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Arizona Complete Health-Complete Care Plan Comprehensive Preferred Drug List

The Arizona Complete Health-Complete Care Plan Comprehensive Drug List includes drugs that have been reviewed and approved by a committee of doctors and pharmacists. This is not a complete list of all covered drugs. If you need a drug that is not in the drug list, call Arizona Complete Health-Complete Care Plan Member Services and ask if it is covered. If the drug is not covered, your doctor may request prior authorization to cover the drug.

The drug list is updated often and may change. You can view the latest drug list at www.azcompletehealth.com/providers/pharmacy.html

Pharmacy Program

Arizona Complete Health-Complete Care Plan provides appropriate, high quality, and cost effective drug therapy to all Arizona Complete Health-Complete Care Plan members. Arizona Complete Health-Complete Care Plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by a doctor. Some drugs require prior authorization (PA) or have limits on age, dosage and maximum amounts.

Generic drugs have the same active ingredient as their brand name equivalents and should be used as the first line of treatment. This is unless a drug specifically notes brand is preferred. If there is no generic available, there may be more than one brand name drug that can be used in your treatment. The Arizona Complete Health-Complete Care Comprehensive PDL is reviewed often by our Arizona Complete Health Pharmacy and Therapeutics (P&T) Committee. This helps promote the appropriate and cost-effective use of medications.

Dispensing Limits

You can get up to a maximum thirty (30) day supply for each new prescription or refill of most medications. You can get up to a ninety (90) day supply if: • The medication is prescribed for chronic illness • You will be out of the service area for an extended period of time • The prescription is limited to the extended time period • The medication is prescribed for contraception A total of 85% of the 30 day supply must have elapsed before the prescription can be refilled for most drugs.

Prior Authorization and Other Limits

Some drugs listed on the Arizona Complete Health-Complete Care Plan Comprehensive PDL may require Prior Authorization (PA). Your doctor or pharmacist will request a PA for you. The information should be submitted by the practitioner or pharmacist on the Medication Prior Authorization Form. This document is located on the Arizona Complete Health-Complete Care Plan web-site at https://www.azcompletehealth.com/providers/pharmacy.html. They may fax the PA form to 1-855-554-5233 or your provider can send a PA request electronically to https://www.covermymeds.com/epa/envolverx/

Not all oncology drugs are listed below. All federally reimbursable oncology (antineoplastic) agents are available through prior authorization.

Arizona Complete Health-Complete Care Plan will cover the medication(s) if:

1. There is a medical reason that requires the specific medication(s) 2. Depending on the medication, other medications on the PDL have not worked

If the request is approved, Arizona Complete Health-Complete Care Plan notifies your prescriber by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Arizona Complete Health-Complete Care Plan will: • Review the request and notify you and your prescriber of our decision • Let you know about alternative medications if available • Provide information about what you can do to appeal our decision if you do not agree with it.

What it Abbreviation means How it works AL Age Limit Some drugs are only covered for certain ages.

These drugs are covered by Arizona Complete F Formulary Health-Complete Care Plan.

Maintenance These drugs are used to treat long-term conditions MP Product or illnesses. These drugs require authorization to be covered by NF Non-Formulary Arizona Complete Health-Complete Care Plan. Your doctor must ask for approval from Arizona Prior Complete Health-Complete Care Plan before some PA Authorization drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. These drugs are used to treat complex or rare Specialty conditions such as hepatitis C or rheumatoid SP Product arthritis. In some cases, you must first try certain drugs before Arizona Complete Health-Complete Care Plan covers another drug for your medical condition.

For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B ST Step Therapy unless you try Drug A first.

Medical Necessity Requests

If you require a medication to treat a condition that does not appear on the PDL, your doctor can make a medical necessity (MN) request for the medication.

Emergency Supply Policy

State and Federal laws require that a pharmacy dispense up to a 4 day supply of medication to any member awaiting PA determination .The purpose is to avoid interruption of current therapy or delay in the start of therapy. Network pharmacies are authorized to provide up to a 4 day supply of traditional (non-specialty) drugs. Have your Pharmacy call the Pharmacy Help Desk at 1-888-624-1131 for help filling a 4 day emergency supply.

Exclusions

The Arizona Complete Health-Complete Care Plan Drug List does not include certain drugs. The following types of drugs are excluded from coverage. They are also not available for a 4 day emergency supply. • Drugs that are considered experimental or investigational (Members who are enrolled may participate in experimental services; however, AHCCCS will not reimburse for the experimental service as per A.A.C. R9-22-203) • Drug Efficacy Study and Implementation (DESI) drugs • Prosthesis, appliances and devices • Drugs prescribed for infertility • Drugs prescribed for erectile or sexual dysfunction • Drugs prescribed solely for cosmetic purposes or hair growth • Oral vitamins and minerals or OTC drugs with the exception of those listed on the PDL or if a member has a deficiency of a vitamin not listed on the PDL • Nutritional supplements • Medical marijuana • Drugs eligible for coverage under Medicare Part D (for Medicare eligible members); copayments and cost-sharing for behavioral health drugs are covered for SMI members who are also eligible for Medicare.

Newly Approved Products

Arizona Complete Health-Complete Care Plan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these drugs will be considered through the PA review process.

Filling a Prescription

You can have prescriptions filled at an Arizona Complete Health-Complete Care Plan network pharmacy. To find a network pharmacy, visit the Arizona Complete Health-Complete Care Plan website https://providersearch.azcompletehealth.com. You may also call member services for help finding a network pharmacy near you. When you pick a pharmacy, please bring your Arizona Complete Health-Complete Care Plan ID card with you. The pharmacy will need the information located on the card to

fill your prescription.

For More information about your pharmacy benefits, please review your Member Handbook or call Member Services at 888-788-4408 (TTY/TDY 711).

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- QL(4 ea daily); OBESITY/ANOREXIANTS - Drugs to Treat clonidine hcl (adhd) tb12 F AL(At least 6 ADHD, Sleep and Eating Disorders yrs old) QL(1 ea daily); Amphetamines guanfacine hcl (adhd) tb24 F AL(At least 6 ADDERALL TABS QL(2 ea daily); yrs old) (amphetamine- F AL(At least 6 dextroamphetamine) yrs old) QL(1 ea daily); INTUNIV TB24 (guanfacine NF hcl (adhd)) AL(At least 6 ADDERALL XR CP24 1.25 QL(1 ea daily); yrs old) MG-1.25 MG-1.25 MG-1.25 AL(At least 6 MG, 2.5 MG-2.5 MG-2.5 yrs old) KAPVAY TB12 (clonidine NF MP MG-2.5 MG, 3.75 MG-3.75 hcl (adhd)) MG-3.75 MG-3.75 MG, QL(1 ea daily); F STRATTERA CAPS NF AL(At least 6 6.25 MG-6.25 MG-6.25 (atomoxetine hcl) MG-6.25 MG, 7.5 MG-7.5 yrs old) MG-7.5 MG-7.5 MG Stimulants - Misc. (amphetamine- dextroamphetamine) APTENSIO XR CP24 QL(1 ea daily); F AL(At least 6 (methylphenidate hcl) ADDERALL XR CP24 5 QL(2 ea daily); yrs old) MG-5 MG-5 MG-5 MG F AL(At least 6 (amphetamine- yrs old) CONCERTA TBCR 18 MG, QL(2 ea daily); dextroamphetamine) 27 MG, 36 MG F AL(At least 6 (methylphenidate hcl) yrs old) amphetamine- QL(2 ea daily); dextroamphetamine tabs AL(At least 6 QL(1 ea daily); CONCERTA TBCR 54 MG F AL(At least 6 1.25 mg-1.25 mg-1.25 mg- yrs old) (methylphenidate hcl) 1.25 mg, 1.875 mg-1.875 yrs old) mg-1.875 mg-1.875 mg, QL(1 ea daily); DAYTRANA PTCH F AL(At least 6 2.5 mg-2.5 mg-2.5 mg-2.5 F mg, 3.125 mg-3.125 mg- yrs old) 3.125 mg-3.125 mg, 3.75 QL(2 ea daily); mg-3.75 mg-3.75 mg-3.75 dexmethylphenidate hcl F AL(At least 6 tabs 2.5 mg, 10 mg, 5 mg mg, 5 mg-5 mg-5 mg-5 mg, yrs old) 7.5 mg-7.5 mg-7.5 mg-7.5 QL(2 ea daily); mg FOCALIN TABS NF (dexmethylphenidate hcl) AL(At least 6 QL(2 ea daily); yrs old) dextroamphetamine sulfate F AL(At least 6 tabs 10 mg, 5 mg FOCALIN XR CP24 10 QL(2 ea daily); yrs old) MG, 15 MG, 20 MG, 5 MG F AL(At least 6 QL(1 ea daily); (dexmethylphenidate hcl) yrs old) VYVANSE CAPS F AL(At least 6 FOCALIN XR CP24 35 QL(1 ea daily); yrs old) MG, 25 MG, 30 MG, 40 MG F AL(At least 6 QL(1 ea daily); (dexmethylphenidate hcl) yrs old) VYVANSE CHEW F AL(At least 6 QL(10 ml yrs old) METHYLIN SOLN F daily); AL(At (methylphenidate hcl) Attention-Deficit/Hyperactivity Disorder (ADHD) least 6 yrs old) QL(1 ea daily); QL(2 ea daily); methylphenidate hcl cp24 F AL(At least 6 atomoxetine hcl caps F AL(At least 6 or 10 mg, 20 mg, 30 mg yrs old) yrs old)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); Aminoglycosides methylphenidate hcl cp24 F AL(At least 6 or 40 mg, 60 mg yrs old) BETHKIS NEBU F PA; SP; MP (tobramycin) methylphenidate hcl cpcr or QL(1 ea daily); 40 mg, 60 mg, 10 mg, 20 F AL(At least 6 KITABIS PAK NEBU F PA; SP; MP (tobramycin) mg, 30 mg, 50 mg yrs old) QL(3 ea daily); neomycin sulfate tabs or F methylphenidate hcl tabs or F AL(At least 6 10 mg, 20 mg, 5 mg yrs old) TOBI NEBU (tobramycin) NF SP QL(2 ea daily); RITALIN LA CP24 10 MG F ANALGESICS - ANTI-INFLAMMATORY - Drugs (methylphenidate hcl) AL(At least 6 yrs old) to Treat Pain, Swelling, Muscle and Joint Conditions RITALIN LA CP24 20 MG, QL(2 ea daily); 30 MG (methylphenidate NF AL(At least 6 Anti-TNF-alpha - Monoclonal Antibodies hcl) yrs old) HUMIRA PEDIATRIC PA; SP QL(1 ea daily); CROHNS DISEASE F RITALIN LA CP24 40 MG NF STARTER PACK PSKT (methylphenidate hcl) AL(At least 6 yrs old) HUMIRA PEN PNKT 40 F PA; SP QL(3 ea daily); MG/0.4ML, 40 MG/0.8ML RITALIN TABS NF AL(At least 6 (methylphenidate hcl) HUMIRA PEN PNKT 80 F PA; SP; MP yrs old) MG/0.8ML ALTERNATIVE MEDICINES HUMIRA PEN-CD/UC/HS PA; SP STARTER PNKT 40 F Alternative Medicine - K's MG/0.8ML HUMIRA PEN-CD/UC/HS PA; SP; MP krill oil caps 24 mg-50 mg- F 90 mg-130 mg-300 mg STARTER PNKT 80 F MG/0.8ML Alternative Medicine Combinations HUMIRA PEN-PEDIATRIC PA; SP; MP FLAX + DHA CAPS F UC STARTER PACK F PNKT HM OMEGA-3-6-9 FATTY F ACIDS CAPS HUMIRA PEN-PS/UV F PA; SP STARTER PNKT OMEGA 3-6-9 COMPLEX F CAPS HUMIRA PEN-PS/UV F PA; SP; MP STARTER PNKT OMEGA-3-6-9 CAPS F HUMIRA PSKT F PA; SP RA OMEGA 3-6-9 CAPS F Antirheumatic - Enzyme Inhibitors SM OMEGA-3 CAPS F XELJANZ TABS F PA; SP; MP

SM OMEGA-3-6-9 FATTY F Antirheumatic Antimetabolites ACIDS CAPS REDITREX SOSY F PA; SP; MP SUPER OMEGA-3 CAPS F Nonsteroidal Anti-inflammatory Agents (NSAIDs) TRIPLE OMEGA-3-6-9 F CAPS ADVIL CAPS (ibuprofen) NF AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Arizona Complete Health - Complete Care Plan Effective September 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL MIGRAINE CAPS NF ibuprofen caps or 200 mg F (ibuprofen) ADVIL TABS (ibuprofen) NF ibuprofen chew or 100 mg F ibuprofen susp or 100 RX/OTC ALEVE ARTHRITIS TABS NF F (naproxen sodium) mg/5ml ibuprofen susp or 40 ALEVE CAPS (naproxen NF F sodium) mg/ml, 50 mg/1.25ml ibuprofen tabs or 400 mg, ALEVE TABS (naproxen NF F sodium) 600 mg, 800 mg, 200 mg ARTHROTEC 50 TBEC NF INDOCIN SUPP F (diclofenac w/ misoprostol) ARTHROTEC 75 TBEC NF INDOCIN SUSP F (diclofenac w/ misoprostol) indomethacin caps or 25 F CELEBREX CAPS NF PA; QL(2 ea mg, 50 mg (celecoxib) daily) indomethacin cpcr or 75 F celecoxib caps or 100 mg, F PA; QL(2 ea mg 200 mg, 400 mg, 50 mg daily) INFANTS ADVIL SUSP NF CHILDRENS ADVIL SUSP NF RX/OTC (ibuprofen) (ibuprofen) ketoprofen caps or 50 mg, F CHILDRENS MOTRIN NF RX/OTC 75 mg SUSP (ibuprofen) ketoprofen cp24 or 200 mg F DAYPRO TABS NF (oxaprozin) ketorolac tromethamine F QL(20 ea per diclofenac potassium tabs F tabs or 10 mg 30 days retail) LODINE TABS (etodolac) NF diclofenac sodium tb24 or F 100 mg meclofenamate sodium F diclofenac sodium tbec or F caps or 100 mg, 50 mg 25 mg, 50 mg, 75 mg mefenamic acid caps or F diclofenac w/ misoprostol F tbec meloxicam tabs or 15 mg, F EC-NAPROSYN TBEC NF 7.5 mg (naproxen) MOBIC TABS (meloxicam) NF etodolac caps 200 mg, 300 F mg MOTRIN CHILDRENS NF CHEW (ibuprofen) etodolac tabs 400 mg, 500 F mg MOTRIN INFANTS NF DROPS SUSP (ibuprofen) FELDENE CAPS NF (piroxicam) nabumetone tabs or 500 F mg, 750 mg fenoprofen calcium caps or F 400 mg NALFON CAPS 400 MG F fenoprofen calcium tabs or F 600 mg NALFON TABS 600 MG NF (fenoprofen calcium) flurbiprofen tabs or 100 mg, F 50 mg

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAPROSYN SUSP NF Analgesic Combinations (naproxen) butalbital-acetaminophen- QL(4 ea daily) NAPROSYN TABS NF caffeine tabs 40 mg-50 mg- F (naproxen) 325 mg naproxen sodium caps or F butalbital-aspirin-caffeine F QL(6 ea daily) 220 mg caps naproxen sodium tabs or F BUTALBITAL/ASPIRIN/CA F QL(6 ea daily) 550 mg, 275 mg, 220 mg FFEINE TABS naproxen susp or 125 F ESGIC TABS (butalbital- NF QL(4 ea daily) mg/5ml acetaminophen-caffeine) naproxen tabs or 250 mg, F FIORINAL CAPS NF QL(6 ea daily) 375 mg, 500 mg (butalbital-aspirin-caffeine) naproxen tbec or 375 mg, F Analgesics Other 500 mg acetaminophen caps or F oxaprozin tabs F 500 mg acetaminophen chew or 80 piroxicam caps or 10 mg, F F 20 mg mg acetaminophen elix or 160 sulindac tabs or 150 mg, F F 200 mg mg/5ml, 80 mg/2.5ml acetaminophen liqd or 160 F tolmetin sodium caps F mg/5ml acetaminophen soln or 160 tolmetin sodium tabs F mg/5ml, 325 mg/10.15ml, F 650 mg/20.3ml Phosphodiesterase 4 (PDE4) Inhibitors PA; SP; MP acetaminophen supp re F OTEZLA TABS F 650 mg, 120 mg PA; SP acetaminophen susp or OTEZLA TBPK F 160 mg/5ml, 650 F mg/20.3ml, 80 mg/2.5ml Pyrimidine Synthesis Inhibitors acetaminophen tabs or 325 F ARAVA TABS NF mg, 500 mg (leflunomide) FEVERALL JUNIOR F leflunomide tabs or 10 mg, F STRENGTH SUPP 20 mg TYLENOL CHILDRENS NF Soluble Tumor Necrosis Factor Receptor Agents SUSP (acetaminophen) ENBREL MINI SOCT F PA; SP; MP TYLENOL EXTRA STRENGTH TABS NF ENBREL SOLR 25 MG F PA; SP; MP (acetaminophen) TYLENOL FOR ENBREL SOSY 25 F PA; SP CHILDREN/ADULTS NF MG/0.5ML, 50 MG/ML SUSP (acetaminophen) ENBREL SURECLICK F PA; SP TYLENOL INFANTS SOAJ PAIN+FEVER SUSP NF ANALGESICS - NonNarcotic - Drugs to Treat (acetaminophen) Pain, Muscle and Joint Conditions TYLENOL INFANTS SUSP NF (acetaminophen) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL TABS NF 12 per (acetaminophen) HYDROMORPHONE HCL F month;QL(0.4 SUPP RE 3 MG ea daily,12 ea Salicylates per fill retail) aspirin buffered (cal carb- F QL(6 ea daily) mag carb-mag oxide) tabs hydromorphone hcl tabs or F 2 mg, 4 mg, 8 mg aspirin chew or 81 mg F meperidine hcl tabs or 50 F mg ASPIRIN SUPP RE 300 F MG, 600 MG 500 per morphine sulfate soln or 10 F month;QL(16.6 mg/5ml, 20 mg/5ml aspirin tabs or 325 mg F 7 ml daily) morphine sulfate soln or aspirin tbec or 325 mg, 81 F F mg 100 mg/5ml, 20 mg/ml BUFFERIN TABS (aspirin morphine sulfate supp re F QL(6 ea daily) buffered (cal carb-mag NF 10 mg, 20 mg, 30 mg, 5 mg carb-mag oxide)) morphine sulfate tabs or 15 F QL(6 ea daily) mg, 30 mg diflunisal tabs F morphine sulfate tbcr or PA 100 mg, 15 mg, 200 mg, 30 F ECOTRIN MAXIMUM NF STRENGTH TBEC mg, 60 mg ECOTRIN REGULAR MS CONTIN TBCR NF PA STRENGTH TBEC NF (morphine sulfate) (aspirin) OXAYDO TABS 5 MG F QL(6 ea daily) ECOTRIN TBEC (aspirin) NF oxycodone hcl caps or 5 F QL(6 ea daily) mg salsalate tabs or 500 mg, F 750 mg oxycodone hcl conc or 100 F QL(6 ml daily) ANALGESICS - OPIOID - Drugs to Treat Pain, mg/5ml Muscle and Joint Conditions oxycodone hcl soln or 5 F QL(6 ml daily) mg/5ml Opioid Agonists oxycodone hcl tabs or 10 QL(6 ea daily) DILAUDID LIQD OR 1 QL(16 ml daily) mg, 20 mg, 15 mg, 30 mg, F MG/ML (hydromorphone NF 5 mg hcl) ROXICODONE TABS NF QL(6 ea daily) DILAUDID TABS OR 2 QL(6 ea daily) (oxycodone hcl) MG, 4 MG, 8 MG NF (hydromorphone hcl) tramadol hcl tabs or 50 mg F QL(6 ea daily) DURAGESIC PT72 PA NF tramadol hcl tb24 or 100 F PA (fentanyl) mg, 200 mg, 300 mg PA EMBEDA CPCR F ULTRAM TABS (tramadol NF QL(6 ea daily) hcl) fentanyl pt72 td 100 PA XTAMPZA ER C12A F PA mcg/hr, 12 mcg/hr, 25 F mcg/hr, 50 mcg/hr, 75 mcg/hr Opioid Combinations acetaminophen w/ codeine QL(16 ml daily) hydromorphone hcl liqd or F QL(16 ml daily) 1 mg/ml soln 12 mg/5ml-120 F mg/5ml Arizona Complete Health - Complete Care Plan Effective September 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acetaminophen w/ codeine QL(6 ea daily) TYLENOL/CODEINE #3 QL(6 ea daily) tabs 15 mg-300 mg, 60 F TABS (acetaminophen w/ NF mg-300 mg, 30 mg-300 mg codeine) butalbital-acetaminophen- F QL(6 ea daily) TYLENOL/CODEINE #4 QL(6 ea daily) caffeine w/ codeine caps TABS (acetaminophen w/ NF codeine) butalbital-aspirin-caffeine F QL(6 ea daily) w/cod caps ULTRACET TABS NF QL(3 ea daily) FIORICET/CODEINE QL(6 ea daily) (tramadol-acetaminophen) CAPS (butalbital- NF Opioid Partial Agonists acetaminophen-caffeine w/ PA Req'd codeine) unless member FIORINAL/CODEINE #3 QL(6 ea daily) is pregnant or CAPS (butalbital-aspirin- NF nursing. caffeine w/cod) ;Prescriber hydrocodone- QL(16 ml daily) must note ICD- acetaminophen soln 2.5 10 diagnosis mg/5ml-108 mg/5ml, 5 F code on mg/10ml-217 mg/10ml, 7.5 prescription.;O mg/15ml-325 mg/15ml 09.91; O09.92; buprenorphine hcl subl sl 2 F O09.93- hydrocodone- QL(6 ea daily) mg acetaminophen tabs 10 Supervision of high risk mg-300 mg, 5 mg-300 mg, F 7.5 mg-300 mg, 10 mg-325 pregnancy, mg, 5 mg-325 mg, 7.5 mg- postpartum 325 mg nursing mothers.;First hydrocodone-ibuprofen F QL(6 ea daily) digit Letter, 2nd tabs digit NORCO TABS QL(6 ea daily) zero;QL(12 ea (hydrocodone- NF daily) acetaminophen) PA Req'd oxycodone w/ F QL(6 ea daily) unless member acetaminophen tabs is pregnant or QL(6 ea daily) nursing. oxycodone-aspirin tabs F ;Prescriber OXYCODONE/ACETAMIN QL(6 ea daily) must note ICD- OPHEN TABS 10 MG-300 F 10 diagnosis MG, 5 MG-300 MG code on PERCOCET TABS QL(6 ea daily) prescription.;O (oxycodone w/ NF buprenorphine hcl subl sl 8 F 09.91; O09.92; acetaminophen) mg O09.93- Supervision of PRIMLEV TABS 10 MG- F QL(6 ea daily) high risk 300 MG, 5 MG-300 MG pregnancy, postpartum PROLATE TABS 10 MG- F QL(6 ea daily) 300 MG, 5 MG-300 MG nursing mothers.;First tramadol-acetaminophen F QL(3 ea daily) tabs digit Letter, 2nd digit zero;QL(3 ea daily)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits buprenorphine hcl- QL(12 ea daily) CORTENEMA ENEM naloxone hcl dihydrate subl F ( NF 0.5 mg-2 mg (intrarectal)) buprenorphine hcl- QL(3 ea daily) CORTIFOAM FOAM F naloxone hcl dihydrate subl F 2 mg-8 mg hydrocortisone (intrarectal) F enem BUTRANS PTWK F PA (buprenorphine) Rectal Combinations SUBLOCADE SOSY F PA; SP ANALPRAM HC CREA (hydrocortisone w/ NF SUBOXONE FILM 0.5 MG- QL(12 ea pramoxine) 2 MG (buprenorphine hcl- F daily); AL(At ) ANALPRAM HC SINGLES naloxone hcl dihydrate least 6 yrs old) CREA (hydrocortisone NF SUBOXONE FILM 1 MG-4 QL(6 ea daily); acetate w/ pramoxine) MG (buprenorphine hcl- F AL(At least 6 ) ANALPRAM-HC CREA 1 naloxone hcl dihydrate yrs old) %-1 % (hydrocortisone NF SUBOXONE FILM 2 MG-8 QL(3 ea daily); acetate w/ pramoxine) MG (buprenorphine hcl- F AL(At least 6 naloxone hcl dihydrate) yrs old) hydrocortisone acetate w/ F pramoxine crea SUBOXONE FILM 3 MG- QL(2 ea daily); 12 MG (buprenorphine hcl- F AL(At least 6 PROCORT CREA F naloxone hcl dihydrate) yrs old) Rectal ANDROGENS-ANABOLIC - Drugs to Regulate Hormones ANUSOL-HC CREA NF (hydrocortisone (rectal)) Androgens hydrocortisone (rectal) crea F ANDRODERM PT24 F PA PROCTOCORT CREA EX ANDROGEL GEL F PA 1 % (hydrocortisone NF (testosterone) (rectal)) ANDROGEL PUMP GEL F PA (testosterone) ANTACIDS caps or 100 mg, F Antacid Combinations 200 mg, 50 mg alum & mag hydrox- DEPO-TESTOSTERONE PA simethicone liqd 40 SOLN (testosterone NF mg/5ml-400 mg/5ml-400 F cypionate) mg/5ml, 20 mg/5ml-200 mg/5ml-200 mg/5ml TESTIM GEL NF (testosterone) testosterone cypionate soln F PA im 100 mg/ml, 200 mg/ml testosterone enanthate F PA soln im ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits alum & mag hydrox- TUMS EXTRA STRENGTH simethicone susp 240 750 CHEW (calcium NF mg/30ml-2400 mg/30ml- carbonate (antacid)) 2400 mg/30ml, 40 mg/5ml- TUMS LASTING EFFECTS 40 mg/5ml-400 mg/5ml-400 CHEW (calcium carbonate NF mg/5ml-400 mg/5ml-400 (antacid)) mg/5ml, 80 mg/10ml-800 mg/10ml-800 mg/10ml, 0.2 F TUMS SMOOTHIES %-40 mg/10ml-400 CHEW (calcium carbonate NF mg/10ml-400 mg/10ml, 120 (antacid)) mg/30ml-1200 mg/30ml- TUMS ULTRA 1000 CHEW 1200 mg/30ml, 20 mg/5ml- (calcium carbonate NF 20 mg/5ml-200 mg/5ml-200 (antacid)) mg/5ml-200 mg/5ml-200 Antacids - Magnesium Salts mg/5ml magnesium oxide tabs 400 F HYVEE ADVANCED mg ANTACID MAXIMUM NF STRENGTH SUSP (alum & ANTHELMINTICS - Drugs to Treat Worm mag hydrox-simethicone) Infections Antacids - Aluminum Salts Anthelmintics PA ALUMINUM HYDROXIDE F albendazole tabs or F SUSP OR ALBENZA TABS NF PA Antacids - Calcium Salts (albendazole) ANTACID CHEW F BILTRICIDE TABS NF (praziquantel) ANTACID SOFT CHEWS F CHEW ivermectin tabs or 3 mg F PA calcium carbonate praziquantel tabs or F (antacid) chew 420 mg, F 400 mg, 1000 mg, 500 mg, 750 mg pyrantel pamoate susp or F CALCIUM CARBONATE F STROMECTOL TABS NF PA TABS OR 648 MG (ivermectin) CVS ANTACID SOFT CHEWS ULTRA F ANTI-INFECTIVE AGENTS - MISC. - Drugs to STRENGTH CHEW Treat Bacterial Infections Anti-infective Agents - Misc. MAALOX CHEW F FLAGYL CAPS NF (metronidazole) TUMS CHEW (calcium NF carbonate (antacid)) FLAGYL TABS NF TUMS CHEWY BITES (metronidazole) CHEW (calcium carbonate NF metronidazole caps or 375 F (antacid)) mg TUMS CHEWY DELIGHTS F metronidazole tabs or 250 F CHEW mg, 500 mg TUMS E-X 750 CHEW (calcium carbonate NF trimethoprim tabs or F (antacid)) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anti-infective Misc. - Combinations VANCOMYCIN SOLN F PA BACTRIM DS TABS (sulfamethoxazole- NF Leprostatics trimethoprim) dapsone tabs or 100 mg, F BACTRIM TABS 25 mg (sulfamethoxazole- NF Lincosamides trimethoprim) CLEOCIN CAPS OR 75 sulfamethoxazole- MG, 150 MG, 300 MG NF trimethoprim susp or 40 F (clindamycin hcl) mg/5ml-200 mg/5ml CLEOCIN PEDIATRIC sulfamethoxazole- GRANULES SOLR NF trimethoprim tabs or 160 F (clindamycin palmitate mg-800 mg, 80 mg-400 mg hydrochloride) Glycopeptides clindamycin hcl caps or 75 F mg, 150 mg, 300 mg FIRST-VANCOMYCIN 25 F PA SOLN clindamycin palmitate F hydrochloride solr FIRST-VANCOMYCIN 50 F PA SOLN Oxazolidinones VANCOCIN CAPS PA NF linezolid susr or 100 F PA (vancomycin hcl) mg/5ml VANCOCIN HCL CAPS NF PA PA (vancomycin hcl) linezolid tabs or 600 mg F VANCOMYCIN HCL + PA F ZYVOX SUSR OR 100 NF PA SYRSPENDSF PH4 SUSP MG/5ML (linezolid) vancomycin hcl caps or PA F ZYVOX TABS OR 600 MG NF PA 125 mg, 250 mg (linezolid) vancomycin hcl solr iv 1.5 F PA Urinary Anti-infectives gm FURADANTIN SUSP NF vancomycin hcl solr iv 750 (nitrofurantoin) mg, 10 gm, 5 gm, 500 mg, F 1 gm, 1000 mg MACROBID CAPS (nitrofurantoin monohyd NF VANCOMYCIN PA macro) HYDROCHLORIDE SOLN IV 1000 MG/10ML, 1000 MACRODANTIN CAPS MG/200ML, 1250 (nitrofurantoin NF macrocrystal) MG/12.5ML, 1500 F MG/15ML, 1500 nitrofurantoin macrocrystal MG/300ML, 1750 caps or 25 mg, 100 mg, 50 F MG/17.5ML, 2000 mg MG/20ML, 500 MG/100ML, nitrofurantoin monohyd F 750 MG/7.5ML macro caps VANCOMYCIN PA HYDROCHLORIDE SOLR F nitrofurantoin susp or F IV 1.25 GM, 1.5 GM ANTIANGINAL AGENTS - Drugs to Treat Chest VANCOMYCIN Pain HYDROCHLORIDE SOLR F IV 750 MG Antianginals-Other

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RANEXA TB12 NF PA hydroxyzine hcl tabs or 10 F QL(8 ea daily) (ranolazine) mg, 25 mg, 50 mg ranolazine tb12 F PA hydroxyzine pamoate caps F QL(4 ea daily) or 100 mg, 50 mg, 25 mg Nitrates VISTARIL CAPS NF QL(4 ea daily) (hydroxyzine pamoate) DILATRATE SR CPCR F Benzodiazepines ISORDIL TITRADOSE MP Limit 1 TABS 5 MG (isosorbide NF anxiolytic per dinitrate) ALPRAZOLAM INTENSOL F 30 days;QL(60 isosorbide dinitrate tabs 30 F MP CONC ml per 15 days mg, 10 mg, 20 mg, 5 mg retail); AL(At least 6 yrs old) isosorbide dinitrate tbcr 40 F MP mg Limit 1 anxiolytic per isosorbide mononitrate F MP alprazolam tabs or 0.25 tabs F 30 days;QL(4 mg, 0.5 mg, 1 mg ea daily); AL(At isosorbide mononitrate F MP tb24 least 6 yrs old) Limit 1 NITRO-BID OINT F anxiolytic per alprazolam tabs or 2 mg F 30 days;QL(2 NITRO-DUR PT24 0.1 MP ea daily); AL(At MG/HR, 0.2 MG/HR, 0.4 NF least 6 yrs old) MG/HR, 0.6 MG/HR (nitroglycerin) Limit 1 anxiolytic per alprazolam tb24 or 0.5 mg, NITRO-DUR PT24 0.3 F F 30 days;QL(1 MG/HR, 0.8 MG/HR 1 mg, 2 mg, 3 mg ea daily); AL(At nitroglycerin cpcr or 6.5 F MP least 6 yrs old) mg, 9 mg, 2.5 mg Limit 1 nitroglycerin pt24 td 0.1 MP anxiolytic per mg/hr, 0.2 mg/hr, 0.4 F alprazolam tbdp or 0.25 F 30 days;QL(4 mg/hr, 0.6 mg/hr mg, 0.5 mg, 1 mg ea daily); AL(At least 6 yrs old) nitroglycerin subl sl 0.3 mg, F MP 0.4 mg, 0.6 mg Limit 1 anxiolytic per NITROSTAT SUBL NF MP (nitroglycerin) alprazolam tbdp or 2 mg F 30 days;QL(2 ea daily); AL(At ANTIANXIETY AGENTS - Drugs to Treat Anxiety least 6 yrs old) Antianxiety Agents - Misc. QL(4 ea daily); ATIVAN TABS OR 0.5 MG, NF AL(At least 6 1 MG (lorazepam) QL(4 ea daily); yrs old) buspirone hcl tabs or 10 F AL(At least 6 mg, 5 mg, 7.5 mg, 15 mg yrs old) Limit 1 anxiolytic per QL(2 ea daily); ATIVAN TABS OR 2 MG NF 30 days;QL(2 buspirone hcl tabs or 30 F AL(At least 6 (lorazepam) mg ea daily); AL(At yrs old) least 6 yrs old) hydroxyzine hcl syrp or 10 F QL(10 ml daily) mg/5ml

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); Limit 1 chlordiazepoxide hcl caps F AL(At least 6 anxiolytic per yrs old) XANAX TABS 2 MG NF 30 days;QL(2 (alprazolam) QL(2 ea daily); ea daily); AL(At clorazepate dipotassium F AL(At least 6 least 6 yrs old) tabs 15 mg yrs old) Limit 1 anxiolytic per QL(4 ea daily); XANAX XR TB24 clorazepate dipotassium F AL(At least 6 NF 30 days;QL(1 tabs 3.75 mg, 7.5 mg (alprazolam) yrs old) ea daily); AL(At least 6 yrs old) QL(2 ml daily,60 ml per ANTIARRHYTHMICS - Drugs to treat abnormal diazepam conc or 5 mg/ml F 30 days retail); heart rhythms AL(Up to 6 yrs Antiarrhythmics Type I-A old ) disopyramide phosphate F QL(10 ml caps diazepam soln or 5 mg/5ml F daily); AL(Up to 6 yrs old ) NORPACE CAPS NF (disopyramide phosphate) QL(4 ea daily); diazepam tabs or 10 mg, 2 F AL(At least 6 mg, 5 mg NORPACE CR CP12 F yrs old) QL(2 ml daily); quinidine gluconate tbcr F lorazepam conc or 2 mg/ml F AL(At least 6 yrs old) quinidine sulfate tabs F QL(4 ea daily); lorazepam tabs or 0.5 mg, F AL(At least 6 Antiarrhythmics Type I-B 1 mg yrs old) mexiletine hcl caps F MP Limit 1 anxiolytic per Antiarrhythmics Type I-C lorazepam tabs or 2 mg F 30 days;QL(2 ea daily); AL(At flecainide acetate tabs F least 6 yrs old) propafenone hcl cp12 F QL(2 ea daily,60 ea per oxazepam caps F 30 days retail); propafenone hcl tabs F AL(At least 6 RYTHMOL SR CP12 NF yrs old) (propafenone hcl) QL(4 ea daily); TRANXENE T TABS NF Antiarrhythmics Type III (clorazepate dipotassium) AL(At least 6 yrs old) amiodarone hcl tabs or 100 F mg, 200 mg QL(4 ea daily); VALIUM TABS (diazepam) NF AL(At least 6 dofetilide caps F PA yrs old) Limit 1 MULTAQ TABS F PA anxiolytic per XANAX TABS 0.25 MG, NF TIKOSYN CAPS PA ) 30 days;QL(4 NF 0.5 MG, 1 MG (alprazolam ea daily); AL(At (dofetilide) least 6 yrs old) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anti-Inflammatory Agents ASMANEX TWISTHALER 14 METERED DOSES F cromolyn sodium nebu in F AEPB ASMANEX TWISTHALER Antiasthmatic - Monoclonal Antibodies 30 METERED DOSES F FASENRA PEN SOAJ F PA; SP; MP AEPB ASMANEX TWISTHALER FASENRA SOSY F PA; SP; MP 60 METERED DOSES F AEPB PA; SP XOLAIR SOLR F ASMANEX TWISTHALER 7 METERED DOSES F XOLAIR SOSY F PA; SP AEPB (inhalation) F AL(Up to 4 yrs Bronchodilators - Anticholinergics susp old ) ATROVENT HFA AERS F FLOVENT DISKUS AEPB F ipratropium bromide soln in F FLOVENT HFA AERO F MP SPIRIVA HANDIHALER QL(1 ea daily) F PULMICORT FLEXHALER F MP CAPS AEPB TUDORZA PRESSAIR F PULMICORT SUSP NF AL(Up to 4 yrs AEPB (budesonide (inhalation)) old ) Leukotriene Modulators Sympathomimetics montelukast sodium chew F QL(1 ea daily) ST; Must try or 4 mg, 5 mg beclomethason age 4 and up ADVAIR DISKUS AEPB F e, fluticasone, requires (fluticasone-salmeterol) montelukast sodium pack F PA;QL(1 ea or 4 mg or daily); AL(Up to inhaler first 3 yrs old ) ST; Must try montelukast sodium tabs or F QL(1 ea daily) beclomethason 10 mg e, fluticasone, ADVAIR HFA AERO F SINGULAIR CHEW 4 MG, QL(1 ea daily) betamethasone 5 MG (montelukast NF or mometasone sodium) inhaler first age 4 and up ALBUTEROL SULFATE F requires NEBU IN 0.5 % SINGULAIR PACK 4 MG NF ) PA;QL(1 ea albuterol sulfate nebu in (montelukast sodium daily); AL(Up to 0.63 mg/3ml, 1.25 mg/3ml, F 3 yrs old ) 0.083 %, 0.5 %, 2.5 mg/0.5ml SINGULAIR TABS 10 MG NF QL(1 ea daily) (montelukast sodium) albuterol sulfate syrp or 2 F Inhalants mg/5ml ASMANEX TWISTHALER BEVESPI AEROSPHERE F PA 120 METERED DOSES F AERO AEPB 1 rtl pack lmt COMBIVENT RESPIMAT F amt,30 rtl pack AERS lmt day(s), Arizona Complete Health - Complete Care Plan Effective September 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Must try XARELTO TABS F QL(2 ea daily) beclomethason DULERA AERO F e, fluticasone, Heparins And Heparinoid-Like Agents betamethasone or mometasone QL(180 ml per enoxaparin sodium soln ij F 30 days retail); inhaler first; MP 300 mg/3ml SP ipratropium-albuterol soln F QL(60 ml per enoxaparin sodium soln sc F 30 days retail); QL(17 gm per 100 mg/ml, 150 mg/ml PROAIR HFA AERS F SP 30 days retail) QL(48 ml per PROVENTIL HFA AERS NF enoxaparin sodium soln sc F 30 days retail); (albuterol sulfate) 120 mg/0.8ml, 80 mg/0.8ml SP SEREVENT DISKUS F PA QL(18 ml per AEPB enoxaparin sodium soln sc F 30 days retail); 30 mg/0.3ml STIOLTO RESPIMAT F PA SP AERS QL(24 ml per ST; Must try enoxaparin sodium soln sc F 30 days retail); 40 mg/0.4ml beclomethason SP SYMBICORT AERO e, fluticasone, (budesonide-formoterol F QL(36 ml per ) betamethasone enoxaparin sodium soln sc F 30 days retail); fumarate dihydrate or mometasone 60 mg/0.6ml SP inhaler first heparin (porcine) in sodium F Xanthines chloride soln theophylline soln 80 F HEPARIN LOCK FLUSH mg/15ml SOLN (heparin sodium NF theophylline tb12 100 mg, F (porcine) lock flush) 200 mg, 300 mg, 450 mg heparin sod (porcine) in F theophylline tb24 400 mg, F d5w soln 600 mg heparin sodium (porcine) F lock flush soln ANTICOAGULANTS - Blood Thinners heparin sodium (porcine) F Coumarin Anticoagulants soln HEPARIN COUMADIN TABS NF (warfarin sodium) SODIUM/DEXTROSE F SOLN warfarin sodium tabs F HEPARIN SODIUM/NACL Direct Factor Xa Inhibitors 0.45% SOLN 0.45 %- F 12500 UNIT/250ML ELIQUIS STARTER PACK F TBPK HEPARIN SODIUM/SODIUM NF ELIQUIS TABS 2.5 MG F QL(2 ea daily) CHLORIDE 0.9% SOLN LOVENOX SOLN IJ 300 QL(180 ml per ELIQUIS TABS 5 MG F QL(74 ea per 30 days retail) MG/3ML (enoxaparin NF 30 days retail); sodium) SP 51 per month XARELTO STARTER F LOVENOX SOLN SC 100 QL(60 ml per PACK TBPK QL(1.7 ea daily) MG/ML, 150 MG/ML NF 30 days retail); (enoxaparin sodium) SP

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOVENOX SOLN SC 120 QL(48 ml per QL(2 ea daily); NF 30 days retail); KLONOPIN TABS 2 MG NF AL(At least 6 MG/0.8ML, 80 MG/0.8ML (clonazepam) (enoxaparin sodium) SP yrs old) LOVENOX SOLN SC 30 QL(18 ml per ONFI SUSP (clobazam) NF PA MG/0.3ML (enoxaparin NF 30 days retail); sodium) SP ONFI TABS (clobazam) NF PA LOVENOX SOLN SC 40 QL(24 ml per MG/0.4ML (enoxaparin NF 30 days retail); Anticonvulsants - Misc. sodium) SP BANZEL SUSP NF PA; SP; MP LOVENOX SOLN SC 60 QL(36 ml per (rufinamide) MG/0.6ML (enoxaparin NF 30 days retail); BANZEL TABS NF PA; SP; MP sodium) SP (rufinamide) Thrombin Inhibitors carbamazepine chew or F 100 mg PRADAXA CAPS F QL(2 ea daily) carbamazepine cp12 or F ANTICONVULSANTS - Drugs to Treat Seizures 100 mg, 200 mg, 300 mg carbamazepine susp or F Anticonvulsants - Benzodiazepines 100 mg/5ml PA clobazam susp F carbamazepine tabs or 200 F mg PA clobazam tabs F carbamazepine tb12 or 100 F mg, 200 mg, 400 mg QL(4 ea daily); CARBATROL CP12 clonazepam tabs or 0.5 F AL(At least 6 NF mg, 1 mg (carbamazepine) yrs old) gabapentin caps or 100 F QL(2 ea daily); mg, 300 mg, 400 mg clonazepam tabs or 2 mg F AL(At least 6 yrs old) gabapentin soln or 250 F mg/5ml, 300 mg/6ml QL(4 ea daily); clonazepam tbdp or 0.125 F AL(At least 6 gabapentin tabs or 600 mg, mg, 0.25 mg, 0.5 mg, 1 mg F yrs old) 800 mg QL(2 ea daily); KEPPRA SOLN OR 100 NF clonazepam tbdp or 2 mg F AL(At least 6 MG/ML (levetiracetam) yrs old) KEPPRA TABS OR 250 DIASTAT ACUDIAL GEL QL(2 ea per 30 MG, 1000 MG, 750 MG, NF (diazepam F days retail) 500 MG (levetiracetam) (anticonvulsant)) KEPPRA XR TB24 NF DIASTAT PEDIATRIC GEL QL(2 ea per 30 (levetiracetam) (diazepam F days retail) LAMICTAL CHEWABLE (anticonvulsant)) DISPERSIBLE CHEW NF (lamotrigine) diazepam (anticonvulsant) F QL(2 ea per 30 gel days retail) LAMICTAL ODT TBDP 100 QL(4 ea daily); MG, 200 MG, 25 MG, 50 NF KLONOPIN TABS 0.5 MG, NF AL(At least 6 MG (lamotrigine) 1 MG (clonazepam) yrs old) LAMICTAL TABS NF (lamotrigine)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR TB24 100 QL(3 ea daily); rufinamide susp F PA; SP; MP MG, 25 MG, 50 MG NF MP (lamotrigine) rufinamide tabs F PA; SP; MP LAMICTAL XR TB24 200 QL(2 ea daily); MG, 250 MG, 300 MG NF MP TEGRETOL SUSP NF (lamotrigine) (carbamazepine) TEGRETOL TABS lamotrigine chew or 25 mg, F NF 5 mg (carbamazepine) TEGRETOL-XR TB12 lamotrigine tabs or 100 mg, F NF 150 mg, 200 mg, 25 mg (carbamazepine) TOPAMAX SPRINKLE lamotrigine tb24 or 100 mg, F QL(3 ea daily); NF 25 mg, 50 mg MP CPSP (topiramate) TOPAMAX TABS lamotrigine tb24 or 200 mg, F QL(2 ea daily); NF 250 mg, 300 mg MP (topiramate) topiramate cpsp or 15 mg, lamotrigine tbdp or 100 mg, F F 200 mg, 25 mg, 50 mg 25 mg topiramate tabs or 100 mg, levetiracetam soln or 100 F F mg/ml, 500 mg/5ml 200 mg, 25 mg, 50 mg levetiracetam tabs or 250 TRILEPTAL SUSP NF mg, 1000 mg, 750 mg, 500 F (oxcarbazepine) mg TRILEPTAL TABS NF (oxcarbazepine) levetiracetam tb24 or 500 F mg, 750 mg VIMPAT SOLN OR 10 F PA MG/ML LYRICA CAPS (pregabalin) NF PA VIMPAT TABS OR 100 PA LYRICA SOLN (pregabalin) NF PA MG, 150 MG, 200 MG, 50 F MG MYSOLINE TABS NF ZONEGRAN CAPS NF (primidone) (zonisamide) NEURONTIN CAPS NF zonisamide caps or 100 F (gabapentin) mg, 25 mg, 50 mg NEURONTIN SOLN NF (gabapentin) Carbamates felbamate susp 600 mg/5ml F NEURONTIN TABS NF (gabapentin) felbamate tabs 400 mg F QL(9 ea daily) oxcarbazepine susp F felbamate tabs 600 mg F QL(6 ea daily) oxcarbazepine tabs F FELBATOL SUSP 600 NF pregabalin caps or 100 mg, PA MG/5ML (felbamate) 150 mg, 200 mg, 225 mg, F 25 mg, 300 mg, 50 mg, 75 FELBATOL TABS 400 MG NF QL(9 ea daily) mg (felbamate) FELBATOL TABS 600 MG QL(6 ea daily) pregabalin soln or 20 F PA NF mg/ml (felbamate) GABA Modulators primidone tabs or 250 mg, F 50 mg

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GABITRIL TABS (tiagabine NF PA divalproex sodium tb24 or F hcl) 250 mg, 500 mg tiagabine hcl tabs F PA divalproex sodium tbec or F QL(16 ea daily) 125 mg, 250 mg Hydantoins divalproex sodium tbec or F QL(8 ea daily) DILANTIN CAPS 100 MG 500 mg (phenytoin sodium NF valproate sodium soln or F extended) 250 mg/5ml DILANTIN CAPS 30 MG F valproic acid caps or F

DILANTIN INFATABS NF ANTIDEPRESSANTS - Drugs to Treat CHEW (phenytoin) Depression DILANTIN-125 SUSP NF Alpha-2 Receptor Antagonists (Tetracyclics) (phenytoin) QL(1 ea daily); PHENYTEK CAPS mirtazapine tabs or 15 mg, F AL(At least 6 30 mg, 45 mg (phenytoin sodium NF yrs old) extended) mirtazapine tabs or 7.5 mg F QL(1 ea daily) phenytoin chew or 50 mg F QL(1 ea daily); phenytoin sodium extended mirtazapine tbdp or 15 mg, F AL(At least 6 F 30 mg, 45 mg caps yrs old) phenytoin susp or 100 F QL(1 ea daily); mg/4ml, 125 mg/5ml REMERON SOLTAB TBDP NF (mirtazapine) AL(At least 6 Succinimides yrs old) ethosuximide caps or 250 QL(1 ea daily); F REMERON TABS NF AL(At least 6 mg (mirtazapine) yrs old) ethosuximide soln or 250 F mg/5ml Antidepressants - Misc. ZARONTIN CAPS NF QL(4 ea daily); (ethosuximide) bupropion hcl tabs or 100 F AL(At least 6 mg, 75 mg yrs old) ZARONTIN SOLN NF (ethosuximide) QL(2 ea daily); bupropion hcl tb12 or 100 F AL(At least 6 Valproic Acid mg, 150 mg, 200 mg yrs old) DEPAKENE CAPS NF (valproic acid) QL(1 ea daily); bupropion hcl tb24 or 150 F AL(At least 6 mg, 300 mg DEPAKOTE ER TB24 NF yrs old) (divalproex sodium) AL(At least 6 maprotiline hcl tabs F DEPAKOTE SPRINKLES NF yrs old) CSDR (divalproex sodium) QL(2 ea daily); DEPAKOTE TBEC 125 QL(16 ea daily) WELLBUTRIN SR TB12 NF (bupropion hcl) AL(At least 6 MG, 250 MG (divalproex NF yrs old) sodium) QL(1 ea daily); DEPAKOTE TBEC 500 MG QL(8 ea daily) WELLBUTRIN XL TB24 NF AL(At least 6 NF (bupropion hcl) (divalproex sodium) yrs old) divalproex sodium csdr or F 125 mg Selective Serotonin Reuptake Inhibitors (SSRIs) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea daily); 45 per CELEXA TABS 10 MG NF AL(At least 6 LEXAPRO TABS 10 MG month;QL(1.5 (citalopram hydrobromide) NF yrs old) (escitalopram oxalate) ea daily); AL(At CELEXA TABS 20 MG, 40 QL(1 ea daily); least 6 yrs old) MG (citalopram NF AL(At least 6 QL(1 ea daily); hydrobromide) yrs old) LEXAPRO TABS 20 MG NF AL(At least 6 (escitalopram oxalate) QL(20 ml yrs old) daily); AL(At QL(2 ea daily); citalopram hydrobromide F least 6 yrs old - LEXAPRO TABS 5 MG NF AL(At least 6 soln 10 mg/5ml (escitalopram oxalate) Up to 12 yrs yrs old) old) QL(1 ea daily); QL(3 ea daily); paroxetine hcl tabs 10 mg, F AL(At least 6 citalopram hydrobromide 20 mg, 30 mg F AL(At least 6 yrs old) tabs 10 mg yrs old) 45 per QL(1 ea daily); F month;QL(1.5 citalopram hydrobromide F AL(At least 6 paroxetine hcl tabs 40 mg ea daily); AL(At tabs 20 mg, 40 mg yrs old) least 6 yrs old) 45 per PAXIL TABS 10 MG, 20 QL(1 ea daily); escitalopram oxalate tabs F month;QL(1.5 MG, 30 MG (paroxetine NF AL(At least 6 10 mg ea daily); AL(At hcl) yrs old) least 6 yrs old) 45 per QL(1 ea daily); PAXIL TABS 40 MG NF month;QL(1.5 escitalopram oxalate tabs F AL(At least 6 ) 20 mg (paroxetine hcl ea daily); AL(At yrs old) least 6 yrs old) QL(2 ea daily); QL(2 ea daily); escitalopram oxalate tabs 5 F AL(At least 6 PROZAC CAPS 10 MG, 40 NF AL(At least 6 mg MG (fluoxetine hcl) yrs old) yrs old) QL(2 ea daily); QL(4 ea daily); fluoxetine hcl caps or 10 F AL(At least 6 PROZAC CAPS 20 MG NF AL(At least 6 mg, 40 mg (fluoxetine hcl) yrs old) yrs old) QL(4 ea daily); QL(10 ml fluoxetine hcl caps or 20 F AL(At least 6 daily); AL(At mg sertraline hcl conc or 20 yrs old) F least 6 yrs old - mg/ml QL(20 ml Up to 12 yrs daily); AL(At old) fluoxetine hcl soln or 20 F least 6 yrs old - QL(2 ea daily); mg/5ml Up to 12 yrs sertraline hcl tabs or 100 F AL(At least 6 mg old) yrs old) QL(3 ea daily); QL(3 ea daily); fluvoxamine maleate tabs F AL(At least 6 F AL(At least 6 100 mg sertraline hcl tabs or 25 mg yrs old) yrs old) QL(2 ea daily); QL(4 ea daily); fluvoxamine maleate tabs F AL(At least 6 F AL(At least 6 25 mg sertraline hcl tabs or 50 mg yrs old) yrs old) QL(6 ea daily); fluvoxamine maleate tabs F AL(At least 6 50 mg yrs old)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml QL(1 ea daily); daily); AL(At venlafaxine hcl cp24 150 F AL(At least 6 ZOLOFT CONC 20 MG/ML NF least 6 yrs old - mg yrs old) (sertraline hcl) Up to 12 yrs QL(3 ea daily); old) venlafaxine hcl cp24 75 F AL(At least 6 mg, 37.5 mg QL(2 ea daily); yrs old) ZOLOFT TABS 100 MG NF AL(At least 6 (sertraline hcl) QL(3 ea daily); yrs old) venlafaxine hcl tabs 100 F AL(At least 6 mg, 37.5 mg, 50 mg QL(3 ea daily); yrs old) ZOLOFT TABS 25 MG NF AL(At least 6 (sertraline hcl) QL(4 ea daily); yrs old) venlafaxine hcl tabs 25 mg F AL(At least 6 QL(4 ea daily); yrs old) ZOLOFT TABS 50 MG NF AL(At least 6 (sertraline hcl) QL(5 ea daily); yrs old) venlafaxine hcl tabs 75 mg F AL(At least 6 Serotonin Modulators yrs old) QL(4 ea daily); Tricyclic Agents trazodone hcl tabs or 100 F AL(At least 6 mg amitriptyline hcl tabs or 10 AL(At least 6 yrs old) mg, 50 mg, 100 mg, 150 F yrs old) QL(2 ea daily); mg, 25 mg, 75 mg trazodone hcl tabs or 150 F AL(At least 6 AL(At least 6 mg amoxapine tabs F yrs old) yrs old) QL(1 ea daily); ANAFRANIL CAPS AL(At least 6 trazodone hcl tabs or 300 F AL(At least 6 NF mg (clomipramine hcl) yrs old) yrs old) clomipramine hcl caps or F AL(At least 6 QL(3 ea daily); 25 mg, 50 mg, 75 mg yrs old) trazodone hcl tabs or 50 F AL(At least 6 mg yrs old) desipramine hcl tabs or 100 AL(At least 6 mg, 150 mg, 75 mg, 10 mg, F yrs old) Serotonin-Norepinephrine Reuptake Inhibitors 25 mg, 50 mg QL(4 ea daily); doxepin hcl caps or 150 QL(3 ea daily); CYMBALTA CPEP 20 MG, NF AL(At least 6 30 MG (duloxetine hcl) mg, 25 mg, 100 mg, 75 mg, F AL(At least 6 yrs old) 10 mg, 50 mg yrs old) QL(2 ea daily); CYMBALTA CPEP 60 MG QL(6 ml daily); NF AL(At least 6 doxepin hcl conc or 10 F AL(At least 6 (duloxetine hcl) mg/ml yrs old) yrs old) QL(4 ea daily); imipramine hcl tabs or 10 AL(At least 6 duloxetine hcl cpep or 20 F AL(At least 6 F mg, 30 mg mg, 25 mg, 50 mg yrs old) yrs old) AL(At least 6 imipramine pamoate caps F QL(2 ea daily); yrs old) duloxetine hcl cpep or 60 F AL(At least 6 mg NORPRAMIN TABS NF AL(At least 6 yrs old) (desipramine hcl) yrs old) QL(1 ea daily); nortriptyline hcl caps or 10 AL(At least 6 EFFEXOR XR CP24 150 NF AL(At least 6 F MG (venlafaxine hcl) mg, 50 mg, 25 mg, 75 mg yrs old) yrs old) nortriptyline hcl soln or 10 F AL(At least 6 EFFEXOR XR CP24 75 QL(3 ea daily); mg/5ml yrs old) MG, 37.5 MG (venlafaxine NF AL(At least 6 hcl) yrs old) PAMELOR CAPS NF AL(At least 6 (nortriptyline hcl) yrs old)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 MP protriptyline hcl tabs F metformin hcl tabs or 1000 F yrs old) mg, 500 mg, 850 mg TOFRANIL TABS NF AL(At least 6 metformin hcl tb24 or 500 F MP (imipramine hcl) yrs old) mg, 750 mg trimipramine maleate caps F AL(At least 6 Diabetic Other or 100 mg, 25 mg, 50 mg yrs old) CVS GLUCOSE BITS F ANTIDIABETICS - Drugs to Regulate Blood CHEW Sugar CVS GLUCOSE CHEW 4 F Alpha-Glucosidase Inhibitors GM MP CVS SOFT GLUCOSE F acarbose tabs F CHEW DEX4 FAST ACTING PRECOSE TABS NF MP (acarbose) GLUCOSEGO-POUCH F GEL Antidiabetic - Amylin Analogs DEX4 QUICK DISSOLVE F SYMLINPEN 120 SOPN F PA GLUCOSE CHEW PA dextrose (diabetic use) gel F MP SYMLINPEN 60 SOPN F 15 gm/38gm, 40 % Antidiabetic Combinations 1 per glucagon (rdna) kit F month;QL(0.03 ACTOPLUS MET TABS MP 4 ea daily) (pioglitazone hcl-metformin NF hcl) GLUCAGON 1 per EMERGENCY KIT KIT NF month;QL(0.03 glyburide-metformin tabs F MP (glucagon (rdna)) 4 ea daily) GLUCOSE CHEW 4 GM F GLYXAMBI TABS F PA GLUCOSE GEL 15 PA F INVOKAMET TABS F GM/33GM PA GNP GLUCOSE CHEW 4 F JANUMET TABS F GM PA GNP QUICK DISSOLVE F JANUMET XR TB24 F GLUCOSE CHEW JENTADUETO TABS F PA INSTA-GLUCOSE GEL F

KOMBIGLYZE XR TB24 F PA LEADER QUICK DISSOLVE GLUCOSE F CHEW pioglitazone hcl-metformin F MP hcl tabs SM GLUCOSE CHEW 4 F SYNJARDY TABS F PA GM WALGREENS GLUCOSE F TRIJARDY XR TB24 F PA CHEW 4 GM Dipeptidyl Peptidase-4 (DPP-4) Inhibitors XIGDUO XR TB24 F PA JANUVIA TABS F PA Biguanides ONGLYZA TABS F PA

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRADJENTA TABS F PA INSULIN ASPART Limit 1.0 ml per PROTAMINE/INSULIN F day;QL(1 ml Incretin Mimetic Agents (GLP-1 Receptor ASPART FLEXPEN SUPN daily); MP PA Limit 1.0 ml per BYDUREON PEN PEN F INSULIN ASPART SOLN F day;QL(1 ml PA daily); MP BYETTA SOPN F Limit 1.0 ml per INSULIN LISPRO JUNIOR F PA KWIKPEN SOPN day;QL(1 ml TRULICITY SOPN F daily); MP VICTOZA SOPN F PA Limit 1.0 ml per INSULIN LISPRO F day;QL(1 ml KWIKPEN SOPN Insulin Sensitizing Agents daily); MP INSULIN LISPRO Limit 1.0 ml per ACTOS TABS NF MP (pioglitazone hcl) PROTAMINE/INSULIN F day;QL(1 ml LISPRO KWIKPEN SUPN daily); MP MP pioglitazone hcl tabs F Limit 1.0 ml per INSULIN LISPRO SOLN F day;QL(1 ml Insulin daily); MP Limit 1.0 ml per Limit 1.0 ml per HUMALOG MIX 50/50 F day;QL(1 ml SUSP LANTUS SOLN F day;QL(1 ml daily) daily) HUMALOG MIX 75/25 Limit 1.0 ml per Limit 1.0 ml per F day;QL(1 ml LANTUS SOLOSTAR F SUSP SOPN day;QL(1 ml daily) daily) HUMALOG SOCT F QL(1 ml daily) Limit 1.0 ml per LANTUS SOLOSTAR F day;QL(1 ml SOPN HUMULIN 70/30 KWIKPEN F QL(1 ml daily) daily); MP SUPN Limit 1.0 ml per Limit 1.0 ml per LEVEMIR FLEXTOUCH F SOPN day;QL(1 ml HUMULIN 70/30 SUSP F day;QL(1 ml daily) daily) Limit 1.0 ml per Limit 1.0 ml per LEVEMIR SOLN F day;QL(1 ml HUMULIN N SUSP F day;QL(1 ml daily) daily) Limit 1.0 ml per Meglitinide Analogues HUMULIN R SOLN F day;QL(1 ml nateglinide tabs F MP daily) PRANDIN TABS MP HUMULIN R U-500 F PA NF (CONCENTRATED) SOLN (repaglinide) repaglinide tabs F MP HUMULIN R U-500 F PA KWIKPEN SOPN STARLIX TABS NF MP Limit 1.0 ml per (nateglinide) INSULIN ASPART F FLEXPEN SOPN day;QL(1 ml daily); MP Sodium-Glucose Co-Transporter 2 (SGLT2) Limit 1.0 ml per FARXIGA TABS F PA; MP INSULIN ASPART F day;QL(1 ml PENFILL SOCT daily); MP INVOKANA TABS F PA; MP

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JARDIANCE TABS F PA; MP PEPTO BISMOL TABS NF (bismuth subsalicylate) Sulfonylureas PEPTO-BISMOL CHEW NF (bismuth subsalicylate) AMARYL TABS NF MP (glimepiride) PEPTO-BISMOL MAX MP STRENGTH SUSP NF glimepiride tabs F (bismuth subsalicylate) PEPTO-BISMOL SUSP glipizide tabs or 10 mg, 5 F MP NF mg (bismuth subsalicylate) PEPTO-BISMOL TO-GO glipizide tb24 or 10 mg, 2.5 F MP mg, 5 mg CHEW (bismuth NF subsalicylate) GLUCOTROL TABS NF MP (glipizide) Antiperistaltic Agents GLUCOTROL XL TB24 NF MP (glipizide) ANTI-DIARRHEAL LIQD F glyburide micronized tabs F MP diphenoxylate w/ atropine F liqd glyburide tabs or 1.25 mg, MP F diphenoxylate w/ atropine F 2.5 mg, 5 mg tabs GLYNASE TABS MP NF IMODIUM A-D CAPS 2 MG NF RX/OTC (glyburide micronized) (loperamide hcl) tolbutamide tabs F IMODIUM A-D LIQD 1 NF MG/7.5ML (loperamide hcl) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs IMODIUM A-D TABS 2 MG NF to Treat Diarrhea (loperamide hcl) Antidiarrheal/Probiotic Agents - Misc. LOMOTIL TABS NF (diphenoxylate w/ atropine) bismuth subsalicylate chew F or 262 mg loperamide hcl caps or 2 F RX/OTC bismuth subsalicylate susp mg loperamide hcl liqd or 1 or 1050 mg/30ml, 525 F F mg/15ml, 262 mg/15ml, mg/7.5ml 525 mg/30ml, 527 mg/30ml loperamide hcl susp or 1 F mg/7.5ml bismuth subsalicylate tabs F or 262 mg loperamide hcl tabs or 2 F mg EQ PROBIOTIC CPDR F ANTIDOTES AND SPECIFIC ANTAGONISTS FORTIFY OPTIMA F PROBIOTIC CPDR Opioid Antagonists FORTIFY PROBIOTIC naloxone hcl soct ij 0.4 F WOMENSEXTRA F mg/ml STRENGTH CPDR naloxone hcl soln ij 0.4 F MVW COMPLETE mg/ml, 4 mg/10ml PROBIOTIC F FORMULATION CPDR naloxone hcl sosy ij 2 F mg/2ml NEXABIOTIC CPDR F naltrexone hcl tabs or F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NARCAN LIQD F Antifungals griseofulvin microsize susp F VIVITROL SUSR F SP ANTIEMETICS - Drugs to Treat Nausea and griseofulvin microsize tabs F Vomiting nystatin tabs or F 5-HT3 Receptor Antagonists QL(90 ea per PA terbinafine hcl tabs or F ANZEMET TABS F 365 days retail) granisetron hcl tabs or 1 F PA Imidazole-Related Antifungals mg DIFLUCAN SUSR 10 QL(20 ml daily) MG/ML, 40 MG/ML NF ondansetron hcl soln or 4 F mg/5ml (fluconazole) DIFLUCAN TABS 100 MG, QL(2 ea daily) ondansetron hcl tabs or 4 F QL(3 ea daily) mg, 8 mg 200 MG, 50 MG, 150 MG NF (fluconazole) ondansetron tbdp F QL(1 ea daily) fluconazole susr or 10 F QL(20 ml daily) mg/ml, 40 mg/ml ZOFRAN TABS NF QL(3 ea daily) (ondansetron hcl) fluconazole tabs or 100 mg, F QL(2 ea daily) Antiemetics - Anticholinergic 200 mg, 50 mg, 150 mg dimenhydrinate tabs or 50 F ANTIHISTAMINES - Drugs to Treat Allergies mg Antihistamines - Alkylamines DRAMAMINE CHEW F CHLOR-TRIMETON SYRP NF (chlorpheniramine maleate) DRAMAMINE TABS NF (dimenhydrinate) CHLOR-TRIMETON TABS NF (chlorpheniramine maleate) meclizine hcl chew or 25 F RX/OTC mg chlorpheniramine maleate F syrp or 2 mg/5ml meclizine hcl tabs or 12.5 F RX/OTC mg, 25 mg chlorpheniramine maleate F tabs or 4 mg TIGAN CAPS OR 300 MG NF (trimethobenzamide hcl) Antihistamines - Ethanolamines trimethobenzamide hcl F caps or ALER-DRYL TABS F Substance P/Neurokinin 1 (NK1) Receptor BENADRYL ALLERGY QL(6 ea per 21 CAPS (diphenhydramine NF aprepitant caps F days retail) hcl) QL(6 ea per 21 BENADRYL ALLERGY aprepitant misc F days retail) CHILDRENS CHEW NF (diphenhydramine hcl) EMEND CAPS OR 125 QL(6 ea per 21 MG, 40 MG, 80 MG NF days retail) BENADRYL ALLERGY (aprepitant) CHILDRENS LIQD NF (diphenhydramine hcl) EMEND TRIPACK CAPS NF QL(6 ea per 21 (aprepitant) days retail) BENADRYL ALLERGY TABS (diphenhydramine NF ANTIFUNGALS - Drugs to Treat Fungal Infections hcl)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENADRYL ALLERGY CLARITIN REDITABS F QL(1 ea daily) ULTRATABS TABS NF TBDP 5 MG (diphenhydramine hcl) CLARITIN SYRP 5 NF QL(5 ml daily) clemastine fumarate tabs F MG/5ML (loratadine) or 2.68 mg, 1.34 mg CLARITIN TABS 10 MG NF QL(1 ea daily) diphenhydramine hcl caps F (loratadine) or 50 mg, 25 mg fexofenadine hcl susp or 30 F QL(5 ml daily) diphenhydramine hcl chew F mg/5ml or 12.5 mg fexofenadine hcl tabs or 60 F QL(1 ea daily) diphenhydramine hcl elix or F mg, 180 mg 12.5 mg/5ml loratadine caps or 10 mg F QL(1 ea daily) diphenhydramine hcl liqd or F 12.5 mg/5ml, 25 mg/10ml, loratadine chew or 5 mg F QL(1 ea daily) 50 mg/20ml QL(5 ml daily) diphenhydramine hcl tabs F loratadine soln or 5 mg/5ml F or 25 mg QL(5 ml daily) Antihistamines - Non-Sedating loratadine syrp or 5 mg/5ml F ALLEGRA ALLERGY QL(5 ml daily) QL(1 ea daily) CHILDRENS SUSP 30 NF loratadine tabs or 10 mg F MG/5ML (fexofenadine hcl) loratadine tbdp or 10 mg F QL(1 ea daily) ALLEGRA ALLERGY F QL(1 ea daily) CHILDRENS TBDP 30 MG ZYRTEC ALLERGY CAPS NF QL(1 ea daily) (cetirizine hcl) ALLEGRA ALLERGY NF QL(1 ea daily) TABS (fexofenadine hcl) ZYRTEC ALLERGY F QL(1 ea daily) cetirizine hcl caps 10 mg F QL(1 ea daily) CHILDRENS TBDP ZYRTEC ALLERGY TABS NF QL(1 ea daily) cetirizine hcl chew 5 mg, F QL(1 ea daily) (cetirizine hcl) 10 mg ZYRTEC ALLERGY TBDP F QL(1 ea daily) cetirizine hcl soln 1 mg/ml, F QL(5 ml daily); 5 mg/5ml RX/OTC ZYRTEC CHILDRENS QL(5 ml daily); ALLERGY SOLN (cetirizine NF RX/OTC cetirizine hcl syrp 1 mg/ml, F QL(5 ml daily); 5 mg/5ml RX/OTC hcl) cetirizine hcl tabs 5 mg, 10 F QL(1 ea daily) Antihistamines - Phenothiazines mg promethazine hcl soln or F CLARITIN ALLERGY QL(5 ml daily) 6.25 mg/5ml CHILDRENS SYRP NF promethazine hcl supp re F (loratadine) 50 mg, 12.5 mg, 25 mg CLARITIN CAPS 10 MG QL(1 ea daily) NF promethazine hcl syrp or F (loratadine) 6.25 mg/5ml CLARITIN CHEW 5 MG QL(1 ea daily) NF promethazine hcl tabs or F (loratadine) 25 mg, 12.5 mg, 50 mg CLARITIN CHILDRENS NF QL(1 ea daily) CHEW (loratadine) Antihistamines - Piperidines cyproheptadine hcl syrp or CLARITIN REDITABS NF QL(1 ea daily) F TBDP 10 MG (loratadine) 2 mg/5ml

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyproheptadine hcl tabs or F CRESTOR TABS NF 4 mg (rosuvastatin calcium) ANTIHYPERLIPIDEMICS - Drugs to Treat High LIPITOR TABS NF QL(1 ea daily); Cholesterol (atorvastatin calcium) MP MP Bile Acid Sequestrants lovastatin tabs F MP cholestyramine light pack F PRAVACHOL TABS NF MP (pravastatin sodium) cholestyramine light powd F MP pravastatin sodium tabs F MP cholestyramine pack or 4 F MP gm rosuvastatin calcium tabs F cholestyramine powd or 4 F MP simvastatin tabs or 5 mg, MP gm/dose 80 mg, 10 mg, 20 mg, 40 F COLESTID TABS 1 GM NF MP mg (colestipol hcl) ZOCOR TABS NF MP colestipol hcl tabs 1 gm F MP (simvastatin) Intestinal Cholesterol Absorption Inhibitors QUESTRAN LIGHT POWD NF MP (cholestyramine light) ezetimibe tabs F QUESTRAN PACK NF MP (cholestyramine) ZETIA TABS (ezetimibe) NF QUESTRAN POWD NF MP (cholestyramine) ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure Fibric Acid Derivatives ACE Inhibitors fenofibrate micronized caps F MP 134 mg, 200 mg, 67 mg ACCUPRIL TABS NF MP (quinapril hcl) fenofibrate tabs or 145 mg, F MP 48 mg, 54 mg, 160 mg ALTACE CAPS (ramipril) NF MP FENOFIBRIC ACID TABS F benazepril hcl tabs or 10 F MP 105 MG mg, 20 mg, 40 mg, 5 mg fenofibric acid tabs 105 mg, F captopril tabs or 100 mg, F MP 35 mg 12.5 mg, 25 mg, 50 mg FIBRICOR TABS NF enalapril maleate soln or 1 F (fenofibric acid) mg/ml gemfibrozil tabs or F MP enalapril maleate tabs or MP 10 mg, 2.5 mg, 20 mg, 5 F LOPID TABS (gemfibrozil) NF MP mg EPANED SOLN (enalapril TRICOR TABS NF MP NF (fenofibrate) maleate) MP HMG CoA Reductase Inhibitors fosinopril sodium tabs F atorvastatin calcium tabs or QL(1 ea daily); lisinopril tabs or 2.5 mg, 10 MP 10 mg, 20 mg, 40 mg, 80 F MP mg, 20 mg, 30 mg, 40 mg, F mg 5 mg

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTENSIN TABS NF MP QL(0.15 ea (benazepril hcl) CATAPRES-TTS-3 PTWK NF daily); AL(At MP (clonidine) least 6 yrs old); moexipril hcl tabs F MP perindopril erbumine tabs F MP clonidine hcl tabs or 0.1 F MP mg, 0.2 mg, 0.3 mg PRINIVIL TABS (lisinopril) NF MP QL(0.15 ea daily); AL(At clonidine ptwk F quinapril hcl tabs F MP least 6 yrs old); MP MP ramipril caps F doxazosin mesylate tabs or F MP 1 mg, 2 mg, 4 mg, 8 mg MP trandolapril tabs F guanfacine hcl tabs F MP VASOTEC TABS (enalapril NF MP MP maleate) methyldopa tabs F MP ZESTRIL TABS (lisinopril) NF MINIPRESS CAPS NF MP (prazosin hcl) Angiotensin II Receptor Antagonists prazosin hcl caps F MP AVAPRO TABS NF MP (irbesartan) terazosin hcl caps F MP COZAAR TABS (losartan NF MP potassium) Antihypertensive Combinations DIOVAN TABS (valsartan) NF MP ACCURETIC TABS MP (quinapril- NF irbesartan tabs F MP hydrochlorothiazide) amlodipine besylate- F MP losartan potassium tabs or F MP benazepril hcl caps 100 mg, 25 mg, 50 mg atenolol & chlorthalidone F MP valsartan tabs F MP tabs AVALIDE TABS MP Antiadrenergic Antihypertensives (irbesartan- NF hydrochlorothiazide) CARDURA TABS NF MP (doxazosin mesylate) benazepril & F MP hydrochlorothiazide tabs CATAPRES TABS NF MP (clonidine hcl) BENAZEPRIL MP QL(0.15 ea HCL/HYDROCHLOROTHI F AZIDE TABS CATAPRES-TTS-1 PTWK NF daily); AL(At (clonidine) least 6 yrs old); bisoprolol & F MP MP hydrochlorothiazide tabs QL(0.15 ea captopril & F MP CATAPRES-TTS-2 PTWK NF daily); AL(At hydrochlorothiazide tabs (clonidine) least 6 yrs old); DIOVAN HCT TABS MP MP (valsartan- NF hydrochlorothiazide) enalapril maleate & F MP hydrochlorothiazide tabs

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fosinopril sodium & F MP INSPRA TABS NF PA hydrochlorothiazide tabs (eplerenone) HYZAAR TABS (losartan MP Vasodilators NF potassium & MP hydrochlorothiazide) hydralazine hcl tabs or 100 F mg, 25 mg, 50 mg, 10 mg irbesartan- F MP MP hydrochlorothiazide tabs minoxidil tabs or 10 mg, 2.5 F mg lisinopril & F MP hydrochlorothiazide tabs ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) LOPRESSOR HCT TABS MP (metoprolol & NF Antimalarial Combinations hydrochlorothiazide) atovaquone-proguanil hcl F tabs losartan potassium & F MP hydrochlorothiazide tabs COARTEM TABS F LOTENSIN HCT TABS MP (benazepril & NF MALARONE TABS NF hydrochlorothiazide) (atovaquone-proguanil hcl) LOTREL CAPS MP Antimalarials (amlodipine besylate- NF benazepril hcl) chloroquine phosphate tabs F or 250 mg, 500 mg metoprolol & F MP hydrochlorothiazide tabs hydroxychloroquine sulfate F tabs or propranolol & F MP hydrochlorothiazide tabs PLAQUENIL TABS (hydroxychloroquine NF quinapril- F MP sulfate) hydrochlorothiazide tabs primaquine phosphate tabs F TENORETIC 100 TABS NF MP (atenolol & chlorthalidone) PRIMAQUINE TENORETIC 50 TABS NF MP PHOSPHATE TABS NF (atenolol & chlorthalidone) (primaquine phosphate) valsartan- MP F QUALAQUIN CAPS NF hydrochlorothiazide tabs (quinine sulfate) VASERETIC TABS MP (enalapril maleate & NF quinine sulfate caps or F hydrochlorothiazide) ANTIMYASTHENIC/CHOLINERGIC AGENTS ZESTORETIC TABS MP (lisinopril & NF Antimyasthenic/Cholinergic Agents hydrochlorothiazide) MESTINON SOLN NF ZIAC TABS (bisoprolol & NF MP (pyridostigmine bromide) hydrochlorothiazide) MESTINON TABS NF Direct Renin Inhibitors (pyridostigmine bromide) TEKTURNA TABS NF MESTINON TIMESPAN (aliskiren fumarate) TBCR (pyridostigmine NF bromide) Selective Aldosterone Receptor Antagonists pyridostigmine bromide PA F eplerenone tabs F soln or 60 mg/5ml

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyridostigmine bromide F leuprolide acetate kit ij F PA; SP tabs or 60 mg LUPRON DEPOT (1- PA; SP pyridostigmine bromide F F tbcr or 180 mg MONTH) KIT ANTIMYCOBACTERIAL AGENTS - Drugs to LUPRON DEPOT (3- F PA; SP Treat Tuberculosis (Bacterial Infections) MONTH) KIT LUPRON DEPOT (4- F PA; SP Antimycobacterial Agents MONTH) KIT ethambutol hcl tabs or 100 F LUPRON DEPOT (6- F PA; SP mg, 400 mg MONTH) KIT isoniazid syrp or 50 mg/5ml F susp or F 40 mg/ml, 400 mg/10ml isoniazid tabs or 100 mg, F 300 mg megestrol acetate tabs or F 40 mg, 20 mg MYAMBUTOL TABS NF (ethambutol hcl) tamoxifen citrate tabs or 20 F mg, 10 mg pyrazinamide tabs or F toremifene citrate tabs F PA RIFADIN CAPS OR 150 NF MG, 300 MG (rifampin) Antineoplastic Enzyme Inhibitors PA; SP rifampin caps or 150 mg, F AFINITOR DISPERZ TBSO F 300 mg PA; SP ANTINEOPLASTICS AND ADJUNCTIVE AFINITOR TABS 10 MG F THERAPIES - Drugs to Treat Cancer AFINITOR TABS 2.5 MG, 5 NF PA; SP Antimetabolites MG, 7.5 MG (everolimus) PA; SP mercaptopurine tabs or F BELEODAQ SOLR F PA; SP methotrexate sodium tabs F CAPRELSA TABS F or 2.5 mg PA; SP Antineoplastic - Hormonal and Related Agents COTELLIC TABS F PA anastrozole tabs or F everolimus tabs F PA; SP ARIMIDEX TABS PA NF GLEEVEC TABS (imatinib F PA; SP (anastrozole) mesylate) PA; SP ELIGARD KIT F JAKAFI TABS F PA; SP FARESTON TABS NF PA PA; SP (toremifene citrate) lapatinib ditosylate tabs F FASLODEX SOLN NF F PA; SP (fulvestrant) NEXAVAR TABS FEMARA TABS (letrozole) NF NINLARO CAPS F PA; SP PA; SP flutamide caps F sunitinib malate caps F letrozole tabs or F SUTENT CAPS (sunitinib NF PA; SP malate)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYKERB TABS (lapatinib NF PA; SP COMTAN TABS NF ditosylate) (entacapone) VOTRIENT TABS F PA; SP entacapone tabs F

ZOLINZA CAPS F PA; SP Antiparkinson Dopaminergics amantadine hcl caps or 100 F Antineoplastics Misc. mg PA; SP ACTIMMUNE SOLN F amantadine hcl syrp or 50 F mg/5ml PA; SP ALFERON N SOLN F bromocriptine mesylate F caps or 5 mg bexarotene caps F PA; SP bromocriptine mesylate F tabs or 2.5 mg HYDREA CAPS NF (hydroxyurea) carbidopa-levodopa tabs 10 mg-100 mg, 25 mg-100 F hydroxyurea caps or F mg, 25 mg-250 mg PA; SP carbidopa-levodopa tbcr 25 F INTRON A SOLN F mg-100 mg, 50 mg-200 mg PA; SP MIRAPEX TABS INTRON A SOLR F (pramipexole NF dihydrochloride) MATULANE CAPS F SP PARLODEL CAPS NF SYLATRON KIT F PA; SP (bromocriptine mesylate) PARLODEL TABS NF TARGRETIN CAPS NF PA; SP (bromocriptine mesylate) (bexarotene) pramipexole tretinoin (chemotherapy) SP F dihydrochloride tabs 0.125 F caps mg, 0.25 mg, 0.5 mg, 0.75 Chemotherapy Rescue/Antidote/Protective Agents mg, 1 mg, 1.5 mg ropinirole hydrochloride leucovorin calcium tabs or F PA 25 mg, 5 mg, 10 mg, 15 mg tabs 0.25 mg, 3 mg, 0.5 F mg, 1 mg, 2 mg, 4 mg, 5 Mitotic Inhibitors mg PA; SP etoposide caps or F SINEMET CR TBCR NF (carbidopa-levodopa) ANTIPARKINSON AND RELATED THERAPY SINEMET TABS NF AGENTS - Drugs to Treat Parkinson's Disease (carbidopa-levodopa) Antiparkinson Anticholinergics STALEVO 100 TABS MP (carbidopa-levodopa- NF benztropine mesylate tabs F or 0.5 mg, 1 mg, 2 mg entacapone) STALEVO 100 TABS trihexyphenidyl hcl soln F (carbidopa-levodopa- NF entacapone) trihexyphenidyl hcl tabs F STALEVO 125 TABS (carbidopa-levodopa- NF Antiparkinson COMT Inhibitors entacapone)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 125 TABS MP QL(2 ea daily); carbidopa-levodopa- NF GEODON CAPS OR 80 NF AL(At least 6 ( MG (ziprasidone hcl) entacapone) yrs old) STALEVO 150 TABS MP QL(1 ea daily); (carbidopa-levodopa- NF LATUDA TABS F AL(At least 6 entacapone) yrs old) STALEVO 150 TABS QL(3 ea daily); NF ziprasidone hcl caps 20 F AL(At least 6 (carbidopa-levodopa- mg, 40 mg, 60 mg entacapone) yrs old) STALEVO 200 TABS MP QL(2 ea daily); (carbidopa-levodopa- NF ziprasidone hcl caps 80 mg F AL(At least 6 entacapone) yrs old) STALEVO 200 TABS Benzisoxazoles (carbidopa-levodopa- NF ) 1 rtl pack lmt entacapone amt,28 rtl pack STALEVO 50 TABS MP INVEGA SUSTENNA F lmt day(s),; (carbidopa-levodopa- NF SUSY AL(At least 18 entacapone) yrs old); SP STALEVO 50 TABS ST; Try Invega (carbidopa-levodopa- NF Sustenna first; entacapone) Limit 1 per 3 STALEVO 75 TABS MP months;1 rtl (carbidopa-levodopa- NF INVEGA TRINZA SUSY F pack lmt entacapone) amt,90 rtl pack STALEVO 75 TABS lmt day(s),; (carbidopa-levodopa- NF AL(At least 18 entacapone) yrs old); SP Limit 2 per 4 ANTIPSYCHOTICS/ANTIMANIC AGENTS - weeks;;2 rtl Drugs to Treat Mood Disorders RISPERDAL CONSTA F MAX fill,28 rtl Antimanic Agents SRER day(s) supply,; AL(At least 18 lithium carbonate caps or F AL(At least 6 150 mg, 300 mg, 600 mg yrs old) yrs old); SP QL(8 ml lithium carbonate tabs or F AL(At least 6 300 mg yrs old) daily,240 ml RISPERDAL SOLN 1 NF per 30 days MG/ML (risperidone) lithium carbonate tbcr or F AL(At least 6 retail); AL(At 300 mg, 450 mg yrs old) least 6 yrs old) AL(At least 6 LITHIUM SOLN F QL(4 ea daily); yrs old) RISPERDAL TABS 0.25 NF AL(At least 6 MG, 0.5 MG (risperidone) LITHOBID TBCR (lithium NF AL(At least 6 yrs old) carbonate) yrs old) QL(3 ea daily); RISPERDAL TABS 1 MG, NF AL(At least 6 Antipsychotics - Misc. 2 MG (risperidone) GEODON CAPS OR 20 QL(3 ea daily); yrs old) MG, 40 MG, 60 MG NF AL(At least 6 QL(2 ea daily); RISPERDAL TABS 3 MG, NF (ziprasidone hcl) yrs old) 4 MG (risperidone) AL(At least 6 yrs old)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(8 ml QL(5 ea daily); daily,240 ml FAZACLO TBDP 100 MG, NF AL(At least 18 25 MG (clozapine) risperidone soln 1 mg/ml F per 30 days yrs old) retail); AL(At FAZACLO TBDP 12.5 MG NF least 6 yrs old) (clozapine) QL(4 ea daily); risperidone tabs 0.25 mg, QL(5 ea daily); F AL(At least 6 FAZACLO TBDP 150 MG F 0.5 mg (clozapine) AL(At least 18 yrs old) yrs old) QL(3 ea daily); AL(At least 6 risperidone tabs 1 mg, 2 F AL(At least 6 loxapine succinate caps F mg yrs old) yrs old) QL(2 ea daily); QL(2 ea daily); olanzapine tabs or 10 mg, F AL(At least 6 risperidone tabs 3 mg, 4 F AL(At least 6 5 mg mg yrs old) yrs old) QL(1 ea daily); risperidone tbdp 0.25 mg, QL(2 ea daily); olanzapine tabs or 15 mg, F AL(At least 6 2.5 mg, 20 mg, 7.5 mg 0.5 mg, 1 mg, 2 mg, 3 mg, F AL(At least 6 yrs old) 4 mg yrs old) QL(2 ea daily); Butyrophenones olanzapine tbdp or 10 mg, F AL(At least 6 5 mg HALDOL DECANOATE AL(At least 18 yrs old) 100 SOLN (haloperidol NF yrs old); SP QL(1 ea daily); decanoate) olanzapine tbdp or 15 mg, F AL(At least 6 20 mg HALDOL DECANOATE 50 AL(At least 18 yrs old) SOLN (haloperidol NF yrs old); SP quetiapine fumarate tabs QL(4 ea daily); decanoate) 100 mg, 200 mg, 25 mg, 50 F AL(At least 6 mg yrs old) HALDOL SOLN NF AL(At least 6 (haloperidol lactate) yrs old); SP QL(2 ea daily); quetiapine fumarate tabs F AL(At least 6 haloperidol decanoate soln F AL(At least 18 300 mg, 400 mg im 100 mg/ml, 50 mg/ml yrs old); SP yrs old) SEROQUEL TABS 100 QL(4 ea daily); haloperidol lactate conc or F AL(At least 6 2 mg/ml yrs old) MG, 200 MG, 25 MG, 50 NF AL(At least 6 MG (quetiapine fumarate) yrs old) haloperidol lactate soln ij 5 F AL(At least 6 mg/ml yrs old); SP SEROQUEL TABS 300 QL(2 ea daily); NF AL(At least 6 MG, 400 MG (quetiapine AL(At least 6 haloperidol tabs or 0.5 mg, fumarate) yrs old) 1 mg, 10 mg, 2 mg, 20 mg, F yrs old) 5 mg QL(2 ea daily); ZYPREXA TABS OR 10 NF AL(At least 6 MG, 5 MG (olanzapine) Dibenzapines yrs old) QL(5 ea daily); ZYPREXA TABS OR 15 QL(1 ea daily); clozapine tabs F AL(At least 18 MG, 2.5 MG, 20 MG, 7.5 NF AL(At least 6 yrs old) MG (olanzapine) yrs old) QL(5 ea daily); QL(2 ea daily); clozapine tbdp F AL(At least 18 ZYPREXA ZYDIS TBDP 10 NF AL(At least 6 MG, 5 MG (olanzapine) yrs old) yrs old) QL(5 ea daily); CLOZARIL TABS QL(1 ea daily); NF AL(At least 18 ZYPREXA ZYDIS TBDP 15 NF AL(At least 6 (clozapine) MG, 20 MG (olanzapine) yrs old) yrs old) Phenothiazines

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chlorpromazine hcl tabs or AL(At least 6 Limit 1 per 8 10 mg, 100 mg, 200 mg, 25 F yrs old) weeks;1 rtl mg, 50 mg pack lmt ARISTADA PRSY 1064 F amt,56 rtl pack fluphenazine decanoate F AL(At least 18 MG/3.9ML soln ij yrs old); SP lmt day(s),; AL(At least 18 fluphenazine hcl conc or 5 F AL(At least 6 yrs old); SP mg/ml yrs old) 1 rtl pack lmt fluphenazine hcl elix or 2.5 F AL(At least 6 ARISTADA PRSY 441 amt,28 rtl pack mg/5ml yrs old) MG/1.6ML, 662 MG/2.4ML, F lmt day(s),; fluphenazine hcl tabs or 1 F AL(At least 6 882 MG/3.2ML AL(At least 18 mg, 10 mg, 2.5 mg, 5 mg yrs old) yrs old); SP perphenazine tabs or 16 F AL(At least 6 Thioxanthenes mg, 2 mg, 4 mg, 8 mg yrs old) AL(At least 6 thiothixene caps F prochlorperazine maleate F AL(At least 6 yrs old) tabs or 10 mg, 5 mg yrs old) AL(At least 6 ANTISEPTICS & DISINFECTANTS prochlorperazine supp F yrs old) Antiseptics & Disinfectants thioridazine hcl tabs or 10 F AL(At least 6 mg, 100 mg, 25 mg, 50 mg yrs old) HYDROGEN PEROXIDE F SOLN EX 3 % AL(At least 6 trifluoperazine hcl tabs F yrs old) hydrogen peroxide soln ex F 3 % Quinolinone Derivatives 1 rtl pack lmt ANTIVIRALS - Drugs to Treat Viral Infections amt,28 rtl pack ABILIFY MAINTENA PRSY F lmt day(s),; Antiretrovirals AL(At least 18 abacavir sulfate soln F MP yrs old); SP 1 rtl pack lmt abacavir sulfate tabs F MP amt,28 rtl pack ABILIFY MAINTENA SRER F lmt day(s),; abacavir sulfate-lamivudine F MP AL(At least 18 tabs yrs old); SP abacavir sulfate- F MP QL(1 ea daily); lamivudine-zidovudine tabs ABILIFY TABS NF MP (aripiprazole) AL(At least 6 APTIVUS CAPS F yrs old) QL(1 ea daily); APTIVUS SOLN F MP aripiprazole tabs F AL(At least 6 yrs old) atazanavir sulfate caps F MP Limit 2 doses per 365 Days;2 ATRIPLA TABS (efavirenz- rtl MAX fill,365 emtricitabine-tenofovir F ARISTADA INITIO PRSY F rtl day(s) disoproxil fumarate) QL(1 ea daily); supply,; AL(At BIKTARVY TABS F least 18 yrs MP old); SP COMBIVIR TABS NF MP (lamivudine-zidovudine)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPLERA TABS F MP ISENTRESS TABS F MP

CRIXIVAN CAPS F MP KALETRA SOLN (lopinavir- NF MP ritonavir) MP DESCOVY TABS F KALETRA TABS (lopinavir- NF MP ritonavir) Generic didanosine cpdr F MP preferred lamivudine soln F MP EDURANT TABS F lamivudine tabs F MP MP efavirenz caps F lamivudine-zidovudine tabs F MP MP efavirenz tabs F LEXIVA SUSP 50 MG/ML F MP MP emtricitabine caps F LEXIVA TABS 700 MG NF MP (fosamprenavir calcium) EMTRIVA CAPS 200 MG NF MP MP (emtricitabine) lopinavir-ritonavir soln F EMTRIVA SOLN 10 F MP MP MG/ML lopinavir-ritonavir tabs F EPIVIR SOLN (lamivudine) NF MP nevirapine susp 50 mg/5ml F MP

EPIVIR TABS (lamivudine) NF MP nevirapine tabs 200 mg F MP

EPZICOM TABS (abacavir NF MP nevirapine tb24 100 mg F sulfate-lamivudine) MP etravirine tabs F MP nevirapine tb24 400 mg F MP EVOTAZ TABS F MP NORVIR SOLN 80 MG/ML F MP NORVIR TABS 100 MG NF MP fosamprenavir calcium tabs F (ritonavir) PA; 1 rtl pack ODEFSEY TABS F MP lmt amt,30 rtl FUZEON SOLR F pack lmt PIFELTRO TABS F day(s),; SP MP GENVOYA TABS F MP PREZCOBIX TABS F PREZISTA SUSP 100 MP INTELENCE TABS 100 NF MP F MG, 200 MG (etravirine) MG/ML INTELENCE TABS 25 MG F MP PREZISTA TABS 150 MG F PREZISTA TABS 600 MG, MP F MP F INVIRASE TABS 75 MG, 800 MG ISENTRESS CHEW F MP RESCRIPTOR TABS F MP MP ISENTRESS PACK F RETROVIR CAPS NF MP (zidovudine)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETROVIR SYRP NF MP VIRAMUNE SUSP NF MP (zidovudine) (nevirapine) REYATAZ CAPS 150 MG, MP VIRAMUNE TABS NF MP 200 MG, 300 MG NF (nevirapine) (atazanavir sulfate) VIRAMUNE XR TB24 NF MP REYATAZ PACK 50 MG F MP (nevirapine) VIREAD POWD 40 MG/GM F MP ritonavir tabs F MP VIREAD TABS 150 MG, F MP SELZENTRY SOLN F PA 200 MG, 250 MG VIREAD TABS 300 MG MP SELZENTRY TABS F PA (tenofovir disoproxil NF fumarate) STAVUDINE CAPS 15 MG, F MP 20 MG, 30 MG, 40 MG ZIAGEN SOLN (abacavir NF MP sulfate) stavudine caps 15 mg, 20 F MP mg, 30 mg, 40 mg ZIAGEN TABS (abacavir NF MP sulfate) STRIBILD TABS F zidovudine caps F MP SUSTIVA CAPS (efavirenz) NF MP zidovudine syrp F MP SUSTIVA TABS (efavirenz) NF MP zidovudine tabs F MP tenofovir disoproxil F MP fumarate tabs CMV Agents PA TIVICAY TABS 10 MG, 25 F cidofovir soln F MG MP CYTOVENE SOLR NF PA TIVICAY TABS 50 MG F (ganciclovir sodium) PA TRIUMEQ TABS F MP foscarnet sodium soln F TRIZIVIR TABS (abacavir MP FOSCAVIR SOLN NF PA sulfate-lamivudine- NF (foscarnet sodium) zidovudine) ganciclovir sodium solr F PA TRUVADA TABS Brand (emtricitabine-tenofovir F Preferred VALCYTE SOLR NF PA disoproxil fumarate) (valganciclovir hcl) QL(1 ea daily) VALCYTE TABS NF PA TYBOST TABS F (valganciclovir hcl) VIDEX EC CPDR 125 MG F Generic valganciclovir hcl solr F PA preferred VIDEX EC CPDR 200 MG, Generic valganciclovir hcl tabs F PA 250 MG, 400 MG NF preferred (didanosine) Hepatitis Agents VIDEXPEDIATRIC SOLR F Generic PA preferred adefovir dipivoxil tabs F VIRACEPT TABS F MP BARACLUDE SOLN 0.05 F PA MG/ML

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BARACLUDE TABS 0.5 NF PA ZOVIRAX SUSP OR 200 NF MG, 1 MG (entecavir) MG/5ML (acyclovir) entecavir tabs F PA ZOVIRAX TABS OR 400 NF MG, 800 MG (acyclovir) EPIVIR HBV SOLN 5 F Influenza Agents MG/ML FLUMADINE TABS NF EPIVIR HBV TABS 100 NF (rimantadine hydrochloride) MG (lamivudine (hbv)) oseltamivir phosphate caps F QL(20 ea per HEPSERA TABS (adefovir NF PA or 30 mg, 45 mg, 75 mg 270 days retail) dipivoxil) oseltamivir phosphate susr F QL(25 ml daily) lamivudine (hbv) tabs F or 6 mg/ml PA; SP RELENZA DISKHALER F MAVYRET TABS F AEPB rimantadine hydrochloride PEGASYS PROCLICK F PA; SP F SOLN tabs PA; SP TAMIFLU CAPS 30 MG, 45 QL(20 ea per PEGASYS SOLN F MG, 75 MG (oseltamivir NF 270 days retail) phosphate) PEGINTRON KIT F PA; SP TAMIFLU SUSR 6 MG/ML NF QL(25 ml daily) (oseltamivir phosphate) RIBASPHERE RIBAPAK F PA; SP TBPK BETA BLOCKERS - Drugs to Treat High Blood RIBASPHERE TABS F PA; SP Pressure Alpha-Beta Blockers ribavirin (hepatitis c) caps F PA; SP carvedilol tabs F MP ribavirin (hepatitis c) tabs F PA; SP COREG TABS (carvedilol) NF MP SOFOSBUVIR/VELPATAS F PA; SP VIR TABS labetalol hcl tabs or 100 F MP mg, 200 mg, 300 mg VEMLIDY TABS F PA; SP Beta Blockers Cardio-Selective Herpes Agents atenolol tabs or 100 mg, 25 F MP mg, 50 mg acyclovir caps or 200 mg F bisoprolol fumarate tabs or F MP 10 mg, 5 mg acyclovir susp or 200 F mg/5ml LOPRESSOR TABS NF MP (metoprolol tartrate) acyclovir tabs or 400 mg, F 800 mg metoprolol succinate tb24 F MP famciclovir tabs or 125 mg, F PA 250 mg, 500 mg metoprolol tartrate tabs or MP 37.5 mg, 75 mg, 100 mg, F valacyclovir hcl tabs or 500 F mg, 1 gm, 1000 mg 25 mg, 50 mg TENORMIN TABS MP VALTREX TABS NF NF (valacyclovir hcl) (atenolol) TOPROL XL TB24 MP ZOVIRAX CAPS OR 200 NF NF MG (acyclovir) (metoprolol succinate)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Beta Blockers Non-Selective CARDIZEM TABS NF MP (diltiazem hcl) BETAPACE AF TABS NF MP (sotalol hcl (afib/afl)) diltiazem hcl coated beads QL(1 ea daily); cp24 120 mg, 180 mg, 240 F MP BETAPACE TABS (sotalol NF MP hcl) mg, 300 mg, 360 mg MP PA req age 19 diltiazem hcl cp12 or 120 F and up or use mg CORGARD TABS (nadolol) NF alternative;AL( diltiazem hcl cp12 or 60 F QL(2 ea daily); Up to 18 yrs old mg, 90 mg MP ); MP diltiazem hcl cp24 or 120 F QL(2 ea daily); mg MP INDERAL LA CP24 NF MP (propranolol hcl) diltiazem hcl cp24 or 180 F QL(1 ea daily); PA req age 19 mg, 240 mg MP and up or use nadolol tabs or 20 mg, 40 diltiazem hcl extended F QL(1 ea daily); F alternative;AL( release beads cp24 MP mg, 80 mg Up to 18 yrs old diltiazem hcl tabs or 120 F MP ); MP mg, 30 mg, 60 mg, 90 mg propranolol hcl cp24 or 60 MP MP mg, 80 mg, 120 mg, 160 F felodipine tb24 F mg nifedipine caps or 10 mg, F MP propranolol hcl soln or 20 F 20 mg mg/5ml nifedipine tb24 or 30 mg, F QL(2 ea daily) propranolol hcl soln or 40 F MP 60 mg, 90 mg mg/5ml nifedipine tb24 or 30 mg, F QL(2 ea daily); propranolol hcl tabs or 10 MP 60 mg, 90 mg MP mg, 20 mg, 80 mg, 40 mg, F NORVASC TABS NF QL(1 ea daily); 60 mg (amlodipine besylate) MP MP sotalol hcl (afib/afl) tabs F PROCARDIA CAPS NF MP (nifedipine) sotalol hcl tabs F MP PROCARDIA XL TB24 NF QL(2 ea daily) (nifedipine) CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure TIAZAC CP24 (diltiazem QL(1 ea daily); hcl extended release NF MP Calcium Channel Blockers beads) ADALAT CC TB24 QL(2 ea daily); NF verapamil hcl cp24 or 120 F QL(1 ea daily) (nifedipine) MP mg, 180 mg, 240 mg amlodipine besylate tabs or QL(1 ea daily); F verapamil hcl tabs or 40 F MP 10 mg, 2.5 mg, 5 mg MP mg, 120 mg, 80 mg CALAN SR TBCR MP NF verapamil hcl tbcr or 120 F MP (verapamil hcl) mg, 180 mg, 240 mg CALAN TABS (verapamil NF MP VERELAN CP24 120 MG, QL(1 ea daily) hcl) 180 MG, 240 MG NF CARDIZEM CD CP24 QL(1 ea daily); (verapamil hcl) (diltiazem hcl coated NF MP CARDIOTONICS - Drugs to Treat Heart Failure beads) and Abnormal Heart Rhythm Cardiac Glycosides Arizona Complete Health - Complete Care Plan Effective September 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits digoxin soln or 0.05 mg/ml F MP cefazolin sodium solr ij 1 F gm digoxin tabs or 0.125 mg, MP F cefazolin sodium solr iv 1 F 125 mcg gm digoxin tabs or 0.25 mg, F CEFAZOLIN SODIUM 250 mcg SOSY IV 1 GM/10ML, 2 F GM/20ML LANOXIN TABS OR 125 NF MP MCG (digoxin) CEFAZOLIN SODIUM/DEXTROSE LANOXIN TABS OR 250 NF F MCG (digoxin) SOLR 1 GM-4 %, 2 GM-3 % LANOXIN TABS OR 62.5 F MCG CEFAZOLIN SOLN F CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions cephalexin caps F Cardiovascular Agents Misc. - Combinations cephalexin susr F ENTRESTO TABS F PA; MP cephalexin tabs F Pulmonary Hypertension - Endothelin Receptor KEFLEX CAPS NF LETAIRIS TABS F PA; SP (cephalexin) (ambrisentan) Cephalosporins - 2nd Generation TRACLEER TABS 125 F PA; SP MG, 62.5 MG (bosentan) cefaclor caps F TRACLEER TBSO 32 MG F PA; SP CEFACLOR ER TB12 F Pulmonary Hypertension - Phosphodiesterase cefaclor susr F ADCIRCA TABS (tadalafil F PA; SP (pulmonary hypertension)) cefprozil susr F REVATIO SUSR 10 AL(Up to 11 yrs MG/ML (sildenafil citrate F old ); SP; MP cefprozil tabs F (pulmonary hypertension)) REVATIO TABS 20 MG PA; SP; MP cefuroxime axetil tabs F (sildenafil citrate NF (pulmonary hypertension)) Cephalosporins - 3rd Generation sildenafil citrate (pulmonary F PA; SP; MP hypertension) tabs 20 mg cefdinir caps F CEPHALOSPORINS - Drugs to Treat Bacterial cefdinir susr F Infections Cephalosporins - 1st Generation cefixime caps 400 mg F cefadroxil caps F 50ml per cefixime susr 100 mg/5ml F month;QL(1.67 cefadroxil susr F ml daily) cefixime susr 200 mg/5ml F QL(10 ml daily) cefadroxil tabs F cefpodoxime proxetil susr F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefpodoxime proxetil tabs F drospirenone-ethinyl estradiol tabs 0.03 mg-3 F mg, 0.02 mg-3 mg ceftriaxone sodium in F dextrose soln ESTROSTEP FE TABS (norethindrone acetate- NF ceftriaxone sodium solr ij 1 F gm, 2 gm, 250 mg, 500 mg ethinyl estradiol-fe) ethynodiol diacet & eth CEFTRIAXONE SODIUM F F SOLR IJ 100 GM estrad tabs GENERESS FE CHEW ceftriaxone sodium solr iv 1 F gm, 2 gm, 10 gm (norethindrone & ethinyl NF estradiol-fe) CEFTRIAXONE/DEXTROS F E SOLR levonorgestrel & eth F estradiol tabs SUPRAX CAPS 400 MG NF (cefixime) levonorgestrel-eth estradiol F (triphasic) tabs SUPRAX CHEW 100 MG, F 200 MG levonorgestrel-ethinyl F 50ml per estradiol (91-day) tabs SUPRAX SUSR 100 NF levonorgestrel-ethinyl MG/5ML (cefixime) month;QL(1.67 F ml daily) estradiol (continuous) tabs LOSEASONIQUE TABS SUPRAX SUSR 200 NF QL(10 ml daily) MG/5ML (cefixime) (levonorgestrel-ethinyl NF estradiol (91-day)) Cephalosporins - 4th Generation MINASTRIN 24 FE CHEW NF cefepime hcl solr F (norethin acet & estrad-fe) MIRCETTE TABS CEFEPIME SOLN F (-ethinyl NF estradiol (biphasic)) MAXIPIME SOLR IJ 1 GM, NF 2 GM (cefepime hcl) norethin acet & estrad-fe F MP caps 1 mg-20 mcg-75 mg CONTRACEPTIVES - Drugs to Prevent Pregnancy norethin acet & estrad-fe F chew 1 mg-20 mcg-75 mg Combination Contraceptives - Oral norethin acet & estrad-fe F QL(1 ea daily) desogestrel & ethinyl tabs 1 mg-20 mcg-75 mg estradiol tabs 0.03 mg-0.15 F norethin acet & estrad-fe mg, 0.15 mg-30 mcg tabs 1 mg-20 mcg-75 mg, F desogestrel & ethinyl MP 1.5 mg-30 mcg-75 mg estradiol tabs 0.15 mg-30 F norethindrone & eth mcg estradiol tabs 0.5 mg-35 F desogestrel-ethinyl F mcg, 0.4 mg-35 mcg, 1 mg- estradiol (biphasic) tabs 35 mcg desogestrel-ethinyl F norethindrone & ethinyl estradiol (triphasic) tabs estradiol-fe chew 0.4 mg- F drospirenone-ethinyl MP 35 mcg, 0.8 mg-25 mcg-75 estradiol tabs 0.03 mg-3 F mg mg norethindrone & ethinyl MP estradiol-fe chew 0.8 mg- F 25 mcg-75 mg

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone acet & eth F levonorgestrel (emergency F estra tabs oc) tabs norethindrone acetate- F PLAN B ONE-STEP TABS ethinyl estradiol-fe tabs (levonorgestrel (emergency F oc)) norethindrone-eth estradiol F (triphasic) tabs PLAN B ONE-STEP TABS (levonorgestrel (emergency NF norgestimate-ethinyl F estradiol (triphasic) tabs oc)) Progestin Contraceptives - Implants norgestimate-ethinyl F estradiol tabs Specialty norgestrel & ethinyl Medication; limit 1 fill per 3 estradiol tabs 0.3 mg-30 F NEXPLANON IMPL F mcg years;QL(1 ea ORTHO TRI-CYCLEN LO per 999 days TABS (norgestimate-ethinyl NF retail) estradiol (triphasic)) Progestin Contraceptives - Injectable ORTHO-NOVUM 1/35 DEPO-PROVERA TABS (norethindrone & eth NF CONTRACEPTIVE SUSP NF estradiol) (medroxyprogesterone ORTHO-NOVUM 7/7/7 acetate (contraceptive)) TABS (norethindrone-eth NF DEPO-PROVERA estradiol (triphasic)) CONTRACEPTIVE SUSY NF SEASONIQUE TABS (medroxyprogesterone (levonorgestrel-ethinyl NF acetate (contraceptive)) estradiol (91-day)) medroxyprogesterone acetate (contraceptive) F TAYTULLA CAPS NF MP (norethin acet & estrad-fe) susp medroxyprogesterone TYBLUME CHEW F acetate (contraceptive) F YASMIN 28 TABS susy (drospirenone-ethinyl NF Progestin Contraceptives - Oral estradiol) norethindrone F MP YAZ TABS (drospirenone- NF (contraceptive) tabs ethinyl estradiol) norethindrone F Combination Contraceptives - Transdermal (contraceptive) tabs XULANE F ORTHO MICRONOR TABS (norethindrone NF Combination Contraceptives - Vaginal (contraceptive)) NUVARING RING - Steroid Hormone Drugs to (-ethinyl F Treat Systemic Swelling Conditions estradiol) Glucocorticosteroids NUVARING RING MP (etonogestrel-ethinyl NF budesonide cpep or 3 mg F QL(3 ea daily) estradiol) CORTEF TABS NF Emergency Contraceptives (hydrocortisone)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPO-MEDROL SUSP 40 sodium MG/ML NF phosphate soln or 15 F ( mg/5ml, 5 mg/5ml, 6.7 acetate) mg/5ml elix or 0.5 F prednisolone sodium mg/5ml phosphate tbdp or 10 mg, F 15 mg, 30 mg DEXAMETHASONE F INTENSOL CONC prednisolone soln or F dexamethasone soln or 0.5 F mg/5ml INTENSOL F dexamethasone tabs or 1 CONC mg, 1.5 mg, 2 mg, 4 mg, F prednisone soln or 5 F 0.5 mg, 0.75 mg, 6 mg mg/5ml prednisone tabs or 1 mg, dexamethasone tbpk or 1.5 F mg 10 mg, 2.5 mg, 5 mg, 50 F mg, 20 mg ENTOCORT EC CPEP NF QL(3 ea daily) (budesonide) prednisone tbpk or 10 mg, F 5 mg hydrocortisone tabs or 10 F mg, 20 mg, 5 mg SOLU-CORTEF SOLR F PA KENALOG-10 SUSP F PA SOLU-MEDROL SOLR 2 F PA GM KENALOG-40 SUSP NF ( acetonide) SOLU-MEDROL SOLR 500 PA MG, 1000 MG, 125 MG, 40 MEDROL DOSEPAK TBPK NF NF (methylprednisolone) MG (methylprednisolone sod succ) MEDROL TABS 16 MG, 32 MG, 8 MG, 4 MG NF TRIAMCINOLONE F PA (methylprednisolone) ACETONIDE PF SUSP TRIAMCINOLONE PA MEDROL TABS 2 MG F ACETONIDE SUSP IJ 50 F MG/ML methylprednisolone sod F PA succ solr Mineralocorticoids acetate tabs methylprednisolone tabs or F F 16 mg, 32 mg, 8 mg, 4 mg or methylprednisolone tbpk or F COUGH/COLD/ALLERGY - Drugs to Treat 4 mg Cough, Cold and Allergy Symptoms MILLIPRED TABS F Antitussives ORAPRED ODT TBDP benzonatate caps F (prednisolone sodium NF phosphate) DELSYM COUGH CHILDRENS SUER NF PEDIAPRED SOLN (dextromethorphan (prednisolone sodium NF polistirex) phosphate) DELSYM SUER (dextromethorphan NF polistirex)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan hbr caps F brompheniramine & F QL(8 ml daily) or 15 mg pseudoeph elix dextromethorphan hbr syrp F brompheniramine & F QL(8 ml daily) or 15 mg/5ml pseudoeph liqd dextromethorphan F BRONKIDS LIQD F polistirex lqcr QL(16 ml daily) dextromethorphan F BRONTUSS DX LIQD F polistirex suer QL(240 ml per cetirizine-pseudoephedrine F QL(2 ea daily) HYCODAN SYRP 12 days retail); tb12 (hydrocodone w/ NF CHERACOL PLUS LIQD QL(16 ml daily) homatropine) AL(At least 18 yrs old) (dextromethorphan- NF QL(240 ml per guaifenesin) hydrocodone w/ CHERACOL-D COUGH QL(16 ml daily) F 12 days retail); homatropine syrp 1.5 AL(At least 18 LIQD (dextromethorphan- NF mg/5ml-5 mg/5ml yrs old) guaifenesin) hydrocodone w/ AL(At least 18 chlorpheniramine & F homatropine tabs 1.5 mg-5 F yrs old) pseudoeph tabs mg CLARITIN-D 12 HOUR QL(2 ea daily) ROBITUSSIN LINGERING TB12 (loratadine & NF pseudoephedrine) COLDLONG-ACTING NF COUGHGELS CAPS CLARITIN-D 24 HOUR QL(1 ea daily) (dextromethorphan hbr) TB24 (loratadine & NF pseudoephedrine) TESSALON PERLES NF CAPS (benzonatate) CVS SINUS RELIEF Cough/Cold/Allergy Combinations DAYTIME/NIGHTTIME F TBPK QL(16 ml daily) ACTIDOM DMX LIQD F dextromethorphan- QL(16 ml daily) QL(16 ml daily) guaifenesin liqd 10 mg/5ml- ACTINEL DM LIQD F 200 mg/5ml, 20 mg/10ml- 400 mg/10ml, 10 mg/5ml- F ALLEGRA-D 12 HOUR QL(2 ea daily) ALLERGY & 100 mg/5ml, 15 mg/7.5ml- 150 mg/7.5ml, 20 mg/10ml- CONGESTION TB12 NF (fexofenadine- 200 mg/10ml pseudoephedrine) dextromethorphan- guaifenesin liqd 20 ALLEGRA-D 24 HOUR QL(1 ea daily) F ALLERGY & mg/20ml-400 mg/20ml, 5 mg/5ml-100 mg/5ml CONGESTION TB24 NF (fexofenadine- dextromethorphan- pseudoephedrine) guaifenesin syrp 10 F mg/5ml-10 mg/5ml-100 BALAMINE DM SYRP F mg/5ml-100 mg/5ml QL(16 ml daily) dextromethorphan- QL(2 ea daily) BIODESP DM SYRP F guaifenesin tabs 20 mg-20 F brompheniramine & mg-400 mg-400 mg dextromethorphan- QL(2 ea daily) phenyleph elix 1 mg/5ml-1 F mg/5ml-2.5 mg/5ml-2.5 guaifenesin tb12 30 mg- F mg/5ml 600 mg Arizona Complete Health - Complete Care Plan Effective September 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIMETAPP COLD & MAXI-TUSS PE LIQD F ALLERGY ELIX NF (brompheniramine & MAXI-TUSS PE MAX LIQD F phenyleph) QL(16 ml daily) MUCINEX CHILDRENS QL(16 ml daily) DOMETUSS-DMX LIQD F FREEFROM MULTI- SYMPTOM COLD AND NF ED BRON GP LIQD F STUFFY NOS LIQD (phenylephrine w/ dm-gg) FATHER JOHNS F MEDICINE PLUS SOLN MUCINEX CHILDRENS QL(16 ml daily) fexofenadine- QL(2 ea daily) MULTI-SYMPTOM COLD NF pseudoephedrine tb12 60 F LIQD (phenylephrine w/ mg-120 mg dm-gg) fexofenadine- QL(1 ea daily) MUCINEX CHILDRENS pseudoephedrine tb24 180 F STUFFYNOSE AND mg-240 mg CHEST CONGESTION NF LIQD (phenylephrine- G-TUSICOF LIQD F QL(16 ml daily) guaifenesin) MUCINEX CONGESTION QL(16 ml daily) G-ZYNCOF SYRP F & COUGH CHILDRENS NF LIQD (phenylephrine w/ GILTUSS COUGH & COLD F RX/OTC TABS dm-gg) MUCINEX COUGH & QL(16 ml daily) GILTUSS TR TABS F RX/OTC CONGESTION NF CHILDRENS LIQD QL(240 ml per (phenylephrine w/ dm-gg) guaifenesin-codeine liqd 10 F 12 days retail); mg/5ml-100 mg/5ml AL(At least 18 MUCINEX D TB12 yrs old) (pseudoephedrine- NF guaifenesin) QL(240 ml per MUCINEX DM TB12 QL(2 ea daily) guaifenesin-codeine soln F 12 days retail); 10 mg/5ml-100 mg/5ml AL(At least 18 (dextromethorphan- NF yrs old) guaifenesin) QL(240 ml per MUCINEX FAST-MAX QL(16 ml daily) SEVERE CONGESTION & guaifenesin-codeine syrp F 12 days retail); 10 mg/5ml-100 mg/5ml AL(At least 18 COUGH CLEAR & COOL NF yrs old) LIQD (phenylephrine w/ dm-gg) QL(16 ml daily) LOHIST-D LIQD F MUCINEX FAST-MAX QL(16 ml daily) SEVERE CONGESTION & LOHIST-DM SYRP F QL(16 ml daily) COUGH LIQD 2.5 NF loratadine & QL(2 ea daily) MG/5ML-5 MG/5ML-100 pseudoephedrine tb12 5 F MG/5ML (phenylephrine w/ mg-120 mg dm-gg) loratadine & QL(1 ea daily) MUCINEX SINUS-MAX pseudoephedrine tb24 10 F DAY TIME/NIGHT TIME F mg-10 mg-240 mg-240 mg LQPK MAXI-TUSS DM LIQD F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUCINEX STUFFY NOSE QL(240 ml per & COLD CHILDRENS NF promethazine w/codeine F 12 days retail); LIQD (phenylephrine- soln AL(At least 18 guaifenesin) yrs old) NEOTUSS PLUS LIQD F QL(240 ml per promethazine w/codeine F 12 days retail); NEOTUSS-D LIQD F QL(16 ml daily) syrp AL(At least 18 yrs old) NIVANEX DMX TABS F promethazine-dm syrp F QL(16 ml daily) phenylephrine w/ dm-gg QL(16 ml daily) pseudoephed-bromphen- F liqd 10 mg/5ml-15 mg/5ml- dm syrp 350 mg/5ml, 2.5 mg/5ml-5 QL(240 ml per mg/5ml-75 mg/5ml, 2.5 pseudoephedrine w/ F 12 days retail); mg/ml-5 mg/ml-100 mg/ml, codeine-gg soln AL(At least 18 10 mg/5ml-15 mg/5ml-300 yrs old) mg/5ml, 2.5 mg/ml-5 mg/ml-50 mg/ml, 5 pseudoephedrine w/ dm-gg mg/2.5ml-7.5 mg/2.5ml-150 liqd 10 mg/5ml-30 mg/5ml- F 100 mg/5ml mg/2.5ml, 5 mg/5ml-10 F mg/5ml-200 mg/5ml, 10 pseudoephedrine- mg/10ml-20 mg/10ml-200 guaifenesin tb12 60 mg- F mg/10ml, 5 mg/5ml-10 600 mg mg/5ml-100 mg/5ml, 5 QC MEDIFIN PE TABS mg/5ml-5 mg/5ml-10 (phenylephrine- NF mg/5ml-10 mg/5ml-100 guaifenesin) mg/5ml-100 mg/5ml, 10 ROBITUSSIN CHILDRENS F QL(16 ml daily) mg/20ml-20 mg/20ml-400 COUGH & COLD CF LIQD mg/20ml, 2.5 mg/5ml-5 mg/5ml-100 mg/5ml ROBITUSSIN PEAK COLD DM SYRP NF phenylephrine w/ dm-gg QL(16 ml daily) (dextromethorphan- syrp 5 mg/5ml-10 mg/5ml- F guaifenesin) 100 mg/5ml ROBITUSSIN PEAK COLD QL(16 ml daily) phenylephrine w/ dm-gg F MULTI-SYMPTOM COLD NF tabs 10 mg-20 mg-400 mg LIQD (phenylephrine w/ phenylephrine-chlorphen- F dm-gg) dm liqd RYCONTUSS LIQD phenylephrine- (phenylephrine-chlorphen- NF diphenhydramine-gg w/ F dm) apap tbpk SUPRESS-PE PEDIATRIC F phenylephrine-guaifenesin F LIQD liqd TUSICOF LIQD F QL(16 ml daily) phenylephrine-guaifenesin F tabs QL(240 ml per promethazine & QL(16 ml daily) F TUSNEL C SYRP F 12 days retail); phenylephrine syrp AL(At least 18 yrs old) TUSNEL DM LIQD F QL(16 ml daily)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUSSI-PRES PEDIATRIC QL(16 ml daily) sodium chloride (inhalant) F LIQD (phenylephrine w/ NF nebu 0.9 %, 3 %, 7 % dm-gg) Mucolytics TUSSLIN LIQD F QL(16 ml daily) acetylcysteine soln in 10 %, F 20 % TUSSLIN PEDIATRIC F QL(16 ml daily) LIQD DERMATOLOGICALS - Drugs to Treat Skin TYLENOL Conditions COLD/FLU/DAY/MULT- F Acne Products ACTION/DAY TABS ABSORICA CAPS NF PA QL(240 ml per (isotretinoin) 12 days retail); VIRTUSSIN DAC SOLN F ACNE MEDICATION 10 F AL(At least 18 LOTN yrs old) ACNE MEDICATION 5 F ZYNCOF SYRP F LOTN ZYRTEC-D QL(2 ea daily) BENZAC AC WASH LIQD NF RX/OTC (benzoyl peroxide) ALLERGY/CONGESTION NF TB12 (cetirizine- benzoyl peroxide bar ex 10 F pseudoephedrine) % Expectorants BENZOYL PEROXIDE F CLEANSER LIQD GILTUSS EX MAXIMUM F QL(16 ml daily) STRENGTH LIQD benzoyl peroxide crea ex F 2.5 %, 10 % guaifenesin liqd or 200 QL(16 ml daily) mg/5ml, 100 mg/5ml, 200 F benzoyl peroxide foam ex F RX/OTC mg/10ml, 400 mg/20ml 5.3 % guaifenesin soln or 100 QL(16 ml daily) benzoyl peroxide foam ex F mg/5ml, 200 mg/10ml, 300 F 9.8 % mg/15ml benzoyl peroxide gel ex 2.5 F %, 5 %, 10 % guaifenesin syrp or 100 F QL(16 ml daily) mg/5ml benzoyl peroxide liqd ex F RX/OTC 2.5 %, 5 % guaifenesin tabs or 200 F mg, 400 mg benzoyl peroxide liqd ex 4 F %, 7 %, 10 % guaifenesin tb12 or 600 F mg, 1200 mg CLEOCIN-T GEL QL(16 ml daily) (clindamycin phosphate NF HERBAL EXPEC LIQD F (topical)) MUCINEX MAXIMUM CLEOCIN-T LOTN STRENGTH TB12 NF (clindamycin phosphate NF (guaifenesin) (topical)) CLINDAGEL GEL MUCINEX TB12 NF (guaifenesin) (clindamycin phosphate NF (topical)) Misc. Respiratory Inhalants clindamycin phosphate F HYPER-SAL NEBU NF (topical) gel (sodium chloride (inhalant)) clindamycin phosphate F HYPERSAL NEBU 7 % NF (topical) lotn (sodium chloride (inhalant)) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate F bacitracin (topical) oint F (topical) soln clindamycin phosphate F bacitracin zinc oint ex F (topical) swab clindamycin phosphate- bacitracin-polymyxin b oint F benzoyl peroxide F (refrigerate) gel 1 %-5 %, CENTANY OINT F 1.2 %-5 % DUAC GEL (clindamycin gentamicin sulfate (topical) F phosphate-benzoyl NF crea peroxide (refrigerate)) gentamicin sulfate (topical) F oint erythromycin (acne aid) F soln mupirocin calcium (topical) F QL(1 gm daily) isotretinoin caps or 25 mg, PA crea 35 mg, 30 mg, 10 mg, 20 F mupirocin oint ex F mg, 40 mg NEUTROGENA ON-THE- neomycin-bacitracin- F SPOT ACNE TREATMENT NF polymyxin oint CREA (benzoyl peroxide) neomycin-bacitracin- F polymyxin-pramoxine oint OC8 GEL F NEOSPORIN ORIGINAL OINT (neomycin-bacitracin- NF PANOXYL LIQD (benzoyl NF RX/OTC peroxide) polymyxin) AL(Up to 26 yrs POLYSPORIN OINT RETIN-A CREA (tretinoin) F NF old ) (bacitracin-polymyxin b) AL(Up to 26 yrs RETIN-A GEL (tretinoin) F Antifungals - Topical old ) butenafine hcl crea F RX/OTC RIAX FOAM F ciclopirox olamine crea ex F tretinoin crea ex 0.05 %, F AL(Up to 26 yrs 0.1 %, 0.025 % old ) ciclopirox soln ex 8 % F tretinoin gel ex 0.01 %, F AL(Up to 26 yrs 0.025 % old ) clotrimazole (topical) crea F RX/OTC ZACLIR CLEANSING F LOTN clotrimazole (topical) soln F RX/OTC Anti-inflammatory Agents - Topical clotrimazole w/ F QL(200 gm per betamethasone crea diclofenac sodium (topical) F 30 days retail); gel 1 % EXELDERM CREA NF RX/OTC (sulconazole nitrate) VOLTAREN GEL QL(200 gm per EXELDERM SOLN NF (diclofenac sodium NF 30 days retail); (sulconazole nitrate) (topical)) RX/OTC (topical) crea F Antibiotics - Topical 2 % BACIGUENT OINT EX NF ketoconazole (topical) F (bacitracin (topical)) sham 2 %

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMISIL AT CREA NF TINACTIN AERP NF (terbinafine hcl (topical)) (tolnaftate) LAMISIL AT JOCK ITCH TINACTIN CREA NF CREA (terbinafine hcl NF (tolnaftate) (topical)) TINACTIN DEODORANT NF LOPROX CREA (ciclopirox NF AERP (tolnaftate) olamine) TINACTIN JOCK ITCH NF LOTRIMIN AF CREA NF RX/OTC AERP (tolnaftate) (clotrimazole (topical)) tolnaftate aero ex F LOTRIMIN AF JOCK ITCH RX/OTC NF CREA (clotrimazole tolnaftate aerp ex F (topical)) LOTRIMIN ANTIFUNGAL tolnaftate crea ex F AERO ( nitrate NF (topical)) tolnaftate liqd ex F LOTRIMIN ULTRA CREA NF RX/OTC (butenafine hcl) tolnaftate powd ex F LOTRISONE CREA (clotrimazole w/ NF tolnaftate soln ex F betamethasone) XOLEGEL GEL F LUZU CREA (luliconazole) NF MICATIN CREA Antihistamines-Topical (miconazole nitrate NF diphenhydramine hcl F (topical)) (topical) gel diphenhydramine hcl miconazole nitrate (topical) F F aero (topical) soln miconazole nitrate (topical) F ITCH RELIEF CREA F crea Antineoplastic or Premalignant Lesion Agents - miconazole nitrate (topical) F powd CARAC CREA (fluorouracil NF (topical)) MICONAZOLE NITRATE F POWD EFUDEX CREA NF (fluorouracil (topical)) NIZORAL SHAM NF (ketoconazole (topical)) fluorouracil (topical) crea 5 F nystatin (topical) crea F % Antipsoriatics nystatin (topical) oint F VECTICAL OINT (calcitriol NF (topical)) nystatin (topical) powd F Antiseborrheic Products PENLAC NAIL LACQUER NF selenium sulfide lotn ex 2.5 F SOLN (ciclopirox) %, 1 % terbinafine hcl (topical) F selenium sulfide sham ex 1 F crea % TINACTIN AERO NF SELSUN BLUE DAILY NF (tolnaftate) LOTN (selenium sulfide) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELSUN BLUE LOTN NF CLODERM CREA NF (selenium sulfide) ( pivalate) SELSUN BLUE DERMA-SMOOTHE/FS 1 rtl pack lmt MEDICATED LOTN NF BODY OIL ( F amt,30 rtl pack (selenium sulfide) acetonide) lmt day(s), SELSUN BLUE DERMA-SMOOTHE/FS 1 rtl pack lmt MOISTURIZING LOTN NF SCALP OIL (fluocinolone F amt,30 rtl pack (selenium sulfide) acetonide) lmt day(s), Antivirals - Topical DIPROLENE AF CREA NF Limit 2 per (betamethasone ABREVA CREA NF dipropionate augmented) (docosanol) month;QL(0.06 7 gm daily) ELOCON CREA NF ) QL(0.5 gm (mometasone furoate acyclovir topical oint F daily) crea ex F QL(2 gm daily) Limit 2 per QL(60 gm per docosanol crea ex F month;QL(0.06 fluocinonide oint ex F 7 gm daily) fill retail) fluocinonide soln ex F ZOVIRAX OINT EX 5 % NF QL(0.5 gm (acyclovir topical) daily) crea F Burn Products ex 0.05 % SILVADENE CREA (silver NF fluticasone propionate oint F sulfadiazine) ex 0.005 % silver sulfadiazine crea ex F halobetasol propionate F QL(2 gm daily) crea Corticosteroids - Topical halobetasol propionate oint F QL(2 gm daily) betamethasone F dipropionate (topical) lotn hydrocortisone (topical) F RX/OTC betamethasone crea 1 % dipropionate augmented F hydrocortisone (topical) F crea crea 2.5 %, 0.5 % hydrocortisone (topical) gel betamethasone valerate F F crea ex 0.1 % 1 % hydrocortisone (topical) lotn betamethasone valerate F F lotn ex 0.1 % 2.5 %, 1 % hydrocortisone (topical) oint RX/OTC betamethasone valerate F F oint ex 0.1 % 1 % hydrocortisone (topical) oint propionate crea F QL(3.34 gm F ex daily) 2.5 %, 0.5 % hydrocortisone acetate F QL(3.34 gm F emollient base crea daily) (topical) crea hydrocortisone-aloe vera clobetasol propionate gel F QL(118 gm per F ex fill retail) crea 1 % mometasone furoate crea clobetasol propionate oint F QL(3.34 gm F ex daily) ex mometasone furoate oint clobetasol propionate soln F QL(3.34 ml F ex daily) ex Arizona Complete Health - Complete Care Plan Effective September 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mometasone furoate soln F Immunomodulating Agents - Topical ex ALDARA CREA NF MONISTAT SOOTHING RX/OTC (imiquimod) CARE ITCH RELIEF CREA NF (hydrocortisone (topical)) imiquimod crea ex 5 % F TACLONEX SUSP Keratolytic/Antimitotic Agents (calcipotriene- NF betamethasone AMBI EVEN & CLEAR dipropionate) EXFOLIATING WASH F LIQD TEMOVATE CREA NF QL(3.34 gm (clobetasol propionate) daily) AMBI EVEN & CLEAR FOAMINGCLEANSER F TEMOVATE OINT NF QL(3.34 gm (clobetasol propionate) daily) LIQD BETASAL SHAM F (topical) crea 0.025 %, 0.5 F %, 0.1 % CERAVE PSORIASIS F CREA triamcinolone acetonide (topical) lotn 0.025 %, 0.1 F CLEAN & CLEAR % BLACKHEAD ERASER F SCRUB CREA triamcinolone acetonide (topical) oint 0.025 %, 0.1 F CLEAN & CLEAR DEEP %, 0.5 %, 0.05 % CLEANING ASTRINGENT F SENSITIVE SKIN LIQD Emollient/Keratolytic Agents CLEARASIL DAILY CLEAN CEROVEL LOTN F GENTLE PREVENTION F LIQD REA-LO CREA F CLN ACNE CLEANSER F LIQD urea crea ex 10 %, 20 % F COMPOUND W LIQD NF (salicylic acid) RX/OTC urea crea ex 40 % F COMPOUND W MAXIMUM STRENGTH GEL (salicylic NF urea lotn ex 40 % F acid) Emollients CORN & CALLUS F REMOVER SOLN LAC-HYDRIN CREA (lactic NF RX/OTC acid (ammonium lactate)) CVS PSORIASIS MEDICATED SHAMPOO F LAC-HYDRIN TWELVE RX/OTC PLUS CONDITIONER LOTN (lactic acid NF SHAM (ammonium lactate)) CVS THERAPEUTIC lactic acid (ammonium F RX/OTC DANDRUFFMAXIMUM F lactate) crea 12 % STRENGTH SHAM lactic acid (ammonium RX/OTC F DENOREX EXTRA F lactate) lotn 12 % STRENGTH 2-IN-1 SHAM LACTIC ACID LOTN EX 10 F DENOREX EXTRA % STRENGTH MEDICATED F NOBLE MYSTIQUE EMU- F SHAM LAC CREA Arizona Complete Health - Complete Care Plan Effective September 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMAREST PSORIASIS F SALVAX FOAM (salicylic NF PA GEL acid) DERMAREST PSORIASIS SELSUN BLUE DEEP F MEDICATED SHAMPOO F CLEANSING SHAM PLUS CONDITIONER SELSUN BLUE SHAM NATURALS DRYSCALP F DUOFILM SOLN F SHAM THERAPEUTIC F FREEZONE LIQD F DANDRUFF SHAM THERAPEUTIC T+PLUS GOLD BOND PSORIASIS MAXIMUM STRENGTH F RELIEF MULTI-SYMPTOM F SHAM CREA Local Anesthetics - Topical KERALYT GEL 3 % F Max 2 tubes per 30 KERALYT GEL 6 % NF (salicylic acid) lidocaine hcl crea ex 4 % F days;QL(266 MG217 PSORIASIS gm per 30 days MULTI-SYMPTOM CREA 3 F retail) % Max 3 tubes per 30 MOSCO CALLUS/CORN F REMOVER SOLN lidocaine hcl crea ex 4 % F days;QL(230 gm per 30 days NEUTROGENA T/SAL F retail) SHAM QL(60 ml per lidocaine hcl gel ex 2 % F P & S SHAM F 30 days retail) QL(60 ml per podofilox soln ex F lidocaine hcl gel ex 2 % F 30 days retail); RX/OTC SALEX SHAM (salicylic NF QL(60 ml per acid) lidocaine hcl prsy ex 2 % F 30 days retail) salicylic acid crea ex 2 %, 6 F % lidocaine hcl soln ex 4 % F salicylic acid foam ex 6 % F PA PA; QL(50 gm lidocaine oint ex 5 % F per fill retail) salicylic acid gel ex 6 %, 17 F PA; QL(3 ea %, 2 % lidocaine ptch ex 5 % F daily) RX/OTC salicylic acid liqd ex 2 % F QL(30 gm per lidocaine-prilocaine crea F 30 days retail) salicylic acid liqd ex 3 %, F 17 % LIDODERM PTCH NF PA; QL(3 ea (lidocaine) daily) salicylic acid lotn ex 0.5 %, F 6 % LMX 4 CREA (lidocaine) NF salicylic acid sham ex 6 % F XOLIDO CREA F salicylic acid soln ex 17 %, F 26 % Misc. Topical SALIMEZ CREA F CALAMINE LOTN EX F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DESITIN RAPID RELIEF F IVERMECTIN LOTN EX F PA; RX/OTC CREA 0.5 % DRYSOL SOLN F LICEMD GEL F

GNP CALAMINE LOTN F lindane sham F

HM CALAMINE LOTN F LYCELLE GEL F

JOHNSONS NO MORE F NATROBA SUSP F PA RASH CREA (spinosad) MEIJER CALAMINE LOTN F nit remover gel F

PX CALAMINE LOTN F NIX CREME RINSE LIQD NF (permethrin) QC CALAMINE LOTN F permethrin crea ex 5 % F

SM CALAMINE LOTN F permethrin liqd ex 1 % F zinc oxide (topical) crea 13 F % permethrin lotn ex 1 % F zinc oxide (topical) oint 20 F pyrethrins-piperonyl %, 40 % butoxide sham 0.3 %-0.33 F %-4 %, 4 %-0.33 % Rosacea Agents pyrethrins-piperonyl METROCREAM CREA NF F (metronidazole (topical)) butoxide-permethrin-nit remover kit METROLOTION LOTN NF (metronidazole (topical)) RID COMPLETE LICE ELIMINATION KIT metronidazole (topical) F (pyrethrins-piperonyl NF crea 0.75 % butoxide-permethrin-nit remover) metronidazole (topical) gel F 0.75 % SCHOOLTIME SHAMPOO F SHAM metronidazole (topical) lotn F 0.75 % SKLICE LOTN (ivermectin NF PA; RX/OTC Scabicides & Pediculicides (pediculicide)) PA crotamiton lotn ex F PA spinosad susp F

CVS LICE SOLUTION KIT F DIAGNOSTIC PRODUCTS 3-STEP KIT Diagnostic Tests ELIMITE CREA NF (permethrin) ALBUSTIX STRP F EURAX CREA F PA CHEMSTRIP MICRAL F STRP EURAX LOTN (crotamiton) NF CHEMSTRIP-K STRP F ivermectin (pediculicide) F PA; RX/OTC lotn KETONE STRP F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KETONE TEST STRIPS F DIURETICS - Drugs to Treat Heart, Circulation STRP Conditions and Blood Pressure KETOSTIX STRP F Carbonic Anhydrase Inhibitors INSULIN acetazolamide cp12 or 500 F MP USERS mg LIMITED TO acetazolamide tabs or 125 F MP 150 PER 30 mg, 250 mg DAYS, NON- ONETOUCH ULTRA STRP F methazolamide tabs or 50 F MP INSULIN mg, 25 mg USERS LIMITED TO Diuretic Combinations 100 PER 90 ALDACTAZIDE TABS 25 MP DAYS;RX/OTC MG-25 MG (spironolactone NF INSULIN & hydrochlorothiazide) USERS ALDACTAZIDE TABS 50 F LIMITED TO MG-50 MG 150 PER 30 amiloride & F MP ONETOUCH VERIO TEST F DAYS, NON- hydrochlorothiazide tabs STRIPS STRP INSULIN USERS DYAZIDE CAPS MP LIMITED TO (triamterene & NF 100 PER 90 hydrochlorothiazide) DAYS;RX/OTC MAXZIDE TABS MP (triamterene & NF RELION KETONE TEST F STRIPS STRP hydrochlorothiazide) MAXZIDE-25 TABS MP DIGESTIVE AIDS - Drugs to Treat Low Digestive (triamterene & NF Enzymes hydrochlorothiazide) Digestive Enzymes spironolactone & F MP PA; 500 per hydrochlorothiazide tabs CREON CPEP F month;QL(16.6 triamterene & F MP 7 ea daily); MP hydrochlorothiazide caps PA; SP SUCRAID SOLN F triamterene & F MP hydrochlorothiazide tabs ZENPEP CPEP 10000 500 per Loop Diuretics UNIT-32000 UNIT-42000 month;;QL(16.6 UNIT, 20000 UNIT-63000 7 ea daily) bumetanide tabs or 0.5 mg, F MP UNIT-84000 UNIT, 3000 F 1 mg, 2 mg UNIT-10000 UNIT-14000 BUMEX TABS NF MP UNIT, 40000 UNIT-126000 (bumetanide) UNIT-168000 UNIT furosemide soln or 10 F MP ZENPEP CPEP 15000 500 per mg/ml, 8 mg/ml UNIT-47000 UNIT-63000 month;QL(16.6 furosemide tabs or 20 mg, F MP UNIT, 25000 UNIT-79000 F 7 ea daily) 40 mg, 80 mg UNIT-105000 UNIT, 5000 UNIT-17000 UNIT-24000 LASIX TABS (furosemide) NF MP UNIT torsemide tabs F MP

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Potassium Sparing Diuretics GENOTROPIN MINIQUICK F PA; SP SOLR ALDACTONE TABS NF MP (spironolactone) GENOTROPIN SOLR 12 F PA; SP MG amiloride hcl tabs or F MP GENOTROPIN SOLR 5 F PA; SP; MP MG DYRENIUM CAPS NF MP (triamterene) NORDITROPIN FLEXPRO PA; SP; MP SOPN 10 MG/1.5ML, 15 F spironolactone tabs or 100 F MP mg, 25 mg, 50 mg MG/1.5ML NORDITROPIN FLEXPRO PA; SP triamterene caps or 100 F MP F mg, 50 mg SOPN 5 MG/1.5ML Thiazides and Thiazide-Like Diuretics Hormone Receptor Modulators MP EVISTA TABS (raloxifene NF chlorothiazide tabs F hcl) chlorthalidone tabs F MP raloxifene hcl tabs F

DIURIL SUSP F Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN F PA; SP hydrochlorothiazide caps or F MP 12.5 mg LHRH/GnRH Agonist Analog Pituitary hydrochlorothiazide tabs or F MP 25 mg, 50 mg FENSOLVI KIT F PA; SP MP indapamide tabs F Metabolic Modifiers MP calcitriol caps or 0.25 mcg, F metolazone tabs F 0.5 mcg ENDOCRINE AND METABOLIC AGENTS - calcitriol soln or 1 mcg/ml F MISC. - Drugs to Treat Bone Disease and Regulate Hormones cinacalcet hcl tabs F PA; SP; MP Bone Density Regulators ELAPRASE SOLN F PA; SP alendronate sodium soln F ROCALTROL CAPS NF alendronate sodium tabs F (calcitriol) ROCALTROL SOLN NF BONIVA TABS NF QL(1 ea per 30 (calcitriol) (ibandronate sodium) days retail) SENSIPAR TABS NF PA; SP; MP calcitonin (salmon) soln F MP (cinacalcet hcl) Posterior Pituitary Hormones FOSAMAX TABS NF (alendronate sodium) DDAVP SOLN NA 0.01 % F QL(1 ea per 30 ibandronate sodium tabs F days retail) DDAVP SOLN NA 0.01 % PA; SP (desmopressin acetate NF PROLIA SOSY F spray) Growth Hormones DDAVP TABS OR 0.1 MG, PA 0.2 MG (desmopressin NF acetate) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DESMOPRESSIN PA; SP; MP FLUOROQUINOLONES - Drugs to Treat Bacterial ACETATE SOLN NA 1.5 F Infections MG/ML Fluoroquinolones desmopressin acetate F spray refrigerated soln CIPRO TABS 250 MG, 500 NF MG (ciprofloxacin hcl) desmopressin acetate F spray soln ciprofloxacin hcl tabs or 100 mg, 250 mg, 500 mg, F desmopressin acetate tabs F PA 750 mg or 0.1 mg, 0.2 mg LEVAQUIN TABS NF STIMATE SOLN F PA; SP; MP (levofloxacin) levofloxacin soln or 25 F ESTROGENS - Hormone Replacement/Modifying mg/ml Drugs levofloxacin tabs or 250 F Estrogen Combinations mg, 500 mg, 750 mg CLIMARA PRO PTWK F ofloxacin tabs 400 mg F PREMPRO TABS F QL(1 ea daily) GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs Estrogens Antiflatulents ALORA PTTW F GAS-X CHEW NF (simethicone) CLIMARA PTWK NF (estradiol) GAS-X EXTRA STRENGTH CHEW 125 NF ESTRACE TABS NF (estradiol) MG (simethicone) estradiol pttw td 0.025 MYLICON INFANTS GAS RELIEF DYE FREE SUSP NF mg/24hr, 0.0375 mg/24hr, F 0.05 mg/24hr, 0.075 (simethicone) mg/24hr, 0.1 mg/24hr MYLICON INFANTS GAS estradiol ptwk td 0.025 RELIEF SUSP NF mg/24hr, 0.075 mg/24hr, (simethicone) 0.1 mg/24hr, 0.05 mg/24hr, F PHAZYME CAPS NF 0.06 mg/24hr, 37.5 (simethicone) mcg/24hr PHAZYME ULTRA STRENGTH CAPS NF estradiol tabs or 0.5 mg, 1 F mg, 2 mg (simethicone) simethicone caps or 180 F MENEST TABS F mg, 125 mg MENOSTAR PTWK F simethicone chew or 80 F mg, 125 mg MINIVELLE PTTW NF simethicone susp or 20 F (estradiol) mg/0.3ml, 40 mg/0.6ml PREMARIN TABS OR 0.3 Gallstone Solubilizing Agents MG, 0.45 MG, 0.625 MG, F 0.9 MG, 1.25 MG ACTIGALL CAPS (ursodiol) NF VIVELLE-DOT PTTW NF (estradiol) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits URSO 250 TABS (ursodiol) NF sulfasalazine tbec or F QL(8 ea daily)

URSO FORTE TABS NF Intestinal Acidifiers (ursodiol) lactulose (encephalopathy) F ursodiol caps or 300 mg F soln Irritable Bowel Syndrome (IBS) Agents ursodiol tabs or 250 mg, F 500 mg LINZESS CAPS 145 MCG, F PA; MP 290 MCG Gastrointestinal Chloride Channel Activators LINZESS CAPS 72 MCG F PA AMITIZA CAPS NF PA (lubiprostone) Phosphate Binder Agents lubiprostone caps F PA calcium acetate (phosphate F binder) caps Gastrointestinal Stimulants calcium acetate (phosphate F RX/OTC metoclopramide hcl soln or F binder) tabs 10 mg/10ml, 5 mg/5ml calcium acetate (phosphate F RX/OTC; MP metoclopramide hcl tabs or F binder) tabs 10 mg, 5 mg RENVELA TABS NF metoclopramide hcl tbdp or F (sevelamer carbonate) 5 mg sevelamer carbonate tabs F METOCLOPRAMIDE ODT F TBDP GENITOURINARY AGENTS - MISCELLANEOUS REGLAN TABS NF - Miscellaneous Drugs to Treat Reproductive (metoclopramide hcl) Organs and Urinary System Inflammatory Bowel Agents Alkalinizers APRISO CP24 F potassium citrate F (mesalamine) (alkalinizer) tbcr AZULFIDINE EN-TABS NF QL(8 ea daily) potassium citrate-citric acid RX/OTC TBEC (sulfasalazine) soln 334 mg/5ml-1100 AZULFIDINE TABS NF QL(8 ea daily) mg/5ml, 334 mg/5ml-334 F (sulfasalazine) mg/5ml-1100 mg/5ml-1100 mg/5ml CANASA SUPP F (mesalamine) sodium citrate & citric acid F RX/OTC soln DELZICOL CPDR F (mesalamine) UROCIT-K 10 TBCR (potassium citrate NF LIALDA TBEC F (mesalamine) (alkalinizer)) PENTASA CPCR F QL(9 ea daily) UROCIT-K 15 TBCR (potassium citrate NF (alkalinizer)) RENFLEXIS SOLR F PA; SP UROCIT-K 5 TBCR SFROWASA ENEM F QL(60 ml daily) (potassium citrate NF (alkalinizer)) sulfasalazine tabs or F QL(8 ea daily) Genitourinary Irrigants

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium chloride (gu F QL(33.3333 ml probenecid tabs F irrigant) soln daily) Interstitial Cystitis Agents HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders ELMIRON CAPS F PA Hematorheologic Agents Prostatic Hypertrophy Agents pentoxifylline tbcr or F alfuzosin hcl tb24 F Platelet Aggregation Inhibitors AVODART CAPS NF PA (dutasteride) BRILINTA TABS F dutasteride caps or F cilostazol tabs F finasteride tabs or F clopidogrel bisulfate tabs or F 300 mg, 75 mg FLOMAX CAPS NF dipyridamole tabs or 25 F (tamsulosin hcl) mg, 50 mg, 75 mg PROSCAR TABS NF PLAVIX TABS (clopidogrel NF (finasteride) bisulfate) RAPAFLO CAPS 4 MG NF (silodosin) HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders tamsulosin hcl caps F Agents for Gaucher Disease PA; SP; MP UROXATRAL TB24 NF CERDELGA CAPS F (alfuzosin hcl) PA; SP Urinary Analgesics CEREZYME SOLR F phenazopyridine hcl tabs or F PA; SP 100 mg, 200 mg ELELYSO SOLR F PYRIDIUM TABS NF PA; SP (phenazopyridine hcl) miglustat caps F PA; SP GOUT AGENTS - Drugs to Treat Gout VPRIV SOLR F Gout Agents Cobalamins allopurinol tabs or 100 mg, F B-12 TABS F 300 mg cyanocobalamin soln ij F colchicine tabs or F 1000 mcg/ml cyanocobalamin tabs or 50 COLCRYS TABS NF (colchicine) mcg, 250 mcg, 1000 mcg, F 100 mcg, 500 mcg febuxostat tabs F PA Folic Acid/Folates PA ULORIC TABS (febuxostat) NF folic acid tabs 1 mg F RX/OTC ZYLOPRIM TABS NF folic acid tabs 800 mcg, F (allopurinol) 400 mcg Uricosurics Hematopoietic Growth Factors

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FULPHILA SOSY F PA; SP HEMOCYTE TABS (ferrous NF fumarate) NEUPOGEN SOLN F PA; SP HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders PA; SP NEUPOGEN SOSY F Hemostatics - Systemic PA; SP NIVESTYM SOLN F AMICAR SOLN NF SP (aminocaproic acid) PA; SP NIVESTYM SOSY F AMICAR TABS NF SP (aminocaproic acid) NPLATE SOLR F PA; SP aminocaproic acid soln or F SP 0.25 gm/ml NYVEPRIA SOSY F PA; SP aminocaproic acid tabs or F SP 500 mg PROMACTA TABS F PA; SP HYPNOTICS/SEDATIVES/SLEEP DISORDER RETACRIT SOLN 10000 PA; SP AGENTS UNIT/ML, 2000 UNIT/ML, Antihistamine Hypnotics 20000 UNIT/2ML, 3000 F UNIT/ML, 4000 UNIT/ML, diphenhydramine hcl F QL(2 ea daily) 40000 UNIT/ML (sleep) caps 25 mg PA; SP diphenhydramine hcl F QL(1 ea daily) UDENYCA SOSY F (sleep) caps 50 mg Iron diphenhydramine hcl F QL(30 ml daily) (sleep) liqd 50 mg/30ml FEMIRON TABS F diphenhydramine hcl F QL(2 ea daily) (sleep) tabs 25 mg FER-IN-SOL SOLN NF (ferrous sulfate) diphenhydramine hcl F QL(1 ea daily) (sleep) tabs 50 mg FERRETTS TABS F diphenhydramine hcl F QL(2 ea daily) (sleep) tbdp 25 mg FERRIMIN 150 TABS F doxylamine succinate F (sleep) tabs FERROUS FUMARATE F TABS OR 29 MG NYTOL MAXIMUM QL(1 ea daily) STRENGTH TABS ferrous fumarate tabs or F NF 324 mg (diphenhydramine hcl (sleep)) FERROUS GLUCONATE F TABS OR 324 MG UNISOM SLEEPGELS QL(1 ea daily) CAPS (diphenhydramine NF ferrous gluconate tabs or F 324 mg, 240 mg, 27 mg hcl (sleep)) UNISOM SLEEPMELTS QL(2 ea daily) FERROUS SULFATE LIQD F 220 MG/5ML TBDP (diphenhydramine NF hcl (sleep)) ferrous sulfate soln 15 F mg/ml UNISOM SLEEPTABS TABS (doxylamine NF ferrous sulfate tabs 27 mg, F succinate (sleep)) 325 mg, 65 mg WAL-SLEEP Z LIQUID F QL(50 ml daily) ferrous sulfate tbec 325 mg F SHOTS LIQD

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZZZQUIL CAPS 25 MG QL(2 ea daily) ST; Must try 2: (diphenhydramine hcl NF temazepam, (sleep)) zolpidem, ROZEREM TABS F ZZZQUIL LIQD 50 QL(30 ml daily) ) eszopiclone;QL (ramelteon (1 ea daily); MG/30ML NF (diphenhydramine hcl AL(At least 6 (sleep)) yrs old) Barbiturate Hypnotics LAXATIVES - Bowel Treatment Drugs phenobarbital elix or 20 F mg/5ml Bulk Laxatives EVAC POWD (psyllium) NF phenobarbital soln or 20 F mg/5ml KONSYL DAILY FIBER NF phenobarbital tabs or 100 POWD 100 % (psyllium) mg, 60 mg, 64.8 mg, 97.2 F mg, 15 mg, 16.2 mg, 30 METAMUCIL CAPS 0.52 NF mg, 32.4 mg GM (psyllium) METAMUCIL ORIGINAL Non-Barbiturate Hypnotics TEXTURE POWD NF QL(1 ea daily); (psyllium) AMBIEN TABS 10 MG NF AL(At least 6 (zolpidem tartrate) METAMUCIL POWD 48.57 NF yrs old) % (psyllium) QL(2 ea daily); psyllium caps 0.52 gm, 520 AMBIEN TABS 5 MG NF AL(At least 6 F (zolpidem tartrate) mg yrs old) psyllium powd 33 %, 68 %, QL(1 ea daily); 30 %, 100 %, 30.9 %, , F eszopiclone tabs F AL(At least 6 48.57 %, 58.6 %, 28.3 % yrs old) QL(1 ea daily); Laxative Combinations LUNESTA TABS NF AL(At least 6 COLYTE-FLAVOR PACKS (eszopiclone) yrs old) SOLR (peg 3350-kcl-sod NF QL(1 ea daily); bicarb-sod chloride-sod RESTORIL CAPS 15 MG, NF AL(At least 6 sulfate) 30 MG (temazepam) yrs old) GOLYTELY SOLR 2.97 QL(1 ea daily); GM-5.86 GM-6.74 GM- temazepam caps 15 mg, F AL(At least 6 22.74 GM-236 GM (peg NF 30 mg yrs old) 3350-kcl-sod bicarb-sod chloride-sod sulfate) QL(1 ea daily); zolpidem tartrate tabs or 10 F AL(At least 6 NULYTELY SOLR (peg mg yrs old) 3350-potassium chloride- NF sod bicarbonate-sod QL(2 ea daily); chloride) zolpidem tartrate tabs or 5 F AL(At least 6 mg yrs old) NULYTELY/FLAVOR PACKS SOLR (peg 3350- NF Selective Melatonin Receptor Agonists potassium chloride-sod bicarbonate-sod chloride) peg 3350-kcl-sod bicarb- sod chloride-sod sulfate F solr

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits peg 3350-potassium bisacodyl supp re 10 mg F chloride-sod bicarbonate- F sod chloride solr bisacodyl tbec or 5 mg F sennosides-docusate F sodium tabs DULCOLAX SUPP NF SENOKOT S TABS (bisacodyl) (sennosides-docusate NF DULCOLAX TBEC NF sodium) (bisacodyl) Laxatives - Miscellaneous EX-LAX TABS NF (sennosides) glycerin (laxative) supp F sennosides liqd 8.8 mg/5ml F GLYCERIN ADULT SUPP NF (glycerin (laxative)) sennosides syrp 8.8 F mg/5ml lactulose soln 10 gm/15ml, F 20 gm/30ml sennosides tabs 17.2 mg, F 15 mg, 25 mg, 8.6 mg MIRALAX MIX-IN PAX PACK (polyethylene glycol NF SENOKOT TABS NF 3350) (sennosides) Surfactant Laxatives MIRALAX PACK NF (polyethylene glycol 3350) COLACE CAPS (docusate NF sodium) MIRALAX POWD NF (polyethylene glycol 3350) COLACE CLEAR CAPS NF (docusate sodium) PEDIA-LAX SUPP RE 1 NF GM (glycerin (laxative)) docusate calcium caps F polyethylene glycol 3350 F pack or 17 gm docusate sodium caps or F 50 mg, 250 mg, 100 mg polyethylene glycol 3350 F powd or 17 gm/scoop, LOCAL ANESTHETICS-Parenteral - Drugs for Saline Laxatives Numbing Local Anesthetics - Amides FLEET ENEMA ENEM NF (sodium phosphates) lidocaine hcl (local anesth.) F PA FLEET ENEMA SIX PACK soln ij 0.5 %, 1 %, 2 %, 4 % ENEM (sodium NF LIDOCAINE PA phosphates) HYDROCHLORIDE SOLN F IJ 1 %, 2 % FLEET PEDIATRIC ENEM NF (sodium phosphates) XYLOCAINE SOLN PA (lidocaine hcl (local NF magnesium citrate soln or F 1.745 gm/30ml, anesth.)) magnesium hydroxide susp XYLOCAINE-MPF SOLN PA 0.5 %, 1 %, 2 % (lidocaine NF or 2400 mg/10ml, 1200 F mg/15ml, 2400 mg/30ml, hcl (local anesth.)) 400 mg/5ml, 7.75 %, MACROLIDES - Drugs to Treat Bacterial sodium phosphates enem F Infections Azithromycin Stimulant Laxatives

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azithromycin pack or 1 gm F ONETOUCH VERIO 1/ 90 CONTROL SOLUTION F days;QL(0.012 HIGH SOLN ea daily) azithromycin susr or 100 F mg/5ml, 200 mg/5ml ONETOUCH VERIO MID 1/ 90 CONTROL SOLUTION F days;QL(0.012 azithromycin tabs or 250 F mg, 500 mg, 600 mg SOLN ea daily) PX LANCETS MICROTHIN ZITHROMAX PACK OR 1 F F GM (azithromycin) 33G MISC ZITHROMAX SUSR OR Misc. Devices 100 MG/5ML, 200 MG/5ML NF (azithromycin) ALCOHOL SWABS F ZITHROMAX TABS OR Parenteral Therapy Supplies 250 MG, 500 MG, 600 MG NF (azithromycin) 1ML TB SYRINGE/25G X F RX/OTC 5/8"/LUER SLIP TIP MISC ZITHROMAX TRI-PAK NF TABS (azithromycin) 1ML TB SYRINGE/27G X F RX/OTC 1/2"/LUER SLIP TIP MISC ZITHROMAX Z-PAK TABS NF (azithromycin) 1ML TUBERCULIN RX/OTC SYRINGE DETACHABLE F Clarithromycin NEEDLE SLIP TIP 25GX5/8" MISC clarithromycin susr or 125 F mg/5ml, 250 mg/5ml 1ML VANISHPOINT RX/OTC TUBERCULIN SYRINGE F clarithromycin tabs or 250 F mg, 500 mg 25GX5/8" MISC 1ML VANISHPOINT RX/OTC clarithromycin tb24 or 500 F mg TUBERCULIN SYRINGE F 27GX1/2" MISC MEDICAL DEVICES AND SUPPLIES 2-3ML SYRINGE/LUER F RX/OTC Bandages-Dressings-Tape LOCK TIP MISC 2-3ML SYRINGE/LUER RX/OTC GAUZE PADS 2X2, 3X3, F F 4X4 SLIP TIP MISC 3ML LUER LOCK SAFETY RX/OTC Contraceptives SYRINGES 3ML/22G X 1 F CONDOMS F 1/2" MISC 3ML LUER LOCK SAFETY F RX/OTC DIAPHRAGMS F SYRINGES MISC 3ML LUER LOCK SAFETY RX/OTC OMNIFLEX DIAPHRAGM F DPRH SYRINGES/3ML/21G X 1 F 1/2" MISC Diabetic Supplies 3ML LUER LOCK SAFETY INSULIN PUMP INFUSION F SYRINGES/3ML/22G X 1" F SUPPLIES MISC LANCETS AND LANCET F 3ML LUER LOCK SAFETY RX/OTC DEVICES SYRINGES/3ML/23G X 1" F 1/ 90 MISC ONETOUCH ULTRA F days;QL(0.012 CONTROL SOLN 3ML LUER LOCK SAFETY RX/OTC ea daily) SYRINGES/3ML/25G X 1" F MISC Arizona Complete Health - Complete Care Plan Effective September 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML LUER LOCK SAFETY RX/OTC 3ML SYRINGE/NEEDLE RX/OTC SYRINGES/3ML/25G X F REGULAR WALL LUER- F 5/8" MISC LOK 25GX5/8" SUB-Q MISC 3ML LUER-LOK SYRINGE F RX/OTC 22GX 1-1/2" MISC ALLERGY RX/OTC 3ML LUER-LOK RX/OTC SYRINGE/1ML/27G X 1/2" F SYRINGE21G X 1-1/2" F MISC MISC AXILLARY BLOCK RX/OTC NEEDLE BLOCK BEVEL F 3ML LUER-LOK F SYRINGE22G X 1" MISC 25GX1" MISC BD 1ML TUBERCULIN RX/OTC 3ML LUER-LOK F RX/OTC SYRINGE25G X 5/8" MISC SYRINGE/SAFETYGLIDE F TB NEEDLE 27GX1/2" 3ML LUER-LOK TIP MISC SYRINGE25G X 1-1/2" F MISC BD 1ML TUBERCULIN RX/OTC SYRINGEDETACHABLE F 3ML SYRINGE/18G X 1- RX/OTC NEEDLE SLIP TIP 1/2"/LUER LOCK TIP F 27GX1/2" MISC MISC BD 1ML TUBERCULIN F RX/OTC 3ML SYRINGE/20G X F RX/OTC SYRINGESLIP-TIP MISC 1"/LUER LOCK TIP MISC BD 3ML LUER-LOCK RX/OTC 3ML SYRINGE/20G X F RX/OTC SYRINGE18G X 1 1/2" F 1"/LUER SLIP TIP MISC MISC 3ML SYRINGE/21G X 1- RX/OTC BD 3ML LUER-LOK RX/OTC 1/2"/LUER LOCK TIP F SYRINGE 18G X 1 1/2" F MISC MISC 3ML SYRINGE/22G 1- RX/OTC BD 3ML LUER-LOK F RX/OTC 1/2"/LUER LOCK TIP F SYRINGE/20G X 1" MISC MISC BD 3ML LUER-LOK RX/OTC 3ML SYRINGE/22G X F SYRINGE/21G X 1-1/2" F 1"/LUER LOCK TIP MISC MISC 3ML SYRINGE/25G X RX/OTC F BD 3ML LUER-LOK F RX/OTC 1"/LUER LOCK TIP MISC SYRINGE/23G X 1" MISC 3ML SYRINGE/INTERLINK RX/OTC BD 3ML LUER-LOK SYRINGE CANNULA F SYRINGE/23G X 1-1/2" F MISC MISC 3ML SYRINGE/INTERLINK RX/OTC BD 3ML LUER-LOK F RX/OTC VIAL ACCESS CANNULA F SYRINGE/25G X 1" MISC MISC BD 3ML SYRINGE LUER- F RX/OTC 3ML SYRINGE/LUER F RX/OTC LOK TIP MISC LOCK TIP MISC BD 3ML SYRINGE SLIP F RX/OTC 3ML SYRINGE/LUER F RX/OTC TIP MISC LOCK TIP23GX1" MISC BD 3ML RX/OTC 3ML SYRINGE/LUER SYRINGE/SAFETYGLIDE F LOCK TIP25G X 1-1/2" F SHIELDING IM NEEDLE MISC 22GX1-1/2" MISC 3ML SYRINGE/LUER SLIP F RX/OTC TIP23GX1" MISC Arizona Complete Health - Complete Care Plan Effective September 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD 3ML RX/OTC BD ECLIPSE RX/OTC SYRINGE/SAFETYGLIDE F SYRINGE/LUER- F SHIELDING IM NEEDLE LOK/3ML/22G X 1-1/2" 23GX1" MISC MISC BD 3ML RX/OTC BD HYPODERMIC RX/OTC SYRINGE/SAFETYGLIDE F NEEDLE REGULAR F SHIELDING NEEDLE BEVEL 18G X 1-1/2" MISC 25GX5/8" MISC BD HYPODERMIC RX/OTC BD RX/OTC NEEDLE REGULAR F ALLERGY/SYRINGE/NEE F BEVEL 22GX1-1/2" MISC DLE/1ML/28G X 1/2" MISC BD HYPODERMIC RX/OTC BD BLUNT FILL RX/OTC NEEDLE REGULAR F NEEDLE/18GX 1-1/2" F BEVEL 25GX1" MISC MISC BD HYPODERMIC RX/OTC BD DISPOSABLE NEEDLE RX/OTC NEEDLE REGULAR F REGULAR BEVEL 25GX1" F BEVEL 25GX5/8" MISC MISC BD HYPODERMIC RX/OTC BD DISPOSABLE NEEDLE RX/OTC NEEDLE REGULAR F REGULAR BEVEL THIN F BEVEL THIN WALL 18G X WALL 18G X 1" MISC 1-1/2" MISC BD ECLIPSE 18G X 1-1/2" F RX/OTC BD HYPODERMIC RX/OTC MISC NEEDLE SHORT BEVEL F 18G X 1-1/2" MISC BD ECLIPSE NEEDLE F RX/OTC 25G X 1.5" MISC BD HYPODERMIC RX/OTC NEEDLE SHORT BEVEL F BD ECLIPSE NEEDLE F RX/OTC 25GX1" MISC 22GX1-1/2" MISC BD HYPODERMIC RX/OTC BD ECLIPSE NEEDLE F RX/OTC F 27G X 1/2" MISC NEEDLES 18GX1" MISC BD ECLIPSE RX/OTC BD HYPODERMIC F RX/OTC NEEDLE/22G X 1-1/2" F NEEDLES 18GX1.5" MISC MISC BD HYPODERMIC F RX/OTC NEEDLES 19GX1" MISC BD ECLIPSE F RX/OTC NEEDLE/25G X5/8" MISC BD HYPODERMIC F RX/OTC NEEDLES 22GX1.5" MISC BD ECLIPSE F RX/OTC NEEDLE/27G X 1/2" MISC BD HYPODERMIC F RX/OTC BD ECLIPSE SYRINGE NEEDLES 25GX1.5" MISC LUER-LOK/3ML/22G X 1" F BD INTEGRA 3ML RX/OTC MISC SYRINGE BD ECLIPSE SYRINGE RX/OTC W/RETRACTING F LUER-LOK/3ML/25G X 1" F NEEDLE/21G X 1-1/2" MISC MISC BD ECLIPSE RX/OTC BD INTEGRA 3ML RX/OTC SYRINGE/3ML/23G X 1" F SYRINGE F MISC W/RETRACTING NEEDLE/25G X 1" MISC BD ECLIPSE RX/OTC SYRINGE/3ML/25GX5/8" F BD INTEGRA F RX/OTC MISC NEEDLE/25G X5/8" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INTEGRA RX/OTC BD SYRINGE SLIP TIP F RX/OTC SYRINGE/3ML/22G X 1.5" F 1ML MISC MISC CAREPOINT SAFETY 1ST RX/OTC BD INTEGRA RX/OTC SYRINGE/NEEDLE F SYRINGE/3ML/23G X 1" F 3ML/23G X 1" MISC MISC CAREPOINT SAFETY 1ST RX/OTC BD INTEGRA RX/OTC SYRINGE/NEEDLE F SYRINGE/3ML/25G X 5/8 F 3ML/25G X 1" MISC MISC CAREPOINT SAFETY 1ST RX/OTC BD NEEDLE/18G 1-1/2" F RX/OTC SYRINGE/NEEDLE F MISC 3ML/25G X 5/8" MISC BD NEEDLE/19G X 1" F RX/OTC DIALYSIS SAFETY RX/OTC MISC SYRINGES/LOW DEAD F SPACE 3ML/22GX1-1/2" BD NEEDLE/22G X 1-1/2" F RX/OTC MISC MISC EASY GLIDE RX/OTC BD NEEDLE/25G X 5/8" F RX/OTC MISC SYRINGE/LUER F LLOC/1ML MISC BD NEEDLE/27G X 1/2" F RX/OTC MISC EASY GLIDE RX/OTC SYRINGE/LUER F BD PEN NEEDLES F LLOCK/3ML MISC BD PLASTIPAK RX/OTC EASY GLIDE RX/OTC SYRINGES ALLERGY F SYRINGE/SLIP F 28GX1/2 MISC LLOCK/1ML MISC EASY TOUCH ALLERGY RX/OTC BD SAFETYGLIDE 27G X F 5/8"NEEDLE MISC TRAY SAFETY F SYRINGE/1ML/27G X 1/2" BD SAFETYGLIDE RX/OTC MISC ALLERGY F SYRINGE/1ML/27GX1/2" EASY TOUCH FLIPLOCK F RX/OTC MISC NEEDLES 18GX1" MISC BD SAFETYGLIDE RX/OTC EASY TOUCH FLIPLOCK RX/OTC HYPODERMICNEEDLE F NEEDLES 18GX1-1/2" F 18G X 1-1/2" MISC MISC BD SAFETYGLIDE RX/OTC EASY TOUCH FLIPLOCK F RX/OTC HYPODERMICNEEDLE F NEEDLES 19GX1" MISC 25GX5/8" MISC EASY TOUCH FLIPLOCK RX/OTC BD SAFETYGLIDE RX/OTC NEEDLES 22GX1-1/2" F INJECTIONNEEDLE F MISC 22GX1-1/2" MISC EASY TOUCH FLIPLOCK F RX/OTC BD SAFETYGLIDE RX/OTC NEEDLES 25GX1" MISC INJECTIONNEEDLE F EASY TOUCH FLIPLOCK RX/OTC 25GX1" MISC NEEDLES 25GX1-1/2" F BD SAFETYGLIDE RX/OTC MISC SYRINGE 3ML/25GX1" F EASY TOUCH FLIPLOCK F RX/OTC MISC NEEDLES 25GX5/8" MISC EASY TOUCH FLIPLOCK RX/OTC BD SYRINGE LUER- F RX/OTC F LOK/1ML MISC NEEDLES 27GX1/2" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH RX/OTC SAFETTY SYRINGES F HYPODERMIC NEEDLES F 3ML/18GX1-1/2" MISC 27GX1/2" MISC EASY TOUCH FLIPLOCK EASY TOUCH SAFETY RX/OTC SAFETY SYRINGE F SYRINGE/3ML/20G X 1" F 3ML/22GX1" MISC MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH SAFETY SAFETY SYRINGE F SYRINGE/3ML/22G X 1" F 3ML/22GX1-1/2" MISC MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH SAFETY RX/OTC SAFETY SYRINGE F SYRINGE/3ML/22G X 1- F 3ML/23GX1" MISC 1/2" MISC EASY TOUCH FLIPLOCK EASY TOUCH SAFETY RX/OTC SAFETY SYRINGE F SYRINGE/3ML/23G X 1" F 3ML/23GX1-1/2" MISC MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH SAFETY RX/OTC SAFETY SYRINGE F SYRINGE/3ML/25G X 1" F 3ML/25GX1" MISC MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH SAFETY RX/OTC SAFETY SYRINGE F SYRINGE/3ML/25G X 5/8" F 3ML/25GX5/8" MISC MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH RX/OTC F SAFETY SYRINGES SHEATHLOCK SAFETY F 3ML/20GX1" MISC SYRINGE 3ML/21GX1-1/2" EASY TOUCH FLIPLOCK RX/OTC MISC SAFETY SYRINGES F EASY TOUCH 3ML/21GX1-1/2" MISC SHEATHLOCK SAFETY F EASY TOUCH RX/OTC SYRINGE 3ML/22GX1" HYPODERMIC NEEDLES F MISC 18GX1" MISC EASY TOUCH RX/OTC EASY TOUCH RX/OTC SHEATHLOCK SAFETY F HYPODERMIC NEEDLES F SYRINGE 3ML/22GX1-1/2" 18GX1-1/2" MISC MISC EASY TOUCH RX/OTC EASY TOUCH RX/OTC HYPODERMIC NEEDLES F SHEATHLOCK SAFETY F 19GX1" MISC SYRINGE 3ML/23GX1" MISC EASY TOUCH RX/OTC HYPODERMIC NEEDLES F EASY TOUCH RX/OTC 22GX1-1/2" MISC SHEATHLOCK SAFETY F SYRINGE 3ML/25GX1" EASY TOUCH RX/OTC MISC HYPODERMIC NEEDLES F 25GX1" MISC EASY TOUCH RX/OTC SHEATHLOCK SAFETY F EASY TOUCH RX/OTC SYRINGE 3ML/25GX5/8" HYPODERMIC NEEDLES F MISC 25GX1-1/2" MISC EASY TOUCH RX/OTC HYPODERMIC NEEDLES F 25GX5/8" MISC Arizona Complete Health - Complete Care Plan Effective September 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH RX/OTC HUBER NEEDLE/RIGHT F RX/OTC TUBERCULIN FLIPLOCK F ANGLE19G X 1" MISC SAFETY SYRINGE HUBER NEEDLE/RIGHT F RX/OTC 1ML/27GX1/2" MISC ANGLE22G X 1-1/2" MISC EASY TOUCH RX/OTC HUBER RX/OTC TUBERCULIN FLIPLOCK F NEEDLE/STRAIGHT F SAFETY SYRINGE 22GX1-1/2" MISC 1ML/28GX1/2" MISC HYPODERMIC NEEDLE F RX/OTC EASY TOUCH RX/OTC 18G X 1" MISC TUBERCULIN SHEATHLOCK SAFETY F HYPODERMIC NEEDLE F RX/OTC SYRINGE 1ML/25GX5/8" 18G X 1-1/2" MISC MISC HYPODERMIC NEEDLE F RX/OTC EASY TOUCH RX/OTC 19G X 1" MISC TUBERCULIN HYPODERMIC NEEDLE F RX/OTC SHEATHLOCK SAFETY F 22GX1-1/2" MISC SYRINGE 1ML/27GX1/2" HYPODERMIC NEEDLE F RX/OTC MISC 25GX1" MISC EASY TOUCH RX/OTC HYPODERMIC NEEDLE F RX/OTC TUBERCULIN 25GX1-1/2" MISC SHEATHLOCK SAFETY F HYPODERMIC NEEDLE F RX/OTC SYRINGE 1ML/28GX1/2" 25GX5/8" MISC MISC HYPODERMIC NEEDLE F RX/OTC EASYPOINT NEEDLE 25G F RX/OTC 27GX1/2" MISC X 1" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT NEEDLE 25G F RX/OTC 18GX1" MISC X 5/8" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT NEEDLE F RX/OTC 18GX1-1/2" MISC 25GX1-1/2" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT NEEDLE/18G F RX/OTC 19GX1" MISC X 1" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT NEEDLE/18G F RX/OTC 22GX1-1/2" MISC X 1-1/2" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT NEEDLE/22G F RX/OTC 25GX1-1/2" MISC X 1-1/2" MISC HYPODERMIC NEEDLES F RX/OTC EASYPOINT RX/OTC 25GX5/8" MISC NEEDLE/SYRINGE F 3ML/18G X 1-1/2" MISC HYPODERMIC NEEDLES F RX/OTC 27GX1/2" MISC EASYPOINT RX/OTC NEEDLE/SYRINGE F INSULIN SYRINGES F 3ML/23 G X 1" MISC MAGELLAN TUBERCULIN RX/OTC EASYPOINT RX/OTC SAFETY F NEEDLE/SYRINGE F SYRINGE/1ML/27G X 1/2" 3ML/25G X 1" MISC MISC EASYPOINT RX/OTC NEEDLE/SYRINGE F 3ML/25G X 5/8" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGELLAN TUBERCULIN RX/OTC MONOJECT RX/OTC SAFETY F HYPO/POLYPROPYLENE F SYRINGE/1ML/28G X 1/2" HUB/LL/INTM BEVEL/25G MISC X 5/8" MISC MONOJECT 1ML LUER RX/OTC MONOJECT RX/OTC LOCK TUBERCULIN F HYPO/POLYPROPYLENE F SYRINGE/TIP CAP MISC HUB/LL/REG BEVEL/19G MONOJECT 3ML RX/OTC TW X 1" MISC SYRINGE/STANDARD F MONOJECT RX/OTC HYPODERMIC HYPO/POLYPROPYLENE F NEEDLE/21GX1-1/2" MISC HUB/LL/REG BEVEL/25G MONOJECT BLUNTIP RX/OTC X 1" MISC SYRINGE/3ML/CANNULA/ F MONOJECT RX/OTC IV ACCESS MISC HYPO/POLYPROPYLENE F HUB/LL/SHORT MONOJECT HYPO/ALUM F RX/OTC HUB/18G X 1-1/2" MISC BEVEL/18G X 1" MISC MONOJECT HYPO/ALUM RX/OTC MONOJECT RX/OTC HUB/LUER LOCK/INTM F HYPO/POLYPROPYLENE F BEVEL/27G X 1/2" MISC HUB/LL/SHORT BEVEL/18G X 1-1/2" MISC MONOJECT HYPO/ALUM RX/OTC HUB/LUER LOCK/REG F MONOJECT RX/OTC BEVEL/18G X 1" MISC HYPO/POLYPROPYLENE F HUB/LL/SHORT MONOJECT HYPO/ALUM RX/OTC BEVEL/19G TW X 1" MISC HUB/LUER LOCK/REG F BEVEL/22G X 1-1/2" MISC MONOJECT RX/OTC HYPO/POLYPROPYLENE F MONOJECT HYPO/ALUM RX/OTC HUB/LL/SHORT HUB/LUER LOCK/REG F BEVEL/22G X 1-1/2" MISC BEVEL/25G X 5/8" MISC MONOJECT RX/OTC MONOJECT HYPO/ALUM RX/OTC HYPO/POLYPROPYLENE F HUB/LUER LOCK/SHORT F HUB/REG BEVEL/27G X BEVEL/18G X 1" MISC 1/2" MISC MONOJECT HYPO/ALUM RX/OTC MONOJECT RX/OTC HUB/LUER LOCK/SHORT F HYPODERMIC NEEDL3 F BEVEL/18G X 1-1/2" MISC 18G X 1" MISC MONOJECT HYPO/ALUM RX/OTC MONOJECT MAGELLAN RX/OTC HUB/LUER LOCK/SPEC F SAFETYNEEDLE 18GX1" F BEVEL/19G TW X 1" MISC MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC HYPO/POLYPROPYLENE F SAFETYNEEDLE 18GX1- F HUB/18G X 1" MISC 1/2" MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC HYPO/POLYPROPYLENE F SAFETYNEEDLE 19GX1" F HUB/18G X 1-1/2" MISC MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC HYPO/POLYPROPYLENE F SAFETYNEEDLE 22GX1- F HUB/LL/BEVEL/25G X 1- 1/2" MISC 1/2" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT MAGELLAN RX/OTC MONOJECT STANDARD RX/OTC F SAFETYNEEDLE 25GX1" HYPODERMIC F MISC NEEDLE/POLYPROPYLE MONOJECT MAGELLAN RX/OTC NE HUB/19GX1" MISC SAFETYNEEDLE F MONOJECT STANDARD RX/OTC 25GX5/8" MISC HYPODERMIC F MONOJECT MAGELLAN RX/OTC NEEDLE/POLYPROPYLE NE/18GX1-1/2" MISC SYRINGE/SAFETY F NEEDLE/3ML/20G X 1" MONOJECT STANDARD RX/OTC MISC HYPODERMIC F MONOJECT MAGELLAN RX/OTC NEEDLE/POLYPROPYLE NE/22GX1-1/2" MISC SYRINGE/SAFETY F NEEDLE/3ML/21G X 1-1/2" MONOJECT STANDARD RX/OTC MISC HYPODERMIC F MONOJECT MAGELLAN NEEDLE/POLYPROPYLE NE/25GX1" MISC SYRINGE/SAFETY F NEEDLE/3ML/22G X 1" MONOJECT STANDARD RX/OTC MISC HYPODERMIC F MONOJECT MAGELLAN RX/OTC NEEDLE/POLYPROPYLE NE/25GX1-1/2" MISC SYRINGE/SAFETY F NEEDLE/3ML/22G X 1-1/2" MONOJECT STANDARD RX/OTC MISC HYPODERMIC F MONOJECT MAGELLAN RX/OTC NEEDLE/POLYPROPYLE NE/25GX5/8" MISC SYRINGE/SAFETY F NEEDLE/3ML/23G X 1" MONOJECT STANDARD RX/OTC MISC HYPODERMIC F MONOJECT MAGELLAN RX/OTC NEEDLE/POLYPROPYLE NE/27GX1/2" MISC SYRINGE/SAFETY F NEEDLE/3ML/25G X 1" MONOJECT SYRINGE RX/OTC MISC PHARMACY TRAY/1ML F MONOJECT MAGELLAN RX/OTC LUER LOCK MISC SYRINGE/SAFETY F MONOJECT RX/OTC NEEDLE/3ML/25G X 5/8" SYRINGE/LUER F MISC LOCK/3ML MISC MONOJECT PHARMACY RX/OTC MONOJECT RX/OTC TRAY/LUER LOCK/3ML F SYRINGE/LUER F MISC LOCK/3ML/20G X 1" MISC MONOJECT PHARMACY RX/OTC MONOJECT TRAY/REG LUER/1ML F SYRINGE/LUER F MISC LOCK/3ML/22G X 1" MISC MONOJECT STANDARD RX/OTC MONOJECT RX/OTC HYPODERMIC F SYRINGE/LUER F NEEDLE/POLYPROPYLE LOCK/3ML/22G X 1-1/2" N/22G X1-1/2" MISC MISC MONOJECT STANDARD RX/OTC MONOJECT RX/OTC F HYPODERMIC F SYRINGE/LUER NEEDLE/POLYPROPYLE LOCK/3ML/23G X 1" MISC NE HUB/18GX1" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER F SYRINGE/STANDARDHY LOCK/3ML/25G X 1" MISC PODERMIC F MONOJECT RX/OTC NEEDLE/3ML/25GX5/8" MISC SYRINGE/LUER F LOCK/3ML/25G X 5/8" MONOJECT TB SYRINGE- F RX/OTC MISC NDL 1ML 27GX1/2" MISC MONOJECT RX/OTC MONOJECT TUBERCULIN RX/OTC SYRINGE/LUER-LOCK F SAFETY F TIP/3ML MISC SYRINGE/1ML/25G X 5/8" MONOJECT RX/OTC MISC SYRINGE/LUER- F MONOJECT TUBERCULIN RX/OTC LOCK/3ML/21G X 1-1/2" SAFETY F MISC SYRINGE/1ML/28G X 1/2" MONOJECT RX/OTC MISC SYRINGE/REG LUER/3ML F MONOJECT TUBERCULIN RX/OTC MISC SYRINGE SOFTPACK F MONOJECT RX/OTC 1ML REGULAR LUER TIP SYRINGE/REGULARTIP/3 F MISC ML MISC MONOJECT TUBERCULIN RX/OTC MONOJECT RX/OTC SYRINGE/1ML/25GX5/8" F SYRINGE/STANDARDHY MISC PODERMIC F MONOJECT TUBERCULIN RX/OTC NEEDLE/3ML/20GX1" SYRINGE/1ML/28G X 1/2" F MISC MISC MONOJECT MONOJECT TUBERCULIN RX/OTC SYRINGE/STANDARDHY SYRINGE/DETACH F PODERMIC F NEEDLE/1ML/25G X 5/8" NEEDLE/3ML/22GX1" MISC MISC MONOJECT TUBERCULIN RX/OTC MONOJECT RX/OTC SYRINGE/DETACH F SYRINGE/STANDARDHY NEEDLE/1ML/27G X 1/2" PODERMIC F MISC NEEDLE/3ML/22GX1-1/2" MONOJECT TUBERCULIN RX/OTC MISC SYRINGE/PERM F MONOJECT RX/OTC NEEDLE/1ML/28G X 1/2" SYRINGE/STANDARDHY MISC PODERMIC F MONOJECT TUBERCULIN RX/OTC NEEDLE/3ML/23GX1" SYRINGE/WITHOUT F MISC NEEDLE/REG LUER/1ML MONOJECT RX/OTC MISC SYRINGE/STANDARDHY MULTI-DRAW NEEDLE F RX/OTC PODERMIC F 22GX1-1/2" MISC NEEDLE/3ML/25GX1" MISC NOKOR ADMIX NEEDLE RX/OTC THIN WALL NON-CORING F 18G X 1-1/2" MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOKOR VENTED NEEDLE RX/OTC SAFESNAP RX/OTC THINWALL NON-CORING F SYRINGE/NEEDLE/3ML/2 F 18G X 1" MISC 2G X 1-1/2" MISC NOKOR VENTED NEEDLE RX/OTC SAFESNAP RX/OTC THINWALL NON-CORING F SYRINGE/NEEDLE/3ML/2 F 18GX1-1/2" MISC 3G X 1" MISC NORM-JECT RX/OTC SAFESNAP TUBERKULIN 1MLLUER F SYRINGE/NEEDLE/3ML/2 F SLIP MISC 3G X 1-1/2" MISC PATIENT SAFE SYRINGE F RX/OTC SAFESNAP RX/OTC 3ML MISC SYRINGE/NEEDLE/3ML/2 F 5G X 1" MISC POLY HUB NEEDLE/18G F RX/OTC X 1" MISC SAFESNAP RX/OTC SYRINGE/NEEDLE/3ML/2 F POLY HUB NEEDLE/18G F RX/OTC X 1-1-1/2" MISC 5G X 5/8" MISC SAFESNAP TUBERCULIN RX/OTC POLY HUB NEEDLE/22G F RX/OTC X 1-1/2" MISC SYRINGE/1ML/25G X 5/8" F MISC POLY HUB NEEDLE/25G F RX/OTC X 1" MISC SAFESNAP TUBERCULIN RX/OTC SYRINGE/1ML/27G X 1/2" F POLY HUB NEEDLE/25G F RX/OTC MISC X 1-1/2" MISC SAFETY RX/OTC POLY HUB NEEDLE/25G F RX/OTC SYRINGES/NEEDLE F X 5/8" MISC 3ML/20GX1" MISC POLY HUB NEEDLE/27G F RX/OTC SAFETY RX/OTC X 1/2" MISC SYRINGES/NEEDLE F REGIONAL BLOCK RX/OTC 3ML/21GX1-1/2" MISC NEEDLE SAFETY BEAD F SAFETY BLOCK BEVEL 22GX1- SYRINGES/NEEDLE F 1/2" MISC 3ML/22GX1" MISC RETROBULBAR NEEDLE F RX/OTC SAFETY RX/OTC 25G TWX 1-1/2" MISC SYRINGES/NEEDLE F SAFESNAP ALLERGY RX/OTC 3ML/22GX1-1/2" MISC SYRINGE/1ML/27G X 1/2" F SAFETY RX/OTC MISC SYRINGES/NEEDLE F SAFESNAP F RX/OTC 3ML/23GX1" MISC SYRINGE/3ML MISC SAFETY RX/OTC SAFESNAP RX/OTC SYRINGES/NEEDLE F SYRINGE/NEEDLE/3ML/2 F 3ML/25GX5/8" MISC 0G X 1" MISC SAFETY-LOK SAFETY RX/OTC SAFESNAP RX/OTC SYRINGE/1ML/25G X 5/8" F SYRINGE/NEEDLE/3ML/2 F MISC 1G X 1-1/2" MISC SAFETY-LOK SYRINGE F RX/OTC SAFESNAP 3ML LUER-LOK MISC SYRINGE/NEEDLE/3ML/2 F SAFETY-LOK RX/OTC 2G X 1" MISC SYRINGE/NEEDLE3ML F LUER-LOK 21GX1-1/2" MISC Arizona Complete Health - Complete Care Plan Effective September 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY-LOK SECURESAFE SYRINGE/NEEDLE3ML F SYRINGE/NEEDLE/3ML/2 F LUER-LOK 22GX1" MISC 2G X 1" MISC SAFETY-LOK RX/OTC SECURESAFE RX/OTC SYRINGE/NEEDLE3ML F SYRINGE/NEEDLE/3ML/2 F LUER-LOK 22GX1-1/2" 2G X 1-1/2" MISC MISC SECURESAFE RX/OTC SAFETY-LOK RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGE/NEEDLE3ML F 3G X 1" MISC LUER-LOK 23GX1" MISC SECURESAFE RX/OTC SAFETY-LOK RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGE/NEEDLE3ML F 5G X 5/8" MISC LUER-LOK 25GX5/8" SECURESAFE RX/OTC MISC TUBERCULIN INSULIN F SAFETY-LOK TB RX/OTC SYRINGE/1ML/25G X 5/8" SYRINGE PERM NEEDLE F MISC 1ML 27GX1/2" MISC SECURESAFE RX/OTC SECURESAFE SAFETY RX/OTC TUBERCULIN INSULIN F HYPODERMIC F SYRINGE/1ML/27G X 1/2" NEEDLE/18G X 1" MISC MISC SECURESAFE SAFETY RX/OTC STIMEX INSULATED RX/OTC HYPODERMIC F NEEDLE TEFLON- F NEEDLE/18G X 1-1/2" COATED BLOCK BEVEL MISC 22GX1-1/2" MISC SECURESAFE SAFETY RX/OTC SYRINGE/BLUNT F RX/OTC HYPODERMIC F PLASTIC CANNULA MISC NEEDLE/19G X 1" MISC SYRINGE/LUER F RX/OTC SECURESAFE SAFETY RX/OTC LOCK/3ML MISC HYPODERMIC F SYRINGE/LUER F RX/OTC NEEDLE/22G X 1-1/2" LOCK/3ML/20G X 1" MISC MISC SYRINGE/LUER RX/OTC SECURESAFE SAFETY RX/OTC LOCK/3ML/21G X 1-1/2" F HYPODERMIC F MISC NEEDLE/25G X 1-1/2" MISC SYRINGE/LUER RX/OTC LOCK/3ML/21GX1-1/2" F SECURESAFE SAFETY RX/OTC MISC HYPODERMIC F NEEDLE/25G X 5/8" MISC SYRINGE/LUER F LOCK/3ML/22G X 1" MISC SECURESAFE SAFETY RX/OTC HYPODERMIC F SYRINGE/LUER RX/OTC NEEDLE/27G X 1/2" MISC LOCK/3ML/22G X 1-1/2" F MISC SECURESAFE RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGE/LUER F 0G X 1" MISC LOCK/3ML/22GX1" MISC SECURESAFE RX/OTC SYRINGE/LUER RX/OTC SYRINGE/NEEDLE/3ML/2 F LOCK/3ML/22GX1-1/2" F 1G X 1-1/2" MISC MISC

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYRINGE/LUER F RX/OTC VANISHPOINT SAFETY LOCK/3ML/23G X 1" MISC SYRINGE/3ML/22GX1" F SYRINGE/LUER MISC LOCK/3ML/23G X 1-1/2" F VANISHPOINT SAFETY RX/OTC MISC SYRINGE/3ML/22GX1-1/2" F MISC SYRINGE/LUER F RX/OTC LOCK/3ML/23GX1" MISC VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/23GX1" F SYRINGE/LUER F RX/OTC LOCK/3ML/25G X 1" MISC MISC SYRINGE/LUER VANISHPOINT SAFETY LOCK/3ML/25G X 1-1/2" F SYRINGE/3ML/23GX1-1/2" F MISC MISC SYRINGE/LUER RX/OTC VANISHPOINT SAFETY RX/OTC LOCK/3ML/25G X 5/8" F SYRINGE/3ML/25GX1" F MISC MISC VANISHPOINT SAFETY SYRINGE/LUER F RX/OTC LOCK/3ML/25GX1" MISC SYRINGE/3ML/25GX1-1/2" F MISC SYRINGE/LUER RX/OTC LOCK/3ML/25GX5/8" F VANISHPOINT SAFETY RX/OTC MISC SYRINGE/3ML/25GX5/8" F MISC SYRINGE/LUER SLIP/1ML F RX/OTC MISC VANISHPOINT RX/OTC SYRINGE/3ML/20G X 1" F SYRINGE/LUER SLIP/3ML F RX/OTC MISC MISC VANISHPOINT RX/OTC SYRINGES/LUER F RX/OTC SYRINGE/3ML/21G X 1- F LOCK/1ML/20GX1" MISC 1/2" MISC SYRINGES/LUER RX/OTC VANISHPOINT LOCK/WITHOUT F SYRINGE/3ML/22G X 1" F NEEDLE/3ML MISC MISC SYRINGES/LUER RX/OTC VANISHPOINT RX/OTC SLIP/WITHOUT F SYRINGE/3ML/22G X 1- F NEEDLE/1ML MISC 1/2" MISC ULTICARE SYRINGE/LOW RX/OTC VANISHPOINT RX/OTC DEADSPACE/3ML/22G F SYRINGE/3ML/23G X 1" F X1-1/2" MISC MISC ULTICARE TUBERCULIN RX/OTC VANISHPOINT SAFETY F SYRINGE/3ML/23G X 1- F SYRINGE/1ML/25G X 5/8" 1/2" MISC MISC VANISHPOINT RX/OTC VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/25G X 1" F SYRINGE/3ML/20GX1" F MISC MISC VANISHPOINT VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/25G X 1- F SYRINGE/3ML/21GX1-1/2" F 1/2" MISC MISC VANISHPOINT RX/OTC SYRINGE/3ML/25G X 5/8" F MISC Arizona Complete Health - Complete Care Plan Effective September 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANISHPOINT RX/OTC Max 1 device TUBERCULIN SYRINGE F per 90 days; IMITREX STATDOSE 1ML/25G X 5/8" MISC NF Use refill SYSTEM SOAJ cartridges;QL(1 VANISHPOINT RX/OTC (sumatriptan succinate) TUBERCULIN SYRINGE F ml per 90 days 1ML/27GX1/2" MISC retail) IMITREX TABS OR 50 MG, 9 per Respiratory Therapy Supplies 100 MG, 25 MG NF month;QL(0.3 SPACER/AEROCHAMBER F Limit 2 per year (sumatriptan succinate) ea daily) 9 per month MIGRAINE PRODUCTS - Drugs to Treat Migraine MAXALT TABS (rizatriptan NF benzoate) QL(0.3 ea Headaches daily) Calcitonin Gene-Related Peptide (CGRP) 9 per month MAXALT-MLT TBDP NF QL(0.3 ea PA; SP (rizatriptan benzoate) AJOVY SOAJ F daily) PA; SP 9 per AJOVY SOSY F naratriptan hcl tabs F month;;QL(0.3 ea daily) EMGALITY SOAJ F PA; SP; MP 9 per month EMGALITY SOSY F PA; SP; MP rizatriptan benzoate tabs F QL(0.3 ea daily) Migraine Combinations 9 per month 10 per rizatriptan benzoate tbdp F QL(0.3 ea CAFERGOT TABS NF daily) (ergotamine w/ caffeine) month;QL(0.34 ea daily) Max 1 device per 90 days; ergotamine w/ caffeine F 12 per month supp re 2 mg-100 mg sumatriptan succinate soaj F Use refill sc 4 mg/0.5ml, 6 mg/0.5ml cartridges;QL(1 10 per ml per 90 days ergotamine w/ caffeine tabs F month;QL(0.34 or 1 mg-100 mg retail) ea daily) 2 doses (1ml) Serotonin Agonists sumatriptan succinate soct F per 9 per sc 4 mg/0.5ml, 6 mg/0.5ml month;QL(0.03 AMERGE TABS NF 4 ml daily) (naratriptan hcl) month;;QL(0.3 ea daily) 2 doses (1ml) IMITREX SOLN NA 20 Limit 6 per sumatriptan succinate soln F per MG/ACT, 5 MG/ACT F month;QL(0.2 sc 6 mg/0.5ml month;QL(0.03 (sumatriptan) ea daily) 4 ml daily) 2 doses (1ml) 9 per IMITREX SOLN SC 6 sumatriptan succinate tabs F month;QL(0.3 per or 50 mg, 100 mg, 25 mg MG/0.5ML (sumatriptan NF ea daily) succinate) month;QL(0.03 4 ml daily) 9 per zolmitriptan tabs or 2.5 mg, F month;;QL(0.3 2 doses (1ml) 5 mg IMITREX STATDOSE ea daily) NF per REFILL SOCT month;QL(0.03 (sumatriptan succinate) 9 per 4 ml daily) zolmitriptan tbdp or 2.5 mg, F month;;QL(0.3 5 mg ea daily)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Try CALCIUM PLUS VITAMIN F Sumatriptan D CAPS ZOMIG SOLN NA 2.5 MG, NS first; limit 6 F CALCIUM TABS 200 UNIT- F 5 MG (zolmitriptan) per 600 MG month;QL(0.2 ea daily) calcium tabs 600 mg F 9 per CHELATED CALCIUM ZOMIG TABS OR 2.5 MG, NF month;;QL(0.3 F 5 MG (zolmitriptan) TABS ea daily) CHEWABLE CALCIUM/D3 F 9 per WAFR ZOMIG ZMT TBDP NF month;;QL(0.3 (zolmitriptan) ea daily) oyster shell tabs F

MINERALS & ELECTROLYTES RA CALCIUM TABS F Calcium Electrolyte Mixtures CAL-CITRATE CAPS F BIOLYTE SOLN F CAL-MINT CHEW F CERALYTE 70 SOLN 20 MEQ/L-30 MEQ/L-60 F CALCIUM CAPS 250 MG F MEQ/L-70 MEQ/L CALCIUM CARBONATE CERASPORT EX1 SOLN F CHEW OR 260 MG, 500 F MG CERASPORT SOLN 4 MEQ/L-6 MEQ/L-18 F calcium carbonate tabs or MEQ/L-20 MEQ/L 1250 mg, 500 mg, 600 mg, F 1500 mg ENFAMIL ENFALYTE F SOLN calcium carbonate-vitamin F d caps EQUALYTE SOLN (oral NF electrolytes) calcium carbonate-vitamin F d chew HYDRALYTE FREEZER F POPS SOLN calcium carbonate-vitamin F d tabs HYDRALYTE SOLN 16 GM/L-20 MEQ/L-45 CALCIUM CHEW 500 MG F MEQ/L-45 MEQ/L-90 F MEQ/L, 210 MG/250ML- CALCIUM CITRATE TABS 270 MG/250ML OR 1040 MG, 200 MG, 250 F MG KINDERLYTE PREMAX SOLN 3.1 MG/360ML-320 calcium citrate tabs or 200 F MG/360ML-620 mg, 950 mg MG/360ML-630 F calcium citrate-vitamin d F MG/360ML, 3.1 tabs 200 unit-250 mg MG/360ML-330 MG/360ML-620 CALCIUM GLUCONATE F TABS OR 50 MG MG/360ML-630 MG/360ML CALCIUM LACTATE TABS F 100 MG, 750 MG

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINDERLYTE SOLN 3.1 MAGNESIUM EXTRA F MG/360ML-300 STRENGTH CAPS MG/360ML-445 magnesium oxide (mg F MG/360ML-560 F supplement) caps MG/360ML, 3.1 MG/360ML-300 magnesium oxide (mg F MG/360ML-460 supplement) tabs MG/360ML-570 MG/360ML MAGNESIUM OXIDE F CAPS 400 MG oral electrolytes soln F MAGOX 400 TABS PEDIALYTE ADVANCED (magnesium oxide (mg NF CARE SOLN (oral NF supplement)) electrolytes) Mineral Combinations PEDIALYTE FREEZER POPS SOLN (oral NF BONE ESSENTIALS CAPS F electrolytes) CAL-MAG-K CHELA MAX F PEDIALYTE SINGLES NF CAPS SOLN (oral electrolytes) CALCIUM & VITAMIN D3 F PEDIALYTE SOLN 0.5 BONEHEALTH LIQD MG/59ML-1.2 MEQ/59ML- 1.5 GM/59ML-2.1 MULTI-MINERALS TABS F MEQ/59ML-2.7 MEQ/59ML, 20 MEQ/L-25 multiple minerals tabs F GM/L-30 MEQ/L-35 NF FORMULAS CALCIUM F MEQ/L-45 MEQ/L, 4.7 MAGNESIUM LIQD MEQ/237ML-8.3 NF MEQ/237ML-10.6 NUTRA-SUPPORT BONE F MEQ/237ML, 5 GM/L-20 CAPS GM/L-20 MEQ/L-35 RA MEQ/L-45 MEQ/L, 7.8 CALCIUM/MAGNESIUM/ZI F MG/L-20 MEQ/L-25 GM/L- NC/COPPER TABS 35 MEQ/L-45 MEQ/L (oral electrolytes) Phosphate K-PHOS NEUTRAL TABS Fluoride (pot phosphate monobasic NF sodium fluoride chew or w/ sod phosphate dibasic & 0.25 mg, 0.5 mg, 1 mg, 2.2 F monobasic) mg pot phosphate monobasic sodium fluoride soln or 0.5 F RX/OTC w/ sod phosphate dibasic & F mg/ml monobasic tabs sodium fluoride tabs or 0.5 F Potassium mg, 1 mg K-TAB TBCR 20 MEQ, 10 NF Magnesium MEQ (potassium chloride) MAG-200 TABS K-TAB TBCR 8 MEQ F (magnesium oxide (mg NF (potassium chloride) supplement)) potassium chloride cpcr or F MAGNESIUM CAPS 400 F 10 meq, 8 meq MG POTASSIUM CHLORIDE F RX/OTC GRAN XX Arizona Complete Health - Complete Care Plan Effective September 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride everolimus F PA; MP microencapsulated crystals F (immunosuppressant) tabs er tbcr 15 meq, 20 meq, 10 IMURAN TABS NF meq (azathioprine) potassium chloride pack or F mycophenolate mofetil F MP 20 meq caps or 250 mg potassium chloride soln or F mycophenolate mofetil susr F MP 20 %, 10 % or 200 mg/ml potassium chloride tbcr or F mycophenolate mofetil tabs F MP 20 meq, 10 meq, 8 meq or 500 mg POTASSIUM TABS F NEORAL CAPS MP (cyclosporine modified (for NF Sodium microemulsion)) NEORAL SOLN MP sodium chloride soln ij 0.9 F % (cyclosporine modified (for NF microemulsion)) sodium chloride soln iv 0.9 F % PROGRAF CAPS NF MP (tacrolimus) MISCELLANEOUS THERAPEUTIC CLASSES RAPAMUNE SOLN 1 NF MP Chelating Agents MG/ML (sirolimus) RAPAMUNE TABS 0.5 QL(1 ea daily); CUPRIMINE CAPS NF (penicillamine) MG, 1 MG, 2 MG NF MP (sirolimus) penicillamine caps or F SANDIMMUNE CAPS 100 NF MP MG, 25 MG (cyclosporine) Immunomodulators SANDIMMUNE SOLN 100 F MP REVLIMID CAPS F PA; SP MG/ML MP THALOMID CAPS F PA; SP sirolimus soln or 1 mg/ml F sirolimus tabs or 0.5 mg, 1 F QL(1 ea daily); Immunosuppressive Agents mg, 2 mg MP MP ASTAGRAF XL CP24 F tacrolimus caps or 0.5 mg, F MP 1 mg, 5 mg azathioprine tabs or 50 mg F ZORTRESS TABS 0.25 PA; MP MG, 0.5 MG, 0.75 MG NF CELLCEPT CAPS NF MP (everolimus (mycophenolate mofetil) (immunosuppressant)) CELLCEPT SUSR NF MP PA; MP (mycophenolate mofetil) ZORTRESS TABS 1 MG F CELLCEPT TABS NF MP Potassium Removing Agents (mycophenolate mofetil) sodium polystyrene F cyclosporine caps or 100 F MP sulfonate powd mg, 25 mg sodium polystyrene F cyclosporine modified (for F MP sulfonate susp microemulsion) caps MOUTH/THROAT/DENTAL AGENTS cyclosporine modified (for F MP microemulsion) soln Arizona Complete Health - Complete Care Plan Effective September 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anesthetics Topical Oral MULTIVITAMINS lidocaine hcl (mouth-throat) F QL(100 ml per soln 2 % 30 days retail) B-Complex w/ Folic Acid Anti-infectives - Throat b-complex w/ c & folic acid F RX/OTC caps clotrimazole troc mt F Multiple Vitamins w/ Minerals nystatin (mouth-throat) F ONEVITE TABS F susp Antiseptics - Mouth/Throat THRIVITE 19 TABS F chlorhexidine gluconate F (mouth-throat) soln UDAMIN SP TABS F PERIDEX SOLN (chlorhexidine gluconate NF VENTRIXYL TABS F (mouth-throat)) Multivitamins Steroids - Mouth/Throat/Dental MULTIVITAMINS /W F triamcinolone acetonide F MINERALS (mouth) pste Ped MV w/ Iron Throat Products - Misc. BPROTECTED PEDIA F AQUORAL SOLN F RX/OTC POLY-VITE/IRON SOLN PC PEDIATRIC POLY- BIOTENE DRY MOUTH RX/OTC VITAMIN DROPS/IRON F MOISTURIZING SPRAY F SOLN SOLN CAPHOSOL SOLN 0.009 RX/OTC POLY-VITA/IRON SOLN F %-0.032 %-0.052 %-0.569 F %, 0.569 %-0.009 %-0.032 Pediatric Multiple Vitamins %-0.052 % BPROTECTED PEDIA F POLY-VITE SOLN CVS DRY MOUTH SPRAY F RX/OTC SOLN MULTIVITAMIN INFANT & F TODDLER SOLN EQL DRY MOUTH ORAL F RX/OTC RINSE SOLN PC PEDIATRIC POLY- F VITAMIN DROPS SOLN MOI-STIR SOLN F RX/OTC pediatric multiple vitamins F soln MOUTH KOTE REMINT F RX/OTC SOLN POLY-VI-SOL SOLN F MOUTH KOTE SOLN F RX/OTC POLY-VITA SOLN F NUMOISYN LIQD F RX/OTC POLY-VITE PEDIATRIC F ORAL RELIEF SPRAY RX/OTC SOLN FOR DRYMOUTH & F Prenatal Vitamins DISCOMFORT SOLN CLASSIC PRENATAL F RA DRY MOUTH SOLN F RX/OTC TABS CO-NATAL FA TABS F RX/OTC XEROSTOMIA RELIEF F RX/OTC SPRAY SOLN Arizona Complete Health - Complete Care Plan Effective September 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPLETENATE CHEW F O-CAL FA TABS F RX/OTC

CVS PRENATAL TABS F O-CAL PRENATAL TABS F

EQL PRENATAL F ONE VITE WOMENS RX/OTC FORMULA TABS PRENATALVITAMIN PLUS F TABS GNP PRENATAL TABS F ONE VITE WOMENS F PRENATALVITAMIN TABS GOODSENSE PRENATAL F VITAMINS TABS ONE-A-DAY WOMENS F PRENATAL MISC HM ONE DAILY F PRENATAL COMBO MISC PERRY PRENATAL CAPS F HM PRENATAL TABS F PNV TABS 29-1 TABS F JENLIVA PRENATAL/POSTNATAL F PRE-NATAL FORMULA F RX/OTC CAPS TABS KP PRENATAL F PRENATABS FA TABS F RX/OTC MULTIVITAMINS TABS PRENATAL 19 CHEW 1 KPN PRENATAL TABS F MG-3 MG-3 MG-7 MG-12 RX/OTC MCG-15 MG-20 MG-20 F M-NATAL PLUS TABS F MG-29 MG-30 UNIT-100 MG-200 MG-400 UNIT- MULTI PRENATAL TABS F 1000 UNIT PRENATAL 19 TABS 1 RX/OTC MYNATAL ADVANCE F TABS MG-3 MG-3 MG-12 MCG- 15 MG-20 MG-20 MG-25 MYNATAL CAPS F MG-29 MG-30 UNIT-400 UNIT-7 MG-100 MG-200 MYNATAL PLUS TABS F MG-1000 UNIT, 1 MG-3 F MG-3 MG-7 MG-12 MCG- MYNATAL ULTRACAPLET F 15 MG-20 MG-20 MG-25 TABS MG-29 MG-30 UNIT-100 MYNATAL-Z TABS F MG-200 MG-400 UNIT- 1000 UNIT MYNATE 90 PLUS TBCR F PRENATAL AND IRON F RX/OTC TABS NATALVIT TABS F PRENATAL FORTE TABS F RX/OTC NEONATAL COMPLETE RX/OTC F PRENATAL LOW IRON TABS F TABS NEONATAL PLUS TABS F RX/OTC PRENATAL F MULTIVITAMIN TABS NEONATAL VITAMIN F TABS PRENATAL ONE DAILY F TABS NIVA-PLUS TABS F RX/OTC PRENATAL PLUS IRON F TABS

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 0.8 MG- prenatal vit w/ iron F 1.5 MG-1.7 MG-2.6 MG-4 carbonyl-folic acid tabs MCG-11 UNIT-18 MG-25 PRENATAL VITAMIN & F MG-27 MG-100 MG-263 MINERAL TABS MG-400 UNIT-4000 UNIT, 0.8 MG-1.5 MG-1.7 MG-2.6 PRENATAL VITAMIN F MG-4 MCG-18 MG-27 MG- TABS 100 MG-263 MG-400 PRENATAL F UNIT-4000 UNIT-25 MG- VITAMIN/IRON TABS 11 UNIT, 0.8 MG-1.7 MG- PRENATAL VITAMINS F RX/OTC 1.8 MG-2.6 MG-8 MCG-20 PLUS LOW IRON TABS MG-25 MG-28 MG-30 PRENATAL VITAMINS F UNIT-120 MG-200 MG-400 TABS UNIT-4000 UNIT, 1.5 MG- 1.7 MG-2.6 MG-4 MCG-5 PRENATAL-U CAPS F MG-10 MCG-18 MG-25 F MG-27 MG-100 MG-200 PRENATRIX TABS F RX/OTC MG-800 MCG-1200 MCG, 1.7 MG-1.8 MG-2.6 MG-8 PRENATRYL TABS F RX/OTC MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 PRENATVITE RX TABS F RX/OTC MG-400 UNIT-800 MCG- 4000 UNIT, 1.7 MG-1.8 PREPLUS TABS F RX/OTC MG-2.6 MG-8 MCG-20 MG-25 MG-28 MG-30 PRETAB TABS F RX/OTC UNIT-120 MG-800 MCG- 4000 UNIT-400 UNIT-200 PX PRENATAL F MG, 1.7 MG-1.84 MG-2.6 MULTIVITAMINS TABS MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 QC PRENATAL TABS F MG-160 MG-200 MG-400 RA PRENATAL UNIT-800 MCG-4000 UNIT FORMULA/FOLICACID F PRENATAL TABS 0.8 MG- RX/OTC TABS 1.7 MG-1.84 MG-2.6 MG-4 MCG-11 UNIT-18 MG-25 F RA PRENATAL TABS F MG-27 MG-100 MG-200 MG-400 UNIT-4000 UNIT RIGHT STEP PRENATAL F TABS PRENATAL TABS 1 MG- RX/OTC 1.84 MG-2 MG-3 MG-10 SE-NATAL 19 CHEW F MCG-10 MG-10 MG-12 F MCG-20 MG-25 MG-27 SE-NATAL 19 TABS F RX/OTC MG-120 MG-200 MG-1200 MCG SM ONE DAILY F PRENATAL MISC prenatal vit w/ docusate- F iron carbonyl-folic acid tabs SM PRENATAL VITAMINS F TABS prenatal vit w/ ferrous F fumarate-folic acid chew THERANATAL CORE F RX/OTC NUTRITION TABS prenatal vit w/ ferrous F fumarate-folic acid tabs THRIVITE RX TABS F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRICARE TABS F RX/OTC Nasal Antiallergy azelastine hcl soln na 0.1 F TRINATAL RX 1 TABS F %, 137 mcg/spray cromolyn sodium (nasal) F VINATE ONE TABS F aers NASALCROM AERS NF VITAFOL-OB TABS F (cromolyn sodium (nasal)) VITATHELY/GINGER F RX/OTC Nasal Anticholinergics TABS ipratropium bromide (nasal) F VOL-NATE TABS F soln Nasal Steroids F RX/OTC VOL-PLUS TABS FLONASE ALLERGY RX/OTC RELIEF CHILDRENS NF VOL-TAB RX TABS F SUSP (fluticasone propionate (nasal)) WESTAB PLUS TABS F RX/OTC FLONASE ALLERGY RX/OTC MUSCULOSKELETAL THERAPY AGENTS - RELIEF SUSP (fluticasone NF Drugs to Treat Spasms propionate (nasal)) Central Muscle Relaxants (nasal) soln F baclofen tabs or 10 mg, 20 F fluticasone propionate F RX/OTC mg (nasal) susp cyclobenzaprine hcl tabs or F NASACORT ALLERGY F 10 mg, 5 mg 24HR AERO methocarbamol tabs or 500 F NASACORT ALLERGY mg, 750 mg 24HR AERO (triamcinolone NF acetonide (nasal)) ROBAXIN-750 TABS NF (methocarbamol) NASACORT ALLERGY 24HR CHILDRENS AERO tizanidine hcl tabs or 4 mg, F NF 2 mg (triamcinolone acetonide (nasal)) ZANAFLEX TABS 4 MG NF (tizanidine hcl) triamcinolone acetonide F (nasal) aero Direct Muscle Relaxants Sympathomimetic Decongestants DANTRIUM CAPS 25 MG NF (dantrolene sodium) pseudoephedrine hcl liqd or F 15 mg/5ml dantrolene sodium caps or F 100 mg, 25 mg pseudoephedrine hcl tabs F or 60 mg, 30 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus pseudoephedrine hcl tb12 F or 120 mg Nasal Agents - Misc. SUDAFED CHILDRENS F OCEAN NASAL SPRAY NF LIQD SOLN (saline) SUDAFED CONGESTION saline soln na 0.002 %- F TABS (pseudoephedrine NF 0.65 % hcl)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUDAFED SINUS ULTRA OMEGA 3 CAPS F CONGESTION TABS NF (pseudoephedrine hcl) ULTRA OMEGA-3 FISH F SUDAFED SINUS OIL BURP-LESS CAPS CONGESTION24 HOUR F TB24 OPHTHALMIC AGENTS - Drugs to Treat the Eye NEUROMUSCULAR AGENTS - Drugs to Artificial Tears and Lubricants Relax/Paralyze Muscles artificial tear solution soln F ALS Agents carboxymethylcellulose F RILUTEK TABS (riluzole) NF sodium (ophth) gel 1 % carboxymethylcellulose riluzole tabs F sodium (ophth) soln 1 %, F 0.25 %, 0.5 % NUTRIENTS GENTEAL SEVERE GEL F Misc. Nutritional Substances GENTEAL SEVERE F FISH OIL CAPS F TEARS GEL

FISH OIL CHEW F ISOPTO TEARS SOLN F polyethylene glycol- FISH OIL PEARLS CAPS F propylene glycol (ophth) F soln FISH OIL TRIPLE F STRENGTH CAPS polyvinyl alcohol soln op F FISH OIL ULTRA CAPS F PURE & GENTLE F LUBRICANT SOLN HM FISH OIL CAPS F REFRESH LIQUIGEL GEL (carboxymethylcellulose NF OMEGA-3 CAPS F sodium (ophth)) REFRESH TEARS SOLN OMEGA-3 EPA FISH OIL F CAPS (carboxymethylcellulose NF sodium (ophth)) omega-3 fatty acids caps F SYSTANE OVERNIGHT THERAPY LUBRICANT F omega-3 fatty acids chew F EYE GEL SYSTANE SOLN OMEGA-3 FISH OIL F EXTRA STRENGTH CAPS (polyethylene glycol- NF propylene glycol (ophth)) SALMON CAPS F SYSTANE ULTRA SOLN (polyethylene glycol- NF SALMON OIL CAPS F propylene glycol (ophth)) SALMON OIL-1000 CAPS F THERATEARS SOLN 0.25 % (carboxymethylcellulose NF SM FISH OIL CAPS F sodium (ophth)) VISTA GEL GEL F SUPER TWIN EPA/DHA F CAPS Arizona Complete Health - Complete Care Plan Effective September 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Beta-blockers - Ophthalmic MYDRIACYL SOLN NF (tropicamide) betaxolol hcl (ophth) soln F phenylephrine hcl F (mydriatic) soln 10 % BETIMOL SOLN F phenylephrine hcl F QL(16 ml daily) (mydriatic) soln 2.5 % BETOPTIC-S SUSP F tropicamide soln op 0.5 %, F carteolol hcl (ophth) soln F 1 % Miotics COSOPT SOLN (dorzolamide hcl-timolol NF ISOPTO CARPINE SOLN NF maleate) (pilocarpine hcl) dorzolamide hcl-timolol pilocarpine hcl soln op 1 %, F 2 %, 4 % maleate soln 0.5 %-2 %, 5 F mg/ml-20 mg/ml, 6.8 Ophthalmic Adrenergic Agents mg/ml-22.3 mg/ml apraclonidine hcl soln F ISTALOL SOLN (timolol NF maleate (ophth)) brimonidine tartrate soln op F levobunolol hcl soln F 0.2 % timolol maleate (ophth) Ophthalmic Anti-infectives F QL(4 gm per 7 solg 0.25 %, 0.5 % bacitracin (ophthalmic) oint F days retail) timolol maleate (ophth) F soln 0.25 %, 0.5 % bacitracin-polymyxin b F (ophth) oint TIMOPTIC OCUDOSE F SOLN 0.25 % BLEPH-10 SOLN (sulfacetamide sodium NF TIMOPTIC OCUDOSE (ophth)) SOLN 0.5 % (timolol NF maleate (ophth)) CILOXAN OINT F TIMOPTIC SOLN (timolol NF maleate (ophth)) CILOXAN SOLN NF (ciprofloxacin hcl (ophth)) TIMOPTIC-XE SOLG F (timolol maleate (ophth)) ciprofloxacin hcl (ophth) F soln Cycloplegic Mydriatics erythromycin (ophth) oint F atropine sulfate F (ophthalmic) oint gentamicin sulfate (ophth) F oint ATROPINE SULFATE F SOLN OP 1 % gentamicin sulfate (ophth) F soln CYCLOGYL SOLN 2 %, 1 NF % (cyclopentolate hcl) levofloxacin (ophth) soln F cyclopentolate hcl soln op F 2 %, 1 % moxifloxacin hcl (ophth) F soln homatropine hbr soln F NATACYN SUSP F ISOPTO ATROPINE SOLN F neomycin-bacitracin zn- F polymyxin oint Arizona Complete Health - Complete Care Plan Effective September 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits neomycin-polymyxin- F RESTASIS EMUL F PA; MP gramicidin soln OCUFLOX SOLN NF Ophthalmic Local Anesthetics (ofloxacin (ophth)) tetracaine hcl (ophth) soln F ofloxacin (ophth) soln F Ophthalmic Steroids polymyxin b-trimethoprim F soln bacitracin-poly-neomycin- F hc oint POLYTRIM SOLN NF (polymyxin b-trimethoprim) BLEPHAMIDE S.O.P. F OINT sulfacetamide sodium F (ophth) oint BLEPHAMIDE SUSP F sulfacetamide sodium F dexamethasone sodium F (ophth) soln phosphate (ophth) soln tobramycin (ophth) soln F (ophth) F susp 1 rtl pack lmt TOBREX OINT F amt,7 rtl pack FML FORTE SUSP F lmt day(s), FML LIQUIFILM SUSP NF TOBREX SOLN NF (fluorometholone (ophth)) (tobramycin (ophth)) FML OINT F trifluridine soln F MAXIDEX SUSP F VIGAMOX SOLN NF (moxifloxacin hcl (ophth)) MAXITROL OINT Ophthalmic Decongestants (neomycin-polymy- NF dexameth) naphazoline w/ F pheniramine soln MAXITROL SUSP NAPHCON-A SOLN (neomycin-polymy- NF (naphazoline w/ NF dexameth) pheniramine) neomycin-polymy- F OPCON-A SOLN dexameth oint (naphazoline w/ NF neomycin-polymy- F pheniramine) dexameth susp neomycin-polymyxin-hc tetrahydrozoline hcl (ophth) F F soln (ophth) susp PRED FORTE SUSP tetrahydrozoline w/ zinc F sulfate soln (prednisolone acetate NF VISINE RED EYE (ophth)) COMFORT SOLN NF PRED MILD SUSP F (tetrahydrozoline hcl (ophth)) PRED-G S.O.P. OINT F VISINE SOLN (tetrahydrozoline hcl NF PRED-G SUSP F (ophth)) prednisolone acetate F Ophthalmic Immunomodulators (ophth) susp

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISOLONE F Prostaglandins - Ophthalmic ACETATE P-F SUSP QL(2.5 ml per latanoprost soln op F PREDNISOLONE SODIUM fill retail) PHOSPHATE SOLN OP 1 F TRAVATAN Z SOLN NF PA % (travoprost) sulfacetamide sod- F PA prednisolone soln travoprost soln F QL(4 gm per 7 TOBRADEX OINT F XALATAN SOLN NF days retail) (latanoprost) TOBRADEX ST SUSP F ZIOPTAN SOLN F PA TOBRADEX SUSP (tobramycin- NF OTIC AGENTS - Drugs to Treat the Ear dexamethasone) Otic Agents - Miscellaneous tobramycin- F dexamethasone susp acetic acid (otic) soln F Ophthalmics - Misc. carbamide peroxide (otic) F ACULAR LS SOLN soln (ketorolac tromethamine NF DEBROX SOLN NF (ophth)) (carbamide peroxide (otic)) ACULAR SOLN (ketorolac NF Otic Anti-infectives tromethamine (ophth)) ciprofloxacin hcl (otic) soln F azelastine hcl (ophth) soln F FLOXIN OTIC SOLN NF AZOPT SUSP NF PA (ofloxacin (otic)) (brinzolamide) ofloxacin (otic) soln F brinzolamide susp F PA Otic Combinations cromolyn sodium (ophth) F soln CIPRODEX SUSP (ciprofloxacin- F diclofenac sodium (ophth) F soln dexamethasone) neomycin-polymyxin-hc F dorzolamide hcl soln F (otic) soln neomycin-polymyxin-hc DORZOLAMIDE HCL F F SOLN (otic) susp flurbiprofen sodium soln F Otic Steroids hydrocortisone w/acetic F ketorolac tromethamine F acid soln (ophth) soln OXYTOCICS - Drugs to Prevent/Control Uterine ketotifen fumarate (ophth) F soln Bleeding Oxytocics TRUSOPT SOLN NF (dorzolamide hcl) methylergonovine maleate F tabs or 0.2 mg ZADITOR SOLN (ketotifen NF fumarate (ophth))

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PASSIVE IMMUNIZING AND TREATMENT amoxicillin & pot F AGENTS - Antibody Drugs to Treat Low Immune clavulanate susr System amoxicillin & pot F clavulanate tabs Immune Serums PA; SP amoxicillin & pot F BIVIGAM SOLN F clavulanate tb12 PA; SP ampicillin & sulbactam FLEBOGAMMA DIF SOLN F sodium solr ij 0.5 gm-1 gm, F 1 gm-2 gm F PA; SP GAMASTAN INJ AUGMENTIN ES-600 SUSR (amoxicillin & pot NF GAMMAGARD LIQUID F PA; SP SOLN clavulanate) GAMMAGARD S/D IGA PA; SP AUGMENTIN SUSR 31.25 F LESS THAN 1MCG/ML F MG/5ML-125 MG/5ML SOLR AUGMENTIN SUSR 62.5 PA; SP MG/5ML-250 MG/5ML NF GAMMAKED SOLN F (amoxicillin & pot clavulanate) GAMUNEX-C SOLN F PA; SP AUGMENTIN TABS 125 HIZENTRA SOLN F PA; SP MG-500 MG (amoxicillin & NF pot clavulanate) PA; SP PRIVIGEN SOLN F UNASYN SOLR (ampicillin NF & sulbactam sodium) Monoclonal Antibodies Penicillinase-Resistant Penicillins PA; SP SYNAGIS SOLN F dicloxacillin sodium caps F

PENICILLINS - Drugs to Treat Bacterial Infections oxacillin sodium solr iv 10 F gm Aminopenicillins PROGESTINS - Hormone Replacement/Modifying amoxicillin caps F Drugs Progestins amoxicillin chew F AYGESTIN TABS NF (norethindrone acetate) amoxicillin susr F MAKENA OIL IM 250 F PA; SP amoxicillin tabs F MG/ML MAKENA OIL IM 250 NF SP ampicillin caps F MG/ML MAKENA SOAJ SC 275 F PA; SP Natural Penicillins MG/1.1ML penicillin v potassium solr F medroxyprogesterone acetate tabs or 10 mg, 2.5 F penicillin v potassium tabs F mg, 5 mg norethindrone acetate tabs F Penicillin Combinations or amoxicillin & pot F caps or 100 F QL(2 ea daily); clavulanate chew mg, 200 mg MP Arizona Complete Health - Complete Care Plan Effective September 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROMETRIUM CAPS NF QL(2 ea daily); RAZADYNE ER CP24 PA (progesterone) MP (galantamine NF PROVERA TABS hydrobromide) (medroxyprogesterone NF RAZADYNE TABS PA acetate) (galantamine NF hydrobromide) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and rivastigmine pt24 F PA Emotional Conditions PA Agents for Chemical Dependency rivastigmine tartrate caps F acamprosate calcium tbec F Multiple Sclerosis Agents AVONEX PEN AJKT F PA; SP ANTABUSE TABS NF (disulfiram) AVONEX PSKT F PA; SP disulfiram tabs or 250 mg, F 500 mg BETASERON KIT F PA; SP Antidementia Agents COPAXONE SOSY 20 PA; SP ARICEPT TABS (donepezil NF PA F hydrochloride) MG/ML (glatiramer acetate) COPAXONE SOSY 40 SP donepezil hydrochloride F PA NF tabs MG/ML (glatiramer acetate) PA; SP donepezil hydrochloride F PA EXTAVIA KIT F tbdp GILENYA CAPS F PA; SP EXELON PT24 NF PA (rivastigmine) glatiramer acetate sosy 40 F PA; SP galantamine hydrobromide F PA mg/ml cp24 glatiramer acetate sosy 40 F PA; SP; MP galantamine hydrobromide F PA mg/ml soln REBIF REBIDOSE SOAJ F PA; SP galantamine hydrobromide F PA tabs REBIF REBIDOSE F PA; SP memantine hcl soln 10 F PA TITRATIONPACK SOAJ mg/5ml, 2 mg/ml REBIF SOSY F PA; SP memantine hcl tabs F PA REBIF TITRATION PACK PA; SP PA; QL(6 ea F memantine hcl tabs 10 mg F SOSY daily); MP Postherpetic Neuralgia (PHN)/Neuropathic Pain PA; QL(6 ea memantine hcl tabs 5 mg F daily) GRALISE TABS 300 MG, F PA 600 MG NAMENDA TABS 10 MG NF PA; QL(6 ea (memantine hcl) daily); MP Psychotherapeutic and Neurological Agents - AL(At least 6 NAMENDA TABS 5 MG NF PA; QL(6 ea pimozide tabs F (memantine hcl) daily) yrs old) NAMENDA TITRATION PA Restless Leg Syndrome (RLS) Agents PAK TABS (memantine NF PA hcl) HORIZANT TBCR F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smoking Deterrents QL(24 ea NICORETTE STARTER daily)84 rtl QL(2 ea nicotine NF MAX day(s) daily)84 rtl KIT GUM ( F polacrilex) supply,180 rtl APO-VARENICLINE TABS MAX day(s) lmt day(s), supply,180 rtl lmt day(s), QL(24 ea daily)84 rtl QL(2 ea nicotine polacrilex gum mt F MAX day(s) daily)84 rtl 4 mg, 2 mg bupropion hcl (smoking F MAX day(s) supply,180 rtl deterrent) tb12 supply,180 rtl lmt day(s), lmt day(s), QL(20 ea daily)84 rtl QL(2 ea nicotine polacrilex lozg mt 2 F MAX day(s) daily)84 rtl mg, 4 mg CHANTIX CONTINUING F supply,180 rtl MAX day(s) lmt day(s), MONTHPAK TABS supply,180 rtl lmt day(s), QL(1 ea daily)84 rtl QL(2 ea nicotine pt24 F MAX day(s) daily)84 rtl CHANTIX STARTING F supply,180 rtl MAX day(s) lmt day(s), MONTH PAK TABS supply,180 rtl lmt day(s), QL(1 ea NICOTINE daily)84 rtl QL(2 ea F daily)84 rtl TRANSDERMAL SYSTEM MAX day(s) KIT supply,180 rtl CHANTIX TABS F MAX day(s) supply,180 rtl lmt day(s), lmt day(s), QL(16.8 ea QL(1 ea daily)84 rtl NICOTROL INHALER F MAX day(s) daily)84 rtl INHA NICODERM CQ PT24 NF supply,180 rtl ) MAX day(s) (nicotine supply,180 rtl lmt day(s), lmt day(s), QL(4 ml daily)84 rtl QL(24 ea F daily)84 rtl NICOTROL NS SOLN MAX day(s) NICORETTE GUM 4 MG, 2 NF supply,180 rtl ) MAX day(s) MG (nicotine polacrilex supply,180 rtl lmt day(s), lmt day(s), RESPIRATORY AGENTS - MISC. - Drugs to QL(20 ea Treat Lung Conditions daily)84 rtl Alpha-Proteinase Inhibitor (Human) NICORETTE LOZG 2 MG, NF ) MAX day(s) 4 MG (nicotine polacrilex supply,180 rtl ARALAST NP SOLR F PA; SP lmt day(s), PA; SP QL(20 ea GLASSIA SOLN F daily)84 rtl PA; SP NICORETTE MINI LOZG NF PROLASTIN-C SOLR F ) MAX day(s) (nicotine polacrilex supply,180 rtl PA; SP lmt day(s), ZEMAIRA SOLR F Cystic Fibrosis Agents

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PULMOZYME SOLN F PA; SP levothyroxine sodium tabs or 300 mcg, 100 mcg, 112 SULFONAMIDES - Drugs to Treat Bacterial mcg, 125 mcg, 137 mcg, F Infections 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 Sulfonamides mcg, 88 mcg SULFADIAZINE TABS OR F liothyronine sodium tabs or F 50 mcg, 25 mcg, 5 mcg TETRACYCLINES - Drugs to Treat Bacterial NATURE-THROID NT-2.5 F Infections TABS Tetracyclines NATURE-THROID TABS F demeclocycline hcl tabs F PA SYNTHROID TABS NF (levothyroxine sodium) doxycycline (monohydrate) F caps 50 mg, 100 mg thyroid tabs or 120 mg, 15 F mg, 30 mg, 60 mg, 90 mg doxycycline hyclate caps or F 50 mg, 100 mg WESTHROID TABS F doxycycline hyclate tabs or F 100 mg, 20 mg WP THYROID TABS F MINOCIN CAPS OR 50 NF MG (minocycline hcl) TOXOIDS minocycline hcl caps or F 100 mg, 50 mg, 75 mg Toxoid Combinations Limit 1 dose VIBRAMYCIN CAPS 100 NF MG (doxycycline hyclate) per 10 years;1 rtl MAX fill,999 THYROID AGENTS - Drugs to Regulate Thyroid ADACEL SUSP F rtl day(s) Hormones supply,; AL(At least 19 yrs Antithyroid Agents old) methimazole tabs or 10 F mg, 5 mg Limit 1 dose per 10 years;1 propylthiouracil tabs or F rtl MAX fill,999 BOOSTRIX SUSP F rtl day(s) TAPAZOLE TABS NF supply,; AL(At (methimazole) least 19 yrs Thyroid Hormones old) ARMOUR THYROID TABS Limit 1 dose 120 MG, 15 MG, 30 MG, NF per 10 years;1 60 MG, 90 MG (thyroid) rtl MAX fill,999 DAPTACEL SUSP F rtl day(s) ARMOUR THYROID TABS F supply,; AL(At 180 MG, 240 MG least 19 yrs ARMOUR THYROID TABS F MP old) 300 MG CYTOMEL TABS NF (liothyronine sodium)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose hyoscyamine sulfate tbdp F QL(4 ea daily) per 10 years;1 or 0.125 mg rtl MAX fill,999 LEVBID TB12 NF QL(2 ea daily) TDVAX SUSP F rtl day(s) (hyoscyamine sulfate) supply,; AL(At least 19 yrs LEVSIN TABS OR 0.125 NF QL(4 ea daily) old) MG (hyoscyamine sulfate) Limit 1 dose LEVSIN/SL SUBL NF QL(4 ea daily) per 10 years;1 (hyoscyamine sulfate) rtl MAX fill,999 methscopolamine bromide F TENIVAC INJ F rtl day(s) tabs or 2.5 mg, 5 mg supply,; AL(At propantheline bromide tabs F least 19 yrs or old) SYMAX DUOTAB TBCR F Limit 1 dose per 10 years;1 H-2 Antagonists TETANUS/DIPHTHERIA rtl MAX fill,999 TOXOIDS-ADSORBED F rtl day(s) DEPRIZINE FUSEPAQ F ADULT SUSP supply,; AL(At SUSR least 19 yrs famotidine susr or 40 F old) mg/5ml ULCER DRUGS - Drugs to Treat Bowel, Intestine famotidine tabs or 20 mg F RX/OTC and Stomach Conditions famotidine tabs or 40 mg, F Antispasmodics 10 mg ANASPAZ TBDP NF QL(4 ea daily) GNP ACID CONTROL 150 RX/OTC (hyoscyamine sulfate) MAXIMUM STRENGTH F CUVPOSA SOLN F TABS PEPCID AC MAXIMUM RX/OTC dicyclomine hcl caps or 10 F STRENGTH TABS NF mg (famotidine) dicyclomine hcl soln or 10 F PEPCID AC TABS 10 MG NF mg/5ml (famotidine) dicyclomine hcl tabs or 20 F PEPCID AC TABS 20 MG NF RX/OTC mg (famotidine) glycopyrrolate tabs or 1 F PEPCID TABS 20 MG NF RX/OTC mg, 2 mg (famotidine) hyoscyamine sulfate elix or F PEPCID TABS 40 MG NF 0.125 mg/5ml (famotidine) hyoscyamine sulfate soln QL(8 ml daily) F ranitidine hcl caps or 150 F or 0.125 mg/ml mg, 300 mg hyoscyamine sulfate subl sl F QL(4 ea daily) ranitidine hcl syrp or 15 0.125 mg mg/ml, 150 mg/10ml, 75 F mg/5ml hyoscyamine sulfate tabs F QL(4 ea daily) or 0.125 mg ranitidine hcl tabs or 150 F RX/OTC mg hyoscyamine sulfate tb12 F QL(2 ea daily) or 0.375 mg ranitidine hcl tabs or 300 F mg, 75 mg

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZANTAC 150 MAXIMUM RX/OTC PA req age 19 STRENGTH TABS NF and up. Use (ranitidine hcl) lansoprazole, omeprazole, ZANTAC 75 TABS NF (ranitidine hcl) F esomeprazole lansoprazole tbdd or 30 mg caps. Max 2 Misc. Anti-Ulcer tab per day;QL(2 ea CARAFATE TABS 1 GM NF (sucralfate) daily); AL(Up to 18 yrs old ); MP sucralfate tabs or 1 gm F NEXIUM 24HR CLEAR RX/OTC Proton Pump Inhibitors MINIS CPDR NF (esomeprazole Max 2 caps per magnesium) esomeprazole magnesium F day;QL(2 ea cpdr 20 mg daily); RX/OTC; NEXIUM 24HR CPDR RX/OTC MP (esomeprazole NF magnesium) Max 2 caps per esomeprazole magnesium F day;QL(2 ea NEXIUM CPDR 20 MG RX/OTC cpdr 40 mg daily); MP (esomeprazole NF magnesium) PA req age 19 and up. Use NEXIUM CPDR 40 MG lansoprazole, (esomeprazole NF omeprazole, magnesium) PA req age 19 esomeprazole magnesium F esomeprazole pack 10 mg, 20 mg, 40 mg caps. Max 1 and up. Use per day;QL(1 lansoprazole, ea daily); omeprazole, NEXIUM PACK 10 MG, 20 esomeprazole AL(Up to 18 yrs MG, 40 MG (esomeprazole NF old ); MP magnesium) caps. Max 1 Max 2 caps per per day;QL(1 ea daily); F day lansoprazole cpdr or 15 mg ;QL(2 ea daily); AL(Up to 18 yrs RX/OTC old ); MP Max 2 caps per PA req age 19 lansoprazole cpdr or 30 mg F day and up. Use ;QL(2 ea daily) lansoprazole, omeprazole, PA req age 19 NEXIUM PACK 2.5 MG, 5 F esomeprazole and up. Use MG caps. Max 1 lansoprazole, per day;QL(1 omeprazole, ea daily); esomeprazole AL(Up to 18 yrs lansoprazole tbdd or 15 mg F caps. Max 2 old ); MP tab per day;QL(2 ea Max 2 caps per daily); AL(Up to omeprazole cpdr or 10 mg, F day 18 yrs old ); 40 mg ;QL(2 ea daily); RX/OTC; MP MP

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Max 2 caps per PA req age 19 F day and up. Use omeprazole cpdr or 20 mg ;QL(2 ea daily); lansoprazole, RX/OTC; MP omeprazole, PA req age 19 PROTONIX PACK OR 40 NF esomeprazole and up. Use MG (pantoprazole sodium) caps. Max 1 lansoprazole, per day;QL(1 omeprazole, ea daily); AL(Up to 18 yrs pantoprazole sodium pack F esomeprazole or 40 mg caps. Max 1 old ) per day;QL(1 PROTONIX TBEC OR 20 ea daily); MG, 40 MG (pantoprazole NF AL(Up to 18 yrs sodium) old ) Ulcer Drugs - Prostaglandins pantoprazole sodium tbec F CYTOTEC TABS NF or 20 mg, 40 mg (misoprostol) PREVACID 24HR CPDR NF RX/OTC (lansoprazole) misoprostol tabs or 100 F mcg, 200 mcg PREVACID 24HR CPDR NF RX/OTC; MP (lansoprazole) URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms PREVACID CPDR 15 MG NF RX/OTC (lansoprazole) Urinary Antispasmodic - Antimuscarinics Try oxybutinin Max 2 caps per DETROL LA CP24 PREVACID CPDR 30 MG NF day F IR/ER or brand (lansoprazole) (tolterodine tartrate) ;QL(2 ea daily) Detrol; MP PA req age 19 Try oxybutinin DETROL TABS (tolterodine F and up. Use tartrate) IR/ER or brand lansoprazole, Detrol; MP omeprazole, DITROPAN XL TB24 NF QL(1 ea daily) PREVACID SOLUTAB esomeprazole (oxybutynin chloride) TBDD 15 MG NF caps. Max 2 (lansoprazole) tab per oxybutynin chloride syrp or F day;QL(2 ea 5 mg/5ml daily); AL(Up to oxybutynin chloride tabs or F 18 yrs old ); 5 mg RX/OTC; MP oxybutynin chloride tb24 or F QL(1 ea daily) PA req age 19 10 mg, 15 mg, 5 mg and up. Use TOVIAZ TB24 F lansoprazole, omeprazole, Urinary Antispasmodics - Cholinergic Agonists PREVACID SOLUTAB esomeprazole TBDD 30 MG NF bethanechol chloride tabs lansoprazole) caps. Max 2 ( tab per or 10 mg, 25 mg, 5 mg, 50 F day;QL(2 ea mg daily); AL(Up to URECHOLINE TABS NF 18 yrs old ); MP (bethanechol chloride) VACCINES Bacterial Vaccines

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 doses Viral Vaccines per lifetime;2 rtl Limit 1 dose F MAX fill,999 rtl BEXSERO SUSY day(s) supply,; per AL(At least 19 AFLURIA QUADRIVALENT F season;QL(0.5 yrs old) 2019-2020 SUSP ml per fill retail); AL(At Limit 1 dose least 3 yrs old) per lifetime;1 rtl Limit 1 dose MENACTRA INJ F MAX fill,999 rtl day(s) supply,; per AL(At least 19 AFLURIA QUADRIVALENT F season;QL(0.5 yrs old) 2019-2020 SUSY ml per fill retail); AL(At Limit 1 dose least 3 yrs old) per lifetime;1 rtl Limit 1 dose MENQUADFI INJ F MAX fill,999 rtl day(s) supply,; per AL(At least 19 AFLURIA QUADRIVALENT F season;QL(0.5 yrs old) 2020-2021 SUSP ml per fill retail); AL(At Limit 1 dose least 3 yrs old) per lifetime;1 rtl Limit 1 dose F MAX fill,999 rtl MENVEO SOLR day(s) supply,; per AL(At least 19 AFLURIA QUADRIVALENT F season;QL(0.5 yrs old) 2020-2021 SUSY ml per fill retail); AL(At PNEUMONIA VACCINE F AL least 3 yrs old) Limit 1 dose Limit 1 dose per per lifetime;1 rtl AFLURIA QUADRIVALENT season;QL(0.5 MAX fill,999 rtl F PNEUMOVAX 23 INJ F 2021-2022 SUSP ml per fill day(s) supply,; retail); AL(At AL(At least 19 least 3 yrs old) yrs old) Limit 1 dose Limit 1 dose per per lifetime;1 rtl AFLURIA QUADRIVALENT F season;QL(0.5 PNEUMOVAX 23/1 DOSE F MAX fill,999 rtl 2021-2022 SUSY ml per fill INJ day(s) supply,; retail); AL(At AL(At least 19 least 3 yrs old) yrs old) Limit 3 doses Limit 1 dose per lifetime;3 rtl per lifetime;1 rtl MAX fill,999 rtl MAX fill,999 rtl ENGERIX-B INJ F PREVNAR 13 SUSP F day(s) supply,; day(s) supply,; AL(At least 19 AL(At least 19 yrs old) yrs old) Limit 3 doses Limit 3 doses per lifetime;3 rtl per lifetime;3 rtl MAX fill,999 rtl MAX fill,999 rtl ENGERIX-B SUSP F TRUMENBA SUSY F day(s) supply,; day(s) supply,; AL(At least 19 AL(At least 19 yrs old) yrs old) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose Limit 1 dose per per FLUBLOK FLUAD 2019-2020 SUSY F season;QL(0.5 F season;QL(0.5 ml per fill QUADRIVALENT 2020- ml per fill retail); AL(At 2021 SOSY retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUBLOK FLUAD 2020-2021 SUSY F season;QL(0.5 F season;QL(0.5 ml per fill QUADRIVALENT 2021- 2022 SOSY ml per fill retail); AL(At retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUCELVAX FLUAD QUADRIVALENT F season;QL(0.5 F season;QL(0.5 2021-2022 PRSY ml per fill QUADRIVALENT 2019- 2020 SUSP ml per fill retail); AL(At retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose FLUAD QUADRIVALENT per per season;QL(0.5 FLUCELVAX season;QL(0.5 INFLUENZA VACCINE F QUADRIVALENT 2019- F FOR ADULTS PRSY ml per fill ml per fill retail); AL(At 2020 SUSY retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUARIX QUADRIVALENT season;QL(0.5 FLUCELVAX F QUADRIVALENT 2020- F season;QL(0.5 2019-2020 SUSY ml per fill ml per fill retail); AL(At 2021 SUSP retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUARIX QUADRIVALENT season;QL(0.5 FLUCELVAX F QUADRIVALENT 2020- F season;QL(0.5 2020-2021 SUSY ml per fill ml per fill retail); AL(At 2021 SUSY retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUARIX QUADRIVALENT season;QL(0.5 FLUCELVAX F QUADRIVALENT 2021- F season;QL(0.5 2021-2022 SUSY ml per fill ml per fill retail); AL(At 2022 SUSP retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLUBLOK season;QL(0.5 FLUCELVAX QUADRIVALENT 2019- F QUADRIVALENT 2021- F season;QL(0.5 2020 SOSY ml per fill ml per fill retail); AL(At 2022 SUSY retail); AL(At least 3 yrs old) least 3 yrs old)

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose Limit 1 dose per per FLULAVAL season;QL(0.5 FLUZONE QUADRIVALENT 2019- F QUADRIVALENT 2020- F season;QL(0.5 2020 SUSP ml per fill ml per fill retail); AL(At 2021 SUSP retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLULAVAL FLUZONE QUADRIVALENT 2019- F season;QL(0.5 F season;QL(0.5 ml per fill QUADRIVALENT 2020- 2020 SUSY 2021 SUSY ml per fill retail); AL(At retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLULAVAL FLUZONE QUADRIVALENT 2020- F season;QL(0.5 F season;QL(0.5 ml per fill QUADRIVALENT 2021- 2021 SUSY 2022 SUSP ml per fill retail); AL(At retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 1 dose per per FLULAVAL season;QL(0.5 FLUZONE QUADRIVALENT 2021- F QUADRIVALENT 2021- F season;QL(0.5 2022 SUSY ml per fill ml per fill retail); AL(At 2022 SUSY retail); AL(At least 3 yrs old) least 3 yrs old) Limit 1 dose Limit 2 doses per season age per lifetime;2 rtl 65 and MAX fill,999 rtl FLUZONE HIGH-DOSE PF F GARDASIL 9 SUSP F 2020-2021 SUSY up;QL(0.7 ml day(s) supply,; per fill retail); AL(At least 19 AL(At least 65 yrs old) yrs old) Limit 2 doses Limit 1 dose per lifetime;2 rtl per season age MAX fill,999 rtl GARDASIL 9 SUSY F FLUZONE HIGH-DOSE PF 65 and day(s) supply,; F up;QL(0.7 ml AL(At least 19 2021-2022 SUSY per fill retail); yrs old) AL(At least 65 Limit 3 doses yrs old) per lifetime;3 rtl Limit 1 dose F MAX fill,999 rtl per HAVRIX SUSP day(s) supply,; FLUZONE QUADRIVALENT 2019- F season;QL(0.5 AL(At least 19 ml per fill yrs old) 2020 SUSP retail); AL(At Limit 3 doses least 3 yrs old) per lifetime;3 rtl Limit 1 dose F MAX fill,999 rtl per HEPLISAV-B SOLN day(s) supply,; FLUZONE QUADRIVALENT 2019- F season;QL(0.5 AL(At least 19 ml per fill yrs old) 2020 SUSY retail); AL(At least 3 yrs old) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 3 doses AVC CREA F per lifetime;3 rtl MAX fill,999 rtl HEPLISAV-B SOSY F CLEOCIN CREA VA 2 % day(s) supply,; (clindamycin phosphate NF AL(At least 19 vaginal) yrs old) CLEOCIN SUPP VA 100 F INFLUENZA VACCINE F AL MG clindamycin phosphate F Limit 1 dose vaginal crea per lifetime;1 rtl clotrimazole vaginal crea F F MAX fill,999 rtl M-M-R II SOLR day(s) supply,; AL(At least 19 GYNE-LOTRIMIN 3 CREA NF yrs old) (clotrimazole vaginal) Limit 3 doses GYNE-LOTRIMIN CREA NF per lifetime;3 rtl (clotrimazole vaginal) METROGEL-VAGINAL RECOMBIVAX HB SUSP F MAX fill,999 rtl day(s) supply,; GEL (metronidazole NF AL(At least 19 vaginal) yrs old) metronidazole vaginal gel F Limit 2 doses per miconazole nitrate vaginal F lifetime;QL(1 crea SHINGRIX SUSR F ea per fill miconazole nitrate vaginal F retail); AL(At kit least 50 yrs old) miconazole nitrate vaginal F supp Limit 3 doses per lifetime;3 rtl MONISTAT 1 COMBO PACK KIT (miconazole NF F MAX fill,999 rtl TWINRIX SUSY day(s) supply,; nitrate vaginal) AL(At least 19 MONISTAT 1 DAY OR yrs old) NIGHT COMBO PACK KIT NF Limit 3 doses (miconazole nitrate vaginal) per lifetime;3 rtl MONISTAT 3 COMBINATION PACK KIT NF F MAX fill,999 rtl VAQTA SUSP day(s) supply,; (miconazole nitrate vaginal) AL(At least 19 MONISTAT 3 CREA NF yrs old) (miconazole nitrate vaginal) Limit 2 doses MONISTAT 7 F per lifetime;2 rtl COMBINATION PACK KIT MAX fill,999 rtl VARIVAX INJ F MONISTAT 7 SIMPLY day(s) supply,; CURE CREA (miconazole NF AL(At least 19 nitrate vaginal) yrs old) terconazole vaginal crea F VAGINAL AND RELATED PRODUCTS 0.4 %, 0.8 % Vaginal Anti-infectives Vaginal Estrogens ESTRACE CREA (estradiol NF vaginal) Arizona Complete Health - Complete Care Plan Effective September 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estradiol vaginal crea 0.1 F cholecalciferol tabs or mg/gm 50000 unit, 125 mcg, 5000 F unit, 400 unit, 2000 unit, 50 estradiol vaginal tabs 10 F QL(58 ea per mcg 168 days retail) mcg, 1000 unit, 25 mcg D-VI-SOL LIQD NF ESTRING RING F (cholecalciferol) FEMRING RING 0.05 F PA; MP DECARA CAPS F MG/24HR DRISDOL CAPS FEMRING RING 0.1 F PA NF MG/24HR (ergocalciferol) PREMARIN CREA VA F PA E600 CAPS F 0.625 MG/GM ergocalciferol caps F VAGIFEM TABS (estradiol NF QL(58 ea per vaginal) 168 days retail) KEY-E CHEW OR F AL(At least 6 VAGINAL PRODUCTS - Drugs to Treat Vaginal yrs old) Infections and Low Hormones MAXIMUM D3 CAPS F Miscellaneous Vaginal Products MEPHYTON TABS NONOXYNOL F NF SPERMICIDES (phytonadione) NATURAL VITAMIN E F VASOPRESSORS - Drugs to Treat Heart and TABS Circulation Conditions Anaphylaxis Therapy Agents OPTIMAL D3 M CAPS F QL(0.067 ea phytonadione tabs or F epinephrine (anaphylaxis) F daily,2 ea per soaj 0.15 mg/0.3ml 30 days retail) THERA-D 4000 TABS F epinephrine (anaphylaxis) QL(2 ea per 30 soaj 0.15 mg/0.3ml, 0.3 F days retail) VITAMIN D2 TABS F mg/0.3ml VITAMIN D3 TABS OR F Vasopressors 10000 UNIT, 3000 UNIT midodrine hcl tabs F QL(3 ea daily) vitamin e caps or 180 mg, 100 unit, 45 mg, 1000 unit, F VITAMINS 450 mg, 200 unit, 90 mg, 400 unit Oil Soluble Vitamins VITAMIN E CHEW OR 400 F AL(At least 6 BABY DDROPS LIQD F UNIT yrs old) VITAMIN E TABS OR 100 F cholecalciferol caps or UNIT, 200 UNIT 4000 unit, 1.25 mg, 400 vitamin e tabs or 400 unit F unit, 50000 unit, 10000 F unit, 250 mcg, 125 mcg, 5000 unit, 1000 unit, 25 Water Soluble Vitamins mcg, 2000 unit, 50 mcg B-1 TABS F cholecalciferol liqd or 10 F mcg/ml, 400 unit/ml niacin cpcr 500 mg, 250 mg F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

93 Drug Requirements/ Drug Name Tier Limits niacin tabs 250 mg, 50 mg, F 100 mg niacin tbcr 750 mg, 250 F mg, 500 mg niacinamide tabs F niacinamide tbcr F pyridoxine hcl tabs F

SLO-NIACIN TBCR (niacin) NF thiamine hcl tabs F thiamine mononitrate tabs F

Arizona Complete Health - Complete Care Plan Effective September 1, 2021

94 Index 1ML TB SYRINGE/25G X 3ML SYRINGE/INTERLINK ADVAIR DISKUS 12 5/8"/LUER SLIP TIP 58 VIAL ACCESS CANNULA 59 ADVAIR HFA 12 1ML TB SYRINGE/27G X 3ML SYRINGE/LUER LOCK 1/2"/LUER SLIP TIP 58 TIP 59 ADVIL 2 1ML TUBERCULIN SYRINGE 3ML SYRINGE/LUER LOCK ADVIL MIGRAINE 3 DETACHABLE NEEDLE SLIP TIP23GX1" 59 AFINITOR 27 TIP 25GX5/8" 58 3ML SYRINGE/LUER LOCK 1ML VANISHPOINT TIP25G X 1-1/2" 59 AFINITOR DISPERZ 27 TUBERCULIN SYRINGE 3ML SYRINGE/LUER SLIP AFLURIA QUADRIVALENT 25GX5/8" 58 TIP23GX1" 59 2019-2020 89 1ML VANISHPOINT 3ML SYRINGE/NEEDLE AFLURIA QUADRIVALENT TUBERCULIN SYRINGE REGULAR WALL LUER-LOK 2020-2021 89 27GX1/2" 58 25GX5/8" SUB-Q 59 AFLURIA QUADRIVALENT 2-3ML SYRINGE/LUER LOCK abacavir sulfate 31 2021-2022 89 TIP 58 abacavir sulfate- AJOVY 70 2-3ML SYRINGE/LUER SLIP TIP lamivudine 31 albendazole 8 58 abacavir sulfate-lamivudine- ALBENZA 8 3ML LUER LOCK SAFETY zidovudine 31 ALBUSTIX 49 SYRINGES 58 ABILIFY 31 3ML LUER LOCK SAFETY ALBUTEROL SULFATE 12 ABILIFY MAINTENA 31 SYRINGES 3ML/22G X 1 1/2" albuterol sulfate 12 ABREVA 46 58 ALCOHOL SWABS 58 3ML LUER LOCK SAFETY ABSORICA 43 ALDACTAZIDE 50 SYRINGES/3ML/21G X 1 1/2" acamprosate calcium 83 58 ALDACTONE 51 acarbose 19 3ML LUER LOCK SAFETY ALDARA 47 SYRINGES/3ML/22G X 1" 58 ACCUPRIL 24 alendronate sodium 51 3ML LUER LOCK SAFETY ACCURETIC 25 SYRINGES/3ML/23G X 1" 58 ALER-DRYL 22 acetaminophen 4 3ML LUER LOCK SAFETY ALEVE 3 SYRINGES/3ML/25G X 1" 58 acetaminophen w/ 3ML LUER LOCK SAFETY codeine 5,6 ALEVE ARTHRITIS 3 SYRINGES/3ML/25G X 5/8" 59 acetazolamide 50 ALFERON N 28 3ML LUER-LOK SYRINGE 22GX acetic acid (otic) 81 alfuzosin hcl 54 1-1/2" 59 ALLEGRA ALLERGY 23 3ML LUER-LOK SYRINGE21G X acetylcysteine 43 ACNE MEDICATION 10 43 ALLEGRA ALLERGY 1-1/2" 59 CHILDRENS 23 3ML LUER-LOK SYRINGE22G X ACNE MEDICATION 5 43 ALLEGRA-D 12 HOUR 1" 59 ACTIDOM DMX 40 ALLERGY & CONGESTION 40 3ML LUER-LOK SYRINGE25G X ALLEGRA-D 24 HOUR 5/8" 59 ACTIGALL 52 ACTIMMUNE 28 ALLERGY & CONGESTION 40 3ML LUER-LOK TIP ALLERGY SYRINGE/1ML/27G X SYRINGE25G X 1-1/2" 59 ACTINEL DM 40 3ML SYRINGE/18G X 1- 1/2" 59 1/2"/LUER LOCK TIP 59 ACTOPLUS MET 19 allopurinol 54 3ML SYRINGE/20G X 1"/LUER ACTOS 20 ALORA 52 LOCK TIP 59 ACULAR 81 alprazolam 10 3ML SYRINGE/20G X 1"/LUER ACULAR LS 81 SLIP TIP 59 ALPRAZOLAM INTENSOL 10 3ML SYRINGE/21G X 1- acyclovir 34 ALTACE 24 1/2"/LUER LOCK TIP 59 acyclovir topical 46 alum & mag hydrox- 3ML SYRINGE/22G 1-1/2"/LUER ADACEL 85 simethicone 7,8 LOCK TIP 59 ADALAT CC 35 ALUMINUM HYDROXIDE 8 3ML SYRINGE/22G X 1"/LUER amantadine hcl 28 LOCK TIP 59 ADCIRCA 36 3ML SYRINGE/25G X 1"/LUER ADDERALL 1 AMARYL 21 AMBI EVEN & CLEAR LOCK TIP 59 ADDERALL XR 1 3ML SYRINGE/INTERLINK EXFOLIATING WASH 47 SYRINGE CANNULA 59 adefovir dipivoxil 33

Index 1 AMBI EVEN & CLEAR ARIMIDEX 27 azithromycin 58 FOAMINGCLEANSER 47 aripiprazole 31 AZOPT 81 AMBIEN 56 ARISTADA 31 AZULFIDINE 53 AMERGE 70 ARISTADA INITIO 31 AZULFIDINE EN-TABS 53 AMICAR 55 ARMOUR THYROID 85 B-1 93 amiloride & hydrochlorothiazide 50 ARTHROTEC 50 3 B-12 54 amiloride hcl 51 ARTHROTEC 75 3 b-complex w/ c & folic acid 74 aminocaproic acid 55 artificial tear solution 78 BABY DDROPS 93 amiodarone hcl 11 ASMANEX TWISTHALER 120 BACIGUENT 44 METERED DOSES 12 bacitracin (ophthalmic) 79 AMITIZA 53 ASMANEX TWISTHALER 14 amitriptyline hcl 18 METERED DOSES 12 bacitracin (topical) 44 amlodipine besylate 35 ASMANEX TWISTHALER 30 bacitracin zinc 44 amlodipine besylate-benazepril METERED DOSES 12 bacitracin-poly-neomycin-hc 80 ASMANEX TWISTHALER 60 hcl 25 bacitracin-polymyxin b 44 amoxapine 18 METERED DOSES 12 ASMANEX TWISTHALER 7 bacitracin-polymyxin b amoxicillin 82 METERED DOSES 12 (ophth) 79 amoxicillin & pot clavulanate 82 aspirin 5 baclofen 77 amphetamine- ASPIRIN 5 BACTRIM 9 dextroamphetamine 1 aspirin 5 BACTRIM DS 9 ampicillin 82 aspirin buffered (cal carb-mag BALAMINE DM 40 ampicillin & sulbactam carb-mag oxide) 5 sodium 82 BANZEL 14 ASTAGRAF XL 73 ANAFRANIL 18 BARACLUDE 33,34 atazanavir sulfate 31 ANALPRAM HC 7 BD 1ML TUBERCULIN atenolol 34 SYRINGE/SAFETYGLIDE TB ANALPRAM HC SINGLES 7 atenolol & chlorthalidone 25 NEEDLE 27GX1/2" 59 ANALPRAM-HC 7 BD 1ML TUBERCULIN ATIVAN 10 ANASPAZ 86 SYRINGEDETACHABLE atomoxetine hcl 1 anastrozole 27 NEEDLE SLIP TIP 27GX1/2"59 atorvastatin calcium 24 BD 1ML TUBERCULIN ANDRODERM 7 atovaquone-proguanil hcl 26 SYRINGESLIP-TIP 59 ANDROGEL 7 BD 3ML LUER-LOCK ATRIPLA 31 ANDROGEL PUMP 7 SYRINGE18G X 1 1/2" 59 ATROPINE SULFATE 79 BD 3ML LUER-LOK SYRINGE ANTABUSE 83 atropine sulfate 18G X 1 1/2" 59 ANTACID 8 (ophthalmic) 79 BD 3ML LUER-LOK ANTACID SOFT CHEWS 8 ATROVENT HFA 12 SYRINGE/20G X 1" 59 BD 3ML LUER-LOK ANTI-DIARRHEAL 21 AUGMENTIN 82 SYRINGE/21G X 1-1/2" 59 ANUSOL-HC 7 AUGMENTIN ES-600 82 BD 3ML LUER-LOK ANZEMET 22 AVALIDE 25 SYRINGE/23G X 1" 59 APO-VARENICLINE 84 BD 3ML LUER-LOK AVAPRO 25 SYRINGE/23G X 1-1/2" 59 apraclonidine hcl 79 AVC 92 BD 3ML LUER-LOK aprepitant 22 AVODART 54 SYRINGE/25G X 1" 59 APRISO 53 AVONEX 83 BD 3ML SYRINGE LUER-LOK TIP 59 APTENSIO XR 1 AVONEX PEN 83 BD 3ML SYRINGE SLIP TIP 59 APTIVUS 31 AXILLARY BLOCK NEEDLE BD 3ML AQUORAL 74 BLOCK BEVEL 25GX1" 59 SYRINGE/SAFETYGLIDE ARALAST NP 84 AYGESTIN 82 SHIELDING IM NEEDLE 22GX1- ARAVA 4 azathioprine 73 1/2" 59 ARICEPT 83 azelastine hcl 77 azelastine hcl (ophth) 81

Index 2 BD 3ML BD HYPODERMIC NEEDLE BELEODAQ 27 SYRINGE/SAFETYGLIDE SHORT BEVEL 22GX1- BENADRYL ALLERGY 22 60 SHIELDING IM NEEDLE 1/2" BENADRYL ALLERGY 23GX1" 60 BD HYPODERMIC NEEDLES BD 3ML 18GX1" 60 CHILDRENS 22 BD HYPODERMIC NEEDLES BENADRYL ALLERGY SYRINGE/SAFETYGLIDE ULTRATABS 23 SHIELDING NEEDLE 18GX1.5" 60 BD HYPODERMIC NEEDLES benazepril & 25GX5/8" 60 hydrochlorothiazide 25 BD 19GX1" 60 ALLERGY/SYRINGE/NEEDLE/1 BD HYPODERMIC NEEDLES benazepril hcl 24 ML/28G X 1/2" 60 22GX1.5" 60 BENAZEPRIL BD BLUNT FILL NEEDLE/18GX BD HYPODERMIC NEEDLES HCL/HYDROCHLOROTHIAZIDE 1-1/2" 60 25GX1.5" 60 25 BD DISPOSABLE NEEDLE BD INTEGRA 3ML SYRINGE BENZAC AC WASH 43 REGULAR BEVEL 25GX1" 60 W/RETRACTING NEEDLE/21G benzonatate 39 X 1-1/2" 60 BD DISPOSABLE NEEDLE benzoyl peroxide 43 REGULAR BEVEL THIN WALL BD INTEGRA 3ML SYRINGE 18G X 1" 60 W/RETRACTING NEEDLE/25G BENZOYL PEROXIDE CLEANSER 43 BD ECLIPSE 18G X 1-1/2" 60 X 1" 60 benztropine mesylate 28 BD ECLIPSE NEEDLE 25G X BD INTEGRA NEEDLE/25G 1.5" 60 X5/8" 60 betamethasone dipropionate BD ECLIPSE NEEDLE BD INTEGRA (topical) 46 25GX1" 60 SYRINGE/3ML/22G X 1.5" 61 betamethasone dipropionate BD ECLIPSE NEEDLE 27G X BD INTEGRA augmented 46 1/2" 60 SYRINGE/3ML/23G X 1" 61 betamethasone valerate 46 BD ECLIPSE NEEDLE/22G X 1- BD INTEGRA BETAPACE 35 SYRINGE/3ML/25G X 5/8 61 1/2" 60 BETAPACE AF 35 BD ECLIPSE NEEDLE/25G BD NEEDLE/18G 1-1/2" 61 X5/8" 60 BD NEEDLE/19G X 1" 61 BETASAL 47 BD ECLIPSE NEEDLE/27G X BD NEEDLE/22G X 1-1/2" 61 BETASERON 83 1/2" 60 BD NEEDLE/25G X 5/8" 61 betaxolol hcl (ophth) 79 BD ECLIPSE SYRINGE LUER- bethanechol chloride 88 LOK/3ML/22G X 1" 60 BD NEEDLE/27G X 1/2" 61 BD ECLIPSE SYRINGE LUER- BD PEN NEEDLES 61 BETHKIS 2 LOK/3ML/25G X 1" 60 BD PLASTIPAK SYRINGES BETIMOL 79 BD ECLIPSE ALLERGY 28GX1/2 61 BETOPTIC-S 79 SYRINGE/3ML/23G X 1" 60 BD SAFETYGLIDE 27G X BEVESPI AEROSPHERE 12 BD ECLIPSE 5/8"NEEDLE 61 SYRINGE/3ML/25GX5/8" 60 BD SAFETYGLIDE ALLERGY bexarotene 28 BD ECLIPSE SYRINGE/LUER- SYRINGE/1ML/27GX1/2" 61 BEXSERO 89 LOK/3ML/22G X 1-1/2" 60 BD SAFETYGLIDE BD HYPODERMIC NEEDLE BIKTARVY 31 HYPODERMICNEEDLE 18G X BILTRICIDE 8 REGULAR BEVEL 18G X 1- 1-1/2" 61 1/2" 60 BD SAFETYGLIDE BIODESP DM 40 BD HYPODERMIC NEEDLE HYPODERMICNEEDLE BIOLYTE 71 REGULAR BEVEL 22GX1- 25GX5/8" 61 BIOTENE DRY MOUTH 1/2" 60 BD SAFETYGLIDE MOISTURIZING SPRAY 74 BD HYPODERMIC NEEDLE INJECTIONNEEDLE 22GX1- bisacodyl 57 REGULAR BEVEL 25GX1" 60 1/2" 61 BD HYPODERMIC NEEDLE BD SAFETYGLIDE bismuth subsalicylate 21 REGULAR BEVEL INJECTIONNEEDLE bisoprolol & 25GX5/8" 60 25GX1" 61 hydrochlorothiazide 25 BD HYPODERMIC NEEDLE BD SAFETYGLIDE SYRINGE bisoprolol fumarate 34 REGULAR BEVEL THIN WALL 3ML/25GX1" 61 BIVIGAM 82 18G X 1-1/2" 60 BD SYRINGE LUER- BLEPH-10 79 BD HYPODERMIC NEEDLE LOK/1ML 61 SHORT BEVEL 18G X 1- BD SYRINGE SLIP TIP BLEPHAMIDE 80 1/2" 60 1ML 61 BLEPHAMIDE S.O.P. 80

Index 3 BONE ESSENTIALS 72 calcitriol 51 cefaclor 36 BONIVA 51 CALCIUM 71 CEFACLOR ER 36 BOOSTRIX 85 calcium 71 cefadroxil 36 BPROTECTED PEDIA POLY- CALCIUM & VITAMIN D3 CEFAZOLIN 36 VITE 74 BONEHEALTH 72 cefazolin sodium 36 BPROTECTED PEDIA POLY- calcium acetate (phosphate VITE/IRON 74 binder) 53 CEFAZOLIN SODIUM 36 BRILINTA 54 CALCIUM CARBONATE 8,71 CEFAZOLIN SODIUM/DEXTROSE 36 brimonidine tartrate 79 calcium carbonate 71 cefdinir 36 brinzolamide 81 calcium carbonate (antacid) 8 CEFEPIME 37 bromocriptine mesylate 28 calcium carbonate-vitamin cefepime hcl 37 brompheniramine & d 71 phenyleph 40 CALCIUM CITRATE 71 cefixime 36 brompheniramine & calcium citrate 71 cefpodoxime proxetil 36 pseudoeph 40 calcium citrate-vitamin d 71 cefprozil 36 BRONKIDS 40 CALCIUM GLUCONATE 71 ceftriaxone sodium 37 BRONTUSS DX 40 CALCIUM LACTATE 71 CEFTRIAXONE SODIUM 37 budesonide 38 CALCIUM PLUS VITAMIN ceftriaxone sodium 37 budesonide (inhalation) 12 D 71 ceftriaxone sodium in BUFFERIN 5 CANASA 53 dextrose 37 bumetanide 50 CAPHOSOL 74 CEFTRIAXONE/DEXTROSE 37 BUMEX 50 CAPRELSA 27 cefuroxime axetil 36 buprenorphine hcl 6 captopril 24 CELEBREX 3 buprenorphine hcl-naloxone hcl captopril & dihydrate 7 hydrochlorothiazide 25 celecoxib 3 bupropion hcl 16 CARAC 45 CELEXA 17 bupropion hcl (smoking CARAFATE 87 CELLCEPT 73 deterrent) 84 carbamazepine 14 CENTANY 44 buspirone hcl 10 carbamide peroxide (otic) 81 cephalexin 36 butalbital-acetaminophen- caffeine 4 CARBATROL 14 CERALYTE 70 71 butalbital-acetaminophen- carbidopa-levodopa 28 CERASPORT 71 caffeine w/ codeine 6 carboxymethylcellulose sodium CERASPORT EX1 71 butalbital-aspirin-caffeine 4 (ophth) 78 CERAVE PSORIASIS 47 butalbital-aspirin-caffeine CARDIZEM 35 CERDELGA 54 w/cod 6 CARDIZEM CD 35 BUTALBITAL/ASPIRIN/CAFFEIN CEREZYME 54 E 4 CARDURA 25 CEROVEL 47 butenafine hcl 44 CAREPOINT SAFETY 1ST SYRINGE/NEEDLE 3ML/23G X cetirizine hcl 23 BUTRANS 7 1" 61 cetirizine-pseudoephedrine 40 BYDUREON PEN 20 CAREPOINT SAFETY 1ST CHANTIX 84 BYETTA 20 SYRINGE/NEEDLE 3ML/25G X CHANTIX CONTINUING CAFERGOT 70 1" 61 MONTHPAK 84 CAREPOINT SAFETY 1ST CHANTIX STARTING MONTH CAL-CITRATE 71 SYRINGE/NEEDLE 3ML/25G X PAK 84 CAL-MAG-K CHELA MAX 72 5/8" 61 CHELATED CALCIUM 71 carteolol hcl (ophth) 79 CAL-MINT 71 CHEMSTRIP MICRAL 49 carvedilol 34 CALAMINE 48 CHEMSTRIP-K 49 CATAPRES 25 CALAN 35 CHERACOL PLUS 40 CATAPRES-TTS-1 25 CALAN SR 35 CHERACOL-D COUGH 40 CATAPRES-TTS-2 25 calcitonin (salmon) 51 CHEWABLE CALCIUM/D3 71 CATAPRES-TTS-3 25

Index 4 CHILDRENS ADVIL 3 CLIMARA 52 CONCERTA 1 CHILDRENS MOTRIN 3 CLIMARA PRO 52 CONDOMS 58 CHLOR-TRIMETON 22 CLINDAGEL 43 COPAXONE 83 chlordiazepoxide hcl 11 clindamycin hcl 9 COREG 34 chlorhexidine gluconate (mouth- clindamycin palmitate CORGARD 35 throat) 74 hydrochloride 9 CORN & CALLUS chloroquine phosphate 26 clindamycin phosphate REMOVER 47 chlorothiazide 51 (topical) 43 CORTEF 38 clindamycin phosphate chlorpheniramine & vaginal 92 CORTENEMA 7 pseudoeph 40 clindamycin phosphate-benzoyl CORTIFOAM 7 chlorpheniramine maleate 22 peroxide (refrigerate) 44 COSOPT 79 chlorpromazine hcl 31 CLN ACNE CLEANSER 47 COTELLIC 27 chlorthalidone 51 clobazam 14 COUMADIN 13 cholecalciferol 93 clobetasol propionate 46 COZAAR 25 cholestyramine 24 clobetasol propionate emollient CREON 50 cholestyramine light 24 base 46 CRESTOR 24 ciclopirox 44 CLODERM 46 CRIXIVAN 32 ciclopirox olamine 44 clomipramine hcl 18 cromolyn sodium 12 cidofovir 33 clonazepam 14 cromolyn sodium (nasal) 77 cilostazol 54 clonidine 25 cromolyn sodium (ophth) 81 CILOXAN 79 clonidine hcl 25 crotamiton 49 cinacalcet hcl 51 clonidine hcl (adhd) 1 CUPRIMINE 73 CIPRO 52 clopidogrel bisulfate 54 CUVPOSA 86 CIPRODEX 81 clorazepate dipotassium 11 clotrimazole 74 CVS ANTACID SOFT CHEWS ciprofloxacin hcl 52 ULTRA STRENGTH 8 ciprofloxacin hcl (ophth) 79 clotrimazole (topical) 44 CVS DRY MOUTH SPRAY 74 ciprofloxacin hcl (otic) 81 clotrimazole vaginal 92 CVS GLUCOSE 19 clotrimazole w/ citalopram hydrobromide 17 betamethasone 44 CVS GLUCOSE BITS 19 clarithromycin 58 clozapine 30 CVS LICE SOLUTION KIT 3- CLARITIN 23 STEP 49 CLOZARIL 30 CVS PRENATAL 75 CLARITIN ALLERGY CO-NATAL FA 74 CHILDRENS 23 CVS PSORIASIS MEDICATED CLARITIN CHILDRENS 23 COARTEM 26 SHAMPOO PLUS COLACE 57 CONDITIONER 47 CLARITIN REDITABS 23 CVS SINUS RELIEF CLARITIN-D 12 HOUR 40 COLACE CLEAR 57 DAYTIME/NIGHTTIME 40 CLARITIN-D 24 HOUR 40 colchicine 54 CVS SOFT GLUCOSE 19 CLASSIC PRENATAL 74 COLCRYS 54 CVS THERAPEUTIC CLEAN & CLEAR BLACKHEAD COLESTID 24 DANDRUFFMAXIMUM ERASER SCRUB 47 colestipol hcl 24 STRENGTH 47 54 CLEAN & CLEAR DEEP COLYTE-FLAVOR PACKS56 cyanocobalamin CLEANING ASTRINGENT cyclobenzaprine hcl 77 COMBIVENT RESPIMAT 12 SENSITIVE SKIN 47 CYCLOGYL 79 CLEARASIL DAILY CLEAN COMBIVIR 31 cyclopentolate hcl 79 GENTLE PREVENTION 47 COMPLERA 32 cyclosporine 73 clemastine fumarate 23 COMPLETENATE 75 CLEOCIN 9,92 cyclosporine modified (for COMPOUND W 47 microemulsion) 73 CLEOCIN PEDIATRIC COMPOUND W MAXIMUM CYMBALTA 18 GRANULES 9 STRENGTH 47 cyproheptadine hcl 23,24 CLEOCIN-T 43 COMTAN 28 CYTOMEL 85

Index 5 CYTOTEC 88 desogestrel-ethinyl estradiol dimenhydrinate 22 CYTOVENE 33 (biphasic) 37 DIMETAPP COLD & desogestrel-ethinyl estradiol D-VI-SOL 93 ALLERGY 41 (triphasic) 37 DIOVAN 25 danazol 7 DETROL 88 DIOVAN HCT 25 DANTRIUM 77 DETROL LA 88 diphenhydramine hcl 23 dantrolene sodium 77 DEX4 FAST ACTING diphenhydramine hcl (sleep) 55 dapsone 9 GLUCOSEGO-POUCH 19 DEX4 QUICK DISSOLVE diphenhydramine hcl DAPTACEL 85 GLUCOSE 19 (topical) 45 DAYPRO 3 dexamethasone 39 diphenoxylate w/ atropine 21 DAYTRANA 1 DEXAMETHASONE DIPROLENE AF 46 DDAVP 51 INTENSOL 39 dipyridamole 54 DEBROX 81 dexamethasone sodium phosphate (ophth) 80 disopyramide phosphate 11 DECARA 93 dexmethylphenidate hcl 1 disulfiram 83 DELSYM 39 dextroamphetamine sulfate 1 DITROPAN XL 88 DELSYM COUGH DIURIL 51 CHILDRENS 39 dextromethorphan hbr 40 divalproex sodium 16 DELZICOL 53 dextromethorphan polistirex 40 docosanol 46 demeclocycline hcl 85 dextromethorphan-guaifenesin docusate calcium 57 DENOREX EXTRA STRENGTH 40 2-IN-1 47 dextrose (diabetic use) 19 docusate sodium 57 DENOREX EXTRA STRENGTH DIALYSIS SAFETY dofetilide 11 MEDICATED 47 SYRINGES/LOW DEAD DOMETUSS-DMX 41 DEPAKENE 16 SPACE 3ML/22GX1-1/2" 61 donepezil hydrochloride 83 DEPAKOTE 16 DIAPHRAGMS 58 dorzolamide hcl 81 DEPAKOTE ER 16 DIASTAT ACUDIAL 14 DORZOLAMIDE HCL 81 DEPAKOTE SPRINKLES 16 DIASTAT PEDIATRIC 14 dorzolamide hcl-timolol DEPO-MEDROL 39 diazepam 11 maleate 79 DEPO-PROVERA diazepam (anticonvulsant) 14 doxazosin mesylate 25 CONTRACEPTIVE 38 diclofenac potassium 3 doxepin hcl 18 DEPO-TESTOSTERONE 7 diclofenac sodium 3 doxycycline (monohydrate) 85 DEPRIZINE FUSEPAQ 86 doxycycline hyclate 85 DERMA-SMOOTHE/FS diclofenac sodium (ophth) 81 BODY 46 diclofenac sodium (topical) 44 doxylamine succinate (sleep) 55 DERMA-SMOOTHE/FS diclofenac w/ misoprostol 3 DRAMAMINE 22 SCALP 46 dicloxacillin sodium 82 DERMAREST PSORIASIS 48 DRISDOL 93 dicyclomine hcl 86 DERMAREST PSORIASIS drospirenone-ethinyl MEDICATED SHAMPOO PLUS didanosine 32 estradiol 37 CONDITIONER 48 DIFLUCAN 22 DRYSOL 49 DESCOVY 32 diflunisal 5 DUAC 44 desipramine hcl 18 digoxin 36 DULCOLAX 57 DESITIN RAPID RELIEF 49 DILANTIN 16 DULERA 13 DESMOPRESSIN DILANTIN INFATABS 16 duloxetine hcl 18 ACETATE 52 DILANTIN-125 16 DUOFILM 48 desmopressin acetate 52 DILATRATE SR 10 DURAGESIC 5 desmopressin acetate spray 52 desmopressin acetate spray DILAUDID 5 dutasteride 54 refrigerated 52 diltiazem hcl 35 DYAZIDE 50 desogestrel & ethinyl diltiazem hcl coated beads 35 DYRENIUM 51 estradiol 37 diltiazem hcl extended release E600 93 beads 35

Index 6 EASY GLIDE SYRINGE/LUER EASY TOUCH HYPODERMIC EASYPOINT NEEDLE 25G X LLOC/1ML 61 NEEDLES 22GX1-1/2" 62 5/8" 63 EASY GLIDE SYRINGE/LUER EASY TOUCH HYPODERMIC EASYPOINT NEEDLE 25GX1- LLOCK/3ML 61 NEEDLES 25GX1" 62 1/2" 63 EASY GLIDE SYRINGE/SLIP EASY TOUCH HYPODERMIC EASYPOINT NEEDLE/18G X LLOCK/1ML 61 NEEDLES 25GX1-1/2" 62 1" 63 EASY TOUCH ALLERGY TRAY EASY TOUCH HYPODERMIC EASYPOINT NEEDLE/18G X 1- SAFETY SYRINGE/1ML/27G X NEEDLES 25GX5/8" 62 1/2" 63 1/2" 61 EASY TOUCH HYPODERMIC EASYPOINT NEEDLE/22G X 1- EASY TOUCH FLIPLOCK NEEDLES 27GX1/2" 62 1/2" 63 NEEDLES 18GX1" 61 EASY TOUCH SAFETY EASYPOINT NEEDLE/SYRINGE EASY TOUCH FLIPLOCK SYRINGE/3ML/20G X 1" 62 3ML/18G X 1-1/2" 63 NEEDLES 18GX1-1/2" 61 EASY TOUCH SAFETY EASYPOINT NEEDLE/SYRINGE EASY TOUCH FLIPLOCK SYRINGE/3ML/22G X 1" 62 3ML/23 G X 1" 63 NEEDLES 19GX1" 61 EASY TOUCH SAFETY EASYPOINT NEEDLE/SYRINGE EASY TOUCH FLIPLOCK SYRINGE/3ML/22G X 1- 3ML/25G X 1" 63 NEEDLES 22GX1-1/2" 61 1/2" 62 EASYPOINT NEEDLE/SYRINGE EASY TOUCH FLIPLOCK EASY TOUCH SAFETY 3ML/25G X 5/8" 63 NEEDLES 25GX1" 61 SYRINGE/3ML/23G X 1" 62 EC-NAPROSYN 3 EASY TOUCH FLIPLOCK EASY TOUCH SAFETY ECOTRIN 5 NEEDLES 25GX1-1/2" 61 SYRINGE/3ML/25G X 1" 62 EASY TOUCH FLIPLOCK EASY TOUCH SAFETY ECOTRIN MAXIMUM NEEDLES 25GX5/8" 61 SYRINGE/3ML/25G X 5/8" 62 STRENGTH 5 EASY TOUCH FLIPLOCK EASY TOUCH SHEATHLOCK ECOTRIN REGULAR NEEDLES 27GX1/2" 61 SAFETY SYRINGE STRENGTH 5 EASY TOUCH FLIPLOCK 3ML/21GX1-1/2" 62 ED BRON GP 41 SAFETTY SYRINGES EASY TOUCH SHEATHLOCK EDURANT 32 3ML/18GX1-1/2" 62 SAFETY SYRINGE efavirenz 32 EASY TOUCH FLIPLOCK 3ML/22GX1" 62 SAFETY SYRINGE EASY TOUCH SHEATHLOCK EFFEXOR XR 18 3ML/22GX1" 62 SAFETY SYRINGE EFUDEX 45 EASY TOUCH FLIPLOCK 3ML/22GX1-1/2" 62 ELAPRASE 51 SAFETY SYRINGE 3ML/22GX1- EASY TOUCH SHEATHLOCK ELELYSO 54 1/2" 62 SAFETY SYRINGE EASY TOUCH FLIPLOCK 3ML/23GX1" 62 ELIGARD 27 SAFETY SYRINGE EASY TOUCH SHEATHLOCK ELIMITE 49 3ML/23GX1" 62 SAFETY SYRINGE ELIQUIS 13 EASY TOUCH FLIPLOCK 3ML/25GX1" 62 ELIQUIS STARTER PACK 13 SAFETY SYRINGE 3ML/23GX1- EASY TOUCH SHEATHLOCK 1/2" 62 SAFETY SYRINGE ELMIRON 54 EASY TOUCH FLIPLOCK 3ML/25GX5/8" 62 ELOCON 46 SAFETY SYRINGE EASY TOUCH TUBERCULIN EMBEDA 5 3ML/25GX1" 62 FLIPLOCK SAFETY SYRINGE EASY TOUCH FLIPLOCK 1ML/27GX1/2" 63 EMEND 22 SAFETY SYRINGE EASY TOUCH TUBERCULIN EMEND TRIPACK 22 3ML/25GX5/8" 62 FLIPLOCK SAFETY SYRINGE EMGALITY 70 EASY TOUCH FLIPLOCK 1ML/28GX1/2" 63 emtricitabine 32 SAFETY SYRINGES EASY TOUCH TUBERCULIN 3ML/20GX1" 62 SHEATHLOCK SAFETY EMTRIVA 32 EASY TOUCH FLIPLOCK SYRINGE 1ML/25GX5/8" 63 enalapril maleate 24 SAFETY SYRINGES EASY TOUCH TUBERCULIN enalapril maleate & 3ML/21GX1-1/2" 62 SHEATHLOCK SAFETY hydrochlorothiazide 25 EASY TOUCH HYPODERMIC SYRINGE 1ML/27GX1/2" 63 ENBREL 4 NEEDLES 18GX1" 62 EASY TOUCH TUBERCULIN ENBREL MINI 4 EASY TOUCH HYPODERMIC SHEATHLOCK SAFETY NEEDLES 18GX1-1/2" 62 SYRINGE 1ML/28GX1/2" 63 ENBREL SURECLICK 4 EASY TOUCH HYPODERMIC EASYPOINT NEEDLE 25G X ENFAMIL ENFALYTE 71 NEEDLES 19GX1" 62 1" 63 ENGERIX-B 89

Index 7 enoxaparin sodium 13 ezetimibe 24 FISH OIL 78 entacapone 28 famciclovir 34 FISH OIL PEARLS 78 entecavir 34 famotidine 86 FISH OIL TRIPLE ENTOCORT EC 39 FARESTON 27 STRENGTH 78 FISH OIL ULTRA 78 ENTRESTO 36 FARXIGA 20 FLAGYL 8 EPANED 24 FASENRA 12 FLAX + DHA 2 epinephrine (anaphylaxis) 93 FASENRA PEN 12 FLEBOGAMMA DIF 82 EPIVIR 32 FASLODEX 27 flecainide acetate 11 EPIVIR HBV 34 FATHER JOHNS MEDICINE FLEET ENEMA 57 eplerenone 26 PLUS 41 FAZACLO 30 FLEET ENEMA SIX PACK 57 EPZICOM 32 febuxostat 54 FLEET PEDIATRIC 57 EQ PROBIOTIC 21 EQL DRY MOUTH ORAL felbamate 15 FLOMAX 54 RINSE 74 FELBATOL 15 FLONASE ALLERGY EQL PRENATAL FORMULA 75 FELDENE 3 RELIEF 77 FLONASE ALLERGY RELIEF EQUALYTE 71 felodipine 35 CHILDRENS 77 ergocalciferol 93 FEMARA 27 FLOVENT DISKUS 12 ergotamine w/ caffeine 70 FEMIRON 55 FLOVENT HFA 12 erythromycin (acne aid) 44 FEMRING 93 FLOXIN OTIC 81 erythromycin (ophth) 79 fenofibrate 24 FLUAD 2019-2020 90 escitalopram oxalate 17 fenofibrate micronized 24 FLUAD 2020-2021 90 ESGIC 4 FENOFIBRIC ACID 24 FLUAD QUADRIVALENT 2021- esomeprazole magnesium 87 fenofibric acid 24 2022 90 FLUAD QUADRIVALENT ESTRACE 52 fenoprofen calcium 3 INFLUENZA VACCINE FOR estradiol 52 FENSOLVI 51 ADULTS 90 estradiol vaginal 93 fentanyl 5 FLUARIX QUADRIVALENT ESTRING 93 FER-IN-SOL 55 2019-2020 90 FLUARIX QUADRIVALENT ESTROSTEP FE 37 FERRETTS 55 2020-2021 90 eszopiclone 56 FERRIMIN 150 55 FLUARIX QUADRIVALENT ethambutol hcl 27 FERROUS FUMARATE 55 2021-2022 90 FLUBLOK QUADRIVALENT ethosuximide 16 ferrous fumarate 55 2019-2020 90 ethynodiol diacet & eth FERROUS GLUCONATE 55 FLUBLOK QUADRIVALENT estrad 37 ferrous gluconate 55 2020-2021 90 etodolac 3 FERROUS SULFATE 55 FLUBLOK QUADRIVALENT etoposide 28 2021-2022 90 ferrous sulfate 55 etravirine 32 FLUCELVAX QUADRIVALENT FEVERALL JUNIOR 2019-2020 90 EURAX 49 STRENGTH 4 FLUCELVAX QUADRIVALENT EVAC 56 fexofenadine hcl 23 2020-2021 90 everolimus 27 fexofenadine-pseudoephedrine FLUCELVAX QUADRIVALENT everolimus 41 2021-2022 90 (immunosuppressant) 73 FIBRICOR 24 fluconazole 22 EVISTA 51 finasteride 54 fludrocortisone acetate 39 EVOTAZ 32 FIORICET/CODEINE 6 FLULAVAL QUADRIVALENT 2019-2020 91 EX-LAX 57 FIORINAL 4 FLULAVAL QUADRIVALENT EXELDERM 44 FIORINAL/CODEINE #3 6 2020-2021 91 EXELON 83 FIRST-VANCOMYCIN 25 9 FLULAVAL QUADRIVALENT EXTAVIA 83 FIRST-VANCOMYCIN 50 9 2021-2022 91 FLUMADINE 34

Index 8 flunisolide (nasal) 77 GABITRIL 16 GLYNASE 21 fluocinonide 46 galantamine hydrobromide 83 GLYXAMBI 19 fluorometholone (ophth) 80 GAMASTAN 82 GNP ACID CONTROL 150 fluorouracil (topical) 45 GAMMAGARD LIQUID 82 MAXIMUM STRENGTH 86 GNP CALAMINE 49 fluoxetine hcl 17 GAMMAGARD S/D IGA LESS GNP GLUCOSE 19 fluphenazine decanoate 31 THAN 1MCG/ML 82 GAMMAKED 82 GNP PRENATAL 75 fluphenazine hcl 31 GAMUNEX-C 82 GNP QUICK DISSOLVE flurbiprofen 3 ganciclovir sodium 33 GLUCOSE 19 flurbiprofen sodium 81 GOLD BOND PSORIASIS GARDASIL 9 91 flutamide 27 RELIEF MULTI-SYMPTOM 48 GAS-X 52 fluticasone propionate 46 GOLYTELY 56 GAS-X EXTRA GOODSENSE PRENATAL fluticasone propionate STRENGTH 52 (nasal) 77 VITAMINS 75 GAUZE PADS 2X2, 3X3, GRALISE 83 fluvoxamine maleate 17 4X4 58 granisetron hcl 22 FLUZONE HIGH-DOSE PF 2020- gemfibrozil 24 2021 91 griseofulvin microsize 22 GENERESS FE 37 FLUZONE HIGH-DOSE PF 2021- guaifenesin 43 2022 91 GENOTROPIN 51 FLUZONE QUADRIVALENT GENOTROPIN guaifenesin-codeine 41 2019-2020 91 MINIQUICK 51 guanfacine hcl 25 FLUZONE QUADRIVALENT gentamicin sulfate (ophth) 79 guanfacine hcl (adhd) 1 2020-2021 91 gentamicin sulfate (topical) 44 GYNE-LOTRIMIN 92 FLUZONE QUADRIVALENT 2021-2022 91 GENTEAL SEVERE 78 GYNE-LOTRIMIN 3 92 FML 80 GENTEAL SEVERE HALDOL 30 TEARS 78 FML FORTE 80 HALDOL DECANOATE 100 30 GENVOYA 32 FML LIQUIFILM 80 HALDOL DECANOATE 50 30 GEODON 29 FOCALIN 1 halobetasol propionate 46 GILENYA 83 haloperidol 30 FOCALIN XR 1 GILTUSS COUGH & folic acid 54 COLD 41 haloperidol decanoate 30 FORTIFY OPTIMA GILTUSS EX MAXIMUM haloperidol lactate 30 PROBIOTIC 21 STRENGTH 43 HAVRIX 91 FORTIFY PROBIOTIC GILTUSS TR 41 HEMOCYTE 55 WOMENSEXTRA GLASSIA 84 STRENGTH 21 heparin (porcine) in sodium FOSAMAX 51 glatiramer acetate 83 chloride 13 HEPARIN LOCK FLUSH 13 fosamprenavir calcium 32 GLEEVEC 27 heparin sod (porcine) in d5w 13 foscarnet sodium 33 glimepiride 21 heparin sodium (porcine) 13 FOSCAVIR 33 glipizide 21 glucagon (rdna) 19 heparin sodium (porcine) lock fosinopril sodium 24 flush 13 fosinopril sodium & GLUCAGON EMERGENCY KIT 19 HEPARIN hydrochlorothiazide 26 SODIUM/DEXTROSE 13 FREEZONE 48 GLUCOSE 19 HEPARIN SODIUM/NACL FULPHILA 55 GLUCOTROL 21 0.45% 13 HEPARIN SODIUM/SODIUM FURADANTIN 9 GLUCOTROL XL 21 glyburide 21 CHLORIDE 0.9% 13 furosemide 50 HEPLISAV-B 91 glyburide micronized 21 FUZEON 32 HEPSERA 34 glyburide-metformin 19 G-TUSICOF 41 HERBAL EXPEC 43 glycerin (laxative) 57 G-ZYNCOF 41 HIZENTRA 82 GLYCERIN ADULT 57 gabapentin 14 HM CALAMINE 49 glycopyrrolate 86

Index 9 HM FISH OIL 78 hydrocortisone acetate w/ imiquimod 47 HM OMEGA-3-6-9 FATTY pramoxine 7 IMITREX 70 ACIDS 2 hydrocortisone w/acetic acid 81 IMITREX STATDOSE HM ONE DAILY PRENATAL REFILL 70 COMBO 75 hydrocortisone-aloe vera 46 IMITREX STATDOSE HM PRENATAL 75 HYDROGEN PEROXIDE 31 SYSTEM 70 homatropine hbr 79 hydrogen peroxide 31 IMODIUM A-D 21 HORIZANT 83 hydromorphone hcl 5 IMURAN 73 HUBER NEEDLE/RIGHT HYDROMORPHONE HCL 5 INCRELEX 51 ANGLE19G X 1" 63 hydromorphone hcl 5 indapamide 51 HUBER NEEDLE/RIGHT ANGLE22G X 1-1/2" 63 hydroxychloroquine sulfate 26 INDERAL LA 35 HUBER NEEDLE/STRAIGHT hydroxyurea 28 INDOCIN 3 22GX1-1/2" 63 hydroxyzine hcl 10 indomethacin 3 HUMALOG 20 hydroxyzine pamoate 10 INFANTS ADVIL 3 HUMALOG MIX 50/50 20 hyoscyamine sulfate 86 INFLUENZA VACCINE 92 HUMALOG MIX 75/25 20 HYPER-SAL 43 INSPRA 26 HUMIRA 2 HYPERSAL 43 INSTA-GLUCOSE 19 HUMIRA PEDIATRIC CROHNS HYPODERMIC NEEDLE 18G X INSULIN ASPART 20 DISEASE STARTER PACK 2 1" 63 HUMIRA PEN 2 INSULIN ASPART HYPODERMIC NEEDLE 18G X FLEXPEN 20 HUMIRA PEN-CD/UC/HS 1-1/2" 63 INSULIN ASPART PENFILL 20 STARTER 2 HYPODERMIC NEEDLE 19G X HUMIRA PEN-PEDIATRIC UC 1" 63 INSULIN ASPART STARTER PACK 2 HYPODERMIC NEEDLE PROTAMINE/INSULIN ASPART HUMIRA PEN-PS/UV 22GX1-1/2" 63 FLEXPEN 20 STARTER 2 HYPODERMIC NEEDLE INSULIN LISPRO 20 HUMULIN 70/30 20 25GX1" 63 INSULIN LISPRO JUNIOR HUMULIN 70/30 KWIKPEN 20 HYPODERMIC NEEDLE KWIKPEN 20 25GX1-1/2" 63 INSULIN LISPRO KWIKPEN 20 HUMULIN N 20 HYPODERMIC NEEDLE INSULIN LISPRO HUMULIN R 20 25GX5/8" 63 PROTAMINE/INSULIN LISPRO HUMULIN R U-500 HYPODERMIC NEEDLE KWIKPEN 20 (CONCENTRATED) 20 27GX1/2" 63 INSULIN PUMP INFUSION HUMULIN R U-500 HYPODERMIC NEEDLES SUPPLIES 58 KWIKPEN 20 18GX1" 63 INSULIN SYRINGES 63 HYCODAN 40 HYPODERMIC NEEDLES INTELENCE 32 hydralazine hcl 26 18GX1-1/2" 63 HYPODERMIC NEEDLES INTRON A 28 HYDRALYTE 71 19GX1" 63 INTUNIV 1 HYDRALYTE FREEZER HYPODERMIC NEEDLES POPS 71 22GX1-1/2" 63 INVEGA SUSTENNA 29 HYDREA 28 HYPODERMIC NEEDLES INVEGA TRINZA 29 hydrochlorothiazide 51 25GX1-1/2" 63 INVIRASE 32 hydrocodone w/ HYPODERMIC NEEDLES INVOKAMET 19 homatropine 40 25GX5/8" 63 HYPODERMIC NEEDLES INVOKANA 20 hydrocodone-acetaminophen 6 27GX1/2" 63 ipratropium bromide 12 hydrocodone-ibuprofen 6 HYVEE ADVANCED ANTACID ipratropium bromide (nasal) 77 MAXIMUM STRENGTH 8 hydrocortisone 39 ipratropium-albuterol 13 HYZAAR 26 hydrocortisone (intrarectal) 7 irbesartan 25 ibandronate sodium 51 hydrocortisone (rectal) 7 irbesartan-hydrochlorothiazide hydrocortisone (topical) 46 ibuprofen 3 26 hydrocortisone acetate imipramine hcl 18 ISENTRESS 32 (topical) 46 imipramine pamoate 18 isoniazid 27

Index 10 ISOPTO ATROPINE 79 KONSYL DAILY FIBER 56 levofloxacin (ophth) 79 ISOPTO CARPINE 79 KP PRENATAL levonorgestrel & eth ISOPTO TEARS 78 MULTIVITAMINS 75 estradiol 37 KPN PRENATAL 75 levonorgestrel (emergency ISORDIL TITRADOSE 10 krill oil 2 oc) 38 isosorbide dinitrate 10 levonorgestrel-eth estradiol labetalol hcl 34 isosorbide mononitrate 10 (triphasic) 37 LAC-HYDRIN 47 levonorgestrel-ethinyl estradiol isotretinoin 44 LAC-HYDRIN TWELVE 47 (91-day) 37 ISTALOL 79 levonorgestrel-ethinyl estradiol LACTIC ACID 47 ITCH RELIEF 45 (continuous) 37 lactic acid (ammonium levothyroxine sodium 85 ivermectin 8 lactate) 47 IVERMECTIN 49 lactulose 57 LEVSIN 86 ivermectin (pediculicide) 49 lactulose (encephalopathy)53 LEVSIN/SL 86 JAKAFI 27 LAMICTAL 14 LEXAPRO 17 JANUMET 19 LAMICTAL CHEWABLE LEXIVA 32 JANUMET XR 19 DISPERSIBLE 14 LIALDA 53 JANUVIA 19 LAMICTAL ODT 14 LICEMD 49 JARDIANCE 21 LAMICTAL XR 15 lidocaine 48 JENLIVA LAMISIL AT 45 lidocaine hcl 48 PRENATAL/POSTNATAL 75 LAMISIL AT JOCK ITCH 45 lidocaine hcl (local anesth.) 57 JENTADUETO 19 lamivudine 32 lidocaine hcl (mouth-throat) 74 JOHNSONS NO MORE lamivudine (hbv) 34 LIDOCAINE RASH 49 lamivudine-zidovudine 32 HYDROCHLORIDE 57 K-PHOS NEUTRAL 72 lamotrigine 15 lidocaine-prilocaine 48 K-TAB 72 LANCETS AND LANCET LIDODERM 48 KALETRA 32 DEVICES 58 lindane 49 KAPVAY 1 LANOXIN 36 linezolid 9 KEFLEX 36 lansoprazole 87 LINZESS 53 KENALOG-10 39 LANTUS 20 liothyronine sodium 85 KENALOG-40 39 LANTUS SOLOSTAR 20 LIPITOR 24 KEPPRA 14 lapatinib ditosylate 27 lisinopril 24 KEPPRA XR 14 LASIX 50 lisinopril & KERALYT 48 latanoprost 81 hydrochlorothiazide 26 ketoconazole (topical) 44 LATUDA 29 LITHIUM 29 KETONE 49 LEADER QUICK DISSOLVE lithium carbonate 29 KETONE TEST STRIPS 50 GLUCOSE 19 LITHOBID 29 ketoprofen 3 leflunomide 4 LMX 4 48 ketorolac tromethamine 3 LETAIRIS 36 LODINE 3 ketorolac tromethamine letrozole 27 LOHIST-D 41 (ophth) 81 leucovorin calcium 28 LOHIST-DM 41 KETOSTIX 50 leuprolide acetate 27 LOMOTIL 21 ketotifen fumarate (ophth) 81 LEVAQUIN 52 loperamide hcl 21 KEY-E 93 LEVBID 86 LOPID 24 KINDERLYTE 72 LEVEMIR 20 lopinavir-ritonavir 32 KINDERLYTE PREMAX 71 LEVEMIR FLEXTOUCH 20 LOPRESSOR 34 KITABIS PAK 2 levetiracetam 15 LOPRESSOR HCT 26 KLONOPIN 14 levobunolol hcl 79 LOPROX 45 KOMBIGLYZE XR 19 levofloxacin 52 loratadine 23

Index 11 loratadine & magnesium oxide (mg methocarbamol 77 pseudoephedrine 41 supplement) 72 methotrexate sodium 27 lorazepam 11 MAGOX 400 72 methscopolamine bromide 86 losartan potassium 25 MAKENA 82 methyldopa 25 losartan potassium & MALARONE 26 methylergonovine maleate 81 hydrochlorothiazide 26 maprotiline hcl 16 LOSEASONIQUE 37 METHYLIN 1 MATULANE 28 LOTENSIN 25 methylphenidate hcl 1,2 MAVYRET 34 LOTENSIN HCT 26 methylprednisolone 39 MAXALT 70 LOTREL 26 methylprednisolone sod MAXALT-MLT 70 succ 39 LOTRIMIN AF 45 MAXI-TUSS DM 41 metoclopramide hcl 53 LOTRIMIN AF JOCK ITCH 45 MAXI-TUSS PE 41 METOCLOPRAMIDE ODT 53 LOTRIMIN ANTIFUNGAL 45 MAXI-TUSS PE MAX 41 metolazone 51 LOTRIMIN ULTRA 45 MAXIDEX 80 metoprolol & LOTRISONE 45 MAXIMUM D3 93 hydrochlorothiazide 26 lovastatin 24 metoprolol succinate 34 MAXIPIME 37 LOVENOX 13,14 metoprolol tartrate 34 MAXITROL 80 loxapine succinate 30 METROCREAM 49 MAXZIDE 50 lubiprostone 53 METROGEL-VAGINAL 92 MAXZIDE-25 50 LUNESTA 56 METROLOTION 49 meclizine hcl 22 LUPRON DEPOT (1- metronidazole 8 meclofenamate sodium 3 MONTH) 27 metronidazole (topical) 49 LUPRON DEPOT (3- MEDROL 39 metronidazole vaginal 92 MONTH) 27 MEDROL DOSEPAK 39 LUPRON DEPOT (4- medroxyprogesterone mexiletine hcl 11 MONTH) 27 acetate 82 MG217 PSORIASIS MULTI- LUPRON DEPOT (6- medroxyprogesterone acetate SYMPTOM 48 MONTH) 27 (contraceptive) 38 MICATIN 45 LUZU 45 mefenamic acid 3 MICONAZOLE NITRATE 45 LYCELLE 49 megestrol acetate 27 miconazole nitrate (topical) 45 LYRICA 15 MEIJER CALAMINE 49 miconazole nitrate vaginal 92 M-M-R II 92 meloxicam 3 midodrine hcl 93 M-NATAL PLUS 75 memantine hcl 83 miglustat 54 MAALOX 8 MENACTRA 89 MILLIPRED 39 MACROBID 9 MENEST 52 MINASTRIN 24 FE 37 MACRODANTIN 9 MENOSTAR 52 MINIPRESS 25 MAG-200 72 MENQUADFI 89 MINIVELLE 52 MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/27G X MENVEO 89 MINOCIN 85 1/2" 63 meperidine hcl 5 minocycline hcl 85 MAGELLAN TUBERCULIN MEPHYTON 93 minoxidil 26 SAFETY SYRINGE/1ML/28G X mercaptopurine 27 MIRALAX 57 1/2" 64 MAGNESIUM 72 MESTINON 26 MIRALAX MIX-IN PAX 57 magnesium citrate 57 MESTINON TIMESPAN 26 MIRAPEX 28 MAGNESIUM EXTRA METAMUCIL 56 MIRCETTE 37 STRENGTH 72 METAMUCIL ORIGINAL mirtazapine 16 magnesium hydroxide 57 TEXTURE 56 misoprostol 88 metformin hcl 19 magnesium oxide 8 MOBIC 3 methazolamide 50 MAGNESIUM OXIDE 72 moexipril hcl 25 methimazole 85

Index 12 MOI-STIR 74 MONOJECT MONOJECT MAGELLAN mometasone furoate 46 HYPO/POLYPROPYLENE SYRINGE/SAFETY 65 MONISTAT 1 COMBO HUB/LL/INTM BEVEL/25G X NEEDLE/3ML/22G X 1-1/2" 5/8" 64 MONOJECT MAGELLAN PACK 92 MONOJECT SYRINGE/SAFETY MONISTAT 1 DAY OR NIGHT 92 HYPO/POLYPROPYLENE NEEDLE/3ML/23G X 1" 65 COMBO PACK HUB/LL/REG BEVEL/19G TW MONOJECT MAGELLAN MONISTAT 3 92 X 1" 64 SYRINGE/SAFETY MONISTAT 3 COMBINATION MONOJECT NEEDLE/3ML/25G X 1" 65 PACK 92 HYPO/POLYPROPYLENE MONOJECT MAGELLAN MONISTAT 7 COMBINATION HUB/LL/REG BEVEL/25G X SYRINGE/SAFETY PACK 92 1" 64 NEEDLE/3ML/25G X 5/8" 65 MONISTAT 7 SIMPLY MONOJECT MONOJECT PHARMACY CURE 92 HYPO/POLYPROPYLENE TRAY/LUER LOCK/3ML 65 MONISTAT SOOTHING CARE HUB/LL/SHORT BEVEL/18G X MONOJECT PHARMACY ITCH RELIEF 47 1" 64 TRAY/REG LUER/1ML 65 MONOJECT 1ML LUER LOCK MONOJECT MONOJECT STANDARD TUBERCULIN SYRINGE/TIP HYPO/POLYPROPYLENE HYPODERMIC CAP 64 HUB/LL/SHORT BEVEL/18G X NEEDLE/POLYPROPYLEN/22G MONOJECT 3ML 1-1/2" 64 X1-1/2" 65 SYRINGE/STANDARD MONOJECT MONOJECT STANDARD HYPODERMIC NEEDLE/21GX1- HYPO/POLYPROPYLENE HYPODERMIC 1/2" 64 HUB/LL/SHORT BEVEL/19G NEEDLE/POLYPROPYLENE MONOJECT BLUNTIP TW X 1" 64 HUB/18GX1" 65 SYRINGE/3ML/CANNULA/IV MONOJECT MONOJECT STANDARD ACCESS 64 HYPO/POLYPROPYLENE HYPODERMIC MONOJECT HYPO/ALUM HUB/LL/SHORT BEVEL/22G X NEEDLE/POLYPROPYLENE HUB/18G X 1-1/2" 64 1-1/2" 64 HUB/19GX1" 65 MONOJECT HYPO/ALUM MONOJECT MONOJECT STANDARD HUB/LUER LOCK/INTM HYPO/POLYPROPYLENE HYPODERMIC BEVEL/27G X 1/2" 64 HUB/REG BEVEL/27G X NEEDLE/POLYPROPYLENE/18 MONOJECT HYPO/ALUM 1/2" 64 GX1-1/2" 65 HUB/LUER LOCK/REG MONOJECT HYPODERMIC MONOJECT STANDARD BEVEL/18G X 1" 64 NEEDL3 18G X 1" 64 HYPODERMIC MONOJECT HYPO/ALUM MONOJECT MAGELLAN NEEDLE/POLYPROPYLENE/22 HUB/LUER LOCK/REG SAFETYNEEDLE 18GX1" 64 GX1-1/2" 65 BEVEL/22G X 1-1/2" 64 MONOJECT MAGELLAN MONOJECT STANDARD MONOJECT HYPO/ALUM SAFETYNEEDLE 18GX1- HYPODERMIC HUB/LUER LOCK/REG 1/2" 64 NEEDLE/POLYPROPYLENE/25 BEVEL/25G X 5/8" 64 MONOJECT MAGELLAN GX1" 65 MONOJECT HYPO/ALUM SAFETYNEEDLE 19GX1" 64 MONOJECT STANDARD HUB/LUER LOCK/SHORT MONOJECT MAGELLAN HYPODERMIC BEVEL/18G X 1" 64 SAFETYNEEDLE 22GX1- NEEDLE/POLYPROPYLENE/25 MONOJECT HYPO/ALUM 1/2" 64 GX1-1/2" 65 HUB/LUER LOCK/SHORT MONOJECT MAGELLAN MONOJECT STANDARD BEVEL/18G X 1-1/2" 64 SAFETYNEEDLE 25GX1" 65 HYPODERMIC MONOJECT HYPO/ALUM MONOJECT MAGELLAN NEEDLE/POLYPROPYLENE/25 HUB/LUER LOCK/SPEC SAFETYNEEDLE GX5/8" 65 BEVEL/19G TW X 1" 64 25GX5/8" 65 MONOJECT STANDARD MONOJECT MONOJECT MAGELLAN HYPODERMIC HYPO/POLYPROPYLENE SYRINGE/SAFETY NEEDLE/POLYPROPYLENE/27 HUB/18G X 1" 64 NEEDLE/3ML/20G X 1" 65 GX1/2" 65 MONOJECT MONOJECT MAGELLAN MONOJECT SYRINGE HYPO/POLYPROPYLENE SYRINGE/SAFETY PHARMACY TRAY/1ML LUER HUB/18G X 1-1/2" 64 NEEDLE/3ML/21G X 1- LOCK 65 MONOJECT 1/2" 65 MONOJECT SYRINGE/LUER HYPO/POLYPROPYLENE MONOJECT MAGELLAN LOCK/3ML 65 HUB/LL/BEVEL/25G X 1- SYRINGE/SAFETY MONOJECT SYRINGE/LUER 1/2" 64 NEEDLE/3ML/22G X 1" 65 LOCK/3ML/20G X 1" 65

Index 13 MONOJECT SYRINGE/LUER MONOJECT TUBERCULIN MULTIVITAMIN INFANT & LOCK/3ML/22G X 1" 65 SYRINGE/DETACH TODDLER 74 MONOJECT SYRINGE/LUER NEEDLE/1ML/27G X 1/2" 66 MULTIVITAMINS /W LOCK/3ML/22G X 1-1/2" 65 MONOJECT TUBERCULIN MINERALS 74 MONOJECT SYRINGE/LUER SYRINGE/PERM mupirocin 44 LOCK/3ML/23G X 1" 65 NEEDLE/1ML/28G X 1/2" 66 mupirocin calcium (topical) 44 MONOJECT SYRINGE/LUER MONOJECT TUBERCULIN MVW COMPLETE PROBIOTIC LOCK/3ML/25G X 1" 66 SYRINGE/WITHOUT FORMULATION 21 MONOJECT SYRINGE/LUER NEEDLE/REG LUER/1ML 66 MYAMBUTOL 27 LOCK/3ML/25G X 5/8" 66 montelukast sodium 12 MONOJECT SYRINGE/LUER- mycophenolate mofetil 73 LOCK TIP/3ML 66 morphine sulfate 5 MOSCO CALLUS/CORN MYDRIACYL 79 MONOJECT SYRINGE/LUER- MYLICON INFANTS GAS LOCK/3ML/21G X 1-1/2" 66 REMOVER 48 MOTRIN CHILDRENS 3 RELIEF 52 MONOJECT SYRINGE/REG MYLICON INFANTS GAS LUER/3ML 66 MOTRIN INFANTS DROPS 3 RELIEF DYE FREE 52 MONOJECT MOUTH KOTE 74 SYRINGE/REGULARTIP/3ML MYNATAL 75 66 MOUTH KOTE REMINT 74 MYNATAL ADVANCE 75 MONOJECT moxifloxacin hcl (ophth) 79 MYNATAL PLUS 75 SYRINGE/STANDARDHYPODE MS CONTIN 5 MYNATAL ULTRACAPLET 75 RMIC NEEDLE/3ML/20GX1"66 MONOJECT MUCINEX 43 MYNATAL-Z 75 SYRINGE/STANDARDHYPODE MUCINEX CHILDRENS MYNATE 90 PLUS 75 FREEFROM MULTI- RMIC NEEDLE/3ML/22GX1"66 MYSOLINE 15 MONOJECT SYMPTOM COLD AND SYRINGE/STANDARDHYPODE STUFFY NOS 41 nabumetone 3 RMIC NEEDLE/3ML/22GX1-1/2" MUCINEX CHILDRENS nadolol 35 66 MULTI-SYMPTOM COLD 41 NALFON 3 MUCINEX CHILDRENS MONOJECT naloxone hcl 21 SYRINGE/STANDARDHYPODE STUFFYNOSE AND CHEST RMIC NEEDLE/3ML/23GX1"66 CONGESTION 41 naltrexone hcl 21 MONOJECT MUCINEX CONGESTION & NAMENDA 83 SYRINGE/STANDARDHYPODE COUGH CHILDRENS 41 MUCINEX COUGH & NAMENDA TITRATION PAK83 RMIC NEEDLE/3ML/25GX1"66 naphazoline w/ pheniramine 80 MONOJECT CONGESTION SYRINGE/STANDARDHYPODE CHILDRENS 41 NAPHCON-A 80 RMIC NEEDLE/3ML/25GX5/8" MUCINEX D 41 NAPROSYN 4 66 MUCINEX DM 41 naproxen 4 MONOJECT TB SYRINGE-NDL MUCINEX FAST-MAX naproxen sodium 4 1ML 27GX1/2" 66 SEVERE CONGESTION & MONOJECT TUBERCULIN COUGH 41 naratriptan hcl 70 SAFETY SYRINGE/1ML/25G X MUCINEX FAST-MAX NARCAN 22 5/8" 66 SEVERE CONGESTION & NASACORT ALLERGY MONOJECT TUBERCULIN COUGH CLEAR & COOL 41 24HR 77 SAFETY SYRINGE/1ML/28G X MUCINEX MAXIMUM NASACORT ALLERGY 24HR 1/2" 66 STRENGTH 43 CHILDRENS 77 MONOJECT TUBERCULIN MUCINEX SINUS-MAX DAY NASALCROM 77 SYRINGE SOFTPACK 1ML TIME/NIGHT TIME 41 REGULAR LUER TIP 66 MUCINEX STUFFY NOSE & NATACYN 79 MONOJECT TUBERCULIN COLD CHILDRENS 42 NATALVIT 75 SYRINGE/1ML/25GX5/8" 66 MULTAQ 11 nateglinide 20 MONOJECT TUBERCULIN NATROBA 49 SYRINGE/1ML/28G X 1/2" 66 MULTI PRENATAL 75 MONOJECT TUBERCULIN MULTI-DRAW NEEDLE NATURAL VITAMIN E 93 SYRINGE/DETACH 22GX1-1/2" 66 NATURE-THROID 85 72 NEEDLE/1ML/25G X 5/8" 66 MULTI-MINERALS NATURE-THROID NT-2.5 85 72 multiple minerals neomycin sulfate 2

Index 14 neomycin-bacitracin zn- NITRO-BID 10 NORVASC 35 polymyxin 79 NITRO-DUR 10 NORVIR 32 neomycin-bacitracin-polymyxin 44 nitrofurantoin 9 NPLATE 55 neomycin-bacitracin-polymyxin- nitrofurantoin macrocrystal 9 NULYTELY 56 pramoxine 44 nitrofurantoin monohyd NULYTELY/FLAVOR neomycin-polymy-dexameth 80 macro 9 PACKS 56 neomycin-polymyxin-gramicidin nitroglycerin 10 NUMOISYN 74 80 NITROSTAT 10 NUTRA-SUPPORT BONE 72 neomycin-polymyxin-hc (ophth) 80 NIVA-PLUS 75 NUVARING 38 neomycin-polymyxin-hc NIVANEX DMX 42 nystatin 22 (otic) 81 NIVESTYM 55 nystatin (mouth-throat) 74 NEONATAL COMPLETE 75 NIX CREME RINSE 49 nystatin (topical) 45 NEONATAL PLUS 75 NIZORAL 45 NYTOL MAXIMUM NEONATAL VITAMIN 75 NOBLE MYSTIQUE EMU- STRENGTH 55 NEORAL 73 LAC 47 NYVEPRIA 55 NEOSPORIN ORIGINAL 44 NOKOR ADMIX NEEDLE THIN O-CAL FA 75 WALL NON-CORING 18G X 1- O-CAL PRENATAL 75 NEOTUSS PLUS 42 1/2" 66 NEOTUSS-D 42 NOKOR VENTED NEEDLE OC8 44 NEUPOGEN 55 THINWALL NON-CORING 18G OCEAN NASAL SPRAY 77 X 1" 67 OCUFLOX 80 NEURONTIN 15 NOKOR VENTED NEEDLE NEUTROGENA ON-THE-SPOT THINWALL NON-CORING ODEFSEY 32 ACNE TREATMENT 44 18GX1-1/2" 67 ofloxacin 52 NEUTROGENA T/SAL 48 NONOXYNOL ofloxacin (ophth) 80 nevirapine 32 SPERMICIDES 93 ofloxacin (otic) 81 NORCO 6 NEXABIOTIC 21 olanzapine 30 NORDITROPIN FLEXPRO51 NEXAVAR 27 OMEGA 3-6-9 COMPLEX 2 norethin acet & estrad-fe 37 NEXIUM 87 OMEGA-3 78 NEXIUM 24HR 87 norethindrone & eth estradiol 37 OMEGA-3 EPA FISH OIL 78 NEXIUM 24HR CLEAR norethindrone & ethinyl omega-3 fatty acids 78 MINIS 87 estradiol-fe 37 OMEGA-3 FISH OIL EXTRA NEXPLANON 38 norethindrone STRENGTH 78 NF FORMULAS CALCIUM (contraceptive) 38 OMEGA-3-6-9 2 MAGNESIUM 72 norethindrone acet & eth niacin 93,94 estra 38 omeprazole 87,88 niacinamide 94 norethindrone acetate 82 OMNIFLEX DIAPHRAGM 58 NICODERM CQ 84 norethindrone acetate-ethinyl ondansetron 22 NICORETTE 84 estradiol-fe 38 ondansetron hcl 22 norethindrone-eth estradiol ONE VITE WOMENS NICORETTE MINI 84 (triphasic) 38 PRENATALVITAMIN 75 NICORETTE STARTER KIT 84 norgestimate-ethinyl ONE VITE WOMENS nicotine 84 estradiol 38 PRENATALVITAMIN PLUS 75 norgestimate-ethinyl estradiol nicotine polacrilex 84 ONE-A-DAY WOMENS (triphasic) 38 PRENATAL 75 NICOTINE TRANSDERMAL norgestrel & ethinyl ONETOUCH ULTRA 50 SYSTEM 84 estradiol 38 NICOTROL INHALER 84 NORM-JECT TUBERKULIN ONETOUCH ULTRA 67 CONTROL 58 NICOTROL NS 84 1MLLUER SLIP ONETOUCH VERIO CONTROL nifedipine 35 NORPACE 11 SOLUTION HIGH 58 NINLARO 27 NORPACE CR 11 ONETOUCH VERIO MID CONTROL SOLUTION 58 nit remover 49 NORPRAMIN 18 nortriptyline hcl 18

Index 15 ONETOUCH VERIO TEST PEDIAPRED 39 pilocarpine hcl 79 STRIPS 50 pediatric multiple vitamins 74 pimozide 83 ONEVITE 74 peg 3350-kcl-sod bicarb-sod pioglitazone hcl 20 ONFI 14 chloride-sod sulfate 56 pioglitazone hcl-metformin ONGLYZA 19 peg 3350-potassium chloride- hcl 19 OPCON-A 80 sod bicarbonate-sod piroxicam 4 chloride 57 OPTIMAL D3 M 93 PEGASYS 34 PLAN B ONE-STEP 38 oral electrolytes 72 PEGASYS PROCLICK 34 PLAQUENIL 26 ORAL RELIEF SPRAY FOR PEGINTRON 34 PLAVIX 54 DRYMOUTH & PNEUMONIA VACCINE 89 DISCOMFORT 74 penicillamine 73 ORAPRED ODT 39 penicillin v potassium 82 PNEUMOVAX 23 89 ORTHO MICRONOR 38 PENLAC NAIL LACQUER 45 PNEUMOVAX 23/1 DOSE 89 ORTHO TRI-CYCLEN LO 38 PENTASA 53 PNV TABS 29-1 75 ORTHO-NOVUM 1/35 38 pentoxifylline 54 podofilox 48 POLY HUB NEEDLE/18G X ORTHO-NOVUM 7/7/7 38 PEPCID 86 1" 67 oseltamivir phosphate 34 PEPCID AC 86 POLY HUB NEEDLE/18G X 1-1- OTEZLA 4 PEPCID AC MAXIMUM 1/2" 67 oxacillin sodium 82 STRENGTH 86 POLY HUB NEEDLE/22G X 1- PEPTO BISMOL 21 1/2" 67 oxaprozin 4 PEPTO-BISMOL 21 POLY HUB NEEDLE/25G X OXAYDO 5 1" 67 PEPTO-BISMOL MAX oxazepam 11 POLY HUB NEEDLE/25G X 1- STRENGTH 21 1/2" 67 oxcarbazepine 15 PEPTO-BISMOL TO-GO 21 POLY HUB NEEDLE/25G X oxybutynin chloride 88 PERCOCET 6 5/8" 67 oxycodone hcl 5 PERIDEX 74 POLY HUB NEEDLE/27G X 1/2" 67 oxycodone w/ acetaminophen 6 perindopril erbumine 25 POLY-VI-SOL 74 oxycodone-aspirin 6 permethrin 49 POLY-VITA 74 OXYCODONE/ACETAMINOPHE perphenazine 31 N 6 POLY-VITA/IRON 74 PERRY PRENATAL 75 oyster shell 71 POLY-VITE PEDIATRIC 74 PHAZYME 52 P & S 48 polyethylene glycol 3350 57 PHAZYME ULTRA polyethylene glycol-propylene PAMELOR 18 STRENGTH 52 glycol (ophth) 78 PANOXYL 44 phenazopyridine hcl 54 polymyxin b-trimethoprim 80 pantoprazole sodium 88 phenobarbital 56 POLYSPORIN 44 PARLODEL 28 phenylephrine hcl POLYTRIM 80 paroxetine hcl 17 (mydriatic) 79 PATIENT SAFE SYRINGE phenylephrine w/ dm-gg 42 polyvinyl alcohol 78 3ML 67 phenylephrine-chlorphen-dm pot phosphate monobasic w/ sod PAXIL 17 42 phosphate dibasic & monobasic 72 PC PEDIATRIC POLY-VITAMIN phenylephrine- DROPS 74 diphenhydramine-gg w/ POTASSIUM 73 PC PEDIATRIC POLY-VITAMIN apap 42 potassium chloride 72 DROPS/IRON 74 phenylephrine-guaifenesin 42 POTASSIUM CHLORIDE 72 PEDIA-LAX 57 PHENYTEK 16 potassium chloride 73 PEDIALYTE 72 phenytoin 16 potassium chloride PEDIALYTE ADVANCED phenytoin sodium microencapsulated crystals CARE 72 extended 16 er 73 PEDIALYTE FREEZER phytonadione 93 potassium citrate POPS 72 PIFELTRO 32 (alkalinizer) 53 PEDIALYTE SINGLES 72 potassium citrate-citric acid 53

Index 16 PRADAXA 14 PRENATRYL 76 PROVERA 83 pramipexole dihydrochloride 28 PRENATVITE RX 76 PROZAC 17 PRANDIN 20 PREPLUS 76 pseudoephed-bromphen-dm 42 PRAVACHOL 24 PRETAB 76 pseudoephedrine hcl 77 pravastatin sodium 24 PREVACID 88 pseudoephedrine w/ codeine- praziquantel 8 PREVACID 24HR 88 gg 42 pseudoephedrine w/ dm-gg 42 prazosin hcl 25 PREVACID SOLUTAB 88 pseudoephedrine-guaifenesin PRE-NATAL FORMULA 75 PREVNAR 13 89 42 PRECOSE 19 PREZCOBIX 32 psyllium 56 PRED FORTE 80 PREZISTA 32 PULMICORT 12 PRED MILD 80 primaquine phosphate 26 PULMICORT FLEXHALER 12 PRED-G 80 PRIMAQUINE PULMOZYME 85 PRED-G S.O.P. 80 PHOSPHATE 26 PURE & GENTLE primidone 15 prednisolone 39 LUBRICANT 78 PRIMLEV 6 prednisolone acetate (ophth) 80 PX CALAMINE 49 PREDNISOLONE ACETATE P- PRINIVIL 25 PX LANCETS MICROTHIN F 81 PRIVIGEN 82 33G 58 prednisolone sodium PX PRENATAL PROAIR HFA 13 MULTIVITAMINS 76 phosphate 39 probenecid 54 PREDNISOLONE SODIUM pyrantel pamoate 8 PHOSPHATE 81 PROCARDIA 35 pyrazinamide 27 prednisone 39 PROCARDIA XL 35 pyrethrins-piperonyl butoxide49 PREDNISONE INTENSOL 39 prochlorperazine 31 pyrethrins-piperonyl butoxide- pregabalin 15 prochlorperazine maleate 31 permethrin-nit remover 49 PREMARIN 52,93 PROCORT 7 PYRIDIUM 54 PREMPRO 52 PROCTOCORT 7 pyridostigmine bromide 26,27 PRENATABS FA 75 progesterone 82 pyridoxine hcl 94 PRENATAL 76 PROGRAF 73 QC CALAMINE 49 PRENATAL 19 75 PROLASTIN-C 84 QC MEDIFIN PE 42 PRENATAL AND IRON 75 PROLATE 6 QC PRENATAL 76 PRENATAL FORTE 75 PROLIA 51 QUALAQUIN 26 PRENATAL LOW IRON 75 PROMACTA 55 QUESTRAN 24 PRENATAL MULTIVITAMIN 75 promethazine & QUESTRAN LIGHT 24 phenylephrine 42 PRENATAL ONE DAILY 75 quetiapine fumarate 30 promethazine hcl 23 PRENATAL PLUS IRON 75 quinapril hcl 25 promethazine w/codeine 42 prenatal vit w/ docusate-iron quinapril-hydrochlorothiazide carbonyl-folic acid 76 promethazine-dm 42 26 prenatal vit w/ ferrous fumarate- PROMETRIUM 83 quinidine gluconate 11 folic acid 76 propafenone hcl 11 quinidine sulfate 11 prenatal vit w/ iron carbonyl-folic quinine sulfate 26 acid 76 propantheline bromide 86 RA CALCIUM 71 PRENATAL VITAMIN 76 propranolol & hydrochlorothiazide 26 RA PRENATAL VITAMIN & CALCIUM/MAGNESIUM/ZINC/C MINERAL 76 propranolol hcl 35 propylthiouracil 85 OPPER 72 PRENATAL VITAMIN/IRON 76 RA DRY MOUTH 74 PROSCAR 54 PRENATAL VITAMINS 76 RA OMEGA 3-6-9 2 PRENATAL VITAMINS PLUS PROTONIX 88 RA PRENATAL 76 LOW IRON 76 protriptyline hcl 19 PRENATAL-U 76 RA PRENATAL PROVENTIL HFA 13 FORMULA/FOLICACID 76 PRENATRIX 76

Index 17 raloxifene hcl 51 RIFADIN 27 SAFESNAP ramipril 25 rifampin 27 SYRINGE/NEEDLE/3ML/23G X 1-1/2" 67 RANEXA 10 RIGHT STEP PRENATAL 76 SAFESNAP ranitidine hcl 86 RILUTEK 78 SYRINGE/NEEDLE/3ML/25G X ranolazine 10 riluzole 78 1" 67 SAFESNAP RAPAFLO 54 rimantadine hydrochloride 34 SYRINGE/NEEDLE/3ML/25G X RAPAMUNE 73 RISPERDAL 29 5/8" 67 RAZADYNE 83 RISPERDAL CONSTA 29 SAFESNAP TUBERCULIN RAZADYNE ER 83 risperidone 30 SYRINGE/1ML/25G X 5/8" 67 SAFESNAP TUBERCULIN REA-LO 47 RITALIN 2 SYRINGE/1ML/27G X 1/2" 67 REBIF 83 RITALIN LA 2 SAFETY SYRINGES/NEEDLE REBIF REBIDOSE 83 ritonavir 33 3ML/20GX1" 67 SAFETY SYRINGES/NEEDLE REBIF REBIDOSE rivastigmine 83 TITRATIONPACK 83 3ML/21GX1-1/2" 67 rivastigmine tartrate 83 SAFETY SYRINGES/NEEDLE REBIF TITRATION PACK 83 rizatriptan benzoate 70 3ML/22GX1" 67 RECOMBIVAX HB 92 ROBAXIN-750 77 SAFETY SYRINGES/NEEDLE 67 REDITREX 2 ROBITUSSIN CHILDRENS 3ML/22GX1-1/2" REFRESH LIQUIGEL 78 SAFETY SYRINGES/NEEDLE COUGH & COLD CF 42 3ML/23GX1" 67 REFRESH TEARS 78 ROBITUSSIN LINGERING SAFETY SYRINGES/NEEDLE REGIONAL BLOCK NEEDLE COLDLONG-ACTING 3ML/25GX5/8" 67 SAFETY BEAD BLOCK BEVEL COUGHGELS 40 SAFETY-LOK SAFETY 22GX1-1/2" 67 ROBITUSSIN PEAK COLD SYRINGE/1ML/25G X 5/8" 67 REGLAN 53 DM 42 SAFETY-LOK SYRINGE 3ML ROBITUSSIN PEAK COLD RELENZA DISKHALER 34 LUER-LOK 67 MULTI-SYMPTOM COLD 42 SAFETY-LOK RELION KETONE TEST ROCALTROL 51 STRIPS 50 SYRINGE/NEEDLE3ML LUER- ropinirole hydrochloride 28 LOK 21GX1-1/2" 67 REMERON 16 rosuvastatin calcium 24 SAFETY-LOK REMERON SOLTAB 16 SYRINGE/NEEDLE3ML LUER- ROXICODONE 5 RENFLEXIS 53 LOK 22GX1" 68 ROZEREM 56 RENVELA 53 SAFETY-LOK rufinamide 15 SYRINGE/NEEDLE3ML LUER- repaglinide 20 RYCONTUSS 42 LOK 22GX1-1/2" 68 RESCRIPTOR 32 SAFETY-LOK RYTHMOL SR 11 RESTASIS 80 SYRINGE/NEEDLE3ML LUER- SAFESNAP ALLERGY LOK 23GX1" 68 RESTORIL 56 SYRINGE/1ML/27G X 1/2" 67 SAFETY-LOK RETACRIT 55 SAFESNAP SYRINGE/NEEDLE3ML LUER- RETIN-A 44 SYRINGE/3ML 67 LOK 25GX5/8" 68 RETROBULBAR NEEDLE 25G SAFESNAP SAFETY-LOK TB SYRINGE TWX 1-1/2" 67 SYRINGE/NEEDLE/3ML/20G X PERM NEEDLE 1ML 1" 67 RETROVIR 32 27GX1/2" 68 SAFESNAP SALEX 48 REVATIO 36 SYRINGE/NEEDLE/3ML/21G X REVLIMID 73 1-1/2" 67 salicylic acid 48 REYATAZ 33 SAFESNAP SALIMEZ 48 SYRINGE/NEEDLE/3ML/22G X saline 77 RIAX 44 1" 67 RIBASPHERE 34 SAFESNAP SALMON 78 RIBASPHERE RIBAPAK 34 SYRINGE/NEEDLE/3ML/22G X SALMON OIL 78 ribavirin (hepatitis c) 34 1-1/2" 67 SALMON OIL-1000 78 SAFESNAP salsalate 5 RID COMPLETE LICE SYRINGE/NEEDLE/3ML/23G X ELIMINATION 49 1" 67 SALVAX 48

Index 18 SANDIMMUNE 73 SELSUN BLUE SOLU-MEDROL 39 SCHOOLTIME SHAMPOO 49 MOISTURIZING 46 sotalol hcl 35 SELSUN BLUE NATURALS SE-NATAL 19 76 DRYSCALP 48 sotalol hcl (afib/afl) 35 SEASONIQUE 38 SELZENTRY 33 SPACER/AEROCHAMBER 70 SECURESAFE SAFETY sennosides 57 spinosad 49 HYPODERMIC NEEDLE/18G X sennosides-docusate SPIRIVA HANDIHALER 12 1" 68 sodium 57 SECURESAFE SAFETY spironolactone 51 HYPODERMIC NEEDLE/18G X SENOKOT 57 spironolactone & 1-1/2" 68 SENOKOT S 57 hydrochlorothiazide 50 SECURESAFE SAFETY SENSIPAR 51 STALEVO 100 28 HYPODERMIC NEEDLE/19G X SEREVENT DISKUS 13 STALEVO 125 28 1" 68 SECURESAFE SAFETY SEROQUEL 30 STALEVO 150 29 HYPODERMIC NEEDLE/22G X sertraline hcl 17 STALEVO 200 29 1-1/2" 68 sevelamer carbonate 53 STALEVO 50 29 SECURESAFE SAFETY SFROWASA 53 STALEVO 75 29 HYPODERMIC NEEDLE/25G X 1-1/2" 68 SHINGRIX 92 STARLIX 20 SECURESAFE SAFETY sildenafil citrate (pulmonary STAVUDINE 33 HYPODERMIC NEEDLE/25G X hypertension) 36 stavudine 33 5/8" 68 SILVADENE 46 STIMATE 52 SECURESAFE SAFETY silver sulfadiazine 46 HYPODERMIC NEEDLE/27G X STIMEX INSULATED NEEDLE 1/2" 68 simethicone 52 TEFLON-COATED BLOCK SECURESAFE simvastatin 24 BEVEL 22GX1-1/2" 68 SYRINGE/NEEDLE/3ML/20G X SINEMET 28 STIOLTO RESPIMAT 13 1" 68 SINEMET CR 28 STRATTERA 1 SECURESAFE STRIBILD 33 SYRINGE/NEEDLE/3ML/21G X SINGULAIR 12 1-1/2" 68 sirolimus 73 STROMECTOL 8 SECURESAFE SKLICE 49 SUBLOCADE 7 SYRINGE/NEEDLE/3ML/22G X SLO-NIACIN 94 SUBOXONE 7 1" 68 SUCRAID 50 SECURESAFE SM CALAMINE 49 SYRINGE/NEEDLE/3ML/22G X SM FISH OIL 78 sucralfate 87 1-1/2" 68 SM GLUCOSE 19 SUDAFED CHILDRENS 77 SECURESAFE SM OMEGA-3 2 SUDAFED CONGESTION 77 SYRINGE/NEEDLE/3ML/23G X SUDAFED SINUS 1" 68 SM OMEGA-3-6-9 FATTY ACIDS 2 CONGESTION 78 SECURESAFE SUDAFED SINUS SYRINGE/NEEDLE/3ML/25G X SM ONE DAILY PRENATAL 76 CONGESTION24 HOUR 78 5/8" 68 sulfacetamide sod- SECURESAFE TUBERCULIN SM PRENATAL VITAMINS76 prednisolone 81 INSULIN SYRINGE/1ML/25G X sodium chloride 73 sulfacetamide sodium 5/8" 68 sodium chloride (gu (ophth) 80 SECURESAFE TUBERCULIN irrigant) 54 SULFADIAZINE 85 INSULIN SYRINGE/1ML/27G X sodium chloride (inhalant) 43 sulfamethoxazole- 1/2" 68 sodium citrate & citric acid 53 trimethoprim 9 selenium sulfide 45 sodium fluoride 72 sulfasalazine 53 SELSUN BLUE 46 sodium phosphates 57 sulindac 4 SELSUN BLUE DAILY 45 sodium polystyrene sumatriptan succinate 70 SELSUN BLUE DEEP sulfonate 73 CLEANSING 48 sunitinib malate 27 SOFOSBUVIR/VELPATASVIR SUPER OMEGA-3 2 SELSUN BLUE 34 MEDICATED 46 SOLU-CORTEF 39 SUPER TWIN EPA/DHA 78

Index 19 SUPRAX 37 SYSTANE 78 THERATEARS 78 SUPRESS-PE PEDIATRIC 42 SYSTANE OVERNIGHT thiamine hcl 94 SUSTIVA 33 THERAPY LUBRICANT thiamine mononitrate 94 EYE 78 SUTENT 27 SYSTANE ULTRA 78 thioridazine hcl 31 SYLATRON 28 TACLONEX 47 thiothixene 31 SYMAX DUOTAB 86 tacrolimus 73 THRIVITE 19 74 SYMBICORT 13 TAMIFLU 34 THRIVITE RX 76 SYMLINPEN 120 19 tamoxifen citrate 27 thyroid 85 SYMLINPEN 60 19 tamsulosin hcl 54 tiagabine hcl 16 SYNAGIS 82 TAPAZOLE 85 TIAZAC 35 SYNJARDY 19 TARGRETIN 28 TIGAN 22 SYNTHROID 85 TAYTULLA 38 TIKOSYN 11 SYRINGE/BLUNT PLASTIC TDVAX 86 timolol maleate (ophth) 79 CANNULA 68 TIMOPTIC 79 SYRINGE/LUER LOCK/3ML 68 TEGRETOL 15 TIMOPTIC OCUDOSE 79 SYRINGE/LUER LOCK/3ML/20G TEGRETOL-XR 15 X 1" 68 TEKTURNA 26 TIMOPTIC-XE 79 SYRINGE/LUER LOCK/3ML/21G temazepam 56 TINACTIN 45 X 1-1/2" 68 TINACTIN DEODORANT 45 SYRINGE/LUER TEMOVATE 47 LOCK/3ML/21GX1-1/2" 68 TENIVAC 86 TINACTIN JOCK ITCH 45 SYRINGE/LUER LOCK/3ML/22G tenofovir disoproxil TIVICAY 33 X 1" 68 fumarate 33 tizanidine hcl 77 SYRINGE/LUER LOCK/3ML/22G TENORETIC 100 26 TOBI 2 X 1-1/2" 68 SYRINGE/LUER TENORETIC 50 26 TOBRADEX 81 LOCK/3ML/22GX1" 68 TENORMIN 34 TOBRADEX ST 81 SYRINGE/LUER terazosin hcl 25 tobramycin (ophth) 80 LOCK/3ML/22GX1-1/2" 68 SYRINGE/LUER LOCK/3ML/23G terbinafine hcl 22 tobramycin-dexamethasone 81 X 1" 69 terbinafine hcl (topical) 45 TOBREX 80 SYRINGE/LUER LOCK/3ML/23G terconazole vaginal 92 TOFRANIL 19 X 1-1/2" 69 TESSALON PERLES 40 SYRINGE/LUER tolbutamide 21 LOCK/3ML/23GX1" 69 TESTIM 7 tolmetin sodium 4 SYRINGE/LUER LOCK/3ML/25G testosterone cypionate 7 tolnaftate 45 X 1" 69 testosterone enanthate 7 TOPAMAX 15 SYRINGE/LUER LOCK/3ML/25G TETANUS/DIPHTHERIA TOPAMAX SPRINKLE 15 X 1-1/2" 69 TOXOIDS-ADSORBED SYRINGE/LUER LOCK/3ML/25G ADULT 86 topiramate 15 X 5/8" 69 TOPROL XL 34 SYRINGE/LUER tetracaine hcl (ophth) 80 LOCK/3ML/25GX1" 69 tetrahydrozoline hcl toremifene citrate 27 SYRINGE/LUER (ophth) 80 torsemide 50 LOCK/3ML/25GX5/8" 69 tetrahydrozoline w/ zinc TOVIAZ 88 SYRINGE/LUER SLIP/1ML 69 sulfate 80 THALOMID 73 TRACLEER 36 SYRINGE/LUER SLIP/3ML 69 theophylline 13 TRADJENTA 20 SYRINGES/LUER tramadol hcl 5 LOCK/1ML/20GX1" 69 THERA-D 4000 93 SYRINGES/LUER THERANATAL CORE tramadol-acetaminophen 6 LOCK/WITHOUT NUTRITION 76 trandolapril 25 NEEDLE/3ML 69 THERAPEUTIC TRANXENE T 11 SYRINGES/LUER DANDRUFF 48 SLIP/WITHOUT THERAPEUTIC T+PLUS TRAVATAN Z 81 NEEDLE/1ML 69 MAXIMUM STRENGTH 48 travoprost 81

Index 20 trazodone hcl 18 TUSSLIN 43 valganciclovir hcl 33 tretinoin 44 TUSSLIN PEDIATRIC 43 VALIUM 11 tretinoin (chemotherapy) 28 TWINRIX 92 valproate sodium 16 TRIAMCINOLONE TYBLUME 38 valproic acid 16 ACETONIDE 39 TYBOST 33 valsartan 25 triamcinolone acetonide (mouth) 74 TYKERB 28 valsartan-hydrochlorothiazide triamcinolone acetonide TYLENOL 5 26 VALTREX 34 (nasal) 77 TYLENOL CHILDRENS 4 triamcinolone acetonide TYLENOL VANCOCIN 9 (topical) 47 COLD/FLU/DAY/MULT- VANCOCIN HCL 9 TRIAMCINOLONE ACETONIDE ACTION/DAY 43 PF 39 VANCOMYCIN 9 TYLENOL EXTRA vancomycin hcl 9 triamterene 51 STRENGTH 4 triamterene & TYLENOL FOR VANCOMYCIN HCL + hydrochlorothiazide 50 CHILDREN/ADULTS 4 SYRSPENDSF PH4 9 TRICARE 77 VANCOMYCIN TYLENOL INFANTS 4 HYDROCHLORIDE 9 TRICOR 24 TYLENOL INFANTS VANISHPOINT SAFETY trifluoperazine hcl 31 PAIN+FEVER 4 SYRINGE/3ML/20GX1" 69 trifluridine 80 TYLENOL/CODEINE #3 6 VANISHPOINT SAFETY SYRINGE/3ML/21GX1-1/2" 69 trihexyphenidyl hcl 28 TYLENOL/CODEINE #4 6 UDAMIN SP 74 VANISHPOINT SAFETY TRIJARDY XR 19 SYRINGE/3ML/22GX1" 69 TRILEPTAL 15 UDENYCA 55 VANISHPOINT SAFETY trimethobenzamide hcl 22 ULORIC 54 SYRINGE/3ML/22GX1-1/2" 69 ULTICARE SYRINGE/LOW VANISHPOINT SAFETY trimethoprim 8 DEADSPACE/3ML/22G X1- SYRINGE/3ML/23GX1" 69 trimipramine maleate 19 1/2" 69 VANISHPOINT SAFETY TRINATAL RX 1 77 ULTICARE TUBERCULIN SYRINGE/3ML/23GX1-1/2" 69 VANISHPOINT SAFETY TRIPLE OMEGA-3-6-9 2 SAFETY SYRINGE/1ML/25G X 5/8" 69 SYRINGE/3ML/25GX1" 69 TRIUMEQ 33 ULTRA OMEGA 3 78 VANISHPOINT SAFETY SYRINGE/3ML/25GX1-1/2" 69 TRIZIVIR 33 ULTRA OMEGA-3 FISH OIL tropicamide 79 VANISHPOINT SAFETY BURP-LESS 78 SYRINGE/3ML/25GX5/8" 69 TRULICITY 20 ULTRACET 6 VANISHPOINT TRUMENBA 89 ULTRAM 5 SYRINGE/3ML/20G X 1" 69 TRUSOPT 81 UNASYN 82 VANISHPOINT SYRINGE/3ML/21G X 1-1/2" 69 TRUVADA 33 UNISOM SLEEPGELS 55 VANISHPOINT TUDORZA PRESSAIR 12 UNISOM SLEEPMELTS 55 SYRINGE/3ML/22G X 1" 69 TUMS 8 UNISOM SLEEPTABS 55 VANISHPOINT urea 47 SYRINGE/3ML/22G X 1-1/2" 69 TUMS CHEWY BITES 8 VANISHPOINT TUMS CHEWY DELIGHTS 8 URECHOLINE 88 SYRINGE/3ML/23G X 1" 69 TUMS E-X 750 8 UROCIT-K 10 53 VANISHPOINT TUMS EXTRA STRENGTH UROCIT-K 15 53 SYRINGE/3ML/23G X 1-1/2" 69 VANISHPOINT 750 8 UROCIT-K 5 53 TUMS LASTING EFFECTS 8 SYRINGE/3ML/25G X 1" 69 UROXATRAL 54 VANISHPOINT TUMS SMOOTHIES 8 URSO 250 53 SYRINGE/3ML/25G X 1-1/2" 69 TUMS ULTRA 1000 8 URSO FORTE 53 VANISHPOINT TUSICOF 42 SYRINGE/3ML/25G X 5/8" 69 ursodiol 53 VANISHPOINT TUBERCULIN TUSNEL C 42 VAGIFEM 93 SYRINGE 1ML/25G X 5/8" 70 TUSNEL DM 42 valacyclovir hcl 34 VANISHPOINT TUBERCULIN TUSSI-PRES PEDIATRIC 43 SYRINGE 1ML/27GX1/2" 70 VALCYTE 33

Index 21 VAQTA 92 WELLBUTRIN SR 16 ZOLINZA 28 VARIVAX 92 WELLBUTRIN XL 16 zolmitriptan 70 VASERETIC 26 WESTAB PLUS 77 ZOLOFT 18 VASOTEC 25 WESTHROID 85 zolpidem tartrate 56 VECTICAL 45 WP THYROID 85 ZOMIG 71 VEMLIDY 34 XALATAN 81 ZOMIG ZMT 71 venlafaxine hcl 18 XANAX 11 ZONEGRAN 15 VENTRIXYL 74 XANAX XR 11 zonisamide 15 verapamil hcl 35 XARELTO 13 ZORTRESS 73 VERELAN 35 XARELTO STARTER ZOVIRAX 34,46 VIBRAMYCIN 85 PACK 13 ZYLOPRIM 54 XELJANZ 2 VICTOZA 20 ZYNCOF 43 XEROSTOMIA RELIEF VIDEX EC 33 SPRAY 74 ZYPREXA 30 VIDEXPEDIATRIC 33 XIGDUO XR 19 ZYPREXA ZYDIS 30 VIGAMOX 80 XOLAIR 12 ZYRTEC ALLERGY 23 VIMPAT 15 XOLEGEL 45 ZYRTEC ALLERGY VINATE ONE 77 CHILDRENS 23 XOLIDO 48 ZYRTEC CHILDRENS VIRACEPT 33 XTAMPZA ER 5 ALLERGY 23 VIRAMUNE 33 XULANE 38 ZYRTEC-D VIRAMUNE XR 33 XYLOCAINE 57 ALLERGY/CONGESTION 43 ZYVOX 9 VIREAD 33 XYLOCAINE-MPF 57 ZZZQUIL 56 VIRTUSSIN DAC 43 YASMIN 28 38 VISINE 80 YAZ 38 VISINE RED EYE ZACLIR CLEANSING 44 COMFORT 80 ZADITOR 81 VISTA GEL 78 ZANAFLEX 77 VISTARIL 10 ZANTAC 150 MAXIMUM VITAFOL-OB 77 STRENGTH 87 VITAMIN D2 93 ZANTAC 75 87 VITAMIN D3 93 ZARONTIN 16 vitamin e 93 ZEMAIRA 84 VITAMIN E 93 ZENPEP 50 vitamin e 93 ZESTORETIC 26 VITATHELY/GINGER 77 ZESTRIL 25 VIVELLE-DOT 52 ZETIA 24 VIVITROL 22 ZIAC 26 VOL-NATE 77 ZIAGEN 33 VOL-PLUS 77 zidovudine 33 VOL-TAB RX 77 zinc oxide (topical) 49 VOLTAREN 44 ZIOPTAN 81 VOTRIENT 28 ziprasidone hcl 29 VPRIV 54 ZITHROMAX 58 VYVANSE 1 ZITHROMAX TRI-PAK 58 WAL-SLEEP Z LIQUID ZITHROMAX Z-PAK 58 SHOTS 55 ZOCOR 24 WALGREENS GLUCOSE 19 ZOFRAN 22 warfarin sodium 13

Index 22