Five Tier Closed Aetna Individual Plan: DE

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2017 Aetna Pharmacy Drug Guide Five Tier Closed Aetna Individual Plan: DE www.aetna.com

©2017 Aetna Inc.13.05.331.1-DE M (12/17)

Do you have questions? Call the toll-free number on your member ID card. Or visit www.aetna.com/formulary for the most up-to-date information.

Dear Member:

We are pleased to provide you with a copy of our 2017 Aetna Pharmacy drug guide that includes information about your pharmacy benefits plan. Take this guide with you when you see your doctor if you want to talk about what medicines are covered under your plan and what they may cost.

Many commonly prescribed drugs are listed in this guide. Note: this is not a complete list of drugs covered under your plan. We list only the most commonly prescribed medicines as thousands of drugs are covered by your plan.

Want to learn more your plan’s drug coverage? Just visit the website on your member ID card and log in to your account.

What pharmacy benefits plan do I have?

You are enrolled in the Aetna Five Tier Closed Individual plan.

Here’s what that means to you:

Think of tier as a level. Five Tier means you could pay five different amounts, depending on the drug you take.

A formulary is a list of generic and brand-name drugs that your health plan covers. A closed formulary means your plan covers most prescription drugs. But it may not cover some others.

What can I expect to pay?

With this health benefits and health insurance plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percent of the prescription’s price. Each drug your plan covers falls under a different level or tier. The lower the tier, the lower the price. The higher the tier, the higher the price.

What you pay falls into one of these tiers or levels:

Tier One: You pay the lowest cost for drugs in this level.Your plan may include an additional benefit where someTier 1 drugs would be provided at an even lower cost to you.These are considered Value Drugs/Tier 1a and include genericsand some over-the-counter brand and generic products. These would be available at the lowest cost share indicated in your plan materials.

Tier Two: You pay a slightly higher cost for drugs in this level.

Tier Three: You pay the highest cost for drugs in this level.

Specialty drugs are on tier four and tier five. Specialty prescription drugs typically include high-cost drugs that requirespecial handling, special storage or monitoring and include butare not limited to oral, topical, inhaled and injected ways ofgiving them.

Tier Four: You pay a higher cost for specialty drugs in this level.

Tier Five: You pay the highest cost for non-Preferred Specialty drugs in this level.

www.aetna.com/formulary

To find your exact costs

Check your Plan Design and Benefits summary in your enrollment kit.

Your pharmacy benefits plan may include a program that encourages you to choose a generic drug over a brand-name drug to help reduce what you pay. This means that if you fill a brand-name drug when a generic is available, that in addition to your standard copay or coinsurance, you must also pay the difference in cost between the brand-name and generic drug.

For a summary of your pharmacy benefits plan, including out-of-pocket costs,visit the website on your member ID card and log in to your account. Or call the toll-free number on your member ID card.

Where can I find more formulary information?

You and your doctor can search for a drug, find out if it’s covered and see what tier it’s in. You can also see if there are alternatives that cost less. Tell your doctor that you pay more for tier five drugs so he or she can consider this when writing a prescription.

Visit www.aetna.com/formulary. You arrive at a page that says “Find a Medication.” This is where you can learn more about the types of drug coverage reviews required for your medicine(s); things like precertification, step therapy or quantity limits. You will arrive at a menu page where you can view various drug lists, including your Aetna Pharmacy drug guide and more.

How is the formulary developed?

Aetna’s Pharmacy and Therapeutics (P&T) Committee meets regularly to review new drugs and new information about drugs that are already on the market. It reviews available information concerning safety, effectiveness and current use in therapy. The P&T Committee reviews scientific evidence, including relevant findings of federal government agencies, pharmaceutical manufacturers, medical professional associations, national commissions and peer-reviewed journals.

Our P&T Committee includes licensed pharmacists and doctors, including those who are currently in practice and others who are Aetna employees. All committee members must tell us if they are in a situation that can create a conflict of interest or if they have a financial stake that might affect their decisions.

Once the P&T Committee completes its clinical review, we also consider overall value (including cost and manufacturer rebate arrangements) and other factors before adding or removing a drug from the formulary. The Aetna Pharmacy drug guide shows you recent changes to the guide. For example, it could show what drugs started requiring coverage reviews like precertification, step therapy or quantity limits. Or which drugs no longer do. The P&T Committee can make recommendations to change the tier level of a drug or to place it on our Formulary Exclusions List, designating it as a drug that is no longer covered.

Why is the formulary subject to change?

We may add or remove drugs for certain reasons. We might also move a drug from one coverage tier to another.

Here are some reasons why:

• As brand-name drugs lose their patents and generic versions become available, the brand-name may be covered at a higher out-of-pocket cost while the generic may be covered at a lower out-of-pocket cost.

• The U.S. Food and Drug Administration (FDA) approves many new drugs throughout the year.

• Drugs can be withdrawn from the market or may become available without a prescription. Over-the-counter (OTC) drugs are not generally covered under a prescription plan, unless required by law.

Our website, www.aetna.com/formulary, reflects the most up-to-date formulary information – so please visit it often.

Why do some drugs require prior authorization or precertification?

This drug coverage review encourages appropriate and cost- effective use of prescription drugs by allowing coverage only when certain conditions are met.

Reasons for precertification include:

• Compliance with dosing guidelines

• Avoiding duplicate therapies

• Helping health care providers check that a drug is being used based on generally accepted medical criteria

The precertification program is based on current medical findings, FDA-approved manufacturer labeling information, and cost and manufacturer rebate arrangements.

If your plan requires precertification, you will find a list of drugs that are subject to precertification with this guide. Please keep in mind that:

• Your doctor must contact Aetna to request approval of coverage for these drugs.

• If we approve the request, we will notify your doctor. The drug will then be covered at the applicable out-of-pocket cost under your plan. You will also be notified of approvals where the state requires notification to members.

If the request is denied, you and your doctor will be notified. You can still purchase the drug, but for the full price.


Medical exceptions for non-covered drugs

In certain circumstances*, You or your prescriber can request a medical exception for a non-covered drug. To submit a request, call our Precertification Department at 1-855-582-2025, or fax a request to 1-855-330-1716. You also can mail a written request to CVS Health, ATTN: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081. If the request is expedited a coverage determination will be made within 24 hours of receiving the request, and notify you or your prescriber of our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved the member is responsible for the highest applicable copay after deductible depending upon the members pharmacy plan design.

Why do some drugs have quantity limits?

This drug coverage review limits coverage of quantities for certain drugs. These limits help your doctor and pharmacist check that your prescribed drug is used correctly and safely.

We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:

• Dose Efficiency Edits – Limit coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.

• Maximum Daily Dose – A message is sent to the pharmacy if a prescription is less than the minimum or higher than the maximum allowed dose.

• Quantity Limits Over Time – Limit coverage of prescriptions to a specific number of units in a defined amount of time.

What is step therapy?

This drug coverage review promotes the appropriate use of equally effective but lower-cost drugs first. These lower-cost drugs are FDA-approved and treat the same condition as the corresponding step therapy drugs.

What is therapeutic duplication?

Therapeutic duplication means that two or more drugs of the same type are prescribed at the same time. This can occur when two doctors prescribe similar drugs or when your doctor switches from one drug to another drug in the same class without cancelling the first prescription.

It is rare that you should ever need two drugs from the same class to treat a medical condition. Since serious side effects may occur, we help bring such duplications to your pharmacist’s and doctor’s attention.

Learn more about drug coverage reviews

If you have a medical need for a drug that requires precertification, quantity limits or step therapy, your doctor can ask for a medical exception. The list of drugs requiring precertification, quantity limits or step therapy is subject to change. Find the most up-to-date information at www.aetna.com/formulary.

You may be able to save with generic drugs

Generic drugs are approved by FDA and proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs. The difference is that generics may be a different color, shape or size.

When appropriate, your doctor may decide to prescribe, or allow substitution with, a generic drug. Please talk to your doctor to find out if a generic is right for you.

Saving on prescriptions

Here are some other tips to pay less out of pocket for your prescription drugs:

• Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug (formulary) Guide.

• Ask your doctor to consider prescribing generic drugs instead of brand-name drugs.

• Check to see if your plan includes our mail-order pharmacy service. Depending upon your plan, mail order may save you money. See Aetna Rx Home Delivery in this guide for details.

• Remind your doctor to check your plan to make sure you get maximum coverage.

*These circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or undergoing a current course of treatment using a non-covered drug.


What is Aetna Rx Home Delivery?

Check your plan documents to see if your plan includes our Aetna Rx Home Delivery mail order pharmacy. It fills prescriptions for maintenance medicine. This type of medicine is used regularly, to treat conditions like arthritis, asthma, diabetes or high cholesterol. If you need this type of drug, you can get up to a 90-day supply, or the maximum supply allowed by your plan, and free delivery right to your mailbox.

You also get:

• Quick, confidential service

• Free standard shipping

• Pharmacists who check all prescriptions for accuracy and can answer questions any time

It’s easy and fast to order – choose one of these ways:

1. CourtesyStartSM – Fill your new mail order prescription online by visiting the website on your member ID card and logging in to your account. Or, call us toll-free at 1-888-RX AETNA (1-888-792-3862) or TDD: 1-800-823-6373. We will contact your doctor to try and get a new prescription for you. You may need to schedule a visit with your doctor before he or she will write a new prescription.

2. Mail – Get a new 90-day prescription from your doctor. Mail it to us with a completed order form. Access the order form online. You’ll find it by visiting the website on your member ID card.

3. Fax – Ask your doctor to fax your new prescription, with your completed order form to 1-877-270-3317. Make sure your doctor includes your member ID number, your date of birth and your mailing address on the fax cover sheet. Only a doctor may fax a prescription.

If your prescription is for a controlled medicine, a written prescription from your doctor may be needed.

Generally, if your order is complete, you will receive your medicine within 10-14 days from when Aetna Rx Home Delivery receives your order. You can request expedited delivery for an additional charge.

What is Aetna Specialty Pharmacy?

Aetna Specialty Pharmacy is Aetna’s in-house specialty pharmacy. It can fill your prescription specialty medicine. These types of drugs may be injected, infused or taken by mouth. Specialty medicine often needs special storage and handling. It must be delivered quickly. And a nurse or pharmacist should monitor you during your treatment. Use Aetna Specialty Pharmacy to get this medicine sent right to your mailbox. You also get:

• Free delivery that is reliable, secure and sent anywhere you choose

• Extra help when you need it – like injection training and side effect monitoring

• Refill reminders

• Proactive outreach to confirm your refills

• Free standard supplies

• Nurses and pharmacists to help 24 hours a day, every day

It’s easy and fast to order – choose one of these ways:

• Fax – Your doctor can fax your prescription to 1-866-FAX-ASRX (1-866-329-2779).

• Mail – You or your doctor can mail your prescription order to: Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL 32809. If you mail in your own prescription, please send it along with a completed Patient Profile Form. Find the form at www.AetnaSpecialtyRx.com by clicking on “Specialty pharmacy: How to enroll.”

• Phone – Your doctor can also call and speak to one of our registered pharmacists at 1-866-782-ASRX (1-866-782-2779) during normal business hours of 8 a.m. until 7 p.m. ET.

To transfer an existing prescription order and have it filled by Aetna Specialty Pharmacy, call toll-free at 1-866-353-1892.


Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY40512 ( CA HMO customers: PO Box 24030Fr esno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379( CA HMO customers: 860-262-7705), [email protected].

You can also filea c ivil rights complaint with theU .S. Department of Health and Human Services, Office for CivilR ights Complaint Portal, availableat https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200I ndependenceA venueSW ., Room 509F, HHH Building, Washington, DC2 0201, or at 1-800-368-1019, 800-537-7697( TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).






Need more information? Visit www.aetna.com/formulary or call the appropriate toll-free number on your member ID card.

Please note that if your prescription drug benefits plan changes, the information herein may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fully- insured members in Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans. In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, fully-insured Commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. In accordance with state law, fully-insured Commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.

www.aetna.com

©2017 Aetna Inc.13.05.331.1-DE M (12/17)

2017 Aetna Pharmacy Drug Guide - Delaware Individual

Table of Contents

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*.................................................................................... 5*Aminoglycosides*....................................................................................................................................... 6*Analgesics - Anti-Inflammatory*................................................................................................................ 6*Analgesics - Nonnarcotic*...........................................................................................................................8*Analgesics - Opioid*................................................................................................................................... 9*Androgens-Anabolic*............................................................................................................................... 12*Anorectal Agents*.....................................................................................................................................12*Anthelmintics*.......................................................................................................................................... 12*Antianginal Agents*..................................................................................................................................12*Antianxiety Agents*..................................................................................................................................13*Antiarrhythmics*...................................................................................................................................... 14*Antiasthmatic And Bronchodilator Agents*............................................................................................. 14*Anticoagulants*........................................................................................................................................ 16*Anticonvulsants*.......................................................................................................................................16*Antidementia Agent Combinations***..................................................................................................... 18*Antidepressants*....................................................................................................................................... 18*Antidiabetics*........................................................................................................................................... 20*Antidiarrheals*..........................................................................................................................................23*Antidotes*.................................................................................................................................................23*Antiemetics*..............................................................................................................................................23*Antifungals*..............................................................................................................................................24*Antihistamines*.........................................................................................................................................24*Antihyperlipidemics*................................................................................................................................ 25*Antihypertensives*.................................................................................................................................... 26*Anti-Infective Agents - Misc.*...................................................................................................................28*Antimalarials*...........................................................................................................................................29*Antimyasthenic Agents*............................................................................................................................30*Antimyasthenic/Cholinergic Agents*........................................................................................................ 30*Antimycobacterial Agents*....................................................................................................................... 30*Antineoplastics And Adjunctive Therapies*..............................................................................................30*Anti-Obesity Agent Combinations**........................................................................................................ 34*Antiparkinson Agents*............................................................................................................................. 34*Antipsychotics/Antimanic Agents*........................................................................................................... 35*Antiretrovirals Adjuvants***.................................................................................................................... 36*Antiseptics & Disinfectants*..................................................................................................................... 36*Antivirals*.................................................................................................................................................36*Assorted Classes*...................................................................................................................................... 39*Beta Blockers*...........................................................................................................................................40*Biologicals Misc*...................................................................................................................................... 41*Calcium Channel Blockers*...................................................................................................................... 41*Cardiotonics*............................................................................................................................................ 43*Cardiovascular Agents - Misc.*.................................................................................................................43*Cephalosporins*........................................................................................................................................43*Chemicals*................................................................................................................................................ 44*Contraceptives*.........................................................................................................................................44*Corticosteroids*........................................................................................................................................ 49*Cough/Cold/Allergy*................................................................................................................................ 50

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*Cyclin-Dependent Kinases (Cdk) Inhibitors***........................................................................................ 51*Cystic Fibrosis Agent - Combinations***................................................................................................. 51*Dermatologicals*...................................................................................................................................... 51*Diagnostic Products*................................................................................................................................ 58*Dietary Products/Dietary Management Products*....................................................................................62*Digestive Aids*......................................................................................................................................... 66*Direct-Acting P2y12 Inhibitors***............................................................................................................66*Diuretics*.................................................................................................................................................. 67*Endocrine And Metabolic Agents - Misc.*................................................................................................67*Estrogens*.................................................................................................................................................70*Estrogen-Selective Estrogen Receptor Modulator Comb***.....................................................................71*Fluoroquinolones*.................................................................................................................................... 71*Gastrointestinal Agents - Misc.*............................................................................................................... 71*Genitourinary Agents - Miscellaneous*.................................................................................................... 72*Gout Agents*............................................................................................................................................ 73*Hematological Agents - Misc.*..................................................................................................................73*Hematopoietic Agents*............................................................................................................................. 74*Hemostatics*.............................................................................................................................................75*Hepatitis C Agent - Combinations***.......................................................................................................75*Hereditary Orotic Aciduria Treatment - Agents**.................................................................................... 75*Hypnotics*................................................................................................................................................ 75*Interleukin Antagonists***....................................................................................................................... 76*Laxatives*................................................................................................................................................. 76*Macrolides*...............................................................................................................................................77*Medical Devices*...................................................................................................................................... 77*Migraine Products*................................................................................................................................... 92*Minerals & Electrolytes*........................................................................................................................... 93*Mouth/Throat/Dental Agents*..................................................................................................................95*Multivitamins*.......................................................................................................................................... 95*Musculoskeletal Therapy Agents*.............................................................................................................98*Nasal Agents - Systemic And Topical*......................................................................................................99*Neuromuscular Agents*............................................................................................................................99*Nutrients*................................................................................................................................................. 99*Ophthalmic Agents*................................................................................................................................100*Orexin Receptor Antagonists***.............................................................................................................103*Otic Agents*............................................................................................................................................103*Oxaborole-Related Antifungals - Topical***.......................................................................................... 104*Oxytocics*............................................................................................................................................... 104*Passive Immunizing Agents - Combinations***...................................................................................... 104*Passive Immunizing Agents*................................................................................................................... 104*Pcsk9 Inhibitors***................................................................................................................................. 104*Penicillins*...............................................................................................................................................104*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors***................................................................................ 105*Phosphodiesterase 4 (Pde4) Inhibitors***............................................................................................... 105*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors**................................................................................105*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***...............................................................................106*Potassium Removing Agents***............................................................................................................. 106*Progestins*.............................................................................................................................................. 106*Protease-Activated Receptor-1 (Par-1) Antagonists***...........................................................................106*Psychotherapeutic And Neurological Agents - Misc.*.............................................................................106

2

*Respiratory Agents - Misc.*.................................................................................................................... 108*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag***................................................................108*Serotonin Modulators***........................................................................................................................108*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***................................................................................ 109*Sinus Node Inhibitors**..........................................................................................................................109*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***......................................................... 109*Sulfonamides*......................................................................................................................................... 109*Tetracyclines*..........................................................................................................................................109*Thyroid Agents*......................................................................................................................................109*Ulcer Drugs*........................................................................................................................................... 110*Urinary Anti-Infectives*..........................................................................................................................112*Urinary Antispasmodics*........................................................................................................................ 112*Vaginal Products*................................................................................................................................... 113*Vasopressors*..........................................................................................................................................113*Vitamins*................................................................................................................................................ 114

3

4


lowercase italics = Generic drugsUPPERCASE = Brand name drugs

Drug StatusCE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply.M = Coverage where required by state lawNL = Not ListedTier 1 = Preferred GenericTier 2 = Preferred BrandTier 3 = Non-Preferred Brand and GenericTier 4 = Tier 4Tier 5 = Tier 5

Drug Details# = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand-name drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy.AL = Age LimitLGC = Lowest Generic Copay AppliesOTC = Covered OTCPA = Prior Authorization AppliesQL = Quantity LimitSP = You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, like Aetna Specialty Pharmacy. Specialty products are limited to a 30 day supply.ST = Step Therapy Applies

Drug Name Drug Status Drug Details

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

amphetamine-dextroamphet er Tier 1 PA; ST; QL

amphetamine-dextroamphetamine Tier 1 QL

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

Tier 3 PA; ST; QL

atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

Tier 3 ST; QL

BELVIQ Tier 3 PA; ST; QL

clonidine hcl er Tier 3 ST; QL

DAYTRANA Tier 3 PA; ST; #; QL

dexmethylphenidate hcl Tier 3 QL

dexmethylphenidate hcl er Tier 3 PA; ST; QL

dextroamphetamine sulfate er Tier 1 PA; QL

dextroamphetamine sulfate oral solution Tier 1 PA; QL

dextroamphetamine sulfate oral tablet Tier 1 QL


Last Update 12/20175


guanfacine hcl er Tier 3 ST; QL

metadate er oral tablet extended release 20 mg Tier 1 PA; ST; QL

methamphetamine hcl Tier 3 QL

methylphenidate hcl er (cd) Tier 3 PA; ST; QL

methylphenidate hcl er (la) Tier 3 PA; ST; QL

methylphenidate hcl er oral tablet extended release 10 mg

Tier 1 PA; ST

methylphenidate hcl er oral tablet extended release 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

Tier 1 PA; ST; QL

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

Tier 1 QL

methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml

Tier 3 QL

methylphenidate hcl oral tablet Tier 1 QL

methylphenidate hcl oral tablet chewable Tier 3 QL

modafinil Tier 3 PA; ST; QL

phendimetrazine tartrate Tier 1

phentermine hcl oral capsule 15 mg Tier 1

QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG

Tier 3 PA; ST; QL

QUILLIVANT XR Tier 3 PA; ST; QL

VYVANSE Tier 3 PA; ST; QL

*Aminoglycosides*

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

Tier 3

gentamicin sulfate injection Tier 5

gentamicin sulfate intravenous Tier 5

neomycin sulfate oral Tier 3

paromomycin sulfate oral Tier 3

streptomycin sulfate intramuscular Tier 5

tobramycin inhalation Tier 4 SP; QL

tobramycin sulfate injection Tier 5

*Analgesics - Anti-Inflammatory*

ACTEMRA INTRAVENOUS Tier 5 PA; ST; SP

ACTEMRA SUBCUTANEOUS Tier 5 PA; ST; SP; QL

ARCALYST Tier 5 PA; SP

celecoxib oral Tier 3 ST; QL




diclofenac potassium Tier 3

diclofenac sodium er Tier 3

diclofenac sodium oral tablet delayed release 25 mg, 50 mg

Tier 1

diclofenac sodium oral tablet delayed release 75 mg

Tier 1 LGC

diclofenac-misoprostol oral tablet delayed release

Tier 3

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

Tier 4 PA; ST; SP; QL

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR


etodolac er Tier 3

etodolac oral Tier 3

fenoprofen calcium oral Tier 3

flurbiprofen oral Tier 3

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


HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT


HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT


HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML


ibuprofen oral tablet 200 mg Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 LGC

ILARIS Tier 5 PA; SP

ILARIS (150MG DELIVERED) Tier 5 PA; SP

INDOCIN ORAL Tier 3

INDOCIN RECTAL Tier 3

indomethacin er Tier 3

indomethacin oral Tier 3 QL

ketoprofen oral Tier 3

ketorolac tromethamine oral Tier 3 QL




KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


leflunomide oral Tier 1 QL

meclofenamate sodium oral Tier 3

mefenamic acid oral Tier 3

meloxicam oral tablet Tier 1 LGC

nabumetone oral Tier 1

naproxen dr Tier 1

naproxen oral suspension Tier 3

naproxen oral tablet Tier 1 LGC

naproxen sodium oral tablet 275 mg Tier 1

naproxen sodium oral tablet 550 mg Tier 1 LGC

ORENCIA CLICKJECT Tier 5 PA; ST; SP; QL

ORENCIA INTRAVENOUS Tier 5 PA; ST; SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML


oxaprozin Tier 1

piroxicam oral Tier 1

RIDAURA Tier 3

SIMPONI ARIA Tier 4 PA; ST; SP; QL

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR


SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


sulindac oral Tier 1

tolmetin sodium Tier 3

XELJANZ Tier 5 PA; ST; SP; QL

XELJANZ XR Tier 5 PA; ST; SP; QL

*Analgesics - Nonnarcotic*

aspirin low dose oral tablet chewable CE

aspirin oral tablet 325 mg CE

aspirin oral tablet chewable CE

aspirin oral tablet delayed release 325 mg CE

aspirin rectal suppository 120 mg, 200 mg CE

bayer advanced aspirin ex st CE

bayer aspirin oral tablet CE




bayer low dose CE

butalbital-acetaminophen oral tablet 50-325 mg Tier 3

butalbital-apap-caffeine oral capsule 50-325-40 mg

Tier 3

butalbital-apap-caffeine oral tablet 50-325-40 mg

Tier 1

butalbital-aspirin-caffeine oral capsule Tier 1

capacet Tier 3

childrens aspirin CE

choline-mag trisalicylate Tier 3

diflunisal oral Tier 3

duraxin Tier 3

ECOTRIN CE

ecotrin low strength CE

marten-tab Tier 3

salsalate oral Tier 3

st joseph aspirin oral tablet delayed release CE

tencon oral tablet 50-325 mg Tier 3

zebutal oral capsule 50-325-40 mg Tier 3

*Analgesics - Opioid*

acetaminophen-codeine #2 Tier 1 PA; QL



acetaminophen-codeine oral solution Tier 1 PA

acetaminophen-codeine oral tablet Tier 1 PA; QL

apap-caff-dihydrocodeine oral capsule Tier 3 PA; QL

ascomp-codeine Tier 1 PA; QL

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG

Tier 3 ST; QL

buprenorphine Tier 1 PA; QL

buprenorphine hcl sublingual Tier 3 QL

buprenorphine hcl-naloxone hcl Tier 3 QL

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg

Tier 1 PA; QL

butalbital-asa-caff-codeine Tier 1 PA; QL

butorphanol tartrate nasal Tier 3 PA; QL




codeine sulfate oral tablet Tier 1 PA; QL

EMBEDA Tier 2 PA; QL

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL

ENDOCET ORAL TABLET 2.5-325 MG Tier 1 PA; QL

fentanyl Tier 3 PA; QL

fentanyl citrate buccal Tier 3 PA; ST; QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

Tier 3 PA

hydrocodone-acetaminophen oral tablet 10-300 mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

Tier 3 PA; QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

Tier 3 PA; QL

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

Tier 3 PA; QL

hydromorphone hcl oral tablet Tier 1 PA; QL

hydromorphone hcl rectal Tier 1 PA

ibudone oral tablet 5-200 mg Tier 3 PA; QL

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG

Tier 3 PA; ST; QL

levorphanol tartrate oral Tier 3 PA; QL

lorcet Tier 1 PA; QL

lorcet hd Tier 1 PA; QL

meperidine hcl oral tablet Tier 3 PA; QL

methadone hcl intensol Tier 3 PA

methadone hcl oral concentrate Tier 3 PA

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

Tier 3 PA; QL

methadone hcl oral tablet Tier 3 PA; QL

methadone hcl oral tablet soluble Tier 3 PA

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

Tier 3 PA

morphine sulfate er beads Tier 3 PA; ST; QL

morphine sulfate er oral capsule extended release 24 hour

Tier 3 PA; ST; QL

morphine sulfate er oral tablet extended release Tier 1 PA; QL




morphine sulfate oral solution Tier 3 PA

morphine sulfate oral tablet Tier 1 PA; QL

morphine sulfate rectal Tier 3 PA

nalbuphine hcl injection Tier 5

NUCYNTA Tier 3 PA; ST; QL

NUCYNTA ER Tier 3 PA; ST; QL

OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

Tier 3 PA; ST; QL

OXAYDO Tier 2 PA; QL

oxycodone hcl er oral tablet er 12 hour abuse-deterrent

Tier 3 PA; QL

oxycodone hcl oral capsule Tier 1 PA; QL

oxycodone hcl oral concentrate 100 mg/5ml Tier 3 PA

oxycodone hcl oral solution Tier 3 PA

oxycodone hcl oral tablet Tier 1 PA; QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL

oxycodone-aspirin oral tablet 4.8355-325 mg Tier 3 PA; QL

oxycodone-ibuprofen Tier 1 PA; QL

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

Tier 3 PA; ST; QL

oxymorphone hcl Tier 3 PA; ST; QL

oxymorphone hcl er Tier 3 PA; ST; QL

pentazocine-naloxone hcl Tier 3 PA; QL

SUBOXONE SUBLINGUAL FILM Tier 3 QL

TALWIN Tier 3

tramadol hcl er (biphasic) Tier 3 PA; ST; QL

tramadol hcl er oral tablet extended release 24 hour

Tier 3 PA; ST; QL

tramadol hcl oral Tier 1 PA; QL

tramadol-acetaminophen Tier 3 PA; QL

vicodin es oral tablet 7.5-300 mg Tier 3 PA; QL

vicodin hp oral tablet 10-300 mg Tier 3 PA; QL

vicodin oral tablet 5-300 mg Tier 3 PA; QL

XTAMPZA ER Tier 2 PA; QL

XYLON Tier 3 PA

ZAMICET Tier 3 PA




*Androgens-Anabolic*

ANADROL-50 Tier 3

danazol oral Tier 1

METHITEST Tier 3

methyltestosterone oral Tier 1

oxandrolone oral Tier 1

STRIANT Tier 3 PA; QL

TESTOPEL Tier 3 PA

testosterone cypionate intramuscular solution100 mg/ml, 200 mg/ml

Tier 1

testosterone enanthate intramuscular solution Tier 3

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

Tier 3 PA; QL

testosterone transdermal solution Tier 3 PA; QL

*Anorectal Agents*

colocort Tier 1

CORTIFOAM Tier 3

hydrocortisone ace-pramoxine rectal cream Tier 3

hydrocortisone rectal enema Tier 1

lidocaine-hydrocortisone ace rectal Tier 3

pramcort rectal Tier 3

PROCORT Tier 3

PROCTOFOAM HC Tier 3

procto-pak Tier 3

proctosol hc Tier 3

proctozone-hc rectal Tier 3

RECTIV Tier 3 QL

*Anthelmintics*

ALBENZA Tier 3

BILTRICIDE Tier 3

EMVERM Tier 3

ivermectin oral Tier 3

*Antianginal Agents*

DILATRATE-SR Tier 3




ISORDIL TITRADOSE ORAL TABLET 40 MG

Tier 3

isosorbide dinitrate er Tier 1

isosorbide dinitrate oral Tier 1

isosorbide mononitrate Tier 1

isosorbide mononitrate er Tier 1

NITRO-BID Tier 3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

Tier 3

nitroglycerin er Tier 3

nitroglycerin sublingual Tier 3

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual Tier 3

nitro-time Tier 3

RANEXA Tier 3 QL

*Antianxiety Agents*

alprazolam er Tier 3 QL

ALPRAZOLAM INTENSOL Tier 3

alprazolam oral tablet Tier 1

alprazolam oral tablet dispersible Tier 3

alprazolam xr Tier 3 QL

buspirone hcl oral tablet 10 mg, 5 mg Tier 1 LGC

buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg Tier 3

chlordiazepoxide hcl Tier 3

clorazepate dipotassium Tier 3

diazepam injection Tier 1

diazepam intensol Tier 1

diazepam intramuscular solution auto-injector Tier 1

diazepam oral solution 1 mg/ml Tier 1

diazepam oral tablet Tier 1

hydroxyzine hcl oral syrup Tier 1 LGC

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral Tier 1

lorazepam oral tablet Tier 1

meprobamate Tier 3

oxazepam Tier 3




*Antiarrhythmics*

amiodarone hcl oral Tier 1

disopyramide phosphate oral Tier 3

dofetilide Tier 1

flecainide acetate Tier 1

mexiletine hcl oral Tier 3

MULTAQ Tier 3 QL

NORPACE CR Tier 3

pacerone oral tablet 100 mg, 200 mg, 400 mg Tier 1

procainamide hcl injection Tier 3

propafenone hcl Tier 1

propafenone hcl er Tier 3 QL

quinidine gluconate er Tier 3

quinidine sulfate oral Tier 3

*Antiasthmatic And Bronchodilator Agents*

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

Tier 3 ST; #; QL

ADVAIR HFA Tier 3 ST; QL

albuterol sulfate er Tier 1

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

Tier 3

albuterol sulfate inhalation nebulization solution0.63 mg/3ml, 1.25 mg/3ml

Tier 1

albuterol sulfate oral Tier 1

ALVESCO Tier 3 ST

aminophylline intravenous Tier 3

ANORO ELLIPTA Tier 2 QL

ARCAPTA NEOHALER Tier 3 QL

ASMANEX 120 METERED DOSES Tier 3 ST




ASMANEX HFA Tier 3 ST

ATROVENT HFA Tier 3

BREO ELLIPTA Tier 3 ST; QL




BROVANA Tier 3 QL

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

Tier 3 PA

budesonide inhalation suspension 1 mg/2ml Tier 3 PA; AL

COMBIVENT RESPIMAT Tier 3

cromolyn sodium inhalation Tier 1

DALIRESP Tier 3 PA; ST; QL

DULERA Tier 2 QL

ELIXOPHYLLIN Tier 3

FLOVENT DISKUS Tier 3 ST; #; QL

FLOVENT HFA Tier 3 ST; QL

fluticasone-salmeterol Tier 1 QL

INCRUSE ELLIPTA Tier 2 QL

ipratropium bromide inhalation Tier 1

ipratropium-albuterol Tier 3

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

Tier 3

metaproterenol sulfate oral Tier 1

montelukast sodium oral Tier 1 QL

PERFOROMIST Tier 3 PA; QL

PULMICORT FLEXHALER Tier 3 ST; QL

QVAR INHALATION AEROSOL SOLUTION

Tier 2

SEREVENT DISKUS Tier 3 QL

SPIRIVA HANDIHALER Tier 3 ST; QL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

Tier 3 ST; QL

STIOLTO RESPIMAT Tier 3 ST; QL

STRIVERDI RESPIMAT Tier 3 PA; ST; QL

SYMBICORT Tier 3 ST; QL

terbutaline sulfate oral Tier 1

THEO-24 Tier 3

theochron oral tablet extended release 12 hour100 mg, 200 mg, 300 mg

Tier 1

theophylline Tier 3

theophylline er Tier 1




TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED

Tier 3 ST; QL

VENTOLIN HFA Tier 2

zafirlukast Tier 3

zileuton er Tier 3

ZYFLO Tier 3

*Anticoagulants*

ANTICOAGULANT COMPOUND Tier 3

ELIQUIS Tier 3 ST

enoxaparin sodium Tier 3 QL

fondaparinux sodium Tier 3 QL

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

Tier 3 QL

heparin lock flush intravenous solution 1 unit/ml, 100 unit/ml

Tier 3

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Tier 3

heparin sodium (porcine) pf Tier 3

heparin sodium flush intravenous kit 100-0.9 unit/ml-%

Tier 3

heparin sodium lock flush intravenous solution100 unit/ml

Tier 3

jantoven Tier 1 LGC

PRADAXA Tier 3

TRICITRASOL Tier 3

warfarin sodium oral Tier 1 LGC

XARELTO Tier 3

XARELTO STARTER PACK Tier 3

*Anticonvulsants*

APTIOM ORAL TABLET 200 MG Tier 3 QL

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3 QL

carbamazepine er Tier 3




carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1 LGC

carbamazepine oral tablet chewable Tier 1

CELONTIN Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet dispersible Tier 3

diazepam rectal Tier 3 QL

DILANTIN ORAL CAPSULE 30 MG Tier 3

divalproex sodium er oral tablet extended release 24 hour

Tier 3

divalproex sodium oral tablet delayed release Tier 1

epitol Tier 1 LGC

ethosuximide oral Tier 1

felbamate Tier 3

fosphenytoin sodium Tier 5

FYCOMPA ORAL SUSPENSION Tier 3

FYCOMPA ORAL TABLET Tier 3 QL

gabapentin oral capsule Tier 1 QL

gabapentin oral solution 250 mg/5ml Tier 3 QL

gabapentin oral tablet Tier 1 QL

LAMICTAL ODT ORAL KIT Tier 3

LAMICTAL XR ORAL KIT Tier 3

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

Tier 3 QL

lamotrigine oral tablet Tier 1

lamotrigine oral tablet chewable Tier 1

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

Tier 3 QL

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

Tier 3 QL

levetiracetam oral Tier 1

LYRICA Tier 3 PA; ST

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3 QL

oxcarbazepine Tier 1




OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

Tier 3 ST; QL

PEGANONE Tier 3

phenytoin infatabs Tier 3

phenytoin oral suspension 125 mg/5ml Tier 1

phenytoin oral tablet chewable Tier 3

phenytoin sodium extended Tier 1

primidone oral Tier 1

SABRIL Tier 5 PA; SP; QL

tiagabine hcl oral tablet 2 mg, 4 mg Tier 3 QL

topiramate oral capsule sprinkle Tier 3 QL

topiramate oral tablet Tier 1

valproic acid oral capsule Tier 1

valproic acid oral solution Tier 1

vigabatrin Tier 4 PA; SP; QL

VIMPAT ORAL TABLET Tier 3 QL

zonisamide oral Tier 1

*Antidementia Agent Combinations***

NAMZARIC Tier 2 PA

*Antidepressants*

amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

Tier 1 LGC

amitriptyline hcl oral tablet 150 mg Tier 1

amoxapine Tier 3

bupropion hcl er (sr) Tier 1 QL

bupropion hcl er (xl) Tier 1 QL

bupropion hcl oral Tier 1 QL

citalopram hydrobromide oral solution Tier 3

citalopram hydrobromide oral tablet Tier 1 LGC; QL

clomipramine hcl oral Tier 3

desipramine hcl oral Tier 3

desvenlafaxine succinate er Tier 3 PA; ST; QL

doxepin hcl oral capsule Tier 1

doxepin hcl oral concentrate Tier 3




duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg

Tier 1 QL

EMSAM Tier 3 PA; ST; QL

escitalopram oxalate oral solution Tier 3

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

Tier 3 QL

FETZIMA Tier 3 PA; ST; QL

FETZIMA TITRATION Tier 3 PA; ST; QL

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg Tier 1 QL

fluoxetine hcl oral capsule delayed release Tier 3 QL

fluoxetine hcl oral solution Tier 3

fluoxetine hcl oral tablet 10 mg, 20 mg Tier 1 QL

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

Tier 3 QL

imipramine hcl oral Tier 3

imipramine pamoate Tier 3

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg Tier 3 QL

MARPLAN Tier 3

mirtazapine oral tablet Tier 1 QL

mirtazapine oral tablet dispersible Tier 3 QL

nefazodone hcl Tier 3

nortriptyline hcl oral capsule 10 mg, 25 mg Tier 1 LGC

nortriptyline hcl oral capsule 50 mg, 75 mg Tier 1

nortriptyline hcl oral solution Tier 3

paroxetine hcl er Tier 3 ST; QL

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

Tier 1 LGC; QL

phenelzine sulfate oral Tier 3

protriptyline hcl Tier 3

sertraline hcl oral concentrate Tier 3

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Tier 1 LGC; QL

tranylcypromine sulfate Tier 3

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg Tier 1

trazodone hcl oral tablet 300 mg Tier 1

TRINTELLIX Tier 3 PA; ST; QL

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

Tier 1 QL




venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Tier 1 QL

VIIBRYD ORAL TABLET Tier 3 PA; ST; QL

VIIBRYD STARTER PACK Tier 3 PA; ST

*Antidiabetics*

acarbose Tier 1

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG, 30-1000 MG

Tier 3 ST; QL

alogliptin benzoate Tier 3 QL

alogliptin-metformin hcl Tier 3 QL

alogliptin-pioglitazone Tier 3 QL

APIDRA Tier 3 ST

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 ST

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3 QL

BYDUREON SUBCUTANEOUS PEN-INJECTOR

Tier 3 PA; ST; QL

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 PA; ST; #; QL

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 PA; ST; #; QL

chlorpropamide oral tablet 100 mg Tier 1 LGC

chlorpropamide oral tablet 250 mg Tier 1

CYCLOSET Tier 3 QL

FARXIGA Tier 3 QL

glimepiride Tier 1 LGC

glipizide er Tier 1

glipizide oral Tier 1 LGC

glipizide xl Tier 1

glipizide-metformin hcl Tier 1

GLUCAGEN HYPOKIT Tier 3 QL

GLUCAGON EMERGENCY Tier 2

glyburide micronized oral tablet 1.5 mg Tier 1

glyburide micronized oral tablet 3 mg, 6 mg Tier 1 LGC

glyburide oral tablet 1.25 mg Tier 1

glyburide oral tablet 2.5 mg, 5 mg Tier 1 LGC




glyburide-metformin Tier 1

HUMALOG Tier 2

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

Tier 2

HUMALOG MIX 50/50 Tier 2

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Tier 2

HUMALOG MIX 75/25 Tier 2

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Tier 2

HUMULIN 70/30 Tier 2

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Tier 2

HUMULIN N Tier 2

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Tier 2

HUMULIN R Tier 2

HUMULIN R U-500 (CONCENTRATED) Tier 2

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 2

INVOKANA Tier 2 QL

JANUMET Tier 2 QL

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG

Tier 2 QL

JANUVIA Tier 2 QL

JARDIANCE Tier 3 QL

JENTADUETO Tier 2 QL

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG

Tier 2 QL

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG

Tier 3 ST; QL




KORLYM Tier 5 PA; SP; QL

LANTUS Tier 3 ST

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 ST

LEVEMIR Tier 2

LEVEMIR FLEXTOUCH Tier 2

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

Tier 3 ST; QL

metformin hcl er oral tablet extended release 24 hour 500 mg

Tier 1 LGC

metformin hcl er oral tablet extended release 24 hour 750 mg

Tier 1

metformin hcl oral Tier 1 LGC

miglitol Tier 3

nateglinide Tier 1

NOVOLOG Tier 3 ST

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 ST

NOVOLOG MIX 70/30 Tier 3 ST

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Tier 3 ST

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE

Tier 3 ST

ONGLYZA Tier 3 ST; QL

pioglitazone hcl Tier 1 QL

pioglitazone hcl-glimepiride Tier 1 QL

pioglitazone hcl-metformin hcl Tier 1 QL

PROGLYCEM Tier 3

repaglinide Tier 3

repaglinide-metformin hcl Tier 3 QL

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 PA; QL

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 PA

TANZEUM Tier 3 PA; ST; QL

tolazamide Tier 1

tolbutamide Tier 1




TRADJENTA Tier 2 QL

TRESIBA FLEXTOUCH Tier 3 ST

TRULICITY Tier 3 PA; ST; QL

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 3 PA; ST; QL

*Antidiarrheals*

diphenoxylate-atropine Tier 1

loperamide hcl oral capsule Tier 3

loperamide hcl oral tablet Tier 3

MOTOFEN Tier 3

MYTESI Tier 3 PA; ST; QL

opium Tier 3

*Antidotes*

CHEMET Tier 3

EXJADE Tier 5 PA; SP

FERRIPROX ORAL SOLUTION Tier 5 PA

FERRIPROX ORAL TABLET Tier 5 PA; SP

naloxone hcl injection solution 0.4 mg/ml Tier 3

naltrexone hcl oral Tier 3

NARCAN Tier 2

*Antiemetics*

AKYNZEO Tier 3 PA; ST; QL

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

Tier 5 PA; #

ANZEMET ORAL Tier 3 QL

aprepitant oral capsule 125 mg Tier 1

aprepitant oral capsule 40 mg, 80 & 125 mg, 80 mg

Tier 1 QL

CESAMET Tier 3 QL

dronabinol Tier 3 PA; ST; QL

EMEND ORAL SUSPENSION RECONSTITUTED

Tier 2

granisetron hcl intravenous Tier 5

granisetron hcl oral Tier 3

meclizine hcl oral tablet Tier 1

ondansetron Tier 1




ondansetron hcl oral Tier 1

SANCUSO Tier 3 PA; ST; QL

scopolamine Tier 3

trimethobenzamide hcl oral Tier 1

*Antifungals*

ABELCET Tier 5

amphotericin b injection Tier 5

CANCIDAS Tier 5

CRESEMBA ORAL Tier 3

ERAXIS Tier 5

fluconazole oral Tier 1

flucytosine oral Tier 3

griseofulvin microsize oral Tier 3

griseofulvin ultramicrosize Tier 3

itraconazole oral Tier 3 PA; ST; QL

ketoconazole oral Tier 3 QL

MYCAMINE Tier 5

NOXAFIL ORAL SUSPENSION Tier 3 PA; ST

nystatin oral tablet Tier 1

SPORANOX ORAL SOLUTION Tier 3 PA; ST

terbinafine hcl oral Tier 1

voriconazole oral tablet Tier 3 PA

*Antihistamines*

alavert oral tablet Tier 1 LGC

ALLEGRA ALLERGY Tier 1

ALLEGRA ALLERGY CHILDRENS ORAL SUSPENSION

Tier 1

ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE

Tier 1

carbinoxamine maleate oral solution Tier 3

carbinoxamine maleate oral tablet Tier 3

cetirizine hcl childrens oral solution Tier 1 LGC

cetirizine hcl oral syrup 1 mg/ml Tier 1 LGC

cetirizine hcl oral syrup 5 mg/5ml Tier 1 LGC

cetirizine hcl oral tablet Tier 1 LGC

cetirizine hcl oral tablet chewable Tier 1




CLARITIN ORAL SYRUP Tier 1

CLARITIN ORAL TABLET Tier 1

CLARITIN ORAL TABLET CHEWABLE Tier 1

CLARITIN REDITABS Tier 1

clemastine fumarate oral tablet Tier 1

cyproheptadine hcl oral Tier 1

dayhist allergy 12 hour relief Tier 1

desloratadine oral tablet Tier 3 ST; QL

desloratadine oral tablet dispersible 2.5 mg Tier 3 ST; QL

desloratadine oral tablet dispersible 5 mg Tier 3 ST

diphenhydramine hcl injection Tier 3

diphenhydramine hcl oral capsule Tier 1

diphenhydramine hcl oral elixir Tier 3

fexofenadine hcl childrens Tier 1

fexofenadine hcl oral tablet 180 mg, 60 mg Tier 1

kp cetirizine hcl oral tablet 5 mg Tier 1 LGC

levocetirizine dihydrochloride oral Tier 1

loratadine allergy relief oral tablet dispersible Tier 1 LGC

loratadine childrens Tier 1 LGC

loratadine hives relief Tier 1 LGC

loratadine oral tablet Tier 1 LGC

phenadoz Tier 1

promethazine hcl oral Tier 1

promethazine hcl rectal suppository 12.5 mg, 25 mg

Tier 1

promethegan Tier 1

ZYRTEC ALLERGY ORAL TABLET Tier 1

*Antihyperlipidemics*

ALTOPREV Tier 3 ST; QL

atorvastatin calcium oral tablet 10 mg CE QL

atorvastatin calcium oral tablet 20 mg, 40 mg, 80 mg

Tier 1 QL

cholestyramine light Tier 1

cholestyramine oral Tier 1

colestipol hcl Tier 1

ezetimibe Tier 3 QL




ezetimibe-simvastatin Tier 3 ST; QL

fenofibrate micronized oral capsule 130 mg, 43 mg

Tier 3 QL

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 1 QL

fenofibrate oral capsule Tier 1 QL

fenofibrate oral tablet 145 mg, 48 mg Tier 3 QL

fenofibrate oral tablet 160 mg, 54 mg Tier 1 QL

fenofibric acid oral tablet Tier 3 QL

fluvastatin sodium Tier 3 QL

fluvastatin sodium er Tier 3 QL

gemfibrozil oral Tier 1 LGC

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG


LIVALO Tier 3 ST; QL

lovastatin Tier 1 LGC; QL

niacin er (antihyperlipidemic) Tier 1

omega-3-acid ethyl esters Tier 3 QL

pravastatin sodium Tier 1 LGC; QL

prevalite Tier 1

rosuvastatin calcium Tier 3 ST; QL

simvastatin oral tablet 10 mg, 5 mg CE LGC; QL

simvastatin oral tablet 20 mg, 40 mg, 80 mg Tier 1 LGC; QL

WELCHOL Tier 3 #

*Antihypertensives*

amlodipine besy-benazepril hcl Tier 3

amlodipine besylate-valsartan Tier 3 QL

amlodipine-olmesartan Tier 3 QL

amlodipine-valsartan-hctz Tier 3 QL

atenolol-chlorthalidone Tier 1 LGC

benazepril hcl oral Tier 1 LGC

benazepril-hydrochlorothiazide Tier 1

bisoprolol-hydrochlorothiazide Tier 1 LGC

candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg

Tier 3 QL

candesartan cilexetil-hctz Tier 3 QL




captopril oral Tier 1

captopril-hydrochlorothiazide Tier 1

clonidine hcl oral Tier 1 LGC

clonidine hcl transdermal Tier 3

CLORPRES Tier 3

DEMSER Tier 3

doxazosin mesylate Tier 1

DUTOPROL Tier 3

EDARBI Tier 3 QL

EDARBYCLOR Tier 3 QL

enalapril maleate oral Tier 1 LGC

enalapril-hydrochlorothiazide Tier 1 LGC

eplerenone Tier 3

eprosartan mesylate Tier 3 QL

fosinopril sodium Tier 3

fosinopril sodium-hctz Tier 3

guanfacine hcl oral Tier 1

hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg Tier 1

hydralazine hcl oral tablet 25 mg Tier 1 LGC

irbesartan Tier 3 QL

irbesartan-hydrochlorothiazide Tier 3 QL

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 LGC

lisinopril oral tablet 30 mg, 40 mg Tier 1

lisinopril-hydrochlorothiazide Tier 1 LGC

losartan potassium oral tablet 100 mg Tier 1 LGC

losartan potassium oral tablet 25 mg, 50 mg Tier 1 LGC; QL

losartan potassium-hctz Tier 1 LGC

methyldopa oral Tier 1

methyldopa-hydrochlorothiazide Tier 3

methyldopate hcl Tier 3

metoprolol-hydrochlorothiazide Tier 1

minoxidil oral Tier 3

moexipril hcl Tier 3

moexipril-hydrochlorothiazide Tier 3

nadolol-bendroflumethiazide Tier 3




olmesartan medoxomil oral Tier 3 QL

olmesartan medoxomil-hctz Tier 3 QL

olmesartan-amlodipine-hctz Tier 3 QL

perindopril erbumine Tier 3

phenoxybenzamine hcl oral Tier 4 PA

prazosin hcl oral Tier 1

PRESTALIA Tier 3

propranolol-hctz Tier 3

quinapril hcl Tier 3

quinapril-hydrochlorothiazide Tier 3

ramipril Tier 1

TEKTURNA Tier 3 QL

TEKTURNA HCT Tier 3 QL

telmisartan Tier 1 QL

telmisartan-amlodipine Tier 3 QL

telmisartan-hctz Tier 1 QL

terazosin hcl oral Tier 1 LGC

trandolapril Tier 3

trandolapril-verapamil hcl er Tier 3

valsartan Tier 3 QL

valsartan-hydrochlorothiazide Tier 3 QL

*Anti-Infective Agents - Misc.*

ALINIA Tier 3

atovaquone oral Tier 3

aztreonam Tier 5

baciim Tier 5

bacitracin intramuscular Tier 5

CAYSTON Tier 5 SP; QL

chloramphenicol sod succinate Tier 5

clindamycin hcl oral Tier 1

clindamycin palmitate hcl Tier 1

clindamycin phosphate injection Tier 5

clindamycin phosphate intravenous solution 900 mg/6ml

Tier 5

colistimethate sodium injection Tier 5 SP

dapsone oral Tier 3




daptomycin Tier 4

DORIBAX Tier 5

imipenem-cilastatin Tier 5

INVANZ Tier 5

LINCOCIN Tier 5

lincomycin hcl injection Tier 1

linezolid oral suspension reconstituted Tier 1 QL

linezolid oral tablet Tier 1 QL

meropenem Tier 5

metronidazole oral Tier 1

NEBUPENT Tier 5

PENTAM Tier 5

polymyxin b sulfate injection Tier 5

PRIMSOL Tier 3

SIVEXTRO ORAL Tier 3 ST; QL

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

Tier 1 LGC

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

Tier 1 LGC

sulfatrim pediatric Tier 1

SYNERCID Tier 5

tinidazole oral Tier 3

trimethoprim oral Tier 3

TYGACIL Tier 5

vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg

Tier 5

vancomycin hcl oral Tier 3

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

Tier 5

XIFAXAN ORAL TABLET 200 MG Tier 3 QL

XIFAXAN ORAL TABLET 550 MG Tier 3 PA; ST; QL

*Antimalarials*

atovaquone-proguanil hcl Tier 3

chloroquine phosphate oral Tier 3

COARTEM Tier 3

DARAPRIM Tier 3




hydroxychloroquine sulfate oral Tier 1

mefloquine hcl Tier 3

primaquine phosphate oral Tier 3

quinine sulfate oral Tier 3

*Antimyasthenic Agents*

guanidine hcl oral Tier 3

MESTINON ORAL SYRUP Tier 3

pyridostigmine bromide er Tier 1

pyridostigmine bromide oral Tier 1

*Antimyasthenic/Cholinergic Agents*

guanidine hcl oral Tier 3

MESTINON ORAL SYRUP Tier 3

pyridostigmine bromide er Tier 1

pyridostigmine bromide oral Tier 1

*Antimycobacterial Agents*

CAPASTAT SULFATE Tier 5

cycloserine oral Tier 3

ethambutol hcl oral Tier 1

isoniazid oral Tier 1

PASER Tier 3

PRIFTIN Tier 3

pyrazinamide oral Tier 3

rifabutin Tier 3

RIFAMATE Tier 3

rifampin oral Tier 1

RIFATER Tier 3

SIRTURO Tier 5 PA; SP; QL

TRECATOR Tier 3

*Antineoplastics And Adjunctive Therapies*

ACTIMMUNE Tier 5 PA; SP

AFINITOR Tier 5 PA; SP; QL

ALIMTA Tier 5 PA

anastrozole oral Tier 1

ARRANON Tier 5

ARZERRA Tier 5 PA




azacitidine Tier 4

bexarotene Tier 1 PA; SP

bicalutamide Tier 3 QL

bleomycin sulfate Tier 5

BOSULIF ORAL TABLET 100 MG, 500 MG Tier 5 PA; ST; SP; QL

BUSULFEX Tier 5

CAMPTOSAR Tier 5

capecitabine Tier 1 PA; SP

CAPRELSA ORAL TABLET 100 MG, 300 MG

Tier 5 PA; SP; QL

carboplatin intravenous solution Tier 5

cisplatin intravenous Tier 5

COMETRIQ (100 MG DAILY DOSE) Tier 5 PA; SP; QL



COSMEGEN Tier 5

cyclophosphamide oral capsule Tier 2

cytarabine (pf) Tier 5

cytarabine injection solution Tier 5

DACOGEN Tier 5 PA

daunorubicin hcl intravenous injectable Tier 5

decitabine Tier 4 PA

dexrazoxane Tier 5

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/0.5ml, 20 mg/ml, 80 mg/2ml, 80 mg/4ml

Tier 5

docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 mg/8ml

Tier 5

doxorubicin hcl Tier 5

doxorubicin hcl liposomal Tier 5

EMCYT Tier 3

epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml

Tier 5

ERIVEDGE Tier 5 PA; SP; QL

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

Tier 5

etoposide oral Tier 1

exemestane Tier 3




FARESTON Tier 3

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

Tier 5 PA; SP

fludarabine phosphate Tier 5

flutamide Tier 1

GILOTRIF Tier 5 PA; SP; QL

GLEOSTINE Tier 2

HALAVEN Tier 5 PA

HEXALEN Tier 5

HYCAMTIN ORAL Tier 5 PA; SP

hydroxyurea oral Tier 1

ICLUSIG ORAL TABLET 15 MG, 45 MG Tier 5 PA; SP; QL

idarubicin hcl Tier 5

imatinib mesylate Tier 1 PA; SP

INLYTA Tier 5 PA; SP; QL

INTRON A Tier 3 PA; SP

irinotecan hcl Tier 5

JAKAFI Tier 5 PA; SP; QL

JEVTANA Tier 5 PA

KEPIVANCE Tier 5 PA

letrozole oral Tier 1

leucovorin calcium oral Tier 1

LEUKERAN Tier 5

lipodox 50 Tier 5

LYSODREN Tier 3

MATULANE Tier 5

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

Tier 1

megestrol acetate oral tablet Tier 1

MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 5 PA; SP; QL

melphalan Tier 3

melphalan hcl Tier 5

mercaptopurine oral Tier 1

mesna Tier 5

MESNEX Tier 5

methotrexate oral Tier 1




methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 250 mg/10ml, 50 mg/2ml

Tier 1

mitomycin intravenous Tier 5

mitoxantrone hcl Tier 3

MYLERAN Tier 3

NEXAVAR Tier 5 PA; SP; QL

nilutamide Tier 3

ODOMZO Tier 5 PA; QL

oxaliplatin Tier 5

paclitaxel Tier 5

POMALYST Tier 5 PA; SP; QL

PROLEUKIN Tier 5 PA

RITUXAN INTRAVENOUS SOLUTION Tier 5 PA; ST

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG


STIVARGA Tier 5 PA; SP; QL

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

Tier 2 PA; SP; QL

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

Tier 5 PA; SP

SYNRIBO Tier 5 PA; ST

TABLOID Tier 3

TAFINLAR Tier 5 PA; SP; QL

tamoxifen citrate oral CE

TARCEVA Tier 3 PA; SP; QL

TASIGNA Tier 5 PA; ST; SP; QL

TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ML, 80 MG/4ML

Tier 5

temozolomide Tier 1 PA; SP

toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

Tier 5

topotecan hcl Tier 1

TORISEL Tier 5

TRELSTAR MIXJECT Tier 5 PA; #; SP

tretinoin oral Tier 1 SP

TREXALL Tier 3

TRISENOX Tier 5




TYKERB Tier 5 PA; SP

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

Tier 5 PA

VELCADE INJECTION Tier 5 PA

VIDAZA Tier 5

vincasar pfs Tier 5

vincristine sulfate intravenous Tier 5

vinorelbine tartrate Tier 5

VORAXAZE Tier 5

VOTRIENT Tier 5 PA; SP; QL

XALKORI Tier 5 PA; SP; QL

XATMEP Tier 3 PA

XTANDI Tier 5 PA; ST; SP; QL

YERVOY Tier 5 PA

ZANOSAR Tier 5

ZELBORAF Tier 5 PA; SP; QL

ZINECARD Tier 5

ZOLINZA Tier 5 PA; SP; QL

ZYKADIA Tier 5 PA; SP

ZYTIGA ORAL TABLET 250 MG Tier 2 PA; SP; QL

ZYTIGA ORAL TABLET 500 MG Tier 2 PA; QL

*Anti-Obesity Agent Combinations**

CONTRAVE Tier 3 PA; ST; QL

*Antiparkinson Agents*

amantadine hcl oral Tier 1

benztropine mesylate injection Tier 5

benztropine mesylate oral Tier 1 LGC

bromocriptine mesylate oral Tier 1

carbidopa oral Tier 3

carbidopa-levodopa Tier 1

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

Tier 1

carbidopa-levodopa-entacapone Tier 3

entacapone Tier 3

NEUPRO Tier 3 ST; QL

pramipexole dihydrochloride Tier 1




pramipexole dihydrochloride er Tier 3 QL

rasagiline mesylate oral Tier 3 QL

ropinirole hcl Tier 1

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

Tier 3 QL

selegiline hcl oral Tier 1

tolcapone Tier 3

trihexyphenidyl hcl oral elixir Tier 1

trihexyphenidyl hcl oral tablet 2 mg Tier 1 LGC

trihexyphenidyl hcl oral tablet 5 mg Tier 1

ZELAPAR Tier 3 ST; QL

*Antipsychotics/Antimanic Agents*

aripiprazole oral solution Tier 1 QL

aripiprazole oral tablet Tier 1 QL

aripiprazole oral tablet dispersible Tier 1 QL

chlorpromazine hcl oral Tier 3

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 QL

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

Tier 3 QL

compro Tier 1

EQUETRO Tier 3

FANAPT Tier 3 ST; QL

FANAPT TITRATION PACK Tier 3 ST

fluphenazine hcl oral Tier 3

haloperidol oral Tier 1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 80 MG

Tier 3 ST; QL

LATUDA ORAL TABLET 60 MG Tier 3 ST

lithium Tier 3

lithium carbonate er Tier 3

lithium carbonate oral Tier 1

loxapine succinate oral Tier 3

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

Tier 3 QL

olanzapine oral tablet dispersible Tier 3 QL




paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

Tier 3 ST; QL

perphenazine oral Tier 3

prochlorperazine Tier 1

prochlorperazine maleate oral Tier 1

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

Tier 3 QL

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

Tier 1 QL

REXULTI Tier 3 PA; ST; QL

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 3 QL

risperidone oral solution Tier 1

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 1 QL

risperidone oral tablet dispersible 0.25 mg Tier 3

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 3 QL

SAPHRIS Tier 3 ST; QL

thioridazine hcl oral Tier 3

thiothixene oral Tier 1

trifluoperazine hcl oral Tier 1

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

Tier 3 PA; ST; QL

VRAYLAR ORAL CAPSULE THERAPY PACK

Tier 3 PA; ST

ziprasidone hcl Tier 1 QL

*Antiretrovirals Adjuvants***

TYBOST Tier 3 QL

*Antiseptics & Disinfectants*

formadon Tier 3

formaldehyde external solution 10 % Tier 3

FORMA-RAY Tier 3

IODOFLEX Tier 3

IODOSORB Tier 3

*Antivirals*

abacavir sulfate oral tablet Tier 1




abacavir sulfate-lamivudine Tier 1

abacavir-lamivudine-zidovudine Tier 1

acyclovir oral capsule Tier 1 LGC

acyclovir oral suspension Tier 1

acyclovir oral tablet 400 mg Tier 1 LGC

acyclovir oral tablet 800 mg Tier 1

acyclovir sodium intravenous solution Tier 5

acyclovir sodium intravenous solution reconstituted 500 mg

Tier 5

adefovir dipivoxil Tier 1 SP; QL

APTIVUS Tier 3

ATRIPLA Tier 3 QL

BARACLUDE ORAL SOLUTION Tier 5 SP

cidofovir intravenous Tier 5 SP

COMBIVIR Tier 3

COMPLERA Tier 3 QL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 2

DAKLINZA Tier 5 PA; ST; SP; QL

DESCOVY Tier 3 PA; QL

didanosine Tier 1

EDURANT Tier 3 QL

EMTRIVA ORAL CAPSULE Tier 3 QL

EMTRIVA ORAL SOLUTION Tier 3

entecavir Tier 4 SP; QL

EPIVIR HBV ORAL SOLUTION Tier 2

EPIVIR HBV ORAL TABLET Tier 3

EPZICOM Tier 3

EVOTAZ Tier 3

famciclovir oral Tier 3 QL

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

Tier 5 #; SP

ganciclovir sodium Tier 5 SP

GENVOYA Tier 5 PA; QL

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

Tier 3 QL




INVIRASE Tier 3

ISENTRESS HD Tier 3 QL

ISENTRESS ORAL PACKET Tier 3

ISENTRESS ORAL TABLET Tier 3 QL

ISENTRESS ORAL TABLET CHEWABLE Tier 3 QL

KALETRA ORAL TABLET Tier 3 #

lamivudine Tier 1

lamivudine-zidovudine Tier 1

LEXIVA Tier 3

lopinavir-ritonavir Tier 1

moderiba oral tablet 200 mg Tier 1 SP

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

Tier 1 QL

nevirapine oral tablet Tier 1

NORVIR ORAL CAPSULE Tier 3 #

NORVIR ORAL SOLUTION Tier 3

NORVIR ORAL TABLET Tier 3

ODEFSEY Tier 3 QL

oseltamivir phosphate oral capsule Tier 1 QL

PEGASYS PROCLICK Tier 2 PA; SP

PEGASYS SUBCUTANEOUS SOLUTION Tier 2 PA; SP

PREZCOBIX Tier 2

PREZISTA ORAL SUSPENSION Tier 3 QL

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 3 QL

REBETOL ORAL SOLUTION Tier 3 SP; QL

RELENZA DISKHALER Tier 3 QL

RESCRIPTOR Tier 3

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 3 QL

ribasphere oral capsule Tier 1 SP

ribasphere oral tablet 200 mg Tier 1 SP

ribasphere oral tablet 400 mg, 600 mg Tier 3 SP

ribavirin oral capsule Tier 1 SP

ribavirin oral tablet 200 mg Tier 1 SP

rimantadine hcl Tier 3




SELZENTRY ORAL SOLUTION Tier 3 QL

SELZENTRY ORAL TABLET 150 MG, 25 MG, 75 MG

Tier 3 QL

SELZENTRY ORAL TABLET 300 MG Tier 3

SOVALDI Tier 4 PA; SP; QL

stavudine oral capsule Tier 1

STRIBILD Tier 5 PA; QL

SUSTIVA Tier 3

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

Tier 3 QL

TIVICAY ORAL TABLET 10 MG, 25 MG Tier 2 QL

TIVICAY ORAL TABLET 50 MG Tier 3 QL

TRIUMEQ Tier 2 QL

TRIZIVIR Tier 3

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

Tier 2 PA

TRUVADA ORAL TABLET 200-300 MG Tier 3 PA

valacyclovir hcl oral Tier 1

VALCYTE ORAL SOLUTION RECONSTITUTED

Tier 5 PA; SP

valganciclovir hcl oral solution reconstituted Tier 4 PA; SP

valganciclovir hcl oral tablet Tier 4 PA; SP; QL

VIDEX Tier 3

VIRACEPT ORAL TABLET Tier 3

VIRAMUNE Tier 3

VIREAD ORAL POWDER Tier 3

VIREAD ORAL TABLET Tier 3 QL

zidovudine Tier 1

*Assorted Classes*

ATGAM Tier 5 SP

AZASAN Tier 5

azathioprine oral Tier 1

BENLYSTA INTRAVENOUS Tier 5 PA; ST; SP

BENLYSTA SUBCUTANEOUS Tier 5 PA; ST; SP; QL

CELLCEPT ORAL SUSPENSION RECONSTITUTED

Tier 5 SP

cyclosporine modified Tier 1




cyclosporine oral capsule Tier 1

gengraf oral capsule 100 mg, 25 mg Tier 1

GENGRAF ORAL CAPSULE 50 MG Tier 1

gengraf oral solution Tier 1

kionex oral powder Tier 3

kionex oral suspension Tier 1

mycophenolate mofetil Tier 1 SP

NULOJIX Tier 5 PA; SP

physiolyte Tier 3

RAPAMUNE Tier 5 SP

REVLIMID Tier 5 PA; SP; QL

ringers irrigation Tier 3

SIMULECT Tier 5 PA; SP

sirolimus oral Tier 1 SP

sodium polystyrene sulfonate oral Tier 1

sodium polystyrene sulfonate rectal Tier 1

SYPRINE Tier 5 PA; ST

tacrolimus oral Tier 1 SP

THALOMID Tier 2 PA; SP

THYMOGLOBULIN Tier 5 SP

TIS-U-SOL Tier 3

XIAFLEX Tier 5 PA; SP

ZORTRESS Tier 5 SP

*Beta Blockers*

acebutolol hcl oral Tier 3

atenolol oral Tier 1 LGC

betaxolol hcl oral Tier 3

bisoprolol fumarate Tier 1 LGC

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

Tier 3 QL

carvedilol Tier 1 LGC

COREG CR Tier 3 ST; #; QL

HEMANGEOL Tier 3 PA

labetalol hcl oral Tier 3

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Tier 1 QL




metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1 LGC

metoprolol tartrate oral tablet 37.5 mg, 75 mg Tier 1

nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 3

pindolol Tier 1

propranolol hcl er Tier 3

propranolol hcl oral solution Tier 1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1 LGC

propranolol hcl oral tablet 60 mg Tier 1

sorine oral tablet 120 mg, 80 mg Tier 1 LGC

sorine oral tablet 160 mg, 240 mg Tier 1

sotalol hcl (af) oral tablet 120 mg Tier 1 LGC

sotalol hcl (af) oral tablet 160 mg, 80 mg Tier 1

sotalol hcl oral tablet 120 mg, 80 mg Tier 1 LGC

sotalol hcl oral tablet 160 mg, 240 mg Tier 1

timolol maleate oral Tier 3

*Biologicals Misc*

ADAGEN Tier 5 SP

GRASTEK Tier 3 PA; ST

yellow jacket venom protein injection solution reconstituted 550 mcg

Tier 5

*Calcium Channel Blockers*

afeditab cr oral tablet extended release 24 hour30 mg, 60 mg

Tier 1 QL

amlodipine besylate oral Tier 1 LGC

cartia xt oral capsule extended release 24 hour120 mg, 180 mg, 240 mg, 300 mg

Tier 1 QL

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 1 QL

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Tier 1 QL

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tier 1 QL

diltiazem hcl er oral capsule extended release 12 hour

Tier 1




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

Tier 1

diltiazem hcl er oral capsule extended release 24 hour 240 mg

Tier 1 QL

diltiazem hcl oral Tier 1 LGC

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg

Tier 1

dilt-xr oral capsule extended release 24 hour 240 mg

Tier 1 QL

felodipine er Tier 3 QL

isradipine Tier 3

matzim la oral tablet extended release 24 hour180 mg, 240 mg, 300 mg, 360 mg

Tier 3 QL

matzim la oral tablet extended release 24 hour420 mg

Tier 3

nicardipine hcl oral Tier 3

nifediac cc oral tablet extended release 24 hour30 mg

Tier 1 QL

nifedical xl oral tablet extended release 24 hour60 mg

Tier 1 QL

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg, 90 mg

Tier 1 QL

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

Tier 1 QL

nifedipine oral Tier 1

nimodipine oral Tier 3

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

Tier 1 QL

nisoldipine er oral tablet extended release 24 hour 25.5 mg

Tier 1

taztia xt oral capsule extended release 24 hour120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tier 1 QL

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

Tier 1 QL

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

Tier 1

verapamil hcl er oral tablet extended release 120 mg

Tier 1 LGC




verapamil hcl er oral tablet extended release 180 mg, 240 mg

Tier 1

verapamil hcl oral Tier 1 LGC

*Cardiotonics*

DIGOX Tier 1

digoxin oral solution Tier 3

digoxin oral tablet Tier 1

*Cardiovascular Agents - Misc.*

ADCIRCA Tier 5 PA; ST; SP; QL

ADEMPAS Tier 5 PA; ST; SP; QL

BIDIL Tier 3

CIALIS ORAL TABLET 5 MG Tier 3 PA; ST; QL

epoprostenol sodium Tier 1 PA; SP

LETAIRIS Tier 4 PA; SP

OPSUMIT Tier 4 PA; SP; QL

ORENITRAM Tier 5 PA; SP

REMODULIN Tier 5 PA; SP

sildenafil citrate oral Tier 1 PA; SP; QL

TRACLEER Tier 4 PA; #; SP

VENTAVIS Tier 5 PA; SP

*Cephalosporins*

cefaclor er Tier 1

cefaclor oral capsule Tier 1

cefaclor oral suspension reconstituted Tier 3

cefadroxil Tier 1

cefazolin sodium injection Tier 5

cefazolin sodium intravenous solution reconstituted

Tier 5

cefazolin sodium-dextrose intravenous solution reconstituted

Tier 3

cefdinir Tier 1

cefditoren pivoxil Tier 3

cefepime hcl injection Tier 5

cefixime Tier 3

cefotaxime sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 500 mg

Tier 5




cefotetan disodium Tier 5

cefoxitin sodium Tier 5

cefpodoxime proxetil Tier 3

cefprozil Tier 1

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

Tier 5

ceftibuten Tier 1

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

Tier 5

ceftriaxone sodium intravenous Tier 5

cefuroxime axetil oral tablet Tier 1

cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg

Tier 5

cefuroxime sodium intravenous solution reconstituted 1.5 gm

Tier 5

cephalexin oral capsule 250 mg, 500 mg Tier 1

cephalexin oral suspension reconstituted Tier 1

cephalexin oral tablet Tier 1

SUPRAX ORAL CAPSULE Tier 3

SUPRAX ORAL TABLET CHEWABLE Tier 3 #

tazicef injection solution reconstituted 2 gm, 6 gm

Tier 5

tazicef intravenous solution reconstituted 1 gm Tier 5

TEFLARO Tier 5

*Chemicals*

sodium phenylbutyrate Tier 3 PA

thioguanine Tier 1

*Contraceptives*

altavera CE

alyacen 1/35 CE

alyacen 7/7/7 CE

amethia CE

amethia lo CE

apri CE

aranelle CE

ASHLYNA CE

aviane CE




azurette CE

balziva CE

BREVICON (28) Tier 3

briellyn CE

camila CE

camrese CE

camrese lo CE

caziant CE

cesia CE

chateal CE

cryselle-28 CE

cyclafem 1/35 CE

cyclafem 7/7/7 CE

CYCLESSA Tier 3

dasetta 1/35 CE

dasetta 7/7/7 CE

daysee CE

deblitane CE

DELYLA CE

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

Tier 3

DESOGEN Tier 3

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

CE

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

CE

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

CE

elinest CE

ELLA CE

emoquette CE

enpresse-28 CE

enskyce CE

errin CE

estarylla CE

ESTROSTEP FE Tier 3




falmina CE

FAYOSIM CE

GENERESS FE Tier 3

gianvi CE

gildagia CE

gildess fe 1.5/30 CE

gildess fe 1/20 CE

heather CE

introvale CE

jencycla CE

jolessa CE

jolivette CE

junel 1.5/30 CE

junel 1/20 CE

junel fe 1.5/30 CE

junel fe 1/20 CE

kariva CE

kelnor 1/35 CE

kurvelo CE

KYLEENA CE

LARIN 1.5/30 CE

larin fe 1.5/30 CE

larin fe 1/20 CE

leena CE

lessina CE

levonest CE

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg

CE

levonorgestrel oral tablet 1.5 mg CE

levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg

CE

levora 0.15/30 (28) CE

LO LOESTRIN FE Tier 3

LOESTRIN FE 1.5/30 Tier 3

LOESTRIN FE 1/20 Tier 3

lomedia 24 fe CE




loryna CE

LOSEASONIQUE Tier 3

low-ogestrel CE

lutera CE

lyza CE

marlissa CE

medroxyprogesterone acetate intramuscular suspension

CE

MIBELAS 24 FE CE

microgestin 1.5/30 CE

microgestin 1/20 CE

microgestin fe 1.5/30 CE

microgestin fe 1/20 CE

MIRCETTE Tier 3

MIRENA (52 MG) CE #

mono-linyah CE

mononessa CE

my way CE

myzilra CE

NATAZIA Tier 3

necon 0.5/35 (28) CE

necon 1/35 (28) CE

necon 1/50 (28) CE

necon 7/7/7 CE

NEXPLANON CE

next choice one dose CE

nikki CE

nora-be CE

norethin ace-eth estrad-fe CE

norethindrone oral CE

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

CE

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg

CE

norlyroc CE

nortrel 0.5/35 (28) CE




nortrel 1/35 (21) CE

nortrel 1/35 (28) CE

nortrel 7/7/7 CE

NUVARING CE #

ocella CE

ogestrel CE

orsythia CE

ORTHO MICRONOR Tier 3

ORTHO TRI-CYCLEN (28) Tier 3

ORTHO TRI-CYCLEN LO Tier 3 #

ORTHO-CYCLEN (28) Tier 3

ORTHO-NOVUM 1/35 (28) Tier 3

PARAGARD INTRAUTERINE COPPER CE

philith CE

pimtrea CE

pirmella 1/35 CE

pirmella 7/7/7 CE

PLAN B ONE-STEP Tier 3

portia-28 CE

previfem CE

quasense CE

RAJANI CE

reclipsen CE

RIVELSA CE

SAFYRAL Tier 3

SEASONIQUE Tier 3

sharobel CE

solia CE

sprintec 28 CE

sronyx CE

syeda CE

take action CE

TAYTULLA Tier 3

tilia fe CE

tri-estarylla CE




tri-legest fe CE

tri-linyah CE

trinessa (28) CE

tri-previfem CE

tri-sprintec CE

trivora (28) CE

velivet CE

vestura CE

viorele CE

vyfemla CE

wera CE

wymzya fe CE

xulane CE

YASMIN 28 Tier 3

YAZ Tier 3

zarah CE

zenchent CE

zovia 1/35e (28) CE

zovia 1/50e (28) CE

*Corticosteroids*

cortisone acetate oral Tier 3

DEXAMETHASONE INTENSOL Tier 3

dexamethasone oral Tier 1

fludrocortisone acetate oral Tier 1

hydrocortisone oral Tier 1

methylprednisolone oral tablet Tier 1

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21)

Tier 2

MILLIPRED ORAL TABLET Tier 2

prednisolone oral solution Tier 1

prednisolone oral syrup 15 mg/5ml Tier 1

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml

Tier 3

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

Tier 1




prednisolone sodium phosphate oral tablet dispersible

Tier 3

PREDNISONE INTENSOL Tier 1

prednisone oral solution Tier 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1 LGC

prednisone oral tablet 50 mg Tier 1

RAYOS Tier 3

UCERIS ORAL Tier 3 QL

*Cough/Cold/Allergy*

acetylcysteine inhalation Tier 3

alavert allergy/sinus Tier 1

ALLEGRA-D ALLERGY & CONGESTION Tier 1

benzonatate Tier 1

bromfed dm Tier 3

cetirizine-pseudoephedrine er Tier 1

cheratussin ac oral syrup Tier 1

CLARITIN-D 12 HOUR Tier 1

fexofenadine-pseudoephed er oral tablet extended release 24 hour

Tier 1

FLOWTUSS Tier 3 ST

guaiatussin ac Tier 1

guaifenesin ac Tier 1

guaifenesin-codeine oral solution Tier 1

hydrocodone-homatropine Tier 1

hydromet Tier 1

loratadine-d 12hr Tier 1

loratadine-d 24hr Tier 1

MAR-COF BP Tier 3

nebusal inhalation nebulization solution 3 % Tier 3

OBREDON Tier 3

promethazine vc/codeine Tier 1

promethazine-codeine Tier 1

promethazine-dm Tier 1

pseudoeph-chlorphen-hydrocod Tier 3

SEMPREX-D Tier 3




sodium chloride inhalation nebulization solution0.9 %, 10 %, 3 %, 7 %

Tier 3

TUSSICAPS Tier 3 QL

tussigon Tier 1

virtussin a/c Tier 1

ZYRTEC-D ALLERGY & CONGESTION Tier 1

*Cyclin-Dependent Kinases (Cdk) Inhibitors***

IBRANCE Tier 5 PA; SP; QL

*Cystic Fibrosis Agent - Combinations***

ORKAMBI Tier 5 PA; QL

*Dermatologicals*

ABREVA Tier 1

acitretin Tier 3 QL

ACZONE EXTERNAL GEL 5 % Tier 3 #

ACZONE EXTERNAL GEL 7.5 % Tier 3

adapalene external cream Tier 3

adapalene external gel 0.3 % Tier 3

adapalene external lotion Tier 3 ST

adapalene-benzoyl peroxide Tier 3

AKTIPAK Tier 3

alclometasone dipropionate Tier 1

ALTABAX Tier 3

aluminum acetate external Tier 3

amcinonide Tier 3

AMELUZ Tier 3

ammonium lactate external Tier 1

amnesteem Tier 3 ST; QL

ANACAINE Tier 3

APEXICON E Tier 3

ATRAPRO HYDROGEL Tier 3

AVAGE Tier 3

avar cleanser Tier 3

avar-e green Tier 3

avita external cream Tier 1

AVO CREAM Tier 3

AZELEX Tier 3




benzoyl peroxide cleanser external lotion 6 % Tier 3

benzoyl peroxide-erythromycin Tier 1

betamethasone dipropionate aug Tier 3

betamethasone dipropionate external Tier 1

betamethasone valerate external Tier 3

BIONECT EXTERNAL CREAM Tier 3

BIONECT EXTERNAL GEL Tier 3

bp 10-1 Tier 3

bp wash external liquid 7 % Tier 3

calcipotriene external Tier 3 ST

calcipotriene-betameth diprop Tier 3 ST

calcitrene Tier 3 ST

calcitriol external Tier 3

CAPEX Tier 3

CENTANY AT Tier 3

cerisa wash Tier 3

ciclodan external cream Tier 3

ciclodan external solution Tier 3 PA

ciclopirox external gel Tier 3

ciclopirox external shampoo Tier 3

ciclopirox external solution Tier 3 PA

ciclopirox olamine external cream Tier 3

ciclopirox olamine external suspension Tier 1

claravis Tier 3 ST; QL

clindacin etz external swab Tier 3

clindacin-p Tier 3

clindamycin phos-benzoyl perox Tier 3

clindamycin phosphate external foam Tier 3

clindamycin phosphate external gel Tier 1

clindamycin phosphate external lotion Tier 1

clindamycin phosphate external solution Tier 1

clindamycin phosphate external swab Tier 3

clindamycin-tretinoin Tier 3

clobetasol propionate e Tier 3

clobetasol propionate emulsion Tier 3




clobetasol propionate external Tier 3

clocortolone pivalate Tier 3

clotrimazole external Tier 1

clotrimazole-betamethasone Tier 1

CONDYLOX EXTERNAL GEL Tier 3

CORDRAN EXTERNAL TAPE Tier 3 QL

cormax scalp application Tier 3

CORTISPORIN EXTERNAL Tier 3

DENAVIR Tier 3 ST

DERMASORB TA Tier 3

desonide external Tier 1

desoximetasone external Tier 3

diclofenac sodium transdermal gel 1 % Tier 3 QL

DIFFERIN EXTERNAL GEL 0.1 % Tier 1 OTC

diflorasone diacetate external Tier 3

doxycycline Tier 1 QL

DRITHO-CREME HP Tier 3

econazole nitrate external Tier 1

ELIDEL Tier 3 PA; ST

EMULSION SB Tier 3

EPIDUO FORTE Tier 3 ST

EPIFOAM Tier 3

ERTACZO Tier 3

ery Tier 1

erythromycin external gel Tier 3

erythromycin external pad Tier 1

erythromycin external solution Tier 1

ethyl chloride Tier 3

EURAX Tier 3

EXELDERM Tier 3

FINACEA Tier 3 #

FIRST-HYDROCORTISONE Tier 3

fluocinolone acetonide body Tier 3

fluocinolone acetonide external Tier 3

fluocinolone acetonide scalp Tier 3




fluocinonide external cream 0.05 % Tier 1 LGC

fluocinonide external cream 0.1 % Tier 3

fluocinonide external gel Tier 1

fluocinonide external ointment Tier 1

fluocinonide external solution Tier 1

FLUOROPLEX Tier 3

fluorouracil external cream 0.5 % Tier 3

fluorouracil external cream 5 % Tier 1

fluorouracil external solution Tier 1

flurandrenolide external cream Tier 3

flurandrenolide external lotion Tier 3

fluticasone propionate external cream Tier 1

fluticasone propionate external lotion Tier 3

fluticasone propionate external ointment Tier 3

fungicure intensive/nailguard Tier 1

GEBAUERS PAIN EASE Tier 3

GEBAUERS SPRAY AND STRETCH Tier 3

gentamicin sulfate external cream Tier 1 LGC

gentamicin sulfate external ointment Tier 1 LGC

HALAC Tier 3

halobetasol propionate Tier 1

HALOG Tier 3

hydrocortisone butyr lipo base Tier 3

hydrocortisone butyrate external Tier 3

hydrocortisone external cream 2.5 % Tier 1

hydrocortisone external lotion 2.5 % Tier 3

hydrocortisone external ointment 1 % Tier 3

hydrocortisone external ointment 2.5 % Tier 1

hydrocortisone valerate Tier 3

imiquimod external Tier 3 QL

JUBLIA Tier 3 PA; ST

ketoconazole external cream Tier 1

ketoconazole external foam Tier 3

ketoconazole external shampoo Tier 1

lactic acid external lotion Tier 1




LEVULAN KERASTICK Tier 3

lidocaine external ointment Tier 3 QL

lidocaine external patch 5 % Tier 3 PA; QL

lidocaine-prilocaine external cream Tier 3 QL

lindane external shampoo Tier 1

LUZU Tier 3

malathion external Tier 3

MENTAX Tier 3

methoxsalen rapid Tier 3

methyl salicylate external liquid Tier 3

metronidazole external cream Tier 3

metronidazole external gel 0.75 % Tier 1

metronidazole external lotion Tier 1

MIRVASO Tier 3 PA; ST

mometasone furoate external Tier 1

mupirocin calcium Tier 3

mupirocin external Tier 1

myorisan oral capsule 10 mg, 20 mg, 40 mg Tier 3 ST; QL

naftifine hcl Tier 3 ST

NAFTIN EXTERNAL GEL 1 % Tier 3 ST

NEO-SYNALAR EXTERNAL CREAM Tier 3

NORITATE Tier 3 ST

nystatin external cream Tier 1

nystatin external ointment Tier 1

nystatin-triamcinolone Tier 3

oscion cleanser external lotion 6 % Tier 3

OVACE PLUS EXTERNAL CREAM Tier 3

oxiconazole nitrate Tier 3

OXISTAT EXTERNAL LOTION Tier 3

PANRETIN Tier 3

permethrin external cream Tier 3

PICATO Tier 3 QL

podofilox external Tier 1

pr benzoyl peroxide wash Tier 3

PRAMOSONE EXTERNAL LOTION 1-2.5 %

Tier 3




prednicarbate Tier 3

PRUDOXIN Tier 3 QL

PRUTECT Tier 3

RADIAPLEXRX Tier 3

REGRANEX Tier 3

rosadan external cream Tier 3

rosadan external gel Tier 1

salacyn external cream Tier 3

salicylic acid external cream Tier 3

salicylic acid external gel Tier 3

salicylic acid external liquid 26 % Tier 3

salicylic acid external shampoo Tier 3

salicylic acid wart remover Tier 3

salicylic acid-cleanser Tier 3

SANTYL Tier 3

scalacort Tier 3

SCALACORT DK Tier 3

seb-prev wash Tier 3

selenium sulfide external lotion Tier 1

selenium sulf-pyrithione-urea Tier 3

SILVASORB Tier 3

silver nitrate external Tier 3

silver sulfadiazine external Tier 1

SKLICE Tier 3

sodium sulfacetamide external shampoo Tier 3

SODIUM SULFACETAMIDE WASH Tier 3

SONAFINE Tier 3

spinosad Tier 3

ssd Tier 1

sss 10-5 external cream Tier 3

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Tier 4 PA; ST; SP

sulfacetamide sodium (acne) Tier 1

sulfacetamide sodium external gel Tier 3

sulfacetamide sodium external liquid Tier 3

sulfacetamide sodium external suspension Tier 1




sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %

Tier 3

sulfacetamide sodium-sulfur external emulsion Tier 3

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %

Tier 3

sulfacetamide sodium-sulfur external lotion 10-5 %

Tier 3

sulfacetamide sodium-sulfur external pad 10-4 % Tier 3

sulfacetamide sodium-sulfur external suspension Tier 3

sulfacetamide-sulfur in urea external emulsion Tier 3

sulfacleanse 8/4 Tier 3

SULFAMYLON Tier 3

SYNERA Tier 3

TACLONEX EXTERNAL SUSPENSION Tier 3 ST

tacrolimus external Tier 3 ST

TARGRETIN EXTERNAL Tier 5 PA; SP

tazarotene external Tier 3 ST

TAZORAC EXTERNAL CREAM 0.05 % Tier 3 ST; #

TAZORAC EXTERNAL GEL Tier 3 ST; #

TEXACORT Tier 3

tretinoin external cream Tier 1

tretinoin external gel 0.01 %, 0.025 % Tier 1

tretinoin external gel 0.05 % Tier 3

triamcinolone acetonide external aerosol solution

Tier 1

triamcinolone acetonide external cream Tier 1 LGC

triamcinolone acetonide external lotion Tier 1

triamcinolone acetonide external ointment Tier 1 LGC

triderm external cream 0.1 % Tier 1 LGC

ULESFIA Tier 3 QL

ULTRAVATE X (CREAM) Tier 3

ULTRAVATE X (OINTMENT) Tier 3

urea external cream 45 % Tier 3

VERDESO Tier 3

VEREGEN Tier 3

VUSION Tier 3




XERESE Tier 3

XOLEGEL Tier 3

ZENATANE Tier 3 ST; QL

zencia Tier 3

ZIANA Tier 3 ST; #

ZONALON Tier 3 QL

ZOVIRAX EXTERNAL CREAM Tier 3 ST

*Diagnostic Products*

ACCU-CHEK AVIVA PLUS IN VITRO Tier 3 PA; QL

ACCU-CHEK COMPACT PLUS Tier 3 PA; QL

ACCU-CHEK SMARTVIEW Tier 3 PA; QL

ACCUTREND GLUCOSE Tier 3 PA; QL

ADVANCE INTUITION TEST Tier 3 PA; QL

ADVOCATE REDI-CODE IN VITRO Tier 3 PA; QL

ADVOCATE REDI-CODE+ TEST Tier 3 PA; QL

ADVOCATE TEST Tier 3 PA; QL

AGAMATRIX AMP TEST Tier 3 PA; QL

AGAMATRIX JAZZ TEST Tier 3 PA; QL

AGAMATRIX KEYNOTE TEST Tier 3 PA; QL

AGAMATRIX PRESTO TEST Tier 3 PA; QL

ASSURE 3 TEST Tier 3 PA; QL

ASSURE 4 TEST Tier 3 PA; QL

ASSURE PLATINUM Tier 3 PA; QL

ASSURE PRO TEST Tier 3 PA; QL

BAYER BREEZE 2 TEST Tier 3 PA; QL

BAYER CONTOUR NEXT TEST Tier 3 PA; QL

BAYER CONTOUR TEST Tier 3 PA; QL

CARESENS N GLUCOSE TEST Tier 3 PA; QL

CHEK-STIX CONTROL Tier 3

CHEMSTRIP 10 MD Tier 3

CHEMSTRIP 10/SG Tier 3

CHEMSTRIP 2 GP Tier 3

CHEMSTRIP 5 OB Tier 3

CHEMSTRIP 7 Tier 3

CHEMSTRIP 9 Tier 3




CHEMSTRIP K Tier 3

CHEMSTRIP UGK Tier 3

CLEVER CHEK AUTO-CODE TEST Tier 3 PA; QL

CLEVER CHEK AUTO-CODE VOICE IN VITRO

Tier 3 PA; QL

CLEVER CHEK TEST Tier 3 PA; QL

CLEVER CHOICE AUTO-CODE TEST Tier 3 PA; QL

CLEVER CHOICE MICRO TEST Tier 3 PA; QL

COMBISTIX Tier 3

CVS KETONE CARE Tier 3

EASY PLUS II GLUCOSE TEST Tier 3 PA; QL

EASY STEP TEST Tier 3 PA; QL

EASY TALK BLOOD GLUCOSE TEST Tier 3 PA; QL

EASY TOUCH TEST Tier 3 PA; QL

EASY TRAK BLOOD GLUCOSE TEST Tier 3 PA; QL

EASYGLUCO IN VITRO Tier 3 PA; QL

EASYMAX 15 TEST Tier 3 PA; QL

EASYMAX TEST Tier 3 PA; QL

EASYPLUS BLOOD GLUCOSE TEST Tier 3 PA; QL

EASYPRO PLUS IN VITRO Tier 3 PA; QL

ELEMENT TEST Tier 3 PA; QL

EMBRACE BLOOD GLUCOSE TEST Tier 3 PA; QL

EVENCARE + BLOOD GLUCOSE TEST Tier 3 PA; QL

EVENCARE BLOOD GLUCOSE TEST Tier 3 PA; QL

EVENCARE G2 TEST Tier 3 PA; QL

EVENCARE G3 TEST Tier 3 PA; QL

EVOLUTION AUTOCODE IN VITRO Tier 3 PA; QL

EZ SMART BLOOD GLUCOSE TEST Tier 3 PA; QL

EZ SMART PLUS GLUCOSE TEST Tier 3 PA; QL

FIFTY50 GLUCOSE TEST 2.0 Tier 3 PA; QL

FORA D15G BLOOD GLUCOSE TEST Tier 3 PA; QL

FORA D20 BLOOD GLUCOSE TEST Tier 3 PA; QL

FORA G20 BLOOD GLUCOSE TEST Tier 3 PA; QL

FORA G30A BLOOD GLUCOSE TEST Tier 3 PA; QL

FORA GD20 TEST Tier 3 PA; QL

FORA V10 BLOOD GLUCOSE TEST Tier 3 PA; QL






FORA V30A BLOOD GLUCOSE TEST Tier 3 PA; QL

FORACARE GD40 TEST Tier 3 PA; QL

FORACARE PREMIUM V10 TEST Tier 3 PA; QL

FREESTYLE INSULINX TEST Tier 2 QL

FREESTYLE LITE TEST Tier 2 QL

FREESTYLE TEST Tier 2 QL

GE100 BLOOD GLUCOSE TEST Tier 3 PA; QL

GLUCAGEN DIAGNOSTIC Tier 3 QL

GLUCOCARD 01 SENSOR PLUS Tier 3 PA; QL

GLUCOCARD EXPRESSION TEST Tier 3 PA; QL

GLUCOCARD VITAL TEST Tier 3 PA; QL

GLUCOCARD X-SENSOR Tier 3 PA; QL

GLUCOCOM TEST Tier 3 PA; QL

HEMA-COMBISTIX Tier 3

INFINITY BLOOD GLUCOSE TEST Tier 3 PA; QL

KETOCARE Tier 3

KETO-DIASTIX Tier 3

KETOSTIX Tier 3

KROGER BLOOD GLUCOSE TEST Tier 3 PA; QL

KROGER PREMIUM GLUCOSE TEST Tier 3 PA; QL

KROGER TEST Tier 3 PA; QL

LABSTIX Tier 3

LIBERTY NEXT GENERATION TEST Tier 3 PA; QL

LIBERTY TEST Tier 3 PA; QL

MEIJER BLOOD GLUCOSE TEST Tier 3 PA; QL

MEIJER PREMIUM GLUCOSE TEST Tier 3 PA; QL

MICRODOT TEST Tier 3 PA; QL

MULTISTIX Tier 3

MULTISTIX 10 SG Tier 3

MULTISTIX 5 Tier 3

MULTISTIX 7 Tier 3

MULTISTIX 8 Tier 3

MULTISTIX 9 Tier 3




MULTISTIX 9 SG Tier 3

MYGLUCOHEALTH TEST Tier 3 PA; QL

NEUTEK 2TEK TEST Tier 3 PA; QL

NOVA MAX GLUCOSE TEST Tier 3 PA; QL

ON CALL PLUS BLOOD GLUCOSE Tier 3 PA; QL

ON CALL VIVID BLOOD GLUCOSE Tier 3 PA; QL

ONETOUCH ULTRA BLUE Tier 2 QL

ONETOUCH VERIO IN VITRO STRIP Tier 2 QL

PHARMACIST CHOICE AUTOCODE Tier 3 PA; QL

POCKETCHEM EZ TEST Tier 3 PA; QL

PRECISION PCX Tier 2 QL

PRECISION PCX PLUS TEST Tier 2 QL

PRECISION POINT OF CARE TEST Tier 2 QL

PRECISION QID TEST Tier 2 QL

PRECISION SOF-TACT TEST Tier 2 QL

PRECISION XTRA BLOOD GLUCOSE Tier 2 QL

PRODIGY NO CODING BLOOD GLUC Tier 3 PA; QL

RA TRUETEST TEST Tier 3 PA; QL

REFUAH PLUS BLOOD GLUCOSE TEST Tier 3 PA; QL

RELION KETONE Tier 3

REVEAL BLOOD GLUCOSE TEST Tier 3 PA; QL

REXALL BLOOD GLUCOSE TEST Tier 3 PA; QL

RIGHTEST GS100 BLOOD GLUCOSE Tier 3 PA; QL



SMARTEST BLOOD GLUCOSE TEST Tier 3 PA; QL

SOLUS V2 TEST Tier 3 PA; QL

SURE EDGE TEST Tier 3 PA; QL

SURECHEK BLOOD GLUCOSE TEST Tier 3 PA; QL

SURE-TEST EASYPLUS MINI TEST Tier 3 PA; QL

TELCARE BLOOD GLUCOSE TEST Tier 3 PA; QL

tgt blood glucose test Tier 3 PA; QL

TRUETEST TEST Tier 3 PA; QL

TRUETRACK TEST Tier 3 PA; QL

ULTIMA TEST Tier 3 PA; QL




ULTRATRAK PRO TEST Tier 3 PA; QL

ULTRATRAK ULTIMATE TEST Tier 3 PA; QL

URISTIX Tier 3

URISTIX 4 Tier 3

VICTORY AGM-4000 TEST Tier 3 PA; QL

VOCAL POINT BLOOD GLUCOSE TEST Tier 3 PA; QL

WAVESENSE PRESTO Tier 3 PA; QL

*Dietary Products/Dietary Management Products*

APPTRIM MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

APPTRIM-D MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

AVAILNEX MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

AXONA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

CARDIOTEK RX ORAL TABLET MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

CEREFOLIN MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

CEREFOLIN NAC MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

DEPLIN 15 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

DEPLIN 7.5 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

ENLYTE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3




ENTERAGAM MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOLBIC MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

FOLBIC RF MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOLTANX MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOLTANX RF MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOLTX ORAL TABLET 1.13-25-2 MG MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOSTEUM MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOSTEUM PLUS MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

FOVEX MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

GABADONE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

HYPERTENSA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

LIMBREL MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

LIMBREL250 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

LIMBREL500 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3




LIPICHOL 540 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

LISTER-V MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methylfolate MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

l-methylfolate ca me-cbl nac MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methylfolate calcium oral MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

l-methylfolate formula 15 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methylfolate formula 7.5 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methylfolate forte MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methylfolate-algae-b12-b6 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

l-methylfolate-b6-b12 MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

l-methyl-mc MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

l-methyl-mc nac MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

LUKAID GLA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

MACUTEK MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3




METAFOLBIC MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

METAFOLBIC PLUS MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

METAFOLBIC PLUS RF MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

METANX ORAL CAPSULE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

PERCURA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

PROTEOLIN DS MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

PROTEOLIN ORAL TABLET MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

PULMONA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

SENTRA AM MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

SENTRA PM MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

THERAMINE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

THERAMINE PLUS MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

TREPADONE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VASCAZEN MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3




VASCULERA MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VAYACOG MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VAYARIN MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VAYAROL MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

virt-vite forte MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 1

vp-gstn MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VSL#3 JUNIOR MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

VSL#3 ORAL PACKET MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; Tier 3

ZYTAZE MOnly covered in states: CT,DE, IN, KY, LA and TX and excluded elsewhere.; TIER 3

*Digestive Aids*

CREON Tier 3 PA; ST

PANCREAZE Tier 3 PA; ST

PERTZYE Tier 3 PA; ST

SUCRAID Tier 5 SP

VIOKACE Tier 3 PA; ST

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT

Tier 2

*Direct-Acting P2y12 Inhibitors***

BRILINTA Tier 3 ST; QL




*Diuretics*

acetazolamide er Tier 1

acetazolamide oral Tier 1

ALDACTAZIDE ORAL TABLET 50-50 MG Tier 3

amiloride hcl oral Tier 1

amiloride-hydrochlorothiazide Tier 1 LGC

bumetanide oral Tier 1

chlorothiazide oral Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

DIURIL Tier 3

DYRENIUM Tier 3

ethacrynic acid oral Tier 3

furosemide oral solution 10 mg/ml, 8 mg/ml Tier 3

furosemide oral tablet Tier 1 LGC

hydrochlorothiazide oral capsule Tier 1 LGC

hydrochlorothiazide oral tablet 12.5 mg Tier 1

hydrochlorothiazide oral tablet 25 mg, 50 mg Tier 1 LGC

indapamide oral Tier 1

methazolamide oral Tier 1

methyclothiazide oral Tier 3

metolazone Tier 1

spironolactone oral tablet 100 mg, 50 mg Tier 1

spironolactone oral tablet 25 mg Tier 1 LGC

spironolactone-hctz Tier 1

torsemide oral Tier 1

triamterene-hctz oral capsule 37.5-25 mg Tier 1 LGC

triamterene-hctz oral capsule 50-25 mg Tier 3

triamterene-hctz oral tablet Tier 1 LGC

*Endocrine And Metabolic Agents - Misc.*

ALDURAZYME Tier 5 PA; SP

alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

Tier 1 QL

BRAVELLE MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

BUPHENYL ORAL TABLET Tier 5 PA; SP




cabergoline Tier 1

calcitonin (salmon) Tier 3 ST; QL

calcitriol oral Tier 1

CARBAGLU Tier 5 PA; SP

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; Tier 5; SP

clomiphene citrate oral MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 3

CYSTADANE Tier 5 SP

desmopressin ace spray refrig Tier 1

desmopressin acetate oral Tier 1

desmopressin acetate spray Tier 1

doxercalciferol oral Tier 1 SP

ELAPRASE Tier 5 PA; SP

etidronate disodium Tier 3

FABRAZYME Tier 5 PA; SP

FOLLISTIM AQ INJECTION SOLUTION 75 UNT/0.5ML

M

ST; Only covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

FOLLISTIM AQ SUBCUTANEOUS M

ST; Only covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

Tier 5 PA; ST; SP

FOSAMAX PLUS D Tier 3 ST; QL

ganirelix acetate MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

GONAL-F MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

GONAL-F RFF MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP




GONAL-F RFF REDIJECT MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML

Tier 5 SP

ibandronate sodium oral Tier 3 PA; ST; QL

INCRELEX Tier 5 PA; SP

KUVAN ORAL PACKET 500 MG Tier 5 PA; SP

KUVAN ORAL TABLET SOLUBLE Tier 5 PA; SP

levocarnitine oral solution Tier 3

levocarnitine oral tablet Tier 3

LUMIZYME Tier 5 PA; SP

MENOPUR MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

MIACALCIN INJECTION Tier 3 ST

NAGLAZYME Tier 5 PA; SP

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 10000 UNIT

MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; Tier 5; SP

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

Tier 4 PA; SP

OMNITROPE SUBCUTANEOUS SOLUTION

Tier 4 PA; ST; SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

Tier 4 PA; SP

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

Tier 5 PA; SP

ORFADIN ORAL CAPSULE 20 MG Tier 5 PA

ORFADIN ORAL SUSPENSION Tier 5 PA; SP

OSPHENA Tier 3 PA; ST; QL

OVIDREL MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

pamidronate disodium Tier 4 PA; SP

paricalcitol oral Tier 1 SP; QL




PREGNYL MOnly covered in states: CT,IL, KS, NC, WV and WI and excluded elsewhere.; TIER 5; SP

PROLIA Tier 5 PA; ST; SP

raloxifene hcl CE

RAVICTI Tier 5 PA; SP; QL

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

Tier 3 ST; QL

risedronate sodium oral tablet delayed release Tier 3 ST; QL

SAMSCA ORAL TABLET 15 MG, 30 MG Tier 5 PA; SP; QL

SENSIPAR Tier 3 PA; #; SP

SIGNIFOR Tier 5 PA; SP; QL

sodium phenylbutyrate oral powder 3 gm/tsp Tier 5 PA; SP

SOMATULINE DEPOT Tier 5 PA; SP

SOMAVERT Tier 5 PA; SP

STIMATE Tier 5 PA

SYNAREL Tier 5 PA; SP

TRIPTODUR Tier 5 PA; SP

XGEVA Tier 5 PA; ST; SP

zoledronic acid intravenous concentrate Tier 4 PA; SP

zoledronic acid intravenous solution Tier 4 PA; SP

*Estrogens*

ANGELIQ Tier 3

CLIMARA PRO Tier 3 #; QL

COMBIPATCH Tier 3 QL

DIVIGEL Tier 3 QL

ELESTRIN Tier 3 QL

estradiol oral Tier 1 LGC

estradiol transdermal patch twice weekly Tier 1 QL

estradiol transdermal patch weekly Tier 1 QL

estradiol-norethindrone acet Tier 3 QL

ESTROGEL Tier 3 QL

estropipate oral Tier 1

EVAMIST Tier 3 QL

FEMHRT LOW DOSE Tier 3

jevantique lo Tier 3




jinteli Tier 3

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

Tier 3

MENOSTAR Tier 3 QL

mimvey Tier 3 QL

MIMVEY LO Tier 3 QL

PREFEST Tier 3 QL

PREMARIN ORAL Tier 3

PREMPHASE Tier 3

PREMPRO Tier 3

*Estrogen-Selective Estrogen Receptor Modulator Comb***

DUAVEE Tier 3 PA; ST; QL

*Fluoroquinolones*

ciprofloxacin hcl oral tablet 100 mg, 750 mg Tier 1

ciprofloxacin hcl oral tablet 250 mg, 500 mg Tier 1

ciprofloxacin oral Tier 1

ciprofloxacin-ciproflox hcl er Tier 3

FACTIVE Tier 3 #

levofloxacin oral tablet Tier 1

moxifloxacin hcl oral Tier 1

ofloxacin oral tablet 400 mg Tier 1

*Gastrointestinal Agents - Misc.*

alosetron hcl Tier 3 ST

AMITIZA Tier 3 ST; QL

APRISO Tier 2 QL

balsalazide disodium Tier 1 QL

calcium acetate (phos binder) oral tablet Tier 1

CANASA Tier 3 ST; QL

CHENODAL Tier 5 PA

CIMZIA PREFILLED Tier 5 PA; ST; SP; QL

CIMZIA STARTER KIT Tier 5 PA; ST; SP; QL

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG


cromolyn sodium oral Tier 3

DELZICOL Tier 3 ST; QL




DIPENTUM Tier 3 ST; QL

ENTEREG Tier 3

enulose Tier 1 LGC

FOSRENOL ORAL PACKET Tier 3

GATTEX Tier 5 PA; SP; QL

generlac Tier 1 LGC

GIAZO Tier 3 ST; #; QL

lactulose encephalopathy Tier 1 LGC

lanthanum carbonate Tier 3

LINZESS Tier 3 ST; QL

mesalamine oral tablet delayed release 1.2 gm, 800 mg

Tier 3 QL

mesalamine rectal Tier 1

mesalamine-cleanser Tier 1

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

Tier 1 LGC

metoclopramide hcl oral tablet 10 mg Tier 1 LGC

metoclopramide hcl oral tablet 5 mg Tier 1

metoclopramide hcl oral tablet dispersible Tier 1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

Tier 3 ST; QL

PHOSLYRA Tier 3

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

Tier 3 PA; QL

REMICADE Tier 4 PA

RENAGEL Tier 3 #

sevelamer carbonate Tier 3

sulfasalazine oral Tier 1 QL

sulfazine Tier 1 QL

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 3

VELPHORO Tier 3

*Genitourinary Agents - Miscellaneous*

acetic acid irrigation Tier 3

alfuzosin hcl er Tier 3 QL

CARDURA XL Tier 3 QL




CYSTAGON Tier 4 PA

cytra k crystals Tier 3

CYTRA-3 Tier 1

cytra-k Tier 3

dutasteride Tier 3 ST; QL

ELMIRON Tier 3

finasteride oral tablet 5 mg Tier 1

K-PHOS NO 2 Tier 3

LITHOSTAT Tier 3

neomycin-polymyxin b gu Tier 1

ORACIT Tier 3

PHENAZO ORAL TABLET 200 MG Tier 1

phenazopyridine hcl oral tablet 100 mg Tier 1 LGC

phenazopyridine hcl oral tablet 200 mg Tier 1

potassium citrate er Tier 1

potassium citrate-citric acid oral solution Tier 3

RAPAFLO Tier 3

sodium chloride irrigation solution 0.9 % Tier 1

sorbitol-mannitol Tier 3

tamsulosin hcl Tier 1

taron-crystals Tier 3

THIOLA Tier 5 PA; ST

tricitrates Tier 1

*Gout Agents*

allopurinol oral Tier 1 LGC

colchicine oral tablet Tier 3 QL

colchicine-probenecid Tier 1

probenecid oral Tier 1

ULORIC Tier 3 ST; QL

*Hematological Agents - Misc.*

ADVATE Tier 5 PA; SP

anagrelide hcl Tier 3

aspirin-dipyridamole er Tier 1

BERINERT Tier 5 PA; ST; SP

BRILINTA Tier 3 ST; QL




cilostazol Tier 3

clopidogrel bisulfate oral Tier 3 QL

dipyridamole oral Tier 1

HELIXATE FS Tier 5 PA; SP

KOGENATE FS Tier 5 PA; SP

KOGENATE FS BIO-SET Tier 5 PA; SP

pentoxifylline er Tier 1

prasugrel hcl Tier 3 PA; QL

*Hematopoietic Agents*

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 4 PA; SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

Tier 4 PA; SP

CERDELGA Tier 4 PA; SP; QL

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

Tier 4 PA; SP

cyanocobalamin injection Tier 3

DROXIA Tier 3

ELELYSO Tier 5 PA; ST; SP

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier 5 PA; SP

folic acid oral capsule 5 mg CE

folic acid oral tablet 1 mg Tier 1 LGC

folic acid oral tablet 400 mcg, 800 mcg CE

LEUKINE INTRAVENOUS Tier 5 PA; SP

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

Tier 5 PA

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML

Tier 5 PA; SP




MOZOBIL Tier 5 PA

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Tier 4 PA

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

Tier 5 PA; SP

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE

Tier 5 PA

NPLATE Tier 5 PA; SP

PROCRIT Tier 4 PA; SP

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG

Tier 5 PA; SP; QL

revesta Tier 3

VPRIV Tier 4 PA; SP

ZARXIO Tier 4 PA

ZAVESCA Tier 5 PA; ST; SP; QL

*Hemostatics*

AMICAR ORAL TABLET 1000 MG Tier 3

tranexamic acid oral Tier 3 QL

*Hepatitis C Agent - Combinations***

EPCLUSA Tier 4 PA; SP; QL

HARVONI Tier 4 PA; SP

MAVYRET Tier 5 PA; ST; SP; QL

TECHNIVIE Tier 5 PA; ST; QL

VIEKIRA PAK Tier 5 PA; ST; SP

VIEKIRA XR Tier 5 PA; ST; QL

VOSEVI Tier 5 PA; ST; SP; QL

ZEPATIER Tier 4 PA; SP; QL

*Hereditary Orotic Aciduria Treatment - Agents**

XURIDEN Tier 5 PA; SP; QL

*Hypnotics*

BUTISOL SODIUM ORAL TABLET 30 MG Tier 3

estazolam Tier 3

eszopiclone Tier 3 QL

flurazepam hcl Tier 1

HETLIOZ Tier 5 PA; SP

midazolam hcl oral Tier 3




phenobarbital oral Tier 1

quazepam Tier 3

ROZEREM Tier 3 PA; ST; QL

SECONAL Tier 3

temazepam oral capsule 15 mg, 30 mg Tier 1

temazepam oral capsule 22.5 mg, 7.5 mg Tier 1 QL

triazolam Tier 3

zaleplon Tier 1 QL

zolpidem tartrate er Tier 1 QL

zolpidem tartrate oral Tier 1 QL

*Interleukin Antagonists***

STELARA INTRAVENOUS Tier 4 PA; ST; SP

*Laxatives*

alophen CE

constulose Tier 1 LGC

gavilyte-c Tier 1

gavilyte-g Tier 1

GAVILYTE-H CE

gavilyte-n with flavor pack Tier 1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

Tier 1

KRISTALOSE Tier 3

lactulose oral Tier 1 LGC

MIRALAX CE

MOVIPREP CE

OSMOPREP CE

peg 3350 CE

peg 3350/electrolytes CE

peg 3350-kcl-na bicarb-nacl Tier 1

peg-3350/electrolytes Tier 1

PEG-PREP CE

polyethylene glycol 3350 oral CE

PREPOPIK CE

SMOOTH LAX ORAL PACKET CE

SUPREP BOWEL PREP KIT CE

trilyte CE




*Macrolides*

azithromycin oral packet Tier 1

azithromycin oral suspension reconstituted Tier 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Tier 1

clarithromycin er Tier 1

clarithromycin oral Tier 1

DIFICID Tier 3 PA; ST; QL

E.E.S. 400 ORAL TABLET Tier 1

E.E.S. GRANULES Tier 3

ERYPED 200 Tier 3

ERYPED 400 Tier 3

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 500 MG

Tier 2

ERY-TAB ORAL TABLET DELAYED RELEASE 333 MG

Tier 3

erythromycin base oral capsule delayed release particles

Tier 1

erythromycin base oral tablet Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

erythromycin stearate oral tablet 250 mg Tier 3

PCE Tier 3

ZMAX Tier 3

*Medical Devices*

1ST TIER UNIFINE PENTIPS Tier 3

1ST TIER UNIFINE PENTIPS PLUS 31G X 8 MM

Tier 3

1ST TIER UNILET COMFORTOUCH Tier 3

ACCU-CHEK FASTCLIX LANCETS Tier 3

ACCU-CHEK MULTICLIX LANCETS Tier 3

ACCU-CHEK SAFE-T PRO LANCETS Tier 3

ACCU-CHEK SOFT TOUCH LANCETS Tier 3

ACCU-CHEK SOFTCLIX LANCET DEV KIT

Tier 3 QL

ACCU-CHEK SOFTCLIX LANCETS Tier 3

ACTI-LANCE 28G Tier 3

ACTI-LANCE LITE LANCETS 28G Tier 3




ACTI-LANCE SPECIAL LANCETS 17G Tier 3

ACTI-LANCE UNIVERSAL 23G Tier 3

adjustable lancing device Tier 1

ADVOCATE DUO DEVICE Tier 3 PA; QL

ADVOCATE INSULIN PEN NEEDLES 31G X 5 MM , 31G X 8 MM

Tier 3

ADVOCATE INSULIN SYRINGE Tier 3

ADVOCATE LANCETS Tier 3

ADVOCATE RAPID-SAFE LANCING Tier 3

ADVOCATE SAFETY LANCETS Tier 3

AGAMATRIX ULTRA-THIN LANCETS Tier 3

alternate site lancing device Tier 1

anti-stick insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Tier 1

ASSURE COMFORT LANCETS 28G Tier 3

ASSURE COMFORT LANCETS 30G Tier 3

ASSURE HAEMOLANCE PLUS HIGH Tier 3

ASSURE HAEMOLANCE PLUS LOW Tier 3

ASSURE HAEMOLANCE PLUS MICRO Tier 3

ASSURE HAEMOLANCE PLUS NORMAL Tier 3

ASSURE HAEMOLANCE PLUS PED Tier 3

ASSURE ID INSULIN SAFETY SYR Tier 3

ASSURE LANCE LANCETS Tier 3

ASSURE LANCETS Tier 3

AURORA LANCET SUPER THIN 30G Tier 3

AURORA LANCET THIN 23G Tier 3

AURORA PEN NEEDLES Tier 3

AURORA UNIFINE PENTIPS Tier 3

BAYER MICROLET LANCETS Tier 3

BD AUTOSHIELD 29G X 5MM , 29G X 8MM

Tier 2

BD ECLIPSE SYRINGE 30G X 1/2" 1 ML Tier 2

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2




BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27G X 1/2" 1 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, U-100 1 ML

Tier 2

BD INSULIN SYRINGE HALF-UNIT Tier 2

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

Tier 2

BD INSULIN SYRINGE ULTRAFINE Tier 2

BD LANCET ULTRAFINE 30G Tier 2

BD LANCET ULTRAFINE 33G Tier 2

BD MICROTAINER LANCETS Tier 2

BD PEN NEEDLE MINI U/F Tier 2

BD PEN NEEDLE NANO U/F Tier 2

BD PEN NEEDLE SHORT U/F Tier 2

BD PEN NEEDLE ULTRAFINE Tier 2

BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML

Tier 2

BD SAFETYGLIDE SYRINGE/NEEDLE 27G X 5/8" 1 ML

Tier 2

BD SAFETY-LOK INSULIN SYRINGE Tier 2

BULLSEYE MINI SAFETY LANCETS Tier 3

CAREFINE PEN NEEDLES 31G X 6 MM Tier 3

CAREONE LANCET THIN 23G Tier 3

CAREONE LANCET ULTRA THIN 28G Tier 3

CAREONE UNIFINE PENTIPS Tier 3

CLEVER CHEK AUTO-CODE Tier 3 PA; QL

CLEVER CHEK LANCETS Tier 3

CLICKFINE PEN NEEDLES 31G X 6 MM , 31G X 8 MM

Tier 3

COMFORT ASSURED LANCETS 28G Tier 3

COMFORT ASSURED LANCETS 33G Tier 3

COMFORT EZ INSULIN SYRINGE Tier 3

COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM

Tier 3

COMFORT LANCETS Tier 3

CVS LANCETS 21G Tier 3

CVS LANCETS MICRO THIN 33G Tier 3




CVS LANCETS ORIGINAL Tier 3

CVS LANCETS THIN 26G Tier 3

CVS LANCETS ULTRA THIN 30G Tier 3

CVS ULTRA THIN LANCETS Tier 3

DIASCREEN 10 Tier 3

DIASCREEN 1B Tier 3

DIASCREEN 1K Tier 3

DIASCREEN 2GK Tier 3

DIASCREEN 2GP Tier 3

DIASCREEN 3 Tier 3

DIASCREEN 4NL Tier 3

DIASCREEN 4OBL Tier 3

DIASCREEN 4PH Tier 3

DIASCREEN 5 Tier 3

DIASCREEN 6 Tier 3

DIASCREEN 7 Tier 3

DIASCREEN 8 Tier 3

DIASCREEN 9 Tier 3

DROPLET LANCETS ULTRA THIN 30G Tier 3

DRUG MART LANCETS THIN 26G Tier 3

DRUG MART UNIFINE PENTIPS Tier 3

DRUG MART UNILET LANCETS 28G Tier 3

DRUG MART UNILET LANCETS 30G Tier 3

EASY COMFORT INSULIN SYRINGE 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 3

EASY COMFORT LANCETS Tier 3

EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML

Tier 3

EASY TOUCH INSULIN SYRINGE Tier 3

EASY TOUCH LANCETS 21G Tier 3




EASY TOUCH LANCETS 28G/TWIST Tier 3









EASY TOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 5 MM , 32G X 6 MM

Tier 3

EASY TOUCH SAFETY LANCETS 21G Tier 3




EASY TWIST & CAP LANCETS Tier 3

elite-thin insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml

Tier 3

EQL COLOR LANCETS 21G Tier 3

EQL COLOR LANCETS MICRO 33G Tier 3

EQL INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML

Tier 3

eql insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml

Tier 3

EQL SUPER THIN LANCETS 30G Tier 3

EQL THIN LANCETS 26G Tier 3

EXEL COMFORT POINT INSULIN SYR Tier 3

E-Z JECT LANCET MICRO-THIN 33G Tier 3

E-Z JECT LANCET SUPER THIN 30G Tier 3

E-Z JECT LANCETS Tier 3

E-Z JECT LANCETS 21G Tier 3

E-Z JECT LANCETS THIN 26G Tier 3

EZ SMART BLOOD GLUCOSE LANCETS Tier 3

FC FEMALE CONDOM CE

FEMCAP CE

FIFTY50 PEN NEEDLES 31G X 5 MM Tier 3

FIFTY50 SAFETY SEAL LANCETS Tier 3

FIFTY50 SUPERIOR COMFORT SYR Tier 3

FINE 30 Tier 3




FINGERSTIX LANCETS Tier 3

FORA D10 2-IN-1 MONITOR Tier 3 PA; QL

FORA D15G 2-IN-1 MONITOR Tier 3 PA; QL

FORA D20 2-IN-1 MONITOR Tier 3 PA; QL

FORA LANCETS Tier 3

FREESTYLE LANCETS Tier 3

FREESTYLE PRECISION INS SYR Tier 3

FREESTYLE UNISTICK II LANCETS Tier 3

GLOBAL EASE INJECT PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 8 MM

Tier 3

GLOBAL INJECT EASE INSULIN SYR Tier 3

GLOBAL INJECT EASE LANCETS 28G Tier 3

GLOBAL INJECT EASE LANCETS 30G Tier 3

GLUCOCOM LANCETS 28G Tier 3



GLUCOPRO INSULIN SYRINGE Tier 3

GNP CLICKFINE PEN NEEDLES Tier 3

GNP INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 3

gnp insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 3

GNP LANCETS Tier 3

GNP LANCETS 21G Tier 3

GNP LANCETS MICRO THIN 33G Tier 3

GNP LANCETS SUPER THIN 30G Tier 3

GNP LANCETS THIN Tier 3

GNP LANCETS THIN 26G Tier 3

GNP MICRO THIN LANCETS 33G Tier 3

GNP SUPER THIN LANCETS 30G Tier 3

GNP ULTRA COM INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 3




gnp ultra com insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 3

GUARDIAN REAL-TIME SYSTEM PED Tier 3 PA

HAEMOLANCE Tier 3

HAEMOLANCE LOW FLOW LANCETS Tier 3

HAEMOLANCE PLUS Tier 3

HAEMOLANCE PLUS HIGH FLOW Tier 3

HAEMOLANCE PLUS LOW FLOW Tier 3

HAEMOLANCE PLUS MAX FLOW Tier 3

HAEMOLANCE PLUS PEDIATRIC FLOW Tier 3

HEALTHWISE MINI PEN NEEDLES Tier 3

HEALTHWISE PEN NEEDLES Tier 3

HEALTHWISE SHORT PEN NEEDLES Tier 3

HEALTHWISE UNIFINE PENTIPS Tier 3

HEALTHY ACCENTS UNIFINE PENTIP 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM

Tier 3

HEALTHY ACCENTS UNILET LANCETS Tier 3

H-E-B INCONTROL LANCETS 28G Tier 3

H-E-B INCONTROL LANCETS 30G Tier 3

H-E-B INCONTROL PEN NEEDLES Tier 3

HY-VEE LANCETS Tier 3

hy-vee thin lancets Tier 3

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 1

insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 1 ml

Tier 1

INSUPEN PEN NEEDLES 32G X 4 MM Tier 3

INSUPEN SENSITIVE Tier 3

INSUPEN ULTRAFIN Tier 3

KINNEY LANCETS Tier 3

KINNEY THIN LANCETS Tier 3

kinray insulin syringe Tier 3

KMART VALU INSULIN SYRINGE 29G Tier 3




KMART VALU INSULIN SYRINGE 30G Tier 3

KROGER INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 3

kroger insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 3

kroger lancets Tier 3

KROGER LANCETS 21G Tier 3

KROGER LANCETS MICRO THIN 33G Tier 3

kroger lancets thin Tier 3

KROGER LANCETS THIN 26G Tier 3

KROGER LANCETS ULTRATHIN 30G Tier 3

KROGER PEN NEEDLES Tier 3

lancet device Tier 1

lancet transporter case Tier 1

lancets Tier 1

lancets 28g Tier 1

lancets 30g Tier 1

lancets thin Tier 1

LANCETS ULTRA FINE Tier 3

LANCETS ULTRA THIN Tier 3

LANCETS ULTRA THIN 30G Tier 3

lancing device Tier 1

LEADER INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 1 ML

Tier 3

leader insulin syringe 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 3

LEADER UNIFINE PENTIPS Tier 3

LITE TOUCH LANCETS Tier 3

LITE TOUCH PEN NEEDLES Tier 3

LITETOUCH INSULIN SYRINGE Tier 3

LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 8 MM

Tier 3

LIVE BETTER LANCET SUPER THIN Tier 3




LIVE BETTER LANCET ULTRA THIN Tier 3

longs insulin syringe 31g x 5/16" 0.5 ml Tier 3

LONGS LANCETS STANDARD Tier 3

LONGS LANCETS THIN Tier 3

LONGS LANCETS ULTRA THIN Tier 3

MAGELLAN INSULIN SAFETY SYR Tier 3

MAXI-COMFORT INSULIN SYRINGE Tier 3

MEDICINE SHOPPE PEN NEEDLES Tier 3

MEDISENSE THIN LANCETS Tier 3

MEDLANCE EXTRA 21G Tier 3

MEDLANCE LITE 25G Tier 3

MEDLANCE PLUS EXTRA 21G Tier 3

MEDLANCE PLUS LANCETS Tier 3

MEDLANCE PLUS LITE 25G Tier 3

MEDLANCE PLUS SUPERLITE 30G Tier 3

MEDLANCE PLUS UNIVERSAL 21G Tier 3

MEDLANCE UNIVERSAL 21G Tier 3

MEIJER LANCETS Tier 3

MEIJER LANCETS THIN Tier 3

MEIJER LANCETS UNIVERSAL 21G Tier 3

MEIJER LANCETS UNIVERSAL 33G Tier 3

MEIJER PEN NEEDLES Tier 3

MEIJER SUPER THIN LANCETS Tier 3

MICROLET LANCETS Tier 3

MONOJECT INSULIN SYRINGE Tier 3

MONOJECT SYRINGE 20G X 1" 3 ML, 21G X 1" 3 ML, 21G X 1-1/2" 3 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 3

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML

Tier 3

MONOLET LANCETS Tier 3

ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 3




multi-lancet device Tier 1

MYGLUCOHEALTH LANCETS 30G Tier 3

NEUTEK 2TEK GLUCOSE/PRESSURE Tier 3 PA; QL

NOVA SAFETY LANCETS 23G Tier 3

NOVA SAFETY LANCETS 28G Tier 3

NOVA SUREFLEX LANCETS Tier 3

NOVOFINE Tier 3

NOVOFINE AUTOCOVER Tier 3

NOVOTWIST 32G X 5 MM Tier 3

ON CALL LANCETS Tier 3

ON CALL PLUS LANCETS Tier 3

ONETOUCH CLUB LANCETS FINE PT Tier 3

ONETOUCH DELICA LANCETS 33G Tier 3

ONETOUCH DELICA LANCETS FINE Tier 3

ONETOUCH DELICA LANCING DEV Tier 3

ONETOUCH FINEPOINT LANCETS Tier 3

ONETOUCH LANCETS Tier 3

ONETOUCH SURESOFT LANCING DEV Tier 3

ONETOUCH ULTRASOFT LANCETS Tier 3

PC LANCETS SUPER THIN 30G Tier 3

PC UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM

Tier 3

pen needles 1/2" Tier 1

pen needles 29g x 12mm , 31g x 6 mm Tier 1



PHARMACIST CHOICE LANCETS Tier 3

PRECISION SUREDOSE PLUS SYR Tier 2

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML

Tier 2

PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML, 30G X 5/16" 0.3 ML

Tier 3

PRECISION THIN LANCETS Tier 3

PRECISION ULTRA LANCET Tier 3

PREFERRED PLUS INSULIN SYRINGE Tier 3




PREFERRED PLUS LANCETS COLORED Tier 3

PREFERRED PLUS LANCETS THIN Tier 3

PREFERRED PLUS UNIFINE PENTIPS Tier 3

PRODIGY INSULIN SYRINGE Tier 3

PRODIGY LANCETS 28G Tier 3

PRODIGY TWIST TOP LANCETS 28G Tier 3

PX EXTRA SHORT PEN NEEDLES Tier 3

PX INSULIN SYRINGE 30G X 1/2" 0.5 ML Tier 3

PX LANCETS ULTRA THIN Tier 3

PX PEN NEEDLE 29G X 12MM Tier 3

QC LANCETS SUPER THIN 30G Tier 3

QC LANCETS ULTRA THIN Tier 3

QC PEN NEEDLES Tier 3

QC UNIFINE PENTIPS Tier 3

RA E-ZJECT LANCETS 28G Tier 3

RA E-ZJECT LANCETS THIN 26G Tier 3

RA E-ZJECT LANCETS THIN 28G Tier 3

RA E-ZJECT LANCETS ULTRA THIN Tier 3

RA INSULIN SYRINGE Tier 3

RA PEN NEEDLES Tier 3

reality insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Tier 3

RELI-ON INSULIN SYRINGE Tier 3

RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 3

RELION LANCETS STANDARD 21G Tier 3

RELION LANCETS THIN 26G Tier 3

RELION LANCETS ULTRA-THIN 30G Tier 3

RELION MINI PEN NEEDLES Tier 3

RELION PEN NEEDLES 29G X 12MM , 31G X 8 MM , 32G X 4 MM

Tier 3

RELION SHORT PEN NEEDLES Tier 3

RELION ULTRA THIN LANCETS 30G Tier 3

RELION ULTRA THIN PLUS LANCETS Tier 3




REXALL LANCETS ULTRA THIN 30G Tier 3

RIGHTEST GL300 LANCETS Tier 3

SAFESNAP INSULIN SYRINGE Tier 3

safety lancet 21g/pressure act Tier 1

safety lancet 28g/pressure act Tier 1

SAFETY LANCETS Tier 3

SAFETY LANCETS 21G Tier 3

safety lancets 28g Tier 1

SAFETY LET LANCETS Tier 3

SAFETY SEAL LANCETS Tier 3

SAFETY-GLIDE SYRINGE Tier 2

SB INSULIN SYRINGE Tier 3

SB LANCETS THIN Tier 3

SB LANCETS ULTRA THIN Tier 3

SHOPKO UNIFINE PENTIPS Tier 3

SHOPKO UNILET LANCETS 28G Tier 3

SHOPKO UNILET LANCETS 30G Tier 3

SINGLE-LET Tier 3

sm insulin syringe 31g x 5/16" 1 ml Tier 3

SM LANCETS 33G Tier 3

SMART SENSE COLOR LANCETS 33G Tier 3

SMART SENSE STANDARD LANCETS Tier 3

SMART SENSE SUPER THIN LANCETS Tier 3

SMART SENSE THIN LANCETS 26G Tier 3

SMARTEST LANCETS 28G Tier 3

SOLUS V2 LANCETS 28G Tier 3

SOLUS V2 TWIST LANCETS 30G Tier 3

STERILANCE PA Tier 3

STERILANCE TL Tier 3

SUPER THIN LANCETS Tier 3




SURE COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 3

SURE COMFORT LANCETS 28G Tier 3

SURE COMFORT LANCETS 30G Tier 3

SURE COMFORT PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM

Tier 3

SURE-FINE PEN NEEDLES Tier 3

SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 3

SURE-LANCE FLAT LANCETS Tier 3

SURE-LANCE THIN LANCETS 28G Tier 3

SURE-LANCE ULTRA THIN LANCETS Tier 3

SURESTEP PRO LINEARITY Tier 3 PA

SURE-TOUCH LANCETS UNIVERSAL Tier 3

TECHLITE AST LANCETS Tier 3

TECHLITE LANCETS Tier 3

TECHLITE LANCETS 30G Tier 3

TGT LANCET MICRO THIN 33G Tier 3

TGT LANCET THIN 26G Tier 3

TGT LANCET ULTRA THIN 30G Tier 3

THINLETS LANCET Tier 3

TODAYS HEALTH MINI PEN NEEDLES Tier 3

TODAYS HEALTH PEN NEEDLES Tier 3

TODAYS HEALTH THIN LANCETS 28G Tier 3

TODAYS HEALTH THIN LANCETS 30G Tier 3

TOPCARE CLICKFINE PEN NEEDLES Tier 3

TOPCARE ULTRA COMFORT INS SYR Tier 3

TRUEPLUS INSULIN SYRINGE Tier 3

TRUEPLUS LANCETS 28G Tier 3






TRUEPLUS SAFETY LANCETS 28G Tier 3

ULTICARE INSULIN SAFETY SYR Tier 3

ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 3

ULTICARE MICRO PEN NEEDLES 32G X 4 MM

Tier 3

ULTICARE MINI PEN NEEDLES Tier 3

ULTICARE PEN NEEDLES 29G X 12.7MM , 29G X 12MM

Tier 3

ULTICARE SHORT PEN NEEDLES Tier 3

ULTILET CLASSIC LANCETS Tier 3

ULTILET LANCETS Tier 3

ULTILET SAFETY LANCETS 23G Tier 3

ULTRA COMFORT INSULIN SYRINGE 30G X 5/16" 0.3 ML

Tier 3

ULTRA-COMFORT INSULIN SYRINGE Tier 3

ULTRALANCE Tier 3

ULTRA-THIN II AUTO LANCET Tier 3

ULTRA-THIN II INS SYR SHORT Tier 3

ULTRA-THIN II INSULIN SYRINGE Tier 3

ULTRA-THIN II LANCETS Tier 3

ULTRA-THIN II MINI PEN NEEDLE Tier 3

ULTRA-THIN II PEN NEEDLE SHORT Tier 3

ULTRA-THIN II PEN NEEDLES Tier 3

UNIFINE PENTIPS Tier 3

UNILET COMFORTOUCH LANCET Tier 3

UNILET EXCELITE Tier 3

UNILET EXCELITE II Tier 3

UNILET G.P. LANCET Tier 3

UNILET G.P. SUPERLITE LANCET Tier 3




UNILET GP 28 ULTRA THIN Tier 3

UNILET LANCET Tier 3

UNILET SUPERLITE LANCET Tier 3

UNISTIK 3 COMFORT Tier 3

UNISTIK 3 EXTRA Tier 3

UNISTIK 3 NORMAL Tier 3

UNISTIK CZT COMFORT Tier 3

UNISTIK CZT NORMAL Tier 3

UNIVERSAL 1 LANCETS THIN 26G Tier 3

UNIVERSAL 1 LANCETS ULTRA THIN Tier 3

VALUE HEALTH INSULIN SYRINGE Tier 3

VALUE PLUS LANCET STANDARD 21G Tier 3

VALUE PLUS LANCETS SUPER THIN Tier 3

VALUE PLUS LANCETS THIN 26G Tier 3

VALUMARK LANCET SUPER THIN 30G Tier 3

VALUMARK LANCET ULTRA THIN 28G Tier 3

VALUMARK PEN NEEDLES Tier 3

VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML

Tier 3

VANISHPOINT SAFETY SYRINGE 20G X 1" 3 ML, 21G X 1" 3 ML, 21G X 1" 5 ML, 21G X 1-1/2" 3 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 22G X 1-1/2" 5 ML, 23G X 1" 3 ML, 23G X 1-1/2" 3 ML, 25G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 3

VANISHPOINT SYRINGE 25G X 1" 1 ML Tier 3

VANISHPOINT TUBERCULIN SYRINGE 25G X 5/8" 1 ML

Tier 3

VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 MM , 31G X 8 MM

Tier 3

VIDA MIA UNILET LANCETS 28G Tier 3

VIDA MIA UNILET LANCETS 30G Tier 3

VP INSULIN SYRINGE Tier 3

W&F LANCETS 26G Tier 3

W&F LANCETS COLORED 21G Tier 3

WALGREENS ADV TRAVEL LANCETS Tier 3

WALGREENS LANCETS Tier 3




WALGREENS LANCETS MICRO THIN Tier 3

WALGREENS LANCETS SUPER THIN Tier 3

WALGREENS THIN LANCETS Tier 3

WALGREENS ULTRA THIN LANCETS Tier 3

WEGMANS UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X 6 MM , 31G X 8 MM

Tier 3

WIDE-SEAL DIAPHRAGM 60 CE QL








*Migraine Products*

almotriptan malate Tier 3 ST; QL

CAFERGOT Tier 3

dihydroergotamine mesylate injection Tier 3

eletriptan hydrobromide Tier 3 ST; QL

ERGOMAR Tier 3

frovatriptan succinate Tier 3 ST; QL

MIGERGOT Tier 3

naratriptan hcl Tier 1 QL

rizatriptan benzoate Tier 1 QL

sumatriptan nasal Tier 1 QL

sumatriptan succinate oral Tier 1 QL

sumatriptan succinate refill subcutaneous solution cartridge

Tier 3 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

Tier 3 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

Tier 3 QL

zolmitriptan oral tablet Tier 3 ST; QL

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Tier 3 ST; QL

ZOMIG NASAL SOLUTION 5 MG Tier 3 ST; QL




*Minerals & Electrolytes*

bd posiflush intravenous Tier 1

calcium chloride Tier 3

calcium gluconate intravenous Tier 1

chromic chloride intravenous Tier 3

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

effer-k oral tablet effervescent 25 meq Tier 3

effervescent pot chloride Tier 1

FLUORABON CE

FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG

CE

fluoritab oral solution CE

fluoritab oral tablet chewable 0.55 (0.25 f) mg Tier 1 LGC

fluoritab oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

CE

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

CE

GALZIN Tier 3

ISOLYTE-S Tier 3

ISOLYTE-S PH 7.4 Tier 3

k-effervescent Tier 3

KLOR-CON 10 Tier 1

KLOR-CON M10 Tier 1

klor-con m20 Tier 1

KLOR-CON ORAL TABLET EXTENDED RELEASE

Tier 1

K-PHOS Tier 3

k-prime Tier 3

k-vescent oral tablet effervescent Tier 3

ludent oral tablet chewable 0.55 (0.25 f) mg Tier 1 LGC

ludent oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

CE

magnesium chloride injection Tier 3

magnesium sulfate injection solution 50 % Tier 3

manganese chloride intravenous Tier 3

monoject flush syringe intravenous Tier 1




monoject sodium chloride flush intravenous Tier 1

NAFRINSE CE

normal saline flush intravenous Tier 1

NORMOSOL-R Tier 3

NORMOSOL-R PH 7.4 Tier 3

phospha 250 neutral Tier 3

PLASMA-LYTE 148 Tier 3

PLASMA-LYTE A Tier 3

pot bicarb-pot chloride Tier 1

potassium acetate intravenous Tier 3

potassium bicarbonate oral Tier 3

potassium chloride crys er Tier 1

potassium chloride er Tier 1

potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/100ml

Tier 1

potassium chloride oral packet Tier 3

potassium chloride oral solution 20 meq/15ml (10%)

Tier 3

potassium phosphates Tier 3

saline flush intravenous Tier 1

saline flush zr Tier 1

sodium chloride flush Tier 1

sodium chloride injection Tier 1

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 4 meq/ml, 5 %

Tier 1

sodium fluoride oral solution CE

sodium fluoride oral tablet CE

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg

Tier 1 LGC

sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

CE

SSKI Tier 3

swabflush saline flush Tier 1

virt-phos 250 neutral Tier 3

zinc sulfate intravenous solution 5 mg/ml Tier 3

zinc sulfate oral capsule Tier 3




zinc-220 Tier 3

*Mouth/Throat/Dental Agents*

cavarest Tier 3

cevimeline hcl Tier 3 QL

chlorhexidine gluconate mouth/throat Tier 3

clinpro 5000 Tier 3

clotrimazole mouth/throat Tier 1

DEBACTEROL Tier 3

denta 5000 plus Tier 3

dentagel Tier 3

GELCLAIR Tier 3

lidocaine viscous Tier 3

neutragard advanced Tier 3

neutral sodium fluoride Tier 1

nystatin mouth/throat Tier 1

oralone Tier 1

ORAMAGICRX Tier 3

ORAVIG Tier 3 ST; QL

paroex Tier 3

periogard Tier 3

pilocarpine hcl oral Tier 1

sf Tier 3

sf 5000 plus Tier 3

triamcinolone acetonide mouth/throat Tier 1

*Multivitamins*

BAL-CARE DHA Tier 1

bp folinatal plus b Tier 1

CITRANATAL 90 DHA ORAL 90-1 & 300 MG

Tier 3

CITRANATAL ASSURE ORAL 35-1 & 300 MG

Tier 3

CITRANATAL B-CALM Tier 3

CITRANATAL RX Tier 3

co-natal fa Tier 1

CONCEPT DHA Tier 3

CONCEPT OB Tier 3




elite-ob Tier 1

FOLCAL DHA ORAL CAPSULE 27-1.25-300 MG

Tier 1

FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG

Tier 1

FOLIVANE-OB Tier 1

inatal advance Tier 1

inatal ultra oral tablet Tier 1

LEVOMEFOLATE DHA Tier 3

MARNATAL-F Tier 3

multi-vit/fluoride oral solution Tier 1

multi-vitamin/fluoride oral solution 0.25 mg/ml Tier 1

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

Tier 1

m-vit Tier 3

mynatal advance Tier 1

mynatal oral tablet Tier 1

mynatal plus Tier 1

mynatal-z Tier 1

NATACHEW ORAL TABLET CHEWABLE 28-1 MG

Tier 3

NATALVIT Tier 3

NATELLE ONE ORAL CAPSULE 28-1-250 MG

Tier 3

NESTABS Tier 3

NESTABS DHA Tier 3

NEXA PLUS Tier 3

OB COMPLETE ONE Tier 3

OB COMPLETE ORAL TABLET Tier 3

OB COMPLETE PREMIER Tier 3

OB COMPLETE/DHA Tier 3

obstetrix ec Tier 1

O-CAL FA Tier 3

O-CAL PRENATAL Tier 3

OCUVEL ORAL CAPSULE 0.5 MG Tier 3

PNV FOLIC ACID + IRON Tier 3

pnv-dha Tier 3




PNV-DHA+DOCUSATE Tier 1

PNV-OMEGA Tier 3

pnv-select Tier 1

PNV-TOTAL Tier 1

POLY-VI-FLOR Tier 3

pr natal 400 Tier 1

pr natal 430 Tier 3

pr natal 430 ec Tier 3

PREFERAOB ONE Tier 3

PRENAISSANCE Tier 3

PRENAISSANCE BALANCE Tier 3

PRENAISSANCE HARMONY DHA Tier 3

PRENAISSANCE NEXT Tier 3

PRENAISSANCE PLUS Tier 3

PRENATA Tier 3

prenatabs rx Tier 1

prenatal 19 oral tablet Tier 1

prenatal 19 oral tablet chewable Tier 1

prenatal low iron oral tablet 27-1 mg Tier 1

PRENATAL PLUS IRON Tier 3

PRENATAL-U Tier 1

PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300 MG

Tier 3

PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG

Tier 3

PRENATE ESSENTIAL ORAL CAPSULE 29-0.6-0.4-340 MG

Tier 3

PRENATE MINI ORAL CAPSULE 29-0.6-0.4-350 MG

Tier 3

RELNATE DHA Tier 1

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

Tier 3

se-natal 19 Tier 1

TARON-BC Tier 3

TARON-C DHA Tier 1

TARON-PREX Tier 1

TL-SELECT Tier 3




tricare Tier 3

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

Tier 3

trinatal rx 1 Tier 1

TRINATE Tier 1

TRIVEEN-DUO DHA Tier 3

TRI-VI-FLOR Tier 3

TRI-VI-FLORO Tier 3

ultimatecare one Tier 1

VEMAVITE-PRX 2 Tier 1

VENA-BAL DHA Tier 1

vinate ii Tier 1

VINATE M Tier 1

vinate one Tier 1

VIRT-PN Tier 1

VIRT-PN DHA Tier 3

VIRT-SELECT Tier 3

VITAFOL-OB Tier 1

VITAFOL-OB+DHA Tier 3

VITAFOL-ONE Tier 3

VITAMEDMD ONE RX/QUATREFOLIC Tier 3

VIVA DHA Tier 3

VOL-NATE Tier 1

VOL-PLUS Tier 1

VOL-TAB RX Tier 1

VP-CH-PNV Tier 3

VP-GGR-B6 PRENATAL Tier 3

VP-PNV-DHA Tier 3

ZATEAN-PN DHA Tier 3

ZATEAN-PN PLUS Tier 3

*Musculoskeletal Therapy Agents*

baclofen oral tablet 10 mg Tier 1 LGC

baclofen oral tablet 20 mg Tier 1

carisoprodol oral tablet 350 mg Tier 3

carisoprodol-aspirin Tier 3

carisoprodol-aspirin-codeine Tier 3




chlorzoxazone oral tablet 500 mg Tier 3

cyclobenzaprine hcl oral tablet 10 mg, 5 mg Tier 1 LGC

cyclobenzaprine hcl oral tablet 7.5 mg Tier 3

dantrolene sodium oral Tier 3

LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/20ML, 10 MG/5ML

Tier 5

metaxalone Tier 3

methocarbamol oral Tier 1

orphenadrine citrate er Tier 3

revonto Tier 5

tizanidine hcl oral tablet Tier 1

*Nasal Agents - Systemic And Topical*

ADRENALIN NASAL Tier 3

azelastine hcl nasal solution 0.1 %, 0.15 % Tier 1

BACTROBAN NASAL Tier 3

BECONASE AQ Tier 3 ST

budesonide nasal Tier 3

flunisolide nasal solution 25 mcg/act (0.025%) Tier 1

fluticasone propionate nasal Tier 1 QL

ipratropium bromide nasal Tier 3 QL

mometasone furoate nasal Tier 3

olopatadine hcl nasal Tier 3

OMNARIS Tier 3 ST

QNASL Tier 3 ST

QNASL CHILDRENS Tier 3 ST

triamcinolone acetonide nasal aerosol Tier 3 ST; QL

ZETONNA Tier 3 ST

*Neuromuscular Agents*

BOTOX Tier 5 PA; ST; SP

MYOBLOC Tier 5 PA

riluzole Tier 1

XEOMIN Tier 5 PA; SP

*Nutrients*

g-levocarnitine s/f Tier 3

levocarnitine (dietary) Tier 3




*Ophthalmic Agents*

ACUVAIL Tier 3

AKTEN Tier 3

alaway Tier 1 LGC

ALOCRIL Tier 3

ALOMIDE Tier 3

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

Tier 3

ALREX Tier 3

altacaine Tier 3

altafluor Tier 3

altafrin ophthalmic solution 10 %, 2.5 % Tier 3

apraclonidine hcl Tier 1

atropine sulfate ophthalmic ointment Tier 1

AZASITE Tier 3

azelastine hcl ophthalmic Tier 1

AZOPT Tier 3

bacitracin ophthalmic Tier 3

bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm

Tier 1

bacitra-neomycin-polymyxin-hc Tier 1

balanced salt intraocular Tier 3

BEPREVE Tier 3

BESIVANCE Tier 3

BETADINE OPHTHALMIC PREP Tier 3

betaxolol hcl ophthalmic Tier 1

BETIMOL Tier 3

BETOPTIC-S Tier 3

bimatoprost ophthalmic Tier 3 PA; ST

bio glo Tier 3

BLEPHAMIDE Tier 3

BLEPHAMIDE S.O.P. Tier 3

brimonidine tartrate ophthalmic Tier 3

bromfenac sodium (once-daily) Tier 3

bss Tier 3

carteolol hcl Tier 3




CILOXAN OPHTHALMIC OINTMENT Tier 3

ciprofloxacin hcl ophthalmic Tier 1

COMBIGAN Tier 3

COSOPT PF Tier 3 ST; #

cromolyn sodium ophthalmic Tier 1

CYCLOMYDRIL Tier 3

cyclopentolate hcl ophthalmic solution 0.5 % Tier 3

cyclopentolate hcl ophthalmic solution 1 %, 2 % Tier 1

CYSTARAN Tier 5 PA; SP; QL

dexamethasone sodium phosphate ophthalmic Tier 1

diclofenac sodium ophthalmic Tier 1

dorzolamide hcl ophthalmic Tier 1

dorzolamide hcl-timolol mal Tier 1

DUREZOL Tier 3

EMADINE Tier 3

epinastine hcl Tier 1

erythromycin ophthalmic Tier 1

FLAREX Tier 3

flucaine Tier 3

fluorescein-benoxinate Tier 3

fluor-i-strips a.t. Tier 3

fluorometholone ophthalmic Tier 3

flurbiprofen sodium Tier 1

flurox Tier 3

FML Tier 3

FML FORTE Tier 3

ful-glo ophthalmic strip 1 mg Tier 3

gatifloxacin ophthalmic Tier 3

gentak ophthalmic ointment Tier 1

gentamicin sulfate ophthalmic solution Tier 1

homatropaire Tier 3

homatropine hbr ophthalmic Tier 3

IOPIDINE OPHTHALMIC SOLUTION 1 % Tier 3

ISTALOL Tier 3

ketorolac tromethamine ophthalmic Tier 1




ketotifen fumarate ophthalmic Tier 1 LGC

LACRISERT Tier 3

LASTACAFT Tier 3

latanoprost ophthalmic Tier 1

levobunolol hcl ophthalmic solution 0.5 % Tier 1

levofloxacin ophthalmic Tier 3

LOTEMAX Tier 3

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

Tier 3 ST

MAXIDEX Tier 3

metipranolol Tier 3

MITOSOL Tier 3

MOXEZA Tier 3

moxifloxacin hcl ophthalmic Tier 3

NATACYN Tier 3

neomycin-bacitracin zn-polymyx Tier 1

neomycin-polymyxin-dexameth ophthalmic ointment

Tier 1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Tier 1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Tier 1

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Tier 3

neo-polycin Tier 1

neo-polycin hc Tier 1

NEVANAC Tier 3

ofloxacin ophthalmic Tier 1

olopatadine hcl ophthalmic Tier 1

PAREMYD Tier 3

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

Tier 3

PHOSPHOLINE IODIDE Tier 3

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Tier 3

polycin Tier 1

polymyxin b-trimethoprim Tier 1




PRED MILD Tier 3

PRED-G Tier 3

PRED-G S.O.P. Tier 3

prednisolone acetate ophthalmic Tier 1

prednisolone sodium phosphate ophthalmic Tier 1

proparacaine hcl ophthalmic Tier 1

proparacaine-fluorescein Tier 3

RESCULA Tier 3 ST

RESTASIS Tier 3

SIMBRINZA Tier 3

sulfacetamide sodium ophthalmic Tier 1

sulfacetamide-prednisolone ophthalmic solution Tier 1

tetcaine Tier 3

tetracaine hcl ophthalmic Tier 3

timolol maleate ophthalmic gel forming solution Tier 3

timolol maleate ophthalmic solution Tier 1

TIMOPTIC OCUDOSE Tier 3

TOBRADEX OPHTHALMIC OINTMENT Tier 3

tobramycin ophthalmic Tier 1

tobramycin-dexamethasone Tier 3

TOBREX OPHTHALMIC OINTMENT Tier 3

TRAVATAN Z Tier 2

trifluridine ophthalmic Tier 3

tropicamide ophthalmic Tier 3

ZADITOR Tier 1 LGC

ZIOPTAN Tier 3 ST

ZIRGAN Tier 3 #

ZYLET Tier 3

*Orexin Receptor Antagonists***

BELSOMRA Tier 3 PA; ST; QL

*Otic Agents*

acetasol hc Tier 1

acetic acid otic Tier 1

CIPRO HC Tier 3 #

CIPRODEX Tier 3




ciprofloxacin hcl otic Tier 3

COLY-MYCIN S Tier 3

fluocinolone acetonide otic Tier 3

hydrocortisone-acetic acid Tier 1

neomycin-polymyxin-hc otic Tier 1

ofloxacin otic Tier 3

*Oxaborole-Related Antifungals - Topical***

KERYDIN Tier 3 PA; ST

*Oxytocics*

PREPIDIL Tier 3

PROSTIN E2 Tier 3

*Passive Immunizing Agents - Combinations***

HYQVIA Tier 5 PA; SP

*Passive Immunizing Agents*

CROFAB Tier 5

FLEBOGAMMA DIF Tier 4 PA

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/200ML, 20 GM/400ML, 5 GM/100ML

Tier 4 PA

GAMUNEX-C Tier 4 PA

OCTAGAM Tier 4 PA

SYNAGIS Tier 4 PA; SP

*Pcsk9 Inhibitors***

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR

Tier 4 PA; ST; QL

REPATHA Tier 4 PA; ST; QL

REPATHA PUSHTRONEX SYSTEM Tier 4 PA; ST; QL

REPATHA SURECLICK Tier 4 PA; ST; QL

*Penicillins*

amoxicillin oral capsule Tier 1

amoxicillin oral suspension reconstituted Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet chewable 125 mg, 250 mg Tier 1

amoxicillin-pot clavulanate er Tier 1

amoxicillin-pot clavulanate oral Tier 1

ampicillin oral capsule 500 mg Tier 1




ampicillin sodium injection Tier 5

ampicillin sodium intravenous Tier 5

ampicillin-sulbactam sodium injection Tier 5

ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm

Tier 5

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 2 GM/50ML

Tier 3

BICILLIN C-R Tier 5

BICILLIN C-R 900/300 Tier 5

BICILLIN L-A Tier 5

dicloxacillin sodium Tier 1

nafcillin sodium Tier 5

oxacillin sodium Tier 5

penicillin g potassium Tier 5

penicillin g procaine Tier 5

penicillin g sodium Tier 5

penicillin v potassium oral solution reconstituted125 mg/5ml

Tier 1

penicillin v potassium oral solution reconstituted250 mg/5ml

Tier 1

penicillin v potassium oral tablet 250 mg Tier 1

penicillin v potassium oral tablet 500 mg Tier 1

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

Tier 5

*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors***

ZYDELIG Tier 5 PA; SP; QL

*Phosphodiesterase 4 (Pde4) Inhibitors***

OTEZLA ORAL TABLET Tier 4 PA; ST; SP; QL

OTEZLA ORAL TABLET THERAPY PACK


*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors**

RUBRACA Tier 5 PA; SP; QL




*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***

RUBRACA Tier 5 PA; SP; QL

*Potassium Removing Agents***

kionex oral powder Tier 3

kionex oral suspension Tier 1

sodium polystyrene sulfonate oral Tier 1

sodium polystyrene sulfonate rectal Tier 1

*Progestins*

medroxyprogesterone acetate oral Tier 1 LGC

megestrol acetate oral suspension 625 mg/5ml Tier 3

norethindrone acetate oral Tier 1

progesterone micronized oral Tier 1 QL

*Protease-Activated Receptor-1 (Par-1) Antagonists***

ZONTIVITY Tier 3 PA; QL

*Psychotherapeutic And Neurological Agents - Misc.*

acamprosate calcium Tier 3 QL

AMPYRA Tier 4 PA; SP; QL

AUBAGIO Tier 5 PA; ST; SP; QL

AVONEX Tier 5 PA; ST; SP; QL

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT


AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT


BETASERON SUBCUTANEOUS KIT Tier 5 PA; ST; SP; QL

bupropion hcl er (smoking det) CE QL

CHANTIX CE QL

CHANTIX CONTINUING MONTH PAK CE QL

CHANTIX STARTING MONTH PAK CE

chlordiazepoxide-amitriptyline Tier 3

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML

Tier 4 PA; SP

disulfiram oral Tier 1




donepezil hcl oral tablet 10 mg, 5 mg Tier 1

donepezil hcl oral tablet 23 mg Tier 3 ST

donepezil hcl oral tablet dispersible Tier 1

ergoloid mesylates oral Tier 3

EXTAVIA SUBCUTANEOUS KIT Tier 5 PA; ST; SP; QL

fluoxetine hcl (pmdd) oral capsule Tier 1 LGC

fluoxetine hcl (pmdd) oral tablet Tier 3

galantamine hydrobromide Tier 3

galantamine hydrobromide er Tier 3

GILENYA Tier 4 PA; SP; QL

GLATOPA Tier 4 PA

GRALISE ORAL TABLET 300 MG, 600 MG Tier 3 ST; QL

GRALISE STARTER Tier 3 ST; QL

hm nicotine transdermal patch 24 hour 7 mg/24hr

CE

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG

Tier 3 ST; QL

LEMTRADA Tier 5 PA; ST; SP; QL

memantine hcl oral tablet Tier 1 PA

NAMENDA XR Tier 2 PA; #

NAMENDA XR TITRATION PACK Tier 2 PA; #

NICODERM CQ Tier 3

nicotine polacrilex mouth/throat gum CE QL

nicotine polacrilex mouth/throat lozenge CE QL

nicotine step 1 CE

nicotine step 2 CE

nicotine step 3 CE

nicotine transdermal patch 24 hour CE

NICOTROL CE QL

NICOTROL NS CE QL

NUEDEXTA Tier 3 PA; QL

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 mg, 6-50 mg

Tier 3 QL

olanzapine-fluoxetine hcl oral capsule 3-25 mg Tier 3

perphenazine-amitriptyline Tier 3

pimozide Tier 3




PLEGRIDY Tier 5 PA; ST; SP; QL

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR


PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Tier 4 PA; SP; QL

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Tier 4 PA; SP; QL

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Tier 4 PA; SP; QL

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Tier 4 PA; SP; QL

rivastigmine Tier 3

rivastigmine tartrate Tier 3

SAVELLA Tier 3 PA; ST; QL

SAVELLA TITRATION PACK Tier 3 PA; ST; QL

TECFIDERA Tier 5 PA; ST; SP; QL

tetrabenazine oral tablet 12.5 mg, 25 mg Tier 4 PA; QL

XYREM Tier 5 PA; SP

*Respiratory Agents - Misc.*

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG

Tier 5 PA; SP

KALYDECO Tier 5 PA; SP; QL

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

Tier 5 PA; SP

PULMOZYME Tier 4 PA; SP; QL

ZEMAIRA Tier 5 PA; SP

*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag***

ADDYI Tier 3 PA; QL

*Serotonin Modulators***

nefazodone hcl Tier 3

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg Tier 1




trazodone hcl oral tablet 300 mg Tier 1

TRINTELLIX Tier 3 PA; ST; QL

VIIBRYD ORAL TABLET Tier 3 PA; ST; QL

VIIBRYD STARTER PACK Tier 3 PA; ST

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***

GLYXAMBI Tier 3 ST; QL

*Sinus Node Inhibitors**

CORLANOR Tier 3 PA; ST; QL

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***

INVOKAMET Tier 2 QL

INVOKAMET XR Tier 2 QL

SYNJARDY Tier 3 QL

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG

Tier 3 QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-1000 MG, 5-500 MG

Tier 3 QL

*Sulfonamides*

sulfadiazine oral Tier 3

*Tetracyclines*

demeclocycline hcl oral Tier 3

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg Tier 1 LGC

doxycycline hyclate oral tablet 20 mg Tier 1

doxycycline monohydrate oral capsule 100 mg, 50 mg

Tier 1

doxycycline monohydrate oral capsule 75 mg Tier 1 QL

minocycline hcl oral capsule Tier 1

MORGIDOX ORAL CAPSULE 100 MG Tier 1

tetracycline hcl oral Tier 1 LGC

VIBRAMYCIN ORAL SYRUP Tier 3

*Thyroid Agents*

ARMOUR THYROID Tier 3




levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1 LGC

levothyroxine sodium oral tablet 300 mcg Tier 1

levoxyl Tier 1 LGC

liothyronine sodium oral Tier 1

methimazole oral Tier 1

NATURE-THROID Tier 3

np thyroid oral tablet 30 mg, 60 mg, 90 mg Tier 1

propylthiouracil oral Tier 1

THYROLAR-1 Tier 3

THYROLAR-1/2 Tier 3

THYROLAR-1/4 Tier 3

THYROLAR-2 Tier 3

THYROLAR-3 Tier 3

TIROSINT Tier 3

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1 LGC

unithroid oral tablet 300 mcg Tier 1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

Tier 3

WP THYROID ORAL TABLET 113.75 MG Tier 3

*Ulcer Drugs*

acid controller complete Tier 3

amoxicill-clarithro-lansopraz Tier 3

belladonna alkaloids-opium Tier 3

belladonna-opium Tier 3

CARAFATE ORAL SUSPENSION Tier 3

cimetidine hcl oral Tier 1

cimetidine oral tablet 200 mg, 300 mg, 400 mg Tier 1

cimetidine oral tablet 800 mg Tier 1 LGC

CUVPOSA Tier 3 PA

DEXILANT Tier 3 PA; ST; QL

dicyclomine hcl oral capsule Tier 1 LGC

dicyclomine hcl oral solution Tier 1

dicyclomine hcl oral tablet Tier 1 LGC




ed-spaz Tier 1

esomeprazole magnesium Tier 3 PA; ST; QL

famotidine oral suspension reconstituted Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1 LGC

FIRST-LANSOPRAZOLE Tier 3

glycopyrrolate oral tablet 1 mg, 2 mg Tier 3

hyoscyamine sulfate er oral tablet extended release 12 hour

Tier 1

hyoscyamine sulfate oral Tier 1

hyoscyamine sulfate sublingual Tier 1

kls omeprazole Tier 1

kp omeprazole magnesium Tier 1

lansoprazole oral capsule delayed release 15 mg, 30 mg

Tier 3 QL

methscopolamine bromide oral Tier 3

misoprostol oral Tier 1

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE

Tier 1 QL

NEXIUM ORAL PACKET Tier 3 PA; ST; #; QL

nizatidine Tier 1

omeprazole magnesium Tier 1 LGC

omeprazole oral capsule delayed release 10 mg, 40 mg

Tier 1

omeprazole oral capsule delayed release 20 mg Tier 1 LGC

omeprazole-sodium bicarbonate oral capsule 20-1100 mg

Tier 1 QL

PAMINE FQ Tier 3

pantoprazole sodium oral Tier 1

PEPCID AC MAXIMUM STRENGTH ORAL TABLET

Tier 1

PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG

Tier 3 QL

PRILOSEC OTC Tier 1 LGC

propantheline bromide oral Tier 3

PYLERA Tier 3

qc omeprazole magnesium Tier 1

rabeprazole sodium Tier 3 PA; ST; QL




ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 150 mg, 300 mg Tier 1 LGC

sucralfate oral Tier 1

ZEGERID OTC Tier 1 #; QL

*Urinary Anti-Infectives*

hyophen Tier 3

methenamine hippurate Tier 3

methenamine mandelate oral Tier 3

MONUROL Tier 3

nitrofurantoin macrocrystal oral Tier 1

nitrofurantoin monohyd macro Tier 1

nitrofurantoin oral suspension Tier 3

phosphasal Tier 3

ur n-c Tier 3

urelle Tier 3

uretron d/s Tier 3

urin ds Tier 3

uryl Tier 3

utira-c Tier 3

utrona-c Tier 3

*Urinary Antispasmodics*

bethanechol chloride oral Tier 1

darifenacin hydrobromide er Tier 3 ST; QL

flavoxate hcl Tier 1

GELNIQUE TRANSDERMAL GEL 10 % Tier 3 ST

MYRBETRIQ Tier 2 ST; QL

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

Tier 3 ST; QL

oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet Tier 1 LGC; QL

tolterodine tartrate Tier 3 ST

tolterodine tartrate er Tier 3 ST; QL

TOVIAZ Tier 3 ST; QL

trospium chloride Tier 1 QL

trospium chloride er Tier 3 ST; QL




VESICARE Tier 2 ST; #; QL

*Vaginal Products*

AVC VAGINAL Tier 3

CLEOCIN VAGINAL SUPPOSITORY Tier 3

clindamycin phosphate vaginal Tier 1

clotrimazole vaginal cream 1 % Tier 1

CRINONE VAGINAL GEL 4 % Tier 3 PA

CRINONE VAGINAL GEL 8 % Tier 3 PA; ST

ENCARE VAGINAL SUPPOSITORY CE

ENDOMETRIN Tier 3 PA

ESTRACE VAGINAL Tier 3

ESTRING Tier 3

FEM PH Tier 3

FEMRING Tier 3 #; QL

FIRST-PROGESTERONE VGS 100 Tier 3 PA

FIRST-PROGESTERONE VGS 200 Tier 3 PA

GYNAZOLE-1 Tier 3

metronidazole vaginal Tier 1

miconazole 3 vaginal suppository Tier 3

PREMARIN VAGINAL Tier 3

RELAGARD Tier 3

terconazole Tier 1

TODAY SPONGE CE

vandazole Tier 1

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

CE

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM

CE

YUVAFEM Tier 3

*Vasopressors*

epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml

Tier 1 QL

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR

Tier 2 QL

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR

Tier 2 QL

midodrine hcl Tier 1




norepinephrine bitartrate intravenous Tier 3

*Vitamins*

DECARA ORAL CAPSULE 50000 UNIT Tier 1

ergocalciferol oral capsule Tier 1

MEPHYTON Tier 3

niacin er oral capsule extended release 500 mg Tier 1

niacin er oral tablet extended release 1000 mg Tier 1

niacin oral tablet 100 mg, 500 mg Tier 1

vitamin d (ergocalciferol) Tier 1

vitamin d2 oral tablet 400 unit CE

vitamin d3 oral capsule 1000 unit, 400 unit CE

vitamin d3 oral liquid 400 unit/ml CE

vitamin d3 oral tablet 1000 unit, 400 unit CE

vitamin d3 oral tablet chewable 400 unit CE



Index

1ST TIER UNIFINE PENTIPS................................ 771ST TIER UNIFINE PENTIPS PLUS......................771ST TIER UNILET COMFORTOUCH.................77abacavir sulfate ........................ 36abacavir sulfate-lamivudine ...... 37abacavir-lamivudine-zidovudine 37ABELCET.............................. 24ABREVA................................ 51acamprosate calcium .............. 106acarbose ...................................20ACCU-CHEK AVIVA PLUS.58ACCU-CHEK COMPACT PLUS...................................... 58ACCU-CHEK FASTCLIX LANCETS.............................. 77ACCU-CHEK MULTICLIX LANCETS.............................. 77ACCU-CHEK SAFE-T PRO LANCETS.............................. 77ACCU-CHEK SMARTVIEW........................ 58ACCU-CHEK SOFT TOUCH LANCETS............... 77ACCU-CHEK SOFTCLIX LANCET DEV....................... 77ACCU-CHEK SOFTCLIX LANCETS.............................. 77ACCUTREND GLUCOSE....58acebutolol hcl ........................... 40acetaminophen-codeine ...............9acetaminophen-codeine #2 ......... 9acetaminophen-codeine #3 ......... 9acetaminophen-codeine #4 ......... 9acetasol hc ..............................103acetazolamide .......................... 67acetazolamide er ...................... 67acetic acid .........................72, 103acetylcysteine ...........................50acid controller complete ..........110acitretin ................................... 51ACTEMRA.............................. 6ACTI-LANCE 28G................ 77ACTI-LANCE LITE LANCETS 28G.......................77

ACTI-LANCE SPECIAL LANCETS 17G.......................78ACTI-LANCE UNIVERSAL 23G......................................... 78ACTIMMUNE....................... 30ACTOPLUS MET XR............20ACUVAIL............................ 100acyclovir .................................. 37acyclovir sodium .......................37ACZONE................................51ADAGEN............................... 41adapalene .................................51adapalene-benzoyl peroxide ......51ADCIRCA..............................43ADDYI................................. 108adefovir dipivoxil ......................37ADEMPAS............................. 43adjustable lancing device ...........78ADRENALIN........................ 99ADVAIR DISKUS................. 14ADVAIR HFA....................... 14ADVANCE INTUITION TEST.......................................58ADVATE................................73ADVOCATE DUO.................78ADVOCATE INSULIN PEN NEEDLES.............................. 78ADVOCATE INSULIN SYRINGE...............................78ADVOCATE LANCETS........78ADVOCATE RAPID-SAFE LANCING..............................78ADVOCATE REDI-CODE... 58ADVOCATE REDI-CODE+ TEST.......................................58ADVOCATE SAFETY LANCETS.............................. 78ADVOCATE TEST................ 58afeditab cr ................................41AFINITOR.............................30AGAMATRIX AMP TEST... 58AGAMATRIX JAZZ TEST...58AGAMATRIX KEYNOTE TEST.......................................58AGAMATRIX PRESTO TEST.......................................58

AGAMATRIX ULTRA-THIN LANCETS................... 78AKTEN.................................100AKTIPAK.............................. 51AKYNZEO.............................23alavert ......................................24alavert allergy/sinus ..................50alaway ....................................100ALBENZA..............................12albuterol sulfate ....................... 14albuterol sulfate er ................... 14alclometasone dipropionate .......51ALDACTAZIDE....................67ALDURAZYME....................67alendronate sodium ...................67alfuzosin hcl er ......................... 72ALIMTA.................................30ALINIA.................................. 28ALLEGRA ALLERGY......... 24ALLEGRA ALLERGY CHILDRENS......................... 24ALLEGRA-D ALLERGY & CONGESTION...................... 50allopurinol ................................73almotriptan malate ................... 92ALOCRIL.............................100alogliptin benzoate ................... 20alogliptin-metformin hcl ........... 20alogliptin-pioglitazone .............. 20ALOMIDE............................100alophen .................................... 76alosetron hcl .............................71ALOXI....................................23ALPHAGAN P.....................100alprazolam ............................... 13alprazolam er ........................... 13ALPRAZOLAM INTENSOL 13alprazolam xr ...........................13ALREX.................................100ALTABAX............................. 51altacaine .................................100altafluor ................................. 100altafrin ................................... 100altavera ....................................44alternate site lancing device ...... 78ALTOPREV........................... 25aluminum acetate ..................... 51



ALVESCO.............................. 14alyacen 1/35 ............................. 44alyacen 7/7/7 ............................ 44amantadine hcl ......................... 34amcinonide ...............................51AMELUZ............................... 51amethia .................................... 44amethia lo ................................ 44AMICAR................................ 75amikacin sulfate ......................... 6amiloride hcl ............................ 67amiloride-hydrochlorothiazide .. 67aminophylline ...........................14amiodarone hcl .........................14AMITIZA............................... 71amitriptyline hcl ....................... 18amlodipine besy-benazepril hcl ..26amlodipine besylate .................. 41amlodipine besylate-valsartan ...26amlodipine-olmesartan ............. 26amlodipine-valsartan-hctz .........26ammonium lactate .................... 51amnesteem ............................... 51amoxapine ............................... 18amoxicill-clarithro-lansopraz ..110amoxicillin ............................. 104amoxicillin-pot clavulanate ..... 104amoxicillin-pot clavulanate er . 104amphetamine-dextroamphet er ... 5amphetamine-dextroamphetamine ....................5amphotericin b ......................... 24ampicillin ............................... 104ampicillin sodium ....................105ampicillin-sulbactam sodium ... 105AMPYRA............................. 106ANACAINE........................... 51ANADROL-50....................... 12anagrelide hcl ........................... 73anastrozole ...............................30ANGELIQ.............................. 70ANORO ELLIPTA.................14ANTICOAGULANT COMPOUND.........................16anti-stick insulin syringe ........... 78ANZEMET.............................23apap-caff-dihydrocodeine ........... 9APEXICON E........................ 51

APIDRA................................. 20APIDRA SOLOSTAR............20APPTRIM...............................62APPTRIM-D.......................... 62apraclonidine hcl .................... 100aprepitant ................................ 23apri .......................................... 44APRISO.................................. 71APTIOM.................................16APTIVUS................................37ARALAST NP......................108aranelle .................................... 44ARANESP (ALBUMIN FREE).....................................74ARCALYST............................. 6ARCAPTA NEOHALER.......14aripiprazole ..............................35armodafinil ................................ 5ARMOUR THYROID.........109ARRANON............................30ARZERRA............................. 30ascomp-codeine .......................... 9ASHLYNA............................. 44ASMANEX 120 METERED DOSES....................................14ASMANEX 14 METERED DOSES....................................14ASMANEX 30 METERED DOSES....................................14ASMANEX 60 METERED DOSES....................................14ASMANEX HFA................... 14aspirin ........................................8aspirin low dose ..........................8aspirin-dipyridamole er .............73ASSURE 3 TEST....................58ASSURE 4 TEST....................58ASSURE COMFORT LANCETS 28G.......................78ASSURE COMFORT LANCETS 30G.......................78ASSURE HAEMOLANCE PLUS HIGH........................... 78ASSURE HAEMOLANCE PLUS LOW.............................78ASSURE HAEMOLANCE PLUS MICRO........................ 78

ASSURE HAEMOLANCE PLUS NORMAL....................78ASSURE HAEMOLANCE PLUS PED..............................78ASSURE ID INSULIN SAFETY SYR........................ 78ASSURE LANCE LANCETS.............................. 78ASSURE LANCETS.............. 78ASSURE PLATINUM...........58ASSURE PRO TEST..............58atenolol .................................... 40atenolol-chlorthalidone ............. 26ATGAM................................. 39atomoxetine hcl ..........................5atorvastatin calcium ................. 25atovaquone ...............................28atovaquone-proguanil hcl ..........29ATRAPRO HYDROGEL......51ATRIPLA............................... 37atropine sulfate .......................100ATROVENT HFA................. 14AUBAGIO............................106AURORA LANCET SUPER THIN 30G...............................78AURORA LANCET THIN 23G......................................... 78AURORA PEN NEEDLES... 78AURORA UNIFINE PENTIPS................................ 78AVAGE.................................. 51AVAILNEX............................62AVANDIA..............................20avar cleanser ............................ 51avar-e green ............................. 51AVC VAGINAL................... 113aviane ...................................... 44avita .........................................51AVO CREAM........................ 51AVONEX..............................106AVONEX PEN..................... 106AVONEX PREFILLED.......106AXONA..................................62azacitidine ................................31AZASAN................................ 39AZASITE..............................100azathioprine ............................. 39azelastine hcl .................... 99, 100



AZELEX.................................51azithromycin ............................ 77AZOPT..................................100aztreonam ................................ 28azurette ....................................45baciim ...................................... 28bacitracin ......................... 28, 100bacitracin-polymyxin b ........... 100bacitra-neomycin-polymyxin-hc ...........................................100baclofen ................................... 98BACTOCILL IN DEXTROSE......................... 105BACTROBAN NASAL..........99balanced salt .......................... 100BAL-CARE DHA...................95balsalazide disodium .................71balziva ..................................... 45BANZEL................................ 16BARACLUDE........................37bayer advanced aspirin ex st ....... 8bayer aspirin .............................. 8BAYER BREEZE 2 TEST......58BAYER CONTOUR NEXT TEST.......................................58BAYER CONTOUR TEST....58bayer low dose ............................9BAYER MICROLET LANCETS.............................. 78BD AUTOSHIELD................ 78BD ECLIPSE SYRINGE....... 78BD INSULIN SYR ULTRAFINE II..................... 78BD INSULIN SYRINGE.......79BD INSULIN SYRINGE HALF-UNIT.......................... 79BD INSULIN SYRINGE MICROFINE......................... 79BD INSULIN SYRINGE ULTRAFINE......................... 79BD LANCET ULTRAFINE 30G......................................... 79BD LANCET ULTRAFINE 33G......................................... 79BD MICROTAINER LANCETS.............................. 79BD PEN NEEDLE MINI U/F..........................................79

BD PEN NEEDLE NANO U/F..........................................79BD PEN NEEDLE SHORT U/F..........................................79BD PEN NEEDLE ULTRAFINE......................... 79bd posiflush .............................. 93BD SAFETYGLIDE INSULIN SYRINGE............. 79BD SAFETYGLIDE SYRINGE/NEEDLE..............79BD SAFETY-LOK INSULIN SYRINGE............. 79BECONASE AQ.....................99belladonna alkaloids-opium .....110belladonna-opium ................... 110BELSOMRA.........................103BELVIQ....................................5benazepril hcl ........................... 26benazepril-hydrochlorothiazide . 26BENLYSTA............................39benzonatate ..............................50benzoyl peroxide cleanser ......... 52benzoyl peroxide-erythromycin .52benztropine mesylate ................ 34BEPREVE.............................100BERINERT............................ 73BESIVANCE........................ 100BETADINE OPHTHALMIC PREP.....................................100betamethasone dipropionate ..... 52betamethasone dipropionate aug ...........................................52betamethasone valerate ............ 52BETASERON.......................106betaxolol hcl ..................... 40, 100bethanechol chloride ............... 112BETIMOL.............................100BETOPTIC-S........................ 100bexarotene ............................... 31bicalutamide .............................31BICILLIN C-R..................... 105BICILLIN C-R 900/300........ 105BICILLIN L-A......................105BIDIL..................................... 43BILTRICIDE..........................12bimatoprost ............................ 100bio glo .................................... 100

BIONECT...............................52bisoprolol fumarate .................. 40bisoprolol-hydrochlorothiazide ..26bleomycin sulfate ......................31BLEPHAMIDE.................... 100BLEPHAMIDE S.O.P.......... 100BOSULIF............................... 31BOTOX...................................99bp 10-1 .....................................52bp folinatal plus b ..................... 95bp wash .................................... 52BRAVELLE............................67BREO ELLIPTA.................... 14BREVICON (28).....................45briellyn .....................................45BRILINTA........................66, 73brimonidine tartrate ................100bromfed dm .............................. 50bromfenac sodium (once-daily)...............................................100bromocriptine mesylate ............ 34BROVANA.............................15bss ..........................................100budesonide ..........................15, 99BULLSEYE MINI SAFETY LANCETS.............................. 79bumetanide ...............................67BUNAVAIL............................. 9BUPHENYL...........................67buprenorphine ............................ 9buprenorphine hcl .......................9buprenorphine hcl-naloxone hcl .. 9bupropion hcl ........................... 18bupropion hcl er (smoking det)...............................................106bupropion hcl er (sr) ................ 18bupropion hcl er (xl) ................18buspirone hcl ............................ 13BUSULFEX........................... 31butalbital-acetaminophen ........... 9butalbital-apap-caff-cod ............. 9butalbital-apap-caffeine ..............9butalbital-asa-caff-codeine ......... 9butalbital-aspirin-caffeine ...........9BUTISOL SODIUM...............75butorphanol tartrate ...................9BYDUREON..........................20BYETTA 10 MCG PEN......... 20



BYETTA 5 MCG PEN........... 20BYSTOLIC............................. 40cabergoline ...............................68CAFERGOT...........................92calcipotriene .............................52calcipotriene-betameth diprop ...52calcitonin (salmon) .................. 68calcitrene ................................. 52calcitriol ............................. 52, 68calcium acetate (phos binder) .. 71calcium chloride ....................... 93calcium gluconate .....................93camila ...................................... 45CAMPTOSAR........................31camrese ....................................45camrese lo ................................ 45CANASA................................ 71CANCIDAS............................24candesartan cilexetil .................26candesartan cilexetil-hctz ......... 26capacet ...................................... 9CAPASTAT SULFATE......... 30capecitabine ............................. 31CAPEX................................... 52CAPRELSA............................31captopril ...................................27captopril-hydrochlorothiazide ... 27CARAFATE......................... 110CARBAGLU.......................... 68carbamazepine ......................... 17carbamazepine er ..................... 16carbidopa ................................. 34carbidopa-levodopa .................. 34carbidopa-levodopa er .............. 34carbidopa-levodopa-entacapone 34carbinoxamine maleate .............24carboplatin ...............................31CARDIOTEK RX.................. 62CARDURA XL......................72CAREFINE PEN NEEDLES 79CAREONE LANCET THIN 23G......................................... 79CAREONE LANCET ULTRA THIN 28G................ 79CAREONE UNIFINE PENTIPS................................ 79CARESENS N GLUCOSE TEST.......................................58

carisoprodol ............................. 98carisoprodol-aspirin ..................98carisoprodol-aspirin-codeine ..... 98carteolol hcl ............................100cartia xt ................................... 41carvedilol ................................. 40cavarest ....................................95CAYSTON............................. 28caziant ..................................... 45cefaclor .................................... 43cefaclor er ................................ 43cefadroxil .................................43cefazolin sodium .......................43cefazolin sodium-dextrose .........43cefdinir .....................................43cefditoren pivoxil ......................43cefepime hcl ............................. 43cefixime ................................... 43cefotaxime sodium ....................43cefotetan disodium ....................44cefoxitin sodium ....................... 44cefpodoxime proxetil ................ 44cefprozil ................................... 44ceftazidime ...............................44ceftibuten ................................. 44ceftriaxone sodium ................... 44cefuroxime axetil ..................... 44cefuroxime sodium ................... 44celecoxib ....................................6CELLCEPT............................ 39CELONTIN............................17CENTANY AT.......................52cephalexin ................................ 44CERDELGA.......................... 74CEREFOLIN..........................62CEREFOLIN NAC................ 62CEREZYME.......................... 74cerisa wash ...............................52CESAMET..............................23cesia .........................................45cetirizine hcl .............................24cetirizine hcl childrens .............. 24cetirizine-pseudoephedrine er .... 50CETROTIDE..........................68cevimeline hcl ........................... 95CHANTIX............................ 106CHANTIX CONTINUING MONTH PAK...................... 106

CHANTIX STARTING MONTH PAK...................... 106chateal ..................................... 45CHEK-STIX CONTROL....... 58CHEMET............................... 23CHEMSTRIP 10 MD............. 58CHEMSTRIP 10/SG...............58CHEMSTRIP 2 GP................ 58CHEMSTRIP 5 OB................ 58CHEMSTRIP 7.......................58CHEMSTRIP 9.......................58CHEMSTRIP K..................... 59CHEMSTRIP UGK............... 59CHENODAL..........................71cheratussin ac ...........................50childrens aspirin ......................... 9chloramphenicol sod succinate .. 28chlordiazepoxide hcl ................. 13chlordiazepoxide-amitriptyline106chlorhexidine gluconate ............ 95chloroquine phosphate .............. 29chlorothiazide ...........................67chlorpromazine hcl ................... 35chlorpropamide ........................ 20chlorthalidone .......................... 67chlorzoxazone .......................... 99cholestyramine ......................... 25cholestyramine light ................. 25choline-mag trisalicylate .............9chromic chloride .......................93CIALIS................................... 43ciclodan ....................................52ciclopirox ................................. 52ciclopirox olamine .................... 52cidofovir ...................................37cilostazol ..................................74CILOXAN............................ 101cimetidine ...............................110cimetidine hcl ......................... 110CIMZIA..................................71CIMZIA PREFILLED........... 71CIMZIA STARTER KIT....... 71CIPRO HC............................103CIPRODEX.......................... 103ciprofloxacin ............................ 71ciprofloxacin hcl ........71, 101, 104ciprofloxacin-ciproflox hcl er ....71cisplatin ................................... 31



citalopram hydrobromide ..........18CITRANATAL 90 DHA........95CITRANATAL ASSURE...... 95CITRANATAL B-CALM...... 95CITRANATAL RX................95claravis .................................... 52clarithromycin ..........................77clarithromycin er ......................77CLARITIN............................. 25CLARITIN REDITABS.........25CLARITIN-D 12 HOUR........50clemastine fumarate ................. 25CLEOCIN.............................113CLEVER CHEK AUTO-CODE..................................... 79CLEVER CHEK AUTO-CODE TEST...........................59CLEVER CHEK AUTO-CODE VOICE........................ 59CLEVER CHEK LANCETS..79CLEVER CHEK TEST.......... 59CLEVER CHOICE AUTO-CODE TEST...........................59CLEVER CHOICE MICRO TEST.......................................59CLICKFINE PEN NEEDLES.............................. 79CLIMARA PRO.....................70clindacin etz ............................. 52clindacin-p ................................52clindamycin hcl .........................28clindamycin palmitate hcl ......... 28clindamycin phos-benzoyl perox ....................................... 52clindamycin phosphate .28, 52, 113clindamycin-tretinoin ................52clinpro 5000 ............................. 95clobetasol propionate ................53clobetasol propionate e ............. 52clobetasol propionate emulsion . 52clocortolone pivalate .................53clomiphene citrate .................... 68clomipramine hcl ...................... 18clonazepam .............................. 17clonidine hcl ............................. 27clonidine hcl er ........................... 5clopidogrel bisulfate ................. 74clorazepate dipotassium ............13

CLORPRES............................27clotrimazole ................ 53, 95, 113clotrimazole-betamethasone ..... 53clozapine .................................. 35COARTEM............................ 29codeine sulfate ..........................10colchicine ................................. 73colchicine-probenecid ............... 73colestipol hcl ............................ 25colistimethate sodium ............... 28colocort ....................................12COLY-MYCIN S..................104COMBIGAN........................ 101COMBIPATCH...................... 70COMBISTIX.......................... 59COMBIVENT RESPIMAT....15COMBIVIR............................ 37COMETRIQ (100 MG DAILY DOSE)....................... 31COMETRIQ (140 MG DAILY DOSE)....................... 31COMETRIQ (60 MG DAILY DOSE).....................................31COMFORT ASSURED LANCETS 28G.......................79COMFORT ASSURED LANCETS 33G.......................79COMFORT EZ INSULIN SYRINGE...............................79COMFORT EZ PEN NEEDLES.............................. 79COMFORT LANCETS..........79COMPLERA.......................... 37compro .....................................35co-natal fa ................................95CONCEPT DHA.................... 95CONCEPT OB........................95CONDYLOX..........................53constulose .................................76CONTRAVE.......................... 34COPAXONE.........................106CORDRAN............................ 53COREG CR............................ 40CORLANOR........................ 109cormax scalp application .......... 53CORTIFOAM........................ 12cortisone acetate ...................... 49CORTISPORIN......................53

COSMEGEN.......................... 31COSOPT PF..........................101CREON.................................. 66CRESEMBA...........................24CRINONE............................ 113CRIXIVAN............................ 37CROFAB.............................. 104cromolyn sodium ......... 15, 71, 101cryselle-28 ................................45CUVPOSA............................ 110CVS KETONE CARE............59CVS LANCETS 21G.............. 79CVS LANCETS MICRO THIN 33G...............................79CVS LANCETS ORIGINAL. 80CVS LANCETS THIN 26G... 80CVS LANCETS ULTRA THIN 30G...............................80CVS ULTRA THIN LANCETS.............................. 80cyanocobalamin ........................74cyclafem 1/35 ........................... 45cyclafem 7/7/7 .......................... 45CYCLESSA............................ 45cyclobenzaprine hcl .................. 99CYCLOMYDRIL.................101cyclopentolate hcl ................... 101cyclophosphamide .................... 31cycloserine ............................... 30CYCLOSET............................20cyclosporine ............................. 40cyclosporine modified ............... 39cyproheptadine hcl ....................25CYSTADANE........................ 68CYSTAGON.......................... 73CYSTARAN.........................101cytarabine ................................ 31cytarabine (pf) ........................ 31cytra k crystals .........................73CYTRA-3............................... 73cytra-k ..................................... 73DACOGEN............................ 31DAKLINZA........................... 37DALIRESP.............................15danazol .................................... 12dantrolene sodium .................... 99dapsone .................................... 28daptomycin .............................. 29



DARAPRIM.......................... 29darifenacin hydrobromide er ... 112dasetta 1/35 ..............................45dasetta 7/7/7 .............................45daunorubicin hcl ....................... 31dayhist allergy 12 hour relief .... 25daysee ...................................... 45DAYTRANA........................... 5DEBACTEROL......................95deblitane .................................. 45DECARA..............................114decitabine .................................31DELYLA................................ 45DELZICOL............................ 71demeclocycline hcl .................. 109DEMSER................................27DENAVIR..............................53denta 5000 plus ........................ 95dentagel ................................... 95DEPLIN 15............................. 62DEPLIN 7.5............................ 62DEPO-PROVERA..................45DERMASORB TA................. 53DESCOVY..............................37desipramine hcl .........................18desloratadine ............................25desmopressin ace spray refrig ... 68desmopressin acetate ................ 68desmopressin acetate spray .......68DESOGEN............................. 45desogestrel-ethinyl estradiol ......45desonide ................................... 53desoximetasone ........................ 53desvenlafaxine succinate er .......18dexamethasone .........................49DEXAMETHASONE INTENSOL............................ 49dexamethasone sodium phosphate ............................... 101DEXILANT..........................110dexmethylphenidate hcl .............. 5dexmethylphenidate hcl er .......... 5dexrazoxane .............................31dextroamphetamine sulfate .........5dextroamphetamine sulfate er .....5DIASCREEN 10.....................80DIASCREEN 1B.................... 80DIASCREEN 1K....................80

DIASCREEN 2GK.................80DIASCREEN 2GP................. 80DIASCREEN 3.......................80DIASCREEN 4NL................. 80DIASCREEN 4OBL...............80DIASCREEN 4PH................. 80DIASCREEN 5.......................80DIASCREEN 6.......................80DIASCREEN 7.......................80DIASCREEN 8.......................80DIASCREEN 9.......................80diazepam ............................ 13, 17diazepam intensol ..................... 13diclofenac potassium .................. 7diclofenac sodium ..........7, 53, 101diclofenac sodium er ...................7diclofenac-misoprostol ................7dicloxacillin sodium ................ 105dicyclomine hcl .......................110didanosine ................................ 37DIFFERIN............................. 53DIFICID.................................77diflorasone diacetate .................53diflunisal .................................... 9DIGOX................................... 43digoxin .....................................43dihydroergotamine mesylate ..... 92DILANTIN............................ 17DILATRATE-SR................... 12diltiazem cd ..............................41diltiazem hcl .............................42diltiazem hcl er ................... 41, 42diltiazem hcl er beads ............... 41diltiazem hcl er coated beads .... 41dilt-xr ...................................... 42DIPENTUM...........................72diphenhydramine hcl .................25diphenoxylate-atropine .............23dipyridamole ............................ 74disopyramide phosphate ............14disulfiram ...............................106DIURIL.................................. 67divalproex sodium .................... 17divalproex sodium er ................ 17DIVIGEL................................70docetaxel ..................................31dofetilide .................................. 14donepezil hcl ...........................107

DORIBAX..............................29dorzolamide hcl ...................... 101dorzolamide hcl-timolol mal ....101doxazosin mesylate ...................27doxepin hcl ...............................18doxercalciferol ......................... 68doxorubicin hcl .........................31doxorubicin hcl liposomal ......... 31doxycycline .............................. 53doxycycline hyclate ................ 109doxycycline monohydrate ....... 109DRITHO-CREME HP........... 53dronabinol ................................23DROPLET LANCETS ULTRA THIN 30G................ 80drospiren-eth estrad-levomefol ..45drospirenone-ethinyl estradiol ...45DROXIA................................ 74DRUG MART LANCETS THIN 26G...............................80DRUG MART UNIFINE PENTIPS................................ 80DRUG MART UNILET LANCETS 28G.......................80DRUG MART UNILET LANCETS 30G.......................80DUAVEE................................71DULERA................................15duloxetine hcl ........................... 19duraxin ...................................... 9DUREZOL........................... 101dutasteride ............................... 73DUTOPROL.......................... 27DYRENIUM..........................67E.E.S. 400................................77E.E.S. GRANULES................77EASY COMFORT INSULIN SYRINGE............. 80EASY COMFORT LANCETS.............................. 80EASY PLUS II GLUCOSE TEST.......................................59EASY STEP TEST..................59EASY TALK BLOOD GLUCOSE TEST................... 59EASY TOUCH INSULIN SAFETY SYR........................ 80



EASY TOUCH INSULIN SYRINGE...............................80EASY TOUCH LANCETS 21G......................................... 80EASY TOUCH LANCETS 23G......................................... 80EASY TOUCH LANCETS 26G......................................... 80EASY TOUCH LANCETS 28G......................................... 80EASY TOUCH LANCETS 28G/TWIST............................ 80EASY TOUCH LANCETS 30G......................................... 80EASY TOUCH LANCETS 30G/TWIST............................ 81EASY TOUCH LANCETS 32G......................................... 81EASY TOUCH LANCETS 32G/TWIST............................ 81EASY TOUCH LANCETS 33G/TWIST............................ 81EASY TOUCH PEN NEEDLES.............................. 81EASY TOUCH SAFETY LANCETS 21G.......................81EASY TOUCH SAFETY LANCETS 23G.......................81EASY TOUCH SAFETY LANCETS 26G.......................81EASY TOUCH SAFETY LANCETS 28G.......................81EASY TOUCH TEST.............59EASY TRAK BLOOD GLUCOSE TEST................... 59EASY TWIST & CAP LANCETS.............................. 81EASYGLUCO........................ 59EASYMAX 15 TEST..............59EASYMAX TEST.................. 59EASYPLUS BLOOD GLUCOSE TEST................... 59EASYPRO PLUS................... 59econazole nitrate ...................... 53ECOTRIN................................ 9ecotrin low strength ....................9EDARBI................................. 27EDARBYCLOR.....................27

ed-spaz ................................... 111EDURANT............................ 37EFFER-K............................... 93effer-k ......................................93effervescent pot chloride ........... 93ELAPRASE............................ 68ELELYSO...............................74ELEMENT TEST...................59ELESTRIN............................. 70eletriptan hydrobromide ........... 92ELIDEL..................................53elinest ...................................... 45ELIQUIS.................................16elite-ob .....................................96elite-thin insulin syringe ............81ELIXOPHYLLIN...................15ELLA...................................... 45ELMIRON............................. 73EMADINE........................... 101EMBEDA............................... 10EMBRACE BLOOD GLUCOSE TEST................... 59EMCYT.................................. 31EMEND..................................23emoquette .................................45EMSAM..................................19EMTRIVA..............................37EMULSION SB......................53EMVERM.............................. 12enalapril maleate ......................27enalapril-hydrochlorothiazide ... 27ENBREL.................................. 7ENBREL SURECLICK...........7ENCARE.............................. 113endocet .....................................10ENDOCET............................. 10ENDOMETRIN................... 113ENLYTE................................ 62enoxaparin sodium ................... 16enpresse-28 .............................. 45enskyce .................................... 45entacapone ............................... 34entecavir .................................. 37ENTERAGAM.......................63ENTEREG............................. 72enulose ..................................... 72EPCLUSA.............................. 75EPIDUO FORTE................... 53

EPIFOAM.............................. 53epinastine hcl ..........................101epinephrine .............................113EPIPEN 2-PAK.................... 113EPIPEN JR 2-PAK............... 113epirubicin hcl ............................31epitol ........................................17EPIVIR HBV.......................... 37eplerenone ................................ 27EPOGEN................................ 74epoprostenol sodium ................. 43eprosartan mesylate ..................27EPZICOM.............................. 37EQL COLOR LANCETS 21G......................................... 81EQL COLOR LANCETS MICRO 33G........................... 81EQL INSULIN SYRINGE.... 81eql insulin syringe ..................... 81EQL SUPER THIN LANCETS 30G.......................81EQL THIN LANCETS 26G... 81EQUETRO............................. 35ERAXIS..................................24ergocalciferol ......................... 114ergoloid mesylates .................. 107ERGOMAR............................92ERIVEDGE............................31errin .........................................45ERTACZO..............................53ery ........................................... 53ERYPED 200..........................77ERYPED 400..........................77ERY-TAB............................... 77erythromycin .................... 53, 101erythromycin base .................... 77erythromycin ethylsuccinate ..... 77erythromycin stearate ...............77escitalopram oxalate ................ 19esomeprazole magnesium ........111estarylla ................................... 45estazolam ................................. 75ESTRACE.............................113estradiol ................................... 70estradiol-norethindrone acet ..... 70ESTRING............................. 113ESTROGEL............................70estropipate ............................... 70



ESTROSTEP FE.....................45eszopiclone ............................... 75ethacrynic acid ......................... 67ethambutol hcl ..........................30ethosuximide ............................ 17ethyl chloride ............................53etidronate disodium .................. 68etodolac ..................................... 7etodolac er ................................. 7etoposide .................................. 31EURAX.................................. 53EVAMIST...............................70EVENCARE + BLOOD GLUCOSE TEST................... 59EVENCARE BLOOD GLUCOSE TEST................... 59EVENCARE G2 TEST...........59EVENCARE G3 TEST...........59EVOLUTION AUTOCODE..59EVOTAZ................................ 37EXEL COMFORT POINT INSULIN SYR....................... 81EXELDERM.......................... 53exemestane ...............................31EXJADE................................. 23EXTAVIA.............................107E-Z JECT LANCET MICRO-THIN 33G................ 81E-Z JECT LANCET SUPER THIN 30G...............................81E-Z JECT LANCETS............. 81E-Z JECT LANCETS 21G..... 81E-Z JECT LANCETS THIN 26G......................................... 81EZ SMART BLOOD GLUCOSE LANCETS...........81EZ SMART BLOOD GLUCOSE TEST................... 59EZ SMART PLUS GLUCOSE TEST................... 59ezetimibe ..................................25ezetimibe-simvastatin ............... 26FABRAZYME....................... 68FACTIVE............................... 71falmina .....................................46famciclovir ............................... 37famotidine .............................. 111FANAPT................................ 35

FANAPT TITRATION PACK..................................... 35FARESTON........................... 32FARXIGA..............................20FAYOSIM.............................. 46FC FEMALE CONDOM.......81felbamate ................................. 17felodipine er ............................. 42FEM PH................................113FEMCAP................................81FEMHRT LOW DOSE.......... 70FEMRING........................... 113fenofibrate ............................... 26fenofibrate micronized ..............26fenofibric acid .......................... 26fenoprofen calcium ..................... 7fentanyl ....................................10fentanyl citrate .........................10FERRIPROX......................... 23FETZIMA.............................. 19FETZIMA TITRATION........19fexofenadine hcl ....................... 25fexofenadine hcl childrens .........25fexofenadine-pseudoephed er .... 50FIFTY50 GLUCOSE TEST 2.0............................................59FIFTY50 PEN NEEDLES..... 81FIFTY50 SAFETY SEAL LANCETS.............................. 81FIFTY50 SUPERIOR COMFORT SYR....................81FINACEA.............................. 53finasteride ................................ 73FINE 30.................................. 81FINGERSTIX LANCETS..... 82FIRMAGON.......................... 32FIRST-HYDROCORTISONE........... 53FIRST-LANSOPRAZOLE...111FIRST-PROGESTERONE VGS 100................................ 113FIRST-PROGESTERONE VGS 200................................ 113FLAREX.............................. 101flavoxate hcl ...........................112FLEBOGAMMA DIF..........104flecainide acetate ......................14FLOVENT DISKUS.............. 15

FLOVENT HFA.....................15FLOWTUSS........................... 50flucaine .................................. 101fluconazole ...............................24flucytosine ................................24fludarabine phosphate ...............32fludrocortisone acetate ............. 49flunisolide .................................99fluocinolone acetonide .......53, 104fluocinolone acetonide body ...... 53fluocinolone acetonide scalp ......53fluocinonide ..............................54FLUORABON....................... 93FLUOR-A-DAY.....................93fluorescein-benoxinate ............ 101fluor-i-strips a.t. ..................... 101fluoritab ................................... 93fluorometholone ..................... 101FLUOROPLEX......................54fluorouracil .............................. 54fluoxetine hcl ............................19fluoxetine hcl (pmdd) .............107fluphenazine hcl ........................35FLURA-DROPS.................... 93flurandrenolide ......................... 54flurazepam hcl ..........................75flurbiprofen ................................7flurbiprofen sodium .................101flurox ..................................... 101flutamide ..................................32fluticasone propionate .........54, 99fluticasone-salmeterol ...............15fluvastatin sodium .................... 26fluvastatin sodium er ................ 26fluvoxamine maleate .................19FML......................................101FML FORTE........................101FOLBIC..................................63FOLBIC RF............................63FOLCAL DHA.......................96FOLCAPS OMEGA 3............ 96folic acid .................................. 74FOLIVANE-OB..................... 96FOLLISTIM AQ.................... 68FOLTANX............................. 63FOLTANX RF....................... 63FOLTX................................... 63fondaparinux sodium ................ 16



FORA D10 2-IN-1 MONITOR............................. 82FORA D15G 2-IN-1 MONITOR............................. 82FORA D15G BLOOD GLUCOSE TEST................... 59FORA D20 2-IN-1 MONITOR............................. 82FORA D20 BLOOD GLUCOSE TEST................... 59FORA G20 BLOOD GLUCOSE TEST................... 59FORA G30A BLOOD GLUCOSE TEST................... 59FORA GD20 TEST................ 59FORA LANCETS.................. 82FORA V10 BLOOD GLUCOSE TEST................... 59FORA V12 BLOOD GLUCOSE TEST................... 60FORA V20 BLOOD GLUCOSE TEST................... 60FORA V30A BLOOD GLUCOSE TEST................... 60FORACARE GD40 TEST..... 60FORACARE PREMIUM V10 TEST................................60formadon ................................. 36formaldehyde ........................... 36FORMA-RAY........................36FORTEO................................ 68FOSAMAX PLUS D.............. 68fosinopril sodium ...................... 27fosinopril sodium-hctz ...............27fosphenytoin sodium ................. 17FOSRENOL........................... 72FOSTEUM............................. 63FOSTEUM PLUS...................63FOVEX................................... 63FRAGMIN.............................16FREESTYLE INSULINX TEST.......................................60FREESTYLE LANCETS.......82FREESTYLE LITE TEST......60FREESTYLE PRECISION INS SYR................................. 82FREESTYLE TEST............... 60

FREESTYLE UNISTICK II LANCETS.............................. 82frovatriptan succinate ...............92ful-glo .................................... 101fungicure intensive/nailguard .... 54furosemide ................................67FUZEON................................37FYCOMPA.............................17GABADONE..........................63gabapentin ............................... 17galantamine hydrobromide ..... 107galantamine hydrobromide er ..107GALZIN................................. 93GAMMAPLEX.................... 104GAMUNEX-C......................104ganciclovir sodium ....................37ganirelix acetate .......................68gatifloxacin ............................ 101GATTEX................................ 72gavilyte-c ................................. 76gavilyte-g ................................. 76GAVILYTE-H........................76gavilyte-n with flavor pack ........76GE100 BLOOD GLUCOSE TEST.......................................60GEBAUERS PAIN EASE......54GEBAUERS SPRAY AND STRETCH.............................. 54GELCLAIR............................ 95GELNIQUE..........................112gemfibrozil ............................... 26GENERESS FE...................... 46generlac ................................... 72gengraf .....................................40GENGRAF............................ 40gentak .................................... 101gentamicin sulfate ......... 6, 54, 101GENVOYA............................ 37gianvi ....................................... 46GIAZO....................................72gildagia .................................... 46gildess fe 1.5/30 ........................ 46gildess fe 1/20 ...........................46GILENYA............................ 107GILOTRIF............................. 32GLATOPA............................107GLEOSTINE.......................... 32g-levocarnitine s/f ..................... 99

glimepiride ............................... 20glipizide ................................... 20glipizide er ............................... 20glipizide xl ............................... 20glipizide-metformin hcl ............. 20GLOBAL EASE INJECT PEN NEEDLES......................82GLOBAL INJECT EASE INSULIN SYR....................... 82GLOBAL INJECT EASE LANCETS 28G.......................82GLOBAL INJECT EASE LANCETS 30G.......................82GLUCAGEN DIAGNOSTIC....................... 60GLUCAGEN HYPOKIT.......20GLUCAGON EMERGENCY.......................20GLUCOCARD 01 SENSOR PLUS...................................... 60GLUCOCARD EXPRESSION TEST..............60GLUCOCARD VITAL TEST.......................................60GLUCOCARD X-SENSOR...60GLUCOCOM LANCETS 28G......................................... 82GLUCOCOM LANCETS 30G......................................... 82GLUCOCOM LANCETS 33G......................................... 82GLUCOCOM TEST...............60GLUCOPRO INSULIN SYRINGE...............................82glyburide .................................. 20glyburide micronized ................ 20glyburide-metformin .................21glycopyrrolate ........................ 111GLYXAMBI.........................109GNP CLICKFINE PEN NEEDLES.............................. 82GNP INSULIN SYRINGE....82gnp insulin syringe ....................82GNP LANCETS..................... 82GNP LANCETS 21G............. 82GNP LANCETS MICRO THIN 33G...............................82



GNP LANCETS SUPER THIN 30G...............................82GNP LANCETS THIN.......... 82GNP LANCETS THIN 26G...82GNP MICRO THIN LANCETS 33G.......................82GNP SUPER THIN LANCETS 30G.......................82GNP ULTRA COM INSULIN SYRINGE............. 82gnp ultra com insulin syringe .... 83GOLYTELY...........................76GONAL-F.............................. 68GONAL-F RFF......................68GONAL-F RFF REDIJECT..69GRALISE............................. 107GRALISE STARTER.......... 107granisetron hcl ......................... 23GRASTEK............................. 41griseofulvin microsize ............... 24griseofulvin ultramicrosize ........24guaiatussin ac ...........................50guaifenesin ac ...........................50guaifenesin-codeine .................. 50guanfacine hcl .......................... 27guanfacine hcl er ........................ 6guanidine hcl ............................ 30GUARDIAN REAL-TIME SYSTEM PED........................ 83GYNAZOLE-1..................... 113HAEMOLANCE....................83HAEMOLANCE LOW FLOW LANCETS..................83HAEMOLANCE PLUS......... 83HAEMOLANCE PLUS HIGH FLOW......................... 83HAEMOLANCE PLUS LOW FLOW...........................83HAEMOLANCE PLUS MAX FLOW...........................83HAEMOLANCE PLUS PEDIATRIC FLOW.............. 83HALAC.................................. 54HALAVEN.............................32halobetasol propionate ..............54HALOG.................................. 54haloperidol ............................... 35HARVONI..............................75

HEALTHWISE MINI PEN NEEDLES.............................. 83HEALTHWISE PEN NEEDLES.............................. 83HEALTHWISE SHORT PEN NEEDLES......................83HEALTHWISE UNIFINE PENTIPS................................ 83HEALTHY ACCENTS UNIFINE PENTIP.................83HEALTHY ACCENTS UNILET LANCETS.............. 83heather .....................................46H-E-B INCONTROL LANCETS 28G.......................83H-E-B INCONTROL LANCETS 30G.......................83H-E-B INCONTROL PEN NEEDLES.............................. 83HECTOROL...........................69HELIXATE FS.......................74HEMA-COMBISTIX............. 60HEMANGEOL...................... 40heparin lock flush ..................... 16heparin sodium (porcine) ......... 16heparin sodium (porcine) pf ..... 16heparin sodium flush .................16heparin sodium lock flush ......... 16HETLIOZ............................... 75HEXALEN............................. 32hm nicotine .............................107homatropaire ..........................101homatropine hbr ..................... 101HORIZANT......................... 107HUMALOG........................... 21HUMALOG KWIKPEN....... 21HUMALOG MIX 50/50......... 21HUMALOG MIX 50/50 KWIKPEN............................. 21HUMALOG MIX 75/25......... 21HUMALOG MIX 75/25 KWIKPEN............................. 21HUMIRA................................. 7HUMIRA PEDIATRIC CROHNS START.................... 7HUMIRA PEN.........................7HUMIRA PEN-CROHNS STARTER................................ 7

HUMIRA PEN-PSORIASIS STARTER................................ 7HUMULIN 70/30................... 21HUMULIN 70/30 KWIKPEN............................. 21HUMULIN N.........................21HUMULIN N KWIKPEN.....21HUMULIN R.........................21HUMULIN R U-500 (CONCENTRATED)............. 21HUMULIN R U-500 KWIKPEN............................. 21HYCAMTIN.......................... 32hydralazine hcl ......................... 27hydrochlorothiazide ..................67hydrocodone-acetaminophen .....10hydrocodone-homatropine ........ 50hydrocodone-ibuprofen ............. 10hydrocortisone .............. 12, 49, 54hydrocortisone ace-pramoxine .. 12hydrocortisone butyr lipo base .. 54hydrocortisone butyrate ............54hydrocortisone valerate ............ 54hydrocortisone-acetic acid ...... 104hydromet ..................................50hydromorphone hcl ...................10hydromorphone hcl er ............... 10hydroxychloroquine sulfate .......30hydroxyurea .............................32hydroxyzine hcl ........................ 13hydroxyzine pamoate ............... 13hyophen ..................................112hyoscyamine sulfate ................111hyoscyamine sulfate er ............111HYPERTENSA...................... 63HYQVIA...............................104HY-VEE LANCETS...............83hy-vee thin lancets .................... 83ibandronate sodium .................. 69IBRANCE.............................. 51ibudone .................................... 10ibuprofen ....................................7ICLUSIG................................ 32idarubicin hcl ............................32ILARIS..................................... 7ILARIS (150MG DELIVERED).......................... 7imatinib mesylate ..................... 32



imipenem-cilastatin .................. 29imipramine hcl ..........................19imipramine pamoate ................. 19imiquimod ................................ 54inatal advance .......................... 96inatal ultra ............................... 96INCRELEX............................ 69INCRUSE ELLIPTA............. 15indapamide ...............................67INDOCIN.................................7indomethacin ..............................7indomethacin er ..........................7INFINITY BLOOD GLUCOSE TEST................... 60INLYTA................................. 32insulin syringe .......................... 83insulin syringe/needle ................83INSUPEN PEN NEEDLES... 83INSUPEN SENSITIVE.......... 83INSUPEN ULTRAFIN......... 83INTELENCE..........................37INTRON A.............................32introvale ...................................46INVANZ.................................29INVIRASE............................. 38INVOKAMET...................... 109INVOKAMET XR............... 109INVOKANA.......................... 21IODOFLEX............................36IODOSORB............................36IOPIDINE............................ 101ipratropium bromide ........... 15, 99ipratropium-albuterol ............... 15irbesartan .................................27irbesartan-hydrochlorothiazide . 27irinotecan hcl ............................32ISENTRESS........................... 38ISENTRESS HD.................... 38ISOLYTE-S............................ 93ISOLYTE-S PH 7.4.................93isoniazid ...................................30ISORDIL TITRADOSE.........13isosorbide dinitrate ................... 13isosorbide dinitrate er ............... 13isosorbide mononitrate ............. 13isosorbide mononitrate er ..........13isradipine ................................. 42ISTALOL..............................101

itraconazole ............................. 24ivermectin ................................ 12JAKAFI.................................. 32jantoven ................................... 16JANUMET............................. 21JANUMET XR...................... 21JANUVIA...............................21JARDIANCE......................... 21jencycla ....................................46JENTADUETO...................... 21JENTADUETO XR............... 21jevantique lo ............................. 70JEVTANA.............................. 32jinteli ........................................71jolessa ...................................... 46jolivette .................................... 46JUBLIA.................................. 54junel 1.5/30 ...............................46junel 1/20 ................................. 46junel fe 1.5/30 ...........................46junel fe 1/20 ..............................46JUXTAPID.............................26KADIAN................................ 10KALETRA............................. 38KALYDECO........................ 108kariva .......................................46k-effervescent ........................... 93kelnor 1/35 ............................... 46KEPIVANCE......................... 32KERYDIN............................104KETOCARE...........................60ketoconazole .......................24, 54KETO-DIASTIX.................... 60ketoprofen ..................................7ketorolac tromethamine ...... 7, 101KETOSTIX.............................60ketotifen fumarate .................. 102KINERET................................ 8KINNEY LANCETS............. 83KINNEY THIN LANCETS...83kinray insulin syringe ................83kionex .............................. 40, 106KLOR-CON........................... 93KLOR-CON 10.......................93KLOR-CON M10................... 93klor-con m20 ............................ 93kls omeprazole ........................111

KMART VALU INSULIN SYRINGE 29G.......................83KMART VALU INSULIN SYRINGE 30G.......................84KOGENATE FS.....................74KOGENATE FS BIO-SET.....74KOMBIGLYZE XR...............21KORLYM...............................22kp cetirizine hcl ........................ 25kp omeprazole magnesium ...... 111K-PHOS..................................93K-PHOS NO 2........................ 73k-prime .................................... 93KRISTALOSE........................76KROGER BLOOD GLUCOSE TEST................... 60KROGER INSULIN SYRINGE...............................84kroger insulin syringe ............... 84kroger lancets ...........................84KROGER LANCETS 21G.....84KROGER LANCETS MICRO THIN 33G................ 84kroger lancets thin ....................84KROGER LANCETS THIN 26G......................................... 84KROGER LANCETS ULTRATHIN 30G................. 84KROGER PEN NEEDLES....84KROGER PREMIUM GLUCOSE TEST................... 60KROGER TEST.....................60kurvelo .....................................46KUVAN..................................69k-vescent .................................. 93KYLEENA............................. 46labetalol hcl ..............................40LABSTIX................................60LACRISERT........................ 102lactic acid .................................54lactulose ...................................76lactulose encephalopathy .......... 72LAMICTAL ODT.................. 17LAMICTAL XR.....................17lamivudine ................................38lamivudine-zidovudine .............. 38lamotrigine ...............................17lamotrigine er ...........................17



lancet device .............................84lancet transporter case ..............84lancets ......................................84lancets 28g ............................... 84lancets 30g ............................... 84lancets thin ...............................84LANCETS ULTRA FINE..... 84LANCETS ULTRA THIN.....84LANCETS ULTRA THIN 30G......................................... 84lancing device ........................... 84lansoprazole ........................... 111lanthanum carbonate ................ 72LANTUS................................ 22LANTUS SOLOSTAR........... 22LARIN 1.5/30......................... 46larin fe 1.5/30 ........................... 46larin fe 1/20 ..............................46LASTACAFT....................... 102latanoprost ............................. 102LATUDA................................35LEADER INSULIN SYRINGE...............................84leader insulin syringe ................ 84LEADER UNIFINE PENTIPS................................ 84leena ........................................ 46leflunomide ................................ 8LEMTRADA........................107lessina ...................................... 46LETAIRIS.............................. 43letrozole ................................... 32leucovorin calcium ....................32LEUKERAN.......................... 32LEUKINE.............................. 74levalbuterol hcl ......................... 15LEVEMIR.............................. 22LEVEMIR FLEXTOUCH..... 22levetiracetam ............................17levetiracetam er ........................17levobunolol hcl ........................102levocarnitine .............................69levocarnitine (dietary) ............. 99levocetirizine dihydrochloride ... 25levofloxacin ...................... 71, 102LEVOMEFOLATE DHA...... 96levonest .................................... 46levonorgest-eth estrad 91-day ... 46

levonorgestrel ...........................46levonorgestrel-ethinyl estrad ..... 46levora 0.15/30 (28) .................. 46levorphanol tartrate ..................10levothyroxine sodium ..............110levoxyl ................................... 110LEVULAN KERASTICK......55LEXIVA..................................38LIBERTY NEXT GENERATION TEST........... 60LIBERTY TEST.....................60lidocaine ...................................55lidocaine viscous .......................95lidocaine-hydrocortisone ace .....12lidocaine-prilocaine .................. 55LIMBREL.............................. 63LIMBREL250.........................63LIMBREL500.........................63LINCOCIN.............................29lincomycin hcl .......................... 29lindane ..................................... 55linezolid ................................... 29LINZESS................................ 72LIORESAL.............................99liothyronine sodium ................ 110LIPICHOL 540....................... 64lipodox 50 ................................ 32lisinopril ...................................27lisinopril-hydrochlorothiazide ... 27LISTER-V...............................64LITE TOUCH LANCETS......84LITE TOUCH PEN NEEDLES.............................. 84LITETOUCH INSULIN SYRINGE...............................84LITETOUCH PEN NEEDLES.............................. 84lithium ..................................... 35lithium carbonate ..................... 35lithium carbonate er ................. 35LITHOSTAT.......................... 73LIVALO..................................26LIVE BETTER LANCET SUPER THIN.........................84LIVE BETTER LANCET ULTRA THIN........................85l-methylfolate ...........................64l-methylfolate ca me-cbl nac ..... 64

l-methylfolate calcium .............. 64l-methylfolate formula 15 ......... 64l-methylfolate formula 7.5 ........ 64l-methylfolate forte ...................64l-methylfolate-algae-b12-b6 ......64l-methylfolate-b6-b12 ............... 64l-methyl-mc ..............................64l-methyl-mc nac ........................64LO LOESTRIN FE.................46LOESTRIN FE 1.5/30............ 46LOESTRIN FE 1/20............... 46lomedia 24 fe ............................46longs insulin syringe ................. 85LONGS LANCETS STANDARD.......................... 85LONGS LANCETS THIN..... 85LONGS LANCETS ULTRA THIN...................................... 85loperamide hcl .......................... 23lopinavir-ritonavir .................... 38loratadine .................................25loratadine allergy relief ............ 25loratadine childrens .................. 25loratadine hives relief ............... 25loratadine-d 12hr ......................50loratadine-d 24hr ......................50lorazepam ................................ 13lorcet ....................................... 10lorcet hd ...................................10loryna ...................................... 47losartan potassium ....................27losartan potassium-hctz ............ 27LOSEASONIQUE..................47LOTEMAX...........................102lovastatin ................................. 26low-ogestrel ..............................47loxapine succinate .................... 35ludent .......................................93LUKAID GLA....................... 64LUMIGAN...........................102LUMIZYME.......................... 69lutera ....................................... 47LUZU..................................... 55LYRICA................................. 17LYSODREN...........................32lyza ..........................................47MACUTEK............................ 64



MAGELLAN INSULIN SAFETY SYR........................ 85magnesium chloride .................. 93magnesium sulfate .................... 93malathion .................................55manganese chloride .................. 93maprotiline hcl ......................... 19MAR-COF BP........................ 50marlissa ................................... 47MARNATAL-F......................96MARPLAN............................ 19marten-tab ................................. 9MATULANE......................... 32matzim la ................................. 42MAVYRET............................ 75MAXI-COMFORT INSULIN SYRINGE............. 85MAXIDEX........................... 102meclizine hcl .............................23meclofenamate sodium ............... 8MEDICINE SHOPPE PEN NEEDLES.............................. 85MEDISENSE THIN LANCETS.............................. 85MEDLANCE EXTRA 21G....85MEDLANCE LITE 25G........ 85MEDLANCE PLUS EXTRA 21G......................................... 85MEDLANCE PLUS LANCETS.............................. 85MEDLANCE PLUS LITE 25G......................................... 85MEDLANCE PLUS SUPERLITE 30G................... 85MEDLANCE PLUS UNIVERSAL 21G..................85MEDLANCE UNIVERSAL 21G......................................... 85medroxyprogesterone acetate......................................... 47, 106mefenamic acid .......................... 8mefloquine hcl .......................... 30megestrol acetate .............. 32, 106MEIJER BLOOD GLUCOSE TEST................... 60MEIJER LANCETS...............85MEIJER LANCETS THIN.... 85

MEIJER LANCETS UNIVERSAL 21G..................85MEIJER LANCETS UNIVERSAL 33G..................85MEIJER PEN NEEDLES...... 85MEIJER PREMIUM GLUCOSE TEST................... 60MEIJER SUPER THIN LANCETS.............................. 85MEKINIST.............................32meloxicam ................................. 8melphalan .................................32melphalan hcl ........................... 32memantine hcl ........................ 107MENEST................................ 71MENOPUR............................ 69MENOSTAR.......................... 71MENTAX...............................55meperidine hcl .......................... 10MEPHYTON........................114meprobamate ........................... 13mercaptopurine ........................ 32meropenem ...............................29mesalamine .............................. 72mesalamine-cleanser .................72mesna .......................................32MESNEX................................32MESTINON........................... 30metadate er ................................ 6METAFOLBIC...................... 65METAFOLBIC PLUS............65METAFOLBIC PLUS RF......65METANX...............................65metaproterenol sulfate ..............15metaxalone .............................. 99metformin hcl ........................... 22metformin hcl er ....................... 22metformin hcl er (osm) ............ 22methadone hcl .......................... 10methadone hcl intensol ..............10methamphetamine hcl .................6methazolamide ......................... 67methenamine hippurate ...........112methenamine mandelate ..........112methimazole ........................... 110METHITEST..........................12methocarbamol .........................99methotrexate ............................32

methotrexate sodium (pf) ........ 33methoxsalen rapid .................... 55methscopolamine bromide .......111methyclothiazide ...................... 67methyl salicylate ...................... 55methyldopa .............................. 27methyldopa-hydrochlorothiazide ..................27methyldopate hcl ...................... 27methylphenidate hcl ....................6methylphenidate hcl er ................6methylphenidate hcl er (cd) ........6methylphenidate hcl er (la) ........ 6methylprednisolone ...................49methyltestosterone ................... 12metipranolol ........................... 102metoclopramide hcl .................. 72metolazone ...............................67metoprolol succinate er .............40metoprolol tartrate ................... 41metoprolol-hydrochlorothiazide 27metronidazole ..............29, 55, 113mexiletine hcl ........................... 14MIACALCIN......................... 69MIBELAS 24 FE.................... 47miconazole 3 ...........................113MICRODOT TEST................ 60microgestin 1.5/30 .................... 47microgestin 1/20 ....................... 47microgestin fe 1.5/30 ................ 47microgestin fe 1/20 ................... 47MICROLET LANCETS.........85midazolam hcl .......................... 75midodrine hcl ..........................113MIGERGOT.......................... 92miglitol .................................... 22MILLIPRED.......................... 49MILLIPRED DP.................... 49mimvey .................................... 71MIMVEY LO......................... 71minocycline hcl .......................109minoxidil ..................................27MIRALAX............................. 76MIRCERA............................. 74MIRCETTE............................47MIRENA (52 MG)................. 47mirtazapine .............................. 19MIRVASO..............................55



misoprostol .............................111mitomycin ................................ 33MITOSOL.............................102mitoxantrone hcl ...................... 33modafinil ....................................6moderiba .................................. 38moexipril hcl ............................ 27moexipril-hydrochlorothiazide .. 27mometasone furoate ............55, 99monoject flush syringe .............. 93MONOJECT INSULIN SYRINGE...............................85monoject sodium chloride flush . 94MONOJECT SYRINGE........ 85MONOJECT ULTRA COMFORT SYRINGE..........85MONOLET LANCETS..........85mono-linyah ............................. 47mononessa ................................47montelukast sodium ..................15MONUROL..........................112MORGIDOX........................109morphine sulfate .......................11morphine sulfate (concentrate) .10morphine sulfate er ...................10morphine sulfate er beads ......... 10MOTOFEN............................ 23MOVIPREP............................76MOXEZA............................. 102moxifloxacin hcl ............... 71, 102MOZOBIL.............................. 75ms insulin syringe ..................... 85MULTAQ...............................14multi-lancet device ....................86MULTISTIX.......................... 60MULTISTIX 10 SG................60MULTISTIX 5........................60MULTISTIX 7........................60MULTISTIX 8........................60MULTISTIX 9........................60MULTISTIX 9 SG..................61multi-vit/fluoride ...................... 96multivitamin/fluoride ................ 96multi-vitamin/fluoride ...............96mupirocin ................................. 55mupirocin calcium .................... 55m-vit ........................................ 96my way .................................... 47

MYCAMINE..........................24mycophenolate mofetil ..............40MYGLUCOHEALTH LANCETS 30G.......................86MYGLUCOHEALTH TEST. 61MYLERAN............................ 33mynatal ....................................96mynatal advance .......................96mynatal plus .............................96mynatal-z .................................96MYOBLOC............................ 99myorisan .................................. 55MYRBETRIQ.......................112MYTESI................................. 23myzilra .....................................47nabumetone ................................8nadolol ..................................... 41nadolol-bendroflumethiazide .....27nafcillin sodium ...................... 105NAFRINSE............................ 94naftifine hcl .............................. 55NAFTIN................................. 55NAGLAZYME.......................69nalbuphine hcl .......................... 11naloxone hcl ............................. 23naltrexone hcl ...........................23NAMENDA XR...................107NAMENDA XR TITRATION PACK.............107NAMZARIC.......................... 18naproxen ....................................8naproxen dr ................................8naproxen sodium ........................ 8naratriptan hcl ......................... 92NARCAN............................... 23NATACHEW......................... 96NATACYN...........................102NATALVIT............................ 96NATAZIA.............................. 47nateglinide ................................22NATELLE ONE.....................96NATURE-THROID.............110NEBUPENT........................... 29nebusal .....................................50necon 0.5/35 (28) .....................47necon 1/35 (28) ........................47necon 1/50 (28) ........................47necon 7/7/7 ...............................47

nefazodone hcl .................. 19, 108neomycin sulfate ........................ 6neomycin-bacitracin zn-polymyx ................................. 102neomycin-polymyxin b gu ......... 73neomycin-polymyxin-dexameth...............................................102neomycin-polymyxin-gramicidin .............................. 102neomycin-polymyxin-hc .. 102, 104neo-polycin .............................102neo-polycin hc ........................ 102NEO-SYNALAR....................55NESTABS...............................96NESTABS DHA..................... 96NEULASTA........................... 75NEUPOGEN.......................... 75NEUPRO................................34NEUTEK 2TEK GLUCOSE/PRESSURE.........86NEUTEK 2TEK TEST...........61neutragard advanced ................ 95neutral sodium fluoride ............. 95NEVANAC...........................102nevirapine .................................38nevirapine er .............................38NEXA PLUS.......................... 96NEXAVAR.............................33NEXIUM..............................111NEXIUM 24HR................... 111NEXPLANON....................... 47next choice one dose ................. 47niacin ..................................... 114niacin er ................................. 114niacin er (antihyperlipidemic) .. 26nicardipine hcl .......................... 42NICODERM CQ.................. 107nicotine .................................. 107nicotine polacrilex .................. 107nicotine step 1 .........................107nicotine step 2 .........................107nicotine step 3 .........................107NICOTROL..........................107NICOTROL NS....................107nifediac cc ................................ 42nifedical xl ............................... 42nifedipine ................................. 42nifedipine er ............................. 42



nifedipine er osmotic release ..... 42nikki ........................................ 47nilutamide ................................ 33nimodipine ................................42nisoldipine er ............................ 42NITRO-BID........................... 13NITRO-DUR......................... 13nitrofurantoin .........................112nitrofurantoin macrocrystal .... 112nitrofurantoin monohyd macro112nitroglycerin .............................13nitroglycerin er .........................13nitro-time ................................. 13nizatidine ................................111nora-be .....................................47norepinephrine bitartrate ........ 114norethin ace-eth estrad-fe ......... 47norethindrone ........................... 47norethindrone acetate ............. 106norgestimate-eth estradiol ........ 47norgestim-eth estrad triphasic ...47NORITATE............................55norlyroc ................................... 47normal saline flush ................... 94NORMOSOL-R......................94NORMOSOL-R PH 7.4..........94NORPACE CR.......................14nortrel 0.5/35 (28) ................... 47nortrel 1/35 (21) ...................... 48nortrel 1/35 (28) ...................... 48nortrel 7/7/7 ............................. 48nortriptyline hcl ........................19NORVIR.................................38NOVA MAX GLUCOSE TEST.......................................61NOVA SAFETY LANCETS 23G......................................... 86NOVA SAFETY LANCETS 28G......................................... 86NOVA SUREFLEX LANCETS.............................. 86NOVAREL............................. 69NOVOFINE........................... 86NOVOFINE AUTOCOVER..86NOVOLOG............................ 22NOVOLOG FLEXPEN..........22NOVOLOG MIX 70/30.......... 22

NOVOLOG MIX 70/30 FLEXPEN.............................. 22NOVOLOG PENFILL........... 22NOVOTWIST.........................86NOXAFIL.............................. 24np thyroid ...............................110NPLATE.................................75NUCYNTA............................ 11NUCYNTA ER...................... 11NUEDEXTA........................ 107NULOJIX............................... 40NUVARING.......................... 48nystatin .........................24, 55, 95nystatin-triamcinolone ..............55OB COMPLETE.....................96OB COMPLETE ONE........... 96OB COMPLETE PREMIER..96OB COMPLETE/DHA...........96OBREDON.............................50obstetrix ec .............................. 96O-CAL FA.............................. 96O-CAL PRENATAL.............. 96ocella ....................................... 48OCTAGAM.......................... 104octreotide acetate ..................... 69OCUVEL................................ 96ODEFSEY.............................. 38ODOMZO...............................33ofloxacin ................... 71, 102, 104ogestrel .................................... 48olanzapine ................................35olanzapine-fluoxetine hcl ........ 107olmesartan medoxomil ............. 28olmesartan medoxomil-hctz ...... 28olmesartan-amlodipine-hctz ......28olopatadine hcl ..................99, 102omega-3-acid ethyl esters ..........26omeprazole .............................111omeprazole magnesium ...........111omeprazole-sodium bicarbonate ............................ 111OMNARIS..............................99OMNITROPE........................ 69ON CALL LANCETS............ 86ON CALL PLUS BLOOD GLUCOSE..............................61ON CALL PLUS LANCETS. 86

ON CALL VIVID BLOOD GLUCOSE..............................61ondansetron ..............................23ondansetron hcl ........................ 24ONETOUCH CLUB LANCETS FINE PT.............. 86ONETOUCH DELICA LANCETS 33G.......................86ONETOUCH DELICA LANCETS FINE.................... 86ONETOUCH DELICA LANCING DEV.....................86ONETOUCH FINEPOINT LANCETS.............................. 86ONETOUCH LANCETS....... 86ONETOUCH SURESOFT LANCING DEV.....................86ONETOUCH ULTRA BLUE......................................61ONETOUCH ULTRASOFT LANCETS.............................. 86ONETOUCH VERIO.............61ONFI...................................... 17ONGLYZA.............................22OPANA ER............................ 11opium .......................................23OPSUMIT...............................43ORACIT................................. 73oralone .....................................95ORAMAGICRX.................... 95ORAVIG.................................95ORENCIA................................ 8ORENCIA CLICKJECT..........8ORENITRAM........................43ORFADIN..............................69ORKAMBI............................. 51orphenadrine citrate er ............. 99orsythia ....................................48ORTHO MICRONOR........... 48ORTHO TRI-CYCLEN (28).. 48ORTHO TRI-CYCLEN LO... 48ORTHO-CYCLEN (28)..........48ORTHO-NOVUM 1/35 (28)... 48oscion cleanser ......................... 55oseltamivir phosphate ............... 38OSMOPREP........................... 76OSPHENA..............................69OTEZLA...............................105



OVACE PLUS........................ 55OVIDREL.............................. 69oxacillin sodium ..................... 105oxaliplatin ................................33oxandrolone ............................. 12oxaprozin ...................................8OXAYDO............................... 11oxazepam .................................13oxcarbazepine .......................... 17oxiconazole nitrate ................... 55OXISTAT............................... 55OXTELLAR XR.................... 18oxybutynin chloride ................ 112oxybutynin chloride er ............ 112oxycodone hcl .......................... 11oxycodone hcl er .......................11oxycodone-acetaminophen ........11oxycodone-aspirin .................... 11oxycodone-ibuprofen ................ 11OXYCONTIN........................ 11oxymorphone hcl ...................... 11oxymorphone hcl er .................. 11pacerone ...................................14paclitaxel ................................. 33paliperidone er ..........................36pamidronate disodium .............. 69PAMINE FQ........................ 111PANCREAZE........................ 66PANRETIN............................55pantoprazole sodium ...............111PARAGARD INTRAUTERINE COPPER..48PAREMYD.......................... 102paricalcitol ............................... 69paroex ......................................95paromomycin sulfate .................. 6paroxetine hcl ...........................19paroxetine hcl er .......................19PASER....................................30PC LANCETS SUPER THIN 30G......................................... 86PC UNIFINE PENTIPS.........86PCE.........................................77peg 3350 ...................................76peg 3350/electrolytes ................ 76peg 3350-kcl-na bicarb-nacl ......76peg-3350/electrolytes ................76PEGANONE.......................... 18

PEGASYS...............................38PEGASYS PROCLICK..........38PEG-PREP............................. 76pen needles ............................... 86pen needles 1/2" ........................86pen needles 3/16" ...................... 86pen needles 5/16" ...................... 86penicillin g potassium ..............105penicillin g procaine ................105penicillin g sodium .................. 105penicillin v potassium ..............105PENTAM................................29PENTASA.............................. 72pentazocine-naloxone hcl ..........11pentoxifylline er ....................... 74PEPCID AC MAXIMUM STRENGTH......................... 111PERCURA............................. 65PERFOROMIST.................... 15perindopril erbumine .................28periogard ..................................95permethrin ................................55perphenazine ............................ 36perphenazine-amitriptyline ..... 107PERTZYE.............................. 66PHARMACIST CHOICE AUTOCODE.......................... 61PHARMACIST CHOICE LANCETS.............................. 86phenadoz ..................................25PHENAZO............................. 73phenazopyridine hcl .................. 73phendimetrazine tartrate ............ 6phenelzine sulfate ..................... 19phenobarbital ........................... 76phenoxybenzamine hcl ..............28phentermine hcl .......................... 6phenylephrine hcl ....................102phenytoin ................................. 18phenytoin infatabs .................... 18phenytoin sodium extended ....... 18philith ...................................... 48PHOSLYRA........................... 72phospha 250 neutral ..................94phosphasal ..............................112PHOSPHOLINE IODIDE....102physiolyte .................................40PICATO..................................55

pilocarpine hcl .................. 95, 102pimozide .................................107pimtrea .................................... 48pindolol .................................... 41pioglitazone hcl ........................ 22pioglitazone hcl-glimepiride ...... 22pioglitazone hcl-metformin hcl ..22piperacillin sod-tazobactam so 105pirmella 1/35 ............................ 48pirmella 7/7/7 ........................... 48piroxicam ...................................8PLAN B ONE-STEP...............48PLASMA-LYTE 148.............. 94PLASMA-LYTE A.................94PLEGRIDY.......................... 108PLEGRIDY STARTER PACK....................................108PNV FOLIC ACID + IRON.. 96pnv-dha .................................... 96PNV-DHA+DOCUSATE...... 97PNV-OMEGA........................ 97pnv-select ................................. 97PNV-TOTAL.......................... 97POCKETCHEM EZ TEST.....61podofilox ..................................55polycin ................................... 102polyethylene glycol 3350 ...........76polymyxin b sulfate .................. 29polymyxin b-trimethoprim ...... 102POLY-VI-FLOR.....................97POMALYST...........................33portia-28 .................................. 48pot bicarb-pot chloride ..............94potassium acetate ..................... 94potassium bicarbonate .............. 94potassium chloride ....................94potassium chloride crys er .........94potassium chloride er ................94potassium citrate er .................. 73potassium citrate-citric acid ......73potassium phosphates ............... 94pr benzoyl peroxide wash ..........55pr natal 400 ..............................97pr natal 430 ..............................97pr natal 430 ec ..........................97PRADAXA.............................16PRALUENT......................... 104pramcort .................................. 12



pramipexole dihydrochloride .....34pramipexole dihydrochloride er .35PRAMOSONE....................... 55prasugrel hcl .............................74pravastatin sodium ................... 26prazosin hcl .............................. 28PRECISION PCX...................61PRECISION PCX PLUS TEST.......................................61PRECISION POINT OF CARE TEST........................... 61PRECISION QID TEST.........61PRECISION SOF-TACT TEST.......................................61PRECISION SUREDOSE PLUS SYR..............................86PRECISION SURE-DOSE SYRINGE...............................86PRECISION THIN LANCETS.............................. 86PRECISION ULTRA LANCET................................ 86PRECISION XTRA BLOOD GLUCOSE..............................61PRED MILD........................ 103PRED-G................................103PRED-G S.O.P..................... 103prednicarbate ........................... 56prednisolone ............................. 49prednisolone acetate ............... 103prednisolone sodium phosphate................................... 49, 50, 103prednisone ................................50PREDNISONE INTENSOL.. 50PREFERAOB ONE............... 97PREFERRED PLUS INSULIN SYRINGE............. 86PREFERRED PLUS LANCETS COLORED.......... 87PREFERRED PLUS LANCETS THIN................... 87PREFERRED PLUS UNIFINE PENTIPS...............87PREFEST............................... 71PREGNYL............................. 70PREMARIN................... 71, 113PREMPHASE........................ 71PREMPRO............................. 71

PRENAISSANCE.................. 97PRENAISSANCE BALANCE............................. 97PRENAISSANCE HARMONY DHA................. 97PRENAISSANCE NEXT.......97PRENAISSANCE PLUS........97PRENATA............................. 97prenatabs rx .............................97prenatal 19 ............................... 97prenatal low iron ...................... 97PRENATAL PLUS IRON..... 97PRENATAL-U.......................97PRENATE DHA.................... 97PRENATE ELITE..................97PRENATE ESSENTIAL........97PRENATE MINI................... 97PREPIDIL............................ 104PREPOPIK.............................76PRESTALIA...........................28PREVACID.......................... 111prevalite ................................... 26previfem ................................... 48PREZCOBIX.......................... 38PREZISTA............................. 38PRIFTIN................................ 30PRILOSEC OTC...................111primaquine phosphate ...............30primidone ................................. 18PRIMSOL...............................29probenecid ................................73procainamide hcl ...................... 14prochlorperazine .......................36prochlorperazine maleate ..........36PROCORT............................. 12PROCRIT...............................75PROCTOFOAM HC..............12procto-pak ................................12proctosol hc ..............................12proctozone-hc ...........................12PRODIGY INSULIN SYRINGE...............................87PRODIGY LANCETS 28G... 87PRODIGY NO CODING BLOOD GLUC...................... 61PRODIGY TWIST TOP LANCETS 28G.......................87progesterone micronized ......... 106

PROGLYCEM....................... 22PROLASTIN-C.................... 108PROLEUKIN.........................33PROLIA..................................70PROMACTA..........................75promethazine hcl ...................... 25promethazine vc/codeine ........... 50promethazine-codeine ............... 50promethazine-dm ......................50promethegan ............................ 25propafenone hcl ........................ 14propafenone hcl er .................... 14propantheline bromide ............ 111proparacaine hcl ..................... 103proparacaine-fluorescein .........103propranolol hcl ......................... 41propranolol hcl er ..................... 41propranolol-hctz .......................28propylthiouracil ......................110PROSTIN E2........................ 104PROTEOLIN..........................65PROTEOLIN DS....................65protriptyline hcl ........................19PRUDOXIN...........................56PRUTECT.............................. 56pseudoeph-chlorphen-hydrocod . 50PULMICORT FLEXHALER........................ 15PULMONA............................ 65PULMOZYME.....................108PX EXTRA SHORT PEN NEEDLES.............................. 87PX INSULIN SYRINGE....... 87PX LANCETS ULTRA THIN...................................... 87PX PEN NEEDLE..................87PYLERA...............................111pyrazinamide ............................30pyridostigmine bromide ............ 30pyridostigmine bromide er ........ 30QC LANCETS SUPER THIN 30G...............................87QC LANCETS ULTRA THIN...................................... 87qc omeprazole magnesium ...... 111QC PEN NEEDLES............... 87QC UNIFINE PENTIPS........ 87QNASL................................... 99



QNASL CHILDRENS........... 99QSYMIA.................................. 6quasense ...................................48quazepam .................................76quetiapine fumarate ..................36quetiapine fumarate er ..............36QUILLIVANT XR...................6quinapril hcl ............................. 28quinapril-hydrochlorothiazide ... 28quinidine gluconate er ...............14quinidine sulfate ....................... 14quinine sulfate .......................... 30QVAR..................................... 15RA E-ZJECT LANCETS 28G......................................... 87RA E-ZJECT LANCETS THIN 26G...............................87RA E-ZJECT LANCETS THIN 28G...............................87RA E-ZJECT LANCETS ULTRA THIN........................87RA INSULIN SYRINGE.......87RA PEN NEEDLES............... 87RA TRUETEST TEST........... 61rabeprazole sodium .................111RADIAPLEXRX....................56RAJANI..................................48raloxifene hcl ........................... 70ramipril ....................................28RANEXA............................... 13ranitidine hcl .......................... 112RAPAFLO..............................73RAPAMUNE......................... 40rasagiline mesylate ................... 35RAVICTI................................70RAYOS...................................50reality insulin syringe ............... 87REBETOL.............................. 38REBIF...................................108REBIF REBIDOSE.............. 108REBIF REBIDOSE TITRATION PACK.............108REBIF TITRATION PACK 108reclipsen ...................................48RECTIV..................................12REFUAH PLUS BLOOD GLUCOSE TEST................... 61REGRANEX..........................56

RELAGARD........................ 113RELENZA DISKHALER......38RELION INSULIN SYRINGE...............................87RELI-ON INSULIN SYRINGE...............................87RELION KETONE................61RELION LANCETS STANDARD 21G.................. 87RELION LANCETS THIN 26G......................................... 87RELION LANCETS ULTRA-THIN 30G................87RELION MINI PEN NEEDLES.............................. 87RELION PEN NEEDLES......87RELION SHORT PEN NEEDLES.............................. 87RELION ULTRA THIN LANCETS 30G.......................87RELION ULTRA THIN PLUS LANCETS....................87RELISTOR.............................72RELNATE DHA....................97REMICADE...........................72REMODULIN....................... 43RENAGEL............................. 72repaglinide ............................... 22repaglinide-metformin hcl .........22REPATHA............................104REPATHA PUSHTRONEX SYSTEM...............................104REPATHA SURECLICK.... 104RESCRIPTOR........................38RESCULA............................ 103RESTASIS............................ 103REVEAL BLOOD GLUCOSE TEST................... 61revesta ..................................... 75REVLIMID............................ 40revonto .....................................99REXALL BLOOD GLUCOSE TEST................... 61REXALL LANCETS ULTRA THIN 30G................ 88REXULTI...............................36REYATAZ............................. 38ribasphere ................................ 38

ribavirin ................................... 38RIDAURA............................... 8rifabutin ................................... 30RIFAMATE........................... 30rifampin ................................... 30RIFATER...............................30RIGHTEST GL300 LANCETS.............................. 88RIGHTEST GS100 BLOOD GLUCOSE..............................61RIGHTEST GS300 BLOOD GLUCOSE..............................61RIGHTEST GS550 BLOOD GLUCOSE..............................61riluzole .....................................99rimantadine hcl ........................ 38ringers irrigation ...................... 40risedronate sodium ................... 70risperidone ............................... 36risperidone m-tab ..................... 36RITUXAN..............................33rivastigmine ............................108rivastigmine tartrate ............... 108RIVELSA............................... 48rizatriptan benzoate ..................92ropinirole hcl ............................ 35ropinirole hcl er ........................ 35rosadan .................................... 56rosuvastatin calcium ................. 26ROZEREM.............................76RUBRACA................... 105, 106SABRIL.................................. 18SAFESNAP INSULIN SYRINGE...............................88safety lancet 21g/pressure act ... 88safety lancet 28g/pressure act ... 88SAFETY LANCETS.............. 88SAFETY LANCETS 21G.......88safety lancets 28g ..................... 88SAFETY LET LANCETS......88SAFETY SEAL LANCETS... 88SAFETY-GLIDE SYRINGE.88SAFYRAL..............................48salacyn .....................................56salicylic acid .............................56salicylic acid wart remover ....... 56salicylic acid-cleanser ............... 56saline flush ............................... 94



saline flush zr ........................... 94salsalate .....................................9SAMSCA................................ 70SANCUSO..............................24SANTYL.................................56SAPHRIS................................36SAVELLA.............................108SAVELLA TITRATION PACK....................................108SB INSULIN SYRINGE........88SB LANCETS THIN.............. 88SB LANCETS ULTRA THIN...................................... 88scalacort .................................. 56SCALACORT DK..................56scopolamine ............................. 24SEASONIQUE....................... 48seb-prev wash ........................... 56SECONAL..............................76SELECT-OB........................... 97selegiline hcl .............................35selenium sulfide ........................ 56selenium sulf-pyrithione-urea .... 56SELZENTRY......................... 39SEMPREX-D......................... 50se-natal 19 ................................97SENSIPAR............................. 70SENTRA AM......................... 65SENTRA PM..........................65SEREVENT DISKUS............ 15sertraline hcl ............................ 19sevelamer carbonate ................. 72sf ..............................................95sf 5000 plus .............................. 95sharobel ................................... 48SHOPKO UNIFINE PENTIPS................................ 88SHOPKO UNILET LANCETS 28G.......................88SHOPKO UNILET LANCETS 30G.......................88SIGNIFOR............................. 70sildenafil citrate ........................43SILVASORB...........................56silver nitrate ............................. 56silver sulfadiazine ..................... 56SIMBRINZA........................ 103SIMPONI................................. 8

SIMPONI ARIA.......................8SIMULECT............................ 40simvastatin ...............................26SINGLE-LET......................... 88sirolimus .................................. 40SIRTURO...............................30SIVEXTRO.............................29SKLICE.................................. 56sm insulin syringe ..................... 88SM LANCETS 33G................ 88SMART SENSE COLOR LANCETS 33G.......................88SMART SENSE STANDARD LANCETS....... 88SMART SENSE SUPER THIN LANCETS................... 88SMART SENSE THIN LANCETS 26G.......................88SMARTEST BLOOD GLUCOSE TEST................... 61SMARTEST LANCETS 28G.88SMOOTH LAX...................... 76sodium chloride ............. 51, 73, 94sodium chloride flush ................ 94sodium fluoride .........................94sodium phenylbutyrate ........ 44, 70sodium polystyrene sulfonate......................................... 40, 106sodium sulfacetamide ................56SODIUM SULFACETAMIDE WASH..56solia ......................................... 48SOLUS V2 LANCETS 28G....88SOLUS V2 TEST.................... 61SOLUS V2 TWIST LANCETS 30G.......................88SOMATULINE DEPOT........ 70SOMAVERT.......................... 70SONAFINE............................ 56sorbitol-mannitol ......................73sorine ....................................... 41sotalol hcl .................................41sotalol hcl (af) ......................... 41SOVALDI...............................39spinosad ................................... 56SPIRIVA HANDIHALER.....15SPIRIVA RESPIMAT............15spironolactone .......................... 67

spironolactone-hctz .................. 67SPORANOX...........................24sprintec 28 ................................48SPRYCEL...............................33sronyx ......................................48ssd ............................................56SSKI........................................94sss 10-5 .................................... 56st joseph aspirin ..........................9stavudine .................................. 39STELARA.........................56, 76STERILANCE PA..................88STERILANCE TL..................88STIMATE...............................70STIOLTO RESPIMAT...........15STIVARGA............................ 33streptomycin sulfate ................... 6STRIANT............................... 12STRIBILD.............................. 39STRIVERDI RESPIMAT...... 15SUBOXONE...........................11SUCRAID.............................. 66sucralfate ............................... 112sulfacetamide sodium ........ 56, 103sulfacetamide sodium (acne) .... 56sulfacetamide sodium-sulfur ......57sulfacetamide-prednisolone ..... 103sulfacetamide-sulfur in urea ......57sulfacleanse 8/4 ........................ 57sulfadiazine ............................ 109sulfamethoxazole-trimethoprim 29SULFAMYLON.....................57sulfasalazine .............................72sulfatrim pediatric .................... 29sulfazine ...................................72sulindac ......................................8sumatriptan ..............................92sumatriptan succinate ...............92sumatriptan succinate refill .......92SUPER THIN LANCETS......88SUPRAX................................ 44SUPREP BOWEL PREP KIT 76SURE COMFORT INSULIN SYRINGE............. 89SURE COMFORT LANCETS 28G.......................89SURE COMFORT LANCETS 30G.......................89



SURE COMFORT PEN NEEDLES.............................. 89SURE EDGE TEST................61SURECHEK BLOOD GLUCOSE TEST................... 61SURE-FINE PEN NEEDLES.............................. 89SURE-JECT INSULIN SYRINGE...............................89SURE-LANCE FLAT LANCETS.............................. 89SURE-LANCE THIN LANCETS 28G.......................89SURE-LANCE ULTRA THIN LANCETS................... 89SURESTEP PRO LINEARITY.......................... 89SURE-TEST EASYPLUS MINI TEST............................ 61SURE-TOUCH LANCETS UNIVERSAL......................... 89SUSTIVA................................39SUTENT.................................33swabflush saline flush ............... 94syeda ........................................48SYLATRON...........................33SYMBICORT......................... 15SYMLINPEN 120...................22SYMLINPEN 60.................... 22SYNAGIS............................. 104SYNAREL..............................70SYNERA................................ 57SYNERCID............................29SYNJARDY......................... 109SYNJARDY XR...................109SYNRIBO...............................33SYPRINE............................... 40TABLOID...............................33TACLONEX...........................57tacrolimus ...........................40, 57TAFINLAR............................33take action ............................... 48TALWIN................................ 11TAMIFLU..............................39tamoxifen citrate ......................33tamsulosin hcl ...........................73TANZEUM............................ 22TARCEVA............................. 33

TARGRETIN.........................57TARON-BC............................97TARON-C DHA.................... 97taron-crystals ........................... 73TARON-PREX.......................97TASIGNA...............................33TAXOTERE........................... 33TAYTULLA...........................48tazarotene ................................ 57tazicef ...................................... 44TAZORAC............................. 57taztia xt ................................... 42TECFIDERA........................108TECHLITE AST LANCETS..89TECHLITE LANCETS..........89TECHLITE LANCETS 30G.. 89TECHNIVIE...........................75TEFLARO..............................44TEKTURNA.......................... 28TEKTURNA HCT................. 28TELCARE BLOOD GLUCOSE TEST................... 61telmisartan ...............................28telmisartan-amlodipine ............. 28telmisartan-hctz ....................... 28temazepam ...............................76temozolomide ........................... 33tencon ........................................ 9terazosin hcl ............................. 28terbinafine hcl .......................... 24terbutaline sulfate .....................15terconazole .............................113TESTOPEL.............................12testosterone ..............................12testosterone cypionate .............. 12testosterone enanthate .............. 12tetcaine .................................. 103tetrabenazine ..........................108tetracaine hcl ..........................103tetracycline hcl ....................... 109TEXACORT...........................57tgt blood glucose test ................ 61TGT LANCET MICRO THIN 33G...............................89TGT LANCET THIN 26G.....89TGT LANCET ULTRA THIN 30G...............................89THALOMID.......................... 40

THEO-24................................ 15theochron ................................. 15theophylline ..............................15theophylline er ..........................15THERAMINE........................ 65THERAMINE PLUS............. 65THINLETS LANCET............ 89thioguanine .............................. 44THIOLA................................. 73thioridazine hcl .........................36thiothixene ............................... 36THYMOGLOBULIN.............40THYROLAR-1..................... 110THYROLAR-1/2.................. 110THYROLAR-1/4.................. 110THYROLAR-2..................... 110THYROLAR-3..................... 110tiagabine hcl .............................18tilia fe ...................................... 48timolol maleate ................. 41, 103TIMOPTIC OCUDOSE....... 103tinidazole ................................. 29TIROSINT............................110TIS-U-SOL............................. 40TIVICAY................................39tizanidine hcl ............................ 99TL-SELECT............................97TOBRADEX.........................103tobramycin ......................... 6, 103tobramycin sulfate ......................6tobramycin-dexamethasone .... 103TOBREX.............................. 103TODAY SPONGE................113TODAYS HEALTH MINI PEN NEEDLES......................89TODAYS HEALTH PEN NEEDLES.............................. 89TODAYS HEALTH THIN LANCETS 28G.......................89TODAYS HEALTH THIN LANCETS 30G.......................89tolazamide ................................22tolbutamide .............................. 22tolcapone ..................................35tolmetin sodium ..........................8tolterodine tartrate ................. 112tolterodine tartrate er ............. 112



TOPCARE CLICKFINE PEN NEEDLES......................89TOPCARE ULTRA COMFORT INS SYR............ 89topiramate ............................... 18toposar .....................................33topotecan hcl ............................33TORISEL................................33torsemide ................................. 67TOVIAZ................................112TRACLEER........................... 43TRADJENTA.........................23tramadol hcl ............................. 11tramadol hcl er ......................... 11tramadol hcl er (biphasic) ........ 11tramadol-acetaminophen .......... 11trandolapril .............................. 28trandolapril-verapamil hcl er .... 28tranexamic acid ........................75tranylcypromine sulfate ............ 19TRAVATAN Z..................... 103trazodone hcl .............19, 108, 109TRECATOR...........................30TRELSTAR MIXJECT..........33TREPADONE........................ 65TRESIBA FLEXTOUCH...... 23tretinoin ..............................33, 57TREXALL..............................33triamcinolone acetonide .57, 95, 99triamterene-hctz ....................... 67triazolam ..................................76tricare ...................................... 98TRICARE PRENATAL DHA ONE.............................. 98TRICITRASOL......................16tricitrates ................................. 73triderm .....................................57tri-estarylla .............................. 48trifluoperazine hcl .................... 36trifluridine ..............................103trihexyphenidyl hcl ................... 35tri-legest fe ...............................49tri-linyah .................................. 49trilyte .......................................76trimethobenzamide hcl ..............24trimethoprim ............................ 29trinatal rx 1 ..............................98TRINATE...............................98

trinessa (28) ............................ 49TRINTELLIX.................19, 109tri-previfem .............................. 49TRIPTODUR......................... 70TRISENOX............................ 33tri-sprintec ............................... 49TRIUMEQ............................. 39TRIVEEN-DUO DHA...........98TRI-VI-FLOR........................ 98TRI-VI-FLORO..................... 98trivora (28) ..............................49TRIZIVIR...............................39tropicamide ............................ 103trospium chloride ....................112trospium chloride er ................112TRUEPLUS INSULIN SYRINGE...............................89TRUEPLUS LANCETS 28G. 89TRUEPLUS LANCETS 30G. 90TRUEPLUS LANCETS 33G. 90TRUEPLUS SAFETY LANCETS 28G.......................90TRUETEST TEST..................61TRUETRACK TEST............. 61TRULICITY...........................23TRUVADA............................ 39TUDORZA PRESSAIR......... 16TUSSICAPS........................... 51tussigon ....................................51TYBOST................................. 36TYGACIL.............................. 29TYKERB................................ 34UCERIS..................................50ULESFIA............................... 57ULORIC................................. 73ULTICARE INSULIN SAFETY SYR........................ 90ULTICARE INSULIN SYRINGE...............................90ULTICARE MICRO PEN NEEDLES.............................. 90ULTICARE MINI PEN NEEDLES.............................. 90ULTICARE PEN NEEDLES 90ULTICARE SHORT PEN NEEDLES.............................. 90ULTILET CLASSIC LANCETS.............................. 90

ULTILET LANCETS.............90ULTILET SAFETY LANCETS 23G.......................90ULTIMA TEST...................... 61ultimatecare one .......................98ULTRA COMFORT INSULIN SYRINGE............. 90ULTRA-COMFORT INSULIN SYRINGE............. 90ULTRALANCE..................... 90ULTRA-THIN II AUTO LANCET................................ 90ULTRA-THIN II INS SYR SHORT................................... 90ULTRA-THIN II INSULIN SYRINGE...............................90ULTRA-THIN II LANCETS.90ULTRA-THIN II MINI PEN NEEDLE................................ 90ULTRA-THIN II PEN NEEDLE SHORT.................. 90ULTRA-THIN II PEN NEEDLES.............................. 90ULTRATRAK PRO TEST.... 62ULTRATRAK ULTIMATE TEST.......................................62ULTRAVATE X (CREAM)...57ULTRAVATE X (OINTMENT)........................ 57UNIFINE PENTIPS...............90UNILET COMFORTOUCH LANCET................................ 90UNILET EXCELITE............. 90UNILET EXCELITE II......... 90UNILET G.P. LANCET........ 90UNILET G.P. SUPERLITE LANCET................................ 90UNILET GP 28 ULTRA THIN...................................... 91UNILET LANCET................ 91UNILET SUPERLITE LANCET................................ 91UNISTIK 3 COMFORT........ 91UNISTIK 3 EXTRA...............91UNISTIK 3 NORMAL.......... 91UNISTIK CZT COMFORT...91UNISTIK CZT NORMAL.....91unithroid ................................ 110



UNIVERSAL 1 LANCETS THIN 26G...............................91UNIVERSAL 1 LANCETS ULTRA THIN........................91ur n-c ..................................... 112urea ......................................... 57urelle ......................................112uretron d/s ..............................112urin ds .................................... 112URISTIX................................ 62URISTIX 4............................. 62ursodiol .................................... 72uryl ........................................ 112utira-c .................................... 112utrona-c ................................. 112valacyclovir hcl .........................39VALCYTE..............................39valganciclovir hcl ......................39valproic acid .............................18valsartan .................................. 28valsartan-hydrochlorothiazide ...28VALUE HEALTH INSULIN SYRINGE...............................91VALUE PLUS LANCET STANDARD 21G.................. 91VALUE PLUS LANCETS SUPER THIN.........................91VALUE PLUS LANCETS THIN 26G...............................91VALUMARK LANCET SUPER THIN 30G................. 91VALUMARK LANCET ULTRA THIN 28G................ 91VALUMARK PEN NEEDLES.............................. 91vancomycin hcl .........................29vandazole ............................... 113VANISHPOINT INSULIN SYRINGE...............................91VANISHPOINT SAFETY SYRINGE...............................91VANISHPOINT SYRINGE...91VANISHPOINT TUBERCULIN SYRINGE....91VASCAZEN........................... 65VASCULERA........................ 66VAYACOG............................ 66VAYARIN..............................66

VAYAROL.............................66VCF VAGINAL CONTRACEPTIVE............. 113VECTIBIX..............................34VELCADE..............................34velivet .......................................49VELPHORO...........................72VEMAVITE-PRX 2................98VENA-BAL DHA.................. 98venlafaxine hcl ......................... 20venlafaxine hcl er ..................... 19VENTAVIS.............................43VENTOLIN HFA...................16verapamil hcl ............................43verapamil hcl er .................. 42, 43VERDESO..............................57VEREGEN............................. 57VESICARE........................... 113vestura ..................................... 49VIBATIV................................ 29VIBRAMYCIN.....................109vicodin ..................................... 11vicodin es ................................. 11vicodin hp .................................11VICTORY AGM-4000 TEST. 62VICTOZA...............................23VIDA MIA UNIFINE PENTIPS................................ 91VIDA MIA UNILET LANCETS 28G.......................91VIDA MIA UNILET LANCETS 30G.......................91VIDAZA................................. 34VIDEX....................................39VIEKIRA PAK...................... 75VIEKIRA XR.........................75vigabatrin .................................18VIIBRYD........................ 20, 109VIIBRYD STARTER PACK......................................... 20, 109VIMPAT................................. 18vinate ii .................................... 98VINATE M.............................98vinate one .................................98vincasar pfs .............................. 34vincristine sulfate ..................... 34vinorelbine tartrate ...................34VIOKACE.............................. 66

viorele ...................................... 49VIRACEPT.............................39VIRAMUNE.......................... 39VIREAD................................. 39virt-phos 250 neutral .................94VIRT-PN................................ 98VIRT-PN DHA...................... 98VIRT-SELECT....................... 98virtussin a/c .............................. 51virt-vite forte ............................ 66VITAFOL-OB.........................98VITAFOL-OB+DHA............. 98VITAFOL-ONE..................... 98VITAMEDMD ONE RX/QUATREFOLIC............. 98vitamin d (ergocalciferol) .......114vitamin d2 .............................. 114vitamin d3 .............................. 114VIVA DHA.............................98VOCAL POINT BLOOD GLUCOSE TEST................... 62VOL-NATE............................ 98VOL-PLUS............................. 98VOL-TAB RX.........................98VORAXAZE.......................... 34voriconazole ............................. 24VOSEVI.................................. 75VOTRIENT............................ 34VP INSULIN SYRINGE....... 91VP-CH-PNV........................... 98VP-GGR-B6 PRENATAL......98vp-gstn ..................................... 66VP-PNV-DHA........................ 98VPRIV.................................... 75VRAYLAR.............................36VSL#3.....................................66VSL#3 JUNIOR..................... 66VUSION................................. 57vyfemla .................................... 49VYVANSE................................6W&F LANCETS 26G.............91W&F LANCETS COLORED 21G......................................... 91WALGREENS ADV TRAVEL LANCETS..............91WALGREENS LANCETS.... 91WALGREENS LANCETS MICRO THIN........................92



WALGREENS LANCETS SUPER THIN.........................92WALGREENS THIN LANCETS.............................. 92WALGREENS ULTRA THIN LANCETS................... 92warfarin sodium ....................... 16WAVESENSE PRESTO.........62WEGMANS UNIFINE PENTIPS PLUS......................92WELCHOL.............................26wera .........................................49WESTHROID.......................110WIDE-SEAL DIAPHRAGM 60.............................................92WIDE-SEAL DIAPHRAGM 65.............................................92WIDE-SEAL DIAPHRAGM 70.............................................92WIDE-SEAL DIAPHRAGM 75.............................................92WIDE-SEAL DIAPHRAGM 80.............................................92WIDE-SEAL DIAPHRAGM 85.............................................92WIDE-SEAL DIAPHRAGM 90.............................................92WIDE-SEAL DIAPHRAGM 95.............................................92WP THYROID..................... 110wymzya fe ................................ 49XALKORI..............................34XARELTO............................. 16XARELTO STARTER PACK..................................... 16XATMEP................................34XELJANZ................................ 8XELJANZ XR..........................8XEOMIN................................ 99XERESE................................. 58XGEVA.................................. 70XIAFLEX...............................40XIFAXAN..............................29XIGDUO XR........................109XOLEGEL..............................58XTAMPZA ER.......................11XTANDI.................................34xulane ...................................... 49

XURIDEN..............................75XYLON.................................. 11XYREM................................108YASMIN 28............................49YAZ........................................ 49yellow jacket venom protein ......41YERVOY................................34YUVAFEM.......................... 113ZADITOR............................ 103zafirlukast ................................16zaleplon ....................................76ZAMICET.............................. 11ZANOSAR............................. 34zarah ........................................49ZARXIO................................. 75ZATEAN-PN DHA................98ZATEAN-PN PLUS...............98ZAVESCA.............................. 75zebutal ....................................... 9ZEGERID OTC....................112ZELAPAR.............................. 35ZELBORAF........................... 34ZEMAIRA............................108ZENATANE...........................58zenchent ................................... 49zencia .......................................58ZENPEP................................. 66ZEPATIER............................. 75ZETONNA............................. 99ZIANA....................................58zidovudine ................................ 39zileuton er ................................ 16zinc sulfate ............................... 94zinc-220 ................................... 95ZINECARD........................... 34ZIOPTAN............................. 103ziprasidone hcl ..........................36ZIRGAN...............................103ZMAX.................................... 77zoledronic acid ......................... 70ZOLINZA...............................34zolmitriptan ............................. 92zolpidem tartrate ......................76zolpidem tartrate er ..................76ZOMIG...................................92ZONALON.............................58zonisamide ............................... 18ZONTIVITY.........................106

ZORTRESS............................ 40zovia 1/35e (28) .......................49zovia 1/50e (28) .......................49ZOVIRAX.............................. 58ZYDELIG.............................105ZYFLO................................... 16ZYKADIA..............................34ZYLET..................................103ZYRTEC ALLERGY.............25ZYRTEC-D ALLERGY & CONGESTION...................... 51ZYTAZE.................................66ZYTIGA................................. 34



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Five Tier Closed Aetna Individual Plan: DE