aetna better health of florida ... - medicaid health plans · aetna better health® formulary guide...

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health of Florida Florida Healthy Kids Formulary GuideOctober 2019


www.aetnabetterhealth.com/florida

What is a Formulary?

A formulary is a list of drugs that are covered by the health plan. A formulary also tells you if there are any rules or restrictions on drugs, such as a limit on the amount you can get. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy.

Can the Plan’s Drug List change?

The plan may add or remove drugs on the list. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use the Plan’s Formulary?

• Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).

• Column #2: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “Ear-Nose-Throat Medications.” If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.

What are generic drugs?

The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).

Are Over-The-Counter (OTC) drugs covered?

The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.

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Are there Medication Copays?

Refer to member handbook for copay information.

What are some types of coverage rules?

• Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Call Member Services team at 1-844-528-5815 for more information.

• Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.

• Step Therapy (ST): This means you may need to try certain drugs first to treat your condition.

After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered.

What if my drug is not on the plan’s Formulary?

First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:

• Ask your doctor for a similar drug that is covered. • Your doctor can ask the plan to cover your drug through the prior approval

process.

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Aetna Better Health Florida CHIP

Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................5 *ALTERNATIVE MEDICINES*........................................................................................................................... 12 *AMINOGLYCOSIDES*....................................................................................................................................... 12 *ANALGESICS - ANTI-INFLAMMATORY*...................................................................................................... 12 *ANALGESICS - NONNARCOTIC*.....................................................................................................................16 *ANALGESICS - OPIOID*.................................................................................................................................... 19 *ANDROGENS-ANABOLIC*............................................................................................................................... 21 *ANORECTAL AGENTS*.....................................................................................................................................22 *ANTACIDS*..........................................................................................................................................................22 *ANTHELMINTICS*............................................................................................................................................. 23 *ANTIANGINAL AGENTS*................................................................................................................................. 23 *ANTIANXIETY AGENTS*..................................................................................................................................24 *ANTIARRHYTHMICS*....................................................................................................................................... 24 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 25 *ANTICOAGULANTS*......................................................................................................................................... 27 *ANTICONVULSANTS*.......................................................................................................................................29 *ANTIDEPRESSANTS*.........................................................................................................................................33 *ANTIDIABETICS*............................................................................................................................................... 34 *ANTIDIARRHEALS*...........................................................................................................................................40 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...............................................................................................40 *ANTIDOTES*....................................................................................................................................................... 40 *ANTIEMETICS*................................................................................................................................................... 40 *ANTIFUNGALS*..................................................................................................................................................41 *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***......................................................... 42 *ANTIHISTAMINES*............................................................................................................................................ 42 *ANTIHYPERLIPIDEMICS*.................................................................................................................................43 *ANTIHYPERTENSIVES*.................................................................................................................................... 44 *ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 47 *ANTIMALARIALS*.............................................................................................................................................48 *ANTIMYASTHENIC AGENTS*......................................................................................................................... 48 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 49 *ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 49 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................49 *ANTIPARKINSON AGENTS*.............................................................................................................................54 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 55 *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR***........................................67 *ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 67 *ANTIVIRALS*......................................................................................................................................................67 *ASSORTED CLASSES*....................................................................................................................................... 71 *BETA BLOCKERS*............................................................................................................................................. 73 *CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***...............................................74 *CALCIUM CHANNEL BLOCKERS*................................................................................................................. 74 *CARDIOTONICS*................................................................................................................................................ 76 *CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 76 *CEPHALOSPORINS*...........................................................................................................................................76 *CHEMICALS*.......................................................................................................................................................78 *CONTRACEPTIVES*...........................................................................................................................................78

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*CORTICOSTEROIDS*......................................................................................................................................... 88 *COUGH/COLD/ALLERGY*................................................................................................................................90 *DERMATOLOGICALS*...................................................................................................................................... 93 *DIAGNOSTIC PRODUCTS*................................................................................................................................99 *DIGESTIVE AIDS*...............................................................................................................................................99 *DIRECT-ACTING P2Y12 INHIBITORS***....................................................................................................... 99 *DIURETICS*.......................................................................................................................................................100 *ENDOCRINE AND METABOLIC AGENTS - MISC.*....................................................................................101 *ESTROGENS*.....................................................................................................................................................103 *FLUOROQUINOLONES*.................................................................................................................................. 104 *GASTROINTESTINAL AGENTS - MISC.*......................................................................................................104 *GENITOURINARY AGENTS - MISCELLANEOUS*..................................................................................... 105 *GLYCOPEPTIDES***........................................................................................................................................106 *GOUT AGENTS*................................................................................................................................................106 *HEMATOLOGICAL AGENTS - MISC.*.......................................................................................................... 107 *HEMATOPOIETIC AGENTS*...........................................................................................................................109 *HEMOSTATICS*................................................................................................................................................113 *HEPATITIS C AGENT - COMBINATIONS***............................................................................................... 113 *HYPNOTICS*..................................................................................................................................................... 113 *LAXATIVES*..................................................................................................................................................... 114 *LHRH/GNRH AGONIST ANALOG COMBINATIONS***............................................................................ 114 *LOCAL ANESTHETICS-PARENTERAL*....................................................................................................... 115 *MACROLIDES*..................................................................................................................................................115 *MEDICAL DEVICES*........................................................................................................................................116 *MIGRAINE PRODUCTS*..................................................................................................................................142 *MINERALS & ELECTROLYTES*....................................................................................................................143 *MONOBACTAMS***........................................................................................................................................ 146 *MOUTH/THROAT/DENTAL AGENTS*..........................................................................................................146 *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS***......................................................................146 *MULTIVITAMINS*............................................................................................................................................146 *MUSCULOSKELETAL THERAPY AGENTS*................................................................................................149 *NASAL AGENTS - SYSTEMIC AND TOPICAL*........................................................................................... 150 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***........................................... 150 *NEUROMUSCULAR AGENTS*....................................................................................................................... 150 *NUTRIENTS*......................................................................................................................................................150 *OPHTHALMIC AGENTS*.................................................................................................................................152 *OPHTHALMIC RHO KINASE INHIBITORS***.............................................................................................155 *OTIC AGENTS*..................................................................................................................................................155 *OXYTOCICS*.....................................................................................................................................................155 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS***...........................................................................156 *PASSIVE IMMUNIZING AGENTS*.................................................................................................................156 *PENICILLINS*....................................................................................................................................................156 *PERITONEAL DIALYSIS SOLUTIONS***.....................................................................................................157 *PHARMACEUTICAL ADJUVANTS*.............................................................................................................. 157 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***..................................................................158 *POTASSIUM REMOVING AGENTS***..........................................................................................................159 *PROGESTINS*....................................................................................................................................................159 *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS***.................................159 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................160 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***..................................................................162 *RESPIRATORY AGENTS - MISC.*..................................................................................................................162 *SEROTONIN MODULATORS***.................................................................................................................... 163

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*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***................................................................... 163 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***................................... 163 *STEROIDS - MOUTH/THROAT/DENTAL***................................................................................................ 164 *SULFONAMIDES*.............................................................................................................................................164 *TETRACYCLINES*........................................................................................................................................... 164 *THYROID AGENTS*......................................................................................................................................... 164 *ULCER DRUGS*................................................................................................................................................ 165 *URINARY ANTI-INFECTIVES*.......................................................................................................................167 *URINARY ANTISPASMODICS*......................................................................................................................167 *VAGINAL PRODUCTS*....................................................................................................................................168 *VASOPRESSORS*............................................................................................................................................. 169 *VITAMINS*........................................................................................................................................................ 169

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Aetna Better Health Florida CHIP

CURRENT AS OF 10/1/2019

Formulary Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour Intuniv

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera AL (Min 6 Years)

*Amphetamine Mixtures***

amphetamine-dextroamphet er capsule extended release 24 hour 10 mg oral Adderall XR

QL: ages =/;18: maximum 50mg/day; QLL (1 EA per 1 day); AL (Min 13 Years)


QL: ages =/>18: maximum 50mg/day; QLL (1 EA per 1 day); AL (Min 13 Years)















5

Formulary Drug Name Reference Restrictions







amphetamine-dextroamphetamine tablet 10 mg oral Adderall AL (Min 3 Years)

amphetamine-dextroamphetamine tablet 10 mg oral Adderall

QL: ages 0-5: maximum of 2 tablets/day, ages =/;18: maximum of 6 tablets/day; AL (Min 3 Years)


QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 6 tablets/day; AL (Min 3 Years)

amphetamine-dextroamphetamine tablet 12.5 mg oral Adderall










QL: ages 0-5: maximum of 0.75 tablets/day, ages =/;18: maximum of 3 tablets/day


QL: ages 0-5: maximum of 0.75 tablets/day, ages =/;18: maximum of 3 tablets/day; AL (Min 3 Years)

6



QL: ages 0-5: maximum of 0.75 tablets/day, ages =/>18: maximum of 3 tablets/day; AL (Min 3 Years)





QL: ages 0-5: maximum of 0.05 tablets/day, ages =/;18: maximum of 2 tablets/day; AL (Min 3 Years)










*Amphetamines***

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg Dexedrine

QL: ages 0-5: maximum 1 capsule/day, ages =/>18: maximum 2 capsule/day; AL (Min 6 Years)





7


dextroamphetamine sulfate tablet 10 mg oral Zenzedi QL: ages 0-5: maximum 1 tablet/day, ages =/>18: maximum 2 tablets/day

dextroamphetamine sulfate tablet 5 mg oral Zenzedi QL: ages 0-5: maximum of 2 tablets/day, ages =/;18: maximum of 2 tablets/day

ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE AL (Min 6 Years)

VYVANSE ORAL CAPSULE QLL (1 EA per 1 day); AL (Min 6 Years)

VYVANSE ORAL TABLET CHEWABLE

*Analeptics***

caffeine citrate intravenous solution Cafcit QLL (90 ML per 30 days); AL (Max 11 Months)

caffeine citrate oral solution QLL (90 ML per 30 days); AL (Max 11 Months)

*Stimulants - Misc.*** dexmethylphenidate hcl er capsule extended release 24 hour 10 mg oral Focalin XR QLL (1 EA per 1 day); AL (Min

6 Years) dexmethylphenidate hcl er capsule extended release 24 hour 15 mg oral Focalin XR QLL (1 EA per 1 day); AL (Min



6 Years)

dexmethylphenidate hcl er capsule extended release 24 hour 25 mg oral Focalin XR

QL: ages 0-5: maximum of 0.6 capsule/day, ages =/>18: maximum of 1 capsule/day; QLL (1 EA per 1 day); AL (Min 6 Years)

dexmethylphenidate hcl er capsule extended release 24 hour 30 mg oral Focalin XR QLL (1 EA per 1 day); AL (Min

6 Years)




6 Years)



8

Formulary Drug Name Reference Restrictions dexmethylphenidate hcl er capsule extended release 24 hour 40 mg oral Focalin XR QLL (1 EA per 1 day); AL (Min

6 Years)




6 Years)

dexmethylphenidate hcl tablet 10 mg oral Focalin


dexmethylphenidate hcl tablet 2.5 mg oral Focalin


dexmethylphenidate hcl tablet 5 mg oral Focalin


methylphenidate hcl er (cd) capsule extended release 10 mg oral AL (Min 6 Years)

methylphenidate hcl er (cd) capsule extended release 10 mg oral

QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years)






QL: ages 0-5: maximum 0.833 capsule/day, ages =/;18: maximum 1 capsule/day; AL (Min 6 Years)




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Formulary Drug Name Reference Restrictions methylphenidate hcl er (cd) capsule extended release 50 mg oral AL (Min 6 Years)






methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg Ritalin LA



QL: ages 0-5: maximum of 0.833 capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years)



methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg


methylphenidate hcl er oral tablet extended release Metadate ER

methylphenidate hcl tablet 10 mg oral Ritalin


methylphenidate hcl tablet 10 mg oral Ritalin AL (Min 6 Years)





QL: ages 0-5: maximum of 1 tablet/day, ages =/>18: maximum of 3 tablets/day; AL (Min 6 Years)


10



QL: ages 0-5: maximum of 1 tablet/day, ages =/>18: maximum of 3 tablets/day; AL (Min 6 Years)



methylphenidate hcl tablet chewable 10 mg oral

QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 3 tablets/day

methylphenidate hcl tablet chewable 2.5 mg oral

QL: ages 0-5: maximum of 5 tablets/day, ages =/>18: maximum of 3 tablets/day

methylphenidate hcl tablet chewable 5 mg oral QL: ages 0-5: maximum of 5 tablets/day, ages =/>18: maximum of 3 tablets/day

modafinil tablet 100 mg oral Provigil Auto-PA; QLL (3 EA per 1 day); AL (Min 18 Years)

modafinil tablet 200 mg oral Provigil Auto-PA; QLL (2 EA per 1 day); AL (Min 18 Years)

APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 10 MG ORAL







QL: ages 0-5: maximum 0.833 capsule/day, ages =/>18: maximum 1 capsule/day; AL (Min 6 Years)





11




DAYTRANA PATCH 10 MG/9HR TRANSDERMAL

QL: age 0-5: maximum 30 patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years)






QL: age 0-5: maximum 0.833 patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years)

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE AL (Min 6 Years)

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED AL (Min 6 Years)

*ALTERNATIVE MEDICINES* *Alternative Medicine - St's*** stevia oral packet OTC

*AMINOGLYCOSIDES* *Aminoglycosides*** gentamicin in saline intravenous solution gentamicin sulfate injection solution neomycin sulfate oral tablet tobramycin inhalation nebulization solution Kitabis Pak tobramycin sulfate injection solution

*ANALGESICS - ANTI-INFLAMMATORY* *Antirheumatic - Janus Kinase (Jak) Inhibitors***

XELJANZ ORAL TABLET Auto-PA; QLL (2 EA per 1 day); AL (Min 18 Years)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR

Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

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Formulary Drug Name Reference Restrictions *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS

Auto-PA; QLL (1 KIT per 365 days)

HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS


HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML SUBCUTANEOUS

Auto-PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

Auto-PA; QLL (2 KITS per 28 days)

HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS



Auto-PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML

Auto-PA

HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS


HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS

Auto-PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

Auto-PA

HUMIRA PREFILLED SYRINGE KIT 10 MG/0.1ML SUBCUTANEOUS Auto-PA

HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS








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Formulary Drug Name Reference Restrictions *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS


HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS


HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML SUBCUTANEOUS

Auto-PA

HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.4ML SUBCUTANEOUS


HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS





Auto-PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML

Auto-PA

HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS


HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS

Auto-PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

Auto-PA








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Formulary Drug Name Reference Restrictions HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS


*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib capsule 100 mg oral CeleBREX QLL (2 EA per 1 day) celecoxib capsule 200 mg oral CeleBREX QLL (2 EA per 1 day) celecoxib capsule 400 mg oral CeleBREX QLL (1 EA per 1 day) celecoxib capsule 50 mg oral CeleBREX QLL (2 EA per 1 day)

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release ec-naproxen oral tablet delayed release EC-Naprosyn ibuprofen oral suspension Childrens Advil ibuprofen oral tablet IBU indomethacin oral capsule ketorolac tromethamine intramuscular solution

QLL (120 MG per 1 day); AL (Min 17 Years)

ketorolac tromethamine oral tablet QLL (4 EA per 1 day); AL (Min 17 Years)

ketorolac tromethamine solution 15 mg/ml injection

QLL (120 Mg per 1 day); AL (Min 17 Years)

ketorolac tromethamine solution 30 mg/ml injection ketorolac tromethamine solution 30 mg/ml injection

QLL (120 MG per 1 day); AL (Min 17 Years)

meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release EC-Naprosyn naproxen oral tablet IBU ORAL TABLET Ibuprofen

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava

*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE

15

Formulary Drug Name Reference Restrictions ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Auto-PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED

Auto-PA; QLL (2 KITS per 28 days); AL (Min 2 Years)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Auto-PA

*ANALGESICS - NONNARCOTIC* *Analgesics Other*** 8 hour arthritis pain reliever oral tablet extended release Midol OTC

8 hr arthritis pain relief oral tablet extended release Midol OTC

8hr muscle aches & pain oral tablet extended release Midol OTC

acetaminophen childrens oral suspension Nortemp OTC; AL (Max 6 Years) acetaminophen childrens oral tablet chewable Mapap Childrens OTC; AL (Max 6 Years) acetaminophen er oral tablet extended release Midol OTC acetaminophen infants oral suspension Nortemp OTC; AL (Max 6 Years) acetaminophen oral liquid Little Remedies for Fever OTC; AL (Max 6 Years) acetaminophen oral tablet chewable Mapap Childrens OTC arthritis pain relief oral tablet extended release Midol OTC

childrens acetaminophen oral suspension Nortemp OTC; AL (Max 6 Years) childrens silapap oral liquid Little Remedies for Fever OTC; AL (Max 6 Years) ed-apap oral liquid Little Remedies for Fever OTC; AL (Max 6 Years) gnp 8 hour pain reliever oral tablet extended release Midol OTC

gnp arthritis pain relief oral tablet extended release Midol OTC

gnp infants pain relief oral suspension Nortemp OTC; AL (Max 6 Years) gnp infants pain/fever oral suspension Nortemp OTC; AL (Max 6 Years) gnp pain & fever childrens oral suspension Nortemp OTC; AL (Max 6 Years) goodsense arthritis pain oral tablet extended release Midol OTC

goodsense pain & fever child oral suspension Nortemp OTC; AL (Max 6 Years) goodsense pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years)

goodsense pain relief oral tablet extended release Midol OTC

hm acetaminophen childrens oral tablet chewable Mapap Childrens OTC; AL (Max 6 Years)

16

Formulary Drug Name Reference Restrictions hm arthritis pain relief oral tablet extended release Midol OTC

hm pain & fever childrens oral suspension Nortemp OTC; AL (Max 6 Years) hm pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years) mapap arthritis pain oral tablet extended release Midol OTC

mapap oral liquid Little Remedies for Fever OTC; AL (Max 6 Years) m-pap oral liquid Little Remedies for Fever OTC non-aspirin childrens oral suspension Nortemp OTC; AL (Max 6 Years) pain & fever childrens suspension 160 mg/5ml oral Nortemp OTC

pain & fever childrens suspension 160 mg/5ml oral Nortemp OTC; AL (Max 6 Years)

pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years) pain relief childrens oral suspension Nortemp OTC; AL (Max 6 Years) qc arthritis pain relief oral tablet extended release Midol OTC

qc non-aspirin childrens oral suspension Nortemp OTC; AL (Max 6 Years) qc non-aspirin jr strength oral tablet dispersible OTC; AL (Max 6 Years)

qc pain relief childrens oral suspension Nortemp OTC; AL (Max 6 Years) sm 8 hour pain relief oral tablet extended release Midol OTC

sm arthritis pain relief oral tablet extended release Midol OTC

sm arthritis pain reliever oral tablet extended release Midol OTC

sm pain & fever childrens oral suspension Nortemp OTC; AL (Max 6 Years) sm pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years) MAPAP CHILDRENS ORAL TABLET CHEWABLE Acetaminophen OTC; AL (Max 6 Years)

*Analgesics-Sedatives*** butalbital-acetaminophen oral capsule butalbital-acetaminophen oral tablet Tencon butalbital-apap-caffeine capsule 50-300-40 mg oral Fioricet QLL (60 EA per 30 days)

butalbital-apap-caffeine capsule 50-325-40 mg oral Esgic QLL (120 EA per 360 days)

butalbital-apap-caffeine oral capsule 50-300-40 mg Fioricet QLL (60 EA per 30 days)

butalbital-apap-caffeine oral tablet Esgic QLL (120 EA per 365 days)

17

Formulary Drug Name Reference Restrictions butalbital-aspirin-caffeine oral capsule Fiorinal

*Salicylates*** adult aspirin regimen oral tablet delayed release Aspir-Low OTC

aspirin 81 oral tablet delayed release Aspir-Low OTC aspirin adult low strength oral tablet chewable Bayer Low Dose OTC

aspirin adult oral tablet Bayer Advanced Aspirin Reg St OTC

aspirin ec low strength oral tablet delayed release Aspir-Low OTC

aspirin ec oral tablet delayed release Bayer Aspirin OTC aspirin low dose oral tablet chewable Bayer Low Dose OTC aspirin low dose oral tablet delayed release Aspir-Low OTC

aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

aspirin oral tablet chewable Bayer Low Dose OTC aspirin oral tablet delayed release Bayer Aspirin OTC aspirin rectal suppository OTC childrens aspirin low strength oral tablet chewable Bayer Low Dose OTC

gnp adult aspirin low strength oral tablet chewable Bayer Low Dose OTC

gnp aspirin low dose oral tablet delayed release Aspir-Low OTC

gnp aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

gnp aspirin oral tablet delayed release Aspir-Low OTC

goodsense aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

goodsense aspirin oral tablet chewable Bayer Low Dose OTC hm aspirin ec low dose oral tablet delayed release Aspir-Low OTC

hm aspirin ec oral tablet delayed release Bayer Aspirin OTC

hm aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

hm aspirin oral tablet chewable Bayer Low Dose OTC qc aspirin low dose oral tablet chewable Bayer Low Dose OTC qc aspirin low dose oral tablet delayed release Aspir-Low OTC

qc aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

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Formulary Drug Name Reference Restrictions qc enteric aspirin oral tablet delayed release Bayer Aspirin OTC salsalate oral tablet sm aspirin adult low strength oral tablet chewable Bayer Low Dose OTC

sm aspirin adult low strength oral tablet delayed release Aspir-Low OTC

sm aspirin ec oral tablet delayed release Bayer Aspirin OTC sm aspirin low dose oral tablet chewable Bayer Low Dose OTC

sm aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

sm childrens aspirin oral tablet chewable Bayer Low Dose OTC ASPIR-LOW ORAL TABLET DELAYED RELEASE HM Aspirin EC Low Dose OTC

ECPIRIN ORAL TABLET DELAYED RELEASE Aspirin OTC

ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE PX Aspirin OTC

*ANALGESICS - OPIOID* *Codeine Combinations***

acetaminophen-codeine #2 oral tablet QLL (12 EA per 1 day); AL (Min 12 Years)

acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (12 EA per 1 day); AL (Min 12 Years)

acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (12 EA per 1 day); AL (Min 12 Years)

acetaminophen-codeine oral solution AL (Min 6 Years)

acetaminophen-codeine tablet 300-15 mg oral QLL (12 EA per 1 day); AL (Min 12 Years)

acetaminophen-codeine tablet 300-30 mg oral Tylenol with Codeine #3

acetaminophen-codeine tablet 300-60 mg oral Tylenol with Codeine #4 QLL (12 EA per 1 day); AL (Min 12 Years)

butalbital-apap-caff-cod oral capsule Auto-PA

*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen tablet 10-300 mg oral Vicodin HP QLL (6 EA per 1 day)

hydrocodone-acetaminophen tablet 10-300 mg oral Vicodin HP

hydrocodone-acetaminophen tablet 10-325 mg oral Lorcet HD

19

Formulary Drug Name Reference Restrictions hydrocodone-acetaminophen tablet 5-300 mg oral Vicodin QLL (8 EA per 1 day)

hydrocodone-acetaminophen tablet 5-325 mg oral Lorcet

hydrocodone-acetaminophen tablet 7.5-300 mg oral Vicodin ES QLL (6 EA per 1 day)

hydrocodone-acetaminophen tablet 7.5-325 mg oral Lorcet Plus

hydrocodone-ibuprofen oral tablet VICODIN ES ORAL TABLET Hydrocodone-Acetaminophen QLL (6 EA per 1 day) VICODIN HP ORAL TABLET Hydrocodone-Acetaminophen QLL (6 EA per 1 day) VICODIN ORAL TABLET Hydrocodone-Acetaminophen QLL (8 EA per 1 day)

*Opioid Agonists*** codeine sulfate oral tablet AL (Min 12 Years)

fentanyl transdermal patch 72 hour Duragesic-25 QLL (10 EA per 30 days); AL (Min 18 Years)

hydromorphone hcl injection solution Dilaudid hydromorphone hcl oral tablet Dilaudid morphine sulfate (concentrate) oral solution morphine sulfate oral solution morphine sulfate oral tablet oxycodone hcl oral solution QLL (60 ML per 1 day) oxycodone hcl tablet 10 mg oral QLL (6 EA per 1 day) oxycodone hcl tablet 15 mg oral Roxicodone QLL (6 EA per 1 day) oxycodone hcl tablet 20 mg oral QLL (9 EA per 1 day) oxycodone hcl tablet 30 mg oral Roxicodone QLL (6 EA per 1 day) oxycodone hcl tablet 5 mg oral Roxicodone QLL (12 EA per 1 day)

tramadol hcl oral tablet Ultram QL: age 0-15: maximum 60 tablets/27 days; QLL (8 EA per 1 day); AL (Min 12 Years)

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT


EMBEDA ORAL CAPSULE EXTENDED RELEASE

QLL (2 EA per 1 day); AL (Min 18 Years)

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT


MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Auto-PA; AL (Min 18 Years)

OXAYDO ORAL TABLET ABUSE-DETERRENT Auto-PA

20

Formulary Drug Name Reference Restrictions ROXYBOND ORAL TABLET ABUSE-DETERRENT Auto-PA

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT Auto-PA; AL (Min 18 Years)

*Opioid Combinations*** oxycodone-acetaminophen tablet 10-325 mg oral Endocet QLL (6 EA per 1 day)

oxycodone-acetaminophen tablet 2.5-325 mg oral Endocet QLL (12 EA per 1 day)

oxycodone-acetaminophen tablet 5-325 mg oral Endocet QLL (12 EA per 1 day)

oxycodone-acetaminophen tablet 7.5-325 mg oral Endocet QLL (8 EA per 1 day)

*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual

PA; Maximum of 7 days of induction therapy every 60 days; QLL (3 EA per 1 day); AL (Min 16 Years)

buprenorphine hcl-naloxone hcl film 12-3 mg sublingual Suboxone PA; QLL (3 EA per 1 day); AL

(Min 16 Years) buprenorphine hcl-naloxone hcl film 2-0.5 mg sublingual Suboxone PA; QLL (3 EA per 1 day); AL

(Min 16 Years) buprenorphine hcl-naloxone hcl film 4-1 mg sublingual Suboxone QLL (3 EA per 1 day); AL (Min

16 Years) buprenorphine hcl-naloxone hcl film 4-1 mg sublingual Suboxone PA; QLL (3 EA per 1 day); AL

(Min 16 Years) buprenorphine hcl-naloxone hcl film 8-2 mg sublingual Suboxone QLL (3 EA per 1 day); AL (Min

16 Years) buprenorphine hcl-naloxone hcl film 8-2 mg sublingual Suboxone PA; QLL (3 EA per 1 day); AL

(Min 16 Years)

buprenorphine transdermal patch weekly Butrans QLL (1 BOX per 28 days); AL (Min 18 Years)

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Auto-PA; QLL (300 MG per 30 days)

*ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule testosterone cypionate intramuscular solution Depo-Testosterone testosterone enanthate intramuscular solution ANDROGEL PUMP TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years)

ANDROGEL TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years)

21

Formulary Drug Name Reference Restrictions *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema Colocort

*Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream lidocaine-hydrocortisone ace rectal gel lidocaine-hydrocortisone ace rectal kit PROCTOFOAM HC RECTAL FOAM

*Rectal Steroids*** hydrocortisone rectal cream Procto-Pak ANUSOL-HC RECTAL CREAM Hydrocortisone PROCTOSOL HC RECTAL CREAM Hydrocortisone PROCTOZONE-HC RECTAL CREAM Hydrocortisone

*ANTACIDS* *Antacids - Bicarbonate*** sodium bicarbonate oral powder

*Antacids - Calcium Salts*** antacid calcium oral tablet chewable Cal-Gest Antacid OTC antacid extra strength oral tablet chewable Antacid Flavor Chews OTC antacid oral tablet chewable Cal-Gest Antacid OTC antacid ultra strength oral tablet chewable Tums Ultra 1000 OTC calcium antacid extra strength oral tablet chewable Antacid Flavor Chews OTC

calcium antacid oral tablet chewable Cal-Gest Antacid OTC calcium antacid ultra max st oral tablet chewable Tums Ultra 1000 OTC

calcium antacid ultra strength oral tablet chewable Tums Ultra 1000 OTC

calcium carbonate antacid oral suspension OTC calcium carbonate antacid oral tablet OTC gnp antacid extra strength oral tablet chewable Antacid Flavor Chews OTC

hm calcium antacid ex st oral tablet chewable Antacid Flavor Chews OTC hm calcium antacid oral tablet chewable Antacid Flavor Chews OTC hm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 OTC

sm calcium antacid ex st oral tablet chewable Antacid Flavor Chews OTC sm calcium antacid oral tablet chewable Cal-Gest Antacid OTC

22

Formulary Drug Name Reference Restrictions CAL-GEST ANTACID ORAL TABLET CHEWABLE Antacid OTC

TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE Antacid OTC

TUMS E-X 750 ORAL TABLET CHEWABLE

Calcium Antacid Extra Strength OTC

TUMS EXTRA STRENGTH 750 ORAL TABLET CHEWABLE


TUMS ORAL TABLET CHEWABLE Antacid OTC TUMS SMOOTHIES ORAL TABLET CHEWABLE


TUMS ULTRA 1000 ORAL TABLET CHEWABLE CVS Antacid Ultra Strength OTC

*ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet Albenza ivermectin oral tablet Stromectol praziquantel oral tablet Biltricide

*ANTIANGINAL AGENTS* *Antianginals-Other*** ranolazine er oral tablet extended release 12 hour Ranexa

*Nitrates***

isosorbide dinitrate tablet 10 mg oral Maintenance drug with max 100 days supply

isosorbide dinitrate tablet 10 mg oral

isosorbide dinitrate tablet 20 mg oral Maintenance drug with max 100 days supply

isosorbide dinitrate tablet 20 mg oral isosorbide dinitrate tablet 30 mg oral

isosorbide dinitrate tablet 5 mg oral Isordil Titradose Maintenance drug with max 100 days supply

isosorbide dinitrate tablet 5 mg oral Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour

Maintenance drug with max 100 day supply

isosorbide mononitrate oral tablet

nitroglycerin sublingual tablet sublingual Nitrostat Maintenance drugs with max 100 day supply; QLL (16 EA per 1 day)

nitroglycerin transdermal patch 24 hour Minitran QLL (1 EA per 1 day)

23

Formulary Drug Name Reference Restrictions *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet droperidol injection solution AL (Min 18 Years) hydroxyzine hcl intramuscular solution hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet QLL (4 EA per 1 day) hydroxyzine pamoate oral capsule Vistaril

*Benzodiazepines***

alprazolam tablet 0.25 mg oral Xanax QLL (5 EA per 1 day); AL (Min 7 Years)

alprazolam tablet 0.5 mg oral Xanax QLL (5 EA per 1 day); AL (Min 7 Years)

alprazolam tablet 0.5 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years)

alprazolam tablet 1 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years)

alprazolam tablet 2 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years)

chlordiazepoxide hcl oral capsule QLL (4 EA per 1 day); AL (Min 6 Years)

clorazepate dipotassium oral tablet QLL (4 EA per 1 day); AL (Min 9 Years)

diazepam oral solution QLL (40 ML per 1 day) diazepam oral tablet Valium QLL (4 EA per 1 day) lorazepam injection solution Ativan lorazepam oral concentrate LORazepam Intensol QLL (5 ML per 1 day) lorazepam oral tablet Ativan QLL (5 EA per 1 day)

oxazepam oral capsule QLL (4 EA per 1 day); AL (Min 6 Years)

LORAZEPAM INTENSOL ORAL CONCENTRATE LORazepam QLL (5 ML per 1 day)

*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace quinidine gluconate er oral tablet extended release quinidine sulfate oral tablet

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule

24

Formulary Drug Name Reference Restrictions *Antiarrhythmics Type I-C***

flecainide acetate oral tablet Maintenance drug with max 100 days supply

propafenone hcl oral tablet

*Antiarrhythmics Type Iii***

amiodarone hcl oral tablet Pacerone Maintenance drug with max 100 days supply

TIKOSYN ORAL CAPSULE Dofetilide

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** fluticasone-salmeterol inhalation aerosol powder breath activated Advair Diskus

ipratropium-albuterol inhalation solution

ADVAIR HFA INHALATION AEROSOL QLL (1 GM per 30 days); AL (Min 5 Years)

BEVESPI AEROSPHERE INHALATION AEROSOL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION

DULERA INHALATION AEROSOL QLL (13 UNITS per 1 Fill); AL (Min 12 Years)

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION

SYMBICORT INHALATION AEROSOL QLL (1 INHALER per 30 days); AL (Min 5 Years)

UTIBRON NEOHALER INHALATION CAPSULE

*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution

*Beta Adrenergics*** albuterol sulfate hfa inhalation aerosol solution ProAir HFA QLL (2 EA per 30 days)

albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation QLL (375 ML per 30 days)

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation

25

Formulary Drug Name Reference Restrictions albuterol sulfate nebulization solution 0.63 mg/3ml inhalation QLL (375 ML per 30 days)

albuterol sulfate nebulization solution 1.25 mg/3ml inhalation QLL (375 ML per 30 days)

albuterol sulfate oral syrup terbutaline sulfate injection solution PROVENTIL HFA INHALATION AEROSOL SOLUTION Albuterol Sulfate HFA QLL (2 INHALERS per 30

days) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

QLL (1 INHALER per 30 days); AL (Min 4 Years)

*Bronchodilators -Anticholinergics*** ipratropium bromide inhalation solution ATROVENT HFA INHALATION AEROSOL SOLUTION QLL (25.8 GM per 30 days)

SPIRIVA HANDIHALER INHALATION CAPSULE


*Leukotriene Receptor Antagonists*** montelukast sodium oral packet Singulair ST; AL (Min 5 Years) montelukast sodium oral tablet Singulair QLL (1 EA per 1 day) montelukast sodium oral tablet chewable Singulair QLL (1 EA per 1 day) SINGULAIR ORAL PACKET Montelukast Sodium ST; AL (Max 4 Years)

*Steroid Inhalants***

budesonide inhalation suspension Pulmicort QLL (120 ML per 30 days); AL (Min 1 Years and Max 8 Years)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT

AL (Min 5 Years)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

QLL (1 EA per 30 days); AL (Min 4 Years)

ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED


ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED


26

Formulary Drug Name Reference Restrictions ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

QLL (2 INHALER per 30 days); AL (Min 4 Years)

FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION QLL (24 GM per 30 days)

FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION QLL (24 GM per 30 days)

FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION QLL (21.2 GM per 30 days)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED

*Xanthines*** theophylline er oral tablet extended release 12 hour Theochron

theophylline er oral tablet extended release 24 hour theophylline oral solution ELIXOPHYLLIN ORAL ELIXIR THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR

*ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium tablet 1 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 10 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 2 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 2.5 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 3 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 4 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 5 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 6 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 7.5 mg oral Coumadin warfarin sodium tablet 7.5 mg oral Coumadin QLL (4 EA per 1 day) COUMADIN ORAL TABLET Warfarin Sodium QLL (4 EA per 1 day) JANTOVEN ORAL TABLET Warfarin Sodium QLL (120 EA per 30 days)

*Direct Factor Xa Inhibitors*** ELIQUIS STARTER PACK ORAL TABLET AL (Min 18 Years)

27


ELIQUIS TABLET 2.5 MG ORAL QLL (2 EA per 1 day); AL (Min 18 Years)

ELIQUIS TABLET 5 MG ORAL QLL (4 EA per 1 day); AL (Min 18 Years)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK AL (Min 18 Years)

XARELTO TABLET 10 MG ORAL AL (Min 18 Years) XARELTO TABLET 15 MG ORAL AL (Min 18 Years) XARELTO TABLET 2.5 MG ORAL AL (Min 18 Years) XARELTO TABLET 20 MG ORAL AL (Max 18 Years) XARELTO TABLET 20 MG ORAL AL (Min 18 Years)

*Heparins And Heparinoid-Like Agents*** heparin (porcine) in nacl injection solution heparin (porcine) in nacl intravenous solution heparin lock flush intravenous solution heparin sod (porcine) in d5w intravenous solution heparin sodium (porcine) injection solution heparin sodium (porcine) injection solution prefilled syringe heparin sodium (porcine) pf injection solution

*Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox QLL (180 ML per 30 days) enoxaparin sodium solution 100 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days)

enoxaparin sodium solution 120 mg/0.8ml subcutaneous Lovenox QLL (48 ML per 30 days)

enoxaparin sodium solution 150 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days)





*Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE AL (Min 18 Years)

28

Formulary Drug Name Reference Restrictions *ANTICONVULSANTS* *Ampa Glutamate Receptor Antagonists*** FYCOMPA ORAL SUSPENSION Auto-PA FYCOMPA ORAL TABLET Auto-PA; AL (Min 12 Years)

*Anticonvulsants -Benzodiazepines*** clobazam oral suspension Onfi AL (Min 2 Years) clobazam oral tablet Onfi AL (Min 2 Years) clonazepam oral tablet KlonoPIN QLL (3 EA per 1 day) clonazepam oral tablet dispersible

diazepam rectal gel Diastat AcuDial QLL (2 KITS per 30 days); AL (Min 18 Years)

KLONOPIN ORAL TABLET ClonazePAM QLL (3 EA per 1 day) ONFI ORAL SUSPENSION CloBAZam Auto-PA ONFI ORAL TABLET CloBAZam Auto-PA; AL (Min 2 Years)

*Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour Carbatrol

carbamazepine er oral tablet extended release 12 hour TEGretol-XR

carbamazepine oral suspension TEGretol carbamazepine oral tablet Epitol carbamazepine oral tablet chewable gabapentin oral capsule Neurontin gabapentin oral solution Neurontin gabapentin oral tablet Neurontin lamotrigine er oral tablet extended release 24 hour LaMICtal XR AL (Min 13 Years)

lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal lamotrigine oral tablet dispersible LaMICtal ODT Auto-PA lamotrigine starter kit-blue oral kit LaMICtal Starter QLL (35 EA per 30 days) lamotrigine starter kit-green oral kit LaMICtal Starter QLL (98 EA per 30 days) lamotrigine starter kit-orange oral kit LaMICtal Starter QLL (49 EA per 30 days) levetiracetam er oral tablet extended release 24 hour Keppra XR

levetiracetam intravenous solution Keppra levetiracetam oral solution Keppra

29

Formulary Drug Name Reference Restrictions levetiracetam oral tablet Keppra oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal pregabalin oral capsule Lyrica primidone oral tablet Mysoline topiramate er oral capsule er 24 hour sprinkle Qudexy XR AL (Min 6 Years) topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax zonisamide oral capsule Zonegran APTIOM ORAL TABLET Auto-PA; AL (Min 4 Years) BANZEL ORAL SUSPENSION Auto-PA; AL (Min 1 Years) BANZEL ORAL TABLET Auto-PA; AL (Min 1 Years) BRIVIACT INTRAVENOUS SOLUTION Auto-PA; AL (Min 16 Years) BRIVIACT ORAL SOLUTION Auto-PA; AL (Min 4 Years) BRIVIACT ORAL TABLET Auto-PA; AL (Min 4 Years) CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR CarBAMazepine ER Auto-PA

EPITOL ORAL TABLET carBAMazepine Auto-PA KEPPRA ORAL SOLUTION LevETIRAcetam KEPPRA ORAL TABLET LevETIRAcetam KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR LevETIRAcetam ER

LAMICTAL ODT KIT 21 X 25 MG & 7 X 50 MG ORAL QLL (28 EA per 30 days)

LAMICTAL ODT KIT 25 & 50 & 100 MG ORAL QLL (35 EA per 30 days)

LAMICTAL ODT KIT 42 X 50 MG & 14X100 MG ORAL QLL (56 EA per 30 days)

LAMICTAL ORAL TABLET lamoTRIgine LAMICTAL ORAL TABLET CHEWABLE LamoTRIgine

LAMICTAL STARTER ORAL KIT lamoTRIgine Starter Kit-Green LAMICTAL XR KIT 21 X 25 MG & 7 X 50 MG ORAL


LAMICTAL XR KIT 25 & 50 & 100 MG ORAL


LAMICTAL XR KIT 50 & 100 & 200 MG ORAL


LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR LamoTRIgine ER AL (Min 13 Years)

MYSOLINE ORAL TABLET Primidone 30

Formulary Drug Name Reference Restrictions NEURONTIN ORAL CAPSULE Gabapentin NEURONTIN ORAL SOLUTION Gabapentin NEURONTIN ORAL TABLET Gabapentin OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 6 Years)

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE Topiramate ER

ROWEEPRA ORAL TABLET LevETIRAcetam ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR LevETIRAcetam ER

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE SUBVENITE ORAL TABLET LamoTRIgine SUBVENITE STARTER KIT-BLUE ORAL KIT lamoTRIgine Starter Kit-Blue

SUBVENITE STARTER KIT-GREEN ORAL KIT lamoTRIgine Starter Kit-Green

SUBVENITE STARTER KIT-ORANGE ORAL KIT

lamoTRIgine Starter Kit-Orange

TEGRETOL ORAL SUSPENSION CarBAMazepine TEGRETOL ORAL TABLET carBAMazepine TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR CarBAMazepine ER

TOPAMAX ORAL TABLET Topiramate TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE Topiramate

TRILEPTAL ORAL SUSPENSION OXcarbazepine TRILEPTAL ORAL TABLET OXcarbazepine TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR AL (Min 6 Years)

VIMPAT ORAL SOLUTION Auto-PA; QLL (40 ML per 1 day)

VIMPAT ORAL TABLET Auto-PA; QLL (2 EA per 1 day)

*Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol FELBATOL ORAL SUSPENSION Felbamate Auto-PA FELBATOL ORAL TABLET Felbamate Auto-PA

*Gaba Modulators*** tiagabine hcl oral tablet Gabitril vigabatrin oral packet Sabril PA

31

Formulary Drug Name Reference Restrictions vigabatrin oral tablet Sabril PA GABITRIL ORAL TABLET TiaGABine HCl Auto-PA SABRIL ORAL PACKET Vigabatrin Auto-PA VIGADRONE ORAL PACKET Vigabatrin

*Hydantoins*** phenytoin oral suspension Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended oral capsule Dilantin DILANTIN CAPSULE 100 MG ORAL Phenytoin Sodium Extended Auto-PA DILANTIN CAPSULE 30 MG ORAL DILANTIN ORAL SUSPENSION Phenytoin Auto-PA PEGANONE ORAL TABLET Auto-PA PHENYTEK ORAL CAPSULE Phenytoin Sodium Extended Auto-PA PHENYTOIN INFATABS ORAL TABLET CHEWABLE Phenytoin

*Succinimides*** ethosuximide oral capsule Zarontin ethosuximide oral solution Zarontin CELONTIN ORAL CAPSULE Auto-PA ZARONTIN ORAL CAPSULE Ethosuximide Auto-PA ZARONTIN ORAL SOLUTION Ethosuximide Auto-PA

*Valproic Acid*** divalproex sodium er tablet extended release 24 hour 250 mg oral Depakote ER

divalproex sodium er tablet extended release 24 hour 500 mg oral Depakote ER

divalproex sodium er tablet extended release 24 hour 500 mg oral Depakote ER PA

divalproex sodium oral capsule delayed release sprinkle Depakote Sprinkles

divalproex sodium oral tablet delayed release Depakote valproic acid oral capsule Depakene valproic acid oral solution DEPAKENE ORAL CAPSULE Valproic Acid Auto-PA DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR Divalproex Sodium ER Auto-PA

DEPAKOTE ORAL TABLET DELAYED RELEASE Divalproex Sodium Auto-PA

32

Formulary Drug Name Reference Restrictions DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

Divalproex Sodium Auto-PA

*ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet AL (Min 6 Years) mirtazapine oral tablet dispersible Remeron SolTab AL (Min 6 Years)

*Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour Wellbutrin SR QLL (2 EA per 1 day); AL (Min

6 Years) bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral Wellbutrin XL QLL (1 EA per 1 day); AL (Min

6 Years) bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral Wellbutrin XL QLL (1 EA per 1 day); AL (Min

6 Years) bupropion hcl er (xl) tablet extended release 24 hour 450 mg oral Forfivo XL AL (Min 18 Years)

bupropion hcl oral tablet AL (Min 6 Years)

*Modified Cyclics*** trazodone hcl oral tablet AL (Min 6 Years)

TRINTELLIX ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

VIIBRYD ORAL TABLET AL (Min 18 Years)

*Selective Serotonin Reuptake Inhibitors (Ssris)***

citalopram hydrobromide oral solution QLL (30 ML per 1 day); AL (Min 6 Years and Max 11 Years)

citalopram hydrobromide tablet 10 mg oral CeleXA QLL (1 EA per 1 day); AL (Min 6 Years)

citalopram hydrobromide tablet 20 mg oral CeleXA QLL (1.5 EA per 1 day); AL (Min 6 Years)

citalopram hydrobromide tablet 40 mg oral CeleXA QLL (1 EA per 1 day); AL (Min 6 Years)

escitalopram oxalate oral tablet Lexapro QLL (1 EA per 1 day); AL (Min 6 Years)

fluoxetine hcl oral capsule PROzac AL (Min 6 Years)

fluoxetine hcl oral solution AL (Min 6 Years and Max 11 Years)

fluvoxamine maleate oral tablet AL (Min 6 Years)

33


paroxetine hcl oral tablet Paxil QLL (2 EA per 1 day); AL (Min 6 Years)

sertraline hcl oral concentrate QLL (10 ML per 1 day); AL (Min 6 Years and Max 11 Years)

sertraline hcl oral tablet Zoloft AL (Min 6 Years)

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour Pristiq QLL (1 EA per 1 day); AL (Min

18 Years) duloxetine hcl oral capsule delayed release particles Cymbalta QLL (2 EA per 1 day); AL (Min

6 Years) venlafaxine hcl er oral capsule extended release 24 hour Effexor XR QLL (1 EA per 1 day); AL (Min

6 Years) venlafaxine hcl oral tablet AL (Min 6 Years)

*Tricyclic Agents*** amitriptyline hcl oral tablet AL (Min 12 Years) amoxapine oral tablet AL (Min 16 Years) clomipramine hcl oral capsule Anafranil Auto-PA; AL (Min 6 Years) desipramine hcl oral tablet AL (Min 13 Years) doxepin hcl oral capsule AL (Min 12 Years) doxepin hcl oral concentrate AL (Min 12 Years) imipramine hcl oral tablet Tofranil AL (Min 6 Years) nortriptyline hcl oral capsule Pamelor AL (Min 13 Years) nortriptyline hcl oral solution AL (Min 13 Years)

*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose miglitol oral tablet Glyset

*Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR

*Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hour Fortamet Maintenance drugs with max

100 day supply metformin hcl er oral tablet extended release 24 hour 500 mg Glucophage XR QLL (5 EA per 1 day)

34


metformin hcl er oral tablet extended release 24 hour 750 mg Glucophage XR

Maintenance drug with max 100 day supply; QLL (3.5 EA per 1 day)

metformin hcl er tablet extended release 24 hour 500 mg oral Glucophage XR

Maintenance drug with max 100 day supply; QLL (5 EA per 1 day)

metformin hcl er tablet extended release 24 hour 500 mg oral Glucophage XR QLL (5 EA per 1 day)

metformin hcl er tablet extended release 24 hour 750 mg oral Glucophage XR

Maintenance drug with max 100 day supply; QLL (3.5 EA per 1 day)

metformin hcl tablet 1000 mg oral Glucophage QLL (2.5 EA per 1 day)

metformin hcl tablet 1000 mg oral Glucophage Maintenance drug with max 100 day supply; QLL (2.5 EA per 1 day)

metformin hcl tablet 500 mg oral Glucophage Maintenance drug with max 100 day supply

metformin hcl tablet 500 mg oral Glucophage Maintenance drug with max 100 day supply; QLL (5 EA per 1 day)

metformin hcl tablet 500 mg oral Glucophage Maintenance drug with max 100 days supply; QLL (5 EA per 1 day)

metformin hcl tablet 850 mg oral Glucophage Maintenance drug with max 100 day supply

metformin hcl tablet 850 mg oral Glucophage Maintenance drug with max 100 day supply; QLL (3 EA per 1 day)

metformin hcl tablet 850 mg oral Glucophage Maintenance drug with max 100 days supply; QLL (3 EA per 1 day)

*Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

alogliptin benzoate oral tablet Nesina QLL (1 EA per 1 day); AL (Min 18 Years)

JANUVIA ORAL TABLET QLL (1 EA per 1 day); AL (Min 18 Years)

35


ONGLYZA ORAL TABLET QLL (1 EA per 1 day); AL (Min 18 Years)

TRADJENTA ORAL TABLET QLL (1 EA per 1 day); AL (Min 18 Years)

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***

alogliptin-metformin hcl oral tablet Kazano QLL (60 EA per 30 days); AL (Min 18 Years)

JANUMET ORAL TABLET QLL (2 EA per 1 day); AL (Min 18 Years)

JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG ORAL






JENTADUETO ORAL TABLET QLL (2 EA per 1 day); AL (Min 18 Years)

KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG ORAL

AL (Min 18 Years)

KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL

AL (Min 18 Years)

KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 5-500 MG ORAL

AL (Min 18 Years)

*Dpp-4 Inhibitor-Thiazolidinedione Combinations***

alogliptin-pioglitazone oral tablet Oseni QLL (30 EA per 30 days); AL (Min 18 Years)

*Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

Insulin Lispro QLL (2 BOXES per 30 days); AL (Max 18 Years)

ADMELOG SUBCUTANEOUS SOLUTION Insulin Lispro QLL (70 ML per 30 days)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

ST; QLL (2 BOXES per 30 days)

36

Formulary Drug Name Reference Restrictions HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION ST; QLL (70 ML per 30 days)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR


HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION ST; QLL (70 ML per 30 days)

HUMALOG SUBCUTANEOUS SOLUTION Insulin Lispro ST; QLL (70 ML per 30 days)

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE


HUMULIN 70/30 SUBCUTANEOUS SUSPENSION OTC; QLL (70 ML per 30 days)

HUMULIN N SUBCUTANEOUS SUSPENSION OTC; QLL (70 ML per 30 days)

HUMULIN R INJECTION SOLUTION OTC; QLL (70 ML per 30 days) LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS


LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

QLL (2 BOXES per 30 days)

LANTUS SOLUTION 100 UNIT/ML SUBCUTANEOUS QLL (70 ML per 30 days)

LANTUS SOLUTION 100 UNIT/ML SUBCUTANEOUS ST; QLL (70 ML per 30 days)

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR

QLL (2 BOXES per 30 days)

LEVEMIR SUBCUTANEOUS SOLUTION QLL (70 ML per 30 days) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION OTC; QLL (70 ML per 30 days)

NOVOLIN N SUBCUTANEOUS SUSPENSION OTC; QLL (70 ML per 30 days)

NOVOLIN R INJECTION SOLUTION OTC; QLL (70 ML per 30 days) NOVOLIN R RELION INJECTION SOLUTION OTC; QLL (70 ML per 30 days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR


NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION ST; QLL (70 ML per 30 days)

37

Formulary Drug Name Reference Restrictions NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE


NOVOLOG SUBCUTANEOUS SOLUTION ST; QLL (70 ML per 30 days)

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN-INJECTOR BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR

ST; QLL (0.05 ML per 1 day)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR

ST; QLL (0.11 ML per 1 day)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR

ST; QLL (0.6 ML per 1 day); AL (Min 18 Years)

*Meglitinide Analogues*** nateglinide oral tablet Starlix repaglinide oral tablet Prandin

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET INVOKANA ORAL TABLET JARDIANCE ORAL TABLET STEGLATRO ORAL TABLET ST; QLL (1 EA per 1 day)

*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet glyburide-metformin oral tablet

*Sulfonylureas*** glimepiride tablet 1 mg oral Amaryl QLL (2 EA per 1 day)

glimepiride tablet 2 mg oral Amaryl Maintenance drug with max 100 days supply; QLL (2 EA per 1 day)

glimepiride tablet 2 mg oral Amaryl QLL (2 EA per 1 day)

38


glimepiride tablet 4 mg oral Amaryl Maintenance drugs with max 100 day supply; QLL (2 EA per 1 day)

glimepiride tablet 4 mg oral Amaryl QLL (2 EA per 1 day) glipizide er tablet extended release 24 hour 10 mg oral Glucotrol XL Maintenance drugs with max

100 day supply glipizide er tablet extended release 24 hour 10 mg oral Glucotrol XL Maintenance drug with max 100

day supply glipizide er tablet extended release 24 hour 10 mg oral Glucotrol XL Maintenance drug with max 100

days supply glipizide er tablet extended release 24 hour 2.5 mg oral Glucotrol XL Maintenance drugs with max

100 day supply glipizide er tablet extended release 24 hour 2.5 mg oral Glucotrol XL Maintenance drug with max 100

day supply glipizide er tablet extended release 24 hour 2.5 mg oral Glucotrol XL Maintenance drug with max 100

days supply glipizide er tablet extended release 24 hour 5 mg oral Glucotrol XL Maintenance drugs with max

100 day supply glipizide er tablet extended release 24 hour 5 mg oral Glucotrol XL Maintenance drug with max 100

day supply glipizide er tablet extended release 24 hour 5 mg oral Glucotrol XL Maintenance drug with max 100

days supply glipizide tablet 10 mg oral Glucotrol

glipizide tablet 5 mg oral Glucotrol Maintenance drug with max 100 days supply

glipizide xl oral tablet extended release 24 hour Glucotrol XL

glyburide micronized oral tablet Glynase

glyburide tablet 1.25 mg oral Maintenance drug with max 100 days supply

glyburide tablet 1.25 mg oral

glyburide tablet 2.5 mg oral Maintenance drug with max 100 days supply

glyburide tablet 2.5 mg oral

glyburide tablet 5 mg oral Maintenance drug with max 100 days supply

glyburide tablet 5 mg oral tolbutamide oral tablet

*Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet Actoplus Met

39

Formulary Drug Name Reference Restrictions *Thiazolidinediones*** pioglitazone hcl oral tablet Actos

*ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule Imodium A-D

*ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** acetylcysteine solution 200 mg/ml intravenous Acetadote acetylcysteine solution 200 mg/ml intravenous Acetadote QLL (1 ML per 365 days) deferoxamine mesylate solution reconstituted 2 gm injection deferoxamine mesylate solution reconstituted 2 gm injection QLL (1 EA per 365 days)

deferoxamine mesylate solution reconstituted 500 mg injection Desferal

deferoxamine mesylate solution reconstituted 500 mg injection Desferal QLL (1 EA per 365 days)

*ANTIDOTES* *Antidotes*** acetylcysteine solution 200 mg/ml intravenous Acetadote acetylcysteine solution 200 mg/ml intravenous Acetadote QLL (1 ML per 365 days) deferoxamine mesylate injection solution reconstituted Desferal

*Opioid Antagonists*** naloxone hcl injection solution naloxone hcl injection solution cartridge naloxone hcl injection solution prefilled syringe naltrexone hcl oral tablet QLL (1 EA per 365 days) NARCAN NASAL LIQUID QLL (2 EA per 365 days)

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl intravenous solution granisetron hcl oral tablet QLL (8 EA per 28 days) ondansetron hcl injection solution QLL (32 ML per 28 days) ondansetron hcl oral solution QLL (600 ML per 28 days) 40

Formulary Drug Name Reference Restrictions ondansetron hcl oral tablet Zofran QLL (2 EA per 1 day) ondansetron oral tablet dispersible QLL (2 EA per 1 day)

*Antiemetic Combinations*** doxylamine-pyridoxine oral tablet delayed release Diclegis

*Antiemetics - Anticholinergic*** meclizine hcl oral tablet TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR Scopolamine

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant capsule 125 mg oral Emend QLL (2 EA per 28 days) aprepitant capsule 40 mg oral Emend QLL (4 EA per 28 days) aprepitant capsule 80 & 125 mg oral Emend Tri-Pack QLL (6 EA per 28 days) aprepitant capsule 80 mg oral Emend QLL (4 EA per 28 days)

*ANTIFUNGALS* *Antifungal - Glucan Synthesis Inhibitors (Echinocandins)*** ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED

*Antifungals*** amphotericin b intravenous solution reconstituted griseofulvin microsize oral suspension griseofulvin microsize oral tablet ST griseofulvin ultramicrosize oral tablet ST nystatin oral tablet terbinafine hcl tablet 250 mg oral LamISIL terbinafine hcl tablet 250 mg oral LamISIL QLL (84 EA per 365 days) ABELCET INTRAVENOUS SUSPENSION

*Triazoles*** fluconazole in sodium chloride intravenous solution fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan

41

Formulary Drug Name Reference Restrictions *ANTIHEMOPHILIC PRODUCTS -MONOCLONAL ANTIBODIES*** *Antihemophilic Products -Monoclonal Antibodies*** HEMLIBRA SUBCUTANEOUS SOLUTION

*ANTIHISTAMINES* *Antihistamines - Ethanolamines*** carbinoxamine maleate oral solution carbinoxamine maleate oral tablet clemastine fumarate oral tablet diphenhydramine hcl injection solution diphenhydramine hcl oral elixir

*Antihistamines - Non-Sedating*** all day allergy childrens oral solution KLS Aller-Tec Childrens OTC; AL (Max 11 Years) all day allergy oral tablet KLS Aller-Tec OTC allergy oral tablet Claritin OTC; QLL (1 EA per 1 day) allergy relief childrens oral solution KLS Aller-Tec Childrens OTC allergy relief oral capsule Wal-Zyr OTC allergy relief oral tablet dispersible Alavert OTC allergy relief tablet 10 mg oral Claritin OTC allergy relief tablet 10 mg oral Claritin OTC; QLL (1 EA per 1 day) allergy relief/indoor/outdoor oral tablet KLS Aller-Tec OTC cetirizine hcl allergy child oral solution KLS Aller-Tec Childrens AL (Max 11 Years) cetirizine hcl childrens alrgy oral solution KLS Aller-Tec Childrens OTC; AL (Max 11 Years) cetirizine hcl childrens oral tablet chewable Wal-Zyr Childrens OTC cetirizine hcl hives relief oral solution KLS Aller-Tec Childrens OTC; AL (Max 11 Years) cetirizine hcl oral solution KLS Aller-Tec Childrens AL (Max 11 Years) cetirizine hcl oral tablet KLS Aller-Tec OTC cetirizine hcl oral tablet chewable Wal-Zyr Childrens OTC childrens loratadine oral solution Claritin OTC; AL (Max 11 Years) childrens loratadine oral syrup Claritin OTC; AL (Max 11 Years) eq allergy relief oral tablet Claritin OTC; QLL (1 EA per 1 day) gnp all day allergy childrens oral solution KLS Aller-Tec Childrens OTC gnp all day allergy oral tablet KLS Aller-Tec OTC gnp allergy relief oral tablet dispersible Alavert OTC gnp loratadine childrens oral solution Claritin OTC; AL (Max 11 Years) gnp loratadine oral syrup Claritin OTC; AL (Max 11 Years)

42

Formulary Drug Name Reference Restrictions gnp loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day) goodsense all day allergy oral solution KLS Aller-Tec Childrens OTC goodsense all day allergy oral tablet KLS Aller-Tec OTC hm all day allergy childrens oral solution KLS Aller-Tec Childrens OTC hm all day allergy oral tablet KLS Aller-Tec OTC hm cetirizine hcl childrens oral solution KLS Aller-Tec Childrens OTC hm loratadine childrens oral syrup Claritin OTC; AL (Max 11 Years) hm loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day) levocetirizine dihydrochloride oral tablet Xyzal Allergy 24HR loratadine childrens oral syrup Claritin OTC; AL (Max 11 Years) loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day) qc all day allergy oral tablet KLS Aller-Tec OTC qc childrens allergy oral solution KLS Aller-Tec Childrens OTC qc loratadine allergy relief oral tablet Claritin OTC; QLL (1 EA per 1 day) sm all day allergy childrens oral solution KLS Aller-Tec Childrens OTC sm all day allergy oral tablet KLS Aller-Tec OTC sm allergy childrens oral syrup Claritin OTC; AL (Max 11 Years) sm childrens loratadine oral syrup Claritin OTC; AL (Max 11 Years) sm loratadine oral syrup Claritin OTC; AL (Max 11 Years) sm loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day)

*Antihistamines - Phenothiazines*** promethazine hcl injection solution Phenergan promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Phenadoz PROMETHEGAN RECTAL SUPPOSITORY Promethazine HCl

*Antihistamines - Piperidines*** cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet

*ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite cholestyramine light oral powder Prevalite cholestyramine oral packet Questran cholestyramine oral powder Questran colestipol hcl oral tablet Colestid

43

Formulary Drug Name Reference Restrictions *Fibric Acid Derivatives*** fenofibrate oral tablet Tricor gemfibrozil oral tablet Lopid

*Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet Lipitor QLL (1 EA per 1 day) lovastatin oral tablet pravastatin sodium oral tablet rosuvastatin calcium oral tablet Crestor simvastatin oral tablet Zocor EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE AL (Min 18 Years)

*Intestinal Cholesterol Absorption Inhibitors***

ezetimibe oral tablet Zetia QLL (1 EA per 1 day); AL (Min 10 Years)

*Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release Niaspan

*ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule

*Ace Inhibitors & Thiazide/Thiazide-Like***

benazepril-hydrochlorothiazide oral tablet Lotensin HCT Maintenance drugs with max 100 day supply

enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet lisinopril-hydrochlorothiazide tablet 10-12.5 mg oral Zestoretic Maintenance drug with max 100

days supply lisinopril-hydrochlorothiazide tablet 10-12.5 mg oral Zestoretic Maintenance drug with max 100

day supply lisinopril-hydrochlorothiazide tablet 20-12.5 mg oral Zestoretic Maintenance drug with max 100

day supply lisinopril-hydrochlorothiazide tablet 20-12.5 mg oral Zestoretic Maintenance drug with max 100

days supply lisinopril-hydrochlorothiazide tablet 20-25 mg oral Zestoretic Maintenance drug with max 100

days supply lisinopril-hydrochlorothiazide tablet 20-25 mg oral Zestoretic Maintenance drug with max 100

day supply

44

Formulary Drug Name Reference Restrictions quinapril-hydrochlorothiazide oral tablet Accuretic

*Ace Inhibitors*** benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet Vasotec fosinopril sodium oral tablet

lisinopril tablet 10 mg oral Prinivil Maintenance drug with max 100 day supply

lisinopril tablet 10 mg oral Prinivil Maintenance drugs with max 100 day supply

lisinopril tablet 2.5 mg oral Zestril Maintenance drug with max 100 days supply

lisinopril tablet 2.5 mg oral Zestril Maintenance drugs with max 100 days supply

lisinopril tablet 20 mg oral Prinivil

lisinopril tablet 30 mg oral Zestril Maintenance drug with max 100 days supply

lisinopril tablet 40 mg oral Zestril Maintenance drug with max 100 days supply

lisinopril tablet 5 mg oral Prinivil quinapril hcl oral tablet Accupril ramipril oral capsule Altace

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet Exforge amlodipine-olmesartan oral tablet Azor

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet Hyzaar olmesartan medoxomil-hctz oral tablet Benicar HCT telmisartan-hctz oral tablet Micardis HCT valsartan-hydrochlorothiazide oral tablet Diovan HCT

*Angiotensin Ii Receptor Antagonists*** irbesartan oral tablet Avapro losartan potassium oral tablet Cozaar olmesartan medoxomil oral tablet Benicar telmisartan oral tablet Micardis

45

Formulary Drug Name Reference Restrictions *Antiadrenergics - Centrally Acting***

clonidine hcl oral tablet Catapres Maintenance drug with max 100 days supply

clonidine transdermal patch weekly Catapres-TTS-1 QLL (8 EA per 30 days) guanfacine hcl tablet 1 mg oral

guanfacine hcl tablet 2 mg oral Maintenance drug with max 100 day supply

methyldopa oral tablet

*Antiadrenergics - Peripherally Acting***

doxazosin mesylate tablet 1 mg oral Cardura Maintenance drug with max 100 day supply

doxazosin mesylate tablet 1 mg oral Cardura Maintenance drug with max 100 days supply







prazosin hcl oral capsule Minipress Maintenance drug with max 100 days supply

terazosin hcl oral capsule

*Beta Blocker & Diuretic Combinations***

atenolol-chlorthalidone tablet 100-25 mg oral Tenoretic 100 Maintenance drugs with max 100 day supply

atenolol-chlorthalidone tablet 100-25 mg oral Tenoretic 100 Maintenance drug with max 100 days supply

atenolol-chlorthalidone tablet 50-25 mg oral Tenoretic 50 Maintenance drugs with max 100 day supply

atenolol-chlorthalidone tablet 50-25 mg oral Tenoretic 50 Maintenance drug with max 100 days supply

bisoprolol-hydrochlorothiazide oral tablet Ziac

46

Formulary Drug Name Reference Restrictions *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra

*Vasodilators*** hydralazine hcl tablet 10 mg oral

hydralazine hcl tablet 10 mg oral Maintenance drug with max 100 days supply

hydralazine hcl tablet 100 mg oral hydralazine hcl tablet 25 mg oral


hydralazine hcl tablet 50 mg oral


minoxidil oral tablet

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** metronidazole in nacl intravenous solution metronidazole intravenous solution metronidazole oral tablet Flagyl tinidazole oral tablet trimethoprim oral tablet vancomycin hcl intravenous solution reconstituted NEBUPENT INHALATION SOLUTION RECONSTITUTED

*Anti-Infective Misc. -Combinations*** sulfamethoxazole-trimethoprim oral suspension Sulfatrim Pediatric

sulfamethoxazole-trimethoprim oral tablet Bactrim

*Antiprotozoal Agents*** atovaquone oral suspension Mepron

*Carbapenem Combinations*** imipenem-cilastatin solution reconstituted 250 mg intravenous QLL (480 EA per 30 days)

imipenem-cilastatin solution reconstituted 500 mg intravenous Primaxin IV QLL (240 EA per 30 days)

47

Formulary Drug Name Reference Restrictions *Carbapenems*** meropenem intravenous solution reconstituted Merrem meropenem-sodium chloride intravenous solution reconstituted

*Leprostatics*** dapsone oral tablet

*Lincosamides*** clindamycin hcl oral capsule Cleocin AL (Min 11 Years) clindamycin palmitate hcl oral solution reconstituted Cleocin AL (Min 12 Years)

clindamycin phosphate injection solution Cleocin Phosphate clindamycin phosphate intravenous solution Cleocin Phosphate lincomycin hcl injection solution Lincocin

*Oxazolidinones*** linezolid oral tablet Zyvox

*Polymyxins*** colistimethate sodium (cba) injection solution reconstituted Coly-Mycin M

polymyxin b sulfate injection solution reconstituted

*ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet hydroxychloroquine sulfate oral tablet Plaquenil mefloquine hcl oral tablet primaquine phosphate oral tablet

*ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** guanidine hcl oral tablet pyridostigmine bromide er oral tablet extended release Mestinon

pyridostigmine bromide oral solution Mestinon pyridostigmine bromide oral syrup Mestinon pyridostigmine bromide oral tablet MESTINON ORAL SYRUP Pyridostigmine Bromide

*Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet

48

Formulary Drug Name Reference Restrictions pyridostigmine bromide er oral tablet extended release Mestinon


*ANTIMYASTHENIC/CHOLINER GIC AGENTS* guanidine hcl oral tablet pyridostigmine bromide er oral tablet extended release Mestinon


*ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin intravenous solution reconstituted Rifadin rifampin oral capsule Rifadin

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** carboplatin intravenous solution cisplatin intravenous solution cisplatin intravenous solution reconstituted oxaliplatin intravenous solution oxaliplatin intravenous solution reconstituted thiotepa injection solution reconstituted Tepadina BUSULFEX INTRAVENOUS SOLUTION Busulfan MYLERAN ORAL TABLET QLL (6 EA per 1 day) TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

49

Formulary Drug Name Reference Restrictions *Androgen Biosynthesis Inhibitors*** abiraterone acetate oral tablet Zytiga ZYTIGA ORAL TABLET AL (Min 18 Years)

*Antiandrogens***

bicalutamide tablet 50 mg oral Casodex QLL (1 EA per 1 day); AL (Min 18 Years)

bicalutamide tablet 50 mg oral Casodex AL (Min 18 Years)

flutamide oral capsule QLL (6 EA per 1 day); AL (Min 18 Years)

nilutamide oral tablet Nilandron QLL (30 EA per 30 days); AL (Min 18 Years)

XTANDI ORAL CAPSULE AL (Min 18 Years)

*Antiestrogens***

tamoxifen citrate tablet 10 mg oral QLL (3 EA per 1 day); AL (Min 18 Years)

tamoxifen citrate tablet 20 mg oral QLL (2 EA per 1 day); AL (Min 18 Years)

toremifene citrate oral tablet Fareston SOLTAMOX ORAL SOLUTION AL (Min 18 Years)

*Antimetabolites*** azacitidine injection suspension reconstituted Vidaza

capecitabine oral tablet Xeloda QLL (4 EA per 1 day); AL (Min 18 Years)

cladribine intravenous solution cytarabine (pf) injection solution cytarabine injection solution decitabine intravenous solution reconstituted Dacogen floxuridine injection solution reconstituted fludarabine phosphate intravenous solution fludarabine phosphate intravenous solution reconstituted fluorouracil intravenous solution Adrucil gemcitabine hcl intravenous solution gemcitabine hcl intravenous solution reconstituted mercaptopurine oral tablet QLL (3 EA per 1 day) methotrexate oral tablet QLL (10 EA per 1 day) methotrexate sodium (pf) injection solution methotrexate sodium injection solution

50

Formulary Drug Name Reference Restrictions methotrexate sodium injection solution reconstituted methotrexate sodium oral tablet QLL (10 EA per 1 day) ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED

*Antineoplastic -Immunomodulators***

POMALYST ORAL CAPSULE QLL (21 EA per 28 days); AL (Min 18 Years)

*Antineoplastic - Monoclonal Antibodies*** ARZERRA INTRAVENOUS CONCENTRATE CAMPATH INTRAVENOUS SOLUTION RITUXAN INTRAVENOUS SOLUTION

*Antineoplastic - Mtor Kinase Inhibitors*** temsirolimus intravenous solution Torisel

*Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET AL (Min 18 Years) SUTENT ORAL CAPSULE AL (Min 18 Years)

*Antineoplastic - Proteasome Inhibitors*** VELCADE INJECTION SOLUTION RECONSTITUTED

*Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet Gleevec

CAPRELSA TABLET 100 MG ORAL QLL (2 EA per 30 days); AL (Min 18 Years)

CAPRELSA TABLET 300 MG ORAL QLL (1 EA per 30 days); AL (Min 18 Years)

IRESSA ORAL TABLET QLL (2 EA per 1 day); AL (Min 18 Years)

VOTRIENT ORAL TABLET AL (Min 18 Years)

*Antineoplastic Antibiotics*** bleomycin sulfate injection solution reconstituted daunorubicin hcl intravenous solution

51

Formulary Drug Name Reference Restrictions doxorubicin hcl intravenous solution Adriamycin doxorubicin hcl liposomal intravenous injectable Doxil

epirubicin hcl intravenous solution Ellence idarubicin hcl intravenous solution Idamycin PFS mitomycin intravenous solution reconstituted Mutamycin mitoxantrone hcl intravenous concentrate AL (Min 18 Years) valrubicin intravesical solution Valstar MUTAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED MitoMYcin

VALSTAR INTRAVESICAL SOLUTION Valrubicin

*Antineoplastic Enzymes*** ONCASPAR INJECTION SOLUTION

*Antineoplastics - Interleukins*** PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED PA

*Antineoplastics Misc.*** dacarbazine intravenous solution reconstituted hydroxyurea oral capsule Hydrea ACTIMMUNE SUBCUTANEOUS SOLUTION QLL (6 ML per 28 days)

INTRON A INJECTION SOLUTION INTRON A INJECTION SOLUTION RECONSTITUTED MATULANE ORAL CAPSULE QLL (56 EA per 30 days)

*Aromatase Inhibitors***

anastrozole oral tablet Arimidex QLL (1 EA per 1 day); AL (Min 18 Years)

exemestane oral tablet Aromasin QLL (1 EA per 1 day); AL (Min 18 Years)

letrozole oral tablet Femara QLL (1 EA per 1 day); AL (Min 18 Years)

*Cardiac Protective Agents*** dexrazoxane hcl intravenous solution reconstituted Zinecard

*Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution

52

Formulary Drug Name Reference Restrictions leucovorin calcium injection solution reconstituted leucovorin calcium oral tablet

*Imidazotetrazines*** temozolomide oral capsule Temodar QLL (2 EA per 1 day) TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED

*Lhrh Analogs*** leuprolide acetate injection kit Auto-PA ELIGARD SUBCUTANEOUS KIT PA; AL (Min 18 Years) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT

Auto-PA; QLL (1 KIT per 28 days); AL (Min 18 Years)

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT


LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT


LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG

PA; QLL (1 KIT per 175 days); AL (Min 18 Years)

LUPRON DEPOT (6-MONTH) KIT 45 MG INTRAMUSCULAR


ZOLADEX SUBCUTANEOUS IMPLANT Auto-PA; AL (Min 18 Years)

*Mitotic Inhibitors*** docetaxel intravenous concentrate AL (Min 18 Years) docetaxel solution 160 mg/16ml intravenous docetaxel solution 160 mg/16ml intravenous AL (Min 18 Years) docetaxel solution 20 mg/2ml intravenous AL (Min 18 Years) docetaxel solution 80 mg/8ml intravenous AL (Min 18 Years) etoposide intravenous solution Toposar paclitaxel intravenous concentrate QLL (1 FILL per 7 days) vinblastine sulfate intravenous solution vincristine sulfate intravenous solution vinorelbine tartrate intravenous solution Navelbine HALAVEN INTRAVENOUS SOLUTION

*Nitrogen Mustards*** cyclophosphamide injection solution reconstituted cyclophosphamide oral capsule ifosfamide intravenous solution ifosfamide intravenous solution reconstituted Ifex

53

Formulary Drug Name Reference Restrictions melphalan hcl intravenous solution reconstituted Alkeran

melphalan oral tablet Alkeran ALKERAN ORAL TABLET Melphalan AL (Min 18 Years) LEUKERAN ORAL TABLET

*Nitrosoureas*** carmustine intravenous solution reconstituted BiCNU

*Progestins-Antineoplastic*** megestrol acetate oral suspension megestrol acetate oral tablet

*Retinoids*** tretinoin oral capsule AL (Min 1 Years)

*Topoisomerase I Inhibitors*** irinotecan hcl intravenous solution Camptosar topotecan hcl intravenous solution topotecan hcl intravenous solution reconstituted Hycamtin

*Urinary Tract Protective Agents*** mesna intravenous solution Mesnex

*ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics***

benztropine mesylate tablet 0.5 mg oral Maintenance drug with max 100 day supply; AL (Min 3 Years)

benztropine mesylate tablet 0.5 mg oral AL (Min 3 Years)

benztropine mesylate tablet 1 mg oral Maintenance drug with max 100 day supply; AL (Min 3 Years)

benztropine mesylate tablet 2 mg oral Maintenance drug with max 100 day supply; AL (Min 3 Years)

benztropine mesylate tablet 2 mg oral AL (Min 3 Years) trihexyphenidyl hcl oral solution AL (Min 18 Years)

trihexyphenidyl hcl tablet 2 mg oral Maintenance drug with max 100 day supply; AL (Min 18 Years)

trihexyphenidyl hcl tablet 2 mg oral Maintenance drug with max 100 days supply; AL (Min 18 Years)

trihexyphenidyl hcl tablet 5 mg oral Maintenance drug with max 100 days supply; AL (Min 18 Years)

trihexyphenidyl hcl tablet 5 mg oral Maintenance drug with max 100 day supply; AL (Min 18 Years)

54

Formulary Drug Name Reference Restrictions *Antiparkinson Dopaminergics*** amantadine hcl capsule 100 mg oral amantadine hcl capsule 100 mg oral AL (Min 1 Years) amantadine hcl oral syrup AL (Min 1 Years) amantadine hcl oral tablet AL (Min 1 Years) GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR AL (Min 18 Years)

*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule AL (Min 18 Years) selegiline hcl oral tablet AL (Min 18 Years)

*Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release Sinemet CR Maintenance drug with max 100

days supply; AL (Min 18 Years)

carbidopa-levodopa oral tablet Sinemet Maintenance drug with max 100 days supply; AL (Min 18 Years)

carbidopa-levodopa oral tablet dispersible Maintenance drug with max 100 days supply; AL (Min 18 Years)

carbidopa-levodopa-entacapone oral tablet Stalevo 50 Maintenance drug with max 100 days supply; AL (Min 18 Years)

*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet Mirapex AL (Min 18 Years) ropinirole hcl oral tablet AL (Min 18 Years)

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release AL (Min 6 Years)

lithium carbonate oral capsule AL (Min 6 Years) lithium carbonate oral tablet AL (Min 6 Years)

lithium oral solution AL (Min 6 Years and Max 11 Years)

*Antipsychotics - Misc.***

ziprasidone hcl capsule 20 mg oral Geodon

QL: age 6-17: maximum 4 capsules/day, age =/;18: maximum 2 capsules/day; AL (Min 6 Years)

55



QL: age 6-17: maximum 4 capsules/day, age =/>18: maximum 2 capsules/day; AL (Min 6 Years)


QL: age 6-11: maximum 80mg/day, age 12-17: maximum 160mg/day, age =/>18: maximum 2 capsules/day; AL (Min 6 Years)





EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR Auto-PA; AL (Min 6 Years)

LATUDA TABLET 120 MG ORAL

ST; QL: age 6-17: maximum0.67 tablets/day, age =/>18: maximum 1 tablets/day; AL (Min 10 Years)


ST; QL: age 6-17: maximum 1 tablets/day, age =/>18: maximum 1 tablets/day; AL (Min 10 Years)







*Benzisoxazoles***

risperidone oral solution RisperDAL

QL: age 6-11: maximum 4ml/day, age 12-17: maximum 6ml/day, age =/>18: maximum 16ml/day; AL (Min 6 Years)

56


risperidone tablet 0.25 mg oral RisperDAL

QL: age 6-17: maximum 8 tablets/day, age =/;18: maximum 2 tablets/day; AL (Min 6 Years)

risperidone tablet 0.5 mg oral RisperDAL


risperidone tablet 1 mg oral RisperDAL

QL: age 6-11: maximum 4 tablet/day, age 12-17: maximum 6 tablets/day, age =/>18: maximum 2 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 2 tablet/day, age 12-17: maximum 3 tablets/day, age =/>18: maximum 2 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 1.33 tablet/day, age 12-17: maximum 2 tablets/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 1 tablet/day, age 12-17: maximum 1.5 tablets/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)

risperidone tablet dispersible 0.25 mg oral


risperidone tablet dispersible 0.5 mg oral


risperidone tablet dispersible 1 mg oral

QL: age 6-11: maximum 4 tablet/day, age 12-17: maximum 6 tablets/day, age =/;18: maximum 2 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 2 tablet/day, age 12-17: maximum 3 tablets/day, age =/;18: maximum 2 tablets/day; AL (Min 6 Years)

57



QL: age 6-11: maximum 1.33 tablet/day, age 12-17: maximum 2 tablets/day, age =/;18: maximum 4 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 1.33 tablet/day, age 12-17: maximum 2 tablets/day, age =/;18: maximum 4 tablets/day; AL (Min 6 Years)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

Auto-PA; QLL (1 SYRINGE per 28 days); AL (Min 18 Years)

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE


PERSERIS SUBCUTANEOUS PREFILLED SYRINGE AL (Min 18 Years)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED

Auto-PA; QLL (2 BOXES per 28 days); AL (Min 18 Years)

*Butyrophenones*** haloperidol decanoate solution 100 mg/ml intramuscular Haldol Decanoate AL (Min 18 Years)

haloperidol decanoate solution 100 mg/ml intramuscular Haldol Decanoate QL: age =/;18: maximum

4.5ml/day; AL (Min 18 Years) haloperidol decanoate solution 100 mg/ml intramuscular Haldol Decanoate QL: age =/>18: maximum

4.5ml/day; AL (Min 18 Years) haloperidol decanoate solution 50 mg/ml intramuscular Haldol Decanoate AL (Min 18 Years)

haloperidol decanoate solution 50 mg/ml intramuscular Haldol Decanoate QL: age =/>18: maximum

3ml/day; AL (Min 18 Years) haloperidol lactate injection solution Haldol

haloperidol lactate oral concentrate

QL: age 6-11: maximum 5mg/day, age 12-17: maximum 10mg/day, age =/>18: maximum 50ml/day; AL (Min 6 Years)

haloperidol tablet 0.5 mg oral AL (Min 6 Years)

haloperidol tablet 0.5 mg oral

QL: age 6-11: maximum 5mg/day, age 12-17: maximum 10mg/day, age =/>18: maximum 3 tablets/day; AL (Min 6 Years)

haloperidol tablet 1 mg oral AL (Min 6 Years)

58


haloperidol tablet 1 mg oral












*Dibenzodiazepines***

clozapine tablet 100 mg oral Clozaril

QL: age 6-11: maximum 300mg/day, age 12-17: maximum 600mg/day, age =/;18: maximum 9 tablets/day; AL (Min 6 Years)



clozapine tablet 200 mg oral

PA; QL: age 6-11: maximum 300mg/day, age 12-17: maximum 600mg/day, age =/;18: maximum 4 tablets/day; AL (Min 6 Years)


PA; QL: age 6-11: maximum 300mg/day, age 12-17: maximum 600mg/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)

59





QL: age 6-17: maximum 8 tablets/day, age =/>18: maximum 2 tablets/day; AL (Min 6 Years)





clozapine tablet dispersible 100 mg oral FazaClo


clozapine tablet dispersible 12.5 mg oral FazaClo








CLOZARIL TABLET 100 MG ORAL CloZAPine


60


CLOZARIL TABLET 25 MG ORAL CloZAPine


*Dibenzothiazepines*** quetiapine fumarate er tablet extended release 24 hour 150 mg oral SEROquel XR QLL (1 EA per 1 day); AL (Min

6 Years) quetiapine fumarate er tablet extended release 24 hour 200 mg oral SEROquel XR QLL (1 EA per 1 day); AL (Min




6 Years)

quetiapine fumarate tablet 100 mg oral SEROquel

QL: age 6-11: maximum 4 tablets/day, age 12-17: maximum 5 tablets/day, age =/;18: maximum 2 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 4 tablets/day, age 12-17: maximum 5 tablets/day, age =/>18: maximum 2 tablets/day; AL (Min 6 Years)






QL: age 6-11: maximum 1.33 tablets/day, age 12-17: maximum 2.7 tablets/day, age =/>18: maximum 3 tablets/day; AL (Min 6 Years)



61




*Dibenzoxazepines***

loxapine succinate capsule 10 mg oral QLL (4 EA per 1 day); AL (Min 18 Years)




*Phenothiazines***

chlorpromazine hcl injection solution QLL (40 ML per 1 day); AL (Min 18 Years)

chlorpromazine hcl tablet 10 mg oral

chlorpromazine hcl tablet 10 mg oral QLL (4 EA per 1 day); AL (Min 18 Years)





fluphenazine decanoate injection solution AL (Min 18 Years)

fluphenazine hcl injection solution QL: age =/>18: maximum 8ml/day; AL (Min 18 Years)

fluphenazine hcl oral concentrate


fluphenazine hcl oral elixir


fluphenazine hcl tablet 1 mg oral

QL: age 6-11: maximum 5mg/day, age 12-17: maximum 10mg/day, age =/>18: maximum4 tablets/day; AL (Min 6 Years)

62



QL: age 6-11: maximum 5mg/day, age 12-17: maximum 10mg/day, age =/>18: maximum 20mg/day; AL (Min 6 Years)

fluphenazine hcl tablet 2.5 mg oral




perphenazine tablet 16 mg oral

QL: age 6-11: maximum 0.75 tablet/day, age 12-17: maximum 1.375 tablets/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)




QL: age 6-11: maximum 3 tablets/day, age 12-17: maximum 5.5 tablets/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)


QL: age 6-11: maximum 1.5 tablets/day, age 12-17: maximum 2.75 tablets/day, age =/>18: maximum 4 tablets/day; AL (Min 6 Years)

prochlorperazine maleate oral tablet

thioridazine hcl tablet 10 mg oral QL: age =/>18: maximum 4 tablets/day; AL (Min 18 Years)




trifluoperazine hcl tablet 1 mg oral AL (Min 18 Years)

trifluoperazine hcl tablet 1 mg oral QL: age =/>18: maximum 3 tablets/day; AL (Min 18 Years)

63

Formulary Drug Name Reference Restrictions trifluoperazine hcl tablet 10 mg oral AL (Min 18 Years)

trifluoperazine hcl tablet 10 mg oral QL: age =/;18: maximum 4 tablets/day; AL (Min 18 Years)





*Quinolinone Derivatives***

aripiprazole oral tablet 10 mg, 15 mg Abilify

Ages 6-11: maximum of 15mg/day, ages 12-17: maximum of 30mg/day; QLL (1 EA per 1 day); AL (Min 6 Years)

aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg Abilify QLL (1 EA per 1 day); AL (Min

6 Years) aripiprazole solution 1 mg/ml oral AL (Min 6 Years)

aripiprazole solution 1 mg/ml oral

QL for: ages 6-11: maximum of 15ml/day, ages =/>12: maximum of 30ml/day; AL (Min 6 Years)

aripiprazole tablet 10 mg oral Abilify QLL (1 EA per 1 day); AL (Min 6 Years)

aripiprazole tablet 10 mg oral Abilify


aripiprazole tablet 15 mg oral Abilify






aripiprazole tablet dispersible 10 mg oral QLL (2 EA per 1 day); AL (Min 6 Years)

64


aripiprazole tablet dispersible 10 mg oral


aripiprazole tablet dispersible 15 mg oral QLL (2 EA per 1 day); AL (Min 6 Years)

aripiprazole tablet dispersible 15 mg oral


ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER


ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR

Auto-PA; QLL (3.2 ML per 60 days); AL (Min 18 Years)

ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR






*Thienbenzodiazepines***

olanzapine tablet 10 mg oral ZyPREXA


olanzapine tablet 15 mg oral ZyPREXA QL: age =/>18: maximum 2 tablets/day; AL (Min 6 Years)

olanzapine tablet 2.5 mg oral ZyPREXA




65








olanzapine tablet dispersible 10 mg oral ZyPREXA Zydis








*Thioxanthenes***

thiothixene capsule 1 mg oral QL: age =/;18: maximum 3 capsules/day; AL (Min 18 Years)

thiothixene capsule 1 mg oral QL: age =/>18: maximum 3 capsules/day; AL (Min 18 Years)




66





*ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR*** *Antiretrovirals - Cd4-Directed Post-Attachment Inhibitor*** TROGARZO INTRAVENOUS SOLUTION PA; AL (Min 18 Years)

*ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants***

TYBOST ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

*ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet Epzicom PA; Auto-PA abacavir-lamivudine-zidovudine oral tablet Trizivir PA lamivudine-zidovudine oral tablet Combivir Auto-PA

ATRIPLA ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

BIKTARVY ORAL TABLET Auto-PA; AL (Min 18 Years) CIMDUO ORAL TABLET Auto-PA

COMPLERA ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

DELSTRIGO ORAL TABLET DESCOVY ORAL TABLET Auto-PA; QLL (1 EA per 1 day) DOVATO ORAL TABLET Auto-PA

EVOTAZ ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

GENVOYA ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

JULUCA ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

67

Formulary Drug Name Reference Restrictions KALETRA ORAL SOLUTION Lopinavir-Ritonavir Auto-PA KALETRA ORAL TABLET Auto-PA

ODEFSEY ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

PREZCOBIX ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

STRIBILD ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

SYMFI LO ORAL TABLET Auto-PA SYMFI ORAL TABLET Auto-PA SYMTUZA ORAL TABLET Auto-PA

TRIUMEQ ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years)

TRUVADA ORAL TABLET Auto-PA; QLL (1 EA per 1 day)

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL SOLUTION AL (Min 16 Years) SELZENTRY ORAL TABLET PA; AL (Min 16 Years)

*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED PA

*Antiretrovirals - Integrase Inhibitors*** ISENTRESS HD ORAL TABLET Auto-PA ISENTRESS ORAL PACKET Auto-PA ISENTRESS ORAL TABLET Auto-PA ISENTRESS ORAL TABLET CHEWABLE Auto-PA

TIVICAY ORAL TABLET Auto-PA

*Antiretrovirals - Protease Inhibitors*** ritonavir oral tablet Norvir APTIVUS ORAL CAPSULE Auto-PA APTIVUS ORAL SOLUTION Auto-PA CRIXIVAN ORAL CAPSULE Auto-PA INVIRASE ORAL TABLET Auto-PA LEXIVA ORAL SUSPENSION Auto-PA LEXIVA ORAL TABLET Fosamprenavir Calcium Auto-PA NORVIR ORAL PACKET Auto-PA 68

Formulary Drug Name Reference Restrictions NORVIR ORAL SOLUTION Auto-PA PREZISTA ORAL SUSPENSION Auto-PA PREZISTA ORAL TABLET Auto-PA REYATAZ ORAL CAPSULE Atazanavir Sulfate Auto-PA REYATAZ ORAL PACKET Auto-PA VIRACEPT ORAL TABLET Auto-PA

*Antiretrovirals - Rti-Non-Nucleoside Analogues*** nevirapine er oral tablet extended release 24 hour Viramune XR Auto-PA

nevirapine oral suspension Viramune Auto-PA nevirapine tablet 200 mg oral Viramune nevirapine tablet 200 mg oral Viramune Auto-PA

EDURANT ORAL TABLET Auto-PA; QLL (1 EA per 1 day); AL (Min 12 Years)

INTELENCE ORAL TABLET Auto-PA PIFELTRO ORAL TABLET RESCRIPTOR ORAL TABLET Auto-PA SUSTIVA ORAL CAPSULE Efavirenz Auto-PA SUSTIVA ORAL TABLET Efavirenz Auto-PA VIRAMUNE ORAL SUSPENSION Nevirapine Auto-PA

*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** abacavir sulfate oral tablet Ziagen Auto-PA didanosine oral capsule delayed release Videx EC Auto-PA VIDEX ORAL SOLUTION RECONSTITUTED Auto-PA

ZIAGEN ORAL SOLUTION Abacavir Sulfate Auto-PA

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** lamivudine oral solution Epivir Auto-PA lamivudine tablet 150 mg oral Epivir lamivudine tablet 150 mg oral Epivir Auto-PA lamivudine tablet 300 mg oral Epivir lamivudine tablet 300 mg oral Epivir Auto-PA EMTRIVA ORAL CAPSULE Auto-PA EMTRIVA ORAL SOLUTION Auto-PA EPIVIR ORAL SOLUTION LamiVUDine Auto-PA

69

Formulary Drug Name Reference Restrictions *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine oral capsule Auto-PA zidovudine oral capsule Retrovir Auto-PA zidovudine oral syrup Retrovir Auto-PA zidovudine oral tablet Auto-PA RETROVIR INTRAVENOUS SOLUTION Auto-PA

*Antiretrovirals - Rti-Nucleotide Analogues*** tenofovir disoproxil fumarate oral tablet Viread VIREAD ORAL POWDER VIREAD ORAL TABLET

*Cmv Agents*** ganciclovir sodium intravenous solution ganciclovir sodium intravenous solution reconstituted Cytovene

valganciclovir hcl oral tablet Valcyte

*Hepatitis B Agents*** entecavir oral tablet Baraclude lamivudine oral tablet Epivir HBV BARACLUDE ORAL SOLUTION EPIVIR HBV ORAL SOLUTION

*Hepatitis C Agents*** ribavirin oral capsule Ribasphere Auto-PA; AL (Min 5 Years) ribavirin oral tablet Ribasphere Auto-PA; AL (Min 5 Years) PEGASYS PROCLICK SUBCUTANEOUS SOLUTION Auto-PA; AL (Min 3 Years)

PEGASYS SUBCUTANEOUS SOLUTION Auto-PA; AL (Min 3 Years) PEGINTRON SUBCUTANEOUS KIT Auto-PA; AL (Min 3 Years) RIBASPHERE ORAL CAPSULE Ribavirin Auto-PA RIBASPHERE ORAL TABLET Auto-PA; AL (Min 5 Years) RIBASPHERE RIBAPAK ORAL TABLET Auto-PA; AL (Min 5 Years) RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK Auto-PA; AL (Min 5 Years)

*Herpes Agents - Purine Analogues*** acyclovir oral capsule Zovirax acyclovir oral suspension Zovirax AL (Max 17 Years)

70

Formulary Drug Name Reference Restrictions acyclovir oral tablet Zovirax valacyclovir hcl oral tablet Valtrex

*Neuraminidase Inhibitors*** oseltamivir phosphate capsule 30 mg oral Tamiflu QLL (20 EA per 1 Fill)

oseltamivir phosphate capsule 30 mg oral Tamiflu Maximum of 2 FILLS per 365 days.; QLL (20 EA per 1 Fill)

oseltamivir phosphate capsule 45 mg oral Tamiflu QLL (10 EA per 1 Fill)


oseltamivir phosphate capsule 75 mg oral Tamiflu QLL (10 EA per 1 Fill)


oseltamivir phosphate oral suspension reconstituted Tamiflu QLL (180 ML per 1 Fill); AL

(Max 12 Years) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

Maximum of 2 FILLS per 365 days.; QLL (20 EA Max Qty Per Fill Retail); AL (Min 6 Years)

*Rsv Agents - Nucleoside Analogues*** ribavirin inhalation solution reconstituted Virazole Auto-PA; AL (Min 5 Years)

*ASSORTED CLASSES* *Antileprotics*** THALOMID CAPSULE 100 MG ORAL QLL (1 EA per 1 Fill) THALOMID CAPSULE 150 MG ORAL QLL (1 EA per 1 Fill) THALOMID CAPSULE 200 MG ORAL QLL (2 EA per 1 Fill) THALOMID CAPSULE 50 MG ORAL QLL (1 EA per 1 Fill)

*Cyclosporine Analogs*** cyclosporine intravenous solution SandIMMUNE cyclosporine modified oral capsule Gengraf SANDIMMUNE INTRAVENOUS SOLUTION CycloSPORINE

SANDIMMUNE ORAL SOLUTION

*Immune Globulin Immunosuppressants*** ATGAM INTRAVENOUS INJECTABLE PA THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED PA

71

Formulary Drug Name Reference Restrictions *Immunomodulators For Myelodysplastic Syndromes***

REVLIMID ORAL CAPSULE QLL (1 EA per 1 day); AL (Min 18 Years)

*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil hcl intravenous solution reconstituted CellCept Intravenous

mycophenolate mofetil oral capsule CellCept mycophenolate mofetil oral tablet CellCept mycophenolate mofetil suspension reconstituted 200 mg/ml oral CellCept

mycophenolate mofetil suspension reconstituted 200 mg/ml oral CellCept AL (Max 11 Years)

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED

Mycophenolate Mofetil HCl

*Irrigation Solutions*** lactated ringers irrigation solution ringers irrigation irrigation solution Tis-U-Sol sterile water for irrigation irrigation solution Argyle Sterile Water TIS-U-SOL IRRIGATION SOLUTION Ringers Irrigation

*Macrolide Immunosuppressants*** sirolimus oral solution Rapamune sirolimus oral tablet Rapamune tacrolimus oral capsule Prograf

*Peritonial Dialysis Solutions*** DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION

*Potassium Removing Resins*** sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension Kionex sodium polystyrene sulfonate rectal suspension SPS ORAL SUSPENSION Sodium Polystyrene Sulfonate

*Purine Analogs*** azathioprine oral tablet Imuran

72

Formulary Drug Name Reference Restrictions *BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet Coreg

labetalol hcl tablet 100 mg oral Maintenance drug with max 100 day supply; QLL (8 EA per 1 day)

labetalol hcl tablet 100 mg oral Maintenance drug with max 100 days supply; QLL (8 EA per 1 day)


labetalol hcl tablet 200 mg oral Maintenance drug with max 100 days supply; QLL (8 EA per 1 day)


*Beta Blockers Cardio-Selective***

acebutolol hcl oral capsule Maintenance drug with max 100 days supply

atenolol oral tablet Tenormin Maintenance drug with max 100 days supply

bisoprolol fumarate oral tablet Maintenance drug with max 100 day supply

metoprolol succinate er tablet extended release 24 hour 100 mg oral Toprol XL Maintenance drug with max 100

day supply metoprolol succinate er tablet extended release 24 hour 100 mg oral Toprol XL Maintenance drug with max 100

days supply metoprolol succinate er tablet extended release 24 hour 200 mg oral Toprol XL Maintenance drug with max 100






days supply

metoprolol tartrate oral tablet Maintenance drug with max 100 days supply

73

Formulary Drug Name Reference Restrictions *Beta Blockers Non-Selective*** propranolol hcl er oral capsule extended release 24 hour Inderal LA Maintenance drug with max 100

days supply

propranolol hcl oral solution Maintenance drug with max 100 days supply

propranolol hcl oral tablet Maintenance drug with max 100 days supply

sotalol hcl (af) oral tablet Betapace AF sotalol hcl oral tablet Betapace BETAPACE AF ORAL TABLET Sotalol HCl (AF)

*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG*** *Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag*** EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

*CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers*** amlodipine besylate oral tablet Norvasc diltiazem hcl er beads capsule extended release 24 hour 120 mg oral Taztia XT Maintenance drug with max 100

days supply diltiazem hcl er beads capsule extended release 24 hour 180 mg oral Taztia XT Maintenance drug with max 100

days supply diltiazem hcl er beads capsule extended release 24 hour 240 mg oral Taztia XT Maintenance drug with max 100

days supply diltiazem hcl er beads capsule extended release 24 hour 300 mg oral Taztia XT

diltiazem hcl er beads capsule extended release 24 hour 360 mg oral Taztia XT

diltiazem hcl er beads capsule extended release 24 hour 420 mg oral Tiazac Maintenance drug with max 100

days supply diltiazem hcl er coated beads capsule extended release 24 hour 120 mg oral Cardizem CD Maintenance drug with max 100

day supply diltiazem hcl er coated beads capsule extended release 24 hour 120 mg oral Cardizem CD Maintenance drug with max 100


days supply

74

Formulary Drug Name Reference Restrictions diltiazem hcl er coated beads capsule extended release 24 hour 180 mg oral Cardizem CD Maintenance drug with max 100







day supply diltiazem hcl er oral capsule extended release 12 hour

Maintenance drug with max 100 days supply

diltiazem hcl er oral capsule extended release 24 hour


diltiazem hcl oral tablet Cardizem Maintenance drug with max 100 days supply

felodipine er tablet extended release 24 hour 10 mg oral


felodipine er tablet extended release 24 hour 2.5 mg oral


felodipine er tablet extended release 24 hour 5 mg oral felodipine er tablet extended release 24 hour 5 mg oral


nifedipine er oral tablet extended release 24 hour Adalat CC Maintenance drug with max 100

days supply nifedipine er osmotic release tablet extended release 24 hour 30 mg oral Procardia XL Maintenance drug with max 100

day supply nifedipine er osmotic release tablet extended release 24 hour 60 mg oral Nifedical XL Maintenance drug with max 100

day supply nifedipine er osmotic release tablet extended release 24 hour 60 mg oral Nifedical XL Maintenance drug with max 100

days supply nifedipine er osmotic release tablet extended release 24 hour 90 mg oral Procardia XL

nifedipine oral capsule Procardia Maintenance drug with max 100 days supply

nimodipine oral capsule AL (Min 18 Years) verapamil hcl er oral capsule extended release 24 hour Verelan

75

Formulary Drug Name Reference Restrictions verapamil hcl er oral tablet extended release Calan SR

verapamil hcl tablet 120 mg oral Calan Maintenance drug with max 100 days supply

verapamil hcl tablet 120 mg oral Calan verapamil hcl tablet 40 mg oral verapamil hcl tablet 80 mg oral

*CARDIOTONICS* *Cardiac Glycosides*** digoxin oral solution

digoxin tablet 125 mcg oral Digitek Maintenance drugs with max 100 day supply

digoxin tablet 125 mcg oral Digitek Maintenance drug with max 100 day supply

digoxin tablet 250 mcg oral Digitek Maintenance drug with max 100 day supply

*Phosphodiesterase Inhibitors*** milrinone lactate in dextrose intravenous solution milrinone lactate intravenous solution

*CARDIOVASCULAR AGENTS -MISC.* *Prostaglandin Vasodilators*** epoprostenol sodium intravenous solution reconstituted Flolan

VENTAVIS INHALATION SOLUTION PA; QLL (270 ML per 30 days)

*Pulmonary Hypertension -Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET Ambrisentan PA TRACLEER ORAL TABLET Bosentan PA

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** sildenafil citrate oral suspension reconstituted Revatio PA sildenafil citrate oral tablet Revatio

*CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule cefazolin sodium injection solution reconstituted

76

Formulary Drug Name Reference Restrictions cefazolin sodium intravenous solution reconstituted cephalexin oral capsule Keflex cephalexin suspension reconstituted 125 mg/5ml oral cephalexin suspension reconstituted 250 mg/5ml oral QLL (80 ML per 1 day)

*Cephalosporins - 2Nd Generation*** cefaclor oral capsule cefotetan disodium injection solution reconstituted Cefotan

cefotetan disodium-dextrose intravenous solution reconstituted cefoxitin sodium injection solution reconstituted cefoxitin sodium intravenous solution reconstituted cefoxitin sodium-dextrose intravenous solution reconstituted cefprozil oral tablet QLL (4 EA per 1 day) cefprozil suspension reconstituted 125 mg/5ml oral cefprozil suspension reconstituted 250 mg/5ml oral QLL (20 ML per 1 day)

cefuroxime axetil oral tablet cefuroxime sodium injection solution reconstituted cefuroxime sodium intravenous solution reconstituted

*Cephalosporins - 3Rd Generation*** cefdinir oral capsule cefdinir oral suspension reconstituted cefixime oral capsule Suprax cefixime oral suspension reconstituted Suprax cefotaxime sodium injection solution reconstituted ceftazidime injection solution reconstituted Tazicef ceftriaxone sodium in dextrose intravenous solution QLL (2 VIALS per 1 day)

77

Formulary Drug Name Reference Restrictions ceftriaxone sodium injection solution reconstituted QLL (2 VIALS per 1 day)

ceftriaxone sodium intravenous solution reconstituted QLL (2 VIALS per 1 day)

ceftriaxone sodium-dextrose intravenous solution reconstituted QLL (2 VIAL per 1 day)

*Cephalosporins - 4Th Generation*** cefepime hcl solution reconstituted 1 gm injection Maxipime QLL (1500 EA per 30 days)

cefepime hcl solution reconstituted 2 gm injection Maxipime QLL (3000 EA per 30 days)

*CHEMICALS* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder

*Bulk Chemicals - St's*** stevia extract powder

*Liquids*** glycerin liquid

*Solids*** sorbitol powder

*CONTRACEPTIVES* *Biphasic Contraceptives - Oral***

desogestrel-ethinyl estradiol oral tablet Azurette QLL (1 EA per 1 day); AL (Min 12 Years)

viorele oral tablet Azurette QLL (1 EA per 1 day); AL (Min 12 Years)

AZURETTE ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

BEKYREE ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

KARIVA ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

LO LOESTRIN FE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

MIRCETTE ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

PIMTREA ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

SIMLIYA ORAL TABLET Desogestrel-Ethinyl Estradiol

78

Formulary Drug Name Reference Restrictions *Combination Contraceptives -Oral***

alyacen 1/35 oral tablet Cyclafem 1/35 QLL (1 EA per 1 day); AL (Min 12 Years)

briellyn oral tablet Balziva QLL (1 EA per 1 day); AL (Min 12 Years)

desogestrel-ethinyl estradiol oral tablet Apri QLL (1 EA per 1 day); AL (Min 12 Years)

drospiren-eth estrad-levomefol tablet 3-0.02-0.451 mg oral Beyaz

drospiren-eth estrad-levomefol tablet 3-0.03-0.451 mg oral Safyral QLL (1 EA per 1 day); AL (Min

12 Years)

drospirenone-ethinyl estradiol oral tablet Gianvi QLL (1 EA per 1 day); AL (Min 12 Years)

ethynodiol diac-eth estradiol oral tablet Kelnor 1/50 QLL (1 EA per 1 day); AL (Min 12 Years)

levonorgestrel-ethinyl estrad tablet 0.1-20 mg-mcg oral Afirmelle QLL (1 EA per 1 day); AL (Min

12 Years) levonorgestrel-ethinyl estrad tablet 0.15-30 mg-mcg oral Altavera

marlissa oral tablet Altavera norethin ace-eth estrad-fe oral tablet Aurovela FE 1/20 norethin ace-eth estrad-fe oral tablet chewable Melodetta 24 Fe

norethindrone acet-ethinyl est oral tablet Aurovela 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

norethin-eth estradiol-fe oral tablet chewable Wymzya Fe

norgestimate-eth estradiol oral tablet Estarylla QLL (1 EA per 1 day); AL (Min 12 Years)

AFIRMELLE ORAL TABLET Levonorgestrel-Ethinyl Estrad

ALTAVERA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

APRI ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

AUBRA EQ ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

AUBRA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

AUROVELA 1.5/30 ORAL TABLET

AUROVELA 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est

AUROVELA 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE

79

Formulary Drug Name Reference Restrictions AUROVELA FE 1.5/30 ORAL TABLET AUROVELA FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE

AVIANE ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

AYUNA ORAL TABLET Levonorgestrel-Ethinyl Estrad

BALCOLTRA ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

BALZIVA ORAL TABLET Briellyn QLL (1 EA per 1 day); AL (Min 12 Years)

BEYAZ ORAL TABLET Drospiren-Eth Estrad-Levomefol


BLISOVI 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE

Med Cert drug - medically acceptable indication required.; QLL (1 EA per 1 day); AL (Min 12 Years)

BLISOVI FE 1.5/30 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

BLISOVI FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE QLL (1 EA per 1 day); AL (Min 12 Years)

CHATEAL EQ ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

CHATEAL ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

CRYSELLE-28 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

CYCLAFEM 1/35 ORAL TABLET Alyacen 1/35 QLL (1 EA per 1 day); AL (Min 12 Years)

CYRED EQ ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

CYRED ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

DASETTA 1/35 ORAL TABLET Alyacen 1/35 QLL (1 EA per 1 day); AL (Min 12 Years)

ELINEST ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

EMOQUETTE ORAL TABLET Desogestrel-Ethinyl Estradiol

ENSKYCE ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

ESTARYLLA ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

FALMINA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

80


FEMYNOR ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

GENERESS FE ORAL TABLET CHEWABLE Norethin-Eth Estradiol-Fe

GIANVI ORAL TABLET Drospirenone-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

HAILEY 1.5/30 ORAL TABLET HAILEY 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE

ISIBLOOM ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

JASMIEL ORAL TABLET Drospirenone-Ethinyl Estradiol

JULEBER ORAL TABLET Desogestrel-Ethinyl Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

JUNEL 1.5/30 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

JUNEL 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est


JUNEL FE 1.5/30 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

JUNEL FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE QLL (1 EA per 1 day); AL (Min 12 Years)

JUNEL FE 24 ORAL TABLET Norethin Ace-Eth Estrad-FE


KAITLIB FE ORAL TABLET CHEWABLE Norethin-Eth Estradiol-Fe QLL (1 EA per 1 day); AL (Min

12 Years) KALLIGA ORAL TABLET Desogestrel-Ethinyl Estradiol

KELNOR 1/35 ORAL TABLET Ethynodiol Diac-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

KELNOR 1/50 ORAL TABLET Ethynodiol Diac-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

KURVELO ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

LARIN 1.5/30 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

LARIN 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est


LARIN 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE


LARIN FE 1.5/30 ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

81


LARIN FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE QLL (1 EA per 1 day); AL (Min 12 Years)

LARISSIA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

LAYOLIS FE ORAL TABLET CHEWABLE Norethin-Eth Estradiol-Fe

LESSINA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

LEVORA 0.15/30 (28) ORAL TABLET Levonorgestrel-Ethinyl Estrad LILLOW ORAL TABLET Levonorgestrel-Ethinyl Estrad LOESTRIN 1.5/30 (21) ORAL TABLET

LOESTRIN 1/20 (21) ORAL TABLET Norethindrone Acet-Ethinyl Est


LORYNA ORAL TABLET Drospirenone-Ethinyl Estradiol LOW-OGESTREL ORAL TABLET LO-ZUMANDIMINE ORAL TABLET Drospirenone-Ethinyl Estradiol

LUTERA ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

MIBELAS 24 FE ORAL TABLET CHEWABLE Norethin Ace-Eth Estrad-FE

MICROGESTIN 1.5/30 ORAL TABLET

MICROGESTIN 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est


MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE

MILI ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

MINASTRIN 24 FE ORAL TABLET CHEWABLE Norethin Ace-Eth Estrad-FE

MONO-LINYAH ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

NECON 0.5/35 (28) ORAL TABLET NIKKI ORAL TABLET Drospirenone-Ethinyl Estradiol NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET Alyacen 1/35 NORTREL 1/35 (28) ORAL TABLET Alyacen 1/35 OCELLA ORAL TABLET Drospirenone-Ethinyl Estradiol OGESTREL ORAL TABLET ORSYTHIA ORAL TABLET Levonorgestrel-Ethinyl Estrad

82

Formulary Drug Name Reference Restrictions ORTHO-NOVUM 1/35 (28) ORAL TABLET Alyacen 1/35

PHILITH ORAL TABLET Briellyn PIRMELLA 1/35 ORAL TABLET Alyacen 1/35 PORTIA-28 ORAL TABLET Levonorgestrel-Ethinyl Estrad

PREVIFEM ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

RECLIPSEN ORAL TABLET Desogestrel-Ethinyl Estradiol

SAFYRAL ORAL TABLET Drospiren-Eth Estrad-Levomefol

SPRINTEC 28 ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

SRONYX ORAL TABLET Levonorgestrel-Ethinyl Estrad QLL (1 EA per 1 day); AL (Min 12 Years)

SYEDA ORAL TABLET Drospirenone-Ethinyl Estradiol TARINA 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE TARINA FE 1/20 EQ ORAL TABLET Norethin Ace-Eth Estrad-FE AL (Min 12 Years) TARINA FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE AL (Min 12 Years) TAYTULLA ORAL CAPSULE

TYDEMY ORAL TABLET Drospiren-Eth Estrad-Levomefol

VIENVA ORAL TABLET Levonorgestrel-Ethinyl Estrad VYFEMLA ORAL TABLET Briellyn

VYLIBRA ORAL TABLET Norgestimate-Eth Estradiol QLL (1 EA per 1 day); AL (Min 12 Years)

WERA ORAL TABLET WYMZYA FE ORAL TABLET CHEWABLE Norethin-Eth Estradiol-Fe

YASMIN 28 ORAL TABLET Drospirenone-Ethinyl Estradiol YAZ ORAL TABLET Drospirenone-Ethinyl Estradiol ZARAH ORAL TABLET Drospirenone-Ethinyl Estradiol ZOVIA 1/35E (28) ORAL TABLET Ethynodiol Diac-Eth Estradiol ZUMANDIMINE ORAL TABLET Drospirenone-Ethinyl Estradiol

*Combination Contraceptives -Transdermal*** XULANE TRANSDERMAL PATCH WEEKLY AL (Min 12 Years)

*Combination Contraceptives -Vaginal***

NUVARING VAGINAL RING QLL (1 EA per 21 days); AL (Min 12 Years)

83

Formulary Drug Name Reference Restrictions *Continuous Contraceptives -Oral***

levonorgestrel-ethinyl estrad oral tablet Amethyst QLL (1 EA per 1 day); AL (Min 12 Years)

*Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

*Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

*Emergency Contraceptives***

levonorgestrel oral tablet Aftera OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

AFTERA TABLET 1.5 MG ORAL Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

AFTERA TABLET 1.5 MG ORAL Levonorgestrel

Med Cert drug - medically acceptable indication required.; OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

ECONTRA EZ ORAL TABLET Levonorgestrel


ECONTRA ONE-STEP ORAL TABLET Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

ELLA ORAL TABLET QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

MY CHOICE ORAL TABLET Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

MY WAY TABLET 1.5 MG ORAL (OTC) Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

MY WAY TABLET 1.5 MG ORAL (OTC) Levonorgestrel


NEW DAY ORAL TABLET Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

OPCICON ONE-STEP ORAL TABLET Levonorgestrel


84

Formulary Drug Name Reference Restrictions PLAN B ONE-STEP TABLET 1.5 MG ORAL (OTC) Levonorgestrel OTC; QLL (2 PACKAGES per

30 days); AL (Min 12 Years)

PLAN B ONE-STEP TABLET 1.5 MG ORAL (OTC) Levonorgestrel


TAKE ACTION TABLET 1.5 MG ORAL Levonorgestrel OTC; QLL (2 PACKAGES per 30 days); AL (Min 12 Years)

TAKE ACTION TABLET 1.5 MG ORAL Levonorgestrel


*Extended-Cycle Contraceptives -Oral***

levonorgest-eth est & eth est oral tablet Fayosim QLL (91 EA per 84 days); AL (Min 12 Years)

levonorgest-eth estrad 91-day oral tablet Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

AMETHIA LO ORAL TABLET Levonorgest-Eth Estrad 91-Day


AMETHIA ORAL TABLET Levonorgest-Eth Estrad 91-Day


ASHLYNA ORAL TABLET Levonorgest-Eth Estrad 91-Day


CAMRESE LO ORAL TABLET Levonorgest-Eth Estrad 91-Day


CAMRESE ORAL TABLET Levonorgest-Eth Estrad 91-Day


DAYSEE ORAL TABLET Levonorgest-Eth Estrad 91-Day


FAYOSIM ORAL TABLET Levonorgest-Eth Est & Eth Est QLL (91 EA per 84 days); AL (Min 12 Years)

INTROVALE ORAL TABLET Levonorgest-Eth Estrad 91-Day


JOLESSA ORAL TABLET Levonorgest-Eth Estrad 91-Day


LOSEASONIQUE ORAL TABLET Levonorgest-Eth Estrad 91-Day


QUARTETTE ORAL TABLET Levonorgest-Eth Est & Eth Est QLL (91 EA per 84 days); AL (Min 12 Years)

RIVELSA ORAL TABLET Levonorgest-Eth Est & Eth Est QLL (91 EA per 84 days); AL (Min 12 Years)

SEASONIQUE ORAL TABLET Levonorgest-Eth Estrad 91-Day


85


SETLAKIN ORAL TABLET Levonorgest-Eth Estrad 91-Day


SIMPESSE ORAL TABLET Levonorgest-Eth Estrad 91-Day

*Four Phase Contraceptives -Oral***

NATAZIA ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

*Progestin Contraceptives -Implants*** NEXPLANON SUBCUTANEOUS IMPLANT

*Progestin Contraceptives -Injectable*** medroxyprogesterone acetate intramuscular suspension Depo-Provera QLL (1 UNIT per 84 days); AL

(Min 12 Years) medroxyprogesterone acetate intramuscular suspension prefilled syringe Depo-Provera QLL (1 UNIT per 84 days)

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

MedroxyPROGESTERone Acetate

QLL (1 UNIT per 84 days); AL (Min 12 Years)

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

MedroxyPROGESTERone Acetate QLL (1 UNIT per 84 days)

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE

QLL (0.65 ML per 84 days)

*Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE INTRAUTERINE DEVICE LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE SKYLA INTRAUTERINE INTRAUTERINE DEVICE

*Progestin Contraceptives - Oral*** norethindrone oral tablet Camila CAMILA ORAL TABLET Norethindrone DEBLITANE ORAL TABLET Norethindrone ERRIN ORAL TABLET Norethindrone HEATHER ORAL TABLET Norethindrone INCASSIA ORAL TABLET Norethindrone

86

Formulary Drug Name Reference Restrictions JENCYCLA ORAL TABLET Norethindrone LYZA ORAL TABLET Norethindrone NORA-BE ORAL TABLET Norethindrone NORLYDA ORAL TABLET Norethindrone SHAROBEL ORAL TABLET Norethindrone SLYND ORAL TABLET AL (Min 12 Years) TULANA ORAL TABLET Norethindrone

*Triphasic Contraceptives - Oral***

alyacen 7/7/7 oral tablet Cyclafem 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

levonorg-eth estrad triphasic oral tablet Enpresse-28 QLL (1 EA per 1 day); AL (Min 12 Years)

norgestim-eth estrad triphasic oral tablet Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

ARANELLE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

CAZIANT ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

CYCLAFEM 7/7/7 ORAL TABLET Alyacen 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

DASETTA 7/7/7 ORAL TABLET Alyacen 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

ENPRESSE-28 ORAL TABLET Levonorg-Eth Estrad Triphasic QLL (1 EA per 1 day); AL (Min 12 Years)

ESTROSTEP FE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

LEENA ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

LEVONEST ORAL TABLET Levonorg-Eth Estrad Triphasic QLL (1 EA per 1 day); AL (Min 12 Years)

NORTREL 7/7/7 ORAL TABLET Alyacen 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET Alyacen 7/7/7 QLL (1 EA per 1 day); AL (Min

12 Years)

PIRMELLA 7/7/7 ORAL TABLET Alyacen 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

TILIA FE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

TRI FEMYNOR ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-ESTARYLLA ORAL TABLET Norgestim-Eth Estrad Triphasic

87


TRI-LEGEST FE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-LINYAH ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-LO-ESTARYLLA ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-LO-MARZIA ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-LO-MILI ORAL TABLET Norgestim-Eth Estrad Triphasic

TRI-LO-SPRINTEC ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-MILI ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-PREVIFEM ORAL TABLET Norgestim-Eth Estrad Triphasic

TRI-SPRINTEC ORAL TABLET Norgestim-Eth Estrad Triphasic


TRIVORA (28) ORAL TABLET Levonorg-Eth Estrad Triphasic QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-VYLIBRA LO ORAL TABLET Norgestim-Eth Estrad Triphasic


TRI-VYLIBRA ORAL TABLET Norgestim-Eth Estrad Triphasic


VELIVET ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

*CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release particles Entocort EC

dexamethasone oral elixir Decadron dexamethasone oral solution

dexamethasone oral tablet Decadron Maintenance drug with max 100 days supply

dexamethasone sod phosphate pf injection solution dexamethasone sodium phosphate injection solution hydrocortisone oral tablet Cortef methylprednisolone acetate injection suspension Depo-Medrol

methylprednisolone sodium succ injection solution reconstituted SOLU-medrol

88

Formulary Drug Name Reference Restrictions methylprednisolone tablet 16 mg oral Medrol methylprednisolone tablet 32 mg oral Medrol

methylprednisolone tablet 4 mg oral Medrol Maintenance drug with max 100 day supply

methylprednisolone tablet 4 mg oral Medrol Maintenance drug with max 100 days supply

methylprednisolone tablet 8 mg oral Medrol methylprednisolone tablet therapy pack 4 mg oral Medrol

methylprednisolone tablet therapy pack 4 mg oral Medrol Maintenance drug with max 100

days supply prednisolone oral solution prednisolone sodium phosphate oral solution prednisolone sodium phosphate oral tablet dispersible Orapred ODT AL (Max 11 Years)

prednisone oral solution

prednisone oral tablet therapy pack Maintenance drugs with max 100 days supply

prednisone tablet 1 mg oral Maintenance drug with max 100 days supply

prednisone tablet 10 mg oral Maintenance drugs with max 100 day supply

prednisone tablet 10 mg oral Maintenance drug with max 100 day supply

prednisone tablet 2.5 mg oral Maintenance drug with max 100 days supply


prednisone tablet 5 mg oral Maintenance drug with max 100 day supply


prednisone tablet 5 mg oral Maintenance drugs with max 100 days supply

prednisone tablet 50 mg oral Maintenance drugs with max 100 days supply

DEXAMETHASONE INTENSOL ORAL CONCENTRATE SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED

*Mineralocorticoids*** fludrocortisone acetate oral tablet

89

Formulary Drug Name Reference Restrictions *Steroid Combinations*** betamethasone sod phos & acet injection suspension Celestone Soluspan

CELESTONE SOLUSPAN INJECTION SUSPENSION Betamethasone Combo

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule AL (Max 20 Years)

*Antitussive - Opioid***

hydrocodone-homatropine oral syrup QLL (300 ML per 30 days); AL (Min 18 Years and Max 20 Years)

hydrocodone-homatropine oral tablet AL (Min 18 Years and Max 20 Years)

*Antitussive-Expectorant***

cough/chest congestion dm oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

dextromethorphan-guaifenesin oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

dm-guaifenesin er oral tablet extended release 12 hour

Mucinex DM Maximum Strength OTC

extra action cough oral syrup Robafen DM Cough Clear OTC gnp mucus dm max strength oral tablet extended release 12 hour


guaifenesin-dm oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

hm tussin adult dm oral liquid Diabetic Tussin Max St OTC

mucus & cough relief childrens oral liquid Delsym Cgh/Chest Cong DM Child OTC

mucus relief dm cough oral tablet Fenesin DM IR OTC

mucus relief dm max oral liquid Delsym Cgh/Chest Cong DM Child OTC

mucus relief dm max oral tablet extended release 12 hour


mucus relief dm oral tablet extended release 12 hour Mucinex DM OTC

mucus-dm maximum strength oral tablet extended release 12 hour


mucusrelief dm cough oral tablet Fenesin DM IR OTC

sm tussin dm max oral liquid Delsym Cgh/Chest Cong DM Child OTC

90

Formulary Drug Name Reference Restrictions tussin dm cough + chest oral liquid Cheracol Plus OTC

tussin dm max adult oral liquid Delsym Cgh/Chest Cong DM Child OTC

ROBAFEN DM COUGH ORAL LIQUID Tussin DM OTC

*Decongestant & Antihistamine*** all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

allergy relief d-24 oral tablet extended release 24 hour Claritin-D 24 Hour OTC

allergy relief/nasal decongest oral tablet extended release 24 hour Claritin-D 24 Hour OTC

allergy relief-d oral tablet extended release 24 hour Claritin-D 24 Hour OTC

allergy/congestion relief oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

cetirizine-pseudoephedrine er oral tablet extended release 12 hour KLS Aller-Tec D OTC

gnp all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

gnp allergy & congestion oral tablet extended release 24 hour Claritin-D 24 Hour OTC

gnp allergy/congestion relief oral tablet extended release 24 hour Claritin-D 24 Hour OTC

gnp loratadine-d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

hm allergy & congestion oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

hm allergy complete-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

hm allergy relief/nasal decong oral tablet extended release 24 hour Claritin-D 24 Hour OTC

loratadine-d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

loratadine-d 24hr oral tablet extended release 24 hour Claritin-D 24 Hour OTC

promethazine-phenylephrine oral syrup QLL (300 ML per 30 days); AL (Min 18 Years and Max 20 Years)

qc loratadine-d oral tablet extended release 24 hour Claritin-D 24 Hour OTC

sm all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

91

Formulary Drug Name Reference Restrictions sm loratadine d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

sm lorata-dine d oral tablet extended release 24 hour Claritin-D 24 Hour OTC

*Expectorants*** chest congestion relief oral tablet Bidex OTC

childrens mucus relief expect oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

diabetic siltussin das-na oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

gnp mucus er oral tablet extended release 12 hour EQ Mucus ER OTC

gnp mucus relief oral tablet Bidex OTC gnp tab tussin oral tablet Bidex OTC

gnp tussin mucus & chest cong oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

guaifenesin oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

guaifenesin oral solution Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

guaifenesin oral tablet Bidex OTC hm chest congestion relief oral tablet Bidex OTC

hm tussin adult oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

mucosa oral tablet Bidex OTC

mucus & chest congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

mucus relief chest congestion oral tablet OTC mucus relief er oral tablet extended release 12 hour EQ Mucus ER OTC

mucus relief max st oral tablet extended release 12 hour EQ Mucus ER OTC

qc medifin 400 oral tablet Bidex OTC qc mucus relief er oral tablet extended release 12 hour EQ Mucus ER OTC

qc mucus relief oral tablet extended release 12 hour EQ Mucus ER OTC

qc tussin mucus/congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

robafen oral syrup Diabetic Tussin EX OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

siltussin sa oral syrup Diabetic Tussin EX OTC

92

Formulary Drug Name Reference Restrictions sm chest congestion relief oral tablet Bidex OTC sm mucus relief max strength oral tablet extended release 12 hour EQ Mucus ER OTC

sm mucus relief oral tablet extended release 12 hour EQ Mucus ER OTC

sm tussin mucus+chest congest oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus & chest congest oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus+chest congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus+chest congestion oral syrup Diabetic Tussin EX OTC MUCINEX FOR KIDS ORAL PACKET OTC MUCINEX MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HOUR

GuaiFENesin ER OTC

MUCINEX ORAL TABLET EXTENDED RELEASE 12 HOUR PA Mucus Relief OTC

ROBAFEN MUCUS/CHEST CONGESTION ORAL LIQUID GuaiFENesin OTC; QLL (300 ML per 30

days); AL (Max 20 Years)

*Misc. Respiratory Inhalants*** sodium chloride nebulization solution 0.9 % inhalation (rx) sodium chloride nebulization solution 10 % inhalation Auto-PA

*Mucolytics*** acetylcysteine inhalation solution

*Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup

*Non-Narc Antitussive-Decongestant-Antihistamine*** pseudoeph-bromphen-dm oral syrup Bromfed DM

*DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external gel Cleocin-T ST clindamycin phosphate external lotion Cleocin-T ST; AL (Min 12 Years) clindamycin phosphate external solution AL (Min 12 Years) clindamycin phosphate external swab Clindacin ETZ AL (Min 12 Years)

93

Formulary Drug Name Reference Restrictions *Acne Combinations*** clindamycin phos-benzoyl perox external gel BenzaClin

*Acne Products*** adapalene external cream Differin ST; AL (Min 12 Years) adapalene external lotion Differin ST; AL (Min 12 Years) benzoyl peroxide external gel OTC isotretinoin oral capsule Absorica ST; AL (Min 12 Years) tretinoin external cream Retin-A ST; AL (Min 12 Years) AMNESTEEM ORAL CAPSULE ISOtretinoin AL (Min 12 Years) AVITA EXTERNAL CREAM Tretinoin AL (Min 12 Years) AZELEX EXTERNAL CREAM AL (Min 12 Years)

CLARAVIS ORAL CAPSULE ISOtretinoin ST; Med Cert drug - medically acceptable indication required.; AL (Min 12 Years)

DIFFERIN EXTERNAL GEL Adapalene OTC Only

MYORISAN ORAL CAPSULE ISOtretinoin ST; Med Cert drug - medically acceptable indication required.; AL (Min 12 Years)

ZENATANE ORAL CAPSULE ISOtretinoin ST; Med Cert drug - medically acceptable indication required.; AL (Min 12 Years)

*Antibiotic Steroid Combinations -Topical*** CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT

*Antibiotics - Topical*** gentamicin sulfate external cream mupirocin ointment 2 % external Centany mupirocin ointment 2 % external Centany QLL (44 GM per 30 days)

*Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream Lotrisone hydrocortisone-iodoquinol external cream Dermazene ALA-QUIN EXTERNAL CREAM

*Antifungals - Topical*** butenafine hcl external cream Lotrimin Ultra OTC ciclopirox external solution Ciclodan ciclopirox olamine external cream Loprox ciclopirox olamine external suspension Loprox

94

Formulary Drug Name Reference Restrictions nystatin external cream nystatin external ointment nystatin external powder Nyamyc

*Anti-Inflammatory Agents -Topical*** diclofenac sodium transdermal gel Voltaren

*Antineoplastic Antimetabolites -Topical*** fluorouracil external cream Carac fluorouracil external solution

*Antineoplastic Or Premalignant Lesions - Topical Nsaid's***

diclofenac sodium gel 3 % transdermal QLL (200 GM per 30 days); AL (Min 18 Years)

diclofenac sodium gel 3 % transdermal Auto-PA; QLL (200 GM per 30 days); AL (Min 18 Years)

*Antineoplastic Retinoids -Topical*** PANRETIN EXTERNAL GEL PA

*Antipruritics - Topical*** doxepin hcl external cream Prudoxin PRUDOXIN EXTERNAL CREAM Doxepin HCl

*Antipsoriatics - Systemic*** acitretin oral capsule Soriatane COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Auto-PA; AL (Min 18 Years)

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Auto-PA

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Auto-PA; AL (Min 18 Years)

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Auto-PA; AL (Min 18 Years)

*Antipsoriatics*** calcipotriene cream 0.005 % external Dovonex PA; QLL (4 GM per 1 day) calcipotriene cream 0.005 % external Dovonex PA; QLL (4 GM per 30 days) calcipotriene external ointment Calcitrene PA; QLL (4 GM per 1 day) calcitriol external ointment Vectical

95

Formulary Drug Name Reference Restrictions tazarotene external cream Tazorac QLL (3 GM per 1 day) TAZORAC EXTERNAL CREAM Tazarotene QLL (3 GM per 1 day)

*Antiseborrheic Combinations*** selenium sulfide external shampoo

*Antiseborrheic Products*** selenium sulfide external lotion selenium sulfide external shampoo

*Antivirals - Topical*** acyclovir external cream Zovirax

acyclovir external ointment Zovirax QLL (30 GM per 30 days); AL (Min 12 Years)

DENAVIR EXTERNAL CREAM

*Burn Products*** silver sulfadiazine external cream Silvadene

*Cauterizing Agents*** silver nitrate external solution

*Corticosteroids - Topical*** betamethasone dipropionate aug external cream Diprolene AF

betamethasone dipropionate aug external gel betamethasone dipropionate aug external ointment Diprolene

betamethasone valerate external cream clobetasol prop emollient base external cream ST clobetasol propionate e external cream ST clobetasol propionate external cream Temovate ST clobetasol propionate external gel ST clobetasol propionate external ointment 0.05 % Temovate ST

clobetasol propionate external solution ST clobetasol propionate ointment 0.05 % external Temovate

fluocinolone acetonide body external oil Derma-Smoothe/FS Body fluocinolone acetonide scalp external oil Derma-Smoothe/FS Scalp fluocinonide external cream fluticasone propionate external cream fluticasone propionate external ointment halobetasol propionate external cream halobetasol propionate external ointment 96

Formulary Drug Name Reference Restrictions hydrocortisone external cream Aveeno Anti-Itch Max St hydrocortisone external ointment Cortizone-10 mometasone furoate external cream Elocon mometasone furoate external ointment mometasone furoate external solution triamcinolone acetonide external cream Triderm triamcinolone acetonide external ointment DERMA-SMOOTHE/FS BODY EXTERNAL OIL Fluocinolone Acetonide Body

TRIDERM EXTERNAL CREAM Triamcinolone Acetonide

*Emollient Combinations*** lactic acid e external cream mineral oil-hydrophil petrolat external ointment OTC

vitamin e beauty external oil OTC CAVILON EMOLLIENT EXTERNAL CREAM OTC

CAVILON FOOT & DRY SKIN EXTERNAL CREAM OTC

VITAMIN E & C BEAUTY LOTION EXTERNAL LOTION OTC

VITAMIN E & K BEAUTIFUL SKIN EXTERNAL OIL OTC

VITAMINS E & A BEAUTY OIL EXTERNAL OIL OTC

VITAMINS E & D BEAUTY OIL EXTERNAL OIL OTC

VITA-RAY EXTERNAL CREAM OTC

*Emollient/Keratolytic Agents*** urea external cream urea external lotion Cerovel

*Emollients*** ammonium lactate external cream Geri-Hydrolac 12 ammonium lactate external lotion AL12

*Enzymes - Topical*** SANTYL EXTERNAL OINTMENT

*Imidazole-Related Antifungals -Topical*** clotrimazole external cream Clotrimazole GRx

97


clotrimazole external solution FungiCure Intensive/NailGuard

econazole nitrate external cream ketoconazole external cream ketoconazole external shampoo Nizoral miconazole nitrate external cream Carrington Antifungal OTC

*Immunomodulators Imidazoquinolinamines - Topical***

imiquimod external cream Aldara QLL (60 EA per 30 days); AL (Min 12 Years)

*Keratolytic/Antimitotic Agents*** podofilox external solution salicylic acid external cream

*Local Anesthetics - Topical*** gnp lidocaine pain relief external patch Aspercreme Lidocaine OTC; QLL (1 EA per 1 day) lidocaine external ointment

lidocaine external patch Lidoderm Auto-PA; QLL (90 EA per 30 days)

lidocaine hcl external cream QLL (60 GM per 30 days) lidocaine hcl external solution lidocaine hcl urethral/mucosal external gel Glydo qc lidocaine pain relief external patch Aspercreme Lidocaine OTC; QLL (1 EA per 1 day) ra lidocaine pain relieving external patch Aspercreme Lidocaine OTC; QLL (1 EA per 1 day) theracare pain relief external patch Aspercreme Lidocaine OTC; QLL (1 EA per 1 day)

*Macrolide Immunosuppressants -Topical*** pimecrolimus external cream Elidel ST; QLL (1 FILL per 28 days) tacrolimus ointment 0.03 % external Protopic QLL (1 FILL per 30 days)

tacrolimus ointment 0.1 % external Protopic QLL (1 FILL per 30 days); AL (Min 16 Years)

ELIDEL EXTERNAL CREAM Pimecrolimus ST; QLL (1 FILL per 28 days)

*Rosacea Agents*** azelaic acid external gel Finacea metronidazole external cream MetroCream metronidazole external gel Rosadan

*Scabicides & Pediculicides***

malathion external lotion Ovide QL: Maximum of 2 prescription fills every 60 days; QLL (60 ML per 30 days)

98

Formulary Drug Name Reference Restrictions permethrin external cream Elimite spinosad external suspension Natroba SKLICE EXTERNAL LOTION

*Topical Anesthetic Combinations*** lidocaine-prilocaine external cream QLL (30 GM per 30 days) lidocaine-prilocaine external kit DermacinRx Empricaine

*DIAGNOSTIC PRODUCTS* *Diagnostic Drugs*** glucagon hcl (diagnostic) injection solution reconstituted QLL (1 EA per 365 days)

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED QLL (1 EA per 365 days)

*Diagnostic Tests*** ketone test in vitro strip Chemstrip K OTC KETOSTIX IN VITRO STRIP Ketone Test OTC ONETOUCH ULTRA BLUE IN VITRO STRIP Liberty Test OTC; QLL (200 EA per 30

days)

ONETOUCH VERIO IN VITRO STRIP Liberty Test OTC; QLL (200 EA per 30 days)

RELION KETONE IN VITRO STRIP Ketone Test OTC

*DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES VIOKACE ORAL TABLET ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES

*DIRECT-ACTING P2Y12 INHIBITORS*** *Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET

99

Formulary Drug Name Reference Restrictions *DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour

Maintenance drug with max 100 day supply

acetazolamide tablet 125 mg oral Maintenance drug with max 100 days supply

acetazolamide tablet 250 mg oral

acetazolamide tablet 250 mg oral Maintenance drug with max 100 days supply

methazolamide oral tablet

*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet spironolactone-hctz oral tablet Aldactazide triamterene-hctz oral capsule Dyazide

triamterene-hctz tablet 37.5-25 mg oral Maxzide-25 Maintenance drug with max 100 day supply

triamterene-hctz tablet 37.5-25 mg oral Maxzide-25

triamterene-hctz tablet 75-50 mg oral Maxzide Maintenance drug with max 100 day supply

*Loop Diuretics*** bumetanide injection solution bumetanide oral tablet Bumex furosemide injection solution furosemide oral solution

furosemide oral tablet Lasix Maintenance drug with max 100 days supply

torsemide oral tablet

*Potassium Sparing Diuretics*** amiloride hcl oral tablet

spironolactone tablet 100 mg oral Aldactone Maintenance drug with max 100 days supply

spironolactone tablet 100 mg oral Aldactone


spironolactone tablet 25 mg oral Aldactone Maintenance drug with max 100 day supply




100

Formulary Drug Name Reference Restrictions *Thiazides And Thiazide-Like Diuretics***

chlorothiazide oral tablet Maintenance drug with max 100 days supply

chlorthalidone tablet 25 mg oral Maintenance drug with max 100 day supply

chlorthalidone tablet 25 mg oral Maintenance drug with max 100 days supply

chlorthalidone tablet 50 mg oral Maintenance drug with max 100 day supply

chlorthalidone tablet 50 mg oral Maintenance drug with max 100 days supply

hydrochlorothiazide capsule 12.5 mg oral Maintenance drug with max 100 days supply

hydrochlorothiazide capsule 12.5 mg oral Maintenance drug with max 100 day supply

hydrochlorothiazide oral tablet Maintenance drug with max 100 days supply

indapamide oral tablet

metolazone oral tablet Maintenance drug with max 100 days supply

DIURIL ORAL SUSPENSION AL (Max 11 Years)

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral tablet pamidronate disodium intravenous solution pamidronate disodium intravenous solution reconstituted zoledronic acid intravenous concentrate zoledronic acid solution 4 mg/100ml intravenous zoledronic acid solution 5 mg/100ml intravenous Reclast QLL (100 ML per 355 days)

*Calcitonins***

calcitonin (salmon) nasal solution Miacalcin QLL (3.7 ML per 28 days); AL (Min 18 Years)

*Carnitine Replenisher - Agents*** levocarnitine oral solution Carnitor levocarnitine oral tablet Carnitor

101

Formulary Drug Name Reference Restrictions *Corticotropin***

ACTHAR INJECTION GEL PA; QL: age =/18: maximum 1.5ml/day

*Dopamine Receptor Agonists*** cabergoline tablet 0.5 mg oral cabergoline tablet 0.5 mg oral QLL (16 EA per 30 days)

*Fabry Disease - Agents*** FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA; AL (Min 8 Years)

*Gnrh/Lhrh Antagonists*** ORILISSA ORAL TABLET PA

*Growth Hormones*** GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED

PA; AL (Max 16 Years)

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED PA; AL (Max 16 Years)

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PA; AL (Max 16 Years)

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; AL (Min 18 Years)

*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents*** ORFADIN ORAL CAPSULE PA ORFADIN ORAL SUSPENSION PA

*Homocystinuria Treatment -Agents*** CYSTADANE ORAL POWDER

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol intravenous solution calcitriol oral capsule Rocaltrol calcitriol oral solution Rocaltrol doxercalciferol oral capsule paricalcitol intravenous solution Zemplar paricalcitol oral capsule Zemplar

102

Formulary Drug Name Reference Restrictions *Lhrh/Gnrh Agonist Analog Pituitary Suppressants***

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT

Auto-PA; QLL (1 EA per 28 days); AL (Min 2 Years and Max 12 Years)

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT

Auto-PA; QLL (1 EA per 84 days); AL (Min 2 Years and Max 12 Years)

SYNAREL NASAL SOLUTION Auto-PA; QLL (20 ML per 27 days)

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

PA; AL (Min 2 Years and Max 12 Years)

*Mucopolysaccharidosis Vi (Mps Vi) - Agents*** NAGLAZYME INTRAVENOUS SOLUTION AL (Min 5 Years)

*Parathyroid Hormone And Derivatives*** TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QLL (1.56 ML per 30 days)

*Somatostatic Agents*** octreotide acetate injection solution

*Vasopressin*** desmopressin acetate injection solution DDAVP desmopressin acetate oral tablet DDAVP desmopressin acetate spray nasal solution DDAVP STIMATE NASAL SOLUTION

*ESTROGENS* *Estrogen & Androgen*** est estrogens-methyltest ds oral tablet Covaryx est estrogens-methyltest hs oral tablet Covaryx HS

*Estrogen & Progestin*** estradiol-norethindrone acet oral tablet Activella AL (Min 18 Years) norethindrone-eth estradiol oral tablet Femhrt Low Dose AL (Min 18 Years) CLIMARA PRO TRANSDERMAL PATCH WEEKLY QLL (4 EA per 28 days)

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY FEMHRT LOW DOSE ORAL TABLET Norethindrone-Eth Estradiol AL (Min 18 Years) PREMPHASE ORAL TABLET QLL (1 EA per 1 day)

103

Formulary Drug Name Reference Restrictions PREMPRO ORAL TABLET QLL (1 EA per 1 day)

*Estrogens*** estradiol oral tablet Estrace estradiol transdermal patch weekly Climara QLL (4 EA per 30 days) estradiol valerate intramuscular oil Delestrogen PREMARIN ORAL TABLET

*FLUOROQUINOLONES* *Fluoroquinolones*** ciprofloxacin hcl oral tablet Cipro AL (Min 12 Years) ciprofloxacin in d5w intravenous solution ciprofloxacin oral suspension reconstituted Cipro AL (Min 11 Years) levofloxacin in d5w intravenous solution levofloxacin oral tablet Levaquin AL (Min 12 Years)

*GASTROINTESTINAL AGENTS -MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule Actigall ursodiol oral tablet Urso 250

*Gastrointestinal Antiallergy Agents*** cromolyn sodium oral concentrate Gastrocrom

*Gastrointestinal Stimulants***

metoclopramide hcl oral solution QL: ages 18: maximum 60mg/day

metoclopramide hcl oral tablet Reglan QL: ages 18: maximum 60mg/day

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS CAPSULE 145 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS CAPSULE 290 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS CAPSULE 72 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS ORAL CAPSULE 290 MCG, 72 MCG PA; AL (Min 18 Years)

*Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** alosetron hcl oral tablet Lotronex LOTRONEX ORAL TABLET Alosetron HCl

104

Formulary Drug Name Reference Restrictions *Inflammatory Bowel Agents*** mesalamine oral capsule delayed release Delzicol mesalamine rectal suppository Canasa sulfasalazine oral tablet Azulfidine sulfasalazine oral tablet delayed release Azulfidine EN-tabs APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR

*Intestinal Acidifiers*** lactulose encephalopathy oral solution

*Peripheral Opioid Receptor Antagonists*** MOVANTIK ORAL TABLET Auto-PA

*Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule PhosLo calcium acetate (phos binder) oral tablet Calphron sevelamer carbonate oral packet Renvela AL (Max 11 Years) sevelamer hcl oral tablet AL (Max 11 Years)

*GENITOURINARY AGENTS -MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** dutasteride oral capsule Avodart finasteride oral tablet Proscar

*Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hour Uroxatral

tamsulosin hcl oral capsule Flomax M; QLL (2 EA per 1 day)

*Anti-Infective Genitourinary Irrigants*** neomycin-polymyxin b gu irrigation solution

*Citrates*** potassium citrate er oral tablet extended release Urocit-K 5

potassium citrate-citric acid oral solution sod citrate-citric acid oral solution tricitrates oral solution ORACIT ORAL SOLUTION

105

Formulary Drug Name Reference Restrictions *Cystinosis Agents*** CYSTAGON ORAL CAPSULE

*Genitourinary Irrigants*** acetic acid irrigation solution sodium chloride irrigation solution Argyle Sterile Saline sorbitol irrigation solution sorbitol-mannitol irrigation solution RENACIDIN IRRIGATION SOLUTION

*Phosphates*** K-PHOS NO 2 ORAL TABLET

*Urinary Analgesics*** phenazopyridine hcl oral tablet Pyridium

*Urinary Stone Agents*** THIOLA ORAL TABLET

*GLYCOPEPTIDES*** *Glycopeptides*** vancomycin hcl in dextrose intravenous solution vancomycin hcl in nacl intravenous solution vancomycin hcl intravenous solution reconstituted vancomycin hcl oral capsule Vancocin HCl

*GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet

*Gout Agents***

allopurinol tablet 100 mg oral Zyloprim Maintenance drug with max 100 day supply

allopurinol tablet 100 mg oral Zyloprim

allopurinol tablet 300 mg oral Zyloprim Maintenance drug with max 100 day supply

colchicine oral capsule Mitigare QLL (6 EA per 30 days); AL (Min 4 Years)

colchicine oral tablet Colcrys QLL (6 EA per 30 days); AL (Min 4 Years)

*Uricosurics*** probenecid oral tablet

106

Formulary Drug Name Reference Restrictions *HEMATOLOGICAL AGENTS -MISC.* *Antihemophilic Products*** adynovate intravenous solution reconstituted obizur intravenous solution reconstituted rixubis intravenous solution reconstituted Ixinity ADVATE INTRAVENOUS SOLUTION RECONSTITUTED AFSTYLA INTRAVENOUS KIT ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED BENEFIX INTRAVENOUS KIT COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED CORIFACT INTRAVENOUS KIT ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED FEIBA INTRAVENOUS SOLUTION RECONSTITUTED HELIXATE FS INTRAVENOUS KIT HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED IDELVION INTRAVENOUS SOLUTION RECONSTITUTED IXINITY INTRAVENOUS SOLUTION RECONSTITUTED Rixubis

JIVI INTRAVENOUS SOLUTION RECONSTITUTED AL (Min 12 Years)

KOATE INTRAVENOUS SOLUTION RECONSTITUTED KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED KOGENATE FS INTRAVENOUS KIT KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED

107

Formulary Drug Name Reference Restrictions MONONINE INTRAVENOUS SOLUTION RECONSTITUTED NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED NUWIQ INTRAVENOUS KIT NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED REBINYN INTRAVENOUS SOLUTION RECONSTITUTED RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED WILATE INTRAVENOUS KIT XYNTHA INTRAVENOUS KIT XYNTHA SOLOFUSE INTRAVENOUS KIT

*Bradykinin B2 Receptor Antagonists***

FIRAZYR SUBCUTANEOUS SOLUTION Icatibant Acetate Auto-PA; QLL (9 ML per 30 days); AL (Min 18 Years)

*C1 Inhibitors***

BERINERT INTRAVENOUS KIT Auto-PA; QLL (16 VIALS per 28 days); AL (Min 12 Years)

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED

Auto-PA; QLL (20 VIALS per 28 days); AL (Min 6 Years)

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED

Auto-PA; QLL (8 VIALS per 30 days); AL (Min 12 Years)

*Cyclopentyltriazolopyrimidine (Cptp) Derivatives*** BRILINTA ORAL TABLET

*Hematorheologic Agents*** pentoxifylline er oral tablet extended release

108

Formulary Drug Name Reference Restrictions *Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet

*Plasma Proteins*** albumin human intravenous solution Albuked 25 PA alburx intravenous solution Albuked 5 PA kedbumin intravenous solution Albuked 25 PA ALBUKED 25 INTRAVENOUS SOLUTION Kedbumin PA

ALBUKED 5 INTRAVENOUS SOLUTION Albumin Human PA

ALBUMINEX INTRAVENOUS SOLUTION PA

ALBUTEIN INTRAVENOUS SOLUTION Kedbumin PA FLEXBUMIN INTRAVENOUS SOLUTION Kedbumin PA

PLASBUMIN-25 INTRAVENOUS SOLUTION Kedbumin

PLASBUMIN-5 INTRAVENOUS SOLUTION Albumin Human PA

PLASMANATE INTRAVENOUS SOLUTION PA

*Platelet Aggregation Inhibitor Combinations*** aspirin-dipyridamole er oral capsule extended release 12 hour Aggrenox

*Platelet Aggregation Inhibitors*** dipyridamole oral tablet

*Quinazoline Agents*** anagrelide hcl oral capsule Agrylin

*Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet Plavix prasugrel hcl oral tablet Effient QLL (1 EA per 1 day)

*Tissue Plasminogen Activators*** CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED QLL (2 EA per 28 days)

*HEMATOPOIETIC AGENTS* *Agents For Gaucher Disease***

miglustat capsule 100 mg oral Zavesca QLL (3 EA per 1 day); AL (Min 18 Years)

miglustat capsule 100 mg oral Zavesca 109


miglustat oral capsule 100 mg Zavesca QLL (3 EA per 1 day); AL (Min 18 Years)

CERDELGA ORAL CAPSULE Auto-PA; QLL (2 EA per 1 day); AL (Min 18 Years)

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED

Auto-PA; QLL (82 EA per 28 days); AL (Min 4 Years)

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED

Auto-PA; QLL (41 EA per 28 days); AL (Min 4 Years)

*Cobalamin Combinations*** FOLTRATE ORAL TABLET Vitamin B12-Folic Acid

*Cobalamins*** cyanocobalamin injection solution QLL (2 ML per 28 days)

*Cxcr4 Receptor Antagonist*** MOZOBIL SUBCUTANEOUS SOLUTION PA

*Erythropoiesis-Stimulating Agents (Esas)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION PA

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

PA

EPOGEN INJECTION SOLUTION Auto-PA RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

PA

RETACRIT SOLUTION 10000 UNIT/ML INJECTION RETACRIT SOLUTION 2000 UNIT/ML INJECTION RETACRIT SOLUTION 3000 UNIT/ML INJECTION RETACRIT SOLUTION 4000 UNIT/ML INJECTION RETACRIT SOLUTION 40000 UNIT/ML INJECTION

*Erythropoietins*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION PA

110

Formulary Drug Name Reference Restrictions ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

PA

EPOGEN INJECTION SOLUTION Auto-PA RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

PA

RETACRIT SOLUTION 10000 UNIT/ML INJECTION RETACRIT SOLUTION 2000 UNIT/ML INJECTION RETACRIT SOLUTION 3000 UNIT/ML INJECTION RETACRIT SOLUTION 4000 UNIT/ML INJECTION RETACRIT SOLUTION 40000 UNIT/ML INJECTION

*Folic Acid/Folates*** folic acid injection solution

folic acid oral tablet Maintenance drug with max 100 day supply

*Granulocyte Colony-Stimulating Factors (G-Csf)*** FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA

GRANIX SUBCUTANEOUS SOLUTION PA GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT PA

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA

NEUPOGEN INJECTION SOLUTION PA NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE PA

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE PA

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

111

Formulary Drug Name Reference Restrictions ZARXIO SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION ZARXIO SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION PA

ZARXIO SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION ZARXIO SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION PA

*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE INJECTION SOLUTION RECONSTITUTED PA

*Iron Combinations*** purevit dualfe plus oral capsule K-Tan Plus se-tan plus oral capsule K-Tan Plus taron forte oral capsule FUSION PLUS ORAL CAPSULE HEMATOGEN FA ORAL CAPSULE HEMOCYTE PLUS ORAL CAPSULE IFEREX 150 FORTE ORAL CAPSULE Poly-Iron 150 Forte INTEGRA PLUS ORAL CAPSULE Virt-FeFA Plus TRICON ORAL CAPSULE Ferotrinsic

*Iron W/ Folic Acid*** FOLIVANE-F ORAL CAPSULE HEMOCYTE-F ORAL TABLET Hematinic/Folic Acid INTEGRA F ORAL CAPSULE

*Iron*** ferrous fumarate oral tablet Ferrocite OTC ferrous gluconate oral tablet OTC ferrous sulfate oral elixir OTC ferrous sulfate oral solution BProtected Pedia Iron OTC ferrous sulfate oral syrup OTC ferrous sulfate oral tablet FeroSul OTC ferrous sulfate oral tablet delayed release OTC ferrousul oral tablet FeroSul OTC gnp iron oral tablet Feosol OTC gnp iron oral tablet extended release Slow Fe OTC sm slow release iron oral tablet extended release OTC

112

Formulary Drug Name Reference Restrictions FEOSOL NATURAL RELEASE ORAL TABLET EQL Carbonyl Iron OTC

FEOSOL ORAL TABLET HM Iron OTC FERATE ORAL TABLET Ferrotabs OTC FER-IN-SOL ORAL SOLUTION Iron Supplement Childrens OTC FEROSUL ORAL TABLET GNP Iron OTC FERRIMIN 150 ORAL TABLET OTC HEMOCYTE ORAL TABLET Ferrous Fumarate OTC

*Iron-B12-Folate*** ferraplus 90 oral tablet

*HEMOSTATICS* *Hemostatics - Systemic*** aminocaproic acid intravenous solution aminocaproic acid oral tablet Amicar tranexamic acid intravenous solution Cyklokapron tranexamic acid oral tablet Lysteda QLL (30 EA per 28 days) tranexamic acid-nacl intravenous solution AMICAR ORAL SOLUTION Aminocaproic Acid

*HEPATITIS C AGENT -COMBINATIONS*** *Hepatitis C Agent -Combinations*** MAVYRET ORAL TABLET PA; AL (Min 18 Years) VOSEVI ORAL TABLET PA; AL (Min 18 Years)

*HYPNOTICS* *Barbiturate Hypnotics*** phenobarbital oral elixir phenobarbital oral solution phenobarbital oral tablet

*Benzodiazepine Hypnotics*** temazepam oral capsule Restoril AL (Min 18 Years)

*Non-Benzodiazepine - Gaba-Receptor Modulators*** zaleplon oral capsule zolpidem tartrate oral tablet Ambien AL (Min 18 Years)

*Selective Melatonin Receptor Agonists*** ramelteon oral tablet Rozerem

113

Formulary Drug Name Reference Restrictions *LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted Colyte with Flavor Packs QLL (4000 ML per 1 Fill)

peg 3350-kcl-na bicarb-nacl oral solution reconstituted GaviLyte-N with Flavor Pack

peg-3350/electrolytes oral solution reconstituted GaviLyte-G QLL (4000 ML per 1 Fill)

GOLYTELY ORAL SOLUTION RECONSTITUTED PEG-3350/Electrolytes QLL (4000 ML per 1 Fill)

TRILYTE ORAL SOLUTION RECONSTITUTED

PEG 3350-KCl-Na Bicarb-NaCl

*Laxatives - Miscellaneous*** lactulose oral solution QLL (180 ML per 1 day) peg 3350 oral packet CVS Purelax OTC

peg 3350 oral powder ClearLax OTC; QLL (527 GM per 30 days)

polyethylene glycol 3350 oral packet CVS Purelax QLL (527 GM per 30 days) polyethylene glycol 3350 oral powder ClearLax QLL (527 GM per 30 days) CLEARLAX ORAL POWDER GentleLax OTC

*Surfactant Laxatives*** ENEMEEZ MINI RECTAL ENEMA Docusate Mini OTC; AL (Min 12 Years) ENEMEEZ PLUS RECTAL ENEMA OTC; AL (Min 12 Years)

*LHRH/GNRH AGONIST ANALOG COMBINATIONS*** *Lhrh/Gnrh Agonist Analog Combinations*** LUPANETA PACK COMBINATION KIT 11.25 & 5 MG


LUPANETA PACK COMBINATION KIT 3.75 & 5 MG


LUPANETA PACK KIT 11.25 & 5 MG COMBINATION


LUPANETA PACK KIT 3.75 & 5 MG COMBINATION


114

Formulary Drug Name Reference Restrictions *LOCAL ANESTHETICS-PARENTERAL* *Local Anesthetic & Sympathomimetic*** bupivacaine-epinephrine (pf) injection solution Marcaine/Epinephrine PF

bupivacaine-epinephrine injection solution Marcaine/Epinephrine lidocaine-epinephrine injection solution Xylocaine/Epinephrine XYLOCAINE/EPINEPHRINE INJECTION SOLUTION Lidocaine-Epinephrine

*Local Anesthetics - Amides*** bupivacaine fisiopharma injection solution Marcaine Preservative Free bupivacaine hcl (pf) injection solution Marcaine Preservative Free bupivacaine hcl injection solution Marcaine bupivacaine spinal intrathecal solution Marcaine Spinal lidocaine hcl (pf) injection solution Xylocaine-MPF lidocaine hcl injection solution Xylocaine lidocaine in dextrose solution XYLOCAINE INJECTION SOLUTION Lidocaine HCl

*MACROLIDES* *Azithromycin*** azithromycin intravenous solution reconstituted Zithromax

azithromycin oral packet Zithromax azithromycin oral suspension reconstituted Zithromax azithromycin oral tablet Zithromax

*Clarithromycin*** clarithromycin er oral tablet extended release 24 hour clarithromycin oral suspension reconstituted clarithromycin oral tablet

*Erythromycins*** erythromycin ethylsuccinate oral suspension reconstituted E.E.S. Granules AL (Min 11 Years)

*Fidaxomicin***

DIFICID ORAL TABLET QLL (20 EA per 10 days); AL (Min 18 Years)

115

Formulary Drug Name Reference Restrictions *MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** alcohol pads pad Alcoh-Glove Contoured Wipe OTC alcohol prep pad Alcoh-Glove Contoured Wipe OTC alcohol swabs pad Alcoh-Glove Contoured Wipe OTC alcohol wipes pad Alcoh-Glove Contoured Wipe OTC alcoh-wipe sheet cvs alcohol prep pads pad Alcoh-Glove Contoured Wipe OTC cvs prep pad Alcoh-Glove Contoured Wipe OTC eql alcohol swabs pad Alcoh-Glove Contoured Wipe OTC global alcohol prep ease pad Alcoh-Glove Contoured Wipe OTC gnp alcohol swabs pad Alcoh-Glove Contoured Wipe OTC h-e-b incontrol alcohol pad Alcoh-Glove Contoured Wipe OTC meijer alcohol swabs pad Alcoh-Glove Contoured Wipe OTC pro comfort alcohol pad Alcoh-Glove Contoured Wipe OTC qc alcohol swabs pad Alcoh-Glove Contoured Wipe OTC ra alcohol swabs pad Alcoh-Glove Contoured Wipe OTC reality swabs pad Alcoh-Glove Contoured Wipe OTC saps care alcohol prep pad Alcoh-Glove Contoured Wipe OTC sb alcohol prep pad Alcoh-Glove Contoured Wipe OTC sm alcohol prep pad Alcoh-Glove Contoured Wipe OTC sure comfort alcohol prep pad Alcoh-Glove Contoured Wipe OTC tgt alcohol swabs pad Alcoh-Glove Contoured Wipe OTC ALCOH-GLOVE CONTOURED WIPE PAD Sure Comfort Alcohol Prep

BD SWAB SINGLE USE REGULAR PAD Sure Comfort Alcohol Prep OTC BD SWABS SINGLE USE BUTTERFLY PAD Sure Comfort Alcohol Prep OTC

CARETOUCH ALCOHOL PREP PAD Sure Comfort Alcohol Prep OTC CURITY ALCOHOL PREPS PAD Sure Comfort Alcohol Prep OTC CURITY ALCOHOL SWABS PAD Sure Comfort Alcohol Prep OTC EASY TOUCH ALCOHOL PREP MEDIUM PAD Sure Comfort Alcohol Prep OTC

FIFTY50 ALCOHOL PREP PAD Sure Comfort Alcohol Prep OTC PHARMACIST CHOICE ALCOHOL PAD Sure Comfort Alcohol Prep OTC RELION ALCOHOL SWABS PAD Sure Comfort Alcohol Prep OTC SHOPKO ALCOHOL SWABS PAD Sure Comfort Alcohol Prep OTC SURE-PREP ALCOHOL PREP PAD Sure Comfort Alcohol Prep OTC ULTICARE ALCOHOL SWABS PAD Sure Comfort Alcohol Prep OTC 116

Formulary Drug Name Reference Restrictions WEBCOL ALCOHOL PREP LARGE PAD Sure Comfort Alcohol Prep OTC

WEBCOL ALCOHOL PREP MEDIUM PAD Sure Comfort Alcohol Prep OTC

*Diaphragms*** CAYA VAGINAL DIAPHRAGM

*Glucose Monitoring Test Supplies*** 1st tier unilet comfortouch Accu-Chek FastClix Lancets OTC acti-lance 28g Accu-Chek FastClix Lancets OTC acti-lance lite lancets 28g Accu-Chek FastClix Lancets OTC acti-lance special lancets 17g Accu-Chek FastClix Lancets OTC acti-lance universal 23g Accu-Chek FastClix Lancets OTC adjustable lancing device Advocate Lancing Device OTC alternate site lancing device Advocate Lancing Device OTC aqua lance adjustable lancing device Advocate Lancing Device OTC assure comfort lancets 28g Accu-Chek FastClix Lancets OTC aurora lancet super thin 30g Accu-Chek FastClix Lancets OTC aurora lancet thin 23g Accu-Chek FastClix Lancets OTC bullseye mini safety lancets Accu-Chek FastClix Lancets OTC careone advanced lancing dev Advocate Lancing Device OTC careone lancet thin 23g Accu-Chek FastClix Lancets OTC careone lancet ultra thin 28g Accu-Chek FastClix Lancets OTC comfort assured lancets 28g Accu-Chek FastClix Lancets OTC comfort assured lancets 33g Accu-Chek FastClix Lancets OTC comfort lancets Accu-Chek FastClix Lancets OTC control in vitro solution Advance Intuition Control OTC cvs lancets 21g Accu-Chek FastClix Lancets OTC cvs lancets micro thin 33g Accu-Chek FastClix Lancets OTC cvs lancets original Accu-Chek FastClix Lancets OTC cvs lancets thin 26g Accu-Chek FastClix Lancets OTC cvs lancets ultra thin 30g Accu-Chek FastClix Lancets OTC cvs lancets ultra-thin 30g Accu-Chek FastClix Lancets OTC cvs lancing device Advocate Lancing Device OTC cvs ultra thin lancets Accu-Chek FastClix Lancets OTC diatrue control level 1 in vitro solution Advocate Control Solution OTC diatrue control level 2 in vitro solution Advance Intuition Control OTC diatrue control level 3 in vitro solution Advocate Control Solution OTC drug mart lancets thin 26g Accu-Chek FastClix Lancets OTC

117

Formulary Drug Name Reference Restrictions easy comfort lancets Accu-Chek FastClix Lancets OTC easy mini eject lancing device Advocate Lancing Device OTC easy mini lancing device Advocate Lancing Device OTC easy plus ii control in vitro solution Advocate Control Solution OTC easy talk control in vitro solution Advocate Control Solution OTC easy trak control in vitro solution Advocate Control Solution OTC element compact control 2 in vitro solution Accu-Chek Aviva OTC element compact control 3 in vitro solution Accu-Chek Aviva OTC eql color lancets 21g Accu-Chek FastClix Lancets OTC eql color lancets micro 33g Accu-Chek FastClix Lancets OTC eql super thin lancets 30g Accu-Chek FastClix Lancets OTC eql thin lancets 26g Accu-Chek FastClix Lancets OTC freds pharmacy autolet lancing Advocate Lancing Device OTC freds pharmacy unilet lanc 28g Accu-Chek FastClix Lancets OTC freds pharmacy unilet lanc 30g Accu-Chek FastClix Lancets OTC ge100 control in vitro solution Advance Intuition Control OTC global inject ease lancets 28g Accu-Chek FastClix Lancets OTC global inject ease lancets 30g Accu-Chek FastClix Lancets OTC global lancing device Advocate Lancing Device OTC glucose control in vitro solution Accu-Chek Aviva OTC gnp lancets Accu-Chek FastClix Lancets OTC gnp lancets 21g Accu-Chek FastClix Lancets OTC gnp lancets micro thin 33g Accu-Chek FastClix Lancets OTC gnp lancets super thin 30g Accu-Chek FastClix Lancets OTC gnp lancets thin Accu-Chek FastClix Lancets OTC gnp lancets thin 26g Accu-Chek FastClix Lancets OTC gnp micro thin lancets 33g Accu-Chek FastClix Lancets OTC gnp super thin lancets 30g Accu-Chek FastClix Lancets OTC goodsense lancets 30g Accu-Chek FastClix Lancets OTC goodsense lancets 33g Accu-Chek FastClix Lancets OTC goodsense lancing device Advocate Lancing Device OTC healthy accents lancing device Advocate Lancing Device OTC healthy accents unilet lancets Accu-Chek FastClix Lancets OTC h-e-b incontrol adv lancing Advocate Lancing Device OTC h-e-b incontrol lancets 28g Accu-Chek FastClix Lancets OTC h-e-b incontrol lancets 30g Accu-Chek FastClix Lancets OTC h-e-b incontrol lancets 33g Accu-Chek FastClix Lancets OTC hy-vee thin lancets Accu-Chek FastClix Lancets OTC

118

Formulary Drug Name Reference Restrictions kinney lancets Accu-Chek FastClix Lancets OTC kinney thin lancets Accu-Chek FastClix Lancets OTC kroger lancets Accu-Chek FastClix Lancets OTC kroger lancets 21g Accu-Chek FastClix Lancets OTC kroger lancets micro thin 33g Accu-Chek FastClix Lancets OTC kroger lancets super thin Accu-Chek FastClix Lancets OTC kroger lancets thin Accu-Chek FastClix Lancets OTC kroger lancets thin 26g Accu-Chek FastClix Lancets OTC kroger lancets ultrathin 30g Accu-Chek FastClix Lancets OTC kroger lancing device Advocate Lancing Device OTC lancet device Advocate Lancing Device OTC lancet device with ejector Advocate Lancing Device OTC lancet transporter case Autolet Platforms OTC lancets Accu-Chek FastClix Lancets OTC lancets 28g Accu-Chek FastClix Lancets OTC lancets 30g Accu-Chek FastClix Lancets OTC lancets micro thin 33g Accu-Chek FastClix Lancets OTC lancets super thin 28g Accu-Chek FastClix Lancets OTC lancets thin Accu-Chek FastClix Lancets OTC lancets ultra thin 30g Accu-Chek FastClix Lancets OTC lancing device Advocate Lancing Device OTC leader advanced lancing device Advocate Lancing Device OTC lite touch lancets Accu-Chek FastClix Lancets OTC live better adv lancing device Advocate Lancing Device OTC live better lancet super thin Accu-Chek FastClix Lancets OTC live better lancet ultra thin Accu-Chek FastClix Lancets OTC longs lancets standard Accu-Chek FastClix Lancets OTC longs lancets thin Accu-Chek FastClix Lancets OTC longs lancets ultra thin Accu-Chek FastClix Lancets OTC medichoice safety lancet Accu-Chek FastClix Lancets OTC medichoice safety lancet extra Accu-Chek FastClix Lancets OTC medichoice safety lancet norm Accu-Chek FastClix Lancets OTC mini lancing device Advocate Lancing Device OTC multi-lancet device Advocate Lancing Device OTC pc lancets super thin 30g Accu-Chek FastClix Lancets OTC preferred plus lancets colored Accu-Chek FastClix Lancets OTC preferred plus lancets thin Accu-Chek FastClix Lancets OTC pressure activat safety lancet Accu-Chek FastClix Lancets OTC

119

Formulary Drug Name Reference Restrictions pro comfort lancets 30g Accu-Chek FastClix Lancets OTC pro comfort lancets 31g Accu-Chek FastClix Lancets OTC push button safety lancets Accu-Chek FastClix Lancets OTC px advanced lancing device Advocate Lancing Device OTC px lancet auto injector Advocate Lancing Device OTC px lancets ultra thin Accu-Chek FastClix Lancets OTC qc advanced lancing device Advocate Lancing Device OTC qc lancets super thin 30g Accu-Chek FastClix Lancets OTC qc lancets ultra thin Accu-Chek FastClix Lancets OTC qc unilet lancets 28g Accu-Chek FastClix Lancets OTC qc unilet lancets micro thin Accu-Chek FastClix Lancets OTC ra lancing device Advocate Lancing Device OTC reality lancets Accu-Chek FastClix Lancets OTC reality trigger lancets Accu-Chek FastClix Lancets OTC safety lancet 21g/pressure act Accu-Chek FastClix Lancets OTC safety lancet 28g/pressure act Accu-Chek FastClix Lancets OTC safety lancets 28g Accu-Chek FastClix Lancets OTC sapscare twist top lancets Accu-Chek FastClix Lancets OTC sb lancets thin Accu-Chek FastClix Lancets OTC sb lancets ultra thin Accu-Chek FastClix Lancets OTC select-lite device/lancets kit Accu-Chek FastClix Lancet OTC select-lite lancing device Advocate Lancing Device OTC side button safety lancet Accu-Chek FastClix Lancets OTC sm lancets 33g Accu-Chek FastClix Lancets OTC super thin lancets Accu-Chek FastClix Lancets OTC supreme ii confidence paddles Chemstrip bG Log Book OTC supreme ii high/low control in vitro liquid Accu-Chek Aviva OTC sure comfort lancets 28g Accu-Chek FastClix Lancets OTC sure comfort lancets 30g Accu-Chek FastClix Lancets OTC sure comfort lancing pen Advocate Lancing Device OTC tgt lancet micro thin 33g Accu-Chek FastClix Lancets OTC tgt lancet thin 26g Accu-Chek FastClix Lancets OTC tgt lancet ultra thin 30g Accu-Chek FastClix Lancets OTC tgt lancing device Advocate Lancing Device OTC todays health lancing device Advocate Lancing Device OTC todays health thin lancets 28g Accu-Chek FastClix Lancets OTC todays health thin lancets 30g Accu-Chek FastClix Lancets OTC topcare lancets micro-thin 33g Accu-Chek FastClix Lancets OTC

120

Formulary Drug Name Reference Restrictions travel lancets Accu-Chek FastClix Lancets OTC value plus lancet standard 21g Accu-Chek FastClix Lancets OTC value plus lancets super thin Accu-Chek FastClix Lancets OTC value plus lancets thin 26g Accu-Chek FastClix Lancets OTC value plus lancing device Advocate Lancing Device OTC valumark lancet super thin 30g Accu-Chek FastClix Lancets OTC valumark lancet ultra thin 28g Accu-Chek FastClix Lancets OTC walgreens adv travel lancets Accu-Chek FastClix Lancets OTC walgreens lancets micro thin Accu-Chek FastClix Lancets OTC walgreens lancets super thin Accu-Chek FastClix Lancets OTC ACCU-CHEK AVIVA IN VITRO SOLUTION Glucose Control OTC

ACCU-CHEK COMPACT PLUS CONTROL IN VITRO SOLUTION Glucose Control OTC

ACCU-CHEK FASTCLIX LANCET KIT Select-Lite Device/Lancets OTC ACCU-CHEK FASTCLIX LANCETS Sure Comfort Lancets 28G OTC ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID Glucose Control OTC

ACCU-CHEK MULTICLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

ACCU-CHEK MULTICLIX LANCETS Sure Comfort Lancets 28G OTC ACCU-CHEK SAFE-T PRO LANCETS Sure Comfort Lancets 28G OTC ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Glucose Control OTC

ACCU-CHEK SOFT TOUCH LANCETS Sure Comfort Lancets 28G OTC ACCU-CHEK SOFTCLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

ACCU-CHEK SOFTCLIX LANCETS Sure Comfort Lancets 28G OTC ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID Easy Talk Control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID Glucose Control OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID Glucose Control OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID Easy Trak Control OTC

ADVOCATE LANCETS Sure Comfort Lancets 28G OTC ADVOCATE LANCETS 30G Sure Comfort Lancets 28G OTC ADVOCATE LANCING DEVICE Multi-Lancet Device OTC

121

Formulary Drug Name Reference Restrictions ADVOCATE RAPID-SAFE LANCING Multi-Lancet Device OTC ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION Easy Trak Control OTC

ADVOCATE SAFETY LANCETS Sure Comfort Lancets 28G OTC ADVOCATE SAFETY LANCETS 26G Sure Comfort Lancets 28G OTC AGAMATRIX CONTROL IN VITRO SOLUTION Glucose Control OTC

AGAMATRIX ULTRA-THIN LANCETS Sure Comfort Lancets 28G OTC AQUALANCE LANCETS 30G Sure Comfort Lancets 28G OTC ASSURE 3 CONTROL IN VITRO LIQUID Glucose Control OTC ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION Easy Talk Control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

ASSURE HAEMOLANCE PLUS HIGH Sure Comfort Lancets 28G OTC ASSURE HAEMOLANCE PLUS LOW Sure Comfort Lancets 28G OTC ASSURE HAEMOLANCE PLUS MICRO Sure Comfort Lancets 28G OTC ASSURE HAEMOLANCE PLUS NORMAL Sure Comfort Lancets 28G OTC

ASSURE HAEMOLANCE PLUS PED Sure Comfort Lancets 28G OTC ASSURE II CONTROL IN VITRO LIQUID Glucose Control OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

ASSURE LANCE LANCETS Sure Comfort Lancets 28G OTC ASSURE LANCE LANCETS 21G Sure Comfort Lancets 28G OTC ASSURE LANCE PLUS SAFETY 25G Sure Comfort Lancets 28G OTC ASSURE LANCE PLUS SAFETY 30G Sure Comfort Lancets 28G OTC ASSURE LANCETS Sure Comfort Lancets 28G OTC ASSURE PRISM CONTROL LEVEL 1&2 IN VITRO SOLUTION Glucose Control OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

AUTO-LANCET Multi-Lancet Device OTC AUTO-LANCET MINI Multi-Lancet Device OTC AUTOLET II CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LANCING DEVICE Multi-Lancet Device OTC AUTOLET LITE CLINISAFE KIT Select-Lite Device/Lancets OTC AUTOLET LITE STARTER PACK KIT Select-Lite Device/Lancets OTC 122

Formulary Drug Name Reference Restrictions AUTOLET MINI Multi-Lancet Device OTC AUTOLET PLATFORMS Lancet Transporter Case OTC AUTOLET PLUS Multi-Lancet Device OTC BD LANCET ULTRAFINE 30G Sure Comfort Lancets 28G OTC BD LANCET ULTRAFINE 33G Sure Comfort Lancets 28G OTC BD MICROTAINER LANCETS Sure Comfort Lancets 28G OTC BULLSEYE SAFETY LANCETS Sure Comfort Lancets 28G OTC CARDIOCOM LANCING DEVICE Multi-Lancet Device OTC CARESENS CONTROL A IN VITRO SOLUTION Glucose Control OTC

CARETOUCH LANCING/EJECTOR Multi-Lancet Device OTC CARETOUCH TWIST LANCETS 30G Sure Comfort Lancets 28G OTC

CHEMSTRIP BG LOG BOOK Supreme II Confidence Paddles OTC

CLEANLET LANCETS 28G Sure Comfort Lancets 28G OTC CLEVER CHEK LANCETS Sure Comfort Lancets 28G OTC CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID Easy Trak Control OTC

COAGUCHEK LANCETS Sure Comfort Lancets 28G OTC CONTOUR CONTROL IN VITRO LIQUID Easy Trak Control OTC

CONTOUR NEXT CONTROL IN VITRO SOLUTION Easy Talk Control OTC

COOL CONTROL A IN VITRO SOLUTION Glucose Control OTC

COOL CONTROL B IN VITRO SOLUTION Glucose Control OTC

DROPLET LANCETS ULTRA THIN 30G Sure Comfort Lancets 28G OTC DROPLET LANCING DEVICE Multi-Lancet Device OTC DRUG MART LANCING DEVICE Multi-Lancet Device OTC DRUG MART ON-THE-GO LANCET 30G Sure Comfort Lancets 28G OTC DRUG MART UNILET LANCETS 28G Sure Comfort Lancets 28G OTC DRUG MART UNILET LANCETS 30G Sure Comfort Lancets 28G OTC DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

EASY STEP CONTROL IN VITRO SOLUTION Easy Trak Control OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Glucose Control OTC

EASY TOUCH HEALTHPRO CONTROL IN VITRO SOLUTION Glucose Control OTC

123

Formulary Drug Name Reference Restrictions EASY TOUCH LANCETS 21G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 23G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 26G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 26G/TWIST Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 28G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 28G/TWIST Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 30G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 30G/TWIST Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 32G Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 32G/TWIST Sure Comfort Lancets 28G OTC EASY TOUCH LANCETS 33G/TWIST Sure Comfort Lancets 28G OTC EASY TOUCH LANCING DEVICE Multi-Lancet Device OTC EASY TOUCH SAFETY LANCETS 21G Sure Comfort Lancets 28G OTC EASY TOUCH SAFETY LANCETS 23G Sure Comfort Lancets 28G OTC EASY TOUCH SAFETY LANCETS 26G Sure Comfort Lancets 28G OTC EASY TOUCH SAFETY LANCETS 28G Sure Comfort Lancets 28G OTC EASY TWIST & CAP LANCETS Sure Comfort Lancets 28G OTC EASYGLUCO CONTROL IN VITRO SOLUTION Easy Trak Control OTC

EASYGLUCO PLUS LEVEL 1 IN VITRO SOLUTION Glucose Control OTC

EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYMAX 15 LEVEL 1-2 CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYMAX CONTROL IN VITRO SOLUTION Easy Trak Control OTC

EASYMAX CONTROL NORMAL/LOW IN VITRO SOLUTION Glucose Control OTC

ELEMENT CONTROL IN VITRO LIQUID Easy Trak Control OTC

EMBRACE CONTROL IN VITRO SOLUTION Easy Talk Control OTC

EMBRACE EVO CONTROL LEVEL 1 IN VITRO LIQUID Easy Talk Control OTC

EMBRACE EVO CONTROL LEVEL 2 IN VITRO LIQUID Easy Talk Control OTC

EMBRACE GLUCOSE CONTROL IN VITRO LIQUID Easy Trak Control OTC

124

Formulary Drug Name Reference Restrictions EMBRACE LANCETS ULTRA THIN 30G Sure Comfort Lancets 28G OTC EMBRACE PRO GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

EVENCARE CONTROL LOW/HIGH IN VITRO LIQUID Glucose Control OTC

EVENCARE G2 LOW/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

EVENCARE G3 LOW/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

EVENCARE MINI CONTROL IN VITRO SOLUTION Easy Talk Control OTC

EVOLUTION CONTROL IN VITRO SOLUTION Easy Talk Control OTC

E-Z JECT LANCET MICRO-THIN 33G Sure Comfort Lancets 28G OTC E-Z JECT LANCET SUPER THIN 30G Sure Comfort Lancets 28G OTC E-Z JECT LANCETS Sure Comfort Lancets 28G OTC E-Z JECT LANCETS 21G Sure Comfort Lancets 28G OTC E-Z JECT LANCETS THIN 26G Sure Comfort Lancets 28G OTC EZ SMART BLOOD GLUCOSE LANCETS Sure Comfort Lancets 28G OTC

EZ-LETS LANCETS 21G Sure Comfort Lancets 28G OTC EZ-LETS LANCETS 23G Sure Comfort Lancets 28G OTC EZ-LETS LANCETS 26G Sure Comfort Lancets 28G OTC EZ-LETS LANCETS 28G Sure Comfort Lancets 28G OTC EZ-LETS LANCETS 30G Sure Comfort Lancets 28G OTC FIFTY50 SAFETY SEAL LANCETS Sure Comfort Lancets 28G OTC FIFTY50 UNILET LANCETS 33G Sure Comfort Lancets 28G OTC FINE 30 Sure Comfort Lancets 28G OTC FINGERSTIX LANCETS Sure Comfort Lancets 28G OTC FORA CONTROL IN VITRO SOLUTION Easy Trak Control OTC FORA LANCETS Sure Comfort Lancets 28G OTC FORA LANCING DEVICE Multi-Lancet Device OTC FORACARE GDH CONTROL IN VITRO SOLUTION Easy Trak Control OTC

FORTISCARE CONTROL IN VITRO SOLUTION Easy Trak Control OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

FREESTYLE LANCETS Sure Comfort Lancets 28G OTC FREESTYLE UNISTICK II LANCETS Sure Comfort Lancets 28G OTC GENTLE-LET GP LANCETS Sure Comfort Lancets 28G OTC

125

Formulary Drug Name Reference Restrictions GENTLE-LET LANCETS Sure Comfort Lancets 28G OTC GENTLE-LET PLATFORMS Lancet Transporter Case OTC GLUCOCARD 01 CONTROL IN VITRO LIQUID Glucose Control OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION Easy Talk Control OTC

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION Glucose Control OTC

GLUCOCARD SHINE CONTROL IN VITRO SOLUTION Glucose Control OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION Easy Talk Control OTC

GLUCOCOM AUTOLINK TELEMONITOR

Supreme II Confidence Paddles OTC

GLUCOCOM CONTROL IN VITRO LIQUID Easy Trak Control OTC

GLUCOCOM LANCETS 28G Sure Comfort Lancets 28G OTC GLUCOCOM LANCETS 30G Sure Comfort Lancets 28G OTC GLUCOCOM LANCETS 33G Sure Comfort Lancets 28G OTC GNP EASY TOUCH CONT HIGH/LOW IN VITRO SOLUTION Glucose Control OTC

HAEMOLANCE Sure Comfort Lancets 28G OTC HAEMOLANCE LOW FLOW LANCETS Sure Comfort Lancets 28G OTC HAEMOLANCE PLUS Sure Comfort Lancets 28G OTC HAEMOLANCE PLUS HIGH FLOW Sure Comfort Lancets 28G OTC HAEMOLANCE PLUS LOW FLOW Sure Comfort Lancets 28G OTC HAEMOLANCE PLUS MAX FLOW Sure Comfort Lancets 28G OTC HAEMOLANCE PLUS PEDIATRIC FLOW Sure Comfort Lancets 28G OTC

HEALTH CARE LANCING DEVICE Multi-Lancet Device OTC HYPOLANCE AST LANCING KIT Select-Lite Device/Lancets OTC HY-VEE LANCETS Sure Comfort Lancets 28G OTC

IN TOUCH Supreme II Confidence Paddles OTC

IN TOUCH GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

IN TOUCH LANCING DEVICE Multi-Lancet Device OTC IN TOUCH STERILE LANCETS 30G Sure Comfort Lancets 28G OTC INFINITY CONTROL IN VITRO SOLUTION Easy Trak Control OTC

LANCETS ULTRA FINE Sure Comfort Lancets 28G OTC

126

Formulary Drug Name Reference Restrictions LANCETS ULTRA THIN Sure Comfort Lancets 28G OTC LANZO Multi-Lancet Device OTC LIBERTY GLUCOSE CONTROL IN VITRO LIQUID Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION Easy Trak Control OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Glucose Control OTC

LIBERTY MEDICAL LANCETS Sure Comfort Lancets 28G OTC LIBERTY MINI LANCING DEVICE Multi-Lancet Device OTC LIFESCAN UNISTIK 2 Sure Comfort Lancets 28G OTC LIFESCAN UNISTIK II LANCETS Sure Comfort Lancets 28G OTC LITE TOUCH LANCING PEN Multi-Lancet Device OTC LITETOUCH LANCETS Sure Comfort Lancets 28G OTC MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID Glucose Control OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE HIGH/LOW CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE MID CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE THIN LANCETS Sure Comfort Lancets 28G OTC MEDLANCE EXTRA 21G Sure Comfort Lancets 28G OTC MEDLANCE LITE 25G Sure Comfort Lancets 28G OTC MEDLANCE PLUS EXTRA 21G Sure Comfort Lancets 28G OTC MEDLANCE PLUS LANCETS Sure Comfort Lancets 28G OTC MEDLANCE PLUS LITE 25G Sure Comfort Lancets 28G OTC MEDLANCE PLUS SPECIAL 0.8MM Sure Comfort Lancets 28G OTC MEDLANCE PLUS SUPERLITE 30G Sure Comfort Lancets 28G OTC MEDLANCE PLUS UNIVERSAL 21G Sure Comfort Lancets 28G OTC MEDLANCE UNIVERSAL 21G Sure Comfort Lancets 28G OTC MEIJER LANCETS Sure Comfort Lancets 28G OTC MEIJER LANCETS THIN Sure Comfort Lancets 28G OTC MEIJER LANCETS UNIVERSAL 21G Sure Comfort Lancets 28G OTC MEIJER LANCETS UNIVERSAL 30G Sure Comfort Lancets 28G OTC MEIJER LANCETS UNIVERSAL 33G Sure Comfort Lancets 28G OTC MEIJER SUPER THIN LANCETS Sure Comfort Lancets 28G OTC MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Glucose Control OTC

127

Formulary Drug Name Reference Restrictions MICROLET LANCETS Sure Comfort Lancets 28G OTC MICROLET NEXT LANCING DEVICE Multi-Lancet Device OTC MICROTAINER SAFETY FLOW LANCET Sure Comfort Lancets 28G OTC

MONOLET LANCETS Sure Comfort Lancets 28G OTC MONOLET OPD LANCETS Sure Comfort Lancets 28G OTC MONOLETTOR SAFETY LANCETS Sure Comfort Lancets 28G OTC MULTI-LANCET DEVICE 2 KIT Select-Lite Device/Lancets OTC MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Glucose Control OTC

MYGLUCOHEALTH LANCETS 30G Sure Comfort Lancets 28G OTC NEUTEK 2TEK CONTROL IN VITRO SOLUTION Glucose Control OTC

NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID Glucose Control OTC

NOVA SAFETY LANCETS 23G Sure Comfort Lancets 28G OTC NOVA SAFETY LANCETS 28G Sure Comfort Lancets 28G OTC NOVA SUREFLEX LANCETS Sure Comfort Lancets 28G OTC NOVA SUREFLEX LANCING DEVICE Multi-Lancet Device OTC ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Glucose Control OTC

ON CALL LANCETS Sure Comfort Lancets 28G OTC ON CALL LANCING DEVICE Multi-Lancet Device OTC ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ON CALL PLUS LANCETS Sure Comfort Lancets 28G OTC ON CALL PLUS LANCING DEVICE Multi-Lancet Device OTC ON CALL VIVID GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ONETOUCH CLUB LANCETS FINE PT Sure Comfort Lancets 28G OTC ONETOUCH COMBO PACK Sure Comfort Lancets 28G OTC ONETOUCH DELICA LANCETS 33G Sure Comfort Lancets 28G OTC ONETOUCH DELICA LANCETS FINE Sure Comfort Lancets 28G OTC ONETOUCH DELICA LANCING DEV Multi-Lancet Device OTC ONETOUCH FINEPOINT LANCETS Sure Comfort Lancets 28G OTC ONETOUCH PING METER REMOTE OTC ONETOUCH SURESOFT LANCING DEV Lancet Transporter Case OTC ONETOUCH ULTRA 2 KIT Meijer Blood Glucose OTC ONETOUCH ULTRA CONTROL IN VITRO SOLUTION Glucose Control OTC

128

Formulary Drug Name Reference Restrictions ONETOUCH ULTRA MINI KIT Meijer Blood Glucose OTC ONETOUCH ULTRALINK KIT Meijer Blood Glucose OTC ONETOUCH ULTRASOFT LANCETS Sure Comfort Lancets 28G OTC ONETOUCH VERIO IN VITRO SOLUTION Glucose Control OTC

ONETOUCH VERIO IQ SYSTEM KIT Meijer Blood Glucose OTC ONETOUCH VERIO KIT Meijer Blood Glucose OTC ONETOUCH VERIO SYNC SYSTEM KIT Meijer Blood Glucose OTC OPTUMRX GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

PENLET II BLOOD SAMPLER KIT Select-Lite Device/Lancets OTC PENLET II REPLACEMENT CAP Lancet Transporter Case OTC PERFECT LANCETS 28G Sure Comfort Lancets 28G OTC PERFECT LANCETS 30G Sure Comfort Lancets 28G OTC PHARMACIST CHOICE LANCETS Sure Comfort Lancets 28G OTC PHARMACY COUNTER LANCETS Sure Comfort Lancets 28G OTC POCKETCHEM EZ CONTROL IN VITRO SOLUTION Glucose Control OTC

PRECISION GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

PRECISION GLUCOSE CONTROL SOLN IN VITRO SOLUTION Glucose Control OTC

PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID Glucose Control OTC

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Glucose Control OTC

PRECISION THINS GP LANCETS Sure Comfort Lancets 28G OTC PRODIGY CONTROL SOLUTION IN VITRO SOLUTION Easy Trak Control OTC

PRODIGY LANCETS 28G Sure Comfort Lancets 28G OTC PRODIGY LANCING DEVICE Multi-Lancet Device OTC PRODIGY SAFETY LANCETS 26G Sure Comfort Lancets 28G OTC PRODIGY TWIST TOP LANCETS 28G Sure Comfort Lancets 28G OTC PSS SELECT GP LANCETS Sure Comfort Lancets 28G OTC PSS SELECT PLATFORMS Lancet Transporter Case OTC PSS SELECT SAFETY LANCETS Sure Comfort Lancets 28G OTC QUICKTEK CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION Glucose Control OTC

RA E-ZJECT COLOR LANCETS 33G Sure Comfort Lancets 28G OTC 129

Formulary Drug Name Reference Restrictions RA E-ZJECT LANCETS 28G Sure Comfort Lancets 28G OTC RA E-ZJECT LANCETS THIN 26G Sure Comfort Lancets 28G OTC RA E-ZJECT LANCETS THIN 28G Sure Comfort Lancets 28G OTC RA E-ZJECT LANCETS ULTRA THIN Sure Comfort Lancets 28G OTC REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

RELION LANCETS MICRO-THIN 33G Sure Comfort Lancets 28G OTC RELION LANCETS STANDARD 21G Sure Comfort Lancets 28G OTC RELION LANCETS THIN 26G Sure Comfort Lancets 28G OTC RELION LANCETS ULTRA-THIN 30G Sure Comfort Lancets 28G OTC RELION LANCING DEVICE Multi-Lancet Device OTC RELION LANCING DEVICE KIT Select-Lite Device/Lancets OTC RELION ULTRA THIN LANCETS 30G Sure Comfort Lancets 28G OTC RELION ULTRA THIN PLUS LANCETS Sure Comfort Lancets 28G OTC REXALL LANCETS ULTRA THIN 30G Sure Comfort Lancets 28G OTC RIGHTEST ALTERNATE SITE ADAPT Lancet Transporter Case OTC RIGHTEST GC300 CONTROL IN VITRO LIQUID Easy Trak Control OTC

RIGHTEST GD500 LANCING DEVICE Multi-Lancet Device OTC RIGHTEST GL300 LANCETS Sure Comfort Lancets 28G OTC SAFE-T-LANCE Sure Comfort Lancets 28G OTC SAFE-T-LANCE PLUS Sure Comfort Lancets 28G OTC SAFETY LANCETS Sure Comfort Lancets 28G OTC SAFETY LANCETS 21G Sure Comfort Lancets 28G OTC SAFETY LET LANCETS Sure Comfort Lancets 28G OTC SAFETY SEAL LANCETS Sure Comfort Lancets 28G OTC SHOPKO AUTOLET LANCING DEVICE Multi-Lancet Device OTC SHOPKO ON-THE-GO LANCETS 30G Sure Comfort Lancets 28G OTC SHOPKO UNILET LANCETS 28G Sure Comfort Lancets 28G OTC SHOPKO UNILET LANCETS 30G Sure Comfort Lancets 28G OTC SIMPLE DIAGNOSTICS LANCING DEV Multi-Lancet Device OTC SINGLE-LET Sure Comfort Lancets 28G OTC SMART DIABETES VANTAGE LANCING Multi-Lancet Device OTC

SMART SENSE COLOR LANCETS 33G Sure Comfort Lancets 28G OTC SMART SENSE STANDARD LANCETS Sure Comfort Lancets 28G OTC SMART SENSE SUPER THIN LANCETS Sure Comfort Lancets 28G OTC SMART SENSE THIN LANCETS 26G Sure Comfort Lancets 28G OTC

130

Formulary Drug Name Reference Restrictions SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Glucose Control OTC

SMARTEST LANCETS 28G Sure Comfort Lancets 28G OTC SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

SOLUS V2 CONTROL IN VITRO SOLUTION Easy Trak Control OTC

SOLUS V2 LANCETS 28G Sure Comfort Lancets 28G OTC SOLUS V2 LANCING DEVICE Multi-Lancet Device OTC SOLUS V2 TWIST LANCETS 30G Sure Comfort Lancets 28G OTC STERILANCE PA Lancet Transporter Case OTC STERILANCE TL Sure Comfort Lancets 28G OTC SURE-LANCE FLAT LANCETS Sure Comfort Lancets 28G OTC SURE-LANCE LANCETS 26G Sure Comfort Lancets 28G OTC SURE-LANCE THIN LANCETS 28G Sure Comfort Lancets 28G OTC SURE-LANCE ULTRA THIN LANCETS Sure Comfort Lancets 28G OTC SURELITE LANCETS Sure Comfort Lancets 28G OTC SURE-PEN Multi-Lancet Device OTC SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID Easy Trak Control OTC

SURESTEP PRO LINEARITY KIT Supreme II Confidence Paddles OTC

SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID Easy Talk Control OTC

SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID Easy Talk Control OTC

SURE-TOUCH LANCETS UNIVERSAL Sure Comfort Lancets 28G OTC TAI DOC CONTROL IN VITRO SOLUTION Easy Talk Control OTC

TECHLITE AST LANCETS Sure Comfort Lancets 28G OTC TECHLITE LANCETS Sure Comfort Lancets 28G OTC TECHLITE LANCETS 30G Sure Comfort Lancets 28G OTC TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

THINLETS GP LANCETS Sure Comfort Lancets 28G OTC

TRACER II 3 VOLT BATTERY Supreme II Confidence Paddles OTC

TRAVEL LANCETS ADVANCED 28G Sure Comfort Lancets 28G OTC

131

Formulary Drug Name Reference Restrictions TRUE METRIX LEVEL 1 IN VITRO SOLUTION Easy Talk Control OTC

TRUE METRIX LEVEL 2 IN VITRO SOLUTION Easy Talk Control OTC

TRUE METRIX LEVEL 3 IN VITRO SOLUTION Easy Trak Control OTC

TRUECONTROL GLUCOSE CONT LEV 0 IN VITRO LIQUID Glucose Control OTC

TRUECONTROL GLUCOSE CONT LEV 1 IN VITRO LIQUID Glucose Control OTC

TRUEDRAW LANCING DEVICE Multi-Lancet Device OTC TRUEPLUS LANCETS 26G Sure Comfort Lancets 28G OTC TRUEPLUS LANCETS 28G Sure Comfort Lancets 28G OTC TRUEPLUS LANCETS 30G Sure Comfort Lancets 28G OTC TRUEPLUS LANCETS 33G Sure Comfort Lancets 28G OTC TRUEPLUS SAFETY LANCETS 28G Sure Comfort Lancets 28G OTC ULTI-LANCE AUTOMATIC Multi-Lancet Device OTC ULTILET CLASSIC LANCETS Sure Comfort Lancets 28G OTC ULTILET LANCETS Sure Comfort Lancets 28G OTC ULTILET SAFETY LANCETS 23G Sure Comfort Lancets 28G OTC ULTRALANCE Lancet Transporter Case OTC ULTRA-THIN II AUTO LANCET Sure Comfort Lancets 28G OTC ULTRA-THIN II LANCETS Sure Comfort Lancets 28G OTC ULTRATRAK PRO CONTROL IN VITRO SOLUTION Glucose Control OTC

ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Glucose Control OTC

UNILET COMFORTOUCH LANCET Sure Comfort Lancets 28G OTC UNILET EXCELITE Sure Comfort Lancets 28G OTC UNILET EXCELITE II Sure Comfort Lancets 28G OTC UNILET G.P. LANCET Sure Comfort Lancets 28G OTC UNILET G.P. SUPERLITE LANCET Sure Comfort Lancets 28G OTC UNILET GP 28 ULTRA THIN Sure Comfort Lancets 28G OTC UNILET LANCET Sure Comfort Lancets 28G OTC UNILET MICRO-THIN 33G Sure Comfort Lancets 28G OTC UNILET SUPERLITE LANCET Sure Comfort Lancets 28G OTC UNILET SUPER-THIN 30G Sure Comfort Lancets 28G OTC UNILET ULTRA-THIN 28G Sure Comfort Lancets 28G OTC UNISTIK 1 Lancet Transporter Case OTC UNISTIK 2 Lancet Transporter Case OTC

132

Formulary Drug Name Reference Restrictions UNISTIK 2 COMFORT Lancet Transporter Case OTC UNISTIK 2 EXTRA Lancet Transporter Case OTC UNISTIK 2 NEONATAL Lancet Transporter Case OTC UNISTIK 2 NORMAL Lancet Transporter Case OTC UNISTIK 2 SUPER Lancet Transporter Case OTC UNISTIK 3 Lancet Transporter Case OTC UNISTIK 3 COMFORT Lancet Transporter Case OTC UNISTIK 3 EXTRA Lancet Transporter Case OTC UNISTIK 3 GENTLE Sure Comfort Lancets 28G OTC UNISTIK 3 NEONATAL Lancet Transporter Case OTC UNISTIK 3 NORMAL Lancet Transporter Case OTC UNISTIK CZT COMFORT Lancet Transporter Case OTC UNISTIK CZT NORMAL Lancet Transporter Case OTC UNISTIK SAFETY LANCETS 28G Sure Comfort Lancets 28G OTC UNISTIK SAFETY LANCETS 30G Sure Comfort Lancets 28G OTC UNISTIK TOUCH SAFETY LANC 21G Sure Comfort Lancets 28G OTC UNISTIK TOUCH SAFETY LANC 23G Sure Comfort Lancets 28G OTC UNISTIK TOUCH SAFETY LANC 28G Sure Comfort Lancets 28G OTC UNISTIK TOUCH SAFETY LANC 30G Sure Comfort Lancets 28G OTC UNISTRIP CONTROL IN VITRO SOLUTION Easy Trak Control OTC

UNIVERSAL 1 LANCETS THIN 26G Sure Comfort Lancets 28G OTC UNIVERSAL 1 LANCETS THIN 33G Sure Comfort Lancets 28G OTC UNIVERSAL 1 LANCETS ULTRA THIN Sure Comfort Lancets 28G OTC VICTORY CONTROL LEVEL 1/2 IN VITRO SOLUTION Glucose Control OTC

VIDA MIA AUTOLET LANCING DEV Multi-Lancet Device OTC VIDA MIA UNILET LANCETS 28G Sure Comfort Lancets 28G OTC VIDA MIA UNILET LANCETS 30G Sure Comfort Lancets 28G OTC VITALET PRO LANCETS Sure Comfort Lancets 28G OTC VITALET PRO PLUS LANCETS Sure Comfort Lancets 28G OTC WALGREENS LANCETS Sure Comfort Lancets 28G OTC WALGREENS THIN LANCETS Sure Comfort Lancets 28G OTC WALGREENS ULTRA THIN LANCETS Sure Comfort Lancets 28G OTC

*Needles & Syringes*** careone insulin syringe BD Insulin Syringe U/F OTC dialysis safety syringe/needle UltiCare Syringe OTC easy comfort insulin syringe Advocate Insulin Syringe OTC elite-thin insulin syringe Advocate Insulin Syringe OTC

133

Formulary Drug Name Reference Restrictions eql insulin syringe Advocate Insulin Syringe OTC global easy glide insulin syr Advocate Insulin Syringe OTC global inject ease insulin syr Advocate Insulin Syringe OTC global insulin syringes Advocate Insulin Syringe OTC gnp insulin syringe Advocate Insulin Syringe OTC gnp ultra com insulin syringe Advocate Insulin Syringe OTC insulin syringe Advocate Insulin Syringe OTC insulin syringe/needle Easy Touch Insulin Syringe OTC kinray insulin syringe Advocate Insulin Syringe OTC kmart valu insulin syringe 29g OTC; QLL (1 EA per 365 days) kmart valu insulin syringe 30g OTC; QLL (1 EA per 365 days) kroger insulin syringe Advocate Insulin Syringe OTC leader insulin syringe Advocate Insulin Syringe OTC longs insulin syringe Advocate Insulin Syringe OTC medic insulin syringe Advocate Insulin Syringe OTC ms insulin syringe Advocate Insulin Syringe OTC preferred plus insulin syringe Advocate Insulin Syringe OTC px insulin syringe BD Insulin Syringe U/F OTC ra insulin syringe Advocate Insulin Syringe OTC reality insulin syringe BD Insulin Syringe MicroFine OTC safety insulin syringes Advocate Insulin Syringe OTC safety syringe/needle BD Eclipse Syringe OTC sb insulin syringe Advocate Insulin Syringe OTC sure comfort insulin syringe Advocate Insulin Syringe OTC syringe OTC syringe luer slip BD Eclipse Syringe OTC syringe/hypodermic safety Monoject LifeShield Syringe OTC topcare ultra comfort ins syr Advocate Insulin Syringe OTC ultra comfort insulin syringe Advocate Insulin Syringe OTC ultra-comfort insulin syringe 28g x 1/2" 0.5 ml BD Insulin Syringe MicroFine OTC ultra-comfort insulin syringe 28g x 1/2" 1 ml BD Insulin Syringe MicroFine OTC ultra-comfort insulin syringe 29g x 1/2" 0.3 ml Advocate Insulin Syringe OTC; QLL (1 EA per 365 days) ultra-comfort insulin syringe 29g x 1/2" 0.5 ml Advocate Insulin Syringe OTC ultra-comfort insulin syringe 29g x 1/2" 1 ml Advocate Insulin Syringe OTC ultra-comfort insulin syringe 30g x 5/16" 0.3 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 30g x 5/16" 0.5 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 30g x 5/16" 1 ml Advocate Insulin Syringe OTC 134

Formulary Drug Name Reference Restrictions ultra-comfort insulin syringe 31g x 5/16" 0.3 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 31g x 5/16" 0.5 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 31g x 5/16" 1 ml Advocate Insulin Syringe OTC value health insulin syringe Advocate Insulin Syringe OTC vp insulin syringe Advocate Insulin Syringe OTC ADVOCATE INSULIN SYRINGE Kroger Insulin Syringe OTC ASSURE ID INSULIN SAFETY SYR Elite-Thin Insulin Syringe BD ECLIPSE SYRINGE Syringe Luer Slip OTC BD INSULIN SYR ULTRAFINE II Longs Insulin Syringe OTC BD INSULIN SYRINGE 25G X 1" 1 ML OTC BD INSULIN SYRINGE 25G X 5/8" 1 ML OTC BD INSULIN SYRINGE 26G X 1/2" 1 ML OTC BD INSULIN SYRINGE 27.5G X 5/8" 2 ML OTC

BD INSULIN SYRINGE 27G X 1/2" 1 ML Safety Insulin Syringes OTC BD INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC BD INSULIN SYRINGE MICROFINE Elite-Thin Insulin Syringe OTC BD INSULIN SYRINGE U/F Global Inject Ease Insulin Syr OTC BD INSULIN SYRINGE U/F 1/2UNIT Insulin Syringe-Needle U-100 OTC

BD INSULIN SYRINGE U-100 1 ML Kmart Valu Insulin Syringe 30G OTC; QLL (1 EA per 365 days)

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML Global Inject Ease Insulin Syr OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.5 ML Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

BD LUER-LOK SYRINGE OTC BD PEN NEEDLE NANO U/F Insupen Pen Needles ST BD PEN NEEDLE SHORT U/F RA Pen Needles ST; OTC BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

135

Formulary Drug Name Reference Restrictions BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML TechLITE Insulin Syringe

BD SAFETYGLIDE INSULIN SYRINGE 31G X 5/16" 0.3 ML Insulin Syringe-Needle U-100 OTC

BD SAFETYGLIDE SYRINGE/NEEDLE OTC BD SAFETY-LOK INSULIN SYRINGE Kroger Insulin Syringe OTC BD SYRINGE/NEEDLE Syringe Luer Slip OTC BD SYRINGE/NEEDLE SLIP TIP Syringe Luer Slip OTC BD VEO INSULIN SYRINGE U/F TechLITE Insulin Syringe OTC COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.3 ML Insulin Syringe-Needle U-100 OTC

COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

COMFORT EZ INSULIN SYRINGE Kroger Insulin Syringe OTC EASY TOUCH FLIPLOCK INSULIN SY Kroger Insulin Syringe OTC EASY TOUCH FLIPLOCK SAFETY SYR OTC EASY TOUCH FLURINGE Syringe Luer Slip OTC EASY TOUCH FLURINGE FLIPLOCK Syringe Luer Slip OTC EASY TOUCH FLURINGE SHEATHLOCK Syringe Luer Slip OTC

EASY TOUCH INSULIN SAFETY SYR Elite-Thin Insulin Syringe OTC EASY TOUCH INSULIN SYRINGE Sure Comfort Insulin Syringe OTC EASY TOUCH SAFETY SYRINGE Syringe Luer Slip OTC EASY TOUCH SHEATHLOCK SYRINGE Kroger Insulin Syringe OTC 136

Formulary Drug Name Reference Restrictions EASY TOUCH TB SHEATHLOCK SYR OTC EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 1 ML Leader Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

FIFTY50 SUPERIOR COMFORT SYR Longs Insulin Syringe OTC FREESTYLE PRECISION INS SYR Longs Insulin Syringe OTC GLUCOPRO INSULIN SYRINGE Sure Comfort Insulin Syringe OTC LITETOUCH INSULIN SYRINGE Kroger Insulin Syringe OTC MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML Kroger Insulin Syringe QLL (1 EA per 365 days)

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML Kroger Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML Elite-Thin Insulin Syringe

MAXI-COMFORT INSULIN SYRINGE Elite-Thin Insulin Syringe OTC MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML OTC

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML (OTC) Safety Insulin Syringes

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML (RX) Safety Insulin Syringes

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML (OTC) Elite-Thin Insulin Syringe

137

Formulary Drug Name Reference Restrictions MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML (RX) Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML (OTC) Leader Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML (RX) Leader Insulin Syringe

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe QLL (1 EA per 365 days)

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 29G X 1/2" 1 ML (RX) Kroger Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.5 ML (RX) Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML (OTC) Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML (RX) Elite-Thin Insulin Syringe

MONOJECT INSULIN SYRINGE 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

MONOJECT INSULIN SYRINGE U-100 1 ML

Kmart Valu Insulin Syringe 30G QLL (1 EA per 365 days)

MONOJECT LIFESHIELD SYRINGE Syringe/Hypodermic Safety MONOJECT MAGELLAN SYRINGE MONOJECT SYRINGE MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML (OTC) Elite-Thin Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML (RX) Elite-Thin Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML (OTC) Leader Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML (RX) Leader Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML (OTC) Sure Comfort Insulin Syringe

138

Formulary Drug Name Reference Restrictions MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML (RX) Sure Comfort Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML (OTC) Elite-Thin Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML (RX) Elite-Thin Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 31G X 5/16" 0.3 ML Insulin Syringe-Needle U-100 OTC

MONOJECT ULTRA COMFORT SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

PRECISION SUREDOSE PLUS SYR Kroger Insulin Syringe OTC PRECISION SURE-DOSE SYRINGE Sure Comfort Insulin Syringe OTC PRODIGY INSULIN SYRINGE Longs Insulin Syringe OTC RELION INSULIN SYRINGE Kroger Insulin Syringe OTC RELI-ON INSULIN SYRINGE 29G 0.3 ML OTC; QLL (1 EA per 365 days)

RELI-ON INSULIN SYRINGE 29G 0.5 ML OTC

RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

RELI-ON INSULIN SYRINGE 30G 0.3 ML OTC; QLL (1 EA per 365 days)

RELI-ON INSULIN SYRINGE 30G 0.5 ML OTC

RELI-ON INSULIN SYRINGE 30G 1 ML OTC SAFESNAP INSULIN SYRINGE Sure Comfort Insulin Syringe OTC SURE-JECT INSULIN SYRINGE Kroger Insulin Syringe OTC TRUEPLUS INSULIN SYRINGE Kroger Insulin Syringe OTC ULTICARE INSULIN SAFETY SYR Elite-Thin Insulin Syringe ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 28G X 1/2" 1 ML Leader Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.5 ML Elite-Thin Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 1 ML Kroger Insulin Syringe OTC

139

Formulary Drug Name Reference Restrictions ULTICARE INSULIN SYRINGE 30G X 1/2" 0.3 ML Global Inject Ease Insulin Syr OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 0.5 ML Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML Global Inject Ease Insulin Syr OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 0.3 ML Sure Comfort Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 0.5 ML Elite-Thin Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML Insulin Syringe-Needle U-100 OTC

ULTICARE INSULIN SYRINGE 31G X 5/16" 0.5 ML Longs Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 31G X 5/16" 1 ML Elite-Thin Insulin Syringe OTC

ULTICARE SYRINGE Dialysis Safety Syringe/Needle OTC ULTILET INSULIN SYRINGE SHORT Sure Comfort Insulin Syringe OTC ULTRA-THIN II INS SYR SHORT Sure Comfort Insulin Syringe OTC ULTRA-THIN II INSULIN SYRINGE Elite-Thin Insulin Syringe OTC VANISHPOINT INSULIN SYRINGE Elite-Thin Insulin Syringe OTC VANISHPOINT SYRINGE OTC

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER MINI CHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

AEROCHAMBER MV Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU MEDIUM Valved Holding Chamber QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Valved Holding Chamber QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLOW VU Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS Valved Holding Chamber QLL (1 EA per 365 days)

140

Formulary Drug Name Reference Restrictions AEROCHAMBER Z-STAT PLUS CHAMBR Valved Holding Chamber QLL (1 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/LARGE Valved Holding Chamber QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS/MEDIUM Valved Holding Chamber QLL (1 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/SMALL Valved Holding Chamber QLL (1 EA per 365 days) AEROVENT PLUS DEVICE Valved Holding Chamber QLL (1 EA per 365 days) ARIAL CHAMBER DEVICE Valved Holding Chamber OTC; QLL (1 EA per 365 days) BREATHERITE Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE COLL SPACER ADULT Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE COLL SPACER CHILD Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE COLL SPACER INFANT Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE RIGID SPACER/MASK Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE SPACER NEONATE Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE SPACER SMALL CHILD Valved Holding Chamber QLL (1 EA per 365 days)

BREATHERITE/LARGE MASK Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE/MEDIUM MASK Valved Holding Chamber QLL (1 EA per 365 days) BREATHERITE/SMALL MASK Valved Holding Chamber QLL (1 EA per 365 days) CLEVER CHOICE HOLDING CHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days) COMPACT SPACE CHAMBER/LG MASK DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/MED MASK DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/SM MASK DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

EASIVENT Valved Holding Chamber QLL (1 EA per 365 days) EASIVENT MASK LARGE Valved Holding Chamber QLL (1 EA per 365 days) EASIVENT MASK MEDIUM Valved Holding Chamber QLL (1 EA per 365 days) EASIVENT MASK SMALL Valved Holding Chamber QLL (1 EA per 365 days) FLEXICHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/LARGE DEVICE Valved Holding Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/MEDIUM DEVICE Valved Holding Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

INSPIRACHAMBER/SMALL DEVICE Valved Holding Chamber QLL (1 EA per 365 days) INSPIREASE Valved Holding Chamber QLL (1 EA per 365 days) LITEAIRE DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

141

Formulary Drug Name Reference Restrictions MICROCHAMBER Valved Holding Chamber QLL (1 EA per 365 days) MICROSPACER Valved Holding Chamber QLL (1 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MASK Valved Holding Chamber QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-MED MASK Valved Holding Chamber QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-SM MASK Valved Holding Chamber QLL (1 EA per 365 days)

OPTICHAMBER DIAMOND Valved Holding Chamber QLL (1 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

OPTICHAMBER DIAMOND-MD MASK Valved Holding Chamber QLL (1 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK Valved Holding Chamber QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-LARGE Valved Holding Chamber OTC; QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-MEDIUM Valved Holding Chamber OTC; QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-SMALL Valved Holding Chamber OTC; QLL (1 EA per 365 days) OPTIHALER Valved Holding Chamber QLL (1 EA per 365 days) OPTIHALER DEVICE Valved Holding Chamber QLL (1 EA per 365 days) POCKET CHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days) POCKET SPACER DEVICE Valved Holding Chamber QLL (1 EA per 365 days) RITEFLO DEVICE Valved Holding Chamber QLL (1 EA per 365 days) VORTEX VALVED HOLDING CHAMBER DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

WATCHHALER DEVICE Valved Holding Chamber QLL (1 EA per 365 days)

*MIGRAINE PRODUCTS* *Selective Serotonin Agonists 5-Ht(1)***

rizatriptan benzoate oral tablet Maxalt QLL (12 EA per 30 days); AL (Min 6 Years)

rizatriptan benzoate oral tablet dispersible Maxalt-MLT QLL (12 EA per 30 days); AL (Min 6 Years)

sumatriptan nasal solution Imitrex QLL (6 UNITS per 30 days); AL (Min 18 Years)

sumatriptan succinate tablet 100 mg oral Imitrex AL (Min 18 Years)

sumatriptan succinate tablet 100 mg oral Imitrex QLL (9 EA per 30 days); AL (Min 18 Years)




142



*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium acetate intravenous solution sodium bicarbonate intravenous solution sodium lactate intravenous solution

*Calcium*** calcium acetate oral tablet OTC calcium carbonate antacid oral suspension OTC calcium carbonate oral tablet Caltrate 600 OTC calcium chloride intravenous solution calcium gluconate intravenous solution gnp calcium oral tablet High Potency Calcium OTC oyster shell calcium oral tablet Oysco 500 OTC CALCITRATE ORAL TABLET OTC OYSCO 500 ORAL TABLET SB Oyster Shell Calcium OTC

*Electrolytes & Dextrose*** dextrose 5%/electrolyte #48 intravenous solution dextrose in lactated ringers intravenous solution dextrose-nacl intravenous solution kcl in d5w lactated ringers intravenous solution kcl in dextrose-nacl intravenous solution kcl-lactated ringers-d5w intravenous solution potassium chloride in dextrose intravenous solution IONOSOL-MB IN D5W INTRAVENOUS SOLUTION ISOLYTE-P IN D5W INTRAVENOUS SOLUTION NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

*Electrolytes Parenteral*** lactated ringers intravenous solution

143

Formulary Drug Name Reference Restrictions potassium chloride in nacl intravenous solution ringers intravenous solution HYPERLYTE-CR INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION NORMOSOL-R INTRAVENOUS SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 148 INTRAVENOUS SOLUTION PLASMA-LYTE A INTRAVENOUS SOLUTION TPN ELECTROLYTES INTRAVENOUS SOLUTION

*Fluoride*** sodium fluoride oral solution sodium fluoride oral tablet chewable Ludent

*Magnesium*** magnesium chloride injection solution magnesium sulfate injection solution magnesium sulfate intravenous solution

*Manganese*** manganese chloride intravenous solution

*Phosphate*** potassium phosphates intravenous solution sodium phosphates intravenous solution virt-phos 250 neutral oral tablet K-Phos-Neutral K-PHOS ORAL TABLET K-PHOS-NEUTRAL ORAL TABLET Virt-Phos 250 Neutral PHOSPHA 250 NEUTRAL ORAL TABLET Virt-Phos 250 Neutral

*Potassium Combinations*** EFFER-K ORAL TABLET EFFERVESCENT

*Potassium*** potassium acetate intravenous solution

144

Formulary Drug Name Reference Restrictions potassium chloride crys er oral tablet extended release Klor-Con M20

potassium chloride er oral capsule extended release Klor-Con Sprinkle

potassium chloride er oral tablet extended release K-Tab

potassium chloride intravenous solution potassium chloride oral packet Klor-Con potassium chloride oral solution EFFER-K ORAL TABLET EFFERVESCENT Potassium Bicarbonate

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE Potassium Chloride ER

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE Potassium Chloride Crys ER

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE KLOR-CON M20 ORAL TABLET EXTENDED RELEASE Potassium Chloride Crys ER

KLOR-CON ORAL PACKET Potassium Chloride KLOR-CON ORAL TABLET EXTENDED RELEASE Potassium Chloride ER

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE Potassium Chloride ER

KLOR-CON/EF ORAL TABLET EFFERVESCENT Potassium Bicarbonate

*Sodium***

normal saline flush intravenous solution BD PosiFlush QLL (150 SYRINGES per 30 days)

sodium chloride injection solution sodium chloride intravenous solution

*Trace Mineral Combinations*** multitrace-4 concentrate intravenous solution multitrace-5 concentrate intravenous solution MULTITRACE-4 INTRAVENOUS SOLUTION MULTITRACE-4 NEONATAL INTRAVENOUS SOLUTION MULTITRACE-4 PEDIATRIC INTRAVENOUS SOLUTION MULTITRACE-5 INTRAVENOUS SOLUTION

145

Formulary Drug Name Reference Restrictions *Trace Minerals*** chromic chloride intravenous solution copper chloride intravenous solution selenium intravenous solution

*Zinc*** zinc sulfate intravenous solution zinc trace metal intravenous solution

*MONOBACTAMS*** *Monobactams*** aztreonam injection solution reconstituted Azactam

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine viscous hcl mouth/throat solution

*Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge clotrimazole mouth/throat troche nystatin mouth/throat suspension

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution Paroex

*Saliva Stimulants*** pilocarpine hcl oral tablet Salagen

*Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste Oralone

*MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** *Mucopolysaccharidosis Vii (Mps Vii) - Agents*** MEPSEVII INTRAVENOUS SOLUTION

*MULTIVITAMINS* *B-Complex W/ C & Folic Acid*** vp-vite rx oral tablet Dialyvite DIALYVITE ORAL TABLET Vol-Care Rx NEPHRO-VITE RX ORAL TABLET Vol-Care Rx

*B-Complex W/ C-Biotin-D-Zinc & Folic Acid*** VITAL-D RX ORAL TABLET

146

Formulary Drug Name Reference Restrictions *B-Complex W/ C-Biotin-E-Minerals & Folic Acid*** DIALYVITE 3000 ORAL TABLET DIALYVITE 5000 ORAL TABLET

*B-Complex W/ C-Zn & Folic Acid*** DIALYVITE/ZINC ORAL TABLET NEPHPLEX RX ORAL TABLET

*Multiple Vitamins W/ Minerals & Folic Acid*** CORVITA ORAL TABLET DIALYVITE SUPREME D ORAL TABLET

*Multiple Vitamins W/ Minerals***

abdek oral capsule ActivNutrients OTC; QLL (2 EA per 1 day); AL (Min 4 Years)

AQUADEKS ORAL TABLET CHEWABLE

EQ Multivitamins Adult Gummy

OTC; QLL (2 EA per 1 day); AL (Min 4 Years)

BACMIN ORAL TABLET RA One Daily Mens 50+ w/Vit D3

STROVITE ONE ORAL TABLET RA One Daily Mens 50+ w/Vit D3

*Multivitamins*** INFUVITE ADULT INTRAVENOUS INJECTABLE M.V.I. ADULT INTRAVENOUS INJECTABLE

*Ped Multi Vitamins W/Fl & Fe*** POLY-VI-FLOR/IRON ORAL SUSPENSION POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE

*Ped Multiple Vitamins W/ Minerals & C***

AQUADEKS ORAL LIQUID ABDEK Pediatric OTC; QLL (60 ML per 30 days); AL (Min 3 Years)

*Ped Mv W/ Fluoride*** multivitamin/fluoride oral tablet chewable MVC-Fluoride AL (Max 12 Years) POLY-VI-FLOR ORAL SUSPENSION

147

Formulary Drug Name Reference Restrictions POLY-VI-FLOR ORAL TABLET CHEWABLE AL (Max 12 Years)

QUFLORA PEDIATRIC TABLET CHEWABLE 0.5 MG ORAL Multivitamins/Fluoride

QUFLORA PEDIATRIC TABLET CHEWABLE 1 MG ORAL Multivitamin/Fluoride AL (Max 12 Years)

*Ped Vitamins Acd & Fa W/ Fluoride*** TRI-VI-FLOR ORAL SUSPENSION Tri-Vi-Floro

*Ped Vitamins Acd W/ Fluoride*** tri-vitamin/fluoride oral solution

*Pediatric Multiple Vitamins*** INFUVITE PEDIATRIC INTRAVENOUS SOLUTION M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

*Prenatal Mv & Min W/Fe-Fa*** c-nate dha oral capsule Viva DHA completenate oral tablet chewable m-natal plus oral tablet M-Vit pnv-omega oral capsule Zatean-Pn Plus prenatal oral tablet M-Vit prenatal vitamin plus low iron oral tablet M-Vit preplus oral tablet M-Vit se-natal 19 oral tablet se-natal 19 oral tablet chewable thrivite 19 oral tablet trinatal rx 1 oral tablet Vinate One virt-c dha oral capsule Concept DHA virt-nate dha oral capsule Viva DHA virt-pn plus oral capsule Zatean-Pn Plus vol-plus oral tablet M-Vit CITRANATAL B-CALM ORAL CONCEPT DHA ORAL CAPSULE Virt-C DHA CONCEPT OB ORAL CAPSULE ELITE-OB ORAL TABLET FOLIVANE-OB ORAL CAPSULE NIVA-PLUS ORAL TABLET Prenatal Plus/Iron OB COMPLETE ORAL TABLET

148

Formulary Drug Name Reference Restrictions PROVIDA OB ORAL CAPSULE SELECT-OB ORAL TABLET CHEWABLE TARON-C DHA ORAL CAPSULE Virt-C DHA VITAFOL GUMMIES ORAL TABLET CHEWABLE VITAFOL-NANO ORAL TABLET VITAFOL-OB ORAL TABLET Mynatal-Z ZATEAN-PN PLUS ORAL CAPSULE Virt-PN Plus

*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** complete natal dha oral TRIVEEN-DUO DHA ORAL

*Prenatal Mv & Min W/Fe-Fa-Dha*** pnv-dha+docusate oral capsule prenaissance oral capsule prenaissance plus oral capsule virt-pn dha oral capsule Zatean-Pn DHA CITRANATAL DHA ORAL CITRANATAL HARMONY ORAL CAPSULE TARON-PREX ORAL CAPSULE VITAFOL FE+ ORAL CAPSULE THERAPY PACK VITAFOL-OB+DHA ORAL VITAFOL-ONE ORAL CAPSULE ZATEAN-PN DHA ORAL CAPSULE Virt-PN DHA

*MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen tablet 10 mg oral QLL (8 EA per 1 day) baclofen tablet 20 mg oral QLL (4 EA per 1 day) baclofen tablet 5 mg oral chlorzoxazone oral tablet QLL (6 FILLS per 365 days) cyclobenzaprine hcl oral tablet QLL (6 FILLS per 365 days) methocarbamol oral tablet 500 mg methocarbamol oral tablet 750 mg Robaxin-750 methocarbamol tablet 500 mg oral

149

Formulary Drug Name Reference Restrictions methocarbamol tablet 500 mg oral QLL (6 FILLS per 365 days) methocarbamol tablet 750 mg oral Robaxin-750 QLL (6 FILLS per 365 days) tizanidine hcl oral tablet QLL (6 FILLS per 365 days)

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Antihistamines*** azelastine hcl nasal solution Astepro

*Nasal Steroids*** budesonide nasal suspension Rhinocort Allergy cvs fluticasone propionate nasal suspension ClariSpray OTC; QLL (16 GM per 30 days) fluticasone propionate nasal suspension 50 mcg/act ClariSpray QLL (16 GM per 30 days)

fluticasone propionate suspension 50 mcg/act nasal (rx) ClariSpray ST; QLL (16 GM per 30 days)

mometasone furoate nasal suspension Nasonex ST; QLL (17 GM per 30 days) triamcinolone acetonide nasal aerosol Nasacort Allergy 24HR FLONASE SENSIMIST NASAL SUSPENSION OTC

*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** ENTRESTO ORAL TABLET

*NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet Rilutek

*Neuromuscular Blocking Agent -Neurotoxins*** BOTOX INJECTION SOLUTION RECONSTITUTED PA

*NUTRIENTS* *Amino Acid Mixtures*** AMINOSYN II INTRAVENOUS SOLUTION Amino Acid

AMINOSYN-PF INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION

150

Formulary Drug Name Reference Restrictions CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION CLINIMIX N14G30E INTRAVENOUS SOLUTION CLINIMIX N9G15E INTRAVENOUS SOLUTION CLINIMIX N9G20E INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION CLINISOL SF INTRAVENOUS SOLUTION FREAMINE HBC INTRAVENOUS SOLUTION FREAMINE III INTRAVENOUS SOLUTION Amino Acid

HEPATAMINE INTRAVENOUS SOLUTION NEPHRAMINE INTRAVENOUS SOLUTION PLENAMINE INTRAVENOUS SOLUTION PREMASOL INTRAVENOUS SOLUTION Amino Acid

PROCALAMINE INTRAVENOUS SOLUTION PROSOL INTRAVENOUS SOLUTION

151

Formulary Drug Name Reference Restrictions SYNTHAMIN 17 INTRAVENOUS SOLUTION Amino Acid

TRAVASOL INTRAVENOUS SOLUTION Amino Acid TROPHAMINE INTRAVENOUS SOLUTION

*Amino Acids-Single*** l-cysteine hcl intravenous solution Elcys

*Carbohydrates*** dextrose intravenous solution glucose intravenous solution

*Lipids*** nutrilipid intravenous emulsion Clinolipid INTRALIPID INTRAVENOUS EMULSION Nutrilipid

*OPHTHALMIC AGENTS* *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** SIMBRINZA OPHTHALMIC SUSPENSION

*Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution Cosopt QLL (10 ML per 30 days)

COMBIGAN OPHTHALMIC SOLUTION

*Beta-Blockers - Ophthalmic*** carteolol hcl ophthalmic solution levobunolol hcl ophthalmic solution timolol maleate ophthalmic gel forming solution Timoptic-XE

timolol maleate ophthalmic solution Istalol QLL (15 ML per 30 days)

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment atropine sulfate ophthalmic solution Isopto Atropine cyclopentolate hcl ophthalmic solution Cyclogyl

*Ophthalmic Antiallergic*** allergy eye drops ophthalmic solution Alaway OTC azelastine hcl ophthalmic solution ST cromolyn sodium ophthalmic solution cvs allergy eye drops ophthalmic solution Alaway OTC

152

Formulary Drug Name Reference Restrictions cvs eye itch relief ophthalmic solution Alaway OTC eye itch relief ophthalmic solution Alaway OTC gnp eye itch relief ophthalmic solution Alaway OTC gnp itchy eye ophthalmic solution Alaway OTC hm eye itch relief ophthalmic solution Alaway OTC ketotifen fumarate ophthalmic solution Alaway kp ketotifen fumarate ophthalmic solution Alaway OTC olopatadine hcl ophthalmic solution Pataday ST ra antihistamine eye drops ophthalmic solution Alaway OTC

ra eye itch relief ophthalmic solution Alaway OTC sm eye itch relief ophthalmic solution Alaway OTC ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION RA Eye Itch Relief OTC

ALAWAY OPHTHALMIC SOLUTION RA Eye Itch Relief OTC CLARITIN EYE OPHTHALMIC SOLUTION RA Eye Itch Relief OTC

PAZEO OPHTHALMIC SOLUTION ST THERATEARS ALLERGY OPHTHALMIC SOLUTION RA Eye Itch Relief OTC

ZADITOR OPHTHALMIC SOLUTION RA Eye Itch Relief OTC

*Ophthalmic Antibiotics*** ciprofloxacin hcl ophthalmic solution Ciloxan erythromycin ophthalmic ointment gentamicin sulfate ophthalmic solution moxifloxacin hcl ophthalmic solution Vigamox QLL (6 ML per 30 days) ofloxacin ophthalmic solution Ocuflox tobramycin ophthalmic solution Tobrex QLL (10 ML per 30 days) MOXEZA OPHTHALMIC SOLUTION

*Ophthalmic Anti-Infective Combinations*** bacitracin-polymyxin b ophthalmic ointment Polycin neomycin-bacitracin zn-polymyx ophthalmic ointment Neo-Polycin

polymyxin b-trimethoprim ophthalmic solution Polytrim

*Ophthalmic Antivirals*** trifluridine ophthalmic solution

153

Formulary Drug Name Reference Restrictions *Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution Trusopt AZOPT OPHTHALMIC SUSPENSION

*Ophthalmic Decongestants*** phenylephrine hcl ophthalmic solution Altafrin

*Ophthalmic Immunomodulators*** RESTASIS MULTIDOSE OPHTHALMIC EMULSION RESTASIS OPHTHALMIC EMULSION

*Ophthalmic Irrigation Solutions*** balanced salt intraocular solution BSS

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution flurbiprofen sodium ophthalmic solution ketorolac tromethamine ophthalmic solution Acular ILEVRO OPHTHALMIC SUSPENSION

*Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic solution

*Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic ointment Neo-Polycin HC

neomycin-polymyxin-dexameth ophthalmic ointment Maxitrol

neomycin-polymyxin-dexameth ophthalmic suspension Maxitrol

sulfacetamide-prednisolone ophthalmic solution QLL (10 ML per 30 days)

tobramycin-dexamethasone ophthalmic suspension TobraDex

TOBRADEX OPHTHALMIC OINTMENT ZYLET OPHTHALMIC SUSPENSION

*Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution loteprednol etabonate ophthalmic suspension Lotemax

154

Formulary Drug Name Reference Restrictions prednisolone acetate ophthalmic suspension Pred Forte ALREX OPHTHALMIC SUSPENSION DUREZOL OPHTHALMIC EMULSION FLAREX OPHTHALMIC SUSPENSION FML FORTE OPHTHALMIC SUSPENSION FML OPHTHALMIC OINTMENT MAXIDEX OPHTHALMIC SUSPENSION

*Ophthalmics - Cystinosis Agents** CYSTARAN OPHTHALMIC SOLUTION QLL (60 ML per 28 days)

*Prostaglandins - Ophthalmic*** latanoprost ophthalmic solution Xalatan QLL (5 ML per 30 days) TRAVATAN Z OPHTHALMIC SOLUTION QLL (5 ML per 30 days)

*OPHTHALMIC RHO KINASE INHIBITORS*** *Ophthalmic Rho Kinase Inhibitors*** RHOPRESSA OPHTHALMIC SOLUTION Auto-PA

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution

*Otic Anti-Infectives*** ofloxacin otic solution Floxin Otic AL (Min 12 Years)

*Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution neomycin-polymyxin-hc otic suspension CIPRODEX OTIC SUSPENSION

*Otic Steroids*** fluocinolone acetonide otic oil DermOtic

*OXYTOCICS* *Oxytocics*** methylergonovine maleate oral tablet Methergine

155

Formulary Drug Name Reference Restrictions *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** *Passive Immunizing Agents -Combinations*** HYQVIA SUBCUTANEOUS KIT PA

*PASSIVE IMMUNIZING AGENTS* *Immune Serums*** BIVIGAM INTRAVENOUS SOLUTION PA CUVITRU SUBCUTANEOUS SOLUTION PA CYTOGAM INTRAVENOUS INJECTABLE PA

FLEBOGAMMA DIF INTRAVENOUS SOLUTION PA

GAMASTAN S/D INTRAMUSCULAR INJECTABLE PA

GAMMAGARD INJECTION SOLUTION PA GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED

PA

GAMMAKED INJECTION SOLUTION PA GAMMAPLEX INTRAVENOUS SOLUTION PA

GAMUNEX-C INJECTION SOLUTION PA HIZENTRA SUBCUTANEOUS SOLUTION PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION PA

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

QLL (2 PRESCRIPTIONS per 365 days)

NABI-HB INTRAMUSCULAR SOLUTION PA

OCTAGAM INTRAVENOUS SOLUTION PA PRIVIGEN INTRAVENOUS SOLUTION PA

*PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable

156

Formulary Drug Name Reference Restrictions ampicillin oral capsule ampicillin sodium injection solution reconstituted ampicillin sodium intravenous solution reconstituted

*Natural Penicillins*** penicillin g procaine intramuscular suspension penicillin g sodium injection solution reconstituted penicillin v potassium oral solution reconstituted penicillin v potassium oral tablet BICILLIN L-A INTRAMUSCULAR SUSPENSION

*Penicillin Combinations*** amoxicillin-pot clavulanate oral suspension reconstituted Augmentin

amoxicillin-pot clavulanate oral tablet ampicillin-sulbactam sodium injection solution reconstituted Unasyn

ampicillin-sulbactam sodium intravenous solution reconstituted piperacillin sod-tazobactam so intravenous solution reconstituted Zosyn

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION BICILLIN C-R INTRAMUSCULAR SUSPENSION

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule

*PERITONEAL DIALYSIS SOLUTIONS*** *Peritoneal Dialysis Solutions*** DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION

*PHARMACEUTICAL ADJUVANTS* *Gelatin Capsules (Empty)*** capsule coni-snap #1 clear capsule DRcaps Size 0

157

Formulary Drug Name Reference Restrictions *Oral Vehicles*** base gelatin gummy troche gel cherry concentrate oral syrup OTC cola syrup oral syrup OTC corn (syrup) oral syrup cvs distilled water oral liquid Nice Distilled Water OTC flavor plus oral liquid Ora-Plus flavor sweet oral syrup MX-Sol lozibase Lozibase S OTC mouth wash-gp oral liquid raspberry syrup oral syrup simple syrup oral syrup sorbitol solution syrpalta oral syrup troche base powder Freedom Peg Troche Base FLAVOR BLEND ORAL SUSPENSION Suspension Vehicle PCCA ACACIA SYRUP BASE ORAL SYRUP SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

TROCHIBASE FLAKES Custom Polyglycol Troche Base OTC

*Parenteral Vehicles*** bacteriostatic water(benz alc) injection solution saline bacteriostatic injection solution sodium chloride bacteriostatic injection solution sterile water for injection injection solution sterile water for injection intravenous solution

*Pharmaceutical Excipients*** lactose monohydrate powder xanthan gum powder

*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** *Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** EUCRISA EXTERNAL OINTMENT ST

158

Formulary Drug Name Reference Restrictions *POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension Kionex sodium polystyrene sulfonate rectal suspension SPS ORAL SUSPENSION Sodium Polystyrene Sulfonate

*PROGESTINS* *Progestins*** hydroxyprogesterone caproate intramuscular oil Makena PA

medroxyprogesterone acetate tablet 10 mg oral Provera Maintenance drug with max 100

day supply medroxyprogesterone acetate tablet 2.5 mg oral Provera Maintenance drug with max 100

days supply medroxyprogesterone acetate tablet 2.5 mg oral Provera

medroxyprogesterone acetate tablet 5 mg oral Provera megestrol acetate oral suspension Megace ES norethindrone acetate oral tablet Aygestin progesterone intramuscular oil progesterone micronized oral capsule Prometrium

MAKENA INTRAMUSCULAR OIL HYDROXYprogesterone Caproate

PA; QLL (4 ML per 28 days); AL (Min 16 Years)

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; AL (Min 16 Years)

PROMETRIUM ORAL CAPSULE Progesterone Micronized

*PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** *Protein-Carbohydrate-Lipid With Electrolyte Combinations*** KABIVEN INTRAVENOUS EMULSION PERIKABIVEN INTRAVENOUS EMULSION

159

Formulary Drug Name Reference Restrictions *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents*** acamprosate calcium oral tablet delayed release disulfiram oral tablet Antabuse

*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet AL (Min 18 Years)

*Cholinomimetics - Ache Inhibitors*** donepezil hcl oral tablet Aricept AL (Min 18 Years) donepezil hcl oral tablet dispersible AL (Min 18 Years) rivastigmine transdermal patch 24 hour Exelon AL (Min 18 Years)

*Movement Disorder Drug Therapy***

tetrabenazine tablet 12.5 mg oral Xenazine Auto-PA; QLL (3 EA per 1 day); AL (Min 18 Years)

tetrabenazine tablet 25 mg oral Xenazine Auto-PA; QLL (4 EA per 1 day); AL (Min 18 Years)

AUSTEDO ORAL TABLET Auto-PA

*Ms Agents - Pyrimidine Synthesis Inhibitors***

AUBAGIO TABLET 14 MG ORAL QLL (1 EA per 1 day); AL (Min 18 Years)

AUBAGIO TABLET 7 MG ORAL QLL (2 EA per 1 day); AL (Min 18 Years)

*Multiple Sclerosis Agents -Interferons*** AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT


AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT


BETASERON SUBCUTANEOUS KIT QLL (1 KIT per 28 days); AL (Min 18 Years)

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR QLL (6 ML per 28 days)

160

Formulary Drug Name Reference Restrictions REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE QLL (6 ML per 28 days)

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Glatiramer Acetate QLL (1 ML per 28 days); AL

(Min 18 Years)

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution AL (Min 18 Years) memantine hcl oral tablet Namenda AL (Min 18 Years)

*Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline tablet 2-10 mg oral

QL: ages =/>18: maximum 8 tablets/day; AL (Min 18 Years)

perphenazine-amitriptyline tablet 2-25 mg oral








*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** fluoxetine hcl (pmdd) oral capsule

*Psychotherapeutic And Neurological Agents - Misc.***

pimozide oral tablet QL: age 6-17: maximum 1 tablet/day; AL (Min 18 Years)

*Smoking Deterrents*** bupropion hcl er (smoking det) oral tablet extended release 12 hour


gnp nicotine mini mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years)

161

Formulary Drug Name Reference Restrictions goodsense nicotine mouth/throat gum KLS Quit4 OTC; AL (Min 18 Years) goodsense nicotine mouth/throat lozenge KLS Quit2 OTC hm nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) hm nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) hm nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) nicotine step 1 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine step 2 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine step 3 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine transdermal kit OTC; AL (Min 18 Years) nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) sm nicotine mouth/throat gum KLS Quit4 OTC; AL (Min 18 Years) sm nicotine mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) sm nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) sm nicotine polacrilex mouth/throat lozenge KLS Quit4 OTC; AL (Min 18 Years) sm nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) CHANTIX CONTINUING MONTH PAK ORAL TABLET


CHANTIX ORAL TABLET QLL (180 EA per 730 days); AL (Min 18 Years)

CHANTIX STARTING MONTH PAK ORAL TABLET


NICORETTE MOUTH/THROAT GUM RA Nicotine OTC

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE AL (Min 10 Years)

*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** *Pulmonary Fibrosis Agents - Kinase Inhibitors*** OFEV ORAL CAPSULE PA

*RESPIRATORY AGENTS -MISC.* *Alpha-Proteinase Inhibitor (Human)*** ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA; AL (Min 18 Years)

162

Formulary Drug Name Reference Restrictions GLASSIA INTRAVENOUS SOLUTION Auto-PA; AL (Min 18 Years) PROLASTIN-C INTRAVENOUS SOLUTION Auto-PA; AL (Min 18 Years)

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA; AL (Min 18 Years)

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA; AL (Min 18 Years)

*Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION

Auto-PA; QLL (5 ML per 1 day); AL (Max 65 Years)

*SEROTONIN MODULATORS*** *Serotonin Modulators*** trazodone hcl tablet 100 mg oral AL (Min 6 Years) trazodone hcl tablet 100 mg oral trazodone hcl tablet 150 mg oral AL (Min 6 Years) trazodone hcl tablet 150 mg oral trazodone hcl tablet 300 mg oral AL (Min 6 Years) trazodone hcl tablet 300 mg oral trazodone hcl tablet 50 mg oral AL (Min 6 Years) trazodone hcl tablet 50 mg oral

TRINTELLIX ORAL TABLET Auto-PA; QLL (30 EA per 30 days); AL (Min 18 Years)

VIIBRYD ORAL TABLET AL (Min 18 Years)

*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** *Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***

GLYXAMBI ORAL TABLET QLL (1 EA per 1 day); AL (Min 18 Years)

*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET SEGLUROMET ORAL TABLET ST; QLL (2 EA per 1 day) SYNJARDY ORAL TABLET XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR

163

Formulary Drug Name Reference Restrictions *STEROIDS -MOUTH/THROAT/DENTAL*** *Steroids - Mouth/Throat/Dental*** triamcinolone acetonide mouth/throat paste Oralone

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet

*TETRACYCLINES* *Tetracyclines*** doxycycline hyclate oral capsule Morgidox doxycycline hyclate oral tablet doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline hcl oral capsule Minocin

*THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet Tapazole propylthiouracil oral tablet

*Thyroid Hormones***

levothyroxine sodium intravenous solution Maintenance drug with max 100 day supply

levothyroxine sodium tablet 100 mcg oral Euthyrox Maintenance drug with max 100 day supply





levothyroxine sodium tablet 175 mcg oral Euthyrox Maintenance drug with max 100 days supply




164




levothyroxine sodium tablet 300 mcg oral Levo-T Maintenance drug with max 100 days supply

levothyroxine sodium tablet 300 mcg oral Levo-T Maintenance drug with max 100 day supply







liothyronine sodium oral tablet Cytomel np thyroid oral tablet Armour Thyroid thyroid oral tablet Armour Thyroid ARMOUR THYROID ORAL TABLET NP Thyroid

EUTHYROX ORAL TABLET Levothyroxine Sodium Maintenance drug with max 100 day supply

LEVOXYL ORAL TABLET Levothyroxine Sodium SYNTHROID ORAL TABLET Levothyroxine Sodium UNITHROID ORAL TABLET Levothyroxine Sodium

*ULCER DRUGS* *Anticholinergic Combinations*** belladonna alkaloids-opium rectal suppository chlordiazepoxide-clidinium oral capsule Librax

*Antispasmodics*** dicyclomine hcl oral capsule dicyclomine hcl oral solution dicyclomine hcl oral tablet

*Belladonna Alkaloids*** hyoscyamine sulfate er oral tablet extended release 12 hour Levbid

hyoscyamine sulfate oral elixir 165

Formulary Drug Name Reference Restrictions hyoscyamine sulfate oral solution hyoscyamine sulfate oral tablet Levsin hyoscyamine sulfate oral tablet dispersible Anaspaz hyoscyamine sulfate sublingual tablet sublingual Levsin/SL

*H-2 Antagonists*** famotidine intravenous solution famotidine oral suspension reconstituted ST famotidine oral tablet Pepcid famotidine premixed intravenous solution ranitidine hcl oral syrup

ranitidine hcl oral tablet Wal-Zan 150 Maximum Strength

*Misc. Anti-Ulcer*** sucralfate oral tablet Carafate

*Proton Pump Inhibitors***

lansoprazole oral tablet dispersible 15 mg Prevacid SoluTab

QL: ages 1-11: maximum 2 capsules/day, ages =/>12: maximum 3 capsules/day; AL (Min 1 Years and Max 11 Years)

lansoprazole tablet dispersible 15 mg oral Prevacid SoluTab AL (Min 1 Years and Max 11 Years)

lansoprazole tablet dispersible 30 mg oral Prevacid SoluTab AL (Min 1 Years and Max 11 Years)

lansoprazole tablet dispersible 30 mg oral Prevacid SoluTab

QL: ages 1-11: maximum 1 capsule/day, ages =/>12: maximum 3 capsules/day; AL (Min 1 Years and Max 11 Years)

omeprazole oral capsule delayed release QLL (1 EA per 1 day); AL (Min 1 Years)

pantoprazole sodium tablet delayed release 20 mg oral Protonix QLL (1 EA per 1 day); AL (Min

5 Years) pantoprazole sodium tablet delayed release 40 mg oral Protonix QLL (2 EA per 1 day); AL (Min

5 Years)

NEXIUM ORAL PACKET QLL (1 EA per 1 day); AL (Max 11 Years)

PROTONIX ORAL PACKET QLL (1 EA per 1 day); AL (Min 5 Years and Max 11 Years)

*Quaternary Anticholinergics*** glycopyrrolate injection solution QLL (30 ML per 1 day)

166

Formulary Drug Name Reference Restrictions glycopyrrolate oral tablet propantheline bromide oral tablet

CUVPOSA ORAL SOLUTION Auto-PA; AL (Min 3 Years and Max 6 Years)

GLYRX-PF INJECTION SOLUTION

*Ulcer Anti-Infective W/ Bismuth Combinations*** PYLERA ORAL CAPSULE

*Ulcer Drugs - Prostaglandins*** misoprostol oral tablet Cytotec

*URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine hippurate oral tablet Hiprex methenamine mandelate oral tablet nitrofurantoin macrocrystal oral capsule Macrodantin nitrofurantoin monohyd macro oral capsule Macrobid nitrofurantoin oral suspension Furadantin AL (Max 11 Years)

*Urinary Antiseptic-Antispasmodic &/Or Analgesics*** UTIRA-C ORAL TABLET Urin DS

*URINARY ANTISPASMODICS* *Urinary Antispasmodic -Antimuscarinic (Anticholinergic)*** oxybutynin chloride er oral tablet extended release 24 hour Ditropan XL

oxybutynin chloride oral syrup

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 day supply

oxybutynin chloride tablet 5 mg oral

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 days supply

solifenacin succinate oral tablet VESIcare TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 18 Years)

*Urinary Antispasmodic -Antimuscarinics (Antichol)***(New) oxybutynin chloride er oral tablet extended release 24 hour 5 mg Ditropan XL Maintenance drug with max 100

days supply

167

Formulary Drug Name Reference Restrictions oxybutynin chloride er tablet extended release 24 hour 10 mg oral Ditropan XL

oxybutynin chloride er tablet extended release 24 hour 15 mg oral oxybutynin chloride er tablet extended release 24 hour 5 mg oral Ditropan XL Maintenance drug with max 100

days supply oxybutynin chloride er tablet extended release 24 hour 5 mg oral Ditropan XL Maintenance drug with max 100

day supply oxybutynin chloride oral syrup

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 day supply

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 days supply

solifenacin succinate oral tablet VESIcare tolterodine tartrate er oral capsule extended release 24 hour Detrol LA AL (Min 5 Years and Max 18

Years)

tolterodine tartrate oral tablet Detrol AL (Min 5 Years and Max 18 Years)

trospium chloride er oral capsule extended release 24 hour QLL (30 EA per 30 days)

trospium chloride oral tablet QLL (60 EA per 30 days) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 18 Years)

*Urinary Antispasmodics -Cholinergic Agonists*** bethanechol chloride oral tablet Urecholine

*Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet Urecholine

*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** 3 day vaginal vaginal cream Gyne-Lotrimin 3 OTC clotrimazole vaginal cream Gyne-Lotrimin OTC gnp clotrimazole 3 vaginal cream Gyne-Lotrimin 3 OTC gnp miconazole 7 vaginal cream Monistat 7 Simply Cure OTC miconazole 1 vaginal kit Monistat 1 Combo Pack OTC miconazole 3 vaginal cream Monistat 3 OTC miconazole 3 vaginal suppository miconazole 7 vaginal cream Monistat 7 Simply Cure OTC miconazole 7 vaginal suppository OTC

168

Formulary Drug Name Reference Restrictions miconazole nitrate vaginal cream Monistat 7 Simply Cure OTC qc 3 day vaginal cream Monistat 3 OTC qc miconazole 7 vaginal cream Monistat 7 Simply Cure OTC sm 3-day vaginal vaginal cream Gyne-Lotrimin 3 OTC sm clotrimazole vaginal vaginal cream Gyne-Lotrimin OTC sm miconazole 7 vaginal cream Monistat 7 Simply Cure OTC sm miconazole 7 vaginal suppository OTC terconazole cream 0.4 % vaginal Terazol 7 QLL (45 GM per 1 Fill) terconazole cream 0.8 % vaginal QLL (20 GM per 1 Fill) GYNAZOLE-1 VAGINAL CREAM

*Vaginal Anti-Infectives*** metronidazole vaginal gel MetroGel-Vaginal CLEOCIN VAGINAL SUPPOSITORY CLINDESSE VAGINAL CREAM NUVESSA VAGINAL GEL

*Vaginal Estrogens*** estradiol tablet 10 mcg vaginal Vagifem estradiol tablet 10 mcg vaginal Vagifem F; QLL (1 Fill per 28 days) ESTRING VAGINAL RING QLL (1 EA per 84 days) PREMARIN VAGINAL CREAM QLL (42.5 GM per 1 Fill)

*VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector EpiPen Jr 2-Pak

*Vasopressors*** dobutamine hcl intravenous solution dobutamine in d5w intravenous solution midodrine hcl oral tablet

*VITAMINS* *Vitamin B-1*** thiamine hcl injection solution

*Vitamin B-6*** pyridoxine hcl injection solution

*Vitamin C*** ascorbic acid injection solution

*Vitamin D*** vitamin d (ergocalciferol) oral capsule Drisdol

169

Formulary Drug Name Reference Restrictions *Vitamin K*** phytonadione injection solution phytonadione oral tablet Mephyton QLL (5 EA per 30 days) vitamin k1 injection solution

170

Index Header 1st tier unilet comfortouch 117 3 day vaginal 168 8 hour arthritis pain reliever 16 8 hr arthritis pain relief 16 8hr muscle aches & pain 16 abacavir sulfate 69 abacavir sulfate-lamivudine 67 abacavir-lamivudine-zidovudine 67 abdek 147 ABELCET 41 ABILIFY MAINTENA 65 abiraterone acetate 50 acamprosate calcium 160 acarbose 34 ACCU-CHEK AVIVA 121 ACCU-CHEK COMPACT PLUS CONTROL 121 ACCU-CHEK FASTCLIX LANCET 121 ACCU-CHEK FASTCLIX LANCETS 121 ACCU-CHEK GUIDE CONTROL 121 ACCU-CHEK MULTICLIX LANCET DEV 121 ACCU-CHEK MULTICLIX LANCETS 121 ACCU-CHEK SAFE-T PRO LANCETS 121 ACCU-CHEK SMARTVIEW CONTROL 121 ACCU-CHEK SOFT TOUCH LANCETS 121 ACCU-CHEK SOFTCLIX LANCET DEV 121 ACCU-CHEK SOFTCLIX LANCETS 121 ACCUTREND GLUCOSE CONTROL 121 acebutolol hcl 73 acetaminophen 16 acetaminophen childrens 16 acetaminophen er 16 acetaminophen infants 16 acetaminophen-codeine 19 acetaminophen-codeine #2 19 acetaminophen-codeine #3 19 acetaminophen-codeine #4 19 acetazolamide 100 acetazolamide er 100 acetic acid 106, 155

acetylcysteine 40, 93 acitretin 95 ACTHAR 102 acti-lance 28g 117 acti-lance lite lancets 28g 117 acti-lance special lancets 17g 117 acti-lance universal 23g 117 ACTIMMUNE 52 acyclovir 70, 71, 96 adapalene 94 adjustable lancing device 117 ADMELOG 36 ADMELOG SOLOSTAR 36 adult aspirin regimen 18 ADVAIR HFA 25 ADVANCE INTUITION CONTROL 121 ADVANCE MICRO-DRAW CONTROL 121 ADVANCE MICRO-DRAW NORMAL 121 ADVATE 107 ADVOCATE CONTROL SOLUTION 121 ADVOCATE INSULIN SYRINGE 135 ADVOCATE LANCETS 121 ADVOCATE LANCETS 30G121 ADVOCATE LANCING DEVICE 121 ADVOCATE RAPID-SAFE LANCING 122 ADVOCATE REDI-CODE+ CONTROL 122 ADVOCATE SAFETY LANCETS 122 ADVOCATE SAFETY LANCETS 26G 122 adynovate 107 ADZENYS XR-ODT 8 AEROCHAMBER MINI CHAMBER 140 AEROCHAMBER MV 140 AEROCHAMBER PLUS FLO-VU 140 AEROCHAMBER PLUS FLO-VU LARGE 140 AEROCHAMBER PLUS FLO-VU MEDIUM 140 AEROCHAMBER PLUS FLO-VU SMALL 140

AEROCHAMBER PLUS FLO-VU W/MASK 140 AEROCHAMBER PLUS FLOW VU 140 AEROCHAMBER W/FLOWSIGNAL 140 AEROCHAMBER Z-STAT PLUS 140 AEROCHAMBER Z-STAT PLUS CHAMBR 141 AEROCHAMBER Z-STAT PLUS/LARGE 141 AEROCHAMBER Z-STAT PLUS/MEDIUM 141 AEROCHAMBER Z-STAT PLUS/SMALL 141 AEROVENT PLUS 141 AFIRMELLE 79 AFSTYLA 107 AFTERA 84 AGAMATRIX CONTROL 122 AGAMATRIX ULTRA-THIN LANCETS 122 ALA-QUIN 94 ALAWAY 153 ALAWAY CHILDRENS ALLERGY 153 albendazole 23 ALBUKED 25 109 ALBUKED 5 109 albumin human 109 ALBUMINEX 109 alburx 109 ALBUTEIN 109 albuterol sulfate 25, 26 albuterol sulfate hfa 25 ALCOH-GLOVE CONTOURED WIPE 116 alcohol pads 116 alcohol prep 116 alcohol swabs 116 alcohol wipes 116 alcoh-wipe 116 alendronate sodium 101 alfuzosin hcl er 105 ALIMTA 51 ALKERAN 54 all day allergy 42 all day allergy childrens 42 all day allergy-d 91 allergy 42

171

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allergy eye drops 152 allergy relief 42 allergy relief childrens 42 allergy relief d-24 91 allergy relief/indoor/outdoor 42 allergy relief/nasal decongest 91 allergy relief-d 91 allergy/congestion relief 91 allopurinol 106 alogliptin benzoate 35 alogliptin-metformin hcl 36 alogliptin-pioglitazone 36 alosetron hcl 104 ALPHANATE/VWF COMPLEX/HUMAN 107 ALPHANINE SD 107 alprazolam 24 ALPROLIX 107 ALREX 155 ALTAVERA 79 alternate site lancing device 117 alyacen 1/35 79 alyacen 7/7/7 87 amantadine hcl 55 AMETHIA 85 AMETHIA LO 85 AMICAR 113 amiloride hcl 100 amiloride-hydrochlorothiazide 100 aminocaproic acid 113 AMINOSYN II 150 AMINOSYN-PF 150 amiodarone hcl 25 amitriptyline hcl 34 amlodipine besy-benazepril hcl 44 amlodipine besylate 74 amlodipine besylate-valsartan 45 amlodipine-olmesartan 45 ammonium lactate 97 AMNESTEEM 94 amoxapine 34 amoxicillin 156 amoxicillin-pot clavulanate 157 amphetamine-dextroamphet er 5, 6 amphetamine-dextroamphetamine 6, 7 amphotericin b 41 ampicillin 157 ampicillin sodium 157 ampicillin-sulbactam sodium 157 anagrelide hcl 109 anastrozole 52

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ANDROGEL 21 ANDROGEL PUMP 21 antacid 22 antacid calcium 22 antacid extra strength 22 antacid ultra strength 22 ANUSOL-HC 22 aprepitant 41 APRI 79 APRISO 105 APTENSIO XR 11, 12 APTIOM 30 APTIVUS 68 aqua lance adjustable lancing 117 AQUADEKS 147 AQUALANCE LANCETS 30G 122 ARALAST NP 162 ARANELLE 87 ARANESP (ALBUMIN FREE) 110, 111 ARIAL CHAMBER 141 aripiprazole 64, 65 ARISTADA 65 ARISTADA INITIO 65 ARMOUR THYROID 165 ARNUITY ELLIPTA 26 arthritis pain relief 16 ARYMO ER 20 ARZERRA 51 ascorbic acid 169 ASHLYNA 85 ASMANEX (120 METERED DOSES) 26 ASMANEX (14 METERED DOSES) 26 ASMANEX (30 METERED DOSES) 26 ASMANEX (60 METERED DOSES) 27 aspirin 18 aspirin 81 18 aspirin adult 18 aspirin adult low strength 18 aspirin ec 18 aspirin ec low strength 18 aspirin low dose 18 aspirin-dipyridamole er 109 ASPIR-LOW 19 ASSURE 3 CONTROL 122 ASSURE 4 CONTROL LEVEL 1 & 2 122

assure comfort lancets 28g 117 ASSURE DOSE CONTROL 122 ASSURE DOSE NORM/HIGH CONTROL 122 ASSURE HAEMOLANCE PLUS HIGH 122 ASSURE HAEMOLANCE PLUS LOW 122 ASSURE HAEMOLANCE PLUS MICRO 122 ASSURE HAEMOLANCE PLUS NORMAL 122 ASSURE HAEMOLANCE PLUS PED 122 ASSURE ID INSULIN SAFETY SYR 135 ASSURE II CONTROL 122 ASSURE II CONTROL LEVEL 1 & 2 122 ASSURE LANCE LANCETS 122 ASSURE LANCE LANCETS 21G 122 ASSURE LANCE PLUS SAFETY 25G 122 ASSURE LANCE PLUS SAFETY 30G 122 ASSURE LANCETS 122 ASSURE PRISM CONTROL LEVEL 1 122 ASSURE PRO CONTROL LEVEL 1 & 2 122 atenolol 73 atenolol-chlorthalidone 46 ATGAM 71 atomoxetine hcl 5 atorvastatin calcium 44 atovaquone 47 ATRIPLA 67 atropine sulfate 152 ATROVENT HFA 26 AUBAGIO 160 AUBRA 79 AUBRA EQ 79 aurora lancet super thin 30g 117 aurora lancet thin 23g 117 AUROVELA 1.5/30 79 AUROVELA 1/20 79 AUROVELA 24 FE 79 AUROVELA FE 1.5/30 80 AUROVELA FE 1/20 80 AUSTEDO 160 AUTO-LANCET 122

AUTO-LANCET MINI 122 AUTOLET II CLINISAFE 122 AUTOLET LANCING DEVICE 122 AUTOLET LITE CLINISAFE 122 AUTOLET LITE STARTER PACK 122 AUTOLET MINI 123 AUTOLET PLATFORMS 123 AUTOLET PLUS 123 AVIANE 80 AVITA 94 AVONEX PEN 160 AVONEX PREFILLED 160 AYUNA 80 azacitidine 50 azathioprine 72 azelaic acid 98 azelastine hcl 150, 152 AZELEX 94 azithromycin 115 AZOPT 154 aztreonam 146 AZURETTE 78 bacitracin-polymyxin b 153 bacitra-neomycin-polymyxin-hc154 baclofen 149 BACMIN 147 bacteriostatic water(benz alc) 158 balanced salt 154 BALCOLTRA 80 BALZIVA 80 BANZEL 30 BARACLUDE 70 BASAGLAR KWIKPEN 36 base gelatin gummy troche 158 BD ECLIPSE SYRINGE 135 BD INSULIN SYR ULTRAFINE II 135 BD INSULIN SYRINGE 135 BD INSULIN SYRINGE MICROFINE 135 BD INSULIN SYRINGE U/F 135 BD INSULIN SYRINGE U/F 1/2UNIT 135 BD INSULIN SYRINGE ULTRAFINE 135 BD LANCET ULTRAFINE 30G 123 BD LANCET ULTRAFINE 33G 123

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BD LUER-LOK SYRINGE 135 BD MICROTAINER LANCETS 123 BD PEN NEEDLE NANO U/F 135 BD PEN NEEDLE SHORT U/F 135 BD SAFETYGLIDE INSULIN SYRINGE 135, 136 BD SAFETYGLIDE SYRINGE/NEEDLE 136 BD SAFETY-LOK INSULIN SYRINGE 136 BD SWAB SINGLE USE REGULAR 116 BD SWABS SINGLE USE BUTTERFLY 116 BD SYRINGE/NEEDLE 136 BD SYRINGE/NEEDLE SLIP TIP 136 BD VEO INSULIN SYRINGE U/F 136 BEKYREE 78 belladonna alkaloids-opium 165 benazepril hcl 45 benazepril-hydrochlorothiazide ..44 BENEFIX 107 benzonatate 90 benzoyl peroxide 94 benztropine mesylate 54 BERINERT 108 betamethasone dipropionate aug 96 betamethasone sod phos & acet 90 betamethasone valerate 96 BETAPACE AF 74 BETASERON 160 bethanechol chloride 168 BEVESPI AEROSPHERE 25 BEYAZ 80 bicalutamide 50 BICILLIN C-R 157 BICILLIN C-R 900/300 157 BICILLIN L-A 157 BIKTARVY 67 bisoprolol fumarate 73 bisoprolol-hydrochlorothiazide 46 BIVIGAM 156 bleomycin sulfate 51 BLISOVI 24 FE 80 BLISOVI FE 1.5/30 80 BLISOVI FE 1/20 80

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BOTOX 150 BREATHERITE 141 BREATHERITE COLL SPACER ADULT 141 BREATHERITE COLL SPACER CHILD 141 BREATHERITE COLL SPACER INFANT 141 BREATHERITE RIGID SPACER/MASK 141 BREATHERITE SPACER NEONATE 141 BREATHERITE SPACER SMALL CHILD 141 BREATHERITE/LARGE MASK 141 BREATHERITE/MEDIUM MASK 141 BREATHERITE/SMALL MASK 141 briellyn 79 BRILINTA 99, 108 brimonidine tartrate 154 BRIVIACT 30 budesonide 26, 88, 150 bullseye mini safety lancets 117 BULLSEYE SAFETY LANCETS 123 bumetanide 100 bupivacaine fisiopharma 115 bupivacaine hcl 115 bupivacaine hcl (pf) 115 bupivacaine spinal 115 bupivacaine-epinephrine 115 bupivacaine-epinephrine (pf) 115 buprenorphine 21 buprenorphine hcl 21 buprenorphine hcl-naloxone hcl .21 bupropion hcl 33 bupropion hcl er (smoking det) 161 bupropion hcl er (sr) 33 bupropion hcl er (xl) 33 buspirone hcl 24 BUSULFEX 49 butalbital-acetaminophen 17 butalbital-apap-caff-cod 19 butalbital-apap-caffeine 17 butalbital-aspirin-caffeine 18 butenafine hcl 94 BYDUREON 38 BYETTA 10 MCG PEN 38 BYETTA 5 MCG PEN 38

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cabergoline 102 caffeine citrate 8 calcipotriene 95 calcitonin (salmon) 101 CALCITRATE 143 calcitriol 95, 102 calcium acetate 143 calcium acetate (phos binder) 105 calcium antacid 22 calcium antacid extra strength 22 calcium antacid ultra max st 22 calcium antacid ultra strength 22 calcium carbonate 143 calcium carbonate antacid ..22, 143 calcium chloride 143 calcium gluconate 143 CAL-GEST ANTACID 23 CAMILA 86 CAMPATH 51 CAMRESE 85 CAMRESE LO 85 capecitabine 50 CAPRELSA 51 capsule coni-snap #1 clear 157 captopril 45 carbamazepine 29 carbamazepine er 29 CARBATROL 30 carbidopa-levodopa 55 carbidopa-levodopa er 55 carbidopa-levodopa-entacapone 55 carbinoxamine maleate 42 carboplatin 49 CARDIOCOM LANCING DEVICE 123 careone advanced lancing dev 117 careone insulin syringe 133 careone lancet thin 23g 117 careone lancet ultra thin 28g 117 CARESENS CONTROL A 123 CARETOUCH ALCOHOL PREP 116 CARETOUCH LANCING/EJECTOR 123 CARETOUCH TWIST LANCETS 30G 123 carmustine 54 carteolol hcl 152 carvedilol 73 CATHFLO ACTIVASE 109 CAVILON EMOLLIENT 97

CAVILON FOOT & DRY SKIN 97 CAYA 117 CAZIANT 87 cefaclor 77 cefadroxil 76 cefazolin sodium 76, 77 cefdinir 77 cefepime hcl 78 cefixime 77 cefotaxime sodium 77 cefotetan disodium 77 cefotetan disodium-dextrose 77 cefoxitin sodium 77 cefoxitin sodium-dextrose 77 cefprozil 77 ceftazidime 77 ceftriaxone sodium 78 ceftriaxone sodium in dextrose 77 ceftriaxone sodium-dextrose 78 cefuroxime axetil 77 cefuroxime sodium 77 celecoxib 15 CELESTONE SOLUSPAN 90 CELLCEPT INTRAVENOUS 72 CELONTIN 32 cephalexin 77 CERDELGA 110 CEREZYME 110 cetirizine hcl 42 cetirizine hcl allergy child 42 cetirizine hcl childrens 42 cetirizine hcl childrens alrgy 42 cetirizine hcl hives relief 42 cetirizine-pseudoephedrine er 91 CHANTIX 162 CHANTIX CONTINUING MONTH PAK 162 CHANTIX STARTING MONTH PAK 162 CHATEAL 80 CHATEAL EQ 80 CHEMSTRIP BG LOG BOOK 123 cherry concentrate 158 chest congestion relief 92 childrens acetaminophen 16 childrens aspirin low strength 18 childrens loratadine 42 childrens mucus relief expect 92 childrens silapap 16 chlordiazepoxide hcl 24

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chlordiazepoxide-amitriptyline 160 chlordiazepoxide-clidinium 165 chlorhexidine gluconate 146 chloroquine phosphate 48 chlorothiazide 101 chlorpromazine hcl 62 chlorthalidone 101 chlorzoxazone 149 cholestyramine 43 cholestyramine light 43 chromic chloride 146 ciclopirox 94 ciclopirox olamine 94 cilostazol 109 CIMDUO 67 CINRYZE 108 CIPRODEX 155 ciprofloxacin 104 ciprofloxacin hcl 104, 153 ciprofloxacin in d5w 104 cisplatin 49 citalopram hydrobromide 33 CITRANATAL B-CALM 148 CITRANATAL DHA 149 CITRANATAL HARMONY .149 cladribine 50 CLARAVIS 94 clarithromycin 115 clarithromycin er 115 CLARITIN EYE 153 CLEANLET LANCETS 28G 123 CLEARLAX 114 clemastine fumarate 42 CLEOCIN 169 CLEVER CHEK LANCETS . 123 CLEVER CHOICE GLUCOSE CONTROL 123 CLEVER CHOICE HOLDING CHAMBER 141 CLIMARA PRO 103 clindamycin hcl 48 clindamycin palmitate hcl 48 clindamycin phos-benzoyl perox .94 clindamycin phosphate 48, 93 CLINDESSE 169 CLINIMIX E/DEXTROSE (2.75/5) 150 CLINIMIX E/DEXTROSE (4.25/10) 151 CLINIMIX E/DEXTROSE (4.25/5) 151

CLINIMIX E/DEXTROSE (5/15) 151 CLINIMIX E/DEXTROSE (5/20) 151 CLINIMIX N14G30E 151 CLINIMIX N9G15E 151 CLINIMIX N9G20E 151 CLINIMIX/DEXTROSE (4.25/10) 151 CLINIMIX/DEXTROSE (4.25/25) 151 CLINIMIX/DEXTROSE (4.25/5) 151 CLINIMIX/DEXTROSE (5/15) 151 CLINIMIX/DEXTROSE (5/20) 151 CLINIMIX/DEXTROSE (5/25) 151 CLINISOL SF 151 clobazam 29 clobetasol prop emollient base 96 clobetasol propionate 96 clobetasol propionate e 96 clomipramine hcl 34 clonazepam 29 clonidine 46 clonidine hcl 46 clopidogrel bisulfate 109 clorazepate dipotassium 24 clotrimazole 97, 98, 146, 168 clotrimazole-betamethasone 94 clozapine 59, 60 CLOZARIL 60, 61 c-nate dha 148 COAGADEX 107 COAGUCHEK LANCETS 123 codeine sulfate 20 cola syrup 158 colchicine 106 colchicine-probenecid 106 colestipol hcl 43 colistimethate sodium (cba) 48 COMBIGAN 152 COMBIPATCH 103 COMBIVENT RESPIMAT 25 COMFORT ASSIST INSULIN SYRINGE 136 comfort assured lancets 28g 117 comfort assured lancets 33g 117 COMFORT EZ INSULIN SYRINGE 136

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comfort lancets 117 COMPACT SPACE CHAMBER 141 COMPACT SPACE CHAMBER/LG MASK 141 COMPACT SPACE CHAMBER/MED MASK 141 COMPACT SPACE CHAMBER/SM MASK 141 COMPLERA 67 complete natal dha 149 completenate 148 CONCEPT DHA 148 CONCEPT OB 148 CONTOUR CONTROL 123 CONTOUR NEXT CONTROL 123 control 117 COOL CONTROL A 123 COOL CONTROL B 123 COPAXONE 161 copper chloride 146 CORIFACT 107 corn (syrup) 158 CORTISPORIN 94 CORVITA 147 COSENTYX 95 COSENTYX (300 MG DOSE) 95 COSENTYX SENSOREADY (300 MG) 95 COSENTYX SENSOREADY PEN 95 cough/chest congestion dm 90 COUMADIN 27 CREON 99 CRIXIVAN 68 cromolyn sodium 25, 104, 152 CRYSELLE-28 80 CURITY ALCOHOL PREPS116 CURITY ALCOHOL SWABS 116 CUVITRU 156 CUVPOSA 167 cvs alcohol prep pads 116 cvs allergy eye drops 152 cvs distilled water 158 cvs eye itch relief 153 cvs fluticasone propionate 150 cvs lancets 21g 117 cvs lancets micro thin 33g 117 cvs lancets original 117 cvs lancets thin 26g 117

cvs lancets ultra thin 30g 117 cvs lancets ultra-thin 30g 117 cvs lancing device 117 cvs prep 116 cvs ultra thin lancets 117 cyanocobalamin 110 CYCLAFEM 1/35 80 CYCLAFEM 7/7/7 87 cyclobenzaprine hcl 149 cyclopentolate hcl 152 cyclophosphamide 53 cyclosporine 71 cyclosporine modified 71 cyproheptadine hcl 43 CYRED 80 CYRED EQ 80 CYSTADANE 102 CYSTAGON 106 CYSTARAN 155 cytarabine 50 cytarabine (pf) 50 CYTOGAM 156 dacarbazine 52 danazol 21 dapsone 48 DASETTA 1/35 80 DASETTA 7/7/7 87 daunorubicin hcl 51 DAYSEE 85 DAYTRANA 12 DEBLITANE 86 decitabine 50 deferoxamine mesylate 40 DELFLEX-SM/1.5% DEXTROSE 72, 157 DELSTRIGO 67 DENAVIR 96 DEPAKENE 32 DEPAKOTE 32 DEPAKOTE ER 32 DEPAKOTE SPRINKLES 33 DEPO-PROVERA 86 DEPO-SUBQ PROVERA 104 86 DERMA-SMOOTHE/FS BODY 97 DESCOVY 67 desipramine hcl 34 desmopressin acetate 103 desmopressin acetate spray 103 desogestrel-ethinyl estradiol 78, 79 desvenlafaxine succinate er 34 dexamethasone 88

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DEXAMETHASONE INTENSOL 89 dexamethasone sod phosphate pf 88 dexamethasone sodium phosphate 88, 154 dexmethylphenidate hcl 9 dexmethylphenidate hcl er 8, 9 dexrazoxane hcl 52 dextroamphetamine sulfate 8 dextroamphetamine sulfate er 7 dextromethorphan-guaifenesin 90 dextrose 152 dextrose 5%/electrolyte #48 143 dextrose in lactated ringers 143 dextrose-nacl 143 diabetic siltussin das-na 92 dialysis safety syringe/needle 133 DIALYVITE 146 DIALYVITE 3000 147 DIALYVITE 5000 147 DIALYVITE SUPREME D 147 DIALYVITE/ZINC 147 diatrue control level 1 117 diatrue control level 2 117 diatrue control level 3 117 diazepam 24, 29 diclofenac potassium 15 diclofenac sodium 15, 95, 154 diclofenac sodium er 15 dicloxacillin sodium 157 dicyclomine hcl 165 didanosine 69 DIFFERIN 94 DIFICID 115 digoxin 76 DILANTIN 32 diltiazem hcl 75 diltiazem hcl er 75 diltiazem hcl er beads 74 diltiazem hcl er coated beads74, 75 diphenhydramine hcl 42 diphenoxylate-atropine 40 dipyridamole 109 disopyramide phosphate 24 disulfiram 160 DIURIL 101 divalproex sodium 32 divalproex sodium er 32 dm-guaifenesin er 90 dobutamine hcl 169 dobutamine in d5w 169

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docetaxel 53 donepezil hcl 160 dorzolamide hcl 154 dorzolamide hcl-timolol mal 152 DOVATO 67 doxazosin mesylate 46 doxepin hcl 34, 95 doxercalciferol 102 doxorubicin hcl 52 doxorubicin hcl liposomal 52 doxycycline hyclate 164 doxycycline monohydrate 164 doxylamine-pyridoxine 41 droperidol 24 DROPLET LANCETS ULTRA THIN 30G 123 DROPLET LANCING DEVICE 123 drospiren-eth estrad-levomefol 79 drospirenone-ethinyl estradiol 79 drug mart lancets thin 26g 117 DRUG MART LANCING DEVICE 123 DRUG MART ON-THE-GO LANCET 30G 123 DRUG MART UNILET LANCETS 28G 123 DRUG MART UNILET LANCETS 30G 123 DULERA 25 duloxetine hcl 34 DUO-CARE CONTROL SOLUTION 123 DUREZOL 155 dutasteride 105 EASIVENT 141 EASIVENT MASK LARGE 141 EASIVENT MASK MEDIUM

141 EASIVENT MASK SMALL 141 easy comfort insulin syringe 133 easy comfort lancets 118 easy mini eject lancing device 118 easy mini lancing device 118 easy plus ii control 118 EASY STEP CONTROL 123 easy talk control 118 EASY TOUCH ALCOHOL PREP MEDIUM 116 EASY TOUCH CONTROL HIGH & LOW 123

EASY TOUCH FLIPLOCK INSULIN SY 136 EASY TOUCH FLIPLOCK SAFETY SYR 136 EASY TOUCH FLURINGE ..136 EASY TOUCH FLURINGE FLIPLOCK 136 EASY TOUCH FLURINGE SHEATHLOCK 136 EASY TOUCH HEALTHPRO CONTROL 123 EASY TOUCH INSULIN SAFETY SYR 136 EASY TOUCH INSULIN SYRINGE 136 EASY TOUCH LANCETS 21G 124 EASY TOUCH LANCETS 23G 124 EASY TOUCH LANCETS 26G 124 EASY TOUCH LANCETS 26G/TWIST 124 EASY TOUCH LANCETS 28G 124 EASY TOUCH LANCETS 28G/TWIST 124 EASY TOUCH LANCETS 30G 124 EASY TOUCH LANCETS 30G/TWIST 124 EASY TOUCH LANCETS 32G 124 EASY TOUCH LANCETS 32G/TWIST 124 EASY TOUCH LANCETS 33G/TWIST 124 EASY TOUCH LANCING DEVICE 124 EASY TOUCH SAFETY LANCETS 21G 124 EASY TOUCH SAFETY LANCETS 23G 124 EASY TOUCH SAFETY LANCETS 26G 124 EASY TOUCH SAFETY LANCETS 28G 124 EASY TOUCH SAFETY SYRINGE 136 EASY TOUCH SHEATHLOCK SYRINGE 136

EASY TOUCH TB SHEATHLOCK SYR 137 easy trak control 118 EASY TWIST & CAP LANCETS 124 EASYGLUCO CONTROL 124 EASYGLUCO PLUS LEVEL 1 124 EASYMAX 15 LEVEL 1 CONTROL 124 EASYMAX 15 LEVEL 1-2 CONTROL 124 EASYMAX 15 LEVEL 2 CONTROL 124 EASYMAX CONTROL 124 EASYMAX CONTROL NORMAL/LOW 124 ec-naproxen 15 econazole nitrate 98 ECONTRA EZ 84 ECONTRA ONE-STEP 84 ECPIRIN 19 ed-apap 16 EDURANT 69 EFFER-K 144, 145 ELELYSO 110 element compact control 2 118 element compact control 3 118 ELEMENT CONTROL 124 ELIDEL 98 ELIGARD 53 ELINEST 80 ELIQUIS 28 ELIQUIS STARTER PACK 27 ELITE-OB 148 elite-thin insulin syringe 133 ELIXOPHYLLIN 27 ELLA 84 ELOCTATE 107 EMBEDA 20 EMBRACE CONTROL 124 EMBRACE EVO CONTROL LEVEL 1 124 EMBRACE EVO CONTROL LEVEL 2 124 EMBRACE GLUCOSE CONTROL 124 EMBRACE LANCETS ULTRA THIN 30G 125 EMBRACE PRO GLUCOSE CONTROL 125 EMGALITY 74

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EMOQUETTE 80EMTRIVA 69enalapril maleate 45enalapril-hydrochlorothiazide 44ENBREL 16ENBREL MINI 15ENBREL SURECLICK 16ENEMEEZ MINI 114ENEMEEZ PLUS 114enoxaparin sodium 28ENPRESSE-28 87ENSKYCE 80entecavir 70ENTRESTO 150epinephrine 169epirubicin hcl 52EPITOL 30EPIVIR 69EPIVIR HBV 70eplerenone 47EPOGEN 110, 111epoprostenol sodium 76eq allergy relief 42eql alcohol swabs 116eql color lancets 21g 118eql color lancets micro 33g 118eql insulin syringe 134eql super thin lancets 30g 118eql thin lancets 26g 118EQUETRO 56ERAXIS 41ERRIN 86erythromycin 153erythromycin ethylsuccinate 115escitalopram oxalate 33est estrogens-methyltest ds 103est estrogens-methyltest hs 103ESTARYLLA 80estradiol 104, 169 estradiol valerate 104estradiol-norethindrone acet 103ESTRING 169ESTROSTEP FE 87ethambutol hcl 49ethosuximide 32ethynodiol diac-eth estradiol 79 etoposide 53 EUCRISA 158EUTHYROX 165EVENCARE CONTROL LOW/HIGH 125

EVENCARE G2 LOW/HIGH CONTROL 125 EVENCARE G3 LOW/HIGH CONTROL 125 EVENCARE MINI CONTROL 125 EVOLUTION CONTROL 125 EVOTAZ 67 EXEL COMFORT POINT INSULIN SYR 137 exemestane 52 extra action cough 90 eye itch relief 153 E-Z JECT LANCET MICRO-THIN 33G 125 E-Z JECT LANCET SUPER THIN 30G 125 E-Z JECT LANCETS 125 E-Z JECT LANCETS 21G 125 E-Z JECT LANCETS THIN 26G 125 EZ SMART BLOOD GLUCOSE LANCETS 125 EZALLOR SPRINKLE 44 ezetimibe 44 EZ-LETS LANCETS 21G 125 EZ-LETS LANCETS 23G 125 EZ-LETS LANCETS 26G 125 EZ-LETS LANCETS 28G 125 EZ-LETS LANCETS 30G 125 FABRAZYME 102 FALMINA 80 famotidine 166 famotidine premixed 166 FARXIGA 38 FAYOSIM 85 FEIBA 107 felbamate 31 FELBATOL 31 felodipine er 75 FEMHRT LOW DOSE 103 FEMYNOR 81 fenofibrate 44 fentanyl 20 FEOSOL 113 FEOSOL NATURAL RELEASE 113 FERATE 113 FER-IN-SOL 113 FEROSUL 113 ferraplus 90 113 FERRIMIN 150 113

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ferrous fumarate 112 ferrous gluconate 112 ferrous sulfate 112 ferrousul 112 FIFTY50 ALCOHOL PREP . 116 FIFTY50 SAFETY SEAL LANCETS 125 FIFTY50 SUPERIOR COMFORT SYR 137 FIFTY50 UNILET LANCETS 33G 125 finasteride 105 FINE 30 125 FINGERSTIX LANCETS 125 FIRAZYR 108 FLAREX 155 FLAVOR BLEND 158 flavor plus 158 flavor sweet 158 FLEBOGAMMA DIF 156 flecainide acetate 25 FLEXBUMIN 109 FLEXICHAMBER 141 FLONASE SENSIMIST 150 FLOVENT DISKUS 27 FLOVENT HFA 27 floxuridine 50 fluconazole 41 fluconazole in sodium chloride 41 fludarabine phosphate 50 fludrocortisone acetate 89 fluocinolone acetonide 155 fluocinolone acetonide body 96 fluocinolone acetonide scalp 96 fluocinonide 96 fluorouracil 50, 95 fluoxetine hcl 33 fluoxetine hcl (pmdd) 161 fluphenazine decanoate 62 fluphenazine hcl 62, 63 flurbiprofen sodium 154 flutamide 50 fluticasone propionate 96, 150 fluticasone-salmeterol 25 fluvoxamine maleate 33 FML 155 FML FORTE 155 folic acid 111 FOLIVANE-F . 112 FOLIVANE-OB 148 FOLTRATE 110 FORA CONTROL 125

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FORA LANCETS 125 FORA LANCING DEVICE 125 FORACARE GDH CONTROL 125 FORTISCARE CONTROL 125 fosinopril sodium 45 fosinopril sodium-hctz 44 FREAMINE HBC 151 FREAMINE III 151 freds pharmacy autolet lancing 118 freds pharmacy unilet lanc 28g 118 freds pharmacy unilet lanc 30g 118 FREESTYLE CONTROL SOLUTION 125 FREESTYLE LANCETS 125 FREESTYLE PRECISION INS SYR 137 FREESTYLE UNISTICK II LANCETS 125 FULPHILA 111 furosemide 100 FUSION PLUS 112 FUZEON 68 FYCOMPA 29 gabapentin 29 GABITRIL 32 GAMASTAN S/D 156 GAMMAGARD 156 GAMMAGARD S/D LESS IGA 156 GAMMAKED 156 GAMMAPLEX 156 GAMUNEX-C 156 ganciclovir sodium 70 ge100 control 118 gemcitabine hcl 50 gemfibrozil 44 GENERESS FE 81 GENOTROPIN 102 GENOTROPIN MINIQUICK

102 gentamicin in saline 12 gentamicin sulfate 12, 94, 153 GENTLE-LET GP LANCETS 125 GENTLE-LET LANCETS 126 GENTLE-LET PLATFORMS

126 GENVOYA 67 GIANVI 81 GILENYA 162 GLASSIA 163

glimepiride 38, 39 glipizide 39 glipizide er 39 glipizide xl 39 glipizide-metformin hcl 38 global alcohol prep ease 116 global easy glide insulin syr 134 global inject ease insulin syr 134 global inject ease lancets 28g 118 global inject ease lancets 30g 118 global insulin syringes 134 global lancing device 118 GLUCAGEN DIAGNOSTIC 99 GLUCAGEN HYPOKIT 35 GLUCAGON EMERGENCY . 35 glucagon hcl (diagnostic) 99 GLUCOCARD 01 CONTROL 126 GLUCOCARD EXPRESSION CONTROL 126 GLUCOCARD SHINE CONTROL 126 GLUCOCARD X-SENSOR CONTROL 126 GLUCOCOM AUTOLINK TELEMONITOR 126 GLUCOCOM CONTROL 126 GLUCOCOM LANCETS 28G 126 GLUCOCOM LANCETS 30G 126 GLUCOCOM LANCETS 33G 126 GLUCOPRO INSULIN SYRINGE 137 glucose 152 glucose control 118 glyburide 39 glyburide micronized 39 glyburide-metformin 38 glycerin 78 glycopyrrolate 166, 167 GLYRX-PF 167 GLYXAMBI 163 gnp 8 hour pain reliever 16 gnp adult aspirin low strength 18 gnp alcohol swabs 116 gnp all day allergy 42 gnp all day allergy childrens 42 gnp all day allergy-d 91 gnp allergy & congestion 91 gnp allergy relief 42

gnp allergy/congestion relief 91 gnp antacid extra strength 22 gnp arthritis pain relief 16 gnp aspirin 18 gnp aspirin low dose 18 gnp calcium 143 gnp clotrimazole 3 168 GNP EASY TOUCH CONT HIGH/LOW 126 gnp eye itch relief 153 gnp infants pain relief 16 gnp infants pain/fever 16 gnp insulin syringe 134 gnp iron 112 gnp itchy eye 153 gnp lancets 118 gnp lancets 21g 118 gnp lancets micro thin 33g 118 gnp lancets super thin 30g 118 gnp lancets thin 118 gnp lancets thin 26g 118 gnp lidocaine pain relief 98 gnp loratadine 42, 43 gnp loratadine childrens 42 gnp loratadine-d 12hr 91 gnp miconazole 7 168 gnp micro thin lancets 33g 118 gnp mucus dm max strength 90 gnp mucus er 92 gnp mucus relief 92 gnp nicotine 161 gnp nicotine mini 161 gnp nicotine polacrilex 161 gnp pain & fever childrens 16 gnp super thin lancets 30g 118 gnp tab tussin 92 gnp tussin mucus & chest cong 92 gnp ultra com insulin syringe 134 GOCOVRI 55 GOLYTELY 114 goodsense all day allergy 43 goodsense arthritis pain 16 goodsense aspirin 18 goodsense lancets 30g 118 goodsense lancets 33g 118 goodsense lancing device 118 goodsense nicotine 162 goodsense pain & fever child 16 goodsense pain & fever infants 16 goodsense pain relief 16 granisetron hcl 40 GRANIX 111

griseofulvin microsize 41 griseofulvin ultramicrosize 41 guaifenesin 92 guaifenesin-dm 90 guanfacine hcl 46 guanfacine hcl er 5 guanidine hcl 48, 49 GYNAZOLE-1 169 HAEMOLANCE 126 HAEMOLANCE LOW FLOW LANCETS 126 HAEMOLANCE PLUS 126 HAEMOLANCE PLUS HIGH FLOW 126 HAEMOLANCE PLUS LOW FLOW 126 HAEMOLANCE PLUS MAX FLOW 126 HAEMOLANCE PLUS PEDIATRIC FLOW 126 HAILEY 1.5/30 81 HAILEY 24 FE 81 HALAVEN 53 halobetasol propionate 96 haloperidol 58, 59 haloperidol decanoate 58 haloperidol lactate 58 HEALTH CARE LANCING DEVICE 126 healthy accents lancing device 118 healthy accents unilet lancets 118 HEATHER 86 h-e-b incontrol adv lancing 118 h-e-b incontrol alcohol 116 h-e-b incontrol lancets 28g 118 h-e-b incontrol lancets 30g 118 h-e-b incontrol lancets 33g 118 HELIXATE FS 107 HEMATOGEN FA 112 HEMLIBRA 42 HEMOCYTE 113 HEMOCYTE PLUS 112 HEMOCYTE-F 112 HEMOFIL M 107 heparin (porcine) in nacl 28 heparin lock flush 28 heparin sod (porcine) in d5w 28 heparin sodium (porcine) 28 heparin sodium (porcine) pf 28 HEPATAMINE 151 HIZENTRA 156 hm acetaminophen childrens 16

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hm all day allergy 43 hm all day allergy childrens 43 hm allergy & congestion 91 hm allergy complete-d 91 hm allergy relief/nasal decong 91 hm arthritis pain relief 17 hm aspirin 18 hm aspirin ec 18 hm aspirin ec low dose 18 hm calcium antacid 22 hm calcium antacid ex st 22 hm calcium antacid ultra st 22 hm cetirizine hcl childrens 43 hm chest congestion relief 92 hm eye itch relief 153 hm loratadine 43 hm loratadine childrens 43 hm nicotine 162 hm nicotine polacrilex 162 hm pain & fever childrens 17 hm pain & fever infants 17 hm tussin adult 92 hm tussin adult dm 90 HUMALOG 37 HUMALOG MIX 50/50 37 HUMALOG MIX 50/50 KWIKPEN 36 HUMALOG MIX 75/25 37 HUMALOG MIX 75/25 KWIKPEN 37 HUMATE-P 107 HUMIRA 13, 14, 15 HUMIRA PEDIATRIC CROHNS START 13, 14 HUMIRA PEN 13, 14 HUMIRA PEN-CD/UC/HS STARTER 13, 14 HUMIRA PEN-PS/UV/ADOL HS START 13, 14 HUMULIN 70/30 37 HUMULIN N 37 HUMULIN R 37 hydralazine hcl 47 hydrochlorothiazide 101 hydrocodone-acetaminophen 19, 20 hydrocodone-homatropine 90 hydrocodone-ibuprofen 20 hydrocortisone 22, 88, 97 hydrocortisone-iodoquinol 94 hydromorphone hcl 20 hydroxychloroquine sulfate 48

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hydroxyprogesterone caproate 78, 159

hydroxyurea 52 hydroxyzine hcl 24 hydroxyzine pamoate 24 hyoscyamine sulfate 165, 166 hyoscyamine sulfate er 165 HYPERHEP B S/D 156 HYPERLYTE-CR 144 HYPERRHO S/D 156 HYPOLANCE AST LANCING 126 HYQVIA 156 HYSINGLA ER 20 HY-VEE LANCETS 126 hy-vee thin lancets 118 IBU 15 ibuprofen 15 idarubicin hcl 52 IDELVION 107 IFEREX 150 FORTE 112 ifosfamide 53 ILEVRO 154 imatinib mesylate 51 imipenem-cilastatin 47 imipramine hcl 34 imiquimod 98 IN TOUCH 126 IN TOUCH GLUCOSE CONTROL 126 IN TOUCH LANCING DEVICE 126 IN TOUCH STERILE LANCETS 30G 126 INCASSIA 86 indapamide 101 indomethacin 15 INFINITY CONTROL 126 INFUVITE ADULT 147 INFUVITE PEDIATRIC 148 INSPIRACHAMBER/LARG E 141 INSPIRACHAMBER/MEDIU M 141 INSPIRACHAMBER/MOUT HPIECE 141 INSPIRACHAMBER/SMAL L 141 INSPIREASE 141 insulin syringe 134 insulin syringe/needle 134 INTEGRA F 112

INTEGRA PLUS 112 INTELENCE 69 INTRALIPID 152 INTRON A 52INTROVALE 85 INVEGA SUSTENNA 58 INVEGA TRINZA 58 INVIRASE 68 INVOKAMET 163 INVOKANA 38 IONOSOL-MB IN D5W 143 ipratropium bromide 26 ipratropium-albuterol 25 irbesartan 45 IRESSA 51 irinotecan hcl 54 ISENTRESS 68 ISENTRESS HD 68 ISIBLOOM 81 ISOLYTE-P IN D5W 143 ISOLYTE-S 144 ISOLYTE-S PH 7.4 144 isoniazid 49 isosorbide dinitrate 23 isosorbide mononitrate 23 isosorbide mononitrate er 23 isotretinoin 94 ivermectin 23 IXINITY 107 JANTOVEN 27 JANUMET 36 JANUMET XR 36 JANUVIA 35 JARDIANCE 38 JASMIEL 81 JENCYCLA 87 JENTADUETO 36 JIVI 107 JOLESSA 85 JULEBER 81 JULUCA 67 JUNEL 1.5/30 81 JUNEL 1/20 81 JUNEL FE 1.5/30 81 JUNEL FE 1/20 81 JUNEL FE 24 81 KABIVEN 159 KAITLIB FE 81 KALETRA 68 KALLIGA 81 KARIVA 78 kcl in d5w lactated ringers 143

kcl in dextrose-nacl 143 kcl-lactated ringers-d5w 143 kedbumin 109 KELNOR 1/35 81 KELNOR 1/50 81 KEPPRA 30 KEPPRA XR 30 ketoconazole 98 ketone test 99 ketorolac tromethamine 15, 154 KETOSTIX 99 ketotifen fumarate 153 kinney lancets 119 kinney thin lancets 119 kinray insulin syringe 134 KLONOPIN 29 KLOR-CON 145 KLOR-CON 10 145 KLOR-CON M10 145 KLOR-CON M15 145 KLOR-CON M20 145 KLOR-CON SPRINKLE 145 KLOR-CON/EF 145 kmart valu insulin syringe 29g 134 kmart valu insulin syringe 30g 134 KOATE 107 KOATE-DVI 107 KOGENATE FS 107 KOMBIGLYZE XR 36 KOVALTRY 107 kp ketotifen fumarate 153 K-PHOS 144 K-PHOS NO 2 106 K-PHOS-NEUTRAL 144 kroger insulin syringe 134 kroger lancets 119 kroger lancets 21g 119 kroger lancets micro thin 33g 119 kroger lancets super thin 119 kroger lancets thin 119 kroger lancets thin 26g 119 kroger lancets ultrathin 30g 119 kroger lancing device 119 KURVELO 81 KYLEENA 86 labetalol hcl 73 lactated ringers 72, 143 lactic acid e 97 lactose monohydrate 158 lactulose 114 lactulose encephalopathy 105 LAMICTAL 30

LAMICTAL ODT 30 LAMICTAL STARTER 30 LAMICTAL XR 30 lamivudine 69, 70 lamivudine-zidovudine 67 lamotrigine 29 lamotrigine er 29 lamotrigine starter kit-blue 29 lamotrigine starter kit-green 29 lamotrigine starter kit-orange 29 lancet device 119 lancet device with ejector 119 lancet transporter case 119 lancets 119 lancets 28g 119 lancets 30g 119 lancets micro thin 33g 119 lancets super thin 28g 119 lancets thin 119 LANCETS ULTRA FINE 126 LANCETS ULTRA THIN 127 lancets ultra thin 30g 119 lancing device 119 lansoprazole 166 LANTUS 37 LANTUS SOLOSTAR 37 LANZO 127 LARIN 1.5/30 81 LARIN 1/20 81 LARIN 24 FE 81 LARIN FE 1.5/30 81 LARIN FE 1/20 82 LARISSIA 82 latanoprost 155 LATUDA 56 LAYOLIS FE 82 l-cysteine hcl 152 leader advanced lancing device119 leader insulin syringe 134 LEENA 87 leflunomide 15 LESSINA 82 LETAIRIS 76 letrozole 52 leucovorin calcium 52, 53 LEUKERAN 54 LEUKINE 112 leuprolide acetate 53 LEVEMIR 37 LEVEMIR FLEXTOUCH 37 levetiracetam 29, 30 levetiracetam er 29

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levobunolol hcl 152 levocarnitine 101 levocetirizine dihydrochloride 43 levofloxacin 104 levofloxacin in d5w 104 LEVONEST 87 levonorgest-eth est & eth est 85 levonorgest-eth estrad 91-day 85 levonorgestrel 84 levonorgestrel-ethinyl estrad 79, 84 levonorg-eth estrad triphasic 87 LEVORA 0.15/30 (28) 82 levothyroxine sodium 164, 165 LEVOXYL 165 LEXIVA 68 LIBERTY GLUCOSE CONTROL 127 LIBERTY GLUCOSE CONTROL MID 127 LIBERTY MEDICAL LANCETS 127 LIBERTY MINI LANCING DEVICE 127 lidocaine 98 lidocaine hcl 98, 115 lidocaine hcl (pf) 115 lidocaine hcl urethral/mucosal 98 lidocaine in dextrose 115 lidocaine viscous hcl 146 lidocaine-epinephrine 115 lidocaine-hydrocortisone ace 22 lidocaine-prilocaine 99 LIFESCAN UNISTIK 2 127 LIFESCAN UNISTIK II LANCETS 127 LILETTA (52 MG) 86 LILLOW 82 lincomycin hcl 48 linezolid 48 LINZESS 104 liothyronine sodium 165 lisinopril 45 lisinopril-hydrochlorothiazide 44 lite touch lancets 119 LITE TOUCH LANCING PEN 127 LITEAIRE 141 LITETOUCH INSULIN SYRINGE 137 LITETOUCH LANCETS 127 lithium 55 lithium carbonate 55

lithium carbonate er 55 live better adv lancing device 119 live better lancet super thin 119 live better lancet ultra thin 119 LO LOESTRIN FE 78 LOESTRIN 1.5/30 (21) 82 LOESTRIN 1/20 (21) 82 longs insulin syringe 134 longs lancets standard 119 longs lancets thin 119 longs lancets ultra thin 119 loperamide hcl 40 loratadine 43 loratadine childrens 43 loratadine-d 12hr 91 loratadine-d 24hr 91 lorazepam 24 LORAZEPAM INTENSOL 24 LORYNA 82 losartan potassium 45 losartan potassium-hctz 45 LOSEASONIQUE 85 loteprednol etabonate 154 LOTRONEX 104 lovastatin 44 LOW-OGESTREL 82 loxapine succinate 62 lozibase 158 LO-ZUMANDIMINE 82 LUPANETA PACK 114 LUPRON DEPOT (1-MONTH) 53 LUPRON DEPOT (3-MONTH) 53 LUPRON DEPOT (4-MONTH) 53 LUPRON DEPOT (6-MONTH) 53 LUPRON DEPOT-PED (1-MONTH) 103 LUPRON DEPOT-PED (3-MONTH) 103 LUTERA 82 LYZA 87 M.V.I. ADULT 147 M.V.I. PEDIATRIC 148 MAGELLAN INSULIN SAFETY SYR 137 magnesium chloride 144 magnesium sulfate 144 MAKENA 159 malathion 98

.

manganese chloride 144 mapap 17 mapap arthritis pain 17 MAPAP CHILDRENS 17 marlissa 79 MATULANE 52 MAVYRET 113 MAXI-COMFORT INSULIN SYRINGE 137 MAXIDEX 155 meclizine hcl 41 medic insulin syringe 134 medichoice safety lancet 119 medichoice safety lancet extra 119 medichoice safety lancet norm 119 MEDISENSE GLUCOSE KETONE CONTR 127 MEDISENSE HI/MID/LOW CONTROL 127 MEDISENSE HIGH/LOW CONTROL 127 MEDISENSE MID CONTROL 127 MEDISENSE THIN LANCETS 127 MEDLANCE EXTRA 21G 127 MEDLANCE LITE 25G 127 MEDLANCE PLUS EXTRA 21G 127 MEDLANCE PLUS LANCETS 127 MEDLANCE PLUS LITE 25G 127 MEDLANCE PLUS SPECIAL 0.8MM 127 MEDLANCE PLUS SUPERLITE 30G 127 MEDLANCE PLUS UNIVERSAL 21G 127 MEDLANCE UNIVERSAL 21G 127 medroxyprogesterone acetate

86, 159 mefloquine hcl 48 megestrol acetate 54, 159 meijer alcohol swabs 116 MEIJER LANCETS 127 MEIJER LANCETS THIN 127 MEIJER LANCETS UNIVERSAL 21G 127 MEIJER LANCETS UNIVERSAL 30G 127

MEIJER LANCETS UNIVERSAL 33G 127 MEIJER SUPER THIN LANCETS 127 meloxicam 15 melphalan 54 melphalan hcl 54 memantine hcl 161 MEPSEVII 146 mercaptopurine 50 meropenem 48 meropenem-sodium chloride 48 mesalamine 105 mesna 54 MESTINON 48, 49 metformin hcl 35 metformin hcl er 34, 35 metformin hcl er (osm) 34 methazolamide 100 methenamine hippurate 167 methenamine mandelate 167 methimazole 164 methocarbamol 149, 150 methotrexate 50 methotrexate sodium 50, 51 methotrexate sodium (pf) 50 methyldopa 46 methylergonovine maleate 155 methylphenidate hcl 10, 11 methylphenidate hcl er 10 methylphenidate hcl er (cd) 9, 10 methylphenidate hcl er (la) 10 methylprednisolone 89 methylprednisolone acetate 88 methylprednisolone sodium succ 88 metoclopramide hcl 104 metolazone 101 metoprolol succinate er 73 metoprolol tartrate 73 metronidazole 47, 98, 169 metronidazole in nacl 47 mexiletine hcl 24 MIBELAS 24 FE 82 miconazole 1 168 miconazole 3 168 miconazole 7 168 miconazole nitrate 98, 169 MICROCHAMBER 142 MICRODOT CONTROL HIGH/LOW 127 MICROGESTIN 1.5/30 82 MICROGESTIN 1/20 82

MICROGESTIN FE 1.5/30 82 MICROGESTIN FE 1/20 82 MICROLET LANCETS 128 MICROLET NEXT LANCING DEVICE 128 MICROSPACER 142 MICROTAINER SAFETY FLOW LANCET 128 midodrine hcl 169 miglitol 34 miglustat 109, 110 MILI 82 milrinone lactate 76 milrinone lactate in dextrose 76 MINASTRIN 24 FE 82 mineral oil-hydrophil petrolat 97 mini lancing device 119 minocycline hcl 164 minoxidil 47 MIRCETTE 78 MIRENA (52 MG) 86 mirtazapine 33 misoprostol 167 mitomycin 52 mitoxantrone hcl 52 m-natal plus 148 modafinil 11 mometasone furoate 97, 150 MONOJECT INSULIN SYRINGE 137, 138 MONOJECT LIFESHIELD SYRINGE 138 MONOJECT MAGELLAN SYRINGE 138 MONOJECT SYRINGE 138 MONOJECT ULTRA COMFORT SYRINGE .. 138, 139 MONOLET LANCETS 128 MONOLET OPD LANCETS 128 MONOLETTOR SAFETY LANCETS 128 MONO-LINYAH 82 MONONINE 108 montelukast sodium 26 MORPHABOND ER 20 morphine sulfate 20 morphine sulfate (concentrate) 20 mouth wash-gp 158 MOVANTIK 105 MOXEZA 153 moxifloxacin hcl 153 MOZOBIL 110

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m-pap 17 ms insulin syringe 134 MUCINEX 93 MUCINEX FOR KIDS 93 MUCINEX MAXIMUM STRENGTH 93 mucosa 92 mucus & chest congestion 92 mucus & cough relief childrens 90 mucus relief chest congestion 92 mucus relief dm 90 mucus relief dm cough 90 mucus relief dm max 90 mucus relief er 92 mucus relief max st 92 mucus-dm maximum strength 90 mucusrelief dm cough 90 multi-lancet device 119 MULTI-LANCET DEVICE 2128 MULTITRACE-4 145 multitrace-4 concentrate 145 MULTITRACE-4 NEONATAL 145 MULTITRACE-4 PEDIATRIC 145 MULTITRACE-5 145 multitrace-5 concentrate 145 multivitamin/fluoride 147 mupirocin 94 MUTAMYCIN 52 MY CHOICE 84 MY WAY 84 mycophenolate mofetil 72 mycophenolate mofetil hcl 72 MYGLUCOHEALTH CONTROL 128 MYGLUCOHEALTH LANCETS 30G 128 MYLERAN 49 MYORISAN 94 MYSOLINE 30 NABI-HB 156 nabumetone 15 NAGLAZYME 103 naloxone hcl 40 naltrexone hcl 40 naproxen 15 naproxen dr 15 NARCAN 40 NATAZIA 86 nateglinide 38 NEBUPENT 47

NECON 0.5/35 (28) 82 neomycin sulfate 12 neomycin-bacitracin znpolymyx 153 neomycin-polymyxin b gu 105 neomycin-polymyxin-dexameth 154 neomycin-polymyxin-hc 155 NEPHPLEX RX 147 NEPHRAMINE 151 NEPHRO-VITE RX 146 NEULASTA 111 NEULASTA ONPRO 111 NEUPOGEN 111 NEURONTIN 31 NEUTEK 2TEK CONTROL 128 nevirapine 69 nevirapine er 69 NEW DAY 84 NEXAVAR 51 NEXIUM 166 NEXPLANON 86 niacin er (antihyperlipidemic) 44 NICORETTE 162 nicotine 162 nicotine polacrilex 162 nicotine step 1 162 nicotine step 2 162 nicotine step 3 162 nifedipine 75 nifedipine er 75 nifedipine er osmotic release 75 NIKKI 82 nilutamide 50 nimodipine 75 nitrofurantoin 167 nitrofurantoin macrocrystal 167 nitrofurantoin monohyd macro .167 nitroglycerin 23 NIVA-PLUS 148 NIVESTYM 111 non-aspirin childrens 17 NORA-BE 87 NORDITROPIN FLEXPRO 102 norethin ace-eth estrad-fe 79 norethindrone 86 norethindrone acetate 159 norethindrone acet-ethinyl est 79 norethindrone-eth estradiol 103 norethin-eth estradiol-fe 79 norgestimate-eth estradiol 79 norgestim-eth estrad triphasic 87 NORLYDA 87

normal saline flush 145 NORMOSOL-M IN D5W 143 NORMOSOL-R 144 NORMOSOL-R IN D5W 143 NORMOSOL-R PH 7.4 144 NORTREL 0.5/35 (28) 82 NORTREL 1/35 (21) 82 NORTREL 1/35 (28) 82 NORTREL 7/7/7 87 nortriptyline hcl 34 NORVIR 68, 69 NOVA MAX PLUS GLU/KET CONTROL 128 NOVA SAFETY LANCETS 23G 128 NOVA SAFETY LANCETS 28G 128 NOVA SUREFLEX LANCETS 128 NOVA SUREFLEX LANCING DEVICE 128 NOVOEIGHT 108 NOVOLIN N 37 NOVOLIN N RELION 37 NOVOLIN R 37 NOVOLIN R RELION 37 NOVOLOG 38 NOVOLOG FLEXPEN 37 NOVOLOG MIX 70/30 37 NOVOLOG MIX 70/30 FLEXPEN 37 NOVOLOG PENFILL 38 NOVOSEVEN RT 108 np thyroid 165 nutrilipid 152 NUVARING 83 NUVESSA 169 NUWIQ 108 nystatin 41, 95, 146 OB COMPLETE 148 obizur 107 OCELLA 82 OCTAGAM 156 octreotide acetate 103 ODEFSEY 68 OFEV 162 ofloxacin 153, 155 OGESTREL 82 olanzapine 65, 66 olmesartan medoxomil 45 olmesartan medoxomil-hctz 45 olopatadine hcl 153

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omeprazole 166 ON CALL EXPRESS GLUCOSE CONTR 128 ON CALL LANCETS 128 ON CALL LANCING DEVICE 128 ON CALL PLUS GLUCOSE CONTROL 128 ON CALL PLUS LANCETS 128 ON CALL PLUS LANCING DEVICE 128 ON CALL VIVID GLUCOSE CONTROL 128 ONCASPAR 52 ondansetron 41 ondansetron hcl 40, 41 ONETOUCH CLUB LANCETS FINE PT 128 ONETOUCH COMBO PACK 128 ONETOUCH DELICA LANCETS 33G 128 ONETOUCH DELICA LANCETS FINE 128 ONETOUCH DELICA LANCING DEV 128 ONETOUCH FINEPOINT LANCETS 128 ONETOUCH PING METER REMOTE 128 ONETOUCH SURESOFT LANCING DEV 128 ONETOUCH ULTRA 2 128 ONETOUCH ULTRA BLUE 99 ONETOUCH ULTRA CONTROL 128 ONETOUCH ULTRA MINI 129 ONETOUCH ULTRALINK 129 ONETOUCH ULTRASOFT LANCETS 129 ONETOUCH VERIO 99, 129 ONETOUCH VERIO IQ SYSTEM 129 ONETOUCH VERIO SYNC SYSTEM 129 ONFI 29 ONGLYZA 36 OPCICON ONE-STEP 84 OPTICHAMBER ADVANTAGE-LG MASK 142 OPTICHAMBER ADVANTAGE-MED MASK 142

OPTICHAMBER ADVANTAGE-SM MASK 142 OPTICHAMBER DIAMOND

142 OPTICHAMBER DIAMOND-LG MASK 142 OPTICHAMBER DIAMOND-MD MASK 142 OPTICHAMBER DIAMOND-SM MASK 142 OPTICHAMBER FACE MASK-LARGE 142 OPTICHAMBER FACE MASK-MEDIUM 142 OPTICHAMBER FACE MASK-SMALL 142 OPTIHALER 142 OPTUMRX GLUCOSE CONTROL 129 ORACIT 105 ORFADIN 102 ORILISSA 102 ORSYTHIA 82 ORTHO-NOVUM 1/35 (28) 83 ORTHO-NOVUM 7/7/7 (28) 87 oseltamivir phosphate 71 oxaliplatin 49 OXAYDO 20 oxazepam 24 oxcarbazepine 30 OXTELLAR XR 31 oxybutynin chloride 167, 168 oxybutynin chloride er 167, 168 oxycodone hcl 20 oxycodone-acetaminophen 21 OYSCO 500 143 oyster shell calcium 143 OZEMPIC (0.25 OR 0.5 MG/DOSE) 38 OZEMPIC (1 MG/DOSE) 38 paclitaxel 53 pain & fever childrens 17 pain & fever infants 17 pain relief childrens 17 pamidronate disodium 101 PANCREAZE 99 PANRETIN 95 pantoprazole sodium 166 PARAGARD INTRAUTERINE COPPER 84 paricalcitol 102 paroxetine hcl 34

PAZEO 153 pc lancets super thin 30g 119 PCCA ACACIA SYRUP BASE 158 peg 3350 114 peg 3350/electrolytes 114 peg 3350-kcl-na bicarb-nacl 114 peg-3350/electrolytes 114 PEGANONE 32 PEGASYS 70 PEGASYS PROCLICK 70 PEGINTRON 70 penicillin g procaine 157 penicillin g sodium 157 penicillin v potassium 157 PENLET II BLOOD SAMPLER 129 PENLET II REPLACEMENT CAP 129 pentoxifylline er 108 PERFECT LANCETS 28G 129 PERFECT LANCETS 30G 129 PERIKABIVEN 159 permethrin 99 perphenazine 63 perphenazine-amitriptyline 161 PERSERIS 58 PERTZYE 99 PHARMACIST CHOICE ALCOHOL 116 PHARMACIST CHOICE LANCETS 129 PHARMACY COUNTER LANCETS 129 phenazopyridine hcl 106 phenobarbital 113 phenylephrine hcl 154 PHENYTEK 32 phenytoin 32 PHENYTOIN INFATABS 32 phenytoin sodium extended 32 PHILITH 83 PHOSPHA 250 NEUTRAL 144 phytonadione 170 PIFELTRO 69 pilocarpine hcl 146 pimecrolimus 98 pimozide 161 PIMTREA 78 pioglitazone hcl 40 pioglitazone hcl-metformin hcl 39 piperacillin sod-tazobactam so 157

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PIRMELLA 1/35 83 PIRMELLA 7/7/7 87 PLAN B ONE-STEP 85 PLASBUMIN-25 109 PLASBUMIN-5 109 PLASMA-LYTE 148 144 PLASMA-LYTE A 144 PLASMANATE 109 PLENAMINE 151 pnv-dha+docusate 149 pnv-omega 148 POCKET CHAMBER 142 POCKET SPACER 142 POCKETCHEM EZ CONTROL 129 podofilox 98 polyethylene glycol 3350 114 polymyxin b sulfate 48 polymyxin b-trimethoprim 153 POLY-VI-FLOR 147, 148 POLY-VI-FLOR/IRON 147 POMALYST 51 PORTIA-28 83 potassium acetate 144 potassium chloride 145 potassium chloride crys er 145 potassium chloride er 145 potassium chloride in dextrose . 143 potassium chloride in nacl 144 potassium citrate er 105 potassium citrate-citric acid 105 potassium phosphates 144 PRADAXA 28 pramipexole dihydrochloride 55 prasugrel hcl 109 pravastatin sodium 44 praziquantel 23 prazosin hcl 46 PRECISION GLUCOSE CONTROL 129 PRECISION GLUCOSE CONTROL SOLN 129 PRECISION GLUCOSE KETONE CONTR 129 PRECISION GLUCOSE/KETONE CONTR 129 PRECISION SUREDOSE PLUS SYR 139 PRECISION SURE-DOSE SYRINGE 139

PRECISION THINS GP LANCETS 129 prednisolone 89 prednisolone acetate 155 prednisolone sodium phosphate . 89 prednisone 89 preferred plus insulin syringe 134 preferred plus lancets colored 119 preferred plus lancets thin 119 pregabalin 30 PREMARIN 104, 169 PREMASOL 151 PREMPHASE 103 PREMPRO 104 prenaissance 149 prenaissance plus 149 prenatal 148 prenatal vitamin plus low iron 148 preplus 148 pressure activat safety lancet 119PREVIFEM 83PREZCOBIX 68PREZISTA 69primaquine phosphate 48primidone 30PRIVIGEN 156pro comfort alcohol 116pro comfort lancets 30g 120pro comfort lancets 31g 120probenecid 106PROCALAMINE 151prochlorperazine maleate 63PROCTOFOAM HC 22PROCTOSOL HC 22PROCTOZONE-HC 22PRODIGY CONTROL SOLUTION 129PRODIGY INSULIN SYRINGE 139PRODIGY LANCETS 28G 129PRODIGY LANCING DEVICE 129PRODIGY SAFETY LANCETS 26G 129PRODIGY TWIST TOP LANCETS 28G 129PROFILNINE 108PROFILNINE SD 108progesterone 159progesterone micronized 159PROGLYCEM 35PROLASTIN-C 163

PROLEUKIN 52 promethazine hcl 43 promethazine-dm 93 promethazine-phenylephrine 91 PROMETHEGAN 43 PROMETRIUM 159 propafenone hcl 25 propantheline bromide 167 propranolol hcl 74 propranolol hcl er 74 propylthiouracil 164 PROSOL 151 PROTONIX 166 PROVENTIL HFA 26 PROVIDA OB 149 PRUDOXIN 95 pseudoeph-bromphen-dm 93 PSS SELECT GP LANCETS 129 PSS SELECT PLATFORMS 129 PSS SELECT SAFETY LANCETS 129 PULMOZYME 163 purevit dualfe plus 112 push button safety lancets 120 px advanced lancing device 120 px insulin syringe 134 px lancet auto injector 120 px lancets ultra thin 120 PYLERA 167 pyrazinamide 49 pyridostigmine bromide 48, 49 pyridostigmine bromide er 48, 49 pyridoxine hcl 169 qc 3 day 169 qc advanced lancing device 120 qc alcohol swabs 116 qc all day allergy 43 qc arthritis pain relief 17 qc aspirin 18 qc aspirin low dose 18 qc childrens allergy 43 qc enteric aspirin 19 qc lancets super thin 30g 120 qc lancets ultra thin 120 qc lidocaine pain relief 98 qc loratadine allergy relief 43 qc loratadine-d 91 qc medifin 400 92 qc miconazole 7 169 qc mucus relief 92 qc mucus relief er 92 qc non-aspirin childrens 17

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qc non-aspirin jr strength 17 qc pain relief childrens 17 qc tussin mucus/congestion 92 qc unilet lancets 28g 120 qc unilet lancets micro thin 120 QUARTETTE 85 QUDEXY XR 31 quetiapine fumarate 61, 62 quetiapine fumarate er 61 QUFLORA PEDIATRIC 148 QUICKTEK CONTROL SOLUTION 129 QUILLICHEW ER 12 QUILLIVANT XR 12 quinapril hcl 45 quinapril-hydrochlorothiazide 45 quinidine gluconate er 24 quinidine sulfate 24 QUINTET CONTROL HIGH/NORMAL 129 QVAR REDIHALER 27 ra alcohol swabs 116 ra antihistamine eye drops 153 ra eye itch relief 153 RA E-ZJECT COLOR LANCETS 33G 129 RA E-ZJECT LANCETS 28G

130 RA E-ZJECT LANCETS THIN 26G 130 RA E-ZJECT LANCETS THIN 28G 130 RA E-ZJECT LANCETS ULTRA THIN 130 ra insulin syringe 134 ra lancing device 120 ra lidocaine pain relieving 98 ramelteon 113 ramipril 45 ranitidine hcl 166 ranolazine er 23 raspberry syrup 158 reality insulin syringe 134 reality lancets 120 reality swabs 116 reality trigger lancets 120 REBIF 161 REBIF REBIDOSE 160 REBIF REBIDOSE TITRATION PACK 161 REBIF TITRATION PACK 161 REBINYN 108

RECLIPSEN 83 RECOMBINATE 108 REFUAH PLUS GLUCOSE CONTROL 130 RELENZA DISKHALER 71 RELION ALCOHOL SWABS 116 RELION INSULIN SYRINGE 139 RELI-ON INSULIN SYRINGE 139 RELION KETONE 99 RELION LANCETS MICRO-THIN 33G 130 RELION LANCETS STANDARD 21G 130 RELION LANCETS THIN 26G 130 RELION LANCETS ULTRA-THIN 30G 130 RELION LANCING DEVICE 130 RELION ULTRA THIN LANCETS 30G 130 RELION ULTRA THIN PLUS LANCETS 130 RENACIDIN 106 repaglinide 38 RESCRIPTOR 69 RESTASIS 154 RESTASIS MULTIDOSE 154 RETACRIT 110, 111 RETROVIR 70 REVLIMID 72 REXALL LANCETS ULTRA THIN 30G 130 REYATAZ 69 RHOPRESSA 155 RIBASPHERE 70 RIBASPHERE RIBAPAK 70 ribavirin 70, 71 rifabutin 49 rifampin 49 RIGHTEST ALTERNATE SITE ADAPT 130 RIGHTEST GC300 CONTROL 130 RIGHTEST GD500 LANCING DEVICE 130 RIGHTEST GL300 LANCETS 130 riluzole 150

ringers 144 ringers irrigation 72 RISPERDAL CONSTA 58 risperidone 56, 57, 58 RITEFLO 142 ritonavir 68 RITUXAN 51 rivastigmine 160 RIVELSA 85 rixubis 107 rizatriptan benzoate 142 robafen 92 ROBAFEN DM COUGH 91 ROBAFEN MUCUS/CHEST CONGESTION 93 ropinirole hcl 55 rosuvastatin calcium 44 ROWEEPRA 31 ROWEEPRA XR 31 ROXYBOND 21 RUCONEST 108 SABRIL 32 SAFESNAP INSULIN SYRINGE 139 SAFE-T-LANCE 130 SAFE-T-LANCE PLUS 130 safety insulin syringes 134 safety lancet 21g/pressure act 120 safety lancet 28g/pressure act 120 SAFETY LANCETS 130 SAFETY LANCETS 21G 130 safety lancets 28g 120 SAFETY LET LANCETS 130 SAFETY SEAL LANCETS 130 safety syringe/needle 134 SAFYRAL 83 salicylic acid 98 saline bacteriostatic 158 salsalate 19 SANDIMMUNE 71 SANTYL 97 saps care alcohol prep 116 sapscare twist top lancets 120 sb alcohol prep 116 sb insulin syringe 134 sb lancets thin 120 sb lancets ultra thin 120 SEASONIQUE 85 SEGLUROMET 163 select-lite device/lancets 120 select-lite lancing device 120 SELECT-OB 149

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selegiline hcl 55 selenium 146 selenium sulfide 96 SELZENTRY 68 se-natal 19 148SEREVENT DISKUS 26 SEROSTIM 102 sertraline hcl 34 se-tan plus 112 SETLAKIN 86 sevelamer carbonate 105 sevelamer hcl 105 SHAROBEL 87 SHOPKO ALCOHOL SWABS 116 SHOPKO AUTOLET LANCING DEVICE 130 SHOPKO ON-THE-GO LANCETS 30G 130 SHOPKO UNILET LANCETS 28G 130 SHOPKO UNILET LANCETS 30G 130 side button safety lancet 120 sildenafil citrate 76 siltussin sa 92 silver nitrate 96 silver sulfadiazine 96 SIMBRINZA 152 SIMLIYA 78 SIMPESSE 86 SIMPLE DIAGNOSTICS LANCING DEV 130 simple syrup 158 simvastatin 44 SINGLE-LET 130 SINGULAIR 26 sirolimus 72 SKLICE 99 SKYLA 86 SLYND 87 sm 3-day vaginal 169 sm 8 hour pain relief 17 sm alcohol prep 116 sm all day allergy 43 sm all day allergy childrens 43 sm all day allergy-d 91 sm allergy childrens 43 sm arthritis pain relief 17 sm arthritis pain reliever 17 sm aspirin 19 sm aspirin adult low strength 19

sm aspirin ec 19 sm aspirin low dose 19 sm calcium antacid 22 sm calcium antacid ex st 22 sm chest congestion relief 93 sm childrens aspirin 19 sm childrens loratadine 43 sm clotrimazole vaginal 169 sm eye itch relief 153 sm lancets 33g 120 sm loratadine 43 sm lorata-dine d 92 sm loratadine d 12hr 92 sm miconazole 7 169 sm mucus relief 93 sm mucus relief max strength 93 sm nicotine 162 sm nicotine polacrilex 162 sm pain & fever childrens 17 sm pain & fever infants 17 sm slow release iron 112 sm tussin dm max 90 sm tussin mucus+chest congest 93 SMART DIABETES VANTAGE LANCING 130 SMART SENSE COLOR LANCETS 33G 130 SMART SENSE STANDARD LANCETS 130 SMART SENSE SUPER THIN LANCETS 130 SMART SENSE THIN LANCETS 26G 130 SMARTEST CONTROL MEDIUM 131 SMARTEST LANCETS 28G 131 sod citrate-citric acid 105 sodium acetate 143 sodium bicarbonate 22, 143 sodium chloride 93, 106, 145 sodium chloride bacteriostatic . 158 sodium fluoride 144 sodium lactate 143 sodium phosphates 144 sodium polystyrene sulfonate

72, 159 SOLARTEK GLUCOSE CONTROL 131 solifenacin succinate 167, 168 SOLTAMOX 50 SOLU-CORTEF 89 SOLUS V2 CONTROL 131

SOLUS V2 LANCETS 28G 131 SOLUS V2 LANCING DEVICE 131 SOLUS V2 TWIST LANCETS 30G 131 sorbitol 78, 106, 158 sorbitol-mannitol 106 sotalol hcl 74 sotalol hcl (af) 74 spinosad 99 SPIRIVA HANDIHALER 26 spironolactone 100 spironolactone-hctz 100 SPRINTEC 28 83 SPRITAM 31 SPS 72, 159 SRONYX 83 ST JOSEPH LOW DOSE 19 stavudine 70 STEGLATRO 38 STERILANCE PA 131 STERILANCE TL 131 sterile water for injection 158 sterile water for irrigation 72 stevia 12 stevia extract 78 STIMATE 103 STIOLTO RESPIMAT 25 STRIBILD 68 STROVITE ONE 147 SUBLOCADE 21 SUBVENITE 31 SUBVENITE STARTER KIT-BLUE 31 SUBVENITE STARTER KIT-GREEN 31 SUBVENITE STARTER KIT-ORANGE 31 sucralfate 166 sulfacetamide-prednisolone 154 sulfadiazine 164 sulfamethoxazole-trimethoprim 47 sulfasalazine 105 sumatriptan 142 sumatriptan succinate 142, 143 super thin lancets 120 supreme ii confidence paddles 120 supreme ii high/low control 120 sure comfort alcohol prep 116 sure comfort insulin syringe 134 sure comfort lancets 28g 120 sure comfort lancets 30g 120

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sure comfort lancing pen 120 SURE-JECT INSULIN SYRINGE 139 SURE-LANCE FLAT LANCETS 131 SURE-LANCE LANCETS 26G 131 SURE-LANCE THIN LANCETS 28G 131 SURE-LANCE ULTRA THIN LANCETS 131 SURELITE LANCETS 131 SURE-PEN 131 SURE-PREP ALCOHOL PREP 116 SURESTEP GLUCOSE CONTROL 131 SURESTEP PRO HIGH GLUCOSE 131 SURESTEP PRO LINEARITY 131 SURESTEP PRO LOW GLUCOSE 131 SURESTEP PRO NORMAL GLUCOSE 131 SURE-TOUCH LANCETS UNIVERSAL 131 SUSTIVA 69 SUTENT 51 SYEDA 83 SYMBICORT 25 SYMFI 68 SYMFI LO 68 SYMLINPEN 120 34 SYMLINPEN 60 34 SYMTUZA 68 SYNAREL 103 SYNJARDY 163 SYNTHAMIN 17 152SYNTHROID 165 syringe 134 syringe luer slip 134 syringe/hypodermic safety 134 syrpalta 158 SYRSPEND SF 158 tacrolimus 72, 98 TAI DOC CONTROL 131 TAKE ACTION 85 tamoxifen citrate 50 tamsulosin hcl 105 TARINA 24 FE 83TARINA FE 1/20 83

TARINA FE 1/20 EQ 83 taron forte 112 TARON-C DHA 149 TARON-PREX 149 TAYTULLA 83 tazarotene 96 TAZORAC 96 TECHLITE AST LANCETS 131 TECHLITE LANCETS 131 TECHLITE LANCETS 30G 131 TEGRETOL 31 TEGRETOL-XR 31 TELCARE GLUCOSE CONTROL 131 telmisartan 45 telmisartan-hctz 45 temazepam 113 TEMODAR 53 temozolomide 53 temsirolimus 51 tenofovir disoproxil fumarate 70 terazosin hcl 46 terbinafine hcl 41 terbutaline sulfate 26 terconazole 169 testosterone cypionate 21 testosterone enanthate 21 tetrabenazine 160 tgt alcohol swabs 116 tgt lancet micro thin 33g 120 tgt lancet thin 26g 120 tgt lancet ultra thin 30g 120 tgt lancing device 120 THALOMID 71 THEO-24 27 theophylline 27 theophylline er 27 theracare pain relief 98 THERATEARS ALLERGY 153 thiamine hcl 169THINLETS GP LANCETS 131 THIOLA 106 thioridazine hcl 63 thiotepa 49 thiothixene 66, 67 thrivite 19 148 THYMOGLOBULIN 71 thyroid 165 tiagabine hcl 31 TIKOSYN 25 TILIA FE 87 timolol maleate 152

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tinidazole 47 TIS-U-SOL 72 TIVICAY 68 tizanidine hcl 150 TOBRADEX 154 tobramycin 12, 153 tobramycin sulfate 12 tobramycin-dexamethasone 154 todays health lancing device 120 todays health thin lancets 28g 120 todays health thin lancets 30g 120 tolbutamide 39 tolterodine tartrate 168 tolterodine tartrate er 168 TOPAMAX 31 TOPAMAX SPRINKLE 31 topcare lancets micro-thin 33g 120 topcare ultra comfort ins syr 134 topiramate .30 topiramate er 30 topotecan hcl 54 toremifene citrate 50 torsemide 100 TOVIAZ 167, 168 TPN ELECTROLYTES 144 TRACER II 3 VOLT BATTERY 131 TRACLEER 76 TRADJENTA 36 tramadol hcl 20 tranexamic acid 113 tranexamic acid-nacl 113 TRANSDERM SCOP (1.5 MG) 41 TRAVASOL 152 TRAVATAN Z 155 travel lancets 121 TRAVEL LANCETS ADVANCED 28G 131 trazodone hcl 33, 163 TREANDA 49 tretinoin 54, 94 TRETTEN 108 TRI FEMYNOR 87 triamcinolone acetonide

97, 146, 150, 164 triamterene-hctz 100 tricitrates 105 TRICON 112 TRIDERM 97 TRI-ESTARYLLA 87 trifluoperazine hcl 63, 64

trifluridine 153 trihexyphenidyl hcl 54 TRI-LEGEST FE 88 TRILEPTAL 31 TRI-LINYAH 88 TRI-LO-ESTARYLLA 88 TRI-LO-MARZIA 88 TRI-LO-MILI 88 TRI-LO-SPRINTEC 88 TRILYTE 114 trimethoprim 47 TRI-MILI 88 trinatal rx 1 148 TRINTELLIX 33, 163 TRI-PREVIFEM 88 TRIPTODUR 103 TRI-SPRINTEC 88 TRIUMEQ 68 TRIVEEN-DUO DHA 149 TRI-VI-FLOR 148 tri-vitamin/fluoride 148 TRIVORA (28) 88 TRI-VYLIBRA 88 TRI-VYLIBRA LO 88 troche base 158 TROCHIBASE 158 TROGARZO 67 TROKENDI XR 31 TROPHAMINE 152 trospium chloride 168 trospium chloride er 168 TRUE METRIX LEVEL 1 132 TRUE METRIX LEVEL 2 132 TRUE METRIX LEVEL 3 132 TRUECONTROL GLUCOSE CONT LEV 0 132 TRUECONTROL GLUCOSE CONT LEV 1 132 TRUEDRAW LANCING DEVICE 132 TRUEPLUS INSULIN SYRINGE 139 TRUEPLUS LANCETS 26G 132 TRUEPLUS LANCETS 28G 132 TRUEPLUS LANCETS 30G 132 TRUEPLUS LANCETS 33G 132 TRUEPLUS SAFETY LANCETS 28G 132 TRUVADA 68 TULANA 87 TUMS 23 TUMS CHEWY DELIGHTS 23

TUMS E-X 750 23 TUMS EXTRA STRENGTH 750 23 TUMS SMOOTHIES 23 TUMS ULTRA 1000 23 tussin dm cough + chest 91 tussin dm max adult 91 tussin mucus & chest congest 93 tussin mucus+chest congestion 93 TYBOST 67 TYDEMY 83 TYMLOS 103 UDENYCA 111 ULTICARE ALCOHOL SWABS 116 ULTICARE INSULIN SAFETY SYR 139 ULTICARE INSULIN SYRINGE 139, 140 ULTICARE SYRINGE 140 ULTI-LANCE AUTOMATIC

132 ULTILET CLASSIC LANCETS 132 ULTILET INSULIN SYRINGE SHORT 140 ULTILET LANCETS 132 ULTILET SAFETY LANCETS 23G 132 ultra comfort insulin syringe 134 ultra-comfort insulin syringe

134, 135 ULTRALANCE 132 ULTRA-THIN II AUTO LANCET 132 ULTRA-THIN II INS SYR SHORT 140 ULTRA-THIN II INSULIN SYRINGE 140 ULTRA-THIN II LANCETS .132 ULTRATRAK PRO CONTROL 132 ULTRATRAK ULTIMATE CONTROL 132 UNILET COMFORTOUCH LANCET 132 UNILET EXCELITE 132 UNILET EXCELITE II 132 UNILET G.P. LANCET 132 UNILET G.P. SUPERLITE LANCET 132

UNILET GP 28 ULTRA THIN 132 UNILET LANCET 132 UNILET MICRO-THIN 33G 132 UNILET SUPERLITE LANCET 132 UNILET SUPER-THIN 30G . 132 UNILET ULTRA-THIN 28G 132 UNISTIK 1 132 UNISTIK 2 132 UNISTIK 2 COMFORT 133 UNISTIK 2 EXTRA 133 UNISTIK 2 NEONATAL 133 UNISTIK 2 NORMAL 133 UNISTIK 2 SUPER 133 UNISTIK 3 133 UNISTIK 3 COMFORT 133 UNISTIK 3 EXTRA 133 UNISTIK 3 GENTLE 133 UNISTIK 3 NEONATAL 133 UNISTIK 3 NORMAL 133 UNISTIK CZT COMFORT 133 UNISTIK CZT NORMAL 133 UNISTIK SAFETY LANCETS 28G 133 UNISTIK SAFETY LANCETS 30G 133 UNISTIK TOUCH SAFETY LANC 21G 133 UNISTIK TOUCH SAFETY LANC 23G 133 UNISTIK TOUCH SAFETY LANC 28G 133 UNISTIK TOUCH SAFETY LANC 30G 133 UNISTRIP CONTROL 133 UNITHROID 165 UNIVERSAL 1 LANCETS THIN 26G 133 UNIVERSAL 1 LANCETS THIN 33G 133 UNIVERSAL 1 LANCETS ULTRA THIN 133 urea 97 ursodiol 104 UTIBRON NEOHALER 25 UTIRA-C 167 valacyclovir hcl 71 valganciclovir hcl 70 valproic acid 32 valrubicin 52 valsartan-hydrochlorothiazide 45

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VALSTAR 52 value health insulin syringe 135 value plus lancet standard 21g 121 value plus lancets super thin 121 value plus lancets thin 26g 121 value plus lancing device 121 valumark lancet super thin 30g 121 valumark lancet ultra thin 28g 121 valved holding chamber 140 vancomycin hcl 47, 106 vancomycin hcl in dextrose 106 vancomycin hcl in nacl 106 VANISHPOINT INSULIN SYRINGE 140 VANISHPOINT SYRINGE 140 VELCADE 51 VELIVET 88 venlafaxine hcl 34 venlafaxine hcl er 34 VENTAVIS 76 verapamil hcl 76 verapamil hcl er 75, 76 VICODIN 20 VICODIN ES 20 VICODIN HP 20 VICTORY CONTROL LEVEL 1/2 133 VICTOZA 38 VIDA MIA AUTOLET LANCING DEV 133 VIDA MIA UNILET LANCETS 28G 133 VIDA MIA UNILET LANCETS 30G 133 VIDEX 69VIENVA 83 vigabatrin 31, 32 VIGADRONE 32 VIIBRYD 33, 163 VIMPAT 31 vinblastine sulfate 53 vincristine sulfate 53 vinorelbine tartrate 53 VIOKACE 99 viorele 78 VIRACEPT 69 VIRAMUNE 69 VIREAD 70 virt-c dha 148 virt-nate dha 148 virt-phos 250 neutral 144 virt-pn dha 149

virt-pn plus 148 VITAFOL FE+ 149 VITAFOL GUMMIES 149 VITAFOL-NANO 149 VITAFOL-OB 149 VITAFOL-OB+DHA 149 VITAFOL-ONE 149 VITAL-D RX 146 VITALET PRO LANCETS 133 VITALET PRO PLUS LANCETS 133 vitamin d (ergocalciferol) 169 VITAMIN E & C BEAUTY LOTION 97 VITAMIN E & K BEAUTIFUL SKIN 97 vitamin e beauty 97 vitamin k1 170 VITAMINS E & A BEAUTY OIL 97 VITAMINS E & D BEAUTY OIL 97 VITA-RAY 97 vol-plus 148 VONVENDI 108 VORTEX VALVED HOLDING CHAMBER 142 VOSEVI 113 VOTRIENT 51 vp insulin syringe 135 VPRIV 110 vp-vite rx 146 VYFEMLA 83 VYLIBRA 83 VYVANSE 8 walgreens adv travel lancets 121 WALGREENS LANCETS 133 walgreens lancets micro thin 121 walgreens lancets super thin 121 WALGREENS THIN LANCETS 133 WALGREENS ULTRA THIN LANCETS 133 warfarin sodium 27 WATCHHALER 142 WEBCOL ALCOHOL PREP LARGE 117 WEBCOL ALCOHOL PREP MEDIUM 117 WERA 83 WILATE 108 WYMZYA FE 83

xanthan gum 158 XARELTO 28 XARELTO STARTER PACK 28 XELJANZ 12 XELJANZ XR 12 XIGDUO XR 163 XTAMPZA ER 21 XTANDI 50 XULANE 83 XYLOCAINE 115 XYLOCAINE/EPINEPHRIN E 115 XYNTHA 108 XYNTHA SOLOFUSE 108 YASMIN 28 83 YAZ 83 ZADITOR 153 zaleplon 113 ZARAH 83 ZARONTIN 32 ZARXIO 111, 112 ZATEAN-PN DHA 149 ZATEAN-PN PLUS 149 ZEMAIRA 163 ZENATANE 94 ZENPEP 99 ZIAGEN 69 zidovudine 70 zinc sulfate 146 zinc trace metal 146 ziprasidone hcl 55, 56 ZOLADEX 53 zoledronic acid 101 zolpidem tartrate 113 zonisamide 30 ZOVIA 1/35E (28) 83 ZUMANDIMINE 83 ZYLET 154 ZYTIGA 50

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