1 acti-lance lite lancets 28g...... 3 LANCETS...... 5 ABATREX...... 1 acti-lance special lancets 17g...... 3 AHIST...... 5 ABATRON...... 1 acti-lance universal 23g...... 3 aimsco lubricated...... 5 ABATRON AF...... 1 ACTIMMUNE...... 3 AIRAVITE...... 5 ABATUSS DMX...... 1 ACTINEL...... 3 AIRBORNE...... 5 ABILIFY MAINTENA...... 1 ACTISEP...... 3 AIRS DISPOSABLE NEBULIZER...... 5 abiraterone acetate...... 1 ACTITROM...... 3 AIRZONE PEAK FLOW METER...... 5 ABRAXANE...... 1 ACTIVE Q...... 3 AJOVY...... 5 ABREVA...... 1 ACTIVE Q MAXIMUM STRENGTH....3 ak-poly-bac...... 5 acamprosate calcium...... 1 ACTIVE-Q...... 3 AL12...... 5 acarbose...... 1 ACTIVE-Q EXTRA STRENGTH...... 3 ALA SEB...... 5 ACCU-CHEK FASTCLIX LANCET...... 1 ACTIVITE EC...... 3 ALA SEB T...... 5 ACCU-CHEK SOFT TOUCH ACTIVON ARTHRITIS ULTRA ST...... 3 ALAHIST DM...... 5 LANCETS...... 2 acyclovir...... 3 ALA-HIST IR...... 5 ACCU-CHEK SOFTCLIX LANCETS....2 ADACEL...... 3 ALA-HIST PE...... 5 ACCUTANE...... 2 ADAGEN...... 3 alanine 1000...... 5 ACCUTREND CHOLESTEROL...... 2 adapalene...... 3 ALAWAY...... 5 ACCUTREND CHOLESTEROL ADDERALL XR...... 3 ALAWAY CHILDRENS ALLERGY..... 5 CONTROL...... 2 adefovir dipivoxil...... 3 alba-lybe nr...... 5 ACCUTREND PLUS...... 2 adhesive bandages sheer...... 3 albendazole...... 5 ACE AEROSOL CLOUD adjustable lancing device...... 3 ALBOLENE...... 5 ENHANCER...... 2 ADMELOG...... 4 ALBUKED 25...... 5 ACE KNEE BRACE ADMELOG SOLOSTAR...... 3 ALBUKED 5...... 5 W/STABILIZERS...... 2 ADRENAL C FORMULA...... 4 albumin human...... 5 acebutolol hcl...... 2 ADRENALIN...... 4 albumin-zlb...... 5 ACEROLA C 500...... 2 ADRUCIL...... 4 alburx...... 5 ACETA-GESIC...... 2 adult gummy...... 4 ALBUTEIN...... 5 acetaminophen...... 2 adult mask...... 4 albuterol sulfate...... 5, 6 acetaminophen-codeine...... 2 adult wash cloths with aloe...... 4 albuterol sulfate er...... 5 acetaminophen-codeine #2...... 2 adult-lock weekly pill remind...... 4 albuterol sulfate hfa...... 5 acetaminophen-codeine #3...... 2 ADVAIR DISKUS...... 4 alcohol (rubbing)...... 6 acetaminophen-codeine #4...... 2 ADVAIR HFA...... 4 alcohol prep...... 6 ACETASOL HC...... 2 advanced acne wash...... 4 alcohol swabs...... 6 acetazolamide...... 2 ADVANCED alcohol wipes...... 6 acetazolamide er...... 2 CALCIUM/D/MAGNESIUM...... 4 alendronate sodium...... 6 acetic acid...... 2 advanced hand sanitizer...... 4 aler-cap...... 6 acetylcysteine...... 2 ADVIL...... 4 aler-dryl...... 6 ACID GONE...... 2 ADVIL ALLERGY & CONGESTION... 4 alertness aid...... 6 acid reducer maximum strength...... 2 ADVIL ALLERGY SINUS...... 4 alevazol...... 6 acidophilus...... 2 ADVIL COLD & SINUS LIQUI- ALEVE...... 6 acidophilus probiotic...... 2 GELS...... 4 ALFERON N...... 6 acidophilus/bifidus...... 2 ADVIL COLD/SINUS...... 4 alfuzosin hcl er...... 6 acidophilus/citrus pectin...... 2 ADVIL PM...... 4 alga...... 6 acidophilus/pectin...... 2 ADVIL SINUS CONGESTION & ALGAL-900 DHA...... 6 acitretin...... 2 PAIN...... 4 ALIMTA...... 6 acne medication 10...... 2 ADVOCATE INSULIN SYRINGE...... 4

153 ALIVE MULTI-VITAMIN ambi 40pse/400gfn...... 8 antiseptic wound/skin cleanser...... 10 CHILDRENS...... 6 ambi 60pse/400gfn...... 8 ANUSOL-HC...... 10 ALIVIO...... 6 ambi 60pse/4cpm...... 8 AO-SEPT CONTACT LENS alka-aid...... 6 AMBI FADE...... 8 HOLDER...... 10 ALKA-SELTZER...... 6 ambrisentan...... 8 APETIGEN...... 10 ALKA-SELTZER HEARTBURN + amcinonide...... 8 APETIGEN-PLUS...... 10 GAS...... 6 AMERICERIN...... 8 ap-hist dm...... 10 all day allergy childrens...... 6 AMERIWASH...... 8 APLIGRAF...... 10 all day pain relief...... 6 AMETHIA...... 8 apothesar...... 10 ALL-DRY SIZE 3...... 6 AMETHIA LO...... 8 apraclonidine hcl...... 10 ALLEGRA ALLERGY...... 6 AMETHYST...... 8 aprepitant...... 10 ALLEGRA ALLERGY CHILDRENS.... 6 amiloride hcl...... 8 APRI...... 10 ALLEGRA-D ALLERGY & amiloride-hydrochlorothiazide...... 8 APRISO...... 10 CONGESTION...... 6 aminoacetic acid...... 8 APTIVUS...... 10 aller-ease...... 6 aminocaproic acid...... 8 AQUA CARE...... 10 allergy childrens...... 6 AMINORELIEFRMS...... 8 aquabase...... 10 allergy eye...... 6 amiodarone hcl...... 8 AQUADEKS...... 10 allergy multi-symptom day/nght...... 6 AMITIZA...... 8 AQUAFRESH DR SEUSS EXTRA allergy relief...... 7 amitriptyline hcl...... 8 SOFT...... 10 allergy spray 24 hour...... 7 amlodipine besy-benazepril hcl...... 8 aquanaz...... 10 ALLEVYN PLUS CAVITY...... 7 amlodipine besylate...... 8 AQUAPHILIC...... 10 ALLI...... 7 amlodipine besylate-valsartan...... 8 AQUAPHILIC/CARBAMIDE...... 10 allopurinol...... 7 amlodipine-atorvastatin...... 8 AQUASONIC 100...... 10 ALMACONE...... 7 amlodipine-olmesartan...... 8 AQUEOUS SELENIUM...... 10 ALOCANE PLUS...... 7 amlodipine-valsartan-hctz...... 9 aqueous vitamin e...... 10 ALOE GRANDE...... 7 ammonia aromatic...... 9 AQUORAL...... 10 aloe vera...... 7 ammonium lactate...... 9 ARANELLE...... 11 aloe vera moisturizing...... 7 AMNESTEEM...... 9 ARCALYST...... 11 ALOE VESTA 2-N-1 PROTECTIVE..... 7 amoxicillin...... 9 ARCAPTA NEOHALER...... 11 ALOE VESTA CLEAR amoxicillin-pot clavulanate...... 9 arctic relief pain relieving...... 11 ANTIFUNGAL...... 7 amphetamine-dextroamphetamine...... 9 arformoterol tartrate...... 11 ALOE VESTA MULTI PURPOSE...... 7 ampicillin...... 9 ARGIMENT AT...... 11 ALOE VESTA PROTECTIVE...... 7 ANA-LEX...... 9 arginine...... 11 ALOE VESTA SKIN PROTECTANT.... 7 ANASEPT...... 9 arginine2000...... 11 aloe/lidocaine pain reliever...... 7 ANASEPT ANTIMICROBIAL...... 9 ARGYLE STERILE SALINE...... 11 alosetron hcl...... 7 anastrozole...... 9 ARGYLE STERILE WATER...... 11 alp high3...... 7 ANBESOL...... 9 aripiprazole...... 11 ALPAWASH...... 7 ANBESOL MAXIMUM STRENGTH....9 ARISTADA...... 11 ALPHAGAN P...... 7 ANDRODERM...... 9 ARISTADA INITIO...... 11 alpha-lipoic acid...... 7 ANDROGEL PUMP...... 9 arkaliox...... 11 ALPHANATE/VWF ANECREAM...... 9 ARMOUR THYROID...... 11 COMPLEX/HUMAN...... 7 animal chews...... 9 arnica...... 11 ALPHANINE SD...... 7 ANORO ELLIPTA...... 9 arnicare arthritis...... 11 alph-e...... 7 antacid...... 9 ARRANON...... 11 alph-e-mixed...... 7 antacid anti-gas...... 9 arthritis pain relieving...... 11 alph-e-mixed 1000...... 7 antacid anti-gas max strength...... 9 artificial tears...... 11 alprazolam...... 7 antacid extra strength...... 9 ARZERRA...... 11 alprazolam er...... 7 antacid multi-symptom...... 9 ARZOL SILVER NIT ALPRAZOLAM INTENSOL...... 7 antacid soft chews...... 9 APPLICATORS...... 11 ALTACAINE...... 8 ANTARA...... 9 asafetida...... 11 ALTAFLUOR...... 8 anthelios 50 mineral...... 9 ascocid-iso-ph...... 11 ALTAVERA...... 8 anti-allergy...... 9 ASCOMP-CODEINE...... 11 aluminum acetate...... 8 antibacterial liquid soap...... 10 ascorbic acid...... 11 aluminum bottle seal...... 8 anti-diarrheal...... 10 ASCRIPTIN...... 11 aluminum hydroxide gel...... 8 antifungal...... 10 asepto oral thermometer...... 11 ALWAYS MAXI MAXIMUM anti-fungal...... 10 ASMANEX (120 METERED DOSES).11 PROTECTION...... 8 anti-itch...... 10 ASMANEX (30 METERED DOSES)...11 alyacen 1/35...... 8 ANTI-ITCH INTENSIVE HEALING... 10 aspartate mg & k...... 11 alyacen 7/7/7...... 8 anti-oxidant...... 10 ASPERCREME W/LIDOCAINE...... 12 ALYQ...... 8 antioxidant formula sg...... 10 aspirin...... 12 amantadine hcl...... 8 antiseptic...... 10 aspirin 81...... 12 ambi 12.5cpd/100gfn/30pse...... 8 ANTISEPTIC HAND RINSE...... 10 aspirin-dipyridamole er...... 12 ambi 12.5cpd/1dcpm/30pse...... 8 antiseptic skin cleanser...... 10 aspirtab maximum strength...... 12 154 ASSURE ID INSULIN SAFETY SYR..12 b-12 tr...... 14 BD LANCET ULTRAFINE 33G...... 16 ASSURE LANCETS...... 12 b-2...... 14 BD LUER-LOK SYRINGE...... 16 ASTHMAPACK FOR CHILDREN...... 12 B-2-400...... 14 BD PEN NEEDLE ORIGINAL U/F...... 16 atazanavir sulfate...... 12 b-6...... 14 BD SAFETYGLIDE INSULIN atenolol...... 12 BABY ANBESOL...... 14 SYRINGE...... 16 atenolol-chlorthalidone...... 12 baby lotion...... 14 BD SAFETYGLIDE NEEDLE...... 17 athletes foot maximum strength...... 12 baby super daily d3...... 14 BD SAFETYGLIDE atomoxetine hcl...... 12 baby teething pain medicine...... 14 SYRINGE/NEEDLE...... 17 ATOPICLAIR...... 12 baby thermometer...... 14 BD SAFETY-LOK INSULIN atorvastatin calcium...... 12 baciim...... 14 SYRINGE...... 17 atovaquone...... 12 bacitracin...... 14 BD SHARPS COLLECTOR...... 17 atovaquone-proguanil hcl...... 12 bacitracin zinc...... 14 BD SWAB SINGLE USE REGULAR.. 17 ATRAC-TAIN...... 12 bacitra-neomycin-polymyxin-hc...... 14 BD SWABS SINGLE USE ATROVENT HFA...... 12 back pain-off...... 14 BUTTERFLY...... 17 atuss da...... 12 baclofen...... 14 BD SYRINGE...... 17 AUBRA...... 12 BACTROBAN NASAL...... 14 BD SYRINGE/NEEDLE SLIP TIP...... 17 auraphene-b...... 12 balamine dm...... 14 BD TB SYRINGE...... 17 aurora lancet super thin 30g...... 12 balanced b-50...... 14 BD VEO INSULIN SYR U/F 1/2UNIT.17 aurora lancet thin 23g...... 12 balanced b-50 complex...... 14 BD VEO INSULIN SYRINGE U/F...... 17 AUROVELA FE 1.5/30...... 12 BAL-CARE DHA...... 14 BEBULIN...... 17 AUTOJECT 2...... 12 BALNEOL...... 14 bec/zinc...... 17 AUTOLET PLATFORMS...... 12 balsalazide disodium...... 14 bee pollen...... 17 autopen...... 12 BALZIVA...... 14 BEELITH...... 17 avalin...... 12 BAND-AID SURGIPAD SURGICAL.. 14 BELBUCA...... 17 AVAR CLEANSER...... 12 BANOPHEN...... 14 belladonna alkaloids-opium...... 17 AVAR-E EMOLLIENT...... 12 BAQSIMI ONE PACK...... 14 belladonna-opium...... 17 AVASTIN...... 12 BAQSIMI TWO PACK...... 14 BENADRYL ALLERGY...... 17 AVEENO BABY GENTLE BARACLUDE...... 14 BENADRYL ALLERGY CONDITION...... 13 BASAGLAR KWIKPEN...... 14 CHILDRENS...... 17 AVEENO BABY SOOTHING WASH. 13 BAYER BACK & BODY...... 14 BENADRYL ALLERGY CON AVEENO INTENSE RELIEF...... 13 BAYER BREEZE 2 CONTROL...... 14 ULTRATABS...... 17 AVEENO POSITIVELY RADIANT BAYER BREEZE 2 SYSTEM...... 14 BENADRYL ALLERGY WASH...... 13 BAYER BREEZE 2 TEST...... 14 ULTRATABS...... 17 AVENOVA/NEUTROX...... 13 BAYER CONTOUR LINK BENADRYL ITCH RELIEF...... 17 AVERTEAX...... 13 MONITOR...... 14 BENADRYL ITCH STOPPING...... 17 AVITENE...... 13 BAYER CONTOUR MONITOR...... 14 BENADRYL-D ALLERGY/SINUS AVITENE FLOUR...... 13 BAYER WOMENS...... 15 CHILD...... 17 AVO CREAM...... 13 BAZA CLEANSE & PROTECT...... 15 benazepril hcl...... 17 AVONEX...... 13 BC FAST PAIN RELIEF...... 15 benazepril-hydrochlorothiazide...... 17 AVONEX PEN...... 13 BC FAST PAIN RELIEF ARTHRITIS. 15 BENEFIBER...... 18 AVONEX PREFILLED...... 13 b-caro-t...... 15 BENEFIBER FOR CHILDREN...... 17 av-phos 250 neutral...... 13 b-complex high potency...... 15 BENEFIBER ON THE GO...... 17 axillary block needle...... 13 BD ALLERGY SYRINGE...... 15 BENEFIBER PLUS B VITS & FA...... 18 AXSAIN...... 13 BD AUTOSHIELD...... 15 BENEFIBER PLUS CALCIUM...... 18 AYR SALINE NASAL...... 13 BD AUTOSHIELD DUO...... 15 BENEFIBER PLUS HEART AYR SALINE NASAL DROPS...... 13 BD BLUNT FILTER NEEDLE...... 15 HEALTH...... 18 AYR SALINE NASAL GEL...... 13 BD DISP NEEDLE...... 15 benfotiamine multi-b...... 18 AYR SALINE NASAL NO-DRIP...... 13 BD DISP NEEDLE TW...... 15 benzalkonium chloride...... 18 AYR SALINE NASAL RINSE...... 13 BD DISP NEEDLES...... 15 BENZEDREX...... 18 azacitidine...... 13 BD ECLIPSE NEEDLE...... 15 BENZEPRO...... 18 azathioprine...... 13 BD ECLIPSE SYRINGE...... 15 BENZEPRO CREAMY WASH...... 18 azec...... 13 BD HYPODERMIC NEEDLE...... 15 BENZEPRO SHORT CONTACT...... 18 azelastine hcl...... 13 BD INSULIN SYR ULTRAFINE II...... 15 BENZODENT...... 18 azithromycin...... 13 BD INSULIN SYRINGE...... 15, 16 benzoin...... 18 AZOPT...... 13 BD INSULIN SYRINGE HALF-UNIT.15 benzonatate...... 18 AZURETTE...... 13 BD INSULIN SYRINGE BENZ-O-STHETIC...... 18 b complete...... 13 MICROFINE...... 15 benzoyl peroxide...... 18 b complex...... 13 BD INSULIN SYRINGE U/F...... 16 benzoyl peroxide cleanser...... 18 b complex formula 1...... 13 BD INSULIN SYRINGE U/F 1/2UNIT 16 benzoyl peroxide wash...... 18 b complex-folic acid...... 13 BD INSULIN SYRINGE U-500...... 16 benzoyl peroxide-erythromycin...... 18 b-1...... 13 BD INSULIN SYRINGE benzphetamine hcl...... 18 b-100 cr...... 13 ULTRAFINE...... 16 benztropine mesylate...... 18 b-12...... 14 BD LANCET ULTRAFINE 30G...... 16 BERINERT...... 18 155 BERRI-FREEZ PAIN RELIEVING...... 18 BLISOVI FE 1/20...... 20 BYDUREON...... 22 BERRI-FREEZ PLUS...... 18 blood pressure monitor/wrist...... 20 BYETTA 10 MCG PEN...... 22 BETA CARE BETATAR GEL...... 18 BOIL EASE MAXIMUM BYETTA 5 MCG PEN...... 22 beta carotene provitamin a...... 18 STRENGTH...... 20 c-1500/rose hips sr...... 22 BETADINE...... 18 BONE DENSITY...... 20 c1500/rose hips/bioflavonoid...... 22 BETADINE SURGICAL SCRUB...... 18 BOOSTRIX...... 20 cabenuva...... 22 BETADINE SWABSTICKS...... 18 borage...... 20 cabergoline...... 22 betaine hcl...... 18 boric acid...... 20 cadeau dha...... 22 betamethasone dipropionate...... 18 boron...... 20 caffeine citrate...... 22 betamethasone dipropionate aug...... 18 BOTOX...... 20 cal/mag...... 22 betamethasone valerate...... 19 BOUDREAUXS BABY KISSES...... 20 CALADRYL...... 22 BETAQUIK...... 19 BOUDREAUXS BUTT PASTE...... 20 CALADRYL CLEAR...... 22 BETASERON...... 19 BOUDREAUXS RASH PREVENTOR 20 CALAGEL MAXIMUM STRENGTH..22 betaxolol hcl...... 19 bp 10-1...... 20 CALAGESIC...... 22 bethanechol chloride...... 19 bp cleansing wash...... 20 calahist clear...... 22 BETHKIS...... 19 bp wash...... 20 calamine...... 22 BEVESPI AEROSPHERE...... 19 BPROTECTED MULTI-VITE...... 20 calamine phenolated...... 22 bexarotene...... 19 BPROTECTED PEDIA IRON...... 20 calamine-zinc oxide...... 22 BIATAIN HEEL ADH FOAM BPROTECTED PEDIA POLY-VITE....20 CAL-CARB FORTE...... 22 DRESSING...... 19 BRAINSTRONG PRENATAL...... 20 CALCET PETITES...... 22 BIATAIN SACRAL FOAM BRASIVOL...... 21 CALCI-CHEW...... 23 DRESSING...... 19 BRAUN NO TOUCH + FOREHEAD...21 calci-max...... 23 bicalutamide...... 19 BREEZE 2 TEST...... 21 calcipotriene...... 23 BICARSIM...... 19 BREVIBLOC IN NACL...... 21 calcitonin (salmon)...... 23 BICARSIM FORTE...... 19 brewers yeast...... 21 CALCITRATE...... 23 BICNU...... 19 BRILINTA...... 21 cal-citrate...... 23 BIKTARVY...... 19 brimonidine tartrate...... 21 calcitriol...... 23 biobron sf...... 19 brinzolamide...... 21 calcium...... 23 biocotron...... 19 BRIVIACT...... 21 calcium + d3...... 23 biodesp dm...... 19 brohist d...... 21 calcium 1200...... 23 BIO-FLAX...... 19 bromi-lotion...... 21 calcium 500 + d3...... 23 BIOFLONEX...... 19 bromocriptine mesylate...... 21 calcium 600...... 23 BIOFREEZE...... 19 bronchial asthma relief...... 21 calcium 600 + d...... 23 BIOGAIA GASTRUS...... 19 BRONKAID...... 21 calcium 600+d3...... 23 biogtuss...... 19 bronkids...... 21 calcium 600+d3 plus minerals...... 23 BIOGUARD NON-ADHERENT brontuss dx...... 21 calcium acetate...... 23 DRESSING...... 19 brotapp dm...... 21 calcium acetate (phos binder)...... 23 BIOLLE GEL TEARS...... 19 btrex...... 21 calcium ascorbate...... 23 bionatuss dxp...... 19 BUCKLEYS CHEST CONGESTION...21 calcium aspartate...... 23 BIOPATCH PROTECTIVE BUCKLEYS COUGH...... 21 calcium carbonate...... 23 DISK/CHG...... 19 budesonide...... 21 calcium carbonate antacid...... 23 biopetit...... 19 BUFFERIN...... 21 calcium carbonate-vitamin d...... 23 BIORX SPONIX ANTI-FUNGAL...... 19 BUFFERIN EXTRA STRENGTH...... 21 calcium citrate...... 23 BIORX SPONIX ARTHR & MUSC..... 19 BUFFERIN LOW DOSE...... 21 calcium citrate + d3...... 23 biospec dmx...... 19 BULL FROG WATER ARMOR calcium citrate malate-vit d...... 23 biotalan clear...... 19 SPORT...... 21 calcium citrate plus...... 23 BIO-THERM PAIN RELIEVING...... 19 bumetanide...... 21 calcium citrate-vitamin d...... 23 biotin...... 19, 20 BUPHENYL...... 21 calcium citrate-vitamin d3...... 23 biotin forte...... 19 buprenorphine...... 21 calcium gluconate...... 23 biotin plus keratin...... 20 buprenorphine hcl...... 21 calcium gummies...... 23 biotuss...... 20 bupropion hcl...... 22 calcium high potency/vitamin d...... 23 biovol...... 20 bupropion hcl er (smoking det)...... 21 calcium lactate...... 23 bisacodyl ec...... 20 bupropion hcl er (sr)...... 22 calcium oyster shell...... 23 bismatrol...... 20 bupropion hcl er (xl)...... 22 calcium pantothenate...... 24 bismatrol maximum strength...... 20 burn relief/lidocaine/aloe...... 22 calcium plus vitamin d3...... 24 bisoprolol fumarate...... 20 buspirone hcl...... 22 calcium soft chews...... 24 bisoprolol-hydrochlorothiazide...... 20 busulfan...... 22 calcium-magnesium-zinc...... 24 bite/itch...... 20 butalbital-acetaminophen...... 22 calcium-vitamin d...... 24 BI-ZETS/BENZOTROCHES...... 20 butalbital-apap-caff-cod...... 22 calcium-vitamin d3...... 24 bleomycin sulfate...... 20 butalbital-apap-caffeine...... 22 calcium-vitamin d-minerals...... 24 BLINK TEARS...... 20 butalbital-aspirin-caffeine...... 22 calendula...... 24 BLISOVI 24 FE...... 20 butorphanol tartrate...... 22 cal-glu...... 24 BLISOVI FE 1.5/30...... 20 BUTRANS...... 22 cal-lac...... 24 156 calmag thins...... 24 CATAPRES-TTS-3...... 26 CHERACOL-D COUGH...... 28 cal-mint...... 24 CAVAREST...... 26 cherry...... 28 CALMOL-4...... 24 CAVILON EMOLLIENT...... 26 cherry concentrate...... 28 calna...... 24 CAVILON FOOT & DRY SKIN...... 26 chest rub...... 28 CALTRATE 600+D...... 24 CAVILON NO STING BARRIER CHEW Q...... 28 CALTRATE 600+D PLUS FILM...... 26 chewable iron...... 28 MINERALS...... 24 CAVILON ONE-STEP SKIN CARE.... 26 CHIGG AWAY...... 28 CALTRATE 600+D3 SOFT...... 24 CAVILON SKIN CLEANSER...... 26 childrens aspirin free...... 28 CALTRATE GUMMY BITES...... 24 CAYA...... 26 CHILDRENS MOTRIN...... 28 CALTRATE MINIS PLUS CAZIANT...... 26 childrens pain reliever...... 28 MINERALS...... 24 cefaclor...... 26 childrens plus multi-sympt cld...... 28 CAMILA...... 24 cefadroxil...... 26 childrens silfedrine...... 28 CAMPHO-PHENIQUE...... 24 cefdinir...... 26 CHILDRENS SOOTHE...... 28 CAMPHOTREX...... 24 cefpodoxime proxetil...... 26 chlo hist...... 28 candesartan cilexetil...... 24 cefprozil...... 26 CHLO TUSS...... 28 candesartan cilexetil-hctz...... 24 ceftriaxone sodium...... 26 chlophed...... 28 CANKAID...... 24 ceftriaxone sodium in dextrose...... 26 CHLORASEPTIC...... 28 capcof...... 24 ceftriaxone sodium-dextrose...... 26 chlordiazepoxide hcl...... 28 capecitabine...... 24 cefuroxime axetil...... 26 chlorella...... 28 capmist dm...... 24 CELACYN...... 27 chlorhexidine gluconate...... 28 capron dm...... 24 celecoxib...... 27 chlorhexidine gluconate cloth...... 28 capron dmt...... 24 celery seed...... 27 chlorophyll...... 28 capsaicin...... 24 CELONTIN...... 27 chloroquine phosphate...... 28 capsaicin hot patch...... 24 CENTRATEX...... 27 chlorothiazide...... 28 CAPSIDERM...... 24 centravites adults...... 27 CHLORPHEN SR...... 28 capsule 1 clear veggie...... 24 CENTRUM...... 27 chlorpromazine hcl...... 28 captopril...... 24 CENTRUM FLAVOR BURST chlorthalidone...... 28 CAPZASIN-HP...... 25 DRINK...... 27 CHLOR-TRIMETON...... 28 CARBAGLU...... 25 CENTRUM SPECIALIST CHLOR-TRIMETON ALLERGY...... 28 carbamazepine...... 25 PRENATAL...... 27 chlorzoxazone...... 28 carbamazepine er...... 25 CEO-TWO...... 27 chocolated laxative...... 29 CARBAPHEN CH...... 25 CEPACOL EXTRA STRENGTH...... 27 cholesterol acetate...... 29 CARBAPHEN PED CH...... 25 CEPACOL SORE THROAT...... 27 cholestyramine...... 29 carbidopa-levodopa...... 25 CEPACOL SORE THROAT & cholestyramine light...... 29 carbidopa-levodopa er...... 25 COUGH...... 27 choline...... 29 carbidopa-levodopa-entacapone...... 25 CEPACOL SORE THROAT EX ST..... 27 choline citrate...... 29 carbinoxamine maleate...... 25 CEPASTAT...... 27 choline sr...... 29 CARBOHOL 940...... 25 cephalexin...... 27 choline-mag trisalicylate...... 29 CARBZERO...... 25 CERACADE...... 27 CHONDROITIN SULFATE CARDENZ...... 25 CERALYTE 70...... 27 COMPLEX...... 29 CAREFINE PEN NEEDLES...... 25 CERAVE BABY...... 27 CHROMACAPS...... 29 careone insulin syringe...... 25 CERAVE ITCH RELIEF...... 27 chromium...... 29 CAREONE LANCET SUPER THIN CERAVE SUNSCREEN SPF50...... 27 chromium aspartate...... 29 30G...... 25 CEROVEL...... 27 chromium gtf...... 29 careone lancet thin 23g...... 25 cesium...... 27 chromium picolate...... 29 CA-REZZ...... 25 CESIUM 1000...... 27 chromium picolinate...... 29 ca-rezz gentle...... 25 cesium 500...... 27 CICLODAN...... 29 ca-rezz norisc...... 25 CETACAINE...... 27 ciclopirox...... 29 CARRACOLLOID 4"X4"...... 25 CETAPHIL GENTLE CLEANSING.... 27 ciclopirox olamine...... 29 CARRASMART...... 25 cetirizine hcl...... 27 ciclopirox treatment...... 29 CARRASORB H...... 25 CETRAXAL...... 27 cilostazol...... 29 CARRASYN V WOUND DRESSING. 25 CHANTIX...... 27 cimetidine...... 29 CARRINGTON DERMAL WOUND....25 CHANTIX CONTINUING MONTH cinnamon...... 29 carteolol hcl...... 25 PAK...... 27 CINRYZE...... 29 CARTIA XT...... 26 CHANTIX STARTING MONTH PAK.27 CIPRO...... 29 carvedilol...... 26 CHAP-EX TROPICALS...... 27 CIPRODEX...... 29 cascara sagrada...... 26 CHAR-FLO WITH SORBITOL...... 27 ciprofloxacin...... 29 castellani paint modified...... 26 chelated calcium...... 27 ciprofloxacin hcl...... 29 CASTIVA COOLING...... 26 chelated magnesium...... 27 ciprofloxacin-dexamethasone...... 29 CASTIVA WARMING...... 26 chelated zinc...... 28 cisplatin...... 29 castor oil stimulant laxative...... 26 CHEMSTRIP CALIBRATION...... 28 citalopram hydrobromide...... 29 CATAPRES-TTS-1...... 26 CHEMSTRIP UGK...... 28 CITRA PH...... 29 CATAPRES-TTS-2...... 26 CHENODAL...... 28 CITRANATAL 90 DHA...... 30 157 CITRANATAL ASSURE...... 30 COARTEM...... 32 CONTOUR CONTROL...... 34 CITRANATAL B-CALM...... 30 COATS ALOE...... 32 CONTOUR MONITOR...... 34 CITRANATAL DHA...... 30 COATS ALOE JUICE DRINK...... 32 CONTOUR NEXT CONTROL...... 34 CITRANATAL HARMONY...... 30 COATS ALOE LINIMENT...... 32 CONTOUR NEXT EZ...... 34 CITRANATAL RX...... 30 cocoa butter skin...... 32 CONTOUR NEXT LINK...... 34 CITRUCEL...... 30 cod liver oil...... 32 CONTOUR NEXT MONITOR...... 34 CITRULLINE 1000...... 30 codeine sulfate...... 32 CONTOUR NEXT ONE...... 34 CITRULLINE200...... 30 coditussin ac...... 32 CONTOUR NEXT TEST...... 34 cladribine...... 30 coditussin dac...... 32 CONTOUR TEST...... 34 CLARAVIS...... 30 coenzyme q10...... 32 control denture adhesive...... 34 clarithromycin...... 30 coenzyme q-10...... 32 control syringe disposable...... 34 clarithromycin er...... 30 coenzyme q10-levocarnitine...... 32 convex eye protector...... 34 CLARITIN...... 30 co-enzyme q10-vitamin e...... 32 cool n heat ex st...... 34 CLARITIN CHILDRENS...... 30 cola syrup...... 32 cool n heat maximum strength...... 34 CLARITIN REDITABS...... 30 COLACE...... 32 COPAXONE...... 34 CLARITIN-D 12 HOUR...... 30 colchicine...... 32 COPPERMIN...... 34 CLARITIN-D 24 HOUR...... 30 colchicine-probenecid...... 32 co-q 10 omega-3 fish oil...... 34 classic prenatal...... 30 cold & cough childrens...... 32 coq10...... 34 CLEAN & CLEAR ACNE cold & cough day/night child...... 32 coq-10...... 34 CLEANSER...... 30 cold remedy...... 32 coral calcium...... 34 CLEAN & CLEAR ADVANTAGE cold sore treatment...... 32 CORICIDIN HBP COLD/FLU...... 34 MARK...... 30 cold therapy pain relief...... 32 CORICIDIN HBP COUGH/COLD...... 34 CLEAN SIGHTS...... 30 COLD-EEZE...... 32 CORICIDIN HBP DAY/NIGHT CLEAN ZING...... 30 colestipol hcl...... 32 COLD...... 34 CLEANLET LANCETS 28G...... 30 collodion flexible...... 32 CORICIDIN HBP NIGHTTIME CLEAR EYES REDNESS RELIEF...... 30 COLOCORT...... 32 COLD...... 34 clear zinc spf 50...... 30 COMBIGAN...... 32 CORIFACT...... 34 CLEARASIL DAILY CLEAN...... 30 COMBIVENT RESPIMAT...... 32 corn oil...... 34 CLEARASIL DAILY CLEAR ACNE...30 COMFORT ASSIST INSULIN CORN REMOVER WATERPROOF.... 34 CLEARCANAL EAR WAX SYRINGE...... 33 corn/callus remover...... 34 REMOVAL...... 30 comfort assured lancets 28g...... 33 CORRECTOL EXTRA GENTLE...... 35 CLEARLAX...... 31 comfort assured lancets 33g...... 33 CORTIC-ND...... 35 CLEARLIFE ALLERGY RELIEF...... 31 COMFORT CLEAN/COMFORT CORTIFOAM...... 35 clemastine fumarate...... 31 SHIELD...... 33 cortisone acetate...... 35 CLEOCIN...... 31 COMFORT EZ PEN NEEDLES...... 33 CORTIZONE-10/ALOE...... 35 CLERZ PLUS...... 31 COMPAT STAY-PUT NJ DOUBLE CORVITA 150...... 35 CLEVER CHOICE BP LUME...... 33 COSAMIN ASU FOR JOINT MONITOR/WRIST...... 31 COMPLERA...... 33 HEALTH...... 35 clindamycin hcl...... 31 complete lice treatment...... 33 COSAMIN VERDE FOR JOINT clindamycin palmitate hcl...... 31 complete natal dha...... 33 HEALTH...... 35 clindamycin phos-benzoyl perox...... 31 completenate...... 33 COTTONTAILS DIAPER RASH clindamycin phosphate...... 31 COMPOUND W MAXIMUM CREAMY...... 35 CLINDESSE...... 31 STRENGTH...... 33 cough & chest congestion dm...... 35 clobazam...... 31 COMPOUND W ONE STEP cough & cold...... 35 clobetasol propionate...... 31 INVISIBLE...... 33 cough drops...... 35 clobetasol propionate e...... 31 compoz...... 33 cough relief...... 35 clobetasol propionate emulsion...... 31 COMPRO...... 33 coughtab...... 35 clofarabine...... 31 COMTREX COLD & COUGH MAX cramp tabs...... 35 clomipramine hcl...... 31 ST...... 33 cranberry...... 35 clonazepam...... 31 COMTREX COLD/COUGH cream base with liposome...... 35 clonidine hcl...... 31 DAY/NITE MS...... 33 creatine...... 35 clonidine hcl (analgesia)...... 31 COMTREX DEEP CHEST COLD...... 33 creatine5000...... 35 clonidine hcl er...... 31 CO-NATAL FA...... 33 CREON...... 35 clopidogrel bisulfate...... 31 CONCEPT DHA...... 33 CR-GTF...... 35 clorazepate dipotassium...... 31 CONCEPT OB...... 33 CRITIC-AID CLEAR AF...... 35 clotrimazole...... 31 CONCEPTIONXR MOTILITY CRIXIVAN...... 35 clotrimazole 3...... 31 SUPPORT...... 33 cromolyn sodium...... 35 clotrimazole anti-fungal...... 31 CONCERTA...... 33 CROTAN...... 35 clotrimazole-betamethasone...... 31 condoms...... 33 CR-PLUS...... 35 clozapine...... 32 constulose...... 33 CRYSELLE-28...... 35 co q-10...... 32 CONTAC COLD+FLU MAX ST...... 34 cu-25...... 35 COAGUCHEK XS PLUS SYSTEM..... 32 CONTOUR BLOOD GLUCOSE cu-5...... 35 COAGUCHEK XS PT TEST...... 32 SYSTEM...... 34 CULTURELLE GENTLE-GO KIDS.... 35 158 CULTURELLE KIDS...... 35 cvs hand wash advanced antibac...... 37 cvs triple magnesium complex...... 38 CURAD GERM SHIELD...... 35 cvs heartburn relief ex st...... 37 cvs ultra thin lancets...... 39 CURAFIL WOUND DRESSING...... 35 cvs heatwraps/back/hip...... 37 cvs vaporizer warm steam...... 39 CURASOL WOUND DRESSING...... 35 cvs hemorrhoidal...... 37 cvs wound wash advanced...... 39 CURITY ALCOHOL PREPS...... 35 cvs hot steam...... 37 cvs yogurt+calcium gummies...... 39 CURITY ALCOHOL SWABS...... 35 cvs hydrocolloid pads...... 37 cvs zinc oxide diaper...... 39 CURITY GAUZE SPONGE...... 36 cvs inner ear plus...... 37 cyanocobalamin...... 39 CURITY MESH GAUZE BNDG cvs instant food thickener...... 37 cyclobenzaprine hcl...... 39 4"X30'...... 36 cvs iron...... 37 CYCLOMYDRIL...... 39 CURITY NURSING...... 36 cvs isopropyl alcohol wipes...... 37 cyclopentolate hcl...... 39 CURX ANTIMICROBIAL...... 36 cvs itch relief...... 37 cyclophosphamide...... 39 CUTINOVA HYDRO 2"X2-3/8"...... 36 cvs lancets 21g...... 37 cyclosporine...... 39 cvs acetaminophen...... 36 cvs lancets micro thin 33g...... 37 cyclosporine modified...... 39 cvs adhesive gauze...... 36 cvs lancets original...... 37 cyproheptadine hcl...... 39 cvs aftersun aloe/lidocaine...... 36 cvs lancets thin 26g...... 37 CYSTADANE...... 39 CVS AIRSHIELD...... 36 cvs lancets ultra thin 30g...... 37 CYSTAGON...... 39 cvs alcohol prep pads...... 36 cvs lancets ultra-thin 30g...... 37 CYSTECH...... 39 cvs allergy relief...... 36 cvs laxative dietary supplemnt...... 37 cystine...... 39 cvs allergy relief childrens...... 36 CVS LICE SOLUTION 3-STEP...... 37 cytarabine (pf)...... 39 cvs allergy relief d...... 36 cvs l-lysine...... 37 CYTO-Q MAX...... 39 cvs all-purpose skin protect...... 36 cvs lubricant drops...... 37 cytra k crystals...... 39 cvs antacid childrens...... 36 cvs magnesium citrate...... 37 d 1000...... 39 cvs anti-diarrheal...... 36 cvs manuka honey wound...... 37 d 2000...... 39 cvs anti-itch sensitive...... 36 cvs melatonin...... 37 dacarbazine...... 39 cvs astringent solution...... 36 cvs melatonin extra strength...... 37 daily care skin protectant...... 39 cvs b complex plus c...... 36 cvs miconazole 1 combo pack...... 37 daily ovulation predictor...... 39 cvs baby safety swabs...... 36 cvs miconazole 3 combo pack...... 38 daily vite multivitamin/iron...... 39 cvs backache relief...... 36 cvs mineral oil...... 38 dairy relief...... 39 cvs beta carotene...... 36 cvs mineral oil enema...... 38 dakins...... 39 cvs calcium...... 36 cvs mini enema kids...... 38 dakins (1/2 strength)...... 39 cvs calcium 600 plus...... 36 cvs multi-purpose...... 38 dakins (1/4 strength)...... 39 cvs cherry menthol drops...... 36 cvs nasal allergy spray...... 38 DAKRINA...... 39 cvs chest rub medicated...... 36 cvs nasal decongestant...... 38 danazol...... 39 cvs cleansing eyelid wipes...... 36 cvs nasal mist...... 38 dandruff shampoo...... 39 cvs cleansing skin...... 36 cvs natural fiber supplement...... 38 dantrolene sodium...... 39 cvs cold & sinus relief...... 36 cvs natural fish oil...... 38 dapsone...... 39 cvs cold remedy...... 36 cvs nerve pain relief...... 38 daunorubicin hcl...... 39 cvs corn/callus remover...... 36 cvs non-drying sinus pe...... 38 day time multi-sympt cold/flu...... 39 cvs creamy acne face wash...... 36 cvs omeprazole...... 38 DAYTIME COLD MEDICINE...... 40 cvs d3...... 36 cvs oral pain reliever...... 38 daytime cough...... 40 cvs dairy relief ex st...... 36 cvs pain relief...... 38 daytime severe cold & flu...... 40 cvs daytime/nighttime cold/flu...... 36 cvs phosphate saline laxative...... 38 DAYTRANA...... 40 cvs daytime/nighttime cough...... 36 cvs potassium gluconate...... 38 DDROPS...... 40 cvs diabetes health support...... 36 cvs prenatal...... 38 DEBACTEROL...... 40 cvs digestive probiotic...... 36 cvs prenatal gummy...... 38 DECARA...... 40 cvs diuretic maximum strength...... 36 cvs prep...... 38 decitabine...... 40 cvs e oil...... 36 cvs protective...... 38 DECONEX DMX...... 40 cvs early result pregnancy...... 36 cvs saline wound wash...... 38 DECONEX IR...... 40 cvs easy fiber/calcium...... 37 cvs selenium...... 38 deferasirox...... 40 cvs enema disposable...... 37 cvs silver...... 38 del clens...... 40 cvs ethyl alcohol...... 37 cvs sinus relief day/night...... 38 DELBASE COMPOUNDING...... 40 cvs eye...... 37 cvs skin relief...... 38 DELSYM COUGH CHILDRENS...... 40 cvs fiber gummies...... 37 cvs sore muscle rub...... 38 DELTUSS DP...... 40 cvs gas relief...... 37 cvs sore throat max strength...... 38 DELZICOL...... 40 cvs gas relief extra strength...... 37 cvs sore throat relief pops...... 38 demeclocycline hcl...... 40 cvs gauze sterile...... 37 cvs steam inhaler...... 38 DEMEROL...... 40 cvs gluco-chondroit plus uc-ii...... 37 cvs stool softener...... 38 DEMSER...... 40 cvs glucosamine-chondroitin...... 37 cvs stuffy nose & cold child...... 38 DENDRACIN cvs glucosamine-chondroit-msm...... 37 cvs super cranberry urinary...... 38 NEURODENDRAXCIN...... 40 cvs glucose bits...... 37 cvs tension headache...... 38 DENTAPAINE...... 40 cvs glucose shot...... 37 cvs therapeutic...... 38 DEPACON...... 40 cvs glycerin adult...... 37 cvs therapeutic dandruff...... 38 DEPO-PROVERA...... 40 cvs hair regrowth for women...... 37 cvs triacting cough/runny nose...... 38 DEQUASINE...... 40 159 DERMA CIDOL 2000...... 40 diethylpropion hcl er...... 42 DRIXORAL COUGH/SORE dermacloud...... 40 DIFFERIN...... 42 THROAT...... 45 DERMAGESIC...... 40 diflunisal...... 42 dronabinol...... 45 DERMAGRAN...... 40 digestive enzyme ultra...... 42 DROPLET LANCETS ULTRA THIN DERMAL THERAPY FINGER CARE.40 DIGITEK...... 42 30G...... 45 DERMAL WOUND CLEANSER...... 40 digoxin...... 42 drospirenone-ethinyl estradiol...... 45 DERMAMED...... 40 DILANTIN...... 42 DROXIA...... 45 DERMAPLEX...... 40 DILAUDID...... 42 drug mart lancets thin 26g...... 45 DERMAREST PSORIASIS...... 40 diltiazem hcl...... 43 DRUG MART UNILET LANCETS DERMASTAT...... 40 diltiazem hcl er...... 43 28G...... 45 DERMASYN...... 40 diltiazem hcl er beads...... 43 DRUG MART UNILET LANCETS DERMAZENE...... 41 diltiazem hcl er coated beads...... 43 30G...... 45 DERMOPLAST...... 41 dilt-xr...... 43 dry skin treatment adv therapy...... 45 DESCOVY...... 41 dimenhydrinate...... 43 drymax extra...... 45 DESENEX FOOT/SNEAKER SPRAY.41 DIMETAPP COLD/ALLERGY...... 43 DRYSOL...... 45 DESGEN DM...... 41 DIMETAPP DM COLD/COUGH...... 43 DULCOLAX...... 45 desipramine hcl...... 41 DIMETAPP LONG ACT DULCOLAX MILK OF MAGNESIA...45 DESITIN MAXIMUM STRENGTH.....41 COUGH/COLD...... 43 DULERA...... 45 desmopressin ace spray refrig...... 41 dimethyl fumarate...... 43 duloxetine hcl...... 45 desmopressin acetate...... 41 dimethyl fumarate starter pack...... 43 DUOFILM...... 45 desmopressin acetate spray...... 41 diphenhydramine hcl...... 43 DURAFLEX COMFORT...... 45 desonide...... 41 diphenhydramine hcl (sleep)...... 43 DURAFLU...... 45 despec dm-g...... 41 diphenoxylate-atropine...... 43 DURAPROXIN...... 45 desvenlafaxine succinate er...... 41 diphtheria-tetanus toxoids dt...... 43 DURAPROXIN ES...... 45 DEVROM...... 41 dipyridamole...... 43 DURASAFE SPINAL/EPIDURAL...... 45 DEWEES CARMINATIVE...... 41 disulfiram...... 43 DURATION SPRAY...... 45 dexamethasone...... 41 divalproex sodium...... 43 DURAVENT DM...... 45 DEXAMETHASONE INTENSOL...... 41 divalproex sodium er...... 43 DURAVENT PE...... 45 dexamethasone sodium phosphate...... 41 dl-pa-500...... 43 DUREZOL...... 45 dexrazoxane...... 41 DML...... 43 dutasteride...... 45 dextroamphetamine sulfate...... 41 DOANS PILLS...... 43 dutasteride-tamsulosin hcl...... 45 dhea...... 41 DOANS PM EXTRA STRENGTH...... 43 D-VI-SOL...... 45 DHS ZINC...... 41 DOC OMEGA...... 43 d-xylose...... 45 DIAB DAILY CARE...... 41 docetaxel...... 43, 44 DY-O-DERM VITILIGO STAIN...... 45 DIABETIC BASICS HEALTHY docosanol...... 44 E.E.S. GRANULES...... 45 FOOT...... 41 docusate sodium...... 44 ear wax cleansing...... 45 DIABETIC TUSSIN ALLERGY...... 41 DOCUSOL KIDS...... 44 EASIVENT...... 45 DIABETIC TUSSIN COLD/FLU...... 41 DOCUSOL PLUS MINI-ENEMA...... 44 EASIVENT MASK LARGE...... 45 DIABETIC TUSSIN NIGHT dofetilide...... 44 EASIVENT MASK MEDIUM...... 46 COLD/FLU...... 41 DOLOGEN...... 44 EASIVENT MASK SMALL...... 46 diabet-x daily prevention...... 41 dologesic-df...... 44 easy fiber...... 46 DIADERM FOOT REJUVENATING...42 dolorex...... 44 EASY TOUCH ALCOHOL PREP DIALYVITE...... 42 DOMEBORO...... 44 MEDIUM...... 46 DIALYVITE 800...... 42 dometuss-da/children...... 44 EASY TOUCH ALLERGY SYRINGE.46 DIALYVITE 800 PLUS D...... 42 donepezil hcl...... 44 EASY TOUCH FLIPLOCK INSULIN DIALYVITE 800/IRON...... 42 dorzolamide hcl...... 44 SY...... 46 DIALYVITE/ZINC...... 42 dorzolamide hcl-timolol mal...... 44 EASY TOUCH FLURINGE...... 46 diaper rash...... 42 DOUBLE-TUSSIN DM...... 44 EASY TOUCH INSULIN SAFETY DIASTIX...... 42 DOVATO...... 44 SYR...... 46 diazepam...... 42 DOVER IRRIGATION TRAY...... 44 EASY TOUCH INSULIN SYRINGE DIAZEPAM INTENSOL...... 42 doxazosin mesylate...... 44 ...... 46, 47 diazoxide...... 42 doxepin hcl...... 44 EASY TOUCH LANCETS 26G...... 47 dibucaine...... 42 doxorubicin hcl...... 44 EASY TOUCH LANCETS 28G...... 47 diclofenac potassium...... 42 doxycycline hyclate...... 44 EASY TOUCH LANCETS diclofenac sodium...... 42 doxycycline monohydrate...... 44 28G/TWIST...... 47 diclofenac sodium er...... 42 DR BOLDTS HINEY HEALER...... 44 EASY TOUCH LANCETS 30G...... 47 dicloxacillin sodium...... 42 DR SMITHS DIAPER...... 44 EASY TOUCH LANCETS dicyclomine hcl...... 42 DR SMITHS DIAPER RASH...... 44 30G/TWIST...... 47 DI-DAK-SOL...... 42 DR SMITHS RASH + SKIN...... 44 EASY TOUCH LANCETS 32G...... 47 didanosine...... 42 DRAMAMINE...... 44 EASY TOUCH LANCETS dieters super tea...... 42 DRITHO-CREME HP...... 44 32G/TWIST...... 47 dietex forte...... 42 DRIXORAL COLD/ALLERGY...... 45 EASY TOUCH LANCETS diethylpropion hcl...... 42 33G/TWIST...... 47 160 EASY TOUCH SHEATHLOCK ENPRESSE-28...... 49 eql eye drops ac...... 51 SYRINGE...... 47 entecavir...... 49 eql fiber therapy...... 51 EASY TWIST & CAP LANCETS...... 47 ENTEX T...... 49 eql gas prevention...... 51 EASYGEL...... 47 ENTRESTO...... 49 eql gentle skin cleanser...... 51 ecee plus...... 47 ENTSOL NASAL...... 49 eql insulin syringe...... 51 econazole nitrate...... 47 enulose...... 49 eql lutein...... 51 ECOTRIN...... 47 e-oil...... 49 eql mouthwash/gargle...... 51 ECOTRIN MAXIMUM STRENGTH... 47 epa/gla...... 49 eql mucus-dm...... 51 e-cream complex...... 47 EPANED...... 49 eql multi-purpose...... 51 ED A-HIST...... 47 ephedrine hcl...... 49 eql omega 3 fish oil...... 51 ed a-hist dm...... 47 EPIDIOLEX...... 49 eql omeprazole...... 51 ed bron gp...... 47 epidural needle...... 49 eql one daily womens...... 51 ED CHLORPED...... 47 epinastine hcl...... 49 eql redness relief...... 51 ED CHLORPED D...... 47 epinephrine...... 49, 50 eql scalp relief max strength...... 51 ed-spaz...... 47 epinephrine pf...... 49, 50 eql super thin lancets 30g...... 51 EDURANT...... 47 EPIPEN 2-PAK...... 50 eql thin lancets 26g...... 51 efavirenz...... 47 EPIPEN JR 2-PAK...... 50 eql ultra protection spf50...... 51 efavirenz-emtricitab-tenofovir...... 47 epirubicin hcl...... 50 eql vitamin d3...... 51 EFFER-K...... 47 EPISORB...... 50 eql wet cleansing towelettes...... 52 effervescent pain relief...... 47 EPITOL...... 50 eql zinc cold relief...... 52 effervescent pot chloride...... 47 EPIVIR HBV...... 50 EQUALACTIN...... 52 EGRIFTA...... 47 eplerenone...... 50 ERBITUX...... 52 ELDERTONIC...... 47 EPOGEN...... 50 ergocalciferol...... 52 eletriptan hydrobromide...... 47 eprosartan mesylate...... 50 ergoloid mesylates...... 52 ELIDEL...... 48 epsom salt...... 50 ery...... 52 ELIGARD...... 48 eq allergy relief...... 50 erythromycin...... 52 ELIQUIS...... 48 eq allergy relief childrens...... 50 erythromycin base...... 52 elite ca/mg...... 48 eq allergy/sinus headache...... 50 erythromycin ethylsuccinate...... 52 elite calcium...... 48 eq aspirin...... 50 escavite lq...... 52 ELITE ZINC...... 48 EQ BABY CHEST RUB...... 50 escitalopram oxalate...... 52 ELITEK...... 48 eq calcium citrate+d3 petites...... 50 esmolol hcl...... 52 ELITE-OB...... 48 eq cough sugar free...... 50 esomeprazole magnesium...... 52 elite-thin insulin syringe...... 48 eq cryogenic wart removal sys...... 50 ESOTERICA FADE NIGHTTIME...... 52 ELIXOPHYLLIN...... 48 eq daily fiber...... 50 ESOTERICA SENSITIVE SKIN...... 52 ELIXSURE COUGH...... 48 eq dairy digestive fast acting...... 50 ESTARYLLA...... 52 ELIXSURE FEVER/PAIN...... 48 eq feminine wash sensitive...... 50 estazolam...... 52 ELLA...... 48 eq ibuprofen pm...... 50 estradiol...... 52 ELLURA...... 48 EQ MUCUS ER...... 50 estradiol valerate...... 52 ELMIRON...... 48 eq multi-symptom cold children...... 50 estradiol-norethindrone acet...... 52 ELTA DERMAL...... 48 eq omeprazole...... 50 estropipate...... 52 ELURYNG...... 48 eq pain relief/rapid burst...... 50 eszopiclone...... 52 EMCYT...... 48 eq sinus relief max st...... 50 ethambutol hcl...... 52 EMETROL...... 48 eq tioconazole 1...... 50 ethosuximide...... 52 EMGALITY...... 48 eql 2 in 1 probiotic...... 50 ethyl alcohol...... 52 EMJOI TENS...... 48 eql advanced relief...... 50 ethyl alcohol (rubbing)...... 52 empty capsule size 1 clear...... 48 eql alcohol swabs...... 50 ethyl chloride...... 52 emtricitabine...... 48 eql aller-ease...... 50 etidronate disodium...... 53 emtricitabine-tenofovir df...... 48 eql allergy...... 51 etodolac...... 53 EMTRIVA...... 49 eql aloe vera after sun...... 51 etodolac er...... 53 EMULSION SB...... 49 eql antacid ultra strength...... 51 ETOPOPHOS...... 53 enalapril maleate...... 49 eql antibacterial hand soap...... 51 etoposide...... 53 enalapril-hydrochlorothiazide...... 49 eql anti-nausea...... 51 etravirine...... 53 ENBREL...... 49 eql biotin...... 51 eucalyptus oil...... 53 ENBREL MINI...... 49 eql color lancets 21g...... 51 EUCERIN...... 53 ENBREL SURECLICK...... 49 eql color lancets micro 33g...... 51 EUCERIN ECZEMA RELIEF...... 53 ENDOXCIN...... 49 eql congestion relief...... 51 EUCERIN ORIGINAL HEALING...... 53 ENDUR-ACIN...... 49 eql denture brush/pick...... 51 EUFLEXXA...... 53 ENEMEEZ MINI...... 49 eql denture cleanser...... 51 EURAX...... 53 ENFAMIL ENFALYTE...... 49 eql digestive enzymes...... 51 EVAC-U-GEN...... 53 ENFAMIL EXPECTA...... 49 eql ear drops...... 51 evening primrose oil...... 53 ENGERIX-B...... 49 eql effervescent cold relief...... 51 everolimus...... 53 ENLITE GLUCOSE SENSOR...... 49 eql ethyl alcohol (rubbing)...... 51 EXACTECH R-S-G TEST...... 53 enoxaparin sodium...... 49 eql everyday clean...... 51 EXACTECH TEST...... 53 161 EXACTUSS TR...... 53 fentanyl citrate (pf)...... 55 FLUCELVAX QUADRIVALENT...... 57 EXAPHEN...... 53 FER-IN-SOL...... 55 fluconazole...... 57 EXAPHEN CH...... 53 ferocon...... 55 fludarabine phosphate...... 57 EXAPHEX TR...... 53 ferraplus 90...... 55 fludrocortisone acetate...... 57 EXCEDRIN PM...... 53 ferretts...... 55 flunisolide...... 57 EXCEDRIN TENSION HEADACHE...53 ferretts chewable iron...... 55 fluocinolone acetonide...... 57 EXCEL AP...... 53 ferretts ips...... 55 fluocinolone acetonide body...... 57 EXCEL-GEL...... 53 FERREX 150...... 55 fluocinolone acetonide scalp...... 57 EXEL COMFORT POINT INSULIN FERREX 150 FORTE PLUS...... 55 fluocinonide...... 57 SYR...... 53 FERREX 28...... 55 fluoride mouth rinse...... 57 EXELON...... 54 FERRIMIN 150...... 55 fluorometholone...... 57 exemestane...... 54 FERROCITE...... 55 fluorouracil...... 57 EXFOLIX EXFOLIATING FOOT FERROCITE PLUS...... 55 fluoxetine hcl...... 57 SOAP...... 54 ferrous gluconate...... 55 fluphenazine decanoate...... 57 EX-LAX...... 54 ferrous sulfate...... 55 fluphenazine hcl...... 57, 58 EX-LAX MAXIMUM STRENGTH...... 54 ferrous sulfate er...... 55 flurazepam hcl...... 58 exoten-c pain relief...... 54 FEVERALL INFANTS...... 55 flurbiprofen...... 58 exotic-hc...... 54 FEVERALL JUNIOR STRENGTH...... 56 flurbiprofen sodium...... 58 EXTRESS-30...... 54 fiber...... 56 flutamide...... 58 eye allergy relief...... 54 fiber laxative...... 56 fluticasone propionate...... 58 eye drops...... 54 FIBERCON...... 56 FLUVIRIN...... 58 eye itch relief...... 54 FIBEREX F15...... 56 fluvoxamine maleate...... 58 EYE STREAM...... 54 FIFTY50 ALCOHOL PREP...... 56 FLUZONE HIGH-DOSE...... 58 E-Z JECT LANCET MICRO-THIN FIFTY50 SUPERIOR COMFORT FLUZONE QUADRIVALENT...... 58 33G...... 54 SYR...... 56 FOCALIN...... 58 E-Z JECT LANCET SUPER THIN filter needle...... 56 FOCALIN XR...... 58 30G...... 54 finasteride...... 56 FOILLE...... 58 E-Z JECT LANCETS...... 54 FINE 30...... 56 FOLET DHA...... 58 E-Z JECT LANCETS 21G...... 54 first aid antibiotic...... 56 FOLGARD...... 58 E-Z JECT LANCETS THIN 26G...... 54 first aid antiseptic...... 56 FOLGARD OS...... 58 EZ SMART BLOOD GLUCOSE first aid antiseptic spray...... 56 FOLIC + B12...... 58 LANCETS...... 54 FIRVANQ...... 56 folic acid...... 58 ezetimibe...... 54 fish oil...... 56 folinic-plus...... 58 ezetimibe-simvastatin...... 54 fish oil + d3...... 56 FOLITAB 500...... 58 EZFE 200...... 54 fish oil adult gummies...... 56 FOLIVANE-F...... 58 E-Z-GAS II...... 54 fish oil-flax oil-borage oil...... 56 FOLIVANE-PLUS...... 58 EZ-LETS LANCETS 21G...... 54 flavoxate hcl...... 56 FOLOTYN...... 58 EZ-LETS LANCETS 23G...... 54 flecainide acetate...... 56 FORA D40 GLUCOSE/PRESSURE..... 58 EZ-LETS LANCETS 28G...... 54 FLEET BISACODYL...... 56 FORA LANCETS...... 58 fabb...... 54 FLEET LIQUID GLYCERIN SUPP..... 56 FORADIL AEROLIZER...... 58 famciclovir...... 54 FLEET NATURALS CLEANSING FORMADON...... 58 famotidine...... 54 ENEMA...... 56 formaldehyde...... 58 FARESTON...... 54 FLEET OIL...... 56 FORMA-RAY...... 58 FARXIGA...... 54 FLEET PEDIATRIC...... 56 formoterol fumarate...... 58 FAST FREEZE PRO STYLE FLEXBUMIN...... 56 FORTEO...... 58 THERAPY...... 54 FLEXICHAMBER...... 56 fosamprenavir calcium...... 58 fast-heat heating pad...... 54 FLEXICHAMBER CHILD fosfomycin tromethamine...... 59 father johns medicine...... 54 MASK/LARGE...... 56 fosinopril sodium...... 59 fa-vitamin b-6-vitamin b-12...... 54 FLINTSTONES TODDLER...... 56 fosinopril sodium-hctz...... 59 FAYOSIM...... 54 FLOGEN...... 56 fosphenytoin sodium...... 59 FC FEMALE CONDOM...... 55 FLONASE ALLERGY RELIEF...... 56 freds pharmacy unilet lanc 28g...... 59 febuxostat...... 55 FLONASE SENSIMIST...... 56 FREE & CLEAR...... 59 FEIBA...... 55 FLORA ASSIST...... 56 FREESTYLE CONTROL SOLUTION.59 felbamate...... 55 FLORANEX...... 57 FREESTYLE FLASH SYSTEM...... 59 felodipine er...... 55 FLORASTOR...... 57 FREESTYLE FREEDOM...... 59 FEM PH...... 55 FLORASTOR KIDS...... 57 FREESTYLE FREEDOM LITE...... 59 FEMINEASE...... 55 FLORICAL...... 57 FREESTYLE INSULINX SYSTEM..... 59 fenofibrate...... 55 FLOVENT DISKUS...... 57 FREESTYLE INSULINX TEST...... 59 fenofibrate micronized...... 55 FLOVENT HFA...... 57 FREESTYLE LANCETS...... 59 fenofibric acid...... 55 flow-eze vented needle...... 57 FREESTYLE LIBRE 14 DAY fenoprofen calcium...... 55 floxuridine...... 57 READER...... 59 fentanyl...... 55 flu hbp...... 57 FREESTYLE LIBRE 14 DAY fentanyl citrate...... 55 FLUCAINE...... 57 SENSOR...... 59 162 FREESTYLE LIBRE 2 READER GENTEAL MILD...... 61 glycopyrrolate...... 64 SYSTM...... 59 GENTEAL MILD TO MODERATE.....61 GLYDO...... 64 FREESTYLE LIBRE 2 SENSOR GENTEAL TEARS PF...... 61 GLYXAMBI...... 64 SYSTM...... 59 gentian violet...... 61 g-myco nail...... 64 FREESTYLE LIBRE READER...... 59 gentle laxative...... 61 gnp 24 hour nasal allergy...... 64 FREESTYLE LIBRE SENSOR GENTLE RAIN...... 61 gnp 4x probiotic...... 64 SYSTEM...... 59 gentle skin cleanser...... 62 gnp advanced eye health...... 64 FREESTYLE LITE TEST...... 59 GENTLE-LET GP LANCETS...... 62 gnp alcohol denatured...... 64 FREESTYLE PRECISION INS SYR....59 GENTLE-LET LANCETS...... 62 gnp alcohol swabs...... 64 FREESTYLE PRECISION NEO GENVOYA...... 62 gnp allergy & sinus headache...... 64 SYSTEM...... 59 geravine...... 62 gnp animal shapes plus iron...... 64 FREESTYLE PRECISION NEO TEST 59 geriatric vitamin...... 62 gnp b-50 complex...... 64 FREESTYLE SIDEKICK II...... 59 gerisilk bath oil...... 62 gnp b-complex plus vitamin c...... 64 FREESTYLE SYSTEM...... 59 GERMBLOC HEALTH...... 62 gnp calamine...... 64 FREESTYLE TEST...... 59 GILTUSS COUGH & COLD...... 62 gnp calcium 600 plus d/mineral...... 64 fruit c...... 59 ginger root...... 62 gnp calcium plus 600 +d...... 64 fulvestrant...... 59 ginseng...... 62 gnp capsaicin...... 64 FUNGI-NAIL...... 59 gla-45...... 62 gnp childrens chewables/ex c...... 64 FUNGI-NAIL TOE & FOOT...... 59 glass syringe 3 ml...... 62 gnp coq-10 & fish oil...... 64 FUNGOID TINCTURE...... 59 glatiramer acetate...... 62 gnp ethyl alcohol...... 64 FUNGOID-D...... 59 glen pe...... 62 gnp fish oil...... 64 furosemide...... 60 glenmax peb...... 62 gnp gentian violet...... 64 FUSION...... 60 glenmax peb dm...... 62 gnp glycerin/rose water...... 64 FUZEON...... 60 glenmax peb dm forte...... 62 gnp headache relief extra str...... 64 FYAVOLV...... 60 glentuss...... 62 gnp insulin syringe...... 64 gabapentin...... 60 g-levocarnitine s/f...... 62 gnp iodides...... 64 GABITRIL...... 60 glimepiride...... 62 gnp iodine...... 64 galantamine hydrobromide...... 60 glipizide...... 62 gnp isopropyl alcohol wipes...... 64 galantamine hydrobromide er...... 60 glipizide er...... 62 gnp lancets...... 64 GARDASIL 9...... 60 glipizide xl...... 62 gnp lancets 21g...... 64 garlic/epa...... 60 glipizide-metformin hcl...... 62 gnp lancets micro thin 33g...... 64 garlic-lecithin...... 60 global inject ease insulin syr...... 62 gnp lancets super thin 30g...... 64 garlic-parsley...... 60 global insulin syringes...... 62 gnp lancets thin 26g...... 64 gas relief...... 60 GLUCAGEN HYPOKIT...... 62 gnp lice egg remover...... 65 GASTROCROM...... 60 glucagon emergency...... 62 gnp liquid bandage...... 65 GAS-X...... 60 GLUCOCOM AUTOLINK gnp l-lysine...... 65 GAS-X CHILDRENS...... 60 TELEMONITOR...... 62 gnp micro thin lancets 33g...... 65 GAS-X EXTRA STRENGTH...... 60 GLUCOCOM LANCETS 28G...... 62 gnp niacin...... 65 GAS-X PREVENTION...... 60 GLUCOCOM LANCETS 30G...... 62 gnp omeprazole...... 65 GAS-X WITH MAALOX EX ST...... 60 GLUCOCOM LANCETS 33G...... 62 gnp pain relief/benzocaine...... 65 GAVILYTE-C...... 60 GLUCOPRO INSULIN SYRINGE. 62, 63 gnp potassium...... 65 GAVILYTE-G...... 60 glucosamine chond complex/msm...... 63 gnp shampoo & body wash...... 65 GAVILYTE-N WITH FLAVOR glucosamine chondroitin complx...... 63 gnp sinus wash refill...... 65 PACK...... 60 glucosamine complex/vitamin d3...... 63 gnp super thin lancets 30g...... 65 GAVISCON...... 60 glucosamine hcl...... 63 gnp terbinafine hydrochloride...... 65 GAVISCON EXTRA STRENGTH...... 60 glucosamine sulfate...... 63 gnp ultra com insulin syringe...... 65 G-BUCAL-C...... 60 glucosamine-chondroitin...... 63 gnp urinary pain relief...... 65 G-DOLOGEN...... 60 glucosamine-chondroitin-msm...... 63 gnp vitamin d super strength...... 65 ge-150...... 60 glucosamine-chondroitin-vit d3...... 63 gnp vitamin d-400...... 65 GEBAUERS INSTANT ICE...... 60 glucosamine-msm...... 63 GOLD BOND MULTI-SYMPTOM...... 65 gelatin...... 61 glucose...... 63 GOLD BOND RAPID RELIEF...... 65 GELFOAM SPONGE...... 61 GLUCOSE NURSETTE...... 63 GOLD BOND ULTIMATE...... 65 GELFOAM SPONGE SIZE 100...... 61 glutamine...... 63 GONIOSOL...... 65 GEL-KAM...... 61 glutathione...... 63 GONIOTAIRE...... 65 GELONASAL...... 61 glutol...... 63 GONIOVISC...... 65 GELUSIL...... 61 glyburide...... 63 GOOD START 5% GLUCOSE gemcitabine hcl...... 61 glyburide micronized...... 63 WATER...... 65 gemfibrozil...... 61 glyburide-metformin...... 63 goodsense all day allergy...... 65 GENCONTUSS...... 61 glycerin...... 63 goodsense cough dm...... 66 GENOTROPIN...... 61 glycerin (adult)...... 63 goodsense eye drops...... 66 GENOTROPIN MINIQUICK...... 61 glycerin (infants & children)...... 63 goodsense flu/cold/cough/night...... 66 gentamicin sulfate...... 61 glycine500...... 63 goodsense flu/cold/daytime...... 66 GENTEAL...... 61 glycolic acid...... 63 goodsense ibuprofen...... 66 163 goodsense ibuprofen childrens...... 66 heparin sodium (porcine)...... 67 HURRICAINE ONE...... 70 goodsense ibuprofen infants...... 66 heparin sodium (porcine) pf...... 67 HURRIVIEW...... 70 goodsense lancets 30g...... 66 HERCEPTIN...... 67 HURRIVIEW II...... 70 goodsense lancets 33g...... 66 hetastarch-nacl...... 67 HYALGAN...... 70 goodsense lubricant eye drops...... 66 HETLIOZ LQ...... 67 HYCAMTIN...... 70 goodsense miconazole 1...... 66 HEXALEN...... 68 hydralazine hcl...... 70 goodsense nicotine...... 66 HIBICLENS...... 68 HYDROCELL ADHESIVE goodsense nighttime cold & flu...... 66 high potency iron...... 68 DRESSING...... 70 goodsense redness relief plus...... 66 histaflex...... 68 hydrocerin...... 70 goodsense sinus congest/pain...... 66 HISTEX...... 68 hydrochlorothiazide...... 70 goodsense sleeptime...... 66 HISTEX PD...... 68 hydrocod polst-cpm polst er...... 70 goodsense sore throat spray...... 66 HISTEX PDX...... 68 hydrocodone-acetaminophen...... 70 gordomatic...... 66 HISTEX-AC...... 68 hydrocodone-homatropine...... 70 GORDONS NO 5...... 66 HISTEX-DM...... 68 hydrocodone-ibuprofen...... 70 gordons urea...... 66 HISTEX-PE...... 68 hydrocortisone...... 70 GORDONS-VITE A...... 66 hm calamine...... 68 hydrocortisone ace-pramoxine...... 70 GORDO-POOL...... 66 hm clear fiber...... 68 hydrocortisone butyrate...... 70 GRANDPAS OATMEAL SOAP...... 66 hm ethyl rubbing alcohol...... 68 hydrocortisone valerate...... 70 GRANDPAS THYLOX SOAP...... 66 hm iodides...... 68 HYDROGEL...... 70 GRANIX...... 66 hm iodine...... 68 hydromet...... 70 green soap...... 66 hm iron...... 68 hydromorphone hcl...... 70, 71 griseofulvin microsize...... 66 hm melatonin quick dissolve...... 68 hydromorphone hcl pf...... 71 grx wound...... 66 hm nighttime sleep aid...... 68 hydrophilic...... 71 G-TRON PED...... 66 hm omeprazole...... 68 hydrophilic petrolatum...... 71 G-TUSICOF...... 66 hm probiotic digestive health...... 68 hydroxychloroquine sulfate...... 71 guaifenesin...... 66 hm rolled gauze bandage...... 68 hydroxyurea...... 71 guaifenesin-codeine...... 66 HM SALONPAS PAIN RELIEF...... 68 hydroxyzine hcl...... 71 guanfacine hcl...... 66 hm severe cold/cough/flu...... 68 hydroxyzine pamoate...... 71 guanfacine hcl er...... 66 hm super vitamin b12...... 68 HYLATOPIC PLUS...... 71 guanidine hcl...... 66 hm vitamin b12...... 68 HYOPHEN...... 71 gumsol...... 66 hm z-sleep...... 68 hyoscyamine sulfate...... 71 GYNE-LOTRIMIN...... 67 HOLD...... 68 hyoscyamine sulfate er...... 71 GYNE-LOTRIMIN 3...... 66 HOMATROPAIRE...... 68 hyoscyamine sulfate sl...... 71 H2Q...... 67 HONEY BEARS W/IRON-ZINC...... 68 HYPERCARE...... 71 HAILEY FE 1.5/30...... 67 HPR PLUS HYDROGEL...... 68 HYPERRHO S/D...... 71 halobetasol propionate...... 67 huber needle...... 68 hypodermic needle...... 71 haloperidol...... 67 HUGGIES NATURAL CARE WIPES..68 HYPOTEARS...... 71 haloperidol decanoate...... 67 HUMALOG...... 69 HYSEPT...... 71 haloperidol lactate...... 67 HUMALOG JUNIOR KWIKPEN...... 68 HYVEE ADVANCED ANTACID...... 71 hand wipes...... 67 HUMALOG KWIKPEN...... 68 HY-VEE LANCETS...... 71 HARD NAILS...... 67 HUMALOG MIX 50/50...... 68 hy-vee thin lancets...... 71 HAVRIX...... 67 HUMALOG MIX 50/50 KWIKPEN..... 68 ibandronate sodium...... 71 HC DERMAPAX...... 67 HUMALOG MIX 75/25...... 69 ibuprofen...... 71 H-CHLOR 12...... 67 HUMALOG MIX 75/25 KWIKPEN..... 69 ibuprofen 100 junior strength...... 71 H-CHLOR 6...... 67 HUMAN ALBUMIN GRIFOLS...... 69 ibuprofen pm...... 71 headache relief pm...... 67 HUMATE-P...... 69 ICAR...... 71 healthy accents unilet lancets...... 67 humidifier...... 69 ICAR-C...... 71 hearing aid batteries...... 67 HUMIRA...... 69 icatibant acetate...... 71 heartburn antacid ex st...... 67 HUMIRA PEDIATRIC CROHNS ice blue...... 71 heartburn treatment 24 hour...... 67 START...... 69 ICY HOT...... 71 h-e-b incontrol alcohol...... 67 HUMIRA PEN...... 69 ICY HOT LIDOCAINE PLUS h-e-b incontrol lancets 28g...... 67 HUMIRA PEN-CD/UC/HS STARTER.69 MENTHOL...... 71 h-e-b incontrol lancets 30g...... 67 HUMIRA PEN-PS/UV/ADOL HS idarubicin hcl...... 72 h-e-b incontrol lancets 33g...... 67 START...... 69 IFEX...... 72 HEET TRIPLE ACTION...... 67 HUMULIN 70/30...... 69 ifosfamide...... 72 hematinic/folic acid...... 67 HUMULIN 70/30 KWIKPEN...... 69 imatinib mesylate...... 72 HEMATOGEN...... 67 HUMULIN N...... 69 imipramine hcl...... 72 HEMATOGEN FA...... 67 HUMULIN N KWIKPEN...... 69 imipramine pamoate...... 72 HEMOCYTE...... 67 HUMULIN R...... 69 imiquimod...... 72 hemorrhoidal...... 67 HUMULIN R U-500 imiquimod pump...... 72 hemorrhoidal cooling...... 67 (CONCENTRATED)...... 69 IMITREX...... 72 hemorrhoidal max st/aloe...... 67 HUMULIN R U-500 KWIKPEN...... 69 immune support...... 72 heparin (porcine) in nacl...... 67 HURRICAINE...... 69 IMODIUM A-D...... 72 164 IMODIUM MULTI-SYMPTOM iron (ferrous sulfate)...... 74 kelp...... 76 RELIEF...... 72 iron 100 plus...... 74 kelp-b6-lecithin-vinegar...... 76 IMOVAX RABIES...... 72 iron 100/c...... 74 KENALOG...... 76 IMPROVUE...... 72 iron 21/7...... 74 KENDALL ALGINATE DRESS indapamide...... 72 iron 27...... 74 8"X8"...... 76 indomethacin...... 72 iron chews pediatric...... 74 KENDALL ANTIMICROBIAL indomethacin er...... 72 iron slow release...... 74 BANDAGE...... 76 INFANRIX...... 72 irrigating eyewash...... 74 KENDALL CA ALGINATE 6"X10".... 76 infants gas relief...... 72 ISENTRESS...... 75 KENDALL HYDROPHILIC FOAM INFED...... 72 ISENTRESS HD...... 75 DRESS...... 76 INFUMORPH 200...... 72 isoleucine...... 75 KENDALL TRANSPARENT FILM INFUMORPH 500...... 72 ISOLEUCINE 1000...... 75 DRESS...... 76 inositol...... 72 isoniazid...... 75 KEPIVANCE...... 76 INOSITOL-5...... 72 isopropyl alcohol...... 75 KERAMATRIX REPLICINE INSPIRACHAMBER/LARGE...... 72 isopropyl alcohol (rubbing)...... 75 10CMX10CM...... 76 INSPIRACHAMBER/MEDIUM...... 72 isopropyl alcohol wipes...... 75 KERASAL...... 76 INSPIRACHAMBER/MOUTHPIECE..72 ISOPTO TEARS...... 75 KERR TRIPLE DYE SWABS...... 76 INSPIRACHAMBER/SMALL...... 72 isosorbide dinitrate...... 75 KESIMPTA...... 76 INSPIREASE...... 72 isosorbide dinitrate er...... 75 ketoconazole...... 76 INSTACLEAN...... 72 isosorbide mononitrate...... 75 ketorolac tromethamine...... 77 INSTA-GLUCOSE...... 72 isosorbide mononitrate er...... 75 KETOSTIX...... 77 instant ear-dry...... 72 isotretinoin...... 75 ketotifen fumarate...... 77 instant hand sanitizer...... 72 isradipine...... 75 kettle neti pot sinus wash...... 77 INSTAT...... 72 itch relief...... 75 KEY OMEGA...... 77 INSUFLON...... 73 ITCH-X...... 75 k-iii...... 77 insulin asp prot & asp flexpen...... 73 itraconazole...... 75 KINERASE...... 77 insulin aspart...... 73 IVAREST MEDICATED POISON kinney lancets...... 77 insulin aspart flexpen...... 73 IVY...... 75 kinney thin lancets...... 77 insulin aspart penfill...... 73 IVAREST POISON IVY ITCH...... 75 kinray insulin syringe...... 77 insulin aspart prot & aspart...... 73 ivermectin...... 75 KINRIX...... 77 insulin lispro...... 73 ivy wash poison ivy cleanser...... 75 KIONEX...... 77 insulin lispro (1 unit dial)...... 73 IXEMPRA KIT...... 75 KITABIS PAK...... 77 insulin lispro junior kwikpen...... 73 IXIARO...... 75 KLOR-CON...... 77 insulin lispro prot & lispro...... 73 J & J ALL-PURPOSE FIRST AID...... 75 KLOR-CON 10...... 77 insulin syringe...... 73 J & J DENTAL FLOSS FOR KIDS...... 75 KLOR-CON M15...... 77 insulin syringe/needle...... 73 JANTOVEN...... 75 KLOR-CON SPRINKLE...... 77 INSUPEN ULTRAFIN...... 73 JANUMET...... 75 KLS ALLER-CORT...... 77 INTEGRA...... 73 JANUMET XR...... 75 kls cold & flu ms day/night...... 77 intense cough reliever ex st...... 73 JANUVIA...... 75 kls esomeprazole magnesium...... 77 INTERDRY AG TEXTILE 10"X144".. 73 JARDIANCE...... 75 kls omeprazole...... 77 INTRASITE GEL APPLIPAK...... 73 JENTADUETO...... 75 K-MAG...... 77 INTRON A...... 73 jessners...... 75 K-MAG ASPARTATE...... 77 INTROVALE...... 73 jock itch spray...... 75 K-MAG-70...... 77 INVEGA SUSTENNA...... 74 JOHNSONS BABY CORNSTARCH....76 kmart valu insulin syringe 29g...... 77 INVEGA TRINZA...... 74 JOHNSONS BABY OIL GEL...... 76 kmart valu insulin syringe 30g...... 77 INVIRASE...... 74 JOHNSONS BABY POWDER...... 76 KONSYL...... 78 INVOKAMET...... 74 JULUCA...... 76 konsyl daily fiber...... 77 INVOKAMET XR...... 74 JUNEL 1/20...... 76 KONSYL-D...... 78 INVOKANA...... 74 JUNEL FE 1.5/30...... 76 korean ginseng...... 78 iodides tincture...... 74 k 100...... 76 kp hydrocortisone-aloe...... 78 iodine...... 74 k-99...... 76 kp ketotifen fumarate...... 78 iodine strong...... 74 KAITLIB FE...... 76 kp mag-oxide magnesium...... 78 iodine tincture...... 74 KALBITOR...... 76 kp silicone scar therapy gel...... 78 IONIL...... 74 KANGAROO ENTRIFLUSH PUMP K-PHOS...... 78 IONIL-T...... 74 SET...... 76 K-PHOS NO 2...... 78 IONSYS...... 74 KANGAROO JOEY PUMP SET...... 76 kpn prenatal...... 78 IPOL...... 74 KANK-A MOUTH PAIN...... 76 krill oil...... 78 ipratropium bromide...... 74 KANK-A SOFTBRUSH...... 76 KROGER HEALTHPRO LANCET ipratropium-albuterol...... 74 KAOPECTATE...... 76 26G...... 78 irbesartan...... 74 KARBOZYME...... 76 kroger insulin syringe...... 78 irbesartan-hydrochlorothiazide...... 74 K-BICARB...... 76 kroger lancets...... 78 irinotecan hcl...... 74 kedbumin...... 76 kroger lancets 21g...... 78 IROFOL...... 74 KELNOR 1/35...... 76 kroger lancets micro thin 33g...... 78 165 kroger lancets super thin...... 78 levetiracetam...... 80 LITTLE TUMMYS LAXATIVE...... 83 kroger lancets thin...... 78 levetiracetam er...... 80 LIVALO...... 83 kroger lancets thin 26g...... 78 levetiracetam in nacl...... 80 live better lancet super thin...... 83 kroger lancets ultrathin 30g...... 78 levobunolol hcl...... 80 live better lancet ultra thin...... 83 KT TAPE PRO...... 78 levocarnitine...... 80 liver...... 83 K-TAN PLUS...... 78 levocarnitine (dietary)...... 80 liver extract...... 83 KWAN LOONG PAIN RELIEVING....78 levocarnitine fumarate...... 80 l-lysine...... 83 KYLEENA...... 78 levocarnitine-b5-taurine...... 80 l-lysine hcl...... 83 labetalol hcl...... 78 levocetirizine dihydrochloride...... 80 LMX 4...... 83 LAC-HYDRIN FIVE...... 78 levofloxacin...... 80, 81 LMX 4 PLUS...... 83 LAC-HYDRIN TWELVE...... 78 levoleucovorin calcium...... 81 LO LOESTRIN FE...... 83 lactated ringers...... 78 LEVO-T...... 81 local anesthesia needle...... 83 lactic acid...... 78 LEXIVA...... 81 LODRANE D...... 83 lactic acid e...... 78 l-glutamine...... 81 LOESTRIN FE 1.5/30...... 83 lacto-bifidus-600...... 78 LICE B GONE...... 81 LOHIST-D...... 83 LAMISIL ADVANCED...... 78 LICE B GONE CAP SATURATED...... 81 lohist-dm...... 83 LAMISIL AT...... 78, 79 lice cure...... 81 longs insulin syringe...... 83 LAMISIL AT SPRAY...... 79 lice killing maximum strength...... 81 longs lancets thin...... 83 LAMISILK PROTECT...... 79 LICEFREEE...... 81 loperamide hcl...... 83 lamivudine...... 79 LICEMD COMPLETE...... 81 lopinavir-ritonavir...... 83 lamivudine-zidovudine...... 79 LICIDE TREATMENT...... 81 loratadine...... 83 lamotrigine...... 79 lidocaine...... 81 loratadine childrens...... 83 lamotrigine er...... 79 lidocaine hcl...... 81 lorazepam...... 83 LANACANE ANTI-BACTERIAL...... 79 lidocaine viscous...... 81 LORAZEPAM INTENSOL...... 83 LANACANE MAXIMUM lidocaine-hydrocortisone ace...... 81 LORTUSS DM...... 83 STRENGTH...... 79 lidocaine-menthol...... 81 LORTUSS EX...... 83 lancets...... 79 lidocaine-prilocaine...... 81 LORTUSS LQ...... 83 lancets 28g...... 79 lidocaine-transparent dressing...... 81 losartan potassium...... 83 lancets 30g...... 79 LIDOPATCH PAIN RELIEF...... 81 losartan potassium-hctz...... 83 lancets micro thin 33g...... 79 LIDOPRO...... 81 LOTRIMIN AF...... 83 lancets super thin 28g...... 79 LIDOZENGEL...... 81 LOTRIMIN ULTRA...... 83 lancets thin...... 79 LILETTA (52 MG)...... 81 lovastatin...... 83 LANCETS ULTRA THIN...... 79 limencin...... 81 loxapine succinate...... 83 lancets ultra thin 30g...... 79 lindane...... 81 LOZIBASE S...... 83 lanolin...... 79 linezolid...... 81 l-phenylalanine...... 83 lanolin anhydrous...... 79 LINZESS...... 81 l-tyrosine...... 83 lanolin hydrous-grx...... 79 liothyronine sodium...... 81 lubiprostone...... 84 lansoprazole...... 79 lip balm...... 81 lubricant drops/dual-action...... 84 LANTUS...... 79 LIP MEDEX...... 81 lubricant eye drops...... 84 LANTUS SOLOSTAR...... 79 lipochol nr...... 81 LUBRISKIN...... 84 l-arginine...... 79 lipochol plus...... 81 LUCENTIS...... 84 LARIN 1/20...... 79 LIPO-GEL...... 82 LUDENS COUGH DROPS...... 84 LARIN FE 1.5/30...... 79 lipoic acid...... 82 LUDENS THROAT DROPS...... 84 latanoprost...... 79 LIPOTRIAD...... 82 LUPKYNIS...... 84 LATUDA...... 79 LIPOTRIAD VISIONARY...... 82 LUPRON DEPOT (1-MONTH)...... 84 laxative...... 79 LIQ-10...... 82 LUPRON DEPOT (3-MONTH)...... 84 laxative pills...... 79 LIQSORB...... 82 LUPRON DEPOT (4-MONTH)...... 84 LAZANDA...... 79 LIQUACEL...... 82 LUPRON DEPOT (6-MONTH)...... 84 l-carnitine...... 79 LIQUIMAT...... 82 LUPRON DEPOT-PED (1-MONTH)....84 leader insulin syringe...... 79, 80 lisinopril...... 82 LUPRON DEPOT-PED (3-MONTH)....84 lecithin-kelp-b6-cider vinegar...... 80 lisinopril-hydrochlorothiazide...... 82 lutein...... 84 leflunomide...... 80 LISTERINE NATURALS LUVENA FEMININE WIPES...... 84 lemon-glycerin...... 80 ANTISEPTIC...... 82 LYCELLE...... 84 LENZAPATCH...... 80 lite touch lancets...... 82 lysine4000...... 84 letrozole...... 80 LITETOUCH INSULIN SYRINGE...... 82 LYSODREN...... 84 leucine...... 80 LITETOUCH LANCETS...... 82 M2 C...... 84 leucovorin calcium...... 80 lithium...... 82 MAALOX...... 84 LEUKERAN...... 80 lithium carbonate...... 82 MAALOX ADVANCED MAX ST...... 84 leuprolide acetate...... 80 lithium carbonate er...... 82 MAALOX JUNIOR PLUS ANTIGAS..84 levalbuterol hcl...... 80 LITTLE COLDS COUGH FORMULA.82 MACUGEN...... 84 levalbuterol tartrate...... 80 LITTLE COLDS DECONGESTANT... 82 MAG-200...... 84 LEVEMIR...... 80 LITTLE REMEDIES POISON mag-al...... 84 LEVEMIR FLEXTOUCH...... 80 TREAT...... 82 magdelay...... 84 166 MAGELLAN INSULIN SAFETY MEDIPORE + PAD ADHESIVE methenamine mandelate...... 88 SYR...... 84, 85 DRESS...... 86 methimazole...... 88 MAGIC3 INTERMITTENT MEDISENSE GLUCOSE KETONE methionine...... 88 CATHETER...... 85 CONTR...... 86 methitest...... 88 MAGIMIN...... 85 MEDISENSE HI/MID/LOW methocarbamol...... 88 magnacaps...... 85 CONTROL...... 86 methotrexate...... 88 MAGNEBIND 200...... 85 MEDISENSE HIGH/LOW CONTROL 86 methotrexate sodium...... 88 MAGNEBIND 300...... 85 MEDISENSE MID CONTROL...... 86 methotrexate sodium (pf)...... 88 magnesium...... 85 MEDISENSE THIN LANCETS...... 86 methyl salicylate...... 88, 89 magnesium aspartate...... 85 medi-tussin dm double strength...... 86 methyldopa...... 89 magnesium carbonate...... 85 MEDROX...... 86 methylphenidate hcl...... 89 magnesium chloride...... 85 medroxyprogesterone acetate...... 87 methylprednisolone...... 89 magnesium chloride-calcium...... 85 mefenamic acid...... 87 methylprednisolone acetate...... 89 magnesium citrate...... 85 mefloquine hcl...... 87 methylprednisolone sodium succ...... 89 magnesium fizz-plus...... 85 mega coq10...... 87 metipranolol...... 89 magnesium gluconate...... 85 MEGA MULTIVITAMIN...... 87 metoclopramide hcl...... 89 magnesium oxide...... 85 megestrol acetate...... 87 metolazone...... 89 magnesium oxide -mg supplement...... 85 meijer alcohol swabs...... 87 metoprolol succinate er...... 89 magnesium sulfate...... 85 MEIJER LANCETS...... 87 metoprolol tartrate...... 89 magnum-75...... 85 MEIJER LANCETS THIN...... 87 metoprolol-hydrochlorothiazide...... 89 MAGONATE...... 85 MEIJER LANCETS UNIVERSAL METRO...... 89 mag-sr plus calcium...... 85 21G...... 87 METROCREAM...... 89 MAG-TAB SR...... 85 MEIJER LANCETS UNIVERSAL METROGEL...... 89 MAKENA...... 85 33G...... 87 METROLOTION...... 89 malathion...... 85 MEIJER SUPER THIN LANCETS...... 87 metronidazole...... 89 manganese...... 85 melatonin...... 87 metronidazole in nacl...... 89 manganese aspartate...... 85 melatonin er...... 87 mexiletine hcl...... 89 manganese gluconate...... 85 melatonin tr...... 87 MEXSANA...... 89 MANGIMIN...... 85 melatonin-pyridoxine...... 87 MG/TAURINE FORTE...... 89 MAOX...... 85 MELLOW-TONE...... 87 MI PASTE PLUS...... 89 MAPAP HEADACHE PLUS...... 85 meloxicam...... 87 MIBELAS 24 FE...... 89 MAR-COF BP...... 85 melphalan...... 87 MICATIN...... 89 MAR-COF CG EXPECTORANT...... 85 melphalan hcl...... 87 miconazole 3...... 89 MASTISOL ADHESIVE...... 85 memantine hcl...... 87 miconazole 7...... 89 MATULANE...... 85 memantine hcl er...... 87 miconazole nitrate...... 89 MAVYRET...... 85 MENACTRA...... 87 microfiber cleaning cloths...... 89 MAXI-COMFORT INSULIN mencaps...... 87 MICROGESTIN 1/20...... 89 SYRINGE...... 86 m-end dmx...... 87 MICROGESTIN FE 1.5/30...... 90 MAXIMUM D3...... 86 M-END PE...... 87 MICROKLENZ...... 90 ME-500...... 86 MENEST...... 87 midazolam hcl...... 90 mecholyl...... 86 menstrual pain relief...... 87 midodrine hcl...... 90 meclizine hcl...... 86 menstrual relief max strength...... 87 MIDOL CAFFEINE FREE...... 90 MEDADYNE ORAL PAIN RELIEF.... 86 MENVEO...... 87 MIDOL COMPLETE...... 90 MEDERMA...... 86 meperidine hcl...... 87 MIGERGOT...... 90 MEDERMA AG FACIAL mercaptopurine...... 87 miglitol...... 90 CLEANSER...... 86 mesalamine...... 88 miglustat...... 90 MEDERMA PM...... 86 mesalamine er...... 88 MIL-A-MULSION...... 90 medic insulin syringe...... 86 mesalamine-cleanser...... 88 MILCO-ZYME...... 90 medicated body...... 86 mesna...... 88 milk of magnesia concentrate...... 90 medicated douche...... 86 MESNEX...... 88 MILLGUARD...... 90 medicated wipes...... 86 MESTINON...... 88 MILTAB #1...... 90 MEDICONE...... 86 METAMUCIL...... 88 mineral oil light...... 90 MEDI-DERM/L-RX...... 86 METAMUCIL MULTIHEALTH mineral oil-hydrophil petrolat...... 90 MEDI-DERM-RX...... 86 FIBER...... 88 MINIMED GUARDIAN LINK 3...... 90 MEDI-FIRST ANTISEPTIC METAMUCIL SMOOTH TEXTURE...88 MINIMED PRO-SET INFUSION 42".. 90 CLEANER...... 86 metaproterenol sulfate...... 88 MINITRAN...... 90 MEDI-FIRST/LIDOCAINE...... 86 METAXALL...... 88 minocycline hcl...... 90 MEDIHONEY WOUND/BURN metformin hcl...... 88 minoxidil...... 90 DRESSING...... 86 metformin hcl er...... 88 minoxidil for women...... 90 medi-laxx...... 86 methadone hcl...... 88 MIRALAX...... 90 MEDI-LYTE...... 86 METHADONE HCL INTENSOL...... 88 MIRENA (52 MG)...... 90 medi-patch-lidocaine...... 86 methazolamide...... 88 mirtazapine...... 90 MEDIPLAST...... 86 methenamine hippurate...... 88 misoprostol...... 90 167 mitomycin...... 90 MUCINEX SINUS-MAX NASAL EASE ALLERGY mitoxantrone hcl...... 90 CONGESTION...... 94 RELIEVER...... 95 M-M-R II...... 90 MUCINEX SINUS-MAX NASALCROM...... 96 mn-50...... 90 DAY/NIGHT...... 94 NASOGEL...... 96 moexipril hcl...... 90 MUCINEX SINUS-MAX PRESS & NASONEB NEBULIZER STARTER... 96 moisture barrier...... 90 PAIN...... 94 NASOPEN PE...... 96 MOISTURE GUARD...... 90 MUCINEX STUFFY NOSE/COLD NATACYN...... 96 MOISTUREL...... 90 CHILD...... 94 nateglinide...... 96 moisturizing skin protectant...... 90 mucus relief cold/sinus max st...... 94 NATROBA...... 96 molybdenum...... 91 mucus relief d...... 94 natural fiber laxative...... 96 mometasone furoate...... 91 mucus relief er...... 94 natural vitamin e moisturizing...... 96 MONOCAL...... 91 mucus relief pe...... 94 NATURAL WHEY...... 96 MONOJECT ALLERGIST TRAY...... 91 mucus-dm max...... 94 NECON 0.5/35 (28)...... 96 MONOJECT BLUNTIP CANNULA.... 91 multi-delyn/iron...... 94 neomycin sulfate...... 96 MONOJECT HYPODERMIC multi-draw needle...... 94 neomycin-bacitracin zn-polymyx...... 96 NEEDLE...... 91 MULTIGEN...... 94 neomycin-polymyxin b gu...... 96 MONOJECT INSULIN SYRINGE...... 91 MULTIGEN FOLIC...... 94 neomycin-polymyxin-dexameth...... 96 MONOJECT LIFESHIELD SYRINGE.91 MULTIGEN PLUS...... 94 neomycin-polymyxin-gramicidin...... 96 MONOJECT MAGELLAN SAFETY multi-minerals...... 94 neomycin-polymyxin-hc...... 96 NDL...... 91 multi-purpose cold compress...... 94 NEOSPORIN + PAIN RELIEF MAX MONOJECT MAGELLAN SYRINGE.91 multi-symptom cold plus child...... 94 ST...... 96 MONOJECT SYRINGE...... 92 multi-vit/fluoride...... 94 NEOSPORIN ORIGINAL...... 96 MONOJECT ULTRA COMFORT multivitamin gummies childrens...... 94 NEOSPORIN PLUS MAX ST...... 96 SYRINGE...... 92 multivitamins/fluoride...... 94 NEOSPORIN PLUS PAIN RELIEF MONOLET LANCETS...... 92 mupirocin...... 94 MS...... 96 MONOLET OPD LANCETS...... 92 MURO 128...... 94 NEOSTRATA FACIAL CLEANSER... 96 MONONINE...... 92 muscle rub ultra strength...... 94 NEOTUSS-D...... 96 MONOVISC...... 92 MUSTARGEN...... 94 NEPHRONEX...... 96 montelukast sodium...... 92 M-VIT...... 94 NEPHRO-VITE...... 96 MORPHABOND ER...... 92 MYCOCIDE CX CALLUS NEULASTA...... 96 morphine sulfate...... 93 EXFOLIATOR...... 94 NEUPOGEN...... 96 morphine sulfate (concentrate)...... 92 mycophenolate mofetil...... 94, 95 NEURO-K-250 T.D...... 96 morphine sulfate (pf)...... 92 mycophenolate sodium...... 95 neuromax...... 96 morphine sulfate er...... 92, 93 MYGLUCOHEALTH LANCETS 30G.95 NEUROPEN...... 96 morphine sulfate er beads...... 92 MYLANTA...... 95 NEUROTIPS...... 96 MOTRIN INFANTS DROPS...... 93 MYLERAN...... 95 NEUTROGENA BODY...... 97 mouth rinse...... 93 MYNATAL...... 95 NEUTROGENA CLEAR PORE...... 97 MOVANTIK...... 93 mynate 90 plus...... 95 NEUTROGENA T/GEL...... 97 moxifloxacin hcl...... 93 mynephrocaps...... 95 NEUTROGENA T/GEL STUBBORN MOZOBIL...... 93 MYOBLOC...... 95 ITCH...... 97 ms insulin syringe...... 93 MYORISAN...... 95 nevirapine...... 97 MUCINEX...... 94 nabumetone...... 95 nevirapine er...... 97 MUCINEX COUGH CHILDRENS...... 93 nac...... 95 NEW DIGNITY ODOR MUCINEX COUGH FOR KIDS...... 93 NAIL SCRUB...... 95 ELIMINATOR...... 97 MUCINEX D...... 93 NAIL-EX...... 95 NEW IMAGE SKIN MUCINEX D MAX STRENGTH...... 93 nalbuphine hcl...... 95 BARRIER/FLANGE...... 97 MUCINEX DM...... 93 naloxone hcl...... 95 NEW IMAGE SKIN/FLANGE/TAPE.. 97 MUCINEX DM MAXIMUM naltrexone hcl...... 95 new terocin...... 97 STRENGTH...... 93 NAMENDA XR TITRATION PACK...95 NEXAFED...... 97 MUCINEX FAST-MAX...... 94 NAMZARIC...... 95 NEXAFED SINUS PRESSURE + MUCINEX FAST-MAX COLD & NAPHCON-A...... 95 PAIN...... 97 SINUS...... 93 naproxen...... 95 NEXAVAR...... 97 MUCINEX FAST-MAX COLD FLU... 93 naproxen dr...... 95 NEXCARE PREMIUM ADHESIVE MUCINEX FAST-MAX CONGEST naproxen sodium...... 95 GAUZE...... 97 COUGH...... 93 naratriptan hcl...... 95 NEXIUM 24HR...... 97 MUCINEX FAST-MAX DAY/NIGHT.93 NARCAN...... 95 NEXPLANON...... 97 MUCINEX FAST-MAX DAY/NIGHT NASACORT ALLERGY 24HR...... 95 niacin...... 97 M/S...... 93 NASACORT ALLERGY 24HR niacin er...... 97 MUCINEX FAST-MAX DAY/NIGHT CHILDREN...... 95 niacin er (antihyperlipidemic)...... 97 TAB...... 93 nasal allergy 24 hour...... 95 niacin flush free...... 97 MUCINEX FOR KIDS...... 94 nasal aspirator...... 95 niacinamide...... 97 MUCINEX MAXIMUM STRENGTH..94 nasal decongestant...... 95 nicardipine hcl...... 97 nasal decongestant spray...... 95 NICODERM CQ...... 97 168 NICORETTE...... 97 NOVOLOG MIX 70/30 RELION...... 99 ondansetron hcl...... 101 nicotine...... 97 NOVOLOG PENFILL...... 99 one step pregnancy...... 101 nicotine polacrilex...... 97 NOVOLOG RELION...... 99 ONE-A-DAY ADULT nicotine step 1...... 97 NOVOPEN ECHO...... 99 VITACRAVES+DHA...... 101 nicotine step 2...... 97 NOXICARE...... 99 ONE-A-DAY WOMENS 50+ nicotine step 3...... 97 np thyroid...... 100 ADVANTAGE...... 102 NICOTROL...... 98 NPLATE...... 100 ONETOUCH DELICA LANCETS NIFEDICAL XL...... 98 NUEDEXTA...... 100 30G...... 102 nifedipine...... 98 NUFERA...... 100 ONETOUCH DELICA LANCETS nifedipine er...... 98 NU-GEL...... 100 33G...... 102 nifedipine er osmotic release...... 98 NULIDO...... 100 ONETOUCH FINEPOINT LANCETS102 nilutamide...... 98 NU-MAG...... 100 ONETOUCH PING METER nimodipine...... 98 NUPERCAINAL...... 100 REMOTE...... 102 NINJACOF...... 98 NUTRA/PRO CHOCOLATE...... 100 ONETOUCH ULTRASOFT NINJACOF-A...... 98 NUTRATEAR...... 100 LANCETS...... 102 NINJACOF-XG...... 98 NUTR-E-SOL...... 100 ONEXTON...... 102 NIPENT...... 98 NUVESSA...... 100 opium...... 102 NISEKO SUNSCREEN SPF 25...... 98 NYAMYC...... 100 OPSUMIT...... 102 nisoldipine er...... 98 NYMALIZE...... 100 OPTIONS CONCEPTROL...... 102 NITEBITE...... 98 nystatin...... 100 OPTIONS GYNOL II nite-time cold/flu relief...... 98 nystatin-triamcinolone...... 100 CONTRACEPTIVE...... 102 NITRO-BID...... 98 NYSTOP...... 100 OPTIUM BLOOD GLUCOSE nitrofurantoin...... 98 NYTOL MAXIMUM STRENGTH.....100 MONITOR...... 102 nitrofurantoin macrocrystal...... 98 OASIS MOISTURIZING OPTIUM GLUCOSE MONITOR nitrofurantoin monohyd macro...... 98 MOUTHWASH...... 100 SYSTEM...... 102 nitroglycerin...... 98 OBSTETRIX DHA...... 100 OPTIUM TEST...... 102 nitroglycerin er...... 98 OBSTETRIX EC...... 100 OPTIUMEZ TEST...... 102 NIVANEX DMX...... 98 OC8...... 100 ORA-FILM...... 102 NIX CREME RINSE...... 98 OCEAN BLUE MINICAPS oral analgesic max st...... 102 nizatidine...... 98 D/OMEGA3...... 100 oral anesthetic...... 102 NIZORAL A-D...... 98 OCEAN BLUE MINICAPS OMEGA- oral electrolytes...... 102 NOBLE FORMULA...... 98 3...... 100 ORAL SWAB PETITE...... 102 NOBLE FORMULA HC...... 98 OCEAN BLUE OPTIMAL HEALTH.100 oral syringe bottle adapter...... 102 nohist-lq...... 98 OCEAN COMPLETE SINUS RINSE.100 ORALONE...... 102 NOKOR ADMIX NEEDLE...... 98 OCEAN NASAL SPRAY...... 100 ORAMAGIC PLUS...... 102 non-stick...... 98 oceanic selenium...... 100 ORAZINC...... 102 NORDITROPIN FLEXPRO...... 98 OCUSOFT LID SCRUB ORFADIN...... 102 NOREL AD...... 98 COMPLIANCE...... 100 ORILISSA...... 102 NOREL CS...... 99 ODEFSEY...... 100 ornithine...... 102 norethin ace-eth estrad-fe...... 99 ODOR EATERS ANTIFUNGAL...... 101 orphenadrine citrate...... 102 norethindrone acetate...... 99 odor spray...... 101 orphenadrine citrate er...... 102 norethindrone acet-ethinyl est...... 99 OFF ACTIVE...... 101 ORTHOVISC...... 102 norgestim-eth estrad triphasic...... 99 OFF FAMILYCARE CLEAN FEEL...101 OS-CAL...... 102 NORMLSHIELD...... 99 ofloxacin...... 101 OS-CAL EXTRA D3...... 102 nortriptyline hcl...... 99 OGESTREL...... 101 OS-CAL ULTRA...... 102 NORVIR...... 99 olanzapine...... 101 oseltamivir phosphate...... 102 NO-STING SKIN-PREP...... 99 olmesartan medoxomil...... 101 OSTEO-PORETICAL...... 102 NOVA SUREFLEX LANCETS...... 99 olmesartan medoxomil-hctz...... 101 ostomy protective...... 103 NOVAFERRUM...... 99 olopatadine hcl...... 101 ovulation predictor...... 103 NOVAFERRUM 125...... 99 omega dha...... 101 oxaliplatin...... 103 NOVAFERRUM 50...... 99 OMEGA POWER...... 101 oxandrolone...... 103 NOVAFERRUM PEDIATRIC DROPS 99 omega-3...... 101 oxaprozin...... 103 NOVOLIN 70/30 FLEXPEN...... 99 omega-3 fish oil...... 101 oxazepam...... 103 NOVOLIN 70/30 FLEXPEN RELION. 99 omega-3 fish oil ex st...... 101 oxcarbazepine...... 103 NOVOLIN N FLEXPEN...... 99 omega-3 fish oil-vitamin d3...... 101 oxybutynin chloride...... 103 NOVOLIN N FLEXPEN RELION...... 99 OMEGA-3 IQ...... 101 oxybutynin chloride er...... 103 NOVOLOG...... 99 omega-3-acid ethyl esters...... 101 oxycodone hcl...... 103 NOVOLOG 70/30 FLEXPEN omeprazole...... 101 oxycodone hcl er...... 103 RELION...... 99 omeprazole magnesium...... 101 oxycodone-acetaminophen...... 103 NOVOLOG FLEXPEN...... 99 omeprazole-sodium bicarbonate...... 101 oxycodone-ibuprofen...... 103 NOVOLOG FLEXPEN RELION...... 99 OMNIFLEX DIAPHRAGM...... 101 OXYCONTIN...... 103 NOVOLOG MIX 70/30...... 99 ONCASPAR...... 101 oxymorphone hcl...... 103 NOVOLOG MIX 70/30 FLEXPEN...... 99 ondansetron...... 101 oxymorphone hcl er...... 103 169 OXYTROL FOR WOMEN...... 103 PEDIAVIT...... 105 pimecrolimus...... 107 OXYZAL WET DRESSING...... 104 PEDVAX HIB...... 105 pindolol...... 107 oyster calcium + d...... 104 PEGANONE...... 105 pioglitazone hcl...... 107 oyster calcium/d3...... 104 PEGINTRON...... 105 pioglitazone hcl-glimepiride...... 107 oyster shell calcium...... 104 penicillamine...... 105 pioglitazone hcl-metformin hcl...... 107 oyster shell calcium 250+d...... 104 penicillin g potassium...... 105 piroxicam...... 107 oyster shell calcium 500+d...... 104 penicillin v potassium...... 106 PLAN B ONE-STEP...... 107 oyster shell calcium plus d...... 104 PENTACEL...... 106 PLASBUMIN-25...... 107 oyster shell calcium/d...... 104 pentamidine isethionate...... 106 PLASBUMIN-5...... 108 oyster shell calcium/d3...... 104 PENTASA...... 106 PLIAGEL...... 108 P & S...... 104 pentoxifylline er...... 106 PLO ULTRAMAX...... 108 p-1000...... 104 PENTRAX GOLD...... 106 PNEUMOVAX 23...... 108 PA CLA...... 104 PEPCID AC...... 106 pnv-dha...... 108 pa fish oil/vit d3 triple st...... 104 PEPCID AC MAXIMUM pnv-omega...... 108 pa glucosamine-chondroitin...... 104 STRENGTH...... 106 pnv-select...... 108 pa prenatal formula...... 104 PEPTO-BISMOL...... 106 podofilox...... 108 pa probiotic complex...... 104 PEPTO-BISMOL MAX STRENGTH. 106 poison ivy wash fast acting...... 108 paclitaxel...... 104 PEPTO-BISMOL TO-GO...... 106 POLAR FREEZE...... 108 pain & fever childrens...... 104 PERFORM ATOMIC HEAT...... 106 POLAR FROST...... 108 pain relief...... 104 PERFORM PAIN RELIEVING...... 106 poly bacitracin...... 108 pain relief day & night ex st...... 104 PERFORM PAIN RELIEVING POLY HIST FORTE...... 108 pain relief roll-on...... 104 ROLL-ON...... 106 poly-hist dm...... 108 pain reliever extra strength...... 104 PERIDIN-C...... 106 poly-hist pd...... 108 pain reliever pm...... 104 perindopril erbumine...... 106 polymyxin b-trimethoprim...... 108 pain reliever pm ex st...... 104 PERIOMED...... 106 POLYSPORIN...... 108 pain reliever/fever reducer...... 104 permethrin...... 106 poly-tussin ac...... 108 pain relieving...... 104 PERNOX...... 106 POLY-VENT DM...... 108 pain relieving + lidocaine...... 104 PEROXYL...... 106 POLY-VENT IR...... 108 PALADIN...... 104 PEROXYL SPOT TREATMENT...... 106 POLY-VI-SOL...... 108 pamidronate disodium...... 104 perphenazine...... 106 POLY-VI-SOL/IRON...... 108 pancreatin...... 104 perphenazine-amitriptyline...... 106 poly-vite pediatric...... 108 PANCREAZE...... 104 PERRY PRENATAL...... 106 potassimin...... 108 PANOXYL...... 104 petroleum jelly...... 106 potassium chloride crys er...... 108 PANOXYL WASH...... 104 PHARMABASE BARRIER...... 106 potassium citrate er...... 108 PANOXYL-4 CREAMY WASH...... 104 PHARMACY COUNTER LANCETS 106 potassium citrate-citric acid...... 108 panto-250...... 104 PHAZYME MAXIMUM STRENGTH potassium gluconate...... 108 pantoprazole sodium...... 105 ...... 106 potassium iodide (antidote)...... 108 pantothenic acid...... 105 PHAZYME ULTRA STRENGTH...... 107 povidone-iodine...... 108 papaya enzyme...... 105 PHENADOZ...... 107 povidone-iodine paint sponge...... 108 PARAGARD INTRAUTERINE PHENAZO...... 107 povidone-iodine prep...... 108 COPPER...... 105 phenazopyridine hcl...... 107 povidone-iodine scrub sponge...... 108 paricalcitol...... 105 phenelzine sulfate...... 107 power oral care system...... 108 PARODONTAX...... 105 phenobarbital...... 107 PR NATAL 400...... 108 paromomycin sulfate...... 105 phenol...... 107 PR NATAL 400 EC...... 108 paroxetine hcl...... 105 PHENOL EZ SWABS...... 107 PR NATAL 430...... 109 paroxetine hcl er...... 105 phenoxybenzamine hcl...... 107 PR NATAL 430 EC...... 108 parvenzyme digestive enzyme...... 105 phentermine hcl...... 107 PRADAXA...... 109 PATADAY...... 105 phenylalanine...... 107 PRALUENT...... 109 PAZEO...... 105 phenytoin...... 107 PRAMEGEL...... 109 pc lancets super thin 30g...... 105 PHENYTOIN INFATABS...... 107 pramipexole dihydrochloride...... 109 PECGEN DMX...... 105 phenytoin sodium...... 107 PRAMOX...... 109 PEDIACARE CHILDRENS LONG- phenytoin sodium extended...... 107 pramoxine hcl...... 109 ACT...... 105 PHLEXY-10...... 107 prasugrel hcl...... 109 PEDIACARE CHILDRENS MULTI- PHOS-FLUR ORTHO DEFENSE...... 107 pravastatin sodium...... 109 SYMP...... 105 phos-nak...... 107 prazosin hcl...... 109 PEDIACARE MULTI-SYMPTOM.....105 PHOSPHASAL...... 107 PRECISION GLUCOSE CONTROL..109 PEDIACLEAR ALLERGY phosphatidyl choline...... 107 PRECISION GLUCOSE CONTROL CHILDRENS...... 105 PHOSPHOLINE IODIDE...... 107 SOLN...... 109 PEDIA-LAX...... 105 PHOTOFRIN...... 107 PRECISION GLUCOSE KETONE PEDIA-LAX FIBER GUMMIES...... 105 phytonadione...... 107 CONTR...... 109 PEDIALYTE ADVANCED CARE.....105 PHYTOPLEX Z-GUARD...... 107 PRECISION GLUCOSE/KETONE PEDIARIX...... 105 PIFELTRO...... 107 CONTR...... 109 PEDIAVENT...... 105 pilocarpine hcl...... 107 PRECISION LINK...... 109 170 PRECISION PCX...... 109 PROBIOMAX PLUS DF...... 111 pure l-citrulline...... 113 PRECISION PCX PLUS TEST...... 109 probiotic...... 111 purefe ob plus...... 113 PRECISION POINT OF CARE TEST 109 probiotic digestive support...... 111 purified water...... 113 PRECISION QID MONITOR...... 109 probiotic-prebiotic...... 111 PURILON...... 113 PRECISION QID TEST...... 109 PROCARE PLUS UNDERWEAR px allergy relief d...... 113 PRECISION SOF-TACT MONITOR..109 MEDIUM...... 111 px allergy sinus pe...... 113 PRECISION SOF-TACT TEST...... 109 PRO-CEPTION...... 112 px antacid extra strength...... 113 PRECISION SUREDOSE PLUS SYR 109 prochlorperazine...... 112 px artificial tears...... 113 PRECISION SURE-DOSE SYRINGE 109 prochlorperazine maleate...... 112 px daytime cold...... 113 PRECISION THINS GP LANCETS... 109 PROCOMYCIN...... 112 px daytime multi-symptom...... 114 PRECISION XTRA...... 109, 110 PROCTOCORT...... 112 px gas relief extra strength...... 114 PRECISION XTRA BLOOD PROCTOFOAM...... 112 px ibuprofen cold & sinus...... 114 GLUCOSE...... 109 PROCTOSOL HC...... 112 px insulin syringe...... 114 PRECISION XTRA KETONE...... 110 PRODIGY INSULIN SYRINGE...... 112 px lancets ultra thin...... 114 PRECISION XTRA MONITOR...... 110 PRODIGY NO CODING BLOOD px minoxidil for men...... 114 PRED MILD...... 110 GLUC...... 112 px nasal four...... 114 prednicarbate...... 110 PRODIGY TWIST TOP LANCETS px nitetime multi-symptom...... 114 prednisolone...... 110 28G...... 112 px omeprazole...... 114 prednisolone acetate...... 110 PROFE...... 112 PYLERA...... 114 prednisolone sodium phosphate...... 110 PROFERRIN ES...... 112 pyrazinamide...... 114 prednisone...... 110 PROFERRIN-FORTE...... 112 pyridostigmine bromide...... 114 PREDNISONE INTENSOL...... 110 PROFILNINE SD...... 112 pyridostigmine bromide er...... 114 preferred plus insulin syringe...... 110 progesterone...... 112 pyridoxine hcl...... 114 preferred plus lancets colored...... 110 progesterone micronized...... 112 PYRIDOXINE/MINERALS...... 114 preferred plus lancets thin...... 110 PROLENSA...... 112 pyrilamine-phenylephrine...... 114 pregabalin...... 110 PROLIDA...... 112 pyrimethamine...... 114 PREGNITUDE...... 110 PROMACTA...... 112 qc alcohol swabs...... 114 PREMARIN...... 110 promethazine hcl...... 112 qc arthritis...... 114 PREMIER UROSTOMY...... 110 promethazine vc/codeine...... 112 qc calamine...... 114 PREMPHASE...... 110 promethazine-codeine...... 112 qc iodides...... 114 PREMPRO...... 110 promethazine-dm...... 112 qc iodine tincture...... 114 prenatal...... 111 PROMETHEGAN...... 112 qc lancets super thin 30g...... 114 prenatal formula...... 110 PROMOLAXIN...... 112 qc lancets ultra thin...... 114 prenatal formula a-free...... 110 PRONUTRIENTS CALCIUM+D3..... 112 QC MEDIFIN PE...... 114 prenatal low iron...... 110 PRONUTRIENTS SUPER B qc natural vegetable...... 114 prenatal multi +dha...... 110 COMPLEX...... 112 qc non-adherent...... 114 prenatal multivitamin plus dha...... 111 propafenone hcl...... 112 qc unilet lancets 28g...... 114 PRENATE...... 111 propafenone hcl er...... 112 qc unilet lancets micro thin...... 114 prep protective skin barrier...... 111 propranolol hcl...... 113 Q-GEL...... 114 PREPARATION H...... 111 propranolol hcl er...... 113 quercetin...... 114 PREPARATION H TOTABLES...... 111 propranolol-hctz...... 113 quetiapine fumarate...... 114 pres gen pediatric...... 111 propylene glycol...... 113 quetiapine fumarate er...... 114 PRESGEN B...... 111 propylthiouracil...... 113 quinapril hcl...... 114 PRETZ...... 111 PRO-RED AC...... 113 quinapril-hydrochlorothiazide...... 114 PREVACARE ANTIMICROBIAL..... 111 PROSHIELD SKIN CARE...... 113 quinidine gluconate er...... 114 PREVACARE EXTRA PROTECTIVE protein...... 113 quinidine sulfate...... 114 ...... 111 PROTEINEX...... 113 quinine sulfate...... 114 PREVACARE PERSONAL PROTEINEX P100...... 113 ra 8 hour pain relief...... 115 PROTECT...... 111 protriptyline hcl...... 113 ra acetaminophen flu cold...... 115 PREVACARE TOTAL SKIN CARE.. 111 PROVENT SLEEP APNEA ra acid reducer plus antacid...... 115 PREVACID 24HR...... 111 THERAPY...... 113 ra acne maximum...... 115 PREVALITE...... 111 PROVIDA DHA...... 113 ra advanced eye health...... 115 PREVIDENT...... 111 PROVIEW...... 113 ra alcohol swabs...... 115 PREVNAR 13...... 111 pseudoeph-bromphen-dm...... 113 ra anorectal...... 115 PREZCOBIX...... 111 pseudoephedrine hcl...... 113 ra antifungal pen...... 115 PREZISTA...... 111 pseudoephedrine hcl er...... 113 ra b-12...... 115 PRIFTIN...... 111 psorcon...... 113 ra back & body pain relief...... 115 PRILOSEC OTC...... 111 PSS SELECT GP LANCETS...... 113 ra b-complex/vitamin c cr...... 115 PRIMATENE ASTHMA...... 111 PSS SELECT SAFETY LANCETS.....113 ra ca/mg/zn/cu...... 115 primidone...... 111 PULMICORT FLEXHALER...... 113 ra calamine...... 115 PRO NUTRIENTS OMEGA 3...... 111 PULMOZYME...... 113 ra calcium...... 115 PROAIR HFA...... 111 PURACYN PLUS DUO-CARE...... 113 ra calcium hi-cal/vitamin d...... 115 probenecid...... 111 PURE & GENTLE LUBRICANT...... 113 ra calcium high potency...... 115 171 ra calcium-boron...... 115 ra saline nasal spray...... 117 RELION LANCETS MICRO-THIN ra cold remedy multi-symptom...... 115 ra saline wound wash...... 117 33G...... 119 ra cold therapy gel...... 115 ra sensitive anti-itch...... 117 RELION LANCETS STANDARD ra cold/sinus max...... 115 ra severe cold/night cold&flu...... 117 21G...... 119 ra corn cushions small...... 115 ra severe congestion/cold max...... 117 RELION LANCETS THIN 26G...... 119 ra corn removers ultra thin...... 115 ra shower & bath body...... 117 RELION LANCETS ULTRA-THIN ra dark tanning...... 115 ra silky lubricant moisturizer...... 117 30G...... 119 ra day/night/cold/flu relief...... 115 ra sinus wash nasal relief...... 117 RELION ULTRA THIN LANCETS ra daytime cold/flu relief...... 115 ra sinus wash neti pot...... 117 30G...... 119 ra ear wax cleansing system...... 115 ra slow release iron...... 117 RELION ULTRA THIN PLUS ra ethyl alcohol...... 115 ra stay awake...... 117 LANCETS...... 119 RA E-ZJECT COLOR LANCETS 33G ra sterile saline nasal mist...... 117 RELISTOR...... 119 ...... 115 ra triple antibiotic...... 117 REMEDY ANTIMICROBIAL RA E-ZJECT LANCETS 28G...... 115 RA TUGABOOS BABY...... 117 CLEANSER...... 119 RA E-ZJECT LANCETS THIN 26G...115 ra vaginal infection screening...... 117 REMEDY CALAZIME...... 119 RA E-ZJECT LANCETS THIN 28G...115 ra vitamin b-12...... 117 REMEDY CLEANSING BODY...... 119 RA E-ZJECT LANCETS ULTRA ra vitamin c...... 117 REMEDY PHYTOPLEX THIN...... 115 ra yeast relief plus...... 117 ANTIFUNGAL...... 119 ra feminine care douche...... 115 rabano yodado...... 117 REMEDY SKIN REPAIR...... 119 ra fever reducer/pain reliever...... 115 RABAVERT...... 117 REMOVE ADHESIVE REMOVER ra fiber weight management...... 115 rabeprazole sodium...... 117 WIPES...... 119 ra first aid iodine...... 115 RADIACARE POST HEALING...... 117 RENACIDIN...... 119 ra first aid non-stick...... 115 raloxifene hcl...... 117 renal vitamin...... 119 ra first aid saline wound wash...... 115 ramelteon...... 117 RENFLEXIS...... 119 ra fish oil...... 115, 116 ramipril...... 117 renuu nl...... 119 RA FISH OIL EXTRA STRENGTH...115 ranitidine hcl...... 117 repaglinide...... 119 ra foaming hand soap refill...... 116 RASH AWAY...... 117 REPATHA...... 119 ra gel toe separator...... 116 RASH RELIEF...... 117 REPATHA SURECLICK...... 119 ra glucosamine-chondroitin...... 116 raspberry syrup...... 117 REPLACE SR...... 119 ra glucosamine-chondroitin-d3...... 116 reality insulin syringe...... 117 RESCON...... 119 ra glucosamine-chondroit-msm...... 116 reality lancets...... 117 RESCRIPTOR...... 120 ra hot & cold lidocaine...... 116 reality swabs...... 117 RESOURCE THICKENUP WATER.. 120 ra hot/cold gel sleeve...... 116 reality trigger lancets...... 117 RESPAIRE-30...... 120 ra hydrogen peroxide...... 116 REA-LO...... 117 RESTASIS...... 120 ra insulin syringe...... 116 REBETOL...... 117 RESTORE CLEANSER & ra intimacy gels/him/her...... 116 RECOMBIVAX HB...... 118 MOISTURIZER...... 120 ra isopropyl alcohol wipes...... 116 RECTICARE...... 118 RETACRIT...... 120 ra lice solution...... 116 red cross cotton sterile...... 118 RETAINE PM...... 120 RA LOTION...... 116 REDNESS RELIEF...... 118 RETIN-A...... 120 ra lubricant eye drops...... 116 reeses pinworm medicine...... 118 REVEAL COLON DISEASE...... 120 ra lutein...... 116 REFENESEN CHEST CONG/PAIN REVEAL DNA PATERNITY TEST...120 RA LYCOPENE...... 116 RLF...... 118 REVEAL GET PREGNANT QUICK. 120 ra melatonin...... 116 REFENESEN CHST CONG/PAIN PE 118 REVEAL MULTI-DRUG TESTING ra miconazole 3 combo pack...... 116 REFRESH...... 118 CUP...... 120 ra mouth pain anesthetic...... 116 REFRESH LACRI-LUBE...... 118 REVEAL URINARY TRACT...... 120 ra mucus relief d max strength...... 116 REFRESH OPTIVE...... 118 REVITADERM WOUND CARE...... 120 ra multihealth fiber...... 116 REFRESH OPTIVE MEGA-3...... 118 REVLIMID...... 120 ra nasal strip/drug free/large...... 116 REFRESH OPTIVE SENSITIVE...... 118 REVONTO...... 120 ra nighttime cold/flu relief...... 116 REFRESH P.M...... 118 REXALL LANCETS ULTRA THIN ra oatmeal moisturizing...... 116 REFRESH TEARS...... 118 30G...... 120 ra omega 3-6-9...... 116 REGENECARE HA...... 118 REZAMID...... 120 ra omeprazole...... 116 REGRANEX...... 118 RHINARIS...... 120 ra omeprazole-sodium bicarb...... 116 relagesic...... 118 RHINASE...... 120 ra oyster shell calcium/d...... 116 relcof c...... 118 RHOPRESSA...... 120 ra pain relief...... 116 RELIADERM...... 118 RIASTAP...... 120 ra personal lubricant...... 116 RELIEF PAIN RELIEVING...... 118 RIAX...... 120 ra prenatal...... 116 RELION ALCOHOL SWABS...... 118 RIBASPHERE...... 120 ra probiotic complex...... 116 RELION ALL-IN-ONE...... 118 riboflavin...... 120 ra probiotic digestive care...... 116 RELION BLOOD GLUCOSE TEST...118 RICOLA CHERRY HONEY HERB... 120 ra probiotic gummies...... 116 RELION GLUCOSE SHOT...... 118 RICOLA HERB...... 120 RA RENEWAL ACNE TREATMENT RELION INSULIN SYRINGE....118, 119 RICOLA LEMON MINT...... 120 ...... 116 RELI-ON INSULIN SYRINGE...... 118 RICOLA W/ECHINACEA...... 120 RA RENEWAL SHOWER & BATH..117 RIDAURA...... 120 172 rifabutin...... 120 sam-e...... 122 severe cold & flu day/night...... 124 rifampin...... 120 SAM-E COMPLETE...... 122 shampoo & body wash rinse-free...... 124 RIGHTEST GL300 LANCETS...... 120 sam-g.l.a...... 122 SHAMROCK LATEX EXAM riluzole...... 120 SAMSCA...... 122 GLOVES...... 124 ringers irrigation...... 121 SANTYL...... 122 SHINGRIX...... 124 RISAMINE...... 121 sapropterin dihydrochloride...... 122 SHOPKO ALCOHOL SWABS...... 124 RISPERDAL CONSTA...... 121 SARNA...... 122 SHOPKO UNILET LANCETS 30G....124 risperidone...... 121 SASTID SOAP...... 122 SHUR-SEAL CONTRACEPTIVE...... 124 ritonavir...... 121 SAVELLA...... 122 silace...... 124 RITUXAN...... 121 SAVELLA TITRATION PACK...... 123 sildenafil citrate...... 124 rivastigmine...... 121 sb alcohol prep...... 123 silver nitrate...... 124 rivastigmine tartrate...... 121 sb bacitracin...... 123 silver sulfadiazine...... 124 rixubis...... 121 sb cold & flu hbp...... 123 SIMILAC STERILIZED WATER...... 124 rizatriptan benzoate...... 121 sb fib lax orange...... 123 simple syrup...... 124 ROBATHOL...... 121 sb insulin syringe...... 123 simvastatin...... 124 ROBITUSSIN CHILD sb lancets thin...... 123 SINADRIN PE COMPLETE SINUS COUGH/COLD CF...... 121 sb lancets ultra thin...... 123 REL...... 124 ROBITUSSIN COUGH+CHEST sb lice treatment...... 123 sinus & cold-d...... 124 CONG DM...... 121 sb omeprazole...... 123 sinus & congestion day/night...... 124 ROBITUSSIN DAY/NIGHT VALUE sb stool softener...... 123 sinus congestion/pain daytime...... 124 PAK...... 121 scarcin...... 123 sinus relief...... 125 ROBITUSSIN LINGERING SCYTERA...... 123 sirolimus...... 125 COUGHGELS...... 121 se-100...... 123 siterol...... 125 ROBITUSSIN MULTI-SYMPTOM SEBUDERM...... 123 skin protectant...... 125 MAX...... 121 SEBULEX...... 123 skin tag remover...... 125 ROBITUSSIN NIGHTTIME COUGH 121 SECONAL...... 123 SKINTEGRITY HYDROGEL...... 125 ROBITUSSIN NIGHTTIME COUGH SECURA EPC SKIN CARE SKYLA...... 125 DM...... 121 STARTER...... 123 sleep aid...... 125 ROBITUSSIN PK COLD DAY/NGHT SECURA EXTRA PROTECTIVE...... 123 SLEEP-N-HEEL...... 125 DM...... 121 SECURA MOISTURIZING SLO-NIACIN...... 125 ROBITUSSIN PK COLD DAY/NGHT CLEANSER...... 123 SLOW FE...... 125 MS...... 121 SECURA PERSONAL CLEANSER...123 slow iron...... 125 ROBITUSSIN SEVERE NIGHTTIME SECURA TOTAL BODY slow magnesium/calcium...... 125 ...... 121 CLEANSER...... 123 slow release iron...... 125 ROBITUSSIN TO GO SECURA TWO-STEP...... 123 sm alcohol prep...... 125 COUGH/COLD CF...... 121 SELECT-OB...... 123 sm allergy relief...... 125 ROCKLATAN...... 121 selegiline hcl...... 123 sm b super vitamin complex...... 125 ROLAIDS...... 121 selenicaps-200...... 123 sm biotin...... 125 ropinirole hcl...... 121 selenimin...... 123 sm calamine...... 125 rose water...... 121 selenium er...... 123 sm chest congestion relief dm...... 125 rosuvastatin calcium...... 122 selenium sulfide...... 123 SM CORAL CALCIUM...... 125 ROTARIX...... 122 SELSUN BLUE DEEP CLEANSING.123 sm cosmetic puffs jumbo...... 125 ROTATEQ...... 122 SELZENTRY...... 123 sm cough drops...... 125 rotex...... 122 senna...... 123, 124 sm daytime cold & cough child...... 125 rufinamide...... 122 senna leaves...... 123 sm dental rinse anti-plaque...... 125 ru-hist d...... 122 SENNA PROMPT...... 124 sm ethyl alcohol (rubbing)...... 125 rutin...... 122 senna s...... 124 sm foaming antacid...... 125 rydex g...... 122 SENOKOT EXTRA STRENGTH...... 124 sm fruit coolers...... 125 rymed...... 122 SENOKOT S...... 124 sm glucosamine hcl-msm...... 125 rynex pse...... 122 SENSI-CARE BODY...... 124 SM GLUCOSAMINE/CALCIUM + D125 SAFE TUSSIN PM...... 122 SENSI-CARE PERINEAL/SKIN...... 124 sm hemorrhoidal...... 125 SAFELET IV CATHETER...... 122 SENSI-CARE PROTECTIVE sm ibuprofen jr...... 125 safety insulin syringes...... 122 BARRIER...... 124 sm iodides...... 125 SAFETY SEAL LANCETS...... 122 SENSIPAR...... 124 sm iodine tincture...... 125 SAFETY-GARD NEEDLE 18G...... 122 SENSITIVE EYES ENZYME sm lancets 33g...... 125 SAFETY-LOK SYRINGE...... 122 CLEANER...... 124 sm medicated chest rub...... 125 SAF-GEL...... 122 SENSODYNE MAXIMUM sm melatonin...... 125 SALEM SUMP TUBE 12FR...... 122 STRENGTH...... 124 sm natural herb cough drops...... 126 salicylic acid...... 122 SE-PLUS PROTEIN...... 124 sm omega-3-6-9 fatty acids...... 126 salicylic acid wart remover...... 122 SEREVENT DISKUS...... 124 sm omeprazole...... 126 salicylic acid-cleanser...... 122 sertraline hcl...... 124 sm one daily prenatal...... 126 saline...... 122 sevelamer carbonate...... 124 sm pain relief/menthol...... 126 SALMON...... 122 sevelamer hcl...... 124 sm prenatal vitamins...... 126 173 sm slow release iron...... 126 STIMULEN...... 127 SWEEN PREP...... 130 sm vitamin b1...... 126 STIOLTO RESPIMAT...... 127 SWIM EAR...... 130 SMART SENSE COLOR LANCETS STOMAHESIVE MOLDABLE swimmers instant ear dry...... 130 33G...... 126 ADHESIVE...... 127 SYLATRON...... 130 SMART SENSE STANDARD STOMAHESIVE PASTE...... 127 SYMBICORT...... 130 LANCETS...... 126 STRIANT...... 127 sympathetic nerve needle...... 130 SMART SENSE SUPER THIN STRIBILD...... 127 SYNAGIS...... 130 LANCETS...... 126 STRIDEX ESSENTIAL...... 127 SYNJARDY...... 130 SMART SENSE THIN LANCETS STRI-DEX SENSITIVE SKIN...... 128 SYNVISC...... 131 26G...... 126 STUART ONE...... 128 SYNVISC ONE...... 131 smoothfit cuff...... 126 SUBLOCADE...... 128 syringe...... 131 sod citrate-citric acid...... 126 SUBOXONE...... 128 syringe 10-12 ml...... 131 sodium bicarbonate...... 126 SUBSYS...... 128 syringe 20-25 ml...... 131 sodium chloride...... 126 sucralfate...... 128 syringe 2-3 ml...... 131 sodium chloride (hypertonic)...... 126 SUDAFED...... 128 syringe 30-35 ml...... 131 sodium fluoride...... 126 SUDAFED 24 HOUR...... 128 syringe 50-60 ml...... 131 sodium polystyrene sulfonate...... 126 SUDAFED CHILDRENS...... 128 syringe 5-6 ml...... 131 sofosbuvir-velpatasvir...... 126 SUDAFED PE CHILDRENS...... 128 syringe luer slip...... 131 solifenacin succinate...... 126 SUDAFED PE COLD & COUGH syringe precisedose dispenser...... 131 SOLIRIS...... 126 CHILD...... 128 SYRSPEND SF...... 131 SOLOSITE WOUND GEL...... 126 SUDAFED PE DAY & NIGHT...... 128 SYRSPEND SF PH4...... 131 solvatech plus...... 126 SUDAFED PE MAXIMUM syrup nf...... 131 SOMBRA COOL THERAPY...... 126 STRENGTH...... 128 SYSTANE...... 131 SOMBRA WARM THERAPY...... 126 SUDAFED PRESSURE+PAIN 12 HR128 SYSTANE BALANCE...... 131 SOOTHE & COOL INZO BARRIER. 126 sulfacetamide sodium...... 128 SYSTANE LID WIPES...... 131 SOOTHE XP XTRA PROTECTION.. 126 sulfacetamide sodium (acne)...... 128 SYSTANE OVERNIGHT THERAPY 131 sorbitol...... 126 sulfacetamide sodium-sulfur...... 128 SYSTANE PRESERVATIVE FREE...131 sorbutuss nr...... 126 sulfacetamide-prednisolone...... 128 SYSTANE ULTRA...... 131 sore throat...... 127 sulfadiazine...... 128 SYSTANE ULTRA PF...... 131 sore throat lozenges...... 126 sulfamethoxazole-trimethoprim...... 128 TABLOID...... 131 SORINE...... 127 SULFAMYLON...... 128 tacrolimus...... 131 sotalol hcl...... 127 sulfasalazine...... 128 tadalafil (pah)...... 131 sotalol hcl (af)...... 127 sulfo-lo...... 128 tamoxifen citrate...... 131 soya lecithin...... 127 sulfur...... 128 tamsulosin hcl...... 131 spinosad...... 127 sulindac...... 129 TANDEM...... 131 SPIRIVA HANDIHALER...... 127 sumatriptan...... 129 tangerine...... 131 spironolactone...... 127 sumatriptan succinate...... 129 TARGRETIN...... 131 spironolactone-hctz...... 127 sumatriptan succinate refill...... 129 taron forte...... 131 sportbalm...... 127 SUMMERS EVE DEODORANT TARON-PREX...... 131 SPORTSCREME...... 127 ULTRA...... 129 TARSUM...... 131 spot acne treatment...... 127 super b-50 complex...... 129 taurine...... 131 SPRAYZOIN...... 127 super c-500 complex...... 129 tazarotene...... 131 SPS...... 127 super cal/mag...... 129 TAZORAC...... 132 stahist ad...... 127 super moleskin...... 129 TAZTIA XT...... 132 STALEVO 100...... 127 SUPER OMEGA-3...... 129 tb syringe 1 ml...... 132 STALEVO 125...... 127 super thin lancets...... 129 tdm solution...... 132 STALEVO 150...... 127 supposibase f...... 129 TEAR FLO...... 132 STALEVO 200...... 127 SUPPRELIN LA...... 129 TEARS NATURALE PM...... 132 STALEVO 75...... 127 SUPREP BOWEL PREP KIT...... 129 TECFIDERA...... 132 STANBACK HEADACHE supress a pediatric...... 129 TECHLITE AST LANCETS...... 132 POWDERS...... 127 supress dm pediatric...... 129 TECHLITE LANCETS...... 132 stavudine...... 127 SUPRESS-PE PEDIATRIC...... 129 TECHLITE LANCETS 30G...... 132 STERILANCE TL...... 127 sure comfort alcohol prep...... 129 TECNU FIRST AID...... 132 sterile...... 127 sure comfort insulin syringe...... 129, 130 TEGADERM CONTACT LAYER...... 132 STERILE LUBRICANT...... 127 sure comfort lancets 28g...... 130 TEGADERM FOAM ADHESIVE...... 132 STERI-STRIP COMPOUND sure comfort lancets 30g...... 130 TEGADERM HYDROGEL WOUND BENZOIN...... 127 SURE-JECT INSULIN SYRINGE...... 130 FILLER...... 132 STERI-TAMP SEALS SURE-LANCE ULTRA THIN telmisartan...... 132 BOTTLES/VIALS...... 127 LANCETS...... 130 telmisartan-hctz...... 132 STERI-TAMP SEALS/BAGS...... 127 SURELITE LANCETS...... 130 temazepam...... 132 STERI-TAMP SEALS/SYRINGES.....127 SUSPENDOL-S...... 130 temozolomide...... 132 STIMATE...... 127 SUTENT...... 130 temsirolimus...... 132 STIMEX INSULATED NEEDLE...... 127 SWEEN...... 130 tenofovir disoproxil fumarate...... 132 174 terazosin hcl...... 132 TIGER BALM LINIMENT...... 134 TRIAMINIC COLD/COUGH...... 137 terbinafine hcl...... 132 TIGER BALM MUSCLE RUB...... 134 TRIAMINIC COLD/COUGH DAY terbutaline sulfate...... 132 TIGER BALM NECK & SHOULDER TIME...... 136 terconazole...... 132 RUB...... 134 TRIAMINIC COUGH/RUNNY NOSE terocin...... 132 TIGER BALM PAIN RELIEVING.....134 ...... 137 teroderm-plus...... 132 TIGER BALM PAIN RELIEVING LG TRIAMINIC COUGH/SORE TESTOPEL...... 132 ...... 134 THROAT...... 137 testosterone...... 132, 133 TILIA FE...... 134 TRIAMINIC FEVER REDUCER...... 137 testosterone cypionate...... 132 timolol maleate...... 134 TRIAMINIC FLU/COUGH/FEVER... 137 testosterone enanthate...... 132 TINACTIN...... 134 TRIAMINIC LONG ACTING tetanus-diphtheria toxoids td...... 133 TINACTIN JOCK ITCH...... 134 COUGH...... 137 tetrabenazine...... 133 TIVICAY...... 134 TRIAMINIC NIGHT TIME tetracycline hcl...... 133 tizanidine hcl...... 134 COLD/CGH...... 137 TETRA-FORMULA CGH/SORE TN DICKINSONS WITCH HAZEL... 134 TRIAMINIC SORE THROAT...... 137 THROAT...... 133 TOBI PODHALER...... 134 triamino...... 137 tgt alcohol swabs...... 133 TOBRADEX...... 135 triamterene-hctz...... 137 tgt first aid cleansing...... 133 tobramycin...... 135 triazolam...... 137 tgt lancet micro thin 33g...... 133 tobramycin-dexamethasone...... 135 tri-buffered aspirin...... 137 tgt lancet thin 26g...... 133 TODAY SPONGE...... 135 tricitrates...... 137 tgt lancet ultra thin 30g...... 133 todays health thin lancets 28g...... 135 trifluoperazine hcl...... 137 tgt lubricant eye drops...... 133 todays health thin lancets 30g...... 135 trifluridine...... 137 tgt lubricant redness reliever...... 133 tolazamide...... 135 trihexyphenidyl hcl...... 137 tgt omeprazole...... 133 tolbutamide...... 135 TRI-LO-SPRINTEC...... 137 THALOMID...... 133 tolmetin sodium...... 135 trimethobenzamide hcl...... 137 THE ITCH ERASER...... 133 tolnaftate...... 135 trimethoprim...... 137 THEOCHRON...... 133 tolterodine tartrate...... 135 trimipramine maleate...... 137 theophylline er...... 133 tolterodine tartrate er...... 135 TRINATE...... 137 THERACOF PLUS COUGH/COLD toomey syringe...... 135 triple antibiotic...... 137 REL...... 133 topcare lancets micro-thin 33g...... 135 TRIPLE FLEX...... 137 THERACYS...... 133 topcare ultra comfort ins syr...... 135 triple helix collagen...... 137 THERA-D 4000...... 133 TOPICAINE 5...... 135 TRIPLE PASTE...... 137 THERAFLU COLD & COUGH...... 133 topiramate...... 135 triprolidine hcl...... 137 THERAFLU EXPRESSMAX...... 133 topotecan hcl...... 135 TRISPEC PSE PEDIATRIC...... 137 THERAFLU SEVERE COLD...... 133 torsemide...... 135 TRIUMEQ...... 137 THERAFLU SEVERE COLD & TOVIAZ...... 135 TRI-VI-SOL...... 137 COUGH...... 133 TRACLEER...... 135 TROCAINE THROAT...... 137 THERAFLU SEVERE COLD TRADJENTA...... 135 TROCAL COUGH SUPPRESSANT.. 137 DAYTIME...... 133 tramadol hcl...... 136 trochibase s...... 138 THERAFLU SEVERE COLD tramadol hcl er...... 136 TROGARZO...... 138 NIGHTTIME...... 133 tramadol hcl er (biphasic)...... 136 TROMBONEX-D...... 138 THERAFLU SEVERE COLD/CGH tramadol-acetaminophen...... 136 trospium chloride...... 138 NIGHT...... 133 trandolapril...... 136 TRUEPLUS GLUCOSE...... 138 THERAFLU WARMING RELIEF tranexamic acid...... 136 TRUEPLUS INSULIN SYRINGE...... 138 SINUS...... 133 TRANQUILITY BRIEFS...... 136 TRUEPLUS LANCETS 26G...... 138 THERA-GESIC...... 133 TRANSANOSIL...... 136 TRUEPLUS LANCETS 28G...... 138 THERANATAL COMPLETE...... 134 transderm-iq...... 136 TRUEPLUS LANCETS 30G...... 138 THERANATAL OVAVITE...... 134 tranylcypromine sulfate...... 136 TRUEPLUS LANCETS 33G...... 138 THERAPLEX T...... 134 TRANZAREL...... 136 TRU-FIT ICE/HEAT ANKLE/GEL THERASEAL HAND PROTECTION 134 TRAVATAN Z...... 136 PAK...... 138 THERATEARS...... 134 travel sickness...... 136 TRULICITY...... 138 THERATEARS NUTRITION...... 134 travoprost (bak free)...... 136 trymine cg...... 138 thiamine...... 134 trazodone hcl...... 136 TUMS E-X 750...... 138 THINLETS GP LANCETS...... 134 TREANDA...... 136 TUMS LASTING EFFECTS...... 138 thioridazine hcl...... 134 T-RELIEF PAIN ARNICA + 12...... 136 TUMS ULTRA 1000...... 138 thiotepa...... 134 T-RELIEF PAIN RELIEF...... 136 tuohy epidural needle tw...... 138 thiothixene...... 134 TRELSTAR MIXJECT...... 136 TUSICOF...... 138 THYROLAR-1...... 134 treprostinil...... 136 TUSNEL C...... 138 THYROLAR-1/2...... 134 tretinoin...... 136 TUSNEL PEDIATRIC...... 138 THYROLAR-1/4...... 134 TREXALL...... 136 TUSNEL-DM PEDIATRIC...... 139 THYROLAR-2...... 134 triamcinolone acetonide...... 136 tussin cf max multi-symptom...... 139 THYROLAR-3...... 134 TRIAMINIC CHEST/NASAL tussin cough dm...... 139 tiagabine hcl...... 134 CONGEST...... 136 tussin cough long-acting...... 139 ticlopidine hcl...... 134 TRIAMINIC COLD & ALLERGY..... 136 tussin dm max...... 139 175 TUSSI-PRES...... 139 UNILET G.P. SUPERLITE LANCET.142 VANTAS...... 144 TUSSI-PRES PE PEDIATRIC...... 139 UNILET GP 28 ULTRA THIN...... 142 VAPOR PATCH...... 144 TUSSI-PRES PEDIATRIC...... 139 UNILET LANCET...... 142 VAQTA...... 144 TUSSLIN PEDIATRIC...... 139 UNILET MICRO-THIN 33G...... 143 VARIVAX...... 144 TWINRIX...... 139 UNILET SUPERLITE LANCET...... 143 VASHE WOUND THERAPY...... 144 TYLENOL...... 139 UNILET SUPER-THIN 30G...... 143 VASOCLEAR-A...... 144 TYLENOL CHILDRENS PLUS MS UNILET ULTRA-THIN 28G...... 143 VASOFLEX D1...... 144 COLD...... 139 UNI-SOLVE...... 143 VCF VAGINAL CONTRACEPTIVE TYLENOL COLD & HEAD...... 139 UNIVERSAL 1 LANCETS THIN 26G ...... 144, 145 TYLENOL COLD MAX...... 139 ...... 143 VECTIBIX...... 145 TYLENOL COLD MULTI- UNIVERSAL 1 LANCETS THIN 33G VELCADE...... 145 SYMPTOM...... 139 ...... 143 venaliv...... 145 TYLENOL COLD/FLU SEVERE...... 139 UNIVERSAL 1 LANCETS ULTRA VENIA...... 145 TYLENOL EXTRA STRENGTH...... 139 THIN...... 143 venlafaxine hcl...... 145 TYLENOL INFANTS...... 139 universal ph...... 143 venlafaxine hcl er...... 145 TYLENOL PM EXTRA STRENGTH.139 urea...... 143 VENTAVIS...... 145 TYLENOL SINUS SEVERE...... 139 urea 20 intensive hydrating...... 143 VENTOLIN HFA...... 145 TYLENOL WARMING urea hydrating...... 143 verapamil hcl...... 145 COUGH/CONGEST...... 139 urea nail...... 143 verapamil hcl er...... 145 TYPHIM VI...... 139 urinary pain relief...... 143 VERELAN PM...... 145 tyrosine...... 139 URO-MAG...... 143 VERQUVO...... 145 TYVASO REFILL...... 139 ursodiol...... 143 VERSAPLUS...... 145 UBRELVY...... 139 USTELL...... 143 VERSIVA XC...... 145 ULCEREASE...... 139 vagicaine...... 143 VIBERZI...... 145 ULTICARE ALCOHOL SWABS...... 139 VAGIFEM...... 143 VIBRAMYCIN...... 145 ULTICARE INSULIN SAFETY SYR 140 VAGISIL...... 143 VICKS DAYQUIL MUCUS ULTICARE INSULIN SYRINGE...... 140 valacyclovir hcl...... 143 CONTROL DM...... 145 ULTICARE SYRINGE...... 140 valerian...... 143 VICKS NYQUIL CHILDRENS ULTICARE TUBERCULIN SAFETY valerian root...... 143 CLD/CGH...... 145 SYR...... 140 valganciclovir hcl...... 143 VICKS NYQUIL COLD & FLU ultilet alcohol swabs...... 140 valine...... 143 NIGHT...... 145 ULTILET CLASSIC LANCETS...... 140 VALINE 1000...... 143 VICKS NYQUIL COUGH...... 145 ULTILET INSULIN SYRINGE.. 140, 141 valproate sodium...... 143 VICKS NYQUIL SEVERE COLD & ULTILET INSULIN SYRINGE valproic acid...... 143 FLU...... 145 SHORT...... 141 valsartan...... 143 VICKS SINEX DAYQUIL/NYQUIL..145 ULTILET LANCETS...... 141 valsartan-hydrochlorothiazide...... 143 VICKS VAPO STEAM...... 145 ultra comfort insulin syringe...... 141 VALSTAR...... 143 VICKS VAPODROPS...... 145 ULTRA FRESH...... 141 VALTOCO 10 MG DOSE...... 143 VICKS VAPOINHALER...... 145 ULTRA FRESH PM...... 141 VALTOCO 15 MG DOSE...... 143 VICKS VAPORUB...... 145 ULTRA MEGA GOLD...... 141 VALTOCO 20 MG DOSE...... 143 VICODIN...... 146 ULTRA MIDE 25...... 141 VALTOCO 5 MG DOSE...... 144 VICODIN ES...... 146 ultracin...... 141 value health insulin syringe...... 144 VICODIN HP...... 146 ULTRACIN M...... 141 value plus lancet standard 21g...... 144 VICTOZA...... 146 ULTRACIN T...... 141 value plus lancets super thin...... 144 VIDA MIA UNILET LANCETS 28G.146 ULTRACIN-M...... 141 value plus lancets thin 26g...... 144 VIDEX...... 146 ultra-comfort insulin syringe...... 141, 142 valumark lancet super thin 30g...... 144 vigabatrin...... 146 ultrasone...... 142 valumark lancet ultra thin 28g...... 144 VIIBRYD...... 146 ULTRA-THIN II INS SYR SHORT....142 VAMOUSSE LICE TREATMENT.....144 VIMPAT...... 146 ULTRA-THIN II INSULIN SYRINGE VANACHOL...... 144 VINATE M...... 146 ...... 142 VANACOF...... 144 vinblastine sulfate...... 146 ULTRA-THIN II LANCETS...... 142 VANACOF AC...... 144 VINCASAR PFS...... 146 UMCKA ELDERBERRY COLD+FLU VANACOF DM...... 144 VINCE...... 146 ...... 142 VANACOF-8...... 144 vinorelbine tartrate...... 146 UMCKA FASTACTIVES vanadium...... 144 VIRACEPT...... 146 COLD+FLU...... 142 VANATAB AC...... 144 virtussin dac...... 146 UMECTA MOUSSE...... 142 VANATAB DM...... 144 VISI-FLOW IRRIGATION STARTER UNDELENIC...... 142 vancomycin hcl...... 144 ...... 146 unibase...... 142 vancomycin hcl in dextrose...... 144 vita-c...... 146 UNILET COMFORTOUCH LANCET vancomycin hcl in nacl...... 144 VITA-CALCIUM...... 146 ...... 142 VANDAZOLE...... 144 VITADYE...... 146 UNILET EXCELITE...... 142 VANICREAM DIAPER RASH...... 144 VITAFOL ULTRA...... 146 UNILET EXCELITE II...... 142 VANIPLY...... 144 VITALINE BIOTIN FORTE/ZINC.....146 UNILET G.P. LANCET...... 142 VANISHPOINT SAFETY SYRINGE.144 VITALINE COQ10...... 146 176 VITA-MAG...... 146 WAL-SLEEP Z...... 148 ZANTAC 150 MAXIMUM VITAMAX...... 146 WAL-SLEEP Z LIQUID SHOTS...... 148 STRENGTH...... 150 VITAMELTS ENERGY VITAMIN B- wal-tap cold/allergy...... 148 ZANTAC 75...... 150 12...... 146 WAL-TUSSIN CF MAX...... 148 Z-BUM...... 150 vitamin a...... 146 wal-tussin cough relief...... 148 ZEASORB...... 150 vitamin a & d...... 146 WAL-ZYR...... 148 ZEGERID OTC...... 150 VITAMIN A FISH...... 146 WAL-ZYR CHILDRENS...... 148 ZELBORAF...... 150 vitamin a palmitate...... 146 warfarin sodium...... 148 ZENATANE...... 150 vitamin a wrinkle treatment...... 146 wart remover maximum strength...... 148 ZENPEP...... 150 vitamin a-beta carotene...... 146 WATCHHALER...... 148 ZEPHREX-D...... 150 vitamin b complex-c...... 146 water tabs...... 148 ZE-PLUS...... 150 vitamin b-1...... 146 wax for braces...... 148 ZEVALIN Y-90...... 150 vitamin b12...... 147 WEBCOL ALCOHOL PREP LARGE 148 ZICAM ALLERGY RELIEF...... 150 vitamin b-12...... 147 WEBCOL ALCOHOL PREP ZICAM COLD REMEDY...... 151 vitamin b-2...... 147 MEDIUM...... 149 zidovudine...... 151 vitamin b-6...... 147 wee care...... 149 ZIKS ARTHRITIS PAIN RELIEF...... 151 vitamin b-6 er...... 147 wegmans complete prenatal+dha...... 149 ZILACTIN...... 151 vitamin c...... 147 WEISS EPIDURAL NEEDLE...... 149 ZILACTIN-B...... 151 vitamin c (calcium ascorbate)...... 147 WEISS EPIDURAL NEEDLE TW..... 149 ZIMS MAX-FREEZE...... 151 vitamin c drops...... 147 WELLMIND MENTAL FOCUS...... 149 zinc...... 151 vitamin c gummies...... 147 WHITE PED ARTERIAL NEEDLE... 149 zinc + vitamin c...... 151 vitamin c plus wild rose hips...... 147 white petrolatum...... 149 ZINC 15...... 151 vitamin c-rose hips er...... 147 WIDE-SEAL DIAPHRAGM 60...... 149 zinc aspartate...... 151 vitamin d2...... 147 WIDE-SEAL DIAPHRAGM 65...... 149 zinc gluconate...... 151 vitamin d3...... 147 WIDE-SEAL DIAPHRAGM 70...... 149 zinc methionate...... 151 vitamin d-400...... 147 WIDE-SEAL DIAPHRAGM 75...... 149 zinc oxide...... 151 vitamin e...... 147 WIDE-SEAL DIAPHRAGM 80...... 149 zinc sulfate...... 151 VITAMIN E & C BEAUTY LOTION 147 WIDE-SEAL DIAPHRAGM 85...... 149 zinc-c-b6...... 151 VITAMIN E & K BEAUTIFUL SKIN 147 WIDE-SEAL DIAPHRAGM 90...... 149 zincolate...... 151 vitamin e beauty...... 147 WIDE-SEAL DIAPHRAGM 95...... 149 ZINC-OXYDE PLUS...... 151 vitamin e/selenium...... 147 WINGS MATERNITY PANTS 2X-3X zinc-vitamin c...... 151 vitamins acd-fluoride...... 147 ...... 149 ziprasidone hcl...... 151 VITAMINS E & A BEAUTY OIL...... 147 WINRHO SDF...... 149 ZITHROMAX...... 151 VITAMINS E & D BEAUTY OIL...... 147 witch hazel...... 149 zn-50...... 151 VITA-RAY...... 147 wound gel...... 149 ZOLADEX...... 151 VITONIC...... 147 wound gel spray...... 149 zoledronic acid...... 151 viva...... 147 WYMZYA FE...... 149 ZOLINZA...... 151 VIVA DROPS...... 147 XARELTO...... 149 zolmitriptan...... 151 VIVABEN...... 147 XARELTO STARTER PACK...... 149 zolpidem tartrate...... 151 VIVITROL...... 148 XEOMIN...... 149 zolpidem tartrate er...... 151 VIVOTIF...... 148 XERAC AC...... 149 ZOMIG...... 151 vocabria...... 148 XEROFORM PETROLAT GAUZE zonisamide...... 151 voriconazole...... 148 1"X8"...... 149 ZOSTAVAX...... 152 vp insulin syringe...... 148 XGEVA...... 149 ZOSTRIX HOT & COLD THERAPY 152 VYVANSE...... 148 XIAFLEX...... 149 ZOSTRIX HP...... 152 WAL-DRYL...... 148 XIFAXAN...... 149 ZOSTRIX-HP...... 152 WAL-DRYL ANTI-ITCH...... 148 XIGDUO XR...... 150 ZOVIRAX...... 152 WAL-DRYL PE ALLERGY & SINUS XOFLUZA (40 MG DOSE)...... 150 Z-TUSS AC...... 152 ...... 148 XOFLUZA (80 MG DOSE)...... 150 ZYLET...... 152 WAL-FEX D ALLERGY & XOLAIR...... 150 ZYNCOF...... 152 CONGESTION...... 148 xolido...... 150 ZYRTEC ALLERGY...... 152 WAL-FLU COLD & SORE THROAT148 X-SEB T PEARL...... 150 ZYRTEC-D ALLERGY & WAL-FLU SEV COLD/CGH XTRA-CARE...... 150 CONGESTION...... 152 DAY/NIGHT...... 148 XULANE...... 150 ZZZQUIL...... 152 WALGREENS LANCETS...... 148 XYREM...... 150 walgreens lancets micro thin...... 148 YES FOR WOMEN...... 150 walgreens lancets super thin...... 148 YF-VAX...... 150 WALGREENS THIN LANCETS...... 148 YUVAFEM...... 150 WALGREENS ULTRA THIN ZADITOR...... 150 LANCETS...... 148 ZAFEMY...... 150 WAL-ITIN D...... 148 zafirlukast...... 150 WAL-PHED PE zaleplon...... 150 DAYTIME/NIGHTTIME...... 148 ZANOSAR...... 150 177