aetna better health of florida florida healthy kids ... · aetna better health® formulary guide ....

AETNA BETTER HEALTH® Formulary Guide

Aetna Better Health of Florida Florida Healthy Kids Formulary Guide

July 2019


www.aetnabetterhealth.com/florida

What is a Formulary?

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

Can the Plan’s Drug List change?

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

How do I use the Plan’s Formulary?

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

• Column #2: shows coverage rules for the drug

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

What are generic drugs?

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

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

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

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Are there Medication Copays?

Refer to member handbook for copay information.

What are some types of coverage rules?

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

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

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

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

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

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

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

process.

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Aetna Better Health Florida CHIP

Table of Contents*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................5*ALTERNATIVE MEDICINES*........................................................................................................................... 12*AMINOGLYCOSIDES*....................................................................................................................................... 12*ANALGESICS - ANTI-INFLAMMATORY*...................................................................................................... 12*ANALGESICS - NONNARCOTIC*.....................................................................................................................16*ANALGESICS - OPIOID*.................................................................................................................................... 19*ANDROGENS-ANABOLIC*............................................................................................................................... 21*ANORECTAL AGENTS*.....................................................................................................................................22*ANTACIDS*..........................................................................................................................................................22*ANTHELMINTICS*............................................................................................................................................. 23*ANTIANGINAL AGENTS*................................................................................................................................. 23*ANTIANXIETY AGENTS*..................................................................................................................................24*ANTIARRHYTHMICS*....................................................................................................................................... 24*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 25*ANTICOAGULANTS*......................................................................................................................................... 27*ANTICONVULSANTS*.......................................................................................................................................29*ANTIDEPRESSANTS*.........................................................................................................................................33*ANTIDIABETICS*............................................................................................................................................... 34*ANTIDIARRHEALS*...........................................................................................................................................40*ANTIDOTES AND SPECIFIC ANTAGONISTS*...............................................................................................40*ANTIDOTES*....................................................................................................................................................... 40*ANTIEMETICS*................................................................................................................................................... 40*ANTIFUNGALS*..................................................................................................................................................41*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***......................................................... 42*ANTIHISTAMINES*............................................................................................................................................ 42*ANTIHYPERLIPIDEMICS*.................................................................................................................................43*ANTIHYPERTENSIVES*.................................................................................................................................... 44*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 47*ANTIMALARIALS*.............................................................................................................................................48*ANTIMYASTHENIC AGENTS*......................................................................................................................... 48*ANTIMYASTHENIC/CHOLINERGIC AGENTS*............................................................................................. 48*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 48*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................49*ANTIPARKINSON AGENTS*.............................................................................................................................54*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 55*ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR***........................................66*ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 66*ANTIVIRALS*......................................................................................................................................................66*ASSORTED CLASSES*....................................................................................................................................... 70*BETA BLOCKERS*............................................................................................................................................. 72*BIOLOGICALS MISC*........................................................................................................................................ 73*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***...............................................73*CALCIUM CHANNEL BLOCKERS*................................................................................................................. 73*CARDIOTONICS*................................................................................................................................................ 75*CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 75*CEPHALOSPORINS*...........................................................................................................................................76*CHEMICALS*.......................................................................................................................................................77

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*CONTRACEPTIVES*...........................................................................................................................................77*CORTICOSTEROIDS*......................................................................................................................................... 87*COUGH/COLD/ALLERGY*................................................................................................................................89*DERMATOLOGICALS*...................................................................................................................................... 92*DIAGNOSTIC PRODUCTS*................................................................................................................................98*DIGESTIVE AIDS*...............................................................................................................................................98*DIRECT-ACTING P2Y12 INHIBITORS***....................................................................................................... 98*DIURETICS*.........................................................................................................................................................98*ENDOCRINE AND METABOLIC AGENTS - MISC.*....................................................................................100*ESTROGENS*.....................................................................................................................................................102*FLUOROQUINOLONES*.................................................................................................................................. 102*GASTROINTESTINAL AGENTS - MISC.*......................................................................................................102*GENITOURINARY AGENTS - MISCELLANEOUS*..................................................................................... 104*GLYCOPEPTIDES***........................................................................................................................................104*GOUT AGENTS*................................................................................................................................................105*HEMATOLOGICAL AGENTS - MISC.*.......................................................................................................... 105*HEMATOPOIETIC AGENTS*...........................................................................................................................108*HEMOSTATICS*................................................................................................................................................111*HEPATITIS C AGENT - COMBINATIONS***............................................................................................... 112*HYPNOTICS*..................................................................................................................................................... 112*LAXATIVES*..................................................................................................................................................... 112*LHRH/GNRH AGONIST ANALOG COMBINATIONS***............................................................................ 113*LOCAL ANESTHETICS-PARENTERAL*....................................................................................................... 113*MACROLIDES*..................................................................................................................................................113*MEDICAL DEVICES*........................................................................................................................................114*MIGRAINE PRODUCTS*..................................................................................................................................141*MINERALS & ELECTROLYTES*....................................................................................................................141*MONOBACTAMS***........................................................................................................................................ 144*MOUTH/THROAT/DENTAL AGENTS*..........................................................................................................144*MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS***......................................................................145*MULTIVITAMINS*............................................................................................................................................145*MUSCULOSKELETAL THERAPY AGENTS*................................................................................................148*NASAL AGENTS - SYSTEMIC AND TOPICAL*........................................................................................... 148*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***........................................... 149*NEUROMUSCULAR AGENTS*....................................................................................................................... 149*NUTRIENTS*......................................................................................................................................................149*OPHTHALMIC AGENTS*.................................................................................................................................151*OPHTHALMIC RHO KINASE INHIBITORS***.............................................................................................154*OTIC AGENTS*..................................................................................................................................................154*OXYTOCICS*.....................................................................................................................................................154*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***...........................................................................154*PASSIVE IMMUNIZING AGENTS*.................................................................................................................154*PENICILLINS*....................................................................................................................................................155*PERITONEAL DIALYSIS SOLUTIONS***.....................................................................................................156*PHARMACEUTICAL ADJUVANTS*.............................................................................................................. 156*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***..................................................................157*POTASSIUM REMOVING AGENTS***..........................................................................................................157*PROGESTINS*....................................................................................................................................................157*PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS***.................................158*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*........................................................158*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***..................................................................161*RESPIRATORY AGENTS - MISC.*..................................................................................................................161

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*SEROTONIN MODULATORS***.................................................................................................................... 161*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***................................................................... 162*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***................................... 162*STEROIDS - MOUTH/THROAT/DENTAL***................................................................................................ 162*SULFONAMIDES*.............................................................................................................................................162*TETRACYCLINES*........................................................................................................................................... 162*THYROID AGENTS*......................................................................................................................................... 163*ULCER DRUGS*................................................................................................................................................ 164*URINARY ANTI-INFECTIVES*.......................................................................................................................166*URINARY ANTISPASMODICS*......................................................................................................................166*VAGINAL PRODUCTS*....................................................................................................................................167*VASOPRESSORS*............................................................................................................................................. 168*VITAMINS*........................................................................................................................................................ 168

3

Aetna Better Health Florida CHIP

CURRENT AS OF 7/01/2019

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

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

*Amphetamine Mixtures***

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

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


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















5

Formulary Drug Name Reference Restrictions







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

amphetamine-dextroamphetamine tablet 10 mg oral Adderall

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


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

amphetamine-dextroamphetamine tablet 12.5 mg oral Adderall











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

6



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













*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)





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

7


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

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

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

VYVANSE ORAL TABLET CHEWABLE

*Analeptics***

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

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

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

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



6 Years)

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

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

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

6 Years)




6 Years)




6 Years)

8





6 Years)

dexmethylphenidate hcl tablet 10 mg oral Focalin


dexmethylphenidate hcl tablet 2.5 mg oral Focalin


dexmethylphenidate hcl tablet 5 mg oral Focalin


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

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

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






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





9







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



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



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


methylphenidate hcl er oral tablet extended release Metadate ER

methylphenidate hcl tablet 10 mg oral Ritalin


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





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


10



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



methylphenidate hcl tablet chewable 10 mg oral

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

methylphenidate hcl tablet chewable 2.5 mg oral

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

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

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

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

APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 10 MG ORAL







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





11




DAYTRANA PATCH 10 MG/9HR TRANSDERMAL

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






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

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

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED AL (Min 6 Years)

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

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

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

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

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR

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

12

Formulary Drug Name Reference Restrictions *Antirheumatic Antimetabolites*** methotrexate (anti-rheumatic) oral tablet

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

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

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


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

Auto-PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

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

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



Auto-PA

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

Auto-PA

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


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

Auto-PA

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

Auto-PA

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

HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS






13

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


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


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


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

Auto-PA

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


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





Auto-PA

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

Auto-PA

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


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

Auto-PA

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

Auto-PA







14

Formulary Drug Name Reference Restrictions HUMIRA PREFILLED SYRINGE KIT 40 MG/0.4ML 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 potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release ec-naproxen oral tablet delayed release EC-Naprosyn ibuprofen oral suspension Childrens Advil ibuprofen oral tablet IBU indomethacin oral capsule ketorolac tromethamine intramuscular solution

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

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

ketorolac tromethamine solution 15 mg/ml injection

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

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

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

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

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava

15

Formulary Drug Name Reference Restrictions *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE

Auto-PA; QLL (7.84 ML per 28 days); AL (Min 2 Years)

ENBREL SOLUTION PREFILLED SYRINGE 25 MG/0.5ML SUBCUTANEOUS


ENBREL SOLUTION PREFILLED SYRINGE 50 MG/ML SUBCUTANEOUS


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED

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

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR


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

8 hr arthritis pain relief oral tablet extended release Midol OTC

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

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

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

gnp arthritis pain relief oral tablet extended release Midol OTC

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

16

Formulary Drug Name Reference Restrictions goodsense pain & fever child oral suspension Nortemp OTC; AL (Max 6 Years) goodsense pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years)

goodsense pain relief oral tablet extended release Midol OTC

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

hm arthritis pain relief oral tablet extended release Midol OTC

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

mapap oral liquid Little Remedies for Fever OTC; AL (Max 6 Years) non-aspirin childrens oral suspension Nortemp OTC; AL (Max 6 Years) pain & fever childrens oral suspension Nortemp OTC; AL (Max 6 Years) pain & fever infants oral suspension Nortemp OTC; AL (Max 6 Years) pain relief childrens oral suspension Nortemp OTC; AL (Max 6 Years) qc arthritis pain relief oral tablet extended release Midol OTC

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

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

sm arthritis pain relief oral tablet extended release Midol OTC

sm arthritis pain reliever oral tablet extended release Midol OTC

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

17

Formulary Drug Name Reference Restrictions butalbital-apap-caffeine oral capsule 50-300-40 mg Fioricet QLL (60 EA per 30 days)

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

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

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

aspirin adult oral tablet Bayer Advanced Aspirin Reg St OTC

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

aspirin ec oral tablet delayed release Aspir-Low 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 Aspir-Low OTC aspirin rectal suppository OTC childrens aspirin low strength oral tablet chewable Bayer Low Dose OTC

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

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

gnp aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

gnp aspirin oral tablet delayed release Aspir-Low OTC

goodsense aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

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

hm aspirin ec oral tablet delayed release Bayer Aspirin OTC

hm aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

hm aspirin oral tablet chewable Bayer Low Dose OTC qc aspirin low dose oral tablet chewable Bayer Low Dose OTC

18

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

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

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

sm aspirin oral tablet Bayer Advanced Aspirin Reg St OTC

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

ECPIRIN ORAL TABLET DELAYED RELEASE Bayer Aspirin OTC

ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE Bayer Low Dose OTC

*ANALGESICS - OPIOID* *Codeine Combinations***

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

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

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

acetaminophen-codeine oral solution AL (Min 6 Years)

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

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

*Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen tablet 10-300 mg oral Vicodin HP

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

hydrocodone-acetaminophen tablet 10-325 mg oral Lorcet HD

19

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

hydrocodone-acetaminophen tablet 5-325 mg oral Lorcet

hydrocodone-acetaminophen tablet 7.5-300 mg oral Vicodin ES

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

hydrocodone-acetaminophen tablet 7.5-325 mg oral Lorcet Plus

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

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

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

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

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

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT


EMBEDA ORAL CAPSULE EXTENDED RELEASE

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

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT


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

20

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

ROXYBOND ORAL TABLET ABUSE-DETERRENT Auto-PA

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

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

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

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

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

*Opioid Partial Agonists***

buprenorphine hcl sublingual tablet sublingual

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

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

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

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

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

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

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

(Min 16 Years)

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

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

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

*ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule testosterone cypionate intramuscular solution Depo-Testosterone testosterone enanthate intramuscular solution

21

Formulary Drug Name Reference Restrictions ANDROGEL PUMP TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years)

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 Anusol-HC PROCTOSOL HC RECTAL CREAM Anusol-HC PROCTOZONE-HC RECTAL CREAM Anusol-HC

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

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

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

calcium antacid ultra strength oral tablet chewable Tums Ultra 1000 OTC

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

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

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

22

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

TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE Antacid Soft Chews OTC

TUMS E-X 750 ORAL TABLET CHEWABLE Antacid Flavor Chews OTC

TUMS EXTRA STRENGTH 750 ORAL TABLET CHEWABLE Antacid Flavor Chews OTC

TUMS ORAL TABLET CHEWABLE Cal-Gest Antacid OTC TUMS SMOOTHIES ORAL TABLET CHEWABLE Antacid Flavor Chews OTC

TUMS ULTRA 1000 ORAL TABLET CHEWABLE Tums Ultra 1000 OTC

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

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

*Nitrates***

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

isosorbide dinitrate tablet 10 mg oral

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

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

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

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

Maintenance drug with max 100 day supply

isosorbide mononitrate oral tablet

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

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

23

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

*Benzodiazepines***

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

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

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

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

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

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

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

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

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

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

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

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

24

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

flecainide acetate oral tablet Maintenance drug with max 100 days supply

propafenone hcl oral tablet

*Antiarrhythmics Type Iii***

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

TIKOSYN ORAL CAPSULE Dofetilide

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

ipratropium-albuterol inhalation solution

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

BEVESPI AEROSPHERE INHALATION AEROSOL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION

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

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION

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

UTIBRON NEOHALER INHALATION CAPSULE

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

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

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

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

25

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

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

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

days) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

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

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

SPIRIVA HANDIHALER INHALATION CAPSULE


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

*Steroid Inhalants***

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

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

AL (Min 5 Years)

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

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

ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED


ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED


26

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


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

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

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

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

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

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED

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

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

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

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

27


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

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

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

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

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

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

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

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





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

28

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

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

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

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

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

carbamazepine er oral tablet extended release 12 hour TEGretol-XR

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

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

levetiracetam intravenous solution Keppra levetiracetam oral solution Keppra

29

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

EPITOL ORAL TABLET Epitol Auto-PA KEPPRA ORAL SOLUTION Keppra KEPPRA ORAL TABLET Keppra KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Keppra XR

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 LaMICtal LAMICTAL ORAL TABLET CHEWABLE LaMICtal

LAMICTAL STARTER ORAL KIT LaMICtal Starter 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 LaMICtal XR AL (Min 13 Years)

LYRICA CAPSULE 100 MG ORAL QLL (180 EA per 30 days) LYRICA CAPSULE 150 MG ORAL QLL (120 EA per 30 days) 30

Formulary Drug Name Reference Restrictions LYRICA CAPSULE 200 MG ORAL QLL (90 EA per 30 days) LYRICA CAPSULE 225 MG ORAL QLL (60 EA per 30 days) LYRICA CAPSULE 25 MG ORAL QLL (720 EA per 30 days) LYRICA CAPSULE 300 MG ORAL QLL (60 EA per 30 days) LYRICA CAPSULE 50 MG ORAL QLL (360 EA per 30 days) LYRICA CAPSULE 75 MG ORAL QLL (240 EA per 30 days) MYSOLINE ORAL TABLET Mysoline NEURONTIN ORAL CAPSULE Neurontin NEURONTIN ORAL SOLUTION Neurontin NEURONTIN ORAL TABLET Neurontin OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 6 Years)

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE Qudexy XR

ROWEEPRA ORAL TABLET Keppra ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Keppra XR

SUBVENITE ORAL TABLET LaMICtal SUBVENITE STARTER KIT-BLUE ORAL KIT LaMICtal Starter

SUBVENITE STARTER KIT-GREEN ORAL KIT LaMICtal Starter

SUBVENITE STARTER KIT-ORANGE ORAL KIT LaMICtal Starter

TEGRETOL ORAL SUSPENSION TEGretol TEGRETOL ORAL TABLET Epitol TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR TEGretol-XR

TOPAMAX ORAL TABLET Topamax TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE Topamax Sprinkle

TRILEPTAL ORAL SUSPENSION Trileptal TRILEPTAL ORAL TABLET Trileptal 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

31

Formulary Drug Name Reference Restrictions felbamate oral tablet Felbatol FELBATOL ORAL SUSPENSION Felbatol Auto-PA FELBATOL ORAL TABLET Felbatol Auto-PA

*Gaba Modulators*** tiagabine hcl oral tablet Gabitril vigabatrin oral packet Sabril PA vigabatrin oral tablet Sabril PA GABITRIL ORAL TABLET Gabitril Auto-PA SABRIL ORAL PACKET Sabril Auto-PA VIGADRONE ORAL PACKET Sabril

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

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

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

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

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

divalproex sodium oral capsule delayed release sprinkle Depakote Sprinkles

divalproex sodium oral tablet delayed release Depakote valproic acid oral capsule Depakene valproic acid oral solution Depakene

32

Formulary Drug Name Reference Restrictions DEPAKENE ORAL CAPSULE Depakene Auto-PA DEPAKENE ORAL SOLUTION Depakene Auto-PA DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR Depakote ER Auto-PA

DEPAKOTE ORAL TABLET DELAYED RELEASE Depakote Auto-PA

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

Depakote Sprinkles Auto-PA

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

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

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

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

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

bupropion hcl oral tablet AL (Min 6 Years)

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

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

VIIBRYD ORAL TABLET AL (Min 18 Years)

*Selective Serotonin Reuptake Inhibitors (Ssris)***

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

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

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

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

33


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

sertraline hcl oral tablet Zoloft AL (Min 6 Years)

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

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

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

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

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

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

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

34

Formulary Drug Name Reference Restrictions *Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hour Fortamet Maintenance drugs with max

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

35


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

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

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

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

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

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






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

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

AL (Min 18 Years)

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

AL (Min 18 Years)

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

AL (Min 18 Years)

*Dpp-4 Inhibitor-Thiazolidinedione Combinations***

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

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

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

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

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

ST; QLL (2 BOXES per 30 days)

36

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

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR


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

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

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE


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

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

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


LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

QLL (2 BOXES per 30 days)

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

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

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR

QLL (2 BOXES per 30 days)

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

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

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

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR


NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR


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

37

Formulary Drug Name Reference Restrictions NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE


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

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN-INJECTOR BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE ST; QLL (0.05 ML per 1 day)

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 1 MG/DOSE ST; QLL (0.11 ML per 1 day)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR

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

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

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

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

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

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

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

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

glimepiride tablet 4 mg oral Amaryl QLL (2 EA per 1 day)

38

Formulary Drug Name Reference Restrictions glipizide er tablet extended release 24 hour 10 mg oral Glucotrol XL Maintenance drugs with max

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

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

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

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

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

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

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

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

days supply glipizide tablet 10 mg oral Glucotrol

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

glipizide xl oral tablet extended release 24 hour Glucotrol XL

glyburide micronized oral tablet Glynase

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

glyburide tablet 1.25 mg oral

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

glyburide tablet 2.5 mg oral

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

glyburide tablet 5 mg oral tolbutamide oral tablet

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

*Thiazolidinediones*** pioglitazone hcl oral tablet Actos

39

Formulary Drug Name Reference Restrictions *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule Imodium A-D

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

deferoxamine mesylate solution reconstituted 500 mg injection Desferal

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

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

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

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet QLL (8 EA per 28 days) ondansetron hcl injection solution QLL (32 ML per 28 days) ondansetron hcl oral solution QLL (600 ML per 28 days) ondansetron hcl oral tablet Zofran QLL (2 EA per 1 day) ondansetron oral tablet dispersible QLL (2 EA per 1 day)

40

Formulary Drug Name Reference Restrictions *Antiemetic Combinations***

DICLEGIS ORAL TABLET DELAYED RELEASE Doxylamine-Pyridoxine

Maximum of 2 fills per rolling 90 days; QLL (4 EA per 1 day); AL (Min 18 Years)

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

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

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

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

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

41

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

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

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

42

Formulary Drug Name Reference Restrictions 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 solution Claritin OTC; AL (Max 11 Years) loratadine childrens oral syrup Claritin OTC; AL (Max 11 Years) loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day) qc all day allergy oral tablet KLS Aller-Tec OTC qc childrens allergy oral solution KLS Aller-Tec Childrens OTC qc loratadine allergy relief oral tablet Claritin OTC; QLL (1 EA per 1 day) sm all day allergy childrens oral solution KLS Aller-Tec Childrens OTC sm all day allergy oral tablet KLS Aller-Tec OTC sm allergy childrens oral syrup Claritin OTC; AL (Max 11 Years) sm childrens loratadine oral syrup Claritin OTC; AL (Max 11 Years) sm loratadine oral syrup Claritin OTC; AL (Max 11 Years) sm loratadine oral tablet Claritin OTC; QLL (1 EA per 1 day)

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

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

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

*Fibric Acid Derivatives*** fenofibrate oral tablet Tricor gemfibrozil oral tablet Lopid

43

Formulary Drug Name Reference Restrictions *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

*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 oral tablet Zestoretic Maintenance drug with max 100 days supply

quinapril-hydrochlorothiazide oral tablet Accuretic

*Ace Inhibitors*** benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet Vasotec fosinopril sodium oral tablet lisinopril tablet 10 mg oral Prinivil

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

44


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

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

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

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

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

*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



45






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

terazosin hcl oral capsule

*Beta Blocker & Diuretic Combinations***

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

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

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

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

bisoprolol-hydrochlorothiazide oral tablet Ziac propranolol-hctz oral tablet

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

*Vasodilators*** hydralazine hcl tablet 10 mg oral

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

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


hydralazine hcl tablet 50 mg oral


minoxidil oral tablet

46

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

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

sulfamethoxazole-trimethoprim oral tablet Bactrim

*Antiprotozoal Agents*** atovaquone oral suspension Mepron

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

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

*Carbapenems*** meropenem intravenous solution reconstituted Merrem meropenem-sodium chloride intravenous solution reconstituted

*Leprostatics*** dapsone oral tablet

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

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

*Oxazolidinones*** linezolid oral tablet Zyvox

47

Formulary Drug Name Reference Restrictions *Polymyxins*** colistimethate sodium (cba) injection solution reconstituted Coly-Mycin M

polymyxin b sulfate injection solution reconstituted

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

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

pyridostigmine bromide oral solution Mestinon pyridostigmine bromide oral tablet Mestinon MESTINON ORAL SYRUP Mestinon

*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 Myambutol 48

Formulary Drug Name Reference Restrictions isoniazid oral syrup isoniazid oral tablet pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin intravenous solution reconstituted Rifadin rifampin oral capsule Rifadin

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

*Androgen Biosynthesis Inhibitors*** abiraterone acetate oral tablet Zytiga ZYTIGA ORAL TABLET AL (Min 18 Years)

*Antiandrogens***

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

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

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

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

XTANDI ORAL CAPSULE AL (Min 18 Years)

*Antiestrogens***

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

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

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

49

Formulary Drug Name Reference Restrictions *Antimetabolites*** azacitidine injection suspension reconstituted Vidaza

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

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

50

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

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

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

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

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

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

VOTRIENT ORAL TABLET AL (Min 18 Years)

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

VALSTAR INTRAVESICAL SOLUTION Valstar

*Antineoplastic Enzymes*** ONCASPAR INJECTION SOLUTION

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

51

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

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

*Aromatase Inhibitors***

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

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

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

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

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

52

Formulary Drug Name Reference Restrictions LUPRON DEPOT (6-MONTH) KIT 45 MG INTRAMUSCULAR


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

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

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

melphalan oral tablet Alkeran ALKERAN ORAL TABLET Alkeran 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

53

Formulary Drug Name Reference Restrictions *Urinary Tract Protective Agents*** mesna intravenous solution Mesnex

*ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** 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 AL (Min 3 Years) trihexyphenidyl hcl oral elixir AL (Min 18 Years)

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

trihexyphenidyl hcl tablet 2 mg oral 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 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 AL (Min 18 Years) selegiline hcl oral tablet AL (Min 18 Years)

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

days supply; AL (Min 18 Years)

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

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

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

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

54

Formulary Drug Name Reference Restrictions *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)

55








*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 RisperDAL

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

risperidone tablet 0.5 mg oral RisperDAL


risperidone tablet 1 mg oral RisperDAL

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


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


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


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

56


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)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

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

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE


PERSERIS SUBCUTANEOUS PREFILLED SYRINGE AL (Min 18 Years)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED

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

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

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

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

57

Formulary Drug Name Reference Restrictions haloperidol decanoate solution 50 mg/ml intramuscular Haldol Decanoate QL: age =/>18: maximum

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

haloperidol lactate oral concentrate

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

haloperidol tablet 0.5 mg oral AL (Min 6 Years)

haloperidol tablet 0.5 mg oral

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

haloperidol tablet 1 mg oral AL (Min 6 Years)

haloperidol tablet 1 mg oral












*Dibenzodiazepines***

clozapine tablet 100 mg oral Clozaril

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

58




clozapine tablet 200 mg oral PA

clozapine tablet 200 mg oral





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

clozapine tablet 50 mg oral


clozapine tablet dispersible 100 mg oral FazaClo


clozapine tablet dispersible 12.5 mg oral FazaClo








59


CLOZARIL TABLET 100 MG ORAL Clozaril


CLOZARIL TABLET 25 MG ORAL Clozaril


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



60




*Dibenzoxazepines***

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




*Phenothiazines***

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

chlorpromazine hcl tablet 10 mg oral

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









fluphenazine decanoate injection solution AL (Min 18 Years)

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

fluphenazine hcl oral concentrate


fluphenazine hcl oral elixir


61


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)

fluphenazine hcl tablet 2.5 mg oral




perphenazine tablet 16 mg oral

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




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


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

prochlorperazine maleate oral tablet

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



62



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)

aripiprazole tablet 10 mg oral Abilify


aripiprazole tablet 15 mg oral Abilify




63




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

aripiprazole tablet dispersible 10 mg oral


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

aripiprazole tablet dispersible 15 mg oral


ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER


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


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


64










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)



65






*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)

66


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

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

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

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

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

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

TIVICAY ORAL TABLET Auto-PA

*Antiretrovirals - Protease Inhibitors*** ritonavir oral tablet Norvir APTIVUS ORAL CAPSULE Auto-PA APTIVUS ORAL SOLUTION Auto-PA CRIXIVAN ORAL CAPSULE Auto-PA

67

Formulary Drug Name Reference Restrictions 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 RESCRIPTOR ORAL TABLET Auto-PA SUSTIVA ORAL CAPSULE Efavirenz Auto-PA SUSTIVA ORAL TABLET Efavirenz Auto-PA VIRAMUNE ORAL SUSPENSION Viramune Auto-PA

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

ZIAGEN ORAL SOLUTION Abacavir Sulfate Auto-PA

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** lamivudine oral solution Epivir Auto-PA lamivudine tablet 150 mg oral Epivir lamivudine tablet 150 mg oral Epivir Auto-PA lamivudine tablet 300 mg oral Epivir lamivudine tablet 300 mg oral Epivir Auto-PA

68

Formulary Drug Name Reference Restrictions EMTRIVA ORAL CAPSULE Auto-PA EMTRIVA ORAL SOLUTION Auto-PA EPIVIR ORAL SOLUTION Epivir Auto-PA

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** stavudine oral capsule Auto-PA zidovudine oral capsule Retrovir Auto-PA zidovudine oral syrup Retrovir Auto-PA zidovudine oral tablet Auto-PA RETROVIR INTRAVENOUS SOLUTION Auto-PA

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

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

valganciclovir hcl oral tablet Valcyte

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

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

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

69

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

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

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

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


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


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

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

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

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

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

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

SANDIMMUNE ORAL SOLUTION

*Immune Globulin Immunosuppressants*** ATGAM INTRAVENOUS INJECTABLE PA

70

Formulary Drug Name Reference Restrictions 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

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

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED

CellCept Intravenous

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

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

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

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

*Purine Analogs*** azathioprine oral tablet Imuran

71

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

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

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


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


*Beta Blockers Cardio-Selective***

acebutolol hcl oral capsule Maintenance drug with max 100 days supply

atenolol oral tablet Tenormin Maintenance drug with max 100 days supply

bisoprolol fumarate oral tablet 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*** propranolol hcl er oral capsule extended release 24 hour Inderal LA Maintenance drug with max 100

days supply

72


propranolol hcl oral solution Maintenance drug with max 100 days supply

propranolol hcl oral tablet Maintenance drug with max 100 days supply

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

*BIOLOGICALS MISC* *Biologicals Misc*** ADAGEN INTRAMUSCULAR SOLUTION

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

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

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

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

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

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

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

days supply diltiazem hcl er capsule extended release 24 hour 120 mg oral diltiazem hcl er capsule extended release 24 hour 180 mg oral

Maintenance drug with max 100 days supply

diltiazem hcl er capsule extended release 24 hour 240 mg oral


73

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








day supply diltiazem hcl er oral capsule extended release 12 hour


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

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

74

Formulary Drug Name Reference Restrictions 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 Calan Maintenance drug with max 100 days supply

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

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

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

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

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

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

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

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

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

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

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

75

Formulary Drug Name Reference Restrictions *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

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

76

Formulary Drug Name Reference Restrictions 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 Maxipime QLL (1500 EA per 30 days)

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

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

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

*Liquids*** glycerin liquid

*Solids*** sorbitol powder

*CONTRACEPTIVES* *Biphasic Contraceptives - Oral***

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

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

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

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

KARIVA ORAL TABLET Azurette 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)

77


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

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

SIMLIYA ORAL TABLET Azurette

*Combination Contraceptives -Oral***

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

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

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

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

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

12 Years)

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

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

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

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

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

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

norethindrone acet-ethinyl est oral tablet chewable Melodetta 24 Fe

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)

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

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

AUBRA EQ ORAL TABLET Afirmelle QLL (1 EA per 1 day); AL (Min 12 Years)

78


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

AUROVELA 1.5/30 ORAL TABLET AUROVELA 1/20 ORAL TABLET Aurovela 1/20 AUROVELA 24 FE ORAL TABLET Aurovela 24 FE AUROVELA FE 1.5/30 ORAL TABLET AUROVELA FE 1/20 ORAL TABLET Aurovela FE 1/20

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

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

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

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

BLISOVI 24 FE ORAL TABLET Aurovela 24 FE

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

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

CHATEAL EQ ORAL TABLET Altavera QLL (1 EA per 1 day); AL (Min 12 Years)

CHATEAL ORAL TABLET Altavera 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 Cyclafem 1/35 QLL (1 EA per 1 day); AL (Min 12 Years)

CYRED EQ ORAL TABLET Apri QLL (1 EA per 1 day); AL (Min 12 Years)

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

DASETTA 1/35 ORAL TABLET Cyclafem 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 Apri

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

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

79


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

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

GENERESS FE ORAL TABLET CHEWABLE Generess FE

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

HAILEY 24 FE ORAL TABLET Aurovela 24 FE

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

JASMIEL ORAL TABLET Gianvi

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

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

JUNEL 1/20 ORAL TABLET Aurovela 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

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

JUNEL FE 1/20 ORAL TABLET Aurovela FE 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

JUNEL FE 24 ORAL TABLET Aurovela 24 FE


KAITLIB FE ORAL TABLET CHEWABLE Generess FE QLL (1 EA per 1 day); AL (Min

12 Years)

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

KELNOR 1/50 ORAL TABLET Kelnor 1/50 QLL (1 EA per 1 day); AL (Min 12 Years)

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

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

LARIN 1/20 ORAL TABLET Aurovela 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

LARIN 24 FE ORAL TABLET Aurovela 24 FE


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

80


LARIN FE 1/20 ORAL TABLET Aurovela FE 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

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

LAYOLIS FE ORAL TABLET CHEWABLE Generess FE

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

LEVORA 0.15/30 (28) ORAL TABLET Altavera LILLOW ORAL TABLET Altavera LOESTRIN 1.5/30 (21) ORAL TABLET

LOESTRIN 1/20 (21) ORAL TABLET Aurovela 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

LORYNA ORAL TABLET Gianvi LOW-OGESTREL ORAL TABLET LO-ZUMANDIMINE ORAL TABLET Gianvi

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

MIBELAS 24 FE ORAL TABLET CHEWABLE Melodetta 24 Fe

MICROGESTIN 1.5/30 ORAL TABLET

MICROGESTIN 1/20 ORAL TABLET Aurovela 1/20 QLL (1 EA per 1 day); AL (Min 12 Years)

MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET Aurovela FE 1/20

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

MINASTRIN 24 FE ORAL TABLET CHEWABLE Melodetta 24 Fe

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

NECON 0.5/35 (28) ORAL TABLET NIKKI ORAL TABLET Gianvi NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET Cyclafem 1/35 NORTREL 1/35 (28) ORAL TABLET Cyclafem 1/35 OCELLA ORAL TABLET Ocella OGESTREL ORAL TABLET ORSYTHIA ORAL TABLET Afirmelle

81

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

PHILITH ORAL TABLET Balziva PIRMELLA 1/35 ORAL TABLET Cyclafem 1/35 PORTIA-28 ORAL TABLET Altavera

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

RECLIPSEN ORAL TABLET Apri SAFYRAL ORAL TABLET Safyral

SPRINTEC 28 ORAL TABLET Estarylla QLL (1 EA per 1 day); AL (Min 12 Years)

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

SYEDA ORAL TABLET Ocella TARINA 24 FE ORAL TABLET Aurovela 24 FE TARINA FE 1/20 EQ ORAL TABLET Aurovela FE 1/20 AL (Min 12 Years) TARINA FE 1/20 ORAL TABLET Aurovela FE 1/20 AL (Min 12 Years) TAYTULLA ORAL CAPSULE TYDEMY ORAL TABLET Safyral VIENVA ORAL TABLET Afirmelle VYFEMLA ORAL TABLET Balziva

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

WERA ORAL TABLET WYMZYA FE ORAL TABLET CHEWABLE Wymzya Fe

YASMIN 28 ORAL TABLET Ocella YAZ ORAL TABLET Gianvi ZARAH ORAL TABLET Ocella ZOVIA 1/35E (28) ORAL TABLET Ethynodiol Diac-Eth Estradiol

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

*Combination Contraceptives -Vaginal***

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

82

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

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

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

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

*Emergency Contraceptives***

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

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

AFTERA TABLET 1.5 MG ORAL Aftera

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

ECONTRA EZ ORAL TABLET Aftera


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

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

MY WAY TABLET 1.5 MG ORAL (OTC) Aftera


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

OPCICON ONE-STEP ORAL TABLET Aftera


83

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

30 days); AL (Min 12 Years)

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


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

TAKE ACTION TABLET 1.5 MG ORAL Aftera


*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 Lo QLL (91 EA per 84 days); AL (Min 12 Years)

AMETHIA LO ORAL TABLET Amethia Lo QLL (91 EA per 84 days); AL (Min 12 Years)

AMETHIA ORAL TABLET Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

ASHLYNA ORAL TABLET Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

CAMRESE LO ORAL TABLET Amethia Lo QLL (91 EA per 84 days); AL (Min 12 Years)

CAMRESE ORAL TABLET Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

DAYSEE ORAL TABLET Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

FAYOSIM ORAL TABLET Fayosim QLL (91 EA per 84 days); AL (Min 12 Years)

INTROVALE ORAL TABLET Introvale QLL (91 EA per 84 days); AL (Min 12 Years)

JOLESSA ORAL TABLET Introvale QLL (91 EA per 84 days); AL (Min 12 Years)

LOSEASONIQUE ORAL TABLET Amethia Lo QLL (91 EA per 84 days); AL (Min 12 Years)

QUARTETTE ORAL TABLET Fayosim QLL (91 EA per 84 days); AL (Min 12 Years)

RIVELSA ORAL TABLET Fayosim QLL (91 EA per 84 days); AL (Min 12 Years)

SEASONIQUE ORAL TABLET Amethia QLL (91 EA per 84 days); AL (Min 12 Years)

84


SETLAKIN ORAL TABLET Introvale QLL (91 EA per 84 days); AL (Min 12 Years)

*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 Depo-Provera QLL (1 UNIT per 84 days); AL

(Min 12 Years) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Depo-Provera QLL (1 UNIT per 84 days)

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE

QLL (0.65 ML per 84 days)

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

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

85

Formulary Drug Name Reference Restrictions LYZA ORAL TABLET Camila NORA-BE ORAL TABLET Camila NORLYDA ORAL TABLET Camila ORTHO MICRONOR ORAL TABLET Camila SHAROBEL ORAL TABLET Camila TULANA ORAL TABLET Camila

*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 Cyclafem 7/7/7 QLL (1 EA per 1 day); AL (Min 12 Years)

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

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

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

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

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

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

ORTHO TRI-CYCLEN LO ORAL TABLET Ortho Tri-Cyclen Lo QLL (1 EA per 1 day); AL (Min

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

12 Years)

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

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

TRI FEMYNOR ORAL TABLET Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-ESTARYLLA ORAL TABLET Tri Femynor

86


TRI-LEGEST FE ORAL TABLET QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-LINYAH ORAL TABLET Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-LO-ESTARYLLA ORAL TABLET Ortho Tri-Cyclen Lo QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-LO-MARZIA ORAL TABLET Ortho Tri-Cyclen Lo QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-LO-MILI ORAL TABLET Ortho Tri-Cyclen Lo

TRI-LO-SPRINTEC ORAL TABLET Ortho Tri-Cyclen Lo QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-MILI ORAL TABLET Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-PREVIFEM ORAL TABLET Tri Femynor

TRI-SPRINTEC ORAL TABLET Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

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

TRI-VYLIBRA LO ORAL TABLET Ortho Tri-Cyclen Lo QLL (1 EA per 1 day); AL (Min 12 Years)

TRI-VYLIBRA ORAL TABLET Tri Femynor QLL (1 EA per 1 day); AL (Min 12 Years)

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

*CORTICOSTEROIDS* *Glucocorticosteroids*** budesonide oral capsule delayed release particles Entocort EC

dexamethasone oral elixir Decadron dexamethasone oral solution

dexamethasone oral tablet Decadron Maintenance drug with max 100 days supply

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

methylprednisolone sodium succ injection solution reconstituted SOLU-medrol

methylprednisolone tablet 16 mg oral Medrol

87

Formulary Drug Name Reference Restrictions methylprednisolone tablet 32 mg oral Medrol

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 oral tablet therapy pack Maintenance drugs with max 100 days supply

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

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

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

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

prednisone tablet 20 mg oral Deltasone Maintenance drug with max 100 days supply

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

prednisone tablet 5 mg oral Maintenance 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

DEXAMETHASONE INTENSOL ORAL CONCENTRATE SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED

*Mineralocorticoids*** fludrocortisone acetate oral tablet

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

88

Formulary Drug Name Reference Restrictions CELESTONE SOLUSPAN INJECTION SUSPENSION Celestone Soluspan

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic*** benzonatate oral capsule AL (Max 20 Years)

*Antitussive - Opioid***

hydrocodone-homatropine oral syrup QLL (300 ML per 30 days); AL (Min 18 Years and Max 20 Years)

hydrocodone-homatropine oral tablet AL (Min 18 Years and Max 20 Years)

*Antitussive-Expectorant***

cough/chest congestion dm oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

dextromethorphan-guaifenesin oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

dm-guaifenesin er oral tablet extended release 12 hour

Mucinex DM Maximum Strength OTC

extra action cough oral syrup Robafen DM Cough Clear OTC gnp mucus dm max strength oral tablet extended release 12 hour


guaifenesin-dm oral syrup Robafen DM Cough Clear OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

hm tussin adult dm oral liquid Diabetic Tussin Max St OTC

mucus & cough relief childrens oral liquid Delsym Cgh/Chest Cong DM Child OTC

mucus relief dm cough oral tablet Fenesin DM IR OTC

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

mucus relief dm max oral tablet extended release 12 hour


mucus relief dm oral tablet extended release 12 hour Mucinex DM OTC

mucus-dm maximum strength oral tablet extended release 12 hour


mucusrelief dm cough oral tablet Fenesin DM IR OTC

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

tussin dm cough + chest oral liquid Cheracol Plus OTC tussin dm max adult oral liquid Diabetic Tussin Max St OTC ROBAFEN DM COUGH ORAL LIQUID Cheracol Plus OTC

89

Formulary Drug Name Reference Restrictions *Decongestant & Antihistamine*** all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

allergy relief d-24 oral tablet extended release 24 hour Claritin-D 24 Hour OTC

allergy relief/nasal decongest oral tablet extended release 24 hour Claritin-D 24 Hour OTC

allergy relief-d oral tablet extended release 24 hour Claritin-D 24 Hour OTC

cetirizine-pseudoephedrine er oral tablet extended release 12 hour KLS Aller-Tec D OTC

gnp all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

gnp allergy & congestion oral tablet extended release 24 hour Claritin-D 24 Hour OTC

gnp allergy/congestion relief oral tablet extended release 24 hour Claritin-D 24 Hour OTC

gnp loratadine-d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

hm allergy & congestion oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

hm allergy complete-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

hm allergy relief/nasal decong oral tablet extended release 24 hour Claritin-D 24 Hour OTC

loratadine-d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

loratadine-d 24hr oral tablet extended release 24 hour Claritin-D 24 Hour OTC

promethazine-phenylephrine oral syrup QLL (300 ML per 30 days); AL (Min 18 Years and Max 20 Years)

qc loratadine-d oral tablet extended release 24 hour Claritin-D 24 Hour OTC

sm all day allergy-d oral tablet extended release 12 hour KLS Aller-Tec D OTC

sm loratadine d 12hr oral tablet extended release 12 hour Alavert Allergy/Sinus OTC

sm loratadine d 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

90

Formulary Drug Name Reference Restrictions *Expectorants*** chest congestion relief oral tablet Bidex OTC

childrens mucus relief expect oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

cough syrup oral syrup Diabetic Tussin EX OTC

diabetic siltussin das-na oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

gnp mucus er oral tablet extended release 12 hour EQ Mucus ER OTC

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

gnp tussin mucus & chest cong oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

guaifenesin oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

guaifenesin oral solution Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

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

hm tussin adult oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

mucosa oral tablet Bidex OTC

mucus & chest congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

mucus relief chest congestion oral tablet OTC mucus relief er oral tablet extended release 12 hour EQ Mucus ER OTC

mucus relief oral tablet Bidex OTC qc medifin 400 oral tablet Bidex OTC qc mucus relief oral tablet extended release 12 hour EQ Mucus ER OTC

qc tussin mucus/congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

robafen oral syrup Diabetic Tussin EX OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

siltussin sa oral syrup Diabetic Tussin EX OTC sm chest congestion relief oral tablet Bidex OTC sm mucus relief max strength oral tablet extended release 12 hour EQ Mucus ER OTC

sm mucus relief oral tablet extended release 12 hour EQ Mucus ER OTC

91


sm tussin mucus+chest congest oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus & chest congest oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus+chest congestion oral liquid Buckleys Chest Congestion OTC; QLL (300 ML per 30 days); AL (Max 20 Years)

tussin mucus+chest congestion oral syrup Diabetic Tussin EX OTC MUCINEX FOR KIDS ORAL PACKET OTC MUCINEX MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HOUR

EQ Mucus ER OTC

MUCINEX ORAL TABLET EXTENDED RELEASE 12 HOUR EQ Mucus ER OTC

ROBAFEN MUCUS/CHEST CONGESTION ORAL LIQUID Buckleys Chest Congestion OTC; QLL (300 ML per 30

days); AL (Max 20 Years)

*Misc. Respiratory Inhalants*** sodium chloride nebulization solution 0.9 % inhalation (rx) sodium chloride nebulization solution 10 % inhalation Auto-PA

*Mucolytics*** acetylcysteine inhalation solution

*Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup

*Non-Narc Antitussive-Decongestant-Antihistamine*** pseudoeph-bromphen-dm oral syrup Bromfed DM

*DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external gel Cleocin-T ST clindamycin phosphate external lotion Cleocin-T ST; AL (Min 12 Years) clindamycin phosphate external solution AL (Min 12 Years) clindamycin phosphate external swab Cleocin-T AL (Min 12 Years)

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

*Acne Products*** adapalene external cream Differin ST; AL (Min 12 Years) adapalene external lotion Differin ST; AL (Min 12 Years) benzoyl peroxide external gel 2.5 % OTC 92

Formulary Drug Name Reference Restrictions benzoyl peroxide external gel 5 % isotretinoin oral capsule Absorica ST; AL (Min 12 Years) tretinoin external cream Retin-A ST; AL (Min 12 Years) AMNESTEEM ORAL CAPSULE Absorica AL (Min 12 Years) AVITA EXTERNAL CREAM Avita AL (Min 12 Years) AZELEX EXTERNAL CREAM AL (Min 12 Years)

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

DIFFERIN EXTERNAL GEL Adapalene OTC Only

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

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

*Antibiotic Steroid Combinations -Topical*** CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT

*Antibiotics - Topical*** gentamicin sulfate external cream mupirocin ointment 2 % external Centany mupirocin ointment 2 % external Centany QLL (44 GM per 30 days)

*Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream Lotrisone hydrocortisone-iodoquinol external cream Dermazene ALA-QUIN EXTERNAL CREAM

*Antifungals - Topical*** 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

93

Formulary Drug Name Reference Restrictions *Antineoplastic Antimetabolites -Topical*** fluorouracil external cream Carac fluorouracil external solution

*Antineoplastic Or Premalignant Lesions - Topical Nsaid's***

diclofenac sodium gel 3 % transdermal QLL (200 GM per 30 days); AL (Min 18 Years)

diclofenac sodium gel 3 % transdermal Auto-PA; QLL (200 GM per 30 days); AL (Min 18 Years)

*Antineoplastic Retinoids -Topical*** PANRETIN EXTERNAL GEL PA

*Antipruritics - Topical*** doxepin hcl external cream Prudoxin PRUDOXIN EXTERNAL CREAM Prudoxin

*Antipsoriatics - Systemic*** acitretin oral capsule Soriatane COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Auto-PA; AL (Min 18 Years)

COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Auto-PA

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Auto-PA; AL (Min 18 Years)

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

*Antipsoriatics*** calcipotriene external cream Dovonex QLL (120 GM per 30 days) calcipotriene external ointment Calcitrene QLL (120 GM per 30 days) calcitriol external ointment Vectical tazarotene external cream Tazorac QLL (3 GM per 1 day) TAZORAC 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

94

Formulary Drug Name Reference Restrictions *Antivirals - Topical*** acyclovir external cream Zovirax

acyclovir external ointment Zovirax QLL (30 GM per 30 days); AL (Min 12 Years)

DENAVIR EXTERNAL CREAM

*Burn Products*** silver sulfadiazine external cream Silvadene

*Cauterizing Agents*** silver nitrate external solution

*Corticosteroids - Topical*** betamethasone dipropionate aug external cream Diprolene AF

betamethasone dipropionate aug external gel betamethasone dipropionate aug external ointment Diprolene

betamethasone valerate external cream clobetasol prop emollient base external cream ST clobetasol propionate e external cream ST clobetasol propionate external cream Temovate ST clobetasol propionate external gel ST clobetasol propionate external ointment 0.05 % Temovate ST

clobetasol propionate external solution ST clobetasol propionate ointment 0.05 % external Temovate

fluocinolone acetonide body external oil Derma-Smoothe/FS Body fluocinolone acetonide scalp external oil Derma-Smoothe/FS Scalp fluocinonide external cream fluticasone propionate external cream fluticasone propionate external ointment halobetasol propionate external cream Ultravate halobetasol propionate external ointment Ultravate 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

95

Formulary Drug Name Reference Restrictions DERMA-SMOOTHE/FS BODY EXTERNAL OIL Derma-Smoothe/FS Body

TRIDERM EXTERNAL CREAM Triderm

*Emollient Combinations*** lactic acid e external cream mineral oil-hydrophil petrolat external ointment OTC

vitamin e beauty external oil OTC CAVILON EMOLLIENT EXTERNAL CREAM OTC

CAVILON FOOT & DRY SKIN EXTERNAL CREAM OTC

VITAMIN E & C BEAUTY LOTION EXTERNAL LOTION OTC

VITAMIN E & K BEAUTIFUL SKIN EXTERNAL OIL OTC

VITAMINS E & A BEAUTY OIL EXTERNAL OIL OTC

VITAMINS E & D BEAUTY OIL EXTERNAL OIL OTC

VITA-RAY EXTERNAL CREAM OTC

*Emollient/Keratolytic Agents*** urea external cream urea external lotion Cerovel

*Emollients*** ammonium lactate external cream Geri-Hydrolac 12 ammonium lactate external lotion AL12

*Enzymes - Topical*** SANTYL EXTERNAL OINTMENT

*Imidazole-Related Antifungals -Topical*** clotrimazole external cream Clotrimazole GRx

clotrimazole external solution FungiCure Intensive/NailGuard

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

96

Formulary Drug Name Reference Restrictions *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*** lidocaine external ointment

lidocaine external patch Lidoderm Auto-PA; QLL (90 EA per 30 days)

lidocaine hcl external cream QLL (60 GM per 30 days) lidocaine hcl external solution lidocaine hcl urethral/mucosal external gel Glydo

*Macrolide Immunosuppressants -Topical*** pimecrolimus external cream Elidel ST; QLL (1 FILL per 28 days) tacrolimus ointment 0.03 % external Protopic QLL (1 FILL per 30 days)

tacrolimus ointment 0.1 % external Protopic QLL (1 FILL per 30 days); AL (Min 16 Years)

ELIDEL EXTERNAL CREAM Elidel ST; QLL (1 FILL per 28 days)

*Rosacea Agents*** azelaic acid external gel Finacea metronidazole external cream MetroCream metronidazole external gel Rosadan

*Scabicides & Pediculicides***

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

permethrin external cream Elimite spinosad external suspension Natroba SKLICE EXTERNAL LOTION

*Topical Anesthetic Combinations*** lidocaine-prilocaine external cream QLL (30 GM per 30 days) lidocaine-prilocaine external kit DermacinRx Empricaine

97

Formulary Drug Name Reference Restrictions *DIAGNOSTIC PRODUCTS* *Diagnostic Drugs*** glucagon hcl (diagnostic) injection solution reconstituted QLL (1 EA per 365 days)

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED QLL (1 EA per 365 days)

*Diagnostic Tests*** ketone test in vitro strip Chemstrip K OTC KETOSTIX IN VITRO STRIP Chemstrip K 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 Chemstrip K OTC

*DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES VIOKACE ORAL TABLET ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES

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

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

Maintenance drug with max 100 day supply

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

acetazolamide tablet 250 mg oral

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

methazolamide oral tablet

98

Formulary Drug Name Reference Restrictions *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet spironolactone-hctz oral tablet Aldactazide triamterene-hctz oral capsule Dyazide triamterene-hctz oral tablet Maxzide-25

*Loop Diuretics*** bumetanide injection solution bumetanide oral tablet Bumex furosemide injection solution furosemide oral solution

furosemide oral tablet Lasix Maintenance drug with max 100 days supply

torsemide oral tablet

*Potassium Sparing Diuretics*** amiloride hcl oral tablet

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

spironolactone tablet 100 mg oral Aldactone





*Thiazides And Thiazide-Like Diuretics***

chlorothiazide oral tablet Maintenance drug with max 100 days supply

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

chlorthalidone tablet 25 mg oral

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

chlorthalidone tablet 50 mg oral

hydrochlorothiazide oral capsule Maintenance drug with max 100 days supply

hydrochlorothiazide oral tablet Maintenance drug with max 100 days supply

indapamide oral tablet

99


metolazone oral tablet Maintenance drug with max 100 days supply

DIURIL ORAL SUSPENSION AL (Max 11 Years)

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral tablet pamidronate disodium intravenous solution pamidronate disodium intravenous solution reconstituted zoledronic acid intravenous concentrate zoledronic acid solution 4 mg/100ml intravenous zoledronic acid solution 5 mg/100ml intravenous Reclast QLL (100 ML per 355 days)

*Calcitonins***

calcitonin (salmon) nasal solution Miacalcin QLL (3.7 ML per 28 days); AL (Min 18 Years)

*Carnitine Replenisher - Agents*** levocarnitine oral solution Carnitor levocarnitine oral tablet Carnitor

*Corticotropin***

HP 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)

100

Formulary Drug Name Reference Restrictions SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; AL (Min 18 Years)

*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents*** ORFADIN ORAL CAPSULE PA ORFADIN ORAL SUSPENSION PA

*Homocystinuria Treatment -Agents*** CYSTADANE ORAL POWDER

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol intravenous solution calcitriol oral capsule Rocaltrol calcitriol oral solution Rocaltrol doxercalciferol oral capsule paricalcitol intravenous solution Zemplar paricalcitol oral capsule Zemplar

*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

*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 SandoSTATIN

101

Formulary Drug Name Reference Restrictions *Vasopressin*** desmopressin acetate injection solution DDAVP desmopressin acetate oral tablet DDAVP desmopressin acetate spray nasal solution DDAVP STIMATE NASAL SOLUTION

*ESTROGENS* *Estrogen & Androgen*** est estrogens-methyltest ds oral tablet Covaryx est estrogens-methyltest hs oral tablet Covaryx HS

*Estrogen & Progestin*** estradiol-norethindrone acet oral tablet Activella AL (Min 18 Years) norethindrone-eth estradiol oral tablet Femhrt Low Dose AL (Min 18 Years) CLIMARA PRO TRANSDERMAL PATCH WEEKLY QLL (4 EA per 28 days)

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY FEMHRT LOW DOSE ORAL TABLET Femhrt Low Dose 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 ciprofloxacin oral suspension reconstituted Cipro AL (Min 11 Years) levofloxacin in d5w intravenous solution levofloxacin oral tablet Levaquin AL (Min 12 Years)

*GASTROINTESTINAL AGENTS -MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule Actigall ursodiol oral tablet Urso 250

102

Formulary Drug Name Reference Restrictions *Gastrointestinal Antiallergy Agents*** cromolyn sodium oral concentrate Gastrocrom

*Gastrointestinal Stimulants***

metoclopramide hcl oral solution QL: ages 18: maximum 60mg/day

metoclopramide hcl oral tablet Reglan QL: ages 18: maximum 60mg/day

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS CAPSULE 145 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS CAPSULE 290 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS CAPSULE 72 MCG ORAL Auto-PA; AL (Min 18 Years) LINZESS ORAL CAPSULE 290 MCG, 72 MCG PA; AL (Min 18 Years)

*Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** alosetron hcl oral tablet Lotronex LOTRONEX ORAL TABLET Lotronex

*Inflammatory Bowel Agents*** mesalamine oral capsule delayed release Delzicol mesalamine rectal suppository Canasa sulfasalazine oral tablet Azulfidine sulfasalazine oral tablet delayed release Azulfidine EN-tabs APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR

*Intestinal Acidifiers*** lactulose encephalopathy oral solution

*Peripheral Opioid Receptor Antagonists*** MOVANTIK ORAL TABLET Auto-PA

*Phosphate Binder Agents*** calcium acetate (phos binder) oral capsule PhosLo calcium acetate (phos binder) oral tablet Calphron sevelamer carbonate oral packet Renvela AL (Max 11 Years) sevelamer hcl oral tablet Renagel AL (Max 11 Years) RENVELA ORAL PACKET Renvela

103

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 Phenazo

*Urinary Stone Agents*** THIOLA ORAL TABLET

*GLYCOPEPTIDES*** *Glycopeptides*** vancomycin hcl in dextrose intravenous solution

104

Formulary Drug Name Reference Restrictions vancomycin hcl in nacl intravenous solution vancomycin hcl intravenous solution reconstituted

*GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet

*Gout Agents*** allopurinol oral tablet Zyloprim

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 CORIFACT INTRAVENOUS KIT ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED FEIBA INTRAVENOUS SOLUTION RECONSTITUTED HELIXATE FS INTRAVENOUS KIT

105

Formulary Drug Name Reference Restrictions HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED IDELVION INTRAVENOUS SOLUTION RECONSTITUTED IXINITY INTRAVENOUS SOLUTION RECONSTITUTED Ixinity

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 VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED WILATE INTRAVENOUS KIT XYNTHA INTRAVENOUS KIT XYNTHA SOLOFUSE INTRAVENOUS KIT

106

Formulary Drug Name Reference Restrictions *Bradykinin B2 Receptor Antagonists***

FIRAZYR SUBCUTANEOUS SOLUTION 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 5 PA alburx intravenous solution Albuked 5 PA kedbumin intravenous solution Albuked 25 PA ALBUKED 25 INTRAVENOUS SOLUTION Albuked 25 PA

ALBUKED 5 INTRAVENOUS SOLUTION Albuked 5 PA

ALBUMINEX INTRAVENOUS SOLUTION PA

ALBUTEIN INTRAVENOUS SOLUTION Albuked 5 PA FLEXBUMIN INTRAVENOUS SOLUTION Albuked 5 PA

PLASBUMIN-25 INTRAVENOUS SOLUTION Albuked 25 PA

PLASBUMIN-5 INTRAVENOUS SOLUTION Albuked 5 PA

PLASMANATE INTRAVENOUS SOLUTION PA

*Platelet Aggregation Inhibitor Combinations*** aspirin-dipyridamole er oral capsule extended release 12 hour Aggrenox

107

Formulary Drug Name Reference Restrictions *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

*Erythropoiesis-Stimulating Agents (Esas)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION PA

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

PA

EPOGEN INJECTION SOLUTION Auto-PA

108

Formulary Drug Name Reference Restrictions 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

*Folic Acid/Folate Combinations*** tl gard rx oral tablet Folgard RX

*Folic Acid/Folates*** folic acid injection solution folic acid oral tablet

109

Formulary Drug Name Reference Restrictions *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

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 FUSION PLUS ORAL CAPSULE HEMATOGEN FA ORAL CAPSULE HEMOCYTE PLUS ORAL CAPSULE IFEREX 150 FORTE ORAL CAPSULE Myferon 150 Forte INTEGRA PLUS ORAL CAPSULE Virt-FeFA Plus TRICON ORAL CAPSULE Ferotrinsic

110

Formulary Drug Name Reference Restrictions *Iron W/ Folic Acid*** FOLIVANE-F ORAL CAPSULE HEMOCYTE-F ORAL TABLET Hematinic/Folic Acid INTEGRA F ORAL CAPSULE

*Iron*** ferrous fumarate oral tablet Ferrocite OTC ferrous gluconate oral tablet OTC ferrous sulfate oral elixir FeroSul OTC ferrous sulfate oral solution BProtected Pedia Iron OTC ferrous sulfate oral syrup OTC ferrous sulfate oral tablet FeroSul OTC ferrous sulfate oral tablet delayed release OTC ferrousul oral tablet FeroSul OTC gnp iron oral tablet Feosol OTC gnp iron oral tablet extended release Slow Fe OTC sm slow release iron oral tablet extended release OTC

FEOSOL NATURAL RELEASE ORAL TABLET EQL Carbonyl Iron OTC

FEOSOL ORAL TABLET Feosol OTC FERATE ORAL TABLET Ferrotabs OTC FER-IN-SOL ORAL SOLUTION BProtected Pedia Iron OTC FEROSUL ORAL ELIXIR FeroSul OTC FEROSUL ORAL TABLET FeroSul OTC FERRIMIN 150 ORAL TABLET OTC HEMOCYTE ORAL TABLET Ferrocite OTC

*Iron-B12-Folate*** ferraplus 90 oral tablet

*HEMOSTATICS* *Hemostatics - Systemic*** aminocaproic acid intravenous solution aminocaproic acid oral tablet Amicar tranexamic acid intravenous solution Cyklokapron tranexamic acid oral tablet Lysteda QLL (30 EA per 28 days) AMICAR ORAL SOLUTION

111

Formulary Drug Name Reference Restrictions *HEPATITIS C AGENT -COMBINATIONS*** *Hepatitis C Agent -Combinations*** MAVYRET ORAL TABLET PA; AL (Min 18 Years) VOSEVI ORAL TABLET PA; AL (Min 18 Years)

*HYPNOTICS* *Barbiturate Hypnotics*** phenobarbital oral elixir phenobarbital oral solution phenobarbital oral tablet

*Benzodiazepine Hypnotics*** temazepam oral capsule Restoril AL (Min 18 Years)

*Non-Benzodiazepine - Gaba-Receptor Modulators*** zaleplon oral capsule zolpidem tartrate oral tablet Ambien AL (Min 18 Years)

*Selective Melatonin Receptor Agonists***

ROZEREM ORAL TABLET QLL (1 EA per 1 day); AL (Min 65 Years)

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted Colyte with Flavor Packs QLL (4000 ML per 1 Fill)

peg 3350-kcl-na bicarb-nacl oral solution reconstituted GaviLyte-N with Flavor Pack

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

GOLYTELY ORAL SOLUTION RECONSTITUTED GaviLyte-G QLL (4000 ML per 1 Fill)

TRILYTE ORAL SOLUTION RECONSTITUTED GaviLyte-N with Flavor Pack

*Laxatives - Miscellaneous*** lactulose oral solution QLL (180 ML per 1 day) peg 3350 oral packet CVS Purelax OTC

peg 3350 oral powder ClearLax OTC; QLL (527 GM per 30 days)

polyethylene glycol 3350 oral packet CVS Purelax QLL (527 GM per 30 days)

112

Formulary Drug Name Reference Restrictions polyethylene glycol 3350 oral powder ClearLax QLL (527 GM per 30 days)

*Surfactant Laxatives*** ENEMEEZ MINI RECTAL ENEMA 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 Xylocaine/Epinephrine

*Local Anesthetics - Amides*** bupivacaine hcl (pf) injection solution Marcaine Preservative Free bupivacaine hcl injection solution Marcaine bupivacaine spinal intrathecal solution Marcaine Spinal lidocaine hcl (pf) injection solution Xylocaine-MPF lidocaine hcl injection solution Xylocaine lidocaine in dextrose solution XYLOCAINE INJECTION SOLUTION Xylocaine

*MACROLIDES* *Azithromycin*** azithromycin intravenous solution reconstituted Zithromax

azithromycin oral packet Zithromax

113

Formulary Drug Name Reference Restrictions azithromycin oral suspension reconstituted Zithromax azithromycin oral tablet Zithromax

*Clarithromycin*** clarithromycin er oral tablet extended release 24 hour clarithromycin oral suspension reconstituted clarithromycin oral tablet

*Erythromycins*** erythromycin ethylsuccinate oral suspension reconstituted E.E.S. Granules AL (Min 11 Years)

*Fidaxomicin***

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

*MEDICAL DEVICES* *Applicators,Cotton Balls,Etc*** alcohol pads pad Alcoh-Glove Contoured Wipe OTC alcohol prep pad Alcoh-Glove Contoured Wipe OTC alcohol swabs pad Alcoh-Glove Contoured Wipe OTC alcohol wipes pad Alcoh-Glove Contoured Wipe OTC alcoh-wipe sheet cvs alcohol prep pads pad Alcoh-Glove Contoured Wipe OTC cvs prep pad Alcoh-Glove Contoured Wipe OTC eql alcohol swabs pad Alcoh-Glove Contoured Wipe OTC global alcohol prep ease pad Alcoh-Glove Contoured Wipe OTC gnp alcohol swabs pad Alcoh-Glove Contoured Wipe OTC h-e-b incontrol alcohol pad Alcoh-Glove Contoured Wipe OTC meijer alcohol swabs pad Alcoh-Glove Contoured Wipe OTC pro comfort alcohol pad Alcoh-Glove Contoured Wipe OTC qc alcohol swabs pad Alcoh-Glove Contoured Wipe OTC ra alcohol swabs pad Alcoh-Glove Contoured Wipe OTC reality swabs pad Alcoh-Glove Contoured Wipe OTC saps care alcohol prep pad Alcoh-Glove Contoured Wipe OTC sb alcohol prep pad Alcoh-Glove Contoured Wipe OTC sm alcohol prep pad Alcoh-Glove Contoured Wipe OTC sure comfort alcohol prep pad Alcoh-Glove Contoured Wipe OTC tgt alcohol swabs pad Alcoh-Glove Contoured Wipe OTC ALCOH-GLOVE CONTOURED WIPE PAD Alcoh-Glove Contoured Wipe

BD SWAB SINGLE USE REGULAR PAD Alcoh-Glove Contoured Wipe OTC 114

Formulary Drug Name Reference Restrictions BD SWABS SINGLE USE BUTTERFLY PAD Alcoh-Glove Contoured Wipe OTC

CARETOUCH ALCOHOL PREP PAD Alcoh-Glove Contoured Wipe OTC CURITY ALCOHOL PREPS PAD Alcoh-Glove Contoured Wipe OTC CURITY ALCOHOL SWABS PAD Alcoh-Glove Contoured Wipe OTC EASY TOUCH ALCOHOL PREP MEDIUM PAD Alcoh-Glove Contoured Wipe OTC

FIFTY50 ALCOHOL PREP PAD Alcoh-Glove Contoured Wipe OTC PHARMACIST CHOICE ALCOHOL PAD Alcoh-Glove Contoured Wipe OTC RELION ALCOHOL SWABS PAD Alcoh-Glove Contoured Wipe OTC SHOPKO ALCOHOL SWABS PAD Alcoh-Glove Contoured Wipe OTC SURE-PREP ALCOHOL PREP PAD Alcoh-Glove Contoured Wipe OTC ULTICARE ALCOHOL SWABS PAD Alcoh-Glove Contoured Wipe OTC WEBCOL ALCOHOL PREP LARGE PAD Alcoh-Glove Contoured Wipe OTC

WEBCOL ALCOHOL PREP MEDIUM PAD Alcoh-Glove Contoured Wipe OTC

*Diaphragms*** CAYA VAGINAL DIAPHRAGM

*Glucose Monitoring Test Supplies*** 1st tier unilet comfortouch Accu-Chek FastClix Lancets OTC acti-lance 28g Accu-Chek FastClix Lancets OTC acti-lance lite lancets 28g Accu-Chek FastClix Lancets OTC acti-lance special lancets 17g Accu-Chek FastClix Lancets OTC acti-lance universal 23g Accu-Chek FastClix Lancets OTC adjustable lancing device Advocate Lancing Device OTC alternate site lancing device Advocate Lancing Device OTC aqua lance adjustable lancing device Advocate Lancing Device OTC assure comfort lancets 28g Accu-Chek FastClix Lancets OTC aurora lancet super thin 30g Accu-Chek FastClix Lancets OTC aurora lancet thin 23g Accu-Chek FastClix Lancets OTC bullseye mini safety lancets Accu-Chek FastClix Lancets OTC careone advanced lancing dev Advocate Lancing Device OTC careone lancet thin 23g Accu-Chek FastClix Lancets OTC careone lancet ultra thin 28g Accu-Chek FastClix Lancets OTC comfort assured lancets 28g Accu-Chek FastClix Lancets OTC comfort assured lancets 33g Accu-Chek FastClix Lancets OTC comfort lancets Accu-Chek FastClix Lancets OTC

115

Formulary Drug Name Reference Restrictions 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 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

116

Formulary Drug Name Reference Restrictions 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 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

117

Formulary Drug Name Reference Restrictions 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 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

118

Formulary Drug Name Reference Restrictions 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 Accu-Chek Aviva OTC

ACCU-CHEK COMPACT PLUS CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ACCU-CHEK FASTCLIX LANCET KIT Accu-Chek FastClix Lancet OTC ACCU-CHEK FASTCLIX LANCETS Accu-Chek FastClix Lancets OTC ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

ACCU-CHEK MULTICLIX LANCET DEV KIT Accu-Chek FastClix Lancet OTC

ACCU-CHEK MULTICLIX LANCETS Accu-Chek FastClix Lancets OTC ACCU-CHEK SAFE-T PRO LANCETS Accu-Chek FastClix Lancets OTC ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

ACCU-CHEK SOFT TOUCH LANCETS Accu-Chek FastClix Lancets OTC ACCU-CHEK SOFTCLIX LANCET DEV KIT Accu-Chek FastClix Lancet OTC

119

Formulary Drug Name Reference Restrictions ACCU-CHEK SOFTCLIX LANCETS Accu-Chek FastClix Lancets OTC ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID Advance Intuition Control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID Accu-Chek Aviva OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID Advocate Control Solution OTC

ADVOCATE LANCETS Accu-Chek FastClix Lancets OTC ADVOCATE LANCETS 30G Accu-Chek FastClix Lancets OTC ADVOCATE LANCING DEVICE Advocate Lancing Device OTC ADVOCATE RAPID-SAFE LANCING Advocate Lancing Device OTC ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

ADVOCATE SAFETY LANCETS Accu-Chek FastClix Lancets OTC ADVOCATE SAFETY LANCETS 26G Accu-Chek FastClix Lancets OTC AGAMATRIX CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

AGAMATRIX ULTRA-THIN LANCETS Accu-Chek FastClix Lancets OTC AQUALANCE LANCETS 30G Accu-Chek FastClix Lancets OTC ASSURE 3 CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID Accu-Chek Aviva OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ASSURE HAEMOLANCE PLUS HIGH Accu-Chek FastClix Lancets OTC ASSURE HAEMOLANCE PLUS LOW Accu-Chek FastClix Lancets OTC ASSURE HAEMOLANCE PLUS MICRO Accu-Chek FastClix Lancets OTC ASSURE HAEMOLANCE PLUS NORMAL Accu-Chek FastClix Lancets OTC

ASSURE HAEMOLANCE PLUS PED Accu-Chek FastClix Lancets OTC ASSURE II CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID Accu-Chek Aviva OTC

ASSURE LANCE LANCETS Accu-Chek FastClix Lancets OTC

120

Formulary Drug Name Reference Restrictions ASSURE LANCE LANCETS 21G Accu-Chek FastClix Lancets OTC ASSURE LANCE PLUS SAFETY 25G Accu-Chek FastClix Lancets OTC ASSURE LANCE PLUS SAFETY 30G Accu-Chek FastClix Lancets OTC ASSURE LANCETS Accu-Chek FastClix Lancets OTC ASSURE PRISM CONTROL LEVEL 1&2 IN VITRO SOLUTION Accu-Chek Aviva OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID Accu-Chek Aviva OTC

AUTO-LANCET Advocate Lancing Device OTC AUTO-LANCET MINI Advocate Lancing Device OTC AUTOLET II CLINISAFE KIT Accu-Chek FastClix Lancet OTC AUTOLET LANCING DEVICE Advocate Lancing Device OTC AUTOLET LITE CLINISAFE KIT Accu-Chek FastClix Lancet OTC AUTOLET LITE STARTER PACK KIT Accu-Chek FastClix Lancet OTC AUTOLET MINI Advocate Lancing Device OTC AUTOLET PLATFORMS Autolet Platforms OTC AUTOLET PLUS Advocate Lancing Device OTC BD LANCET ULTRAFINE 30G Accu-Chek FastClix Lancets OTC BD LANCET ULTRAFINE 33G Accu-Chek FastClix Lancets OTC BD MICROTAINER LANCETS Accu-Chek FastClix Lancets OTC BULLSEYE SAFETY LANCETS Accu-Chek FastClix Lancets OTC CARDIOCOM LANCING DEVICE Advocate Lancing Device OTC CARESENS CONTROL A IN VITRO SOLUTION Accu-Chek Aviva OTC

CARETOUCH LANCING/EJECTOR Advocate Lancing Device OTC CARETOUCH TWIST LANCETS 30G Accu-Chek FastClix Lancets OTC CHEMSTRIP BG LOG BOOK Chemstrip bG Log Book OTC CLEANLET LANCETS 28G Accu-Chek FastClix Lancets OTC CLEVER CHEK LANCETS Accu-Chek FastClix Lancets OTC CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID Advocate Control Solution OTC

COAGUCHEK LANCETS Accu-Chek FastClix Lancets OTC CONTOUR CONTROL IN VITRO LIQUID Advocate Control Solution OTC

CONTOUR NEXT CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

COOL CONTROL A IN VITRO SOLUTION Accu-Chek Aviva OTC

COOL CONTROL B IN VITRO SOLUTION Accu-Chek Aviva OTC

121

Formulary Drug Name Reference Restrictions DROPLET LANCETS ULTRA THIN 30G Accu-Chek FastClix Lancets OTC DROPLET LANCING DEVICE Advocate Lancing Device OTC DRUG MART LANCING DEVICE Advocate Lancing Device OTC DRUG MART ON-THE-GO LANCET 30G Accu-Chek FastClix Lancets OTC DRUG MART UNILET LANCETS 28G Accu-Chek FastClix Lancets OTC DRUG MART UNILET LANCETS 30G Accu-Chek FastClix Lancets OTC DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Accu-Chek Aviva OTC

EASY STEP CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Accu-Chek Aviva OTC

EASY TOUCH HEALTHPRO CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

EASY TOUCH LANCETS 21G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 23G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 26G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 26G/TWIST Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 28G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 28G/TWIST Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 30G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 30G/TWIST Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 32G Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 32G/TWIST Accu-Chek FastClix Lancets OTC EASY TOUCH LANCETS 33G/TWIST Accu-Chek FastClix Lancets OTC EASY TOUCH LANCING DEVICE Advocate Lancing Device OTC EASY TOUCH SAFETY LANCETS 21G Accu-Chek FastClix Lancets OTC EASY TOUCH SAFETY LANCETS 23G Accu-Chek FastClix Lancets OTC EASY TOUCH SAFETY LANCETS 26G Accu-Chek FastClix Lancets OTC EASY TOUCH SAFETY LANCETS 28G Accu-Chek FastClix Lancets OTC EASY TWIST & CAP LANCETS Accu-Chek FastClix Lancets OTC EASYGLUCO CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

EASYGLUCO PLUS LEVEL 1 IN VITRO SOLUTION Accu-Chek Aviva OTC

EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

EASYMAX 15 LEVEL 1-2 CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

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Formulary Drug Name Reference Restrictions EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

EASYMAX CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

EASYMAX CONTROL NORMAL/LOW IN VITRO SOLUTION Accu-Chek Aviva OTC

ELEMENT CONTROL IN VITRO LIQUID Advocate Control Solution OTC

EMBRACE CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

EMBRACE EVO CONTROL LEVEL 1 IN VITRO LIQUID Advocate Control Solution OTC

EMBRACE EVO CONTROL LEVEL 2 IN VITRO LIQUID Advance Intuition Control OTC

EMBRACE GLUCOSE CONTROL IN VITRO LIQUID Advocate Control Solution OTC

EMBRACE LANCETS ULTRA THIN 30G Accu-Chek FastClix Lancets OTC EMBRACE PRO GLUCOSE CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

EVENCARE CONTROL LOW/HIGH IN VITRO LIQUID Accu-Chek Aviva OTC

EVENCARE G2 LOW/HIGH CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

EVENCARE G3 LOW/HIGH CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

EVENCARE MINI CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

EVOLUTION CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

E-Z JECT LANCET MICRO-THIN 33G Accu-Chek FastClix Lancets OTC E-Z JECT LANCET SUPER THIN 30G Accu-Chek FastClix Lancets OTC E-Z JECT LANCETS Accu-Chek FastClix Lancets OTC E-Z JECT LANCETS 21G Accu-Chek FastClix Lancets OTC E-Z JECT LANCETS THIN 26G Accu-Chek FastClix Lancets OTC EZ SMART BLOOD GLUCOSE LANCETS Accu-Chek FastClix Lancets OTC

EZ-LETS LANCETS 21G Accu-Chek FastClix Lancets OTC EZ-LETS LANCETS 23G Accu-Chek FastClix Lancets OTC EZ-LETS LANCETS 26G Accu-Chek FastClix Lancets OTC EZ-LETS LANCETS 28G Accu-Chek FastClix Lancets OTC EZ-LETS LANCETS 30G Accu-Chek FastClix Lancets OTC FIFTY50 SAFETY SEAL LANCETS Accu-Chek FastClix Lancets OTC

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Formulary Drug Name Reference Restrictions FIFTY50 UNILET LANCETS 33G Accu-Chek FastClix Lancets OTC FINE 30 Accu-Chek FastClix Lancets OTC FINGERSTIX LANCETS Accu-Chek FastClix Lancets OTC FORA CONTROL IN VITRO SOLUTION Advocate Control Solution OTC FORA LANCETS Accu-Chek FastClix Lancets OTC FORA LANCING DEVICE Advocate Lancing Device OTC FORACARE GDH CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

FORTISCARE CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Accu-Chek Aviva OTC

FREESTYLE LANCETS Accu-Chek FastClix Lancets OTC FREESTYLE UNISTICK II LANCETS Accu-Chek FastClix Lancets OTC GENTLE-LET GP LANCETS Accu-Chek FastClix Lancets OTC GENTLE-LET LANCETS Accu-Chek FastClix Lancets OTC GENTLE-LET PLATFORMS Autolet Platforms OTC GLUCOCARD 01 CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

GLUCOCARD SHINE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

GLUCOCOM AUTOLINK TELEMONITOR Chemstrip bG Log Book OTC

GLUCOCOM CONTROL IN VITRO LIQUID Advocate Control Solution OTC

GLUCOCOM LANCETS 28G Accu-Chek FastClix Lancets OTC GLUCOCOM LANCETS 30G Accu-Chek FastClix Lancets OTC GLUCOCOM LANCETS 33G Accu-Chek FastClix Lancets OTC GNP EASY TOUCH CONT HIGH/LOW IN VITRO SOLUTION Accu-Chek Aviva OTC

HAEMOLANCE Accu-Chek FastClix Lancets OTC HAEMOLANCE LOW FLOW LANCETS Accu-Chek FastClix Lancets OTC HAEMOLANCE PLUS Accu-Chek FastClix Lancets OTC HAEMOLANCE PLUS HIGH FLOW Accu-Chek FastClix Lancets OTC HAEMOLANCE PLUS LOW FLOW Accu-Chek FastClix Lancets OTC

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Formulary Drug Name Reference Restrictions HAEMOLANCE PLUS MAX FLOW Accu-Chek FastClix Lancets OTC HAEMOLANCE PLUS PEDIATRIC FLOW Accu-Chek FastClix Lancets OTC

HEALTH CARE LANCING DEVICE Advocate Lancing Device OTC HYPOLANCE AST LANCING KIT Accu-Chek FastClix Lancet OTC HY-VEE LANCETS Accu-Chek FastClix Lancets OTC IN TOUCH Chemstrip bG Log Book OTC IN TOUCH GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

IN TOUCH LANCING DEVICE Advocate Lancing Device OTC IN TOUCH STERILE LANCETS 30G Accu-Chek FastClix Lancets OTC INFINITY CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

LANCETS ULTRA FINE Accu-Chek FastClix Lancets OTC LANCETS ULTRA THIN Accu-Chek FastClix Lancets OTC LANZO Advocate Lancing Device OTC LIBERTY GLUCOSE CONTROL IN VITRO LIQUID Advance Intuition Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Accu-Chek Aviva OTC

LIBERTY MEDICAL LANCETS Accu-Chek FastClix Lancets OTC LIBERTY MINI LANCING DEVICE Advocate Lancing Device OTC LIFESCAN UNISTIK 2 Accu-Chek FastClix Lancets OTC LIFESCAN UNISTIK II LANCETS Accu-Chek FastClix Lancets OTC LITE TOUCH LANCING PEN Advocate Lancing Device OTC LITETOUCH LANCETS Accu-Chek FastClix Lancets OTC MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID Accu-Chek Aviva OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

MEDISENSE HIGH/LOW CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

MEDISENSE MID CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

MEDISENSE THIN LANCETS Accu-Chek FastClix Lancets OTC MEDLANCE EXTRA 21G Accu-Chek FastClix Lancets OTC MEDLANCE LITE 25G Accu-Chek FastClix Lancets OTC MEDLANCE PLUS EXTRA 21G Accu-Chek FastClix Lancets OTC MEDLANCE PLUS LANCETS Accu-Chek FastClix Lancets OTC

125

Formulary Drug Name Reference Restrictions MEDLANCE PLUS LITE 25G Accu-Chek FastClix Lancets OTC MEDLANCE PLUS SPECIAL 0.8MM Accu-Chek FastClix Lancets OTC MEDLANCE PLUS SUPERLITE 30G Accu-Chek FastClix Lancets OTC MEDLANCE PLUS UNIVERSAL 21G Accu-Chek FastClix Lancets OTC MEDLANCE UNIVERSAL 21G Accu-Chek FastClix Lancets OTC MEIJER LANCETS Accu-Chek FastClix Lancets OTC MEIJER LANCETS THIN Accu-Chek FastClix Lancets OTC MEIJER LANCETS UNIVERSAL 21G Accu-Chek FastClix Lancets OTC MEIJER LANCETS UNIVERSAL 30G Accu-Chek FastClix Lancets OTC MEIJER LANCETS UNIVERSAL 33G Accu-Chek FastClix Lancets OTC MEIJER SUPER THIN LANCETS Accu-Chek FastClix Lancets OTC MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Accu-Chek Aviva OTC

MICROLET LANCETS Accu-Chek FastClix Lancets OTC MICROLET NEXT LANCING DEVICE Advocate Lancing Device OTC MICROTAINER SAFETY FLOW LANCET Accu-Chek FastClix Lancets OTC

MONOLET LANCETS Accu-Chek FastClix Lancets OTC MONOLET OPD LANCETS Accu-Chek FastClix Lancets OTC MONOLETTOR SAFETY LANCETS Accu-Chek FastClix Lancets OTC MULTI-LANCET DEVICE 2 KIT Accu-Chek FastClix Lancet OTC MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

MYGLUCOHEALTH LANCETS 30G Accu-Chek FastClix Lancets OTC NEUTEK 2TEK CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

NOVA SAFETY LANCETS 23G Accu-Chek FastClix Lancets OTC NOVA SAFETY LANCETS 28G Accu-Chek FastClix Lancets OTC NOVA SUREFLEX LANCETS Accu-Chek FastClix Lancets OTC NOVA SUREFLEX LANCING DEVICE Advocate Lancing Device OTC ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Accu-Chek Aviva OTC

ON CALL LANCETS Accu-Chek FastClix Lancets OTC ON CALL LANCING DEVICE Advocate Lancing Device OTC ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ON CALL PLUS LANCETS Accu-Chek FastClix Lancets OTC ON CALL PLUS LANCING DEVICE Advocate Lancing Device OTC

126

Formulary Drug Name Reference Restrictions ON CALL VIVID GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ONETOUCH CLUB LANCETS FINE PT Accu-Chek FastClix Lancets OTC ONETOUCH COMBO PACK Accu-Chek FastClix Lancets OTC ONETOUCH DELICA LANCETS 33G Accu-Chek FastClix Lancets OTC ONETOUCH DELICA LANCETS FINE Accu-Chek FastClix Lancets OTC ONETOUCH DELICA LANCING DEV Advocate Lancing Device OTC ONETOUCH FINEPOINT LANCETS Accu-Chek FastClix Lancets OTC ONETOUCH PING METER REMOTE OTC ONETOUCH SURESOFT LANCING DEV Autolet Platforms OTC

ONETOUCH ULTRA 2 KIT Blood Glucose Monitor System OTC

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

ONETOUCH ULTRA MINI KIT Blood Glucose Monitor System OTC

ONETOUCH ULTRALINK KIT Blood Glucose Monitor System OTC

ONETOUCH ULTRASOFT LANCETS Accu-Chek FastClix Lancets OTC ONETOUCH VERIO IN VITRO SOLUTION Accu-Chek Aviva OTC

ONETOUCH VERIO IQ SYSTEM KIT Blood Glucose Monitor System OTC

ONETOUCH VERIO KIT Blood Glucose Monitor System OTC

ONETOUCH VERIO SYNC SYSTEM KIT Blood Glucose Monitor System OTC

OPTUMRX GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

PENLET II BLOOD SAMPLER KIT Accu-Chek FastClix Lancet OTC PENLET II REPLACEMENT CAP Autolet Platforms OTC PERFECT LANCETS 28G Accu-Chek FastClix Lancets OTC PERFECT LANCETS 30G Accu-Chek FastClix Lancets OTC PHARMACIST CHOICE LANCETS Accu-Chek FastClix Lancets OTC PHARMACY COUNTER LANCETS Accu-Chek FastClix Lancets OTC POCKETCHEM EZ CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

PRECISION GLUCOSE CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

PRECISION GLUCOSE CONTROL SOLN IN VITRO SOLUTION Accu-Chek Aviva OTC

127

Formulary Drug Name Reference Restrictions PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID Accu-Chek Aviva OTC

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Accu-Chek Aviva OTC

PRECISION THINS GP LANCETS Accu-Chek FastClix Lancets OTC PRODIGY CONTROL SOLUTION IN VITRO SOLUTION Advocate Control Solution OTC

PRODIGY LANCETS 28G Accu-Chek FastClix Lancets OTC PRODIGY LANCING DEVICE Advocate Lancing Device OTC PRODIGY SAFETY LANCETS 26G Accu-Chek FastClix Lancets OTC PRODIGY TWIST TOP LANCETS 28G Accu-Chek FastClix Lancets OTC PSS SELECT GP LANCETS Accu-Chek FastClix Lancets OTC PSS SELECT PLATFORMS Autolet Platforms OTC PSS SELECT SAFETY LANCETS Accu-Chek FastClix Lancets OTC QUICKTEK CONTROL SOLUTION IN VITRO LIQUID Accu-Chek Aviva OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION Accu-Chek Aviva OTC

RA E-ZJECT COLOR LANCETS 33G Accu-Chek FastClix Lancets OTC RA E-ZJECT LANCETS 28G Accu-Chek FastClix Lancets OTC RA E-ZJECT LANCETS THIN 26G Accu-Chek FastClix Lancets OTC RA E-ZJECT LANCETS THIN 28G Accu-Chek FastClix Lancets OTC RA E-ZJECT LANCETS ULTRA THIN Accu-Chek FastClix Lancets OTC REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

RELION LANCETS MICRO-THIN 33G Accu-Chek FastClix Lancets OTC RELION LANCETS STANDARD 21G Accu-Chek FastClix Lancets OTC RELION LANCETS THIN 26G Accu-Chek FastClix Lancets OTC RELION LANCETS ULTRA-THIN 30G Accu-Chek FastClix Lancets OTC RELION LANCING DEVICE Advocate Lancing Device OTC RELION LANCING DEVICE KIT Accu-Chek FastClix Lancet OTC RELION ULTRA THIN LANCETS 30G Accu-Chek FastClix Lancets OTC RELION ULTRA THIN PLUS LANCETS Accu-Chek FastClix Lancets OTC REXALL LANCETS ULTRA THIN 30G Accu-Chek FastClix Lancets OTC RIGHTEST ALTERNATE SITE ADAPT Autolet Platforms OTC RIGHTEST GC300 CONTROL IN VITRO LIQUID Advocate Control Solution OTC

RIGHTEST GD500 LANCING DEVICE Advocate Lancing Device OTC RIGHTEST GL300 LANCETS Accu-Chek FastClix Lancets OTC SAFE-T-LANCE Accu-Chek FastClix Lancets OTC

128

Formulary Drug Name Reference Restrictions SAFE-T-LANCE PLUS Accu-Chek FastClix Lancets OTC SAFETY LANCETS Accu-Chek FastClix Lancets OTC SAFETY LANCETS 21G Accu-Chek FastClix Lancets OTC SAFETY LET LANCETS Accu-Chek FastClix Lancets OTC SAFETY SEAL LANCETS Accu-Chek FastClix Lancets OTC SHOPKO AUTOLET LANCING DEVICE Advocate Lancing Device OTC SHOPKO ON-THE-GO LANCETS 30G Accu-Chek FastClix Lancets OTC SHOPKO UNILET LANCETS 28G Accu-Chek FastClix Lancets OTC SHOPKO UNILET LANCETS 30G Accu-Chek FastClix Lancets OTC SIMPLE DIAGNOSTICS LANCING DEV Advocate Lancing Device OTC SINGLE-LET Accu-Chek FastClix Lancets OTC SMART DIABETES VANTAGE LANCING Advocate Lancing Device OTC

SMART SENSE COLOR LANCETS 33G Accu-Chek FastClix Lancets OTC SMART SENSE STANDARD LANCETS Accu-Chek FastClix Lancets OTC SMART SENSE SUPER THIN LANCETS Accu-Chek FastClix Lancets OTC SMART SENSE THIN LANCETS 26G Accu-Chek FastClix Lancets OTC SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Accu-Chek Aviva OTC

SMARTEST LANCETS 28G Accu-Chek FastClix Lancets OTC SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Accu-Chek Aviva OTC

SOLUS V2 CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

SOLUS V2 LANCETS 28G Accu-Chek FastClix Lancets OTC SOLUS V2 LANCING DEVICE Advocate Lancing Device OTC SOLUS V2 TWIST LANCETS 30G Accu-Chek FastClix Lancets OTC STERILANCE PA Autolet Platforms OTC STERILANCE TL Accu-Chek FastClix Lancets OTC SURE-LANCE FLAT LANCETS Accu-Chek FastClix Lancets OTC SURE-LANCE LANCETS 26G Accu-Chek FastClix Lancets OTC SURE-LANCE THIN LANCETS 28G Accu-Chek FastClix Lancets OTC SURE-LANCE ULTRA THIN LANCETS Accu-Chek FastClix Lancets OTC SURELITE LANCETS Accu-Chek FastClix Lancets OTC SURE-PEN Advocate Lancing Device OTC SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID Advocate Control Solution OTC

SURESTEP PRO LINEARITY KIT Chemstrip bG Log Book OTC 129

Formulary Drug Name Reference Restrictions SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID Advocate Control Solution OTC

SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID Advance Intuition Control OTC

SURE-TOUCH LANCETS UNIVERSAL Accu-Chek FastClix Lancets OTC TAI DOC CONTROL IN VITRO SOLUTION Advance Intuition Control OTC

TECHLITE AST LANCETS Accu-Chek FastClix Lancets OTC TECHLITE LANCETS Accu-Chek FastClix Lancets OTC TECHLITE LANCETS 30G Accu-Chek FastClix Lancets OTC TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

THINLETS GP LANCETS Accu-Chek FastClix Lancets OTC TRACER II 3 VOLT BATTERY Chemstrip bG Log Book OTC TRAVEL LANCETS ADVANCED 28G Accu-Chek FastClix Lancets OTC TRUE METRIX LEVEL 1 IN VITRO SOLUTION Advocate Control Solution OTC

TRUE METRIX LEVEL 2 IN VITRO SOLUTION Advance Intuition Control OTC

TRUE METRIX LEVEL 3 IN VITRO SOLUTION Advocate Control Solution OTC

TRUECONTROL GLUCOSE CONT LEV 0 IN VITRO LIQUID Accu-Chek Aviva OTC

TRUECONTROL GLUCOSE CONT LEV 1 IN VITRO LIQUID Accu-Chek Aviva OTC

TRUEDRAW LANCING DEVICE Advocate Lancing Device OTC TRUEPLUS LANCETS 26G Accu-Chek FastClix Lancets OTC TRUEPLUS LANCETS 28G Accu-Chek FastClix Lancets OTC TRUEPLUS LANCETS 30G Accu-Chek FastClix Lancets OTC TRUEPLUS LANCETS 33G Accu-Chek FastClix Lancets OTC TRUEPLUS SAFETY LANCETS 28G Accu-Chek FastClix Lancets OTC ULTI-LANCE AUTOMATIC Advocate Lancing Device OTC ULTILET CLASSIC LANCETS Accu-Chek FastClix Lancets OTC ULTILET LANCETS Accu-Chek FastClix Lancets OTC ULTILET SAFETY LANCETS 23G Accu-Chek FastClix Lancets OTC ULTRALANCE Autolet Platforms OTC ULTRA-THIN II AUTO LANCET Accu-Chek FastClix Lancets OTC ULTRA-THIN II LANCETS Accu-Chek FastClix Lancets OTC ULTRATRAK PRO CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

130

Formulary Drug Name Reference Restrictions ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Accu-Chek Aviva OTC

UNILET COMFORTOUCH LANCET Accu-Chek FastClix Lancets OTC UNILET EXCELITE Accu-Chek FastClix Lancets OTC UNILET EXCELITE II Accu-Chek FastClix Lancets OTC UNILET G.P. LANCET Accu-Chek FastClix Lancets OTC UNILET G.P. SUPERLITE LANCET Accu-Chek FastClix Lancets OTC UNILET GP 28 ULTRA THIN Accu-Chek FastClix Lancets OTC UNILET LANCET Accu-Chek FastClix Lancets OTC UNILET MICRO-THIN 33G Accu-Chek FastClix Lancets OTC UNILET SUPERLITE LANCET Accu-Chek FastClix Lancets OTC UNILET SUPER-THIN 30G Accu-Chek FastClix Lancets OTC UNILET ULTRA-THIN 28G Accu-Chek FastClix Lancets OTC UNISTIK 1 Autolet Platforms OTC UNISTIK 2 Autolet Platforms OTC UNISTIK 2 COMFORT Autolet Platforms OTC UNISTIK 2 EXTRA Autolet Platforms OTC UNISTIK 2 NEONATAL Autolet Platforms OTC UNISTIK 2 NORMAL Autolet Platforms OTC UNISTIK 2 SUPER Autolet Platforms OTC UNISTIK 3 Autolet Platforms OTC UNISTIK 3 COMFORT Autolet Platforms OTC UNISTIK 3 EXTRA Autolet Platforms OTC UNISTIK 3 GENTLE Accu-Chek FastClix Lancets OTC UNISTIK 3 NEONATAL Autolet Platforms OTC UNISTIK 3 NORMAL Autolet Platforms OTC UNISTIK CZT COMFORT Autolet Platforms OTC UNISTIK CZT NORMAL Autolet Platforms OTC UNISTIK SAFETY LANCETS 28G Accu-Chek FastClix Lancets OTC UNISTIK SAFETY LANCETS 30G Accu-Chek FastClix Lancets OTC UNISTIK TOUCH SAFETY LANC 21G Accu-Chek FastClix Lancets OTC UNISTIK TOUCH SAFETY LANC 23G Accu-Chek FastClix Lancets OTC UNISTIK TOUCH SAFETY LANC 28G Accu-Chek FastClix Lancets OTC UNISTIK TOUCH SAFETY LANC 30G Accu-Chek FastClix Lancets OTC UNISTRIP CONTROL IN VITRO SOLUTION Advocate Control Solution OTC

UNIVERSAL 1 LANCETS THIN 26G Accu-Chek FastClix Lancets OTC UNIVERSAL 1 LANCETS THIN 33G Accu-Chek FastClix Lancets OTC UNIVERSAL 1 LANCETS ULTRA THIN Accu-Chek FastClix Lancets OTC

131

Formulary Drug Name Reference Restrictions VICTORY CONTROL LEVEL 1/2 IN VITRO SOLUTION Accu-Chek Aviva OTC

VIDA MIA AUTOLET LANCING DEV Advocate Lancing Device OTC VIDA MIA UNILET LANCETS 28G Accu-Chek FastClix Lancets OTC VIDA MIA UNILET LANCETS 30G Accu-Chek FastClix Lancets OTC VITALET PRO LANCETS Accu-Chek FastClix Lancets OTC VITALET PRO PLUS LANCETS Accu-Chek FastClix Lancets OTC WALGREENS LANCETS Accu-Chek FastClix Lancets OTC WALGREENS THIN LANCETS Accu-Chek FastClix Lancets OTC WALGREENS ULTRA THIN LANCETS Accu-Chek FastClix 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 Eclipse Syringe OTC sb insulin syringe Advocate Insulin Syringe OTC

132

Formulary Drug Name Reference Restrictions sure comfort insulin syringe Advocate Insulin Syringe OTC syringe OTC syringe luer slip BD Eclipse Syringe OTC syringe/hypodermic safety Monoject LifeShield Syringe OTC topcare ultra comfort ins syr Advocate Insulin Syringe OTC ultra comfort insulin syringe Advocate Insulin Syringe OTC ultra-comfort insulin syringe 28g x 1/2" 0.5 ml BD Insulin Syringe MicroFine OTC ultra-comfort insulin syringe 28g x 1/2" 1 ml BD Insulin Syringe MicroFine OTC ultra-comfort insulin syringe 29g x 1/2" 0.3 ml Advocate Insulin Syringe OTC; QLL (1 EA per 365 days) ultra-comfort insulin syringe 29g x 1/2" 0.5 ml Advocate Insulin Syringe OTC ultra-comfort insulin syringe 29g x 1/2" 1 ml Advocate Insulin Syringe OTC ultra-comfort insulin syringe 30g x 5/16" 0.3 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 30g x 5/16" 0.5 ml Advocate Insulin Syringe OTC

ultra-comfort insulin syringe 30g x 5/16" 1 ml Advocate Insulin Syringe OTC 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 Advocate Insulin Syringe OTC ASSURE ID INSULIN SAFETY SYR Advocate Insulin Syringe BD ECLIPSE SYRINGE BD Eclipse Syringe OTC BD INSULIN SYR ULTRAFINE II Advocate 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 BD Insulin Syringe OTC BD INSULIN SYRINGE 29G X 1/2" 1 ML Advocate Insulin Syringe OTC BD INSULIN SYRINGE MICROFINE BD Insulin Syringe MicroFine OTC BD INSULIN SYRINGE U/F BD Insulin Syringe U/F OTC BD INSULIN SYRINGE U/F 1/2UNIT Advocate Insulin Syringe OTC BD INSULIN SYRINGE U-100 1 ML BD Insulin Syringe OTC; QLL (1 EA per 365 days) BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)

133

Formulary Drug Name Reference Restrictions BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML Advocate Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML Advocate Insulin Syringe OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML BD Insulin Syringe U/F OTC

BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.5 ML BD Insulin Syringe U/F OTC

BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 ML Advocate Insulin Syringe OTC

BD LUER-LOK SYRINGE OTC BD PEN NEEDLE NANO U/F Insupen Pen Needles ST BD PEN NEEDLE SHORT U/F RA Pen Needles ST; OTC BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)

BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML Advocate Insulin Syringe OTC


BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML TechLITE Insulin Syringe


BD SAFETYGLIDE SYRINGE/NEEDLE OTC BD SAFETY-LOK INSULIN SYRINGE Advocate Insulin Syringe OTC BD SYRINGE/NEEDLE BD Eclipse Syringe OTC BD SYRINGE/NEEDLE SLIP TIP BD Eclipse Syringe OTC BD VEO INSULIN SYRINGE U/F TechLITE Insulin Syringe OTC COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.5 ML Advocate Insulin Syringe OTC

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML Advocate Insulin Syringe OTC





134

Formulary Drug Name Reference Restrictions COMFORT ASSIST INSULIN SYRINGE 31G X 5/16" 0.5 ML Advocate Insulin Syringe OTC


COMFORT EZ INSULIN SYRINGE Advocate Insulin Syringe OTC EASY TOUCH FLIPLOCK INSULIN SY Advocate Insulin Syringe OTC EASY TOUCH FLIPLOCK SAFETY SYR OTC EASY TOUCH FLURINGE BD Eclipse Syringe OTC EASY TOUCH FLURINGE FLIPLOCK BD Eclipse Syringe OTC EASY TOUCH FLURINGE SHEATHLOCK BD Eclipse Syringe OTC

EASY TOUCH INSULIN SAFETY SYR Advocate Insulin Syringe OTC EASY TOUCH INSULIN SYRINGE Advocate Insulin Syringe OTC EASY TOUCH SAFETY SYRINGE BD Eclipse Syringe OTC EASY TOUCH SHEATHLOCK SYRINGE Advocate Insulin Syringe OTC EASY TOUCH TB SHEATHLOCK SYR OTC EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML BD Insulin Syringe MicroFine OTC

EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 1 ML BD Insulin Syringe MicroFine OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.5 ML Advocate Insulin Syringe OTC

EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 1 ML Advocate Insulin Syringe OTC



EXEL COMFORT POINT INSULIN SYR 30G X 5/16" 1 ML Advocate Insulin Syringe OTC

FIFTY50 SUPERIOR COMFORT SYR Advocate Insulin Syringe OTC FREESTYLE PRECISION INS SYR Advocate Insulin Syringe OTC GLUCOPRO INSULIN SYRINGE Advocate Insulin Syringe OTC LITETOUCH INSULIN SYRINGE Advocate Insulin Syringe OTC MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML Advocate Insulin Syringe QLL (1 EA per 365 days)

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML Advocate Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML Advocate Insulin Syringe

135

Formulary Drug Name Reference Restrictions MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.3 ML Advocate Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 0.5 ML Advocate Insulin Syringe

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML Advocate Insulin Syringe

MAXI-COMFORT INSULIN SYRINGE BD Insulin Syringe MicroFine OTC MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML OTC

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML (OTC) BD Insulin Syringe

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML (RX) BD Insulin Syringe

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML (OTC) BD Insulin Syringe MicroFine

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML (RX) BD Insulin Syringe MicroFine

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML (OTC) BD Insulin Syringe MicroFine

MONOJECT INSULIN SYRINGE 28G X 1/2" 1 ML (RX) BD Insulin Syringe MicroFine

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe QLL (1 EA per 365 days)

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.5 ML Advocate Insulin Syringe

MONOJECT INSULIN SYRINGE 29G X 1/2" 1 ML (RX) Advocate Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML Advocate Insulin Syringe

MONOJECT INSULIN SYRINGE 30G X 5/16" 0.5 ML (RX) Advocate Insulin Syringe

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

MONOJECT INSULIN SYRINGE 30G X 5/16" 1 ML (RX) Advocate Insulin Syringe

MONOJECT INSULIN SYRINGE 31G X 5/16" 1 ML Advocate Insulin Syringe OTC

MONOJECT INSULIN SYRINGE U-100 1 ML BD Insulin Syringe QLL (1 EA per 365 days)

MONOJECT LIFESHIELD SYRINGE Monoject LifeShield Syringe MONOJECT MAGELLAN SYRINGE MONOJECT SYRINGE

136

Formulary Drug Name Reference Restrictions MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML (OTC) BD Insulin Syringe MicroFine

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML (RX) BD Insulin Syringe MicroFine

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML (OTC) BD Insulin Syringe MicroFine

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 ML (RX) BD Insulin Syringe MicroFine

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.5 ML Advocate Insulin Syringe OTC

MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 1 ML Advocate Insulin Syringe OTC

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

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3 ML (RX) Advocate Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML (OTC) Advocate Insulin Syringe

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5 ML (RX) Advocate Insulin Syringe



PRECISION SUREDOSE PLUS SYR Advocate Insulin Syringe OTC PRECISION SURE-DOSE SYRINGE Advocate Insulin Syringe OTC PRODIGY INSULIN SYRINGE Advocate Insulin Syringe OTC RELION INSULIN SYRINGE Advocate 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 Advocate 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 Advocate Insulin Syringe OTC SURE-JECT INSULIN SYRINGE Advocate Insulin Syringe OTC

137

Formulary Drug Name Reference Restrictions TRUEPLUS INSULIN SYRINGE Advocate Insulin Syringe OTC ULTICARE INSULIN SAFETY SYR Advocate Insulin Syringe ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML BD Insulin Syringe MicroFine OTC

ULTICARE INSULIN SYRINGE 28G X 1/2" 1 ML BD Insulin Syringe MicroFine OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 29G X 1/2" 0.3 ML Advocate Insulin Syringe OTC; QLL (1 EA per 365 days)


ULTICARE INSULIN SYRINGE 29G X 1/2" 1 ML Advocate Insulin Syringe OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 0.3 ML BD Insulin Syringe U/F OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 0.5 ML BD Insulin Syringe U/F OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML BD Insulin Syringe U/F OTC







ULTICARE SYRINGE UltiCare Syringe OTC ULTILET INSULIN SYRINGE SHORT Advocate Insulin Syringe OTC ULTRA-THIN II INS SYR SHORT Advocate Insulin Syringe OTC ULTRA-THIN II INSULIN SYRINGE Advocate Insulin Syringe OTC VANISHPOINT INSULIN SYRINGE Advocate Insulin Syringe OTC VANISHPOINT SYRINGE OTC

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device AeroChamber Mini Chamber QLL (1 EA per 365 days)

138

Formulary Drug Name Reference Restrictions AEROCHAMBER MINI CHAMBER DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

AEROCHAMBER MV AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU MEDIUM AeroChamber Mini Chamber QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLO-VU SMALL AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK AeroChamber Mini Chamber QLL (1 EA per 365 days)

AEROCHAMBER PLUS FLOW VU AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR AeroChamber Mini Chamber QLL (1 EA per 365 days)

AEROCHAMBER Z-STAT PLUS/LARGE AeroChamber Mini Chamber QLL (1 EA per 365 days) AEROCHAMBER Z-STAT PLUS/MEDIUM AeroChamber Mini Chamber QLL (1 EA per 365 days)

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

BREATHERITE/LARGE MASK AeroChamber Mini Chamber QLL (1 EA per 365 days) BREATHERITE/MEDIUM MASK AeroChamber Mini Chamber QLL (1 EA per 365 days) BREATHERITE/SMALL MASK AeroChamber Mini Chamber QLL (1 EA per 365 days) CLEVER CHOICE HOLDING CHAMBER DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) COMPACT SPACE CHAMBER/LG MASK DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/MED MASK DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

COMPACT SPACE CHAMBER/SM MASK DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

139

Formulary Drug Name Reference Restrictions EASIVENT AeroChamber Mini Chamber QLL (1 EA per 365 days) EASIVENT MASK LARGE AeroChamber Mini Chamber QLL (1 EA per 365 days) EASIVENT MASK MEDIUM AeroChamber Mini Chamber QLL (1 EA per 365 days) EASIVENT MASK SMALL AeroChamber Mini Chamber QLL (1 EA per 365 days) FLEXICHAMBER DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/LARGE DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/MEDIUM DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) INSPIRACHAMBER/MOUTHPIECE DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

INSPIRACHAMBER/SMALL DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) INSPIREASE AeroChamber Mini Chamber QLL (1 EA per 365 days) LITEAIRE DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days) MICROCHAMBER AeroChamber Mini Chamber QLL (1 EA per 365 days) MICROSPACER AeroChamber Mini Chamber QLL (1 EA per 365 days) OPTICHAMBER ADVANTAGE-LG MASK AeroChamber Mini Chamber QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-MED MASK AeroChamber Mini Chamber QLL (1 EA per 365 days)

OPTICHAMBER ADVANTAGE-SM MASK AeroChamber Mini Chamber QLL (1 EA per 365 days)

OPTICHAMBER DIAMOND AeroChamber Mini Chamber QLL (1 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

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

WATCHHALER DEVICE AeroChamber Mini Chamber QLL (1 EA per 365 days)

140

Formulary Drug Name Reference Restrictions *MIGRAINE PRODUCTS* *Selective Serotonin Agonists 5-Ht(1)***

rizatriptan benzoate oral tablet Maxalt QLL (12 EA per 30 days); AL (Min 6 Years)

rizatriptan benzoate oral tablet dispersible Maxalt-MLT QLL (12 EA per 30 days); AL (Min 6 Years)

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

sumatriptan succinate tablet 100 mg oral Imitrex AL (Min 18 Years)

sumatriptan succinate tablet 100 mg oral Imitrex QLL (9 EA per 30 days); AL (Min 18 Years)





*MINERALS & ELECTROLYTES* *Bicarbonates*** sodium acetate intravenous solution sodium bicarbonate intravenous solution sodium lactate intravenous solution

*Calcium*** calcium acetate oral tablet OTC calcium carbonate antacid oral suspension OTC calcium carbonate oral tablet Caltrate 600 OTC calcium chloride intravenous solution calcium gluconate intravenous solution gnp calcium oral tablet High Potency Calcium OTC oyster shell calcium oral tablet Oysco 500 OTC CALCITRATE ORAL TABLET OTC OYSCO 500 ORAL TABLET Oysco 500 OTC

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

141

Formulary Drug Name Reference Restrictions kcl in d5w lactated ringers intravenous solution kcl in dextrose-nacl intravenous solution kcl-lactated ringers-d5w intravenous solution potassium chloride in dextrose intravenous solution IONOSOL-MB IN D5W INTRAVENOUS SOLUTION ISOLYTE-P IN D5W INTRAVENOUS SOLUTION NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

*Electrolytes Parenteral*** lactated ringers intravenous solution 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

142

Formulary Drug Name Reference Restrictions *Manganese*** manganese chloride intravenous solution

*Phosphate*** potassium phosphates intravenous solution sodium phosphates intravenous solution virt-phos 250 neutral oral tablet K-Phos-Neutral K-PHOS ORAL TABLET K-PHOS-NEUTRAL ORAL TABLET K-Phos-Neutral PHOSPHA 250 NEUTRAL ORAL TABLET K-Phos-Neutral

*Potassium Combinations*** EFFER-K ORAL TABLET EFFERVESCENT

*Potassium*** potassium acetate intravenous solution potassium chloride crys er oral tablet extended release Klor-Con M20

potassium chloride er oral capsule extended release Klor-Con Sprinkle

potassium chloride er oral tablet extended release K-Tab

potassium chloride intravenous solution potassium chloride oral packet Klor-Con potassium chloride oral solution EFFER-K ORAL TABLET EFFERVESCENT Potassium Bicarbonate

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE K-Tab

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE Klor-Con M10

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE KLOR-CON M20 ORAL TABLET EXTENDED RELEASE Klor-Con M20

KLOR-CON ORAL PACKET Klor-Con KLOR-CON ORAL TABLET EXTENDED RELEASE K-Tab

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE Klor-Con Sprinkle

KLOR-CON/EF ORAL TABLET EFFERVESCENT Potassium Bicarbonate

143

Formulary Drug Name Reference Restrictions *Sodium***

normal saline flush intravenous solution BD PosiFlush QLL (150 SYRINGES per 30 days)

sodium chloride injection solution sodium chloride intravenous solution

*Trace Mineral Combinations*** multitrace-4 concentrate intravenous solution multitrace-5 concentrate intravenous solution MULTITRACE-4 INTRAVENOUS SOLUTION MULTITRACE-4 NEONATAL INTRAVENOUS SOLUTION MULTITRACE-4 PEDIATRIC INTRAVENOUS SOLUTION MULTITRACE-5 INTRAVENOUS SOLUTION

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

*Zinc*** zinc sulfate intravenous solution zinc trace metal intravenous solution

*MONOBACTAMS*** *Monobactams*** aztreonam injection solution reconstituted Azactam

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine viscous hcl mouth/throat solution

*Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge clotrimazole mouth/throat troche nystatin mouth/throat suspension

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution Paroex

*Saliva Stimulants*** pilocarpine hcl oral tablet Salagen

144

Formulary Drug Name Reference Restrictions *Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste Oralone

*MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** *Mucopolysaccharidosis Vii (Mps Vii) - Agents*** MEPSEVII INTRAVENOUS SOLUTION

*MULTIVITAMINS* *B-Complex W/ C & Folic Acid*** vp-vite rx oral tablet Dialyvite DIALYVITE ORAL TABLET Dialyvite NEPHRO-VITE RX ORAL TABLET Dialyvite

*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 & Calcium-Folic Acid*** TL G-FOL OS ORAL TABLET

*Multiple Vitamins W/ Minerals & Folic Acid*** CORVITA ORAL TABLET DIALYVITE SUPREME D ORAL TABLET

*Multiple Vitamins W/ Minerals***

abdek oral capsule ActivNutrients OTC; QLL (2 EA per 1 day); AL (Min 4 Years)

AQUADEKS ORAL TABLET CHEWABLE RA One Daily Gummy Vites OTC; QLL (2 EA per 1 day);

AL (Min 4 Years)

BACMIN ORAL TABLET EQ Complete Multivit Adult 50+

145


STROVITE ONE ORAL TABLET EQ Complete Multivit Adult 50+

*Multivitamins*** INFUVITE ADULT INTRAVENOUS INJECTABLE M.V.I. ADULT INTRAVENOUS INJECTABLE

*Ped Multi Vitamins W/Fl & Fe*** POLY-VI-FLOR/IRON ORAL SUSPENSION POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE

*Ped Multiple Vitamins W/ Minerals & C***

AQUADEKS ORAL LIQUID ABDEK Pediatric OTC; QLL (60 ML per 30 days); AL (Min 3 Years)

*Ped Mv W/ Fluoride*** multivitamin/fluoride oral tablet chewable MVC-Fluoride AL (Max 12 Years) POLY-VI-FLOR ORAL SUSPENSION POLY-VI-FLOR ORAL TABLET CHEWABLE AL (Max 12 Years)

QUFLORA PEDIATRIC TABLET CHEWABLE 0.5 MG ORAL MVC-Fluoride

QUFLORA PEDIATRIC TABLET CHEWABLE 1 MG ORAL MVC-Fluoride AL (Max 12 Years)

*Ped Vitamins Acd & Fa W/ Fluoride*** TRI-VI-FLOR ORAL SUSPENSION Tri-Vi-Floro

*Ped Vitamins Acd W/ Fluoride*** tri-vitamin/fluoride oral solution

*Pediatric Multiple Vitamins*** INFUVITE PEDIATRIC INTRAVENOUS SOLUTION M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

*Prenatal Mv & Min W/Fe-Fa*** c-nate dha oral capsule Viva DHA completenate oral tablet chewable m-natal plus oral tablet M-Vit pnv-omega oral capsule Zatean-Pn Plus

146

Formulary Drug Name Reference Restrictions prenatal oral tablet M-Vit prenatal vitamin plus low iron oral tablet M-Vit preplus oral tablet M-Vit se-natal 19 oral tablet se-natal 19 oral tablet chewable thrivite 19 oral tablet trinatal rx 1 oral tablet Vinate One virt-c dha oral capsule Concept DHA virt-nate dha oral capsule Viva DHA virt-pn plus oral capsule Zatean-Pn Plus vol-plus oral tablet M-Vit CITRANATAL B-CALM ORAL CONCEPT DHA ORAL CAPSULE Concept DHA CONCEPT OB ORAL CAPSULE ELITE-OB ORAL TABLET FOLIVANE-OB ORAL CAPSULE NIVA-PLUS ORAL TABLET M-Vit OB COMPLETE ORAL TABLET PROVIDA OB ORAL CAPSULE SELECT-OB ORAL TABLET CHEWABLE TARON-C DHA ORAL CAPSULE Concept DHA VITAFOL GUMMIES ORAL TABLET CHEWABLE VITAFOL-NANO ORAL TABLET VITAFOL-OB ORAL TABLET Mynatal-Z ZATEAN-PN PLUS ORAL CAPSULE Zatean-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

147

Formulary Drug Name Reference Restrictions 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 Zatean-Pn DHA

*MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen tablet 10 mg oral QLL (8 EA per 1 day) baclofen tablet 20 mg oral QLL (4 EA per 1 day) baclofen tablet 5 mg oral chlorzoxazone oral tablet QLL (6 FILLS per 365 days) cyclobenzaprine hcl oral tablet QLL (6 FILLS per 365 days) methocarbamol oral tablet 500 mg Robaxin methocarbamol oral tablet 750 mg Robaxin-750 methocarbamol tablet 500 mg oral Robaxin methocarbamol tablet 500 mg oral Robaxin QLL (6 FILLS per 365 days) methocarbamol tablet 750 mg oral Robaxin-750 QLL (6 FILLS per 365 days) tizanidine hcl oral tablet QLL (6 FILLS per 365 days)

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Antihistamines*** azelastine hcl nasal solution

*Nasal Steroids*** budesonide nasal suspension Rhinocort Allergy cvs fluticasone propionate nasal suspension ClariSpray OTC; QLL (16 GM per 30 days) fluticasone propionate nasal suspension 50 mcg/act ClariSpray QLL (16 GM per 30 days)

fluticasone propionate suspension 50 mcg/act nasal (rx) ClariSpray ST; QLL (16 GM per 30 days)

mometasone furoate nasal suspension Nasonex ST; QLL (17 GM per 30 days) triamcinolone acetonide nasal aerosol Nasacort Allergy 24HR FLONASE SENSIMIST NASAL SUSPENSION OTC

148

Formulary Drug Name Reference Restrictions *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** ENTRESTO ORAL TABLET

*NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet Rilutek

*Neuromuscular Blocking Agent -Neurotoxins*** BOTOX INJECTION SOLUTION RECONSTITUTED PA

*NUTRIENTS* *Amino Acid Mixtures*** AMINOSYN II INTRAVENOUS SOLUTION Amino Acid

AMINOSYN-PF INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION CLINIMIX N14G30E INTRAVENOUS SOLUTION CLINIMIX N9G15E INTRAVENOUS SOLUTION CLINIMIX N9G20E INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION

149

Formulary Drug Name Reference Restrictions CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION CLINISOL SF INTRAVENOUS SOLUTION FREAMINE HBC INTRAVENOUS SOLUTION FREAMINE III INTRAVENOUS SOLUTION Amino Acid

HEPATAMINE INTRAVENOUS SOLUTION NEPHRAMINE INTRAVENOUS SOLUTION PLENAMINE INTRAVENOUS SOLUTION PREMASOL INTRAVENOUS SOLUTION Amino Acid

PROCALAMINE INTRAVENOUS SOLUTION PROSOL INTRAVENOUS SOLUTION SYNTHAMIN 17 INTRAVENOUS SOLUTION Amino Acid

TRAVASOL INTRAVENOUS SOLUTION Amino Acid TROPHAMINE INTRAVENOUS SOLUTION

*Amino Acids-Single*** l-cysteine hcl intravenous solution Elcys

*Carbohydrates*** dextrose intravenous solution glucose intravenous solution

*Lipids*** nutrilipid intravenous emulsion Intralipid INTRALIPID INTRAVENOUS EMULSION Intralipid

150

Formulary Drug Name Reference Restrictions *OPHTHALMIC AGENTS* *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** SIMBRINZA OPHTHALMIC SUSPENSION

*Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution Cosopt QLL (10 ML per 30 days)

COMBIGAN OPHTHALMIC SOLUTION

*Beta-Blockers - Ophthalmic*** carteolol hcl ophthalmic solution levobunolol hcl ophthalmic solution timolol maleate ophthalmic gel forming solution Timoptic-XE

timolol maleate ophthalmic solution Istalol QLL (15 ML per 30 days)

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment atropine sulfate ophthalmic solution Isopto Atropine cyclopentolate hcl ophthalmic solution Cyclogyl

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

151

Formulary Drug Name Reference Restrictions ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION Alaway OTC

ALAWAY OPHTHALMIC SOLUTION Alaway OTC CLARITIN EYE OPHTHALMIC SOLUTION Alaway OTC

PAZEO OPHTHALMIC SOLUTION ST THERATEARS ALLERGY OPHTHALMIC SOLUTION Alaway OTC

ZADITOR OPHTHALMIC SOLUTION Alaway OTC

*Ophthalmic Antibiotics*** ciprofloxacin hcl ophthalmic solution Ciloxan erythromycin ophthalmic ointment gentamicin sulfate ophthalmic solution moxifloxacin hcl ophthalmic solution Vigamox QLL (6 ML per 30 days) ofloxacin ophthalmic solution Ocuflox tobramycin ophthalmic solution Tobrex QLL (10 ML per 30 days) MOXEZA OPHTHALMIC SOLUTION

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

polymyxin b-trimethoprim ophthalmic solution Polytrim

*Ophthalmic Antivirals*** trifluridine ophthalmic solution

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

*Ophthalmic Decongestants*** phenylephrine hcl ophthalmic solution Altafrin

*Ophthalmic Immunomodulators*** RESTASIS MULTIDOSE OPHTHALMIC EMULSION RESTASIS OPHTHALMIC EMULSION

*Ophthalmic Irrigation Solutions*** balanced salt intraocular solution BSS

152

Formulary Drug Name Reference Restrictions *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution flurbiprofen sodium ophthalmic solution ketorolac tromethamine ophthalmic solution Acular ILEVRO OPHTHALMIC SUSPENSION

*Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic solution

*Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic ointment Neo-Polycin HC

neomycin-polymyxin-dexameth ophthalmic ointment Maxitrol

neomycin-polymyxin-dexameth ophthalmic suspension Maxitrol

sulfacetamide-prednisolone ophthalmic solution QLL (10 ML per 30 days)

tobramycin-dexamethasone ophthalmic suspension TobraDex

TOBRADEX OPHTHALMIC OINTMENT ZYLET OPHTHALMIC SUSPENSION

*Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution loteprednol etabonate ophthalmic suspension Lotemax prednisolone acetate ophthalmic suspension Pred Forte ALREX OPHTHALMIC SUSPENSION DUREZOL OPHTHALMIC EMULSION FLAREX OPHTHALMIC SUSPENSION FML FORTE OPHTHALMIC SUSPENSION FML OPHTHALMIC OINTMENT LOTEMAX OPHTHALMIC SUSPENSION Lotemax

MAXIDEX OPHTHALMIC SUSPENSION

*Ophthalmics - Cystinosis Agents** CYSTARAN OPHTHALMIC SOLUTION QLL (60 ML per 28 days)

153

Formulary Drug Name Reference Restrictions *Prostaglandins - Ophthalmic*** latanoprost ophthalmic solution Xalatan QLL (5 ML per 30 days) TRAVATAN Z OPHTHALMIC SOLUTION QLL (5 ML per 30 days)

*OPHTHALMIC RHO KINASE INHIBITORS*** *Ophthalmic Rho Kinase Inhibitors*** RHOPRESSA OPHTHALMIC SOLUTION Auto-PA

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution

*Otic Anti-Infectives*** ofloxacin otic solution Floxin Otic AL (Min 12 Years)

*Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution neomycin-polymyxin-hc otic suspension CIPRODEX OTIC SUSPENSION

*Otic Steroids*** fluocinolone acetonide otic oil DermOtic

*OXYTOCICS* *Oxytocics*** methylergonovine maleate oral tablet Methergine

*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

154

Formulary Drug Name Reference Restrictions FLEBOGAMMA DIF INTRAVENOUS SOLUTION PA

GAMASTAN S/D INTRAMUSCULAR INJECTABLE PA

GAMMAGARD INJECTION SOLUTION PA GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED

PA

GAMMAKED INJECTION SOLUTION PA GAMMAPLEX INTRAVENOUS SOLUTION PA

GAMUNEX-C INJECTION SOLUTION PA HIZENTRA SUBCUTANEOUS SOLUTION PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION PA

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

QLL (2 PRESCRIPTIONS per 365 days)

NABI-HB INTRAMUSCULAR SOLUTION PA

OCTAGAM INTRAVENOUS SOLUTION PA PRIVIGEN INTRAVENOUS SOLUTION PA

*PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable 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

155

Formulary Drug Name Reference Restrictions BICILLIN L-A INTRAMUSCULAR SUSPENSION

*Penicillin Combinations*** amoxicillin-pot clavulanate oral suspension reconstituted amoxicillin-pot clavulanate oral tablet ampicillin-sulbactam sodium injection solution reconstituted Unasyn

ampicillin-sulbactam sodium intravenous solution reconstituted piperacillin sod-tazobactam so intravenous solution reconstituted Zosyn

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION BICILLIN C-R INTRAMUSCULAR SUSPENSION

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule

*PERITONEAL DIALYSIS SOLUTIONS*** *Peritoneal Dialysis Solutions*** DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION

*PHARMACEUTICAL ADJUVANTS* *Gelatin Capsules (Empty)*** capsule coni-snap #1 clear capsule DRcaps Size 0

*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 156

Formulary Drug Name Reference Restrictions sorbitol solution syrpalta oral syrup troche base powder Freedom Peg Troche Base FLAVOR BLEND ORAL SUSPENSION Suspension Vehicle PCCA ACACIA SYRUP BASE ORAL SYRUP SYRSPEND SF ORAL SUSPENSION RECONSTITUTED OTC

TROCHIBASE FLAKES Custom Polyglycol Troche Base OTC

*Parenteral Vehicles*** bacteriostatic water(benz alc) injection solution saline bacteriostatic injection solution sodium chloride bacteriostatic injection solution sterile water for injection injection solution sterile water for injection intravenous solution

*Pharmaceutical Excipients*** lactose monohydrate powder xanthan gum powder

*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** *Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** EUCRISA EXTERNAL OINTMENT ST

*POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension Kionex sodium polystyrene sulfonate rectal suspension SPS ORAL SUSPENSION Kionex

*PROGESTINS* *Progestins*** medroxyprogesterone acetate tablet 10 mg oral Provera

157

Formulary Drug Name Reference Restrictions 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 Prometrium

*PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** *Protein-Carbohydrate-Lipid With Electrolyte Combinations*** KABIVEN INTRAVENOUS EMULSION PERIKABIVEN INTRAVENOUS EMULSION

*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)

158

Formulary Drug Name Reference Restrictions *Movement Disorder Drug Therapy***

tetrabenazine tablet 12.5 mg oral Xenazine Auto-PA; QLL (3 EA per 1 day); AL (Min 18 Years)

tetrabenazine tablet 25 mg oral Xenazine Auto-PA; QLL (4 EA per 1 day); AL (Min 18 Years)

AUSTEDO ORAL TABLET Auto-PA

*Ms Agents - Pyrimidine Synthesis Inhibitors***

AUBAGIO TABLET 14 MG ORAL QLL (1 EA per 1 day); AL (Min 18 Years)

AUBAGIO TABLET 7 MG ORAL QLL (2 EA per 1 day); AL (Min 18 Years)

*Multiple Sclerosis Agents -Interferons***

AVONEX INTRAMUSCULAR KIT QLL (4 EA per 28 days); AL (Min 18 Years)

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)

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE QLL (6 ML per 28 days)

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Glatiramer Acetate QLL (1 ML per 28 days); AL

(Min 18 Years)

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution AL (Min 18 Years) memantine hcl oral tablet Namenda AL (Min 18 Years)

159

Formulary Drug Name Reference Restrictions *Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline tablet 2-10 mg oral

QL: ages =/>18: maximum 8 tablets/day; AL (Min 18 Years)

perphenazine-amitriptyline tablet 2-25 mg oral








*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** fluoxetine hcl (pmdd) oral capsule

*Psychotherapeutic And Neurological Agents - Misc.***

pimozide oral tablet QL: age 6-17: maximum 1 tablet/day; AL (Min 18 Years)

*Smoking Deterrents*** bupropion hcl er (smoking det) oral tablet extended release 12 hour Zyban QLL (2 EA per 1 day); AL (Min

18 Years) gnp nicotine mini mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) gnp nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) goodsense nicotine mouth/throat gum KLS Quit4 OTC; AL (Min 18 Years) hm nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) hm nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) hm nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years) nicotine polacrilex mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) nicotine step 1 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine step 2 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine step 3 transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) nicotine transdermal kit OTC; AL (Min 18 Years) nicotine transdermal patch 24 hour Nicoderm CQ OTC; AL (Min 18 Years) sm nicotine mouth/throat gum KLS Quit4 OTC; AL (Min 18 Years) sm nicotine mouth/throat lozenge KLS Quit2 OTC; AL (Min 18 Years) sm nicotine polacrilex mouth/throat gum KLS Quit2 OTC; AL (Min 18 Years)

160

Formulary Drug Name Reference Restrictions 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


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

*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** *Pulmonary Fibrosis Agents - Kinase Inhibitors*** OFEV ORAL CAPSULE PA

*RESPIRATORY AGENTS -MISC.* *Alpha-Proteinase Inhibitor (Human)*** ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED Auto-PA; AL (Min 18 Years)

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)

161

Formulary Drug Name Reference Restrictions trazodone hcl tablet 300 mg oral trazodone hcl tablet 50 mg oral AL (Min 6 Years) trazodone hcl tablet 50 mg oral

TRINTELLIX ORAL TABLET Auto-PA; QLL (30 EA per 30 days); AL (Min 18 Years)

VIIBRYD ORAL TABLET AL (Min 18 Years)

*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** *Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***

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

*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET SEGLUROMET ORAL TABLET ST; QLL (2 EA per 1 day) SYNJARDY ORAL TABLET XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR

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

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet

*TETRACYCLINES* *Tetracyclines*** doxycycline hyclate oral capsule Morgidox doxycycline hyclate oral tablet doxycycline monohydrate oral capsule Mondoxyne NL doxycycline monohydrate oral tablet minocycline hcl oral capsule Minocin

162

Formulary Drug Name Reference Restrictions *THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet Tapazole propylthiouracil oral tablet

*Thyroid Hormones***

levothyroxine sodium intravenous solution Maintenance drug with max 100 day supply

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





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






levothyroxine sodium tablet 300 mcg oral Levo-T Maintenance drug with max 100 days supply

levothyroxine sodium tablet 300 mcg oral Levo-T Maintenance drug with max 100 day supply





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liothyronine sodium oral tablet Cytomel np thyroid oral tablet Armour Thyroid thyroid oral tablet Armour Thyroid ARMOUR THYROID ORAL TABLET Armour Thyroid LEVOXYL ORAL TABLET Euthyrox SYNTHROID ORAL TABLET Euthyrox THYROLAR-1 ORAL TABLET THYROLAR-1/2 ORAL TABLET THYROLAR-1/4 ORAL TABLET THYROLAR-2 ORAL TABLET THYROLAR-3 ORAL TABLET UNITHROID ORAL TABLET Euthyrox

*ULCER DRUGS* *Anticholinergic Combinations*** belladonna alkaloids-opium rectal suppository chlordiazepoxide-clidinium oral capsule Librax pb-hyoscy-atropine-scopolamine oral tablet Donnatal

*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 164

Formulary Drug Name Reference Restrictions ranitidine hcl oral syrup

ranitidine hcl oral tablet Wal-Zan 150 Maximum Strength

*Misc. Anti-Ulcer*** sucralfate oral tablet Carafate

*Proton Pump Inhibitors***

lansoprazole oral tablet dispersible 15 mg Prevacid SoluTab

QL: ages 1-11: maximum 2 capsules/day, ages =/>12: maximum 3 capsules/day; AL (Min 1 Years and Max 11 Years)

lansoprazole tablet dispersible 15 mg oral Prevacid SoluTab AL (Min 1 Years and Max 11 Years)

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

lansoprazole tablet dispersible 30 mg oral Prevacid SoluTab

QL: ages 1-11: maximum 1 capsule/day, ages =/>12: maximum 3 capsules/day; AL (Min 1 Years and Max 11 Years)

omeprazole oral capsule delayed release QLL (1 EA per 1 day); AL (Min 1 Years)

pantoprazole sodium tablet delayed release 20 mg oral Protonix QLL (1 EA per 1 day); AL (Min

5 Years) pantoprazole sodium tablet delayed release 40 mg oral Protonix QLL (2 EA per 1 day); AL (Min

5 Years)

NEXIUM ORAL PACKET QLL (1 EA per 1 day); AL (Max 11 Years)

PROTONIX ORAL PACKET QLL (1 EA per 1 day); AL (Min 5 Years and Max 11 Years)

*Quaternary Anticholinergics*** glycopyrrolate injection solution QLL (30 ML per 1 day) 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

165

Formulary Drug Name Reference Restrictions *URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine hippurate oral tablet Hiprex methenamine mandelate oral tablet nitrofurantoin macrocrystal oral capsule Macrodantin nitrofurantoin monohyd macro oral capsule Macrobid nitrofurantoin oral suspension Furadantin AL (Max 11 Years)

*Urinary Antiseptic-Antispasmodic &/Or Analgesics*** UTIRA-C ORAL TABLET Urin DS

*URINARY ANTISPASMODICS* *Urinary Antispasmodic -Antimuscarinic (Anticholinergic)*** oxybutynin chloride er oral tablet extended release 24 hour Ditropan XL

oxybutynin chloride oral syrup oxybutynin chloride tablet 5 mg oral

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 days supply

solifenacin succinate oral tablet VESIcare TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 18 Years)

*Urinary Antispasmodic -Antimuscarinics (Antichol)***(New) oxybutynin chloride er oral tablet extended release 24 hour 5 mg Ditropan XL Maintenance drug with max 100

days supply 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 oral syrup

oxybutynin chloride tablet 5 mg oral Maintenance drug with max 100 days supply

oxybutynin chloride tablet 5 mg oral solifenacin succinate oral tablet VESIcare tolterodine tartrate er oral capsule extended release 24 hour Detrol LA AL (Min 5 Years and Max 18

Years)

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tolterodine tartrate oral tablet Detrol AL (Min 5 Years and Max 18 Years)

trospium chloride er oral capsule extended release 24 hour QLL (30 EA per 30 days)

trospium chloride oral tablet QLL (60 EA per 30 days) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR AL (Min 18 Years)

*Urinary Antispasmodics -Cholinergic Agonists*** bethanechol chloride oral tablet Urecholine

*Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet Urecholine

*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** 3 day vaginal vaginal cream Gyne-Lotrimin 3 OTC clotrimazole vaginal cream Gyne-Lotrimin OTC gnp clotrimazole 3 vaginal cream Gyne-Lotrimin 3 OTC gnp miconazole 7 vaginal cream Monistat 7 Simply Cure OTC miconazole 1 vaginal kit Monistat 1 Combo Pack OTC miconazole 3 vaginal cream Monistat 3 OTC miconazole 3 vaginal suppository miconazole 7 vaginal cream Monistat 7 Simply Cure OTC miconazole 7 vaginal suppository OTC miconazole nitrate vaginal cream Monistat 7 Simply Cure OTC qc 3 day vaginal cream Monistat 3 OTC qc miconazole 7 vaginal cream Monistat 7 Simply Cure OTC sm 3-day vaginal vaginal cream Gyne-Lotrimin 3 OTC sm clotrimazole vaginal vaginal cream Gyne-Lotrimin OTC sm miconazole 7 vaginal cream Monistat 7 Simply Cure OTC sm miconazole 7 vaginal suppository OTC terconazole cream 0.4 % vaginal Terazol 7 QLL (45 GM per 1 Fill) terconazole cream 0.8 % vaginal QLL (20 GM per 1 Fill) GYNAZOLE-1 VAGINAL CREAM

*Vaginal Anti-Infectives*** CLEOCIN VAGINAL SUPPOSITORY CLINDESSE VAGINAL CREAM NUVESSA VAGINAL GEL

167

Formulary Drug Name Reference Restrictions *Vaginal Estrogens*** estradiol tablet 10 mcg vaginal Vagifem estradiol tablet 10 mcg vaginal Vagifem F; QLL (1 Fill per 28 days) ESTRING VAGINAL RING QLL (1 EA per 84 days) PREMARIN VAGINAL CREAM QLL (42.5 GM per 1 Fill)

*VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector EpiPen Jr 2-Pak

*Vasopressors*** dobutamine hcl intravenous solution dobutamine in d5w intravenous solution midodrine hcl oral tablet

*VITAMINS* *Vitamin B-1*** thiamine hcl injection solution

*Vitamin B-6*** pyridoxine hcl injection solution

*Vitamin C*** ascorbic acid injection solution

*Vitamin D*** vitamin d (ergocalciferol) oral capsule Drisdol

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

168

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Index Header1st tier unilet comfortouch 1153 day vaginal 1678 hour arthritis pain reliever 168 hr arthritis pain relief 168hr muscle aches & pain 16abacavir sulfate 68abacavir sulfate-lamivudine 66abacavir-lamivudine-zidovudine 66abdek 145ABELCET 41ABILIFY MAINTENA 64abiraterone acetate 49acamprosate calcium 158acarbose 34ACCU-CHEK AVIVA 119ACCU-CHEK COMPACT PLUS CONTROL 119ACCU-CHEK FASTCLIX LANCET 119ACCU-CHEK FASTCLIX LANCETS 119ACCU-CHEK GUIDE CONTROL 119ACCU-CHEK MULTICLIX LANCET DEV 119ACCU-CHEK MULTICLIX LANCETS 119ACCU-CHEK SAFE-T PRO LANCETS 119ACCU-CHEK SMARTVIEW CONTROL 119ACCU-CHEK SOFT TOUCH LANCETS 119ACCU-CHEK SOFTCLIX LANCET DEV 119ACCU-CHEK SOFTCLIX LANCETS 120ACCUTREND GLUCOSE CONTROL 120acebutolol hcl 72acetaminophen 16acetaminophen childrens 16acetaminophen er 16acetaminophen infants 16acetaminophen-codeine 19acetaminophen-codeine #2 19acetaminophen-codeine #3 19acetaminophen-codeine #4 19acetazolamide 98acetazolamide er 98acetic acid 104, 154

acetylcysteine 40, 92acitretin 94acti-lance 28g 115acti-lance lite lancets 28g 115acti-lance special lancets 17g 115acti-lance universal 23g 115ACTIMMUNE 52acyclovir 70, 95ADAGEN 73adapalene 92adjustable lancing device 115ADMELOG 36ADMELOG SOLOSTAR 36adult aspirin regimen 18ADVAIR HFA 25ADVANCE INTUITION CONTROL 120ADVANCE MICRO-DRAW CONTROL 120ADVANCE MICRO-DRAW NORMAL 120ADVATE 105ADVOCATE CONTROL SOLUTION 120ADVOCATE INSULIN SYRINGE 133ADVOCATE LANCETS 120ADVOCATE LANCETS 30G120ADVOCATE LANCING DEVICE 120ADVOCATE RAPID-SAFE LANCING 120ADVOCATE REDI-CODE+ CONTROL 120ADVOCATE SAFETY LANCETS 120ADVOCATE SAFETY LANCETS 26G 120adynovate 105ADZENYS XR-ODT 8AEROCHAMBER MINI CHAMBER 139AEROCHAMBER MV 139AEROCHAMBER PLUS FLO-VU 139AEROCHAMBER PLUS FLO-VU LARGE 139AEROCHAMBER PLUS FLO-VU MEDIUM 139AEROCHAMBER PLUS FLO-VU SMALL 139

AEROCHAMBER PLUS FLO-VU W/MASK 139AEROCHAMBER PLUS FLOW VU 139AEROCHAMBER W/FLOWSIGNAL 139AEROCHAMBER Z-STAT PLUS 139AEROCHAMBER Z-STAT PLUS CHAMBR 139AEROCHAMBER Z-STAT PLUS/LARGE 139AEROCHAMBER Z-STAT PLUS/MEDIUM 139AEROCHAMBER Z-STAT PLUS/SMALL 139AEROVENT PLUS 139AFSTYLA 105AFTERA 83AGAMATRIX CONTROL 120AGAMATRIX ULTRA-THIN LANCETS 120ALA-QUIN 93ALAWAY 152ALAWAY CHILDRENS ALLERGY 152albendazole 23ALBUKED 25 107ALBUKED 5 107albumin human 107ALBUMINEX 107alburx 107ALBUTEIN 107albuterol sulfate 25, 26albuterol sulfate hfa 25ALCOH-GLOVE CONTOURED WIPE 114alcohol pads 114alcohol prep 114alcohol swabs 114alcohol wipes 114alcoh-wipe 114alendronate sodium 100alfuzosin hcl er 104ALIMTA 50ALKERAN 53all day allergy 42all day allergy childrens 42all day allergy-d 90allergy 42allergy eye drops 151

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allergy relief 42allergy relief childrens 42allergy relief d-24 90allergy relief/nasal decongest 90allergy relief-d 90allopurinol 105alogliptin benzoate 35alogliptin-metformin hcl 36alogliptin-pioglitazone 36alosetron hcl 103ALPHANATE/VWF COMPLEX/HUMAN 105ALPHANINE SD 105alprazolam 24ALPROLIX 105ALREX 153ALTAVERA 78alternate site lancing device 115alyacen 1/35 78alyacen 7/7/7 86amantadine hcl 54AMETHIA 84AMETHIA LO 84AMICAR 111amiloride hcl 99amiloride-hydrochlorothiazide 99aminocaproic acid 111AMINOSYN II 149AMINOSYN-PF 149amiodarone hcl 25amitriptyline hcl 34amlodipine besy-benazepril hcl 44amlodipine besylate 73amlodipine besylate-valsartan 45amlodipine-olmesartan 45ammonium lactate 96AMNESTEEM 93amoxapine 34amoxicillin 155amoxicillin-pot clavulanate 156amphetamine-dextroamphet er 5, 6amphetamine-dextroamphetamine 6, 7amphotericin b 41ampicillin 155ampicillin sodium 155ampicillin-sulbactam sodium 156anagrelide hcl 108anastrozole 52ANDROGEL 22ANDROGEL PUMP 22antacid 22

antacid calcium 22antacid extra strength 22ANUSOL-HC 22aprepitant 41APRI 78APRISO 103APTENSIO XR 11, 12APTIOM 30APTIVUS 67aqua lance adjustable lancing 115AQUADEKS 145, 146AQUALANCE LANCETS 30G 120ARALAST NP 161ARANELLE 86ARANESP (ALBUMIN FREE) 108, 109ARIAL CHAMBER 139aripiprazole 63, 64ARISTADA 64ARISTADA INITIO 64ARMOUR THYROID 164ARNUITY ELLIPTA 26arthritis pain relief 16ARYMO ER 20ARZERRA 50ascorbic acid 168ASHLYNA 84ASMANEX 120 METERED DOSES 26ASMANEX 14 METERED DOSES 26ASMANEX 30 METERED DOSES 26ASMANEX 60 METERED DOSES 27aspirin 18aspirin 81 18aspirin adult 18aspirin adult low strength 18aspirin ec 18aspirin ec low strength 18aspirin low dose 18aspirin-dipyridamole er 107ASPIR-LOW 19ASSURE 3 CONTROL 120ASSURE 4 CONTROL LEVEL 1 & 2 120assure comfort lancets 28g 115ASSURE DOSE CONTROL 120ASSURE DOSE NORM/HIGH CONTROL 120

ASSURE HAEMOLANCE PLUS HIGH 120ASSURE HAEMOLANCE PLUS LOW 120ASSURE HAEMOLANCE PLUS MICRO 120ASSURE HAEMOLANCE PLUS NORMAL 120ASSURE HAEMOLANCE PLUS PED 120ASSURE ID INSULIN SAFETY SYR 133ASSURE II CONTROL 120ASSURE II CONTROL LEVEL 1 & 2 120ASSURE LANCE LANCETS 120ASSURE LANCE LANCETS 21G 121ASSURE LANCE PLUS SAFETY 25G 121ASSURE LANCE PLUS SAFETY 30G 121ASSURE LANCETS 121ASSURE PRISM CONTROL LEVEL 1 121ASSURE PRO CONTROL LEVEL 1 & 2 121atenolol 72atenolol-chlorthalidone 46ATGAM 70atomoxetine hcl 5atorvastatin calcium 44atovaquone 47ATRIPLA 66atropine sulfate 151ATROVENT HFA 26AUBAGIO 159AUBRA 79AUBRA EQ 78aurora lancet super thin 30g 115aurora lancet thin 23g 115AUROVELA 1.5/30 79AUROVELA 1/20 79AUROVELA 24 FE 79AUROVELA FE 1.5/30 79AUROVELA FE 1/20 79AUSTEDO 159AUTO-LANCET 121AUTO-LANCET MINI 121AUTOLET II CLINISAFE 121AUTOLET LANCING DEVICE 121

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AUTOLET LITE CLINISAFE 121AUTOLET LITE STARTER PACK 121AUTOLET MINI 121AUTOLET PLATFORMS 121AUTOLET PLUS 121AVIANE 79AVITA 93AVONEX 159AVONEX PEN 159AVONEX PREFILLED 159azacitidine 50azathioprine 71azelaic acid 97azelastine hcl 148, 151AZELEX 93azithromycin 113, 114AZOPT 152aztreonam 144AZURETTE 77bacitracin-polymyxin b 152bacitra-neomycin-polymyxin-hc153baclofen 148BACMIN 145bacteriostatic water(benz alc) 157balanced salt 152BALCOLTRA 79BALZIVA 79BANZEL 30BARACLUDE 69BASAGLAR KWIKPEN 36base gelatin gummy troche 156BD ECLIPSE SYRINGE 133BD INSULIN SYR ULTRAFINE II 133BD INSULIN SYRINGE 133BD INSULIN SYRINGE MICROFINE 133BD INSULIN SYRINGE U/F 133BD INSULIN SYRINGE U/F 1/2UNIT 133BD INSULIN SYRINGE ULTRAFINE 133, 134BD LANCET ULTRAFINE 30G 121BD LANCET ULTRAFINE 33G 121BD LUER-LOK SYRINGE 134BD MICROTAINER LANCETS 121

BD PEN NEEDLE NANO U/F 134BD PEN NEEDLE SHORT U/F 134BD SAFETYGLIDE INSULIN SYRINGE 134BD SAFETYGLIDE SYRINGE/NEEDLE 134BD SAFETY-LOK INSULIN SYRINGE 134BD SWAB SINGLE USE REGULAR 114BD SWABS SINGLE USE BUTTERFLY 115BD SYRINGE/NEEDLE 134BD SYRINGE/NEEDLE SLIP TIP 134BD VEO INSULIN SYRINGE U/F 134BEKYREE 77belladonna alkaloids-opium 164benazepril hcl 44benazepril-hydrochlorothiazide 44BENEFIX 105benzonatate 89benzoyl peroxide 92, 93benztropine mesylate 54BERINERT 107betamethasone dipropionate aug 95betamethasone sod phos & acet 88betamethasone valerate 95BETAPACE AF 73BETASERON 159bethanechol chloride 167BEVESPI AEROSPHERE 25BEYAZ 79bicalutamide 49BICILLIN C-R 156BICILLIN C-R 900/300 156BICILLIN L-A 156BIKTARVY 66bisoprolol fumarate 72bisoprolol-hydrochlorothiazide 46BIVIGAM 154bleomycin sulfate 51BLISOVI 24 FE 79BLISOVI FE 1.5/30 79BOTOX 149BREATHERITE 139BREATHERITE COLL SPACER ADULT 139

BREATHERITE COLL SPACER CHILD 139BREATHERITE COLL SPACER INFANT 139BREATHERITE RIGID SPACER/MASK 139BREATHERITE SPACER NEONATE 139BREATHERITE SPACER SMALL CHILD 139BREATHERITE/LARGE MASK 139BREATHERITE/MEDIUM MASK 139BREATHERITE/SMALL MASK 139briellyn 78BRILINTA 98, 107brimonidine tartrate 153BRIVIACT 30budesonide 26, 87, 148bullseye mini safety lancets 115BULLSEYE SAFETY LANCETS 121bumetanide 99bupivacaine hcl 113bupivacaine hcl (pf) 113bupivacaine spinal 113bupivacaine-epinephrine 113bupivacaine-epinephrine (pf) 113buprenorphine 21buprenorphine hcl 21buprenorphine hcl-naloxone hcl .21bupropion hcl 33bupropion hcl er (smoking det) .160bupropion hcl er (sr) 33bupropion hcl er (xl) 33buspirone hcl 24BUSULFEX 49butalbital-acetaminophen 17butalbital-apap-caff-cod 19butalbital-apap-caffeine 17, 18butalbital-aspirin-caffeine 18BYDUREON 38BYETTA 10 MCG PEN 38BYETTA 5 MCG PEN 38cabergoline 100caffeine citrate 8calcipotriene 94calcitonin (salmon) 100CALCITRATE 141calcitriol 94, 101

171

.........................calcium acetate 141calcium acetate (phos binder) 103calcium antacid 22calcium antacid extra strength 22calcium antacid ultra max st 22calcium antacid ultra strength 22calcium carbonate 141calcium carbonate antacid 22, 141calcium chloride 141calcium gluconate 141CAL-GEST ANTACID 23CAMILA 85CAMPATH 50CAMRESE 84CAMRESE LO 84capecitabine 50CAPRELSA 51capsule coni-snap #1 clear 156captopril 44carbamazepine 29carbamazepine er 29CARBATROL 30carbidopa-levodopa 54carbidopa-levodopa er 54carbidopa-levodopa-entacapone 54carbinoxamine maleate 42carboplatin 49CARDIOCOM LANCING DEVICE 121careone advanced lancing dev 115careone insulin syringe 132careone lancet thin 23g 115careone lancet ultra thin 28g 115CARESENS CONTROL A 121CARETOUCH ALCOHOL PREP 115CARETOUCH LANCING/EJECTOR 121CARETOUCH TWIST LANCETS 30G 121carmustine 53carteolol hcl 151carvedilol 72CATHFLO ACTIVASE 108CAVILON EMOLLIENT 96CAVILON FOOT & DRY SKIN 96CAYA 115CAZIANT 86cefaclor 76cefadroxil 76cefazolin sodium 76

cefdinir 76cefepime hcl 77cefixime 76cefotaxime sodium 77cefotetan disodium 76cefotetan disodium-dextrose 76cefoxitin sodium 76cefoxitin sodium-dextrose 76cefprozil 76ceftazidime 77ceftriaxone sodium 77ceftriaxone sodium in dextrose 77ceftriaxone sodium-dextrose 77cefuroxime axetil 76cefuroxime sodium 76celecoxib 15CELESTONE SOLUSPAN 89CELLCEPT INTRAVENOUS 71CELONTIN 32cephalexin 76CERDELGA 108CEREZYME 108cetirizine hcl 42cetirizine hcl allergy child 42cetirizine hcl childrens 42cetirizine hcl childrens alrgy 42cetirizine hcl hives relief 42cetirizine-pseudoephedrine er 90CHANTIX 161CHANTIX CONTINUING MONTH PAK 161CHANTIX STARTING MONTH PAK 161CHATEAL 79CHATEAL EQ 79CHEMSTRIP BG LOG BOOK 121cherry concentrate 156chest congestion relief 91childrens acetaminophen 16childrens aspirin low strength 18childrens loratadine 42childrens mucus relief expect 91childrens silapap 16chlordiazepoxide hcl 24chlordiazepoxide-amitriptyline 158chlordiazepoxide-clidinium 164chlorhexidine gluconate 144chloroquine phosphate 48chlorothiazide 99chlorpromazine hcl 61chlorthalidone 99

chlorzoxazone 148cholestyramine 43cholestyramine light 43chromic chloride 144ciclopirox 93ciclopirox olamine 93cilostazol 107CIMDUO 66CINRYZE 107CIPRODEX 154ciprofloxacin 102ciprofloxacin hcl 102, 152ciprofloxacin in d5w 102cisplatin 49citalopram hydrobromide 33CITRANATAL B-CALM 147CITRANATAL DHA 147CITRANATAL HARMONY .148cladribine 50CLARAVIS 93clarithromycin 114clarithromycin er 114CLARITIN EYE 152CLEANLET LANCETS 28G 121clemastine fumarate 42CLEOCIN 167CLEVER CHEK LANCETS . 121CLEVER CHOICE GLUCOSE CONTROL 121CLEVER CHOICE HOLDING CHAMBER 139CLIMARA PRO 102clindamycin hcl 47clindamycin palmitate hcl 47clindamycin phos-benzoyl perox .92clindamycin phosphate 47, 92CLINDESSE 167CLINIMIX E/DEXTROSE (2.75/10) 149CLINIMIX E/DEXTROSE (2.75/5) 149CLINIMIX E/DEXTROSE (4.25/10) 149CLINIMIX E/DEXTROSE (4.25/25) 149CLINIMIX E/DEXTROSE (4.25/5) 149CLINIMIX E/DEXTROSE (5/15) 149CLINIMIX E/DEXTROSE (5/20) 149CLINIMIX N14G30E 149

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...............CLINIMIX N9G15E 149CLINIMIX N9G20E 149CLINIMIX/DEXTROSE (4.25/10) 149CLINIMIX/DEXTROSE (4.25/25) 150CLINIMIX/DEXTROSE (4.25/5) 150CLINIMIX/DEXTROSE (5/15) 150CLINIMIX/DEXTROSE (5/20) 150CLINIMIX/DEXTROSE (5/25) 150CLINISOL SF 150clobazam 29clobetasol prop emollient base 95clobetasol propionate 95clobetasol propionate e 95clomipramine hcl 34clonazepam 29clonidine 45clonidine hcl 45clopidogrel bisulfate 108clorazepate dipotassium 24clotrimazole 96, 144, 167clotrimazole-betamethasone 93clozapine 58, 59CLOZARIL 60c-nate dha 146COAGADEX 105COAGUCHEK LANCETS 121codeine sulfate 20cola syrup 156colchicine 105colchicine-probenecid 105colestipol hcl 43colistimethate sodium (cba) 48COMBIGAN 151COMBIPATCH 102COMBIVENT RESPIMAT 25COMFORT ASSIST INSULIN SYRINGE 134, 135comfort assured lancets 28g 115comfort assured lancets 33g 115COMFORT EZ INSULIN SYRINGE 135comfort lancets 115COMPACT SPACE CHAMBER 139COMPACT SPACE CHAMBER/LG MASK 139

COMPACT SPACE CHAMBER/MED MASK 139COMPACT SPACE CHAMBER/SM MASK 139COMPLERA 66complete natal dha 147completenate 146CONCEPT DHA 147CONCEPT OB 147CONTOUR CONTROL 121CONTOUR NEXT CONTROL 121control 116COOL CONTROL A 121COOL CONTROL B 121COPAXONE 159copper chloride 144CORIFACT 105corn (syrup) 156CORTISPORIN 93CORVITA 145COSENTYX 94COSENTYX 300 DOSE 94COSENTYX SENSOREADY 300 DOSE 94COSENTYX SENSOREADY PEN 94cough syrup 91cough/chest congestion dm 89COUMADIN 27CREON 98CRIXIVAN 67cromolyn sodium 25, 103, 151CRYSELLE-28 79CURITY ALCOHOL PREPS115CURITY ALCOHOL SWABS 115CUVITRU 154CUVPOSA 165cvs alcohol prep pads 114cvs allergy eye drops 151cvs distilled water 156cvs eye itch relief 151cvs fluticasone propionate 148cvs lancets 21g 116cvs lancets micro thin 33g 116cvs lancets original 116cvs lancets thin 26g 116cvs lancets ultra thin 30g 116cvs lancets ultra-thin 30g 116cvs lancing device 116cvs prep 114

cvs ultra thin lancets 116cyanocobalamin 108CYCLAFEM 1/35 79CYCLAFEM 7/7/7 86cyclobenzaprine hcl 148cyclopentolate hcl 151cyclophosphamide 53cyclosporine 70cyclosporine modified 70cyproheptadine hcl 43CYRED 79CYRED EQ 79CYSTADANE 101CYSTAGON 104CYSTARAN 153cytarabine 50cytarabine (pf) 50CYTOGAM 154dacarbazine 52danazol 21dapsone 47DASETTA 1/35 79DASETTA 7/7/7 86daunorubicin hcl 51DAYSEE 84DAYTRANA 12DEBLITANE 85decitabine 50deferoxamine mesylate 40DELFLEX-SM/1.5% DEXTROSE 71, 156DELSTRIGO 66DENAVIR 95DEPAKENE 33DEPAKOTE 33DEPAKOTE ER 33DEPAKOTE SPRINKLES 33DEPO-PROVERA 85DEPO-SUBQ PROVERA 104 . 85DERMA-SMOOTHE/FS BODY 96DESCOVY 66desipramine hcl 34desmopressin acetate 102desmopressin acetate spray 102desogestrel-ethinyl estradiol .77, 78desvenlafaxine succinate er 34dexamethasone 87DEXAMETHASONE INTENSOL 88dexamethasone sod phosphate pf 87

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dexamethasone sodium phosphate 87, 153dexmethylphenidate hcl 9dexmethylphenidate hcl er 8, 9dexrazoxane hcl 52dextroamphetamine sulfate 7, 8dextroamphetamine sulfate er 7dextromethorphan-guaifenesin 89dextrose 150dextrose 5%/electrolyte #48 141dextrose in lactated ringers 141dextrose-nacl 141diabetic siltussin das-na 91dialysis safety syringe/needle 132DIALYVITE 145DIALYVITE 3000 145DIALYVITE 5000 145DIALYVITE SUPREME D 145DIALYVITE/ZINC 145diatrue control level 1 116diatrue control level 2 116diatrue control level 3 116diazepam 24, 29DICLEGIS 41diclofenac potassium 15diclofenac sodium 15, 93, 94, 153diclofenac sodium er 15dicloxacillin sodium 156dicyclomine hcl 164didanosine 68DIFFERIN 93DIFICID 114digoxin 75DILANTIN 32diltiazem hcl 74diltiazem hcl er 73, 74diltiazem hcl er beads 73diltiazem hcl er coated beads 74diphenhydramine hcl 42diphenoxylate-atropine 40dipyridamole 108disopyramide phosphate 24disulfiram 158DIURIL 100divalproex sodium 32divalproex sodium er 32dm-guaifenesin er 89dobutamine hcl 168dobutamine in d5w 168docetaxel 53donepezil hcl 158dorzolamide hcl 152

dorzolamide hcl-timolol mal 151DOVATO 66doxazosin mesylate 45, 46doxepin hcl 34, 94doxercalciferol 101doxorubicin hcl 51doxorubicin hcl liposomal 51doxycycline hyclate 162doxycycline monohydrate 162droperidol 24DROPLET LANCETS ULTRA THIN 30G 122DROPLET LANCING DEVICE 122drospiren-eth estrad-levomefol 78drospirenone-ethinyl estradiol 78drug mart lancets thin 26g 116DRUG MART LANCING DEVICE 122DRUG MART ON-THE-GO LANCET 30G 122DRUG MART UNILET LANCETS 28G 122DRUG MART UNILET LANCETS 30G 122DULERA 25duloxetine hcl 34DUO-CARE CONTROL SOLUTION 122DUREZOL 153dutasteride 104EASIVENT 140EASIVENT MASK LARGE 140EASIVENT MASK MEDIUM

140EASIVENT MASK SMALL 140easy comfort insulin syringe 132easy comfort lancets 116easy mini eject lancing device 116easy mini lancing device 116easy plus ii control 116EASY STEP CONTROL 122easy talk control 116EASY TOUCH ALCOHOL PREP MEDIUM 115EASY TOUCH CONTROL HIGH & LOW 122EASY TOUCH FLIPLOCK INSULIN SY 135EASY TOUCH FLIPLOCK SAFETY SYR 135EASY TOUCH FLURINGE 135

EASY TOUCH FLURINGE FLIPLOCK 135EASY TOUCH FLURINGE SHEATHLOCK 135EASY TOUCH HEALTHPRO CONTROL 122EASY TOUCH INSULIN SAFETY SYR 135EASY TOUCH INSULIN SYRINGE 135EASY TOUCH LANCETS 21G 122EASY TOUCH LANCETS 23G 122EASY TOUCH LANCETS 26G 122EASY TOUCH LANCETS 26G/TWIST 122EASY TOUCH LANCETS 28G 122EASY TOUCH LANCETS 28G/TWIST 122EASY TOUCH LANCETS 30G 122EASY TOUCH LANCETS 30G/TWIST 122EASY TOUCH LANCETS 32G 122EASY TOUCH LANCETS 32G/TWIST 122EASY TOUCH LANCETS 33G/TWIST 122EASY TOUCH LANCING DEVICE 122EASY TOUCH SAFETY LANCETS 21G 122EASY TOUCH SAFETY LANCETS 23G 122EASY TOUCH SAFETY LANCETS 26G 122EASY TOUCH SAFETY LANCETS 28G 122EASY TOUCH SAFETY SYRINGE 135EASY TOUCH SHEATHLOCK SYRINGE 135EASY TOUCH TB SHEATHLOCK SYR 135easy trak control 116EASY TWIST & CAP LANCETS 122EASYGLUCO CONTROL 122

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EASYGLUCO PLUS LEVEL 1 122EASYMAX 15 LEVEL 1 CONTROL 122EASYMAX 15 LEVEL 1-2 CONTROL 122EASYMAX 15 LEVEL 2 CONTROL 123EASYMAX CONTROL 123EASYMAX CONTROL NORMAL/LOW 123ec-naproxen 15econazole nitrate 96ECONTRA EZ 83ECONTRA ONE-STEP 83ECPIRIN 19ed-apap 16EDURANT 68EFFER-K 143ELELYSO 108element compact control 2 116element compact control 3 116ELEMENT CONTROL 123ELIDEL 97ELIGARD 52ELINEST 79ELIQUIS 28ELIQUIS STARTER PACK 27ELITE-OB 147elite-thin insulin syringe 132ELIXOPHYLLIN 27ELLA 83ELOCTATE 105EMBEDA 20EMBRACE CONTROL 123EMBRACE EVO CONTROL LEVEL 1 123EMBRACE EVO CONTROL LEVEL 2 123EMBRACE GLUCOSE CONTROL 123EMBRACE LANCETS ULTRA THIN 30G 123EMBRACE PRO GLUCOSE CONTROL 123EMGALITY 73EMOQUETTE 79EMTRIVA 69enalapril maleate 44enalapril-hydrochlorothiazide 44ENBREL 16ENBREL MINI 16

ENBREL SURECLICK 16ENEMEEZ MINI 113ENEMEEZ PLUS 113enoxaparin sodium 28ENPRESSE-28 86ENSKYCE 79entecavir 69ENTRESTO 149epinastine hcl 151epinephrine 168epirubicin hcl 51EPITOL 30EPIVIR 69EPIVIR HBV 69eplerenone 46EPOGEN 108, 109epoprostenol sodium 75eq allergy relief 42eql alcohol swabs 114eql color lancets 21g 116eql color lancets micro 33g 116eql insulin syringe 132eql super thin lancets 30g 116eql thin lancets 26g 116EQUETRO 55ERAXIS 41ERRIN 85erythromycin 152erythromycin ethylsuccinate 114escitalopram oxalate 34est estrogens-methyltest ds 102est estrogens-methyltest hs 102ESTARYLLA 79estradiol 102, 168estradiol valerate 102estradiol-norethindrone acet 102ESTRING 168ESTROSTEP FE 86ethambutol hcl 48ethosuximide 32ethynodiol diac-eth estradiol 78etoposide 53EUCRISA 157EVENCARE CONTROL LOW/HIGH 123EVENCARE G2 LOW/HIGH CONTROL 123EVENCARE G3 LOW/HIGH CONTROL 123EVENCARE MINI CONTROL 123EVOLUTION CONTROL 123

EVOTAZ 66EXEL COMFORT POINT INSULIN SYR 135exemestane 52extra action cough 89eye itch relief 151E-Z JECT LANCET MICRO-THIN 33G 123E-Z JECT LANCET SUPER THIN 30G 123E-Z JECT LANCETS 123E-Z JECT LANCETS 21G 123E-Z JECT LANCETS THIN 26G 123EZ SMART BLOOD GLUCOSE LANCETS 123ezetimibe 44EZ-LETS LANCETS 21G 123EZ-LETS LANCETS 23G 123EZ-LETS LANCETS 26G 123EZ-LETS LANCETS 28G 123EZ-LETS LANCETS 30G 123FABRAZYME 100FALMINA 80famotidine 164famotidine premixed 164FARXIGA 38FAYOSIM 84FEIBA 105felbamate 31, 32FELBATOL 32felodipine er 74FEMHRT LOW DOSE 102FEMYNOR 80fenofibrate 43fentanyl 20FEOSOL 111FEOSOL NATURAL RELEASE 111FERATE 111FER-IN-SOL 111FEROSUL 111ferraplus 90 111FERRIMIN 150 111ferrous fumarate 111ferrous gluconate 111ferrous sulfate 111ferrousul 111FIFTY50 ALCOHOL PREP . 115FIFTY50 SAFETY SEAL LANCETS 123

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FIFTY50 SUPERIOR COMFORT SYR 135FIFTY50 UNILET LANCETS 33G 124finasteride 104FINE 30 124FINGERSTIX LANCETS 124FIRAZYR 107FLAREX 153FLAVOR BLEND 157flavor plus 156flavor sweet 156FLEBOGAMMA DIF 155flecainide acetate 25FLEXBUMIN 107FLEXICHAMBER 140FLONASE SENSIMIST 148FLOVENT DISKUS 27FLOVENT HFA 27floxuridine 50fluconazole 41fluconazole in sodium chloride 41fludarabine phosphate 50fludrocortisone acetate 88fluocinolone acetonide 154fluocinolone acetonide body 95fluocinolone acetonide scalp 95fluocinonide 95fluorouracil 50, 94fluoxetine hcl 34fluoxetine hcl (pmdd) 160fluphenazine decanoate 61fluphenazine hcl 61, 62flurbiprofen sodium 153flutamide 49fluticasone propionate 95, 148fluticasone-salmeterol 25fluvoxamine maleate 34FML 153FML FORTE 153folic acid 109FOLIVANE-F 111FOLIVANE-OB 147FOLTRATE 108FORA CONTROL 124FORA LANCETS 124FORA LANCING DEVICE 124FORACARE GDH CONTROL 124FORTISCARE CONTROL 124fosinopril sodium 44fosinopril sodium-hctz 44

FREAMINE HBC 150FREAMINE III 150freds pharmacy autolet lancing 116freds pharmacy unilet lanc 28g 116freds pharmacy unilet lanc 30g 116FREESTYLE CONTROL SOLUTION 124FREESTYLE LANCETS 124FREESTYLE PRECISION INS SYR 135FREESTYLE UNISTICK II LANCETS 124FULPHILA 110furosemide 99FUSION PLUS 110FUZEON 67FYCOMPA 29gabapentin 29GABITRIL 32GAMASTAN S/D 155GAMMAGARD 155GAMMAGARD S/D LESS IGA 155GAMMAKED 155GAMMAPLEX 155GAMUNEX-C 155ganciclovir sodium 69ge100 control 116gemcitabine hcl 50gemfibrozil 43GENERESS FE 80GENOTROPIN 100GENOTROPIN MINIQUICK

100gentamicin in saline 12gentamicin sulfate 12, 93, 152GENTLE-LET GP LANCETS 124GENTLE-LET LANCETS 124GENTLE-LET PLATFORMS

124GENVOYA 67GIANVI 80GILENYA 161GLASSIA 161glimepiride 38glipizide 39glipizide er 39glipizide xl 39glipizide-metformin hcl 38global alcohol prep ease 114global easy glide insulin syr 132

global inject ease insulin syr 132global inject ease lancets 28g 116global inject ease lancets 30g 116global insulin syringes 132global lancing device 116GLUCAGEN DIAGNOSTIC 98GLUCAGEN HYPOKIT 35GLUCAGON EMERGENCY . 35glucagon hcl (diagnostic) 98GLUCOCARD 01 CONTROL 124GLUCOCARD EXPRESSION CONTROL 124GLUCOCARD SHINE CONTROL 124GLUCOCARD X-SENSOR CONTROL 124GLUCOCOM AUTOLINK TELEMONITOR 124GLUCOCOM CONTROL 124GLUCOCOM LANCETS 28G 124GLUCOCOM LANCETS 30G 124GLUCOCOM LANCETS 33G 124GLUCOPRO INSULIN SYRINGE 135glucose 150glucose control 116glyburide 39glyburide micronized 39glyburide-metformin 38glycerin 77glycopyrrolate 165GLYRX-PF 165GLYXAMBI 162gnp 8 hour pain reliever 16gnp adult aspirin low strength 18gnp alcohol swabs 114gnp all day allergy 42gnp all day allergy childrens 42gnp all day allergy-d 90gnp allergy & congestion 90gnp allergy relief 42gnp allergy/congestion relief 90gnp antacid extra strength 22gnp arthritis pain relief 16gnp aspirin 18gnp aspirin low dose 18gnp calcium 141gnp clotrimazole 3 167

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GNP EASY TOUCH CONT HIGH/LOW 124gnp eye itch relief 151gnp infants pain relief 16gnp infants pain/fever 16gnp insulin syringe 132gnp iron 111gnp itchy eye 151gnp lancets 116gnp lancets 21g 116gnp lancets micro thin 33g 116gnp lancets super thin 30g 116gnp lancets thin 116gnp lancets thin 26g 117gnp loratadine 42gnp loratadine childrens 42gnp loratadine-d 12hr 90gnp miconazole 7 167gnp micro thin lancets 33g 117gnp mucus dm max strength 89gnp mucus er 91gnp mucus relief 91gnp nicotine 160gnp nicotine mini 160gnp nicotine polacrilex 160gnp pain & fever childrens 16gnp super thin lancets 30g 117gnp tab tussin 91gnp tussin mucus & chest cong 91gnp ultra com insulin syringe 132GOCOVRI 54GOLYTELY 112goodsense all day allergy 42goodsense arthritis pain 16goodsense aspirin 18goodsense lancets 30g 117goodsense lancets 33g 117goodsense lancing device 117goodsense nicotine 160goodsense pain & fever child 17goodsense pain & fever infants 17goodsense pain relief 17granisetron hcl 40GRANIX 110griseofulvin microsize 41griseofulvin ultramicrosize 41guaifenesin 91guaifenesin-dm 89guanfacine hcl 45guanfacine hcl er 5guanidine hcl 48GYNAZOLE-1 167

HAEMOLANCE 124HAEMOLANCE LOW FLOW LANCETS 124HAEMOLANCE PLUS 124HAEMOLANCE PLUS HIGH FLOW 124HAEMOLANCE PLUS LOW FLOW 124HAEMOLANCE PLUS MAX FLOW 125HAEMOLANCE PLUS PEDIATRIC FLOW 125HAILEY 24 FE 80HALAVEN 53halobetasol propionate 95haloperidol 58haloperidol decanoate 57, 58haloperidol lactate 58HEALTH CARE LANCING DEVICE 125healthy accents lancing device . 117healthy accents unilet lancets 117HEATHER 85h-e-b incontrol adv lancing 117h-e-b incontrol alcohol 114h-e-b incontrol lancets 28g 117h-e-b incontrol lancets 30g 117h-e-b incontrol lancets 33g 117HELIXATE FS 105HEMATOGEN FA 110HEMLIBRA 42HEMOCYTE 111HEMOCYTE PLUS 110HEMOCYTE-F 111HEMOFIL M 106heparin (porcine) in nacl 28heparin lock flush 28heparin sod (porcine) in d5w 28heparin sodium (porcine) 28heparin sodium (porcine) pf 28HEPATAMINE 150HIZENTRA 155hm acetaminophen childrens 17hm all day allergy 43hm all day allergy childrens 43hm allergy & congestion 90hm allergy complete-d 90hm allergy relief/nasal decong 90hm arthritis pain relief 17hm aspirin 18hm aspirin ec 18hm aspirin ec low dose 18

hm calcium antacid 22hm calcium antacid ex st 22hm calcium antacid ultra st 22hm cetirizine hcl childrens 43hm chest congestion relief 91hm eye itch relief 151hm loratadine 43hm loratadine childrens 43hm nicotine 160hm nicotine polacrilex 160hm pain & fever childrens 17hm pain & fever infants 17hm tussin adult 91hm tussin adult dm 89HP ACTHAR 100HUMALOG 37HUMALOG MIX 50/50 37HUMALOG MIX 50/50 KWIKPEN 36HUMALOG MIX 75/25 37HUMALOG MIX 75/25 KWIKPEN 37HUMATE-P 106HUMIRA 13, 14, 15HUMIRA PEDIATRIC CROHNS START 13, 14HUMIRA PEN 13, 14HUMIRA PEN-CD/UC/HS STARTER 13, 14HUMIRA PEN-PS/UV/ADOL HS START 13, 14HUMULIN 70/30 37HUMULIN N 37HUMULIN R 37hydralazine hcl 46hydrochlorothiazide 99hydrocodone-acetaminophen 19, 20hydrocodone-homatropine 89hydrocodone-ibuprofen 20hydrocortisone 22, 87, 95hydrocortisone-iodoquinol 93hydromorphone hcl 20hydroxychloroquine sulfate 48hydroxyprogesterone caproate 77hydroxyurea 52hydroxyzine hcl 24hydroxyzine pamoate 24hyoscyamine sulfate 164hyoscyamine sulfate er 164HYPERHEP B S/D 155HYPERLYTE-CR 142HYPERRHO S/D 155

177

HYPOLANCE AST LANCING 125HYQVIA 154HYSINGLA ER 20HY-VEE LANCETS 125hy-vee thin lancets 117IBU 15ibuprofen 15idarubicin hcl 51IDELVION 106IFEREX 150 FORTE 110ifosfamide 53ILEVRO 153imatinib mesylate 51imipenem-cilastatin 47imipramine hcl 34imiquimod 97IN TOUCH 125IN TOUCH GLUCOSE CONTROL 125IN TOUCH LANCING DEVICE 125IN TOUCH STERILE LANCETS 30G 125INCASSIA 85indapamide 99indomethacin 15INFINITY CONTROL 125INFUVITE ADULT 146INFUVITE PEDIATRIC 146INSPIRACHAMBER/LARGE 140INSPIRACHAMBER/MEDIUM 140INSPIRACHAMBER/MOUTHPIECE 140INSPIRACHAMBER/SMALL 140INSPIREASE 140insulin syringe 132insulin syringe/needle 132INTEGRA F 111INTEGRA PLUS 110INTELENCE 68INTRALIPID 150INTRON A 52INTROVALE 84INVEGA SUSTENNA 57INVEGA TRINZA 57INVIRASE 68INVOKAMET 162INVOKANA 38

IONOSOL-MB IN D5W 142ipratropium bromide 26ipratropium-albuterol 25irbesartan 45IRESSA 51irinotecan hcl 53ISENTRESS 67ISENTRESS HD 67ISIBLOOM 80ISOLYTE-P IN D5W 142ISOLYTE-S 142ISOLYTE-S PH 7.4 142isoniazid 49isosorbide dinitrate 23isosorbide mononitrate 23isosorbide mononitrate er 23isotretinoin 93ivermectin 23IXINITY 106JANTOVEN 27JANUMET 36JANUMET XR 36JANUVIA 35JARDIANCE 38JASMIEL 80JENCYCLA 85JENTADUETO 36JIVI 106JOLESSA 84JOLIVETTE 85JULEBER 80JULUCA 67JUNEL 1.5/30 80JUNEL 1/20 80JUNEL FE 1.5/30 80JUNEL FE 1/20 80JUNEL FE 24 80KABIVEN 158KAITLIB FE 80KALETRA 67KARIVA 77kcl in d5w lactated ringers 142kcl in dextrose-nacl 142kcl-lactated ringers-d5w 142kedbumin 107KELNOR 1/35 80KELNOR 1/50 80KEPPRA 30KEPPRA XR 30ketoconazole 96ketone test 98ketorolac tromethamine 15, 153

KETOSTIX 98ketotifen fumarate 151kinney lancets 117kinney thin lancets 117kinray insulin syringe 132KLONOPIN 29KLOR-CON 143KLOR-CON 10 143KLOR-CON M10 143KLOR-CON M15 143KLOR-CON M20 143KLOR-CON SPRINKLE 143KLOR-CON/EF 143kmart valu insulin syringe 29g 132kmart valu insulin syringe 30g 132KOATE 106KOATE-DVI 106KOGENATE FS 106KOMBIGLYZE XR 36KOVALTRY 106kp ketotifen fumarate 151K-PHOS 143K-PHOS NO 2 104K-PHOS-NEUTRAL 143kroger insulin syringe 132kroger lancets 117kroger lancets 21g 117kroger lancets micro thin 33g 117kroger lancets super thin 117kroger lancets thin 117kroger lancets thin 26g 117kroger lancets ultrathin 30g 117kroger lancing device 117KURVELO 80KYLEENA 85labetalol hcl 72lactated ringers 71, 142lactic acid e 96lactose monohydrate 157lactulose 112lactulose encephalopathy 103LAMICTAL 30LAMICTAL ODT 30LAMICTAL STARTER 30LAMICTAL XR 30lamivudine 68, 69lamivudine-zidovudine 66lamotrigine 29lamotrigine er 29lamotrigine starter kit-blue 29lamotrigine starter kit-green 29lamotrigine starter kit-orange 29

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lancet device 117lancet device with ejector 117lancet transporter case 117lancets 117lancets 28g 117lancets 30g 117lancets micro thin 33g 117lancets super thin 28g 117lancets thin 117LANCETS ULTRA FINE 125LANCETS ULTRA THIN 125lancets ultra thin 30g 117lancing device 117lansoprazole 165LANTUS 37LANTUS SOLOSTAR 37LANZO 125LARIN 1.5/30 80LARIN 1/20 80LARIN 24 FE 80LARIN FE 1.5/30 80LARIN FE 1/20 81LARISSIA 81latanoprost 154LATUDA 55, 56LAYOLIS FE 81l-cysteine hcl 150leader advanced lancing device117leader insulin syringe 132LEENA 86leflunomide 15LESSINA 81LETAIRIS 75letrozole 52leucovorin calcium 52LEUKERAN 53LEUKINE 110leuprolide acetate 52LEVEMIR 37LEVEMIR FLEXTOUCH 37levetiracetam 29, 30levetiracetam er 29levobunolol hcl 151levocarnitine 100levocetirizine dihydrochloride 43levofloxacin 102levofloxacin in d5w 102LEVONEST 86levonorgest-eth est & eth est 84levonorgest-eth estrad 91-day 84levonorgestrel 83levonorgestrel-ethinyl estrad 78, 83

levonorg-eth estrad triphasic 86LEVORA 0.15/30 (28) 81levothyroxine sodium 163, 164LEVOXYL 164LEXIVA 68LIBERTY GLUCOSE CONTROL 125LIBERTY GLUCOSE CONTROL MID 125LIBERTY MEDICAL LANCETS 125LIBERTY MINI LANCING DEVICE 125lidocaine 97lidocaine hcl 97, 113lidocaine hcl (pf) 113lidocaine hcl urethral/mucosal 97lidocaine in dextrose 113lidocaine viscous hcl 144lidocaine-epinephrine 113lidocaine-hydrocortisone ace 22lidocaine-prilocaine 97LIFESCAN UNISTIK 2 125LIFESCAN UNISTIK II LANCETS 125LILETTA (52 MG) 85LILLOW 81lincomycin hcl 47linezolid 47LINZESS 103liothyronine sodium 164lisinopril 44, 45lisinopril-hydrochlorothiazide 44lite touch lancets 117LITE TOUCH LANCING PEN 125LITEAIRE 140LITETOUCH INSULIN SYRINGE 135LITETOUCH LANCETS 125lithium 55lithium carbonate 55lithium carbonate er 55live better adv lancing device 117live better lancet super thin 117live better lancet ultra thin 118LO LOESTRIN FE 77LOESTRIN 1.5/30 (21) 81LOESTRIN 1/20 (21) 81longs insulin syringe 132longs lancets standard 118longs lancets thin 118

longs lancets ultra thin 118loperamide hcl 40loratadine 43loratadine childrens 43loratadine-d 12hr 90loratadine-d 24hr 90lorazepam 24LORAZEPAM INTENSOL 24LORYNA 81losartan potassium 45losartan potassium-hctz 45LOSEASONIQUE 84LOTEMAX 153loteprednol etabonate 153LOTRONEX 103lovastatin 44LOW-OGESTREL 81loxapine succinate 61lozibase 156LO-ZUMANDIMINE 81LUPANETA PACK 113LUPRON DEPOT (1-MONTH) 52LUPRON DEPOT (3-MONTH) 52LUPRON DEPOT (4-MONTH) 52LUPRON DEPOT (6-MONTH) 52, 53LUPRON DEPOT-PED (1-MONTH) 101LUPRON DEPOT-PED (3-MONTH) 101LUTERA 81LYRICA 30, 31LYZA 86M.V.I. ADULT 146M.V.I. PEDIATRIC 146MAGELLAN INSULIN SAFETY SYR 135, 136magnesium chloride 142magnesium sulfate 142MAKENA 158malathion 97manganese chloride 143mapap 17mapap arthritis pain 17MAPAP CHILDRENS 17marlissa 78MATULANE 52MAVYRET 112

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MAXI-COMFORT INSULIN SYRINGE 136MAXIDEX 153meclizine hcl 41medic insulin syringe 132medichoice safety lancet 118medichoice safety lancet extra 118medichoice safety lancet norm 118MEDISENSE GLUCOSE KETONE CONTR 125MEDISENSE HI/MID/LOW CONTROL 125MEDISENSE HIGH/LOW CONTROL 125MEDISENSE MID CONTROL 125MEDISENSE THIN LANCETS 125MEDLANCE EXTRA 21G 125MEDLANCE LITE 25G 125MEDLANCE PLUS EXTRA 21G 125MEDLANCE PLUS LANCETS 125MEDLANCE PLUS LITE 25G 126MEDLANCE PLUS SPECIAL 0.8MM 126MEDLANCE PLUS SUPERLITE 30G 126MEDLANCE PLUS UNIVERSAL 21G 126MEDLANCE UNIVERSAL 21G 126medroxyprogesterone acetate

85, 157, 158mefloquine hcl 48megestrol acetate 53, 158meijer alcohol swabs 114MEIJER LANCETS 126MEIJER LANCETS THIN 126MEIJER LANCETS UNIVERSAL 21G 126MEIJER LANCETS UNIVERSAL 30G 126MEIJER LANCETS UNIVERSAL 33G 126MEIJER SUPER THIN LANCETS 126meloxicam 15melphalan 53melphalan hcl 53

memantine hcl 159MEPSEVII 145mercaptopurine 50meropenem 47meropenem-sodium chloride 47mesalamine 103mesna 54MESTINON 48metformin hcl 35metformin hcl er 35metformin hcl er (osm) 35methazolamide 98methenamine hippurate 166methenamine mandelate 166methimazole 163methocarbamol 148methotrexate 50methotrexate (anti-rheumatic) 13methotrexate sodium 50methotrexate sodium (pf) 50methyldopa 45methylergonovine maleate 154methylphenidate hcl 10, 11methylphenidate hcl er 10methylphenidate hcl er (cd) 9, 10methylphenidate hcl er (la) 10methylprednisolone 87, 88methylprednisolone acetate 87methylprednisolone sodium succ 87metoclopramide hcl 103metolazone 100metoprolol succinate er 72metoprolol tartrate 72metronidazole 47, 97metronidazole in nacl 47mexiletine hcl 24MIBELAS 24 FE 81miconazole 1 167miconazole 3 167miconazole 7 167miconazole nitrate 96, 167MICROCHAMBER 140MICRODOT CONTROL HIGH/LOW 126MICROGESTIN 1.5/30 81MICROGESTIN 1/20 81MICROGESTIN FE 1.5/30 81MICROGESTIN FE 1/20 81MICROLET LANCETS 126MICROLET NEXT LANCING DEVICE 126MICROSPACER 140

MICROTAINER SAFETY FLOW LANCET 126midodrine hcl 168miglitol 34miglustat 108MILI 81milrinone lactate 75milrinone lactate in dextrose 75MINASTRIN 24 FE 81mineral oil-hydrophil petrolat 96mini lancing device 118minocycline hcl 162minoxidil 46MIRCETTE 78MIRENA (52 MG) 85mirtazapine 33misoprostol 165mitomycin 51mitoxantrone hcl 51m-natal plus 146modafinil 11mometasone furoate 95, 148MONOJECT INSULIN SYRINGE 136MONOJECT LIFESHIELD SYRINGE 136MONOJECT MAGELLAN SYRINGE 136MONOJECT SYRINGE 136MONOJECT ULTRA COMFORT SYRINGE 137MONOLET LANCETS 126MONOLET OPD LANCETS 126MONOLETTOR SAFETY LANCETS 126MONO-LINYAH 81MONONINE 106montelukast sodium 26MORPHABOND ER 20morphine sulfate 20morphine sulfate (concentrate) 20mouth wash-gp 156MOVANTIK 103MOXEZA 152moxifloxacin hcl 152MOZOBIL 108ms insulin syringe 132MUCINEX 92MUCINEX FOR KIDS 92MUCINEX MAXIMUM STRENGTH 92mucosa 91

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mucus & chest congestion 91mucus & cough relief childrens 89mucus relief 91mucus relief chest congestion 91mucus relief dm 89mucus relief dm cough 89mucus relief dm max 89mucus relief er 91mucus-dm maximum strength 89mucusrelief dm cough 89multi-lancet device 118MULTI-LANCET DEVICE 2126MULTITRACE-4 144multitrace-4 concentrate 144MULTITRACE-4 NEONATAL 144MULTITRACE-4 PEDIATRIC 144MULTITRACE-5 144multitrace-5 concentrate 144multivitamin/fluoride 146mupirocin 93MUTAMYCIN 51MY CHOICE 83MY WAY 83mycophenolate mofetil 71mycophenolate mofetil hcl 71MYGLUCOHEALTH CONTROL 126MYGLUCOHEALTH LANCETS 30G 126MYLERAN 49MYORISAN 93MYSOLINE 31NABI-HB 155nabumetone 15NAGLAZYME 101naloxone hcl 40naltrexone hcl 40naproxen 15naproxen dr 15NARCAN 40NATAZIA 85nateglinide 38NEBUPENT 47NECON 0.5/35 (28) 81neomycin sulfate 12neomycin-bacitracin zn-polymyx 152neomycin-polymyxin b gu 104neomycin-polymyxin-dexameth 153neomycin-polymyxin-hc 154

NEPHPLEX RX 145NEPHRAMINE 150NEPHRO-VITE RX 145NEULASTA 110NEULASTA ONPRO 110NEUPOGEN 110NEURONTIN 31NEUTEK 2TEK CONTROL 126nevirapine 68nevirapine er 68NEW DAY 83NEXAVAR 51NEXIUM 165NEXPLANON 85niacin er (antihyperlipidemic) 44nicotine 160nicotine polacrilex 160nicotine step 1 160nicotine step 2 160nicotine step 3 160nifedipine 74nifedipine er 74nifedipine er osmotic release 74NIKKI 81nilutamide 49nimodipine 75nitrofurantoin 166nitrofurantoin macrocrystal 166nitrofurantoin monohyd macro 166nitroglycerin 23NIVA-PLUS 147NIVESTYM 110non-aspirin childrens 17NORA-BE 86NORDITROPIN FLEXPRO 100norethin ace-eth estrad-fe 78norethindrone 85norethindrone acetate 158norethindrone acet-ethinyl est 78norethindrone-eth estradiol 102norethin-eth estradiol-fe 78norgestimate-eth estradiol 78norgestim-eth estrad triphasic 86NORLYDA 86normal saline flush 144NORMOSOL-M IN D5W 142NORMOSOL-R 142NORMOSOL-R IN D5W 142NORMOSOL-R PH 7.4 142NORTREL 0.5/35 (28) 81NORTREL 1/35 (21) 81NORTREL 1/35 (28) 81

NORTREL 7/7/7 86nortriptyline hcl 34NORVIR 68NOVA MAX PLUS GLU/KET CONTROL 126NOVA SAFETY LANCETS 23G 126NOVA SAFETY LANCETS 28G 126NOVA SUREFLEX LANCETS 126NOVA SUREFLEX LANCING DEVICE 126NOVOEIGHT 106NOVOLIN N 37NOVOLIN N RELION 37NOVOLIN R 37NOVOLIN R RELION 37NOVOLOG 38NOVOLOG FLEXPEN 37NOVOLOG MIX 70/30 37NOVOLOG MIX 70/30 FLEXPEN 37NOVOLOG PENFILL 38NOVOSEVEN RT 106np thyroid 164nutrilipid 150NUVARING 82NUVESSA 167NUWIQ 106nystatin 41, 93, 144OB COMPLETE 147obizur 105OCELLA 81OCTAGAM 155octreotide acetate 101ODEFSEY 67OFEV 161ofloxacin 152, 154OGESTREL 81olanzapine 64, 65olmesartan medoxomil 45olmesartan medoxomil-hctz 45olopatadine hcl 151omeprazole 165ON CALL EXPRESS GLUCOSE CONTR 126ON CALL LANCETS 126ON CALL LANCING DEVICE 126ON CALL PLUS GLUCOSE CONTROL 126

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ON CALL PLUS LANCETS 126ON CALL PLUS LANCING DEVICE 126ON CALL VIVID GLUCOSE CONTROL 127ONCASPAR 51ondansetron 40ondansetron hcl 40ONETOUCH CLUB LANCETS FINE PT 127ONETOUCH COMBO PACK 127ONETOUCH DELICA LANCETS 33G 127ONETOUCH DELICA LANCETS FINE 127ONETOUCH DELICA LANCING DEV 127ONETOUCH FINEPOINT LANCETS 127ONETOUCH PING METER REMOTE 127ONETOUCH SURESOFT LANCING DEV 127ONETOUCH ULTRA 2 127ONETOUCH ULTRA BLUE 98ONETOUCH ULTRA CONTROL 127ONETOUCH ULTRA MINI 127ONETOUCH ULTRALINK 127ONETOUCH ULTRASOFT LANCETS 127ONETOUCH VERIO 98, 127ONETOUCH VERIO IQ SYSTEM 127ONETOUCH VERIO SYNC SYSTEM 127ONFI 29ONGLYZA 36OPCICON ONE-STEP 83OPTICHAMBER ADVANTAGE-LG MASK 140OPTICHAMBER ADVANTAGE-MED MASK 140OPTICHAMBER ADVANTAGE-SM MASK 140OPTICHAMBER DIAMOND

140OPTICHAMBER DIAMOND-LG MASK 140OPTICHAMBER DIAMOND-MD MASK 140

OPTICHAMBER DIAMOND-SM MASK 140OPTICHAMBER FACE MASK-LARGE 140OPTICHAMBER FACE MASK-MEDIUM 140OPTICHAMBER FACE MASK-SMALL 140OPTIHALER 140OPTUMRX GLUCOSE CONTROL 127ORACIT 104ORFADIN 101ORILISSA 100ORSYTHIA 81ORTHO MICRONOR 86ORTHO TRI-CYCLEN LO 86ORTHO-NOVUM 1/35 (28) 82ORTHO-NOVUM 7/7/7 (28) 86oseltamivir phosphate 70oxaliplatin 49OXAYDO 21oxazepam 24oxcarbazepine 30OXTELLAR XR 31oxybutynin chloride 166oxybutynin chloride er 166oxycodone hcl 20oxycodone-acetaminophen 21OYSCO 500 141oyster shell calcium 141OZEMPIC 38paclitaxel 53pain & fever childrens 17pain & fever infants 17pain relief childrens 17pamidronate disodium 100PANCREAZE 98PANRETIN 94pantoprazole sodium 165PARAGARD INTRAUTERINE COPPER 83paricalcitol 101paroxetine hcl 34PAZEO 152pb-hyoscy-atropine-scopolamine 164pc lancets super thin 30g 118PCCA ACACIA SYRUP BASE 157peg 3350 112peg 3350/electrolytes 112

peg 3350-kcl-na bicarb-nacl 112peg-3350/electrolytes 112PEGANONE 32PEGASYS 69PEGASYS PROCLICK 69PEGINTRON 69penicillin g procaine 155penicillin g sodium 155penicillin v potassium 155PENLET II BLOOD SAMPLER 127PENLET II REPLACEMENT CAP 127pentoxifylline er 107PERFECT LANCETS 28G 127PERFECT LANCETS 30G 127PERIKABIVEN 158permethrin 97perphenazine 62perphenazine-amitriptyline 160PERSERIS 57PERTZYE 98PHARMACIST CHOICE ALCOHOL 115PHARMACIST CHOICE LANCETS 127PHARMACY COUNTER LANCETS 127phenazopyridine hcl 104phenobarbital 112phenylephrine hcl 152PHENYTEK 32phenytoin 32PHENYTOIN INFATABS 32phenytoin sodium extended 32PHILITH 82PHOSPHA 250 NEUTRAL 143phytonadione 168PIFELTRO 68pilocarpine hcl 144pimecrolimus 97pimozide 160PIMTREA 78pioglitazone hcl 39pioglitazone hcl-metformin hcl 39piperacillin sod-tazobactam so 156PIRMELLA 1/35 82PIRMELLA 7/7/7 86PLAN B ONE-STEP 84PLASBUMIN-25 107PLASBUMIN-5 107PLASMA-LYTE 148 142

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PLASMA-LYTE A 142PLASMANATE 107PLENAMINE 150pnv-dha+docusate 147pnv-omega 146POCKET CHAMBER 140POCKET SPACER 140POCKETCHEM EZ CONTROL 127podofilox 97polyethylene glycol 3350 112, 113polymyxin b sulfate 48polymyxin b-trimethoprim 152POLY-VI-FLOR 146POLY-VI-FLOR/IRON 146POMALYST 50PORTIA-28 82potassium acetate 143potassium chloride 143potassium chloride crys er 143potassium chloride er 143potassium chloride in dextrose 142potassium chloride in nacl 142potassium citrate er 104potassium citrate-citric acid 104potassium phosphates 143PRADAXA 28pramipexole dihydrochloride 54prasugrel hcl 108pravastatin sodium 44praziquantel 23prazosin hcl 46PRECISION GLUCOSE CONTROL 127PRECISION GLUCOSE CONTROL SOLN 127PRECISION GLUCOSE KETONE CONTR 128PRECISION GLUCOSE/KETONE CONTR 128PRECISION SUREDOSE PLUS SYR 137PRECISION SURE-DOSE SYRINGE 137PRECISION THINS GP LANCETS 128prednisolone 88prednisolone acetate 153prednisolone sodium phosphate . 88prednisone 88preferred plus insulin syringe 132

preferred plus lancets colored 118preferred plus lancets thin 118PREMARIN 102, 168PREMASOL 150PREMPHASE 102PREMPRO 102prenaissance 147prenaissance plus 147prenatal 147prenatal vitamin plus low iron 147preplus 147pressure activat safety lancet 118PREVIFEM 82PREZCOBIX 67PREZISTA 68primaquine phosphate 48primidone 30PRIVIGEN 155pro comfort alcohol 114pro comfort lancets 30g 118pro comfort lancets 31g 118probenecid 105PROCALAMINE 150prochlorperazine maleate 62PROCTOFOAM HC 22PROCTOSOL HC 22PROCTOZONE-HC 22PRODIGY CONTROL SOLUTION 128PRODIGY INSULIN SYRINGE 137PRODIGY LANCETS 28G 128PRODIGY LANCING DEVICE 128PRODIGY SAFETY LANCETS 26G 128PRODIGY TWIST TOP LANCETS 28G 128PROFILNINE 106PROFILNINE SD 106progesterone 158progesterone micronized 158PROGLYCEM 35PROLASTIN-C 161PROLEUKIN 51promethazine hcl 43promethazine-dm 92promethazine-phenylephrine 90PROMETHEGAN 43PROMETRIUM 158propafenone hcl 25propantheline bromide 165

propranolol hcl 73propranolol hcl er 72propranolol-hctz 46propylthiouracil 163PROSOL 150PROTONIX 165PROVENTIL HFA 26PROVIDA OB 147PRUDOXIN 94pseudoeph-bromphen-dm 92PSS SELECT GP LANCETS 128PSS SELECT PLATFORMS 128PSS SELECT SAFETY LANCETS 128PULMOZYME 161purevit dualfe plus 110push button safety lancets 118px advanced lancing device 118px insulin syringe 132px lancet auto injector 118px lancets ultra thin 118PYLERA 165pyrazinamide 49pyridostigmine bromide 48pyridostigmine bromide er 48pyridoxine hcl 168qc 3 day 167qc advanced lancing device 118qc alcohol swabs 114qc all day allergy 43qc arthritis pain relief 17qc aspirin 19qc aspirin low dose 18, 19qc childrens allergy 43qc enteric aspirin 19qc lancets super thin 30g 118qc lancets ultra thin 118qc loratadine allergy relief 43qc loratadine-d 90qc medifin 400 91qc miconazole 7 167qc mucus relief 91qc non-aspirin childrens 17qc non-aspirin jr strength 17qc pain relief childrens 17qc tussin mucus/congestion 91qc unilet lancets 28g 118qc unilet lancets micro thin 118QUARTETTE 84QUDEXY XR 31quetiapine fumarate 60, 61quetiapine fumarate er 60

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QUFLORA PEDIATRIC 146QUICKTEK CONTROL SOLUTION 128QUILLICHEW ER 12QUILLIVANT XR 12quinapril hcl 45quinapril-hydrochlorothiazide 44quinidine gluconate er 24quinidine sulfate 24QUINTET CONTROL HIGH/NORMAL 128QVAR REDIHALER 27ra alcohol swabs 114ra antihistamine eye drops 151ra eye itch relief 151RA E-ZJECT COLOR LANCETS 33G 128RA E-ZJECT LANCETS 28G

128RA E-ZJECT LANCETS THIN 26G 128RA E-ZJECT LANCETS THIN 28G 128RA E-ZJECT LANCETS ULTRA THIN 128ra insulin syringe 132ra lancing device 118ramipril 45ranitidine hcl 165ranolazine er 23raspberry syrup 156reality insulin syringe 132reality lancets 118reality swabs 114reality trigger lancets 118REBETOL 69REBIF 159REBIF REBIDOSE 159REBIF REBIDOSE TITRATION PACK 159REBIF TITRATION PACK 159REBINYN 106RECLIPSEN 82RECOMBINATE 106REFUAH PLUS GLUCOSE CONTROL 128RELENZA DISKHALER 70RELION ALCOHOL SWABS 115RELION INSULIN SYRINGE 137

RELI-ON INSULIN SYRINGE 137RELION KETONE 98RELION LANCETS MICRO-THIN 33G 128RELION LANCETS STANDARD 21G 128RELION LANCETS THIN 26G 128RELION LANCETS ULTRA-THIN 30G 128RELION LANCING DEVICE 128RELION ULTRA THIN LANCETS 30G 128RELION ULTRA THIN PLUS LANCETS 128RENACIDIN 104RENVELA 103repaglinide 38RESCRIPTOR 68RESTASIS 152RESTASIS MULTIDOSE 152RETACRIT 109RETROVIR 69REVLIMID 71REXALL LANCETS ULTRA THIN 30G 128REYATAZ 68RHOPRESSA 154RIBASPHERE 69RIBASPHERE RIBAPAK 69ribavirin 69, 70rifabutin 49rifampin 49RIGHTEST ALTERNATE SITE ADAPT 128RIGHTEST GC300 CONTROL 128RIGHTEST GD500 LANCING DEVICE 128RIGHTEST GL300 LANCETS 128riluzole 149ringers 142ringers irrigation 71RISPERDAL CONSTA 57risperidone 56, 57RITEFLO 140ritonavir 67RITUXAN 50rivastigmine 158

RIVELSA 84rixubis 105rizatriptan benzoate 141robafen 91ROBAFEN DM COUGH 89ROBAFEN MUCUS/CHEST CONGESTION 92ropinirole hcl 54rosuvastatin calcium 44ROWEEPRA 31ROWEEPRA XR 31ROXYBOND 21ROZEREM 112RUCONEST 107SABRIL 32SAFESNAP INSULIN SYRINGE 137SAFE-T-LANCE 128SAFE-T-LANCE PLUS 129safety insulin syringes 132safety lancet 21g/pressure act 118safety lancet 28g/pressure act 118SAFETY LANCETS 129SAFETY LANCETS 21G 129safety lancets 28g 118SAFETY LET LANCETS 129SAFETY SEAL LANCETS 129safety syringe/needle 132SAFYRAL 82salicylic acid 97saline bacteriostatic 157salsalate 19SANDIMMUNE 70SANTYL 96saps care alcohol prep 114sapscare twist top lancets 118sb alcohol prep 114sb insulin syringe 132sb lancets thin 118sb lancets ultra thin 118SEASONIQUE 84SEGLUROMET 162select-lite device/lancets 118select-lite lancing device 118SELECT-OB 147selegiline hcl 54selenium 144selenium sulfide 94SELZENTRY 67se-natal 19 147SEREVENT DISKUS 26SEROSTIM 101

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sertraline hcl 34se-tan plus 110SETLAKIN 85sevelamer carbonate 103sevelamer hcl 103SHAROBEL 86SHOPKO ALCOHOL SWABS 115SHOPKO AUTOLET LANCING DEVICE 129SHOPKO ON-THE-GO LANCETS 30G 129SHOPKO UNILET LANCETS 28G 129SHOPKO UNILET LANCETS 30G 129side button safety lancet 118sildenafil citrate 75siltussin sa 91silver nitrate 95silver sulfadiazine 95SIMBRINZA 151SIMLIYA 78SIMPLE DIAGNOSTICS LANCING DEV 129simple syrup 156simvastatin 44SINGLE-LET 129SINGULAIR 26sirolimus 71SKLICE 97SKYLA 85sm 3-day vaginal 167sm 8 hour pain relief 17sm alcohol prep 114sm all day allergy 43sm all day allergy childrens 43sm all day allergy-d 90sm allergy childrens 43sm 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 91sm childrens aspirin 19sm childrens loratadine 43sm clotrimazole vaginal 167sm eye itch relief 151

sm lancets 33g 118sm loratadine 43sm loratadine d 90sm lorata-dine d 90sm loratadine d 12hr 90sm miconazole 7 167sm mucus relief 91sm mucus relief max strength 91sm nicotine 160, 161sm nicotine polacrilex 160, 161sm pain & fever childrens 17sm pain & fever infants 17sm slow release iron 111sm tussin dm max 89sm tussin mucus+chest congest 92SMART DIABETES VANTAGE LANCING 129SMART SENSE COLOR LANCETS 33G 129SMART SENSE STANDARD LANCETS 129SMART SENSE SUPER THIN LANCETS 129SMART SENSE THIN LANCETS 26G 129SMARTEST CONTROL MEDIUM 129SMARTEST LANCETS 28G 129sod citrate-citric acid 104sodium acetate 141sodium bicarbonate 22, 141sodium chloride 92, 104, 144sodium chloride bacteriostatic 157sodium fluoride 142sodium lactate 141sodium phosphates 143sodium polystyrene sulfonate

71, 157SOLARTEK GLUCOSE CONTROL 129solifenacin succinate 166SOLTAMOX 49SOLU-CORTEF 88SOLUS V2 CONTROL 129SOLUS V2 LANCETS 28G 129SOLUS V2 LANCING DEVICE 129SOLUS V2 TWIST LANCETS 30G 129sorbitol 77, 104, 157sorbitol-mannitol 104sotalol hcl 73

sotalol hcl (af) 73spinosad 97SPIRIVA HANDIHALER 26spironolactone 99spironolactone-hctz 99SPRINTEC 28 82SPS 71, 157SRONYX 82ST JOSEPH LOW DOSE 19stavudine 69STEGLATRO 38STERILANCE PA 129STERILANCE TL 129sterile water for injection 157sterile water for irrigation 71stevia 12stevia extract 77STIMATE 102STIOLTO RESPIMAT 25STRIBILD 67STROVITE ONE 146SUBLOCADE 21SUBVENITE 31SUBVENITE STARTER KIT-BLUE 31SUBVENITE STARTER KIT-GREEN 31SUBVENITE STARTER KIT-ORANGE 31sucralfate 165sulfacetamide-prednisolone 153sulfadiazine 162sulfamethoxazole-trimethoprim 47sulfasalazine 103sumatriptan 141sumatriptan succinate 141super thin lancets 118supreme ii confidence paddles 119supreme ii high/low control 119sure comfort alcohol prep 114sure comfort insulin syringe 133sure comfort lancets 28g 119sure comfort lancets 30g 119sure comfort lancing pen 119SURE-JECT INSULIN SYRINGE 137SURE-LANCE FLAT LANCETS 129SURE-LANCE LANCETS 26G 129SURE-LANCE THIN LANCETS 28G 129

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SURE-LANCE ULTRA THIN LANCETS 129SURELITE LANCETS 129SURE-PEN 129SURE-PREP ALCOHOL PREP 115SURESTEP GLUCOSE CONTROL 129SURESTEP PRO HIGH GLUCOSE 129SURESTEP PRO LINEARITY 129SURESTEP PRO LOW GLUCOSE 130SURESTEP PRO NORMAL GLUCOSE 130SURE-TOUCH LANCETS UNIVERSAL 130SUSTIVA 68SUTENT 51SYEDA 82SYMBICORT 25SYMFI 67SYMFI LO 67SYMLINPEN 120 34SYMLINPEN 60 34SYMTUZA 67SYNAREL 101SYNJARDY 162SYNTHAMIN 17 150SYNTHROID 164syringe 133syringe luer slip 133syringe/hypodermic safety 133syrpalta 157SYRSPEND SF 157tacrolimus 71, 97TAI DOC CONTROL 130TAKE ACTION 84tamoxifen citrate 49tamsulosin hcl 104TARINA 24 FE 82TARINA FE 1/20 82TARINA FE 1/20 EQ 82taron forte 110TARON-C DHA 147TARON-PREX 148TAYTULLA 82tazarotene 94TAZORAC 94TECHLITE AST LANCETS 130TECHLITE LANCETS 130

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TECHLITE LANCETS 30G . 130TEGRETOL 31TEGRETOL-XR 31TELCARE GLUCOSE CONTROL 130telmisartan 45telmisartan-hctz 45temazepam 112TEMODAR 52temozolomide 52temsirolimus 50tenofovir disoproxil fumarate 69terazosin hcl 46terbinafine hcl 41terbutaline sulfate 26terconazole 167testosterone cypionate 21testosterone enanthate 21tetrabenazine 159tgt alcohol swabs 114tgt lancet micro thin 33g 119tgt lancet thin 26g 119tgt lancet ultra thin 30g 119tgt lancing device 119THALOMID 70THEO-24 27theophylline 27theophylline er 27THERATEARS ALLERGY 152thiamine hcl 168THINLETS GP LANCETS 130THIOLA 104thioridazine hcl 62, 63thiotepa 49thiothixene 65, 66thrivite 19 147THYMOGLOBULIN 71thyroid 164THYROLAR-1 164THYROLAR-1/2 164THYROLAR-1/4 164THYROLAR-2 164THYROLAR-3 164tiagabine hcl 32TIKOSYN 25TILIA FE 86timolol maleate 151tinidazole 47TIS-U-SOL 71TIVICAY 67tizanidine hcl 148tl gard rx 109

TL G-FOL OS 145TOBRADEX 153tobramycin 12, 152tobramycin sulfate 12tobramycin-dexamethasone 153todays health lancing device 119todays health thin lancets 28g 119todays health thin lancets 30g 119tolbutamide 39tolterodine tartrate 167tolterodine tartrate er 166TOPAMAX 31TOPAMAX SPRINKLE 31topcare lancets micro-thin 33g 119topcare ultra comfort ins syr 133topiramate 30topiramate er 30topotecan hcl 53toremifene citrate 49torsemide 99TOVIAZ 166, 167TPN ELECTROLYTES 142TRACER II 3 VOLT BATTERY 130TRACLEER 75TRADJENTA 36tramadol hcl 20tranexamic acid 111TRANSDERM SCOP (1.5 MG) 41TRAVASOL 150TRAVATAN Z 154travel lancets 119TRAVEL LANCETS ADVANCED 28G 130trazodone hcl 33, 161, 162TREANDA 49tretinoin 53, 93TRETTEN 106TRI FEMYNOR 86triamcinolone acetonide

95, 145, 148, 162triamterene-hctz 99tricitrates 104TRICON 110TRIDERM 96TRI-ESTARYLLA 86trifluoperazine hcl 63trifluridine 152trihexyphenidyl hcl 54TRI-LEGEST FE 87TRILEPTAL 31

TRI-LINYAH 87TRI-LO-ESTARYLLA 87TRI-LO-MARZIA 87TRI-LO-MILI 87TRI-LO-SPRINTEC 87TRILYTE 112trimethoprim 47TRI-MILI 87trinatal rx 1 147TRINTELLIX 33, 162TRI-PREVIFEM 87TRIPTODUR 101TRI-SPRINTEC 87TRIUMEQ 67TRIVEEN-DUO DHA 147TRI-VI-FLOR 146tri-vitamin/fluoride 146TRIVORA (28) 87TRI-VYLIBRA 87TRI-VYLIBRA LO 87troche base 157TROCHIBASE 157TROGARZO 66TROKENDI XR 31TROPHAMINE 150trospium chloride 167trospium chloride er 167TRUE METRIX LEVEL 1 130TRUE METRIX LEVEL 2 130TRUE METRIX LEVEL 3 130TRUECONTROL GLUCOSE CONT LEV 0 130TRUECONTROL GLUCOSE CONT LEV 1 130TRUEDRAW LANCING DEVICE 130TRUEPLUS INSULIN SYRINGE 138TRUEPLUS LANCETS 26G 130TRUEPLUS LANCETS 28G 130TRUEPLUS LANCETS 30G 130TRUEPLUS LANCETS 33G 130TRUEPLUS SAFETY LANCETS 28G 130TRUVADA 67TULANA 86TUMS 23TUMS CHEWY DELIGHTS 23TUMS E-X 750 23TUMS EXTRA STRENGTH 750 23TUMS SMOOTHIES 23

TUMS ULTRA 1000 23tussin dm cough + chest 89tussin dm max adult 89tussin mucus & chest congest 92tussin mucus+chest congestion 92TYBOST 66TYDEMY 82TYMLOS 101ULTICARE ALCOHOL SWABS 115ULTICARE INSULIN SAFETY SYR 138ULTICARE INSULIN SYRINGE 138ULTICARE SYRINGE 138ULTI-LANCE AUTOMATIC

130ULTILET CLASSIC LANCETS 130ULTILET INSULIN SYRINGE SHORT 138ULTILET LANCETS 130ULTILET SAFETY LANCETS 23G 130ultra comfort insulin syringe 133ultra-comfort insulin syringe 133ULTRALANCE 130ULTRA-THIN II AUTO LANCET 130ULTRA-THIN II INS SYR SHORT 138ULTRA-THIN II INSULIN SYRINGE 138ULTRA-THIN II LANCETS 130ULTRATRAK PRO CONTROL 130ULTRATRAK ULTIMATE CONTROL 131UNILET COMFORTOUCH LANCET 131UNILET EXCELITE 131UNILET EXCELITE II 131UNILET G.P. LANCET 131UNILET G.P. SUPERLITE LANCET 131UNILET GP 28 ULTRA THIN 131UNILET LANCET 131UNILET MICRO-THIN 33G 131UNILET SUPERLITE LANCET 131UNILET SUPER-THIN 30G 131

UNILET ULTRA-THIN 28G 131UNISTIK 1 131UNISTIK 2 131UNISTIK 2 COMFORT 131UNISTIK 2 EXTRA 131UNISTIK 2 NEONATAL 131UNISTIK 2 NORMAL 131UNISTIK 2 SUPER 131UNISTIK 3 131UNISTIK 3 COMFORT 131UNISTIK 3 EXTRA 131UNISTIK 3 GENTLE 131UNISTIK 3 NEONATAL 131UNISTIK 3 NORMAL 131UNISTIK CZT COMFORT 131UNISTIK CZT NORMAL 131UNISTIK SAFETY LANCETS 28G 131UNISTIK SAFETY LANCETS 30G 131UNISTIK TOUCH SAFETY LANC 21G 131UNISTIK TOUCH SAFETY LANC 23G 131UNISTIK TOUCH SAFETY LANC 28G 131UNISTIK TOUCH SAFETY LANC 30G 131UNISTRIP CONTROL 131UNITHROID 164UNIVERSAL 1 LANCETS THIN 26G 131UNIVERSAL 1 LANCETS THIN 33G 131UNIVERSAL 1 LANCETS ULTRA THIN 131urea 96ursodiol 102UTIBRON NEOHALER 25UTIRA-C 166valacyclovir hcl 70valganciclovir hcl 69valproic acid 32valrubicin 51valsartan-hydrochlorothiazide 45VALSTAR 51value health insulin syringe 133value plus lancet standard 21g 119value plus lancets super thin 119value plus lancets thin 26g 119value plus lancing device 119valumark lancet super thin 30g 119

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valumark lancet ultra thin 28g 119valved holding chamber 138vancomycin hcl 47, 105vancomycin hcl in dextrose 104vancomycin hcl in nacl 105VANISHPOINT INSULIN SYRINGE 138VANISHPOINT SYRINGE 138VELCADE 51VELIVET 87venlafaxine hcl 34venlafaxine hcl er 34VENTAVIS 75verapamil hcl 75verapamil hcl er 75VICODIN 20VICODIN ES 20VICODIN HP 20VICTORY CONTROL LEVEL 1/2 132VICTOZA 38VIDA MIA AUTOLET LANCING DEV 132VIDA MIA UNILET LANCETS 28G 132VIDA MIA UNILET LANCETS 30G 132VIDEX 68VIENVA 82vigabatrin 32VIGADRONE 32VIIBRYD 33, 162VIMPAT 31vinblastine sulfate 53vincristine sulfate 53vinorelbine tartrate 53VIOKACE 98viorele 77VIRACEPT 68VIRAMUNE 68VIREAD 69virt-c dha 147virt-nate dha 147virt-phos 250 neutral 143virt-pn dha 147virt-pn plus 147VITAFOL FE+ 148VITAFOL GUMMIES 147VITAFOL-NANO 147VITAFOL-OB 147VITAFOL-OB+DHA 148VITAFOL-ONE 148

VITAL-D RX 145VITALET PRO LANCETS 132VITALET PRO PLUS LANCETS 132vitamin d (ergocalciferol) 168VITAMIN E & C BEAUTY LOTION 96VITAMIN E & K BEAUTIFUL SKIN 96vitamin e beauty 96vitamin k1 168VITAMINS E & A BEAUTY OIL 96VITAMINS E & D BEAUTY OIL 96VITA-RAY 96vol-plus 147VONVENDI 106VORTEX VALVED HOLDING CHAMBER 140VOSEVI 112VOTRIENT 51vp insulin syringe 133VPRIV 108vp-vite rx 145VYFEMLA 82VYLIBRA 82VYVANSE 8walgreens adv travel lancets 119WALGREENS LANCETS 132walgreens lancets micro thin 119walgreens lancets super thin 119WALGREENS THIN LANCETS 132WALGREENS ULTRA THIN LANCETS 132warfarin sodium 27WATCHHALER 140WEBCOL ALCOHOL PREP LARGE 115WEBCOL ALCOHOL PREP MEDIUM 115WERA 82WILATE 106WYMZYA FE 82xanthan gum 157XARELTO 28XARELTO STARTER PACK 28XELJANZ 12XELJANZ XR 12XIGDUO XR 162XTAMPZA ER 21

XTANDI 49XULANE 82XYLOCAINE 113XYLOCAINE/EPINEPHRINE 113XYNTHA 106XYNTHA SOLOFUSE 106YASMIN 28 82YAZ 82ZADITOR 152zaleplon 112ZARAH 82ZARONTIN 32ZARXIO 110ZATEAN-PN DHA 148ZATEAN-PN PLUS 147ZEMAIRA 161ZENATANE 93ZENPEP 98ZIAGEN 68zidovudine 69zinc sulfate 144zinc trace metal 144ziprasidone hcl 55ZOLADEX 53zoledronic acid 100zolpidem tartrate 112zonisamide 30ZOVIA 1/35E (28) 82ZYLET 153ZYTIGA 49

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