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Your 2021 Formulary

Effective January 1, 2021

For the most current list of covered or if you have questions:

Call the number on your member ID card.

Visit your plan’s website on your member ID card to: • Find a participating retail pharmacy by ZIP code. • Look up possible lower-cost alternatives. • Compare medication pricing and options. Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications or other About this formulary pharmacy care products, services or supplies chosen Where differences between this for their safety, cost, and effectiveness. Medications are formulary and your benefit plan listed by categories or classes and are placed into cost exist, the benefit plan documents levels known as tiers. It includes both brand and generic rule. This may not be a complete prescription medications. list of medications that are covered by your plan. Please review your To create the list, OptumRx® is guided by the Pharmacy and benefit plan for full details. Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

How do I use my formulary? You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equal becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID card.

2 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter medications Generic medications contain the same active ingredients An over-the-counter (OTC) (offer the same effect) as brand-name medications, but they medication may be the right often cost less. Once the patent for a brand-name medication treatment for some conditions. ends, the FDA can approve a generic version with the same Talk to your doctor about active ingredients. OTC options. Even though OTC medications may not be What if my doctor writes a brand-name prescription? covered by your pharmacy If your doctor gives you a prescription for a brand-name benefit, they may cost less than medication, ask if a generic or lower-cost option could be right a prescription medication. for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication? Specialty medications are used to treat complex conditions. These high-cost medications may be injected, infused or taken by mouth. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and have your prescriptions delivered right to your home or doctor’s office.

3 Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug Tier Includes Helpful Tips Tier 1 $ Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs. and some brand name Tier 2 $$ Mid-range cost to Tier 2 are all brand name drugs. high-cost preferred brand name

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

QL Quantity Limit – Medication may be limited to a certain quantity. SP Specialty Medication – Medication is designated as specialty.

4 Table of Contents Analgesics - Drugs for Pain...... 7 Analgesics - Drugs for Pain and Inflammation...... 14 Anesthetics...... 17 Anti-Addiction / Substance Abuse Treatment Agents...... 20 Antibacterials...... 21 ...... 32 Anticonvulsants - Drugs for Seizures...... 34 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia...... 38 Antidepressants...... 38 Antiemetics - Drugs for Nausea and Vomiting...... 41 Antifungals...... 43 Antigout Agents...... 46 Anti-inflammatory Agents...... 46 Antimigraine Agents...... 46 Antimyasthenic Agents...... 48 Antimycobacterials...... 48 Antineoplastics - Drugs for Cancer...... 49 Antiparasitics...... 60 Antiparkinson Agents...... 61 Antiplatelets...... 63 Antipsychotics - Drugs for Mood Disorders...... 63 Antivirals...... 65 Anxiolytics - Drugs for Anxiety...... 70 Bipolar Agents - Drugs for Mood Disorders...... 72 Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders...... 72 Cardiovascular Agents - Drugs for Heart and Circulation Conditions...... 76 Central Nervous System Agents - Drugs for Attention Deficit Disorder...... 89 Central Nervous System Agents - Drugs for Multiple Sclerosis...... 91 Central Nervous System Agents - Miscellaneous...... 92 Dental and Oral Agents - Drugs for Mouth and Throat Conditions...... 94 Dermatological Agents - Drugs for Skin Conditions...... 96 Diabetes - Antidiabetic Agents...... 105 Diabetes - Glucose Monitoring...... 107 Diabetes - Glycemic Agents...... 112 Diabetes - Insulins...... 113 Electrolytes / Minerals / Metals / Vitamins...... 116 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...... 131 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...... 132 Genetic or Disorder - Drugs for Replacement, Modification, Treatment...... 135 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions...... 138 Genitourinary Agents - Drugs for Prostate Conditions...... 140 Hormonal Agents - Adrenal...... 140 Hormonal Agents - Men's Health...... 143 Hormonal Agents - Osteoporosis...... 144 Hormonal Agents - Pituitary...... 144 Hormonal Agents - Prostaglandins...... 147 Hormonal Agents - Sex Hormones and Birth Control...... 147 Hormonal Agents - Thyroid...... 153 Immunological Agents - Drugs for Immune System Stimulation or Suppression...... 154 Immunological Agents - Drugs for Vaccination...... 160 Inflammatory Bowel Disease Agents...... 162

5 Metabolic Bone Disease Agents - Drugs for Osteoporosis...... 164 Metabolic Bone Disease Agents - Other...... 165 Miscellaneous Therapeutic Agents...... 165 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...... 176 Ophthalmic Agents - Drugs for Glaucoma...... 179 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions...... 180 Otic Agents - Drugs for Ear Conditions...... 183 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold...... 183 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...... 186 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis...... 191 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension...... 191 Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...... 192 Sleep Disorder Agents...... 194

6 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Analgesics - Drugs BENZHYDROCODON for Pain E-ACETAMINOPHEN 2 ABSTRAL ORAL TABLET SUBLINGUAL TABLET BUPAP ORAL TABLET 2 SUBLINGUAL 100 QL 2 BUPRENEX MCG, 200 MCG, 300 INJECTION 2 MCG, 400 MCG, 600 SOLUTION MCG, 800 MCG buprenorphine hcl acetaminophen- QL 1 1 injection solution codeine #2 oral tablet buprenorphine acetaminophen- QL QL 1 transdermal patch 1 codeine #3 oral tablet weekly acetaminophen- QL 1 butalbital- codeine #4 oral tablet acetaminophen capsule 1 acetaminophen- QL 50-300 mg oral 1 codeine oral solution BUTALBITAL- acetaminophen- QL ACETAMINOPHEN 1 2 codeine oral tablet CAPSULE 50-300 MG ACTIQ BUCCAL ORAL QL LOZENGE ON A 2 butalbital- HANDLE acetaminophen oral 1 alfentanil hcl tablet 1 intravenous solution butalbital-apap oral 1 ALLZITAL ORAL tablet 50-325 mg 2 TABLET butalbital-apap-caff-cod QL 1 APADAZ ORAL oral capsule 2 TABLET butalbital-apap- 1 apap-caff- oral capsule QL dihydrocodeine oral 1 butalbital-apap-caffeine 1 capsule oral tablet apap-caff- butalbital-asa-caff- QL QL 1 dihydrocodeine oral 1 codeine oral capsule tablet butalbital-- 1 ARYMO ER ORAL caffeine oral capsule TABLET EXTENDED QL butalbital-aspirin- 2 1 RELEASE ABUSE- caffeine oral tablet DETERRENT butorphanol tartrate QL ascomp-codeine oral QL 1 1 injection solution capsule butorphanol tartrate QL BELBUCA BUCCAL QL 1 2 nasal solution FILM BUTRANS QL TRANSDERMAL 2 PATCH WEEKLY

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 7 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits carisoprodol-aspirin- QL duraxin oral capsule 1 1 codeine oral tablet 300-200-20 mg clonidine hcl QL dvorah oral tablet 1 (analgesia) epidural 1 solution EMBEDA ORAL codeine sulfate oral QL CAPSULE EXTENDED 1 tablet RELEASE 100-4 MG, QL 2 CONZIP ORAL 20-0.8 MG, 30-1.2 MG, QL CAPSULE EXTENDED 2 50-2 MG, 60-2.4 MG, RELEASE 24 HOUR 80-3.2 MG DEMEROL INJECTION QL QL 2 endocet oral tablet 1 SOLUTION DILAUDID INJECTION ESGIC ORAL 2 2 SOLUTION 0.2 MG/ML CAPSULE DILAUDID INJECTION ESGIC ORAL TABLET 2 QL SOLUTION 1 MG/ML, 2 EXALGO ORAL 2 MG/ML TABLET EXTENDED QL DILAUDID ORAL QL RELEASE 24 HOUR 2 2 LIQUID 12 MG, 16 MG, 32 MG, 8 MG DILAUDID ORAL QL 2 TABLET fentanyl citrate (pf) injection solution 100 DOLOPHINE ORAL QL mcg/2ml, 1000 2 QL TABLET mcg/20ml, 250 1 DURACLON mcg/5ml, 2500 2 EPIDURAL SOLUTION mcg/50ml, 500 DURAGESIC-100 mcg/10ml QL TRANSDERMAL 2 fentanyl citrate (pf) PATCH 72 HOUR injection solution 50 1 DURAGESIC-12 mcg/ml QL TRANSDERMAL 2 fentanyl citrate (pf) QL PATCH 72 HOUR injection solution 1 DURAGESIC-25 cartridge QL TRANSDERMAL 2 fentanyl citrate buccal QL 1 PATCH 72 HOUR lozenge on a handle DURAGESIC-50 FENTANYL CITRATE QL QL 2 TRANSDERMAL 2 BUCCAL TABLET PATCH 72 HOUR FENTANYL CITRATE QL DURAGESIC-75 INJECTION 2 QL TRANSDERMAL 2 SOLUTION PATCH 72 HOUR duramorph injection QL 1 solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 8 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FENTANYL CITRATE FENTANYL CIT- INJECTION ROPIVACAINE-NACL QL SOLUTION 2 EPIDURAL SOLUTION QL PREFILLED SYRINGE PREFILLED SYRINGE 2 50 MCG/5ML 0.1-0.125-0.9 FENTANYL CITRATE MG/50ML-%, 0.1-0.2- INJECTION 0.9 MG/50ML-% SOLUTION 2 fentanyl transdermal QL 1 PREFILLED SYRINGE patch 72 hour 50 MCG/ML FENTANYL- FENTANYL CITRATE BUPIVACAINE-NACL QL INTRAVENOUS 2 EPIDURAL SOLUTION SOLUTION 0.2-0.08-0.9 FENTANYL CITRATE MG/100ML-%, 0.3- INTRAVENOUS 0.125-0.9 MG/100ML- %, 0.5-0.0625-0.9 SOLUTION QL PREFILLED SYRINGE QL MG/100ML-%, 0.5-0.1- 2 2 100 MCG/2ML, 1500 0.9 MG/100ML-%, 1- MCG/30ML, 250 0.0625-0.9 MG/250ML- MCG/5ML, 2750 %, 1-0.1-0.9 MCG/55ML MG/250ML-%, 1-0.125- 0.9 MG/250ML-%, FENTANYL CITRATE- QL 1.25-0.0625-0.9 NACL INTRAVENOUS 2 MG/250ML-% SOLUTION FENTORA BUCCAL QL 2 FENTANYL CITRATE- TABLET NACL INTRAVENOUS FIORICET ORAL SOLUTION 2 PREFILLED SYRINGE CAPSULE QL 10-0.9 MCG/2ML-%, 5- 2 FIORICET/CODEINE QL 2 0.9 MCG/ML-%, 50-0.9 ORAL CAPSULE MCG/5ML-%, 500-0.9 FIORINAL ORAL 2 MCG/50ML-%, 550-0.9 CAPSULE MCG/55ML-% FIORINAL/CODEINE QL 2 FENTANYL CIT- #3 ORAL CAPSULE ROPIVACAINE-NACL EPIDURAL SOLUTION hydrocodone bitartrate 0.2-0.125-0.9 QL er oral capsule QL 2 1 MG/100ML-%, 0.4- extended release 12 0.15-0.9 MG/200ML-%, hour 0.5-0.0625-0.9 hydrocodone- MG/100ML-% acetaminophen oral 1 solution 10-325 mg/15ml

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 9 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits hydrocodone- HYDROMORPHONE acetaminophen oral HCL-NACL INJECTION 2 solution 2.5-108 QL SOLUTION 1 mg/5ml, 5-217 PREFILLED SYRINGE mg/10ml, 7.5-325 HYDROMORPHONE mg/15ml HCL-NACL QL 2 hydrocodone- INTRAVENOUS QL acetaminophen oral 1 SOLUTION tablet HYDROMORPHONE hydrocodone-ibuprofen QL HCL-NACL 1 QL oral tablet INTRAVENOUS 2 hydromorphone hcl er SOLUTION QL oral tablet extended 1 PREFILLED SYRINGE release 24 hour HYDROMORPHONE- BUPIVACAINE-NACL HYDROMORPHONE QL HCL INJECTION 2 EPIDURAL SOLUTION 2 SOLUTION 0.2 MG/ML 4-0.125-0.9 MG/200ML-% hydromorphone hcl QL injection solution 4 1 HYDROMORPHONE- ROPIVACAINE-NACL QL mg/ml 2 EPIDURAL SOLUTION HYDROMORPHONE 2-0.1-0.9 MG/250ML-% HCL INTRAVENOUS 2 HYSINGLA ER ORAL SOLUTION QL TABLET ER 24 HOUR 2 hydromorphone hcl oral QL 1 ABUSE-DETERRENT liquid IBUDONE ORAL QL hydromorphone hcl oral QL 2 1 TABLET 10-200 MG tablet ibudone oral tablet 5- QL hydromorphone hcl pf QL 1 1 200 mg injection solution INFUMORPH 200 HYDROMORPHONE QL QL INJECTION 2 HCL SOLUTION 1 2 SOLUTION MG/ML INJECTION INFUMORPH 500 hydromorphone hcl QL QL INJECTION 2 solution 1 mg/ml 1 SOLUTION injection KADIAN ORAL HYDROMORPHONE QL QL CAPSULE EXTENDED 2 HCL SOLUTION 2 2 RELEASE 24 HOUR MG/ML INJECTION LAZANDA NASAL QL hydromorphone hcl 2 QL SOLUTION solution 2 mg/ml 1 levorphanol tartrate oral QL injection 1 tablet 2 mg HYDROMORPHONE QL levorphanol tartrate oral HCL-NACL INJECTION 2 1 SOLUTION tablet 3 mg

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 10 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits lorcet hd oral tablet 10- QL methadose oral tablet QL 1 1 325 mg soluble lorcet oral tablet 5-325 QL methadose sugar-free QL 1 1 mg oral concentrate lorcet plus oral tablet QL QL 1 mitigo injection solution 1 7.5-325 mg QL MORPHABOND ER LORTAB ORAL ELIXIR 2 ORAL TABLET ER 12 QL MEDROX-RX HOUR ABUSE- 2 EXTERNAL 2 DETERRENT 100 MG, OINTMENT 15 MG, 30 MG, 60 MG meperidine hcl injection QL morphine sulfate 1 (concentrate) oral QL solution 1 solution 100 mg/5ml, meperidine hcl oral QL 1 20 mg/ml solution morphine sulfate (pf) QL meperidine hcl oral QL 1 1 injection solution tablet morphine sulfate (pf) QL 1 MEPERIDINE HCL- intravenous solution SODIUM CHLORIDE INTRAVENOUS morphine sulfate er QL beads oral capsule QL SOLUTION 1000-0.9 2 1 MG/100ML-%, 300-0.9 extended release 24 MG/30ML-%, 500-0.9 hour MG/50ML-% morphine sulfate er oral QL methadone hcl injection QL capsule extended 1 1 solution release 24 hour methadone hcl intensol QL morphine sulfate er oral QL 1 1 oral concentrate tablet extended release methadone hcl oral QL MORPHINE SULFATE 1 concentrate IN DEXTROSE INTRAVENOUS QL methadone hcl oral QL 2 1 SOLUTION 100-5 solution MG/100ML-%, 250-5 methadone hcl oral QL MG/250ML-% 1 tablet MORPHINE SULFATE methadone hcl oral QL IN DEXTROSE 1 tablet soluble INTRAVENOUS QL 2 METHADONE HCL- SOLUTION NACL INTRAVENOUS PREFILLED SYRINGE 2 SOLUTION 50-5 MG/25ML-% PREFILLED SYRINGE MORPHINE SULFATE QL methadose oral QL INJECTION 2 1 concentrate 10 mg/ml SOLUTION 1 MG/ML

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 11 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits morphine sulfate MS CONTIN ORAL QL injection solution 10 TABLET EXTENDED 2 QL mg/ml, 2 mg/ml, 4 1 RELEASE mg/ml, 5 mg/ml, 8 nalbuphine hcl injection QL 1 mg/ml solution morphine sulfate NALOCET ORAL QL QL 2 intramuscular device 10 1 TABLET mg/0.7ml NORCO ORAL QL MORPHINE SULFATE 2 QL TABLET INTRAVENOUS 2 NUCYNTA ER ORAL SOLUTION 0.5 MG/ML QL TABLET EXTENDED 2 morphine sulfate QL RELEASE 12 HOUR intravenous solution 1 NUCYNTA ORAL QL 150 mg/30ml 2 TABLET morphine sulfate oral QL 1 QL solution OPANA ORAL TABLET 2 morphine sulfate oral QL 1 OXAYDO ORAL QL tablet 2 TABLET MORPHINE SULFATE QL SOLUTION 1 MG/ML 2 OXYCODONE HCL ER ORAL TABLET ER 12 QL INTRAVENOUS 2 HOUR ABUSE- morphine sulfate QL DETERRENT solution 1 mg/ml 1 oxycodone hcl oral QL intravenous 1 capsule MORPHINE SULFATE- NACL INJECTION oxycodone hcl oral 2 QL SOLUTION concentrate 100 1 PREFILLED SYRINGE mg/5ml oxycodone hcl oral QL MORPHINE SULFATE- 1 NACL INTRAVENOUS solution SOLUTION 100-0.9 oxycodone hcl oral QL 1 MG/100ML-%, 1000- tablet QL 0.9 MG/100ML-%, 150- 2 OXYCODONE- 0.9 MG/150ML-%, 250- ACETAMINOPHEN QL 0.9 MG/250ML-%, 50- ORAL TABLET 10-300 2 0.9 MG/50ML-%, 500- MG, 2.5-300 MG, 5-300 0.9 MG/100ML-% MG MORPHINE SULFATE- oxycodone- NACL INTRAVENOUS acetaminophen oral 2 QL SOLUTION 250-0.9 tablet 10-325 mg, 2.5- 1 MG/50ML-% 325 mg, 5-325 mg, 7.5- MORPHINE SULFATE- 325 mg NACL INTRAVENOUS QL oxycodone-aspirin oral QL 2 1 SOLUTION tablet PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 12 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits oxycodone-ibuprofen QL tramadol hcl er 1 oral tablet 5-400 mg (biphasic) oral tablet QL 1 OXYCONTIN ORAL extended release 24 QL TABLET ER 12 HOUR 2 hour ABUSE-DETERRENT TRAMADOL HCL ER oxymorphone hcl er ORAL CAPSULE QL QL oral tablet extended 1 EXTENDED RELEASE 2 release 12 hour 24 HOUR 100 MG, 200 MG, 300 MG oxymorphone hcl oral QL 1 tramadol hcl er oral tablet QL capsule extended 1 pentazocine-naloxone QL 1 release 24 hour 150 mg hcl oral tablet tramadol hcl er oral PERCOCET ORAL QL QL 2 tablet extended release 1 TABLET 24 hour phrenilin forte oral tramadol hcl oral tablet 1 1 capsule 50-300-40 mg 100 mg PRIALT tramadol hcl oral tablet QL 1 INTRATHECAL 2 SP 50 mg SOLUTION tramadol- PRIMLEV ORAL QL QL 2 acetaminophen oral 1 TABLET tablet PROBUPHINE TREZIX ORAL QL IMPLANT KIT 2 2 CAPSULE SUBCUTANEOUS TYLENOL WITH IMPLANT QL CODEINE #3 ORAL 2 PROLATE ORAL QL 2 TABLET 300-30 MG TABLET TYLENOL WITH QDOLO ORAL QL 2 CODEINE #4 ORAL 2 SOLUTION TABLET 300-60 MG remifentanil hcl QL ULTIVA intravenous solution 1 INTRAVENOUS QL 2 reconstituted SOLUTION ROXICODONE ORAL QL RECONSTITUTED 2 TABLET ULTRACET ORAL QL 2 SUBSYS QL TABLET 2 SUBLINGUAL LIQUID ULTRAM ORAL QL 2 sufentanil citrate QL TABLET 1 intravenous solution VANATOL LQ ORAL 2 SYNAPRYN FUSEPAQ SOLUTION QL ORAL SUSPENSION 2 VANATOL S ORAL 2 RECONSTITUTED SOLUTION TENCON ORAL VTOL LQ ORAL 2 2 TABLET SOLUTION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 13 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits XTAMPZA ER ORAL DICLOFENAC ORAL 2 CAPSULE ER 12 QL CAPSULE 2 HOUR ABUSE- diclofenac potassium 1 DETERRENT oral tablet ZEBUTAL ORAL 2 diclofenac sodium er CAPSULE oral tablet extended 1 ZOHYDRO ER ORAL release 24 hour QL CAPSULE EXTENDED 2 diclofenac sodium 1 RELEASE 12 HOUR external gel 1 % Analgesics - Drugs diclofenac sodium 1 for Pain and external solution Inflammation diclofenac sodium oral 1 ACTIVE- tablet delayed release KETOPROFEN 2 EXTERNAL CREAM diclofenac-misoprostol oral tablet delayed 1 ACTIVE-PREP KIT I 2 release EXTERNAL CREAM DICLOFONO ACTIVE-PREP KIT II 2 2 EXTERNAL GEL EXTERNAL CREAM diflunisal oral tablet 1 ACTIVE-PREP KIT III 2 EXTERNAL CREAM DUAL COMPLEX FORMULA 1 KIT 2 AIF #2 DRUG EXTERNAL CREAM PREPARATION KIT 2 DUEXIS ORAL EXTERNAL CREAM 2 TABLET AIF #3 DRUG PREPARATION KIT 2 EC-NAPROSYN ORAL EXTERNAL CREAM TABLET DELAYED 2 RELEASE ARTHROTEC ORAL ec-naproxen oral tablet TABLET DELAYED 2 1 RELEASE delayed release CALDOLOR ENOVARX- DICLOFENAC INTRAVENOUS 2 2 SOLUTION SODIUM EXTERNAL CREAM CAMBIA ORAL 2 PACKET ENOVARX- IBUPROFEN 2 CELEBREX ORAL 2 EXTERNAL CREAM CAPSULE ENOVARX- celecoxib oral capsule 1 NAPROXEN 2 DAYPRO ORAL EXTERNAL CREAM 2 TABLET etodolac er oral tablet DICLOFENAC extended release 24 1 EPOLAMINE 2 hour EXTERNAL PATCH etodolac oral capsule 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 14 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits etodolac oral tablet 1 KETOPHENE FBL KIT EXTERNAL RAPIDPAQ 2 2 CREAM EXTERNAL CREAM FELDENE ORAL ketoprofen er oral 2 CAPSULE capsule extended 1 release 24 hour fenoprofen oral 1 capsule ketoprofen oral capsule 1 fenoprofen calcium oral KETOROLAC 1 tablet TROMETHAMINE 2 EXTERNAL GEL fenortho oral capsule 1 ketorolac tromethamine FLECTOR EXTERNAL 2 injection solution 15 1 PATCH mg/ml flurbiprofen oral tablet 1 KETOROLAC FROTEK EXTERNAL TROMETHAMINE 2 CREAM INJECTION 2 GABAPENTIN- SOLUTION NAPROXEN CMPD PREFILLED SYRINGE 2 KIT EXTERNAL 60 MG/20ML CREAM KETOROLAC ibuprofen lysine TROMETHAMINE 2 1 intravenous solution NASAL SOLUTION ibuprofen oral ketorolac tromethamine 1 1 suspension oral tablet ibuprofen oral tablet 1 KETOROLAC TROMETHAMINE INDOCIN ORAL 2 2 SOLUTION 30 MG/ML SUSPENSION INJECTION INDOCIN RECTAL 2 ketorolac tromethamine SUPPOSITORY solution 30 mg/ml 1 indomethacin er oral injection capsule extended 1 KETOROLAC release TROMETHAMINE INDOMETHACIN SOLUTION 60 2 ORAL CAPSULE 20 2 MG/2ML MG INTRAMUSCULAR indomethacin oral ketorolac tromethamine 1 capsule 25 mg, 50 mg solution 60 mg/2ml 1 indomethacin sodium intramuscular intravenous solution 1 klofensaid ii external 1 reconstituted solution 1.5 % K.B.G.L IN LICART EXTERNAL 2 TERODERM 2 PATCH 24 HOUR EXTERNAL CREAM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 15 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LIDOPROFEN NP #2 DRUG 2 EXTERNAL CREAM PREPARATION KIT 2 LODINE ORAL EXTERNAL CREAM 2 TABLET oxaprozin oral tablet 1 meclofenamate sodium PENNSAID 1 oral capsule EXTERNAL 2 mefenamic acid oral SOLUTION 1 capsule piroxicam oral capsule 1 meloxicam oral tablet 1 profeno oral tablet 600 1 MOBIC ORAL TABLET 2 mg nabumetone oral tablet 1 QMIIZ ODT ORAL TABLET 2 NALFON ORAL 2 DISPERSIBLE CAPSULE RELAFEN DS ORAL NALFON ORAL 2 2 TABLET TABLET RELAFEN ORAL 2 NAPRELAN ORAL TABLET TABLET EXTENDED 2 RELEASE 24 HOUR salsalate oral tablet 1 NAPRO EXTERNAL SPRIX NASAL 2 2 CREAM SOLUTION NAPROSYN ORAL sulindac oral tablet 1 2 SUSPENSION TIVORBEX ORAL 2 NAPROXEN CAPSULE COMFORT PAC tolmetin sodium oral 2 1 COMBINATION KIT capsule 500 MG tolmetin sodium oral 1 naproxen dr oral tablet tablet 1 delayed release TRIPLE COMPLEX naproxen oral FORMULA 3 KIT 2 1 suspension EXTERNAL CREAM naproxen oral tablet 1 VIMOVO ORAL naproxen sodium er TABLET DELAYED 2 oral tablet extended 1 RELEASE release 24 hour VIVLODEX ORAL 2 naproxen sodium oral CAPSULE 1 tablet 275 mg, 550 mg VOLTAREN 2 naproxen- EXTERNAL GEL esomeprazole oral 1 VOPAC GB 2 tablet delayed release EXTERNAL CREAM NEOPROFEN VOPAC KT 2 INTRAVENOUS 2 EXTERNAL CREAM SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 16 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VP FC KIT EXTERNAL BUPIVACAINE HCL- 2 CREAM NACL EPIDURAL VP GKL KIT SOLUTION 0.0625-0.9 2 2 EXTERNAL CREAM %, 0.1-0.9 %, 0.125-0.9 %, 0.15-0.9 %, 0.2-0.9 ZIPSOR ORAL 2 %, 0.25-0.9 % CAPSULE BUPIVACAINE HCL- ZORVOLEX ORAL 2 NACL EPIDURAL CAPSULE SOLUTION 2 Anesthetics PREFILLED SYRINGE ARTICADENT 0.1-0.9 %, 0.5-0.9 % DENTAL INJECTION BUPIVACAINE HCL- 2 SOLUTION NACL INJECTION CARTRIDGE SOLUTION 0.03-0.9 %, BUFFERED 0.0625-0.9 %, 0.1-0.9 2 LIDOCAINE %, 0.125-0.9 %, 0.2-0.9 INJECTION %, 0.25-0.9 %, 0.375- SOLUTION 2 0.9 %, 0.5-0.9 % PREFILLED SYRINGE BUPIVACAINE HCL- 0.5-8.4 %, 0.9-8.4 %, 1- NACL INJECTION 8.4 %, 1.8-8.4 % SOLUTION bupivacaine PREFILLED SYRINGE 0.0625-0.9 % (50 ML), fisiopharma injection 1 2 solution 0.1-0.9 % (50 ML), 0.125-0.9 % (50 ML), bupivacaine hcl (pf) 1 0.25-0.9 %, 0.25-0.9 % injection solution (20 ML), 0.25-0.9 % (30 bupivacaine hcl ML), 0.375-0.9 % injection solution 0.25 1 bupivacaine in dextrose 1 % intrathecal solution BUPIVACAINE HCL BUPIVACAINE IN INJECTION DEXTROSE SOLUTION SOLUTION 2 PREFILLED SYRINGE 2 PREFILLED SYRINGE 0.25 % (30 ML), 0.5 % 0.75-8.25 % (2 ML) (20 ML), 0.5 % (30 ML), bupivacaine spinal 0.5 % (60 ML) 1 intrathecal solution BUPIVACAINE HCL SOLUTION 0.5 % 2 bupivacaine- INJECTION epinephrine (pf) 1 injection solution bupivacaine hcl 1 solution 0.5 % injection bupivacaine- epinephrine injection 1 solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 17 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BUPIVACAINE- lidocaine external 1 EPINEPHRINE ointment INJECTION lidocaine external patch 2 1 SOLUTION 5 % PREFILLED SYRINGE 0.75% -1:400000 lidocaine hcl (cardiac) intravenous solution 1 CARBOCAINE prefilled syringe INJECTION 2 lidocaine hcl (cardiac) SOLUTION 1 pf intravenous solution CARBOCAINE PRESERVATIVE- lidocaine hcl (cardiac) 2 FREE INJECTION pf intravenous solution 1 SOLUTION prefilled syringe chloroprocaine hcl (pf) lidocaine hcl (pf) 1 1 injection solution injection solution CITANEST FORTE LIDOCAINE HCL EPIDURAL SOLUTION DENTAL INJECTION 2 2 SOLUTION PREFILLED SYRINGE 400 MG/20ML CITANEST PLAIN lidocaine hcl external DENTAL INJECTION 2 1 SOLUTION solution lidocaine hcl injection D-CARE 100X 1 INJECTION KIT 1 %- 2 solution 0.5 % 1:200000 LIDOCAINE HCL INJECTION ENOVARX- 2 LIDOCAINE HCL 2 SOLUTION EXTERNAL CREAM PREFILLED SYRINGE ethyl chloride external LIDOCAINE HCL 1 aerosol SOLUTION 1 % 2 INJECTION EXPAREL INJECTION 2 lidocaine hcl solution 1 SUSPENSION 1 % injection GEBAUERS PAIN EASE EXTERNAL 2 LIDOCAINE HCL AEROSOL SOLUTION 2 % 2 INJECTION GEBAUERS SPRAY lidocaine hcl solution 2 AND STRETCH 2 1 EXTERNAL AEROSOL % injection glydo external prefilled lidocaine hcl 1 syringe urethral/mucosal 1 external gel IV NOVICE PACK COMBINATION KIT 2 lidocaine hcl urethral/mucosal 2.5-2.5 & 0.9 % 1 external prefilled L.E.T. EXTERNAL GEL 2 syringe LETS KIT 2 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 18 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LIDOCAINE HCL- LIDO-EPINEPHRINE- SODIUM CHLORIDE TETRACAINE 2 2 INJECTION EXTERNAL SOLUTION 0.25-0.9 % SOLUTION LIDOCAINE HCL- LIDTOPIC MAX 2 SODIUM CHLORIDE EXTERNAL CREAM INJECTION MARCAINE SOLUTION INJECTION 2 PREFILLED SYRINGE 2 SOLUTION 0.5-0.9 % (1 ML), 1-0.9 %, 1-0.9 % (1 ML), 1- MARCAINE PRESERVATIVE 0.9 % (10 ML), 1-0.9 % 2 (3 ML) FREE INJECTION SOLUTION LIDOCAINE IN D5W INTRAVENOUS MARCAINE SPINAL SOLUTION 2-5 2 INTRATHECAL 2 MG/ML-%, 3-5 MG/ML- SOLUTION % MARCAINE/EPINEPH lidocaine in d5w RINE INJECTION 2 intravenous solution 4- SOLUTION 1 5 mg/ml-%, 8-5 mg/ml- MARCAINE/EPINEPH % RINE PF INJECTION 2 LIDOCAINE IN SOLUTION DEXTROSE 2 NAROPIN INJECTION 2 SOLUTION SOLUTION lidocaine pak external NESACAINE 1 ointment 5 % INJECTION 2 lidocaine-epinephrine SOLUTION 1 injection solution NESACAINE-MPF lidocaine-prilocaine INJECTION 2 1 external cream SOLUTION LIDOCAINE-SODIUM ORABLOC INJECTION BICARBONATE SOLUTION 2 INJECTION 2 CARTRIDGE SOLUTION PLIAGLIS EXTERNAL 2 PREFILLED SYRINGE CREAM LIDOCAINE- polocaine injection 1 TETRACAINE solution 2 EXTERNAL CREAM 7- polocaine-mpf injection 1 7 % solution LIDODERM PREPIV SUPPLY 2 2 EXTERNAL PATCH COMBINATION KIT ROPIVACAINE HCL EPIDURAL SOLUTION 2 0.5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 19 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ROPIVACAINE HCL sensorcaine-mpf EPIDURAL SOLUTION solution 0.25 % 1 2 PREFILLED SYRINGE injection 0.5 % SENSORCAINE-MPF ropivacaine hcl SOLUTION 0.25 % 2 injection solution 10 INJECTION 1 mg/ml, 2 mg/ml, 7.5 sensorcaine-mpf 1 mg/ml solution 0.5 % injection ROPIVACAINE HCL SENSORCAINE-MPF INJECTION 2 SOLUTION 0.5 % 2 SOLUTION INJECTION PREFILLED SYRINGE SENSORCAINE- ropivacaine hcl solution MPF/EPINEPHRINE 1 2 5 mg/ml injection INJECTION ROPIVACAINE HCL SOLUTION SOLUTION 5 MG/ML 2 SYNERA EXTERNAL 2 INJECTION PATCH ROPIVACAINE HCL- VENIPUNCTURE PX1 NACL EPIDURAL PHLEBOTOMY 2 SOLUTION 0.07-0.9 %, 2 EXTERNAL KIT 0.1-0.9 %, 0.125-0.9 %, xylocaine dental 0.2-0.9 %, 0.25-0.9 % 1 injection solution ROPIVACAINE HCL- NACL EPIDURAL XYLOCAINE SOLUTION 2 INJECTION 2 PREFILLED SYRINGE SOLUTION 0.2-0.9 % XYLOCAINE/EPINEPH ROPIVACAINE HCL- RINE INJECTION 2 NACL INJECTION 2 SOLUTION SOLUTION XYLOCAINE-MPF ROPIVACAINE HCL- INJECTION 2 NACL INJECTION SOLUTION SOLUTION 2 XYLOCAINE- PREFILLED SYRINGE MPF/EPINEPHRINE 2 0.1-0.9 %, 0.2-0.9 % INJECTION SENSORCAINE SOLUTION INJECTION 2 ZTLIDO EXTERNAL 2 SOLUTION PATCH SENSORCAINE/EPINE Anti-Addiction / PHRINE INJECTION 2 Substance Abuse SOLUTION Treatment Agents SENSORCAINE-MPF acamprosate calcium INJECTION 2 oral tablet delayed 1 SOLUTION 0.75 % release

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 20 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ANTABUSE ORAL naltrexone hcl oral 2 1 TABLET tablet BUNAVAIL BUCCAL NARCAN NASAL 2 2 FILM LIQUID buprenorphine hcl NICOTROL sublingual tablet 1 INHALATION 2 sublingual INHALER buprenorphine hcl- NICOTROL NS NASAL 2 naloxone hcl sublingual 1 SOLUTION film SUBLOCADE buprenorphine hcl- SUBCUTANEOUS 2 SP naloxone hcl sublingual 1 SOLUTION tablet sublingual PREFILLED SYRINGE bupropion hcl er SUBOXONE 2 (smoking det) oral SUBLINGUAL FILM 1 tablet extended release VIVITROL 12 hour INTRAMUSCULAR 2 SP CHANTIX SUSPENSION CONTINUING MONTH 2 RECONSTITUTED PAK ORAL TABLET ZUBSOLV 2 CHANTIX ORAL SUBLINGUAL TABLET 2 TABLET ZYBAN ORAL TABLET CHANTIX STARTING EXTENDED RELEASE 2 MONTH PAK ORAL 2 12 HOUR 150 MG TABLET Antibacterials disulfiram oral tablet 1 ACTICLATE ORAL 2 EVZIO INJECTION TABLET SOLUTION AUTO- 2 AEMCOLO ORAL INJECTOR 2 TABLET DELAYED 2 MG/0.4ML RELEASE LUCEMYRA ORAL ALTABAX EXTERNAL 2 2 TABLET OINTMENT naloxone hcl injection amikacin sulfate 1 1 solution injection solution NALOXONE HCL amoxicillin oral capsule 1 INJECTION SOLUTION AUTO- 2 amoxicillin oral INJECTOR 2 suspension 1 MG/0.4ML reconstituted naloxone hcl injection amoxicillin oral tablet 1 1 solution cartridge amoxicillin oral tablet 1 naloxone hcl injection chewable solution prefilled 1 syringe You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 21 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits amoxicillin-potassium AVYCAZ clavulanate er oral INTRAVENOUS 1 2 tablet extended release SOLUTION 12 hour RECONSTITUTED amoxicillin-potassium AZACTAM IN clavulanate oral DEXTROSE 1 suspension INTRAVENOUS 2 reconstituted SOLUTION 1 amoxicillin-potassium GM/50ML, 2 GM/50ML 1 clavulanate oral tablet AZACTAM INJECTION amoxicillin-potassium SOLUTION 2 clavulanate oral tablet 1 RECONSTITUTED chewable azithromycin ampicillin oral capsule 1 intravenous solution 1 reconstituted ampicillin sodium azithromycin oral injection solution 1 1 reconstituted packet ampicillin sodium azithromycin oral intravenous solution 1 suspension 1 reconstituted reconstituted ampicillin-sulbactam azithromycin oral tablet 1 sodium injection 1 aztreonam injection 1 solution reconstituted solution reconstituted ampicillin-sulbactam baciim intramuscular 1 sodium intravenous 1 solution reconstituted solution reconstituted bacitracin intramuscular 1 ARIKAYCE solution reconstituted INHALATION 2 SP BACTRIM DS ORAL 2 SUSPENSION TABLET AUGMENTIN ES-600 BACTRIM ORAL 2 ORAL SUSPENSION 2 TABLET RECONSTITUTED BACTROBAN AUGMENTIN ORAL EXTERNAL CREAM 2 2 SUSPENSION 2 % RECONSTITUTED BACTROBAN NASAL AUGMENTIN ORAL 2 NASAL OINTMENT 2 2 TABLET % AVELOX BAXDELA INTRAVENOUS INTRAVENOUS 2 2 SOLUTION 400 SOLUTION MG/250ML RECONSTITUTED AVELOX ORAL BAXDELA ORAL 2 2 TABLET 400 MG TABLET avidoxy oral tablet 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 22 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits benzalkonium chloride cefazolin sodium- 1 external solution dextrose intravenous 1 BICILLIN C-R 900/300 solution 1-4 gm/50ml- INTRAMUSCULAR 2 %, 2-4 gm/100ml-% SUSPENSION CEFAZOLIN SODIUM- BICILLIN C-R DEXTROSE INTRAMUSCULAR 2 INTRAVENOUS SUSPENSION SOLUTION 2-5 2 GM/100ML-%, 2-5 BICILLIN L-A GM/50ML-%, 3-5 INTRAMUSCULAR 2 GM/100ML-% SUSPENSION cefazolin sodium- cefaclor er oral tablet dextrose intravenous 1 extended release 12 1 solution reconstituted hour CEFAZOLIN SODIUM- cefaclor oral capsule 1 NACL INTRAVENOUS cefaclor oral SOLUTION 2 suspension 1 PREFILLED SYRINGE reconstituted 1-0.9 GM/10ML-% cefadroxil oral capsule 1 cefdinir oral capsule 1 cefadroxil oral cefdinir oral suspension 1 suspension 1 reconstituted reconstituted cefditoren pivoxil oral 1 cefadroxil oral tablet 1 tablet 200 mg, 400 mg CEFAZOLIN IN cefepime hcl injection 1 SODIUM CHLORIDE solution reconstituted 2 INTRAVENOUS cefepime hcl 1 SOLUTION intravenous solution CEFAZOLIN IN cefepime-dextrose SODIUM CHLORIDE intravenous solution 1 INTRAVENOUS 2 reconstituted SOLUTION PREFILLED SYRINGE cefixime oral capsule 1 2-0.9 GM/10ML-% cefixime oral cefazolin sodium suspension 1 injection solution 1 reconstituted reconstituted CEFOTAN INJECTION CEFAZOLIN SODIUM SOLUTION 2 INTRAVENOUS RECONSTITUTED 2 SOLUTION cefotaxime sodium PREFILLED SYRINGE injection solution 1 cefazolin sodium reconstituted intravenous solution 1 cefotetan disodium reconstituted injection solution 1 reconstituted

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 23 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits cefotetan disodium- cefuroxime sodium dextrose intravenous 1 injection solution 1 solution reconstituted reconstituted cefoxitin sodium cefuroxime sodium injection solution 1 intravenous solution 1 reconstituted reconstituted cefoxitin sodium CENTANY EXTERNAL 2 intravenous solution 1 OINTMENT reconstituted cephalexin oral capsule 1 CEFOXITIN SODIUM- cephalexin oral DEXTROSE suspension 1 INTRAVENOUS 2 reconstituted SOLUTION RECONSTITUTED cephalexin oral tablet 1 cefpodoxime proxetil chloramphenicol sod oral suspension 1 succinate intravenous 1 reconstituted solution reconstituted cefpodoxime proxetil CIPRO IN D5W 1 INTRAVENOUS oral tablet 2 SOLUTION 400 cefprozil oral MG/200ML suspension 1 reconstituted CIPRO ORAL SUSPENSION 2 cefprozil oral tablet 1 RECONSTITUTED ceftazidime and CIPRO ORAL TABLET 2 dextrose intravenous 1 ciprofloxacin hcl oral solution reconstituted 1 tablet ceftazidime injection 1 ciprofloxacin in d5w solution reconstituted 1 intravenous solution ceftriaxone sodium in dextrose intravenous 1 ciprofloxacin oral suspension solution 1 reconstituted 500 ceftriaxone sodium mg/5ml (10%) injection solution 1 reconstituted ciprofloxacin-ciproflox hcl er oral tablet 1 ceftriaxone sodium extended release 24 intravenous solution 1 hour 1000 mg, 500 mg reconstituted clarithromycin er oral ceftriaxone sodium- tablet extended release 1 dextrose intravenous 1 24 hour solution reconstituted clarithromycin oral cefuroxime axetil oral 1 suspension 1 tablet reconstituted

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 24 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits clarithromycin oral colistimethate sodium 1 tablet (cba) injection solution 1 CLEOCIN ORAL reconstituted 2 CAPSULE COLY-MYCIN M INJECTION CLEOCIN ORAL 2 SOLUTION 2 SOLUTION RECONSTITUTED RECONSTITUTED CLEOCIN coremino oral tablet PHOSPHATE extended release 24 1 2 INJECTION hour SOLUTION CUBICIN INTRAVENOUS CLEOCIN 2 PHOSPHATE SOLUTION INTRAVENOUS RECONSTITUTED 2 SOLUTION 300 CUBICIN RF MG/2ML, 600 MG/4ML, INTRAVENOUS 2 900 MG/6ML SOLUTION CLEOCIN VAGINAL RECONSTITUTED 2 CREAM DALVANCE CLEOCIN VAGINAL INTRAVENOUS 2 2 SUPPOSITORY SOLUTION RECONSTITUTED clindamycin hcl oral 1 daptomycin intravenous capsule 1 solution reconstituted clindamycin palmitate demeclocycline hcl oral hcl oral solution 1 1 reconstituted tablet dicloxacillin sodium oral clindamycin phosphate 1 in d5w intravenous 1 capsule solution DIFICID ORAL 2 CLINDAMYCIN TABLET PHOSPHATE IN NACL DORIPENEM 2 INTRAVENOUS INTRAVENOUS SOLUTION SOLUTION 2 clindamycin phosphate RECONSTITUTED 250 1 injection solution MG, 500 MG clindamycin phosphate DORYX MPC ORAL intravenous solution TABLET DELAYED 2 1 300 mg/2ml, 600 RELEASE mg/4ml, 900 mg/6ml DORYX ORAL clindamycin phosphate TABLET DELAYED 2 1 vaginal cream RELEASE CLINDESSE VAGINAL doxy 100 intravenous 2 1 CREAM solution reconstituted

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 25 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits doxycycline hyclate ERYTHROCIN intravenous solution 1 LACTOBIONATE reconstituted INTRAVENOUS 2 doxycycline hyclate oral SOLUTION 1 capsule RECONSTITUTED doxycycline hyclate oral ERYTHROCIN 1 tablet STEARATE ORAL 2 TABLET doxycycline hyclate oral tablet delayed release base oral 1 100 mg, 150 mg, 200 capsule delayed 1 mg, 50 mg, 75 mg release particles erythromycin base oral DOXYCYCLINE 1 HYCLATE ORAL tablet 2 TABLET DELAYED erythromycin base oral 1 RELEASE 80 MG tablet delayed release doxycycline erythromycin monohydrate oral 1 ethylsuccinate oral 1 capsule suspension doxycycline reconstituted monohydrate oral erythromycin 1 suspension ethylsuccinate oral 1 reconstituted tablet doxycycline erythromycin oral tablet 1 1 monohydrate oral tablet delayed release E.E.S. 400 ORAL FETROJA 2 TABLET INTRAVENOUS 2 E.E.S. GRANULES SOLUTION ORAL SUSPENSION 2 RECONSTITUTED RECONSTITUTED FIRST- METRONIDAZOLE ertapenem sodium 2 injection solution 1 ORAL SUSPENSION reconstituted RECONSTITUTED ERYPED 200 ORAL FIRST-VANCOMYCIN SUSPENSION 2 ORAL SOLUTION 25 2 RECONSTITUTED MG/ML, 50 MG/ML ERYPED 400 ORAL FIRVANQ ORAL SUSPENSION 2 SOLUTION 2 RECONSTITUTED RECONSTITUTED FLAGYL ORAL ERY-TAB ORAL 2 TABLET DELAYED 2 CAPSULE RELEASE FLAGYL ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 26 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FORTAZ INJECTION LINCOCIN INJECTION 2 SOLUTION 2 SOLUTION RECONSTITUTED lincomycin hcl injection 1 FORTAZ solution INTRAVENOUS 2 linezolid in sodium SOLUTION chloride intravenous 1 RECONSTITUTED solution fosfomycin linezolid intravenous 1 tromethamine oral 1 solution packet linezolid oral FURADANTIN ORAL suspension 1 SUSPENSION 25 2 reconstituted MG/5ML linezolid oral tablet 1 gentamicin in saline 1 intravenous solution lugols external solution 1 gentamicin sulfate MACROBID ORAL 1 2 external cream CAPSULE gentamicin sulfate MACRODANTIN ORAL 1 2 external ointment CAPSULE gentamicin sulfate mafenide acetate 1 1 injection solution external packet HIPREX ORAL MAXIPIME INJECTION 2 SOLUTION TABLET 2 RECONSTITUTED 1 hydrogen peroxide 1 GM, 2 GM solution MAXIPIME imipenem-cilastatin INTRAVENOUS intravenous solution 1 SOLUTION 2 reconstituted RECONSTITUTED 1 INVANZ INJECTION GM, 2 GM SOLUTION 2 meropenem RECONSTITUTED intravenous solution 1 KEFLEX ORAL reconstituted 2 CAPSULE MEROPENEM- LEVAQUIN ORAL SODIUM CHLORIDE TABLET 500 MG, 750 2 INTRAVENOUS 2 MG SOLUTION levofloxacin in d5w RECONSTITUTED 1 intravenous solution MERREM levofloxacin INTRAVENOUS 1 2 intravenous solution SOLUTION RECONSTITUTED levofloxacin oral 1 methenamine hippurate solution 1 oral tablet levofloxacin oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 27 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits METROGEL-VAGINAL moxifloxacin hcl in nacl 2 1 VAGINAL GEL 0.75 % intravenous solution METRONIDAZOLE MOXIFLOXACIN HCL BENZO+SYRSPEND INTRAVENOUS 2 2 ORAL SUSPENSION SOLUTION RECONSTITUTED moxifloxacin hcl oral 1 metronidazole in nacl tablet 1 intravenous solution mupirocin calcium 1 METRONIDAZOLE external cream INTRAVENOUS 2 mupirocin external 1 SOLUTION 5 MG/ML ointment metronidazole oral 1 NAFCILLIN SODIUM capsule IN DEXTROSE 2 metronidazole oral INTRAVENOUS 1 tablet SOLUTION metronidazole vaginal nafcillin sodium 1 gel injection solution 1 MINOCIN reconstituted 1 gm, 2 INTRAVENOUS gm 2 SOLUTION nafcillin sodium RECONSTITUTED intravenous solution 1 MINOCIN ORAL reconstituted 2 CAPSULE 50 MG neomycin sulfate oral 1 MINOCYCLINE HCL tablet ER ORAL CAPSULE neomycin-polymyxin b 2 1 EXTENDED RELEASE gu irrigation solution 24 HOUR nitrofurantoin minocycline hcl er oral macrocrystal oral 1 tablet extended release 1 capsule 24 hour nitrofurantoin minocycline hcl oral monohydrate 1 1 capsule macrocrystals oral minocycline hcl oral capsule 1 tablet nitrofurantoin oral 1 MINOLIRA ORAL suspension TABLET EXTENDED 2 NUVESSA VAGINAL 2 RELEASE 24 HOUR GEL mondoxyne nl oral NUZYRA 1 capsule INTRAVENOUS 2 MONUROL ORAL SOLUTION 2 PACKET RECONSTITUTED NUZYRA ORAL morgidox oral capsule 1 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 28 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ofloxacin oral tablet 1 piperacillin sod- okebo oral capsule 75 tazobactam so 1 1 mg intravenous solution reconstituted ORBACTIV INTRAVENOUS polymyxin b sulfate 2 SOLUTION injection solution 1 RECONSTITUTED reconstituted OXACILLIN SODIUM PRIMAXIN IV IN DEXTROSE INTRAVENOUS 2 2 INTRAVENOUS SOLUTION SOLUTION RECONSTITUTED PRIMSOL ORAL oxacillin sodium 2 injection solution 1 SOLUTION reconstituted RECARBRIO INTRAVENOUS oxacillin sodium 2 intravenous solution 1 SOLUTION reconstituted RECONSTITUTED paromomycin sulfate SEYSARA ORAL 1 2 oral capsule TABLET SILVADENE PENICILLIN G POT IN 2 DEXTROSE EXTERNAL CREAM 2 INTRAVENOUS silver nitrate external 1 SOLUTION ointment 10 % penicillin g potassium silver sulfadiazine 1 injection solution 1 external cream reconstituted SIVEXTRO penicillin g procaine INTRAVENOUS 2 intramuscular 1 SOLUTION suspension RECONSTITUTED penicillin g sodium SIVEXTRO ORAL 2 injection solution 1 TABLET reconstituted SOLODYN ORAL penicillin v potassium TABLET EXTENDED 2 oral solution 1 RELEASE 24 HOUR reconstituted SOLOSEC ORAL 2 penicillin v potassium PACKET 1 oral tablet ssd external cream 1 PFIZERPEN streptomycin sulfate INJECTION 2 intramuscular solution 1 SOLUTION reconstituted RECONSTITUTED sulfadiazine oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 29 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sulfamethoxazole- tobramycin sulfate 1 trimethoprim 1 injection solution intravenous solution tobramycin sulfate sulfamethoxazole- injection solution 1 trimethoprim oral 1 reconstituted suspension trimethoprim oral tablet 1 sulfamethoxazole- 1 TYGACIL trimethoprim oral tablet INTRAVENOUS 2 SULFAMYLON SOLUTION 2 EXTERNAL CREAM RECONSTITUTED SULFAMYLON UNASYN INJECTION 2 EXTERNAL PACKET SOLUTION 2 sulfatrim pediatric oral RECONSTITUTED 1 suspension UNASYN SUPRAX ORAL INTRAVENOUS 2 2 CAPSULE SOLUTION RECONSTITUTED SUPRAX ORAL SUSPENSION 2 VABOMERE INTRAVENOUS RECONSTITUTED 2 SOLUTION SUPRAX ORAL 2 RECONSTITUTED TABLET CHEWABLE VANCOCIN HCL ORAL 2 SYNERCID CAPSULE INTRAVENOUS 2 VANCOCIN ORAL SOLUTION 2 RECONSTITUTED CAPSULE TARGADOX ORAL VANCOMYCIN HCL IN 2 TABLET DEXTROSE INTRAVENOUS tazicef injection solution 1 SOLUTION 1-5 reconstituted GM/100ML-%, 1-5 TAZICEF GM/250ML-%, 1.25-5 2 INTRAVENOUS 2 GM/250ML-%, 1.5-5 SOLUTION GM/250ML-%, 1.5-5 tazicef intravenous GM/300ML-%, 1.5-5 1 solution reconstituted GM/500ML-%, 1.75-5 GM/500ML-%, 2-5 TEFLARO GM/500ML-% INTRAVENOUS 2 SOLUTION vancomycin hcl in dextrose intravenous RECONSTITUTED 1 solution 1-5 gm/200ml- tetracycline hcl oral 1 %, 500-5 mg/100ml-% capsule vancomycin hcl in tigecycline intravenous dextrose solution 750-5 1 1 solution reconstituted mg/150ml-% tinidazole oral tablet 1 intravenous

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 30 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VANCOMYCIN HCL IN vancomycin hcl DEXTROSE intravenous solution SOLUTION 750-5 2 1000 mg/200ml, 1250 MG/150ML-% mg/250ml, 1500 INTRAVENOUS mg/300ml, 1750 1 VANCOMYCIN HCL IN mg/350ml, 2000 NACL INTRAVENOUS mg/400ml, 500 SOLUTION 1-0.9 mg/100ml, 750 GM/150ML-%, 1-0.9 mg/150ml GM/250ML-%, 1.25-0.9 vancomycin hcl GM/150ML-%, 1.25-0.9 intravenous solution 1 GM/250ML-%, 1.5-0.9 reconstituted GM/150ML-%, 1.5-0.9 vancomycin hcl oral GM/250ML-%, 1.5-0.9 1 2 capsule GM/300ML-%, 1.5-0.9 vancomycin hcl oral GM/500ML-%, 1.75-0.9 1 GM/250ML-%, 1.75-0.9 solution reconstituted GM/300ML-%, 1.75-0.9 VANCOMYCIN+SYRS GM/500ML-%, 2-0.9 PEND SF ORAL 2 GM/250ML-%, 2-0.9 SUSPENSION GM/500ML-%, 2.5-0.9 vandazole vaginal gel 1 GM/500ML-%, 750-0.9 MG/250ML-% VIBATIV INTRAVENOUS 2 vancomycin hcl in nacl SOLUTION intravenous solution 1- 1 RECONSTITUTED 0.9 gm/200ml-%, 500- VIBRAMYCIN ORAL 0.9 mg/100ml-% 2 CAPSULE VANCOMYCIN HCL IN NACL SOLUTION 750- VIBRAMYCIN ORAL 2 0.9 MG/150ML-% SUSPENSION 2 INTRAVENOUS RECONSTITUTED VIBRAMYCIN ORAL vancomycin hcl in nacl 2 solution 750-0.9 SYRUP 1 mg/150ml-% XENLETA intravenous INTRAVENOUS 2 VANCOMYCIN HCL SOLUTION INTRAVENOUS XENLETA ORAL 2 SOLUTION 1000 TABLET MG/10ML, 1250 XEPI EXTERNAL 2 MG/12.5ML, 1500 2 CREAM MG/15ML, 1750 MG/17.5ML, 2000 XERAVA INTRAVENOUS MG/20ML, 750 2 MG/7.5ML SOLUTION RECONSTITUTED XIFAXAN ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 31 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits XIMINO ORAL Anticoagulants CAPSULE EXTENDED 2 acd formula a in vitro 1 RELEASE 24 HOUR solution ZEMDRI ACD-A NOCLOT-50 IN 2 INTRAVENOUS 2 VITRO SOLUTION SOLUTION ANGIOMAX ZERBAXA INTRAVENOUS INTRAVENOUS 2 2 SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED cit dext 1 ZITHROMAX soln a in vitro solution INTRAVENOUS 2 anticoagulant sodium SOLUTION 1 RECONSTITUTED citrate in vitro solution ZITHROMAX ORAL intravenous 2 1 PACKET solution ZITHROMAX ORAL ARIXTRA SUSPENSION 2 SUBCUTANEOUS 2 SP RECONSTITUTED SOLUTION ZITHROMAX ORAL BEVYXXA ORAL 2 TABLET CAPSULE 40 MG, 80 2 MG ZITHROMAX TRI-PAK 2 ORAL TABLET trifluoroacetate ZITHROMAX Z-PAK 1 2 intravenous solution ORAL TABLET reconstituted ZOSYN COUMADIN ORAL INTRAVENOUS 2 TABLET 1 MG, 10 MG, SOLUTION 2 MG, 2.5 MG, 3 MG, 4 2 ZOSYN MG, 5 MG, 6 MG, 7.5 INTRAVENOUS MG SOLUTION ELIQUIS DVT/PE RECONSTITUTED STARTER PACK 2 2 2.25 (2-0.25) GM, ORAL TABLET 3.375 (3-0.375) GM, THERAPY PACK 4.5 (4-0.5) GM, 40.5 ELIQUIS ORAL (36-4.5) GM 2 TABLET ZYVOX INTRAVENOUS 2 1 SP SOLUTION injection solution enoxaparin sodium ZYVOX ORAL 1 SP SUSPENSION 2 subcutaneous solution RECONSTITUTED sodium 1 SP ZYVOX ORAL TABLET 2 subcutaneous solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 32 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FRAGMIN sod (porcine) in SUBCUTANEOUS 2 SP d5w solution 100 1 SOLUTION unit/ml intravenous HEPARIN (PORCINE) HEPARIN SOD IN NACL (PORCINE) IN D5W 2 INTRAVENOUS SOLUTION 100 2 SOLUTION UNIT/ML heparin (porcine) in INTRAVENOUS nacl intravenous 1 heparin sod (porcine) in solution d5w solution 40-5 1 HEPARIN (PORCINE) unit/ml-% intravenous IN NACL HEPARIN SOD INTRAVENOUS 2 (PORCINE) IN D5W SOLUTION SOLUTION 40-5 2 PREFILLED SYRINGE UNIT/ML-% heparin (porcine) in INTRAVENOUS nacl solution 1000-0.9 1 HEPARIN SOD ut/500ml-% intravenous (PORCINE)-D10 HEPARIN (PORCINE) INTRAVENOUS 2 IN NACL SOLUTION SOLUTION 2 1000-0.9 UT/500ML-% PREFILLED SYRINGE INTRAVENOUS heparin sodium heparin (porcine) in (porcine) injection 1 nacl solution 2000-0.9 1 solution unit/l-% intravenous heparin sodium (porcine) injection HEPARIN (PORCINE) 1 IN NACL SOLUTION solution prefilled 2 2000-0.9 UNIT/L-% syringe INTRAVENOUS HEPARIN SODIUM heparin (porcine) in (PORCINE) nacl solution 25000- INTRAVENOUS 2 1 0.45 ut/500ml-% SOLUTION intravenous PREFILLED SYRINGE HEPARIN (PORCINE) heparin sodium IN NACL SOLUTION (porcine) pf injection 1 2 25000-0.45 UT/500ML- solution % INTRAVENOUS jantoven oral tablet 1 HEPARIN SOD LOVENOX INJECTION 2 SP (PORCINE) IN D5W SOLUTION 2 INTRAVENOUS LOVENOX SOLUTION SUBCUTANEOUS 2 SP heparin sod (porcine) in SOLUTION d5w intravenous 1 PRADAXA ORAL 2 solution CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 33 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits RETAVASE HALF-KIT BRIVIACT 2 INTRAVENOUS KIT INTRAVENOUS 2 RETAVASE SOLUTION 2 INTRAVENOUS KIT BRIVIACT ORAL 2 SAVAYSA ORAL SOLUTION 2 TABLET BRIVIACT ORAL 2 SODIUM CITRATE IN TABLET VITRO SOLUTION 2 carbamazepine er oral PREFILLED SYRINGE capsule extended 1 SODIUM CITRATE release 12 hour INTRAVENOUS carbamazepine er oral SOLUTION 2 tablet extended release 1 PREFILLED SYRINGE 12 hour 4 % carbamazepine oral 1 SODIUM CITRATE suspension LOCK FLUSH carbamazepine oral 1 INTRAVENOUS 2 tablet SOLUTION carbamazepine oral PREFILLED SYRINGE 1 tablet chewable THROMBATE III INTRAVENOUS CARBATROL ORAL 2 SP SOLUTION CAPSULE EXTENDED 2 RECONSTITUTED RELEASE 12 HOUR TNKASE CELONTIN ORAL 2 2 INTRAVENOUS KIT CAPSULE CEREBYX INJECTION TRICITRASOL IN 2 VITRO 2 SOLUTION CONCENTRATE clobazam oral 1 sodium oral suspension 1 tablet clobazam oral tablet 1 XARELTO ORAL DEPACON 2 TABLET INTRAVENOUS 2 XARELTO STARTER SOLUTION 100 PACK ORAL TABLET 2 MG/ML THERAPY PACK DEPAKENE ORAL 2 Anticonvulsants - CAPSULE 250 MG Drugs for Seizures DEPAKENE ORAL APTIOM ORAL SOLUTION 250 2 2 TABLET MG/5ML BANZEL ORAL DEPAKOTE ER ORAL 2 SUSPENSION TABLET EXTENDED 2 RELEASE 24 HOUR BANZEL ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 34 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits DEPAKOTE ORAL felbamate oral tablet 1 TABLET DELAYED 2 FELBATOL ORAL 2 RELEASE SUSPENSION DEPAKOTE FELBATOL ORAL SPRINKLES ORAL 2 2 TABLET CAPSULE DELAYED FINTEPLA ORAL RELEASE SPRINKLE 2 SP SOLUTION DIACOMIT ORAL 2 SP fosphenytoin sodium CAPSULE 1 injection solution DIACOMIT ORAL 2 SP FYCOMPA ORAL PACKET 2 SUSPENSION DIASTAT ACUDIAL 2 FYCOMPA ORAL RECTAL GEL 2 TABLET DIASTAT PEDIATRIC 2 gabapentin oral RECTAL GEL 1 capsule diazepam rectal gel 1 gabapentin oral 1 DILANTIN INFATABS solution ORAL TABLET 2 CHEWABLE gabapentin oral tablet 1 DILANTIN ORAL GABITRIL ORAL 2 2 CAPSULE TABLET DILANTIN ORAL KEPPRA 2 SUSPENSION INTRAVENOUS 2 SOLUTION divalproex sodium er KEPPRA ORAL oral tablet extended 1 2 release 24 hour SOLUTION KEPPRA ORAL divalproex sodium oral 2 capsule delayed 1 TABLET release sprinkle KEPPRA XR ORAL divalproex sodium oral TABLET EXTENDED 2 1 tablet delayed release RELEASE 24 HOUR EPIDIOLEX ORAL LAMICTAL ODT ORAL 2 SP 2 SOLUTION KIT epitol oral tablet 1 LAMICTAL ODT ORAL TABLET 2 ethosuximide oral 1 DISPERSIBLE capsule LAMICTAL ORAL ethosuximide oral 2 1 TABLET solution LAMICTAL ORAL FANATREX FUSEPAQ 2 2 TABLET CHEWABLE ORAL SUSPENSION LAMICTAL STARTER felbamate oral 2 1 ORAL KIT suspension

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 35 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LAMICTAL XR ORAL NEURONTIN ORAL 2 2 KIT TABLET LAMICTAL XR ORAL ONFI ORAL 2 TABLET EXTENDED 2 SUSPENSION RELEASE 24 HOUR ONFI ORAL TABLET 2 lamotrigine er oral oxcarbazepine oral 1 tablet extended release 1 suspension 24 hour oxcarbazepine oral 1 lamotrigine oral kit 1 tablet lamotrigine oral tablet 1 OXTELLAR XR ORAL lamotrigine oral tablet TABLET EXTENDED 2 1 chewable RELEASE 24 HOUR lamotrigine oral tablet PEGANONE ORAL 1 2 dispersible TABLET lamotrigine starter kit- pentobarbital sodium 1 1 blue oral kit injection solution lamotrigine starter kit- phenobarbital oral elixir 1 1 green oral kit phenobarbital oral 1 lamotrigine starter kit- solution 20 mg/5ml 1 orange oral kit phenobarbital oral 1 levetiracetam er oral tablet tablet extended release 1 phenobarbital sodium 1 24 hour injection solution levetiracetam in nacl PHENYTEK ORAL 1 2 intravenous solution CAPSULE levetiracetam phenytoin infatabs oral 1 1 intravenous solution tablet chewable levetiracetam oral phenytoin oral 1 1 solution suspension levetiracetam oral phenytoin oral tablet 1 1 tablet chewable MYSOLINE ORAL phenytoin sodium 2 1 TABLET extended oral capsule NAYZILAM NASAL phenytoin sodium 2 1 SOLUTION injection solution NEMBUTAL primidone oral tablet 1 INJECTION 2 SOLUTION QUDEXY XR ORAL CAPSULE ER 24 2 NEURONTIN ORAL 2 HOUR SPRINKLE CAPSULE roweepra oral tablet 1 NEURONTIN ORAL 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 36 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits roweepra xr oral tablet TRILEPTAL ORAL 2 extended release 24 1 TABLET hour TROKENDI XR ORAL SABRIL ORAL CAPSULE EXTENDED 2 2 SP PACKET RELEASE 24 HOUR SABRIL ORAL valproate sodium 2 SP 1 TABLET intravenous solution SPRITAM ORAL valproic acid oral 1 TABLET capsule 2 DISINTEGRATING valproic acid oral 1 SOLUBLE solution subvenite oral tablet 1 VALTOCO 10 MG 2 subvenite starter kit- DOSE NASAL LIQUID 1 blue oral kit VALTOCO 15 MG subvenite starter kit- DOSE NASAL LIQUID 2 1 green oral kit THERAPY PACK subvenite starter kit- VALTOCO 20 MG 1 orange oral kit DOSE NASAL LIQUID 2 SYMPAZAN ORAL THERAPY PACK 2 FILM VALTOCO 5 MG 2 TEGRETOL ORAL DOSE NASAL LIQUID 2 SUSPENSION vigabatrin oral packet 1 SP TEGRETOL ORAL vigabatrin oral tablet 1 SP 2 TABLET vigadrone oral packet 1 SP TEGRETOL-XR ORAL VIMPAT TABLET EXTENDED 2 INTRAVENOUS 2 RELEASE 12 HOUR SOLUTION tiagabine hcl oral tablet 1 VIMPAT ORAL 2 TOPAMAX ORAL SOLUTION 2 TABLET VIMPAT ORAL 2 TOPAMAX SPRINKLE TABLET ORAL CAPSULE 2 XCOPRI (250 MG SPRINKLE DAILY DOSE) ORAL 2 topiramate er oral TABLET THERAPY capsule er 24 hour 1 PACK sprinkle XCOPRI (350 MG topiramate oral capsule DAILY DOSE) ORAL 1 2 sprinkle TABLET THERAPY topiramate oral tablet 1 PACK TRILEPTAL ORAL XCOPRI ORAL 2 2 SUSPENSION TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 37 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits XCOPRI ORAL NAMENDA TITRATION 2 TABLET THERAPY 2 PAK ORAL TABLET PACK NAMENDA XR ORAL ZARONTIN ORAL CAPSULE EXTENDED 2 2 CAPSULE RELEASE 24 HOUR ZARONTIN ORAL NAMENDA XR 2 SOLUTION TITRATION PACK ZONEGRAN ORAL ORAL CAPSULE 2 2 CAPSULE EXTENDED RELEASE 24 HOUR zonisamide oral 1 capsule NAMZARIC ORAL CAPSULE ER 24 2 Antidementia Agents HOUR THERAPY - Drugs for PACK Alzheimer's Disease and Dementia NAMZARIC ORAL CAPSULE EXTENDED 2 ARICEPT ORAL 2 RELEASE 24 HOUR TABLET RAZADYNE ER ORAL donepezil hcl oral tablet 1 CAPSULE EXTENDED 2 donepezil hcl oral tablet RELEASE 24 HOUR 1 dispersible RAZADYNE ORAL EXELON TABLET 12 MG, 4 MG, 2 TRANSDERMAL 2 8 MG PATCH 24 HOUR rivastigmine tartrate 1 galantamine oral capsule hydrobromide er oral 1 rivastigmine capsule extended transdermal patch 24 1 release 24 hour hour galantamine Antidepressants hydrobromide oral 1 amitriptyline hcl oral solution 1 tablet galantamine hydrobromide oral 1 amoxapine oral tablet 1 tablet ANAFRANIL ORAL 2 memantine hcl er oral CAPSULE capsule extended 1 APLENZIN ORAL release 24 hour TABLET EXTENDED 2 memantine hcl oral RELEASE 24 HOUR 1 solution BRISDELLE ORAL 2 memantine hcl oral CAPSULE 1 tablet bupropion hcl er (sr) NAMENDA ORAL oral tablet extended 1 2 TABLET release 12 hour

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 38 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits bupropion hcl er (xl) duloxetine hcl oral oral tablet extended capsule delayed 1 1 release 24 hour 150 release particles mg, 300 mg EFFEXOR XR ORAL BUPROPION HCL ER CAPSULE EXTENDED 2 (XL) ORAL TABLET RELEASE 24 HOUR 2 EXTENDED RELEASE EMSAM 24 HOUR 450 MG TRANSDERMAL 2 bupropion hcl oral PATCH 24 HOUR 1 tablet escitalopram 1 CELEXA ORAL oral solution 2 TABLET escitalopram oxalate 1 chlordiazepoxide- oral tablet 1 amitriptyline oral tablet FETZIMA ORAL citalopram CAPSULE EXTENDED 2 hydrobromide oral 1 RELEASE 24 HOUR solution FETZIMA TITRATION citalopram ORAL CAPSULE ER 2 hydrobromide oral 1 24 HOUR THERAPY tablet PACK clomipramine hcl oral fluoxetine hcl (pmdd) 1 capsule oral capsule 10 mg, 20 1 CYMBALTA ORAL mg CAPSULE DELAYED 2 fluoxetine hcl (pmdd) 1 RELEASE PARTICLES oral tablet desipramine hcl oral fluoxetine hcl oral 1 1 tablet capsule DESVENLAFAXINE fluoxetine hcl oral ER ORAL TABLET capsule delayed 1 2 EXTENDED RELEASE release 24 HOUR fluoxetine hcl oral 1 desvenlafaxine solution succinate er oral tablet 1 fluoxetine hcl oral tablet 1 extended release 24 hour fluvoxamine maleate er oral capsule extended 1 doxepin hcl oral 1 release 24 hour capsule fluvoxamine maleate doxepin hcl oral 1 1 oral tablet concentrate FORFIVO XL ORAL DRIZALMA SPRINKLE TABLET EXTENDED 2 ORAL CAPSULE 2 RELEASE 24 HOUR DELAYED RELEASE imipramine hcl oral SPRINKLE 1 tablet

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 39 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits imipramine pamoate PAXIL ORAL 1 2 oral capsule SUSPENSION KHEDEZLA ORAL PAXIL ORAL TABLET 2 TABLET EXTENDED perphenazine- 2 1 RELEASE 24 HOUR amitriptyline oral tablet 100 MG, 50 MG PEXEVA ORAL LEXAPRO ORAL 2 2 TABLET TABLET phenelzine sulfate oral maprotiline hcl oral 1 1 tablet tablet PRISTIQ ORAL MARPLAN ORAL 2 TABLET EXTENDED 2 TABLET RELEASE 24 HOUR mirtazapine oral tablet 1 protriptyline hcl oral 1 mirtazapine oral tablet tablet 1 dispersible PROZAC ORAL 2 NARDIL ORAL CAPSULE 2 TABLET REMERON ORAL 2 nefazodone hcl oral TABLET 1 tablet REMERON SOLTAB NORPRAMIN ORAL ORAL TABLET 2 2 TABLET DISPERSIBLE nortriptyline hcl oral SARAFEM ORAL 1 2 capsule TABLET nortriptyline hcl oral sertraline hcl oral 1 1 solution concentrate olanzapine-fluoxetine sertraline hcl oral tablet 1 1 hcl oral capsule SPRAVATO (56 MG PAMELOR ORAL DOSE) NASAL 2 2 SP CAPSULE SOLUTION THERAPY PARNATE ORAL PACK 2 TABLET SPRAVATO (84 MG DOSE) NASAL paroxetine hcl er oral 2 SP tablet extended release 1 SOLUTION THERAPY 24 hour PACK paroxetine hcl oral SURMONTIL ORAL 1 tablet CAPSULE 100 MG, 25 2 MG, 50 MG paroxetine mesylate 1 SYMBYAX ORAL oral capsule 2 CAPSULE PAXIL CR ORAL TABLET EXTENDED 2 TOFRANIL ORAL RELEASE 24 HOUR TABLET 10 MG, 25 2 MG, 50 MG

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 40 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits tranylcypromine sulfate AKYNZEO 1 oral tablet INTRAVENOUS 2 trazodone hcl oral SOLUTION 1 tablet RECONSTITUTED trimipramine maleate AKYNZEO ORAL 1 2 oral capsule CAPSULE TRINTELLIX ORAL ALOXI INTRAVENOUS 2 2 TABLET SOLUTION ANZEMET ORAL venlafaxine hcl er oral 2 capsule extended 1 TABLET release 24 hour aprepitant oral capsule 1 venlafaxine hcl er oral BARHEMSYS tablet extended release 1 INTRAVENOUS 2 24 hour SOLUTION venlafaxine hcl oral BONJESTA ORAL 1 tablet TABLET EXTENDED 2 VIIBRYD ORAL RELEASE 2 TABLET CESAMET ORAL 2 VIIBRYD STARTER CAPSULE 1 MG 2 PACK ORAL KIT CINVANTI WELLBUTRIN SR INTRAVENOUS 2 ORAL TABLET EMULSION 2 EXTENDED RELEASE compro rectal 1 12 HOUR suppository WELLBUTRIN XL DICLEGIS ORAL ORAL TABLET TABLET DELAYED 2 2 EXTENDED RELEASE RELEASE 24 HOUR dimenhydrinate 1 ZOLOFT ORAL injection solution 2 CONCENTRATE doxylamine-pyridoxine ZOLOFT ORAL oral tablet delayed 1 2 TABLET release ZULRESSO dronabinol oral capsule 1 INTRAVENOUS 2 SP droperidol injection 1 SOLUTION solution Antiemetics - Drugs EMEND for Nausea and INTRAVENOUS 2 Vomiting SOLUTION AKYNZEO RECONSTITUTED INTRAVENOUS 2 EMEND ORAL 2 SOLUTION CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 41 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits EMEND ORAL ONDANSETRON HCL- SUSPENSION 2 DEXTROSE RECONSTITUTED INTRAVENOUS 2 EMEND TRI-PACK SOLUTION 8-5 2 ORAL CAPSULE MG/50ML-% fosaprepitant ONDANSETRON HCL- dimeglumine NACL INTRAVENOUS 1 intravenous solution SOLUTION 12-0.9 reconstituted MG/50ML-%, 16-0.9 2 MG/50ML-%, 4-0.9 GIMOTI NASAL 2 MG/50ML-%, 8-0.9 SOLUTION MG/50ML-% granisetron hcl ondansetron odt oral 1 1 intravenous solution tablet dispersible granisetron hcl oral palonosetron hcl 1 1 tablet intravenous solution MARINOL ORAL 2 palonosetron hcl CAPSULE intravenous solution 1 meclizine hcl oral tablet prefilled syringe 1 12.5 mg, 25 mg perphenazine oral 1 metoclopramide hcl tablet 1 injection solution prochlorperazine metoclopramide hcl edisylate injection 1 1 oral solution solution metoclopramide hcl prochlorperazine 1 1 oral tablet maleate oral tablet metoclopramide hcl prochlorperazine rectal 1 1 oral tablet dispersible suppository ondansetron hcl REGLAN ORAL 2 injection solution 40 1 TABLET mg/20ml SANCUSO ondansetron hcl oral TRANSDERMAL 2 1 solution PATCH ondansetron hcl oral scopolamine 1 tablet transdermal patch 72 1 ONDANSETRON HCL hour SOLUTION 4 MG/2ML 2 SUSTOL INJECTION SUBCUTANEOUS 2 ondansetron hcl PREFILLED SYRINGE solution 4 mg/2ml 1 SYNDROS ORAL 2 injection SOLUTION TIGAN INTRAMUSCULAR 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 42 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits TIGAN ORAL CANCIDAS 2 CAPSULE INTRAVENOUS 2 TRANSDERM SCOP SOLUTION (1.5 MG) RECONSTITUTED 2 TRANSDERMAL caspofungin acetate PATCH 72 HOUR intravenous solution 1 TRANSDERM-SCOP reconstituted (1.5 MG) ciclodan external 2 1 TRANSDERMAL solution PATCH 72 HOUR CICLODAN SOLUTION 2 trimethobenzamide hcl EXTERNAL KIT 8 % 1 oral capsule ciclopirox external gel 1 VARUBI (180 MG ciclopirox external 1 DOSE) ORAL TABLET 2 shampoo THERAPY PACK ciclopirox external ZOFRAN ORAL 1 2 solution SOLUTION 4 MG/5ML ciclopirox olamine ZOFRAN ORAL 1 2 external cream TABLET ciclopirox olamine 1 ZUPLENZ ORAL FILM 2 external suspension Antifungals CICLOPIROX 2 ABELCET OLAMINE POWDER INTRAVENOUS 2 clotrimazole external 1 SUSPENSION cream ACTIVE-PREP KIT V clotrimazole external 2 1 EXTERNAL CREAM solution AMBISOME clotrimazole INTRAVENOUS 1 2 mouth/throat troche SUSPENSION CLOTRIMAZOLE RECONSTITUTED 2 POWDER amphotericin b intravenous solution 1 clotrimazole- reconstituted betamethasone 1 external cream ANCOBON ORAL 2 CAPSULE clotrimazole- betamethasone 1 AVC VAGINAL external lotion VAGINAL CREAM 15 2 % CRESEMBA INTRAVENOUS BIO-STATIN ORAL 2 2 SOLUTION CAPSULE RECONSTITUTED CRESEMBA ORAL 2 CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 43 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits DIFLUCAN ORAL oral 1 SUSPENSION 2 solution RECONSTITUTED JUBLIA EXTERNAL 2 DIFLUCAN ORAL SOLUTION 2 TABLET KERYDIN EXTERNAL 2 econazole nitrate SOLUTION 1 external cream external 1 ECOZA EXTERNAL cream 2 FOAM ketoconazole external 1 ERAXIS foam INTRAVENOUS ketoconazole external 2 1 SOLUTION shampoo RECONSTITUTED ketoconazole oral tablet 1 ERTACZO EXTERNAL 2 CREAM ketodan external foam 1 EXELDERM LOPROX EXTERNAL 2 2 EXTERNAL CREAM CREAM LOPROX EXTERNAL EXELDERM 2 EXTERNAL 2 SHAMPOO SOLUTION LOPROX EXTERNAL 2 EXODERM SUSPENSION 2 EXTERNAL LOTION LOTRISONE EXTINA EXTERNAL EXTERNAL CREAM 1- 2 2 FOAM 0.05 % LULICONAZOLE fluconazole in sodium 2 chloride intravenous 1 EXTERNAL CREAM solution LUZU EXTERNAL 2 fluconazole oral CREAM suspension 1 MENTAX EXTERNAL 2 reconstituted CREAM fluconazole oral tablet 1 micafungin sodium flucytosine oral capsule 1 intravenous solution 1 reconstituted griseofulvin microsize 1 miconazole 3 vaginal oral suspension 1 suppository griseofulvin microsize 1 oral tablet MICONAZOLE- OXIDE-PETROLAT 2 griseofulvin EXTERNAL ultramicrosize oral 1 OINTMENT tablet MYCAMINE GYNAZOLE-1 INTRAVENOUS 2 2 VAGINAL CREAM SOLUTION itraconazole oral RECONSTITUTED 1 capsule You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 44 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits naftifine hcl external posaconazole oral 1 1 cream tablet delayed release naftifine hcl external gel 1 SPORANOX ORAL 2 NAFTIN EXTERNAL CAPSULE 2 CREAM SPORANOX ORAL 2 NAFTIN EXTERNAL SOLUTION 2 GEL SPORANOX NIZORAL EXTERNAL PULSEPAK ORAL 2 2 SHAMPOO 2 % CAPSULE NOXAFIL SULCONAZOLE INTRAVENOUS 2 NITRATE EXTERNAL 2 SOLUTION CREAM NOXAFIL ORAL SULCONAZOLE 2 SUSPENSION NITRATE EXTERNAL 2 SOLUTION NOXAFIL ORAL tavaborole external TABLET DELAYED 2 1 RELEASE solution nyamyc external terbinafine hcl oral 1 1 powder tablet terconazole vaginal nystatin external cream 1 1 cream nystatin external 1 terconazole vaginal ointment 1 suppository nystatin external 1 TOLNAFTATE powder 2 POWDER nystatin mouth/throat 1 TOLSURA ORAL suspension 2 CAPSULE nystatin oral tablet 1 VFEND IV nystatin-triamcinolone INTRAVENOUS 1 2 external cream SOLUTION nystatin-triamcinolone RECONSTITUTED 1 external ointment VFEND ORAL nystop external powder 1 SUSPENSION 2 ORAVIG BUCCAL RECONSTITUTED 2 TABLET VFEND ORAL TABLET 2 oxiconazole nitrate voriconazole 1 external cream intravenous solution 1 OXISTAT EXTERNAL reconstituted 2 CREAM voriconazole oral OXISTAT EXTERNAL suspension 1 2 LOTION reconstituted PENLAC EXTERNAL voriconazole oral tablet 1 2 SOLUTION 8 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 45 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VUSION EXTERNAL EMFLAZA ORAL 2 2 SP OINTMENT TABLET XOLEGEL EXTERNAL Antimigraine Agents 2 GEL AIMOVIG Antigout Agents SUBCUTANEOUS oral tablet 1 SOLUTION AUTO- 2 INJECTOR 140 allopurinol sodium MG/ML, 70 MG/ML intravenous solution 1 reconstituted AJOVY SUBCUTANEOUS 2 ALOPRIM SOLUTION AUTO- INTRAVENOUS 2 INJECTOR SOLUTION RECONSTITUTED AJOVY SUBCUTANEOUS COLCHICINE ORAL 2 2 SOLUTION CAPSULE PREFILLED SYRINGE colchicine oral tablet 1 almotriptan malate oral 1 colchicine-probenecid tablet 1 oral tablet AMERGE ORAL 2 COLCRYS ORAL TABLET 2 TABLET CAFERGOT ORAL 2 DUZALLO ORAL TABLET TABLET 200-200 MG, 2 D.H.E. 45 INJECTION 2 200-300 MG SOLUTION oral tablet 1 dihydroergotamine GLOPERBA ORAL mesylate injection 1 2 SOLUTION solution KRYSTEXXA dihydroergotamine 1 INTRAVENOUS 2 SP mesylate nasal solution SOLUTION eletriptan hydrobromide 1 MITIGARE ORAL oral tablet 2 CAPSULE EMGALITY (300 MG probenecid oral tablet 1 DOSE) ULORIC ORAL SUBCUTANEOUS 2 2 TABLET SOLUTION PREFILLED SYRINGE ZURAMPIC ORAL 2 TABLET 200 MG EMGALITY SUBCUTANEOUS ZYLOPRIM ORAL 2 2 SOLUTION AUTO- TABLET INJECTOR Anti-inflammatory EMGALITY Agents SUBCUTANEOUS 2 EMFLAZA ORAL SOLUTION 2 SP SUSPENSION PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 46 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ERGOMAR RELPAX ORAL 2 SUBLINGUAL TABLET 2 TABLET SUBLINGUAL REYVOW ORAL 2 ergotamine-caffeine TABLET 1 oral tablet rizatriptan benzoate 1 FROVA ORAL TABLET 2 oral tablet frovatriptan succinate rizatriptan benzoate 1 1 oral tablet oral tablet dispersible IMITREX NASAL sumatriptan nasal 2 1 SOLUTION solution IMITREX ORAL sumatriptan succinate 2 1 TABLET oral tablet IMITREX STATDOSE sumatriptan succinate REFILL refill subcutaneous 1 SUBCUTANEOUS 2 solution cartridge SOLUTION sumatriptan succinate 1 CARTRIDGE subcutaneous solution IMITREX STATDOSE sumatriptan succinate SYSTEM subcutaneous solution 1 SUBCUTANEOUS 2 auto-injector SOLUTION AUTO- INJECTOR sumatriptan succinate subcutaneous solution 1 IMITREX prefilled syringe SUBCUTANEOUS 2 sumatriptan-naproxen SOLUTION 1 sodium oral tablet MAXALT ORAL 2 TOSYMRA NASAL TABLET 2 SOLUTION MAXALT-MLT ORAL TREXIMET ORAL TABLET 2 2 DISPERSIBLE TABLET MIGERGOT RECTAL UBRELVY ORAL 2 2 SUPPOSITORY TABLET MIGRANAL NASAL VYEPTI 2 SOLUTION INTRAVENOUS 2 SOLUTION naratriptan hcl oral 1 tablet ZEMBRACE SYMTOUCH NURTEC ORAL SUBCUTANEOUS 2 TABLET 2 SOLUTION AUTO- DISPERSIBLE INJECTOR ONZETRA XSAIL zolmitriptan oral tablet 1 NASAL EXHALER 2 zolmitriptan oral tablet POWDER 1 dispersible

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 47 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ZOMIG NASAL Antimycobacterials 2 SOLUTION CAPASTAT SULFATE ZOMIG ORAL TABLET 2 INJECTION 2 ZOMIG ZMT ORAL SOLUTION TABLET 2 RECONSTITUTED DISPERSIBLE cycloserine oral 1 Antimyasthenic capsule Agents dapsone oral tablet 1 BLOXIVERZ ethambutol hcl oral 1 INTRAVENOUS 2 tablet SOLUTION isoniazid injection 1 GUANIDINE HCL solution 2 ORAL TABLET isoniazid oral syrup 1 MESTINON ORAL 2 isoniazid oral tablet 1 SOLUTION MYAMBUTOL ORAL MESTINON ORAL 2 2 TABLET TABLET MYCOBUTIN ORAL 2 MESTINON ORAL CAPSULE TABLET EXTENDED 2 PASER ORAL RELEASE 2 PACKET neostigmine methylsulfate PRETOMANID ORAL 1 2 intravenous solution 10 TABLET mg/10ml, 5 mg/10ml PRIFTIN ORAL 2 NEOSTIGMINE TABLET METHYLSULFATE pyrazinamide oral 1 INTRAVENOUS 2 tablet SOLUTION 3 MG/3ML, rifabutin oral capsule 1 5 MG/5ML RIFADIN NEOSTIGMINE INTRAVENOUS 2 METHYLSULFATE SOLUTION INTRAVENOUS 2 RECONSTITUTED SOLUTION PREFILLED SYRINGE RIFADIN ORAL CAPSULE 150 MG, 2 pyridostigmine bromide 300 MG er oral tablet extended 1 RIFAMATE ORAL release 2 CAPSULE 150-300 MG pyridostigmine bromide 1 rifampin intravenous oral solution 1 solution reconstituted pyridostigmine bromide 1 oral tablet rifampin oral capsule 1 REGONOL RIFAMPIN+SYRSPEN INTRAVENOUS 2 D SF ORAL 2 SOLUTION SUSPENSION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 48 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits RIFATER ORAL ALKERAN TABLET 50-120-300 2 INTRAVENOUS 2 SP MG SOLUTION SIRTURO ORAL RECONSTITUTED 2 TABLET ALKERAN ORAL 2 SP TRECATOR ORAL TABLET 2 TABLET ALUNBRIG ORAL 2 SP Antineoplastics - TABLET Drugs for Cancer ALUNBRIG ORAL abiraterone acetate oral TABLET THERAPY 2 SP 1 SP tablet PACK ABRAXANE anastrozole oral tablet 1 INTRAVENOUS ARIMIDEX ORAL 2 SP 2 SUSPENSION TABLET RECONSTITUTED AROMASIN ORAL 2 ADCETRIS TABLET INTRAVENOUS 2 SP ARRANON SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION adriamycin intravenous arsenic trioxide 1 SP 1 SP solution intravenous solution adriamycin intravenous 1 SP ARZERRA solution reconstituted INTRAVENOUS 2 SP adrucil intravenous CONCENTRATE solution 2.5 gm/50ml, 5 1 SP ASPARLAS gm/100ml, 500 INTRAVENOUS 2 SP mg/10ml SOLUTION AFINITOR DISPERZ AVASTIN ORAL TABLET 2 SP INTRAVENOUS 2 SP SOLUBLE SOLUTION AFINITOR ORAL AYVAKIT ORAL 2 SP 2 SP TABLET TABLET ALECENSA ORAL 2 SP azacitidine injection CAPSULE suspension 1 SP ALIMTA reconstituted INTRAVENOUS BALVERSA ORAL 2 SP 2 SP SOLUTION TABLET RECONSTITUTED BAVENCIO ALIQOPA INTRAVENOUS 2 SP INTRAVENOUS 2 SP SOLUTION SOLUTION RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 49 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BELEODAQ BRUKINSA ORAL 2 SP INTRAVENOUS CAPSULE 2 SP SOLUTION busulfan intravenous 1 SP RECONSTITUTED solution BELRAPZO BUSULFEX INTRAVENOUS 2 SP INTRAVENOUS 2 SP SOLUTION SOLUTION BENDAMUSTINE HCL CABOMETYX ORAL INTRAVENOUS 2 SP 2 SP TABLET SOLUTION 100 CALQUENCE ORAL MG/4ML 2 SP CAPSULE BENDEKA INTRAVENOUS 2 SP CAMPATH SOLUTION INTRAVENOUS 2 SP SOLUTION BESPONSA INTRAVENOUS CAMPTOSAR 2 SP SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION bexarotene oral capecitabine oral tablet 1 SP 1 SP capsule CAPRELSA ORAL 2 SP bicalutamide oral tablet 1 TABLET carboplatin intravenous BICNU 1 SP INTRAVENOUS solution 2 SP SOLUTION carmustine intravenous 1 SP RECONSTITUTED solution reconstituted BLENREP CASODEX ORAL 2 INTRAVENOUS TABLET 2 SP SOLUTION cisplatin intravenous 1 SP RECONSTITUTED solution bleomycin sulfate CISPLATIN injection solution 1 SP INTRAVENOUS 2 SP reconstituted SOLUTION BLINCYTO RECONSTITUTED INTRAVENOUS cladribine intravenous 2 SP 1 SP SOLUTION solution RECONSTITUTED clofarabine intravenous 1 SP BORTEZOMIB solution INTRAVENOUS 2 SP SOLUTION CLOLAR RECONSTITUTED INTRAVENOUS 2 SP SOLUTION BOSULIF ORAL 2 SP TABLET COMETRIQ (100 MG DAILY DOSE) ORAL 2 SP BRAFTOVI ORAL 2 SP KIT CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 50 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits COMETRIQ (140 MG DARZALEX DAILY DOSE) ORAL 2 SP INTRAVENOUS 2 SP KIT SOLUTION COMETRIQ (60 MG daunorubicin hcl 1 SP DAILY DOSE) ORAL 2 SP intravenous solution KIT DAURISMO ORAL 2 SP COPIKTRA ORAL TABLET 2 SP CAPSULE decitabine intravenous 1 SP COSMEGEN solution reconstituted INTRAVENOUS 2 SP dexrazoxane hcl SOLUTION intravenous solution 1 SP RECONSTITUTED reconstituted COTELLIC ORAL 2 SP docetaxel (non-) TABLET intravenous solution 1 SP cyclophosphamide 160 mg/8ml, 20 mg/ml, injection solution 1 SP 80 mg/4ml reconstituted docetaxel intravenous 1 SP CYCLOPHOSPHAMID concentrate E INTRAVENOUS 2 SP docetaxel intravenous 1 SP SOLUTION solution cyclophosphamide oral DOXIL INTRAVENOUS 1 2 SP capsule INJECTABLE CYRAMZA doxorubicin hcl 1 SP INTRAVENOUS 2 SP intravenous solution SOLUTION doxorubicin hcl cytarabine (pf) injection 1 SP intravenous solution 1 SP solution reconstituted 50 mg cytarabine injection 1 SP doxorubicin hcl solution liposomal intravenous 1 SP dacarbazine injectable intravenous solution 1 SP DROXIA ORAL 2 reconstituted CAPSULE DACOGEN ELITEK INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED dactinomycin ELLENCE intravenous solution 1 SP INTRAVENOUS 2 SP reconstituted SOLUTION DARZALEX FASPRO ELZONRIS SUBCUTANEOUS 2 SP INTRAVENOUS 2 SP SOLUTION SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 51 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits EMCYT ORAL FARESTON ORAL 2 2 CAPSULE TABLET EMPLICITI FARYDAK ORAL 2 SP INTRAVENOUS CAPSULE 2 SP SOLUTION FASLODEX RECONSTITUTED INTRAMUSCULAR 2 SP ENHERTU SOLUTION INTRAVENOUS FEMARA ORAL 2 SP 2 SOLUTION TABLET RECONSTITUTED floxuridine injection epirubicin hcl 1 SP 1 SP solution reconstituted intravenous solution fludarabine phosphate 1 SP ERBITUX intravenous solution INTRAVENOUS 2 SP SOLUTION fludarabine phosphate intravenous solution 1 SP ERIVEDGE ORAL 2 SP reconstituted CAPSULE fluorouracil intravenous ERLEADA ORAL 1 SP 2 SP solution TABLET flutamide oral capsule 1 erlotinib hcl oral tablet 1 SP FOLOTYN ERWINAZE INTRAVENOUS 2 SP INJECTION 2 SP SOLUTION SOLUTION fulvestrant RECONSTITUTED 1 SP intramuscular solution ETHYOL INTRAVENOUS FUSILEV 2 SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 2 SP RECONSTITUTED 50 ETOPOPHOS MG INTRAVENOUS 2 SP GAVRETO ORAL SOLUTION 2 SP RECONSTITUTED CAPSULE etoposide intravenous GAZYVA 1 SP solution INTRAVENOUS 2 SP SOLUTION etoposide oral capsule 1 SP gemcitabine hcl everolimus oral tablet 1 SP 1 SP intravenous solution 2.5 mg, 5 mg, 7.5 mg gemcitabine hcl EVOMELA intravenous solution 1 SP INTRAVENOUS 2 SP reconstituted SOLUTION GILOTRIF ORAL RECONSTITUTED 2 SP TABLET exemestane oral tablet 1 GLEEVEC ORAL 2 SP TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 52 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits GLEOSTINE ORAL ifosfamide intravenous 2 SP 1 SP CAPSULE solution HALAVEN ifosfamide intravenous 1 SP INTRAVENOUS 2 SP solution reconstituted SOLUTION imatinib mesylate oral 1 SP HERCEPTIN tablet HYLECTA IMBRUVICA ORAL 2 SP 2 SP SUBCUTANEOUS CAPSULE SOLUTION IMBRUVICA ORAL 2 SP HERCEPTIN TABLET INTRAVENOUS 2 SP SOLUTION IMFINZI RECONSTITUTED INTRAVENOUS 2 SP SOLUTION HERZUMA INTRAVENOUS IMLYGIC 2 SP SOLUTION INTRALESIONAL 2 SP RECONSTITUTED SUSPENSION HYCAMTIN INFUGEM INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED INLYTA ORAL TABLET 2 SP HYCAMTIN ORAL INQOVI ORAL TABLET 2 SP 2 SP CAPSULE INREBIC ORAL 2 SP HYDREA ORAL CAPSULE 2 CAPSULE IRESSA ORAL 2 SP hydroxyurea oral TABLET 1 capsule irinotecan hcl 1 SP IBRANCE ORAL intravenous solution 2 SP CAPSULE ISTODAX (OVERFILL) IBRANCE ORAL INTRAVENOUS 2 SP 2 SP TABLET SOLUTION ICLUSIG ORAL RECONSTITUTED 2 SP TABLET IXEMPRA KIT INTRAVENOUS IDAMYCIN PFS 2 SP INTRAVENOUS 2 SP SOLUTION SOLUTION RECONSTITUTED idarubicin hcl JAKAFI ORAL TABLET 2 SP 1 SP intravenous solution JEVTANA IDHIFA ORAL TABLET 2 SP INTRAVENOUS 2 SP SOLUTION IFEX INTRAVENOUS SOLUTION 2 SP KADCYLA INTRAVENOUS RECONSTITUTED 2 SP SOLUTION RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 53 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits KANJINTI LENVIMA (10 MG INTRAVENOUS DAILY DOSE) ORAL 2 SP 2 SP SOLUTION CAPSULE THERAPY RECONSTITUTED PACK KEYTRUDA LENVIMA (12 MG INTRAVENOUS 2 SP DAILY DOSE) ORAL 2 SP SOLUTION CAPSULE THERAPY KHAPZORY PACK INTRAVENOUS LENVIMA (14 MG 2 SP SOLUTION DAILY DOSE) ORAL 2 SP RECONSTITUTED CAPSULE THERAPY KISQALI (200 MG PACK DOSE) ORAL TABLET 2 SP LENVIMA (18 MG THERAPY PACK DAILY DOSE) ORAL 2 SP KISQALI (400 MG CAPSULE THERAPY DOSE) ORAL TABLET 2 SP PACK THERAPY PACK LENVIMA (20 MG DAILY DOSE) ORAL KISQALI (600 MG 2 SP DOSE) ORAL TABLET 2 SP CAPSULE THERAPY THERAPY PACK PACK KISQALI FEMARA LENVIMA (24 MG (400 MG DOSE) ORAL DAILY DOSE) ORAL 2 SP 2 SP TABLET THERAPY CAPSULE THERAPY PACK PACK KISQALI FEMARA LENVIMA (4 MG (600 MG DOSE) ORAL DAILY DOSE) ORAL 2 SP 2 SP TABLET THERAPY CAPSULE THERAPY PACK PACK KISQALI FEMARA(200 LENVIMA (8 MG MG DOSE) ORAL DAILY DOSE) ORAL 2 SP 2 SP TABLET THERAPY CAPSULE THERAPY PACK PACK KOSELUGO ORAL letrozole oral tablet 1 2 SP CAPSULE leucovorin calcium 1 KYPROLIS injection solution INTRAVENOUS leucovorin calcium 2 SP SOLUTION injection solution 1 RECONSTITUTED reconstituted lapatinib ditosylate oral leucovorin calcium oral 1 SP 1 tablet tablet LARTRUVO LEUKERAN ORAL 2 INTRAVENOUS 2 SP TABLET SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 54 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LEVOLEUCOVORIN mesna intravenous 1 SP CALCIUM solution INTRAVENOUS 2 MESNEX SOLUTION INTRAVENOUS 2 SP RECONSTITUTED 175 SOLUTION MG MESNEX ORAL 2 SP levoleucovorin calcium TABLET intravenous solution 1 SP reconstituted 50 mg METASTRON INTRAVENOUS 2 levoleucovorin calcium 1 SP SOLUTION 1 MCI/ML pf intravenous solution mitomycin intravenous 1 SP LIBTAYO solution reconstituted INTRAVENOUS 2 SP SOLUTION mitoxantrone hcl intravenous 1 SP lipodox 50 intravenous 1 SP concentrate injectable 2 mg/ml MONJUVI LONSURF ORAL INTRAVENOUS 2 SP 2 SP TABLET SOLUTION LORBRENA ORAL RECONSTITUTED 2 SP TABLET mutamycin intravenous 1 SP LUMOXITI solution reconstituted INTRAVENOUS 2 SP MVASI SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION LYNPARZA ORAL MYLERAN ORAL 2 SP 2 TABLET TABLET LYSODREN ORAL 2 MYLOTARG TABLET INTRAVENOUS 2 SP MARQIBO SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SUSPENSION NAVELBINE MATULANE ORAL INTRAVENOUS 2 SP 2 SP CAPSULE SOLUTION MEKINIST ORAL NERLYNX ORAL 2 SP 2 SP TABLET TABLET MEKTOVI ORAL NEXAVAR ORAL 2 SP 2 SP TABLET TABLET melphalan hcl NILANDRON ORAL 2 SP intravenous solution 1 SP TABLET reconstituted nilutamide oral tablet 1 SP melphalan oral tablet 1 SP NINLARO ORAL 2 SP mercaptopurine oral CAPSULE 1 tablet

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 55 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits NIPENT PERJETA INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED PHESGO NUBEQA ORAL SUBCUTANEOUS 2 SP 2 SP TABLET SOLUTION ODOMZO ORAL PHOTOFRIN 2 SP CAPSULE INTRAVENOUS 2 SP OGIVRI SOLUTION INTRAVENOUS RECONSTITUTED 2 SP SOLUTION PIQRAY (200 MG RECONSTITUTED DAILY DOSE) ORAL 2 SP ONCASPAR TABLET THERAPY INJECTION 2 SP PACK SOLUTION PIQRAY (250 MG DAILY DOSE) ORAL ONIVYDE 2 SP INTRAVENOUS 2 SP TABLET THERAPY INJECTABLE PACK ONTRUZANT PIQRAY (300 MG INTRAVENOUS DAILY DOSE) ORAL 2 SP 2 SP SOLUTION TABLET THERAPY RECONSTITUTED PACK ONUREG ORAL POLIVY 2 SP INTRAVENOUS TABLET 2 SP SOLUTION OPDIVO RECONSTITUTED INTRAVENOUS 2 SP POMALYST ORAL SOLUTION 2 SP CAPSULE oxaliplatin intravenous 1 SP solution PORTRAZZA INTRAVENOUS 2 SP oxaliplatin intravenous 1 SP SOLUTION solution reconstituted POTELIGEO paclitaxel intravenous 1 SP INTRAVENOUS 2 SP concentrate SOLUTION PADCEV PROLEUKIN INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED PANRETIN PURIXAN ORAL 2 2 SP EXTERNAL GEL SUSPENSION paraplatin intravenous QINLOCK ORAL 1 SP 2 SP solution TABLET PEMAZYRE ORAL 2 SP TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 56 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits QUADRAMET SYLVANT INTRAVENOUS 2 INTRAVENOUS 2 SP SOLUTION SOLUTION RETEVMO ORAL RECONSTITUTED 2 SP CAPSULE SYNRIBO REVLIMID ORAL SUBCUTANEOUS 2 SP 2 SP CAPSULE SOLUTION RECONSTITUTED RITUXAN HYCELA TABLOID ORAL SUBCUTANEOUS 2 SP 2 SP SOLUTION TABLET TABRECTA ORAL RITUXAN 2 SP INTRAVENOUS 2 SP TABLET SOLUTION TAFINLAR ORAL 2 SP ROMIDEPSIN CAPSULE INTRAVENOUS 2 SP TAGRISSO ORAL 2 SP SOLUTION TABLET ROMIDEPSIN TALZENNA ORAL 2 SP INTRAVENOUS CAPSULE SOLUTION 2 SP tamoxifen citrate oral 1 RECONSTITUTED 10 tablet MG TARCEVA ORAL ROZLYTREK ORAL 2 SP 2 SP TABLET CAPSULE TARGRETIN RUBRACA ORAL 2 SP 2 SP EXTERNAL GEL TABLET TARGRETIN ORAL 2 SP RUXIENCE CAPSULE INTRAVENOUS 2 SP TASIGNA ORAL SOLUTION 2 SP CAPSULE RYDAPT ORAL 2 SP CAPSULE TAXOTERE INTRAVENOUS 2 SP SARCLISA CONCENTRATE INTRAVENOUS 2 SP TAZVERIK ORAL SOLUTION 2 SP TABLET SIKLOS ORAL 2 TABLET TECARTUS INTRAVENOUS 2 SP SOLTAMOX ORAL 2 SUSPENSION SOLUTION TECENTRIQ SPRYCEL ORAL 2 SP INTRAVENOUS 2 SP TABLET SOLUTION STIVARGA ORAL 2 SP TEMODAR TABLET INTRAVENOUS 2 SP SUTENT ORAL SOLUTION 2 SP CAPSULE RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 57 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits TEMODAR ORAL TRODELVY 2 SP CAPSULE INTRAVENOUS 2 SP temozolomide oral SOLUTION 1 SP capsule RECONSTITUTED teniposide intravenous TRUXIMA 1 SP solution INTRAVENOUS 2 SP SOLUTION TEPADINA INJECTION TUKYSA ORAL SOLUTION 2 SP 2 SP RECONSTITUTED TABLET THALOMID ORAL TURALIO ORAL 2 SP 2 SP CAPSULE CAPSULE thiotepa injection TYKERB ORAL 1 SP 2 SP solution reconstituted TABLET TIBSOVO ORAL UNITUXIN 2 SP TABLET INTRAVENOUS 2 SP SOLUTION toposar intravenous 1 SP VALCHLOR solution 2 SP EXTERNAL GEL topotecan hcl 1 SP valrubicin intravesical intravenous solution 1 SP solution topotecan hcl intravenous solution 1 SP VALSTAR reconstituted INTRAVESICAL 2 SP SOLUTION toremifene citrate oral 1 tablet VECTIBIX INTRAVENOUS 2 SP TOTECT SOLUTION INTRAVENOUS 2 SP SOLUTION VELCADE INJECTION RECONSTITUTED SOLUTION 2 SP RECONSTITUTED TRAZIMERA INTRAVENOUS VENCLEXTA ORAL 2 SP 2 SP SOLUTION TABLET RECONSTITUTED VENCLEXTA STARTING PACK TREANDA 2 SP INTRAVENOUS ORAL TABLET 2 SP SOLUTION THERAPY PACK RECONSTITUTED VERZENIO ORAL 2 SP tretinoin oral capsule 1 SP TABLET TRISENOX VIDAZA INJECTION INTRAVENOUS 2 SP SUSPENSION 2 SP SOLUTION RECONSTITUTED vinblastine sulfate 1 SP intravenous solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 58 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits vincasar pfs XPOVIO (60 MG intravenous solution 1 1 SP ONCE WEEKLY) 2 SP mg/ml ORAL TABLET vincristine sulfate THERAPY PACK 1 SP intravenous solution XPOVIO (60 MG vinorelbine tartrate TWICE WEEKLY) 1 SP 2 SP intravenous solution ORAL TABLET THERAPY PACK VITRAKVI ORAL 2 SP CAPSULE XPOVIO (80 MG ONCE WEEKLY) VITRAKVI ORAL 2 SP 2 SP ORAL TABLET SOLUTION THERAPY PACK VIZIMPRO ORAL 2 SP XPOVIO (80 MG TABLET TWICE WEEKLY) 2 SP VORAXAZE ORAL TABLET INTRAVENOUS THERAPY PACK 2 SOLUTION XTANDI ORAL 2 SP RECONSTITUTED CAPSULE VOTRIENT ORAL 2 SP YERVOY TABLET INTRAVENOUS 2 SP VYXEOS SOLUTION INTRAVENOUS 2 SP YESCARTA SUSPENSION INTRAVENOUS 2 SP RECONSTITUTED SUSPENSION XALKORI ORAL 2 SP YONDELIS CAPSULE INTRAVENOUS 2 SP XELODA ORAL SOLUTION 2 SP TABLET RECONSTITUTED XOFIGO YONSA ORAL TABLET 2 SP INTRAVENOUS 2 ZALTRAP SOLUTION INTRAVENOUS 2 SP XOSPATA ORAL SOLUTION 2 SP TABLET ZANOSAR XPOVIO (100 MG INTRAVENOUS 2 SP ONCE WEEKLY) SOLUTION 2 SP ORAL TABLET RECONSTITUTED THERAPY PACK ZEJULA ORAL 2 SP XPOVIO (40 MG CAPSULE ONCE WEEKLY) ZELBORAF ORAL 2 SP 2 SP ORAL TABLET TABLET THERAPY PACK ZEPZELCA XPOVIO (40 MG INTRAVENOUS TWICE WEEKLY) 2 SP 2 SP SOLUTION ORAL TABLET RECONSTITUTED THERAPY PACK You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 59 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ZEVALIN Y-90 crotan external lotion 1 2 SP INTRAVENOUS KIT DARAPRIM ORAL 2 SP ZINECARD TABLET INTRAVENOUS EGATEN ORAL 2 SOLUTION 2 SP TABLET RECONSTITUTED 250 ELIMITE EXTERNAL MG, 500 MG 2 CREAM ZIRABEV EMVERM ORAL INTRAVENOUS 2 SP 2 SOLUTION TABLET CHEWABLE ZOLINZA ORAL EURAX EXTERNAL 2 SP 2 CAPSULE CREAM 10 % ZYDELIG ORAL EURAX EXTERNAL 2 SP 2 TABLET LOTION 10 % ZYKADIA ORAL hydroxychloroquine 2 SP 1 CAPSULE 150 MG sulfate oral tablet ZYKADIA ORAL IMPAVIDO ORAL 2 SP 2 TABLET CAPSULE ZYTIGA ORAL oral tablet 1 2 SP TABLET KRINTAFEL ORAL 2 Antiparasitics TABLET LAMPIT ORAL albendazole oral tablet 1 2 TABLET ALBENZA ORAL 2 lindane external TABLET 1 shampoo ALINIA ORAL MALARONE ORAL SUSPENSION 2 2 RECONSTITUTED TABLET malathion external ALINIA ORAL TABLET 2 1 lotion ARAKODA ORAL 2 mefloquine hcl oral TABLET 1 tablet atovaquone oral 1 MEPRON ORAL suspension 2 SUSPENSION atovaquone-proguanil 1 NATROBA EXTERNAL hcl oral tablet 2 SUSPENSION BENZNIDAZOLE 2 ORAL TABLET NEBUPENT INHALATION BILTRICIDE ORAL 2 2 SOLUTION TABLET RECONSTITUTED chloroquine phosphate OVIDE EXTERNAL 1 2 oral tablet LOTION COARTEM ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 60 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits PENTAM INJECTION APOKYN SOLUTION 2 SUBCUTANEOUS 2 SP RECONSTITUTED SOLUTION pentamidine isethionate CARTRIDGE inhalation solution 1 AZILECT ORAL 2 reconstituted TABLET pentamidine isethionate benztropine mesylate 1 injection solution 1 injection solution reconstituted benztropine mesylate 1 permethrin external oral tablet 1 cream bromocriptine mesylate 1 PLAQUENIL ORAL oral capsule 2 TABLET bromocriptine mesylate 1 praziquantel oral tablet 1 oral tablet primaquine phosphate carbidopa oral tablet 1 1 oral tablet carbidopa-levodopa er pyrimethamine oral oral tablet extended 1 1 SP tablet release PYRIMETHAMINE- carbidopa-levodopa 1 LEUCOVORIN ORAL 2 oral tablet CAPSULE carbidopa-levodopa 1 QUALAQUIN ORAL oral tablet dispersible 2 CAPSULE carbidopa-levodopa- 1 quinine sulfate oral entacapone oral tablet 1 capsule COGENTIN SKLICE EXTERNAL INJECTION 2 2 LOTION SOLUTION spinosad external COMTAN ORAL 1 2 suspension TABLET STROMECTOL ORAL DUOPA ENTERAL 2 2 TABLET SUSPENSION sulfurated lime external entacapone oral tablet 1 1 solution GOCOVRI ORAL ULESFIA EXTERNAL CAPSULE EXTENDED 2 2 LOTION 5 % RELEASE 24 HOUR Antiparkinson Agents INBRIJA INHALATION 2 SP amantadine hcl oral CAPSULE 1 capsule KYNMOBI 2 SP amantadine hcl oral SUBLINGUAL FILM 1 syrup KYNMOBI TITRATION 2 SP amantadine hcl oral KIT SUBLINGUAL KIT 1 tablet

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 61 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LODOSYN ORAL ropinirole hcl er oral 2 TABLET tablet extended release 1 MIRAPEX ER ORAL 24 hour TABLET EXTENDED 2 ropinirole hcl oral tablet 1 RELEASE 24 HOUR RYTARY ORAL MIRAPEX ORAL CAPSULE EXTENDED 2 2 TABLET RELEASE NEUPRO selegiline hcl oral 1 TRANSDERMAL 2 capsule PATCH 24 HOUR selegiline hcl oral tablet 1 NOURIANZ ORAL 2 SINEMET CR ORAL TABLET TABLET EXTENDED 2 ONGENTYS ORAL RELEASE 25-100 MG, 2 CAPSULE 50-200 MG OSMOLEX ER ORAL SINEMET ORAL 2 TABLET ER 24 HOUR 2 TABLET THERAPY PACK STALEVO 100 ORAL 2 OSMOLEX ER ORAL TABLET TABLET EXTENDED 2 STALEVO 125 ORAL 2 RELEASE 24 HOUR TABLET PARLODEL ORAL STALEVO 150 ORAL 2 2 CAPSULE TABLET PARLODEL ORAL STALEVO 200 ORAL 2 2 TABLET TABLET pramipexole STALEVO 50 ORAL dihydrochloride er oral 2 1 TABLET tablet extended release STALEVO 75 ORAL 24 hour 2 TABLET pramipexole TASMAR ORAL dihydrochloride oral 1 2 tablet TABLET rasagiline mesylate oral tolcapone oral tablet 1 1 tablet trihexyphenidyl hcl oral 1 REQUIP ORAL solution TABLET 0.25 MG, 1 trihexyphenidyl hcl oral 2 1 MG, 2 MG, 4 MG, 5 tablet MG XADAGO ORAL 2 REQUIP XL ORAL TABLET TABLET EXTENDED ZELAPAR ORAL RELEASE 24 HOUR 2 TABLET 2 12 MG, 2 MG, 4 MG, 6 DISPERSIBLE MG, 8 MG

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 62 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Antiplatelets REOPRO AGGRASTAT INTRAVENOUS 2 INTRAVENOUS 2 SOLUTION 2 MG/ML CONCENTRATE YOSPRALA ORAL AGGRASTAT TABLET DELAYED 2 INTRAVENOUS 2 RELEASE SOLUTION ZONTIVITY ORAL 2 AGGRENOX ORAL TABLET CAPSULE EXTENDED Antipsychotics - 2 RELEASE 12 HOUR Drugs for Mood 25-200 MG Disorders aspirin- er ABILIFY MAINTENA oral capsule extended 1 INTRAMUSCULAR 2 release 12 hour PREFILLED SYRINGE ASPIRIN- ABILIFY MAINTENA ORAL INTRAMUSCULAR 2 2 TABLET DELAYED SUSPENSION RELEASE RECONSTITUTED ER BRILINTA ORAL ABILIFY MYCITE 2 2 TABLET ORAL TABLET CABLIVI INJECTION ABILIFY ORAL 2 SP 2 KIT TABLET oral tablet 1 ADASUVE bisulfate INHALATION 1 2 oral tablet AEROSOL POWDER BREATH ACTIVATED dipyridamole oral tablet 1 aripiprazole oral 1 DURLAZA ORAL solution CAPSULE EXTENDED 2 RELEASE 24 HOUR aripiprazole oral tablet 1 EFFIENT ORAL aripiprazole oral tablet 2 1 TABLET dispersible intravenous ARISTADA INITIO 1 solution INTRAMUSCULAR 2 PREFILLED SYRINGE INTEGRILIN INTRAVENOUS 2 ARISTADA SOLUTION INTRAMUSCULAR 2 PREFILLED SYRINGE KENGREAL INTRAVENOUS CAPLYTA ORAL 2 2 SOLUTION CAPSULE RECONSTITUTED chlorpromazine hcl 1 PLAVIX ORAL TABLET 2 injection solution chlorpromazine hcl oral hcl oral tablet 1 1 tablet

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 63 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits clozapine oral tablet 1 INVEGA ORAL clozapine oral tablet TABLET EXTENDED 2 1 dispersible RELEASE 24 HOUR CLOZARIL ORAL INVEGA SUSTENNA 2 INTRAMUSCULAR TABLET 2 SUSPENSION FANAPT ORAL 2 PREFILLED SYRINGE TABLET INVEGA TRINZA FANAPT TITRATION INTRAMUSCULAR 2 2 PACK ORAL TABLET SUSPENSION FAZACLO ORAL PREFILLED SYRINGE TABLET LATUDA ORAL 2 DISPERSIBLE 100 2 TABLET MG, 12.5 MG, 150 MG, loxapine succinate oral 200 MG, 25 MG 1 capsule fluphenazine molindone hcl oral decanoate injection 1 1 solution tablet fluphenazine hcl NUPLAZID ORAL 1 2 injection solution CAPSULE fluphenazine hcl oral NUPLAZID ORAL 1 2 concentrate TABLET fluphenazine hcl oral olanzapine 1 elixir intramuscular solution 1 reconstituted fluphenazine hcl oral 1 tablet olanzapine oral tablet 1 olanzapine oral tablet GEODON 1 INTRAMUSCULAR dispersible 2 SOLUTION paliperidone er oral RECONSTITUTED tablet extended release 1 GEODON ORAL 24 hour 2 CAPSULE PERSERIS HALDOL DECANOATE SUBCUTANEOUS 2 INTRAMUSCULAR 2 PREFILLED SYRINGE SOLUTION pimozide oral tablet 1 HALDOL INJECTION quetiapine fumarate er 2 SOLUTION oral tablet extended 1 haloperidol decanoate release 24 hour 1 intramuscular solution quetiapine fumarate 1 haloperidol lactate oral tablet 1 injection solution REXULTI ORAL 2 haloperidol lactate oral TABLET 1 concentrate haloperidol oral tablet 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 64 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits RISPERDAL CONSTA ziprasidone mesylate INTRAMUSCULAR intramuscular solution 1 2 SUSPENSION reconstituted RECONSTITUTED ER ZYPREXA RISPERDAL ORAL INTRAMUSCULAR 2 2 SOLUTION SOLUTION RISPERDAL ORAL RECONSTITUTED 2 TABLET ZYPREXA ORAL 2 risperidone m-tab oral TABLET tablet dispersible 0.5 1 ZYPREXA RELPREVV mg, 1 mg, 2 mg INTRAMUSCULAR 2 risperidone oral SUSPENSION 1 solution RECONSTITUTED risperidone oral tablet 1 ZYPREXA ZYDIS ORAL TABLET 2 risperidone oral tablet 1 DISPERSIBLE dispersible Antivirals SAPHRIS abacavir sulfate oral SUBLINGUAL TABLET 2 1 SUBLINGUAL solution abacavir sulfate oral SECUADO 1 TRANSDERMAL 2 tablet PATCH 24 HOUR abacavir sulfate- 1 SEROQUEL ORAL lamivudine oral tablet 2 TABLET abacavir-lamivudine- 1 SEROQUEL XR ORAL zidovudine oral tablet TABLET EXTENDED 2 acyclovir external 1 RELEASE 24 HOUR cream thioridazine hcl oral acyclovir external 1 1 tablet ointment thiothixene oral capsule 1 acyclovir oral capsule 1 trifluoperazine hcl oral acyclovir oral 1 1 tablet suspension VERSACLOZ ORAL acyclovir oral tablet 1 2 SUSPENSION acyclovir sodium 1 VRAYLAR ORAL intravenous solution 2 CAPSULE adefovir dipivoxil oral 1 SP VRAYLAR ORAL tablet CAPSULE THERAPY 2 APTIVUS ORAL 2 PACK CAPSULE ziprasidone hcl oral APTIVUS ORAL 1 2 capsule SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 65 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits atazanavir sulfate oral efavirenz-emtricitab- 1 1 capsule tenofovir oral tablet ATRIPLA ORAL efavirenz-lamivudine- 2 1 TABLET tenofovir oral tablet BARACLUDE ORAL emtricitabine oral 2 SP 1 SOLUTION capsule BARACLUDE ORAL emtricitabine-tenofovir 2 SP 1 TABLET df oral tablet BIKTARVY ORAL EMTRIVA ORAL 2 2 TABLET CAPSULE cidofovir intravenous EMTRIVA ORAL 1 2 solution SOLUTION CIMDUO ORAL entecavir oral tablet 1 SP 2 TABLET EPCLUSA ORAL 2 SP COMBIVIR ORAL TABLET 2 TABLET EPIVIR HBV ORAL 2 SP COMPLERA ORAL SOLUTION 2 TABLET EPIVIR HBV ORAL 2 SP CRIXIVAN ORAL TABLET 2 CAPSULE EPIVIR ORAL 2 CYTOVENE SOLUTION INTRAVENOUS EPIVIR ORAL TABLET 2 SOLUTION 2 EPZICOM ORAL RECONSTITUTED 500 2 MG TABLET EVOTAZ ORAL DAKLINZA ORAL 2 TABLET 30 MG, 60 2 SP TABLET MG famciclovir oral tablet 1 DELSTRIGO ORAL FAVIPIRAVIR ORAL 2 2 TABLET TABLET DENAVIR EXTERNAL FLUMADINE ORAL 2 2 CREAM TABLET 100 MG DESCOVY ORAL fosamprenavir calcium 2 1 TABLET oral tablet didanosine oral capsule FOSCAVIR 1 delayed release INTRAVENOUS 2 DOVATO ORAL SOLUTION 2 TABLET FUZEON EDURANT ORAL SUBCUTANEOUS 2 2 TABLET SOLUTION RECONSTITUTED efavirenz oral capsule 1 efavirenz oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 66 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits GANCICLOVIR lamivudine oral tablet 1 INTRAVENOUS 2 150 mg, 300 mg SOLUTION lamivudine-zidovudine 1 ganciclovir sodium oral tablet 1 intravenous solution LEDIPASVIR- ganciclovir sodium SOFOSBUVIR ORAL 2 SP intravenous solution 1 TABLET reconstituted LEXIVA ORAL 2 GENVOYA ORAL SUSPENSION 2 TABLET LEXIVA ORAL TABLET 2 HARVONI ORAL lopinavir-ritonavir oral 2 SP 1 PACKET solution HARVONI ORAL MAVYRET ORAL 2 SP 2 SP TABLET TABLET HEPSERA ORAL 2 SP MODERIBA (1200 MG TABLET PACK) ORAL TABLET 2 SP INTELENCE ORAL THERAPY PACK 600 2 TABLET MG INTRON A INJECTION moderiba oral tablet 2 SP 1 SP SOLUTION 200 mg INTRON A INJECTION nevirapine er oral tablet SOLUTION 2 SP extended release 24 1 RECONSTITUTED hour INVIRASE ORAL nevirapine oral 2 1 TABLET suspension ISENTRESS HD ORAL nevirapine oral tablet 1 2 TABLET NORVIR ORAL 2 ISENTRESS ORAL PACKET 2 PACKET NORVIR ORAL 2 ISENTRESS ORAL SOLUTION 2 TABLET NORVIR ORAL 2 ISENTRESS ORAL TABLET 2 TABLET CHEWABLE ODEFSEY ORAL 2 JULUCA ORAL TABLET 2 TABLET oseltamivir phosphate 1 KALETRA ORAL oral capsule 2 SOLUTION oseltamivir phosphate KALETRA ORAL oral suspension 1 2 TABLET reconstituted lamivudine oral solution 1 lamivudine oral tablet 1 SP 100 mg

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 67 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits PEGASYS PROCLICK RETROVIR ORAL 2 SUBCUTANEOUS SYRUP SOLUTION 135 2 SP REYATAZ ORAL 2 MCG/0.5ML, 180 CAPSULE MCG/0.5ML REYATAZ ORAL 2 PEGASYS PACKET SUBCUTANEOUS 2 SP ribasphere oral capsule SOLUTION 1 SP 200 mg PEGINTRON 2 SP ribasphere oral tablet SUBCUTANEOUS KIT 1 SP 200 mg PIFELTRO ORAL 2 TABLET RIBASPHERE ORAL TABLET 400 MG, 600 2 SP PREVYMIS MG INTRAVENOUS 2 SP SOLUTION RIBASPHERE RIBAPAK (1000 PACK) PREVYMIS ORAL 2 SP ORAL TABLET 2 SP TABLET THERAPY PACK 400 PREZCOBIX ORAL & 600 MG 2 TABLET RIBASPHERE PREZISTA ORAL RIBAPAK (1200 PACK) 2 SUSPENSION ORAL TABLET 2 SP PREZISTA ORAL THERAPY PACK 600 2 TABLET MG RAPIVAB RIBASPHERE INTRAVENOUS 2 RIBAPAK (600 PACK) SOLUTION ORAL TABLET 2 SP THERAPY PACK 200 REBETOL ORAL 2 SP & 400 MG SOLUTION 40 MG/ML RIBASPHERE RELENZA DISKHALER RIBAPAK (800 PACK) INHALATION 2 ORAL TABLET 2 SP AEROSOL POWDER THERAPY PACK 400 BREATH ACTIVATED MG REMDESIVIR ribavirin inhalation INTRAVENOUS 1 2 solution reconstituted SOLUTION RECONSTITUTED ribavirin oral capsule 1 SP RESCRIPTOR ORAL ribavirin oral tablet 1 SP 2 TABLET 200 MG rimantadine hcl oral 1 RETROVIR tablet INTRAVENOUS 2 ritonavir oral tablet 1 SOLUTION RUKOBIA ORAL RETROVIR ORAL TABLET EXTENDED 2 2 CAPSULE RELEASE 12 HOUR

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 68 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SELZENTRY ORAL TRIUMEQ ORAL 2 2 SOLUTION TABLET SELZENTRY ORAL TRIZIVIR ORAL 2 2 TABLET TABLET SITAVIG BUCCAL TROGARZO 2 TABLET INTRAVENOUS 2 SOFOSBUVIR- SOLUTION VELPATASVIR ORAL 2 SP TRUVADA ORAL 2 TABLET TABLET SOVALDI ORAL TYBOST ORAL 2 SP 2 PACKET TABLET SOVALDI ORAL valacyclovir hcl oral 2 SP 1 TABLET tablet stavudine oral capsule 1 VALCYTE ORAL STRIBILD ORAL SOLUTION 2 2 TABLET RECONSTITUTED SUSTIVA ORAL VALCYTE ORAL 2 2 CAPSULE TABLET SUSTIVA ORAL valganciclovir hcl oral 2 1 TABLET solution reconstituted valganciclovir hcl oral SYLATRON 1 SUBCUTANEOUS KIT tablet 2 SP 200 MCG, 300 MCG, VALTREX ORAL 2 600 MCG TABLET SYMFI LO ORAL VEKLURY 2 TABLET INTRAVENOUS 2 SYMFI ORAL TABLET 2 SOLUTION SYMTUZA ORAL VEKLURY 2 INTRAVENOUS TABLET 2 SOLUTION TAMIFLU ORAL 2 RECONSTITUTED CAPSULE VEMLIDY ORAL 2 SP TAMIFLU ORAL TABLET SUSPENSION 2 RECONSTITUTED VIDEX EC ORAL CAPSULE DELAYED TEMIXYS ORAL 2 RELEASE 125 MG, 2 TABLET 200 MG, 250 MG, 400 tenofovir disoproxil MG 1 fumarate oral tablet VIDEX ORAL TIVICAY ORAL SOLUTION 2 2 TABLET RECONSTITUTED 2 TIVICAY PD ORAL GM, 4 GM 2 TABLET SOLUBLE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 69 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VIEKIRA PAK ORAL ZOVIRAX EXTERNAL 2 TABLET THERAPY 2 SP OINTMENT PACK ZOVIRAX ORAL 2 VIRACEPT ORAL CAPSULE 200 MG 2 TABLET ZOVIRAX ORAL 2 VIRAMUNE ORAL SUSPENSION 2 SUSPENSION ZOVIRAX ORAL VIRAMUNE ORAL TABLET 400 MG, 800 2 2 TABLET 200 MG MG VIRAMUNE XR ORAL Anxiolytics - Drugs TABLET EXTENDED 2 for Anxiety RELEASE 24 HOUR alprazolam er oral VIRAZOLE tablet extended release 1 INHALATION 24 hour 2 SOLUTION alprazolam intensol oral 1 RECONSTITUTED concentrate VIREAD ORAL 2 alprazolam oral tablet 1 POWDER alprazolam oral tablet VIREAD ORAL 1 2 dispersible TABLET alprazolam xr oral VOSEVI ORAL 2 SP tablet extended release 1 TABLET 24 hour XERESE EXTERNAL ATIVAN INJECTION 2 2 CREAM SOLUTION XOFLUZA (40 MG ATIVAN ORAL 2 DOSE) ORAL TABLET 2 TABLET THERAPY PACK buspirone hcl oral 1 XOFLUZA (80 MG tablet DOSE) ORAL TABLET 2 chlordiazepoxide hcl THERAPY PACK 1 oral capsule ZEPATIER ORAL 2 SP TABLET clonazepam oral tablet 1 ZIAGEN ORAL clonazepam oral tablet 2 1 SOLUTION dispersible ZIAGEN ORAL clorazepate 2 1 TABLET dipotassium oral tablet diazepam intensol oral zidovudine oral capsule 1 1 concentrate zidovudine oral syrup 1 diazepam zidovudine oral tablet 1 intramuscular solution 1 ZOVIRAX EXTERNAL auto-injector 2 CREAM diazepam oral 1 concentrate

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 70 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits diazepam oral solution 1 midazolam hcl oral 1 diazepam oral tablet 1 syrup diazepam solution 5 MIDAZOLAM HCL- 1 mg/ml injection DEXTROSE INTRAVENOUS 2 DIAZEPAM SOLUTION 2 SOLUTION 50-5 5 MG/ML INJECTION MG/50ML-% DORAL ORAL TABLET 2 MIDAZOLAM HCL- estazolam oral tablet 1 SODIUM CHLORIDE 2 HALCION ORAL INTRAVENOUS 2 TABLET SOLUTION hydroxyzine hcl MIDAZOLAM HCL- 1 intramuscular solution SODIUM CHLORIDE INTRAVENOUS 2 hydroxyzine hcl oral 1 SOLUTION syrup PREFILLED SYRINGE hydroxyzine hcl oral 1 MIDAZOLAM tablet INJECTION 2 hydroxyzine pamoate SOLUTION 1 oral capsule PREFILLED SYRINGE KLONOPIN ORAL MIDAZOLAM 2 TABLET INTRAVENOUS 2 lorazepam injection SOLUTION 1 solution MIDAZOLAM+SYRSP lorazepam intensol oral END SF ORAL 2 1 concentrate SUSPENSION lorazepam oral MIDAZOLAM-SODIUM 1 CHLORIDE concentrate 2 mg/ml 2 INTRAVENOUS lorazepam oral tablet 1 SOLUTION LORAZEPAM- oxazepam oral capsule 1 DEXTROSE INTRAVENOUS 2 quazepam oral tablet 1 SOLUTION 100-5 TRANXENE-T ORAL 2 MG/100ML-% TABLET meprobamate oral triazolam oral tablet 1 1 tablet VALIUM ORAL 2 midazolam hcl (pf) TABLET 1 injection solution VISTARIL ORAL 2 midazolam hcl injection CAPSULE 1 solution XANAX ORAL TABLET 2 MIDAZOLAM HCL XANAX XR ORAL INTRAVENOUS 2 TABLET EXTENDED 2 SOLUTION 30 RELEASE 24 HOUR MG/30ML

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 71 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Bipolar Agents - ALPROLIX Drugs for Mood INTRAVENOUS 2 SP Disorders SOLUTION EQUETRO ORAL RECONSTITUTED CAPSULE EXTENDED 2 AMICAR ORAL 2 RELEASE 12 HOUR SOLUTION lithium carbonate er AMICAR ORAL 2 oral tablet extended 1 TABLET release aminocaproic acid 1 lithium carbonate oral intravenous solution 1 capsule aminocaproic acid oral 1 lithium carbonate oral solution 1 tablet aminocaproic acid oral 1 lithium oral solution 1 tablet LITHOBID ORAL hcl oral 1 TABLET EXTENDED 2 capsule RELEASE ARANESP (ALBUMIN Blood Products / FREE) INJECTION 2 SP Modifiers / Volume SOLUTION Expanders - Drugs for ARANESP (ALBUMIN Bleeding Disorders FREE) INJECTION 2 SP ADVATE SOLUTION INTRAVENOUS PREFILLED SYRINGE 2 SP SOLUTION ASTRINGYN RECONSTITUTED EXTERNAL 2 ADYNOVATE SOLUTION INTRAVENOUS BENEFIX 2 SP 2 SP SOLUTION INTRAVENOUS KIT RECONSTITUTED CEPROTIN AFSTYLA INTRAVENOUS 2 SP 2 SP INTRAVENOUS KIT SOLUTION AGRYLIN ORAL RECONSTITUTED 2 CAPSULE COAGADEX ALPHANATE/VWF INTRAVENOUS 2 SP COMPLEX/HUMAN SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION CORIFACT 2 SP RECONSTITUTED INTRAVENOUS KIT ALPHANINE SD CYKLOKAPRON INTRAVENOUS 2 SP INTRAVENOUS 2 SOLUTION SOLUTION RECONSTITUTED DOPTELET ORAL 2 SP TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 72 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ELOCTATE HEXTEND INTRAVENOUS INTRAVENOUS 2 2 SP SOLUTION SOLUTION RECONSTITUTED HUMATE-P EPOGEN INJECTION INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION ESPEROCT RECONSTITUTED INTRAVENOUS IDELVION 2 SP SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION FEIBA INTRAVENOUS RECONSTITUTED SOLUTION 2 SP IXINITY RECONSTITUTED INTRAVENOUS 2 SP FIBRYGA SOLUTION INTRAVENOUS RECONSTITUTED 2 SP SOLUTION JIVI INTRAVENOUS RECONSTITUTED SOLUTION 2 SP FULPHILA RECONSTITUTED SUBCUTANEOUS KCENTRA 2 SP 2 SOLUTION INTRAVENOUS KIT PREFILLED SYRINGE KOATE GRANIX INTRAVENOUS 2 SP SUBCUTANEOUS 2 SP SOLUTION SOLUTION RECONSTITUTED GRANIX KOATE-DVI SUBCUTANEOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION PREFILLED SYRINGE RECONSTITUTED HELIXATE FS KOGENATE FS 2 SP INTRAVENOUS KIT INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 2 SP KOVALTRY 250 UNIT, 3000 UNIT, INTRAVENOUS 2 SP 500 UNIT SOLUTION HEMLIBRA RECONSTITUTED SUBCUTANEOUS 2 SP LEUKINE INJECTION SOLUTION SOLUTION 2 SP HEMOFIL M RECONSTITUTED INTRAVENOUS 2 SP LMD IN D5W SOLUTION INTRAVENOUS 2 RECONSTITUTED SOLUTION HESPAN LMD IN NACL INTRAVENOUS 2 INTRAVENOUS 2 SOLUTION SOLUTION hetastarch-nacl 1 intravenous solution You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 73 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LYSTEDA ORAL NOVOSEVEN RT 2 TABLET INTRAVENOUS 2 SP MIRCERA INJECTION SOLUTION SOLUTION 2 SP RECONSTITUTED PREFILLED SYRINGE NPLATE SUBCUTANEOUS MONOCLATE-P 2 SP INTRAVENOUS KIT 2 SP SOLUTION 1000 UNIT RECONSTITUTED NUWIQ MONONINE 2 SP INTRAVENOUS INTRAVENOUS KIT 2 SP SOLUTION NUWIQ RECONSTITUTED INTRAVENOUS 2 SP MOZOBIL SOLUTION SUBCUTANEOUS 2 SP RECONSTITUTED SOLUTION OBIZUR MULPLETA ORAL INTRAVENOUS 2 SP 2 SP TABLET SOLUTION RECONSTITUTED NEULASTA ONPRO SUBCUTANEOUS PANHEMATIN 2 SP INTRAVENOUS PREFILLED SYRINGE 2 SP KIT SOLUTION RECONSTITUTED NEULASTA SUBCUTANEOUS PROCRIT INJECTION 2 SP 2 SP SOLUTION SOLUTION PREFILLED SYRINGE PROFILNINE INTRAVENOUS NEUPOGEN 2 SP INJECTION 2 SP SOLUTION SOLUTION RECONSTITUTED NEUPOGEN PROFILNINE SD INJECTION INTRAVENOUS 2 SP SOLUTION SOLUTION 2 SP PREFILLED SYRINGE RECONSTITUTED 500 UNIT NIVESTYM PROMACTA ORAL INJECTION 2 SP 2 SP SOLUTION PACKET PROMACTA ORAL NIVESTYM 2 SP INJECTION TABLET 2 SP SOLUTION protamine sulfate 1 PREFILLED SYRINGE intravenous solution NOVOEIGHT REBINYN INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 74 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits REBLOZYL -JMI SUBCUTANEOUS EXTERNAL 2 SP 2 SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED RECOMBINATE THROMBOGEN 2 INTRAVENOUS EXTERNAL KIT 2 SP SOLUTION THROMBOGEN RECONSTITUTED EXTERNAL 2 RECOTHROM SOLUTION EXTERNAL RECONSTITUTED 2 SOLUTION tranexamic acid 1 RECONSTITUTED intravenous solution RECOTHROM SPRAY tranexamic acid oral KIT EXTERNAL 1 2 tablet SOLUTION RECONSTITUTED TRANEXAMIC ACID- NACL INTRAVENOUS 2 RETACRIT INJECTION SOLUTION SOLUTION 10000 UNIT/ML, 2000 TRETTEN INTRAVENOUS UNIT/ML, 3000 2 SP 2 SP UNIT/ML, 4000 SOLUTION UNIT/ML, 40000 RECONSTITUTED UNIT/ML UDENYCA SUBCUTANEOUS RIASTAP 2 SP INTRAVENOUS SOLUTION 2 SP SOLUTION PREFILLED SYRINGE RECONSTITUTED ULTOMIRIS RIXUBIS INTRAVENOUS 2 SP INTRAVENOUS SOLUTION 2 SP SOLUTION VOLUVEN RECONSTITUTED INTRAVENOUS 2 SEVENFACT SOLUTION 6-0.9 % INTRAVENOUS VONVENDI 2 SP SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION SOLIRIS RECONSTITUTED INTRAVENOUS 2 SP WILATE 2 SP SOLUTION INTRAVENOUS KIT TAVALISSE ORAL XYNTHA 2 SP 2 SP TABLET INTRAVENOUS KIT THROMBIN-JMI XYNTHA SOLOFUSE 2 SP EPISTAXIS 2 INTRAVENOUS KIT EXTERNAL KIT ZARXIO INJECTION THROMBIN-JMI SOLUTION 2 SP 2 EXTERNAL KIT PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 75 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ZIEXTENZO ALTACE ORAL 2 SUBCUTANEOUS CAPSULE 2 SP SOLUTION ALTOPREV ORAL PREFILLED SYRINGE TABLET EXTENDED 2 Cardiovascular RELEASE 24 HOUR Agents - Drugs for amiloride hcl oral tablet 1 Heart and Circulation Conditions amiloride- hydrochlorothiazide 1 ACCUPRIL ORAL 2 oral tablet TABLET AMIODARONE HCL IN ACCURETIC ORAL 2 DEXTROSE TABLET INTRAVENOUS acebutolol hcl oral SOLUTION 1000-5 1 capsule MG/500ML-%, 150-5 2 acetazolamide sodium MG/100ML-%, 450-5 injection solution 1 MG/250ML-%, 750-5 reconstituted MG/500ML-%, 900-5 MG/500ML-% ADALAT CC ORAL TABLET EXTENDED amiodarone hcl 2 1 RELEASE 24 HOUR intravenous solution 30 MG, 60 MG, 90 MG amiodarone hcl oral 1 ADENOCARD tablet INTRAVENOUS 2 AMLODIPINE SOLUTION BES+SYRSPEND SF 2 intravenous ORAL SUSPENSION solution 12 mg/4ml, 6 1 amlodipine besylate 1 mg/2ml oral tablet ADENOSINE amlodipine besylate- INTRAVENOUS benazepril hcl oral 1 SOLUTION capsule 2 PREFILLED SYRINGE amlodipine besylate- 1 60 MG/20ML, 90 valsartan oral tablet MG/30ML amlodipine-atorvastatin 1 AKOVAZ oral tablet INTRAVENOUS 2 amlodipine-olmesartan SOLUTION 1 oral tablet ALDACTAZIDE ORAL 2 amlodipine-valsartan- TABLET 1 hctz oral tablet ALDACTONE ORAL 2 ANTARA ORAL TABLET 2 CAPSULE aliskiren fumarate oral 1 tablet ASCLERA INTRAVENOUS 2 alprostadil injection 1 SOLUTION solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 76 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ATACAND HCT ORAL BREVIBLOC IN NACL 2 TABLET INTRAVENOUS 2 ATACAND ORAL SOLUTION 2 TABLET BREVIBLOC atenolol oral tablet 1 INTRAVENOUS 2 SOLUTION ATENOLOL+SYRSPE ND SF ORAL 2 BREVIBLOC PREMIXED DS SUSPENSION 2 INTRAVENOUS atenolol-chlorthalidone 1 SOLUTION oral tablet BREVIBLOC atorvastatin calcium PREMIXED 1 2 oral tablet INTRAVENOUS AVALIDE ORAL SOLUTION 2 TABLET bumetanide injection 1 AVAPRO ORAL solution 2 TABLET bumetanide oral tablet 1 AZOR ORAL TABLET 2 BUMEX ORAL 2 benazepril hcl oral TABLET 1 tablet BYSTOLIC ORAL 2 benazepril- TABLET hydrochlorothiazide 1 BYVALSON ORAL 2 oral tablet TABLET 5-80 MG BENICAR HCT ORAL CADUET ORAL 2 2 TABLET TABLET BENICAR ORAL CALAN ORAL TABLET 2 2 TABLET 120 MG BETAPACE AF ORAL 2 CALAN SR ORAL TABLET TABLET EXTENDED 2 BETAPACE ORAL RELEASE 2 TABLET candesartan cilexetil 1 betaxolol hcl oral tablet 1 oral tablet BIDIL ORAL TABLET 2 candesartan cilexetil- 1 BIORPHEN hctz oral tablet INTRAVENOUS 2 captopril oral tablet 1 SOLUTION captopril- bisoprolol fumarate oral hydrochlorothiazide 1 1 tablet oral tablet bisoprolol- CARDENE IV hydrochlorothiazide 1 INTRAVENOUS 2 oral tablet SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 77 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CARDIZEM CD ORAL cholestyramine oral 1 CAPSULE EXTENDED 2 powder RELEASE 24 HOUR CLEVIPREX CARDIZEM LA ORAL INTRAVENOUS 2 TABLET EXTENDED 2 EMULSION RELEASE 24 HOUR clonidine hcl oral tablet 1 CARDIZEM ORAL clonidine transdermal 2 1 TABLET patch weekly CARDURA ORAL colesevelam hcl oral 2 1 TABLET packet CAROSPIR ORAL colesevelam hcl oral 2 1 SUSPENSION tablet cartia xt oral capsule COLESTID extended release 24 1 FLAVORED ORAL 2 hour GRANULES carvedilol oral tablet 1 COLESTID carvedilol phosphate er FLAVORED ORAL 2 oral capsule extended 1 PACKET release 24 hour COLESTID ORAL 2 CATAPRES ORAL GRANULES 2 TABLET COLESTID ORAL 2 CATAPRES-TTS-1 PACKET TRANSDERMAL 2 COLESTID ORAL 2 PATCH WEEKLY TABLET CATAPRES-TTS-2 colestipol hcl oral 1 TRANSDERMAL 2 granules PATCH WEEKLY colestipol hcl oral 1 CATAPRES-TTS-3 packet TRANSDERMAL 2 PATCH WEEKLY colestipol hcl oral tablet 1 chlorothiazide oral CONJUPRI ORAL 1 2 tablet 250 mg, 500 mg TABLET CONSENSI ORAL chlorothiazide sodium 2 intravenous solution 1 TABLET reconstituted COREG CR ORAL chlorthalidone oral CAPSULE EXTENDED 2 1 tablet RELEASE 24 HOUR cholestyramine light COREG ORAL 1 2 oral packet TABLET cholestyramine light CORGARD ORAL 1 2 oral powder TABLET cholestyramine oral CORLANOR ORAL 1 2 packet SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 78 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CORLANOR ORAL hcl er oral 2 TABLET capsule extended 1 CORLOPAM release 12 hour INTRAVENOUS diltiazem hcl er oral 2 SOLUTION 10 MG/ML, capsule extended 1 20 MG/2ML release 24 hour CORVERT diltiazem hcl 1 INTRAVENOUS 2 intravenous solution SOLUTION DILTIAZEM HCL CORZIDE ORAL INTRAVENOUS TABLET 40-5 MG, 80-5 2 SOLUTION 2 MG PREFILLED SYRINGE COZAAR ORAL 25 MG/5ML 2 TABLET diltiazem hcl CRESTOR ORAL intravenous solution 1 2 TABLET reconstituted DEMADEX ORAL diltiazem hcl oral tablet 1 2 TABLET 10 MG DILTIAZEM HCL- DEMSER ORAL DEXTROSE 2 2 CAPSULE INTRAVENOUS SOLUTION DIBENZYLINE ORAL 2 CAPSULE DILTIAZEM HCL- SODIUM CHLORIDE 2 digitek oral tablet 1 INTRAVENOUS digox oral tablet 1 SOLUTION digoxin injection dilt-xr oral capsule 1 solution extended release 24 1 digoxin oral solution 1 hour DIOVAN HCT ORAL digoxin oral tablet 1 2 TABLET DILATRATE-SR ORAL DIOVAN ORAL CAPSULE EXTENDED 2 2 RELEASE TABLET disopyramide diltiazem hcl er beads 1 oral capsule extended 1 phosphate oral capsule release 24 hour DIURIL ORAL 2 diltiazem hcl er coated SUSPENSION beads oral capsule dobutamine hcl 1 1 extended release 24 intravenous solution hour dobutamine in d5w 1 diltiazem hcl er coated intravenous solution beads oral tablet 1 dofetilide oral capsule 1 extended release 24 dopamine hcl hour 1 intravenous solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 79 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits dopamine in d5w EPHEDRINE 1 intravenous solution SULFATE-NACL doxazosin mesylate INTRAVENOUS 2 1 oral tablet SOLUTION PREFILLED SYRINGE DUTOPROL ORAL TABLET EXTENDED 2 EPINEPHRINE HCL- DEXTROSE RELEASE 24 HOUR 2 INTRAVENOUS DYAZIDE ORAL 2 SOLUTION CAPSULE EPINEPHRINE HCL- DYRENIUM ORAL 2 DEXTROSE CAPSULE INTRAVENOUS EDARBI ORAL SOLUTION 2 2 TABLET PREFILLED SYRINGE EDARBYCLOR ORAL 5000-5 MCG/50ML-%, 2 TABLET 750-5 MCG/25ML-% EDECRIN ORAL EPINEPHRINE HCL- 2 TABLET NACL EPIDURAL SOLUTION 2 enalapril maleate oral 1 PREFILLED SYRINGE tablet 80-0.9 MCG/10ML-% enalaprilat intravenous 1 EPINEPHRINE HCL- injectable NACL INTRAVENOUS 2 enalapril- SOLUTION hydrochlorothiazide 1 EPINEPHRINE HCL- oral tablet NACL INTRAVENOUS ENTRESTO ORAL SOLUTION 2 TABLET PREFILLED SYRINGE EPANED ORAL 10-0.9 MCG/10ML-%, 2 SOLUTION 100-0.9 MCG/10ML-%, 1000-0.9 MCG/10ML- EPHEDRINE %, 1000-0.9 SULFATE MCG/20ML-%, 1200- (PRESSORS) 2 0.9 MCG/50ML-%, 160- INJECTION 0.9 MCG/10ML-%, 200- 2 SOLUTION 0.9 MCG/10ML-%, 200- PREFILLED SYRINGE 0.9 MCG/20ML-%, ephedrine sulfate 3000-0.9 MCG/15ML- 1 intravenous solution %, 40-0.9 MCG/10ML- EPHEDRINE %, 50-0.9 MCG/5ML- SULFATE %, 500-0.9 MCG/10ML- INTRAVENOUS 2 %, 500-0.9 MCG/50ML- SOLUTION %, 5000-0.9 PREFILLED SYRINGE MCG/50ML-%, 6000- 0.9 MCG/50ML-%, 800- 0.9 MCG/50ML-%

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 80 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits EPINEPHRINE ethacrynate sodium INTRAVENOUS intravenous solution 1 2 SOLUTION reconstituted PREFILLED SYRINGE ethacrynic acid oral 1 epinephrine pf injection tablet 1 solution ETHAMOLIN epinephrine solution INTRAVENOUS 2 prefilled syringe 1 1 SOLUTION mg/10ml injection EXFORGE HCT ORAL 2 EPINEPHRINE TABLET SOLUTION EXFORGE ORAL 2 PREFILLED SYRINGE 2 TABLET 1 MG/10ML INJECTION EZALLOR SPRINKLE ORAL CAPSULE 2 EPINEPHRINE- SPRINKLE DEXTROSE 2 INTRAVENOUS ezetimibe oral tablet 1 SOLUTION ezetimibe-simvastatin 1 EPINEPHRINE-NACL oral tablet INTRAVENOUS felodipine er oral tablet 2 SOLUTION 2-0.9 extended release 24 1 MG/250ML-% hour EPINEPHRINE-NACL fenofibrate micronized 1 INTRAVENOUS oral capsule 2 SOLUTION fenofibrate oral capsule 1 PREFILLED SYRINGE fenofibrate oral tablet 1 eplerenone oral tablet 1 fenofibric acid oral eprosartan mesylate 1 capsule delayed 1 oral tablet 600 mg release esmolol hcl intravenous fenofibric acid oral 1 1 solution 100 mg/10ml tablet ESMOLOL HCL FENOGLIDE ORAL 2 INTRAVENOUS TABLET SOLUTION 2000 2 FIBRICOR ORAL MG/100ML, 2500 2 MG/250ML TABLET ESMOLOL HCL FIRST - INTRAVENOUS METOPROLOL ORAL 2 SOLUTION 2 SOLUTION PREFILLED SYRINGE FIRST-ATENOLOL 2 100 MG/10ML ORAL SOLUTION esmolol hcl-sodium flecainide acetate oral 1 chloride intravenous 1 tablet solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 81 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FLOLIPID ORAL INDERAL LA ORAL 2 SUSPENSION CAPSULE EXTENDED 2 fluvastatin sodium er RELEASE 24 HOUR oral tablet extended 1 INDERAL XL ORAL release 24 hour CAPSULE EXTENDED 2 fluvastatin sodium oral RELEASE 24 HOUR 1 capsule INNOPRAN XL ORAL fosinopril sodium oral CAPSULE EXTENDED 2 1 tablet RELEASE 24 HOUR fosinopril sodium-hctz INSPRA ORAL 1 2 oral tablet TABLET FUROSEMIDE IN irbesartan oral tablet 1 SODIUM CHLORIDE irbesartan- 2 INTRAVENOUS hydrochlorothiazide 1 SOLUTION oral tablet furosemide injection isoproterenol hcl 1 1 solution injection solution furosemide oral ISORDIL TITRADOSE 1 2 solution ORAL TABLET furosemide oral tablet 1 isosorbide dinitrate er gemfibrozil oral tablet 1 oral tablet extended 1 release 40 mg GONITRO isosorbide dinitrate oral SUBLINGUAL 2 1 PACKET tablet guanfacine hcl oral isosorbide mononitrate 1 tablet er oral tablet extended 1 release 24 hour HEMANGEOL ORAL 2 isosorbide mononitrate SOLUTION 1 oral tablet hydralazine hcl 1 injection solution isradipine oral capsule 1 hydralazine hcl oral ISUPREL INJECTION 1 2 tablet SOLUTION hydrochlorothiazide JUXTAPID ORAL 1 2 SP oral capsule CAPSULE hydrochlorothiazide KAPSPARGO 1 SPRINKLE ORAL oral tablet 2 CAPSULE ER 24 HYZAAR ORAL 2 HOUR SPRINKLE TABLET KATERZIA ORAL ibutilide fumarate 2 1 SUSPENSION intravenous solution indapamide oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 82 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LABETALOL HCL lisinopril- INTRAVENOUS hydrochlorothiazide 1 2 SOLUTION oral tablet PREFILLED SYRINGE LIVALO ORAL TABLET 2 labetalol hcl oral tablet 1 LOPID ORAL TABLET 2 labetalol hcl solution 5 LOPRESSOR HCT 1 2 mg/ml intravenous ORAL TABLET LABETALOL HCL LOPRESSOR ORAL 2 SOLUTION 5 MG/ML 2 TABLET INTRAVENOUS losartan potassium oral 1 LABETALOL HCL- tablet DEXTROSE losartan potassium-hctz INTRAVENOUS 1 SOLUTION 100-5 oral tablet 2 MG/100ML-%, 200-5 LOTENSIN HCT ORAL 2 MG/200ML-%, 250-5 TABLET MG/250ML-%, 500-5 LOTENSIN ORAL 2 MG/250ML-% TABLET LABETALOL HCL- LOTREL ORAL 2 SODIUM CHLORIDE CAPSULE INTRAVENOUS 2 SOLUTION 200-0.9 lovastatin oral tablet 1 MG/200ML-%, 500-0.9 LOVAZA ORAL 2 MG/500ML-% CAPSULE LANOXIN INJECTION mannitol intravenous 2 1 SOLUTION solution LANOXIN ORAL matzim la oral tablet 2 TABLET extended release 24 1 LANOXIN PEDIATRIC hour INJECTION 2 MAXZIDE ORAL 2 SOLUTION TABLET LASIX ORAL TABLET 2 MAXZIDE-25 ORAL 2 LESCOL XL ORAL TABLET TABLET EXTENDED 2 methyclothiazide oral 1 RELEASE 24 HOUR tablet 5 mg LEVOPHED methyldopa oral tablet 1 INTRAVENOUS 2 methyldopa- SOLUTION hydrochlorothiazide 1 LIPITOR ORAL oral tablet 2 TABLET metolazone oral tablet 1 LIPOFEN ORAL 2 metoprolol succinate er CAPSULE oral tablet extended 1 lisinopril oral tablet 1 release 24 hour

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 83 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits metoprolol tartrate MULTAQ ORAL 1 2 intravenous solution TABLET metoprolol tartrate nadolol oral tablet 1 intravenous solution 1 nadolol- cartridge 5 mg/5ml bendroflumethiazide 1 METOPROLOL oral tablet 40-5 mg TARTRATE NATRECOR INTRAVENOUS 2 INTRAVENOUS SOLUTION SOLUTION 2 PREFILLED SYRINGE RECONSTITUTED 1.5 5 MG/5ML MG metoprolol tartrate oral NEXLETOL ORAL 1 2 tablet TABLET METOPROLOL-HCTZ NEXLIZET ORAL 2 ER ORAL TABLET TABLET EXTENDED RELEASE 2 24 HOUR 100-12.5 NEXTERONE MG, 25-12.5 MG, 50- INTRAVENOUS 2 12.5 MG SOLUTION metoprolol- niacin hydrochlorothiazide 1 (antihyperlipidemic) 1 oral tablet oral tablet metyrosine oral capsule 1 niacin er (antihyperlipidemic) mexiletine hcl oral 1 1 oral tablet extended capsule release MICARDIS HCT ORAL 2 niacor oral tablet 1 TABLET NIASPAN ORAL MICARDIS ORAL 2 TABLET EXTENDED 2 TABLET RELEASE midodrine hcl oral 1 NICARDIPINE HCL IN tablet DEXTROSE lactate in INTRAVENOUS 2 dextrose intravenous 1 SOLUTION 25-5 solution MG/250ML-% milrinone lactate NICARDIPINE HCL IN 1 intravenous solution NACL INTRAVENOUS 2 MINIPRESS ORAL SOLUTION 2 CAPSULE NICARDIPINE HCL IN minitran transdermal NACL INTRAVENOUS 1 2 patch 24 hour SOLUTION PREFILLED SYRINGE minoxidil oral tablet 1 nicardipine hcl 1 moexipril hcl oral tablet 1 intravenous solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 84 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits nicardipine hcl oral NITROSTAT 1 capsule SUBLINGUAL TABLET 2 nifedipine er oral tablet SUBLINGUAL extended release 24 1 NITRO-TIME ORAL hour CAPSULE EXTENDED 2 nifedipine er osmotic RELEASE 2.5 MG release oral tablet norepinephrine 1 extended release 24 bitartrate intravenous 1 hour solution nifedipine oral capsule 1 NOREPINEPHRINE- DEXTROSE nimodipine oral capsule 1 2 INTRAVENOUS nisoldipine er oral tablet SOLUTION extended release 24 1 hour NOREPINEPHRINE- DEXTROSE NITRO-BID INTRAVENOUS 2 TRANSDERMAL 2 SOLUTION OINTMENT PREFILLED SYRINGE NITRO-DUR 40-5 MCG/10ML-% TRANSDERMAL 2 NOREPINEPHRINE- PATCH 24 HOUR SODIUM CHLORIDE 2 nitroglycerin in d5w INTRAVENOUS 1 intravenous solution SOLUTION nitroglycerin NOREPINEPHRINE- 1 intravenous solution SODIUM CHLORIDE nitroglycerin sublingual INTRAVENOUS 1 tablet sublingual SOLUTION PREFILLED SYRINGE 2 nitroglycerin 0.08-0.9 MG/10ML-%, transdermal patch 24 1 0.16-0.9 MG/10ML-%, hour 0.4-0.9 MG/50ML-%, nitroglycerin 0.8-0.9 MG/50ML-%, 2- 1 translingual solution 0.9 MG/50ML-% NITROLINGUAL NORPACE CR ORAL TRANSLINGUAL 2 CAPSULE EXTENDED 2 SOLUTION RELEASE 12 HOUR NITROMIST NORPACE ORAL 2 TRANSLINGUAL 2 CAPSULE AEROSOL SOLUTION NORTHERA ORAL 2 SP NITROPRESS CAPSULE INTRAVENOUS 2 NORVASC ORAL 2 SOLUTION TABLET nitroprusside sodium NYMALIZE ORAL 1 2 intravenous solution SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 85 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits olmesartan medoxomil PHENYLEPHRINE 1 oral tablet HCL-DEXTROSE olmesartan medoxomil- INTRAVENOUS 1 hctz oral tablet SOLUTION 10-5 MG/250ML-%, 100-5 olmesartan-amlodipine- 1 MG/250ML-%, 20-5 hctz oral tablet MG/250ML-%, 20-5 omega-3-acid ethyl MG/500ML-%, 200-5 1 2 esters oral capsule MG/250ML-%, 25-5 OSMITROL MG/250ML-%, 30-5 INTRAVENOUS 2 MG/250ML-%, 40-5 SOLUTION MG/250ML-%, 40-5 MG/500ML-%, 50-5 PACERONE ORAL 2 MG/250ML-%, 50-5 TABLET MG/500ML-%, 8-5 er oral MG/100ML-% 1 tablet extended release PHENYLEPHRINE perindopril erbumine HCL-NACL 1 2 oral tablet INTRAVENOUS phenoxybenzamine hcl SOLUTION 1 oral capsule PHENYLEPHRINE phentolamine mesylate HCL-NACL injection solution 1 INTRAVENOUS 2 reconstituted SOLUTION PREFILLED SYRINGE PHENYLEPHRINE HCL (PRESSORS) pindolol oral tablet 1 2 INTRAVENOUS PRALUENT SOLUTION SUBCUTANEOUS 2 PHENYLEPHRINE SOLUTION AUTO- HCL (PRESSORS) INJECTOR INTRAVENOUS 2 PRAVACHOL ORAL 2 SOLUTION TABLET PREFILLED SYRINGE pravastatin sodium oral 1 PHENYLEPHRINE tablet HCL INTRAVENOUS prazosin hcl oral 2 1 SOLUTION 1 capsule MG/10ML PRESTALIA ORAL 2 phenylephrine hcl TABLET intravenous solution 10 1 mg/ml prevalite oral packet 1 PHENYLEPHRINE prevalite oral powder 1 HCL INTRAVENOUS PRINIVIL ORAL 2 2 SOLUTION TABLET PREFILLED SYRINGE procainamide hcl 1 injection solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 86 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits PROCARDIA ORAL quinidine sulfate oral 2 1 CAPSULE tablet PROCARDIA XL ORAL ramipril oral capsule 1 TABLET EXTENDED 2 RANEXA ORAL RELEASE 24 HOUR TABLET EXTENDED 2 propafenone hcl er oral RELEASE 12 HOUR capsule extended 1 ranolazine er oral tablet release 12 hour extended release 12 1 propafenone hcl oral hour 1 tablet RECTIV RECTAL 2 propranolol hcl er oral OINTMENT capsule extended 1 REPATHA release 24 hour PUSHTRONEX propranolol hcl SYSTEM 1 2 intravenous solution SUBCUTANEOUS propranolol hcl oral SOLUTION 1 solution CARTRIDGE propranolol hcl oral REPATHA 1 SUBCUTANEOUS tablet 2 SOLUTION propranolol-hctz oral 1 PREFILLED SYRINGE tablet REPATHA PROSTIN VR SURECLICK INJECTION 2 SUBCUTANEOUS 2 SOLUTION SOLUTION AUTO- QBRELIS ORAL INJECTOR 2 SOLUTION rosuvastatin calcium 1 QUESTRAN LIGHT oral tablet 2 ORAL POWDER RYTHMOL SR ORAL QUESTRAN ORAL CAPSULE EXTENDED 2 2 PACKET RELEASE 12 HOUR QUESTRAN ORAL SIMVASTATIN ORAL 2 POWDER SUSPENSION 20 2 quinapril hcl oral tablet 1 MG/5ML quinapril- simvastatin oral tablet 1 hydrochlorothiazide 1 SODIUM DIURIL oral tablet INTRAVENOUS 2 quinidine gluconate er SOLUTION oral tablet extended 1 RECONSTITUTED release SODIUM EDECRIN INTRAVENOUS QUINIDINE 2 GLUCONATE SOLUTION 2 INJECTION RECONSTITUTED SOLUTION 80 MG/ML

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 87 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sodium nitroprusside TIAZAC ORAL 1 intravenous solution CAPSULE EXTENDED 2 sorine oral tablet 1 RELEASE 24 HOUR sotalol hcl (af) oral TIKOSYN ORAL 1 2 tablet CAPSULE timolol maleate oral SOTALOL HCL 1 INTRAVENOUS 2 tablet SOLUTION TOPROL XL ORAL sotalol hcl oral tablet 1 TABLET EXTENDED 2 RELEASE 24 HOUR SOTYLIZE ORAL 2 SOLUTION torsemide oral tablet 1 spironolactone oral trandolapril oral tablet 1 1 tablet trandolapril-verapamil spironolactone-hctz hcl er oral tablet 1 1 oral tablet extended release triamterene oral SULAR ORAL TABLET 1 EXTENDED RELEASE 2 capsule 24 HOUR triamterene-hctz oral 1 TARKA ORAL TABLET capsule 2 EXTENDED RELEASE triamterene-hctz oral 1 taztia xt oral capsule tablet extended release 24 1 TRIBENZOR ORAL 2 hour TABLET TEKTURNA HCT TRICOR ORAL 2 2 ORAL TABLET TABLET TEKTURNA ORAL TRIGLIDE ORAL 2 2 TABLET TABLET 160 MG telmisartan oral tablet 1 TRILIPIX ORAL telmisartan-amlodipine CAPSULE DELAYED 2 1 oral tablet RELEASE telmisartan-hctz oral TWYNSTA ORAL 1 2 tablet TABLET TENORETIC 100 valsartan oral tablet 1 2 ORAL TABLET valsartan- TENORETIC 50 ORAL hydrochlorothiazide 1 2 TABLET oral tablet TENORMIN ORAL VARITHENA 2 2 TABLET INTRAVENOUS FOAM VASCEPA ORAL tiadylt er oral capsule 2 extended release 24 1 CAPSULE hour VASERETIC ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 88 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VASOTEC ORAL Central Nervous 2 TABLET System Agents - VAZCULEP Drugs for Attention INTRAVENOUS 2 Deficit Disorder SOLUTION ADDERALL ORAL 2 VECAMYL ORAL TABLET 2 TABLET ADDERALL XR ORAL verapamil hcl er oral CAPSULE EXTENDED 2 capsule extended 1 RELEASE 24 HOUR release 24 hour ADHANSIA XR ORAL verapamil hcl er oral CAPSULE EXTENDED 2 1 tablet extended release RELEASE 24 HOUR verapamil hcl ADZENYS ER ORAL 1 intravenous solution SUSPENSION 2 EXTENDED RELEASE verapamil hcl oral tablet 1 ADZENYS XR-ODT VERELAN ORAL ORAL TABLET 2 CAPSULE EXTENDED 2 EXTENDED RELEASE RELEASE 24 HOUR DISPERSIBLE VERELAN PM ORAL AMPHETAMINE ER CAPSULE EXTENDED 2 ORAL SUSPENSION 2 RELEASE 24 HOUR EXTENDED RELEASE VYNDAMAX ORAL amphetamine sulfate 2 SP 1 CAPSULE oral tablet VYNDAQEL ORAL 2 SP amphetamine- CAPSULE dextroamphetamine er 1 VYTORIN ORAL oral capsule extended 2 TABLET release 24 hour WELCHOL ORAL amphetamine- 2 PACKET dextroamphetamine 1 WELCHOL ORAL oral tablet 2 TABLET APTENSIO XR ORAL ZESTORETIC ORAL CAPSULE EXTENDED 2 2 TABLET RELEASE 24 HOUR ZESTRIL ORAL atomoxetine hcl oral 2 1 TABLET capsule ZETIA ORAL TABLET 2 clonidine hcl er oral tablet extended release 1 ZIAC ORAL TABLET 2 12 hour ZOCOR ORAL 2 CONCERTA ORAL TABLET TABLET EXTENDED 2 ZYPITAMAG ORAL RELEASE 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 89 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits COTEMPLA XR-ODT INTUNIV ORAL ORAL TABLET TABLET EXTENDED 2 2 EXTENDED RELEASE RELEASE 24 HOUR DISPERSIBLE JORNAY PM ORAL DAYTRANA CAPSULE EXTENDED 2 TRANSDERMAL 2 RELEASE 24 HOUR PATCH KAPVAY ORAL DESOXYN ORAL TABLET EXTENDED 2 2 TABLET RELEASE 12 HOUR DEXEDRINE ORAL metadate er oral tablet 1 CAPSULE EXTENDED 2 extended release RELEASE 24 HOUR methamphetamine hcl 1 dexmethylphenidate hcl oral tablet er oral capsule METHYLIN ORAL 1 2 extended release 24 SOLUTION hour methylphenidate hcl er dexmethylphenidate hcl 1 (cd) oral capsule 1 oral tablet extended release dextroamphetamine methylphenidate hcl er sulfate er oral capsule (la) oral capsule 1 1 extended release 24 extended release 24 hour hour dextroamphetamine 1 methylphenidate hcl er sulfate oral solution (xr) oral capsule 1 dextroamphetamine extended release 24 1 sulfate oral tablet hour DYANAVEL XR ORAL methylphenidate hcl er SUSPENSION 2 oral tablet extended 1 EXTENDED RELEASE release EVEKEO ODT ORAL methylphenidate hcl er TABLET 2 oral tablet extended 1 DISPERSIBLE release 24 hour EVEKEO ORAL methylphenidate hcl 2 1 TABLET oral solution FOCALIN ORAL methylphenidate hcl 2 1 TABLET oral tablet FOCALIN XR ORAL methylphenidate hcl 1 CAPSULE EXTENDED 2 oral tablet chewable RELEASE 24 HOUR MYDAYIS ORAL guanfacine hcl er oral CAPSULE EXTENDED 2 tablet extended release 1 RELEASE 24 HOUR 24 hour PROCENTRA ORAL 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 90 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits QUILLICHEW ER COPAXONE ORAL TABLET SUBCUTANEOUS 2 2 SP CHEWABLE SOLUTION EXTENDED RELEASE PREFILLED SYRINGE QUILLIVANT XR ORAL dalfampridine er oral SUSPENSION 2 tablet extended release 1 SP RECONSTITUTED ER 12 hour relexxii oral tablet dimethyl fumarate oral 1 extended release capsule delayed 1 SP RITALIN LA ORAL release CAPSULE EXTENDED 2 dimethyl fumarate 1 SP RELEASE 24 HOUR starter pack oral RITALIN ORAL EXTAVIA 2 2 SP TABLET SUBCUTANEOUS KIT STRATTERA ORAL GILENYA ORAL 2 2 SP CAPSULE CAPSULE VYVANSE ORAL glatiramer acetate 2 CAPSULE subcutaneous solution 1 SP VYVANSE ORAL prefilled syringe 2 TABLET CHEWABLE glatopa subcutaneous ZENZEDI ORAL solution prefilled 1 SP 2 TABLET syringe Central Nervous KESIMPTA SUBCUTANEOUS System Agents - 2 SP Drugs for Multiple SOLUTION AUTO- Sclerosis INJECTOR AMPYRA ORAL LEMTRADA TABLET EXTENDED 2 SP INTRAVENOUS 2 SP RELEASE 12 HOUR SOLUTION AUBAGIO ORAL MAVENCLAD (10 2 SP TABLET TABS) ORAL TABLET 2 SP THERAPY PACK AVONEX PEN INTRAMUSCULAR 2 SP MAVENCLAD (4 AUTO-INJECTOR KIT TABS) ORAL TABLET 2 SP THERAPY PACK AVONEX PREFILLED INTRAMUSCULAR MAVENCLAD (5 2 SP PREFILLED SYRINGE TABS) ORAL TABLET 2 SP KIT THERAPY PACK BAFIERTAM ORAL MAVENCLAD (6 CAPSULE DELAYED 2 SP TABS) ORAL TABLET 2 SP RELEASE THERAPY PACK BETASERON MAVENCLAD (7 2 SP SUBCUTANEOUS KIT TABS) ORAL TABLET 2 SP THERAPY PACK

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 91 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits MAVENCLAD (8 REBIF TITRATION TABS) ORAL TABLET 2 SP PACK THERAPY PACK SUBCUTANEOUS 2 SP MAVENCLAD (9 SOLUTION TABS) ORAL TABLET 2 SP PREFILLED SYRINGE THERAPY PACK TECFIDERA 2 SP MAYZENT ORAL STARTER PACK 2 SP TABLET TECFIDERA ORAL MAYZENT STARTER CAPSULE DELAYED 2 SP PACK ORAL TABLET 2 SP RELEASE THERAPY PACK TYSABRI OCREVUS INTRAVENOUS 2 SP INTRAVENOUS 2 SP CONCENTRATE SOLUTION VUMERITY (STARTER) ORAL PLEGRIDY STARTER 2 SP PACK CAPSULE DELAYED SUBCUTANEOUS 2 SP RELEASE 231 MG SOLUTION PEN- VUMERITY ORAL INJECTOR CAPSULE DELAYED 2 SP PLEGRIDY STARTER RELEASE PACK ZEPOSIA 7-DAY SUBCUTANEOUS 2 SP STARTER PACK 2 SP SOLUTION ORAL CAPSULE PREFILLED SYRINGE THERAPY PACK PLEGRIDY ZEPOSIA ORAL 2 SP SUBCUTANEOUS CAPSULE 2 SP SOLUTION PEN- ZEPOSIA STARTER INJECTOR KIT ORAL CAPSULE 2 SP PLEGRIDY THERAPY PACK SUBCUTANEOUS 2 SP Central Nervous SOLUTION System Agents - PREFILLED SYRINGE Miscellaneous REBIF REBIDOSE ADDYI ORAL TABLET 2 SUBCUTANEOUS 2 SP ADIPEX-P ORAL SOLUTION AUTO- 2 INJECTOR CAPSULE ADIPEX-P ORAL REBIF REBIDOSE 2 TITRATION PACK TABLET SUBCUTANEOUS 2 SP ANECTINE SOLUTION AUTO- INJECTION 2 INJECTOR SOLUTION REBIF atracurium besylate 1 SUBCUTANEOUS intravenous solution 2 SP SOLUTION AUSTEDO ORAL 2 SP PREFILLED SYRINGE TABLET You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 92 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits benzphetamine hcl oral INGREZZA ORAL 1 tablet CAPSULE THERAPY 2 SP CAFCIT PACK INTRAVENOUS 2 LOMAIRA ORAL 2 SOLUTION TABLET LYRICA CR ORAL 1 intravenous solution TABLET EXTENDED 2 caffeine citrate oral RELEASE 24 HOUR 1 solution LYRICA ORAL 2 CAFFEINE-SODIUM CAPSULE BENZOATE LYRICA ORAL 2 2 INJECTION SOLUTION SOLUTION NEURAPTINE 2 cisatracurium besylate EXTERNAL CREAM (pf) intravenous 1 NIMBEX solution INTRAVENOUS 2 cisatracurium besylate SOLUTION 1 intravenous solution NUEDEXTA ORAL 2 CISATRACURIUM CAPSULE BESYLATE ONPATTRO INTRAVENOUS INTRAVENOUS 2 SP SOLUTION 2 SOLUTION PREFILLED SYRINGE pancuronium bromide 10 MG/5ML, 20 1 MG/10ML intravenous solution CONTRAVE ORAL phendimetrazine tartrate er oral capsule TABLET EXTENDED 2 1 RELEASE 12 HOUR extended release 24 hour diethylpropion hcl er phendimetrazine oral tablet extended 1 1 release 24 hour tartrate oral tablet diethylpropion hcl oral phentermine hcl oral 1 1 tablet capsule phentermine hcl oral DOPRAM 1 INTRAVENOUS 2 tablet SOLUTION pregabalin oral capsule 1 GRALISE ORAL pregabalin oral solution 1 2 TABLET QSYMIA ORAL HORIZANT ORAL CAPSULE EXTENDED 2 TABLET EXTENDED 2 RELEASE 24 HOUR RELEASE QUELICIN INJECTION 2 INGREZZA ORAL SOLUTION 2 SP CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 93 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits RADICAVA tetrabenazine oral 1 SP INTRAVENOUS 2 SP tablet SOLUTION TIGLUTIK ORAL 2 SP REGIMEX ORAL SUSPENSION 2 TABLET 25 MG VECURONIUM RILUTEK ORAL BROMIDE 2 TABLET INTRAVENOUS 2 riluzole oral tablet 1 SOLUTION PREFILLED SYRINGE rocuronium bromide 1 intravenous solution vecuronium bromide intravenous solution 1 ROCURONIUM reconstituted BROMIDE INTRAVENOUS 2 VYLEESI SUBCUTANEOUS SOLUTION 2 PREFILLED SYRINGE SOLUTION AUTO- INJECTOR SAVELLA ORAL 2 XENAZINE ORAL TABLET 2 SP TABLET SAVELLA TITRATION 2 XENICAL ORAL PACK ORAL 2 CAPSULE SAXENDA SUBCUTANEOUS Dental and Oral 2 SOLUTION PEN- Agents - Drugs for INJECTOR Mouth and Throat Conditions SUCCINYLCHOLINE CHLORIDE cavarest dental gel 1 INJECTION 2 cevimeline hcl oral 1 SOLUTION capsule PREFILLED SYRINGE chlorhexidine gluconate 1 SUCCINYLCHOLINE mouth/throat solution CHLORIDE CLINPRO 5000 2 INTRAVENOUS 2 DENTAL PASTE SOLUTION PREFILLED SYRINGE DEBACTEROL MOUTH/THROAT 2 succinylcholine chloride SOLUTION solution 20 mg/ml 1 DENTA 5000 PLUS injection 2 DENTAL CREAM SUCCINYLCHOLINE DENTAGEL DENTAL CHLORIDE SOLUTION 2 2 20 MG/ML INJECTION GEL TEGSEDI easygel dental gel 1 SUBCUTANEOUS EVOXAC ORAL 2 SP 2 SOLUTION CAPSULE PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 94 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FIRST-MOUTHWASH paroex mouth/throat 1 BLM MOUTH/THROAT 2 solution SUSPENSION PERIDEX fluoridex daily renewal MOUTH/THROAT 2 mouth/throat 1 SOLUTION concentrate periogard mouth/throat 1 FLUORIDEX DENTAL solution 2 PASTE pilocarpine hcl oral 1 FLUORIDEX tablet ENHANCED 2 PREVIDENT 5000 WHITENING DENTAL BOOSTER PLUS 2 PASTE DENTAL PASTE FLUORIDEX PREVIDENT 5000 SENSITIVITY RELIEF 2 DRY MOUTH DENTAL 2 DENTAL PASTE GEL KEPIVANCE PREVIDENT 5000 INTRAVENOUS 2 SP ENAMEL PROTECT 2 SOLUTION DENTAL PASTE RECONSTITUTED PREVIDENT 5000 lidocaine hcl 1 ORTHO DEFENSE 2 mouth/throat solution DENTAL PASTE lidocaine viscous hcl 1 PREVIDENT 5000 mouth/throat solution PLUS DENTAL 2 MI PASTE DENTAL CREAM 2 PASTE PREVIDENT 5000 MI PASTE PLUS SENSITIVE DENTAL 2 2 DENTAL PASTE PASTE NAFRINSE DAILY PREVIDENT DENTAL 2 ACIDULATED GEL MOUTH/THROAT 2 prevident mouth/throat 1 SOLUTION solution RECONSTITUTED REMESENSE DENTAL 2 NAFRINSE SALAGEN ORAL DAILY/NEUTRAL 2 MOUTH/THROAT 2 TABLET SOLUTION sf 5000 plus dental 1 RECONSTITUTED cream NAFRINSE WEEKLY sf dental gel 1 MOUTH/THROAT sodium fluoride 5000 2 1 SOLUTION plus dental cream RECONSTITUTED sodium fluoride 5000 oralone mouth/throat 1 1 ppm dental cream paste sodium fluoride 5000 1 ppm dental paste You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 95 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sodium fluoride 5000 adapalene-benzoyl 1 1 sensitive dental paste peroxide external gel sodium fluoride dental AKLIEF EXTERNAL 1 2 cream CREAM sodium fluoride dental AKTIPAK EXTERNAL 1 2 gel PACKET 5-3 % TOPEX TOPICAL ALA SCALP 2 ANESTHETIC EXTERNAL LOTION 2 MOUTH/THROAT ala-cort external cream 1 AEROSOL alclometasone triamcinolone acetonide 1 dipropionate external 1 mouth/throat paste cream Dermatological alclometasone Agents - Drugs for dipropionate external 1 Skin Conditions ointment A.A.G.C. KIT IN ALCOHOL PREP TERODERM 2 PADS EXTERNAL 70 2 EXTERNAL CREAM % ABSORICA LD ORAL ALDARA EXTERNAL 2 2 CAPSULE CREAM ABSORICA ORAL ALTRENO EXTERNAL 2 2 CAPSULE LOTION ACANYA EXTERNAL 2 ALUMINUM GEL CHLORIDE 2 acitretin oral capsule 1 ANHYDROUS ACTIVE-PREP KIT IV POWDER 2 EXTERNAL CREAM ALUMINUM ACTIVE-TRAMADOL CHLORIDE 2 2 EXTERNAL CREAM HEXAHYDRATE POWDER ACZONE EXTERNAL 2 amcinonide external GEL 1 cream adapalene external 1 amcinonide external cream 1 lotion adapalene external gel 1 amcinonide external 1 ADAPALENE ointment EXTERNAL LOTION 2 ammonium lactate 0.1 % 1 external cream ADAPALENE 2 ammonium lactate EXTERNAL PAD 1 external lotion ADAPALENE amnesteem oral EXTERNAL 2 1 SOLUTION capsule

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 96 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits AMZEEQ EXTERNAL betamethasone 2 FOAM dipropionate aug 1 APEXICON E external lotion 2 EXTERNAL CREAM betamethasone AQUACEL AG BURN dipropionate aug 1 2 EXTERNAL PAD external ointment ARAZLO EXTERNAL betamethasone 2 LOTION dipropionate external 1 cream ATRALIN EXTERNAL 2 GEL betamethasone dipropionate external 1 ATRAPRO DERMAL lotion SPRAY EXTERNAL 2 LIQUID betamethasone dipropionate external 1 AVAGE EXTERNAL 2 ointment CREAM 0.1 % betamethasone AVITA EXTERNAL 1 2 valerate external cream CREAM betamethasone AVITA EXTERNAL 1 2 valerate external foam GEL betamethasone azelaic acid external 1 1 valerate external lotion gel betamethasone AZELEX EXTERNAL 2 valerate external 1 CREAM ointment balsam peru-castor oil 1 blanche external cream 1 external ointment BOTOX COSMETIC BENZACLIN INTRAMUSCULAR 2 2 SP EXTERNAL GEL SOLUTION BENZACLIN WITH RECONSTITUTED PUMP EXTERNAL 2 BPCO EXTERNAL 2 GEL OINTMENT BENZAMYCIN BRYHALI EXTERNAL 2 2 EXTERNAL GEL LOTION benzoyl peroxide- CALAMINE POWDER 2 erythromycin external 1 calcipotriene external gel 1 cream beser external lotion 1 CALCIPOTRIENE 2 betamethasone EXTERNAL FOAM dipropionate aug 1 calcipotriene external external cream 1 ointment betamethasone calcipotriene external dipropionate aug 1 1 external gel solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 97 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits calcipotriene-betameth clindamycin phosphate 1 diprop external 1 gel 1 % external ointment CLINDAMYCIN calcipotriene-betameth PHOSPHATE GEL 1 % 2 diprop external 1 EXTERNAL suspension clindamycin-tretinoin 1 CALCITRENE external gel EXTERNAL 2 CLINOIN EXTERNAL 2 OINTMENT CREAM calcitriol external 1 clobetasol prop ointment emollient base external 1 CAPEX EXTERNAL cream 2 SHAMPOO clobetasol propionate e 1 CARAC EXTERNAL external cream 2 CREAM clobetasol propionate 1 claravis oral capsule 1 emulsion external foam CLEOCIN-T clobetasol propionate 2 1 EXTERNAL GEL 1 % external cream CLEOCIN-T clobetasol propionate 2 1 EXTERNAL LOTION external foam CLEOCIN-T clobetasol propionate 1 EXTERNAL 2 external gel SOLUTION 1 % clobetasol propionate 1 CLEOCIN-T external liquid 2 EXTERNAL SWAB 1 % clobetasol propionate 1 clindacin etz external external lotion 1 swab clobetasol propionate 1 clindacin-p external external ointment 1 swab clobetasol propionate 1 CLINDAGEL external shampoo 2 EXTERNAL GEL clobetasol propionate 1 clindamycin phos- external solution benzoyl perox external 1 CLOBEX EXTERNAL 2 gel LOTION clindamycin phosphate CLOBEX EXTERNAL 1 2 external foam SHAMPOO clindamycin phosphate CLOBEX SPRAY 1 2 external lotion EXTERNAL LIQUID clindamycin phosphate clocortolone pivalate 1 1 external solution external cream clindamycin phosphate 1 external swab

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 98 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits clocortolone pivalate DESONATE 2 pump external cream 1 EXTERNAL GEL 0.1 % desonide external 1 clodan external cream 1 shampoo desonide external gel 1 CLODERM EXTERNAL 2 desonide external lotion 1 CREAM desonide external 1 CLODERM PUMP ointment EXTERNAL CREAM 2 DESOWEN 0.1 % 2 EXTERNAL CREAM coal tar external 1 solution DESOWEN EXTERNAL LOTION 2 CONDYLOX 2 0.05 % EXTERNAL GEL desoximetasone CORDRAN 1 2 external cream EXTERNAL CREAM desoximetasone CORDRAN 1 2 external gel EXTERNAL LOTION desoximetasone 1 CORDRAN external liquid EXTERNAL 2 desoximetasone OINTMENT 1 external ointment CORDRAN 2 diclofenac sodium EXTERNAL TAPE 1 external gel 3 % CORTISPORIN 2 DIFFERIN EXTERNAL EXTERNAL CREAM 2 CREAM CORTISPORIN DIFFERIN EXTERNAL EXTERNAL 2 2 OINTMENT GEL CUTIVATE EXTERNAL DIFFERIN EXTERNAL 2 2 LOTION LOTION dapsone external gel 5 diflorasone diacetate 1 1 % external cream DAPSONE EXTERNAL diflorasone diacetate 2 1 GEL 7.5 % external ointment DERMA-SMOOTHE/FS DIPROLENE AF 2 2 BODY EXTERNAL OIL EXTERNAL CREAM DERMA-SMOOTHE/FS DIPROLENE SCALP EXTERNAL 2 EXTERNAL 2 OIL OINTMENT DOVONEX EXTERNAL DERMULCERA 2 EXTERNAL 2 CREAM OINTMENT doxepin hcl external 1 cream

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 99 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits doxycycline oral erythromycin external 1 capsule delayed 1 gel release erythromycin external 1 DRYSOL EXTERNAL pad 2 % 2 SOLUTION erythromycin external 1 DUAC EXTERNAL solution 2 GEL 1.2-5 % EUCRISA EXTERNAL 2 DUOBRII EXTERNAL OINTMENT 2 LOTION EVOCLIN EXTERNAL 2 DUPIXENT FOAM SUBCUTANEOUS FABIOR EXTERNAL 2 SP 2 SOLUTION PEN- FOAM INJECTOR FINACEA EXTERNAL 2 DUPIXENT FOAM SUBCUTANEOUS 2 SP FINACEA EXTERNAL SOLUTION 2 PREFILLED SYRINGE GEL EFUDEX EXTERNAL finasteride oral tablet 1 2 1 CREAM mg ELIDEL EXTERNAL fluocinolone acetonide 2 1 CREAM body external oil ELOCON EXTERNAL fluocinolone acetonide 2 1 CREAM 0.1 % external cream fluocinolone acetonide ENOVARX- 1 TRAMADOL 2 external ointment EXTERNAL CREAM fluocinolone acetonide 1 ENSTILAR EXTERNAL external solution 2 FOAM fluocinolone acetonide 1 ENTTY SPRAY scalp external oil EXTERNAL 2 fluocinonide emulsified 1 EMULSION base external cream EPIDUO EXTERNAL fluocinonide external 2 1 GEL cream EPIDUO FORTE fluocinonide external 2 1 EXTERNAL GEL gel EPIFOAM EXTERNAL fluocinonide external 2 1 FOAM ointment EPIQUIN MICRO fluocinonide external 2 1 EXTERNAL CREAM solution ery external pad 1 FLUOROPLEX 2 ERYGEL EXTERNAL EXTERNAL CREAM 2 GEL

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 100 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FLUOROURACIL hydrocortisone butyrate 1 EXTERNAL CREAM 2 external cream 0.5 % hydrocortisone butyrate 1 fluorouracil external external lotion 1 cream 5 % hydrocortisone butyrate 1 fluorouracil external external ointment 1 solution hydrocortisone butyrate 1 flurandrenolide external external solution 1 cream hydrocortisone external 1 flurandrenolide external cream 1 %, 2.5 % 1 lotion hydrocortisone external 1 flurandrenolide external lotion 2.5 % 1 ointment hydrocortisone external 1 fluticasone propionate ointment 1 %, 2.5 % 1 external cream hydrocortisone in fluticasone propionate absorbase external 1 1 external lotion ointment 1 % fluticasone propionate hydrocortisone valerate 1 1 external ointment external cream GORDOFILM hydrocortisone valerate 1 EXTERNAL 2 external ointment SOLUTION hydroquinone external 1 halcinonide external cream 1 cream hydroquinone time 1 halobetasol propionate release external cream 1 external cream imiquimod external 1 HALOBETASOL cream PROPIONATE 2 IMIQUIMOD PUMP 2 EXTERNAL FOAM EXTERNAL CREAM halobetasol propionate IMPOYZ EXTERNAL 1 2 external ointment CREAM HALOG EXTERNAL 2 isotretinoin oral capsule 1 CREAM ivermectin external HALOG EXTERNAL 1 2 cream 1 % OINTMENT KENALOG EXTERNAL HALOG EXTERNAL 2 2 AEROSOL SOLUTION SOLUTION KERAMATRIX HYALUCIL-4 REPLICINE 5CMX5CM 2 TRANSDERMAL 2 EXTERNAL SHEET CREAM KLARON EXTERNAL 2 hydrocortisone butyr LOTION lipo base external 1 cream You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 101 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits KYBELLA MICROCYN 2 SUBCUTANEOUS 2 EXTERNAL LIQUID SOLUTION MIMYX EXTERNAL 2 LAC-HYDRIN CREAM EXTERNAL CREAM 12 2 MIRVASO EXTERNAL 2 % GEL lactic acid e external mometasone furoate 1 1 cream external cream lactic acid external mometasone furoate 1 1 lotion external ointment LEVULAN KERASTICK mometasone furoate EXTERNAL 1 2 external solution SOLUTION RECONSTITUTED myorisan oral capsule 1 LEXETTE EXTERNAL NEO-SYNALAR 2 2 FOAM EXTERNAL CREAM LOCOID EXTERNAL neuac external gel 1 2 CREAM 0.1 % nolix external cream 1 LOCOID EXTERNAL nolix external lotion 1 2 LOTION NORITATE 2 LOCOID EXTERNAL EXTERNAL CREAM 2 SOLUTION 0.1 % OLUX EXTERNAL 2 LOCOID LIPOCREAM FOAM 2 EXTERNAL CREAM OLUX-E EXTERNAL 2 LUXIQ EXTERNAL FOAM 2 FOAM ONEXTON EXTERNAL 2 methoxsalen rapid oral GEL 1 capsule ORACEA ORAL METROCREAM CAPSULE DELAYED 2 2 EXTERNAL CREAM RELEASE METROGEL OXSORALEN ULTRA 2 2 EXTERNAL GEL ORAL CAPSULE METROLOTION PANDEL EXTERNAL 2 2 EXTERNAL LOTION CREAM metronidazole external PICATO EXTERNAL 1 2 cream GEL metronidazole external pimecrolimus external 1 1 gel cream metronidazole external podofilox external 1 1 lotion solution MICORT-HC prednicarbate external 1 EXTERNAL CREAM 2 cream 2.5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 102 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits prednicarbate external RIAX EXTERNAL 1 2 ointment FOAM PROPECIA ORAL rosadan external cream 1 2 TABLET rosadan external gel 1 PROTOPIC SANTYL EXTERNAL 2 EXTERNAL 2 OINTMENT OINTMENT SCENESSE PRUDOXIN 2 SUBCUTANEOUS 2 SP EXTERNAL CREAM IMPLANT PSORCON selenium sulfide 2 1 EXTERNAL CREAM external lotion PYROGALLIC ACID SERNIVO EXTERNAL 2 EXTERNAL 2 EMULSION OINTMENT SOOLANTRA QBREXZA EXTERNAL 2 2 EXTERNAL CREAM PAD SORIATANE ORAL RADIAPLEXRX 2 2 CAPSULE EXTERNAL GEL SORILUX EXTERNAL REFISSA EXTERNAL 2 2 FOAM CREAM sulfacetamide sodium REGENECARE 1 2 (acne) external lotion EXTERNAL GEL SYNALAR EXTERNAL REGRANEX 2 2 CREAM EXTERNAL GEL SYNALAR EXTERNAL remergent hq external 2 1 OINTMENT cream SYNALAR EXTERNAL RENOVA EXTERNAL 2 2 SOLUTION CREAM TACLONEX RENOVA PUMP 2 EXTERNAL 2 EXTERNAL CREAM OINTMENT RETIN-A EXTERNAL 2 TACLONEX CREAM EXTERNAL 2 RETIN-A EXTERNAL SUSPENSION 2 GEL tacrolimus external 1 RETIN-A MICRO ointment 2 EXTERNAL GEL tazarotene external 1 RETIN-A MICRO cream PUMP EXTERNAL 2 TAZORAC EXTERNAL 2 GEL CREAM RHOFADE EXTERNAL TAZORAC EXTERNAL 2 2 CREAM GEL

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 103 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits TEMOVATE TRIANEX EXTERNAL 2 2 EXTERNAL CREAM OINTMENT TEMOVATE TRI-CHLOR 2 EXTERNAL 2 EXTERNAL LIQUID OINTMENT triderm external cream 1 TEXACORT TRIDESILON 2 EXTERNAL 2 EXTERNAL CREAM SOLUTION TRI-LUMA EXTERNAL THERAHONEY 2 2 CREAM EXTERNAL SHEET ULTRAVATE tl hydroquinone 1 EXTERNAL CREAM 2 external cream 0.05 % TOLAK EXTERNAL ULTRAVATE 2 SP 2 CREAM EXTERNAL LOTION TOPICORT 2 ULTRAVATE EXTERNAL CREAM EXTERNAL 2 TOPICORT OINTMENT 0.05 % 2 EXTERNAL GEL VANIQA EXTERNAL 2 TOPICORT CREAM EXTERNAL 2 VANOS EXTERNAL 2 OINTMENT CREAM TOPICORT SPRAY 2 VASHE CLEANSING EXTERNAL LIQUID EXTERNAL 2 tovet external foam 1 SOLUTION tretinoin (emollient) VECTICAL EXTERNAL 1 2 external cream OINTMENT tretinoin external cream 1 VELTIN EXTERNAL 2 tretinoin external gel 1 GEL tretinoin microsphere VENELEX EXTERNAL 1 2 external gel OINTMENT tretinoin microsphere VERDESO EXTERNAL 1 2 pump external gel FOAM VEREGEN EXTERNAL triamcinolone acetonide 2 external aerosol 1 OINTMENT solution XALIX EXTERNAL 2 triamcinolone acetonide SOLUTION 1 external cream XERAC AC triamcinolone acetonide EXTERNAL 2 1 external lotion SOLUTION triamcinolone acetonide XEROFORM OIL 1 external ointment EMULSION 2"X2" 2 EXTERNAL PAD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 104 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits XEROFORM OIL ACTOPLUS MET XR EMULSION GAUZE 2 ORAL TABLET EXTERNAL PAD EXTENDED RELEASE 2 XEROFORM OIL 24 HOUR 15-1000 MG, EMULSION STRIP 2 30-1000 MG EXTERNAL ACTOS ORAL TABLET 2 XEROFORM OIL ROLL ADLYXIN STARTER 2 4"X9' EXTERNAL PACK 2 XEROFORM SUBCUTANEOUS PETROLAT GAUZE 2 PEN-INJECTOR KIT 1"X8" EXTERNAL ADLYXIN SUBCUTANEOUS XEROFORM 2 PETROLAT GAUZE 2 SOLUTION PEN- 5"X9" EXTERNAL INJECTOR XEROFORM ALOGLIPTIN PETROLAT PATCH 2 BENZOATE ORAL 2 2"X2" EXTERNAL PAD TABLET XEROFORM ALOGLIPTIN- PETROLAT PATCH 2 METFORMIN HCL 2 4"X4" EXTERNAL PAD ORAL TABLET XEROFORM ALOGLIPTIN- PETROLATUM ROLL 2 PIOGLITAZONE ORAL 2 4"X9' EXTERNAL TABLET AMARYL ORAL zenatane oral capsule 1 2 TABLET ZIANA EXTERNAL 2 AVANDIA ORAL GEL 2 TABLET ZILXI EXTERNAL 2 FOAM BYDUREON BCISE AUTOINJECTOR ZONALON EXTERNAL 2 2 SUBCUTANEOUS CREAM AUTO-INJECTOR ZYCLARA EXTERNAL 2 BYDUREON PEN 2 CREAM BYETTA 10 MCG PEN 2 ZYCLARA PUMP 2 EXTERNAL CREAM BYETTA 5 MCG PEN 2 chlorpropamide oral Diabetes - 1 Antidiabetic Agents tablet 100 mg, 250 mg CYCLOSET ORAL acarbose oral tablet 1 2 TABLET ACTOPLUS MET 2 DUETACT ORAL ORAL TABLET 2 TABLET FARXIGA ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 105 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FORTAMET ORAL INVOKAMET XR ORAL TABLET EXTENDED 2 TABLET EXTENDED 2 RELEASE 24 HOUR RELEASE 24 HOUR glimepiride oral tablet 1 INVOKANA ORAL 2 glipizide er oral tablet TABLET extended release 24 1 JANUMET ORAL 2 hour TABLET glipizide oral tablet 1 JANUMET XR ORAL glipizide xl oral tablet TABLET EXTENDED 2 extended release 24 1 RELEASE 24 HOUR hour JANUVIA ORAL 2 glipizide-metformin hcl TABLET 1 oral tablet JARDIANCE ORAL 2 GLUCOPHAGE ORAL TABLET TABLET 1000 MG, 500 2 JENTADUETO ORAL 2 MG, 850 MG TABLET GLUCOPHAGE XR JENTADUETO XR ORAL TABLET ORAL TABLET 2 EXTENDED RELEASE 2 EXTENDED RELEASE 24 HOUR 500 MG, 750 24 HOUR MG KAZANO ORAL 2 GLUCOTROL ORAL TABLET 2 TABLET KOMBIGLYZE XR GLUCOTROL XL ORAL TABLET 2 ORAL TABLET EXTENDED RELEASE 2 EXTENDED RELEASE 24 HOUR 24 HOUR metformin hcl er (mod) GLUMETZA ORAL oral tablet extended 1 TABLET EXTENDED 2 release 24 hour RELEASE 24 HOUR metformin hcl er (osm) glyburide micronized oral tablet extended 1 1 oral tablet release 24 hour glyburide oral tablet 1 metformin hcl er oral glyburide-metformin tablet extended release 1 1 oral tablet 24 hour GLYNASE ORAL metformin hcl oral 2 1 TABLET solution GLYSET ORAL metformin hcl oral 2 1 TABLET tablet GLYXAMBI ORAL miglitol oral tablet 1 2 TABLET nateglinide oral tablet 1 INVOKAMET ORAL NESINA ORAL 2 2 TABLET TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 106 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ONGLYZA ORAL SYMLINPEN 120 2 2 TABLET SYMLINPEN 60 2 OSENI ORAL TABLET 2 SYNJARDY ORAL 2 OZEMPIC TABLET SUBCUTANEOUS 2 SYNJARDY XR ORAL SOLUTION PEN- TABLET EXTENDED 2 INJECTOR RELEASE 24 HOUR pioglitazone hcl oral tolazamide oral tablet 1 1 tablet 250 mg, 500 mg pioglitazone hcl- 1 tolbutamide oral tablet 1 glimepiride oral tablet TRADJENTA ORAL 2 pioglitazone hcl- TABLET metformin hcl oral 1 tablet TRIJARDY XR ORAL TABLET EXTENDED 2 PRANDIN ORAL 2 RELEASE 24 HOUR TABLET 1 MG, 2 MG TRULICITY PRECOSE ORAL SUBCUTANEOUS 2 2 TABLET SOLUTION PEN- QTERN ORAL TABLET 2 INJECTOR repaglinide oral tablet 1 VICTOZA 2 repaglinide-metformin XIGDUO XR ORAL hcl oral tablet 1-500 1 TABLET EXTENDED 2 mg, 2-500 mg RELEASE 24 HOUR RIOMET ER ORAL XULTOPHY SUSPENSION 2 SUBCUTANEOUS 2 RECONSTITUTED ER SOLUTION PEN- RIOMET ORAL INJECTOR 2 SOLUTION Diabetes - Glucose RYBELSUS ORAL Monitoring 2 TABLET ACCU-CHEK AVIVA SEGLUROMET ORAL CONNECT KIT 2 2 TABLET W/DEVICE KIT ACCU-CHEK AVIVA SOLIQUA 2 SUBCUTANEOUS DEVICE 2 SOLUTION PEN- ACCU-CHEK AVIVA IN 2 INJECTOR VITRO SOLUTION STARLIX ORAL ACCU-CHEK AVIVA 2 2 TABLET PLUS IN VITRO STRIP STEGLATRO ORAL ACCU-CHEK AVIVA 2 2 TABLET PLUS KIT STEGLUJAN ORAL ACCU-CHEK 2 TABLET COMPACT PLUS 2 CARE KIT KIT You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 107 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ACCU-CHEK AGAMATRIX PRESTO 2 COMPACT PLUS TEST IN VITRO STRIP 2 CONTROL IN VITRO ASSURE PLATINUM 2 SOLUTION IN VITRO STRIP ACCU-CHEK AUTOLET II COMPACT PLUS 2 2 CLINISAFE KIT TEST STRIPS IN AUTOLET LANCING VITRO STRIP 2 DEVICE ACCU-CHEK FASTCLIX LANCET 2 BAYER CONTOUR KIT KIT LINK 2.4 KIT 2 W/DEVICE ACCU-CHEK GUIDE BIOTEL CARE BLOOD CONTROL IN VITRO 2 2 LIQUID GLUCOSE SYST KIT ACCU-CHEK GUIDE BLOOD GLUCOSE 2 2 IN VITRO STRIP TEST IN VITRO STRIP ACCU-CHEK GUIDE CARETOUCH 2 KIT CONTROL SOL LEVEL 2 2 IN VITRO LIQUID ACCU-CHEK GUIDE 2 CARETOUCH ME KIT 2 LANCING/EJECTOR ACCU-CHEK CARETOUCH TEST IN MULTICLIX LANCET 2 2 DEVICE KIT KIT VITRO STRIP CEQUR SIMPLICITY ACCU-CHEK NANO 2 SMARTVIEW KIT 2 2U DEVICE W/DEVICE KIT CEQUR SIMPLICITY 2 ACCU-CHEK INSERTER SMARTVIEW CEQUR SIMPLICITY 2 2 CONTROL IN VITRO STARTER KIT LIQUID CHEMSTRIP UGK IN 2 ACCU-CHEK VITRO STRIP SMARTVIEW TEST CONTOUR CONTROL 2 2 STRIPS IN VITRO IN VITRO LIQUID STRIP CONTOUR NEXT ACCU-CHEK CONTROL IN VITRO 2 SOFTCLIX LANCET 2 SOLUTION DEVICE KIT CONTOUR NEXT LINK 2 AGAMATRIX KIT CONTROL LEVEL 2 IN 2 CONTOUR NEXT VITRO SOLUTION 2 MONITOR KIT AGAMATRIX CONTOUR NEXT CONTROL LEVEL 4 IN 2 2 VITRO SOLUTION TEST IN VITRO STRIP

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 108 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CONTOUR TEST IN EASYMAX 15 LEVEL 2 VITRO STRIP 2-3 CONTROL IN 2 DEXCOM G4 / G5 / G6 VITRO LIQUID RECEIVER, EASYMAX CONTROL 2 TRANSMITTER, IN VITRO SOLUTION SENSOR (INCLUDING 2 EASYMAX CONTROL PLATINUM, NORMAL/HIGH IN 2 PLATINUM VITRO LIQUID PEDIATRIC) EMBRACE TALK DEXCOM G4 / G5 / G6 BLOOD GLUCOSE 2 RECEIVER, DEVICE TRANSMITTER, SENSOR (INCLUDING 2 EMBRACE TALK PLATINUM, GLUCOSE CONTROL 2 PLATINUM IN VITRO SOLUTION PEDIATRIC) DEVICE EMBRACE TALK DIATHRIVE BLOOD GLUCOSE TEST IN 2 GLUCOSE METER 2 VITRO STRIP DEVICE EMBRACE TALK DIATHRIVE BLOOD MONITORING 2 GLUCOSE TEST IN 2 SYSTEM KIT VITRO STRIP ENLITE GLUCOSE 2 DIATHRIVE GLUCOSE SENSOR CONTROL SOLN IN 2 EVENCARE PROVIEW VITRO LIQUID GLUCOSE TEST IN 2 DIATHRIVE GLUCOSE VITRO STRIP 2 TEST IN VITRO STRIP EVERSENSE 2 DIATHRIVE LANCING SENSOR 2 DEVICE EVERSENSE 2 DIATHRIVE+ SENSOR/HOLDER GLUCOSE MONITOR 2 EVERSENSE SMART 2 DEVICE TRANSMITTER DIATHRIVE+ FORA 6 CONNECT IN 2 GLUCOSE TEST IN 2 VITRO STRIP VITRO STRIP FORA GTEL BLOOD EASY TRAK II BLOOD GLUCOSE SYSTEM 2 GLUCOSE SYS 2 DEVICE DEVICE FORA GTEL BLOOD EASY TRAK II GLUCOSE TEST IN 2 CONTROL IN VITRO 2 VITRO STRIP LIQUID FORTISCARE EASY TRAK II CONTROL IN VITRO 2 GLUCOSE TEST IN 2 SOLUTION VITRO STRIP

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 109 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FORTISCARE GLUCOCARD SHINE 2 GLUCOSE SYSTEM 2 CONNEX KIT DEVICE GLUCOCARD SHINE 2 FORTISCARE T1 EXPRESS KIT GLUCOSE SYSTEM 2 GLUCOCARD SHINE 2 DEVICE TEST IN VITRO STRIP FREESTYLE GLUCOCARD VITAL 2 2 FREEDOM LITE KIT TEST IN VITRO STRIP FREESTYLE GOJJI BLOOD INSULINX SYSTEM 2 GLUCOSE TEST IN 2 KIT VITRO STRIP FREESTYLE GOJJI BLOOD TEST INSULINX TEST IN 2 STRIP/LANCETS IN 2 VITRO STRIP VITRO STRIP FREESTYLE LIBRE 14 GOJJI CONTROL IN 2 2 DAY READER DEVICE VITRO SOLUTION FREESTYLE LIBRE 14 GOJJI LANCING 2 2 DAY SENSOR DEVICE/CLEAR CAP FREESTYLE LIBRE 2 GUARDIAN CONNECT 2 READER SYSTM 2 TRANSMITTER DEVICE GUARDIAN LINK 3 FREESTYLE LIBRE 2 2 2 TRANSMITTER SENSOR SYSTM GUARDIAN REAL- FREESTYLE LIBRE 2 2 TIME SYSTEM KIT READER DEVICE GUARDIAN SENSOR FREESTYLE LIBRE 2 2 (3) SENSOR SYSTEM HARMONY BLOOD FREESTYLE LITE 2 GLUCOSE TEST IN 2 TEST IN VITRO STRIP VITRO STRIP FREESTYLE HW EMBRACE PRO PRECISION NEO 2 GLUCOSE METER 2 TEST IN VITRO STRIP DEVICE FREESTYLE TEST IN 2 HW EMBRACE PRO VITRO STRIP GLUCOSE TEST IN 2 GENTEEL LANCING VITRO STRIP 2 KIT (BLUE) KIT HW EMBRACE TALK GLUCOCARD 01 BLOOD GLUCOSE 2 SENSOR PLUS IN 2 DEVICE VITRO STRIP HW EMBRACE TALK GLUCOCARD GLUCOSE TEST IN 2 EXPRESSION TEST 2 VITRO STRIP IN VITRO STRIP

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 110 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits INFINITY BLOOD ONETOUCH DELICA 2 GLUCOSE TEST IN 2 LANCING DEV VITRO STRIP ONETOUCH DELICA 2 INPEN 100-BLUE- PLUS LANCING 2 LILLY DEVICE ONETOUCH ULTRA 2 2 INPEN 100-BLUE- KIT 2 NOVO DEVICE ONETOUCH ULTRA IN 2 INPEN 100-GRAY- VITRO STRIP 2 LILLY DEVICE ONETOUCH ULTRA 2 INPEN 100-GREY- MINI KIT 2 NOVO DEVICE ONETOUCH VERIO INPEN 100-PINK- FLEX SYSTEM KIT 2 2 LILLY DEVICE W/DEVICE KIT INPEN 100-PINK- ONETOUCH VERIO IN 2 NOVO DEVICE VITRO SOLUTION 2 KETONE TEST IN HIGH 2 VITRO STRIP ONETOUCH VERIO 2 KETOSTIX IN VITRO TEST STRIPS 2 STRIP ONETOUCH VERIO IQ 2 KROGER SYSTEM KIT HEALTHPRO ONETOUCH VERIO 2 2 GLUCOSE TEST IN KIT VITRO STRIP ONETOUCH VERIO 2 LANCETS 2 REFLECT KIT LANCETS KIT 2 ONETOUCH VERIO MICRODOT TEST IN SYNC SYSTEM KIT 2 2 VITRO STRIP W/DEVICE KIT MICROLET NEXT PARADIGM REAL- 2 2 LANCING DEVICE TIME STARTER KIT MINIMED GUARDIAN PRECISION LINK KIT 2 2 SENSOR 3 PRECISION PCX NOVOPEN ECHO PLUS TEST IN VITRO 2 2 DEVICE STRIP OMNIPOD DASH PRECISION QID 2 2 SYSTEM KIT MONITOR DEVICE OMNIPOD STARTER PRECISION QID TEST 2 2 KIT IN VITRO STRIP ONE DROP BLOOD PRECISION SOF- GLUCOSE MONITOR 2 TACT MONITOR 2 KIT DEVICE ONE DROP TEST IN PRECISION SOF- 2 VITRO STRIP TACT TEST IN VITRO 2 STRIP You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 111 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits PRECISION XTRA TRUE METRIX PRO BLOOD GLUCOSE IN 2 BLOOD GLUCOSE IN 2 VITRO STRIP VITRO STRIP PRECISION XTRA TRUETRACK TEST IN 2 2 DEVICE VITRO STRIP PRECISION XTRA KIT 2 UNISTRIP CONTROL PRECISION XTRA IN VITRO SOLUTION 2 2 MONITOR DEVICE LOW PRODIGY NO V-GO 20 KIT 2 CODING BLOOD 2 V-GO 30 KIT 2 GLUC KIT V-GO 40 KIT 2 RELION BLOOD VIVAGUARD INO GLUCOSE TEST IN 2 CONTROL SOLUTION 2 VITRO STRIP IN VITRO LIQUID RELION PREMIER 2 VIVAGUARD INO CLASSIC DEVICE GLUCOSE METER 2 RELION PREMIER DEVICE 2 TEST IN VITRO STRIP VIVAGUARD INO RELION ULTIMA TEST TEST STRIPS IN 2 2 IN VITRO STRIP VITRO STRIP SOF-SENSOR 2 VIVAGUARD 2 SURESTEP PRO LANCING DEVICE HIGH GLUCOSE IN 2 Diabetes - Glycemic VITRO LIQUID Agents SURESTEP PRO LOW BAQSIMI ONE PACK 2 GLUCOSE IN VITRO 2 NASAL POWDER LIQUID BAQSIMI TWO PACK 2 SURESTEP PRO NASAL POWDER NORMAL GLUCOSE 2 diazoxide oral 1 IN VITRO LIQUID suspension TRUE FOCUS BLOOD GLUCAGEN HYPOKIT GLUCOSE METER 2 INJECTION 2 DEVICE SOLUTION TRUE METRIX BLOOD RECONSTITUTED GLUCOSE TEST IN 2 GLUCAGON VITRO STRIP EMERGENCY KIT 2 TRUE METRIX LEVEL INJECTION KIT 2 1 IN VITRO SOLUTION GLUCAGON TRUE METRIX LEVEL EMERGENCY KIT 2 2 IN VITRO SOLUTION INJECTION 2 TRUE METRIX LEVEL SOLUTION 2 3 IN VITRO SOLUTION RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 112 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits GVOKE HYPOPEN 1- BD ULTRA-FINE 2 PACK INSULIN SYRINGES SUBCUTANEOUS 2 BD ULTRA-FINE PEN 2 SOLUTION AUTO- NEEDLES INJECTOR BD VEO INSULIN SYR 2 GVOKE HYPOPEN 2- U/F 1/2UNIT PACK DIATHRIVE PEN SUBCUTANEOUS 2 2 SOLUTION AUTO- NEEDLE INJECTOR DROPLET MICRON 2 GVOKE PFS EASYPOINT NEEDLE SUBCUTANEOUS 18G X 1" , 18G X 1- 2 SOLUTION 1/2" , 20G X 1" , 20G X 2 PREFILLED SYRINGE 1-1/2" , 21G X 1" , 21G PROGLYCEM ORAL X 1-1/2" , 22G X 1" , 2 SUSPENSION 22G X 1-1/2" Diabetes - Insulins FIASP FLEXTOUCH SUBCUTANEOUS 2 ADMELOG SOLUTION PEN- SOLOSTAR INJECTOR SUBCUTANEOUS 2 SOLUTION PEN- FIASP PENFILL SUBCUTANEOUS INJECTOR 2 SOLUTION ADMELOG CARTRIDGE SUBCUTANEOUS 2 SOLUTION FIASP SUBCUTANEOUS 2 AFREZZA SOLUTION INHALATION 2 POWDER HUMALOG KWIKPEN SUBCUTANEOUS 2 APIDRA SOLOSTAR 2 SOLUTION PEN- APIDRA VIAL INJECTOR INJECTION 2 HUMALOG MIX 50/50 2 SOLUTION KWIKPEN BASAGLAR KWIKPEN HUMALOG MIX 50/50 SUBCUTANEOUS VIAL 2 2 SOLUTION PEN- SUBCUTANEOUS INJECTOR SUSPENSION BD AUTOSHIELD DUO HUMALOG MIX 75/25 2 2 PEN NEEDLES KWIKPEN BD INTEGRA NEEDLE 2 HUMALOG MIX 75/25 25G X 5/8" VIAL 2 BD SAFETYGLIDE SUBCUTANEOUS SYRINGE/NEEDLE 2 SUSPENSION 21G X 1-1/2"

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 113 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits HUMALOG U-100 INSULIN ASPART JUNIOR KWIKPEN PROT & ASPART 2 SUBCUTANEOUS 2 SUBCUTANEOUS SOLUTION PEN- SUSPENSION INJECTOR INSULIN ASPART HUMALOG VIAL SUBCUTANEOUS 2 SUBCUTANEOUS 2 SOLUTION SOLUTION INSULIN LISPRO (1 HUMALOG VIAL UNIT DIAL) SUBCUTANEOUS SUBCUTANEOUS 2 2 SOLUTION SOLUTION PEN- CARTRIDGE INJECTOR HUMULIN 70/30 INSULIN LISPRO 2 KWIKPEN JUNIOR KWIKPEN HUMULIN 70/30 VIAL SUBCUTANEOUS 2 SUBCUTANEOUS 2 SOLUTION PEN- SUSPENSION INJECTOR HUMULIN N KWIKPEN 2 INSULIN LISPRO PROT & LISPRO HUMULIN N VIAL SUBCUTANEOUS 2 SUBCUTANEOUS 2 SUSPENSION PEN- SUSPENSION INJECTOR HUMULIN R U-500 2 INSULIN LISPRO KWIKPEN SUBCUTANEOUS 2 HUMULIN R U-500 SOLUTION VIAL INSULIN PEN 2 2 SUBCUTANEOUS NEEDLES SOLUTION INSULIN SYRINGES 2 HUMULIN R VIAL LANTUS U-100 INJECTION 2 2 SOLUTION SOLOSTAR INSULIN ASP PROT & LANTUS U-100 VIAL ASP FLEXPEN SUBCUTANEOUS 2 SUBCUTANEOUS 2 SOLUTION SUSPENSION PEN- LEVEMIR U-100 INJECTOR FLEXTOUCH INSULIN ASPART SUBCUTANEOUS 2 FLEXPEN SOLUTION PEN- SUBCUTANEOUS 2 INJECTOR SOLUTION PEN- LEVEMIR U-100 VIAL INJECTOR SUBCUTANEOUS 2 INSULIN ASPART SOLUTION PENFILL LYUMJEV INJECTION 2 SUBCUTANEOUS 2 SOLUTION SOLUTION CARTRIDGE You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 114 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LYUMJEV KWIKPEN NOVOLIN N RELION SUBCUTANEOUS SUBCUTANEOUS 2 2 SOLUTION PEN- SUSPENSION INJECTOR NOVOLIN N VIAL MAXICOMFORT SYR SUBCUTANEOUS 2 2 27G X 1/2" SUSPENSION MONOJECT NOVOLIN R FLEXPEN HYPODERMIC 2 INJECTION 2 NEEDLE 22G X 1-1/2" SOLUTION PEN- MYXREDLIN INJECTOR INTRAVENOUS 2 NOVOLIN R FLEXPEN SOLUTION RELION INJECTION 2 NOVOFINE SOLUTION PEN- AUTOCOVER PEN 2 INJECTOR NEEDLE NOVOLIN R RELION NOVOFINE PEN INJECTION 2 2 NEEDLE SOLUTION NOVOFINE PLUS PEN NOVOLIN R VIAL 2 NEEDLE INJECTION 2 SOLUTION NOVOLIN 70/30 NOVOLOG U-100 FLEXPEN RELION 2 SUBCUTANEOUS 2 FLEXPEN SUSPENSION PEN- NOVOLOG MIX 70/30 2 INJECTOR FLEXPEN NOVOLIN 70/30 NOVOLOG MIX 70/30 FLEXPEN VIAL 2 SUBCUTANEOUS 2 SUBCUTANEOUS SUSPENSION PEN- SUSPENSION INJECTOR NOVOLOG U-100 2 NOVOLIN 70/30 PENFILL RELION 2 NOVOLOG U-100 VIAL SUBCUTANEOUS SUBCUTANEOUS 2 SUSPENSION SOLUTION NOVOLIN 70/30 VIAL NOVOTWIST PEN 2 SUBCUTANEOUS 2 NEEDLE SUSPENSION SECURESAFE NOVOLIN N FLEXPEN HYPODERMIC RELION NEEDLE 18G X 1" , 2 SUBCUTANEOUS 2 19G X 1" , 19G X 1- SUSPENSION PEN- 1/2" , 22G X 1" INJECTOR SEMGLEE NOVOLIN N FLEXPEN SUBCUTANEOUS 2 SUBCUTANEOUS 2 SOLUTION SUSPENSION PEN- INJECTOR You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 115 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SEMGLEE AMINOSYN II SUBCUTANEOUS INTRAVENOUS 2 2 SOLUTION PEN- SOLUTION INJECTOR AMINOSYN TOUJEO MAX II/ELECTROLYTES 2 SOLOSTAR INTRAVENOUS SUBCUTANEOUS 2 SOLUTION 8.5 % SOLUTION PEN- AMINOSYN INJECTOR INTRAVENOUS 2 TOUJEO SOLOSTAR SOLUTION 10 %, 8.5 SUBCUTANEOUS % 2 SOLUTION PEN- AMINOSYN M INJECTOR INTRAVENOUS 2 TRESIBA SOLUTION 3.5 % FLEXTOUCH AMINOSYN/ELECTRO SUBCUTANEOUS 2 LYTES 2 SOLUTION PEN- INTRAVENOUS INJECTOR SOLUTION 7 %, 8.5 % TRESIBA AMINOSYN-HBC SUBCUTANEOUS 2 INTRAVENOUS 2 SOLUTION SOLUTION 7 % Electrolytes / Minerals AMINOSYN-PF / Metals / Vitamins INTRAVENOUS 2 ABANEU-SL SOLUTION SUBLINGUAL TABLET 2 AMINOSYN-RF SUBLINGUAL INTRAVENOUS 2 ACTIVE FE ORAL SOLUTION 5.2 % 2 TABLET AQUASOL A adc/f (0.5mg/ml) oral INTRAMUSCULAR 2 1 solution SOLUTION ADRENAL C ARGININE HCL FORMULA ORAL 2 INJECTION 2 TABLET SOLUTION ADVANCED AM/PM argyle sterile saline 2 1 ORAL irrigation solution airavite oral tablet 1 argyle sterile water 1 ALANINE POWDER 2 irrigation solution ATABEX OB ORAL AMINO ACID 2 INTRAVENOUS 2 TABLET SOLUTION b-6 folic acid oral 1 AMINOPROTECT capsule INTRAVENOUS 2 BACMIN ORAL 2 SOLUTION TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 116 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BCAA INJECTION CALCIUM SOLUTION 15-10-40 2 GLUCONATE- MG/ML DEXTROSE BCAA INTRAVENOUS INTRAVENOUS SOLUTION 1-5 SOLUTION 15-10-40 2 2 MG/ML GM/100ML-%, 1-5 GM/50ML-%, 2-5 bd posiflush GM/100ML-%, 2-5 intravenous solution 0.9 1 GM/50ML-%, 4-5 % GM/250ML-% biocel oral tablet 1 CALCIUM bp vit 3 oral capsule 1 GLUCONATE-NACL b-plex oral tablet 1 INTRAVENOUS 2 SOLUTION 1-0.675 b-plex plus oral tablet 1 GM/50ML-% CALCIFOL ORAL 2 CALCIUM WAFER GLUCONATE-NACL CALCIUM CHLORIDE INTRAVENOUS 2 DIHYDRATE POWDER SOLUTION 1-0.9 GM/100ML-%, 1-0.9 calcium chloride 2 solution 10 % 1 GM/50ML-%, 2-0.9 intravenous GM/100ML-%, 2-0.9 GM/50ML-%, 3-0.9 CALCIUM CHLORIDE GM/100ML-%, 4-0.9 SOLUTION 10 % 2 GM/250ML-% INTRAVENOUS CALCIUM CALCIUM GLUCONATE-NACL GLUCONATE 2 INTRAVENOUS ANHYDROUS SOLUTION 2 POWDER PREFILLED SYRINGE calcium gluconate 1-0.9 GM/50ML-%, 2- 1 intravenous solution 0.9 GM/50ML-% CALCIUM CALCIUM LACTATE GLUCONATE PENTAHYDRATE 2 2 MONOHYDRATE POWDER POWDER CALCIUM CALCIUM PHOSPHATE DIBASIC 2 GLUCONATE 2 POWDER POWDER CALCIUM PHOSPHATE 2 TRIBASIC POWDER CALM INJECTION 2 SOLUTION CARBAGLU ORAL 2 SP TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 117 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CARNITOR CLINIMIX INTRAVENOUS 2 E/DEXTROSE SOLUTION (4.25/25) 2 CARNITOR ORAL INTRAVENOUS 2 SOLUTION SOLUTION 4.25 % CARNITOR ORAL CLINIMIX 2 E/DEXTROSE (4.25/5) TABLET 2 INTRAVENOUS CARNITOR SF ORAL 2 SOLUTION SOLUTION CLINIMIX CENFOL ORAL E/DEXTROSE (5/15) 2 2 TABLET INTRAVENOUS CENTRATEX ORAL SOLUTION 2 CAPSULE CLINIMIX CEREFOLIN NAC E/DEXTROSE (5/20) 2 2 ORAL TABLET INTRAVENOUS CEREFOLIN ORAL SOLUTION 2 TABLET CLINIMIX CHEMET ORAL E/DEXTROSE (8/10) 2 2 CAPSULE INTRAVENOUS SOLUTION CHOLINE BITARTRATE 2 CLINIMIX E/DEXTROSE (8/14) POWDER 2 INTRAVENOUS CHROMAGEN ORAL 2 SOLUTION CAPSULE CLINIMIX N14G30E chromic chloride 1 INTRAVENOUS 2 intravenous solution SOLUTION 4.25 % CLINIMIX CLINIMIX N9G15E E/DEXTROSE INTRAVENOUS 2 (2.75/10) 2 SOLUTION 2.75 % INTRAVENOUS SOLUTION 2.75 % CLINIMIX/DEXTROSE (4.25/10) 2 CLINIMIX INTRAVENOUS E/DEXTROSE (2.75/5) 2 SOLUTION INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/25) 2 CLINIMIX INTRAVENOUS E/DEXTROSE SOLUTION 4.25 % (4.25/10) 2 INTRAVENOUS CLINIMIX/DEXTROSE (4.25/5) SOLUTION 2 INTRAVENOUS SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 118 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CLINIMIX/DEXTROSE cyanocobalamin (5/15) INTRAVENOUS 2 injection solution 1000 1 SOLUTION mcg/ml CLINIMIX/DEXTROSE CYANOCOBALAMIN (5/20) INTRAVENOUS 2 INJECTION 2 SOLUTION SOLUTION 2000 CLINIMIX/DEXTROSE MCG/ML (5/25) INTRAVENOUS 2 deferasirox granules 1 SOLUTION 5 % oral packet CLINIMIX/DEXTROSE deferasirox oral tablet 1 (6/5) INTRAVENOUS 2 deferasirox oral tablet 1 SOLUTION soluble CLINIMIX/DEXTROSE deferiprone oral tablet 1 (8/10) INTRAVENOUS 2 dehydrated alcohol SOLUTION 1 injection solution CLINIMIX/DEXTROSE DEPLIN 15 ORAL (8/14) INTRAVENOUS 2 2 SOLUTION CAPSULE DEPLIN 7.5 ORAL CLINISOL SF 2 INTRAVENOUS 2 CAPSULE SOLUTION DEXPANTHENOL CLINOLIPID INJECTION 2 INTRAVENOUS 2 SOLUTION EMULSION dextrose intravenous clovique oral capsule 1 SP solution 10 %, 20 %, 30 1 %, 40 %, 5 %, 70 % cod oil oral oil 1 DEXTROSE corvita 150 oral tablet 1 SOLUTION 250 2 CORVITA ORAL MG/ML 2 TABLET INTRAVENOUS CORVITE 150 ORAL dextrose solution 250 2 1 TABLET mg/ml intravenous CORVITE FE ORAL DEXTROSE 2 TABLET SOLUTION 50 % 2 corvite free oral tablet 1 INTRAVENOUS CORVITE ORAL dextrose solution 50 % 2 1 TABLET 1.25 MG intravenous DIALYVITE 3000 CUPRIC CHLORIDE 2 INTRAVENOUS 2 ORAL TABLET SOLUTION DIALYVITE 5000 2 curity sterile saline ORAL TABLET 1 irrigation solution DIALYVITE ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 119 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits DIALYVITE SUPREME FERAHEME 2 D ORAL TABLET INTRAVENOUS 2 DIALYVITE/ZINC SOLUTION 2 ORAL TABLET ferocon oral capsule 1 DILUENT FOR ferotrinsic oral capsule 1 LEFAMULIN FERRALET 90 ORAL 2 2 INTRAVENOUS TABLET SOLUTION ferraplus 90 oral tablet 1 DL-ALANINE 2 FERRIPROX ORAL POWDER 2 SOLUTION DL-LEUCINE 2 FERRIPROX ORAL POWDER 2 TABLET DL-METHIONINE 2 FERRIPROX TWICE- POWDER 2 A-DAY ORAL TABLET DL-PHENYLALANINE 2 POWDER FERRLECIT INTRAVENOUS 2 DRISDOL ORAL 2 SOLUTION CAPSULE ferrocite plus oral tablet 1 EDETATE DISODIUM INTRAVENOUS 2 FERRO-PLEX SOLUTION HEMATINIC ORAL 2 TABLET EFFER-K ORAL TABLET FERROTRIN ORAL 2 2 EFFERVESCENT 10 CAPSULE MEQ, 20 MEQ FLUORABON ORAL 2 effer-k oral tablet SOLUTION 1 effervescent 25 meq fluoritab oral solution 1 ELFOLATE ORAL fluoritab oral tablet 2 1 TABLET chewable ELFOLATE PLUS FLURA-DROPS ORAL 2 2 ORAL TABLET SOLUTION ELITE-OB ORAL folbee oral tablet 1 2 TABLET FOLBEE PLUS CZ 2 ergocalciferol oral ORAL TABLET 1 capsule folbee plus oral tablet 1 ESCAVITE ORAL FOLBIC RF ORAL 2 TABLET CHEWABLE 2 TABLET 0.25-7.5 MG FOLGARD OS ORAL EXJADE ORAL 2 2 TABLET TABLET SOLUBLE FOLGARD RX ORAL 2 fabb oral tablet 1 TABLET fa-vitamin b-6-vitamin 1 b-12 oral tablet You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 120 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits folic acid injection GLUTATHIONE 1 solution INJECTION 2 folic acid oral tablet 1 SOLUTION 200 1 mg MG/ML FOLIVANE-F ORAL GLUTATHIONE 2 CAPSULE INTRAVENOUS 2 SOLUTION FOLIVANE-PLUS 2 GLYCINE INJECTION ORAL CAPSULE 2 SOLUTION folplex 2.2 oral tablet 1 GLYCOPHOS FOLTANX ORAL 2 INTRAVENOUS 2 TABLET SOLUTION FOLTANX RF ORAL hematinic plus 2 1 CAPSULE vit/minerals oral tablet FOLTRATE ORAL hematinic/folic acid oral 2 1 TABLET tablet foltrin oral capsule 1 HEMATOGEN FA 2 FOLTX ORAL TABLET 2 ORAL CAPSULE FORTAVIT ORAL HEMATOGEN FORTE 2 2 CAPSULE ORAL CAPSULE FOSTEUM ORAL HEMATOGEN ORAL 2 2 CAPSULE CAPSULE FREAMINE HBC HEMATRON-AF ORAL 2 INTRAVENOUS 2 TABLET SOLUTION HEMOCYTE PLUS 2 FREAMINE III ORAL CAPSULE INTRAVENOUS 2 hemocyte-f oral tablet 1 SOLUTION hemocyte-plus oral FUSION PLUS ORAL 1 2 tablet CAPSULE HEPATAMINE FUSION SPRINKLES INTRAVENOUS 2 ORAL PACKET 7-0.25- 2 SOLUTION 50-5 MG hydroxocobalamin GABA INJECTION acetate intramuscular 1 SOLUTION 1000 2 solution MG/10ML ICAR-C PLUS ORAL GALZIN ORAL 2 2 TABLET CAPSULE iferex 150 forte oral glucose intravenous 1 1 capsule solution 5 % INFED INJECTION 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 121 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits INFUVITE ADULT klor-con oral tablet 1 INTRAVENOUS 2 extended release INJECTABLE klor-con sprinkle oral INFUVITE PEDIATRIC capsule extended 1 INTRAVENOUS 2 release SOLUTION klor-con/ef oral tablet 1 INJECTAFER effervescent INTRAVENOUS 2 K-PHOS ORAL 2 SOLUTION TABLET INTEGRA F ORAL K-PHOS-NEUTRAL 2 2 CAPSULE ORAL TABLET INTEGRA PLUS ORAL k-prime oral tablet 2 1 CAPSULE effervescent INTRALIPID K-TAB ORAL TABLET 2 INTRAVENOUS 2 EXTENDED RELEASE EMULSION k-tan plus oral capsule 1 iodine strong oral 1 k-vescent oral tablet solution 1 effervescent 25 meq IS 24/6 ORAL 2 lactated ringers JADENU ORAL 1 2 irrigation solution TABLET L-ALANINE POWDER 2 JADENU SPRINKLE 2 ORAL PACKET L-ARGININE POWDER 2 JYNARQUE ORAL L-CYSTINE POWDER 2 2 SP TABLET LEVOCARNITINE JYNARQUE ORAL INJECTION 2 TABLET THERAPY 2 SP SOLUTION PACK levocarnitine oral 1 KABIVEN solution INTRAVENOUS 2 levocarnitine oral tablet 1 EMULSION levocarnitine sf oral 1 kionex oral suspension 1 solution klor-con 10 oral tablet L-GLUTAMIC ACID 1 2 extended release POWDER klor-con m10 oral tablet L-HISTIDINE 1 extended release MONOHYDROCHLORI 2 KLOR-CON M15 ORAL DE POWDER TABLET EXTENDED 2 LIPO RELEASE INTRAMUSCULAR 2 klor-con m20 oral tablet SOLUTION 1 extended release LIPO-B klor-con oral packet 1 INTRAMUSCULAR 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 122 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LIPO-C LYSINE HCL INTRAMUSCULAR 2 INJECTION 2 SOLUTION SOLUTION L-ISOLEUCINE lysiplex plus oral tablet 1 2 POWDER M.V.I. ADULT L-LEUCINE POWDER 2 INTRAVENOUS 2 L-METHIONINE INJECTABLE 2 POWDER M.V.I. PEDIATRIC l-methylfolate ca me-cbl INTRAVENOUS 1 2 nac oral tablet SOLUTION RECONSTITUTED l-methylfolate calcium 1 MAGNEBIND 400 oral tablet 2 ORAL TABLET l-methylfolate forte oral 1 capsule 15-90.314 mg CARBONATE HEAVY 2 L-METHYLFOLATE POWDER FORTE ORAL 2 CAPSULE 7.5-90.314 MAGNESIUM MG CARBONATE 2 POWDER l-methylfolate oral 1 magnesium chloride tablet 1 injection solution l-methylfolate-algae 1 oral capsule magnesium sulfate in d5w intravenous l-methylfolate-algae- 1 1 solution 1-5 gm/100ml- b12-b6 oral capsule % l-methylfolate-b6-b12 1 oral tablet L-METHYL-MC NAC 2 ORAL TABLET L-METHYL-MC ORAL 2 TABLET LOKELMA ORAL 2 PACKET L-PHENYLALANINE 2 POWDER L-PROLINE POWDER 2 L-TRYPTOPHAN 2 POWDER L-TYROSINE 2 POWDER L-VALINE POWDER 2

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 123 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits MAGNESIUM MAGNESIUM SULFATE IN D5W SULFATE-LACT INTRAVENOUS RINGERS SOLUTION 1-5 INTRAVENOUS GM/50ML-%, 10-5 SOLUTION 10 GM/100ML-%, 10-5 GM/250ML, 20 2 GM/250ML-%, 2-5 GM/250ML, 20 GM/100ML-%, 2-5 GM/500ML, 25 GM/50ML-%, 20-5 GM/250ML, 40 GM/250ML-%, 20-5 GM/1000ML, 40 GM/500ML-%, 20-5 GM/500ML, 50 2 GM/L-%, 25-5 GM/500ML GM/250ML-%, 3-5 MAGNESIUM GM/50ML-%, 4-5 SULFATE-NACL 2 GM/100ML-%, 4-5 INTRAVENOUS GM/50ML-%, 40-5 SOLUTION GM/500ML-%, 40-5 GM/L-%, 5-5 MANGANESE CHLORIDE GM/100ML-%, 50-5 2 GM/500ML-%, 6-5 INTRAVENOUS GM/100ML-%, 6-5 SOLUTION GM/50ML-% MAXFE ORAL TABLET 2 MAGNESIUM 160-1 MG SULFATE MEPHYTON ORAL 2 INTRAVENOUS TABLET SOLUTION 1000 METAFOLBIC ORAL 2 2 MG/1.6ML, 2000 TABLET MG/3.2ML, 3000 METAFOLBIC PLUS MG/4.8ML, 4000 2 MG/6.4ML ORAL TABLET METAFOLBIC PLUS magnesium sulfate 2 intravenous solution 2 RF ORAL TABLET gm/50ml, 20 gm/500ml, METANX ORAL 1 2 4 gm/100ml, 4 CAPSULE gm/50ml, 40 METHIONINE 2 gm/1000ml POWDER MAGNESIUM METHYLCOBALAMIN SULFATE SOLUTION 2 INJECTION 2 50 % INJECTION SOLUTION magnesium sulfate RECONSTITUTED 1 solution 50 % injection methylfol-algae-b12- 1 acetylcyst oral tablet M-NATAL PLUS ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 124 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits MONOFERRIC n-acetyl-l-cysteine oral 1 INTRAVENOUS 2 capsule SOLUTION nafrinse drops oral 1 monoject flush syringe solution 1 intravenous solution nafrinse oral tablet 1 monoject sodium chewable chloride flush 1 NASCOBAL NASAL 2 intravenous solution SOLUTION MULTIGEN FOLIC NEOKE ALCAR ORAL 2 2 ORAL TABLET POWDER MULTIGEN ORAL NEONATAL 19 ORAL 2 2 TABLET TABLET MULTIGEN PLUS NEONATAL PLUS 2 2 ORAL TABLET ORAL TABLET multi-vit/iron/fluoride NEOVITE ORAL 1 2 oral solution TABLET multivitamin/fluoride NEPHPLEX RX ORAL 1 2 oral solution TABLET multi-vitamin/fluoride 1 NEPHRAMINE oral solution INTRAVENOUS 2 multivitamin/fluoride SOLUTION oral tablet chewable 1 NEPHRON FA ORAL 2 0.25 mg, 0.5 mg, 1 mg TABLET MULTIVITAMIN/FLUO nephronex oral tablet 1 RIDE ORAL TABLET NEPHRO-VITE RX CHEWABLE 0.25-0.3 2 2 MG, 0.5-0.3 MG, 1-0.3 ORAL TABLET MG NESTABS ORAL 2 multi- TABLET vitamin/fluoride/iron 1 NEURIN-SL oral solution SUBLINGUAL TABLET 2 multivitamins/fluoride SUBLINGUAL 1 oral tablet chewable NICOMIDE ORAL 2 myferon 150 forte oral TABLET 1 capsule NIFEREX ORAL 2 mynephrocaps oral TABLET 1 capsule normal saline flush 1 MYNEPHRON ORAL intravenous solution 2 CAPSULE NUFERA ORAL 2 na ferric gluc cplx in TABLET sucrose intravenous 1 nufol oral tablet 1 solution NUFOLA ORAL 2 CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 125 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits NUTRICAP ORAL POLY-VI-FLOR ORAL 2 2 TABLET SUSPENSION nutrifac zx oral tablet 1 POLY-VI-FLOR/IRON 2 nutrilipid intravenous ORAL SUSPENSION 1 emulsion pot bicarb-pot chloride 1 NUTRIVIT ORAL oral tablet effervescent 2 LIQUID potassium acetate 1 ONE VITE WOMENS intravenous solution 2 PLUS ORAL TABLET POTASSIUM ORACIT ORAL ACETATE-NACL 2 SOLUTION INTRAVENOUS 2 SOLUTION 10 PERIKABIVEN MEQ/100ML INTRAVENOUS 2 potassium bicarbonate EMULSION 1 oral tablet effervescent PHOSPHA 250 NEUTRAL ORAL 2 potassium chloride crys TABLET er oral tablet extended 1 release phosphorous oral tablet 1 potassium chloride er phospho-trin 250 1 oral capsule extended 1 neutral oral tablet release PHYSIOLYTE potassium chloride er IRRIGATION 2 oral tablet extended 1 SOLUTION release PHYSIOSOL potassium chloride IRRIGATION 2 intravenous solution 0.4 IRRIGATION meq/ml, 10 meq/100ml, 1 SOLUTION 10 meq/50ml, 20 phytonadione injection meq/50ml, 40 1 solution meq/100ml phytonadione oral potassium chloride oral 1 1 tablet packet PLENAMINE potassium chloride oral 1 INTRAVENOUS 2 solution SOLUTION potassium chloride PODIAPN ORAL proamp intravenous 1 2 CAPSULE solution 2 meq/ml poly-iron 150 forte oral potassium chloride 1 capsule solution 2 meq/ml 1 polysaccharide iron intravenous 1 forte oral capsule POTASSIUM POLY-VI-FLOR FS CHLORIDE SOLUTION 2 2 ORAL STRIP 2 MEQ/ML INTRAVENOUS

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 126 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits POTASSIUM prenatal oral tablet 27-1 1 CHLORIDE SOLUTION mg 2 20 MEQ/100ML prenatal plus iron oral 1 INTRAVENOUS tablet potassium chloride prenatal vitamin plus 1 solution 20 meq/100ml 1 low iron oral tablet intravenous PRENATVITE PLUS 2 potassium citrate er ORAL TABLET oral tablet extended 1 PRENATVITE RX release 2 ORAL TABLET POTASSIUM PHOSPHATE-NACL preplus oral tablet 1 INTRAVENOUS 2 PRETAB ORAL 2 SOLUTION 15 TABLET MMOL/100ML PRISMASOL B22GK potassium 4/0 INTRAVENOUS 2 phosphates(71 meq k) 1 SOLUTION intravenous solution PRISMASOL BGK POTASSIUM 0/2.5 INTRAVENOUS 2 PHOSPHATES- SOLUTION DEXTROSE PRISMASOL BGK 2/0 INTRAVENOUS INTRAVENOUS 2 SOLUTION 15 2 SOLUTION MMOL/250ML, 30 MMOL/500ML, 7.5 PRISMASOL BGK MMOL/100ML, 9 2/3.5 INTRAVENOUS 2 MMOL/50ML SOLUTION POTASSIUM PRISMASOL BGK PHOSPHATES-NACL 4/2.5 INTRAVENOUS 2 INTRAVENOUS SOLUTION SOLUTION 10 PRISMASOL BK MMOL/250ML, 15 0/0/1.2 INTRAVENOUS 2 MMOL/250ML, 20 SOLUTION MMOL/100ML, 22 PROCALAMINE MMOL/500ML, 30 2 INTRAVENOUS 2 MMOL/250ML, 30 SOLUTION MMOL/500ML, 40 MMOL/250ML, 5 PROSOL MMOL/250ML, 7 INTRAVENOUS 2 MMOL/100ML, 7.5 SOLUTION MMOL/100ML, 9 purevit dualfe plus oral 1 MMOL/100ML capsule PREMASOL PYRIDOXINE HCL INTRAVENOUS 2 SOLUTION 100 2 SOLUTION MG/ML INJECTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 127 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits pyridoxine hcl solution SODIUM 1 100 mg/ml injection BICARBONATE 2 RELNATE DHA ORAL INJECTION 2 CAPSULE SOLUTION 8.4 % REMEDIENT ORAL sodium bicarbonate 2 CAPSULE intravenous solution 4.2 1 %, 7.5 % RENAL ORAL 2 CAPSULE sodium bicarbonate solution 8.4 % 1 RENATABS ORAL 2 intravenous TABLET SODIUM RENATABS WITH BICARBONATE 2 2 IRON ORAL SOLUTION 8.4 % REQ 49+ ORAL INTRAVENOUS 2 TABLET sodium chloride (pf) 1 ringers irrigation injection solution 1 irrigation solution sodium chloride saline bacteriostatic bacteriostatic injection 1 1 injection solution solution saline flush intravenous sodium chloride flush 1 1 solution intravenous solution saline flush zr SODIUM CHLORIDE 1 intravenous solution INJECTION 2 SALINE-PHENOL SOLUTION 0.9 % INJECTION 2 sodium chloride SOLUTION injection solution 2.5 1 SAMSCA ORAL meq/ml 2 SP TABLET sodium chloride intravenous solution se-tan plus oral capsule 1 1 0.45 %, 3 %, 4 meq/ml, SIDEROL ORAL 2 5 % TABLET SODIUM CHLORIDE SMOFLIPID INTRAVENOUS 2 INTRAVENOUS 2 SOLUTION 23.4 % EMULSION sodium chloride sod citrate- 1 1 irrigation solution oral solution SODIUM CHLORIDE sodium acetate 1 SOLUTION 0.9 % 2 intravenous solution INTRAVENOUS SODIUM ASCORBATE 2 sodium chloride POWDER solution 0.9 % 1 intravenous sodium fluoride oral 1 solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 128 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sodium fluoride oral SUPPORT ORAL 1 2 tablet LIQUID sodium fluoride oral SUPPORT-500 ORAL 1 2 tablet chewable CAPSULE sodium lactate swabflush saline flush 1 intravenous solution 5 1 intravenous solution meq/ml SYNAGEX ORAL 2 SODIUM CAPSULE PHOSPHATE-NACL SYNATEK ORAL 2 INTRAVENOUS CAPSULE SOLUTION 10 SYPRINE ORAL MMOL/100ML, 15 2 SP MMOL/100ML, 15 2 CAPSULE MMOL/250ML, 30 TANDEM PLUS ORAL MMOL/250ML, 40 CAPSULE 162-115.2-1 2 MMOL/250ML, 7.5 MG MMOL/100ML, 9 TARON FORTE ORAL 2 MMOL/50ML CAPSULE sodium phosphates TAURINE INJECTION 1 2 intravenous solution SOLUTION SODIUM TAURINE POWDER 2 PHOSPHATES- THAM INTRAVENOUS DEXTROSE 2 INTRAVENOUS 2 SOLUTION SOLUTION 15 THE LIQUILIFT MMOL/100ML, 15 TRACE 2 MMOL/250ML INTRAVENOUS KIT sodium polystyrene thiamine hcl injection 1 1 sulfonate oral powder solution sodium polystyrene THREONINE 2 sulfonate oral 1 POWDER suspension tis-u-sol irrigation 1 sodium polystyrene solution sulfonate rectal 1 tl gard rx oral tablet 2.2- 1 suspension 25-1 mg sps oral suspension 1 TL G-FOL OS ORAL 2 sterile water for TABLET 500-1.1 MG irrigation irrigation 1 tl icon oral capsule 1 solution TL-FLUORIVITE ORAL STROVITE FORTE 2 TABLET CHEWABLE 2 ORAL SYRUP 0.25-7.5 MG SUPERVITE ORAL 2 tl-hem 150 oral tablet 1 LIQUID TOLVAPTAN ORAL 2 SP TABLET 15 MG

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 129 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits tolvaptan oral tablet 30 UDAMIN SP ORAL 1 SP 2 mg TABLET TRALEMENT UROCIT-K 10 ORAL INTRAVENOUS 2 TABLET EXTENDED 2 SOLUTION RELEASE TRAVASOL UROCIT-K 15 ORAL INTRAVENOUS 2 TABLET EXTENDED 2 SOLUTION RELEASE TRI-AMINO UROCIT-K 5 ORAL INJECTION 2 TABLET EXTENDED 2 SOLUTION RELEASE TRICARE PRENATAL urosex oral tablet 1 DHA ONE ORAL 2 VALINE POWDER 2 CAPSULE v-c forte oral capsule 1 TRICON ORAL 2 VELTASSA ORAL CAPSULE 2 PACKET trientine hcl oral 1 SP capsule VENOFER INTRAVENOUS 2 TRIFERIC SOLUTION HEMODIALYSIS 2 PACKET vic-forte oral capsule 1 trigels-f forte oral VIL-RX ORAL TABLET 1 2 capsule 29-1 MG TRINATE ORAL VINATE ONE ORAL 2 2 TABLET TABLET triphrocaps oral virt-caps oral capsule 1 1 capsule VIRT-FEFA PLUS 2 TRISODIUM ORAL CAPSULE CITRATE/CRRT virt-gard oral tablet 1 2 INTRAVENOUS virt-phos 250 neutral 1 SOLUTION oral tablet TRI-VI-FLOR ORAL 2 VIT B12-METHIONINE- SUSPENSION INOS-CHOL 2 TRI-VI-FLORO ORAL INTRAMUSCULAR 2 SUSPENSION SOLUTION tri-vite/fluoride oral vita s forte oral tablet 1 1 solution vitacel oral tablet 1 TROPHAMINE VITAFOL STRIPS 2 INTRAVENOUS 2 ORAL FILM SOLUTION VITAL-D RX ORAL TRYPTOPHAN 2 2 TABLET POWDER VITAMAX PEDIATRIC 2 ORAL SOLUTION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 130 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits vitamin d CARAFATE ORAL 2 (ergocalciferol) oral TABLET 1 capsule 1.25 mg cimetidine hcl oral 1 (50000 ut) solution vitamin k1 injection 1 cimetidine oral tablet 1 solution CYTOTEC ORAL 2 vita-min oral capsule 1 TABLET vitamins acd-fluoride 1 DEXILANT ORAL oral solution CAPSULE DELAYED 2 VITAROCA PLUS RELEASE 2 ORAL TABLET esomeprazole vol-care rx oral tablet 1 magnesium oral 1 1 mg capsule delayed vp-pnv-dha oral release 1 capsule esomeprazole 1 vp-vite rx oral tablet 1 magnesium oral packet water for irrigation, esomeprazole sodium 1 sterile irrigation solution intravenous solution 1 reconstituted westab mini oral tablet 1 ESOMEPRAZOLE westab one oral tablet 1 STRONTIUM ORAL 2 WESTAB PLUS ORAL CAPSULE DELAYED 2 TABLET RELEASE XAQUIL XR ORAL FAMOTIDINE IN NACL TABLET EXTENDED 2 INTRAVENOUS RELEASE SOLUTION 2 ZINC CHLORIDE PREFILLED SYRINGE INTRAVENOUS 2 20-0.9 MG/10ML-%, SOLUTION 20-0.9 MG/5ML-% famotidine intravenous ZINC SULFATE 1 INTRAVENOUS 2 solution SOLUTION 5 MG/ML famotidine oral Gastrointestinal suspension 1 Agents - Drugs for reconstituted Acid Reflux and Ulcer famotidine oral tablet 1 ACIPHEX ORAL 20 mg, 40 mg TABLET DELAYED 2 famotidine premixed 1 RELEASE intravenous solution ACIPHEX SPRINKLE FIRST- ORAL CAPSULE 2 2 SPRINKLE ORAL SUSPENSION CARAFATE ORAL FIRST-OMEPRAZOLE 2 2 SUSPENSION ORAL SUSPENSION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 131 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits lansoprazole oral PREVACID ORAL capsule delayed 1 CAPSULE DELAYED 2 release RELEASE lansoprazole oral tablet PREVACID SOLUTAB delayed release 1 ORAL TABLET 2 dispersible DELAYED RELEASE misoprostol oral tablet 1 DISPERSIBLE PRILOSEC ORAL NEXIUM I.V. 2 INTRAVENOUS PACKET 2 SOLUTION PROTONIX RECONSTITUTED INTRAVENOUS 2 NEXIUM ORAL SOLUTION CAPSULE DELAYED 2 RECONSTITUTED RELEASE PROTONIX ORAL 2 NEXIUM ORAL PACKET 2 PACKET PROTONIX ORAL nizatidine oral capsule 1 TABLET DELAYED 2 RELEASE nizatidine oral solution 1 RABEPRAZOLE omeppi oral capsule SODIUM ORAL 2 20-1100 mg, 40-1100 1 CAPSULE SPRINKLE mg rabeprazole sodium omeprazole oral oral tablet delayed 1 capsule delayed 1 release release sucralfate oral 1 OMEPRAZOLE+SYRS suspension PEND SF ALKA ORAL 2 SUSPENSION sucralfate oral tablet 1 ZEGERID ORAL omeprazole-sodium 2 bicarbonate oral 1 CAPSULE capsule ZEGERID ORAL 2 omeprazole-sodium PACKET 1 bicarbonate oral packet Gastrointestinal pantoprazole sodium Agents - Drugs for intravenous solution 1 Bowel, Intestine and reconstituted Stomach Conditions pantoprazole sodium ACTIGALL ORAL 1 2 oral packet CAPSULE pantoprazole sodium alosetron hcl oral tablet 1 oral tablet delayed 1 AMITIZA ORAL 2 release CAPSULE PEPCID ORAL amoxicill-clarithro- 2 1 TABLET lansopraz oral

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 132 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ANASPAZ ORAL dicyclomine hcl oral 1 TABLET 2 capsule DISPERSIBLE dicyclomine hcl oral 1 ATROPEN solution INTRAMUSCULAR dicyclomine hcl oral 2 1 SOLUTION AUTO- tablet INJECTOR diphenoxylate-atropine 1 atropine sulfate oral liquid injection solution 8 1 diphenoxylate-atropine mg/20ml 1 oral tablet atropine sulfate injection solution 1 ED-SPAZ ORAL prefilled syringe TABLET 2 DISPERSIBLE ATROPINE SULFATE INTRAVENOUS ENTEREG ORAL 2 2 SOLUTION CAPSULE PREFILLED SYRINGE enulose oral solution 1 BENTYL GASTROCROM ORAL 2 INTRAMUSCULAR 2 CONCENTRATE SOLUTION GATTEX 2 SP BIO-KULT INFANTIS SUBCUTANEOUS KIT 2 ORAL PACKET gavilyte-c oral solution 1 BISACODYL POWDER 2 reconstituted cascara sagrada oral gavilyte-g oral solution 1 1 fluid extract reconstituted CHENODAL ORAL gavilyte-h oral kit 1 2 SP TABLET gavilyte-n with flavor chlordiazepoxide- pack oral solution 1 1 clidinium oral capsule reconstituted CLENPIQ ORAL generlac oral solution 1 2 SOLUTION GIALAX ORAL KIT 2 COLYTE WITH GLYCATE ORAL 2 FLAVOR PACKS TABLET ORAL SOLUTION 2 glycopyrrolate injection RECONSTITUTED 240 1 GM solution constulose oral solution 1 GLYCOPYRROLATE INJECTION cromolyn sodium oral 2 1 SOLUTION concentrate PREFILLED SYRINGE CUVPOSA ORAL 2 GLYCOPYRROLATE SOLUTION INTRAVENOUS 2 dicyclomine hcl SOLUTION 1 intramuscular solution PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 133 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits glycopyrrolate oral loperamide hcl oral 1 1 tablet 1 mg, 2 mg capsule GLYCOPYRROLATE LOTRONEX ORAL 2 2 ORAL TABLET 1.5 MG TABLET glycopyrrolate pf methscopolamine 1 injection solution 1 bromide oral tablet prefilled syringe mineral oil heavy oral 1 GLYRX-PF INJECTION oil 2 SOLUTION MOTEGRITY ORAL 2 GOLYTELY ORAL TABLET SOLUTION 2 MOTOFEN ORAL 2 RECONSTITUTED TABLET HELIDAC THERAPY MOVANTIK ORAL 2 2 ORAL TABLET hyoscyamine sulfate 1 MOVIPREP ORAL oral elixir SOLUTION 2 hyoscyamine sulfate RECONSTITUTED 1 oral solution MYTESI ORAL hyoscyamine sulfate TABLET DELAYED 2 1 oral tablet RELEASE hyoscyamine sulfate NULEV ORAL TABLET 1 2 oral tablet dispersible DISPERSIBLE hyoscyamine sulfate sl NULYTELY LEMON- sublingual tablet 1 LIME ORAL 2 sublingual SOLUTION hyoscyamine sulfate RECONSTITUTED sublingual tablet 1 NULYTELY WITH sublingual FLAVOR PACKS 2 KRISTALOSE ORAL ORAL SOLUTION 2 PACKET RECONSTITUTED OMECLAMOX-PAK lactulose 2 encephalopathy oral 1 ORAL solution oscimin oral tablet 1 lactulose oral packet 1 oscimin oral tablet 1 lactulose oral solution 1 dispersible 0.125 mg LIBRAX ORAL oscimin sublingual 2 1 CAPSULE tablet sublingual LINZESS ORAL OSMOPREP ORAL 2 2 CAPSULE TABLET LOMOTIL ORAL peg 3350/electrolytes 2 TABLET oral solution 1 reconstituted 240 gm

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 134 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits peg 3350-kcl-na bicarb- SUPREP BOWEL nacl oral solution 1 PREP KIT ORAL 2 reconstituted SOLUTION peg-3350/electrolytes SYMPROIC ORAL 2 oral solution 1 TABLET reconstituted TALICIA ORAL peg- CAPSULE DELAYED 2 3350/electrolytes/ascor RELEASE 1 bat oral solution trilyte oral solution 1 reconstituted reconstituted peg-kcl-nacl-nasulf-na TRULANCE ORAL 2 asc-c oral solution 1 TABLET reconstituted URSO 250 ORAL 2 peg-prep oral kit 1 TABLET PLENVU ORAL URSO FORTE ORAL 2 SOLUTION 2 TABLET RECONSTITUTED ursodiol oral capsule 1 PREPOPIK ORAL PACKET 10-3.5-12 2 ursodiol oral tablet 1 MG-GM-GM URSODIOL+SYRSPE propantheline bromide ND SF ORAL 2 1 oral tablet SUSPENSION PYLERA ORAL VIBERZI ORAL 2 2 CAPSULE TABLET RELISTOR ORAL XERMELO ORAL 2 2 SP TABLET TABLET ZELNORM ORAL RELISTOR 2 SUBCUTANEOUS 2 TABLET SOLUTION ZORBTIVE RESTORA RX ORAL SUBCUTANEOUS 2 2 SP CAPSULE SOLUTION RECONSTITUTED RESTORE ORAL 2 PACKET Genetic or Enzyme Disorder - Drugs for SEROSTIM Replacement, SUBCUTANEOUS 2 SP Modification, SOLUTION Treatment RECONSTITUTED ALDURAZYME SIMILAC PROBIOTIC INTRAVENOUS 2 SP TRI-BLEND ORAL 2 SOLUTION PACKET AMMONUL sodium bicarbonate 1 INTRAVENOUS 2 oral powder SOLUTION BRINEURA KIT 2 SP

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 135 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BUPHENYL ORAL KUVAN ORAL TABLET 2 SP 2 SP POWDER SOLUBLE BUPHENYL ORAL L-GLUTAMIC ACID 2 SP 2 TABLET HCL POWDER CERDELGA ORAL LUMIZYME 2 SP CAPSULE INTRAVENOUS 2 SP CEREZYME SOLUTION INTRAVENOUS RECONSTITUTED 2 SP SOLUTION MEPSEVII RECONSTITUTED INTRAVENOUS 2 SP CHOLBAM ORAL SOLUTION 2 SP CAPSULE miglustat oral capsule 1 SP CREON ORAL MYALEPT CAPSULE DELAYED 2 SUBCUTANEOUS 2 SP RELEASE PARTICLES SOLUTION CRYSVITA RECONSTITUTED SUBCUTANEOUS 2 SP NAGLAZYME SOLUTION INTRAVENOUS 2 SP CYSTADANE ORAL SOLUTION 2 SP POWDER nitisinone oral capsule 1 SP CYSTAGON ORAL NITYR ORAL TABLET 2 SP 2 SP CAPSULE OCALIVA ORAL 2 SP ELAPRASE TABLET INTRAVENOUS 2 SP ORFADIN ORAL 2 SP SOLUTION CAPSULE ELELYSO ORFADIN ORAL INTRAVENOUS 2 SP 2 SP SUSPENSION SOLUTION RECONSTITUTED PALYNZIQ SUBCUTANEOUS 2 SP EXONDYS 51 SOLUTION INTRAVENOUS 2 SP PREFILLED SYRINGE SOLUTION PANCREAZE ORAL FABRAZYME CAPSULE DELAYED 2 INTRAVENOUS 2 SP RELEASE PARTICLES SOLUTION RECONSTITUTED PERTZYE ORAL CAPSULE DELAYED 2 GALAFOLD ORAL 2 SP RELEASE PARTICLES CAPSULE PROCYSBI ORAL KANUMA CAPSULE DELAYED 2 SP INTRAVENOUS 2 SP RELEASE SOLUTION PROCYSBI ORAL KUVAN ORAL 2 SP 2 SP PACKET PACKET RAVICTI ORAL LIQUID 2 SP

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 136 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits REVCOVI ZOLGENSMA 10.6- INTRAMUSCULAR 2 SP 11.0 KG 2 SP SOLUTION INTRAVENOUS KIT sapropterin ZOLGENSMA 11.1- dihydrochloride oral 1 SP 11.5 KG 2 SP packet INTRAVENOUS KIT sapropterin ZOLGENSMA 11.6- dihydrochloride oral 1 SP 12.0 KG 2 SP tablet soluble INTRAVENOUS KIT sod benz-sod ZOLGENSMA 12.1- phenylacet intravenous 1 12.5 KG 2 SP solution INTRAVENOUS KIT sodium phenylbutyrate ZOLGENSMA 12.6- 1 SP oral powder 13.0 KG 2 SP sodium phenylbutyrate INTRAVENOUS KIT 1 SP oral tablet ZOLGENSMA 13.1- STRENSIQ 13.5 KG 2 SP SUBCUTANEOUS 2 SP INTRAVENOUS KIT SOLUTION ZOLGENSMA 2.6-3.0 SUCRAID ORAL KG INTRAVENOUS 2 SP 2 SP SOLUTION KIT VIMIZIM ZOLGENSMA 3.1-3.5 INTRAVENOUS 2 SP KG INTRAVENOUS 2 SP SOLUTION KIT VIOKACE ORAL ZOLGENSMA 3.6-4.0 2 TABLET KG INTRAVENOUS 2 SP KIT VPRIV INTRAVENOUS SOLUTION 2 SP ZOLGENSMA 4.1-4.5 RECONSTITUTED KG INTRAVENOUS 2 SP KIT VYONDYS 53 INTRAVENOUS 2 SP ZOLGENSMA 4.6-5.0 SOLUTION KG INTRAVENOUS 2 SP KIT XURIDEN ORAL 2 SP PACKET ZOLGENSMA 5.1-5.5 KG INTRAVENOUS 2 SP ZAVESCA ORAL 2 SP KIT CAPSULE ZOLGENSMA 5.6-6.0 ZENPEP ORAL KG INTRAVENOUS 2 SP CAPSULE DELAYED 2 KIT RELEASE PARTICLES ZOLGENSMA 6.1-6.5 ZOLGENSMA 10.1- KG INTRAVENOUS 2 SP 10.5 KG 2 SP KIT INTRAVENOUS KIT

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 137 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ZOLGENSMA 6.6-7.0 CIALIS ORAL TABLET 2 PA KG INTRAVENOUS 2 SP CUPRIMINE ORAL 2 SP KIT CAPSULE ZOLGENSMA 7.1-7.5 darifenacin KG INTRAVENOUS 2 SP hydrobromide er oral 1 KIT tablet extended release ZOLGENSMA 7.6-8.0 24 hour KG INTRAVENOUS 2 SP DEPEN TITRATABS 2 SP KIT ORAL TABLET ZOLGENSMA 8.1-8.5 DETROL LA ORAL KG INTRAVENOUS 2 SP CAPSULE EXTENDED 2 KIT RELEASE 24 HOUR ZOLGENSMA 8.6-9.0 DETROL ORAL 2 KG INTRAVENOUS 2 SP TABLET KIT DITROPAN XL ORAL ZOLGENSMA 9.1-9.5 TABLET EXTENDED 2 KG INTRAVENOUS 2 SP RELEASE 24 HOUR KIT D-PENAMINE ORAL 2 SP ZOLGENSMA 9.6-10.0 TABLET 125 MG KG INTRAVENOUS 2 SP ELMIRON ORAL KIT 2 CAPSULE Genitourinary Agents - Drugs for Bladder, ENABLEX ORAL Genital and Kidney TABLET EXTENDED 2 Conditions RELEASE 24 HOUR acetic acid irrigation flavoxate hcl oral tablet 1 1 solution FOSRENOL ORAL 2 aminoacetic acid PACKET 1 irrigation solution FOSRENOL ORAL 2 AURYXIA ORAL TABLET CHEWABLE 2 TABLET GELNIQUE PUMP bethanechol chloride TRANSDERMAL GEL 2 1 oral tablet 10 % calcium acetate (phos GELNIQUE 1 2 binder) oral capsule TRANSDERMAL GEL calcium acetate (phos glycine irrigation 1 1 binder) oral tablet solution calcium acetate oral glycine urologic 1 1 tablet 667 mg irrigation solution INTRAROSA VAGINAL CAVERJECT 2 INTRACAVERNOSAL INSERT SOLUTION 2 PA lanthanum carbonate 1 RECONSTITUTED 20 oral tablet chewable MCG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 138 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LEVITRA ORAL sevelamer carbonate 2 PA 1 TABLET oral packet LITHOSTAT ORAL sevelamer carbonate 2 1 TABLET oral tablet MUSE URETHRAL sevelamer hcl oral 2 PA 1 PELLET tablet MYRBETRIQ ORAL citrate oral TABLET EXTENDED 2 tablet 100 mg, 25 mg, 1 PA RELEASE 24 HOUR 50 mg oxybutynin chloride er solifenacin succinate 1 oral tablet extended 1 oral tablet release 24 hour STAXYN ORAL oxybutynin chloride oral TABLET 2 PA 1 syrup DISPERSIBLE oxybutynin chloride oral STENDRA ORAL 1 2 PA tablet TABLET OXYTROL oral tablet 1 PA TRANSDERMAL 2 THIOLA EC ORAL PATCH TWICE TABLET DELAYED 2 SP WEEKLY RELEASE penicillamine oral THIOLA ORAL 1 SP 2 SP capsule TABLET penicillamine oral tablet 1 SP tolterodine tartrate er phenazo oral tablet 200 oral capsule extended 1 1 mg release 24 hour phenazopyridine hcl tolterodine tartrate oral 1 oral tablet 100 mg, 200 1 tablet mg TOVIAZ ORAL PHOSLYRA ORAL TABLET EXTENDED 2 2 SOLUTION RELEASE 24 HOUR RENACIDIN trospium chloride er IRRIGATION 2 oral capsule extended 1 SOLUTION release 24 hour RENAGEL ORAL trospium chloride oral 2 1 TABLET tablet RENVELA ORAL URECHOLINE ORAL 2 PACKET TABLET 10 MG, 25 2 RENVELA ORAL MG, 5 MG, 50 MG 2 TABLET uretron d/s oral tablet 1 RIMSO-50 urin ds oral tablet 1 INTRAVESICAL 2 utrona-c oral tablet 1 SOLUTION hcl oral tablet 1 PA

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 139 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits vardenafil hcl oral tablet Hormonal Agents - 1 PA dispersible Adrenal VELPHORO ORAL ALKINDI SPRINKLE 2 TABLET CHEWABLE ORAL CAPSULE 2 VESICARE ORAL SPRINKLE 2 TABLET betamethasone sod VIAGRA ORAL phos & acet injection 2 PA 1 TABLET suspension 6 (3-3) mg/ml Genitourinary Agents - Drugs for Prostate CELESTONE SOLUSPAN Conditions 2 INJECTION alfuzosin hcl er oral SUSPENSION tablet extended release 1 CORTEF ORAL 24 hour 2 TABLET AVODART ORAL 2 cortisone acetate oral CAPSULE 1 tablet CARDURA XL ORAL DECADRON ORAL TABLET EXTENDED 2 2 RELEASE 24 HOUR ELIXIR 0.5 MG/5ML dutasteride oral DECADRON ORAL 1 2 capsule TABLET dutasteride-tamsulosin DEPO-MEDROL 1 hcl oral capsule INJECTION 2 SUSPENSION finasteride oral tablet 5 1 mg DEXABLISS ORAL TABLET THERAPY 2 FLOMAX ORAL 2 PACK CAPSULE DEXAMETHASONE JALYN ORAL 2 (LA) INJECTION 2 CAPSULE SUSPENSION PROSCAR ORAL 2 dexamethasone TABLET intensol oral 1 RAPAFLO ORAL concentrate 2 CAPSULE dexamethasone oral 1 silodosin oral capsule 1 elixir tamsulosin hcl oral dexamethasone oral 1 1 capsule solution terazosin hcl oral dexamethasone oral 1 1 capsule tablet UROXATRAL ORAL dexamethasone oral 1 TABLET EXTENDED 2 tablet therapy pack RELEASE 24 HOUR

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 140 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits DEXAMETHASONE DEXAMETHASONE SOD PHOS IN D5W SODIUM PHOSPHATE 2 INTRAVENOUS SOLUTION 4 MG/ML SOLUTION 10-5 INJECTION 2 MG/50ML-%, 12-5 dexamethasone MG/50ML-%, 20-5 sodium phosphate 1 MG/50ML-%, 8-5 solution 4 mg/ml MG/50ML-% injection DEXAMETHASONE DEXONTO 0.4% SOD PHOS-NACL IONTOPHORESIS 2 INTRAVENOUS SOLUTION SOLUTION 10-0.9 2 MG/50ML-%, 12-0.9 DEXPAK 10 DAY ORAL TABLET MG/50ML-%, 20-0.9 2 MG/50ML-%, 8-0.9 THERAPY PACK 1.5 MG/50ML-% MG (35) dexamethasone sod DEXPAK 13 DAY ORAL TABLET phosphate pf injection 1 2 solution THERAPY PACK 1.5 MG (51) dexamethasone sod phosphate pf injection DEXPAK 6 DAY ORAL 1 solution prefilled TABLET THERAPY 2 syringe PACK 1.5 MG (21) dexamethasone DXEVO 11-DAY ORAL sodium phosphate TABLET THERAPY 2 injection solution 100 1 PACK mg/10ml, 120 mg/30ml, fludrocortisone acetate 1 20 mg/5ml oral tablet DEXAMETHASONE HEMADY ORAL 2 SODIUM PHOSPHATE TABLET INTRAVENOUS HIDEX 6-DAY ORAL SOLUTION 2 TABLET THERAPY 2 PREFILLED SYRINGE PACK 10 MG/2.5ML, 4 hydrocortisone oral MG/ML, 8 MG/2ML 1 tablet dexamethasone sodium phosphate KENALOG INJECTION 1 2 solution 10 mg/ml SUSPENSION injection KENALOG-80 DEXAMETHASONE INJECTION 2 SODIUM PHOSPHATE SUSPENSION 2 SOLUTION 10 MG/ML MEDROL ORAL 2 INJECTION TABLET MEDROL ORAL TABLET THERAPY 2 PACK

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 141 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits METHYLPREDNISOL ORAPRED ODT ORAL ONE ACETATE TABLET 2 INJECTION 2 DISPERSIBLE SUSPENSION 50 PEDIAPRED ORAL 2 MG/ML SOLUTION methylprednisolone prednisolone oral 1 acetate suspension 40 1 solution mg/ml injection prednisolone sodium 1 METHYLPREDNISOL phosphate oral solution ONE ACETATE 2 SUSPENSION 40 prednisolone sodium MG/ML INJECTION phosphate oral tablet 1 dispersible methylprednisolone prednisone intensol acetate suspension 80 1 1 mg/ml injection oral concentrate prednisone oral METHYLPREDNISOL 1 ONE ACETATE solution 2 SUSPENSION 80 prednisone oral tablet 1 MG/ML INJECTION prednisone oral tablet 1 methylprednisolone therapy pack 1 oral tablet RAYOS ORAL TABLET 2 methylprednisolone DELAYED RELEASE 1 oral tablet therapy pack SOLU-CORTEF methylprednisolone INJECTION 2 sodium succ injection 1 SOLUTION solution reconstituted RECONSTITUTED METHYLPREDNISOL SOLU-MEDROL ONE-BUPIVACAINE INJECTION 2 2 INJECTION SOLUTION SUSPENSION RECONSTITUTED MILLIPRED DP 12- TAPERDEX 12-DAY DAY ORAL TABLET 2 ORAL TABLET 2 THERAPY PACK THERAPY PACK MILLIPRED DP ORAL TAPERDEX 6-DAY TABLET THERAPY ORAL TABLET 2 2 PACK 5 MG (21), 5 MG THERAPY PACK (48) TAPERDEX 7-DAY MILLIPRED ORAL ORAL TABLET 2 SOLUTION 10 2 THERAPY PACK MG/5ML TRIAMCINOLONE MILLIPRED ORAL ACETONIDE 2 2 TABLET SUSPENSION 40 MG/ML INJECTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 142 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits triamcinolone acetonide EC-RX suspension 40 mg/ml 1 TESTOSTERONE 2 injection TRANSDERMAL TRIAMCINOLONE CREAM DIACETATE FORTESTA 2 INJECTION 2 TRANSDERMAL GEL SUSPENSION 80 JATENZO ORAL 2 MG/ML CAPSULE TRIAMCINOLONE- METHITEST ORAL BUPIVACAINE 2 2 TABLET INJECTION methyltestosterone oral SUSPENSION 1 capsule VERIPRED 20 ORAL METHYLTESTOSTER SOLUTION 20 2 2 MG/5ML ONE POWDER ZCORT 7-DAY ORAL NANDROLONE DECANOATE TABLET THERAPY 2 2 PACK INJECTION OIL 200 MG/ML ZILRETTA INTRA- ARTICULAR NATESTO NASAL GEL 2 2 SUSPENSION oxandrolone oral tablet 1 RECONSTITUTED ER STRIANT BUCCAL 30 2 Hormonal Agents - MG Men's Health TESTIM 2 ANADROL-50 ORAL TRANSDERMAL GEL 2 TABLET TESTOPEL IMPLANT 2 ANDRODERM PELLET TRANSDERMAL 2 TESTOSTERONE PATCH 24 HOUR COMPOUNDING KIT 2 ANDROGEL PUMP TRANSDERMAL 2 TRANSDERMAL GEL CREAM ANDROGEL testosterone cypionate 2 1 TRANSDERMAL GEL intramuscular solution AVEED testosterone enanthate 1 INTRAMUSCULAR 2 intramuscular solution SOLUTION testosterone 1 danazol oral capsule 1 transdermal gel DEPO- testosterone 1 TESTOSTERONE transdermal solution 2 INTRAMUSCULAR VOGELXO PUMP 2 SOLUTION TRANSDERMAL GEL VOGELXO 2 TRANSDERMAL GEL

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 143 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits XYOSTED EGRIFTA SV SUBCUTANEOUS SUBCUTANEOUS 2 2 SP SOLUTION AUTO- SOLUTION INJECTOR RECONSTITUTED Hormonal Agents - ELIGARD 2 SP Osteoporosis SUBCUTANEOUS KIT EVISTA ORAL FENSOLVI (6 MONTH) 2 2 SP TABLET SUBCUTANEOUS KIT OSPHENA ORAL FIRMAGON (240 MG 2 TABLET DOSE) raloxifene hcl oral tablet 1 SUBCUTANEOUS 2 SP SOLUTION Hormonal Agents - RECONSTITUTED Pituitary FIRMAGON ACTHAR INJECTION SUBCUTANEOUS 2 SP 2 SP GEL SOLUTION BYNFEZIA PEN RECONSTITUTED SUBCUTANEOUS 2 SP GENOTROPIN SOLUTION PEN- MINIQUICK INJECTOR SUBCUTANEOUS 2 SP cabergoline oral tablet 1 SOLUTION DDAVP INJECTION RECONSTITUTED 2 SOLUTION GENOTROPIN DDAVP NASAL SUBCUTANEOUS 2 2 SP SOLUTION SOLUTION RECONSTITUTED DDAVP ORAL TABLET 2 HUMATROPE DDAVP RHINAL TUBE INJECTION 2 2 SP NASAL SOLUTION SOLUTION desmopressin ace RECONSTITUTED spray refrig nasal 1 INCRELEX solution SUBCUTANEOUS 2 SP desmopressin acetate SOLUTION 1 injection solution ISTURISA ORAL 2 SP desmopressin acetate TABLET 1 oral tablet leuprolide acetate 1 SP desmopressin acetate injection kit 1 spray nasal solution LEUPROLIDE EGRIFTA ACETATE- SUBCUTANEOUS BUPIVACAINE 2 SOLUTION 2 SP INTRAMUSCULAR RECONSTITUTED 1 SOLUTION MG LUPANETA PACK 2 SP COMBINATION KIT

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 144 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LUPRON DEPOT (1- NUTROPIN AQ MONTH) 2 SP NUSPIN 20 INTRAMUSCULAR KIT SUBCUTANEOUS 2 SP LUPRON DEPOT (3- SOLUTION PEN- MONTH) 2 SP INJECTOR INTRAMUSCULAR KIT NUTROPIN AQ LUPRON DEPOT (4- NUSPIN 5 MONTH) SUBCUTANEOUS 2 SP INTRAMUSCULAR KIT 2 SP SOLUTION PEN- 30MG INJECTOR INTRAMUSCULAR KIT octreotide acetate 1 SP LUPRON DEPOT (6- injection solution MONTH) OMNITROPE INTRAMUSCULAR KIT 2 SP SUBCUTANEOUS 2 SP 45MG SOLUTION INTRAMUSCULAR KIT CARTRIDGE LUPRON DEPOT-PED OMNITROPE (1-MONTH) 2 SP SUBCUTANEOUS 2 SP INTRAMUSCULAR KIT SOLUTION LUPRON DEPOT-PED RECONSTITUTED (3-MONTH) 2 SP ORILISSA ORAL 2 INTRAMUSCULAR KIT TABLET MYCAPSSA ORAL oxytocin injection 1 CAPSULE DELAYED 2 SP solution RELEASE OXYTOCIN- NOCDURNA DEXTROSE SUBLINGUAL TABLET 2 INTRAVENOUS SUBLINGUAL SOLUTION 10-5 NOCTIVA NASAL UNT/L-%, 10-5 EMULSION 0.83 UT/500ML-%, 15-5 2 2 MCG/0.1ML, 1.66 UT/250ML-%, 20-5 MCG/0.1ML UNT/L-%, 20-5 UT/500ML-%, 30-5 NORDITROPIN UNIT/L-%, 30-5 FLEXPRO UT/500ML-% SUBCUTANEOUS 2 SP SOLUTION PEN- INJECTOR NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS 2 SP SOLUTION PEN- INJECTOR

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 145 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits OXYTOCIN- SOMAVERT DEXTROSE-LACT SUBCUTANEOUS 2 SP RINGERS SOLUTION INTRAVENOUS RECONSTITUTED SOLUTION 10-5 STIMATE NASAL UNIT/L-%, 10-5 2 2 SOLUTION UT/500ML-%, 20-5 SUPPRELIN LA UNIT/L-%, 20-5 2 SP UT/500ML-%, 30-5 SUBCUTANEOUS KIT UNIT/L-%, 30-5 SYNAREL NASAL 2 UT/500ML-%, 40-5 SOLUTION UNIT/L-% TEPEZZA OXYTOCIN- INTRAVENOUS 2 SP LACTATED RINGERS SOLUTION 2 INTRAVENOUS RECONSTITUTED SOLUTION TRELSTAR MIXJECT OXYTOCIN-SODIUM INTRAMUSCULAR 2 SP CHLORIDE SUSPENSION 2 INTRAVENOUS RECONSTITUTED SOLUTION TRIPTODUR PITOCIN INJECTION INTRAMUSCULAR 2 2 SP SOLUTION SUSPENSION SAIZEN INJECTION RECONSTITUTED ER SOLUTION 2 SP VANTAS 2 SP RECONSTITUTED SUBCUTANEOUS KIT SAIZENPREP VAPRISOL INJECTION INTRAVENOUS 2 2 SP SOLUTION SOLUTION RECONSTITUTED VASOPRESSIN- SANDOSTATIN DEXTROSE INJECTION 2 SP INTRAVENOUS SOLUTION SOLUTION 100-5 SANDOSTATIN LAR UT/100ML-%, 20-5 2 DEPOT 2 SP UT/100ML-%, 25-5 INTRAMUSCULAR KIT UT/250ML-%, 50-5 UT/250ML-%, 60-5 SIGNIFOR LAR UT/100ML-% INTRAMUSCULAR 2 SP SUSPENSION RECONSTITUTED ER SIGNIFOR SUBCUTANEOUS 2 SP SOLUTION SOMATULINE DEPOT SUBCUTANEOUS 2 SP SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 146 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VASOPRESSIN- alyacen 7/7/7 oral 1 SODIUM CHLORIDE tablet INTRAVENOUS amabelz oral tablet 1 SOLUTION 100-0.9 UT/100ML-%, 100-0.9 amethia lo oral tablet 1 UT/250ML-%, 25-0.9 amethia oral tablet 1 2 UT/250ML-%, 40-0.9 amethyst oral tablet 1 UT/100ML-%, 50-0.9 ANGELIQ ORAL UT/250ML-%, 50-0.9 2 UT/50ML-%, 60-0.9 TABLET UT/100ML-%, 80-0.9 ANNOVERA VAGINAL 2 UT/100ML-% RING VASOSTRICT apri oral tablet 1 INTRAVENOUS 2 aranelle oral tablet 1 SOLUTION ashlyna oral tablet 1 ZOLADEX SUBCUTANEOUS 2 SP aubra eq oral tablet 1 IMPLANT aubra oral tablet 1 ZOMACTON (FOR aurovela 1.5/30 oral 1 ZOMA-JET 10) tablet SUBCUTANEOUS 2 SP aurovela 1/20 oral 1 SOLUTION tablet RECONSTITUTED aurovela 24 fe oral 1 ZOMACTON tablet SUBCUTANEOUS 2 SP aurovela fe 1.5/30 oral SOLUTION 1 RECONSTITUTED tablet aurovela fe 1/20 oral Hormonal Agents - 1 Prostaglandins tablet KORLYM ORAL aviane oral tablet 1 2 SP TABLET AYGESTIN ORAL 2 Hormonal Agents - TABLET Sex Hormones and ayuna oral tablet 1 Birth Control azurette oral tablet 1 ACTIVELLA ORAL BALCOLTRA ORAL 2 2 TABLET TABLET afirmelle oral tablet 1 balziva oral tablet 1 ALORA bekyree oral tablet 1 TRANSDERMAL 2 PATCH TWICE BEYAZ ORAL TABLET 2 WEEKLY BI-EST 80:20 altavera oral tablet 1 2 TRANSDERMAL alyacen 1/35 oral tablet 1 CREAM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 147 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BIEST/PROGESTERO deblitane oral tablet 1 NE TRANSDERMAL 2 DELESTROGEN 2 CREAM INTRAMUSCULAR OIL BIJUVA ORAL 2 delyla oral tablet 1 CAPSULE DEPO- 2 blisovi 24 fe oral tablet 1 INTRAMUSCULAR OIL blisovi fe 1.5/30 oral 1 DEPO-PROVERA tablet INTRAMUSCULAR QL 2 blisovi fe 1/20 oral SUSPENSION 150 1 tablet MG/ML briellyn oral tablet 1 DEPO-PROVERA INTRAMUSCULAR camila oral tablet 1 2 SUSPENSION 400 camrese lo oral tablet 1 MG/ML camrese oral tablet 1 DEPO-PROVERA caziant oral tablet 1 INTRAMUSCULAR QL 2 charlotte 24 fe oral SUSPENSION 1 tablet chewable PREFILLED SYRINGE chateal eq oral tablet 1 DEPO-SUBQ PROVERA 104 QL chateal oral tablet 1 SUBCUTANEOUS 2 CLIMARA PRO SUSPENSION TRANSDERMAL 2 PREFILLED SYRINGE PATCH WEEKLY desogestrel-ethinyl 1 CLIMARA estradiol oral tablet TRANSDERMAL 2 DIVIGEL 2 PATCH WEEKLY TRANSDERMAL GEL COMBIPATCH dotti transdermal patch TRANSDERMAL 1 2 twice weekly PATCH TWICE drospiren-eth estrad- WEEKLY 1 levomefol oral tablet CRINONE VAGINAL 2 drospirenone-ethinyl GEL 1 estradiol oral tablet cryselle-28 oral tablet 1 DUAVEE ORAL cyclafem 1/35 oral 2 1 TABLET tablet EC-RX ESTRADIOL cyclafem 7/7/7 oral 1 TRANSDERMAL 2 tablet CREAM cyred eq oral tablet 1 EC-RX cyred oral tablet 1 PROGESTERONE 2 dasetta 1/35 oral tablet 1 TRANSDERMAL CREAM dasetta 7/7/7 oral tablet 1 daysee oral tablet 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 148 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ELESTRIN falmina oral tablet 1 2 TRANSDERMAL GEL fayosim oral tablet 1 elinest oral tablet 1 FEMHRT LOW DOSE 2 ELLA ORAL TABLET 2 ORAL TABLET eluryng vaginal ring 1 FEMRING VAGINAL 2 emoquette oral tablet 1 RING ENDOMETRIN femynor oral tablet 1 2 VAGINAL INSERT FIRST- PROGESTERONE enpresse-28 oral tablet 1 2 VGS VAGINAL enskyce oral tablet 1 SUPPOSITORY errin oral tablet 1 fyavolv oral tablet 1 estarylla oral tablet 1 GENERESS FE ORAL 2 ESTRACE ORAL TABLET CHEWABLE 2 TABLET gianvi oral tablet 1 ESTRACE VAGINAL 2 hailey 1.5/30 oral tablet 1 CREAM hailey 24 fe oral tablet 1 estradiol oral tablet 1 hailey fe 1.5/30 oral estradiol transdermal 1 1 tablet patch twice weekly hailey fe 1/20 oral estradiol transdermal 1 1 tablet patch weekly heather oral tablet 1 estradiol vaginal cream 1 hydroxyprogesterone estradiol vaginal tablet 1 caproate intramuscular 1 SP estradiol valerate oil 1 intramuscular oil hydroxyprogesterone estradiol-norethindrone caproate intramuscular 1 SP 1 acet oral tablet solution ESTRING VAGINAL IMVEXXY 2 RING MAINTENANCE PACK 2 ESTROGEL VAGINAL INSERT 2 TRANSDERMAL GEL IMVEXXY STARTER ESTROSTEP FE PACK VAGINAL 2 2 ORAL TABLET INSERT ethynodiol diac-eth incassia oral tablet 1 1 estradiol oral tablet introvale oral tablet 1 etonogestrel-ethinyl isibloom oral tablet 1 1 estradiol vaginal ring jaimiess oral tablet 1 EVAMIST jasmiel oral tablet 1 TRANSDERMAL 2 SOLUTION jencycla oral tablet 1 jinteli oral tablet 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 149 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits jolessa oral tablet 1 levonorg-eth estrad 1 jolivette oral tablet 0.35 triphasic oral tablet 1 mg levora 0.15/30 (28) oral 1 juleber oral tablet 1 tablet junel 1.5/30 oral tablet 1 LILETTA (52 MG) INTRAUTERINE 2 junel 1/20 oral tablet 1 INTRAUTERINE junel fe 1.5/30 oral DEVICE 1 tablet lillow oral tablet 1 junel fe 1/20 oral tablet 1 LO LOESTRIN FE 2 junel fe 24 oral tablet 1 ORAL TABLET kaitlib fe oral tablet LOESTRIN 1.5/30 (21) 1 2 chewable ORAL TABLET kalliga oral tablet 1 LOESTRIN 1/20 (21) 2 kariva oral tablet 1 ORAL TABLET LOESTRIN FE 1.5/30 kelnor 1/35 oral tablet 1 2 ORAL TABLET kelnor 1/50 oral tablet 1 LOESTRIN FE 1/20 2 kurvelo oral tablet 1 ORAL TABLET KYLEENA lojaimiess oral tablet 1 INTRAUTERINE 2 lopreeza oral tablet 0.5- INTRAUTERINE 1 DEVICE 0.1 mg, 1-0.5 mg larin 1.5/30 oral tablet 1 loryna oral tablet 1 LOSEASONIQUE larin 1/20 oral tablet 1 2 ORAL TABLET larin 24 fe oral tablet 1 low-ogestrel oral tablet 1 larin fe 1.5/30 oral 1 lo-zumandimine oral tablet 1 tablet larin fe 1/20 oral tablet 1 lutera oral tablet 1 larissia oral tablet 1 lyza oral tablet 1 layolis fe oral tablet 1 MAKENA chewable 2 SP INTRAMUSCULAR OIL leena oral tablet 1 MAKENA lessina oral tablet 1 SUBCUTANEOUS 2 SP levonest oral tablet 1 SOLUTION AUTO- levonorgest-eth est & INJECTOR 1 eth est oral tablet marlissa oral tablet 1 levonorgest-eth estrad medroxyprogesterone 1 QL 91-day oral tablet acetate intramuscular 1 levonorgestrel-ethinyl suspension 1 estrad oral tablet

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 150 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits medroxyprogesterone MIRENA (52 MG) acetate intramuscular QL INTRAUTERINE 1 2 suspension prefilled INTRAUTERINE syringe DEVICE medroxyprogesterone mono-linyah oral tablet 1 1 acetate oral tablet mononessa oral tablet 1 MEGACE ES ORAL myzilra oral tablet 50- 1 SUSPENSION 625 2 30/75-40/ 125-30 mcg MG/5ML NATAZIA ORAL megestrol acetate oral 2 1 TABLET suspension necon 0.5/35 (28) oral megestrol acetate oral 1 1 tablet tablet NEXPLANON melodetta 24 fe oral 1 SUBCUTANEOUS 2 tablet chewable IMPLANT MENEST ORAL 2 nikki oral tablet 1 TABLET nora-be oral tablet 1 MENOSTAR norethin ace-eth TRANSDERMAL 2 1 PATCH WEEKLY estrad-fe oral tablet mibelas 24 fe oral norethin ace-eth 1 tablet chewable estrad-fe oral tablet 1 chewable microgestin 1.5/30 oral 1 norethindrone acetate tablet 1 oral tablet microgestin 1/20 oral 1 norethindrone acet- tablet 1 ethinyl est oral tablet microgestin fe 1.5/30 1 oral tablet norethindrone acet- ethinyl est oral tablet microgestin fe 1/20 oral 1 1 chewable 1-20 mg- tablet mcg(24) mili oral tablet 1 norethindrone oral 1 mimvey lo oral tablet tablet 1 0.5-0.1 mg norethindrone-eth 1 mimvey oral tablet 1 estradiol oral tablet MINASTRIN 24 FE norethin-eth estradiol-fe 1 ORAL TABLET 2 oral tablet chewable CHEWABLE norgestimate-eth 1 MINIVELLE estradiol oral tablet TRANSDERMAL 2 norgestimate-ethinyl PATCH TWICE estradiol triphasic oral 1 WEEKLY tablet MIRCETTE ORAL 2 norlyda oral tablet 1 TABLET You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 151 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits norlyroc oral tablet 1 pirmella 1/35 oral tablet 1 nortrel 0.5/35 (28) oral pirmella 7/7/7 oral 1 1 tablet tablet nortrel 1/35 (21) oral portia-28 oral tablet 1 1 tablet PREFEST ORAL 2 nortrel 1/35 (28) oral TABLET 1 tablet PREMARIN nortrel 7/7/7 oral tablet 1 INJECTION 2 NUVARING VAGINAL SOLUTION 2 RING RECONSTITUTED PREMARIN ORAL ocella oral tablet 1 2 TABLET ogestrel oral tablet 0.5- 1 PREMARIN VAGINAL 50 mg-mcg 2 CREAM ORIAHNN ORAL PREMPHASE ORAL CAPSULE THERAPY 2 2 PACK TABLET PREMPRO ORAL orsythia oral tablet 1 2 TABLET ORTHO MICRONOR 2 ORAL TABLET previfem oral tablet 1 ORTHO TRI-CYCLEN PROGESTERONE (28) ORAL TABLET COMPOUNDING KIT 2 2 0.18/0.215/0.25 MG-35 TRANSDERMAL MCG CREAM ORTHO TRI-CYCLEN progesterone 2 1 LO ORAL TABLET intramuscular oil progesterone ORTHO-CYCLEN (28) 1 ORAL TABLET 0.25-35 2 micronized oral capsule MG-MCG progesterone ORTHO-NOVUM 1/35 micronized transdermal 1 (28) ORAL TABLET 1- 2 cream 35 MG-MCG PROMETRIUM ORAL 2 ORTHO-NOVUM 7/7/7 CAPSULE (28) ORAL TABLET 2 PROVERA ORAL 2 0.5/0.75/1-35 MG-MCG TABLET PARAGARD QUARTETTE ORAL 2 INTRAUTERINE TABLET quasense oral tablet 2 1 INTRAUTERINE 0.15-0.03 mg INTRAUTERINE DEVICE reclipsen oral tablet 1 philith oral tablet 1 rivelsa oral tablet 1 SAFYRAL ORAL pimtrea oral tablet 1 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 152 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SEASONIQUE ORAL tulana oral tablet 1 2 TABLET TWIRLA setlakin oral tablet 1 TRANSDERMAL 2 sharobel oral tablet 1 PATCH WEEKLY simliya oral tablet 1 tyblume oral tablet 1 simpesse oral tablet 1 tydemy oral tablet 1 VAGIFEM VAGINAL SKYLA 2 INTRAUTERINE TABLET 2 INTRAUTERINE velivet oral tablet 1 DEVICE vienva oral tablet 1 SLYND ORAL TABLET 2 viorele oral tablet 1 sprintec 28 oral tablet 1 VIVELLE-DOT sronyx oral tablet 1 TRANSDERMAL 2 syeda oral tablet 1 PATCH TWICE WEEKLY tarina 24 fe oral tablet 1 volnea oral tablet 1 tarina fe 1/20 eq oral 1 tablet vyfemla oral tablet 1 tarina fe 1/20 oral tablet 1 vylibra oral tablet 1 TAYTULLA ORAL wera oral tablet 1 2 CAPSULE wymzya fe oral tablet 1 tilia fe oral tablet 1 chewable xulane transdermal tri femynor oral tablet 1 1 patch weekly tri-estarylla oral tablet 1 YASMIN 28 ORAL 2 tri-legest fe oral tablet 1 TABLET tri-linyah oral tablet 1 YAZ ORAL TABLET 2 tri-lo-estarylla oral 1 yuvafem vaginal tablet 1 tablet zarah oral tablet 1 tri-lo-marzia oral tablet 1 zovia 1/35e (28) oral 1 tri-lo-mili oral tablet 1 tablet tri-lo-sprintec oral tablet 1 zumandimine oral 1 tri-mili oral tablet 1 tablet TRI-NORINYL (28) Hormonal Agents - ORAL TABLET 2 Thyroid 0.5/1/0.5-35 MG-MCG ARMOUR THYROID 2 tri-previfem oral tablet 1 ORAL TABLET tri-sprintec oral tablet 1 CYTOMEL ORAL 2 trivora (28) oral tablet 1 TABLET tri-vylibra lo oral tablet 1 euthyrox oral tablet 1 tri-vylibra oral tablet 1 levo-t oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 153 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits levothyroxine sodium Immunological 1 intravenous solution Agents - Drugs for levothyroxine sodium Immune System intravenous solution 1 Stimulation or reconstituted Suppression levothyroxine sodium ACTEMRA ACTPEN 1 SUBCUTANEOUS oral tablet 2 SP SOLUTION AUTO- levoxyl oral tablet 1 INJECTOR liothyronine sodium 1 ACTEMRA intravenous solution INTRAVENOUS 2 SP liothyronine sodium oral SOLUTION 1 tablet ACTEMRA methimazole oral tablet 1 SUBCUTANEOUS 2 SP NATURE-THROID SOLUTION 2 ORAL TABLET PREFILLED SYRINGE np thyroid oral tablet 1 ACTIMMUNE SUBCUTANEOUS 2 SP propylthiouracil oral 1 SOLUTION tablet ALFERON N SYNTHROID ORAL 2 INJECTION 2 SP TABLET SOLUTION TAPAZOLE ORAL 2 ARAVA ORAL TABLET 2 TABLET ARCALYST thyroid oral tablet 120 SUBCUTANEOUS 2 SP mg, 15 mg, 30 mg, 60 1 SOLUTION mg, 90 mg RECONSTITUTED TIROSINT ORAL 2 ASCENIV CAPSULE INTRAVENOUS 2 SP TIROSINT-SOL ORAL SOLUTION 2 SOLUTION ASTAGRAF XL ORAL TRIOSTAT CAPSULE EXTENDED 2 SP INTRAVENOUS 2 RELEASE 24 HOUR SOLUTION ATGAM unithroid oral tablet 1 INTRAVENOUS 2 SP WESTHROID ORAL INJECTABLE 2 TABLET AVSOLA WP THYROID ORAL INTRAVENOUS 2 2 SP TABLET SOLUTION RECONSTITUTED AZASAN ORAL 2 TABLET oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 154 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits azathioprine sodium CINRYZE injection solution 1 INTRAVENOUS 2 SP reconstituted SOLUTION BENLYSTA RECONSTITUTED INTRAVENOUS COSENTYX (300 MG 2 SP SOLUTION DOSE) RECONSTITUTED SUBCUTANEOUS 2 SP BENLYSTA SOLUTION SUBCUTANEOUS PREFILLED SYRINGE 2 SP SOLUTION AUTO- COSENTYX 150 INJECTOR MG/ML BENLYSTA SUBCUTANEOUS 2 SP SUBCUTANEOUS SOLUTION 2 SP SOLUTION PREFILLED SYRINGE PREFILLED SYRINGE COSENTYX BERINERT SENSOREADY (300 2 SP INTRAVENOUS KIT MG) SUBCUTANEOUS 2 SP SOLUTION AUTO- BIVIGAM INJECTOR INTRAVENOUS 2 SP SOLUTION COSENTYX SENSOREADY PEN CARIMUNE NF SUBCUTANEOUS 2 SP INTRAVENOUS 2 SP SOLUTION AUTO- SOLUTION INJECTOR RECONSTITUTED CUTAQUIG CELLCEPT SUBCUTANEOUS 2 SP INTRAVENOUS SOLUTION INTRAVENOUS 2 SP SOLUTION CUVITRU RECONSTITUTED SUBCUTANEOUS 2 SP SOLUTION CELLCEPT ORAL 2 SP cyclosporine CAPSULE 1 SP intravenous solution CELLCEPT ORAL cyclosporine modified SUSPENSION 2 SP 1 SP RECONSTITUTED oral capsule CELLCEPT ORAL cyclosporine modified 2 SP 1 SP TABLET oral solution cyclosporine oral CIMZIA PREFILLED 1 SP KIT SUBCUTANEOUS 2 SP capsule KIT CYTOGAM CIMZIA STARTER KIT INTRAVENOUS 2 SP 2 SP SUBCUTANEOUS KIT INJECTABLE CIMZIA ENBREL MINI 2 SP SUBCUTANEOUS SUBCUTANEOUS KIT 2 SP SOLUTION CARTRIDGE You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 155 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ENBREL GAMMAGARD S/D SUBCUTANEOUS 2 SP LESS IGA SOLUTION INTRAVENOUS 2 SP ENBREL SOLUTION SUBCUTANEOUS RECONSTITUTED 2 SP SOLUTION GAMMAKED PREFILLED SYRINGE INJECTION 2 SP ENBREL SOLUTION SUBCUTANEOUS GAMMAPLEX 2 SP SOLUTION INTRAVENOUS 2 SP RECONSTITUTED SOLUTION ENBREL SURECLICK GAMUNEX-C SUBCUTANEOUS INJECTION 2 SP 2 SP SOLUTION AUTO- SOLUTION INJECTOR gengraf oral capsule 1 SP ENSPRYNG gengraf oral solution 1 SP SUBCUTANEOUS 2 SP SOLUTION HAEGARDA SUBCUTANEOUS PREFILLED SYRINGE 2 SP SOLUTION ENTYVIO RECONSTITUTED INTRAVENOUS 2 SP SOLUTION HIZENTRA RECONSTITUTED SUBCUTANEOUS 2 SP SOLUTION ENVARSUS XR ORAL TABLET EXTENDED 2 SP HIZENTRA SUBCUTANEOUS RELEASE 24 HOUR 2 SP SOLUTION everolimus oral tablet PREFILLED SYRINGE 0.25 mg, 0.5 mg, 0.75 1 SP mg HUMIRA PEDIATRIC CROHNS START FIRAZYR SUBCUTANEOUS 2 SP SUBCUTANEOUS 2 SP PREFILLED SYRINGE SOLUTION KIT FLEBOGAMMA DIF HUMIRA PEN INTRAVENOUS 2 SP SUBCUTANEOUS 2 SP SOLUTION PEN-INJECTOR KIT GAMASTAN HUMIRA PEN- INTRAMUSCULAR 2 SP CD/UC/HS STARTER 2 SP INJECTABLE SUBCUTANEOUS GAMIFANT PEN-INJECTOR KIT INTRAVENOUS 2 SP HUMIRA PEN- SOLUTION PS/UV/ADOL HS GAMMAGARD START 2 SP INJECTION 2 SP SUBCUTANEOUS SOLUTION PEN-INJECTOR KIT

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 156 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits HUMIRA oral tablet 1 SUBCUTANEOUS methotrexate sodium 2 SP 1 PREFILLED SYRINGE (pf) injection solution KIT methotrexate sodium 1 HYPERRHO S/D injection solution INTRAMUSCULAR 2 SP SOLUTION methotrexate sodium PREFILLED SYRINGE injection solution 1 reconstituted HYQVIA 2 SP methotrexate sodium SUBCUTANEOUS KIT 1 oral tablet icatibant acetate 1 SP subcutaneous solution MICRHOGAM ULTRA- FILTERED PLUS ILARIS INTRAMUSCULAR 2 SP SUBCUTANEOUS 2 SP SOLUTION SOLUTION PREFILLED SYRINGE ILUMYA mycophenolate mofetil SUBCUTANEOUS 2 SP hcl intravenous solution 1 SP SOLUTION reconstituted PREFILLED SYRINGE mycophenolate mofetil IMURAN ORAL 1 SP 2 oral capsule TABLET mycophenolate mofetil INFLECTRA oral suspension 1 SP INTRAVENOUS 2 SP reconstituted SOLUTION mycophenolate mofetil RECONSTITUTED 1 SP oral tablet KALBITOR SUBCUTANEOUS 2 SP mycophenolate sodium SOLUTION oral tablet delayed 1 SP release KEVZARA SUBCUTANEOUS MYFORTIC ORAL 2 SP SOLUTION AUTO- TABLET DELAYED 2 SP INJECTOR RELEASE NEORAL ORAL KEVZARA 2 SP SUBCUTANEOUS CAPSULE 2 SP SOLUTION NEORAL ORAL 2 SP PREFILLED SYRINGE SOLUTION KINERET NULOJIX SUBCUTANEOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION PREFILLED SYRINGE RECONSTITUTED KYMRIAH OCTAGAM INTRAVENOUS 2 SP INTRAVENOUS 2 SP SUSPENSION SOLUTION leflunomide oral tablet 1

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 157 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits OLUMIANT ORAL RASUVO 2 SP TABLET SUBCUTANEOUS 2 ORENCIA CLICKJECT SOLUTION AUTO- SUBCUTANEOUS INJECTOR 2 SP SOLUTION AUTO- REMICADE INJECTOR INTRAVENOUS 2 SP ORENCIA SOLUTION INTRAVENOUS RECONSTITUTED 2 SP SOLUTION RENFLEXIS RECONSTITUTED INTRAVENOUS 2 SP ORENCIA SOLUTION SUBCUTANEOUS RECONSTITUTED 2 SP SOLUTION RHOGAM ULTRA- PREFILLED SYRINGE FILTERED PLUS OTEZLA ORAL INTRAMUSCULAR 2 SP 2 SP TABLET SOLUTION PREFILLED SYRINGE OTEZLA ORAL TABLET THERAPY 2 SP RHOPHYLAC INJECTION PACK 2 SOLUTION OTREXUP PREFILLED SYRINGE SUBCUTANEOUS 2 RIDAURA ORAL SOLUTION AUTO- 2 SP INJECTOR CAPSULE PANZYGA RINVOQ ORAL INTRAVENOUS 2 SP TABLET EXTENDED 2 SP SOLUTION RELEASE 24 HOUR PRIVIGEN RUCONEST INTRAVENOUS INTRAVENOUS 2 SP 2 SP SOLUTION SOLUTION RECONSTITUTED PROGRAF INTRAVENOUS 2 SP SANDIMMUNE SOLUTION INTRAVENOUS 2 SP SOLUTION PROGRAF ORAL 2 SP SANDIMMUNE ORAL CAPSULE 2 SP CAPSULE PROGRAF ORAL 2 SP SANDIMMUNE ORAL PACKET 2 SP SOLUTION PROVENGE INTRAVENOUS 2 SP SILIQ SUBCUTANEOUS SUSPENSION 2 SP SOLUTION RAPAMUNE ORAL 2 SP PREFILLED SYRINGE SOLUTION SIMPONI ARIA RAPAMUNE ORAL 2 SP INTRAVENOUS 2 SP TABLET SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 158 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SIMPONI temsirolimus 1 SP SUBCUTANEOUS intravenous solution 2 SP SOLUTION AUTO- THYMOGLOBULIN INJECTOR INTRAVENOUS 2 SIMPONI SOLUTION SUBCUTANEOUS RECONSTITUTED 2 SP SOLUTION TICE BCG PREFILLED SYRINGE INTRAVESICAL 2 SP SIMULECT SUSPENSION INTRAVENOUS RECONSTITUTED 2 SOLUTION TORISEL RECONSTITUTED INTRAVENOUS 2 SP sirolimus oral solution 1 SP SOLUTION sirolimus oral tablet 1 SP TREMFYA SUBCUTANEOUS SKYRIZI (150 MG 2 SP DOSE) SOLUTION PEN- SUBCUTANEOUS 2 SP INJECTOR PREFILLED SYRINGE TREMFYA KIT SUBCUTANEOUS 2 SP STELARA SOLUTION INTRAVENOUS 2 SP PREFILLED SYRINGE SOLUTION TREXALL ORAL 2 STELARA TABLET SUBCUTANEOUS 2 SP UPLIZNA SOLUTION INTRAVENOUS 2 SP STELARA SOLUTION SUBCUTANEOUS WINRHO SDF 2 SP SOLUTION INJECTION 2 SP PREFILLED SYRINGE SOLUTION SYNAGIS XATMEP ORAL 2 INTRAMUSCULAR 2 SP SOLUTION SOLUTION XELJANZ ORAL 2 SP tacrolimus oral capsule 1 SP TABLET TAKHZYRO XELJANZ XR ORAL SUBCUTANEOUS 2 SP TABLET EXTENDED 2 SP SOLUTION RELEASE 24 HOUR TALTZ XEMBIFY SUBCUTANEOUS SUBCUTANEOUS 2 SP 2 SP SOLUTION AUTO- SOLUTION INJECTOR ZINPLAVA TALTZ INTRAVENOUS 2 SUBCUTANEOUS SOLUTION 2 SP SOLUTION ZORTRESS ORAL 2 SP PREFILLED SYRINGE TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 159 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Immunological DIPHTHERIA- Agents - Drugs for TETANUS TOXOIDS 2 Vaccination DT INTRAMUSCULAR ACTHIB SUSPENSION INTRAMUSCULAR ENGERIX-B 2 SOLUTION INJECTION 2 RECONSTITUTED SUSPENSION ADACEL ENGERIX-B INTRAMUSCULAR 2 INTRAMUSCULAR SUSPENSION INJECTABLE 10 2 AFLURIA MCG/0.5ML, 20 INTRAMUSCULAR 70 MCG/ML SUSPENSION EZ FLU SHOT- AFLURIA FLUCELVAX QUAD PRESERVATIVE INTRAMUSCULAR 70 FREE PREFILLED SYRINGE INTRAMUSCULAR 70 KIT 0.5 ML SUSPENSION FLUAD PREFILLED SYRINGE INTRAMUSCULAR 70 0.5 ML SUSPENSION AFLURIA PREFILLED SYRINGE QUADRIVALENT FLUAD 70 INTRAMUSCULAR QUADRIVALENT 70 SUSPENSION INTRAMUSCULAR AFLURIA PREFILLED SYRINGE QUADRIVALENT FLUARIX INTRAMUSCULAR 70 QUADRIVALENT SUSPENSION INTRAMUSCULAR 70 PREFILLED SYRINGE SUSPENSION BCG VACCINE PREFILLED SYRINGE INJECTION 2 FLUBLOK INJECTABLE QUADRIVALENT BEXSERO INTRAMUSCULAR 70 INTRAMUSCULAR SOLUTION 2 SUSPENSION PREFILLED SYRINGE PREFILLED SYRINGE FLUCELVAX QUADRIVALENT BIOTHRAX 70 INTRAMUSCULAR 2 INTRAMUSCULAR SUSPENSION SUSPENSION BOOSTRIX FLUCELVAX INTRAMUSCULAR 2 QUADRIVALENT SUSPENSION INTRAMUSCULAR 70 SUSPENSION DAPTACEL PREFILLED SYRINGE INTRAMUSCULAR 2 SUSPENSION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 160 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits FLULAVAL HEPLISAV-B QUADRIVALENT INTRAMUSCULAR 70 2 INTRAMUSCULAR SOLUTION 20 SUSPENSION MCG/0.5ML FLULAVAL HEPLISAV-B QUADRIVALENT INTRAMUSCULAR 2 INTRAMUSCULAR 70 SOLUTION SUSPENSION PREFILLED SYRINGE PREFILLED SYRINGE HIBERIX INJECTION FLUMIST SOLUTION 2 QUADRIVALENT 70 RECONSTITUTED NASAL SUSPENSION IMOVAX RABIES FLUZONE HIGH- INTRAMUSCULAR 2 DOSE INJECTABLE INTRAMUSCULAR 70 INFANRIX SUSPENSION INTRAMUSCULAR 2 PREFILLED SYRINGE SUSPENSION 0.5 ML IPOL INJECTION 2 FLUZONE HIGH- INJECTABLE DOSE QUADRIVALENT IXIARO 70 INTRAMUSCULAR INTRAMUSCULAR 2 SUSPENSION SUSPENSION PREFILLED SYRINGE KINRIX FLUZONE INTRAMUSCULAR 2 QUADRIVALENT SUSPENSION 70 INTRAMUSCULAR MENACTRA SUSPENSION INTRAMUSCULAR 2 FLUZONE INJECTABLE QUADRIVALENT MENQUADFI INTRAMUSCULAR 70 INTRAMUSCULAR 2 SUSPENSION INJECTABLE PREFILLED SYRINGE MENVEO GARDASIL 9 INTRAMUSCULAR 2 INTRAMUSCULAR 2 SOLUTION SUSPENSION RECONSTITUTED GARDASIL 9 M-M-R II INJECTION INTRAMUSCULAR SOLUTION 2 2 SUSPENSION RECONSTITUTED PREFILLED SYRINGE PEDIARIX HAVRIX INTRAMUSCULAR 2 INTRAMUSCULAR 2 SUSPENSION SUSPENSION PEDVAX HIB INTRAMUSCULAR 2 SUSPENSION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 161 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits PENTACEL TETANUS- INTRAMUSCULAR DIPHTHERIA 2 SUSPENSION TOXOIDS TD 2 RECONSTITUTED INTRAMUSCULAR PNEUMOVAX 23 SUSPENSION INJECTION 70 TRUMENBA INJECTABLE INTRAMUSCULAR 2 PREVNAR 13 SUSPENSION INTRAMUSCULAR 70 PREFILLED SYRINGE SUSPENSION TWINRIX INTRAMUSCULAR PROQUAD 2 SUBCUTANEOUS SUSPENSION 2 SUSPENSION PREFILLED SYRINGE RECONSTITUTED TYPHIM VI QUADRACEL INTRAMUSCULAR 2 INTRAMUSCULAR 2 SOLUTION SUSPENSION VAQTA RABAVERT INTRAMUSCULAR 2 INTRAMUSCULAR SUSPENSION 2 SUSPENSION VARIVAX RECONSTITUTED SUBCUTANEOUS 2 RECOMBIVAX HB INJECTABLE INJECTION 2 VAXCHORA ORAL SUSPENSION SUSPENSION 2 ROTARIX ORAL RECONSTITUTED SUSPENSION 2 VIVOTIF ORAL RECONSTITUTED CAPSULE DELAYED 2 ROTATEQ ORAL RELEASE 2 SOLUTION YF-VAX SHINGRIX SUBCUTANEOUS 2 INTRAMUSCULAR INJECTABLE 2 SUSPENSION ZOSTAVAX RECONSTITUTED SUBCUTANEOUS STAMARIL INJECTION SUSPENSION 2 SUSPENSION 2 RECONSTITUTED RECONSTITUTED 19400 UNT/0.65ML TDVAX Inflammatory Bowel INTRAMUSCULAR 2 Disease Agents SUSPENSION ANUSOL-HC 2 TENIVAC EXTERNAL CREAM INTRAMUSCULAR 2 APRISO ORAL INJECTABLE CAPSULE EXTENDED 2 RELEASE 24 HOUR

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 162 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ASACOL HD ORAL LIALDA ORAL TABLET 2 TABLET DELAYED 2 DELAYED RELEASE RELEASE mesalamine er oral AZULFIDINE EN-TABS capsule extended 1 ORAL TABLET 2 release 24 hour DELAYED RELEASE mesalamine oral AZULFIDINE ORAL capsule delayed 1 2 TABLET release balsalazide disodium mesalamine oral tablet 1 1 oral capsule delayed release budesonide er oral mesalamine rectal 1 tablet extended release 1 enema 24 hour mesalamine rectal 1 budesonide oral suppository capsule delayed 1 mesalamine-cleanser 1 release particles rectal kit CANASA RECTAL 2 ORTIKOS ORAL SUPPOSITORY CAPSULE EXTENDED 2 COLAZAL ORAL RELEASE 24 HOUR 6 2 CAPSULE MG colocort rectal enema PENTASA ORAL 1 100 mg/60ml CAPSULE EXTENDED 2 CORTENEMA RELEASE 2 RECTAL ENEMA PROCTOCORT 2 CORTIFOAM EXTERNAL CREAM 2 EXTERNAL FOAM PROCTOFOAM HC 2 DELZICOL ORAL EXTERNAL FOAM CAPSULE DELAYED 2 procto-med hc external 1 RELEASE cream DIPENTUM ORAL procto-pak external 2 1 CAPSULE cream ENTOCORT EC ORAL proctosol hc external 1 CAPSULE DELAYED 2 cream 2.5 % RELEASE PARTICLES proctozone-hc external 1 hydrocortisone cream (perianal) external 1 ROWASA RECTAL KIT 2 cream SFROWASA RECTAL 2 hydrocortisone ace- ENEMA pramoxine external 1 cream 1-1 % sulfasalazine oral tablet 1 hydrocortisone rectal sulfasalazine oral tablet 1 1 enema delayed release

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 163 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits UCERIS ORAL ibandronate sodium 1 TABLET EXTENDED 2 oral tablet RELEASE 24 HOUR MIACALCIN UCERIS RECTAL INJECTION 2 2 FOAM SOLUTION Metabolic Bone pamidronate disodium 1 SP Disease Agents - intravenous solution Drugs for pamidronate disodium Osteoporosis intravenous solution 1 SP ACTONEL ORAL reconstituted 2 TABLET PROLIA alendronate sodium SUBCUTANEOUS 1 2 SP oral solution SOLUTION alendronate sodium PREFILLED SYRINGE 1 oral tablet RAYALDEE ORAL ATELVIA ORAL CAPSULE EXTENDED 2 TABLET DELAYED 2 RELEASE RELEASE RECLAST BINOSTO ORAL INTRAVENOUS 2 SP TABLET 2 SOLUTION EFFERVESCENT risedronate sodium oral 1 BONIVA tablet INTRAVENOUS 2 risedronate sodium oral 1 SOLUTION tablet delayed release BONIVA ORAL TERIPARATIDE 2 TABLET (RECOMBINANT) calcitonin (salmon) SUBCUTANEOUS 2 SP 1 nasal solution SOLUTION PEN- INJECTOR EVENITY SUBCUTANEOUS TYMLOS 2 SP SUBCUTANEOUS SOLUTION 2 SP PREFILLED SYRINGE SOLUTION PEN- INJECTOR FORTEO SUBCUTANEOUS XGEVA 2 SP SOLUTION PEN- SUBCUTANEOUS 2 SP INJECTOR SOLUTION FOSAMAX ORAL zoledronic acid 2 TABLET intravenous 1 SP concentrate FOSAMAX PLUS D 2 zoledronic acid ORAL TABLET 1 SP intravenous solution ibandronate sodium 1 intravenous solution zoledronic acid intravenous solution 1 SP reconstituted 4 mg

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 164 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ZOMETA ZEMPLAR INTRAVENOUS INTRAVENOUS 2 2 SP CONCENTRATE 4 SOLUTION MG/5ML ZEMPLAR ORAL 2 ZOMETA CAPSULE INTRAVENOUS 2 SP Miscellaneous SOLUTION 4 Therapeutic Agents MG/100ML ACCU-CHEK 2 Metabolic Bone FLEXLINK PLUS 6MM Disease Agents - ACCU-CHEK Other 2 ULTRAFLEX INF SET calcitriol intravenous 1 solution ACETADOTE INTRAVENOUS 2 calcitriol oral capsule 1 SOLUTION calcitriol oral solution 1 acetylcysteine 1 cinacalcet hcl oral intravenous solution 1 tablet ACTHREL doxercalciferol INTRAVENOUS 1 2 SP intravenous solution SOLUTION doxercalciferol oral RECONSTITUTED 1 capsule ACTIPHYTE OF SEA 2 etidronate disodium KELP LIQUID oral tablet 200 mg, 400 1 ACTIPHYTE OF 2 mg SUGAR KELP LIQUID HECTOROL ADAKVEO INTRAVENOUS 2 INTRAVENOUS 2 SP SOLUTION SOLUTION NATPARA adenosine (diagnostic) 1 SUBCUTANEOUS 2 SP intravenous solution CARTRIDGE adenosine intravenous 1 paricalcitol intravenous solution 3 mg/ml 1 solution ALBUKED 25 paricalcitol oral capsule 1 INTRAVENOUS 2 PARSABIV SOLUTION INTRAVENOUS 2 SP ALBUKED 5 SOLUTION INTRAVENOUS 2 ROCALTROL ORAL SOLUTION 2 CAPSULE albumin human 1 ROCALTROL ORAL intravenous solution 2 SOLUTION ALBUMINAR-25 SENSIPAR ORAL INTRAVENOUS 2 2 TABLET SOLUTION 25 %

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 165 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ALBUMINAR-5 ANESTHESIA S/I-60 INTRAVENOUS 2 INTRAVENOUS KIT 2 SOLUTION 5 % 200 MG/20ML ALBUMINEX APPTRIM ORAL 2 INTRAVENOUS 2 CAPSULE SOLUTION APPTRIM-D ORAL 2 albumin-zlb intravenous CAPSULE 1 solution ARTISS EXTERNAL 2 alburx intravenous SOLUTION 1 solution ASPARTAME ALBUTEIN (NUTRASWEET) 2 INTRAVENOUS 2 POWDER SOLUTION ASPARTAME 2 ALCOHOL PREP POWDER 2 PADS PAD ASTAMED MYO ORAL 2 ALCOHOL PREP CAPSULE 2 PADS PAD 70 % AUTOSOFT 30 2 ALGESIS ORAL INFUSION SET 2 TABLET AUTOSOFT 90 2 ALPHA-LIPOIC ACID INFUSION SET INJECTION 2 AUTOSOFT XC 2 SOLUTION INFUSION SET AMD FOAM AVAILNEX ORAL 2 2 DRESSING PAD TABLET CHEWABLE AMD FOAM AXONA ORAL 2 DRESSING 2 PACKET TOPSHEET PAD BACTERIOSTATIC AMIDATE WATER(BENZ ALC) 2 INTRAVENOUS 2 INJECTION SOLUTION SOLUTION AMPHADASE bal in oil intramuscular 1 INJECTION 2 solution SOLUTION BD SYRINGE LUER- 2 ANESTHESIA S/I-40 LOK 30 ML INTRAVENOUS KIT 2 200 MG/20ML BINAXNOW COVID-19 AG CARD IN VITRO 2 ANESTHESIA S/I-40A 2 KIT INTRAVENOUS KIT BIOGUARD GAUZE ANESTHESIA S/I-40H 2 2 SPONGES PAD 4"X4" INTRAVENOUS KIT BIOGUARD ISLAND ANESTHESIA S/I-40S 2 2 DRESSINGS PAD INTRAVENOUS KIT

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 166 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BIOGUARD NON- CICLOPIROX 2 ADHERENT 2 POWDER DRESSING PAD CLEO 90 INFUSION 2 BOTOX INJECTION SET 24"/6MM SOLUTION 2 SP COENZYME Q-10 RECONSTITUTED INJECTION 2 BREVITAL SODIUM SOLUTION 20 MG/ML INJECTION COMFORT INFUSION 2 2 SOLUTION SET 23"/17MM RECONSTITUTED COMFORT SHORT 2 BRIDION INF SET 23"/13MM INTRAVENOUS 2 SOLUTION CORTROSYN INJECTION BROMELAIN 2 2 SOLUTION POWDER RECONSTITUTED CALCIUM DISODIUM cosyntropin injection VERSENATE 1 2 solution reconstituted INJECTION SOLUTION CURITY AMD ANTIMICROBIAL 2 CARDIOTEK RX ORAL 2 SPNGE PAD 4"X4" TABLET CURITY AMD CARTICEL INTRA- 2 ANTIMICROBIAL 2 ARTICULAR IMPLANT STRIP CAYA VAGINAL CURITY IODOFORM 2 2 DIAPHRAGM PACKING STRIP CETYLCIDE-G 2 CYANOKIT CONCENTRATE INTRAVENOUS 2 CETYLEV ORAL SOLUTION TABLET RECONSTITUTED 2 EFFERVESCENT 2.5 CYSVIEW GM, 500 MG INTRAVESICAL 2 CHARCOAL SOLUTION 2 ACTIVATED POWDER RECONSTITUTED CHIRHOSTIM CYTOTINE ORAL 2 INTRAVENOUS POWDER 2 SOLUTION deferoxamine mesylate RECONSTITUTED injection solution 1 CHLORHEXIDINE reconstituted GLUCONATE 2 DELTEC COZMO 2 SOLUTION 20 % CLEO SET 24" 6MM CHOLEXMAX ORAL 2 DESFERAL POWDER INJECTION 2 CHOLEXTRA T/F SOLUTION 2 ORAL POWDER RECONSTITUTED You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 167 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits desflurane inhalation EASY GLIDE LUER 1 2 solution LOCK SYRINGE dexmedetomidine hcl in EASYPOINT NEEDLE 2 nacl intravenous 25G X 1-1/2" solution 200 mcg/50ml, 1 EC-RX DHEA 2 400 mcg/100ml, 80 EXTERNAL CREAM mcg/20ml ENDARI ORAL 2 DEXMEDETOMIDINE PACKET HCL INTRAVENOUS SOLUTION 1000 2 ENOVARX- MCG/10ML, 400 AMITRIPTYLINE 2 MCG/4ML EXTERNAL KIT ENTERAGAM ORAL dexmedetomidine hcl 2 intravenous solution 1 PACKET 200 mcg/2ml ergoloid mesylates oral 1 DEXMEDETOMIDINE tablet HCL-DEXTROSE EROS-CTD DEVICE 2 2 INTRAVENOUS etomidate intravenous 1 SOLUTION solution DIGIFAB EUFLEXXA INTRA- INTRAVENOUS ARTICULAR 2 2 SP SOLUTION SOLUTION RECONSTITUTED PREFILLED SYRINGE diluent for 1 EVRYSDI ORAL intravenous solution SOLUTION 2 SP DIPRIVAN RECONSTITUTED INTRAVENOUS 2 EXCILON AMD DRAIN 2 EMULSION SPONGES PAD dipyridamole FDGARD ORAL 1 2 intravenous solution CAPSULE DOJOLVI ORAL FEMCAP VAGINAL 2 2 LIQUID DEVICE DUODOTE FILTER NEEDLE 18G INTRAMUSCULAR 2 2 X 1-1/2" SOLUTION AUTO- FIRDAPSE ORAL INJECTOR 2 SP TABLET DUROLANE INTRA- ARTICULAR 2 SP FLEXBUMIN PREFILLED SYRINGE INTRAVENOUS 2 SOLUTION DYSPORT INTRAMUSCULAR flumazenil intravenous 2 SP 1 SOLUTION solution RECONSTITUTED FOLBIC ORAL 2 TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 168 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits fomepizole intravenous GLUCAGON HCL 1 solution (DIAGNOSTIC) FORA D40G INJECTION 2 GLUCOSE/PRESSUR 2 SOLUTION E DEVICE RECONSTITUTED FORANE INHALATION glutaraldehyde external 2 1 SOLUTION solution heparin lock flush FORMADON 1 EXTERNAL 2 intravenous solution SOLUTION 10 % heparin sodium flush formaldehyde external intravenous kit 100-0.9 1 1 solution 37 % unit/ml-% fresenius propoven heparin sodium lock intravenous emulsion flush intravenous 1 1 1000 mg/100ml, 200 solution mg/20ml, 500 mg/50ml HISTATROL GABADONE ORAL INJECTION 2 2 CAPSULE SOLUTION GALAXTRA ORAL HOME PAP KIT IN 2 2 POWDER VITRO KIT GEL-ONE INTRA- HUMAN ALBUMIN GRIFOLS ARTICULAR 2 SP 2 PREFILLED SYRINGE INTRAVENOUS SOLUTION GELSYN-3 INTRA- ARTICULAR HUMATROPEN FOR 2 SP 2 SOLUTION 12MG DEVICE PREFILLED SYRINGE HUMATROPEN FOR 2 GENVISC 850 INTRA- 24MG DEVICE ARTICULAR HUMATROPEN FOR 2 SP 2 SOLUTION 6MG DEVICE PREFILLED SYRINGE HYALGAN INTRA- GIVLAARI ARTICULAR 2 SP SUBCUTANEOUS 2 SP SOLUTION SOLUTION HYALGAN INTRA- GLEOLAN ORAL ARTICULAR 2 SP SOLUTION 2 SOLUTION RECONSTITUTED PREFILLED SYRINGE GLUCAGEN HYLENEX INJECTION 2 DIAGNOSTIC SOLUTION INJECTION 2 HYMOVIS INTRA- SOLUTION ARTICULAR 2 SP RECONSTITUTED SOLUTION PREFILLED SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 169 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits HYPNOSOM ORAL KETAMINE HCL 2 TABLET INJECTION 2 IC GREEN SOLUTION 0.6 INTRAVENOUS MG/ML, 1 MG/ML 2 SOLUTION ketamine hcl injection RECONSTITUTED solution 10 mg/ml, 100 1 ID NOW COVID-19 mg/ml, 50 mg/ml CONTROL IN VITRO 2 KETAMINE HCL KIT INJECTION 2 ID NOW COVID-19 IN SOLUTION 2 VITRO KIT PREFILLED SYRINGE indigo carmine injection KETAMINE HCL 1 solution INTRAVENOUS 2 SOLUTION indocyanine green intravenous solution 1 KETAMINE HCL INTRAVENOUS reconstituted 2 SOLUTION INSET INFUSION SET 2 PREFILLED SYRINGE 23" 9MM KETAMINE HCL INSULIN PUMP 2 SUBLINGUAL 2 IR2020 KIT TROCHE INULIN KETAMINE HCL- INTRAVENOUS 2 SODIUM CHLORIDE SOLUTION INJECTION 2 isoflurane inhalation SOLUTION 1 solution PREFILLED SYRINGE isosulfan blue KETAMINE HCL- 1 subcutaneous solution SODIUM CHLORIDE IV STABILIZER FOR INTRAVENOUS 2 LUMOXITI SOLUTION 2 INTRAVENOUS PREFILLED SYRINGE SOLUTION KINEVAC INJECTION J-TIP KIT W/VIAL SOLUTION 2 2 ADAPTERS KIT RECONSTITUTED kedbumin intravenous LDL CARE ORAL 1 2 solution POWDER KERLIX AMD LEXISCAN 2 ANTIMICROBIAL INTRAVENOUS 2 SOLUTION KERLIX AMD SUPER 2 LIMBREL ORAL SPONGES PAD 2 CAPSULE KETALAR INJECTION 2 LIMBREL250 ORAL SOLUTION 2 CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 170 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LIMBREL500 ORAL MINIMED MIO 2 CAPSULE ADVANCE INFUSE 2 LIPICHOL 540 ORAL SET 2 CAPSULE MINIMED MIO 2 LISTER-V ORAL INFUSION SET 2 CAPSULE MINIMED PRO-SET 2 LOSARTAN INFUSION 24" POTASSIUM 2 MINIMED PUMP 2 POWDER RESERVOIR 3ML LYRA DIRECT SARS- MINIMED QUICK SET 2 COV-2 ASSAY IN 2 INF SET 18" VITRO KIT MINIMED QUICK SET 2 LYRA SARS-COV-2 INF SET 23" 2 ASSAY IN VITRO KIT MINIMED QUICK SET 2 MACUTEK ORAL INF SET 32" TABLET 2 MINIMED QUICK SET 2 DISPERSIBLE INF SET 43" MEBOLIC ORAL 2 MINIMED TABLET SILHOUETTE INF SET 2 MEDACTIV ORAL 32" 2 TABLET MINIMED METHACHOLINE SILHOUETTE INF SET 2 CHLORIDE 2 43" INHALATION KIT MONOVISC INTRA- methergine oral tablet 1 ARTICULAR 2 SP METHOHEXITAL SOLUTION SODIUM PREFILLED SYRINGE INTRAVENOUS 2 MYOBLOC SOLUTION INTRAMUSCULAR 2 SP PREFILLED SYRINGE SOLUTION methylergonovine NEOKE BCAA4 ORAL 2 maleate injection 1 POWDER solution NEOKE BHB ORAL 2 methylergonovine POWDER 1 maleate oral tablet NEOKE RA LIPOIC 2 MINIMED 530G ORAL POWDER INSULIN PUMP 2 NEOPHE ORAL 2 DEVICE TABLET MINIMED 770G NEUREPA ORAL 2 INSULIN PUMP SYS 2 CAPSULE KIT NEXAVIR INJECTION 2 SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 171 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits NICAPRIN ORAL ORTHOVISC INTRA- 2 TABLET ARTICULAR 2 SP NICAZYME ORAL SOLUTION 2 TABLET PREFILLED SYRINGE OXBRYTA ORAL NIFEDIPINE 2 SP MICRONIZED 2 TABLET POWDER PARADIGM INSULIN 2 NIFEDIPINE POWDER 2 PUMP DEVICE NITHIODOTE PARADIGM QUICK- 2 2 INTRAVENOUS KIT SET 23" 9MM niva-fol oral tablet 2.5- PENTETATE 1 CALCIUM TRISODIUM 25-2 mg 2 COMBINATION NORDIPEN 5 2 SOLUTION INJECTION DEVICE PENTETATE ZINC NORM-JECT LUER TRISODIUM 2 2 SLIP SYRINGE COMBINATION NOZIN NASAL SOLUTION SANITIZER POPSWAB 2 PH STRIPS IN VITRO 2 PAD DIAGNOSTIC TEST OCTAPLAS BLOOD PHEXXI VAGINAL GEL 2 GROUP A 2 INTRAVENOUS PHOTREXA VISCOUS OPHTHALMIC SOLUTION 2 SOLUTION OCTAPLAS BLOOD PREFILLED SYRINGE GROUP AB 2 INTRAVENOUS PHOTREXA- SOLUTION PHOTREXA VISCOUS KIT OPHTHALMIC 2 OCTAPLAS BLOOD SOLUTION GROUP B 2 PREFILLED SYRINGE INTRAVENOUS SOLUTION PLASBUMIN-25 INTRAVENOUS 2 OCTAPLAS BLOOD SOLUTION GROUP O 2 INTRAVENOUS PLASBUMIN-5 SOLUTION INTRAVENOUS 2 SOLUTION OMNIPOD 5 PACK 2 PLASMANATE OMNIPOD DASH 5 2 INTRAVENOUS 2 PACK PODS SOLUTION OMNIVEX ORAL POLYFIN INFUSION 2 2 TABLET SET 42"

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 172 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits pralidoxime chloride QUICKVUE DIPSTICK intramuscular solution STREP A TEST IN 2 1 auto-injector 600 VITRO KIT mg/2ml QUICKVUE PRECEDEX INFLUENZA A+B 2 INTRAVENOUS TEST IN VITRO KIT 2 SOLUTION 200 QUICKVUE IN-LINE MCG/2ML STREP A TEST IN 2 PRE-PEN VITRO KIT INTRADERMAL 2 RADIOGARDASE 2 SOLUTION ORAL CAPSULE PROFESSIONAL DNA RAPPORT RLS KIT 2 COLLECTION 2 COMBINATION KIT RAPPORT VTD KIT 2 PROLEEVA ORAL RESECTISOL 2 CAPSULE IRRIGATION 2 SOLUTION PROLEVA ORAL 2 RESERVAPAK ORAL TABLET 2 SYRUP propofol intravenous 1 RESERVAPAK PLUS emulsion 2 ORAL SYRUP PROPOFOL INTRAVENOUS R-GENE 10 PREFILLED SYRINGE INTRAVENOUS 2 2 100 MG/10ML, 150 SOLUTION MG/15ML, 200 RUZURGI ORAL 2 SP MG/20ML, 50 MG/5ML TABLET PROTEOLIN ORAL SACCHARIN 2 2 TABLET POWDER PROTOPAM sash kit intravenous kit 1 CHLORIDE 100-0.9 unit/ml-% INTRAVENOUS 2 SECREFLO SOLUTION INTRAVENOUS 2 RECONSTITUTED SOLUTION PROVAYBLUE RECONSTITUTED INTRAVENOUS 2 SECURESAFE SOLUTION HYPODERMIC 2 PROVOCHOLINE NEEDLE 25G X 1-1/2" INHALATION 2 SERMORELIN SOLUTION ACETATE RECONSTITUTED DIAGNOSTIC PULMONA ORAL INJECTION 2 2 CAPSULE SOLUTION QUICKVUE + STREP RECONSTITUTED 15 2 A TEST IN VITRO KIT MG, 6 MG, 9 MG

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 173 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sevoflurane inhalation STERILE DILUENT 1 solution FLOLAN PH 12 2 SILHOUETTE 23" INTRAVENOUS 2 INFUSION SET SOLUTION SILHOUETTE 43" STERILE DILUENT 2 FOR FLOLAN INFUSION SET 2 INTRAVENOUS SILHOUETTE 2 SOLUTION INFUSION SET 18" sterile SODIUM diluent/epoprostenol 1 HYALURONATE intravenous solution INTRA-ARTICULAR 2 SP SOLUTION sterile water for PREFILLED SYRINGE injection intravenous 1 solution sodium nitrite 1 intravenous solution STERILE WATER FOR INJECTION sodium saccharin 2 1 SOLUTION powder INJECTION sodium thiosulfate 1 sterile water for intravenous solution injection solution 1 SOFIA INFLUENZA injection 2 A+B FIA IN VITRO KIT SUPARTZ FX INTRA- SOFIA SARS ARTICULAR 2 SP ANTIGEN FIA IN 2 SOLUTION VITRO KIT PREFILLED SYRINGE SOFIA STREP A FIA SUPRANE 2 IN VITRO KIT INHALATION 2 SOFIA STREP A+ FIA SOLUTION 2 IN VITRO KIT SURE T INFUSION 2 SOFIA2 SARS SET 18"/6MM ANTIGEN FIA IN 2 SURE T INFUSION 2 VITRO KIT SET 23"/10MM SOF-SET INFUSION SURE T INFUSION 2 2 SET 42" SET 23"/6MM SORBITOL SURE T INFUSION 2 IRRIGATION 2 SET 23"/8MM SOLUTION 3 % SURE T INFUSION 2 sorbitol irrigation SET 32"/10MM 1 solution 3.3 % SURE T INFUSION 2 sorbitol-mannitol SET 32"/6MM 1 irrigation solution SURE T INFUSION 2 SPINRAZA SET 32"/8MM INTRATHECAL 2 SP SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 174 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SYNVISC INTRA- THYROGEN ARTICULAR INTRAMUSCULAR 2 SP 2 SP SOLUTION SOLUTION PREFILLED SYRINGE RECONSTITUTED SYNVISC ONE INTRA- TISSEEL EXTERNAL 2 ARTICULAR KIT 2 SP SOLUTION TISSEEL EXTERNAL 2 PREFILLED SYRINGE SOLUTION SYRINGE LUER LOCK 2 TISSEEL VH 30 ML EXTERNAL KIT 10 ML, 2 SYRINGE LUER SLIP 2 ML, 4 ML 2 1 ML TISSEEL VHSD T: SLIM X2 INS EXTERNAL 2 PMP/CONTROL 7.4 2 SOLUTION DEVICE TL-ICARE ORAL 2 T:SLIM X2 3ML CAPSULE 2 CARTRIDGE TOXICOLOGY SALIVA T:SLIM X2 INS COLLECTION ORAL 2 PUMP/CONTROL-IQ 2 KIT DEVICE TRILURON INTRA- T:SLIM X2 INSULIN ARTICULAR 2 SP PMP BASAL IQ 2 SOLUTION DEVICE PREFILLED SYRINGE T:SLIM X2 INSULIN TRIVISC INTRA- PMP BASAL6.4 2 ARTICULAR 2 SP DEVICE SOLUTION T:SLIM X2 INSULIN PREFILLED SYRINGE PMP/RFURB IQ 2 TRUSTEEL INFUSION 2 DEVICE SET T:SLIM X2/CONTROL- ULTANE INHALATION 2 2 IQ/REFURB DEVICE SOLUTION TACHOSIL EXTERNAL VARISOFT INFUSION 2 2 PATCH SET TELFA AMD ISLAND VASCAZEN ORAL 2 2 DRESSING PAD CAPSULE TELFA AMD NON- VASCULERA ORAL 2 2 ADHERENT PAD TABLET terrell inhalation VAYACOG ORAL 1 solution CAPSULE 100-19.5- 2 THERAMINE PLUS 6.5 MG 2 ORAL PACKET VAYARIN ORAL CAPSULE 75-21.5-8.5 2 MG

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 175 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits VAYARIN PLUS ORAL WIDE-SEAL 2 CAPSULE DIAPHRAGM 90 2 VAYAROL ORAL VAGINAL CAPSULE 630-232.5- 2 DIAPHRAGM 92.5 MG WIDE-SEAL VB6 P5P ORAL DIAPHRAGM 95 2 2 POWDER VAGINAL DIAPHRAGM VILTEPSO INTRAVENOUS 2 SP XEOMIN INTRAMUSCULAR SOLUTION 2 SP SOLUTION VISCO-3 INTRA- RECONSTITUTED ARTICULAR 2 SP SOLUTION XIAFLEX INJECTION PREFILLED SYRINGE SOLUTION 2 SP RECONSTITUTED VISTOGARD ORAL 2 XYZBAC ORAL PACKET 2 TABLET VITRASE INJECTION 2 ZYVEXOL ORAL SOLUTION 2 TABLET WESTAB MAX ORAL 2 TABLET ZYVIT ORAL TABLET 2 WIDE-SEAL Ophthalmic Agents - DIAPHRAGM 60 Drugs for Eye Allergy, 2 VAGINAL Infection and DIAPHRAGM Inflammation WIDE-SEAL ACULAR LS DIAPHRAGM 65 OPHTHALMIC 2 2 VAGINAL SOLUTION DIAPHRAGM ACULAR WIDE-SEAL OPHTHALMIC 2 DIAPHRAGM 70 SOLUTION 2 VAGINAL ACUVAIL DIAPHRAGM OPHTHALMIC 2 WIDE-SEAL SOLUTION 0.45 % DIAPHRAGM 75 ALOCRIL 2 VAGINAL OPHTHALMIC 2 DIAPHRAGM SOLUTION WIDE-SEAL ALOMIDE DIAPHRAGM 80 OPHTHALMIC 2 2 VAGINAL SOLUTION DIAPHRAGM ALREX OPHTHALMIC 2 WIDE-SEAL SUSPENSION DIAPHRAGM 85 2 AZASITE VAGINAL OPHTHALMIC 2 DIAPHRAGM SOLUTION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 176 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits azelastine hcl EMADINE 1 ophthalmic solution OPHTHALMIC 2 bacitracin ophthalmic SOLUTION 0.05 % 1 ointment epinastine hcl 1 BEPREVE ophthalmic solution OPHTHALMIC 2 erythromycin 1 SOLUTION ophthalmic ointment BESIVANCE FLAREX OPHTHALMIC 2 OPHTHALMIC 2 SUSPENSION SUSPENSION BETADINE fluorometholone 1 OPHTHALMIC PREP ophthalmic suspension 2 OPHTHALMIC flurbiprofen sodium 1 SOLUTION ophthalmic solution BLEPH-10 FML FORTE OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SUSPENSION bromfenac sodium FML LIQUIFILM (once-daily) ophthalmic 1 OPHTHALMIC 2 solution SUSPENSION BROMSITE FML OPHTHALMIC 2 OPHTHALMIC 2 OINTMENT SOLUTION gatifloxacin ophthalmic 1 CILOXAN solution OPHTHALMIC 2 gentak ophthalmic OINTMENT 1 ointment CILOXAN gentamicin sulfate OPHTHALMIC 2 1 SOLUTION ophthalmic solution ciprofloxacin hcl ILEVRO OPHTHALMIC 1 2 ophthalmic solution SUSPENSION cromolyn sodium INVELTYS 1 ophthalmic solution OPHTHALMIC 2 SUSPENSION dexamethasone ketorolac tromethamine sodium phosphate 1 1 ophthalmic solution ophthalmic solution diclofenac sodium levofloxacin ophthalmic 1 1 ophthalmic solution solution LOTEMAX DUREZOL 2 OPHTHALMIC 2 OPHTHALMIC GEL EMULSION LOTEMAX ELESTAT OPHTHALMIC 2 OPHTHALMIC 2 OINTMENT SOLUTION 0.05 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 177 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LOTEMAX PATANOL OPHTHALMIC 2 OPHTHALMIC 2 SUSPENSION SOLUTION 0.1 % LOTEMAX SM PAZEO OPHTHALMIC 2 2 OPHTHALMIC GEL SOLUTION loteprednol etabonate POVIDONE-IODINE 1 ophthalmic suspension OPHTHALMIC 2 MAXIDEX SOLUTION OPHTHALMIC 2 SP PRED FORTE SUSPENSION OPHTHALMIC 2 MITOSOL SUSPENSION 2 OPHTHALMIC KIT PRED MILD MOXEZA OPHTHALMIC 2 OPHTHALMIC 2 SUSPENSION SOLUTION prednisolone acetate 1 moxifloxacin hcl (2x ophthalmic suspension day) ophthalmic 1 prednisolone sodium solution phosphate ophthalmic 1 moxifloxacin hcl solution 1 ophthalmic solution PROLENSA NATACYN OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SUSPENSION sulfacetamide sodium 1 NEVANAC ophthalmic ointment OPHTHALMIC 2 sulfacetamide sodium 1 SUSPENSION ophthalmic solution OCUFLOX tobramycin ophthalmic 1 OPHTHALMIC 2 solution SOLUTION TOBREX ofloxacin ophthalmic OPHTHALMIC 2 1 solution OINTMENT olopatadine hcl TOBREX 1 ophthalmic solution OPHTHALMIC 2 OMNIPRED SOLUTION OPHTHALMIC 2 TRIESENCE SUSPENSION 1 % INTRAOCULAR 2 OZURDEX SUSPENSION INTRAVITREAL 2 SP trifluridine ophthalmic 1 IMPLANT solution PATADAY TRIPLE PMB OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION 0.2 % SOLUTION RECONSTITUTED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 178 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits TRIPLE PMK BETOPTIC-S OPHTHALMIC OPHTHALMIC 2 2 SOLUTION SUSPENSION RECONSTITUTED bimatoprost ophthalmic 1 UPNEEQ solution OPHTHALMIC 2 brimonidine tartrate 1 SOLUTION ophthalmic solution VIGAMOX carteolol hcl ophthalmic 1 OPHTHALMIC 2 solution SOLUTION COMBIGAN VIROPTIC OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION 1 % COSOPT ZERVIATE OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION COSOPT PF ZIRGAN 2 OPHTHALMIC 2 OPHTHALMIC GEL SOLUTION ZYMAXID dorzolamide hcl 1 OPHTHALMIC 2 solution 2 % ophthalmic SOLUTION DORZOLAMIDE HCL Ophthalmic Agents - SOLUTION 2 % 2 Drugs for Glaucoma OPHTHALMIC acetazolamide er oral dorzolamide hcl-timolol 1 capsule extended 1 mal ophthalmic solution release 12 hour dorzolamide hcl-timolol acetazolamide oral 1 mal pf ophthalmic 1 tablet solution ALPHAGAN P IOPIDINE OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION apraclonidine hcl 1 ISOPTO CARPINE ophthalmic solution OPHTHALMIC 2 AZOPT OPHTHALMIC SOLUTION 2 SUSPENSION ISTALOL BETAGAN OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION 0.5 % KEVEYIS ORAL 2 SP betaxolol hcl TABLET 1 ophthalmic solution latanoprost ophthalmic 1 BETIMOL solution OPHTHALMIC 2 levobunolol hcl 1 SOLUTION ophthalmic solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 179 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits LUMIGAN VYZULTA OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION methazolamide oral XALATAN 1 tablet OPHTHALMIC 2 PHOSPHOLINE SOLUTION IODIDE OPHTHALMIC XELPROS 2 SOLUTION OPHTHALMIC 2 RECONSTITUTED EMULSION pilocarpine hcl ZIOPTAN 1 ophthalmic solution OPHTHALMIC 2 RHOPRESSA SOLUTION OPHTHALMIC 2 Ophthalmic Agents - SOLUTION Drugs for ROCKLATAN Miscellaneous Eye OPHTHALMIC 2 Conditions SOLUTION ak-fluor intravenous 1 SIMBRINZA solution OPHTHALMIC 2 ak-poly-bac ophthalmic 1 SUSPENSION ointment timolol maleate AKTEN OPHTHALMIC 2 ophthalmic gel forming 1 GEL solution ALCAINE timolol maleate OPHTHALMIC 2 1 ophthalmic solution SOLUTION TIMOPTIC OCUDOSE ALTACAINE OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION TIMOPTIC ALTAFLUOR BENOX OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION TIMOPTIC-XE altafrin ophthalmic 1 OPHTHALMIC GEL 2 solution FORMING SOLUTION atropine sulfate 1 TRAVATAN Z ophthalmic ointment OPHTHALMIC 2 atropine sulfate 1 SOLUTION ophthalmic solution 1 % travoprost (bak free) bacitracin-polymyxin b 1 1 ophthalmic solution ophthalmic ointment TRUSOPT bacitra-neomycin- OPHTHALMIC 2 polymyxin-hc 1 SOLUTION ophthalmic ointment

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 180 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BEOVU FLUORESCITE INTRAVITREAL 2 SP INTRAVENOUS 2 SOLUTION SOLUTION BEVACIZUMAB fluor-i-strips a.t. 1 INTRAVITREAL ophthalmic strip 2 SP SOLUTION FLURA-SAFE PREFILLED SYRINGE OPHTHALMIC 2 bimatoprost external SOLUTION 1 solution GLOSTRIPS BLEPHAMIDE OPHTHALMIC STRIP 2 OPHTHALMIC 2 1 MG SUSPENSION homatropaire 1 BLEPHAMIDE S.O.P. ophthalmic solution OPHTHALMIC 2 homatropine hbr 1 OINTMENT ophthalmic solution 5 % CEQUA OPHTHALMIC 2 ISOPTO ATROPINE SOLUTION OPHTHALMIC 2 CYCLOGYL SOLUTION OPHTHALMIC 2 JETREA SOLUTION INTRAVITREAL 2 SP CYCLOMYDRIL SOLUTION 0.375 OPHTHALMIC 2 MG/0.3ML SOLUTION LACRISERT 2 cyclopentolate hcl OPHTHALMIC INSERT 1 ophthalmic solution LASTACAFT CYSTADROPS OPHTHALMIC 2 OPHTHALMIC 2 SP SOLUTION SOLUTION LATISSE EXTERNAL 2 CYSTARAN SOLUTION OPHTHALMIC 2 SP lissamine green 1 SOLUTION ophthalmic strip DOUBLE PM LUCENTIS OPHTHALMIC 2 INTRAVITREAL 2 SP SOLUTION SOLUTION RECONSTITUTED LUCENTIS EYLEA INTRAVITREAL 2 SP INTRAVITREAL 2 SP SOLUTION SOLUTION PREFILLED SYRINGE EYLEA MAXITROL INTRAVITREAL 2 SP OPHTHALMIC 2 SOLUTION OINTMENT PREFILLED SYRINGE MAXITROL fluorescein-benoxinate 1 OPHTHALMIC 2 ophthalmic solution SUSPENSION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 181 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits MEMBRANEBLUE POLYTRIM OPHTHALMIC 2 OPHTHALMIC 2 SOLUTION SOLUTION MIOCHOL-E PRED-G INTRAOCULAR OPHTHALMIC 2 2 SOLUTION SUSPENSION RECONSTITUTED PRED-G S.O.P. MYDRIACYL OPHTHALMIC 2 OPHTHALMIC 2 OINTMENT SOLUTION proparacaine hcl 1 neomycin-bacitracin zn- ophthalmic solution polymyx ophthalmic 1 proparacaine- ointment fluorescein ophthalmic 1 neomycin-polymyxin- solution dexameth ophthalmic 1 RESTASIS ointment MULTIDOSE 2 neomycin-polymyxin- OPHTHALMIC dexameth ophthalmic EMULSION 1 suspension 3.5-10000- RESTASIS 0.1 OPHTHALMIC 2 neomycin-polymyxin- EMULSION gramicidin ophthalmic 1 ROSE GLO 2 solution OPHTHALMIC STRIP neomycin-polymyxin-hc 1 sulfacetamide- ophthalmic suspension prednisolone 1 neo-polycin hc ophthalmic solution 1 ophthalmic ointment tetcaine ophthalmic 1 neo-polycin ophthalmic solution 0.5 % 1 ointment tetracaine hcl 1 OXERVATE ophthalmic solution OPHTHALMIC 2 SP TETRAVISC FORTE SOLUTION OPHTHALMIC 2 PAREMYD SOLUTION 0.5 % OPHTHALMIC 2 TETRAVISC SOLUTION OPHTHALMIC 2 phenylephrine hcl SOLUTION 0.5 % 1 ophthalmic solution TOBRADEX polycin ophthalmic OPHTHALMIC 2 1 ointment OINTMENT polymyxin b- TOBRADEX trimethoprim 1 OPHTHALMIC 2 ophthalmic solution SUSPENSION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 182 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits TOBRADEX ST DERMOTIC OTIC OIL 2 OPHTHALMIC 2 flac otic oil 1 SUSPENSION FLOXIN OTIC OTIC 2 tobramycin- SOLUTION 0.3 % dexamethasone 1 fluocinolone acetonide ophthalmic suspension 1 otic oil tropicamide ophthalmic 1 hydrocortisone-acetic solution 1 acid otic solution TROPICAMIDE- CYCLOPENTOLATE- neomycin-polymyxin-hc 2 1 PE OPHTHALMIC otic solution SOLUTION neomycin-polymyxin-hc 1 VISIONBLUE otic suspension OPHTHALMIC 2 ofloxacin otic solution 1 SOLUTION OTOVEL OTIC 2 VISUDYNE SOLUTION INTRAVENOUS PRAMOTIC OTIC 2 SP 2 SOLUTION LIQUID RECONSTITUTED Respiratory Tract / XIIDRA OPHTHALMIC 2 Pulmonary Agents - SOLUTION Drugs for Allergies, ZYLET OPHTHALMIC Cough, Cold 2 SUSPENSION azelastine hcl nasal 1 Otic Agents - Drugs solution for Ear Conditions azelastine-fluticasone 1 acetic acid otic solution 1 nasal suspension CETRAXAL OTIC BECONASE AQ 2 2 SOLUTION NASAL SUSPENSION CIPRO HC OTIC benzonatate oral 2 1 SUSPENSION capsule CIPRODEX OTIC bromfed dm oral syrup 1 2 SUSPENSION carbinoxamine maleate 1 ciprofloxacin hcl otic oral solution 1 solution carbinoxamine maleate 1 ciprofloxacin- oral tablet dexamethasone otic 1 cetirizine hcl oral 1 suspension solution CIPROFLOXACIN- CINQAIR FLUOCINOLONE PF 2 INTRAVENOUS 2 SP OTIC SOLUTION SOLUTION COLY-MYCIN S OTIC CLARINEX ORAL 2 SUSPENSION 3.3-3- 2 SYRUP 0.5 MG/ML 10-0.5 MG/ML

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 183 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits CLARINEX ORAL FASENRA 2 TABLET SUBCUTANEOUS 2 SP CLARINEX-D 12 SOLUTION HOUR ORAL TABLET PREFILLED SYRINGE 2 EXTENDED RELEASE flunisolide nasal 1 12 HOUR solution clemastine fumarate fluticasone propionate 1 1 oral tablet 2.68 mg nasal suspension CUROSURF GILPHEX TR ORAL 2 INTRATRACHEAL 2 TABLET SUSPENSION GILTUSS ORAL cyproheptadine hcl oral LIQUID 10-28-388 2 1 syrup MG/5ML cyproheptadine hcl oral giltuss pediatric oral 1 1 tablet liquid 2.5-7.5-88 mg/ml desloratadine oral GILTUSS TR ORAL 1 2 tablet TABLET desloratadine oral guaiatussin ac oral QL 1 1 tablet dispersible syrup dexchlorpheniramine guaifenesin ac oral QL 1 1 maleate oral solution syrup DICOPANOL hydrocodone polst- FUSEPAQ ORAL chlorphen polst er susp QL 2 1 SUSPENSION oral suspension RECONSTITUTED extended release DICOPANOL HYDROCODONE- RAPIDPAQ ORAL GUAIFENESIN ORAL QL 2 2 SUSPENSION SOLUTION 2.5-200 RECONSTITUTED MG/5ML diphen oral elixir 1 hydrocodone- QL 1 DI-PHEN ORAL homatropine oral syrup 2 LIQUID hydrocodone- QL 1 diphenhydramine hcl homatropine oral tablet 1 injection solution QL hydromet oral syrup 1 diphenhydramine hcl 1 oral elixir HYPERSAL DYMISTA NASAL INHALATION 2 2 SUSPENSION NEBULIZATION SOLUTION FASENRA PEN SUBCUTANEOUS INFASURF 2 SP SOLUTION AUTO- INTRATRACHEAL 2 INJECTOR SUSPENSION

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 184 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ipratropium bromide phenadoz rectal 1 nasal solution suppository 12.5 mg, 1 KARBINAL ER ORAL 25 mg SUSPENSION 2 PHENERGAN EXTENDED RELEASE INJECTION 2 levocetirizine SOLUTION dihydrochloride oral 1 promethazine hcl 1 solution injection solution levocetirizine promethazine hcl oral 1 dihydrochloride oral 1 solution tablet promethazine hcl oral 1 maxi-tuss ac oral QL syrup 1 solution promethazine hcl oral 1 mometasone furoate tablet 1 nasal suspension promethazine hcl rectal 1 NASONEX NASAL suppository 2 SUSPENSION promethazine-codeine QL 1 nebusal inhalation oral solution nebulization solution 3 1 promethazine-codeine QL 1 % oral syrup NEBUSAL promethazine-dm oral INHALATION 2 solution 6.25-15 1 NEBULIZATION mg/5ml SOLUTION 6 % promethazine-dm oral NEOTUSS PLUS 1 2 syrup ORAL LIQUID promethazine- QL NUCALA phenyleph-codeine oral 1 SUBCUTANEOUS 2 SP syrup SOLUTION AUTO- INJECTOR promethazine- phenylephrine oral 1 NUCALA syrup SUBCUTANEOUS 2 SP promethegan rectal SOLUTION 1 PREFILLED SYRINGE suppository pseudoeph-chlorphen- NUCALA QL SUBCUTANEOUS hydrocod oral solution 1 2 SP SOLUTION 60-4-5 mg/5ml RECONSTITUTED pseudoephedrine- olopatadine hcl nasal bromphen-dm oral 1 1 solution liquid OMNARIS NASAL pseudoephedrine- 2 SUSPENSION bromphen-dm oral 1 syrup PATANASE NASAL 2 SOLUTION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 185 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits pulmosal inhalation XOLAIR nebulization solution 7 1 SUBCUTANEOUS 2 SP % SOLUTION QNASL CHILDRENS PREFILLED SYRINGE NASAL AEROSOL 2 XOLAIR SOLUTION SUBCUTANEOUS 2 SP QNASL NASAL SOLUTION 2 AEROSOL SOLUTION RECONSTITUTED RYCLORA ORAL ZETONNA NASAL 2 2 SOLUTION AEROSOL SOLUTION Z-TUSS AC ORAL QL ryvent oral tablet 1 2 LIQUID SEMPREX-D ORAL 2 CAPSULE Respiratory Tract / Pulmonary Agents - SINUVA NASAL 2 Drugs for Asthma and IMPLANT Other Lung sodium chloride Conditions inhalation nebulization 1 ACCOLATE ORAL 2 solution TABLET SURVANTA acetylcysteine 1 INTRATRACHEAL 2 inhalation solution SUSPENSION ADRENALIN TESSALON PERLES 2 INJECTION 2 ORAL CAPSULE SOLUTION TUSSICAPS ORAL QL ADVAIR DISKUS CAPSULE EXTENDED 2 INHALATION 2 RELEASE 12 HOUR AEROSOL POWDER TUSSIONEX BREATH ACTIVATED PENNKINETIC ER QL ADVAIR HFA ORAL SUSPENSION 2 INHALATION 2 EXTENDED RELEASE AEROSOL 10-8 MG/5ML AIRDUO DIGIHALER TUXARIN ER ORAL INHALATION 2 TABLET EXTENDED 2 AEROSOL POWDER RELEASE 12 HOUR BREATH ACTIVATED TUZISTRA XR ORAL QL AIRDUO RESPICLICK SUSPENSION 2 113/14 INHALATION 2 EXTENDED RELEASE AEROSOL POWDER virtussin ac w/alc oral QL BREATH ACTIVATED 1 liquid AIRDUO RESPICLICK XHANCE NASAL 232/14 INHALATION 2 EXHALER 2 AEROSOL POWDER SUSPENSION BREATH ACTIVATED

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 186 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits AIRDUO RESPICLICK ARNUITY ELLIPTA 55/14 INHALATION INHALATION 2 2 AEROSOL POWDER AEROSOL POWDER BREATH ACTIVATED BREATH ACTIVATED albuterol sulfate er oral ASMANEX (120 tablet extended release 1 METERED DOSES) 12 hour INHALATION 2 albuterol sulfate hfa AEROSOL POWDER aerosol solution 108 BREATH ACTIVATED 1 (90 base) mcg/act ASMANEX (14 inhalation METERED DOSES) ALBUTEROL INHALATION 2 SULFATE HFA AEROSOL POWDER AEROSOL SOLUTION BREATH ACTIVATED 2 108 (90 BASE) ASMANEX (30 MCG/ACT METERED DOSES) INHALATION INHALATION 2 albuterol sulfate AEROSOL POWDER inhalation nebulization 1 BREATH ACTIVATED solution ASMANEX (60 albuterol sulfate oral METERED DOSES) 1 syrup INHALATION 2 AEROSOL POWDER albuterol sulfate oral 1 BREATH ACTIVATED tablet ASMANEX (7 ALVESCO METERED DOSES) INHALATION 2 INHALATION 2 AEROSOL SOLUTION AEROSOL POWDER BREATH ACTIVATED 1 intravenous solution ASMANEX HFA ANORO ELLIPTA INHALATION 2 INHALATION AEROSOL 2 AEROSOL POWDER ATROVENT HFA BREATH ACTIVATED INHALATION 2 ARALAST NP AEROSOL SOLUTION INTRAVENOUS 2 SP AUVI-Q INJECTION SOLUTION SOLUTION AUTO- 2 RECONSTITUTED INJECTOR ARCAPTA NEOHALER BEVESPI INHALATION 2 AEROSPHERE 2 CAPSULE INHALATION ARMONAIR AEROSOL DIGIHALER INHALATION 2 AEROSOL POWDER BREATH ACTIVATED You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 187 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits BREO ELLIPTA EPIPEN 2-PAK INHALATION INJECTION 2 2 AEROSOL POWDER SOLUTION AUTO- BREATH ACTIVATED INJECTOR BREZTRI EPIPEN JR 2-PAK AEROSPHERE INJECTION 2 2 INHALATION SOLUTION AUTO- AEROSOL INJECTOR BROVANA ESBRIET ORAL 2 SP INHALATION CAPSULE 2 NEBULIZATION ESBRIET ORAL 2 SP SOLUTION TABLET budesonide inhalation 1 FLOVENT DISKUS suspension INHALATION 2 BUDESONIDE- AEROSOL POWDER FORMOTEROL BREATH ACTIVATED FUMARATE 2 FLOVENT HFA INHALATION INHALATION 2 AEROSOL AEROSOL COMBIVENT fluticasone-salmeterol RESPIMAT 2 inhalation aerosol INHALATION powder breath AEROSOL SOLUTION activated 100-50 1 cromolyn sodium mcg/dose, 250-50 inhalation nebulization 1 mcg/dose, 500-50 solution mcg/dose DALIRESP ORAL FLUTICASONE- 2 TABLET SALMETEROL difil-g forte oral liquid 1 INHALATION AEROSOL POWDER 2 DUAKLIR PRESSAIR BREATH ACTIVATED INHALATION 2 113-14 MCG/ACT, 232- AEROSOL POWDER 14 MCG/ACT, 55-14 BREATH ACTIVATED MCG/ACT DULERA INHALATION 2 GLASSIA AEROSOL INTRAVENOUS 2 SP ELIXOPHYLLIN ORAL SOLUTION 2 ELIXIR INCRUSE ELLIPTA epinephrine injection INHALATION 1 2 solution AEROSOL POWDER epinephrine injection BREATH ACTIVATED 1 solution auto-injector ipratropium bromide 1 inhalation solution ipratropium-albuterol 1 inhalation solution

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 188 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits levalbuterol hcl PROLASTIN-C inhalation nebulization 1 INTRAVENOUS 2 SP solution SOLUTION LEVALBUTEROL HFA PROLASTIN-C INHALATION INTRAVENOUS 2 2 SP AEROSOL 45 SOLUTION MCG/ACT RECONSTITUTED LONHALA MAGNAIR PROVENTIL HFA REFILL KIT INHALATION 2 2 INHALATION AEROSOL SOLUTION SOLUTION PULMICORT LONHALA MAGNAIR FLEXHALER STARTER KIT INHALATION 2 2 INHALATION AEROSOL POWDER SOLUTION BREATH ACTIVATED metaproterenol sulfate PULMICORT 1 oral syrup 10 mg/5ml SUSPENSION 2 metaproterenol sulfate INHALATION oral tablet 10 mg, 20 1 SUSPENSION mg QVAR REDIHALER montelukast sodium INHALATION 1 2 oral packet AEROSOL BREATH ACTIVATED montelukast sodium 1 oral tablet SCLEROSOL INTRAPLEURAL montelukast sodium 2 1 INTRAPLEURAL oral tablet chewable AEROSOL POWDER OFEV ORAL 2 SP SEEBRI NEOHALER CAPSULE INHALATION 2 PERFOROMIST CAPSULE INHALATION 2 SEREVENT DISKUS NEBULIZATION INHALATION 2 SOLUTION AEROSOL POWDER PROAIR DIGIHALER BREATH ACTIVATED INHALATION SINGULAIR ORAL 2 2 AEROSOL POWDER PACKET BREATH ACTIVATED SINGULAIR ORAL 2 PROAIR HFA TABLET INHALATION 2 SINGULAIR ORAL AEROSOL SOLUTION 2 TABLET CHEWABLE PROAIR RESPICLICK INHALATION SPIRIVA 2 HANDIHALER AEROSOL POWDER 2 BREATH ACTIVATED INHALATION CAPSULE

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 189 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits SPIRIVA RESPIMAT TRELEGY ELLIPTA INHALATION 2 INHALATION 2 AEROSOL SOLUTION AEROSOL POWDER STERILE TALC BREATH ACTIVATED POWDER TUDORZA PRESSAIR INTRAPLEURAL 2 INHALATION 2 SUSPENSION AEROSOL POWDER RECONSTITUTED BREATH ACTIVATED STERITALC UTIBRON NEOHALER INTRAPLEURAL 2 INHALATION 2 POWDER CAPSULE STIOLTO RESPIMAT VENTOLIN HFA INHALATION 2 INHALATION 2 AEROSOL SOLUTION AEROSOL SOLUTION STRIVERDI wixela inhub inhalation RESPIMAT aerosol powder breath 1 2 INHALATION activated AEROSOL SOLUTION XOPENEX SYMBICORT CONCENTRATE INHALATION 2 INHALATION 2 AEROSOL NEBULIZATION SYMJEPI INJECTION SOLUTION SOLUTION 2 XOPENEX HFA PREFILLED SYRINGE INHALATION 2 terbutaline sulfate AEROSOL 1 injection solution XOPENEX terbutaline sulfate oral INHALATION 1 2 tablet NEBULIZATION SOLUTION THEO-24 ORAL YUPELRI INHALATION CAPSULE EXTENDED 2 2 RELEASE 24 HOUR SOLUTION er oral zafirlukast oral tablet 1 tablet extended release 1 ZEMAIRA 12 hour INTRAVENOUS 2 SP theophylline er oral SOLUTION tablet extended release 1 RECONSTITUTED 24 hour zileuton er oral tablet theophylline in d5w extended release 12 1 1 intravenous solution hour theophylline oral ZYFLO CR ORAL 1 TABLET EXTENDED solution 2 RELEASE 12 HOUR 600 MG ZYFLO ORAL TABLET 2

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 190 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Respiratory Tract / TOBRAMYCIN Pulmonary Agents - NEBULIZATION 2 SP Drugs for Cystic SOLUTION 300 Fibrosis MG/5ML INHALATION BETHKIS INHALATION TRIKAFTA ORAL NEBULIZATION 2 SP TABLET THERAPY 2 SP SOLUTION PACK CAYSTON Respiratory Tract / INHALATION Pulmonary Agents - 2 SP SOLUTION Drugs for Pulmonary RECONSTITUTED Hypertension KALYDECO ORAL ADCIRCA ORAL 2 SP 2 SP PACKET TABLET KALYDECO ORAL ADEMPAS ORAL 2 SP 2 SP TABLET TABLET KITABIS PAK alyq oral tablet 1 SP INHALATION 2 SP ambrisentan oral tablet 1 SP NEBULIZATION SOLUTION bosentan oral tablet 1 SP ORKAMBI ORAL epoprostenol sodium 2 SP PACKET intravenous solution 1 SP reconstituted ORKAMBI ORAL 2 SP TABLET FLOLAN INTRAVENOUS 2 SP PULMOZYME SOLUTION INHALATION 2 SP RECONSTITUTED SOLUTION LETAIRIS ORAL 2 SP SYMDEKO ORAL TABLET TABLET THERAPY 2 SP OPSUMIT ORAL PACK 2 SP TABLET TOBI NEBULIZER INHALATION ORENITRAM ORAL 2 SP NEBULIZATION TABLET EXTENDED 2 SP SOLUTION RELEASE TOBI PODHALER REMODULIN INHALATION 2 SP INJECTION 2 SP CAPSULE SOLUTION tobramycin inhalation REVATIO nebulization solution 1 SP INTRAVENOUS 2 SP 300 mg/4ml SOLUTION tobramycin nebulization REVATIO ORAL solution 300 mg/5ml 1 SP SUSPENSION 2 SP inhalation RECONSTITUTED REVATIO ORAL 2 SP TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 191 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits sildenafil citrate AMRIX ORAL 1 SP intravenous solution CAPSULE EXTENDED 2 sildenafil citrate oral RELEASE 24 HOUR suspension 1 SP baclofen external 1 reconstituted cream sildenafil citrate oral baclofen intrathecal 1 SP 1 tablet 20 mg solution tadalafil (pah) oral baclofen oral tablet 1 1 SP tablet carisoprodol oral tablet 1 TRACLEER 62.5 MG, carisoprodol-aspirin 2 SP 1 125 MG oral tablet 200-325 mg TRACLEER 32 MG 2 SP chlorzoxazone oral 1 treprostinil injection tablet 1 SP solution cyclobenzaprine hcl er TYVASO INHALATION oral capsule extended 1 2 SP SOLUTION release 24 hour TYVASO REFILL cyclobenzaprine hcl 1 INHALATION 2 SP oral tablet SOLUTION CYCLOPHENE TYVASO STARTER RAPIDPAQ 2 INHALATION 2 SP TRANSDERMAL SOLUTION CREAM UPTRAVI ORAL DANTRIUM 2 SP TABLET INTRAVENOUS 2 UPTRAVI ORAL SOLUTION TABLET THERAPY 2 SP RECONSTITUTED PACK DANTRIUM ORAL 2 VELETRI CAPSULE INTRAVENOUS dantrolene sodium 2 SP SOLUTION intravenous solution 1 RECONSTITUTED reconstituted VENTAVIS dantrolene sodium oral 1 INHALATION 2 SP capsule SOLUTION ENOVARX- Skeletal Muscle BACLOFEN 2 Relaxants - Drugs for EXTERNAL CREAM Muscle Pain and enovarx- Spasm cyclobenzaprine hcl 1 ACTIVE- cream 20 mg/gm CYCLOBENZAPRINE transdermal 2 TRANSDERMAL CREAM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 192 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits ENOVARX- OZOBAX ORAL 2 CYCLOBENZAPRINE SOLUTION HCL CREAM 20 2 revonto intravenous 1 MG/GM solution reconstituted TRANSDERMAL ROBAXIN INJECTION FEXMID ORAL 2 2 SOLUTION TABLET ROBAXIN ORAL FIRST-BACLOFEN 2 2 TABLET 500 MG ORAL SUSPENSION ROBAXIN-750 ORAL 2 GABLOFEN TABLET INTRATHECAL 2 SOLUTION RYANODEX INTRAVENOUS 2 GABLOFEN SUSPENSION INTRATHECAL 2 RECONSTITUTED SOLUTION SKELAXIN ORAL PREFILLED SYRINGE 2 TABLET LIORESAL INTRATHECAL 2 SOMA ORAL TABLET 2 SOLUTION TABRADOL FUSEPAQ 2 LORZONE ORAL ORAL SUSPENSION 2 TABLET TABRADOL metaxall oral tablet 800 RAPIDPAQ ORAL 2 1 mg SUSPENSION metaxalone oral tablet 1 TIZANIDINE COMFORT PAC 2 methocarbamol 1 COMBINATION 4 MG injection solution tizanidine hcl oral methocarbamol oral 1 1 capsule tablet tizanidine hcl oral tablet 1 NORGESIC FORTE 2 VANADOM ORAL ORAL TABLET 2 TABLET orphenadrine citrate er oral tablet extended 1 VECURONIUM release 12 hour BROMIDE-NACL INTRAVENOUS 2 orphenadrine citrate 1 SOLUTION 100-0.9 injection solution MG/100ML-% orphenadrine-asa- ZANAFLEX ORAL 1 2 caffeine oral tablet CAPSULE orphenadrine-aspirin- ZANAFLEX ORAL 2 caffeine oral tablet 50- 1 TABLET 770-60 mg ORPHENGESIC 2 FORTE ORAL TABLET

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 193 Drug Name Drug Tier Requirements Drug Name Drug Tier Requirements /Limits /Limits Sleep Disorder SUNOSI ORAL 2 Agents TABLET AMBIEN CR ORAL temazepam oral 1 TABLET EXTENDED 2 capsule RELEASE WAKIX ORAL TABLET 2 SP AMBIEN ORAL XYREM ORAL 2 2 SP TABLET SOLUTION armodafinil oral tablet 1 XYWAV ORAL 2 SP BELSOMRA ORAL SOLUTION 2 TABLET zaleplon oral capsule 1 BUTISOL SODIUM zolpidem tartrate er oral 2 1 ORAL TABLET 30 MG tablet extended release DAYVIGO ORAL zolpidem tartrate oral 2 1 TABLET tablet doxepin hcl oral tablet 1 zolpidem tartrate EDLUAR sublingual tablet 1 SUBLINGUAL TABLET 2 sublingual SUBLINGUAL ZOLPIMIST ORAL 2 eszopiclone oral tablet 1 SOLUTION flurazepam hcl oral 1 capsule HETLIOZ ORAL 2 SP CAPSULE INTERMEZZO SUBLINGUAL TABLET 2 SUBLINGUAL LUNESTA ORAL 2 TABLET modafinil oral tablet 1 NUVIGIL ORAL 2 TABLET PROVIGIL ORAL 2 TABLET ramelteon oral tablet 1 RESTORIL ORAL 2 CAPSULE ROZEREM ORAL 2 TABLET SECONAL ORAL 2 CAPSULE 100 MG SILENOR ORAL 2 TABLET You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 194 Index of Drugs A.A.G.C. KIT IN TERODERM... 96 acd formula a...... 32 ADAPALENE...... 96 abacavir sulfate...... 65 ACD-A NOCLOT-50...... 32 adapalene-benzoyl peroxide.....96 abacavir sulfate-lamivudine...... 65 acebutolol hcl...... 76 ADASUVE...... 63 abacavir-lamivudine- ACETADOTE...... 165 adc/f (0.5mg/ml)...... 116 zidovudine...... 65 acetaminophen-codeine...... 7 ADCETRIS...... 49 ABANEU-SL...... 116 acetaminophen-codeine #2...... 7 ADCIRCA...... 191 ABELCET...... 43 acetaminophen-codeine #3...... 7 ADDERALL...... 89 ABILIFY...... 63 acetaminophen-codeine #4...... 7 ADDERALL XR...... 89 ABILIFY MAINTENA...... 63 acetazolamide...... 179 ADDYI...... 92 ABILIFY MYCITE...... 63 acetazolamide er...... 179 adefovir dipivoxil...... 65 abiraterone acetate oral tablet acetazolamide sodium...... 76 ADEMPAS...... 191 250 mg...... 49 acetic acid...... 138, 183 ADENOCARD...... 76 ABRAXANE...... 49 acetylcysteine...... 165, 186 adenosine...... 76, 165 ABSORICA...... 96 ACIPHEX...... 131 ADENOSINE...... 76 ABSORICA LD...... 96 ACIPHEX SPRINKLE...... 131 adenosine (diagnostic)...... 165 ABSTRAL...... 7 acitretin...... 96 ADHANSIA XR...... 89 acamprosate calcium...... 20 ACTEMRA...... 154 ADIPEX-P...... 92 ACANYA...... 96 ACTEMRA ACTPEN...... 154 ADLYXIN...... 105 acarbose...... 105 ACTHAR...... 144 ADLYXIN STARTER PACK.... 105 ACCOLATE...... 186 ACTHIB...... 160 ADMELOG...... 113 ACCU-CHEK AVIVA ACTHREL...... 165 ADMELOG SOLOSTAR...... 113 CONNECT KIT W/DEVICE.....107 ACTICLATE...... 21 ADRENAL C FORMULA...... 116 ACCU-CHEK AVIVA DEVICE.107 ACTIGALL...... 132 ADRENALIN...... 186 ACCU-CHEK AVIVA PLUS ACTIMMUNE...... 154 adriamycin...... 49 KIT W/DEVICE...... 107 ACTIPHYTE OF SEA KELP... 165 adrucil...... 49 ACCU-CHEK COMPACT ACTIPHYTE OF SUGAR ADVAIR DISKUS...... 186 PLUS CARE KIT...... 107 KELP...... 165 ADVAIR HFA...... 186 ACCU-CHEK COMPACT ACTIQ...... 7 ADVANCED AM/PM...... 116 PLUS CONTROL...... 108 ACTIVE FE...... 116 ADVATE...... 72 ACCU-CHEK COMPACT ACTIVE-CYCLOBENZAPRINE ADYNOVATE...... 72 PLUS TEST STRIPS...... 108 ...... 192 ADZENYS ER...... 89 ACCU-CHEK FASTCLIX ACTIVE-KETOPROFEN...... 14 ADZENYS XR-ODT...... 89 LANCET KIT...... 108 ACTIVELLA...... 147 AEMCOLO...... 21 ACCU-CHEK FLEXLINK PLUS ACTIVE-PREP KIT I...... 14 AFINITOR...... 49 6MM...... 165 ACTIVE-PREP KIT II...... 14 AFINITOR DISPERZ...... 49 ACCU-CHEK GUIDE ACTIVE-PREP KIT III...... 14 afirmelle...... 147 CONTROL...... 108 ACTIVE-PREP KIT IV...... 96 AFLURIA...... 160 ACCU-CHEK GUIDE KIT ACTIVE-PREP KIT V...... 43 AFLURIA PRESERVATIVE W/DEVICE...... 108 ACTIVE-TRAMADOL...... 96 FREE...... 160 ACCU-CHEK MULTICLIX ACTONEL...... 164 AFLURIA QUADRIVALENT....160 LANCET DEVICE KIT...... 108 ACTOPLUS MET...... 105 AFREZZA...... 113 ACCU-CHEK NANO ACTOPLUS MET XR...... 105 AFSTYLA...... 72 SMARTVIEW KIT W/DEVICE.108 ACTOS...... 105 AGAMATRIX CONTROL ACCU-CHEK SMARTVIEW ACULAR...... 176 LEVEL 2...... 108 CONTROL...... 108 ACULAR LS...... 176 AGAMATRIX CONTROL ACCU-CHEK SMARTVIEW ACUVAIL...... 176 LEVEL 4...... 108 TEST STRIPS...... 108 acyclovir...... 65 AGAMATRIX PRESTO TEST.108 ACCU-CHEK SOFTCLIX acyclovir sodium...... 65 AGGRASTAT...... 63 LANCET DEVICE KIT...... 108 ACZONE...... 96 AGGRENOX...... 63 ACCU-CHEK ULTRAFLEX ADACEL...... 160 AGRYLIN...... 72 INF SET...... 165 ADAKVEO...... 165 AIF #2 DRUG PREPARATION ACCUPRIL...... 76 ADALAT CC...... 76 KIT...... 14 ACCURETIC...... 76 adapalene...... 96 195 AIF #3 DRUG PREPARATION allopurinol...... 46 AMD FOAM DRESSING KIT...... 14 allopurinol sodium...... 46 TOPSHEET...... 166 AIMOVIG...... 46 ALLZITAL...... 7 AMERGE...... 46 airavite...... 116 almotriptan malate...... 46 amethia...... 147 AIRDUO DIGIHALER...... 186 ALOCRIL...... 176 amethia lo...... 147 AIRDUO RESPICLICK 113/14 186 ALOGLIPTIN BENZOATE...... 105 amethyst...... 147 AIRDUO RESPICLICK 232/14 186 ALOGLIPTIN-METFORMIN AMICAR...... 72 AIRDUO RESPICLICK 55/14..187 HCL...... 105 AMIDATE...... 166 AJOVY...... 46 ALOGLIPTIN-PIOGLITAZONE amikacin sulfate...... 21 ak-fluor...... 180 ...... 105 amiloride hcl...... 76 AKLIEF...... 96 ALOMIDE...... 176 amiloride-hydrochlorothiazide... 76 AKOVAZ...... 76 ALOPRIM...... 46 AMINO ACID...... 116 ak-poly-bac...... 180 ALORA...... 147 aminoacetic acid...... 138 AKTEN...... 180 alosetron hcl...... 132 aminocaproic acid...... 72 AKTIPAK...... 96 ALOXI...... 41 aminophylline...... 187 AKYNZEO...... 41 ALPHAGAN P...... 179 AMINOPROTECT...... 116 ALA SCALP...... 96 ALPHA-LIPOIC ACID...... 166 AMINOSYN...... 116 ala-cort...... 96 ALPHANATE/VWF AMINOSYN II...... 116 ALANINE...... 116 COMPLEX/HUMAN...... 72 AMINOSYN albendazole...... 60 ALPHANINE SD...... 72 II/ELECTROLYTES...... 116 ALBENZA...... 60 alprazolam...... 70 AMINOSYN M...... 116 ALBUKED 25...... 165 alprazolam er...... 70 AMINOSYN/ELECTROLYTES116 ALBUKED 5...... 165 alprazolam intensol...... 70 AMINOSYN-HBC...... 116 albumin human...... 165 alprazolam xr...... 70 AMINOSYN-PF...... 116 ALBUMINAR-25...... 165 ALPROLIX...... 72 AMINOSYN-RF...... 116 ALBUMINAR-5...... 166 alprostadil...... 76 amiodarone hcl...... 76 ALBUMINEX...... 166 ALREX...... 176 AMIODARONE HCL IN albumin-zlb...... 166 ALTABAX...... 21 DEXTROSE...... 76 alburx...... 166 ALTACAINE...... 180 AMITIZA...... 132 ALBUTEIN...... 166 ALTACE...... 76 amitriptyline hcl...... 38 albuterol sulfate...... 187 ALTAFLUOR BENOX...... 180 AMLODIPINE albuterol sulfate er...... 187 altafrin...... 180 BES+SYRSPEND SF...... 76 albuterol sulfate hfa...... 187 altavera...... 147 amlodipine besylate...... 76 ALBUTEROL SULFATE HFA. 187 ALTOPREV...... 76 amlodipine besylate-benazepril ALCAINE...... 180 ALTRENO...... 96 hcl...... 76 alclometasone dipropionate...... 96 ALUMINUM CHLORIDE amlodipine besylate-valsartan.. 76 ALCOHOL PREP PADS... 96, 166 ANHYDROUS...... 96 amlodipine-atorvastatin...... 76 ALDACTAZIDE...... 76 ALUMINUM CHLORIDE amlodipine-olmesartan...... 76 ALDACTONE...... 76 HEXAHYDRATE...... 96 amlodipine-valsartan-hctz...... 76 ALDARA...... 96 ALUNBRIG...... 49 ammonium lactate...... 96 ALDURAZYME...... 135 ALVESCO...... 187 AMMONUL...... 135 ALECENSA...... 49 alyacen 1/35...... 147 amnesteem...... 96 alendronate sodium...... 164 alyacen 7/7/7...... 147 amoxapine...... 38 alfentanil hcl...... 7 alyq...... 191 amoxicill-clarithro-lansopraz... 132 ALFERON N...... 154 amabelz...... 147 amoxicillin...... 21 alfuzosin hcl er...... 140 amantadine hcl...... 61 amoxicillin-potassium ALGESIS...... 166 AMARYL...... 105 clavulanate...... 22 ALIMTA...... 49 AMBIEN...... 194 amoxicillin-potassium ALINIA...... 60 AMBIEN CR...... 194 clavulanate er...... 22 ALIQOPA...... 49 AMBISOME...... 43 AMPHADASE...... 166 aliskiren fumarate...... 76 ambrisentan...... 191 AMPHETAMINE ER...... 89 ALKERAN...... 49 amcinonide...... 96 amphetamine sulfate...... 89 ALKINDI SPRINKLE...... 140 AMD FOAM DRESSING...... 166

196 amphetamine- AQUASOL A...... 116 ASPIRIN-OMEPRAZOLE...... 63 dextroamphetamine...... 89 ARAKODA...... 60 ASSURE PLATINUM...... 108 amphetamine- ARALAST NP...... 187 ASTAGRAF XL...... 154 dextroamphetamine er...... 89 aranelle...... 147 ASTAMED MYO...... 166 amphotericin b...... 43 ARANESP (ALBUMIN FREE)...72 ASTRINGYN...... 72 ampicillin...... 22 ARAVA...... 154 ATABEX OB...... 116 ampicillin sodium...... 22 ARAZLO...... 97 ATACAND...... 77 ampicillin-sulbactam sodium..... 22 ARCALYST...... 154 ATACAND HCT...... 77 AMPYRA...... 91 ARCAPTA NEOHALER...... 187 atazanavir sulfate...... 66 AMRIX...... 192 argatroban...... 32 ATELVIA...... 164 AMZEEQ...... 97 ARGININE HCL...... 116 atenolol...... 77 ANADROL-50...... 143 argyle sterile saline...... 116 ATENOLOL+SYRSPEND SF... 77 ANAFRANIL...... 38 argyle sterile water...... 116 atenolol-chlorthalidone...... 77 anagrelide hcl...... 72 ARICEPT...... 38 ATGAM...... 154 ANASPAZ...... 133 ARIKAYCE...... 22 ATIVAN...... 70 anastrozole...... 49 ARIMIDEX...... 49 atomoxetine hcl...... 89 ANCOBON...... 43 aripiprazole...... 63 atorvastatin calcium...... 77 ANDRODERM...... 143 ARISTADA...... 63 atovaquone...... 60 ANDROGEL...... 143 ARISTADA INITIO...... 63 atovaquone-proguanil hcl...... 60 ANDROGEL PUMP...... 143 ARIXTRA...... 32 atracurium besylate...... 92 ANECTINE...... 92 armodafinil...... 194 ATRALIN...... 97 ANESTHESIA S/I-40...... 166 ARMONAIR DIGIHALER...... 187 ATRAPRO DERMAL SPRAY... 97 ANESTHESIA S/I-40A...... 166 ARMOUR THYROID...... 153 ATRIPLA...... 66 ANESTHESIA S/I-40H...... 166 ARNUITY ELLIPTA...... 187 ATROPEN...... 133 ANESTHESIA S/I-40S...... 166 AROMASIN...... 49 atropine sulfate...... 133, 180 ANESTHESIA S/I-60...... 166 ARRANON...... 49 ATROPINE SULFATE...... 133 ANGELIQ...... 147 arsenic trioxide...... 49 ATROVENT HFA...... 187 ANGIOMAX...... 32 ARTHROTEC...... 14 AUBAGIO...... 91 ANNOVERA...... 147 ARTICADENT DENTAL...... 17 aubra...... 147 ANORO ELLIPTA...... 187 ARTISS...... 166 aubra eq...... 147 ANTABUSE...... 21 ARYMO ER...... 7 AUGMENTIN...... 22 ANTARA...... 76 ARZERRA...... 49 AUGMENTIN ES-600...... 22 anticoagulant cit dext soln a...... 32 ASACOL HD...... 163 aurovela 1.5/30...... 147 anticoagulant sodium citrate..... 32 ASCENIV...... 154 aurovela 1/20...... 147 ANUSOL-HC...... 162 ASCLERA...... 76 aurovela 24 fe...... 147 ANZEMET...... 41 ascomp-codeine...... 7 aurovela fe 1.5/30...... 147 APADAZ...... 7 ashlyna...... 147 aurovela fe 1/20...... 147 apap-caff-dihydrocodeine...... 7 ASMANEX (120 METERED AURYXIA...... 138 APEXICON E...... 97 DOSES)...... 187 AUSTEDO...... 92 APIDRA SOLOSTAR...... 113 ASMANEX (14 METERED AUTOLET II CLINISAFE...... 108 APIDRA VIAL...... 113 DOSES)...... 187 AUTOLET LANCING DEVICE 108 APLENZIN...... 38 ASMANEX (30 METERED AUTOSOFT 30 INFUSION APOKYN...... 61 DOSES)...... 187 SET...... 166 APPTRIM...... 166 ASMANEX (60 METERED AUTOSOFT 90 INFUSION APPTRIM-D...... 166 DOSES)...... 187 SET...... 166 apraclonidine hcl...... 179 ASMANEX (7 METERED AUTOSOFT XC INFUSION aprepitant...... 41 DOSES)...... 187 SET...... 166 apri...... 147 ASMANEX HFA...... 187 AUVI-Q...... 187 APRISO...... 162 ASPARLAS...... 49 AVAGE...... 97 APTENSIO XR...... 89 ASPARTAME...... 166 AVAILNEX...... 166 APTIOM...... 34 ASPARTAME AVALIDE...... 77 APTIVUS...... 65 (NUTRASWEET)...... 166 AVANDIA...... 105 AQUACEL AG BURN...... 97 aspirin-dipyridamole er...... 63 AVAPRO...... 77

197 AVASTIN...... 49 balsam peru-castor oil...... 97 BEOVU...... 181 AVC VAGINAL...... 43 BALVERSA...... 49 BEPREVE...... 177 AVEED...... 143 balziva...... 147 BERINERT...... 155 AVELOX...... 22 BANZEL...... 34 beser...... 97 aviane...... 147 BAQSIMI ONE PACK...... 112 BESIVANCE...... 177 avidoxy...... 22 BAQSIMI TWO PACK...... 112 BESPONSA...... 50 AVITA...... 97 BARACLUDE...... 66 BETADINE OPHTHALMIC AVODART...... 140 BARHEMSYS...... 41 PREP...... 177 AVONEX PEN...... 91 BASAGLAR KWIKPEN...... 113 BETAGAN...... 179 AVONEX PREFILLED...... 91 BAVENCIO...... 49 betamethasone dipropionate.... 97 AVSOLA...... 154 BAXDELA...... 22 betamethasone dipropionate AVYCAZ...... 22 BAYER CONTOUR LINK 2.4..108 aug...... 97 AXONA...... 166 BCAA...... 117 betamethasone sod phos & AYGESTIN...... 147 BCG VACCINE...... 160 acet...... 140 ayuna...... 147 BD AUTOSHIELD DUO PEN betamethasone valerate...... 97 AYVAKIT...... 49 NEEDLES...... 113 BETAPACE...... 77 azacitidine...... 49 BD INTEGRA NEEDLE...... 113 BETAPACE AF...... 77 AZACTAM...... 22 bd posiflush...... 117 BETASERON...... 91 AZACTAM IN DEXTROSE...... 22 BD SAFETYGLIDE betaxolol hcl...... 77, 179 AZASAN...... 154 SYRINGE/NEEDLE...... 113 bethanechol chloride...... 138 AZASITE...... 176 BD SYRINGE LUER-LOK...... 166 BETHKIS...... 191 azathioprine...... 154 BD ULTRA-FINE INSULIN BETIMOL...... 179 azathioprine sodium...... 155 SYRINGES...... 113 BETOPTIC-S...... 179 azelaic acid...... 97 BD ULTRA-FINE PEN BEVACIZUMAB...... 181 azelastine hcl...... 177, 183 NEEDLES...... 113 BEVESPI AEROSPHERE...... 187 azelastine-fluticasone...... 183 BD VEO INSULIN SYR U/F BEVYXXA...... 32 AZELEX...... 97 1/2UNIT...... 113 bexarotene...... 50 AZILECT...... 61 BECONASE AQ...... 183 BEXSERO...... 160 azithromycin...... 22 bekyree...... 147 BEYAZ...... 147 AZOPT...... 179 BELBUCA...... 7 bicalutamide...... 50 AZOR...... 77 BELEODAQ...... 50 BICILLIN C-R...... 23 aztreonam...... 22 BELRAPZO...... 50 BICILLIN C-R 900/300...... 23 AZULFIDINE...... 163 BELSOMRA...... 194 BICILLIN L-A...... 23 AZULFIDINE EN-TABS...... 163 benazepril hcl...... 77 BICNU...... 50 azurette...... 147 benazepril-hydrochlorothiazide. 77 BIDIL...... 77 b-6 folic acid...... 116 BENDAMUSTINE HCL...... 50 BI-EST 80:20 baciim...... 22 BENDEKA...... 50 PROGESTERONE...... 147 bacitracin...... 22, 177 BENEFIX...... 72 BIEST/PROGESTERONE...... 148 bacitracin-polymyxin b...... 180 BENICAR...... 77 BIJUVA...... 148 bacitra-neomycin-polymyxin-hc BENICAR HCT...... 77 BIKTARVY...... 66 ...... 180 BENLYSTA...... 155 BILTRICIDE...... 60 baclofen...... 192 BENTYL...... 133 bimatoprost...... 179, 181 BACMIN...... 116 BENZACLIN...... 97 BINAXNOW COVID-19 AG BACTERIOSTATIC BENZACLIN WITH PUMP...... 97 CARD...... 166 WATER(BENZ ALC)...... 166 benzalkonium chloride...... 23 BINOSTO...... 164 BACTRIM...... 22 BENZAMYCIN...... 97 biocel...... 117 BACTRIM DS...... 22 BENZHYDROCODONE- BIOGUARD GAUZE BACTROBAN...... 22 ACETAMINOPHEN...... 7 SPONGES...... 166 BACTROBAN NASAL...... 22 BENZNIDAZOLE...... 60 BIOGUARD ISLAND BAFIERTAM...... 91 benzonatate...... 183 DRESSINGS...... 166 bal in oil...... 166 benzoyl peroxide-erythromycin. 97 BIOGUARD NON-ADHERENT BALCOLTRA...... 147 benzphetamine hcl...... 93 DRESSING...... 167 balsalazide disodium...... 163 benztropine mesylate...... 61 BIO-KULT INFANTIS...... 133

198 BIORPHEN...... 77 bromfenac sodium (once-daily) BYDUREON BCISE BIO-STATIN...... 43 ...... 177 AUTOINJECTOR...... 105 BIOTEL CARE BLOOD bromocriptine mesylate...... 61 BYETTA 10 MCG PEN...... 105 GLUCOSE SYST...... 108 BROMSITE...... 177 BYETTA 5 MCG PEN...... 105 BIOTHRAX...... 160 BROVANA...... 188 BYNFEZIA PEN...... 144 BISACODYL...... 133 BRUKINSA...... 50 BYSTOLIC...... 77 bisoprolol fumarate...... 77 BRYHALI...... 97 BYVALSON...... 77 bisoprolol-hydrochlorothiazide.. 77 budesonide...... 163, 188 cabergoline...... 144 bivalirudin trifluoroacetate...... 32 budesonide er...... 163 CABLIVI...... 63 BIVIGAM...... 155 BUDESONIDE- CABOMETYX...... 50 blanche...... 97 FORMOTEROL FUMARATE..188 CADUET...... 77 BLENREP...... 50 BUFFERED LIDOCAINE...... 17 CAFCIT...... 93 bleomycin sulfate...... 50 bumetanide...... 77 CAFERGOT...... 46 BLEPH-10...... 177 BUMEX...... 77 caffeine citrate...... 93 BLEPHAMIDE...... 181 BUNAVAIL...... 21 CAFFEINE-SODIUM BLEPHAMIDE S.O.P...... 181 BUPAP...... 7 BENZOATE...... 93 BLINCYTO...... 50 BUPHENYL...... 136 CALAMINE...... 97 blisovi 24 fe...... 148 bupivacaine fisiopharma...... 17 CALAN...... 77 blisovi fe 1.5/30...... 148 bupivacaine hcl...... 17 CALAN SR...... 77 blisovi fe 1/20...... 148 BUPIVACAINE HCL...... 17 CALCIFOL...... 117 BLOOD GLUCOSE TEST...... 108 bupivacaine hcl (pf)...... 17 calcipotriene...... 97 BLOXIVERZ...... 48 BUPIVACAINE HCL-NACL...... 17 CALCIPOTRIENE...... 97 BONIVA...... 164 bupivacaine in dextrose...... 17 calcipotriene-betameth diprop...98 BONJESTA...... 41 BUPIVACAINE IN DEXTROSE 17 calcitonin (salmon)...... 164 BOOSTRIX...... 160 bupivacaine spinal...... 17 CALCITRENE...... 98 BORTEZOMIB...... 50 bupivacaine-epinephrine...... 17 calcitriol...... 98, 165 bosentan...... 191 BUPIVACAINE-EPINEPHRINE 18 calcium acetate...... 138 BOSULIF...... 50 bupivacaine-epinephrine (pf).... 17 calcium acetate (phos binder).138 BOTOX...... 167 BUPRENEX...... 7 calcium chloride...... 117 BOTOX COSMETIC...... 97 buprenorphine...... 7 CALCIUM CHLORIDE...... 117 bp vit 3...... 117 buprenorphine hcl...... 7, 21 CALCIUM CHLORIDE BPCO...... 97 buprenorphine hcl-naloxone DIHYDRATE...... 117 b-plex...... 117 hcl...... 21 CALCIUM DISODIUM b-plex plus...... 117 bupropion hcl...... 39 VERSENATE...... 167 BRAFTOVI...... 50 bupropion hcl er (smoking det). 21 calcium gluconate...... 117 BREO ELLIPTA...... 188 bupropion hcl er (sr)...... 38 CALCIUM GLUCONATE...... 117 BREVIBLOC...... 77 bupropion hcl er (xl)...... 39 CALCIUM GLUCONATE BREVIBLOC IN NACL...... 77 BUPROPION HCL ER (XL)...... 39 ANHYDROUS...... 117 BREVIBLOC PREMIXED...... 77 buspirone hcl...... 70 CALCIUM GLUCONATE BREVIBLOC PREMIXED DS....77 busulfan...... 50 MONOHYDRATE...... 117 BREVITAL SODIUM...... 167 BUSULFEX...... 50 CALCIUM GLUCONATE- BREZTRI AEROSPHERE...... 188 butalbital-acetaminophen...... 7 DEXTROSE...... 117 BRIDION...... 167 BUTALBITAL- CALCIUM GLUCONATE- briellyn...... 148 ACETAMINOPHEN...... 7 NACL...... 117 BRILINTA...... 63 butalbital-apap...... 7 CALCIUM LACTATE brimonidine tartrate...... 179 butalbital-apap-caff-cod...... 7 PENTAHYDRATE...... 117 BRINEURA...... 135 butalbital-apap-caffeine...... 7 CALCIUM PHOSPHATE BRISDELLE...... 38 butalbital-asa-caff-codeine...... 7 DIBASIC...... 117 BRIVIACT...... 34 butalbital-aspirin-caffeine...... 7 CALCIUM PHOSPHATE BROMELAIN...... 167 BUTISOL SODIUM...... 194 TRIBASIC...... 117 bromfed dm...... 183 butorphanol tartrate...... 7 CALDOLOR...... 14 BUTRANS...... 7 CALM...... 117 BYDUREON...... 105 CALQUENCE...... 50

199 CAMBIA...... 14 carteolol hcl...... 179 CELLCEPT...... 155 camila...... 148 cartia xt...... 78 CELLCEPT INTRAVENOUS.. 155 CAMPATH...... 50 CARTICEL...... 167 CELONTIN...... 34 CAMPTOSAR...... 50 carvedilol...... 78 CENFOL...... 118 camrese...... 148 carvedilol phosphate er...... 78 CENTANY...... 24 camrese lo...... 148 cascara sagrada...... 133 CENTRATEX...... 118 CANASA...... 163 CASODEX...... 50 cephalexin...... 24 CANCIDAS...... 43 caspofungin acetate...... 43 CEPROTIN...... 72 candesartan cilexetil...... 77 CATAPRES...... 78 CEQUA...... 181 candesartan cilexetil-hctz...... 77 CATAPRES-TTS-1...... 78 CEQUR SIMPLICITY 2U...... 108 CAPASTAT SULFATE...... 48 CATAPRES-TTS-2...... 78 CEQUR SIMPLICITY capecitabine...... 50 CATAPRES-TTS-3...... 78 INSERTER...... 108 CAPEX...... 98 cavarest...... 94 CEQUR SIMPLICITY CAPLYTA...... 63 CAVERJECT...... 138 STARTER...... 108 CAPRELSA...... 50 CAYA...... 167 CERDELGA...... 136 captopril...... 77 CAYSTON...... 191 CEREBYX...... 34 captopril-hydrochlorothiazide.... 77 caziant...... 148 CEREFOLIN...... 118 CARAC...... 98 cefaclor...... 23 CEREFOLIN NAC...... 118 CARAFATE...... 131 cefaclor er...... 23 CEREZYME...... 136 CARBAGLU...... 117 cefadroxil...... 23 CESAMET...... 41 carbamazepine...... 34 CEFAZOLIN IN SODIUM cetirizine hcl...... 183 carbamazepine er...... 34 CHLORIDE...... 23 CETRAXAL...... 183 CARBATROL...... 34 cefazolin sodium...... 23 CETYLCIDE-G...... 167 carbidopa...... 61 CEFAZOLIN SODIUM...... 23 CETYLEV...... 167 carbidopa-levodopa...... 61 cefazolin sodium-dextrose...... 23 cevimeline hcl...... 94 carbidopa-levodopa er...... 61 CEFAZOLIN SODIUM- CHANTIX...... 21 carbidopa-levodopa- DEXTROSE...... 23 CHANTIX CONTINUING entacapone...... 61 CEFAZOLIN SODIUM-NACL....23 MONTH PAK...... 21 carbinoxamine maleate...... 183 cefdinir...... 23 CHANTIX STARTING MONTH CARBOCAINE...... 18 cefditoren pivoxil...... 23 PAK...... 21 CARBOCAINE cefepime hcl...... 23 CHARCOAL ACTIVATED...... 167 PRESERVATIVE-FREE...... 18 cefepime-dextrose...... 23 charlotte 24 fe...... 148 carboplatin...... 50 cefixime...... 23 chateal...... 148 CARDENE IV...... 77 CEFOTAN...... 23 chateal eq...... 148 CARDIOTEK RX...... 167 cefotaxime sodium...... 23 CHEMET...... 118 CARDIZEM...... 78 cefotetan disodium...... 23 CHEMSTRIP UGK...... 108 CARDIZEM CD...... 78 cefotetan disodium-dextrose.....24 CHENODAL...... 133 CARDIZEM LA...... 78 cefoxitin sodium...... 24 CHIRHOSTIM...... 167 CARDURA...... 78 CEFOXITIN SODIUM- chloramphenicol sod succinate.24 CARDURA XL...... 140 DEXTROSE...... 24 chlordiazepoxide hcl...... 70 CARETOUCH CONTROL SOL cefpodoxime proxetil...... 24 chlordiazepoxide-amitriptyline...39 LEVEL 2...... 108 cefprozil...... 24 chlordiazepoxide-clidinium...... 133 CARETOUCH ceftazidime...... 24 chlorhexidine gluconate...... 94 LANCING/EJECTOR...... 108 ceftazidime and dextrose...... 24 CHLORHEXIDINE CARETOUCH TEST...... 108 ceftriaxone sodium...... 24 GLUCONATE...... 167 CARIMUNE NF...... 155 ceftriaxone sodium in dextrose. 24 chloroprocaine hcl (pf)...... 18 carisoprodol...... 192 ceftriaxone sodium-dextrose.....24 chloroquine phosphate...... 60 carisoprodol-aspirin...... 192 cefuroxime axetil...... 24 chlorothiazide...... 78 carisoprodol-aspirin-codeine...... 8 cefuroxime sodium...... 24 chlorothiazide sodium...... 78 carmustine...... 50 CELEBREX...... 14 chlorpromazine hcl...... 63 CARNITOR...... 118 celecoxib...... 14 chlorpropamide...... 105 CARNITOR SF...... 118 CELESTONE SOLUSPAN...... 140 chlorthalidone...... 78 CAROSPIR...... 78 CELEXA...... 39 chlorzoxazone...... 192

200 CHOLBAM...... 136 clemastine fumarate...... 184 CLINIMIX/DEXTROSE (6/5)... 119 cholestyramine...... 78 CLENPIQ...... 133 CLINIMIX/DEXTROSE (8/10). 119 cholestyramine light...... 78 CLEO 90 INFUSION SET CLINIMIX/DEXTROSE (8/14). 119 CHOLEXMAX...... 167 24"/6MM...... 167 CLINISOL SF...... 119 CHOLEXTRA T/F...... 167 CLEOCIN...... 25 CLINOIN...... 98 CHOLINE BITARTRATE...... 118 CLEOCIN PHOSPHATE...... 25 CLINOLIPID...... 119 CHROMAGEN...... 118 CLEOCIN-T...... 98 CLINPRO 5000...... 94 chromic chloride...... 118 CLEVIPREX...... 78 clobazam...... 34 CIALIS...... 138 CLIMARA...... 148 clobetasol prop emollient base. 98 ciclodan...... 43 CLIMARA PRO...... 148 clobetasol propionate...... 98 CICLODAN SOLUTION...... 43 clindacin etz...... 98 clobetasol propionate e...... 98 ciclopirox...... 43 clindacin-p...... 98 clobetasol propionate emulsion 98 CICLOPIROX...... 167 CLINDAGEL...... 98 CLOBEX...... 98 ciclopirox olamine...... 43 clindamycin hcl...... 25 CLOBEX SPRAY...... 98 CICLOPIROX OLAMINE...... 43 clindamycin palmitate hcl...... 25 clocortolone pivalate...... 98 cidofovir...... 66 clindamycin phosphate...... 25, 98 clocortolone pivalate pump...... 99 cilostazol...... 63 CLINDAMYCIN PHOSPHATE.. 98 clodan...... 99 CILOXAN...... 177 clindamycin phosphate in d5w.. 25 CLODERM...... 99 CIMDUO...... 66 CLINDAMYCIN PHOSPHATE CLODERM PUMP...... 99 cimetidine...... 131 IN NACL...... 25 clofarabine...... 50 cimetidine hcl...... 131 clindamycin phosphate- CLOLAR...... 50 CIMZIA...... 155 benzoyl peroxide...... 98 clomipramine hcl...... 39 CIMZIA PREFILLED KIT...... 155 clindamycin-tretinoin...... 98 clonazepam...... 70 CIMZIA STARTER KIT...... 155 CLINDESSE...... 25 clonidine...... 78 cinacalcet hcl...... 165 CLINIMIX E/DEXTROSE clonidine hcl...... 78 CINQAIR...... 183 (2.75/10)...... 118 clonidine hcl (analgesia)...... 8 CINRYZE...... 155 CLINIMIX E/DEXTROSE clonidine hcl er...... 89 CINVANTI...... 41 (2.75/5)...... 118 clopidogrel bisulfate...... 63 CIPRO...... 24 CLINIMIX E/DEXTROSE clorazepate dipotassium...... 70 CIPRO HC...... 183 (4.25/10)...... 118 clotrimazole...... 43 CIPRO IN D5W...... 24 CLINIMIX E/DEXTROSE CLOTRIMAZOLE...... 43 CIPRODEX...... 183 (4.25/25)...... 118 clotrimazole-betamethasone.....43 ciprofloxacin...... 24 CLINIMIX E/DEXTROSE clovique...... 119 ciprofloxacin hcl...... 24, 177, 183 (4.25/5)...... 118 clozapine...... 64 ciprofloxacin in d5w...... 24 CLINIMIX E/DEXTROSE CLOZARIL...... 64 ciprofloxacin-ciproflox hcl er...... 24 (5/15)...... 118 COAGADEX...... 72 ciprofloxacin-dexamethasone. 183 CLINIMIX E/DEXTROSE coal tar...... 99 CIPROFLOXACIN- (5/20)...... 118 COARTEM...... 60 FLUOCINOLONE PF...... 183 CLINIMIX E/DEXTROSE cod liver oil...... 119 cisatracurium besylate...... 93 (8/10)...... 118 codeine sulfate...... 8 CISATRACURIUM BESYLATE 93 CLINIMIX E/DEXTROSE COENZYME Q-10...... 167 cisatracurium besylate (pf)...... 93 (8/14)...... 118 COGENTIN...... 61 cisplatin...... 50 CLINIMIX N14G30E...... 118 COLAZAL...... 163 CISPLATIN...... 50 CLINIMIX N9G15E...... 118 COLCHICINE...... 46 citalopram hydrobromide...... 39 CLINIMIX/DEXTROSE colchicine...... 46 CITANEST FORTE DENTAL....18 (4.25/10)...... 118 colchicine-probenecid...... 46 CITANEST PLAIN DENTAL...... 18 CLINIMIX/DEXTROSE COLCRYS...... 46 cladribine...... 50 (4.25/25)...... 118 colesevelam hcl...... 78 claravis...... 98 CLINIMIX/DEXTROSE (4.25/5) COLESTID...... 78 CLARINEX...... 183, 184 ...... 118 COLESTID FLAVORED...... 78 CLARINEX-D 12 HOUR...... 184 CLINIMIX/DEXTROSE (5/15). 119 colestipol hcl...... 78 clarithromycin...... 24, 25 CLINIMIX/DEXTROSE (5/20). 119 colistimethate sodium (cba)...... 25 clarithromycin er...... 24 CLINIMIX/DEXTROSE (5/25). 119 colocort...... 163

201 COLY-MYCIN M...... 25 CORVITE...... 119 cyclopentolate hcl...... 181 COLY-MYCIN S...... 183 CORVITE 150...... 119 CYCLOPHENE RAPIDPAQ....192 COLYTE WITH FLAVOR CORVITE FE...... 119 cyclophosphamide...... 51 PACKS...... 133 corvite free...... 119 CYCLOPHOSPHAMIDE...... 51 COMBIGAN...... 179 CORZIDE...... 79 cycloserine...... 48 COMBIPATCH...... 148 COSENTYX (300 MG DOSE).155 CYCLOSET...... 105 COMBIVENT RESPIMAT...... 188 COSENTYX 150 MG/ML...... 155 cyclosporine...... 155 COMBIVIR...... 66 COSENTYX SENSOREADY cyclosporine modified...... 155 COMETRIQ (100 MG DAILY (300 MG)...... 155 CYKLOKAPRON...... 72 DOSE)...... 50 COSENTYX SENSOREADY CYMBALTA...... 39 COMETRIQ (140 MG DAILY PEN...... 155 cyproheptadine hcl...... 184 DOSE)...... 51 COSMEGEN...... 51 CYRAMZA...... 51 COMETRIQ (60 MG DAILY COSOPT...... 179 cyred...... 148 DOSE)...... 51 COSOPT PF...... 179 cyred eq...... 148 COMFORT INFUSION SET cosyntropin...... 167 CYSTADANE...... 136 23"/17MM...... 167 COTELLIC...... 51 CYSTADROPS...... 181 COMFORT SHORT INF SET COTEMPLA XR-ODT...... 90 CYSTAGON...... 136 23"/13MM...... 167 COUMADIN...... 32 CYSTARAN...... 181 COMPLERA...... 66 COZAAR...... 79 CYSVIEW...... 167 compro...... 41 CREON...... 136 cytarabine...... 51 COMTAN...... 61 CRESEMBA...... 43 cytarabine (pf)...... 51 CONCERTA...... 89 CRESTOR...... 79 CYTOGAM...... 155 CONDYLOX...... 99 CRINONE...... 148 CYTOMEL...... 153 CONJUPRI...... 78 CRIXIVAN...... 66 CYTOTEC...... 131 CONSENSI...... 78 cromolyn sodium.....133, 177, 188 CYTOTINE...... 167 constulose...... 133 crotan...... 60 CYTOVENE...... 66 CONTOUR CONTROL...... 108 cryselle-28...... 148 D.H.E. 45...... 46 CONTOUR NEXT CONTROL.108 CRYSVITA...... 136 dacarbazine...... 51 CONTOUR NEXT LINK...... 108 CUBICIN...... 25 DACOGEN...... 51 CONTOUR NEXT MONITOR. 108 CUBICIN RF...... 25 dactinomycin...... 51 CONTOUR NEXT TEST...... 108 CUPRIC CHLORIDE...... 119 DAKLINZA...... 66 CONTOUR TEST...... 109 CUPRIMINE...... 138 dalfampridine er...... 91 CONTRAVE...... 93 CURITY AMD DALIRESP...... 188 CONZIP...... 8 ANTIMICROBIAL SPNGE...... 167 DALVANCE...... 25 COPAXONE...... 91 CURITY AMD danazol...... 143 COPIKTRA...... 51 ANTIMICROBIAL STRIP...... 167 DANTRIUM...... 192 CORDRAN...... 99 CURITY IODOFORM dantrolene sodium...... 192 COREG...... 78 PACKING STRIP...... 167 dapsone...... 48, 99 COREG CR...... 78 curity sterile saline...... 119 DAPSONE...... 99 coremino...... 25 CUROSURF...... 184 DAPTACEL...... 160 CORGARD...... 78 CUTAQUIG...... 155 daptomycin...... 25 CORIFACT...... 72 CUTIVATE...... 99 DARAPRIM...... 60 CORLANOR...... 78, 79 CUVITRU...... 155 darifenacin hydrobromide er... 138 CORLOPAM...... 79 CUVPOSA...... 133 DARZALEX...... 51 CORTEF...... 140 cyanocobalamin...... 119 DARZALEX FASPRO...... 51 CORTENEMA...... 163 CYANOCOBALAMIN...... 119 dasetta 1/35...... 148 CORTIFOAM...... 163 CYANOKIT...... 167 dasetta 7/7/7...... 148 cortisone acetate...... 140 cyclafem 1/35...... 148 daunorubicin hcl...... 51 CORTISPORIN...... 99 cyclafem 7/7/7...... 148 DAURISMO...... 51 CORTROSYN...... 167 cyclobenzaprine hcl...... 192 DAYPRO...... 14 CORVERT...... 79 cyclobenzaprine hcl er...... 192 daysee...... 148 CORVITA...... 119 CYCLOGYL...... 181 DAYTRANA...... 90 corvita 150...... 119 CYCLOMYDRIL...... 181 DAYVIGO...... 194

202 D-CARE 100X...... 18 desonide...... 99 DIASTAT ACUDIAL...... 35 DDAVP...... 144 DESOWEN...... 99 DIASTAT PEDIATRIC...... 35 DDAVP RHINAL TUBE...... 144 desoximetasone...... 99 DIATHRIVE BLOOD DEBACTEROL...... 94 DESOXYN...... 90 GLUCOSE METER...... 109 deblitane...... 148 DESVENLAFAXINE ER...... 39 DIATHRIVE BLOOD DECADRON...... 140 desvenlafaxine succinate er...... 39 GLUCOSE TEST...... 109 decitabine...... 51 DETROL...... 138 DIATHRIVE GLUCOSE deferasirox...... 119 DETROL LA...... 138 CONTROL SOLN...... 109 deferasirox granules...... 119 DEXABLISS...... 140 DIATHRIVE GLUCOSE TEST 109 deferiprone...... 119 dexamethasone...... 140 DIATHRIVE LANCING deferoxamine mesylate...... 167 DEXAMETHASONE (LA)...... 140 DEVICE...... 109 dehydrated alcohol...... 119 dexamethasone intensol...... 140 DIATHRIVE PEN NEEDLE..... 113 DELESTROGEN...... 148 DEXAMETHASONE SOD DIATHRIVE+ GLUCOSE DELSTRIGO...... 66 PHOS IN D5W...... 141 MONITOR...... 109 DELTEC COZMO CLEO SET DEXAMETHASONE SOD DIATHRIVE+ GLUCOSE 24" 6MM...... 167 PHOS-NACL...... 141 TEST...... 109 delyla...... 148 dexamethasone sod diazepam...... 35, 70, 71 DELZICOL...... 163 phosphate pf...... 141 DIAZEPAM...... 71 DEMADEX...... 79 dexamethasone sodium diazepam intensol...... 70 demeclocycline hcl...... 25 phosphate...... 141, 177 diazoxide...... 112 DEMEROL...... 8 DEXAMETHASONE SODIUM DIBENZYLINE...... 79 DEMSER...... 79 PHOSPHATE...... 141 DICLEGIS...... 41 DENAVIR...... 66 dexchlorpheniramine maleate.184 DICLOFENAC...... 14 DENTA 5000 PLUS...... 94 DEXCOM G4 / G5 / G6 DICLOFENAC EPOLAMINE.....14 DENTAGEL...... 94 RECEIVER, TRANSMITTER, diclofenac potassium...... 14 DEPACON...... 34 SENSOR (INCLUDING diclofenac sodium...... 14, 99, 177 DEPAKENE...... 34 PLATINUM, PLATINUM diclofenac sodium er...... 14 DEPAKOTE...... 35 PEDIATRIC)...... 109 diclofenac-misoprostol...... 14 DEPAKOTE ER...... 34 DEXEDRINE...... 90 DICLOFONO...... 14 DEPAKOTE SPRINKLES...... 35 DEXILANT...... 131 dicloxacillin sodium...... 25 DEPEN TITRATABS...... 138 DEXMEDETOMIDINE HCL.... 168 DICOPANOL FUSEPAQ...... 184 DEPLIN 15...... 119 dexmedetomidine hcl...... 168 DICOPANOL RAPIDPAQ...... 184 DEPLIN 7.5...... 119 dexmedetomidine hcl in nacl...168 dicyclomine hcl...... 133 DEPO-ESTRADIOL...... 148 DEXMEDETOMIDINE HCL- didanosine...... 66 DEPO-MEDROL...... 140 DEXTROSE...... 168 diethylpropion hcl...... 93 DEPO-PROVERA...... 148 dexmethylphenidate hcl...... 90 diethylpropion hcl er...... 93 DEPO-SUBQ PROVERA 104.148 dexmethylphenidate hcl er...... 90 DIFFERIN...... 99 DEPO-TESTOSTERONE...... 143 DEXONTO 0.4%...... 141 DIFICID...... 25 DERMA-SMOOTHE/FS BODY.99 DEXPAK 10 DAY...... 141 difil-g forte...... 188 DERMA-SMOOTHE/FS DEXPAK 13 DAY...... 141 diflorasone diacetate...... 99 SCALP...... 99 DEXPAK 6 DAY...... 141 DIFLUCAN...... 44 DERMOTIC...... 183 DEXPANTHENOL...... 119 diflunisal...... 14 DERMULCERA...... 99 dexrazoxane hcl...... 51 DIGIFAB...... 168 DESCOVY...... 66 dextroamphetamine sulfate...... 90 digitek...... 79 DESFERAL...... 167 dextroamphetamine sulfate er.. 90 digox...... 79 desflurane...... 168 dextrose...... 119 digoxin...... 79 desipramine hcl...... 39 DEXTROSE...... 119 dihydroergotamine mesylate.....46 desloratadine...... 184 DIACOMIT...... 35 DILANTIN...... 35 desmopressin ace spray refrig 144 DIALYVITE...... 119 DILANTIN INFATABS...... 35 desmopressin acetate...... 144 DIALYVITE 3000...... 119 DILATRATE-SR...... 79 desmopressin acetate spray... 144 DIALYVITE 5000...... 119 DILAUDID...... 8 desogestrel-ethinyl estradiol... 148 DIALYVITE SUPREME D...... 120 diltiazem hcl...... 79 DESONATE...... 99 DIALYVITE/ZINC...... 120 DILTIAZEM HCL...... 79

203 diltiazem hcl er...... 79 DORZOLAMIDE HCL...... 179 dutasteride...... 140 diltiazem hcl er beads...... 79 dorzolamide hcl-timolol mal.... 179 dutasteride-tamsulosin hcl...... 140 diltiazem hcl er coated beads... 79 dorzolamide hcl-timolol mal pf 179 DUTOPROL...... 80 DILTIAZEM HCL-DEXTROSE.. 79 dotti...... 148 DUZALLO...... 46 DILTIAZEM HCL-SODIUM DOUBLE PM...... 181 dvorah...... 8 CHLORIDE...... 79 DOVATO...... 66 DXEVO 11-DAY...... 141 dilt-xr...... 79 DOVONEX...... 99 DYANAVEL XR...... 90 DILUENT FOR LEFAMULIN...120 doxazosin mesylate...... 80 DYAZIDE...... 80 diluent for treprostinil...... 168 doxepin hcl...... 39, 99, 194 DYMISTA...... 184 dimenhydrinate...... 41 doxercalciferol...... 165 DYRENIUM...... 80 dimethyl fumarate...... 91 DOXIL...... 51 DYSPORT...... 168 dimethyl fumarate starter pack..91 doxorubicin hcl...... 51 E.E.S. 400...... 26 DIOVAN...... 79 doxorubicin hcl liposomal...... 51 E.E.S. GRANULES...... 26 DIOVAN HCT...... 79 doxy 100...... 25 EASY GLIDE LUER LOCK DIPENTUM...... 163 doxycycline...... 100 SYRINGE...... 168 diphen...... 184 doxycycline hyclate...... 26 EASY TRAK II BLOOD DI-PHEN...... 184 DOXYCYCLINE HYCLATE...... 26 GLUCOSE SYS...... 109 diphenhydramine hcl...... 184 doxycycline monohydrate...... 26 EASY TRAK II CONTROL...... 109 diphenoxylate-atropine...... 133 doxylamine-pyridoxine...... 41 EASY TRAK II GLUCOSE DIPHTHERIA-TETANUS D-PENAMINE...... 138 TEST...... 109 TOXOIDS DT...... 160 DRISDOL...... 120 easygel...... 94 DIPRIVAN...... 168 DRIZALMA SPRINKLE...... 39 EASYMAX 15 LEVEL 2-3 DIPROLENE...... 99 dronabinol...... 41 CONTROL...... 109 DIPROLENE AF...... 99 droperidol...... 41 EASYMAX CONTROL...... 109 dipyridamole...... 63, 168 DROPLET MICRON...... 113 EASYMAX CONTROL disopyramide phosphate...... 79 drospiren-eth estrad-levomefol148 NORMAL/HIGH...... 109 disulfiram...... 21 drospirenone-ethinyl estradiol.148 EASYPOINT NEEDLE.... 113, 168 DITROPAN XL...... 138 DROXIA...... 51 EC-NAPROSYN...... 14 DIURIL...... 79 DRYSOL...... 100 ec-naproxen...... 14 divalproex sodium...... 35 DUAC...... 100 econazole nitrate...... 44 divalproex sodium er...... 35 DUAKLIR PRESSAIR...... 188 ECOZA...... 44 DIVIGEL...... 148 DUAL COMPLEX FORMULA 1 EC-RX DHEA...... 168 DL-ALANINE...... 120 KIT...... 14 EC-RX ESTRADIOL...... 148 DL-LEUCINE...... 120 DUAVEE...... 148 EC-RX PROGESTERONE..... 148 DL-METHIONINE...... 120 DUETACT...... 105 EC-RX TESTOSTERONE...... 143 DL-PHENYLALANINE...... 120 DUEXIS...... 14 EDARBI...... 80 dobutamine hcl...... 79 DULERA...... 188 EDARBYCLOR...... 80 dobutamine in d5w...... 79 duloxetine hcl...... 39 EDECRIN...... 80 docetaxel...... 51 DUOBRII...... 100 EDETATE DISODIUM...... 120 docetaxel (non-alcohol)...... 51 DUODOTE...... 168 EDLUAR...... 194 dofetilide...... 79 DUOPA...... 61 ED-SPAZ...... 133 DOJOLVI...... 168 DUPIXENT...... 100 EDURANT...... 66 DOLOPHINE...... 8 DURACLON...... 8 efavirenz...... 66 donepezil hcl...... 38 DURAGESIC-100...... 8 efavirenz-emtricitab-tenofovir....66 dopamine hcl...... 79 DURAGESIC-12...... 8 efavirenz-lamivudine-tenofovir.. 66 dopamine in d5w...... 80 DURAGESIC-25...... 8 EFFER-K...... 120 DOPRAM...... 93 DURAGESIC-50...... 8 effer-k...... 120 DOPTELET...... 72 DURAGESIC-75...... 8 EFFEXOR XR...... 39 DORAL...... 71 duramorph...... 8 EFFIENT...... 63 DORIPENEM...... 25 duraxin...... 8 EFUDEX...... 100 DORYX...... 25 DUREZOL...... 177 EGATEN...... 60 DORYX MPC...... 25 DURLAZA...... 63 EGRIFTA...... 144 dorzolamide hcl...... 179 DUROLANE...... 168 EGRIFTA SV...... 144

204 ELAPRASE...... 136 ENBREL SURECLICK...... 156 EPIPEN 2-PAK...... 188 ELELYSO...... 136 ENDARI...... 168 EPIPEN JR 2-PAK...... 188 ELESTAT...... 177 endocet...... 8 EPIQUIN MICRO...... 100 ELESTRIN...... 149 ENDOMETRIN...... 149 epirubicin hcl...... 52 eletriptan hydrobromide...... 46 ENGERIX-B...... 160 epitol...... 35 ELFOLATE...... 120 ENHERTU...... 52 EPIVIR...... 66 ELFOLATE PLUS...... 120 ENLITE GLUCOSE SENSOR.109 EPIVIR HBV...... 66 ELIDEL...... 100 ENOVARX-AMITRIPTYLINE.. 168 eplerenone...... 81 ELIGARD...... 144 ENOVARX-BACLOFEN...... 192 EPOGEN...... 73 ELIMITE...... 60 enovarx-cyclobenzaprine hcl.. 192 epoprostenol sodium...... 191 elinest...... 149 ENOVARX- eprosartan mesylate...... 81 ELIQUIS...... 32 CYCLOBENZAPRINE HCL.... 193 eptifibatide...... 63 ELIQUIS DVT/PE STARTER ENOVARX-DICLOFENAC EPZICOM...... 66 PACK...... 32 SODIUM...... 14 EQUETRO...... 72 ELITEK...... 51 ENOVARX-IBUPROFEN...... 14 ERAXIS...... 44 ELITE-OB...... 120 ENOVARX-LIDOCAINE HCL....18 ERBITUX...... 52 ELIXOPHYLLIN...... 188 ENOVARX-NAPROXEN...... 14 ergocalciferol...... 120 ELLA...... 149 ENOVARX-TRAMADOL...... 100 ergoloid mesylates...... 168 ELLENCE...... 51 enoxaparin sodium...... 32 ERGOMAR...... 47 ELMIRON...... 138 enpresse-28...... 149 ergotamine-caffeine...... 47 ELOCON...... 100 enskyce...... 149 ERIVEDGE...... 52 ELOCTATE...... 73 ENSPRYNG...... 156 ERLEADA...... 52 eluryng...... 149 ENSTILAR...... 100 erlotinib hcl...... 52 ELZONRIS...... 51 entacapone...... 61 EROS-CTD...... 168 EMADINE...... 177 entecavir...... 66 errin...... 149 EMBEDA...... 8 ENTERAGAM...... 168 ERTACZO...... 44 EMBRACE TALK BLOOD ENTEREG...... 133 ertapenem sodium...... 26 GLUCOSE...... 109 ENTOCORT EC...... 163 ERWINAZE...... 52 EMBRACE TALK GLUCOSE ENTRESTO...... 80 ery...... 100 CONTROL...... 109 ENTTY SPRAY...... 100 ERYGEL...... 100 EMBRACE TALK GLUCOSE ENTYVIO...... 156 ERYPED 200...... 26 TEST...... 109 enulose...... 133 ERYPED 400...... 26 EMBRACE TALK ENVARSUS XR...... 156 ERY-TAB...... 26 MONITORING SYSTEM...... 109 EPANED...... 80 ERYTHROCIN EMCYT...... 52 EPCLUSA...... 66 LACTOBIONATE...... 26 EMEND...... 41, 42 ephedrine sulfate...... 80 ERYTHROCIN STEARATE...... 26 EMEND TRI-PACK...... 42 EPHEDRINE SULFATE...... 80 erythromycin...... 26, 100, 177 EMFLAZA...... 46 EPHEDRINE SULFATE erythromycin base...... 26 EMGALITY...... 46 (PRESSORS)...... 80 erythromycin ethylsuccinate...... 26 EMGALITY (300 MG DOSE).... 46 EPHEDRINE SULFATE-NACL. 80 ESBRIET...... 188 emoquette...... 149 EPIDIOLEX...... 35 ESCAVITE...... 120 EMPLICITI...... 52 EPIDUO...... 100 escitalopram oxalate...... 39 EMSAM...... 39 EPIDUO FORTE...... 100 ESGIC...... 8 emtricitabine...... 66 EPIFOAM...... 100 esmolol hcl...... 81 emtricitabine-tenofovir df...... 66 epinastine hcl...... 177 ESMOLOL HCL...... 81 EMTRIVA...... 66 EPINEPHRINE...... 81 esmolol hcl-sodium chloride...... 81 EMVERM...... 60 epinephrine...... 81, 188 esomeprazole magnesium...... 131 ENABLEX...... 138 EPINEPHRINE HCL- esomeprazole sodium...... 131 enalapril maleate...... 80 DEXTROSE...... 80 ESOMEPRAZOLE enalaprilat...... 80 EPINEPHRINE HCL-NACL...... 80 STRONTIUM...... 131 enalapril-hydrochlorothiazide.... 80 epinephrine pf...... 81 ESPEROCT...... 73 ENBREL...... 156 EPINEPHRINE-DEXTROSE.....81 estarylla...... 149 ENBREL MINI...... 155 EPINEPHRINE-NACL...... 81 estazolam...... 71

205 ESTRACE...... 149 EXFORGE HCT...... 81 FENSOLVI (6 MONTH)...... 144 estradiol...... 149 EXJADE...... 120 fentanyl...... 9 estradiol valerate...... 149 EXODERM...... 44 fentanyl citrate...... 8 estradiol-norethindrone acet... 149 EXONDYS 51...... 136 FENTANYL CITRATE...... 8, 9 ESTRING...... 149 EXPAREL...... 18 fentanyl citrate (pf)...... 8 ESTROGEL...... 149 EXTAVIA...... 91 FENTANYL CITRATE-NACL...... 9 ESTROSTEP FE...... 149 EXTINA...... 44 FENTANYL CIT- eszopiclone...... 194 EYLEA...... 181 ROPIVACAINE-NACL...... 9 ethacrynate sodium...... 81 EZ FLU SHOT-FLUCELVAX FENTANYL-BUPIVACAINE- ethacrynic acid...... 81 QUAD...... 160 NACL...... 9 ethambutol hcl...... 48 EZALLOR SPRINKLE...... 81 FENTORA...... 9 ETHAMOLIN...... 81 ezetimibe...... 81 FERAHEME...... 120 ethosuximide...... 35 ezetimibe-simvastatin...... 81 ferocon...... 120 ethyl chloride...... 18 fabb...... 120 ferotrinsic...... 120 ethynodiol diac-eth estradiol... 149 FABIOR...... 100 FERRALET 90...... 120 ETHYOL...... 52 FABRAZYME...... 136 ferraplus 90...... 120 etidronate disodium...... 165 falmina...... 149 FERRIPROX...... 120 etodolac...... 14, 15 famciclovir...... 66 FERRIPROX TWICE-A-DAY.. 120 etodolac er...... 14 famotidine...... 131 FERRLECIT...... 120 etomidate...... 168 FAMOTIDINE IN NACL...... 131 ferrocite plus...... 120 etonogestrel-ethinyl estradiol.. 149 famotidine premixed...... 131 FERRO-PLEX HEMATINIC.... 120 ETOPOPHOS...... 52 FANAPT...... 64 FERROTRIN...... 120 etoposide...... 52 FANAPT TITRATION PACK..... 64 FETROJA...... 26 EUCRISA...... 100 FANATREX FUSEPAQ...... 35 FETZIMA...... 39 EUFLEXXA...... 168 FARESTON...... 52 FETZIMA TITRATION...... 39 EURAX...... 60 FARXIGA...... 105 FEXMID...... 193 euthyrox...... 153 FARYDAK...... 52 FIASP...... 113 EVAMIST...... 149 FASENRA...... 184 FIASP FLEXTOUCH...... 113 EVEKEO...... 90 FASENRA PEN...... 184 FIASP PENFILL...... 113 EVEKEO ODT...... 90 FASLODEX...... 52 FIBRICOR...... 81 EVENCARE PROVIEW FAVIPIRAVIR...... 66 FIBRYGA...... 73 GLUCOSE TEST...... 109 fa-vitamin b-6-vitamin b-12..... 120 FILTER NEEDLE...... 168 EVENITY...... 164 fayosim...... 149 FINACEA...... 100 everolimus...... 52, 156 FAZACLO...... 64 finasteride...... 100, 140 EVERSENSE SENSOR...... 109 FBL KIT...... 15 FINTEPLA...... 35 EVERSENSE FDGARD...... 168 FIORICET...... 9 SENSOR/HOLDER...... 109 febuxostat...... 46 FIORICET/CODEINE...... 9 EVERSENSE SMART FEIBA...... 73 FIORINAL...... 9 TRANSMITTER...... 109 felbamate...... 35 FIORINAL/CODEINE #3...... 9 EVISTA...... 144 FELBATOL...... 35 FIRAZYR...... 156 EVOCLIN...... 100 FELDENE...... 15 FIRDAPSE...... 168 EVOMELA...... 52 felodipine er...... 81 FIRMAGON...... 144 EVOTAZ...... 66 FEMARA...... 52 FIRMAGON (240 MG DOSE). 144 EVOXAC...... 94 FEMCAP...... 168 FIRST - METOPROLOL...... 81 EVRYSDI...... 168 FEMHRT LOW DOSE...... 149 FIRST-ATENOLOL...... 81 EVZIO...... 21 FEMRING...... 149 FIRST-BACLOFEN...... 193 EXALGO...... 8 femynor...... 149 FIRST-LANSOPRAZOLE...... 131 EXCILON AMD DRAIN fenofibrate...... 81 FIRST-METRONIDAZOLE...... 26 SPONGES...... 168 fenofibrate micronized...... 81 FIRST-MOUTHWASH BLM...... 95 EXELDERM...... 44 fenofibric acid...... 81 FIRST-OMEPRAZOLE...... 131 EXELON...... 38 FENOGLIDE...... 81 FIRST-PROGESTERONE exemestane...... 52 fenoprofen calcium...... 15 VGS...... 149 EXFORGE...... 81 fenortho...... 15 FIRST-VANCOMYCIN...... 26

206 FIRVANQ...... 26 fluoxetine hcl (pmdd)...... 39 FORANE...... 169 flac...... 183 fluphenazine decanoate...... 64 FORFIVO XL...... 39 FLAGYL...... 26 fluphenazine hcl...... 64 FORMADON...... 169 FLAREX...... 177 FLURA-DROPS...... 120 formaldehyde...... 169 flavoxate hcl...... 138 flurandrenolide...... 101 FORTAMET...... 106 FLEBOGAMMA DIF...... 156 FLURA-SAFE...... 181 FORTAVIT...... 121 flecainide acetate...... 81 flurazepam hcl...... 194 FORTAZ...... 27 FLECTOR...... 15 flurbiprofen...... 15 FORTEO...... 164 FLEXBUMIN...... 168 flurbiprofen sodium...... 177 FORTESTA...... 143 FLOLAN...... 191 flutamide...... 52 FORTISCARE CONTROL...... 109 FLOLIPID...... 82 fluticasone propionate.....101, 184 FORTISCARE GLUCOSE FLOMAX...... 140 fluticasone-salmeterol...... 188 SYSTEM...... 110 FLOVENT DISKUS...... 188 FLUTICASONE- FORTISCARE T1 GLUCOSE FLOVENT HFA...... 188 SALMETEROL...... 188 SYSTEM...... 110 FLOXIN OTIC...... 183 fluvastatin sodium...... 82 FOSAMAX...... 164 floxuridine...... 52 fluvastatin sodium er...... 82 FOSAMAX PLUS D...... 164 FLUAD...... 160 fluvoxamine maleate...... 39 fosamprenavir calcium...... 66 FLUAD QUADRIVALENT...... 160 fluvoxamine maleate er...... 39 fosaprepitant dimeglumine...... 42 FLUARIX QUADRIVALENT....160 FLUZONE HIGH-DOSE...... 161 FOSCAVIR...... 66 FLUBLOK QUADRIVALENT...160 FLUZONE HIGH-DOSE fosfomycin tromethamine...... 27 FLUCELVAX QUADRIVALENT...... 161 fosinopril sodium...... 82 QUADRIVALENT...... 160 FLUZONE QUADRIVALENT.. 161 fosinopril sodium-hctz...... 82 fluconazole...... 44 FML...... 177 fosphenytoin sodium...... 35 fluconazole in sodium chloride..44 FML FORTE...... 177 FOSRENOL...... 138 flucytosine...... 44 FML LIQUIFILM...... 177 FOSTEUM...... 121 fludarabine phosphate...... 52 FOCALIN...... 90 FRAGMIN...... 33 fludrocortisone acetate...... 141 FOCALIN XR...... 90 FREAMINE HBC...... 121 FLULAVAL QUADRIVALENT. 161 folbee...... 120 FREAMINE III...... 121 FLUMADINE...... 66 folbee plus...... 120 FREESTYLE FREEDOM LITE110 flumazenil...... 168 FOLBEE PLUS CZ...... 120 FREESTYLE INSULINX FLUMIST QUADRIVALENT....161 FOLBIC...... 168 SYSTEM...... 110 flunisolide...... 184 FOLBIC RF...... 120 FREESTYLE INSULINX TEST110 fluocinolone acetonide.... 100, 183 FOLGARD OS...... 120 FREESTYLE LIBRE 14 DAY fluocinolone acetonide body... 100 FOLGARD RX...... 120 READER...... 110 fluocinolone acetonide scalp...100 folic acid...... 121 FREESTYLE LIBRE 14 DAY fluocinonide...... 100 FOLIVANE-F...... 121 SENSOR...... 110 fluocinonide emulsified base...100 FOLIVANE-PLUS...... 121 FREESTYLE LIBRE 2 FLUORABON...... 120 FOLOTYN...... 52 READER SYSTM...... 110 fluorescein-benoxinate...... 181 folplex 2.2...... 121 FREESTYLE LIBRE 2 FLUORESCITE...... 181 FOLTANX...... 121 SENSOR SYSTM...... 110 FLUORIDEX...... 95 FOLTANX RF...... 121 FREESTYLE LIBRE READER 110 fluoridex daily renewal...... 95 FOLTRATE...... 121 FREESTYLE LIBRE SENSOR FLUORIDEX ENHANCED foltrin...... 121 SYSTEM...... 110 WHITENING...... 95 FOLTX...... 121 FREESTYLE LITE TEST...... 110 FLUORIDEX SENSITIVITY fomepizole...... 169 FREESTYLE PRECISION RELIEF...... 95 fondaparinux sodium...... 32 NEO TEST...... 110 fluor-i-strips a.t...... 181 FORA 6 CONNECT...... 109 FREESTYLE TEST...... 110 fluoritab...... 120 FORA D40G fresenius propoven...... 169 fluorometholone...... 177 GLUCOSE/PRESSURE...... 169 FROTEK...... 15 FLUOROPLEX...... 100 FORA GTEL BLOOD FROVA...... 47 fluorouracil...... 52, 101 GLUCOSE SYSTEM...... 109 frovatriptan succinate...... 47 FLUOROURACIL...... 101 FORA GTEL BLOOD FULPHILA...... 73 fluoxetine hcl...... 39 GLUCOSE TEST...... 109 fulvestrant...... 52

207 FURADANTIN...... 27 GENOTROPIN...... 144 GLUCOTROL XL...... 106 furosemide...... 82 GENOTROPIN MINIQUICK....144 GLUMETZA...... 106 FUROSEMIDE IN SODIUM gentak...... 177 glutaraldehyde...... 169 CHLORIDE...... 82 gentamicin in saline...... 27 GLUTATHIONE...... 121 FUSILEV...... 52 gentamicin sulfate...... 27, 177 glyburide...... 106 FUSION PLUS...... 121 GENTEEL LANCING KIT glyburide micronized...... 106 FUSION SPRINKLES...... 121 (BLUE)...... 110 glyburide-metformin...... 106 FUZEON...... 66 GENVISC 850...... 169 GLYCATE...... 133 fyavolv...... 149 GENVOYA...... 67 GLYCINE...... 121 FYCOMPA...... 35 GEODON...... 64 glycine...... 138 GABA...... 121 GIALAX...... 133 glycine urologic...... 138 GABADONE...... 169 gianvi...... 149 GLYCOPHOS...... 121 gabapentin...... 35 GILENYA...... 91 glycopyrrolate...... 133, 134 GABAPENTIN-NAPROXEN GILOTRIF...... 52 GLYCOPYRROLATE...... 133, 134 CMPD KIT...... 15 GILPHEX TR...... 184 glycopyrrolate pf...... 134 GABITRIL...... 35 GILTUSS...... 184 glydo...... 18 GABLOFEN...... 193 giltuss pediatric...... 184 GLYNASE...... 106 GALAFOLD...... 136 GILTUSS TR...... 184 GLYRX-PF...... 134 galantamine hydrobromide...... 38 GIMOTI...... 42 GLYSET...... 106 galantamine hydrobromide er... 38 GIVLAARI...... 169 GLYXAMBI...... 106 GALAXTRA...... 169 GLASSIA...... 188 GOCOVRI...... 61 GALZIN...... 121 glatiramer acetate...... 91 GOJJI BLOOD GLUCOSE GAMASTAN...... 156 glatopa...... 91 TEST...... 110 GAMIFANT...... 156 GLEEVEC...... 52 GOJJI BLOOD TEST GAMMAGARD...... 156 GLEOLAN...... 169 STRIP/LANCETS...... 110 GAMMAGARD S/D LESS IGA 156 GLEOSTINE...... 53 GOJJI CONTROL...... 110 GAMMAKED...... 156 glimepiride...... 106 GOJJI LANCING GAMMAPLEX...... 156 glipizide er...... 106 DEVICE/CLEAR CAP...... 110 GAMUNEX-C...... 156 glipizide ir...... 106 GOLYTELY...... 134 GANCICLOVIR...... 67 glipizide xl...... 106 GONITRO...... 82 ganciclovir sodium...... 67 glipizide-metformin hcl...... 106 GORDOFILM...... 101 GARDASIL 9...... 161 GLOPERBA...... 46 GRALISE...... 93 GASTROCROM...... 133 GLOSTRIPS...... 181 granisetron hcl...... 42 gatifloxacin...... 177 GLUCAGEN DIAGNOSTIC.... 169 GRANIX...... 73 GATTEX...... 133 GLUCAGEN HYPOKIT...... 112 griseofulvin microsize...... 44 gavilyte-c...... 133 GLUCAGON EMERGENCY griseofulvin ultramicrosize...... 44 gavilyte-g...... 133 KIT...... 112 guaiatussin ac...... 184 gavilyte-h...... 133 GLUCAGON HCL guaifenesin ac...... 184 gavilyte-n with flavor pack...... 133 (DIAGNOSTIC)...... 169 guanfacine hcl...... 82 GAVRETO...... 52 GLUCOCARD 01 SENSOR guanfacine hcl er...... 90 GAZYVA...... 52 PLUS...... 110 GUANIDINE HCL...... 48 GEBAUERS PAIN EASE...... 18 GLUCOCARD EXPRESSION GUARDIAN CONNECT GEBAUERS SPRAY AND TEST...... 110 TRANSMITTER...... 110 STRETCH...... 18 GLUCOCARD SHINE GUARDIAN LINK 3 GELNIQUE...... 138 CONNEX...... 110 TRANSMITTER...... 110 GELNIQUE PUMP...... 138 GLUCOCARD SHINE GUARDIAN REAL-TIME GEL-ONE...... 169 EXPRESS...... 110 SYSTEM...... 110 GELSYN-3...... 169 GLUCOCARD SHINE TEST...110 GUARDIAN SENSOR (3)...... 110 gemcitabine hcl...... 52 GLUCOCARD VITAL TEST....110 GVOKE HYPOPEN 1-PACK...113 gemfibrozil...... 82 GLUCOPHAGE...... 106 GVOKE HYPOPEN 2-PACK...113 GENERESS FE...... 149 GLUCOPHAGE XR...... 106 GVOKE PFS...... 113 generlac...... 133 glucose...... 121 GYNAZOLE-1...... 44 gengraf...... 156 GLUCOTROL...... 106 HAEGARDA...... 156

208 hailey 1.5/30...... 149 HEPLISAV-B...... 161 HW EMBRACE TALK BLOOD hailey 24 fe...... 149 HEPSERA...... 67 GLUCOSE...... 110 hailey fe 1.5/30...... 149 HERCEPTIN...... 53 HW EMBRACE TALK hailey fe 1/20...... 149 HERCEPTIN HYLECTA...... 53 GLUCOSE TEST...... 110 HALAVEN...... 53 HERZUMA...... 53 HYALGAN...... 169 halcinonide...... 101 HESPAN...... 73 HYALUCIL-4...... 101 HALCION...... 71 hetastarch-nacl...... 73 HYCAMTIN...... 53 HALDOL...... 64 HETLIOZ...... 194 hydralazine hcl...... 82 HALDOL DECANOATE...... 64 HEXTEND...... 73 HYDREA...... 53 halobetasol propionate...... 101 HIBERIX...... 161 hydrochlorothiazide...... 82 HALOBETASOL HIDEX 6-DAY...... 141 hydrocodone bitartrate er...... 9 PROPIONATE...... 101 HIPREX...... 27 hydrocodone polst-chlorphen HALOG...... 101 HISTATROL...... 169 polst er susp...... 184 haloperidol...... 64 HIZENTRA...... 156 hydrocodone-acetaminophen9, 10 haloperidol decanoate...... 64 homatropaire...... 181 HYDROCODONE- haloperidol lactate...... 64 homatropine hbr...... 181 GUAIFENESIN...... 184 HARMONY BLOOD HOME PAP KIT...... 169 hydrocodone-homatropine...... 184 GLUCOSE TEST...... 110 HORIZANT...... 93 hydrocodone-ibuprofen...... 10 HARVONI...... 67 HUMALOG KWIKPEN...... 113 hydrocortisone...... 101, 141, 163 HAVRIX...... 161 HUMALOG MIX 50/50 hydrocortisone (perianal)...... 163 heather...... 149 KWIKPEN...... 113 hydrocortisone ace-pramoxine 163 HECTOROL...... 165 HUMALOG MIX 50/50 VIAL....113 hydrocortisone butyr lipo base 101 HELIDAC THERAPY...... 134 HUMALOG MIX 75/25 hydrocortisone butyrate...... 101 HELIXATE FS...... 73 KWIKPEN...... 113 hydrocortisone in absorbase...101 HEMADY...... 141 HUMALOG MIX 75/25 VIAL....113 hydrocortisone valerate...... 101 HEMANGEOL...... 82 HUMALOG U-100 JUNIOR hydrocortisone-acetic acid...... 183 hematinic plus vit/minerals...... 121 KWIKPEN...... 114 hydrogen peroxide...... 27 hematinic/folic acid...... 121 HUMALOG VIAL...... 114 hydromet...... 184 HEMATOGEN...... 121 HUMAN ALBUMIN GRIFOLS. 169 HYDROMORPHONE HCL...... 10 HEMATOGEN FA...... 121 HUMATE-P...... 73 hydromorphone hcl...... 10 HEMATOGEN FORTE...... 121 HUMATROPE...... 144 hydromorphone hcl er...... 10 HEMATRON-AF...... 121 HUMATROPEN FOR 12MG... 169 hydromorphone hcl pf...... 10 HEMLIBRA...... 73 HUMATROPEN FOR 24MG... 169 HYDROMORPHONE HCL- HEMOCYTE PLUS...... 121 HUMATROPEN FOR 6MG..... 169 NACL...... 10 hemocyte-f...... 121 HUMIRA...... 157 HYDROMORPHONE- hemocyte-plus...... 121 HUMIRA PEDIATRIC BUPIVACAINE-NACL...... 10 HEMOFIL M...... 73 CROHNS START...... 156 HYDROMORPHONE- HEPARIN (PORCINE) IN HUMIRA PEN...... 156 ROPIVACAINE-NACL...... 10 NACL...... 33 HUMIRA PEN-CD/UC/HS hydroquinone...... 101 heparin (porcine) in nacl...... 33 STARTER...... 156 hydroquinone time release...... 101 heparin lock flush...... 169 HUMIRA PEN-PS/UV/ADOL hydroxocobalamin acetate...... 121 HEPARIN SOD (PORCINE) IN HS START...... 156 hydroxychloroquine sulfate...... 60 D5W...... 33 HUMULIN 70/30 KWIKPEN.... 114 hydroxyprogesterone caproate149 heparin sod (porcine) in d5w.....33 HUMULIN 70/30 VIAL...... 114 hydroxyurea...... 53 HEPARIN SOD (PORCINE)- HUMULIN N KWIKPEN...... 114 hydroxyzine hcl...... 71 D10...... 33 HUMULIN N VIAL...... 114 hydroxyzine pamoate...... 71 heparin sodium (porcine)...... 33 HUMULIN R U-500 KWIKPEN 114 HYLENEX...... 169 HEPARIN SODIUM HUMULIN R U-500 VIAL...... 114 HYMOVIS...... 169 (PORCINE)...... 33 HUMULIN R VIAL...... 114 hyoscyamine sulfate...... 134 heparin sodium (porcine) pf...... 33 HW EMBRACE PRO hyoscyamine sulfate sl...... 134 heparin sodium flush...... 169 GLUCOSE METER...... 110 HYPERRHO S/D...... 157 heparin sodium lock flush...... 169 HW EMBRACE PRO HYPERSAL...... 184 HEPATAMINE...... 121 GLUCOSE TEST...... 110 HYPNOSOM...... 170

209 HYQVIA...... 157 INDERAL XL...... 82 INTEGRILIN...... 63 HYSINGLA ER...... 10 indigo carmine...... 170 INTELENCE...... 67 HYZAAR...... 82 INDOCIN...... 15 INTERMEZZO...... 194 ibandronate sodium...... 164 indocyanine green...... 170 INTRALIPID...... 122 IBRANCE...... 53 INDOMETHACIN...... 15 INTRAROSA...... 138 IBUDONE...... 10 indomethacin...... 15 INTRON A...... 67 ibudone...... 10 indomethacin er...... 15 introvale...... 149 ibuprofen...... 15 indomethacin sodium...... 15 INTUNIV...... 90 ibuprofen lysine...... 15 INFANRIX...... 161 INULIN...... 170 ibutilide fumarate...... 82 INFASURF...... 184 INVANZ...... 27 IC GREEN...... 170 INFED...... 121 INVEGA...... 64 ICAR-C PLUS...... 121 INFINITY BLOOD GLUCOSE INVEGA SUSTENNA...... 64 icatibant acetate...... 157 TEST...... 111 INVEGA TRINZA...... 64 ICLUSIG...... 53 INFLECTRA...... 157 INVELTYS...... 177 ID NOW COVID-19...... 170 INFUGEM...... 53 INVIRASE...... 67 ID NOW COVID-19 CONTROL INFUMORPH 200...... 10 INVOKAMET...... 106 ...... 170 INFUMORPH 500...... 10 INVOKAMET XR...... 106 IDAMYCIN PFS...... 53 INFUVITE ADULT...... 122 INVOKANA...... 106 idarubicin hcl...... 53 INFUVITE PEDIATRIC...... 122 iodine strong...... 122 IDELVION...... 73 INGREZZA...... 93 IOPIDINE...... 179 IDHIFA...... 53 INJECTAFER...... 122 IPOL...... 161 iferex 150 forte...... 121 INLYTA...... 53 ipratropium bromide...... 185, 188 IFEX...... 53 INNOPRAN XL...... 82 ipratropium-albuterol...... 188 ifosfamide...... 53 INPEN 100-BLUE-LILLY...... 111 irbesartan...... 82 ILARIS...... 157 INPEN 100-BLUE-NOVO...... 111 irbesartan-hydrochlorothiazide..82 ILEVRO...... 177 INPEN 100-GRAY-LILLY...... 111 IRESSA...... 53 ILUMYA...... 157 INPEN 100-GREY-NOVO...... 111 irinotecan hcl...... 53 imatinib mesylate...... 53 INPEN 100-PINK-LILLY...... 111 IS 24/6...... 122 IMBRUVICA...... 53 INPEN 100-PINK-NOVO...... 111 ISENTRESS...... 67 IMFINZI...... 53 INQOVI...... 53 ISENTRESS HD...... 67 imipenem-cilastatin...... 27 INREBIC...... 53 isibloom...... 149 imipramine hcl...... 39 INSET INFUSION SET 23" isoflurane...... 170 imipramine pamoate...... 40 9MM...... 170 isoniazid...... 48 imiquimod...... 101 INSPRA...... 82 isoproterenol hcl...... 82 IMIQUIMOD PUMP...... 101 INSULIN ASP PROT & ASP ISOPTO ATROPINE...... 181 IMITREX...... 47 FLEXPEN...... 114 ISOPTO CARPINE...... 179 IMITREX STATDOSE REFILL..47 INSULIN ASPART...... 114 ISORDIL TITRADOSE...... 82 IMITREX STATDOSE INSULIN ASPART FLEXPEN. 114 isosorbide dinitrate...... 82 SYSTEM...... 47 INSULIN ASPART PENFILL...114 isosorbide dinitrate er...... 82 IMLYGIC...... 53 INSULIN ASPART PROT & isosorbide mononitrate...... 82 IMOVAX RABIES...... 161 ASPART...... 114 isosorbide mononitrate er...... 82 IMPAVIDO...... 60 INSULIN LISPRO...... 114 isosulfan blue...... 170 IMPOYZ...... 101 INSULIN LISPRO (1 UNIT isotretinoin...... 101 IMURAN...... 157 DIAL)...... 114 isradipine...... 82 IMVEXXY MAINTENANCE INSULIN LISPRO JUNIOR ISTALOL...... 179 PACK...... 149 KWIKPEN...... 114 ISTODAX (OVERFILL)...... 53 IMVEXXY STARTER PACK... 149 INSULIN LISPRO PROT & ISTURISA...... 144 INBRIJA...... 61 LISPRO...... 114 ISUPREL...... 82 incassia...... 149 INSULIN PEN NEEDLES...... 114 itraconazole...... 44 INCRELEX...... 144 INSULIN PUMP IR2020...... 170 IV NOVICE PACK...... 18 INCRUSE ELLIPTA...... 188 INSULIN SYRINGES...... 114 IV STABILIZER FOR indapamide...... 82 INTEGRA F...... 122 LUMOXITI...... 170 INDERAL LA...... 82 INTEGRA PLUS...... 122 ivermectin...... 60, 101

210 IXEMPRA KIT...... 53 KCENTRA...... 73 KLARON...... 101 IXIARO...... 161 kedbumin...... 170 klofensaid ii...... 15 IXINITY...... 73 KEFLEX...... 27 KLONOPIN...... 71 JADENU...... 122 kelnor 1/35...... 150 klor-con...... 122 JADENU SPRINKLE...... 122 kelnor 1/50...... 150 klor-con 10...... 122 jaimiess...... 149 KENALOG...... 101, 141 klor-con m10...... 122 JAKAFI...... 53 KENALOG-80...... 141 KLOR-CON M15...... 122 JALYN...... 140 KENGREAL...... 63 klor-con m20...... 122 jantoven...... 33 KEPIVANCE...... 95 klor-con sprinkle...... 122 JANUMET...... 106 KEPPRA...... 35 klor-con/ef...... 122 JANUMET XR...... 106 KEPPRA XR...... 35 KOATE...... 73 JANUVIA...... 106 KERAMATRIX REPLICINE KOATE-DVI...... 73 JARDIANCE...... 106 5CMX5CM...... 101 KOGENATE FS...... 73 jasmiel...... 149 KERLIX AMD KOMBIGLYZE XR...... 106 JATENZO...... 143 ANTIMICROBIAL...... 170 KORLYM...... 147 jencycla...... 149 KERLIX AMD SUPER KOSELUGO...... 54 JENTADUETO...... 106 SPONGES...... 170 KOVALTRY...... 73 JENTADUETO XR...... 106 KERYDIN...... 44 K-PHOS...... 122 JETREA...... 181 KESIMPTA...... 91 K-PHOS-NEUTRAL...... 122 JEVTANA...... 53 KETALAR...... 170 k-prime...... 122 jinteli...... 149 KETAMINE HCL...... 170 KRINTAFEL...... 60 JIVI...... 73 ketamine hcl...... 170 KRISTALOSE...... 134 jolessa...... 150 KETAMINE HCL-SODIUM KROGER HEALTHPRO jolivette...... 150 CHLORIDE...... 170 GLUCOSE TEST...... 111 JORNAY PM...... 90 ketoconazole...... 44 KRYSTEXXA...... 46 J-TIP KIT W/VIAL ADAPTERS170 ketodan...... 44 K-TAB...... 122 JUBLIA...... 44 KETONE TEST...... 111 k-tan plus...... 122 juleber...... 150 KETOPHENE RAPIDPAQ...... 15 kurvelo...... 150 JULUCA...... 67 ketoprofen...... 15 KUVAN...... 136 junel 1.5/30...... 150 ketoprofen er...... 15 k-vescent...... 122 junel 1/20...... 150 KETOROLAC KYBELLA...... 102 junel fe 1.5/30...... 150 TROMETHAMINE...... 15 KYLEENA...... 150 junel fe 1/20...... 150 ketorolac tromethamine.... 15, 177 KYMRIAH...... 157 junel fe 24...... 150 KETOSTIX...... 111 KYNMOBI...... 61 JUXTAPID...... 82 KEVEYIS...... 179 KYNMOBI TITRATION KIT...... 61 JYNARQUE...... 122 KEVZARA...... 157 KYPROLIS...... 54 K.B.G.L IN TERODERM...... 15 KEYTRUDA...... 54 L.E.T...... 18 KABIVEN...... 122 KHAPZORY...... 54 LABETALOL HCL...... 83 KADCYLA...... 53 KHEDEZLA...... 40 labetalol hcl...... 83 KADIAN...... 10 KINERET...... 157 LABETALOL HCL-DEXTROSE 83 kaitlib fe...... 150 KINEVAC...... 170 LABETALOL HCL-SODIUM KALBITOR...... 157 KINRIX...... 161 CHLORIDE...... 83 KALETRA...... 67 kionex...... 122 LAC-HYDRIN...... 102 kalliga...... 150 KISQALI (200 MG DOSE)...... 54 LACRISERT...... 181 KALYDECO...... 191 KISQALI (400 MG DOSE)...... 54 lactated ringers...... 122 KANJINTI...... 54 KISQALI (600 MG DOSE)...... 54 lactic acid...... 102 KANUMA...... 136 KISQALI FEMARA (400 MG lactic acid e...... 102 KAPSPARGO SPRINKLE...... 82 DOSE)...... 54 lactulose...... 134 KAPVAY...... 90 KISQALI FEMARA (600 MG lactulose encephalopathy...... 134 KARBINAL ER...... 185 DOSE)...... 54 L-ALANINE...... 122 kariva...... 150 KISQALI FEMARA(200 MG LAMICTAL...... 35 KATERZIA...... 82 DOSE)...... 54 LAMICTAL ODT...... 35 KAZANO...... 106 KITABIS PAK...... 191 LAMICTAL STARTER...... 35

211 LAMICTAL XR...... 36 LENVIMA (8 MG DAILY L-HISTIDINE lamivudine...... 67 DOSE)...... 54 MONOHYDROCHLORIDE..... 122 lamivudine-zidovudine...... 67 LESCOL XL...... 83 LIALDA...... 163 lamotrigine...... 36 lessina...... 150 LIBRAX...... 134 lamotrigine er...... 36 LETAIRIS...... 191 LIBTAYO...... 55 lamotrigine starter kit-blue...... 36 letrozole...... 54 LICART...... 15 lamotrigine starter kit-green...... 36 LETS...... 18 lidocaine...... 18 lamotrigine starter kit-orange.... 36 leucovorin calcium...... 54 LIDOCAINE HCL...... 18 LAMPIT...... 60 LEUKERAN...... 54 lidocaine hcl...... 18, 95 LANCETS...... 111 LEUKINE...... 73 lidocaine hcl (cardiac)...... 18 LANOXIN...... 83 leuprolide acetate...... 144 lidocaine hcl (cardiac) pf...... 18 LANOXIN PEDIATRIC...... 83 LEUPROLIDE ACETATE- lidocaine hcl (pf)...... 18 lansoprazole...... 132 BUPIVACAINE...... 144 lidocaine hcl urethral/mucosal...18 lanthanum carbonate...... 138 levalbuterol hcl...... 189 LIDOCAINE HCL-SODIUM LANTUS SOLOSTAR...... 114 LEVALBUTEROL HFA...... 189 CHLORIDE...... 19 LANTUS U-100 VIAL...... 114 LEVAQUIN...... 27 LIDOCAINE IN D5W...... 19 lapatinib ditosylate...... 54 LEVEMIR U-100 FLEXTOUCH lidocaine in d5w...... 19 L-ARGININE...... 122 ...... 114 LIDOCAINE IN DEXTROSE..... 19 larin 1.5/30...... 150 LEVEMIR U-100 VIAL...... 114 lidocaine pak...... 19 larin 1/20...... 150 levetiracetam...... 36 lidocaine viscous hcl...... 95 larin 24 fe...... 150 levetiracetam er...... 36 lidocaine-epinephrine...... 19 larin fe 1.5/30...... 150 levetiracetam in nacl...... 36 lidocaine-prilocaine...... 19 larin fe 1/20...... 150 LEVITRA...... 139 LIDOCAINE-SODIUM larissia...... 150 levobunolol hcl...... 179 BICARBONATE...... 19 LARTRUVO...... 54 LEVOCARNITINE...... 122 LIDOCAINE-TETRACAINE...... 19 LASIX...... 83 levocarnitine...... 122 LIDODERM...... 19 LASTACAFT...... 181 levocarnitine sf...... 122 LIDO-EPINEPHRINE- latanoprost...... 179 levocetirizine dihydrochloride..185 TETRACAINE...... 19 LATISSE...... 181 levofloxacin...... 27, 177 LIDOPROFEN...... 16 LATUDA...... 64 levofloxacin in d5w...... 27 LIDTOPIC MAX...... 19 layolis fe...... 150 LEVOLEUCOVORIN LILETTA (52 MG)...... 150 LAZANDA...... 10 CALCIUM...... 55 lillow...... 150 L-CYSTINE...... 122 levoleucovorin calcium...... 55 LIMBREL...... 170 LDL CARE...... 170 levoleucovorin calcium pf...... 55 LIMBREL250...... 170 LEDIPASVIR-SOFOSBUVIR.... 67 levonest...... 150 LIMBREL500...... 171 leena...... 150 levonorgest-eth est & eth est.. 150 LINCOCIN...... 27 leflunomide...... 157 levonorgest-eth estrad 91-day 150 lincomycin hcl...... 27 LEMTRADA...... 91 levonorgestrel-ethinyl estrad...150 lindane...... 60 LENVIMA (10 MG DAILY levonorg-eth estrad triphasic...150 linezolid...... 27 DOSE)...... 54 LEVOPHED...... 83 linezolid in sodium chloride...... 27 LENVIMA (12 MG DAILY levora 0.15/30 (28)...... 150 LINZESS...... 134 DOSE)...... 54 levorphanol tartrate...... 10 LIORESAL...... 193 LENVIMA (14 MG DAILY levo-t...... 153 liothyronine sodium...... 154 DOSE)...... 54 levothyroxine sodium...... 154 LIPICHOL 540...... 171 LENVIMA (18 MG DAILY levoxyl...... 154 LIPITOR...... 83 DOSE)...... 54 LEVULAN KERASTICK...... 102 LIPO...... 122 LENVIMA (20 MG DAILY LEXAPRO...... 40 LIPO-B...... 122 DOSE)...... 54 LEXETTE...... 102 LIPO-C...... 123 LENVIMA (24 MG DAILY LEXISCAN...... 170 lipodox 50...... 55 DOSE)...... 54 LEXIVA...... 67 LIPOFEN...... 83 LENVIMA (4 MG DAILY L-GLUTAMIC ACID...... 122 lisinopril...... 83 DOSE)...... 54 L-GLUTAMIC ACID HCL...... 136 lisinopril-hydrochlorothiazide.....83 L-ISOLEUCINE...... 123

212 lissamine green...... 181 lorcet plus...... 11 LYRICA...... 93 LISTER-V...... 171 LORTAB...... 11 LYRICA CR...... 93 lithium...... 72 loryna...... 150 LYSINE HCL...... 123 lithium carbonate...... 72 LORZONE...... 193 lysiplex plus...... 123 lithium carbonate er...... 72 losartan potassium...... 83 LYSODREN...... 55 LITHOBID...... 72 LOSARTAN POTASSIUM...... 171 LYSTEDA...... 74 LITHOSTAT...... 139 losartan potassium-hctz...... 83 LYUMJEV...... 114 LIVALO...... 83 LOSEASONIQUE...... 150 LYUMJEV KWIKPEN...... 115 L-LEUCINE...... 123 LOTEMAX...... 177, 178 lyza...... 150 LMD IN D5W...... 73 LOTEMAX SM...... 178 M.V.I. ADULT...... 123 LMD IN NACL...... 73 LOTENSIN...... 83 M.V.I. PEDIATRIC...... 123 L-METHIONINE...... 123 LOTENSIN HCT...... 83 MACROBID...... 27 l-methylfolate...... 123 loteprednol etabonate...... 178 MACRODANTIN...... 27 l-methylfolate ca me-cbl nac... 123 LOTREL...... 83 MACUTEK...... 171 l-methylfolate calcium...... 123 LOTRISONE...... 44 mafenide acetate...... 27 l-methylfolate forte...... 123 LOTRONEX...... 134 MAGNEBIND 400...... 123 L-METHYLFOLATE FORTE... 123 lovastatin...... 83 MAGNESIUM CARBONATE.. 123 l-methylfolate-algae...... 123 LOVAZA...... 83 MAGNESIUM CARBONATE l-methylfolate-algae-b12-b6.... 123 LOVENOX...... 33 HEAVY...... 123 l-methylfolate-b6-b12...... 123 low-ogestrel...... 150 magnesium chloride...... 123 L-METHYL-MC...... 123 loxapine succinate...... 64 MAGNESIUM SULFATE...... 124 L-METHYL-MC NAC...... 123 lo-zumandimine...... 150 magnesium sulfate...... 124 LO LOESTRIN FE...... 150 L-PHENYLALANINE...... 123 magnesium sulfate in d5w...... 123 LOCOID...... 102 L-PROLINE...... 123 MAGNESIUM SULFATE IN LOCOID LIPOCREAM...... 102 L-TRYPTOPHAN...... 123 D5W...... 124 LODINE...... 16 L-TYROSINE...... 123 MAGNESIUM SULFATE-LACT LODOSYN...... 62 LUCEMYRA...... 21 RINGERS...... 124 LOESTRIN 1.5/30 (21)...... 150 LUCENTIS...... 181 MAGNESIUM SULFATE- LOESTRIN 1/20 (21)...... 150 lugols...... 27 NACL...... 124 LOESTRIN FE 1.5/30...... 150 LULICONAZOLE...... 44 MAKENA...... 150 LOESTRIN FE 1/20...... 150 LUMIGAN...... 180 MALARONE...... 60 lojaimiess...... 150 LUMIZYME...... 136 malathion...... 60 LOKELMA...... 123 LUMOXITI...... 55 MANGANESE CHLORIDE..... 124 LOMAIRA...... 93 LUNESTA...... 194 mannitol...... 83 LOMOTIL...... 134 LUPANETA PACK...... 144 maprotiline hcl...... 40 LONHALA MAGNAIR REFILL LUPRON DEPOT (1-MONTH) 145 MARCAINE...... 19 KIT...... 189 LUPRON DEPOT (3-MONTH) 145 MARCAINE PRESERVATIVE LONHALA MAGNAIR LUPRON DEPOT (4-MONTH) FREE...... 19 STARTER KIT...... 189 INTRAMUSCULAR KIT 30MG 145 MARCAINE SPINAL...... 19 LONSURF...... 55 LUPRON DEPOT (6-MONTH) MARCAINE/EPINEPHRINE...... 19 loperamide hcl...... 134 INTRAMUSCULAR KIT 45MG 145 MARCAINE/EPINEPHRINE LOPID...... 83 LUPRON DEPOT-PED (1- PF...... 19 lopinavir-ritonavir...... 67 MONTH)...... 145 MARINOL...... 42 lopreeza...... 150 LUPRON DEPOT-PED (3- marlissa...... 150 LOPRESSOR...... 83 MONTH)...... 145 MARPLAN...... 40 LOPRESSOR HCT...... 83 lutera...... 150 MARQIBO...... 55 LOPROX...... 44 LUXIQ...... 102 MATULANE...... 55 lorazepam...... 71 LUZU...... 44 matzim la...... 83 lorazepam intensol...... 71 L-VALINE...... 123 MAVENCLAD (10 TABS)...... 91 LORAZEPAM-DEXTROSE...... 71 LYNPARZA...... 55 MAVENCLAD (4 TABS)...... 91 LORBRENA...... 55 LYRA DIRECT SARS-COV-2 MAVENCLAD (5 TABS)...... 91 lorcet...... 11 ASSAY...... 171 MAVENCLAD (6 TABS)...... 91 lorcet hd...... 11 LYRA SARS-COV-2 ASSAY...171 MAVENCLAD (7 TABS)...... 91

213 MAVENCLAD (8 TABS)...... 92 MEROPENEM-SODIUM methylphenidate hcl er (la)...... 90 MAVENCLAD (9 TABS)...... 92 CHLORIDE...... 27 methylphenidate hcl er (xr)...... 90 MAVYRET...... 67 MERREM...... 27 methylprednisolone...... 142 MAXALT...... 47 mesalamine...... 163 METHYLPREDNISOLONE MAXALT-MLT...... 47 mesalamine er...... 163 ACETATE...... 142 MAXFE...... 124 mesalamine-cleanser...... 163 methylprednisolone acetate.... 142 MAXICOMFORT SYR 27G X mesna...... 55 methylprednisolone sodium 1/2"...... 115 MESNEX...... 55 succ...... 142 MAXIDEX...... 178 MESTINON...... 48 METHYLPREDNISOLONE- MAXIPIME...... 27 metadate er...... 90 BUPIVACAINE...... 142 MAXITROL...... 181 METAFOLBIC...... 124 methyltestosterone...... 143 maxi-tuss ac...... 185 METAFOLBIC PLUS...... 124 METHYLTESTOSTERONE.... 143 MAXZIDE...... 83 METAFOLBIC PLUS RF...... 124 metoclopramide hcl...... 42 MAXZIDE-25...... 83 METANX...... 124 metolazone...... 83 MAYZENT...... 92 metaproterenol sulfate...... 189 metoprolol succinate er...... 83 MAYZENT STARTER PACK.... 92 METASTRON...... 55 metoprolol tartrate...... 84 MEBOLIC...... 171 metaxall...... 193 METOPROLOL TARTRATE..... 84 meclizine hcl...... 42 metaxalone...... 193 METOPROLOL-HCTZ ER...... 84 meclofenamate sodium...... 16 metformin hcl er...... 106 metoprolol-hydrochlorothiazide.84 MEDACTIV...... 171 metformin hcl er (mod)...... 106 METROCREAM...... 102 MEDROL...... 141 metformin hcl er (osm)...... 106 METROGEL...... 102 MEDROX-RX...... 11 metformin hcl ir...... 106 METROGEL-VAGINAL...... 28 medroxyprogesterone acetate METHACHOLINE CHLORIDE 171 METROLOTION...... 102 ...... 150, 151 methadone hcl...... 11 METRONIDAZOLE...... 28 mefenamic acid...... 16 methadone hcl intensol...... 11 metronidazole...... 28, 102 mefloquine hcl...... 60 METHADONE HCL-NACL...... 11 METRONIDAZOLE MEGACE ES...... 151 methadose...... 11 BENZO+SYRSPEND...... 28 megestrol acetate...... 151 methadose sugar-free...... 11 metronidazole in nacl...... 28 MEKINIST...... 55 methamphetamine hcl...... 90 metyrosine...... 84 MEKTOVI...... 55 methazolamide...... 180 mexiletine hcl...... 84 melodetta 24 fe...... 151 methenamine hippurate...... 27 MI PASTE...... 95 meloxicam...... 16 methergine...... 171 MI PASTE PLUS...... 95 melphalan...... 55 methimazole...... 154 MIACALCIN...... 164 melphalan hcl...... 55 METHIONINE...... 124 mibelas 24 fe...... 151 memantine hcl...... 38 METHITEST...... 143 micafungin sodium...... 44 memantine hcl er...... 38 methocarbamol...... 193 MICARDIS...... 84 MEMBRANEBLUE...... 182 METHOHEXITAL SODIUM.....171 MICARDIS HCT...... 84 MENACTRA...... 161 methotrexate...... 157 miconazole 3...... 44 MENEST...... 151 methotrexate sodium...... 157 MICONAZOLE-ZINC OXIDE- MENOSTAR...... 151 methotrexate sodium (pf)...... 157 PETROLAT...... 44 MENQUADFI...... 161 methoxsalen rapid...... 102 MICORT-HC...... 102 MENTAX...... 44 methscopolamine bromide...... 134 MICRHOGAM ULTRA- MENVEO...... 161 methyclothiazide...... 83 FILTERED PLUS...... 157 meperidine hcl...... 11 METHYLCOBALAMIN...... 124 MICROCYN...... 102 MEPERIDINE HCL-SODIUM methyldopa...... 83 MICRODOT TEST...... 111 CHLORIDE...... 11 methyldopa- microgestin 1.5/30...... 151 MEPHYTON...... 124 hydrochlorothiazide...... 83 microgestin 1/20...... 151 meprobamate...... 71 methylergonovine maleate...... 171 microgestin fe 1.5/30...... 151 MEPRON...... 60 methylfol-algae-b12-acetylcyst124 microgestin fe 1/20...... 151 MEPSEVII...... 136 METHYLIN...... 90 MICROLET NEXT LANCING mercaptopurine...... 55 methylphenidate hcl...... 90 DEVICE...... 111 meropenem...... 27 methylphenidate hcl er...... 90 MIDAZOLAM...... 71 methylphenidate hcl er (cd)...... 90 midazolam hcl...... 71

214 MIDAZOLAM HCL...... 71 MINIVELLE...... 151 MORPHINE SULFATE IN midazolam hcl (pf)...... 71 MINOCIN...... 28 DEXTROSE...... 11 MIDAZOLAM HCL- minocycline hcl...... 28 MORPHINE SULFATE-NACL...12 DEXTROSE...... 71 MINOCYCLINE HCL ER...... 28 MOTEGRITY...... 134 MIDAZOLAM HCL-SODIUM minocycline hcl er...... 28 MOTOFEN...... 134 CHLORIDE...... 71 MINOLIRA...... 28 MOVANTIK...... 134 MIDAZOLAM+SYRSPEND SF. 71 minoxidil...... 84 MOVIPREP...... 134 MIDAZOLAM-SODIUM MIOCHOL-E...... 182 MOXEZA...... 178 CHLORIDE...... 71 MIRAPEX...... 62 MOXIFLOXACIN HCL...... 28 midodrine hcl...... 84 MIRAPEX ER...... 62 moxifloxacin hcl...... 28, 178 MIGERGOT...... 47 MIRCERA...... 74 moxifloxacin hcl (2x day)...... 178 miglitol...... 106 MIRCETTE...... 151 moxifloxacin hcl in nacl...... 28 miglustat...... 136 MIRENA (52 MG)...... 151 MOZOBIL...... 74 MIGRANAL...... 47 mirtazapine...... 40 MS CONTIN...... 12 mili...... 151 MIRVASO...... 102 MULPLETA...... 74 MILLIPRED...... 142 misoprostol...... 132 MULTAQ...... 84 MILLIPRED DP...... 142 MITIGARE...... 46 MULTIGEN...... 125 MILLIPRED DP 12-DAY...... 142 mitigo...... 11 MULTIGEN FOLIC...... 125 milrinone lactate...... 84 mitomycin...... 55 MULTIGEN PLUS...... 125 milrinone lactate in dextrose..... 84 MITOSOL...... 178 multi-vit/iron/fluoride...... 125 mimvey...... 151 mitoxantrone hcl...... 55 multivitamin/fluoride...... 125 mimvey lo...... 151 M-M-R II...... 161 MULTIVITAMIN/FLUORIDE... 125 MIMYX...... 102 M-NATAL PLUS...... 124 multi-vitamin/fluoride...... 125 MINASTRIN 24 FE...... 151 MOBIC...... 16 multi-vitamin/fluoride/iron...... 125 mineral oil heavy...... 134 modafinil...... 194 multivitamins/fluoride...... 125 MINIMED 530G INSULIN moderiba...... 67 mupirocin...... 28 PUMP...... 171 MODERIBA (1200 MG PACK)..67 mupirocin calcium...... 28 MINIMED 770G INSULIN moexipril hcl...... 84 MUSE...... 139 PUMP SYS...... 171 molindone hcl...... 64 mutamycin...... 55 MINIMED GUARDIAN mometasone furoate...... 102, 185 MVASI...... 55 SENSOR 3...... 111 mondoxyne nl...... 28 MYALEPT...... 136 MINIMED MIO ADVANCE MONJUVI...... 55 MYAMBUTOL...... 48 INFUSE SET...... 171 MONOCLATE-P...... 74 MYCAMINE...... 44 MINIMED MIO INFUSION SET MONOFERRIC...... 125 MYCAPSSA...... 145 ...... 171 monoject flush syringe...... 125 MYCOBUTIN...... 48 MINIMED PRO-SET MONOJECT HYPODERMIC mycophenolate mofetil...... 157 INFUSION 24"...... 171 NEEDLE...... 115 mycophenolate mofetil hcl...... 157 MINIMED PUMP RESERVOIR monoject sodium chloride flush mycophenolate sodium...... 157 3ML...... 171 ...... 125 MYDAYIS...... 90 MINIMED QUICK SET INF mono-linyah...... 151 MYDRIACYL...... 182 SET 18"...... 171 mononessa...... 151 myferon 150 forte...... 125 MINIMED QUICK SET INF MONONINE...... 74 MYFORTIC...... 157 SET 23"...... 171 MONOVISC...... 171 MYLERAN...... 55 MINIMED QUICK SET INF montelukast sodium...... 189 MYLOTARG...... 55 SET 32"...... 171 MONUROL...... 28 mynephrocaps...... 125 MINIMED QUICK SET INF morgidox...... 28 MYNEPHRON...... 125 SET 43"...... 171 MORPHABOND ER...... 11 MYOBLOC...... 171 MINIMED SILHOUETTE INF MORPHINE SULFATE...... 11, 12 myorisan...... 102 SET 32"...... 171 morphine sulfate...... 12 MYRBETRIQ...... 139 MINIMED SILHOUETTE INF morphine sulfate (concentrate). 11 MYSOLINE...... 36 SET 43"...... 171 morphine sulfate (pf)...... 11 MYTESI...... 134 MINIPRESS...... 84 morphine sulfate er...... 11 MYXREDLIN...... 115 minitran...... 84 morphine sulfate er beads...... 11 myzilra...... 151

215 na ferric gluc cplx in sucrose...125 NAVELBINE...... 55 NEVANAC...... 178 nabumetone...... 16 NAYZILAM...... 36 nevirapine...... 67 n-acetyl-l-cysteine...... 125 NEBUPENT...... 60 nevirapine er...... 67 nadolol...... 84 nebusal...... 185 NEXAVAR...... 55 nadolol-bendroflumethiazide.....84 NEBUSAL...... 185 NEXAVIR...... 171 nafcillin sodium...... 28 necon 0.5/35 (28)...... 151 NEXIUM...... 132 NAFCILLIN SODIUM IN nefazodone hcl...... 40 NEXIUM I.V...... 132 DEXTROSE...... 28 NEMBUTAL...... 36 NEXLETOL...... 84 nafrinse...... 125 NEOKE ALCAR...... 125 NEXLIZET...... 84 NAFRINSE DAILY NEOKE BCAA4...... 171 NEXPLANON...... 151 ACIDULATED...... 95 NEOKE BHB...... 171 NEXTERONE...... 84 NAFRINSE DAILY/NEUTRAL...95 NEOKE RA LIPOIC...... 171 niacin (antihyperlipidemic)...... 84 nafrinse drops...... 125 neomycin sulfate...... 28 niacin er (antihyperlipidemic).... 84 NAFRINSE WEEKLY...... 95 neomycin-bacitracin zn- niacor...... 84 naftifine hcl...... 45 polymyx...... 182 NIASPAN...... 84 NAFTIN...... 45 neomycin-polymyxin b gu...... 28 NICAPRIN...... 172 NAGLAZYME...... 136 neomycin-polymyxin-dexameth nicardipine hcl...... 84, 85 nalbuphine hcl...... 12 ...... 182 NICARDIPINE HCL IN NALFON...... 16 neomycin-polymyxin- DEXTROSE...... 84 NALOCET...... 12 gramicidin...... 182 NICARDIPINE HCL IN NACL... 84 naloxone hcl...... 21 neomycin-polymyxin-hc.. 182, 183 NICAZYME...... 172 NALOXONE HCL...... 21 NEONATAL 19...... 125 NICOMIDE...... 125 naltrexone hcl...... 21 NEONATAL PLUS...... 125 NICOTROL...... 21 NAMENDA...... 38 NEOPHE...... 171 NICOTROL NS...... 21 NAMENDA TITRATION PAK....38 neo-polycin...... 182 nifedipine...... 85 NAMENDA XR...... 38 neo-polycin hc...... 182 NIFEDIPINE...... 172 NAMENDA XR TITRATION NEOPROFEN...... 16 nifedipine er...... 85 PACK...... 38 NEORAL...... 157 nifedipine er osmotic release.... 85 NAMZARIC...... 38 neostigmine methylsulfate...... 48 NIFEDIPINE MICRONIZED.... 172 NANDROLONE DECANOATE143 NEOSTIGMINE NIFEREX...... 125 NAPRELAN...... 16 METHYLSULFATE...... 48 nikki...... 151 NAPRO...... 16 NEO-SYNALAR...... 102 NILANDRON...... 55 NAPROSYN...... 16 NEOTUSS PLUS...... 185 nilutamide...... 55 naproxen...... 16 NEOVITE...... 125 NIMBEX...... 93 NAPROXEN COMFORT PAC.. 16 NEPHPLEX RX...... 125 nimodipine...... 85 naproxen dr...... 16 NEPHRAMINE...... 125 NINLARO...... 55 naproxen sodium...... 16 NEPHRON FA...... 125 NIPENT...... 56 naproxen sodium er...... 16 nephronex...... 125 nisoldipine er...... 85 naproxen-esomeprazole...... 16 NEPHRO-VITE RX...... 125 NITHIODOTE...... 172 naratriptan hcl...... 47 NERLYNX...... 55 nitisinone...... 136 NARCAN...... 21 NESACAINE...... 19 NITRO-BID...... 85 NARDIL...... 40 NESACAINE-MPF...... 19 NITRO-DUR...... 85 NAROPIN...... 19 NESINA...... 106 nitrofurantoin...... 28 NASCOBAL...... 125 NESTABS...... 125 nitrofurantoin macrocrystal...... 28 NASONEX...... 185 neuac...... 102 nitrofurantoin monohydrate NATACYN...... 178 NEULASTA...... 74 macrocrystals...... 28 NATAZIA...... 151 NEULASTA ONPRO...... 74 nitroglycerin...... 85 nateglinide...... 106 NEUPOGEN...... 74 nitroglycerin in d5w...... 85 NATESTO...... 143 NEUPRO...... 62 NITROLINGUAL...... 85 NATPARA...... 165 NEURAPTINE...... 93 NITROMIST...... 85 NATRECOR...... 84 NEUREPA...... 171 NITROPRESS...... 85 NATROBA...... 60 NEURIN-SL...... 125 nitroprusside sodium...... 85 NATURE-THROID...... 154 NEURONTIN...... 36 NITROSTAT...... 85

216 NITRO-TIME...... 85 NOVOLIN 70/30 FLEXPEN.... 115 NUVARING...... 152 NITYR...... 136 NOVOLIN 70/30 FLEXPEN NUVESSA...... 28 niva-fol...... 172 RELION...... 115 NUVIGIL...... 194 NIVESTYM...... 74 NOVOLIN 70/30 RELION...... 115 NUWIQ...... 74 nizatidine...... 132 NOVOLIN 70/30 VIAL...... 115 NUZYRA...... 28 NIZORAL...... 45 NOVOLIN N FLEXPEN...... 115 nyamyc...... 45 NOCDURNA...... 145 NOVOLIN N FLEXPEN NYMALIZE...... 85 NOCTIVA...... 145 RELION...... 115 nystatin...... 45 nolix...... 102 NOVOLIN N RELION...... 115 nystatin-triamcinolone...... 45 nora-be...... 151 NOVOLIN N VIAL...... 115 nystop...... 45 NORCO...... 12 NOVOLIN R FLEXPEN...... 115 OBIZUR...... 74 NORDIPEN 5 INJECTION NOVOLIN R FLEXPEN OCALIVA...... 136 DEVICE...... 172 RELION...... 115 ocella...... 152 NORDITROPIN FLEXPRO..... 145 NOVOLIN R RELION...... 115 OCREVUS...... 92 norepinephrine bitartrate...... 85 NOVOLIN R VIAL...... 115 OCTAGAM...... 157 NOREPINEPHRINE- NOVOLOG FLEXPEN...... 115 OCTAPLAS BLOOD GROUP DEXTROSE...... 85 NOVOLOG MIX 70/30 A...... 172 NOREPINEPHRINE-SODIUM FLEXPEN...... 115 OCTAPLAS BLOOD GROUP CHLORIDE...... 85 NOVOLOG MIX 70/30 VIAL....115 AB...... 172 norethin ace-eth estrad-fe...... 151 NOVOLOG PENFILL...... 115 OCTAPLAS BLOOD GROUP norethindrone...... 151 NOVOLOG U-100 VIAL...... 115 B...... 172 norethindrone acetate...... 151 NOVOPEN ECHO...... 111 OCTAPLAS BLOOD GROUP norethindrone acet-ethinyl est.151 NOVOSEVEN RT...... 74 O...... 172 norethindrone-eth estradiol..... 151 NOVOTWIST PEN NEEDLE.. 115 octreotide acetate...... 145 norethin-eth estradiol-fe...... 151 NOXAFIL...... 45 OCUFLOX...... 178 NORGESIC FORTE...... 193 NOZIN NASAL SANITIZER ODEFSEY...... 67 norgestimate-eth estradiol...... 151 POPSWAB...... 172 ODOMZO...... 56 norgestimate-ethinyl estradiol NP #2 DRUG PREPARATION OFEV...... 189 triphasic...... 151 KIT...... 16 ofloxacin...... 29, 178, 183 NORITATE...... 102 np thyroid...... 154 ogestrel...... 152 norlyda...... 151 NPLATE...... 74 OGIVRI...... 56 norlyroc...... 152 NUBEQA...... 56 okebo...... 29 normal saline flush...... 125 NUCALA...... 185 olanzapine...... 64 NORM-JECT LUER SLIP NUCYNTA...... 12 olanzapine-fluoxetine hcl...... 40 SYRINGE...... 172 NUCYNTA ER...... 12 olmesartan medoxomil...... 86 NORPACE...... 85 NUEDEXTA...... 93 olmesartan medoxomil-hctz...... 86 NORPACE CR...... 85 NUFERA...... 125 olmesartan-amlodipine-hctz...... 86 NORPRAMIN...... 40 nufol...... 125 olopatadine hcl...... 178, 185 NORTHERA...... 85 NUFOLA...... 125 OLUMIANT...... 158 nortrel 0.5/35 (28)...... 152 NULEV...... 134 OLUX...... 102 nortrel 1/35 (21)...... 152 NULOJIX...... 157 OLUX-E...... 102 nortrel 1/35 (28)...... 152 NULYTELY LEMON-LIME...... 134 OMECLAMOX-PAK...... 134 nortrel 7/7/7...... 152 NULYTELY WITH FLAVOR omega-3-acid ethyl esters...... 86 nortriptyline hcl...... 40 PACKS...... 134 omeppi...... 132 NORVASC...... 85 NUPLAZID...... 64 omeprazole...... 132 NORVIR...... 67 NURTEC...... 47 OMEPRAZOLE+SYRSPEND NOURIANZ...... 62 NUTRICAP...... 126 SF ALKA...... 132 NOVOEIGHT...... 74 nutrifac zx...... 126 omeprazole-sodium NOVOFINE AUTOCOVER nutrilipid...... 126 bicarbonate...... 132 PEN NEEDLE...... 115 NUTRIVIT...... 126 OMNARIS...... 185 NOVOFINE PEN NEEDLE..... 115 NUTROPIN AQ NUSPIN 10... 145 OMNIPOD 5 PACK...... 172 NOVOFINE PLUS PEN NUTROPIN AQ NUSPIN 20... 145 OMNIPOD DASH 5 PACK NEEDLE...... 115 NUTROPIN AQ NUSPIN 5..... 145 PODS...... 172

217 OMNIPOD DASH SYSTEM.... 111 ORBACTIV...... 29 OXYCODONE- OMNIPOD STARTER...... 111 ORENCIA...... 158 ACETAMINOPHEN...... 12 OMNIPRED...... 178 ORENCIA CLICKJECT...... 158 oxycodone-acetaminophen...... 12 OMNITROPE...... 145 ORENITRAM...... 191 oxycodone-aspirin...... 12 OMNIVEX...... 172 ORFADIN...... 136 oxycodone-ibuprofen...... 13 ONCASPAR...... 56 ORIAHNN...... 152 OXYCONTIN...... 13 ondansetron hcl...... 42 ORILISSA...... 145 oxymorphone hcl...... 13 ONDANSETRON HCL...... 42 ORKAMBI...... 191 oxymorphone hcl er...... 13 ONDANSETRON HCL- orphenadrine citrate...... 193 oxytocin...... 145 DEXTROSE...... 42 orphenadrine citrate er...... 193 OXYTOCIN-DEXTROSE...... 145 ONDANSETRON HCL-NACL... 42 orphenadrine-asa-caffeine...... 193 OXYTOCIN-DEXTROSE- ondansetron odt...... 42 orphenadrine-aspirin-caffeine. 193 LACT RINGERS...... 146 ONE DROP BLOOD ORPHENGESIC FORTE...... 193 OXYTOCIN-LACTATED GLUCOSE MONITOR...... 111 orsythia...... 152 RINGERS...... 146 ONE DROP TEST...... 111 ORTHO MICRONOR...... 152 OXYTOCIN-SODIUM ONE VITE WOMENS PLUS... 126 ORTHO TRI-CYCLEN (28)..... 152 CHLORIDE...... 146 ONETOUCH DELICA ORTHO TRI-CYCLEN LO...... 152 OXYTROL...... 139 LANCING DEV...... 111 ORTHO-CYCLEN (28)...... 152 OZEMPIC...... 107 ONETOUCH DELICA PLUS ORTHO-NOVUM 1/35 (28)..... 152 OZOBAX...... 193 LANCING...... 111 ORTHO-NOVUM 7/7/7 (28).... 152 OZURDEX...... 178 ONETOUCH ULTRA...... 111 ORTHOVISC...... 172 PACERONE...... 86 ONETOUCH ULTRA 2 KIT ORTIKOS...... 163 paclitaxel...... 56 W/DEVICE...... 111 oscimin...... 134 PADCEV...... 56 ONETOUCH ULTRA MINI KIT oseltamivir phosphate...... 67 paliperidone er...... 64 W/DEVICE...... 111 OSENI...... 107 palonosetron hcl...... 42 ONETOUCH VERIO FLEX OSMITROL...... 86 PALYNZIQ...... 136 SYSTEM KIT W/DEVICE...... 111 OSMOLEX ER...... 62 PAMELOR...... 40 ONETOUCH VERIO IQ OSMOPREP...... 134 pamidronate disodium...... 164 SYSTEM...... 111 OSPHENA...... 144 PANCREAZE...... 136 ONETOUCH VERIO KIT OTEZLA...... 158 pancuronium bromide...... 93 W/DEVICE...... 111 OTOVEL...... 183 PANDEL...... 102 ONETOUCH VERIO OTREXUP...... 158 PANHEMATIN...... 74 REFLECT...... 111 OVIDE...... 60 PANRETIN...... 56 ONETOUCH VERIO SYNC oxacillin sodium...... 29 pantoprazole sodium...... 132 SYSTEM KIT W/DEVICE...... 111 OXACILLIN SODIUM IN PANZYGA...... 158 ONEXTON...... 102 DEXTROSE...... 29 PARADIGM INSULIN PUMP.. 172 ONFI...... 36 oxaliplatin...... 56 PARADIGM QUICK-SET 23" ONGENTYS...... 62 oxandrolone...... 143 9MM...... 172 ONGLYZA...... 107 oxaprozin...... 16 PARADIGM REAL-TIME ONIVYDE...... 56 OXAYDO...... 12 STARTER...... 111 ONPATTRO...... 93 oxazepam...... 71 PARAGARD INTRAUTERINE ONTRUZANT...... 56 OXBRYTA...... 172 COPPER...... 152 ONUREG...... 56 oxcarbazepine...... 36 paraplatin...... 56 ONZETRA XSAIL...... 47 OXERVATE...... 182 PAREMYD...... 182 OPANA...... 12 oxiconazole nitrate...... 45 paricalcitol...... 165 OPDIVO...... 56 OXISTAT...... 45 PARLODEL...... 62 OPSUMIT...... 191 OXSORALEN ULTRA...... 102 PARNATE...... 40 ORABLOC...... 19 OXTELLAR XR...... 36 paroex...... 95 ORACEA...... 102 oxybutynin chloride...... 139 paromomycin sulfate...... 29 ORACIT...... 126 oxybutynin chloride er...... 139 paroxetine hcl...... 40 oralone...... 95 oxycodone hcl...... 12 paroxetine hcl er...... 40 ORAPRED ODT...... 142 OXYCODONE HCL ER...... 12 paroxetine mesylate...... 40 ORAVIG...... 45 PARSABIV...... 165

218 PASER...... 48 PERSERIS...... 64 pioglitazone hcl-glimepiride.....107 PATADAY...... 178 PERTZYE...... 136 pioglitazone hcl-metformin hcl 107 PATANASE...... 185 PEXEVA...... 40 piperacillin sod-tazobactam so..29 PATANOL...... 178 PFIZERPEN...... 29 PIQRAY (200 MG DAILY PAXIL...... 40 PH STRIPS...... 172 DOSE)...... 56 PAXIL CR...... 40 phenadoz...... 185 PIQRAY (250 MG DAILY PAZEO...... 178 phenazo...... 139 DOSE)...... 56 PEDIAPRED...... 142 phenazopyridine hcl...... 139 PIQRAY (300 MG DAILY PEDIARIX...... 161 phendimetrazine tartrate...... 93 DOSE)...... 56 PEDVAX HIB...... 161 phendimetrazine tartrate er...... 93 pirmella 1/35...... 152 peg 3350/electrolytes...... 134 phenelzine sulfate...... 40 pirmella 7/7/7...... 152 peg 3350-kcl-na bicarb-nacl....135 PHENERGAN...... 185 piroxicam...... 16 peg-3350/electrolytes...... 135 phenobarbital...... 36 PITOCIN...... 146 peg-3350/electrolytes/ascorbat phenobarbital sodium...... 36 PLAQUENIL...... 61 ...... 135 phenoxybenzamine hcl...... 86 PLASBUMIN-25...... 172 PEGANONE...... 36 phentermine hcl...... 93 PLASBUMIN-5...... 172 PEGASYS...... 68 phentolamine mesylate...... 86 PLASMANATE...... 172 PEGASYS PROCLICK...... 68 PHENYLEPHRINE HCL...... 86 PLAVIX...... 63 PEGINTRON...... 68 phenylephrine hcl...... 86, 182 PLEGRIDY...... 92 peg-kcl-nacl-nasulf-na asc-c... 135 PHENYLEPHRINE HCL PLEGRIDY STARTER PACK... 92 peg-prep...... 135 (PRESSORS)...... 86 PLENAMINE...... 126 PEMAZYRE...... 56 PHENYLEPHRINE HCL- PLENVU...... 135 penicillamine...... 139 DEXTROSE...... 86 PLIAGLIS...... 19 PENICILLIN G POT IN PHENYLEPHRINE HCL-NACL.86 PNEUMOVAX 23...... 162 DEXTROSE...... 29 PHENYTEK...... 36 PODIAPN...... 126 penicillin g potassium...... 29 phenytoin...... 36 podofilox...... 102 penicillin g procaine...... 29 phenytoin infatabs...... 36 POLIVY...... 56 penicillin g sodium...... 29 phenytoin sodium...... 36 polocaine...... 19 penicillin v potassium...... 29 phenytoin sodium extended...... 36 polocaine-mpf...... 19 PENLAC...... 45 PHESGO...... 56 polycin...... 182 PENNSAID...... 16 PHEXXI...... 172 POLYFIN INFUSION SET 42" 172 PENTACEL...... 162 philith...... 152 poly-iron 150 forte...... 126 PENTAM...... 61 PHOSLYRA...... 139 polymyxin b sulfate...... 29 pentamidine isethionate...... 61 PHOSPHA 250 NEUTRAL...... 126 polymyxin b-trimethoprim...... 182 PENTASA...... 163 PHOSPHOLINE IODIDE...... 180 polysaccharide iron forte...... 126 pentazocine-naloxone hcl...... 13 phosphorous...... 126 POLYTRIM...... 182 PENTETATE CALCIUM phospho-trin 250 neutral...... 126 POLY-VI-FLOR...... 126 TRISODIUM...... 172 PHOTOFRIN...... 56 POLY-VI-FLOR FS...... 126 PENTETATE ZINC PHOTREXA VISCOUS...... 172 POLY-VI-FLOR/IRON...... 126 TRISODIUM...... 172 PHOTREXA-PHOTREXA POMALYST...... 56 pentobarbital sodium...... 36 VISCOUS KIT...... 172 portia-28...... 152 pentoxifylline er...... 86 phrenilin forte...... 13 PORTRAZZA...... 56 PEPCID...... 132 PHYSIOLYTE...... 126 posaconazole...... 45 PERCOCET...... 13 PHYSIOSOL IRRIGATION..... 126 pot bicarb-pot chloride...... 126 PERFOROMIST...... 189 phytonadione...... 126 potassium acetate...... 126 PERIDEX...... 95 PICATO...... 102 POTASSIUM ACETATE-NACL PERIKABIVEN...... 126 PIFELTRO...... 68 ...... 126 perindopril erbumine...... 86 pilocarpine hcl...... 95, 180 potassium bicarbonate...... 126 periogard...... 95 pimecrolimus...... 102 potassium chloride...... 126, 127 PERJETA...... 56 pimozide...... 64 POTASSIUM CHLORIDE126, 127 permethrin...... 61 pimtrea...... 152 potassium chloride crys er...... 126 perphenazine...... 42 pindolol...... 86 potassium chloride er...... 126 perphenazine-amitriptyline...... 40 pioglitazone hcl...... 107 potassium chloride proamp.....126

219 potassium citrate er...... 127 PREMPRO...... 152 probenecid...... 46 POTASSIUM PHOSPHATE- prenatal...... 127 PROBUPHINE IMPLANT KIT... 13 NACL...... 127 prenatal plus iron...... 127 procainamide hcl...... 86 potassium phosphates(71 meq prenatal vitamin plus low iron..127 PROCALAMINE...... 127 k)...... 127 PRENATVITE PLUS...... 127 PROCARDIA...... 87 POTASSIUM PHOSPHATES- PRENATVITE RX...... 127 PROCARDIA XL...... 87 DEXTROSE...... 127 PRE-PEN...... 173 PROCENTRA...... 90 POTASSIUM PHOSPHATES- PREPIV SUPPLY...... 19 prochlorperazine...... 42 NACL...... 127 preplus...... 127 prochlorperazine edisylate...... 42 POTELIGEO...... 56 PREPOPIK...... 135 prochlorperazine maleate...... 42 POVIDONE-IODINE...... 178 PRESTALIA...... 86 PROCRIT...... 74 PRADAXA...... 33 PRETAB...... 127 PROCTOCORT...... 163 pralidoxime chloride...... 173 PRETOMANID...... 48 PROCTOFOAM HC...... 163 PRALUENT...... 86 PREVACID...... 132 procto-med hc...... 163 pramipexole dihydrochloride..... 62 PREVACID SOLUTAB...... 132 procto-pak...... 163 pramipexole dihydrochloride er.62 prevalite...... 86 proctosol hc...... 163 PRAMOTIC...... 183 PREVIDENT...... 95 proctozone-hc...... 163 PRANDIN...... 107 prevident...... 95 PROCYSBI...... 136 prasugrel hcl...... 63 PREVIDENT 5000 BOOSTER PRODIGY NO CODING PRAVACHOL...... 86 PLUS...... 95 BLOOD GLUC...... 112 pravastatin sodium...... 86 PREVIDENT 5000 DRY profeno...... 16 praziquantel...... 61 MOUTH...... 95 PROFESSIONAL DNA prazosin hcl...... 86 PREVIDENT 5000 ENAMEL COLLECTION...... 173 PRECEDEX...... 173 PROTECT...... 95 PROFILNINE...... 74 PRECISION LINK...... 111 PREVIDENT 5000 ORTHO PROFILNINE SD...... 74 PRECISION PCX PLUS TEST111 DEFENSE...... 95 progesterone...... 152 PRECISION QID MONITOR...111 PREVIDENT 5000 PLUS...... 95 PROGESTERONE PRECISION QID TEST...... 111 PREVIDENT 5000 SENSITIVE.95 COMPOUNDING KIT...... 152 PRECISION SOF-TACT previfem...... 152 progesterone micronized...... 152 MONITOR...... 111 PREVNAR 13...... 162 PROGLYCEM...... 113 PRECISION SOF-TACT TEST PREVYMIS...... 68 PROGRAF...... 158 ...... 111 PREZCOBIX...... 68 PROLASTIN-C...... 189 PRECISION XTRA...... 112 PREZISTA...... 68 PROLATE...... 13 PRECISION XTRA BLOOD PRIALT...... 13 PROLEEVA...... 173 GLUCOSE...... 112 PRIFTIN...... 48 PROLENSA...... 178 PRECISION XTRA MONITOR 112 PRILOSEC...... 132 PROLEUKIN...... 56 PRECOSE...... 107 primaquine phosphate...... 61 PROLEVA...... 173 PRED FORTE...... 178 PRIMAXIN IV...... 29 PROLIA...... 164 PRED MILD...... 178 primidone...... 36 PROMACTA...... 74 PRED-G...... 182 PRIMLEV...... 13 promethazine hcl...... 185 PRED-G S.O.P...... 182 PRIMSOL...... 29 promethazine-codeine...... 185 prednicarbate...... 102, 103 PRINIVIL...... 86 promethazine-dm...... 185 prednisolone...... 142 PRISMASOL B22GK 4/0...... 127 promethazine-phenyleph- prednisolone acetate...... 178 PRISMASOL BGK 0/2.5...... 127 codeine...... 185 prednisolone sodium PRISMASOL BGK 2/0...... 127 promethazine-phenylephrine.. 185 phosphate...... 142, 178 PRISMASOL BGK 2/3.5...... 127 promethegan...... 185 prednisone...... 142 PRISMASOL BGK 4/2.5...... 127 PROMETRIUM...... 152 prednisone intensol...... 142 PRISMASOL BK 0/0/1.2...... 127 propafenone hcl...... 87 PREFEST...... 152 PRISTIQ...... 40 propafenone hcl er...... 87 pregabalin...... 93 PRIVIGEN...... 158 propantheline bromide...... 135 PREMARIN...... 152 PROAIR DIGIHALER...... 189 proparacaine hcl...... 182 PREMASOL...... 127 PROAIR HFA...... 189 proparacaine-fluorescein...... 182 PREMPHASE...... 152 PROAIR RESPICLICK...... 189 PROPECIA...... 103

220 propofol...... 173 QSYMIA...... 93 REBETOL...... 68 PROPOFOL...... 173 QTERN...... 107 REBIF...... 92 propranolol hcl...... 87 QUADRACEL...... 162 REBIF REBIDOSE...... 92 propranolol hcl er...... 87 QUADRAMET...... 57 REBIF REBIDOSE propranolol-hctz...... 87 QUALAQUIN...... 61 TITRATION PACK...... 92 propylthiouracil...... 154 QUARTETTE...... 152 REBIF TITRATION PACK...... 92 PROQUAD...... 162 quasense...... 152 REBINYN...... 74 PROSCAR...... 140 quazepam...... 71 REBLOZYL...... 75 PROSOL...... 127 QUDEXY XR...... 36 RECARBRIO...... 29 PROSTIN VR...... 87 QUELICIN...... 93 RECLAST...... 164 protamine sulfate...... 74 QUESTRAN...... 87 reclipsen...... 152 PROTEOLIN...... 173 QUESTRAN LIGHT...... 87 RECOMBINATE...... 75 PROTONIX...... 132 quetiapine fumarate...... 64 RECOMBIVAX HB...... 162 PROTOPAM CHLORIDE...... 173 quetiapine fumarate er...... 64 RECOTHROM...... 75 PROTOPIC...... 103 QUICKVUE + STREP A TEST173 RECOTHROM SPRAY KIT...... 75 protriptyline hcl...... 40 QUICKVUE DIPSTICK STREP RECTIV...... 87 PROVAYBLUE...... 173 A TEST...... 173 REFISSA...... 103 PROVENGE...... 158 QUICKVUE INFLUENZA A+B REGENECARE...... 103 PROVENTIL HFA...... 189 TEST...... 173 REGIMEX...... 94 PROVERA...... 152 QUICKVUE IN-LINE STREP A REGLAN...... 42 PROVIGIL...... 194 TEST...... 173 REGONOL...... 48 PROVOCHOLINE...... 173 QUILLICHEW ER...... 91 REGRANEX...... 103 PROZAC...... 40 QUILLIVANT XR...... 91 RELAFEN...... 16 PRUDOXIN...... 103 quinapril hcl...... 87 RELAFEN DS...... 16 pseudoeph-chlorphen- quinapril-hydrochlorothiazide.... 87 RELENZA DISKHALER...... 68 hydrocod...... 185 QUINIDINE GLUCONATE...... 87 relexxii...... 91 pseudoephedrine-bromphen- quinidine gluconate er...... 87 RELION BLOOD GLUCOSE dm...... 185 quinidine sulfate...... 87 TEST...... 112 PSORCON...... 103 quinine sulfate...... 61 RELION PREMIER CLASSIC.112 PULMICORT FLEXHALER.....189 QVAR REDIHALER...... 189 RELION PREMIER TEST...... 112 PULMICORT SUSPENSION.. 189 RABAVERT...... 162 RELION ULTIMA TEST...... 112 PULMONA...... 173 RABEPRAZOLE SODIUM...... 132 RELISTOR...... 135 pulmosal...... 186 rabeprazole sodium...... 132 RELNATE DHA...... 128 PULMOZYME...... 191 RADIAPLEXRX...... 103 RELPAX...... 47 purevit dualfe plus...... 127 RADICAVA...... 94 REMDESIVIR...... 68 PURIXAN...... 56 RADIOGARDASE...... 173 REMEDIENT...... 128 PYLERA...... 135 raloxifene hcl...... 144 remergent hq...... 103 pyrazinamide...... 48 ramelteon...... 194 REMERON...... 40 pyridostigmine bromide...... 48 ramipril...... 87 REMERON SOLTAB...... 40 pyridostigmine bromide er...... 48 RANEXA...... 87 REMESENSE...... 95 PYRIDOXINE HCL...... 127 ranolazine er...... 87 REMICADE...... 158 pyridoxine hcl...... 128 RAPAFLO...... 140 remifentanil hcl...... 13 pyrimethamine...... 61 RAPAMUNE...... 158 REMODULIN...... 191 PYRIMETHAMINE- RAPIVAB...... 68 RENACIDIN...... 139 LEUCOVORIN...... 61 RAPPORT RLS...... 173 RENAGEL...... 139 PYROGALLIC ACID...... 103 RAPPORT VTD...... 173 RENAL...... 128 QBRELIS...... 87 rasagiline mesylate...... 62 RENATABS...... 128 QBREXZA...... 103 RASUVO...... 158 RENATABS WITH IRON...... 128 QDOLO...... 13 RAVICTI...... 136 RENFLEXIS...... 158 QINLOCK...... 56 RAYALDEE...... 164 RENOVA...... 103 QMIIZ ODT...... 16 RAYOS...... 142 RENOVA PUMP...... 103 QNASL...... 186 RAZADYNE...... 38 RENVELA...... 139 QNASL CHILDRENS...... 186 RAZADYNE ER...... 38 REOPRO...... 63

221 repaglinide...... 107 RIDAURA...... 158 RUBRACA...... 57 repaglinide-metformin hcl...... 107 rifabutin...... 48 RUCONEST...... 158 REPATHA...... 87 RIFADIN...... 48 RUKOBIA...... 68 REPATHA PUSHTRONEX RIFAMATE...... 48 RUXIENCE...... 57 SYSTEM...... 87 rifampin...... 48 RUZURGI...... 173 REPATHA SURECLICK...... 87 RIFAMPIN+SYRSPEND SF..... 48 RYANODEX...... 193 REQ 49+...... 128 RIFATER...... 49 RYBELSUS...... 107 REQUIP...... 62 RILUTEK...... 94 RYCLORA...... 186 REQUIP XL...... 62 riluzole...... 94 RYDAPT...... 57 RESCRIPTOR...... 68 rimantadine hcl...... 68 RYTARY...... 62 RESECTISOL...... 173 RIMSO-50...... 139 RYTHMOL SR...... 87 RESERVAPAK...... 173 ringers irrigation...... 128 ryvent...... 186 RESERVAPAK PLUS...... 173 RINVOQ...... 158 SABRIL...... 37 RESTASIS...... 182 RIOMET...... 107 SACCHARIN...... 173 RESTASIS MULTIDOSE...... 182 RIOMET ER...... 107 SAFYRAL...... 152 RESTORA RX...... 135 risedronate sodium...... 164 SAIZEN...... 146 RESTORE...... 135 RISPERDAL...... 65 SAIZENPREP...... 146 RESTORIL...... 194 RISPERDAL CONSTA...... 65 SALAGEN...... 95 RETACRIT...... 75 risperidone...... 65 saline bacteriostatic...... 128 RETAVASE...... 34 risperidone m-tab...... 65 saline flush...... 128 RETAVASE HALF-KIT...... 34 RITALIN...... 91 saline flush zr...... 128 RETEVMO...... 57 RITALIN LA...... 91 SALINE-PHENOL...... 128 RETIN-A...... 103 ritonavir...... 68 salsalate...... 16 RETIN-A MICRO GEL 0.04 %, RITUXAN...... 57 SAMSCA...... 128 0.1 %...... 103 RITUXAN HYCELA...... 57 SANCUSO...... 42 RETIN-A MICRO PUMP...... 103 rivastigmine...... 38 SANDIMMUNE...... 158 RETROVIR...... 68 rivastigmine tartrate...... 38 SANDOSTATIN...... 146 REVATIO...... 191 rivelsa...... 152 SANDOSTATIN LAR DEPOT. 146 REVCOVI...... 137 RIXUBIS...... 75 SANTYL...... 103 REVLIMID...... 57 rizatriptan benzoate...... 47 SAPHRIS...... 65 revonto...... 193 ROBAXIN...... 193 sapropterin dihydrochloride.....137 REXULTI...... 64 ROBAXIN-750...... 193 SARAFEM...... 40 REYATAZ...... 68 ROCALTROL...... 165 SARCLISA...... 57 REYVOW...... 47 ROCKLATAN...... 180 sash kit...... 173 R-GENE 10...... 173 rocuronium bromide...... 94 SAVAYSA...... 34 RHOFADE...... 103 ROCURONIUM BROMIDE...... 94 SAVELLA...... 94 RHOGAM ULTRA-FILTERED ROMIDEPSIN...... 57 SAVELLA TITRATION PACK... 94 PLUS...... 158 ropinirole hcl...... 62 SAXENDA...... 94 RHOPHYLAC...... 158 ropinirole hcl er...... 62 SCENESSE...... 103 RHOPRESSA...... 180 ROPIVACAINE HCL...... 19, 20 SCLEROSOL RIASTAP...... 75 ropivacaine hcl...... 20 INTRAPLEURAL...... 189 RIAX...... 103 ROPIVACAINE HCL-NACL...... 20 scopolamine...... 42 ribasphere...... 68 rosadan...... 103 SEASONIQUE...... 153 RIBASPHERE...... 68 ROSE GLO...... 182 SECONAL...... 194 RIBASPHERE RIBAPAK rosuvastatin calcium...... 87 SECREFLO...... 173 (1000 PACK)...... 68 ROTARIX...... 162 SECUADO...... 65 RIBASPHERE RIBAPAK ROTATEQ...... 162 SECURESAFE HYPODERMIC (1200 PACK)...... 68 ROWASA...... 163 NEEDLE...... 115, 173 RIBASPHERE RIBAPAK (600 roweepra...... 36 SEEBRI NEOHALER...... 189 PACK)...... 68 roweepra xr...... 37 SEGLUROMET...... 107 RIBASPHERE RIBAPAK (800 ROXICODONE...... 13 selegiline hcl...... 62 PACK)...... 68 ROZEREM...... 194 selenium sulfide...... 103 ribavirin...... 68 ROZLYTREK...... 57 SELZENTRY...... 69

222 SEMGLEE...... 115, 116 SIMPONI ARIA...... 158 SOFIA STREP A+ FIA...... 174 SEMPREX-D...... 186 SIMULECT...... 159 SOFIA2 SARS ANTIGEN FIA.174 SENSIPAR...... 165 SIMVASTATIN...... 87 SOFOSBUVIR-VELPATASVIR.69 SENSORCAINE...... 20 simvastatin...... 87 SOF-SENSOR...... 112 SENSORCAINE/EPINEPHRIN SINEMET...... 62 SOF-SET INFUSION SET 42" 174 E...... 20 SINEMET CR...... 62 solifenacin succinate...... 139 SENSORCAINE-MPF...... 20 SINGULAIR...... 189 SOLIQUA...... 107 sensorcaine-mpf...... 20 SINUVA...... 186 SOLIRIS...... 75 SENSORCAINE- sirolimus...... 159 SOLODYN...... 29 MPF/EPINEPHRINE...... 20 SIRTURO...... 49 SOLOSEC...... 29 SEREVENT DISKUS...... 189 SITAVIG...... 69 SOLTAMOX...... 57 SERMORELIN ACETATE SIVEXTRO...... 29 SOLU-CORTEF...... 142 DIAGNOSTIC...... 173 SKELAXIN...... 193 SOLU-MEDROL...... 142 SERNIVO...... 103 SKLICE...... 61 SOMA...... 193 SEROQUEL...... 65 SKYLA...... 153 SOMATULINE DEPOT...... 146 SEROQUEL XR...... 65 SKYRIZI (150 MG DOSE)...... 159 SOMAVERT...... 146 SEROSTIM...... 135 SLYND...... 153 SOOLANTRA...... 103 sertraline hcl...... 40 SMOFLIPID...... 128 SORBITOL...... 174 se-tan plus...... 128 sod benz-sod phenylacet...... 137 sorbitol...... 174 setlakin...... 153 sod citrate-citric acid...... 128 sorbitol-mannitol...... 174 sevelamer carbonate...... 139 sodium acetate...... 128 SORIATANE...... 103 sevelamer hcl...... 139 SODIUM ASCORBATE...... 128 SORILUX...... 103 SEVENFACT...... 75 SODIUM BICARBONATE...... 128 sorine...... 88 sevoflurane...... 174 sodium bicarbonate...... 128, 135 SOTALOL HCL...... 88 SEYSARA...... 29 SODIUM CHLORIDE...... 128 sotalol hcl...... 88 sf...... 95 sodium chloride...... 128, 186 sotalol hcl (af)...... 88 sf 5000 plus...... 95 sodium chloride (pf)...... 128 SOTYLIZE...... 88 SFROWASA...... 163 sodium chloride bacteriostatic.128 SOVALDI...... 69 sharobel...... 153 sodium chloride flush...... 128 spinosad...... 61 SHINGRIX...... 162 SODIUM CITRATE...... 34 SPINRAZA...... 174 SIDEROL...... 128 SODIUM CITRATE LOCK SPIRIVA HANDIHALER...... 189 SIGNIFOR...... 146 FLUSH...... 34 SPIRIVA RESPIMAT...... 190 SIGNIFOR LAR...... 146 SODIUM DIURIL...... 87 spironolactone...... 88 SIKLOS...... 57 SODIUM EDECRIN...... 87 spironolactone-hctz...... 88 sildenafil citrate...... 139, 192 sodium fluoride...... 96, 128, 129 SPORANOX...... 45 SILENOR...... 194 sodium fluoride 5000 plus...... 95 SPORANOX PULSEPAK...... 45 SILHOUETTE 23" INFUSION sodium fluoride 5000 ppm...... 95 SPRAVATO (56 MG DOSE)..... 40 SET...... 174 sodium fluoride 5000 sensitive..96 SPRAVATO (84 MG DOSE)..... 40 SILHOUETTE 43" INFUSION SODIUM HYALURONATE...... 174 sprintec 28...... 153 SET...... 174 sodium lactate...... 129 SPRITAM...... 37 SILHOUETTE INFUSION SET sodium nitrite...... 174 SPRIX...... 16 18"...... 174 sodium nitroprusside...... 88 SPRYCEL...... 57 SILIQ...... 158 sodium phenylbutyrate...... 137 sps...... 129 silodosin...... 140 SODIUM PHOSPHATE-NACL 129 sronyx...... 153 SILVADENE...... 29 sodium phosphates...... 129 ssd...... 29 silver nitrate...... 29 SODIUM PHOSPHATES- STALEVO 100...... 62 silver sulfadiazine...... 29 DEXTROSE...... 129 STALEVO 125...... 62 SIMBRINZA...... 180 sodium polystyrene sulfonate. 129 STALEVO 150...... 62 SIMILAC PROBIOTIC TRI- sodium saccharin...... 174 STALEVO 200...... 62 BLEND...... 135 sodium thiosulfate...... 174 STALEVO 50...... 62 simliya...... 153 SOFIA INFLUENZA A+B FIA..174 STALEVO 75...... 62 simpesse...... 153 SOFIA SARS ANTIGEN FIA...174 STAMARIL...... 162 SIMPONI...... 159 SOFIA STREP A FIA...... 174 STARLIX...... 107

223 stavudine...... 69 sumatriptan...... 47 SYNAGEX...... 129 STAXYN...... 139 sumatriptan succinate...... 47 SYNAGIS...... 159 STEGLATRO...... 107 sumatriptan succinate refill...... 47 SYNALAR...... 103 STEGLUJAN...... 107 sumatriptan-naproxen sodium.. 47 SYNAPRYN FUSEPAQ...... 13 STELARA...... 159 SUNOSI...... 194 SYNAREL...... 146 STENDRA...... 139 SUPARTZ FX...... 174 SYNATEK...... 129 STERILE DILUENT FLOLAN SUPERVITE...... 129 SYNDROS...... 42 PH 12...... 174 SUPPORT...... 129 SYNERA...... 20 STERILE DILUENT FOR SUPPORT-500...... 129 SYNERCID...... 30 FLOLAN...... 174 SUPPRELIN LA...... 146 SYNJARDY...... 107 sterile diluent/epoprostenol..... 174 SUPRANE...... 174 SYNJARDY XR...... 107 STERILE TALC POWDER...... 190 SUPRAX...... 30 SYNRIBO...... 57 sterile water for injection...... 174 SUPREP BOWEL PREP KIT..135 SYNTHROID...... 154 STERILE WATER FOR SURE T INFUSION SET SYNVISC...... 175 INJECTION...... 174 18"/6MM...... 174 SYNVISC ONE...... 175 sterile water for irrigation...... 129 SURE T INFUSION SET SYPRINE...... 129 STERITALC...... 190 23"/10MM...... 174 SYRINGE LUER LOCK...... 175 STIMATE...... 146 SURE T INFUSION SET SYRINGE LUER SLIP...... 175 STIOLTO RESPIMAT...... 190 23"/6MM...... 174 T: SLIM X2 INS STIVARGA...... 57 SURE T INFUSION SET PMP/CONTROL 7.4...... 175 STRATTERA...... 91 23"/8MM...... 174 T:SLIM X2 3ML CARTRIDGE.175 STRENSIQ...... 137 SURE T INFUSION SET T:SLIM X2 INS streptomycin sulfate...... 29 32"/10MM...... 174 PUMP/CONTROL-IQ...... 175 STRIANT...... 143 SURE T INFUSION SET T:SLIM X2 INSULIN PMP STRIBILD...... 69 32"/6MM...... 174 BASAL IQ...... 175 STRIVERDI RESPIMAT...... 190 SURE T INFUSION SET T:SLIM X2 INSULIN PMP STROMECTOL...... 61 32"/8MM...... 174 BASAL6.4...... 175 STROVITE FORTE...... 129 SURESTEP PRO HIGH T:SLIM X2 INSULIN SUBLOCADE...... 21 GLUCOSE...... 112 PMP/RFURB IQ...... 175 SUBOXONE...... 21 SURESTEP PRO LOW T:SLIM X2/CONTROL- SUBSYS...... 13 GLUCOSE...... 112 IQ/REFURB...... 175 subvenite...... 37 SURESTEP PRO NORMAL TABLOID...... 57 subvenite starter kit-blue...... 37 GLUCOSE...... 112 TABRADOL FUSEPAQ...... 193 subvenite starter kit-green...... 37 SURMONTIL...... 40 TABRADOL RAPIDPAQ...... 193 subvenite starter kit-orange...... 37 SURVANTA...... 186 TABRECTA...... 57 SUCCINYLCHOLINE SUSTIVA...... 69 TACHOSIL...... 175 CHLORIDE...... 94 SUSTOL...... 42 TACLONEX...... 103 succinylcholine chloride...... 94 SUTENT...... 57 tacrolimus...... 103, 159 SUCRAID...... 137 swabflush saline flush...... 129 tadalafil...... 139 sucralfate...... 132 syeda...... 153 tadalafil (pah)...... 192 sufentanil citrate...... 13 SYLATRON...... 69 TAFINLAR...... 57 SULAR...... 88 SYLVANT...... 57 TAGRISSO...... 57 SULCONAZOLE NITRATE...... 45 SYMBICORT...... 190 TAKHZYRO...... 159 sulfacetamide sodium...... 178 SYMBYAX...... 40 TALICIA...... 135 sulfacetamide sodium (acne).. 103 SYMDEKO...... 191 TALTZ...... 159 sulfacetamide-prednisolone.... 182 SYMFI...... 69 TALZENNA...... 57 sulfadiazine...... 29 SYMFI LO...... 69 TAMIFLU...... 69 sulfamethoxazole-trimethoprim.30 SYMJEPI...... 190 tamoxifen citrate...... 57 SULFAMYLON...... 30 SYMLINPEN 120...... 107 tamsulosin hcl...... 140 sulfasalazine...... 163 SYMLINPEN 60...... 107 TANDEM PLUS...... 129 sulfatrim pediatric...... 30 SYMPAZAN...... 37 TAPAZOLE...... 154 sulfurated lime...... 61 SYMPROIC...... 135 TAPERDEX 12-DAY...... 142 sulindac...... 16 SYMTUZA...... 69 TAPERDEX 6-DAY...... 142

224 TAPERDEX 7-DAY...... 142 TEPEZZA...... 146 TIGAN...... 42, 43 TARCEVA...... 57 terazosin hcl...... 140 tigecycline...... 30 TARGADOX...... 30 terbinafine hcl...... 45 TIGLUTIK...... 94 TARGRETIN...... 57 terbutaline sulfate...... 190 TIKOSYN...... 88 tarina 24 fe...... 153 terconazole...... 45 tilia fe...... 153 tarina fe 1/20...... 153 TERIPARATIDE timolol maleate...... 88, 180 tarina fe 1/20 eq...... 153 (RECOMBINANT)...... 164 TIMOPTIC...... 180 TARKA...... 88 terrell...... 175 TIMOPTIC OCUDOSE...... 180 TARON FORTE...... 129 TESSALON PERLES...... 186 TIMOPTIC-XE...... 180 TASIGNA...... 57 TESTIM...... 143 tinidazole...... 30 TASMAR...... 62 TESTOPEL...... 143 TIROSINT...... 154 TAURINE...... 129 testosterone...... 143 TIROSINT-SOL...... 154 tavaborole...... 45 TESTOSTERONE TISSEEL...... 175 TAVALISSE...... 75 COMPOUNDING KIT...... 143 TISSEEL VH...... 175 TAXOTERE...... 57 testosterone cypionate...... 143 TISSEEL VHSD...... 175 TAYTULLA...... 153 testosterone enanthate...... 143 tis-u-sol...... 129 tazarotene...... 103 TETANUS-DIPHTHERIA TIVICAY...... 69 tazicef...... 30 TOXOIDS TD...... 162 TIVICAY PD...... 69 TAZICEF...... 30 tetcaine...... 182 TIVORBEX...... 16 TAZORAC...... 103 tetrabenazine...... 94 TIZANIDINE COMFORT PAC 193 taztia xt...... 88 tetracaine hcl...... 182 tizanidine hcl...... 193 TAZVERIK...... 57 tetracycline hcl...... 30 tl gard rx...... 129 TDVAX...... 162 TETRAVISC...... 182 TL G-FOL OS...... 129 TECARTUS...... 57 TETRAVISC FORTE...... 182 tl hydroquinone...... 104 TECENTRIQ...... 57 TEXACORT...... 104 tl icon...... 129 TECFIDERA...... 92 THALOMID...... 58 TL-FLUORIVITE...... 129 TEFLARO...... 30 THAM...... 129 tl-hem 150...... 129 TEGRETOL...... 37 THE LIQUILIFT TRACE...... 129 TL-ICARE...... 175 TEGRETOL-XR...... 37 THEO-24...... 190 TNKASE...... 34 TEGSEDI...... 94 theophylline...... 190 TOBI NEBULIZER...... 191 TEKTURNA...... 88 theophylline er...... 190 TOBI PODHALER...... 191 TEKTURNA HCT...... 88 theophylline in d5w...... 190 TOBRADEX...... 182 TELFA AMD ISLAND THERAHONEY...... 104 TOBRADEX ST...... 183 DRESSING...... 175 THERAMINE PLUS...... 175 tobramycin...... 178, 191 TELFA AMD NON- thiamine hcl...... 129 TOBRAMYCIN...... 191 ADHERENT...... 175 THIOLA...... 139 tobramycin sulfate...... 30 telmisartan...... 88 THIOLA EC...... 139 tobramycin-dexamethasone....183 telmisartan-amlodipine...... 88 thioridazine hcl...... 65 TOBREX...... 178 telmisartan-hctz...... 88 thiotepa...... 58 TOFRANIL...... 40 temazepam...... 194 thiothixene...... 65 TOLAK...... 104 TEMIXYS...... 69 THREONINE...... 129 tolazamide...... 107 TEMODAR...... 57, 58 THROMBATE III...... 34 tolbutamide...... 107 TEMOVATE...... 104 THROMBIN-JMI...... 75 tolcapone...... 62 temozolomide...... 58 THROMBIN-JMI EPISTAXIS.... 75 tolmetin sodium...... 16 temsirolimus...... 159 THROMBOGEN...... 75 TOLNAFTATE...... 45 TENCON...... 13 THYMOGLOBULIN...... 159 TOLSURA...... 45 teniposide...... 58 THYROGEN...... 175 tolterodine tartrate...... 139 TENIVAC...... 162 thyroid...... 154 tolterodine tartrate er...... 139 tenofovir disoproxil fumarate.....69 tiadylt er...... 88 TOLVAPTAN...... 129 TENORETIC 100...... 88 tiagabine hcl...... 37 tolvaptan...... 130 TENORETIC 50...... 88 TIAZAC...... 88 TOPAMAX...... 37 TENORMIN...... 88 TIBSOVO...... 58 TOPAMAX SPRINKLE...... 37 TEPADINA...... 58 TICE BCG...... 159

225 TOPEX TOPICAL TRETTEN...... 75 TRINATE...... 130 ANESTHETIC...... 96 TREXALL...... 159 TRI-NORINYL (28)...... 153 TOPICORT...... 104 TREXIMET...... 47 TRINTELLIX...... 41 TOPICORT SPRAY...... 104 TREZIX...... 13 TRIOSTAT...... 154 topiramate...... 37 tri femynor...... 153 triphrocaps...... 130 topiramate er...... 37 triamcinolone acetonide TRIPLE COMPLEX FORMULA toposar...... 58 ...... 96, 104, 143 3 KIT...... 16 topotecan hcl...... 58 TRIAMCINOLONE TRIPLE PMB...... 178 TOPROL XL...... 88 ACETONIDE...... 142 TRIPLE PMK...... 179 toremifene citrate...... 58 TRIAMCINOLONE tri-previfem...... 153 TORISEL...... 159 DIACETATE...... 143 TRIPTODUR...... 146 torsemide...... 88 TRIAMCINOLONE- TRISENOX...... 58 TOSYMRA...... 47 BUPIVACAINE...... 143 TRISODIUM CITRATE/CRRT 130 TOTECT...... 58 TRI-AMINO...... 130 tri-sprintec...... 153 TOUJEO MAX SOLOSTAR.... 116 triamterene...... 88 TRIUMEQ...... 69 TOUJEO SOLOSTAR...... 116 triamterene-hctz...... 88 TRI-VI-FLOR...... 130 tovet...... 104 TRIANEX...... 104 TRI-VI-FLORO...... 130 TOVIAZ...... 139 triazolam...... 71 TRIVISC...... 175 TOXICOLOGY SALIVA TRIBENZOR...... 88 tri-vite/fluoride...... 130 COLLECTION...... 175 TRICARE PRENATAL DHA trivora (28)...... 153 TRACLEER...... 192 ONE...... 130 tri-vylibra...... 153 TRADJENTA...... 107 TRI-CHLOR...... 104 tri-vylibra lo...... 153 TRALEMENT...... 130 TRICITRASOL...... 34 TRIZIVIR...... 69 TRAMADOL HCL ER...... 13 TRICON...... 130 TRODELVY...... 58 tramadol hcl er...... 13 TRICOR...... 88 TROGARZO...... 69 tramadol hcl er (biphasic)...... 13 triderm...... 104 TROKENDI XR...... 37 tramadol hcl ir...... 13 TRIDESILON...... 104 TROPHAMINE...... 130 tramadol-acetaminophen...... 13 trientine hcl...... 130 tropicamide...... 183 trandolapril...... 88 TRIESENCE...... 178 TROPICAMIDE- trandolapril-verapamil hcl er...... 88 tri-estarylla...... 153 CYCLOPENTOLATE-PE...... 183 tranexamic acid...... 75 TRIFERIC...... 130 trospium chloride...... 139 TRANEXAMIC ACID-NACL...... 75 trifluoperazine hcl...... 65 trospium chloride er...... 139 TRANSDERM SCOP (1.5 MG).43 trifluridine...... 178 TRUE FOCUS BLOOD TRANSDERM-SCOP (1.5 MG).43 trigels-f forte...... 130 GLUCOSE METER...... 112 TRANXENE-T...... 71 TRIGLIDE...... 88 TRUE METRIX BLOOD tranylcypromine sulfate...... 41 trihexyphenidyl hcl...... 62 GLUCOSE TEST...... 112 TRAVASOL...... 130 TRIJARDY XR...... 107 TRUE METRIX LEVEL 1...... 112 TRAVATAN Z...... 180 TRIKAFTA...... 191 TRUE METRIX LEVEL 2...... 112 travoprost (bak free)...... 180 tri-legest fe...... 153 TRUE METRIX LEVEL 3...... 112 TRAZIMERA...... 58 TRILEPTAL...... 37 TRUE METRIX PRO BLOOD trazodone hcl...... 41 tri-linyah...... 153 GLUCOSE...... 112 TREANDA...... 58 TRILIPIX...... 88 TRUETRACK TEST...... 112 TRECATOR...... 49 tri-lo-estarylla...... 153 TRULANCE...... 135 TRELEGY ELLIPTA...... 190 tri-lo-marzia...... 153 TRULICITY...... 107 TRELSTAR MIXJECT...... 146 tri-lo-mili...... 153 TRUMENBA...... 162 TREMFYA...... 159 tri-lo-sprintec...... 153 TRUSOPT...... 180 treprostinil...... 192 TRI-LUMA...... 104 TRUSTEEL INFUSION SET... 175 TRESIBA...... 116 TRILURON...... 175 TRUVADA...... 69 TRESIBA FLEXTOUCH...... 116 trilyte...... 135 TRUXIMA...... 58 tretinoin...... 58, 104 trimethobenzamide hcl...... 43 TRYPTOPHAN...... 130 tretinoin (emollient)...... 104 trimethoprim...... 30 TUDORZA PRESSAIR...... 190 tretinoin microsphere...... 104 tri-mili...... 153 TUKYSA...... 58 tretinoin microsphere pump.... 104 trimipramine maleate...... 41 tulana...... 153

226 TURALIO...... 58 UTIBRON NEOHALER...... 190 VASOPRESSIN-SODIUM TUSSICAPS...... 186 utrona-c...... 139 CHLORIDE...... 147 TUSSIONEX PENNKINETIC VABOMERE...... 30 VASOSTRICT...... 147 ER...... 186 VAGIFEM...... 153 VASOTEC...... 89 TUXARIN ER...... 186 valacyclovir hcl...... 69 VAXCHORA...... 162 TUZISTRA XR...... 186 VALCHLOR...... 58 VAYACOG...... 175 TWINRIX...... 162 VALCYTE...... 69 VAYARIN...... 175 TWIRLA...... 153 valganciclovir hcl...... 69 VAYARIN PLUS...... 176 TWYNSTA...... 88 VALINE...... 130 VAYAROL...... 176 tyblume...... 153 VALIUM...... 71 VAZCULEP...... 89 TYBOST...... 69 valproate sodium...... 37 VB6 P5P...... 176 tydemy...... 153 valproic acid...... 37 v-c forte...... 130 TYGACIL...... 30 valrubicin...... 58 VECAMYL...... 89 TYKERB...... 58 valsartan...... 88 VECTIBIX...... 58 TYLENOL WITH CODEINE #3. 13 valsartan-hydrochlorothiazide... 88 VECTICAL...... 104 TYLENOL WITH CODEINE #4. 13 VALSTAR...... 58 VECURONIUM BROMIDE...... 94 TYMLOS...... 164 VALTOCO 10 MG DOSE...... 37 vecuronium bromide...... 94 TYPHIM VI...... 162 VALTOCO 15 MG DOSE...... 37 VECURONIUM BROMIDE- TYSABRI...... 92 VALTOCO 20 MG DOSE...... 37 NACL...... 193 TYVASO...... 192 VALTOCO 5 MG DOSE...... 37 VEKLURY...... 69 TYVASO REFILL...... 192 VALTREX...... 69 VELCADE...... 58 TYVASO STARTER...... 192 VANADOM...... 193 VELETRI...... 192 UBRELVY...... 47 VANATOL LQ...... 13 velivet...... 153 UCERIS...... 164 VANATOL S...... 13 VELPHORO...... 140 UDAMIN SP...... 130 VANCOCIN...... 30 VELTASSA...... 130 UDENYCA...... 75 VANCOCIN HCL...... 30 VELTIN...... 104 ULESFIA...... 61 VANCOMYCIN HCL...... 31 VEMLIDY...... 69 ULORIC...... 46 vancomycin hcl...... 31 VENCLEXTA...... 58 ULTANE...... 175 VANCOMYCIN HCL IN VENCLEXTA STARTING ULTIVA...... 13 DEXTROSE...... 30, 31 PACK...... 58 ULTOMIRIS...... 75 vancomycin hcl in dextrose...... 30 VENELEX...... 104 ULTRACET...... 13 VANCOMYCIN HCL IN NACL.. 31 VENIPUNCTURE PX1 ULTRAM...... 13 vancomycin hcl in nacl...... 31 PHLEBOTOMY...... 20 ULTRAVATE...... 104 VANCOMYCIN+SYRSPEND venlafaxine hcl...... 41 UNASYN...... 30 SF...... 31 venlafaxine hcl er...... 41 UNISTRIP CONTROL...... 112 vandazole...... 31 VENOFER...... 130 unithroid...... 154 VANIQA...... 104 VENTAVIS...... 192 UNITUXIN...... 58 VANOS...... 104 VENTOLIN HFA...... 190 UPLIZNA...... 159 VANTAS...... 146 verapamil hcl...... 89 UPNEEQ...... 179 VAPRISOL...... 146 verapamil hcl er...... 89 UPTRAVI...... 192 VAQTA...... 162 VERDESO...... 104 URECHOLINE...... 139 vardenafil hcl...... 139, 140 VEREGEN...... 104 uretron d/s...... 139 VARISOFT INFUSION SET....175 VERELAN...... 89 urin ds...... 139 VARITHENA...... 88 VERELAN PM...... 89 UROCIT-K 10...... 130 VARIVAX...... 162 VERIPRED 20...... 143 UROCIT-K 15...... 130 VARUBI (180 MG DOSE)...... 43 VERSACLOZ...... 65 UROCIT-K 5...... 130 VASCAZEN...... 175 VERZENIO...... 58 urosex...... 130 VASCEPA...... 88 VESICARE...... 140 UROXATRAL...... 140 VASCULERA...... 175 VFEND...... 45 URSO 250...... 135 VASERETIC...... 88 VFEND IV...... 45 URSO FORTE...... 135 VASHE CLEANSING...... 104 V-GO 20...... 112 ursodiol...... 135 VASOPRESSIN-DEXTROSE. 146 V-GO 30...... 112 URSODIOL+SYRSPEND SF..135 V-GO 40...... 112

227 VIAGRA...... 140 vitamin k1...... 131 warfarin sodium...... 34 VIBATIV...... 31 vitamins acd-fluoride...... 131 water for irrigation, sterile...... 131 VIBERZI...... 135 VITAROCA PLUS...... 131 WELCHOL...... 89 VIBRAMYCIN...... 31 VITRAKVI...... 59 WELLBUTRIN SR...... 41 vic-forte...... 130 VITRASE...... 176 WELLBUTRIN XL...... 41 VICTOZA...... 107 VIVAGUARD INO CONTROL wera...... 153 VIDAZA...... 58 SOLUTION...... 112 WESTAB MAX...... 176 VIDEX...... 69 VIVAGUARD INO GLUCOSE westab mini...... 131 VIDEX EC...... 69 METER...... 112 westab one...... 131 VIEKIRA PAK...... 70 VIVAGUARD INO TEST WESTAB PLUS...... 131 vienva...... 153 STRIPS...... 112 WESTHROID...... 154 vigabatrin...... 37 VIVAGUARD LANCING WIDE-SEAL DIAPHRAGM 60 176 vigadrone...... 37 DEVICE...... 112 WIDE-SEAL DIAPHRAGM 65 176 VIGAMOX...... 179 VIVELLE-DOT...... 153 WIDE-SEAL DIAPHRAGM 70 176 VIIBRYD...... 41 VIVITROL...... 21 WIDE-SEAL DIAPHRAGM 75 176 VIIBRYD STARTER PACK...... 41 VIVLODEX...... 16 WIDE-SEAL DIAPHRAGM 80 176 VIL-RX...... 130 VIVOTIF...... 162 WIDE-SEAL DIAPHRAGM 85 176 VILTEPSO...... 176 VIZIMPRO...... 59 WIDE-SEAL DIAPHRAGM 90 176 VIMIZIM...... 137 VOGELXO...... 143 WIDE-SEAL DIAPHRAGM 95 176 VIMOVO...... 16 VOGELXO PUMP...... 143 WILATE...... 75 VIMPAT...... 37 vol-care rx...... 131 WINRHO SDF...... 159 VINATE ONE...... 130 volnea...... 153 wixela inhub...... 190 vinblastine sulfate...... 58 VOLTAREN...... 16 WP THYROID...... 154 vincasar pfs...... 59 VOLUVEN...... 75 wymzya fe...... 153 vincristine sulfate...... 59 VONVENDI...... 75 XADAGO...... 62 vinorelbine tartrate...... 59 VOPAC GB...... 16 XALATAN...... 180 VIOKACE...... 137 VOPAC KT...... 16 XALIX...... 104 viorele...... 153 VORAXAZE...... 59 XALKORI...... 59 VIRACEPT...... 70 voriconazole...... 45 XANAX...... 71 VIRAMUNE...... 70 VOSEVI...... 70 XANAX XR...... 71 VIRAMUNE XR...... 70 VOTRIENT...... 59 XAQUIL XR...... 131 VIRAZOLE...... 70 VP FC KIT...... 17 XARELTO...... 34 VIREAD...... 70 VP GKL KIT...... 17 XARELTO STARTER PACK.....34 VIROPTIC...... 179 vp-pnv-dha...... 131 XATMEP...... 159 virt-caps...... 130 VPRIV...... 137 XCOPRI...... 37, 38 VIRT-FEFA PLUS...... 130 vp-vite rx...... 131 XCOPRI (250 MG DAILY virt-gard...... 130 VRAYLAR...... 65 DOSE)...... 37 virt-phos 250 neutral...... 130 VTOL LQ...... 13 XCOPRI (350 MG DAILY virtussin ac w/alc...... 186 VUMERITY...... 92 DOSE)...... 37 VISCO-3...... 176 VUMERITY (STARTER)...... 92 XELJANZ...... 159 VISIONBLUE...... 183 VUSION...... 46 XELJANZ XR...... 159 VISTARIL...... 71 VYEPTI...... 47 XELODA...... 59 VISTOGARD...... 176 vyfemla...... 153 XELPROS...... 180 VISUDYNE...... 183 VYLEESI...... 94 XEMBIFY...... 159 VIT B12-METHIONINE-INOS- vylibra...... 153 XENAZINE...... 94 CHOL...... 130 VYNDAMAX...... 89 XENICAL...... 94 vita s forte...... 130 VYNDAQEL...... 89 XENLETA...... 31 vitacel...... 130 VYONDYS 53...... 137 XEOMIN...... 176 VITAFOL STRIPS...... 130 VYTORIN...... 89 XEPI...... 31 VITAL-D RX...... 130 VYVANSE...... 91 XERAC AC...... 104 VITAMAX PEDIATRIC...... 130 VYXEOS...... 59 XERAVA...... 31 vita-min...... 131 VYZULTA...... 180 XERESE...... 70 vitamin d (ergocalciferol)...... 131 WAKIX...... 194 XERMELO...... 135

228 XEROFORM OIL EMULSION xylocaine dental...... 20 ZESTRIL...... 89 2"X2"...... 104 XYLOCAINE/EPINEPHRINE.... 20 ZETIA...... 89 XEROFORM OIL EMULSION XYLOCAINE-MPF...... 20 ZETONNA...... 186 GAUZE...... 105 XYLOCAINE- ZEVALIN Y-90...... 60 XEROFORM OIL EMULSION MPF/EPINEPHRINE...... 20 ZIAC...... 89 STRIP...... 105 XYNTHA...... 75 ZIAGEN...... 70 XEROFORM OIL ROLL 4"X9'.105 XYNTHA SOLOFUSE...... 75 ZIANA...... 105 XEROFORM PETROLAT XYOSTED...... 144 zidovudine...... 70 GAUZE 1"X8"...... 105 XYREM...... 194 ZIEXTENZO...... 76 XEROFORM PETROLAT XYWAV...... 194 zileuton er...... 190 GAUZE 5"X9"...... 105 XYZBAC...... 176 ZILRETTA...... 143 XEROFORM PETROLAT YASMIN 28...... 153 ZILXI...... 105 PATCH 2"X2"...... 105 YAZ...... 153 ZINC CHLORIDE...... 131 XEROFORM PETROLAT YERVOY...... 59 ZINC SULFATE...... 131 PATCH 4"X4"...... 105 YESCARTA...... 59 ZINECARD...... 60 XEROFORM PETROLATUM YF-VAX...... 162 ZINPLAVA...... 159 ROLL 4"X9'...... 105 YONDELIS...... 59 ZIOPTAN...... 180 XGEVA...... 164 YONSA...... 59 ziprasidone hcl...... 65 XHANCE...... 186 YOSPRALA...... 63 ziprasidone mesylate...... 65 XIAFLEX...... 176 YUPELRI...... 190 ZIPSOR...... 17 XIFAXAN...... 31 yuvafem...... 153 ZIRABEV...... 60 XIGDUO XR...... 107 zafirlukast...... 190 ZIRGAN...... 179 XIIDRA...... 183 zaleplon...... 194 ZITHROMAX...... 32 XIMINO...... 32 ZALTRAP...... 59 ZITHROMAX TRI-PAK...... 32 XOFIGO...... 59 ZANAFLEX...... 193 ZITHROMAX Z-PAK...... 32 XOFLUZA (40 MG DOSE)...... 70 ZANOSAR...... 59 ZOCOR...... 89 XOFLUZA (80 MG DOSE)...... 70 zarah...... 153 ZOFRAN...... 43 XOLAIR...... 186 ZARONTIN...... 38 ZOHYDRO ER...... 14 XOLEGEL...... 46 ZARXIO...... 75 ZOLADEX...... 147 XOPENEX...... 190 ZAVESCA...... 137 zoledronic acid...... 164 XOPENEX CONCENTRATE.. 190 ZCORT 7-DAY...... 143 ZOLGENSMA 10.1-10.5 KG... 137 XOPENEX HFA...... 190 ZEBUTAL...... 14 ZOLGENSMA 10.6-11.0 KG... 137 XOSPATA...... 59 ZEGERID...... 132 ZOLGENSMA 11.1-11.5 KG... 137 XPOVIO (100 MG ONCE ZEJULA...... 59 ZOLGENSMA 11.6-12.0 KG... 137 WEEKLY)...... 59 ZELAPAR...... 62 ZOLGENSMA 12.1-12.5 KG... 137 XPOVIO (40 MG ONCE ZELBORAF...... 59 ZOLGENSMA 12.6-13.0 KG... 137 WEEKLY)...... 59 ZELNORM...... 135 ZOLGENSMA 13.1-13.5 KG... 137 XPOVIO (40 MG TWICE ZEMAIRA...... 190 ZOLGENSMA 2.6-3.0 KG...... 137 WEEKLY)...... 59 ZEMBRACE SYMTOUCH...... 47 ZOLGENSMA 3.1-3.5 KG...... 137 XPOVIO (60 MG ONCE ZEMDRI...... 32 ZOLGENSMA 3.6-4.0 KG...... 137 WEEKLY)...... 59 ZEMPLAR...... 165 ZOLGENSMA 4.1-4.5 KG...... 137 XPOVIO (60 MG TWICE zenatane...... 105 ZOLGENSMA 4.6-5.0 KG...... 137 WEEKLY)...... 59 ZENPEP...... 137 ZOLGENSMA 5.1-5.5 KG...... 137 XPOVIO (80 MG ONCE ZENZEDI...... 91 ZOLGENSMA 5.6-6.0 KG...... 137 WEEKLY)...... 59 ZEPATIER...... 70 ZOLGENSMA 6.1-6.5 KG...... 137 XPOVIO (80 MG TWICE ZEPOSIA...... 92 ZOLGENSMA 6.6-7.0 KG...... 138 WEEKLY)...... 59 ZEPOSIA 7-DAY STARTER ZOLGENSMA 7.1-7.5 KG...... 138 XTAMPZA ER...... 14 PACK...... 92 ZOLGENSMA 7.6-8.0 KG...... 138 XTANDI...... 59 ZEPOSIA STARTER KIT...... 92 ZOLGENSMA 8.1-8.5 KG...... 138 xulane...... 153 ZEPZELCA...... 59 ZOLGENSMA 8.6-9.0 KG...... 138 XULTOPHY...... 107 ZERBAXA...... 32 ZOLGENSMA 9.1-9.5 KG...... 138 XURIDEN...... 137 ZERVIATE...... 179 ZOLGENSMA 9.6-10.0 KG..... 138 XYLOCAINE...... 20 ZESTORETIC...... 89 ZOLINZA...... 60

229 zolmitriptan...... 47 ZOLOFT...... 41 zolpidem tartrate...... 194 zolpidem tartrate er...... 194 ZOLPIMIST...... 194 ZOMACTON...... 147 ZOMACTON (FOR ZOMA-JET 10)...... 147 ZOMETA...... 165 ZOMIG...... 48 ZOMIG ZMT...... 48 ZONALON...... 105 ZONEGRAN...... 38 zonisamide...... 38 ZONTIVITY...... 63 ZORBTIVE...... 135 ZORTRESS...... 159 ZORVOLEX...... 17 ZOSTAVAX...... 162 ZOSYN...... 32 zovia 1/35e (28)...... 153 ZOVIRAX...... 70 ZTLIDO...... 20 Z-TUSS AC...... 186 ZUBSOLV...... 21 ZULRESSO...... 41 zumandimine...... 153 ZUPLENZ...... 43 ZURAMPIC...... 46 ZYBAN...... 21 ZYCLARA...... 105 ZYCLARA PUMP...... 105 ZYDELIG...... 60 ZYFLO...... 190 ZYFLO CR...... 190 ZYKADIA...... 60 ZYLET...... 183 ZYLOPRIM...... 46 ZYMAXID...... 179 ZYPITAMAG...... 89 ZYPREXA...... 65 ZYPREXA RELPREVV...... 65 ZYPREXA ZYDIS...... 65 ZYTIGA...... 60 ZYVEXOL...... 176 ZYVIT...... 176 ZYVOX...... 32

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