Comprehensive PREFERRED DRUG LIST

Buckeye Health Plan

PAGE 1 LAST UPDATED 12/18/2017 Buckeye Health Plan Pharmacy Program

Buckeye Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and cost effective drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Buckeye covers prescription medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The Pharmacy program covers all medically necessary Medicaid covered drugs. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section provides an overview of the Buckeye pharmacy program. For more detailed information, please visit our website at www.buckeyehealthplan.com. The following program covers both the Covered Families & Children (CFC) and Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled in Buckeye.

Plan Preferred Drug List

The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes all drugs available without PA, drugs that require PA, and those agents that have the restrictions of Step Therapy (ST). The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacy Director, and several Ohio primary care physicians, pharmacists, and specialists. The PDL does not:

o Require or prohibit the prescribing or dispensing of any medication o Substitute for the independent professional judgment of the physician/clinician or pharmacist, or o Relieve the physician/clinician or pharmacist of any obligation to the patient or others

Envolve Pharmacy Solutions

With the exceptions of biopharmaceuticals and specialty drugs, Buckeye works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL list require a PA and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Follow these guidelines for efficient processing of your authorization requests:

1. Complete the Buckeye Health Plan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. 2. Fax to Envolve Pharmacy Solutions at 1-866-399-0929. 3. Once approved, Envolve Pharmacy Solutions notifies the prescriber by fax. 4. If the clinical information provided does not explain the medical necessity for the requested PA medication, Envolve Pharmacy Solutions will deny the request and offer PDL alternatives to the prescriber by fax. 5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply of medication by calling 1-800-460-8988. Prior Authorization Process

The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will require PA and those are listed on the PDL with “PA” noted in the Requirements/Limits column. In addition, all name brand drugs not listed on the PDL list will require prior authorization. If a request for authorization is needed the information should be submitted by your physician/clinician to Envolve Pharmacy Solutions on the Buckeye Health Plan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Buckeye website at www.buckeyehealthplan.com. Buckeye will cover the medication if it is determined that:

1. There is a medical reason you need the specific medication. 2. Depending on the medication, other medications on the PDL have not worked.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. The P&T committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. A phone or fax-in process is available for PA requests.

Envolve Pharmacy Solutions Contact Information: Prior Authorization Fax 1-866-399-0929 Prior Authorization Phone 1-866-399-0928

Mailing Address: 2425 W Shaw Ave, Fresno, CA 93711

When calling, please have patient information, including Medicaid number, complete diagnosis, medication history and current medications readily available. Envolve Pharmacy Solutions will provide a decision to the request by fax or phone within 24 hours. When incomplete information is received to support medical necessity of a drug requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy claims processing system will be changed to allow the specific member to receive this specific drug. If the request is denied, information about the denial will be provided to the clinician. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the pharmacist should attempt to contact the clinician to request a change to a product included in the PDL.

Phone Numbers for Buckeye Health Plan Member Services The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members cannot be assisted if they call the PA toll-free number. Buckeye Member Services may be reached at 1-866-246-4358 (TTY 1-800-750-0750).

Transition Period

Buckeye members new to managed care will be able to receive their prescription drugs with no new PA requirements than traditional Fee-for-Service (FFS) Medicaid for 30 days they are enrolled in our plan if the prescription drug does not require PA by traditional FFS Medicaid. This means that if you needed a PA under traditional FFS Medicaid to get your prescriptions you will most likely still need a PA to get the same medication. If you have not needed PA under traditional FFS Medicaid to get your prescription you will not need PA from Buckeye to get the same medication for the first 30 days you are enrolled. This will allow you and your doctor time to consider other medications that do not require PA and to learn the steps to getting PA. Buckeye’s PDL identify the drugs that will require PA once you have been a managed care member for 30 days. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at 1-866-246-4358 (TTY 1-800-750-0750).

72-Hour Emergency Supply Policy

State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72- hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call the Envolve Pharmacy Solutions Pharmacy Help Desk at 1-800-460-8988 for a prescription override to submit the 72-hour medication supply for payment.

Step Therapy

Some medications listed on the Buckeye PDL may require specific medications to be used before you can receive the step therapy medication. If Buckeye has a record that the required medication was tried first the ST medications are automatically covered. If Buckeye does not have a record that the required medication was tried, you or your physician/clinician may be required to provide additional information. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Dispensing Limits, Quantity Limits, and Age Limits

Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance. For most medications, a total of 75 percent (75%) of the days supplied must have elapsed before the prescription can be refilled. That means a prescription for these medications can be filled after 25 days. For some narcotic pain medications, a total of 90 percent (90%) of the days supplied must have elapsed before the next fill of the narcotic pain medication can be obtained. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. Buckeye may limit how much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If you require a medication that does not appear on the PDL, you or your physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Buckeye requires:

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

o Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or

o Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process.

Appropriate Use and Safety Edits

Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Point-of-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Buckeye website at www.buckeyehealthplan.com.

DUR (Drug Utilization Review) Programs Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews prescribing retrospectively to review for both safety and efficacy. Buckeye will work with Envolve Pharmacy Solutions to review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. Buckeye will continue to monitor for issues going forward and take action as needed.

Mandatory Generic Substitution When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA. We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need the particular brand name drug. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L- thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin.

Over-The-Counter Medications

The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.

Filling a Prescription

You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription and your Buckeye ID card. Please visit the Buckeye website at www.buckeyehealthplan.com to access the Buckeye PDL, important forms, and provider/member information 24 hours a day, seven days a week.

Mail Order Program

Buckeye Health Plan offers a 90 day supply (3 month supply) of maintenance medications by mail. These drugs are used to treat long-term conditions or illnesses. You can find a list of covered maintenance medications in the Maintenance Drug Pharmacy Program document located on the Buckeye website at www.buckeyehealthplan.com. Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call Homescripts at 1-800-785- 4197.

Buckeye Health Plan Pharmacy Program - Additional Information Working with Our Pharmacy Benefit Managers

Buckeye works with two Pharmacy Benefit Managers (PBMs). Acaria Health is the preferred provider of biopharmaceuticals and injectables for Buckeye. Envolve Pharmacy Solutions administers all other prescribed drugs. Certain drugs require PA to be approved for payment by Buckeye. These include:

o Some Buckeye drugs listed on the PDL with “PA” in the Requirements/Limits column o Most injectables including Procrit, Neulasta and Neupogen.

AcariaHealth – Biopharmaceuticals and Injectables

AcariaHealth is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require PA to be approved for payment. All reviews are performed by a licensed healthcare professional using the criteria established by the Buckeye P&T Committee.. Buckeye provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the Buckeye website at www.buckeyehealthplan.com. Follow these guidelines for the most efficient processing of your authorization requests. Providers can request that AcariaHealth deliver the specialty drug to the office/member. If you want AcariaHealth to deliver the specialty drug to the office/member:

1. Fax the AcariaHealth PA form to 1-855-217-0926 for PA. 2. If approved, AcariaHealth will contact the provider or member for delivery confirmation.

Pharmacy and Therapeutics Committee

The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacist, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update the PDL accordingly based on the results of both the Buckeye P&T Committee and the requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification when changes are made to the list of drugs that require PA.

Unapproved Use of Preferred Medication

Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs are not eligible for coverage.

Benefit Exclusions

The following drug categories are not part of the Buckeye PDL and are not covered by the 72-hour emergency supply policy: - Fertility enhancing drugs - Anorexia, weight loss, or weight gain drugs - Immunizations and vaccines (except flu vaccine) - Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective - Infusion therapy and supplies - Drugs and other agents used for cosmetic purposes or for hair growth - Erectile dysfunction drugs prescribed to treat impotence

DESI drugs products and known related drug products are defined as less than effective by the FDA because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. State programs may allow coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL.

Newly Approved Products

We review new drugs for safety and effectiveness for the first 12 months before adding them to the Buckeye PDL. During this period, access to these medications will be considered through the PA review process. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Medical Benefits

The following drugs and medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy:

1. Members will receive vaccines as a medical benefit under physician reimbursement if listed the vaccine covered under the vaccine for children program. 2. Cosmetic-botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a PA from Buckeye. 3. Blood and blood products. 4. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from Buckeye.

Prescribers who request medical prior authorizations at Envolve Pharmacy Solutions will be redirected to contact Buckeye Health Plan as applicable.

DME/Home Health Benefits

The following medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy:

1. Enteral products 2. Nebulizers 3. Medical supplies

Injectable Drugs

Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and Depo-Provera IM are covered by Buckeye and do not require a PA. Pre-filled insulin cartridges and syringes require PA. Most other injectables require PA.

Coordinated Services Program

Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services Program, or CSP. CSP members may need to select one pharmacy to get medications filled, select one doctor to write their scripts, or both depending on the CSP enrollment. While in CSP, the member will still be able to get all medically necessary Medicaid-covered health care services. However, the member must use the selected pharmacy or doctor for pharmacy services. Members enrolled in the CSP program will also be offered enrollment in Care Management to help better coordinate the member’s needs. Care Managers will work with the CSP members, to help make sure all their needs are met. Except in an emergency, the member should contact their PCP before seeing other doctors. By knowing the complete medical history, the PCP can take better care of the patient.

We help keep you informed

The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current Buckeye PDL can be downloaded from our website at www.buckeyehealthplan.com.

Contacts for Pharmacy Appeals/Grievances

Members: In the event that a member disagrees with the decision regarding coverage of a medication, the member may file an appeal with Buckeye by calling Buckeye Member Services at 1- 866-246-4358 (TTY 1-800-750-0750).

Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to Buckeye in writing to the Appeals Department at the following address:

Buckeye Health Plan 4349 Easton Way, Suite 300 Columbus, Ohio 43219

A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a member by calling Buckeye at 1-866-246-4356 ext. 24084 (TTY 1- 800-750-0750). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be possible.

Abbreviations

The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column:

AL: Age Limit Drug Tier: Tier F drugs are preferred drugs DS: Days Supply PA: Prior Authorization QL: Quantity Limit RX/OTC: These drugs are made in both prescription form and Over-the-counter (OTC) form. ST: Step Therapy Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- QL(2 ea daily); dextroamphetamine sulfate F AL; At least 3 OBESITY/ANOREXIANTS - Drugs to Treat tabs 10 mg, 5 mg ADHD, Sleep and Eating Disorders yrs old PA Amphetamines methamphetamine hcl tabs F ADDERALL TABS (Use QL(2 ea daily); PROCENTRA SOLN (Use PA Amphetamine- *** AL; At least 3 Dextroamphetamine *** Dextroamphetamine) yrs old Sulfate) ADDERALL XR CP24 (Use QL(1 ea daily); F PA; QL(1 ea Amphetamine- *** AL; At least 6 VYVANSE CAPS daily) Dextroamphetamine) yrs old PA amphetamine- QL(1 ea daily); ZENZEDI TABS F dextroamphetamine cp24 AL; At least 6 6.25mg-6.25mg-6.25mg- yrs old Analeptics QL(45 ml per 6.25mg, 1.25mg-1.25mg- caffeine citrate soln F 1.25mg-1.25mg, 2.5mg- F fill retail) 2.5mg-2.5mg-2.5mg, 5mg- CAFFEINE CITRATED F QL(45 gm per 5mg-5mg-5mg, 3.75mg- POWD fill retail) 3.75mg-3.75mg-3.75mg, 7.5mg-7.5mg-7.5mg-7.5mg Attention-Deficit/Hyperactivity Disorder (ADHD) ST; AL; At least amphetamine- QL(2 ea daily); atomoxetine hcl caps F dextroamphetamine tabs AL; At least 3 6 yrs old 5mg-5mg-5mg-5mg, yrs old clonidine hcl (adhd) tb12 F PA 3.125mg-3.125mg- 3.125mg-3.125mg, 2.5mg- QL(1 ea daily); 2.5mg-2.5mg-2.5mg, F guanfacine hcl (adhd) tb24 F AL; At least 6 3.75mg-3.75mg-3.75mg- yrs old 3.75mg, 7.5mg-7.5mg- QL(1 ea daily); 7.5mg-7.5mg, 1.875mg- INTUNIV TB24 (Use *** )) AL; At least 6 1.875mg-1.875mg- Guanfacine HCl (ADHD yrs old 1.875mg, 1.25mg-1.25mg- 1.25mg-1.25mg KAPVAY TB12 (Use *** PA Clonidine HCl (ADHD)) DESOXYN TABS (Use *** PA Methamphetamine HCl) STRATTERA CAPS (Use *** ST; AL; At least Atomoxetine HCl) 6 yrs old DEXEDRINE CP24 15 MG, QL(2 ea daily); Stimulants - Misc. 10 MG (Use *** AL; At least 6 Dextroamphetamine yrs old armodafinil tabs F PA Sulfate) DEXEDRINE CP24 5 MG QL(1 ea daily); QL(2 ea daily); CONCERTA TBCR 36 MG *** (Use Dextroamphetamine *** AL; At least 6 (Use Methylphenidate HCl) AL; At least 6 Sulfate) yrs old yrs old QL(2 ea daily); CONCERTA TBCR 54 MG, QL(1 ea daily); dextroamphetamine sulfate F AL; At least 6 27 MG, 18 MG (Use *** AL; At least 6 cp24 10 mg, 15 mg yrs old Methylphenidate HCl) yrs old QL(1 ea daily); DAYTRANA PTCH F PA dextroamphetamine sulfate F AL; At least 6 cp24 5 mg yrs old dexmethylphenidate hcl PA; QL(1 ea cp24 15 mg, 35 mg, 40 mg, daily) dextroamphetamine sulfate F PA F soln 5 mg/5ml 25 mg, 30 mg, 10 mg, 5 mg, 20 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); NUVIGIL TABS (Use *** PA dexmethylphenidate hcl F AL; At least 6 Armodafinil) tabs 10 mg, 2.5 mg, 5 mg yrs old PROVIGIL TABS (Use *** PA QL(2 ea daily); Modafinil) FOCALIN TABS (Use *** ) AL; At least 6 PA Dexmethylphenidate HCl yrs old QUILLIVANT XR SUSR F FOCALIN XR CP24 (Use *** PA; QL(1 ea RITALIN LA CP24 10 MG F PA Dexmethylphenidate HCl) daily) QL(1 ea daily); RITALIN LA CP24 20 MG, PA METADATE CD CPCR *** 30 MG, 40 MG (Use *** ) AL; At least 6 (Use Methylphenidate HCl yrs old Methylphenidate HCl) METHYLIN CHEW 10 MG, PA QL(3 ea daily); RITALIN TABS (Use *** 2.5 MG, 5 MG (Use *** Methylphenidate HCl) AL; At least 3 Methylphenidate HCl) yrs old METHYLIN SOLN 5 ALLERGENIC EXTRACTS/BIOLOGICALS MISC MG/5ML, 10 MG/5ML (Use *** Methylphenidate HCl) Allergenic Extracts METHYLPHENIDATE HCL PA PA CHEW 5 MG, 2.5 MG, 10 F GRASTEK SUBL F MG ORALAIR ADULT SAMPLE F PA; SP methylphenidate hcl cp24 F PA KIT SUBL 30 mg, 40 mg, 20 mg ORALAIR ADULT F PA; SP methylphenidate hcl cpcr QL(1 ea daily); STARTER PACK SUBL 20 mg, 60 mg, 50 mg, 10 F AL; At least 6 PA; SP mg, 30 mg, 40 mg yrs old ORALAIR SUBL F METHYLPHENIDATE HCL QL(1 ea daily) PA ER TB24 18 MG, 54 MG, F RAGWITEK SUBL F 27 MG ALTERNATIVE MEDICINES METHYLPHENIDATE HCL F QL(2 ea daily) ER TB24 36 MG Alternative Medicine - A's QL(1 ea daily); METHYLPHENIDATE HCL ALPHA LIPOIC ACID F F AL; At least 6 CAPS ER TBCR 18 MG yrs old Alternative Medicine - C's methylphenidate hcl soln F 10 mg/5ml, 5 mg/5ml CHEW Q CHEW F QL(3 ea daily); methylphenidate hcl tabs F AL; At least 3 coenzyme q10 PA 10 mg, 20 mg, 5 mg yrs old (ubidecarenone) caps 30 F mg, 100mg-5unit, 100 mg QL(1 ea daily); methylphenidate hcl tbcr 27 F AL; At least 6 coenzyme q10 mg, 18 mg, 54 mg yrs old (ubidecarenone) caps 50 F mg QL(2 ea daily); methylphenidate hcl tbcr 36 F AL; At least 6 Alternative Medicine - G's mg, 20 mg, 10 mg yrs old ginger (zingiber officinalis) F QL(4 ea daily) caps modafinil tabs F PA Alternative Medicine - M's

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits melatonin caps 5 mg F ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint MELATONIN LIQD 1 F Conditions MG/4ML, 2.5 MG/10ML Anti-TNF-alpha - Monoclonal Antibodies melatonin tabs 300 mcg, 1 F mg HUMIRA PEDIATRIC PA; SP CROHNS DISEASE F melatonin tabs 5 mg, 3 mg F QL(1 ea daily) STARTER PACK PSKT PA; SP Alternative Medicine - U HUMIRA PEN PNKT F CYTO-Q MAX LIQD F HUMIRA PEN-CROHNS F PA; SP DISEASESTARTER PNKT QH LIQD F HUMIRA PEN-PSORIASIS F PA; SP STARTER PNKT Alternative Medicine Combinations HUMIRA PSKT F PA; SP LIQ-10 SYRP F SIMPONI SOAJ F PA; SP melatonin-pyridoxine tabs F SIMPONI SOSY F PA; SP AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Antirheumatic - Enzyme Inhibitors Aminoglycosides XELJANZ TABS F PA; SP BETHKIS NEBU F PA; SP Antirheumatic Antimetabolites PA; SP KITABIS PAK NEBU F OTREXUP SOAJ F PA; SP neomycin sulfate tabs F RASUVO SOAJ F PA; SP PA paromomycin sulfate caps F RHEUMATREX TABS F

TOBI NEBU (Use *** PA; SP Gold Compounds Tobramycin) RIDAURA CAPS F TOBI PODHALER CAPS F PA; SP Interleukin-1 Blockers TOBRAMYCIN NEBU F PA; SP ARCALYST SOLR F PA; SP tobramycin nebu F PA; SP Interleukin-1 Receptor Antagonist (IL-1Ra) TOBRAMYCIN SULFATE F PA PA; SP POWD XX KINERET SOSY F TOBRAMYCIN SULFATE PA Interleukin-6 Receptor Inhibitors SOLN IJ 10 MG/ML, 40 F MG/ML ACTEMRA SOSY F PA; SP tobramycin sulfate soln ij PA 80 mg/2ml, 1.2 gm/30ml, F Nonsteroidal Anti-inflammatory Agents (NSAIDs) 40 mg/ml, 10 mg/ml ADVIL CAPS (Use *** Ibuprofen) tobramycin sulfate solr ij F PA 1.2 gm

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL MIGRAINE CAPS *** FENORTHO CAPS F PA (Use Ibuprofen) ADVIL TABS (Use *** flurbiprofen tabs F Ibuprofen) ALEVE ARTHRITIS TABS *** QL(2 ea daily) ibuprofen caps 200 mg F (Use Naproxen Sodium) ibuprofen chew 100 mg F ALEVE TABS (Use *** QL(2 ea daily) Naproxen Sodium) ibuprofen susp 100 mg/5ml F RX/OTC ANAPROX DS TABS (Use *** Naproxen Sodium) ibuprofen susp 50 F CELEBREX CAPS 100 PA; QL(2 ea mg/1.25ml, 40 mg/ml MG, 200 MG, 50 MG (Use *** daily) ibuprofen tabs 200 mg, 400 Celecoxib) mg, 600 mg, 800 mg, 100 F CELEBREX CAPS 400 MG *** PA mg (Use Celecoxib) INDOCIN SUPP F celecoxib caps 200 mg, F PA; QL(2 ea 100 mg, 50 mg daily) INDOCIN SUSP F celecoxib caps 400 mg F PA indomethacin caps F CHILDRENS ADVIL SUSP *** RX/OTC (Use Ibuprofen) indomethacin cpcr F CHILDRENS MOTRIN *** RX/OTC SUSP (Use Ibuprofen) INFANTS ADVIL SUSP *** (Use Ibuprofen) DAYPRO TABS (Use *** Oxaprozin) ketoprofen caps F diclofenac potassium tabs F KETOPROFEN ER CP24 F diclofenac sodium tb24 F QL(20 ea per ketorolac tromethamine F 30 days retail); diclofenac sodium tbec F tabs AL; At least 17 yrs old DUEXIS TABS F PA LODINE TABS (Use *** Etodolac) EC-NAPROSYN TBEC *** QL(2 ea daily) (Use Naproxen) MECLOFENAMATE F SODIUM CAPS etodolac caps F mefenamic acid caps F PA etodolac tabs F MELOXICAM SUSP 7.5 F MG/5ML etodolac tb24 F meloxicam tabs 15 mg, 7.5 F mg FELDENE CAPS (Use *** Piroxicam) MOBIC SUSP 7.5 MG/5ML F FENOPROFEN CALCIUM F PA CAPS 400 MG MOBIC TABS 15 MG, 7.5 *** MG (Use Meloxicam) fenoprofen calcium tabs F 600 mg

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOTRIN INFANTS ZIPSOR CAPS F PA DROPS SUSP (Use *** Ibuprofen) ZORVOLEX CAPS F PA nabumetone tabs F Phosphodiesterase 4 (PDE4) Inhibitors PA NALFON CAPS F OTEZLA TABS F PA; SP NAPRELAN TB24 500 MG, PA PA; SP 375 MG (Use Naproxen *** OTEZLA TBPK F Sodium) Pyrimidine Synthesis Inhibitors NAPRELAN TB24 750 MG F PA ARAVA TABS (Use *** QL(1 ea daily) Leflunomide) NAPROSYN SUSP (Use *** Naproxen) leflunomide tabs F QL(1 ea daily) NAPROSYN TABS (Use *** Naproxen) Selective Costimulation Modulators PA; SP naproxen sodium tabs 220 F QL(2 ea daily) ORENCIA SOLR F mg PA; SP naproxen sodium tabs 550 F ORENCIA SOSY F mg, 275 mg Soluble Tumor Necrosis Factor Receptor Agents naproxen sodium tb24 500 F PA mg, 375 mg ENBREL SOLR F PA; SP naproxen susp 125 mg/5ml F ENBREL SOSY F PA; SP NAPROXEN SUSP 125 F MG/5ML ENBREL SURECLICK F PA; SP SOAJ naproxen tabs 250 mg, 500 F mg, 375 mg ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions naproxen tbec 500 mg, 375 F QL(2 ea daily) mg Analgesic Combinations oxaprozin tabs F acetaminophen-caffeine F tabs piroxicam caps F aspirin-acetaminophen- F caffeine tabs PONSTEL CAPS (Use *** PA Mefenamic Acid) butalbital-acetaminophen F tabs sulindac tabs F butalbital-acetaminophen- PA caffeine caps 300mg- F TOLMETIN SODIUM F PA CAPS 400 MG 50mg-40mg butalbital-acetaminophen- QL(4 ea daily) tolmetin sodium caps 400 F PA mg caffeine caps 325mg- F 50mg-40mg TOLMETIN SODIUM TABS F PA 200 MG, 600 MG butalbital-acetaminophen- QL(4 ea daily) caffeine tabs 325mg-50mg- F VIMOVO TBEC F PA 40mg butalbital-aspirin-caffeine F QL(4 ea daily) caps ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESGIC TABS (Use QL(4 ea daily) acetaminophen tbcr or 650 F Butalbital-Acetaminophen- *** mg Caffeine) acetaminophen tbdp or 80 F EXCEDRIN EXTRA mg STRENGTH TABS (Use *** TRIAMINIC FEVER Aspirin-Acetaminophen- REDUCERPAIN F Caffeine) RELIEVER CHILDRENS EXCEDRIN MENSTRUAL SYRP COMPLETE TABS (Use *** TRIAMINIC FEVER Aspirin-Acetaminophen- REDUCERPAIN F Caffeine) RELIEVER INFANTS EXCEDRIN MIGRAINE SYRP TABS (Use Aspirin- *** TYLENOL 8 HOUR Acetaminophen-Caffeine) ARTHRITISPAIN TBCR *** EXCEDRIN TENSION (Use Acetaminophen) HEADACHE TABS (Use *** TYLENOL 8 HOUR TBCR *** Acetaminophen-Caffeine) (Use Acetaminophen) FIORICET CAPS (Use PA TYLENOL CHILDRENS Butalbital-Acetaminophen- *** SUSP (Use *** Caffeine) Acetaminophen) FIORINAL CAPS (Use *** QL(4 ea daily) TYLENOL EXTRA Butalbital-Aspirin-Caffeine) STRENGTH TABS (Use *** LEVACET TABS F Acetaminophen) TYLENOL INFANTS TENCON TABS F PAIN+FEVER SUSP (Use *** Acetaminophen) Analgesics Other TYLENOL INFANTS SUSP *** (Use Acetaminophen) acetaminophen caps or F 500 mg TYLENOL SORE THROAT DAYTIME LIQD (Use *** acetaminophen chew or F 160 mg, 80 mg Acetaminophen) TYLENOL TABS (Use acetaminophen elix or 160 F *** mg/5ml, 80 mg/2.5ml Acetaminophen) acetaminophen liqd or 500 Salicylates mg/15ml, 1000 mg/30ml, F aspirin buffered (cal carb- F 160 mg/5ml mag carb-mag oxide) tabs acetaminophen soln or 160 mg/5ml, 325 mg/10.15ml, F aspirin chew or 81 mg F 650 mg/20.3ml ASPIRIN LOW DOSE F acetaminophen supp re F QL(12 ea per TABS 650 mg, 325 mg, 120 mg 30 days retail) ASPIRIN SUPP RE 120 F QL(12 ea per acetaminophen susp or MG, 200 MG 30 days retail) 160 mg/5ml, 80 mg/2.5ml, F aspirin supp re 300 mg, F QL(12 ea per 80 mg/0.8ml 600 mg 30 days retail) acetaminophen tabs or 325 F mg, 500 mg aspirin tabs or 325 mg F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aspirin tbec or 500 mg, 324 F fentanyl citrate lpop F PA mg, 325 mg, 81 mg QL(0.34 ea BUFFERIN TABS (Use fentanyl pt72 F Aspirin Buffered (Cal Carb- *** daily) Mag Carb-Mag Oxide)) FENTORA TABS F PA choline & mag salicylate F PA liqd hydromorphone hcl liqd or F QL(80 ml daily) 1 mg/ml diflunisal tabs F HYDROMORPHONE HCL F SUPP RE 3 MG DISALCID TABS (Use *** Salsalate) hydromorphone hcl tabs or F QL(8 ea daily) ECOTRIN MAXIMUM 2 mg, 4 mg, 8 mg STRENGTH TBEC (Use *** KADIAN CP24 200 MG F PA Aspirin) ECOTRIN REGULAR KADIAN CP24 30 MG, 20 PA STRENGTH TBEC (Use *** MG, 60 MG, 10 MG, 100 *** Aspirin) MG, 50 MG, 80 MG (Use Morphine Sulfate) salsalate tabs F LAZANDA SOLN F PA ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions LEVORPHANOL F PA TARTRATE TABS Opioid Agonists MEPERIDINE HCL SOLN F ABSTRAL SUBL F PA 50 MG/5ML meperidine hcl tabs 100 F QL(6 ea daily) ACTIQ LPOP (Use *** PA mg, 50 mg Fentanyl Citrate) methadone hcl conc 10 F QL(10 ml daily) codeine sulfate tabs 15 mg, F QL(2 ea daily) mg/ml 30 mg, 60 mg methadone hcl soln 10 F QL(60 ml daily) CODEINE SULFATE TABS QL(2 ea daily) mg/5ml 30 MG, 60 MG, 15 MG *** (Use Codeine Sulfate) METHADONE HCL SOLN QL(60 ml daily) 10 MG/5ML (Use *** CONZIP CP24 F PA Methadone HCl) methadone hcl soln 5 QL(30 ml daily) DEMEROL TABS (Use *** QL(6 ea daily) F Meperidine HCl) mg/5ml METHADONE HCL SOLN QL(30 ml daily) DILAUDID LIQD 1 MG/ML *** QL(80 ml daily) (Use Hydromorphone HCl) 5 MG/5ML (Use *** Methadone HCl) DILAUDID TABS 8 MG, 4 QL(8 ea daily) PA; QL(10 ea MG, 2 MG (Use *** methadone hcl tabs 10 mg F Hydromorphone HCl) daily) PA; QL(4 ea DOLOPHINE TABS 10 MG *** PA; QL(10 ea methadone hcl tabs 5 mg F (Use Methadone HCl) daily) daily) METHADOSE CONC (Use QL(10 ml daily) DOLOPHINE TABS 5 MG *** PA; QL(4 ea *** (Use Methadone HCl) daily) Methadone HCl) METHADOSE SUGAR- QL(10 ml daily) DURAGESIC PT72 (Use *** QL(0.34 ea Fentanyl) daily) FREE CONC (Use *** Methadone HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits morphine sulfate cp24 or PA SUBSYS LIQD F PA 10 mg, 50 mg, 30 mg, 80 F mg, 100 mg, 60 mg, 20 mg TRAMADOL HCL ER CP24 F PA MORPHINE SULFATE ER F PA CP24 tramadol hcl tabs 50 mg F QL(8 ea daily) morphine sulfate soln or 10 F QL(500 ml per mg/5ml, 20 mg/5ml 30 days retail) tramadol hcl tb24 300 mg, F PA 100 mg, 200 mg morphine sulfate soln or 20 F QL(240 ml per mg/ml, 100 mg/5ml fill retail) ULTRAM ER TB24 (Use *** PA Tramadol HCl) MORPHINE SULFATE QL(24 ea per SUPP RE 20 MG, 5 MG, F fill retail) ULTRAM TABS (Use *** QL(8 ea daily) 10 MG, 30 MG Tramadol HCl) Opioid Combinations MORPHINE SULFATE F QL(6 ea daily) TABS OR 15 MG, 30 MG acetaminophen w/ codeine F QL(30 ml daily) morphine sulfate tbcr or 30 QL(3 ea daily) soln 120mg/5ml-12mg/5ml mg, 200 mg, 15 mg, 100 F acetaminophen w/ codeine QL(6 ea daily) mg, 60 mg tabs 300mg-15mg, 300mg- F 60mg, 300mg-30mg MS CONTIN TBCR (Use *** QL(3 ea daily) Morphine Sulfate) ASPIRIN-CAFFEINE- F PA NUCYNTA ER TB12 F PA DIHYDROCODEINE CAPS butalbital-acetaminophen- PA NUCYNTA TABS F PA caffeine w/ codeine caps F 300mg-50mg-40mg-30mg OPANA TABS (Use *** PA butalbital-acetaminophen- QL(4 ea daily) Oxymorphone HCl) caffeine w/ codeine caps F oxycodone hcl caps 5 mg F QL(6 ea daily) 325mg-50mg-40mg-30mg butalbital-aspirin-caffeine F QL(4 ea daily) oxycodone hcl conc 100 F QL(6 ml daily) w/cod caps mg/5ml CAPITAL/CODEINE SUSP F PA OXYCODONE HCL ER F PA T12A FIORICET/CODEINE PA oxycodone hcl soln 5 F CAPS (Use Butalbital- *** mg/5ml Acetaminophen-Caffeine w/ Codeine) oxycodone hcl tabs 20 mg, F QL(6 ea daily) 30 mg, 10 mg, 5 mg, 15 mg FIORINAL/CODEINE #3 QL(4 ea daily) PA CAPS (Use Butalbital- *** OXYCONTIN T12A F Aspirin-Caffeine w/Cod) oxymorphone hcl tabs F PA HYCET SOLN (Use QL(180 ml Hydrocodone- *** daily) Acetaminophen) oxymorphone hcl tb12 F PA hydrocodone- PA OXYMORPHONE PA acetaminophen soln F HYDROCHLORIDE ER F 10mg/15ml-325mg/15ml TB12 ROXICODONE TABS (Use *** QL(6 ea daily) Oxycodone HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone- QL(180 ml PERCOCET TABS 10MG- QL(6 ea daily) acetaminophen soln daily) 325MG, 7.5MG-325MG, 5mg/10ml-217mg/10ml, F 5MG-325MG (Use *** 2.5mg/5ml-108mg/5ml, Oxycodone w/ 7.5mg/15ml-325mg/15ml Acetaminophen) hydrocodone- PA PERCOCET TABS 2.5MG- acetaminophen tabs 10mg- F 325MG (Use Oxycodone w/ *** 300mg, 2.5mg-325mg, Acetaminophen) 5mg-300mg, 7.5mg-300mg PRIMLEV TABS F PA hydrocodone- QL(6 ea daily) acetaminophen tabs 10mg- F REPREXAIN TABS (Use *** PA 325mg Hydrocodone-Ibuprofen) hydrocodone- QL(12 ea daily) SYNALGOS-DC CAPS F PA acetaminophen tabs 5mg- F 325mg tramadol-acetaminophen F PA hydrocodone- QL(8 ea daily) tabs acetaminophen tabs F TYLENOL/CODEINE #3 QL(6 ea daily) 7.5mg-325mg TABS (Use Acetaminophen *** w/ Codeine) hydrocodone-ibuprofen F PA tabs TYLENOL/CODEINE #4 QL(6 ea daily) TABS (Use Acetaminophen *** IBUDONE TABS (Use *** PA Hydrocodone-Ibuprofen) w/ Codeine) PA ULTRACET TABS (Use *** PA LORTAB ELIX F Tramadol-Acetaminophen) NORCO TABS 10MG- QL(6 ea daily) VICOPROFEN TABS (Use *** PA 325MG (Use Hydrocodone- *** Hydrocodone-Ibuprofen) Acetaminophen) XARTEMIS XR TBCR F PA NORCO TABS 5MG- QL(12 ea daily) 325MG (Use Hydrocodone- *** XODOL TABS (Use PA Acetaminophen) Hydrocodone- *** NORCO TABS 7.5MG- QL(8 ea daily) Acetaminophen) 325MG (Use Hydrocodone- *** PA Acetaminophen) ZAMICET SOLN F oxycodone w/ Opioid Partial Agonists acetaminophen tabs F F PA; Use 2.5mg-325mg BELBUCA FILM Suboxone Film oxycodone w/ QL(6 ea daily) BUNAVAIL FILM F PA; Use acetaminophen tabs 5mg- F Suboxone Film 325mg, 10mg-325mg, 7.5mg-325mg BUPRENEX SOLN (Use *** Buprenorphine HCl) oxycodone-aspirin tabs F buprenorphine hcl soln ij F 0.3 mg/ml OXYCODONE/ACETAMIN F QL(30 ml daily) OPHEN SOLN buprenorphine hcl subl sl 2 F PA mg, 8 mg OXYCODONE/IBUPROFE F PA N TABS buprenorphine hcl- F PA naloxone hcl dihydrate subl

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F PA; Use METHITEST TABS F PA BUPRENORPHINE PTWK Suboxone Film PA butorphanol tartrate soln na F PA; AL; At least methyltestosterone caps F 10 mg/ml 18 yrs old PA F PA; Use STRIANT MISC F BUTRANS PTWK Suboxone Film TESTIM GEL (Use *** PA pentazocine w/ naloxone F PA Testosterone) tabs QL(4 ml per 30 testosterone cypionate soln F SUBOXONE FILM 12MG- F PA; QL(2 ea days retail) 3MG, 8MG-2MG daily) TESTOSTERONE GEL 10 PA SUBOXONE FILM 2MG- F PA; QL(1 ea MG/ACT, 25 MG/2.5GM, 1 F 0.5MG, 4MG-1MG daily) %, 50 MG/5GM PA; Use ZUBSOLV SUBL F testosterone gel 25 F PA Suboxone Film mg/2.5gm, 1 %, 50 mg/5gm ANDROGENS-ANABOLIC - Drugs to Regulate TESTOSTERONE PUMP F PA Hormones GEL Anabolic Steroids testosterone soln 30 mg/act F PA ANADROL-50 TABS F PA TESTRED CAPS (Use *** PA Methyltestosterone) OXANDRIN TABS (Use *** PA Oxandrolone) VOGELXO GEL F PA oxandrolone tabs F PA VOGELXO PUMP GEL F PA Androgens QL(1 ea daily) ANORECTAL AGENTS - Rectal Drugs to Treat ANDRODERM PT24 F Pain, Swelling and Itching ANDROGEL GEL 25 PA Intrarectal Steroids MG/2.5GM, 50 MG/5GM *** CORTENEMA ENEM (Use (Use Testosterone) Hydrocortisone *** ANDROGEL GEL 40.5 PA (Intrarectal)) MG/2.5GM, 20.25 F PA MG/1.25GM CORTIFOAM FOAM F PA ANDROGEL PUMP GEL F hydrocortisone (intrarectal) F enem ANDROID CAPS (Use *** PA Rectal Combinations Methyltestosterone) ANALPRAM-HC LOTN F QL(62 ml per AXIRON SOLN (Use *** PA 30 days retail) Testosterone) phenylephrine-shark liver F QL(12 ea per danazol caps F oil-cocoa butter supp 30 days retail) DEPO-TESTOSTERONE QL(4 ml per 30 phenylephrine-shark liver F QL(54 gm per SOLN (Use Testosterone *** days retail) oil-glycerin-petrolatum crea fill retail) Cypionate) phenylephrine-shark liver QL(31 gm per PA oil-mineral oil-petrolatum F 30 days retail) FORTESTA GEL F oint

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pramoxine-phenylephrine- F alum & mag hydrox- QL(744 ml per glycerin-petrolatum crea simethicone susp 30 days retail) PREPARATION H CREA 200mg/5ml-20mg/5ml- 200mg/5ml, 200mg/5ml- F (Use Pramoxine- *** Phenylephrine-Glycerin- 200mg/5ml-20mg/5ml- Petrolatum) 20mg/5ml-200mg/5ml- 200mg/5ml PREPARATION H TOTABLES PAIN RELIEF alum & mag hydrox- CREA (Use Pramoxine- *** simethicone susp Phenylephrine-Glycerin- 400mg/5ml-400mg/5ml- Petrolatum) 40mg/5ml-40mg/5ml- F 400mg/5ml-400mg/5ml, Rectal Local Anesthetics 400mg/5ml-40mg/5ml- dibucaine (rectal) oint F 400mg/5ml aluminum hydroxide-mag F NUPERCAINAL OINT (Use *** carb susp Dibucaine (Rectal)) aluminum hydroxide-mag F pramoxine hcl (rectal) foam F trisil chew GAVISCON SUSP (Use PROCTOFOAM FOAM Aluminum Hydroxide-Mag *** (Use Pramoxine HCl *** Carb) (Rectal)) HYVEE ADVANCED Rectal Steroids ANTACID MAXIMUM STRENGTH SUSP (Use *** ANUSOL-HC CREA (Use *** Hydrocortisone (Rectal)) Alum & Mag Hydrox- Simethicone) hydrocortisone (rectal) crea F PA 1 % Antacids - Aluminum Salts hydrocortisone (rectal) crea F ALUMINUM HYDROXIDE F 2.5 % SUSP OR PROCTOCORT CREA PA Antacids - Bicarbonate (Use Hydrocortisone *** (Rectal)) sodium bicarbonate F QL(100 ea per (antacid) tabs 30 days retail) Vasodilating Agents Antacids - Calcium Salts RECTIV OINT F PA calcium carbonate (antacid) F chew ANTACIDS - Ulcer and Stomach Acid Drugs calcium carbonate (antacid) F tabs Antacid Combinations CALCIUM CARBONATE F alum & mag hydrox- QL(744 ml per TABS 648 MG simethicone liqd F 30 days retail) 200mg/5ml-20mg/5ml- TUMS CHEW (Use 200mg/5ml Calcium Carbonate *** (Antacid)) alum & mag hydrox- TUMS LASTING EFFECTS simethicone liqd F 400mg/5ml-40mg/5ml- CHEW (Use Calcium *** 400mg/5ml Carbonate (Antacid)) Antacids - Magnesium Salts

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits magnesium oxide tabs F trimethoprim tabs F

ANTHELMINTICS - Drugs to Treat Worm TRIMPEX SOLN F PA Infections VANCOCIN HCL CAPS QL(4 ea daily) Anthelmintics 125 MG (Use Vancomycin *** ALBENZA TABS F PA HCl) VANCOCIN HCL CAPS QL(8 ea daily) BILTRICIDE TABS F PA 250 MG (Use Vancomycin *** HCl) QL(1 ea per 14 EMVERM CHEW F vancomycin hcl caps or F QL(4 ea daily) days retail) 125 mg ivermectin tabs F PA vancomycin hcl caps or F QL(8 ea daily) 250 mg Limit 1 fill per pyrantel pamoate susp F Month;QL(60 vancomycin hcl solr iv 1000 F QL(14 ea per ml per fill retail) mg fill retail) vancomycin hcl solr iv 500 QL(14 ea per REESES PINWORM F QL(16 ea per F MEDICINE TABS fill retail) mg 30 days retail) PA STROMECTOL TABS (Use *** PA XIFAXAN TABS F Ivermectin) Anti-infective Misc. - Combinations ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections BACTRIM DS TABS (Use Sulfamethoxazole- *** Anti-infective Agents - Misc. Trimethoprim) CAYSTON SOLR F PA; SP BACTRIM TABS (Use Sulfamethoxazole- *** FIRST-VANCOMYCIN 25 F Trimethoprim) SOLN sulfamethoxazole- F FIRST-VANCOMYCIN 50 F trimethoprim susp SOLN sulfamethoxazole- F FLAGYL CAPS 375 MG *** PA trimethoprim tabs (Use Metronidazole) Antiprotozoal Agents FLAGYL TABS 500 MG, 250 MG (Use *** ALINIA SUSR F PA Metronidazole) ALINIA TABS F PA metronidazole caps 375 F PA mg atovaquone susp F metronidazole tabs 500 F mg, 250 mg MEPRON SUSP (Use *** NEBUPENT SOLR F PA Atovaquone) Ketolides PRIMSOL SOLN F PA KETEK TABS F PA TINDAMAX TABS (Use *** PA Tinidazole) Leprostatics tinidazole tabs F PA dapsone tabs F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Lincosamides isosorbide mononitrate F QL(1 ea daily) tb24 120 mg, 30 mg, 60 mg CLEOCIN CAPS OR 150 MG, 300 MG (Use *** NITRO-BID OINT F Clindamycin HCl) NITRO-DUR PT24 0.6 CLEOCIN CAPS OR 75 *** PA MG (Use Clindamycin HCl) MG/HR, 0.4 MG/HR, 0.2 *** MG/HR, 0.1 MG/HR (Use CLEOCIN PEDIATRIC QL(300 ml per Nitroglycerin) GRANULES SOLR (Use *** fill retail) Clindamycin Palmitate NITRO-DUR PT24 0.8 F PA Hydrochloride) MG/HR, 0.3 MG/HR nitroglycerin cpcr or 6.5 clindamycin hcl caps 300 F F mg, 150 mg mg, 2.5 mg, 9 mg PA nitroglycerin pt24 td 0.2 clindamycin hcl caps 75 mg F mg/hr, 0.4 mg/hr, 0.6 F mg/hr, 0.1 mg/hr clindamycin palmitate F QL(300 ml per hydrochloride solr fill retail) nitroglycerin soln tl 0.4 F PA mg/spray Oxazolidinones nitroglycerin subl sl 0.3 mg, F linezolid susr F PA 0.6 mg, 0.4 mg NITROLINGUAL PA linezolid tabs F PA PUMPSPRAY SOLN (Use *** Nitroglycerin) SIVEXTRO TABS F PA; QL(6 ea per fill retail) NITROSTAT SUBL (Use *** Nitroglycerin) ZYVOX SUSR (Use *** PA Linezolid) ANTIANXIETY AGENTS - Drugs to Treat Anxiety ZYVOX TABS (Use *** PA Linezolid) Antianxiety Agents - Misc. QL(3 ea daily) ANTIANGINAL AGENTS - Drugs to Treat Chest buspirone hcl tabs F Pain hydroxyzine hcl syrp F Antianginals-Other RANEXA TB12 F PA hydroxyzine hcl tabs F

Nitrates HYDROXYZINE F PAMOATE CAPS 100 MG DILATRATE SR CPCR F PA hydroxyzine pamoate caps F 25 mg, 50 mg ISORDIL TITRADOSE F TABS 40 MG meprobamate tabs F ISORDIL TITRADOSE TABS 5 MG (Use *** VISTARIL CAPS (Use *** Isosorbide Dinitrate) Hydroxyzine Pamoate) Benzodiazepines ISOSORBIDE DINITRATE F ER TBCR ALPRAZOLAM INTENSOL F CONC isosorbide dinitrate tabs F alprazolam tabs 2 mg, 1 F QL(4 ea daily) isosorbide mononitrate F QL(2 ea daily) mg, 0.25 mg, 0.5 mg tabs 20 mg, 10 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits alprazolam tb24 2 mg, 1 F PA QUINIDINE SULFATE F mg, 3 mg, 0.5 mg TABS alprazolam tbdp 0.5 mg, F PA Antiarrhythmics Type I-B 0.25 mg, 2 mg, 1 mg mexiletine hcl caps F ATIVAN TABS 0.5 MG, 2 *** QL(3 ea daily) MG (Use Lorazepam) Antiarrhythmics Type I-C ATIVAN TABS 1 MG (Use *** QL(4 ea daily) Lorazepam) flecainide acetate tabs F QL(4 ea daily) chlordiazepoxide hcl caps F propafenone hcl cp12 325 F PA mg, 425 mg, 225 mg clorazepate dipotassium F QL(3 ea daily) tabs propafenone hcl tabs 300 F mg, 150 mg, 225 mg diazepam conc or 5 mg/ml F RYTHMOL SR CP12 (Use *** PA Propafenone HCl) DIAZEPAM SOLN OR 1 F MG/ML RYTHMOL TABS (Use *** Propafenone HCl) diazepam tabs or 2 mg, 10 F QL(4 ea daily) mg, 5 mg Antiarrhythmics Type III lorazepam conc 2 mg/ml F PA amiodarone hcl tabs 100 F PA mg lorazepam tabs 0.5 mg, 2 QL(3 ea daily) F amiodarone hcl tabs 400 F mg mg, 200 mg QL(4 ea daily) lorazepam tabs 1 mg F CORDARONE TABS (Use *** Amiodarone HCl) QL(4 ea daily) oxazepam caps F dofetilide caps F TRANXENE T TABS (Use QL(3 ea daily) *** F PA; QL(2 ea Clorazepate Dipotassium) MULTAQ TABS daily) VALIUM TABS (Use QL(4 ea daily) *** TIKOSYN CAPS (Use *** Diazepam) Dofetilide) XANAX TABS (Use *** QL(4 ea daily) Alprazolam) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions XANAX XR TB24 (Use *** PA Alprazolam) Anti-Inflammatory Agents ANTIARRHYTHMICS - Drugs to treat abnormal cromolyn sodium nebu F QL(8 ml daily) heart rhythms Bronchodilators - Anticholinergics Antiarrhythmics Type I-A ATROVENT HFA AERS F disopyramide phosphate F caps INCRUSE ELLIPTA AEPB F QL(7 ea per 30 NORPACE CAPS (Use F days retail) Disopyramide Phosphate) INCRUSE ELLIPTA AEPB F QL(30 ea per NORPACE CR CP12 F 30 days retail) QL(375 ml per ipratropium bromide soln F quinidine gluconate tbcr F 25 days retail) SPIRIVA HANDIHALER F PA; QL(90 ea CAPS per fill retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUDORZA PRESSAIR F QL(1 ea per 30 QL(120 ml per AEPB days retail) 30 days retail); budesonide (inhalation) F AL; At least 1 Leukotriene Modulators susp yrs old - Up to ACCOLATE TABS (Use *** PA 8 yrs old ) Zafirlukast FLOVENT DISKUS AEPB QL(2 ea daily) montelukast sodium chew F QL(1 ea daily) 100 MCG/BLIST, 250 F MCG/BLIST montelukast sodium pack F QL(1 ea daily) FLOVENT DISKUS AEPB F 50 MCG/BLIST montelukast sodium tabs F QL(1 ea daily) FLOVENT HFA AERO 110 F QL(12 gm per MCG/ACT, 220 MCG/ACT fill retail) SINGULAIR CHEW (Use *** QL(1 ea daily) Montelukast Sodium) FLOVENT HFA AERO 44 F QL(10.6 gm per MCG/ACT fill retail) SINGULAIR PACK (Use *** QL(1 ea daily) Montelukast Sodium) PULMICORT FLEXHALER F PA AEPB SINGULAIR TABS (Use *** QL(1 ea daily) Montelukast Sodium) QL(120 ml per PA 30 days retail); zafirlukast tabs F PULMICORT SUSP (Use *** )) AL; At least 1 Budesonide (Inhalation yrs old - Up to ZYFLO TABS F PA 8 yrs old PA; QL(17.4 Selective Phosphodiesterase 4 (PDE4) Inhibitors QVAR AERS F gm per fill DALIRESP TABS F PA retail) Sympathomimetics Steroid Inhalants F PA; QL(60 ea PA; QL(8.9 gm ADVAIR DISKUS AEPB per fill retail) AEROSPAN AERS F per 30 days retail) F PA; QL(12 gm ADVAIR HFA AERO per fill retail) ALVESCO AERS F PA ALBUTEROL SULFATE F ASMANEX TWISTHALER PA ER TB12 120 METERED DOSES F albuterol sulfate nebu in F QL(12.5 ml AEPB 0.083 % daily) ASMANEX TWISTHALER PA albuterol sulfate nebu in 0.5 F 14 METERED DOSES F % AEPB albuterol sulfate nebu in F QL(375 ml per ASMANEX TWISTHALER PA 1.25 mg/3ml, 0.63 mg/3ml 30 days retail) 30 METERED DOSES F albuterol sulfate syrp or 2 F AEPB mg/5ml ASMANEX TWISTHALER PA albuterol sulfate tabs or 2 F 60 METERED DOSES F mg, 4 mg AEPB albuterol sulfate tb12 or 8 F ASMANEX TWISTHALER PA mg, 4 mg 7 METERED DOSES F PA AEPB ANORO ELLIPTA AEPB F ARCAPTA NEOHALER F PA CAPS ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREO ELLIPTA AEPB F PA Xanthines ELIXOPHYLLIN ELIX F BROVANA NEBU F PA THEO-24 CP24 F COMBIVENT RESPIMAT F QL(4 gm per 30 AERS days retail) theophylline soln 80 F QL(475 ml per F QL(13 gm per mg/15ml fill retail) DULERA AERO 30 days retail) theophylline tb12 200 mg, F ipratropium-albuterol soln F QL(12 ml daily) 300 mg, 100 mg, 450 mg theophylline tb24 400 mg, F levalbuterol hcl nebu F PA 600 mg

LEVALBUTEROL F PA ANTICOAGULANTS - Blood Thinners TARTRATE HFA AERO METAPROTERENOL QL(30 ml daily) Coumarin Anticoagulants SULFATE SYRP 10 F COUMADIN TABS (Use F MG/5ML Warfarin Sodium) METAPROTERENOL warfarin sodium tabs F SULFATE TABS 10 MG, F 20 MG Direct Factor Xa Inhibitors PA PERFOROMIST NEBU F ELIQUIS TABS F QL(4 ea daily) PROAIR HFA AERS *** QL(1 ea XARELTO TABS 10 MG F daily,35 ea per PROVENTIL HFA AERS *** 180 days retail) XARELTO TABS 15 MG F QL(2 ea daily) SEREVENT DISKUS F QL(60 ea per AEPB 30 days retail) XARELTO TABS 20 MG F QL(1 ea daily) STRIVERDI RESPIMAT F PA AERS Heparins And Heparinoid-Like Agents QL(11 gm per SYMBICORT AERO F ARIXTRA SOLN (Use *** PA; SP fill retail) Fondaparinux Sodium) terbutaline sulfate tabs F Limit 3 fills per 180 Limit 1 enoxaparin sodium soln ij F days;QL(42 ml 300 mg/3ml VENTOLIN HFA AERS F package per per 7 days Claim, 2 per retail); SP Month Limit 3 fills per VOSPIRE ER TB12 (Use *** 180 Albuterol Sulfate) enoxaparin sodium soln sc F days;QL(14 ml XOPENEX PA 150 mg/ml, 100 mg/ml per 7 days CONCENTRATE NEBU *** retail); SP (Use Levalbuterol HCl) Limit 3 fills per PA XOPENEX HFA AERO F enoxaparin sodium soln sc F 180 days;QL(5 30 mg/0.3ml ml per 7 days XOPENEX NEBU (Use *** PA retail); SP Levalbuterol HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 3 fills per AMPA Glutamate Receptor Antagonists enoxaparin sodium soln sc F 180 days;QL(6 40 mg/0.4ml ml per 7 days FYCOMPA TABS F PA retail); SP Limit 3 fills per Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1 QL(4 ea daily) enoxaparin sodium soln sc F 180 days;QL(9 F 60 mg/0.6ml ml per 7 days mg, 2 mg retail); SP clonazepam tbdp 0.5 mg, 2 PA Limit 3 fills per mg, 0.125 mg, 1 mg, 0.25 F 180 mg enoxaparin sodium soln sc F days;QL(12 ml 80 mg/0.8ml, 120 mg/0.8ml QL(1 ea per fill per 7 days DIASTAT ACUDIAL GEL F retail); AL; At retail); SP least 2 yrs old fondaparinux sodium soln F PA; SP QL(1 ea per fill DIASTAT PEDIATRIC GEL F retail); AL; At heparin sodium (porcine) F least 2 yrs old soln QL(1 ea per fill Limit 3 fills per DIAZEPAM GEL RE 10 F retail); AL; At LOVENOX SOLN IJ 300 180 MG, 20 MG, 2.5 MG least 2 yrs old MG/3ML (Use Enoxaparin *** days;QL(42 ml QL(1 ea per fill Sodium) per 7 days DIAZEPAM RECTAL GEL F retail); AL; At retail); SP GEL least 2 yrs old Limit 3 fills per KLONOPIN TABS (Use *** QL(4 ea daily) LOVENOX SOLN SC 150 180 Clonazepam) MG/ML, 100 MG/ML (Use *** days;QL(14 ml Enoxaparin Sodium) per 7 days ONFI SUSP F PA retail); SP PA Limit 3 fills per ONFI TABS F LOVENOX SOLN SC 30 180 days;QL(5 MG/0.3ML (Use *** Anticonvulsants - Misc. Enoxaparin Sodium) ml per 7 days retail); SP APTIOM TABS F PA Limit 3 fills per LOVENOX SOLN SC 40 180 days;QL(6 PA; SP MG/0.4ML (Use *** BANZEL SUSP F Enoxaparin Sodium) ml per 7 days retail); SP BANZEL TABS F PA; SP Limit 3 fills per LOVENOX SOLN SC 60 180 days;QL(9 MG/0.6ML (Use *** carbamazepine chew F Enoxaparin Sodium) ml per 7 days retail); SP carbamazepine cp12 F Limit 3 fills per LOVENOX SOLN SC 80 180 carbamazepine susp F MG/0.8ML, 120 MG/0.8ML *** days;QL(12 ml (Use Enoxaparin Sodium) per 7 days carbamazepine tabs F retail); SP Thrombin Inhibitors carbamazepine tb12 F PA PRADAXA CAPS F CARBATROL CP12 (Use F Carbamazepine) ANTICONVULSANTS - Drugs to Treat Seizures ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gabapentin caps 300 mg, F QL(4 ea daily) LYRICA CAPS F PA 100 mg, 400 mg MYSOLINE TABS (Use gabapentin soln 250 F *** mg/5ml, 300 mg/6ml Primidone) NEURONTIN CAPS 400 QL(4 ea daily) gabapentin tabs 600 mg, F QL(4 ea daily) 800 mg MG, 300 MG, 100 MG (Use *** KEPPRA SOLN 100 QL(16 ml daily) Gabapentin) MG/ML (Use *** NEURONTIN SOLN 250 *** Levetiracetam) MG/5ML (Use Gabapentin) KEPPRA TABS 250 MG, QL(4 ea daily) NEURONTIN TABS 800 QL(4 ea daily) 750 MG, 1000 MG, 500 *** MG, 600 MG (Use *** MG (Use Levetiracetam) Gabapentin) KEPPRA XR TB24 (Use *** PA oxcarbazepine susp F Levetiracetam) LAMICTAL CHEWABLE oxcarbazepine tabs F DISPERSIBLE CHEW (Use *** Lamotrigine) POTIGA TABS F PA LAMICTAL ODT KIT (Use *** PA Lamotrigine) primidone tabs F LAMICTAL ODT TBDP *** PA PA (Use Lamotrigine) QUDEXY XR CS24 F LAMICTAL TABS (Use *** TEGRETOL SUSP (Use F Lamotrigine) Carbamazepine) PA LAMICTAL XR KIT F TEGRETOL TABS (Use F Carbamazepine) LAMICTAL XR TB24 50 PA; QL(1 ea TEGRETOL-XR TB12 (Use F MG, 300 MG, 25 MG, 200 *** daily) Carbamazepine) MG, 100 MG, 250 MG (Use Lamotrigine) TOPAMAX SPRINKLE QL(6 ea daily) CPSP 15 MG (Use *** lamotrigine chew 5 mg, 25 F Topiramate) mg TOPAMAX SPRINKLE QL(8 ea daily) lamotrigine kit F PA CPSP 25 MG (Use *** Topiramate) lamotrigine tabs 150 mg, F 200 mg, 25 mg, 100 mg TOPAMAX TABS (Use *** QL(3 ea daily) Topiramate) lamotrigine tb24 250 mg, PA; QL(1 ea 300 mg, 100 mg, 200 mg, F daily) topiramate cpsp 15 mg F QL(6 ea daily) 25 mg, 50 mg topiramate cpsp 25 mg F QL(8 ea daily) lamotrigine tbdp 200 mg, F PA 25 mg, 100 mg, 50 mg TOPIRAMATE ER CS24 F PA levetiracetam soln 500 F QL(16 ml daily) mg/5ml, 100 mg/ml topiramate tabs 25 mg, 100 F QL(3 ea daily) levetiracetam tabs 1000 QL(4 ea daily) mg, 200 mg, 50 mg mg, 750 mg, 250 mg, 500 F TRILEPTAL SUSP (Use *** mg Oxcarbazepine) levetiracetam tb24 500 mg, PA F TRILEPTAL TABS (Use *** 750 mg Oxcarbazepine) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TROKENDI XR CP24 F PA phenytoin chew F

VIMPAT SOLN F PA phenytoin sodium extended F caps PA VIMPAT TABS F phenytoin susp F ZONEGRAN CAPS (Use *** Succinimides Zonisamide) CELONTIN CAPS F PA zonisamide caps F Carbamates ethosuximide caps F felbamate susp F ethosuximide soln F felbamate tabs F ZARONTIN CAPS (Use F Ethosuximide) FELBATOL SUSP (Use *** ZARONTIN SOLN (Use F Felbamate) Ethosuximide) FELBATOL TABS (Use *** Valproic Acid Felbamate) DEPAKENE CAPS (Use F GABA Modulators Valproic Acid) GABITRIL TABS 12 MG, F DEPAKOTE ER TB24 (Use *** 16 MG Divalproex Sodium) GABITRIL TABS 4 MG, 2 *** DEPAKOTE SPRINKLES MG (Use Tiagabine HCl) CSDR (Use Divalproex *** Sodium) SABRIL PACK (Use *** PA; SP Vigabatrin) DEPAKOTE TBEC (Use *** SABRIL TABS F PA; SP Divalproex Sodium) divalproex sodium csdr F tiagabine hcl tabs F divalproex sodium tb24 F vigabatrin pack F PA; SP divalproex sodium tbec F Hydantoins DILANTIN CAPS 100 MG valproic acid caps F (Use Phenytoin Sodium F Extended) ANTIDEPRESSANTS - Drugs to Treat Depression DILANTIN CAPS 30 MG F Alpha-2 Receptor Antagonists (Tetracyclics) DILANTIN INFATABS F mirtazapine tabs F QL(1 ea daily) CHEW (Use Phenytoin) QL(1 ea daily) DILANTIN-125 SUSP (Use F mirtazapine tbdp F Phenytoin) PA REMERON SOLTAB TBDP *** QL(1 ea daily) PEGANONE TABS F (Use Mirtazapine) PHENYTEK CAPS (Use REMERON TABS (Use *** QL(1 ea daily) Phenytoin Sodium F Mirtazapine) Extended) Antidepressants - Misc. ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APLENZIN TB24 F PA fluoxetine hcl caps 20 mg, F QL(4 ea daily) 10 mg bupropion hcl tabs 75 mg, F QL(3 ea daily) QL(2 ea daily) 100 mg fluoxetine hcl caps 40 mg F bupropion hcl tb12 200 mg, F QL(2 ea daily) fluoxetine hcl soln 20 F QL(120 ml per 100 mg, 150 mg mg/5ml 30 days retail) FORFIVO XL TB24 F PA QL(1 ea daily); fluoxetine hcl tabs 10 mg F AL; At least 7 yrs old F Limit 2 fills per MAPROTILINE HCL TABS month fluoxetine hcl tabs 20 mg F QL(4 ea daily) WELLBUTRIN SR TB12 *** QL(2 ea daily) (Use Bupropion HCl) fluoxetine hcl tabs 60 mg F PA WELLBUTRIN TABS (Use *** QL(3 ea daily) Bupropion HCl) FLUOXETINE HCL TABS F PA 60 MG Monoamine Oxidase Inhibitors (MAOIs) FLUOXETINE HCL TABS PA EMSAM PT24 9 MG/24HR F PA 60 MG (Use Fluoxetine *** HCl) MARPLAN TABS F PA fluvoxamine maleate cp24 F PA 100 mg, 150 mg NARDIL TABS (Use *** Phenelzine Sulfate) fluvoxamine maleate tabs F QL(3 ea daily) 100 mg PARNATE TABS (Use *** Tranylcypromine Sulfate) fluvoxamine maleate tabs F QL(2 ea daily) 50 mg, 25 mg phenelzine sulfate tabs F LEXAPRO SOLN 5 PA MG/5ML (Use Escitalopram *** tranylcypromine sulfate F tabs Oxalate) LEXAPRO TABS 20 MG, 5 QL(1 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs) MG, 10 MG (Use *** CELEXA TABS 20 MG, 10 QL(2 ea daily) Escitalopram Oxalate) MG (Use Citalopram *** paroxetine hcl tabs 30 mg, F QL(2 ea daily) Hydrobromide) 10 mg, 20 mg, 40 mg CELEXA TABS 40 MG QL(1 ea daily) paroxetine hcl tb24 37.5 F PA; QL(40 ea (Use Citalopram *** mg, 12.5 mg, 25 mg daily) Hydrobromide) PAXIL CR TB24 (Use *** PA; QL(40 ea citalopram hydrobromide F Paroxetine HCl) daily) soln 10 mg/5ml PAXIL SUSP 10 MG/5ML F QL(40 ml daily) citalopram hydrobromide F QL(2 ea daily) tabs 20 mg, 10 mg PAXIL TABS 10 MG, 30 QL(2 ea daily) citalopram hydrobromide F QL(1 ea daily) MG, 40 MG, 20 MG (Use *** tabs 40 mg Paroxetine HCl) escitalopram oxalate soln 5 F PA PA mg/5ml PEXEVA TABS F escitalopram oxalate tabs F QL(1 ea daily) PROZAC CAPS 20 MG, 10 *** QL(4 ea daily) 10 mg, 5 mg, 20 mg MG (Use Fluoxetine HCl) FLUOXETINE DR CPDR F PA PROZAC CAPS 40 MG *** QL(2 ea daily) (Use Fluoxetine HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROZAC WEEKLY CPDR *** PA FETZIMA CP24 F PA (Use Fluoxetine HCl) FETZIMA TITRATION PA sertraline hcl conc 20 F F mg/ml PACK C4PK PA sertraline hcl tabs 100 mg, F QL(2 ea daily) KHEDEZLA TB24 F 25 mg, 50 mg PRISTIQ TB24 (Use PA ZOLOFT CONC 20 MG/ML *** *** (Use Sertraline HCl) Desvenlafaxine Succinate) ZOLOFT TABS 50 MG, QL(2 ea daily) venlafaxine hcl cp24 150 F QL(2 ea daily) 100 MG, 25 MG (Use *** mg, 75 mg Sertraline HCl) venlafaxine hcl cp24 37.5 F QL(1 ea daily) mg Serotonin Modulators VENLAFAXINE HCL ER QL(1 ea daily) PA; QL(1 ea TB24 150 MG, 75 MG, 37.5 *** BRINTELLIX TABS F daily); AL; At MG (Use Venlafaxine HCl) least 18 yrs old VENLAFAXINE HCL ER F QL(1 ea daily) NEFAZODONE HCL TABS F TB24 225 MG 200 MG, 150 MG, 100 MG venlafaxine hcl tabs 25 mg, nefazodone hcl tabs 50 F 100 mg, 37.5 mg, 50 mg, F mg, 250 mg 75 mg QL(2 ea daily) trazodone hcl tabs 300 mg F venlafaxine hcl tb24 75 mg, F QL(1 ea daily) 37.5 mg, 225 mg, 150 mg trazodone hcl tabs 50 mg, F 100 mg, 150 mg Tricyclic Agents PA; QL(1 ea amitriptyline hcl tabs F TRINTELLIX TABS F daily); AL; At least 18 yrs old AMOXAPINE TABS F VIIBRYD TABS F PA; QL(1 ea daily) ANAFRANIL CAPS (Use *** PA Clomipramine HCl) Serotonin-Norepinephrine Reuptake Inhibitors PA QL(2 ea daily); clomipramine hcl caps F CYMBALTA CPEP (Use *** ) AL; At least 7 QL(2 ea daily) Duloxetine HCl yrs old desipramine hcl tabs 25 mg F DESVENLAFAXINE ER F PA desipramine hcl tabs 75 TB24 100 MG, 50 MG mg, 10 mg, 100 mg, 150 F mg, 50 mg DESVENLAFAXINE ER F PA TB24 50 MG, 100 MG doxepin hcl caps F desvenlafaxine succinate F PA tb24 doxepin hcl conc F QL(2 ea daily); duloxetine hcl cpep 20 mg, F AL; At least 7 ELAVIL TABS (Use *** 30 mg, 60 mg yrs old Amitriptyline HCl) EFFEXOR XR CP24 150 QL(2 ea daily) imipramine hcl tabs F MG, 75 MG (Use *** Venlafaxine HCl) imipramine pamoate caps F QL(3 ea daily) 100 mg EFFEXOR XR CP24 37.5 *** QL(1 ea daily) MG (Use Venlafaxine HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits imipramine pamoate caps F QL(2 ea daily) ACTOPLUS MET XR TB24 F PA 125 mg, 150 mg ALOGLIPTIN/METFORMIN PA; QL(2 ea imipramine pamoate caps F QL(1 ea daily) F 75 mg HCL TABS daily) ALOGLIPTIN/PIOGLITAZO PA; QL(1 ea NORPRAMIN TABS 25 MG *** QL(2 ea daily) F (Use Desipramine HCl) NE TABS daily) NORPRAMIN TABS 50 DUETACT TABS (Use PA Pioglitazone HCl- *** MG, 75 MG, 100 MG, 150 *** MG, 10 MG (Use Glimepiride) Desipramine HCl) glipizide-metformin hcl tabs F nortriptyline hcl caps 75 F mg, 25 mg, 50 mg, 10 mg GLUCOVANCE TABS (Use *** Glyburide-Metformin) NORTRIPTYLINE HCL F QL(20 ml daily) SOLN 10 MG/5ML glyburide-metformin tabs F PAMELOR CAPS (Use *** Nortriptyline HCl) INVOKAMET TABS F PA protriptyline hcl tabs 10 mg F JANUMET TABS F PA SURMONTIL CAPS (Use *** PA Trimipramine Maleate) JANUMET XR TB24 F PA TOFRANIL TABS (Use *** QL(2 ea daily) Imipramine HCl) JENTADUETO TABS F PA trimipramine maleate caps F F PA; QL(2 ea JENTADUETO XR TB24 daily) ANTIDIABETICS - Drugs to Regulate Blood Sugar KAZANO TABS (Use *** Alogliptin-Metformin HCl) Alpha-Glucosidase Inhibitors KOMBIGLYZE XR TB24 F PA; QL(2 ea acarbose tabs F QL(3 ea daily) daily) OSENI TABS (Use *** GLYSET TABS (Use *** PA Alogliptin-Pioglitazone) Miglitol) pioglitazone hcl-glimepiride F PA miglitol tabs F PA tabs pioglitazone hcl-metformin F QL(2 ea daily) PRECOSE TABS (Use *** QL(3 ea daily) hcl tabs Acarbose) PRANDIMET TABS (Use PA Antidiabetic - Amylin Analogs Repaglinide-Metformin *** PA; QL(10.8 ml HCl) SYMLINPEN 120 SOPN F per 30 days REPAGLINIDE/METFORM PA retail) IN HYDROCHLORIDE F PA; QL(6 ml TABS SYMLINPEN 60 SOPN F per 30 days Biguanides retail) FORTAMET TB24 (Use *** PA Antidiabetic Combinations Metformin HCl) ACTOPLUS MET TABS QL(2 ea daily) GLUCOPHAGE TABS 500 *** QL(4 ea daily) (Use Pioglitazone HCl- *** MG (Use Metformin HCl) Metformin HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPHAGE TABS 850 Limit 1 package *** MG, 1000 MG (Use GLUCAGON F per claim, 1 Metformin HCl) EMERGENCY KIT KIT claim per GLUCOPHAGE XR TB24 QL(4 ea daily) month *** 500 MG (Use Metformin F QL(50 ea per HCl) GLUCOSE CHEW 4 GM 30 days retail) GLUCOPHAGE XR TB24 QL(3 ea daily) GLUCOSE CHEW 4GM- F 750 MG (Use Metformin *** 6MG, 4GM-4GM-6MG HCl) GLUCOSE INSTANT F GLUMETZA TB24 (Use *** PA ENERGY CHEW Metformin HCl) GNP GLUCOSE CHEW 4 F QL(50 ea per metformin hcl tabs 500 mg F QL(4 ea daily) GM 30 days retail) GNP GLUCOSE CHEW F metformin hcl tabs 850 mg, F 4GM-6MG 1000 mg GNP QUICK DISSOLVE F QL(50 ea per metformin hcl tb24 1000 F PA GLUCOSE CHEW 30 days retail) mg, 500 mg GOODSENSE GLUCOSE F metformin hcl tb24 500 mg F QL(4 ea daily) CHEW HM GLUCOSE CHEW F metformin hcl tb24 750 mg F QL(3 ea daily) Diabetic Other HY-VEE GLUCOSE CHEW F PA; SP F QL(50 ea per KORLYM TABS F BD GLUCOSE CHEW 30 days retail) KROGER GLUCOSE CVS GLUCOSE CHEW 4 F QL(50 ea per F GM 30 days retail) CHEW LEADER GLUCOSE CVS GLUCOSE CHEW F F 4GM-6MG CHEW LEADER QUICK QL(50 ea per DEX4 CHEW F DISSOLVE GLUCOSE F 30 days retail) CHEW DEX4 FAST ACTING F GLUCOSE CHEW LONGS GLUCOSE CHEW F DEX4 NATURALS CHEW F MEIJER GLUCOSE CHEW F DEX4 POUCH PACK F CHEW PREFERRED PLUS F GLUCOSE CHEW DEX4 QUICK DISSOLVE F QL(50 ea per GLUCOSE CHEW 30 days retail) PROGLYCEM SUSP F PA dextrose (diabetic use) gel F PX GLUCOSE CHEW F Limit 1 RA GLUCOSE CHEW F GLUCAGEN HYPOKIT F package per SOLR claim, 1 claim per month RELION GLUCOSE CHEW F

SM GLUCOSE CHEW 4 F QL(50 ea per GM 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM GLUCOSE CHEW F F PA; QL(1.8 ml 4GM-6MG VICTOZA SOPN daily) SMART SENSE F Insulin Sensitizing Agents GLUCOSE CHEW ACTOS TABS (Use *** QL(1 ea daily) SMART SENSE Pioglitazone HCl) GLUCOSE TABLETS F CHEW F PA; QL(1 ea AVANDIA TABS daily) F TGT GLUCOSE CHEW pioglitazone hcl tabs F QL(1 ea daily) UP & UP GLUCOSE F CHEW Insulin PA VALUE PLUS GLUCOSE F AFREZZA POWD F CHEW QL(40 ml per WALGREENS GLUCOSE F QL(50 ea per APIDRA SOLN F CHEW 4 GM 30 days retail) 30 days retail) APIDRA SOLOSTAR WALGREENS GLUCOSE F F CHEW 4GM-6MG SOPN BASAGLAR KWIKPEN F QL(30 ml per Dipeptidyl Peptidase-4 (DPP-4) Inhibitors SOPN 30 days retail) PA; QL(1 ea ALOGLIPTIN TABS F FIASP FLEXTOUCH F QL(30 ml per daily) SOPN 30 days retail) PA JANUVIA TABS F F QL(40 ml per FIASP SOLN 30 days retail) NESINA TABS (Use *** QL(1 ea daily) Alogliptin Benzoate) HUMALOG JUNIOR F QL(30 ml per KWIKPEN SOPN 30 days retail) ONGLYZA TABS F PA HUMALOG KWIKPEN F QL(30 ml per SOPN 100 UNIT/ML 30 days retail) TRADJENTA TABS F PA HUMALOG MIX 50/50 F QL(30 ml per KWIKPEN SUPN 30 days retail) Incretin Mimetic Agents (GLP-1 Receptor HUMALOG MIX 50/50 F QL(40 ml per PA; QL(4 ea SUSP 30 days retail) BYDUREON PEN PEN F per 28 days retail); AL; At HUMALOG MIX 75/25 F QL(30 ml per least 18 yrs old KWIKPEN SUPN 30 days retail) PA; QL(4 ea HUMALOG MIX 75/25 F QL(40 ml per SUSP 30 days retail) BYDUREON SRER F per 28 days retail); AL; At HUMALOG SOCT F QL(30 ml per least 18 yrs old 30 days retail) PA; QL(2.4 ml F QL(40 ml per HUMALOG SOLN 30 days retail) BYETTA SOPN 10 F per 30 days MCG/0.04ML retail); AL; At HUMULIN 70/30 KWIKPEN F QL(30 ml per least 18 yrs old SUPN 30 days retail) PA; QL(1.2 ml HUMULIN 70/30 SUSP F QL(40 ml per BYETTA SOPN 5 F per 30 days 30 days retail) MCG/0.02ML retail); AL; At HUMULIN N KWIKPEN F QL(30 ml per least 18 yrs old SUPN 30 days retail) TANZEUM PEN F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(40 ml per nateglinide tabs F QL(3 ea daily) HUMULIN N SUSP 30 days retail) PRANDIN TABS (Use PA F QL(40 ml per *** HUMULIN R SOLN 30 days retail) Repaglinide) PA HUMULIN R U-500 F repaglinide tabs F (CONCENTRATED) SOLN STARLIX TABS (Use QL(3 ea daily) HUMULIN R U-500 F *** KWIKPEN SOPN Nateglinide) Sodium-Glucose Co-Transporter 2 (SGLT2) LANTUS 100 UNIT/ML *** Use preferred SOLN BASAGLAR INVOKANA TABS F PA LANTUS SOLOSTAR 100 PA; Use *** preferred JARDIANCE TABS F PA; QL(1 ea UNIT/ML SOPN BASAGLAR daily) PA; QL(2 ml Sulfonylureas LEVEMIR FLEXTOUCH F daily,30 ml per SOPN AMARYL TABS 2 MG, 1 *** QL(1 ea daily) 30 days retail) MG (Use Glimepiride) LEVEMIR SOLN F PA AMARYL TABS 4 MG (Use *** QL(2 ea daily) Glimepiride) NOVOLIN 70/30 RELION F QL(40 ml per SUSP 30 days retail) CHLORPROPAMIDE F TABS NOVOLIN 70/30 SUSP F QL(40 ml per 30 days retail) DIABETA TABS F NOVOLIN N RELION F QL(40 ml per QL(1 ea daily) SUSP 30 days retail) glimepiride tabs 2 mg, 1 mg F F QL(40 ml per QL(2 ea daily) NOVOLIN N SUSP 30 days retail) glimepiride tabs 4 mg F NOVOLIN R RELION F QL(40 ml per glipizide tabs F SOLN 30 days retail) F QL(40 ml per glipizide tb24 F NOVOLIN R SOLN 30 days retail) GLUCOTROL TABS (Use NOVOLOG FLEXPEN F QL(30 ml per *** SOPN 30 days retail) Glipizide) NOVOLOG MIX 70/30 QL(30 ml per GLUCOTROL XL TB24 *** PREFILLED FLEXPEN F 30 days retail) (Use Glipizide) SUPN glyburide micronized tabs F NOVOLOG MIX 70/30 F QL(40 ml per SUSP 30 days retail) glyburide tabs F NOVOLOG PENFILL F QL(30 ml per SOCT 30 days retail) GLYNASE TABS (Use *** Glyburide Micronized) F QL(40 ml per NOVOLOG SOLN 30 days retail) TOLAZAMIDE TABS F TOUJEO SOLOSTAR F PA SOPN TOLBUTAMIDE TABS F TRESIBA FLEXTOUCH F PA SOPN ANTIDIARRHEALS - Drugs to Treat Diarrhea Meglitinide Analogues Antidiarrheal - Chloride Channel Antagonists

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FULYZAQ TBEC F PA CVS ADULT PROBIOTIC F CAPS PA MYTESI TBEC F CVS DIGESTIVE F PROBIOTIC CAPS Antidiarrheal Agents - Misc. CVS PROBIOTIC CAPS F ACIDOPHILUS CAPS F CVS PROBIOTIC MAXIMUM STRENGTH F ACIDOPHILUS HIGH- F POTENCY CAPS CAPS CVS PROBIOTIC PEARLS ACIDOPHILUS PEARLS F F CAPS EXTRA STRENGTH CAPS CVS SENIOR PROBIOTIC ACIDOPHILUS F F PROBIOTIC BLEND CAPS CAPS ACIDOPHILUS SUPER F DAILY PROBIOTIC CAPS F PROBIOTIC CAPS ACIDOPHILUS/GOAT F DIFF-STAT CAPS F MILK CAPS DIGESTIVE ADVANTAGE ADVANCED PROBIOTIC F F 10 CAPS CAPS DIGESTIVE ADVANTAGE ADVANCED PROBIOTIC F LACTOSE DEFENSE F CAPS FORMULA CAPS ALIGN CAPS F EQ PROBIOTIC DIGESTIVE SYSTEM F BIOHM PROBIOTIC F SUPPORT CAPS SUPPLEMENT CAPS EQL ACIDOPHILUS F BIOHM PROBIOTIC EXTRA STRENGTH CAPS SUPPLEMENT/VITAMIN C F CAPS EQL DAILY PROBIOTIC F CAPS bismuth subsalicylate chew F 262 mg EQL PROBIOTIC COLON F SUPPORT CAPS bismuth subsalicylate susp F 525 mg/15ml FLORA VANCE CAPS F bismuth subsalicylate tabs F 262 mg FLORA-Q 2 CAPS F CHILDRENS PROBIOTIC F PEARLS CAPS FLORA-Q CAPS F CULTURELLE FLORAJEN ACIDOPHILUS F ADVANCED IMMUNE F CAPS DEFENSE CAPS FLORAJEN BIFIDOBLEND F CULTURELLE PRO-WELL F CAPS CAPS CVS ACIDOPHILUS FLORAJEN3 CAPS F PROBIOTICFORMULA F TABS FLORAJEN4KIDS CAPS F CVS ADULT 50+ F FORTIFY DAILY F PROBIOTIC CAPS PROBIOTIC CAPS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ACIDOPHILUS HIGH F PROBIOTIC + OMEGA-3 F POTENCY CAPS CAPS GNP PROBIOTIC COLON F PROBIOTIC SUPPORT CAPS ACIDOPHILUS BEADS F CAPS HM ACIDOPHILUS CAPS F PROBIOTIC F LACTO-PECTIN CAPS F ACIDOPHILUS CAPS PROBIOTIC ADVANCED F lactobacillus caps F ULTRAPOTENCY CAPS PROBIOTIC CAPS F lactobacillus tabs F PROBIOTIC COLON F MEGA PROBIOTIC CAPS F SUPPORT CAPS PROBIOTIC META BIOTIC/BIO- F COMPLEX/ACIDOPHILUS F ACTIVE 12 CAPS CAPS NATRUL PROBIOTIC F CAPS PROBIOTIC DAILY CAPS F

PEARLS IC CAPS F PROBIOTIC GOLD EXTRA F STRENGTH CAPS PEPTO BISMOL TABS PROBIOTIC MATURE F (Use Bismuth *** ADULT CAPS Subsalicylate) PROBIOTIC PEARLS F PEPTO-BISMOL CHEW ADVANTAGE CAPS 262 MG (Use Bismuth *** Subsalicylate) PROBIOTIC PEARLS F CAPS PEPTO-BISMOL INSTACOOL CHEW (Use *** PROBIOTIC-10 CAPS F Bismuth Subsalicylate) PEPTO-BISMOL MAX PROBIOTIC-10 ULTIMATE F STRENGTH SUSP (Use *** CAPS Bismuth Subsalicylate) RA PROBIOTIC COLON F PEPTO-BISMOL TO-GO CARE CAPS CHEW (Use Bismuth *** RA PROBIOTIC F Subsalicylate) COMPLEX CAPS PHILLIPS COLON F REPHRESH PRO-B CAPS F HEALTH CAPS PREORBOTIC CAPS F RESTORA CAPS F

PRO-BIOTIC BLEND F RISAQUAD CAPS F CAPS RISAQUAD-2 CAPS F PRO-FLORA IMMUNE F CAPS SM ACIDOPHILUS F PROBIOMAX DAILY DF F PEARLS CAPS CAPS PROBIOTIC & SUPER PROBIOTIC CAPS F ACIDOPHILUS FORMULA F EXTRA STRENGTH CAPS ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPER PROBIOTIC MOTOFEN TABS F PA DIGESTIVE SUPPORT F CAPS opium tincture tinc F PA TRUBIOTICS CAPS F PAREGORIC TINC F PA TRUNATURE DIGESTIVE F PROBIOTIC CAPS ANTIDOTES AND SPECIFIC ANTAGONISTS ULTRAFLORA IMMUNE F HEALTH CAPS Antidotes - Chelating Agents VISBIOME PROBIOTIC F CHEMET CAPS F HIGH POTENCY CAPS PA; SP VSL#3 CAPS F EXJADE TBSO F PA; SP Antidiarrheal Combinations FERRIPROX TABS F ACIDOPHILUS PLUS F PA; SP PECTIN TABS JADENU TABS F ACIDOPHILUS/CITRUS F Antidotes and Specific Antagonists PECTIN TABS SM IPECAC SYRUP SYRP F IMODIUM MULTI- F SYMPTOM RELIEF TABS VISTOGARD PACK F KALA TABS F Opioid Antagonists loperamide-simethicone F tabs EVZIO SOAJ F PA Antiperistaltic Agents NALOXONE HCL SOCT F 0.4 MG/ML diphenoxylate w/ atropine F tabs naloxone hcl soln 4 F mg/10ml, 0.4 mg/ml DIPHENOXYLATE/ATROP F INE LIQD NALOXONE HCL SOSY 2 F QL(4 ml per 90 MG/2ML days retail) IMODIUM A-D CAPS 2 MG *** RX/OTC (Use Loperamide HCl) naltrexone hcl tabs F IMODIUM A-D LIQD 1 MG/7.5ML (Use *** F QL(2 ea per 60 Loperamide HCl) NARCAN LIQD days retail) IMODIUM A-D TABS 2 MG *** QL(2 ea daily) VIVITROL SUSR F SP (Use Loperamide HCl) LOMOTIL TABS (Use *** ANTIEMETICS - Drugs to Treat Nausea and Diphenoxylate w/ Atropine) Vomiting loperamide hcl caps 2 mg F RX/OTC 5-HT3 Receptor Antagonists ANZEMET TABS F PA loperamide hcl liqd 1 F mg/7.5ml, 1 mg/5ml granisetron hcl tabs F PA loperamide hcl susp 1 F mg/7.5ml ondansetron hcl soln ij 40 F loperamide hcl tabs 2 mg F QL(2 ea daily) mg/20ml, 4 mg/2ml

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ondansetron hcl soln or 4 F QL(50 ml per EMETROL SOLN (Use mg/5ml 30 days retail) Fructose-Dextrose- *** Phosphoric Acid) ondansetron hcl tabs or 24 F QL(1 ea per 14 mg days retail) fructose-dextrose- F phosphoric acid liqd ondansetron hcl tabs or 4 F QL(2 ea daily) mg, 8 mg fructose-dextrose- F phosphoric acid soln ondansetron tbdp F QL(2 ea daily) MARINOL CAPS (Use *** SANCUSO PTCH F PA Dronabinol) Substance P/Neurokinin 1 (NK1) Receptor ZOFRAN ODT TBDP (Use *** QL(2 ea daily) Ondansetron) aprepitant caps F PA ZOFRAN SOLN 4 MG/5ML QL(50 ml per *** EMEND CAPS (Use *** PA (Use Ondansetron HCl) 30 days retail) Aprepitant) ZOFRAN TABS 8 MG, 4 QL(2 ea daily) EMEND TRIPACK CAPS *** PA MG (Use Ondansetron *** (Use Aprepitant) HCl) ZUPLENZ FILM F PA ANTIFUNGALS - Drugs to Treat Fungal Infections Antifungals Antiemetics - Anticholinergic ANCOBON CAPS (Use *** PA F QL(24 ea per Flucytosine) dimenhydrinate tabs fill retail) flucytosine caps F PA F QL(24 ea per DRAMAMINE CHEW fill retail) GRIFULVIN V TABS (Use *** DRAMAMINE TABS (Use *** QL(24 ea per Griseofulvin Microsize) Dimenhydrinate) fill retail) GRIS-PEG TABS (Use *** meclizine hcl chew 25 mg F Griseofulvin Ultramicrosize) griseofulvin microsize susp F meclizine hcl tabs 12.5 mg, F RX/OTC 25 mg griseofulvin microsize tabs F scopolamine pt72 F PA griseofulvin ultramicrosize F TIGAN CAPS (Use *** tabs Trimethobenzamide HCl) LAMISIL PACK 125 MG, F PA TRANSDERM-SCOP PT72 F PA 187.5 MG QL(1 ea TRANSDERM-SCOP PT72 PA LAMISIL TABS 250 MG *** *** ) daily,90 ea per (Use Scopolamine) (Use Terbinafine HCl 120 days retail) trimethobenzamide hcl F QL(6 ea daily) caps nystatin tabs F Antiemetics - Miscellaneous QL(1 ea PA terbinafine hcl tabs F daily,90 ea per CESAMET CAPS F 120 days retail) DICLEGIS TBEC F PA Imidazole-Related Antifungals DIFLUCAN SUSR 10 *** QL(70 ml per dronabinol caps F MG/ML (Use Fluconazole) fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIFLUCAN SUSR 40 *** CHLOR-TRIMETON MG/ML (Use Fluconazole) ALLERGY TBCR (Use *** Chlorpheniramine Maleate) DIFLUCAN TABS 100 MG, *** 200 MG (Use Fluconazole) CHLOR-TRIMETON SYRP 2 MG/5ML (Use *** DIFLUCAN TABS 150 MG *** QL(2 ea per fill (Use Fluconazole) retail) Chlorpheniramine Maleate) CHLOR-TRIMETON TABS QL(120 ea per DIFLUCAN TABS 50 MG *** QL(3 ea per 14 (Use Fluconazole) days retail) 4 MG (Use *** fill retail) Chlorpheniramine Maleate) QL(70 ml per fluconazole susr 10 mg/ml F fill retail) chlorpheniramine maleate F syrp 2 mg/5ml fluconazole susr 40 mg/ml F chlorpheniramine maleate F QL(120 ea per QL(2 ea per fill tabs 4 mg fill retail) fluconazole tabs 150 mg F retail) chlorpheniramine maleate F tbcr 12 mg fluconazole tabs 200 mg, F 100 mg ED CHLORPED LIQD F F QL(3 ea per 14 fluconazole tabs 50 mg days retail) Antihistamines - Ethanolamines itraconazole caps F PA ALER-DRYL TABS F QL(4 ea daily) ketoconazole tabs F QL(1 ea daily) BENADRYL ALLERGY QL(4 ea daily) CAPS (Use *** Diphenhydramine HCl) NOXAFIL SUSP F PA BENADRYL ALLERGY NOXAFIL TBEC F PA CHILDRENS CHEW 12.5 F MG ONMEL TABS F PA BENADRYL ALLERGY QL(240 ml per CHILDRENS LIQD 12.5 *** fill retail) SPORANOX CAPS 100 *** PA MG/5ML (Use MG (Use Itraconazole) Diphenhydramine HCl) SPORANOX PULSEPAK *** PA BENADRYL ALLERGY QL(4 ea daily) CAPS (Use Itraconazole) TABS (Use *** Diphenhydramine HCl) SPORANOX SOLN 10 F PA MG/ML carbinoxamine maleate F PA tabs VFEND SUSR (Use *** PA Voriconazole) clemastine fumarate tabs F QL(2 ea daily) 1.34 mg VFEND TABS (Use *** PA Voriconazole) CLEMASTINE FUMARATE F TABS 2.68 MG voriconazole susr F PA clemastine fumarate tabs F voriconazole tabs F PA 2.68 mg diphenhydramine hcl caps F QL(4 ea daily) ANTIHISTAMINES - Drugs to Treat Allergies 25 mg diphenhydramine hcl caps F QL(4 ea daily); Antihistamines - Alkylamines 50 mg RX/OTC diphenhydramine hcl chew F 12.5 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per diphenhydramine hcl elix CLARITIN REDITABS QL(1 ea daily) F fill retail); TBDP 10 MG (Use *** 12.5 mg/5ml RX/OTC Loratadine) diphenhydramine hcl liqd QL(240 ml per CLARITIN REDITABS F PA 12.5 mg/5ml, 50 mg/20ml, F fill retail) TBDP 5 MG 25 mg/10ml CLARITIN SYRP 5 *** QL(240 ml per diphenhydramine hcl syrp F QL(240 ml per MG/5ML (Use Loratadine) fill retail) 12.5 mg/5ml fill retail) CLARITIN TABS 10 MG *** QL(1 ea daily) diphenhydramine hcl tabs F QL(4 ea daily) (Use Loratadine) 25 mg DESLORATADINE ODT F PA F QL(240 ml per TBDP SILPHEN COUGH SYRP fill retail) desloratadine tabs F PA TAVIST ALLERGY TABS QL(2 ea daily) (Use Clemastine *** fexofenadine hcl susp F Fumarate) Antihistamines - Non-Sedating fexofenadine hcl tabs F ALLEGRA ALLERGY levocetirizine F PA; RX/OTC CHILDRENS SUSP (Use *** dihydrochloride tabs Fexofenadine HCl) ALLEGRA ALLERGY loratadine caps 10 mg F TABS (Use Fexofenadine *** HCl) F QL(240 ml per loratadine soln 5 mg/5ml fill retail) cetirizine hcl caps 10 mg F F QL(240 ml per loratadine syrp 5 mg/5ml fill retail) cetirizine hcl chew 5 mg, F QL(1 ea daily) 10 mg loratadine tabs 10 mg F QL(1 ea daily) QL(240 ml per cetirizine hcl soln 5 F fill retail); loratadine tbdp 10 mg F QL(1 ea daily) mg/5ml, 1 mg/ml RX/OTC XYZAL ALLERGY 24HR PA; RX/OTC QL(240 ml per cetirizine hcl syrp 5 TABS (Use Levocetirizine *** F fill retail); Dihydrochloride) mg/5ml, 1 mg/ml RX/OTC XYZAL TABS (Use PA; RX/OTC cetirizine hcl tabs 10 mg, 5 F QL(1 ea daily) Levocetirizine *** mg Dihydrochloride) CLARINEX SYRP 0.5 PA F ZYRTEC ALLERGY CAPS *** MG/ML (Use Cetirizine HCl) CLARINEX TABS 5 MG PA *** ZYRTEC ALLERGY TABS *** QL(1 ea daily) (Use Desloratadine) (Use Cetirizine HCl) CLARITIN ALLERGY QL(240 ml per ZYRTEC CHILDRENS QL(240 ml per CHILDRENS SYRP (Use *** fill retail) ALLERGY SYRP (Use *** fill retail); Loratadine) Cetirizine HCl) RX/OTC CLARITIN CAPS 10 MG *** (Use Loratadine) Antihistamines - Phenothiazines promethazine hcl soln or F AL; At least 2 CLARITIN CHEW 5 MG F 6.25 mg/5ml yrs old CLARITIN CHILDRENS F CHEW ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per promethazine hcl supp re COLESTID TABS 1 GM *** F fill retail); AL; At (Use Colestipol HCl) 12.5 mg, 50 mg, 25 mg least 2 yrs old colestipol hcl gran 5 gm F PA promethazine hcl syrp or F AL; At least 2 6.25 mg/5ml yrs old colestipol hcl pack 5 gm F PA promethazine hcl tabs or F AL; At least 2 12.5 mg, 25 mg, 50 mg yrs old colestipol hcl tabs 1 gm F Antihistamines - Piperidines QUESTRAN LIGHT POWD *** cyproheptadine hcl syrp F (Use Cholestyramine Light) QUESTRAN PACK (Use *** cyproheptadine hcl tabs F Cholestyramine) QUESTRAN POWD (Use *** ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholestyramine) Cholesterol WELCHOL PACK F PA Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs F PA WELCHOL TABS F PA

VYTORIN TABS (Use *** PA Fibric Acid Derivatives Ezetimibe-Simvastatin) ANTARA CAPS F PA Antihyperlipidemics - Misc. PA KYNAMRO SOSY F PA; SP choline fenofibrate cpdr F LOVAZA CAPS (Use PA FENOFIBRATE CAPS 150 F PA Omega-3-acid Ethyl *** MG, 50 MG Esters) fenofibrate micronized caps F PA 130 mg, 43 mg omega-3-acid ethyl esters F PA caps fenofibrate micronized caps F QL(1 ea daily) 134 mg, 200 mg VASCEPA CAPS F PA fenofibrate micronized caps F QL(2 ea daily) Bile Acid Sequestrants 67 mg QL(1 ea daily) cholestyramine light pack F fenofibrate tabs 160 mg F fenofibrate tabs 48 mg, 145 F PA cholestyramine light powd F mg QL(3 ea daily) cholestyramine pack F fenofibrate tabs 54 mg F PA cholestyramine powd F FENOFIBRIC ACID TABS F PA COLESTID FLAVORED *** PA FIBRICOR TABS F GRAN (Use Colestipol HCl) QL(2 ea daily) COLESTID FLAVORED *** PA gemfibrozil tabs F PACK (Use Colestipol HCl) LIPOFEN CAPS F PA COLESTID GRAN 5 GM *** PA (Use Colestipol HCl) LOFIBRA CAPS 134 MG, QL(1 ea daily) COLESTID PACK 5 GM *** PA 200 MG (Use Fenofibrate *** (Use Colestipol HCl) Micronized) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOFIBRA CAPS 67 MG QL(2 ea daily) PRAVACHOL TABS (Use *** QL(1 ea daily) (Use Fenofibrate *** Pravastatin Sodium) Micronized) pravastatin sodium tabs F QL(1 ea daily) LOFIBRA TABS 160 MG *** QL(1 ea daily) (Use Fenofibrate) rosuvastatin calcium tabs F PA LOFIBRA TABS 54 MG *** QL(3 ea daily) (Use Fenofibrate) SIMCOR TB24 F PA LOPID TABS (Use *** QL(2 ea daily) Gemfibrozil) simvastatin tabs 40 mg, 5 F QL(1 ea daily) mg, 10 mg, 20 mg TRICOR TABS (Use *** PA Fenofibrate) F PA; QL(1 ea simvastatin tabs 80 mg daily) QL(1 ea daily) TRIGLIDE TABS F ZOCOR TABS 40 MG, 20 QL(1 ea daily) MG, 10 MG, 5 MG (Use *** TRILIPIX CPDR (Use *** PA Choline Fenofibrate) Simvastatin) ZOCOR TABS 80 MG (Use *** PA; QL(1 ea HMG CoA Reductase Inhibitors Simvastatin) daily) PA ADVICOR TB24 F Intestinal Cholesterol Absorption Inhibitors PA ALTOPREV TB24 F PA ezetimibe tabs F ZETIA TABS (Use PA atorvastatin calcium tabs F ST *** 10 mg, 20 mg Ezetimibe) atorvastatin calcium tabs F ST; QL(1 ea Microsomal Triglyceride Transfer Protein (MTP) 80 mg, 40 mg daily) JUXTAPID CAPS F PA; SP CRESTOR TABS (Use *** PA Rosuvastatin Calcium) Nicotinic Acid Derivatives PA fluvastatin sodium caps F niacin (antihyperlipidemic) F tbcr fluvastatin sodium tb24 F PA NIACOR TABS F LESCOL XL TB24 (Use *** PA Fluvastatin Sodium) NIASPAN TBCR (Use *** Niacin (Antihyperlipidemic)) LIPITOR TABS 10 MG, 20 ST MG (Use Atorvastatin *** ANTIHYPERTENSIVES - Drugs to Treat High Calcium) Blood Pressure LIPITOR TABS 40 MG, 80 ST; QL(1 ea ACE Inhibitors MG (Use Atorvastatin *** daily) ACCUPRIL TABS (Use *** Calcium) Quinapril HCl) PA LIVALO TABS F ACEON TABS (Use *** Perindopril Erbumine) lovastatin tabs 10 mg, 20 QL(1 ea daily) F ALTACE CAPS (Use *** QL(2 ea daily) mg Ramipril) lovastatin tabs 40 mg F QL(2 ea daily) benazepril hcl tabs 10 mg, F QL(1 ea daily) 20 mg, 5 mg MEVACOR TABS (Use *** QL(2 ea daily) Lovastatin) benazepril hcl tabs 40 mg F QL(2 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits captopril tabs F QL(3 ea daily) ATACAND TABS (Use *** PA Candesartan Cilexetil) QL(2 ea daily) enalapril maleate tabs F AVAPRO TABS (Use *** QL(1 ea daily) Irbesartan) EPANED SOLN F BENICAR TABS (Use *** PA Olmesartan Medoxomil) EPANED SOLR F candesartan cilexetil tabs F PA fosinopril sodium tabs F QL(1 ea daily) COZAAR TABS (Use *** QL(1 ea daily) Losartan Potassium) lisinopril tabs 10 mg, 40 F QL(2 ea daily) mg, 20 mg, 30 mg, 5 mg DIOVAN TABS (Use *** QL(1 ea daily) Valsartan) lisinopril tabs 2.5 mg F QL(1 ea daily) EPROSARTAN F PA MESYLATE TABS LOTENSIN TABS 20 MG *** QL(1 ea daily) (Use Benazepril HCl) irbesartan tabs F QL(1 ea daily) LOTENSIN TABS 40 MG *** QL(2 ea daily) (Use Benazepril HCl) losartan potassium tabs F QL(1 ea daily) MAVIK TABS 2 MG, 1 MG *** QL(1 ea daily) (Use Trandolapril) MICARDIS TABS (Use *** QL(1 ea daily) Telmisartan) MAVIK TABS 4 MG (Use *** QL(2 ea daily) Trandolapril) olmesartan medoxomil tabs F PA moexipril hcl tabs F telmisartan tabs F QL(1 ea daily) perindopril erbumine tabs F valsartan tabs F QL(1 ea daily) PRINIVIL TABS (Use *** QL(2 ea daily) Lisinopril) Antiadrenergic Antihypertensives CARDURA TABS (Use *** quinapril hcl tabs F Doxazosin Mesylate) QL(2 ea daily) CATAPRES TABS (Use *** ramipril caps F Clonidine HCl) CATAPRES-TTS-1 PTWK PA trandolapril tabs 1 mg, 2 F QL(1 ea daily) *** mg (Use Clonidine HCl) trandolapril tabs 4 mg F QL(2 ea daily) CATAPRES-TTS-2 PTWK *** PA (Use Clonidine HCl) VASOTEC TABS (Use QL(2 ea daily) *** CATAPRES-TTS-3 PTWK *** PA Enalapril Maleate) (Use Clonidine HCl) ZESTRIL TABS 2.5 MG *** QL(1 ea daily) clonidine hcl ptwk td 0.3 PA (Use Lisinopril) mg/24hr, 0.2 mg/24hr, 0.1 F ZESTRIL TABS 40 MG, 5 QL(2 ea daily) mg/24hr MG, 10 MG, 20 MG, 30 MG *** clonidine hcl tabs or 0.1 F (Use Lisinopril) mg, 0.2 mg, 0.3 mg Agents for Pheochromocytoma doxazosin mesylate tabs F DEMSER CAPS F PA; SP guanfacine hcl tabs F Angiotensin II Receptor Antagonists

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methyldopa tabs F CAPTOPRIL/HYDROCHL QL(2 ea daily) OROTHIAZIDE TABS F 25MG-15MG, 50MG- MINIPRESS CAPS (Use *** Prazosin HCl) 15MG, 25MG-25MG prazosin hcl caps F CAPTOPRIL/HYDROCHL QL(3 ea daily) OROTHIAZIDE TABS F 50MG-25MG RESERPINE TABS F CLORPRES TABS F PA TENEX TABS (Use *** Guanfacine HCl) CORZIDE TABS (Use Nadolol & *** terazosin hcl caps F Bendroflumethiazide) Antihypertensive Combinations DIOVAN HCT TABS (Use QL(1 ea daily) ACCURETIC TABS (Use QL(2 ea daily) Valsartan- *** Quinapril- *** Hydrochlorothiazide) Hydrochlorothiazide) DUTOPROL TB24 F QL(1 ea daily) amlodipine besylate- F QL(1 ea daily) benazepril hcl caps EDARBYCLOR TABS F PA amlodipine besylate- PA F enalapril maleate & F QL(2 ea daily) olmesartan medoxomil tabs hydrochlorothiazide tabs amlodipine besylate- F PA EXFORGE HCT TABS PA valsartan tabs (Use Amlodipine-Valsartan- *** amlodipine-valsartan- F PA Hydrochlorothiazide) hydrochlorothiazide tabs EXFORGE TABS (Use PA ATACAND HCT TABS PA Amlodipine Besylate- *** (Use Candesartan Cilexetil- *** Valsartan) Hydrochlorothiazide) fosinopril sodium & F QL(1 ea daily) atenolol & chlorthalidone F QL(2 ea daily) hydrochlorothiazide tabs tabs HYZAAR TABS (Use QL(1 ea daily) AVALIDE TABS (Use QL(1 ea daily) Losartan Potassium & *** Irbesartan- *** Hydrochlorothiazide) Hydrochlorothiazide) irbesartan- F QL(1 ea daily) AZOR TABS (Use PA hydrochlorothiazide tabs Amlodipine Besylate- *** lisinopril & QL(2 ea daily) Olmesartan Medoxomil) hydrochlorothiazide tabs F benazepril & F QL(1 ea daily) 10mg-12.5mg, 20mg- hydrochlorothiazide tabs 12.5mg BENICAR HCT TABS (Use PA lisinopril & QL(1 ea daily) Olmesartan Medoxomil- *** hydrochlorothiazide tabs F Hydrochlorothiazide) 20mg-25mg bisoprolol & F QL(1 ea daily) LOPRESSOR HCT TABS QL(2 ea daily) hydrochlorothiazide tabs (Use Metoprolol & *** Hydrochlorothiazide) candesartan cilexetil- F PA hydrochlorothiazide tabs losartan potassium & F QL(1 ea daily) hydrochlorothiazide tabs

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTENSIN HCT TABS QL(1 ea daily) TENORETIC 50 TABS QL(2 ea daily) (Use Benazepril & *** (Use Atenolol & *** Hydrochlorothiazide) Chlorthalidone) LOTREL CAPS (Use QL(1 ea daily) trandolapril-verapamil hcl F PA Amlodipine Besylate- *** tbcr Benazepril HCl) TWYNSTA TABS (Use *** PA METHYLDOPA/HYDROCH F Telmisartan-Amlodipine) LOROTHIAZIDE TABS valsartan- F QL(1 ea daily) metoprolol & QL(1 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs F VASERETIC TABS (Use QL(2 ea daily) 100mg-50mg Enalapril Maleate & *** metoprolol & QL(2 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs F ZESTORETIC TABS QL(2 ea daily) 50mg-25mg, 100mg-25mg 10MG-12.5MG, 20MG- *** METOPROLOL QL(1 ea daily) 12.5MG (Use Lisinopril & SUCCINATE F Hydrochlorothiazide) ER/HYDROCHLOROTHIA ZESTORETIC TABS QL(1 ea daily) ZIDE TB24 20MG-25MG (Use *** METOPROLOL/HYDROCH F QL(1 ea daily) Lisinopril & LOROTHIAZIDE TABS Hydrochlorothiazide) MICARDIS HCT TABS QL(1 ea daily) ZIAC TABS (Use Bisoprolol *** QL(1 ea daily) (Use Telmisartan- *** & Hydrochlorothiazide) Hydrochlorothiazide) Antihypertensives - Misc. moexipril- F QL(2 ea daily) hydrochlorothiazide tabs VECAMYL TABS F PA; SP nadolol & F bendroflumethiazide tabs Direct Renin Inhibitors TEKTURNA TABS F PA olmesartan medoxomil- F PA hydrochlorothiazide tabs Selective Aldosterone Receptor Antagonists PROPRANOLOL/HYDROC F QL(2 ea daily) HLOROTHIAZIDE TABS eplerenone tabs F quinapril- F QL(2 ea daily) hydrochlorothiazide tabs INSPRA TABS (Use *** Eplerenone) TARKA TBCR (Use PA Trandolapril-Verapamil *** Vasodilators HCl) hydralazine hcl tabs F TEKTURNA HCT TABS F PA minoxidil tabs 10 mg F QL(10 ea daily) telmisartan-amlodipine tabs F PA minoxidil tabs 2.5 mg F QL(3 ea daily) telmisartan- F QL(1 ea daily) hydrochlorothiazide tabs ANTIMALARIALS - Drugs to Treat Malaria TENORETIC 100 TABS QL(2 ea daily) (Parasitic Infections) (Use Atenolol & *** Antimalarial Combinations Chlorthalidone) atovaquone-proguanil hcl F PA tabs

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COARTEM TABS F QL(24 ea per ANTIMYCOBACTERIAL AGENTS - Drugs to fill retail) Treat Tuberculosis (Bacterial Infections) MALARONE TABS (Use *** PA Atovaquone-Proguanil HCl) Anti TB Combinations PA Antimalarials RIFAMATE CAPS F chloroquine phosphate F RIFATER TABS F PA tabs 250 mg CHLOROQUINE Antimycobacterial Agents PHOSPHATE TABS 250 F PA MG CYCLOSERINE CAPS F chloroquine phosphate F QL(1 ea daily) tabs 500 mg ethambutol hcl tabs F DARAPRIM TABS F PA; SP ISONIAZID SYRP 50 F MG/5ML hydroxychloroquine sulfate F isoniazid tabs 300 mg, 100 F tabs mg mefloquine hcl tabs F MYAMBUTOL TABS (Use *** Ethambutol HCl) MEFLOQUINE HCL TABS F MYCOBUTIN CAPS (Use *** Rifabutin) PLAQUENIL TABS (Use Hydroxychloroquine *** PASER PACK F PA Sulfate) PRIFTIN TABS F PA PRIMAQUINE F PHOSPHATE TABS pyrazinamide tabs F QUALAQUIN CAPS (Use *** Quinine Sulfate) rifabutin caps F quinine sulfate caps F RIFADIN CAPS (Use *** Rifampin) ANTIMYASTHENIC/CHOLINERGIC AGENTS rifampin caps F Antimyasthenic/Cholinergic Agents PA GUANIDINE HCL TABS F PA SIRTURO TABS F

MESTINON SYRP 60 F TRECATOR TABS F MG/5ML MESTINON TABS 60 MG ANTINEOPLASTICS AND ADJUNCTIVE (Use Pyridostigmine *** THERAPIES - Drugs to Treat Cancer Bromide) Alkylating Agents MESTINON TIMESPAN ALKERAN TABS (Use *** TBCR (Use Pyridostigmine *** Melphalan) Bromide) CYCLOPHOSPHAMIDE F pyridostigmine bromide F CAPS tabs GLEOSTINE CAPS F pyridostigmine bromide F tbcr

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEXALEN CAPS F PA anastrozole tabs F

LEUKERAN TABS F ARIMIDEX TABS (Use *** Anastrozole) LOMUSTINE CAPS F AROMASIN TABS (Use *** ST; SP Exemestane) melphalan tabs F bicalutamide tabs F QL(1 ea daily)

MYLERAN TABS F CASODEX TABS (Use *** QL(1 ea daily) Bicalutamide) TEMODAR CAPS OR 180 PA; SP EMCYT CAPS F PA; SP MG, 100 MG, 20 MG, 140 *** MG, 250 MG, 5 MG (Use Temozolomide) exemestane tabs F ST; SP TEMODAR SOLR IV 100 F PA; SP PA MG FARESTON TABS F PA; SP temozolomide caps F FEMARA TABS (Use *** PA Letrozole) Antimetabolites flutamide caps F capecitabine tabs F PA; SP PA; QL(41.67 mercaptopurine tabs F HYDROXYPROGESTERO F ml daily); AL; At NE CAPROATE SOLN IM least 16 yrs old; METHOTREXATE SP SODIUM SOLN IJ 250 F HYDROXYPROGESTERO F MG/10ML NE CAPROATE SOLN IM methotrexate sodium soln ij letrozole tabs F PA 50 mg/2ml, 1 gm/40ml, 250 F mg/10ml, 100 mg/4ml, 200 SP mg/8ml LYSODREN TABS F methotrexate sodium tabs F MEGACE ORAL SUSP *** or 2.5 mg (Use Megestrol Acetate) PURIXAN SUSP F megestrol acetate susp F

TABLOID TABS F PA; SP megestrol acetate tabs F

TREXALL TABS F NILANDRON TABS (Use *** PA Nilutamide) XELODA TABS (Use *** PA; SP PA Capecitabine) nilutamide tabs F Antineoplastic - Antibodies tamoxifen citrate tabs F ADCETRIS SOLR F PA; SP XTANDI CAPS F PA; SP Antineoplastic - Hedgehog Pathway Inhibitors ZYTIGA TABS F PA; SP ERIVEDGE CAPS F PA; SP Antineoplastic - Immunomodulators Antineoplastic - Hormonal and Related Agents

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POMALYST CAPS F PA; SP TARCEVA TABS F PA; SP

Antineoplastic Enzyme Inhibitors TASIGNA CAPS F PA; SP AFINITOR DISPERZ TBSO F PA; SP TYKERB TABS F PA; SP AFINITOR TABS F PA; SP VOTRIENT TABS F PA; SP BOSULIF TABS F PA; SP ZELBORAF TABS F PA; SP CAPRELSA TABS F PA; SP ZOLINZA CAPS F PA; SP COMETRIQ KIT F PA; SP ZYDELIG TABS F PA; SP PA; SP COTELLIC TABS F Antineoplastics Misc. GILOTRIF TABS F PA; SP ACTIMMUNE SOLN F PA; SP

GLEEVEC TABS (Use *** PA; SP bexarotene caps F PA; SP Imatinib Mesylate) PA; SP HYDREA CAPS (Use *** IBRANCE CAPS F Hydroxyurea) ICLUSIG TABS F PA; SP hydroxyurea caps F

IDHIFA TABS F PA; SP INTRON A SOLN F PA; SP imatinib mesylate tabs F PA; SP INTRON A SOLR F PA; SP

IMBRUVICA CAPS F PA; SP INTRON A W/DILUENT F PA; SP SOLR PA; SP INLYTA TABS F MATULANE CAPS F PA; SP PA; SP JAKAFI TABS F PROLEUKIN SOLR F PA; SP PA; SP LYNPARZA TABS F SYLATRON KIT F PA; SP PA; SP MEKINIST TABS F TARGRETIN CAPS (Use *** PA; SP Bexarotene) PA; SP NEXAVAR TABS F tretinoin (chemotherapy) F PA; SP caps PA; SP NINLARO CAPS F Chemotherapy Rescue/Antidote Agents SPRYCEL TABS F PA; SP LEUCOVORIN CALCIUM F TABS 10 MG, 15 MG PA; SP STIVARGA TABS F leucovorin calcium tabs 5 F mg, 25 mg PA; SP SUTENT CAPS F Mitotic Inhibitors SP TAFINLAR CAPS F PA; SP ETOPOSIDE CAPS F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Topoisomerase I Inhibitors carbidopa-levodopa tbdp PA 25mg-100mg, 10mg- F HYCAMTIN CAPS F PA; SP 100mg, 25mg-250mg CARBIDOPA/LEVODOPA/ F PA ANTIPARKINSON AGENTS - Drugs to Treat ENTACAPONE TABS Parkinson's Disease MIRAPEX ER TB24 (Use PA Antiparkinson Adjuvants Pramipexole *** carbidopa tabs F PA Dihydrochloride) MIRAPEX TABS (Use QL(3 ea daily); LODOSYN TABS (Use *** PA Pramipexole *** AL; At least 18 Carbidopa) Dihydrochloride) yrs old Antiparkinson Anticholinergics PARLODEL CAPS (Use *** Bromocriptine Mesylate) benztropine mesylate tabs F PARLODEL TABS (Use *** Bromocriptine Mesylate) trihexyphenidyl hcl elix 0.4 F QL(16.7 ml mg/ml daily) pramipexole QL(3 ea daily); dihydrochloride tabs 0.5 AL; At least 18 trihexyphenidyl hcl tabs 2 F F mg, 5 mg mg, 0.125 mg, 0.75 mg, yrs old 0.25 mg, 1 mg, 1.5 mg Antiparkinson COMT Inhibitors pramipexole PA COMTAN TABS (Use *** dihydrochloride tb24 4.5 F Entacapone) mg, 0.375 mg, 3 mg, 1.5 entacapone tabs F mg, 0.75 mg REQUIP TABS 0.5 MG, 1 QL(3 ea daily) TASMAR TABS (Use *** PA MG, 5 MG, 2 MG (Use *** Tolcapone) Ropinirole Hydrochloride) tolcapone tabs F PA REQUIP TABS 3 MG, 4 QL(6 ea daily) MG, 0.25 MG (Use *** Antiparkinson Dopaminergics Ropinirole Hydrochloride) REQUIP XL TB24 (Use PA amantadine hcl caps 100 F *** mg Ropinirole Hydrochloride) ropinirole hydrochloride QL(3 ea daily) amantadine hcl syrp 50 F mg/5ml tabs 0.5 mg, 5 mg, 2 mg, 1 F mg amantadine hcl tabs 100 F PA mg ropinirole hydrochloride F QL(6 ea daily) tabs 4 mg, 3 mg, 0.25 mg bromocriptine mesylate F caps ropinirole hydrochloride PA tb24 6 mg, 12 mg, 4 mg, 8 F bromocriptine mesylate F tabs mg, 2 mg carbidopa-levodopa tabs SINEMET CR TBCR (Use *** 25mg-100mg, 10mg- F Carbidopa-Levodopa) 100mg, 25mg-250mg SINEMET TABS (Use *** carbidopa-levodopa tbcr Carbidopa-Levodopa) 50mg-200mg, 25mg- F STALEVO 100 TABS F PA 100mg STALEVO 125 TABS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 150 TABS F PA F PA; QL(2 ea LATUDA TABS 80 MG daily) PA STALEVO 200 TABS F F PA; QL(2 ea NUPLAZID TABS daily) PA STALEVO 50 TABS F VRAYLAR CAPS F PA PA STALEVO 75 TABS F VRAYLAR CPPK F PA Antiparkinson Monoamine Oxidase Inhibitors QL(2 ea daily); ziprasidone hcl caps F AL; At least 18 AZILECT TABS (Use *** PA Rasagiline Mesylate) yrs old ELDEPRYL CAPS (Use *** Benzisoxazoles Selegiline HCl) FANAPT TABS F PA rasagiline mesylate tabs F PA FANAPT TITRATION F PA selegiline hcl caps F PACK TABS INVEGA SUSTENNA F PA selegiline hcl tabs F SUSP INVEGA TB24 (Use *** PA ZELAPAR TBDP F PA Paliperidone) PA ANTIPSYCHOTICS/ANTIMANIC AGENTS - INVEGA TRINZA SUSP F Drugs to Treat Mood Disorders paliperidone tb24 F PA Antimanic Agents LITHIUM CARBONATE QL(2 ea daily); RISPERDAL M-TAB TBDP *** CAPS 600 MG, 150 MG F (Use Risperidone) AL; At least 5 (Use Lithium Carbonate) yrs old lithium carbonate caps 600 QL(4 ml daily); F RISPERDAL SOLN 1 *** mg, 150 mg, 300 mg ) AL; At least 5 MG/ML (Use Risperidone yrs old lithium carbonate tabs 300 F mg RISPERDAL TABS 4 MG, QL(2 ea daily); 0.25 MG, 2 MG, 3 MG, 0.5 AL; At least 5 lithium carbonate tbcr 450 F *** mg, 300 mg MG, 1 MG (Use yrs old Risperidone) LITHIUM SOLN F RISPERIDONE ODT TBDP F LITHOBID TBCR (Use F Lithium Carbonate) QL(4 ml daily); risperidone soln 1 mg/ml F AL; At least 5 Antipsychotics - Misc. yrs old EQUETRO CP12 F PA risperidone tabs 3 mg, 0.25 QL(2 ea daily); mg, 2 mg, 0.5 mg, 1 mg, 4 F AL; At least 5 GEODON CAPS OR 40 QL(2 ea daily); mg yrs old MG, 60 MG, 80 MG, 20 MG *** AL; At least 18 (Use Ziprasidone HCl) yrs old risperidone tbdp 0.25 mg F LATUDA TABS 40 MG, F PA; QL(1 ea QL(2 ea daily); 120 MG, 20 MG, 60 MG daily) risperidone tbdp 3 mg, 0.5 F AL; At least 5 mg, 2 mg, 4 mg, 1 mg yrs old

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Butyrophenones quetiapine fumarate tabs QL(2 ea daily) 50 mg, 300 mg, 200 mg, F HALDOL DECANOATE 400 mg, 25 mg, 100 mg 100 SOLN (Use *** Haloperidol Decanoate) quetiapine fumarate tb24 PA; QL(1 ea F daily) HALDOL DECANOATE 50 300 mg, 400 mg, 50 mg, SOLN (Use Haloperidol *** 150 mg, 200 mg Decanoate) SAPHRIS SUBL 5 MG, 10 F PA MG haloperidol decanoate soln F SEROQUEL TABS (Use *** QL(2 ea daily) Quetiapine Fumarate) haloperidol lactate conc F SEROQUEL XR TB24 (Use *** PA; QL(1 ea Quetiapine Fumarate) daily) haloperidol tabs 0.5 mg, 1 F QL(3 ea daily) mg, 10 mg VERSACLOZ SUSP F PA haloperidol tabs 5 mg, 2 F mg, 20 mg ZYPREXA TABS OR 10 QL(1 ea daily); MG, 20 MG, 2.5 MG, 7.5 *** AL; At least 10 Dibenzapines MG, 5 MG, 15 MG (Use yrs old CLOZAPINE ODT TBDP F PA Olanzapine) ZYPREXA ZYDIS TBDP *** PA; QL(1 ea QL(9 ea daily); (Use Olanzapine) daily) clozapine tabs 100 mg F AL; At least 18 yrs old Dihydroindolones QL(3 ea daily); MOLINDONE F PA clozapine tabs 25 mg, 50 F AL; At least 18 HYDROCHLORIDE TABS mg, 200 mg yrs old Phenothiazines clozapine tbdp 25 mg, 100 F PA QL(3 ea daily) mg chlorpromazine hcl tabs F QL(9 ea daily); fluphenazine decanoate CLOZARIL TABS 100 MG *** F ) AL; At least 18 soln (Use Clozapine yrs old FLUPHENAZINE HCL F QL(3 ea daily); CONC OR 5 MG/ML CLOZARIL TABS 25 MG *** AL; At least 18 (Use Clozapine) FLUPHENAZINE HCL F yrs old ELIX OR 2.5 MG/5ML FAZACLO TBDP 100 MG, PA *** FLUPHENAZINE HCL F 25 MG (Use Clozapine) SOLN IJ 2.5 MG/ML FAZACLO TBDP 150 MG, PA F fluphenazine hcl tabs or 5 F 200 MG, 12.5 MG mg, 10 mg, 2.5 mg, 1 mg loxapine succinate caps 25 F QL(4 ea daily) QL(4 ea daily) mg, 10 mg, 50 mg perphenazine tabs F loxapine succinate caps 5 F prochlorperazine maleate F mg tabs olanzapine tabs or 7.5 mg, QL(1 ea daily); 2.5 mg, 5 mg, 10 mg, 15 F AL; At least 10 prochlorperazine supp F mg, 20 mg yrs old thioridazine hcl tabs F QL(3 ea daily) olanzapine tbdp or 15 mg, F PA; QL(1 ea 5 mg, 10 mg, 20 mg daily) trifluoperazine hcl tabs F QL(3 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Quinolinone Derivatives F QL(3800 ml per povidone-iodine soln 10 % fill retail) ABILIFY MAINTENA PRSY F PA F QL(15200 ml povidone-iodine soln 7.5 % per fill retail) ABILIFY MAINTENA SRER F PA ANTIVIRALS - Drugs to Treat Viral Infections ABILIFY TABS (Use *** PA; QL(1 ea Aripiprazole) daily) Antiretrovirals PA; QL(750 ml abacavir sulfate soln 20 F QL(30 ml aripiprazole soln 1 mg/ml F per 30 days mg/ml daily); SP retail) abacavir sulfate tabs 300 F QL(2 ea daily); aripiprazole tabs 20 mg, 10 PA; QL(1 ea mg SP mg, 2 mg, 30 mg, 5 mg, 15 F daily) abacavir sulfate-lamivudine F QL(1 ea daily); mg tabs SP aripiprazole tbdp 15 mg, 10 PA; AL; At least F abacavir sulfate- F QL(2 ea daily); mg 6 yrs old lamivudine-zidovudine tabs SP ARISTADA PRSY F PA F QL(4 ea daily); APTIVUS CAPS 250 MG SP REXULTI TABS F PA APTIVUS SOLN 100 F QL(10 ml MG/ML daily); SP Thioxanthenes ATRIPLA TABS F SP thiothixene caps F QL(3 ea daily) COMBIVIR TABS (Use *** QL(2 ea daily); ANTISEPTICS & DISINFECTANTS - Drugs to Lamivudine-Zidovudine) SP Prevent Bacterial Skin Infections COMPLERA TABS F QL(1 ea daily); Antiseptics & Disinfectants SP QL(9 ea daily); F QL(90 ml per CRIXIVAN CAPS 200 MG F formaldehyde soln fill retail) SP F QL(6 ea daily); hydrogen peroxide soln F CRIXIVAN CAPS 400 MG SP Chlorine Antiseptics DESCOVY TABS F PA chlorhexidine gluconate F QL(946 ml per liqd fill retail) F QL(1 ea daily); didanosine cpdr SP HIBICLENS LIQD (Use *** QL(946 ml per Chlorhexidine Gluconate) fill retail) F QL(1 ea daily); EDURANT TABS SP Iodine Antiseptics F QL(1 ea daily); BETADINE SKIN QL(15200 ml EMTRIVA CAPS 200 MG SP CLEANSER SOLN (Use *** per fill retail) EMTRIVA SOLN 10 F SP Povidone-Iodine) MG/ML BETADINE SOLN (Use QL(3800 ml per *** EPIVIR SOLN 10 MG/ML *** QL(30 ml Povidone-Iodine) fill retail) (Use Lamivudine) daily); SP BETADINE SURGICAL QL(15200 ml EPIVIR TABS 150 MG *** QL(2 ea daily); SCRUB SOLN (Use *** per fill retail) (Use Lamivudine) SP Povidone-Iodine) EPIVIR TABS 300 MG *** QL(1 ea daily); F QL(200 gm per (Use Lamivudine) SP povidone-iodine oint 10 % fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPZICOM TABS (Use QL(1 ea daily); lopinavir-ritonavir soln F SP Abacavir Sulfate- *** SP Lamivudine) NEVIRAPINE SUSP 50 F QL(40 ml MG/5ML daily); SP F QL(1 ea daily); EVOTAZ TABS SP F QL(2 ea daily); nevirapine tabs 200 mg SP F QL(4 ea daily); fosamprenavir calcium tabs SP F QL(3 ea daily); nevirapine tb24 100 mg SP F PA; QL(1 ea GENVOYA TABS daily); SP F QL(1 ea daily); nevirapine tb24 400 mg SP INTELENCE TABS 200 F QL(2 ea daily); MG SP F QL(12 ea NORVIR CAPS 100 MG daily); SP INTELENCE TABS 25 MG, F QL(4 ea daily); 100 MG SP F QL(15 ml NORVIR SOLN 80 MG/ML daily); SP F QL(10 ea INVIRASE CAPS 200 MG daily); SP F QL(12 ea NORVIR TABS 100 MG daily); SP INVIRASE TABS 500 MG F QL(4 ea daily); SP ODEFSEY TABS F PA; SP ISENTRESS CHEW 100 F QL(6 ea daily); MG SP F QL(1 ea daily); PREZCOBIX TABS SP ISENTRESS CHEW 25 MG F QL(12 ea daily); SP PREZISTA SUSP 100 F QL(12 ml MG/ML daily); SP ISENTRESS PACK 100 F QL(2 ea daily); MG SP F QL(3 ea daily); PREZISTA TABS 150 MG SP ISENTRESS TABS 400 F QL(2 ea daily); MG SP PREZISTA TABS 600 MG, F QL(2 ea daily); KALETRA SOLN SP 75 MG SP 400MG/5ML-100MG/5ML *** PREZISTA TABS 800 MG F QL(1 ea daily); (Use Lopinavir-Ritonavir) SP RESCRIPTOR TABS 100 QL(12 ea KALETRA TABS 100MG- F QL(4 ea daily); F 25MG SP MG daily); SP RESCRIPTOR TABS 200 QL(6 ea daily); KALETRA TABS 200MG- F QL(6 ea daily); F 50MG SP MG SP RETROVIR CAPS 100 MG QL(6 ea daily); F QL(30 ml *** lamivudine soln 10 mg/ml daily); SP (Use Zidovudine) SP RETROVIR SYRP 50 QL(60 ml F QL(2 ea daily); *** lamivudine tabs 150 mg SP MG/5ML (Use Zidovudine) daily); SP REYATAZ CAPS 200 MG, QL(2 ea daily); F QL(1 ea daily); F lamivudine tabs 300 mg SP 300 MG, 150 MG SP QL(6 ea daily); F QL(2 ea daily); REYATAZ PACK 50 MG F lamivudine-zidovudine tabs SP SP SELZENTRY TABS 150 QL(2 ea daily); F QL(56 ml F LEXIVA SUSP 50 MG/ML daily); SP MG SP LEXIVA TABS 700 MG QL(4 ea daily); QL 2 per SELZENTRY TABS 25 F (Use Fosamprenavir *** SP MG, 75 MG day;QL(2 ea Calcium) daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELZENTRY TABS 300 F QL(4 ea daily); VIRAMUNE XR TB24 400 *** QL(1 ea daily); MG SP MG (Use Nevirapine) SP stavudine caps 30 mg, 40 F QL(2 ea daily); VIREAD POWD 40 MG/GM F SP mg, 15 mg, 20 mg SP VIREAD TABS 300 MG, QL(1 ea daily); F QL(80 ml F stavudine solr 1 mg/ml daily); SP 150 MG, 250 MG, 200 MG SP QL(1 ea daily); F PA; QL(1 ea STRIBILD TABS daily); SP VITEKTA TABS F AL; At least 18 yrs old; SP F QL(1 ea daily); SUSTIVA CAPS 200 MG SP ZERIT CAPS 15 MG, 30 QL(2 ea daily); MG, 40 MG, 20 MG (Use *** SP F QL(2 ea daily); SUSTIVA CAPS 50 MG SP Stavudine) QL(80 ml F QL(1 ea daily); ZERIT SOLR 1 MG/ML F SUSTIVA TABS 600 MG SP daily); SP SP ZIAGEN SOLN 20 MG/ML *** QL(30 ml TIVICAY TABS 50 MG F (Use Abacavir Sulfate) daily); SP QL(1 ea daily); ZIAGEN TABS 300 MG *** QL(2 ea daily); TRIUMEQ TABS F AL; At least 18 (Use Abacavir Sulfate) SP yrs old; SP QL(6 ea daily); zidovudine caps 100 mg F TRIZIVIR TABS (Use QL(2 ea daily); SP Abacavir Sulfate- *** SP F QL(60 ml Lamivudine-Zidovudine) zidovudine syrp 50 mg/5ml daily); SP QL(2 ea daily); TRUVADA TABS 250MG- PA; SP zidovudine tabs 300 mg F 167MG, 200MG-133MG, F SP 150MG-100MG CMV Agents TRUVADA TABS 300MG- QL(1 ea daily); F VALCYTE TABS (Use *** QL(2 ea daily) 200MG SP Valganciclovir HCl) QL(1 ea daily); QL(2 ea daily) TYBOST TABS F AL; At least 18 valganciclovir hcl tabs F yrs old; SP Hepatitis Agents VIDEX EC CPDR (Use *** QL(1 ea daily); Didanosine) SP adefovir dipivoxil tabs F PA VIDEXPEDIATRIC SOLR 2 F QL(20 ml GM daily); SP BARACLUDE SOLN 0.05 F PA MG/ML VIDEXPEDIATRIC SOLR 4 F SP GM BARACLUDE TABS 0.5 *** PA MG, 1 MG (Use Entecavir) VIRACEPT TABS 250 MG F QL(9 ea daily); SP COPEGUS TABS (Use *** PA; SP Ribavirin (Hepatitis C)) VIRACEPT TABS 625 MG F QL(4 ea daily); SP entecavir tabs F PA VIRAMUNE SUSP 50 QL(40 ml F F PA; QL(1 ea MG/5ML daily); SP EPCLUSA TABS daily); SP VIRAMUNE TABS 200 MG QL(2 ea daily); *** EPIVIR HBV SOLN 5 F PA (Use Nevirapine) SP MG/ML VIRAMUNE XR TB24 100 *** QL(3 ea daily); MG (Use Nevirapine) SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPIVIR HBV TABS 100 PA Herpes Agents MG (Use Lamivudine *** )) F QL(50 ea per (HBV acyclovir caps 200 mg 30 days retail) PA; QL(1 ea HARVONI TABS F F QL(400 ml per daily); SP acyclovir susp 200 mg/5ml 30 days retail) HEPSERA TABS (Use *** PA QL(3 ea daily) Adefovir Dipivoxil) acyclovir tabs 400 mg F PA lamivudine (hbv) tabs F F QL(50 ea per acyclovir tabs 800 mg 30 days retail) MODERIBA 1200 DOSE F PA; SP PACK TABS famciclovir tabs F PA MODERIBA 800 DOSE PA; SP F FAMVIR TABS (Use *** PA PACK TABS Famciclovir) PA; SP OLYSIO CAPS F SITAVIG TABS F PA PA; SP PEG-INTRON KIT F valacyclovir hcl tabs 1000 F QL(21 ea per mg, 1 gm 30 days retail) PEG-INTRON REDIPEN F PA; SP KIT valacyclovir hcl tabs 500 F QL(60 ea per mg 30 days retail) PEG-INTRON REDIPEN F PA; SP PAK 4 KIT VALTREX TABS 1 GM *** QL(21 ea per (Use Valacyclovir HCl) 30 days retail) PEGASYS PROCLICK F PA; SP SOLN VALTREX TABS 500 MG *** QL(60 ea per (Use Valacyclovir HCl) 30 days retail) PEGASYS SOLN F PA; SP ZOVIRAX CAPS OR 200 *** QL(50 ea per MG (Use Acyclovir) 30 days retail) PEGINTRON KIT F PA; SP ZOVIRAX SUSP OR 200 *** QL(400 ml per REBETOL CAPS 200 MG PA; SP MG/5ML (Use Acyclovir) 30 days retail) (Use Ribavirin (Hepatitis *** ZOVIRAX TABS OR 400 *** QL(3 ea daily) C)) MG (Use Acyclovir) ZOVIRAX TABS OR 800 QL(50 ea per REBETOL SOLN 40 F PA; SP *** MG/ML MG (Use Acyclovir) 30 days retail) RIBASPHERE RIBAPAK F PA; SP Influenza Agents TABS FLUMADINE TABS (Use QL(20 ea per RIBASPHERE TABS F PA; SP Rimantadine *** 10 days retail) Hydrochloride) RIBATAB TABS F PA; SP Limit 1 Fill per 180 oseltamivir phosphate caps ribavirin (hepatitis c) caps F PA; SP F days;QL(20 ea 30 mg per 30 days ribavirin (hepatitis c) tabs F PA; SP retail) Limit 1 Fill per SOVALDI TABS F PA; SP 180 oseltamivir phosphate caps F days;QL(10 ea 75 mg, 45 mg TYZEKA TABS F PA per 30 days retail) F PA; QL(1 ea ZEPATIER TABS daily); SP ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 Fill per acebutolol hcl caps F 180 oseltamivir phosphate susr F days;QL(120 atenolol tabs F QL(2 ea daily) 6 mg/ml ml per 30 days retail) betaxolol hcl tabs F QL(1 ea daily) RELENZA DISKHALER F QL(20 ea per AEPB fill retail) bisoprolol fumarate tabs F QL(1 ea daily) rimantadine hydrochloride F QL(20 ea per tabs 10 days retail) BYSTOLIC TABS F PA Limit 1 Fill per TAMIFLU CAPS 30 MG 180 LOPRESSOR TABS 100 QL(2 ea daily) (Use Oseltamivir *** days;QL(20 ea MG (Use Metoprolol *** Phosphate) per 30 days Tartrate) retail) LOPRESSOR TABS 50 QL(3 ea daily) Limit 1 Fill per MG (Use Metoprolol *** TAMIFLU CAPS 45 MG, 75 180 Tartrate) MG (Use Oseltamivir *** days;QL(10 ea metoprolol succinate tb24 F QL(2 ea daily) Phosphate) per 30 days 200 mg retail) metoprolol succinate tb24 F QL(1 ea daily) Limit 1 Fill per 50 mg, 100 mg, 25 mg TAMIFLU SUSR 6 MG/ML 180 metoprolol tartrate tabs 100 F QL(2 ea daily) (Use Oseltamivir *** days;QL(120 mg, 25 mg Phosphate) ml per 30 days metoprolol tartrate tabs 50 F QL(3 ea daily) retail) mg BETA BLOCKERS - Drugs to Treat High Blood SECTRAL CAPS (Use *** Pressure Acebutolol HCl) Alpha-Beta Blockers TENORMIN TABS (Use *** QL(2 ea daily) Atenolol) carvedilol phosphate cp24 F PA TOPROL XL TB24 100 QL(1 ea daily) MG, 25 MG, 50 MG (Use *** carvedilol tabs 12.5 mg, F QL(3 ea daily) 6.25 mg, 3.125 mg Metoprolol Succinate) QL(4 ea daily) TOPROL XL TB24 200 MG *** QL(2 ea daily) carvedilol tabs 25 mg F (Use Metoprolol Succinate) COREG CR CP24 (Use PA *** ZEBETA TABS (Use *** QL(1 ea daily) Carvedilol Phosphate) Bisoprolol Fumarate) COREG TABS 25 MG (Use *** QL(4 ea daily) Beta Blockers Non-Selective Carvedilol) BETAPACE AF TABS (Use *** QL(2 ea daily) COREG TABS 3.125 MG, QL(3 ea daily) Sotalol HCl (AFIB/AFL)) 12.5 MG, 6.25 MG (Use *** Carvedilol) BETAPACE TABS (Use *** Sotalol HCl) labetalol hcl tabs 100 mg F QL(3 ea daily) CORGARD TABS (Use *** QL(2 ea daily) Nadolol) labetalol hcl tabs 200 mg F QL(6 ea daily) HEMANGEOL SOLN F PA labetalol hcl tabs 300 mg F QL(8 ea daily) INDERAL LA CP24 (Use *** QL(2 ea daily) Propranolol HCl) Beta Blockers Cardio-Selective

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INDERAL XL CP24 F PA CARDIZEM LA TB24 120 F MG INNOPRAN XL CP24 F PA CARDIZEM LA TB24 240 MG, 300 MG, 360 MG, 420 nadolol tabs F QL(2 ea daily) MG, 180 MG (Use *** Diltiazem HCl Coated pindolol tabs F Beads) CARDIZEM TABS (Use *** QL(3 ea daily) propranolol hcl cp24 80 QL(2 ea daily) Diltiazem HCl) mg, 120 mg, 160 mg, 60 F diltiazem hcl coated beads QL(1 ea daily) mg cp24 180 mg, 300 mg, 120 F PROPRANOLOL HCL mg SOLN 40 MG/5ML, 20 F diltiazem hcl coated beads F QL(2 ea daily) MG/5ML cp24 240 mg propranolol hcl tabs 60 mg, diltiazem hcl coated beads F 20 mg, 10 mg, 80 mg, 40 F cp24 360 mg mg diltiazem hcl coated beads sotalol hcl (afib/afl) tabs F QL(2 ea daily) tb24 420 mg, 240 mg, 180 F mg, 360 mg, 300 mg sotalol hcl tabs F diltiazem hcl cp12 60 mg, F QL(2 ea daily) 120 mg, 90 mg TIMOLOL MALEATE TABS F diltiazem hcl cp24 180 mg, F QL(1 ea daily) CALCIUM CHANNEL BLOCKERS - Drugs to 120 mg Treat High Blood Pressure diltiazem hcl cp24 240 mg F QL(2 ea daily) Calcium Channel Blockers diltiazem hcl extended QL(2 ea daily) ADALAT CC TB24 60 MG *** QL(2 ea daily) release beads cp24 240 F (Use Nifedipine) mg ADALAT CC TB24 90 MG, *** QL(1 ea daily) diltiazem hcl extended QL(1 ea daily) 30 MG (Use Nifedipine) release beads cp24 360 F QL(1 ea daily) mg, 180 mg, 420 mg, 300 amlodipine besylate tabs F mg, 120 mg CALAN SR TBCR (Use QL(2 ea daily) *** diltiazem hcl tabs 30 mg, F QL(3 ea daily) Verapamil HCl) 120 mg, 90 mg, 60 mg CALAN TABS (Use *** QL(3 ea daily) felodipine tb24 F QL(1 ea daily) Verapamil HCl) CARDIZEM CD CP24 240 QL(2 ea daily) isradipine caps F PA MG (Use Diltiazem HCl *** Coated Beads) nicardipine hcl caps F QL(3 ea daily) CARDIZEM CD CP24 300 QL(1 ea daily) nifedipine caps 10 mg, 20 QL(4 ea daily) MG, 120 MG, 180 MG (Use *** F Diltiazem HCl Coated mg ) Beads nifedipine tb24 30 mg, 90 F QL(1 ea daily) CARDIZEM CD CP24 360 mg MG (Use Diltiazem HCl *** nifedipine tb24 60 mg F QL(2 ea daily) Coated Beads) nimodipine caps F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NISOLDIPINE ER TB24 F PA digoxin tabs 0.125 mg, 250 F mcg, 0.25 mg, 125 mcg PA nisoldipine tb24 F LANOXIN TABS 125 MCG, F 250 MCG (Use Digoxin) NORVASC TABS (Use QL(1 ea daily) *** LANOXIN TABS 187.5 F PA Amlodipine Besylate) MCG, 62.5 MCG PA NYMALIZE SOLN F CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions PROCARDIA CAPS (Use *** QL(4 ea daily) Nifedipine) Cardiovascular Agents Misc. - Combinations PROCARDIA XL TB24 60 QL(2 ea daily) *** amlodipine besylate- F PA MG (Use Nifedipine) atorvastatin calcium tabs PROCARDIA XL TB24 90 QL(1 ea daily) BIDIL TABS F PA MG, 30 MG (Use *** Nifedipine) CADUET TABS (Use PA Amlodipine Besylate- *** SULAR TB24 (Use *** PA Nisoldipine) Atorvastatin Calcium) TIAZAC CP24 240 MG QL(2 ea daily) Peripheral Vasodilators (Use Diltiazem HCl *** Extended Release Beads) inositol niacinate caps F TIAZAC CP24 300 MG, QL(1 ea daily) Prostaglandin Vasodilators 120 MG, 420 MG, 180 MG, 360 MG (Use Diltiazem *** epoprostenol sodium solr F PA; SP HCl Extended Release Beads) FLOLAN SOLR (Use *** PA; SP Epoprostenol Sodium) verapamil hcl cp24 200 mg, F QL(2 ea daily) 100 mg ORENITRAM TBCR F PA; SP verapamil hcl cp24 300 mg, QL(1 ea daily) 240 mg, 180 mg, 360 mg, F REMODULIN SOLN F PA; SP 120 mg TYVASO REFILL SOLN F PA; SP verapamil hcl tabs 80 mg, F QL(3 ea daily) 40 mg, 120 mg TYVASO SOLN F PA; SP verapamil hcl tbcr 180 mg, F QL(2 ea daily) 120 mg, 240 mg TYVASO STARTER SOLN F PA; SP VERELAN CP24 (Use *** QL(1 ea daily) Verapamil HCl) VELETRI SOLR F PA; SP VERELAN PM CP24 100 QL(2 ea daily) MG, 200 MG (Use *** VENTAVIS SOLN F PA; SP Verapamil HCl) Pulmonary Hypertension - Endothelin Receptor VERELAN PM CP24 300 *** QL(1 ea daily) MG (Use Verapamil HCl) LETAIRIS TABS F PA; SP CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm OPSUMIT TABS F PA; SP Cardiac Glycosides TRACLEER TABS F PA; SP DIGOXIN SOLN 0.05 F MG/ML Pulmonary Hypertension - Phosphodiesterase

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADCIRCA TABS F PA; SP CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, F REVATIO SOLN IV 10 PA; SP 375 MG/5ML MG/12.5ML (Use Sildenafil *** F QL(200 ml per Citrate (Pulmonary cefprozil susr 125 mg/5ml fill retail) Hypertension)) QL(100 ml per cefprozil susr 250 mg/5ml F REVATIO SUSR OR 10 F PA; SP fill retail) MG/ML cefprozil tabs 500 mg, 250 F QL(20 ea per REVATIO TABS OR 20 PA; SP mg fill retail) MG (Use Sildenafil Citrate *** CEFTIN SUSR 250 F QL(100 ml per (Pulmonary Hypertension)) MG/5ML, 125 MG/5ML fill retail) sildenafil citrate (pulmonary F PA; SP CEFTIN TABS 500 MG, QL(20 ea per hypertension) soln 250 MG (Use Cefuroxime *** fill retail) sildenafil citrate (pulmonary F PA; SP Axetil) hypertension) tabs QL(20 ea per cefuroxime axetil tabs F Pulmonary Hypertension - Sol Guanylate Cyclase fill retail) ADEMPAS TABS F PA; SP Cephalosporins - 3rd Generation PA CEPHALOSPORINS - Drugs to Treat Bacterial CEDAX CAPS F Infections CEDAX SUSR F PA Cephalosporins - 1st Generation QL(20 ea per F QL(20 ea per cefdinir caps 300 mg F cefadroxil caps 500 mg fill retail) fill retail) cefdinir susr 250 mg/5ml, QL(100 ml per cefadroxil susr 500 mg/5ml, F QL(100 ml per F 250 mg/5ml fill retail) 125 mg/5ml fill retail) CEFDITOREN PIVOXIL PA F QL(10 ea per F cefadroxil tabs 1 gm fill retail) TABS 200 MG, 400 MG cefixime susr F PA cephalexin caps 250 mg, F 500 mg cefpodoxime proxetil susr F PA cephalexin caps 750 mg F PA cefpodoxime proxetil tabs F PA cephalexin susr 125 F mg/5ml, 250 mg/5ml CEFTIBUTEN CAPS F PA CEPHALEXIN TABS 250 F PA MG, 500 MG CEFTIBUTEN SUSR F PA KEFLEX CAPS 250 MG, *** 500 MG (Use Cephalexin) Limit 1 fill per ceftriaxone sodium solr F Month;QL(3 ea KEFLEX CAPS 750 MG *** PA (Use Cephalexin) per fill retail) Cephalosporins - 2nd Generation SPECTRACEF TABS F PA cefaclor caps 500 mg, 250 F PA mg SUPRAX CAPS 400 MG F PA CEFACLOR ER TB12 F SUPRAX CHEW 100 MG, F PA 200 MG

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPRAX SUSR 100 PA drospirenone-ethinyl F MG/5ML, 200 MG/5ML *** estradiol tabs 3mg-0.03mg (Use Cefixime) drospirenone-ethinyl PA F SUPRAX SUSR 500 F PA estradiol-levomefolate MG/5ML calcium tabs DROSPIRENONE/ETHINY PA CHEMICALS L F Bulk Chemicals - H's ESTRADIOL/LEVOMEFOL ATE CALCIUM TABS HYDROXYPROGESTERO F NE CAPROATE POWD XX ESTROSTEP FE TABS PA (Use Norethindrone *** Bulk Chemicals - P's Acetate-Ethinyl Estradiol- Fe) PROMETHAZINE HCL F POWD XX ethynodiol diacet & eth F Liquids estrad tabs PA GLYCERIN LIQD F RX/OTC FALESSA KIT F RX/OTC FEMCON FE CHEW (Use PA GLYCERINE LIQD F Norethindrone & Ethinyl *** Estradiol-Fe) GLYCEROL FORMAL F RX/OTC LIQD levonorgestrel & eth F estradiol tabs CONTRACEPTIVES - Drugs to Prevent Pregnancy LEVONORGESTREL AND PA ETHINYL ESTRADIOL F Combination Contraceptives - Oral TABS BEYAZ TABS (Use PA levonorgestrel-eth estradiol F Drospirenone-Ethinyl *** (triphasic) tabs Estradiol-Levomefolate levonorgestrel-ethinyl F QL(91 ea per Calcium) estradiol (91-day) tabs 91 days retail) BREVICON-28 TABS (Use levonorgestrel-ethinyl F QL(4 ea per 91 Norethindrone & Eth *** estradiol (91-day) tabs days retail) Estradiol) levonorgestrel-ethinyl F PA CYCLESSA TABS (Use estradiol (91-day) tabs Desogestrel-Ethinyl *** Estradiol (Triphasic)) levonorgestrel-ethinyl F PA estradiol (continuous) tabs DESOGEN TABS (Use Desogestrel & Ethinyl *** LO LOESTRIN FE TABS F PA Estradiol) LOESTRIN 1.5/30-21 desogestrel & ethinyl F TABS (Use Norethindrone *** estradiol tabs Acet & Eth Estra) desogestrel-ethinyl F LOESTRIN 1/20-21 TABS estradiol (biphasic) tabs (Use Norethindrone Acet & *** desogestrel-ethinyl F Eth Estra) estradiol (triphasic) tabs LOESTRIN FE 1.5/30 drospirenone-ethinyl F QL(1 ea daily) TABS (Use Norethin Acet & *** estradiol tabs 3mg-0.02mg Estrad-Fe)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOESTRIN FE 1/20 TABS NORINYL 1+50 TABS F (Use Norethin Acet & *** Estrad-Fe) OGESTREL TABS F LOSEASONIQUE TABS PA (Use Levonorgestrel- *** ORTHO TRI-CYCLEN LO Ethinyl Estradiol (91-Day)) TABS (Use Norgestimate- *** MINASTRIN 24 FE CHEW PA Ethinyl Estradiol (Use Norethin Acet & *** (Triphasic)) Estrad-Fe) ORTHO TRI-CYCLEN MIRCETTE TABS (Use TABS (Use Norgestimate- *** Desogestrel-Ethinyl *** Ethinyl Estradiol Estradiol (Biphasic)) (Triphasic)) MODICON TABS (Use ORTHO-CYCLEN TABS Norethindrone & Eth *** (Use Norgestimate-Ethinyl *** Estradiol) Estradiol) PA ORTHO-NOVUM 1/35 NATAZIA TABS F TABS (Use Norethindrone *** & Eth Estradiol) NECON 1/50-28 TABS F ORTHO-NOVUM 7/7/7 TABS (Use Norethindrone- *** NECON 10/11-28 TABS F Eth Estradiol (Triphasic)) OVCON-35 TABS (Use norethin acet & estrad-fe F PA chew 75mg-20mcg-1mg Norethindrone & Eth *** norethin acet & estrad-fe Estradiol) tabs 75mg-20mcg-1mg, F QUARTETTE TABS (Use PA 75mg-30mcg-1.5mg Levonorgestrel-Ethinyl *** Estradiol (91-Day)) norethindrone & eth F estradiol tabs SAFYRAL TABS F PA norethindrone & ethinyl PA estradiol-fe chew 0.4mg- F SEASONIQUE TABS (Use QL(4 ea per 91 35mcg Levonorgestrel-Ethinyl *** days retail) Estradiol (91-Day)) norethindrone acet & eth F estra tabs TRI-NORINYL 28 TABS (Use Norethindrone-Eth *** norethindrone acetate- F PA Estradiol (Triphasic)) ethinyl estradiol-fe tabs YASMIN 28 TABS (Use norethindrone-eth estradiol F Drospirenone-Ethinyl *** (triphasic) tabs Estradiol) norgestimate-ethinyl F YAZ TABS (Use QL(1 ea daily) estradiol (triphasic) tabs Drospirenone-Ethinyl *** norgestimate-ethinyl F Estradiol) estradiol tabs Combination Contraceptives - Transdermal norgestrel & ethinyl F QL(2 ea daily) estradiol tabs norelgestromin-ethinyl 1 QL(3 ea per fill estradiol ptwk retail) NORINYL 1+35 TABS (Use Norethindrone & Eth *** XULANE PTWK *** QL(3 ea per fill Estradiol) retail) Combination Contraceptives - Vaginal

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(1 ea per fill dexamethasone elix 0.5 F NUVARING RING retail) mg/5ml Emergency Contraceptives DEXAMETHASONE F INTENSOL CONC F QL(4 ea per ELLA TABS 365 days retail) dexamethasone sodium QL(150 ml per Limit 4 per phosphate soln ij 20 F 30 days retail) mg/5ml, 4 mg/ml, 120 levonorgestrel (emergency F year;QL(1 ea oc) tabs per 21 days mg/30ml retail) DEXAMETHASONE SOLN F 0.5 MG/5ML PLAN B ONE-STEP TABS Limit 4 per year;QL(1 ea DEXAMETHASONE TABS F (Use Levonorgestrel *** 2 MG, 1 MG (Emergency OC)) per 21 days retail) dexamethasone tabs 4 mg, Progestin Contraceptives - Injectable 0.5 mg, 1.5 mg, 6 mg, 0.75 F mg DEPO-PROVERA QL(1 ml per hydrocortisone tabs F CONTRACEPTIVE SUSP *** days mail) (Use Medroxyprogesterone Acetate (Contraceptive)) MEDROL DOSEPAK TBPK *** (Use Methylprednisolone) DEPO-PROVERA QL(1 ml per fill MEDROL TABS (Use CONTRACEPTIVE SUSY *** retail); GL *** (Use Medroxyprogesterone Methylprednisolone) Acetate (Contraceptive)) methylprednisolone tabs F DEPO-SUBQ PROVERA F QL(1 ml per fill 104 SUSY retail); GL methylprednisolone tbpk F medroxyprogesterone QL(1 ml per acetate (contraceptive) F days mail) MILLIPRED SOLN 10 PA susp MG/5ML (Use *** Prednisolone Sodium medroxyprogesterone QL(1 ml per fill Phosphate) acetate (contraceptive) F retail); GL susy MILLIPRED TABS 5 MG F Progestin Contraceptives - Oral ORAPRED ODT TBDP PA NOR-QD TABS (Use (Use Prednisolone Sodium *** Norethindrone *** Phosphate) (Contraceptive)) PEDIAPRED SOLN (Use Prednisolone Sodium *** norethindrone F (contraceptive) tabs Phosphate) ORTHO MICRONOR prednisolone sodium PA TABS (Use Norethindrone *** phosphate soln or 10 F (Contraceptive)) mg/5ml CORTICOSTEROIDS - Steroid Hormone Drugs to prednisolone sodium Treat Systemic Swelling Conditions phosphate soln or 15 F mg/5ml, 5 mg/5ml, 6.7 Glucocorticosteroids mg/5ml CORTEF TABS (Use *** prednisolone sodium QL(150 ml per Hydrocortisone) phosphate soln or 20 F fill retail) mg/5ml CORTISONE ACETATE F TABS ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prednisolone sodium PA dextromethorphan hbr liqd F QL(240 ml per phosphate tbdp or 30 mg, F 7.5 mg/5ml 6 days retail) 15 mg, 10 mg dextromethorphan hbr syrp F prednisolone soln F 7.5 mg/5ml, 15 mg/5ml dextromethorphan F QL(240 ml per prednisolone syrp F polistirex suer 6 days retail) hydrocodone w/ PREDNISONE INTENSOL F homatropine syrp 5mg/5ml- F CONC 1.5mg/5ml PREDNISONE SOLN 5 F hydrocodone w/ PA MG/5ML homatropine tabs 5mg- F prednisone tabs 2.5 mg, 10 F 1.5mg mg, 5 mg, 1 mg, 20 mg ROBITUSSIN CHILDRENS PREDNISONE TABS 50 F COUGH LONG-ACTING F MG SYRP PREDNISONE TBPK 5 F ROBITUSSIN LINGERING MG, 10 MG COLDLONG-ACTING *** VERIPRED 20 SOLN (Use QL(150 ml per COUGHGELS CAPS (Use Prednisolone Sodium *** fill retail) Dextromethorphan HBr) Phosphate) TESSALON PERLES *** Mineralocorticoids CAPS (Use Benzonatate) TRIAMINIC LONG ACTING QL(240 ml per fludrocortisone acetate F tabs COUGH LIQD (Use *** 6 days retail) Dextromethorphan HBr) COUGH/COLD/ALLERGY - Drugs to Treat VICKS DAYQUIL COUGH Cough, Cold and Allergy Symptoms LIQD (Use *** Antitussives Dextromethorphan HBr) ZONATUSS CAPS (Use *** PA benzonatate caps 100 mg F Benzonatate) benzonatate caps 150 mg F PA Cough/Cold/Allergy Combinations Limit 1 fill per acetaminophen w/ dm liqd F F Month;QL(20 benzonatate caps 200 mg ea per 30 days ACTICON SOLN F PA retail) DELSYM COUGH QL(240 ml per ACTINEL LIQD F CHILDRENS SUER (Use 6 days retail) *** ACTINEL PEDIATRIC F Dextromethorphan LIQD Polistirex) ADVIL COLD & SINUS DELSYM SUER (Use QL(240 ml per TABS (Use *** Dextromethorphan *** 6 days retail) Pseudoephedrine- Polistirex) Ibuprofen) dextromethorphan hbr caps F ALLEGRA-D 12 HOUR 15 mg ALLERGY & dextromethorphan hbr liqd F CONGESTION TB12 (Use *** 15 mg/5ml, 15 mg/15ml Fexofenadine- Pseudoephedrine)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALLEGRA-D 24 HOUR chlorpheniramine- F ALLERGY & acetaminophen tabs CONGESTION TB24 (Use *** chlorpheniramine- PA Fexofenadine- phenylephrine- Pseudoephedrine) acetaminophen misc 2mg- F BENADRYL-D ALLERGY & F 325mg-5mg, 2mg-2mg- SINUS CHILDRENS SOLN 325mg-325mg-5mg-5mg, BIONEL LIQD F chlorpheniramine- phenylephrine- BIONEL PEDIATRIC LIQD F acetaminophen tabs 2mg- F 2mg-325mg-325mg-5mg- 5mg, 2mg-325mg-5mg BIOSPEC DMX LIQD F CLARINEX-D 12 HOUR F PA Limit 1 fill per TB12 brompheniramine & F Month;QL(120 CLARITIN-D 12 HOUR QL(2 ea daily) phenyleph elix ml per 30 days TB12 (Use Loratadine & *** retail) Pseudoephedrine) Limit 1 fill per CLARITIN-D 24 HOUR QL(1 ea daily) brompheniramine & F Month;QL(120 TB24 (Use Loratadine & *** pseudoeph elix ml per 30 days Pseudoephedrine) retail) CLEAR COUGH PM Limit 1 fill per MULTI-SYMPTOM LIQD brompheniramine & F Month;QL(120 (Use Dextromethorphan- *** pseudoeph liqd ml per 30 days Doxylamine- retail) Acetaminophen) QL(240 ml per BROTAPP DM LIQD F F QL(240 ml per fill retail) CODITUSS DM SYRP fill retail) CAPCOF SYRP F COLD & FLU RELIEF F NIGHTTIME D LIQD CAPMIST DM TABS F COMTREX COLD & COUGH MAXIMUM PA CAPRON DM LIQD F STRENGTH TABS (Use *** Dextromethorphan- cetirizine-pseudoephedrine F QL(2 ea daily) Phenylephrine- tb12 Acetaminophen) CHERACOL PLUS LIQD QL(240 ml per COMTREX COLD & (Use Dextromethorphan- *** fill retail) COUGH NIGHTTIME Guaifenesin) MAXIMUM STRENGTH *** CHERACOL-D COUGH QL(240 ml per TABS (Use Phenylephrine- LIQD (Use *** fill retail) Chlorpheniramine-DM w/ Dextromethorphan- APAP) Guaifenesin) CONEX COLD/ALLERGY F PA chlorpheniramine & F SOLN phenylephrine liqd CORICIDIN HBP COLD & chlorpheniramine & F FLU TABS (Use *** phenylephrine tabs Chlorpheniramine- Acetaminophen) chlorpheniramine & F pseudoeph tabs

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DAY TIME MULTI- dextromethorphan- QL(2 ea SYMPTOM COLD/FLU guaifenesin tb12 30mg- F daily,210 ea RELIEF CAPS (Use *** 600mg per fill retail) Dextromethorphan- dextromethorphan- Phenylephrine- guaifenesin tb12 60mg- F Acetaminophen) 1200mg DECON-A ELIX F dextromethorphan- phenylephrine- F DECON-A LIQD F acetaminophen caps dextromethorphan- dextromethorphan- phenylephrine- F acetaminophen- F acetaminophen liqd chlorpheniramine susp dextromethorphan- dextromethorphan- phenylephrine- F doxylamine-acetaminophen F acetaminophen tabs liqd DIABETIC TUSSIN F dextromethorphan- COLD/FLU CAPS guaifenesin caps 10mg- F 200mg DIMETAPP COLD & Limit 1 fill per ALLERGY ELIX (Use *** Month;QL(120 dextromethorphan- QL(240 ml per Brompheniramine & ml per 30 days guaifenesin liqd fill retail) Phenyleph) retail) 15mg/7.5ml-150mg/7.5ml, DIMETAPP DM COLD & 10mg/5ml-100mg/5ml, F 10mg/5ml-200mg/5ml, COUGH LIQD (Use *** 20mg/10ml-200mg/10ml, Phenylephrine- 10mg/5ml-10mg/5ml- Brompheniramine-DM) 100mg/5ml-100mg/5ml DIMETAPP LONG ACTING QL(240 ml per dextromethorphan- COUGH PLUS COLD F fill retail) guaifenesin liqd 30mg/5ml- SYRP 200mg/5ml, 30mg/5ml- diphenhydramine- F phenylephrine liqd 30mg/5ml-200mg/5ml- F 200mg/5ml, 20mg/20ml- diphenhydramine- F 400mg/20ml, 10mg/15ml- phenylephrine soln 200mg/15ml, 5mg/5ml- diphenhydramine- 100mg/5ml phenylephrine- dextromethorphan- QL(240 ml per acetaminophen liqd guaifenesin soln 10mg/5ml- F fill retail) 12.5mg/15ml-325mg/15ml- 100mg/5ml, 20mg/10ml- 5mg/15ml, 12.5mg/15ml- F 200mg/10ml 12.5mg/15ml-325mg/15ml- dextromethorphan- QL(240 ml per 325mg/15ml-10%- guaifenesin syrp fill retail) 5mg/15ml-5mg/15ml, 10mg/5ml-10mg/5ml- F 12.5mg/10ml-325mg/10ml- 100mg/5ml-100mg/5ml, 5mg/10ml 10mg/5ml-100mg/5ml diphenhydramine- QL(237 ml per dextromethorphan- phenylephrine- fill retail) acetaminophen liqd F guaifenesin tabs 20mg- F 20mg-400mg-400mg, 6.25mg/5ml-160mg/5ml- 20mg-400mg 2.5mg/5ml

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxylamine-dm liqd F MUCINEX CHILDRENS PA; QL(266 ml COLD COUGH & SORE per fill retail) DURAFLU TABS F PA THROAT LIQD (Use *** Phenylephrine-DM-GG w/ ED A-HIST LIQD (Use APAP) Chlorpheniramine & *** MUCINEX CHILDRENS PA; QL(266 ml Phenylephrine) MULTI-SYMPTOM COLD per fill retail) & FEVER LIQD (Use *** F QL(240 ml per ED BRON GP LIQD 6 days retail) Phenylephrine-DM-GG w/ EQL INFANTS QL(30 ml per 6 APAP) DECONGESTANT/COUG F days retail) MUCINEX CHILDRENS H SOLN MULTI-SYMPTOM COLD *** LIQD (Use Phenylephrine fexofenadine- F pseudoephedrine tb12 w/ DM-GG) MUCINEX CONGESTION fexofenadine- F pseudoephedrine tb24 & COUGH CHILDRENS *** LIQD (Use Phenylephrine GLENMAX PEB LIQD F w/ DM-GG) MUCINEX COUGH FOR F GNP DAY TIME MUCUS KIDS PACK RELIEFDM LIQD (Use *** Dextromethorphan- MUCINEX D MAXIMUM QL(2 ea daily) Guaifenesin) STRENGTH TB12 (Use *** Pseudoephedrine- guaifenesin-codeine liqd F Guaifenesin) 100mg/5ml-10mg/5ml MUCINEX D TB12 (Use QL(210 ea per guaifenesin-codeine soln F Pseudoephedrine- *** fill retail) 100mg/5ml-10mg/5ml Guaifenesin) guaifenesin-codeine soln F PA MUCINEX DM MAXIMUM 100mg/5ml-6.3mg/5ml STRENGTH TB12 (Use *** guaifenesin-codeine syrp F Dextromethorphan- 100mg/5ml-10mg/5ml Guaifenesin) LITTLE REMEDIES FOR MUCINEX DM TB12 (Use QL(2 ea COLDSMULTI SYMPTOM F Dextromethorphan- *** daily,210 ea LIQD Guaifenesin) per fill retail) LOHIST-D LIQD F QL(240 ml per MUCINEX FAST-MAX fill retail) COLD & SINUS LIQD (Use loratadine & QL(2 ea daily) Phenylephrine- *** pseudoephedrine tb12 F Acetaminophen- 5mg-120mg Guaifenesin) loratadine & QL(1 ea daily) MUCINEX FAST-MAX PA; QL(266 ml COLD FLU& SORE per fill retail) pseudoephedrine tb24 F 10mg-240mg, 10mg-10mg- THROAT CLEAR & COOL *** 240mg-240mg LIQD (Use Phenylephrine- DM-GG w/ APAP) M-END PE LIQD F PA MUCINEX FAST-MAX PA; QL(266 ml COLD FLU& SORE per fill retail) THROAT LIQD (Use *** Phenylephrine-DM-GG w/ APAP) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUCINEX FAST-MAX PA; QL(266 ml phenylephrine- F SEVERE COLD LIQD (Use *** per fill retail) chlorpheniramine-dm w/ Phenylephrine-DM-GG w/ apap susp APAP) phenylephrine- MUCINEX FAST-MAX chlorpheniramine-dm w/ F SEVERE CONGESTION & apap tabs COUGH CLEAR & COOL *** F QL(240 ml per LIQD (Use Phenylephrine phenylephrine-dm liqd fill retail) w/ DM-GG) F QL(240 ml per MUCINEX FAST-MAX phenylephrine-dm soln fill retail) SEVERE CONGESTION & *** COUGH LIQD (Use phenylephrine-dm-gg w/ PA; QL(266 ml Phenylephrine w/ DM-GG) apap liqd 20mg/20ml- per fill retail) 650mg/20ml-400mg/20ml- F MUCINEX STUFFY NOSE 10mg/20ml, 10mg/10ml- & COLD CHILDRENS *** 325mg/10ml-200mg/10ml- LIQD (Use Phenylephrine- 5mg/10ml Guaifenesin) phenylephrine-dm-gg w/ NORTUSS-EX LIQD F apap liqd 20mg/30ml- 650mg/30ml-400mg/30ml- F phenylephrine w/ F 10mg/30ml, 10mg/15ml- acetaminophen tabs 325mg/15ml-200mg/15ml- 5mg/15ml phenylephrine w/ dm-gg F liqd phenylephrine-dm-gg w/ apap tabs 10mg-10mg- phenylephrine w/ dm-gg F syrp 325mg-325mg-200mg- F phenylephrine- 200mg-5mg-5mg, 10mg- acetaminophen- 325mg-200mg-5mg guaifenesin liqd F phenylephrine-doxylamine- 650mg/20ml-400mg/20ml- dextromethorphan- F 10mg/20ml acetaminophen liqd phenylephrine- PA phenylephrine-guaifenesin F acetaminophen- liqd 100mg/5ml-2.5mg/5ml guaifenesin tabs 325mg- F phenylephrine-guaifenesin F QL(240 ml per 200mg-5mg, 325mg- liqd 100mg/5ml-5mg/5ml 6 days retail) 325mg-200mg-200mg- PHENYLEPHRINE/GUAIF F 5mg-5mg ENESIN LIQD phenylephrine- PHENYLHISTINE DH LIQD F acetaminophen- F guaifenesin tabs 650mg- 400mg-10mg PRO-CLEAR AC SYRP F phenylephrine- F PA brompheniramine-dm elix PRO-RED AC SYRP F phenylephrine- F promethazine & F QL(240 ml per brompheniramine-dm liqd phenylephrine soln 5 days retail) phenylephrine-chlorphen- F promethazine & F QL(240 ml per dm liqd phenylephrine syrp 5 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per PX NITETIME MULTI- F promethazine w/codeine F fill retail); AL; At syrp SYMPTOM CAPS least 6 yrs old REFENESEN CHEST QL(240 ml per CONGESTION & PAIN F promethazine-dm syrp F fill retail); AL; At RELIEF PE TABS least 2 yrs old RESCON DM SYRP F promethazine- QL(240 ml per phenylephrine-codeine F fill retail); AL; At RESCON-GG LIQD (Use QL(240 ml per syrp least 6 yrs old Phenylephrine- *** 6 days retail) Guaifenesin) PROMETHAZINE/PHENYL F QL(240 ml per EPHRINE SYRP 5 days retail) RESPAIRE-30 CAPS F pseudoephed-bromphen- F QL(240 ml per dm elix fill retail) ROBITUSSIN CHILDRENS F COUGH & COLD CF LIQD pseudoephed-bromphen- F QL(240 ml per dm syrp fill retail) ROBITUSSIN CHILDRENS COUGH/COLD LONG- F pseudoephed-doxyl-dm F w/apap caps ACTING LIQD ROBITUSSIN DM SYRP QL(240 ml per pseudoephedrine w/ F QL(240 ml per codeine-gg soln 6 days retail) (Use Dextromethorphan- *** fill retail) Guaifenesin) pseudoephedrine w/ dm-gg F QL(240 ml per liqd 6 days retail) ROBITUSSIN NIGHTTIME COUGH LONG-ACTING F pseudoephedrine- DM CHILDRENS LIQD acetaminophen- F dextromethorphan caps ROBITUSSIN PEAK COLD QL(240 ml per COUGH+ CHEST fill retail) pseudoephedrine- QL(240 ml per F CONGESTION DM MAX *** chlorphen-dm liqd fill retail) STRENGTH LIQD (Use QL(240 ml per pseudoephedrine-dm liqd F Dextromethorphan- fill retail) Guaifenesin) pseudoephedrine- QL(240 ml per ROBITUSSIN PEAK COLD QL(240 ml per guaifenesin syrp F fill retail) DM SYRP (Use *** fill retail) 30mg/5ml-100mg/5ml Dextromethorphan- pseudoephedrine- Guaifenesin) guaifenesin tabs 40mg- F ROBITUSSIN PEAK COLD 400mg MULTI-SYMPTOM COLD *** pseudoephedrine- QL(2 ea daily) LIQD (Use Phenylephrine guaifenesin tb12 120mg- F w/ DM-GG) 1200mg ROBITUSSIN TO GO pseudoephedrine- QL(210 ea per COUGH &COLD CF LIQD *** guaifenesin tb12 60mg- F fill retail) (Use Phenylephrine w/ DM- 600mg GG) QL(240 ml per pseudoephedrine-ibuprofen F SCOT-TUSSIN DM LIQD F susp fill retail) SCOT-TUSSIN LIQD (Use pseudoephedrine-ibuprofen F tabs Pheniramine-PE w/ Sod *** Salicylate & Caffeine PX DAYTIME MULTI- F SYMPTOM CAPS Citrate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SCOT-TUSSIN SENIOR F TYLENOL COLD MAX LIQD LIQD (Use PA Dextromethorphan- *** SEMPREX-D CAPS F Phenylephrine- TGQ Acetaminophen) 30PSE/150GFN/15DM F TYLENOL COLD MULTI- SYRP SYMPTOM NIGHTTIME THERAFLU SEVERE LIQD (Use Phenylephrine- *** COLD NIGHTTIME TABS Doxylamine- (Use Phenylephrine- *** Dextromethorphan- Chlorpheniramine-DM w/ Acetaminophen) APAP) TYLENOL COLD MULTI- TRIAMINIC COLD & QL(240 ml per SYMPTOM SEVERE COUGH DAY TIME F fill retail) DAYTIME LIQD (Use *** CHILDRENS SOLN Phenylephrine-DM-GG w/ APAP) TRIAMINIC COLD & QL(240 ml per COUGH DAY TIME F fill retail) TYLENOL CHILDRENS SYRP COLD/COUGH/RUNNYNO SE CHILDRENS SUSP *** TRIAMINIC FLU COUGH & F (Use Dextromethorphan- FEVER SYRP Acetaminophen- triprolidine & F Chlorpheniramine) pseudoephedrine tabs TYLENOL SINUS SEVERE PA TUSNEL LIQD F TABS (Use Phenylephrine- *** Acetaminophen- TUSNEL PEDIATRIC LIQD F Guaifenesin) TYLENOL WARMING TYLENOL CHILDRENS COUGH & SEVER PLUS FLU SUSP (Use CONGESTION DAYTIME *** Phenylephrine- *** LIQD (Use Phenylephrine- Chlorpheniramine-DM w/ DM-GG w/ APAP) APAP) VICKS NYQUIL COUGH TYLENOL CHILDRENS LIQD (Use Doxylamine- *** PLUS MULTI-SYMPTOM DM) COLD SUSP (Use *** ZYRTEC-D QL(2 ea daily) Phenylephrine- ALLERGY/CONGESTION *** Chlorpheniramine-DM w/ TB12 (Use Cetirizine- APAP) Pseudoephedrine) TYLENOL COLD & FLU Expectorants SEVERE TABS (Use *** Phenylephrine-DM-GG w/ Limit 1 fill per APAP) guaifenesin liqd 100 F Month;QL(240 TYLENOL COLD & HEAD PA mg/5ml, 400 mg/20ml ml per 6 days SEVERE CONGESTION retail) TABS (Use Phenylephrine- *** Limit 1 fill per guaifenesin soln 100 Month;QL(240 Acetaminophen- mg/5ml, 300 mg/15ml, 200 F Guaifenesin) ml per 6 days mg/10ml retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 fill per ADAPALENE LOTN 0.1 % F PA guaifenesin syrp 200 F Month;QL(240 mg/10ml, 100 mg/5ml ml per 6 days AKTIPAK PACK F PA retail) PA ATRALIN GEL (Use *** PA guaifenesin tabs 200 mg F Tretinoin) guaifenesin tabs 400 mg F AVAR LS CLEANSER PA LIQD (Use Sulfacetamide *** guaifenesin tb12 1200 mg F QL(2 ea daily) Sodium w/ Sulfur) PA Limit 1 fill per AVAR LS PADS F F Month;QL(40 PA guaifenesin tb12 600 mg ea per 30 days AVAR PADS F retail) AZELEX CREA F PA MUCINEX FOR KIDS F PA PACK BENZAC AC WASH LIQD *** RX/OTC MUCINEX MAXIMUM QL(2 ea daily) (Use Benzoyl Peroxide) STRENGTH TB12 (Use *** BENZACLIN GEL (Use PA Guaifenesin) Clindamycin Phosphate- *** Limit 1 fill per Benzoyl Peroxide) MUCINEX TB12 (Use *** Month;QL(40 BENZACLIN WITH PUMP PA Guaifenesin) ea per 30 days GEL (Use Clindamycin *** retail) Phosphate-Benzoyl Misc. Respiratory Inhalants Peroxide) BENZAMYCIN GEL (Use PA; QL(46.6 sodium chloride (inhalant) F QL(240 ml per aers 0.9 % fill retail) Benzoyl Peroxide- *** gm per fill Erythromycin) retail) sodium chloride (inhalant) F nebu 0.9 %, 10 %, 3 % BENZEFOAM FOAM (Use *** PA; RX/OTC Benzoyl Peroxide) Mucolytics BENZEFOAM ULTRA PA acetylcysteine soln F FOAM (Use Benzoyl *** Peroxide) DERMATOLOGICALS - Drugs to Treat Skin BENZEFOAMULTRA PA Conditions FOAM (Use Benzoyl *** Acne Products Peroxide) PA; QL(2 ea BENZOYL PEROXIDE 8% F PA ABSORICA CAPS *** daily); AL; At GEL least 12 yrs old benzoyl peroxide bar 10 % F ACANYA GEL F PA BENZOYL PEROXIDE F QL(340.2 gm CLEANSER LOTN per fill retail) ACNE MEDICATION 10 F LOTN benzoyl peroxide crea 10 F %, 2.5 % ACNE MEDICATION 5 F LOTN benzoyl peroxide foam 5.3 F PA; RX/OTC % adapalene crea 0.1 % F PA benzoyl peroxide foam 9.8 F PA % adapalene gel 0.3 % F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzoyl peroxide gel 10 % F RX/OTC CLINDAGEL GEL ***

BENZOYL PEROXIDE F clindamycin phosphate F PA GEL 2.5 % (topical) foam benzoyl peroxide gel 5 % F clindamycin phosphate 1 (topical) gel PA benzoyl peroxide kit F clindamycin phosphate F (topical) lotn QL(237 gm per clindamycin phosphate F benzoyl peroxide liqd 10 % F fill retail); (topical) soln RX/OTC clindamycin phosphate F PA benzoyl peroxide liqd 2.5 F RX/OTC (topical) swab %, 5 % clindamycin phosphate- F PA F QL(204 gm per benzoyl peroxide gel benzoyl peroxide liqd 4 % fill retail) clindamycin phosphate- F PA benzoyl peroxide liqd 7 % F PA tretinoin gel QL(340.2 gm DESQUAM-X WASH LIQD QL(237 gm per benzoyl peroxide lotn 6 % F per fill retail); 10 % (Use Benzoyl *** fill retail); RX/OTC Peroxide) RX/OTC PA DESQUAM-X WASH LIQD RX/OTC benzoyl peroxide misc 6 % F 5 % (Use Benzoyl *** Peroxide) PA; QL(46.6 benzoyl peroxide- F gm per fill DIFFERIN CREA 0.1 % *** PA erythromycin gel retail) (Use Adapalene) DIFFERIN GEL 0.3 % (Use PA BP CLEANSING WASH F PA *** EMUL Adapalene) PA BPO CREAMY WASH F PA DIFFERIN LOTN 0.1 % F COMPLETEPACK KIT CLARIFOAM EF FOAM PA ERYGEL GEL (Use *** QL(60 gm per (Use Sulfacetamide *** Erythromycin (Acne Aid)) fill retail) QL(60 gm per Sodium w/ Sulfur) erythromycin (acne aid) gel F CLEAN & CLEAR fill retail) erythromycin (acne aid) PA ADVANTAGE 3-IN-1 F F EXFOLIATING CLEANSER pads LOTN erythromycin (acne aid) F CLEOCIN-T GEL (Use soln Clindamycin Phosphate *** EVOCLIN FOAM (Use PA (Topical)) Clindamycin Phosphate *** CLEOCIN-T LOTN (Use (Topical)) Clindamycin Phosphate *** PA (Topical)) FABIOR FOAM F CLEOCIN-T SOLN (Use INOVA 4/1 ACNE F PA Clindamycin Phosphate *** CONTROL THERAPY KIT (Topical)) INOVA 8/2 ACNE F PA CLEOCIN-T SWAB (Use PA CONTROL THERAPY KIT Clindamycin Phosphate *** PA (Topical)) INOVA KIT F ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea sulfacetamide sodium w/ F PA isotretinoin caps F daily); AL; At sulfur crea 5%-10% least 12 yrs old sulfacetamide sodium w/ F PA KLARON LOTN (Use QL(236 ml per sulfur emul 1%-10% Sulfacetamide Sodium *** fill retail) sulfacetamide sodium w/ F QL(340.2 gm (Acne)) sulfur emul 5%-10% per fill retail) NEUAC KIT KIT F PA sulfacetamide sodium w/ PA sulfur liqd 2%-10%, 2%- F NEUTROGENA ON-THE- 2%-10%-10%, 4%-9%, SPOT ACNE TREATMENT *** 4.5%-9% CREA (Use Benzoyl sulfacetamide sodium w/ F QL(60 gm per Peroxide) sulfur lotn 5%-10% fill retail) PANOXYL LIQD (Use *** RX/OTC sulfacetamide sodium w/ PA Benzoyl Peroxide) sulfur pads 4%-10%, 4%- F PANOXYL-4 CREAMY QL(204 gm per 4%-10%-10% WASH LIQD (Use Benzoyl *** fill retail) sulfacetamide sodium w/ F PA Peroxide) sulfur susp 4%-8% RETIN-A CREA 0.1 %, QL(20 gm per sulfacetamide sodium- F PA 0.025 %, 0.05 % (Use *** fill retail); AL; sulfur w/ skin cleanser kit Tretinoin) Up to 35 yrs old SUMADAN KIT KIT (Use PA QL(15 gm per Sulfacetamide Sodium- *** RETIN-A GEL 0.01 % (Use *** ) fill retail); AL; Sulfur w/ Skin Cleanser) Tretinoin Up to 35 yrs old SUMADAN WASH LIQD PA RETIN-A GEL 0.025 % *** AL; Up to 35 (Use Sulfacetamide *** (Use Tretinoin) yrs old Sodium w/ Sulfur) RETIN-A MICRO GEL (Use *** PA PA Tretinoin Microsphere) SUMAXIN CP KIT KIT F RETIN-A MICRO PUMP PA SUMAXIN PADS (Use PA GEL 0.04 %, 0.1 % (Use *** Sulfacetamide Sodium w/ *** Tretinoin Microsphere) Sulfur) RETIN-A MICRO PUMP F PA SUMAXIN TS SUSP (Use PA GEL 0.08 % Sulfacetamide Sodium w/ *** ROSULA PADS F PA Sulfur) SUMAXIN WASH LIQD PA SODIUM QL(60 gm per (Use Sulfacetamide *** SULFACETAMIDE/SULFU F fill retail) Sodium w/ Sulfur) R LOTN QL(20 gm per SODIUM QL(30 gm per tretinoin crea 0.025 %, 0.1 F fill retail); AL; SULFACETAMIDE/SULFU F fill retail) %, 0.05 % Up to 35 yrs old R SUSP QL(15 gm per SSS 10-5 FOAM F PA tretinoin gel 0.01 % F fill retail); AL; Up to 35 yrs old sulfacetamide sodium QL(236 ml per F F AL; Up to 35 (acne) lotn fill retail) tretinoin gel 0.025 % yrs old sulfacetamide sodium F QL(236 ml per PA (acne) susp fill retail) tretinoin gel 0.05 % F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tretinoin microsphere gel F PA CORTISPORIN OINT F PA

VELTIN GEL F PA gentamicin sulfate (topical) F QL(60 gm per crea fill retail) ZIANA GEL (Use PA GENTAMICIN SULFATE F QL(60 gm per Clindamycin Phosphate- *** OINT fill retail) Tretinoin) mupirocin calcium (topical) F QL(30 gm per Agents for External Genital and Perianal Warts crea fill retail) VEREGEN OINT F PA F QL(30 gm per mupirocin oint fill retail) Analgesics - Topical NEO-SYNALAR CREA F PA ICY HOT PAIN RELIEVING GEL GEL (Use Menthol *** neomycin-bacitracin- F QL(907.8 gm (Topical Analgesic)) polymyxin oint per fill retail) neomycin-bacitracin- QL(56 gm per menthol (topical analgesic) F F gel polymyxin-pramoxine oint fill retail) neomycin-polymyxin w/ F QL(15 gm per Anti-inflammatory Agents - Topical pramoxine crea 30 days retail) diclofenac sodium (topical) F PA; QL(6.68 gel 1 % gm daily) NEOSPORIN ORIGINAL QL(907.8 gm OINT (Use Neomycin- *** per fill retail) diclofenac sodium (topical) F PA Bacitracin-Polymyxin) soln 1.5 %, 1.5% NEOSPORIN PLUS PAIN QL(15 gm per FLECTOR PTCH F PA RELIEF MAXIMUM 30 days retail) STRENGTH CREA (Use *** VOLTAREN GEL (Use PA; QL(6.68 Neomycin-Polymyxin w/ Diclofenac Sodium *** gm daily) Pramoxine) (Topical)) POLYSPORIN OINT (Use *** QL(144 gm per Antibiotics - Topical Bacitracin-Polymyxin B) fill retail) ALTABAX OINT F PA Antifungals - Topical ALEVAZOL OINT F PA BACIGUENT OINT (Use *** Bacitracin (Topical)) ALOE VESTA QL(2712 gm bacitracin (topical) oint F ANTIFUNGAL OINT (Use *** per fill retail) Miconazole Nitrate QL(30 gm per bacitracin zinc oint F (Topical)) fill retail) ALOE VESTA CLEAR QL(2712 gm QL(144 gm per bacitracin-polymyxin b oint F ANTIFUNGAL OINT (Use *** per fill retail) fill retail) Miconazole Nitrate BACTROBAN CREA (Use QL(30 gm per (Topical)) Mupirocin Calcium *** fill retail) AZOLEN TINCTURE F QL(29.57 ml (Topical)) SOLN per fill retail) BACTROBAN OINT (Use *** QL(30 gm per butenafine hcl crea F RX/OTC Mupirocin) fill retail) QL(100 gm per F QL(30 gm per ciclopirox gel 0.77 % F CENTANY OINT fill retail) fill retail) CORTISPORIN CREA F PA ciclopirox olamine crea F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(60 ml per ciclopirox olamine susp F F QL(125 ml per fill retail) LAMISIL AT SPRAY SOLN fill retail) ciclopirox sham 1 % F PA LOPROX CREA (Use *** Ciclopirox Olamine) QL(6.6 ml per ciclopirox soln 8 % F LOPROX SHAMPOO *** PA fill retail) SHAM (Use Ciclopirox) QL(113 gm per LOPROX SUSP (Use *** QL(60 ml per clotrimazole (topical) crea F fill retail); Ciclopirox Olamine) fill retail) RX/OTC QL(113 gm per QL(60 ml per LOTRIMIN AF CREA (Use *** )) fill retail); clotrimazole (topical) soln F fill retail); Clotrimazole (Topical RX/OTC RX/OTC LOTRIMIN AF FOR HER QL(113 gm per clotrimazole w/ F QL(45 gm per CREA (Use Clotrimazole *** fill retail); betamethasone crea 30 days retail) (Topical)) RX/OTC clotrimazole w/ F QL(30 ml per LOTRIMIN AF JOCK ITCH QL(113 gm per betamethasone lotn 30 days retail) CREA (Use Clotrimazole *** fill retail); (Topical)) RX/OTC F QL(30 gm per econazole nitrate crea fill retail) LOTRIMIN ULTRA CREA F RX/OTC ERTACZO CREA F PA LOTRIMIN ULTRA CREA *** RX/OTC EXELDERM CREA F PA (Use Butenafine HCl) LOTRISONE CREA (Use QL(45 gm per EXELDERM SOLN F PA Clotrimazole w/ *** 30 days retail) Betamethasone) EXTINA FOAM (Use *** PA RX/OTC Ketoconazole (Topical)) MENTAX CREA F FUNGOID TINCTURE F QL(29.57 ml MICATIN CREA (Use SOLN per fill retail) Miconazole Nitrate *** (Topical)) GENTIAN VIOLET SOLN F miconazole nitrate (topical) F GNP GENTIAN VIOLET F crea SOLN miconazole nitrate (topical) F QL(2712 gm JUBLIA SOLN F PA oint per fill retail) miconazole nitrate (topical) F QL(1020 gm F QL(60 gm per powd per fill retail) ketoconazole (topical) crea fill retail) naftifine hcl crea F PA ketoconazole (topical) foam F PA NAFTIN CREA 2 % (Use *** PA ketoconazole (topical) F QL(120 ml per Naftifine HCl) sham fill retail) NAFTIN GEL 1 %, 2 % F PA F QL(12 gm per LAMISIL ADVANCED GEL fill retail) NIZORAL A-D SHAM F LAMISIL AT CREA (Use *** QL(42 gm per Terbinafine HCl (Topical)) fill retail) NIZORAL SHAM (Use *** QL(120 ml per LAMISIL AT JOCK ITCH QL(42 gm per Ketoconazole (Topical)) fill retail) CREA (Use Terbinafine *** fill retail) F QL(30 gm per HCl (Topical)) nystatin (topical) crea fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(30 gm per Antihistamines-Topical nystatin (topical) oint fill retail) BENADRYL EXTRA QL(30 gm per QL(60 gm per nystatin-triamcinolone crea F STRENGTH CREA (Use *** fill retail) fill retail) Diphenhydramine-Zinc QL(60 gm per Acetate) nystatin-triamcinolone oint F fill retail) BENADRYL ITCH oxiconazole nitrate crea F PA STOPPING CREA (Use *** Diphenhydramine-Zinc Acetate) OXISTAT CREA (Use *** PA Oxiconazole Nitrate) diphenhydramine hcl F (topical) crea OXISTAT LOTN F PA diphenhydramine hcl F PEDIADERM AF F PA (topical) gel COMPLETE KIT KIT diphenhydramine hcl F PENLAC NAIL LACQUER *** QL(6.6 ml per (topical) soln SOLN (Use Ciclopirox) fill retail) diphenhydramine-zinc F terbinafine hcl (topical) F QL(42 gm per acetate crea 0.1%-1% crea fill retail) diphenhydramine-zinc QL(30 gm per TINACTIN AERP (Use *** QL(138 gm per acetate crea 0.1%-2%, F fill retail) Tolnaftate) fill retail) 0.1%-0.1%-2%-2% TINACTIN CREA (Use QL(30 gm per *** diphenhydramine-zinc F Tolnaftate) fill retail) acetate liqd 0.1%-2% TINACTIN DEODORANT *** QL(138 gm per Antineoplastic or Premalignant Lesion Agents - AERP (Use Tolnaftate) fill retail) CARAC CREA F TINACTIN JOCK ITCH *** QL(138 gm per AERP (Use Tolnaftate) fill retail) diclofenac sodium (actinic F PA TINACTIN JOCK ITCH *** QL(30 gm per keratoses) gel CREA (Use Tolnaftate) fill retail) EFUDEX CREA (Use *** QL(40 gm per TINACTIN POWD (Use *** QL(113 gm per Fluorouracil (Topical)) 30 days retail) Tolnaftate) fill retail) FLUOROPLEX CREA F PA F QL(138 gm per tolnaftate aerp ex fill retail) fluorouracil (topical) crea 5 F QL(40 gm per % 30 days retail) F QL(30 gm per tolnaftate crea ex fill retail) fluorouracil (topical) soln 2 F QL(10 ml per %, 5 % 30 days retail) F QL(151 ml per tolnaftate liqd ex fill retail) FLUOROURACIL CREA F 0.5 % F QL(113 gm per tolnaftate powd ex fill retail) FLUOROURACIL SOLN 2 F QL(10 ml per TOLNAFTATE POWD XX F %, 5 % 30 days retail) PANRETIN GEL F PA F QL(151 ml per tolnaftate soln ex fill retail) PICATO GEL F PA VUSION OINT F PA SOLARAZE GEL (Use PA XOLEGEL GEL F PA Diclofenac Sodium (Actinic *** Keratoses))

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALCHLOR GEL F PA QL(200 gm per TAZORAC GEL 0.05 %, F 0.1 % fill retail); AL; Antipruritics - Topical Up to 21 yrs old QL(222 ml per Antiseborrheic Products camphor & menthol lotn F fill retail) HEAD & SHOULDERS 2IN1 CLASSIC DOXEPIN F PA *** HYDROCHLORIDE CREA CLEAN/NORMAL SHAM (Use Pyrithione Zinc) PRUDOXIN CREA F PA HEAD & SHOULDERS CLASSICCLEAN/NORMAL SARNA LOTN (Use *** QL(222 ml per *** Camphor & Menthol) fill retail) SHAM (Use Pyrithione PA Zinc) ZONALON CREA F HEAD & SHOULDERS *** Antipsoriatics DRY SCALP 2 IN 1 SHAM (Use Pyrithione Zinc) 8-MOP CAPS F PA OVACE PLUS LOTN F PA PA acitretin caps F OVACE PLUS WASH GEL PA (Use Sulfacetamide *** F QL(120 gm per Sodium) calcipotriene crea fill retail) OVACE PLUS WASH LIQD calcipotriene oint F (Use Sulfacetamide *** Sodium) QL(60 ml per calcipotriene soln F fill retail) OVACE WASH LIQD (Use *** Sulfacetamide Sodium) DOVONEX CREA (Use *** QL(120 gm per Calcipotriene) fill retail) pyrithione zinc sham F DRITHO-CREME HP F F QL(355 ml per CREA salicylic acid & sulfur sham fill retail) methoxsalen rapid caps F PA SEBULEX SHAM (Use *** QL(355 ml per Salicylic Acid & Sulfur) fill retail) OXSORALEN ULTRA PA QL(420 ml per CAPS (Use Methoxsalen *** selenium sulfide lotn 1 % F Rapid) fill retail) QL(120 ml per SORIATANE CAPS (Use *** PA selenium sulfide lotn 2.5 % F Acitretin) fill retail) PA F QL(420 ml per SORILUX FOAM F selenium sulfide sham 1 % fill retail) QL(120 gm per SELSUN BLUE DAILY QL(420 ml per tazarotene crea F fill retail); AL; LOTN (Use Selenium *** fill retail) Up to 21 yrs old Sulfide) QL(240 gm per SELSUN BLUE LOTN (Use *** QL(420 ml per TAZORAC CREA 0.05 % F fill retail); AL; Selenium Sulfide) fill retail) Up to 21 yrs old SELSUN BLUE QL(420 ml per QL(120 gm per MEDICATED LOTN (Use *** fill retail) TAZORAC CREA 0.1 % *** Selenium Sulfide) ) fill retail); AL; (Use Tazarotene Up to 21 yrs old

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELSUN BLUE QL(420 ml per AUGMENTED QL(50 gm per MOISTURIZING LOTN *** fill retail) BETAMETHASONE F fill retail) (Use Selenium Sulfide) DIPROPIONATE GEL sulfacetamide sodium gel F PA betamethasone F ex dipropionate (topical) crea sulfacetamide sodium liqd F betamethasone F QL(60 ml per ex dipropionate (topical) lotn fill retail) Antivirals - Topical betamethasone F dipropionate (topical) oint F QL(30 gm per acyclovir topical oint 30 days retail) betamethasone QL(50 gm per F PA dipropionate augmented fill retail) DENAVIR CREA F gel PA betamethasone QL(50 gm per XERESE CREA F dipropionate augmented F fill retail) QL(5 gm per fill oint ZOVIRAX CREA EX 5 % F retail) betamethasone valerate F crea 0.1 % ZOVIRAX OINT EX 5 % *** QL(30 gm per (Use Acyclovir Topical) 30 days retail) betamethasone valerate F PA foam 0.12 % Burn Products betamethasone valerate F mafenide acetate pack F PA lotn 0.1 % betamethasone valerate SILVADENE CREA (Use *** F Silver Sulfadiazine) oint 0.1 % PA silver sulfadiazine crea F CAPEX SHAM F QL(60 gm per SULFAMYLON CREA 85 F clobetasol propionate crea F MG/GM fill retail) clobetasol propionate QL(60 gm per SULFAMYLON PACK 5 % *** PA F (Use Mafenide Acetate) emollient base crea fill retail) clobetasol propionate F PA Corticosteroids - Topical emulsion foam ACLOVATE CREA (Use PA PA Alclometasone *** clobetasol propionate foam F Dipropionate) QL(60 gm per clobetasol propionate gel F alclometasone dipropionate F PA fill retail) crea clobetasol propionate liqd F PA alclometasone dipropionate F PA oint clobetasol propionate lotn F PA F QL(60 gm per AMCINONIDE CREA fill retail) F QL(60 gm per clobetasol propionate oint fill retail) AMCINONIDE LOTN F PA clobetasol propionate sham F PA AMCINONIDE OINT F PA QL(50 ml per clobetasol propionate soln F APEXICON E CREA F PA fill retail) CLOBEX LIQD (Use *** PA Clobetasol Propionate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLOBEX LOTN (Use *** PA DIFLORASONE F QL(60 gm per Clobetasol Propionate) DIACETATE CREA fill retail) CLOBEX SHAM (Use *** PA DIFLORASONE F QL(60 gm per Clobetasol Propionate) DIACETATE OINT fill retail) CLOCORTOLONE F PA DIPROLENE OINT (Use QL(50 gm per PIVALATE CREA Betamethasone *** fill retail) Dipropionate Augmented) CLOCORTOLONE F PA PIVALATE PUMP CREA ELOCON CREA (Use *** QL(50 gm per Mometasone Furoate) fill retail) CLODAN KIT KIT F PA ELOCON LOTN (Use *** PA CLODERM CREA F PA Mometasone Furoate) ELOCON OINT (Use *** QL(45 gm per CLODERM PUMP CREA F PA Mometasone Furoate) fill retail) EPIFOAM FOAM F CORDRAN TAPE F PA fluocinolone acetonide crea F PA; QL(60 gm CORDRAN TAPE TAPE F PA 0.01 % per fill retail) fluocinolone acetonide crea F PA; QL(120 gm CUTIVATE CREA (Use *** QL(60 gm per 0.025 % per fill retail) Fluticasone Propionate) fill retail) fluocinolone acetonide oint F PA; QL(120 gm CUTIVATE LOTN (Use *** PA 0.025 % per fill retail) Fluticasone Propionate) fluocinolone acetonide soln F PA DERMATOP CREA (Use *** PA 0.01 % Prednicarbate) QL(120 gm per fluocinonide crea 0.05 % F DERMATOP OINT (Use *** PA fill retail) Prednicarbate) fluocinonide crea 0.1 % F PA DESONATE GEL F PA fluocinonide emulsified F QL(60 gm per F PA; QL(60 gm base crea fill retail) desonide crea per fill retail) QL(60 gm per fluocinonide gel 0.05 % F F PA; QL(118 ml fill retail) desonide lotn per fill retail) QL(60 gm per fluocinonide oint 0.05 % F F PA; QL(60 gm fill retail) desonide oint per fill retail) QL(60 ml per fluocinonide soln 0.05 % F DESOWEN CREA (Use *** PA; QL(60 gm fill retail) Desonide) per fill retail) fluticasone propionate crea F QL(60 gm per DESOWEN LOTN (Use *** PA; QL(118 ml 0.05 % fill retail) Desonide) per fill retail) fluticasone propionate lotn F PA desoximetasone crea 0.05 F QL(300 gm per 0.05 % % fill retail) fluticasone propionate oint F QL(60 gm per desoximetasone crea 0.25 F PA; QL(200 gm 0.005 % fill retail) % per fill retail) halobetasol propionate F PA desoximetasone gel 0.05 F PA; QL(60 gm crea % per fill retail) halobetasol propionate oint F PA desoximetasone oint 0.25 F PA; QL(100 gm % per fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALOG CREA F PA LOCOID OINT (Use *** Hydrocortisone Butyrate) PA HALOG OINT F LOCOID SOLN (Use *** Hydrocortisone Butyrate) hydrocortisone (topical) F LUXIQ FOAM (Use *** PA crea 0.5 % Betamethasone Valerate) QL(454 gm per hydrocortisone (topical) F QL(50 gm per F fill retail); mometasone furoate crea fill retail) crea 1%, 1 % RX/OTC QL(45 gm per mometasone furoate oint F hydrocortisone (topical) F QL(120 gm per fill retail) crea 2.5 % 30 days retail) mometasone furoate soln F PA hydrocortisone (topical) F QL(120 ml per lotn 1 % fill retail) MONISTAT SOOTHING QL(454 gm per hydrocortisone (topical) QL(118 ml per F CARE ITCH RELIEF CREA *** fill retail); lotn 2.5 % fill retail) (Use Hydrocortisone RX/OTC (Topical)) hydrocortisone (topical) F QL(56 gm per oint 0.5 % fill retail) OLUX FOAM (Use *** PA QL(60 gm per Clobetasol Propionate) hydrocortisone (topical) F 30 days retail); oint 1 % OLUX-E FOAM (Use PA RX/OTC Clobetasol Propionate *** Emulsion) hydrocortisone (topical) F oint 2.5 % PANDEL CREA F PA hydrocortisone acetate F (topical) crea PEDIADERM HC KIT F PA hydrocortisone butyrate F crea prednicarbate crea F PA hydrocortisone butyrate F PA hydrophilic lipo base crea prednicarbate oint F PA hydrocortisone butyrate F F QL(60 gm per oint PSORCON CREA fill retail) hydrocortisone butyrate F SYNALAR CREA 0.025 % PA; QL(120 gm soln (Use Fluocinolone *** per fill retail) hydrocortisone valerate F QL(60 gm per Acetonide) crea fill retail) SYNALAR OINT 0.025 % PA; QL(120 gm hydrocortisone valerate F PA (Use Fluocinolone *** per fill retail) oint Acetonide) hydrocortisone-aloe vera F QL(224 gm per SYNALAR SOLN 0.01 % PA crea fill retail) (Use Fluocinolone *** KENALOG AERS (Use PA Acetonide) Triamcinolone Acetonide *** TEMOVATE CREA (Use *** QL(60 gm per (Topical)) Clobetasol Propionate) fill retail) LOCOID CREA (Use *** TEMOVATE E CREA (Use QL(60 gm per Hydrocortisone Butyrate) Clobetasol Propionate *** fill retail) LOCOID LIPOCREAM PA Emollient Base) CREA (Use Hydrocortisone *** TEMOVATE GEL (Use *** QL(60 gm per Butyrate Hydrophilic Lipo Clobetasol Propionate) fill retail) Base) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEMOVATE OINT (Use *** QL(60 gm per Emollient/Keratolytic Agents Clobetasol Propionate) fill retail) ATRAC-TAIN CREA (Use *** QL(1704 gm TEMOVATE SOLN (Use *** QL(50 ml per Urea) per fill retail) Clobetasol Propionate) fill retail) CARMOL 10 LOTN (Use *** QL(480 ml per TEXACORT SOLN F PA Urea) fill retail) CARMOL 20 CREA (Use *** TOPICORT CREA 0.05 % *** QL(300 gm per Urea) (Use Desoximetasone) fill retail) QL(1704 gm urea crea 10 % F TOPICORT CREA 0.25 % *** PA; QL(200 gm per fill retail) (Use Desoximetasone) per fill retail) urea crea 20 %, 40 % F TOPICORT GEL 0.05 % *** PA; QL(60 gm (Use Desoximetasone) per fill retail) urea crea 50 % F PA TOPICORT LIQD 0.25 % F PA urea in zinc undecylenate- F PA TOPICORT OINT 0.25 % *** PA; QL(100 gm lactic acid vehicle emul ( ) Use Desoximetasone per fill retail) UREA IN ZINC PA triamcinolone acetonide F PA UNDECYLENATE/LACTIC F (topical) aers 0.147 mg/gm ACID VEHICLE EMUL triamcinolone acetonide QL(120 gm per F F QL(480 ml per (topical) crea 0.025 % 30 days retail) urea lotn 10 % fill retail) triamcinolone acetonide F (topical) crea 0.1 % urea lotn 40 % F triamcinolone acetonide F QL(15 gm per Emollients (topical) crea 0.5 % fill retail) A + D PERSONAL CARE F RX/OTC triamcinolone acetonide QL(60 ml per LOTION LOTN (topical) lotn 0.1 %, 0.025 F fill retail) % ALBOLENE CREA F RX/OTC triamcinolone acetonide QL(454 gm per F ALOE AFTERSUN F RX/OTC (topical) oint 0.025 % fill retail) LOTION LOTN triamcinolone acetonide F AMLACTIN CERAPEUTIC F RX/OTC (topical) oint 0.1 % LOTN triamcinolone acetonide F QL(15 gm per RX/OTC (topical) oint 0.5 % fill retail) AMLACTIN ULTRA CREA F TRIDESILON CREA (Use PA; QL(60 gm *** AQUA GLYCOLIC FACE F RX/OTC Desonide) per fill retail) CREAM CREA ULTRAVATE CREA (Use PA *** AQUA GLYCOLIC HAND & F RX/OTC Halobetasol Propionate) BODYLOTION LOTN ULTRAVATE OINT (Use *** PA RX/OTC Halobetasol Propionate) AQUA LACTEN LOTN F RX/OTC VANOS CREA (Use *** PA AQUADERM CREA F Fluocinonide) AQUADERM RX/OTC WESTCORT OINT (Use *** PA Hydrocortisone Valerate) TREATMENT/MOISTURIZ F ER LOTN Diaper Rash Products AQUAMED LOTN F RX/OTC diaper rash products oint F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AQUAPHILIC OINT F QL(10896 gm AVEENO POSITIVELY RX/OTC per fill retail) AGELESSSKIN F STRENGTHENING HAND AQUAPHOR ADVANCED F QL(10896 gm THERAPY OINT per fill retail) CREAM CREA AVEENO POSITIVELY RX/OTC AQUAPHOR OINT F QL(10896 gm per fill retail) NOURISHING 24-HOUR F ULTRA-HYDRATING AVEENO ACTIVE RX/OTC CREA NATURALS DAILY F MOISTURIZING BODY AVEENO POSITIVELY RX/OTC YOGURT LOTN NOURISHING F ENERGIZING LOTN AVEENO ACTIVE RX/OTC AVEENO POSITIVELY RX/OTC NATURALS DAILY F F MOISTURIZING BODY RADIANT LOTN YOGURT/APRICO LOTN AVEENO POSITIVELY RX/OTC AVEENO ACTIVE RADIANTOVERNIGHT F HYDRATING FACIAL NATURALS ECZEMA *** THERAPY CREA (Use MOISTURI CREA ) Colloidal Oatmeal AVEENO STRESS RELIEF F RX/OTC AVEENO ACTIVE MOISTURIZING LOTN NATURALS ECZEMA *** BASLE CREA F RX/OTC THERAPY HAND CREA (Use Colloidal Oatmeal) BETA CARE CREA F RX/OTC AVEENO ACTIVE RX/OTC RX/OTC NATURALS SKIN RELIEF F BETA CARE LOTN F MOISTURE REPAIR CREA BETA XMA CREA F RX/OTC AVEENO BABY ECZEMA THERAPY CREA (Use *** BOUDREAUXS BABY QL(10896 gm Colloidal Oatmeal) BUTT SMOOTH DRY SKIN F per fill retail) AVEENO DAILY RX/OTC OINT MOISTURIZINGSPF 15 F CAM LOTN F RX/OTC LOTN RX/OTC AVEENO INTENSE F RX/OTC CARB-O-LAN 10 CREA F RELIEF HAND CREA RX/OTC AVEENO POSITIVELY RX/OTC CARB-O-LAN 20 CREA F F AGELESS LIFT & FIRM RX/OTC EYE CREA CARB-O-PHILIC/20 CREA F AVEENO POSITIVELY F RX/OTC RX/OTC AGELESS NIGHT CREA CARB-O-SAL 5 CREA F AVEENO POSITIVELY RX/OTC CERAVE AM SPF 30 F RX/OTC AGELESSFIRMING BODY F LOTN LOTN RX/OTC AVEENO POSITIVELY RX/OTC CERAVE CREA F AGELESSSKIN F RX/OTC STRENGTHENING BODY CERAVE LOTN F CREAM CREA CERAVE PM LOTN F RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CERAVE RENEWING SA F RX/OTC DERMAL THERAPY RX/OTC CREA EXTRA STRENGTH BODY F LOTION LOTN CERAVE SA RENEWING F RX/OTC LOTN DERMAL THERAPY FACE RX/OTC RX/OTC CAREMOISTURIZING F CETAPHIL CREA F LOTION LOTN CETAPHIL DAILY RX/OTC DERMAL THERAPY FOOT F RX/OTC ADVANCE ULTRA F MASSAGE LOTN HYDRATING LOTN DERMAL THERAPY HAND RX/OTC ELBOW & KNEE CREAM F CETAPHIL DAILY FACIAL F RX/OTC MOISTURIZER LOTN LOTN CETAPHIL RX/OTC DERMAL THERAPY HEEL F RX/OTC CARE LOTN DERMACONTROL F MOISTURIZER/SPF 30 DERMALUBE DAILY RX/OTC LOTN MOISTURIZING LOTION F CETAPHIL RX/OTC LOTN MOISTURIZING CREA *** DERMEND RX/OTC (Use Emollient) MOISTURIZING BRUISE F FORMULA CREA CETAPHIL F RX/OTC MOISTURIZING LOTN DHEA CREA F RX/OTC CETAPHIL F RX/OTC RESTORADERM LOTN DIABETIDERM CREA F RX/OTC CETAPHIL THERAPEUTIC F RX/OTC HAND CREA DIABETIDERM FOOT F RX/OTC CLN FACIAL RX/OTC REJUVENATING CREA MOISTURIZER F DIABETIDERM HAND & F RX/OTC NOURISHING LOTN BODY LOTN RX/OTC COCOA BUTTER HAND & F RX/OTC DIABETIDERM LOTN F BODYLOTION LOTN RX/OTC COCOA BUTTER LOTN F RX/OTC DMAE CREA F RX/OTC COCONUT OIL BEAUTY F RX/OTC DML FORTE CREA F CREA DROXY CREAM CREA F RX/OTC colloidal oatmeal crea F ELON SKIN REPAIR F RX/OTC CVS DAILY ULTRA F RX/OTC SYSTEM CREA MOISTURELOTION LOTN ELTA CREA F RX/OTC CVS MOISTURIZING F RX/OTC CREAM CREA EMOLLIA-CREME CREA F RX/OTC DAILY CONDITIONING F QL(10896 gm TREATMENT OINT per fill retail) EMOLLIA-LOTION LOTN F RX/OTC DERMABASEOIL IN F RX/OTC WATER CREA emollient crea F RX/OTC DERMAIDE ALOE CREA F RX/OTC emollient lotn 1.25 %, F RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits emollient oint 41 %, , 52 %, QL(10896 gm FORMULA 405 FACE F RX/OTC 0.16gm/30gm- F per fill retail) CREAM CREA 300mg/30gm-100unit/30gm FORMULA 405 LIGHT RX/OTC EPILYT LOTN F RX/OTC TEXTURED F MOISTURIZER CREA EQ THERAPEUTIC RX/OTC FORMULA 405 F RX/OTC MOISTURIZING CREAM F MOISTURIZING LOTN CREA RX/OTC EQL ADVANCED RX/OTC GENTLE CREA F RECOVERY SKIN CARE F GNP ADVANCED F RX/OTC LOTN RECOVERY LOTN EQL MOISTURIZING F RX/OTC GOLD BOND MEDICATED RX/OTC CREAM CREA BODYLOTION EXTRA F EQL ULTRA RX/OTC STRENGTH LOTN MOISTURIZING DAILY F GOLD BOND MEDICATED F RX/OTC LOTION LOTN BODYLOTION LOTN EUCERIN BABY LOTN F RX/OTC GOLD BOND ULTIMATE RX/OTC DIABETICS' DRY RELIEF F EUCERIN CALMING RX/OTC LOTN DAILY MOISTURIZER *** GOLD BOND ULTIMATE F RX/OTC CREA (Use Emollient) HEALING CREA EUCERIN DAILY RX/OTC GOLD BOND ULTIMATE F RX/OTC PROTECTION/SPF 30 F HEALING LOTN LOTN GOLD BOND ULTIMATE F QL(10896 gm EUCERIN INTENSIVE F RX/OTC HEALING OINT per fill retail) REPAIR LOTN GOLD BOND ULTIMATE F RX/OTC EUCERIN INTENSIVE F RX/OTC LOTN REPAIRHAND CREA GOLD BOND ULTIMATE F RX/OTC EUCERIN LOTN F RX/OTC PROTECTION LOTN EUCERIN ORIGINAL RX/OTC GOLD BOND ULTIMATE F RX/OTC HEALINGSOOTHING F RESTORING LOTN REPAIR LOTN GOLD BOND ULTIMATE RX/OTC RX/OTC SHEERRIBBONS F EUCERIN PLUS CREA F PEARLRADIANCE LOTN EUCERIN PLUS RX/OTC GOLD BOND ULTIMATE RX/OTC INTENSIVE REPAIR *** SHEERRIBBONS F CREA (Use Emollient) SILKSOFTNESS LOTN RX/OTC GOLD BOND ULTIMATE F RX/OTC EUCERIN PLUS LOTN F SOFTENING LOTN EUCERIN SKIN CALMING RX/OTC GOLD BOND ULTIMATE F RX/OTC DAILY MOISTURIZING *** SOOTHING CREA CREA (Use Emollient) GOLD BOND ULTIMATE F RX/OTC EUCERIN SMOOTHING RX/OTC SOOTHING LOTN REPAIRADVANCED F RX/OTC FORMULA LOTN GRX VITAMIN E LOTN F FORMULA 405 F RX/OTC RX/OTC ENRICHED EYE CREA HYDRASYN25 CREA F ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDRO-LAN CREA F RX/OTC LADY ESTHER 4 RX/OTC PURPOSE FACE CREAM F J & J BURN CREAM CREA F RX/OTC CREA LANAPHILIC OINT F QL(10896 gm KERADAN CREA F RX/OTC per fill retail) RX/OTC KERI ADVANCED RX/OTC LANOLOR CREA F MOISTURE THERAPY F LANTISEPTIC F RX/OTC LOTN THERAPEUTIC CREA KERI BASIC ESSENTIALS RX/OTC F LEADER FINGER CREAM F RX/OTC LOTN CREA KERI LONG LASTING RX/OTC F LUBRIDERM ADVANCED F RX/OTC CREA THERAPY LOTN KERI NOURISHING SHEA F RX/OTC LUBRIDERM DAILY RX/OTC BUTTER LOTN MOISTURE/NORMAL TO F KERI ORIGINAL LOTN F RX/OTC DRY SKIN LOTN LUBRIDERM DAILY RX/OTC RX/OTC KERI OVERNIGHT LOTN F MOISTURESHEA + F CALMING LAVENDER KERI RENEWAL MILK F RX/OTC JASMINE LOTN BODY LOTN LUBRIDERM INTENSE F RX/OTC KERI RENEWAL SKIN F RX/OTC SKIN REPAIR LOTN FIRMING LOTN RX/OTC KERI RENEWAL RX/OTC LUBRIDERM LOTN F STRETCH MARK F LUBRIDERM MENS 3-IN-1 F RX/OTC MINIMIZER LOTN LOTN KERI SENSITIVE SKIN RX/OTC F LUBRIDERM SERIOUSLY F RX/OTC LOTN SENSITIVE LOTN LAC-HYDRIN CREA (Use QL(385 gm per LUBRIDERM SKIN RX/OTC Lactic Acid (Ammonium *** fill retail); NOURISHINGWITH SHEA F Lactate)) RX/OTC AND COCOA BUTTERS LAC-HYDRIN LOTN (Use QL(1368 ml per LOTN Lactic Acid (Ammonium *** fill retail); LUBRIDERM SOOTHING F RX/OTC Lactate)) RX/OTC RELIEF/COOLING LOTN LAC-HYDRIN TWELVE QL(1368 ml per RX/OTC LOTN (Use Lactic Acid *** fill retail); LUBRISOFT LOTN F (Ammonium Lactate)) RX/OTC RX/OTC QL(385 gm per MAXAM LOTN F lactic acid (ammonium F fill retail); lactate) crea 12 % MEDELA TENDER CARE F RX/OTC RX/OTC LANOLIN CREA QL(1368 ml per lactic acid (ammonium MEDERMA AG FACE F RX/OTC F fill retail); CREAM CREA lactate) lotn 12 % RX/OTC MEDERMA AG HAND & F RX/OTC lactic acid (ammonium F BODY LOTION LOTN lactate) lotn 5 % MEDERMA STRETCH F RX/OTC LACTINOL HX CREA F RX/OTC MARKS THERAPY CREA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOISTURIZING CREAM F RX/OTC NIVEA ORIGINAL F RX/OTC CREA MOISTURE LOTN MOTHERS FRIEND CREA F RX/OTC NIVEA SOFT CREA F RX/OTC

MOTHERS FRIEND LOTN F RX/OTC NIVEA VISAGE CREA F RX/OTC

MSM SKIN LOTION LOTN F RX/OTC NIVEA VISAGE INNER RX/OTC BEAUTY NIGHTTIME F NEOSALUS LOTN F RX/OTC RENEWAL CREA RX/OTC NEOSPORIN ECZEMA NIVEA VISAGE LOTN F ESSENTIALS CREA (Use *** NUTRADERM ADVANCED F RX/OTC Colloidal Oatmeal) FORMULA LOTN NEUTROGENA BODY RX/OTC RX/OTC LIGHT SESAME F NUTRADERM CREA F FORMULA LOTN NUTRADERM LOTN F RX/OTC NEUTROGENA HAND F RX/OTC CREA NUTRASEB CREA F RX/OTC NEUTROGENA RX/OTC QL(10896 gm HAND/NORWEGIANFOR F OINTMENT BASE OINT F MULA/FAST ABSORBING per fill retail) CREA PEN-KERA CREA F RX/OTC NEUTROGENA HEALTHY F RX/OTC SKIN CREA PENTRAVAN CREA F RX/OTC NEUTROGENA HEALTHY F RX/OTC SKIN FACE SPF 15 LOTN PENTRAVAN PLUS CREA F RX/OTC NEUTROGENA RX/OTC QL(454 gm per MOISTURE SENSITIVE F PETROLATUM OINT F SKIN LOTN fill retail) NISEKO HYDRATING RX/OTC PRETTY FEET & HANDS F RX/OTC FACIAL MOISTURIZER F CREA CREA RA GENTLE SKIN CREAM F RX/OTC CREA NIVEA CREA F RX/OTC RA RENEWAL DRY SKIN F RX/OTC THERAPY LOTN NIVEA EXTRA ENRICHED F RX/OTC LOTION LOTN RADIAGUARD F RX/OTC ADVANCED LOTN NIVEA EXTRA ENRICHED F RX/OTC LOTN RESTA CREA F RX/OTC NIVEA GENTLE BODY F RX/OTC EXFOLIATOR LOTN RESTA LITE LOTN F RX/OTC NIVEA LIGHT CREA F RX/OTC RISABAL-PH CREA F RX/OTC NIVEA LIGHT LOTN F RX/OTC ROC DEEP WRINKLE F RX/OTC RX/OTC SERUM LOTN NIVEA LOTN F ROC MULTI CORREXION RX/OTC RX/OTC 5 IN1 RESTORING EYE F NIVEA ORIGINAL LOTN F CREAM CREA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROC MULTI CORREXION RX/OTC THERAPEUTIC F RX/OTC 5 IN1 RESTORING NIGHT F MOISTURIZING CREA CREAM CREA THERAPLEX F RX/OTC ROC MULTI CORREXION RX/OTC HYDROLOTION LOTN LIFTANTI-GRAVITY F RX/OTC NIGHT CREA TRIPLE CREAM CREA F ROC RETINOL F RX/OTC TROPAZONE LOTN F RX/OTC CORREXION CREA UDDERLY SMOOTH RX/OTC ROC RETINOL F RX/OTC F CORREXION MAX CREA CREA ROC RETINOL RX/OTC UDDERLY SMOOTH F RX/OTC CORREXION NIGHT F EXTRA CARE CREA CREA UDDERLY SMOOTH F RX/OTC ROC RETINOL RX/OTC EXTRA CARE20 CREA CORREXION SENSITIVE F RX/OTC EYE CREA VANICREAM CREA F ROC RETINOL RX/OTC VANICREAM LITE LOTN F RX/OTC CORREXION SENSITIVE F NIGHT CREA VELVACHOL CREA F RX/OTC ROSE MILK LOTN F RX/OTC VITAMIN E WITH F RX/OTC PANTHENOL CREA SKIN REPAIR LOTN F RX/OTC vitamins a & d (topical) oint F SOOTHE & COOL RX/OTC MOISTURIZING BODY F VP DERMABASE CREA F RX/OTC LOTION WITH ALOE LOTN WIBI LOTN F RX/OTC SOOTHE & COOL SKIN RX/OTC CREAMWITH ALOE & F ZIMS CRACK CREME F RX/OTC VITAMINS A, D & E CREA DAYTIME CREA SORBOLENE CREA F RX/OTC Enzymes - Topical GRANULEX AERS (Use PA SPECIAL CARE CREAM F RX/OTC Trypsin w/ Castor Oil & *** CREA Peruvian Balsam) ST IVES SWISS RX/OTC PA FORMULA 24HOUR F SANTYL OINT F MOISTURE LOTN PA STUDIO 35 EXTRA RX/OTC TBC AERS F MOISTURIZING LOTION F LOTN Immunomodulating Agents - Topical ALDARA CREA (Use *** PA STUDIO 35 RX/OTC Imiquimod) MOISTURIZING SKIN F CREA imiquimod crea F PA SWEEN CREAM CREA F ZYCLARA CREA F PA THERABETIC SKIN CARE F RX/OTC LOTN ZYCLARA PUMP CREA F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Immunosuppressive Agents - Topical CORN REMOVER ULTRA THIN PADS (Use Salicylic *** PA; QL(30 gm Acid) ELIDEL CREA F per 30 days retail) CORN REMOVER WATERPROOF PADS *** PA; QL(30 gm (Use Salicylic Acid) PROTOPIC OINT 0.03 % *** per 30 days (Use Tacrolimus (Topical)) retail); AL; At DERMAREST PSORIASIS F least 2 yrs old GEL PA; QL(30 gm KERALYT GEL 3 % F PROTOPIC OINT 0.1 % *** per 30 days (Use Tacrolimus (Topical)) retail); AL; At KERALYT GEL 6 % (Use *** least 16 yrs old Salicylic Acid) PA; QL(30 gm podofilox soln F tacrolimus (topical) oint F per 30 days 0.03 % retail); AL; At SALEX CREAM KIT (Use *** PA least 2 yrs old Salicylic Acid w/ Cleanser) PA; QL(30 gm SALEX LOTION KIT (Use *** PA Salicylic Acid w/ Cleanser) tacrolimus (topical) oint 0.1 F per 30 days % retail); AL; At SALEX SHAM (Use *** least 16 yrs old Salicylic Acid) QL(14 gm per Keratolytic/Antimitotic Agents salicylic acid gel 17 % F CLEAR AWAY ONE STEP fill retail) WARTREMOVER PADS *** salicylic acid gel 6 % F (Use Salicylic Acid) CLEAR AWAY PLANTAR salicylic acid liqd 17 % F SYSTEM PADS (Use *** Salicylic Acid) salicylic acid pads 40 % F CLEAR AWAY WART REMOVER SYSTEM *** salicylic acid sham 6 % F PADS (Use Salicylic Acid) F QL(15 ml per COMPOUND W FREEZE salicylic acid soln 17 % fill retail) OFF WART REMOVAL F SYSTEM AERO salicylic acid w/ cleanser kit F PA COMPOUND W LIQD (Use *** Salicylic Acid) Liniments COMPOUND W MAXIMUM QL(14 gm per ASPERCREME/ALOE STRENGTH GEL (Use *** fill retail) CREA (Use Trolamine *** Salicylic Acid) Salicylate) PA BENGAY GREASELESS CONDYLOX GEL F CREA (Use Menthol-Methyl *** Salicylate (Liniments)) CONDYLOX SOLN (Use *** Podofilox) BENGAY ULTRA CORN REMOVER ONE STRENGTH CREA (Use *** STEP PADS (Use Salicylic *** Camphor-Menthol-Methyl Acid) Salicylate) camphor-menthol-methyl F salicylate crea

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits liniments & rubs oint F F QL(42.5 gm per CAPZASIN-P CREA fill retail) menthol-methyl salicylate F CASTIVA WARMING F QL(113 gm per (liniments) crea LOTN fill retail) menthol-methyl salicylate F (liniments) oint DERMOPLAST AERO F MOBISYL CREA (Use *** DERMOPLAST PAIN F Trolamine Salicylate) RELIEVINGSPRAY AERO MYOFLEX CREA (Use *** F QL(31 gm per Trolamine Salicylate) dibucaine oint 30 days retail) SPORTSCREME CREA *** EMLA CREA (Use *** QL(30 gm per (Use Trolamine Salicylate) Lidocaine-Prilocaine) fill retail) TIGER BALM PAIN F GOLD BOND MULTI- QL(1 ml daily) RELIEVING PTCH SYMPTOM/ITCH & PAIN F RELIEF/MAXIMUM F QL(60 gm per TRIXAICIN CREA fill retail) STRENGTH CREA trolamine salicylate crea F ITCH-X GEL F QL(1 gm ZIKS ARTHRITIS PAIN F QL(56.6 gm per RELIEF CREA fill retail) lidocaine crea 4 % F daily,120 gm per fill retail) Local Anesthetics - Topical QL(453.6 gm lidocaine hcl crea 3 % F ARTHRITIS PAIN F QL(60 gm per per fill retail) RELIEVING CREA fill retail) QL(100 ml per AVEENO ANTI-ITCH F lidocaine hcl gel 2 % F fill retail); LOTN RX/OTC benzocaine-triclosan aero F F PA; QL(1 ea lidocaine ptch 5 % daily) CALADRYL LOTN (Use *** F QL(30 gm per Pramoxine-Calamine) lidocaine-prilocaine crea fill retail) CAPSAGEL EXTRA F QL(60 gm per STRENGTH GEL fill retail) lidocaine-prilocaine kit F QL(60 gm per CAPSAGEL GEL F lidocaine-transparent F fill retail) dressing kit CAPSAGEL MAXIMUM QL(30 gm per F LIDODERM PTCH (Use *** PA; QL(1 ea STRENGTH GEL fill retail) Lidocaine) daily) capsaicin crea 0.025 % F QL(1 gm LMX 4 CREA (Use *** daily,120 gm QL(60 gm per Lidocaine) capsaicin crea 0.075 % F per fill retail) fill retail) LMX 4 PLUS KIT (Use QL(56.6 gm per capsaicin crea 0.1 % F Lidocaine-Transparent *** fill retail) Dressing) CAPZASIN QUICK RELIEF F QL(1 ml daily) GEL NEUROMED7 CREA F CAPZASIN-HP CREA (Use *** QL(56.6 gm per pramoxine-calamine lotn F Capsaicin) fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pramoxine-zinc acetate lotn F A-MANTLE CREA F

PREDATOR CREA F QL(1 ml daily) F QL(10896 ml ABSORBASE OINT per fill retail) QL(1 ml daily) RA PAIN RELIEF CREA F ACUWASH LIQD F XOLIDO XP CREA F QL(1 ml daily) ALOE VESTA DAILY QL(11328 ml MOISTURIZER LOTN (Use *** per fill retail) ZOSTRIX DIABETIC FOOT QL(60 gm per Dimethicone (Topical)) PAIN CREA (Use *** fill retail) ALOE VESTA F QL(10896 ml Capsaicin) PROTECTIVE OINT per fill retail) Misc. Dermatological Products ALOE VESTA SKIN QL(11328 ml QL(473 ml per CONDITIONER LOTN *** per fill retail) 5 DAY LIQD F fill retail); (Use Dimethicone RX/OTC (Topical)) QL(2712 gm QL(473 ml per aluminum hydroxide oint ex F ALEVICYN ANTIPRURITIC F fill retail); per fill retail) SG LIQD RX/OTC aluminum sulfate & calcium F QL(473 ml per acetate pack dermatological products, F fill retail); misc. liqd AMERIDERM F QL(10896 ml RX/OTC PERISHIELD OINT per fill retail) QL(473 ml per AQUA GLYCOLIC FACIAL DIABETIDERM MASSAGE F F STIMULATOR LIQD fill retail); CLEANSER LIQD RX/OTC AQUA GLYCOLIC QL(473 ml per SHAMPOO & BODY F GENADUR LIQD F fill retail); CLEANSER LIQD RX/OTC AQUA GLYCOLIC TONER F QL(473 ml per LIQD JOBST IT STAYS/ROLL- F fill retail); ON LIQD AQUAPHOR LIP REPAIR F QL(10896 ml RX/OTC OINT per fill retail) QL(473 ml per ASC LOTIONIZED KERASAL FUNGAL NAIL F RENEWAL LIQD fill retail); ANTIMICROBIAL SKIN F RX/OTC CLEANSER LIQD QL(473 ml per AVEENO BABY CALMING F NAIL SCRUB LIQD F fill retail); COMFORT BATH LIQD RX/OTC AVEENO BABY QL(473 ml per CLEANSING THERAPY REMOVE ADHESIVE F F REMOVER LIQD fill retail); MOISTURIZING WASH RX/OTC LIQD QL(473 ml per AVEENO POSITIVELY THUM LIQD F fill retail); NOURISHING F RX/OTC ANTIOXIDANT INFUSED Misc. Topical BODY WASH LIQD AVEENO POSITIVELY F QL(5676 ml per 4-N-1 CREA fill retail) RADIANT60 SECOND IN- F SHOWER FACIAL LIQD F QL(10896 ml A+D FIRST AID OINT per fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BASIS CLEANSER EXTRA F CHAPSTICK ULTRA QL(10896 ml DRY LIQD MOISTUREDAYTIME F per fill retail) FORMULA OINT BASIS CLEANSER F NORMAL/DRY LIQD CHAPSTICK QL(10896 ml ULTRASMOOTH FORTIFY F per fill retail) BASIS CLEANSER F SENSITIVE LIQD OINT QL(10896 gm CHAPSTICK QL(10896 ml BASIS FACIAL F per fill retail); ULTRASMOOTH F per fill retail) MOISTURIZER CREA RX/OTC NOURISH OINT QL(10896 gm CHAPSTICK QL(10896 ml BASIS OVERNIGHT CREA F per fill retail); ULTRASMOOTH F per fill retail) RX/OTC REJUVENATE OINT BOUDREAUXS BUTT CHAPSTICK QL(10896 ml BATH BODYWASH & F ULTRASMOOTH SOOTHE F per fill retail) SHAMPOO LIQD OINT CLEAN & CLEAR BOUDREAUXS BUTT F PASTE OINT ESSENTIALSFOAMING F FACIAL CLEANSER LIQD CALAMINE LOTN F CLEAN & CLEAR FOAMING FACIAL F CARA-KLENZ SOLN F CLEANSER SENSITIVE QL(10896 gm SKIN LIQD CARRINGTON MOISTURE F per fill retail); CLEAN & CLEAR BARRIER CREA RX/OTC MORNING BURST BODY F QL(10896 gm WASH BOOST LIQD CARRINGTON MOISTURE F CLEAN & CLEAR BARRIER/ZINC CREA per fill retail); RX/OTC MORNING BURST F DETOXIFYING FACIAL CERAVE FOAMING F FACIAL CLEANSER LIQD CLEANSER LIQD CLEAN & CLEAR CERAVE HYDRATING F CLEANSER LIQD MORNING BURST FACIAL F CLEANSER LIQD F QL(10896 ml CERAVE OINT per fill retail) CLEAN & CLEAR MORNING BURST F CETAKLENZ LIQD F HYDRATING FACIAL CLEANSER LIQD CETAPHIL CLEAN & CLEAR NIGHT DERMACONTROL FOAM F RELAXING DEEP F WASH LIQD CLEANING FACE WASH CETAPHIL GENTLE F LIQD CLEANSER LIQD CLEANSING EYELID F CETAPHIL LIQD F PADS PADS CLN BODY WASH CETAPHIL F GENTLE NON-DRYING F RESTORADERM LIQD LIQD CHAPSTICK OVERNIGHT F QL(10896 ml CLN FACIAL CLEANSER OINT per fill retail) MOISTURE BALANCING F LIQD

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLN HAND & FOOT Limit 1 package WASH DEEP CLEANSING F CUTTER SPORT AERO *** per Claim, 2 LIQD per Month CLN SPORT WASH HIGH F CVS CLEANSING EYELID F PERFORMANCE LIQD WIPES PADS CLN SPORTWASH LIQD F Limit 1 package CVS INSECT REPELLENT *** AERO per Claim, 2 COLEMAN 100 MAX Limit 1 per Month INSECT package per *** CVS ISOPROPYL F RX/OTC REPELLENT/CONTINUOU Claim, 2 per ALCOHOL WIPES MISC S SPRAY AERO Month CVS SALINE WOUND F QL(7200 ml per COLEMAN INSECT Limit 1 WASH SOLN fill retail) REPELLENT/HIGH & DRY *** package per CVS TOTAL HOME Limit 1 package AERO Claim, 2 per INSECT REPELLENT *** per Claim, 2 Month AERO per Month Limit 1 COLEMAN INSECT DERMADROX OINT F QL(10896 ml REPELLENT/SPORTSME *** package per per fill retail) N AERO Claim, 2 per Month DERMAGRAN OINT (Use *** QL(2712 gm Aluminum Hydroxide) per fill retail) F QL(5676 ml per COOL BOTTOMS CREA fill retail) DERMAGRAN SKIN QL(2712 gm PROTECTANT OINT (Use *** per fill retail) CRITIC-AID CLEAR QL(10896 ml Aluminum Hydroxide) MOISTUREBARRIER F per fill retail) OINT F QL(11328 ml dimethicone (topical) lotn per fill retail) Limit 1 DOMEBORO PACK (Use *** package per CUTTER AERO Claim, 2 per Aluminum Sulfate & *** Month Calcium Acetate) Limit 1 DRYSOL SOLN F CUTTER ALL FAMILY *** package per AERO Claim, 2 per EQL BODY Month WASH/SENSITIVE SKIN F Limit 1 LIQD EQL BODY WASH/SHEA CUTTER BACKWOODS *** package per F AERO Claim, 2 per BUTTER LIQD Month EQL CLEAR HAND SOAP F Limit 1 REFILL LIQD CUTTER BACKWOODS *** package per EQL INVIGORATING DRY AERO Claim, 2 per MAKEUP REMOVER F Month TOWELETTES PADS Limit 1 EQL LIQUID HAND SOAP F *** package per LIQD CUTTER DRY AERO Claim, 2 per EQL LIQUID HAND SOAP F Month REFILL LIQD Limit 1 EQL MAKEUP REMOVER F CUTTER SKINSATIONS *** package per TOWELETTES PADS AERO Claim, 2 per Month EQL SKIN ASTRINGENT F LIQD ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESSENTRA WIPES 9X9" RX/OTC ISOPROPYL ALCOHOL F RX/OTC CLEANROOM F WIPES MISC SUPPLIES/PRESATURAT KP GENTLE SKIN F ED MISC CLEANSER LIQD QL(10896 gm EUCERIN CREA (Use Skin *** lanolin (topical) crea F ) per fill retail); Protectants, Misc. RX/OTC LANTISEPTIC SKIN F QL(10896 ml EUCERIN SKIN CALMING F PROTECTANT OINT per fill retail) BODYWASH LIQD MEDERMA AG BODY F EYE-SCRUB PADS F CLEANSER LIQD MEDERMA AG FACIAL F EYESCRUB LIQD F CLEANSER LIQD MEDERMA AG FACIAL F FREE & CLEAR FOR F TONER LIQD SENSITIVE SKIN LIQD MEIJER CALAMINE LOTN F F QL(10896 ml GERI PROTECT OINT per fill retail) NATURES WASH PLUS F GERI-WASH LIQD F LIQD NEOSPORIN LIP HEALTH QL(10896 ml GNP ISOPROPYL F RX/OTC OVERNIGHT RENEWAL F per fill retail) ALCOHOL WIPES MISC THERAPY OINT GNP SALINE WOUND QL(7200 ml per F F QL(5676 ml per WASH SOLN fill retail) NEUTRAPHOR CREA fill retail) GOLD BOND ULTIMATE NEUTRAPHORUS REX F QL(5676 ml per DEEP MOISTURE BODY F CREA fill retail) WASH EXFOLIATING LIQD NEUTROGENA DEEP CLEAN FACIAL F GOLD BOND ULTIMATE CLEANSER LIQD DEEP MOISTURE BODY F WASH HEALING LIQD NEUTROGENA FRESH FOAMINGCLEANSER F GOLD BOND ULTIMATE LIQD DEEP MOISTURE BODY F WASH SENSITIVE/OAT NIVEA VISAGE FOAMING F EXT LIQD FACIAL LIQD GOLD BOND ULTIMATE NIVEA VISAGE MOISTURIZING TONER F DEEP MOISTURE BODY F WASH SOFTENING/SHEA LIQD LIQD NOBLE MYSTIQUE BODY F GRX ASC LOTIONIZED CLEANSER LIQD ANTIMICROBIAL SKIN F OCUSOFT BABY EYELID CLEANSER LIQD & EYELASH CLEANSER F PADS HM EYELID WIPES PADS F OCUSOFT EYELID F QL(10896 gm CLEANSINGPADS PADS HYDROCERIN CREA F per fill retail); OCUSOFT LID SCRUB F RX/OTC PADS IONIL LIQD F OCUSOFT LID SCRUB F PLUS PADS ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 PROSHIELD PLUS SKIN F QL(5676 ml per OFF ACTIVE AERO *** package per PROTECTANT CREA fill retail) Claim, 2 per PROSHIELD QL(10896 gm Month PROTECTIVE F per fill retail); Limit 1 HANDCREAM CREA RX/OTC *** package per OFF DEEP WOODS AERO Claim, 2 per QC CALAMINE LOTN F Month RA ISOPROPYL F RX/OTC Limit 1 ALCOHOL WIPES MISC package per OFF DEEP WOODS AERO F RA MAKEUP REMOVER F Claim, 2 per EYELIDWIPES XL PADS Month RA RENEWAL QL(10896 ml Limit 1 ADVANCED HEALING F per fill retail) OFF DEEP WOODS DRY *** package per OINT AERO Claim, 2 per Month RA SALINE WOUND F QL(7200 ml per WASH SOLN fill retail) Limit 1 REFRESH CLEANSER OFF DEEP WOODS DRY F package per F AERO Claim, 2 per LIQD Month REHYLA HAIR + BODY F Limit 1 CLEANSER LIQD OFF DEEP WOODS *** package per REHYLA WASH LIQD F SPORTSMEN AERO Claim, 2 per Month REMEDY CLEAR-AID F QL(10896 ml Limit 1 OINT per fill retail) REMEDY FOAMING OFF FAMILYCARE *** package per SMOOTH & DRY AERO Claim, 2 per BODY F Month CLEANER/OLIVAMINE Limit 1 LIQD REMEDY NUTRASHIELD QL(5676 ml per OFF SMOOTH & DRY *** package per F AERO Claim, 2 per CREA fill retail) Month REMEDY SKIN REPAIR F QL(946 ml per CREA fill retail) PALOMAR E OINT F QL(10896 ml per fill retail) Limit 1 package REPEL FAMILY AERO *** per Claim, 2 F QL(10896 ml PELEVERUS CLEAR OINT per fill retail) per Month Limit 1 package F QL(10896 ml REPEL FAMILY DRY PELEVERUS GOLD OINT per fill retail) *** per Claim, 2 AERO per Month F QL(10896 ml PELEVERUS OINT per fill retail) Limit 1 package REPEL HUNTERS *** per Claim, 2 PERI-WASH LIQD F FORMULA AERO per Month PETROLEUM JELLY LIP QL(10896 ml Limit 1 package F REPEL SPORTSMEN *** TREATMENT OINT per fill retail) AERO per Claim, 2 PHARMACIST CHOICE RX/OTC per Month ALCOHOL PRED PADS F REPEL SPORTSMEN DRY Limit 1 package PADS *** per Claim, 2 AERO per Month

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 SOOTHE & COOL FREE F QL(10896 ml REPEL SPORTSMEN *** package per SKIN PASTE OINT per fill retail) MAX AERO Claim, 2 per SOOTHE & COOL QL(10896 ml Month MOISTURE BARRIER F per fill retail) Limit 1 OINT REPEL SPORTSMEN *** package per SOOTHE & COOL QL(10896 ml MAX LOTN Claim, 2 per PROTECT MOISTURE F per fill retail) Month BARRIER OINT RISAMINE OINT F SOOTHE & COOL SHAMPOO ANDBODY F ROC MAX RESURFACING F WASH WITH ALOE LIQD FACIAL CLEANSER LIQD SORBIDON HYDRATE QL(10896 gm SAFE WASH SOLN F QL(7200 ml per F per fill retail); fill retail) CREA RX/OTC SALINE WOUND WASH F QL(7200 ml per SOLN fill retail) STAPHSCRUB LIQD F SALJET RINSE SOLN F QL(7200 ml per SUMMERS EVE fill retail) CLEANSING F WASH/SENSITIVE SKIN F QL(7200 ml per SALJET SOLN fill retail) LIQD Limit 1 SUMMERS EVE NIGHT- TIME CLEANSING SAWYER INSECT *** package per F REPELLENT AERO Claim, 2 per WASH/SENSITIVE SKIN Month LIQD SAWYER INSECT Limit 1 SURE COMFORT RX/OTC ALCOHOL PREP PADS F REPELLENT *** package per CONTROLLED RELEASE Claim, 2 per PADS LOTN Month SYSTANE LID WIPES F PADS SENSI-CARE QL(10896 gm F per fill retail); TENA SKIN-CARING F MOISTURIZING CREA RX/OTC BODY WASH LIQD SENSI-CARE SEPTI-SOFT F TENA SKIN-CARING F CONENTRATE LIQD WASH CREAM LIQD QL(10896 gm TRIPLE PASTE OINT F skin protectants, misc. crea F per fill retail); RX/OTC TRIPLE PASTE SP OINT F skin protectants, misc. oint QL(10896 ml 51.1 %, , 0.7%-0.4%-1.7%, F per fill retail) ULTRATHON INSECT Limit 1 package 0.5%-6.3%-70% F per Claim, 2 REPELLENT 8 AERO per Month SM CALAMINE LOTN F Limit 1 package ULTRATHON INSECT F per Claim, 2 soap & cleansers liqd F REPELLENT LOTN per Month SOOTHE & COOL FREE F QL(10896 ml witch hazel-glycerin pads F MEDSEPTIC OINT per fill retail) SOOTHE & COOL FREE QL(10896 ml WOUND WASH SALINE F QL(7200 ml per MOISTURE BARRIER F per fill retail) SOLN fill retail) OINT ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zinc oxide (topical) crea 13 F Scabicides & Pediculicides % A-200 GEL EX 0.33%-4% F zinc oxide (topical) oint 20 F QL(500 gm per % fill retail) A-200 KIT CO 0.5%- zinc oxide (topical) oint 40 F 0.33%-4% (Use Permethrin *** % & Pyrethrins-Piperonyl Pigmenting-Depigmenting Agents Butoxide) PA ELIMITE CREA (Use *** QL(360 gm per hydroquinone crea F Permethrin) fill retail) PA F QL(60 gm per OXSORALEN LOTN F EURAX CREA fill retail) TRI-LUMA CREA F PA F QL(454 gm per EURAX LOTN fill retail) Poison Ivy Products F QL(1 ml per 14 KLOUT SHAM days retail) poison ivy treatments misc F LICEMD GEL F ZANFEL MISC (Use *** Poison Ivy Treatments) LICIDE TREATMENT KIT F KIT Rosacea Agents LINDANE LOTN F PA DOXYCYCLINE CPDR F PA lindane lotn F PA FINACEA GEL F PA PA METROCREAM CREA QL(45 gm per lindane sham F (Use Metronidazole *** 30 days retail) PA (Topical)) LINDANE SHAM F METROGEL GEL (Use *** PA Limit 2 fills per Metronidazole (Topical)) malathion lotn F month;QL(59 METROLOTION LOTN ml per fill retail) (Use Metronidazole *** (Topical)) NATROBA SUSP F metronidazole (topical) QL(45 gm per F NIX CREME RINSE LIQD *** crea 0.75 % 30 days retail) (Use Permethrin) PA; QL(45 gm metronidazole (topical) gel Limit 2 fills per F per 31 days OVIDE LOTN (Use *** 0.75 % ) month;QL(59 retail) Malathion ml per fill retail) metronidazole (topical) gel PA F permethrin & pyrethrins- F 1 % piperonyl butoxide kit metronidazole (topical) lotn F permethrin aero xx 0.5 % F 0.75 % PA F QL(360 gm per MIRVASO GEL F permethrin crea ex 5 % fill retail) NORITATE CREA F PA permethrin liqd ex 1 % F PA ORACEA CPDR F F QL(240 ml per permethrin lotn ex 1 % fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyrethrins-piperonyl F Wound Care Products butoxide liqd ACTIMARIS WOUND GEL QL(3000 ml per pyrethrins-piperonyl F F fill retail); butoxide sham GEL RX/OTC pyrethrins-piperonyl QL(3000 ml per butoxide-permethrin-nit F ALEVICYN ANTIPRURITIC F fill retail); remover kit GEL GEL RX/OTC RID AERO (Use *** QL(3000 ml per Permethrin) AMERIGEL WOUND F DRESSING GEL fill retail); RID COMPLETE LICE RX/OTC ELIMINATION KIT (Use QL(3000 ml per Pyrethrins-Piperonyl *** ATRAPRO ANTIPRURITIC F fill retail); Butoxide-Permethrin-Nit HYDROGEL GEL RX/OTC Remover) ATRAPRO DERMAL QL(4260 ml per RID ESSENTIAL LICE F F fill retail); ELIMINATION KIT KIT SPRAY LIQD RX/OTC RID LIQD (Use Pyrethrins- *** QL(3000 ml per Piperonyl Butoxide) CARRASMART GEL F fill retail); RX/OTC SCHOOLTIME SHAMPOO F QL(1 ml per 14 SHAM days retail) CARRASYN HYDROGEL QL(3000 ml per SPINOSAD SUSP F F fill retail); WOUND DRESSING GEL RX/OTC ULESFIA LOTN F PA CARRASYN V QL(3000 ml per HYDROGEL F fill retail); Tar Products WOUNDDRESSING GEL RX/OTC F QL(2040 ml per coal tar extract sham 0.5 % F COMFEEL PASTE PSTE fill retail) QL(473 ml per coal tar extract sham 1 % F QL(3000 ml per fill retail) CURAFIL GEL WOUND F DRESSING GEL fill retail); QL(480 ml per RX/OTC coal tar extract sham 2.5 % F fill retail) QL(3000 ml per CVS MANUKA HONEY F DENOREX THERAPEUTIC QL(480 ml per WOUND GEL GEL fill retail); 2-IN-1 SHAM (Use Coal *** fill retail) RX/OTC Tar Extract) QL(3000 ml per CVS SILVER GEL GEL F fill retail); DHS TAR GEL SHAM (Use *** Coal Tar Extract) RX/OTC DERMAGRAN QL(3000 ml per DHS TAR SHAM (Use Coal *** Tar Extract) HYDROGEL F fill retail); WOUNDDRESSING GEL RX/OTC NEUTROGENA T/GEL SHAM (Use Coal Tar *** DERMAGRAN-B QL(3000 ml per Extract) HYDROPHILIC WOUND F fill retail); DRESSING GEL RX/OTC NEUTROGENA T/GEL QL(3000 ml per STUBBORN ITCH *** CONTROL SHAM (Use DERMASYN GEL F fill retail); Coal Tar Extract) RX/OTC THERAPLEX T SHAM *** QL(473 ml per (Use Coal Tar Extract) fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3000 ml per QL(4260 ml per DIAB DAILY CARE GEL F fill retail); MICROCYN LIQD F fill retail); RX/OTC RX/OTC QL(3000 ml per MICROKLENZ QL(4260 ml per DIAB F.D.G. FREEZE- F F DRIED GEL fill retail); ANTISEPTIC WOUND fill retail); RX/OTC CLEANSER LIQD RX/OTC QL(3000 ml per QL(4260 ml per DIAB GEL F fill retail); NEXCARE WOUND F fill retail); RX/OTC CLEANSER LIQD RX/OTC QL(3000 ml per QL(3000 ml per ELTA DERMAL GEL GEL F fill retail); NU-GEL COLLAGEN F fill retail); RX/OTC WOUND DRESSING GEL RX/OTC QL(4260 ml per QL(4260 ml per ELTA DERMAL WOUND F F CLEANSER LIQD fill retail); PELEVERUS LIQD fill retail); RX/OTC RX/OTC QL(3000 ml per QL(4260 ml per ELTA DERMAL WOUND F PURACYN PLUS DUO- F GEL GEL fill retail); fill retail); RX/OTC CARE LIQD RX/OTC QL(3000 ml per QL(3000 ml per EXCEL-GEL GEL F fill retail); PURILON GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per GRX WOUND GEL F fill retail); RADIAGEL GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per HYDROGEL AG GEL F fill retail); RADIAPLEXRX GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per REGENECARE GEL F PA HYDROGEL GEL F fill retail); RX/OTC REGRANEX GEL F PA QL(3000 ml per INTRASITE GEL F fill retail); REMEDY 4-IN-1 BODY QL(4260 ml per APPLIPAK GEL RX/OTC CLEANSER/FOAMER F fill retail); KENDALL AMORPHOUS QL(3000 ml per LIQD RX/OTC HYDROGEL WOUND F fill retail); QL(4260 ml per RESTA WOUND F fill retail); DRESSING GEL RX/OTC CLEANSER LIQD QL(3000 ml per RX/OTC KERAGEL GEL F fill retail); QL(3000 ml per RESTORE HYDROGEL F RX/OTC DRESSING GEL fill retail); QL(3000 ml per RX/OTC KERAGELT GEL F fill retail); QL(3000 ml per REVITADERM WOUND F RX/OTC CARE GEL fill retail); MEDIHONEY QL(3000 ml per RX/OTC WOUND/BURNDRESSING F fill retail); QL(4260 ml per GEL RX/OTC SAF-CLENS AF LIQD F fill retail); MEDIHONEY QL(2040 ml per RX/OTC WOUND/BURNDRESSING F fill retail) PSTE ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3000 ml per WOUN'DRES COLLAGEN QL(3000 ml per SAF-GEL GEL F fill retail); HYDROGEL WOUND F fill retail); RX/OTC DRESSING GEL RX/OTC QL(4260 ml per QL(4260 ml per SEA-CLENS WOUND F F CLEANSER LIQD fill retail); WOUND CLEANSER LIQD fill retail); RX/OTC RX/OTC QL(4260 ml per QL(4260 ml per SHUR-CLENS LIQD F fill retail); wound cleansers liqd F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per SILVASORB GEL F fill retail); WOUND GEL GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per SILVERMED GEL F fill retail); WOUND GEL SPRAY GEL F fill retail); RX/OTC RX/OTC QL(4260 ml per QL(4260 ml per SILVERMED LIQD F fill retail); WOUND WASH LIQD F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per SKINTEGRITY F ZANABIN ANTIPRURITIC F fill retail); HYDROGEL GEL fill retail); HYDROGEL GEL RX/OTC RX/OTC QL(4260 ml per SKINTEGRITY WOUND F DIAGNOSTIC PRODUCTS LIQD fill retail); RX/OTC Diagnostic Drugs QL(3000 ml per GLUCAGEN DIAGNOSTIC F Limit 1 fill per SOLOSITE GEL F fill retail); SOLR Month RX/OTC QL(3000 ml per Diagnostic Tests SP ANTIPRURITIC GEL F fill retail); ALBUSTIX STRP F QL(100 ea per RX/OTC 30 days retail) QL(3000 ml per CHEK-STIX COMBO PAK QL(100 ea per SPECTRAGEL GEL F fill retail); URINALYSIS CONTROL F fill retail) RX/OTC STRP QL(3000 ml per CHEK-STIX CONTROL F QL(100 ea per STIMULEN GEL F fill retail); STRP fill retail) RX/OTC QL(1 ea CHEMSTRIP -10 WITH SG F QL(3000 ml per STRP daily,30 ea per TEGADERM HYDROGEL F 30 days retail) WOUND FILLER GEL fill retail); RX/OTC QL(1 ea QL(3000 ml per CHEMSTRIP 10 MD STRP F daily,30 ea per THERAHONEY GEL F fill retail); 30 days retail) RX/OTC QL(1 ea CHEMSTRIP 2 GP F daily,30 ea per TRIAD HYDROPHILIC F QL(2040 ml per STRIPS STRP WOUND DRESSING PSTE fill retail) 30 days retail) QL(3000 ml per QL(1 ea VASCUDERM HYDROGEL F fill retail); CHEMSTRIP 5 OB STRP F daily,30 ea per WOUNDDRESSING GEL RX/OTC 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea QL(1 ea CHEMSTRIP 7 STRP F daily,30 ea per MULTISTIX 8 SG STRP F daily,30 ea per 30 days retail) 30 days retail) QL(1 ea QL(1 ea CHEMSTRIP 9 STRIPS F F STRP daily,30 ea per MULTISTIX 9 SG STRP daily,30 ea per 30 days retail) 30 days retail) CHEMSTRIP UGK STRP F QL(100 ea per QL(1 ea 30 days retail) MULTISTIX 9 STRP F daily,30 ea per 30 days retail) CHEMSTRIP-K STRP F QL(100 ea per fill retail) QL(1 ea MULTISTIX STRP F daily,30 ea per CHEMSTRIP-MICRAL F QL(100 ea per STRP 30 days retail) 30 days retail) NOVA MAX PLUS QL(1 ea daily) CLINITEST REAGENT F TABS KETONE TESTSTRIPS F STRP CLINITEST TABS F PRECISION XTRA STRP F QL(1 ea daily) QL(1 ea VI COMBISTIX STRP F daily,30 ea per PTS PANELS KETONE F QL(1 ea daily) 30 days retail) TEST STRP PTS PANELS KETONE QL(1 ea daily) CVS KETONE CARE F QL(100 ea per *** STRP 30 days retail) TEST STRP F QL(30 ea per RELION KETONE STRP *** DIASTIX STRP 30 days retail) QL(1 ea RELION KETONE TEST *** HEMA-COMBISTIX STRP F daily,30 ea per STRIPS STRP 30 days retail) TRUE METRIX BLOOD F QL (5 ea daily); GLUCOSE TEST STRIPS RX/OTC KETO-DIASTIX STRP F QL(100 ea per 30 days retail) TRUETEST BLOOD F QL (5 ea daily); GLUCOSE TEST STRIPS RX/OTC KETOCARE STRP F QL(100 ea per fill retail) TRUETRACK BLOOD F QL (5 ea daily); GLUCOSE TEST STRIPS RX/OTC KETONE TEST STRIPS *** STRP QL(1 ea URISTIX 4 STRP F daily,30 ea per F QL(100 ea per KETOSTIX STRP fill retail) 30 days retail) QL(1 ea QL(1 ea LABSTIX STRP F daily,30 ea per URISTIX STRP F daily,30 ea per 30 days retail) 30 days retail) QL(1 ea UTI HOME TEST TEST F QL(30 ea per MULTISTIX 10 SG STRP F daily,30 ea per 30 days retail) 30 days retail) DIETARY PRODUCTS/DIETARY MANAGEMENT QL(1 ea PRODUCTS F MULTISTIX 5 STRP daily,30 ea per Dietary Management Products 30 days retail) PA QL(1 ea L-METHYL-MC NAC TABS F MULTISTIX 7 STRP F daily,30 ea per 30 days retail) METAFOLBIC PLUS TABS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOKE BCAA4 POWD F RX/OTC ALDACTAZIDE TABS 25MG-25MG (Use *** SULFZIX POWD F RX/OTC Spironolactone & Hydrochlorothiazide) RX/OTC XIZFLUS POWD F ALDACTAZIDE TABS F PA 50MG-50MG DIGESTIVE AIDS - Drugs to Treat Low Digestive amiloride & F QL(1 ea daily) Enzymes hydrochlorothiazide tabs Digestive Enzymes DYAZIDE CAPS (Use CREON CPEP PA Triamterene & *** 114000UNIT-36000UNIT- F Hydrochlorothiazide) 180000UNIT MAXZIDE TABS (Use CREON CPEP Triamterene & *** 76000UNIT-24000UNIT- Hydrochlorothiazide) 120000UNIT, 9500UNIT- MAXZIDE-25 TABS (Use 3000UNIT-15000UNIT, F Triamterene & *** 38000UNIT-12000UNIT- Hydrochlorothiazide) 60000UNIT, 19000UNIT- spironolactone & F 6000UNIT-30000UNIT hydrochlorothiazide tabs LACTAID FAST ACT TABS *** triamterene & F (Use Lactase) hydrochlorothiazide caps LACTAID TABS (Use *** triamterene & F Lactase) hydrochlorothiazide tabs lactase tabs F TRIAMTERENE/HYDROC F HLOROTHIAZIDE CAPS PANCREAZE CPEP F Loop Diuretics SUCRAID SOLN F PA; SP bumetanide tabs F PA BUMEX TABS (Use *** ULTRESA CPEP F Bumetanide) DEMADEX TABS (Use *** QL(1 ea daily) ZENPEP CPEP F Torsemide) DIURETICS - Drugs to Treat Heart, Circulation EDECRIN TABS (Use *** PA Conditions and Blood Pressure Ethacrynic Acid) Carbonic Anhydrase Inhibitors ethacrynic acid tabs F PA acetazolamide cp12 F furosemide soln 10 mg/ml F acetazolamide tabs F FUROSEMIDE SOLN 8 F MG/ML DIAMOX CP12 (Use *** Acetazolamide) furosemide tabs 20 mg, 40 F mg, 80 mg methazolamide tabs F LASIX TABS (Use *** Furosemide) NEPTAZANE TABS (Use *** Methazolamide) torsemide tabs F QL(1 ea daily) Diuretic Combinations ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Potassium Sparing Diuretics F QL(3.7 ml per calcitonin (salmon) soln fill retail) ALDACTONE TABS (Use *** Spironolactone) ETIDRONATE DISODIUM F PA TABS amiloride hcl tabs F QL(4 ea daily) FORTEO SOLN F PA; SP spironolactone tabs F F QL(3.7 ml per FORTICAL SOLN fill retail) Thiazides and Thiazide-Like Diuretics FOSAMAX PLUS D TABS F PA CHLOROTHIAZIDE TABS F QL(2 ea daily) 250 MG FOSAMAX TABS (Use *** QL(0.15 ea chlorothiazide tabs 500 mg F QL(4 ea daily) Alendronate Sodium) daily) ibandronate sodium tabs F PA chlorthalidone tabs F MIACALCIN SOLN IJ 200 F QL(2 ml per fill DIURIL SUSP F PA UNIT/ML retail) MIACALCIN SOLN NA 200 QL(3.7 ml per hydrochlorothiazide caps F UNIT/ACT (Use Calcitonin *** fill retail) (Salmon)) hydrochlorothiazide tabs F risedronate sodium tabs F PA indapamide tabs F risedronate sodium tbec F PA METHYCLOTHIAZIDE F PA TABS Fertility Regulators metolazone tabs F CHORIONIC F PA; SP GONADOTROPIN SOLR MICROZIDE CAPS (Use *** PA; SP Hydrochlorothiazide) NOVAREL SOLR F ENDOCRINE AND METABOLIC AGENTS - PREGNYL W/DILUENT PA; SP MISC. - Drugs to Treat Bone Disease and BENZYLALCOHOL/NACL F Regulate Hormones SOLR Bone Density Regulators Growth Hormone Receptor Antagonists PA; SP ACTONEL TABS (Use *** PA SOMAVERT SOLR F Risedronate Sodium) Growth Hormones ALENDRONATE SODIUM F QL(10.8 ml SOLN 70 MG/75ML daily) GENOTROPIN MINIQUICK F PA; SP SOLR alendronate sodium tabs F QL(1 ea daily) 10 mg, 5 mg GENOTROPIN SOLR F PA; SP alendronate sodium tabs F QL(0.15 ea 35 mg, 70 mg daily) HUMATROPE COMBO F PA; SP PACK SOLR ALENDRONATE SODIUM F QL(1 ea daily) TABS 40 MG HUMATROPE SOLR F PA; SP ATELVIA TBEC (Use *** PA Risedronate Sodium) NORDITROPIN FLEXPRO F PA; SP SOLN BONIVA TABS (Use *** PA Ibandronate Sodium)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUTROPIN AQ NUSPIN F PA; SP CARNITOR SF SOLN (Use QL(30 ml daily) 10 SOLN Levocarnitine (Metabolic *** Modifiers)) NUTROPIN AQ NUSPIN F PA; SP 20 SOLN CARNITOR SOLN 1 QL(30 ml daily) GM/10ML (Use NUTROPIN AQ NUSPIN 5 F PA; SP *** SOLN Levocarnitine (Metabolic Modifiers)) PA; SP NUTROPIN AQ PEN SOLN F CARNITOR TABS 330 MG QL(3 ea daily); PA; SP (Use Levocarnitine *** RX/OTC OMNITROPE SOLN F (Metabolic Modifiers)) PA OMNITROPE SOLR F PA; SP doxercalciferol caps F HECTOROL CAPS (Use PA SAIZEN CLICK.EASY F PA; SP *** SOLR Doxercalciferol) PA; SP SAIZEN SOLR F PA; SP KUVAN TBSO F

SAIZENPREP PA; SP levocarnitine (metabolic F QL(30 ml daily) RECONSTITUTIONKIT F modifiers) soln 1 gm/10ml SOLR levocarnitine (metabolic F QL(3 ea daily); modifiers) tabs 330 mg RX/OTC SEROSTIM SOLR F PA; SP ORFADIN CAPS F PA; SP ZOMACTON SOLR F PA; SP paricalcitol caps F PA ZORBTIVE SOLR F PA; SP ROCALTROL CAPS (Use *** Hormone Receptor Modulators Calcitriol) ROCALTROL SOLN (Use EVISTA TABS (Use *** QL(1 ea daily) *** Raloxifene HCl) Calcitriol) PA; SP raloxifene hcl tabs F QL(1 ea daily) SENSIPAR TABS F Insulin-Like Growth Factors (Somatomedins) sodium phenylbutyrate tabs F PA; SP PA; SP INCRELEX SOLN F ZEMPLAR CAPS (Use *** PA Paricalcitol) LHRH/GnRH Agonist Analog Pituitary Posterior Pituitary Hormones PA; SP SYNAREL SOLN F DDAVP SOLN NA 0.01 % QL(5 ml per fill (Use Desmopressin *** retail) Metabolic Modifiers Acetate Refrigerated) BUPHENYL TABS F PA; SP DDAVP SOLN NA 0.01 % QL(5 ml per fill (Use Desmopressin *** retail) BUPHENYL TABS (Use *** PA; SP Acetate Spray) Sodium Phenylbutyrate) DDAVP TABS OR 0.2 MG, QL(6 ea daily) calcitriol caps F 0.1 MG (Use *** Desmopressin Acetate) calcitriol soln F desmopressin acetate F QL(5 ml per fill refrigerated soln retail) CARBAGLU TABS F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desmopressin acetate F QL(5 ml per fill FEMHRT LOW DOSE PA spray refrigerated soln retail) TABS (Use Norethindrone *** Acetate-Ethinyl Estradiol) desmopressin acetate F QL(5 ml per fill spray soln retail) norethindrone acetate- F PA ethinyl estradiol tabs desmopressin acetate tabs F QL(6 ea daily) PREMPHASE TABS F PA STIMATE SOLN F PA; SP PREMPRO TABS F Prolactin Inhibitors Estrogens cabergoline tabs F PA Limit 8 patches Somatostatic Agents F per ALORA PTTW month;QL(0.3 octreotide acetate soln F PA; SP ea daily) Limit 4 patches SANDOSTATIN SOLN *** PA; SP (Use Octreotide Acetate) CLIMARA PTWK (Use *** per Estradiol) month;QL(0.15 SIGNIFOR SOLN F PA; SP ea daily) PA Vasopressin Receptor Antagonists DIVIGEL GEL F PA SAMSCA TABS F ENJUVIA TABS F PA ESTROGENS - Hormone Replacement/Modifying ESTRACE TABS OR 2 Drugs MG, 1 MG, 0.5 MG (Use *** Estradiol) Estrogen Combinations estradiol pttw td 0.05 Limit 8 patches ACTIVELLA TABS 0.1MG- PA; QL(1 ea mg/24hr, 0.1 mg/24hr, F per 0.5MG (Use Estradiol & *** daily) 0.025 mg/24hr, 0.0375 month;QL(0.3 Norethindrone Acetate) mg/24hr, 0.075 mg/24hr ea daily) ACTIVELLA TABS 0.5MG- PA estradiol ptwk td 0.025 Limit 4 patches 1MG (Use Estradiol & *** mg/24hr, 0.06 mg/24hr, per Norethindrone Acetate) 0.075 mg/24hr, 37.5 F month;QL(0.15 ANGELIQ TABS F PA mcg/24hr, 0.05 mg/24hr, ea daily) 0.1 mg/24hr PA CLIMARA PRO PTWK F estradiol tabs or 2 mg, 1 F mg, 0.5 mg COMBIPATCH PTTW F ESTROPIPATE TABS 0.75 F QL(1 ea daily) MG, 1.5 MG DUAVEE TABS F PA ESTROPIPATE TABS 3 F QL(2 ea daily) MG esterified estrogens & F QL(1 ea daily) methyltestosterone tabs EVAMIST SOLN F PA estradiol & norethindrone F PA; QL(1 ea acetate tabs 0.1mg-0.5mg daily) MENEST TABS F PA estradiol & norethindrone F PA Limit 8 patches acetate tabs 0.5mg-1mg F per MINIVELLE PTTW month;QL(0.3 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN TABS OR 0.3 QL(1 ea daily) moxifloxacin hcl tabs F PA MG, 0.9 MG, 1.25 MG, F 0.45 MG, 0.625 MG QL(56 ea per ofloxacin tabs F Limit 8 patches fill retail) VIVELLE-DOT PTTW (Use *** per GASTROINTESTINAL AGENTS - MISC. - Estradiol) month;QL(0.3 Miscellaneous Gastrointestinal Drugs ea daily) Antiflatulents FLUOROQUINOLONES - Drugs to Treat Bacterial Infections GAS-X CHEW (Use *** Simethicone) Fluoroquinolones GAS-X EXTRA AVELOX ABC PACK TABS *** PA STRENGTH CHEW (Use *** (Use Moxifloxacin HCl) Simethicone) AVELOX TABS (Use *** PA MYLICON INFANTS GAS QL(31 ml per Moxifloxacin HCl) RELIEF SUSP (Use *** 30 days retail) CIPRO SUSR 5 PA Simethicone) GM/100ML, 500 MG/5ML *** MYLICON SUSP (Use *** QL(31 ml per (Use Ciprofloxacin) Simethicone) 30 days retail) CIPRO TABS 250 MG, 500 simethicone chew 80 mg, F MG (Use Ciprofloxacin *** 125 mg HCl) simethicone liqd 20 F QL(31 ml per CIPRO XR TB24 (Use PA mg/0.3ml, 40 mg/0.6ml 30 days retail) Ciprofloxacin-Ciprofloxacin *** simethicone susp 40 F QL(31 ml per HCl) mg/0.6ml, 20 mg/0.3ml 30 days retail) CIPROFLOXACIN HCL F QL(6 ea per fill TABS 100 MG retail) Bile Acid Synthesis Disorder Agents PA; QL(5 ea ciprofloxacin hcl tabs 500 F CHOLBAM CAPS F mg, 750 mg, 250 mg daily); SP Gallstone Solubilizing Agents ciprofloxacin susr or 500 F PA mg/5ml, 250 mg/5ml ACTIGALL CAPS (Use *** Ursodiol) ciprofloxacin-ciprofloxacin F PA hcl tb24 CHENODAL TABS F PA FACTIVE TABS F PA URSO 250 TABS (Use *** QL(7 ea daily) Ursodiol) LEVAQUIN TABS ( QL(1 ea Use *** daily,14 ea per Levofloxacin) URSO FORTE TABS (Use *** fill retail) Ursodiol) levofloxacin soln iv 25 F PA ursodiol caps 300 mg F mg/ml QL(7 ea daily) LEVOFLOXACIN SOLN F PA ursodiol tabs 250 mg F OR 25 MG/ML levofloxacin soln or 25 F PA ursodiol tabs 500 mg F mg/ml QL(1 ea Gastrointestinal Antiallergy Agents levofloxacin tabs or 750 F daily,14 ea per mg, 250 mg, 500 mg cromolyn sodium F PA fill retail) (mastocytosis) conc

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GASTROCROM CONC PA mesalamine tbec or 1.2 gm F PA (Use Cromolyn Sodium *** (Mastocytosis)) mesalamine w/ cleanser kit F PA Gastrointestinal Chloride Channel Activators REMICADE SOLR F PA; SP AMITIZA CAPS F PA ROWASA KIT (Use *** PA Gastrointestinal Stimulants Mesalamine w/ Cleanser) metoclopramide hcl soln F SFROWASA ENEM F metoclopramide hcl tabs F sulfasalazine tabs F

METOCLOPRAMIDE ODT F PA TBDP sulfasalazine tbec F METOZOLV ODT TBDP *** PA Intestinal Acidifiers (Use Metoclopramide HCl) lactulose (encephalopathy) F REGLAN TABS (Use *** soln Metoclopramide HCl) Irritable Bowel Syndrome (IBS) Agents Inflammatory Bowel Agents alosetron hcl tabs F PA APRISO CP24 F PA LINZESS CAPS 290 MCG, F PA; SP ASACOL HD TBEC F QL(3 ea daily) 145 MCG LOTRONEX TABS (Use *** PA AZULFIDINE EN-TABS *** Alosetron HCl) TBEC (Use Sulfasalazine) Phosphate Binder Agents AZULFIDINE TABS (Use *** Sulfasalazine) calcium acetate (phosphate F binder) caps balsalazide disodium caps F QL(9 ea daily) calcium acetate (phosphate F RX/OTC binder) tabs CANASA SUPP F PA ELIPHOS TABS (Use RX/OTC CIMZIA KIT F PA; SP Calcium Acetate *** (Phosphate Binder)) COLAZAL CAPS (Use QL(9 ea daily) *** FOSRENOL CHEW (Use *** PA Balsalazide Disodium) Lanthanum Carbonate) QL(6 ea daily) DELZICOL CPDR F lanthanum carbonate chew F PA PA DIPENTUM CAPS F PHOSLYRA SOLN F PA PA GIAZO TABS F RENAGEL TABS F PA LIALDA TBEC (Use PA *** RENVELA PACK (Use *** PA Mesalamine) Sevelamer Carbonate) QL(3 ea daily) MESALAMINE DR TBEC F RENVELA TABS (Use *** PA Sevelamer Carbonate) QL(60 ml daily) mesalamine enem re 4 gm F sevelamer carbonate pack F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sevelamer carbonate tabs F PA Cystinosis Agents CYSTAGON CAPS F PA; SP VELPHORO CHEW F PA Genitourinary Irrigants Short Bowel Syndrome (SBS) Agents acetic acid soln F PA GATTEX KIT F PA; SP PA GENITOURINARY AGENTS - MISCELLANEOUS glycine (gu irrigant) soln F - Miscellaneous Drugs to Treat Reproductive neomycin/polymyxin b gu F PA Organs and Urinary System soln Acidifiers NEOSPORIN GU PA PA IRRIGANT SOLN (Use *** K-PHOS NO 2 TABS F Neomycin/Polymyxin B GU) Alkalinizers RENACIDIN SOLN F PA CYTRA-3 SYRP F PA sodium chloride (gu F pot & sod citrates w/citric F PA irrigant) soln ac soln SORBITOL SOLN IR 3.3 F PA potassium citrate %, 3 % (alkalinizer) tbcr 1080 mg, F 540 mg Interstitial Cystitis Agents PA potassium citrate F PA ELMIRON CAPS F (alkalinizer) tbcr 15 meq potassium citrate-citric acid F PA Prostatic Hypertrophy Agents pack 3300mg-1002mg alfuzosin hcl tb24 F PA potassium citrate-citric acid PA; RX/OTC soln 1100mg/5ml- AVODART CAPS (Use *** PA 1100mg/5ml-334mg/5ml- F Dutasteride) 334mg/5ml, 1100mg/5ml- PA 334mg/5ml CARDURA XL TB24 F SHOHLS SOLUTION QL(500 ml per dutasteride caps F PA MODIFIED SOLN (Use *** 30 days retail); Sodium Citrate & Citric RX/OTC dutasteride-tamsulosin hcl F PA Acid) caps QL(500 ml per QL(1 ea daily) sodium citrate & citric acid F 30 days retail); finasteride tabs F soln RX/OTC FLOMAX CAPS (Use *** QL(2 ea daily) UROCIT-K 10 TBCR (Use Tamsulosin HCl) Potassium Citrate *** JALYN CAPS (Use PA (Alkalinizer)) Dutasteride-Tamsulosin *** UROCIT-K 15 TBCR (Use PA HCl) Potassium Citrate *** PROSCAR TABS (Use *** QL(1 ea daily) (Alkalinizer)) Finasteride) UROCIT-K 5 TBCR (Use PA Potassium Citrate *** RAPAFLO CAPS F (Alkalinizer)) tamsulosin hcl caps F QL(2 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UROXATRAL TB24 (Use *** PA ALPROLIX SOLR F PA; SP Alfuzosin HCl) Urinary Analgesics BENEFIX KIT 3000 UNIT F PA; SP phenazopyridine hcl tabs F ELOCTATE SOLR F PA; SP PYRIDIUM TABS (Use *** PA; SP Phenazopyridine HCl) FEIBA NF SOLR F Urinary Stone Agents FEIBA SOLR F PA; SP LITHOSTAT TABS F PA HELIXATE FS KIT F PA; SP PA THIOLA TABS F HEMOFIL M SOLR 1501 - PA; SP 2000 UNIT, 801 -1500 F GOUT AGENTS - Drugs to Treat Gout UNIT Gout Agent Combinations HUMATE-P SOLR F PA; SP colchicine w/ probenecid F IXINITY SOLR 500 UNIT, PA; SP tabs 250 UNIT, 1000 UNIT, F Gout Agents 3000 UNIT, 2000 UNIT allopurinol tabs F KOGENATE FS BIO-SET F PA; SP KIT QL(6 ea per fill PA; SP COLCHICINE TABS F retail); AL; At KOGENATE FS KIT F least 16 yrs old MONOCLATE-P KIT F PA; SP QL(6 ea per fill COLCRYS TABS F retail); AL; At MONONINE SOLR F PA; SP least 16 yrs old PA; SP ULORIC TABS F PA RECOMBINATE SOLR F PA; SP ZYLOPRIM TABS (Use *** RIXUBIS SOLR F Allopurinol) PA; SP Uricosurics TRETTEN SOLR F probenecid tabs F Bradykinin B2 Receptor Antagonists PA; SP HEMATOLOGICAL AGENTS - MISC. - Drugs to FIRAZYR SOLN F Treat Blood Disorders Hematorheologic Agents Antihemophilic Products ADVATE SOLR 1500 PA; SP pentoxifylline tbcr F UNIT, 500 UNIT, 3000 F UNIT, 1000 UNIT, 2000 Plasma Kallikrein Inhibitors UNIT, 250 UNIT KALBITOR SOLN F PA; SP ALPHANATE/VON PA; SP WILLEBRANDFACTOR F Platelet Aggregation Inhibitors COMPLEX/HUMAN SOLR AGGRENOX CP12 (Use *** PA Aspirin-Dipyridamole) ALPHANINE SD SOLR F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AGRYLIN CAPS (Use *** cyanocobalamin tbcr or F Anagrelide HCl) 1000 mcg anagrelide hcl caps F NASCOBAL SOLN F PA aspirin-dipyridamole cp12 F PA Folic Acid/Folates folic acid tabs 1 mg F RX/OTC BRILINTA TABS F QL(2 ea daily) folic acid tabs 400 mcg, F QL(1 ea daily) cilostazol tabs F QL(2 ea daily) 800 mcg Hematopoietic Growth Factors clopidogrel bisulfate tabs F ARANESP ALBUMIN F PA; SP dipyridamole tabs F FREE SOLN ARANESP ALBUMIN F PA; SP EFFIENT TABS (Use *** PA FREE SOSY Prasugrel HCl) EPOGEN SOLN F PA; SP PERSANTINE TABS (Use *** Dipyridamole) GRANIX SOSY F PA; SP PLAVIX TABS (Use *** Clopidogrel Bisulfate) LEUKINE SOLR F PA; SP PLETAL TABS (Use *** QL(2 ea daily) Cilostazol) NEULASTA ONPRO KIT F PA; SP PSKT prasugrel hcl tabs F PA NEULASTA SOSY F PA; SP ZONTIVITY TABS F PA NEUPOGEN SOLN F PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders NEUPOGEN SOSY F PA; SP Agents for Gaucher Disease PROCRIT SOLN 40000 PA; SP CERDELGA CAPS F PA; SP UNIT/ML, 10000 UNIT/ML, 3000 UNIT/ML, 20000 F PA; SP UNIT/ML, 4000 UNIT/ML, ZAVESCA CAPS F 2000 UNIT/ML Agents for Sickle Cell Anemia PROMACTA TABS F PA; SP DROXIA CAPS F ZARXIO SOSY F PA; SP Cobalamins Hematopoietic Mixtures B-12 LOZG F B-12 1000 SUBL F cyanocobalamin soln ij F QL(10 ml per 1000 mcg/ml 270 days retail) B-12 SUBL F cyanocobalamin subl sl F 1000 mcg BIFERA TABS F cyanocobalamin tabs or fe fum-iron polysacch PA 1000 mcg, 250 mcg, 2000 F complex-fa-b complex-c- F mcg, 100 mcg, 500 mcg zn-mn-cu caps

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fe fumarate-vitamin c- F PA FEOSOL TABS (Use *** vitamin b12-folic acid caps Ferrous Sulfate Dried) FEOSOL BIFERA TABS F FER-IN-SOL SOLN (Use *** QL(3.4 ml Ferrous Sulfate) daily) PA FERRALET 90 TABS F FERGON TABS (Use *** Ferrous Gluconate) PA FERRAPLUS 90 TABS F FERRETTS TABS F QL(2 ea daily) ferrous fumarate w/ b12-vit F PA QL(2 ea daily) c-fa-ifc caps ferrous fumarate tabs F ferrous fumarate-fa-b QL(1 ea daily) FERROUS GLUCONATE F complex-c-zn-mg-mn-cu F TABS 225 MG, 324 MG tabs ferrous gluconate tabs 240 F ferrous fumarate-folic acid F PA mg, 324 mg, 27 mg tabs ferrous sulfate dried tabs F FOCALGIN DSS TABS F PA ferrous sulfate dried tbcr F FOLGARD TABS F ferrous sulfate elix 220 F folic acid-vitamin b6- F mg/5ml vitamin b12 tabs FERROUS SULFATE LIQD F HEMATOGEN FA CAPS F PA 220 MG/5ML ferrous sulfate soln 15 F QL(3.4 ml iron polysaccharide mg/ml daily) complex-vit b12-folic acid F caps FERROUS SULFATE F SYRP 300 MG/5ML MULTIGEN FOLIC TABS F PA ferrous sulfate tabs 325 F mg, 65 mg MULTIGEN PLUS TABS F PA FERROUS SULFATE F TBCR 140 MG MULTIGEN TABS F PA ferrous sulfate tbcr 142 mg, F NEPHRON FA TABS F PA 47.5 mg, 50 mg, 45 mg FERROUS SULFATE F NOVAFERRUM 125 LIQD F TBEC 324 MG TANDEM PLUS CAPS PA ferrous sulfate tbec 325 mg F (Use Fe Fum-Iron *** HEMOCYTE TABS (Use *** QL(2 ea daily) Polysacch Complex-FA-B Ferrous Fumarate) Complex-C-Zn-Mn-Cu) IRON CHEWS PEDIATRIC F TARON FORTE CAPS F PA CHEW Iron IRON TABS F carbonyl iron tabs F MYKIDZ IRON 10 SUSP F FEOSOL TABS (Use *** Carbonyl Iron) NOVAFERRUM 50 CAPS F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits polysaccharide iron F QL(1 ea daily) BUTISOL SODIUM TABS F PA complex caps phenobarbital elix 20 F PROFE CAPS F mg/5ml SLOW FE TBCR (Use *** phenobarbital soln 20 F Ferrous Sulfate) mg/5ml HEMOSTATICS - Drugs to Stop Bleeding/Treat PHENOBARBITAL TABS Blood Disorders 15 MG, 100 MG, 60 MG, F 30 MG Hemostatics - Systemic phenobarbital tabs 32.4 AMICAR TABS 1000 MG F PA; SP mg, 16.2 mg, 97.2 mg, 64.8 F mg F QL(24 ea per PA AMICAR TABS 500 MG fill retail); SP SECONAL CAPS F Limit 1 fill per PA Month;QL(30 SECONAL SODIUM CAPS F LYSTEDA TABS (Use *** Tranexamic Acid) ea per 5 days retail); AL; At Hypnotics - Tricyclic Agents least 12 yrs old SILENOR TABS F PA Limit 1 fill per Month;QL(30 Non-Barbiturate Hypnotics tranexamic acid tabs F ea per 5 days AMBIEN CR TBCR (Use *** PA retail); AL; At Zolpidem Tartrate) least 12 yrs old AMBIEN TABS (Use *** QL(1 ea daily) HYPNOTICS/SEDATIVES/SLEEP DISORDER Zolpidem Tartrate) AGENTS DORAL TABS F PA Antihistamine Hypnotics EDLUAR SUBL F PA diphenhydramine hcl F (sleep) caps 50 mg estazolam tabs F diphenhydramine hcl F QL(1 ea daily) (sleep) tabs 25 mg eszopiclone tabs F PA diphenhydramine hcl F (sleep) tabs 50 mg FLURAZEPAM HCL CAPS F QL(1 ea daily) doxylamine succinate F (sleep) tabs HALCION TABS (Use *** QL(1 ea daily) NYTOL MAXIMUM Triazolam) STRENGTH TABS (Use *** INTERMEZZO SUBL (Use *** PA Diphenhydramine HCl Zolpidem Tartrate) (Sleep)) LUNESTA TABS (Use *** PA UNISOM SLEEPGELS Eszopiclone) CAPS (Use *** midazolam hcl soln ij 10 QL(20 ml per Diphenhydramine HCl mg/10ml, 50 mg/10ml, 5 F 30 days retail) (Sleep)) mg/ml UNISOM TABS (Use midazolam hcl soln ij 10 F QL(4 ml per 30 Doxylamine Succinate *** mg/2ml, 5 mg/ml, 2 mg/2ml days retail) (Sleep)) midazolam hcl soln ij 5 F QL(10 ml per Barbiturate Hypnotics mg/5ml, 25 mg/5ml 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits midazolam hcl soln ij 5 F QL(6 ml per 84 mg/ml days retail) LAXATIVES - Bowel Treatment Drugs midazolam hcl syrp or 2 F PA Bulk Laxatives mg/ml BENEFIBER FOR QUAZEPAM TABS F PA CHILDREN POWD (Use *** Wheat Dextrin) QL(1 ea daily); BENEFIBER POWD (Use RESTORIL CAPS 15 MG, *** *** 30 MG (Use Temazepam) AL; At least 18 Wheat Dextrin) yrs old QL(10 ea daily) RESTORIL CAPS 7.5 MG, PA calcium polycarbophil tabs F 22.5 MG (Use *** CITRUCEL FIBER Temazepam) LAXATIVE POWD (Use *** SONATA CAPS 10 MG *** ST; QL(2 ea Methylcellulose (Laxative)) (Use Zaleplon) daily) CITRUCEL TABS (Use *** SONATA CAPS 5 MG (Use *** ST; QL(1 ea Methylcellulose (Laxative)) Zaleplon) daily) CVS NATURAL FIBER F temazepam caps 22.5 mg, F PA SUPPLEMENT PACK 7.5 mg EVAC POWD (Use *** QL(1 ea daily); Psyllium) temazepam caps 30 mg, F AL; At least 18 15 mg FIBERCON TABS (Use *** QL(10 ea daily) yrs old Calcium Polycarbophil) TRIAZOLAM TABS 0.125 QL(1 ea daily) F HYDROCIL INSTANT F MG PACK QL(1 ea daily) triazolam tabs 0.25 mg F HYDROCIL INSTANT *** POWD (Use Psyllium) F ST; QL(2 ea zaleplon caps 10 mg daily) KONSYL PACK 100 % F ST; QL(1 ea zaleplon caps 5 mg F KONSYL POWD 100 % *** daily) (Use Psyllium) zolpidem tartrate subl sl PA F KONSYL POWD 71.67 %, F 1.75 mg, 3.5 mg 60.3 % zolpidem tartrate tabs or 5 F QL(1 ea daily) mg, 10 mg KONSYL-D POWD F zolpidem tartrate tbcr or PA F METAMUCIL CAPS (Use *** 12.5 mg, 6.25 mg Psyllium) ZOLPIMIST SOLN F PA METAMUCIL MULTIHEALTH FIBER F Orexin Receptor Antagonists SINGLES PACK METAMUCIL ORIGINAL BELSOMRA TABS 20 MG, F PA 10 MG, 5 MG TEXTURE POWD (Use *** Psyllium) Selective Melatonin Receptor Agonists METAMUCIL POWD (Use *** HETLIOZ CAPS F PA; SP Psyllium) PA METAMUCIL SMOOTH ROZEREM TABS F TEXTUREFIBER SINGLES F PACK

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methylcellulose (laxative) F Laxatives - Miscellaneous powd glycerin (laxative) supp F methylcellulose (laxative) F tabs GLYCERIN ADULT SUPP *** psyllium caps F (Use Glycerin (Laxative)) KRISTALOSE PACK F PA psyllium powd F lactulose soln F wheat dextrin powd F MIRALAX PACK (Use *** RX/OTC Laxative Combinations Polyethylene Glycol 3350) bisacodyl-peg 3350-pot MIRALAX POWD (Use *** QL(34 gm chloride-sod bicarb-sod F Polyethylene Glycol 3350) daily); RX/OTC chloride kit PEDIA-LAX SUPP RE 1 COLYTE-FLAVOR PACKS QL(4000 ml per GM (Use Glycerin *** SOLR (Use PEG 3350- *** fill retail) (Laxative)) KCl-Sod Bicarb-Sod PEDIA-LAX SUPP RE 2.8 F Chloride-Sod Sulfate) GM GOLYTELY SOLR polyethylene glycol 3350 F RX/OTC 227.1GM-21.5GM-5.53GM- F pack 2.82GM-6.36GM polyethylene glycol 3350 F QL(34 gm GOLYTELY SOLR 236GM- QL(4000 ml per powd daily); RX/OTC 22.74GM-5.86GM-2.97GM- fill retail) 6.74GM (Use PEG 3350- *** SORBITOL SOLN OR 70 F KCl-Sod Bicarb-Sod % Chloride-Sod Sulfate) Lubricant Laxatives PA MOVIPREP SOLR F FLEET OIL ENEM (Use *** Mineral Oil) NULYTELY/FLAVOR PACKS SOLR (Use PEG KONDREMUL EMUL F 3350-Potassium Chloride- *** Sod Bicarbonate-Sod mineral oil enem re 100 % F Chloride) mineral oil oil or 100 %, F RX/OTC peg 3350-kcl-sod bicarb- QL(4000 ml per 99.9 % sod chloride-sod sulfate F fill retail) MINERAL OIL OIL OR 55 F RX/OTC solr % peg 3350-potassium chloride-sod bicarbonate- F Saline Laxatives sod chloride solr FLEET ENEMA ENEM *** PA (Use Sodium Phosphates) PREPOPIK PACK F FLEET ENEMA SIX PACK ENEM (Use Sodium *** sennosides-docusate F QL(4 ea daily) sodium tabs Phosphates) SENOKOT S TABS (Use QL(4 ea daily) FLEET PEDIATRIC ENEM *** Sennosides-Docusate *** (Use Sodium Phosphates) Sodium) magnesium citrate soln F SUPREP BOWEL PREP F PA KIT SOLN ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(992 ml per docusate sodium caps 250 F QL(3 ea daily) magnesium hydroxide susp 30 days retail) mg, 100 mg MILK OF MAGNESIA F docusate sodium caps 50 F CONCENTRATE SUSP mg OSMOPREP TABS F PA docusate sodium liqd 150 F mg/15ml, 50 mg/5ml PEDIA-LAX CHEW OR 400 F docusate sodium syrp 60 F MG mg/15ml sodium phosphates enem F docusate sodium tabs 100 F mg sodium phosphates soln F DOCUSOL MINI ENEM F Stimulant Laxatives DOCUSOL PLUS MINI- F ENEMA ENEM F QL(12 ea per bisacodyl supp re 10 mg fill retail) ENEMEEZ MINI ENEM F bisacodyl tbec or 5 mg F QL(1 ea daily) ENEMEEZ PLUS ENEM F DULCOLAX SUPP RE 10 *** QL(12 ea per MG (Use Bisacodyl) fill retail) PEDIA-LAX LIQD OR 50 F MG/15ML DULCOLAX TBEC OR 5 *** QL(1 ea daily) MG (Use Bisacodyl) MACROLIDES - Drugs to Treat Bacterial Infections EX-LAX CHEW (Use *** Sennosides) Azithromycin EX-LAX TABS (Use *** AZITHROMYCIN PACK 1 F QL(2 ea per fill Sennosides) GM retail) FLEET BISACODYL ENEM F azithromycin susr 100 F QL(15 ml per mg/5ml fill retail) SENNA SYRP F azithromycin susr 200 F QL(60 ml per mg/5ml fill retail) sennosides chew F F QL(6 ea per fill azithromycin tabs 250 mg retail) sennosides liqd F azithromycin tabs 500 mg F QL(4 ea daily) sennosides syrp F QL(8 ea per 28 azithromycin tabs 600 mg F sennosides tabs F days retail) ZITHROMAX PACK 1 GM F QL(2 ea per fill SENOKOT TABS (Use *** retail) Sennosides) ZITHROMAX SUSR 100 QL(15 ml per Surfactant Laxatives MG/5ML (Use *** fill retail) Azithromycin) COLACE CAPS (Use *** QL(3 ea daily) Docusate Sodium) ZITHROMAX SUSR 200 QL(60 ml per MG/5ML (Use *** fill retail) COLACE CLEAR CAPS *** (Use Docusate Sodium) Azithromycin) ZITHROMAX TABS 250 *** QL(6 ea per fill docusate calcium caps F MG (Use Azithromycin) retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZITHROMAX TABS 500 *** QL(4 ea daily) ERYTHROMYCIN BASE F MG (Use Azithromycin) TABS 250 MG, 500 MG ZITHROMAX TABS 600 *** QL(8 ea per 28 erythromycin MG (Use Azithromycin) days retail) ethylsuccinate susr 200 F mg/5ml ZITHROMAX TRI-PAK *** QL(4 ea daily) TABS (Use Azithromycin) ERYTHROMYCIN ETHYLSUCCINATE TABS F ZITHROMAX Z-PAK TABS *** QL(6 ea per fill (Use Azithromycin) retail) 400 MG ZMAX SUSR F PA PCE TBEC F Clarithromycin Fidaxomicin BIAXIN SUSR 250 DIFICID TABS F PA MG/5ML (Use *** Clarithromycin) MEDICAL DEVICES AND SUPPLIES BIAXIN TABS 500 MG, 250 *** QL(28 ea per MG (Use Clarithromycin) fill retail) Bandages-Dressings-Tape CLARITHROMYCIN SUSR F QL(100 ml per Adhesive Tape F 125 MG/5ML fill retail) clarithromycin susr 125 F QL(100 ml per Gauze Bandages F mg/5ml fill retail) Gauze Pads F clarithromycin susr 250 F mg/5ml Gauze Pads - Misc F CLARITHROMYCIN SUSR F 250 MG/5ML Transparent Dressings - F clarithromycin tabs 500 mg, F QL(28 ea per Misc 250 mg fill retail) Contraceptives QL(14 ea per clarithromycin tb24 500 mg F fill retail) F QL (36 ea per Condoms - Female 30 days) Erythromycins Condoms Latex Lubricated F QL (36 ea per E.E.S. 400 TABS F - Male 30 days) Condoms Latex Non- F QL (36 ea per E.E.S. GRANULES SUSR Lubricated - Male 30 days) (Use Erythromycin *** Ethylsuccinate) Condoms Non-Latex Non- F QL (36 ea per Lubricated - Male 30 days) ERY-TAB TBEC F Diabetic Supplies ERYPED 200 SUSR (Use Blood Glucose Calibration - F QL (1 ea per 90 Erythromycin *** Liquid days) Ethylsuccinate) Blood Glucose Calibration - F QL (1 ea per 90 ERYPED 400 SUSR F Liquid - High days) Blood Glucose Calibration - F QL (1 ea per 90 ERYTHROCIN STEARATE F Liquid - Low days) TABS Blood Glucose Calibration - F QL (1 ea per 90 erythromycin base cpep F Liquid - Normal days) 250 mg F QL (200 ea per Lancets - Misc 30 days) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL (1 ea per Insulin Pen Needle 32 G X F QL (5ea daily) Lancets Devices - Misc 180 days) 5 MM (1/5" or 3/16") TRUECONTROL QL(3 ea per Insulin Pen Needle 32 G X F QL (5ea daily) GLUCOSE CONTROL F 270 days retail) 6 MM (1/4") LEVEL 0 LIQD Insulin Pen Needle 32 G X F QL (5 ea daily) TRUECONTROL QL(3 ea per 8 MM GLUCOSE CONTROL F 270 days retail) Insulin Pen Needle 33 G X F QL (5ea daily) LEVEL 1 LIQD 4 MM (5/32") TRUETEST GLUCOSE QL(3 ea per F Insulin Syringe (Disp) U­ F QL (5 ea daily) CONTROLLEVEL 1 LIQD 270 days retail) 100 1 ML TRUETEST GLUCOSE QL(3 ea per F Insulin Syringe/Needle U- F QL (5ea daily) CONTROLLEVEL 2 LIQD 270 days retail) 100 0.3 ML 28 x 1/2" TRUETEST GLUCOSE QL(3 ea per F Insulin Syringe/Needle U- F QL (5ea daily) CONTROLLEVEL 3 LIQD 270 days retail) 100 0.3 ML 29 x 1" Misc. Devices Insulin Syringe/Needle U- F QL (5ea daily) 100 0.3 ML 29 x 1/2" F QL (400 ea per Alcohol Swabs - Misc 30 days) Insulin Syringe/Needle U- F QL (5ea daily) Parenteral Therapy Supplies 100 0.3 ML 30 x 1/2" Insulin Syringe/Needle U- QL (5ea daily) Allergy Tray Kit 1 ML 26 x F F 1/2" 100 0.3 ML 30 x 3/8" Insulin Syringe/Needle U- QL (5ea daily) Allergy Tray Kit 1/2 ML 27 F F x 1/2" 100 0.3 ML 30 x 5/16" EASY TOUCH PEN QL(5 ea daily); Insulin Syringe/Needle U- F QL (5ea daily) NEEDLE 30G X 5/16" F RX/OTC 100 0.3 ML 31 x 5/16" MISC Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 25 x 1" Insulin Pen Needle 29 G X F QL (5 ea daily) 10 MM Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 25 x 5/8" Insulin Pen Needle 29 G X F QL (5ea daily) 12 MM (1/2") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 26 x 1/2" Insulin Pen Needle 29 G X F QL (5 ea daily) 12.7 MM Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 27 x 1/2" Insulin Pen Needle 29 G X F QL (5ea daily) 13 MM (1/2") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 27 x 5/8" Insulin Pen Needle 30 G X F QL (5ea daily) 8 MM (1/3" or 5/16") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 28 x 1/2" Insulin Pen Needle 31 G X F QL (5ea daily) 4 MM (1/6") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 29 x 1/2" Insulin Pen Needle 31 G X F QL (5ea daily) 5 MM (3/16") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 30 x 1/2" Insulin Pen Needle 31 G X F QL (5ea daily) 6 MM (1/4") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 30 x 5/16" Insulin Pen Needle 31 G X F QL (5ea daily) 8 MM (1/3" or 5/16") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 31 x 15/64" Insulin Pen Needle 32 G X F QL (5ea daily) 4 MM (5/32") Insulin Syringe/Needle U- F QL (5ea daily) 100 1 ML 31 x 5/16" ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Insulin Syringe/Needle U- F QL (5ea daily) Tuberculin/Allergy 100 1/2 ML 27 x 1/2" Syringe/Needle (Disp) 1 ML F 25 x 5/8" Insulin Syringe/Needle U- F QL (5ea daily) 100 1/2 ML 28 x 1/2" Tuberculin/Allergy Syringe/Needle (Disp) 1 ML F Insulin Syringe/Needle U- F QL (5ea daily) 100 1/2 ML 29 x 1/2" 26 x 3/8" Tuberculin/Allergy Insulin Syringe/Needle U- F QL (5ea daily) 100 1/2 ML 30 x 1/2" Syringe/Needle (Disp) 1 ML F 28 x 1/2" Insulin Syringe/Needle U- F QL (5ea daily) 100 1/2 ML 30 x 3/8" Respiratory Therapy Supplies *Respiratory Therapy QL (1 ea per Insulin Syringe/Needle U- F QL (5ea daily) F 100 1/2 ML 30 x 5/16" Supplies - Misc** year) *Respiratory Therapy QL (1 ea per Insulin Syringe/Needle U- F QL (5ea daily) F 100 1/2 ML 31 x 5/16" Supplies - Mouthpieces** year) Needle (Disp) 25 x 5/8" F *Spacer/Aerosol-Holding QL (3 ea per Chamber Supplies - F year) Bags*** Syringe (Disposable) 3 ML F *Spacer/Aerosol-Holding F QL (2 ea per Syringe/Needle (Disp) 1 F Chambers - Device*** year) ML 20 x 1" Peak Flow Meter F QL (2 ea per Syringe/Needle (Disp) 3 F year) ML 20 x 1" MIGRAINE PRODUCTS - Drugs to Treat Migraine Syringe/Needle (Disp) 3 F Headaches ML 20 x 1-1/2" Migraine Combinations Syringe/Needle (Disp) 3 F ML 22 x 1" CAFERGOT TABS (Use *** Ergotamine w/ Caffeine) Syringe/Needle (Disp) 3 F ML 22 x 1-1/2" ergotamine w/ caffeine tabs F Syringe/Needle (Disp) 3 F ML 22 x 3/4" MIGERGOT SUPP F PA Syringe/Needle (Disp) 3 F SUMATRIPTAN/NAPROX F PA ML 23 x 1" EN SODIM TABS Syringe/Needle (Disp) 3 F TREXIMET TABS 85MG- F PA ML 23 x 1-1/2" 500MG Syringe/Needle (Disp) 3 F ML 25 x 1" Migraine Products D.H.E. 45 SOLN (Use Syringe/Needle (Disp) 3 F ML 25 x 1-1/2" Dihydroergotamine *** Mesylate) Syringe/Needle (Disp) 3 F ML 25 x 5/8" dihydroergotamine F mesylate soln ij 1 mg/ml Syringe/Needle (Disp) 3 F ML 26 x 5/8" DIHYDROERGOTAMINE MESYLATE SOLN NA 4 F Tuberculin/Allergy MG/ML Syringe/Needle (Disp) 1 F ML 21 x 1" MIGRANAL SOLN F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Serotonin Agonists MAXALT-MLT TBDP (Use *** PA ) PA Rizatriptan Benzoate almotriptan malate tabs F QL(9 ea per 30 QL(9 ea per 30 F days retail); AL; naratriptan hcl tabs At least 18 yrs AMERGE TABS (Use *** days retail); AL; Naratriptan HCl) At least 18 yrs old old RELPAX TABS (Use *** PA Eletriptan Hydrobromide) AXERT TABS (Use *** PA Almotriptan Malate) QL(12 ea per rizatriptan benzoate tabs 5 30 days retail); eletriptan hydrobromide F PA F tabs mg, 10 mg AL; At least 6 yrs old FROVA TABS (Use *** PA Frovatriptan Succinate) rizatriptan benzoate tbdp F PA 10 mg, 5 mg PA frovatriptan succinate tabs F QL(6 ea per 30 days retail); AL; IMITREX SOLN NA 5 QL(6 ea per 30 sumatriptan soln F days retail); AL; At least 12 yrs MG/ACT, 20 MG/ACT (Use *** old ) At least 12 yrs Sumatriptan old QL(3 ml per 30 sumatriptan succinate soaj days retail); AL; IMITREX SOLN SC 6 QL(3 ml per 30 F days retail); AL; sc 4 mg/0.5ml At least 12 yrs MG/0.5ML (Use *** old ) At least 12 yrs Sumatriptan Succinate old QL(2 ml per 30 IMITREX STATDOSE QL(3 ml per 30 sumatriptan succinate soaj F days retail); AL; sc 6 mg/0.5ml At least 12 yrs REFILL SOCT 4 MG/0.5ML *** days retail); AL; (Use Sumatriptan At least 12 yrs old Succinate) old QL(3 ml per 30 IMITREX STATDOSE QL(2 ml per 30 sumatriptan succinate soct F days retail); AL; sc 4 mg/0.5ml At least 12 yrs REFILL SOCT 6 MG/0.5ML *** days retail); AL; (Use Sumatriptan At least 12 yrs old Succinate) old QL(2 ml per 30 IMITREX STATDOSE QL(3 ml per 30 sumatriptan succinate soct F days retail); AL; sc 6 mg/0.5ml At least 12 yrs SYSTEM SOAJ 4 *** days retail); AL; MG/0.5ML (Use At least 12 yrs old Sumatriptan Succinate) old QL(3 ml per 30 IMITREX STATDOSE QL(2 ml per 30 sumatriptan succinate soln F days retail); AL; sc 6 mg/0.5ml At least 12 yrs SYSTEM SOAJ 6 *** days retail); AL; MG/0.5ML (Use At least 12 yrs old Sumatriptan Succinate) old QL(3 ml per 30 SUMATRIPTAN days retail); AL; IMITREX TABS OR 50 MG, QL(9 ea per 30 SUCCINATE SOSY SC 6 F days retail); AL; At least 12 yrs 25 MG, 100 MG (Use *** MG/0.5ML old ) At least 12 yrs Sumatriptan Succinate old QL(9 ea per 30 QL(12 ea per sumatriptan succinate tabs F days retail); AL; or 100 mg, 25 mg, 50 mg At least 12 yrs MAXALT TABS (Use *** 30 days retail); Rizatriptan Benzoate) AL; At least 6 old yrs old zolmitriptan tabs F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zolmitriptan tbdp F PA calcium citrate tabs F

ZOMIG SOLN NA 2.5 MG F PA calcium citrate-vitamin d F tabs AL; At least 12 ZOMIG SOLN NA 5 MG F CALCIUM GLUCONATE F yrs old TABS ZOMIG TABS OR 5 MG, *** PA 2.5 MG (Use Zolmitriptan) CALCIUM LACTATE TABS F ZOMIG ZMT TBDP (Use *** PA CALCIUM TABS F Zolmitriptan) MINERALS & ELECTROLYTES calcium w/ vitamin d tabs F Calcium calcium w/ vitamins d & k F chew CALCI-CHEW CHEW F CALTRATE 600+D PLUS MINERALS CHEW (Use *** CALCIONATE SYRP F Calcium Carbonate-Vitamin D w/ Minerals) calcium & phosphorus w/ F vitamin d tabs CITRACAL + D3 MAXIMUM TABS (Use *** calcium carbonate tabs 600 Calcium Citrate-Vitamin D) mg, 600mg, 500 mg, 1500 F mg, 1250 mg CITRACAL MAXIMUM TABS (Use Calcium *** calcium carbonate- F Citrate-Vitamin D) cholecalciferol chew CITRACAL calcium carbonate- F PETITES/VITAMIND TABS *** cholecalciferol tabs (Use Calcium Citrate- calcium carbonate- F Vitamin D) ergocalciferol tabs MAGNEBIND 300 TABS F calcium carbonate-vitamin F d caps 600mg-200unit OS-CAL ULTRA TABS F calcium carbonate-vitamin F d chew 600mg-400unit oyster shell tabs F calcium carbonate-vitamin d tabs 500mg-500mg- RA OYSTER SHELL 200unit-200unit, 500mg- CALCIUM/VITAMIN D F 400unit, 200unit-500mg, TABS 600mg-125unit, 125unit- F 500mg, 500mg-200unit, RISACAL-D TABS F 125unit-250mg, 250mg- VIACTIV CHEW (Use *** 125unit, 500mg-125unit, Calcium w/ Vitamins D & K) 125unit-600mg Electrolyte Mixtures calcium carbonate-vitamin QL(62 ea per d tabs 600mg-200unit, F 31 days retail) CERALYTE 70 SOLN F 400unit-600mg, 600mg- 400unit, 200unit-600mg CERASPORT EX1 SOLN F calcium carbonate-vitamin F d w/ minerals chew CERASPORT SOLN F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENFAMIL ENFALYTE F MAGNESIUM SOLN GLUCONATE TABS 500 F MG EQUALYTE SOLN (Use *** Oral Electrolytes) magnesium gluconate tabs F 500 mg, 27.5 mg lactated ringer's soln F PA magnesium oxide (mg oral electrolytes soln F supplement) tabs 250 mg, F 241.3 mg, 500 mg PEDIALYTE ADVANCED magnesium oxide (mg F QL(2 ea daily) CARE SOLN (Use Oral *** supplement) tabs 400 mg Electrolytes) MAGNESIUM OXIDE F PEDIALYTE FREEZER CAPS POPS SOLN (Use Oral *** MAGNESIUM TABS 200 F Electrolytes) MG PEDIALYTE SINGLES SOLN (Use Oral *** magnesium tabs 200 mg F Electrolytes) MAGONATE LIQD F PEDIALYTE SOLN (Use *** Oral Electrolytes) MAGOX 400 TABS (Use Fluoride Magnesium Oxide (Mg *** Supplement)) FLUOR-A-DAY CHEW F PA NU-MAG TBEC F FLURA-DROPS SOLN F SLOW-MAG TBEC F LURIDE SOLN (Use *** Sodium Fluoride) Mineral Combinations sodium fluoride chew 0.25 ADVANCED mg, 2.2 mg, 1.1 mg, 0.5 F CALCIUM/VITAMIND/MAG F mg, 1 mg NESIUM TABS sodium fluoride soln 0.5 F BONE DENSITY BUILDER F mg/ml, 0.125 mg/drop TABS SODIUM FLUORIDE TABS F CAL MAG ZINC +D3 TABS F 1 MG Iodine Products CAL-MAG-ZINC-D TABS F

SSKI SOLN F CAL-MAG-ZINC-D3 TABS F Magnesium CALCIUM/MAGNESIUM/ZI F NC TABS MAG-TAB SR TBCR F CALCIUM/MAGNESIUM/ZI F MAG64 TBCR F NC/VITAMIN D3 TABS CITRACAL PLUS TABS F MAGNEBIND 400 TABS F PA FEM-CAL CITRATE TABS F MAGNESIUM CAPS 400 F MG MULTI MEGA MINERALS F TABS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple minerals w/ F potassium chloride cpcr 10 F vitamins tabs meq MULTISOURCE CALCIUM potassium chloride cpcr 8 F QL(1 ea daily) MAGNESIUM & D F meq FORMULA TABS POTASSIUM CHLORIDE F NATRUL-CAL TABS F ER TBCR potassium chloride PROSTEON TABS F microencapsulated crystals F er tbcr THERACAL D2000 TABS F potassium chloride pack 20 F meq THERACAL D4000 TABS F POTASSIUM CHLORIDE F SOLN 20 % THERACAL RAPID F REPLETION TABS potassium chloride soln 20 F %, 10 % Phosphate potassium chloride tbcr 8 F K-PHOS NEUTRAL TABS QL(8 ea daily) meq, 10 meq (Use Pot Phosphate Monobasic w/ Sod *** Zinc Phosphate Dibasic & GALZIN CAPS F PA Monobasic) K-PHOS TABS F PA zinc sulfate caps or F ZINC SULFATE RX/OTC PHOS-NAK POWDER F F CONCENTRATE PACK HEPTAHYDRATE POWD pot phosphate monobasic QL(8 ea daily) ZINC SULFATE F RX/OTC w/ sod phosphate dibasic & F MONOHYDRATE POWD monobasic tabs ZINC SULFATE POWD XX F RX/OTC Potassium zinc tabs F EFFER-K TBEF F PA MISCELLANEOUS THERAPEUTIC CLASSES K-TAB TBCR 10 MEQ (Use *** Potassium Chloride) Chelating Agents K-TAB TBCR 8 MEQ F CUPRIMINE CAPS F PA KLOR-CON M15 TBCR F DEPEN TITRATABS TABS F KLOR-CON/25 PACK F Immunomodulators MICRO-K CPCR 10 MEQ *** PA; SP (Use Potassium Chloride) REVLIMID CAPS F PA; SP MICRO-K CPCR 8 MEQ *** QL(1 ea daily) THALOMID CAPS F (Use Potassium Chloride) potassium bicarb & F PA Immunosuppressive Agents chloride tbef ASTAGRAF XL CP24 F PA; SP potassium bicarbonate tbef F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATGAM INJ F PA; SP NEORAL CAPS (Use SP Cyclosporine Modified (For *** Microemulsion)) AZASAN TABS F PA; QL(3 ea daily) NEORAL SOLN (Use SP azathioprine tabs F QL(3 ea daily) Cyclosporine Modified (For *** Microemulsion)) CELLCEPT CAPS 250 MG QL(6 ea daily); PROGRAF CAPS OR 5 PA (Use Mycophenolate *** SP MG, 1 MG, 0.5 MG (Use *** Mofetil) Tacrolimus) CELLCEPT SUSR 200 SP RAPAMUNE SOLN 1 F SP MG/ML (Use *** MG/ML Mycophenolate Mofetil) RAPAMUNE TABS 0.5 SP CELLCEPT TABS 500 MG PA; QL(6 ea MG, 2 MG, 1 MG (Use *** (Use Mycophenolate *** daily); SP Sirolimus) Mofetil) SANDIMMUNE CAPS OR SP cyclosporine caps or 25 F SP 25 MG, 100 MG (Use F mg, 100 mg Cyclosporine) cyclosporine modified (for SP F SANDIMMUNE SOLN OR F PA; SP microemulsion) caps 100 MG/ML cyclosporine modified (for F SP SP microemulsion) soln sirolimus tabs F CYCLOSPORINE SP tacrolimus caps F PA MODIFIED CAPS (Use *** Cyclosporine Modified (For ZORTRESS TABS F PA; SP Microemulsion)) ENVARSUS XR TB24 F PA Irrigation Solutions lactated ringer's (irrigation) F PA IMURAN TABS (Use *** QL(3 ea daily) soln Azathioprine) water for irrigation, sterile F mycophenolate mofetil F QL(6 ea daily); soln caps 250 mg SP Lymphatic Agents mycophenolate mofetil susr F SP 200 mg/ml SYLVANT SOLR F PA; SP mycophenolate mofetil tabs F PA; QL(6 ea 500 mg daily); SP Potassium Removing Agents KAYEXALATE POWD (Use QL(454 gm per mycophenolate sodium F QL(3 ea daily); tbec 180 mg SP Sodium Polystyrene *** fill retail) Sulfonate) mycophenolate sodium F QL(4 ea daily); tbec 360 mg SP sodium polystyrene F QL(454 gm per sulfonate powd fill retail) MYFORTIC TBEC 180 MG QL(3 ea daily); (Use Mycophenolate *** SP sodium polystyrene F Sodium) sulfonate susp MYFORTIC TBEC 360 MG QL(4 ea daily); MOUTH/THROAT/DENTAL AGENTS (Use Mycophenolate *** SP Sodium) Anesthetics Topical Oral

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANBESOL MAXIMUM ORABASE PSTE (Use *** STRENGTH GEL (Use *** Benzocaine (Dental)) Benzocaine (Dental)) ORABASE-B PSTE (Use *** ANBESOL MAXIMUM Benzocaine (Dental)) STRENGTH LIQD (Use *** Benzocaine (Dental)) ORAMAGIC PLUS SUSR F BABY ANBESOL GEL *** Anti-infectives - Throat (Use Benzocaine (Dental)) clotrimazole lozg F benzocaine (dental) gel F clotrimazole troc F benzocaine (dental) liqd F nystatin (mouth-throat) F benzocaine (dental) pste F susp F PA benzocaine (dental) soln F ORAVIG TABS Antiseptics - Mouth/Throat benzocaine-menthol F (mouth-throat) lozg CHERACOL SORE CEPACOL DUAL RELIEF THROAT LIQD (Use *** SORETHROAT SPRAY F Phenol (Antiseptic)) LIQD chlorhexidine gluconate F CEPACOL SORE THROAT (mouth-throat) soln EXTRA STRENGTH LOZG *** PAIN-A-LAY LIQD (Use *** (Use Benzocaine-Menthol Phenol (Antiseptic)) (Mouth-Throat)) PERIDEX SOLN (Use CEPACOL SORE THROAT F Chlorhexidine Gluconate *** LOZG 2.1MG-10MG (Mouth-Throat)) CEPACOL SORE THROAT phenol (antiseptic) liqd F LOZG 3.6MG-15MG (Use *** Benzocaine-Menthol Dental Products (Mouth-Throat)) GEL-KAM ORAL CARE RX/OTC CEPACOL SORE THROAT RINSE CONC (Use *** MAXIMUM NUMBING F Stannous Fluoride) LOZG PREVIDENT 5000 CHLORASEPTIC LOZG BOOSTER PLUS PSTE *** (Use Benzocaine-Menthol *** (Use Sodium Fluoride (Mouth-Throat)) (Dental)) CHLORASEPTIC SORE PREVIDENT 5000 THROAT/LIQUID CENTER *** BOOSTER PSTE (Use *** LOZG (Use Benzocaine- Sodium Fluoride (Dental)) Menthol (Mouth-Throat)) PREVIDENT 5000 DRY QL(60 ml per HURRICAINE ONE SOLN *** MOUTH GEL (Use Sodium *** 30 days retail) (Use Benzocaine (Dental)) Fluoride (Dental)) HURRICAINE SOLN (Use *** PREVIDENT 5000 PLUS Benzocaine (Dental)) CREA (Use Sodium *** lidocaine hcl (mouth-throat) F QL(100 ml per Fluoride (Dental)) soln fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREVIDENT FLUORIDE QL(60 ml per QL(900 ml per GEL (Use Sodium Fluoride *** 30 days retail) MOUTHKOTE SOLN F fill retail); (Dental)) RX/OTC PREVIDENT SOLN (Use *** QL(900 ml per Sodium Fluoride (Dental)) NUMOISYN LIQD F fill retail); RX/OTC sodium fluoride (dental) F crea dt 1.1 % ORAL RELIEF SPRAY QL(900 ml per FOR DRYMOUTH & F fill retail); sodium fluoride (dental) gel F QL(60 ml per dt 1.1 % 30 days retail) DISCOMFORT SOLN RX/OTC pilocarpine hcl (oral) tabs 5 QL(6 ea daily) sodium fluoride (dental) F F pste dt 1.1 % mg pilocarpine hcl (oral) tabs sodium fluoride (dental) F F soln mt 0.2 % 7.5 mg RX/OTC QL(900 ml per stannous fluoride conc F RA DRY MOUTH SOLN F fill retail); RX/OTC THERA-FLUR-N GEL (Use *** QL(60 ml per Sodium Fluoride (Dental)) 30 days retail) SALAGEN TABS 5 MG QL(6 ea daily) (Use Pilocarpine HCl *** Steroids - Mouth/Throat (Oral)) triamcinolone acetonide F QL(5 gm per fill SALAGEN TABS 7.5 MG (mouth) pste retail) (Use Pilocarpine HCl *** Throat Products - Misc. (Oral)) QL(900 ml per MULTIVITAMINS AQUORAL SOLN F fill retail); RX/OTC B-Complex Vitamins BIOTENE DRY MOUTH QL(900 ml per b-complex vitamin F QL (1 ea daily) MOISTURIZING SPRAY F fill retail); caps/tabs SOLN RX/OTC QL (1 ea daily) QL(900 ml per b-complex w/ c caps F CAPHOSOL SOLN F fill retail); RX/OTC b-complex w/ c tabs/tabcr F cevimeline hcl caps F PA B-Complex w/ Folic Acid QL(900 ml per b-complex w/ biotin F CVS DRY MOUTH SPRAY F SOLN fill retail); RX/OTC b-complex w/ c F QL (1 ea daily) QL(900 ml per DRY MOUTH SPRAY F fill retail); b-complex w/ folic acid tabs F SOLN RX/OTC Iron w/ Vitamins EQL DRY MOUTH ORAL QL(900 ml per F fill retail); iron w/ vitamins liqd F RINSE SOLN RX/OTC iron w/ vitamins tabs F RX/OTC EVOXAC CAPS (Use *** PA Cevimeline HCl) QL(900 ml per Multiple Vitamins w/ Calcium MOI-STIR SOLN F fill retail); multiple vitamins w/ F RX/OTC calcium tabs

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Multiple Vitamins w/ Iron BAL-CARE DHA MISC F PA multiple vitamins w/ iron F QL (1 ea daily) tabs CALCIUM PNV CAPS F PA Multiple Vitamins w/ Minerals CALNA TABS F multiple vitamins w/ F RX/OTC minerals caps CITRANATAL 90 DHA F PA MISC multiple vitamins w/ F minerals chew CITRANATAL ASSURE F PA MISC multiple vitamins w/ F RX/OTC minerals liqd CITRANATAL DHA MISC F PA multiple vitamins w/ F QL (1 ea daily); minerals tabs RX/OTC CITRANATAL HARMONY F PA CAPS Multivitamins CITRANATAL RX TABS F PA multiple vitamin caps F CLASSIC PRENATAL F QL(1 ea daily); multiple vitamin tabs F QL (1 ea daily) TABS GL F QL(1 ea daily); Ped MV w/ Fluoride CO-NATAL FA TABS GL QL (50 ml per pediatric multivitamins w/ fl F COMPLETE NATAL DHA F PA fill) MISC pediatric multivitamins w/ fl F QL (1 ea daily) COMPLETE PRENATAL chew MULTIVITAMIN/PRENATA F L DHA MISC pediatric multivitamins w/ fl F QL (50 ml per soln fill) QL(1 ea Ped MV w/ Iron daily,100 ea COMPLETENATE CHEW F per 100 days pediatric multiple vitamins F retail,100 ea w/ iron chew per days mail); pediatric multiple vitamins F QL (60 ml per GL w/ iron soln fill) CONCEPT DHA CAPS F PA Ped Multiple Vitamins w/ Minerals PA pediatric multiple vitamin w/ F RX/OTC CONCEPT OB CAPS F minerals liqd/soln QL(1 ea daily); pediatric multiple vitamin w/ F QL (1 ea daily) CVS PRENATAL TABS F c GL CVS WOMENS pediatric multiple vitamin w/ F F minerals PRENATAL+DHA MISC PA Pediatric Multiple Vitamins DOTHELLE DHA CAPS F pediatric multiple vitamin w/ F QL (50 ml per c soln fill) ENFAMIL EXPECTA MISC F pediatric multiple vitamins F EQL PRENATAL F QL(1 ea daily); liqd FORMULA TABS GL Prenatal Vitamins EXTRA-VIRT PLUS DHA F PA CAPS ACTIVE OB CAPS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EZFE FORTE CAPS F KPN PRENATAL TABS F

FOCALGIN 90 DHA MISC F PA LEVOMEFOLATE DHA F PA CAPS FOCALGIN CA MISC F PA QL(1 ea daily,100 ea PA FOLCAL DHA CAPS F M-VIT TABS F per 100 days retail,100 ea FOLCAPS OMEGA 3 F PA per days mail); CAPS GL; RX/OTC PA FOLIVANE-OB CAPS F MACNATAL CN DHA F PA CAPS GNP DAILY PRENATAL F PA MISC MARNATAL-F CAPS F QL(1 ea daily); GNP PRENATAL TABS F F QL(1 ea daily); GL MULTI PRENATAL TABS GL GOODSENSE PRENATAL F QL(1 ea daily); QL(1 ea VITAMINS TABS GL daily,100 ea MYNATAL ADVANCE per 100 days HEMENATAL OB + DHA F PA F MISC TABS retail,100 ea per days mail); HEMENATAL OB TABS F PA GL

HM ONE DAILY F MYNATAL CAPS F PRENATAL COMBO MISC MYNATAL PLUS TABS F QL(1 ea daily); F QL(1 ea daily); GL HM PRENATAL TABS GL QL(1 ea QL(1 ea daily,100 ea daily,100 ea MYNATAL ULTRACAPLET F per 100 days INATAL ADVANCE TABS F per 100 days TABS retail,100 ea retail,100 ea per days mail); per days mail); GL GL F QL(1 ea daily); QL(1 ea MYNATAL-Z TABS GL daily,100 ea QL(1 ea daily); F per 100 days MYNATE 90 PLUS TBCR F INATAL GT TABS retail,100 ea GL per days mail); NAT-RUL PRENATAL F QL(1 ea daily); GL VITAMINS TABS GL QL(1 ea F QL(1 ea daily); daily,100 ea NATALVIT TABS GL F per 100 days PA INATAL ULTRA TABS retail,100 ea NATELLE ONE CAPS F per days mail); PA GL NEEVO DHA CAPS F INFANATE BALANCE F PA PA CAPS NESTABS ABC MISC F KP PRENATAL F QL(1 ea daily); NESTABS DHA MISC F PA MULTIVITAMINS TABS GL

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXA PLUS CAPS F PA QL(1 ea daily,100 ea QL(1 ea PNV PRENATAL PLUS F per 100 days daily,100 ea MULTIVITAMIN TABS retail,100 ea per days mail); NIVA-PLUS TABS F per 100 days retail,100 ea GL; RX/OTC per days mail); GL; RX/OTC PNV TABS 29-1 TABS F NUTRICION PORVIDA F PNV-DHA CAPS F PA TABS QL(1 ea PNV-DHA+DOCUSATE F PA daily,100 ea CAPS F per 100 days PNV-OMEGA CAPS F PA O-CAL FA TABS retail,100 ea per days mail); PA GL; RX/OTC PNV-SELECT TABS F O-CAL PRENATAL TABS F PNV-TOTAL CAPS F PA QL(1 ea daily); OB COMPLETE ONE F PA PNV-VP-U CAPS F CAPS GL PA OB COMPLETE PETITE F PA PR NATAL 400 EC MISC F CAPS PA OB COMPLETE PREMIER F PA PR NATAL 400 MISC F TABS PA OBSTETRIX DHA MISC F RX/OTC PR NATAL 430 EC MISC F PA OBTREX DHA MISC F RX/OTC PR NATAL 430 MISC F PRE-NATAL FORMULA ONE-A-DAY WOMENS F F PRENATAL MISC TABS PA PA PRENATAL FORMULA F PREFERAOB ONE CAPS F TABS PRENAISSANCE CAPS F PA PERRY PRENATAL CAPS F PRENAISSANCE PLUS F PA PNV FERROUS CAPS FUMARATE/DOCUSATE/F F OLIC ACID TABS F QL(1 ea daily); PRENATABS FA TABS GL QL(1 ea daily,100 ea PRENATABS RX TABS F PNV FOLIC ACID + IRON F per 100 days MULTIVITAMIN TABS retail,100 ea per days mail); GL; RX/OTC PNV OB+DHA MISC F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 CHEW QL(1 ea QL(1 ea 1000UNIT-400UNIT- daily,100 ea daily,100 ea 20MG-25MG-3MG-200MG- per 100 days F per 100 days 29MG-7MG-6MG-3MG- retail,100 ea PRENATAL PLUS TABS retail,100 ea 12MCG-1MG-30UNIT- F per days mail); per days mail); 20MG-100MG, 30UNIT- GL GL; RX/OTC 1000UNIT-20MG-3MG- PRENATAL TABS 22MG- QL(1 ea 200MG-29MG-7MG-15MG- 2MG-25MG-1.84MG- daily,100 ea 3MG-12MCG-400UNIT- 200MG-27MG-4000UNIT- F per 100 days 1MG-20MG-100MG 20MG-3MG-12MCG- retail,100 ea PRENATAL 19 TABS 400UNIT-1MG-10MG- per days mail); 30UNIT-1000UNIT-20MG- 120MG GL; RX/OTC 25MG-3MG-200MG-29MG- PRENATAL TABS 30UNIT- QL(1 ea daily); 7MG-15MG-3MG-12MCG- 4000UNIT-25MG-1.8MG- GL 400UNIT-1MG-20MG- 200MG-28MG-20MG- 100MG, 1000UNIT- F 1.7MG-8MCG-400UNIT- 30UNIT-20MG-25MG- 0.8MG-2.6MG-120MG, 3MG-200MG-29MG-15MG- 30UNIT-25MG-1.8MG- 3MG-7MG-12MCG- 200MG-28MG-20MG- 400UNIT-20MG-1MG- 1.7MG-4000UNIT-8MCG- 100MG 400UNIT-800MCG-2.6MG- PRENATAL AND IRON F 120MG, 160MG-11UNIT- TABS 200MG-25MG-1.84MG- 27MG-4000UNIT-18MG- PRENATAL COMPLETE F TABS 1.7MG-4MCG-400UNIT- 800MCG-2.6MG-100MG, PRENATAL FORMULA A- F 11UNIT-263MG-25MG- FREE TABS 1.5MG-27MG-4000UNIT- F PRENATAL FORMULA F QL(1 ea daily); 18MG-1.7MG-4MCG- TABS GL 400UNIT-0.8MG-2.6MG- PRENATAL FORTE TABS F 100MG, 30UNIT- 4000UNIT-25MG-1.8MG- 200MG-28MG-20MG- PRENATAL LOW IRON F QL(1 ea daily); TABS GL 1.7MG-8MCG-400UNIT- 800MCG-2.6MG-120MG, PRENATAL MULTI +DHA F CAPS 4000UNIT-30UNIT-25MG- 1.8MG-200MG-28MG- PRENATAL 20MG-1.7MG-8MCG- MULTIVITAMIN + DHA F 400UNIT-800MCG-2.6MG- MISC 120MG, 4000UNIT- PRENATAL F QL(1 ea daily); 30UNIT-200MG-25MG- MULTIVITAMIN TABS GL 1.8MG-28MG-20MG- 1.7MG-8MCG-400UNIT- PRENATAL ONE DAILY F QL(1 ea daily); TABS GL 800MCG-2.6MG-120MG PRENATAL TABS PRENATAL PLUS IRON F TABS 4000UNIT-200MG-11UNIT- 27MG-25MG-1.84MG- F 18MG-1.7MG-4MCG- 400UNIT-0.8MG-2.6MG- 100MG

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL VITAMIN & F QL(1 ea daily); QL(1 ea MINERAL TABS GL daily,100 ea per 100 days PRENATAL VITAMIN F QL(1 ea daily); PREPLUS TABS F TABS GL retail,100 ea per days mail); PRENATAL F QL(1 ea daily); GL; RX/OTC VITAMIN/IRON TABS GL F QL(1 ea daily); QL(1 ea PRETAB TABS GL daily,100 ea PRENATAL VITAMINS F per 100 days PROFE FORTE CAPS F PLUS LOW IRON TABS retail,100 ea per days mail); PROVIDA OB CAPS F PA GL; RX/OTC PRENATAL VITAMINS QL(1 ea daily); PUREFE OB PLUS CAPS F PA TABS 30UNIT-4000UNIT- GL PX PRENATAL QL(1 ea daily); 25MG-1.8MG-200MG- F F 28MG-20MG-1.7MG- MULTIVITAMINS TABS GL 8MCG-400UNIT-800MCG- QC PRENATAL TABS F QL(1 ea daily); 2.6MG-120MG GL PRENATAL VITAMINS R-NATAL OB CAPS F PA TABS 4000UNIT- 4000UNIT-200MG-200MG- RA ONE DAILY MISC F 25MG-25MG-27MG-27MG- 11UNIT-11UNIT-400UNIT- F RA PRENATAL QL(1 ea daily); 400UNIT-1.7MG-1.7MG- FORMULA/FOLICACID F GL 4MCG-4MCG-18MG- TABS 18MG-1.84MG-1.84MG- F QL(1 ea daily); 800MCG-800MCG-2.6MG- RA PRENATAL TABS GL 2.6MG-100MG-100MG RIGHT STEP PRENATAL F QL(1 ea daily); PRENATAL+DHA MISC F TABS GL PA F QL(1 ea daily); RULAVITE DHA CAPS F PRENATAL-U CAPS GL QL(1 ea PRENATE DHA CAPS PA SE-NATAL 19 CHEW daily,100 ea 18MG-600MCG-40UNIT- 30UNIT-1000UNIT-100MG- F per 100 days 300MG-50MG-155MG- F 20MG-3MG-200MG-29MG- retail,100 ea 25MCG-400UNIT- 7MG-15MG-3MG-12MCG- 400UNIT-1MG-20MG per days mail); 400MCG-26MG-90MG GL PRENATE ENHANCE F PA SE-NATAL 19 TABS CAPS 30UNIT-1000UNIT-20MG- PRENATE ESSENTIAL PA F 25MG-200MG-29MG-7MG- F CAPS 15MG-3MG-12MCG- PA 400UNIT-3MG-20MG- PRENATE PIXIE CAPS F 1MG-100MG PRENATE RESTORE F PA SE-TAN DHA CAPS F PA CAPS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELECT-OB CHEW PA QL(1 ea 1700UNIT-29MG-30UNIT- daily,100 ea 15MG-25MG-1.6MG- F TRINATAL GT TABS F per 100 days 15MG-1.8MG-5MCG- retail,100 ea 400UNIT-1MG-2.5MG- per days mail); 60MG GL SELECT-OB+DHA MISC F PA QL(1 ea daily,100 ea per 100 days SM ONE DAILY F TRINATAL RX 1 TABS F PRENATAL MISC retail,100 ea per days mail); SM PRENATAL VITAMINS F QL(1 ea daily); TABS GL GL PA TARON-C DHA CAPS F PA TRINATE TABS F PA TARON-PREX CAPS F PA TRIVEEN-DUO DHA MISC F QL(1 ea ULTIMATECARE ONE F PA daily,100 ea CAPS PA THERANATAL CORE F per 100 days VEMAVITE-PRX 2 CAPS F NUTRITION TABS retail,100 ea per days mail); VENA-BAL DHA MISC F PA GL; RX/OTC PA THRIVITE 19 TABS F VINATE DHA RF CAPS F PA THRIVITE RX TABS F VINATE II TABS F PA F QL(1 ea daily); TL-CARE DHA CAPS F VINATE M TABS GL TL-SELECT CAPS F PA QL(1 ea daily,100 ea TRI-TABS DHA MISC F PA F per 100 days VINATE ONE TABS retail,100 ea QL(1 ea per days mail); daily,100 ea GL F per 100 days PA TRIADVANCE TABS retail,100 ea VIRT NATE TABS F per days mail); QL(1 ea GL daily,100 ea per 100 days TRICARE PRENATAL F PA VIRT-ADVANCE TABS F DHA ONE CAPS retail,100 ea QL(1 ea per days mail); daily,100 ea GL PA F per 100 days VIRT-C DHA CAPS F TRICARE TABS retail,100 ea per days mail); VIRT-PN DHA CAPS F PA GL; RX/OTC VIRT-PN PLUS CAPS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRT-PN TABS F PA baclofen tabs F

VIRT-SELECT CAPS F PA carisoprodol tabs 250 mg F PA

QL(1 ea F PA; QL(4 ea daily,100 ea carisoprodol tabs 350 mg daily) VIRT-VITE GT TABS F per 100 days retail,100 ea CHLORZOXAZONE TABS F per days mail); cyclobenzaprine hcl tabs F QL(3 ea daily) GL 10 mg PA VITAFOL ULTRA CAPS F cyclobenzaprine hcl tabs 5 F mg VITAFOL-NANO TABS F PA cyclobenzaprine hcl tabs F PA 7.5 mg VITAFOL-OB TABS F QL(1 ea daily); GL FEXMID TABS (Use *** PA Cyclobenzaprine HCl) VOL-NATE TABS F PA LIORESAL INTRATHECAL F PA QL(1 ea SOLN daily,100 ea LORZONE TABS F PA VOL-PLUS TABS F per 100 days retail,100 ea metaxalone tabs F PA per days mail); GL; RX/OTC methocarbamol tabs F VOL-TAB RX TABS F orphenadrine citrate tb12 F QL(2 ea daily) VP-CH PLUS CAPS F PA PARAFON FORTE DSC *** TABS (Use Chlorzoxazone) VP-HEME OB + DHA F PA MISC ROBAXIN TABS (Use *** Methocarbamol) VP-HEME OB TABS F PA ROBAXIN-750 TABS (Use *** VP-HEME ONE CAPS F PA Methocarbamol) SKELAXIN TABS (Use *** PA WEGMANS COMPLETE F Metaxalone) PRENATAL+DHA MISC SOMA TABS 250 MG (Use *** PA ZATEAN-CH CAPS F PA Carisoprodol) SOMA TABS 350 MG (Use *** PA; QL(4 ea ZATEAN-PN DHA CAPS F PA Carisoprodol) daily) PA tizanidine hcl caps 2 mg, 4 F PA ZATEAN-PN PLUS CAPS F mg, 6 mg MUSCULOSKELETAL THERAPY AGENTS - tizanidine hcl tabs 2 mg, 4 F Drugs to Treat Spasms mg ZANAFLEX CAPS 2 MG, 6 PA Central Muscle Relaxants MG, 4 MG (Use Tizanidine *** AMRIX CP24 F PA HCl) ZANAFLEX TABS 4 MG *** (Use Tizanidine HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Direct Muscle Relaxants PATANASE SOLN (Use *** PA Olopatadine HCl (Nasal)) DANTRIUM CAPS (Use *** Dantrolene Sodium) Nasal Anticholinergics dantrolene sodium caps F ATROVENT SOLN 0.03 % QL(31 ml per (Use Ipratropium Bromide *** 30 days retail) Muscle Relaxant Combinations (Nasal)) ATROVENT SOLN 0.06 % QL(15 ml per carisoprodol w/ aspirin & F PA codeine tabs (Use Ipratropium Bromide *** 30 days retail) (Nasal)) carisoprodol w/ aspirin tabs F PA ipratropium bromide (nasal) F QL(31 ml per soln 0.03 % 30 days retail) NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus ipratropium bromide (nasal) F QL(15 ml per soln 0.06 % 30 days retail) Nasal Agent Combinations Nasal Steroids DYMISTA SUSP F PA BECONASE AQ SUSP F PA Nasal Agents - Misc. budesonide (nasal) susp F PA; RX/OTC AYR NASAL DROPS F SOLN FLONASE ALLERGY QL(16 ml per AYR NASAL MIST RELIEF CHILDRENS *** 30 days retail); SUSP (Use Fluticasone RX/OTC ALLERGY &SINUS F HYPERTONIC SALINE Propionate (Nasal)) SOLN FLONASE ALLERGY QL(16 ml per RELIEF SUSP (Use 30 days retail); OCEAN NASAL SPRAY *** QL(480 ml per *** SOLN (Use Saline) fill retail) Fluticasone Propionate RX/OTC (Nasal)) RHINARIS GEL F PA FLONASE SENSIMIST F PA; RX/OTC SUSP saline gel F FLUNISOLIDE SOLN F QL(25 ml per saline soln 0.65%-0.002%, F QL(480 ml per 30 days retail) 0.65%, 0.65 % fill retail) QL(16 ml per fluticasone propionate Nasal Anti-infectives F 30 days retail); (nasal) susp RX/OTC BACTROBAN NASAL F OINT PA; QL(17 gm mometasone furoate F per 30 days Nasal Antiallergy (nasal) susp retail) ASTEPRO SOLN (Use *** QL(30 ml per QL(17 ml per Azelastine HCl) fill retail) NASACORT ALLERGY F 30 days retail); QL(30 ml per 24HR AERO azelastine hcl soln F RX/OTC fill retail) NASACORT ALLERGY QL(17 ml per cromolyn sodium (nasal) QL(26 ml per F 24HR AERO (Use *** 30 days retail); aers 30 days retail) Triamcinolone Acetonide RX/OTC (Nasal)) NASALCROM AERS (Use *** QL(26 ml per Cromolyn Sodium (Nasal)) 30 days retail) NASACORT ALLERGY QL(17 ml per PA 24HR CHILDRENS AERO *** 30 days retail); olopatadine hcl (nasal) soln F (Use Triamcinolone RX/OTC Acetonide (Nasal))

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NASONEX SUSP (Use PA; QL(17 gm DURATION 12 HOUR Mometasone Furoate *** per 30 days SOLN (Use Oxymetazoline *** (Nasal)) retail) HCl) OMNARIS SUSP F PA DURATION SPRAY SOLN *** (Use Oxymetazoline HCl) QNASL AERS F PA LITTLE NOSES DECONGESTANTNOSE F RHINOCORT AQUA SUSP *** PA; RX/OTC DROPS SOLN (Use Budesonide (Nasal)) NASAL DECONGESTANT F QL(17 ml per LIQD triamcinolone acetonide F 30 days retail); (nasal) aero NASAL DECONGESTANT F RX/OTC SYRP VERAMYST SUSP F PA; RX/OTC NEO-SYNEPHRINE 12 HOUR EXTRA *** ZETONNA AERS F PA MOISTURIZING SOLN (Use Oxymetazoline HCl) Sympathomimetic Decongestants NEO-SYNEPHRINE COLD ADRENALIN SOLN F & SINUS EXTRA SOLN *** (Use Phenylephrine HCl) AFRIN 12 HOUR SOLN *** NEO-SYNEPHRINE COLD (Use Oxymetazoline HCl) & SINUS MILD SOLN (Use *** AFRIN ALL NIGHT Phenylephrine HCl) NODRIP SOLN (Use *** NEO-SYNEPHRINE COLD F Oxymetazoline HCl) & SINUS REGULAR SOLN AFRIN NASAL SPRAY NEO-SYNEPHRINE SOLN *** SOLN (Use Oxymetazoline *** (Use Phenylephrine HCl) HCl) AFRIN NODRIP EXTRA oxymetazoline hcl soln F MOISTURIZING SOLN *** phenylephrine hcl (oral) F QL(24 ea per (Use Oxymetazoline HCl) tabs fill retail) AFRIN NODRIP ORIGINAL SOLN (Use Oxymetazoline *** phenylephrine hcl soln F HCl) pseudoephedrine hcl liqd F AFRIN NODRIP SEVERE 15 mg/5ml CONGESTION SOLN (Use *** pseudoephedrine hcl tabs F Oxymetazoline HCl) 30 mg, 60 mg AFRIN NODRIP SINUS pseudoephedrine hcl tb12 F QL(62 ea per SOLN (Use Oxymetazoline *** 120 mg 30 days retail) HCl) SUDAFED 24 HOUR TB24 F AFRIN SINUS SOLN (Use *** Oxymetazoline HCl) SUDAFED CHILDRENS AFRIN SOLN (Use *** LIQD (Use *** Oxymetazoline HCl) Pseudoephedrine HCl) DRISTAN SPRAY SOLN *** SUDAFED CONGESTION (Use Oxymetazoline HCl) TABS (Use *** Pseudoephedrine HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUDAFED NASAL POLYCOSE POWD F DECONGESTANT MAXIMUM STRENGTH *** Misc. Nutritional Substances TABS (Use Pseudoephedrine HCl) docosahexaenoic acid caps F SUDAFED PE QL(120 ml per EXPECTA LIPIL CAPS CHILDRENS NASAL F fill retail) (Use Docosahexaenoic *** DECONGESTANT SOLN Acid) SUDAFED PE QL(24 ea per CONGESTION TABS (Use *** fill retail) omega-3 fatty acids caps F Phenylephrine HCl (Oral)) omega-3 fatty acids cpdr F TYZINE PEDIATRIC F PA NASAL DROPS SOLN Proteins VICKS SINEX 12 HOUR DECONGESTANT SOLN *** ARGININE TABS F (Use Oxymetazoline HCl) VICKS SINEX 12 HOUR arginine tabs F DECONGESTANT ULTRA *** FINE MIST SOLN (Use OPHTHALMIC AGENTS - Drugs to Treat the Eye Oxymetazoline HCl) Artificial Tears and Lubricants VICKS SINEX 12 HOUR QL(4 gm per fill DECONGESTANT ULTRA artificial tear ointment oint F FINE MIST/MOISTURIZNG *** retail) SOLN (Use Oxymetazoline artificial tear solution soln F HCl) VICKS SINEX ARTIFICIAL TEARS SOLN F QL(15 ml per MOISTURIZING SOLN *** fill retail) (Use Oxymetazoline HCl) carboxymethylcellulose F VICKS SINEX SEVERE sodium (ophth) soln NASALDECONGESTANT *** carboxymethylcellulose- F SOLN (Use Oxymetazoline glycerin soln HCl) GENTEAL MILD SOLN F VICKS SINEX SOLN (Use *** Oxymetazoline HCl) GENTEAL MILD TO NEUROMUSCULAR AGENTS - Drugs to MODERATE SOLN (Use *** Relax/Paralyze Muscles Hypromellose (Ophth)) ALS Agents GENTEAL SEVERE GEL F RILUTEK TABS (Use PA *** GENTEAL TEARS F Riluzole) MODERATEPF SOLN riluzole tabs F PA glycerin-hypromellose- polyethylene glycol 400 F NUTRIENTS soln F QL(31 ml per Carbohydrates HYPOTEARS SOLN 30 days retail) POLYCOSE LIQD F hypromellose (ophth) soln F 0.3 %, 3 mg/ml

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hypromellose (ophth) soln F QL(15 ml per SYSTANE ULTRA HOME 0.4 % fill retail) & AWAY PACK SOLN (Use *** Polyethylene Glycol- ISOPTO TEARS SOLN F Propylene Glycol (Ophth)) LACRISERT INST F PA SYSTANE ULTRA SOLN (Use Polyethylene Glycol- *** MOISTURE EYES SOLN Propylene Glycol (Ophth)) (Use Propylene Glycol- *** TEARS NATURALE PM QL(42 gm per Glycerin) OINT (Use White *** fill retail) polyethylene glycol- Petrolatum-Mineral Oil) propylene glycol (ophth) F VISINE TEARS SOLN (Use soln Glycerin-Hypromellose- *** Polyethylene Glycol 400) F QL(31 ml per polyvinyl alcohol soln 30 days retail) white petrolatum-mineral oil F QL(42 gm per oint fill retail) polyvinyl alcohol-povidone F (ophth) soln Beta-blockers - Ophthalmic propylene glycol (ophth) F BETAGAN SOLN (Use *** QL(15 ml per soln Levobunolol HCl) 30 days retail) propylene glycol-glycerin F F QL(15 ml per soln betaxolol hcl (ophth) soln fill retail) REFRESH LIQUIGEL F F QL(15 ml per SOLN BETIMOL SOLN 30 days retail) REFRESH OPTIVE F PA SENSITIVE SOLN BETOPTIC-S SUSP F REFRESH OPTIVE SOLN Limit 1 fill per carteolol hcl (ophth) soln F (Use *** Month Carboxymethylcellulose- PA Glycerin) COMBIGAN SOLN F REFRESH SOLN (Use PA Polyvinyl Alcohol-Povidone *** COSOPT PF SOLN F (Ophth)) COSOPT SOLN (Use QL(10 ml per REFRESH TEARS SOLN Dorzolamide HCl-Timolol *** 30 days retail) (Use *** Maleate) Carboxymethylcellulose dorzolamide hcl-timolol F QL(10 ml per Sodium (Ophth)) maleate soln 30 days retail) SYSTANE BALANCE ISTALOL SOLN F PA RESTORATIVE FORMULA *** SOLN (Use Propylene ISTALOL SOLN (Use *** PA Glycol (Ophth)) Timolol Maleate (Ophth)) SYSTANE OVERNIGHT F QL(15 ml per THERAPY LUBRICANT F levobunolol hcl soln 30 days retail) EYE GEL PA SYSTANE SOLN (Use METIPRANOLOL SOLN F Polyethylene Glycol- *** timolol maleate (ophth) solg F QL(5 ml per fill Propylene Glycol (Ophth)) 0.25 %, 0.5 % retail) timolol maleate (ophth) soln F PA 0.5 %

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits timolol maleate (ophth) F QL(15 ml per apraclonidine hcl soln F PA soln 0.5 %, 0.25 % fill retail) brimonidine tartrate soln PA TIMOPTIC OCUDOSE F QL(60 ea per F SOLN fill retail) 0.15 % brimonidine tartrate soln QL(15 ml per TIMOPTIC SOLN (Use *** QL(15 ml per F Timolol Maleate (Ophth)) fill retail) 0.2 % fill retail) IOPIDINE SOLN 0.5 % PA TIMOPTIC-XE SOLG (Use *** QL(5 ml per fill *** Timolol Maleate (Ophth)) retail) (Use Apraclonidine HCl) Cycloplegic Mydriatics IOPIDINE SOLN 1 % F ATROPINE SULFATE F PA OINT SIMBRINZA SUSP F ATROPINE SULFATE F Ophthalmic Anti-infectives SOLN AZASITE SOLN F PA CYCLOGYL SOLN 0.5 % *** QL(15 ml per (Use Cyclopentolate HCl) 30 days retail) BACITRACIN OINT F QL(4 gm per 30 CYCLOGYL SOLN 1 % *** days retail) (Use Cyclopentolate HCl) bacitracin-polymyxin b F QL(4 gm per 30 CYCLOGYL SOLN 2 % *** QL(15 ml per (ophth) oint days retail) (Use Cyclopentolate HCl) fill retail) BESIVANCE SUSP F PA CYCLOMYDRIL SOLN F PA BLEPH-10 SOLN (Use QL(15 ml per cyclopentolate hcl soln 0.5 F QL(15 ml per Sulfacetamide Sodium *** 30 days retail) % 30 days retail) (Ophth)) cyclopentolate hcl soln 1 % F F QL(3.5 gm per CILOXAN OINT fill retail) QL(15 ml per cyclopentolate hcl soln 2 % F CILOXAN SOLN (Use *** QL(10 ml per fill retail) Ciprofloxacin HCl (Ophth)) fill retail) homatropine hbr soln F ciprofloxacin hcl (ophth) F QL(10 ml per soln fill retail) MYDRIACYL SOLN (Use *** Tropicamide) erythromycin (ophth) oint F tropicamide soln F gatifloxacin (ophth) soln F PA Miotics GENTAK OINT F QL(4 gm per 30 days retail) ISOPTO CARPINE SOLN *** (Use Pilocarpine HCl) gentamicin sulfate (ophth) F QL(4 gm per 30 oint days retail) PHOSPHOLINE IODIDE F PA SOLR gentamicin sulfate (ophth) F QL(30 ml per pilocarpine hcl soln F soln fill retail) levofloxacin (ophth) soln F PA Ophthalmic Adrenergic Agents PA ALPHAGAN P SOLN 0.1 % F PA MOXEZA SOLN F ALPHAGAN P SOLN 0.15 PA moxifloxacin hcl (ophth) F QL(3 ml per fill % (Use Brimonidine *** soln retail) Tartrate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATACYN SUSP F PA NAPHCON-A SOLN (Use Naphazoline w/ *** Pheniramine) neomycin-bacitracin zn- F QL(4 gm per 30 polymyxin oint days retail) OPCON-A SOLN (Use QL(15 ml per Naphazoline w/ *** 30 days retail) neomycin-polymyxin- F QL(10 ml per gramicidin soln 30 days retail) Pheniramine) NEOSPORIN SOLN (Use QL(10 ml per phenylephrine hcl (ophth) F PA Neomycin-Polymyxin- *** 30 days retail) soln 10 % Gramicidin) phenylephrine hcl (ophth) F QL(5 ml per 30 soln 2.5 % days retail) OCUFLOX SOLN (Use *** QL(10 ml per Ofloxacin (Ophth)) 30 days retail) tetrahydrozoline hcl (ophth) F QL(30 ml per soln fill retail) F QL(10 ml per ofloxacin (ophth) soln 30 days retail) tetrahydrozoline w/ zinc F sulfate soln polymyxin b-trimethoprim F QL(10 ml per soln fill retail) VISINE EXTRA SOLN (Use QL(30 ml per Tetrahydrozoline HCl *** fill retail) POLYTRIM SOLN (Use *** QL(10 ml per Polymyxin B-Trimethoprim) fill retail) (Ophth)) VISINE SOLN (Use QL(30 ml per sulfacetamide sodium F QL(15 ml per (ophth) soln 30 days retail) Tetrahydrozoline HCl *** fill retail) (Ophth)) SULFACETAMIDE F QL(4 gm per 30 SODIUM OINT OP days retail) Ophthalmic Immunomodulators F QL(5 ml per 30 PA tobramycin (ophth) soln days retail) RESTASIS EMUL F TOBREX OINT F RESTASIS MULTIDOSE F PA EMUL TOBREX SOLN (Use *** QL(5 ml per 30 Ophthalmic Local Anesthetics Tobramycin (Ophth)) days retail) ALCAINE SOLN (Use *** PA F QL(8 ml per 30 Proparacaine HCl) trifluridine soln days retail) proparacaine hcl soln F PA VIGAMOX SOLN (Use *** QL(3 ml per fill Moxifloxacin HCl (Ophth)) retail) tetracaine hcl (ophth) soln F PA VIROPTIC SOLN (Use *** QL(8 ml per 30 Trifluridine) days retail) Ophthalmic Steroids F PA ZIRGAN GEL ALREX SUSP F PA ZYMAXID SOLN (Use PA *** bacitracin-poly-neomycin- F Gatifloxacin (Ophth)) hc oint Ophthalmic Decongestants BLEPHAMIDE S.O.P. F NAPHAZOLINE HCL F OINT SOLN BLEPHAMIDE SUSP F QL(10 ml per naphazoline w/ fill retail) pheniramine soln 0.025%- F DEXAMETHASONE 0.3% SODIUM PHOSPHATE F naphazoline w/ QL(15 ml per SOLN OP 0.1 % pheniramine soln 0.027%- F 30 days retail) PA 0.315% DUREZOL EMUL F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluorometholone (ophth) F QL(15 ml per prednisolone acetate F QL(15 ml per susp fill retail) (ophth) susp fill retail) FML FORTE SUSP F PA PREDNISOLONE SODIUM QL(15 ml per PHOSPHATE SOLN OP 1 F 30 days retail) FML LIQUIFILM SUSP QL(15 ml per % (Use Fluorometholone *** fill retail) sulfacetamide sod- F QL(10 ml per (Ophth)) prednisolone soln 30 days retail) QL(4 gm per 30 FML OINT F F QL(4 gm per 30 days retail) TOBRADEX OINT days retail) PA LOTEMAX GEL F TOBRADEX ST SUSP F PA LOTEMAX SUSP F PA TOBRADEX SUSP (Use QL(10 ml per Tobramycin- *** fill retail) MAXIDEX SUSP F PA Dexamethasone) tobramycin- F QL(10 ml per MAXITROL OINT QL(4 gm per 30 dexamethasone susp fill retail) 10000UNIT/GM- days retail) 3.5MG/GM-0.1% (Use *** VEXOL SUSP F Neomycin-Polymy- Dexameth) ZYLET SUSP F PA MAXITROL SUSP QL(10 ml per Ophthalmics - Misc. 10000UNIT/ML-3.5MG/ML- *** 30 days retail) 0.1% (Use Neomycin- ACULAR LS SOLN (Use Polymy-Dexameth) Ketorolac Tromethamine *** neomycin-polymy- QL(4 gm per 30 (Ophth)) ACULAR SOLN (Use QL(10 ml per dexameth oint F days retail) 10000unit/gm-3.5mg/gm- Ketorolac Tromethamine *** fill retail) 0.1% (Ophth)) neomycin-polymy- QL(10 ml per ACUVAIL SOLN F PA dexameth susp F 30 days retail) 10000unit/ml-3.5mg/ml- ST; QL(5 ml 0.1% ALOCRIL SOLN F per 30 days NEOMYCIN/POLYMYXIN/ QL(15 ml per retail) HYDROCORTISONE F 30 days retail) ST; QL(10 ml SUSP ALOMIDE SOLN F per 30 days OMNIPRED SUSP (Use QL(15 ml per retail) Prednisolone Acetate *** fill retail) F QL(6 ml per 30 (Ophth)) azelastine hcl (ophth) soln days retail) PRED FORTE SUSP (Use QL(15 ml per F QL(15 ml per Prednisolone Acetate *** fill retail) AZOPT SUSP fill retail) (Ophth)) bromfenac sodium (ophth) F PA F QL(10 ml per soln PRED MILD SUSP 30 days retail) BROMFENAC SOLN F PA PRED-G S.O.P. OINT F PA cromolyn sodium (ophth) F QL(10 ml per F QL(5 ml per fill soln fill retail) PRED-G SUSP retail) diclofenac sodium (ophth) F QL(3 ml per 30 soln days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(10 ml per F QL(5 ml per 30 dorzolamide hcl soln 30 days retail) latanoprost soln days retail) ELESTAT SOLN (Use *** PA LUMIGAN SOLN F PA Epinastine HCl (Ophth)) PA EMADINE SOLN F PA RESCULA SOLN F PA epinastine hcl (ophth) soln F PA TRAVOPROST SOLN F XALATAN SOLN (Use QL(5 ml per 30 F QL(5 ml per 30 *** flurbiprofen sodium soln days retail) Latanoprost) days retail) FLURBIPROFEN SODIUM F QL(5 ml per 30 OTIC AGENTS - Drugs to Treat the Ear SOLN days retail) Otic Agents - Miscellaneous ILEVRO SUSP F PA QL(15 ml per acetic acid (otic) soln F ketorolac tromethamine F 30 days retail) (ophth) soln 0.4 % ACETIC ACID/ALUMINUM F ketorolac tromethamine F QL(10 ml per ACETATE SOLN (ophth) soln 0.5 % fill retail) carbamide peroxide (otic) F QL(15 ml per ketotifen fumarate (ophth) F QL(240 ml per soln 30 days retail) soln fill retail) DEBROX SOLN (Use *** QL(15 ml per LASTACAFT SOLN F PA Carbamide Peroxide (Otic)) 30 days retail) Otic Anti-infectives MURO 128 OINT (Use QL(7 gm per fill Sodium Chloride *** retail) CETRAXAL SOLN F PA Hypertonic) MURO 128 SOLN (Use QL(30 ml per CIPROFLOXACIN SOLN F PA Sodium Chloride *** fill retail) OT 0.2 % Hypertonic) FLOXIN OTIC SOLN (Use *** QL(10 ml per Ofloxacin (Otic)) fill retail) OCUFEN SOLN (Use *** QL(5 ml per 30 Flurbiprofen Sodium) days retail) F QL(10 ml per ofloxacin (otic) soln fill retail) olopatadine hcl soln F PA Otic Combinations PATADAY SOLN (Use *** PA PA Olopatadine HCl) CIPRO HC SUSP F PROLENSA SOLN F PA CIPRODEX SUSP F PA sodium chloride hypertonic F QL(7 gm per fill COLY-MYCIN S SUSP F PA oint retail) CORTANE-B AQUEOUS QL(10 ml per sodium chloride hypertonic F QL(30 ml per F soln fill retail) SOLN fill retail) CORTANE-B-OTIC SOLN QL(15 ml per TRUSOPT SOLN (Use *** QL(10 ml per Dorzolamide HCl) 30 days retail) (Use Pramoxine-HC- *** fill retail) ZADITOR SOLN (Use QL(240 ml per Chloroxylenol) Ketotifen Fumarate *** fill retail) CORTISPORIN-TC SUSP F PA (Ophth)) neomycin-polymyxin-hc F QL(10 ml per Prostaglandins - Ophthalmic (otic) soln fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits neomycin-polymyxin-hc F QL(20 ml per GAMMAPLEX SOLN F PA; SP (otic) susp 30 days retail) OTICIN HC NR SOLN (Use QL(15 ml per GAMUNEX-C SOLN F PA; SP Pramoxine-HC- *** fill retail) Chloroxylenol) HEPAGAM B SOLN F PA; SP pramoxine-hc-chloroxylenol F QL(15 ml per soln fill retail) HIZENTRA SOLN F PA; SP Otic Steroids HYPERRAB S/D INJ F PA DERMOTIC OIL (Use QL(20 ml per Fluocinolone Acetonide *** fill retail); AL; At HYPERRHO S/D MINI- F PA; SP (Otic)) least 2 yrs old DOSE SOSY QL(20 ml per PA; SP fluocinolone acetonide F fill retail); AL; At HYPERRHO S/D SOSY F (otic) oil least 2 yrs old IMOGAM RABIES-HT INJ F PA hydrocortisone w/acetic F QL(20 ml per acid soln 30 days retail) MICRHOGAM ULTRA- F PA; SP FILTEREDPLUS SOSY OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding OCTAGAM SOLN F PA; SP Oxytocics PRIVIGEN SOLN F PA; SP METHERGINE TABS F RHOGAM ULTRA- F PA; SP methylergonovine maleate F FILTERED PLUS SOSY tabs RHOPHYLAC SOSY F PA; SP PASSIVE IMMUNIZING AGENTS - Antibody Drugs to Treat Low Immune System WINRHO SDF SOLN F PA; SP Immune Serums Monoclonal Antibodies BIVIGAM SOLN F PA; SP SYNAGIS SOLN F PA; SP CARIMUNE F PA; SP NANOFILTERED SOLR PENICILLINS - Drugs to Treat Bacterial Infections PA; SP CUVITRU SOLN F Aminopenicillins CYTOGAM INJ F PA; SP amoxicillin caps 500 mg, F 250 mg PA; SP FLEBOGAMMA DIF SOLN F AMOXICILLIN CHEW 250 F MG, 125 MG PA; SP GAMASTAN S/D INJ F AMOXICILLIN ER TB24 F PA GAMMAGARD LIQUID F PA; SP amoxicillin susr 125 SOLN mg/5ml, 200 mg/5ml, 250 F GAMMAGARD S/D IGA PA; SP mg/5ml, 400 mg/5ml LESS THAN 1MCG/ML F PA SOLR amoxicillin tabs 500 mg F PA; SP GAMMAKED SOLN F amoxicillin tabs 875 mg F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin caps 250 mg, F AUGMENTIN SUSR QL(150 ml per 500 mg 250MG/5ML-62.5MG/5ML *** fill retail) (Use Amoxicillin & Pot AMPICILLIN CAPS 500 F MG Clavulanate) AUGMENTIN TABS QL(30 ea per AMPICILLIN SUSR 125 F MG/5ML, 250 MG/5ML 500MG-125MG (Use *** fill retail) Amoxicillin & Pot MOXATAG TB24 F PA Clavulanate) AUGMENTIN TABS QL(20 ea per Natural Penicillins 875MG-125MG (Use *** fill retail) PENICILLIN V Amoxicillin & Pot POTASSIUM SOLR 125 F Clavulanate) MG/5ML, 250 MG/5ML AUGMENTIN XR TB12 QL(40 ea per penicillin v potassium solr F (Use Amoxicillin & Pot *** 30 days retail) 125 mg/5ml, 250 mg/5ml Clavulanate) penicillin v potassium tabs F Penicillinase-Resistant Penicillins 500 mg, 250 mg Penicillin Combinations dicloxacillin sodium caps F amoxicillin & pot QL(100 ml per PHARMACEUTICAL ADJUVANTS clavulanate susr F fill retail) 200mg/5ml-28.5mg/5ml Internal Vehicle Ingredients/Agents amoxicillin & pot QL(150 ml per F QL(6000 gm clavulanate susr F fill retail) SIMPLYTHICK GEL per fill retail) 250mg/5ml-62.5mg/5ml starch-maltodextrin F amoxicillin & pot QL(200 ml per (thickening) powd clavulanate susr F fill retail) 400mg/5ml-57mg/5ml THICK-IT ORIGINAL POWD (Use Starch- *** amoxicillin & pot QL(400 ml per Maltodextrin (Thickening)) clavulanate susr F fill retail) 600mg/5ml-42.9mg/5ml Liquid Vehicles amoxicillin & pot QL(30 ea per CVS DISTILLED WATER F RX/OTC clavulanate tabs 250mg- F fill retail) LIQD 125mg, 500mg-125mg CVS PURIFIED WATER F RX/OTC amoxicillin & pot QL(20 ea per LIQD clavulanate tabs 875mg- F fill retail) DISTILLED WATER LIQD F RX/OTC 125mg amoxicillin & pot QL(40 ea per FLAVOR BLEND SUSP F RX/OTC clavulanate tb12 1000mg- F 30 days retail) 62.5mg FLAVOR PLUS LIQD F RX/OTC AMOXICILLIN/CLAVULAN F QL(20 ea per ATE POTASSIUM CHEW fill retail) FLAVOR SWEET SYRP F RX/OTC AUGMENTIN ES-600 QL(400 ml per SUSR (Use Amoxicillin & *** fill retail) FLAVOR SWEET-SF F RX/OTC Pot Clavulanate) SYRP GRAPE SYRUP SYRP F RX/OTC AUGMENTIN SUSR F QL(150 ml per 125MG/5ML-31.25MG/5ML fill retail) MX-SOL BLEND SF SUSP F RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MX-SOL BLEND SUSP F RX/OTC SOLVATECH SWEET SF F RX/OTC SYRP RX/OTC MX-SOL SF SYRP F SORBITOL SOLN XX 70 % F RX/OTC MX-SOL SUSPEND SUSP F RX/OTC STERILE DILUENT FOR PA; SP EPOPROSTENOL F MX-SOL SYRP F RX/OTC SODIUM SOLN STERILE DILUENT FOR F PA; SP NICE DISTILLED WATER F RX/OTC REMODOULIN SOLN LIQD SUSPENSION VEHICLE F RX/OTC ORA-BLEND SF SUSP F RX/OTC SUSP SYRPALTA SYRP F RX/OTC ORA-BLEND SUSP F RX/OTC SYRSPEND SF LIQD F RX/OTC ORA-PLUS LIQD F RX/OTC SYRUP VEHICLE SF F RX/OTC ORA-SWEET SF SYRP F RX/OTC SYRP RX/OTC ORA-SWEET SYRP F RX/OTC SYRUP VEHICLE SYRP F ORAL MIX FLAVORED RX/OTC VERSAFREE SYRP F RX/OTC SUSPENDING VEHICLE F SUSP VERSAPLUS SYRP F RX/OTC RX/OTC ORAL MIX SF SUSP F Semi Solid Vehicles ORAL SUSPEND LIQD F RX/OTC DELBASE F RX/OTC COMPOUNDING OINT ORAL SYRUP FLAVORED F RX/OTC RX/OTC VEHICLE SYRP HYDROPHILIC OINT F ORAL SYRUP SF SYRP F RX/OTC HYDROPHILIC F PETROLATUM OINT RX/OTC PCCA SWEET-SF SYRP F LANOLIN ANHYDROUS F RX/OTC OINT PCCA SYRUP VEHICLE RX/OTC F LANOLIN ANHYDROUS- F RX/OTC SYRP GRX OINT RX/OTC PCCA-PLUS SUSP F lanolin oint F RX/OTC PH 12 STERILE DILUENT F PA; SP RX/OTC FORFLOLAN SOLN OCCLUVAN OINT F RX/OTC PURIFIED WATER LIQD F white petrolatum gel F RX/OTC PX PURIFIED WATER F RX/OTC PROGESTINS - Hormone Replacement/Modifying LIQD Drugs RA CRYSTAL LAKE F RX/OTC DISTILLEDWATER LIQD Progestins RX/OTC AYGESTIN TABS (Use *** SOLVATECH PLUS SUSP F Norethindrone Acetate) F QL(4 ml per 28 MAKENA OIL days retail); SP ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAKENA OIL F SP EXELON CAPS OR 1.5 QL(2 ea daily) MG, 4.5 MG, 3 MG, 6 MG *** (Use Rivastigmine Tartrate) medroxyprogesterone F acetate tabs EXELON PT24 TD 9.5 PA MEGACE ES SUSP (Use PA MG/24HR, 4.6 MG/24HR *** Megestrol Acetate *** (Use Rivastigmine) (Appetite)) galantamine hydrobromide F QL(1 ea daily) cp24 8 mg, 16 mg, 24 mg megestrol acetate F PA (appetite) susp GALANTAMINE QL(6 ml daily) norethindrone acetate tabs F HYDROBROMIDE SOLN 4 F MG/ML progesterone micronized QL(30 ea per F galantamine hydrobromide F QL(2 ea daily) caps 30 days retail) tabs 12 mg, 8 mg, 4 mg PROMETRIUM CAPS (Use QL(30 ea per *** memantine hcl soln 2 F PA; QL(2 ml Progesterone Micronized) 30 days retail) mg/ml daily) PROVERA TABS (Use PA Medroxyprogesterone *** memantine hcl tabs F Acetate) memantine hcl tabs 5 mg, F PSYCHOTHERAPEUTIC AND NEUROLOGICAL 10 mg AGENTS - MISC. - Drugs to Treat Mental and NAMENDA SOLN 10 PA; QL(2 ml Emotional Conditions MG/5ML (Use Memantine *** daily) HCl) Agents for Chemical Dependency NAMENDA TABS 5 MG, 10 *** acamprosate calcium tbec F PA MG (Use Memantine HCl) NAMENDA TITRATION PA ANTABUSE TABS (Use *** Disulfiram) PAK TABS (Use *** Memantine HCl) disulfiram tabs F NAMENDA XR CP24 28 F PA; QL(2 ea MG, 21 MG, 14 MG daily) Anti-Cataplectic Agents NAMENDA XR CP24 7 MG F PA XYREM SOLN F PA; SP NAMENDA XR TITRATION F PA Antidementia Agents PACK CP24 ARICEPT TABS 10 MG, 5 QL(31 ea per RAZADYNE ER CP24 (Use QL(1 ea daily) MG (Use Donepezil *** 31 days retail) Galantamine *** Hydrochloride) Hydrobromide) ARICEPT TABS 23 MG PA RAZADYNE TABS (Use QL(2 ea daily) (Use Donepezil *** Galantamine *** Hydrochloride) Hydrobromide) donepezil hydrochloride F PA rivastigmine pt24 F PA tabs 23 mg QL(2 ea daily) donepezil hydrochloride F QL(31 ea per rivastigmine tartrate caps F tabs 5 mg, 10 mg 31 days retail) Combination Psychotherapeutics donepezil hydrochloride F QL(31 ea per tbdp 5 mg, 10 mg 31 days retail) CHLORDIAZEPOXIDE/AMI F TRIPTYLINE TABS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine-fluoxetine hcl F PA REBIF REBIDOSE SOAJ F PA; SP caps REBIF REBIDOSE PA; SP PERPHENAZINE/AMITRIP F F TYLINE TABS TITRATIONPACK SOAJ SYMBYAX CAPS (Use PA REBIF SOSY F PA; SP Olanzapine-Fluoxetine *** HCl) REBIF TITRATION PACK F PA; SP SOSY Fibromyalgia Agents TECFIDERA CPDR F PA; SP F PA; QL(2 ea SAVELLA TABS daily) TECFIDERA STARTER F PA; SP PA; QL(55 ea PACK MISC SAVELLA TITRATION F per 365 days PACK MISC retail) Postherpetic Neuralgia (PHN) Agents PA Movement Disorder Drug Therapy GRALISE STARTER MISC F PA; SP tetrabenazine tabs F GRALISE TABS F PA XENAZINE TABS (Use *** PA; SP Tetrabenazine) Premenstrual Dysphoric Disorder (PMDD) Agents F QL(124 ea per Multiple Sclerosis Agents FLUOXETINE CAPS 30 days retail) PA; SP AMPYRA TB12 F Pseudobulbar Affect (PBA) Agents PA AUBAGIO TABS F PA; SP NUEDEXTA CAPS F

AVONEX KIT F PA; SP Psychotherapeutic and Neurological Agents - ERGOLOID MESYLATES F PA AVONEX PEN AJKT F PA; SP TABS ORAP TABS (Use *** AVONEX PSKT F PA; SP Pimozide) F BETASERON KIT F PA; SP pimozide tabs Restless Leg Syndrome (RLS) Agents COPAXONE SOSY (Use *** PA; SP Glatiramer Acetate) HORIZANT TBCR F PA EXTAVIA KIT F PA; SP Smoking Deterrents PA; SP GILENYA CAPS F bupropion hcl (smoking F QL(2 ea daily) deterrent) tb12 glatiramer acetate sosy F PA; SP Limit 180 days CHANTIX CONTINUING F MONTHPAK TABS supply per 365 PLEGRIDY SOPN F PA; SP days Limit 180 days PLEGRIDY SOSY F PA; SP CHANTIX STARTING F supply per 365 MONTH PAK TABS days;QL(53 ea PLEGRIDY STARTER F PA; SP per fill retail) PACK SOPN Limit 180 days PLEGRIDY STARTER F PA; SP CHANTIX TABS F supply per 365 PACK SOSY days ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICODERM CQ PT24 21 QL(1 ea daily) KALYDECO TABS F PA; SP MG/24HR, 14 MG/24HR *** (Use Nicotine) ORKAMBI TABS F PA; SP NICODERM CQ PT24 7 *** MG/24HR (Use Nicotine) PULMOZYME SOLN F PA; SP NICORETTE GUM 2 MG, 4 QL(24 ea daily) MG (Use Nicotine *** SULFONAMIDES - Drugs to Treat Bacterial Polacrilex) Infections NICORETTE LOZG 4 MG, QL(20 ea daily) Sulfonamides 2 MG (Use Nicotine *** PA Polacrilex) SULFADIAZINE TABS F NICORETTE MINI LOZG *** QL(20 ea daily) (Use Nicotine Polacrilex) TETRACYCLINES - Drugs to Treat Bacterial Infections NICORETTE STARTER QL(24 ea daily) KIT GUM (Use Nicotine *** Tetracyclines Polacrilex) ADOXA CAPS (Use PA Doxycycline *** nicotine polacrilex gum 4 F QL(24 ea daily) mg, 2 mg (Monohydrate)) ADOXA PAK 1/100 TABS PA nicotine polacrilex lozg 4 F QL(20 ea daily) mg, 2 mg (Use Doxycycline *** (Monohydrate)) nicotine pt24 21 mg/24hr, F QL(1 ea daily) 14 mg/24hr ADOXA PAK 1/150 TABS PA (Use Doxycycline *** nicotine pt24 7 mg/24hr F (Monohydrate)) NICOTINE QL(56 ea per ADOXA PAK 2/100 TABS PA TRANSDERMAL SYSTEM F fill retail) (Use Doxycycline *** KIT (Monohydrate)) ADOXA TABS (Use PA NICOTROL INHALER F QL(504 ea per INHA fill retail) Doxycycline *** (Monohydrate)) NICOTROL NS SOLN F QL(120 ml per 30 days retail) demeclocycline hcl tabs F PA ZYBAN TB12 (Use QL(2 ea daily) doxycycline (monohydrate) F PA Bupropion HCl (Smoking *** caps Deterrent)) doxycycline (monohydrate) F PA Vasomotor Symptom Agents susr BRISDELLE CAPS (Use PA doxycycline (monohydrate) F PA Paroxetine Mesylate *** tabs (Vasomotor)) doxycycline hyclate caps F paroxetine mesylate F PA 100 mg, 50 mg (vasomotor) caps doxycycline hyclate tabs F RESPIRATORY AGENTS - MISC. - Drugs to 100 mg, 20 mg Treat Lung Conditions doxycycline hyclate tbec 75 F PA Cystic Fibrosis Agents mg, 100 mg, 150 mg PA; SP MINOCIN CAPS (Use *** KALYDECO PACK F Minocycline HCl)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits minocycline hcl caps 100 F NATURE-THROID TABS F mg, 50 mg, 75 mg SYNTHROID TABS (Use MINOCYCLINE HCL ER F PA F TB24 Levothyroxine Sodium) minocycline hcl tb24 45 F PA thyroid tabs F mg, 135 mg, 90 mg MONODOX CAPS (Use PA THYROLAR-1 TABS F Doxycycline *** (Monohydrate)) THYROLAR-1/2 TABS F SOLODYN TB24 F PA THYROLAR-1/4 TABS F tetracycline hcl caps 500 F mg, 250 mg THYROLAR-2 TABS F TETRACYCLINE HCL CAPS 500 MG, 250 MG *** THYROLAR-3 TABS F (Use Tetracycline HCl) PA VIBRAMYCIN CAPS 100 TIROSINT CAPS F MG (Use Doxycycline *** Hyclate) WESTHROID TABS F VIBRAMYCIN SUSR 25 PA WP THYROID TABS F MG/5ML (Use Doxycycline *** (Monohydrate)) ULCER DRUGS - Drugs to Treat Bowel, Intestine VIBRAMYCIN SYRP 50 F PA and Stomach Conditions MG/5ML Antispasmodics THYROID AGENTS - Drugs to Regulate Thyroid ANASPAZ TBDP (Use *** Hormones Hyoscyamine Sulfate) Antithyroid Agents BELLADONNA & OPIUM F PA SUPP methimazole tabs F BELLADONNA PA propylthiouracil tabs F ALKALOIDS & OPIUM F SUPP TAPAZOLE TABS (Use *** BENTYL CAPS (Use *** Methimazole) Dicyclomine HCl) Thyroid Hormones BENTYL TABS (Use *** ARMOUR THYROID TABS Dicyclomine HCl) 15 MG, 30 MG, 120 MG, F CANTIL TABS F PA 60 MG, 90 MG (Use Thyroid) CUVPOSA SOLN F PA ARMOUR THYROID TABS F 180 MG, 240 MG, 300 MG dicyclomine hcl caps 10 mg F CYTOMEL TABS (Use *** Liothyronine Sodium) dicyclomine hcl soln 10 F QL(496 ml per mg/5ml 30 days retail) levothyroxine sodium tabs F dicyclomine hcl tabs 20 mg F liothyronine sodium tabs F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DONNATAL ELIX PROPANTHELINE F QL(4 ea daily) 0.1037MG/5ML- BROMIDE TABS 0.0065MG/5ML- F ROBINUL FORTE TABS *** QL(4 ea daily) 0.0194MG/5ML- (Use Glycopyrrolate) 16.2MG/5ML ROBINUL TABS (Use *** QL(4 ea daily) DONNATAL TABS Glycopyrrolate) 0.1037MG-0.0065MG- SYMAX DUOTAB TBCR F 0.0194MG-16.2MG (Use *** Phenobarbital- Hyoscyamine-Atropine- H-2 Antagonists Scopolamine) CIMETIDINE HCL SOLN F glycopyrrolate tabs F QL(4 ea daily) cimetidine tabs 200 mg F RX/OTC hyoscyamine sulfate elix or F 0.125 mg/5ml cimetidine tabs 300 mg, F 800 mg, 400 mg HYOSCYAMINE SULFATE F POWD XX famotidine susr 40 mg/5ml F hyoscyamine sulfate soln F or 0.125 mg/ml famotidine tabs 20 mg F RX/OTC hyoscyamine sulfate subl sl F 0.125 mg famotidine tabs 40 mg, 10 F mg hyoscyamine sulfate tabs F or 0.125 mg nizatidine caps 300 mg, F PA 150 mg hyoscyamine sulfate tb12 F QL(4 ea daily) or 0.375 mg NIZATIDINE SOLN 15 F PA MG/ML hyoscyamine sulfate tbdp F or 0.125 mg PEPCID AC MAXIMUM RX/OTC STRENGTH TABS (Use *** LEVBID TB12 (Use *** QL(4 ea daily) Famotidine) Hyoscyamine Sulfate) PEPCID AC TABS (Use *** LEVSIN SOLN IJ 0.5 F Famotidine) MG/ML PEPCID SUSR 40 MG/5ML *** LEVSIN TABS OR 0.125 (Use Famotidine) MG (Use Hyoscyamine *** Sulfate) PEPCID TABS 20 MG (Use *** RX/OTC Famotidine) LEVSIN/SL SUBL (Use *** Hyoscyamine Sulfate) PEPCID TABS 40 MG (Use *** Famotidine) methscopolamine bromide F PA tabs ranitidine hcl caps 150 mg F QL(2 ea daily) PAMINE FORTE TABS PA QL(1 ea daily) (Use Methscopolamine *** ranitidine hcl caps 300 mg F Bromide) ranitidine hcl syrp 150 QL(20 ml daily) PAMINE TABS (Use *** PA mg/10ml, 15 mg/ml, 75 F Methscopolamine Bromide) mg/5ml phenobarbital- RX/OTC hyoscyamine-atropine- F ranitidine hcl tabs 150 mg F scopolamine tabs ranitidine hcl tabs 300 mg F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl tabs 75 mg F QL(2 ea daily) F QL(4 ea daily); lansoprazole cpdr 15 mg RX/OTC TAGAMET HB TABS (Use *** RX/OTC QL(2 ea daily) Cimetidine) lansoprazole cpdr 30 mg F ZANTAC 150 MAXIMUM RX/OTC NEXIUM 24HR CLEAR QL(2 ea daily); STRENGTH TABS (Use *** MINIS CPDR (Use *** RX/OTC Ranitidine HCl) Esomeprazole Magnesium) ZANTAC 75 TABS (Use *** QL(2 ea daily) NEXIUM 24HR CPDR (Use *** QL(2 ea daily); Ranitidine HCl) Esomeprazole Magnesium) RX/OTC ZANTAC TABS 150 MG *** RX/OTC NEXIUM CPDR 20 MG QL(2 ea daily); (Use Ranitidine HCl) (Use Esomeprazole *** RX/OTC Magnesium) ZANTAC TABS 300 MG *** (Use Ranitidine HCl) NEXIUM CPDR 40 MG PA (Use Esomeprazole *** Misc. Anti-Ulcer Magnesium) CARAFATE SUSP 1 F QL(420 ml per GM/10ML fill retail) NEXIUM PACK 40 MG, 20 F PA MG, 10 MG CARAFATE TABS 1 GM *** (Use Sucralfate) OMEPRAZOLE + QL(300 ml per SYRSPEND SFALKA F 30 days sucralfate tabs F retail,900 ml SUSP per days mail) Proton Pump Inhibitors omeprazole cpdr 10 mg, 40 F QL(1 ea daily) mg, 20 mg ACIPHEX SPRINKLE F PA CPSP omeprazole magnesium F cpdr ACIPHEX TBEC (Use *** PA Rabeprazole Sodium) OMEPRAZOLE TBEC 20 F QL(1 ea daily) CVS OMEPRAZOLE TBEC F QL(1 ea daily) MG pantoprazole sodium tbec F QL(1 ea daily) DEXILANT CPDR F PA; ST 20 mg pantoprazole sodium tbec F QL(2 ea daily) EQ OMEPRAZOLE TBEC F QL(1 ea daily) 40 mg PREVACID 24HR CPDR *** QL(4 ea daily); EQL OMEPRAZOLE TBEC F QL(1 ea daily) (Use Lansoprazole) RX/OTC PREVACID CPDR 15 MG QL(4 ea daily); esomeprazole magnesium F QL(2 ea daily); *** cpdr 20 mg RX/OTC (Use Lansoprazole) RX/OTC PREVACID CPDR 30 MG QL(2 ea daily) esomeprazole magnesium F PA *** cpdr 40 mg (Use Lansoprazole) QL(300 ml per PREVACID SOLUTAB F QL(1 ea daily) TBDP FIRST-OMEPRAZOLE F 30 days SUSP retail,900 ml PRILOSEC CPDR 20 MG, QL(1 ea daily) per days mail) 40 MG, 10 MG (Use *** Omeprazole) GNP OMEPRAZOLE F QL(1 ea daily) TBEC PRILOSEC OTC TBEC F QL(1 ea daily) HM OMEPRAZOLE TBEC F QL(1 ea daily) PRILOSEC PACK 2.5 MG, F PA 10 MG KLS OMEPRAZOLE TBEC F QL(1 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROTONIX PACK 40 MG F PA PREVPAC MISC (Use PA Amoxicillin-Clarithromycin *** PROTONIX TBEC 20 MG QL(1 ea daily) w/ Lansoprazole) (Use Pantoprazole *** PA Sodium) PYLERA CAPS F PROTONIX TBEC 40 MG QL(2 ea daily) ZEGERID CAPS 20MG- QL(2 ea daily); (Use Pantoprazole *** 1100MG (Use Omeprazole- *** RX/OTC Sodium) Sodium Bicarbonate) PX OMEPRAZOLE TBEC F QL(1 ea daily) ZEGERID CAPS 40MG- PA 1100MG (Use Omeprazole- *** RA OMEPRAZOLE TBEC F QL(1 ea daily) Sodium Bicarbonate) ZEGERID OTC CAPS (Use QL(2 ea daily); rabeprazole sodium tbec F PA Omeprazole-Sodium *** RX/OTC Bicarbonate) SB OMEPRAZOLE TBEC F QL(1 ea daily) ZEGERID PACK 40MG- 1680MG, 20MG-1680MG *** SM OMEPRAZOLE TBEC F QL(1 ea daily) (Use Omeprazole-Sodium Bicarbonate) QL(1 ea daily) SW OMEPRAZOLE TBEC F URINARY ANTI-INFECTIVES - Drugs to Treat Bladder/Kidney Infections TGT OMEPRAZOLE TBEC F QL(1 ea daily) Urinary Anti-infective Combinations Ulcer Drugs - Prostaglandins methenamine-hyosc- PA methylene blue-benzoic F CYTOTEC TABS (Use *** Misoprostol) acid-phenyl sal tabs methenamine-hyosc- PA misoprostol tabs F methylene blue-sod phos- phenyl sal caps 40.8mg- F Ulcer Therapy Combinations 0.12mg-36mg-120mg- amoxicillin-clarithromycin F PA 10mg w/ lansoprazole misc methenamine-hyosc- famotidine-calcium methylene blue-sod phos- carbonate-magnesium F phenyl sal tabs 40.8mg- hydroxide chew 36.2mg-0.12mg-81.6mg- F PA 10.8mg, 40.8mg-0.12mg- OMECLAMOX-PAK MISC F 36.2mg-81.6mg-10.8mg, omeprazole-sodium QL(2 ea daily); 40.8mg-0.12mg-32.4mg- bicarbonate caps 20mg- F RX/OTC 81mg-10.8mg 1100mg methenamine-hyoscamine- PA omeprazole-sodium PA methylene blue-sodium F bicarbonate caps 40mg- F phosphate caps 1100mg methenamine-hyoscamine- PA omeprazole-sodium methylene blue-sodium F bicarbonate pack 40mg- F phosphate tabs 1680mg, 20mg-1680mg UROGESIC-BLUE TABS PA PEPCID COMPLETE (Use Methenamine- *** Hyoscamine-Methylene CHEW (Use Famotidine- *** Calcium Carbonate- Blue-Sodium Phosphate) Magnesium Hydroxide) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Urinary Anti-infectives oxybutynin chloride tb24 15 F QL(2 ea daily) mg, 10 mg, 5 mg FURADANTIN SUSP (Use *** QL(40 ml daily) Nitrofurantoin) OXYTROL FOR WOMEN F PA; RX/OTC PTTW HIPREX TABS (Use *** PA Methenamine Hippurate) OXYTROL PTTW F PA; RX/OTC MACROBID CAPS (Use Nitrofurantoin Monohyd *** tolterodine tartrate cp24 2 F Macro) mg, 4 mg MACRODANTIN CAPS tolterodine tartrate tabs 2 F PA (Use Nitrofurantoin *** mg, 1 mg Macrocrystal) TOVIAZ TB24 F PA methenamine hippurate F PA tabs trospium chloride cp24 60 F PA mg METHENAMINE MANDELATE TABS 0.5 F trospium chloride tabs 20 F QL(2 ea daily) GM mg PA methenamine mandelate F VESICARE TABS F tabs 1 gm Urinary Antispasmodics - Cholinergic Agonists nitrofurantoin macrocrystal F caps bethanechol chloride tabs F nitrofurantoin monohyd F macro caps URECHOLINE TABS (Use *** Bethanechol Chloride) nitrofurantoin susp F QL(40 ml daily) Urinary Antispasmodics - Direct Muscle Relaxants URINARY ANTISPASMODICS - Drugs to Treat flavoxate hcl tabs F Miscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics VACCINES darifenacin hydrobromide F PA tb24 Bacterial Vaccines QL(1 ml per DETROL LA CP24 (Use *** Tolterodine Tartrate) F 9999 days PNEUMOVAX 23 INJ retail); AL; At DETROL TABS (Use *** PA least 18 yrs old Tolterodine Tartrate) QL(1 ml per DITROPAN XL TB24 (Use QL(2 ea daily) *** PNEUMOVAX 23/1 DOSE F 9999 days Oxybutynin Chloride) INJ retail); AL; At ENABLEX TB24 (Use *** PA least 18 yrs old Darifenacin Hydrobromide) QL(1 ml per PA GELNIQUE GEL F F 9999 days PREVNAR 13 SUSP retail); AL; At GELNIQUE PUMP GEL F PA least 18 yrs old Viral Vaccines oxybutynin chloride syrp 5 F QL(16.6 ml mg/5ml daily) AFLURIA 2015-2016 SUSP F oxybutynin chloride tabs 5 F QL(3 ea daily) mg AFLURIA 2016-2017 SUSP F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFLURIA 2017-2018 F QL(0.5 ml per SUSP FLUARIX QUADRIVALENT F 180 days 2016-2017 SUSY retail); AL; At AFLURIA PF 2015-2016 F SUSY least 9 yrs old QL(0.5 ml per AFLURIA PF 2016-2017 F SUSY FLUARIX QUADRIVALENT F 180 days 2017-2018 SUSY retail); AL; At AFLURIA PF 2017-2018 F least 9 yrs old SUSY FLUBLOK 2015-2016 F QL(0.5 ml per SOLN AFLURIA QUADRIVALENT F 180 days 2016-2017 SUSY retail); AL; At FLUBLOK 2016-2017 F least 9 yrs old SOLN QL(1 ml per FLUBLOK 2017-2018 F SOLN AFLURIA QUADRIVALENT F 180 days 2017-2018 SUSP retail); AL; At FLUBLOK QL(1 ml per least 9 yrs old QUADRIVALENT 2017- F 180 days QL(0.5 ml per retail); AL; At 2018 SOSY least 9 yrs old AFLURIA QUADRIVALENT F 180 days 2017-2018 SUSY retail); AL; At FLUCELVAX 2015-2016 F least 9 yrs old SUSY QL(1.5 ml per FLUCELVAX F F 9999 days QUADRIVALENT 2016- CERVARIX SUSP retail); AL; At 2017 SUSY least 18 yrs old FLUCELVAX QL(1 ml per QL(1.5 ml per QUADRIVALENT 2017- F 180 days ENGERIX-B INJ IM 10 F 9999 days 2018 SUSP retail); AL; At MCG/0.5ML retail); AL; At least 9 yrs old least 18 yrs old FLUCELVAX QL(3 ml per QUADRIVALENT 2017- F ENGERIX-B INJ IM 20 F 9999 days 2018 SUSY MCG/ML retail); AL; At QL(0.5 ml per least 18 yrs old FLULAVAL QUADRIVALENT 2014- F 180 days QL(1.5 ml per 2015 SUSY retail); AL; At ENGERIX-B SUSP IJ 10 F 9999 days least 9 yrs old MCG/0.5ML retail); AL; At QL(1 ml per least 18 yrs old FLULAVAL QUADRIVALENT 2015- F 180 days QL(3 ml per 2016 SUSP retail); AL; At ENGERIX-B SUSP IJ 20 F 9999 days least 9 yrs old MCG/ML retail); AL; At QL(1 ml per least 18 yrs old FLULAVAL QUADRIVALENT 2016- F 180 days FLUAD 2016-2017 SUSY F retail); AL; At 2017 SUSP least 9 yrs old FLUAD 2017-2018 SUSY F QL(0.5 ml per FLULAVAL 180 days QL(0.5 ml per QUADRIVALENT 2016- F 2017 SUSY retail); AL; At FLUARIX QUADRIVALENT F 180 days least 9 yrs old 2015-2016 SUSY retail); AL; At least 9 yrs old

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ml per QL(0.5 ml per FLULAVAL 180 days FLUZONE QUADRIVALENT 2017- F QUADRIVALENT 2015- F 180 days 2018 SUSP retail); AL; At retail); AL; At least 9 yrs old 2016 SUSP least 9 yrs old QL(0.5 ml per QL(0.5 ml per FLULAVAL 180 days FLUZONE QUADRIVALENT 2017- F QUADRIVALENT 2015- F 180 days 2018 SUSY retail); AL; At retail); AL; At least 9 yrs old 2016 SUSY least 9 yrs old FLUVIRIN 2015-2016 F FLUZONE QL(0.25 ml per SUSP F 180 days QUADRIVALENT 2015- retail); AL; At FLUVIRIN 2015-2016 F 2016 SUSY SUSY least 9 yrs old QL(1 ml per FLUVIRIN 2016-2017 F FLUZONE SUSP QUADRIVALENT 2016- F 180 days 2017 SUSP retail); AL; At FLUVIRIN 2016-2017 F least 9 yrs old SUSY FLUZONE QL(0.5 ml per FLUVIRIN 2017-2018 F 180 days SUSP QUADRIVALENT 2016- F 2017 SUSP retail); AL; At FLUVIRIN 2017-2018 F least 9 yrs old SUSY QL(0.5 ml per QL(0.5 ml per FLUZONE QUADRIVALENT 2016- F 180 days FLUZONE HIGH-DOSE PF F 180 days retail); AL; At 2015-2016 SUSY retail); AL; At 2017 SUSY least 9 yrs old least 9 yrs old QL(0.25 ml per QL(0.5 ml per FLUZONE QUADRIVALENT 2016- F 180 days FLUZONE HIGH-DOSE PF F 180 days retail); AL; At 2016-2017 SUSY retail); AL; At 2017 SUSY least 9 yrs old least 9 yrs old QL(0.5 ml per QL(0.5 ml per FLUZONE QUADRIVALENT 2017- F 180 days FLUZONE HIGH-DOSE PF F 180 days retail); AL; At 2017-2018 SUSY retail); AL; At 2018 SUSP least 9 yrs old least 9 yrs old QL(1 ml per QL(0.1 ml per FLUZONE 180 days FLUZONE INTRADERMAL 180 days QUADRIVALENT 2017- F QUADRIVALENT 2015- F 2018 SUSP retail); AL; At 2016 SUPN retail); AL; At least 9 yrs old least 9 yrs old QL(0.5 ml per QL(0.1 ml per FLUZONE 180 days FLUZONE INTRADERMAL 180 days QUADRIVALENT 2017- F QUADRIVALENT 2016- F 2018 SUSY retail); AL; At 2017 SUPN retail); AL; At least 9 yrs old least 9 yrs old QL(0.25 ml per QL(0.1 ml per FLUZONE FLUZONE INTRADERMAL QUADRIVALENT 2017- F 180 days QUADRIVALENT 2017- F 180 days retail); AL; At retail); AL; At 2018 SUSY least 9 yrs old 2018 SUPN least 9 yrs old FLUZONE SPLIT 2015- F FLUZONE QL(1 ml per 2016 SUSP F 180 days QUADRIVALENT 2015- retail); AL; At 2016 SUSP least 9 yrs old

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1.5 ml per QL(2 ml per GARDASIL 9 SUSP F 9999 days F 9999 days retail); AL; At VAQTA SUSP 50 UNIT/ML retail); AL; At least 18 yrs old least 18 yrs old QL(1.5 ml per QL(2 ea per GARDASIL 9 SUSY F 9999 days F 9999 days retail); AL; At VARIVAX INJ retail); AL; At least 18 yrs old least 18 yrs old QL(1.5 ml per QL(1 ea per GARDASIL SUSP F 9999 days F 9999 days retail); AL; At ZOSTAVAX SUSR retail); AL; At least 18 yrs old least 18 yrs old QL(2 ml per VAGINAL PRODUCTS - Drugs to Treat Vaginal HAVRIX SUSP 1440 F 9999 days Infections and Low Hormones ELU/ML retail); AL; At least 18 yrs old Spermicides QL(1 ml per F QL(12 ea per ENCARE SUPP fill retail) HAVRIX SUSP 720 F 9999 days ELU/0.5ML retail); AL; At F QL(25.5 gm per least 18 yrs old nonoxynol-9 gel fill retail) QL(2 ea per OPTIONS CONCEPTROL QL(25.5 gm per 9999 days M-M-R II INJ F VAGINAL *** fill retail) retail); AL; At CONTRACEPTIVE GEL least 18 yrs old (Use Nonoxynol-9) MEDICAL PROVIDER EZ OPTIONS GYNOL II QL(81 gm per FLU SHOT 2015-2016 F VAGINALCONTRACEPTIV F fill retail) PSKT E GEL QL(1 ea per MEDICAL PROVIDER SHUR-SEAL GEL F QL(24 gm per SINGLE USE EZ FLU F 180 days fill retail) SHOT PSKT retail); AL; At VCF VAGINAL least 9 yrs old CONTRACEPTIVE FILM F MEDICAL PROVIDER FILM SINGLE USE EZ FLU F VCF VAGINAL QL(17 gm per SHOT PSKT CONTRACEPTIVE FOAM F fill retail) QL(3 ml per FOAM RECOMBIVAX HB SUSP F 9999 days 10 MCG/ML, 40 MCG/ML retail); AL; At Vaginal Anti-infectives least 18 yrs old CLEOCIN CREA VA 2 % QL(1.5 ml per (Use Clindamycin *** Phosphate Vaginal) RECOMBIVAX HB SUSP 5 F 9999 days MCG/0.5ML retail); AL; At CLEOCIN SUPP VA 100 F PA least 18 yrs old MG QL(1 ml per clindamycin phosphate F vaginal crea VAQTA SUSP 25 F 9999 days UNIT/0.5ML retail); AL; At CLINDESSE CREA F least 18 yrs old clotrimazole vaginal crea 1 F QL(45 gm per % 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clotrimazole vaginal crea 2 F QL(31 gm per tioconazole vaginal oint F % 30 days retail) VAGISTAT-1 OINT (Use *** GYNAZOLE-1 CREA F Tioconazole Vaginal) GYNE-LOTRIMIN 3 CREA *** QL(31 gm per Vaginal Estrogens (Use Clotrimazole Vaginal) 30 days retail) ESTRACE CREA VA 0.1 F QL(43 gm per GYNE-LOTRIMIN CREA *** QL(45 gm per MG/GM 30 days retail) ) (Use Clotrimazole Vaginal 30 days retail) PA METROGEL-VAGINAL QL(70 gm per estradiol vaginal tabs F GEL (Use Metronidazole *** 30 days retail) PA Vaginal) ESTRING RING F F QL(70 gm per PA metronidazole vaginal gel 30 days retail) FEMRING RING F PREMARIN CREA VA QL(43 gm per F QL(3 ea per 30 F MICONAZOLE 3 SUPP days retail) 0.625 MG/GM 30 days retail) VAGIFEM TABS (Use PA miconazole nitrate vaginal F QL(45 gm per *** crea 2 %, 4 % 30 days retail) Estradiol Vaginal) miconazole nitrate vaginal F QL(24 gm per Vaginal Progestins kit fill retail) AL; At least 14 CRINONE GEL F miconazole nitrate vaginal F QL(1 ea per fill yrs old kit retail) FIRST-PROGESTERONE AL; At least 14 miconazole nitrate vaginal F QL(7 ea per 30 VGS 100 COMPOUNDING F yrs old supp 100 mg days retail) KIT SUPP MONISTAT 1 COMBO QL(1 ea per fill FIRST-PROGESTERONE AL; At least 14 PACK KIT (Use *** retail) VGS 200 F yrs old Miconazole Nitrate Vaginal) COMPOUNDING KIT MONISTAT 1 DAY OR QL(1 ea per fill SUPP NIGHT COMBO PACK KIT *** retail) FIRST-PROGESTERONE AL; At least 14 (Use Miconazole Nitrate VGS 25 COMPOUNDING F yrs old Vaginal) KIT SUPP MONISTAT 3 QL(24 gm per FIRST-PROGESTERONE AL; At least 14 COMBINATION PACK KIT *** fill retail) VGS 400 COMPOUNDING F yrs old (Use Miconazole Nitrate KIT SUPP Vaginal) FIRST-PROGESTERONE AL; At least 14 MONISTAT 3 CREA (Use *** QL(45 gm per VGS 50 COMPOUNDING F yrs old Miconazole Nitrate Vaginal) 30 days retail) KIT SUPP MONISTAT 7 SIMPLY QL(45 gm per VASOPRESSORS - Drugs to Treat Heart and CURE CREA (Use *** 30 days retail) Circulation Conditions Miconazole Nitrate Vaginal) Anaphylaxis Therapy Agents TERAZOL 3 CREA (Use *** Terconazole Vaginal) PA; Limit 1 fill (2 pens) per TERAZOL 7 CREA (Use *** Terconazole Vaginal) ADRENACLICK SOAJ 0.15 F month; 4 pens MG/0.15ML per year;QL(4 terconazole vaginal crea F ea per 365 days retail) terconazole vaginal supp F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 fill (2 cholecalciferol caps 5000 F QL(2 ea daily) pens) per unit ADRENACLICK SOAJ 0.3 month; 4 pens F cholecalciferol caps 50000 F QL(8 ea per 30 MG/0.3ML per year;QL(4 unit days retail) ea per 365 days retail) cholecalciferol chew 1000 F unit, 400 unit PA; Limit 1 fill (2 pens) per cholecalciferol liqd 5000 F unit/ml, 400 unit/ml AUVI-Q SOAJ 0.15 F month; 4 pens MG/0.15ML per year;QL(4 cholecalciferol tabs 400 ea per 365 unit, 1000 unit, 2000 unit, F days retail) 5000 unit D-VI-SOL LIQD (Use AUVI-Q SOAJ 0.3 *** *** MG/0.3ML Cholecalciferol) PA; Limit 1 fill DRISDOL CAPS (Use *** (2 pens) per Ergocalciferol) EPINEPHRINE SOAJ 0.15 month; 4 pens F DRISDOL SOLN (Use *** MG/0.15ML per year;QL(4 Ergocalciferol) ea per 365 days retail) ergocalciferol caps F EPINEPHRINE SOAJ 0.3 *** MG/0.3ML ergocalciferol soln F Limit 1 fill (2 KEY-E CHEW F QL(62 ea per pens) per 30 days retail) EPINEPHRINE SOAJ 0.3 F month; 4 pens MG/0.3ML, 0.15 MG/0.3ML per year;QL(4 MEPHYTON TABS F ea per 365 days retail) REPLESTA WAFR F EPIPEN 2-PAK SOAJ *** VITAMIN D3 LIQD F

EPIPEN-JR 2-PAK SOAJ *** vitamin e caps 200 unit, F QL(62 ea per 400 unit, 100 unit 30 days retail) Neurogenic Orthostatic Hypotension (NOH) - VITAMIN E CHEW 400 F QL(62 ea per UNIT 30 days retail) NORTHERA CAPS 200 F PA; QL(3 ea MG, 100 MG daily); SP vitamin e soln 15 unit/0.3ml F NORTHERA CAPS 300 F PA; QL(6 ea MG daily); SP Water Soluble Vitamins Vasopressors ascorbic acid chew 7.5mg- 500mg, 500 mg, 250mg, F midodrine hcl tabs F 250 mg, 500mg ascorbic acid tabs 250 mg, QL(100 ea per VITAMINS 500 mg, 500mg, 1000 mg, 30 days retail) Oil Soluble Vitamins 37mg-500mg, 37mg- F 1000mg, 10mg-500mg, cholecalciferol caps 2000 F QL(100 ea per 14mg-25mg-500mg, unit, 1000 unit fill retail) 1000mg cholecalciferol caps 400 F ascorbic acid tbcr 500 mg, F unit, 10000 unit 500mg

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

145 Drug Requirements/ Drug Name Tier Limits F QL(100 ea per B-1 TABS 30 days retail) biotin caps F

BIOTIN FORTE TABS F biotin tabs F niacin cpcr F niacin tabs F niacin tbcr F

NIACIN TR TBCR F pyridoxine hcl tabs F

F QL(100 ea per riboflavin tabs 30 days retail) SLO-NIACIN TBCR (Use *** Niacin) F QL(100 ea per thiamine hcl tabs 30 days retail) F QL(100 ea per thiamine mononitrate tabs 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated December 20, 2017

146 Index *Respiratory Therapy Supplies - ACIDOPHILUS PROBIOTIC ADRENACLICK 144,145 Misc** 107 BLEND 26 ADRENALIN 123 *Respiratory Therapy Supplies - ACIDOPHILUS SUPER Mouthpieces** 107 PROBIOTIC 26 ADVAIR DISKUS 15 *Spacer/Aerosol-Holding ACIDOPHILUS/CITRUS ADVAIR HFA 15 Chamber Supplies - Bags*** PECTIN 28 ADVANCED 107 ACIDOPHILUS/GOAT CALCIUM/VITAMIND/MAGNESI *Spacer/Aerosol-Holding MILK 26 UM 110 Chambers - Device*** 107 ACIPHEX 138 ADVANCED PROBIOTIC 26 4-N-1 80 ACIPHEX SPRINKLE 138 ADVANCED PROBIOTIC 10 26 5 DAY 80 acitretin 67 ADVATE 98 8-MOP 67 ACLOVATE 68 ADVICOR 33 A + D PERSONAL CARE ACNE MEDICATION 10 61 LOTION 71 ADVIL 3 A+D FIRST AID 80 ACNE MEDICATION 5 61 ADVIL COLD & SINUS 54 A-200 86 ACTEMRA 3 ADVIL MIGRAINE 4 A-MANTLE 80 ACTICON 54 AEROSPAN 15 abacavir sulfate 43 ACTIGALL 95 AFINITOR 39 abacavir sulfate-lamivudine 43 ACTIMARIS WOUND GEL 87 AFINITOR DISPERZ 39 abacavir sulfate-lamivudine- ACTIMMUNE 39 AFLURIA 2015-2016 140 zidovudine 43 ACTINEL 54 AFLURIA 2016-2017 140 ABILIFY 43 ACTINEL PEDIATRIC 54 AFLURIA 2017-2018 141 ABILIFY MAINTENA 43 ACTIQ 7 AFLURIA PF 2015-2016 141 ABSORBASE 80 ACTIVE OB 115 AFLURIA PF 2016-2017 141 ABSORICA 61 ACTIVELLA 94 AFLURIA PF 2017-2018 141 ABSTRAL 7 ACTONEL 92 AFLURIA QUADRIVALENT acamprosate calcium 133 ACTOPLUS MET 22 2016-2017 141 ACANYA 61 AFLURIA QUADRIVALENT ACTOPLUS MET XR 22 2017-2018 141 acarbose 22 ACTOS 24 AFREZZA 24 ACCOLATE 15 ACULAR 128 AFRIN 123 ACCUPRIL 33 ACULAR LS 128 AFRIN 12 HOUR 123 ACCURETIC 35 ACUVAIL 128 AFRIN ALL NIGHT acebutolol hcl 47 ACUWASH 80 NODRIP 123 ACEON 33 acyclovir 46 AFRIN NASAL SPRAY 123 acetaminophen 6 acyclovir topical 68 AFRIN NODRIP EXTRA MOISTURIZING 123 acetaminophen w/ codeine 8 ADALAT CC 48 AFRIN NODRIP ORIGINAL123 acetaminophen w/ dm 54 adapalene 61 AFRIN NODRIP SEVERE acetaminophen-caffeine 5 ADAPALENE 61 CONGESTION 123 acetazolamide 91 ADCETRIS 38 AFRIN NODRIP SINUS 123 acetic acid 97 ADCIRCA 50 AFRIN SINUS 123 acetic acid (otic) 129 ADDERALL 1 AGGRENOX 98 ACETIC ACID/ALUMINUM ADDERALL XR 1 AGRYLIN 99 ACETATE 129 adefovir dipivoxil 45 AKTIPAK 61 acetylcysteine 61 ADEMPAS 50 ALBENZA 12 ACIDOPHILUS 26 ALBOLENE 71 ACIDOPHILUS HIGH- Adhesive Tape 105 POTENCY 26 ADOXA 135 ALBUSTIX 89 ACIDOPHILUS PEARLS 26 ADOXA PAK 1/100 135 albuterol sulfate 15 ACIDOPHILUS PLUS ADOXA PAK 1/150 135 ALBUTEROL SULFATE ER 15 PECTIN 28 ADOXA PAK 2/100 135 ALCAINE 127

Index 1 alclometasone dipropionate 68 ALPHA LIPOIC ACID 2 amlodipine-valsartan- Alcohol Swabs - Misc 106 ALPHAGAN P 126 hydrochlorothiazide 35 AMOXAPINE 21 ALDACTAZIDE 91 ALPHANATE/VON amoxicillin 130 ALDACTONE 92 WILLEBRANDFACTOR COMPLEX/HUMAN 98 AMOXICILLIN 130 ALDARA 77 ALPHANINE SD 98 amoxicillin 130 ALENDRONATE SODIUM 92 alprazolam 13,14 amoxicillin & pot alendronate sodium 92 ALPRAZOLAM INTENSOL13 clavulanate 131 ALENDRONATE SODIUM 92 ALPROLIX 98 AMOXICILLIN ER 130 ALER-DRYL 30 ALREX 127 amoxicillin-clarithromycin w/ ALEVAZOL 64 lansoprazole 139 ALTABAX 64 AMOXICILLIN/CLAVULANATE ALEVE 4 ALTACE 33 POTASSIUM 131 ALEVE ARTHRITIS 4 ALTOPREV 33 amphetamine- ALEVICYN ANTIPRURITIC alum & mag hydrox- dextroamphetamine 1 GEL 87 simethicone 11 ampicillin 131 ALEVICYN ANTIPRURITIC AMPICILLIN 131 SG 80 ALUMINUM HYDROXIDE 11 alfuzosin hcl 97 aluminum hydroxide 80 AMPYRA 134 ALIGN 26 aluminum hydroxide-mag AMRIX 121 carb 11 ANADROL-50 10 ALINIA 12 aluminum hydroxide-mag ALKERAN 37 trisil 11 ANAFRANIL 21 ALLEGRA ALLERGY 31 aluminum sulfate & calcium anagrelide hcl 99 ALLEGRA ALLERGY acetate 80 ANALPRAM-HC 10 CHILDRENS 31 ALVESCO 15 ANAPROX DS 4 ALLEGRA-D 12 HOUR amantadine hcl 40 ANASPAZ 136 ALLERGY & CONGESTION 54 AMARYL 25 ALLEGRA-D 24 HOUR anastrozole 38 ALLERGY & CONGESTION 55 AMBIEN 101 ANBESOL MAXIMUM Allergy Tray Kit 1 ML 26 x AMBIEN CR 101 STRENGTH 113 1/2" 106 AMCINONIDE 68 ANCOBON 29 Allergy Tray Kit 1/2 ML 27 x AMERGE 108 ANDRODERM 10 1/2" 106 AMERIDERM ANDROGEL 10 allopurinol 98 PERISHIELD 80 ANDROGEL PUMP 10 almotriptan malate 108 AMERIGEL WOUND ANDROID 10 ALOCRIL 128 DRESSING 87 ANGELIQ 94 ALOE AFTERSUN LOTION 71 AMICAR 101 ANORO ELLIPTA 15 ALOE VESTA ANTIFUNGAL64 amiloride & 91 ANTABUSE 133 ALOE VESTA CLEAR hydrochlorothiazide ANTIFUNGAL 64 amiloride hcl 92 ANTARA 32 ALOE VESTA DAILY amiodarone hcl 14 ANUSOL-HC 11 MOISTURIZER 80 AMITIZA 96 ANZEMET 28 ALOE VESTA PROTECTIVE80 amitriptyline hcl 21 APEXICON E 68 ALOE VESTA SKIN AMLACTIN CERAPEUTIC 71 CONDITIONER 80 APIDRA 24 ALOGLIPTIN 24 AMLACTIN ULTRA 71 APIDRA SOLOSTAR 24 ALOGLIPTIN/METFORMIN amlodipine besylate 48 APLENZIN 20 HCL 22 amlodipine besylate- apraclonidine hcl 126 atorvastatin calcium 49 ALOGLIPTIN/PIOGLITAZONE aprepitant 29 22 amlodipine besylate-benazepril ALOMIDE 128 hcl 35 APRISO 96 amlodipine besylate-olmesartan ALORA 94 APTIOM 17 medoxomil 35 APTIVUS 43 alosetron hcl 96 amlodipine besylate- valsartan 35

Index 2 AQUA GLYCOLIC FACE ASMANEX TWISTHALER 60 AVAR 61 CREAM 71 METERED DOSES 15 AVAR LS 61 AQUA GLYCOLIC FACIAL ASMANEX TWISTHALER 7 CLEANSER 80 METERED DOSES 15 AVAR LS CLEANSER 61 AQUA GLYCOLIC HAND & ASPERCREME/ALOE 78 AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY BODYLOTION 71 aspirin 6 AQUA GLYCOLIC SHAMPOO & YOGURT 72 BODY CLEANSER 80 ASPIRIN 6 AVEENO ACTIVE NATURALS AQUA GLYCOLIC TONER 80 aspirin 6,7 DAILY MOISTURIZING BODY AQUA LACTEN 71 aspirin buffered (cal carb-mag YOGURT/APRICO 72 carb-mag oxide) 6 AVEENO ACTIVE NATURALS AQUADERM 71 ASPIRIN LOW DOSE 6 ECZEMA THERAPY 72 AQUADERM AVEENO ACTIVE NATURALS TREATMENT/MOISTURIZER aspirin-acetaminophen- ECZEMA THERAPY HAND 72 71 caffeine 5 AVEENO ACTIVE NATURALS ASPIRIN-CAFFEINE- AQUAMED 71 8 SKIN RELIEF MOISTURE DIHYDROCODEINE REPAIR 72 AQUAPHILIC 72 99 aspirin-dipyridamole AVEENO ANTI-ITCH 79 AQUAPHOR 72 ASTAGRAF XL 111 AVEENO BABY CALMING AQUAPHOR ADVANCED ASTEPRO 122 COMFORT BATH 80 THERAPY 72 AVEENO BABY CLEANSING AQUAPHOR LIP REPAIR 80 ATACAND 34 ATACAND HCT 35 THERAPY MOISTURIZING AQUORAL 114 WASH 80 ARANESP ALBUMIN FREE 99 ATELVIA 92 AVEENO BABY ECZEMA ARAVA 5 atenolol 47 THERAPY 72 atenolol & chlorthalidone 35 AVEENO DAILY ARCALYST 3 MOISTURIZINGSPF 15 72 ARCAPTA NEOHALER 15 ATGAM 112 AVEENO INTENSE RELIEF ARGININE 124 ATIVAN 14 HAND 72 AVEENO POSITIVELY arginine 124 atomoxetine hcl 1 atorvastatin calcium 33 AGELESS LIFT & FIRM ARICEPT 133 EYE 72 ARIMIDEX 38 atovaquone 12 AVEENO POSITIVELY aripiprazole 43 atovaquone-proguanil hcl 36 AGELESS NIGHT 72 ATRAC-TAIN 71 AVEENO POSITIVELY ARISTADA 43 AGELESSFIRMING BODY 72 ARIXTRA 16 ATRALIN 61 AVEENO POSITIVELY ATRAPRO ANTIPRURITIC armodafinil 1 AGELESSSKIN HYDROGEL 87 STRENGTHENING BODY ARMOUR THYROID 136 ATRAPRO DERMAL CREAM 72 AROMASIN 38 SPRAY 87 AVEENO POSITIVELY ARTHRITIS PAIN ATRIPLA 43 AGELESSSKIN RELIEVING 79 ATROPINE SULFATE 126 STRENGTHENING HAND artificial tear ointment 124 ATROVENT 122 CREAM 72 artificial tear solution 124 AVEENO POSITIVELY ATROVENT HFA 14 NOURISHING 24-HOUR ULTRA- ARTIFICIAL TEARS 124 AUBAGIO 134 HYDRATING 72 ASACOL HD 96 AUGMENTED AVEENO POSITIVELY ASC LOTIONIZED BETAMETHASONE NOURISHING ANTIOXIDANT ANTIMICROBIAL SKIN DIPROPIONATE 68 INFUSED BODY WASH 80 CLEANSER 80 AUGMENTIN 131 AVEENO POSITIVELY ascorbic acid 145 NOURISHING ENERGIZING72 AUGMENTIN ES-600 131 AVEENO POSITIVELY ASMANEX TWISTHALER 120 AUGMENTIN XR 131 METERED DOSES 15 RADIANT 72 ASMANEX TWISTHALER 14 AUVI-Q 145 AVEENO POSITIVELY METERED DOSES 15 AVALIDE 35 RADIANT60 SECOND IN- SHOWER FACIAL 80 ASMANEX TWISTHALER 30 AVANDIA 24 METERED DOSES 15 AVAPRO 34

Index 3 AVEENO POSITIVELY bacitracin-polymyxin b 64 BENZAC AC WASH 61 RADIANTOVERNIGHT bacitracin-polymyxin b BENZACLIN 61 HYDRATING FACIAL (ophth) 126 BENZACLIN WITH PUMP 61 MOISTURI 72 baclofen 121 AVEENO STRESS RELIEF BENZAMYCIN 61 BACTRIM 12 MOISTURIZING 72 BENZEFOAM 61 BACTRIM DS 12 AVELOX 95 BENZEFOAM ULTRA 61 BACTROBAN 64 AVELOX ABC PACK 95 BENZEFOAMULTRA 61 BACTROBAN NASAL 122 AVODART 97 benzocaine (dental) 113 AVONEX 134 BAL-CARE DHA 115 benzocaine-menthol (mouth- AVONEX PEN 134 balsalazide disodium 96 throat) 113 AXERT 108 BANZEL 17 benzocaine-triclosan 79 AXIRON 10 BARACLUDE 45 benzonatate 54 AYGESTIN 132 BASAGLAR KWIKPEN 24 benzoyl peroxide 61 AYR NASAL DROPS 122 BASIS CLEANSER EXTRA BENZOYL PEROXIDE 62 DRY 81 benzoyl peroxide 62 AYR NASAL MIST ALLERGY BASIS CLEANSER &SINUS HYPERTONIC NORMAL/DRY 81 BENZOYL PEROXIDE 8% 61 SALINE 122 BASIS CLEANSER BENZOYL PEROXIDE AZASAN 112 SENSITIVE 81 CLEANSER 61 AZASITE 126 BASIS FACIAL benzoyl peroxide- azathioprine 112 MOISTURIZER 81 erythromycin 62 benztropine mesylate 40 azelastine hcl 122 BASIS OVERNIGHT 81 BESIVANCE 126 azelastine hcl (ophth) 128 BASLE 72 BETA CARE 72 AZELEX 61 BD GLUCOSE 23 BETA XMA 72 AZILECT 41 BECONASE AQ 122 BETADINE 43 AZITHROMYCIN 104 BELBUCA 9 BETADINE SKIN azithromycin 104 BELLADONNA & OPIUM 136 BELLADONNA ALKALOIDS & CLEANSER 43 AZOLEN TINCTURE 64 OPIUM 136 BETADINE SURGICAL SCRUB 43 AZOPT 128 BELSOMRA 102 AZOR 35 BETAGAN 125 BENADRYL ALLERGY 30 betamethasone dipropionate AZULFIDINE 96 BENADRYL ALLERGY (topical) 68 AZULFIDINE EN-TABS 96 CHILDRENS 30 betamethasone dipropionate B-1 146 BENADRYL EXTRA augmented 68 STRENGTH 66 betamethasone valerate 68 B-12 99 BENADRYL ITCH B-12 1000 99 STOPPING 66 BETAPACE 47 b-complex vitamin BENADRYL-D ALLERGY & BETAPACE AF 47 caps/tabs 114 SINUS CHILDRENS 55 BETASERON 134 b-complex w/ biotin 114 benazepril & hydrochlorothiazide 35 betaxolol hcl 47 b-complex w/ c 114 benazepril hcl 33 betaxolol hcl (ophth) 125 b-complex w/ c caps 114 BENEFIBER 102 bethanechol chloride 140 b-complex w/ c tabs/tabcr 114 BENEFIBER FOR BETHKIS 3 b-complex w/ folic acid tabs114 CHILDREN 102 BETIMOL 125 BABY ANBESOL 113 BENEFIX 98 BETOPTIC-S 125 BACIGUENT 64 BENGAY GREASELESS 78 bexarotene 39 BACITRACIN 126 BENGAY ULTRA BEYAZ 51 bacitracin (topical) 64 STRENGTH 78 BENICAR 34 BIAXIN 105 bacitracin zinc 64 BENICAR HCT 35 bicalutamide 38 bacitracin-poly-neomycin-hc BIDIL 49 127 BENTYL 136

Index 4 BIFERA 99 bromocriptine mesylate 40 CALAN 48 BILTRICIDE 12 brompheniramine & CALAN SR 48 BIOHM PROBIOTIC phenyleph 55 CALCI-CHEW 109 brompheniramine & SUPPLEMENT 26 CALCIONATE 109 BIOHM PROBIOTIC pseudoeph 55 SUPPLEMENT/VITAMIN C 26 BROTAPP DM 55 calcipotriene 67 BIONEL 55 BROVANA 16 calcitonin (salmon) 92 BIONEL PEDIATRIC 55 budesonide (inhalation) 15 calcitriol 93 BIOSPEC DMX 55 budesonide (nasal) 122 CALCIUM 109 BIOTENE DRY MOUTH BUFFERIN 7 calcium & phosphorus w/ vitamin d 109 MOISTURIZING SPRAY 114 bumetanide 91 biotin 146 calcium acetate (phosphate BUMEX 91 binder) 96 BIOTIN FORTE 146 BUNAVAIL 9 CALCIUM CARBONATE 11 bisacodyl 104 BUPHENYL 93 calcium carbonate 109 bisacodyl-peg 3350-pot chloride- sod bicarb-sod chloride 103 BUPRENEX 9 calcium carbonate (antacid) 11 bismuth subsalicylate 26 BUPRENORPHINE 10 calcium carbonate- bisoprolol & buprenorphine hcl 9 cholecalciferol 109 hydrochlorothiazide 35 calcium carbonate- buprenorphine hcl-naloxone hcl ergocalciferol 109 bisoprolol fumarate 47 dihydrate 9 calcium carbonate-vitamin BIVIGAM 130 bupropion hcl 20 d 109 BLEPH-10 126 bupropion hcl (smoking calcium carbonate-vitamin d w/ deterrent) 134 BLEPHAMIDE 127 minerals 109 buspirone hcl 13 calcium citrate 109 BLEPHAMIDE S.O.P. 127 butalbital-acetaminophen 5 Blood Glucose Calibration - calcium citrate-vitamin d 109 Liquid 105 butalbital-acetaminophen- CALCIUM GLUCONATE 109 Blood Glucose Calibration - caffeine 5 butalbital-acetaminophen- CALCIUM LACTATE 109 Liquid - High 105 CALCIUM PNV 115 Blood Glucose Calibration - caffeine w/ codeine 8 Liquid - Low 105 butalbital-aspirin-caffeine 5 calcium polycarbophil 102 Blood Glucose Calibration - butalbital-aspirin-caffeine calcium w/ vitamin d 109 Liquid - Normal 105 w/cod 8 calcium w/ vitamins d & k 109 BONE DENSITY BUILDER 110 butenafine hcl 64 CALCIUM/MAGNESIUM/ZINC BONIVA 92 BUTISOL SODIUM 101 110 BOSULIF 39 butorphanol tartrate 10 CALCIUM/MAGNESIUM/ZINC/VI BOUDREAUXS BABY BUTT BUTRANS 10 TAMIN D3 110 CALNA 115 SMOOTH DRY SKIN 72 BYDUREON 24 BOUDREAUXS BUTT BATH CALTRATE 600+D PLUS BODYWASH & SHAMPOO 81 BYDUREON PEN 24 MINERALS 109 BOUDREAUXS BUTT BYETTA 24 CAM 72 PASTE 81 BYSTOLIC 47 camphor & menthol 67 BP CLEANSING WASH 62 cabergoline 94 camphor-menthol-methyl BPO CREAMY WASH CADUET 49 salicylate 78 COMPLETEPACK 62 CANASA 96 BREO ELLIPTA 16 CAFERGOT 107 caffeine citrate 1 candesartan cilexetil 34 BREVICON-28 51 candesartan cilexetil- BRILINTA 99 CAFFEINE CITRATED 1 hydrochlorothiazide 35 brimonidine tartrate 126 CAL MAG ZINC +D3 110 CANTIL 136 BRINTELLIX 21 CAL-MAG-ZINC-D 110 CAPCOF 55 BRISDELLE 135 CAL-MAG-ZINC-D3 110 capecitabine 38 BROMFENAC 128 CALADRYL 79 CAPEX 68 bromfenac sodium (ophth) 128 CALAMINE 81 CAPHOSOL 114

Index 5 CAPITAL/CODEINE 8 CARNITOR 93 CEPHALEXIN 50 CAPMIST DM 55 CARNITOR SF 93 CERALYTE 70 109 CAPRELSA 39 CARRASMART 87 CERASPORT 109 CAPRON DM 55 CARRASYN HYDROGEL CERASPORT EX1 109 CAPSAGEL 79 WOUND DRESSING 87 CERAVE 72 CARRASYN V HYDROGEL CAPSAGEL EXTRA WOUNDDRESSING 87 CERAVE AM SPF 30 72 STRENGTH 79 CARRINGTON MOISTURE CERAVE FOAMING FACIAL CAPSAGEL MAXIMUM BARRIER 81 CLEANSER 81 STRENGTH 79 CARRINGTON MOISTURE CERAVE HYDRATING capsaicin 79 BARRIER/ZINC 81 CLEANSER 81 captopril 34 carteolol hcl (ophth) 125 CERAVE PM 72 CAPTOPRIL/HYDROCHLOROT carvedilol 47 CERAVE RENEWING SA 73 HIAZIDE 35 carvedilol phosphate 47 CERAVE SA RENEWING 73 CAPZASIN QUICK RELIEF 79 CASODEX 38 CERDELGA 99 CAPZASIN-HP 79 CASTIVA WARMING 79 CERVARIX 141 CAPZASIN-P 79 CATAPRES 34 CESAMET 29 CARA-KLENZ 81 CATAPRES-TTS-1 34 CETAKLENZ 81 CARAC 66 CATAPRES-TTS-2 34 CETAPHIL 73 CARAFATE 138 CATAPRES-TTS-3 34 CETAPHIL DAILY ADVANCE CARB-O-LAN 10 72 ULTRA HYDRATING 73 CAYSTON 12 CARB-O-LAN 20 72 CETAPHIL DAILY FACIAL CEDAX 50 CARB-O-PHILIC/20 72 MOISTURIZER 73 cefaclor 50 CETAPHIL DERMACONTROL CARB-O-SAL 5 72 CEFACLOR 50 FOAM WASH 81 CARBAGLU 93 CETAPHIL DERMACONTROL CEFACLOR ER 50 carbamazepine 17 MOISTURIZER/SPF 30 73 cefadroxil 50 CETAPHIL GENTLE carbamide peroxide (otic) 129 cefdinir 50 CLEANSER 81 CARBATROL 17 CEFDITOREN PIVOXIL 50 CETAPHIL MOISTURIZING 73 carbidopa 40 CETAPHIL cefixime 50 carbidopa-levodopa 40 RESTORADERM 73 CARBIDOPA/LEVODOPA/ENTA cefpodoxime proxetil 50 CETAPHIL THERAPEUTIC CAPONE 40 cefprozil 50 HAND 73 carbinoxamine maleate 30 CEFTIBUTEN 50 cetirizine hcl 31 carbonyl iron 100 CEFTIN 50 cetirizine-pseudoephedrine 55 carboxymethylcellulose sodium ceftriaxone sodium 50 CETRAXAL 129 (ophth) 124 cefuroxime axetil 50 cevimeline hcl 114 carboxymethylcellulose-glycerin CHANTIX 134 124 CELEBREX 4 celecoxib 4 CHANTIX CONTINUING CARDIZEM 48 MONTHPAK 134 CARDIZEM CD 48 CELEXA 20 CHANTIX STARTING MONTH CARDIZEM LA 48 CELLCEPT 112 PAK 134 CARDURA 34 CELONTIN 19 CHAPSTICK OVERNIGHT 81 CARDURA XL 97 CENTANY 64 CHAPSTICK ULTRA MOISTUREDAYTIME CARIMUNE CEPACOL DUAL RELIEF SORETHROAT SPRAY 113 FORMULA 81 NANOFILTERED 130 CHAPSTICK ULTRASMOOTH carisoprodol 121 CEPACOL SORE THROAT 113 FORTIFY 81 carisoprodol w/ aspirin 122 CEPACOL SORE THROAT CHAPSTICK ULTRASMOOTH carisoprodol w/ aspirin & EXTRA STRENGTH 113 NOURISH 81 codeine 122 CEPACOL SORE THROAT CHAPSTICK ULTRASMOOTH CARMOL 10 71 MAXIMUM NUMBING 113 REJUVENATE 81 CARMOL 20 71 cephalexin 50

Index 6 CHAPSTICK ULTRASMOOTH chlorpromazine hcl 42 CLARITHROMYCIN 105 SOOTHE 81 CHLORPROPAMIDE 25 clarithromycin 105 CHEK-STIX COMBO PAK URINALYSIS CONTROL 89 chlorthalidone 92 CLARITHROMYCIN 105 CHEK-STIX CONTROL 89 CHLORZOXAZONE 121 clarithromycin 105 CHEMET 28 CHOLBAM 95 CLARITIN 31 CHEMSTRIP -10 WITH SG 89 cholecalciferol 145 CLARITIN ALLERGY CHILDRENS 31 CHEMSTRIP 10 MD 89 cholestyramine 32 CLARITIN CHILDRENS 31 CHEMSTRIP 2 GP STRIPS 89 cholestyramine light 32 CLARITIN REDITABS 31 CHEMSTRIP 5 OB 89 choline & mag salicylate 7 CLARITIN-D 12 HOUR 55 CHEMSTRIP 7 90 choline fenofibrate 32 CLARITIN-D 24 HOUR 55 CHEMSTRIP 9 STRIPS 90 CHORIONIC GONADOTROPIN 92 CLASSIC PRENATAL 115 CHEMSTRIP UGK 90 ciclopirox 64,65 CLEAN & CLEAR ADVANTAGE CHEMSTRIP-K 90 ciclopirox olamine 64 3-IN-1 EXFOLIATING CHEMSTRIP-MICRAL 90 CLEANSER 62 cilostazol 99 CHENODAL 95 CLEAN & CLEAR CILOXAN 126 ESSENTIALSFOAMING FACIAL CHERACOL PLUS 55 cimetidine 137 CLEANSER 81 CHERACOL SORE CLEAN & CLEAR FOAMING THROAT 113 CIMETIDINE HCL 137 FACIAL CLEANSER SENSITIVE CHERACOL-D COUGH 55 CIMZIA 96 SKIN 81 CHEW Q 2 CIPRO 95 CLEAN & CLEAR MORNING CHILDRENS ADVIL 4 CIPRO HC 129 BURST BODY WASH BOOST 81 CHILDRENS MOTRIN 4 CIPRO XR 95 CLEAN & CLEAR MORNING CHILDRENS PROBIOTIC CIPRODEX 129 BURST DETOXIFYING FACIAL PEARLS 26 ciprofloxacin 95 CLEANSER 81 CHLOR-TRIMETON 30 CIPROFLOXACIN 129 CLEAN & CLEAR MORNING CHLOR-TRIMETON BURST FACIAL CLEANSER81 ALLERGY 30 CIPROFLOXACIN HCL 95 CLEAN & CLEAR MORNING CHLORASEPTIC 113 ciprofloxacin hcl 95 BURST HYDRATING FACIAL CHLORASEPTIC SORE ciprofloxacin hcl (ophth) 126 CLEANSER 81 THROAT/LIQUID CENTER 113 ciprofloxacin-ciprofloxacin CLEAN & CLEAR NIGHT hcl 95 RELAXING DEEP CLEANING chlordiazepoxide hcl 14 FACE WASH 81 citalopram hydrobromide 20 CHLORDIAZEPOXIDE/AMITRIP CLEANSING EYELID PADS 81 TYLINE 133 CITRACAL + D3 MAXIMUM 109 CLEAR AWAY ONE STEP chlorhexidine gluconate 43 WARTREMOVER 78 chlorhexidine gluconate (mouth- CITRACAL MAXIMUM 109 CLEAR AWAY PLANTAR throat) 113 CITRACAL SYSTEM 78 chloroquine phosphate 37 PETITES/VITAMIND 109 CLEAR AWAY WART CHLOROQUINE CITRACAL PLUS 110 REMOVER SYSTEM 78 PHOSPHATE 37 CITRANATAL 90 DHA 115 CLEAR COUGH PM MULTI- chloroquine phosphate 37 CITRANATAL ASSURE 115 SYMPTOM 55 clemastine fumarate 30 CHLOROTHIAZIDE 92 CITRANATAL DHA 115 chlorothiazide 92 CITRANATAL CLEMASTINE FUMARATE 30 chlorpheniramine & HARMONY 115 clemastine fumarate 30 phenylephrine 55 CITRANATAL RX 115 CLEOCIN 13,143 chlorpheniramine & CITRUCEL 102 CLEOCIN PEDIATRIC pseudoeph 55 CITRUCEL FIBER GRANULES 13 chlorpheniramine maleate 30 LAXATIVE 102 CLEOCIN-T 62 chlorpheniramine-acetaminophen CLARIFOAM EF 62 CLIMARA 94 55 chlorpheniramine-phenylephrine- CLARINEX 31 CLIMARA PRO 94 acetaminophen 55 CLARINEX-D 12 HOUR 55 CLINDAGEL 62

Index 7 clindamycin hcl 13 CO-NATAL FA 115 COMPOUND W FREEZE OFF clindamycin palmitate coal tar extract 87 WART REMOVAL SYSTEM 78 COMPOUND W MAXIMUM hydrochloride 13 COARTEM 37 clindamycin phosphate STRENGTH 78 (topical) 62 COCOA BUTTER 73 COMTAN 40 clindamycin phosphate COCOA BUTTER HAND & COMTREX COLD & COUGH vaginal 143 BODYLOTION 73 MAXIMUM STRENGTH 55 clindamycin phosphate-benzoyl COCONUT OIL BEAUTY 73 COMTREX COLD & COUGH peroxide 62 codeine sulfate 7 NIGHTTIME MAXIMUM clindamycin phosphate- STRENGTH 55 CODEINE SULFATE 7 tretinoin 62 CONCEPT DHA 115 CODITUSS DM 55 CLINDESSE 143 CONCEPT OB 115 CLINITEST 90 coenzyme q10 (ubidecarenone) 2 CONCERTA 1 CLINITEST REAGENT 90 COLACE 104 Condoms - Female 105 CLN BODY WASH GENTLE COLACE CLEAR 104 Condoms Latex Lubricated - NON-DRYING 81 Male 105 CLN FACIAL CLEANSER COLAZAL 96 Condoms Latex Non-Lubricated - MOISTURE BALANCING 81 COLCHICINE 98 Male 105 CLN FACIAL MOISTURIZER colchicine w/ probenecid 98 Condoms Non-Latex Non- NOURISHING 73 COLCRYS 98 Lubricated - Male 105 CLN HAND & FOOT WASH CONDYLOX 78 DEEP CLEANSING 82 COLD & FLU RELIEF CLN SPORT WASH HIGH NIGHTTIME D 55 CONEX COLD/ALLERGY 55 PERFORMANCE 82 COLEMAN 100 MAX INSECT CONZIP 7 CLN SPORTWASH 82 REPELLENT/CONTINUOUS COOL BOTTOMS 82 SPRAY 82 clobetasol propionate 68 COLEMAN INSECT COPAXONE 134 clobetasol propionate emollient REPELLENT/HIGH & DRY82 COPEGUS 45 base 68 COLEMAN INSECT CORDARONE 14 clobetasol propionate REPELLENT/SPORTSMEN emulsion 68 82 CORDRAN 69 CLOBEX 68 COLESTID 32 CORDRAN TAPE 69 CLOCORTOLONE COREG 47 PIVALATE 69 COLESTID FLAVORED 32 CLOCORTOLONE PIVALATE colestipol hcl 32 COREG CR 47 PUMP 69 colloidal oatmeal 73 CORGARD 47 CLODAN KIT 69 COLY-MYCIN S 129 CORICIDIN HBP COLD & FLU 55 CLODERM 69 COLYTE-FLAVOR CORN REMOVER ONE CLODERM PUMP 69 PACKS 103 STEP 78 clomipramine hcl 21 COMBIGAN 125 CORN REMOVER ULTRA clonazepam 17 COMBIPATCH 94 THIN 78 COMBISTIX 90 CORN REMOVER clonidine hcl 34 WATERPROOF 78 COMBIVENT RESPIMAT 16 clonidine hcl (adhd) 1 CORTANE-B AQUEOUS 129 COMBIVIR 43 clopidogrel bisulfate 99 CORTANE-B-OTIC 129 COMETRIQ 39 clorazepate dipotassium 14 CORTEF 53 COMFEEL PASTE 87 CLORPRES 35 CORTENEMA 10 COMPLERA 43 clotrimazole 113 CORTIFOAM 10 COMPLETE NATAL DHA115 clotrimazole (topical) 65 CORTISONE ACETATE 53 clotrimazole vaginal 143,144 COMPLETE PRENATAL MULTIVITAMIN/PRENATAL CORTISPORIN 64 clotrimazole w/ DHA 115 CORTISPORIN-TC 129 betamethasone 65 COMPLETENATE 115 CORZIDE 35 clozapine 42 COMPOUND W 78 COSOPT 125 CLOZAPINE ODT 42 COSOPT PF 125 CLOZARIL 42

Index 8 COTELLIC 39 CVS MOISTURIZING dapsone 12 COUMADIN 16 CREAM 73 DARAPRIM 37 CVS NATURAL FIBER COZAAR 34 SUPPLEMENT 102 darifenacin hydrobromide 140 CREON 91 CVS OMEPRAZOLE 138 DAY TIME MULTI-SYMPTOM COLD/FLU RELIEF 56 CRESTOR 33 CVS PRENATAL 115 DAYPRO 4 CRINONE 144 CVS PROBIOTIC 26 DAYTRANA 1 CRITIC-AID CLEAR CVS PROBIOTIC MAXIMUM MOISTUREBARRIER 82 STRENGTH 26 DDAVP 93 CRIXIVAN 43 CVS PROBIOTIC PEARLS DEBROX 129 cromolyn sodium 14 EXTRA STRENGTH 26 DECON-A 56 cromolyn sodium CVS PURIFIED WATER 131 DELBASE (mastocytosis) 95 CVS SALINE WOUND COMPOUNDING 132 cromolyn sodium (nasal) 122 WASH 82 DELSYM 54 cromolyn sodium (ophth) 128 CVS SENIOR PROBIOTIC26 DELSYM COUGH CULTURELLE ADVANCED CVS SILVER GEL 87 CHILDRENS 54 IMMUNE DEFENSE 26 CVS TOTAL HOME INSECT DELZICOL 96 CULTURELLE PRO-WELL 26 REPELLENT 82 DEMADEX 91 CVS WOMENS CUPRIMINE 111 PRENATAL+DHA 115 demeclocycline hcl 135 CURAFIL GEL WOUND cyanocobalamin 99 DEMEROL 7 DRESSING 87 DEMSER 34 CUTIVATE 69 CYCLESSA 51 DENAVIR 68 CUTTER 82 cyclobenzaprine hcl 121 CYCLOGYL 126 DENOREX THERAPEUTIC 2-IN- CUTTER ALL FAMILY 82 1 87 CUTTER BACKWOODS 82 CYCLOMYDRIL 126 DEPAKENE 19 CUTTER BACKWOODS cyclopentolate hcl 126 DEPAKOTE 19 DRY 82 CYCLOPHOSPHAMIDE 37 DEPAKOTE ER 19 CUTTER DRY 82 CYCLOSERINE 37 DEPAKOTE SPRINKLES 19 CUTTER SKINSATIONS 82 cyclosporine 112 DEPEN TITRATABS 111 CUTTER SPORT 82 CYCLOSPORINE DEPO-PROVERA CUVITRU 130 MODIFIED 112 CONTRACEPTIVE 53 cyclosporine modified (for CUVPOSA 136 DEPO-SUBQ PROVERA microemulsion) 112 104 53 CVS ACIDOPHILUS CYMBALTA 21 PROBIOTICFORMULA 26 DEPO-TESTOSTERONE 10 CVS ADULT 50+ cyproheptadine hcl 32 DERMABASEOIL IN PROBIOTIC 26 CYSTAGON 97 WATER 73 CVS ADULT PROBIOTIC 26 CYTO-Q MAX 3 DERMADROX 82 CVS CLEANSING EYELID CYTOGAM 130 DERMAGRAN 82 WIPES 82 CYTOMEL 136 DERMAGRAN HYDROGEL CVS DAILY ULTRA WOUNDDRESSING 87 MOISTURELOTION 73 CYTOTEC 139 DERMAGRAN SKIN CVS DIGESTIVE CYTRA-3 97 PROTECTANT 82 PROBIOTIC 26 D-VI-SOL 145 DERMAGRAN-B HYDROPHILIC CVS DISTILLED WATER 131 D.H.E. 45 107 WOUND DRESSING 87 CVS DRY MOUTH SPRAY 114 DAILY CONDITIONING DERMAIDE ALOE 73 CVS GLUCOSE 23 TREATMENT 73 DERMAL THERAPY EXTRA CVS INSECT REPELLENT 82 DAILY PROBIOTIC 26 STRENGTH BODY LOTION 73 DERMAL THERAPY FACE CVS ISOPROPYL ALCOHOL DALIRESP 15 CAREMOISTURIZING WIPES 82 danazol 10 LOTION 73 CVS KETONE CARE 90 DANTRIUM 122 DERMAL THERAPY FOOT CVS MANUKA HONEY WOUND MASSAGE 73 GEL 87 dantrolene sodium 122

Index 9 DERMAL THERAPY HAND DEXAMETHASONE 53 DIAZEPAM RECTAL GEL 17 ELBOW & KNEE CREAM 73 dexamethasone 53 dibucaine 79 DERMAL THERAPY HEEL CARE 73 DEXAMETHASONE dibucaine (rectal) 11 DERMALUBE DAILY INTENSOL 53 DICLEGIS 29 MOISTURIZING LOTION 73 dexamethasone sodium phosphate 53 diclofenac potassium 4 DERMAREST PSORIASIS 78 DEXAMETHASONE SODIUM diclofenac sodium 4 DERMASYN 87 PHOSPHATE 127 diclofenac sodium (actinic dermatological products, DEXEDRINE 1 keratoses) 66 misc. 80 DEXILANT 138 diclofenac sodium (ophth) 128 DERMATOP 69 dexmethylphenidate hcl 1,2 diclofenac sodium (topical) 64 DERMEND MOISTURIZING BRUISE FORMULA 73 dextroamphetamine sulfate 1 dicloxacillin sodium 131 DERMOPLAST 79 dextromethorphan hbr 54 dicyclomine hcl 136 DERMOPLAST PAIN dextromethorphan didanosine 43 RELIEVINGSPRAY 79 polistirex 54 DIFF-STAT 26 DERMOTIC 130 dextromethorphan- acetaminophen- DIFFERIN 62 DESCOVY 43 chlorpheniramine 56 DIFICID 105 desipramine hcl 21 dextromethorphan-doxylamine- DIFLORASONE desloratadine 31 acetaminophen 56 DIACETATE 69 DESLORATADINE ODT 31 dextromethorphan-guaifenesin DIFLUCAN 29,30 56 diflunisal 7 desmopressin acetate 94 dextromethorphan- desmopressin acetate phenylephrine-acetaminophen DIGESTIVE ADVANTAGE 26 refrigerated 93 56 DIGESTIVE ADVANTAGE desmopressin acetate spray 94 dextrose (diabetic use) 23 LACTOSE DEFENSE FORMULA 26 desmopressin acetate spray DHEA 73 refrigerated 94 DIGOXIN 49 DHS TAR 87 DESOGEN 51 digoxin 49 desogestrel & ethinyl DHS TAR GEL 87 dihydroergotamine estradiol 51 DIAB 88 mesylate 107 desogestrel-ethinyl estradiol DIAB DAILY CARE 88 DIHYDROERGOTAMINE (biphasic) 51 DIAB F.D.G. FREEZE- MESYLATE 107 desogestrel-ethinyl estradiol DRIED 88 DILANTIN 19 (triphasic) 51 DIABETA 25 DILANTIN INFATABS 19 DESONATE 69 DIABETIC TUSSIN DILANTIN-125 19 desonide 69 COLD/FLU 56 DILATRATE SR 13 DESOWEN 69 DIABETIDERM 73 DILAUDID 7 desoximetasone 69 DIABETIDERM FOOT diltiazem hcl 48 DESOXYN 1 REJUVENATING 73 DIABETIDERM HAND & diltiazem hcl coated beads 48 DESQUAM-X WASH 62 BODY 73 diltiazem hcl extended release DESVENLAFAXINE ER 21 DIABETIDERM MASSAGE beads 48 desvenlafaxine succinate 21 STIMULATOR 80 dimenhydrinate 29 DETROL 140 DIAMOX 91 DIMETAPP COLD & DETROL LA 140 diaper rash products 71 ALLERGY 56 DIASTAT ACUDIAL 17 DIMETAPP DM COLD & DEX4 23 COUGH 56 DEX4 FAST ACTING DIASTAT PEDIATRIC 17 DIMETAPP LONG ACTING GLUCOSE 23 DIASTIX 90 COUGH PLUS COLD 56 DEX4 NATURALS 23 diazepam 14 dimethicone (topical) 82 DEX4 POUCH PACK 23 DIAZEPAM 14 DIOVAN 34 DEX4 QUICK DISSOLVE diazepam 14 DIOVAN HCT 35 GLUCOSE 23 17 DIPENTUM 96 dexamethasone 53 DIAZEPAM

Index 10 diphenhydramine hcl 30,31 doxycycline hyclate 135 EDARBYCLOR 35 diphenhydramine hcl doxylamine succinate EDECRIN 91 (sleep) 101 (sleep) 101 EDLUAR 101 diphenhydramine hcl doxylamine-dm 57 EDURANT 43 (topical) 66 DRAMAMINE 29 diphenhydramine-phenylephrine EFFER-K 111 DRISDOL 145 56 EFFEXOR XR 21 diphenhydramine-phenylephrine- DRISTAN SPRAY 123 EFFIENT 99 acetaminophen 56 DRITHO-CREME HP 67 diphenhydramine-zinc EFUDEX 66 dronabinol 29 acetate 66 ELAVIL 21 diphenoxylate w/ atropine 28 drospirenone-ethinyl estradiol 51 ELDEPRYL 41 DIPHENOXYLATE/ATROPINE drospirenone-ethinyl estradiol- ELESTAT 129 28 levomefolate calcium 51 eletriptan hydrobromide 108 DIPROLENE 69 DROSPIRENONE/ETHINYL dipyridamole 99 ESTRADIOL/LEVOMEFOLATE ELIDEL 78 DISALCID 7 CALCIUM 51 ELIMITE 86 disopyramide phosphate 14 DROXIA 99 ELIPHOS 96 DISTILLED WATER 131 DROXY CREAM 73 ELIQUIS 16 disulfiram 133 DRY MOUTH SPRAY 114 ELIXOPHYLLIN 16 DITROPAN XL 140 DRYSOL 82 ELLA 53 DIURIL 92 DUAVEE 94 ELMIRON 97 divalproex sodium 19 DUETACT 22 ELOCON 69 DIVIGEL 94 DUEXIS 4 ELOCTATE 98 ELON SKIN REPAIR DMAE 73 DULCOLAX 104 DULERA 16 SYSTEM 73 DML FORTE 73 ELTA 73 duloxetine hcl 21 docosahexaenoic acid 124 ELTA DERMAL GEL 88 DURAFLU 57 docusate calcium 104 ELTA DERMAL WOUND docusate sodium 104 DURAGESIC 7 CLEANSER 88 DOCUSOL MINI 104 DURATION 12 HOUR 123 ELTA DERMAL WOUND GEL 88 DOCUSOL PLUS MINI- DURATION SPRAY 123 ENEMA 104 DUREZOL 127 EMADINE 129 dofetilide 14 dutasteride 97 EMCYT 38 DOLOPHINE 7 dutasteride-tamsulosin hcl 97 EMEND 29 DOMEBORO 82 DUTOPROL 35 EMEND TRIPACK 29 donepezil hydrochloride 133 DYAZIDE 91 EMETROL 29 DONNATAL 137 DYMISTA 122 EMLA 79 DORAL 101 E.E.S. 400 105 EMOLLIA-CREME 73 dorzolamide hcl 129 E.E.S. GRANULES 105 EMOLLIA-LOTION 73 dorzolamide hcl-timolol EASY TOUCH PEN NEEDLE emollient 73,74 maleate 125 30G X 5/16" 106 EMSAM 20 DOTHELLE DHA 115 EC-NAPROSYN 4 EMTRIVA 43 DOVONEX 67 econazole nitrate 65 EMVERM 12 doxazosin mesylate 34 ECOTRIN MAXIMUM ENABLEX 140 doxepin hcl 21 STRENGTH 7 ECOTRIN REGULAR enalapril maleate 34 DOXEPIN enalapril maleate & HYDROCHLORIDE 67 STRENGTH 7 ED A-HIST 57 hydrochlorothiazide 35 doxercalciferol 93 ENBREL 5 ED BRON GP 57 DOXYCYCLINE 86 ENBREL SURECLICK 5 ED CHLORPED 30 doxycycline (monohydrate) 135 ENCARE 143

Index 11 ENEMEEZ MINI 104 EQL MAKEUP REMOVER ESTROSTEP FE 51 ENEMEEZ PLUS 104 TOWELETTES 82 eszopiclone 101 EQL MOISTURIZING ENFAMIL ENFALYTE 110 CREAM 74 ethacrynic acid 91 ENFAMIL EXPECTA 115 EQL OMEPRAZOLE 138 ethambutol hcl 37 ENGERIX-B 141 EQL PRENATAL ethosuximide 19 ENJUVIA 94 FORMULA 115 ethynodiol diacet & eth EQL PROBIOTIC COLON enoxaparin sodium 16,17 estrad 51 SUPPORT 26 ETIDRONATE DISODIUM 92 entacapone 40 EQL SKIN ASTRINGENT 82 etodolac 4 entecavir 45 EQL ULTRA MOISTURIZING ETOPOSIDE 39 ENVARSUS XR 112 DAILY LOTION 74 EUCERIN 74 EPANED 34 EQUALYTE 110 EUCERIN BABY 74 EPCLUSA 45 EQUETRO 41 ergocalciferol 145 EUCERIN CALMING DAILY EPIFOAM 69 MOISTURIZER 74 EPILYT 74 ERGOLOID EUCERIN DAILY MESYLATES 134 epinastine hcl (ophth) 129 PROTECTION/SPF 30 74 ergotamine w/ caffeine 107 EUCERIN INTENSIVE EPINEPHRINE 145 ERIVEDGE 38 REPAIR 74 EPIPEN 2-PAK 145 ERTACZO 65 EUCERIN INTENSIVE REPAIRHAND 74 EPIPEN-JR 2-PAK 145 ERY-TAB 105 EPIVIR 43 EUCERIN ORIGINAL ERYGEL 62 HEALINGSOOTHING EPIVIR HBV 45,46 ERYPED 200 105 REPAIR 74 eplerenone 36 ERYPED 400 105 EUCERIN PLUS 74 EPOGEN 99 ERYTHROCIN EUCERIN PLUS INTENSIVE epoprostenol sodium 49 STEARATE 105 REPAIR 74 erythromycin (acne aid) 62 EUCERIN SKIN CALMING EPROSARTAN MESYLATE 34 BODYWASH 83 EPZICOM 44 erythromycin (ophth) 126 EUCERIN SKIN CALMING EQ OMEPRAZOLE 138 erythromycin base 105 DAILY MOISTURIZING 74 EQ PROBIOTIC DIGESTIVE ERYTHROMYCIN BASE 105 EUCERIN SMOOTHING SYSTEM SUPPORT 26 erythromycin REPAIRADVANCED EQ THERAPEUTIC ethylsuccinate 105 FORMULA 74 MOISTURIZING CREAM 74 ERYTHROMYCIN EURAX 86 EQL ACIDOPHILUS EXTRA ETHYLSUCCINATE 105 EVAC 102 STRENGTH 26 escitalopram oxalate 20 EVAMIST 94 EQL ADVANCED RECOVERY SKIN CARE 74 ESGIC 6 EVISTA 93 EQL BODY WASH/SENSITIVE esomeprazole EVOCLIN 62 magnesium 138 SKIN 82 EVOTAZ 44 EQL BODY WASH/SHEA ESSENTRA WIPES 9X9" BUTTER 82 CLEANROOM EVOXAC 114 EQL CLEAR HAND SOAP SUPPLIES/PRESATURATED EVZIO 28 REFILL 82 83 EX-LAX 104 EQL DAILY PROBIOTIC 26 estazolam 101 EXCEDRIN EXTRA EQL DRY MOUTH ORAL esterified estrogens & STRENGTH 6 RINSE 114 methyltestosterone 94 EXCEDRIN MENSTRUAL EQL INFANTS ESTRACE 94,144 COMPLETE 6 DECONGESTANT/COUGH 57 estradiol 94 EXCEDRIN MIGRAINE 6 EQL INVIGORATING MAKEUP estradiol & norethindrone EXCEDRIN TENSION REMOVER TOWELETTES 82 acetate 94 HEADACHE 6 EQL LIQUID HAND SOAP 82 estradiol vaginal 144 EXCEL-GEL 88 EQL LIQUID HAND SOAP ESTRING 144 EXELDERM 65 REFILL 82 ESTROPIPATE 94 EXELON 133

Index 12 exemestane 38 fentanyl 7 FIRST-OMEPRAZOLE 138 EXFORGE 35 fentanyl citrate 7 FIRST-PROGESTERONE VGS EXFORGE HCT 35 FENTORA 7 100 COMPOUNDING KIT 144 FIRST-PROGESTERONE VGS EXJADE 28 FEOSOL 100 200 COMPOUNDING KIT 144 EXPECTA LIPIL 124 FEOSOL BIFERA 100 FIRST-PROGESTERONE VGS EXTAVIA 134 FER-IN-SOL 100 25 COMPOUNDING KIT 144 FIRST-PROGESTERONE VGS EXTINA 65 FERGON 100 400 COMPOUNDING KIT 144 EXTRA-VIRT PLUS DHA 115 FERRALET 90 100 FIRST-PROGESTERONE VGS EYE-SCRUB 83 FERRAPLUS 90 100 50 COMPOUNDING KIT 144 EYESCRUB 83 FERRETTS 100 FIRST-VANCOMYCIN 25 12 ezetimibe 33 FERRIPROX 28 FIRST-VANCOMYCIN 50 12 ezetimibe-simvastatin 32 ferrous fumarate 100 FLAGYL 12 EZFE FORTE 116 ferrous fumarate w/ b12-vit c-fa- FLAVOR BLEND 131 FABIOR 62 ifc 100 FLAVOR PLUS 131 ferrous fumarate-fa-b complex- FLAVOR SWEET 131 FACTIVE 95 c-zn-mg-mn-cu 100 FALESSA 51 ferrous fumarate-folic FLAVOR SWEET-SF 131 famciclovir 46 acid 100 flavoxate hcl 140 famotidine 137 FERROUS GLUCONATE100 FLEBOGAMMA DIF 130 famotidine-calcium carbonate- ferrous gluconate 100 flecainide acetate 14 magnesium hydroxide 139 ferrous sulfate 100 FLECTOR 64 FAMVIR 46 FERROUS SULFATE 100 FLEET BISACODYL 104 FANAPT 41 ferrous sulfate 100 FLEET ENEMA 103 FANAPT TITRATION PACK 41 FERROUS SULFATE 100 FLEET ENEMA SIX PACK 103 FARESTON 38 ferrous sulfate 100 FLEET OIL 103 FAZACLO 42 FERROUS SULFATE 100 FLEET PEDIATRIC 103 fe fum-iron polysacch complex-fa- ferrous sulfate 100 FLOLAN 49 b complex-c-zn-mn-cu 99 fe fumarate-vitamin c-vitamin FERROUS SULFATE 100 FLOMAX 97 b12-folic acid 100 ferrous sulfate 100 FLONASE ALLERGY FEIBA 98 ferrous sulfate dried 100 RELIEF 122 FLONASE ALLERGY RELIEF FEIBA NF 98 FETZIMA 21 CHILDRENS 122 felbamate 19 FETZIMA TITRATION FLONASE SENSIMIST 122 FELBATOL 19 PACK 21 FEXMID 121 FLORA VANCE 26 FELDENE 4 fexofenadine hcl 31 FLORA-Q 26 felodipine 48 fexofenadine-pseudoephedrine FLORA-Q 2 26 FEM-CAL CITRATE 110 57 FLORAJEN ACIDOPHILUS 26 FEMARA 38 FIASP 24 FLORAJEN BIFIDOBLEND 26 FEMCON FE 51 FIASP FLEXTOUCH 24 FLORAJEN3 26 FEMHRT LOW DOSE 94 FIBERCON 102 FLORAJEN4KIDS 26 FEMRING 144 FIBRICOR 32 FLOVENT DISKUS 15 FENOFIBRATE 32 FINACEA 86 FLOVENT HFA 15 fenofibrate 32 finasteride 97 FLOXIN OTIC 129 fenofibrate micronized 32 FIORICET 6 FLUAD 2016-2017 141 FENOFIBRIC ACID 32 FIORICET/CODEINE 8 FLUAD 2017-2018 141 FENOPROFEN CALCIUM 4 FIORINAL 6 FLUARIX QUADRIVALENT fenoprofen calcium 4 FIORINAL/CODEINE #3 8 2015-2016 141 FENORTHO 4 FLUARIX QUADRIVALENT FIRAZYR 98 2016-2017 141

Index 13 FLUARIX QUADRIVALENT fluticasone propionate FORMULA 405 LIGHT 2017-2018 141 (nasal) 122 TEXTURED MOISTURIZER 74 FLUBLOK 2015-2016 141 fluvastatin sodium 33 FORMULA 405 FLUBLOK 2016-2017 141 FLUVIRIN 2015-2016 142 MOISTURIZING 74 FORTAMET 22 FLUBLOK 2017-2018 141 FLUVIRIN 2016-2017 142 FORTEO 92 FLUBLOK QUADRIVALENT FLUVIRIN 2017-2018 142 FORTESTA 10 2017-2018 141 fluvoxamine maleate 20 FLUCELVAX 2015-2016 141 FLUZONE HIGH-DOSE PF FORTICAL 92 FLUCELVAX QUADRIVALENT 2015-2016 142 FORTIFY DAILY 2016-2017 141 FLUZONE HIGH-DOSE PF PROBIOTIC 26 FLUCELVAX QUADRIVALENT 2016-2017 142 FOSAMAX 92 2017-2018 141 FLUZONE HIGH-DOSE PF FOSAMAX PLUS D 92 fluconazole 30 2017-2018 142 fosamprenavir calcium 44 flucytosine 29 FLUZONE INTRADERMAL fosinopril sodium 34 fludrocortisone acetate 54 QUADRIVALENT 2015- 2016 142 fosinopril sodium & FLULAVAL QUADRIVALENT FLUZONE INTRADERMAL hydrochlorothiazide 35 2014-2015 141 QUADRIVALENT 2016- FOSRENOL 96 FLULAVAL QUADRIVALENT 2017 142 2015-2016 141 FREE & CLEAR FOR FLUZONE INTRADERMAL SENSITIVE SKIN 83 FLULAVAL QUADRIVALENT QUADRIVALENT 2017- 2016-2017 141 FROVA 108 FLULAVAL QUADRIVALENT 2018 142 frovatriptan succinate 108 142 FLUZONE QUADRIVALENT 2017-2018 2015-2016 142 fructose-dextrose-phosphoric FLUMADINE 46 FLUZONE QUADRIVALENT acid 29 FLUNISOLIDE 122 2016-2017 142 FULYZAQ 26 fluocinolone acetonide 69 FLUZONE QUADRIVALENT FUNGOID TINCTURE 65 fluocinolone acetonide 2017-2018 142 FURADANTIN 140 FLUZONE SPLIT 2015- (otic) 130 furosemide 91 fluocinonide 69 2016 142 FML 128 FUROSEMIDE 91 fluocinonide emulsified base 69 FML FORTE 128 furosemide 91 FLUOR-A-DAY 110 FML LIQUIFILM 128 FYCOMPA 17 fluorometholone (ophth) 128 FOCALGIN 90 DHA 116 gabapentin 18 FLUOROPLEX 66 FOCALGIN CA 116 GABITRIL 19 FLUOROURACIL 66 FOCALGIN DSS 100 galantamine hydrobromide 133 fluorouracil (topical) 66 FOCALIN 2 GALANTAMINE FLUOXETINE 134 HYDROBROMIDE 133 FOCALIN XR 2 FLUOXETINE DR 20 galantamine hydrobromide 133 FOLCAL DHA 116 fluoxetine hcl 20 GALZIN 111 FOLCAPS OMEGA 3 116 FLUOXETINE HCL 20 GAMASTAN S/D 130 FOLGARD 100 fluphenazine decanoate 42 GAMMAGARD LIQUID 130 folic acid 99 FLUPHENAZINE HCL 42 GAMMAGARD S/D IGA LESS folic acid-vitamin b6-vitamin THAN 1MCG/ML 130 fluphenazine hcl 42 b12 100 GAMMAKED 130 FLURA-DROPS 110 FOLIVANE-OB 116 GAMMAPLEX 130 FLURAZEPAM HCL 101 fondaparinux sodium 17 GAMUNEX-C 130 flurbiprofen 4 FORFIVO XL 20 GARDASIL 143 flurbiprofen sodium 129 formaldehyde 43 GARDASIL 9 143 FLURBIPROFEN SODIUM 129 FORMULA 405 ENRICHED GAS-X 95 flutamide 38 EYE 74 FORMULA 405 FACE GAS-X EXTRA STRENGTH 95 fluticasone propionate 69 CREAM 74 GASTROCROM 96 gatifloxacin (ophth) 126

Index 14 GATTEX 97 GLUCOSE INSTANT GOLD BOND ULTIMATE DEEP Gauze Bandages 105 ENERGY 23 MOISTURE BODY WASH GLUCOTROL 25 HEALING 83 Gauze Pads 105 GLUCOTROL XL 25 GOLD BOND ULTIMATE DEEP Gauze Pads - Misc 105 MOISTURE BODY WASH GLUCOVANCE 22 GAVISCON 11 SENSITIVE/OAT EXT 83 GEL-KAM ORAL CARE GLUMETZA 23 GOLD BOND ULTIMATE DEEP RINSE 113 glyburide 25 MOISTURE BODY WASH SOFTENING/SHEA 83 GELNIQUE 140 glyburide micronized 25 GOLD BOND ULTIMATE GELNIQUE PUMP 140 glyburide-metformin 22 DIABETICS' DRY RELIEF 74 gemfibrozil 32 GLYCERIN 51 GOLD BOND ULTIMATE GENADUR 80 glycerin (laxative) 103 HEALING 74 GOLD BOND ULTIMATE GENOTROPIN 92 GLYCERIN ADULT 103 PROTECTION 74 GENOTROPIN MINIQUICK 92 glycerin-hypromellose- GOLD BOND ULTIMATE GENTAK 126 polyethylene glycol 400 124 RESTORING 74 GLYCERINE 51 GOLD BOND ULTIMATE GENTAMICIN SULFATE 64 GLYCEROL FORMAL 51 SHEERRIBBONS gentamicin sulfate (ophth) 126 glycine (gu irrigant) 97 PEARLRADIANCE 74 gentamicin sulfate (topical) 64 GOLD BOND ULTIMATE glycopyrrolate 137 GENTEAL MILD 124 SHEERRIBBONS GENTEAL MILD TO GLYNASE 25 SILKSOFTNESS 74 MODERATE 124 GLYSET 22 GOLD BOND ULTIMATE GNP ACIDOPHILUS HIGH SOFTENING 74 GENTEAL SEVERE 124 GOLD BOND ULTIMATE GENTEAL TEARS POTENCY 27 GNP ADVANCED SOOTHING 74 MODERATEPF 124 GOLYTELY 103 GENTIAN VIOLET 65 RECOVERY 74 GNP DAILY PRENATAL 116 GOODSENSE GLUCOSE 23 GENTLE 74 GNP DAY TIME MUCUS GOODSENSE PRENATAL GENVOYA 44 RELIEFDM 57 VITAMINS 116 GEODON 41 GNP GENTIAN VIOLET 65 GRALISE 134 GERI PROTECT 83 GNP GLUCOSE 23 GRALISE STARTER 134 GERI-WASH 83 GNP ISOPROPYL ALCOHOL granisetron hcl 28 GIAZO 96 WIPES 83 GRANIX 99 GILENYA 134 GNP OMEPRAZOLE 138 GRANULEX 77 GILOTRIF 39 GNP PRENATAL 116 GRAPE SYRUP 131 GNP PROBIOTIC COLON ginger (zingiber officinalis) 2 SUPPORT 27 GRASTEK 2 glatiramer acetate 134 GNP QUICK DISSOLVE GRIFULVIN V 29 GLEEVEC 39 GLUCOSE 23 GRIS-PEG 29 GLENMAX PEB 57 GNP SALINE WOUND griseofulvin microsize 29 WASH 83 GLEOSTINE 37 GOLD BOND MEDICATED griseofulvin ultramicrosize 29 glimepiride 25 BODYLOTION 74 GRX ASC LOTIONIZED glipizide 25 GOLD BOND MEDICATED ANTIMICROBIAL SKIN BODYLOTION EXTRA CLEANSER 83 glipizide-metformin hcl 22 STRENGTH 74 GRX VITAMIN E 74 GLUCAGEN DIAGNOSTIC 89 GOLD BOND MULTI- GRX WOUND 88 SYMPTOM/ITCH & PAIN GLUCAGEN HYPOKIT 23 guaifenesin 60,61 GLUCAGON EMERGENCY RELIEF/MAXIMUM KIT 23 STRENGTH 79 guaifenesin-codeine 57 GLUCOPHAGE 22,23 GOLD BOND ULTIMATE 74 guanfacine hcl 34 GLUCOPHAGE XR 23 GOLD BOND ULTIMATE guanfacine hcl (adhd) 1 DEEP MOISTURE BODY GUANIDINE HCL 37 GLUCOSE 23 WASH EXFOLIATING 83 GYNAZOLE-1 144

Index 15 GYNE-LOTRIMIN 144 HUMALOG MIX 50/50 24 hydrocortisone butyrate 70 GYNE-LOTRIMIN 3 144 HUMALOG MIX 50/50 hydrocortisone butyrate HALCION 101 KWIKPEN 24 hydrophilic lipo base 70 HUMALOG MIX 75/25 24 hydrocortisone valerate 70 HALDOL DECANOATE 100 42 HUMALOG MIX 75/25 hydrocortisone w/acetic HALDOL DECANOATE 50 42 KWIKPEN 24 acid 130 halobetasol propionate 69 HUMATE-P 98 hydrocortisone-aloe vera 70 HALOG 70 HUMATROPE 92 HYDROGEL 88 haloperidol 42 HUMATROPE COMBO HYDROGEL AG 88 haloperidol decanoate 42 PACK 92 hydrogen peroxide 43 HUMIRA 3 haloperidol lactate 42 hydromorphone hcl 7 HUMIRA PEDIATRIC CROHNS HARVONI 46 DISEASE STARTER PACK 3 HYDROMORPHONE HCL 7 HAVRIX 143 HUMIRA PEN 3 hydromorphone hcl 7 HEAD & SHOULDERS 2IN1 HUMIRA PEN-CROHNS HYDROPHILIC 132 CLASSIC CLEAN/NORMAL 67 DISEASESTARTER 3 HYDROPHILIC HEAD & SHOULDERS HUMIRA PEN-PSORIASIS PETROLATUM 132 CLASSICCLEAN/NORMAL 67 STARTER 3 hydroquinone 86 HEAD & SHOULDERS DRY HUMULIN 70/30 24 SCALP 2 IN 1 67 hydroxychloroquine sulfate 37 HUMULIN 70/30 HYDROXYPROGESTERONE HECTOROL 93 KWIKPEN 24 HELIXATE FS 98 CAPROATE 38 HUMULIN N 25 hydroxyurea 39 HEMA-COMBISTIX 90 HUMULIN N KWIKPEN 24 hydroxyzine hcl 13 HEMANGEOL 47 HUMULIN R 25 HYDROXYZINE PAMOATE 13 HEMATOGEN FA 100 HUMULIN R U-500 hydroxyzine pamoate 13 HEMENATAL OB 116 (CONCENTRATED) 25 hyoscyamine sulfate 137 HEMENATAL OB + DHA 116 HUMULIN R U-500 KWIKPEN 25 HYOSCYAMINE SULFATE 137 HEMOCYTE 100 HURRICAINE 113 hyoscyamine sulfate 137 HEMOFIL M 98 HURRICAINE ONE 113 HYPERRAB S/D 130 HEPAGAM B 130 HY-VEE GLUCOSE 23 HYPERRHO S/D 130 heparin sodium (porcine) 17 HYCAMTIN 40 HYPERRHO S/D MINI- HEPSERA 46 HYCET 8 DOSE 130 HETLIOZ 102 hydralazine hcl 36 HYPOTEARS 124 HEXALEN 38 HYDRASYN25 74 hypromellose (ophth) 124,125 HIBICLENS 43 HYDREA 39 HYVEE ADVANCED ANTACID MAXIMUM STRENGTH 11 HIPREX 140 HYDRO-LAN 75 HIZENTRA 130 HYZAAR 35 HYDROCERIN 83 ibandronate sodium 92 HM ACIDOPHILUS 27 hydrochlorothiazide 92 HM EYELID WIPES 83 IBRANCE 39 HYDROCIL INSTANT 102 IBUDONE 9 HM GLUCOSE 23 hydrocodone w/ HM OMEPRAZOLE 138 homatropine 54 ibuprofen 4 HM ONE DAILY PRENATAL hydrocodone- ICLUSIG 39 COMBO 116 acetaminophen 8,9 ICY HOT PAIN RELIEVING HM PRENATAL 116 hydrocodone-ibuprofen 9 GEL 64 homatropine hbr 126 hydrocortisone 53 IDHIFA 39 HORIZANT 134 hydrocortisone (intrarectal) 10 ILEVRO 129 HUMALOG 24 hydrocortisone (rectal) 11 imatinib mesylate 39 HUMALOG JUNIOR hydrocortisone (topical) 70 IMBRUVICA 39 KWIKPEN 24 hydrocortisone acetate imipramine hcl 21 HUMALOG KWIKPEN 24 (topical) 70 imipramine pamoate 21,22

Index 16 imiquimod 77 Insulin Pen Needle 32 G X 5 Insulin Syringe/Needle U-100 1/2 IMITREX 108 MM (1/5" or 3/16") 106 ML 31 x 5/16" 107 Insulin Pen Needle 32 G X 6 IMITREX STATDOSE INTELENCE 44 MM (1/4") 106 INTERMEZZO 101 REFILL 108 Insulin Pen Needle 32 G X 8 IMITREX STATDOSE MM 106 INTRASITE GEL APPLIPAK 88 SYSTEM 108 Insulin Pen Needle 33 G X 4 INTRON A 39 IMODIUM A-D 28 MM (5/32") 106 INTRON A W/DILUENT 39 IMODIUM MULTI-SYMPTOM Insulin Syringe (Disp) U-100 1 RELIEF 28 ML 106 INTUNIV 1 IMOGAM RABIES-HT 130 Insulin Syringe/Needle U-100 INVEGA 41 IMURAN 112 0.3 ML 28 x 1/2" 106 INVEGA SUSTENNA 41 Insulin Syringe/Needle U-100 INVEGA TRINZA 41 INATAL ADVANCE 116 0.3 ML 29 x 1" 106 INATAL GT 116 Insulin Syringe/Needle U-100 INVIRASE 44 INATAL ULTRA 116 0.3 ML 29 x 1/2" 106 INVOKAMET 22 INCRELEX 93 Insulin Syringe/Needle U-100 INVOKANA 25 0.3 ML 30 x 1/2" 106 INCRUSE ELLIPTA 14 Insulin Syringe/Needle U-100 IONIL 83 indapamide 92 0.3 ML 30 x 3/8" 106 IOPIDINE 126 INDERAL LA 47 Insulin Syringe/Needle U-100 ipratropium bromide 14 0.3 ML 30 x 5/16" 106 INDERAL XL 48 Insulin Syringe/Needle U-100 ipratropium bromide (nasal)122 INDOCIN 4 0.3 ML 31 x 5/16" 106 ipratropium-albuterol 16 indomethacin 4 Insulin Syringe/Needle U-100 1 irbesartan 34 INFANATE BALANCE 116 ML 25 x 1" 106 irbesartan-hydrochlorothiazide Insulin Syringe/Needle U-100 1 35 INFANTS ADVIL 4 ML 25 x 5/8" 106 IRON 100 INLYTA 39 Insulin Syringe/Needle U-100 1 IRON CHEWS PEDIATRIC 100 INNOPRAN XL 48 ML 26 x 1/2" 106 Insulin Syringe/Needle U-100 1 iron polysaccharide complex-vit inositol niacinate 49 ML 27 x 1/2" 106 b12-folic acid 100 INOVA 62 Insulin Syringe/Needle U-100 1 iron w/ vitamins liqd 114 INOVA 4/1 ACNE CONTROL ML 27 x 5/8" 106 iron w/ vitamins tabs 114 Insulin Syringe/Needle U-100 1 THERAPY 62 ISENTRESS 44 INOVA 8/2 ACNE CONTROL ML 28 x 1/2" 106 THERAPY 62 Insulin Syringe/Needle U-100 1 ISONIAZID 37 INSPRA 36 ML 29 x 1/2" 106 isoniazid 37 Insulin Pen Needle 29 G X 10 Insulin Syringe/Needle U-100 1 ISOPROPYL ALCOHOL MM 106 ML 30 x 1/2" 106 WIPES 83 Insulin Pen Needle 29 G X 12 Insulin Syringe/Needle U-100 1 ISOPTO CARPINE 126 ML 30 x 5/16" 106 MM (1/2") 106 ISOPTO TEARS 125 Insulin Pen Needle 29 G X 12.7 Insulin Syringe/Needle U-100 1 MM 106 ML 31 x 15/64" 106 ISORDIL TITRADOSE 13 Insulin Pen Needle 29 G X 13 Insulin Syringe/Needle U-100 1 isosorbide dinitrate 13 MM (1/2") 106 ML 31 x 5/16" 106 ISOSORBIDE DINITRATE Insulin Pen Needle 30 G X 8 MM Insulin Syringe/Needle U-100 ER 13 (1/3" or 5/16") 106 1/2 ML 27 x 1/2" 107 Insulin Syringe/Needle U-100 isosorbide mononitrate 13 Insulin Pen Needle 31 G X 4 MM isotretinoin 63 (1/6") 106 1/2 ML 28 x 1/2" 107 Insulin Pen Needle 31 G X 5 MM Insulin Syringe/Needle U-100 isradipine 48 (3/16") 106 1/2 ML 29 x 1/2" 107 ISTALOL 125 Insulin Syringe/Needle U-100 Insulin Pen Needle 31 G X 6 MM ITCH-X 79 (1/4") 106 1/2 ML 30 x 1/2" 107 Insulin Pen Needle 31 G X 8 MM Insulin Syringe/Needle U-100 itraconazole 30 (1/3" or 5/16") 106 1/2 ML 30 x 3/8" 107 ivermectin 12 Insulin Pen Needle 32 G X 4 MM Insulin Syringe/Needle U-100 1/2 ML 30 x 5/16" 107 IXINITY 98 (5/32") 106 J & J BURN CREAM 75

Index 17 JADENU 28 KERI RENEWAL STRETCH LACTAID 91 JAKAFI 39 MARK MINIMIZER 75 LACTAID FAST ACT 91 KERI SENSITIVE SKIN 75 JALYN 97 lactase 91 KETEK 12 JANUMET 22 lactated ringer's 110 KETO-DIASTIX 90 JANUMET XR 22 lactated ringer's (irrigation) 112 KETOCARE 90 JANUVIA 24 lactic acid (ammonium ketoconazole 30 JARDIANCE 25 lactate) 75 ketoconazole (topical) 65 LACTINOL HX 75 JENTADUETO 22 KETONE TEST STRIPS 90 LACTO-PECTIN 27 JENTADUETO XR 22 ketoprofen 4 lactobacillus 27 JOBST IT STAYS/ROLL-ON 80 KETOPROFEN ER 4 lactulose 103 JUBLIA 65 ketorolac tromethamine 4 lactulose (encephalopathy) 96 JUXTAPID 33 ketorolac tromethamine LADY ESTHER 4 PURPOSE K-PHOS 111 (ophth) 129 FACE CREAM 75 K-PHOS NEUTRAL 111 KETOSTIX 90 LAMICTAL 18 K-PHOS NO 2 97 ketotifen fumarate (ophth)129 LAMICTAL CHEWABLE K-TAB 111 KEY-E 145 DISPERSIBLE 18 LAMICTAL ODT 18 KADIAN 7 KHEDEZLA 21 LAMICTAL XR 18 KALA 28 KINERET 3 LAMISIL 29 KALBITOR 98 KITABIS PAK 3 LAMISIL ADVANCED 65 KALETRA 44 KLARON 63 LAMISIL AT 65 KALYDECO 135 KLONOPIN 17 LAMISIL AT JOCK ITCH 65 KAPVAY 1 KLOR-CON M15 111 LAMISIL AT SPRAY 65 KAYEXALATE 112 KLOR-CON/25 111 lamivudine 44 KAZANO 22 KLOUT 86 lamivudine (hbv) 46 KEFLEX 50 KLS OMEPRAZOLE 138 lamivudine-zidovudine 44 KENALOG 70 KOGENATE FS 98 lamotrigine 18 KENDALL AMORPHOUS KOGENATE FS BIO-SET 98 HYDROGEL WOUND LANAPHILIC 75 KOMBIGLYZE XR 22 DRESSING 88 Lancets - Misc 105 KONDREMUL 103 KEPPRA 18 Lancets Devices - Misc 106 KONSYL 102 KEPPRA XR 18 lanolin 132 KONSYL-D 102 KERADAN 75 lanolin (topical) 83 KORLYM 23 KERAGEL 88 LANOLIN ANHYDROUS 132 KERAGELT 88 KP GENTLE SKIN CLEANSER 83 LANOLIN ANHYDROUS- KERALYT 78 KP PRENATAL GRX 132 KERASAL FUNGAL NAIL MULTIVITAMINS 116 LANOLOR 75 RENEWAL 80 KPN PRENATAL 116 LANOXIN 49 KERI ADVANCED MOISTURE THERAPY 75 KRISTALOSE 103 lansoprazole 138 KERI BASIC ESSENTIALS 75 KROGER GLUCOSE 23 lanthanum carbonate 96 KERI LONG LASTING 75 KUVAN 93 LANTISEPTIC SKIN KYNAMRO 32 PROTECTANT 83 KERI NOURISHING SHEA LANTISEPTIC BUTTER 75 L-METHYL-MC NAC 90 THERAPEUTIC 75 KERI ORIGINAL 75 labetalol hcl 47 LANTUS 100 UNIT/ML KERI OVERNIGHT 75 LABSTIX 90 SOLN 25 LANTUS SOLOSTAR 100 KERI RENEWAL MILK LAC-HYDRIN 75 BODY 75 UNIT/ML SOPN 25 KERI RENEWAL SKIN LAC-HYDRIN TWELVE 75 LASIX 91 FIRMING 75 LACRISERT 125 LASTACAFT 129

Index 18 latanoprost 129 LEXIVA 44 LOHIST-D 57 LATUDA 41 LIALDA 96 LOMOTIL 28 LAZANDA 7 LICEMD 86 LOMUSTINE 38 LEADER FINGER CREAM 75 LICIDE TREATMENT KIT 86 LONGS GLUCOSE 23 LEADER GLUCOSE 23 lidocaine 79 loperamide hcl 28 LEADER QUICK DISSOLVE lidocaine hcl 79 loperamide-simethicone 28 GLUCOSE 23 lidocaine hcl (mouth- LOPID 33 leflunomide 5 throat) 113 lopinavir-ritonavir 44 LESCOL XL 33 lidocaine-prilocaine 79 LOPRESSOR 47 LETAIRIS 49 lidocaine-transparent LOPRESSOR HCT 35 letrozole 38 dressing 79 LIDODERM 79 LOPROX 65 LEUCOVORIN CALCIUM 39 LINDANE 86 LOPROX SHAMPOO 65 leucovorin calcium 39 lindane 86 loratadine 31 LEUKERAN 38 linezolid 13 loratadine & LEUKINE 99 pseudoephedrine 57 liniments & rubs 79 LEVACET 6 lorazepam 14 LINZESS 96 levalbuterol hcl 16 LORTAB 9 LIORESAL LEVALBUTEROL TARTRATE INTRATHECAL 121 LORZONE 121 HFA 16 liothyronine sodium 136 losartan potassium 34 LEVAQUIN 95 LIPITOR 33 losartan potassium & LEVBID 137 hydrochlorothiazide 35 LIPOFEN 32 LEVEMIR 25 LOSEASONIQUE 52 LIQ-10 3 LEVEMIR FLEXTOUCH 25 LOTEMAX 128 lisinopril 34 levetiracetam 18 LOTENSIN 34 lisinopril & levobunolol hcl 125 hydrochlorothiazide 35 LOTENSIN HCT 36 levocarnitine (metabolic LITHIUM 41 LOTREL 36 modifiers) 93 LITHIUM CARBONATE 41 LOTRIMIN AF 65 levocetirizine dihydrochloride31 lithium carbonate 41 LOTRIMIN AF FOR HER 65 levofloxacin 95 LITHOBID 41 LOTRIMIN AF JOCK ITCH 65 LEVOFLOXACIN 95 LITHOSTAT 98 LOTRIMIN ULTRA 65 levofloxacin 95 LITTLE NOSES LOTRISONE 65 levofloxacin (ophth) 126 DECONGESTANTNOSE LOTRONEX 96 LEVOMEFOLATE DHA 116 DROPS 123 lovastatin 33 levonorgestrel & eth LITTLE REMEDIES FOR estradiol 51 COLDSMULTI SYMPTOM 57 LOVAZA 32 levonorgestrel (emergency LIVALO 33 LOVENOX 17 oc) 53 LMX 4 79 loxapine succinate 42 LEVONORGESTREL AND ETHINYL ESTRADIOL 51 LMX 4 PLUS 79 LUBRIDERM 75 levonorgestrel-eth estradiol LO LOESTRIN FE 51 LUBRIDERM ADVANCED (triphasic) 51 LOCOID 70 THERAPY 75 LUBRIDERM DAILY levonorgestrel-ethinyl estradiol LOCOID LIPOCREAM 70 (91-day) 51 MOISTURE/NORMAL TO DRY levonorgestrel-ethinyl estradiol LODINE 4 SKIN 75 (continuous) 51 LODOSYN 40 LUBRIDERM DAILY LEVORPHANOL TARTRATE 7 MOISTURESHEA + CALMING LOESTRIN 1.5/30-21 51 LAVENDER JASMINE 75 levothyroxine sodium 136 LOESTRIN 1/20-21 51 LUBRIDERM INTENSE SKIN LEVSIN 137 LOESTRIN FE 1.5/30 51 REPAIR 75 LEVSIN/SL 137 LOESTRIN FE 1/20 52 LUBRIDERM MENS 3-IN-1 75 LEXAPRO 20 LOFIBRA 32,33 LUBRIDERM SERIOUSLY SENSITIVE 75

Index 19 LUBRIDERM SKIN MAXALT-MLT 108 MELOXICAM 4 NOURISHINGWITH SHEA AND MAXAM 75 meloxicam 4 COCOA BUTTERS 75 LUBRIDERM SOOTHING MAXIDEX 128 melphalan 38 RELIEF/COOLING 75 MAXITROL 128 memantine hcl 133 LUBRISOFT 75 MAXZIDE 91 MENEST 94 LUMIGAN 129 MAXZIDE-25 91 MENTAX 65 LUNESTA 101 meclizine hcl 29 menthol (topical analgesic) 64 LURIDE 110 MECLOFENAMATE menthol-methyl salicylate LUXIQ 70 SODIUM 4 (liniments) 79 MEDELA TENDER CARE LYNPARZA 39 MEPERIDINE HCL 7 LANOLIN 75 meperidine hcl 7 LYRICA 18 MEDERMA AG BODY LYSODREN 38 CLEANSER 83 MEPHYTON 145 LYSTEDA 101 MEDERMA AG FACE meprobamate 13 CREAM 75 MEPRON 12 M-END PE 57 MEDERMA AG FACIAL M-M-R II 143 CLEANSER 83 mercaptopurine 38 M-VIT 116 MEDERMA AG FACIAL mesalamine 96 TONER 83 MACNATAL CN DHA 116 MESALAMINE DR 96 MEDERMA AG HAND & BODY mesalamine w/ cleanser 96 MACROBID 140 LOTION 75 MACRODANTIN 140 MEDERMA STRETCH MARKS MESTINON 37 mafenide acetate 68 THERAPY 75 MESTINON TIMESPAN 37 MEDICAL PROVIDER EZ FLU META BIOTIC/BIO-ACTIVE MAG-TAB SR 110 SHOT 2015-2016 143 12 27 MAG64 110 MEDICAL PROVIDER SINGLE METADATE CD 2 MAGNEBIND 300 109 USE EZ FLU SHOT 143 MEDIHONEY METAFOLBIC PLUS 90 MAGNEBIND 400 110 WOUND/BURNDRESSING 8 METAMUCIL 102 MAGNESIUM 110 8 METAMUCIL MULTIHEALTH magnesium 110 MEDROL 53 FIBER SINGLES 102 magnesium citrate 103 MEDROL DOSEPAK 53 METAMUCIL ORIGINAL TEXTURE 102 MAGNESIUM medroxyprogesterone METAMUCIL SMOOTH GLUCONATE 110 acetate 133 TEXTUREFIBER SINGLES 102 magnesium gluconate 110 medroxyprogesterone acetate METAPROTERENOL magnesium hydroxide 104 (contraceptive) 53 SULFATE 16 mefenamic acid 4 magnesium oxide 12 metaxalone 121 mefloquine hcl 37 MAGNESIUM OXIDE 110 metformin hcl 23 magnesium oxide (mg MEFLOQUINE HCL 37 methadone hcl 7 supplement) 110 MEGA PROBIOTIC 27 METHADONE HCL 7 MAGONATE 110 MEGACE ES 133 methadone hcl 7 MAGOX 400 110 MEGACE ORAL 38 METHADONE HCL 7 MAKENA 132 megestrol acetate 38 methadone hcl 7 megestrol acetate MALARONE 37 METHADOSE 7 malathion 86 (appetite) 133 MEIJER CALAMINE 83 METHADOSE SUGAR-FREE 7 MAPROTILINE HCL 20 MEIJER GLUCOSE 23 methamphetamine hcl 1 MARINOL 29 MEKINIST 39 methazolamide 91 MARNATAL-F 116 melatonin 3 methenamine hippurate 140 MARPLAN 20 MELATONIN 3 METHENAMINE MATULANE 39 MANDELATE 140 melatonin 3 MAVIK 34 methenamine mandelate 140 melatonin-pyridoxine 3 MAXALT 108

Index 20 methenamine-hyosc-methylene MEVACOR 33 moexipril hcl 34 blue-benzoic acid-phenyl mexiletine hcl 14 moexipril-hydrochlorothiazide sal 139 MIACALCIN 92 36 methenamine-hyosc-methylene MOI-STIR 114 blue-sod phos-phenyl sal 139 MICARDIS 34 MOISTURE EYES 125 methenamine-hyoscamine- MICARDIS HCT 36 methylene blue-sodium MOISTURIZING CREAM 76 MICATIN 65 phosphate 139 MOLINDONE METHERGINE 130 MICONAZOLE 3 144 HYDROCHLORIDE 42 methimazole 136 miconazole nitrate (topical)65 mometasone furoate 70 METHITEST 10 miconazole nitrate mometasone furoate vaginal 144 (nasal) 122 methocarbamol 121 MICRHOGAM ULTRA- MONISTAT 1 COMBO METHOTREXATE SODIUM 38 FILTEREDPLUS 130 PACK 144 methotrexate sodium 38 MICRO-K 111 MONISTAT 1 DAY OR NIGHT methoxsalen rapid 67 MICROCYN 88 COMBO PACK 144 MONISTAT 3 144 methscopolamine bromide 137 MICROKLENZ ANTISEPTIC WOUND CLEANSER 88 MONISTAT 3 COMBINATION 92 METHYCLOTHIAZIDE MICROZIDE 92 PACK 144 103 MONISTAT 7 SIMPLY methylcellulose (laxative) midazolam hcl 101,102 35 CURE 144 methyldopa midodrine hcl 145 METHYLDOPA/HYDROCHLOR MONISTAT SOOTHING CARE ITCH RELIEF 70 OTHIAZIDE 36 MIGERGOT 107 98 methylergonovine maleate 130 miglitol 22 MONOCLATE-P 136 METHYLIN 2 MIGRANAL 107 MONODOX 98 METHYLPHENIDATE HCL 2 MILK OF MAGNESIA MONONINE CONCENTRATE 104 2 montelukast sodium 15 methylphenidate hcl MILLIPRED 53 METHYLPHENIDATE HCL morphine sulfate 8 ER 2 MINASTRIN 24 FE 52 MORPHINE SULFATE 8 methylprednisolone 53 mineral oil 103 morphine sulfate 8 methyltestosterone 10 MINERAL OIL 103 MORPHINE SULFATE ER 8 METIPRANOLOL 125 MINIPRESS 35 MOTHERS FRIEND 76 metoclopramide hcl 96 MINIVELLE 94 MOTOFEN 28 METOCLOPRAMIDE ODT 96 MINOCIN 135 MOTRIN INFANTS DROPS 5 metolazone 92 minocycline hcl 136 MOUTHKOTE 114 metoprolol & MINOCYCLINE HCL ER 136 MOVIPREP 103 hydrochlorothiazide 36 minoxidil 36 MOXATAG 131 metoprolol succinate 47 MIRALAX 103 METOPROLOL SUCCINATE MOXEZA 126 ER/HYDROCHLOROTHIAZIDE MIRAPEX 40 moxifloxacin hcl 95 36 MIRAPEX ER 40 moxifloxacin hcl (ophth) 126 metoprolol tartrate 47 MIRCETTE 52 MS CONTIN 8 METOPROLOL/HYDROCHLOR mirtazapine 19 MSM SKIN LOTION 76 OTHIAZIDE 36 MIRVASO 86 61 METOZOLV ODT 96 MUCINEX misoprostol 139 MUCINEX CHILDRENS COLD METROCREAM 86 MOBIC 4 COUGH & SORE THROAT 57 METROGEL 86 MOBISYL 79 MUCINEX CHILDRENS MULTI- METROGEL-VAGINAL 144 SYMPTOM COLD 57 modafinil 2 MUCINEX CHILDRENS MULTI- METROLOTION 86 MODERIBA 1200 DOSE SYMPTOM COLD & FEVER 57 metronidazole 12 PACK 46 MUCINEX CONGESTION & metronidazole (topical) 86 MODERIBA 800 DOSE COUGH CHILDRENS 57 metronidazole vaginal 144 PACK 46 MUCINEX COUGH FOR MODICON 52 KIDS 57

Index 21 MUCINEX D 57 MULTISTIX 9 90 NAMENDA XR TITRATION MUCINEX D MAXIMUM MULTISTIX 9 SG 90 PACK 133 NAPHAZOLINE HCL 127 STRENGTH 57 mupirocin 64 MUCINEX DM 57 naphazoline w/ mupirocin calcium (topical) 64 MUCINEX DM MAXIMUM pheniramine 127 STRENGTH 57 MURO 128 129 NAPHCON-A 127 MUCINEX FAST-MAX COLD & MX-SOL 132 NAPRELAN 5 SINUS 57 MX-SOL BLEND 132 NAPROSYN 5 MUCINEX FAST-MAX COLD FLU& SORE THROAT 57 MX-SOL BLEND SF 131 naproxen 5 MUCINEX FAST-MAX COLD MX-SOL SF 132 NAPROXEN 5 FLU& SORE THROAT CLEAR & MX-SOL SUSPEND 132 naproxen 5 COOL 57 MYAMBUTOL 37 MUCINEX FAST-MAX SEVERE naproxen sodium 5 COLD 58 MYCOBUTIN 37 naratriptan hcl 108 MUCINEX FAST-MAX SEVERE mycophenolate mofetil 112 NARCAN 28 CONGESTION & COUGH 58 mycophenolate sodium 112 NARDIL 20 MUCINEX FAST-MAX SEVERE CONGESTION & COUGH MYDRIACYL 126 NASACORT ALLERGY MYFORTIC 112 24HR 122 CLEAR & COOL 58 NASACORT ALLERGY 24HR MUCINEX FOR KIDS 61 MYKIDZ IRON 10 100 CHILDRENS 122 MUCINEX MAXIMUM MYLERAN 38 NASAL DECONGESTANT 123 STRENGTH 61 MYLICON 95 MUCINEX STUFFY NOSE & NASALCROM 122 COLD CHILDRENS 58 MYLICON INFANTS GAS NASCOBAL 99 RELIEF 95 MULTAQ 14 MYNATAL 116 NASONEX 123 MULTI MEGA MINERALS 110 NAT-RUL PRENATAL MYNATAL ADVANCE 116 MULTI PRENATAL 116 VITAMINS 116 MYNATAL PLUS 116 MULTIGEN 100 NATACYN 127 MYNATAL NATALVIT 116 MULTIGEN FOLIC 100 ULTRACAPLET 116 MULTIGEN PLUS 100 MYNATAL-Z 116 NATAZIA 52 multiple minerals w/ MYNATE 90 PLUS 116 nateglinide 25 vitamins 111 MYOFLEX 79 NATELLE ONE 116 multiple vitamin caps 115 MYSOLINE 18 NATROBA 86 multiple vitamin tabs 115 MYTESI 26 NATRUL PROBIOTIC 27 multiple vitamins w/ calcium NATRUL-CAL 111 tabs 114 nabumetone 5 multiple vitamins w/ iron nadolol 48 NATURE-THROID 136 tabs 115 nadolol & NATURES WASH PLUS 83 multiple vitamins w/ minerals bendroflumethiazide 36 NEBUPENT 12 caps 115 naftifine hcl 65 NECON 1/50-28 52 multiple vitamins w/ minerals chew 115 NAFTIN 65 NECON 10/11-28 52 multiple vitamins w/ minerals NAIL SCRUB 80 Needle (Disp) 25 x 5/8" 107 liqd 115 NALFON 5 NEEVO DHA 116 multiple vitamins w/ minerals NALOXONE HCL 28 tabs 115 NEFAZODONE HCL 21 MULTISOURCE CALCIUM naloxone hcl 28 nefazodone hcl 21 MAGNESIUM & D NALOXONE HCL 28 NEO-SYNALAR 64 FORMULA 111 naltrexone hcl 28 NEO-SYNEPHRINE 123 MULTISTIX 90 NAMENDA 133 NEO-SYNEPHRINE 12 HOUR MULTISTIX 10 SG 90 NAMENDA TITRATION EXTRA MOISTURIZING 123 MULTISTIX 5 90 PAK 133 NEO-SYNEPHRINE COLD & MULTISTIX 7 90 NAMENDA XR 133 SINUS EXTRA 123 NEO-SYNEPHRINE COLD & MULTISTIX 8 SG 90 SINUS MILD 123

Index 22 NEO-SYNEPHRINE COLD & NEUTROGENA HAND 76 NISEKO HYDRATING FACIAL SINUS REGULAR 123 NEUTROGENA MOISTURIZER 76 NEOKE BCAA4 91 HAND/NORWEGIANFORMUL nisoldipine 49 neomycin sulfate 3 A/FAST ABSORBING 76 NISOLDIPINE ER 49 neomycin-bacitracin zn- NEUTROGENA HEALTHY NITRO-BID 13 SKIN 76 polymyxin 127 NITRO-DUR 13 neomycin-bacitracin-polymyxin NEUTROGENA HEALTHY 64 SKIN FACE SPF 15 76 nitrofurantoin 140 neomycin-bacitracin-polymyxin- NEUTROGENA MOISTURE nitrofurantoin macrocrystal 140 pramoxine 64 SENSITIVE SKIN 76 nitrofurantoin monohyd neomycin-polymy- NEUTROGENA ON-THE- macro 140 SPOT ACNE dexameth 128 nitroglycerin 13 neomycin-polymyxin w/ TREATMENT 63 NEUTROGENA T/GEL 87 NITROLINGUAL pramoxine 64 PUMPSPRAY 13 neomycin-polymyxin-gramicidin NEUTROGENA T/GEL 127 STUBBORN ITCH NITROSTAT 13 neomycin-polymyxin-hc CONTROL 87 NIVA-PLUS 117 (otic) 129 NEVIRAPINE 44 NIVEA 76 neomycin/polymyxin b gu 97 nevirapine 44 NIVEA EXTRA ENRICHED 76 NEOMYCIN/POLYMYXIN/HYDR NEXA PLUS 117 NIVEA EXTRA ENRICHED OCORTISONE 128 LOTION 76 NEORAL 112 NEXAVAR 39 NIVEA GENTLE BODY NEOSALUS 76 NEXCARE WOUND EXFOLIATOR 76 CLEANSER 88 NIVEA LIGHT 76 NEOSPORIN 127 NEXIUM 138 NEOSPORIN ECZEMA NIVEA ORIGINAL 76 ESSENTIALS 76 NEXIUM 24HR 138 NIVEA ORIGINAL NEOSPORIN GU IRRIGANT97 NEXIUM 24HR CLEAR MOISTURE 76 MINIS 138 NEOSPORIN LIP HEALTH NIVEA SOFT 76 niacin 146 OVERNIGHT RENEWAL NIVEA VISAGE 76 THERAPY 83 niacin (antihyperlipidemic) 33 NIVEA VISAGE FOAMING NEOSPORIN ORIGINAL 64 NIACIN TR 146 FACIAL 83 NEOSPORIN PLUS PAIN NIACOR 33 NIVEA VISAGE INNER BEAUTY RELIEF MAXIMUM NIASPAN 33 NIGHTTIME RENEWAL 76 STRENGTH 64 NIVEA VISAGE MOISTURIZING nicardipine hcl 48 NEPHRON FA 100 TONER 83 NICE DISTILLED NIX CREME RINSE 86 NEPTAZANE 91 WATER 132 nizatidine 137 NESINA 24 NICODERM CQ 135 NIZATIDINE 137 NESTABS ABC 116 NICORETTE 135 NIZORAL 65 NESTABS DHA 116 NICORETTE MINI 135 NEUAC KIT 63 NICORETTE STARTER NIZORAL A-D 65 NEULASTA 99 KIT 135 NOBLE MYSTIQUE BODY nicotine 135 CLEANSER 83 NEULASTA ONPRO KIT 99 nonoxynol-9 143 NEUPOGEN 99 nicotine polacrilex 135 NICOTINE TRANSDERMAL NOR-QD 53 NEUROMED7 79 SYSTEM 135 NORCO 9 NEURONTIN 18 NICOTROL INHALER 135 NORDITROPIN FLEXPRO 92 NEUTRAPHOR 83 NICOTROL NS 135 norelgestromin-ethinyl NEUTRAPHORUS REX 83 nifedipine 48 estradiol 52 52 NEUTROGENA BODY LIGHT NILANDRON 38 norethin acet & estrad-fe SESAME FORMULA 76 52 nilutamide 38 norethindrone & eth estradiol NEUTROGENA DEEP CLEAN norethindrone & ethinyl estradiol- FACIAL CLEANSER 83 nimodipine 48 fe 52 NEUTROGENA FRESH NINLARO 39 norethindrone FOAMINGCLEANSER 83 (contraceptive) 53

Index 23 norethindrone acet & eth NULYTELY/FLAVOR OFF DEEP WOODS estra 52 PACKS 103 SPORTSMEN 84 norethindrone acetate 133 NUMOISYN 114 OFF FAMILYCARE SMOOTH & norethindrone acetate-ethinyl NUPERCAINAL 11 DRY 84 OFF SMOOTH & DRY 84 estradiol 94 NUPLAZID 41 norethindrone acetate-ethinyl ofloxacin 95 NUTRADERM 76 estradiol-fe 52 ofloxacin (ophth) 127 norethindrone-eth estradiol NUTRADERM ADVANCED (triphasic) 52 FORMULA 76 ofloxacin (otic) 129 norgestimate-ethinyl NUTRASEB 76 OGESTREL 52 estradiol 52 NUTRICION PORVIDA 117 OINTMENT BASE 76 norgestimate-ethinyl estradiol NUTROPIN AQ NUSPIN (triphasic) 52 olanzapine 42 10 93 olanzapine-fluoxetine hcl 134 norgestrel & ethinyl estradiol 52 NUTROPIN AQ NUSPIN NORINYL 1+35 52 20 93 olmesartan medoxomil 34 NORINYL 1+50 52 NUTROPIN AQ NUSPIN 5 93 olmesartan medoxomil- hydrochlorothiazide 36 NUTROPIN AQ PEN 93 NORITATE 86 olopatadine hcl 129 NUVARING 53 NORPACE 14 olopatadine hcl (nasal) 122 NUVIGIL 2 NORPACE CR 14 OLUX 70 NYMALIZE 49 NORPRAMIN 22 OLUX-E 70 nystatin 29 NORTHERA 145 OLYSIO 46 nystatin (mouth-throat) 113 nortriptyline hcl 22 OMECLAMOX-PAK 139 nystatin (topical) 65 NORTRIPTYLINE HCL 22 omega-3 fatty acids 124 nystatin-triamcinolone 66 NORTUSS-EX 58 omega-3-acid ethyl esters 32 NORVASC 49 NYTOL MAXIMUM STRENGTH 101 omeprazole 138 NORVIR 44 O-CAL FA 117 OMEPRAZOLE 138 NOVA MAX PLUS KETONE O-CAL PRENATAL 117 OMEPRAZOLE + SYRSPEND TESTSTRIPS 90 SFALKA 138 OB COMPLETE ONE 117 NOVAFERRUM 125 100 omeprazole magnesium 138 NOVAFERRUM 50 100 OB COMPLETE PETITE 117 omeprazole-sodium NOVAREL 92 OB COMPLETE bicarbonate 139 PREMIER 117 NOVOLIN 70/30 25 OMNARIS 123 OBSTETRIX DHA 117 NOVOLIN 70/30 RELION 25 OMNIPRED 128 OBTREX DHA 117 NOVOLIN N 25 OMNITROPE 93 OCCLUVAN 132 NOVOLIN N RELION 25 ondansetron 29 OCEAN NASAL SPRAY 122 NOVOLIN R 25 ondansetron hcl 28,29 OCTAGAM 130 NOVOLIN R RELION 25 ONE-A-DAY WOMENS octreotide acetate 94 PRENATAL 117 NOVOLOG 25 OCUFEN 129 ONFI 17 NOVOLOG FLEXPEN 25 OCUFLOX 127 ONGLYZA 24 NOVOLOG MIX 70/30 25 OCUSOFT BABY EYELID & ONMEL 30 NOVOLOG MIX 70/30 EYELASH CLEANSER 83 OPANA 8 PREFILLED FLEXPEN 25 OCUSOFT EYELID NOVOLOG PENFILL 25 CLEANSINGPADS 83 OPCON-A 127 NOXAFIL 30 OCUSOFT LID SCRUB 83 opium tincture 28 NU-GEL COLLAGEN WOUND OCUSOFT LID SCRUB OPSUMIT 49 DRESSING 88 PLUS 83 OPTIONS CONCEPTROL NU-MAG 110 ODEFSEY 44 VAGINAL NUCYNTA 8 OFF ACTIVE 84 CONTRACEPTIVE 143 OPTIONS GYNOL II NUCYNTA ER 8 OFF DEEP WOODS 84 VAGINALCONTRACEPTIVE NUEDEXTA 134 OFF DEEP WOODS DRY 84 143

Index 24 ORA-BLEND 132 OVACE WASH 67 PARNATE 20 ORA-BLEND SF 132 OVCON-35 52 paromomycin sulfate 3 ORA-PLUS 132 OVIDE 86 paroxetine hcl 20 ORA-SWEET 132 OXANDRIN 10 paroxetine mesylate ORA-SWEET SF 132 oxandrolone 10 (vasomotor) 135 PASER 37 ORABASE 113 oxaprozin 5 PATADAY 129 ORABASE-B 113 oxazepam 14 PATANASE 122 ORACEA 86 oxcarbazepine 18 PAXIL 20 oral electrolytes 110 oxiconazole nitrate 66 PAXIL CR 20 ORAL MIX FLAVORED OXISTAT 66 PCCA SWEET-SF 132 SUSPENDING VEHICLE 132 OXSORALEN 86 ORAL MIX SF 132 PCCA SYRUP VEHICLE 132 OXSORALEN ULTRA 67 ORAL RELIEF SPRAY FOR PCCA-PLUS 132 oxybutynin chloride 140 DRYMOUTH & PCE 105 DISCOMFORT 114 oxycodone hcl 8 Peak Flow Meter 107 ORAL SUSPEND 132 OXYCODONE HCL ER 8 ORAL SYRUP FLAVORED oxycodone w/ PEARLS IC 27 VEHICLE 132 acetaminophen 9 PEDIA-LAX 103,104 ORAL SYRUP SF 132 oxycodone-aspirin 9 PEDIADERM AF COMPLETE ORALAIR 2 OXYCODONE/ACETAMINOPH KIT 66 ORALAIR ADULT SAMPLE EN 9 PEDIADERM HC 70 KIT 2 OXYCODONE/IBUPROFEN9 PEDIALYTE 110 ORALAIR ADULT STARTER OXYCONTIN 8 PEDIALYTE ADVANCED PACK 2 oxymetazoline hcl 123 CARE 110 ORAMAGIC PLUS 113 PEDIALYTE FREEZER oxymorphone hcl 8 ORAP 134 POPS 110 OXYMORPHONE PEDIALYTE SINGLES 110 ORAPRED ODT 53 HYDROCHLORIDE ER 8 PEDIAPRED 53 ORAVIG 113 OXYTROL 140 pediatric multiple vitamin w/ ORENCIA 5 OXYTROL FOR WOMEN140 minerals liqd/soln 115 ORENITRAM 49 oyster shell 109 pediatric multiple vitamin w/ c ORFADIN 93 PA PRENATAL 115 ORKAMBI 135 FORMULA 117 pediatric multiple vitamin w/ c PAIN-A-LAY 113 soln 115 orphenadrine citrate 121 pediatric multiple vitamin w/ ORTHO MICRONOR 53 paliperidone 41 minerals 115 ORTHO TRI-CYCLEN 52 PALOMAR E 84 pediatric multiple vitamins liqd 115 ORTHO TRI-CYCLEN LO 52 PAMELOR 22 PAMINE 137 pediatric multiple vitamins w/ iron ORTHO-CYCLEN 52 chew 115 ORTHO-NOVUM 1/35 52 PAMINE FORTE 137 pediatric multiple vitamins w/ iron ORTHO-NOVUM 7/7/7 52 PANCREAZE 91 soln 115 PANDEL 70 pediatric multivitamins w/ fl 115 OS-CAL ULTRA 109 pediatric multivitamins w/ fl oseltamivir phosphate 46,47 PANOXYL 63 PANOXYL-4 CREAMY chew 115 OSENI 22 WASH 63 pediatric multivitamins w/ fl OSMOPREP 104 soln 115 PANRETIN 66 peg 3350-kcl-sod bicarb-sod OTEZLA 5 pantoprazole sodium 138 chloride-sod sulfate 103 OTICIN HC NR 130 PARAFON FORTE DSC 121 peg 3350-potassium chloride-sod OTREXUP 3 PAREGORIC 28 bicarbonate-sod chloride 103 PEG-INTRON 46 OVACE PLUS 67 paricalcitol 93 PEG-INTRON REDIPEN 46 OVACE PLUS WASH 67 PARLODEL 40

Index 25 PEG-INTRON REDIPEN PAK PHARMACIST CHOICE pimozide 134 4 46 ALCOHOL PRED PADS 84 pindolol 48 PEGANONE 19 phenazopyridine hcl 98 pioglitazone hcl 24 PEGASYS 46 phenelzine sulfate 20 pioglitazone hcl-glimepiride 22 PEGASYS PROCLICK 46 phenobarbital 101 pioglitazone hcl-metformin PEGINTRON 46 PHENOBARBITAL 101 hcl 22 PELEVERUS 84 phenobarbital 101 piroxicam 5 PELEVERUS CLEAR 84 phenobarbital-hyoscyamine- PLAN B ONE-STEP 53 PELEVERUS GOLD 84 atropine-scopolamine 137 PLAQUENIL 37 phenol (antiseptic) 113 PEN-KERA 76 PLAVIX 99 phenylephrine hcl 123 PENICILLIN V PLEGRIDY 134 POTASSIUM 131 phenylephrine hcl (ophth) 127 PLEGRIDY STARTER penicillin v potassium 131 phenylephrine hcl (oral) 123 PACK 134 PENLAC NAIL LACQUER 66 phenylephrine w/ PLETAL 99 pentazocine w/ naloxone 10 acetaminophen 58 PNEUMOVAX 23 140 phenylephrine w/ dm-gg 58 pentoxifylline 98 PNEUMOVAX 23/1 DOSE 140 phenylephrine-acetaminophen- PENTRAVAN 76 guaifenesin 58 PNV FERROUS PENTRAVAN PLUS 76 phenylephrine- FUMARATE/DOCUSATE/FOLIC ACID 117 PEPCID 137 brompheniramine-dm 58 phenylephrine-chlorphen-dm PNV FOLIC ACID + IRON PEPCID AC 137 58 MULTIVITAMIN 117 PEPCID AC MAXIMUM phenylephrine- PNV OB+DHA 117 STRENGTH 137 chlorpheniramine-dm w/ PNV PRENATAL PLUS PEPCID COMPLETE 139 apap 58 MULTIVITAMIN 117 PEPTO BISMOL 27 phenylephrine-dm 58 PNV TABS 29-1 117 PEPTO-BISMOL 27 phenylephrine-dm-gg w/ PNV-DHA 117 PEPTO-BISMOL apap 58 PNV-DHA+DOCUSATE 117 phenylephrine-doxylamine- INSTACOOL 27 PNV-OMEGA 117 PEPTO-BISMOL MAX dextromethorphan- STRENGTH 27 acetaminophen 58 PNV-SELECT 117 PEPTO-BISMOL TO-GO 27 phenylephrine-guaifenesin 58 PNV-TOTAL 117 PERCOCET 9 phenylephrine-shark liver oil- PNV-VP-U 117 cocoa butter 10 podofilox 78 PERFOROMIST 16 phenylephrine-shark liver oil- PERI-WASH 84 glycerin-petrolatum 10 poison ivy treatments 86 PERIDEX 113 phenylephrine-shark liver oil- POLYCOSE 124 mineral oil-petrolatum 10 polyethylene glycol 3350 103 perindopril erbumine 34 PHENYLEPHRINE/GUAIFENE permethrin 86 polyethylene glycol-propylene SIN 58 glycol (ophth) 125 permethrin & pyrethrins-piperonyl PHENYLHISTINE DH 58 polymyxin b-trimethoprim 127 butoxide 86 PHENYTEK 19 perphenazine 42 polysaccharide iron phenytoin 19 101 PERPHENAZINE/AMITRIPTYLIN complex E 134 phenytoin sodium POLYSPORIN 64 extended 19 POLYTRIM 127 PERRY PRENATAL 117 PHILLIPS COLON PERSANTINE 99 HEALTH 27 polyvinyl alcohol 125 PETROLATUM 76 PHOS-NAK POWDER polyvinyl alcohol-povidone (ophth) 125 PETROLEUM JELLY LIP CONCENTRATE 111 TREATMENT 84 PHOSLYRA 96 POMALYST 39 PEXEVA 20 PHOSPHOLINE IODIDE 126 PONSTEL 5 PH 12 STERILE DILUENT PICATO 66 pot & sod citrates w/citric ac 97 FORFLOLAN 132 pilocarpine hcl 126 pilocarpine hcl (oral) 114

Index 26 pot phosphate monobasic w/ sod prednisolone sodium PRENATE PIXIE 119 phosphate dibasic & phosphate 53,54 PRENATE RESTORE 119 monobasic 111 PREDNISOLONE SODIUM potassium bicarb & chloride111 PHOSPHATE 128 PREORBOTIC 27 potassium bicarbonate 111 PREDNISONE 54 PREPARATION H 11 prednisone 54 PREPARATION H TOTABLES potassium chloride 111 PAIN RELIEF 11 PREDNISONE 54 POTASSIUM CHLORIDE 111 PREPLUS 119 PREDNISONE INTENSOL 54 potassium chloride 111 PREPOPIK 103 PREFERAOB ONE 117 POTASSIUM CHLORIDE PRETAB 119 ER 111 PREFERRED PLUS potassium chloride GLUCOSE 23 PRETTY FEET & HANDS 76 microencapsulated crystals PREGNYL W/DILUENT PREVACID 138 er 111 BENZYLALCOHOL/NACL 92 PREVACID 24HR 138 potassium citrate PREMARIN 95,144 PREVACID SOLUTAB 138 (alkalinizer) 97 PREMPHASE 94 97 PREVIDENT 114 potassium citrate-citric acid PREMPRO 94 POTIGA 18 PREVIDENT 5000 PRENAISSANCE 117 BOOSTER 113 43 povidone-iodine PRENAISSANCE PLUS 117 PREVIDENT 5000 BOOSTER 117 PLUS 113 PR NATAL 400 PRENATABS FA 117 PR NATAL 400 EC 117 PREVIDENT 5000 DRY PRENATABS RX 117 MOUTH 113 117 PR NATAL 430 PRENATAL 118 PREVIDENT 5000 PLUS 113 117 PR NATAL 430 EC PRENATAL 19 118 PREVIDENT FLUORIDE 114 17 PRADAXA PRENATAL AND IRON 118 PREVNAR 13 140 40 pramipexole dihydrochloride PRENATAL COMPLETE 118 PREVPAC 139 11 pramoxine hcl (rectal) PRENATAL FORMULA 118 PREZCOBIX 44 pramoxine-calamine 79 PRENATAL FORMULA A- PREZISTA 44 pramoxine-hc-chloroxylenol FREE 118 PRIFTIN 37 130 PRENATAL FORTE 118 pramoxine-phenylephrine- PRILOSEC 138 PRENATAL LOW IRON 118 glycerin-petrolatum 11 PRILOSEC OTC 138 pramoxine-zinc acetate 80 PRENATAL MULTI +DHA 118 PRIMAQUINE PHOSPHATE37 PRANDIMET 22 PRENATAL primidone 18 PRANDIN 25 MULTIVITAMIN 118 PRIMLEV 9 PRENATAL MULTIVITAMIN + prasugrel hcl 99 PRIMSOL 12 PRAVACHOL 33 DHA 118 PRENATAL ONE DAILY 118 PRINIVIL 34 pravastatin sodium 33 PRENATAL PLUS 118 PRISTIQ 21 prazosin hcl 35 PRENATAL PLUS IRON 118 PRIVIGEN 130 PRE-NATAL FORMULA 117 PRENATAL VITAMIN 119 PRO-BIOTIC BLEND 27 PRECISION XTRA 90 PRENATAL VITAMIN & PRO-CLEAR AC 58 PRECOSE 22 MINERAL 119 PRO-FLORA IMMUNE 27 PRED FORTE 128 PRENATAL PRO-RED AC 58 PRED MILD 128 VITAMIN/IRON 119 119 PROAIR HFA 16 PRED-G 128 PRENATAL VITAMINS PRENATAL VITAMINS PLUS probenecid 98 PRED-G S.O.P. 128 LOW IRON 119 PROBIOMAX DAILY DF 27 PREDATOR 80 PRENATAL+DHA 119 PROBIOTIC 27 prednicarbate 70 PRENATAL-U 119 PROBIOTIC & ACIDOPHILUS prednisolone 54 PRENATE DHA 119 FORMULA EXTRA prednisolone acetate PRENATE ENHANCE 119 STRENGTH 27 (ophth) 128 PROBIOTIC + OMEGA-3 27 PRENATE ESSENTIAL 119

Index 27 PROBIOTIC ACIDOPHILUS 27 PROPRANOLOL HCL 48 PURIFIED WATER 132 PROBIOTIC ACIDOPHILUS propranolol hcl 48 PURILON 88 BEADS 27 PROPRANOLOL/HYDROCHL PURIXAN 38 PROBIOTIC ADVANCED OROTHIAZIDE 36 PX DAYTIME MULTI- ULTRAPOTENCY 27 propylene glycol (ophth) 125 PROBIOTIC COLON SYMPTOM 59 SUPPORT 27 propylene glycol-glycerin 125 PX GLUCOSE 23 PROBIOTIC propylthiouracil 136 PX NITETIME MULTI- COMPLEX/ACIDOPHILUS 27 PROSCAR 97 SYMPTOM 59 PROBIOTIC DAILY 27 PROSHIELD PLUS SKIN PX OMEPRAZOLE 139 PROBIOTIC GOLD EXTRA PROTECTANT 84 PX PRENATAL STRENGTH 27 PROSHIELD PROTECTIVE MULTIVITAMINS 119 PROBIOTIC MATURE HANDCREAM 84 PX PURIFIED WATER 132 ADULT 27 PROSTEON 111 PYLERA 139 PROBIOTIC PEARLS 27 PROTONIX 139 pyrantel pamoate 12 PROBIOTIC PEARLS ADVANTAGE 27 PROTOPIC 78 pyrazinamide 37 PROBIOTIC-10 27 protriptyline hcl 22 pyrethrins-piperonyl butoxide87 PROBIOTIC-10 ULTIMATE 27 PROVENTIL HFA 16 pyrethrins-piperonyl butoxide- PROVERA 133 permethrin-nit remover 87 PROCARDIA 49 PYRIDIUM 98 PROVIDA OB 119 PROCARDIA XL 49 pyridostigmine bromide 37 PROVIGIL 2 PROCENTRA 1 pyridoxine hcl 146 PROZAC 20 prochlorperazine 42 pyrithione zinc 67 PROZAC WEEKLY 21 prochlorperazine maleate 42 QC CALAMINE 84 PRUDOXIN 67 PROCRIT 99 QC PRENATAL 119 PROCTOCORT 11 pseudoephed-bromphen- dm 59 QH 3 PROCTOFOAM 11 pseudoephed-doxyl-dm QNASL 123 PROFE 101 w/apap 59 QUALAQUIN 37 pseudoephedrine hcl 123 PROFE FORTE 119 QUARTETTE 52 progesterone micronized 133 pseudoephedrine w/ codeine- gg 59 QUAZEPAM 102 PROGLYCEM 23 pseudoephedrine w/ dm- QUDEXY XR 18 PROGRAF 112 gg 59 QUESTRAN 32 pseudoephedrine- PROLENSA 129 QUESTRAN LIGHT 32 PROLEUKIN 39 acetaminophen- dextromethorphan 59 quetiapine fumarate 42 PROMACTA 99 pseudoephedrine-chlorphen- QUILLIVANT XR 2 promethazine & dm 59 quinapril hcl 34 phenylephrine 58 pseudoephedrine-dm 59 promethazine hcl 31,32 quinapril-hydrochlorothiazide pseudoephedrine-guaifenesin 36 PROMETHAZINE HCL 51 59 quinidine gluconate 14 promethazine w/codeine 59 pseudoephedrine- ibuprofen 59 QUINIDINE SULFATE 14 promethazine-dm 59 PSORCON 70 quinine sulfate 37 promethazine-phenylephrine- codeine 59 psyllium 103 QVAR 15 PROMETHAZINE/PHENYLEPHR PTS PANELS KETONE R-NATAL OB 119 INE 59 TEST 90 RA CRYSTAL LAKE PROMETRIUM 133 PULMICORT 15 DISTILLEDWATER 132 propafenone hcl 14 PULMICORT FLEXHALER15 RA DRY MOUTH 114 PROPANTHELINE PULMOZYME 135 RA GENTLE SKIN CREAM 76 BROMIDE 137 PURACYN PLUS DUO- RA GLUCOSE 23 proparacaine hcl 127 CARE 88 RA ISOPROPYL ALCOHOL propranolol hcl 48 PUREFE OB PLUS 119 WIPES 84

Index 28 RA MAKEUP REMOVER REFRESH OPTIVE 125 RESCON-GG 59 EYELIDWIPES XL 84 REFRESH OPTIVE RESCRIPTOR 44 RA OMEPRAZOLE 139 SENSITIVE 125 RESCULA 129 RA ONE DAILY 119 REFRESH TEARS 125 RESERPINE 35 RA OYSTER SHELL REGENECARE 88 RESPAIRE-30 59 CALCIUM/VITAMIN D 109 REGLAN 96 RA PAIN RELIEF 80 RESTA 76 REGRANEX 88 RESTA LITE 76 RA PRENATAL 119 REHYLA HAIR + BODY RA PRENATAL CLEANSER 84 RESTA WOUND CLEANSER 88 FORMULA/FOLICACID 119 REHYLA WASH 84 RA PROBIOTIC COLON RESTASIS 127 RELENZA DISKHALER 47 CARE 27 RESTASIS MULTIDOSE 127 RELION GLUCOSE 23 RA PROBIOTIC COMPLEX 27 RESTORA 27 RA RENEWAL ADVANCED RELION KETONE 90 RESTORE HYDROGEL HEALING 84 RELION KETONE TEST DRESSING 88 RA RENEWAL DRY SKIN STRIPS 90 RESTORIL 102 THERAPY 76 RELPAX 108 RETIN-A 63 RA SALINE WOUND WASH 84 REMEDY 4-IN-1 BODY rabeprazole sodium 139 CLEANSER/FOAMER 88 RETIN-A MICRO 63 RADIAGEL 88 REMEDY CLEAR-AID 84 RETIN-A MICRO PUMP 63 RADIAGUARD ADVANCED 76 REMEDY FOAMING BODY RETROVIR 44 CLEANER/OLIVAMINE 84 RADIAPLEXRX 88 REVATIO 50 REMEDY NUTRASHIELD 84 RAGWITEK 2 REVITADERM WOUND REMEDY SKIN REPAIR 84 CARE 88 raloxifene hcl 93 REMERON 19 REVLIMID 111 ramipril 34 REMERON SOLTAB 19 REXULTI 43 RANEXA 13 REMICADE 96 REYATAZ 44 ranitidine hcl 137,138 REMODULIN 49 RHEUMATREX 3 RAPAFLO 97 REMOVE ADHESIVE RHINARIS 122 RAPAMUNE 112 REMOVER 80 RHINOCORT AQUA 123 rasagiline mesylate 41 RENACIDIN 97 RHOGAM ULTRA-FILTERED RASUVO 3 RENAGEL 96 PLUS 130 RAZADYNE 133 RENVELA 96 RHOPHYLAC 130 RAZADYNE ER 133 repaglinide 25 RIBASPHERE 46 REBETOL 46 REPAGLINIDE/METFORMIN RIBASPHERE RIBAPAK 46 REBIF 134 HYDROCHLORIDE 22 RIBATAB 46 REPEL FAMILY 84 REBIF REBIDOSE 134 ribavirin (hepatitis c) 46 REBIF REBIDOSE REPEL FAMILY DRY 84 riboflavin 146 REPEL HUNTERS TITRATIONPACK 134 RID 87 REBIF TITRATION PACK 134 FORMULA 84 REPEL SPORTSMEN 84 RID COMPLETE LICE RECOMBINATE 98 ELIMINATION 87 REPEL SPORTSMEN RECOMBIVAX HB 143 RID ESSENTIAL LICE DRY 84 ELIMINATION KIT 87 RECTIV 11 REPEL SPORTSMEN RIDAURA 3 REESES PINWORM MAX 85 MEDICINE 12 REPHRESH PRO-B 27 rifabutin 37 REFENESEN CHEST REPLESTA 145 RIFADIN 37 CONGESTION & PAIN RELIEF RIFAMATE 37 PE 59 REPREXAIN 9 rifampin 37 REFRESH 125 REQUIP 40 RIFATER 37 REFRESH CLEANSER 84 REQUIP XL 40 RIGHT STEP PRENATAL 119 REFRESH LIQUIGEL 125 RESCON DM 59 RILUTEK 124

Index 29 riluzole 124 ROC MULTI CORREXION 5 SANDIMMUNE 112 rimantadine hydrochloride 47 IN1 RESTORING NIGHT SANDOSTATIN 94 CREAM 77 RISABAL-PH 76 ROC MULTI CORREXION SANTYL 77 RISACAL-D 109 LIFTANTI-GRAVITY SAPHRIS 42 RISAMINE 85 NIGHT 77 SARNA 67 ROC RETINOL RISAQUAD 27 CORREXION 77 SAVELLA 134 RISAQUAD-2 27 ROC RETINOL CORREXION SAVELLA TITRATION risedronate sodium 92 MAX 77 PACK 134 SAWYER INSECT RISPERDAL 41 ROC RETINOL CORREXION NIGHT 77 REPELLENT 85 RISPERDAL M-TAB 41 ROC RETINOL CORREXION SAWYER INSECT REPELLENT risperidone 41 SENSITIVE EYE 77 CONTROLLED RELEASE 85 RISPERIDONE ODT 41 ROC RETINOL CORREXION SB OMEPRAZOLE 139 SENSITIVE NIGHT 77 RITALIN 2 SCHOOLTIME SHAMPOO 87 ROCALTROL 93 RITALIN LA 2 scopolamine 29 ropinirole hydrochloride 40 rivastigmine 133 SCOT-TUSSIN 59 ROSE MILK 77 rivastigmine tartrate 133 SCOT-TUSSIN DM 59 ROSULA 63 RIXUBIS 98 SCOT-TUSSIN SENIOR 60 rosuvastatin calcium 33 rizatriptan benzoate 108 SE-NATAL 19 119 ROWASA 96 ROBAXIN 121 SE-TAN DHA 119 ROXICODONE 8 SEA-CLENS WOUND ROBAXIN-750 121 ROZEREM 102 CLEANSER 89 ROBINUL 137 RULAVITE DHA 119 SEASONIQUE 52 ROBINUL FORTE 137 RYTHMOL 14 SEBULEX 67 ROBITUSSIN CHILDRENS SECONAL 101 COUGH & COLD CF 59 RYTHMOL SR 14 ROBITUSSIN CHILDRENS SABRIL 19 SECONAL SODIUM 101 COUGH LONG-ACTING 54 SAF-CLENS AF 88 SECTRAL 47 ROBITUSSIN CHILDRENS SELECT-OB 120 COUGH/COLD LONG- SAF-GEL 89 ACTING 59 SAFE WASH 85 SELECT-OB+DHA 120 ROBITUSSIN DM 59 SAFYRAL 52 selegiline hcl 41 ROBITUSSIN LINGERING SAIZEN 93 selenium sulfide 67 COLDLONG-ACTING SAIZEN CLICK.EASY 93 SELSUN BLUE 67 COUGHGELS 54 SELSUN BLUE DAILY 67 ROBITUSSIN NIGHTTIME SAIZENPREP RECONSTITUTIONKIT 93 SELSUN BLUE COUGH LONG-ACTING DM MEDICATED 67 CHILDRENS 59 SALAGEN 114 SALEX 78 SELSUN BLUE ROBITUSSIN PEAK COLD MOISTURIZING 68 COUGH+ CHEST CONGESTION SALEX CREAM 78 DM MAX STRENGTH 59 SELZENTRY 44,45 ROBITUSSIN PEAK COLD SALEX LOTION 78 SEMPREX-D 60 DM 59 salicylic acid 78 SENNA 104 ROBITUSSIN PEAK COLD salicylic acid & sulfur 67 sennosides 104 MULTI-SYMPTOM COLD 59 salicylic acid w/ cleanser 78 ROBITUSSIN TO GO COUGH sennosides-docusate &COLD CF 59 saline 122 sodium 103 ROC DEEP WRINKLE SALINE WOUND WASH 85 SENOKOT 104 SERUM 76 SALJET 85 SENOKOT S 103 ROC MAX RESURFACING SALJET RINSE 85 SENSI-CARE FACIAL CLEANSER 85 MOISTURIZING 85 ROC MULTI CORREXION 5 IN1 salsalate 7 SENSI-CARE SEPTI-SOFT RESTORING EYE CREAM 76 SAMSCA 94 CONENTRATE 85 SANCUSO 29 SENSIPAR 93

Index 30 SEREVENT DISKUS 16 SM ONE DAILY SORBIDON HYDRATE 85 SEROQUEL 42 PRENATAL 120 SORBITOL 97,103 SM PRENATAL SEROQUEL XR 42 VITAMINS 120 SORBOLENE 77 SEROSTIM 93 SMART SENSE SORIATANE 67 sertraline hcl 21 GLUCOSE 24 SORILUX 67 SMART SENSE GLUCOSE sevelamer carbonate 96 TABLETS 24 sotalol hcl 48 SFROWASA 96 soap & cleansers 85 sotalol hcl (afib/afl) 48 SHOHLS SOLUTION sodium bicarbonate SOVALDI 46 MODIFIED 97 (antacid) 11 SP ANTIPRURITIC 89 SHUR-CLENS 89 sodium chloride (gu SPECIAL CARE CREAM 77 SHUR-SEAL 143 irrigant) 97 SPECTRACEF 50 SIGNIFOR 94 sodium chloride (inhalant) 61 SPECTRAGEL 89 sildenafil citrate (pulmonary sodium chloride hypertension) 50 hypertonic 129 SPINOSAD 87 SILENOR 101 sodium citrate & citric acid 97 SPIRIVA HANDIHALER 14 SILPHEN COUGH 31 sodium fluoride 110 spironolactone 92 SILVADENE 68 SODIUM FLUORIDE 110 spironolactone & hydrochlorothiazide 91 SILVASORB 89 sodium fluoride (dental) 114 SPORANOX 30 silver sulfadiazine 68 sodium phenylbutyrate 93 SPORANOX PULSEPAK 30 SILVERMED 89 sodium phosphates 104 SPORTSCREME 79 SIMBRINZA 126 sodium polystyrene sulfonate 112 SPRYCEL 39 SIMCOR 33 SODIUM SSKI 110 simethicone 95 SULFACETAMIDE/SULFUR SSS 10-5 63 SIMPLYTHICK 131 63 SOLARAZE 66 ST IVES SWISS FORMULA SIMPONI 3 24HOUR MOISTURE 77 simvastatin 33 SOLODYN 136 STALEVO 100 40 SINEMET 40 SOLOSITE 89 STALEVO 125 40 SINEMET CR 40 SOLVATECH PLUS 132 STALEVO 150 41 SINGULAIR 15 SOLVATECH SWEET SF132 STALEVO 200 41 sirolimus 112 SOMA 121 STALEVO 50 41 SIRTURO 37 SOMAVERT 92 STALEVO 75 41 SITAVIG 46 SONATA 102 stannous fluoride 114 SOOTHE & COOL FREE SIVEXTRO 13 MEDSEPTIC 85 STAPHSCRUB 85 SKELAXIN 121 SOOTHE & COOL FREE starch-maltodextrin skin protectants, misc. 85 MOISTURE BARRIER 85 (thickening) 131 STARLIX 25 SKIN REPAIR 77 SOOTHE & COOL FREE SKIN PASTE 85 stavudine 45 SKINTEGRITY HYDROGEL 89 SOOTHE & COOL MOISTURE STERILE DILUENT FOR SKINTEGRITY WOUND 89 BARRIER 85 EPOPROSTENOL SLO-NIACIN 146 SOOTHE & COOL SODIUM 132 MOISTURIZING BODY SLOW FE 101 STERILE DILUENT FOR LOTION WITH ALOE 77 REMODOULIN 132 SLOW-MAG 110 SOOTHE & COOL PROTECT STIMATE 94 SM ACIDOPHILUS PEARLS27 MOISTURE BARRIER 85 STIMULEN 89 SM CALAMINE 85 SOOTHE & COOL SHAMPOO ANDBODY WASH WITH STIVARGA 39 SM GLUCOSE 23,24 ALOE 85 STRATTERA 1 SM IPECAC SYRUP 28 SOOTHE & COOL SKIN STRIANT 10 SM OMEPRAZOLE 139 CREAMWITH ALOE & VITAMINS A, D & E 77 STRIBILD 45

Index 31 STRIVERDI RESPIMAT 16 SUMAXIN WASH 63 Syringe/Needle (Disp) 3 ML 25 x STROMECTOL 12 SUMMERS EVE CLEANSING 1-1/2" 107 WASH/SENSITIVE SKIN 85 Syringe/Needle (Disp) 3 ML 25 x STUDIO 35 EXTRA 5/8" 107 MOISTURIZING LOTION 77 SUMMERS EVE NIGHT-TIME CLEANSING Syringe/Needle (Disp) 3 ML 26 x STUDIO 35 MOISTURIZING 5/8" 107 SKIN 77 WASH/SENSITIVE SKIN 85 SYRPALTA 132 SUBOXONE 10 SUPER PROBIOTIC 27 SYRSPEND SF 132 SUBSYS 8 SUPER PROBIOTIC DIGESTIVE SUPPORT 28 SYRUP VEHICLE 132 SUCRAID 91 SUPRAX 50,51 SYRUP VEHICLE SF 132 sucralfate 138 SUPREP BOWEL PREP SYSTANE 125 SUDAFED 24 HOUR 123 103 KIT SYSTANE BALANCE SUDAFED CHILDRENS 123 SURE COMFORT ALCOHOL PREP PADS 85 RESTORATIVE FORMULA125 SUDAFED CONGESTION 123 SURMONTIL 22 SYSTANE LID WIPES 85 SUDAFED NASAL SYSTANE OVERNIGHT DECONGESTANT MAXIMUM SUSPENSION VEHICLE 132 THERAPY LUBRICANT STRENGTH 124 SUSTIVA 45 EYE 125 SUDAFED PE CHILDRENS SUTENT 39 SYSTANE ULTRA 125 NASAL DECONGESTANT 124 SW OMEPRAZOLE 139 SYSTANE ULTRA HOME & SUDAFED PE AWAY PACK 125 CONGESTION 124 SWEEN CREAM 77 TABLOID 38 SULAR 49 SYLATRON 39 tacrolimus 112 sulfacetamide sod- SYLVANT 112 tacrolimus (topical) 78 prednisolone 128 SYMAX DUOTAB 137 sulfacetamide sodium 68 TAFINLAR 39 SYMBICORT 16 SULFACETAMIDE TAGAMET HB 138 SYMBYAX 134 SODIUM 127 TAMIFLU 47 sulfacetamide sodium (acne)63 SYMLINPEN 120 22 tamoxifen citrate 38 sulfacetamide sodium SYMLINPEN 60 22 tamsulosin hcl 97 (ophth) 127 SYNAGIS 130 sulfacetamide sodium w/ TANDEM PLUS 100 SYNALAR 70 sulfur 63 TANZEUM 24 sulfacetamide sodium-sulfur w/ SYNALGOS-DC 9 TAPAZOLE 136 skin cleanser 63 SYNAREL 93 TARCEVA 39 SULFADIAZINE 135 SYNTHROID 136 sulfamethoxazole-trimethoprim Syringe (Disposable) 3 TARGRETIN 39 12 ML 107 TARKA 36 SULFAMYLON 68 Syringe/Needle (Disp) 1 ML 20 TARON FORTE 100 sulfasalazine 96 x 1" 107 TARON-C DHA 120 SULFZIX 91 Syringe/Needle (Disp) 3 ML 20 x 1" 107 TARON-PREX 120 sulindac 5 Syringe/Needle (Disp) 3 ML 20 TASIGNA 39 SUMADAN KIT 63 x 1-1/2" 107 TASMAR 40 SUMADAN WASH 63 Syringe/Needle (Disp) 3 ML 22 x 1" 107 TAVIST ALLERGY 31 sumatriptan 108 Syringe/Needle (Disp) 3 ML 22 tazarotene 67 sumatriptan succinate 108 x 1-1/2" 107 TAZORAC 67 SUMATRIPTAN Syringe/Needle (Disp) 3 ML 22 TBC 77 SUCCINATE 108 x 3/4" 107 sumatriptan succinate 108 Syringe/Needle (Disp) 3 ML 23 TEARS NATURALE PM 125 SUMATRIPTAN/NAPROXEN x 1" 107 TECFIDERA 134 SODIM 107 Syringe/Needle (Disp) 3 ML 23 TECFIDERA STARTER SUMAXIN 63 x 1-1/2" 107 PACK 134 Syringe/Needle (Disp) 3 ML 25 TEGADERM HYDROGEL SUMAXIN CP KIT 63 x 1" 107 WOUND FILLER 89 SUMAXIN TS 63 TEGRETOL 18

Index 32 TEGRETOL-XR 18 theophylline 16 tioconazole vaginal 144 TEKTURNA 36 THERA-FLUR-N 114 TIROSINT 136 TEKTURNA HCT 36 THERABETIC SKIN CARE77 TIVICAY 45 telmisartan 34 THERACAL D2000 111 tizanidine hcl 121 telmisartan-amlodipine 36 THERACAL D4000 111 TL-CARE DHA 120 telmisartan-hydrochlorothiazide THERACAL RAPID TL-SELECT 120 36 REPLETION 111 TOBI 3 temazepam 102 THERAFLU SEVERE COLD TOBI PODHALER 3 TEMODAR 38 NIGHTTIME 60 THERAHONEY 89 TOBRADEX 128 TEMOVATE 70 THERANATAL CORE TOBRADEX ST 128 TEMOVATE E 70 NUTRITION 120 TOBRAMYCIN 3 temozolomide 38 THERAPEUTIC tobramycin 3 TENA SKIN-CARING BODY MOISTURIZING 77 WASH 85 THERAPLEX tobramycin (ophth) 127 TENA SKIN-CARING WASH HYDROLOTION 77 TOBRAMYCIN SULFATE 3 CREAM 85 THERAPLEX T 87 tobramycin sulfate 3 TENCON 6 thiamine hcl 146 tobramycin- TENEX 35 thiamine mononitrate 146 dexamethasone 128 TENORETIC 100 36 THICK-IT ORIGINAL 131 TOBREX 127 TENORETIC 50 36 THIOLA 98 TOFRANIL 22 TENORMIN 47 thioridazine hcl 42 TOLAZAMIDE 25 TERAZOL 3 144 thiothixene 43 TOLBUTAMIDE 25 TERAZOL 7 144 THRIVITE 19 120 tolcapone 40 terazosin hcl 35 THRIVITE RX 120 TOLMETIN SODIUM 5 terbinafine hcl 29 THUM 80 tolmetin sodium 5 terbinafine hcl (topical) 66 thyroid 136 TOLMETIN SODIUM 5 terbutaline sulfate 16 THYROLAR-1 136 tolnaftate 66 terconazole vaginal 144 THYROLAR-1/2 136 TOLNAFTATE 66 TESSALON PERLES 54 THYROLAR-1/4 136 tolterodine tartrate 140 TESTIM 10 THYROLAR-2 136 TOPAMAX 18 TESTOSTERONE 10 THYROLAR-3 136 TOPAMAX SPRINKLE 18 testosterone 10 tiagabine hcl 19 TOPICORT 71 testosterone cypionate 10 TIAZAC 49 topiramate 18 TESTOSTERONE PUMP 10 TIGAN 29 TOPIRAMATE ER 18 TESTRED 10 TIGER BALM PAIN TOPROL XL 47 tetrabenazine 134 RELIEVING 79 torsemide 91 tetracaine hcl (ophth) 127 TIKOSYN 14 TOUJEO SOLOSTAR 25 tetracycline hcl 136 TIMOLOL MALEATE 48 TOVIAZ 140 timolol maleate TRACLEER 49 TETRACYCLINE HCL 136 (ophth) 125,126 tetrahydrozoline hcl (ophth) 127 TIMOPTIC 126 TRADJENTA 24 tetrahydrozoline w/ zinc TIMOPTIC OCUDOSE 126 tramadol hcl 8 sulfate 127 TIMOPTIC-XE 126 TRAMADOL HCL ER 8 TEXACORT 71 tramadol-acetaminophen 9 TGQ 30PSE/150GFN/15DM 60 TINACTIN 66 TINACTIN DEODORANT 66 trandolapril 34 TGT GLUCOSE 24 trandolapril-verapamil hcl 36 TGT OMEPRAZOLE 139 TINACTIN JOCK ITCH 66 TINDAMAX 12 tranexamic acid 101 THALOMID 111 TRANSDERM-SCOP 29 THEO-24 16 tinidazole 12

Index 33 Transparent Dressings - trihexyphenidyl hcl 40 Tuberculin/Allergy Misc 105 TRILEPTAL 18 Syringe/Needle (Disp) 1 ML 26 x TRANXENE T 14 3/8" 107 TRILIPIX 33 tranylcypromine sulfate 20 Tuberculin/Allergy trimethobenzamide hcl 29 Syringe/Needle (Disp) 1 ML 28 x TRAVOPROST 129 trimethoprim 12 1/2" 107 trazodone hcl 21 trimipramine maleate 22 TUDORZA PRESSAIR 15 TRECATOR 37 TRIMPEX 12 TUMS 11 TRESIBA FLEXTOUCH 25 TRINATAL GT 120 TUMS LASTING EFFECTS 11 tretinoin 63 TRINATAL RX 1 120 TUSNEL 60 tretinoin (chemotherapy) 39 TRINATE 120 TUSNEL PEDIATRIC 60 tretinoin microsphere 64 TRINTELLIX 21 TWYNSTA 36 TRETTEN 98 TRIPLE CREAM 77 TYBOST 45 TREXALL 38 TRIPLE PASTE 85 TYKERB 39 TREXIMET 107 TRIPLE PASTE SP 85 TYLENOL 6 TRI-LUMA 86 triprolidine & TYLENOL 8 HOUR 6 TRI-NORINYL 28 52 pseudoephedrine 60 TYLENOL 8 HOUR TRI-TABS DHA 120 TRIUMEQ 45 ARTHRITISPAIN 6 TRIAD HYDROPHILIC WOUND TRIVEEN-DUO DHA 120 TYLENOL CHILDRENS 6 TYLENOL CHILDRENS PLUS DRESSING 89 TRIXAICIN 79 TRIADVANCE 120 FLU 60 TRIZIVIR 45 triamcinolone acetonide TYLENOL CHILDRENS PLUS (mouth) 114 TROKENDI XR 19 MULTI-SYMPTOM COLD 60 triamcinolone acetonide trolamine salicylate 79 TYLENOL COLD & FLU SEVERE 60 (nasal) 123 TROPAZONE 77 triamcinolone acetonide TYLENOL COLD & HEAD (topical) 71 tropicamide 126 SEVERE CONGESTION 60 TRIAMINIC COLD & COUGH trospium chloride 140 TYLENOL COLD MAX 60 DAY TIME CHILDRENS 60 TRUBIOTICS 28 TYLENOL COLD MULTI- TRIAMINIC FEVER TRUE METRIX BLOOD SYMPTOM NIGHTTIME 60 REDUCERPAIN RELIEVER GLUCOSE TEST STRIPS 90 TYLENOL COLD MULTI- CHILDRENS 6 TRUECONTROL GLUCOSE SYMPTOM SEVERE TRIAMINIC FEVER CONTROL LEVEL 0 106 DAYTIME 60 REDUCERPAIN RELIEVER TRUECONTROL GLUCOSE TYLENOL INFANTS 6 CONTROL LEVEL 1 106 COLD/COUGH/RUNNYNOSE TRIAMINIC FLU COUGH & TRUETEST BLOOD CHILDRENS 60 FEVER 60 GLUCOSE TEST STRIPS 90 TYLENOL EXTRA TRIAMINIC LONG ACTING TRUETEST GLUCOSE STRENGTH 6 COUGH 54 CONTROLLEVEL 1 106 TYLENOL INFANTS 6 triamterene & TRUETEST GLUCOSE TYLENOL INFANTS hydrochlorothiazide 91 CONTROLLEVEL 2 106 PAIN+FEVER 6 TRIAMTERENE/HYDROCHLOR TRUETEST GLUCOSE TYLENOL SINUS SEVERE 60 OTHIAZIDE 91 CONTROLLEVEL 3 106 TYLENOL SORE THROAT TRIAZOLAM 102 TRUETRACK BLOOD DAYTIME 6 triazolam 102 GLUCOSE TEST STRIPS 90 TYLENOL WARMING COUGH & TRICARE 120 TRUNATURE DIGESTIVE SEVER CONGESTION PROBIOTIC 28 TRICARE PRENATAL DHA DAYTIME 60 ONE 120 TRUSOPT 129 TYLENOL/CODEINE #3 9 TRICOR 33 TRUVADA 45 TYLENOL/CODEINE #4 9 TRIDESILON 71 Tuberculin/Allergy TYVASO 49 Syringe/Needle (Disp) 1 ML 21 trifluoperazine hcl 42 x 1" 107 TYVASO REFILL 49 trifluridine 127 Tuberculin/Allergy TYVASO STARTER 49 TRIGLIDE 33 Syringe/Needle (Disp) 1 ML 25 TYZEKA 46 x 5/8" 107

Index 34 TYZINE PEDIATRIC NASAL valsartan 34 VICKS NYQUIL COUGH 60 DROPS 124 valsartan-hydrochlorothiazide VICKS SINEX 124 UDDERLY SMOOTH 77 36 VICKS SINEX 12 HOUR UDDERLY SMOOTH EXTRA VALTREX 46 DECONGESTANT 124 CARE 77 VALUE PLUS GLUCOSE 24 VICKS SINEX 12 HOUR UDDERLY SMOOTH EXTRA VANCOCIN HCL 12 DECONGESTANT ULTRA FINE CARE20 77 MIST 124 ULESFIA 87 vancomycin hcl 12 VICKS SINEX 12 HOUR ULORIC 98 VANICREAM 77 DECONGESTANT ULTRA FINE ULTIMATECARE ONE 120 VANICREAM LITE 77 MIST/MOISTURIZNG 124 VICKS SINEX ULTRACET 9 VANOS 71 MOISTURIZING 124 ULTRAFLORA IMMUNE VAQTA 143 VICKS SINEX SEVERE HEALTH 28 VARIVAX 143 NASALDECONGESTANT 124 ULTRAM 8 VASCEPA 32 VICOPROFEN 9 ULTRAM ER 8 VASCUDERM HYDROGEL VICTOZA 24 ULTRATHON INSECT WOUNDDRESSING 89 VIDEX EC 45 REPELLENT 85 VASERETIC 36 ULTRATHON INSECT VIDEXPEDIATRIC 45 REPELLENT 8 85 VASOTEC 34 vigabatrin 19 ULTRAVATE 71 VCF VAGINAL VIGAMOX 127 CONTRACEPTIVE FILM 143 ULTRESA 91 VCF VAGINAL VIIBRYD 21 UNISOM 101 CONTRACEPTIVE VIMOVO 5 UNISOM SLEEPGELS 101 FOAM 143 VIMPAT 19 UP & UP GLUCOSE 24 VECAMYL 36 VINATE DHA RF 120 urea 71 VELETRI 49 VINATE II 120 urea in zinc undecylenate-lactic VELPHORO 97 VINATE M 120 acid vehicle 71 VELTIN 64 VINATE ONE 120 UREA IN ZINC VELVACHOL 77 UNDECYLENATE/LACTIC ACID VIRACEPT 45 VEHICLE 71 VEMAVITE-PRX 2 120 VIRAMUNE 45 URECHOLINE 140 VENA-BAL DHA 120 VIRAMUNE XR 45 URISTIX 90 venlafaxine hcl 21 VIREAD 45 URISTIX 4 90 VENLAFAXINE HCL ER 21 VIROPTIC 127 UROCIT-K 10 97 VENTAVIS 49 VIRT NATE 120 UROCIT-K 15 97 VENTOLIN HFA 16 VIRT-ADVANCE 120 UROCIT-K 5 97 VERAMYST 123 VIRT-C DHA 120 UROGESIC-BLUE 139 verapamil hcl 49 VIRT-PN 121 UROXATRAL 98 VEREGEN 64 VIRT-PN DHA 120 URSO 250 95 VERELAN 49 VIRT-PN PLUS 120 URSO FORTE 95 VERELAN PM 49 VIRT-SELECT 121 ursodiol 95 VERIPRED 20 54 VIRT-VITE GT 121 UTI HOME TEST 90 VERSACLOZ 42 VISBIOME PROBIOTIC HIGH VAGIFEM 144 VERSAFREE 132 POTENCY 28 VAGISTAT-1 144 VERSAPLUS 132 VISINE 127 valacyclovir hcl 46 VESICARE 140 VISINE EXTRA 127 VALCHLOR 67 VEXOL 128 VISINE TEARS 125 VALCYTE 45 VFEND 30 VISTARIL 13 valganciclovir hcl 45 VIACTIV 109 VISTOGARD 28 VALIUM 14 VIBRAMYCIN 136 VITAFOL ULTRA 121 valproic acid 19 VICKS DAYQUIL COUGH 54 VITAFOL-NANO 121

Index 35 VITAFOL-OB 121 WOUN'DRES COLLAGEN ZARXIO 99 VITAMIN D3 145 HYDROGEL WOUND ZATEAN-CH 121 DRESSING 89 vitamin e 145 WOUND CLEANSER 89 ZATEAN-PN DHA 121 VITAMIN E 145 wound cleansers 89 ZATEAN-PN PLUS 121 vitamin e 145 WOUND GEL 89 ZAVESCA 99 VITAMIN E WITH WOUND GEL SPRAY 89 ZEBETA 47 PANTHENOL 77 ZEGERID 139 vitamins a & d (topical) 77 WOUND WASH 89 ZEGERID OTC 139 VITEKTA 45 WOUND WASH SALINE 85 ZELAPAR 41 VIVELLE-DOT 95 WP THYROID 136 ZELBORAF 39 VIVITROL 28 XALATAN 129 ZEMPLAR 93 VOGELXO 10 XANAX 14 ZENPEP 91 VOGELXO PUMP 10 XANAX XR 14 ZENZEDI 1 VOL-NATE 121 XARELTO 16 ZEPATIER 46 VOL-PLUS 121 XARTEMIS XR 9 ZERIT 45 VOL-TAB RX 121 XELJANZ 3 ZESTORETIC 36 VOLTAREN 64 XELODA 38 ZESTRIL 34 voriconazole 30 XENAZINE 134 ZETIA 33 VOSPIRE ER 16 XERESE 68 ZETONNA 123 VOTRIENT 39 XIFAXAN 12 ZIAC 36 VP DERMABASE 77 XIZFLUS 91 ZIAGEN 45 VP-CH PLUS 121 XODOL 9 ZIANA 64 VP-HEME OB 121 XOLEGEL 66 XOLIDO XP 80 zidovudine 45 VP-HEME OB + DHA 121 ZIKS ARTHRITIS PAIN VP-HEME ONE 121 XOPENEX 16 RELIEF 79 VRAYLAR 41 XOPENEX ZIMS CRACK CREME CONCENTRATE 16 VSL#3 28 DAYTIME 77 XOPENEX HFA 16 zinc 111 VUSION 66 XTANDI 38 zinc oxide (topical) 86 VYTORIN 32 XULANE 52 zinc sulfate 111 VYVANSE 1 XYREM 133 ZINC SULFATE 111 WALGREENS GLUCOSE 24 XYZAL 31 ZINC SULFATE warfarin sodium 16 XYZAL ALLERGY 24HR 31 HEPTAHYDRATE 111 water for irrigation, sterile 112 YASMIN 28 52 ZINC SULFATE WEGMANS COMPLETE MONOHYDRATE 111 PRENATAL+DHA 121 YAZ 52 ziprasidone hcl 41 WELCHOL 32 ZADITOR 129 ZIPSOR 5 WELLBUTRIN 20 zafirlukast 15 ZIRGAN 127 WELLBUTRIN SR 20 zaleplon 102 ZITHROMAX 104,105 WESTCORT 71 ZAMICET 9 ZITHROMAX TRI-PAK 105 WESTHROID 136 ZANABIN ANTIPRURITIC HYDROGEL 89 ZITHROMAX Z-PAK 105 wheat dextrin 103 ZANAFLEX 121 ZMAX 105 white petrolatum 132 ZANFEL 86 ZOCOR 33 white petrolatum-mineral oil125 ZANTAC 138 ZOFRAN 29 WIBI 77 ZANTAC 150 MAXIMUM ZOFRAN ODT 29 WINRHO SDF 130 STRENGTH 138 ZOLINZA 39 witch hazel-glycerin 85 ZANTAC 75 138 zolmitriptan 108 ZARONTIN 19 ZOLOFT 21

Index 36 zolpidem tartrate 102 ZOLPIMIST 102 ZOMACTON 93 ZOMIG 109 ZOMIG ZMT 109 ZONALON 67 ZONATUSS 54 ZONEGRAN 19 zonisamide 19 ZONTIVITY 99 ZORBTIVE 93 ZORTRESS 112 ZORVOLEX 5 ZOSTAVAX 143 ZOSTRIX DIABETIC FOOT PAIN 80 ZOVIRAX 46,68 ZUBSOLV 10 ZUPLENZ 29 ZYBAN 135 ZYCLARA 77 ZYCLARA PUMP 77 ZYDELIG 39 ZYFLO 15 ZYLET 128 ZYLOPRIM 98 ZYMAXID 127 ZYPREXA 42 ZYPREXA ZYDIS 42 ZYRTEC ALLERGY 31 ZYRTEC CHILDRENS ALLERGY 31 ZYRTEC-D ALLERGY/CONGESTION 60 ZYTIGA 38 ZYVOX 13

Index 37