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AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health of Florida Florida Healthy Kids Formulary Guide

April 2020


Updated: 04/01/2020 P a g e | 2

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.

Updated: 04/01/2020 P a g e | 3

Aetna Better Health Florida CHIP

Table of Contents*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................5*ALTERNATIVE MEDICINES*........................................................................................................................... 12*AMINOGLYCOSIDES*....................................................................................................................................... 12*ANALGESICS - ANTI-INFLAMMATORY*...................................................................................................... 13*ANALGESICS - NONNARCOTIC*.....................................................................................................................16*ANALGESICS - OPIOID*.................................................................................................................................... 19*ANDROGENS-ANABOLIC*............................................................................................................................... 21*ANORECTAL AGENTS*.....................................................................................................................................22*ANTACIDS*..........................................................................................................................................................22*ANTHELMINTICS*............................................................................................................................................. 23*ANTIANGINAL AGENTS*................................................................................................................................. 23*ANTIANXIETY AGENTS*..................................................................................................................................24*ANTIARRHYTHMICS*....................................................................................................................................... 25*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 25*ANTICOAGULANTS*......................................................................................................................................... 28*ANTICONVULSANTS*.......................................................................................................................................29*ANTIDEPRESSANTS*.........................................................................................................................................33*ANTIDIABETICS*............................................................................................................................................... 35*ANTIDIARRHEALS*...........................................................................................................................................41*ANTIDOTES AND SPECIFIC ANTAGONISTS*...............................................................................................41*ANTIDOTES*....................................................................................................................................................... 41*ANTIEMETICS*................................................................................................................................................... 42*ANTIFUNGALS*..................................................................................................................................................42*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***......................................................... 43*ANTIHISTAMINES*............................................................................................................................................ 43*ANTIHYPERLIPIDEMICS*.................................................................................................................................45*ANTIHYPERTENSIVES*.................................................................................................................................... 45*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 48*ANTIMALARIALS*.............................................................................................................................................50*ANTIMYASTHENIC AGENTS*......................................................................................................................... 50*ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 50*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 50*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................51*ANTIPARKINSON AGENTS*.............................................................................................................................56*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 57*ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR***........................................69*ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 69*ANTIVIRALS*......................................................................................................................................................69*ASSORTED CLASSES*....................................................................................................................................... 73*BETA BLOCKERS*............................................................................................................................................. 74*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***...............................................76*CALCIUM CHANNEL BLOCKERS*................................................................................................................. 77*CARDIOTONICS*................................................................................................................................................ 78*CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 79*CEPHALOSPORINS*...........................................................................................................................................79*CHEMICALS*.......................................................................................................................................................81*CONTRACEPTIVES*...........................................................................................................................................81

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*CORTICOSTEROIDS*......................................................................................................................................... 91*COUGH/COLD/ALLERGY*................................................................................................................................93*DERMATOLOGICALS*...................................................................................................................................... 97*DIAGNOSTIC PRODUCTS*..............................................................................................................................102*DIGESTIVE AIDS*.............................................................................................................................................102*DIRECT-ACTING P2Y12 INHIBITORS***..................................................................................................... 103*DIURETICS*.......................................................................................................................................................103*ENDOCRINE AND METABOLIC AGENTS - MISC.*....................................................................................105*ESTROGENS*.....................................................................................................................................................107*FLUOROQUINOLONES*.................................................................................................................................. 107*GASTROINTESTINAL AGENTS - MISC.*......................................................................................................107*GENITOURINARY AGENTS - MISCELLANEOUS*..................................................................................... 109*GLYCOPEPTIDES***........................................................................................................................................109*GOUT AGENTS*................................................................................................................................................110*HEMATOLOGICAL AGENTS - MISC.*.......................................................................................................... 110*HEMATOPOIETIC AGENTS*...........................................................................................................................113*HEMOSTATICS*................................................................................................................................................116*HEPATITIS C AGENT - COMBINATIONS***............................................................................................... 117*HYPNOTICS*..................................................................................................................................................... 117*LAXATIVES*..................................................................................................................................................... 117*LHRH/GNRH AGONIST ANALOG COMBINATIONS***............................................................................ 118*LOCAL ANESTHETICS-PARENTERAL*....................................................................................................... 118*MACROLIDES*..................................................................................................................................................119*MEDICAL DEVICES*........................................................................................................................................119*MIGRAINE PRODUCTS*..................................................................................................................................145*MINERALS & ELECTROLYTES*....................................................................................................................146*MONOBACTAMS***........................................................................................................................................ 149*MOUTH/THROAT/DENTAL AGENTS*..........................................................................................................149*MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS***......................................................................150*MULTIVITAMINS*............................................................................................................................................150*MUSCULOSKELETAL THERAPY AGENTS*................................................................................................153*NASAL AGENTS - SYSTEMIC AND TOPICAL*........................................................................................... 153*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***........................................... 153*NEUROMUSCULAR AGENTS*....................................................................................................................... 153*NUTRIENTS*......................................................................................................................................................154*OPHTHALMIC AGENTS*.................................................................................................................................155*OPHTHALMIC KINASE INHIBITORS - COMBINATIONS***.................................................................... 158*OPHTHALMIC RHO KINASE INHIBITORS***.............................................................................................158*OTIC AGENTS*..................................................................................................................................................158*OXYTOCICS*.....................................................................................................................................................159*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***...........................................................................159*PASSIVE IMMUNIZING AGENTS*.................................................................................................................159*PENICILLINS*....................................................................................................................................................159*PERITONEAL DIALYSIS SOLUTIONS***.....................................................................................................160*PHARMACEUTICAL ADJUVANTS*.............................................................................................................. 161*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***..................................................................162*POTASSIUM REMOVING AGENTS***..........................................................................................................162*PROGESTINS*....................................................................................................................................................162*PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS***.................................162*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................163*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***..................................................................166*RESPIRATORY AGENTS - MISC.*..................................................................................................................166

2

*SEROTONIN MODULATORS***.................................................................................................................... 166*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***................................................................... 167*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***................................... 167*STEROIDS - MOUTH/THROAT/DENTAL***................................................................................................ 167*TETRACYCLINES*........................................................................................................................................... 167*THYROID AGENTS*......................................................................................................................................... 167*ULCER DRUGS*................................................................................................................................................ 168*URINARY ANTI-INFECTIVES*.......................................................................................................................170*URINARY ANTISPASMODICS*......................................................................................................................170*VAGINAL PRODUCTS*....................................................................................................................................171*VASOPRESSORS*............................................................................................................................................. 172*VITAMINS*........................................................................................................................................................ 172

3

Aetna Better Health Florida CHIP

CURRENT AS OF 4/1/2020

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 capsule 10 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 10 mg oral Strattera atomoxetine hcl capsule 100 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 100 mg oral Strattera atomoxetine hcl capsule 18 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 18 mg oral Strattera atomoxetine hcl capsule 25 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 25 mg oral Strattera atomoxetine hcl capsule 40 mg oral Strattera atomoxetine hcl capsule 40 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 60 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 60 mg oral Strattera atomoxetine hcl capsule 80 mg oral Strattera AL (Min 6 Years) atomoxetine hcl capsule 80 mg oral Strattera

*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

QL: ages 0-5: maximum of 1 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 1 tablets/day, ages =/>18: maximum of 4 tablets/day; AL (Min 3 Years)





6



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)


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 solution 20 mg/ml oral

caffeine citrate solution 20 mg/ml oral QLL (90 ML per 30 days); AL (Max 11 Months)

caffeine citrate solution 60 mg/3ml oral 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)

8





6 Years)




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)




9

Formulary Drug Name Reference Restrictions methylphenidate hcl er (cd) capsule extended release 30 mg oral AL (Min 6 Years)


QL: ages 0-5: maximum 0.833 capsule/day, ages =/;18: maximum 1 capsule/day; 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

methylphenidate hcl tablet 10 mg oral Ritalin


10

Formulary Drug Name Reference Restrictions methylphenidate hcl tablet 10 mg oral Ritalin AL (Min 6 Years)



methylphenidate hcl tablet 20 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)

methylphenidate hcl tablet 5 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)



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






11



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







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

12

Formulary Drug Name Reference Restrictions tobramycin inhalation nebulization solution Kitabis Pak PA tobramycin sulfate injection solution BETHKIS INHALATION NEBULIZATION 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)

*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS

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

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

13

Formulary Drug Name Reference Restrictions HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS



HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS





*Anti-Tnf-Alpha - Monoclonoal Antibodies*** 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




14

Formulary Drug Name Reference Restrictions HUMIRA PREFILLED SYRINGE KIT 20 MG/0.2ML SUBCUTANEOUS Auto-PA






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

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)

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

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava

*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Auto-PA

15

Formulary Drug Name Reference Restrictions 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 solution OTC acetaminophen childrens oral suspension PediaCare Children 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 PediaCare Children OTC; AL (Max 6 Years) acetaminophen oral tablet chewable Mapap Childrens OTC arthritis pain relief oral tablet extended release Midol OTC

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

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

hm arthritis pain relief oral tablet extended release Midol OTC

hm pain & fever childrens oral suspension PediaCare Children OTC; AL (Max 6 Years)

16

Formulary Drug Name Reference Restrictions hm pain & fever infants oral suspension PediaCare Children OTC; AL (Max 6 Years) mapap arthritis pain oral tablet extended release Midol OTC

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

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

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

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

qc pain relief childrens oral suspension PediaCare Children 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 PediaCare Children OTC; AL (Max 6 Years) sm pain & fever infants oral suspension PediaCare Children OTC; AL (Max 6 Years) MAPAP CHILDRENS ORAL TABLET CHEWABLE Pain & Fever Childrens 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 tablet 50-325-40 mg oral Esgic

butalbital-apap-caffeine tablet 50-325-40 mg oral Esgic QLL (120 EA per 365 days)

butalbital-aspirin-caffeine oral capsule Fiorinal

17

Formulary Drug Name Reference Restrictions *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 EcPirin 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 EcPirin 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 EcPirin 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

qc enteric aspirin oral tablet delayed release EcPirin OTC

18

Formulary Drug Name Reference Restrictions 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 EcPirin 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 CVS Aspirin EC OTC

ECPIRIN ORAL TABLET DELAYED RELEASE HM 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 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 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

hydrocodone-acetaminophen tablet 5-300 mg oral Xodol QLL (8 EA per 1 day)

hydrocodone-acetaminophen tablet 5-325 mg oral Lorcet

19

Formulary Drug Name Reference Restrictions hydrocodone-acetaminophen tablet 7.5-300 mg oral QLL (6 EA per 1 day)

hydrocodone-acetaminophen tablet 7.5-325 mg oral Lorcet Plus

hydrocodone-ibuprofen oral tablet VICODIN HP ORAL TABLET Hydrocodone-Acetaminophen QLL (6 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 er oral tablet extended release MS Contin

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 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


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

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

20

Formulary Drug Name Reference Restrictions 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 2.5-325 mg oral Endocet

oxycodone-acetaminophen tablet 5-325 mg oral Endocet

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

oxycodone-acetaminophen tablet 7.5-325 mg oral Endocet

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 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


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


(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

21

Formulary Drug Name Reference Restrictions testosterone transdermal gel AndroGel Pump ANDROGEL TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years)

*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 Tums E-X 750 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 Tums E-X 750 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 Tums E-X 750 OTC

hm calcium antacid ex st oral tablet chewable Tums E-X 750 OTC hm calcium antacid oral tablet chewable Tums E-X 750 OTC hm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 OTC

sm calcium antacid ex st oral tablet chewable Tums E-X 750 OTC 22

Formulary Drug Name Reference Restrictions sm calcium antacid oral tablet chewable Cal-Gest Antacid OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE Antacid OTC

TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE Antacid Soft Chews OTC

TUMS E-X 750 ORAL TABLET CHEWABLE Calcium Carbonate Antacid OTC

TUMS EXTRA STRENGTH 750 ORAL TABLET CHEWABLE Calcium Carbonate Antacid OTC

TUMS ORAL TABLET CHEWABLE Antacid OTC TUMS SMOOTHIES ORAL TABLET CHEWABLE Calcium Carbonate Antacid OTC

TUMS ULTRA 1000 ORAL TABLET CHEWABLE Antacid Maximum 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 Maintenance drug with max 100 day supply

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



isosorbide dinitrate tablet 40 mg oral Isordil Titradose Maintenance drug with max 100 day supply

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

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

23

Formulary Drug Name Reference Restrictions isosorbide mononitrate er oral tablet extended release 24 hour

Maintenance drug with max 100 day supply

isosorbide mononitrate oral tablet

nitroglycerin tablet sublingual 0.3 mg sublingual Nitrostat

Maintenance drug with max 100 day supply; QLL (16 EA per 1 day)


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)

*ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet AL (Min 6 Years) 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 QLL (4 EA per 1 day)

*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 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)

24


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

diazepam oral solution QLL (40 ML per 1 day) diazepam tablet 10 mg oral Valium diazepam tablet 10 mg oral Valium QLL (4 EA per 1 day) diazepam tablet 2 mg oral Valium QLL (4 EA per 1 day) diazepam tablet 5 mg oral Valium QLL (4 EA per 1 day) lorazepam injection solution Ativan

lorazepam oral concentrate LORazepam Intensol QLL (2 ML per 1 day); AL (Min 12 Years)

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 (2 ML per 1 day); AL

(Min 12 Years)

*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** quinidine sulfate oral tablet

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

*Antiarrhythmics Type I-C***

flecainide acetate oral tablet Maintenance drug with max 100 days supply

propafenone hcl oral tablet Maintenance drug with max 100 day supply

*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*** budesonide-formoterol fumarate inhalation aerosol Symbicort

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)

25

Formulary Drug Name Reference Restrictions BEVESPI AEROSPHERE INHALATION AEROSOL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION DULERA AEROSOL 100-5 MCG/ACT INHALATION

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

DULERA AEROSOL 200-5 MCG/ACT INHALATION

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

DULERA AEROSOL 50-5 MCG/ACT INHALATION STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION

SYMBICORT INHALATION AEROSOL Budesonide-Formoterol Fumarate

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 Proventil 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 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 nebulization solution 2.5 mg/0.5ml inhalation 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


26

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

SPIRIVA HANDIHALER INHALATION CAPSULE

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

*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






FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED


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)

27

Formulary Drug Name Reference Restrictions 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 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 DVT/PE STARTER PACK ORAL TABLET AL (Min 18 Years)

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)

28

Formulary Drug Name Reference Restrictions XARELTO TABLET 20 MG ORAL AL (Min 18 Years)

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

*Low Molecular Weight Heparins*** 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

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


enoxaparin sodium solution 300 mg/3ml injection Lovenox QLL (180 ML per 1 day)

enoxaparin sodium solution 300 mg/3ml injection Lovenox QLL (180 ML per 30 days)




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

*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)

29

Formulary Drug Name Reference Restrictions clobazam tablet 10 mg oral Onfi clobazam tablet 10 mg oral Onfi AL (Min 2 Years) clobazam tablet 20 mg oral Onfi clobazam tablet 20 mg oral 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) SYMPAZAN ORAL FILM

*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 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)

30

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

31

Formulary Drug Name Reference Restrictions QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE Topiramate ER

ROWEEPRA ORAL TABLET LevETIRAcetam 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 tablet Sabril PA vigabatrin packet 500 mg oral Sabril vigabatrin packet 500 mg oral Sabril PA GABITRIL ORAL TABLET TiaGABine HCl Auto-PA SABRIL ORAL PACKET Vigabatrin Auto-PA VIGADRONE ORAL PACKET Vigabatrin

32

Formulary Drug Name Reference Restrictions *Hydantoins*** phenytoin oral suspension Dilantin phenytoin oral tablet chewable Phenytoin 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 valproic acid oral solution DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR Divalproex Sodium ER Auto-PA

DEPAKOTE ORAL TABLET DELAYED RELEASE Divalproex Sodium Auto-PA

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

Divalproex Sodium Auto-PA

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

33

Formulary Drug Name Reference Restrictions 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)

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

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

sertraline hcl oral tablet Zoloft AL (Min 6 Years)

34

Formulary Drug Name Reference Restrictions *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 capsule delayed release particles 20 mg oral Cymbalta QLL (2 EA per 1 day); AL (Min

6 Years) duloxetine hcl capsule delayed release particles 20 mg oral Cymbalta

duloxetine hcl capsule delayed release particles 30 mg oral Cymbalta

duloxetine hcl capsule delayed release particles 30 mg oral Cymbalta QLL (2 EA per 1 day); AL (Min

6 Years) duloxetine hcl capsule delayed release particles 40 mg oral


duloxetine hcl capsule delayed release particles 60 mg oral Cymbalta QLL (2 EA per 1 day); AL (Min

6 Years) duloxetine hcl capsule delayed release particles 60 mg oral Cymbalta

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 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

35

Formulary Drug Name Reference Restrictions *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg QLL (5 EA per 1 day)

metformin hcl er oral tablet extended release 24 hour 750 mg

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


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

metformin hcl er tablet extended release 24 hour 750 mg oral

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

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

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

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

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

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

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

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

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

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

36

Formulary Drug Name Reference Restrictions *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)

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 (1 Unit Dial) QLL (2 BOXES per 30 days); AL (Max 18 Years)

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

37

Formulary Drug Name Reference Restrictions BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

ST; QLL (2 BOXES per 30 days)

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)

38

Formulary Drug Name Reference Restrictions NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Insulin Aspart FlexPen ST; QLL (2 BOXES per 30

days) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Insulin Asp Prot & Asp FlexPen


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION Insulin Aspart Prot & Aspart ST; QLL (70 ML per 30 days)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE Insulin Aspart PenFill ST; QLL (2 BOXES per 30

days) NOVOLOG SUBCUTANEOUS SOLUTION Insulin Aspart 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 (0.1071 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

*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

39

Formulary Drug Name Reference Restrictions *Sulfonylureas***

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

glimepiride tablet 4 mg oral Amaryl Maintenance drug with max 100 day supply


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

40

Formulary Drug Name Reference Restrictions 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

*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 intravenous solution Acetadote QLL (1 ML per 365 days) deferoxamine mesylate injection solution reconstituted

*Opioid Antagonists*** naloxone hcl injection solution naloxone hcl injection solution cartridge

41

Formulary Drug Name Reference Restrictions 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 ST; QLL (8 EA per 28 days) ondansetron hcl oral solution QLL (600 ML per 28 days) ondansetron hcl oral tablet Zofran QLL (2 EA per 1 day) ondansetron hcl solution 4 mg/2ml injection ondansetron hcl solution 4 mg/2ml injection QLL (32 ML per 28 days) ondansetron hcl solution 40 mg/20ml injection QLL (32 ML per 28 days) 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 scopolamine transdermal patch 72 hour Transderm Scop (1.5 MG) AL (Min 18 Years) TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR Scopolamine AL (Min 18 Years)

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant capsule 125 mg oral 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 500 mg ST griseofulvin microsize tablet 500 mg oral ST 42

Formulary Drug Name Reference Restrictions griseofulvin microsize tablet 500 mg oral 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

*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 relief childrens oral solution KLS Aller-Tec Childrens OTC allergy relief oral tablet 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 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 childrens loratadine oral solution Claritin OTC; AL (Max 11 Years) childrens loratadine oral syrup Claritin OTC; AL (Max 11 Years)

43

Formulary Drug Name Reference Restrictions 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) 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

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

44

Formulary Drug Name Reference Restrictions *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

*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

45

Formulary Drug Name Reference Restrictions 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 quinapril-hydrochlorothiazide oral tablet Accuretic

*Ace Inhibitors*** benazepril hcl tablet 10 mg oral Lotensin benazepril hcl tablet 20 mg oral Lotensin

benazepril hcl tablet 40 mg oral Lotensin Maintenance drug with max 100 day supply

benazepril hcl tablet 5 mg oral

captopril oral tablet Maintenance drug with max 100 day supply

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

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 day 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

46

Formulary Drug Name Reference Restrictions 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

*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







47


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 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 day supply

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

bisoprolol-hydrochlorothiazide oral tablet Ziac Maintenance drug with max 100 day supply

*Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra

*Vasodilators***

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

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






minoxidil oral tablet

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** metronidazole in nacl intravenous solution 48

Formulary Drug Name Reference Restrictions metronidazole oral tablet Flagyl tinidazole oral tablet trimethoprim oral tablet vancomycin hcl intravenous solution reconstituted NEBUPENT INHALATION SOLUTION RECONSTITUTED Pentamidine Isethionate

*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)

*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 lincomycin hcl injection solution Lincocin CLEOCIN PHOSPHATE INJECTION SOLUTION Clindamycin Phosphate

*Oxazolidinones*** linezolid oral tablet Zyvox

*Polymyxins*** polymyxin b sulfate injection solution reconstituted

49

Formulary Drug Name Reference Restrictions *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 tablet MESTINON ORAL SOLUTION Pyridostigmine Bromide

*Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet 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 isoniazid oral syrup isoniazid oral tablet pyrazinamide oral tablet rifabutin oral capsule Mycobutin

50

Formulary Drug Name Reference Restrictions rifampin intravenous solution reconstituted Rifadin rifampin oral capsule Rifadin

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** carboplatin intravenous solution Paraplatin 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) PARAPLATIN INTRAVENOUS SOLUTION CARBOplatin

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

*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)

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

*Antimetabolites*** azacitidine injection suspension reconstituted Vidaza

capecitabine oral tablet 150 mg, 500 mg Xeloda QLL (4 EA per 1 day); AL (Min 18 Years)

capecitabine tablet 150 mg oral Xeloda

51


capecitabine tablet 150 mg oral Xeloda QLL (4 EA per 1 day); AL (Min 18 Years)

capecitabine tablet 500 mg oral Xeloda QLL (4 EA per 1 day); AL (Min 18 Years)

capecitabine tablet 500 mg oral Xeloda 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 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

52

Formulary Drug Name Reference Restrictions *Antineoplastic - Multikinase Inhibitors*** SUTENT ORAL CAPSULE AL (Min 18 Years)

*Antineoplastic - Proteasome Inhibitors*** bortezomib intravenous solution reconstituted 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 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 Misc.*** dacarbazine intravenous solution reconstituted hydroxyurea oral capsule Hydrea

53

Formulary Drug Name Reference Restrictions 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 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)

54

Formulary Drug Name Reference Restrictions *Mitotic Inhibitors*** docetaxel intravenous concentrate Taxotere 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 melphalan hcl intravenous solution reconstituted 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

55

Formulary Drug Name Reference Restrictions *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)

*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 Maintenance drug with max 100 day supply; 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-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) 56

Formulary Drug Name Reference Restrictions 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)


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)

57








*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)

risperidone tablet 0.25 mg oral

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)

58


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)


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)

FANAPT ORAL TABLET

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 ER

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

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

4.5ml/day haloperidol decanoate solution 100 mg/ml intramuscular Haldol Decanoate QL: age =/;18: maximum

4.5ml/day; AL (Min 18 Years)

59

Formulary Drug Name Reference Restrictions 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 QL: age =/;18: maximum

3ml/day; 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

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













60










*Dibenzodiazepines***

clozapine tablet 100 mg oral Clozaril





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)




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

61






clozapine tablet dispersible 100 mg oral


clozapine tablet dispersible 12.5 mg oral








CLOZARIL TABLET 100 MG ORAL CloZAPine






62

Formulary Drug Name Reference Restrictions *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)





63

Formulary Drug Name Reference Restrictions *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 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)


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

64


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 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 6 tablets/day, age 12-17: maximum 11 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 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)

65



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)


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)

66


aripiprazole tablet 10 mg oral Abilify


aripiprazole tablet 15 mg oral Abilify






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


67










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)



68






*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)

69


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)

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 TEMIXYS ORAL TABLET

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; AL (Min 6 Years)

*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

70

Formulary Drug Name Reference Restrictions 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 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 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 tablet 300 mg oral Ziagen abacavir sulfate tablet 300 mg oral Ziagen Auto-PA didanosine oral capsule delayed release 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

71

Formulary Drug Name Reference Restrictions lamivudine tablet 300 mg oral Epivir Auto-PA EMTRIVA ORAL CAPSULE Auto-PA EMTRIVA ORAL SOLUTION Auto-PA EPIVIR ORAL SOLUTION LamiVUDine Auto-PA

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine oral capsule Zerit 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 solution reconstituted Valcyte 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 Auto-PA; AL (Min 5 Years) ribavirin oral tablet Auto-PA; AL (Min 5 Years) PEGASYS SUBCUTANEOUS SOLUTION Auto-PA; AL (Min 3 Years) PEGINTRON SUBCUTANEOUS KIT Auto-PA; AL (Min 3 Years)

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

72

Formulary Drug Name Reference Restrictions *Neuraminidase Inhibitors*** oseltamivir phosphate capsule 30 mg oral Tamiflu 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)

*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

*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

73

Formulary Drug Name Reference Restrictions 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 water for irrigation, sterile 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 SPS ORAL SUSPENSION Sodium Polystyrene Sulfonate

*Purine Analogs*** azathioprine oral tablet Imuran

*BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet Coreg labetalol hcl tablet 100 mg oral QLL (8 EA per 1 day)

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)

74



*Beta Blockers Cardio-Selective***

acebutolol hcl oral capsule Maintenance drug with max 100 days supply

atenolol tablet 100 mg oral Tenormin Maintenance drug with max 100 days supply


atenolol tablet 50 mg oral Tenormin


bisoprolol fumarate oral tablet Maintenance drug with max 100 day supply

metoprolol succinate er tablet extended release 24 hour 100 mg oral Toprol XL

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

*Beta Blockers Non-Selective***

nadolol oral tablet Corgard Maintenance drug with max 100 day supply

propranolol hcl er capsule extended release 24 hour 120 mg oral Inderal LA Maintenance drug with max 100

day supply propranolol hcl er capsule extended release 24 hour 120 mg oral Inderal LA Maintenance drug with max 100

days supply

75

Formulary Drug Name Reference Restrictions propranolol hcl er capsule extended release 24 hour 160 mg oral Inderal LA Maintenance drug with max 100


days supply propranolol hcl er capsule extended release 24 hour 60 mg oral Inderal LA Maintenance drug with max 100


days supply propranolol hcl er capsule extended release 24 hour 80 mg oral Inderal LA Maintenance drug with max 100


days supply

propranolol hcl oral solution Maintenance drug with max 100 days supply

propranolol hcl tablet 10 mg oral

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









sotalol hcl (af) oral tablet Betapace AF Maintenance drug with max 100 day supply

sotalol hcl oral tablet Betapace BETAPACE AF ORAL TABLET Sotalol Hydrochloride

*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG*** *Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag*** EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

76

Formulary Drug Name Reference Restrictions 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 Tiadylt ER 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 diltiazem hcl er oral capsule extended release 12 hour

Maintenance drug with max 100 days supply

77


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

verapamil hcl er oral tablet extended release Calan SR

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

verapamil hcl tablet 120 mg oral 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

78

Formulary Drug Name Reference Restrictions *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 tablet Revatio sildenafil citrate suspension reconstituted 10 mg/ml oral Revatio

sildenafil citrate suspension reconstituted 10 mg/ml oral Revatio PA

tadalafil (pah) oral tablet Adcirca PA

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

79

Formulary Drug Name Reference Restrictions 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)

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 QLL (1500 EA per 30 days)

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

80

Formulary Drug Name Reference Restrictions *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

*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)

81


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 1.5/30 norethin ace-eth estrad-fe oral tablet chewable Mibelas 24 Fe

norethindrone acet-ethinyl est tablet 1.5-30 mg-mcg oral Aurovela 1.5/30

norethindrone acet-ethinyl est tablet 1-20 mg-mcg oral 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 Norethindrone Acet-Ethinyl Est

AUROVELA 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est

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

82


BEYAZ ORAL TABLET Drospiren-Eth Estrad-Levomefol


BLISOVI 24 FE ORAL TABLET Norethin Ace-Eth Estrad-FE BLISOVI FE 1.5/30 ORAL TABLET Norethin Ace-Eth Estrad-FE BLISOVI FE 1/20 ORAL TABLET Norethin Ace-Eth Estrad-FE

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

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)

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 Norethindrone Acet-Ethinyl Est

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 Norethindrone Acet-Ethinyl Est


83


JUNEL 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est


JUNEL FE 1.5/30 ORAL TABLET Norethin Ace-Eth Estrad-FE 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

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

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 Norethindrone Acet-Ethinyl Est


LARIN 1/20 ORAL TABLET Norethindrone Acet-Ethinyl Est


LARIN 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)

LARIN FE 1.5/30 ORAL TABLET Norethin Ace-Eth Estrad-FE QLL (1 EA per 1 day); AL (Min 12 Years)

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 Norethindrone Acet-Ethinyl Est

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


LORYNA ORAL TABLET Drospirenone-Ethinyl Estradiol 84

Formulary Drug Name Reference Restrictions 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 FE 1.5/30 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 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

85


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*** etonogestrel-ethinyl estradiol vaginal ring EluRyng ANNOVERA VAGINAL RING ELURYNG VAGINAL RING Etonogestrel-Ethinyl Estradiol

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

*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)

86


AFTERA ORAL TABLET 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


PLAN B ONE-STEP ORAL TABLET Levonorgestrel


TAKE ACTION ORAL TABLET 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


87


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


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)

88

Formulary Drug Name Reference Restrictions 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*** LILETTA (52 MG) 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 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)

89


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

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

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)

90

Formulary Drug Name Reference Restrictions *CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release particles Entocort EC

dexamethasone oral elixir dexamethasone oral solution

dexamethasone oral tablet Decadron Maintenance drug with max 100 days supply

dexamethasone sod phosphate pf injection solution dexamethasone sod phosphate pf injection solution prefilled syringe dexamethasone sodium phosphate injection solution hydrocortisone oral tablet Cortef methylprednisolone acetate injection suspension Depo-Medrol

methylprednisolone sodium succ injection solution reconstituted SOLU-medrol

methylprednisolone tablet 16 mg oral Medrol methylprednisolone tablet 32 mg oral Medrol methylprednisolone tablet 4 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 Maintenance drug with max 100

days supply methylprednisolone tablet therapy pack 4 mg oral Medrol

prednisolone oral solution prednisolone sodium phosphate oral solution prednisolone sodium phosphate oral tablet dispersible Orapred ODT AL (Max 11 Years)

prednisone oral solution

prednisone tablet 1 mg oral Maintenance drug with max 100 day supply

prednisone tablet 1 mg oral Maintenance drug with max 100 days supply

prednisone tablet 10 mg oral

91



prednisone tablet 10 mg oral Maintenance drugs with max 100 day supply

prednisone tablet 2.5 mg oral

prednisone tablet 2.5 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 drugs with max 100 days supply



prednisone tablet 50 mg oral Maintenance drugs with max 100 days supply

prednisone tablet therapy pack 10 mg (21) oral



Maintenance drugs with max 100 days supply




Maintenance drugs with max 100 days supply

prednisone tablet therapy pack 5 mg (21) oral Maintenance drug with max 100 day supply

prednisone tablet therapy pack 5 mg (21) oral Maintenance drugs with max 100 days supply

prednisone tablet therapy pack 5 mg (48) oral Maintenance drug with max 100 day supply

prednisone tablet therapy pack 5 mg (48) oral Maintenance drugs with max 100 days supply

92

Formulary Drug Name Reference Restrictions DEXAMETHASONE INTENSOL ORAL CONCENTRATE PA

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED

*Mineralocorticoids*** fludrocortisone acetate oral tablet

*Steroid Combinations*** betamethasone sod phos & acet injection suspension Celestone Soluspan

CELESTONE SOLUSPAN INJECTION SUSPENSION Betamethasone Combo

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule Tessalon Perles 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 liquid Robafen DM Cough OTC

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 Robafen DM Cough 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


93


mucus relief dm oral liquid Delsym Cgh/Chest Cong DM Child OTC

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

tusnel diabetic oral liquid Robafen DM Cough OTC tussin dm cough + chest oral liquid Robafen DM Cough OTC

tussin dm max adult oral liquid Delsym Cgh/Chest Cong DM Child OTC

MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HOUR Mucus-DM OTC

ROBAFEN DM COUGH ORAL LIQUID QC Tussin DM Cough/Congestion OTC

ROBAFEN DM PEAK COLD CGH/CONG ORAL LIQUID

QC Tussin DM Cough/Congestion 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-d oral tablet extended release 24 hour Claritin-D 24 Hour 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

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

94

Formulary Drug Name Reference Restrictions 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

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 Robafen Mucus/Chest Congestion

OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

gnp mucus er oral tablet extended release 12 hour Mucinex OTC

gnp mucus relief oral tablet Bidex OTC gnp tab tussin oral tablet Bidex OTC

gnp tussin mucus & chest cong oral liquid Robafen Mucus/Chest Congestion


guaifenesin oral liquid Robafen Mucus/Chest Congestion


guaifenesin oral solution Robafen Mucus/Chest Congestion


guaifenesin oral tablet Bidex OTC hm chest congestion relief oral tablet Bidex OTC

hm tussin adult oral liquid Robafen Mucus/Chest Congestion


mucosa oral tablet Bidex OTC

mucus & chest congestion oral liquid Robafen Mucus/Chest Congestion


mucus relief chest congestion oral tablet OTC mucus relief er oral tablet extended release 12 hour Mucinex OTC

mucus relief max st oral tablet extended release 12 hour Mucinex Maximum Strength OTC

mucus relief oral tablet extended release 12 hour Mucinex OTC

qc medifin 400 oral tablet Bidex OTC

95

Formulary Drug Name Reference Restrictions qc mucus relief er oral tablet extended release 12 hour Mucinex Maximum Strength OTC

qc mucus relief oral tablet extended release 12 hour Mucinex OTC

qc tussin mucus/congestion oral liquid Robafen Mucus/Chest Congestion


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 sm chest congestion relief oral tablet Bidex OTC sm mucus relief max strength oral tablet extended release 12 hour Mucinex Maximum Strength OTC

sm mucus relief oral tablet extended release 12 hour Mucinex OTC

sm tussin mucus+chest congest oral liquid Robafen Mucus/Chest Congestion


tussin mucus & chest congest oral liquid Robafen Mucus/Chest Congestion


tussin mucus+chest congestion oral liquid Robafen Mucus/Chest Congestion


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

CVS Tussin Adult Chest Congest


*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 96

Formulary Drug Name Reference Restrictions *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)

*Acne Combinations*** clindamycin phos-benzoyl perox external gel BenzaClin

*Acne Products*** adapalene external cream Differin ST; AL (Min 12 Years) isotretinoin oral capsule Claravis 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)

CLARAVIS ORAL CAPSULE ISOtretinoin ST; Med Cert drug - medically acceptable indication required.; AL (Min 12 Years)

DIFFERIN EXTERNAL GEL Adapalene OTC Only; AL (Min 12 Years)

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 nystatin-triamcinolone external cream nystatin-triamcinolone external ointment ALA-QUIN EXTERNAL CREAM

97

Formulary Drug Name Reference Restrictions *Antifungals - Topical*** butenafine hcl external cream Lotrimin Ultra OTC ciclopirox external solution Ciclodan ciclopirox olamine external cream Loprox ciclopirox olamine external suspension Loprox 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 Efudex 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; QLL (2 ML per 30 days); AL (Min 18 Years)

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Auto-PA; AL (Min 18 Years)

98

Formulary Drug Name Reference Restrictions *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 tazarotene external cream Tazorac 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

99

Formulary Drug Name Reference Restrictions fluticasone propionate external cream fluticasone propionate external ointment halobetasol propionate external cream halobetasol propionate external ointment 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 Trianex 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 100

Formulary Drug Name Reference Restrictions *Imidazole-Related Antifungals -Topical*** clotrimazole external cream Clotrimazole GRx

clotrimazole external solution FungiCure Intensive/NailGuard

econazole nitrate external cream ketoconazole external cream ketoconazole external shampoo Nizoral miconazole nitrate external cream Carrington Antifungal

*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 cream 3 % external (otc) QLL (60 GM per 30 days) lidocaine hcl cream 3 % external (rx) lidocaine hcl cream 3 % external (rx) QLL (60 GM per 30 days) lidocaine hcl external solution lidocaine hcl urethral/mucosal external gel lidocaine hcl urethral/mucosal external prefilled syringe 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) ZTLIDO EXTERNAL PATCH

*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)

101

Formulary Drug Name Reference Restrictions *Rosacea Agents*** azelaic acid external gel Finacea metronidazole external cream MetroCream metronidazole external gel Rosadan

*Scabicide Combinations*** VANALICE EXTERNAL GEL OTC

*Scabicides & Pediculicides***

malathion external lotion Ovide QL: Maximum of 2 prescription fills every 60 days; QLL (60 ML per 30 days)

permethrin external cream Elimite spinosad external suspension Natroba

*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 Ketostix 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

102

Formulary Drug Name Reference Restrictions ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES

*DIRECT-ACTING P2Y12 INHIBITORS*** *Direct-Acting P2y12 Inhibitors*** BRILINTA ORAL TABLET

*DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour


acetazolamide tablet 125 mg oral Maintenance drug with max 100 day supply

acetazolamide tablet 125 mg oral Maintenance drug with max 100 days supply

acetazolamide tablet 250 mg oral Maintenance drug with max 100 day supply

acetazolamide tablet 250 mg oral Maintenance drug with max 100 days supply

methazolamide oral tablet ST

*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 Maintenance drug with max 100 day supply

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

103


spironolactone tablet 100 mg oral Aldactone Maintenance drug with max 100 days supply

spironolactone tablet 100 mg oral Aldactone Maintenance drug with max 100 day supply


spironolactone tablet 25 mg oral Aldactone Maintenance drug with max 100 day supply

spironolactone tablet 25 mg oral Aldactone


spironolactone tablet 50 mg oral Aldactone

*Thiazides And Thiazide-Like Diuretics***

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 tablet 12.5 mg oral

hydrochlorothiazide tablet 12.5 mg oral Maintenance drug with max 100 days supply

hydrochlorothiazide tablet 25 mg oral Maintenance drug with max 100 days supply

hydrochlorothiazide tablet 50 mg oral Maintenance drug with max 100 days supply

indapamide oral tablet

metolazone tablet 10 mg oral Maintenance drug with max 100 days supply

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

metolazone tablet 5 mg oral Maintenance drug with max 100 day supply

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

DIURIL ORAL SUSPENSION AL (Max 11 Years) 104

Formulary Drug Name Reference Restrictions *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

*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)

105

Formulary Drug Name Reference Restrictions *Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents*** ORFADIN ORAL CAPSULE Nitisinone 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 intravenous solution Hectorol doxercalciferol oral capsule paricalcitol intravenous solution Zemplar paricalcitol oral capsule Zemplar

*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

106

Formulary Drug Name Reference Restrictions 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) 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 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

107

Formulary Drug Name Reference Restrictions *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

*Inflammatory Bowel Agents*** balsalazide disodium oral capsule Colazal mesalamine er oral capsule extended release 24 hour Apriso

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 Mesalamine ER

*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)

108

Formulary Drug Name Reference Restrictions *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

*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

109

Formulary Drug Name Reference Restrictions vancomycin hcl in nacl intravenous solution vancomycin hcl intravenous solution reconstituted vancomycin hcl oral capsule Vancocin HCl FIRVANQ ORAL SOLUTION RECONSTITUTED Vancomycin 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

*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

110

Formulary Drug Name Reference Restrictions CORIFACT INTRAVENOUS KIT ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 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 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

111

Formulary Drug Name Reference Restrictions 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

*Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet

*Plasma Proteins*** albumin human intravenous solution Albuked 25 PA alburx intravenous solution Albuked 5 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

112

Formulary Drug Name Reference Restrictions 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

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

113

Formulary Drug Name Reference Restrictions *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

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

114

Formulary Drug Name Reference Restrictions *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

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 virt-fefa plus oral capsule Integra Plus

115

Formulary Drug Name Reference Restrictions 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 Foltrin

*Iron W/ Folic Acid*** FOLIVANE-F ORAL CAPSULE HEMOCYTE-F ORAL TABLET Hematinic/Folic Acid INTEGRA F ORAL CAPSULE

*Iron*** ferrous fumarate oral tablet Hemocyte OTC ferrous gluconate oral tablet OTC ferrous sulfate oral elixir OTC ferrous sulfate oral solution Fer-In-Sol 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

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 solution Amicar aminocaproic acid oral tablet Amicar

116

Formulary Drug Name Reference Restrictions 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*** sofosbuvir-velpatasvir oral tablet Epclusa PA 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

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350-kcl-na bicarb-nacl oral solution reconstituted TriLyte

peg-3350/electrolytes oral solution reconstituted Golytely QLL (4000 ML per 1 Fill)

CLENPIQ ORAL SOLUTION 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)

117

Formulary Drug Name Reference Restrictions 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 Polyethylene Glycol 3350 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


*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 lidocaine hcl (pf) injection solution Xylocaine-MPF lidocaine hcl injection solution Xylocaine lidocaine in dextrose solution XYLOCAINE INJECTION SOLUTION Lidocaine HCl

118

Formulary Drug Name Reference Restrictions *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)

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED Erythromycin Ethylsuccinate AL (Min 11 Years)

*Fidaxomicin***

DIFICID ORAL TABLET QLL (20 EA per 10 days); AL (Min 18 Years)

*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

119

Formulary Drug Name Reference Restrictions 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 SAPS care Alcohol Prep

BD SWABS SINGLE USE BUTTERFLY PAD SAPS care Alcohol Prep OTC

CARETOUCH ALCOHOL PREP PAD SAPS care Alcohol Prep OTC CURITY ALCOHOL PREPS PAD SAPS care Alcohol Prep OTC CURITY ALCOHOL SWABS PAD SAPS care Alcohol Prep OTC EASY TOUCH ALCOHOL PREP MEDIUM PAD SAPS care Alcohol Prep OTC

FIFTY50 ALCOHOL PREP PAD SAPS care Alcohol Prep OTC PHARMACIST CHOICE ALCOHOL PAD SAPS care Alcohol Prep OTC RELION ALCOHOL SWABS PAD SAPS care Alcohol Prep OTC SHOPKO ALCOHOL SWABS PAD SAPS care Alcohol Prep OTC SURE-PREP ALCOHOL PREP PAD SAPS care Alcohol Prep OTC ULTICARE ALCOHOL SWABS PAD SAPS care Alcohol Prep OTC WEBCOL ALCOHOL PREP LARGE PAD SAPS care Alcohol Prep OTC

WEBCOL ALCOHOL PREP MEDIUM PAD SAPS care 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

120

Formulary Drug Name Reference Restrictions 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 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

121

Formulary Drug Name Reference Restrictions 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 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

122

Formulary Drug Name Reference Restrictions 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 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

123

Formulary Drug Name Reference Restrictions 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 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 Lancets OTC ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID Glucose Control OTC

ACCU-CHEK MULTICLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

124

Formulary Drug Name Reference Restrictions ACCU-CHEK MULTICLIX LANCETS Lancets OTC ACCU-CHEK SAFE-T PRO LANCETS Lancets OTC ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Glucose Control OTC

ACCU-CHEK SOFTCLIX LANCET DEV KIT Select-Lite Device/Lancets OTC

ACCU-CHEK SOFTCLIX LANCETS Lancets 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 DiaTrue Control Level 3 OTC

ADVOCATE LANCETS Lancets OTC ADVOCATE LANCETS 30G Lancets OTC ADVOCATE LANCING DEVICE Multi-Lancet Device OTC ADVOCATE RAPID-SAFE LANCING Multi-Lancet Device OTC ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

ADVOCATE SAFETY LANCETS Lancets OTC ADVOCATE SAFETY LANCETS 26G Lancets OTC AGAMATRIX CONTROL IN VITRO SOLUTION Glucose Control OTC

AGAMATRIX ULTRA-THIN LANCETS Lancets OTC AQUALANCE LANCETS 30G Lancets 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 Lancets OTC ASSURE HAEMOLANCE PLUS LOW Lancets OTC ASSURE HAEMOLANCE PLUS MICRO Lancets OTC ASSURE HAEMOLANCE PLUS NORMAL Lancets OTC

125

Formulary Drug Name Reference Restrictions ASSURE HAEMOLANCE PLUS PED Lancets 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 Lancets OTC ASSURE LANCE LANCETS 21G Lancets OTC ASSURE LANCE PLUS SAFETY 25G Lancets OTC ASSURE LANCE PLUS SAFETY 30G Lancets OTC ASSURE LANCETS Lancets 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 AUTOLET MINI Multi-Lancet Device OTC AUTOLET PLATFORMS Lancet Transporter Case OTC AUTOLET PLUS Multi-Lancet Device OTC BD LANCET ULTRAFINE 30G Lancets OTC BD LANCET ULTRAFINE 33G Lancets OTC BD MICROTAINER LANCETS Lancets OTC BULLSEYE SAFETY LANCETS Lancets 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 Lancets OTC

CHEMSTRIP BG LOG BOOK Supreme II Confidence Paddles OTC

CLEANLET LANCETS 28G Lancets OTC CLEVER CHEK LANCETS Lancets OTC CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID DiaTrue Control Level 3 OTC

COAGUCHEK LANCETS Lancets OTC

126

Formulary Drug Name Reference Restrictions CONTOUR CONTROL IN VITRO LIQUID DiaTrue Control Level 3 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 Lancets OTC DROPLET LANCING DEVICE Multi-Lancet Device OTC DRUG MART LANCING DEVICE Multi-Lancet Device OTC DRUG MART ON-THE-GO LANCET 30G Lancets OTC DRUG MART UNILET LANCETS 28G Lancets OTC DRUG MART UNILET LANCETS 30G Lancets OTC DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

EASY STEP CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Glucose Control OTC

EASY TOUCH LANCETS 21G Lancets OTC EASY TOUCH LANCETS 23G Lancets OTC EASY TOUCH LANCETS 26G Lancets OTC EASY TOUCH LANCETS 28G Lancets OTC EASY TOUCH LANCETS 28G/TWIST Lancets OTC EASY TOUCH LANCETS 30G Lancets OTC EASY TOUCH LANCETS 32G Lancets OTC EASY TOUCH LANCETS 32G/TWIST Lancets OTC EASY TOUCH LANCING DEVICE Multi-Lancet Device OTC EASY TOUCH SAFETY LANCETS 21G Lancets OTC EASY TOUCH SAFETY LANCETS 23G Lancets OTC EASY TOUCH SAFETY LANCETS 26G Lancets OTC EASY TOUCH SAFETY LANCETS 28G Lancets OTC EASY TWIST & CAP LANCETS Lancets OTC EASYGLUCO CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

EASYGLUCO PLUS LEVEL 1 IN VITRO SOLUTION Glucose Control OTC

EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Glucose Control OTC

127

Formulary Drug Name Reference Restrictions 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 DiaTrue Control Level 3 OTC

EASYMAX CONTROL NORMAL/LOW IN VITRO SOLUTION Glucose Control OTC

ELEMENT CONTROL IN VITRO LIQUID DiaTrue Control Level 3 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 DiaTrue Control Level 3 OTC

EMBRACE LANCETS ULTRA THIN 30G Lancets 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 Lancets OTC E-Z JECT LANCET SUPER THIN 30G Lancets OTC E-Z JECT LANCETS Lancets OTC E-Z JECT LANCETS 21G Lancets OTC E-Z JECT LANCETS THIN 26G Lancets OTC EZ SMART BLOOD GLUCOSE LANCETS Lancets OTC

EZ-LETS LANCETS 21G Lancets OTC EZ-LETS LANCETS 26G Lancets OTC EZ-LETS LANCETS 28G Lancets OTC EZ-LETS LANCETS 30G Lancets OTC

128

Formulary Drug Name Reference Restrictions FIFTY50 SAFETY SEAL LANCETS Lancets OTC FIFTY50 UNILET LANCETS 33G Lancets OTC FINE 30 Lancets OTC FINGERSTIX LANCETS Lancets OTC FORA CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC FORA LANCETS Lancets OTC FORA LANCING DEVICE Multi-Lancet Device OTC FORACARE GDH CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

FORTISCARE CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

FREESTYLE LANCETS Lancets OTC FREESTYLE UNISTICK II LANCETS Lancets OTC GENTLE-LET GP LANCETS Lancets OTC GENTLE-LET LANCETS Lancets 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 DiaTrue Control Level 3 OTC

GLUCOCOM LANCETS 28G Lancets OTC GLUCOCOM LANCETS 30G Lancets OTC GLUCOCOM LANCETS 33G Lancets OTC GNP EASY TOUCH CONT HIGH/LOW IN VITRO SOLUTION Glucose Control OTC

HAEMOLANCE Lancets OTC HAEMOLANCE LOW FLOW LANCETS Lancets OTC HAEMOLANCE PLUS Lancets OTC HAEMOLANCE PLUS HIGH FLOW Lancets OTC

129

Formulary Drug Name Reference Restrictions HAEMOLANCE PLUS LOW FLOW Lancets OTC HAEMOLANCE PLUS MAX FLOW Lancets OTC HAEMOLANCE PLUS PEDIATRIC FLOW Lancets OTC

HEALTH CARE LANCING DEVICE Multi-Lancet Device OTC HYPOLANCE AST LANCING KIT Select-Lite Device/Lancets OTC HY-VEE LANCETS Lancets 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 Lancets OTC INFINITY CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

KROGER HEALTHPRO CONTROL HI/LO IN VITRO LIQUID Glucose Control OTC

KROGER HEALTHPRO LANCET 26G Lancets OTC KROGER HEALTHPRO LANCET 30G Lancets OTC KROGER HEALTHPRO LANCET 33G Lancets OTC LANCETS ULTRA FINE Lancets OTC LANCETS ULTRA THIN Lancets OTC LANZO Multi-Lancet Device OTC LIBERTY GLUCOSE CONTROL IN VITRO LIQUID Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Glucose Control OTC

LIBERTY MEDICAL LANCETS Lancets OTC LIBERTY MINI LANCING DEVICE Multi-Lancet Device OTC LIFESCAN UNISTIK 2 Lancets OTC LIFESCAN UNISTIK II LANCETS Lancets OTC LITE TOUCH LANCING PEN Multi-Lancet Device OTC LITETOUCH LANCETS Lancets 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

130

Formulary Drug Name Reference Restrictions MEDISENSE MID CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE THIN LANCETS Lancets OTC MEDLANCE EXTRA 21G Lancets OTC MEDLANCE LITE 25G Lancets OTC MEDLANCE PLUS EXTRA 21G Lancets OTC MEDLANCE PLUS LANCETS Lancets OTC MEDLANCE PLUS LITE 25G Lancets OTC MEDLANCE PLUS SPECIAL 0.8MM Lancets OTC MEDLANCE PLUS SUPERLITE 30G Lancets OTC MEDLANCE PLUS UNIVERSAL 21G Lancets OTC MEDLANCE UNIVERSAL 21G Lancets OTC MEIJER LANCETS Lancets OTC MEIJER LANCETS THIN Lancets OTC MEIJER LANCETS UNIVERSAL 21G Lancets OTC MEIJER LANCETS UNIVERSAL 30G Lancets OTC MEIJER LANCETS UNIVERSAL 33G Lancets OTC MEIJER SUPER THIN LANCETS Lancets OTC MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Glucose Control OTC

MICROLET LANCETS Lancets OTC MICROLET NEXT LANCING DEVICE Multi-Lancet Device OTC MONOLET LANCETS Lancets OTC MONOLET OPD LANCETS Lancets OTC MONOLETTOR SAFETY LANCETS Lancets OTC MULTI-LANCET DEVICE 2 KIT Select-Lite Device/Lancets OTC MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Glucose Control OTC

MYGLUCOHEALTH LANCETS 30G Lancets 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 Lancets OTC NOVA SAFETY LANCETS 28G Lancets OTC NOVA SUREFLEX LANCETS Lancets OTC NOVA SUREFLEX LANCING DEVICE Multi-Lancet Device OTC ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Glucose Control OTC

ON CALL LANCETS Lancets OTC 131

Formulary Drug Name Reference Restrictions ON CALL LANCING DEVICE Multi-Lancet Device OTC ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ON CALL PLUS LANCETS Lancets 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 Lancets OTC ONETOUCH DELICA LANCETS 30G Lancets OTC ONETOUCH DELICA LANCETS 33G Lancets OTC ONETOUCH DELICA LANCING DEV Multi-Lancet Device OTC ONETOUCH FINEPOINT LANCETS Lancets 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

ONETOUCH ULTRA MINI KIT Meijer Blood Glucose OTC ONETOUCH ULTRALINK KIT Meijer Blood Glucose OTC ONETOUCH ULTRASOFT LANCETS Lancets 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 Lancets OTC PERFECT LANCETS 30G Lancets OTC PHARMACIST CHOICE LANCETS Lancets OTC PHARMACY COUNTER LANCETS Lancets 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

132

Formulary Drug Name Reference Restrictions PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Glucose Control OTC

PRECISION THINS GP LANCETS Lancets OTC PRODIGY CONTROL SOLUTION IN VITRO SOLUTION DiaTrue Control Level 3 OTC

PRODIGY LANCETS 28G Lancets OTC PRODIGY LANCING DEVICE Multi-Lancet Device OTC PRODIGY SAFETY LANCETS 26G Lancets OTC PRODIGY TWIST TOP LANCETS 28G Lancets OTC PSS SELECT GP LANCETS Lancets OTC PSS SELECT PLATFORMS Lancet Transporter Case OTC PSS SELECT SAFETY LANCETS Lancets 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 Lancets OTC RA E-ZJECT LANCETS 28G Lancets OTC RA E-ZJECT LANCETS THIN 26G Lancets OTC RA E-ZJECT LANCETS THIN 28G Lancets OTC RA E-ZJECT LANCETS ULTRA THIN Lancets OTC REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

RELION LANCETS MICRO-THIN 33G Lancets OTC RELION LANCETS STANDARD 21G Lancets OTC RELION LANCETS THIN 26G Lancets OTC RELION LANCETS ULTRA-THIN 30G Lancets OTC RELION LANCING DEVICE Multi-Lancet Device OTC RELION LANCING DEVICE KIT Select-Lite Device/Lancets OTC RELION ULTRA THIN LANCETS 30G Lancets OTC RELION ULTRA THIN PLUS LANCETS Lancets OTC REXALL LANCETS ULTRA THIN 30G Lancets OTC RIGHTEST ALTERNATE SITE ADAPT Lancet Transporter Case OTC RIGHTEST GC300 CONTROL IN VITRO LIQUID DiaTrue Control Level 3 OTC

RIGHTEST GD500 LANCING DEVICE Multi-Lancet Device OTC RIGHTEST GL300 LANCETS Lancets OTC SAFE-T-LANCE Lancets OTC SAFE-T-LANCE PLUS Lancets OTC SAFETY LANCETS Lancets OTC

133

Formulary Drug Name Reference Restrictions SAFETY LANCETS 21G Lancets OTC SAFETY LET LANCETS Lancets OTC SAFETY SEAL LANCETS Lancets OTC SHOPKO AUTOLET LANCING DEVICE Multi-Lancet Device OTC SHOPKO ON-THE-GO LANCETS 30G Lancets OTC SHOPKO UNILET LANCETS 28G Lancets OTC SHOPKO UNILET LANCETS 30G Lancets OTC SIMPLE DIAGNOSTICS LANCING DEV Multi-Lancet Device OTC SINGLE-LET Lancets OTC SMART DIABETES VANTAGE LANCING Multi-Lancet Device OTC

SMART SENSE COLOR LANCETS 33G Lancets OTC SMART SENSE STANDARD LANCETS Lancets OTC SMART SENSE SUPER THIN LANCETS Lancets OTC SMART SENSE THIN LANCETS 26G Lancets OTC SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Glucose Control OTC

SMARTEST LANCETS 28G Lancets OTC SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

SOLUS V2 CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

SOLUS V2 LANCETS 28G Lancets OTC SOLUS V2 LANCING DEVICE Multi-Lancet Device OTC SOLUS V2 TWIST LANCETS 30G Lancets OTC STERILANCE PA Lancet Transporter Case OTC STERILANCE TL Lancets OTC SURE-LANCE FLAT LANCETS Lancets OTC SURE-LANCE LANCETS 26G Lancets OTC SURE-LANCE THIN LANCETS 28G Lancets OTC SURE-LANCE ULTRA THIN LANCETS Lancets OTC SURELITE LANCETS Lancets OTC SURE-PEN Multi-Lancet Device OTC SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID DiaTrue Control Level 3 OTC

SURESTEP PRO LINEARITY KIT Supreme II Confidence Paddles OTC

134

Formulary Drug Name Reference Restrictions 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 Lancets OTC TAI DOC CONTROL IN VITRO SOLUTION Easy Talk Control OTC

TECHLITE AST LANCETS Lancets OTC TECHLITE LANCETS Lancets OTC TECHLITE LANCETS 30G Lancets OTC TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

THINLETS GP LANCETS Lancets OTC

TRACER II 3 VOLT BATTERY Supreme II Confidence Paddles OTC

TRAVEL LANCETS ADVANCED 28G Lancets OTC 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 DiaTrue Control Level 3 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 Lancets OTC TRUEPLUS LANCETS 28G Lancets OTC TRUEPLUS LANCETS 30G Lancets OTC TRUEPLUS LANCETS 33G Lancets OTC TRUEPLUS SAFETY LANCETS 28G Lancets OTC ULTI-LANCE AUTOMATIC Multi-Lancet Device OTC ULTILET CLASSIC LANCETS Lancets OTC ULTILET LANCETS Lancets OTC ULTILET SAFETY LANCETS 23G Lancets OTC ULTRALANCE Lancet Transporter Case OTC ULTRA-THIN II AUTO LANCET Lancets OTC ULTRA-THIN II LANCETS Lancets OTC ULTRATRAK PRO CONTROL IN VITRO SOLUTION Glucose Control OTC

135

Formulary Drug Name Reference Restrictions ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Glucose Control OTC

UNILET COMFORTOUCH LANCET Lancets OTC UNILET EXCELITE Lancets OTC UNILET EXCELITE II Lancets OTC UNILET G.P. LANCET Lancets OTC UNILET G.P. SUPERLITE LANCET Lancets OTC UNILET GP 28 ULTRA THIN Lancets OTC UNILET LANCET Lancets OTC UNILET MICRO-THIN 33G Lancets OTC UNILET SUPERLITE LANCET Lancets OTC UNILET SUPER-THIN 30G Lancets OTC UNILET ULTRA-THIN 28G Lancets OTC UNISTIK 1 Lancet Transporter Case OTC UNISTIK 2 Lancet Transporter Case OTC 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 Lancets 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 Lancets OTC UNISTIK SAFETY LANCETS 30G Lancets OTC UNISTIK TOUCH SAFETY LANC 21G Lancets OTC UNISTIK TOUCH SAFETY LANC 23G Lancets OTC UNISTIK TOUCH SAFETY LANC 28G Lancets OTC UNISTIK TOUCH SAFETY LANC 30G Lancets OTC UNISTRIP CONTROL IN VITRO SOLUTION DiaTrue Control Level 3 OTC

UNIVERSAL 1 LANCETS THIN 26G Lancets OTC UNIVERSAL 1 LANCETS THIN 33G Lancets OTC UNIVERSAL 1 LANCETS ULTRA THIN Lancets OTC 136

Formulary Drug Name Reference Restrictions 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 Lancets OTC VIDA MIA UNILET LANCETS 30G Lancets OTC WALGREENS LANCETS Lancets OTC WALGREENS THIN LANCETS Lancets OTC WALGREENS ULTRA THIN LANCETS Lancets 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 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 Luer-Lok Syringe OTC sb insulin syringe Advocate Insulin Syringe OTC sure comfort insulin syringe Advocate Insulin Syringe OTC syringe OTC

137

Formulary Drug Name Reference Restrictions syringe luer slip BD Luer-Lok 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 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 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 Leader 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

138

Formulary Drug Name Reference Restrictions BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML Leader 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 Easy Comfort 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 Wegmans Unifine Pentips Plus ST; OTC BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML Kroger Insulin Syringe OTC; QLL (1 EA per 365 days)

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 Easy Comfort 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 SAFETY-LOK INSULIN SYRINGE Leader Insulin Syringe 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 Leader 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 Easy Comfort Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 30G X 5/16" 1 ML Ultra-Comfort 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 Elite-Thin Insulin Syringe OTC

139

Formulary Drug Name Reference Restrictions EASY TOUCH FLIPLOCK SAFETY SYR OTC EASY TOUCH FLURINGE Safety Syringe/Needle OTC EASY TOUCH FLURINGE FLIPLOCK Safety Syringe/Needle OTC EASY TOUCH FLURINGE SHEATHLOCK Safety Syringe/Needle OTC

EASY TOUCH INSULIN SAFETY SYR Elite-Thin Insulin Syringe OTC EASY TOUCH INSULIN SYRINGE Sure Comfort Insulin Syringe OTC EASY TOUCH SAFETY SYRINGE Safety Syringe/Needle OTC EASY TOUCH SHEATHLOCK SYRINGE Elite-Thin Insulin Syringe OTC 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 Leader 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 Easy Comfort Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 1 ML Ultra-Comfort 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 Leader 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 Easy Comfort Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML Ultra-Comfort Insulin Syringe

140

Formulary Drug Name Reference Restrictions 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

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) Leader 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) Easy Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML (OTC) Ultra-Comfort Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML (RX) Ultra-Comfort 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

141

Formulary Drug Name Reference Restrictions 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 Leader Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML (OTC) Sure Comfort Insulin Syringe

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) Easy Comfort Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML (RX) Easy Comfort 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 Leader 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

142

Formulary Drug Name Reference Restrictions 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 Leader Insulin Syringe OTC

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 Easy Comfort 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 Easy Comfort Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 5/16" 1 ML Ultra-Comfort 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 Easy Comfort 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 Pro Comfort Spacer Adult QLL (1 EA per 365 days)

AEROCHAMBER MV Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

143

Formulary Drug Name Reference Restrictions AEROCHAMBER PLUS FLO-VU MEDIUM Pro Comfort Spacer Adult QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLOW VU Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR Pro Comfort Spacer Adult QLL (1 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/LARGE Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS/MEDIUM Pro Comfort Spacer Adult QLL (1 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/SMALL Pro Comfort Spacer Adult QLL (1 EA per 365 days) AEROVENT PLUS DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) ARIAL CHAMBER DEVICE Pro Comfort Spacer Adult OTC; QLL (1 EA per 365 days) BREATHERITE Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE COLL SPACER ADULT Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE COLL SPACER CHILD Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE COLL SPACER INFANT Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE RIGID SPACER/MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE SPACER NEONATE Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE SPACER SMALL CHILD Pro Comfort Spacer Adult QLL (1 EA per 365 days)

BREATHERITE/LARGE MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE/MEDIUM MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) BREATHERITE/SMALL MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) CLEVER CHOICE HOLDING CHAMBER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) COMPACT SPACE CHAMBER/LG MASK DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/MED MASK DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/SM MASK DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

EASIVENT Pro Comfort Spacer Adult QLL (1 EA per 365 days) EASIVENT MASK LARGE Pro Comfort Spacer Adult QLL (1 EA per 365 days) EASIVENT MASK MEDIUM Pro Comfort Spacer Adult QLL (1 EA per 365 days) EASIVENT MASK SMALL Pro Comfort Spacer Adult QLL (1 EA per 365 days)

144

Formulary Drug Name Reference Restrictions FLEXICHAMBER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) INSPIRACHAMBER/LARGE DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) INSPIRACHAMBER/MEDIUM DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

INSPIRACHAMBER/SMALL DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) INSPIREASE Pro Comfort Spacer Adult QLL (1 EA per 365 days) LITEAIRE DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) MICROCHAMBER Pro Comfort Spacer Adult QLL (1 EA per 365 days) MICROSPACER Pro Comfort Spacer Adult QLL (1 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-MED MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-SM MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days)

OPTICHAMBER DIAMOND Pro Comfort Spacer Adult QLL (1 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

OPTICHAMBER DIAMOND-MD MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK Pro Comfort Spacer Adult QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-LARGE Pro Comfort Spacer Adult OTC; QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-MEDIUM Pro Comfort Spacer Adult OTC; QLL (1 EA per 365 days) OPTICHAMBER FACE MASK-SMALL Pro Comfort Spacer Adult OTC; QLL (1 EA per 365 days) OPTIHALER Pro Comfort Spacer Adult QLL (1 EA per 365 days) OPTIHALER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) POCKET CHAMBER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) POCKET SPACER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) RITEFLO DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days) VORTEX VALVED HOLDING CHAMBER DEVICE Pro Comfort Spacer Adult QLL (1 EA per 365 days)

WATCHHALER DEVICE Pro Comfort Spacer Adult 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)

145


sumatriptan nasal solution Imitrex QLL (6 UNITS per 30 days); AL (Min 18 Years)

sumatriptan succinate subcutaneous solution Imitrex 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)

sumatriptan succinate tablet 25 mg oral Imitrex AL (Min 18 Years)


sumatriptan succinate tablet 50 mg oral Imitrex AL (Min 18 Years)


*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium acetate intravenous solution sodium bicarbonate 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 RA Oyster Shell Calcium OTC

*Electrolytes & Dextrose*** dextrose 5%/electrolyte #48 intravenous solution dextrose in lactated ringers intravenous solution dextrose-nacl intravenous solution dextrose-sodium chloride 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

146

Formulary Drug Name Reference Restrictions ISOLYTE-P IN D5W INTRAVENOUS SOLUTION NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

*Electrolytes Parenteral*** lactated ringers intravenous solution 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 potassium phosphates(66 meq k) intravenous solution sodium phosphates intravenous solution

147

Formulary Drug Name Reference Restrictions 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 potassium chloride crys er oral tablet extended release Klor-Con M10

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/EF ORAL TABLET EFFERVESCENT Potassium Bicarbonate

*Sodium***

normal saline flush intravenous solution Monoject Flush Syringe QLL (150 SYRINGES per 30 days)

sodium chloride (pf) injection solution sodium chloride injection solution sodium chloride intravenous solution

148

Formulary Drug Name Reference Restrictions *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

*Trace Minerals*** chromic chloride intravenous solution copper chloride intravenous solution

*Zinc*** zinc chloride intravenous solution zinc sulfate 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

*Fluoride Dental Products*** sodium fluoride dental gel Cavarest

*Saliva Stimulants*** pilocarpine hcl oral tablet Salagen

149

Formulary Drug Name Reference Restrictions *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 VP-Vite Rx NEPHRO-VITE RX ORAL TABLET VP-Vite Rx

*B-Complex W/ C-Biotin-D-Zinc & Folic Acid*** VITAL-D RX ORAL TABLET

*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*** 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

150

Formulary Drug Name Reference Restrictions *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 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 POLY-VI-FLOR ORAL TABLET CHEWABLE AL (Max 12 Years)

QUFLORA PEDIATRIC TABLET CHEWABLE 0.5 MG ORAL Polyvitamin/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 Niva-Plus pnv-omega oral capsule Zatean-Pn Plus prenatal oral tablet Niva-Plus prenatal vitamin plus low iron oral tablet Niva-Plus preplus oral tablet Niva-Plus se-natal 19 oral tablet chewable thrivite 19 oral tablet trinatal rx 1 oral tablet Vinate One

151

Formulary Drug Name Reference Restrictions 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 Niva-Plus 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 PrePLUS OB COMPLETE ORAL TABLET 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

152

Formulary Drug Name Reference Restrictions *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 QLL (6 FILLS per 365 days) methocarbamol oral tablet 750 mg Robaxin-750 QLL (6 FILLS per 365 days) methocarbamol tablet 500 mg oral methocarbamol tablet 500 mg oral QLL (6 FILLS per 365 days) methocarbamol tablet 750 mg oral Robaxin-750 QLL (6 FILLS per 365 days) methocarbamol tablet 750 mg oral Robaxin-750 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) 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

153

Formulary Drug Name Reference Restrictions *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 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/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/20) 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

154

Formulary Drug Name Reference Restrictions PROCALAMINE INTRAVENOUS SOLUTION PROSOL INTRAVENOUS SOLUTION SYNTHAMIN 17 INTRAVENOUS SOLUTION Amino Acid

TRAVASOL INTRAVENOUS SOLUTION Amino Acid TROPHAMINE INTRAVENOUS SOLUTION Amino Acid

*Carbohydrates*** dextrose intravenous solution

*Lipids*** nutrilipid intravenous emulsion Intralipid 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 ST; QLL (10 ML per 30 days)

COMBIGAN OPHTHALMIC SOLUTION QLL (10 ML per 30 days)

*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 QLL (3.5 GM per 30 days) atropine sulfate ophthalmic solution Isopto Atropine QLL (5 ML per 30 days) cyclopentolate hcl ophthalmic solution Cyclogyl phenylephrine hcl ophthalmic solution Altafrin

*Ophthalmic Antiallergic*** azelastine hcl ophthalmic solution ST cromolyn sodium ophthalmic solution cvs allergy eye drops ophthalmic solution Alaway OTC

155

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 KP Ketotifen Fumarate OTC

ALAWAY OPHTHALMIC SOLUTION KP Ketotifen Fumarate OTC CLARITIN EYE OPHTHALMIC SOLUTION KP Ketotifen Fumarate OTC

PAZEO OPHTHALMIC SOLUTION ST THERATEARS ALLERGY OPHTHALMIC SOLUTION KP Ketotifen Fumarate OTC

ZADITOR OPHTHALMIC SOLUTION KP Ketotifen Fumarate OTC

*Ophthalmic Antibiotics*** ciprofloxacin hcl ophthalmic solution Ciloxan erythromycin ophthalmic ointment gentamicin sulfate ophthalmic solution levofloxacin ophthalmic solution QLL (5 ML per 30 days) moxifloxacin hcl (2x day) ophthalmic solution Moxeza 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)

*Ophthalmic Anti-Infective Combinations*** ak-poly-bac ophthalmic ointment Polycin bacitracin-polymyxin b ophthalmic ointment Polycin neomycin-bacitracin zn-polymyx ophthalmic ointment Neo-Polycin

polymyxin b-trimethoprim ophthalmic solution Polytrim POLYCIN OPHTHALMIC OINTMENT AK-Poly-Bac

156

Formulary Drug Name Reference Restrictions *Ophthalmic Antivirals*** trifluridine ophthalmic solution QLL (7.5 ML per 30 days)

*Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution Trusopt AZOPT OPHTHALMIC SUSPENSION

*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 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 prednisolone acetate ophthalmic suspension Pred Forte

157

Formulary Drug Name Reference Restrictions 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) travoprost (bak free) ophthalmic solution Travatan Z

*OPHTHALMIC KINASE INHIBITORS -COMBINATIONS*** *Ophthalmic Kinase Inhibitors -Combinations*** ROCKLATAN OPHTHALMIC SOLUTION

*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 solution 0.3 % otic ofloxacin solution 0.3 % 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*** DERMOTIC OTIC OIL Fluocinolone Acetonide

158

Formulary Drug Name Reference Restrictions *OXYTOCICS* *Oxytocics*** methylergonovine maleate oral tablet Methergine

*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

159

Formulary Drug Name Reference Restrictions amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable 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

160

Formulary Drug Name Reference Restrictions *PHARMACEUTICAL ADJUVANTS* *Gelatin Capsules (Empty)*** capsule coni-snap #1 clear capsule DRcaps Size 0

*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

161

Formulary Drug Name Reference Restrictions *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** *Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** EUCRISA EXTERNAL OINTMENT ST

*POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder 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

162

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 INGREZZA ORAL CAPSULE

*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)

163

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 - Nrf2 Pathway Activators*** TECFIDERA ORAL TECFIDERA ORAL CAPSULE DELAYED RELEASE

*Multiple Sclerosis Agents -Potassium Channel Blockers*** dalfampridine er oral tablet extended release 12 hour Ampyra

*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 tablet Namenda QLL (1 EA per 1 day); 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








*Pseudobulbar Affect Agent Combinations*** NUEDEXTA ORAL CAPSULE

164

Formulary Drug Name Reference Restrictions *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 Nicorette 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) goodsense nicotine mouth/throat gum Nicorette OTC; AL (Min 18 Years) goodsense nicotine mouth/throat lozenge KLS Quit4 OTC hm nicotine polacrilex mouth/throat gum Nicorette 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 mini mouth/throat lozenge KLS Quit2 OTC nicotine polacrilex mouth/throat gum Nicorette 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 Nicorette OTC; AL (Min 18 Years) sm nicotine mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) sm nicotine polacrilex mouth/throat gum Nicorette 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 Gum OTC

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE AL (Min 10 Years)

165

Formulary Drug Name Reference Restrictions *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)

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)

166

Formulary Drug Name Reference Restrictions *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)

*STEROIDS -MOUTH/THROAT/DENTAL*** *Steroids - Mouth/Throat/Dental*** triamcinolone acetonide mouth/throat paste Oralone

*TETRACYCLINES* *Tetracyclines*** doxycycline hyclate oral capsule 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




167



levothyroxine sodium tablet 175 mcg oral Euthyrox Maintenance drug with max 100 days supply






levothyroxine sodium tablet 300 mcg oral Synthroid Maintenance drug with max 100 days supply

levothyroxine sodium tablet 300 mcg oral Synthroid 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

168

Formulary Drug Name Reference Restrictions 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 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 suspension Carafate sucralfate oral tablet Carafate

*Proton Pump Inhibitors*** lansoprazole tablet delayed release dispersible 15 mg oral (rx) Prevacid SoluTab AL (Min 1 Years and Max 11

Years) lansoprazole tablet delayed release dispersible 30 mg oral Prevacid SoluTab AL (Min 1 Years and Max 11

Years)

lansoprazole tablet delayed release 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)

169

Formulary Drug Name Reference Restrictions 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) 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 AL (Max 11 Years)

*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)

170

Formulary Drug Name Reference Restrictions *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 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 oral tablet Maintenance drug with max 100 day 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

171

Formulary Drug Name Reference Restrictions miconazole 7 vaginal cream Monistat 7 Simply Cure OTC miconazole 7 vaginal suppository OTC 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 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 Vandazole CLEOCIN VAGINAL SUPPOSITORY CLINDESSE VAGINAL CREAM NUVESSA VAGINAL GEL PA

*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

172

Formulary Drug Name Reference Restrictions *Vitamin D*** vitamin d (ergocalciferol) oral capsule Drisdol

*Vitamin K*** phytonadione injection solution phytonadione oral tablet Mephyton QLL (5 EA per 30 days) vitamin k1 injection solution

173

Index Header 1st tier unilet comfortouch 1203 day vaginal 1718 hour arthritis pain reliever 168 hr arthritis pain relief 168hr muscle aches & pain 16abacavir sulfate 71abacavir sulfate-lamivudine 69abacavir-lamivudine-zidovudine 69ABELCET 43ABILIFY MAINTENA 67abiraterone acetate 51acamprosate calcium 163acarbose 35ACCU-CHEK AVIVA 124ACCU-CHEK COMPACT PLUS CONTROL 124ACCU-CHEK FASTCLIX LANCET 124ACCU-CHEK FASTCLIX LANCETS 124ACCU-CHEK GUIDE CONTROL 124ACCU-CHEK MULTICLIX LANCET DEV 124ACCU-CHEK MULTICLIX LANCETS 125ACCU-CHEK SAFE-T PRO LANCETS 125ACCU-CHEK SMARTVIEW CONTROL 125ACCU-CHEK SOFTCLIX LANCET DEV 125ACCU-CHEK SOFTCLIX LANCETS 125ACCUTREND GLUCOSE CONTROL 125acebutolol hcl 75acetaminophen 16acetaminophen childrens 16acetaminophen er 16acetaminophen infants 16acetaminophen-codeine 19acetaminophen-codeine #2 19acetaminophen-codeine #3 19acetaminophen-codeine #4 19acetazolamide 103acetazolamide er 103acetic acid 109, 158acetylcysteine 41, 96acitretin 98ACTHAR 105

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acti-lance 28g 120acti-lance lite lancets 28g 120acti-lance special lancets 17g 120acti-lance universal 23g 120ACTIMMUNE 54acyclovir 72, 99adapalene 97adjustable lancing device 120ADMELOG 37ADMELOG SOLOSTAR 37adult aspirin regimen 18ADVAIR HFA 25ADVANCE INTUITION CONTROL 125ADVANCE MICRO-DRAW CONTROL 125ADVANCE MICRO-DRAW NORMAL 125ADVATE 110ADVOCATE CONTROL SOLUTION 125ADVOCATE INSULIN SYRINGE 138ADVOCATE LANCETS 125ADVOCATE LANCETS 30G125ADVOCATE LANCING DEVICE 125ADVOCATE RAPID-SAFE LANCING 125ADVOCATE REDI-CODE+ CONTROL 125ADVOCATE SAFETY LANCETS 125ADVOCATE SAFETY LANCETS 26G 125adynovate 110ADZENYS XR-ODT 8AEROCHAMBER MINI CHAMBER 143AEROCHAMBER MV 143AEROCHAMBER PLUS FLO-VU 143AEROCHAMBER PLUS FLO-VU LARGE 143AEROCHAMBER PLUS FLO-VU MEDIUM 144AEROCHAMBER PLUS FLO-VU SMALL 144AEROCHAMBER PLUS FLO-VU W/MASK 144

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AEROCHAMBER PLUS FLOW VU 144AEROCHAMBER W/FLOWSIGNAL 144AEROCHAMBER Z-STAT PLUS 144AEROCHAMBER Z-STAT PLUS CHAMBR 144AEROCHAMBER Z-STAT PLUS/LARGE 144AEROCHAMBER Z-STAT PLUS/MEDIUM 144AEROCHAMBER Z-STAT PLUS/SMALL 144AEROVENT PLUS 144AFIRMELLE 82AFSTYLA 110AFTERA 87AGAMATRIX CONTROL 125AGAMATRIX ULTRA-THIN LANCETS 125ak-poly-bac 156ALA-QUIN 97ALAWAY 156ALAWAY CHILDRENS ALLERGY 156albendazole 23ALBUKED 25 112ALBUKED 5 112albumin human 112ALBUMINEX 112alburx 112ALBUTEIN 112albuterol sulfate 26albuterol sulfate hfa 26ALCOH-GLOVE CONTOURED WIPE 120alcohol pads 119alcohol prep 119alcohol swabs 119alcohol wipes 119alcoh-wipe 119alendronate sodium 105alfuzosin hcl er 109ALIMTA 52ALKERAN 55all day allergy 43all day allergy childrens 43all day allergy-d 94allergy relief 43allergy relief childrens 43

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allergy relief d-24 94allergy relief/indoor/outdoor 43allergy relief-d 94allopurinol 110alogliptin benzoate 37alogliptin-metformin hcl 37alogliptin-pioglitazone 37alosetron hcl 108ALPHANATE/VWF COMPLEX/HUMAN 110ALPHANINE SD 110alprazolam 24ALPROLIX 110ALREX 158ALTAVERA 82alternate site lancing device 120alyacen 1/35 81alyacen 7/7/7 89amantadine hcl 56AMETHIA 87AMETHIA LO 87AMICAR 117amiloride hcl 103amiloride-hydrochlorothiazide 103aminocaproic acid 116AMINOSYN II 154AMINOSYN-PF 154amiodarone hcl 25amitriptyline hcl 35amlodipine besy-benazepril hcl 45amlodipine besylate 77amlodipine besylate-valsartan 46amlodipine-olmesartan 47ammonium lactate 100AMNESTEEM 97amoxapine 35amoxicillin 159, 160amoxicillin-pot clavulanate 160amphetamine-dextroamphet er 5, 6amphetamine-dextroamphetamine 6, 7amphotericin b 42ampicillin 160ampicillin sodium 160ampicillin-sulbactam sodium 160anagrelide hcl 113anastrozole 54ANDROGEL 22ANNOVERA 86antacid 22antacid calcium 22antacid extra strength 22

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antacid ultra strength 22ANUSOL-HC 22aprepitant 42APRI 82APRISO 108APTENSIO XR 11, 12APTIOM 31APTIVUS 70aqua lance adjustable lancing 120AQUADEKS 150, 151AQUALANCE LANCETS 30G 125ARALAST NP 166ARANELLE 89ARANESP (ALBUMIN FREE) 114ARIAL CHAMBER 144aripiprazole 66, 67ARISTADA 67ARISTADA INITIO 67ARMOUR THYROID 168ARNUITY ELLIPTA 27arthritis pain relief 16ARYMO ER 20ARZERRA 52ascorbic acid 172ASHLYNA 88ASMANEX (120 METERED DOSES) 27ASMANEX (14 METERED DOSES) 27ASMANEX (30 METERED DOSES) 27ASMANEX (60 METERED DOSES) 27aspirin 18aspirin 81 18aspirin adult 18aspirin adult low strength 18aspirin ec 18aspirin ec low strength 18aspirin low dose 18aspirin-dipyridamole er 113ASPIR-LOW 19ASSURE 3 CONTROL 125ASSURE 4 CONTROL LEVEL 1 & 2 125assure comfort lancets 28g 120ASSURE DOSE CONTROL 125ASSURE DOSE NORM/HIGH CONTROL 125

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ASSURE HAEMOLANCE PLUS HIGH 125ASSURE HAEMOLANCE PLUS LOW 125ASSURE HAEMOLANCE PLUS MICRO 125ASSURE HAEMOLANCE PLUS NORMAL 125ASSURE HAEMOLANCE PLUS PED 126ASSURE ID INSULIN SAFETY SYR 138ASSURE II CONTROL 126ASSURE II CONTROL LEVEL 1 & 2 126ASSURE LANCE LANCETS 126ASSURE LANCE LANCETS 21G 126ASSURE LANCE PLUS SAFETY 25G 126ASSURE LANCE PLUS SAFETY 30G 126ASSURE LANCETS 126ASSURE PRISM CONTROL LEVEL 1 126ASSURE PRO CONTROL LEVEL 1 & 2 126atenolol 75atenolol-chlorthalidone 48ATGAM 73atomoxetine hcl 5atorvastatin calcium 45atovaquone 49ATRIPLA 69atropine sulfate 155ATROVENT HFA 27AUBAGIO 163AUBRA 82AUBRA EQ 82aurora lancet super thin 30g 120aurora lancet thin 23g 120AUROVELA 1.5/30 82AUROVELA 1/20 82AUROVELA 24 FE 82AUROVELA FE 1.5/30 82AUROVELA FE 1/20 82AUSTEDO 163AUTO-LANCET 126AUTO-LANCET MINI 126AUTOLET II CLINISAFE 126AUTOLET LANCING DEVICE 126

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AUTOLET LITE CLINISAFE 126AUTOLET LITE STARTER PACK 126AUTOLET MINI 126AUTOLET PLATFORMS 126AUTOLET PLUS 126AVIANE 82AVITA 97AVONEX PEN 163AVONEX PREFILLED 163AYUNA 82azacitidine 51azathioprine 74azelaic acid 102azelastine hcl 153, 155azithromycin 119AZOPT 157aztreonam 149AZURETTE 81bacitracin-polymyxin b 156bacitra-neomycin-polymyxin-hc157baclofen 153BACMIN 150bacteriostatic water(benz alc) 161balanced salt 157BALCOLTRA 82balsalazide disodium 108BALZIVA 82BANZEL 31BARACLUDE 72BASAGLAR KWIKPEN 38base gelatin gummy troche 161BD INSULIN SYR ULTRAFINE II 138BD INSULIN SYRINGE 138BD INSULIN SYRINGE MICROFINE 138BD INSULIN SYRINGE U/F 138BD INSULIN SYRINGE U/F 1/2UNIT 138BD INSULIN SYRINGE ULTRAFINE 138, 139BD LANCET ULTRAFINE 30G 126BD LANCET ULTRAFINE 33G 126BD LUER-LOK SYRINGE 139BD MICROTAINER LANCETS 126BD PEN NEEDLE NANO U/F 139

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BD PEN NEEDLE SHORT U/F 139BD SAFETYGLIDE INSULIN SYRINGE 139BD SAFETY-LOK INSULIN SYRINGE 139BD SWABS SINGLE USE BUTTERFLY 120BD VEO INSULIN SYRINGE U/F 139BEKYREE 81belladonna alkaloids-opium 168benazepril hcl 46benazepril-hydrochlorothiazide 45BENEFIX 110benzonatate 93benztropine mesylate 56BERINERT 112betamethasone dipropionate aug 99betamethasone sod phos & acet 93betamethasone valerate 99BETAPACE AF 76BETASERON 163bethanechol chloride 171BETHKIS 13BEVESPI AEROSPHERE 26BEYAZ 83bicalutamide 51BICILLIN C-R 160BICILLIN C-R 900/300 160BICILLIN L-A 160BIKTARVY 69bisoprolol fumarate 75bisoprolol-hydrochlorothiazide 48BIVIGAM 159bleomycin sulfate 53BLISOVI 24 FE 83BLISOVI FE 1.5/30 83BLISOVI FE 1/20 83bortezomib 53BOTOX 154BREATHERITE 144BREATHERITE COLL SPACER ADULT 144BREATHERITE COLL SPACER CHILD 144BREATHERITE COLL SPACER INFANT 144BREATHERITE RIGID SPACER/MASK 144

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BREATHERITE SPACER NEONATE 144BREATHERITE SPACER SMALL CHILD 144BREATHERITE/LARGE MASK 144BREATHERITE/MEDIUM MASK 144BREATHERITE/SMALL MASK 144briellyn 81BRILINTA 103, 112brimonidine tartrate 157BRIVIACT 31budesonide 27, 91, 153budesonide-formoterol fumarate 25bullseye mini safety lancets 120BULLSEYE SAFETY LANCETS 126bumetanide 103bupivacaine fisiopharma 118bupivacaine hcl 118bupivacaine hcl (pf) 118bupivacaine-epinephrine 118bupivacaine-epinephrine (pf) 118buprenorphine 21buprenorphine hcl 21buprenorphine hcl-naloxone hcl 21bupropion hcl 34bupropion hcl er (smoking det) 165bupropion hcl er (sr) 34bupropion hcl er (xl) 34buspirone hcl 24BUSULFEX 51butalbital-acetaminophen 17butalbital-apap-caff-cod 19butalbital-apap-caffeine 17butalbital-aspirin-caffeine 17butenafine hcl 98BYDUREON 39BYETTA 10 MCG PEN 39BYETTA 5 MCG PEN 39cabergoline 105caffeine citrate 8calcipotriene 99calcitonin (salmon) 105CALCITRATE 146calcitriol 99, 106calcium acetate 146calcium acetate (phos binder) 108calcium antacid 22calcium antacid extra strength 22

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calcium antacid ultra max st 22calcium antacid ultra strength 22calcium carbonate 146calcium carbonate antacid 22, 146calcium chloride 146calcium gluconate 146CAL-GEST ANTACID 23CAMILA 89CAMPATH 52CAMRESE 88CAMRESE LO 88capecitabine 51, 52CAPRELSA 53capsule coni-snap #1 clear 161captopril 46carbamazepine 30carbamazepine er 30CARBATROL 31carbidopa-levodopa 56carbidopa-levodopa er 56carbidopa-levodopa-entacapone 56carbinoxamine maleate 43carboplatin 51CARDIOCOM LANCING DEVICE 126careone advanced lancing dev 121careone insulin syringe 137careone lancet thin 23g 121careone lancet ultra thin 28g 121CARESENS CONTROL A 126CARETOUCH ALCOHOL PREP 120CARETOUCH LANCING/EJECTOR 126CARETOUCH TWIST LANCETS 30G 126carmustine 55carteolol hcl 155carvedilol 74CATHFLO ACTIVASE 113CAVILON EMOLLIENT 100CAVILON FOOT & DRY SKIN 100CAYA 120CAZIANT 89cefaclor 79cefadroxil 79cefazolin sodium 79cefdinir 80cefepime hcl 80cefixime 80cefotaxime sodium 80

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cefotetan disodium 79cefotetan disodium-dextrose 80cefoxitin sodium 80cefoxitin sodium-dextrose 80cefprozil 80ceftazidime 80ceftriaxone sodium 80ceftriaxone sodium in dextrose 80ceftriaxone sodium-dextrose 80cefuroxime axetil 80cefuroxime sodium 80celecoxib 15CELESTONE SOLUSPAN 93CELLCEPT INTRAVENOUS 74CELONTIN 33cephalexin 79CERDELGA 113CEREZYME 113cetirizine hcl 43cetirizine hcl allergy child 43cetirizine hcl childrens alrgy 43cetirizine hcl hives relief 43cetirizine-pseudoephedrine er 94CHANTIX 165CHANTIX CONTINUING MONTH PAK 165CHANTIX STARTING MONTH PAK 165CHATEAL 83CHATEAL EQ 83CHEMSTRIP BG LOG BOOK 126cherry concentrate 161chest congestion relief 95childrens aspirin low strength 18childrens loratadine 43childrens mucus relief expect 95childrens silapap 16chlordiazepoxide hcl 24chlordiazepoxide-amitriptyline 163chlordiazepoxide-clidinium 169chlorhexidine gluconate 149chloroquine phosphate 50chlorpromazine hcl 64chlorthalidone 104chlorzoxazone 153cholestyramine 45cholestyramine light 45chromic chloride 149ciclopirox 98ciclopirox olamine 98cilostazol 112

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CIMDUO 69CINRYZE 112CIPRODEX 158ciprofloxacin hcl 107, 156ciprofloxacin in d5w 107cisplatin 51citalopram hydrobromide 34CITRANATAL B-CALM 152CITRANATAL DHA 152CITRANATAL HARMONY 152cladribine 52CLARAVIS 97clarithromycin 119clarithromycin er 119CLARITIN EYE 156CLEANLET LANCETS 28G 126CLEARLAX 118clemastine fumarate 43CLENPIQ 117CLEOCIN 172CLEOCIN PHOSPHATE 49CLEVER CHEK LANCETS 126CLEVER CHOICE GLUCOSE CONTROL 126CLEVER CHOICE HOLDING CHAMBER 144CLIMARA PRO 107clindamycin hcl 49clindamycin palmitate hcl 49clindamycin phos-benzoyl perox 97clindamycin phosphate 49, 97CLINDESSE 172CLINIMIX E/DEXTROSE (2.75/5) 154CLINIMIX E/DEXTROSE (4.25/10) 154CLINIMIX E/DEXTROSE (4.25/5) 154CLINIMIX E/DEXTROSE (5/15) 154CLINIMIX E/DEXTROSE (5/20) 154CLINIMIX/DEXTROSE (4.25/10) 154CLINIMIX/DEXTROSE (4.25/5) 154CLINIMIX/DEXTROSE (5/15) 154CLINIMIX/DEXTROSE (5/20) 154CLINISOL SF 154clobazam 29, 30

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clobetasol prop emollient base 99clobetasol propionate 99clobetasol propionate e 99clomipramine hcl 35clonazepam 30clonidine 47clonidine hcl 47clopidogrel bisulfate 113clorazepate dipotassium 25clotrimazole 101, 149, 171clotrimazole-betamethasone 97clozapine 61, 62CLOZARIL 62c-nate dha 151COAGADEX 110COAGUCHEK LANCETS 126codeine sulfate 20cola syrup 161colchicine 110colchicine-probenecid 110colestipol hcl 45COMBIGAN 155COMBIPATCH 107COMBIVENT RESPIMAT 26COMFORT ASSIST INSULIN SYRINGE 139comfort assured lancets 28g 121comfort assured lancets 33g 121COMFORT EZ INSULIN SYRINGE 139comfort lancets 121COMPACT SPACE CHAMBER 144COMPACT SPACE CHAMBER/LG MASK 144COMPACT SPACE CHAMBER/MED MASK 144COMPACT SPACE CHAMBER/SM MASK 144COMPLERA 69complete natal dha 152completenate 151CONCEPT DHA 152CONCEPT OB 152CONTOUR CONTROL 127CONTOUR NEXT CONTROL 127control 121COOL CONTROL A 127COOL CONTROL B 127COPAXONE 164copper chloride 149

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CORIFACT 111corn (syrup) 161CORTISPORIN 97CORVITA 150COSENTYX 98COSENTYX (300 MG DOSE) 98COSENTYX SENSOREADY (300 MG) 98COSENTYX SENSOREADY PEN 98cough/chest congestion dm 93COUMADIN 28CREON 102CRIXIVAN 71cromolyn sodium 26, 107, 155CRYSELLE-28 83CURITY ALCOHOL PREPS120CURITY ALCOHOL SWABS 120CUVITRU 159CUVPOSA 170cvs alcohol prep pads 119cvs allergy eye drops 155cvs distilled water 161cvs eye itch relief 156cvs fluticasone propionate 153cvs lancets 21g 121cvs lancets micro thin 33g 121cvs lancets original 121cvs lancets thin 26g 121cvs lancets ultra thin 30g 121cvs lancets ultra-thin 30g 121cvs lancing device 121cvs prep 119cvs ultra thin lancets 121cyanocobalamin 113CYCLAFEM 1/35 83CYCLAFEM 7/7/7 89cyclobenzaprine hcl 153cyclopentolate hcl 155cyclophosphamide 55cyclosporine 73cyclosporine modified 73cyproheptadine hcl 44CYRED 83CYRED EQ 83CYSTADANE 106CYSTAGON 109CYSTARAN 158cytarabine 52cytarabine (pf) 52CYTOGAM 159

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dacarbazine 53dalfampridine er 164danazol 21dapsone 49DASETTA 1/35 83DASETTA 7/7/7 89daunorubicin hcl 53DAYSEE 88DAYTRANA 12DEBLITANE 89decitabine 52deferoxamine mesylate 41DELFLEX-SM/1.5% DEXTROSE 74, 160DELSTRIGO 69DENAVIR 99DEPAKOTE 33DEPAKOTE ER 33DEPAKOTE SPRINKLES 33DEPO-PROVERA 88, 89DEPO-SUBQ PROVERA 104 89DERMA-SMOOTHE/FS BODY 100DERMOTIC 158DESCOVY 69desipramine hcl 35desmopressin acetate 106, 107desmopressin acetate spray 107desogestrel-ethinyl estradiol 81desvenlafaxine succinate er 35dexamethasone 91DEXAMETHASONE INTENSOL 93dexamethasone sod phosphate pf 91dexamethasone sodium phosphate 91, 157dexmethylphenidate hcl 9dexmethylphenidate hcl er 8, 9dexrazoxane hcl 54dextroamphetamine sulfate 8dextroamphetamine sulfate er 7, 8dextromethorphan-guaifenesin 93dextrose 155dextrose 5%/electrolyte #48 146dextrose in lactated ringers 146dextrose-nacl 146dextrose-sodium chloride 146dialysis safety syringe/needle 137DIALYVITE 150DIALYVITE 3000 150DIALYVITE 5000 150

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DIALYVITE SUPREME D 150DIALYVITE/ZINC 150diatrue control level 1 121diatrue control level 2 121diatrue control level 3 121diazepam 25, 30diclofenac sodium 15, 98, 157dicloxacillin sodium 160dicyclomine hcl 169didanosine 71DIFFERIN 97DIFICID 119digoxin 78DILANTIN 33diltiazem hcl 78diltiazem hcl er 77diltiazem hcl er beads 77diltiazem hcl er coated beads 77diphenhydramine hcl 43diphenoxylate-atropine 41dipyridamole 113disulfiram 163DIURIL 104divalproex sodium 33divalproex sodium er 33dm-guaifenesin er 93dobutamine hcl 172dobutamine in d5w 172docetaxel 55donepezil hcl 163dorzolamide hcl 157dorzolamide hcl-timolol mal 155DOVATO 69doxazosin mesylate 47doxepin hcl 35, 98doxercalciferol 106doxorubicin hcl 53doxorubicin hcl liposomal 53doxycycline hyclate 167doxycycline monohydrate 167doxylamine-pyridoxine 42droperidol 24DROPLET LANCETS ULTRA THIN 30G 127DROPLET LANCING DEVICE 127drospiren-eth estrad-levomefol 81drospirenone-ethinyl estradiol 82drug mart lancets thin 26g 121DRUG MART LANCING DEVICE 127

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DRUG MART ON-THE-GO LANCET 30G 127DRUG MART UNILET LANCETS 28G 127DRUG MART UNILET LANCETS 30G 127DULERA 26duloxetine hcl 35DUO-CARE CONTROL SOLUTION 127DUREZOL 158dutasteride 109E.E.S. GRANULES 119EASIVENT 144EASIVENT MASK LARGE 144EASIVENT MASK MEDIUM

144EASIVENT MASK SMALL 144easy comfort insulin syringe 137easy comfort lancets 121easy mini eject lancing device 121easy mini lancing device 121easy plus ii control 121EASY STEP CONTROL 127easy talk control 121EASY TOUCH ALCOHOL PREP MEDIUM 120EASY TOUCH CONTROL HIGH & LOW 127EASY TOUCH FLIPLOCK INSULIN SY 139EASY TOUCH FLIPLOCK SAFETY SYR 140EASY TOUCH FLURINGE 140EASY TOUCH FLURINGE FLIPLOCK 140EASY TOUCH FLURINGE SHEATHLOCK 140EASY TOUCH INSULIN SAFETY SYR 140EASY TOUCH INSULIN SYRINGE 140EASY TOUCH LANCETS 21G 127EASY TOUCH LANCETS 23G 127EASY TOUCH LANCETS 26G 127EASY TOUCH LANCETS 28G 127EASY TOUCH LANCETS 28G/TWIST 127

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EASY TOUCH LANCETS 30G 127EASY TOUCH LANCETS 32G 127EASY TOUCH LANCETS 32G/TWIST 127EASY TOUCH LANCING DEVICE 127EASY TOUCH SAFETY LANCETS 21G 127EASY TOUCH SAFETY LANCETS 23G 127EASY TOUCH SAFETY LANCETS 26G 127EASY TOUCH SAFETY LANCETS 28G 127EASY TOUCH SAFETY SYRINGE 140EASY TOUCH SHEATHLOCK SYRINGE 140EASY TOUCH TB SHEATHLOCK SYR 140easy trak control 121EASY TWIST & CAP LANCETS 127EASYGLUCO CONTROL 127EASYGLUCO PLUS LEVEL 1 127EASYMAX 15 LEVEL 1 CONTROL 127EASYMAX 15 LEVEL 1-2 CONTROL 128EASYMAX 15 LEVEL 2 CONTROL 128EASYMAX CONTROL 128EASYMAX CONTROL NORMAL/LOW 128ec-naproxen 15econazole nitrate 101ECONTRA EZ 87ECONTRA ONE-STEP 87ECPIRIN 19ed-apap 16EDURANT 71EFFER-K 148ELELYSO 113element compact control 2 121element compact control 3 121ELEMENT CONTROL 128ELIGARD 54ELINEST 83ELIQUIS 28

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180

ELIQUIS DVT/PE STARTER PACK 28ELITE-OB 152elite-thin insulin syringe 137ELIXOPHYLLIN 28ELLA 87ELOCTATE 111ELURYNG 86EMBRACE CONTROL 128EMBRACE EVO CONTROL LEVEL 1 128EMBRACE EVO CONTROL LEVEL 2 128EMBRACE GLUCOSE CONTROL 128EMBRACE LANCETS ULTRA THIN 30G 128EMBRACE PRO GLUCOSE CONTROL 128EMGALITY 77EMGALITY (300 MG DOSE) 76EMOQUETTE 83EMTRIVA 72enalapril maleate 46enalapril-hydrochlorothiazide 45ENBREL 15, 16ENBREL MINI 15ENBREL SURECLICK 16ENEMEEZ MINI 118ENEMEEZ PLUS 118enoxaparin sodium 29ENPRESSE-28 89ENSKYCE 83entecavir 72ENTRESTO 153epinephrine 172epirubicin hcl 53EPITOL 31EPIVIR 72EPIVIR HBV 72eplerenone 48EPOGEN 114epoprostenol sodium 79eq allergy relief 44eql alcohol swabs 119eql color lancets 21g 121eql color lancets micro 33g 121eql insulin syringe 137eql super thin lancets 30g 121eql thin lancets 26g 121EQUETRO 57ERAXIS 42

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ERRIN 89erythromycin 156erythromycin ethylsuccinate 119escitalopram oxalate 34ESPEROCT 111est estrogens-methyltest ds 107est estrogens-methyltest hs 107ESTARYLLA 83estradiol 107, 172estradiol valerate 107estradiol-norethindrone acet 107ESTRING 172ESTROSTEP FE 89ethambutol hcl 50ethosuximide 33ethynodiol diac-eth estradiol 82etonogestrel-ethinyl estradiol 86etoposide 55EUCRISA 162EUTHYROX 168EVENCARE CONTROL LOW/HIGH 128EVENCARE G2 LOW/HIGH CONTROL 128EVENCARE G3 LOW/HIGH CONTROL 128EVENCARE MINI CONTROL 128EVOLUTION CONTROL 128EVOTAZ 69EXEL COMFORT POINT INSULIN SYR 140exemestane 54extra action cough 93eye itch relief 156E-Z JECT LANCET MICRO-THIN 33G 128E-Z JECT LANCET SUPER THIN 30G 128E-Z JECT LANCETS 128E-Z JECT LANCETS 21G 128E-Z JECT LANCETS THIN 26G 128EZ SMART BLOOD GLUCOSE LANCETS 128EZALLOR SPRINKLE 45ezetimibe 45EZ-LETS LANCETS 21G 128EZ-LETS LANCETS 26G 128EZ-LETS LANCETS 28G 128EZ-LETS LANCETS 30G 128FABRAZYME 105

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FALMINA 83famotidine 169famotidine premixed 169FANAPT 59FARXIGA 39FAYOSIM 88FEIBA 111felbamate 32FELBATOL 32felodipine er 78FEMHRT LOW DOSE 107FEMYNOR 83fenofibrate 45fentanyl 20FEOSOL 116FEOSOL NATURAL RELEASE 116FERATE 116FER-IN-SOL 116FEROSUL 116ferraplus 90 116FERRIMIN 150 116ferrous fumarate 116ferrous gluconate 116ferrous sulfate 116ferrousul 116FIFTY50 ALCOHOL PREP 120FIFTY50 SAFETY SEAL LANCETS 129FIFTY50 SUPERIOR COMFORT SYR 140FIFTY50 UNILET LANCETS 33G 129finasteride 109FINE 30 129FINGERSTIX LANCETS 129FIRAZYR 112FIRVANQ 110FLAREX 158FLAVOR BLEND 161flavor plus 161flavor sweet 161FLEBOGAMMA DIF 159flecainide acetate 25FLEXBUMIN 112FLEXICHAMBER 145FLONASE SENSIMIST 153FLOVENT DISKUS 27FLOVENT HFA 27, 28floxuridine 52fluconazole 43fluconazole in sodium chloride 43

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181

fludarabine phosphate 52fludrocortisone acetate 93fluocinolone acetonide body 99fluocinolone acetonide scalp 99fluocinonide 99fluorouracil 52, 98fluoxetine hcl 34fluphenazine decanoate 64fluphenazine hcl 64, 65flutamide 51fluticasone propionate 100, 153fluticasone-salmeterol 25fluvoxamine maleate 34FML 158FML FORTE 158folic acid 115FOLIVANE-F 116FOLIVANE-OB 152FOLTRATE 113FORA CONTROL 129FORA LANCETS 129FORA LANCING DEVICE 129FORACARE GDH CONTROL 129FORTISCARE CONTROL 129fosinopril sodium 46fosinopril sodium-hctz 45FREAMINE HBC 154FREAMINE III 154freds pharmacy autolet lancing 121freds pharmacy unilet lanc 28g 121freds pharmacy unilet lanc 30g 121FREESTYLE CONTROL SOLUTION 129FREESTYLE LANCETS 129FREESTYLE PRECISION INS SYR 140FREESTYLE UNISTICK II LANCETS 129FULPHILA 115furosemide 103FUSION PLUS 116FUZEON 70FYCOMPA 29gabapentin 30GABITRIL 32GAMASTAN S/D 159GAMMAGARD 159GAMMAGARD S/D LESS IGA 159GAMMAKED 159GAMMAPLEX 159

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GAMUNEX-C 159ganciclovir sodium 72ge100 control 121gemcitabine hcl 52gemfibrozil 45GENERESS FE 83GENOTROPIN 105GENOTROPIN MINIQUICK

105gentamicin in saline 12gentamicin sulfate 12, 97, 156GENTLE-LET GP LANCETS 129GENTLE-LET LANCETS 129GENTLE-LET PLATFORMS

129GENVOYA 70GIANVI 83GILENYA 165GLASSIA 166glimepiride 40glipizide 40glipizide er 40glipizide xl 40glipizide-metformin hcl 39global alcohol prep ease 119global easy glide insulin syr 137global inject ease insulin syr 137global inject ease lancets 28g 121global inject ease lancets 30g 121global insulin syringes 137global lancing device 121GLUCAGEN DIAGNOSTIC 102GLUCAGEN HYPOKIT 36GLUCAGON EMERGENCY 36glucagon hcl (diagnostic) 102GLUCOCARD 01 CONTROL 129GLUCOCARD EXPRESSION CONTROL 129GLUCOCARD SHINE CONTROL 129GLUCOCARD X-SENSOR CONTROL 129GLUCOCOM AUTOLINK TELEMONITOR 129GLUCOCOM CONTROL 129GLUCOCOM LANCETS 28G 129GLUCOCOM LANCETS 30G 129

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GLUCOCOM LANCETS 33G 129GLUCOPRO INSULIN SYRINGE 140glucose control 122glyburide 40, 41glyburide micronized 40glyburide-metformin 39glycerin 81glycopyrrolate 170GLYRX-PF 170GLYXAMBI 167gnp 8 hour pain reliever 16gnp adult aspirin low strength 18gnp alcohol swabs 119gnp all day allergy 44gnp all day allergy childrens 44gnp all day allergy-d 94gnp allergy & congestion 94gnp allergy relief 44gnp allergy/congestion relief 94gnp antacid extra strength 22gnp arthritis pain relief 16gnp aspirin 18gnp aspirin low dose 18gnp calcium 146gnp clotrimazole 3 171GNP EASY TOUCH CONT HIGH/LOW 129gnp eye itch relief 156gnp infants pain relief 16gnp infants pain/fever 16gnp insulin syringe 137gnp iron 116gnp itchy eye 156gnp lancets 122gnp lancets 21g 122gnp lancets micro thin 33g 122gnp lancets super thin 30g 122gnp lancets thin 122gnp lancets thin 26g 122gnp lidocaine pain relief 101gnp loratadine 44gnp loratadine childrens 44gnp miconazole 7 171gnp micro thin lancets 33g 122gnp mucus dm max strength 93gnp mucus er 95gnp mucus relief 95gnp nicotine 165gnp nicotine mini 165gnp nicotine polacrilex 165

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gnp pain & fever childrens 16gnp super thin lancets 30g 122gnp tab tussin 95gnp tussin mucus & chest cong 95gnp ultra com insulin syringe 137GOCOVRI 56GOLYTELY 117goodsense all day allergy 44goodsense arthritis pain 16goodsense aspirin 18goodsense lancets 30g 122goodsense lancets 33g 122goodsense lancing device 122goodsense nicotine 165goodsense pain & fever child 16goodsense pain & fever infants 16goodsense pain relief 16granisetron hcl 42GRANIX 115griseofulvin microsize 42, 43griseofulvin ultramicrosize 43guaifenesin 95guaifenesin-dm 93guanfacine hcl 47guanfacine hcl er 5guanidine hcl 50GYNAZOLE-1 172HAEMOLANCE 129HAEMOLANCE LOW FLOW LANCETS 129HAEMOLANCE PLUS 129HAEMOLANCE PLUS HIGH FLOW 129HAEMOLANCE PLUS LOW FLOW 130HAEMOLANCE PLUS MAX FLOW 130HAEMOLANCE PLUS PEDIATRIC FLOW 130HAILEY 1.5/30 83HAILEY 24 FE 83HALAVEN 55halobetasol propionate 100haloperidol 60, 61haloperidol decanoate 59, 60haloperidol lactate 60HEALTH CARE LANCING DEVICE 130healthy accents lancing device 122healthy accents unilet lancets 122HEATHER 89h-e-b incontrol adv lancing 122

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h-e-b incontrol alcohol 119h-e-b incontrol lancets 28g 122h-e-b incontrol lancets 30g 122h-e-b incontrol lancets 33g 122HEMATOGEN FA 116HEMLIBRA 43HEMOCYTE 116HEMOCYTE PLUS 116HEMOCYTE-F 116HEMOFIL M 111heparin lock flush 29heparin sodium (porcine) 29heparin sodium (porcine) pf 29heparin sodium lock flush 29HEPATAMINE 154HIZENTRA 159hm acetaminophen childrens 16hm all day allergy 44hm all day allergy childrens 44hm allergy & congestion 94hm allergy complete-d 94hm allergy relief/nasal decong 94hm arthritis pain relief 16hm aspirin 18hm aspirin ec 18hm aspirin ec low dose 18hm calcium antacid 22hm calcium antacid ex st 22hm calcium antacid ultra st 22hm cetirizine hcl childrens 44hm chest congestion relief 95hm eye itch relief 156hm loratadine 44hm loratadine childrens 44hm nicotine 165hm nicotine polacrilex 165hm pain & fever childrens 16hm pain & fever infants 17hm tussin adult 95hm tussin adult dm 93HUMALOG 38HUMALOG MIX 50/50 38HUMALOG MIX 50/50 KWIKPEN 38HUMALOG MIX 75/25 38HUMALOG MIX 75/25 KWIKPEN 38HUMATE-P 111HUMIRA 13, 14, 15HUMIRA PEDIATRIC CROHNS START 13, 14HUMIRA PEN 13, 14

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HUMIRA PEN-CD/UC/HS STARTER 13, 14HUMIRA PEN-PS/UV/ADOL HS START 13, 14HUMULIN 70/30 38HUMULIN N 38HUMULIN R 38hydralazine hcl 48hydrochlorothiazide 104hydrocodone-acetaminophen 19, 20hydrocodone-homatropine 93hydrocodone-ibuprofen 20hydrocortisone 22, 91, 100hydromorphone hcl 20hydroxychloroquine sulfate 50hydroxyprogesterone caproate

81, 162hydroxyurea 53hydroxyzine hcl 24hydroxyzine pamoate 24hyoscyamine sulfate 169hyoscyamine sulfate er 169HYPERHEP B S/D 159HYPERLYTE-CR 147HYPERRHO S/D 159HYPOLANCE AST LANCING 130HYQVIA 159HYSINGLA ER 20HY-VEE LANCETS 130hy-vee thin lancets 122IBU 15ibuprofen 15idarubicin hcl 53IDELVION 111IFEREX 150 FORTE 116ifosfamide 55ILEVRO 157imatinib mesylate 53imipenem-cilastatin 49imipramine hcl 35imiquimod 101IN TOUCH 130IN TOUCH GLUCOSE CONTROL 130IN TOUCH LANCING DEVICE 130IN TOUCH STERILE LANCETS 30G 130INCASSIA 89indapamide 104indomethacin 15

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183

INFINITY CONTROL 130INFUVITE ADULT 150INFUVITE PEDIATRIC 151INGREZZA 163INSPIRACHAMBER/LARGE 145INSPIRACHAMBER/MEDIUM 145INSPIRACHAMBER/MOUTHPIECE 145INSPIRACHAMBER/SMALL 145INSPIREASE 145insulin syringe 137insulin syringe/needle 137INTEGRA F 116INTEGRA PLUS 116INTELENCE 71INTRALIPID 155INTRON A 54INTROVALE 88INVEGA SUSTENNA 59INVEGA TRINZA 59INVIRASE 71INVOKAMET 167INVOKANA 39IONOSOL-MB IN D5W 146ipratropium bromide 27ipratropium-albuterol 25irbesartan 47IRESSA 53irinotecan hcl 55ISENTRESS 70ISENTRESS HD 70ISIBLOOM 83ISOLYTE-P IN D5W 147ISOLYTE-S 147ISOLYTE-S PH 7.4 147isoniazid 50isosorbide dinitrate 23isosorbide mononitrate 24isosorbide mononitrate er 24isotretinoin 97ivermectin 23IXINITY 111JANTOVEN 28JANUMET 37JANUMET XR 37JANUVIA 37JARDIANCE 39JASMIEL 83JENCYCLA 89

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JENTADUETO 37JIVI 111JOLESSA 88JULEBER 83JULUCA 70JUNEL 1.5/30 83JUNEL 1/20 84JUNEL FE 1.5/30 84JUNEL FE 1/20 84JUNEL FE 24 84KABIVEN 162KAITLIB FE 84KALETRA 70KALLIGA 84KARIVA 81kcl in dextrose-nacl 146kcl-lactated ringers-d5w 146KELNOR 1/35 84KELNOR 1/50 84KEPPRA 31KEPPRA XR 31ketoconazole 101ketone test 102ketorolac tromethamine 15, 157KETOSTIX 102ketotifen fumarate 156kinney lancets 122kinney thin lancets 122kinray insulin syringe 137KLONOPIN 30KLOR-CON 148KLOR-CON 10 148KLOR-CON M10 148KLOR-CON M15 148KLOR-CON M20 148KLOR-CON/EF 148kmart valu insulin syringe 29g 137kmart valu insulin syringe 30g 137KOATE 111KOATE-DVI 111KOGENATE FS 111KOMBIGLYZE XR 37KOVALTRY 111kp ketotifen fumarate 156K-PHOS 148K-PHOS NO 2 109K-PHOS-NEUTRAL 148KROGER HEALTHPRO CONTROL HI/LO 130KROGER HEALTHPRO LANCET 26G 130

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KROGER HEALTHPROLANCET 30G 130KROGER HEALTHPROLANCET 33G 130kroger insulin syringe 137kroger lancets 122kroger lancets 21g 122kroger lancets micro thin 33g 122kroger lancets super thin 122kroger lancets thin 122kroger lancets thin 26g 122kroger lancets ultrathin 30g 122kroger lancing device 122KURVELO 84labetalol hcl 74, 75lactated ringers 74, 147lactic acid e 100lactose monohydrate 161lactulose 117lactulose encephalopathy 108LAMICTAL 31LAMICTAL ODT 31LAMICTAL STARTER 31LAMICTAL XR 31lamivudine 71, 72lamivudine-zidovudine 69lamotrigine 30lamotrigine er 30lamotrigine starter kit-blue 30lamotrigine starter kit-green 30lamotrigine starter kit-orange 30lancet device 122lancet device with ejector 122lancet transporter case 122lancets 122lancets 28g 122lancets 30g 122lancets micro thin 33g 122lancets super thin 28g 122lancets thin 122LANCETS ULTRA FINE 130LANCETS ULTRA THIN 130lancets ultra thin 30g 123lancing device 123lansoprazole 169LANTUS 38LANTUS SOLOSTAR 38LANZO 130LARIN 1.5/30 84LARIN 1/20 84LARIN 24 FE 84LARIN FE 1.5/30 84

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184

LARIN FE 1/20 84LARISSIA 84latanoprost 158LATUDA 57, 58LAYOLIS FE 84leader advanced lancing device123leader insulin syringe 137LEENA 90leflunomide 15LESSINA 84LETAIRIS 79letrozole 54leucovorin calcium 54LEUKERAN 55LEUKINE 115leuprolide acetate 54LEVEMIR 38LEVEMIR FLEXTOUCH 38levetiracetam 30levetiracetam er 30levobunolol hcl 155levocarnitine 105levocetirizine dihydrochloride 44levofloxacin 107, 156levofloxacin in d5w 107LEVONEST 90levonorgest-eth est & eth est 87levonorgest-eth estrad 91-day 87levonorgestrel 86levonorgestrel-ethinyl estrad 82, 86levonorg-eth estrad triphasic 89LEVORA 0.15/30 (28) 84levothyroxine sodium 167, 168LEVOXYL 168LEXIVA 71LIBERTY GLUCOSE CONTROL 130LIBERTY GLUCOSE CONTROL MID 130LIBERTY MEDICAL LANCETS 130LIBERTY MINI LANCINGDEVICE 130lidocaine 101lidocaine hcl 101, 118lidocaine hcl (pf) 118lidocaine hcl urethral/mucosal 101lidocaine in dextrose 118lidocaine viscous hcl 149lidocaine-epinephrine 118lidocaine-hydrocortisone ace 22lidocaine-prilocaine 102

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LIFESCAN UNISTIK 2 130LIFESCAN UNISTIK II LANCETS 130LILETTA (52 MG) 89LILLOW 84lincomycin hcl 49linezolid 49LINZESS 108liothyronine sodium 168lisinopril 46lisinopril-hydrochlorothiazide

45, 46lite touch lancets 123LITE TOUCH LANCING PEN 130LITEAIRE 145LITETOUCH INSULIN SYRINGE 140LITETOUCH LANCETS 130lithium 57lithium carbonate 57lithium carbonate er 57live better adv lancing device 123live better lancet super thin 123live better lancet ultra thin 123LO LOESTRIN FE 81LOESTRIN 1.5/30 (21) 84LOESTRIN 1/20 (21) 84longs insulin syringe 137longs lancets standard 123longs lancets thin 123longs lancets ultra thin 123loperamide hcl 41loratadine 44loratadine childrens 44loratadine-d 12hr 94loratadine-d 24hr 95lorazepam 25LORAZEPAM INTENSOL 25LORYNA 84losartan potassium 47losartan potassium-hctz 47LOSEASONIQUE 88loteprednol etabonate 157LOTRONEX 108lovastatin 45LOW-OGESTREL 85loxapine succinate 64lozibase 161LO-ZUMANDIMINE 85LUPANETA PACK 118

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LUPRON DEPOT (1-MONTH) 54LUPRON DEPOT (3-MONTH) 54LUPRON DEPOT (4-MONTH) 54LUPRON DEPOT (6-MONTH) 54LUPRON DEPOT-PED (1-MONTH) 106LUPRON DEPOT-PED (3-MONTH) 106LUTERA 85LYZA 89M.V.I. ADULT 150M.V.I. PEDIATRIC 151MAGELLAN INSULIN SAFETY SYR 140magnesium chloride 147magnesium sulfate 147MAKENA 162malathion 102manganese chloride 147mapap arthritis pain 17MAPAP CHILDRENS 17marlissa 82MATULANE 54MAVYRET 117MAXI-COMFORT INSULINSYRINGE 141MAXIDEX 158meclizine hcl 42medic insulin syringe 137medichoice safety lancet 123medichoice safety lancet extra 123medichoice safety lancet norm 123MEDISENSE GLUCOSE KETONE CONTR 130MEDISENSE HI/MID/LOWCONTROL 130MEDISENSE HIGH/LOW CONTROL 130MEDISENSE MID CONTROL 131MEDISENSE THIN LANCETS 131MEDLANCE EXTRA 21G 131MEDLANCE LITE 25G 131MEDLANCE PLUS EXTRA21G 131MEDLANCE PLUSLANCETS 131

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185

MEDLANCE PLUS LITE25G 131MEDLANCE PLUS SPECIAL 0.8MM 131MEDLANCE PLUS SUPERLITE 30G 131MEDLANCE PLUS UNIVERSAL 21G 131MEDLANCE UNIVERSAL 21G 131medroxyprogesterone acetate

88, 162mefloquine hcl 50megestrol acetate 55, 162meijer alcohol swabs 119MEIJER LANCETS 131MEIJER LANCETS THIN 131MEIJER LANCETS UNIVERSAL 21G 131MEIJER LANCETS UNIVERSAL 30G 131MEIJER LANCETS UNIVERSAL 33G 131MEIJER SUPER THIN LANCETS 131meloxicam 15melphalan hcl 55memantine hcl 164MEPSEVII 150mercaptopurine 52meropenem 49meropenem-sodium chloride 49mesalamine 108mesalamine er 108mesna 55MESTINON 50metformin hcl 36metformin hcl er 36methazolamide 103methenamine hippurate 170methenamine mandelate 170methimazole 167methocarbamol 153methotrexate 52methotrexate sodium 52methotrexate sodium (pf) 52methyldopa 47methylergonovine maleate 159methylphenidate hcl 10, 11methylphenidate hcl er 10methylphenidate hcl er (cd) 9, 10methylphenidate hcl er (la) 10

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methylprednisolone 91methylprednisolone acetate 91methylprednisolone sodium succ 91metoclopramide hcl 108metolazone 104metoprolol succinate er 75metoprolol tartrate 75metronidazole 49, 102, 172metronidazole in nacl 48mexiletine hcl 25MIBELAS 24 FE 85miconazole 1 171miconazole 3 171miconazole 7 172miconazole nitrate 101, 172MICROCHAMBER 145MICRODOT CONTROL HIGH/LOW 131MICROGESTIN FE 1.5/30 85MICROLET LANCETS 131MICROLET NEXT LANCING DEVICE 131MICROSPACER 145midodrine hcl 172miglitol 35miglustat 113MILI 85milrinone lactate 79milrinone lactate in dextrose 79MINASTRIN 24 FE 85mineral oil-hydrophil petrolat 100mini lancing device 123minocycline hcl 167minoxidil 48MIRCETTE 81mirtazapine 33, 34misoprostol 170mitomycin 53mitoxantrone hcl 53m-natal plus 151modafinil 11mometasone furoate 100, 153MONOJECT INSULIN SYRINGE 141MONOJECT LIFESHIELD SYRINGE 141MONOJECT MAGELLAN SYRINGE 141MONOJECT SYRINGE 141MONOJECT ULTRA COMFORT SYRINGE 141, 142MONOLET LANCETS 131

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MONOLET OPD LANCETS 131MONOLETTOR SAFETY LANCETS 131MONO-LINYAH 85MONONINE 111montelukast sodium 27MORPHABOND ER 20morphine sulfate 20morphine sulfate (concentrate) 20morphine sulfate er 20mouth wash-gp 161MOVANTIK 108moxifloxacin hcl 156moxifloxacin hcl (2x day) 156MOZOBIL 113m-pap 17ms insulin syringe 137MUCINEX 96MUCINEX DM 94MUCINEX FOR KIDS 96MUCINEX MAXIMUM STRENGTH 96mucosa 95mucus & chest congestion 95mucus & cough relief childrens 93mucus relief 95mucus relief chest congestion 95mucus relief dm 94mucus relief dm cough 93mucus relief dm max 93mucus relief er 95mucus relief max st 95mucus-dm maximum strength 94mucusrelief dm cough 94multi-lancet device 123MULTI-LANCET DEVICE 2131MULTITRACE-4 149multitrace-4 concentrate 149MULTITRACE-4 NEONATAL 149MULTITRACE-4 PEDIATRIC 149MULTITRACE-5 149multitrace-5 concentrate 149multivitamin/fluoride 151mupirocin 97MUTAMYCIN 53MY CHOICE 87MY WAY 87mycophenolate mofetil 73, 74mycophenolate mofetil hcl 73

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186

MYGLUCOHEALTH CONTROL 131MYGLUCOHEALTH LANCETS 30G 131MYLERAN 51MYORISAN 97MYSOLINE 31NABI-HB 159nabumetone 15nadolol 75NAGLAZYME 106naloxone hcl 41, 42naltrexone hcl 42naproxen 15naproxen dr 15NARCAN 42NATAZIA 88nateglinide 39NEBUPENT 49NECON 0.5/35 (28) 85neomycin sulfate 12neomycin-bacitracin zn-polymyx 156neomycin-polymyxin b gu 109neomycin-polymyxin-dexameth 157neomycin-polymyxin-hc 158NEPHPLEX RX 150NEPHRAMINE 154NEPHRO-VITE RX 150NEULASTA 115NEULASTA ONPRO 115NEUPOGEN 115NEURONTIN 31NEUTEK 2TEK CONTROL 131nevirapine 71nevirapine er 71NEW DAY 87NEXIUM 170NEXPLANON 88niacin er (antihyperlipidemic) 45NICORETTE 165nicotine 165nicotine mini 165nicotine polacrilex 165nicotine step 1 165nicotine step 2 165nicotine step 3 165nifedipine 78nifedipine er 78nifedipine er osmotic release 78NIKKI 85nimodipine 78

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nitrofurantoin 170nitrofurantoin macrocrystal 170nitrofurantoin monohyd macro 170nitroglycerin 24NIVA-PLUS 152NIVESTYM 115non-aspirin childrens 17NORA-BE 89NORDITROPIN FLEXPRO 105norethin ace-eth estrad-fe 82norethindrone 89norethindrone acetate 162norethindrone acet-ethinyl est 82norethindrone-eth estradiol 107norethin-eth estradiol-fe 82norgestimate-eth estradiol 82norgestim-eth estrad triphasic 89NORLYDA 89normal saline flush 148NORMOSOL-M IN D5W 147NORMOSOL-R 147NORMOSOL-R IN D5W 147NORMOSOL-R PH 7.4 147NORTREL 0.5/35 (28) 85NORTREL 1/35 (21) 85NORTREL 1/35 (28) 85NORTREL 7/7/7 90nortriptyline hcl 35NORVIR 71NOVA MAX PLUS GLU/KET CONTROL 131NOVA SAFETY LANCETS 23G 131NOVA SAFETY LANCETS 28G 131NOVA SUREFLEX LANCETS 131NOVA SUREFLEX LANCING DEVICE 131NOVOEIGHT 111NOVOLIN N 38NOVOLIN N RELION 38NOVOLIN R 38NOVOLIN R RELION 38NOVOLOG 39NOVOLOG FLEXPEN 39NOVOLOG MIX 70/30 39NOVOLOG MIX 70/30 FLEXPEN 39NOVOLOG PENFILL 39NOVOSEVEN RT 111np thyroid 168

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NUEDEXTA 164nutrilipid 155NUVARING 86NUVESSA 172NUWIQ 111nystatin 43, 98, 149nystatin-triamcinolone 97OB COMPLETE 152obizur 110OCELLA 85OCTAGAM 159octreotide acetate 106ODEFSEY 70OFEV 166ofloxacin 156, 158OGESTREL 85olanzapine 67, 68olmesartan medoxomil 47olmesartan medoxomil-hctz 47olopatadine hcl 156omeprazole 169ON CALL EXPRESS GLUCOSE CONTR 131ON CALL LANCETS 131ON CALL LANCING DEVICE 132ON CALL PLUS GLUCOSE CONTROL 132ON CALL PLUS LANCETS 132ON CALL PLUS LANCING DEVICE 132ON CALL VIVID GLUCOSE CONTROL 132ONCASPAR 53ondansetron 42ondansetron hcl 42ONETOUCH CLUB LANCETS FINE PT 132ONETOUCH DELICA LANCETS 30G 132ONETOUCH DELICA LANCETS 33G 132ONETOUCH DELICA LANCING DEV 132ONETOUCH FINEPOINT LANCETS 132ONETOUCH SURESOFT LANCING DEV 132ONETOUCH ULTRA 2 132ONETOUCH ULTRA BLUE 102ONETOUCH ULTRA CONTROL 132

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ONETOUCH ULTRA MINI 132ONETOUCH ULTRALINK 132ONETOUCH ULTRASOFT LANCETS 132ONETOUCH VERIO 102, 132ONETOUCH VERIO IQ SYSTEM 132ONETOUCH VERIO SYNC SYSTEM 132ONGLYZA 37OPCICON ONE-STEP 87OPTICHAMBER ADVANTAGE-LG MASK 145OPTICHAMBER ADVANTAGE-MED MASK 145OPTICHAMBER ADVANTAGE-SM MASK 145OPTICHAMBER DIAMOND

145OPTICHAMBER DIAMOND-LG MASK 145OPTICHAMBER DIAMOND-MD MASK 145OPTICHAMBER DIAMOND-SM MASK 145OPTICHAMBER FACE MASK-LARGE 145OPTICHAMBER FACE MASK-MEDIUM 145OPTICHAMBER FACE MASK-SMALL 145OPTIHALER 145OPTUMRX GLUCOSE CONTROL 132ORACIT 109ORFADIN 106ORILISSA 105ORSYTHIA 85ORTHO-NOVUM 1/35 (28) 85ORTHO-NOVUM 7/7/7 (28) 90oseltamivir phosphate 73oxaliplatin 51OXAYDO 20oxazepam 25oxcarbazepine 30OXTELLAR XR 31oxybutynin chloride 170, 171oxybutynin chloride er 170, 171oxycodone hcl 20oxycodone-acetaminophen 20, 21OYSCO 500 146oyster shell calcium 146

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OZEMPIC (0.25 OR 0.5 MG/DOSE) 39OZEMPIC (1 MG/DOSE) 39paclitaxel 55pain & fever childrens 17pain & fever infants 17pain relief childrens 17pamidronate disodium 105PANCREAZE 102PANRETIN 98pantoprazole sodium 169, 170PARAGARD INTRAUTERINE COPPER 86PARAPLATIN 51paricalcitol 106paroxetine hcl 34PAZEO 156pc lancets super thin 30g 123PCCA ACACIA SYRUP BASE 161peg 3350 118peg 3350-kcl-na bicarb-nacl 117peg-3350/electrolytes 117PEGANONE 33PEGASYS 72PEGINTRON 72penicillin g procaine 160penicillin g sodium 160penicillin v potassium 160PENLET II BLOOD SAMPLER 132PENLET II REPLACEMENT CAP 132pentoxifylline er 112PERFECT LANCETS 28G 132PERFECT LANCETS 30G 132PERIKABIVEN 162permethrin 102perphenazine 65, 66perphenazine-amitriptyline 164PERSERIS 59PERTZYE 102PHARMACIST CHOICE ALCOHOL 120PHARMACIST CHOICE LANCETS 132PHARMACY COUNTER LANCETS 132phenazopyridine hcl 109phenobarbital 117phenylephrine hcl 155PHENYTEK 33

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phenytoin 33PHENYTOIN INFATABS 33phenytoin sodium extended 33PHILITH 85PHOSPHA 250 NEUTRAL 148phytonadione 173PIFELTRO 71pilocarpine hcl 149pimecrolimus 101pimozide 165PIMTREA 81pioglitazone hcl 41pioglitazone hcl-metformin hcl 41piperacillin sod-tazobactam so 160PIRMELLA 1/35 85PIRMELLA 7/7/7 90PLAN B ONE-STEP 87PLASBUMIN-25 112PLASBUMIN-5 112PLASMA-LYTE 148 147PLASMA-LYTE A 147PLASMANATE 113PLENAMINE 154pnv-dha+docusate 152pnv-omega 151POCKET CHAMBER 145POCKET SPACER 145POCKETCHEM EZ CONTROL 132podofilox 101POLYCIN 156polyethylene glycol 3350 118polymyxin b sulfate 49polymyxin b-trimethoprim 156POLY-VI-FLOR 151POLY-VI-FLOR/IRON 151POMALYST 52PORTIA-28 85potassium acetate 148potassium chloride 148potassium chloride crys er 148potassium chloride er 148potassium chloride in dextrose 146potassium chloride in nacl 147potassium citrate er 109potassium citrate-citric acid 109potassium phosphates 147potassium phosphates(66 meq k) 147PRADAXA 29pramipexole dihydrochloride 56prasugrel hcl 113

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pravastatin sodium 45praziquantel 23prazosin hcl 48PRECISION GLUCOSE CONTROL 132PRECISION GLUCOSE CONTROL SOLN 132PRECISION GLUCOSE KETONE CONTR 132PRECISION GLUCOSE/KETONE CONTR 133PRECISION SUREDOSE PLUS SYR 142PRECISION SURE-DOSE SYRINGE 142PRECISION THINS GP LANCETS 133prednisolone 91prednisolone acetate 157prednisolone sodium phosphate 91prednisone 91, 92preferred plus insulin syringe 137preferred plus lancets colored 123preferred plus lancets thin 123pregabalin 30PREMARIN 107, 172PREMASOL 154PREMPHASE 107PREMPRO 107prenaissance 152prenaissance plus 152prenatal 151prenatal vitamin plus low iron 151preplus 151pressure activat safety lancet 123PREVIFEM 85PREZCOBIX 70PREZISTA 71primaquine phosphate 50primidone 30PRIVIGEN 159pro comfort alcohol 119pro comfort lancets 30g 123pro comfort lancets 31g 123probenecid 110PROCALAMINE 155prochlorperazine maleate 66PROCTOFOAM HC 22PROCTOSOL HC 22PROCTOZONE-HC 22

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PRODIGY CONTROL SOLUTION 133PRODIGY INSULIN SYRINGE 142PRODIGY LANCETS 28G 133PRODIGY LANCING DEVICE 133PRODIGY SAFETY LANCETS 26G 133PRODIGY TWIST TOP LANCETS 28G 133PROFILNINE 111PROFILNINE SD 111progesterone 162progesterone micronized 162PROGLYCEM 36PROLASTIN-C 166promethazine hcl 44promethazine-dm 96promethazine-phenylephrine 95PROMETHEGAN 44PROMETRIUM 162propafenone hcl 25propantheline bromide 170propranolol hcl 76propranolol hcl er 75, 76propylthiouracil 167PROSOL 155PROTONIX 170PROVENTIL HFA 26PROVIDA OB 152PRUDOXIN 98pseudoeph-bromphen-dm 96PSS SELECT GP LANCETS 133PSS SELECT PLATFORMS 133PSS SELECT SAFETY LANCETS 133PULMOZYME 166purevit dualfe plus 115push button safety lancets 123px advanced lancing device 123px insulin syringe 137px lancet auto injector 123px lancets ultra thin 123PYLERA 170pyrazinamide 50pyridostigmine bromide 50pyridostigmine bromide er 50pyridoxine hcl 172qc 3 day 172qc advanced lancing device 123qc alcohol swabs 119

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qc all day allergy 44qc arthritis pain relief 17qc aspirin 18qc aspirin low dose 18qc childrens allergy 44qc enteric aspirin 18qc lancets super thin 30g 123qc lancets ultra thin 123qc lidocaine pain relief 101qc loratadine allergy relief 44qc loratadine-d 95qc medifin 400 95qc miconazole 7 172qc mucus relief 96qc mucus relief er 96qc non-aspirin childrens 17qc non-aspirin jr strength 17qc pain relief childrens 17qc tussin mucus/congestion 96qc unilet lancets 28g 123qc unilet lancets micro thin 123QUARTETTE 88QUDEXY XR 32quetiapine fumarate 63quetiapine fumarate er 63QUFLORA PEDIATRIC 151QUICKTEK CONTROL SOLUTION 133QUILLICHEW ER 12QUILLIVANT XR 12quinapril hcl 46quinapril-hydrochlorothiazide 46quinidine sulfate 25QUINTET CONTROL HIGH/NORMAL 133QVAR REDIHALER 28ra alcohol swabs 119ra antihistamine eye drops 156ra eye itch relief 156RA E-ZJECT COLOR LANCETS 33G 133RA E-ZJECT LANCETS 28G

133RA E-ZJECT LANCETS THIN 26G 133RA E-ZJECT LANCETS THIN 28G 133RA E-ZJECT LANCETS ULTRA THIN 133ra insulin syringe 137ra lancing device 123ra lidocaine pain relieving 101

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189

ramelteon 117ramipril 46ranitidine hcl 169ranolazine er 23raspberry syrup 161reality insulin syringe 137reality lancets 123reality swabs 119reality trigger lancets 123REBIF 164REBIF REBIDOSE 163REBIF REBIDOSE TITRATION PACK 164REBIF TITRATION PACK 164REBINYN 111RECLIPSEN 85RECOMBINATE 111REFUAH PLUS GLUCOSE CONTROL 133RELION ALCOHOL SWABS 120RELION INSULIN SYRINGE 142RELI-ON INSULIN SYRINGE 142RELION KETONE 102RELION LANCETS MICRO-THIN 33G 133RELION LANCETS STANDARD 21G 133RELION LANCETS THIN 26G 133RELION LANCETS ULTRA-THIN 30G 133RELION LANCING DEVICE 133RELION ULTRA THIN LANCETS 30G 133RELION ULTRA THIN PLUS LANCETS 133RENACIDIN 109repaglinide 39RESTASIS 157RESTASIS MULTIDOSE 157RETACRIT 114RETROVIR 72REVLIMID 73REXALL LANCETS ULTRA THIN 30G 133REYATAZ 71RHOPRESSA 158ribavirin 72, 73

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rifabutin 50rifampin 51RIGHTEST ALTERNATE SITE ADAPT 133RIGHTEST GC300 CONTROL 133RIGHTEST GD500 LANCING DEVICE 133RIGHTEST GL300 LANCETS 133riluzole 153ringers 147ringers irrigation 74RISPERDAL CONSTA 59risperidone 58, 59RITEFLO 145ritonavir 70RITUXAN 52rivastigmine 163RIVELSA 88rixubis 110rizatriptan benzoate 145robafen 96ROBAFEN DM COUGH 94ROBAFEN DM PEAK COLD CGH/CONG 94ROBAFEN MUCUS/CHEST CONGESTION 96ROCKLATAN 158ropinirole hcl 57rosuvastatin calcium 45ROWEEPRA 32RUCONEST 112SABRIL 32SAFESNAP INSULIN SYRINGE 142SAFE-T-LANCE 133SAFE-T-LANCE PLUS 133safety insulin syringes 137safety lancet 21g/pressure act 123safety lancet 28g/pressure act 123SAFETY LANCETS 133SAFETY LANCETS 21G 134safety lancets 28g 123SAFETY LET LANCETS 134SAFETY SEAL LANCETS 134safety syringe/needle 137SAFYRAL 85salicylic acid 101saline bacteriostatic 161salsalate 19SANDIMMUNE 73

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SANTYL 100saps care alcohol prep 119sapscare twist top lancets 123sb alcohol prep 120sb insulin syringe 137sb lancets thin 123sb lancets ultra thin 124scopolamine 42SEASONIQUE 88SEGLUROMET 167select-lite device/lancets 124select-lite lancing device 124SELECT-OB 152selegiline hcl 56selenium sulfide 99SELZENTRY 70se-natal 19 151SEREVENT DISKUS 26SEROSTIM 105sertraline hcl 34se-tan plus 115SETLAKIN 88sevelamer carbonate 108sevelamer hcl 108SHAROBEL 89SHOPKO ALCOHOL SWABS 120SHOPKO AUTOLET LANCING DEVICE 134SHOPKO ON-THE-GO LANCETS 30G 134SHOPKO UNILET LANCETS 28G 134SHOPKO UNILET LANCETS 30G 134side button safety lancet 124sildenafil citrate 79siltussin sa 96silver nitrate 99silver sulfadiazine 99SIMBRINZA 155SIMLIYA 81SIMPESSE 88SIMPLE DIAGNOSTICS LANCING DEV 134simple syrup 161simvastatin 45SINGLE-LET 134SINGULAIR 27sirolimus 74SLYND 89sm 3-day vaginal 172

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190

sm 8 hour pain relief 17sm alcohol prep 120sm all day allergy 44sm all day allergy childrens 44sm all day allergy-d 95sm allergy childrens 44sm arthritis pain relief 17sm arthritis pain reliever 17sm aspirin 19sm aspirin adult low strength 19sm aspirin ec 19sm aspirin low dose 19sm calcium antacid 23sm calcium antacid ex st 22sm chest congestion relief 96sm childrens aspirin 19sm childrens loratadine 44sm clotrimazole vaginal 172sm eye itch relief 156sm lancets 33g 124sm loratadine 44sm lorata-dine d 95sm loratadine d 12hr 95sm miconazole 7 172sm mucus relief 96sm mucus relief max strength 96sm nicotine 165sm nicotine polacrilex 165sm pain & fever childrens 17sm pain & fever infants 17sm slow release iron 116sm tussin dm max 94sm tussin mucus+chest congest 96SMART DIABETES VANTAGE LANCING 134SMART SENSE COLOR LANCETS 33G 134SMART SENSE STANDARD LANCETS 134SMART SENSE SUPER THIN LANCETS 134SMART SENSE THIN LANCETS 26G 134SMARTEST CONTROL MEDIUM 134SMARTEST LANCETS 28G 134sod citrate-citric acid 109sodium acetate 146sodium bicarbonate 22, 146sodium chloride 96, 109, 148sodium chloride (pf) 148sodium chloride bacteriostatic 161

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sodium fluoride 147, 149sodium phosphates 147sodium polystyrene sulfonate

74, 162sofosbuvir-velpatasvir 117SOLARTEK GLUCOSE CONTROL 134solifenacin succinate 170, 171SOLU-CORTEF 93SOLUS V2 CONTROL 134SOLUS V2 LANCETS 28G 134SOLUS V2 LANCING DEVICE 134SOLUS V2 TWIST LANCETS 30G 134sorbitol 81, 109, 161sorbitol-mannitol 109sotalol hcl 76sotalol hcl (af) 76spinosad 102SPIRIVA HANDIHALER 27spironolactone 104spironolactone-hctz 103SPRINTEC 28 85SPRITAM 32SPS 74, 162SRONYX 85stavudine 72STEGLATRO 39STERILANCE PA 134STERILANCE TL 134sterile water for injection 161sterile water for irrigation 74stevia 12stevia extract 81STIMATE 107STIOLTO RESPIMAT 26STRIBILD 70STROVITE ONE 150SUBLOCADE 21SUBVENITE 32SUBVENITE STARTER KIT-BLUE 32SUBVENITE STARTER KIT-GREEN 32SUBVENITE STARTER KIT-ORANGE 32sucralfate 169sulfacetamide-prednisolone 157sulfamethoxazole-trimethoprim 49sulfasalazine 108sumatriptan 146

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sumatriptan succinate 146super thin lancets 124supreme ii confidence paddles 124supreme ii high/low control 124sure comfort alcohol prep 120sure comfort insulin syringe 137sure comfort lancets 28g 124sure comfort lancets 30g 124sure comfort lancing pen 124SURE-JECT INSULIN SYRINGE 142SURE-LANCE FLAT LANCETS 134SURE-LANCE LANCETS 26G 134SURE-LANCE THIN LANCETS 28G 134SURE-LANCE ULTRA THIN LANCETS 134SURELITE LANCETS 134SURE-PEN 134SURE-PREP ALCOHOL PREP 120SURESTEP GLUCOSE CONTROL 134SURESTEP PRO HIGH GLUCOSE 134SURESTEP PRO LINEARITY 134SURESTEP PRO LOW GLUCOSE 135SURESTEP PRO NORMAL GLUCOSE 135SURE-TOUCH LANCETS UNIVERSAL 135SUSTIVA 71SUTENT 53SYEDA 85SYMBICORT 26SYMFI 70SYMFI LO 70SYMLINPEN 120 35SYMLINPEN 60 35SYMPAZAN 30SYMTUZA 70SYNAREL 106SYNTHAMIN 17 155SYNTHROID 168syringe 137syringe luer slip 138syringe/hypodermic safety 138syrpalta 161

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191

SYRSPEND SF 161tacrolimus 74, 101tadalafil (pah) 79TAI DOC CONTROL 135TAKE ACTION 87tamoxifen citrate 51tamsulosin hcl 109TARINA 24 FE 85TARINA FE 1/20 85TARINA FE 1/20 EQ 85taron forte 115TARON-C DHA 152TARON-PREX 152TAYTULLA 85tazarotene 99TECFIDERA 164TECHLITE AST LANCETS 135TECHLITE LANCETS 135TECHLITE LANCETS 30G 135TEGRETOL 32TEGRETOL-XR 32TELCARE GLUCOSE CONTROL 135telmisartan 47telmisartan-hctz 47temazepam 117TEMIXYS 70TEMODAR 54temozolomide 54temsirolimus 52tenofovir disoproxil fumarate 72terazosin hcl 48terbinafine hcl 43terbutaline sulfate 26terconazole 172testosterone 22testosterone cypionate 21testosterone enanthate 21tetrabenazine 163tgt alcohol swabs 120tgt lancet micro thin 33g 124tgt lancet thin 26g 124tgt lancet ultra thin 30g 124tgt lancing device 124THALOMID 73THEO-24 28theophylline 28theophylline er 28theracare pain relief 101THERATEARS ALLERGY 156thiamine hcl 172THINLETS GP LANCETS 135

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THIOLA 109thioridazine hcl 66thiotepa 51thiothixene 68, 69thrivite 19 151THYMOGLOBULIN 73thyroid 168tiagabine hcl 32TIKOSYN 25TILIA FE 90timolol maleate 155tinidazole 49TIS-U-SOL 74TIVICAY 70tizanidine hcl 153TOBRADEX 157tobramycin 13, 156tobramycin sulfate 13tobramycin-dexamethasone 157todays health lancing device 124todays health thin lancets 28g 124todays health thin lancets 30g 124tolbutamide 41tolterodine tartrate 171tolterodine tartrate er 171TOPAMAX 32TOPAMAX SPRINKLE 32topcare lancets micro-thin 33g 124topcare ultra comfort ins syr 138topiramate 31topiramate er 30topotecan hcl 55toremifene citrate 51torsemide 103TOVIAZ 170, 171TPN ELECTROLYTES 147TRACER II 3 VOLT BATTERY 135TRACLEER 79TRADJENTA 37tramadol hcl 20tranexamic acid 117tranexamic acid-nacl 117TRANSDERM SCOP (1.5 MG) 42TRAVASOL 155travel lancets 124TRAVEL LANCETS ADVANCED 28G 135travoprost (bak free) 158trazodone hcl 34, 166TREANDA 51

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tretinoin 55, 97TRETTEN 111TRI FEMYNOR 90triamcinolone acetonide 100, 167triamterene-hctz 103tricitrates 109TRICON 116TRIDERM 100TRI-ESTARYLLA 90trifluoperazine hcl 66trifluridine 157trihexyphenidyl hcl 56TRI-LEGEST FE 90TRILEPTAL 32TRI-LINYAH 90TRI-LO-ESTARYLLA 90TRI-LO-MARZIA 90TRI-LO-MILI 90TRI-LO-SPRINTEC 90TRILYTE 117trimethoprim 49TRI-MILI 90trinatal rx 1 151TRINTELLIX 34, 166TRI-PREVIFEM 90TRIPTODUR 106TRI-SPRINTEC 90TRIUMEQ 70TRIVEEN-DUO DHA 152TRI-VI-FLOR 151tri-vitamin/fluoride 151TRIVORA (28) 90TRI-VYLIBRA 90TRI-VYLIBRA LO 90troche base 161TROCHIBASE 161TROGARZO 69TROKENDI XR 32TROPHAMINE 155trospium chloride 171trospium chloride er 171TRUE METRIX LEVEL 1 135TRUE METRIX LEVEL 2 135TRUE METRIX LEVEL 3 135TRUECONTROL GLUCOSE CONT LEV 0 135TRUECONTROL GLUCOSE CONT LEV 1 135TRUEDRAW LANCING DEVICE 135TRUEPLUS INSULIN SYRINGE 142

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192

TRUEPLUS LANCETS 26G 135TRUEPLUS LANCETS 28G 135TRUEPLUS LANCETS 30G 135TRUEPLUS LANCETS 33G 135TRUEPLUS SAFETY LANCETS 28G 135TRUVADA 70TULANA 89TUMS 23TUMS CHEWY DELIGHTS 23TUMS E-X 750 23TUMS EXTRA STRENGTH 750 23TUMS SMOOTHIES 23TUMS ULTRA 1000 23tusnel diabetic 94tussin dm cough + chest 94tussin dm max adult 94tussin mucus & chest congest 96tussin mucus+chest congestion 96TYBOST 69TYDEMY 86TYMLOS 106UDENYCA 115ULTICARE ALCOHOL SWABS 120ULTICARE INSULIN SAFETY SYR 142ULTICARE INSULIN SYRINGE 142, 143ULTICARE SYRINGE 143ULTI-LANCE AUTOMATIC

135ULTILET CLASSIC LANCETS 135ULTILET INSULIN SYRINGE SHORT 143ULTILET LANCETS 135ULTILET SAFETY LANCETS 23G 135ultra comfort insulin syringe 138ultra-comfort insulin syringe 138ULTRALANCE 135ULTRA-THIN II AUTO LANCET 135ULTRA-THIN II INS SYR SHORT 143ULTRA-THIN II INSULIN SYRINGE 143ULTRA-THIN II LANCETS 135ULTRATRAK PRO CONTROL 135

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ULTRATRAK ULTIMATE CONTROL 136UNILET COMFORTOUCH LANCET 136UNILET EXCELITE 136UNILET EXCELITE II 136UNILET G.P. LANCET 136UNILET G.P. SUPERLITE LANCET 136UNILET GP 28 ULTRA THIN 136UNILET LANCET 136UNILET MICRO-THIN 33G 136UNILET SUPERLITE LANCET 136UNILET SUPER-THIN 30G 136UNILET ULTRA-THIN 28G 136UNISTIK 1 136UNISTIK 2 136UNISTIK 2 COMFORT 136UNISTIK 2 EXTRA 136UNISTIK 2 NEONATAL 136UNISTIK 2 NORMAL 136UNISTIK 2 SUPER 136UNISTIK 3 136UNISTIK 3 COMFORT 136UNISTIK 3 EXTRA 136UNISTIK 3 GENTLE 136UNISTIK 3 NEONATAL 136UNISTIK 3 NORMAL 136UNISTIK CZT COMFORT 136UNISTIK CZT NORMAL 136UNISTIK SAFETY LANCETS 28G 136UNISTIK SAFETY LANCETS 30G 136UNISTIK TOUCH SAFETY LANC 21G 136UNISTIK TOUCH SAFETY LANC 23G 136UNISTIK TOUCH SAFETY LANC 28G 136UNISTIK TOUCH SAFETY LANC 30G 136UNISTRIP CONTROL 136UNITHROID 168UNIVERSAL 1 LANCETS THIN 26G 136UNIVERSAL 1 LANCETS THIN 33G 136UNIVERSAL 1 LANCETS ULTRA THIN 136

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urea 100ursodiol 107UTIBRON NEOHALER 26valacyclovir hcl 72valganciclovir hcl 72valproic acid 33valrubicin 53valsartan-hydrochlorothiazide 47VALSTAR 53value health insulin syringe 138value plus lancet standard 21g 124value plus lancets super thin 124value plus lancets thin 26g 124value plus lancing device 124valumark lancet super thin 30g 124valumark lancet ultra thin 28g 124valved holding chamber 143VANALICE 102vancomycin hcl 49, 110vancomycin hcl in dextrose 109vancomycin hcl in nacl 110VANISHPOINT INSULIN SYRINGE 143VANISHPOINT SYRINGE 143VELCADE 53VELIVET 90venlafaxine hcl 35venlafaxine hcl er 35VENTAVIS 79verapamil hcl 78verapamil hcl er 78VICODIN HP 20VICTORY CONTROL LEVEL 1/2 137VICTOZA 39VIDA MIA AUTOLET LANCING DEV 137VIDA MIA UNILET LANCETS 28G 137VIDA MIA UNILET LANCETS 30G 137VIDEX 71VIENVA 86vigabatrin 32VIGADRONE 32VIIBRYD 34, 166VIMPAT 32vinblastine sulfate 55vincristine sulfate 55vinorelbine tartrate 55VIOKACE 102viorele 81

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VIRACEPT 71VIRAMUNE 71VIREAD 72virt-c dha 152virt-fefa plus 115virt-nate dha 152virt-phos 250 neutral 148virt-pn dha 152virt-pn plus 152VITAFOL FE+ 152VITAFOL GUMMIES 152VITAFOL-NANO 152VITAFOL-OB 152VITAFOL-OB+DHA 152VITAFOL-ONE 152VITAL-D RX 150vitamin d (ergocalciferol) 173VITAMIN E & C BEAUTY LOTION 100VITAMIN E & K BEAUTIFUL SKIN 100vitamin e beauty 100vitamin k1 173VITAMINS E & A BEAUTY OIL 100VITAMINS E & D BEAUTY OIL 100VITA-RAY 100vol-plus 152VONVENDI 112VORTEX VALVED HOLDING CHAMBER 145VOSEVI 117VOTRIENT 53vp insulin syringe 138VPRIV 113vp-vite rx 150VYFEMLA 86VYLIBRA 86VYVANSE 8walgreens adv travel lancets 124WALGREENS LANCETS 137walgreens lancets micro thin 124walgreens lancets super thin 124WALGREENS THIN LANCETS 137WALGREENS ULTRA THIN LANCETS 137warfarin sodium 28WATCHHALER 145water for irrigation, sterile 74

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WEBCOL ALCOHOL PREP LARGE 120WEBCOL ALCOHOL PREP MEDIUM 120WERA 86WILATE 112WYMZYA FE 86xanthan gum 161XARELTO 28, 29XARELTO STARTER PACK 28XELJANZ 13XELJANZ XR 13XTAMPZA ER 20XTANDI 51XULANE 86XYLOCAINE 118XYLOCAINE/EPINEPHRINE 118XYNTHA 112XYNTHA SOLOFUSE 112YASMIN 28 86YAZ 86ZADITOR 156zaleplon 117ZARAH 86ZARONTIN 33ZARXIO 115ZATEAN-PN DHA 152ZATEAN-PN PLUS 152ZEMAIRA 166ZENATANE 97ZENPEP 103ZIAGEN 71zidovudine 72zinc chloride 149zinc sulfate 149ziprasidone hcl 57ZOLADEX 54zoledronic acid 105zolpidem tartrate 117zonisamide 31ZOVIA 1/35E (28) 86ZTLIDO 101ZUMANDIMINE 86ZYLET 157ZYTIGA 51

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