SmithRx Standard Formulary

Transcription

1 mithrx tandard Formulary Understanding the costs of your prescriptions Welcome to the mithrx tandard Formulary. The tandard Formulary is a list of drugs that your doctor may prescribe for you and includes information related to the coverage and cost of these drugs. This list may change over time, so please refer to plan documents or formulary update documents for detailed information about your drug benefit coverage. The drugs included on the tandard Formulary are organized by categories depending on the type of medical conditions that they are used to treat. Medications are listed as Tier 1 Generic, Tier 2 preferred Brand, and Tier 3 non-preferred Brand. Medications listed as pecialty Drugs are used to treat complex medical conditions that require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may apply. Please refer to your plan document for detailed information about your Tiers and Copay structures. Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug s safety and efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects appropriate Tier placement based on the drugs safety, efficacy and cost- effectiveness. Please note all drugs on the mithrx tandard Formulary are subjected to periodic review and amendment. Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their pharmacy benefit plan. When clinically appropriate, please consider talking to your doctor about choosing a generic product. For the most up-to-date tandard Formulary, visit our website at If you have any questions about the mithrx tandard formulary please call our dedicated customer service team at

2 TIER DECRIPTION 1 Generics 2 Preferred Brands 3 Non-Preferred Brands TYPE T Quantity Limit Prior Authorization tep Therapy DECRIPTION There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. Your provider is required to get prior authorization before you fill 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 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.. AL Age Limit This prescription drug may only be covered if you meet the minimum or maximum age limit. C Custom This drug has unique restrictions. pecialty Drug pecialty drugs are high-cost drugs used to treat complex or rare conditions. ome examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. P Preferred pecialty Preferred pecialty. GE 2 LAT UPDATED 04/2017

3 ANTI-INFECTIVE AGENT PRODUCT DECRIPTION TIER LIMIT & RETRICTION ALLERGENIC EXTRACT (THERAPEUTIC) GRATEK 3 ORALAIR ( IR CHILD AMPL, 300 IR ADULT AMPLE KT, 300 IR TARTER CK, 300 IR UBLINGUAL TAB) 3 ORALAIR 100 IR TARTER CK 3 RAGWITEK 3 ANTHELMINTIC ALBENZA 3 4 / day BILTRICIDE 3 ivermectin 1 TROMECTOL 3 ANTITOXIN AND IMMUNE GLOBULIN BIVIGAM 3 CARIMUNE NF NANOFILTERED 3 CUVITRU 3 CYTOGAM 2.5 GM/50 ML VIAL 3 DIGIFAB 3 FLEBOGAMMA DIF 3 GE 3 LAT UPDATED 04/2017

4 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GAMATAN -D VIAL 3 GAMMAGARD LIQUID 3 GAMMAGARD -D (2.5 GM VL W/T, 5 G (IGA<1) OLN, 5 GM VL W/ET, 10 G (IGA<1) OL, 10 GM VL W/T) 3 GAMMAKED 3 GAMMAPLEX (5 GRAM/100 ML VIAL, 5% VIAL, 10 GRAM/200 ML VIAL, 20 GRAM/400 ML VIAL) GAMMAPLEX (5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL) 3 3 GAMUNEX 3 GAMUNEX-C 3 HEGAM B 3 HIZENTRA 3 HYPERHEP B -D 3 HYPERRAB -D 3 HYPERRHO -D 3 HYPERTET -D 3 HYQVIA 3 GE 4 LAT UPDATED 04/2017

5 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HYQVIA IG COMPONENT 3 IMOGAM RABIE-HT 3 MICRHOGAM ULTRA-FILTERED PLU 3 NABI-HB 3 OCTAGAM 3 PRIVIGEN 3 RHOGAM ULTRA-FILTERED PLU 3 RHOPHYLAC 3 VARIZIG 125 UNIT VIAL 2 VARIZIG 125 UNIT/1.2 ML VIAL 3 WINRHO DF 3 TOXOID ADACEL TDAP 2 BOOTRIX TDAP 2 DAPTACEL DTAP 2 diphtheria-tetanus toxoids-ped 1 INFANRIX DTAP 2 PEDIARIX 2 TENIVAC 2 tetanus diphtheria toxoids 1 VACCINE ACTHIB VACCINE WITH DILUENT 2 GE 5 LAT UPDATED 04/2017

6 PRODUCT DECRIPTION TIER LIMIT & RETRICTION AFLURIA ( YRINGE, VIAL) AFLURIA QUAD ( YRINGE, VIAL) 2 2 bcg (tice strain) 3 BEXERO 2 CERVARIX 2 ENGERIX-B ADULT 2 ENGERIX-B PEDIATRIC-ADOLECENT 2 EZ FLU (FLUZON QUAD PED) 2 EZ FLU (AFLURIA) 2 EZ FLU (FLUVIRIN) 2 FLUAD FLUARIX QUAD FLUBLOK FLUCELVAX QUAD FLULAVAL QUAD ( YR, VIAL) FLUVIRIN ( YRINGE, VIAL) 2 2 FLUZONE HIGH-DOE FLUZONE INTRADERM QUAD FLUZONE QUAD FLUZONE QUAD PEDI GARDAIL 2 GARDAIL 9 2 HAVRIX 2 HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIE VACCINE 2 GE 6 LAT UPDATED 04/2017

7 PRODUCT DECRIPTION TIER LIMIT & RETRICTION IPOL 2 IXIARO 2 KINRIX 2 M-M-R II VACCINE 2 MENACTRA 2 MENHIBRIX 2 MENOMUNE-A-C-Y-W MENVEO A-C-Y-W-135-DIP 2 MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2 PNEUMOVAX 23 2 PREVNAR 13 2 PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB 2 ROTARIX 2 ROTATEQ 2 THERACY 3 TRUMENBA 3 TWINRIX 2 TYPHIM VI 2 VAQTA 2 GE 7 LAT UPDATED 04/2017

8 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VARIVAX VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2 YF-VAX 2 ZOTAVAX 2 ANTIHITAMINE DRUG AMMONIA DETOXICANT CONTULOE 1 KRITALOE 3 lactulose 1 ANTIVERT 3 CENTERGY 1 CENTERGY DM 1 ENDACOF-C 1 hydrocod-cpm-pseudoephedrine 1 hydrocodone-chlorpheniramne er 1 AL AL 4 / day At least 18 yrs old 10 / day At least 6 yrs old hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 10 mg tablet, 25 mg/ml vial, hcl 25 mg tablet, 50 mg/ml vial, hcl 50 mg tablet, 100 mg/2 ml vial, 500 mg/10 ml vial) 1 AL At least 2 yrs old hydroxyzine pam 100 mg cap 1 hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrs old meclizine hcl 1 PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML AMPUL, 50 MG/ML VIAL) 3 AL At least 2 yrs old GE 8 LAT UPDATED 04/2017

9 PRODUCT DECRIPTION TIER LIMIT & RETRICTION promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg suppos, 12.5 mg tablet, 25 mg suppository, 25 mg tablet, 25 mg/ml ampul, 25 mg/ml syringe, 25 mg/ml vial, 50 mg suppository, 50 mg tablet, 50 mg/ml ampul, 50 mg/ml vial) 1 AL At least 2 yrs old promethazine vc 1 promethazine vc-codeine 1 AL 3 / day At least 6 yrs old PROMETHEGAN 1 AL At least 2 yrs old RE A.R. 3 TUICAP 3 TUIONEX 3 AL AL 6 / day At least 6 yrs old 10 / day At least 6 yrs old VITARIL 3 AL At least 2 yrs old VITUZ 3 ZUTRIPRO 3 DIURETIC AL AL 4 / day At least 6 yrs old 4 / day At least 18 yrs old ACCURETIC 3 acetazolamide 1 acetazolamide sodium 1 ALDACTAZIDE 3 ALDACTONE 3 amiloride hcl 1 amiloride-hydrochlorothiazide 1 amlodipine-valsartan-hctz 1 GE 9 LAT UPDATED 04/2017

10 PRODUCT DECRIPTION TIER LIMIT & RETRICTION AMTURNIDE 3 T ATACAND HCT ( MG TAB, MG TABLET) 3 ATACAND HCT MG TAB 3 2 / day atenolol-chlorthalidone 1 AVALIDE MG TABLET 3 2 / day AVALIDE MG TABLET 3 benazepril-hydrochlorothiazide 1 BENICAR HCT 3 bisoprolol-hydrochlorothiazide 1 candesartan-hctz mg tb 1 2 / day candesartan-hydrochlorothiazid ( mg tb, mg tab) 1 captopril-hydrochlorothiazide 1 2 / day CLORPRE 3 CORZIDE 3 DIAMOX EQUEL 3 DIOVAN HCT 3 DUTOPROL 3 2 / day DYAZIDE 3 DYRENIUM 3 EDARBYCLOR 3 T enalapril-hctz mg tablet 1 2 / day enalapril-hctz mg tab 1 GE 10 LAT UPDATED 04/2017

11 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EXFORGE HCT 3 fosinopril-hydrochlorothiazide 1 HYZAAR ( TABLET, TABLET) 3 HYZAAR TABLET 3 2 / day irbesartan-hctz mg tb 1 2 / day irbesartan-hctz mg tb 1 lisinopril-hydrochlorothiazide 1 2 / day LOPREOR HCT 3 losartan-hctz mg tab 1 2 / day losartan-hydrochlorothiazide ( mg tab, mg tab) 1 LOTENIN HCT 3 mannitol 1 MAXZIDE 3 MAXZIDE-25 MG 3 methyldopa-hydrochlorothiazide 1 metoprolol-hydrochlorothiazide 1 MICARDI HCT ( MG TABLET, MG TABLET) 3 MICARDI HCT MG TABLET 3 2 / day moexipril-hydrochlorothiazide 1 nadolol-bendroflumethiazide 1 olmesartan-amlodipine-hctz 1 olmesartan-hydrochlorothiazide 1 OMITROL 1 propranolol-hydrochlorothiazid 1 GE 11 LAT UPDATED 04/2017

12 PRODUCT DECRIPTION TIER LIMIT & RETRICTION quinapril-hydrochlorothiazide 1 spironolactone 1 spironolactone-hctz 1 TEKTURNA HCT ( MG TAB, MG TABLET, MG TAB, MG TABLET) 3 T telmisartan-hctz mg tb 1 2 / day telmisartan-hydrochlorothiazid ( mg tb, mg tab) 1 TENORETIC TENORETIC 50 3 triamterene-hydrochlorothiazid 1 TRIBENZOR 3 valsartan-hydrochlorothiazide 1 VAERETIC 3 2 / day ZETORETIC 3 2 / day ZIAC 3 FIRT GENERATION ANTIHITAMINE ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old carbinoxamine maleate (4 mg/5 ml liquid, maleate 4 mg tab) clemastine fumarate (0.5 mg/5 ml syrup, fum 2.68 mg tab) cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml syrp) 1 AL At least 2 yrs old 1 AL At least 2 yrs old 1 AL At least 2 yrs old dimenhydrinate 1 diphenhydramine hcl 1 KARBINAL ER 3 AL At least 2 yrs old GE 12 LAT UPDATED 04/2017

13 PRODUCT DECRIPTION TIER LIMIT & RETRICTION probenecid 1 4 / day probenecid-colchicine 1 2 / day ZURAMPIC 3 ION-REMOVING AGENT RADIOGARDAE 3 IRRIGATING OLUTION REECTIOL 3 REPLACEMENT PRERATION AL At least 18 yrs old ATABEX EC 3 GL Female BAL-CARE DHA 3 GL Female CALCIUM PNV 3 FOLBECAL 3 GL Female FOLINATAL PLU B 3 GL Female INATAL ADVANCE 3 GL Female INATAL ULTRA 3 GL Female levomefolate dha 3 GL Female MACNATAL CN DHA 3 GL Female MARNATAL-F 3 GL Female MYNATAL ADVANCE 3 GL Female MYNATAL CAPULE 3 GL Female MYNATAL PLU 3 GL Female MYNATAL-Z 3 GL Female GE 13 LAT UPDATED 04/2017

14 PRODUCT DECRIPTION TIER LIMIT & RETRICTION NATELLE ONE 3 GL Female NETAB 3 GL Female NETAB DHA 3 GL Female NEWGEN 3 NIVA-PLU 3 O-CAL FA 3 GL Female O-CAL PRENATAL 3 GL Female OB COMPLETE ONE 3 GL Female OB COMPLETE PREMIER 3 GL Female PNV GL Female PNV OB+DHA 3 GL Female PNV-DHA + DOCUATE 3 GL Female PNV-OMEGA 3 GL Female PR NATAL GL Female PR NATAL 400 EC 3 GL Female PR NATAL GL Female PR NATAL 430 EC 3 GL Female PRENAIANCE 3 GL Female PRENAIANCE 90 DHA 3 GL Female PRENAIANCE DHA 3 GL Female PRENAIANCE NEXT 3 GL Female PRENAIANCE NEXT-B 3 GL Female PRENAIANCE PLU 3 GL Female GE 14 LAT UPDATED 04/2017

15 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PRENAIANCE PROMIE 3 GL Female PRENATAB FA 3 GL Female PRENATAB RX 3 GL Female prenatal low iron 3 GL Female prenatal plus (iron tablet, pnv multivit tab, tablet) 3 GL Female prenatal plus multivitamin tab 3 prenatal vitamin plus low iron 3 GL Female PRENATE CHEWABLE 3 GL Female PREPLU 3 GL Female PRETAB 3 GL Female TARON-BC 3 GL Female THRIVITE RX 3 TL-ELECT 3 GL Female TRI-TAB DHA 3 GL Female TRIADVANCE 3 GL Female TRINATAL RX 1 3 GL Female TRINATE 3 GL Female TRIVEEN-DUO DHA 3 GL Female TRIVEEN-ONE 3 GL Female TRIVEEN-PRX RNF 3 GL Female ULTIMATECARE ONE 3 GL Female ULTIMATECARE ONE NF 3 GL Female VEMAVITE-PRX 2 3 GL Female GE 15 LAT UPDATED 04/2017

16 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VENA-BAL DHA 3 GL Female VENATAL COMPLETE DHA 3 GL Female VINACAL 3 GL Female VINATE DHA 3 GL Female VINATE II 3 GL Female VINATE ONE 3 GL Female VINATE ULTRA 3 GL Female VIRT NATE 3 VIRT-ADVANCE 3 GL Female VIRT-BAL DHA 3 GL Female VIRT-BAL DHA PLU 3 GL Female VIRT-CARE ONE 3 GL Female VIRT-NATE 3 GL Female VIRT-PN PLU 3 GL Female VIRT-ELECT 3 GL Female VIRTPREX 3 VITAFOL GUMMIE 3 GL Female VITAFOL-OB 3 GL Female VITAFOL-OB+DHA 3 GL Female VOL-NATE 3 GL Female VOL-PLU 3 GL Female VOL-TAB RX 3 GL Female VP-GGR-B6 3 GL Female GE 16 LAT UPDATED 04/2017

17 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VYNATAL-FA 1 GL Female ZATEAN-CH 3 GL Female ZATEAN-PN PLU 3 GL Female zinc chloride 1 zinc sulfate 1 ZINGIBER 3 GL Female ECOND GENERATION ANTIHITAMINE cetirizine hcl 1 10 / day CLARINEX 0.5 MG/ML (2.5 MG/5) 3 10 / day CLARINEX 5 MG TABLET 3 CLARINEX-D 12 HOUR 3 2 / day desloratadine 1 levocetirizine 2.5 mg/5 ml sol 1 30 / day levocetirizine 5 mg tablet 1 EMPREX-D 3 4 / day XYZAL 2.5 MG/5 ML OLUTION 3 30 / day XYZAL 5 MG TABLET 3 ANTINEOPLATIC AGENT ABRAXANE 3 ADCETRI 3 ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG VIAL, 20 MG/10 ML VIAL, 50 MG/25 ML VIAL) ADRIAMYCIN (2 MG/ML VIAL, 10 MG VIAL, 50 MG VIAL, 200 MG/100 ML VIAL) 3 1 GE 17 LAT UPDATED 04/2017

18 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ADRUCIL 1 AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 3 AFINITOR 2.5 MG TABLET 3 AFINITOR DIPERZ 3 ALECENA 3 ALIMTA 3 ALKERAN 2 MG TABLET 3 AL 2 / day 8 / day At least 18 yrs old ALKERAN 50 MG VIAL 3 anastrozole 1 ARIMIDEX 3 AROMAIN 3 ARRANON 3 ARZERRA 3 AVATIN 3 azacitidine 1 GE 18 LAT UPDATED 04/2017

19 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BELEODAQ 3 bexarotene 1 BEXXAR (14 MG/ML DOIMETRIC, 14 MG/ML THERAPEUTIC, 131 IODINE DOIMETRIC, 131 IODINE THERAPEUTIC) 3 bicalutamide 1 BICNU 3 BLEO 15K 1 bleomycin sulfate 1 BLINCYTO 3 BOULIF 100 MG TABLET 3 BOULIF 500 MG TABLET 3 P P 4 / day busulfan 3 BUULFEX 60 MG/10 ML VIAL 3 CABOMETYX 20 MG TABLET 3 CABOMETYX 40 MG TABLET 3 4 / day 2 / day GE 19 LAT UPDATED 04/2017

20 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CABOMETYX 60 MG TABLET 3 CAMTH / day CAMPTOAR 3 capecitabine 1 CAPRELA 100 MG TABLET 3 CAPRELA 300 MG TABLET 3 2 / day carboplatin (50 mg/5 ml vial, 150 mg vial, 150 mg/15 ml vial, 450 mg/45 ml vial, 600 mg/60 ml vial) 1 CAODEX 3 CERUBIDINE 3 cisplatin (50 mg/50 ml vial, 100 mg/100 ml vial, 200 mg/200 ml vial) 1 cladribine 1 CLOLAR 3 COMETRIQ 100 MG DAILY-DOE PK 3 COMETRIQ 140 MG DAILY-DOE PK 3 2 / day 4 / day GE 20 LAT UPDATED 04/2017

21 PRODUCT DECRIPTION TIER LIMIT & RETRICTION COMETRIQ 60 MG DAILY-DOE CK 3 3 / day COMEGEN 3 COTELLIC 3 cyclophosphamide (1 gm vial, 2 gm vial, 500 mg vial) 1 AL 2.5 / day At least 18 yrs old cyclophosphamide (25 mg capsule, 25 mg tab, 50 mg capsule, 50 mg tablet) 1 CYRAMZA 3 cytarabine (1 gm vial, 2 g/20 ml vial, 20 mg/ml vial, 100 mg vial, 100 mg/5 ml vial, 500 mg vial, 1000 mg/50 ml vial) 1 dacarbazine 1 DACOGEN 3 dactinomycin 1 DARZALEX 3 daunorubicin hcl (20 mg vial, 20 mg/4 ml vial, 50 mg/10 ml vial) 1 DAUNOXOME 50 MG (2 MG/ML) VIAL 3 decitabine 1 DEPOCYT 3 GE 21 LAT UPDATED 04/2017

22 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DOCEFREZ 3 docetaxel 1 DOXIL 3 doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 20 mg/10 ml vial, 50 mg vial, 50 mg/25 ml vial, 150 mg/75 ml vial, 200 mg/100 ml vial) 1 doxorubicin hcl liposome 1 DROXIA 3 ELIGARD 3 ELLENCE 3 ELOXATIN (50 MG/10 ML VIAL, 100 MG/20 ML VIAL) 3 ELR 3 EMCYT 3 epirubicin hcl (50 mg/25 ml vial, hcl 50 mg vial, 200 mg/100 ml vial, hcl 200 mg vial) 1 ERBITUX 3 ERIVEDGE 3 ERWINAZE 3 ETOPOPHO 3 etoposide (50 mg capsule, 100 mg/5 ml vial, 500 mg/25 ml vial, 1,000 mg/50 ml vial) 1 EVOMELA 3 exemestane 1 GE 22 LAT UPDATED 04/2017

23 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FARETON 2 FARYDAK 3 FALODEX 3 FEMARA 3 FIRMAGON (2 X 120 MG KIT, 2 X 120 MG VIAL, 80 MG KIT, 80 MG VIAL) 3 FIRMAGON 120 MG VIAL 3 floxuridine 1 fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) 1 fluorouracil (2.5 gm/50 ml btl, 2.5 gm/50 ml vial, 5 gm/100 ml btl, 5 gm/100 ml vial, 500 mg/10 ml vial, 1,000 mg/20 ml vl, 2,500 mg/50 ml vl, 5,000 mg/100 ml) 1 flutamide 1 FOLOTYN 3 GAZYVA 3 gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram vial, 2 gram/52.6 ml vl, hcl 2 gram vial, 200 mg/5.26 ml vl, hcl 200 mg vial) 1 GEMZAR 3 GILOTRIF 3 GLEEVEC 100 MG TABLET 3 P 8 / day GE 23 LAT UPDATED 04/2017

24 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GLEEVEC 400 MG TABLET 3 GLEOTINE 3 GLIADEL 3 HALAVEN 3 HERCEPTIN 3 P 2 / day HEXALEN 3 HYCAMTIN (0.25 MG CAPULE, 1 MG CAPULE) 3 HYCAMTIN 4 MG VIAL 3 HYDREA 3 hydroxyurea 1 IBRANCE 3 ICLUIG 15 MG TABLET 3 ICLUIG 45 MG TABLET 3 P 2 / day IDAMYCIN PF 3 idarubicin hcl (5 mg/5 ml vial, 10 mg/10 ml vl, 20 mg/20 ml vl) 1 GE 24 LAT UPDATED 04/2017

25 PRODUCT DECRIPTION TIER LIMIT & RETRICTION IFEX 3 ifosfamide (1 gm vial, 1 gm/20 ml vial, 3 gm vial, 3 gm/ 60 ml vial) 1 ifosfamide-mesna 1 IMBRUVICA 3 INLYTA 3 IREA 3 P 4 / day 4 / day specialty irinotecan hcl 1 ITODAX 10 MG KIT 3 ITODAX 10 MG VIAL 3 IXEMPRA 3 JAKAFI 3 JEVTANA 3 KADCYLA 3 2 / day GE 25 LAT UPDATED 04/2017

26 PRODUCT DECRIPTION TIER LIMIT & RETRICTION KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL) 3 KYPROLI 30 MG VIAL 3 KYPROLI 60 MG VIAL 3 LENVIMA (10 MG DAILY, 14 MG DAILY, 20 MG DAILY, 24 MG DAILY) 3 3 / 1 days LENVIMA (8 MG DAILY, 18 MG DAILY) 3 letrozole 1 LEUKERAN 3 leuprolide 2wk 14 mg/2.8 ml vl 1 3 / day leuprolide acetate (1 mg/0.2 ml vial, 2wk 1 mg/0.2 ml kit, 2wk 14 mg/2.8 ml kt) 1 LIPODOX 1 LIPODOX 50 1 lomustine 1 LONURF 15 MG-6.14 MG TABLET 3 LONURF 20 MG-8.19 MG TABLET / dayspecialty 3 / dayspecialty GE 26 LAT UPDATED 04/2017

27 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LUNETA CK 3 LUPRON DEPOT 3 LUPRON DEPOT (LUNETA) 3 LUPRON DEPOT-PED 3 LYNRZA 3 P P LYODREN 3 MARQIBO 3 MATULANE 3 MEGACE 3 MEGACE E 3 GL Female megestrol acetate (20 mg tablet, 40 mg tablet, acet 40 mg/ml susp, acet 400 mg/10 ml, 625 mg/5 ml susp) 1 MEKINIT 0.5 MG TABLET 3 MEKINIT 2 MG TABLET 3 4 / day melphalan hcl 1 GE 27 LAT UPDATED 04/2017

28 PRODUCT DECRIPTION TIER LIMIT & RETRICTION mercaptopurine 1 methotrexate (1 gm vial, 2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10 ml vial) 1 methotrexate sodium 1 mitomycin 1 mitoxantrone hcl 1 MUTARGEN 3 MYLERAN 3 NAVELBINE 3 NEXAVAR 3 NILANDRON 3 nilutamide 3 NINLARO 3 AL 4 / day / day At least 18 yrs old NIPENT 3 ODOMZO 3 specialty ONCAR 3 GE 28 LAT UPDATED 04/2017

29 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OPDIVO 3 OTREXUP / day oxaliplatin (50 mg vial, 50 mg/10 ml vial, 100 mg vial, 100 mg/20 ml vial) 1 paclitaxel 1 pentostatin 1 PERJETA 3 PHOTOFRIN 3 POMALYT 3 PROLEUKIN 3 PURINETHOL 3 PURIXAN 3 RAUVO 3 REVLIMID 3 RHEUMATREX 3 RITUXAN / day GE 29 LAT UPDATED 04/2017

30 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OLTAMOX 3 PRYCEL (100 MG TABLET, 140 MG TABLET) 3 PRYCEL (70 MG TABLET, 80 MG TABLET) 3 PRYCEL 20 MG TABLET 3 PRYCEL 50 MG TABLET 3 TIVARGA 3 UPPRELIN LA 3 UTENT 12.5 MG CAPULE 3 UTENT 25 MG CAPULE 3 UTENT 37.5 MG CAPULE 3 P P P 2 / day 9 / day 3 / day 2 / days 7 / day 3 / day s GE 30 LAT UPDATED 04/2017

31 PRODUCT DECRIPTION TIER LIMIT & RETRICTION UTENT 50 MG CAPULE 3 YLVANT 3 YNRIBO 3 TABLOID 3 TAFINLAR 50 MG CAPULE 3 TAFINLAR 75 MG CAPULE 3 TAGRIO 3 tamoxifen citrate 1 TARCEVA (100 MG TABLET, 150 MG TABLET) 3 TARCEVA 25 MG TABLET 3 TARGRETIN (75 MG CAPULE, 75 MG OFTGEL) 3 P AL P 6 / day 4 / day At least 18 yrs old 6 / day GE 31 LAT UPDATED 04/2017

32 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TAIGNA 3 P 4 / day TAXOTERE (20 MG/ML VIAL, 80 MG/4 ML VIAL) 3 TECENTRIQ 3 TEMODAR (5 MG CAPULE, 20 MG CAPULE, 100 MG CAPULE, 140 MG CAPULE, 180 MG CAPULE, 250 MG CAPULE) 3 TEMODAR 100 MG VIAL 3 temozolomide 1 P teniposide 1 thiotepa 1 TOPOAR 1 topotecan hcl (4 mg vial, 4 mg/4 ml vial) 1 TORIEL / day TREANDA (25 MG VIAL, 45 MG/0.5 ML VIAL, 100 MG VIAL, 180 MG/2 ML VIAL) 3 TRELTAR 3 tretinoin 10 mg capsule 1 90 / 365 daysspecialty GE 32 LAT UPDATED 04/2017

33 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TREXALL 2 TRIENOX 3 TYKERB 3 P 6 / day VALTAR 3 VANTA 3 VECTIBIX 3 VELCADE 3 VENCLEXTA 3 VENCLEXTA TARTING CK 3 4 / day 1.5 / day VIDAZA 3 vinblastine sulfate (1 mg/ml vial, sulf 10 mg vial) 1 VINCAAR PF 1 vincristine sulfate 1 vinorelbine tartrate 1 VOTRIENT 3 4 / day GE 33 LAT UPDATED 04/2017

34 PRODUCT DECRIPTION TIER LIMIT & RETRICTION XALKORI 3 2 / day XELODA 3 XTANDI 3 YERVOY 3 ZALTRAP 3 4 / days ZANOAR 3 ZELBORAF 3 8 / day ZEVALIN 3 ZOLADEX 3 ZOLINZA 3 ZYDELIG 3 ZYKADIA 3 P AL 4 / day 2 / days 5 / day At least 18 yrs old GE 34 LAT UPDATED 04/2017

35 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ZYTIGA 3 AUTONOMIC DRUG ANTICHOLINERGIC AGENT P 4 / days ANORO ELLIPTA 2 2 / day ATROVENT HFA / day BENTYL (10 MG CAPULE, 10 MG/ML AMPUL, 20 MG TABLET) benztropine mesylate (mes 0.5 mg tab, mes 1 mg tablet, 2 mg/2 ml ampule, 2 mg/2 ml vial, mes 2 mg tablet) 3 1 BEVEPI AEROPHERE 3 CANTIL 3 chlordiazepoxide-clidinium 1 COGENTIN 3 T / day COMBIVENT REPIMAT / day CUVPOA 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg tablet, 20 mg/2 ml vial) diphenoxylate-atropine (diphenoxylat-atrop /5, diphenoxylate-atrop ) 1 1 DUODOTE 3 glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1 mg tablet, 1 mg/5 ml vial, 2 mg tablet, 4 mg/20 ml vial) glycopyrrolate (0.4 mg/2 ml syr, 0.6 mg/3 ml syr, 1 mg/5 ml syrng) 1 1 glycopyrrolate-sterile water 1 GE 35 LAT UPDATED 04/2017

36 PRODUCT DECRIPTION TIER LIMIT & RETRICTION hydrocodone bt-homatropine mbr 1 hydrocodone-homatropine mbr 1 HYDROMET 1 AL AL AL 6 / day At least 6 yrs old 30 / day At least 2 yrs old 30 / day At least 2 yrs old INCRUE ELLIPTA 2 ipratropium br 0.02% soln / day ipratropium-albuterol 1 LIBRAX 3 LOMOTIL 3 propantheline bromide 1 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG TABLET, 1 MG/5 ML VIAL, 4 MG/20 ML VIAL) 3 ROBINUL FORTE 3 EEBRI NEOHALER 3 AL 2 / day At least 18 yrs old PIRIVA 2 PIRIVA REPIMAT 2 TIOLTO REPIMAT / day trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg tablet) 1 TUDORZA PREAIR 3 TUIGON 1 AL 0.04 / day 6 / day At least 6 yrs old GE 36 LAT UPDATED 04/2017

37 PRODUCT DECRIPTION TIER LIMIT & RETRICTION UTIBRON NEOHALER 3 AUTONOMIC DRUG, MICELLANEOU T AL At least 18 yrs old CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET) 3 2 / day CHANTIX TARTING MONTH BOX 3 NICOTROL 3 20 / day NICOTROL N 3 20 / day RAYMTHOMIMETIC (CHOLINERGIC AGENT) ARICEPT (5 MG TABLET, 10 MG TABLET) 3 AL At least 40 yrs old ARICEPT 23 MG TABLET 3 bethanechol chloride 1 BLOXIVERZ 3 cevimeline hcl 1 T AL At least 40 yrs old donepezil hcl 1 AL At least 40 yrs old donepezil hcl odt 1 AL At least 40 yrs old EVOXAC 3 EXELON (1.5 MG CAPULE, 3 MG CAPULE, 4.5 MG CAPULE, 4.6 MG/24HR TCH, 6 MG CAPULE, 9.5 MG/24HR TCH, 13.3 MG/24HR TCH) 3 AL At least 40 yrs old galantamine er 1 galantamine hbr 1 galantamine hydrobromide 1 guanidine hcl 1 METINON (60 MG TABLET, 180 MG TIMEN) 3 GE 37 LAT UPDATED 04/2017

38 PRODUCT DECRIPTION TIER LIMIT & RETRICTION METINON 60 MG/5 ML YRUP 2 NAMZARIC 3 T neostigmine methylsulfate 1 physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine bromide 1 pyridostigmine bromide er 1 RAZADYNE 3 RAZADYNE ER 3 REGONOL 3 rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr ptch) 1 AL At least 40 yrs old ALAGEN 3 URECHOLINE 3 KELETAL MUCLE RELAXANT AMRIX 3 baclofen 1 BOTOX 3 BOTOX COMETIC 3 carisoprodol 1 carisoprodol compound 1 carisoprodol compound-codeine 1 2 carisoprodol-aspirin 1 carisoprodol-aspirin-codeine 1 2 GE 38 LAT UPDATED 04/2017

39 PRODUCT DECRIPTION TIER LIMIT & RETRICTION chlorzoxazone 1 cyclobenzaprine hcl 1 DANTRIUM (25 MG CAPULE, 50 MG CAPULE) 3 DANTRIUM 20 MG VIAL 3 dantrolene sodium 1 DYPORT 3 FEXMID 3 GABLOFEN 3 LIOREAL INTRATHECAL 3 LORZONE 3 METAXALL 1 metaxalone 1 methocarbamol (500 mg tablet, 750 mg tablet, 1,000 mg/10 ml) 1 MYOBLOC 3 orphenadrine citrate (30 mg/ml vial, 60 mg/2 ml ampule, 60 mg/2 ml vial, er 100 mg tablet) 1 RAFON FORTE DC 3 REVONTO 1 ROBAXIN (500 MG TABLET, 1,000 MG/10 ML VIAL) 3 ROBAXIN KELAXIN 3 OMA 3 tizanidine hcl 1 XEOMIN (50 VIAL, 100 VIAL) 3 GE 39 LAT UPDATED 04/2017

40 PRODUCT DECRIPTION TIER LIMIT & RETRICTION XEOMIN 200 UNIT VIAL 3 ZANAFLEX 3 YMTHOLYTIC ADRENERGIC BLOCKING AGENT acebutolol hcl 1 alfuzosin hcl er 1 atenolol 1 BETACE 3 BETACE AF 3 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 GL Male BREVIBLOC (10 MG/ML IV BAG, 10 MG/ML VIAL, 20 MG/ML IV BAG) 3 BYTOLIC (5 MG TABLET, 10 MG TABLET) 2 3 / day BYTOLIC 2.5 MG TABLET 2 BYTOLIC 20 MG TABLET 2 2 / day BYVALON 3 CAFERGOT 3 CARDURA 3 CARDURA XL 3 carvedilol 1 COREG 3 T T COREG CR (CR 10 MG CAPULE, CR 20 MG CAPULE, CR 40 MG CAPULE) 3 T 2 / day GE 40 LAT UPDATED 04/2017

41 PRODUCT DECRIPTION TIER LIMIT & RETRICTION COREG CR 80 MG CAPULE 3 CORGARD 3 D.H.E.45 3 DIBENZYLINE 3 T dihydroergotamine 4 mg/ml spry 1 8 / 30 days dihydroergotamine mesylate (1 mg/ml am, 1 mg/ml vl) 1 doxazosin mesylate 1 dutasteride-tamsulosin 1 ergoloid mesylates 1 ERGOMAR 3 ergotamine-caffeine 1 esmolol hcl (100 mg/10 ml syrg, 100 mg/10 ml vial) 1 GL Male FLOMAX 3 2 / day HEMANGEOL 3 INDERAL LA 3 INDERAL XL 3 T INNOPRAN XL 3 T JALYN 3 GL Male labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) labetalol hcl (20 mg/4 ml crpj, 100 mg/20 ml vl, 200 mg/40 ml vl) 1 1 LOPREOR (50 MG TABLET, 100 MG TABLET) 3 LOPREOR 5 MG/5 ML AMPUL 3 GE 41 LAT UPDATED 04/2017

42 PRODUCT DECRIPTION TIER LIMIT & RETRICTION metoprolol succinate 1 metoprolol tartrate (1 mg/ml carpuject, tart 5 mg/5 ml amp, tart 5 mg/5 ml vial) metoprolol tartrate (25 mg tab, 37.5 mg tb, 50 mg tab, 75 mg tab, 100 mg tab) 1 1 MIGERGOT 3 MIGRANAL 3 8 / 30 days MINIPRE 3 nadolol 1 phenoxybenzamine hcl 1 phentolamine mesylate 1 phentolamine-alprostadil 1 pindolol 1 prazosin hcl 1 propranolol 1 mg/ml vial 1 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mg tablet) 1 propranolol hcl er 1 RAFLO 2 ECTRAL 3 ORINE 1 sotalol 1 sotalol af 1 sotalol hcl 1 OTYLIZE 3 GL Male tamsulosin hcl 1 2 / day TENORMIN 3 GE 42 LAT UPDATED 04/2017

43 PRODUCT DECRIPTION TIER LIMIT & RETRICTION terazosin hcl 1 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 TOPROL XL 3 UROXATRAL 3 ZEBETA 3 YMTHOMIMETIC (ADRENERGIC) AGENT ADRENACLICK 3 GL Male 2 / fill ADVAIR DIKU 2 2 / day ADVAIR HFA / day ADYPHREN 3 2 / fill ADYPHREN AMP 3 2 / fill ADYPHREN AMP II 3 2 / fill ADYPHREN II 3 2 / fill albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sulf 2 mg/5 ml syrup, sulfate 2 mg tab, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulfate 4 mg tab, sulfate er 4 mg tab, 5 mg/ml solution, sulfate er 8 mg tab) 1 ARCAPTA NEOHALER 3 AUVI-Q 3 T 2 / fill BREO ELLIPTA 2 2 / day BROMFED DM 1 AL At least 2 yrs old brompheniramine-pseudoephed-dm 1 AL At least 2 yrs old GE 43 LAT UPDATED 04/2017

44 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BROVANA 3 4 / day CATAPRE 3 CATAPRE-TT / day CATAPRE-TT / day CATAPRE-TT / day clonidine (0.2 mg/day patch, 0.3 mg/day patch) / day clonidine 0.1 mg/day patch / day clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 clonidine hcl (1,000 mcg/10 ml vial, 5,000 mcg/10 ml vial) 1 clonidine hcl er 1 2 / day DULERA 3 DURACLON / day epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 C Epipen Generic Only/Mylan Only EPIPEN 2-K 2 2 / fill EPIPEN JR 2-K 2 4 / fill EPINAP 3 2 / fill FORADIL 3 3 / day HYCOFENIX 3 KAPVAY 3 levalbuterol concentrate 1 levalbuterol hcl 1 AL T 40/ day At least 18 yrs old 2 / day GE 44 LAT UPDATED 04/2017

45 PRODUCT DECRIPTION TIER LIMIT & RETRICTION metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet) 1 methyldopa 1 methyldopate hcl 1 midodrine hcl 1 NORTHERA 3 84 / 14 daysspecialty PERFOROMIT / 30 days PROAIR HFA / day PROAIR REPICLICK 2 PROVENTIL HFA 3 REZIRA 3 AL AL 0.07 / day At least 12 yrs old 0.6 / day 20 / day At least 18 yrs old EREVENT DIKU 2 2 / day TRIVERDI REPIMAT 2 T.144 / day YMBICORT / day terbutaline sulfate (sulf 1 mg/ml vial, sulfate 2.5 mg tab, sulfate 5 mg tab) 1 VENTOLIN HFA / day VOPIRE ER 3 XOPENEX 3 XOPENEX CONCENTRATE 3 XOPENEX HFA / day GE 45 LAT UPDATED 04/2017

46 PRODUCT DECRIPTION TIER LIMIT & RETRICTION Anti-infective Agents Anthelmintics EMVERM 3 Antibacterials ACTICLATE 3 T ADOXA 3 T amikacin sulfate 1 amox-clav mg tablet / 90 days amox-clav mg/5 ml sus / 90 days amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 875 mg tablet) 1 amoxicillin er 1 amoxicillin-clavulanate pot er 1 amoxicillin-clavulanate potass ( mg tab chew, mg tab chew, mg tablet, mg tablet) amoxicillin-clavulanate potass ( mg/5 ml sus, mg/5 ml susp, mg/5 ml sus) ampicillin sodium (1 gm a-v vial, 2 gm a-v vial, 10 gm vial) ampicillin sodium (1 gm vial, 2 gm vial, 125 mg vial, 250 mg vial, 500 mg vial) ampicillin trihydrate (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule) / 90 days ampicillin-sulbactam (3 gm vial, 15 gm vl) 1 ampicillin-sulbactam (ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gm vl) 1 AUGMENTIN ( TABLET, TABLET) 3 GE 46 LAT UPDATED 04/2017

47 PRODUCT DECRIPTION TIER LIMIT & RETRICTION AUGMENTIN MG/5 ML / 90 days AUGMENTIN MG/5 ML / day AUGMENTIN E / 90 days AUGMENTIN XR 3 AVELOX 3 21 / fill AVELOX ABC CK 3 5 / day AVELOX IV 3 AVIDOXY 1 AVIDOXY DK 3 AVYCAZ 3 AZACTAM 3 AZACTAM-IO-OMOTIC DEXTROE 3 azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200 mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 6 / 5 days azithromycin i.v. 500 mg vial 1 aztreonam 1 AZULFIDINE 3 BACIIM 1 bacitracin 50,000 units vial 1 BACTRIM 3 BACTRIM D 3 BETHKI 3 P BIAXIN (250 MG TABLET, 250 MG/5 ML UPENION, 500 MG TABLET) 3 GE 47 LAT UPDATED 04/2017

48 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BICILLIN C-R 3 BICILLIN L-A 3 CAYTON 3 CEDAX (90 MG/5 ML UPENION, 180 MG/5 ML UPENION, 400 MG CAPULE) cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) 3 1 cefaclor er 1 cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg/5 ml susp) cefazolin sodium (1 gm add-van vial, 1 gm vial, 10 gm vial, 20 gm bulk vial, 500 mg vial) 1 1 cefazolin sodium (100 gm bag, 300 gm bag) 1 cefazolin sodium-0.9% nacl 1 cefazolin sodium-dextrose (1 g/50, 2 g/100, 2 g/50) 1 cefazolin sodium-sterile water 1 cefazolin-0.9% nacl 1 cefazolin-d5w 1 cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) 1 cefditoren pivoxil 1 cefepime 1 cefepime hcl 1 cefepime-dextrose 1 cefixime / 90 days CEFOTAN 3 cefotaxime sodium 1 cefotetan & dextrose 1 GE 48 LAT UPDATED 04/2017

49 PRODUCT DECRIPTION TIER LIMIT & RETRICTION cefotetan (1 gm vial, 2 gm vial) 1 cefotetan 10 gm vial 1 cefoxitin 1 cefoxitin sodium 1 cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100 mg/5 ml susp, 200 mg tablet) cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 ml susp, 500 mg tablet) 1 1 ceftazidime (1 gm piggyback, 2 gm piggyback) 1 ceftazidime (1 gm vial, 2 gm vial, 6 gm vial) 1 ceftibuten (180 mg/5 ml susp, 400 mg capsule) 1 CEFTIN (125 MG/5 ML ORAL UP, 250 MG/5 ML ORAL UP) / 90 days CEFTIN (250 MG TABLET, 500 MG TABLET) 3 ceftriaxone (1 gm piggyback, 1 gm vial, 1 gm-d5w bag, 2 gm add vial, 2 gm piggyback, 2 gm-d5w bag) ceftriaxone (2 gm vial, 10 gm vial, 100 gram bulk bag, 250 mg vial, 500 mg vial) 1 1 cefuroxime 1 cefuroxime sodium 1 cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 750 mg capsule) 1 chloramphenicol sod succinate 1 CIPRO (250 MG TABLET, 500 MG TABLET) 3 2 / day CIPRO (5% UPENION, 10% UPENION) 3 CIPRO I.V. 3 CIPRO XR 3 ciprofloxacin (200 mg/20 ml vl, 400 mg/40 ml vl) 1 ciprofloxacin (250 mg/5 ml susp, 500 mg/5 ml susp) 1 GE 49 LAT UPDATED 04/2017

50 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ciprofloxacin er 1 ciprofloxacin hcl (100 mg tab, 750 mg tab) 1 ciprofloxacin hcl (250 mg tab, 500 mg tab) 1 2 / day ciprofloxacin-d5w 1 CLAFORAN (1 GM ADD-VANTAGE VL, 1 GM VIAL, 2 GM ADD-VANTAGE VL) 3 CLAFORAN (2 GM VIAL, 10 GM VIAL, 500 MG VIAL) 3 CLAFORAN-DEXTROE 3 clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet) 1 clarithromycin er 1 CLEOCIN HCL 3 4 / day CLEOCIN LMITATE 3 70/ day CLEOCIN PHOPHATE (150 MG/ML ADDVN VIAL, PHO 150 MG/ML VIAL, PHO 300 MG/2ML ADDVAN) CLEOCIN PHOPHATE (9 G/60 ML VIAL, 300 MG/2 ML VIAL, 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) 3 3 CLEOCIN PHOPHATE IN D5W 3 CLIN INGLE UE 3 clindamycin hcl 1 4 / day clindamycin palmitate hcl 1 70/ day clindamycin pediatric 1 70/ day clindamycin phosphate (300 mg/2 ml vl, 600 mg/4 ml vl, 900 mg/6 ml vl) clindamycin phosphate (ph 9 g/60 ml vial, 150 mg/ml addvan, 300 mg/2 ml addvan, 600 mg/4 ml addvan, 900 mg/6 ml addvan) 1 1 clindamycin phosphate-d5w 1 colistimethate 1 GE 50 LAT UPDATED 04/2017

51 PRODUCT DECRIPTION TIER LIMIT & RETRICTION COLY-MYCIN M RENTERAL 3 CUBICIN 3 CUBICIN RF 3 daptomycin 1 demeclocycline hcl 1 dicloxacillin sodium 1 DIFICID 3 DORIBAX 3 doripenem 1 DORYX (DR 50 MG TABLET, DR 150 MG TABLET) 3 T DORYX DR 200 MG TABLET 3 T 7/ rx DORYX MPC 3 T DOXY doxycycline hyc 100 mg vial 1 doxycycline hyc dr 200 mg tab 1 7/ rx doxycycline hyclate (hyc dr 50 mg tab, hyc dr 75 mg tab, hyc dr 100 mg tab, hyc dr 150 mg tab, hyclate 50 mg cap, hyclate 100 mg cap, hyclate 100 mg tab) 1 doxycycline ir-dr 1 doxycycline mono 150 mg cap 1 30 / fill doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg capsule, mono 75 mg tablet, mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet) 1 E.E E.E ERY-TAB 3 GE 51 LAT UPDATED 04/2017

52 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ERYPED ERYPED ERYTHROCIN LACTOBIONATE 3 ERYTHROCIN TEARATE 3 erythromycin (250 mg filmtab, dr 250 mg cap, ec 250 mg cap, 500 mg filmtab) erythromycin ethylsuccinate (200 mg/5 ml gran, es 400 mg tab) 1 1 erythromycin-sulfisoxazole 1 FACTIVE 3 7 / day FORTAZ (1 GM VIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) 3 FORTAZ (1 GM, 2 GM) 3 FORTAZ IN IO-OMOTIC DEXTROE 3 gentamicin 10 mg/ml vial 1 gentamicin sulfate (20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) 1 gentamicin sulfate in ns 1 imipenem-cilastatin sodium 1 INVANZ 1 GM ADD-VANTAGE VIAL 3 INVANZ 1 GM VIAL 3 KEFLEX 3 KETEK 3 KITABI K 3 lansoprazol-amoxicil-clarithro / 365 days LEVAQUIN (250 MG TABLET, 500 MG TABLET, 750 MG TABLET) 3 21 / fill LEVAQUIN (500 MG/100 ML BAG, 750 MG/150 ML BAG) 3 LEVAQUIN 25 MG/ML OLUTION 3 GE 52 LAT UPDATED 04/2017

53 PRODUCT DECRIPTION TIER LIMIT & RETRICTION levofloxacin (25 mg/ml solution, 250 mg tablet, 250 mg/10 ml soln, 500 mg tablet, 500 mg/20 ml soln, 750 mg tablet) 1 levofloxacin (500 mg/20 ml vial, 750 mg/30 ml vial) 1 levofloxacin-d5w 1 LINCOCIN 3 lincomycin hcl 1 10 / day linezolid 100 mg/5 ml susp / rx linezolid 600 mg tablet 1 2 / day linezolid 600 mg/300 ml iv sol 1 linezolid-0.9% nacl 1 MAXIPIME (1 GM VL, 2 GM VL) 3 MAXIPIME (1 VIAL, 2 VIAL) 3 MEFOXIN 3 meropenem 1 meropenem-0.9% nacl 1 MERREM 3 MINOCIN (50 MG PELLETIZED CAP, KIT 50 MG COMBO, 75 MG PELLETIZED CAP, 100 MG PELLETIZED CAP, KIT 100 MG COMBO) 3 MINOCIN 100 MG VIAL 3 minocycline er 45 mg tablet 1 3 / day minocycline hcl 1 minocycline hcl er (er 90 mg tablet, er 135 mg tablet) 1 MONDOXYNE NL 1 MONODOX 3 MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3 MORGIDOX (50 MG CAPULE, 100 MG CAPULE) 1 GE 53 LAT UPDATED 04/2017

54 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MOXATAG 3 moxifloxacin 1 moxifloxacin hcl 1 21 / fill MYCOBUTIN 3 nafcillin 3 nafcillin sodium (1 gm add-van vial, 2 gm add-vant vial) 1 nafcillin sodium (1 gm vial, 2 gm vial, 10 gm bulk vial, 10 gm vial) 1 neomycin sulfate 1 ofloxacin 400 mg tablet 1 56 / fill OMECLAMOX-K 3 80 / 365 days ORACEA 3 oxacillin 3 oxacillin sodium (1 gm vial, 2 gm vial, 10 gm vial) 1 oxacillin sodium (1 gm vl, 2 gm vl) 1 paromomycin sulfate 1 PCE 3 penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin gk-iso-osm dextrose 1 T penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet) 1 PFIZERPEN 3 piperacil-tazobact 13.5 gm vl 3 GE 54 LAT UPDATED 04/2017

55 PRODUCT DECRIPTION TIER LIMIT & RETRICTION piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl, piperacil-tazobact 2.25 gm vl, piperacil-tazobact gm vl, piperacil-tazobact 4.5 gm vial, piperacil-tazobact 40.5 gram) 1 polymyxin b sulfate 1 PREVC / 365 days PRIFTIN / day PRIMAXIN 3 PYLERA / 365 days rifabutin 1 RIFADIN (150 MG CAPULE, 300 MG CAPULE) 3 RIFADIN IV 600 MG VIAL 3 RIFAMATE 3 rifampin (150 mg capsule, 300 mg capsule) 1 rifampin iv 600 mg vial 1 RIFATER 3 IVEXTRO 200 MG TABLET 3 IVEXTRO 200 MG VIAL 3 OLODYN 3 PECTRACEF 3 streptomycin sulfate 1 sulfadiazine 1 sulfamethoxazole-tmp inj vial 1 sulfamethoxazole-trimethoprim (ds tablet, ss tablet, susp) 1 sulfasalazine 1 T 6 / 30 days 6 / 30 days GE 55 LAT UPDATED 04/2017

56 PRODUCT DECRIPTION TIER LIMIT & RETRICTION sulfasalazine dr 1 ULFATRIM 1 UPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPULE, 500 MG/5 ML UPENION) UPRAX (100 MG/5 ML UPENION, 200 MG/5 ML UPENION) / 90 days YNERCID 3 TARGADOX 3 T TAZICEF (1 GM VIAL, 2 GM) 1 TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1 TEFLARO 3 tetracycline hcl 1 tigecycline 1 TOBI 3 TOBI PODHALER 3 tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 1 tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10 mg/ml vial, 40 mg/ml vial) 1 tobramycin sulfate (80 mg/2 ml vial, 1,200 mg/30 ml vial) 1 tobramycin sulfate in ns 1 TYGACIL 3 UNAYN 3 VANCOCIN HCL 3 vancomycin 1 GE 56 LAT UPDATED 04/2017

57 PRODUCT DECRIPTION TIER LIMIT & RETRICTION vancomycin hcl (1 gm add-van vial, 1 gm vial, hcl 1g/200 ml bag, hcl 5 gm vial, hcl 10 gm vial, hcl 100 gm smartpak, 500 mg a-v vial, 500 mg vial, hcl 750 mg vial) vancomycin hcl (125 mg/2.5 ml oral, hcl 125 mg capsule, hcl 250 mg capsule) vancomycin hcl-0.9% nacl (vanco 1 gram/250 ml-0.9%, vanco 1.25 gm/250 ml-0.9%, vanco 1.5 gm/250 ml-0.9%, vanco 1.5 gm/500 ml-0.9%, vanco 500 mg/100 ml-0.9%, vanco 750 mg/150 ml-0.9%, vanco 750 mg/250 ml- 0.9%, vancomycin 1 g/100ml-0.9%, vancomycin 1 g/200ml-0.9%) vancomycin hcl-d5w (vancomycin 1.5 gram/250 ml-d5w, vancomycin 750 mg/250 ml-d5w, vancomycin-d5w 1.5 gram/250 ml, vancomycin-d5w 500 mg/100 ml) VIBATIV 3 VIBRAMYCIN (25 MG/5 ML UP, 50 MG/5 ML YRUP, 100 MG CAPULE) 3 T XIFAXAN 3 ZINACEF (1.5 GM TWITVIAL, 1.5 GM VIAL, 1.5 GRAM/50 ML, 7.5 GM VIAL, 750 MG TWITVIAL) 3 ZINACEF 750 MG VIAL 3 ZITHROMAX (1 GM POWDER CKET, 250 MG Z-K TABLET) 3 ZITHROMAX 100 MG/5 ML UP 3 30 / fill ZITHROMAX 200 MG/5 ML UP 3 60 / fill ZITHROMAX 250 MG TABLET 3 6 / 5 days ZITHROMAX 500 MG TABLET 3 5 / fill ZITHROMAX 600 MG TABLET / day ZITHROMAX I.V. 500 MG VIAL 3 ZITHROMAX TRI-K 3 ZMAX 2 60 / fill GE 57 LAT UPDATED 04/2017

58 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ZOYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL, GM/50 ML GALAXY, GRAM VIAL, 4.5 GM/100 ML GALAXY BAG, 4.5 GRAM VIAL, 40.5 GRAM BULK VIAL) ZYVOX (200 MG/100 ML IV OLN, 600 MG/300 ML IV OLN) 3 3 ZYVOX 100 MG/5 ML UPENION / rx ZYVOX 600 MG TABLET 3 2 / day Antifungals ABELCET 3 AMBIOME 3 amphotericin b 1 ANCOBON 3 CANCIDA 3 CREEMBA 186 MG CAPULE 3 CREEMBA 372 MG VIAL 3 DIFLUCAN (10 MG/ML UPENION, 40 MG/ML UPENION, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 3 DIFLUCAN 150 MG TABLET 3 ERAXI (WATER DILUENT) 3 GL 2 / 30 days Female fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 fluconazole 150 mg tablet 1 2 / 30 days fluconazole in dextrose 1 fluconazole in saline 1 fluconazole-nacl 1 flucytosine 1 GRIFULVIN V 3 GE 58 LAT UPDATED 04/2017

59 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GRI-PEG 3 griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 1 griseofulvin ultramicrosize 1 itraconazole 1 ketoconazole 200 mg tablet 1 LAMIIL 3 MYCAMINE 3 NOXAFIL (40 MG/ML UPENION, DR 100 MG TABLET) 3 NOXAFIL 300 MG/16.7 ML VIAL 3 nystatin (100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus, 50,000,000 units pwd, 150,000,000 units pwd, 500,000,000 units pwd) 1 ONMEL 3 PORANOX (10 MG/ML OLUTION, 100 MG CAPULE) 3 terbinafine hcl 1 triacetin 1 VFEND (50 MG TABLET, 200 MG TABLET) 3 4 / day VFEND 40 MG/ML UPENION 3 20 / day VFEND IV 3 voriconazole (50 mg tablet, 200 mg tablet) 1 4 / day voriconazole 200 mg vial 1 voriconazole 40 mg/ml susp 1 20 / day Antimycobacterials CATAT ULFATE 3 cycloserine 1 dapsone 1 ethambutol hcl 1 GE 59 LAT UPDATED 04/2017

60 PRODUCT DECRIPTION TIER LIMIT & RETRICTION isoniazid (50 mg/5 ml solution, 100 mg tablet, 100 mg/ml vial, 300 mg tablet) 1 MYAMBUTOL 3 ER 3 pyrazinamide 1 IRTURO 3 TRECATOR 3 Antiprotozoals ALINIA (100 MG/5 ML UPENION, 500 MG TABLET) 3 atovaquone 1 atovaquone-proguanil hcl 1 chloroquine phosphate 1 COARTEM 3 FLAGYL 3 FLAGYL ER 3 hydroxychloroquine sulfate 1 IMVIDO 3 MALARONE 3 mefloquine hcl 1 MEPRON 3 METRO IV 3 metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1 metronidazole 500 mg/100 ml 1 NEBUPENT 3 PENTAM PLAQUENIL 3 GE 60 LAT UPDATED 04/2017

61 PRODUCT DECRIPTION TIER LIMIT & RETRICTION primaquine 1 QUALAQUIN 3 quinidine gluconate (80 mg/ml vial, er 324 mg tab) 1 quinidine sulfate 1 quinine sulfate 1 TINDAMAX 3 tinidazole 1 Antivirals 42 / 365 days 42 / 365 days abacavir 1 abacavir-lamivudine 1 abacavir-lamivudine-zidovudine 1 acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mg tablet, 800 mg tablet) acyclovir sodium (sodium 1 gm vial, 500 mg/10 ml vial, sodium 500 mg vial, 1,000 mg/20 ml vial) 1 1 acyclovir sodium-d5w 1 adefovir dipivoxil 1 ALFERON N 3 amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet, 100 mg/10 ml soln) 1 APTIVU (100 MG/ML OLUTION, 250 MG CAPULE) 3 ATRIPLA 3 BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3 P P GE 61 LAT UPDATED 04/2017

62 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BARACLUDE 0.05 MG/ML OLUTION 3 20 / day cidofovir 1 COMBIVIR 3 COMPLERA 3 COPEGU 3 CRIXIVAN 3 P P CYTOVENE 3 DAKLINZA 30 MG TABLET 3 DAKLINZA 60 MG TABLET 3 DAKLINZA 90 MG TABLET 3 DECOVY 3 P P P 1 / 1 day GE 62 LAT UPDATED 04/2017

63 PRODUCT DECRIPTION TIER LIMIT & RETRICTION didanosine 1 EDURANT 3 EMTRIVA (10 MG/ML OLUTION, 200 MG CAPULE) 3 entecavir 1 EPCLUA 3 P P P EPIVIR (10 MG/ML ORAL OLN, 150 MG TABLET, 300 MG TABLET) 3 EPIVIR HBV (25 MG/5 ML OLN, 100 MG TABLET) 3 EPZICOM 3 P EVOTAZ 3 famciclovir 1 FAMVIR 3 FLUMADINE 3 foscarnet sodium 1 FOCAVIR 3 FUZEON 3 2 / 1 days ganciclovir sodium 1 GENVOYA 3 GE 63 LAT UPDATED 04/2017

64 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HARVONI 3 HEPERA 3 INCIVEK 3 INFERGEN 3 INTELENCE 3 P P 6 / day INTRON A (10 MILLION UNIT VIL, 18 MILLION UNIT/3 ML, 18 MILLION UNIT VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNIT VIL) 3 INVIRAE 3 IENTRE 3 P P KALETRA (80 MG-20 MG/ML OLN, MG TABLET, MG TABLET) lamivudine (10 mg/ml oral soln, 100 mg tablet, 150 mg tablet, 300 mg tablet) 3 1 lamivudine hbv 1 lamivudine-zidovudine 1 LEXIVA (50 MG/ML UPENION, 700 MG TABLET) 3 P GE 64 LAT UPDATED 04/2017

65 PRODUCT DECRIPTION TIER LIMIT & RETRICTION lopinavir-ritonavir 1 P MODERIBA ( MG DOECK, MG DOECK, MG DOECK, MG DOECK) 3 MODERIBA 200 MG TABLET 1 nevirapine (50 mg/5 ml susp, 200 mg tablet) 1 nevirapine er 1 NORVIR (80 MG/ML OLUTION, 100 MG OFTGEL CAP, 100 MG TABLET) 3 ODEFEY 3 OLYIO 3 oseltamivir phosphate 1 20 / 365 days PEGAY 180 MCG/0.5 ML YRINGE 3 PEGAY 180 MCG/ML VIAL 3 PEGAY PROCLICK 3 PEGINTRON 3 PEGINTRON REDIPEN 3 P P GE 65 LAT UPDATED 04/2017

66 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PREZCOBIX 3 PREZITA (75 MG TABLET, 100 MG/ML UPENION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) 3 P REBETOL (40 MG/ML OLUTION, 200 MG CAPULE) 3 RELENZA 3 40 / 365 days RECRIPTOR 3 RETROVIR (10 MG/ML YRUP, 100 MG CAPULE, 300 MG TABLET) 3 RETROVIR 200 MG/20 ML VIAL 3 REYATAZ 3 RIBAPHERE (200 MG CAPULE, 200 MG TABLET) 1 RIBAPHERE (400 MG TABLET, 600 MG TABLET) 3 RIBAPHERE RIBAK 3 RIBATAB 3 ribavirin (200 mg capsule, 200 mg tablet) 1 P ribavirin 6 gm inhalation vial 1 rimantadine hcl 1 ELZENTRY (150 MG TABLET, 300 MG TABLET) 3 P GE 66 LAT UPDATED 04/2017

67 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ELZENTRY (25 MG TABLET, 75 MG TABLET) 3 ITAVIG 3 OVALDI 3 P AL P 2 / fill At least 18 yrs old stavudine (1 mg/ml solution, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) 1 TRIBILD 3 UTIVA 3 YLATRON 3 YLATRON 4-CK 3 YNAGI 3 TAMIFLU (30 MG CAPULE, 45 MG CAPULE, 75 MG CAPULE) 3 20 / 365 days TAMIFLU 6 MG/ML UPENION / 30 days TECHNIVIE 3 2 / dayspecialty TIVICAY 3 GE 67 LAT UPDATED 04/2017

68 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TRIUMEQ 3 TRIZIVIR 3 TRUVADA 3 TYZEKA 3 valacyclovir 1 P VALCYTE 450 MG TABLET 3 4 / day VALCYTE 50 MG/ML OLUTION 3 valganciclovir 450 mg tablet 1 4 / day valganciclovir hcl 50 mg/ml 1 VALTREX 3 VEMLIDY 3 VICTRELI 3 VIDEX 3 AL P At least 18 yrs old 12 / day VIDEX EC 3 VIEKIRA K 3 4 / days GE 68 LAT UPDATED 04/2017

69 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VIEKIRA XR 3 VIRACEPT 3 P 3 / day VIRAMUNE (50 MG/5 ML UP, 200 MG TABLET) 3 VIRAMUNE XR 3 VIRAZOLE 3 VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET) 3 P VIREAD POWDER 3 VITIDE 3 VITEKTA 3 ZETIER 3 P 4 / days ZERIT (1 MG/ML OLUTION, 15 MG CAPULE, 20 MG CAPULE, 30 MG CAPULE, 40 MG CAPULE) 3 ZIAGEN (20 MG/ML OLUTION, 300 MG TABLET) 3 zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) ZOVIRAX (200 MG CAPULE, 200 MG/5 ML UP, 400 MG TABLET, 800 MG TABLET) 1 3 GE 69 LAT UPDATED 04/2017

70 PRODUCT DECRIPTION TIER LIMIT & RETRICTION Urinary Anti-infectives FURADANTIN 3 MACROBID 3 MACRODANTIN 3 nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mg cap, mcr 100 mg cap) 1 nitrofurantoin mono-macro 1 Antihistamine Drugs First Generation Antihistamines diphenhydramine-0.9% nacl 1 hydroxyzine 50 mg/25 ml syrup 1 AL At least 2 yrs old PHENADOZ 1 AL At least 2 yrs old promethazine-dm 1 AL At least 2 yrs old promethazine-phenyleph-codeine 1 promethazine-phenylephrine 1 TUZITRA XR 3 BLOOD FORMATION, COAGULATION, THROMBOI ANTIANEMIA DRUG AL AL 3 / day At least 6 yrs old 20 / day At least 18 yrs old ACTIVE FE 3 GL Female ACTIVE OB 3 GL Female BAL-CARE DHA EENTIAL 3 GL Female BIFERA RX 3 C-NATE DHA 3 GL Female GE 70 LAT UPDATED 04/2017

71 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CADEAU DHA 3 CENTRATEX 3 CITRANATAL 90 DHA 3 CITRANATAL AURE 3 CITRANATAL B-CALM 3 GL Female CITRANATAL DHA 3 CITRANATAL HARMONY 3 GL Female CITRANATAL RX 3 GL Female COMPLETENATE 3 GL Female CONCEPT DHA 3 GL Female CONCEPT OB 3 GL Female CORVITA CORVITE CORVITE FE 3 DEXFERRUM 1 DOTHELLE DHA 3 DUET DHA GL Female DUET DHA BALANCED 3 GL Female ELITE-OB 3 GL Female ELITE-OB GL Female ENBRACE HR 3 ENLYTE 3 ECAVITE 3 ECAVITE D 3 ECAVITE LQ 3 GE 71 LAT UPDATED 04/2017

72 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EXTRA-VIRT PLU DHA 3 GL Female FE 90 PLU 3 FE C PLU 1 FERAHEME 3 FERIVA 3 FERIVA FA 3 FEROCON 1 FERRALET 90 3 FERRAPLU 90 3 FERRLECIT 62.5 MG/5 ML VIAL 3 FERROCITE PLU 1 FERROGEL FORTE 1 FOCALGIN 90 DHA 3 FOCALGIN CA 3 GL Female FOCALGIN D 3 GL Female FOLET DHA 3 FOLET ONE 3 GL Female FOLIVANE-F 3 FOLIVANE-OB 3 GL Female FOLIVANE-PLU 3 FUION PLU 3 FUION PRINKLE 3 HEMATINIC PLU 1 HEMATINIC WITH FOLIC ACID 1 HEMATOGEN 1 HEMATOGEN FA 3 GE 72 LAT UPDATED 04/2017

73 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HEMATOGEN FORTE 1 HEMATRON 1 HEMATRON-AF 3 HEMAX 1 HEMENATAL OB 3 GL Female HEMENATAL OB + DHA 3 GL Female HEMETAB 3 HEMOCYTE PLU 3 HEMOCYTE-F 1 ICAR-C PLU 3 INFANATE BALANCE 3 GL Female INFANATE PLU 3 GL Female INFED 1 INJECTAFER 3 INTEGRA F 3 INTEGRA PLU 3 IRON 3 KOHER PRENATAL PLU IRON 3 GL Female M-VIT 3 GL Female MAXARON FORTE 3 multi-vitamin w-fluoride-iron 1 multi-vitamin-fluor-iron 1 MULTIGEN FOLIC 3 MULTIGEN PLU 3 multivitamin-iron-fluoride 1 multivitamins w-fluoride-iron 1 GE 73 LAT UPDATED 04/2017

74 PRODUCT DECRIPTION TIER LIMIT & RETRICTION mv-iron fum-asp-asc-b12-fa-suc 1 MYKIDZ IRON FL 3 NATACHEW 3 GL Female NEEVODHA 3 GL Female NEPHRON FA 3 NETAB ABC 3 GL Female NEXA PLU 3 GL Female NUFERA 3 NULECIT 1 OB COMPLETE 3 GL Female OB COMPLETE GOLD 3 GL Female OB COMPLETE PETITE 3 GL Female OB COMPLETE WITH DHA 3 GL Female OBTETRIX DHA 3 GL Female OBTETRIX EC 3 GL Female OBTETRIX ONE 1 GL Female OBTREX DHA 3 GL Female IRE OB PLU DHA 3 GL Female PNV-DHA 3 GL Female pnv-ferrous fumarate-docu-fa 3 GL Female PNV-ELECT 3 GL Female PNV-TOTAL 3 GL Female POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) 3 PREFERA OB 3 GL Female GE 74 LAT UPDATED 04/2017

75 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PREFERA-OB ONE 3 GL Female PREFERA-OB PLU DHA 3 GL Female PRENA1 PEARL 3 GL Female PRENA1 TRUE 3 GL Female PRENAIANCE BALANCE 3 GL Female PRENATA 3 GL Female prenatal 19 (19 chewable tablet, 19 tablet) 3 GL Female prenatal plus-dha 3 GL Female PRENATE DHA 3 GL Female PRENATE ELITE 3 GL Female PRENATE ENHANCE 3 GL Female PRENATE EENTIAL 3 PRENATE MINI 3 GL Female PRENATE PIXIE 3 PRENATE RETORE 3 GL Female PRENATE TAR 3 GL Female PREQUE 10 3 GL Female PRIMACARE 3 PROFERRIN-FORTE 3 PROVIDA DHA 3 PROVIDA OB 3 GL Female PUREFE OB PLU 3 GL Female PUREFE PLU 3 PUREVIT DUALFE PLU 1 GE 75 LAT UPDATED 04/2017

76 PRODUCT DECRIPTION TIER LIMIT & RETRICTION QUFLORA FE 3 R-NATAL OB 3 GL Female RELNATE DHA 3 GL Female RULAVITE DHA 3 E-NATAL 19 (19 CHEWABLE TABLET, 19 TABLET) 3 GL Female E-TAN DHA 3 GL Female E-TAN PLU 1 ELECT-OB 3 ELECT-OB + DHA 3 GL Female sod ferric gluconate complex 1 TANDEM PLU 3 TARON FORTE 3 TARON-C DHA 3 GL Female TARON-PREX PRENATAL 3 GL Female TEXAVITE LQ 3 THRIVITE 19 3 TL FOLATE 3 TL ICON 1 TL-FLUORIVITE 3 TL-HEM tri-vit with fluoride-iron 3 TRICARE 3 GL Female TRICARE PRENATAL 3 GL Female TRICARE PRENATAL DHA ONE 3 GL Female TRICARE PRENATAL WITH DHA 3 GL Female GE 76 LAT UPDATED 04/2017

77 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TRICON 1 TRIFERIC (272 MG POWDER CKET, 272 MG/50 ML AMPULE) 3 TRIGEL-F FORTE 1 TRINATAL GT 3 GL Female TRITART DHA 3 VENOFER 3 VINATE CARE 3 GL Female VINATE DHA RF 3 GL Female VINATE GT 3 GL Female VIRT-C DHA 3 VIRT-NATE DHA 3 GL Female VIRT-PN 3 GL Female VIRT-PN DHA 3 GL Female VIRT-VITE GT 3 GL Female VITAFOL 3 VITAFOL FE+ 3 GL Female VITAFOL NANO 3 VITAFOL ULTRA 3 GL Female VITAFOL-ONE 3 GL Female VITAMEDMD ONE RX 3 GL Female VITAMEDMD PLU RX 3 GL Female VITAPEARL 3 GL Female VITAPIRE 3 GL Female VITATRUE 3 GL Female GE 77 LAT UPDATED 04/2017

78 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VIVA DHA 3 GL Female VP CH ULTRA 3 VP-CH PLU 3 GL Female VP-CH-PNV 3 GL Female VP-ERA OB PLU 3 GL Female VP-HEME OB 3 GL Female VP-HEME OB + DHA 3 GL Female VP-HEME ONE 3 GL Female VP-PNV-DHA CAPULE 3 GL Female VP-PNV-DHA OFTGEL 3 ZATEAN-PN 3 GL Female ZATEAN-PN DHA 3 GL Female ANTIHEMORRHAGIC AGENT ADVATE 3 ADVATE H 3 ADVATE L 3 ADVATE M 3 ADVATE H 3 ADVATE UH 3 ADYNOVATE 3 AFTYLA 3 ALPHANATE 3 GE 78 LAT UPDATED 04/2017

79 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ALPHANINE D 3 ALPROLIX (250 UNIT, 4,000 UNIT) 3 ALPROLIX (500 UNIT, 1,000 UNIT, 2,000 UNIT, 3,000 UNIT) 3 BEBULIN 3 BEBULIN VH IMMUNO 3 BENEFIX (250 UNIT KIT, 500 UNIT KIT, 1,000 UNIT KIT, 2,000 UNIT KIT, 3,000 UNIT KIT) 3 COAGADEX 3 P CORIFACT 3 DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 4 MCG/ML AMPUL, 4 MCG/ML VIAL, 10 MCG/0.1 ML OLUTION) desmopressin acetate (0.01% solution, 0.01% spray, 0.1 mg/ml sol, ac 4 mcg/ml ampul, ac 4 mcg/ml vial, acetate 0.1 mg tb, acetate 0.2 mg tb, 40 mcg/10 ml vial) ELOCTATE (250 UNIT, 500 UNIT, 750 UNIT, 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 3,000 UNIT) ELOCTATE (4,000 UNIT, 5,000 UNIT, 6,000 UNIT) 3 FEIBA NF 3 HELIXATE F 3 HEMOFIL M (HEOFIL 250 UNIT NOINAL, HEOFIL 500 UNIT NOINAL, HEOFIL 1,000 UNIT NOINAL, HEOFIL 1,700 UNIT NOINAL) 3 HUMATE-P (600 UNIT, 1,200 UNIT, 2,400 UNIT) 3 GE 79 LAT UPDATED 04/2017

80 PRODUCT DECRIPTION TIER LIMIT & RETRICTION IDELVION 3 IXINITY (250 UNIT RANGE, 500 UNIT RANGE, 1,000 UNIT RANGE, 1,000 UNIT RANGE-2 VL, 1,500 UNIT RANGE, 1,500 UNIT RANGE-2 VL, 2,000 UNIT RANGE, 3,000 UNIT RANGE) IXINITY (500 UNIT VIAL, 1,000 UNIT VIAL, 1,000 UNIT VIAL -2 VL, 1,500 UNIT VIAL, 1,500 UNIT VIAL -2 VL) 3 3 KCENTRA 3 KOATE 3 KOATE-DVI 3 KOGENATE F 3 KOVALTRY 3 MONOCLATE-P 3 MONONINE 1,000 UNIT KIT 3 NOVOEIGHT 3 NOVOEVEN RT 3 NUWIQ 3 OBIZUR 3 PROFILNINE 3 protamine sulfate 1 RECOMBINATE 3 GE 80 LAT UPDATED 04/2017

81 PRODUCT DECRIPTION TIER LIMIT & RETRICTION RIXUBI 3 TIMATE 3 TRETTEN 3 VONVENDI 3 WILATE 3 XYNTHA 3 XYNTHA OLOFUE 3 ANTITHROMBOTIC AGENT ACTIVAE 3 AGGRATAT (3.75 MG/15 ML VIAL, 5 MG/100 ML IV OLN, 12.5 MG/250 ML) 3 AGGRENOX 3 2 / day AGRYLIN 3 4 / day anagrelide hcl 1 4 / day ANGIOMAX 3 argatroban 1 argatroban-0.9% nacl (argatroban 50 mg/50ml- 0.9%nacl, argatrobn-0.9% nacl 125 mg/125) 1 argatroban-sodium chloride 1 argatrobn-0.9% nacl 250 mg/250 3 ARIXTRA 3 aspirin-caffeine-dihydrocodein 1 10 / day aspirin-dipyridamole er 1 2 / day GE 81 LAT UPDATED 04/2017

82 PRODUCT DECRIPTION TIER LIMIT & RETRICTION bivalirudin 1 BRILINTA 2 2 / day butalbital-aspirin-caffeine 1 6 / day CATHFLO ACTIVAE 3 cilostazol 1 2 / day clopidogrel 1 COUMADIN 2 dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 4 / day DURLAZA 3 EFFIENT 2 ELIQUI 3 2 / day enoxaparin sodium 1 eptifibatide 1 FIORINAL 3 6 / day fondaparinux sodium 1 FRAGMIN 3 HERIN 50 UNIT/5 ML (10/ML) 1 GE 82 LAT UPDATED 04/2017

83 PRODUCT DECRIPTION TIER LIMIT & RETRICTION heparin flush (hep-lock flush 10 units/ml kit, hep-lock flush 100 unit/ml kit, heparin 2 unit/2 ml (1/ml) syr, heparin 3 unit/3 ml (1/ml) syr, heparin 5 unit/5 ml (1/ml) syr, heparin 10 unit/10 ml (1/ml), heparin 20 units/2 ml (10/ml), heparin 30 units/3 ml (10/ml), heparin 50 units/5 ml (10/ml), heparin 60 units/6 ml (10/ml), heparin 100 unit/10 ml (10/ml), heparin 200 unit/2 ml (100/ml), heparin 300 unit/3 ml (100/ml), heparin 500 unit/5 ml (100/ml), heparin 1,000 unit/10 (100/ml), heparin flush 10 units/ml syr, heparin iv flush 1 unit/ml syr, heparin iv flush 100 units/ml, heparin lock flush 10 units/ml) 1 heparin lock 1 heparin sod 5,000 unit/ml syrg 1 heparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2 ml vial, sod 5,000 unit/ 0.5 ml, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syr, sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000 unit/ml vl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial, 40,000 units/4 ml vial, 50,000 unit/10 ml vial, 50,000 units/10 ml vl, 50,000 units/5 ml vial) 1 heparin sodium in 0.45% nacl 1 heparin sodium-0.9% nacl (heparin 1,000 unit/1,000 mlns, heparin 2,000 units/500 ml-ns, heparin 4,000 unit/1,000 ml-ns, heparin 6,000 unit/1,000 ml-ns, heparin-ns 30 units/3 ml syrng, heparin-ns 1,000 units/500 ml, heparin-ns 2,000 unit/1,000 ml) 1 heparin sodium-d5w 1 INTEGRILIN 3 IPRIVAK 3 JANTOVEN 1 KENGREAL 3 LOVENOX 3 MONOJECT PREFILL ADVANCED (30 UNIT/3 ML (10/ML), 100 UNIT/10 ML (10/ML), 300 UNIT/3 ML (100/ML), 500 UNIT/5 ML (100/ML), 1,000 UNIT/10 (100/ML)) 1 PERANTINE 3 4 / day GE 83 LAT UPDATED 04/2017

84 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PLAVIX 3 PLETAL 3 2 / day PRADAXA 2 2 / day REOPRO 3 AVAYA 3 YNALGO-DC 3 10 / day ticlopidine hcl 1 2 / day TNKAE 3 warfarin sodium 1 XARELTO (10 MG TABLET, 20 MG TABLET) 2 XARELTO 15 MG TABLET 2 2 / day XARELTO TARTER CK 2 ZONTIVITY 3 HEMATOPOIETIC AGENT ARANEP 3 P EPOGEN (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL, 4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 20,000 UNIT/2 ML VIAL, 20,000 UNIT/ML VIAL) 3 GRANIX (300 MCG/0.5 ML YR, 480 MCG/0.8 ML YR) 3 GRANIX (300 MCG/0.5 ML YRINGE, 480 MCG/0.8 ML YRINGE) 3 GE 84 LAT UPDATED 04/2017

85 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL) 3 MIRCERA 3 MOZOBIL 3 NEULATA 3 NEUMEGA 3 NEUPOGEN 3 NPLATE 3 OMONTY 3 PROCRIT 3 PROMACTA 3 ZARXIO 3 P P P 90 / 30 daysspecialty GE 85 LAT UPDATED 04/2017

86 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HEMORRHEOLOGIC AGENT pentoxifylline 1 CARDIOVACULAR DRUG ANTILIPEMIC AGENT ADVICOR (500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3 2 / day ADVICOR 1,000 MG-40 MG TABLET 3 ALTOPREV 3 amlodipine-atorvastatin 1 ANTARA 30 MG CAPULE 3 2 / day ANTARA 90 MG CAPULE 3 atorvastatin calcium 1 CADUET 3 cholestyramine light packet 1 4 / day cholestyramine light powder 1 24 / day cholestyramine packet 1 4 / day cholestyramine powder 1 24 / day COLETID (FLAVORED GRANULE, GRANULE, GRANULE CKET) 3 6 / day COLETID 1 GM TABLET 3 2 / day colestipol hcl (granules, granules packet) 1 6 / day colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1 2 / day CRETOR 3 ezetimibe 1 fenofibrate (40 mg tablet, 43 mg capsule, 48 mg tablet, 50 mg capsule, 54 mg tablet) 1 2 / day GE 86 LAT UPDATED 04/2017

87 PRODUCT DECRIPTION TIER LIMIT & RETRICTION fenofibrate (67 mg capsule, 120 mg tablet, 130 mg capsule, 134 mg capsule, 145 mg tablet, 150 mg capsule, 160 mg tablet, 200 mg capsule) 1 fenofibric acid (105 mg tablet, dr 135 mg cap) 1 fenofibric acid (35 mg tablet, dr 45 mg cap) 1 2 / day FENOGLIDE 120 MG TABLET 3 FENOGLIDE 40 MG TABLET 3 2 / day FIBRICOR 105 MG TABLET 3 FIBRICOR 35 MG TABLET 3 2 / day fluvastatin er 1 fluvastatin sodium 20 mg cap 1 fluvastatin sodium 40 mg cap 1 2 / day gemfibrozil 1 2 / day JUXTAPID (30 MG CAPULE, 40 MG CAPULE, 60 MG CAPULE) 3 JUXTAPID (5 MG CAPULE, 10 MG CAPULE) 3 JUXTAPID 20 MG CAPULE 3 KYNAMRO 3 2 / day 3 / day LECOL 20 MG CAPULE 3 LECOL 40 MG CAPULE 3 2 / day LECOL XL 3 GE 87 LAT UPDATED 04/2017

88 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 LIPITOR 80 MG TABLET 3 LIPOFEN 150 MG CAPULE 3 LIPOFEN 50 MG CAPULE 3 2 / day LIPTRUZET 3 LIVALO 3 LOFIBRA (67 MG CAPULE, 134 MG CAPULE, 160 MG TABLET, 200 MG CAPULE) 3 LOFIBRA 54 MG TABLET 3 2 / day LOPID 3 2 / day lovastatin (10 mg tablet, 20 mg tablet) 1 lovastatin 40 mg tablet 1 LOVAZA 3 4 / day niacin er (er 750 mg tablet, er 1,000 mg tablet) 1 2 / day niacin er 500 mg tablet 1 3 / day NIACOR 3 3 / day NIAN (ER 750 MG TABLET, ER 1,000 MG TABLET) 3 2 / day NIAN ER 500 MG TABLET 3 3 / day omega-3 acid ethyl esters 1 4 / day PRALUENT 150 MG/ML PEN 3 PRALUENT 75 MG/ML PEN 3 P P 0.08 / day 0.07 / 1 days GE 88 LAT UPDATED 04/2017

89 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PRALUENT YRINGE 3 P 0.07 / 1 days PRAVACHOL 3 pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab) 1 pravastatin sodium 80 mg tab 1 PREVALITE CKET 1 4 / day PREVALITE POWDER 1 24 / day QUETRAN LIGHT POWDER 3 24 / day QUETRAN CKET 3 4 / day QUETRAN POWDER 3 24 / day RETHA PUHTRONEX 3 RETHA URECLICK 3 RETHA YRINGE 3 P P P 0.08 / day 0.07 / 1 days 0.07 / 1 days rosuvastatin calcium 1 IMCOR ( MG TABLET, MG TABLET, 1, MG TABLET) 3 2 / day GE 89 LAT UPDATED 04/2017

90 PRODUCT DECRIPTION TIER LIMIT & RETRICTION IMCOR ( MG TABLET, 1, MG TABLET) 3 simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) / day simvastatin 5 mg tablet 1 simvastatin 80 mg tablet 1 TRICOR 145 MG TABLET 3 TRICOR 48 MG TABLET 3 2 / day TRIGLIDE 3 TRILIPIX DR 135 MG CAPULE 3 TRILIPIX DR 45 MG CAPULE 3 2 / day VACE 3 4 / day VYTORIN 2 WELCHOL 3.75G CKET 2 WELCHOL 625 MG TABLET 2 6 / day ZETIA 3 ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) / day ZOCOR 5 MG TABLET 3 ZOCOR 80 MG TABLET 3 BETA-ADRENERGIC BLOCKING AGENT LEVATOL 3 CALCIUM-CHANNEL BLOCKING AGENT ADALAT CC 30 MG TABLET 3 ADALAT CC 60 MG TABLET 3 2 / day GE 90 LAT UPDATED 04/2017

91 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ADALAT CC 90 MG TABLET 3 AFEDITAB CR 30 MG TABLET 1 AFEDITAB CR 60 MG TABLET 1 2 / day amlodipine besylate 1 amlodipine besylate-benazepril 1 amlodipine-olmesartan 1 amlodipine-valsartan (5-320 mg, mg, mg) 1 amlodipine-valsartan mg 1 2 / day AZOR 3 CALAN 3 3 / day CALAN R 3 CARDENE I.V. (CARDENE I.V. 25 MG/10 ML AMPUL, CARDENE-DEX 20 MG/200 ML OLN, CARDENE-DEX 40 MG/200 ML IV, CARDENE-NACL 20 MG/200 ML OLN, CARDENE-NACL 40 MG/200 ML IV) 3 CARDENE R 3 2 / day CARDIZEM 3 4 / day CARDIZEM CD (180 MG CAPULE, 240 MG CAPULE, 300 MG CAPULE, 360 MG CAPULE) 3 CARDIZEM CD 120 MG CAPULE 3 CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 3 CARDIZEM LA 120 MG TABLET 3 4 / day CARDIZEM LA 180 MG TABLET 3 3 / day CARDIZEM LA 240 MG TABLET 3 2 / day CARTIA XT 1 GE 91 LAT UPDATED 04/2017

92 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CLEVIPREX 3 DILT XR 120 MG CAPULE 1 DILT-XR (180 MG CAPULE, 240 MG CAPULE) 1 diltiazem 12hr er 1 diltiazem 24hr cd (24hr 180 mg cap, 24hr 240 mg cap, 24hr 300 mg cap, 24hr 360 mg cap) 1 diltiazem 24hr cd 120 mg cap 1 diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mg cap, 24hr er 300 mg tab, 24hr er 360 mg tab, 24hr er 420 mg tab) diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 1 diltiazem 24hr er 180 mg tab 1 3 / day diltiazem 24hr er 240 mg tab 1 2 / day diltiazem 90 mg tablet 1 diltiazem er (er 120 mg capsule, er 180 mg capsule) 1 diltiazem er 240 mg capsule 1 diltiazem hcl (25 mg/5 ml vial, 50 mg/10 ml vial, hcl 100 mg vial, 125 mg/25 ml vial) 1 diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 4 / day diltiazem hcl-0.9 % nacl 1 diltiazem-d5w 1 EXFORGE 3 felodipine er 1 isradipine 1 2 / day LOTREL 3 MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 GE 92 LAT UPDATED 04/2017

93 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MATZIM LA 180 MG TABLET 1 3 / day MATZIM LA 240 MG TABLET 1 2 / day nicardipine hcl (2.5 mg/ml syringe, 25 mg/10 ml ampule, 25 mg/10 ml vial) 1 nicardipine hcl (20 mg capsule, 30 mg capsule) 1 nicardipine hcl-0.9% nacl 1 NIFEDIAC CC 1 NIFEDICAL XL 1 nifedipine 10 mg capsule 1 3 / day nifedipine 20 mg capsule 1 4 / day nifedipine er (er 30 mg tablet, er 90 mg tablet) 1 nifedipine er 60 mg tablet 1 2 / day nimodipine 1 nisoldipine 1 NORVAC 3 NYMALIZE / day PRETALIA 3 T PROCARDIA 3 3 / day PROCARDIA XL 3 ULAR 3 TARKA 3 TAZTIA XT (120 MG CAPULE, 180 MG CAPULE) 1 TAZTIA XT (240 MG CAPULE, 300 MG CAPULE, 360 MG CAPULE) 1 GE 93 LAT UPDATED 04/2017

94 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TEKAMLO 3 telmisartan-amlodipine 1 TIAZAC (ER 120 MG CAPULE, ER 180 MG CAPULE) 3 TIAZAC (ER 240 MG CAPULE, ER 300 MG CAPULE, ER 360 MG CAPULE, ER 420 MG CAPULE) 3 trandolapril-verapamil er 1 TWYNTA 3 verapamil er (er 120 mg capsule, er 180 mg capsule, er 240 mg capsule) verapamil er (er 120 mg tablet, er 180 mg tablet, er 240 mg tablet) 1 1 verapamil er pm (er 200 mg capsule, er 300 mg capsule) 1 verapamil er pm 100 mg capsule 1 verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml syringe, 2.5 mg/ml vial, 5 mg/2 ml vial) 1 verapamil hcl (40 mg tablet, 360 mg cap pellet) 1 verapamil hcl (80 mg tablet, 120 mg tablet) 1 3 / day verapamil sr 1 VERELAN 3 VERELAN PM (200 MG CAP PELLET, 300 MG CAP PELLET) 3 VERELAN PM 100 MG CAP PELLET 3 CARDIAC DRUG ADENOCARD 3 adenosine (6 mg/2 ml syringe, 6 mg/2 ml vial, 12 mg/4 ml syringe, 12 mg/4 ml vial) amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 1 GE 94 LAT UPDATED 04/2017

95 PRODUCT DECRIPTION TIER LIMIT & RETRICTION amiodarone hcl (150 mg/3 ml amp, 150 mg/3 ml syringe, 150 mg/3 ml vial, 450 mg/9 ml vial, 900 mg/18 ml vial) amiodarone hcl-d5w (amiodarone 150 mg/100 ml-d5w, amiodarone 900 mg/500 ml-d5w, amiodarone-d5w 150 mg/100 ml) 1 1 CORDARONE 2 CORLANOR 2 CORVERT 3 DIGITEK 1 DIGOX 1 T 2 / day digoxin (0.05 mg/ml solution, mg tablet, 0.25 mg tablet, 0.25 mg/ml syringe, 125 mcg tablet, 250 mcg tablet) 1 digoxin 500 mcg/2 ml ampule 1 DILANTIN (30 MG CAPULE, 50 MG INFATAB, 100 MG CAPULE) 2 DILANTIN disopyramide phosphate 1 dofetilide 1 flecainide acetate 1 ibutilide fumarate 1 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, MCG TABLET, 250 MCG TABLET, 500 MCG/2 ML AMPULE) 2 LANOXIN PEDIATRIC 2 lidocaine hcl (1% abboject, 1% syringe, 2% abboject, 2% luer-jet, 2% syringe, 2% vial) 1 lidocaine hcl 100 mg/10 ml syr 1 lidocaine hcl in 5% dextrose 1 mexiletine hcl 1 GE 95 LAT UPDATED 04/2017

96 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MULTAQ 3 NEXTERONE 3 NORCE 3 NORCE CR 100 MG CAPULE 2 NORCE CR 150 MG CAPULE 3 CERONE 1 PHENYTEK 2 phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4 ml susp, 125 mg/5 ml susp) 1 phenytoin sodium 1 phenytoin sodium extended 1 procainamide hcl (100 mg/ml vial, 500 mg/ml vial) 1 propafenone hcl 1 propafenone hcl er 1 RANEXA 2 2 / day RYTHMOL 3 RYTHMOL R 3 TIKOYN 3 XYLOCAINE IV 3 HYPOTENIVE AGENT ACCUPRIL 3 2 / day ACEON 3 ALTACE 3 2 / day ATACAND 3 AVAPRO 3 benazepril hcl (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 2 / day GE 96 LAT UPDATED 04/2017

97 PRODUCT DECRIPTION TIER LIMIT & RETRICTION benazepril hcl 5 mg tablet 1 3 / day BENICAR 3 3 / day BIDIL 3 6 / day candesartan cilexetil 1 captopril 1 4 / day CORLOM 3 COZAAR (25 MG TABLET, 50 MG TABLET) 3 2 / day COZAAR 100 MG TABLET 3 DIOVAN 3 EDARBI 3 T enalapril maleate 1 2 / day enalaprilat 1 ENED 3 5 / day eplerenone 1 eprosartan mesylate 1 fosinopril sodium (10 mg tab, 20 mg tab) 1 fosinopril sodium 40 mg tab 1 2 / day guanfacine hcl 1 guanfacine hcl er 1 hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 INPRA 3 INTUNIV 3 irbesartan 1 GE 97 LAT UPDATED 04/2017

98 PRODUCT DECRIPTION TIER LIMIT & RETRICTION lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet) 1 lisinopril 40 mg tablet 1 2 / day losartan potassium (25 mg tab, 50 mg tab) 1 2 / day losartan potassium 100 mg tab 1 LOTENIN 20 MG TABLET 3 LOTENIN 40 MG TABLET 3 MAVIK 3 MICARDI 3 minoxidil 1 moexipril hcl 1 NITROPRE 3 olmesartan medoxomil 1 3 / day perindopril erbumine 1 PRINIVIL 3 PROGLYCEM 3 QBRELI 3 5 / day quinapril hcl 1 2 / day ramipril 1 2 / day reserpine 1 sodium nitroprusside 1 telmisartan 1 TENEX 3 trandolapril 1 valsartan 1 GE 98 LAT UPDATED 04/2017

99 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VAOTEC 3 2 / day VECAMYL 3 ZETRIL 3 RENIN-ANGIOTENIN-ALDOTERONE Y. INHIB ENTRETO 3 TEKTURNA (150 MG TABLET, 300 MG TABLET) 3 VAODILATING AGENT ADCIRCA 3 ADEM 3 amyl nitrite 1 T 2 / day 2 / day 3 / day CAVERJECT (IMPULE 10 MCG KIT, 20 MCG VIAL, IMPULE 20 MCG KIT, 40 MCG VIAL) 3 GL Male CIALI (10 MG TABLET, 20 MG TABLET) 2 CIALI (2.5 MG TABLET, 5 MG TABLET) 2 GL GL 0.2 / day Male Male DILATRATE-R 2 4 / day EDEX 3 GL Male epoprostenol sodium 1 GE 99 LAT UPDATED 04/2017

100 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FLOLAN 3 GONITRO 3 AL 1.25 / day At least 18 yrs old IOCHRON 1 4 / day IORDIL 2 12 / day IORDIL TITRADOE 3 12 / day isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet) 1 12 / day isosorbide dn er 40 mg tablet 1 4 / day isosorbide mononitrate 1 2 / day isosorbide mononitrate er 1 2 / day isoxsuprine hcl 1 LETAIRI 3 LEVITRA 3 P GL AL 0.2 / day Male At least 18 yrs old MINITRAN 1 MUE 3 GL Male NATRECOR 3 NITRO-BID 2 4 / day NITRO-DUR (0.1 MG/HR TCH, 0.2 MG/HR TCH, 0.3 MG/HR TCH, 0.4 MG/HR TCH, 0.6 MG/HR TCH) 3 GE 100 LAT UPDATED 04/2017

101 PRODUCT DECRIPTION TIER LIMIT & RETRICTION NITRO-DUR 0.8 MG/HR TCH 2 NITRO-TIME 1 4 / day nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 6 / day nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mg capsule) 1 4 / day nitroglycerin 400 mcg spray / day nitroglycerin 5 mg/ml vial 1 nitroglycerin in d5w 1 nitroglycerin lingual 0.4 mg / day nitroglycerin patch 1 NITROLINGUAL / day NITROMIT / day NITRONAL 3 NITROTAT 3 6 / day OPUMIT 3 ORENITRAM ER 3 papaverine hcl 1 papaverine-alprostadil 1 REMODULIN 3 REVATIO 10 MG/12.5 ML VIAL 3 AL At least 18 yrs old GE 101 LAT UPDATED 04/2017

102 PRODUCT DECRIPTION TIER LIMIT & RETRICTION REVATIO 10 MG/ML ORAL UP 3 REVATIO 20 MG TABLET 3 sildenafil 1 sildenafil citrate 1 TAXYN 3 TENDRA 3 TRACLEER 3 TYVAO 3 TYVAO INTITUTIONAL TART KIT 3 AL AL AL GL GL P 6 / days At least 18 yrs old 3 / days At least 18 yrs old 3 / day At least 18 yrs old 0.2 / day Male 0.2 / day Male 2 / day s s GE 102 LAT UPDATED 04/2017

103 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TYVAO REFILL KIT 3 TYVAO TARTER KIT 3 s s UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) 3 AL 2 / day At least 18 yrs old UPTRAVI TITRATION CK 3 VELETRI 3 AL At least 18 yrs old VENTAVI (10 MCG/1 ML OLUTION, 20 MCG/1 ML OLUTION) 3 9 / days VIAGRA 2 CELLULAR THERAPY PROVENGE 3 GL AL 0.2 / day Male At least 18 yrs old GE 103 LAT UPDATED 04/2017

104 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CENTRAL NERVOU YTEM AGENT ANALGEIC AND ANTIPYRETIC ABTRAL 3 4 / day acetaminophen-cod #2 tablet 1 22 / day acetaminophen-cod #3 tablet 1 12 / day acetaminophen-cod #4 tablet 1 6 / day acetaminophen-codeine (acetamin-codein mg/12.5, acetaminop-codeine mg/5) / day ACTIQ 3 4 / day ALLZITAL 1 6 / day ANAPROX 3 ANAPROX D 3 ARTHROTEC 50 3 ARTHROTEC 75 3 asa-butalb-caffeine-codeine 1 6 / day ACOMP WITH CODEINE 1 6 / day ATRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) / day ATRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 50 / day AVINZA 3 BELBUCA 3 AL 2 / day At least 18 yrs old belladonna-opium supp 1 2 / day GE 104 LAT UPDATED 04/2017

105 PRODUCT DECRIPTION TIER LIMIT & RETRICTION belladonna-opium supp 1 BUNAVAIL ( MG FILM, MG FILM) 3 BUNAVAIL MG FILM 3 3 / day 2 / day BUP 1 6 / day BUPRENEX 3 17 / day buprenorphine hcl (0.3 mg/ml syrn, 0.3 mg/ml vial) 1 17 / day buprenorphine hcl (2 mg tablet, 8 mg tablet) 1 buprenorphine-naloxone 1 3 / day 3 / day butalb-acetaminoph-caff-codein 1 6 / day butalb-caff-acetaminoph-codein 1 6 / day butalbital compound-codeine 1 6 / day butalbital-acetaminophen 1 6 / day butalbital-acetaminophen-caffe 1 6 / day butorphanol 1 mg/ml vial 1 7 / day butorphanol 10 mg/ml spray / day butorphanol 2 mg/ml vial 1 4 / day BUTRAN 3 CALDOLOR 3 CAMBIA / day GE 105 LAT UPDATED 04/2017

106 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CACET 1 6 / day CAPITAL W-CODEINE / day CELEBREX (50 MG CAPULE, 200 MG CAPULE) 3 2 / day CELEBREX 100 MG CAPULE 3 3 / day CELEBREX 400 MG CAPULE 3 celecoxib (50 mg capsule, 200 mg capsule) 1 2 / day celecoxib 100 mg capsule 1 3 / day celecoxib 400 mg capsule 1 choline mag trisalicylate 1 codeine sulfate 1 6 / day CONZIP 3 DAYPRO 3 DEMEROL (100 MG TABLET, 100 MG/ML AMPUL, 100 MG/ML YRINGE, 100 MG/ML VIAL) DEMEROL (50 MG TABLET, 50 MG/ML AMPUL, 50 MG/ML CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 ML AMPUL) 3 5 / day 3 10 / day DEMEROL 25 MG/ML CARPUJECT 3 20 / day DEMEROL 75 MG/ML YRINGE 3 7 / day diclofenac potassium 1 diclofenac sodium (1.5% topical soln, sod dr 25 mg tab, sod dr 50 mg tab, sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sod ec 75 mg tab) 1 diclofenac sodium 1% gel / 30 days diclofenac sodium er 1 diclofenac sodium-misoprostol 1 diflunisal 1 GE 106 LAT UPDATED 04/2017

107 PRODUCT DECRIPTION TIER LIMIT & RETRICTION dihydrocodein-acetaminoph-caff 1 10 / day DILAUDID (0.5 MG/0.5 ML YRINGE, 1 MG/ML YRINGE, 2 MG/ML YRINGE, 4 MG/ML YRINGE) 3 DILAUDID (1 MG/ML AMPUL, 1 MG/ML LIQUID) 3 13 / day DILAUDID (2 MG TABLET, 2 MG/ML AMPUL, 4 MG TABLET, 8 MG TABLET) 3 6 / day DILAUDID 4 MG/ML AMPUL 3 3 / day DILAUDID-HP (10 MG/ML AMPUL, 10 MG/ML VIAL) 3 DILAUDID-HP 250 MG VIAL 3 DIALCID 3 DOLOPHINE HCL 3 DUEXI 3 DURAGEIC 3 3 / day 3 / day 0.5 / day DURAMORPH 10 MG/10 ML AMPUL 1 5 / day DURAMORPH 5 MG/10 ML AMPUL 1 10 / day DYLOJECT 3 EC-NAPROYN 3 EMBEDA 2 2 / day ENDOCET 1 12 / day ENDODAN 1 7 / day EGIC MG TABLET 3 6 / day EGIC CAPULE 1 6 / day GE 107 LAT UPDATED 04/2017

108 PRODUCT DECRIPTION TIER LIMIT & RETRICTION etodolac 1 etodolac er 1 EXALGO 3 FELDENE 3 fenoprofen calcium 1 FENORTHO 3 fentanyl / day fentanyl 1,375 mcg/55-0.9%nacl 1 15 / day fentanyl 2 mcg-bupivac 0.1%-ns 1 fentanyl 2 mcg-ropiv 0.2%-ns / day fentanyl 250 mcg/5 ml syringe 1 2 / day fentanyl 5,000mcg/ %nacl 1 fentanyl citrate (0.05 mg/ml syringe, 100 mcg/2 ml syringe, 1,500 mcg/30 ml syr, 2,750 mcg/55 ml syr) 1 8 / day fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) 1 4 / day fentanyl citrate-0.9% nacl (600 mcg/30ml-0.9%nacl, 2,000mcg/ %nacl) fentanyl citrate-0.9% nacl (fentanyl-0.9%nacl 1,000mcg/100, fentanyl 10 mcg/ml-0.9% nacl, fentanyl 1,000mcg/ %nacl, fentanyl 2,500mcg/ %nacl) 1 19 / day 1 38 / day fentanyl-bup-ns 4 mcg/ml-0.1% 1 96 / day fentanyl-bupivacaine-0.9% nacl (2 mcg-bupiv 0.125%- ns, 2mcg-bupiv %-ns) / day GE 108 LAT UPDATED 04/2017

109 PRODUCT DECRIPTION TIER LIMIT & RETRICTION fentanyl-bupivacaine-0.9% nacl (fentanyl 2 mcg-bup %-ns, fentanyl 2 mcg-bupiv 0.1%-ns, fentanylbupiv-ns 2 mcg-0.1%, fentanyl-bupiv-ns 2 mcg-0.125%) fentanyl-ropivacaine-0.9% nacl (fentanyl 2 mcg-ropiv 0.1%-ns, fentanyl 2 mcg-ropiv 0.15%-ns, fentanyl-ropivns 2 mcg-0.1%) / day / day FENTORA 3 4 / day FIORICET 3 6 / day FIORICET WITH CODEINE 3 6 / day FIORINAL WITH CODEINE #3 3 6 / day FLECTOR 3 2 / day flurbiprofen 1 gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 9 / day gabapentin 250 mg/5 ml soln 1 36/ day gabapentin 300 mg/6 ml soln 1 gabapentin 600 mg tablet 1 6 / day gabapentin 800 mg tablet 1 5 / day GRALIE 30-DAY TARTER CK 3 T GRALIE ER 300 MG TABLET 3 GRALIE ER 600 MG TABLET 3 T T 3 / day HORIZANT ER 300 MG TABLET 3 2 / day HORIZANT ER 600 MG TABLET 3 HYCET / day GE 109 LAT UPDATED 04/2017

110 PRODUCT DECRIPTION TIER LIMIT & RETRICTION hydrocodon-acetaminoph / day hydrocodon-acetaminoph / day hydrocodone-acetamin / / day hydrocodone-acetaminophen (hydrocodon-acetamin /15, hydrocodone-acetamin /5, hydrocodoneacetamin 5-217/10) hydrocodone-acetaminophen (hydrocodon-acetaminoph , hydrocodon-acetaminophen 5-300, hydrocodonacetaminophn ) hydrocodone-acetaminophen (hydrocodonacetaminophen 5-325, hydrocodon-acetaminophn ) / day 1 13 / day 1 12 / day hydrocodone-ibuprofen ( , , ) 1 5 / day hydrocodone-ibuprofen mg 1 6 / day hydromor 5 mcg-bupiva 0.1%-ns 1 10 / day hydromorp 20 mcg-bupiv 0.1%-ns 1 3 / day hydromorph-ropiva-0.9% nacl 1 6 / day hydromorphone 0.5 mg/0.5 ml 1 50 / day hydromorphone 0.5 mg/50 ml-ns / day hydromorphone 1 mg/50 ml-ns 1 50 / day hydromorphone 10 mg/50 ml-ns 1 hydromorphone 2 mg/50 ml-ns / day hydromorphone 3 mg suppos 1 4 / day hydromorphone 4 mg/ml carpujct 1 3 / day hydromorphone 50 mg/50 ml-ns 1 hydromorphone 6 mg/30 ml-ns 1 63 / day GE 110 LAT UPDATED 04/2017

111 PRODUCT DECRIPTION TIER LIMIT & RETRICTION hydromorphone er 1 hydromorphone hcl (1 mg/ml carpujct, 1 mg/ml syringe, hcl 1 mg/ml amp) 1 13 / day hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1 13 / day hydromorphone hcl (10 mg/ml vial, hcl 10 mg/ml amp, hcl 10 mg/ml vl, 50 mg/5 ml vial, 500 mg/50 ml via) hydromorphone hcl (2 mg tablet, 2 mg/ml carpujct, 2 mg/ml syringe, 2 mg/ml vial, 4 mg tablet, 8 mg tablet) / day hydromorphone hcl (hcl 2 mg/ml amp, 60 mg/30 ml syr) 1 6 / day hydromorphone hcl 4 mg/ml amp 1 3 / day hydromorphone hcl-0.9% nacl (100 mg/50 ml-ns, 200 mg/100 ml-ns) hydromorphone hcl-0.9% nacl (15 mg/30 ml-ns, 25 mg/50 ml-ns) hydromorphone hcl-0.9% nacl (30 mg/30 ml-ns, 55 mg/55 ml-ns) hydromorphone hcl-0.9% nacl (hydromorphone 20 mg/100 ml-ns, hydromorphone-ns 6 mg/30 ml, hydromorphone-ns 10 mg/50 ml, hydromorphone-ns 20 mg/100 ml) 1 6 / day 1 25 / day 1 13 / day 1 63 / day HYINGLA ER 3 IBUDONE MG TABLET 3 5 / day IBUDONE MG TABLET 1 6 / day ibuprofen (100 mg/5 ml susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1 ibuprofen lysine 3 INDOCIN 25 MG/5 ML UPENION 3 6 / day INDOCIN 50 MG UPPOITORY 3 4 / day GE 111 LAT UPDATED 04/2017

112 PRODUCT DECRIPTION TIER LIMIT & RETRICTION indomethacin (25 mg capsule, 50 mg capsule, er 75 mg capsule) 1 indomethacin 1 mg vial 1 INFUMORPH 200 MG/20 ML AMPUL 3 5 / day INFUMORPH 500 MG/20 ML AMPUL 3 2 / day IONY 3 isomethept-caff-acetaminophen 1 isomethept-dichloralp-acetamin 1 KADIAN (ER 10 MG CAPULE, ER 20 MG CAPULE, ER 50 MG CAPULE, ER 100 MG CAPULE) 3 2 / day KADIAN (ER 30 MG CAPULE, ER 40 MG CAPULE, ER 60 MG CAPULE, ER 80 MG CAPULE, ER 200 MG CAPULE) 3 ketoprofen 1 ketorolac 10 mg tablet 1 21 / fill ketorolac 30 mg/ml syringe 1 20 / 23 days ketorolac tromethamine (15 mg/ml carpuject, 15 mg/ml isecure syr, 15 mg/ml vial) ketorolac tromethamine (30 mg/ml carpuject, 60 mg/2 ml syringe, 60 mg/2 ml vial, 300 mg/10 ml vial) ketorolac tromethamine (30 mg/ml isecure syr, 30 mg/ml vial) 1 40 / 23 days 1 20 / 30 days 1 20 / 23 days KLOFENAID II 1 LAZANDA 3 4 / day levorphanol tartrate 1 4 / day LODINE 3 LORCET 1 12 / day GE 112 LAT UPDATED 04/2017

113 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LORCET HD 1 12 / day LORCET PLU 1 6 / day LORTAB (5-325 MG TABLET, MG TABLET, MG TABLET) 1 8 / day LORTAB 10 MG-300 MG/15 ML ELXR 3 90 / day MARGEIC 1 6 / day MARTEN-TAB 1 6 / day meclofenamate sodium 1 mefenamic acid 1 5 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 meloxicam 7.5 mg/5 ml susp 1 10 / day meperidine 25 mg/ml vial 1 20 / day meperidine hcl (10 mg/ml cartrdge, 50 mg/5 ml solution) 1 50 / day meperidine hcl (100 mg tablet, 100 mg/ml vial) 1 5 / day meperidine hcl (50 mg tablet, 50 mg/ml vial) 1 10 / day meperidine hcl-0.9% nacl (meperidine 550 mg/55 ml-ns syr, meperidine-ns 250 mg/25 ml syr, meperidine-ns 550 mg/55 ml syr, meperidine-ns 1,000 mg/100 ml) 1 50 / day methadone 10 mg/5 ml solution 1 methadone 5 mg/5 ml solution 1 methadone hcl (10 mg/ml oral conc, hcl 10 mg tablet) 1 methadone hcl 10 mg/ml syringe 1 8 / day 18 / day 2 / day 2 / day GE 113 LAT UPDATED 04/2017

114 PRODUCT DECRIPTION TIER LIMIT & RETRICTION methadone hcl 10 mg/ml vial 1 2 / day methadone hcl 5 mg tablet 1 METHADONE INTENOL 1 METHADOE 10 MG/ML ORAL CONC 3 MIGRAGEIC IDA 1 3 / day 2 / day 2 / day MOBIC (7.5 MG TABLET, 15 MG TABLET) 3 MOBIC 7.5 MG/5 ML UPENION 3 10 / day morphine 0.5 mg/ml vial 1 morphine 0.5 mg/ml-0.9% nacl 1 morphine 1 mg/2 ml syringe 1 morphine 1 mg/ml vial p-f 1 morphine 1,000 mg/100 ml-ns 1 morphine 1,250 mg/250 ml-ns 1 morphine 15 mg/ml carpuject 1 morphine 2 mg/ml syringe 1 morphine 300 mg/30ml-0.9% nacl / day 100 / day 100 / day 50 / day 10 / day 3 / day 25 / day 5 / day GE 114 LAT UPDATED 04/2017

115 PRODUCT DECRIPTION TIER LIMIT & RETRICTION morphine 4 mg/ml syringe 1 morphine 5 mg/ml syringe 1 morphine 5 mg/ml vial 1 morphine 500mg/100ml-0.9% nacl 1 morphine 8 mg/ml vial 1 13 / day 10 / day 10 / day 10 / day 6 / day morphine sulf 10 mg suppos 1 5 / day morphine sulf 10 mg/5 ml soln 1 25 / day morphine sulf 20 mg/5 ml soln 1 13 / day morphine sulf 5 mg suppos 1 10 / day morphine sulfate (10 mg/ml carpuject, 10 mg/ml isecure syr, sulfate 10 mg/ml vial) 1 5 / day morphine sulfate (10 mg/ml syringe, 10 mg/ml vial, 100 mg/10 ml vial) 1 5 / day morphine sulfate (2 mg/ml carpuject, 2 mg/ml isecure syr) 1 morphine sulfate (25 mg/ml vial, 25 mg/ml vl) 1 25 / day 2 / day morphine sulfate (4 mg/ml carpuject, 4 mg/ml isecure syr, sulfate 4 mg/ml vial) 1 13 / day morphine sulfate (8 mg/ml isecure syr, 8 mg/ml syringe, sulfate 8 mg/ml vial) 1 6 / day GE 115 LAT UPDATED 04/2017

116 PRODUCT DECRIPTION TIER LIMIT & RETRICTION morphine sulfate (sulf 10 mg/0.7 ml syr, 15 mg/ml vial, 300 mg/20 ml vial) 1 3 / day morphine sulfate (sulf 20 mg suppos, sulf 100 mg/5 ml soln, sulfate ir 15 mg tab) 1 3 / day morphine sulfate (sulf 30 mg suppos, sulfate ir 30 mg tab) 1 2 / day morphine sulfate (sulfate 1 mg/ml vial, 30 mg/30 ml syringe) 1 50 / day morphine sulfate 50 mg/ml vial 1 morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, er 100 mg cap) 1 2 / day morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg tablet, er 100 mg tablet, er 200 mg tablet) 1 3 / day morphine sulfate er (er 30 mg cap, er 45 mg cap, er 60 mg cap, er 75 mg cap, er 80 mg cap, er 90 mg cap, er 120 mg cap) 1 morphine sulfate-0.9% nacl (30 mg/30 ml-0.9%, 50 mg/50 ml-0.9%, 100mg/100ml-0.9%) 1 50 / day morphine sulfate-0.9% nacl (morphine 1 mg/ml-0.9% nacl syr, morphine 2 mg/2 ml-0.9% nacl, morphine 10 mg/10 ml-ns syrng, morphine-ns 50 mg/50 ml bag, morphine-ns 100 mg/100 ml) 1 50 / day M CONTIN 3 nabumetone 1 3 / day nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1 5 / day nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1 3 / day NALFON 3 NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3 GE 116 LAT UPDATED 04/2017

117 PRODUCT DECRIPTION TIER LIMIT & RETRICTION NAPRELAN CR 750 MG TABLET 3 NAPROYN (125 MG/5 ML UPEN, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET) naproxen (125 mg/5 ml suspen, 250 mg tablet, 375 mg tablet, dr 375 mg tablet, ec 375 mg tablet, 500 mg kit, 500 mg tablet, dr 500 mg tablet, ec 500 mg tablet) 3 1 naproxen sod er 375 mg tablet 1 naproxen sodium 1 naproxen sodium cr 1 naproxen sodium ds 1 NEOPROFEN 3 NEURONTIN (100 MG CAPULE, 300 MG CAPULE, 400 MG CAPULE) 3 9 / day NEURONTIN 250 MG/5 ML OLN 3 15 / day NEURONTIN 600 MG TABLET 3 6 / day NEURONTIN 800 MG TABLET 3 5 / day NODOLOR 1 NORCO 3 12 / day NUCYNTA (50 MG TABLET, 75 MG TABLET) 3 6 / day NUCYNTA 100 MG TABLET 3 7 / day NUCYNTA ER 3 2 / day ONA (5 MG TABLET, 10 MG TABLET) 3 12 / day ONA 1 MG/ML INJ AMPULE 3 17 / day ONA ER 3 oxaprozin 1 2 / day GE 117 LAT UPDATED 04/2017

118 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OXAYDO 3 8 / day OXECTA 3 8 / day oxycodon 10 mg/0.5 ml oral syr 1 4 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) 1 8 / day oxycodone hcl 100 mg/5 ml soln 1 2 / day oxycodone hcl 5 mg/5 ml soln 1 33 / day oxycodone hcl er 1 3 / day oxycodone hcl-aspirin 1 7 / day oxycodone hcl-ibuprofen 1 4 / day oxycodone-acetaminophen (oxycodon-acetaminophen , oxycodon-acetaminophen , oxycodoneacetaminophen 5-325, oxycodone-acetaminophen ) 1 12 / day oxycodone-acetaminophn 5-325/ / day OXYCONTIN 3 3 / day oxymorphone hcl 10 mg tablet 1 2 / day oxymorphone hcl 5 mg tablet 1 3 / day oxymorphone hcl er 1 PENNAID (1.5% OLUTION, 2% OLUTION CKET) 3 2 / day PENNAID 2% PUMP / day pentazocine-naloxone hcl 1 12 / day PERCOCET 3 12 / day GE 118 LAT UPDATED 04/2017

119 PRODUCT DECRIPTION TIER LIMIT & RETRICTION piroxicam 1 AL Up to 75 yrs old PONTEL 3 5 / day PRIALT 3 PRIMLEV MG TABLET 3 3 / day PRIMLEV MG TABLET 3 7 / day PRIMLEV MG TABLET 3 4 / day PRODRIN 3 REPREXAIN MG TABLET 1 5 / day REPREXAIN MG TABLET 3 5 / day REPREXAIN MG TABLET 3 6 / day ROXICET 3 33 / day ROXICODONE 3 8 / day salsalate 1 PRIX 3 5 days UBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 UBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 UBY 3 sulindac 1 3 / day 2 / day 12 / day TALWIN 3 5 / day TENCON 1 6 / day TIVORBEX 3 GE 119 LAT UPDATED 04/2017

120 PRODUCT DECRIPTION TIER LIMIT & RETRICTION tolmetin sodium 1 tramadol hcl 1 8 / day tramadol hcl er 1 tramadol hcl-acetaminophen 1 8 / day TREXIMET 3 T 0.3 / day TREZIX 3 10 / day TYLENOL-CODEINE NO / day TYLENOL-CODEINE NO / day ULTRACET 3 8 / day ULTRAM 3 8 / day ULTRAM ER 3 VANATOL LQ 3 VERDROCET 1 20 / day VICODIN 1 8 / day VICODIN E 1 13 / day VICODIN HP 1 13 / day VICOPROFEN 3 5 / day VIMOVO 3 VIVLODEX 3 T AL 2 / day At least 18 yrs old GE 120 LAT UPDATED 04/2017

121 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VOLTAREN / 30 days VOLTAREN-XR 3 XARTEMI XR 3 12 / day XODOL / day XODOL / day XODOL / day XTAMPZA ER 3 2 / day ZAMICET 3 90 / day ZEBUTAL 1 6 / day ZIPOR 3 4 / day ZOHYDRO ER 3 2 / day ZORVOLEX 3 3 / day ZUBOLV 3 ANOREXIGENIC;REPIRATORY,CN TIMULANT ADDERALL 3 ADDERALL XR 3 ADIPEX-P 3 ADZENY XR-ODT 3 T T AL T AL 3 / day 2 / day 2 / day 2 / day At least 17 yrs old At least 6 yrs old GE 121 LAT UPDATED 04/2017

122 PRODUCT DECRIPTION TIER LIMIT & RETRICTION APTENIO XR 10 MG CAPULE 3 APTENIO XR 15 MG CAPULE 3 APTENIO XR 20 MG CAPULE 3 APTENIO XR 30 MG CAPULE 3 APTENIO XR 40 MG CAPULE 3 APTENIO XR 50 MG CAPULE 3 APTENIO XR 60 MG CAPULE 3 6 / day 4 / day 3 / day 2 / day 1.5 / day 1.25 / day armodafinil 1 BELVIQ 3 BELVIQ XR 3 benzphetamine hcl 25 mg tablet 1 benzphetamine hcl 50 mg tablet 1 AL AL AL 2 / day At least 18 yrs old At least 18 yrs old 3 / day At least 12 yrs old 3 / day GE 122 LAT UPDATED 04/2017

123 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BONTRIL PDM 3 AL 3 / day At least 17 yrs old CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36 MG TABLET) 3 T 2 / day CONCERTA ER 54 MG TABLET 3 CONTRAVE 3 T AL 4 / day At least 18 yrs old d-amphetamine er 10 mg capsule 1 5 / day d-amphetamine er 15 mg capsule 1 4 / day d-amphetamine er 5 mg capsule 1 2 / day DAYTRANA 3 DEOXYN 3 T T 5 / day DEXEDRINE 10 MG TABLET 1 6 / day DEXEDRINE 5 MG TABLET 1 2 / day DEXEDRINE NULE 10 MG 3 5 / day DEXEDRINE NULE 15 MG 3 4 / day DEXEDRINE NULE 5 MG 3 2 / day dexmethylphenidate 10 mg tab 1 2 / day dexmethylphenidate er 20 mg cp 1 2 / day dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 3 / day GE 123 LAT UPDATED 04/2017

124 PRODUCT DECRIPTION TIER LIMIT & RETRICTION dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) 1 dextroamphetamine 10 mg tab 1 6 / day dextroamphetamine 5 mg tab 1 2 / day dextroamphetamine 5 mg/5 ml 1 60 / day dextroamphetamine-amphet er 1 2 / day dextroamphetamine-amphetamine 1 2 / day DIDREX 3 diethylpropion hcl 1 diethylpropion hcl er 1 DOPRAM 3 doxapram hcl 1 DYANAVEL XR 3 EVEKEO 3 AL T AL T 3 / day 3 / day At least 16 yrs old 24 / day At least 6 yrs old 6 / day FOCALIN 3 2 / day FOCALIN XR (5 MG CAPULE, 10 MG CAPULE, 15 MG CAPULE, 25 MG CAPULE, 30 MG CAPULE, 35 MG CAPULE, 40 MG CAPULE) 3 T FOCALIN XR 20 MG CAPULE 3 T 2 / day GE 124 LAT UPDATED 04/2017

125 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LOMAIRA 1 METADATE CD 3 AL T 3 / day At least 17 yrs old METADATE ER 1 3 / day methamphetamine hcl 1 5 / day METHYLIN (2.5 MG TAB, 5 MG TABLET) 3 3 / day METHYLIN 10 MG CHEWABLE TABLET 3 6 / day METHYLIN 10 MG/5 ML OLUTION 3 30 / day METHYLIN 5 MG/5 ML OLUTION 3 60 / day methylphenidate 10 mg chew tab 1 6 / day methylphenidate 10 mg tablet 1 5 / day methylphenidate 10 mg/5 ml sol 1 30 / day methylphenidate 2.5 mg chew tb 1 methylphenidate 5 mg/5 ml soln 1 60 / day methylphenidate er (er 18 mg tab, er 27 mg tab, er 30 mg cap, er 36 mg tab) methylphenidate er (er 20 mg cap, er 40 mg cap, er 54 mg tab) 1 2 / day 1 methylphenidate er 10 mg tab 1 5 / day methylphenidate er 20 mg tab 1 3 / day methylphenidate hcl (5 mg chew tab, 5 mg tablet, 20 mg tablet) 1 3 / day methylphenidate hcl cd 1 methylphenidate hcl er (er 10 mg cap, er 50 mg cap, er 60 mg cap) 1 GE 125 LAT UPDATED 04/2017

126 PRODUCT DECRIPTION TIER LIMIT & RETRICTION methylphenidate la (20 mg cap, 40 mg cap, 60 mg cap) 1 methylphenidate la 30 mg cap 1 2 / day modafinil 1 2 / day NUVIGIL 3 phendimetrazine 35 mg tablet 1 phendimetrazine er 105 mg cap 1 phentermine hcl (15 mg capsule, 30 mg capsule) 1 phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PROCENTRA 3 PROVIGIL 3 QYMIA 3 QUILLICHEW ER 3 QUILLIVANT XR 3 AL T AL T AL T 3 / day 2 / day At least 17 yrs old 60 / day 2 / day At least 18 yrs old At least 6 yrs old 12 / day GE 126 LAT UPDATED 04/2017

127 PRODUCT DECRIPTION TIER LIMIT & RETRICTION REGIMEX 3 AL 3 / day At least 12 yrs old RITALIN (5 MG TABLET, 20 MG TABLET) 3 3 / day RITALIN 10 MG TABLET 3 5 / day RITALIN LA (10 MG CAPULE, 20 MG CAPULE, 40 MG CAPULE, 60 MG CAPULE) 3 T RITALIN LA 30 MG CAPULE 3 T 2 / day UPRENZA ODT 3 VYVANE 2 ZENZEDI (15 MG TABLET, 30 MG TABLET) 3 2 / day ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3 3 / day ZENZEDI 10 MG TABLET 1 6 / day ZENZEDI 5 MG TABLET 1 2 / day ZENZEDI 7.5 MG TABLET 3 8 / day ANTICONVULANT APTIOM 3 ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3 3 / day ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 ML VIAL, 40 MG/10 ML VIAL) 3 ATIVAN 2 MG TABLET 3 5 / day BANZEL (40 MG/ML UPENION, 200 MG TABLET, 400 MG TABLET) 3 BRIVIACT (10 MG TABLET, 50 MG TABLET) 3 4 / day GE 127 LAT UPDATED 04/2017

128 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BRIVIACT 10 MG/ML ORAL OLN 3 BRIVIACT 100 MG TABLET 3 BRIVIACT 25 MG TABLET 3 BRIVIACT 50 MG/5 ML VIAL 3 BRIVIACT 75 MG TABLET 3 20 / day 2 / day 8 / day 20 / day 3 / day carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mg tablet) 1 carbamazepine er 1 CARBATROL 2 CELONTIN 3 CEREBYX 3 clonazepam (0.125 mg dis tab, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg tablet, 1 mg dis tablet, 1 mg tablet) 1 3 / day clonazepam (2 mg odt, 2 mg tablet) 1 10 / day clorazepate 15 mg tablet 1 6 / day clorazepate 3.75 mg tablet 1 24 / day clorazepate 7.5 mg tablet 1 12 / day DECON 3 DEKENE (250 MG CAPULE, 250 MG/5 ML OLUTION) 3 DEKOTE 3 DEKOTE ER 2 DEKOTE PRINKLE 2 GE 128 LAT UPDATED 04/2017

129 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DIATAT / day DIATAT ACUDIAL / day diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 5 mg/ml vial, 10 mg tablet, 10 mg/2 ml carpuject, 10 mg/2 ml isecure, 10 mg/2 ml syringe, 50 mg/10 ml vial) diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20 mg rectal gel syst) / day divalproex sodium 1 divalproex sodium er 1 EPITOL 1 EQUETRO 3 ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML UP) 1 3 fosphenytoin sodium 1 FYCOM (2 MG TABLET, 2 MG-4 MG TABLET KIT, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 FYCOM 0.5 MG/ML ORAL UP 3 6 / day GABITRIL (12 MG TABLET, 16 MG TABLET) 2 GABITRIL (2 MG TABLET, 4 MG TABLET) 3 KEPPRA (100 MG/ML ORAL OLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3 KEPPRA 500 MG/5 ML VIAL 3 KEPPRA XR 3 KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3 3 / day KLONOPIN 2 MG TABLET 3 10 / day GE 129 LAT UPDATED 04/2017

130 PRODUCT DECRIPTION TIER LIMIT & RETRICTION LAMICTAL 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 LAMICTAL XR (ORANGE) 3 lamotrigine 1 lamotrigine er 1 lamotrigine odt 1 lamotrigine odt (blue) 1 lamotrigine odt (green) 1 lamotrigine odt (orange) 1 levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) 1 levetiracetam 500 mg/5 ml soln / 30 days levetiracetam 500 mg/5 ml vial 1 levetiracetam er 1 levetiracetam-nacl 1 lorazepam (0.5 mg tablet, 1 mg tablet) 1 3 / day lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 5 / day GE 130 LAT UPDATED 04/2017

131 PRODUCT DECRIPTION TIER LIMIT & RETRICTION lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20 mg/10 ml vial, 40 mg/10 ml vial) 1 LORAZEM INTENOL 1 5 / day lorazepam-0.9% nacl 1 lorazepam-d5w 1 LUMINAL ODIUM 3 LYRICA (225 MG CAPULE, 300 MG CAPULE) 3 2 / day LYRICA (25 MG CAPULE, 50 MG CAPULE, 75 MG CAPULE, 100 MG CAPULE, 150 MG CAPULE, 200 MG CAPULE) 3 3 / day LYRICA 20 MG/ML ORAL OLUTION 3 MYOLINE 3 30 / day ONFI (2.5 MG/ML UPENION, 5 MG TABLET, 10 MG TABLET, 20 MG TABLET) oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5 ml susp, 600 mg tablet) 3 1 OXTELLAR XR 3 PEGANONE 3 phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) 1 phenobarbital sodium 1 POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET) 3 3 / day POTIGA 50 MG TABLET 3 primidone 1 9 / day GE 131 LAT UPDATED 04/2017

132 PRODUCT DECRIPTION TIER LIMIT & RETRICTION QUDEXY XR 3 ROWEEPRA 1 ABRIL 3 PRITAM 3 TEGRETOL (100 MG/5 ML UP, 200 MG TABLET) 3 TEGRETOL XR 2 tiagabine hcl 1 TOMAX 2 topiramate 1 topiramate er 1 AL 6 / day 3 / day At least 4 yrs old TRANXENE T-TAB 3.75 MG 3 24 / day TRANXENE T-TAB 7.5 MG 3 12 / day TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML UP, 600 MG TABLET) 3 TROKENDI XR 3 VALIUM 3 valproate sodium 1 valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/10 ml sol) VIMT (10 MG/ML OLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, TARTER KIT) 1 3 VIMT 200 MG/20 ML VIAL 3 ZARONTIN (250 MG CAPULE, 250 MG/5 ML OLUTION) 2 ZONEGRAN 2 zonisamide 1 GE 132 LAT UPDATED 04/2017

133 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ANTIMANIC AGENT lithium 1 lithium carbonate 1 lithium carbonate er 1 LITHOBID 3 ANTIMIGRAINE AGENT almotriptan malate / day ALUMA / day AMERGE / day AXERT / day FROVA / day frovatriptan succinate / day IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) / day IMITREX (4 MG/0.5 ML CARTRIDGE, 4 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGE, 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML VIAL) / day IMITREX (5 MG NAAL PRAY, 20 MG NAAL PRAY) 3 6 / 30 days MAXALT / day MAXALT MLT / day naratriptan / day naratriptan hcl / day ONZETRA XAIL 3 T RELX / day rizatriptan / day sumatriptan 1 6 / 30 days GE 133 LAT UPDATED 04/2017

134 PRODUCT DECRIPTION TIER LIMIT & RETRICTION sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject, 6 mg/0.5 ml inject, 6 mg/0.5 ml refill, 6 mg/0.5 ml syrng, 6 mg/0.5 ml vial) / day / day UMAVEL DOEPRO / day ZEMBRACE YMTOUCH 3 T / day zolmitriptan / day zolmitriptan odt / day ZOMIG (2.5 MG NAAL PRAY, 5 MG NAAL PRAY) / day ZOMIG (2.5 MG TABLET, 5 MG TABLET) / day ZOMIG ZMT / day ANTIRKINONIAN AGENT (CN) APOKYN 3 AZILECT 3 bromocriptine mesylate 1 cabergoline 1 carbidopa-levodopa 1 carbidopa-levodopa er 1 carbidopa-levodopa-entacapone 1 COMTAN 3 CYCLOET 3 DUO 3 6 / day 1 / 1 days GE 134 LAT UPDATED 04/2017

135 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ELDEPRYL 3 EMAM 3 entacapone 1 MIRAPEX 3 MIRAPEX ER 3 T NEUPRO 3 RLODEL 3 pramipexole dihydrochloride 1 pramipexole er 1 rasagiline mesylate 1 REQUIP 3 REQUIP XL 3 ropinirole er 1 ropinirole hcl 1 RYTARY 3 selegiline hcl 1 INEMET INEMET INEMET INEMET CR 3 TALEVO TALEVO TALEVO TALEVO TALEVO 50 3 TALEVO 75 3 TAMAR 3 GE 135 LAT UPDATED 04/2017

136 PRODUCT DECRIPTION TIER LIMIT & RETRICTION tolcapone 1 ZELAR 3 ANXIOLYTIC, EDATIVE AND HYPNOTIC alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 4 / day alprazolam 2 mg tablet 1 5 / day alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 alprazolam er 2 mg tablet 1 5 / day alprazolam er 3 mg tablet 1 3 / day ALPRAZOLAM INTENOL 3 10 / day alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) 1 4 / day alprazolam odt 2 mg tab 1 5 / day alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 alprazolam xr 2 mg tablet 1 5 / day alprazolam xr 3 mg tablet 1 3 / day AMBIEN 3 AMBIEN CR 3 AMYTAL ODIUM 3 T T BELOMRA 3 T buspirone hcl 1 BUTIOL ODIUM 3 chlordiazepoxide 10 mg capsule 1 30 / day chlordiazepoxide 25 mg capsule 1 12 / day GE 136 LAT UPDATED 04/2017

137 PRODUCT DECRIPTION TIER LIMIT & RETRICTION chlordiazepoxide 5 mg capsule 1 4 / day chlordiazepoxide-amitriptyline 1 dexmedetomidine 200 mcg/2 ml 1 DORAL 3 droperidol 1 EDLUAR 3 T estazolam 1 eszopiclone (1 mg tablet, 2 mg tablet) 1 eszopiclone 3 mg tablet 1 AL Up to 65 yrs old flurazepam hcl 1 HALCION 3 2 / day HETLIOZ 3 INTERMEZZO 3 LUNETA (1 MG TABLET, 2 MG TABLET) 3 LUNETA 3 MG TABLET 3 meprobamate 1 midazolam hcl 2 mg/ml syrup 1 NEMBUTAL ODIUM 3 T T T AL Up to 65 yrs old GE 137 LAT UPDATED 04/2017

138 PRODUCT DECRIPTION TIER LIMIT & RETRICTION oxazepam 1 4 / day PRECEDEX (80 MCG/20 ML INJECT, 200 MCG/2 ML VIAL, 200 MCG/50 ML INJECT, 400 MCG/100 ML INJECT) 3 quazepam 1 RETORIL 3 ROZEREM 3 ECONAL ODIUM 3 ONATA 3 T T temazepam 1 triazolam mg tablet 1 triazolam 0.25 mg tablet 1 2 / day XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 4 / day XANAX 2 MG TABLET 3 5 / day XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 XANAX XR 2 MG TABLET 3 5 / day XANAX XR 3 MG TABLET 3 3 / day zaleplon 1 zolpidem tartrate 1 zolpidem tartrate er 1 ZOLPIMIT / day CENTRAL NERVOU YTEM AGENT, MIC. acamprosate calcium 1 GE 138 LAT UPDATED 04/2017

139 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ADDYI 3 carbidopa 1 flumazenil 1 LODOYN 3 GL AL Female 18 to 60 yrs old memantine 5-10 mg titration pk 1 AL At least 40 yrs old memantine hcl 10 mg tablet 1 memantine hcl 2 mg/ml solution 1 memantine hcl 5 mg tablet 1 AL AL AL 2 / day At least 40 yrs old 360 / 30 days At least 40 yrs old 3 / day At least 40 yrs old NAMENDA (2 MG/ML OLUTION, 5 MG TABLET, 5-10 MG TITRATION PK, 10 MG TABLET) 3 AL At least 40 yrs old NAMENDA XR 3 T AL At least 40 yrs old NUEDEXTA 2 RILUTEK 3 riluzole 1 TRATTERA (10 MG CAPULE, 18 MG CAPULE, 25 MG CAPULE) 2 AL 2 / day At least 6 yrs old TRATTERA (40 MG CAPULE, 60 MG CAPULE, 80 MG CAPULE, 100 MG CAPULE) 2 AL At least 6 yrs old tetrabenazine 1 GE 139 LAT UPDATED 04/2017

140 PRODUCT DECRIPTION TIER LIMIT & RETRICTION XENAZINE 3 XYREM 3 FIBROMYALGIA AGENT 18 / dayspecialty CYMBALTA (20 MG CAPULE, 30 MG CAPULE) 3 CYMBALTA 60 MG CAPULE 3 2 / day duloxetine hcl (dr 20 mg cap, dr 30 mg cap, dr 40 mg cap) 1 duloxetine hcl dr 60 mg cap 1 2 / day IRENKA 3 AVELLA 3 OPIATE ANTAGONIT DEDE 1 EVZIO 3 T 2 / day 2 / rx naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 2 mg/2 ml syringe) 1 naltrexone hcl 1 NARCAN 3 2 / rx REVIA 3 VIVITROL (380 MG VIAL, 380 MG VIAL + DILUENT) 3 GE 140 LAT UPDATED 04/2017

141 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PYCHOTHERAPEUTIC AGENT ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET) 3 AL At least 6 yrs old ABILIFY 1 MG/ML OLUTION 3 ABILIFY 9.7 MG/1.3 ML VIAL 3 ABILIFY DICMELT 3 ABILIFY MAINTENA 3 AL AL AL AL 30 / day At least 6 yrs old At least 6 yrs old 2 / day At least 6 yrs old 0.04 / day At least 18 yrs old ADAUVE 3 AL At least 18 yrs old amitriptyline hcl 1 amoxapine 1 ANAFRANIL 3 APLENZIN 3 aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) 1 AL At least 6 yrs old aripiprazole 1 mg/ml solution 1 aripiprazole odt 1 ARITADA ER 441 MG/1.6 ML YRN 3 AL AL AL 30 / day At least 6 yrs old At least 6 yrs old 0.07 / day At least 18 yrs old GE 141 LAT UPDATED 04/2017

142 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ARITADA ER 662 MG/2.4 ML YRN 3 ARITADA ER 882 MG/3.2 ML YRN 3 BRINTELLIX 3 AL AL T 0.08 / day At least 18 yrs old 0.12 / day At least 18 yrs old BRIDELLE 3 BUPROBAN 1 2 / day bupropion hcl 100 mg tablet 1 5 / day bupropion hcl 75 mg tablet 1 6 / day bupropion hcl sr (150 mg tablet, 200 mg tablet) 1 2 / day bupropion hcl sr 100 mg tablet 1 4 / day bupropion hcl xl 150 mg tablet 1 3 / day bupropion hcl xl 300 mg tablet 1 CELEXA 3 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25 mg/ml amp, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 citalopram hbr 10 mg/5 ml soln 1 20 / day clomipramine hcl 1 clozapine 100 mg tablet 1 clozapine 200 mg tablet 1 AL AL 9 / day At least 18 yrs old 4 / day At least 18 yrs old GE 142 LAT UPDATED 04/2017

143 PRODUCT DECRIPTION TIER LIMIT & RETRICTION clozapine 25 mg tablet 1 clozapine 50 mg tablet 1 AL AL 18 / day At least 18 yrs old 3 / day At least 18 yrs old clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt 150 mg tablet, odt 200 mg tablet) 1 AL 3 / day At least 18 yrs old clozapine odt 100 mg tablet 1 CLOZARIL 100 MG TABLET 3 CLOZARIL 25 MG TABLET 3 COMZINE (5 MG TABLET, 10 MG TABLET) 3 COMZINE 25 MG UPPOITORY 1 COMPRO 1 desipramine hcl 1 AL AL AL 9 / day At least 18 yrs old 9 / day At least 18 yrs old 18 / day At least 18 yrs old desvenlafaxine er 1 desvenlafaxine fumarate er 1 desvenlafaxine succinate er 1 doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) 1 EFFEXOR XR (37.5 MG CAPULE, 75 MG CAPULE) 3 3 / day EFFEXOR XR 150 MG CAPULE 3 2 / day escitalopram 20 mg tablet 1 escitalopram oxalate (5 mg tablet, 10 mg tablet) / day GE 143 LAT UPDATED 04/2017

144 PRODUCT DECRIPTION TIER LIMIT & RETRICTION escitalopram oxalate 5 mg/5 ml 1 20 / day FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 T AL 2 / day At least 18 yrs old FANAPT TITRATION CK 3 AL 8 / rx At least 18 yrs old FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200 MG ODT) 3 AL 3 / day At least 18 yrs old FAZACLO 100 MG ODT 3 FETZIMA 3 AL T 9 / day At least 18 yrs old fluoxetine 20 mg/5 ml solution 1 20 / day fluoxetine dr / day fluoxetine hcl (10 mg tablet, 60 mg tablet) / day fluoxetine hcl (20 mg capsule, 20 mg tablet) 1 4 / day fluoxetine hcl 10 mg capsule 1 fluoxetine hcl 40 mg capsule 1 2 / day fluphenazine decanoate 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 ml elix, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 fluvoxamine maleate (25 mg tab, 50 mg tab) 1 fluvoxamine maleate 100 mg tab 1 3 / day fluvoxamine maleate er 1 2 / day FORFIVO XL 3 GE 144 LAT UPDATED 04/2017

145 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GEODON (20 MG CAPULE, 40 MG CAPULE, 60 MG CAPULE, 80 MG CAPULE) 3 T AL 2 / day At least 18 yrs old GEODON 20 MG/ML VIAL 3 T HALDOL 3 HALDOL DECANOATE HALDOL DECANOATE 50 3 haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 5 mg/ml ampul, 10 mg tablet, 20 mg tablet) 1 haloperidol decan 50 mg/ml amp 1 haloperidol decanoate (50 mg/ml vial, 100 mg/ml vial) 1 haloperidol decanoate haloperidol lactate 1 imipramine hcl 1 imipramine pamoate 1 INVEGA 3 INVEGA UTENNA 117 MG/0.75 ML 3 INVEGA UTENNA 156 MG/ML YRG 3 INVEGA UTENNA 234 MG/1.5 ML 3 INVEGA UTENNA 39 MG/0.25 ML 3 T AL AL AL AL AL At least 12 yrs old / day At least 18 yrs old 0.04 / day At least 18 yrs old / day At least 18 yrs old At least 18 yrs old GE 145 LAT UPDATED 04/2017

146 PRODUCT DECRIPTION TIER LIMIT & RETRICTION INVEGA UTENNA 78 MG/0.5 ML 3 INVEGA TRINZA 273 MG/0.875 ML 3 INVEGA TRINZA 410 MG/1.315 ML 3 INVEGA TRINZA 546 MG/1.75 ML 3 INVEGA TRINZA 819 MG/2.625 ML 3 AL AL AL AL AL 0.02 / day At least 18 yrs old / day At least 18 yrs old / day At least 18 yrs old / day At least 18 yrs old 0. At least 18 yrs old KHEDEZLA 3 LATUDA 3 AL At least 18 yrs old LEXAPRO (5 MG TABLET, 10 MG TABLET) / day LEXAPRO 20 MG TABLET 3 LEXAPRO 5 MG/5 ML OLUTION 3 20 / day loxapine 1 AL At least 18 yrs old maprotiline hcl 1 MARPLAN 3 6 / day mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mg tablet, 45 mg odt, 45 mg tablet) 1 mirtazapine 7.5 mg tablet 1 2 / day GE 146 LAT UPDATED 04/2017

147 PRODUCT DECRIPTION TIER LIMIT & RETRICTION molindone hcl 1 NARDIL 3 6 / day nefazodone hcl 100 mg tablet 1 6 / day nefazodone hcl 150 mg tablet 1 4 / day nefazodone hcl 200 mg tablet 1 3 / day nefazodone hcl 250 mg tablet / day nefazodone hcl 50 mg tablet 1 12 / day NORPRAMIN 3 nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) 1 NUPLAZID 3 2 / day olanzapine (2.5 mg tablet, 5 mg tablet) 1 6 / day olanzapine 10 mg tablet 1 3 / day olanzapine 10 mg vial 1 olanzapine 15 mg tablet 1 2 / day olanzapine 20 mg tablet 1 olanzapine 7.5 mg tablet 1 4 / day olanzapine odt 10 mg tablet 1 3 / day olanzapine odt 15 mg tablet 1 2 / day olanzapine odt 20 mg tablet 1 olanzapine odt 5 mg tablet 1 6 / day olanzapine-fluoxetine hcl 1 AL At least 10 yrs old GE 147 LAT UPDATED 04/2017

148 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OLEPTRO ER 3 ORAP 3 paliperidone er 1 AL At least 12 yrs old MELOR 3 RNATE 3 6 / day paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 2 / day paroxetine cr 12.5 mg tablet 1 paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 2 / day paroxetine er 12.5 mg tablet 1 paroxetine hcl (20 mg tablet, 40 mg tablet) 1 paroxetine hcl 10 mg tablet / day paroxetine hcl 30 mg tablet 1 2 / day XIL (20 MG TABLET, 40 MG TABLET) 3 XIL 10 MG TABLET / day XIL 10 MG/5 ML UPENION 3 42 / day XIL 30 MG TABLET 3 2 / day XIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3 2 / day XIL CR 12.5 MG TABLET 3 perphenazine 1 AL At least 18 yrs old perphenazine-amitriptyline 1 PEXEVA 3 phenelzine sulfate 1 6 / day pimozide 1 PRITIQ 3 GE 148 LAT UPDATED 04/2017

149 PRODUCT DECRIPTION TIER LIMIT & RETRICTION prochlorperazine 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 protriptyline hcl 1 PROZAC 10 MG PULVULE 3 PROZAC 20 MG PULVULE 3 4 / day PROZAC 40 MG PULVULE 3 2 / day PROZAC WEEKLY / day quetiapine er 150 mg tablet 1 quetiapine er 200 mg tablet 1 quetiapine er 50 mg tablet 1 quetiapine fumarate (25 mg tab, 50 mg tab) 1 quetiapine fumarate (300 mg tab, 400 mg tab) 1 quetiapine fumarate 100 mg tab 1 quetiapine fumarate 200 mg tab 1 AL AL AL AL AL AL AL 5 / day At least 10 yrs old 4 / day At least 10 yrs old 6 / day At least 10 yrs old 6 / day At least 10 yrs old At least 10 yrs old 3 / day At least 10 yrs old 1.5 / day At least 10 yrs old quetiapine fumarate er (er 300 mg tablet, er 400 mg tablet) 1 AL 2 / day At least 10 yrs old REMERON 3 REXULTI 3 AL At least 18 yrs old GE 149 LAT UPDATED 04/2017

150 PRODUCT DECRIPTION TIER LIMIT & RETRICTION RIPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 AL 8 / day At least 5 yrs old RIPERDAL 1 MG/ML OLUTION 3 RIPERDAL 3 MG TABLET 3 RIPERDAL 4 MG TABLET 3 RIPERDAL CONTA 3 RIPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG ODT) 3 RIPERDAL M-TAB 3 MG ODT 3 RIPERDAL M-TAB 4 MG ODT 3 AL AL AL AL AL AL AL 16/day At least 5 yrs old 5 / day At least 5 yrs old 4 / day At least 5 yrs old 0. At least 18 yrs old 8 / day At least 5 yrs old 5 / day At least 5 yrs old 4 / day At least 5 yrs old risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 AL 8 / day At least 5 yrs old risperidone 1 mg/ml solution 1 risperidone 3 mg odt 1 risperidone 3 mg tablet 1 risperidone 4 mg odt 1 AL AL AL AL 16/day At least 5 yrs old 5 / day At least 5 yrs old 5 / day At least 5 yrs old 4 / day At least 5 yrs old GE 150 LAT UPDATED 04/2017

151 PRODUCT DECRIPTION TIER LIMIT & RETRICTION risperidone 4 mg tablet 1 AL 4 / day At least 5 yrs old risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt) 1 AL 8 / day At least 5 yrs old APHRI 3 T AL 2 / day At least 10 yrs old ARAFEM 10 MG TABLET / day ARAFEM 20 MG TABLET 3 4 / day EROQUEL (25 MG TABLET, 50 MG TABLET) 3 EROQUEL (300 MG TABLET, 400 MG TABLET) 3 EROQUEL 100 MG TABLET 3 EROQUEL 200 MG TABLET 3 EROQUEL XR (300 MG TABLET, 400 MG TABLET) 2 EROQUEL XR 150 MG TABLET 2 EROQUEL XR 200 MG TABLET 2 EROQUEL XR 50 MG TABLET 2 AL AL AL AL AL AL AL AL 6 / day At least 10 yrs old At least 10 yrs old 3 / day At least 10 yrs old 1.5 / day At least 10 yrs old 2 / day At least 10 yrs old 5 / day At least 10 yrs old 4 / day At least 10 yrs old 6 / day At least 10 yrs old EROQUEL XR AMPLE KIT 2 AL At least 10 yrs old GE 151 LAT UPDATED 04/2017

152 PRODUCT DECRIPTION TIER LIMIT & RETRICTION sertraline 20 mg/ml oral conc 1 10 / day sertraline hcl (25 mg tablet, 50 mg tablet) / day sertraline hcl 100 mg tablet 1 2 / day ILENOR 3 URMONTIL 3 YMBYAX 3 thioridazine hcl 1 thiothixene 1 TOFRANIL 3 TOFRANIL-PM 3 AL At least 10 yrs old tranylcypromine sulfate 1 6 / day trazodone 100 mg tablet 1 4 / day trazodone 150 mg tablet 1 2 / day trazodone 300 mg tablet 1 trazodone 50 mg tablet 1 3 / day trifluoperazine hcl 1 TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) 3 venlafaxine hcl 1 T venlafaxine hcl er (er 150 mg cap, er 150 mg tab) 1 2 / day venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 75 mg tab) 1 3 / day venlafaxine hcl er 225 mg tab 1 venlafaxine hcl er 37.5 mg tab 1 GE 152 LAT UPDATED 04/2017

153 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VERACLOZ 3 AL 20 / day At least 18 yrs old VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 VIIBRYD (10-20 MG CK, MG PK) 3 VRAYLAR 3 AL At least 18 yrs old WELLBUTRIN 100 MG TABLET 3 5 / day WELLBUTRIN 75 MG TABLET 3 6 / day WELLBUTRIN R (150 MG TABLET, 200 MG TABLET) 3 2 / day WELLBUTRIN R 100 MG TABLET 3 4 / day WELLBUTRIN XL 150 MG TABLET 3 3 / day WELLBUTRIN XL 300 MG TABLET 3 ziprasidone hcl 1 AL 2 / day At least 18 yrs old ZOLOFT (25 MG TABLET, 50 MG TABLET) / day ZOLOFT 100 MG TABLET 3 2 / day ZOLOFT 20 MG/ML ORAL CONC 3 10 / day ZYBAN 3 2 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 6 / day ZYPREXA 10 MG TABLET 3 3 / day ZYPREXA 10 MG VIAL 3 ZYPREXA 15 MG TABLET 3 2 / day ZYPREXA 20 MG TABLET 3 GE 153 LAT UPDATED 04/2017

154 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ZYPREXA 7.5 MG TABLET 3 4 / day ZYPREXA RELPREVV 3 AL 0.08 / day At least 18 yrs old ZYPREXA ZYDI 10 MG TABLET 3 3 / day ZYPREXA ZYDI 15 MG TABLET 3 2 / day ZYPREXA ZYDI 20 MG TABLET 3 ZYPREXA ZYDI 5 MG TABLET 3 6 / day DEVICE 2tek glucose-wrist monitor kit 3 accu-chek aviva connect meter 2 accu-chek aviva plus meter 2 accu-chek compact plus kit 2 accu-chek guide monitor system 2 accu-chek nano smartview meter 2 accu-chek voicemate system 2 advocate blood glucose monitor 3 advocate duo glu-wrist monitor 3 advocate duo meter 3 advocate redi-code duo meter 3 advocate redi-code glu meter 3 advocate redi-code glu monitor 3 advocate redi-code+ glu meter 3 agamatrix amp gluc monitor sys 3 assure platinum glucose meter 3 GE 154 LAT UPDATED 04/2017

155 PRODUCT DECRIPTION TIER LIMIT & RETRICTION assure prism multi meter 3 bd eclipse needle 18gx1 1/2" 3 blood glucose monitoring syst 3 breeze 2 meter 3 careone glucose monitoring sys 3 caresens n blood glucose syst 3 caresens n voice glucose meter 3 caresens n voice glucose sys 3 choicedm clarus monitor system 3 clever chek blood glucose syst 3 clever choice blood glucos sys 3 clever choice glucose monitor 3 clever choice hd glucose syst 3 clever choice micro monitor 3 clever choice pro glucose mtr 3 clever choice talk glucose sys 3 contour link meter 3 contour meter 3 contour meter system 3 contour next ez meter 3 contour next ez meter system 3 contour next link meter 3 contour next meter 3 GE 155 LAT UPDATED 04/2017

156 PRODUCT DECRIPTION TIER LIMIT & RETRICTION contour next one meter 3 contour next usb meter 3 control ast monitoring system 3 control ast monitoring system 3 10 / day cool blood glucose meter 3 cool blood glucose meter kit 3 cvs advanced glucose meter 3 dexcom g4 ((ped) receiver kit, receiver kit, receiver-share (ped), receiver-share kit, transmitter kit) 3 dexcom g4 (ped) receiver kit 3 dexcom g4 receiver kit 3 dexcom g4 receiver-share (ped) 3 dexcom g4 receiver-share kit 3 dexcom g5 3 dexcom g5 receiver kit 3 dexcom g5-g4 sensor kit 3 diatrue plus blood glucose sys 3 easy check blood glucose sys 3 easy check glucose meter 3 easy plus blood glucose kit 3 easy plus blood glucose system 3 easy plus ii blood glucose sys 3 easy step blood glucose meter 3 easy step glucose system kit 3 GE 156 LAT UPDATED 04/2017

157 PRODUCT DECRIPTION TIER LIMIT & RETRICTION easy talk blood glucose meter 3 easy talk glucose system kit 3 easy touch glucose monitor sys 3 easy trak blood glucose meter 3 easy trak blood glucose meter 99 easy trak glucose system kit 3 easygluco meter 3 easygluco meter starter kit 3 easygluco plus meter kit 3 easygluco plus starter kit 3 easymax l blood glucose system 3 easymax ng blood glucose sys 3 easymax ng glucose system kit 3 easymax v speaking glucose sys 3 easymax v2 blood glucose sys 3 easyplus r13n glucose sys kit 3 easyplus v glucose system kit 3 eclipse needle (needle 23gx1", needle 25gx5/8", needle 27gx1/2") 3 element blood glucose meter kt 3 element compact glucose meter 3 element compact v glucose mtr 3 element plus blood glucose kit 3 embrace blood glucose kit 3 GE 157 LAT UPDATED 04/2017

158 PRODUCT DECRIPTION TIER LIMIT & RETRICTION embrace blood glucose system 3 embrace evo blood glucose kit 3 embrace pro blood glucose mtr 3 enlite glucose sensor 3 enlite system kit 3 EPIIL LIQUID 3 EUFLEXXA 20 MG/2 ML YRINGE 3 P evencare g2 blood glucose sys 3 evencare g3 blood glucose sys 3 evencare mini monitor system 3 evencare monitoring system 3 evolution blood glucose meter 3 ez smart plus system kit 3 ez smart system kit 3 fifty glucose meter 3 filter needle (needle 5 micron, needle 19gx1-1/2") 3 fora d10 blood glucose system 3 fora d20 blood glucose system 3 fora g20 blood glucose system 3 fora g30a blood glucose system 3 fora gd50 blood glucose system 3 fora premium v10 glucose meter 3 GE 158 LAT UPDATED 04/2017

159 PRODUCT DECRIPTION TIER LIMIT & RETRICTION fora test n'go voice system 3 fora tn'g voice glucose meter 3 fora v10 blood glucose system 3 fora v12 blood glucose system 3 fora v20 blood glucose system 3 fora v30a blood glucose system 3 foracare gd20 glucose system 3 foracare gd40a glucose system 3 foracare gd40b glucose system 3 fortiscare blood glucose syst 3 freestyle flash system kit 3 freestyle freedom kit 3 freestyle freedom lite meter 3 freestyle freedom lite nfrs 3 freestyle insulinx glucose sys 3 freestyle lite meter 3 freestyle lite meter nfrs 3 freestyle navigator sensor kit 3 freestyle precision neo meter 3 freestyle sidekick ii valpk 3 freestyle system kit 3 gdrive blood glucose system 3 ge100 blood glucose system 3 GE 159 LAT UPDATED 04/2017

160 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GEL-ONE 30 MG/3 ML YRINGE 3 GENVIC MG/2.5 ML YR 1 gluco navii glucose monitor kt 3 glucocard 01 meter kit 3 glucocard 01-mini meter kit 3 glucocard expression meter 3 glucocard expression meter kit 3 glucocard shine meter 3 glucocard shine meter kit 3 glucocard vital meter kit 3 glucocom blood glucose kit 3 glucocom blood glucose meter 3 glucocom value kit 3 gmate smart meter kit 3 gmate smart starter kit 3 gmate voice meter monitor syst 3 gmate voice starter kit 3 gnp easy touch glucose monitor 3 gs blood glucose monitor sys 3 guardian real time starter kit 3 guardian real-time glu monitor 3 guardian real-time glu monitor 3 GE 160 LAT UPDATED 04/2017

161 PRODUCT DECRIPTION TIER LIMIT & RETRICTION guardian rt replace charger 3 guardian rt replace monitor 3 guardian test plug (, rt replace) 3 healthpro glucose monitor syst 3 humana true metrix air glu mtr 3 humana true metrix air meter 3 humana trueresult glucose mtr 3 HYALGAN 3 HYMOVI 24 MG/3 ML YRINGE 3 hypodermic needle (needle 22x1, needle 22x1.5, needle 23x0.5, needle 23x1, needle 25x1, needle 25x1.5, needle 25x5/8, needle 26x1.5, needle 27x0.5, needle 30x3/4) 3 infinity meter kit 3 infinity starter kit 3 jazz wireless 2 meter kit 3 kro premium blood glucose syst 3 liberty blood glucose meter 3 liberty blood glucose monitor 3 LYCELLE HEAD LICE REMOVAL KIT 3 microdot blood glucose system 3 minilink real-time transmitter 3 minimed 630g guardian start kt 3 monoject blood collection (needl 20gx1.5, needle 20gx1", needle 21gx1", needle 22gx1") 3 GE 161 LAT UPDATED 04/2017

162 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MONOVIC 88 MG/4 ML YRINGE 3 myglucohealth monitoring kit 3 nova max blood glucose meter 3 NUMOIYN 3 on call express meter 3 on call express meter system 3 on call plus meter 3 on call vivid meter 3 on call vivid pal meter 3 onetouch ultra2 glucose syst 2 onetouch ultra2 glucose syst 2 onetouch ultramini meter 2 onetouch ultramini meter 2 onetouch verio flex startr kit 2 10 / day onetouch verio flex startr kit 2 10 / day onetouch verio flex system kit 2 10 / day onetouch verio flex system kit 2 10 / day onetouch verio iq meter 2 onetouch verio iq meter 2 onetouch verio iq system kit 2 onetouch verio iq system kit 2 onetouch verio meter system 2 onetouch verio meter system 2 onetouch verio sync syst kit 2 GE 162 LAT UPDATED 04/2017

163 PRODUCT DECRIPTION TIER LIMIT & RETRICTION onetouch verio sync syst kit 2 optumrx blood glucose meter 3 optumrx blood glucose system 3 ORAFATE 1 GM/10 ML TE 3 ORTHOVIC 15 MG/ML YRINGE 3 paradigm insulin pump pathway 3 paradigm real-time system 3 pen needle (pen needle 30g 5/16", pen needle 31g 3/16", pen needle 31g 5/16") 2 pharmacist choice glucose sys 3 pharmacist choice mini glu sys 3 phaseal protector (14, 21, 28, 50) 3 precision link direct monit 3 precision xtra monitor 3 precision xtra monitor nfrs 3 premium blood glucose monitor 3 premium blood glucose system 3 premium v10 blood glucose mtr 3 presto pro blood glucose meter 3 prodigy autocode meter kit 3 prodigy autocode monitor syst 3 prodigy pocket meter kit 3 prodigy voice meter kit 3 PROTHELIAL 1 GM/10 ML TE 1 GE 163 LAT UPDATED 04/2017

164 PRODUCT DECRIPTION TIER LIMIT & RETRICTION pv truetrack smart system 3 quintet ac blood glucose meter 3 quintet blood glucose system 3 ra blood glucose monitor 3 refuah plus monitoring system 3 relion all-in-one meter kit 3 relion confirm glucose monitor 3 relion confirm system kit 3 relion micro blood glucose sys 3 relion micro system kit 3 relion prime blood glucose mtr 3 relion ultima glucose meter 3 replacement pediatric monitor 3 reveal blood glucose meter 3 rexall glucose monitoring sys 3 rightest gm100 system kit 3 rightest gm250s glucose meter 3 rightest gm260 glucose meter 3 rightest gm300 system kit 3 rightest gm550 system kit 3 ILVRTAT DREING GEL 3 smart caresens n glucose systm 3 smart sense monitoring system 3 GE 164 LAT UPDATED 04/2017

165 PRODUCT DECRIPTION TIER LIMIT & RETRICTION smartdiabetes xpres gluc syst 3 smartest eject meter 3 smartest persona glucose meter 3 smartest persona starter kit 3 smartest pronto glucose meter 3 smartest pronto starter kit 3 smartest protege meter 3 smartest smart code meter 3 smartest talking meter 3 sof-sensor 3 OLETA INJECTABLE GEL 3 solus v2 audible meter 3 solus v2 audible meter sys kit 3 P ANTIPRURITIC GEL 3 URTZ (10 MG/ML YRINGE, 25 MG/2.5 ML YRINGE) 3 URTZ FX 25 MG/2.5 ML YR 3 sure-test easyplus mini meter 3 surechek blood glucose monitor 3 surestep pro linearity kit 3 YNVIC YRINGE 3 P GE 165 LAT UPDATED 04/2017

166 PRODUCT DECRIPTION TIER LIMIT & RETRICTION YNVIC-ONE YRINGE 3 P td gold blood glucose monitor 3 td gold voice glucose monitor 3 telcare blood glucose monitor 3 terumo surguard2 (ndl 21gx1 1.5, ndl 22x1-1/2", ndl 23x1-1/2", needle 18gx1", needle 18x1.5, needle 19gx1", needle 19x1.5, needle 20gx1", needle 20x1.5, needle 21gx1", needle 22gx1", needle 23gx1", needle 25gx1", needle 25x1.5, needle 25x5/8, needle 26x1/2, needle 27x1/2, needle 30x1/2) 3 test n'go blood glucose system 3 true metrix air glucose meter 3 true metrix blood glucose mtr 3 true metrix go glucose meter 3 true2go blood glucose system 3 trueresult blood glucose systm 3 truetrack blood glucose system 3 truetrack smart system 3 ultima monitor kit 3 ultratrak blood glucose meter 3 ultratrak pro glucose mtr sys 3 ultratrak pro meter kit 3 ultratrak ultimate glucose mtr 3 unistik 2 normal 0.81mm device 2 GE 166 LAT UPDATED 04/2017

167 PRODUCT DECRIPTION TIER LIMIT & RETRICTION up & up blood monitoring syst 3 wavesense amp system kit 3 wavesense presto system kit 3 DIAGNOTIC AGENT ADRENOCORTICAL INUFFICIENCY ACTHREL 3 CORTROYN 3 cosyntropin 0.25 mg vial 1 H.P. ACTHAR 3 DIABETE MELLITU accu-chek aviva plus test strp 2 10 / day accu-chek aviva test strips 2 10 / day accu-chek compact drum strips 2 10 / day accu-chek compact plus strips 2 10 / day accu-chek compact strips 2 10 / day accu-chek guide test strip 2 10 / day accu-chek smartview test strip 2 10 / day accutrend glucose test strip 3 acura test strips 3 advocate redi-code test strip 3 10 / day 10 / day 10 / day GE 167 LAT UPDATED 04/2017

168 PRODUCT DECRIPTION TIER LIMIT & RETRICTION advocate redi-code+ test strip 3 advocate test strip 3 agamatrix amp test strips 3 assure 4 test strips 3 assure platinum test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day assure prism multi test strips 3 bg-star glucose test strips 3 blood glucose test strip 3 blood glucose test strips 3 breeze 2 disc test strip 3 careone blood glucose tst strp 3 caresens n test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day choicedm clarus test strips 3 clever choice micro test strip 3 10 / day GE 168 LAT UPDATED 04/2017

169 PRODUCT DECRIPTION TIER LIMIT & RETRICTION clever choice pro test strip 3 10 / day clever choice talk test strips 3 clever choice test strips 3 clever choice voice+ tst strip 3 contour next strips 3 contour test strips 3 control ast test strip 3 control test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day cool glucose test strip 3 cvs advanced glucose test str 3 diatrue plus test strip 3 10 / day 10 / day easy gluco g2 test strip 3 easy plus glucose test strip 3 easy plus ii test strips 3 easy step glucose test strips 3 10 / day 10 / day GE 169 LAT UPDATED 04/2017

170 PRODUCT DECRIPTION TIER LIMIT & RETRICTION easy talk glucose test strip 3 easy touch glucose test strip 3 easy trak glucose test strip 3 10 / day 10 / day 10 / day easygluco plus test strips 3 easygluco test strips 3 easymax 15 glucose test strip 3 easymax glucose test strips 3 element compact test strips 3 element test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day embrace evo test strips 3 embrace glucose test strips 3 10 / day embrace pro test strips 3 embrace test strips 3 10 / day equate blood glucose test strp 3 evencare g2 test strip 3 10 / day GE 170 LAT UPDATED 04/2017

171 PRODUCT DECRIPTION TIER LIMIT & RETRICTION evencare g3 test strip 3 evencare glucose tst strips 3 10 / day 10 / day evencare mini glucose test str 3 evencare test strips 3 evolution test strips 3 ez smart plus test strips 3 ez smart test strips 3 fifty50 glucose test strip 3 fora blood glucose test strip 3 fora d15g glucose test strips 3 fora d20 glucose test strips 3 fora d40-g31 test strips 3 fora g20 glucose test strips 3 fora g30a glucose test strip 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day GE 171 LAT UPDATED 04/2017

172 PRODUCT DECRIPTION TIER LIMIT & RETRICTION fora gd50 test strips 3 10 / day fora tn'g voice test strips 3 fora v10 glucose test strip 3 fora v10-v12-d10-d20 strips 3 fora v12 glucose test strip 3 fora v20 glucose test strips 3 fora v30a glucose test strip 3 foracare gd20 test strips 3 foracare gd40 glucose strips 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day fortiscare glucose test strips 3 freestyle insulinx strip nfrs 3 freestyle insulinx test strip 3 freestyle insulinx test strips 3 freestyle lite test strip 3 10 / day 10 / day 10 / day 10 / day GE 172 LAT UPDATED 04/2017

173 PRODUCT DECRIPTION TIER LIMIT & RETRICTION freestyle lite test strip nfrs 3 freestyle lite test strips 3 10 / day 10 / day freestyle prec neo test strips 3 freestyle test strips 3 freestyle test strips nfrs 3 g-4 test strips 3 ge100 blood glucose test strip 3 10 / day 10 / day 10 / day 10 / day genstrip glucose test strip 3 genultimate test strip 3 ght blood glucose test strips 3 gluco navii glucose test strip 3 glucocard 01 sensor plus strip 3 glucocard expression test strp 3 10 / day 10 / day 10 / day glucocard shine test strips 3 glucocard vital sensor strip 3 10 / day GE 173 LAT UPDATED 04/2017

174 PRODUCT DECRIPTION TIER LIMIT & RETRICTION glucocard vital test strips 3 glucocom glucose test strip 3 gmate test strips 3 10 / day 10 / day 10 / day gnp easy touch gluc test strip 3 gs blood glucose test strips 3 healthpro glucose test strips 3 10 / day humana true metrix test strips 3 humana truetest test strips 3 infinity test strips 3 kro premium blood glucose test 3 liberty test strips 3 maxima test strip 3 10 / day 10 / day 10 / day 10 / day 10 / day meijer blood glucose test strp 3 microdot test strips 3 10 / day microdot xtra test strips 3 GE 174 LAT UPDATED 04/2017

175 PRODUCT DECRIPTION TIER LIMIT & RETRICTION myglucohealth test strips 3 neutek 2tek test strips 3 nova max glucose test strip 3 10 / day 10 / day 10 / day on call express test strip 3 on call plus test strip 3 on call vivid test strip 3 10 / day 10 / day onetouch ultra test strips 2 10 / day onetouch ultra test strips 2 10 / day onetouch verio test strip 2 10 / day onetouch verio test strip 2 10 / day optium ez test strip 3 optium test strip 3 optumrx test strip 3 pharmacist choice test strips 3 precision pcx plus test str 3 10 / day 10 / day 10 / day 10 / day 10 / day GE 175 LAT UPDATED 04/2017

176 PRODUCT DECRIPTION TIER LIMIT & RETRICTION precision pcx test strips 3 precision point of care str 3 precision q-i-d test strips 3 precision xtra test strips 3 premium blood glucose test str 3 premium blood glucose tst strp 3 premium v10 glucose test strip 3 prodigy no coding test strips 3 pv truetrack smart sys strips 3 quintet ac glucose test strips 3 quintet glucose test strips 3 ra truetest glucose test strip 3 refuah plus test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day GE 176 LAT UPDATED 04/2017

177 PRODUCT DECRIPTION TIER LIMIT & RETRICTION relion confirm-micro test strp 3 relion micro test strips 3 relion prime test strips 3 relion ultima test strips 3 reveal test strip 3 rexall blood glucose test strp 3 rightest gs100 test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day rightest gs250s test strips 3 rightest gs260 test strips 3 rightest gs300 test strips 3 rightest gs550 test strips 3 smart sense test strips 3 smartdiabetes xpres test strip 3 smartest test strips 3 10 / day 10 / day 10 / day 10 / day 10 / day GE 177 LAT UPDATED 04/2017

178 PRODUCT DECRIPTION TIER LIMIT & RETRICTION solus v2 audible test strips 3 sure-test easyplus mini strip 3 10 / day 10 / day td gold test strip 3 telcare test strips 3 test n'go glucose test strip 3 true metrix glucose test strip 3 truetest glucose test strip 3 truetest glucose test strips 3 truetrack glucose test strips 3 ultima test strips 3 ultratrak test strip 3 ultratrak ultimate test strips 3 unistrip1 glucose test strip 3 up & up blood glucose tst strp 3 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day 10 / day GE 178 LAT UPDATED 04/2017

179 PRODUCT DECRIPTION TIER LIMIT & RETRICTION v-r glucose test strip 3 wavesense jazz test strips 3 wavesense presto test strips 3 MYATHENIA GRAVI ENLON 3 ENLON-PLU 3 OCULAR DIORDER FLUCAINE 1 fluorescein-proparacaine 1 THYROID FUNCTION 10 / day 10 / day 10 / day THYROGEN 3 ENZYME ADAGEN 3 ALDURAZYME 3 CEREZYME 400 UNIT VIAL 3 ELAPRAE 3 ELELYO 3 P ELITEK 3 GE 179 LAT UPDATED 04/2017

180 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FABRAZYME 3 HYLENEX 3 HYQVIA HY COMPONENT 3 LUMIZYME 3 MYOZYME 3 NAGLAZYME 3 PULMOZYME 3 TRENIQ 3 AL P 5 / days Up to 18 yrs old UCRAID 3 VIMIZIM 3 VITRAE 3 VORAXAZE 3 VPRIV 3 XIAFLEX 3 GE 180 LAT UPDATED 04/2017

181 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EYE, EAR, NOE AND THROAT (EENT) PREP. ANTI-INFECTIVE (EENT) ACETAOL HC 1 acetic acid 2% ear solution 1 acetic acid-aluminum 1 AK-POLY-BAC / day AZAITE / 30 days bacitracin 500 unit/gm ophth / day bacitracin-polymyxin / day BACTROBAN NAAL 2 BEIVANCE / day BETADINE 3 BLEPH / fill BLEPHAMIDE / day BLEPHAMIDE.O.P / day CETRAXAL / day chlorhexidine gluconate 1 CILOXAN 0.3% EYE DROP / day CILOXAN 0.3% OINTMENT / day CIPRO HC / day CIPRODEX / day ciprofloxacin 0.2% otic soln / day ciprofloxacin 0.3% eye drop / day COLY-MYCIN /day GE 181 LAT UPDATED 04/2017

182 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CORTIPORIN EAR OLUTION /day CORTIPORIN-TC /day doxycycline hyclate 20 mg tab 1 erythromycin 0.5% eye ointment / day FLOXIN 3 10 / 30 days gatifloxacin / day GENTAK / day gentamicin 0.3% eye ointment / day gentamicin sulfate (0.3% drops, 3 mg/ml drops) 1 5 / fill hydrocortisone-acetic acid 1 ILOTYCIN / day levofloxacin 0.5% eye drops / day MAXITROL (DROP, OINTMENT) / day MOXEZA 2 0. NATACYN / day NEO-POLYCIN / day NEO-POLYCIN HC / day neomycin-bacitracin-poly-hc / day neomycin-bacitracin-polymyxin / day neomycin-poly-hc eye drops / day neomycin-polymyxin-dexameth (neomyc-polym-dexamet ointm, neomyc-polym-dexameth drop) / day neomycin-polymyxin-gramicidin 1 10 / fill neomycin-polymyxin-hc ear susp 1 GE 182 LAT UPDATED 04/2017

183 PRODUCT DECRIPTION TIER LIMIT & RETRICTION neomycin-polymyxin-hydrocort /day NEOPORIN 3 10 / fill OCUFLOX 3 10 / 30 days ofloxacin (ear drops, eye drops) 1 10 / 30 days OTICIN 1 OTIPRIO 3 OTOVEL 3 ROEX 1 PERIDEX 0.12% ORAL RINE 3 PERIOGARD 1 POLYCIN / day polymyxin b sul-trimethoprim 1 10 / fill POLYTRIM 3 10 / fill PRED-G 1% EYE DROP / day PRED-G.O.P. EYE OINTMENT / day sulfacetamide 10% eye drops 1 15 / 30 days sulfacetamide 10% eye ointment / day sulfacetamide-prednisolone / day TOBRADEX (DROP, OINTMENT) / day TOBRADEX T / day tobramycin 0.3% eye drops 1 5 / fill tobramycin-dexamethasone / day TOBREX 0.3% EYE DROP 3 5 / fill TOBREX 0.3% EYE OINTMENT / day GE 183 LAT UPDATED 04/2017

184 PRODUCT DECRIPTION TIER LIMIT & RETRICTION trifluridine 1 TRIOXIN 3 VIGAMOX 2 0. VIROPTIC 3 ZIRGAN / day ZYLET / day ZYMAXID / day ANTI-INFLAMMATORY AGENT (EENT) ACULAR 3 15 / 30 days ACULAR L 3 5 / fill ACUVAIL / day AERO OTIC HC 1 ALREX / day BECONAE AQ / day bromfenac sodium 1 8 / rx BROMITE 3 15/ 180 days budesonide 32 mcg nasal spray / day CORTANE-B 3 DERMOTIC 3 dexamethasone 0.1% eye drop 1 5 / fill diclofenac 0.1% eye drops 1 5 / fill DUREZOL 3 5 / fill DYMITA / day EXOTIC-HC 1 GE 184 LAT UPDATED 04/2017

185 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FLAREX 3 5 / fill flunisolide / day fluocinolone acetonide oil 1 fluorometholone 1 10 / fill flurbiprofen sodium 1 3/ fill fluticasone prop 50 mcg spray / day FML 3 10 / fill FML FORTE 3 10 / fill FML.O.P. 3 4 / fill ILEVRO 3 4 / fill ILUVIEN 3 max 1 per 365 days ketorolac 0.4% ophth solution 1 5 / fill ketorolac 0.5% ophth solution 1 15 / 30 days LOTEMAX (EYE DROP, OPHTHALMIC GEL) / day LOTEMAX 0.5% EYE OINTMENT 3 4 / fill MAXIDEX 3 5 / fill mometasone furoate 50 mcg spry / day NAACORT AQ / day NAONEX / day NEVANAC 3 3/ fill OCUFEN 3 3/ fill OMNARI / day GE 185 LAT UPDATED 04/2017

186 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OMNIPRED / day OTICIN HC 3 OTO-END 10 1 OTOMAX-HC 1 OZURDEX / day PRED FORTE / day PRED MILD 3 10 / fill prednisolone acetate / day prednisolone sod 1% eye drop 1 10 / fill PROLENA 3 3/ fill QNAL / day QNAL CHILDREN 3 RETAI 2 RETAI MULTIDOE 2 RETIERT 3 max 1 per 365 days RHINOCORT AQUA / day triamcinolone 55 mcg nasal spr / day TRIEENCE 3 VERAMYT / day VEXOL 3 10 / fill XIIDRA 3 AL 2 / day At least 17 yrs old GE 186 LAT UPDATED 04/2017

187 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ZETONNA / day ANTIALLERGIC AGENT ALOCRIL / day ALOMIDE / day ATELIN 3 2 / day ATEPRO 3 2 / day azelastine hcl 1 2 / day BEPREVE / day cromolyn 4% eye drops 1 10 / 30 days ELETAT / day EMADINE / day epinastine hcl 1 LATACAFT 3 T 3 / 30 days olopatadine 665 mcg nasal spry 1 31 / 30 days olopatadine hcl 0.1% eye drops 1 5 / 30 days TADAY 3 TANAE 3 31 / 30 days TANOL 3 5 / 30 days ZEO 3 0. ANTIGLAUCOMA AGENT ALPHAGAN P 0.1% DROP / day ALPHAGAN P 0.15% EYE DROP / day AZOPT / day GE 187 LAT UPDATED 04/2017

188 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BETAGAN / day betaxolol hcl 0.5% eye drop / day BETIMOL 0.25% EYE DROP / day BETIMOL 0.5% EYE DROP / day BETOPTIC / day bimatoprost 0.03% eye drops / day bimatoprost 0.03% eyelash soln 1 brimonidine 0.2% eye drop / day brimonidine tartrate 0.15% drp / day carteolol hcl / day COMBIGAN / day COOPT 3 2 / day COOPT PF 3 2 / day dorzolamide hcl 1 10 / 30 days dorzolamide-timolol 1 10 / 30 days IOPTO CARPINE / day ITALOL / day KEVEYI 3 4 / dayspecialty latanoprost / day LATIE 3 levobunolol hcl / day LUMIGAN / day GE 188 LAT UPDATED 04/2017

189 PRODUCT DECRIPTION TIER LIMIT & RETRICTION methazolamide 1 metipranolol / day MIOCHOL-E 3 MIOTAT 3 MITOOL 3 NEPTAZANE 3 PHOPHOLINE IODIDE 3 pilocarpine 4% eye drops / day pilocarpine hcl (1% drops, 2% drops) / day PILOPINE H 3 IMBRINZA / day timolol 0.5% eye drops / day timolol maleate (0.25% eye drops, 0.25% gel-solution, 0.25% gfs gel-solution, 0.5% gel-solution, 0.5% gfs gelsolution) / day TIMOPTIC 0.25% EYE DROP / day TIMOPTIC 0.5% EYE DROP / day TIMOPTIC OCUDOE 3 2 / day TIMOPTIC-XE / day TRAVATAN Z / day travoprost / day TRUOPT 3 10 / 30 days XALATAN / day ZIOPTAN 3 GE 189 LAT UPDATED 04/2017

190 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EENT DRUG, MICELLANEOU apraclonidine hcl / day ATROVENT 3 2 / day CYTARAN 3 IOPIDINE 0.5% EYE DROP / day IOPIDINE 1% EYE DROP / day ipratropium bromide (0.03% spray, 0.06% spray) 1 2 / day JETREA 3 LUCENTI 3 RECULA / day VIUDYNE 3 LOCAL ANETHETIC (EENT) AKTEN 3 ALCAINE 3 ALTACAINE 1 ALTAFLUOR 1 antipyrine-benzocaine 1 AUROGUARD 1 fluorescein-benoxinate 1 FLUROX 1 OTIC CARE 1 OTOZIN 3 PINNACAINE 3 GE 190 LAT UPDATED 04/2017

191 PRODUCT DECRIPTION TIER LIMIT & RETRICTION proparacaine hcl 1 TETCAINE 1 tetracaine 0.5% eye drops 1 tetracaine 0.5% steri-unit sol 1 TETRAVIC 1 TETRAVIC FORTE 1 TREAGAN OTIC 3 VAOCONTRICTOR ADRENALIN 1 MG/ML NAAL OLN 3 naphazoline hcl 1 phenylephrine hcl (2.5% drop, 10% drops) 1 TYZINE 3 GATROINTETINAL DRUG ANTI-INFLAMMATORY AGENT (GI DRUG) alosetron hcl 1 APRIO 2 GL AL Female At least 18 yrs old AACOL HD 3 balsalazide disodium 1 CANAA 2 COLAZAL 3 DELZICOL 3 DIPENTUM 3 GIAZO 3 GL Male LIALDA 2 LOTRONEX 3 GL AL Female At least 18 yrs old GE 191 LAT UPDATED 04/2017

192 PRODUCT DECRIPTION TIER LIMIT & RETRICTION mesalamine (4 gm/60 ml enema, 4 gm/60 ml kit) 1 PENTAA 3 ROWAA 3 FROWAA 3 ANTIDIARRHEA AGENT FULYZAQ 3 loperamide 1 MOTOFEN 3 MYTEI 3 opium tincture 1 5 / day paregoric 1 ANTIEMETIC AKYNZEO / day ALOXI 0.25 MG/5 ML VIAL 3 ANZEMET (50 MG TABLET, 100 MG TABLET) / day ANZEMET 20 MG/ML VIAL 3 aprepitant (40 mg capsule, 125 mg capsule) / day aprepitant mg pack 1 3/ fill aprepitant 80 mg capsule / day CEAMET 3 DICLEGI / 1 days GE 192 LAT UPDATED 04/2017

193 PRODUCT DECRIPTION TIER LIMIT & RETRICTION dronabinol 1 EMEND (115 MG VIAL, 150 MG VIAL) 3 5 / day 2 / fillspecialty EMEND (40 MG CAPULE, 125 MG CAPULE, 125 MG POWDER CKET) / day EMEND 80 MG CAPULE / day EMEND TRICK 3 3/ fill granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 mg/4 ml vial) 1 granisetron hcl 1 mg tablet 1 6 / 30 days MARINOL 3 5 / day ondansetron 4 mg/5 ml solution 1 20 / day ondansetron hcl (4 mg tablet, 8 mg tablet) 1 ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial) C 1 24 / 30 days Max allowable- 3/day with max of 24 / 30 days ondansetron hcl (hcl 4 mg/2 ml amp, 40 mg/20 ml vial) 1 ondansetron hcl 24 mg tablet 1 3 days ondansetron hcl in dextrose 1 ondansetron hcl-0.9% nacl 1 ondansetron in sodium chloride 1 ondansetron odt 1 C 24 / 30 days Max allowable- 3/day with max of 24 / 30 days GE 193 LAT UPDATED 04/2017

194 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ANCUO 3 TIGAN (100 MG/ML VIAL, 300 MG CAPULE) 3 TRANDERM-COP 2 trimethobenzamide hcl 1 VARUBI 3 ZOFRAN (4 MG TABLET, 8 MG TABLET) 3 C 1 / fillspecialty 0.15 / day 24 / 30 days Max allowable- 3/day with max of 24 / 30 days ZOFRAN 2 MG/ML VIAL 3 ZOFRAN 4 MG/5 ML ORAL OLN 3 20 / day ZOFRAN ODT 3 C 24 / 30 days Max allowable- 3/day with max of 24 / 30 days ZUPLENZ 3 24 / 30 days ANTIULCER AGENT AND ACID UPPREANT ACIPHEX 3 T 2 / day ACIPHEX PRINKLE 3 AXID 3 CARAFATE 1 GM TABLET 3 CARAFATE 1 GM/10 ML UP 2 cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 800 mg tablet) 1 CYTOTEC 3 GE 194 LAT UPDATED 04/2017

195 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DEPRIZINE 3 DEXILANT 3 T esomeprazole magnesium 1 esomeprazole sodium 1 esomeprazole strontium 1 famotidine (20 mg piggyback, 20 mg/2 ml vial, 40 mg/4 ml vial, 200 mg/20 ml vial, 500 mg/50 ml vial) 1 famotidine (20 mg tablet, 40 mg tablet, 40 mg/5 ml susp) 1 lansoprazole dr 30 mg capsule 1 misoprostol 1 NEXIUM (DR 2.5 MG CKET, DR 5 MG CKET, DR 10 MG CKET, DR 20 MG CKET, DR 40 MG CKET) 3 2 / day NEXIUM (DR 20 MG CAPULE, DR 40 MG CAPULE) 3 NEXIUM I.V. 3 nizatidine (15 mg/ml solution, 300 mg capsule) 1 nizatidine 150 mg capsule 1 2 / day omeprazole 1 omeprazole-sodium bicarbonate 1 pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1 pantoprazole sodium 40 mg vial 1 PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML ORAL UP) 3 PREVACID (15 MG OLUTAB, DR 15 MG CAPULE, 30 MG OLUTAB, DR 30 MG CAPULE) 3 T PRILOEC (DR 10 MG CAPULE, DR 20 MG CAPULE, DR 40 MG CAPULE) 3 T GE 195 LAT UPDATED 04/2017

196 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PRILOEC (DR 2.5 MG UPENION, DR 10 MG UPENION) 3 T PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 3 T PROTONIX 40 MG UPENION 3 PROTONIX IV 3 rabeprazole sodium 1 2 / day ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 ml vial, 150 mg capsule, 150 mg tablet, 150 mg/10 ml syrup, hcl 150 mg/6 ml vl, 300 mg capsule, 300 mg tablet) 1 sucralfate 1 ZANTAC (50 MG/2 ML VIAL, 150 MG TABLET, 150 MG/6 ML VIAL, 300 MG TABLET, 1,000 MG/40 ML VIAL) ZEGERID (20 MG CAPULE, 20 MG CKET, 40 MG CAPULE) 3 3 T ZEGERID 40 MG CKET 3 CATHARTIC AND LAXATIVE AMITIZA 2 COLYTE WITH FLAVOR CKET 3 COLYTE WITH FLAVOR CK 3 GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-H AND BIACODYL 1 GAVILYTE-N 1 GOLYTELY (CKET, OLUTION) 3 MOVIPREP 3 NULYTELY WITH FLAVOR CK 3 T AL 2 / day At least 18 yrs old GE 196 LAT UPDATED 04/2017

197 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OMOPREP 3 peg 3350-electrolyte (3350 electrolyte soln, electrolyte solution) 1 peg-3350 and electrolytes 1 peg-3350 with flavor packs 1 PEG-PREP 1 polyethylene glycol PREPOPIK / day UCLEAR 3 UPREP / fill TRILYTE WITH FLAVOR CKET 1 CHOLELITHOLYTIC AGENT ACTIGALL 3 CHENODAL 3 URO 3 URO FORTE 3 ursodiol 1 DIGETANT CREON 2 NCREAZE 3 NCRELIE 5,000 1 PERTZYE 3 ULTREA 3 VIOKACE 3 ZENPEP 2 GE 197 LAT UPDATED 04/2017

198 GI DRUG, MICELLANEOU PRODUCT DECRIPTION TIER LIMIT & RETRICTION CHOLBAM 250 MG CAPULE 3 CHOLBAM 50 MG CAPULE 3 7 / 1 days 4 / 1 days CIMZIA (200 MG/ML TARTER KIT, 200 MG/ML YRINGE KIT) 3 1 / 365 days CIMZIA 200 MG VIAL KIT 3 ENTEREG 3 ENTYVIO 3 GATTEX / 1 days 0.08 / day HUMIRA (20 MG/0.4 ML YRINGE, 40 MG/0.8 ML YRINGE) 3 P HUMIRA 10 MG/0.2 ML YRINGE 3 HUMIRA PEDIATRIC CROHN' 3 P P 0.08 / days 0.22 / dayspecialty GE 198 LAT UPDATED 04/2017

199 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HUMIRA PEN 3 HUMIRA PEN CROHN-UC-H TARTER 3 HUMIRA PEN PORIAI-UVEITI 3 LINZE 2 MOVANTIK 3 OCALIVA 3 P P P T 0.08 / days 0.22 / dayspecialty 0.22 / dayspecialty RELITOR (8 MG/0.4 ML YRINGE, 12 MG/0.6 ML KIT, 12 MG/0.6 ML YRINGE, 12 MG/0.6 ML VIAL, 150 MG TABLET) 3 REMICADE 3 RETORA PRINKLE 3 VIBERZI 2 XENICAL 3 2 / day GE 199 LAT UPDATED 04/2017

200 PROKINETIC AGENT PRODUCT DECRIPTION TIER LIMIT & RETRICTION metoclopramide hcl (5 mg tablet, 10 mg tablet, 10 mg/2 ml syr, 10 mg/2 ml vial) 1 metoclopramide hcl (5 mg/5 ml soln, 10 mg/10 ml sol) 1 84 days metoclopramide hcl odt 1 METOZOLV ODT 3 84 days REGLAN 3 GOLD COMPOUND RIDAURA 2 HEAVY METAL ANTAGONIT BAL IN OIL 3 CA-DT 1 calcium disodium versenate 1 CHEMET 3 CUPRIMINE 3 deferoxamine mesylate 1 DEPEN 2 DEFERAL 3 DEFERAL MEYLATE 3 EXJADE 3 FERRIPROX (100 MG/ML OLUTION, 500 MG TABLET) 3 GALZIN 3 JADENU 3 YPRINE 3 ZN-DT 1 GE 200 LAT UPDATED 04/2017

201 PRODUCT DECRIPTION TIER LIMIT & RETRICTION HORMONE AND YNTHETIC UBTITUTE ADRENAL A-HYDROCORT 3 A-METHAPRED 1 AERON / day ALVECO 3 ARITON / day ARNUITY ELLIPTA 100 MCG INH 2 2 / day ARNUITY ELLIPTA 200 MCG INH 2 AMANEX 3 AMANEX HFA 3 BETA 1 3 betamethasone acetate-sod phos / day / day budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2 ml inh susp) 1 budesonide ec 1 CELETONE 3 CORTEF 3 cortisone acetate 1 DELTAONE 1 DEPO-MEDROL 3 dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) 1 GE 201 LAT UPDATED 04/2017

202 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DEXAMETHAONE INTENOL 2 dexamethasone sodium phosphate (4 mg/ml syringe, 100 mg/10 ml vl, 120 mg/30 ml vl) dexamethasone sodium phosphate (4 mg/ml vial, 10 mg/ml vial, 20 mg/5 ml vial) 1 1 dexamethasone-0.9% nacl 1 DEXK 2 ENTOCORT EC 3 EZ UE JOINT-TUNNEL-TRIGGER 3 FLO-PRED 3 FLOVENT 250 MCG DIKU 2 8 / day FLOVENT DIKU (50 MCG, 100 MCG) 2 4 / day FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) / day FLOVENT HFA 44 MCG INHALER / day fludrocortisone acetate 1 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 KENALOG-10 3 KENALOG-40 3 MEDROL (4 MG DOEK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) 3 MEDROL 2 MG TABLET 2 methylprednisolone 1 methylprednisolone acetate 1 methylprednisolone sod succ (40 mg vial, 125 mg vial) 1 methylprednisolone sodium succ 1 methylprednisolone ss 1 gm vl 1 MILLIPRED 10 MG/5 ML OLUTION 3 GE 202 LAT UPDATED 04/2017

203 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MILLIPRED 5 MG TABLET 2 MILLIPRED DP 5 MG 12-DAY CK 2 MILLIPRED DP 5 MG 6-DAY CK 3 ORAPRED ODT 3 PEDIAPRED 3 prednisolone 1 prednisolone sodium phos odt 1 prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5 ml soln, 15 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25 mg/5 ml) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mg tablet, 20 mg tablet, 50 mg tablet) 1 1 PREDNIONE INTENOL 2 PRELONE 3 PRO-C-DURE 5 3 PRO-C-DURE 6 3 PULMICORT / 30 days PULMICORT FLEXHALER / day QVAR 40 MCG ORAL INHALER / day QVAR 80 MCG ORAL INHALER / day RAYO 3 OLU-CORTEF 3 OLU-MEDROL (1 GM VIAL, 500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) 3 OLU-MEDROL (40 MG VIAL, 125 MG VIAL) 3 triamcinolone acetonide (40mg/ml vl, 50mg/5ml vl) 1 UCERI (2 MG RECTAL FOAM, 9 MG ER TABLET) 3 VERIPRED 20 3 GE 203 LAT UPDATED 04/2017

204 ANDROGEN PRODUCT DECRIPTION TIER LIMIT & RETRICTION ANADROL-50 3 GL Male ANDRODERM 2 GL Male ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 GL 5 / day Male ANDROGEL 1% GEL PUMP 3 ANDROGEL 1%(2.5G) GEL CKET 3 ANDROGEL 1%(5G) GEL CKET 3 ANDROID 3 ANDROXY 3 AVEED 3 AXIRON 3 GL GL GL GL GL GL 10 / day Male 2.5 / day Male 5 / day Male Male Male 6 / day Male COVARYX 1 GL Female GE 204 LAT UPDATED 04/2017

205 PRODUCT DECRIPTION TIER LIMIT & RETRICTION COVARYX H.. 1 GL Female danazol 1 DELATETRYL 3 GL Male DEPO-TETOTERONE (100 MG/ML VL, 200 MG/ML) 3 GL Male EEMT 1 GL Female EEMT H.. 1 GL Female estrogen & methyltestosterone 1 GL Female estrogen-methyltestos h.s. tab 1 estrogen-methyltestosterone (estrogen-methyltestos f.s. tab, estrogen-methyltestosterone tb) 1 GL Female FORTETA 3 METHITET 3 methyltestosterone 1 NATETO 3 OXANDRIN 3 oxandrolone 1 TRIANT 3 GL GL GL AL GL GL GL 4 / day Male Male 3 / day Male At least 18 yrs old Male Male Male GE 205 LAT UPDATED 04/2017

206 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TETIM 3 TETONE CIK 3 TETOPEL 3 GL GL GL 300 / 30 days Male Male Male testosterone (12.5 mg/1.25 gram, 25 mg/2.5 gm pkt, 50 mg/5 gram gel, 50 mg/5 gram pkt) 1 GL Male testosterone 10 mg gel pump 1 GL 4 / day Male testosterone cyp 200 mg/ml 1 GL Male testosterone cypionate (testosteron 1,000 mg/10 ml, testosteron 2,000 mg/10 ml, testosterone 100 mg/ml) 1 GL Male testosterone enanthate 1 TETRED 3 VOGELXO 3 ANTIDIABETIC AGENT GL GL Male Male 10 / day acarbose 100 mg tablet 1 3 / day acarbose 25 mg tablet 1 12 / day acarbose 50 mg tablet 1 6 / day ACTOPLU MET 3 3 / day ACTOPLU MET XR 15-1,000 MG TB 2 3 / day GE 206 LAT UPDATED 04/2017

207 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ACTOPLU MET XR 30-1,000 MG TB 2 ACTO 3 ADLYXIN MCG TARTER CK 3 ADLYXIN 20 MCG MAINTENANCE PK 3 14 / 1 rx 0.22 / day AFREZZA 3 AMARYL 3 APIDRA 3 T APIDRA OLOTAR 3 T AVANDAMET 2 AVANDARYL 2 AVANDIA 2 MG TABLET 2 AVANDIA 4 MG TABLET 2 AVANDIA 8 MG TABLET 2 2 / day 3 / day 2 / day BAAGLAR KWIKPEN U BYDUREON / day BYDUREON PEN 2.15 / day BYETTA 10 MCG DOE PEN INJ / day BYETTA 5 MCG DOE PEN INJ / day GE 207 LAT UPDATED 04/2017

208 PRODUCT DECRIPTION TIER LIMIT & RETRICTION chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 3 / day DIABETA 3 DUETACT 3 FARXIGA 3 glimepiride 1 glipizide 1 glipizide er 1 glipizide xl 1 glipizide-metformin ( mg, mg) 1 4 / day glipizide-metformin mg 1 8 / day GLUCOPHAGE 1,000 MG TABLET / day GLUCOPHAGE 500 MG TABLET 3 5 / day GLUCOPHAGE 850 MG TABLET 3 3 / day GLUCOPHAGE XR 500 MG TAB 3 5 / day GLUCOPHAGE XR 750 MG TAB 3 3 / day GLUCOTROL 3 GLUCOTROL XL 3 GLUCOVANCE 3 4 / day glyburid-metformin mg 1 8 / day glyburide 1 glyburide micronized 1 glyburide-metformin hcl ( mg, mg) 1 4 / day GLYNAE 3 GE 208 LAT UPDATED 04/2017

209 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GLYET 3 3 / day GLYXAMBI 3 HUMALOG 2 HUMALOG KWIKPEN U HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 2 HUMALOG MIX HUMALOG MIX KWIKPEN 2 HUMULIN R U HUMULIN R U-500 KWIKPEN 2 INVOKAMET 2 2 / day INVOKAMET XR 2 2 / day INVOKANA 2 JANUMET 2 2 / day JANUMET XR (50-1,000 MG TABLET, MG TABLET) 2 2 / day JANUMET XR 100-1,000 MG TABLET 2 JANUVIA 2 JARDIANCE 2 JENTADUETO 2 2 / day JENTADUETO XR 2 KAZANO 3 KOMBIGLYZE XR 3 2 / day GE 209 LAT UPDATED 04/2017

210 PRODUCT DECRIPTION TIER LIMIT & RETRICTION KORLYM 3 LANTU 2 LANTU OLOTAR 2 LEVEMIR 2 LEVEMIR FLEXTOUCH 2 metformin hcl 1,000 mg tablet / day metformin hcl 500 mg tablet 1 5 / day metformin hcl 850 mg tablet 1 3 / day metformin hcl er 500 mg tablet 1 metformin hcl er 750 mg tablet 1 C C 5 / day Only Glucophage ER generic covered 3 / day Only Glucophage ER generic covered miglitol 1 3 / day nateglinide 1 3 / day NEINA 3 NOVOLOG 2 NOVOLOG FLEXPEN 2 NOVOLOG MIX NOVOLOG MIX FLEXPEN 2 ONGLYZA 3 OENI 3 GE 210 LAT UPDATED 04/2017

211 PRODUCT DECRIPTION TIER LIMIT & RETRICTION pioglitazone hcl 1 pioglitazone-glimepiride 1 pioglitazone-metformin 1 3 / day PRANDIMET 3 5 / day PRANDIN (0.5 MG TABLET, 1 MG TABLET) 3 4 / day PRANDIN 2 MG TABLET 3 8 / day PRECOE 100 MG TABLET 3 3 / day PRECOE 25 MG TABLET 3 12 / day PRECOE 50 MG TABLET 3 6 / day repaglinide (0.5 mg tablet, 1 mg tablet) 1 4 / day repaglinide 2 mg tablet 1 8 / day repaglinide-metformin hcl 1 5 / day RIOMET 3 25 / day AXENDA 3 AL 0.5 / day At least 18 yrs old OLIQUA TARLIX 3 3 / day YMLINPEN / day YMLINPEN / day YNJARDY 2 2 / day YNJARDY XR 2 TANZEUM / day GE 211 LAT UPDATED 04/2017

212 PRODUCT DECRIPTION TIER LIMIT & RETRICTION tolazamide 250 mg tablet 1 4 / day tolazamide 500 mg tablet 1 2 / day tolbutamide 1 6 / day TOUJEO OLOTAR 2 TRADJENTA 2 TREIBA FLEXTOUCH U TREIBA FLEXTOUCH U / day TRULICITY 0.75 MG/0.5 ML PEN / day TRULICITY 1.5 MG/0.5 ML PEN / day VICTOZA 2-K / day VICTOZA 3-K / day XIGDUO XR (5 MG-500 MG TABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET) 3 XIGDUO XR 5 MG-1,000 MG TABLET 3 2 / day XULTOPHY ANTIHYPOGLYCEMIC AGENT GLUCAGEN 1 MG HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 CONTRACEPTIVE ALTAVERA 1 GL Female ALYACEN 1 GL Female AMETHIA 1 GL 91 days Female GE 212 LAT UPDATED 04/2017

213 PRODUCT DECRIPTION TIER LIMIT & RETRICTION AMETHIA LO 1 AMETHYT 1 GL GL 91 days Female Female APRI 1 GL Female ARANELLE 1 GL Female AHLYNA 1 GL Female AUBRA 1 AVIANE 1 GL GL Female Female AZURETTE 1 GL Female BALZIVA 1 GL Female BEKYREE 1 GL Female BEYAZ 3 GL Female BLIOVI 24 FE 1 GL Female BLIOVI FE 1 GL Female BREVICON 3 GL Female BRIELLYN 1 GL Female CAMILA 1 GL Female CAMREE 1 CAMREE LO 1 GL GL 91 days Female 91 days Female GE 213 LAT UPDATED 04/2017

214 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CAZIANT 1 GL Female CHATEAL 1 GL Female CRYELLE 1 GL Female CYCLAFEM 1 GL Female CYCLEA 3 GL Female CYRED 1 GL Female DAETTA 1 GL Female DAYEE 1 GL 91 days Female DEBLITANE 1 GL Female DELYLA 1 GL Female DEOGEN 3 GL Female desogestr-eth estrad eth estra 1 GL Female desogestrel-ethinyl estradiol 1 GL Female drospirenone-eth estra-levomef 1 GL Female drospirenone-ethinyl estradiol 1 GL Female ELINET 1 GL Female ELLA 3 GL Female EMOQUETTE 1 GL Female ENPREE 1 GL Female ENKYCE 1 GL Female GE 214 LAT UPDATED 04/2017

215 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ERRIN 1 GL Female ETARYLLA 1 GL Female ETROTEP FE 3 GL Female ethynodiol-ethinyl estradiol 1 GL Female FALMINA 1 GL Female FEMCON FE 3 GL Female FEMYNOR 1 GL Female GENERE FE 3 GL Female GIANVI 1 GL Female GILDAGIA 1 GL Female GILDE 1 GL Female GILDE 24 FE 1 GL Female GILDE FE 1 GL Female HEATHER 1 GL Female IMPLANON 3 INTROVALE 1 GL 91 days Female JENCYCLA 1 GL Female JOLEA 1 GL 91 days Female JOLIVETTE 1 GL Female JULEBER 1 GL Female JUNEL 1 GL Female GE 215 LAT UPDATED 04/2017

216 PRODUCT DECRIPTION TIER LIMIT & RETRICTION JUNEL FE 1 GL Female JUNEL FE 24 1 GL Female KAITLIB FE 1 GL Female KARIVA 1 GL Female KELNOR GL Female KIMIDE 1 GL Female KURVELO 1 GL Female LARIN 1 GL Female LARIN 24 FE 1 GL Female LARIN FE 1 GL Female LARIIA 1 GL Female LAYOLI FE 1 GL Female LEENA 1 GL Female LEINA 1 GL Female LEVONET 1 GL Female levono-e estrad GL 91 days Female levono-e estrad GL Female levonor-eth estrad GL 91 days Female levonor-eth estrad triphasic 1 GL Female GE 216 LAT UPDATED 04/2017

217 PRODUCT DECRIPTION TIER LIMIT & RETRICTION levonorgestrel 1 GL 0.07 / day Female levonorgestrel-eth estradiol (estra mg, estrad mg) 1 GL Female LEVORA-28 1 GL Female LILETTA 3 LO LOETRIN FE 3 GL Female LO MINATRIN FE 3 GL Female LOETRIN 3 GL Female LOETRIN FE 3 GL Female LOMEDIA 24 FE 1 GL Female LORYNA 1 GL Female LOEAONIQUE 3 GL 91 days Female LOW-OGETREL 1 GL Female LUTERA 1 GL Female LYZA 1 GL Female MARLIA 1 GL Female MIBELA 24 FE 1 GL Female MICROGETIN 1 GL Female MICROGETIN 24 FE 3 GL Female GE 217 LAT UPDATED 04/2017

218 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MICROGETIN FE 1-20 TABLET 3 GL Female MICROGETIN FE TAB 1 GL Female MINATRIN 24 FE 3 GL Female MIRCETTE 3 GL Female MIRENA 3 GL P Female MODICON 3 GL Female MONO-LINYAH 1 GL Female MONONEA 1 GL Female MYZILRA 1 GL Female NATAZIA 2 GL Female NECON ( TABLET, TABLET, TABLET) 1 GL Female NECON TABLET 3 GL Female NECON TABLET 1 GL Female NEXPLANON 3 NIKKI 1 GL Female NOR-Q-D 3 GL Female NORA-BE 1 GL Female norethin-eth estra-ferrous fum (noret-estr-fe (21)-75, noreth-estrad-fe (21)-75, norethestrad-fe (24)-75, norethin-estra-fe mg) 1 GL Female norethind-eth estrad mg 1 GL Female norethindrone 1 GL Female GE 218 LAT UPDATED 04/2017

219 PRODUCT DECRIPTION TIER LIMIT & RETRICTION norgestimate-ethinyl estradiol 1 GL Female NORINYL GL Female NORINYL GL Female NORLYROC 1 GL Female NORTREL 1 GL Female NUVARING 2 GL Female OCELLA 1 GL Female OGETREL 1 ORYTHIA 1 GL GL Female Female ORTHO EVRA 3 GL Female 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 RAGARD T 380-A 3 PHILITH 1 GL Female PIMTREA 1 GL Female PIRMELLA 1 GL Female GE 219 LAT UPDATED 04/2017

220 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PLAN B ONE-TEP 3 PORTIA 1 GL GL 2 / 30 days Female Female PREVIFEM 1 GL Female QUARTETTE 3 GL Female QUAENE 1 GL 91 days Female RAJANI 1 GL Female RECLIPEN 1 GL Female AFYRAL 3 GL Female EAONIQUE 3 ETLAKIN 1 GL GL 91 days Female 91 days Female HAROBEL 1 GL Female KYLA 3 GL P Female PRINTEC 1 GL Female RONYX 1 GL Female YEDA 1 GL Female TARINA FE 1 GL Female TAYTULLA 3 GL Female GE 220 LAT UPDATED 04/2017

221 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TILIA FE 1 GL Female TRI-ETARYLLA 1 GL Female TRI-LEGET FE 1 GL Female TRI-LINYAH 1 GL Female TRI-LO-ETARYLLA 1 GL Female TRI-LO-MARZIA 1 GL Female TRI-LO-PRINTEC 1 GL Female TRI-NORINYL 3 GL Female TRI-PREVIFEM 1 GL Female TRI-PRINTEC 1 GL Female TRINEA 1 GL Female TRINEA LO 1 GL Female TRIVORA-28 1 GL Female VELIVET 1 GL Female VETURA 1 GL Female VIENVA 1 GL Female VIORELE 1 GL Female VYFEMLA 1 GL Female WERA 1 GL Female WYMZYA FE 1 GL Female XULANE 1 GL 0.12 / day Female GE 221 LAT UPDATED 04/2017

222 PRODUCT DECRIPTION TIER LIMIT & RETRICTION YAMIN 28 3 GL Female YAZ 3 GL Female ZARAH 1 GL Female ZENCHENT 1 GL Female ZENCHENT FE 1 GL Female ZEOA 1 GL Female ZOVIA 1-35E 1 GL Female ZOVIA 1-50E 1 GL Female ETROGEN AND ANTIETROGEN ACTIVELLA 3 ALORA 3 AMABELZ 1 ANGELIQ 3 CLIMARA 3 CLIMARA PRO 2 GL GL GL GL GL GL Female 0.29 / day Female Female Female 0.15 / day Female 0.15 / day Female clomiphene citrate 1 GL Female COMBITCH 3 GL 0.29 / day Female DELETROGEN 3 GL Female GE 222 LAT UPDATED 04/2017

223 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DEPO-ETRADIOL 3 GL Female DIVIGEL (0.25 MG GEL CKET, 0.5 MG GEL CKET, 1 MG GEL CKET) 2 GL Female DUAVEE 2 ELETRIN 3 GL Female ENJUVIA 2 ETRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 GL GL Female Female ETRACE 0.01% CREAM 2 GL Female estradiol (0.025 mg patch, mg patch, 0.05 mg patch, mg patch, 0.1 mg patch) 1 GL 0.29 / day Female estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 GL Female estradiol (tds mg/day, mg/day patch, tds mg/day, 0.05 mg/day patch, tds 0.05 mg/day, tds 0.06 mg/day, mg/day patch, tds mg/day, 0.1 mg/day patch, tds 0.1 mg/day) 1 GL 0.15 / day Female estradiol 0.06 mg/day patch 1 GL.15 / day Female estradiol valerate 1 GL Female estradiol-norethindrone acetat 1 ETRING 2 ETROGEL 3 GL GL GL Female 90 days Female / day Female GE 223 LAT UPDATED 04/2017

224 PRODUCT DECRIPTION TIER LIMIT & RETRICTION estropipate 1 EVAMIT 3 GL GL Female 0.54 / day Female EVITA 3 FEMHRT 3 FEMRING 3 GL GL Female 0.02 / day Female FYAVOLV 1 GL Female JEVANTIQUE LO 3 GL Female JINTELI 1 LOPREEZA 1 GL GL Female Female MENET (0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 3 GL Female MENET 0.3 MG TABLET 2 MENOTAR 3 MIMVEY 1 MIMVEY LO 1 MINIVELLE 3 GL GL GL GL Female 0.15 / day Female Female 0.29 / day Female GE 224 LAT UPDATED 04/2017

225 PRODUCT DECRIPTION TIER LIMIT & RETRICTION norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg, norethind-eth ) 1 OPHENA 3 PREFET 3 GL Female PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET) 2 GL Female PREMARIN 25 MG VIAL 2 PREMARIN VAGINAL CREAM-APPL 2 GL Female PREMPHAE 2 PREMPRO 2 raloxifene hcl 1 GL GL Female Female EROPHENE 1 GL Female VAGIFEM 3 GL Female VIVELLE-DOT 3 GL 8 / 28 days Female YUVAFEM 1 GL Female GONADOTROPIN BRAVELLE 3 GL P Female chorionic gonadotropin 1 FOLLITIM AQ 3 GE 225 LAT UPDATED 04/2017

226 PRODUCT DECRIPTION TIER LIMIT & RETRICTION GONAL-F 3 GONAL-F RFF (75 VIAL, 300 PEN, 450 PEN, 900 PEN) 3 GONAL-F RFF REDI-JECT 3 MENOPUR 3 NOVAREL 1 OVIDREL 3 PREGNYL 1 REPRONEX 3 YNAREL 3 P GL P GL P GL P P GL Female Female Female Female GE 226 LAT UPDATED 04/2017

227 LEPTIN PRODUCT DECRIPTION TIER LIMIT & RETRICTION MYALEPT 3 RATHYROID calcitonin-salmon / day FORTEO 3 P FORTICAL / day MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL) 3 MIACALCIN 200 UNIT NAAL PRAY / day NATRA 3 PITUITARY DDAVP 0.01% NAAL PRAY 3 desmopressin acetate (0.1 mg/ml spray, 10 mcg/0.1 ml spr) 1 GENOTROPIN 3 HUMATROPE 3 NORDITROPIN FLEXPRO 3 NORDITROPIN NORDIFLEX 30 MG/3 3 P P GE 227 LAT UPDATED 04/2017

228 PRODUCT DECRIPTION TIER LIMIT & RETRICTION NUTROPIN 3 NUTROPIN AQ 3 NUTROPIN AQ NUPIN 3 OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 3 AIZEN 3 EROTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL) 3 TEV-TROPIN 3 vasopressin 1 ZOMACTON 3 ZORBTIVE 3 PROGETIN AYGETIN 3 GL Female CRINONE 3 GL Female DEPO-PROVERA (150 MG/ML YRINGE, 150 MG/ML VIAL) 3 GL Female DEPO-PROVERA 400 MG/ML VIAL 3 GE 228 LAT UPDATED 04/2017

229 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DEPO-UBQ PROVERA ENDOMETRIN 3 hydroxyprogesterone caproate 3 MAKENA 1,250 MG/5 ML VIAL 3 MAKENA 250 MG/ML VIAL 3 medroxyprogesterone 150 mg/ml 1 GL GL P GL GL P GL P GL 90 days Female Female Female Female Female 0.04 / day Female medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 GL Female norethindrone ac (lupaneta) 1 GL Female norethindrone acetate 1 GL Female progesterone (oil 50 mg/ml vl, 100 mg capsule, 200 mg capsule) 1 GL Female progesterone in oil 1 GL Female PROMETRIUM 3 GL Female PROVERA 3 GL Female GE 229 LAT UPDATED 04/2017

230 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OMATOTATIN AGONIT AND ANTAGONIT octreotide acetate 1 ANDOTATIN 3 ANDOTATIN LAR 3 ANDOTATIN LAR DEPOT 3 IGNIFOR 3 IGNIFOR LAR (20 MG KIT, 20 MG VIAL) 3 IGNIFOR LAR (40 MG KIT, 40 MG VIAL) 3 IGNIFOR LAR (60 MG KIT, 60 MG VIAL) / day 0.04 / day OMATULINE DEPOT (60 MG/0.2 ML, 90 MG/0.3 ML, 120 MG/0.5 ML) / day OMATOTROPIN AGONIT AND ANTAGONIT EGRIFTA 1 MG VIAL 3 2 / 1 days GE 230 LAT UPDATED 04/2017

231 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EGRIFTA 2 MG VIAL 3 INCRELEX 3 OMAVERT 3 THYROID AND ANTITHYROID AGENT ARMOUR THYROID 3 CYTOMEL 3 LEVO-T 1 2 / 1 days levothyroxine sodium (100 mcg vial, 200 mcg vial, 500 mcg vial) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) 1 1 LEVOXYL 1 liothyronine sod 10 mcg/ml vl 1 liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1 methimazole 1 NATURE-THROID 3 NP THYROID 1 propylthiouracil 1 YNTHROID 2 TAZOLE 3 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 GE 231 LAT UPDATED 04/2017

232 PRODUCT DECRIPTION TIER LIMIT & RETRICTION THYROLAR-2 3 THYROLAR-3 3 TIROINT 3 TRIOTAT 3 UNITHROID (25 MCG TABLET, 50 MCG TABLET, 75 MCG TABLET, 88 MCG TABLET, 100 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 200 MCG TABLET, 300 MCG TABLET) 1 WETHROID 3 WP THYROID 3 MICELLANEOU THERAPEUTIC AGENT 5-ALPHA-REDUCTAE INHIBITOR AVODART 3 dutasteride 1 finasteride 5 mg tablet 1 PROCAR 3 ALCOHOL DETERRENT ANTABUE 3 disulfiram 1 ANTIDOTE ACETADOTE 3 CYANOKIT 3 fomepizole 1 GL GL GL GL Male Male Male Male GE 232 LAT UPDATED 04/2017

233 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FUILEV 3 leucovorin cal 500 mg/50 ml vl 1 leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vl) levoleucovorin calcium (50 mg vial, 175 mg vial, 175 mg/17.5 ml, 250 mg/25 ml vl) MEPHYTON 2 methylene blue 1 NITHIODOTE 3 phytonadione 1 pralidoxime chloride 1 PROTOM CHLORIDE 3 sodium nitrite 1 sodium thiosulfate 1 VITOGARD 3 vitamin k1 1 ANTIGOUT AGENT allopurinol 100 mg tablet 1 3 / day allopurinol 300 mg tablet 1 2 / day allopurinol sodium 1 ALOPRIM 3 colchicine 0.6 mg capsule 1 2 / day colchicine 0.6 mg tablet 1 4 / day COLCRY 2 4 / day KRYTEXXA / day GE 233 LAT UPDATED 04/2017

234 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MITIGARE 3 ULORIC 2 T T 2 / day ZYLOPRIM 100 MG TABLET 3 3 / day ZYLOPRIM 300 MG TABLET 3 2 / day BONE REORPTION INHIBITOR ACTONEL (5 MG TABLET, 30 MG TABLET) 3 ACTONEL 150 MG TABLET / day ACTONEL 35 MG TABLET / day alendronate sod 70 mg/75 ml / day alendronate sodium (35 mg tab, 40 mg tab, 70 mg tab) 1.15 / day alendronate sodium (5 mg tablet, 10 mg tab) 1 ATELVIA 3 T 0.15 / day BINOTO 3.15 / day BONIVA 150 MG TABLET / day BONIVA 3 MG/3 ML YRINGE 3 etidronate disodium 1 FOAMAX 3.15 / day FOAMAX PLU D / day ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial) 1 ibandronate sodium 150 mg tab / day GE 234 LAT UPDATED 04/2017

235 PRODUCT DECRIPTION TIER LIMIT & RETRICTION pamidronate disodium (30 mg/10 ml vial, disod 30 mg vial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90 mg vial) 1 PROLIA 3 1 / 135 daysspecialty RECLAT 3 risedronate sodium 150 mg tab / day risedronate sodium 30 mg tab 1 risedronate sodium 35 mg tab / day risedronate sodium 5 mg tablet 1 risedronate sodium dr 1 XGEVA / day zoledronic acid (4 mg vial, 4 mg/100 ml, 4 mg/5 ml vial, 5 mg/100 ml) 1 ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML VIAL) 3 CARIOTATIC AGENT FLORIVA (0.25 MG CHEW TABLET, 0.5 MG CHEWABLE TABLET, 1 MG CHEWABLE TABLET) 3 FLORIVA PLU 3 mult-vit-fluor 0.5 mg tab chw 1 multi-vitamin w-fluoride 1 multi-vitamin with fluoride 1 multivitamin and fluoride 1 multivitamin with fluoride (0.25 mg/ml drop, 0.5 mg/ml drop) 1 GE 235 LAT UPDATED 04/2017

236 PRODUCT DECRIPTION TIER LIMIT & RETRICTION multivitamin with fluoride (multivit-fluor 0.25 mg tab chw, multivit-fluor 0.5 mg tab chew, multivit-fluoride 1 mg tab chw) 3 MVC-FLUORIDE 1 POLY-VI-FLOR (0.25 MG DROP, 0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) 3 POLY-VI-FLOR F 3 QUFLORA (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 1 MG CHEW TAB) 3 TRI-VI-FLOR 3 TRI-VI-FLORO 3 tri-vitamin with fluoride 1 triple-vitamin w-fluoride 1 vitamins a,c,d and fluoride 1 COMPLEMENT INHIBITOR BERINERT 3 CINRYZE 3 FIRAZYR 3 KALBITOR 3 RUCONET 3 OLIRI / day GE 236 LAT UPDATED 04/2017

237 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DIEAE-MODIFYING ANTIRHEUMATIC AGENT ACTEMRA (80 MG/4 ML VIAL, 200 MG/10 ML VIAL, 400 MG/20 ML VIAL) / day ACTEMRA 162 MG/0.9 ML YRINGE 3 ARAVA 3 AZAAN 3 azathioprine 1 azathioprine sodium / day cyclosporine (25 mg capsule, 100 mg capsule, 100 mg/ml soln) 1 cyclosporine (50 mg/ml ampul, 50 mg/ml vial) 1 cyclosporine modified 1 ENBREL (25 MG KIT, 25 MG/0.5 ML YRINGE) 3 ENBREL 50 MG/ML URECLICK YR 3 ENBREL 50 MG/ML YRINGE 3 P P P 0.29 / day 0.15 / day 0.15 / days GENGRAF (25 MG CAPULE, 50 MG CAPULE, 100 MG CAPULE, 100 MG/ML OLUTION) 1 GE 237 LAT UPDATED 04/2017

238 PRODUCT DECRIPTION TIER LIMIT & RETRICTION IMURAN / day KINERET 100 MG/0.67 ML YRINGE 3 leflunomide 1 NEORAL (25 MG GELATIN CAPULE, 100 MG GELATIN CAPULE, 100 MG/ML OLUTION) 3 4 / 30 daysspecialty ORENCIA 125 MG/ML YRINGE 3 4 / 30 daysspecialty ORENCIA 250 MG VIAL / day ORENCIA CLICKJECT 3 OTEZLA 28 DAY TARTER CK 3 55 lifetimespecialty / 1 2 / day OTEZLA 30 MG TABLET 3 40 / 365 daysspecialty OTEZLA TARTER CK 3 ANDIMMUNE (25 MG CAPULE, 100 MG CAPULE) 3 ANDIMMUNE 100 MG/ML OLN 3 P GE 238 LAT UPDATED 04/2017

239 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ANDIMMUNE 50 MG/ML AMPUL 3 IMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML YRINGE) / day IMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML YRINGE) / day IMPONI ARIA 3 TELARA 130 MG/26 ML VIAL 3 TELARA 45 MG/0.5 ML YRINGE 3 TELARA 90 MG/ML YRINGE 3 XELJANZ 3 XELJANZ XR 3 GONADOTROPIN-RELEAING HORMONE ANTAGNT CETROTIDE 3 GL P / day 0.5 / 90 daysspecialty 1 / 90 daysspecialty 2 / day Female GE 239 LAT UPDATED 04/2017

240 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ganirelix acetate 1 IMMUNOMODULATORY AGENT GL Female ACTIMMUNE 3 AUBAGIO 3 P AVONEX (PREFILLED YR 30 MCG, PREFILLED YR 30 MCG KT) 3 P / day AVONEX 30 MCG VIAL KIT 3 AVONEX PEN 30 MCG/0.5 ML 3 AVONEX PEN 30 MCG/0.5 ML KIT 3 BETAERON 0.3 MG KIT 3 P P P 0.04 / day / 1 days / day / 1 days GE 240 LAT UPDATED 04/2017

241 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BETAERON 0.3 MG VIAL daysspecialty / 1 1 / 1 daysspecialty COXONE 3 P / 1 days EXTAVIA 3 GILENYA 3 GLATO 3 LEMTRADA 3 PLEGRIDY 125 MCG/0.5 ML PEN 3 PLEGRIDY 125 MCG/0.5 ML YRING 3 PLEGRIDY PEN INJ TARTER CK 3 P P P P 1 / 1 daysspecialty 0.04 / day 0.04 / 1 days 1 / lifetimespecialty GE 241 LAT UPDATED 04/2017

242 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PLEGRIDY YRINGE TARTER CK 3 P 1 / lifetimespecialty REBIF (22 MCG/0.5 ML YRINGE, 44 MCG/0.5 ML YRINGE) / dayspecialty REBIF REBIDOE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 3 REBIF REBIDOE TITRATION CK 3 REBIF TITRATION CK 3 TECFIDERA 3 THALOMID (150 MG CAPULE, 200 MG CAPULE) 3 THALOMID (50 MG CAPULE, 100 MG CAPULE) 3 TYABRI 3 P 0.22 / dayspecialty 4.2 / 365 daysspecialty 4.2 / 365 daysspecialty 2 / day 8 / day 4 / day GE 242 LAT UPDATED 04/2017

243 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ZINBRYTA 3 IMMUNOUPPREIVE AGENT ATAGRAF XL 3 ATGAM 3 BENLYTA 3 CELLCEPT (200 MG/ML ORAL UP, 250 MG CAPULE, 500 MG TABLET) 3 CELLCEPT 500 MG VIAL 3 ELIDEL 2 ENVARU XR 3 T AL / day At least 2 yrs old specialty HECORIA 1 mycophenolate 500 mg vial 1 mycophenolate mofetil (200 mg/ml susp, 250 mg capsule, 500 mg tablet) 1 mycophenolic acid 1 MYFORTIC 3 NULOJIX 3 PROGRAF (0.5 MG CAPULE, 1 MG CAPULE, 5 MG CAPULE) 2 GE 243 LAT UPDATED 04/2017

244 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PROGRAF 5 MG/ML AMPULE 2 RAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL OLN, 2 MG TABLET) 3 IMULECT 3 sirolimus 1 tacrolimus 0.5 mg capsule 1 tacrolimus 1 mg capsule 1 tacrolimus 5 mg capsule 1 THYMOGLOBULIN 3 ZORTRE 3 OTHER MICELLANEOU THERAPEUTIC AGENT acetylcysteine (10% vial, 20% vial) 1 AMPYRA 3 ARCALYT 3 CARNITOR (100 MG/ML ORAL OLN, 330 MG TABLET) 3 CARNITOR 1 GM/5 ML VIAL 3 CARNITOR F 3 CERDELGA 3 P 2 / dayspecialty 8 / dayspecialty 4 / day 2 / day 2 / day GE 244 LAT UPDATED 04/2017

245 PRODUCT DECRIPTION TIER LIMIT & RETRICTION CYTADANE 3 CYTAGON 3 DEMER 3 ELMIRON 3 ILARI 180 MG VIAL 3 KUVAN 100 MG POWDER CKET 3 KUVAN 100 MG TABLET 3 KUVAN 500 MG POWDER CKET 3 levocarnitine (1 g/10 ml soln, 330 mg tablet) 1 levocarnitine 200 mg/ml vial 1 NEXAVIR / 1 days 30 / 30 days ORFADIN (2 MG CAPULE, 5 MG CAPULE, 10 MG CAPULE) 3 ORFADIN (4 MG/ML UPENION, 20 MG CAPULE) 3 NHEMATIN 3 POTABA 3 PROCYBI 3 ENIR 3 OD POLYULTHIONATE-FOLIC ACID 3 GE 245 LAT UPDATED 04/2017

246 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ULFZIX 3 THIOLA 3 TYBOT 3 P XURIDEN 3 ZAVECA 3 PROTECTIVE AGENT amifostine 1 dexrazoxane 1 ETHYOL 3 mesna 1 MENEX (1 GRAM/10 ML VIAL, 400 MG TABLET) 3 TOTECT 3 ZINECARD 3 OXYTOCIC MIFEPREX 3 PHARMACEUTICAL AID ethyl acetate 1 FORMA-RAY 3 GE 246 LAT UPDATED 04/2017

247 PRODUCT DECRIPTION TIER LIMIT & RETRICTION RADIOACTIVE AGENT HICON 3 METATRON 3 XOFIGO 3 REPIRATORY TRACT AGENT ANTI-INFLAMMATORY AGENT (REPIRATORY) ACCOLATE 3 2 / day cromolyn sodium (20 mg/2 ml neb soln, 100 mg/5 ml oral conc) 1 GATROCROM 3 montelukast sodium 1 INGULAIR 3 zafirlukast 1 2 / day zileuton 1 4 / day ZYFLO 3 4 / day ZYFLO CR 3 4 / day ANTIFIBROTIC AGENT EBRIET 3 OFEV 3 ANTIHITAMINE (REPIRATORY TRACT AGNT) promethazine-codeine 1 2 / days GE 247 LAT UPDATED 04/2017

248 ANTITUIVE PRODUCT DECRIPTION TIER LIMIT & RETRICTION benzonatate 1 AL At least 11 yrs old FLOWTU 3 AL 60 / day At least 18 yrs old TEALON PERLE 3 AL At least 11 yrs old ZONATU 3 AL At least 11 yrs old CYTIC FIBROI (CFTR) MODULATOR KALYDECO (50 MG GRANULE CKET, 75 MG GRANULE CKET) 3 2 / days KALYDECO 150 MG TABLET 3 ORKAMBI 100 MG-125 MG TABLET 3 ORKAMBI 200 MG-125 MG TABLET 3 PHOPHODIETERAE TYPE 4 INHIBITOR DALIREP 3 PULMONARY URFACTANT CUROURF 3 INFAURF 3 URVANTA 3 2 / day 4 / day 4 / 1 days GE 248 LAT UPDATED 04/2017

249 PRODUCT DECRIPTION TIER LIMIT & RETRICTION REPIRATORY TRACT AGENT, MICELLANEOU ARALAT NP 3 GLAIA 3 PROLATIN 3 PROLATIN C 3 XOLAIR 3 ZEMAIRA 3 KIN AND MUCOU MEMBRANE AGENT ANTI-INFECTIVE (KIN, MUCOU MEMBRANE) ACANYA 3 acyclovir 5% ointment 1 ALA-QUIN 3 ALCORTIN A 3 ALTABAX 3 AVC 3 BACTROBAN (CREAM, OINTMENT) 3 BENZACLIN 3 AL At least 6 yrs old / day / day GE 249 LAT UPDATED 04/2017

250 PRODUCT DECRIPTION TIER LIMIT & RETRICTION BENZAMYCIN 3 BENZAMYCINK 3 CENTANY 3 CENTANY AT 3 CICLODAN 0.77% CREAM 1 CICLODAN 0.77% CREAM KIT 3 CICLODAN 8% OLUTION / day 2 / day 0.22 / day ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp, 1% shampoo) 1 ciclopirox 8% solution 1 CLEOCIN 100 MG VAGINAL OVULE 2 CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN T (LOION, PLEDGE, OLUION) / day CLEOCIN T 1% GEL 3 75 / 30 days CLINDACIN ETZ 1% PLEDGET 1 CLINDACIN ETZ KIT 3 CLINDACIN P 1 CLINDACIN C 3 CLINDAGEL 3 75 / 30 days clindamycin ph 1% gel 1 75 / 30 days clindamycin phos-benzoyl perox / day clindamycin phos-tretinoin 1 2 / day GE 250 LAT UPDATED 04/2017

251 PRODUCT DECRIPTION TIER LIMIT & RETRICTION clindamycin phosphate (ph 1% solution, phos 1% pledget, phosp 1% lotion, 2% vaginal cream) 1 clindamycin phosphate 1% foam / day clindamycin-benzoyl peroxide / day CLINDEE 3 clotrimazole (1% cream, 1% solution, 10 mg troche) 1 clotrimazole-betamethasone (crm, lot) 1 CNL 8 3 CORTIPORIN CREAM / day CORTIPORIN OINTMENT / day DENAVIR 3 DERMAORB AF 3 DERMAZENE 1 DUAC 3 econazole nitrate 1 ECOZA 3 ELIMITE 3 ERTACZO 3 ERY 1 AL / day At least 12 yrs old 1.5 / day ERYGEL 3 erythromycin (pledgets, solution) 1 erythromycin 2% gel 1 erythromycin-benzoyl peroxide / day GE 251 LAT UPDATED 04/2017

252 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EURAX 3 T EVOCLIN / day EXELDERM (CREAM, OLUTION) 3 EXODERM 1 EXTINA 3 FEM PH 3 gentamicin sulfate (cream, ointment) 1 GYNAZOLE 1 3 hydrocortisone-iodoquinol 1 hydrocortisone-iodoquinol-aloe 1 IODOFLEX 3 IODOORB 3 JUBLIA 3 KERYDIN 3 ketoconazole (cream, foam, shampoo) 1 KETODAN 2% FOAM 1 KETODAN 2% FOAM KIT 3 AL AL 0.54 / day At least 18 yrs old 0.67 / day At least 18 yrs old KLARON 3 4 / day lindane 1 LOPROX (0.77% TOPICAL UP, 1% HAMPOO) 3 LOTRIONE 3 LUGOL' TRONG IODINE OLUTION 1 LUZU 3 2 / day GE 252 LAT UPDATED 04/2017

253 PRODUCT DECRIPTION TIER LIMIT & RETRICTION malathion 1 MENTAX 3 METROCREAM 3 METROGEL 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole (0.75% cream, 0.75% lotion, top 1% gel pump, topical 0.75% gl, topical 1% gel, vaginal 0.75% gl) 1 miconazole 3 3 GL Female mupirocin (cream, ointment) 1 naftifine hcl 1 NAFTIN 3 NATROBA 3 T NEO-YNALAR (0.5%-0.025% CREAM, % CRM KIT) 3 NEUAC 1.2-5% KIT 3 NEUAC GEL / day NIZORAL 3 NORITATE 3 NYAMYC 1 NYATA 100,000 UNIT/GM POWDER 1 nystatin (unit/gm cream, unit/gm powd, units/gm oint) 1 nystatin-triamcinolone 1 NYTOP 1 ONEXTON 1.2%-3.75% GEL / day ONEXTON GEL PUMP / day ORAVIG 3 14 / 1 rx GE 253 LAT UPDATED 04/2017

254 PRODUCT DECRIPTION TIER LIMIT & RETRICTION OVIDE 3 T oxiconazole nitrate 1 OXITAT (CREAM, LOTION) 3 PEDIADERM AF 3 PENLAC 3 permethrin 1 RELAGARD 3 ROADAN (CREAM KIT, GEL KIT) 3 ROADAN (CREAM, GEL) / day silver nitrate (0.5% soln, 10% ointment, 25% solution, 50% solution) 1 KLICE 3 T sodium sulfacetamide 10% lot 1 4 / day spinosad 1 sulfacetamide sodium (sod top susp, sodium lotn) 1 4 / day TERAZOL 3 3 GL Female TERAZOL 7 3 terconazole (0.4% cream, 0.8% cream) 1 GL Female terconazole 80 mg suppository 1 TRIPLE DYE 3 GL 1.5 / day Female ULEFIA 3 T VANDAZOLE 1 VELTIN 3 2 / day GE 254 LAT UPDATED 04/2017

255 PRODUCT DECRIPTION TIER LIMIT & RETRICTION VUION 3 VYTONE 3 XEREE 3 XOLEGEL 3 ZIANA 3 ZOVIRAX 5% CREAM 2 ZOVIRAX 5% OINTMENT 3 ANTI-INFLAMMATORY AGENT (KIN, MUCOU) ADV ALLERGY COLLECTION KIT 3 ALA-CORT 1 ALA-CALP 3 alclometasone dipropionate 1 amcinonide (cream, lotion, ointment) 1 ANA-LEX 2-2% CREAM 3 ANALPRAM ADVANCED 3 ANALPRAM E 3 AL AL AL / day At least 6 yrs old 2 / day / day At least 12 yrs old At least 12 yrs old ANALPRAM HC (1% CREAM, 2.5% CREAM, 2.5% CRM INGLE, 2.5% LOTION, 2.5%-1% CREAM, 2.5%-1% CRM INGLE, 2.5%-1% LOTION) 3 ANUCORT-HC 1 ANUOL-HC (2.5% CREAM, 25 MG UPPOITORY) 3 GE 255 LAT UPDATED 04/2017

256 PRODUCT DECRIPTION TIER LIMIT & RETRICTION APEXICON 1 APEXICON E 3 AQUA GLYCOLIC HC 3 betamethasone dipropionate (aug crm, aug gel, aug lot, aug oin, crm, lot, oint) betamethasone valerate (va 0.1% cream, va 0.1% lotion, valer 0.1% ointm, valer 0.12% foam) 1 1 calcipotriene-betamethasone dp 1 3 / day CAPEX HAMPOO 3 clobetasol emollient 1 clobetasol emulsion 1 clobetasol propionate (cream, gel, ointment, prop foam, prop spray, shampoo, solution, topical lotn) 1 CLOBEX 3 clocortolone pivalate 1 CLODAN 0.05% HAMPOO 1 CLODERM 3 COLOCORT 1 CORDRAN (4 MCG/Q CM TAPE LARGE, 4 MCG/Q CM TAPE MALL) / day CORDRAN 0.05% CREAM 3 2 / day CORDRAN 0.05% LOTION 3 4 / day CORDRAN 0.05% OINTMENT 3 CORMAX 1 CORTENEMA 3 CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3 DERMA-MOOTHE-F (BODY OIL, CALP OIL) 3 GE 256 LAT UPDATED 04/2017

257 PRODUCT DECRIPTION TIER LIMIT & RETRICTION DERMAORB HC 3 DERMATOP 3 DEONATE 3 desonide (cream, lotion, ointment) 1 DEOWEN (CREAM, LOTION) 3 desoximetasone 1 diflorasone diacetate 1 DIPROLENE (LOTION, OINTMENT) 3 DIPROLENE AF 3 ELOCON (CREAM, LOTION, OINTMENT) 3 ENTILAR 3 2 / day EPIFOAM 3 fluocinolone acetonide (0.01% body oil, 0.01% cream, 0.01% scalp oil, 0.01% solution, 0.025% cream, 0.025% ointment) fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment, 0.05% solution, 0.1% cream) 1 1 fluocinonide-e 1 flurandrenolide 0.05% cream 1 2 / day flurandrenolide 0.05% lotion 1 4 / day flurandrenolide 0.05% ointment 1 fluticasone propionate (0.005% oint, 0.05% cream, 0.05% lotion) 1 halobetasol propionate 1 HALOG 3 HEMMOREX-HC 1 hydrocortisone (1% absorbase, 1% cream, 1% ointment, 2.5% cream, 2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1 hydrocortisone acetate 1 GE 257 LAT UPDATED 04/2017

258 PRODUCT DECRIPTION TIER LIMIT & RETRICTION hydrocortisone butyrate (hydrocort buty lipid crm, hydrocort buty lipo cream, hydrocortisone buty cream, hydrocortisone butyr oint, hydrocortisone butyr soln) 1 hydrocortisone valerate 1 hydrocortisone-pramoxine (hydrocort-pram 2.5%-1% crm kit, hydrocort-pramoxine 1%-1% crm, hydrocortpramoxine 2.5%-1% cm, hydrocort-pramoxine 2.5-1% crm) 1 hydrocortisone-pramoxine hcl 1 KENALOG 3 lidocaine-hydrocortisone (lidocaine-hc 2-2% cream kit, lidocaine-hc % gel, lidocaine-hc 3-0.5% cream, lidocaine-hc 3-0.5% cream kit, lidocaine-hc 3-1% cream, lidocaine-hc 3-1% cream kit, lidocaine-hc 3-2.5% gel kit, lidocaine-hydrocort 3-2.5% gel) 1 LOCOID (CREAM, LOTION, OINTMENT, OLUTION) 3 LOCOID LIPOCREAM 3 LUXIQ 3 MICORT-HC 3 mometasone furoate (cream, oint, soln) 1 NOVACORT GEL 3 OLUX 3 OLUX-E 3 ORALONE 1 NDEL 3 PEDIADERM HC 3 PEDIADERM TA 3 PRAMCORT 1 PRAMOONE (1% CREAM, 1% LOTION, 1% OINTMENT, 1%-1% CREAM, 1%-1% OINTMENT, 2.5% LOTION, 2.5% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%- 1% OINTMENT) 3 GE 258 LAT UPDATED 04/2017

259 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PRAMOONE E 3 prednicarbate 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-K 1 PROCTOCORT (1% CREAM, 30 MG UPPOITORY) 3 PROCTOFOAM-HC 2 PROCTOOL-HC 1 PROCTOZONE-HC 1 PORCON 3 RECTACORT-HC 1 RIMO-50 3 ANADERMRX 1 CALACORT 1 CALACORT DK 3 ERNIVO 3 YNALAR (0.01% OLUTION, 0.025% CREAM, 0.025% CREAM KIT, 0.025% OINTMENT, 0.025% OINTMENT KIT) 3 YNALAR T 3 TACLONEX 3 3 / day 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% PRAY) triamcinolone acetonide (0.025% cream, 0.025% lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment, 0.1% paste, mg/g spray, 0.5% cream, 0.5% ointment) 3 1 GE 259 LAT UPDATED 04/2017

260 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TRIANEX 1 TRIDERM 1 TRIDEILON 1 U-CORT 1 ULTRAVATE (CREAM, LOTION, OINTMENT) 3 ULTRAVATE X 3 VANO 3 VANOXIDE-HC / day VERDEO 3 ZYPRAM 3 ANTIPRURITIC AND LOCAL ANETHETIC doxepin 5% cream 1 phenazopyridine hcl 1 PRUDOXIN 3 PYRIDIUM 3 ZONALON 3 ATRINGENT DRYOL 3 HYPERCARE 1 CELL TIMULANT AND PROLIFERANT ATRALIN / day AVITA 1 KEPIVANCE 3 REFIA 3 RENOVA 3 RENOVA PUMP 3 GE 260 LAT UPDATED 04/2017

261 PRODUCT DECRIPTION TIER LIMIT & RETRICTION RETIN-A 3 RETIN-A MICRO 3 50 / 30 days RETIN-A MICRO PUMP 3 50 / 30 days TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3 tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05% cream, 0.05% emollient crm, 0.1% cream) 1 tretinoin 0.05% gel / day tretinoin microsphere / day DEPIGMENTING AND PIGMENTING AGENT 8-MOP 3 ACLARO 3 ALPHAQUIN HP 1 BLANCHE 1 EPIQUIN MICRO 3 hydroquinone (cream, tl cream, tr cream) 1 LUTRA 3 LUTRA-AF 3 LUTRA-ULTRA 3 MELQUE HP 1 MELQUIN HP 1 MELQUIN-3 3 methoxsalen 1 OXORALEN 3 OXORALEN-ULTRA 3 TRI-LUMA 3 UVADEX 3 GE 261 LAT UPDATED 04/2017

262 PRODUCT DECRIPTION TIER LIMIT & RETRICTION KERATOLYTIC AGENT ALUVEA 3 BENAL HP 3 BENZEFOAM 3 2 / day BENZEFOAM ULTRA / day BENZEPRO (6% FOAMING CLOTH, 7% CREAMY WAH) 1 benzoyl peroxide 5.3% foam 1 2 / day benzoyl peroxide 9.8% foam / day BP-50% UREA 1 BPO (3%, 9%) 3 2 / day BPO (4% GEL, 8% GEL) 3 BPO 6% FOAMING CLOTH 1 2 / day CARB-O-PHILIC 1 CEM-UREA 3 DERMAORB XM 3 GORDO-UREA 40% OINTMENT 3 grafco silver nit applicator 1 HYDRO 35 3 HYDRO 40 3 INOVA 3 2 / day INOVA / day INOVA / day KERAFOAM 3 KERALAC 3 KERALYT 3 GE 262 LAT UPDATED 04/2017

263 PRODUCT DECRIPTION TIER LIMIT & RETRICTION KERALYT CALP 3 LATRIX 1 NUOX / day CNEX 1 CNEX HP 3 CNEX LP 3 potassium hydroxide 1 PR BENZOYL PEROXIDE 1 pr benzoyl peroxide 7% wash 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 RYNODERM 3 ALACYN (CREAM, LOTION) 1 ALEX (CREAM KIT, LOTION KIT, HAMPOO) 3 salicylic acid (6% cream, 6% cream kit, 6% foam, 6% gel, 6% lotion, 6% lotion kit, 6% shampoo, 26% liquid, 27.5% liquid) 1 salicylic acid er 1 ALKERA 3 ALVAX 3 ALVAX DUO PLU 3 silver nitrate 10% solution 1 silver nitrate applicator 3 ULTRAAL-ER 3 UMECTA (EMULION, NAIL FILM PEN, NAIL FILM UP) 3 UMECTA 40% MOUE 1 UMECTA PD 3 URAMAXIN (20% FOAM, 45% LOTION, 45% NAIL GEL, 45% UREA CREAM) 3 GE 263 LAT UPDATED 04/2017

264 PRODUCT DECRIPTION TIER LIMIT & RETRICTION URAMAXIN GT (KIT, PRE-FILLED APP) 3 URE-K 1 urea (35% foam, 39% cream, 40% cream, 40% gel, 40% lotion, 40% nail film susp, 45% cream, 45% lotion, 45% nail gel, 47% cream, 50% cream) 1 urea (40% kit, 50% stick) 3 UREVAZ 3 UTOPIC 3 VIRAAL 3 X-VIATE (CREAM, GEL, LOTION) 1 KERATOPLATIC AGENT coal tar 1 DRITHOCREME HP 3 ZITHRANOL 3 ZITHRANOL-RR 3 KIN AND MUCOU MEMBRANE AGENT, MIC. ABORICA 3 acitretin (17.5 mg capsule, 25 mg capsule) 1 2 / day acitretin 10 mg capsule 1 4 / day ACZONE 3 2 / day adapalene (0.1% cream, 0.1% gel, 0.3% gel, 0.3% gel pump) / day adapalene 0.1% lotion 1 2 / day ALDARA 3 AL / day At least 12 yrs old AMNETEEM 1 AVAGE / day GE 264 LAT UPDATED 04/2017

265 PRODUCT DECRIPTION TIER LIMIT & RETRICTION AZELEX / day calcipotriene (cream, ointment, solution) 1 2 / day CALCITRENE 1 2 / day calcitriol 3 mcg/g ointment / day CARAC 2 CLARAVI 1 CONDYLOX (GEL, TOPICAL OLN) 3 COENTYX (2 YRINGE) 3 COENTYX PEN 3 COENTYX PEN (2 PEN) 3 COENTYX YRINGE 3 DEBACTEROL (OLUTION, WABTICK) / day / day / day / day diclofenac sodium 3% gel / 30 days DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL PUMP) / day DIFFERIN 0.1% LOTION / day DOVONEX 3 2 / day EFUDEX 3 GE 265 LAT UPDATED 04/2017

266 PRODUCT DECRIPTION TIER LIMIT & RETRICTION EPIDUO % GEL / day EPIDUO % GEL PUMP / day EPIDUO FORTE / day FABIOR 3 FINACEA 3 finasteride 1 mg tablet 1 FLUOROPLEX 2 AL 1.47 / day Up to 34 yrs old 50 / 30 days fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5% top solution) 1 FORMADON 1 formaldehyde 1 GRANULEX 3 imiquimod 1 AL / day At least 12 yrs old MIRVAO 2 MUCOTROL 3 MYORIAN 1 NRETIN 3 PICATO 3 T PODOCON-25 3 podofilox 1 PROPECIA 3 PROTOPIC 0.03% OINTMENT 3 T AL 100 / 30 days At least 2 yrs old GE 266 LAT UPDATED 04/2017

267 PRODUCT DECRIPTION TIER LIMIT & RETRICTION PROTOPIC 0.1% OINTMENT 3 PYROGALLIC ACID 1 QROXIN 3 T AL 100 / 30 days At least 16 yrs old QUTENZA 3 RECTIV 3 REGRANEX 3 RENOVO 3 ANTYL 3 ILMANIX 3 INELEE 3 OLARAZE / 30 days OOLANTRA 2 ORIATANE (17.5 MG CAPULE, 25 MG CAPULE) 3 2 / day ORIATANE 10 MG CAPULE 3 4 / day ORILUX 3 2 / day tacrolimus (0.03% ointment, 0.1% ointment) 1 TALTZ AUTOINJECTOR 3 TALTZ AUTOINJECTOR (2 CK) 3 TALTZ AUTOINJECTOR (3 CK) 3 T 100 / 30 days 0.15 / day 0.15 / day 0.15 / day GE 267 LAT UPDATED 04/2017

268 PRODUCT DECRIPTION TIER LIMIT & RETRICTION TALTZ YRINGE 3 TALTZ YRINGE (2 CK) 3 TALTZ YRINGE (3 CK) 3 TARGRETIN 1% GEL / day 0.15 / day 0.15 / day TAZORAC / day TOLAK 3 TRI-CHLOR 3 trichloroacetic acid 1 VALCHLOR 3 VANIQA 3 VAOLEX 1 T 1.47 / day 3 / day VECTICAL / day VEREGEN 3 ZENATANE 1 ZYCLARA (CREAM, CREAM PUMP) 3 ZYCLARA 2.5% CREAM PUMP 3 AL AL 56 / 60 days At least 12 yrs old 56 / 30 days At least 12 yrs old GE 268 LAT UPDATED 04/2017

269 PRODUCT DECRIPTION TIER LIMIT & RETRICTION UNCREEN AGENT NUQUIN HP 4% CREAM 1 NUQUIN HP 4% GEL 3 MOOTH MUCLE RELAXANT GENITOURINARY MOOTH MUCLE RELAXANT darifenacin er 1 DETROL 3 2 / day DETROL LA 3 DITRON XL (10 MG TABLET, 15 MG TABLET) 3 2 / day DITRON XL 5 MG TABLET 3 ENABLEX 3 flavoxate hcl 1 GELNIQUE 10% GEL ACHET 2 GELNIQUE 3% GEL / day MYRBETRIQ 3 oxybutynin 5 mg tablet 1 3 / day oxybutynin 5 mg/5 ml syrup 1 oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 2 / day oxybutynin cl er 5 mg tablet 1 OXYTROL / day tolterodine tartrate 1 2 / day tolterodine tartrate er 1 TOVIAZ 3 GE 269 LAT UPDATED 04/2017

270 PRODUCT DECRIPTION TIER LIMIT & RETRICTION trospium chloride 1 2 / day trospium chloride er 1 VEICARE 2 UNCATEGORIZED onetouch ultra test strips 2 10 / day onetouch ultra2 glucose syst 2 onetouch ultramini meter 2 onetouch verio flex startr kit 2 10 / day onetouch verio flex system kit 2 10 / day onetouch verio iq meter 2 onetouch verio iq system kit 2 onetouch verio meter system 2 onetouch verio sync syst kit 2 onetouch verio test strip 2 10 / day VITAMIN MULTIVITAMIN PRERATION COMPLETE NATAL DHA 3 GL Female ELITE OB DHA 3 GL Female INFUVITE 1 M.V.I. PEDIATRIC 3 MACUZIN 3 MAXINATE 3 GL Female multivitamins-a,b,d,e,k,zn (chewables tablet, pediatric drops) 1 MYNATAL ULTRACAPLET 3 GL Female GE 270 LAT UPDATED 04/2017

271 PRODUCT DECRIPTION TIER LIMIT & RETRICTION MYNATE 90 PLU 3 GL Female PNV-VP-U 3 PRENA1 CHEW 3 GL Female prenatal-u 3 GL Female PRENATE AM 3 GL Female REQ49+ 3 TRIVEEN-U 3 GL Female TRUT NATAL DHA 3 GL Female VINATE PN CARE 3 GL Female VINATE-M 3 GL Female VITAMEDMD REDICHEW RX 3 VITAMIN A AQUAOL A 3 VITAMIN B COMPLEX B-12 COMPLIANCE 3 B-12 KIT 1 b-complex 1 CARDIOTEK-RX 3 CIFEREX 3 cyanocobalamin injection 1 dexpanthenol 1 DIALYVITE 1 DIALYVITE DIALYVITE DIALYVITE UPREME D 3 DIALYVITE ZINC 3 GE 271 LAT UPDATED 04/2017

272 PRODUCT DECRIPTION TIER LIMIT & RETRICTION FABB 1 FOLBEE 1 FOLBEE AR 3 FOLBEE PLU 1 FOLBEE PLU CZ 1 FOLGARD RX 3 folic acid (1 mg tablet, 5 mg/ml vial) 1 folic acid-vit b6-vit b12 1 FOLIXAPURE 1 FOLPLEX FOLTRATE 3 hydroxocobalamin 1 MYNEPHROCAP 1 MYNEPHRON 3 NACOBAL 3 NEPHPLEX RX 3 NEPHRO-VITE RX 3 NEPHROCAP 3 NEPHROCAP QT 3 NEURIN-L 3 NOXIFOL-D3 3 ORTHO D 3 pyridoxine hcl 1 RENA-VITE RX 1 RENAL CAP 1 RENO CAP 1 REVETA 3 GE 272 LAT UPDATED 04/2017

273 PRODUCT DECRIPTION TIER LIMIT & RETRICTION ROXIFOL-D 3 UPERVITE 3 thiamine hcl 1 TL GARD RX 1 TRIPHROCAP 1 VIRT-CAP 1 VIRT-GARD 1 VIRT-VITE 1 VIRT-VITE PLU 1 VITA-RE 3 VITAL-D RX 3 VOL-CARE RX 1 VP-VITE RX 1 ZAVARA 3 ZOLATE 1 VITAMIN C ascorbic acid 1 VITAMIN D calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 calcitriol 1 mcg/ml ampul 1 doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 1 doxercalciferol (4 mcg/2 ml amp, 4 mcg/2 ml vl) 1 DRIDOL 3 HECTOROL (0.5 MCG CAPULE, 1 MCG CAPULE, 2.5 MCG CAPULE) 3 HECTOROL (2 MCG/ML VIAL, 4 MCG/2 ML VIAL) 3 GE 273 LAT UPDATED 04/2017

274 PRODUCT DECRIPTION TIER LIMIT & RETRICTION paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1 paricalcitol (2 mcg/ml vial, 5 mcg/ml vial, 10 mcg/2 ml vial) 1 RAYALDEE 3 ROCALTROL (0.25 MCG CAPULE, 0.5 MCG CAPULE, 1 MCG/ML ORAL OLN) 3 vitamin d2 1 ZEMPLAR (1 MCG CAPULE, 2 MCG CAPULE, 4 MCG CAPULE) ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL) 3 3 GE 274 LAT UPDATED 04/2017

275 Index of Covered Drugs 2 2tek glucose-wrist monitor kit MOP 261 A A-HYDROCORT 201 A-METHAPRED 201 abacavir 61 abacavir-lamivudine 61 abacavir-lamivudine-zidovudine 61 ABELCET 58 ABILIFY 141 ABILIFY DICMELT 141 ABILIFY MAINTENA 141 ABRAXANE 17 ABORICA 264 ABTRAL 104 acamprosate calcium 138 ACANYA 249 acarbose 206 ACCOLATE 247 accu-chek aviva connect meter 154 accu-chek aviva plus meter 154 accu-chek aviva plus test strp 167 accu-chek aviva test strips 167 accu-chek compact drum strips 167 accu-chek compact plus kit 154 accu-chek compact plus strips 167 accu-chek compact strips 167 accu-chek guide monitor system 154 accu-chek guide test strip 167 accu-chek nano smartview meter 154 accu-chek smartview test strip 167 accu-chek voicemate system 154 ACCUPRIL 96 ACCURETIC 9 accutrend glucose test strip 167 acebutolol hcl 40 ACEON 96 ACETADOTE 232 acetaminophen-codeine 104 ACETAOL HC 181 acetazolamide 9 acetazolamide sodium 9 acetic acid 181 acetic acid-aluminum 181 acetylcysteine 244 ACIPHEX 194 ACIPHEX PRINKLE 194 acitretin 264 ACLARO 261 ACTEMRA 237 ACTHIB 5 ACTHREL 167 ACTICLATE 46 ACTIGALL 197 ACTIMMUNE 240 ACTIQ 104 ACTIVAE 81 ACTIVE FE 70 ACTIVE OB 70 ACTIVELLA 222 ACTONEL 234 ACTOPLU MET 206 ACTOPLU MET XR 206,207 ACTO 207 ACULAR 184 ACULAR L 184 acura test strips 167 ACUVAIL 184 acyclovir 61,249 acyclovir sodium 61 acyclovir sodium-d5w 61 ACZONE 264 ADACEL TDAP 5 ADAGEN 179 ADALAT CC 90,91 adapalene 264 ADAUVE 141

276 ADCETRI 17 ADCIRCA 99 ADDERALL 121 ADDERALL XR 121 ADDYI 139 adefovir dipivoxil 61 ADEM 99 ADENOCARD 94 adenosine 94 ADIPEX-P 121 ADLYXIN 207 ADOXA 46 ADRENACLICK 43 ADRENALIN CHLORIDE 191 ADRIAMYCIN 17 ADRUCIL 18 ADV ALLERGY COLLECTION KIT 255 ADVAIR DIKU 43 ADVAIR HFA 43 ADVATE 78 ADVATE H 78 ADVATE L 78 ADVATE M 78 ADVATE H 78 ADVATE UH 78 ADVICOR 86 advocate blood glucose monitor 154 advocate duo glu-wrist monitor 154 advocate duo meter 154 advocate redi-code duo meter 154 advocate redi-code glu meter 154 advocate redi-code glu monitor 154 advocate redi-code test strip 167 advocate redi-code+ glu meter 154 advocate redi-code+ test strip 168 advocate test strip 168 ADYNOVATE 78 ADYPHREN 43 ADYPHREN AMP 43 ADYPHREN AMP II 43 ADYPHREN II 43 ADZENY XR-ODT 121 AERO OTIC HC 184 AERON 201 AFEDITAB CR 91 AFINITOR 18 AFINITOR DIPERZ 18 AFLURIA AFLURIA QUAD AFREZZA 207 AFTYLA 78 agamatrix amp gluc monitor sys 154 agamatrix amp test strips 168 AGGRATAT 81 AGGRENOX 81 AGRYLIN 81 AK-POLY-BAC 181 AKTEN 190 AKYNZEO 192 ALA-CORT 255 ALA-QUIN 249 ALA-CALP 255 ALBENZA 3 albuterol sulfate 43 ALCAINE 190 alclometasone dipropionate 255 ALCORTIN A 249 ALDACTAZIDE 9 ALDACTONE 9 ALDARA 264 ALDURAZYME 179 ALECENA 18 alendronate sodium 234 ALFERON N 61 alfuzosin hcl er 40 ALIMTA 18 ALINIA 60 ALKERAN 18 allopurinol 233 allopurinol sodium 233 ALLZITAL 104 almotriptan malate 133

277 ALOCRIL 187 ALOMIDE 187 ALOPRIM 233 ALORA 222 alosetron hcl 191 ALOXI 192 ALPHAGAN P 187 ALPHANATE 78 ALPHANINE D 79 ALPHAQUIN HP 261 alprazolam 136 alprazolam er 136 ALPRAZOLAM INTENOL 136 alprazolam odt 136 alprazolam xr 136 ALPROLIX 79 ALREX 184 ALUMA 133 ALTABAX 249 ALTACAINE 190 ALTACE 96 ALTAFLUOR 190 ALTAVERA 212 ALTOPREV 86 ALUVEA 262 ALVECO 201 ALYACEN 212 AMABELZ 222 amantadine 61 AMARYL 207 AMBIEN 136 AMBIEN CR 136 AMBIOME 58 amcinonide 255 AMERGE 133 AMETHIA 212 AMETHIA LO 213 AMETHYT 213 amifostine 246 amikacin sulfate 46 amiloride hcl 9 amiloride-hydrochlorothiazide 9 amiodarone hcl 94,95 amiodarone hcl-d5w 95 AMITIZA 196 amitriptyline hcl 141 amlodipine besylate 91 amlodipine besylate-benazepril 91 amlodipine-atorvastatin 86 amlodipine-olmesartan 91 amlodipine-valsartan 91 amlodipine-valsartan-hctz 9 AMNETEEM 264 amoxapine 141 amoxicillin 46 amoxicillin er 46 amoxicillin-clavulanate pot er 46 amoxicillin-clavulanate potass 46 amphotericin b 58 ampicillin sodium 46 ampicillin trihydrate 46 ampicillin-sulbactam 46 AMPYRA 244 AMRIX 38 AMTURNIDE 10 amyl nitrite 99 AMYTAL ODIUM 136 ANA-LEX 255 ANADROL ANAFRANIL 141 anagrelide hcl 81 ANALPRAM ADVANCED 255 ANALPRAM E 255 ANALPRAM HC 255 ANAPROX 104 ANAPROX D 104 anastrozole 18 ANCOBON 58 ANDRODERM 204 ANDROGEL 204 ANDROID 204 ANDROXY 204

278 ANGELIQ 222 ANGIOMAX 81 ANORO ELLIPTA 35 ANTABUE 232 ANTARA 86 antipyrine-benzocaine 190 ANTIVERT 8 ANUCORT-HC 255 ANUOL-HC 255 ANZEMET 192 APEXICON 256 APEXICON E 256 APIDRA 207 APIDRA OLOTAR 207 APLENZIN 141 APOKYN 134 apraclonidine hcl 190 aprepitant 192 APRI 213 APRIO 191 APTENIO XR 122 APTIOM 127 APTIVU 61 AQUA GLYCOLIC HC 256 AQUAOL A 271 ARALAT NP 249 ARANELLE 213 ARANEP 84 ARAVA 237 ARBINOXA 12 ARCALYT 244 ARCAPTA NEOHALER 43 argatroban 81 argatroban-0.9% nacl 81 argatroban-sodium chloride 81 ARICEPT 37 ARIMIDEX 18 aripiprazole 141 aripiprazole odt 141 ARITADA 141,142 ARITON 201 ARIXTRA 81 armodafinil 122 ARMOUR THYROID 231 ARNUITY ELLIPTA 201 AROMAIN 18 ARRANON 18 ARTHROTEC ARTHROTEC ARZERRA 18 asa-butalb-caffeine-codeine 104 AACOL HD 191 ACOMP WITH CODEINE 104 ascorbic acid 273 AHLYNA 213 AMANEX 201 AMANEX HFA 201 aspirin-caffeine-dihydrocodein 81 aspirin-dipyridamole er 81 assure 4 test strips 168 assure platinum glucose meter 154 assure platinum test strips 168 assure prism multi meter 155 assure prism multi test strips 168 ATAGRAF XL 243 ATELIN 187 ATEPRO 187 ATRAMORPH-PF 104 ATABEX EC 13 ATACAND 96 ATACAND HCT 10 ATELVIA 234 atenolol 40 atenolol-chlorthalidone 10 ATGAM 243 ATIVAN 127 atorvastatin calcium 86 atovaquone 60 atovaquone-proguanil hcl 60 ATRALIN 260 ATRIPLA 61 ATROVENT 190

279 ATROVENT HFA 35 AUBAGIO 240 AUBRA 213 AUGMENTIN 46,47 AUGMENTIN E AUGMENTIN XR 47 AUROGUARD 190 AUVI-Q 43 AVAGE 264 AVALIDE 10 AVANDAMET 207 AVANDARYL 207 AVANDIA 207 AVAPRO 96 AVATIN 18 AVC 249 AVEED 204 AVELOX 47 AVELOX ABC CK 47 AVELOX IV 47 AVIANE 213 AVIDOXY 47 AVIDOXY DK 47 AVINZA 104 AVITA 260 AVODART 232 AVONEX 240 AVONEX PEN 240 AVYCAZ 47 AXERT 133 AXID 194 AXIRON 204 AYGETIN 228 azacitidine 18 AZACTAM 47 AZACTAM-IO-OMOTIC DEXTROE 47 AZAAN 237 AZAITE 181 azathioprine 237 azathioprine sodium 237 azelastine hcl 187 AZELEX 265 AZILECT 134 azithromycin 47 AZOPT 187 AZOR 91 aztreonam 47 AZULFIDINE 47 AZURETTE 213 B B-12 COMPLIANCE 271 B-12 KIT 271 b-complex 271 BACIIM 47 bacitracin 47,181 bacitracin-polymyxin 181 baclofen 38 BACTRIM 47 BACTRIM D 47 BACTROBAN 249 BACTROBAN NAAL 181 BAL IN OIL 200 BAL-CARE DHA 13 BAL-CARE DHA EENTIAL 70 balsalazide disodium 191 BALZIVA 213 BANZEL 127 BARACLUDE 61,62 BAAGLAR KWIKPEN U bcg (tice strain) 6 BEBULIN 79 BEBULIN VH IMMUNO 79 BECONAE AQ 184 BEKYREE 213 BELBUCA 104 BELEODAQ 19 belladonna-opium 104,105 BELOMRA 136 BELVIQ 122 BELVIQ XR 122 benazepril hcl 96,97

280 benazepril-hydrochlorothiazide 10 BENEFIX 79 BENICAR 97 BENICAR HCT 10 BENLYTA 243 BENAL HP 262 BENTYL 35 BENZACLIN 249 BENZAMYCIN 250 BENZAMYCINK 250 BENZEFOAM 262 BENZEFOAM ULTRA 262 BENZEPRO 262 benzonatate 248 benzoyl peroxide 262,263 benzphetamine hcl 122 benztropine mesylate 35 BEPREVE 187 BERINERT 236 BEIVANCE 181 BETA BETADINE 181 BETAGAN 188 betamethasone acetate-sod phos 201 betamethasone dipropionate 256 betamethasone valerate 256 BETACE 40 BETACE AF 40 BETAERON 240,241 betaxolol hcl 40,188 bethanechol chloride 37 BETHKI 47 BETIMOL 188 BETOPTIC 188 BEVEPI AEROPHERE 35 bexarotene 19 BEXERO 6 BEXXAR 19 BEYAZ 213 bg-star glucose test strips 168 BIAXIN 47 bicalutamide 19 BICILLIN C-R 48 BICILLIN L-A 48 BICNU 19 BIDIL 97 BIFERA RX 70 BILTRICIDE 3 bimatoprost 188 BINOTO 234 bisoprolol fumarate 40 bisoprolol-hydrochlorothiazide 10 bivalirudin 82 BIVIGAM 3 BLANCHE 261 BLEO 15K 19 bleomycin sulfate 19 BLEPH BLEPHAMIDE 181 BLEPHAMIDE.O.P. 181 BLINCYTO 19 BLIOVI 24 FE 213 BLIOVI FE 213 blood glucose monitoring syst 155 blood glucose test strip 168 blood glucose test strips 168 BLOXIVERZ 37 BONIVA 234 BONTRIL PDM 123 BOOTRIX TDAP 5 BOULIF 19 BOTOX 38 BOTOX COMETIC 38 BP-50% UREA 262 BPO 262 BRAVELLE 225 breeze 2 disc test strip 168 breeze 2 meter 155 BREO ELLIPTA 43 BREVIBLOC 40 BREVICON 213 BRIELLYN 213

281 BRILINTA 82 brimonidine tartrate 188 BRINTELLIX 142 BRIDELLE 142 BRIVIACT 127,128 BROMFED DM 43 bromfenac sodium 184 bromocriptine mesylate 134 brompheniramine-pseudoephed-dm 43 BROMITE 184 BROVANA 44 budesonide 184,201 budesonide ec 201 BUNAVAIL 105 BUP 105 BUPRENEX 105 buprenorphine hcl 105 buprenorphine-naloxone 105 BUPROBAN 142 bupropion hcl 142 bupropion hcl sr 142 bupropion xl 142 buspirone hcl 136 busulfan 19 BUULFEX 19 butalb-acetaminoph-caff-codein 105 butalb-caff-acetaminoph-codein 105 butalbital compound-codeine 105 butalbital-acetaminophen 105 butalbital-acetaminophen-caffe 105 butalbital-aspirin-caffeine 82 BUTIOL ODIUM 136 butorphanol tartrate 105 BUTRAN 105 BYDUREON 207 BYDUREON PEN 207 BYETTA 207 BYTOLIC 40 BYVALON 40 C C-NATE DHA 70 CA-DT 200 cabergoline 134 CABOMETYX 19,20 CADEAU DHA 71 CADUET 86 CAFERGOT 40 CALAN 91 CALAN R 91 calcipotriene 265 calcipotriene-betamethasone dp 256 calcitonin-salmon 227 CALCITRENE 265 calcitriol 265,273 calcium disodium versenate 200 CALCIUM PNV 13 CALDOLOR 105 CAMBIA 105 CAMILA 213 CAMTH 20 CAMPTOAR 20 CAMREE 213 CAMREE LO 213 CANAA 191 CANCIDA 58 candesartan cilexetil 97 candesartan-hydrochlorothiazid 10 CANTIL 35 CACET 106 CATAT ULFATE 59 capecitabine 20 CAPEX HAMPOO 256 CAPITAL W-CODEINE 106 CAPRELA 20 captopril 97 captopril-hydrochlorothiazide 10 CARAC 265 CARAFATE 194 CARB-O-PHILIC 262

282 carbamazepine 128 carbamazepine er 128 CARBATROL 128 carbidopa 139 carbidopa-levodopa 134 carbidopa-levodopa er 134 carbidopa-levodopa-entacapone 134 carbinoxamine maleate 12 carboplatin 20 CARDENE I.V. 91 CARDENE R 91 CARDIOTEK-RX 271 CARDIZEM 91 CARDIZEM CD 91 CARDIZEM LA 91 CARDURA 40 CARDURA XL 40 careone blood glucose tst strp 168 careone glucose monitoring sys 155 caresens n blood glucose syst 155 caresens n test strips 168 caresens n voice glucose meter 155 caresens n voice glucose sys 155 CARIMUNE NF NANOFILTERED 3 carisoprodol 38 carisoprodol compound 38 carisoprodol compound-codeine 38 carisoprodol-aspirin 38 carisoprodol-aspirin-codeine 38 CARNITOR 244 CARNITOR F 244 carteolol hcl 188 CARTIA XT 91 carvedilol 40 CAODEX 20 CATAPRE 44 CATAPRE-TT 1 44 CATAPRE-TT 2 44 CATAPRE-TT 3 44 CATHFLO ACTIVAE 82 CAVERJECT 99 CAYTON 48 CAZIANT 214 CEDAX 48 cefaclor 48 cefaclor er 48 cefadroxil 48 cefazolin sodium 48 cefazolin sodium-0.9% nacl 48 cefazolin sodium-dextrose 48 cefazolin sodium-sterile water 48 cefazolin-0.9% nacl 48 cefazolin-d5w 48 cefdinir 48 cefditoren pivoxil 48 cefepime 48 cefepime hcl 48 cefepime-dextrose 48 cefixime 48 CEFOTAN 48 cefotaxime sodium 48 cefotetan 49 cefotetan & dextrose 48 cefoxitin 49 cefoxitin sodium 49 cefpodoxime proxetil 49 cefprozil 49 ceftazidime 49 ceftibuten 49 CEFTIN 49 ceftriaxone 49 cefuroxime 49 cefuroxime sodium 49 CELEBREX 106 celecoxib 106 CELETONE 201 CELEXA 142 CELLCEPT 243 CELONTIN 128 CEM-UREA 262 CENTANY 250 CENTANY AT 250

283 CENTERGY 8 CENTERGY DM 8 CENTRATEX 71 cephalexin 49 CERDELGA 244 CEREBYX 128 CEREZYME 179 CERUBIDINE 20 CERVARIX 6 CEAMET 192 cetirizine hcl 17 CETRAXAL 181 CETROTIDE 239 cevimeline hcl 37 CHANTIX 37 CHATEAL 214 CHEMET 200 CHENODAL 197 chloramphenicol sod succinate 49 chlordiazepoxide hcl 136,137 chlordiazepoxide-amitriptyline 137 chlordiazepoxide-clidinium 35 chlorhexidine gluconate 181 chloroquine phosphate 60 chlorpromazine hcl 142 chlorpropamide 208 chlorzoxazone 39 choicedm clarus monitor system 155 choicedm clarus test strips 168 CHOLBAM 198 cholestyramine 86 cholestyramine light 86 choline mag trisalicylate 106 chorionic gonadotropin 225 CIALI 99 CICLODAN 250 ciclopirox 250 cidofovir 62 CIFEREX 271 cilostazol 82 CILOXAN 181 cimetidine 194 CIMZIA 198 CINRYZE 236 CIPRO 49 CIPRO HC 181 CIPRO I.V. 49 CIPRO XR 49 CIPRODEX 181 ciprofloxacin 49 ciprofloxacin er 50 ciprofloxacin hcl 50,181 ciprofloxacin-d5w 50 cisplatin 20 citalopram hbr 142 CITRANATAL 90 DHA 71 CITRANATAL AURE 71 CITRANATAL B-CALM 71 CITRANATAL DHA 71 CITRANATAL HARMONY 71 CITRANATAL RX 71 cladribine 20 CLAFORAN 50 CLAFORAN-DEXTROE 50 CLARAVI 265 CLARINEX 17 CLARINEX-D 12 HOUR 17 clarithromycin 50 clarithromycin er 50 clemastine fumarate 12 CLEOCIN 250 CLEOCIN HCL 50 CLEOCIN LMITATE 50 CLEOCIN PHOPHATE 50 CLEOCIN PHOPHATE IN D5W 50 CLEOCIN T 250 clever chek blood glucose syst 155 clever choice blood glucos sys 155 clever choice glucose monitor 155 clever choice hd glucose syst 155 clever choice micro monitor 155 clever choice micro test strip 168

284 clever choice pro glucose mtr 155 clever choice pro test strip 169 clever choice talk glucose sys 155 clever choice talk test strips 169 clever choice test strips 169 clever choice voice+ tst strip 169 CLEVIPREX 92 CLIMARA 222 CLIMARA PRO 222 CLIN INGLE UE 50 CLINDACIN ETZ 250 CLINDACIN P 250 CLINDACIN C 250 CLINDAGEL 250 clindamycin hcl 50 clindamycin palmitate hcl 50 clindamycin pediatric 50 clindamycin phos-benzoyl perox 250 clindamycin phos-tretinoin 250 clindamycin phosphate 50,250,251 clindamycin phosphate-d5w 50 clindamycin-benzoyl peroxide 251 CLINDEE 251 clobetasol emollient 256 clobetasol emulsion 256 clobetasol propionate 256 CLOBEX 256 clocortolone pivalate 256 CLODAN 256 CLODERM 256 CLOLAR 20 clomiphene citrate 222 clomipramine hcl 142 clonazepam 128 clonidine 44 clonidine hcl 44 clonidine hcl er 44 clopidogrel 82 clorazepate dipotassium 128 CLORPRE 10 clotrimazole 251 clotrimazole-betamethasone 251 clozapine 142,143 clozapine odt 143 CLOZARIL 143 CNL COAGADEX 79 coal tar 264 COARTEM 60 codeine sulfate 106 COGENTIN 35 COLAZAL 191 colchicine 233 COLCRY 233 COLETID 86 colestipol hcl 86 colistimethate 50 COLOCORT 256 COLY-MYCIN M RENTERAL 51 COLY-MYCIN 181 COLYTE WITH FLAVOR CKET 196 COLYTE WITH FLAVOR CK 196 COMBIGAN 188 COMBITCH 222 COMBIVENT REPIMAT 35 COMBIVIR 62 COMETRIQ 20,21 COMZINE 143 COMPLERA 62 COMPLETE NATAL DHA 270 COMPLETENATE 71 COMPRO 143 COMTAN 134 CONCEPT DHA 71 CONCEPT OB 71 CONCERTA 123 CONDYLOX 265 CONTULOE 8 contour link meter 155 contour meter 155 contour meter system 155 contour next ez meter 155

285 contour next ez meter system 155 contour next link meter 155 contour next meter 155 contour next one meter 156 contour next strips 169 contour next usb meter 156 contour test strips 169 CONTRAVE 123 control ast monitoring system 156 control ast test strip 169 control test strips 169 CONZIP 106 cool blood glucose meter 156 cool blood glucose meter kit 156 cool glucose test strip 169 COXONE 241 COPEGU 62 CORDARONE 95 CORDRAN 256 COREG 40 COREG CR 40,41 CORGARD 41 CORIFACT 79 CORLANOR 95 CORLOM 97 CORMAX 256 CORTANE-B 184 CORTEF 201 CORTENEMA 256 CORTIFOAM 256 cortisone acetate 201 CORTIPORIN 182,251 CORTIPORIN-TC 182 CORTROYN 167 CORVERT 95 CORVITA CORVITE CORVITE FE 71 CORZIDE 10 COENTYX (2 YRINGE) 265 COENTYX PEN 265 COENTYX PEN (2 PEN) 265 COENTYX YRINGE 265 COMEGEN 21 COOPT 188 COOPT PF 188 cosyntropin 167 COTELLIC 21 COUMADIN 82 COVARYX 204 COVARYX H COZAAR 97 CREON 197 CREEMBA 58 CRETOR 86 CRINONE 228 CRIXIVAN 62 cromolyn sodium 187,247 CRYELLE 214 CUBICIN 51 CUBICIN RF 51 CUPRIMINE 200 CUROURF 248 CUTIVATE 256 CUVITRU 3 CUVPOA 35 cvs advanced glucose meter 156 cvs advanced glucose test str 169 cyanocobalamin injection 271 CYANOKIT 232 CYCLAFEM 214 CYCLEA 214 cyclobenzaprine hcl 39 cyclophosphamide 21 cycloserine 59 CYCLOET 134 cyclosporine 237 cyclosporine modified 237 CYMBALTA 140 cyproheptadine hcl 12 CYRAMZA 21 CYRED 214

286 CYTADANE 245 CYTAGON 245 CYTARAN 190 cytarabine 21 CYTOGAM 3 CYTOMEL 231 CYTOTEC 194 CYTOVENE 62 D D.H.E dacarbazine 21 DACOGEN 21 dactinomycin 21 DAKLINZA 62 DALIREP 248 danazol 205 DANTRIUM 39 dantrolene sodium 39 dapsone 59 DAPTACEL DTAP 5 daptomycin 51 darifenacin er 269 DARZALEX 21 DAETTA 214 daunorubicin hcl 21 DAUNOXOME 21 DAYPRO 106 DAYEE 214 DAYTRANA 123 DDAVP 79,227 DEBACTEROL 265 DEBLITANE 214 decitabine 21 deferoxamine mesylate 200 DELATETRYL 205 DELETROGEN 222 DELTAONE 201 DELYLA 214 DELZICOL 191 demeclocycline hcl 51 DEMEROL 106 DEMER 245 DENAVIR 251 DECON 128 DEDE 140 DEKENE 128 DEKOTE 128 DEKOTE ER 128 DEKOTE PRINKLE 128 DEPEN 200 DEPO-ETRADIOL 223 DEPO-MEDROL 201 DEPO-PROVERA 228 DEPO-UBQ PROVERA DEPO-TETOTERONE 205 DEPOCYT 21 DEPRIZINE 195 DERMA-MOOTHE-F 256 DERMAORB AF 251 DERMAORB HC 257 DERMAORB XM 262 DERMATOP 257 DERMAZENE 251 DERMOTIC 184 DECOVY 62 DEFERAL 200 DEFERAL MEYLATE 200 desipramine hcl 143 desloratadine 17 desmopressin acetate 79,227 DEOGEN 214 desogestr-eth estrad eth estra 214 desogestrel-ethinyl estradiol 214 DEONATE 257 desonide 257 DEOWEN 257 desoximetasone 257 DEOXYN 123 desvenlafaxine er 143 desvenlafaxine fumarate er 143 desvenlafaxine succinate er 143

287 DETROL 269 DETROL LA 269 dexamethasone 201 DEXAMETHAONE INTENOL 202 dexamethasone sodium phosphate 184,202 dexamethasone-0.9% nacl 202 dexcom g4 156 dexcom g4 (ped) receiver kit 156 dexcom g4 receiver kit 156 dexcom g4 receiver-share (ped) 156 dexcom g4 receiver-share kit 156 dexcom g5 156 dexcom g5 receiver kit 156 dexcom g5-g4 sensor 156 DEXEDRINE 123 DEXFERRUM 71 DEXILANT 195 dexmedetomidine hcl 137 dexmethylphenidate hcl 123 dexmethylphenidate hcl er 123,124 DEXK 202 dexpanthenol 271 dexrazoxane 246 dextroamphetamine sulfate 124 dextroamphetamine sulfate er 123 dextroamphetamine-amphet er 124 dextroamphetamine-amphetamine 124 DIABETA 208 DIALYVITE 271 DIALYVITE DIALYVITE DIALYVITE UPREME D 271 DIALYVITE ZINC 271 DIAMOX EQUEL 10 DIATAT 129 DIATAT ACUDIAL 129 diatrue plus blood glucose sys 156 diatrue plus test strip 169 diazepam 129 DIBENZYLINE 41 DICLEGI 192 diclofenac potassium 106 diclofenac sodium 106,184,265 diclofenac sodium er 106 diclofenac sodium-misoprostol 106 dicloxacillin sodium 51 dicyclomine hcl 35 didanosine 63 DIDREX 124 diethylpropion hcl 124 diethylpropion hcl er 124 DIFFERIN 265 DIFICID 51 diflorasone diacetate 257 DIFLUCAN 58 diflunisal 106 DIGIFAB 3 DIGITEK 95 DIGOX 95 digoxin 95 dihydrocodein-acetaminoph-caff 107 dihydroergotamine mesylate 41 DILANTIN 95 DILANTIN DILATRATE-R 99 DILAUDID 107 DILAUDID-HP 107 DILT-XR 92 diltiazem 12hr er 92 diltiazem 24hr cd 92 diltiazem 24hr er 92 diltiazem er 92 diltiazem hcl 92 diltiazem hcl-0.9 % nacl 92 diltiazem-d5w 92 dimenhydrinate 12 DIOVAN 97 DIOVAN HCT 10 DIPENTUM 191 diphenhydramine hcl 12 diphenhydramine-0.9% nacl 70 diphenoxylate-atropine 35

288 diphtheria-tetanus toxoids-ped 5 DIPROLENE 257 DIPROLENE AF 257 dipyridamole 82 DIALCID 107 disopyramide phosphate 95 disulfiram 232 DITRON XL 269 divalproex sodium 129 divalproex sodium er 129 DIVIGEL 223 DOCEFREZ 22 docetaxel 22 dofetilide 95 DOLOPHINE HCL 107 donepezil hcl 37 donepezil hcl odt 37 DOPRAM 124 DORAL 137 DORIBAX 51 doripenem 51 DORYX 51 DORYX MPC 51 dorzolamide hcl 188 dorzolamide-timolol 188 DOTHELLE DHA 71 DOVONEX 265 doxapram hcl 124 doxazosin mesylate 41 doxepin hcl 143,260 doxercalciferol 273 DOXIL 22 doxorubicin hcl 22 doxorubicin hcl liposome 22 DOXY doxycycline hyclate 51,182 doxycycline ir-dr 51 doxycycline monohydrate 51 DRIDOL 273 DRITHOCREME HP 264 dronabinol 193 droperidol 137 drospirenone-eth estra-levomef 214 drospirenone-ethinyl estradiol 214 DROXIA 22 DRYOL 260 DUAC 251 DUAVEE 223 DUET DHA DUET DHA BALANCED 71 DUETACT 208 DUEXI 107 DULERA 44 duloxetine hcl 140 DUODOTE 35 DUO 134 DURACLON 44 DURAGEIC 107 DURAMORPH 107 DUREZOL 184 DURLAZA 82 dutasteride 232 dutasteride-tamsulosin 41 DUTOPROL 10 DYANAVEL XR 124 DYAZIDE 10 DYLOJECT 107 DYMITA 184 DYRENIUM 10 DYPORT 39 E E.E E.E easy check blood glucose sys 156 easy check glucose meter 156 easy gluco g2 test strip 169 easy plus blood glucose kit 156 easy plus blood glucose system 156 easy plus glucose test strip 169 easy plus ii blood glucose sys 156 easy plus ii test strips 169

289 easy step blood glucose meter 156 easy step glucose system kit 156 easy step glucose test strips 169 easy talk blood glucose meter 157 easy talk glucose system kit 157 easy talk glucose test strip 170 easy touch glucose monitor sys 157 easy touch glucose test strip 170 easy trak blood glucose meter 157 easy trak glucose system kit 157 easy trak glucose test strip 170 easygluco meter 157 easygluco meter starter kit 157 easygluco plus meter kit 157 easygluco plus starter kit 157 easygluco plus test strips 170 easygluco test strips 170 easymax 15 glucose test strip 170 easymax glucose test strips 170 easymax l blood glucose system 157 easymax ng blood glucose sys 157 easymax ng glucose system kit 157 easymax v speaking glucose sys 157 easymax v2 blood glucose sys 157 easyplus r13n glucose sys kit 157 easyplus v glucose system kit 157 EC-NAPROYN 107 eclipse needle 157 econazole nitrate 251 ECOZA 251 EDARBI 97 EDARBYCLOR 10 EDEX 99 EDLUAR 137 EDURANT 63 EEMT 205 EEMT H EFFEXOR XR 143 EFFIENT 82 EFUDEX 265 EGRIFTA 230,231 ELAPRAE 179 ELDEPRYL 135 ELELYO 179 element blood glucose meter kt 157 element compact glucose meter 157 element compact test strips 170 element compact v glucose mtr 157 element plus blood glucose kit 157 element test strips 170 ELETAT 187 ELETRIN 223 ELIDEL 243 ELIGARD 22 ELIMITE 251 ELINET 214 ELIQUI 82 ELITE OB DHA 270 ELITE-OB 71 ELITE-OB ELITEK 179 ELLA 214 ELLENCE 22 ELMIRON 245 ELOCON 257 ELOCTATE 79 ELOXATIN 22 ELR 22 EMADINE 187 EMBEDA 107 embrace blood glucose kit 157 embrace blood glucose system 158 embrace evo blood glucose kit 158 embrace evo test strips 170 embrace glucose test strips 170 embrace pro blood glucose mtr 158 embrace pro test strips 170 embrace test strips 170 EMCYT 22 EMEND 193 EMOQUETTE 214 EMAM 135

290 EMTRIVA 63 EMVERM 46 ENABLEX 269 enalapril maleate 97 enalapril-hydrochlorothiazide 10 enalaprilat 97 ENBRACE HR 71 ENBREL 237 ENDACOF-C 8 ENDOCET 107 ENDODAN 107 ENDOMETRIN 229 ENGERIX-B ADULT 6 ENGERIX-B PEDIATRIC-ADOLECENT 6 ENJUVIA 223 enlite 158 enlite glucose sensor 158 ENLON 179 ENLON-PLU 179 ENLYTE 71 enoxaparin sodium 82 ENPREE 214 ENKYCE 214 ENTILAR 257 entacapone 135 entecavir 63 ENTEREG 198 ENTOCORT EC 202 ENTRETO 99 ENTYVIO 198 ENVARU XR 243 ENED 97 EPCLUA 63 EPIDUO 266 EPIDUO FORTE 266 EPIFOAM 257 epinastine hcl 187 epinephrine 44 EPIPEN 2-K 44 EPIPEN JR 2-K 44 EPIQUIN MICRO 261 epirubicin hcl 22 EPIIL 158 EPINAP 44 EPITOL 129 EPIVIR 63 EPIVIR HBV 63 eplerenone 97 EPOGEN 84 epoprostenol sodium 99 eprosartan mesylate 97 eptifibatide 82 EPZICOM 63 equate blood glucose test strp 170 EQUETRO 129 ERAXI (WATER DILUENT) 58 ERBITUX 22 ergoloid mesylates 41 ERGOMAR 41 ergotamine-caffeine 41 ERIVEDGE 22 ERRIN 215 ERTACZO 251 ERWINAZE 22 ERY 251 ERY-TAB 51 ERYGEL 251 ERYPED ERYPED ERYTHROCIN LACTOBIONATE 52 ERYTHROCIN TEARATE 52 erythromycin 52,182,251 erythromycin ethylsuccinate 52 erythromycin-benzoyl peroxide 251 erythromycin-sulfisoxazole 52 EBRIET 247 ECAVITE 71 ECAVITE D 71 ECAVITE LQ 71 escitalopram oxalate 143,144 EGIC 107 esmolol hcl 41

291 esomeprazole magnesium 195 esomeprazole sodium 195 esomeprazole strontium 195 ETARYLLA 215 estazolam 137 ETRACE 223 estradiol 223 estradiol valerate 223 estradiol-norethindrone acetat 223 ETRING 223 ETROGEL 223 estrogen & methyltestosterone 205 estrogen-methyltestosterone 205 estropipate 224 ETROTEP FE 215 eszopiclone 137 ethambutol hcl 59 ethosuximide 129 ethyl acetate 246 ethynodiol-ethinyl estradiol 215 ETHYOL 246 etidronate disodium 234 etodolac 108 etodolac er 108 ETOPOPHO 22 etoposide 22 EUFLEXXA 158 EURAX 252 EVAMIT 224 EVEKEO 124 evencare g2 blood glucose sys 158 evencare g2 test strip 170 evencare g3 blood glucose sys 158 evencare g3 test strip 171 evencare glucose tst strips 171 evencare mini glucose test str 171 evencare mini monitor system 158 evencare monitoring system 158 evencare test strips 171 EVITA 224 EVOCLIN 252 evolution blood glucose meter 158 evolution test strips 171 EVOMELA 22 EVOTAZ 63 EVOXAC 37 EVZIO 140 EXALGO 108 EXELDERM 252 EXELON 37 exemestane 22 EXFORGE 92 EXFORGE HCT 11 EXJADE 200 EXODERM 252 EXOTIC-HC 184 EXTAVIA 241 EXTINA 252 EXTRA-VIRT PLU DHA 72 EZ FLU (FLUZON QUAD PED) 6 EZ FLU (AFLURIA) 6 EZ FLU (FLUVIRIN) 6 ez smart plus system kit 158 ez smart plus test strips 171 ez smart system kit 158 ez smart test strips 171 EZ UE JOINT-TUNNEL-TRIGGER 202 ezetimibe 86 F FABB 272 FABIOR 266 FABRAZYME 180 FACTIVE 52 FALMINA 215 famciclovir 63 famotidine 195 FAMVIR 63 FANAPT 144 FARETON 23 FARXIGA 208 FARYDAK 23

292 FALODEX 23 FAZACLO 144 FE 90 PLU 72 FE C PLU 72 FEIBA NF 79 felbamate 129 FELBATOL 129 FELDENE 108 felodipine er 92 FEM PH 252 FEMARA 23 FEMCON FE 215 FEMHRT 224 FEMRING 224 FEMYNOR 215 fenofibrate 86,87 fenofibric acid 87 FENOGLIDE 87 fenoprofen calcium 108 FENORTHO 108 fentanyl 108 fentanyl citrate 108 fentanyl citrate-0.9% nacl 108 fentanyl-bupivacaine-0.9% nacl 108,109 fentanyl-ropivacaine-0.9% nacl 108,109 FENTORA 109 FERAHEME 72 FERIVA 72 FERIVA FA 72 FEROCON 72 FERRALET FERRAPLU FERRIPROX 200 FERRLECIT 72 FERROCITE PLU 72 FERROGEL FORTE 72 FETZIMA 144 FEXMID 39 FIBRICOR 87 fifty glucose meter 158 fifty50 glucose test strip 171 filter needle 158 FINACEA 266 finasteride 232,266 FIORICET 109 FIORICET WITH CODEINE 109 FIORINAL 82 FIORINAL WITH CODEINE #3 109 FIRAZYR 236 FIRMAGON 23 FLAGYL 60 FLAGYL ER 60 FLAREX 185 flavoxate hcl 269 FLEBOGAMMA DIF 3 flecainide acetate 95 FLECTOR 109 FLO-PRED 202 FLOLAN 100 FLOMAX 41 FLORIVA 235 FLORIVA PLU 235 FLOVENT DIKU 202 FLOVENT HFA 202 FLOWTU 248 FLOXIN 182 floxuridine 23 FLUAD FLUARIX QUAD FLUBLOK FLUCAINE 179 FLUCELVAX QUAD fluconazole 58 fluconazole in dextrose 58 fluconazole in saline 58 fluconazole-nacl 58 flucytosine 58 fludarabine phosphate 23 fludrocortisone acetate 202 FLULAVAL QUAD FLUMADINE 63 flumazenil 139

293 flunisolide 185 fluocinolone acetonide 257 fluocinolone acetonide oil 185 fluocinonide 257 fluocinonide-e 257 fluorescein-benoxinate 190 fluorescein-proparacaine 179 fluorometholone 185 FLUOROPLEX 266 fluorouracil 23,266 fluoxetine dr 144 fluoxetine hcl 144 fluphenazine decanoate 144 fluphenazine hcl 144 flurandrenolide 257 flurazepam hcl 137 flurbiprofen 109 flurbiprofen sodium 185 FLUROX 190 flutamide 23 fluticasone propionate 185,257 fluvastatin er 87 fluvastatin sodium 87 FLUVIRIN fluvoxamine maleate 144 fluvoxamine maleate er 144 FLUZONE HIGH-DOE FLUZONE INTRADERM QUAD FLUZONE QUAD FLUZONE QUAD PEDI FML 185 FML FORTE 185 FML.O.P. 185 FOCALGIN 90 DHA 72 FOCALGIN CA 72 FOCALGIN D 72 FOCALIN 124 FOCALIN XR 124 FOLBECAL 13 FOLBEE 272 FOLBEE AR 272 FOLBEE PLU 272 FOLBEE PLU CZ 272 FOLET DHA 72 FOLET ONE 72 FOLGARD RX 272 folic acid 272 folic acid-vit b6-vit b FOLINATAL PLU B 13 FOLIVANE-F 72 FOLIVANE-OB 72 FOLIVANE-PLU 72 FOLIXAPURE 272 FOLLITIM AQ 225 FOLOTYN 23 FOLPLEX FOLTRATE 272 fomepizole 232 fondaparinux sodium 82 fora blood glucose test strip 171 fora d10 blood glucose system 158 fora d15g glucose test strips 171 fora d20 blood glucose system 158 fora d20 glucose test strips 171 fora d40-g31 test strips 171 fora g20 blood glucose system 158 fora g20 glucose test strips 171 fora g30a blood glucose system 158 fora g30a glucose test strip 171 fora gd50 blood glucose system 158 fora gd50 test strips 172 fora premium v10 glucose meter 158 fora test n'go voice system 159 fora tn'g voice glucose meter 159 fora tn'g voice test strips 172 fora v10 blood glucose system 159 fora v10 glucose test strip 172 fora v10-v12-d10-d20 strips 172 fora v12 blood glucose system 159 fora v12 glucose test strip 172 fora v20 blood glucose system 159 fora v20 glucose test strips 172

294 fora v30a blood glucose system 159 fora v30a glucose test strip 172 foracare gd20 glucose system 159 foracare gd20 test strips 172 foracare gd40 glucose strips 172 foracare gd40a glucose system 159 foracare gd40b glucose system 159 FORADIL 44 FORFIVO XL 144 FORMA-RAY 246 FORMADON 266 formaldehyde 266 FORTAZ 52 FORTAZ IN IO-OMOTIC DEXTROE 52 FORTEO 227 FORTETA 205 FORTICAL 227 fortiscare blood glucose syst 159 fortiscare glucose test strips 172 FOAMAX 234 FOAMAX PLU D 234 foscarnet sodium 63 FOCAVIR 63 fosinopril sodium 97 fosinopril-hydrochlorothiazide 11 fosphenytoin sodium 129 FRAGMIN 82 freestyle flash system kit 159 freestyle freedom kit 159 freestyle freedom lite meter 159 freestyle freedom lite nfrs 159 freestyle insulinx glucose sys 159 freestyle insulinx strip nfrs 172 freestyle insulinx test strip 172 freestyle insulinx test strips 172 freestyle lite meter 159 freestyle lite meter nfrs 159 freestyle lite test strip 172 freestyle lite test strip nfrs 173 freestyle lite test strips 173 freestyle navigator 159 freestyle prec neo test strips 173 freestyle precision neo meter 159 freestyle sidekick ii valpk 159 freestyle system kit 159 freestyle test strips 173 freestyle test strips nfrs 173 FROVA 133 frovatriptan succinate 133 FULYZAQ 192 FURADANTIN 70 FUILEV 233 FUION PLU 72 FUION PRINKLE 72 FUZEON 63 FYAVOLV 224 FYCOM 129 G g-4 test strips 173 gabapentin 109 GABITRIL 129 GABLOFEN 39 galantamine er 37 galantamine hbr 37 galantamine hydrobromide 37 GALZIN 200 GAMATAN -D 4 GAMMAGARD LIQUID 4 GAMMAGARD -D 4 GAMMAKED 4 GAMMAPLEX 4 GAMUNEX 4 GAMUNEX-C 4 ganciclovir sodium 63 ganirelix acetate 240 GARDAIL 6 GARDAIL 9 6 GATROCROM 247 gatifloxacin 182 GATTEX 198 GAVILYTE-C 196

295 GAVILYTE-G 196 GAVILYTE-H AND BIACODYL 196 GAVILYTE-N 196 GAZYVA 23 gdrive blood glucose system 159 ge100 blood glucose system 159 ge100 blood glucose test strip 173 GEL-ONE 160 GELNIQUE 269 gemcitabine hcl 23 gemfibrozil 87 GEMZAR 23 GENERE FE 215 GENGRAF 237 GENOTROPIN 227 genstrip glucose test strip 173 GENTAK 182 gentamicin sulfate 52,182,252 gentamicin sulfate in ns 52 genultimate test strip 173 GENVIC GENVOYA 63 GEODON 145 ght blood glucose test strips 173 GIANVI 215 GIAZO 191 GILDAGIA 215 GILDE 215 GILDE 24 FE 215 GILDE FE 215 GILENYA 241 GILOTRIF 23 GLAIA 249 GLATO 241 GLEEVEC 23,24 GLEOTINE 24 GLIADEL 24 glimepiride 208 glipizide 208 glipizide er 208 glipizide xl 208 glipizide-metformin 208 GLUCAGEN 212 GLUCAGON EMERGENCY KIT 212 gluco navii glucose monitor kt 160 gluco navii glucose test strip 173 glucocard 01 meter kit 160 glucocard 01 sensor plus strip 173 glucocard 01-mini meter kit 160 glucocard expression meter 160 glucocard expression meter kit 160 glucocard expression test strp 173 glucocard shine meter 160 glucocard shine meter kit 160 glucocard shine test strips 173 glucocard vital meter kit 160 glucocard vital sensor strip 173 glucocard vital test strips 174 glucocom blood glucose kit 160 glucocom blood glucose meter 160 glucocom glucose test strip 174 glucocom value kit 160 GLUCOPHAGE 208 GLUCOPHAGE XR 208 GLUCOTROL 208 GLUCOTROL XL 208 GLUCOVANCE 208 glyburide 208 glyburide micronized 208 glyburide-metformin hcl 208 glycopyrrolate 35 glycopyrrolate-sterile water 35 GLYNAE 208 GLYET 209 GLYXAMBI 209 gmate smart meter kit 160 gmate smart starter kit 160 gmate test strips 174 gmate voice meter monitor syst 160 gmate voice starter kit 160 gnp easy touch gluc test strip 174 gnp easy touch glucose monitor 160

296 GOLYTELY 196 GONAL-F 226 GONAL-F RFF 226 GONAL-F RFF REDI-JECT 226 GONITRO 100 GORDO-UREA 262 GRALIE 109 granisetron hcl 193 GRANIX 84 GRANULEX 266 GRATEK 3 GRIFULVIN V 58 GRI-PEG 59 griseofulvin 59 griseofulvin ultramicrosize 59 gs blood glucose monitor sys 160 gs blood glucose test strips 174 guanfacine hcl 97 guanfacine hcl er 97 guanidine hcl 37 guardian real-time 160 guardian real-time glu monitor 160 guardian rt charger 161 guardian rt starter kit 160 guardian rt system 161 guardian test plug 161 GYNAZOLE H H.P. ACTHAR 167 HALAVEN 24 HALCION 137 HALDOL 145 HALDOL DECANOATE HALDOL DECANOATE halobetasol propionate 257 HALOG 257 haloperidol 145 haloperidol decanoate 145 haloperidol decanoate haloperidol lactate 145 HARVONI 64 HAVRIX 6 healthpro glucose monitor syst 161 healthpro glucose test strips 174 HEATHER 215 HECORIA 243 HECTOROL 273 HELIXATE F 79 HEMANGEOL 41 HEMATINIC PLU 72 HEMATINIC WITH FOLIC ACID 72 HEMATOGEN 72 HEMATOGEN FA 72 HEMATOGEN FORTE 73 HEMATRON 73 HEMATRON-AF 73 HEMAX 73 HEMENATAL OB 73 HEMENATAL OB + DHA 73 HEMETAB 73 HEMMOREX-HC 257 HEMOCYTE PLU 73 HEMOCYTE-F 73 HEMOFIL M 79 HEGAM B 4 heparin flush 83 heparin lock 83 heparin sodium 83 heparin sodium in 0.45% nacl 83 heparin sodium-0.9% nacl 83 heparin sodium-d5w 83 HEPERA 64 HERCEPTIN 24 HETLIOZ 137 HEXALEN 24 HIBERIX 6 HICON 247 HIZENTRA 4 HORIZANT 109 HUMALOG 209 HUMALOG KWIKPEN U

297 HUMALOG KWIKPEN U HUMALOG MIX HUMALOG MIX KWIKPEN 209 HUMALOG MIX HUMALOG MIX KWIKPEN 209 humana true metrix air glu mtr 161 humana true metrix air meter 161 humana true metrix test strips 174 humana trueresult glucose mtr 161 humana truetest test strips 174 HUMATE-P 79 HUMATROPE 227 HUMIRA 198 HUMIRA PEDIATRIC CROHN' 198 HUMIRA PEN 199 HUMIRA PEN CROHN-UC-H TARTER 199 HUMIRA PEN PORIAI-UVEITI 199 HUMULIN R U HUMULIN R U-500 KWIKPEN 209 HYALGAN 161 HYCAMTIN 24 HYCET 109 HYCOFENIX 44 hydralazine hcl 97 HYDREA 24 HYDRO HYDRO hydrocod-cpm-pseudoephedrine 8 hydrocodone bt-homatropine mbr 36 hydrocodone-acetaminophen 110 hydrocodone-chlorpheniramne er 8 hydrocodone-homatropine mbr 36 hydrocodone-ibuprofen 110 hydrocortisone 202,257 hydrocortisone acetate 257 hydrocortisone butyrate 258 hydrocortisone valerate 258 hydrocortisone-acetic acid 182 hydrocortisone-iodoquinol 252 hydrocortisone-iodoquinol-aloe 252 hydrocortisone-pramoxine 258 hydrocortisone-pramoxine hcl 258 HYDROMET 36 hydromorph-bupivac-0.9% nacl 110 hydromorph-ropiva-0.9% nacl 110 hydromorphone er 111 hydromorphone hcl 110,111 hydromorphone hcl-0.9% nacl 110,111 hydroquinone 261 hydroxocobalamin 272 hydroxychloroquine sulfate 60 hydroxyprogesterone caproate 229 hydroxyurea 24 hydroxyzine hcl 8,70 hydroxyzine pamoate 8 HYLENEX 180 HYMOVI 161 HYPERCARE 260 HYPERHEP B -D 4 HYPERRAB -D 4 HYPERRHO -D 4 HYPERTET -D 4 hypodermic needle 161 HYQVIA 4 HYQVIA HY COMPONENT 180 HYQVIA IG COMPONENT 5 HYINGLA ER 111 HYZAAR 11 I ibandronate sodium 234 IBRANCE 24 IBUDONE 111 ibuprofen 111 ibuprofen lysine 111 ibutilide fumarate 95 ICAR-C PLU 73 ICLUIG 24 IDAMYCIN PF 24 idarubicin hcl 24 IDELVION 80 IFEX 25

298 ifosfamide 25 ifosfamide-mesna 25 ILARI 245 ILEVRO 185 ILOTYCIN 182 ILUVIEN 185 IMBRUVICA 25 imipenem-cilastatin sodium 52 imipramine hcl 145 imipramine pamoate 145 imiquimod 266 IMITREX 133 IMOGAM RABIE-HT 5 IMOVAX RABIE VACCINE 6 IMVIDO 60 IMPLANON 215 IMURAN 238 INATAL ADVANCE 13 INATAL ULTRA 13 INCIVEK 64 INCRELEX 231 INCRUE ELLIPTA 36 INDERAL LA 41 INDERAL XL 41 INDOCIN 111 indomethacin 112 INFANATE BALANCE 73 INFANATE PLU 73 INFANRIX DTAP 5 INFAURF 248 INFED 73 INFERGEN 64 infinity meter kit 161 infinity starter kit 161 infinity test strips 174 INFUMORPH 112 INFUVITE 270 INJECTAFER 73 INLYTA 25 INNOPRAN XL 41 INOVA 262 INOVA INOVA INPRA 97 INTEGRA F 73 INTEGRA PLU 73 INTEGRILIN 83 INTELENCE 64 INTERMEZZO 137 INTRON A 64 INTROVALE 215 INTUNIV 97 INVANZ 52 INVEGA 145 INVEGA UTENNA 145,146 INVEGA TRINZA 146 INVIRAE 64 INVOKAMET 209 INVOKAMET XR 209 INVOKANA 209 IODOFLEX 252 IODOORB 252 IONY 112 IOPIDINE 190 IPOL 7 ipratropium bromide 36,190 ipratropium-albuterol 36 IPRIVAK 83 irbesartan 97 irbesartan-hydrochlorothiazide 11 IRENKA 140 IREA 25 irinotecan hcl 25 IRON 73 IENTRE 64 IOCHRON 100 isomethept-caff-acetaminophen 112 isomethept-dichloralp-acetamin 112 isoniazid 60 IOPTO CARPINE 188 IORDIL 100 IORDIL TITRADOE 100

299 isosorbide dinitrate 100 isosorbide mononitrate 100 isosorbide mononitrate er 100 isoxsuprine hcl 100 isradipine 92 ITALOL 188 ITODAX 25 itraconazole 59 ivermectin 3 IXEMPRA 25 IXIARO 7 IXINITY 80 J JADENU 200 JAKAFI 25 JALYN 41 JANTOVEN 83 JANUMET 209 JANUMET XR 209 JANUVIA 209 JARDIANCE 209 jazz wireless 2 meter kit 161 JENCYCLA 215 JENTADUETO 209 JENTADUETO XR 209 JETREA 190 JEVANTIQUE LO 224 JEVTANA 25 JINTELI 224 JOLEA 215 JOLIVETTE 215 JUBLIA 252 JULEBER 215 JUNEL 215 JUNEL FE 216 JUNEL FE JUXTAPID 87 K KADCYLA 25 KADIAN 112 KAITLIB FE 216 KALBITOR 236 KALETRA 64 KALYDECO 248 KAPVAY 44 KARBINAL ER 12 KARIVA 216 KAZANO 209 KCENTRA 80 KEFLEX 52 KELNOR KENALOG 258 KENALOG KENALOG KENGREAL 83 KEPIVANCE 260 KEPPRA 129 KEPPRA XR 129 KERAFOAM 262 KERALAC 262 KERALYT 262 KERALYT CALP 263 KERYDIN 252 KETEK 52 ketoconazole 59,252 KETODAN 252 ketoprofen 112 ketorolac tromethamine 112,185 KEVEYI 188 KEYTRUDA 26 KHEDEZLA 146 KIMIDE 216 KINERET 238 KINRIX 7 KITABI K 52 KLARON 252 KLOFENAID II 112 KLONOPIN 129 KOATE 80 KOATE-DVI 80

300 KOGENATE F 80 KOMBIGLYZE XR 209 KORLYM 210 KOHER PRENATAL PLU IRON 73 KOVALTRY 80 KRITALOE 8 kro premium blood glucose syst 161 kro premium blood glucose test 174 KRYTEXXA 233 KURVELO 216 KUVAN 245 KYNAMRO 87 KYPROLI 26 L labetalol hcl 41 lactulose 8 LAMICTAL 130 LAMICTAL (BLUE) 130 LAMICTAL (GREEN) 130 LAMICTAL (ORANGE) 130 LAMICTAL ODT 130 LAMICTAL ODT (BLUE) 130 LAMICTAL ODT (GREEN) 130 LAMICTAL ODT (ORANGE) 130 LAMICTAL XR 130 LAMICTAL XR (BLUE) 130 LAMICTAL XR (GREEN) 130 LAMICTAL XR (ORANGE) 130 LAMIIL 59 lamivudine 64 lamivudine hbv 64 lamivudine-zidovudine 64 lamotrigine 130 lamotrigine er 130 lamotrigine odt 130 lamotrigine odt (blue) 130 lamotrigine odt (green) 130 lamotrigine odt (orange) 130 LANOXIN 95 LANOXIN PEDIATRIC 95 lansoprazol-amoxicil-clarithro 52 lansoprazole 195 LANTU 210 LANTU OLOTAR 210 LARIN 216 LARIN 24 FE 216 LARIN FE 216 LARIIA 216 LATACAFT 187 latanoprost 188 LATIE 188 LATRIX 263 LATUDA 146 LAYOLI FE 216 LAZANDA 112 LEENA 216 leflunomide 238 LEMTRADA 241 LENVIMA 26 LECOL 87 LECOL XL 87 LEINA 216 LETAIRI 100 letrozole 26 leucovorin calcium 233 LEUKERAN 26 LEUKINE 85 leuprolide acetate 26 levalbuterol concentrate 44 levalbuterol hcl 44 LEVAQUIN 52 LEVATOL 90 LEVEMIR 210 LEVEMIR FLEXTOUCH 210 levetiracetam 130 levetiracetam er 130 levetiracetam-nacl 130 LEVITRA 100 LEVO-T 231 levobunolol hcl 188 levocarnitine 245

301 levocetirizine dihydrochloride 17 levofloxacin 53,182 levofloxacin-d5w 53 levoleucovorin calcium 233 levomefolate dha 13 LEVONET 216 levonorg-eth estrad eth estrad 216 levonorgestrel 217 levonorgestrel-eth estradiol 216,217 LEVORA levorphanol tartrate 112 levothyroxine sodium 231 LEVOXYL 231 LEXAPRO 146 LEXIVA 64 LIALDA 191 liberty blood glucose meter 161 liberty blood glucose monitor 161 liberty test strips 174 LIBRAX 36 lidocaine hcl 95 lidocaine hcl in 5% dextrose 95 lidocaine-hydrocortisone 258 LILETTA 217 LINCOCIN 53 lincomycin hcl 53 lindane 252 linezolid 53 linezolid-0.9% nacl 53 LINZE 199 LIOREAL INTRATHECAL 39 liothyronine sodium 231 LIPITOR 88 LIPODOX 26 LIPODOX LIPOFEN 88 LIPTRUZET 88 lisinopril 98 lisinopril-hydrochlorothiazide 11 lithium 133 lithium carbonate 133 lithium carbonate er 133 LITHOBID 133 LIVALO 88 LO LOETRIN FE 217 LO MINATRIN FE 217 LOCOID 258 LOCOID LIPOCREAM 258 LODINE 112 LODOYN 139 LOETRIN 217 LOETRIN FE 217 LOFIBRA 88 LOMAIRA 125 LOMEDIA 24 FE 217 LOMOTIL 36 lomustine 26 LONURF 26 loperamide 192 LOPID 88 lopinavir-ritonavir 65 LOPREEZA 224 LOPREOR 41 LOPREOR HCT 11 LOPROX 252 lorazepam 130,131 LORAZEM INTENOL 131 lorazepam-0.9% nacl 131 lorazepam-d5w 131 LORCET 112 LORCET HD 113 LORCET PLU 113 LORTAB 113 LORYNA 217 LORZONE 39 losartan potassium 98 losartan-hydrochlorothiazide 11 LOEAONIQUE 217 LOTEMAX 185 LOTENIN 98 LOTENIN HCT 11 LOTREL 92

302 LOTRIONE 252 LOTRONEX 191 lovastatin 88 LOVAZA 88 LOVENOX 83 LOW-OGETREL 217 loxapine 146 LUCENTI 190 LUGOL' 252 LUMIGAN 188 LUMINAL ODIUM 131 LUMIZYME 180 LUNETA 137 LUNETA CK 27 LUPRON DEPOT 27 LUPRON DEPOT (LUNETA) 27 LUPRON DEPOT-PED 27 LUTRA 261 LUTRA-AF 261 LUTRA-ULTRA 261 LUTERA 217 LUXIQ 258 LUZU 252 LYCELLE 161 LYNRZA 27 LYRICA 131 LYODREN 27 LYZA 217 M M-M-R II VACCINE 7 M-VIT 73 M.V.I. PEDIATRIC 270 MACNATAL CN DHA 13 MACROBID 70 MACRODANTIN 70 MACUZIN 270 MAKENA 229 MALARONE 60 malathion 253 mannitol 11 maprotiline hcl 146 MARGEIC 113 MARINOL 193 MARLIA 217 MARNATAL-F 13 MARPLAN 146 MARQIBO 27 MARTEN-TAB 113 MATULANE 27 MATZIM LA 92,93 MAVIK 98 MAXALT 133 MAXALT MLT 133 MAXARON FORTE 73 MAXIDEX 185 maxima test strip 174 MAXINATE 270 MAXIPIME 53 MAXITROL 182 MAXZIDE 11 MAXZIDE-25 MG 11 meclizine hcl 8 meclofenamate sodium 113 MEDROL 202 medroxyprogesterone acetate 229 mefenamic acid 113 mefloquine hcl 60 MEFOXIN 53 MEGACE 27 MEGACE E 27 megestrol acetate 27 meijer blood glucose test strp 174 MEKINIT 27 meloxicam 113 MELQUE HP 261 melphalan hcl 27 MELQUIN HP 261 MELQUIN memantine hcl 139 MENACTRA 7 MENET 224

303 MENHIBRIX 7 MENOMUNE-A-C-Y-W MENOPUR 226 MENOTAR 224 MENTAX 253 MENVEO A-C-Y-W-135-DIP 7 MENVEO MENA COMPONENT 7 MENVEO MENCYW-135 COMPONENT 7 meperidine hcl 113 meperidine hcl-0.9% nacl 113 MEPHYTON 233 meprobamate 137 MEPRON 60 mercaptopurine 28 meropenem 53 meropenem-0.9% nacl 53 MERREM 53 mesalamine 192 mesna 246 MENEX 246 METINON 37,38 METADATE CD 125 METADATE ER 125 metaproterenol sulfate 45 METATRON 247 METAXALL 39 metaxalone 39 metformin hcl 210 metformin hcl er 210 methadone hcl 113,114 METHADONE INTENOL 114 METHADOE 114 methamphetamine hcl 125 methazolamide 189 methimazole 231 METHITET 205 methocarbamol 39 methotrexate 28 methotrexate sodium 28 methoxsalen 261 methyldopa 45 methyldopa-hydrochlorothiazide 11 methyldopate hcl 45 methylene blue 233 METHYLIN 125 methylphenidate er 125 methylphenidate hcl 125 methylphenidate hcl cd 125 methylphenidate hcl er 125 methylphenidate la 126 methylprednisolone 202 methylprednisolone acetate 202 methylprednisolone sod succ 202 methylprednisolone sodium succ 202 methyltestosterone 205 metipranolol 189 metoclopramide hcl 200 metoclopramide hcl odt 200 metoprolol succinate 42 metoprolol tartrate 42 metoprolol-hydrochlorothiazide 11 METOZOLV ODT 200 METRO IV 60 METROCREAM 253 METROGEL 253 METROGEL-VAGINAL 253 METROLOTION 253 metronidazole 60,253 mexiletine hcl 95 MIACALCIN 227 MIBELA 24 FE 217 MICARDI 98 MICARDI HCT 11 miconazole MICORT-HC 258 MICRHOGAM ULTRA-FILTERED PLU 5 microdot blood glucose system 161 microdot test strips 174 microdot xtra test strips 174 MICROGETIN 217 MICROGETIN 24 FE 217 MICROGETIN FE 218

304 midazolam hcl 137 midodrine hcl 45 MIFEPREX 246 MIGERGOT 42 miglitol 210 MIGRAGEIC IDA 114 MIGRANAL 42 MILLIPRED 202,203 MILLIPRED DP 203 MIMVEY 224 MIMVEY LO 224 MINATRIN 24 FE 218 minilink real-time transmitter 161 minimed 630g guardian start kt 161 MINIPRE 42 MINITRAN 100 MINIVELLE 224 MINOCIN 53 minocycline hcl 53 minocycline hcl er 53 minoxidil 98 MIOCHOL-E 189 MIOTAT 189 MIRAPEX 135 MIRAPEX ER 135 MIRCERA 85 MIRCETTE 218 MIRENA 218 mirtazapine 146 MIRVAO 266 misoprostol 195 MITIGARE 234 mitomycin 28 MITOOL 189 mitoxantrone hcl 28 MOBIC 114 modafinil 126 MODERIBA 65 MODICON 218 moexipril hcl 98 moexipril-hydrochlorothiazide 11 molindone hcl 147 mometasone furoate 185,258 MONDOXYNE NL 53 MONO-LINYAH 218 MONOCLATE-P 80 MONODOX 53 monoject blood collection 161 MONOJECT PREFILL 82 MONOJECT PREFILL ADVANCED 83 MONONEA 218 MONONINE 80 MONOVIC 162 montelukast sodium 247 MORGIDOX 53 morphine sulfate 114,115,116 morphine sulfate er 116 morphine sulfate-0.9% nacl 114,115,116 MOTOFEN 192 MOVANTIK 199 MOVIPREP 196 MOXATAG 54 MOXEZA 182 moxifloxacin 54 moxifloxacin hcl 54 MOZOBIL 85 M CONTIN 116 MUCOTROL 266 MULTAQ 96 multi-vitamin w-fluoride 235 multi-vitamin w-fluoride-iron 73 multi-vitamin with fluoride 235 multi-vitamin-fluor-iron 73 MULTIGEN FOLIC 73 MULTIGEN PLU 73 multivitamin and fluoride 235 multivitamin with fluoride 235,236 multivitamin-iron-fluoride 73 multivitamins w-fluoride-iron 73 multivitamins with fluoride 235 multivitamins-a,b,d,e,k,zn 270 mupirocin 253

305 MUE 100 MUTARGEN 28 mv-iron fum-asp-asc-b12-fa-suc 74 MVC-FLUORIDE 236 MYALEPT 227 MYAMBUTOL 60 MYCAMINE 59 MYCOBUTIN 54 mycophenolate mofetil 243 mycophenolic acid 243 MYFORTIC 243 myglucohealth monitoring kit 162 myglucohealth test strips 175 MYKIDZ IRON FL 74 MYLERAN 28 MYNATAL 13,270 MYNATAL ADVANCE 13 MYNATAL PLU 13 MYNATAL-Z 13 MYNATE 90 PLU 271 MYNEPHROCAP 272 MYNEPHRON 272 MYOBLOC 39 MYORIAN 266 MYOZYME 180 MYRBETRIQ 269 MYOLINE 131 MYTEI 192 MYZILRA 218 N NABI-HB 5 nabumetone 116 nadolol 42 nadolol-bendroflumethiazide 11 nafcillin 54 nafcillin sodium 54 naftifine hcl 253 NAFTIN 253 NAGLAZYME 180 nalbuphine hcl 116 NALFON 116 naloxone hcl 140 naltrexone hcl 140 NAMENDA 139 NAMENDA XR 139 NAMZARIC 38 naphazoline hcl 191 NAPRELAN 116,117 NAPROYN 117 naproxen 117 naproxen sodium 117 naproxen sodium cr 117 naproxen sodium ds 117 naproxen sodium er 117 naratriptan 133 naratriptan hcl 133 NARCAN 140 NARDIL 147 NAACORT AQ 185 NACOBAL 272 NAONEX 185 NATACHEW 74 NATACYN 182 NATAZIA 218 nateglinide 210 NATELLE ONE 14 NATETO 205 NATRA 227 NATRECOR 100 NATROBA 253 NATURE-THROID 231 NAVELBINE 28 NEBUPENT 60 NECON 218 needle 155 NEEVODHA 74 nefazodone hcl 147 NEMBUTAL ODIUM 137 NEO-POLYCIN 182 NEO-POLYCIN HC 182 NEO-YNALAR 253

306 neomycin sulfate 54 neomycin-bacitracin-poly-hc 182 neomycin-bacitracin-polymyxin 182 neomycin-polymyxin-dexameth 182 neomycin-polymyxin-gramicidin 182 neomycin-polymyxin-hc 182 neomycin-polymyxin-hydrocort 183 NEOPROFEN 117 NEORAL 238 NEOPORIN 183 neostigmine methylsulfate 38 NEPHPLEX RX 272 NEPHRO-VITE RX 272 NEPHROCAP 272 NEPHROCAP QT 272 NEPHRON FA 74 NEPTAZANE 189 NEINA 210 NETAB 14 NETAB ABC 74 NETAB DHA 14 NEUAC 253 NEULATA 85 NEUMEGA 85 NEUPOGEN 85 NEUPRO 135 NEURIN-L 272 NEURONTIN 117 neutek 2tek test strips 175 NEVANAC 185 nevirapine 65 nevirapine er 65 NEWGEN 14 NEXA PLU 74 NEXAVAR 28 NEXAVIR 245 NEXIUM 195 NEXIUM I.V. 195 NEXPLANON 218 NEXTERONE 96 niacin er 88 NIACOR 88 NIAN 88 nicardipine hcl 93 nicardipine hcl-0.9% nacl 93 NICOTROL 37 NICOTROL N 37 NIFEDIAC CC 93 NIFEDICAL XL 93 nifedipine 93 nifedipine er 93 NIKKI 218 NILANDRON 28 nilutamide 28 nimodipine 93 NINLARO 28 NIPENT 28 nisoldipine 93 NITHIODOTE 233 NITRO-BID 100 NITRO-DUR 100,101 NITRO-TIME 101 nitrofurantoin 70 nitrofurantoin mono-macro 70 nitroglycerin 101 nitroglycerin in d5w 101 nitroglycerin patch 101 NITROLINGUAL 101 NITROMIT 101 NITRONAL 101 NITROPRE 98 NITROTAT 101 NIVA-PLU 14 nizatidine 195 NIZORAL 253 NODOLOR 117 NOR-Q-D 218 NORA-BE 218 NORCO 117 NORDITROPIN FLEXPRO 227 NORDITROPIN NORDIFLEX 227 norethin-eth estra-ferrous fum 218

307 norethindron-ethinyl estradiol 218,225 norethindrone 218 norethindrone ac (lupaneta) 229 norethindrone acetate 229 norgestimate-ethinyl estradiol 219 NORINYL NORINYL NORITATE 253 NORLYROC 219 NORCE 96 NORCE CR 96 NORPRAMIN 147 NORTHERA 45 NORTREL 219 nortriptyline hcl 147 NORVAC 93 NORVIR 65 nova max blood glucose meter 162 nova max glucose test strip 175 NOVACORT 258 NOVAREL 226 NOVOEIGHT 80 NOVOLOG 210 NOVOLOG FLEXPEN 210 NOVOLOG MIX NOVOLOG MIX FLEXPEN 210 NOVOEVEN RT 80 NOXAFIL 59 NOXIFOL-D3 272 NP THYROID 231 NPLATE 85 NUCYNTA 117 NUCYNTA ER 117 NUEDEXTA 139 NUFERA 74 NULECIT 74 NULOJIX 243 NULYTELY WITH FLAVOR CK 196 NUMOIYN 162 NUOX 263 NUPLAZID 147 NUQUIN HP 269 NUTROPIN 228 NUTROPIN AQ 228 NUTROPIN AQ NUPIN 228 NUVARING 219 NUVIGIL 126 NUWIQ 80 NYAMYC 253 NYATA 253 NYMALIZE 93 nystatin 59,253 nystatin-triamcinolone 253 NYTOP 253 O O-CAL FA 14 O-CAL PRENATAL 14 OB COMPLETE 74 OB COMPLETE GOLD 74 OB COMPLETE ONE 14 OB COMPLETE PETITE 74 OB COMPLETE PREMIER 14 OB COMPLETE WITH DHA 74 OBIZUR 80 OBTETRIX DHA 74 OBTETRIX EC 74 OBTETRIX ONE 74 OBTREX DHA 74 OCALIVA 199 OCELLA 219 OCTAGAM 5 octreotide acetate 230 OCUFEN 185 OCUFLOX 183 ODEFEY 65 ODOMZO 28 OFEV 247 ofloxacin 54,183 OGETREL 219 olanzapine 147 olanzapine odt 147

308 olanzapine-fluoxetine hcl 147 OLEPTRO ER 148 olmesartan medoxomil 98 olmesartan-amlodipine-hctz 11 olmesartan-hydrochlorothiazide 11 olopatadine hcl 187 OLUX 258 OLUX-E 258 OLYIO 65 OMECLAMOX-K 54 omega-3 acid ethyl esters 88 omeprazole 195 omeprazole-sodium bicarbonate 195 OMNARI 185 OMNIPRED 186 OMNITROPE 228 OMONTY 85 on call express meter 162 on call express meter system 162 on call express test strip 175 on call plus meter 162 on call plus test strip 175 on call vivid meter 162 on call vivid pal meter 162 on call vivid test strip 175 ONCAR 28 ondansetron hcl 193 ondansetron hcl in dextrose 193 ondansetron hcl-0.9% nacl 193 ondansetron in sodium chloride 193 ondansetron odt 193 onetouch ultra test strips 175,270 onetouch ultra2 glucose syst 162,270 onetouch ultramini meter 162,270 onetouch verio flex startr kit 162,270 onetouch verio flex system kit 162,270 onetouch verio iq meter 162,270 onetouch verio iq system kit 162,270 onetouch verio meter system 162,270 onetouch verio sync syst kit 162,163,270 onetouch verio test strip 175,270 ONEXTON 253 ONFI 131 ONGLYZA 210 ONMEL 59 ONZETRA XAIL 133 ONA 117 ONA ER 117 OPDIVO 29 opium tincture 192 OPUMIT 101 optium ez test strip 175 optium test strip 175 optumrx blood glucose meter 163 optumrx blood glucose system 163 optumrx test strip 175 ORACEA 54 ORAFATE 163 ORALAIR 3 ORALONE 258 ORAP 148 ORAPRED ODT 203 ORAVIG 253 ORENCIA 238 ORENCIA CLICKJECT 238 ORENITRAM ER 101 ORFADIN 245 ORKAMBI 248 orphenadrine citrate 39 ORYTHIA 219 ORTHO D 272 ORTHO EVRA 219 ORTHO MICRONOR 219 ORTHO TRI-CYCLEN 219 ORTHO TRI-CYCLEN LO 219 ORTHO-CEPT 219 ORTHO-CYCLEN 219 ORTHO-NOVUM 219 ORTHOVIC 163 oseltamivir phosphate 65 OENI 210 OMITROL 11

309 OMOPREP 197 OPHENA 225 OTEZLA 238 OTIC CARE 190 OTICIN 183 OTICIN HC 186 OTIPRIO 183 OTO-END OTOMAX-HC 186 OTOVEL 183 OTOZIN 190 OTREXUP 29 OVCON OVIDE 254 OVIDREL 226 oxacillin 54 oxacillin sodium 54 oxaliplatin 29 OXANDRIN 205 oxandrolone 205 oxaprozin 117 OXAYDO 118 oxazepam 138 oxcarbazepine 131 OXECTA 118 oxiconazole nitrate 254 OXITAT 254 OXORALEN 261 OXORALEN-ULTRA 261 OXTELLAR XR 131 oxybutynin chloride 269 oxybutynin chloride er 269 oxycodone hcl 118 oxycodone hcl er 118 oxycodone hcl-aspirin 118 oxycodone hcl-ibuprofen 118 oxycodone-acetaminophen 118 OXYCONTIN 118 oxymorphone hcl 118 oxymorphone hcl er 118 OXYTROL 269 OZURDEX 186 P CERONE 96 paclitaxel 29 CNEX 263 CNEX HP 263 CNEX LP 263 IRE OB PLU DHA 74 paliperidone er 148 MELOR 148 pamidronate disodium 235 NCREAZE 197 NCRELIE 5, NDEL 258 NHEMATIN 245 NRETIN 266 pantoprazole sodium 195 papaverine hcl 101 papaverine-alprostadil 101 paradigm insulin pump pathway 163 paradigm real-time 163 RAFON FORTE DC 39 RAGARD T 380-A 219 paregoric 192 paricalcitol 274 RLODEL 135 RNATE 148 ROEX 183 paromomycin sulfate 54 paroxetine cr 148 paroxetine er 148 paroxetine hcl 148 ER 60 TADAY 187 TANAE 187 TANOL 187 XIL 148 XIL CR 148 ZEO 187 PCE 54

310 PEDIADERM AF 254 PEDIADERM HC 258 PEDIADERM TA 258 PEDIAPRED 203 PEDIARIX 5 PEDVAXHIB 7 peg 3350-electrolyte 197 peg-3350 and electrolytes 197 peg-3350 with flavor packs 197 PEG-PREP 197 PEGANONE 131 PEGAY 65 PEGAY PROCLICK 65 PEGINTRON 65 PEGINTRON REDIPEN 65 pen needle 163 penicillin g potassium 54 penicillin g procaine 54 penicillin g sodium 54 penicillin gk-iso-osm dextrose 54 penicillin v potassium 54 PENLAC 254 PENNAID 118 PENTACEL 7 PENTACEL ACTHIB COMPONENT 7 PENTACEL DTAP-IPV COMPONENT 7 PENTAM PENTAA 192 pentazocine-naloxone hcl 118 pentostatin 29 pentoxifylline 86 PEPCID 195 PERCOCET 118 PERFOROMIT 45 PERIDEX 183 perindopril erbumine 98 PERIOGARD 183 PERJETA 29 permethrin 254 perphenazine 148 perphenazine-amitriptyline 148 PERANTINE 83 PERTZYE 197 PEXEVA 148 PFIZERPEN 54 pharmacist choice glucose sys 163 pharmacist choice mini glu sys 163 pharmacist choice test strips 175 phaseal protector 163 PHENADOZ 70 phenazopyridine hcl 260 phendimetrazine tartrate 126 phenelzine sulfate 148 PHENERGAN 8 phenobarbital 131 phenobarbital sodium 131 phenoxybenzamine hcl 42 phentermine hcl 126 phentolamine mesylate 42 phentolamine-alprostadil 42 phenylephrine hcl 191 PHENYTEK 96 phenytoin 96 phenytoin sodium 96 phenytoin sodium extended 96 PHILITH 219 PHOPHOLINE IODIDE 189 PHOTOFRIN 29 physostigmine salicylate 38 phytonadione 233 PICATO 266 pilocarpine hcl 38,189 PILOPINE H 189 pimozide 148 PIMTREA 219 pindolol 42 PINNACAINE 190 pioglitazone hcl 211 pioglitazone-glimepiride 211 pioglitazone-metformin 211 piperacillin-tazobactam 54,55 PIRMELLA 219

311 piroxicam 119 PLAN B ONE-TEP 220 PLAQUENIL 60 PLAVIX 84 PLEGRIDY 241,242 PLEGRIDY PEN 241 PLETAL 84 PNEUMOVAX 23 7 PNV PNV OB+DHA 14 PNV-DHA 74 PNV-DHA + DOCUATE 14 pnv-ferrous fumarate-docu-fa 74 PNV-OMEGA 14 PNV-ELECT 74 PNV-TOTAL 74 PNV-VP-U 271 PODOCON podofilox 266 POLY-VI-FLOR 236 POLY-VI-FLOR F 236 POLY-VI-FLOR WITH IRON 74 POLYCIN 183 polyethylene glycol polymyxin b sul-trimethoprim 183 polymyxin b sulfate 55 POLYTRIM 183 POMALYT 29 PONTEL 119 PORTIA 220 POTABA 245 potassium hydroxide 263 POTIGA 131 PR BENZOYL PEROXIDE 263 PR NATAL PR NATAL 400 EC 14 PR NATAL PR NATAL 430 EC 14 PRADAXA 84 pralidoxime chloride 233 PRALUENT PEN 88 PRALUENT YRINGE 89 PRAMCORT 258 pramipexole dihydrochloride 135 pramipexole er 135 PRAMOONE 258 PRAMOONE E 259 PRANDIMET 211 PRANDIN 211 PRAVACHOL 89 pravastatin sodium 89 prazosin hcl 42 PRECEDEX 138 precision link direct monit 163 precision pcx plus test str 175 precision pcx test strips 176 precision point of care str 176 precision q-i-d test strips 176 precision xtra monitor 163 precision xtra monitor nfrs 163 precision xtra test strips 176 PRECOE 211 PRED FORTE 186 PRED MILD 186 PRED-G 183 prednicarbate 259 prednisolone 203 prednisolone acetate 186 prednisolone sodium phos odt 203 prednisolone sodium phosphate 186,203 prednisone 203 PREDNIONE INTENOL 203 PREFERA OB 74 PREFERA-OB ONE 75 PREFERA-OB PLU DHA 75 PREFET 225 PREGNYL 226 PRELONE 203 PREMARIN 225 premium blood glucose monitor 163 premium blood glucose system 163 premium blood glucose test str 176

312 premium blood glucose tst strp 176 premium v10 blood glucose mtr 163 premium v10 glucose test strip 176 PREMPHAE 225 PREMPRO 225 PRENA1 CHEW 271 PRENA1 PEARL 75 PRENA1 TRUE 75 PRENAIANCE 14 PRENAIANCE 90 DHA 14 PRENAIANCE BALANCE 75 PRENAIANCE DHA 14 PRENAIANCE NEXT 14 PRENAIANCE NEXT-B 14 PRENAIANCE PLU 14 PRENAIANCE PROMIE 15 PRENATA 75 PRENATAB FA 15 PRENATAB RX 15 prenatal prenatal low iron 15 prenatal plus 15 prenatal plus-dha 75 prenatal vitamin plus low iron 15 prenatal-u 271 PRENATE AM 271 PRENATE CHEWABLE 15 PRENATE DHA 75 PRENATE ELITE 75 PRENATE ENHANCE 75 PRENATE EENTIAL 75 PRENATE MINI 75 PRENATE PIXIE 75 PRENATE RETORE 75 PRENATE TAR 75 PREPLU 15 PREPOPIK 197 PREQUE PRETALIA 93 presto pro blood glucose meter 163 PRETAB 15 PREVACID 195 PREVALITE 89 PREVIFEM 220 PREVNAR 13 7 PREVC 55 PREZCOBIX 66 PREZITA 66 PRIALT 119 PRIFTIN 55 PRILOEC 195,196 PRIMACARE 75 primaquine 61 PRIMAXIN 55 primidone 131 PRIMLEV 119 PRINIVIL 98 PRITIQ 148 PRIVIGEN 5 PRO-C-DURE PRO-C-DURE PROAIR HFA 45 PROAIR REPICLICK 45 probenecid 13 probenecid-colchicine 13 procainamide hcl 96 PROCARDIA 93 PROCARDIA XL 93 PROCENTRA 126 prochlorperazine 149 prochlorperazine edisylate 149 prochlorperazine maleate 149 PROCORT 259 PROCRIT 85 PROCTO-MED HC 259 PROCTO-K 259 PROCTOCORT 259 PROCTOFOAM-HC 259 PROCTOOL-HC 259 PROCTOZONE-HC 259 PROCYBI 245 prodigy autocode meter kit 163

313 prodigy autocode monitor syst 163 prodigy no coding test strips 176 prodigy pocket meter kit 163 prodigy voice meter kit 163 PRODRIN 119 PROFERRIN-FORTE 75 PROFILNINE 80 progesterone 229 progesterone in oil 229 PROGLYCEM 98 PROGRAF 243,244 PROLATIN 249 PROLATIN C 249 PROLENA 186 PROLEUKIN 29 PROLIA 235 PROMACTA 85 promethazine hcl 9 promethazine vc 9 promethazine vc-codeine 9 promethazine-codeine 247 promethazine-dm 70 promethazine-phenyleph-codeine 70 promethazine-phenylephrine 70 PROMETHEGAN 9 PROMETRIUM 229 propafenone hcl 96 propafenone hcl er 96 propantheline bromide 36 proparacaine hcl 191 PROPECIA 266 propranolol hcl 42 propranolol hcl er 42 propranolol-hydrochlorothiazid 11 propylthiouracil 231 PROQUAD 7 PROCAR 232 protamine sulfate 80 PROTHELIAL 163 PROTONIX 196 PROTONIX IV 196 PROTOM CHLORIDE 233 PROTOPIC 266,267 protriptyline hcl 149 PROVENGE 103 PROVENTIL HFA 45 PROVERA 229 PROVIDA DHA 75 PROVIDA OB 75 PROVIGIL 126 PROZAC 149 PROZAC WEEKLY 149 PRUDOXIN 260 PORCON 259 PULMICORT 203 PULMICORT FLEXHALER 203 PULMOZYME 180 PUREFE OB PLU 75 PUREFE PLU 75 PUREVIT DUALFE PLU 75 PURINETHOL 29 PURIXAN 29 pv truetrack smart sys strips 176 pv truetrack smart system 164 PYLERA 55 pyrazinamide 60 PYRIDIUM 260 pyridostigmine bromide 38 pyridostigmine bromide er 38 pyridoxine hcl 272 PYROGALLIC ACID 267 Q QBRELI 98 QNAL 186 QNAL CHILDREN 186 QROXIN 267 QYMIA 126 QUADRACEL DTAP-IPV 7 QUALAQUIN 61 QUARTETTE 220 QUAENE 220

314 quazepam 138 QUDEXY XR 132 QUETRAN 89 QUETRAN LIGHT 89 quetiapine fumarate 149 quetiapine fumarate er 149 QUFLORA 236 QUFLORA FE 76 QUILLICHEW ER 126 QUILLIVANT XR 126 quinapril hcl 98 quinapril-hydrochlorothiazide 12 quinidine gluconate 61 quinidine sulfate 61 quinine sulfate 61 quintet ac blood glucose meter 164 quintet ac glucose test strips 176 quintet blood glucose system 164 quintet glucose test strips 176 QUTENZA 267 QVAR 203 R R-NATAL OB 76 ra blood glucose monitor 164 ra truetest glucose test strip 176 RABAVERT 7 rabeprazole sodium 196 RADIOGARDAE 13 RAGWITEK 3 RAJANI 220 raloxifene hcl 225 ramipril 98 RANEXA 96 ranitidine hcl 196 RAFLO 42 RAMUNE 244 rasagiline mesylate 135 RAUVO 29 RAYALDEE 274 RAYO 203 RAZADYNE 38 RAZADYNE ER 38 REA LO REBETOL 66 REBIF 242 REBIF REBIDOE 242 RECLAT 235 RECLIPEN 220 RECOMBINATE 80 RECOMBIVAX HB 7 RECTACORT-HC 259 RECTIV 267 REFIA 260 refuah plus monitoring system 164 refuah plus test strips 176 REGIMEX 127 REGLAN 200 REGONOL 38 REGRANEX 267 RELAGARD 254 RELENZA 66 relion all-in-one meter kit 164 relion confirm glucose monitor 164 relion confirm system kit 164 relion confirm-micro test strp 177 relion micro blood glucose sys 164 relion micro system kit 164 relion micro test strips 177 relion prime blood glucose mtr 164 relion prime test strips 177 relion ultima glucose meter 164 relion ultima test strips 177 RELITOR 199 RELNATE DHA 76 RELX 133 REMERON 149 REMEVEN 263 REMICADE 199 REMODULIN 101 RENA-VITE RX 272 RENAL CAP 272

315 RENO CAP 272 RENOVA 260 RENOVA PUMP 260 RENOVO 267 REOPRO 84 repaglinide 211 repaglinide-metformin hcl 211 RETHA PUHTRONEX 89 RETHA URECLICK 89 RETHA YRINGE 89 replacement pediatric monitor 164 REPREXAIN 119 REPRONEX 226 REQ REQUIP 135 REQUIP XL 135 RECRIPTOR 66 RECULA 190 REECTIOL 13 reserpine 98 RE A.R. 9 RETAI 186 RETAI MULTIDOE 186 RETORA PRINKLE 199 RETORIL 138 RETIN-A 261 RETIN-A MICRO 261 RETIN-A MICRO PUMP 261 RETIERT 186 RETROVIR 66 REVATIO 101,102 reveal blood glucose meter 164 reveal test strip 177 REVETA 272 REVIA 140 REVLIMID 29 REVONTO 39 rexall blood glucose test strp 177 rexall glucose monitoring sys 164 REXULTI 149 REYATAZ 66 REZIRA 45 RHEUMATREX 29 RHINOCORT AQUA 186 RHOGAM ULTRA-FILTERED PLU 5 RHOPHYLAC 5 RIBAPHERE 66 RIBAPHERE RIBAK 66 RIBATAB 66 ribavirin 66 RIDAURA 200 rifabutin 55 RIFADIN 55 RIFAMATE 55 rifampin 55 RIFATER 55 rightest gm100 system kit 164 rightest gm250s glucose meter 164 rightest gm260 glucose meter 164 rightest gm300 system kit 164 rightest gm550 system kit 164 rightest gs100 test strips 177 rightest gs250s test strips 177 rightest gs260 test strips 177 rightest gs300 test strips 177 rightest gs550 test strips 177 RILUTEK 139 riluzole 139 rimantadine hcl 66 RIMO RIOMET 211 risedronate sodium 235 risedronate sodium dr 235 RIPERDAL 150 RIPERDAL CONTA 150 RIPERDAL M-TAB 150 risperidone 150,151 risperidone odt 150,151 RITALIN 127 RITALIN LA 127 RITUXAN 29 rivastigmine 38

316 RIXUBI 81 rizatriptan 133 ROBAXIN 39 ROBAXIN ROBINUL 36 ROBINUL FORTE 36 ROCALTROL 274 ropinirole er 135 ropinirole hcl 135 ROADAN 254 rosuvastatin calcium 89 ROTARIX 7 ROTATEQ 7 ROWAA 192 ROWEEPRA 132 ROXICET 119 ROXICODONE 119 ROXIFOL-D 273 ROZEREM 138 RUCONET 236 RULAVITE DHA 76 RYNODERM 263 RYTARY 135 RYTHMOL 96 RYTHMOL R 96 ABRIL 132 AFYRAL 220 AIZEN 228 ALACYN 263 ALAGEN 38 ALEX 263 salicylic acid 263 salicylic acid er 263 ALKERA 263 salsalate 119 ALVAX 263 ALVAX DUO PLU 263 ANADERMRX 259 ANCUO 194 ANDIMMUNE 238,239 ANDOTATIN 230 ANDOTATIN LAR 230 ANDOTATIN LAR DEPOT 230 ANTYL 267 APHRI 151 ARAFEM 151 AVAYA 84 AVELLA 140 AXENDA 211 CALACORT 259 CALACORT DK 259 E-NATAL E-TAN DHA 76 E-TAN PLU 76 EAONIQUE 220 ECONAL ODIUM 138 ECTRAL 42 EEBRI NEOHALER 36 ELECT-OB 76 ELECT-OB + DHA 76 selegiline hcl 135 ELZENTRY 66,67 EMPREX-D 17 ENIR 245 EREVENT DIKU 45 ERNIVO 259 EROPHENE 225 EROQUEL 151 EROQUEL XR 151 EROTIM 228 sertraline hcl 152 ETLAKIN 220 FROWAA 192 HAROBEL 220 IGNIFOR 230 IGNIFOR LAR 230 sildenafil 102 sildenafil citrate 102 ILENOR 152 ILMANIX 267

317 silver nitrate 254,263 silver nitrate applicator 262,263 ILVRTAT 164 IMBRINZA 189 IMCOR 89,90 IMPONI 239 IMPONI ARIA 239 IMULECT 244 simvastatin 90 INELEE 267 INEMET INEMET INEMET INEMET CR 135 INGULAIR 247 sirolimus 244 IRTURO 60 ITAVIG 67 IVEXTRO 55 KELAXIN 39 KLICE 254 KYLA 220 smart caresens n glucose systm 164 smart sense monitoring system 164 smart sense test strips 177 smartdiabetes xpres gluc syst 165 smartdiabetes xpres test strip 177 smartest eject meter 165 smartest persona glucose meter 165 smartest persona starter kit 165 smartest pronto glucose meter 165 smartest pronto starter kit 165 smartest protege meter 165 smartest smart code meter 165 smartest talking meter 165 smartest test strips 177 sod ferric gluconate complex 76 OD POLYULTHIONATE-FOLIC ACID 245 sodium nitrite 233 sodium nitroprusside 98 sodium sulfacetamide 254 sodium thiosulfate 233 sof-sensor 165 OLARAZE 267 OLETA 165 OLIQUA OLIRI 236 OLODYN 55 OLTAMOX 30 OLU-CORTEF 203 OLU-MEDROL 203 solus v2 audible meter 165 solus v2 audible meter sys kit 165 solus v2 audible test strips 178 OMA 39 OMATULINE DEPOT 230 OMAVERT 231 ONATA 138 OOLANTRA 267 ORIATANE 267 ORILUX 267 ORINE 42 sotalol 42 sotalol af 42 sotalol hcl 42 OTYLIZE 42 OVALDI 67 P ANTIPRURITIC 165 PECTRACEF 55 spinosad 254 PIRIVA 36 PIRIVA REPIMAT 36 spironolactone 12 spironolactone-hctz 12 PORANOX 59 PRINTEC 220 PRITAM 132 PRIX 119 PRYCEL 30 RONYX 220 TALEVO TALEVO

318 TALEVO TALEVO TALEVO TALEVO TARLIX 211 stavudine 67 TAXYN 102 TELARA 239 TENDRA 102 TIMATE 81 TIOLTO REPIMAT 36 TIVARGA 30 TRATTERA 139 TRENIQ 180 streptomycin sulfate 55 TRIANT 205 TRIBILD 67 TRIVERDI REPIMAT 45 TROMECTOL 3 UBOXONE 119 UBY 119 UCLEAR 197 UCRAID 180 sucralfate 196 ULAR 93 sulfacetamide sodium 183,254 sulfacetamide-prednisolone 183 sulfadiazine 55 sulfamethoxazole-trimethoprim 55 sulfasalazine 55 sulfasalazine dr 56 ULFATRIM 56 ULFZIX 246 sulindac 119 sumatriptan 133 sumatriptan succinate 134 UMAVEL DOEPRO 134 URTZ 165 URTZ FX 165 UPERVITE 273 UPPRELIN LA 30 UPRAX 56 UPRENZA ODT 127 UPREP 197 sure-test easyplus mini meter 165 sure-test easyplus mini strip 178 surechek blood glucose monitor 165 surestep pro linearity kit 165 URMONTIL 152 URVANTA 248 UTIVA 67 UTENT 30,31 YEDA 220 YLATRON 67 YLATRON 4-CK 67 YLVANT 31 YMBICORT 45 YMBYAX 152 YMLINPEN YMLINPEN YNAGI 67 YNALAR 259 YNALAR T 259 YNALGO-DC 84 YNAREL 226 YNERCID 56 YNJARDY 211 YNJARDY XR 211 YNRIBO 31 YNTHROID 231 YNVIC 165 YNVIC-ONE 166 YPRINE 200 T TABLOID 31 TACLONEX 259 tacrolimus 244,267 TAFINLAR 31 TAGRIO 31 TALTZ AUTOINJECTOR 267 TALTZ AUTOINJECTOR (2 CK) 267

319 TALTZ AUTOINJECTOR (3 CK) 267 TALTZ YRINGE 268 TALTZ YRINGE (2 CK) 268 TALTZ YRINGE (3 CK) 268 TALWIN 119 TAMIFLU 67 tamoxifen citrate 31 tamsulosin hcl 42 TANDEM PLU 76 TANZEUM 211 TAZOLE 231 TARCEVA 31 TARGADOX 56 TARGRETIN 31,268 TARINA FE 220 TARKA 93 TARON FORTE 76 TARON-BC 15 TARON-C DHA 76 TARON-PREX PRENATAL 76 TAIGNA 32 TAMAR 135 TAXOTERE 32 TAYTULLA 220 TAZICEF 56 TAZORAC 268 TAZTIA XT 93 td gold blood glucose monitor 166 td gold test strip 178 td gold voice glucose monitor 166 TECENTRIQ 32 TECFIDERA 242 TECHNIVIE 67 TEFLARO 56 TEGRETOL 132 TEGRETOL XR 132 TEKAMLO 94 TEKTURNA 99 TEKTURNA HCT 12 telcare blood glucose monitor 166 telcare test strips 178 telmisartan 98 telmisartan-amlodipine 94 telmisartan-hydrochlorothiazid 12 temazepam 138 TEMODAR 32 TEMOVATE 259 TEMOVATE EMOLLIENT 259 temozolomide 32 TENCON 119 TENEX 98 teniposide 32 TENIVAC 5 TENORETIC TENORETIC TENORMIN 42 TERAZOL TERAZOL terazosin hcl 43 terbinafine hcl 59 terbutaline sulfate 45 terconazole 254 terumo surguard2 166 TEALON PERLE 248 test n'go blood glucose system 166 test n'go glucose test strip 178 TETIM 206 TETONE CIK 206 TETOPEL 206 testosterone 206 testosterone cypionate 206 testosterone enanthate 206 TETRED 206 tetanus diphtheria toxoids 5 TETCAINE 191 tetrabenazine 139 tetracaine hcl 191 tetracycline hcl 56 TETRAVIC 191 TETRAVIC FORTE 191 TEV-TROPIN 228 TEXACORT 259

320 TEXAVITE LQ 76 THALOMID 242 THERACY 7 thiamine hcl 273 THIOLA 246 thioridazine hcl 152 thiotepa 32 thiothixene 152 THRIVITE THRIVITE RX 15 THYMOGLOBULIN 244 THYROGEN 179 THYROLAR THYROLAR-1/2 231 THYROLAR-1/4 231 THYROLAR THYROLAR tiagabine hcl 132 TIAZAC 94 ticlopidine hcl 84 TIGAN 194 tigecycline 56 TIKOYN 96 TILIA FE 221 timolol maleate 43,189 TIMOPTIC 189 TIMOPTIC OCUDOE 189 TIMOPTIC-XE 189 TINDAMAX 61 tinidazole 61 TIROINT 232 TIVICAY 67 TIVORBEX 119 tizanidine hcl 39 TL FOLATE 76 TL GARD RX 273 TL ICON 76 TL-FLUORIVITE 76 TL-HEM TL-ELECT 15 TNKAE 84 TOBI 56 TOBI PODHALER 56 TOBRADEX 183 TOBRADEX T 183 tobramycin 56,183 tobramycin sulfate 56 tobramycin sulfate in ns 56 tobramycin-dexamethasone 183 TOBREX 183 TOFRANIL 152 TOFRANIL-PM 152 TOLAK 268 tolazamide 212 tolbutamide 212 tolcapone 136 tolmetin sodium 120 tolterodine tartrate 269 tolterodine tartrate er 269 TOMAX 132 TOPICORT 259 topiramate 132 topiramate er 132 TOPOAR 32 topotecan hcl 32 TOPROL XL 43 TORIEL 32 TOTECT 246 TOUJEO OLOTAR 212 TOVIAZ 269 TRACLEER 102 TRADJENTA 212 tramadol hcl 120 tramadol hcl er 120 tramadol hcl-acetaminophen 120 trandolapril 98 trandolapril-verapamil er 94 TRANDERM-COP 194 TRANXENE T-TAB 132 tranylcypromine sulfate 152 TRAVATAN Z 189 travoprost 189

321 trazodone hcl 152 TREAGAN OTIC 191 TREANDA 32 TRECATOR 60 TRELTAR 32 TREIBA FLEXTOUCH U TREIBA FLEXTOUCH U TRETIN-X 261 tretinoin 32,261 tretinoin microsphere 261 TRETTEN 81 TREXALL 33 TREXIMET 120 TREZIX 120 TRI-CHLOR 268 TRI-ETARYLLA 221 TRI-LEGET FE 221 TRI-LINYAH 221 TRI-LO-ETARYLLA 221 TRI-LO-MARZIA 221 TRI-LO-PRINTEC 221 TRI-LUMA 261 TRI-NORINYL 221 TRI-PREVIFEM 221 TRI-PRINTEC 221 TRI-TAB DHA 15 TRI-VI-FLOR 236 TRI-VI-FLORO 236 tri-vit with fluoride-iron 76 tri-vitamin with fluoride 236 triacetin 59 TRIADVANCE 15 triamcinolone acetonide 186,203,259 triamterene-hydrochlorothiazid 12 TRIANEX 260 triazolam 138 TRIBENZOR 12 TRICARE 76 TRICARE PRENATAL 76 TRICARE PRENATAL DHA ONE 76 TRICARE PRENATAL WITH DHA 76 trichloroacetic acid 268 TRICON 77 TRICOR 90 TRIDERM 260 TRIDEILON 260 TRIEENCE 186 TRIFERIC 77 trifluoperazine hcl 152 trifluridine 184 TRIGEL-F FORTE 77 TRIGLIDE 90 trihexyphenidyl hcl 36 TRILEPTAL 132 TRILIPIX 90 TRILYTE WITH FLAVOR CKET 197 trimethobenzamide hcl 194 TRINATAL GT 77 TRINATAL RX 1 15 TRINATE 15 TRINEA 221 TRINEA LO 221 TRINTELLIX 152 TRIOTAT 232 TRIOXIN 184 TRIPHROCAP 273 TRIPLE DYE 254 triple-vitamin w-fluoride 236 TRIENOX 33 TRITART DHA 77 TRIUMEQ 68 TRIVEEN-DUO DHA 15 TRIVEEN-ONE 15 TRIVEEN-PRX RNF 15 TRIVEEN-U 271 TRIVORA TRIZIVIR 68 TROKENDI XR 132 trospium chloride 270 trospium chloride er 270 true metrix air glucose meter 166 true metrix blood glucose mtr 166

322 true metrix glucose test strip 178 true metrix go glucose meter 166 true2go blood glucose system 166 trueresult blood glucose systm 166 truetest glucose test strip 178 truetest glucose test strips 178 truetrack blood glucose system 166 truetrack glucose test strips 178 truetrack smart system 166 TRULICITY 212 TRUMENBA 7 TRUOPT 189 TRUT NATAL DHA 271 TRUVADA 68 TUDORZA PREAIR 36 TUICAP 9 TUIGON 36 TUIONEX 9 TUZITRA XR 70 TWINRIX 7 TWYNTA 94 TYBOT 246 TYGACIL 56 TYKERB 33 TYLENOL-CODEINE NO TYLENOL-CODEINE NO TYPHIM VI 7 TYABRI 242 TYVAO 102 TYVAO INTITUTIONAL TART KIT 102 TYVAO REFILL KIT 103 TYVAO TARTER KIT 103 TYZEKA 68 TYZINE 191 U U-CORT 260 UCERI 203 ULEFIA 254 ULORIC 234 ultima monitor kit 166 ultima test strips 178 ULTIMATECARE ONE 15 ULTIMATECARE ONE NF 15 ULTRACET 120 ULTRAM 120 ULTRAM ER 120 ULTRAAL-ER 263 ultratrak blood glucose meter 166 ultratrak pro glucose mtr sys 166 ultratrak pro meter kit 166 ultratrak test strip 178 ultratrak ultimate glucose mtr 166 ultratrak ultimate test strips 178 ULTRAVATE 260 ULTRAVATE X 260 ULTREA 197 UMECTA 263 UMECTA PD 263 UNAYN 56 unistik 2 normal 166 unistrip1 glucose test strip 178 UNITHROID 232 up & up blood glucose tst strp 178 up & up blood monitoring syst 167 UPTRAVI 103 URAMAXIN 263 URAMAXIN GT 264 URE-K 264 urea 264 URECHOLINE 38 UREVAZ 264 UROXATRAL 43 URO 197 URO FORTE 197 ursodiol 197 UTIBRON NEOHALER 37 UTOPIC 264 UVADEX 261 V v-r glucose test strip 179

323 VAGIFEM 225 valacyclovir 68 VALCHLOR 268 VALCYTE 68 valganciclovir hcl 68 VALIUM 132 valproate sodium 132 valproic acid 132 valsartan 98 valsartan-hydrochlorothiazide 12 VALTAR 33 VALTREX 68 VANATOL LQ 120 VANCOCIN HCL 56 vancomycin 56 vancomycin hcl 57 vancomycin hcl-0.9% nacl 57 vancomycin hcl-d5w 57 VANDAZOLE 254 VANIQA 268 VANO 260 VANOXIDE-HC 260 VANTA 33 VAQTA 7 VARIVAX VACCINE 8 VARIZIG 5 VARUBI 194 VACE 90 VAERETIC 12 VAOLEX 268 vasopressin 228 VAOTEC 99 VECAMYL 99 VECTIBIX 33 VECTICAL 268 VELCADE 33 VELETRI 103 VELIVET 221 VELTIN 254 VEMAVITE-PRX 2 15 VEMLIDY 68 VENA-BAL DHA 16 VENATAL COMPLETE DHA 16 VENCLEXTA 33 VENCLEXTA TARTING CK 33 venlafaxine hcl 152 venlafaxine hcl er 152 VENOFER 77 VENTAVI 103 VENTOLIN HFA 45 VERAMYT 186 verapamil er 94 verapamil er pm 94 verapamil hcl 94 verapamil sr 94 VERDEO 260 VERDROCET 120 VEREGEN 268 VERELAN 94 VERELAN PM 94 VERIPRED VERACLOZ 153 VEICARE 270 VETURA 221 VEXOL 186 VFEND 59 VFEND IV 59 VIAGRA 103 VIBATIV 57 VIBERZI 199 VIBRAMYCIN 57 VICODIN 120 VICODIN E 120 VICODIN HP 120 VICOPROFEN 120 VICTOZA 2-K 212 VICTOZA 3-K 212 VICTRELI 68 VIDAZA 33 VIDEX 68 VIDEX EC 68 VIEKIRA K 68

324 VIEKIRA XR 69 VIENVA 221 VIGAMOX 184 VIIBRYD 153 VIMIZIM 180 VIMOVO 120 VIMT 132 VINACAL 16 VINATE CARE 77 VINATE DHA 16 VINATE DHA RF 77 VINATE GT 77 VINATE II 16 VINATE ONE 16 VINATE PN CARE 271 VINATE ULTRA 16 VINATE-M 271 vinblastine sulfate 33 VINCAAR PF 33 vincristine sulfate 33 vinorelbine tartrate 33 VIOKACE 197 VIORELE 221 VIRACEPT 69 VIRAMUNE 69 VIRAMUNE XR 69 VIRAAL 264 VIRAZOLE 69 VIREAD 69 VIROPTIC 184 VIRT NATE 16 VIRT-ADVANCE 16 VIRT-BAL DHA 16 VIRT-BAL DHA PLU 16 VIRT-C DHA 77 VIRT-CAP 273 VIRT-CARE ONE 16 VIRT-GARD 273 VIRT-NATE 16 VIRT-NATE DHA 77 VIRT-PN 77 VIRT-PN DHA 77 VIRT-PN PLU 16 VIRT-ELECT 16 VIRT-VITE 273 VIRT-VITE GT 77 VIRT-VITE PLU 273 VIRTPREX 16 VITARIL 9 VITIDE 69 VITOGARD 233 VIUDYNE 190 VITA-RE 273 VITAFOL 77 VITAFOL FE+ 77 VITAFOL GUMMIE 16 VITAFOL NANO 77 VITAFOL ULTRA 77 VITAFOL-OB 16 VITAFOL-OB+DHA 16 VITAFOL-ONE 77 VITAL-D RX 273 VITAMEDMD ONE RX 77 VITAMEDMD PLU RX 77 VITAMEDMD REDICHEW RX 271 vitamin d2 274 vitamin k1 233 vitamins a,c,d and fluoride 236 VITAPEARL 77 VITAPIRE 77 VITATRUE 77 VITEKTA 69 VITRAE 180 VITUZ 9 VIVA DHA 78 VIVELLE-DOT 225 VIVITROL 140 VIVLODEX 120 VIVOTIF 8 VIVOTIF BERNA 8 VOGELXO 206 VOL-CARE RX 273

325 VOL-NATE 16 VOL-PLU 16 VOL-TAB RX 16 VOLTAREN 121 VOLTAREN-XR 121 VONVENDI 81 VORAXAZE 180 voriconazole 59 VOPIRE ER 45 VOTRIENT 33 VP CH ULTRA 78 VP-CH PLU 78 VP-CH-PNV 78 VP-ERA OB PLU 78 VP-GGR-B6 16 VP-HEME OB 78 VP-HEME OB + DHA 78 VP-HEME ONE 78 VP-PNV-DHA 78 VP-VITE RX 273 VPRIV 180 VRAYLAR 153 VUION 255 VYFEMLA 221 VYNATAL-FA 17 VYTONE 255 VYTORIN 90 VYVANE 127 W warfarin sodium 84 wavesense amp system kit 167 wavesense jazz test strips 179 wavesense presto system kit 167 wavesense presto test strips 179 WELCHOL 90 WELLBUTRIN 153 WELLBUTRIN R 153 WELLBUTRIN XL 153 WERA 221 WETHROID 232 WILATE 81 WINRHO DF 5 WP THYROID 232 WYMZYA FE 221 X X-VIATE 264 XALATAN 189 XALKORI 34 XANAX 138 XANAX XR 138 XARELTO 84 XARTEMI XR 121 XELJANZ 239 XELJANZ XR 239 XELODA 34 XENAZINE 140 XENICAL 199 XEOMIN 39,40 XEREE 255 XGEVA 235 XIAFLEX 180 XIFAXAN 57 XIGDUO XR 212 XIIDRA 186 XODOL XODOL XODOL XOFIGO 247 XOLAIR 249 XOLEGEL 255 XOPENEX 45 XOPENEX CONCENTRATE 45 XOPENEX HFA 45 XTAMPZA ER 121 XTANDI 34 XULANE 221 XULTOPHY XURIDEN 246 XYLOCAINE IV 96 XYNTHA 81

326 XYNTHA OLOFUE 81 XYREM 140 XYZAL 17 Y YAMIN YAZ 222 YERVOY 34 YF-VAX 8 YUVAFEM 225 Z zafirlukast 247 zaleplon 138 ZALTRAP 34 ZAMICET 121 ZANAFLEX 40 ZANOAR 34 ZANTAC 196 ZARAH 222 ZARONTIN 132 ZARXIO 85 ZATEAN-CH 17 ZATEAN-PN 78 ZATEAN-PN DHA 78 ZATEAN-PN PLU 17 ZAVARA 273 ZAVECA 246 ZEBETA 43 ZEBUTAL 121 ZEGERID 196 ZELAR 136 ZELBORAF 34 ZEMAIRA 249 ZEMBRACE YMTOUCH 134 ZEMPLAR 274 ZENATANE 268 ZENCHENT 222 ZENCHENT FE 222 ZENPEP 197 ZENZEDI 127 ZEOA 222 ZETIER 69 ZERIT 69 ZETORETIC 12 ZETRIL 99 ZETIA 90 ZETONNA 187 ZEVALIN 34 ZIAC 12 ZIAGEN 69 ZIANA 255 zidovudine 69 zileuton 247 ZINACEF 57 ZINBRYTA 243 zinc chloride 17 zinc sulfate 17 ZINECARD 246 ZINGIBER 17 ZIOPTAN 189 ziprasidone hcl 153 ZIPOR 121 ZIRGAN 184 ZITHRANOL 264 ZITHRANOL-RR 264 ZITHROMAX 57 ZITHROMAX TRI-K 57 ZMAX 57 ZN-DT 200 ZOCOR 90 ZOFRAN 194 ZOFRAN ODT 194 ZOHYDRO ER 121 ZOLADEX 34 ZOLATE 273 zoledronic acid 235 ZOLINZA 34 zolmitriptan 134 zolmitriptan odt 134 ZOLOFT 153 zolpidem tartrate 138

327 zolpidem tartrate er 138 ZOLPIMIT 138 ZOMACTON 228 ZOMETA 235 ZOMIG 134 ZOMIG ZMT 134 ZONALON 260 ZONATU 248 ZONEGRAN 132 zonisamide 132 ZONTIVITY 84 ZORBTIVE 228 ZORTRE 244 ZORVOLEX 121 ZOTAVAX 8 ZOYN 58 ZOVIA 1-35E 222 ZOVIA 1-50E 222 ZOVIRAX 69,255 ZUBOLV 121 ZUPLENZ 194 ZURAMPIC 13 ZUTRIPRO 9 ZYBAN 153 ZYCLARA 268 ZYDELIG 34 ZYFLO 247 ZYFLO CR 247 ZYKADIA 34 ZYLET 184 ZYLOPRIM 234 ZYMAXID 184 ZYPRAM 260 ZYPREXA 153,154 ZYPREXA RELPREVV 154 ZYPREXA ZYDI 154 ZYTIGA 35 ZYVOX 58