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Home , Acetarsol, Androstenedione, Chrysin, Glutamic acid, Mequinol, Nicotinamide

2018 Formulary Drug List

For State, Education, and Local Government Employees

GlobalHealth, Inc. 701 NE 10th Street, Suite 300 MSTDF18 Lists Updated 12/2017 Oklahoma City, OK 73104-5403 www.GlobalHealth.com/state HELPFUL NUMBERS Plan Issuer: Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.5600 (local) 1.877.280.5600 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/state 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.5600 (local) 24/7 Nurse Help Line: 1.877.280.5600 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected]

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

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

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

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

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

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

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

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

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

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

iii TIER DESCRIPTION

0 Health Care Reform

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Specialty Drug

TYPE DESCRIPTION

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

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

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

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

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

C Custom This drug has unique restrictions.

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

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

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

PAGE 1 LAST UPDATED 11/2017 PS Preferred Specialty Preferred Specialty.

HCG High Cost Generic High Cost Generic.

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

PAGE 2 LAST UPDATED 11/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS

ALPHA AND BETA ADRENERGIC (RESPR)

QL 2 / fill ADRENACLICK 3 PA

ADRENALIN 3

ADYPHREN 3 QL 2 / fill

ADYPHREN AMP 3 QL 2 / fill

ADYPHREN AMP II 3 QL 2 / fill

ADYPHREN II 3 QL 2 / fill

QL 2 / fill AUVI-Q 3 PA

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

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

epinephrine bitartrate powder 3 epinephrine hcl 3 epinephrine hcl/pf 1 epinephrine/pf 1

EPINEPHRINESNAP-V 3 QL 2 / fill

QL 2 / fill EPIPEN 3 PA

QL 2 / fill EPIPEN 2-PAK 3 PA

PAGE 3 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / fill EPIPEN JR 2-PAK 3 PA

EPISNAP 3 QL 2 / fill

EPY 3 QL 2 / fill

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

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

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

ADVAIR DISKUS 2 QL 2 / day

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

ANORO ELLIPTA 2 QL 2 / day

QL 1 / day ARCAPTA NEOHALER 3 ST

QL 0.357 / day BEVESPI AEROSPHERE 3 ST

PAGE 4 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BREO ELLIPTA 2 QL 2 / day

BROVANA 3 QL 4 / day

COMBIVENT RESPIMAT 2 QL 0.267 / day

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

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

PERFOROMIST 3 QL 120 / 30 days

PROAIR HFA 2 QL .8 / day

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

SEREVENT DISKUS 2 QL 2 / day

QL .144 / day STRIVERDI RESPIMAT 2 ST

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

PAGE 5 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

VENTOLIN HFA 2 QL 1.5 / day

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

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS

CARDURA 3

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

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

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

QL 8 / 30 days dihydroergotamine mesylate 0.5mg/spry spray/pump 3 HCG dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1

PAGE 6 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mesylates 100 % powder 3 ergoloid mesylates 1 mg tablet 1 ERGOMAR 3 tartrate 3 ergotamine tartrate/ 1 methysergide maleate 3 MIGERGOT 3

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

QL 1 / day alfuzosin hcl 1 GL Male 1 carvedilol phosphate (10 mg cpmp 24hr, 20 mg cpmp 24hr, 40 2 / day mg cpmp 24hr) 1 QL carvedilol phosphate 80 mg cpmp 24hr 1 QL 1 / day

COREG 3

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

QL 1 / day COREG CR 80 MG CAPSULE 3 ST

QL 1 / day /tamsulosin hcl 1 GL Male

PAGE 7 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLOMAX 3 QL 2 / day

QL 1 / day JALYN 3 GL Male labetalol hcl powder 3 labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

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

QL 1 / day UROXATRAL 3 GL Male

ANALGESICS AND ANTIPYRETICS

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

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

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

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

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

ALLZITAL 3 QL 6 / day

BUPAP 3 QL 6 / day

PAGE 8 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS /acetaminophen 3 QL 6 / day butalbital/acetaminophen/caffeine (butalb/acetaminophen/caffeine 50-300-40 capsule, 6 / day butalb/acetaminophen/caffeine 50-325-40 capsule, 1 QL butalb/acetaminophen/caffeine 50-325-40 tablet) butalbital/acetaminophen/caffeine/codeine phosphate 1 QL 6 / day

CAPACET 1 QL 6 / day

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

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

ESGIC CAPSULE 1 QL 6 / day

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

FIORICET 3 QL 6 / day

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

GRALISE 30-DAY STARTER PACK 3 ST

QL 1 / day GRALISE ER 300 MG TABLET 3 ST

QL 3 / day GRALISE ER 600 MG TABLET 3 ST

HORIZANT ER 300 MG TABLET 3 QL 4 / day

PAGE 9 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HORIZANT ER 600 MG TABLET 3 QL 2 / day

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

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

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

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

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

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

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

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

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

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

MARGESIC 1 QL 6 / day

MARTEN-TAB 1 QL 6 / day

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

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

NEURONTIN 600 MG TABLET 3 QL 6 / day

NEURONTIN 800 MG TABLET 3 QL 5 / day

NODOLOR 1

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

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

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

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

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

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

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

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

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

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

PRODRIN 3

TENCON 1 QL 6 / day

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

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

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

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

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

VANATOL LQ 3

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

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

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

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

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

PAGE 12 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

ZEBUTAL 1 QL 6 / day

OPIATE

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

QL 3 / day ARYMO ER 3 PA

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

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

ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 QL 100 / day //codeine 200-325-16 tablet 1 QL 21 / day codeine phosphate 3

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

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

PAGE 13 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

PAGE 14 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day DOLOPHINE HCL 3 PA

QL 0.5 / day DURAGESIC 3 PA

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

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

QL 2 / day EMBEDA 2 PA

QL 2 / day EXALGO 3 PA (12 mcg/hr patch td72, 25 mcg/hr patch td72, 37.5mcg/hr patch td72, 50mcg/hr patch td72, 62.5mcg/hr QL 0.5 / day 1 patch td72, 75mcg/hr patch td72, 87.5mcg/hr patch td72, 100 PA mcg/hr patch td72) fentanyl 100 % powder 3

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

PAGE 15 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf (fentanyl/ropivacaine/ns/pf 2-1500mcg pump resvr, 1 QL 192 / day fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 pump resvr)

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

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

QL 13 / day hydromorphone hcl 1 mg/ml liquid 1 AL At least 18 yrs old hydromorphone hcl 100 % powder 3 hydromorphone hcl 3 mg supp.rect 1 QL 4 / day

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

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

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

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

QL 2 / day hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32 mg tab er 24h) 3 PA HCG

PAGE 16 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

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

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

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

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

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

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

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

PAGE 17 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

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

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

QL 2 / day METHADONE INTENSOL 1 PA

QL 2 / day METHADOSE 10 MG/ML ORAL CONC 3 PA sulfate (10 mg cap er pel, 20 mg cap er pel, 50 mg cap QL 2 / day 1 er pel, 100 mg cap er pel) PA morphine sulfate (30 mg cap er pel, 30 mg cpmp 24hr, 45 mg QL 1 / day cpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp 1 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 120 mg cpmp 24hr) PA morphine sulfate 100 % powder 3 PA morphine sulfate (20 mg supp.rect, 100 mg/5ml solution) 1 QL 3 / day

PAGE 18 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS morphine sulfate 10 mg/5 ml solution 1 QL 25 / day morphine sulfate 20 mg/5 ml solution 1 QL 13 / day morphine sulfate 10 mg supp.rect 1 QL 5 / day morphine sulfate 30 mg supp.rect 1 QL 2 / day morphine sulfate 5 mg supp.rect 1 QL 10 / day

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

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

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

QL 3 / day morphine sulfate (10mg/0.7ml pen injctr, 15 mg/ml vial) 1 PA

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

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

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

QL 3 / day MS CONTIN 3 PA

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

PAGE 19 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

OXECTA 3 QL 8 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mg QL 8 / day 1 tablet, 30 mg tablet) AL At least 18 yrs old oxycodone hcl 20 mg/ml oral conc 1 QL 2 / day oxycodone hcl 100 % powder 3 oxycodone hcl 5 mg/5 ml solution 1 QL 33 / day oxycodone hcl 10mg/0.5ml syringe 1 QL 4 / day oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab QL 3 / day er 12h, 30 mg tab er 12h, 40 mg tab er 12h, 60 mg tab er 12h, 1 80 mg tab er 12h) PA oxycodone hcl 10 mg tablet 1 QL 8 / day

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

PAGE 20 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day OXYCONTIN 3 PA

QL 2 / day oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg PA tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er 3 12h, 40 mg tab er 12h) AL At least 18 yrs old HCG

QL 12 / day oxymorphone hcl (5 mg tablet, 10 mg tablet) 3 AL At least 18 yrs old HCG

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

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

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

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

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

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

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

PAGE 21 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg PA tab er 24h, 200 mg tbmp 24hr, 300 mg tab er 24h, 300 mg 3 tbmp 24hr) AL At least 18 yrs old HCG

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

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

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

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

XYLON 10 1

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

OPIATE PARTIAL AGONISTS

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

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

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

BUPRENEX 3 QL 17 / day

QL 0.144 / day buprenorphine 3 PA

PAGE 22 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS buprenorphine hcl powder 3 buprenorphine hcl (0.3 mg/ml syringe, 0.3 mg/ml vial) 1 QL 17 / day

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

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

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

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

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

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

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

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

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

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

PAGE 23 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day ZUBSOLV 3 PA

ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

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

QL 3 / day BONTRIL PDM 3 PA AL At least 17 yrs old diethylpropion hcl 100 % powder 3

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

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

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

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

QL 3 / day phendimetrazine tartrate 35 mg tablet 1 PA

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

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

PAGE 24 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

SUPRENZA ODT 3 PA

ANOREXIGENIC AGENTS, MISCELLANEOUS

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

SELECTIVE AGONISTS

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

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

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

QL 2 / day 3 ST

QL 2 / day ADDERALL XR 3 ST

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

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

PAGE 25 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day benzphetamine hcl 50 mg tablet 1 PA

QL 5 / day DESOXYN 3 ST

QL 5 / day DEXEDRINE SPANSULE 10 MG 3 ST

QL 4 / day DEXEDRINE SPANSULE 15 MG 3 ST

QL 2 / day DEXEDRINE SPANSULE 5 MG 3 ST

DEXEDRINE 10 MG TABLET 1 QL 6 / day

DEXEDRINE 5 MG TABLET 1 QL 2 / day

PAGE 26 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulf-saccharate/ sulf- aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h, dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg cap er 24h, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, 2 / day dextroamphetamine/amphetamine 15 mg cap er 24h, 1 QL dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg cap er 24h, dextroamphetamine/amphetamine 20 mg tablet, dextroamphetamine/amphetamine 25 mg cap er 24h, dextroamphetamine/amphetamine 30 mg cap er 24h, dextroamphetamine/amphetamine 30 mg tablet)

QL 5 / day dextroamphetamine sulfate 10 mg capsule er 3 HCG

QL 4 / day dextroamphetamine sulfate 15 mg capsule er 3 HCG

QL 60 / day dextroamphetamine sulfate 5 mg/5 ml solution 3 HCG

QL 2 / day dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet) 3 HCG

QL 6 / day dextroamphetamine sulfate 10 mg tablet 3 HCG

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

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

QL 60 / day PROCENTRA 3 ST

PAGE 27 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

ZENZEDI 10 MG TABLET 1 QL 6 / day

ZENZEDI 5 MG TABLET 1 QL 2 / day

QL 8 / day ZENZEDI 7.5 MG TABLET 3 ST

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

QL 1 / day APTENSIO XR 3 ST caffeine 3 caffeine citrate powder 3 caffeine citrate 60 mg/3 ml solution 1 caffeine/sodium benzoate 1

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

PAGE 28 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day CONCERTA ER 54 MG TABLET 3 ST

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

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

QL 2 / day FOCALIN 3 ST

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

QL 2 / day FOCALIN XR 20 MG CAPSULE 3 ST

QL 1 / day METADATE CD 3 ST

QL 3 / day METADATE ER 1 LCG

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

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

QL 3 / day METHYLIN (2.5 MG TAB, 5 MG TABLET, 10 MG TABLET) 3 ST

PAGE 29 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 20 QL 1 / day mg cpbp 50-50, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg 3 cpbp 30-70, 60 mg cpbp 30-70) HCG

QL 2 / day methylphenidate hcl (30 mg cpbp 30-70, 30 mg cpbp 50-50) 3 HCG methylphenidate hcl (54 mg tab er 24, 60 mg cpbp 50-50) 1 QL 1 / day methylphenidate hcl powder 3 methylphenidate hcl 10 mg/5 ml solution 1 QL 30 / day methylphenidate hcl 5 mg/5 ml solution 1 QL 60 / day methylphenidate hcl 2.5 mg tab chew 1 methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg 2 / day tab er 24) 1 QL

QL 5 / day methylphenidate hcl 10 mg tablet 1 LCG

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

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

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

QL 12 / day QUILLIVANT XR 3 ST

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

PAGE 30 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 5 / day RITALIN 10 MG TABLET 3 ST

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

QL 2 / day RITALIN LA 30 MG CAPSULE 3 ST

WAKEFULNESS-PROMOTING AGENTS

QL 1 / day armodafinil 3 PA HCG

QL 1 / day modafinil 1 PA

QL 1 / day NUVIGIL 3 PA

QL 1 / day PROVIGIL 3 PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS albendazole 3

QL 4 / day ALBENZA 3 PA

BILTRICIDE 3 PA

EMVERM 3 PA powder 3 ivermectin 3 mg tablet 1 PA levamisole hcl 3

PAGE 31 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mebendazole 3 niclosamide 3 praziquantel 3 pyrantel pamoate 3

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

AZUPHEN MB 1 FURADANTIN 3 HIPREX 3 HYOPHEN 1 INDIOMIN MB 1 MACROBID 3 MACRODANTIN 3 methenamine 3 methenamine hippurate 1 methenamine mandelate powder 3 methenamine mandelate (1 g tablet, 500 mg tablet) 1 methenamine/sod phosph,monobasic//hyoscyamine 1

MONUROL 3 nitrofurantoin 25 mg/5 ml oral susp 1 nitrofurantoin powder 3 nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule, 100 mg capsule) 1

PAGE 32 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nitrofurantoin macrocrystal 100 % powder 3 nitrofurantoin monohydrate/macrocrystals 1 PHOSPHASAL 1 PRIMSOL 3 PROSED-DS 3 trimethoprim 100 % powder 3 trimethoprim 100 mg tablet 1 trimethoprim, micronized 3 UR N-C 1 URELLE 1 URETRON D-S 1

URIBEL 1 QL 4 / day

URIMAR-T 1 URIN D.S. 1 URO-458 1 URO-BLUE 1 URO-L 1 UROGESIC-BLUE 3 UROPHEN MB 1 UROQID- NO.2 3 URYL 1 USTELL 1 UTA 1 UTIRA-C 1

PAGE 33 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC 1 QL 0.434 / day

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

BACTROBAN NASAL 2

BESIVANCE 3 QL 0.767 / day

BLEPH-10 3 QL 5 / fill

BLEPHAMIDE 3 QL 5 / fill

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

CETRAXAL 3 QL 0.567 / day

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

CIPRO HC 3 QL 0.434 / day

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

COLY-MYCIN S 3 QL 10 / fill

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

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

PAGE 34 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gatifloxacin 100 % powder 3

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

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

MAXITROL EYE DROPS 3 QL 5 / fill

MAXITROL EYE OINTMENT 3 QL 4 / fill

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

NEO-POLYCIN 1 QL 0.124 / day

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

NEOSPORIN 3 QL 1.47 / day

OCUFLOX 3 QL 1.47 / day

PAGE 35 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 0.3 % drops 1 QL 1.47 / day

OTIPRIO 3 OTOVEL 3

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

POLYTRIM 3 QL 1.47 / day

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

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

TOBRADEX EYE DROPS 3 QL 5 / fill

TOBRADEX EYE OINTMENT 3 QL 4 / fill

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

TOBREX 0.3% EYE DROPS 3 QL 2.143 / day

TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day

VIGAMOX 2 QL 0.434 / day

ZYLET 3 QL 5 / fill

ZYMAXID 3 QL 0.36/day

ANTIFUNGALS (EENT)

NATACYN 3 QL 0.767 / day

PAGE 36 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIVIRALS (EENT) idoxuridine 3 trifluridine 1 % drops 1 trifluridine 100 % powder 3 VIROPTIC 3

ZIRGAN 3 QL 0.167 / day

EENT ANTI-INFECTIVES, MISCELLANEOUS

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

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ALTABAX 3 bacitracin (5mm unit powder(ea), 65 unit/mg powder) 3 bacitracin zinc micronized 3 bacitracin, micronized 3 BACTROBAN (CREAM, OINTMENT) 3 CENTANY 3 CENTANY AT 3

PAGE 37 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN 100 MG VAGINAL OVULE 2

CLEOCIN T 1% GEL 3 QL 75 / 30 days

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

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

QL 1.5 / day clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 3 HCG clindamycin phosphate/benzoyl (phos/benzoyl 1 % gel QL 1.667 / day 3 (gram), phos/benzoyl 1 % gel w/pump) HCG

QL 2 / day clindamycin phosphate/ 3 HCG

CLINDESSE 3

CORTISPORIN CREAM 3 QL 0.25 / day

CORTISPORIN OINTMENT 3 QL 0.5 / day

ERY 1

ERYGEL 3 QL 1 / day

QL 1.60 / day erythromycin base/ 3 HCG

PAGE 38 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS erythromycin base/ 2 % gel (gram) 1 QL 1 / day erythromycin base/ethyl (base/ethanol 2 % med. swab, base/ethanol 2 % solution) 1

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

NEUAC GEL 1 QL 1.5 / day

NORITATE 3 NUVESSA 3

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

ONEXTON GEL PUMP 3 QL 1.967 / day

ROSADAN (CREAM, GEL) 1 ROSADAN (CREAM KIT, GEL KIT) 3 VANDAZOLE 1 ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) acyclovir 5 % oint. (g) 3 HCG

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

PAGE 39 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS docosanol 3

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

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

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

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVAR CLEANSER 1 AVAR 9.5-5% CLEANSING PADS 3 AVAR LS (10-2% CLEANSING PADS, CLEANSER) 3 AVAR LS 10%-2% FOAM 3 AVAR-E 1 AVAR-E GREEN 1 AVAR-E LS 3 AVC 3 3 BP 10-1 1 carbamide peroxide 3 chlorhexidine gluconate 20 % solution 3 CLARIFOAM EF 3 CLEANSING WASH 1 DERMAZENE 1 FEM PH 3

PAGE 40 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 1 hydrocortisone acetate/iodoquinol/aloe vera 1 hydrocortisone/iodoquinol 1 iodine 3 IODOFLEX 3 IODOSORB 3

KLARON 3 QL 4 / day

LUGOL'S STRONG IODINE SOLUTION 1 mafenide acetate 3 3

OVACE 3 QL 12 / day

OVACE PLUS 10% WASH 3 QL 15.767 / day

OVACE PLUS 10% CREAM 3 QL 2 / day

OVACE PLUS 9.8% FOAM 3 QL 3.334 / day

OVACE PLUS 9.8% LOTION 3 QL 4 / day

OVACE PLUS 10% 3 QL 8 / day

OVACE PLUS WASH 3 QL 12 / day (89 % liquid, 100 % crystals) 3 phenol liquid 1 PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% CLNSING CLOTH, 9.8- 4.8% CREAM, 9.8-4.8% LOTION) 3 polyhexamethylene /gauze bandage (biguan/gauze bandage 0.2%-2"x2" sponge, biguan/gauze bandage 0.2- 3 6x6.75 sponge, biguan/gauze bandage .2-4.5x4.1 bandage) povidone-iodine 100 % powder 3 RELAGARD 3 ROSANIL 1

PAGE 41 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 12 / day SEB-PREV 3 HCG selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1 selenium sulfide 52 %-55.5% powder 3 SELRX 3 SILVADENE 3 gel (gram) 3 crystals 3 silver nitrate (0.5 % solution, 10 % oint. (g), 25 % solution, 50 % solution) 1 silver ,mild 3 silver 1 % cream (g) 1 silver sulfadiazine 100 % powder 3 SSD 1 SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1

QL 12 / day sulfacetamide sodium (10 % cleanser, 10 % clnsr gel) 3 HCG sulfacetamide sodium 10 % shampoo 1 QL 8 / day sulfacetamide sodium 10 % suspension 1 QL 4 / day

PAGE 42 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfacetamide sodium/ (sodium/sulfur 8 %-4 % suspension, sodium/sulfur 9 %-4 % cleanser, sodium/sulfur 9 %-4.5 % cleanser, sodium/sulfur 9.8%-4.8% cleanser, sodium/sulfur 10 %-2 % cleanser, sodium/sulfur 10 %-2 % cream (g), sodium/sulfur 10 %-4 % med. pad, sodium/sulfur 10 1 %-5 % foam, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion, sodium/sulfur 10-5%(w/w) suspension) sulfacetamide sodium/sulfur 10-5%(w/w) cleanser 1 sulfacetamide sodium/sulfur/skin cleanser comb no.23 1 sulfacetamide sodium/sulfur/ 1

SULFACLEANSE 8-4 3 HCG

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

ULESFIA 3 ST

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

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

PAGE 43 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NATROBA 3 ST

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

SKLICE 3 ST spinosad 3 HCG

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

ALREX 3 QL 0.5 / day

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

DUREZOL 3

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

FML 3 QL 10 / fill

FML FORTE 3 QL 10 / fill

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

PAGE 44 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill

LOTEMAX 0.5% EYE DROPS 3 QL 21 / fill

LOTEMAX 0.5% EYE OINTMENT 3 QL 4 / fill

MAXIDEX 3 QL 10 / fill furoate 100 % powder 3 mometasone furoate 50 mcg spray/pump 1 QL 0.567 / day

NASONEX 3 QL 0.567 / day

OMNARIS 3 QL 0.434 / day

OMNIPRED 3 QL 21 / fill

PRED FORTE 3 QL 21 / fill

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

QNASL 3 QL 0.3 / day

QNASL CHILDREN 3

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

TRIESENCE 3 QL 1 / day

VERAMYST 3 QL 0.357 / day

VEXOL 3 QL 10 / fill

ZETONNA 3 QL 0.22 / day

EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS 2 PA

PAGE 45 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RESTASIS MULTIDOSE 2 PA

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

EENT ANTI-INFLAM. AGENTS

ACULAR 3 QL 15 / 30 days

ACULAR LS 3 QL 5 / fill

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

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

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

NEVANAC 3 QL 3/ fill

OCUFEN 3 QL 3/ fill

PROLENSA 3 QL 3/ fill

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

LEUKOTRIENE MODIFIERS

ACCOLATE 3 QL 2 / day montelukast sodium powder 3 montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab 1 / day chew, 10 mg tablet) 1 QL

PAGE 46 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG 1 / day TABLET CHEW, 10 MG TABLET) 3 QL 1 QL 2 / day

QL 4 / day zileuton 3 ST

QL 4 / day ZYFLO 3 ST

QL 4 / day ZYFLO CR 3 ST

MAST-CELL STABILIZERS

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

IRON PREPARATIONS

ACTIVE FE 3 GL Female

ATABEX EC 3 GL Female

CADEAU DHA 3 DIALYVITE 800 WITH IRON 3 DOTHELLE DHA 3

ELITE-OB 400 3 GL Female

ESCAVITE LQ 3

PAGE 47 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FEROCON 1 FEROTRINSIC 1 FERREX 150 FORTE 3 ferric sulfate 3 FERROCITE PLUS 1 ferrous fumarate 3 ferrous gluconate 3 ferrous sulfate, dried 3 FOCALGIN 90 DHA 3

FOCALGIN CA 3 GL Female

FOCALGIN DSS 3 GL Female

FOLIVANE-PLUS 3 FORTAVIT 3 FUSION PLUS 3 FUSION SPRINKLES 3 HEMATINIC PLUS 1 HEMATINIC WITH FOLIC ACID 1 HEMATRON-AF 3 HEMAX 1 HEMOCYTE PLUS 3 HEMOCYTE-F 1 ICAR-C PLUS 3

INFED 4 S

MACNATAL CN DHA 3 GL Female

MAXARON FORTE 3 MULTICHEW 3 MULTIGEN FOLIC 3

PAGE 48 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MULTIGEN PLUS 3 MYKIDZ IRON FL 3

MYNATAL CAPSULE 3 GL Female

MYNATAL ADVANCE 3 GL Female

MYNATAL PLUS 3 GL Female

MYNATAL-Z 3 GL Female

NEWGEN 3 NUTRICAP 3

O-CAL FA 3 GL Female

OBSTETRIX EC 3 GL Female

OBSTETRIX ONE 1 GL Female

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

PNV 29-1 3 GL Female

PNV-DHA + 3 GL Female

PNV-OMEGA 3 GL Female

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

PRENA1 PEARL 3 GL Female

PRENA1 TRUE 3 GL Female

PRENATABS RX 3 GL Female prenatal no.79/iron fum/folic acid/levomefolate/dha 3 GL Female prenatal vits with calcium #74/ferrous fumarate/folic acid 3 GL Female prenatal vits with calcium no.72/ferrous fumarate/folic acid 3

PAGE 49 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal vits with calcium no.74/ferrous fumarate/folic acid 3 GL Female

PREPLUS 3 GL Female

PRETAB 3 GL Female

PROFERRIN-FORTE 3 PROTECT IRON 3 PROVIDA DHA 3

PROVIDA OB 3 GL Female

R-NATAL OB 3 GL Female

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

TRI-TABS DHA 3 GL Female

TRICARE PRENATAL 3 GL Female

TRIFERIC 272 MG POWDER PACKET 4 S

TRINATE 3 GL Female

TRIVEEN-ONE 3 GL Female

VINATE DHA 3 GL Female

VINATE DHA RF 3 GL Female

VINATE GT 3 GL Female

VINATE II 3 GL Female

VINATE ONE 3 GL Female

VINATE ULTRA 3 GL Female

PAGE 50 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VIRT-ADVANCE 3 GL Female

VIRT-C DHA 3

VIRT-NATE 3 GL Female

VIRT-NATE DHA 3 GL Female

VIRT-PN 3 GL Female

VIRT-PN DHA 3 GL Female

VIRT-PN PLUS 3 GL Female

VITAFOL GUMMIES 3 GL Female

VITATRUE 3 GL Female

VIVA DHA 3 GL Female

VOL-TAB RX 3 GL Female

VP-CH-PNV 3 GL Female

VP- OB 3 GL Female

VP-HEME ONE 3 GL Female

VP-PNV-DHA 3

VYNATAL-FA 1 GL Female

ANTIARRHYTHMIC AGENTS

ANTIARRHYTHMICS, MISCELLANEOUS

DIGITEK 1 DIGOX 1 digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) 1 digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1 LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET) 2

PAGE 51 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANOXIN PEDIATRIC 2 sulfate 100 % crystals 3 (4 meq/ml syringe, 4 meq/ml vial) 1 CLASS IA ANTIARRHYTHMICS disopyramide phosphate 1 NORPACE 3 NORPACE CR 100 MG CAPSULE 2 NORPACE CR 150 MG CAPSULE 3 procainamide hcl powder 3 procainamide hcl 500 mg/ml vial 1 gluconate 324 mg tablet er 1 quinidine gluconate 80 mg/ml vial 1 quinidine sulfate (100 % powder, crystals) 3 quinidine sulfate (200 mg tablet, 300 mg tablet, 300 mg tablet er) 1 CLASS IB ANTIARRHYTHMICS

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2 DILANTIN-125 2 lidocaine hcl (20 mg/ml vial, 30 mg/3 ml syringe, 100mg/10ml syringe) 1 lidocaine hcl/pf 100mg/10ml syringe 1 lidocaine hcl/pf (hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial) 1 MED Medical Drug mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) 1 mexiletine hcl 100 % powder 3 PHENYTEK 2 powder 3 phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1

PAGE 52 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phenytoin sodium powder 3 phenytoin sodium extended 1 XYLOCAINE 2% VIAL 3 XYLOCAINE-MPF (AMPUL, VIAL) 3 CLASS IC ANTIARRHYTHMICS flecainide acetate 1 propafenone hcl (225 mg cap er 12h, 325 mg cap er 12h, 425 mg cap er 12h) 3 HCG propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg tablet) 1 RYTHMOL 3 RYTHMOL SR 3 CLASS II ANTIARRHYTHMICS acebutolol hcl (200 mg capsule, 400 mg capsule) 1 acebutolol hcl powder 3 atenolol 100 % powder 3 atenolol (25 mg tablet, 50 mg tablet) 1 LCG atenolol 100 mg tablet 1 atenolol/chlorthalidone 1 BETAPACE 3 BETAPACE AF 3 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 bisoprolol fumarate/ 1 LCG

CORGARD 3 CORZIDE 3

DUTOPROL 3 QL 2 / day

HEMANGEOL 4 S

PAGE 53 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INDERAL LA 3

INDERAL XL 3 ST

INNOPRAN XL 3 ST

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3 LOPRESSOR HCT 3 metoprolol succinate 1 metoprolol tartrate 100 % powder 3 metoprolol tartrate (25 mg tablet, 50 mg tablet) 1 LCG metoprolol tartrate (37.5 mg tablet, 75 mg tablet) 1 metoprolol tartrate 100 mg tablet 1 metoprolol tartrate/hydrochlorothiazide 1 nadolol powder 3 nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1 nadolol/bendroflumethiazide 1 pindolol 1 propranolol hcl powder 3 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa 1 24h, 160 mg cap sa 24h) propranolol hcl/hydrochlorothiazide 1 SECTRAL 3 SORINE 1 sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1

SOTYLIZE 3 TENORETIC 100 3 TENORETIC 50 3

PAGE 54 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TENORMIN 3 timolol maleate 100 % powder 3 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 TOPROL XL 3 ZEBETA 3 ZIAC 3 CLASS III ANTIARRHYTHMICS hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 CORDARONE 2 dofetilide 4 S

MULTAQ 3 PA

PACERONE 1

TIKOSYN 4 S

CLASS IV ANTIARRHYTHMICS powder 3

CALAN 3 QL 3 / day

CALAN SR 3 QL 1 / day

CARDIZEM 3 QL 4 / day

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

CARDIZEM CD 120 MG CAPSULE 3 QL 1 / day

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

CARDIZEM LA 120 MG TABLET 3 QL 4 / day

CARDIZEM LA 180 MG TABLET 3 QL 3 / day

CARDIZEM LA 240 MG TABLET 3 QL 2 / day

PAGE 55 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CARTIA XT 1 QL 1 / day

DILT XR 120 MG CAPSULE 1 QL 1 / day

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

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

MATZIM LA 180 MG TABLET 1 QL 3 / day

MATZIM LA 240 MG TABLET 1 QL 2 / day

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

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

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

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

PAGE 56 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil hcl 40 mg tablet 1

VERELAN 3 QL 1 / day

VERELAN PM 3 QL 1 / day

ANTIBACTERIALS

AMINOGLYCOSIDES amikacin 3 amikacin sulfate 1

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

PA KITABIS PAK 4 S neomycin sulfate powder 3 neomycin sulfate 500 mg tablet 1 sulfate 250 mg capsule 1 paromomycin sulfate 675 mcg/mg powder 3 sulfate powder 3 streptomycin sulfate 1 g vial 1

PA TOBI 4 S

PA TOBI PODHALER 4 S

PAGE 57 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tobramycin 900 mcg/mg powder 3

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

PA tobramycin/nebulizer 4 S

CHLORAMPHENICOL 3 chloramphenicol palmitate 3 MACROLIDES clarithromycin 100 % powder 3 E.E.S. 200 3 E.E.S. 400 3 ERY-TAB 3 ERYPED 200 2 ERYPED 400 3 ERYTHROCIN STEARATE 3 erythromycin base 250 mg capsule dr 1 erythromycin base (250 mg tablet, 500 mg tablet) 3 HCG erythromycin ethylsuccinate 200 mg/5ml susp recon 1 erythromycin ethylsuccinate 400 mg tablet 3 HCG

PCE 3 QUINOLONES

AVELOX 3 QL 21 / fill

AVELOX ABC PACK 3 QL 5 / day

PAGE 58 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CIPRO 10% SUSPENSION 3 QL 10 / day

CIPRO 5% SUSPENSION 3 QL 7 / day

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

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

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

QL 2 / day ciprofloxacin hcl 500 mg tablet 1 LCG ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr 1 QL 14 / 1 rx ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr 1 QL 28 / fill

QL 7 / day FACTIVE 3 PA

LEVAQUIN 3 QL 30 / fill levofloxacin 100 % powder 3 levofloxacin (250mg/10ml solution, 500mg/20ml solution) 1 levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill moxifloxacin hcl 100 % powder 3 moxifloxacin hcl 400 mg tablet 1 QL 21 / fill nalidixic acid 3 ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill

PAGE 59 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SULFONAMIDES (SYSTEMIC)

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

ACTICLATE 3 ST

ADOXA 3 ST

AVIDOXY 1 demeclocycline hcl 1

PAGE 60 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 7/ rx DORYX DR 200 MG TABLET 3 ST

DORYX DR 50 MG TABLET 3 ST

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

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

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

QL 1 / day minocycline hcl (90 mg tab er 24h, 135 mg tab er 24h) 3 HCG

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

MONDOXYNE NL 1 MONODOX 3

PAGE 61 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1 OKEBO 1

QL 1 / day ORACEA 3 ST hcl 3

PYLERA 2 QL 120 / 365 days

QL 1 / day SOLODYN 3 ST

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

BACITRACINS

BACIIM 1 bacitracin 50000 unit vial 1 GLYCOPEPTIDES

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

CLEOCIN HCL 3 QL 4 / day

CLEOCIN PALMITATE 3 QL 70/ day

CLEOCIN PHOS 150 MG/ML VIAL 3 MED Medical Drug

PAGE 62 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 300 MG/2 ML VIAL, 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) 3 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg 4 / day capsule) 1 QL clindamycin hcl powder 3 clindamycin palmitate hcl 75 mg/5 ml soln recon 1 QL 70/ day clindamycin phosphate (crystals, powder) 3 clindamycin phosphate 150 mg/ml vial 1 LINCOCIN 3 lincomycin hcl 1 QL 10 / day

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

QL 6 / 30 days SIVEXTRO 200 MG TABLET 3 PA

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

QL 2 / day ZYVOX 600 MG TABLET 3 PA

POLYMYXINS (colistimethate na) 390 mcg/mg powder 3 colistin (colistimethate na) 150 mg vial 1 colistin sulfate 3 COLY-MYCIN M PARENTERAL 3 polymyxin b sulfate 1 polymyxin b sulfate, micronized 3 polymyxin b sulfate,micronized 3

PAGE 63 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIFAMYCINS

MYCOBUTIN 3

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

XIFAXAN 3 PA

ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

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

ATROVENT HFA 3 QL 1.29 / day

B-DONNA 1 belladonna alkaloids 3 belladonna alkaloids leaf extract 3 BENTYL 10 MG/ML AMPUL 3 BENTYL (10 MG CAPSULE, 20 MG TABLET) 3 CANTIL 3 /clidinium bromide 1 clidinium bromide 3

PAGE 64 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CUVPOSA 3 dicyclomine hcl 100 % powder 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1 LCG dicyclomine hcl 10 mg/ml vial 1 hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine 2.5-.025mg tablet) 1

DONNATAL (ELIXIR, TABLET) 3 DUODOTE 3 ED-SPAZ 1 glycopyrrolate 100 % powder 3 glycopyrrolate (1 mg tablet, 2 mg tablet) 1

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

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

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

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

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

LEVBID 3 LEVSIN 0.5 MG/ML AMPUL 3

PAGE 65 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVSIN 0.125 MG TABLET 3 LEVSIN-SL 3 LIBRAX 3 LOMOTIL 3 methscopolamine bromide powder 3 methscopolamine bromide (2.5 mg tablet, 5 mg tablet) 1 methylscopolamine nitrate 3 NULEV 1 OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1 OSCIMIN SL 1 OSCIMIN SR 1 /hyoscyamine sulf/atropine sulf/scopolamine hb 1 PHENOHYTRO 1 propantheline bromide powder 3 propantheline bromide 15 mg tablet 1 ROBINUL 1 MG TABLET 3 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG/5 ML VIAL, 4 MG/20 ML VIAL) 3

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

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

SPIRIVA 2 QL 1 / day

SPIRIVA RESPIMAT 2 QL 1 / day

STIOLTO RESPIMAT 2 QL 0.134 / day

PAGE 66 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMAX 1 SYMAX DUOTAB 3 SYMAX-SL 1 SYMAX-SR 1

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

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

ANTICOAGULANTS, MISCELLANEOUS

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

COUMADIN 2 dicumarol 3 JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET, 4 MG TABLET, 5 MG TABLET) 1 LCG JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 1 sodium 100 % powder 3 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 LCG warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1

PAGE 67 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIRECT FACTOR XA INHIBITORS

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

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

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

QL 1 / day SAVAYSA 3 PA

XARELTO STARTER PACK 2

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

XARELTO 15 MG TABLET 2 QL 2 / day

DIRECT THROMBIN INHIBITORS

IPRIVASK 4 S

PRADAXA 2 QL 2 / day

HEPARINS enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe, 4 S 120mg/.8ml syringe, 150 mg/ml syringe, 300mg/3ml vial) FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 4 S 95,000 UNITS/3.8 ML VL) heparin sodium,porcine (5000/ml(1) cartridge, 20000/ml vial) 1 heparin sodium,porcine 180/mg powder 3 heparin sodium,porcine 10000/ml vial 1 MED Medical Drug heparin sodium,porcine/pf (sodium,porcine/pf 5000/0.5ml syringe, sodium,porcine/pf 5000/0.5ml vial) 1

PAGE 68 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 4 S MG/3 ML VIAL)

ANTICONVULSANTS, MISCELLANEOUS

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

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

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

QL 2 / day BRIVIACT 100 MG TABLET 3 PA

QL 8 / day BRIVIACT 25 MG TABLET 3 PA

QL 3 / day BRIVIACT 75 MG TABLET 3 PA powder 3 carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tablet, 300 mg 1 cpmp 12hr) carbamazepine (100 mg tab er 12h, 200 mg tab er 12h, 400 mg tab er 12h) 3 HCG

CARBATROL 2 DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 DEPAKOTE 3 DEPAKOTE ER 2

PAGE 69 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEPAKOTE SPRINKLE 2 divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mg 1 tablet dr)

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

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

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

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

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

LAMICTAL (BLUE) 3 LAMICTAL (GREEN) 3 LAMICTAL (ORANGE) 3 LAMICTAL ODT 3 LAMICTAL ODT (BLUE) 3 LAMICTAL ODT (GREEN) 3 LAMICTAL ODT (ORANGE) 3 LAMICTAL XR 3 LAMICTAL XR (BLUE) 3 LAMICTAL XR (GREEN) 3

PAGE 70 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LAMICTAL XR (ORANGE) 3 100 % powder 3 lamotrigine (25 mg tab er 24, 50 mg tab er 24, 100 mg tab er 24, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) 3 HCG lamotrigine (5 mg tb chw dsp, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab rapdis, 50(42)-100 tb rd dspk, 100 mg tab rapdis, 1 100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mg tablet) levetiracetam 100 % powder 3 levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 1 mg tablet) levetiracetam 500 mg/5ml solution 1 QL 946 / 30 days

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

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

QL 30 / day LYRICA 20 MG/ML ORAL SOLUTION 3 PA magnesium chloride 200 mg/ml vial 1 oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) 1

OXTELLAR XR 3

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

QL 9 / day POTIGA 50 MG TABLET 3 PA pregabalin 3

PAGE 71 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QUDEXY XR 3 ROWEEPRA 1

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

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

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

TROKENDI XR 3 valproic acid 250 mg capsule 1 valproic acid 100 % liquid 3 valproic acid (as sodium ) 100 % powder 3 valproic acid (as sodium salt) ( sodium) (250 mg/5ml solution, 500mg/10ml solution) 1

QL 6 / day vigabatrin 4 PA S

PAGE 72 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, STARTER KIT) 3

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

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

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

ATIVAN 2 MG TABLET 3 QL 5 / day

ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 ML VIAL, 40 MG/10 ML VIAL) 3 100 % powder 3 clonazepam (2 mg tab rapdis, 2 mg tablet) 1 QL 10 / day clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg 3 / day tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL dipotassium 15 mg tablet 1 QL 6 / day clorazepate dipotassium 3.75 mg tablet 1 QL 24 / day clorazepate dipotassium 7.5 mg tablet 1 QL 12 / day

DIASTAT 3 QL 0.07 / day

PAGE 73 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

LORAZEPAM INTENSOL 1 QL 5 / day

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

TRANXENE T-TAB 3.75 MG 3 QL 24 / day

TRANXENE T-TAB 7.5 MG 3 QL 12 / day

VALIUM 3 HYDANTOINS

CEREBYX 3 PEGANONE 3 SUCCINIMIDES

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

PAGE 74 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 3 QL 1 / day benactyzine hcl 3

QL 2 / day BUPROBAN 0 HCR bupropion hcl 100 % powder 3 bupropion hcl (200 mg tab er 12h, 200 mg tablet er) 1 QL 2 / day bupropion hcl 150 mg tab er 24h 1 QL 3 / day bupropion hcl 300 mg tab er 24h 1 QL 1 / day bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl (100 mg tab er 12h, 100 mg tablet er) 1 QL 4 / day

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

FORFIVO XL 3 QL 1 / day mirtazapine 100 % powder 3 mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 1 / day 30 mg tablet, 45 mg tab rapdis, 45 mg tablet) 1 QL mirtazapine 7.5 mg tablet 1 QL 2 / day

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

WELLBUTRIN 100 MG TABLET 3 QL 5 / day

WELLBUTRIN 75 MG TABLET 3 QL 6 / day

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

PAGE 75 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

WELLBUTRIN SR 100 MG TABLET 3 QL 4 / day

WELLBUTRIN XL 150 MG TABLET 3 QL 3 / day

WELLBUTRIN XL 300 MG TABLET 3 QL 1 / day

ZYBAN 3 QL 2 / day

MONOAMINE OXIDASE INHIBITORS

AZILECT 3 ELDEPRYL 3

EMSAM 3 QL 1 / day

MARPLAN 3 QL 6 / day

NARDIL 3 QL 6 / day

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

ZELAPAR 3 SEL.SEROTONIN,NOREPI INHIBITOR

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

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

QL 1 / day desvenlafaxine fumarate 3 HCG

PAGE 76 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

EFFEXOR XR 75 MG CAPSULE 3 QL 3 / day

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

IRENKA 3 QL 2 / day

KHEDEZLA 3 QL 1 / day

PRISTIQ 3 QL 1 / day

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 QL 2 / day 3 MG TABLET, TITRATION PACK) ST venlafaxine hcl 75 mg cap er 24h 1 QL 3 / day venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tab er 24, 75 mg tab er 24, 150 mg cap er 24h, 150 mg tab er 24, 225 mg tab er 1 QL 1 / day 24) venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet) 1 venlafaxine hcl 25 mg tablet 1 LCG

SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

BRISDELLE 3 QL 1 / day

CELEXA 3 QL 1 / day citalopram hydrobromide 10 mg/5 ml solution 1 QL 20 / day citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg QL 1 / day 1 tablet) LCG

PAGE 77 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS escitalopram oxalate 5 mg/5 ml solution 1 QL 20 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day escitalopram oxalate 20 mg tablet 1 QL 1 / day 3

QL 1 / day fluoxetine hcl 10 mg capsule 1 LCG

QL 4 / day fluoxetine hcl 20 mg capsule 1 LCG fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine hcl 90 mg capsule dr 1 QL 0.142 / day fluoxetine hcl 20 mg/5 ml solution 1 QL 20 / day

QL 1.5 / day fluoxetine hcl 10 mg tablet 1 LCG fluoxetine hcl 20 mg tablet 1 QL 4 / day fluoxetine hcl 60 mg tablet 1 QL 1.5 / day

QL 2 / day fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 3 HCG fluvoxamine maleate (25 mg tablet, 50 mg tablet) 1 QL 1 / day fluvoxamine maleate 100 mg tablet 1 QL 3 / day

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

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

LEXAPRO 20 MG TABLET 3 QL 1 / day

QL 1 / day olanzapine/fluoxetine hcl 3 AL At least 10 yrs old HCG

PAGE 78 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 2 / day 24h) 1 QL paroxetine hcl (12.5 mg tab er 24h, 40 mg tablet) 1 QL 1 / day

QL 1.5 / day paroxetine hcl 10 mg tablet 1 LCG

QL 1 / day paroxetine hcl 20 mg tablet 1 LCG paroxetine mesylate 1 QL 1 / day

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

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

PAXIL 10 MG TABLET 3 QL 1.5 / day

PAXIL 30 MG TABLET 3 QL 2 / day

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

PAXIL CR 12.5 MG TABLET 3 QL 1 / day

PEXEVA 3 QL 1 / day

PROZAC 10 MG PULVULE 3

PROZAC 20 MG PULVULE 3 QL 4 / day

PROZAC 40 MG PULVULE 3 QL 2 / day

PROZAC WEEKLY 3 QL 0.15 / day

SARAFEM 10 MG TABLET 3 QL 1.5 / day

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

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

PAGE 79 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day sertraline hcl 100 mg tablet 1 LCG

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

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

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

ZOLOFT 100 MG TABLET 3 QL 2 / day

SEROTONIN MODULATORS

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

QL 4 / day trazodone hcl 100 mg tablet 1 LCG

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

QL 3 / day trazodone hcl 50 mg tablet 1 LCG

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

PAGE 80 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIIBRYD 10-20 MG STARTER PACK 3

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

TRICYCLICS, OTHER NOREPI-RU INHIBITORS amitriptyline hcl powder 3 amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 1 LCG amitriptyline hcl/chlordiazepoxide 1 1 ANAFRANIL 3 clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) 3 HCG clomipramine hcl 100 % powder 3 desipramine hcl powder 3 desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 3 HCG doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 100 mg capsule) 1 LCG doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mg capsule) 1 doxepin hcl powder 3 hcl 100 % powder 3 imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG imipramine pamoate 3 HCG maprotiline hcl 1 NORPRAMIN 3 nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1 nortriptyline hcl powder 3 PAMELOR 3

PAGE 81 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS perphenazine/amitriptyline hcl 1 protriptyline hcl 1

SILENOR 3 QL 1 / day

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

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

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

PRECOSE 100 MG TABLET 3 QL 3 / day

PRECOSE 25 MG TABLET 3 QL 12 / day

PRECOSE 50 MG TABLET 3 QL 6 / day

AMYLINOMIMETICS

SYMLINPEN 120 2 QL 0.4 / day

SYMLINPEN 60 2 QL 0.2 / day

ANTIDIABETIC AGENTS, MISCELLANEOUS

PA KORLYM 4 S

WELCHOL 3.75G PACKET 2 QL 1 / day

PAGE 82 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

WELCHOL 625 MG TABLET 2 QL 6 / day

BIGUANIDES

ACTOPLUS MET 3 QL 3 / day

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

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

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

GLUCOPHAGE 1,000 MG TABLET 3 QL 2.5 / day

GLUCOPHAGE 500 MG TABLET 3 QL 5 / day

GLUCOPHAGE 850 MG TABLET 3 QL 3 / day

GLUCOPHAGE XR 500 MG TAB 3 QL 5 / day

GLUCOPHAGE XR 750 MG TAB 3 QL 3 / day

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

QL 8 / day glyburide/metformin hcl 1.25-250mg tablet 1 LCG

QL 2 / day INVOKAMET 2 ST

QL 2 / day INVOKAMET XR 2 ST

PAGE 83 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day JANUMET 2 ST

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

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

QL 2 / day JENTADUETO 2 ST

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

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

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

QL 2.5 / day metformin hcl 1000 mg tablet 1 LCG

QL 5 / day metformin hcl 500 mg tablet 1 LCG

QL 3 / day metformin hcl 850 mg tablet 1 LCG

QL 3 / day pioglitazone hcl/metformin hcl 3 HCG

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

PAGE 84 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RIOMET 3 QL 25 / day

QL 2 / day SYNJARDY 2 ST

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

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

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

QL 1 / day GLYXAMBI 3 PA

QL 1 / day JANUVIA 2 ST

QL 1 / day TRADJENTA 2 ST

INCRETIN MIMETICS

QL 0.15 / day BYDUREON 2 ST

QL .15 / day BYDUREON PEN 2 ST

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

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

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

PAGE 85 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.6 / day SOLIQUA 100-33 2 PA

QL 0.08 / day TRULICITY 2 ST

QL 0.3 / day VICTOZA 2-PAK 2 ST

QL 0.3 / day VICTOZA 3-PAK 2 ST

INSULINS

AFREZZA 3 PA

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

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

PRANDIN 2 MG TABLET 3 QL 8 / day

PAGE 86 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day

STARLIX 3 QL 3 / day

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

QL 1 / day INVOKANA 2 ST

QL 1 / day JARDIANCE 2 ST

SULFONYLUREAS

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

DIABETA 3

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

GLUCOTROL 3 GLUCOTROL XL 3 glyburide powder 3 glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG glyburide,micronized 1 LCG

GLYNASE 3 pioglitazone hcl/glimepiride 1 QL 1 / day

PAGE 87 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day

THIAZOLIDINEDIONES

ACTOS 3 QL 1 / day

QL 3 / day AVANDIA 2 MG TABLET 2 PA

QL 2 / day AVANDIA 4 MG TABLET 2 PA

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

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

QL 0.15 / day AKYNZEO 4 PA S

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

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

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

PAGE 88 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ondansetron hcl 24 mg tablet 1 QL 3 days ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 ml vial) 4 S ondansetron hcl/pf 4 mg/2 ml syringe 4 S

QL 0.144 / day SANCUSO 4 S

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

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

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

ZUPLENZ 3 QL 24 / 30 days

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

QL 0.67 / day CESAMET 4 PA S

QL 4 / day DICLEGIS 3 PA diphenidol hcl 3

QL 5 / day 3 HCG

PAGE 89 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EMEND TRIPACK 3 QL 3/ fill

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

EMEND 80 MG CAPSULE 3 QL 0.15 / day

QL 5 / day MARINOL 3 PA scopolamine 1

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

TRANSDERM-SCOP 2

QL 0.15 / day VARUBI 90 MG TABLET 4 PA S

ANTIHISTAMINES (GI DRUGS)

ANTIVERT 3 COMPAZINE 25 MG SUPPOSITORY 1 COMPAZINE (5 MG TABLET, 10 MG TABLET) 3 COMPRO 1 dimenhydrinate 50 mg/ml vial 1 hcl powder 3 meclizine hcl (12.5 mg tablet, 25 mg tablet) 1 prochlorperazine 1 prochlorperazine edisylate 100 % powder 3 prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial) 1 prochlorperazine maleate powder 3 prochlorperazine maleate (5 mg tablet, 10 mg tablet) 1 TIGAN 300 MG CAPSULE 3

PAGE 90 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TIGAN 100 MG/ML VIAL 3 trimethobenzamide hcl 300 mg capsule 1 trimethobenzamide hcl 100 % powder 3 (SYSTEMIC)

ALLYLAMINES

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

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

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

CRESEMBA 186 MG CAPSULE 3 PA

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

QL 0.4 / day DIFLUCAN 150 MG TABLET 3 GL Female

PAGE 91 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluconazole 100 % powder 3 fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1

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

ONMEL 3 PA

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

VFEND 40 MG/ML SUSPENSION 3 QL 20 / day

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

QL 20 / day voriconazole 200 mg/5ml susp recon 3 HCG

QL 4 / day voriconazole (50 mg tablet, 200 mg tablet) 3 HCG

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

PAGE 92 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PYRIMIDINES

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

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

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

PAGE 93 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXTINA 3 GYNAZOLE 1 3

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

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

NIZORAL 3 ORAVIG 3 nitrate 3 HCG

OXISTAT (CREAM, LOTION) 3

QL 1.5 / day TERAZOL 3 3 GL Female

TERAZOL 7 3 QL 1.5 / day

QL 1.5 / day 1 GL Female

VUSION 3 XOLEGEL 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)

MENTAX 3

PAGE 94 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 0.77% CREAM KIT 3 CICLODAN 0.77% CREAM 1

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

PENLAC 3 QL 0.22 / day

OXABOROLES

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

POLYENES (SKIN AND MUCOUS MEMBRANE)

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

NYSTOP 1 PEDIADERM AF 3

PAGE 95 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day

ALPHAGAN P 0.15% EYE DROPS 3 QL 0.4 / day tartrate (0.15 % drops, 0.2 % drops) 1 QL 0.4 / day brimonidine tartrate 100 % powder 3

COMBIGAN 2 QL 0.334 / day

SIMBRINZA 3 QL 0.4 / day

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

BETAGAN 3 QL 0.4 / day betaxolol hcl 0.5 % drops 1 QL 0.54 / day

BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day

BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day

BETOPTIC S 3 QL 0.54 / day carteolol hcl 1 QL 0.334 / day

COSOPT 3 QL 0.334 / day

COSOPT PF 3 QL 2 / day dorzolamide hcl/timolol maleate 1 QL 0.334 / day

ISTALOL 3 QL 0.286 / day levobunolol hcl 1 QL 0.4 / day metipranolol 1 QL 0.334 / day timolol maleate 0.5 % drops 1 QL 0.334 / day timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel) 1 QL 0.286 / day

PAGE 96 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TIMOPTIC 0.25% EYE DROPS 3 QL 0.286 / day

TIMOPTIC 0.5% EYE DROPS 3 QL 0.334 / day

TIMOPTIC OCUDOSE 3 QL 2 / day

TIMOPTIC-XE 3 QL 0.286 / day

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

AZOPT 2 QL 0.334 / day

DIAMOX SEQUELS 3 dorzolamide hcl 1 QL 0.4 / day methazolamide powder 3 methazolamide (25 mg tablet, 50 mg tablet) 1 NEPTAZANE 3

TRUSOPT 3 QL 0.4 / day

MIOTICS chloride 3 carbachol 3

ISOPTO CARPINE 3 QL 0.54 / day

MIOCHOL-E 3 MIOSTAT 3 PHOSPHOLINE IODIDE 3 pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1 QL 0.54 / day pilocarpine hcl powder 3

PAGE 97 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pilocarpine nitrate 3 OSMOTIC AGENTS mannitol powder 3 ANALOGS bimatoprost 0.03 % drops 1 QL 0.13 / day bimatoprost 0.03 % drop w/app 1 latanoprost 0.005 % drops 1 QL 0.13 / day latanoprost 100 % oil 3 LATISSE 3

LUMIGAN 2 QL 0.13 / day

TRAVATAN Z 2 QL 0.167 / day travoprost (benzalkonium) 1 QL 0.167 / day

XALATAN 3 QL 0.13 / day

ANTIHEMORRHAGIC AGENTS

ANTIHEPARIN AGENTS protamine sulfate 100 % powder 3 HEMOSTATICS

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

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

PAGE 98 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS desmopressin acetate powder 3 desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump) 1

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

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

MONSEL'S 3 OXYCEL 3

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

STIMATE 4 S

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

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

ULTRAFOAM 3 DRUGS

FIRST GENERATION

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

PAGE 99 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1 AL At least 2 yrs old chlorpheniramine maleate 3 clemastine fumarate powder 3 AL At least 2 yrs old clemastine fumarate 2.68 mg tablet 1 AL At least 2 yrs old hcl 100 % powder 3 AL At least 2 yrs old cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml At least 2 yrs old syrup) 1 AL dimenhydrinate 100 % powder 3 diphenhydramine hcl 12.5mg/5ml elixir 1 diphenhydramine hcl powder 3 diphenhydramine hcl (50 mg/ml syringe, 50 mg/ml vial) 1 doxylamine succinate 3

KARBINAL ER 3 AL At least 2 yrs old

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

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

CLARINEX 5 MG TABLET 3 QL 1 / day

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

PAGE 100 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine dihydrochloride powder 3 levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 30 / day levocetirizine dihydrochloride 5 mg tablet 1 QL 1 / day 3 loratadine, micronized 3

SEMPREX-D 3 QL 4 / day

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

XYZAL 5 MG TABLET 3 QL 1 / day

ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)

FIRST GENERATION ANTIHIST.(RESPIR TRACT)

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

CENTERGY 1 CENTERGY DM 1

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

PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML At least 2 yrs old AMPUL, 50 MG/ML VIAL) 3 AL phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1 promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 At least 2 yrs old mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL promethazine hcl 100 % powder 3 AL At least 2 yrs old promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 50 mg At least 2 yrs old tablet) 1 AL

PAGE 101 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

AL At least 2 yrs old promethazine/dextromethorphan 6.25-15/5 syrup 1 LCG

RESPA A.R. 3

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

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

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

SECOND GENERATION ANTIHIST(RESPIR TRACT)

DYMISTA 2 QL 0.8 / day

ANTIHYPOGLYCEMIC AGENTS

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS 3 PROGLYCEM 3 GLYCOGENOLYTIC AGENTS

GLUCAGEN 2 GLUCAGON EMERGENCY KIT 2 glucagon hcl 1 ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

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

PAGE 102 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

QL 0.15 / day KYNAMRO 4 PA S

LOVAZA 3 QL 4 / day powder 3 niacin (750 mg tab er 24h, 1000 mg tab er 24h) 1 QL 2 / day niacin 500 mg tab er 24h 1 QL 3 / day

NIACOR 3 QL 12 / day

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

NIASPAN ER 500 MG TABLET 3 QL 3 / day

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

QL 4 / day TRIKLO 3 HCG

QL 4 / day VASCEPA 3 ST

VIT 3 3 SEQUESTRANTS cholestyramine 3 cholestyramine (with sugar) 4 g powder 1 QL 24 / day cholestyramine (with sugar) 4 g powd pack 1 QL 4 / day

QL 24 / day cholestyramine/ 4 g powder 3 HCG

PAGE 103 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day cholestyramine/aspartame 4 g powd pack 3 HCG

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

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

QL 24 / day PREVALITE POWDER 3 HCG

QL 4 / day PREVALITE PACKET 3 HCG

QUESTRAN POWDER 3 QL 24 / day

QUESTRAN PACKET 3 QL 4 / day

QUESTRAN LIGHT 3 QL 24 / day

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

VYTORIN 3 QL 1 / day

ZETIA 3 QL 1 / day

FIBRIC ACID DERIVATIVES

ANTARA 30 MG CAPSULE 3 QL 2 / day

ANTARA 90 MG CAPSULE 3 QL 1 / day fenofibrate (150 mg capsule, 160 mg tablet) 1 QL 1 / day fenofibrate (40 mg tablet, 50 mg capsule) 1 QL 2 / day

PAGE 104 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenofibrate 120 mg tablet 1 QL 1 / day fenofibrate 54 mg tablet 1 QL 2 / day fenofibrate nanocrystallized 145mg tablet 1 QL 1 / day fenofibrate nanocrystallized 48 mg tablet 1 QL 2 / day fenofibrate,micronized (67 mg capsule, 130 mg capsule, 134 1 / day mg capsule, 200 mg capsule) 1 QL fenofibrate,micronized 43 mg capsule 1 QL 2 / day fenofibric acid 105 mg tablet 1 QL 1 / day fenofibric acid 35 mg tablet 1 QL 2 / day fenofibric acid (choline) 135 mg capsule dr 1 QL 1 / day fenofibric acid (choline) 45 mg capsule dr 1 QL 2 / day

FENOGLIDE 120 MG TABLET 3 QL 1 / day

FENOGLIDE 40 MG TABLET 3 QL 2 / day

FIBRICOR 105 MG TABLET 3 QL 1 / day

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

LIPOFEN 150 MG CAPSULE 3 QL 1 / day

LIPOFEN 50 MG CAPSULE 3 QL 2 / day

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

LOFIBRA 54 MG TABLET 3 QL 2 / day

LOPID 3 QL 2 / day

TRICOR 145 MG TABLET 3 QL 1 / day

PAGE 105 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRICOR 48 MG TABLET 3 QL 2 / day

TRIGLIDE 3 QL 1 / day

TRILIPIX DR 135 MG CAPSULE 3 QL 1 / day

TRILIPIX DR 45 MG CAPSULE 3 QL 2 / day

HMG-COA REDUCTASE INHIBITORS

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

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

ALTOPREV 3 QL 1 / day

QL 1 / day besylate/atorvastatin calcium 3 HCG atorvastatin calcium 1 QL 1 / day

CADUET 3 QL 1 / day

CRESTOR 3 QL 1 / day fluvastatin sodium 40 mg capsule 1 QL 2 / day fluvastatin sodium (20 mg capsule, 80 mg tab er 24h) 1 QL 1 / day

LESCOL 20 MG CAPSULE 3 QL 1 / day

LESCOL 40 MG CAPSULE 3 QL 2 / day

LESCOL XL 3

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

LIPITOR 80 MG TABLET 3

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

PRAVACHOL 3 QL 1 / day

PAGE 106 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

QL 1.5 / day simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG

QL 1 / day simvastatin 5 mg tablet 1 LCG

QL 1 / day simvastatin 80 mg tablet 1 PA

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

ZOCOR 5 MG TABLET 3 QL 1 / day

QL 1 / day ZOCOR 80 MG TABLET 3 PA

PCSK9 INHIBITORS

QL 0.08 / day PA PRALUENT PEN 4 S PS

QL 0.08 / day PA PRALUENT SYRINGE 4 S PS

PAGE 107 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.13 / day PA REPATHA PUSHTRONEX 4 S PS

QL 0.08 / day PA REPATHA SURECLICK 4 S PS

QL 0.08 / day PA REPATHA SYRINGE 4 S PS

ANTIMIGRAINE AGENTS

SELECTIVE SEROTONIN AGONISTS

QL 0.4 / day almotriptan malate 3 HCG

ALSUMA 3 QL 0.167 / day

AMERGE 3 QL 0.3 / day

AXERT 3 QL 0.4 / day

QL 0.4 / day eletriptan hbr 3 HCG

FROVA 3 QL 0.6 / day

QL 0.6 / day frovatriptan succinate 3 HCG

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

PAGE 108 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

MAXALT 3 QL 0.6 / day

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

ONZETRA XSAIL 3 ST

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

QL 6 / 30 days sumatriptan (5 mg spray, 20 mg spray) 3 HCG sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen QL 0.167 / day injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml 3 vial) HCG sumatriptan succinate 100 % powder 3 sumatriptan succinate 6 mg/0.5ml syringe 1 QL 0.167 / day sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg 0.3 / day tablet) 1 QL

SUMAVEL DOSEPRO 3 QL 0.134 / day

QL 0.3 / day TREXIMET 3 ST

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

QL 0.2 / day zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis) 3 HCG

PAGE 109 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

ZOMIG ZMT 3 QL 0.2 / day

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS clofazimine 3 98 % powder 3 dapsone (25 mg tablet, 100 mg tablet) 1 ANTITUBERCULOSIS AGENTS sodium 3 aminosalicylic acid 3 BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3

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

SIRTURO 3 PA

PAGE 110 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRECATOR 3 ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS) hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1 amantadine hcl powder 3 CATECHOL-O-(COMT)INHIB. carbidopa/levodopa/entacapone 1 COMTAN 3 entacapone 1 STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 TASMAR 3 tolcapone 1 PRECURSORS carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 1 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg-200mg tablet er)

QL 1 / day DUOPA 4 PA S levodopa 3

PAGE 111 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RYTARY 3 SINEMET 10-100 3 SINEMET 25-100 3 SINEMET 25-250 3 SINEMET CR 3 B INHIBITORS

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

ANTIPROTOZOALS

AMEBICIDES

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

MALARONE 3 PA hcl 1

PAGE 112 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PLAQUENIL 3 phosphate 1 3

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

QL 42 / 365 days quinine sulfate 324 mg capsule 1 PA quinine sulfate powder 3 , MISCELLANEOUS

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

IMPAVIDO 4 S

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

ANTIPSYCHOTICS, MISCELLANEOUS

ADASUVE 3 AL At least 18 yrs old loxapine succinate 1 AL At least 18 yrs old molindone hcl 1

PAGE 113 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORAP 3 pimozide 1 ATYPICAL ANTIPSYCHOTICS

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

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

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

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

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

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

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

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

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

PAGE 114 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

QL 9 / day clozapine (100 mg tab rapdis, 100 mg tablet) 1 AL At least 18 yrs old clozapine (150 mg tab rapdis, 200 mg tab rapdis) 1 AL At least 18 yrs old

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

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

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

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

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

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

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

GEODON 20 MG/ML VIAL 3 ST

ST INVEGA 3 AL At least 12 yrs old

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

PAGE 115 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

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

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

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

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

QL 2 / day NUPLAZID 4 PA S

PAGE 116 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day olanzapine 10 mg tablet 1 QL 3 / day olanzapine 15 mg tablet 1 QL 2 / day olanzapine 20 mg tablet 1 QL 1 / day olanzapine 7.5 mg tablet 1 QL 4 / day

QL 3 / day olanzapine 10 mg tab rapdis 3 HCG

QL 2 / day olanzapine 15 mg tab rapdis 3 HCG

QL 1 / day olanzapine 20 mg tab rapdis 3 HCG

QL 6 / day olanzapine 5 mg tab rapdis 3 HCG olanzapine 10 mg vial 1

AL At least 12 yrs old paliperidone 3 HCG

QL 2 / day quetiapine fumarate (300 mg tab er 24h, 400 mg tab er 24h) 3 AL At least 10 yrs old HCG

QL 5 / day quetiapine fumarate 150 mg tab er 24h 3 AL At least 10 yrs old HCG

QL 4 / day quetiapine fumarate 200 mg tab er 24h 3 AL At least 10 yrs old HCG

QL 6 / day quetiapine fumarate 50 mg tab er 24h 3 AL At least 10 yrs old HCG

PAGE 117 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

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

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

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

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

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

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

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

PAGE 118 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

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

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

QL 8 / day risperidone (0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab At least 5 yrs old rapdis, 2 mg tab rapdis) 3 AL HCG

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

QL 4 / day risperidone 4 mg tab rapdis 3 AL At least 5 yrs old HCG

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

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

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

PAGE 119 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old

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

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

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

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

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

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

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

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

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

PAGE 120 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

ZYPREXA 10 MG VIAL 3 AL At least 13 yrs old

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

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

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

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

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

BUTYROPHENONES

HALDOL 3 HALDOL DECANOATE 100 3 HALDOL DECANOATE 50 3 powder 3 haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) 1 haloperidol 1 mg tablet 1 LCG 50 mg/ml ampul 1

PAGE 121 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS haloperidol decanoate 100 % powder 3 haloperidol decanoate (50 mg/ml vial, 100 mg/ml ampul, 100 mg/ml vial) 1 haloperidol lactate 5 mg/ml ampul 1 haloperidol lactate 2 mg/ml oral conc 1 haloperidol lactate 5 mg/ml vial 1 PHENOTHIAZINES acepromazine maleate 3 hcl 25 mg/ml ampul 1 chlorpromazine hcl 100 % powder 3 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 3 HCG fluphenazine decanoate (2.5 %(w/w) oil, 100 % liquid) 3 fluphenazine decanoate 25 mg/ml vial 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1 fluphenazine hcl 2.5 mg/ml vial 1 perphenazine 100 % powder 3 AL At least 18 yrs old perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg At least 18 yrs old tablet) 1 AL promazine hcl 3 thioridazine hcl 100 % powder 3 thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 trifluoperazine hcl 1 THIOXANTHENES thiothixene 1

PAGE 122 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

QL 2 / day FUZEON 4 S

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

HIV INTEGRASE INHIBITORS

GENVOYA 4 S

S ISENTRESS 100 MG POWDER PACKET 4 PS

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

S ISENTRESS HD 4 PS

STRIBILD 4 S

TIVICAY 4 S

TRIUMEQ 4 S

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

S ATRIPLA 4 PS

S COMPLERA 4 PS

S EDURANT 4 PS

S INTELENCE 4 PS

PAGE 123 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 4 S

ODEFSEY 4 S

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

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

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

VIRAMUNE XR 4 S

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

COMBIVIR 4 S

QL 1 / day DESCOVY 4 S didanosine 4 S

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

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

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

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

PAGE 124 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

TRIZIVIR 4 S

S TRUVADA 4 PS

S VIDEX 4 PS

VIDEX EC 4 S

VIREAD POWDER 4 S

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

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

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

HIV INHIBITORS

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

S CRIXIVAN 4 PS

EVOTAZ 4 S fosamprenavir calcium 4 S

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

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

PAGE 125 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

S lopinavir/ 4 PS

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

PREZCOBIX 4 S

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

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

S REYATAZ 50 MG POWDER PACKET 4 PS

QL 2 / day TECHNIVIE 4 PA S

QL 4 / day VIEKIRA PAK 4 PA S

QL 3 / day VIEKIRA XR 4 PA S

S VIRACEPT 4 PS

ANTITHROMBOTIC AGENTS

PLATELET-AGGREGATION INHIBITORS

AGGRENOX 3 QL 2 / day

PAGE 126 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aspirin 100 % powder 3

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

QL 2 / day aspirin/dipyridamole 3 HCG

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

DURLAZA 3 QL 1 / day

EFFIENT 3 QL 1 / day

FIORINAL 3 QL 6 / day

LEVACET 3 PA

PERSANTINE 3 QL 4 / day

PLAVIX 3 QL 1 / day

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

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

QL 1 / day ZONTIVITY 3 PA

PAGE 127 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PLATELET-REDUCING AGENTS

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

THROMBOLYTIC AGENTS

CATHFLO ACTIVASE 4 S

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

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

PA CUVITRU 4 S

PA GAMMAGARD LIQUID 4 S

PA GAMMAKED 4 S

PA GAMUNEX-C 4 S

PA HIZENTRA 4 S

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

HYPERRAB S-D 4 S

HYPERTET S-D 4 S

PA HYQVIA 4 S

PAGE 128 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA HYQVIA IG COMPONENT 4 S

IMOGAM RABIES-HT 4 S

NABI-HB 4 S

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

TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 0 HCR

BOOSTRIX TDAP (SYRINGE, VIAL) 0 HCR

DAPTACEL DTAP 0 HCR

INFANRIX DTAP (SYRINGE, VIAL) 2 PEDIARIX 2

TENIVAC (SYRINGE, VIAL) 0 HCR tetanus and diphtheria toxoids, adult 0 HCR tetanus,diphtheria toxoid ped/pf 1 VACCINES

ACTHIB VACCINE WITH DILUENT 2

AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR bcg vaccine, live/pf 3 BEXSERO 2 BIOTHRAX 2

CERVARIX 0 HCR

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 0 HCR

ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) 0 HCR

PAGE 129 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EZ FLU 16-17 (FLUZON QUAD PED) 0 HCR

EZ FLU 2016-2017 (AFLURIA) 0 HCR

EZ FLU 2016-2017 (FLUVIRIN) 0 HCR

FLUAD 2016-2017 0 HCR

FLUARIX QUAD 2016-2017 0 HCR

FLUBLOK 2016-2017 0 HCR

FLUCELVAX QUAD 2016-2017 0 HCR

FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL) 0 HCR

FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

FLUZONE HIGH-DOSE 2016-2017 0 HCR

FLUZONE INTRADERM QUAD 2016-17 0 HCR

FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

FLUZONE QUAD PEDI 2016-2017 0 HCR

GARDASIL (SYRINGE, VIAL) 0 HCR

GARDASIL 9 (9 SYRINGE, 9 VIAL) 0 HCR

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 0 HCR

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

M-M-R II VACCINE 0 HCR

MENACTRA 0 HCR

PAGE 130 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MENHIBRIX 2

MENOMUNE-A-C-Y-W-135 0 HCR

MENVEO A-C-Y-W-135-DIP 0 HCR

MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 0 HCR

PREVNAR 13 0 HCR

PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 0 HCR

ROTARIX 2 ROTATEQ 2 STAMARIL 2

THERACYS 4 S

TRUMENBA 3

TWINRIX (SYRINGE, VIAL) 0 HCR

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2 VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 0 HCR

VARIVAX VACCINE 0 HCR

VAXCHORA ACTIVE COMPONENT 2

PAGE 131 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2 YF-VAX 2

ZOSTAVAX 0 HCR

ANTIULCER AGENTS AND ACID SUPPRESSANTS

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

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

ARTHROTEC 50 3 ARTHROTEC 75 3 CYTOTEC 3

PAGE 132 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diclofenac sodium/misoprostol (sodium/misoprostol 50 tab ir dr, sodium/misoprostol 75 tab ir dr) 1 misoprostol 1 % powder 3 misoprostol (100 mcg tablet, 200 mcg tablet) 1 PROTECTANTS

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

QL 2 / day ACIPHEX 3 ST

ACIPHEX SPRINKLE 3 QL 1 / day

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

QL 1 / day esomeprazole magnesium 40 mg capsule dr 3 HCG esomeprazole 1 QL 1 / day lansoprazole 15 mg capsule dr 1 lansoprazole 30 mg capsule dr 1 QL 1 / day lansoprazole 100 % powder 3

QL 112 / 365 days lansoprazole/amoxicillin trihydrate/clarithromycin 3 HCG

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

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

PAGE 133 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OMECLAMOX-PAK 3 QL 80 / 365 days (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule 1 / day dr) 1 QL omeprazole 100 % powder 3 omeprazole/sodium bicarbonate (omeprazole/sodium 20- 1680mg packet, omeprazole/sodium 20mg-1.1g capsule, 1 omeprazole/sodium 40-1680mg packet) omeprazole/sodium bicarbonate 40mg-1.1g capsule 3 HCG

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

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

PREVPAC 3 QL 112 / 365 days

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

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

PROTONIX 40 MG SUSPENSION 3 QL 1 / day

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

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

QL 1 / day ZEGERID 40 MG PACKET 3 ST

ANTIVIRALS (SYSTEMIC)

ADAMANTANES

FLUMADINE 3

PAGE 134 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl 1 ANTIVIRALS, MISCELLANEOUS

2-deoxy-d-glucose powder 3 INTERFERONS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 PA MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS 4 VIL) S

PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4 S

PA PEGASYS PROCLICK 4 S

PA PEGINTRON 4 S PS

PA PEGINTRON REDIPEN 4 S PS

PA SYLATRON 4 S

NEURAMINIDASE INHIBITORS oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 mg 20 / 365 days capsule) 1 QL oseltamivir phosphate 6 mg/ml susp recon 1 QL 180 / 30 days

RELENZA 3 QL 40 / 365 days

TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) 3 QL 20 / 365 days

TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 / 30 days

PAGE 135 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NUCLEOSIDES AND acyclovir 100 % powder 3 acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1 adefovir dipivoxil 4 S

QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 4 PA S

QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4 PA S cidofovir 100 % powder 3

QL 6 / day COPEGUS 4 PA S

QL 1 / day entecavir 4 S famciclovir 1 FAMVIR 3

QL 1 / day HEPSERA 4 PA S

QL 2 / day MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 4 PA S

QL 6 / day MODERIBA 200 MG TABLET 4 PA S

PAGE 136 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day REBETOL 200 MG CAPSULE 4 PA S

QL 30 / day REBETOL 40 MG/ML SOLUTION 4 PA S

QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 4 PA S

QL 3 / day RIBASPHERE 400 MG TABLET 4 PA S

QL 2 / day RIBASPHERE 600 MG TABLET 4 PA S

QL 2 / day RIBASPHERE RIBAPAK 4 PA S

QL 2 / day RIBATAB 4 PA S

QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 4 PA S ribavirin 6 g vial-neb 1

QL 2 / fill SITAVIG 3 PA AL At least 18 yrs old

PAGE 137 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day TYZEKA 4 PA S valacyclovir hcl 100 % powder 3 valacyclovir hcl (500 mg tablet, 1000 mg tablet) 3 HCG

VALCYTE 50 MG/ML SOLUTION 3

VALCYTE 450 MG TABLET 3 QL 4 / day valganciclovir hcl 50 mg/ml soln recon 1 valganciclovir hcl 450 mg tablet 1 QL 4 / day

VALTREX 3

QL 1 / day PA VEMLIDY 4 AL At least 18 yrs old S vidarabine 3 vidarabine monohydrate 3 VIRAZOLE 3 ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET) 3 ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

QL 1 / day AMBIEN 3 ST

QL 1 / day AMBIEN CR 3 ST

BELSOMRA 3 ST buspirone hcl 100 % powder 3

PAGE 138 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 1 hydrate 3 PA dichloralphenazone 3 droperidol powder 3 droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1

QL 1 / day EDLUAR 3 ST (1 mg tablet, 2 mg tablet) 1 QL 1 / day

QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old

QL 1 / day HETLIOZ 4 PA S hydroxyzine hcl powder 3 AL At least 2 yrs old hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg At least 2 yrs old tablet, 50 mg tablet, 50 mg/25ml solution) 1 AL hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) 1 AL At least 2 yrs old hydroxyzine pamoate (25 mg capsule, 50 mg capsule) 1 AL At least 2 yrs old hydroxyzine pamoate 100 mg capsule 1 hydroxyzine pamoate powder 3

QL 1 / day INTERMEZZO 3 ST

QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) 3 ST

QL 1 / day LUNESTA 3 MG TABLET 3 ST AL Up to 65 yrs old

PAGE 139 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 1

PHENADOZ 1 AL At least 2 yrs old

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg At least 2 yrs old supp.rect) 1 AL

PROMETHEGAN 1 AL At least 2 yrs old

QL 1 / day ROZEREM 3 ST

QL 1 / day SONATA 3 ST 3

VISTARIL 3 AL At least 2 yrs old 1 QL 1 / day tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg 1 / day tablet, 6.25 mg tab mphase, 10 mg tablet, 12.5 mg tab mphase) 1 QL

ZOLPIMIST 3 QL 0.257 / day

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

AMYTAL SODIUM 3 butalbital 3 BUTISOL SODIUM 3 NEMBUTAL SODIUM 3 sodium 100 % powder 3 pentobarbital sodium 50 mg/ml vial 1 phenobarbital powder 3 SECONAL SODIUM 3

PAGE 140 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 100 % powder 3 alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h) 1 QL 1 / day alprazolam 3 mg tab er 24h 1 QL 3 / day alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab 4 / day rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL alprazolam (2 mg tab er 24h, 2 mg tab rapdis, 2 mg tablet) 1 QL 5 / day

ALPRAZOLAM INTENSOL 3 QL 10 / day chlordiazepoxide hcl 10 mg capsule 1 QL 30 / day chlordiazepoxide hcl 25 mg capsule 1 QL 12 / day chlordiazepoxide hcl 5 mg capsule 1 QL 4 / day

DORAL 3 QL 1 / day 1 QL 1 / day hcl 1 QL 1 / day

HALCION 3 QL 2 / day 3 midazolam hcl 2 mg/ml syrup 1 midazolam hcl (2 mg/2 ml vial, 5 mg/5 ml vial, 5 mg/ml vial, 5 mg/ml(1) vial, 10 mg/10ml vial, 10 mg/2 ml vial) 1 midazolam hcl/pf (hcl/pf 2 mg/2 ml vial, hcl/pf 5 mg/5 ml vial, hcl/pf 5 mg/ml syringe, hcl/pf 5 mg/ml(1) vial, hcl/pf 10 mg/2 1 ml vial) 1 QL 4 / day 1 QL 1 / day

RESTORIL 3 QL 1 / day 1 QL 1 / day

PAGE 141 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day

XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day

XANAX 2 MG TABLET 3 QL 5 / day

XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 1 / day

XANAX XR 2 MG TABLET 3 QL 5 / day

XANAX XR 3 MG TABLET 3 QL 3 / day

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 0 HCR

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG QL 2 / day 0 TABLET) HCR polacrilex 3

NICOTROL 3 QL 16/day

NICOTROL NS 3 QL 20 / day

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

ARICEPT (5 MG TABLET, 10 MG TABLET) 3 AL At least 40 yrs old

ST ARICEPT 23 MG TABLET 3 AL At least 40 yrs old bethanechol chloride powder 3 bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) 1 cevimeline hcl 3 HCG donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, At least 40 yrs old 10 mg tablet, 23 mg tablet) 1 AL

PAGE 142 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EVOXAC 3 EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6 MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 3 AL At least 40 yrs old 13.3 MG/24HR PATCH) galantamine hbr (8 mg cap24h pel, 16 mg cap24h pel, 24 mg cap24h pel) 3 HCG galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12 mg tablet) 1 hcl 1 MESTINON 60 MG/5 ML SYRUP 2 MESTINON (60 MG TABLET, 180 MG TIMESPAN) 3 NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK) 3 ST neostigmine methylsulfate 100 % powder 3 physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine bromide 100 % powder 3 pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1 RAZADYNE 3 RAZADYNE ER 3 REGONOL 3 rivastigmine 1 AL At least 40 yrs old rivastigmine tartrate 1 AL At least 40 yrs old

SALAGEN 3 URECHOLINE 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS isometheptene mucate 3

PAGE 143 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ 2 QL 1 / day

BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-1-ADRENERGIC AGONISTS dopamine hcl powder 3 BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)

NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS

BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day

BYSTOLIC 2.5 MG TABLET 2 QL 1 / day

BYSTOLIC 20 MG TABLET 2 QL 2 / day

BYVALSON 2 QL 1 / day

BLOOD FORMATION, , THROMBOSIS

HEMATOPOIETIC AGENTS

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 4 S MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 PS MCG/1 ML SYRINGE)

PA EPOGEN 4 S

PA GRANIX 4 S

PA LEUKINE 4 S

PAGE 144 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA MIRCERA 4 S

PA MOZOBIL 4 S

PA NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4 S PS

PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4 S PS

PA PROCRIT 4 S PS

PA PROMACTA 4 S

QL 90 / 30 days ZARXIO 4 PA S

HEMORRHEOLOGIC AGENTS pentoxifylline 100 % powder 3 pentoxifylline 400 mg tablet er 1 BRONCHODILATORS

XANTHINE DERIVATIVES aminophylline powder 3 dyphylline 3 ELIXOPHYLLIN 3 THEO-24 3

PAGE 145 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THEOCHRON 1 theophylline anhydrous powder 3 theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 1 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h) CALCIUM-CHANNEL BLOCKING AGENTS

DIHYDROPYRIDINES 1 QL 1 / day isradipine 1 QL 2 / day

QL 1 / day 3 HCG

SULAR 3 QL 1 / day

CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)

CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)

TARKA 3 QL 1 / day trandolapril/verapamil hcl 1 DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)

ADALAT CC 30 MG TABLET 3 QL 1 / day

ADALAT CC 60 MG TABLET 3 QL 2 / day

ADALAT CC 90 MG TABLET 3

AFEDITAB CR 30 MG TABLET 1 QL 1 / day

AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besylate 100 % powder 3 amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1 QL 1 / day amlodipine besylate/benazepril hcl 1 QL 1 / day

PAGE 146 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day amlodipine besylate/olmesartan medoxomil 3 HCG amlodipine besylate/valsartan (besylate/valsartan 5 mg-320mg tablet, besylate/valsartan 10mg-160mg tablet, 1 QL 1 / day besylate/valsartan 10mg-320mg tablet) amlodipine besylate/valsartan 5 mg-160mg tablet 1 QL 2 / day

QL 1 / day amlodipine besylate/valsartan/hydrochlorothiazide 3 HCG

AZOR 3 QL 1 / day

CARDENE SR 30 MG CAPSULE 3 QL 2 / day

EXFORGE 3 QL 1 / day

EXFORGE HCT 3 QL 1 / day

LOTREL 3 QL 1 / day hcl (20 mg capsule, 30 mg capsule) 3 HCG

NIFEDICAL XL 1 QL 1 / day (10 mg capsule, 20 mg capsule) 1 QL 4 / day nifedipine powder 3 nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg tab er 24, 1 / day 90 mg tablet er) 1 QL nifedipine (60 mg tab er 24, 60 mg tablet er) 1 QL 2 / day 30 mg capsule 1 nimodipine 100 % powder 3

NORVASC 3 QL 1 / day

NYMALIZE 60 MG/20 ML SOLUTION 3 QL 120 / day

PROCARDIA 3 QL 4 / day

PROCARDIA XL 3 QL 1 / day

PAGE 147 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TEKAMLO 3 QL 1 / day

CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

QL 2 / day CORLANOR 2 ST

RANEXA 2 QL 2 / day

CARDIOVASCULAR DRUGS

BETA-ADRENERGIC BLOCKING AGENTS

LEVATOL 3 CALCIUM-CHANNEL BLOCKING AGENTS

QL 1 / day PRESTALIA 3 ST /amlodipine besylate 1 QL 1 / day

TWYNSTA 3 QL 1 / day

SCLEROSING AGENTS

SCLEROSOL 3 sodium tetradecyl sulfate (27 % solution, powder) 3 talc 3 VASODILATING AGENTS betahistine hcl 100 % powder 3 cyclandelate 3 nylidrin hcl 3

PAGE 148 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CENTRAL AGENTS

ANTIMANIC AGENTS carbonate 99 % powder 3 lithium carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mg capsule) 1 lithium citrate 1 LITHOBID 3 CENTRAL NERVOUS SYSTEM AGENTS, MISC. calcium 3 HCG

QL 1 / day PA ADDYI 3 GL Female AL 18 to 60 yrs old

QL 2 / day hcl 1 AL At least 6 yrs old

QL 4 / day PA AUSTEDO 4 AL At least 18 yrs old S carbidopa powder 3 carbidopa 25 mg tablet 1 flibanserin 3 100 % powder 3 guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er 24h) 1 guanfacine hcl (1 mg tablet, 2 mg tablet) 1 idebenone 3

QL 2 / day PA INGREZZA 40 MG CAPSULE 4 AL At least 18 yrs old S

PAGE 149 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INTUNIV 3 QL 1 / day

LODOSYN 3 hcl 100 % powder 3 AL At least 40 yrs old

QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old memantine hcl 5 mg-10 mg tab ds pk 1 AL At least 40 yrs old

QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old

QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old

NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG At least 40 yrs old TITRATION PK, 10 MG TABLET) 3 AL

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG ST 3 CAPSULE, 28 MG CAPSULE, TITRATION PACK) AL At least 40 yrs old

NUEDEXTA 2 PA

RILUTEK 3 1

QL 2 / day STRATTERA 3 AL At least 6 yrs old

TENEX 3

PA tetrabenazine 4 S

PA XENAZINE 4 S

QL 18 / day XYREM 4 PA S

PAGE 150 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OPIATE ANTAGONISTS

DEPADE 1 naloxone hcl powder 3 naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml syringe) 1 naltrexone hcl 100 % powder 3 naltrexone hcl 50 mg tablet 1 naltrexone hydrochloride dihydrate 3

NARCAN 2 MG NASAL SPRAY 3 QL 5 / 30 days

NARCAN 4 MG NASAL SPRAY 3 QL 2 / 30 days

REVIA 3

PA VIVITROL 380 MG VIAL 4 S

CEPHALOSPORINS

FIRST GENERATION CEPHALOSPORINS cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) 1 cefazolin sodium (10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial) 1 cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 1 750 mg capsule)

QL 4 / day DAXBIA 3 ST

KEFLEX 3 FOURTH GENERATION CEPHALOSPORINS cefepime hcl 1 MAXIPIME (1 VIAL, 2 VIAL) 3

PAGE 151 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SECOND GENERATION CEPHALOSPORINS cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 mg capsule) 1 cefaclor 500 mg tab er 12h 1 QL 20 / 30 days

CEFOTAN 3 cefotetan disodium (1 g vial, 2 g vial) 1 cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) 1

CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2 CEFTIN (250 MG TABLET, 500 MG TABLET) 3 cefuroxime axetil 1 cefuroxime sodium 750 mg vial 1 ZINACEF 750 MG VIAL 3 THIRD GENERATION CEPHALOSPORINS

CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1 cefditoren pivoxil 1

QL 1200 / 90 days cefixime 3 HCG cefotaxime sodium 1 cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) 1 ceftazidime 100 % powder 3 ceftazidime (1 g vial, 2 g vial, 6 g vial) 1 ceftibuten (180 mg/5ml susp recon, 400 mg capsule) 3 HCG ceftriaxone sodium powder 3 ceftriaxone sodium (1 g vial, 2 g vial, 10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial) 1

PAGE 152 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLAFORAN (1 GM VIAL, 2 GM VIAL, 10 GM VIAL, 500 MG VIAL) 3 FORTAZ (1 GM VIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) 3 SPECTRACEF 3 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) 3 SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML 1200 / 90 days SUSPENSION) 3 QL

TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1 (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS ()

AEROSPAN 2 QL 0.334 / day

ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day

ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb) 1

FLOVENT 250 MCG DISKUS 2 QL 8 / day

FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day

FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day

PULMICORT 3 QL 120 / 30 days

PULMICORT FLEXHALER 2 QL 0.07 / day

CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

QL 4 / day ORKAMBI 4 PA S

PAGE 153 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYSTIC FIBROSIS (CFTR) POTENTIATORS

QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 4 PA S

DEPIGMENTING AND PIGMENTING AGENTS

DEPIGMENTING AGENTS

ACLARO 3 ALPHAQUIN HP 1 BLANCHE 1 4 % cream (g) 1 hydroquinone (100 % crystals, powder) 3 hydroquinone microspheres 1 MELPAQUE HP 1 MELQUIN-3 3 mequinol 3 3 TRI-LUMA 3 PIGMENTING AGENTS

8-MOP 3 methoxsalen 10 mg cap lq rap 1 methoxsalen (crystals, powder) 3 OXSORALEN 3 OXSORALEN-ULTRA 3

UVADEX 4 S

PAGE 154 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY corticotropin powder 3 CORTROSYN 3 cosyntropin 0.25 mg vial 1

PA H.P. ACTHAR 4 S

ALLERGENIC EXTRACTS (DIAGNOSTIC) allergenic extract tree -american elm 3 allergenic extract, grass pollen-bermuda, standard 3 allergenic extract, grass pollen-orchard grass, standard 3 allergenic extract, mite-d.farinae-d.pteronyssinus,standard 3 allergenic extract,grass pollen-june(kentucky blue),standard 3 allergenic extract,grass pollen-redtop, standard 3 grass pollen-timothy, standard 100k/ml vial 3 QL 1 / day grass pollen-timothy, standard 10k unit/1 vial 3 allergenic extract,mite-dermatophagoides pteronyssinus, std 3 allergenic extract-acremonium strictum 3 allergenic extract-alternaria alternata 3 allergenic extract-american cockroach 3 allergenic extract-aspergillus fumigatus 3 allergenic extract-aspergillus,mixed 3 allergenic extract-aureobasidium pullulans 3 allergenic extract-botrytis cinerea 3 allergenic extract-candida albicans 3 allergenic extract-cattle epithelium 3 allergenic extract-cladosporium cladosporioides 3

PAGE 155 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-cladosporium sphaerospermum 3 allergenic extract-cockroach (american and german) 3 allergenic extract-corn smut 3 allergenic extract-cultivated crop pollen-corn 3 allergenic extract-curvularia 3 allergenic extract-dog epithelium 3 allergenic extract-drechslera sorokiniana 3 allergenic extract-epicoccum nigrum 3 allergenic extract-fire ant 3 allergenic extract-fusarium oxysporum 3 allergenic extract-german cockroach 3 allergenic extract-grass pollen-bahia 3 allergenic extract-grass pollen-johnson 3 allergenic extract-grass pollen-meadow fescue, standardized 3 allergenic extract-grass pollen-perennial rye, standard 3 allergenic extract-grass pollen-quack 3 allergenic extract-grass pollen-smooth brome 3 allergenic extract-horse epithelium 3 allergenic extract-mixed feathers, chicken, duck, goose 3 allergenic extract-mixed weed pollen-short and tall ragweed 3 allergenic extract-mosquito 3 allergenic extract-mouse epithelium 3 allergenic extract-mucor plumbeus 3 allergenic extract-penicillium notatum 3 allergenic extract-phoma herbarum 3 allergenic extract-rabbit epithelium 3 allergenic extract-rhizopus oryzae 3

PAGE 156 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract- 3 allergenic extract-sweet vernal, standardized 3 allergenic extract-tree pollen-acacia 3 allergenic extract-tree pollen-alder white 3 allergenic extract-tree pollen-american beech 3 allergenic extract-tree pollen-american sycamore 3 allergenic extract-tree pollen-arizona cypress 3 allergenic extract-tree pollen-australian pine 3 allergenic extract-tree pollen-bald cypress 3 allergenic extract-tree pollen-bayberry 3 allergenic extract-tree pollen-black walnut 3 allergenic extract-tree pollen-black willow 3 allergenic extract-tree pollen-box elder 3 allergenic extract-tree pollen-eastern cottonwood 3 allergenic extract-tree pollen-elm, cedar 3 allergenic extract-tree pollen-hackberry 3 allergenic extract-tree pollen-juniper, western 3 allergenic extract-tree pollen-kapok 3 allergenic extract-tree pollen-melaleuca 3 allergenic extract-tree pollen-mesquite 3 allergenic extract-tree pollen-mountain cedar 3 allergenic extract-tree pollen-mulberry, red 3 allergenic extract-tree pollen-mulberry, white 3 allergenic extract-tree pollen-olive 3 allergenic extract-tree pollen-palm, queen 3 allergenic extract-tree pollen-pecan 3 allergenic extract-tree pollen-pepper tree, california 3

PAGE 157 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-tree pollen-pine, white 3 allergenic extract-tree pollen-privet 3 allergenic extract-tree pollen-red birch 3 allergenic extract-tree pollen-red cedar 3 allergenic extract-tree pollen-red maple 3 allergenic extract-tree pollen-red oak 3 allergenic extract-tree pollen-shagbark 3 allergenic extract-tree pollen-sweet gum 3 allergenic extract-tree pollen-virginia live oak 3 allergenic extract-tree pollen-white ash 3 allergenic extract-tree pollen-white birch 3 allergenic extract-tree pollen-white oak 3 allergenic extract-trichophyton mentagrophytes 3 allergenic extract-venom- bee 3 allergenic extract-venom-mixed vespid protein 3 allergenic extract-venom-wasp protein 3 allergenic extract-venom-white-faced hornet protein 3 allergenic extract-venom-yellow hornet protein 3 allergenic extract-venom-yellow jacket protein 3 allergenic extract-weed pollen-carelessweed 3 allergenic extract-weed pollen-cocklebur 3 allergenic extract-weed pollen-dog fennel 3 allergenic extract-weed pollen-english plantain 3 allergenic extract-weed pollen-giant (tall) ragweed 3 allergenic extract-weed pollen-goldenrod 3 allergenic extract-weed pollen-kochia (firebush) 3 allergenic extract-weed pollen-lambsquarters 3

PAGE 158 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-weed pollen-mugwort 3 allergenic extract-weed pollen-rough pigweed 3 allergenic extract-weed pollen-russian thistle 3 allergenic extract-weed pollen-sagebrush 3 allergenic extract-weed pollen-sheep sorrel 3 allergenic extract-weed pollen-sheep sorrel,yellow dock 3 allergenic extract-weed pollen-short ragweed 3 allergenic extract-weed pollen-spiny pigweed 3 allergenic extract-weed pollen-true marsh elder 3 allergenic extract-weed pollen-western ragweed 3 allergenic extract-weed pollen-yellow dock 3 extract 3 apple extract 3 avocado extract 3 banana extract 3 beef extract 3 cantaloupe extract 3 extract 3 cat hair standardized allergenic extract 3 chicken extract 3 cocoa extract 3 corn extract 3 crab extract 3 egg extract 3 egg white extract 3 mite-dermatophagoides farinae, standardized 3 oats extract 3

PAGE 159 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS orange extract 3 extract 3 pecan extract 3 pistachio nut extract 3 extract 3 rice extract 3 sesame seed extract 3 shrimp extract 3 extract 3 strawberry extract 3 CARDIAC FUNCTION

IC GREEN 3 indocyanine green 1 DRUG HYPERSENSITIVITY

PRE-PEN 3 FUNGI

CANDIN 3 SPHERUSOL 3 GALLBLADDER FUNCTION

KINEVAC 3 FUNCTION

INDIGO CARMINE 1 indigotindisulfonate sodium in water for injection,sterile 1 LYMPHATIC SYSTEM

LYMPHAZURIN 3

PAGE 160 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MYASTHENIA GRAVIS edrophonium chloride 3 ENLON 3 OCULAR DISORDERS

BIOGLO 1 FLUCAINE 1 FLUOR-I-STRIP AT 1 fluorescein sodium 3 FUL-GLO 1 MG OPTH STRIPS 1 FUL-GLO EYE STRIPS 3 MEMBRANEBLUE 3 proparacaine hcl/fluorescein sodium 1 PANCREATIC FUNCTION acetate (human) 3 PITUITARY FUNCTION

METOPIRONE 3 ROENTGENOGRAPHY barium sulfate 3 CONRAY 3 CYSTOGRAFIN 3 CYSTOGRAFIN-DILUTE 3 E-Z DISK 3 E-Z-CAT 3 E-Z-HD 3 E-Z-PAQUE 3 E-Z-PASTE 3 ENTERO VU 3

PAGE 161 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GASTROGRAFIN 3 ISOVUE-200 41% VIAL 3 LIQUID E-Z PAQUE 3 LIQUID POLIBAR PLUS 3 MD-76 R (R 66-10 INFUSION BOTTLE, R 66-10 VIAL) 3 MD-GASTROVIEW 1 POLIBAR ACB 3 READI-CAT 2 3 SINOGRAFIN 3 SITZMARKS 3 TAGITOL 3 ULTRAVIST 3 VARIBAR HONEY 3 VARIBAR NECTAR 3 VARIBAR PUDDING 3 VARIBAR THIN HONEY 3 VARIBAR THIN LIQUID 3 VOLUMEN 3 THYROID FUNCTION protirelin 3 TUBERCULOSIS

APLISOL 3 TUBERSOL 3 DIURETICS

LOOP DIURETICS (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 bumetanide 0.25 mg/ml vial 1

PAGE 162 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEMADEX 3 EDECRIN 3 ethacrynic acid 1 powder 3 furosemide (10 mg/ml syringe, 10 mg/ml vial) 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) 1

LASIX 3 torsemide 1 OSMOTIC DIURETICS mannitol/sorbitol solution 1 POTASSIUM-SPARING DIURETICS hcl 1 amiloride hcl/hydrochlorothiazide 1 DYAZIDE 3 DYRENIUM 3 MAXZIDE 3 MAXZIDE-25 MG 3 triamterene 3 triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg tablet, 1 triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet) THIAZIDE DIURETICS chlorothiazide 1 DIURIL 3 hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 50 mg tablet) 1

PAGE 163 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydrochlorothiazide 100 % powder 3 hydrochlorothiazide 25 mg tablet 1 LCG methyclothiazide 1 MICROZIDE 3

QL 1 / day TEKTURNA HCT 3 ST trichlormethiazide 3 THIAZIDE-LIKE DIURETICS chlorthalidone 1 indapamide 1 metolazone 1 ANTAGONISTS

QL 1 / day SAMSCA 15 MG TABLET 4 PA S

QL 2 / day SAMSCA 30 MG TABLET 4 PA S

DIURETICS (HYPOTENSIVE AGENTS)

POTASSIUM-SPARING DIURETICS (HYPOTEN)

ALDACTAZIDE 3 ALDACTONE 3 3 HCG

INSPRA 3 100 % powder 3 spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

PAGE 164 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS spironolactone, micronized 3 spironolactone/hydrochlorothiazide 1 THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)

ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3 QL 2 / day

ACCURETIC 20-25 MG TABLET 3 QL 1 / day

ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3 QL 1 / day

ATACAND HCT 16-12.5 MG TAB 3 QL 2 / day

AVALIDE 150-12.5 MG TABLET 3 QL 2 / day

AVALIDE 300-12.5 MG TABLET 3 QL 1 / day benazepril hcl/hydrochlorothiazide 1 QL 1 / day

BENICAR HCT 3 QL 1 / day candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 32-12.5mg tablet, 1 QL 1 / day candesartan/hydrochlorothiazid 32mg-25mg tablet) candesartan/hydrochlorothiazid 16-12.5mg tablet 1 QL 2 / day captopril/hydrochlorothiazide 1 QL 2 / day

DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3 QL 1 / day

DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB, 160-25 2 / day MG TABLET) 3 QL enalapril/hydrochlorothiazide 10 mg-25mg tablet 1 QL 2 / day enalapril/hydrochlorothiazide 5mg-12.5mg tablet 1 fosinopril sodium/hydrochlorothiazide 1 QL 2 / day

HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3 QL 1 / day

HYZAAR 50-12.5 TABLET 3 QL 2 / day irbesartan/hydrochlorothiazide 150-12.5mg tablet 1 QL 2 / day

PAGE 165 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS irbesartan/hydrochlorothiazide 300-12.5mg tablet 1 QL 1 / day lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide 10-12.5mg tablet, lisinopril/hydrochlorothiazide 20-12.5 mg 1 QL 2 / day tablet) lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide QL 2 / day 20 mg-25mg tablet, lisinopril/hydrochlorothiazide 20-25mg 1 tablet) LCG losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 100-12.5mg tablet, 1 QL 1 / day losartan/hydrochlorothiazide 100mg-25mg tablet) losartan/hydrochlorothiazide 50-12.5 mg tablet 1 QL 2 / day

LOTENSIN HCT 3 QL 1 / day methyldopa/hydrochlorothiazide 1

MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3 QL 1 / day

MICARDIS HCT 80-12.5 MG TABLET 3 QL 2 / day moexipril hcl/hydrochlorothiazide 1 QL 2 / day olmesartan medoxomil/amlodipine QL 1 / day 3 besylate/hydrochlorothiazide HCG olmesartan medoxomil/hydrochlorothiazide 1 QL 1 / day quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 10-12.5mg tablet, 1 QL 2 / day quinapril/hydrochlorothiazide 20-12.5 mg tablet) quinapril/hydrochlorothiazide 20 mg-25mg tablet 1 QL 1 / day

QL 2 / day telmisartan/hydrochlorothiazid 80-12.5mg tablet 3 HCG telmisartan/hydrochlorothiazide QL 1 / day (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, 3 telmisartan/hydrochlorothiazid 80 mg-25mg tablet) HCG

TRIBENZOR 3 QL 1 / day

PAGE 166 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 320-12.5mg tablet, valsartan/hydrochlorothiazide 320mg- 1 QL 1 / day 25mg tablet) valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, valsartan/hydrochlorothiazide 160-12.5mg 1 QL 2 / day tablet, valsartan/hydrochlorothiazide 160-25mg tablet)

VASERETIC 3 QL 2 / day

ZESTORETIC 3 QL 2 / day

THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT)

CLORPRES 3

QL 1 / day EDARBYCLOR 3 ST

DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS mesylate (2.5 mg tablet, 5 mg capsule) 1 bromocriptine mesylate powder 3 cabergoline 1

QL 6 / day CYCLOSET 3 PA

PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3 NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

PA APOKYN 4 S apomorphine hcl 3 MIRAPEX 3

MIRAPEX ER 3 ST

NEUPRO 3

PAGE 167 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pramipexole di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h, 1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg 3 HCG tab er 24h, 4.5 mg tab er 24h) pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 1

REQUIP 3

REQUIP XL 3 QL 1 / day ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 1 / day 24h, 8 mg tab er 24h, 12 mg tab er 24h) 1 QL ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS chloride granules 3 K-PHOS NEUTRAL 3 K-PHOS NO.2 3 K-PHOS ORIGINAL 3 PHOSPHA 250 NEUTRAL 1 VIRT-PHOS 250 NEUTRAL 1 ALKALINIZING AGENTS /sodium citrate 1 CYTRA-2 1 CYTRA-3 3 CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1 ORACIT 3 potassium citrate 1 potassium citrate/citric acid 1100-334/5 solution 1 SHOHL'S MODIFIED 3 sodium citrate 100 % powder 3

PAGE 168 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium citrate dihydrate 3 sodium/potassium/potassium citrate/sodium citrate/cit ac 1 TARON-CRYSTALS 1 TRICITRASOL 3 TRICITRATES 1 UROCIT-K 3 VIRTRATE-2 1 VIRTRATE-3 1 VIRTRATE-K 1 AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 4 S

CARBAGLU 4 S

CONSTULOSE 1 ENULOSE 1 GENERLAC 1 KRISTALOSE 1 lactulose 1 LITHOSTAT 3

QL 20 / day RAVICTI 4 PA S 100 % powder 3 sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 4 S

CALORIC AGENTS

ACD 1 powder 3 (100 % crystals, 100 % powder) 3

PAGE 169 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS arginine hcl 3 3 hcl powder 3 dextrose 3 (100 % crystals, powder) 3 hcl 3 LYSIPLEX PLUS 1 3 ribose 3 3 IRRIGATING

RESECTISOL 3 REPLACEMENT PREPARATIONS

0.9 % sodium chloride 0.9 % syringe 1 0.9 % sodium chloride 0.9 % vial 1 bacteriostatic sodium chloride 1 calcium chelate 3 calcium carbonate 3 calcium citrate 3 calcium glubionate 3 calcium glucarate 3 monohydrate 3 calcium levulinate dihydrate 3 calcium phosphate 3 cardioplegic solution no.1 1 cardioplegic solution no.10 3 EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3

PAGE 170 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EFFER-K 25 MEQ TABLET EFF 1

FOLBECAL 3 GL Female

FOLGARD OS 3 HYPER-SAL 3 K EFFERVESCENT 1 K-SOL 1 K-TAB ER 3 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 25 MEQ PACKET 3 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 3 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 magnesium amino acid chelate 3 magnesium glycinate 3 chloride 100 % powder 3 manganese gluconate 3 molybdenum 3 MONOJECT 0.9% SODIUM CHLORIDE 1 MONOJECT PREFILL 0.9% FLUSH 1 MONOJECT PREFILL ADVANCED 1 NEBUSAL 3% VIAL 1 NEBUSAL 6% VIAL 3 PLEGISOL 3

PAGE 171 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium bicarbonate/citric acid 1 potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid, 1 40meq/15ml liquid) potassium chloride (granules, powder) 3 potassium chloride/potassium bicarbonate/citric acid 1 potassium citrate monohydrate (100 % granules, 100 % powder) 3 potassium phosphate, dibasic 3 potassium phosphate,monobasic 3

PRENAISSANCE NEXT 3 GL Female

PRISMASOL (B22GK 2/0, B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5, BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2) 3

PULMOSAL 1 selenomethionine 3 sodium acetate trihydrate (100 % powder, crystals, granules) 3 sodium aspartate monohydrate 3 sodium cacodylate 3 sodium chloride for inhalation 1 SYREX 1 zinc chloride 100 % powder 3 zinc picolinate 3 zinc sulfate 100 % powder 3 zinc sulfate heptahydrate 3 SALT AND SUGAR SUBSTITUTES saccharin 1 URICOSURIC AGENTS probenecid 1 QL 4 / day

PAGE 172 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS probenecid/ 1 QL 2 / day

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

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS ammonium lactate 12 % lotion 1 ATOPICLAIR 3 calamine 3 10 % lotion 1 PRUCLAIR 3 BASIC OILS AND OTHER SOLVENTS

AVO CREAM 3 BIAFINE 3 LUXAMEND 1 mineral oil 3 PRUTECT 3 SONAFINE 3 SYNERDERM 3 BASIC OINTMENTS AND PROTECTANTS ammonium lactate 12 % cream (g) 1 DEXERYL 3 ELETONE CREAM 3 lactic acid 10 % cream (g) 1 TETRIX 3 VASELINE WHITE PETROLEUM 3 XCLAIR 3

PAGE 173 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AND

ESTROGEN AGONIST-ANTAGONISTS clomiphene citrate 100 % powder 3 clomiphene citrate 50 mg tablet 1 GL Female

DUAVEE 2

EVISTA 3 QL 1 / day

OSPHENA 3 hcl 0 HCR

SEROPHENE 1 GL Female

ESTROGENS

QL 1 / day ACTIVELLA 3 GL Female

QL 0.29 / day ALORA 3 GL Female

QL 1 / day AMABELZ 1 GL Female

QL 1 / day ANGELIQ 3 GL Female

QL 0.15 / day CLIMARA 3 GL Female

QL 0.15 / day CLIMARA PRO 2 GL Female

QL 0.29 / day COMBIPATCH 3 GL Female

COVARYX 1 GL Female

PAGE 174 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COVARYX H.S. 1 GL Female

DELESTROGEN 3 GL Female

DEPO- 3 GL Female 3 DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL Female PACKET) 2 GL

EEMT 1 GL Female

EEMT H.S. 1 GL Female

ELESTRIN 3 GL Female

QL 1 / day ENJUVIA 2 GL Female

ESTRACE 0.01% CREAM 2 GL Female

QL 1 / day ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 GL Female estradiol (.025mg/24h patch tdsw, .0375mg/24 patch tdsw, QL 0.29 / day 0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hr 1 patch tdsw) GL Female estradiol (.025mg/24h patch tdwk, 0.05mg/24h patch tdwk, QL 0.15 / day 1 0.1mg/24hr patch tdwk) GL Female estradiol (.0375mg/24 patch tdwk, 0.06mg/24h patch tdwk, QL 0.15 / day 1 .075mg/24h patch tdwk) GL Female estradiol 100 % powder 3

QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female LCG estradiol 10 mcg tablet 1 GL Female

QL 1 / day estradiol 2 mg tablet 1 GL Female

PAGE 175 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 3 estradiol hemihydrate, micronized 3 estradiol micronized 3 powder 3 estradiol valerate (20 mg/ml vial, 40 mg/ml vial) 1 GL Female

QL 1 / day estradiol/norethindrone acetate 1 GL Female

QL 90 days ESTRING 2 GL Female 3 GL Female estriol micronized 3 GL Female

QL 1.667 / day ESTROGEL 3 GL Female estrogens,esterified/ 1 GL Female (100 % powder, crystals) 3

QL 1 / day 1 GL Female LCG

QL 0.54 / day EVAMIST 3 GL Female

QL 1 / day FEMHRT 3 GL Female

QL 0.02 / day FEMRING 3 GL Female

FYAVOLV 1 GL Female

PAGE 176 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

JEVANTIQUE LO 3 GL Female

QL 1 / day JINTELI 0 GL Female HCR

QL 1 / day LOPREEZA 1 GL Female

QL 1 / day MENEST (0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 3 GL Female

QL 1 / day MENEST 0.3 MG TABLET 2 GL Female

QL 0.15 / day MENOSTAR 3 GL Female

QL 1 / day MIMVEY 1 GL Female

MIMVEY LO 1

QL 0.29 / day MINIVELLE 3 GL Female norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg- 5mcg tablet) 0 HCR

QL 1 / day OGEN 3 GL Female

QL 1 / day PREFEST 3 GL Female

PREMARIN VAGINAL CREAM-APPL 2 GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, QL 1 / day 2 0.9 MG TABLET, 1.25 MG TABLET) GL Female

PREMARIN 25 MG VIAL 2

PAGE 177 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PREMPHASE 2 GL Female

QL 1 / day PREMPRO 2 GL Female

VAGIFEM 3 GL Female

QL 8 / 28 days VIVELLE-DOT 3 GL Female

YUVAFEM 1 GL Female

EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

ALOMIDE 3 QL 10 / fill

ASTEPRO 3 QL 2 / day azelastine hcl 0.05 % drops 1 QL 0.267 / day azelastine hcl 100 % powder 3 azelastine hcl (137 mcg spray/pump, 205.5 mcg spray/pump) 1 QL 2 / day

BEPREVE 3 QL 0.286 / day

ELESTAT 3 QL 0.286 / day

EMADINE 3 QL 5 / fill epinastine hcl 1 QL 0.286 / day

QL 3 / 30 days LASTACAFT 3 ST olopatadine hcl (0.1 % drops, 0.2 % drops) 1 QL 0.286 / day

QL 31 / 30 days olopatadine hcl 0.6 % spray/pump 3 HCG

PAGE 178 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PATADAY 3 QL 0.286 / day

PATANASE 3 QL 31 / 30 days

PATANOL 3 QL 0.286 / day

PAZEO 3 QL 0.286 / day

EENT DRUGS, MISCELLANEOUS in sterile water/pf 1 QL 10 / 30 days apraclonidine hcl 1 QL 0.8 / day

ATROVENT 3 QL 2 / day balanced salt irrig soln no.2 1 BSS 1 BSS PLUS 3 CELLUGEL 3

PA CYSTARAN 4 S

GELFILM 3

IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day ipratropium bromide (21 mcg spray, 42 mcg spray) 1 QL 2 / day

LACRISERT 3

QL 0.04 / day LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 4 PA S

OCUCOAT 1 LOCAL ANESTHETICS (EENT)

AKTEN 3 ALCAINE 3

PAGE 179 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALTACAINE 1 ALTAFLUOR 1 benoxinate hcl/fluorescein sodium 1 BUCALSEP (SOLUTION, SPRAY) 3 hcl 100 % crystals 3 cocaine hcl 4 % solution 1 cyclopentolate hcl/lidocaine hcl/phenylephrine/tropicamide 1 dyclonine hcl 3 FLUROX 1 GLYDO 1 lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 40 mg/ml solution) 1 proparacaine hcl 0.5 % drops 1 proparacaine hcl 100 % powder 3 TETCAINE 1 tetracaine hcl 0.5 % drops 1 tetracaine hcl/pf 0.5 % drops 1 TETRAVISC 1 TETRAVISC FORTE 1 XYLOCAINE 4% SOLUTION 3 MYDRIATICS atropine sulfate (1 % drops, 1 % oint. (g)) 1 CYCLOGYL 3 CYCLOMYDRIL 3 cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1 cyclopentolate hcl 100 % powder 3 cyclopentolate hcl/tropicamide/phenylephrine hcl in water 1 HOMATROPAIRE 1

PAGE 180 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS homatropine hbr 1 homatropine methylbromide 3 hydroxyamphetamine hbr 3 ISOPTO ATROPINE 3 MYDRIACYL 3 PAREMYD 3 tropicamide (0.5 % drops, 1 % drops) 1 tropicamide powder 3 VASOCONSTRICTORS

ADRENALIN CHLORIDE 3 PA naphazoline hcl 1 oxymetazoline hcl 3 phenylephrine hcl (2.5 % drops, 10 % drops) 1 tetrahydrozoline hcl 3 TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE DROPS, 0.1% NOSE SPRAY) 3 FIRST GENERATION ANTIHISTAMINES

ETHYLENEDIAMINE DERIVATIVES pyrilamine maleate 3 tripelennamine hcl 3 PHENOTHIAZINE DERIVATIVES trimeprazine tartrate 3 GASTROINTESTINAL DRUGS

ANTACIDS AND ADSORBENTS aluminum hydroxide 3 magnesium oxide 3

PAGE 181 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTI-INFLAMMATORY AGENTS (GI DRUGS)

GL Female alosetron hcl 1 AL At least 18 yrs old

APRISO 2 disodium 1 CANASA 2 COLAZAL 3 DIPENTUM 3

GIAZO 3 GL Male

LIALDA 2

PA LOTRONEX 3 GL Female AL At least 18 yrs old mesalamine 4 g/60 ml enema 1 mesalamine powder 3 mesalamine 1.2 g tablet dr 3 HCG mesalamine with cleansing wipes 1 PENTASA 3 ROWASA 3 SFROWASA 3 ANTIDIARRHEA AGENTS attapulgite 3 bismuth subsalicylate 3

FULYZAQ 4 S lactobacillus acidophilus 3 hcl 2 mg capsule 1

PAGE 182 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS loperamide hcl powder 3 MOTOFEN 3

MYTESI 4 S opium tincture 1 QL 5 / day 1

PA XERMELO 4 AL At least 18 yrs old S

ANTIFLATULENTS simethicone 3 CATHARTICS AND LAXATIVES

QL 2 / day AMITIZA 2 AL At least 18 yrs old aromatic cascara fluid extract 3 bisacodyl 3 COLYTE WITH PACKETS 3 docusate sodium 3

GAVILYTE-C 0 HCR

GAVILYTE-G 0 HCR

GAVILYTE-N 0 HCR

GOLYTELY PACKET 0 HCR

GOLYTELY SOLUTION 3 karaya gum 3

MOVIPREP 0 HCR

NULYTELY WITH FLAVOR PACKS 3 OSMOPREP 3

PAGE 183 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 0 HCR

PEG-PREP 1 3350 (3350 17g powd pack, 3350 17g/dose powder) 0 HCR

PREPOPIK 3 QL 2 / fill sodium chloride/nahco3/kcl/peg 420g soln recon 0 HCR sodium phosphate dibasic, heptahydrate 3 sodium phosphate,dibasic 3 sodium sulfate 3 sorbitol solution 70 % solution 1

SUPREP 3 QL 354 / fill

TRILYTE WITH FLAVOR PACKETS 0 HCR

CHOLELITHOLYTIC AGENTS

ACTIGALL 3

CHENODAL 4 S

URSO 3 URSO FORTE 3 ursodiol 100 % powder 3 ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1 DIGESTANTS

CREON 2 3 pancreatin powder 3 ZENPEP 2 GI DRUGS, MISCELLANEOUS

QL 7 / day CHOLBAM 250 MG CAPSULE 4 PA S

PAGE 184 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day CHOLBAM 50 MG CAPSULE 4 PA S

QL 0.08 / day CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 4 PA S

QL 3/ fill CIMZIA 200 MG/ML STARTER KIT 4 PA S

ENTEREG 3

PA GATTEX 4 S powder 3

QL 0.22 / day PA HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4 S PS

QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 4 S PS

QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 4 S PS

QL 0.22 / day PA HUMIRA PEN 4 S PS

PAGE 185 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.22 / day PA HUMIRA PEN CROHN-UC-HS STARTER 4 S PS

QL 0.22 / day PA HUMIRA PEN PSORIASIS-UVEITIS 4 S PS

QL 1 / day LINZESS 2 ST

NUTRESTORE 3

QL 1 / day OCALIVA 4 PA S

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL) 3 PA

RELISTOR 150 MG TABLET 3 PA

RESTORA SPRINKLES 3

QL 2 / day VIBERZI 2 PA

XENICAL 3 LIPOTROPIC AGENTS choline bitartrate 3 phosphatidylcholine 3 PROKINETIC AGENTS hcl powder 3 metoclopramide hcl 10 mg/2 ml syringe 1

PAGE 186 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution) 1 LCG metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1 metoclopramide hcl 5 mg/ml vial 1 LCG

METOZOLV ODT 3 REGLAN 3 GENERAL ANESTHETICS

GENERAL ANESTHETICS, MISCELLANEOUS

KETALAR 3 hcl 100 % powder 3 ketamine hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial) 1 INHALATION ANESTHETICS 3 COMPOUND 347 1 FORANE 3 1 1 SOJOURN 1 SUPRANE 3 TERRELL 1 ULTANE 3 GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

QL 1 / day darifenacin hydrobromide 3 HCG

DETROL 3 QL 2 / day

DETROL LA 3 QL 1 / day

PAGE 187 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DITROPAN XL (10 MG TABLET, 15 MG TABLET) 3 QL 2 / day

DITROPAN XL 5 MG TABLET 3 QL 1 / day

ENABLEX 3 QL 1 / day flavoxate hcl 1

QL 3.067 / day GELNIQUE 3% GEL 3 ST

QL 1 / day GELNIQUE (GEL PUMP, GEL SACHETS) 3 ST oxybutynin chloride powder 3 oxybutynin chloride 5 mg/5 ml syrup 1 QL 20 / day oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24) 1 QL 2 / day oxybutynin chloride 5 mg tab er 24 1 QL 1 / day oxybutynin chloride 5 mg tablet 1 QL 4 / day

QL 0.357 / day OXYTROL 3 ST

QL 1 / day tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 24h) 3 HCG tolterodine tartrate (1 mg tablet, 2 mg tablet) 1 QL 2 / day

TOVIAZ 3 QL 1 / day

QL 1 / day trospium chloride 60 mg cap er 24h 3 HCG

QL 2 / day trospium chloride 20 mg tablet 3 HCG

VESICARE 2 QL 1 / day

PAGE 188 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HCV ANTIVIRALS

HCV POLYMERASE INHIBITORS

QL 1 / day PA EPCLUSA 4 S PS

QL 1 / day PA HARVONI 4 S PS

QL 1 / day PA SOVALDI 4 S PS

HCV PROTEASE INHIBITORS

QL 1 / day OLYSIO 4 PA S

QL 1 / day ZEPATIER 4 PA S

HCV REPLICATION COMPLEX INHIBITORS

QL 1 / day DAKLINZA 4 PA S

PAGE 189 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AND SYNTHETIC SUBSTITUTES

ADRENALS

A-HYDROCORT 3 A-METHAPRED 1 3 ARISTOSPAN 3 beclomethasone dipropionate 3 betamethasone acetate, micronized 3 betamethasone acetate/betamethasone sodium phosphate 1 betamethasone sodium phosphate 3 budesonide 3 mg capdr - er 3 HCG

CELESTONE 3 CORTEF 3 acetate powder 3 25 mg tablet 1 DELTASONE 1 DEPO-MEDROL 3 desoxycorticosterone acetate 3 dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 1 4 mg tablet, 6 mg tablet) dexamethasone acetate 3 dexamethasone acetate, micro 100 % powder 3 DEXAMETHASONE INTENSOL 2 dexamethasone isonicotinate 3 dexamethasone sod phosphate 100 % powder 3 dexamethasone, micronized 3 DEXPAK 3

PAGE 190 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL At least 5 yrs old SUSP, 30 MG TABLET, 36 MG TABLET) 4 AL S

ENTOCORT EC 3 EZ USE JOINT-TUNNEL-TRIGGER 3 FLO-PRED 3 acetate powder 3 fludrocortisone acetate 0.1 mg tablet 1 flunisolide 100 % powder 3 fluticasone propionate 100 % powder 3 fluticasone propionate, micronized 3 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

QL 1 / day INTRAROSA 3 AL At least 18 yrs old

KENALOG-10 3 KENALOG-40 3 MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) 3

MEDROL 2 MG TABLET 2 (4 mg tab ds pk, 4 mg tablet, 8 mg tablet, 16 mg tablet, 32 mg tablet) 1 methylprednisolone acetate 1 methylprednisolone acetate, micronized 3 methylprednisolone sodium succinate (40 mg vial, 125 mg vial) 1 methylprednisolone, micronized 3 MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3 MILLIPRED DP 3 ORAPRED ODT 3

PAGE 191 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PEDIAPRED 3 prednisolone 1 prednisolone acetate, micronized 3 prednisolone sod phosphate powder 3 prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tab 1 rapdis) prednisolone, micronized 100 % powder 3 powder 3 prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg tablet, 20 1 mg tablet, 50 mg tablet)

PREDNISONE INTENSOL 2 prednisone micronized 3 RAYOS 3 SOLU-CORTEF 3 SOLU-MEDROL (40 MG VIAL, 125 MG VIAL) 3 triamcinolone 3 triamcinolone acetonide 100 % powder 3 triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial) 1 triamcinolone diacetate 3 triamcinolone diacetate, micronized 3 triamcinolone hexacetonide 3 triamcinolone hexacetonide, micronized 3 UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3 VERIPRED 20 3 ZODEX 6 DAY 1.5 MG TABLET 3

PAGE 192 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANADROL-50 3 GL Male

QL 1 / day ANDRODERM 2 PA GL Male

QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 PA GL Male

PA ANDROID 3 GL Male 3

PA ANDROXY 3 GL Male (50 mg capsule, 100 mg capsule, 200 mg capsule) 1 danazol powder 3

PA DELATESTRYL 3 GL Male

DEPO- (100 MG/ML VL, 200 MG/ML) 3 GL Male 3

PA METHITEST 3 GL Male methyltestosterone 10 mg capsule 1 methyltestosterone powder 3 methyltestosterone, micronized 3 decanoate 3

QL 3 / day PA NATESTO 3 GL Male AL At least 18 yrs old

PAGE 193 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA OXANDRIN 3 GL Male 100 % powder 3

PA oxandrolone (2.5 mg tablet, 10 mg tablet) 1 GL Male (dhea) 3 prasterone (dhea), micronized 100 % powder 3 3 stanozolol micronized 3

PA STRIANT 3 GL Male testosterone powder 3 GL Male 100 % powder 3 GL Male testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1 GL Male testosterone cypionate, micronized 3 GL Male

PA 1 GL Male testosterone micronized 3 GL Male 3 GL Male

PA TESTRED 3 GL Male

CONTRACEPTIVES

QL 1 / day ALTAVERA 0 GL Female HCR

GL Female ALYACEN 0 HCR

PAGE 194 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 91 days AMETHIA 0 GL Female HCR

QL 91 days AMETHIA LO 0 GL Female HCR

QL 1 / day AMETHYST 0 GL Female HCR

GL Female APRI 0 HCR

GL Female ARANELLE 0 HCR

GL Female ASHLYNA 0 HCR

QL 1 / day AUBRA 0 GL Female HCR

QL 1 / day AVIANE 0 GL Female HCR

GL Female AZURETTE 0 HCR

GL Female BALZIVA 0 HCR

GL Female BEKYREE 0 HCR

PAGE 195 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BEYAZ 3 GL Female

GL Female BLISOVI 24 FE 0 HCR

GL Female BLISOVI FE 0 HCR

BREVICON 3 GL Female

GL Female BRIELLYN 0 HCR

GL Female CAMILA 0 HCR

QL 91 days CAMRESE 0 GL Female HCR

QL 91 days CAMRESE LO 0 GL Female HCR

GL Female CAZIANT 0 HCR

QL 1 / day CHATEAL 0 GL Female HCR

GL Female CRYSELLE 0 HCR

GL Female CYCLAFEM 0 HCR

CYCLESSA 3 GL Female

PAGE 196 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female CYRED 0 HCR

GL Female DASETTA 0 HCR

QL 91 days DAYSEE 0 GL Female HCR

GL Female DEBLITANE 0 HCR

QL 1 / day DELYLA 0 GL Female HCR

DESOGEN 3 GL Female

GL Female -ethinyl estradiol 0.15-0.03 tablet 0 HCR

GL Female desogestrel-ethinyl estradiol/ethinyl estradiol 0 HCR

GL Female /ethinyl estradiol/levomefolate calcium 0 HCR

GL Female ELINEST 0 HCR

QL 1 / day ELLA 0 GL Female HCR

GL Female EMOQUETTE 0 HCR

PAGE 197 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female ENPRESSE 0 HCR

GL Female ENSKYCE 0 HCR

GL Female ERRIN 0 HCR

GL Female ESTARYLLA 0 HCR

ESTROSTEP FE 3 GL Female

GL Female ethinyl estradiol/drospirenone 0 HCR

GL Female ethynodiol diacetate-ethinyl estradiol 0 HCR

QL 1 / day FALMINA 0 GL Female HCR

QL 91 days FAYOSIM 0 GL Female HCR

FEMCON FE 3 GL Female

GL Female FEMYNOR 0 HCR

GENERESS FE 3 GL Female

GL Female GIANVI 0 HCR

GL Female GILDAGIA 0 HCR

PAGE 198 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female GILDESS 0 HCR

GL Female GILDESS 24 FE 0 HCR

GL Female GILDESS FE 0 HCR

GL Female HEATHER 0 HCR

QL 91 days INTROVALE 0 GL Female HCR

GL Female ISIBLOOM 0 HCR

GL Female JENCYCLA 0 HCR

QL 91 days JOLESSA 0 GL Female HCR

GL Female JOLIVETTE 0 HCR

GL Female JULEBER 0 HCR

GL Female JUNEL 0 HCR

GL Female JUNEL FE 0 HCR

PAGE 199 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female JUNEL FE 24 0 HCR

GL Female KAITLIB FE 0 HCR

GL Female KARIVA 0 HCR

GL Female KELNOR 1-35 0 HCR

GL Female KIMIDESS 0 HCR

QL 1 / day KURVELO 0 GL Female HCR

GL Female LARIN 0 HCR

GL Female LARIN 24 FE 0 HCR

GL Female LARIN FE 0 HCR

QL 1 / day LARISSIA 0 GL Female HCR

GL Female LAYOLIS FE 0 HCR

GL Female LEENA 0 HCR

PAGE 200 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day LESSINA 0 GL Female HCR

GL Female LEVONEST 0 HCR

QL 0.07 / day 0 GL Female HCR

QL 91 days levonorgestrel-ethin estradiol 0.15-0.03 tablet 0 GL Female HCR

GL Female levonorgestrel-ethin estradiol 6-5-10 tablet 0 HCR

QL 1 / day levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 90-20 mcg Female tablet) 0 GL HCR

QL 91 days levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo 0 GL Female HCR

GL Female l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo 0 HCR

91 days levonorgestrel/ethinyl estradiol and ethinyl estradiol (l- QL norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo, l- 0 GL Female norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo) HCR

QL 1 / day LEVORA-28 0 GL Female HCR

PAGE 201 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day LILLOW 0 GL Female HCR

GL Female LO LOESTRIN FE 0 HCR

LOESTRIN 3 GL Female

LOESTRIN FE 1-20 TABLET 3 GL Female

GL Female LOESTRIN FE 1.5-30 TABLET 0 HCR

GL Female LOMEDIA 24 FE 0 HCR

GL Female LORYNA 0 HCR

QL 91 days LOSEASONIQUE 3 GL Female

GL Female LOW-OGESTREL 0 HCR

QL 1 / day LUTERA 0 GL Female HCR

GL Female LYZA 0 HCR

QL 1 / day MARLISSA 0 GL Female HCR

GL Female MELODETTA 24 FE 0 HCR

PAGE 202 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female MIBELAS 24 FE 0 HCR

GL Female MICROGESTIN 0 HCR

GL Female MICROGESTIN 24 FE 0 HCR

GL Female MICROGESTIN FE 0 HCR

MINASTRIN 24 FE 3 GL Female

MIRCETTE 3 GL Female

MODICON 3 GL Female

GL Female MONO-LINYAH 0 HCR

GL Female MONONESSA 0 HCR

GL Female MYZILRA 0 HCR

NATAZIA 2 GL Female

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, GL Female 0 10-11-28 TABLET) HCR

QL 1 / day NECON 7-7-7-28 TABLET 3 GL Female HCR

GL Female NIKKI 0 HCR

NOR-Q-D 3 GL Female

PAGE 203 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female NORA-BE 0 HCR

GL Female norethindrone 0.35 mg tablet 0 HCR

GL Female norethindrone ac-eth estradiol 1mg-20mcg tablet 0 HCR norethindrone acetate-ethinyl estradiol/ferrous fumarate (1mg- GL Female 0 20(21) tablet, 1mg-20(24) tab chew, 1mg-20(24) tablet) HCR

GL Female norethindrone-ethinyl estradiol/ferrous fumarate 0 HCR

GL Female -ethinyl estradiol 0 HCR

GL Female NORINYL 1+50 0 HCR

NORINYL 1-35 3 GL Female

GL Female NORLYDA 0 HCR

GL Female NORLYROC 0 HCR

GL Female NORTREL 0 HCR

GL Female NUVARING 0 HCR

GL Female OCELLA 0 HCR

QL 1 / day OGESTREL 0 GL Female HCR

PAGE 204 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day ORSYTHIA 0 GL Female HCR

ORTHO MICRONOR 3 GL Female

ORTHO TRI-CYCLEN 3 GL Female

ORTHO TRI-CYCLEN LO 3 GL Female

ORTHO-CEPT 3 GL Female

ORTHO-CYCLEN 3 GL Female

ORTHO-NOVUM 3 GL Female

OVCON-35 3 GL Female

GL Female PHILITH 0 HCR

GL Female PIMTREA 0 HCR

GL Female PIRMELLA 0 HCR

QL 2 / 30 days PLAN B ONE-STEP 3 GL Female

QL 1 / day PORTIA 0 GL Female HCR

GL Female PREVIFEM 0 HCR

QUARTETTE 3 GL Female

QL 91 days QUASENSE 0 GL Female HCR

PAGE 205 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female RAJANI 0 HCR

GL Female RECLIPSEN 0 HCR

QL 91 days RIVELSA 0 GL Female HCR

SAFYRAL 3 GL Female

QL 91 days SEASONIQUE 3 GL Female

QL 91 days SETLAKIN 0 GL Female HCR

GL Female SHAROBEL 0 HCR

GL Female SPRINTEC 0 HCR

QL 1 / day SRONYX 0 GL Female HCR

GL Female SYEDA 0 HCR

GL Female TARINA FE 0 HCR

GL Female TAYTULLA 0 HCR

PAGE 206 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female TILIA FE 0 HCR

GL Female TRI FEMYNOR 0 HCR

GL Female TRI-ESTARYLLA 0 HCR

GL Female TRI-LEGEST FE 0 HCR

GL Female TRI-LINYAH 0 HCR

GL Female TRI-LO-ESTARYLLA 0 HCR

GL Female TRI-LO-MARZIA 0 HCR

GL Female TRI-LO-SPRINTEC 0 HCR

TRI-NORINYL 3 GL Female

GL Female TRI-PREVIFEM 0 HCR

GL Female TRI-SPRINTEC 0 HCR

GL Female TRINESSA 0 HCR

GL Female TRINESSA LO 0 HCR

GL Female TRIVORA-28 0 HCR

PAGE 207 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female VELIVET 0 HCR

GL Female VESTURA 0 HCR

QL 1 / day VIENVA 0 GL Female HCR

GL Female VIORELE 0 HCR

GL Female VYFEMLA 0 HCR

GL Female WERA 0 HCR

GL Female WYMZYA FE 0 HCR

QL 0.12 / day XULANE 0 GL Female HCR

YASMIN 28 3 GL Female

YAZ 3 GL Female

GL Female ZARAH 0 HCR

GL Female ZENCHENT 0 HCR

GL Female ZENCHENT FE 0 HCR

PAGE 208 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female ZEOSA 0 HCR

GL Female ZOVIA 1-35E 0 HCR

GL Female ZOVIA 1-50E 0 HCR

GONADOTROPINS

PA GL Female BRAVELLE 4 S PS chorionic , human (1mm unit powder(ea), 2mm unit powder(ea), 5mm unit powder(ea), 10mm unit powder(ea), 4 S 10000 unit vial)

PA ELIGARD 4 S

FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNIT PA 4 CARTRIDG, 900 UNIT CARTRIDG) S

PA GONAL-F 4 S PS

PA GL Female GONAL-F RFF 4 S PS

PA GL Female GONAL-F RFF REDI-JECT 4 S PS

PAGE 209 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial) 4 S

LUPANETA PACK 4 S

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, PA DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 4 MG 6MO KIT) S

PA LUPRON DEPOT 3.75 MG KIT 4 S

PA LUPRON DEPO 11.25MG (LUPANETA) 4 S

PA LUPRON DEPOT 3.75MG (LUPANETA) 4 S

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG PA 4 KIT, 15 MG KIT, 30 MG 3MO KIT) S

PA GL Female MENOPUR 4 S PS

PA NOVAREL 10,000 UNITS VIAL 4 S

PA OVIDREL 4 S PS

PA PREGNYL 4 S

PA SYNAREL 4 S

PAGE 210 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA MYALEPT 4 S

PARATHYROID ,salmon,synthetic 1 QL 0.13 / day

PA FORTEO 4 S

FORTICAL 3 QL 0.13 / day

MIACALCIN 200 UNIT NASAL SPRAY 3 QL 0.13 / day

MIACALCIN 400 UNIT/2 ML VIAL 4 S

PA NATPARA 4 S

QL 1.60 / day PA TYMLOS 4 AL At least 18 yrs old S

PITUITARY

DDAVP 0.01% NASAL SPRAY 3 desmopressin acetate (non-refrigerated) 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, PA MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, 4 MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG S CARTRIDGE)

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, PA 4 24 MG CARTRIDGE) S

PA NORDITROPIN FLEXPRO 4 S PS

PAGE 211 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA NUTROPIN AQ 4 S

PA NUTROPIN AQ NUSPIN 4 S

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML PA 4 CRTG) S

PA SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 4 S

PA SAIZEN-SAIZENPREP 4 S sermorelin acetate 3

QL 1 / day SEROSTIM 4 PA S vasopressin 1

PA ZOMACTON 4 S

QL 1 / day ZORBTIVE 4 PA S

PROGESTINS

AYGESTIN 3 GL Female

CRINONE 4% GEL 3 GL Female

CRINONE 8% GEL 3 GL Female

DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL) 3 GL Female

DEPO-PROVERA 400 MG/ML VIAL 3

PAGE 212 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 days DEPO-SUBQ PROVERA 104 0 GL Female HCR

GL Female ENDOMETRIN 4 S PS hydroxyprogesterone caproate 100 % powder 3

PA hydroxyprogesterone caproate 250 mg/ml vial 4 GL Female S

PA GL Female MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4 S PS medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 GL Female 1 mg tablet) LCG

QL 0.04 / day medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml Female vial) 0 GL HCR medroxyprogesterone acetate, micronized 3 norethindrone 100 % powder 3 norethindrone acetate 1 GL Female 100 % powder 3 progesterone 50 mg/ml vial 1 GL Female progesterone, micronized (100 mg capsule, 200 mg capsule) 1 GL Female progesterone, micronized 100 % powder 3 GL Female progesterone,micronized 3 GL Female

PAGE 213 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROMETRIUM 3 GL Female

PROVERA 3 GL Female

HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

CATAPRES 3

CATAPRES-TTS 1 3 QL 0.15 / day

CATAPRES-TTS 2 3 QL 0.4 / day

CATAPRES-TTS 3 3 QL 0.4 / day

QL 0.29 / day clonidine (0.2mg/24hr patch tdwk, 0.3mg/24hr patch tdwk) 3 HCG

QL 0.15 / day clonidine 0.1mg/24hr patch tdwk 3 HCG clonidine hcl powder 3

QL 4 / day clonidine hcl 0.1 mg tab er 12h 3 HCG clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG guanabenz acetate 3

QL 4 / day KAPVAY 3 ST methyldopa 1 DIRECT VASODILATORS

BIDIL 3 QL 6 / day hydralazine hcl powder 3 hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hydralazine hcl 20 mg/ml vial 1

PAGE 214 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS powder 3 minoxidil (2.5 mg tablet, 10 mg tablet) 1 HYPOTENSIVE AGENTS, MISCELLANEOUS guanethidine sulfate 3 mecamylamine hcl 3

PA VECAMYL 4 S

PERIPHERAL ADRENERGIC INHIBITORS rauwolfia serpentina 3 100 % powder 3 reserpine (0.1 mg tablet, 0.25 mg tablet) 1 -REMOVING AGENTS

OTHER ION-REMOVING AGENTS

RADIOGARDASE 3 PHOSPHATE-REMOVING AGENTS

AURYXIA 3 calcium acetate 1 ELIPHOS 3 FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MG TABLET CHEW) 2 carbonate 1 PHOSLYRA 3 RENAGEL 3 RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET) 3 RENVELA 800 MG TABLET 2

PAGE 215 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack, 800 mg tablet) 3 HCG

VELPHORO 3 POTASSIUM-REMOVING AGENTS

KAYEXALATE 3 KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 sodium polystyrene sulfonate (15 g/60 ml oral susp, 30 g/120ml enema, 50 g/200ml enema, powder) 1

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1

QL 1 / day VELTASSA 3 PA

MACROLIDES

ERYTHROMYCINS erythromycin base powder 3 erythromycin estolate 3 erythromycin ethylsuccinate powder 3 KETOLIDES

KETEK 3 OTHER MACROLIDES azithromycin 100 % powder 3 azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 QL 6 / 5 days

DIFICID 3 PA

ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill

ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill

ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK TABLET) 3

PAGE 216 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days

ZITHROMAX 500 MG TABLET 3 QL 5 / fill

ZITHROMAX 600 MG TABLET 3 QL 0.29 / day

ZITHROMAX TRI-PAK 3

ZMAX 2 QL 60 / fill

MISCELLANEOUS B-LACTAM

CARBAPENEMS

INVANZ 1 GM VIAL 3 MONOBACTAMS

AZACTAM 3 aztreonam 1

PA CAYSTON 4 S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

QL 1 / day AVODART 3 GL Male

QL 1 / day dutasteride 3 GL Male HCG 100 % powder 3

QL 1 / day finasteride 5 mg tablet 1 GL Male

QL 1 / day PROSCAR 3 GL Male

PAGE 217 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALCOHOL DETERRENTS

ANTABUSE 3 disulfiram 100 % powder 3 disulfiram (250 mg tablet, 500 mg tablet) 1 ANTIDOTES amyl nitrite 1 BAL IN OIL 3 CHEMET 3 deferoxamine mesylate 1 DESFERAL 3 DESFERAL MESYLATE 3 edetate calcium disodium 200 mg/ml ampul 1 edetate calcium disodium 100 % powder 3 fomepizole 100 % liquid 3 leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1 leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vial) 4 S

MEPHYTON 2 phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml syringe, 10 mg/ml ampul) 1 pralidoxime chloride 600 mg/2ml pen injctr 1 pralidoxime chloride 100 % powder 3 PROTOPAM CHLORIDE 3 succimer 98 % powder 3

VISTOGARD 4 S

ANTIGOUT AGENTS allopurinol powder 3

PAGE 218 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day allopurinol 100 mg tablet 1 LCG

QL 2 / day allopurinol 300 mg tablet 1 LCG

ANAPROX 3 ANAPROX DS 3 colchicine 0.6 mg capsule 1 QL 2 / day colchicine powder 3 colchicine 0.6 mg tablet 1 QL 4 / day

COLCRYS 2 QL 4 / day

EC-NAPROSYN 3

INDOCIN 25 MG/5 ML SUSPENSION 3 QL 6 / day

INDOCIN 50 MG SUPPOSITORY 3 QL 4 / day indomethacin (50 mg capsule, 75 mg capsule er) 1 indomethacin 25 mg capsule 1 LCG

QL 2 / day MITIGARE 3 ST

NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3

NAPRELAN CR 750 MG TABLET 3 QL 1 / day

NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 500 MG TABLET) 3 naproxen (125 mg/5ml oral susp, 375 mg tablet, 500 mg tablet) 1 LCG naproxen (250 mg tablet, 375 mg tablet dr, 500 mg tablet dr) 1 naproxen sodium (275 mg tablet, 550 mg tablet) 1 naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 3 HCG

TIVORBEX 3

PAGE 219 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day ULORIC 2 ST

ZYLOPRIM 100 MG TABLET 3 QL 3 / day

ZYLOPRIM 300 MG TABLET 3 QL 2 / day

BONE RESORPTION INHIBITORS

ACTONEL (5 MG TABLET, 30 MG TABLET) 3 QL 1 / day

ACTONEL 150 MG TABLET 3 QL 0.04 / day

ACTONEL 35 MG TABLET 3 QL 0.15 / day alendronate sodium (35 mg tablet, 40 mg tablet, 70 mg tablet, .15 / day 70 mg/75ml solution) 1 QL alendronate sodium (5 mg tablet, 10 mg tablet) 1 QL 1 / day

QL 0.15 / day ATELVIA 3 ST

BINOSTO 3 QL .15 / day

BONIVA 150 MG TABLET 3 QL 0.04 / day etidronate disodium 1

FOSAMAX 3 QL .15 / day

FOSAMAX PLUS D 3 QL 0.15 / day ibandronate sodium 150 mg tablet 1 QL 0.04 / day

QL 0.04 / day risedronate sodium 150 mg tablet 3 HCG risedronate sodium 30 mg tablet 3 HCG

QL 0.15 / day risedronate sodium 35 mg tablet 3 HCG

QL 1 / day risedronate sodium 5 mg tablet 3 HCG

PAGE 220 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS risedronate sodium 35 mg tablet dr 1 CARIOSTATIC AGENTS

CLINPRO 5000 1 DENTA 5000 PLUS 1 DENTAGEL 1

FLUOR-A-DAY 2.5 MG/ML DROPS 0 HCR

FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) 3

FLUORABON 3 fluoride (sodium) powder 3 fluoride (sodium) 0.2 % solution 1 fluoride (sodium) (0.25(0.55) tab chew, 0.5 mg/ml drops, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew) 0 HCR

FLUORIDEX 1 FLUORIDEX DAILY DEFENSE 1 FLUORIDEX SENSITIVITY RELIEF 1 FLUORITAB (0.125 MG/DRP DROPS, 0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 0 HCR

FLURA-DROPS 0 HCR

LUDENT FLUORIDE 0 HCR pediatric multivitamin no.150 with sodium fluoride 1 pediatric multivitamin no.16/sodium fluoride 3 pediatric multivitamin no.2/sodium fluoride 1 POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) 3 PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS, DENTAL RINSE) 3

PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL PROTECT 3

PAGE 221 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 TRI-VI-FLOR 3 COMPLEMENT INHIBITORS

PA FIRAZYR 4 S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 4 PA S

ARAVA 3 AZASAN 3 azathioprine powder 3 azathioprine 50 mg tablet 1 azathioprine sodium 1 CUPRIMINE 3 cyclosporine (25 mg capsule, 100 mg capsule) 4 S cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) 4 S

DEPEN 2

QL 0.15 / day PA ENBREL 50 MG/ML SURECLICK SYR 4 S PS

QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML PA 4 SYRINGE) S PS

PAGE 222 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLUTION) 4 S gold sodium thiomalate 3 IMURAN 3

QL 0.1 / day PA KEVZARA 4 AL At least 18 yrs old S leflunomide 1 methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1 methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1 NEORAL (25 MG CAPSULE, 100 MG GELATIN CAPSULE, 100 MG/ML SOLUTION) 4 S

QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE) 4 PA S

QL 0.15 / day ORENCIA CLICKJECT 4 PA S

QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK) 4 PA S

QL 0.08 / day OTREXUP 3 PA penicillamine powder 3

QL .08 / day RASUVO (10 MG/0.2 ML, 12.5 MG/0.25 ML) 3 PA

PAGE 223 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RASUVO (7.5 MG/0.15 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 QL 0.08 / day MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 3 ML, 30 MG/0.6 ML) PA

RHEUMATREX 3 RIDAURA 2

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 4 S

S SANDIMMUNE 100 MG/ML SOLN 4 PS

QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 4 PA S

QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE) 4 PA S

TREXALL 2

QL 4 / day XATMEP 3 PA AL Up to 18 yrs old

QL 2 / day XELJANZ 4 PA S

QL 1 / day XELJANZ XR 4 PA S

GONADOTROPIN-RELEASING ANTAGNTS

PA GL Female CETROTIDE 4 S PS

PAGE 224 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA FIRMAGON 120 MG VIAL 4 S

GL Female ganirelix acetate 4 S

IMMUNOMODULATORY AGENTS

ACTIMMUNE 4 S

QL 1 / day PA AUBAGIO 4 S PS

QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLED PA 4 SYR 30 MCG KT) S PS

QL 0.15 / day PA AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4 S PS

QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) 4 PA S

QL 1 / day PA COPAXONE 4 S PS

QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 4 PA S

PAGE 225 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA GILENYA 4 S PS

QL 1 / day GLATOPA 4 PA S

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML SYRING 4 S PS

QL 1 / lifetime PA PLEGRIDY SYRINGE STARTER PACK 4 S PS

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML PEN 4 S PS

QL 1 / lifetime PA PLEGRIDY PEN INJ STARTER PACK 4 S PS

QL 1 / day POMALYST 4 PA S

QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 4 PA S

PAGE 226 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4.2 / 365 days REBIF TITRATION PACK 4 PA S

QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4 PA S

QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 4 PA S

QL 1 / day REVLIMID 4 PA S

QL 2 / day PA TECFIDERA 4 S PS

QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4 PA S

QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4 PA S

QL 1 / day ZINBRYTA 4 PA S

IMMUNOSUPPRESSIVE AGENTS

QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 4 PA S

PAGE 227 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / day ASTAGRAF XL 1 MG CAPSULE 4 PA S

QL 6 / day ASTAGRAF XL 5 MG CAPSULE 4 PA S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 4 S (25 mg capsule, 50 mg capsule) 1 PA cyclophosphamide 100 % powder 3 cyclosporine powder 3

QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old

QL 1 / day ENVARSUS XR 4 PA S mercaptopurine 100 % powder 3 mercaptopurine 50 mg tablet 1 mycophenolate mofetil (250 mg capsule, 500 mg tablet) 4 S mycophenolate mofetil 200 mg/ml susp recon 4 S mycophenolate sodium 4 S

MYFORTIC 4 S

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 4 S

PA PURIXAN 4 S

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) 4 S

PAGE 228 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 100 % powder 3 sirolimus (1 mg tablet, 2 mg tablet) 4 S sirolimus 0.5 mg tablet 4 S

QL 2 / day 0.5 mg capsule 4 S

QL 8 / day tacrolimus 1 mg capsule 4 S

QL 4 / day tacrolimus 5 mg capsule 4 S tacrolimus 100 % powder 3 tacrolimus anhydrous 3 tacrolimus, micronized 3

PA ZORTRESS 4 S

OTHER MISCELLANEOUS THERAPEUTIC AGENTS acetylcarnitine hcl 3 acetylcysteine powder 3 acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1 amifampridine 3

QL 2 / day PA AMPYRA 4 S PS

PA ARCALYST 4 S beta 1,3 glucan 3

PAGE 229 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS betaine hcl 3

PA BOTOX COSMETIC 4 S butylated hydroxytoluene 3 CARDIOVID PLUS 3 CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 CARNITOR SF 3

QL 2 / day CERDELGA 4 PA S chondroitin sulfate a sodium 100 % powder 3 coumarin 3

CYSTADANE 4 S

CYSTAGON 4 S cysteamine hcl 3 dalfampridine 3 DEMSER 3 dimethyl sulfoxide 99 % vial 3 edetate disodium 3 EPIFIX AMNIOTIC MEMBRANE 3 ethyl alcohol (98 % ampul, 98 % vial) 1 gamma-aminobutyric acid 3 3 glucosamine hcl powder 3 glucosamine sulfate (dipotassium chloride) 3 glucosamine sulfate sodium cl 3 GRAFIX CORE 5CM X 5CM MATRIX 3

PAGE 230 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GRAFIX PRIME 5CM X 5CM MATRIX 3

QL 1 / day GRASTEK 3 PA

QL 0.04 / day ILARIS 150 MG/ML VIAL 4 PA S indole-3-carbinol 3

QL 4 / day KEVEYIS 4 PA S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MG PA 4 POWDER PACKET) S leucovorin calcium powder 3 levocarnitine powder 3 levocarnitine hcl 3 lycopene 3 3 NEXAVIR 3 - dinucleotide, reduced, disodium 3

ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT, PA 4 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) S

ORALAIR 100 IR STARTER PACK 4 S

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG PA 4 CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S

POTABA 3 potassium perchlorate 3

PROCYSBI 4 S

PAGE 231 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3

QL 1 / day RAGWITEK 3 PA 3

QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 4 PA S

QL 4 / day SENSIPAR 90 MG TABLET 4 PA S squaric acid dibutylester 3 STRAVIX (STRAVI3CM 6CM, STRAVI4CM 7CM) 3 99.1 % powder 3 THIOLA 3 tiopronin 3 turmeric (95 % powder, 100 % powder) 3

S TYBOST 4 PS ubidecarenone (100 % powder, powder) 3 ubiquinol 3 VP-ZEL 3

XURIDEN 4 S

PA ZAVESCA 4 S

PROTECTIVE AGENTS

ELMIRON 3

MESNEX 400 MG TABLET 4 S

PAGE 232 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pentosan polysulfate sodium 3 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3 QL 2 / day

CELEBREX 100 MG CAPSULE 3 QL 3 / day

CELEBREX 400 MG CAPSULE 3 QL 1 / day celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day celecoxib 100 % powder 3 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

ANSAID 3 DAYPRO 3 diclofenac potassium 1 diclofenac sodium 1.5 % drops 3 HCG

QL 1000/ 30 days diclofenac sodium 1 % gel (gram) 3 HCG diclofenac sodium 100 % powder 3 diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) 1 diclofenac sodium, micronized 3 diflunisal 1 etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 1 24h)

FELDENE 3 fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 mg tablet) 1

PAGE 233 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenoprofen calcium, dihydrate 3 FENORTHO 3

FLECTOR 3 QL 2 / day flurbiprofen powder 3 flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen 100 mg/5ml oral susp 1 ibuprofen 100 % powder 3 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG indomethacin powder 3 ketoprofen 200 mg cap24h pel 3 HCG ketoprofen 50 mg capsule 1 LCG ketoprofen 75 mg capsule 1 ketoprofen 100 % powder 3 ketoprofen, micronized 3

QL 20 / 30 days ketorolac tromethamine 30 mg/ml cartridge 1 LCG ketorolac tromethamine 100 % powder 3 ketorolac tromethamine 30 mg/ml syringe 1 QL 20 / 23 days

QL 21 / fill ketorolac tromethamine 10 mg tablet 1 LCG ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml vial) 1 QL 40 / 23 days ketorolac tromethamine (30 mg/ml vial, 60 mg/2 ml syringe) 1 QL 20 / 30 days ketorolac tromethamine (60 mg/2 ml cartridge, 60 mg/2 ml QL 20 / 30 days 1 vial) LCG

QL 20 / 23 days ketorolac tromethamine 30mg/ml(1) vial 1 LCG

PAGE 234 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

KLOFENSAID II 3 HCG

LODINE 3 meclofenamate sodium (50 mg capsule, 100 mg capsule) 1 meclofenamate sodium powder 3

QL 5 / day 250 mg capsule 3 HCG mefenamic acid 100 % powder 3 meloxicam 7.5 mg/5ml oral susp 1 QL 10 / day meloxicam 100 % powder 3

QL 1 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 LCG

MOBIC 7.5 MG/5 ML SUSPENSION 3 QL 10 / day

MOBIC (7.5 MG TABLET, 15 MG TABLET) 3 QL 1 / day nabumetone 100 % powder 3 nabumetone (500 mg tablet, 750 mg tablet) 1 nabumetone, micronized 3 NALFON 3 naproxen powder 3 naproxen sodium powder 3 oxaprozin 600 mg tablet 3 HCG

PENNSAID 2% PUMP 3 QL 3.8 / day phenylbutazone 3 piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old piroxicam 100 % powder 3

PONSTEL 3 QL 5 / day

PROFENO 1

PAGE 235 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SPRIX 3 QL 5 days sulindac powder 3 sulindac (150 mg tablet, 200 mg tablet) 1 tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mg tablet) 1

TOXICOLOGY SALIVA COLLECTION 3

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

VOLTAREN 3 QL 1000/ 30 days

VOLTAREN-XR 3

ZIPSOR 3 QL 4 / day

SALICYLATES carisoprodol/aspirin 200-325 mg tablet 1 choline salicyl/mag salicylate 500 mg/5ml liquid 1 choline salicyl/mag salicylate powder 3 DISALCID 3 salsalate 100 % powder 3 salsalate (500 mg tablet, 750 mg tablet) 1

AMINOPENICILLINS amoxicillin 100 % powder 3 amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 775 mg tbmp 24hr) 1 amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 400 mg/5ml susp recon, 875 mg tablet) 1 LCG amoxicillin/potassium clav 4:1 powder 3 amoxicillin/potassium clav 1000-62.5 tab er 12h 3 HCG

PAGE 236 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amoxicillin/potassium clavulanate (amoxicillin/potassium 200- 28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, 1 amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet) ampicillin sodium (1 g vial, 2 g vial, 10 g vial, 125 mg vial, 250 mg vial, 500 mg vial) 1 ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 g vial, sodium/sulbactam 3 g vial, sodium/sulbactam 15 g vial) 1 ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) 1

AUGMENTIN 125-31.25 MG/5 ML 2 AUGMENTIN (250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET) 3

AUGMENTIN ES-600 3 AUGMENTIN XR 3 MOXATAG 3 UNASYN 3 EXTENDED-SPECTRUM PENICILLINS ticarcillin disodium/potassium clavulanate 3 NATURAL PENICILLINS

BICILLIN C-R 3 BICILLIN L-A 3 g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) 1 LCG

PAGE 237 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PFIZERPEN 3 PENICILLINASE-RESISTANT PENICILLINS sodium 250 mg capsule 1 dicloxacillin sodium 500 mg capsule 1 LCG sodium (1 g vial, 2 g vial, 10 g vial) 1 oxacillin sodium (1 g vial, 2 g vial, 10 g vial) 1 --ALDOSTER.INHIB(HYPOTN)

ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)

ATACAND 3 QL 1 / day

AVAPRO 3 QL 1 / day

BENICAR 3 QL 3 / day candesartan cilexetil 1 QL 1 / day

COZAAR (25 MG TABLET, 50 MG TABLET) 3 QL 2 / day

COZAAR 100 MG TABLET 3 QL 1 / day

DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3 QL 2 / day

DIOVAN 320 MG TABLET 3 QL 1 / day

QL 1 / day EDARBI 3 ST eprosartan mesylate 1 QL 1 / day irbesartan 1 QL 1 / day

QL 2 / day losartan potassium (25 mg tablet, 50 mg tablet) 1 LCG

QL 1 / day losartan potassium 100 mg tablet 1 LCG

PAGE 238 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MICARDIS 3 QL 1 / day olmesartan medoxomil 1 QL 3 / day telmisartan 1 QL 1 / day valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day valsartan 320 mg tablet 1 QL 1 / day

ANGIOTENSIN-CONVERT. INHIB(HYPOTN)

ACCUPRIL 3 QL 2 / day

ACEON 3 QL 1 / day

ALTACE 3 QL 2 / day benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day captopril 100 % powder 3 captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg 4 / day tablet) 1 QL enalapril maleate 100 % powder 3 enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 2 / day mg tablet) 1 QL

EPANED (1 MG/ML ORAL SOLUTION, 1 MG/ML SOLUTION) 3 QL 5 / day fosinopril sodium 1 QL 2 / day lisinopril 100 % powder 3

QL 1 / day lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1 LCG lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day lisinopril 40 mg tablet 1 QL 2 / day

PAGE 239 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LOTENSIN 20 MG TABLET 3 QL 4 / day

LOTENSIN 40 MG TABLET 3 QL 2 / day

MAVIK 3 QL 2 / day moexipril hcl 1 QL 1 / day perindopril erbumine 1 QL 1 / day

PRINIVIL 3 QL 1 / day

QBRELIS 3 QL 40/ day quinapril hcl 1 QL 2 / day ramipril 1 QL 2 / day trandolapril 1 QL 2 / day

VASOTEC 3 QL 2 / day

ZESTRIL 3 QL 1 / day

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

QL 2 / day ENTRESTO 3 PA

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS benazepril hcl 100 % powder 3 RENIN INHIBITORS

QL 1 / day TEKTURNA 3 ST

PAGE 240 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 4 PA S

QL 3 / day ESBRIET 801 MG TABLET 4 PA S

QL 2 / day OFEV 4 PA S

ANTITUSSIVES benzonatate 1 AL At least 11 yrs old dextromethorphan hbr 3

QL 60 / day FLOWTUSS 3 AL At least 18 yrs old

TESSALON PERLE 3 AL At least 11 yrs old

ZONATUSS 3 AL At least 11 yrs old

EXPECTORANTS bromhexine hcl 3 guaifenesin 3 terpin hydrate 3 MUCOLYTIC AGENTS

QL 5 / day PULMOZYME 4 PA S

PAGE 241 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHOSPHODIESTERASE TYPE 4 INHIBITORS

QL 1 / day DALIRESP 3 PA

PULMONARY SURFACTANTS

CUROSURF 3 INFASURF 3 SURVANTA 3 VASODILATING AGENTS (RESPIRATORY TRACT)

QL 2 / day ADCIRCA 4 PA S

QL 3 / day ADEMPAS 4 PA S

QL 1 / day PA LETAIRIS 4 S PS

QL 1 / day OPSUMIT 4 PA S

QL 3 / day ORENITRAM ER 4 PA S

PA REMODULIN 4 S

QL 6 / day PA REVATIO 10 MG/ML ORAL SUSP 4 AL At least 18 yrs old S

PAGE 242 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day PA REVATIO 20 MG TABLET 4 AL At least 18 yrs old S sildenafil citrate 100 % powder 3

QL 3 / day sildenafil citrate 20 mg tablet 4 PA S

QL 2 / day PA TRACLEER (62.5 MG TABLET, 125 MG TABLET) 4 S PS

QL 1 / day TYVASO 4 PA S

QL 1 / day TYVASO INSTITUTIONAL START KIT 4 PA S

QL 1 / day TYVASO REFILL KIT 4 PA S

QL 1 / day TYVASO STARTER KIT 4 PA S

PA UPTRAVI 200-800 TITRATION PACK 4 AL At least 18 yrs old S

PAGE 243 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG PA TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG 4 TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) AL At least 18 yrs old S

SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

AMRIX 3 carisoprodol powder 3 carisoprodol (250 mg tablet, 350 mg tablet) 1 chlorzoxazone 500 mg tablet 1 cyclobenzaprine hcl 100 % powder 3 cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet) 1 cyclobenzaprine hcl 10 mg tablet 1 LCG

FEXMID 3 LORZONE 3 METAXALL 1 metaxalone 3 HCG methocarbamol 100 % powder 3 methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 100 mg/ml vial 1 PARAFON FORTE DSC 3 ROBAXIN 500 MG TABLET 3 ROBAXIN 1,000 MG/10 ML VIAL 3 ROBAXIN-750 3 SKELAXIN 3 SOMA 3 tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mg tablet, 6 mg capsule) 1

PAGE 244 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tizanidine hcl 100 % powder 3 ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, 6 MG CAPSULE) 3 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3 dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule) 1 dantrolene sodium powder 3 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT 100 % powder 3 baclofen (10 mg tablet, 20 mg tablet) 1 NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide 100 % powder 3 rocuronium bromide 100 % powder 3 succinylcholine chloride 100 % powder 3 vecuronium bromide 100 % powder 3 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS citrate powder 3 orphenadrine citrate 100 mg tablet er 1 orphenadrine citrate (30 mg/ml ampul, 30 mg/ml vial) 1 SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ALA-CORT 1 ALA-SCALP 3 dipropionate (0.05 % cream (g), 0.05 % oint. (g)) 1 (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1 ANA-LEX 2-2% CREAM 3

PAGE 245 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE, 2.5%-1% LOTION) 3

ANUCORT-HC 1 ANUSOL-HC 2.5% CREAM 3 ANUSOL-HC 25 MG SUPPOSITORY 1 APEXICON E 3 betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g)) 1 betamethasone dipropionate powder 3 betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), betamethasone/propylene 0.05 % lotion, 1 betamethasone/propylene 0.05 % oint. (g)) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 % foam) 1 betamethasone valerate powder 3 calcipotriene/betamethasone dipropionate 1 QL 3 / day

CAPEX SHAMPOO 3 propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05 % lotion, 0.05 % oint. (g), 0.05 % shampoo, 1 0.05 % solution, 0.05 % spray) powder 3 clobetasol propionate/emollient base (propionate/emoll 0.05 % cream (g), propionate/emoll 0.05 % foam) 1

CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) 3 pivalate 0.1 % cream (g) 1 CLODAN 0.05% SHAMPOO 1 CLODERM 3 COLOCORT 1 CORMAX 1 CORTENEMA 3

PAGE 246 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3 DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3 DERMATOP (EMOLLIENT CREAM, OINTMENT) 3 DESONATE 3 (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 3 HCG desonide, micronized 3 DESOWEN (CREAM, LOTION) 3 (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 % cream (g), 0.25 % oint. (g)) 3 HCG desoximetasone, micronized 3 diacetate (0.05 % cream (g), 0.05 % oint. (g)) 1 DIPROLENE (LOTION, OINTMENT) 3 DIPROLENE AF 3 ELOCON (CREAM, LOTION, OINTMENT) 3

ENSTILAR 3 QL 2 / day

EPIFOAM 3

QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old (0.01 % cream (g), 0.01 % oil, 0.025 % cream (g), 0.025 % oint. (g)) 3 HCG fluocinolone acetonide powder 3 fluocinolone acetonide 0.01 % solution 1 fluocinolone acetonide/shower cap 3 HCG (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % solution, 0.1 % cream (g)) 1 fluocinonide, micronized 3

PAGE 247 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluocinonide/emollient base 1 fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1 halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 3 HCG

HALOG (CREAM, OINTMENT) 3 HEMMOREX-HC 1 hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. 1 (g), 100mg/60ml enema) hydrocortisone powder 3 hydrocortisone acetate powder 3 hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1 hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl 1 hydrocortisone acetate/pramoxine hcl (hydrocortisone/pramoxine 1 %-1 % cream/appl, hydrocortisone/pramoxine 2.5 %-1 % cream (g), 1 hydrocortisone/pramoxine 2.5 %-1 % cream/appl, hydrocortisone/pramoxine 2.5-1%(4g) cream/appl) (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1 hydrocortisone butyrate/emoll 0.1 % cream (g) 1 hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g)) 1 hydrocortisone/mineral oil/petrolatum,white 1 KENALOG 3 lidocaine/hydrocortisone ac 3 %-0.5 % cream (g) 3 HCG lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3-2.5%(7g) 1 gel w/appl)

LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 LUXIQ 3 MICORT-HC 3

PAGE 248 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

NOVACORT GEL 3 OLUX 3 OLUX-E 3 ORALONE 1 PANDEL 3 PRAMCORT 1 PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1% 3 OINTMENT)

PRAMOSONE E 3 (0.1 % cream (g), 0.1 % oint. (g)) 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3 PROCTOFOAM-HC 2 PROCTOSOL-HC 1 PROCTOZONE-HC 1 PSORCON 3 RIMSO-50 3 SANADERMRX 1 SCALACORT 1 SERNIVO 3 SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3 SYNALAR TS 3

TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) 3 QL 3 / day

PAGE 249 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEMOVATE (CREAM, OINTMENT) 3 TEMOVATE EMOLLIENT 3 TEXACORT 3 TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM, 0.25% OINTMENT, 0.25% SPRAY) 3 triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.1 % paste (g), 0.147mg/g aerosol, 0.5 % cream (g), 0.5 % 1 oint. (g))

TRIANEX 1 TRIDERM 1 TRIDESILON 3 ULTRAVATE (CREAM, LOTION, OINTMENT) 3 VANOS 3

VANOXIDE-HC 3 QL 0.84 / day

VERDESO 3 ANTIPRURITICS AND LOCAL ANESTHETICS

ANACAINE 3 ANASTIA 3 CETACAINE 3 CIDALEAZE 1 dibucaine hcl 3 doxepin hcl 5 % cream (g) 1 EMLA 3 ethyl chloride 1

QL 3 / day lidocaine 5 % adh. patch 3 HCG lidocaine 5 % oint. (g) 1 lidocaine hcl (3 % cream (g), 3 % lotion, 4 % solution) 1

PAGE 250 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5 kit) 1 lidocaine/tetracaine 1

LIDODERM 3 QL 3 / day

LIDOPIN 3% CREAM 1 LIDOPIN 3.25% CREAM 3 LIDOPRIL 1

QL 1 / day LIDORX 2 PA

LIDOTRAL 3 LIDOVEX 3 LIDTOPIC MAX 3 LP LITE PAK 1 NUMBONEX 3 PAIN EASE 3 phenazopyridine hcl 100 % powder 3 phenazopyridine hcl (100 mg tablet, 200 mg tablet) 1 PLIAGLIS 3 PONTOCAINE 3 pramoxine hcl 3 PRE-ATTACHED LTA KIT 3 PRUDOXIN 3 PYRIDIUM 3 REGENECARE 3 SPRAY AND STRETCH 3 SYNERA 3 ZONALON 3

PAGE 251 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ASTRINGENTS

DRYSOL 3 CELL STIMULANTS AND PROLIFERANTS

ATRALIN 3 QL 1.5 / day

AVITA (CREAM, GEL) 1 REFISSA 3 RENOVA 3 RENOVA PUMP 3 RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% CREAM, 0.1% CREAM) 3

RETIN-A MICRO 3 QL 50 / 30 days

RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.08% GEL, 50 / 30 days PUMP 0.1% GEL) 3 QL

TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3 tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g)) 1 tretinoin powder 3 tretinoin microspheres (0.04 % gel (gram), 0.04 % gel w/pump, QL 1.667 / day 3 0.1 % gel (gram), 0.1 % gel w/pump) HCG tretinoin/emollient base 1 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

ALEVICYN ANTIPRURITIC SG 3 AGENTS

ALUVEA 3 BENSAL HP 3

BENZEFOAM 3 QL 2 / day

BENZEFOAM ULTRA 3 QL 3.334 / day

PAGE 252 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1 benzoyl peroxide 7 % cleanser 1 BP-50% UREA 1 BPO (4% GEL, 8% GEL) 3

BPO 6% FOAMING CLOTHS 1 QL 2 / day

CEM-UREA 3 GORDO-UREA 40% OINTMENT 3 HYDRO 35 3 HYDRO 40 3 KERAFOAM 3 KERALAC 3 KERALYT 3 lactic acid 88% to 92% liquid 3 LATRIX 1

NUOX 3 QL 1.47 / day

PACNEX 1 PACNEX HP 3 PACNEX LP 3 podophyllum resin 3 potassium hydroxide pellet (g) 3 potassium hydroxide 5 % solution 1 PR BENZOYL PEROXIDE 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 RYNODERM 3 SALACYN (CREAM, LOTION) 1 SALEX 6% SHAMPOO 3

PAGE 253 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (6 % cream (g), 6 % crm er (g), 6 % foam, 6 % gel (gram), 6 % lotion, 6 % lotion er, 6 % shampoo, 26 % liquid, 1 27.5 % liq-film, 28.5 % sol-filmer) salicylic acid powder 3 salicylic acid/ammonium lactate/aloe vera 1 SALKERA 3 SALVAX 3 silver nitrate 10 % solution 1 silver nitrate/potassium nitrate 1 (10 % solution, 100 % pellet (g), flakes, granules) 3 sulfur 3 sulfur sublimed 3 ULTRASAL-ER 3 UMECTA (EMULSION, NAIL FILM PEN, NAIL FILM SUSP) 3 UMECTA 40% MOUSSE 1 UMECTA PD (PD EMULSION, PD SUSPENSION) 3 URAMAXIN (20% FOAM, 45% LOTION, 45% NAIL GEL, 45% UREA CREAM) 3

URAMAXIN GT 45% PRE-FILLED APP 3 URE-K 1 urea (35 % foam, 39 % cream (g), 40 % cream (g), 40 % gel (ml), 40 % lotion, 40 % nl fm susp, 45 % cream (g), 45 % gel 1 (ml), 45 % lotion, 47 % cream (g), 50 % cream (g)) urea (50 % sol/pf app, 100 % powder) 3 UREVAZ 3 UTOPIC 3 VIRASAL 3

PAGE 254 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KERATOPLASTIC AGENTS anthralin 3 (tar tar, tar 20 % solution) 3 DRITHOCREME HP 3 ZITHRANOL 3 ZITHRANOL-RR 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

ABSORICA 3 PA

QL 2 / day acitretin (17.5 mg capsule, 25 mg capsule) 3 HCG

QL 4 / day acitretin 10 mg capsule 3 HCG

ACZONE (5% GEL, 7.5% GEL PUMP) 3 QL 3 / day 0.1 % gel (gram) 1 QL 1.5 / day adapalene (0.1 % cream (g), 0.3 % gel (gram), 0.3 % gel QL 1.5 / day 3 w/pump) HCG adapalene 0.1 % lotion 1 QL 2 / day adapalene/benzoyl peroxide 3 QL 1.5 / day

QL 0.434 / day ALDARA 3 AL At least 12 yrs old

PA AMNESTEEM 3 HCG

ARTISS 3

AVAGE 3 QL 1.47 / day (85 % flakes, 88 % flakes, 100 % flakes, 100 % powder) 3

PAGE 255 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AZELEX 3 QL 1.667 / day

QL 2 / day calcipotriene (0.005 % cream (g), 0.005 % oint. (g)) 3 HCG calcipotriene 0.005 % solution 1 QL 2 / day

CALCITRENE 1 QL 2 / day 3 mcg/g oint. (g) 1 QL 3.334 / day camphor 3 3 capsaicin palmitate 3 capsicum oleoresin 3 CARAC 2

PA CLARAVIS 3 HCG clostridium histolyticum 3 CONDYLOX (GEL, TOPICAL SOLN) 3

QL 0.357 / day COSENTYX (2 SYRINGES) 4 PA S

QL 0.357 / day COSENTYX PEN 4 PA S

QL 0.357 / day COSENTYX PEN (2 PENS) 4 PA S

QL 0.357 / day COSENTYX SYRINGE 4 PA S

PAGE 256 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dapsone 5 % gel (gram) 1 QL 3 / day

DEBACTEROL (SOLUTION, SWABSTICK) 3 diclofenac sodium 3 % gel (gram) 1 QL 100 / 30 days

DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL 1.5 / day PUMP) 3 QL

DIFFERIN 0.1% LOTION 3 QL 1.967 / day

DOVONEX 3 QL 2 / day

QL 0.15 / day PA DUPIXENT 4 AL At least 18 yrs old S

EFUDEX 3

EPIDUO 0.1-2.5% GEL 3 QL 1.667 / day

EPIDUO 0.1-2.5% GEL PUMP 3 QL 1.5 / day

EPIDUO FORTE 3 QL 1.667 / day

QL 3.73 / day FABIOR 3 AL Up to 34 yrs old

QL 50 / 30 days FINACEA (FOAM, GEL) 3 PA finasteride 1 mg tablet 1 FLUOROPLEX 2 fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g), 5 % solution) 1

FORMADON 1 formaldehyde 1 GRANULEX 3

QL 0.434 / day imiquimod 5 % cream pack 1 AL At least 12 yrs old

PAGE 257 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS imiquimod 100 % powder 3 3 LEVULAN 3 methyl aminolevulinate hcl 3

MIRVASO (GEL, GEL PUMP) 2 QL 1 / day

MUCOTROL 3

PA MYORISAN 3 HCG

PANRETIN 3

PICATO 3 ST

PODOCON-25 3 podofilox 0.5 % solution 1 PROPECIA 3

QL 2.5 / day PROTOPIC 0.03% OINTMENT 3 ST AL At least 2 yrs old

QL 2.5 / day PROTOPIC 0.1% OINTMENT 3 ST AL At least 16 yrs old

PYROGALLIC ACID 1 RECTIV 3

REGRANEX 3 QL 1 / day

RENOVO 3

QL 1.25 / day RHOFADE 3 PA

SANTYL 3 SINELEE 5%-0.05% PATCH 3

PAGE 258 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SOLARAZE 3 QL 100 / 30 days

SOOLANTRA 2 QL 1.5 / day

SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) 3 QL 2 / day

SORIATANE 10 MG CAPSULE 3 QL 4 / day

SORILUX 3 QL 2 / day

QL 100 / 30 days tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 3 ST HCG

QL 0.15 / day TALTZ AUTOINJECTOR 4 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (2 PACK) 4 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (3 PACK) 4 PA S

QL 0.15 / day TALTZ SYRINGE 4 PA S

QL 0.15 / day TALTZ SYRINGE (2 PACK) 4 PA S

QL 0.15 / day TALTZ SYRINGE (3 PACK) 4 PA S

PAGE 259 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA TARGRETIN 1% GEL 4 S

QL 1.47 / day 0.1 % cream (g) 3 HCG tazarotene 100 % powder 3

TAZORAC (0.05% CREAM, 0.1% CREAM) 3 QL 2 / day

TAZORAC (0.05% GEL, 0.1% GEL) 3 QL 3.334 / day

QL 1.47 / day TOLAK 3 ST

TRI-CHLOR 3 trichloroacetic acid (25 % soln recon, 75 % soln recon) 1

QL 3 / day VALCHLOR 4 PA S

VANIQA 3

VECTICAL 3 QL 3.334 / day

VENELEX (OINTMENT, OINTMENT PACKET) 3 VEREGEN 3

PA ZENATANE 3 HCG

QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) 3 AL At least 12 yrs old

QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP 3 AL At least 12 yrs old

SUNSCREEN AGENTS zinc oxide 3

PAGE 260 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 100 PA mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 500 4 mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial) S octreotide acetate (50 mcg/ml vial, 200 mcg/ml vial, PA 4 1000mcg/ml vial) S

QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 4 PA S

QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 4 PA S

QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 4 PA S

QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 4 PA S

QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 4 PA S

QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30 MG VL) 4 PA S

QL 0.07 / day SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4 PA S

PAGE 261 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA SIGNIFOR 4 S

QL 0.1 / day SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4 PA S

QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 4 PA S

QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 4 PA S

SOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN AGONISTS

QL 2 / day EGRIFTA 4 PA S

PA INCRELEX 4 S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 4 S

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) hcl powder 3

PAGE 262 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS bupivacaine hcl/epinephrine 1 bupivacaine hcl/epinephrine bitartrate 1 bupivacaine hcl/epinephrine/pf 1 lidocaine hcl/epinephrine (hcl/epinephrine 0.5-1:200k vial, hcl/epinephrine 1%-1:100k vial, hcl/epinephrine 1.5-1:200k ampul, hcl/epinephrine 1.5-1:200k vial, hcl/epinephrine 2 %- 1 1:100k vial, hcl/epinephrine 2%-1:200k vial) lidocaine hcl/epinephrine bitartrate 1 MARCAINE-EPINEPHRINE 3 bitartrate 100 % powder 3

QL 84 / 14 days NORTHERA 4 PA S phenylpropanolamine hcl 3 SENSORCAINE-EPINEPHRINE 1 SENSORC MPF 0.75%-EPI 1:200000 3 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI, SENSORCN-MPF 0.5%-EPI) 1

XYLOCAINE DENTAL-EPINEPHRINE 1 XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 1%-EPI 1:100,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000) 3

XYLOCAINE-MPF WITH EPINEPHRINE 3 ALPHA-ADRENERGIC AGONISTS midodrine hcl 1 phenylephrine hcl 100 % powder 3 phenylephrine hcl 10 mg/ml vial 1

PAGE 263 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS carbimazole 3 methimazole 100 % powder 3 methimazole (5 mg tablet, 10 mg tablet) 1 propylthiouracil 100 % powder 3 propylthiouracil 50 mg tablet 1 TAPAZOLE 3 THYROID AGENTS

ARMOUR THYROID 3 CYTOMEL 3 LEVO-T 1 sodium (1 mg/g powder, 100 % powder) 3 levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 1 LCG mcg tablet, 175mcg tablet) levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcg tablet, 300 mcg tablet) 1

LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET) 1 LCG

LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 1 MCG TABLET, 200 MCG TABLET) liothyronine sodium (1 mg/g powder, 100 % powder) 3 liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1

NATURE-THROID 3 NP THYROID 1 SYNTHROID 2 THYROID 3

PAGE 264 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS thyroid,pork 3 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3

TIROSINT 3 QL 1 / day

UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET, 112 MCG TABLET) 1 LCG UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 1 200 MCG TABLET, 300 MCG TABLET)

WESTHROID 3 WP THYROID 3 Uncategorized

Unclassified

0.9 % sodium chloride 0.9 % syringe cp 1 2-methoxyestradiol 3 3,5-diiodothyronine 3 5hydroxytryptophan(oxitriptan) powder 3 7-oxodehydroepiandrosterone 3 7-oxodehydroepiandrosterone, micronized 3 acacia 3 acetarsol 3 acetyl hexapeptide-8 3 acetylglucosamine 3

QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 4 PA S

PAGE 265 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day AFINITOR 2.5 MG TABLET 4 PA S

PA AFINITOR DISPERZ 4 S

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR albumin, serum, bovine 3

QL 8 / day PA ALECENSA 4 AL At least 18 yrs old S alginic acid 3 ALKERAN 2 MG TABLET 3 allantoin 3 ALLFEN CDX 3 almond oil oil 3 aloe vera leaf gel extract 3 alpha (100 % powder, powder) 3 aluminum acetate 3 aluminum chloride 3 aluminum chlorohydrate 3 aluminum sulfate 3

QL 6 / day PA ALUNBRIG 4 AL At least 18 yrs old S

PAGE 266 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS american root 3 ammonium lactate 70 % solution 3 ammonium sulfate 3 ammonium tetrathiomolybdate 3 AMVISC 3 AMVISC PLUS 3 100 % powder 3 anastrozole 1 mg tablet 1 anisindione 3 APLIGRAF 3 AQUORAL 3 ARIMIDEX 3 arnica flower extract 3 AROMASIN 3 arsenic trioxide 3 ashwagandha root extract 3 3 astragalus root extract 3 ATRAPRO DERMAL SPRAY 3 ATRAPRO HYDROGEL 3 AURSTAT ANTI-ITCH HYDROGEL 3 AVAILNEX 3 AVENOVA 3 azacitidine 4 S

B-PLEX PLUS 1 BEAU RX 3

PA BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 4 S

PAGE 267 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS benzocaine 3 benzocaine micronized 3 benzoic acid 3 benzoyl peroxide 65% to 82% powder 3 benzyl alcohol 3 bergamot 3 beta-glucan, (1-3) (1-4) 3 betadex 3

PA bexarotene 4 S 1 BIONECT (CREAM, GEL) 3 100 % powder 3 bismuth citrate 3 bismuth subgallate 3 bismuth tribromophenate/petrolatum,white (tribromoph/petrolatum 1"x8" bandage, tribromoph/petrolatum 2" x 2" bandage, tribromoph/petrolatum 4" x 4" bandage, 3 tribromoph/petrolatum 4"x108" bandage, tribromoph/petrolatum 5"x9" bandage) bitter melon extract 3

BLEO 15K 4 S bleomycin sulfate 4 S blood-glucose sensor 3 blood-glucose transmitter each 3 blue-green algae 3

QL 4 / day PA BOSULIF 100 MG TABLET 4 S PS

PAGE 268 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA BOSULIF 500 MG TABLET 4 S PS boswellia serrata extract 3 bromelains 3 bromfenac sodium 100 % powder 3 buflomedil hcl 3 bupivacaine hcl 100 % powder 3 bupivacaine hcl/dex-water/pf 0.75 % ampul 1 bupivacaine hcl/pf (hcl/pf 2.5 mg/ml ampul, hcl/pf 5 mg/ml ampul, hcl/pf 7.5 mg/ml ampul) 1 butalbital/aspirin/caffeine 50-325-40 tablet 1 QL 6 / day

BYDUREON BCISE 2 QL 0.15 / day

QL 4 / day CABOMETYX 20 MG TABLET 4 PA S

QL 2 / day CABOMETYX 40 MG TABLET 4 PA S

QL 1.5 / day CABOMETYX 60 MG TABLET 4 PA S calcipotriene 100 % powder 3 calcipotriene monohydrate 3 calcitriol/almond oil 3 cantharidin (100 % crystals, powder) 3 capecitabine 4 S

PAGE 269 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CAPHOSOL 3

QL 2 / day CAPRELSA 100 MG TABLET 4 PA S

QL 1 / day CAPRELSA 300 MG TABLET 4 PA S carbitol 3 CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) 3

CARDENE SR 45 MG CAPSULE 3 QL 2 / day

CASODEX 3 catheter (6fr-16" each, 8 fr each, 8fr-16" each, 10 fr each, 10fr- 16" each, 12 fr each, 12fr-16" each, 14 fr-16 " each, 14fr-6" 3 each, 16 fr each, 16fr-16" each, 18fr-16" each, 28 fr each) catheter 14 fr each 1 catheterization tray tray 3 CEDAX 90 MG/5 ML SUSPENSION 3 cellulose 3 CERAMAX 1 cervical cap (cap 26mm each, cap 30mm each) 3 cervical cap 22mm each 0 HCR

CERVIDIL 3 GL Female cesium chloride 3 cetyl myristoleate (20 % powder, 40 % oil, 40 % wax) 3 3 chinese red pine bark extract 3 chlorambucil 3 chloroallyl methenamine chloride 3

PAGE 270 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 3 chloroprocaine hcl/pf 1 3 3 chlorzoxazone 250 mg tablet 1 3 chromium picolinate 3 chromium polynicotinate 3 3 chymotrypsin 3 citric acid (100 % granules, powder) 3 clemizole hcl 3 cobalt gluconate 3 colostomy bag, non-sterile 3

QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 4 PA S

QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 4 PA S

QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 4 PA S compression stocking, knee high, regular length, medium 3 compression stocking, knee high, regular length, small 3 compression stocking,knee high,long length, large circumfer. 3 compression stocking,knee high,long length, x-large circumf. 3

PAGE 271 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS compression stocking,knee high,long length,medium circumfer. 3 compression stocking,knee high,long length,small circumferen 3 compression stocking,knee high,regular length,large circumf. 3 compression stocking,knee high,regular length,x-large circum 3 compression stocking,thigh high,long length,extra-large circ 3 compression stocking,thigh high,long length,large circumfer. 3 compression stocking,thigh high,long length,medium circumfer 3 compression stocking,thigh high,long length,small circumfer. 3 compression stocking,thigh high,long length,x-small circumf. 3 compression stocking,thigh high,reg length,x-large circumfer 3 compression stocking,thigh high,regular length,large circumf 3 compression stocking,thigh high,regular length,medium circum 3 compression stocking,thigh high,regular length,small circumf 3 compression stocking,thigh high,regular length,x-small circ. 3 compression stocking,thigh high,short length,large circumfer 3 compression stocking,thigh high,short length,medium circumf. 3 compression stocking,thigh high,short length,small circumfer 3 compressor, for nebulizer each 3 conception assistance supplies combination no.1 1

QL 2.5 / day PA COTELLIC 4 AL At least 18 yrs old S

QL 1 / day COTEMPLA XR-ODT 3 ST cream base no.134 3 3

PAGE 272 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS creatine monohydrate 3 3 cytarabine 4 S cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 100 mg/5ml vial) 4 S cytarabine/pf 20 mg/ml vial 4 S dapiprazole hcl 3 deanol 3 demecarium bromide 3 deoxycholic acid 3 DERMAGRAFT 3 devil's claw extract 3 dexchlorpheniramine maleate 1 dexpanthenol 3 diaphragms, wide seal 0 HCR dibucaine 3 dichloroacetic acid 3 diethanolamine 3 diindolylmethane 3 DILUENT FOR ELITEK 3 dimethyl sulfoxide (99 % liquid, 99.99 % liquid) 3 dimethylacetamide 3 dinitrochlorobenzene (2,4) 3 diphencyprone 3 DISCOVISC 3 dl-3-hydroxybutyric acid, sodium salt 3 drainage bag (bag each, bag 2000ml each) 3

PAGE 273 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS , /sodium alginate/carboxymethylcellulose 3 dressing,collagen/silver/sod alginate/carboxymethylcellulose 3 DROXIA 3 DUOVISC 3

EMCYT 4 S

EMULSION SB TOPICAL EMULSION 3

QL 0.15 / day PA ENBREL 50 MG/ML MINI CARTRIDGE 4 S PS

ENDOFORM (4" 5" TEMPLATE, FENESTRATED, FENESTRATED 4" 5", TEMPLATE) 3

ENTTY 3 EPICERAM 3 3 EPISIL 3

QL 1 / day ERIVEDGE 4 PA S

ERWINAZE 4 S ethoxydiglycol 3 ethyl acetate 1 ethyl oleate 3 1

PA EXJADE 4 S

EXPAREL 3

PAGE 274 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FARESTON 2

PA FARYDAK 4 S feeder container 3 feeder container with gravity set 3 feeder container with gravity set, enfit 3 feeder container with pump set 3

FEMARA 3 PA ferric ammonium citrate 3 ferric subsulfate 3

PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 4 S fexofenadine hcl/pseudoephedrine hcl 1 QL 1 / day floxuridine 100 % powder 3 floxuridine 500 mg vial 4 S

AL At least 65 yrs old FLUAD 2017-2018 0 HCR

FLUARIX QUAD 2017-2018 0 HCR

FLUBLOK 2017-2018 0 HCR

FLUBLOK QUAD 2017-2018 0 HCR

FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR fluorouracil 100 % powder 3 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

PAGE 275 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 65 yrs old FLUZONE HIGH-DOSE 2017-2018 0 HCR

FLUZONE INTRADERM QUAD 2017-18 0 HCR

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

FLUZONE QUAD PEDI 2017-2018 0 HCR foam bandage 1 foam/gauze bandage/lidocaine/chlorhexidine/ 3 FORMA-RAY 3 GALZIN 3 GASTROMARK 3 gauze bandage 3 gel dressing gel (gram) 3 gelatin 3 GELCLAIR 3 GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200 SPONGE) 3

GELFOAM COMPRESSED 3 GELFOAM JMI SPONGE KIT 3 GELX 3 GENADUR NAIL LACQUER 3

QL 1 / day GILOTRIF 4 PA S

QL 8 / day PA GLEEVEC 100 MG TABLET 4 S PS

PAGE 276 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day PA GLEEVEC 400 MG TABLET 4 S PS

GLEOSTINE 3 gluconolactone 3 3 1 3 3 (70 % solution, crystals) 3 glycopyrrolate 1.5 mg tablet 1 glycosaminoglycans,mixed 3 glycyrrhizin 3 gramicidin d 3 guarana seed extract 3 HEMABATE 3

PA HEXALEN 4 S

HICON (500 MCI/0.5 ML KIT, 1,000 MCI/ML KIT) 3 phosphate 3 3 histidine hcl 3 HPR 3 HPR PLUS (CREAM, EMOLLIENT FOAM) 3 HUMALOG JUNIOR KWIKPEN 2 hyaluronate sodium (94 % powder, 100 % powder) 3

PAGE 277 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hyaluronidase, bovine 3

PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 4 S hydrazine sulfate 3 HYDREA 3 hydrocolloid dressing (4" 4" bandage, 6" 6" bandage, 8" 8" bandage) 1 hydrocolloid dressing 7"x8" bandage 3 peroxide 3 hydroxyethyl methacrylate 3 hydroxypropyl betadex 3 hydroxyurea 500 mg capsule 1 hydroxyurea 100 % powder 3 HYGEL 3 HYLATOPIC 3 HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3 HYLENEX 3

PA HYQVIA HY COMPONENT 4 S

QL 1.25 / day IBRANCE 100 MG CAPSULE 4 PA S

QL 1 / day IBRANCE 125 MG CAPSULE 4 PA S

QL 1.667 / day IBRANCE 75 MG CAPSULE 4 PA S

PAGE 278 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ichthammol 3

QL 2 / day ICLUSIG 15 MG TABLET 4 PA S

QL 1 / day ICLUSIG 45 MG TABLET 4 PA S

QL 4 / day IMBRUVICA 4 PA S

INDICLOR 3

QL 1 / day PA INGREZZA 80 MG CAPSULE 4 AL At least 18 yrs old S inhaler, assist devices spacer 3 inhaler,assist device,accesory each 3

QL 4 / day PA INLYTA 4 S PS inositol 3 (1" x 5yard bandage, 1/2"x5yd bandage, 1/4"x180" bandage, 2"x180" bandage) 3 iodoform 100 % powder 3 iopanoic acid 3 IPOL SINGLE DOSE SYRINGE 2

QL 1 / day IRESSA 4 PA S

PAGE 279 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (100 % crystals, powder) 3 isopropamide iodide 3 isopropyl myristate 3 isoproterenol hcl 0.2 mg/ml vial 1

PA JADENU 4 S

PA JADENU SPRINKLE 4 S

QL 2 / day JAKAFI 4 PA S

QL 3 / day PA KISQALI 200 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI 400 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 1 / day PA KISQALI 600 MG DAILY DOSE 4 AL At least 18 yrs old S

QL 3 / day PA KISQALI FEMARA 200 MG CO-PACK 4 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI FEMARA 400 MG CO-PACK 4 AL At least 18 yrs old S

PAGE 280 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA KISQALI FEMARA 600 MG CO-PACK 4 AL At least 18 yrs old S kojic acid 3 lancing device/lancets 2

QL 3 / day LENVIMA 4 PA S 100 % powder 3 letrozole 2.5 mg tablet 1 LEUKERAN 3 leuprolide acetate 100 % powder 3 lidocaine powder 3 lidocaine hcl 100 % powder 3 lidocaine hcl (5 mg/ml vial, 10 mg/ml syringe, 10 mg/ml vial, 50 mg/5 ml syringe) 1 lidocaine hcl buffered with 8.4 % sodium bicarbonate (0.9 %(1ml) syringe, 0.9 %(3ml) syringe, 0.9 %(5ml) syringe, 0.9%(.5ml) syringe, 0.9%(10ml) syringe, 1.8 %(3ml) syringe, 3 1.8 %(5ml) syringe) lidocaine hcl/pf 10 mg/ml ampul 1 MED Medical Drug lidocaine hcl/pf (hcl/pf 10 mg/ml syringe, hcl/pf 10 mg/ml vial, hcl/pf 15 mg/ml ampul) 1 lomustine 1

QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 4 PA S

QL 3 / day LONSURF 20 MG-8.19 MG TABLET 4 PA S

PAGE 281 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOUTREX 3 LUMINAL SODIUM 3 lutein 3

PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 4 S

LYSODREN 4 S maca 3 magnesium aspartate dihydrate 3 magnesium chloride crystals 3 magnesium malate 3 malic acid 3 MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL) 3 MARCAINE SPINAL AMPUL 3

MATULANE 4 S

QL 3 / day PA MAVYRET 4 AL At least 18 yrs old S PS

MAXIFED CDX 3 MAXIPHEN CD 3 MAXIPHEN CDX 3 mechlorethamine hcl 3 medical supply, miscellaneous miscell 3 MEGACE 3

MEGACE ES 3 GL Female (400mg/10ml oral susp, 625mg/5ml oral susp) 1

PAGE 282 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS megestrol acetate (20 mg tablet, 40 mg tablet) 1 megestrol acetate,micronized 3

QL 4 / day MEKINIST 0.5 MG TABLET 4 PA S

QL 1 / day MEKINIST 2 MG TABLET 4 PA S melphalan 1 3 3 mepivacaine hcl/pf 1 methacholine chloride 3

QL 2 / day methadone hcl 5 mg/0.5ml syringe 1 PA

METHERGINE 1 powder 3 methotrexate 3 methylene blue/gentian violet/foam bandage 1 methylergonovine maleate (.2mg/ml(1) ampul, .2mg/ml(1) vial) 1 methylergonovine maleate 0.2 mg tablet 1 methylparaben 3 methylsulfonylmethane 3 MICROCYN 3 MICROCYN HYDROGEL 3 middle ear inflation device 1 MIFEPREX 3

PAGE 283 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS milk thistle 3 mitomycin powder 3 3 monochloroacetic acid 3 clearing device each 3 MUGARD 3

MUSTARGEN 4 S

MYLERAN 4 S nadide 3 NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL, 0.2% 200 MG/100 ML BAG, 0.2% 40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400 MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 100 MG/20 ML AMP, 0.5% 100 MG/20 ML VIAL, 0.5% 150 MG/30 ML VIAL, 0.75% 150 MG/20 ML 3 AMP, 0.75% 150 MG/20 ML VL, 1% 100 MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20 ML AMPULE, 1% 200 MG/20 ML VIAL, 2 MG/ML INFUSION BTL, 5 MG/ML INFUSION BTL, 200 MG/100 ML INF BTL) nasal exhalation resistance device 3 nebulizer each 3 nebulizer accessories (each, kit) 3 nebulizer and compressor each 3 needles, blood collection 3 needles, disposable 3 needles, filter 19gx1 1/2" dis needle 3 needles, filter 19gx1" dis needle 3

PAGE 284 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS needles, safety (18gx1 1/2" dis needle, 18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 21 g x 1" dis needle, 21gx1 1/2" dis needle, 22gx1 1/2" dis needle, 22gx1" dis needle, 23gx1 1/2" 3 dis needle, 23gx1" dis needle, 25gx1 1/2" dis needle, 25gx1" dis needle, 25gx5/8" dis needle, 26gx1/2" dis needle, 27gx1/2" dis needle, 30gx1 1/2" dis needle)

NEOSALUS (CREAM, FOAM, LOTION) 3 NEOSALUS CP 3 NESACAINE 3 NESACAINE-MPF 3 nettle leaf 3 NEUTRASAL 538 MG POWDER PACKET 3

QL 4 / day NEXAVAR 4 PA S

NILANDRON 4 S

PA 4 S

QL 0.124 / day PA NINLARO 4 AL At least 18 yrs old S

NIVATOPIC PLUS 3

PA NOVAREL 5,000 UNIT VIAL 4 S

NUMOISYN (LIQUID, LOZENGE) 3 NUVAIL 3

NYMALIZE 30 MG/10 ML SOLUTION 3 QL 120 / day

PAGE 285 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS octanoic acid 3

QL 1 / day ODOMZO 4 PA S omega-3 fatty /dha/epa/fish oil/sunflower oil 3

ONCASPAR 4 S

ORAFATE 4 S

ORAMAGICRX 3 powder 3 ostomy kit 3 ostomy supply each 3 powder 3 oxytocin 10 unit/ml vial 1 panax ginseng root 3 papain 3 parachlorophenol 3 peak flow meter each 3 peak flow meter/inh assit dev kit 3 pen needle, diabetic 2 3 phenindione 3 phenolsulfonic acid 3 3 phenyltoloxamine citrate (dihydrogen) 3 phosphatidyl 3 PITOCIN 3 podofilox 100 % powder 3

PAGE 286 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1 POLOCAINE-MPF 1 polyhexam biguan/gauze bandage 0.2%-1/2x3 strip 3 polyvinyl alcohol 3 polyvinyl alcohol/gentian violet/methylene blue 3 porcine acell submucosa,meshed 3 porcine acellular small intestine submucosa, fenestrated (3 cm x7 cm sheet, 3cm x3.5cm sheet) 3 potassium aminobenzoate 100 % powder 3 (100 % powder, crystals) 3 (crystals, granules) 3 potassium sorbate (crystals, powder) 3 povidone k-30 powder 3 3 pregnenolone, micronized 3

PREPIDIL 3 GL Female

PRESERA 3 prezatide copper 3 prilocaine hcl 3 procaine hcl 3 procarbazine hcl 3 3 PROMISEB 3 propyl gallate 3 propylene glycol 3

PROSTIN E2 VAGINAL SUPPOSITORY 3 GL Female

PROTHELIAL 4 S

PAGE 287 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prothrombin time/inr test meter 3 PROVISC 3 PROVOCHOLINE 3 PRUMYX 3 pump set 3 3 pyrithione zinc 3 dihydrate 3 RADIAPLEXRX 3 RADIGEL 3 RECEDO 3 red rice extract 3 (crystals, powder) 3

RETIN-A MICRO PUMP 0.06% GEL 3 QL 50 / 30 days retinal 3 ropivacaine hcl 3 ropivacaine hcl in 0.9 % sodium chloride/pf (ropivacae chl/pf 0.1% 400ml els pmp hr, ropivacae chl/pf 0.2% 550ml els pmp 1 hr) ropivacaine hcl/pf (hcl/pf 2 mg/ml vial, hcl/pf 5 mg/ml vial, hcl/pf 7.5 mg/ml vial, hcl/pf 10 mg/ml vial) 1

QL 2 / day PA RUBRACA (200 MG TABLET, 250 MG TABLET) 4 AL At least 18 yrs old S

QL 2 / day PA RUBRACA 300 MG TABLET 4 AL At least 18 yrs old S

PAGE 288 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day PA RYDAPT 4 AL At least 18 yrs old S s-adenosylmethionine sulfate tosylate 3 SALIVAMAX 3 SALIVATERX 3 sapropterin dihydrochloride (100 % powder, powder) 3 saw palmetto fruit 3 SEBUDERM 3 SENSORCAINE 1 SENSORCAINE WITH DEXTROSE 1 SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1 serine 3 serotonin hcl 3 silver (1" x 24" bandage, 2" x 2" bandage, 4" x 4" bandage, 4" x 5" bandage, 5"x5" bandage, 6" x 6" bandage) 3 silver (4" x 8" bandage, 4"x48" bandage, 8"x16" bandage, 16"x16" bandage) 1 silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5 %-2"x 2" bandage, sulfadiaz/foam bandage 5 %-4"x 4" bandage, sulfadiaz/foam bandage 5 %-6"x 6" bandage, 1 sulfadiaz/foam bandage 5 %-8"x 8" bandage) silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5 %-3" x3" bandage, sulfadiaz/foam bandage 5 %-5" x5" 3 bandage, sulfadiaz/foam bandage 5 %-7" x7" bandage) silver sulfate/foam bandage 3 silver sulfate/non-adherent bandage 3 silver/calcium alginate 3 silver/foam bandage 1

PAGE 289 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS silver/hydrocolloid dressing 3 SILVRSTAT 3 sodium benzoate 3 3 sodium desoxycholate 3 sodium dichloroacetate 3 sodium iodide 3 sodium metabisulfite (100 % granules, powder) 3 sodium stearyl fumarate 3 sodium succinate 1 SOLTAMOX 3 sorbic acid 3 SP ANTIPRURITIC 3 spirometers and accessories each 3

QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 4 PA S

QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 4 PA S

QL 9 / day SPRYCEL 20 MG TABLET 4 PA S

QL 3 / day SPRYCEL 50 MG TABLET 4 PA S

QL 4 / day STIVARGA 4 PA S

PAGE 290 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA AL Up to 18 yrs old STRENSIQ 4 S PS

SUCRAID 4 S sulfurated potash 3

QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4 S PS

QL 7 / day PA SUTENT 12.5 MG CAPSULE 4 S PS

QL 3 / day PA SUTENT 25 MG CAPSULE 4 S PS

SWABFLUSH 1

PA SYNRIBO 4 S

PA SYPRINE 4 S syring w-needl 0.5 ml,kit-tray 3 syringe cap, enfit,non-sterile 1 syringe with cannula, disposable, 3 ml 3 syringe with cannula, disposable, 6 ml 3

PAGE 291 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe with cannula,disposable 12 ml 3 syringe with needle, , safety, 0.3 ml 2 syringe with needle, insulin, safety, 0.5 ml 2 syringe with needle, insulin, safety, 1 ml 2 syringe with needle,disposable 3 syringe with needle,disposable, 0.5 ml 3 syringe with needle,disposable, 1 ml (syringe 1 ml 25gx1" disp syrin, syringe 1 ml 25gx5/8" disp syrin) 3 syringe with needle,disposable, 1 ml (syringe 1 ml 26gx1/2" disp syrin, syringe 1 ml 26gx3/8" disp syrin, syringe 1 ml 3 27gx0.375" disp syrin, syringe 1 ml 27gx1/2" disp syrin) syringe with needle,disposable, 6 ml 3 syringe with needle,disposable,insulin 1 ml (syringe disp syrin, syringe 28gx1/2" disp syrin, syringe 29 g x1/2" disp syrin, 2 syringe 30g x5/16" disp syrin, syringe 30gx1/2" disp syrin) syringe with needle,insulin,0.3 ml 2 syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin, ml 29 g x1/2" disp syrin, ml 30g x5/16" disp syrin, ml 30gx1/2" 2 disp syrin) syringe, disposable irrigation, 70 ml 1 syringe, disposable, 1 ml disp syrin 3 syringe, disposable, 12 ml disp syrin 3 syringe, disposable, 3 ml 3 syringe, disposable, 5 ml 3 syringe, disposable, 6 ml 3 syringe, enfit 1 ml, sterile 1 syringe, enfit 12 ml, sterile 1 syringe, enfit 3 ml, sterile 1 syringe, enfit 35 ml, sterile 1 syringe, enfit 6 ml, sterile 1

PAGE 292 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe, enfit 60 ml, sterile 1 syringe, insulin u-500 with needle, disposable, 0.5 ml 2 syringe,safety with needle,1 ml (25gx1" syringe, 25gx5/8" disp syrin, 26gx3/8" disp syrin, 27gx1/2" disp syrin) 3 syringe,safety with needle,10 ml 3 syringe,safety with needle,12 ml 3 syringe,safety with needle,3 ml (20gx1 1/2" disp syrin, 20gx1" disp syrin, 21 g x 1" disp syrin, 21gx1 1/2" disp syrin, 22gx1 1/2" disp syrin, 22gx1" disp syrin, 23gx1" disp syrin, 25gx1" 3 disp syrin, 25gx5/8" disp syrin) syringe,safety with needle,5 ml 3 TABLOID 3

QL 6 / day TAFINLAR 50 MG CAPSULE 4 PA S

QL 4 / day TAFINLAR 75 MG CAPSULE 4 PA S

QL 1 / day PA TAGRISSO 4 AL At least 18 yrs old S PS citrate powder 3 tamoxifen citrate (10 mg tablet, 20 mg tablet) 0 HCR

QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 4 PA S

QL 6 / day TARCEVA 25 MG TABLET 4 PA S

PAGE 293 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA TARGRETIN 75 MG CAPSULE 4 S

QL 4 / day PA TASIGNA 4 S PS

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, PA 4 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) S

PA temozolomide 4 S tetracaine 3 tetracaine hcl powder 3 tetracaine hcl/pf 10 mg/ml ampul 1 theobromine 3 thioguanine 3 thiotepa 100 % powder 3 thiotepa 15 mg vial 4 S (crystals, powder) 3 THROMBI-GEL 3 THROMBI-PAD 3 titanium dioxide 3 TL-CERMIDE 3 topical cream metered-dose device 3

PA TRACLEER 32 MG TABLET FOR SUSP 4 S PS tens unit each 3

PAGE 294 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS transfer device, closed system (13mm each, 20mm each, 28mm each) 3

TREAGAN OTIC 3

QL 90 / 365 days tretinoin 10 mg capsule 4 S trichloroacetic acid (crystals, powder) 3 triethanolamine 3 3 trioxsalen 3 TROPAZONE 3 3

QL 6 / day PA TYKERB 4 S PS unithiol (97 % powder, crystals) 3 urinary bag/catheter (bag/catheter 6 fr combo. pkg, bag/catheter 8fr-14" combo. pkg) 3 urinary bag/catheter 14 fr-16 " combo. pkg 3 urinary bag/catheterization tray 3 vacuum erection device system 3 3

VALSTAR 4 S

VAXCHORA BUFFER COMPONENT 2

VENATAL COMPLETE DHA 3 GL Female

QL 4 / day VENCLEXTA 4 PA S

PAGE 295 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1.5 / day VENCLEXTA STARTING PACK 4 PA S

VIASPAN BELZER-UW 3 VISCOAT 3

VITASPIRE 3 GL Female

VITRASE 3

QL 1 / day PA VOSEVI 4 AL At least 18 yrs old S PS

QL 4 / day VOTRIENT 4 PA S water for inj.,bacteriostatic 1 water for inj.,bacteriostatic/methylparaben/propylparaben 1 water for injection,sterile (ampul, vial) 1 white willow bark/salicin 3

QL 2 / day XALKORI 4 PA S xanthan gum 3

QL 4 / day XELODA 4 PA S

QL 4 / day XTANDI 4 PA S

PAGE 296 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XYLOCAINE (0.5% VIAL, 1% VIAL) 3 XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1% VIAL, 1.5% AMPUL, 4% AMPUL) 3 xylometazoline hcl 3 yohimbine hcl 5.4 mg tablet 1 ZANABIN 3 zeaxanthin 3

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

QL 8 / day ZELBORAF 4 PA S zinc acetate dihydrate (100 % crystals, 100 % powder) 3 ZINGO 3 ZODEX 12 DAY 1.5 MG TABLET 3

QL 4 / day ZOLINZA 4 PA S

ZOTEX-C 3

QL 2 / day ZYDELIG 4 PA S

QL 8 / day PA ZYKADIA 4 AL At least 18 yrs old S

PAGE 297 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day PA ZYTIGA 250 MG TABLET 4 S PS

QL 2 / day PA ZYTIGA 500 MG TABLET 4 S PS

VASODILATING AGENTS

NITRATES AND NITRITES

DILATRATE-SR 3 QL 4 / day

QL 1.25 / day GONITRO 3 PA AL At least 18 yrs old

ISOCHRON 1 QL 4 / day

ISORDIL 3 QL 12 / day

ISORDIL TITRADOSE 3 QL 12 / day isosorbide 3 isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 12 / day mg tablet) 1 QL isosorbide dinitrate 40 mg tablet er 1 QL 4 / day isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab 2 / day er 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1 QL

MINITRAN 1 QL 1 / day

NITRO-BID 2 QL 4 / day

NITRO-DUR 3 QL 1 / day

NITRO-TIME 1 QL 4 / day

PAGE 298 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 mg 4 / day capsule er) 1 QL nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 1 / day 0.4mg/hr patch td24, 0.6mg/hr patch td24) 1 QL

QL 0.8 / day nitroglycerin 400mcg/spr spray 3 HCG nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1 QL 6 / day

NITROLINGUAL 3 QL 0.8 / day

NITROMIST 3 QL 0.3 / day

NITROSTAT 3 QL 6 / day sodium nitrite granules 3 PHOSPHODIESTERASE TYPE 5 INHIBITORS

QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 2 GL Male

QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 2 GL Male

QL 0.2 / day VIAGRA 2 GL Male AL At least 18 yrs old

VASODILATING AGENTS, MISCELLANEOUS alprostadil 100 % powder 3 alprostadil 500 mcg/ml vial 1 CAVERJECT 40 MCG/2 ML AMPUL 3 CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 Male MCG KIT, 40 MCG VIAL) 3 GL

EDEX 3 GL Male hcl 100 % powder 3

PAGE 299 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1

MUSE 3 GL Male papaverine hcl powder 3 papaverine hcl 30 mg/ml vial 1 papaverine hcl/alprostadil in bacteriostatic water 1 PROSTIN VR PEDIATRIC 3 tolazoline hcl 3 VITAMINS

MULTIVITAMIN PREPARATIONS

ELDERCAPS 1

ELITE OB DHA 3 GL Female

ELITE-OB 3 GL Female

MATERNITY 1 GL Female

MAXINATE 3 GL Female multivitamin-minerals no.44/ (vit d3)/vit k1 1

MYNATAL ULTRACAPLET 3 GL Female

MYNATE 90 PLUS 3 GL Female pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) 1 pediatric multivit no.22/cholecalciferol(d3)/phytonadione(k) 1 PNV-VP-U 3

PRENA1 CHEW 3 GL Female prenatal vitamins no.5/ferrous fumarate/folic acid 3 GL Female

REQ49+ 3 SUPERVITE EC 3 THERAPEUTIC W-MINERALS 1

PAGE 300 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRIVEEN-U 3 GL Female

TRUST NATAL DHA 3 GL Female

UDAMIN SP 3 V-C FORTE 1 VIC-FORTE 1

VINATE PN CARE 3 GL Female

VINATE-M 3 GL Female

VITAMIN A

AQUASOL A 3 beta-carotene 3 ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops 1 acetate 3 vitamin a palmitate (plmitte 1.06 mm/g liquid, plmitte 1.7mm/g liquid, plmitte 18000/ml liquid) 3 VITAMIN B COMPLEX

B-12 COMPLIANCE 3 B-12 KIT 1 calcium pantothenate 3 CARDIOTEK-RX 3 cobamamide 100 % powder 3 (vitamin b-12) powder 3 cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1 cyanocobalamin/folic acid/ 1 FOLBEE 1 FOLBEE AR 3 FOLBEE PLUS CZ 1 FOLGARD RX 3

PAGE 301 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS folic acid 100 % powder 3 folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 FOLPLEX 2.2 1 powder 3 hydroxocobalamin 1000mcg/ml vial 1 levomefolate calcium 100 % powder 3 mecobalamin 3 methyltetrahydrofolate calcium 3 methyltetrahydrofolate glucosamine 3 NASCOBAL 3 NEPHRO-VITE RX 3 NEURIN-SL 3 niacinamide 3 3 pyridoxine hcl () (100 % powder, crystals) 3 pyridoxine hcl (vitamin b6) 100 mg/ml vial 1 RENA-VITE RX 1 (vitamin b2) 3 riboflavin 5-phosphate sodium (b2) 3 SUPERVITE 3 hcl powder 3 thiamine hcl 100 mg/ml vial 1 thiamine hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 1 VIRT-CAPS 1 VIRT-GARD 1 VIRT-VITE 1

PAGE 302 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIRT-VITE PLUS 1 VITA-RESPA 3 VP-VITE RX 1 ZOLATE 1 ascorbate sodium 3 ascorbic acid 100 % powder 3 ascorbic acid 500 mg/ml vial 1 calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 calcitriol (100 % crystals, 100 % powder) 3 cholecalciferol (vitamin d3) (2400/ml liquid, 100000/g powder) 3 doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 4 S

DRISDOL 3 (vitamin d2) 50000 unit capsule 1 ergocalciferol (vitamin d2) powder 3 HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 4 S (1 mcg capsule, 2 mcg capsule, 4mcg capsule) 4 S

RAYALDEE 4 S

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORAL SOLN) 3

PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4 S

VITAMIN E (dl-alpha tocopheryl acetate) 3

PAGE 303 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS vitamin e acetate (actat50 % powdr, actat125/ml liquid) 3 vitamin e acid succinate 3 vitamin e mixed 3 ACTIVITY phytonadione (vit k1) 100 % liquid 3 3

PAGE 304 LAST UPDATED 11/2017 Index of Covered Drugs acetaminophen 8 0 acetaminophen with codeine phosphate 8 0.9 % sodium chloride 170,265 acetaminophen/caffeine/dihydrocodeine bitartrate 8 acetarsol 265 2 ACETASOL HC 37 2-deoxy-d-glucose 135 acetazolamide 97 2-methoxyestradiol 265 acetazolamide sodium 97 acetic acid 37 3 acetic acid/aluminum acetate 37 3,5-diiodothyronine 265 acetyl hexapeptide-8 265 acetylcarnitine hcl 229 5 acetylcholine chloride 97 5-hydroxy-l-tryptophan (oxitriptan) 265 acetylcysteine 229 acetylcysteine in sterile water/pf 179 7 acetylglucosamine 265 7-oxodehydroepiandrosterone 265 ACIPHEX 133 7-oxodehydroepiandrosterone, micronized 265 ACIPHEX SPRINKLE 133 acitretin 255 8 ACLARO 154 8-MOP 154 ACTEMRA 222 ACTHIB 129 A ACTICLATE 60 A-HYDROCORT 190 ACTIGALL 184 A-METHAPRED 190 ACTIMMUNE 225 abacavir sulfate 124 ACTIQ 13 abacavir sulfate/lamivudine 124 ACTIVE FE 47 abacavir sulfate/lamivudine/zidovudine 124 ACTIVELLA 174 ABILIFY 114 ACTONEL 220 ABILIFY MAINTENA 114 ACTOPLUS MET 83 ABSORICA 255 ACTOPLUS MET XR 83 acacia 265 ACTOS 88 acamprosate calcium 149 ACULAR 46 acarbose 82 ACULAR LS 46 ACCOLATE 46 ACUVAIL 46 ACCUPRIL 239 acyclovir 39,136 ACCURETIC 165 ACZONE 255 ACD 169 ADACEL TDAP 129 ACD-A 67 ADALAT CC 146 acebutolol hcl 53 adapalene 255 ACEON 239 adapalene/benzoyl peroxide 255 acepromazine maleate 122 ADASUVE 113 ADCIRCA 242 albuterol sulfate 4 ADDERALL 25 ALCAINE 179 ADDERALL XR 25 alclometasone dipropionate 245 ADDYI 149 ALDACTAZIDE 164 adefovir dipivoxil 136 ALDACTONE 164 ADEMPAS 242 ALDARA 255 adenosine 55 aldosterone 190 ADIPEX-P 24 ALECENSA 266 ADOXA 60 alendronate sodium 220 ADRENACLICK 3 ALEVICYN ANTIPRURITIC SG 252 ADRENALIN 3 alfentanil hcl 13 ADRENALIN CHLORIDE 181 alfuzosin hcl 7 ADVAIR DISKUS 4 alginic acid 266 ADVAIR HFA 4 ALINIA 113 ADVICOR 106 ALKERAN 266 ADYPHREN 3 allantoin 266 ADYPHREN AMP 3 allergenic extract tree pollen-american elm 155 ADYPHREN AMP II 3 allergenic extract, grass pollen-bermuda, standard 155 ADYPHREN II 3 allergenic extract, grass pollen-orchard grass, standard 155 ADZENYS XR-ODT 25 allergenic extract, mite-d.farinae- AEROSPAN 153 d.pteronyssinus,standard 155 AFEDITAB CR 146 allergenic extract,grass pollen-june(kentucky AFINITOR 265,266 blue),standard 155 AFINITOR DISPERZ 266 allergenic extract,grass pollen-redtop, standard 155 AFLURIA 2016-2017 129 allergenic extract,grass pollen-timothy,standard 155 AFLURIA 2017-2018 266 allergenic extract,mite-dermatophagoides pteronyssinus, AFLURIA QUAD 2016-2017 129 std 155 AFLURIA QUAD 2017-2018 266 allergenic extract-acremonium strictum 155 AFREZZA 86 allergenic extract-alternaria alternata 155 AGGRENOX 126 allergenic extract-american cockroach 155 AGRYLIN 128 allergenic extract-aspergillus fumigatus 155 AK-POLY-BAC 34 allergenic extract-aspergillus,mixed 155 AKTEN 179 allergenic extract-aureobasidium pullulans 155 AKYNZEO 88 allergenic extract-botrytis cinerea 155 ALA-CORT 245 allergenic extract-candida albicans 155 ALA-QUIN 93 allergenic extract-cattle epithelium 155 ALA-SCALP 245 allergenic extract-cladosporium cladosporioides 155 alanine 169 allergenic extract-cladosporium sphaerospermum 156 albendazole 31 allergenic extract-cockroach (american and german) 156 ALBENZA 31 allergenic extract-corn smut 156 albumin, serum, bovine 266 allergenic extract-cultivated crop pollen-corn 156 allergenic extract-curvularia 156 allergenic extract-tree pollen-juniper, western 157 allergenic extract-dog epithelium 156 allergenic extract-tree pollen-kapok 157 allergenic extract-drechslera sorokiniana 156 allergenic extract-tree pollen-melaleuca 157 allergenic extract-epicoccum nigrum 156 allergenic extract-tree pollen-mesquite 157 allergenic extract-fire ant 156 allergenic extract-tree pollen-mountain cedar 157 allergenic extract-fusarium oxysporum 156 allergenic extract-tree pollen-mulberry, red 157 allergenic extract-german cockroach 156 allergenic extract-tree pollen-mulberry, white 157 allergenic extract-grass pollen-bahia 156 allergenic extract-tree pollen-olive 157 allergenic extract-grass pollen-johnson 156 allergenic extract-tree pollen-palm, queen 157 allergenic extract-grass pollen-meadow fescue, allergenic extract-tree pollen-pecan 157 standardized 156 allergenic extract-tree pollen-pepper tree, california 157 allergenic extract-grass pollen-perennial rye, standard 156 allergenic extract-tree pollen-pine, white 158 allergenic extract-grass pollen-quack 156 allergenic extract-tree pollen-privet 158 allergenic extract-grass pollen-smooth brome 156 allergenic extract-tree pollen-red birch 158 allergenic extract-horse epithelium 156 allergenic extract-tree pollen-red cedar 158 allergenic extract-mixed feathers, chicken, duck, goose 156 allergenic extract-tree pollen-red maple 158 allergenic extract-mixed weed pollen-short and tall allergenic extract-tree pollen-red oak 158 ragweed 156 allergenic extract-tree pollen-shagbark hickory 158 allergenic extract-mosquito 156 allergenic extract-tree pollen-sweet gum 158 allergenic extract-mouse epithelium 156 allergenic extract-tree pollen-virginia live oak 158 allergenic extract-mucor plumbeus 156 allergenic extract-tree pollen-white ash 158 allergenic extract-penicillium notatum 156 allergenic extract-tree pollen-white birch 158 allergenic extract-phoma herbarum 156 allergenic extract-tree pollen-white oak 158 allergenic extract-rabbit epithelium 156 allergenic extract-trichophyton mentagrophytes 158 allergenic extract-rhizopus oryzae 156 allergenic extract-venom-honey bee 158 allergenic extract-saccharomyces cerevisiae 157 allergenic extract-venom-mixed vespid protein 158 allergenic extract-sweet vernal, standardized 157 allergenic extract-venom-wasp protein 158 allergenic extract-tree pollen-acacia 157 allergenic extract-venom-white-faced hornet protein 158 allergenic extract-tree pollen-alder white 157 allergenic extract-venom-yellow hornet protein 158 allergenic extract-tree pollen-american beech 157 allergenic extract-venom-yellow jacket protein 158 allergenic extract-tree pollen-american sycamore 157 allergenic extract-weed pollen-carelessweed 158 allergenic extract-tree pollen-arizona cypress 157 allergenic extract-weed pollen-cocklebur 158 allergenic extract-tree pollen-australian pine 157 allergenic extract-weed pollen-dog fennel 158 allergenic extract-tree pollen-bald cypress 157 allergenic extract-weed pollen-english plantain 158 allergenic extract-tree pollen-bayberry 157 allergenic extract-weed pollen-giant (tall) ragweed 158 allergenic extract-tree pollen-black walnut 157 allergenic extract-weed pollen-goldenrod 158 allergenic extract-tree pollen-black willow 157 allergenic extract-weed pollen-kochia (firebush) 158 allergenic extract-tree pollen-box elder 157 allergenic extract-weed pollen-lambsquarters 158 allergenic extract-tree pollen-eastern cottonwood 157 allergenic extract-weed pollen-mugwort 159 allergenic extract-tree pollen-elm, cedar 157 allergenic extract-weed pollen-rough pigweed 159 allergenic extract-tree pollen-hackberry 157 allergenic extract-weed pollen-russian thistle 159 allergenic extract-weed pollen-sagebrush 159 ALYACEN 194 allergenic extract-weed pollen-sheep sorrel 159 AMABELZ 174 allergenic extract-weed pollen-sheep sorrel,yellow amantadine hcl 111 dock 159 AMARYL 87 allergenic extract-weed pollen-short ragweed 159 AMBIEN 138 allergenic extract-weed pollen-spiny pigweed 159 AMBIEN CR 138 allergenic extract-weed pollen-true marsh elder 159 amcinonide 245 allergenic extract-weed pollen-western ragweed 159 AMERGE 108 allergenic extract-weed pollen-yellow dock 159 american ginseng root 267 ALLFEN CDX 266 AMETHIA 195 allopurinol 218,219 AMETHIA LO 195 ALLZITAL 8 AMETHYST 195 almond extract 159 AMICAR 98 almond oil 266 amifampridine 229 almotriptan malate 108 amikacin 57 ALOCRIL 47 amikacin sulfate 57 aloe vera leaf gel extract 266 amiloride hcl 163 ALOMIDE 178 amiloride hcl/hydrochlorothiazide 163 ALORA 174 aminocaproic acid 98 alosetron hcl 182 aminophylline 145 alpha lipoic acid 266 aminosalicylate sodium 110 ALPHAGAN P 96 aminosalicylic acid 110 ALPHAQUIN HP 154 amiodarone hcl 55 alprazolam 141 AMITIZA 183 ALPRAZOLAM INTENSOL 141 amitriptyline hcl 81 alprostadil 299 amitriptyline hcl/chlordiazepoxide 81 ALREX 44 amlodipine besylate 146 ALSUMA 108 amlodipine besylate/atorvastatin calcium 106 ALTABAX 37 amlodipine besylate/benazepril hcl 146 ALTACAINE 180 amlodipine besylate/olmesartan medoxomil 147 ALTACE 239 amlodipine besylate/valsartan 147 ALTAFLUOR 180 amlodipine besylate/valsartan/hydrochlorothiazide 147 ALTAVERA 194 ammonium chloride 168 ALTOPREV 106 ammonium lactate 173,267 aluminum acetate 266 ammonium sulfate 267 aluminum chloride 266 ammonium tetrathiomolybdate 267 aluminum chlorohydrate 266 AMNESTEEM 255 aluminum hydroxide 181 amoxapine 81 aluminum sulfate 266 amoxicillin 236 ALUNBRIG 266 amoxicillin/potassium clavulanate 236,237 ALUVEA 252 amphotericin b 92 ampicillin sodium 237 APLENZIN 75 ampicillin sodium/sulbactam sodium 237 APLIGRAF 267 ampicillin trihydrate 237 APLISOL 162 AMPYRA 229 APOKYN 167 AMRIX 244 apomorphine hcl 167 AMVISC 267 apple extract 159 AMVISC PLUS 267 apraclonidine hcl 179 amyl nitrite 218 aprepitant 89 AMYTAL SODIUM 140 APRI 195 ANA-LEX 245 APRISO 182 ANACAINE 250 APTENSIO XR 28 ANADROL-50 193 APTIOM 69 ANAFRANIL 81 APTIVUS 125 anagrelide hcl 128 AQUASOL A 301 ANALPRAM HC 246 AQUORAL 267 ANAPROX 219 ARANELLE 195 ANAPROX DS 219 ARANESP 144 ANASPAZ 64 ARAVA 222 ANASTIA 250 ARBINOXA 99 anastrozole 267 ARCALYST 229 ANCOBON 93 ARCAPTA NEOHALER 4 ANDRODERM 193 arginine 169 ANDROGEL 193 arginine hcl 170 ANDROID 193 ARICEPT 142 androstenedione 193 ARIMIDEX 267 ANDROXY 193 aripiprazole 114 ANGELIQ 174 ARISTADA 114 anisindione 267 ARISTOSPAN 190 ANORO ELLIPTA 4 ARIXTRA 68 ANSAID 233 armodafinil 31 ANTABUSE 218 ARMOUR THYROID 264 ANTARA 104 arnica flower extract 267 anthralin 255 ARNUITY ELLIPTA 153 antimony trichloride 113 AROMASIN 267 antivenin,latrodectus mactans 128 aromatic cascara fluid extract 183 antivenin,micrurus fulvius 128 arsenic trioxide 267 ANTIVERT 90 ARTHROTEC 50 132 ANUCORT-HC 246 ARTHROTEC 75 132 ANUSOL-HC 246 ARTISS 255 ANZEMET 88 ARYMO ER 13 APEXICON E 246 ASCOMP WITH CODEINE 13 ascorbate sodium 303 AUSTEDO 149 ascorbic acid 303 AUVI-Q 3 ASHLYNA 195 AVAGE 255 ashwagandha root extract 267 AVAILNEX 267 aspartic acid 267 AVALIDE 165 aspirin 127 AVANDAMET 83 aspirin/caffeine/dihydrocodeine bitartrate 127 AVANDIA 88 aspirin/dipyridamole 127 AVAPRO 238 ASTAGRAF XL 227,228 AVAR 40 ASTEPRO 178 AVAR LS 40 astragalus root extract 267 AVAR-E 40 ASTRAMORPH-PF 13 AVAR-E GREEN 40 ASTRINGYN 98 AVAR-E LS 40 ATABEX EC 47 AVC 40 ATACAND 238 AVELOX 58 ATACAND HCT 165 AVELOX ABC PACK 58 ATELVIA 220 AVENOVA 267 atenolol 53 AVIANE 195 atenolol/chlorthalidone 53 AVIDOXY 60 ATIVAN 73 AVITA 252 atomoxetine hcl 149 AVITENE 98 ATOPICLAIR 173 AVO CREAM 173 atorvastatin calcium 106 avocado extract 159 atovaquone 113 AVODART 217 atovaquone/proguanil hcl 112 AVONEX 225 ATRALIN 252 AVONEX PEN 225 ATRAPRO DERMAL SPRAY 267 AXERT 108 ATRAPRO HYDROGEL 267 AYGESTIN 212 ATRIPLA 123 azacitidine 267 ATROPEN 64 AZACTAM 217 atropine sulfate 64,180 AZASAN 222 ATROVENT 179 AZASITE 34 ATROVENT HFA 64 azathioprine 222 attapulgite 182 azathioprine sodium 222 AUBAGIO 225 azelaic acid 255 AUBRA 195 azelastine hcl 178 AUGMENTIN 237 AZELEX 256 AUGMENTIN ES-600 237 AZILECT 76 AUGMENTIN XR 237 azithromycin 216 AURSTAT 267 AZOPT 97 AURYXIA 215 AZOR 147 aztreonam 217 benactyzine hcl 75 AZULFIDINE 60 benazepril hcl 239,240 AZUPHEN MB 32 benazepril hcl/hydrochlorothiazide 165 AZURETTE 195 BENICAR 238 BENICAR HCT 165 B BENLYSTA 267 B-12 COMPLIANCE 301 benoxinate hcl/fluorescein sodium 180 B-12 KIT 301 BENSAL HP 252 B-DONNA 64 BENTYL 64 B-PLEX PLUS 267 benzalkonium chloride 40 BACIIM 62 BENZEFOAM 252 bacitracin 34,37,62 BENZEFOAM ULTRA 252 bacitracin zinc micronized 37 BENZEPRO 253 bacitracin, micronized 37 benzocaine 268 bacitracin/polymyxin b sulfate 34 benzocaine micronized 268 baclofen 245 benzoic acid 268 bacteriostatic sodium chloride 170 benzonatate 241 BACTRIM 60 benzoyl peroxide 253,268 BACTRIM DS 60 benzphetamine hcl 25,26 BACTROBAN 37 benztropine mesylate 67 BACTROBAN NASAL 34 benzyl alcohol 268 BAL IN OIL 218 benzyl benzoate 43 balanced salt irrig soln no.2 179 BEPREVE 178 balsalazide disodium 182 bergamot 268 BALZIVA 195 BESIVANCE 34 banana extract 159 beta 1,3 glucan 229 BANZEL 69 beta-carotene 301 BARACLUDE 136 beta-glucan, (1-3) (1-4) 268 barium sulfate 161 betadex 268 bcg vaccine, live/pf 129 BETADINE 37 BEAU RX 267 BETAGAN 96 beclomethasone dipropionate 190 betahistine hcl 148 BECONASE AQ 44 betaine hcl 230 beef extract 159 betamethasone acetate, micronized 190 BEKYREE 195 betamethasone acetate/betamethasone sodium BELBUCA 22 phosphate 190 belladonna alkaloids 64 betamethasone dipropionate 246 belladonna alkaloids leaf extract 64 betamethasone dipropionate/propylene glycol 246 BELSOMRA 138 betamethasone sodium phosphate 190 BELVIQ 25 betamethasone valerate 246 BELVIQ XR 25 BETAPACE 53 BETAPACE AF 53 blood-glucose transmitter 268 BETASERON 225 blue-green algae 268 betaxolol hcl 53,96 BONIVA 220 bethanechol chloride 142 BONTRIL PDM 24 BETHKIS 57 BOOSTRIX TDAP 129 BETIMOL 96 boric acid 37 BETOPTIC S 96 BOSULIF 268,269 BEVESPI AEROSPHERE 4 boswellia serrata extract 269 bexarotene 268 BOTOX COSMETIC 230 BEXSERO 129 BP 10-1 40 BEYAZ 196 BP-50% UREA 253 BIAFINE 173 BPO 253 BIAXIN 110 BRAVELLE 209 bicalutamide 268 BREO ELLIPTA 5 BICILLIN C-R 237 BREVICON 196 BICILLIN L-A 237 BREVITAL SODIUM 73 BIDIL 214 BRIELLYN 196 BILTRICIDE 31 BRILINTA 127 bimatoprost 98 brimonidine tartrate 96 BINOSTO 220 BRINTELLIX 80 BIOGLO 161 BRISDELLE 77 BIONECT 268 BRIVIACT 69 BIOTHRAX 129 bromelains 269 biotin 268 BROMFED DM 101 bisacodyl 183 bromfenac sodium 46,269 bismuth citrate 268 bromhexine hcl 241 bismuth subgallate 268 bromocriptine mesylate 167 bismuth subsalicylate 182 brompheniramine maleate 99 bismuth tribromophenate/petrolatum,white 268 brompheniramine maleate/pseudoephedrine bisoprolol fumarate 53 hcl/dextromethorphan 101 bisoprolol fumarate/hydrochlorothiazide 53 BROMSITE 46 bitter melon extract 268 BROVANA 5 BLANCHE 154 BSS 179 BLEO 15K 268 BSS PLUS 179 bleomycin sulfate 268 BUCALSEP 180 BLEPH-10 34 budesonide 44,153,190 BLEPHAMIDE 34 budesonide, micronized 44 BLEPHAMIDE S.O.P. 34 buflomedil hcl 269 BLISOVI 24 FE 196 bumetanide 162 BLISOVI FE 196 BUNAVAIL 22 blood-glucose sensor 268 BUPAP 8 BUPHENYL 169 CALAN SR 55 bupivacaine hcl 269 calcipotriene 256,269 bupivacaine hcl/dextrose-water/pf 269 calcipotriene monohydrate 269 bupivacaine hcl/epinephrine 263 calcipotriene/betamethasone dipropionate 246 bupivacaine hcl/epinephrine bitartrate 263 calcitonin,salmon,synthetic 211 bupivacaine hcl/epinephrine/pf 263 CALCITRENE 256 bupivacaine hcl/pf 269 calcitriol 256,303 BUPRENEX 22 calcitriol/almond oil 269 buprenorphine 22 calcium acetate 215 buprenorphine hcl 23 calcium amino acid chelate 170 buprenorphine hcl/naloxone hcl 23 calcium carbonate 170 BUPROBAN 75 calcium citrate 170 bupropion hcl 75 calcium glubionate 170 buspirone hcl 138,139 calcium glucarate 170 butalbital 140 calcium gluconate monohydrate 170 butalbital/acetaminophen 9 calcium levulinate dihydrate 170 butalbital/acetaminophen/caffeine 9 calcium pantothenate 301 butalbital/acetaminophen/caffeine/codeine phosphate 9 calcium phosphate 170 butalbital/aspirin/caffeine 127,269 CAMILA 196 BUTISOL SODIUM 140 camphor 256 butorphanol tartrate 23 CAMRESE 196 BUTRANS 23 CAMRESE LO 196 butylated hydroxytoluene 230 CANASA 182 BYDUREON 85 candesartan cilexetil 238 BYDUREON BCISE 269 candesartan cilexetil/hydrochlorothiazide 165 BYDUREON PEN 85 CANDIN 160 BYETTA 85 cantaloupe extract 159 BYSTOLIC 144 cantharidin 269 BYVALSON 144 CANTIL 64 CAPACET 9 C CAPASTAT SULFATE 110 cabergoline 167 capecitabine 269 CABOMETYX 269 CAPEX SHAMPOO 246 CADEAU DHA 47 CAPHOSOL 270 CADUET 106 CAPITAL W-CODEINE 9 CAFERGOT 6 CAPRELSA 270 caffeine 28 capsaicin 256 caffeine citrate 28 capsaicin palmitate 256 caffeine/sodium benzoate 28 capsicum oleoresin 256 calamine 173 captopril 239 CALAN 55 captopril/hydrochlorothiazide 165 CARAC 256 catheterization tray 270 CARAFATE 133 CATHFLO ACTIVASE 128 carbachol 97 CAVERJECT 299 CARBAGLU 169 CAYSTON 217 carbamazepine 69 CAZIANT 196 carbamide peroxide 40 CEDAX 152,270 CARBATROL 69 cefaclor 152 carbidopa 149 cefadroxil 151 carbidopa/levodopa 111 cefazolin sodium 151 carbidopa/levodopa/entacapone 111 cefdinir 152 carbimazole 264 cefditoren pivoxil 152 carbinoxamine maleate 100 cefepime hcl 151 carbitol 270 cefixime 152 CARBOCAINE 270 CEFOTAN 152 CARDENE SR 147,270 cefotaxime sodium 152 cardioplegic solution no.1 170 cefotetan disodium 152 cardioplegic solution no.10 170 cefpodoxime proxetil 152 CARDIOTEK-RX 301 cefprozil 152 CARDIOVID PLUS 230 ceftazidime 152 CARDIZEM 55 ceftibuten 152 CARDIZEM CD 55 CEFTIN 152 CARDIZEM LA 55 ceftriaxone sodium 152 CARDURA 6 cefuroxime axetil 152 CARDURA XL 6 cefuroxime sodium 152 carisoprodol 244 CELEBREX 233 carisoprodol/aspirin 236 celecoxib 233 carisoprodol/aspirin/codeine phosphate 13 CELESTONE 190 CARNITOR 230 CELEXA 77 CARNITOR SF 230 CELLCEPT 228 carteolol hcl 96 CELLUGEL 179 CARTIA XT 56 cellulose 270 carvedilol 7 CELONTIN 74 carvedilol phosphate 7 CEM-UREA 253 casein extract 159 CENTANY 37 CASODEX 270 CENTANY AT 37 cat hair standardized allergenic extract 159 CENTERGY 101 CATAPRES 214 CENTERGY DM 101 CATAPRES-TTS 1 214 cephalexin 151 CATAPRES-TTS 2 214 CERAMAX 270 CATAPRES-TTS 3 214 CERDELGA 230 catheter 270 CEREBYX 74 CERVARIX 129 cholestyramine 103 cervical cap 270 cholestyramine (with sugar) 103 CERVIDIL 270 cholestyramine/aspartame 103,104 CESAMET 89 choline bitartrate 186 cesium chloride 270 choline salicylate/magnesium salicylate 236 CETACAINE 250 chondroitin sulfate a sodium 230 cetirizine hcl 100 chorionic gonadotropin, human 209 CETRAXAL 34 chromium picolinate 271 CETROTIDE 224 chromium polynicotinate 271 cetyl myristoleate 270 chrysin 271 cetylpyridinium chloride 270 chymotrypsin 271 cevimeline hcl 142 CIALIS 299 CHANTIX 142 CICLODAN 95 CHATEAL 196 ciclopirox 95 CHEMET 218 ciclopirox olamine 95 CHENODAL 184 CIDALEAZE 250 chicken meat extract 159 cidofovir 136 chinese red pine bark extract 270 cilostazol 127 139 CILOXAN 34 chlorambucil 270 cimetidine 132 chloramphenicol 58 cimetidine hcl 132 chloramphenicol palmitate 58 CIMZIA 185 chlordiazepoxide hcl 141 CIPRO 59 chlordiazepoxide/clidinium bromide 64 CIPRO HC 34 chlorhexidine gluconate 37,40 CIPRO XR 59 chloroallyl methenamine chloride 270 CIPRODEX 34 chlorobutanol 271 ciprofloxacin 59 chloroform 187 ciprofloxacin hcl 34,59 chloroprocaine hcl/pf 271 ciprofloxacin/ciprofloxacin hcl 59 chloroquine phosphate 112 citalopram hydrobromide 77 chlorothiazide 163 citrate phosphate dextros soln 67 chloroxine 271 citric acid 271 chloroxylenol 271 citric acid/sodium citrate 168 chlorpheniramine maleate 100 citrulline 170 chlorpromazine hcl 122 CLAFORAN 153 chlorpropamide 87 CLARAVIS 256 chlorthalidone 164 CLARIFOAM EF 40 chlorzoxazone 244,271 CLARINEX 100 CHOLBAM 184,185 CLARINEX-D 12 HOUR 100 cholecalciferol (vitamin d3) 303 clarithromycin 58,110 cholesterol 271 CLEANSING WASH 40 clemastine fumarate 100 CNL 8 95 clemizole hcl 271 coal tar 255 CLEOCIN 38 COARTEM 112 CLEOCIN HCL 62 cobalt gluconate 271 CLEOCIN PALMITATE 62 cobamamide 301 CLEOCIN PHOSPHATE 62,63 cocaine hcl 180 CLEOCIN T 38 cocoa extract 159 clidinium bromide 64 codeine phosphate 13 CLIMARA 174 codeine phosphate/butalbital/aspirin/caffeine 13 CLIMARA PRO 174 codeine sulfate 13 CLINDACIN ETZ 38 COGENTIN 67 CLINDACIN P 38 COLAZAL 182 CLINDACIN PAC 38 colchicine 219 CLINDAGEL 38 COLCRYS 219 clindamycin hcl 63 COLESTID 104 clindamycin palmitate hcl 63 colestipol hcl 104 clindamycin phosphate 38,63 colistin (as colistimethate sodium) 63 clindamycin phosphate/benzoyl peroxide 38 colistin sulfate 63 clindamycin phosphate/tretinoin 38 collagenase clostridium histolyticum 256 CLINDESSE 38 COLOCORT 246 CLINPRO 5000 221 colostomy bag, non-sterile 271 clioquinol 93 COLY-MYCIN M PARENTERAL 63 clobetasol propionate 246 COLY-MYCIN S 34 clobetasol propionate/emollient base 246 COLYTE WITH FLAVOR PACKETS 183 CLOBEX 246 COMBIGAN 96 246 COMBIPATCH 174 CLODAN 246 COMBIVENT RESPIMAT 5 CLODERM 246 COMBIVIR 124 clofazimine 110 COMETRIQ 271 clomiphene citrate 174 COMPAZINE 90 clomipramine hcl 81 COMPLERA 123 clonazepam 73 COMPOUND 347 187 clonidine 214 compression stocking, knee high, regular length, clonidine hcl 214 medium 271 clopidogrel bisulfate 127 compression stocking, knee high, regular length, small 271 clorazepate dipotassium 73 compression stocking,knee high,long length, large CLORPRES 167 circumfer. 271 clotrimazole 93 compression stocking,knee high,long length, x-large clotrimazole/betamethasone dipropionate 93 circumf. 271 clozapine 114,115 compression stocking,knee high,long length,medium CLOZARIL 115 circumfer. 272 compression stocking,knee high,long length,small CONZIP 14 circumferen 272 COPAXONE 225 compression stocking,knee high,regular length,large COPEGUS 136 circumf. 272 CORDARONE 55 compression stocking,knee high,regular length,x-large COREG 7 circum 272 COREG CR 7 compression stocking,thigh high,long length,extra-large CORGARD 53 circ 272 CORLANOR 148 compression stocking,thigh high,long length,large CORMAX 246 circumfer. 272 corn extract 159 compression stocking,thigh high,long length,medium CORTANE-B 44 circumfer 272 CORTEF 190 compression stocking,thigh high,long length,small CORTENEMA 246 circumfer. 272 corticotropin 155 compression stocking,thigh high,long length,x-small CORTIFOAM 247 circumf. 272 cortisone acetate 190 compression stocking,thigh high,reg length,x-large CORTISPORIN 38 circumfer 272 CORTISPORIN-TC 34 compression stocking,thigh high,regular length,large CORTROSYN 155 circumf 272 CORZIDE 53 compression stocking,thigh high,regular length,medium COSENTYX (2 SYRINGES) 256 circum 272 COSENTYX PEN 256 compression stocking,thigh high,regular length,small COSENTYX PEN (2 PENS) 256 circumf 272 COSENTYX SYRINGE 256 compression stocking,thigh high,regular length,x-small COSOPT 96 circ. 272 COSOPT PF 96 compression stocking,thigh high,short length,large cosyntropin 155 circumfer 272 COTELLIC 272 compression stocking,thigh high,short length,medium COTEMPLA XR-ODT 272 circumf. 272 COUMADIN 67 compression stocking,thigh high,short length,small coumarin 230 circumfer 272 COVARYX 174 compressor, for nebulizer 272 COVARYX H.S. 175 COMPRO 90 COZAAR 238 COMTAN 111 crab extract 159 conception assistance supplies combination no.1 272 cream base no.134 272 CONCERTA 28,29 creatine 272 CONDYLOX 256 creatine monohydrate 273 CONRAY 161 creatinine 273 CONSTULOSE 169 CREON 184 CONTRAVE 25 CRESEMBA 91 CRESTOR 106 cytarabine/pf 273 CRINONE 212 CYTOMEL 264 CRIXIVAN 125 CYTOTEC 132 CROFAB 128 CYTRA-2 168 cromolyn sodium 47 CYTRA-3 168 crotamiton 43 CYTRA-K 168 CRYSELLE 196 CUPRIMINE 222 D CUROSURF 242 D.H.E.45 6 CUTIVATE 247 DAKLINZA 189 CUVITRU 128 dalfampridine 230 CUVPOSA 65 DALIRESP 242 cyanocobalamin (vitamin b-12) 301 danazol 193 cyanocobalamin/folic acid/pyridoxine 301 DANTRIUM 245 CYCLAFEM 196 dantrolene sodium 245 cyclandelate 148 dapiprazole hcl 273 CYCLESSA 196 dapsone 110,257 cyclobenzaprine hcl 244 DAPTACEL DTAP 129 CYCLOGYL 180 darifenacin hydrobromide 187 CYCLOMYDRIL 180 DASETTA 197 cyclopentolate hcl 180 DAXBIA 151 cyclopentolate hcl/lidocaine DAYPRO 233 hcl/phenylephrine/tropicamide 180 DAYSEE 197 cyclopentolate hcl/tropicamide/phenylephrine hcl in DAYTRANA 29 water 180 DDAVP 98,211 cyclophosphamide 228 deanol 273 cycloserine 110 DEBACTEROL 257 CYCLOSET 167 DEBLITANE 197 cyclosporine 222,228 deferoxamine mesylate 218 cyclosporine, modified 222 DELATESTRYL 193 CYMBALTA 76 DELESTROGEN 175 cyproheptadine hcl 100 DELTASONE 190 CYRED 197 DELYLA 197 CYSTADANE 230 DEMADEX 163 CYSTAGON 230 demecarium bromide 273 CYSTARAN 179 demeclocycline hcl 60 cysteamine hcl 230 DEMEROL 14 cysteine hcl 170 DEMSER 230 CYSTOGRAFIN 161 DENAVIR 39 CYSTOGRAFIN-DILUTE 161 DENTA 5000 PLUS 221 cytarabine 273 DENTAGEL 221 deoxycholic acid 273 dexamethasone 190 DEPADE 151 dexamethasone acetate 190 DEPAKENE 69 dexamethasone acetate, micronized 190 DEPAKOTE 69 DEXAMETHASONE INTENSOL 190 DEPAKOTE ER 69 dexamethasone isonicotinate 190 DEPAKOTE SPRINKLE 70 dexamethasone sod phosphate 44,190 DEPEN 222 dexamethasone, micronized 190 DEPO-ESTRADIOL 175 dexchlorpheniramine maleate 273 DEPO-MEDROL 190 DEXEDRINE 26 DEPO-PROVERA 212 DEXERYL 173 DEPO-SUBQ PROVERA 104 213 DEXILANT 133 DEPO-TESTOSTERONE 193 dexmethylphenidate hcl 29 DERMA-SMOOTHE-FS 247 DEXPAK 190 DERMAGRAFT 273 dexpanthenol 273 DERMATOP 247 dextroamphetamine sulf-saccharate/amphetamine sulf- DERMAZENE 40 aspartate 27 DERMOTIC 44 dextroamphetamine sulfate 27 DESCOVY 124 dextromethorphan hbr 241 DESFERAL 218 dextrose 170 DESFERAL MESYLATE 218 DIABETA 87 desipramine hcl 81 DIALYVITE 800 WITH IRON 47 desloratadine 100 DIAMOX SEQUELS 97 desmopressin acetate 98,99 diaphragms, wide seal 273 desmopressin acetate (non-refrigerated) 211 DIASTAT 73 DESOGEN 197 DIASTAT ACUDIAL 74 desogestrel-ethinyl estradiol 197 diazepam 74 desogestrel-ethinyl estradiol/ethinyl estradiol 197 diazoxide 102 DESONATE 247 DIBENZYLINE 6 desonide 247 dibucaine 273 desonide, micronized 247 dibucaine hcl 250 DESOWEN 247 dichloralphenazone 139 desoximetasone 247 dichloroacetic acid 273 desoximetasone, micronized 247 DICLEGIS 89 desoxycorticosterone acetate 190 diclofenac potassium 233 DESOXYN 26 diclofenac sodium 46,233,257 desvenlafaxine 76 diclofenac sodium, micronized 233 desvenlafaxine fumarate 76 diclofenac sodium/misoprostol 133 desvenlafaxine succinate 77 dicloxacillin sodium 238 DETROL 187 dicumarol 67 DETROL LA 187 dicyclomine hcl 65 devil's claw extract 273 didanosine 124 diethanolamine 273 DITROPAN XL 188 diethylcarbamazine citrate 32 DIURIL 163 diethylpropion hcl 24 divalproex sodium 70 diethylstilbestrol 175 DIVIGEL 175 DIFFERIN 257 dl-3-hydroxybutyric acid, sodium salt 273 DIFICID 216 docosanol 40 247 docusate sodium 183 DIFLUCAN 91 dofetilide 55 diflunisal 233 DOLOPHINE HCL 15 DIGITEK 51 donepezil hcl 142 DIGOX 51 DONNATAL 65 digoxin 51 dopamine hcl 144 dihydrocodeine bitartrate 14 DORAL 141 dihydroergotamine mesylate 6 DORYX 61 diindolylmethane 273 DORYX MPC 61 DILANTIN 52 dorzolamide hcl 97 DILANTIN-125 52 dorzolamide hcl/timolol maleate 96 DILATRATE-SR 298 DOTHELLE DHA 47 DILAUDID 14 DOVONEX 257 DILAUDID-HP 14 doxazosin mesylate 6 DILT-XR 56 doxepin hcl 81,250 diltiazem hcl 56 doxercalciferol 303 DILUENT FOR ELITEK 273 doxycycline hyclate 34,61 dimenhydrinate 90,100 doxycycline monohydrate 61 dimethyl sulfoxide 230,273 doxylamine succinate 100 dimethylacetamide 273 drainage bag 273 dinitrochlorobenzene (2,4) 273 dressing, collagen/sodium DIOVAN 238 alginate/carboxymethylcellulose 274 DIOVAN HCT 165 dressing,collagen/silver/sod DIPENTUM 182 alginate/carboxymethylcellulose 274 diphencyprone 273 DRISDOL 303 diphenhydramine hcl 100 DRITHOCREME HP 255 diphenidol hcl 89 dronabinol 89 diphenoxylate hcl/atropine sulfate 65 droperidol 139 DIPROLENE 247 drospirenone/ethinyl estradiol/levomefolate calcium 197 DIPROLENE AF 247 DROXIA 274 dipyridamole 127 DRYSOL 252 DISALCID 236 DUAVEE 174 DISCOVISC 273 DUETACT 87 disopyramide phosphate 52 duloxetine hcl 77 disulfiram 218 DUODOTE 65 DUOPA 111 EFFEXOR XR 77 DUOVISC 274 EFFIENT 127 DUPIXENT 257 EFUDEX 257 DURAGESIC 15 egg extract 159 DURAMORPH 15 egg white extract 159 DUREZOL 44 EGRIFTA 262 DURLAZA 127 ELDEPRYL 76 dutasteride 217 ELDERCAPS 300 dutasteride/tamsulosin hcl 7 ELESTAT 178 DUTOPROL 53 ELESTRIN 175 DYANAVEL XR 27 ELETONE 173 DYAZIDE 163 eletriptan hbr 108 dyclonine hcl 180 ELIDEL 228 DYMISTA 102 ELIGARD 209 dyphylline 145 ELIMITE 43 DYRENIUM 163 ELINEST 197 ELIPHOS 215 E ELIQUIS 68 E-Z DISK 161 ELITE OB DHA 300 E-Z-CAT 161 ELITE-OB 300 E-Z-HD 161 ELITE-OB 400 47 E-Z-PAQUE 161 ELIXOPHYLLIN 145 E-Z-PASTE 161 ELLA 197 E.E.S. 200 58 ELMIRON 232 E.E.S. 400 58 ELOCON 247 EC-NAPROSYN 219 EMADINE 178 econazole nitrate 93 EMBEDA 15 ECOZA 93 EMCYT 274 ED-SPAZ 65 EMEND 90 EDARBI 238 EMFLAZA 191 EDARBYCLOR 167 EMLA 250 EDECRIN 163 EMOQUETTE 197 edetate calcium disodium 218 EMSAM 76 edetate disodium 230 EMTRIVA 124 EDEX 299 EMULSION SB 274 EDLUAR 139 EMVERM 31 edrophonium chloride 161 ENABLEX 188 EDURANT 123 enalapril maleate 239 EEMT 175 enalapril maleate/hydrochlorothiazide 165 EEMT H.S. 175 ENBREL 222,274 EFFER-K 170,171 ENDO-AVITENE 99 ENDOCET 9 EPISNAP 4 ENDOFORM 274 EPITOL 70 ENDOMETRIN 213 EPIVIR 124 ENGERIX-B ADULT 129 EPIVIR HBV 124 ENGERIX-B PEDIATRIC-ADOLESCENT 129 eplerenone 164 ENJUVIA 175 EPOGEN 144 ENLON 161 eprosartan mesylate 238 enoxaparin sodium 68 EPY 4 ENPRESSE 198 EPZICOM 124 ENSKYCE 198 EQUETRO 70 ENSTILAR 247 ergocalciferol (vitamin d2) 303 entacapone 111 ergoloid mesylates 7 entecavir 136 ERGOMAR 7 ENTEREG 185 ergotamine tartrate 7 ENTERO VU 161 ergotamine tartrate/caffeine 7 ENTOCORT EC 191 ERIVEDGE 274 ENTRESTO 240 ERRIN 198 ENTTY 274 ERTACZO 93 ENULOSE 169 ERWINAZE 274 ENVARSUS XR 228 ERY 38 EPANED 239 ERY-TAB 58 EPCLUSA 189 ERYGEL 38 ephedrine hcl 3 ERYPED 200 58 ephedrine sulfate 3 ERYPED 400 58 EPICERAM 274 ERYTHROCIN STEARATE 58 EPIDUO 257 erythromycin base 34,58,216 EPIDUO FORTE 257 erythromycin base/benzoyl peroxide 38 EPIFIX AMNIOTIC MEMBRANE 230 erythromycin base/ethyl alcohol 39 EPIFOAM 247 erythromycin estolate 216 epigallocatechin gallate 274 erythromycin ethylsuccinate 58,216 epinastine hcl 178 ESBRIET 241 epinephrine 3 ESCAVITE LQ 47 epinephrine bitartrate 3 escitalopram oxalate 78 epinephrine hcl 3 ESGIC 9 epinephrine hcl/pf 3 esomeprazole magnesium 133 epinephrine/pf 3 esomeprazole strontium 133 EPINEPHRINESNAP-V 3 ESTARYLLA 198 EPIPEN 3 estazolam 141 EPIPEN 2-PAK 3 ESTRACE 175 EPIPEN JR 2-PAK 4 estradiol 175 EPISIL 274 estradiol benzoate 176 estradiol cypionate 176 EXFORGE HCT 147 estradiol hemihydrate, micronized 176 EXJADE 274 estradiol micronized 176 EXODERM 93 estradiol valerate 176 EXPAREL 274 estradiol/norethindrone acetate 176 EXTAVIA 225 ESTRING 176 EXTINA 94 estriol 176 EZ FLU 16-17 (FLUZON QUAD PED) 130 estriol micronized 176 EZ FLU 2016-2017 (AFLURIA) 130 ESTROGEL 176 EZ FLU 2016-2017 (FLUVIRIN) 130 estrogens,esterified/methyltestosterone 176 EZ USE JOINT-TUNNEL-TRIGGER 191 estrone 176 ezetimibe 104 estropipate 176 ezetimibe/simvastatin 104 ESTROSTEP FE 198 eszopiclone 139 F ethacrynic acid 163 FABIOR 257 ethambutol hcl 110 FACTIVE 59 ethinyl estradiol/drospirenone 198 FALMINA 198 ethosuximide 74 famciclovir 136 ethoxydiglycol 274 famotidine 132 ethyl acetate 274 FAMVIR 136 ethyl alcohol 230 FANAPT 115 ethyl chloride 250 FARESTON 275 ethyl oleate 274 FARYDAK 275 ethynodiol diacetate-ethinyl estradiol 198 FAYOSIM 198 etidronate disodium 220 FAZACLO 115 etodolac 233 feeder container 275 EUCRISA 247 feeder container with gravity set 275 EURAX 43 feeder container with gravity set, enfit 275 EVAMIST 176 feeder container with pump set 275 EVARREST 99 felbamate 70 EVEKEO 27 FELBATOL 70 EVICEL 99 FELDENE 233 EVISTA 174 felodipine 146 EVOCLIN 39 FEM PH 40 EVOTAZ 125 FEMARA 275 EVOXAC 143 FEMCON FE 198 EXALGO 15 FEMHRT 176 EXELDERM 93 FEMRING 176 EXELON 143 FEMYNOR 198 exemestane 274 fenofibrate 104,105 EXFORGE 147 fenofibrate nanocrystallized 105 fenofibrate,micronized 105 FLAREX 44 fenofibric acid 105 flavoxate hcl 188 fenofibric acid (choline) 105 flecainide acetate 53 FENOGLIDE 105 FLECTOR 234 fenoprofen calcium 233 flibanserin 149 fenoprofen calcium, dihydrate 234 FLO-PRED 191 FENORTHO 234 FLOMAX 8 fentanyl 15 FLOVENT DISKUS 153 fentanyl citrate 15 FLOVENT HFA 153 fentanyl citrate in 0.9 % sodium chloride/pf 15 FLOWTUSS 241 fentanyl citrate/bupivacaine hcl in 0.9 % sodium FLOXIN 34 chloride/pf 15 floxuridine 275 fentanyl citrate/pf 15 FLUAD 2016-2017 130 fentanyl citrate/ropivacaine hcl/sodium chloride FLUAD 2017-2018 275 0.9%/pf 16 FLUARIX QUAD 2016-2017 130 FEROCON 48 FLUARIX QUAD 2017-2018 275 FEROTRINSIC 48 FLUBLOK 2016-2017 130 FERREX 150 FORTE 48 FLUBLOK 2017-2018 275 ferric ammonium citrate 275 FLUBLOK QUAD 2017-2018 275 ferric subsulfate 275 FLUCAINE 161 ferric sulfate 48 FLUCELVAX QUAD 2016-2017 130 FERRIPROX 275 FLUCELVAX QUAD 2017-2018 275 FERROCITE PLUS 48 fluconazole 92 ferrous fumarate 48 flucytosine 93 ferrous gluconate 48 fludrocortisone acetate 191 ferrous sulfate, dried 48 FLULAVAL QUAD 2016-2017 130 FETZIMA 77 FLULAVAL QUAD 2017-2018 275 FEXMID 244 FLUMADINE 134 fexofenadine hcl 100,101 flumazenil 149 fexofenadine hcl/pseudoephedrine hcl 275 flunisolide 44,191 FIBRICOR 105 fluocinolone acetonide 247 FINACEA 257 fluocinolone acetonide oil 44 finasteride 217,257 fluocinolone acetonide/shower cap 247 FIORICET 9 fluocinonide 247 FIORICET WITH CODEINE 9 fluocinonide, micronized 247 FIORINAL 127 fluocinonide/emollient base 248 FIORINAL WITH CODEINE #3 16 FLUOR-A-DAY 221 FIRAZYR 222 FLUOR-I-STRIP AT 161 FIRMAGON 225 FLUORABON 221 FLAGYL 112 fluorescein sodium 161 FLAGYL ER 112 fluoride (sodium) 221 FLUORIDEX 221 FOCALGIN DSS 48 FLUORIDEX DAILY DEFENSE 221 FOCALIN 29 FLUORIDEX SENSITIVITY RELIEF 221 FOCALIN XR 29 FLUORITAB 221 FOLBECAL 171 fluorometholone 44 FOLBEE 301 FLUOROPLEX 257 FOLBEE AR 301 fluorouracil 257,275 FOLBEE PLUS CZ 301 fluoxetine 78 FOLGARD OS 171 fluoxetine hcl 78 FOLGARD RX 301 fluoxymesterone 193 folic acid 302 fluphenazine decanoate 122 FOLIVANE-PLUS 48 fluphenazine hcl 122 FOLLISTIM AQ 209 FLURA-DROPS 221 FOLPLEX 2.2 302 flurazepam hcl 141 fomepizole 218 flurbiprofen 234 fondaparinux sodium 68 flurbiprofen sodium 46 FORADIL 5 FLUROX 180 FORANE 187 flutamide 275 FORFIVO XL 75 fluticasone propionate 44,191,248 FORMA-RAY 276 fluticasone propionate, micronized 191 FORMADON 257 fluticasone propionate/salmeterol xinafoate 5 formaldehyde 257 fluvastatin sodium 106 formoterol fumarate 5 FLUVIRIN 2016-2017 130 formoterol fumarate dihydrate, micronized 5 FLUVIRIN 2017-2018 275 FORTAVIT 48 fluvoxamine maleate 78 FORTAZ 153 FLUZONE HIGH-DOSE 2016-2017 130 FORTEO 211 FLUZONE HIGH-DOSE 2017-2018 276 FORTICAL 211 FLUZONE INTRADERM QUAD 2016-17 130 FOSAMAX 220 FLUZONE INTRADERM QUAD 2017-18 276 FOSAMAX PLUS D 220 FLUZONE QUAD 2016-2017 130 fosamprenavir calcium 125 FLUZONE QUAD 2017-2018 276 fosinopril sodium 239 FLUZONE QUAD PEDI 2016-2017 130 fosinopril sodium/hydrochlorothiazide 165 FLUZONE QUAD PEDI 2017-2018 276 FOSRENOL 215 FML 44 FRAGMIN 68 FML FORTE 44 FROVA 108 FML S.O.P. 44 frovatriptan succinate 108 foam bandage 276 FUL-GLO 161 foam/gauze bandage/lidocaine/chlorhexidine/isopropyl FULYZAQ 182 alcohol 276 FURADANTIN 32 FOCALGIN 90 DHA 48 furazolidone 32 FOCALGIN CA 48 furosemide 163 FUSION PLUS 48 GENOTROPIN 211 FUSION SPRINKLES 48 GENTAK 35 FUZEON 123 gentamicin sulfate 35,39,57 FYAVOLV 176 gentamicin sulfate/pf 57 FYCOMPA 70 GENVOYA 123 GEODON 115 G GIANVI 198 gabapentin 9 GIAZO 182 GABITRIL 70 GILDAGIA 198 galantamine hbr 143 GILDESS 199 GALZIN 276 GILDESS 24 FE 199 gamma-aminobutyric acid 230 GILDESS FE 199 GAMMAGARD LIQUID 128 GILENYA 226 GAMMAKED 128 GILOTRIF 276 GAMUNEX-C 128 ginkgo biloba 230 ganirelix acetate 225 GLATOPA 226 GARDASIL 130 GLEEVEC 276,277 GARDASIL 9 130 GLEOSTINE 277 GASTROCROM 47 glimepiride 87 GASTROGRAFIN 162 glipizide 87 GASTROMARK 276 glipizide/metformin hcl 83 gatifloxacin 34,35 GLUCAGEN 102 GATTEX 185 GLUCAGON EMERGENCY KIT 102 gauze bandage 276 glucagon hcl 102 GAVILYTE-C 183 gluconolactone 277 GAVILYTE-G 183 GLUCOPHAGE 83 GAVILYTE-N 183 GLUCOPHAGE XR 83 gel dressing 276 glucosamine hcl 230 gelatin 276 glucosamine sulfate (dipotassium chloride) 230 GELCLAIR 276 glucosamine sulfate sodium cl 230 GELFILM 179 GLUCOTROL 87 GELFOAM 99,276 GLUCOTROL XL 87 GELFOAM COMPRESSED 276 GLUCOVANCE 83 GELFOAM JMI 276 glutamic acid 277 GELNIQUE 188 glutamine 185 GELX 276 glutaraldehyde 277 gemfibrozil 105 glutathione 277 GENADUR 276 glyburide 87 GENERESS FE 198 glyburide,micronized 87 GENERLAC 169 glyburide/metformin hcl 83 GENGRAF 223 glycine 277 glycolic acid 277 HALDOL DECANOATE 100 121 glycopyrrolate 65,277 HALDOL DECANOATE 50 121 glycosaminoglycans,mixed 277 halobetasol propionate 248 glycyrrhizin 277 HALOG 248 GLYDO 180 haloperidol 121 GLYNASE 87 haloperidol decanoate 121,122 GLYSET 82 haloperidol lactate 122 GLYXAMBI 85 HARVONI 189 gold sodium thiomalate 223 HAVRIX 130 GOLYTELY 183 HEATHER 199 GONAL-F 209 HECTOROL 303 GONAL-F RFF 209 HEMABATE 277 GONAL-F RFF REDI-JECT 209 HEMANGEOL 53 GONITRO 298 HEMATINIC PLUS 48 GORDO-UREA 253 HEMATINIC WITH FOLIC ACID 48 GRAFIX CORE 230 HEMATRON-AF 48 GRAFIX PRIME 231 HEMAX 48 GRALISE 9 HEMMOREX-HC 248 gramicidin d 277 HEMOCYTE PLUS 48 granisetron hcl 88 HEMOCYTE-F 48 GRANIX 144 heparin sodium,porcine 68 GRANULEX 257 heparin sodium,porcine/pf 68 GRASTEK 231 HEPSERA 136 GRIFULVIN V 91 HETLIOZ 139 GRIS-PEG 91 HEXALEN 277 griseofulvin 91 HIBERIX 130 griseofulvin ultramicrosize 91 HICON 277 griseofulvin, microsize 91 HIPREX 32 guaiacol 41 histamine phosphate 277 guaifenesin 241 histidine 277 guanabenz acetate 214 histidine hcl 277 guanethidine sulfate 215 HIZENTRA 128 guanfacine hcl 149 HOMATROPAIRE 180 guanidine hcl 143 homatropine hbr 181 guarana seed extract 277 homatropine methylbromide 181 GYNAZOLE 1 94 HORIZANT 9,10 HPR 277 H HPR PLUS 277 H.P. ACTHAR 155 HUMALOG 86 HALCION 141 HUMALOG JUNIOR KWIKPEN 277 HALDOL 121 HUMALOG KWIKPEN U-100 86 HUMALOG KWIKPEN U-200 86 hydrocortisone/acetic acid 37 HUMALOG MIX 50-50 86 hydrocortisone/iodoquinol 41 HUMALOG MIX 50-50 KWIKPEN 86 hydrocortisone/mineral oil/petrolatum,white 248 HUMALOG MIX 75-25 86 278 HUMALOG MIX 75-25 KWIKPEN 86 HYDROMET 65 HUMATROPE 211 hydromorphone hcl 16,17 HUMIRA 185 hydromorphone hcl/pf 17 HUMIRA PEDIATRIC CROHN'S 185 hydroquinone 154 HUMIRA PEN 185 hydroquinone microspheres 154 HUMIRA PEN CROHN-UC-HS STARTER 186 hydroxocobalamin 302 HUMIRA PEN PSORIASIS-UVEITIS 186 hydroxyamphetamine hbr 181 HUMULIN R U-500 86 hydroxychloroquine sulfate 112 HUMULIN R U-500 KWIKPEN 86 hydroxyethyl methacrylate 278 hyaluronate sodium 277 hydroxyprogesterone caproate 213 hyaluronidase, bovine 278 hydroxypropyl betadex 278 HYCAMTIN 278 hydroxyurea 278 HYCET 10 hydroxyzine hcl 139 HYCOFENIX 4 hydroxyzine pamoate 139 hydralazine hcl 214 HYGEL 278 hydrazine sulfate 278 HYLATOPIC 278 HYDREA 278 HYLATOPICPLUS 278 HYDRO 35 253 HYLENEX 278 HYDRO 40 253 HYOPHEN 32 hydrochloric acid 184 hyoscyamine sulfate 65 hydrochlorothiazide 163,164 HYOSYNE 65 hydrocodone bitart/chlorpheniramine HYPER-SAL 171 maleate/pseudoephedrine 16 HYPERHEP B S-D 128 hydrocodone bitartrate 16 HYPERRAB S-D 128 hydrocodone bitartrate/acetaminophen 10 HYPERTET S-D 128 hydrocodone bitartrate/homatropine methylbromide 65 HYQVIA 128 hydrocodone polistirex/chlorpheniramine polistirex 101 HYQVIA HY COMPONENT 278 hydrocodone/ibuprofen 16 HYQVIA IG COMPONENT 129 hydrocolloid dressing 278 HYZAAR 165 hydrocortisone 191,248 hydrocortisone acetate 248 I hydrocortisone acetate/iodoquinol/aloe vera 41 ibandronate sodium 220 hydrocortisone acetate/lidocaine hcl/aloe vera 248 IBRANCE 278 hydrocortisone acetate/pramoxine hcl 248 IBUDONE 17 hydrocortisone butyrate 248 ibuprofen 234 hydrocortisone butyrate/emollient base 248 ibuprofen/oxycodone hcl 17 hydrocortisone valerate 248 IC GREEN 160 ICAR-C PLUS 48 INSPRA 164 ichthammol 279 INTELENCE 123 ICLUSIG 279 INTERMEZZO 139 idebenone 149 INTRAROSA 191 idoxuridine 37 INTRON A 135 ILARIS 231 INTROVALE 199 ILEVRO 46 INTUNIV 150 ILOTYCIN 35 INVANZ 217 IMBRUVICA 279 INVEGA 115 imipramine hcl 81 INVEGA SUSTENNA 115,116 imipramine pamoate 81 INVEGA TRINZA 116 imiquimod 257,258 INVIRASE 125 IMITREX 108,109 INVOKAMET 83 IMOGAM RABIES-HT 129 INVOKAMET XR 83 IMOVAX RABIES VACCINE 130 INVOKANA 87 IMPAVIDO 113 iodine 41 IMURAN 223 IODOFLEX 41 INCRELEX 262 iodoform 279 INCRUSE ELLIPTA 65 iodoquinol 112 indapamide 164 IODOSORB 41 INDERAL LA 54 iopanoic acid 279 INDERAL XL 54 IOPIDINE 179 INDICLOR 279 IPOL 130,279 INDIGO CARMINE 160 ipratropium bromide 65,179 indigotindisulfonate sodium in water for ipratropium bromide/albuterol sulfate 5 injection,sterile 160 IPRIVASK 68 INDIOMIN MB 32 irbesartan 238 INDOCIN 219 irbesartan/hydrochlorothiazide 165,166 indocyanine green 160 IRENKA 77 indole-3-carbinol 231 IRESSA 279 indomethacin 219,234 ISENTRESS 123 INFANRIX DTAP 129 ISENTRESS HD 123 INFASURF 242 ISIBLOOM 199 INFED 48 ISOCHRON 298 INFUMORPH 17 isoflurane 187 INGREZZA 149,279 isoleucine 280 inhaler, assist devices 279 isometheptene mucate 143 inhaler, assist devices, accessories 279 isometheptene mucate/caffeine/acetaminophen 10 INLYTA 279 isometheptene INNOPRAN XL 54 mucate/dichloralphenazone/acetaminophen 10 inositol 279 isoniazid 110 isopropamide iodide 280 JUNEL FE 199 isopropyl myristate 280 JUNEL FE 24 200 isoproterenol hcl 4,280 JUXTAPID 102,103 ISOPTO ATROPINE 181 ISOPTO CARPINE 97 K ISORDIL 298 K EFFERVESCENT 171 ISORDIL TITRADOSE 298 K-PHOS NEUTRAL 168 isosorbide 298 K-PHOS NO.2 168 isosorbide dinitrate 298 K-PHOS ORIGINAL 168 isosorbide mononitrate 298 K-SOL 171 isotretinoin 258 K-TAB ER 171 ISOVUE-200 162 KAITLIB FE 200 isoxsuprine hcl 299,300 KALETRA 125 isradipine 146 KALYDECO 154 ISTALOL 96 kanamycin sulfate 57 ISUPREL 4 KAPVAY 214 itraconazole 92 karaya gum 183 itraconazole, micronized 92 KARBINAL ER 100 ivermectin 31 KARIVA 200 IXIARO 130 KAYEXALATE 216 KEFLEX 151 J KELNOR 1-35 200 JADENU 280 KENALOG 248 JADENU SPRINKLE 280 KENALOG-10 191 JAKAFI 280 KENALOG-40 191 JALYN 8 KEPPRA 70 JANTOVEN 67 KEPPRA XR 70 JANUMET 84 KERAFOAM 253 JANUMET XR 84 KERALAC 253 JANUVIA 85 KERALYT 253 JARDIANCE 87 KERYDIN 95 JENCYCLA 199 KETALAR 187 JENTADUETO 84 ketamine hcl 187 JENTADUETO XR 84 KETEK 216 JEVANTIQUE LO 177 ketoconazole 92,94 JINTELI 177 ketoconazole, micronized 92 JOLESSA 199 ketoprofen 234 JOLIVETTE 199 ketoprofen, micronized 234 JUBLIA 94 ketorolac tromethamine 46,234 JULEBER 199 ketotifen fumarate 100 JUNEL 199 KEVEYIS 231 KEVZARA 223 LAMICTAL XR 70 KHEDEZLA 77 LAMICTAL XR (BLUE) 70 KIMIDESS 200 LAMICTAL XR (GREEN) 70 KINEVAC 160 LAMICTAL XR (ORANGE) 71 KINRIX 130 LAMISIL 91 KIONEX 216 lamivudine 124 KISQALI 280 lamivudine/zidovudine 124 KISQALI FEMARA CO-PACK 280,281 lamotrigine 71 KITABIS PAK 57 lancing device/lancets 281 KLARON 41 LANOXIN 51 KLOFENSAID II 235 LANOXIN PEDIATRIC 52 KLONOPIN 74 lansoprazole 133 KLOR-CON 171 lansoprazole/amoxicillin trihydrate/clarithromycin 133 KLOR-CON 10 171 lanthanum carbonate 215 KLOR-CON 8 171 LANTUS 86 KLOR-CON M10 171 LANTUS SOLOSTAR 86 KLOR-CON M15 171 LARIN 200 KLOR-CON M20 171 LARIN 24 FE 200 KLOR-CON SPRINKLE 171 LARIN FE 200 KLOR-CON-EF 171 LARISSIA 200 kojic acid 281 LASIX 163 KORLYM 82 LASTACAFT 178 KRISTALOSE 169 latanoprost 98 KURVELO 200 LATISSE 98 KUVAN 231 LATRIX 253 KYNAMRO 103 LATUDA 116 LAYOLIS FE 200 L LEENA 200 labetalol hcl 8 leflunomide 223 LACRISERT 179 LENVIMA 281 lactic acid 173,253 LESCOL 106 lactobacillus acidophilus 182 LESCOL XL 106 lactulose 169 LESSINA 201 LAMICTAL 70 LETAIRIS 242 LAMICTAL (BLUE) 70 letrozole 281 LAMICTAL (GREEN) 70 leucine 170 LAMICTAL (ORANGE) 70 leucovorin calcium 218,231 LAMICTAL ODT 70 LEUKERAN 281 LAMICTAL ODT (BLUE) 70 LEUKINE 144 LAMICTAL ODT (GREEN) 70 leuprolide acetate 210,281 LAMICTAL ODT (ORANGE) 70 LEVACET 127 levalbuterol hcl 5 LIDORX 251 levamisole hcl 31 LIDOTRAL 251 LEVAQUIN 59 LIDOVEX 251 LEVATOL 148 LIDTOPIC MAX 251 LEVBID 65 LILLOW 202 levetiracetam 71 LINCOCIN 63 LEVO-T 264 lincomycin hcl 63 levobunolol hcl 96 lindane 43 levocarnitine 231 linezolid 63 levocarnitine hcl 231 LINZESS 186 levocetirizine dihydrochloride 101 liothyronine sodium 264 levodopa 111 LIPITOR 106 levofloxacin 35,59 LIPOFEN 105 levomefolate calcium 302 LIQUID E-Z PAQUE 162 LEVONEST 201 LIQUID POLIBAR PLUS 162 levonorgestrel 201 lisinopril 239 levonorgestrel-ethinyl estradiol 201 lisinopril/hydrochlorothiazide 166 levonorgestrel/ethinyl estradiol and ethinyl estradiol 201 lithium carbonate 149 LEVORA-28 201 lithium citrate 149 levorphanol tartrate 17 LITHOBID 149 levothyroxine sodium 264 LITHOSTAT 169 LEVOXYL 264 LIVALO 106 LEVSIN 65,66 LO LOESTRIN FE 202 LEVSIN-SL 66 LOCOID 248 LEVULAN 258 LODINE 235 LEXAPRO 78 LODOSYN 150 LEXIVA 126 LOESTRIN 202 LIALDA 182 LOESTRIN FE 202 LIBRAX 66 LOFIBRA 105 lidocaine 250,281 LOMAIRA 24 lidocaine hcl 52,180,250,281 LOMEDIA 24 FE 202 lidocaine hcl buffered with 8.4 % sodium bicarbonate 281 LOMOTIL 66 lidocaine hcl/epinephrine 263 lomustine 281 lidocaine hcl/epinephrine bitartrate 263 LONSURF 281 lidocaine hcl/hydrocortisone acetate 248 loperamide hcl 182,183 lidocaine hcl/pf 52,281 LOPID 105 lidocaine/prilocaine 251 lopinavir/ritonavir 126 lidocaine/tetracaine 251 LOPREEZA 177 LIDODERM 251 LOPRESSOR 54 LIDOPIN 251 LOPRESSOR HCT 54 LIDOPRIL 251 LOPROX 95 loratadine 101 lycopene 231 loratadine, micronized 101 LYMPHAZURIN 160 lorazepam 74 LYNPARZA 282 LORAZEPAM INTENSOL 74 LYRICA 71 LORCET 10 lysine hcl 170 LORCET HD 10 LYSIPLEX PLUS 170 LORCET PLUS 10 LYSODREN 282 LORTAB 10,11 LYSTEDA 99 LORYNA 202 LYZA 202 LORZONE 244 losartan potassium 238 M losartan potassium/hydrochlorothiazide 166 M-M-R II VACCINE 130 LOSEASONIQUE 202 maca 282 LOTEMAX 45 MACNATAL CN DHA 48 LOTENSIN 240 MACROBID 32 LOTENSIN HCT 166 MACRODANTIN 32 LOTREL 147 mafenide acetate 41 LOTRISONE 94 magnesium amino acid chelate 171 LOTRONEX 182 magnesium aspartate dihydrate 282 LOUTREX 282 magnesium chloride 71,282 lovastatin 106 magnesium glycinate 171 LOVAZA 103 magnesium malate 282 LOVENOX 69 magnesium oxide 181 LOW-OGESTREL 202 magnesium sulfate 52 loxapine succinate 113 MAKENA 213 LP LITE PAK 251 MALARONE 112 LUCENTIS 179 malathion 43 LUDENT FLUORIDE 221 malic acid 282 LUGOL'S 41,91 manganese chloride 171 LUMIGAN 98 manganese gluconate 171 LUMINAL SODIUM 282 mannitol 98 LUNESTA 139 mannitol/sorbitol solution 163 LUPANETA PACK 210 maprotiline hcl 81 LUPRON DEPOT 210 MARCAINE 282 LUPRON DEPOT (LUPANETA) 210 MARCAINE SPINAL 282 LUPRON DEPOT-PED 210 MARCAINE-EPINEPHRINE 263 lutein 282 MARGESIC 11 LUTERA 202 MARINOL 90 LUXAMEND 173 MARLISSA 202 LUXIQ 248 MARPLAN 76 LUZU 94 MARTEN-TAB 11 MATERNITY 300 melphalan 283 MATULANE 282 MELQUIN-3 154 MATZIM LA 56 memantine hcl 150 MAVIK 240 MEMBRANEBLUE 161 MAVYRET 282 MENACTRA 130 MAXALT 109 menadione 283 MAXALT MLT 109 MENEST 177 MAXARON FORTE 48 MENHIBRIX 131 MAXIDEX 45 MENOMUNE-A-C-Y-W-135 131 MAXIFED CDX 282 MENOPUR 210 MAXINATE 300 MENOSTAR 177 MAXIPHEN CD 282 MENTAX 94 MAXIPHEN CDX 282 menthol 283 MAXIPIME 151 MENVEO A-C-Y-W-135-DIP 131 MAXITROL 35 MENVEO MENA COMPONENT 131 MAXZIDE 163 MENVEO MENCYW-135 COMPONENT 131 MAXZIDE-25 MG 163 meperidine hcl 17 MD-76 R 162 meperidine hcl/pf 18 MD-GASTROVIEW 162 MEPHYTON 218 mebendazole 32 mepivacaine hcl/pf 283 mecamylamine hcl 215 meprobamate 140 mechlorethamine hcl 282 MEPRON 113 meclizine hcl 90 mequinol 154 meclofenamate sodium 235 mercaptopurine 228 meclofenoxate hcl 28 mesalamine 182 mecobalamin 302 mesalamine with cleansing wipes 182 medical supply, miscellaneous 282 MESNEX 232 MEDROL 191 MESTINON 143 medroxyprogesterone acetate 213 METADATE CD 29 medroxyprogesterone acetate, micronized 213 METADATE ER 29 mefenamic acid 235 metaproterenol sulfate 5 mefloquine hcl 112 METAXALL 244 MEGACE 282 metaxalone 244 MEGACE ES 282 metformin hcl 84 megestrol acetate 282,283 methacholine chloride 283 megestrol acetate,micronized 283 methadone hcl 18,283 MEKINIST 283 METHADONE INTENSOL 18 melatonin 231 METHADOSE 18 MELODETTA 24 FE 202 methamphetamine hcl 27 meloxicam 235 methazolamide 97 MELPAQUE HP 154 methenamine 32 methenamine hippurate 32 metoprolol tartrate/hydrochlorothiazide 54 methenamine mandelate 32 METOZOLV ODT 187 methenamine/sod phosph,monobasic/methylene METROCREAM 39 blue/hyoscyamine 32 METROGEL 39 METHERGINE 283 METROGEL-VAGINAL 39 methimazole 264 METROLOTION 39 methionine 283 metronidazole 39,112 METHITEST 193 metronidazole benzoate 112 methocarbamol 244 mexiletine hcl 52 methotrexate 283 MIACALCIN 211 methotrexate sodium 223 MIBELAS 24 FE 203 methotrexate sodium/pf 223 MICARDIS 239 methoxsalen 154 MICARDIS HCT 166 methscopolamine bromide 66 miconazole 94 methyclothiazide 164 miconazole nitrate 94 methyl aminolevulinate hcl 258 MICORT-HC 248 methyldopa 214 MICROCYN 283 methyldopa/hydrochlorothiazide 166 MICROCYN HYDROGEL 283 methylene blue/gentian violet/foam bandage 283 MICROGESTIN 203 methylergonovine maleate 283 MICROGESTIN 24 FE 203 METHYLIN 29 MICROGESTIN FE 203 methylparaben 283 MICROZIDE 164 methylphenidate hcl 30 midazolam 141 methylprednisolone 191 midazolam hcl 141 methylprednisolone acetate 191 midazolam hcl/pf 141 methylprednisolone acetate, micronized 191 middle ear inflation device 283 methylprednisolone sodium succinate 191 midodrine hcl 263 methylprednisolone, micronized 191 MIFEPREX 283 methylscopolamine nitrate 66 MIGERGOT 7 methylsulfonylmethane 283 miglitol 82 methyltestosterone 193 MIGRANAL 7 methyltestosterone, micronized 193 milk thistle 284 methyltetrahydrofolate calcium 302 MILLIPRED 191 methyltetrahydrofolate glucosamine 302 MILLIPRED DP 191 methysergide maleate 7 MIMVEY 177 metipranolol 96 MIMVEY LO 177 metoclopramide hcl 186,187 MINASTRIN 24 FE 203 metolazone 164 mineral oil 173 METOPIRONE 161 MINIPRESS 6 metoprolol succinate 54 MINITRAN 298 metoprolol tartrate 54 MINIVELLE 177 MINOCIN 61 MOVIPREP 183 minocycline hcl 61 MOXATAG 237 minoxidil 215 MOXEZA 35 MIOCHOL-E 97 moxifloxacin hcl 35,59 MIOSTAT 97 MOZOBIL 145 MIRAPEX 167 MS CONTIN 19 MIRAPEX ER 167 MUCOTROL 258 MIRCERA 145 mucus clearing device 284 MIRCETTE 203 MUGARD 284 mirtazapine 75 MULTAQ 55 MIRVASO 258 MULTICHEW 48 misoprostol 133 MULTIGEN FOLIC 48 mite-dermatophagoides farinae, standardized 159 MULTIGEN PLUS 49 MITIGARE 219 multivitamin-minerals no.44/cholecalciferol (vit d3)/vit mitomycin 284 k1 300 mitotane 284 mupirocin 35,39 MOBIC 235 mupirocin calcium 39 modafinil 31 MUSE 300 MODERIBA 136 MUSTARGEN 284 MODICON 203 MYALEPT 211 moexipril hcl 240 MYAMBUTOL 110 moexipril hcl/hydrochlorothiazide 166 MYCOBUTIN 64 molindone hcl 113 mycophenolate mofetil 228 molybdenum 171 mycophenolate sodium 228 mometasone furoate 45,249 MYDRIACYL 181 MONDOXYNE NL 61 MYFORTIC 228 MONO-LINYAH 203 MYKIDZ IRON FL 49 monobenzone 154 MYLERAN 284 monochloroacetic acid 284 MYNATAL 49,300 MONODOX 61 MYNATAL ADVANCE 49 MONOJECT 0.9% SODIUM CHLORIDE 171 MYNATAL PLUS 49 MONOJECT PREFILL 171 MYNATAL-Z 49 MONOJECT PREFILL ADVANCED 171 MYNATE 90 PLUS 300 MONONESSA 203 MYORISAN 258 MONSEL'S 99 MYRBETRIQ 144 montelukast sodium 46 MYSOLINE 73 MONUROL 32 MYTESI 183 MORGIDOX 62 MYZILRA 203 morphine sulfate 18,19 morphine sulfate/pf 19 N MOTOFEN 183 NABI-HB 129 nabumetone 235 NEBUSAL 171 nabumetone, micronized 235 NECON 203 nadide 284 needles, blood collection 284 nadolol 54 needles, disposable 284 nadolol/bendroflumethiazide 54 needles, filter 284 nafcillin sodium 238 needles, safety 285 naftifine hcl 93 nefazodone hcl 80 NAFTIN 93 NEMBUTAL SODIUM 140 nalbuphine hcl 23 NEO-POLYCIN 35 NALFON 235 NEO-POLYCIN HC 35 nalidixic acid 59 NEO-SYNALAR 39 naloxone hcl 151 neomycin sulfate 57 naltrexone hcl 151 neomycin sulfate/bacitracin zinc/polymyxin naltrexone hydrochloride dihydrate 151 b/hydrocortisone 35 NAMENDA 150 neomycin sulfate/bacitracin/polymyxin b 35 NAMENDA XR 150 neomycin sulfate/polymyxin b sulfate/gramicidin d 35 NAMZARIC 143 neomycin sulfate/polymyxin b sulfate/hydrocortisone 35 193 neomycin/polymyxin b sulfate/dexamethasone 35 naphazoline hcl 181 NEORAL 223 NAPRELAN 219 NEOSALUS 285 NAPROSYN 219 NEOSALUS CP 285 naproxen 219,235 NEOSPORIN 35 naproxen sodium 219,235 neostigmine methylsulfate 143 naratriptan hcl 109 NEPHRO-VITE RX 302 NARCAN 151 NEPTAZANE 97 NARDIL 76 NESACAINE 285 NAROPIN 284 NESACAINE-MPF 285 nasal exhalation resistance device 284 nettle leaf 285 NASCOBAL 302 NEUAC 39 NASONEX 45 NEULASTA 145 NATACYN 36 NEUPOGEN 145 NATAZIA 203 NEUPRO 167 nateglinide 86 NEURIN-SL 302 NATESTO 193 NEURONTIN 11 NATPARA 211 NEUTRASAL 285 NATROBA 44 NEVANAC 46 NATURE-THROID 264 nevirapine 124 nebulizer 284 NEWGEN 49 nebulizer accessories 284 NEXAVAR 285 nebulizer and compressor 284 NEXAVIR 231 NEBUPENT 113 NEXIUM 133 niacin 103 norethindrone acetate-ethinyl estradiol/ferrous niacinamide 302 fumarate 204 NIACOR 103 norethindrone-ethinyl estradiol/ferrous fumarate 204 NIASPAN 103 norgestimate-ethinyl estradiol 204 nicardipine hcl 147 NORINYL 1+50 204 niclosamide 32 NORINYL 1-35 204 nicotinamide-adenine dinucleotide, reduced, disodium 231 NORITATE 39 nicotine polacrilex 142 NORLYDA 204 NICOTROL 142 NORLYROC 204 NICOTROL NS 142 NORPACE 52 NIFEDICAL XL 147 NORPACE CR 52 nifedipine 147 NORPRAMIN 81 NIKKI 203 NORTHERA 263 NILANDRON 285 NORTREL 204 nilutamide 285 nortriptyline hcl 81 nimodipine 147 NORVASC 147 NINLARO 285 NORVIR 126 nisoldipine 146 NOVACORT 249 NITRO-BID 298 NOVAREL 210,285 NITRO-DUR 298 NOXAFIL 92 NITRO-TIME 298 NP THYROID 264 nitrofurantoin 32 NUCYNTA 19,20 nitrofurantoin macrocrystal 32,33 NUEDEXTA 150 nitrofurantoin monohydrate/macrocrystals 33 NULEV 66 nitrofurazone 41 NULYTELY WITH FLAVOR PACKS 183 nitroglycerin 299 NUMBONEX 251 NITROLINGUAL 299 NUMOISYN 285 NITROMIST 299 NUOX 253 NITROSTAT 299 NUPLAZID 116 NIVATOPIC PLUS 285 NUTRESTORE 186 nizatidine 132 NUTRICAP 49 NIZORAL 94 NUTROPIN AQ 212 NODOLOR 11 NUTROPIN AQ NUSPIN 212 NOR-Q-D 203 NUVAIL 285 NORA-BE 204 NUVARING 204 NORCO 11 NUVESSA 39 NORDITROPIN FLEXPRO 211 NUVIGIL 31 norepinephrine bitartrate 263 NYAMYC 95 norethindrone 204,213 NYATA 95 norethindrone acetate 213 nylidrin hcl 148 norethindrone acetate-ethinyl estradiol 177,204 NYMALIZE 147,285 nystatin 92,95 OMNITROPE 212 nystatin/triamcinolone acetonide 95 ONCASPAR 286 NYSTOP 95 ondansetron 88 ondansetron hcl 88,89 O ondansetron hcl/pf 89 O-CAL FA 49 ONEXTON 39 oats extract 159 ONFI 74 OBSTETRIX EC 49 ONMEL 92 OBSTETRIX ONE 49 ONZETRA XSAIL 109 OBTREX DHA 49 OPANA 20 OCALIVA 186 OPANA ER 20 OCELLA 204 opium tincture 183 octanoic acid 286 opium/belladonna alkaloids 20 octreotide acetate 261 OPSUMIT 242 OCUCOAT 179 ORACEA 62 OCUFEN 46 ORACIT 168 OCUFLOX 35 ORAFATE 286 ODEFSEY 124 ORALAIR 231 ODOMZO 286 ORALONE 249 OFEV 241 ORAMAGICRX 286 ofloxacin 36,59 orange extract 160 OGEN 177 ORAP 114 OGESTREL 204 ORAPRED ODT 191 OKEBO 62 ORAVIG 94 olanzapine 117 ORENCIA 223 olanzapine/fluoxetine hcl 78 ORENCIA CLICKJECT 223 olmesartan medoxomil 239 ORENITRAM ER 242 olmesartan medoxomil/amlodipine ORFADIN 231 besylate/hydrochlorothiazide 166 ORKAMBI 153 olmesartan medoxomil/hydrochlorothiazide 166 ornithine 286 olopatadine hcl 178 orphenadrine citrate 245 OLUX 249 ORSYTHIA 205 OLUX-E 249 ORTHO MICRONOR 205 OLYSIO 189 ORTHO TRI-CYCLEN 205 OMECLAMOX-PAK 134 ORTHO TRI-CYCLEN LO 205 omega-3 acid ethyl esters 103 ORTHO-CEPT 205 omega-3 fatty acids/dha/epa/fish oil/sunflower oil 286 ORTHO-CYCLEN 205 omeprazole 134 ORTHO-NOVUM 205 omeprazole/sodium bicarbonate 134 OSCIMIN 66 OMNARIS 45 OSCIMIN SL 66 OMNIPRED 45 OSCIMIN SR 66 oseltamivir phosphate 135 OSMOPREP 183 P OSPHENA 174 PACERONE 55 ostomy kit 286 PACNEX 253 ostomy supply 286 PACNEX HP 253 OTEZLA 223 PACNEX LP 253 OTIPRIO 36 PAIN EASE 251 OTOVEL 36 paliperidone 117 OTREXUP 223 PAMELOR 81 OVACE 41 panax ginseng root 286 OVACE PLUS 41 pancreatin 184 OVACE PLUS WASH 41 pancuronium bromide 245 OVCON-35 205 PANDEL 249 OVIDE 44 PANRETIN 258 OVIDREL 210 panthenol 302 oxacillin sodium 238 pantoprazole sodium 134 OXANDRIN 194 papain 286 oxandrolone 194 papaverine hcl 300 oxaprozin 235 papaverine hcl/alprostadil in bacteriostatic water 300 OXAYDO 20 parachlorophenol 286 oxazepam 141 PARAFON FORTE DSC 244 oxcarbazepine 71 paregoric 183 OXECTA 20 PAREMYD 181 oxiconazole nitrate 94 paricalcitol 303 OXISTAT 94 PARLODEL 167 OXSORALEN 154 PARNATE 76 OXSORALEN-ULTRA 154 PAROEX 37 OXTELLAR XR 71 paromomycin sulfate 57 oxybutynin chloride 188 paroxetine hcl 79 OXYCEL 99 paroxetine mesylate 79 oxycodone hcl 20 PASER 110 oxycodone hcl/acetaminophen 11 PATADAY 179 oxycodone hcl/aspirin 20 PATANASE 179 OXYCONTIN 21 PATANOL 179 oxymetazoline hcl 181 PAXIL 79 oxymorphone hcl 21 PAXIL CR 79 oxytetracycline hcl 62 PAZEO 179 oxytocin 286 PCE 58 OXYTROL 188 peak flow meter 286 peak flow meter/inhaler, assist devices 286 peanut extract 160 pecan extract 160 PEPCID 132 pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit PERCOCET 11 k) 300 PERFOROMIST 5 PEDIADERM AF 95 PERIDEX 37 PEDIAPRED 192 perindopril erbumine 240 PEDIARIX 129 PERIOGARD 37 pediatric multivit permethrin 44 no.22/cholecalciferol(d3)/phytonadione(k) 300 perphenazine 122 pediatric multivit with a,c,d3 no.21/sodium fluoride 301 perphenazine/amitriptyline hcl 82 pediatric multivitamin no.150 with sodium fluoride 221 PERSANTINE 127 pediatric multivitamin no.16/sodium fluoride 221 PEXEVA 79 pediatric multivitamin no.2/sodium fluoride 221 PFIZERPEN 238 pediatric multivitamin no.45/sodium fluoride/ferrous PHENADOZ 140 sulfate 49 phenazopyridine hcl 251 PEDVAXHIB 131 phendimetrazine tartrate 24 peg 3350/sod sulf/sod bicarb/sod chloride/potassium phenelzine sulfate 76 chloride 184 PHENERGAN 101,140 PEG-PREP 184 phenindione 286 PEGANONE 74 phenobarbital 73,140 PEGASYS 135 phenobarbital sodium 73 PEGASYS PROCLICK 135 phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine PEGINTRON 135 hb 66 PEGINTRON REDIPEN 135 PHENOHYTRO 66 pen needle, diabetic 286 phenol 41 penicillamine 223 phenolsulfonic acid 286 penicillin g potassium 237 phenoxybenzamine hcl 7 penicillin g procaine 237 phentermine hcl 24 penicillin g sodium 237 phentolamine mesylate 7 penicillin v potassium 237 phentolamine mesylate/alprostadil in bacteriostatic water 7 PENLAC 95 phenylalanine 170 PENNSAID 235 phenylbutazone 235 PENTACEL 131 phenylephrine hcl 181,263 PENTACEL ACTHIB COMPONENT 131 phenylephrine hcl/promethazine hcl 101 PENTACEL DTAP-IPV COMPONENT 131 phenylmercuric nitrate 286 PENTAM 300 113 phenylpropanolamine hcl 263 PENTASA 182 phenyltoloxamine citrate (dihydrogen) 286 pentazocine hcl/naloxone hcl 23 PHENYTEK 52 pentobarbital sodium 140 phenytoin 52 pentosan polysulfate sodium 233 phenytoin sodium 53 pentoxifylline 145 phenytoin sodium extended 53 pentylenetetrazol 286 PHILITH 205 PHOSLYRA 215 POLY-VI-FLOR 221 PHOSPHA 250 NEUTRAL 168 POLY-VI-FLOR WITH IRON 49 PHOSPHASAL 33 POLYCIN 36 phosphatidyl serine 286 polyethylene glycol 3350 184 phosphatidylcholine 186 polyhexamethylene biguanide/gauze bandage 41,287 PHOSPHOLINE IODIDE 97 polymyxin b sulfate 63 physostigmine salicylate 143 polymyxin b sulfate, micronized 63 phytonadione (vit k1) 218,304 polymyxin b sulfate,micronized 63 PICATO 258 polymyxin b sulfate/trimethoprim 36 pilocarpine hcl 97,143 POLYSACCHARIDE IRON FORTE 49 pilocarpine nitrate 98 POLYTRIM 36 pimozide 114 polyvinyl alcohol 287 PIMTREA 205 polyvinyl alcohol/gentian violet/methylene blue 287 pindolol 54 POMALYST 226 pioglitazone hcl 88 PONSTEL 235 pioglitazone hcl/glimepiride 87 PONTOCAINE 251 pioglitazone hcl/metformin hcl 84 porcine acell submucosa,meshed 287 PIRMELLA 205 porcine acellular small intestine submucosa, piroxicam 235 fenestrated 287 pistachio nut extract 160 pork extract 160 PITOCIN 286 PORTIA 205 PLAN B ONE-STEP 205 POTABA 231 PLAQUENIL 113 potassium aminobenzoate 287 PLAVIX 127 potassium bicarbonate/citric acid 172 PLEGISOL 171 potassium bromide 287 PLEGRIDY 226 potassium chloride 172 PLEGRIDY PEN 226 potassium chloride/potassium bicarbonate/citric acid 172 PLETAL 127 potassium citrate 168 PLEXION 41 potassium citrate monohydrate 172 PLIAGLIS 251 potassium citrate/citric acid 168 PNEUMOVAX 23 131 potassium hydroxide 253 PNV 29-1 49 potassium iodide 91 PNV-DHA + DOCUSATE 49 potassium iodide/iodine 91 PNV-OMEGA 49 potassium perchlorate 231 PNV-VP-U 300 potassium permanganate 287 PODOCON-25 258 potassium phosphate, dibasic 172 podofilox 258,286 potassium phosphate,monobasic 172 podophyllum resin 253 potassium sorbate 287 POLIBAR ACB 162 POTIGA 71 POLOCAINE 287 povidone 287 POLOCAINE-MPF 287 povidone-iodine 37,41 PR BENZOYL PEROXIDE 253 PREMPRO 178 PRADAXA 68 PRENA1 CHEW 300 pralidoxime chloride 218 PRENA1 PEARL 49 PRALUENT PEN 107 PRENA1 TRUE 49 PRALUENT SYRINGE 107 PRENAISSANCE NEXT 172 PRAMCORT 249 PRENATABS RX 49 pramipexole di-hcl 168 prenatal vitamins no.5/ferrous fumarate/folic acid 300 PRAMOSONE 249 prenatal vitamins no.79/iron fum/folic PRAMOSONE E 249 acid/levomefolate/dha 49 pramoxine hcl 251 prenatal vits with calcium #74/ferrous fumarate/folic PRANDIMET 84 acid 49 PRANDIN 86 prenatal vits with calcium no.72/ferrous fumarate/folic prasterone (dhea) 194 acid 49 prasterone (dhea), micronized 194 prenatal vits with calcium no.74/ferrous fumarate/folic prasugrel hcl 127 acid 50 PRAVACHOL 106 PREPIDIL 287 pravastatin sodium 107 PREPLUS 50 praziquantel 32 PREPOPIK 184 prazosin hcl 6 PRESERA 287 PRE-ATTACHED LTA KIT 251 PRESTALIA 148 PRE-PEN 160 PRETAB 50 PRECOSE 82 PREVACID 134 PRED FORTE 45 PREVALITE 104 PRED MILD 45 PREVIDENT 221 PRED-G 36 PREVIDENT 5000 221 prednicarbate 249 PREVIDENT 5000 ENAMEL PROTECT 221 prednisolone 192 PREVIDENT 5000 PLUS 222 prednisolone acetate 45 PREVIDENT 5000 SENSITIVE 222 prednisolone acetate, micronized 192 PREVIFEM 205 prednisolone sod phosphate 45,192 PREVNAR 13 131 prednisolone, micronized 192 PREVPAC 134 prednisone 192 prezatide copper 287 PREDNISONE INTENSOL 192 PREZCOBIX 126 prednisone micronized 192 PREZISTA 126 PREFEST 177 PRIFTIN 64 pregabalin 71 prilocaine hcl 287 pregnenolone 287 PRILOSEC 134 pregnenolone, micronized 287 primaquine phosphate 113 PREGNYL 210 primidone 73 PREMARIN 177 PRIMLEV 11,12 PREMPHASE 178 PRIMSOL 33 PRINIVIL 240 PROMETHEGAN 140 PRISMASOL 172 PROMETRIUM 214 PRISTIQ 77 PROMISEB 287 PROAIR HFA 5 propafenone hcl 53 PROAIR RESPICLICK 5 propantheline bromide 66 probenecid 172 proparacaine hcl 180 probenecid/colchicine 173 proparacaine hcl/fluorescein sodium 161 procainamide hcl 52 PROPECIA 258 procaine hcl 287 propranolol hcl 54 procarbazine hcl 287 propranolol hcl/hydrochlorothiazide 54 PROCARDIA 147 propyl gallate 287 PROCARDIA XL 147 propylene glycol 287 PROCENTRA 27 propylthiouracil 264 prochlorperazine 90 PROQUAD 131 prochlorperazine edisylate 90 PROSCAR 217 prochlorperazine maleate 90 PROSED-DS 33 PROCORT 249 PROSTIN E2 VAGINAL SUPPOSITORY 287 PROCRIT 145 PROSTIN VR PEDIATRIC 300 PROCTO-MED HC 249 protamine sulfate 98 PROCTO-PAK 249 PROTECT IRON 50 PROCTOCORT 249 PROTHELIAL 287 PROCTOFOAM-HC 249 prothrombin time/inr test meter 288 PROCTOSOL-HC 249 protirelin 162 PROCTOZONE-HC 249 PROTONIX 134 PROCYSBI 231 PROTOPAM CHLORIDE 218 PRODRIN 12 PROTOPIC 258 PROFENO 235 protriptyline hcl 82 PROFERRIN-FORTE 50 PROVERA 214 progesterone 213 PROVIDA DHA 50 progesterone, micronized 213 PROVIDA OB 50 progesterone,micronized 213 PROVIGIL 31 PROGLYCEM 102 PROVISC 288 PROGRAF 228 PROVOCHOLINE 288 PROLENSA 46 PROZAC 79 proline 287 PROZAC WEEKLY 79 PROMACTA 145 PRUCLAIR 173 promazine hcl 122 PRUDOXIN 251 promethazine hcl 101,102,140 PRUMYX 288 promethazine hcl/codeine 102 PRUTECT 173 promethazine hcl/dextromethorphan hbr 102 pseudoephedrine hcl 4 promethazine/phenylephrine hcl/codeine 21 PSORCON 249 PULMICORT 153 quinine hcl dihydrate 113 PULMICORT FLEXHALER 153 quinine sulfate 113 PULMOSAL 172 PULMOZYME 241 R pump set 288 R-NATAL OB 50 PURIXAN 228 RABAVERT 131 PYLERA 62 rabeprazole sodium 134 pyrantel pamoate 32 racepinephrine hcl 4 pyrazinamide 110 RADIAPLEXRX 288 PYRIDIUM 251 RADIGEL 288 pyridostigmine bromide 143 RADIOGARDASE 215 pyridoxal phosphate 288 RAGWITEK 232 pyridoxine hcl (vitamin b6) 302 RAJANI 206 pyrilamine maleate 181 raloxifene hcl 174 pyrimethamine 113 ramipril 240 pyrithione zinc 288 RANEXA 148 PYROGALLIC ACID 258 ranitidine hcl 132 pyruvic acid 232 RAPAFLO 8 RAPAMUNE 228 Q rasagiline mesylate 76 QBRELIS 240 RASUVO 223,224 QNASL 45 rauwolfia serpentina 215 QNASL CHILDREN 45 RAVICTI 169 QSYMIA 25 RAYALDEE 303 QUADRACEL DTAP-IPV 131 RAYOS 192 QUALAQUIN 113 RAZADYNE 143 QUARTETTE 205 RAZADYNE ER 143 QUASENSE 205 REA LO 40 253 quazepam 141 READI-CAT 2 162 QUDEXY XR 72 REBETOL 137 quercetin dihydrate 288 REBIF 226,227 QUESTRAN 104 REBIF REBIDOSE 227 QUESTRAN LIGHT 104 RECEDO 288 quetiapine fumarate 117,118 RECLIPSEN 206 QUILLICHEW ER 30 RECOMBIVAX HB 131 QUILLIVANT XR 30 RECOTHROM 99 quinacrine hcl 113 RECTIV 258 quinapril hcl 240 red yeast rice extract 288 quinapril hcl/hydrochlorothiazide 166 REFISSA 252 quinidine gluconate 52 REGENECARE 251 quinidine sulfate 52 REGIMEX 28 REGLAN 187 REVIA 151 REGONOL 143 REVLIMID 227 REGRANEX 258 REXULTI 118 RELAGARD 41 REYATAZ 126 RELENZA 135 REZIRA 4 RELISTOR 186 RHEUMATREX 224 RELPAX 109 RHINOCORT AQUA 45 REMERON 75 RHOFADE 258 REMEVEN 253 RIBASPHERE 137 REMODULIN 242 RIBASPHERE RIBAPAK 137 RENA-VITE RX 302 RIBATAB 137 RENAGEL 215 ribavirin 137 RENOVA 252 riboflavin (vitamin b2) 302 RENOVA PUMP 252 riboflavin 5-phosphate sodium (b2) 302 RENOVO 258 ribose 170 RENVELA 215 rice extract 160 repaglinide 87 RIDAURA 224 repaglinide/metformin hcl 84 rifabutin 64 REPATHA PUSHTRONEX 108 RIFADIN 64 REPATHA SURECLICK 108 RIFAMATE 64 REPATHA SYRINGE 108 rifampin 64 REPREXAIN 21 RIFATER 64 REQ49+ 300 rifaximin 64 REQUIP 168 RILUTEK 150 REQUIP XL 168 riluzole 150 RESCRIPTOR 124 rimantadine hcl 135 RESECTISOL 170 RIMSO-50 249 reserpine 215 RIOMET 85 resorcinol 288 risedronate sodium 220,221 RESPA A.R. 102 RISPERDAL 118 RESTASIS 45 RISPERDAL CONSTA 118 RESTASIS MULTIDOSE 46 RISPERDAL M-TAB 118,119 RESTORA SPRINKLES 186 risperidone 119 RESTORIL 141 RITALIN 30,31 resveratrol 232 RITALIN LA 31 RETIN-A 252 rivastigmine 143 RETIN-A MICRO 252 rivastigmine tartrate 143 RETIN-A MICRO PUMP 252,288 RIVELSA 206 retinal 288 rizatriptan benzoate 109 RETROVIR 125 ROBAXIN 244 REVATIO 242,243 ROBAXIN-750 244 ROBINUL 66 salsalate 236 ROBINUL FORTE 66 SALVAX 254 ROCALTROL 303 SAMSCA 164 rocuronium bromide 245 SANADERMRX 249 ropinirole hcl 168 SANCUSO 89 ropivacaine hcl 288 SANDIMMUNE 224 ropivacaine hcl in 0.9 % sodium chloride/pf 288 SANDOSTATIN 261 ropivacaine hcl/pf 288 SANDOSTATIN LAR DEPOT 261 ROSADAN 39 SANTYL 258 ROSANIL 41 SAPHRIS 119 rosuvastatin calcium 107 sapropterin dihydrochloride 289 ROTARIX 131 SARAFEM 79 ROTATEQ 131 SAVAYSA 68 ROWASA 182 SAVELLA 77 ROWEEPRA 72 saw palmetto fruit 289 ROXICODONE 21 SAXENDA 85 ROZEREM 140 SCALACORT 249 RUBRACA 288 SCLEROSOL 148 RULAVITE DHA 50 scopolamine 90 RYDAPT 289 scopolamine hydrobromide 66 RYNODERM 253 SEASONIQUE 206 RYTARY 112 SEB-PREV 42 RYTHMOL 53 SEBUDERM 289 RYTHMOL SR 53 SECONAL SODIUM 140 RYVENT 100 secretin acetate (human) 161 SECTRAL 54 S SEEBRI NEOHALER 66 s-adenosylmethionine sulfate tosylate 289 selegiline hcl 76 SABRIL 72 selenium sulfide 42 saccharin 172 selenomethionine 172 SAFYRAL 206 SELRX 42 SAIZEN 212 SELZENTRY 123 SAIZEN-SAIZENPREP 212 SEMPREX-D 101 SALACYN 253 SENSIPAR 232 SALAGEN 143 SENSORCAINE 289 SALEX 253 SENSORCAINE WITH DEXTROSE 289 salicylic acid 254 SENSORCAINE-EPINEPHRINE 263 salicylic acid/ammonium lactate/aloe vera 254 SENSORCAINE-MPF 289 SALIVAMAX 289 SENSORCAINE-MPF EPINEPHRINE 263 SALIVATERX 289 SEREVENT DISKUS 5 SALKERA 254 serine 289 sermorelin acetate 212 SINEMET 10-100 112 SERNIVO 249 SINEMET 25-100 112 SEROPHENE 174 SINEMET 25-250 112 SEROQUEL 119,120 SINEMET CR 112 SEROQUEL XR 120 SINGULAIR 47 SEROSTIM 212 SINOGRAFIN 162 serotonin hcl 289 sirolimus 229 sertraline hcl 79,80 SIRTURO 110 sesame seed extract 160 SITAVIG 137 SETLAKIN 206 SITZMARKS 162 sevelamer carbonate 216 SIVEXTRO 63 sevoflurane 187 SKELAXIN 244 SF 222 SKLICE 44 SF 5000 PLUS 222 sodium acetate trihydrate 172 SFROWASA 182 sodium aspartate monohydrate 172 SHAROBEL 206 sodium benzoate 290 SHOHL'S MODIFIED 168 sodium butyrate 290 shrimp extract 160 sodium cacodylate 172 SIGNIFOR 262 sodium caprylate 91 SIGNIFOR LAR 262 sodium chloride for inhalation 172 sildenafil citrate 243 sodium chloride/sodium bicarbonate/potassium SILENOR 82 chloride/peg 184 SILVADENE 42 sodium citrate 67,168 silver 42,289 sodium citrate dihydrate 169 silver nitrate 42,254 sodium desoxycholate 290 silver nitrate/potassium nitrate 254 sodium dichloroacetate 290 silver protein,mild 42 sodium hydroxide 254 silver sulfadiazine 42 sodium iodide 290 silver sulfadiazine/foam bandage 289 sodium metabisulfite 290 silver sulfate/foam bandage 289 sodium nitrite 299 silver sulfate/non-adherent bandage 289 sodium phenylbutyrate 169 silver/calcium alginate 289 sodium phosphate dibasic, heptahydrate 184 silver/foam bandage 289 sodium phosphate,dibasic 184 silver/hydrocolloid dressing 290 sodium polystyrene sulfonate 216 SILVRSTAT 290 sodium stearyl fumarate 290 SIMBRINZA 96 sodium succinate 290 SIMCOR 107 sodium sulfate 184 simethicone 183 sodium tetradecyl sulfate 148 SIMPONI 224 sodium thiosulfate 93 simvastatin 107 sodium/potassium/potassium citrate/sodium citrate/cit SINELEE 258 ac 169 SOJOURN 187 SSKI 91 SOLARAZE 259 SSS 10-5 42 SOLIQUA 100-33 86 STALEVO 100 111 SOLODYN 62 STALEVO 125 111 SOLTAMOX 290 STALEVO 150 111 SOLU-CORTEF 192 STALEVO 200 111 SOLU-MEDROL 192 STALEVO 50 111 SOMA 244 STALEVO 75 111 SOMAVERT 262 STAMARIL 131 SONAFINE 173 stanozolol 194 SONATA 140 stanozolol micronized 194 SOOLANTRA 259 STARLIX 87 sorbic acid 290 stavudine 125 sorbitol solution 184 STELARA 224 SORIATANE 259 STIMATE 99 SORILUX 259 STIOLTO RESPIMAT 66 SORINE 54 STIVARGA 290 sotalol hcl 54 STRATTERA 150 SOTYLIZE 54 STRAVIX 232 SOVALDI 189 strawberry extract 160 soybean extract 160 STRENSIQ 291 SP ANTIPRURITIC 290 streptomycin sulfate 57 SPECTRACEF 153 STRIANT 194 SPHERUSOL 160 STRIBILD 123 spinosad 44 STRIVERDI RESPIMAT 5 SPIRIVA 66 STROMECTOL 32 SPIRIVA RESPIMAT 66 SUBOXONE 23 spirometers and accessories 290 succimer 218 spironolactone 164 succinylcholine chloride 245 spironolactone, micronized 165 SUCRAID 291 spironolactone/hydrochlorothiazide 165 sucralfate 133 SPORANOX 92 sufentanil citrate 21 SPRAY AND STRETCH 251 SULAR 146 SPRINTEC 206 sulfacetamide 60 SPRITAM 72 sulfacetamide sodium 36,42,60 SPRIX 236 sulfacetamide sodium, monohydrate 60 SPRYCEL 290 sulfacetamide sodium/prednisolone sodium phosphate 36 SPS 216 sulfacetamide sodium/sulfur 43 squaric acid dibutylester 232 sulfacetamide sodium/sulfur/skin cleanser comb no.23 43 SRONYX 206 sulfacetamide sodium/sulfur/urea 43 SSD 42 SULFACLEANSE 8-4 43 sulfadiazine 60 SYMLINPEN 60 82 sulfadiazine sodium 60 SYNALAR 249 sulfamethoxazole 60 SYNALAR TS 249 sulfamethoxazole/trimethoprim 60 SYNALGOS-DC 127 SULFAMYLON 43 SYNAREL 210 sulfanilamide 60 SYNDROS 90 sulfapyridine 60 SYNERA 251 sulfasalazine 60 SYNERDERM 173 sulfathiazole 60 SYNJARDY 85 SULFATRIM 60 SYNJARDY XR 85 sulfisoxazole 60 SYNRIBO 291 sulfur 254 SYNTHROID 264 sulfur sublimed 254 SYPRINE 291 sulfurated potash 291 SYREX 172 sulindac 236 syring w-needl 0.5 ml,kit-tray 291 SUMADAN 43 SYRINGE AVITENE 99 sumatriptan 109 syringe cap, enfit,non-sterile 291 sumatriptan succinate 109 syringe with cannula, disposable, 3 ml 291 SUMAVEL DOSEPRO 109 syringe with cannula, disposable, 6 ml 291 SUMAXIN 43 syringe with cannula,disposable 12 ml 292 SUMAXIN TS 43 syringe with needle, insulin, safety, 0.3 ml 292 SUPERVITE 302 syringe with needle, insulin, safety, 0.5 ml 292 SUPERVITE EC 300 syringe with needle, insulin, safety, 1 ml 292 SUPRANE 187 syringe with needle,disposable 292 SUPRAX 153 syringe with needle,disposable, 0.5 ml 292 SUPRENZA ODT 25 syringe with needle,disposable, 1 ml 292 SUPREP 184 syringe with needle,disposable, 6 ml 292 SURMONTIL 82 syringe with needle,disposable,insulin 1 ml 292 SURVANTA 242 syringe with needle,insulin,0.3 ml 292 SUSTIVA 124 syringe with needle,insulin,0.5 ml 292 SUTENT 291 syringe, disposable irrigation, 70 ml 292 SWABFLUSH 291 syringe, disposable, 1 ml 292 SYEDA 206 syringe, disposable, 12 ml 292 SYLATRON 135 syringe, disposable, 3 ml 292 SYMAX 67 syringe, disposable, 5 ml 292 SYMAX DUOTAB 67 syringe, disposable, 6 ml 292 SYMAX-SL 67 syringe, enfit 1 ml, sterile 292 SYMAX-SR 67 syringe, enfit 12 ml, sterile 292 SYMBICORT 5 syringe, enfit 3 ml, sterile 292 SYMBYAX 80 syringe, enfit 35 ml, sterile 292 SYMLINPEN 120 82 syringe, enfit 6 ml, sterile 292 syringe, enfit 60 ml, sterile 293 TAZORAC 260 syringe, insulin u-500 with needle, disposable, 0.5 ml 293 TAZTIA XT 56 syringe,safety with needle,1 ml 293 TECFIDERA 227 syringe,safety with needle,10 ml 293 TECHNIVIE 126 syringe,safety with needle,12 ml 293 TEGRETOL 72 syringe,safety with needle,3 ml 293 TEGRETOL XR 72 syringe,safety with needle,5 ml 293 TEKAMLO 148 TEKTURNA 240 T TEKTURNA HCT 164 TABLOID 293 telmisartan 239 TACHOSIL 99 telmisartan/amlodipine besylate 148 TACLONEX 249 telmisartan/hydrochlorothiazide 166 tacrolimus 229,259 temazepam 141 tacrolimus anhydrous 229 TEMODAR 294 tacrolimus, micronized 229 TEMOVATE 250 TAFINLAR 293 TEMOVATE EMOLLIENT 250 TAGITOL 162 temozolomide 294 TAGRISSO 293 TENCON 12 talc 148 TENEX 150 TALTZ AUTOINJECTOR 259 TENIVAC 129 TALTZ AUTOINJECTOR (2 PACK) 259 TENORETIC 100 54 TALTZ AUTOINJECTOR (3 PACK) 259 TENORETIC 50 54 TALTZ SYRINGE 259 TENORMIN 55 TALTZ SYRINGE (2 PACK) 259 TERAZOL 3 94 TALTZ SYRINGE (3 PACK) 259 TERAZOL 7 94 TALWIN 23 terazosin hcl 6 TAMIFLU 135 terbinafine hcl 91 tamoxifen citrate 293 terbutaline sulfate 5 tamsulosin hcl 8 terconazole 94 TAPAZOLE 264 terpin hydrate 241 TARCEVA 293 TERRELL 187 TARGADOX 62 TERSI FOAM 43 TARGRETIN 260,294 TESSALON PERLE 241 TARINA FE 206 testosterone 194 TARKA 146 testosterone cypionate 194 TARON-CRYSTALS 169 testosterone cypionate, micronized 194 TASIGNA 294 testosterone enanthate 194 TASMAR 111 testosterone micronized 194 TAYTULLA 206 testosterone propionate 194 tazarotene 260 TESTRED 194 TAZICEF 153 tetanus and diphtheria toxoids, adult 129 tetanus,diphtheria toxoid ped/pf 129 THYROLAR-1/4 265 TETCAINE 180 THYROLAR-2 265 tetrabenazine 150 THYROLAR-3 265 tetracaine 294 tiagabine hcl 72 tetracaine hcl 180,294 TIAZAC 56 tetracaine hcl/pf 180,294 ticarcillin disodium/potassium clavulanate 237 tetracycline hcl 62 ticlopidine hcl 127 tetrahydrozoline hcl 181 TIGAN 90,91 TETRAVISC 180 TIKOSYN 55 TETRAVISC FORTE 180 TILIA FE 207 TETRIX 173 timolol maleate 55,96 TEXACORT 250 TIMOPTIC 97 TEXAVITE LQ 50 TIMOPTIC OCUDOSE 97 THALOMID 227 TIMOPTIC-XE 97 theanine 232 TINDAMAX 113 THEO-24 145 tinidazole 113 theobromine 294 tiopronin 232 THEOCHRON 146 TIROSINT 265 theophylline anhydrous 146 TISSEEL VHSD 99 THERACYS 131 titanium dioxide 294 THERAPEUTIC VITAMIN W-MINERALS 300 TIVICAY 123 THERMAZENE 43 TIVORBEX 219 thiabendazole 32 tizanidine hcl 244,245 thiamine hcl 302 TL FOLATE 50 thiamine TL-CERMIDE 294 hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 302 TOBI 57 thioguanine 294 TOBI PODHALER 57 THIOLA 232 TOBRADEX 36 thioridazine hcl 122 TOBRADEX ST 36 thiotepa 294 tobramycin 36,58 thiothixene 122 tobramycin in 0.225 % sodium chloride 58 threonine 294 tobramycin sulfate 58 THRIVITE 19 50 tobramycin/dexamethasone 36 THRIVITE RX 50 tobramycin/nebulizer 58 THROMBI-GEL 294 TOBREX 36 THROMBI-PAD 294 TOFRANIL 82 THROMBIN-JMI 99 TOFRANIL-PM 82 THYROID 264 TOLAK 260 thyroid,pork 265 tolazamide 88 THYROLAR-1 265 tolazoline hcl 300 THYROLAR-1/2 265 tolbutamide 88 tolcapone 111 TRI-LINYAH 207 tolmetin sodium 236 TRI-LO-ESTARYLLA 207 tolterodine tartrate 188 TRI-LO-MARZIA 207 TOPAMAX 72 TRI-LO-SPRINTEC 207 topical cream metered-dose device 294 TRI-LUMA 154 TOPICORT 250 TRI-NORINYL 207 topiramate 72 TRI-PREVIFEM 207 TOPROL XL 55 TRI-SPRINTEC 207 torsemide 163 TRI-TABS DHA 50 TOUJEO SOLOSTAR 86 TRI-VI-FLOR 222 TOVIAZ 188 triacetin 91 TOXICOLOGY SALIVA COLLECTION 236 triamcinolone 192 TRACLEER 243,294 triamcinolone acetonide 45,192,250 TRADJENTA 85 triamcinolone diacetate 192 tramadol hcl 21,22 triamcinolone diacetate, micronized 192 tramadol hcl/acetaminophen 12 triamcinolone hexacetonide 192 trandolapril 240 triamcinolone hexacetonide, micronized 192 trandolapril/verapamil hcl 146 triamterene 163 tranexamic acid 99 triamterene/hydrochlorothiazide 163 tranilast 47 TRIANEX 250 transcutaneous electrical nerve stimulators (tens units) 294 triazolam 142 TRANSDERM-SCOP 90 TRIBENZOR 166 transfer device, closed system 295 TRICARE PRENATAL 50 TRANXENE T-TAB 74 trichlormethiazide 164 tranylcypromine sulfate 76 trichloroacetic acid 260,295 TRAVATAN Z 98 TRICITRASOL 169 travoprost (benzalkonium) 98 TRICITRATES 169 trazodone hcl 80 triclosan 43 TREAGAN OTIC 295 TRICOR 105,106 TRECATOR 111 TRIDERM 250 TRETIN-X 252 TRIDESILON 250 tretinoin 252,295 TRIESENCE 45 tretinoin microspheres 252 triethanolamine 295 tretinoin/emollient base 252 TRIFERIC 50 TREXALL 224 trifluoperazine hcl 122 TREXIMET 109 trifluridine 37 TREZIX 12 TRIGLIDE 106 TRI FEMYNOR 207 trihexyphenidyl hcl 67 TRI-CHLOR 260 TRIKLO 103 TRI-ESTARYLLA 207 TRILEPTAL 72 TRI-LEGEST FE 207 TRILIPIX 106 trilostane 295 TYLENOL-CODEINE NO.3 12 TRILYTE WITH FLAVOR PACKETS 184 TYLENOL-CODEINE NO.4 12 trimeprazine tartrate 181 TYMLOS 211 trimethobenzamide hcl 91 TYPHIM VI 131 trimethoprim 33 tyrosine 170 trimethoprim, micronized 33 TYVASO 243 trimipramine maleate 82 TYVASO INSTITUTIONAL START KIT 243 TRINATE 50 TYVASO REFILL KIT 243 TRINESSA 207 TYVASO STARTER KIT 243 TRINESSA LO 207 TYZEKA 138 TRINTELLIX 80 TYZINE 181 trioxsalen 295 tripelennamine hcl 181 U TRIPLE DYE 93 ubidecarenone 232 triprolidine hcl 100 ubiquinol 232 TRIUMEQ 123 UCERIS 192 TRIVEEN-ONE 50 UDAMIN SP 301 TRIVEEN-U 301 ULESFIA 43 TRIVORA-28 207 ULORIC 220 TRIZIVIR 125 ULTANE 187 TROKENDI XR 72 ULTRACET 12 TROPAZONE 295 ULTRAFOAM 99 tropicamide 181 ULTRAM 22 trospium chloride 188 ULTRAM ER 22 TRULICITY 86 ULTRASAL-ER 254 TRUMENBA 131 ULTRAVATE 250 TRUSOPT 97 ULTRAVIST 162 TRUST NATAL DHA 301 UMECTA 254 TRUVADA 125 UMECTA PD 254 trypsin 295 UNASYN 237 tryptophan 140 undecylenic acid 93 TUBERSOL 162 unithiol 295 turmeric 232 UNITHROID 265 TUSSICAPS 102 UPTRAVI 243,244 TUSSIGON 67 UR N-C 33 TUSSIONEX 102 URAMAXIN 254 TUZISTRA XR 22 URAMAXIN GT 254 TWINRIX 131 URE-K 254 TWYNSTA 148 urea 254 TYBOST 232 URECHOLINE 143 TYKERB 295 URELLE 33 URETRON D-S 33 VALTREX 138 UREVAZ 254 VANATOL LQ 12 URIBEL 33 VANCOCIN HCL 62 URIMAR-T 33 vancomycin hcl 62 URIN D.S. 33 VANDAZOLE 39 urinary bag/catheter 295 VANIQA 260 urinary bag/catheterization tray 295 VANOS 250 URO-458 33 VANOXIDE-HC 250 URO-BLUE 33 VAQTA 131 URO-L 33 VARIBAR HONEY 162 UROCIT-K 169 VARIBAR NECTAR 162 UROGESIC-BLUE 33 VARIBAR PUDDING 162 UROPHEN MB 33 VARIBAR THIN HONEY 162 UROQID-ACID NO.2 33 VARIBAR THIN LIQUID 162 UROXATRAL 8 VARIVAX VACCINE 131 URSO 184 VARIZIG 129 URSO FORTE 184 VARUBI 90 ursodiol 184 VASCEPA 103 URYL 33 VASELINE WHITE PETROLEUM 173 USTELL 33 VASERETIC 167 UTA 33 vasopressin 212 UTIBRON NEOHALER 6 VASOTEC 240 UTIRA-C 33 VAXCHORA ACTIVE COMPONENT 131 UTOPIC 254 VAXCHORA BUFFER COMPONENT 295 UVADEX 154 VAXCHORA VACCINE 132 VECAMYL 215 V VECTICAL 260 V-C FORTE 301 vecuronium bromide 245 vacuum erection device system 295 VELIVET 208 VAGIFEM 178 VELPHORO 216 valacyclovir hcl 138 VELTASSA 216 VALCHLOR 260 VEMLIDY 138 VALCYTE 138 VENATAL COMPLETE DHA 295 valganciclovir hcl 138 VENCLEXTA 295 valine 295 VENCLEXTA STARTING PACK 296 VALIUM 74 VENELEX 260 valproic acid 72 venlafaxine hcl 77 valproic acid (as sodium salt) (valproate sodium) 72 VENTOLIN HFA 6 valsartan 239 VERAMYST 45 valsartan/hydrochlorothiazide 167 verapamil hcl 56,57 VALSTAR 295 VERDESO 250 VERDROCET 12 VIRACEPT 126 VEREGEN 260 VIRAMUNE 124 VERELAN 57 VIRAMUNE XR 124 VERELAN PM 57 VIRASAL 254 VERIPRED 20 192 VIRAZOLE 138 VERSACLOZ 120 VIREAD 125 VESICARE 188 VIROPTIC 37 VESTURA 208 VIRT-ADVANCE 51 VEXOL 45 VIRT-C DHA 51 VFEND 92 VIRT-CAPS 302 VIAGRA 299 VIRT-GARD 302 VIASPAN BELZER-UW 296 VIRT-NATE 51 VIBERZI 186 VIRT-NATE DHA 51 VIBRAMYCIN 62 VIRT-PHOS 250 NEUTRAL 168 VIC-FORTE 301 VIRT-PN 51 VICODIN 12 VIRT-PN DHA 51 VICODIN ES 12 VIRT-PN PLUS 51 VICODIN HP 12 VIRT-VITE 302 VICOPROFEN 22 VIRT-VITE PLUS 303 VICTOZA 2-PAK 86 VIRTRATE-2 169 VICTOZA 3-PAK 86 VIRTRATE-3 169 vidarabine 138 VIRTRATE-K 169 vidarabine monohydrate 138 VISCOAT 296 VIDEX 125 VISTARIL 140 VIDEX EC 125 VISTOGARD 218 VIEKIRA PAK 126 VIT 3 103 VIEKIRA XR 126 VITA-RESPA 303 VIENVA 208 VITAFOL GUMMIES 51 vigabatrin 72 vitamin a acetate 301 VIGAMOX 36 vitamin a palmitate 301 VIIBRYD 81 vitamin e (dl-alpha tocopheryl acetate) 303 VIMPAT 73 vitamin e acetate 304 VINATE DHA 50 vitamin e acid succinate 304 VINATE DHA RF 50 vitamin e mixed 304 VINATE GT 50 vitamin k2 304 VINATE II 50 VITASPIRE 296 VINATE ONE 50 VITATRUE 51 VINATE PN CARE 301 VITRASE 296 VINATE ULTRA 50 VITUZ 102 VINATE-M 301 VIVA DHA 51 VIORELE 208 VIVELLE-DOT 178 VIVITROL 151 VIVLODEX 236 X VIVOTIF 132 XADAGO 112 VIVOTIF BERNA 132 XALATAN 98 VOL-TAB RX 51 XALKORI 296 VOLTAREN 236 XANAX 142 VOLTAREN-XR 236 XANAX XR 142 VOLUMEN 162 xanthan gum 296 voriconazole 92 XARELTO 68 VOSEVI 296 XARTEMIS XR 12 VOSPIRE ER 6 XATMEP 224 VOTRIENT 296 XCLAIR 173 VP-CH-PNV 51 XELJANZ 224 VP-HEME OB 51 XELJANZ XR 224 VP-HEME ONE 51 XELODA 296 VP-PNV-DHA 51 XENAZINE 150 VP-VITE RX 303 XENICAL 186 VP-ZEL 232 XERESE 40 VRAYLAR 120 XERMELO 183 VUSION 94 XIFAXAN 64 VYFEMLA 208 XIIDRA 46 VYNATAL-FA 51 XODOL 10-300 13 VYTONE 43 XODOL 5-300 13 VYTORIN 104 XODOL 7.5-300 13 VYVANSE 28 XOLEGEL 94 XOPENEX 6 W XOPENEX CONCENTRATE 6 warfarin sodium 67 XTANDI 296 water for inj.,bacteriostatic 296 XULANE 208 water for XURIDEN 232 inj.,bacteriostatic/methylparaben/propylparaben 296 XYLOCAINE 53,180,297 water for injection,sterile 296 XYLOCAINE DENTAL-EPINEPHRINE 263 WELCHOL 82,83 XYLOCAINE WITH EPINEPHRINE 263 WELLBUTRIN 75 XYLOCAINE-MPF 53,297 WELLBUTRIN SR 75,76 XYLOCAINE-MPF WITH EPINEPHRINE 263 WELLBUTRIN XL 76 xylometazoline hcl 297 WERA 208 XYLON 10 22 WESTHROID 265 XYREM 150 white willow bark/salicin 296 XYZAL 101 WP THYROID 265 WYMZYA FE 208 ZIAC 55 Y ZIAGEN 125 YASMIN 28 208 zidovudine 125 YAZ 208 zileuton 47 YF-VAX 132 ZINACEF 152 yohimbine hcl 262,297 ZINBRYTA 227 YUVAFEM 178 zinc acetate dihydrate 297 zinc chloride 172 Z zinc oxide 260 zafirlukast 47 zinc picolinate 172 zaleplon 140 zinc sulfate 172 ZAMICET 13 zinc sulfate heptahydrate 172 ZANABIN 297 zinc undecylenate 93 ZANAFLEX 245 ZINGO 297 ZANTAC 132 ziprasidone hcl 120 ZARAH 208 ZIPSOR 236 ZARONTIN 74 ZIRGAN 37 ZARXIO 145 ZITHRANOL 255 ZAVESCA 232 ZITHRANOL-RR 255 zeaxanthin 297 ZITHROMAX 216,217 ZEBETA 55 ZITHROMAX TRI-PAK 217 ZEBUTAL 13 ZMAX 217 ZEGERID 134 ZOCOR 107 ZEJULA 297 ZODEX 192,297 ZELAPAR 76 ZOFRAN 89 ZELBORAF 297 ZOFRAN ODT 89 ZEMBRACE SYMTOUCH 109 ZOLATE 303 ZEMPLAR 303 ZOLINZA 297 ZENATANE 260 zolmitriptan 109 ZENCHENT 208 ZOLOFT 80 ZENCHENT FE 208 zolpidem tartrate 140 ZENCIA 43 ZOLPIMIST 140 ZENPEP 184 ZOMACTON 212 ZENZEDI 28 ZOMIG 110 ZEOSA 209 ZOMIG ZMT 110 ZEPATIER 189 ZONALON 251 ZERIT 125 ZONATUSS 241 ZESTORETIC 167 ZONEGRAN 73 ZESTRIL 240 zonisamide 73 ZETIA 104 ZONTIVITY 127 ZETONNA 45 ZORBTIVE 212 ZORTRESS 229 ZOSTAVAX 132 ZOTEX-C 297 ZOVIA 1-35E 209 ZOVIA 1-50E 209 ZOVIRAX 40,138 ZUBSOLV 24 ZUPLENZ 89 ZURAMPIC 173 ZUTRIPRO 22 ZYBAN 76 ZYCLARA 260 ZYDELIG 297 ZYFLO 47 ZYFLO CR 47 ZYKADIA 297 ZYLET 36 ZYLOPRIM 220 ZYMAXID 36 ZYPREXA 120,121 ZYPREXA RELPREVV 121 ZYPREXA ZYDIS 121 ZYTIGA 298 ZYVOX 63 NOTICE ABOUT NON-DISCRIMINATION

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