Illinois Medicaid Preferred Drug List

Effective April 1, 2023

▪

The Preferred Drug List (PDL) has products listed in groups by drug class, drug name, dosage form, and PDL status

▪

Multi-source drugs are listed by both brand and generic names when applicable

▪ ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19 years of age and

older

▪

Budesonide: Prior authorization NOT required for participants age 7 years and under

▪

Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a

diagnosis of epilepsy or seizure disorder in Department records

▪

Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents

▪

Proton Pump Inhibitors, oral: Prior authorization required for participants age 21 and over. Adults with non-

complicated GERD have to pay out of pocket for a PPI or use a prescribed H2 blocker. PA is needed for coverage of

indications requiring longer term use.

▪

Lansoprazole ODT: Prior authorization NOT required for participants age 10 years and under.

▪

For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com

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Drug Class Drug Name Dosage Form

DYANAVEL XR CHER NON_PREFERRED

DYANAVEL XR SUER PREFERRED_WITH_PA

ADZENYS XR-ODT TBED NON_PREFERRED

AMPHETAMINE SULFATE TABS NON_PREFERRED

EVEKEO TABS NON_PREFERRED

EVEKEO ODT TBDP NON_PREFERRED

XELSTRYM PTCH NON_PREFERRED

DEXEDRINE CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE ER CP24 NON_PREFERRED

DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED

PROCENTRA SOLN NON_PREFERRED

DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED

ZENZEDI TABS NON_PREFERRED

VYVANSE CAPS PREFERRED

VYVANSE CHEW PREFERRED

DESOXYN TABS NON_PREFERRED

METHAMPHETAMINE HCL TABS NON_PREFERRED

ADDERALL XR CP24 NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED

MYDAYIS CP24 NON_PREFERRED

ADDERALL TABS NON_PREFERRED

AMPHETAMINE/DEXTROAMPHETAMINE TABS PREFERRED

CLONIDINE HCL ER TB12 PREFERRED

CLONIDINE HYDROCHLORIDE TB12 PREFERRED

CLONIDINE HYDROCHLORIDE ER TB12 PREFERRED

GUANFACINE ER TB24 PREFERRED

GUANFACINE HYDROCHLORIDE TB24 PREFERRED

INTUNIV TB24 NON_PREFERRED

ATOMOXETINE CAPS NON_PREFERRED

ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED

STRATTERA CAPS PREFERRED

QELBREE CP24 NON_PREFERRED

SUNOSI TABS NON_PREFERRED

WAKIX TABS NON_PREFERRED

ARMODAFINIL TABS NON_PREFERRED

NUVIGIL TABS NON_PREFERRED

DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED

DEXMETHYLPHENIDATE HYDROCHLORIDE CP24 NON_PREFERRED

PDL Status

ADHD / ANTI-NARCOLEPSY AGENTS :

AMPHETAMINES

ADHD / ANTI-NARCOLEPSY AGENTS : MISC

ADHD / ANTI-NARCOLEPSY AGENTS :

STIMULANTS

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DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED

FOCALIN XR CP24 PREFERRED

DEXMETHYLPHENIDATE HCL TABS PREFERRED

DEXMETHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED

FOCALIN TABS NON_PREFERRED

DAYTRANA PTCH PREFERRED_WITH_PA

METHYLPHENIDATE PTCH NON_PREFERRED

COTEMPLA XR-ODT TBED NON_PREFERRED

QUILLICHEW ER CHER NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE CHEW NON_PREFERRED

ADHANSIA XR CP24 NON_PREFERRED

APTENSIO XR CP24 NON_PREFERRED

JORNAY PM CP24 PREFERRED_WITH_PA

METHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 NON_PREFERRED

RITALIN LA CP24 NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE CD CPCR NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER CPCR NON_PREFERRED

METHYLIN SOLN NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE SOLN NON_PREFERRED

QUILLIVANT XR SRER NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED

RITALIN TABS NON_PREFERRED

METHYLPHENIDATE HYDROCHLORIDE ER TB24 NON_PREFERRED

METHYLPHENID TAB 10MG ER TBCR PREFERRED

METHYLPHENID TAB 20MG ER TBCR PREFERRED

CONCERTA TBCR PREFERRED

METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED

METHYLPHENID TAB 27MG ER TBCR NON_PREFERRED

METHYLPHENID TAB 36MG ER TBCR NON_PREFERRED

METHYLPHENID TAB 54MG ER TBCR NON_PREFERRED

METHYLPHENID TAB 72MG ER TBCR NON_PREFERRED

RELEXXII TBCR NON_PREFERRED

MODAFINIL TABS PREFERRED

PROVIGIL TABS NON_PREFERRED

AZSTARYS CAPS NON_PREFERRED

RIDAURA CAPS NON_PREFERRED

OTREXUP SOAJ NON_PREFERRED

RASUVO SOAJ NON_PREFERRED

ADHD / ANTI-NARCOLEPSY AGENTS :

STIMULANTS

ANALGESICS - ANTI-INFLAMMATORY :

MISC

3/6/2023 8:01:09 AM Page 3 of 147

REDITREX SOSY NON_PREFERRED

ARAVA TABS NON_PREFERRED

LEFLUNOMIDE TABS PREFERRED

DICLOFENAC POTASSIUM CAPS NON_PREFERRED

DICLOFENAC POTASSIUM TABS PREFERRED

LOFENA TABS PREFERRED

DICLOFENAC SODIUM ER TB24 PREFERRED

DICLOFENAC SODIUM DR TBEC PREFERRED

ETODOLAC CAPS PREFERRED

ETODOLAC TABS PREFERRED

ETODOLAC ER TB24 PREFERRED

FENOPROFEN CALCIUM CAPS NON_PREFERRED

NALFON CAPS NON_PREFERRED

FENOPROFEN CALCIUM TABS NON_PREFERRED

NALFON TABS NON_PREFERRED

FLURBIPROFEN TABS PREFERRED

IBUPAK KIT NON_PREFERRED

IBUPROFEN SUSP NON_PREFERRED

IBU TABS PREFERRED

IBUPROFEN TABS PREFERRED

INDOMETHACIN CAPS PREFERRED

INDOMETHACIN ER CPCR PREFERRED

KETOPROFEN CAPS PREFERRED

KETOPROFEN ER CP24 NON_PREFERRED

KETOROLAC TROMETHAMINE SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE TABS PREFERRED

MECLOFENAMATE SODIUM CAPS NON_PREFERRED

MEFENAMIC ACID CAPS NON_PREFERRED

MELOXICAM CAPS NON_PREFERRED

MELOXICAM TABS PREFERRED

MOBIC TABS NON_PREFERRED

NABUMETONE TABS PREFERRED

RELAFEN DS TABS NON_PREFERRED

NAPROXEN SUSP PREFERRED

NAPROXEN TABS PREFERRED

EC-NAPROXEN TBEC PREFERRED

NAPROXEN TBEC PREFERRED

NAPROXEN SODIUM TABS PREFERRED

NAPRELAN TB24 NON_PREFERRED

ANALGESICS - ANTI-INFLAMMATORY :

MISC

ANALGESICS - ANTI-INFLAMMATORY :

NONSTEROIDAL ANTI-INFLAMMATORY

AGENTS (NSAIDs)

3/6/2023 8:01:09 AM Page 4 of 147

NAPROXEN SODIUM TB24 NON_PREFERRED

NAPROXEN SODIUM CR TB24 NON_PREFERRED

NAPROXEN SODIUM ER TB24 NON_PREFERRED

DAYPRO TABS NON_PREFERRED

OXAPROZIN TABS NON_PREFERRED

FELDENE CAPS NON_PREFERRED

PIROXICAM CAPS NON_PREFERRED

SULINDAC TABS PREFERRED

TOLMETIN SODIUM TABS NON_PREFERRED

CELEBREX CAPS NON_PREFERRED

CELECOXIB CAPS PREFERRED

ARTHROTEC 50 TBEC NON_PREFERRED

ARTHROTEC 75 TBEC NON_PREFERRED

DICLOFENAC SODIUM/MISOPROSTOL TBEC NON_PREFERRED

DUEXIS TABS NON_PREFERRED

IBUPROFEN/FAMOTIDINE TABS NON_PREFERRED

NAPROXEN/ESOMEPRAZOLE MAGNESIUM TBEC NON_PREFERRED

VIMOVO TBEC NON_PREFERRED

DIFLUNISAL TABS PREFERRED

SALSALATE TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED

ALLZITAL TABS NON_PREFERRED

BUPAP TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS PREFERRED

ESGIC CAPS PREFERRED

FIORICET CAPS NON_PREFERRED

ZEBUTAL CAPS PREFERRED

VTOL LQ SOLN NON_PREFERRED

BAC TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS PREFERRED

ESGIC TABS NON_PREFERRED

BUTALBITAL/ASPIRIN/CAFFEINE CAPS PREFERRED

CODEINE SULFATE TABS PREFERRED

FENTANYL PT72 NON_PREFERRED

ACTIQ LPOP NON_PREFERRED

FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON_PREFERRED

FENTANYL CITRATE TABS NON_PREFERRED

FENTORA TABS NON_PREFERRED

ANALGESICS - ANTI-INFLAMMATORY :

NONSTEROIDAL ANTI-INFLAMMATORY

AGENTS (NSAIDs)

ANALGESICS - NONNARCOTIC

ANALGESICS : OPIOID

3/6/2023 8:01:09 AM Page 5 of 147

HYDROCODONE BITARTRATE ER CP12 NON_PREFERRED

ZOHYDRO ER CP12 NON_PREFERRED

HYDROCODONE BITARTRATE ER T24A NON_PREFERRED

HYSINGLA ER T24A NON_PREFERRED

DILAUDID LIQD NON_PREFERRED

HYDROMORPHONE HCL LIQD PREFERRED

HYDROMORPHONE HYDROCHLORIDE LIQD PREFERRED

HYDROMORPHONE HCL SUPP PREFERRED

DILAUDID TABS NON_PREFERRED

HYDROMORPHONE HCL TABS PREFERRED

HYDROMORPHONE HYDROCHLORIDE TABS PREFERRED

HYDROMORPHONE HCL ER TB24 NON_PREFERRED

HYDROMORPHONE HYDROCHLORIDE ER TB24 NON_PREFERRED

LEVORPHANOL TARTRATE TABS NON_PREFERRED

MEPERIDINE HCL SOLN NON_PREFERRED

MEPERIDINE HCL TABS NON_PREFERRED

METHADONE HYDROCHLORIDE CONC NON_PREFERRED

METHADONE HYDROCHLORIDE INTENSOL CONC NON_PREFERRED

METHADOSE CONC NON_PREFERRED

METHADOSE SUGAR-FREE CONC NON_PREFERRED

METHADONE HCL SOLN NON_PREFERRED

METHADONE HYDROCHLORIDE SOLN NON_PREFERRED

METHADONE HCL TABS NON_PREFERRED

METHADONE HYDROCHLORIDE TABS NON_PREFERRED

METHADONE HCL TBSO NON_PREFERRED

METHADOSE TBSO NON_PREFERRED

KADIAN CP24 NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

MORPHINE SULFATE SOLN PREFERRED

MORPHINE SULFATE SUPP PREFERRED

MORPHINE SULFATE TABS PREFERRED

MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA

MS CONTIN TBCR NON_PREFERRED

MORPHINE SULFATE ER CP24 NON_PREFERRED

XTAMPZA ER C12A NON_PREFERRED

OXYCODONE HCL CAPS PREFERRED

OXYCODONE HYDROCHLORIDE CAPS PREFERRED

OXYCODONE HYDROCHLORIDE CONC PREFERRED

OXYCODONE HYDROCHLORIDE SOLN PREFERRED

ANALGESICS : OPIOID

3/6/2023 8:01:09 AM Page 6 of 147

OXYCODONE HCL ER T12A NON_PREFERRED

OXYCODONE HYDROCHLORIDE ER T12A NON_PREFERRED

OXYCONTIN T12A NON_PREFERRED

ROXYBOND TABA NON_PREFERRED

OXYCODONE HYDROCHLORIDE TABS PREFERRED

ROXICODONE TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED

OXYMORPHONE HYDROCHLORIDE ER TB12 NON_PREFERRED

OXYMORPHONE HYDROCHLORIDEER TB12 NON_PREFERRED

NUCYNTA TABS NON_PREFERRED

NUCYNTA ER TB12 NON_PREFERRED

CONZIP CP24 NON_PREFERRED

TRAMADOL HCL ER CP24 NON_PREFERRED

TRAMADOL HYDROCHLORIDE SOLN NON_PREFERRED

TRAMADOL HCL TABS PREFERRED

TRAMADOL HYDROCHLORIDE TABS NON_PREFERRED

TRAMADOL HYDROCHLORIDE TABS PREFERRED

TRAMADOL HCL ER TB24 NON_PREFERRED

TRAMADOL HYDROCHLORIDE ER TB24 NON_PREFERRED

BUPRENORPHINE PTWK NON_PREFERRED

BUTRANS PTWK NON_PREFERRED

BELBUCA FILM NON_PREFERRED

BUTORPHANOL TARTRATE SOLN NON_PREFERRED

PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED

APADAZ TABS NON_PREFERRED

BENZHYDROCODONE/ACETAMINOPHEN TABS NON_PREFERRED

OXYCODONE HYDROCHLORIDE/ACETAMINOPHEN SOLN PREFERRED

ENDOCET TABS PREFERRED

OXYCODONE/ACETAMINOPHEN TABS PREFERRED

PERCOCET TABS NON_PREFERRED

PRIMLEV TABS NON_PREFERRED

ACETAMINOPHEN/CODEINE SOLN PREFERRED

ACETAMINOPHEN/CODEINE TABS PREFERRED

ACETAMINOPHEN/CODEINE PHOSPHATE TABS PREFERRED

BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS NON_PREFERRED

FIORICET/CODEINE CAPS NON_PREFERRED

ASCOMP/CODEINE CAPS PREFERRED

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS PREFERRED

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPS NON_PREFERRED

ANALGESICS : OPIOID

ANALGESICS : OPIOID COMBINATIONS

3/6/2023 8:01:09 AM Page 7 of 147

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE TABS NON_PREFERRED

LORTAB ELIX NON_PREFERRED

HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN PREFERRED

HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS PREFERRED

HYDROCODONE/ACETAMINOPHEN TABS PREFERRED

HYDROCODONE/IBUPROFEN TABS PREFERRED

SEGLENTIS TABS NON_PREFERRED

TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN TABS NON_PREFERRED

EPINEPHRINE SOAJ PREFERRED

EPIPEN 2-PAK SOAJ NON_PREFERRED

EPIPEN-JR 2-PAK SOAJ NON_PREFERRED

SYMJEPI SOSY NON_PREFERRED

ANUSOL-HC CREA NON_PREFERRED

HYDROCORTISONE CREA PREFERRED

PROCTO-MED HC CREA PREFERRED

PROCTOSOL HC CREA PREFERRED

PROCTOZONE-HC CREA PREFERRED

UCERIS FOAM NON_PREFERRED

CORTENEMA ENEM NON_PREFERRED

HYDROCORTISONE ENEM PREFERRED

CORTIFOAM FOAM NON_PREFERRED

RECTIV OINT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTISONE ACETATE CREA NON_PREFERRED

LIDOCORT CREA NON_PREFERRED

LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL NON_PREFERRED

ANA-LEX KIT NON_PREFERRED

LIDOCAINE HCL/HYDROCORTISONE ACETATE KIT NON_PREFERRED

PROCTOFOAM HC FOAM NON_PREFERRED

ALPRAZOLAM INTENSOL CONC PREFERRED

ALPRAZOLAM TABS PREFERRED

XANAX TABS NON_PREFERRED

ALPRAZOLAM ER TB24 NON_PREFERRED

ALPRAZOLAM XR TB24 NON_PREFERRED

XANAX XR TB24 NON_PREFERRED

ALPRAZOLAM ODT TBDP NON_PREFERRED

CHLORDIAZEPOXIDE HCL CAPS PREFERRED

CHLORDIAZEPOXIDE HYDROCHLORIDE CAPS PREFERRED

CLORAZEPATE DIPOTASSIUM TABS PREFERRED

DIAZEPAM CONC PREFERRED

ANALGESICS : OPIOID COMBINATIONS

ANAPHYLAXIS THERAPY AGENTS

ANORECTAL AGENTS

ANTIANXIETY AGENTS :

BENZODIAZEPINES

3/6/2023 8:01:09 AM Page 8 of 147

DIAZEPAM INTENSOL CONC PREFERRED

DIAZEPAM SOLN PREFERRED

DIAZEPAM TABS PREFERRED

LORAZEPAM CONC PREFERRED

LORAZEPAM INTENSOL CONC PREFERRED

LOREEV XR CS24 NON_PREFERRED

ATIVAN TABS NON_PREFERRED

LORAZEPAM TABS PREFERRED

OXAZEPAM CAPS PREFERRED

BUSPIRONE HCL TABS PREFERRED

BUSPIRONE HYDROCHLORIDE TABS PREFERRED

HYDROXYZINE HYDROCHLORIDE SYRP PREFERRED

HYDROXYZINE HCL TABS PREFERRED

HYDROXYZINE HYDROCHLORIDE TABS PREFERRED

HYDROXYZINE PAMOATE CAPS PREFERRED

VISTARIL CAPS NON_PREFERRED

MEPROBAMATE TABS NON_PREFERRED

COMBIVENT RESPIMAT AERS NON_PREFERRED

IPRATROPIUM BROMIDE/ALBUTEROL SULFATE SOLN PREFERRED

DUAKLIR PRESSAIR AEPB NON_PREFERRED

BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE AERO NON_PREFERRED

SYMBICORT AERO PREFERRED

BEVESPI AEROSPHERE AERO NON_PREFERRED

ADVAIR DISKUS AEPB PREFERRED

AIRDUO RESPICLICK 113/14 AEPB PREFERRED

AIRDUO RESPICLICK 232/14 AEPB PREFERRED

AIRDUO RESPICLICK 55/14 AEPB PREFERRED

FLUTICASONE PROPIONATE/SALMETEROL AEPB NON_PREFERRED

FLUTICASONE PROPIONATE/SALMETEROL DISKUS AEPB NON_PREFERRED

WIXELA INHUB AEPB NON_PREFERRED

ADVAIR HFA AERO PREFERRED

AIRDUO DIGIHALER 113/14 AEPB PREFERRED

AIRDUO DIGIHALER 232/14 AEPB PREFERRED

AIRDUO DIGIHALER 55/14 AEPB PREFERRED

BREO ELLIPTA AEPB NON_PREFERRED

FLUTICASONE FUROATE/VILANTEROL ELLIPTA AEPB NON_PREFERRED

DULERA AERO PREFERRED

STIOLTO RESPIMAT AERS NON_PREFERRED

ANORO ELLIPTA AEPB PREFERRED

ANTIANXIETY AGENTS : MISC

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : ADRENERGIC COMBINATIONS

ANTIANXIETY AGENTS :

BENZODIAZEPINES

3/6/2023 8:01:09 AM Page 9 of 147

BREZTRI AEROSPHERE AERO NON_PREFERRED

TRELEGY ELLIPTA AEPB NON_PREFERRED

TUDORZA PRESSAIR AEPB NON_PREFERRED

LONHALA MAGNAIR REFILL KIT SOLN NON_PREFERRED

LONHALA MAGNAIR STARTER KIT SOLN NON_PREFERRED

IPRATROPIUM BROMIDE SOLN PREFERRED

ATROVENT HFA AERS PREFERRED

YUPELRI SOLN NON_PREFERRED

SPIRIVA RESPIMAT AERS PREFERRED

SPIRIVA HANDIHALER CAPS PREFERRED

INCRUSE ELLIPTA AEPB PREFERRED

CROMOLYN SODIUM NEBU PREFERRED

PROAIR RESPICLICK AEPB NON_PREFERRED

ALBUTEROL SULFATE HFA AERS PREFERRED

PROAIR HFA AERS PREFERRED

PROVENTIL HFA AERS PREFERRED

VENTOLIN HFA AERS PREFERRED

ALBUTEROL SULFATE NEBU PREFERRED

ALBUTEROL SULFATE SYRP PREFERRED

ALBUTEROL TABS NON_PREFERRED

ALBUTEROL SULFATE TABS NON_PREFERRED

PROAIR DIGIHALER AEPB NON_PREFERRED

ARFORMOTEROL TARTRATE NEBU NON_PREFERRED

BROVANA NEBU NON_PREFERRED

FORMOTEROL FUMARATE NEBU NON_PREFERRED

PERFOROMIST NEBU NON_PREFERRED

LEVALBUTEROL NEBU PREFERRED

LEVALBUTEROL HCL NEBU PREFERRED

LEVALBUTEROL HYDROCHLORIDE NEBU PREFERRED

XOPENEX NEBU NON_PREFERRED

XOPENEX CONCENTRATE NEBU NON_PREFERRED

LEVALBUTEROL TARTRATE HFA AERO PREFERRED

XOPENEX HFA AERO PREFERRED

STRIVERDI RESPIMAT AERS NON_PREFERRED

SEREVENT DISKUS AEPB PREFERRED

TERBUTALINE SULFATE TABS PREFERRED

ZYFLO TABS NON_PREFERRED

ZILEUTON ER TB12 NON_PREFERRED

MONTELUKAST SODIUM CHEW PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : ADRENERGIC COMBINATIONS

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : ANTICHOLINERGICS

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : BETA ADRENERGICS

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : LEUKOTRIENE MODULATORS

3/6/2023 8:01:09 AM Page 10 of 147

SINGULAIR CHEW NON_PREFERRED

MONTELUKAST SODIUM PACK PREFERRED

SINGULAIR PACK NON_PREFERRED

MONTELUKAST SODIUM TABS PREFERRED

SINGULAIR TABS NON_PREFERRED

ACCOLATE TABS NON_PREFERRED

ZAFIRLUKAST TABS PREFERRED

THEO-24 CP24 PREFERRED

THEOPHYLLINE ELIX PREFERRED

THEOPHYLLINE SOLN PREFERRED

THEOPHYLLINE ER TB12 PREFERRED

THEOPHYLLINE ER TB24 PREFERRED

DALIRESP TABS NON_PREFERRED

ROFLUMILAST TABS NON_PREFERRED

XOLAIR SOLR PREFERRED_WITH_PA

XOLAIR SOSY PREFERRED_WITH_PA

FASENRA PEN SOAJ PREFERRED_WITH_PA

FASENRA SOSY PREFERRED_WITH_PA

NUCALA SOAJ PREFERRED_WITH_PA

NUCALA SOLR PREFERRED_WITH_PA

NUCALA SOSY PREFERRED_WITH_PA

CINQAIR SOLN NON_PREFERRED

TEZSPIRE SOAJ NON_PREFERRED

TEZSPIRE SOSY NON_PREFERRED

CIBINQO TABS NON_PREFERRED

OPZELURA CREA NON_PREFERRED

DUPIXENT SOPN PREFERRED_WITH_PA

DUPIXENT SOSY PREFERRED_WITH_PA

ADBRY SOSY NON_PREFERRED

QVAR REDIHALER AERB NON_PREFERRED

PULMICORT FLEXHALER AEPB NON_PREFERRED

BUDESONIDE SUSP PREFERRED

PULMICORT SUSP NON_PREFERRED

ALVESCO AERS NON_PREFERRED

ARNUITY ELLIPTA AEPB NON_PREFERRED

FLOVENT DISKUS AEPB PREFERRED

ARMONAIR DIGIHALER AEPB NON_PREFERRED

FLOVENT HFA AERO PREFERRED

FLUTICASONE PROPIONATE HFA AERO NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : LEUKOTRIENE MODULATORS

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : MISC

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : MONOCLONAL ANTIBODIES

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : STEROID INHALANTS

3/6/2023 8:01:09 AM Page 11 of 147

ASMANEX TWISTHALER 120 METERED DOSES AEPB PREFERRED

ASMANEX TWISTHALER 14 METERED DOSES AEPB PREFERRED

ASMANEX TWISTHALER 30 METERED DOSES AEPB PREFERRED

ASMANEX TWISTHALER 60 METERED DOSES AEPB PREFERRED

ASMANEX HFA AERO NON_PREFERRED

CIPRO SUSR NON_PREFERRED

CIPROFLOXACIN SUSR PREFERRED

CIPRO TABS NON_PREFERRED

CIPROFLOXACIN HCL TABS PREFERRED

CIPROFLOXACIN HYDROCHLORIDE TABS PREFERRED

BAXDELA TABS NON_PREFERRED

LEVOFLOXACIN SOLN PREFERRED

LEVOFLOXACIN TABS PREFERRED

MOXIFLOXACIN HYDROCHLORIDE TABS PREFERRED

OFLOXACIN TABS NON_PREFERRED

NEOMYCIN SULFATE TABS PREFERRED

PAROMOMYCIN SULFATE CAPS PREFERRED

ARIKAYCE SUSP NON_PREFERRED

TOBI PODHALER CAPS NON_PREFERRED

BETHKIS NEBU NON_PREFERRED

KITABIS PAK NEBU PREFERRED

TOBI NEBU NON_PREFERRED

TOBRAMYCIN NEBU NON_PREFERRED

SULFADIAZINE TABS PREFERRED

SOLOSEC PACK NON_PREFERRED

FLAGYL CAPS NON_PREFERRED

METRONIDAZOLE CAPS NON_PREFERRED

METRONIDAZOLE TABS PREFERRED

NEBUPENT SOLR PREFERRED

PENTAMIDINE ISETHIONATE SOLR PREFERRED

AEMCOLO TBEC NON_PREFERRED

XIFAXAN TABS NON_PREFERRED

TINIDAZOLE TABS NON_PREFERRED

TRIMETHOPRIM TABS PREFERRED

CAYSTON SOLR NON_PREFERRED

CLEOCIN CAPS NON_PREFERRED

CLINDAMYCIN HCL CAPS PREFERRED

CLINDAMYCIN HYDROCHLORIDE CAPS PREFERRED

CLEOCIN PEDIATRIC GRANULES SOLR NON_PREFERRED

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS : STEROID INHALANTS

ANTIBIOITICS : FLUOROQUINOLONES

ANTIBIOTICS : AMINOGLYCOSIDES

ANTIBIOTICS : AMINOGLYCOSIDES -

INHALED

ANTIBIOTICS : ANTI-INFECTIVE AGENTS

3/6/2023 8:01:09 AM Page 12 of 147

CLINDAMYCIN PALMITATE HCL SOLR PREFERRED

CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLR PREFERRED

LINEZOLID SUSR NON_PREFERRED

ZYVOX SUSR NON_PREFERRED

LINEZOLID TABS NON_PREFERRED

ZYVOX TABS NON_PREFERRED

SIVEXTRO TABS NON_PREFERRED

XENLETA TABS NON_PREFERRED

VANCOCIN CAPS NON_PREFERRED

VANCOMYCIN HYDROCHLORIDE CAPS PREFERRED

FIRST-VANCOMYCIN 25 SOLN NON_PREFERRED

FIRST-VANCOMYCIN 50 SOLN NON_PREFERRED

FIRVANQ SOLR NON_PREFERRED

VANCOMYCIN HYDROCHLORIDE SOLR PREFERRED

DAPSONE TABS PREFERRED

ATOVAQUONE SUSP PREFERRED

MEPRON SUSP NON_PREFERRED

LAMPIT TABS NON_PREFERRED

NITAZOXANIDE TABS NON_PREFERRED

FOSFOMYCIN TROMETHAMINE PACK PREFERRED

MONUROL PACK PREFERRED

METHENAMINE MANDELATE TABS PREFERRED

HIPREX TABS NON_PREFERRED

METHENAMINE HIPPURATE TABS PREFERRED

FURADANTIN SUSP NON_PREFERRED

NITROFURANTOIN SUSP PREFERRED

MACRODANTIN CAPS NON_PREFERRED

NITROFURANTOIN MACROCRYSTALS CAPS PREFERRED

MACROBID CAPS NON_PREFERRED

NITROFURANTOIN MONOHYDRATE CAPS PREFERRED

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS CAPS PREFERRED

SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP PREFERRED

SULFATRIM PEDIATRIC SUSP PREFERRED

BACTRIM TABS NON_PREFERRED

BACTRIM DS TABS NON_PREFERRED

SULFAMETHOXAZOLE/TRIMETHOPRIM TABS PREFERRED

SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS PREFERRED

ME/NAPHOS/MB/HYO 1 TABS NON_PREFERRED

UROGESIC-BLUE TABS NON_PREFERRED

ANTIBIOTICS : ANTI-INFECTIVE AGENTS

3/6/2023 8:01:09 AM Page 13 of 147

HYOPHEN TABS NON_PREFERRED

URO-MP CAPS NON_PREFERRED

USTELL CAPS NON_PREFERRED

PHOSPHASAL TABS NON_PREFERRED

URIMAR-T TABS NON_PREFERRED

PASER PACK NON_PREFERRED

SIRTURO TABS NON_PREFERRED

CYCLOSERINE CAPS PREFERRED

ETHAMBUTOL HYDROCHLORIDE TABS PREFERRED

MYAMBUTOL TABS NON_PREFERRED

TRECATOR TABS PREFERRED

ISONIAZID SYRP PREFERRED

ISONIAZID TABS PREFERRED

PRETOMANID TABS NON_PREFERRED

PYRAZINAMIDE TABS PREFERRED

MYCOBUTIN CAPS NON_PREFERRED

RIFABUTIN CAPS PREFERRED

RIFAMPIN CAPS PREFERRED

PRIFTIN TABS PREFERRED

CEFADROXIL CAPS PREFERRED

CEFADROXIL SUSR PREFERRED

CEFADROXIL TABS PREFERRED

CEPHALEXIN CAPS PREFERRED

CEPHALEXIN SUSR PREFERRED

CEPHALEXIN TABS PREFERRED

CEFACLOR CAPS PREFERRED

CEFACLOR SUSR PREFERRED

CEFACLOR ER TB12 NON_PREFERRED

CEFPROZIL SUSR PREFERRED

CEFPROZIL TABS NON_PREFERRED

CEFUROXIME AXETIL TABS PREFERRED

CEFDINIR CAPS PREFERRED

CEFDINIR SUSR PREFERRED

CEFIXIME CAPS PREFERRED

SUPRAX CHEW NON_PREFERRED

CEFIXIME SUSR NON_PREFERRED

SUPRAX SUSR NON_PREFERRED

CEFPODOXIME PROXETIL SUSR NON_PREFERRED

CEFPODOXIME PROXETIL TABS NON_PREFERRED

ANTIBIOTICS : ANTIMYCOBACTERIAL

AGENTS

ANTIBIOTICS : CEPHALOSPORINS

ANTIBIOTICS : ANTI-INFECTIVE AGENTS

3/6/2023 8:01:09 AM Page 14 of 147

ERYTHROMYCIN CPEP PREFERRED

ERYTHROMYCIN TABS PREFERRED

ERYTHROMYCIN BASE TABS PREFERRED

ERY-TAB TBEC PREFERRED

ERYTHROMYCIN DR TBEC PREFERRED

ERYTHROCIN STEARATE TABS PREFERRED

E.E.S. GRANULES SUSR PREFERRED

ERYPED 200 SUSR PREFERRED

ERYPED 400 SUSR PREFERRED

ERYTHROMYCIN ETHYLSUCCINATE SUSR PREFERRED

E.E.S. 400 TABS PREFERRED

ERYTHROMYCIN ETHYLSUCCINATE TABS PREFERRED

AZITHROMYCIN PACK PREFERRED

ZITHROMAX PACK PREFERRED

AZITHROMYCIN SUSR PREFERRED

ZITHROMAX SUSR NON_PREFERRED

AZITHROMYCIN TABS PREFERRED

ZITHROMAX TABS NON_PREFERRED

ZITHROMAX TRI-PAK TABS NON_PREFERRED

ZITHROMAX Z-PAK TABS NON_PREFERRED

CLARITHROMYCIN SUSR PREFERRED

CLARITHROMYCIN TABS PREFERRED

CLARITHROMYCIN ER TB24 PREFERRED

DIFICID SUSR NON_PREFERRED

DIFICID TABS NON_PREFERRED

PENICILLIN V POTASSIUM SOLR PREFERRED

PENICILLIN V POTASSIUM TABS PREFERRED

AMOXICILLIN CAPS PREFERRED

AMOXICILLIN CHEW PREFERRED

AMOXICILLIN SUSR PREFERRED

AMOXICILLIN TABS PREFERRED

AMPICILLIN CAPS PREFERRED

DICLOXACILLIN SODIUM CAPS PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM SUSR PREFERRED

AUGMENTIN SUSR PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM TABS PREFERRED

AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 NON_PREFERRED

DEMECLOCYCLINE HCL TABS PREFERRED

ANTIBIOTICS : MACROLIDES

ANTIBIOTICS : PENICILLINS

ANTIBIOTICS : TETRACYCLINES

3/6/2023 8:01:09 AM Page 15 of 147

DEMECLOCYCLINE HYDROCHLORIDE TABS PREFERRED

DOXYCYCLINE MONOHYDRATE CAPS PREFERRED

DOXYCYCLINE SUSR PREFERRED

DOXYCYCLINE MONOHYDRATE TABS PREFERRED

DOXYCYCLINE HYCLATE CAPS PREFERRED

MORGIDOX 1X100MG CAPS PREFERRED

MORGIDOX 1X50MG CAPS PREFERRED

MORGIDOX 2X100MG CAPS PREFERRED

VIBRAMYCIN CAPS NON_PREFERRED

DOXYCYCLINE HYCLATE TABS PREFERRED

TARGADOX TABS PREFERRED

DORYX TBEC NON_PREFERRED

DORYX MPC TBEC NON_PREFERRED

DOXYCYCLINE HYCLATE DR TBEC NON_PREFERRED

VIBRAMYCIN SYRP PREFERRED

MORGIDOX 1X100MG KIT NON_PREFERRED

MORGIDOX 1X50MG KIT KIT NON_PREFERRED

MORGIDOX 2X100MG KIT NON_PREFERRED

MINOCYCLINE HCL CAPS PREFERRED

MINOCYCLINE HYDROCHLORIDE CAPS PREFERRED

MINOCYCLINE HYDROCHLORIDEER CP24 NON_PREFERRED

XIMINO CP24 NON_PREFERRED

MINOCYCLINE HCL TABS PREFERRED

MINOCYCLINE HYDROCHLORIDE TABS PREFERRED

MINOCYCLINE HYDROCHLORIDE ER TB24 NON_PREFERRED

MINOLIRA TB24 NON_PREFERRED

SOLODYN TB24 NON_PREFERRED

TETRACYCLINE HYDROCHLORIDE CAPS PREFERRED

NUZYRA TABS NON_PREFERRED

JANTOVEN TABS PREFERRED

WARFARIN SODIUM TABS PREFERRED

DABIGATRAN ETEXILATE CAPS NON_PREFERRED

PRADAXA CAPS NON_PREFERRED

PRADAXA PACK NON_PREFERRED

ELIQUIS TABS PREFERRED_WITH_PA

ELIQUIS STARTER PACK TBPK PREFERRED_WITH_PA

SAVAYSA TABS NON_PREFERRED

XARELTO SUSR NON_PREFERRED

XARELTO TABS PREFERRED_WITH_PA

ANTIBIOTICS : TETRACYCLINES

ANTICOAGULANTS : COUMARIN

ANTICOAGULANTS : DIRECT FACTOR XA

INHIBITORS & MISC

3/6/2023 8:01:09 AM Page 16 of 147

XARELTO STARTER PACK TBPK PREFERRED_WITH_PA

HEPARIN SODIUM SOLN PREFERRED

HEPARIN SODIUM SOSY PREFERRED

FRAGMIN INJ PREFERRED

FRAGMIN SOLN PREFERRED

FRAGMIN SOSY PREFERRED

ENOXAPARIN SODIUM SOLN PREFERRED

LOVENOX SOLN NON_PREFERRED

ENOXAPARIN SODIUM SOSY PREFERRED

LOVENOX SOSY NON_PREFERRED

ARIXTRA SOLN NON_PREFERRED

FONDAPARINUX SODIUM SOLN PREFERRED

SYMPAZAN FILM NON_PREFERRED

CLOBAZAM SUSP NON_PREFERRED

ONFI SUSP NON_PREFERRED

CLOBAZAM TABS NON_PREFERRED

ONFI TABS NON_PREFERRED

CLONAZEPAM TABS PREFERRED

KLONOPIN TABS NON_PREFERRED

CLONAZEPAM ODT TBDP NON_PREFERRED

DIASTAT ACUDIAL GEL PREFERRED

DIASTAT PEDIATRIC GEL PREFERRED

DIAZEPAM RECTAL GEL GEL PREFERRED

VALTOCO LIQD NON_PREFERRED

VALTOCO LQPK NON_PREFERRED

NAYZILAM SOLN NON_PREFERRED

XCOPRI TABS PREFERRED

XCOPRI TBPK PREFERRED

FELBAMATE SUSP NON_PREFERRED

FELBATOL SUSP NON_PREFERRED

FELBAMATE TABS NON_PREFERRED

FELBATOL TABS NON_PREFERRED

GABITRIL TABS NON_PREFERRED

TIAGABINE HYDROCHLORIDE TABS NON_PREFERRED

SABRIL PACK NON_PREFERRED

VIGABATRIN PACK NON_PREFERRED

VIGADRONE PACK NON_PREFERRED

SABRIL TABS NON_PREFERRED

VIGABATRIN TABS NON_PREFERRED

ANTICOAGULANTS : DIRECT FACTOR XA

INHIBITORS & MISC

ANTICOAGULANTS : HEPARIN AND

HEPARINOID-LIKE AGENTS

ANTICONVULSANTS

3/6/2023 8:01:09 AM Page 17 of 147

DILANTIN INFATABS CHEW NON_PREFERRED

PHENYTOIN CHEW PREFERRED

PHENYTOIN INFATABS CHEW PREFERRED

DILANTIN-125 SUSP NON_PREFERRED

PHENYTOIN SUSP PREFERRED

DILANTIN CAPS NON_PREFERRED

PHENYTEK CAPS NON_PREFERRED

PHENYTOIN SODIUM EXTENDED CAPS PREFERRED

ETHOSUXIMIDE CAPS PREFERRED

ZARONTIN CAPS NON_PREFERRED

ETHOSUXIMIDE SOLN PREFERRED

ZARONTIN SOLN NON_PREFERRED

CELONTIN CAPS NON_PREFERRED

DEPAKOTE SPRINKLES CSDR NON_PREFERRED

DIVALPROEX SODIUM CSDR PREFERRED

DEPAKOTE ER TB24 NON_PREFERRED

DIVALPROEX SODIUM ER TB24 PREFERRED

DEPAKOTE TBEC NON_PREFERRED

DIVALPROEX SODIUM DR TBEC PREFERRED

VALPROIC ACID SOLN PREFERRED

VALPROIC ACID CAPS PREFERRED

FYCOMPA SUSP NON_PREFERRED

FYCOMPA TABS NON_PREFERRED

BRIVIACT SOLN NON_PREFERRED

BRIVIACT TABS NON_PREFERRED

EPIDIOLEX SOLN NON_PREFERRED

CARBAMAZEPINE CHEW PREFERRED

CARBAMAZEPINE ER CP12 NON_PREFERRED

CARBATROL CP12 NON_PREFERRED

CARBAMAZEPINE SUSP PREFERRED

TEGRETOL SUSP NON_PREFERRED

CARBAMAZEPINE TABS PREFERRED

EPITOL TABS PREFERRED

TEGRETOL TABS NON_PREFERRED

CARBAMAZEPINE ER TB12 PREFERRED

TEGRETOL-XR TB12 NON_PREFERRED

APTIOM TABS NON_PREFERRED

FINTEPLA SOLN NON_PREFERRED

GABAPENTIN CAPS PREFERRED

ANTICONVULSANTS

3/6/2023 8:01:09 AM Page 18 of 147

NEURONTIN CAPS NON_PREFERRED

GABAPENTIN SOLN PREFERRED

NEURONTIN SOLN NON_PREFERRED

GABAPENTIN TABS PREFERRED

NEURONTIN TABS NON_PREFERRED

ZTALMY SUSP NON_PREFERRED

LACOSAMIDE SOLN NON_PREFERRED

VIMPAT SOLN NON_PREFERRED

LACOSAMIDE TABS NON_PREFERRED

VIMPAT TABS NON_PREFERRED

LAMICTAL CHEWABLE DISPERSIBLE CHEW NON_PREFERRED

LAMOTRIGINE CHEW PREFERRED

LAMICTAL ODT KIT NON_PREFERRED

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT NON_PREFERRED

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING

VALPROATE

KIT NON_PREFERRED

LAMICTAL STARTER/TAKING VALPROATE KIT NON_PREFERRED

LAMICTAL XR KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/BLUE KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/GREEN KIT NON_PREFERRED

LAMOTRIGINE STARTER KIT/ORANGE KIT NON_PREFERRED

LAMOTRIGINE TITRATION KIT NON_PREFERRED

SUBVENITE STARTER KIT/BLUE KIT NON_PREFERRED

SUBVENITE STARTER KIT/GREEN KIT NON_PREFERRED

SUBVENITE STARTER KIT/ORANGE KIT NON_PREFERRED

LAMICTAL TABS NON_PREFERRED

LAMOTRIGINE TABS PREFERRED

SUBVENITE TABS PREFERRED

LAMICTAL XR TB24 NON_PREFERRED

LAMOTRIGINE ER TB24 NON_PREFERRED

LAMICTAL ODT TBDP NON_PREFERRED

LAMOTRIGINE ODT TBDP NON_PREFERRED

KEPPRA SOLN NON_PREFERRED

LEVETIRACETAM SOLN PREFERRED

KEPPRA TABS NON_PREFERRED

LEVETIRACETAM TABS PREFERRED

ROWEEPRA TABS PREFERRED

ELEPSIA XR TB24 NON_PREFERRED

KEPPRA XR TB24 NON_PREFERRED

ANTICONVULSANTS

3/6/2023 8:01:09 AM Page 19 of 147

LEVETIRACETAM ER TB24 PREFERRED

SPRITAM TB3D NON_PREFERRED

OXCARBAZEPINE SUSP PREFERRED

TRILEPTAL SUSP NON_PREFERRED

OXCARBAZEPINE TABS PREFERRED

TRILEPTAL TABS NON_PREFERRED

OXTELLAR XR TB24 NON_PREFERRED

LYRICA CAPS NON_PREFERRED

PREGABALIN CAPS PREFERRED

LYRICA SOLN NON_PREFERRED

PREGABALIN SOLN PREFERRED

MYSOLINE TABS NON_PREFERRED

PRIMIDONE TABS PREFERRED

BANZEL SUSP NON_PREFERRED

RUFINAMIDE SUSP NON_PREFERRED

BANZEL TABS NON_PREFERRED

RUFINAMIDE TABS NON_PREFERRED

DIACOMIT CAPS NON_PREFERRED

DIACOMIT PACK NON_PREFERRED

TOPIRAMATE ER CP24 NON_PREFERRED

TROKENDI XR CP24 NON_PREFERRED

TOPAMAX SPRINKLE CPSP NON_PREFERRED

TOPIRAMATE CPSP PREFERRED

QUDEXY XR CS24 NON_PREFERRED

TOPIRAMATE ER CS24 NON_PREFERRED

EPRONTIA SOLN NON_PREFERRED

TOPAMAX TABS NON_PREFERRED

TOPIRAMATE TABS PREFERRED

ZONISAMIDE CAPS PREFERRED

ZONISADE SUSP NON_PREFERRED

MIRTAZAPINE TABS PREFERRED

REMERON TABS NON_PREFERRED

MIRTAZAPINE ODT TBDP PREFERRED

REMERON SOLTAB TBDP NON_PREFERRED

MARPLAN TABS NON_PREFERRED

NARDIL TABS NON_PREFERRED

PHENELZINE SULFATE TABS PREFERRED

EMSAM PT24 NON_PREFERRED

TRANYLCYPROMINE SULFATE TABS PREFERRED

ANTICONVULSANTS

ANTIDEPRESSANTS : MISC

3/6/2023 8:01:09 AM Page 20 of 147

SPRAVATO 56MG DOSE SOPK NON_PREFERRED

SPRAVATO 84MG DOSE SOPK NON_PREFERRED

NEFAZODONE HYDROCHLORIDE TABS NON_PREFERRED

TRAZODONE HYDROCHLORIDE TABS PREFERRED

VIIBRYD STARTER PACK KIT NON_PREFERRED

VIIBRYD TABS NON_PREFERRED

VILAZODONE HYDROCHLORIDE TABS NON_PREFERRED

TRINTELLIX TABS NON_PREFERRED

AMITRIPTYLINE HCL TABS PREFERRED

AMITRIPTYLINE HYDROCHLORIDE TABS PREFERRED

AMOXAPINE TABS NON_PREFERRED

ANAFRANIL CAPS NON_PREFERRED

CLOMIPRAMINE HCL CAPS PREFERRED

CLOMIPRAMINE HYDROCHLORIDE CAPS PREFERRED

DESIPRAMINE HCL TABS PREFERRED

DESIPRAMINE HYDROCHLORIDE TABS PREFERRED

NORPRAMIN TABS NON_PREFERRED

DOXEPIN HCL CAPS PREFERRED

DOXEPIN HYDROCHLORIDE CAPS PREFERRED

DOXEPIN HCL CONC PREFERRED

IMIPRAMINE HCL TABS PREFERRED

IMIPRAMINE HYDROCHLORIDE TABS PREFERRED

IMIPRAMINE PAMOATE CAPS NON_PREFERRED

NORTRIPTYLINE HCL CAPS PREFERRED

NORTRIPTYLINE HYDROCHLORIDE CAPS PREFERRED

PAMELOR CAPS NON_PREFERRED

NORTRIPTYLINE HCL SOLN PREFERRED

PROTRIPTYLINE HCL TABS PREFERRED

TRIMIPRAMINE MALEATE CAPS NON_PREFERRED

BUPROPION HCL TABS PREFERRED

BUPROPION HYDROCHLORIDE TABS PREFERRED

BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED

WELLBUTRIN SR TB12 NON_PREFERRED

BUPROPION HYDROCHLORIDE ER (XL) TB24 PREFERRED

FORFIVO XL TB24 NON_PREFERRED

WELLBUTRIN XL TB24 NON_PREFERRED

APLENZIN TB24 NON_PREFERRED

AUVELITY TBCR NON_PREFERRED

ANTIDEPRESSANTS : MISC

3/6/2023 8:01:09 AM Page 21 of 147

CITALOPRAM HYDROBROMIDE CAPS NON_PREFERRED

CITALOPRAM HYDROBROMIDE SOLN PREFERRED

CELEXA TABS NON_PREFERRED

CITALOPRAM HYDROBROMIDE TABS PREFERRED

ESCITALOPRAM OXALATE SOLN PREFERRED

ESCITALOPRAM OXALATE TABS PREFERRED

LEXAPRO TABS NON_PREFERRED

FLUOXETINE HCL CAPS PREFERRED

FLUOXETINE HYDROCHLORIDE CAPS PREFERRED

PROZAC CAPS NON_PREFERRED

FLUOXETINE DR CPDR NON_PREFERRED

FLUOXETINE HCL SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE SOLN PREFERRED

FLUOXETINE HYDROCHLORIDE TABS PREFERRED

FLUVOXAMINE MALEATE ER CP24 NON_PREFERRED

FLUVOXAMINE MALEATE TABS PREFERRED

PAROXETINE HYDROCHLORIDE SUSP PREFERRED

PAXIL SUSP NON_PREFERRED

PAROXETINE HCL TABS PREFERRED

PAROXETINE HYDROCHLORIDE TABS PREFERRED

PAXIL TABS NON_PREFERRED

PAROXETINE HCL ER TB24 NON_PREFERRED

PAROXETINE HYDROCHLORIDEER TB24 NON_PREFERRED

PAXIL CR TB24 NON_PREFERRED

PEXEVA TABS NON_PREFERRED

SERTRALINE HYDROCHLORIDE CAPS NON_PREFERRED

SERTRALINE HCL CONC PREFERRED

SERTRALINE HYDROCHLORIDE CONC PREFERRED

ZOLOFT CONC NON_PREFERRED

SERTRALINE HCL TABS PREFERRED

SERTRALINE HYDROCHLORIDE TABS PREFERRED

ZOLOFT TABS NON_PREFERRED

DESVENLAFAXINE ER TB24 NON_PREFERRED

PRISTIQ TB24 NON_PREFERRED

CYMBALTA CPEP NON_PREFERRED

DULOXETINE HCL CPEP PREFERRED

DULOXETINE HYDROCHLORIDE CPEP PREFERRED

DRIZALMA SPRINKLE CSDR NON_PREFERRED

ANTIDEPRESSANTS : SELECTIVE

SEROTONIN REUPTAKE INHIBITOR (SSRIs)

ANTIDEPRESSANTS : SELECTIVE

SEROTONIN-NOREPINEPHRINE

REUPTAKE INHIBITOR (SNRIs)

3/6/2023 8:01:09 AM Page 22 of 147

FETZIMA TITRATION PACK C4PK NON_PREFERRED

FETZIMA CP24 NON_PREFERRED

VENLAFAXINE BESYLATE ER TB24 PREFERRED

EFFEXOR XR CP24 NON_PREFERRED

VENLAFAXINE HCL ER CP24 PREFERRED

VENLAFAXINE HYDROCHLORIDE ER CP24 PREFERRED

VENLAFAXINE HCL TABS PREFERRED

VENLAFAXINE HYDROCHLORIDE TABS PREFERRED

VENLAFAXINE HCL ER TB24 NON_PREFERRED

VENLAFAXINE HYDROCHLORIDE ER TB24 NON_PREFERRED

XULTOPHY 100/3.6 SOPN NON_PREFERRED

SOLIQUA 100/33 SOPN NON_PREFERRED

ALOGLIPTIN/METFORMIN HCL TABS NON_PREFERRED

ALOGLIPTIN/METFORMIN HYDROCHLORIDE TABS NON_PREFERRED

KAZANO TABS NON_PREFERRED

JENTADUETO TABS NON_PREFERRED

JENTADUETO XR TB24 NON_PREFERRED

KOMBIGLYZE XR TB24 NON_PREFERRED

JANUMET TABS NON_PREFERRED

JANUMET XR TB24 NON_PREFERRED

ALOGLIPTIN/PIOGLITAZONE TABS NON_PREFERRED

OSENI TABS NON_PREFERRED

REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS NON_PREFERRED

INVOKAMET TABS NON_PREFERRED

INVOKAMET XR TB24 NON_PREFERRED

XIGDUO XR TB24 NON_PREFERRED

SYNJARDY TABS NON_PREFERRED

SYNJARDY XR TB24 NON_PREFERRED

SEGLUROMET TABS NON_PREFERRED

QTERN TABS NON_PREFERRED

GLYXAMBI TABS NON_PREFERRED

STEGLUJAN TABS NON_PREFERRED

TRIJARDY XR TB24 NON_PREFERRED

GLIPIZIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED

GLYBURIDE/METFORMIN HYDROCHLORIDE TABS PREFERRED

DUETACT TABS NON_PREFERRED

PIOGLITAZONE HCL-GLIMEPIRIDE TABS NON_PREFERRED

ACTOPLUS MET TABS NON_PREFERRED

PIOGLITAZONE HCL/METFORMIN HCL TABS NON_PREFERRED

ANTIDIABETICS : COMBINATIONS

ANTIDEPRESSANTS : SELECTIVE

SEROTONIN-NOREPINEPHRINE

REUPTAKE INHIBITOR (SNRIs)

3/6/2023 8:01:09 AM Page 23 of 147

ALOGLIPTIN TABS NON_PREFERRED

NESINA TABS NON_PREFERRED

TRADJENTA TABS PREFERRED

ONGLYZA TABS NON_PREFERRED

JANUVIA TABS PREFERRED

TRULICITY SOPN PREFERRED

BYDUREON BCISE AUIJ NON_PREFERRED

BYDUREON PEN PEN NON_PREFERRED

BYETTA SOPN NON_PREFERRED

VICTOZA SOPN PREFERRED

ADLYXIN STARTER PACK PNKT NON_PREFERRED

ADLYXIN SOPN NON_PREFERRED

OZEMPIC SOPN NON_PREFERRED

RYBELSUS TABS PREFERRED_WITH_PA

MOUNJARO SOPN NON_PREFERRED

INSULIN ASPART PENFILL SOCT NON_PREFERRED

NOVOLOG PENFILL SOCT NON_PREFERRED

INSULIN ASPART SOLN NON_PREFERRED

NOVOLOG SOLN NON_PREFERRED

NOVOLOG RELION SOLN NON_PREFERRED

INSULIN ASPART FLEXPEN SOPN NON_PREFERRED

NOVOLOG FLEXPEN SOPN NON_PREFERRED

NOVOLOG FLEXPEN RELION SOPN NON_PREFERRED

FIASP PENFILL SOCT NON_PREFERRED

FIASP SOLN NON_PREFERRED

FIASP FLEXTOUCH SOPN NON_PREFERRED

INSULIN GLARGINE SOLN NON_PREFERRED

LANTUS SOLN PREFERRED

BASAGLAR KWIKPEN SOPN NON_PREFERRED

BASAGLAR TEMPO PEN SOPN NON_PREFERRED

INSULIN GLARGINE SOLOSTAR SOPN NON_PREFERRED

LANTUS SOLOSTAR SOPN PREFERRED

TOUJEO MAX SOLOSTAR SOPN NON_PREFERRED

TOUJEO SOLOSTAR SOPN NON_PREFERRED

INSULIN GLARGINE SOLN NON_PREFERRED

SEMGLEE SOLN NON_PREFERRED

INSULIN GLARGINE SOPN NON_PREFERRED

SEMGLEE SOPN NON_PREFERRED

APIDRA SOLN NON_PREFERRED

ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-

4 (DPP-4) INHIBITORS

ANTIDIABETICS : INCRETIN MIMETIC

AGENTS (GLP-1 RECEPTOR AGONISTS)

ANTIDIABETICS : INSULIN

3/6/2023 8:01:09 AM Page 24 of 147

APIDRA SOLOSTAR SOPN NON_PREFERRED

HUMALOG SOCT PREFERRED

ADMELOG SOLN NON_PREFERRED

HUMALOG SOLN PREFERRED

INSULIN LISPRO SOLN PREFERRED

ADMELOG SOLOSTAR SOPN NON_PREFERRED

HUMALOG JUNIOR KWIKPEN SOPN PREFERRED

HUMALOG KWIKPEN SOPN PREFERRED

HUMALOG TEMPO PEN SOPN NON_PREFERRED

INSULIN LISPRO JUNIOR KWIKPEN SOPN PREFERRED

INSULIN LISPRO KWIKPEN SOPN PREFERRED

LYUMJEV SOLN NON_PREFERRED

LYUMJEV KWIKPEN SOPN NON_PREFERRED

LYUMJEV TEMPO PEN SOPN NON_PREFERRED

LEVEMIR SOLN PREFERRED

LEVEMIR FLEXPEN SOPN PREFERRED

LEVEMIR FLEXTOUCH SOPN PREFERRED

INSULIN DEGLUDEC SOLN NON_PREFERRED

TRESIBA SOLN NON_PREFERRED

INSULIN DEGLUDEC FLEXTOUCH SOPN NON_PREFERRED

TRESIBA FLEXTOUCH SOPN NON_PREFERRED

AFREZZA POWD NON_PREFERRED

HUMULIN R SOLN PREFERRED

HUMULIN R U-500 (CONCENTRATED) SOLN PREFERRED

NOVOLIN R SOLN NON_PREFERRED

NOVOLIN R RELION SOLN NON_PREFERRED

HUMULIN R U-500 KWIKPEN SOPN PREFERRED

NOVOLIN R FLEXPEN SOPN NON_PREFERRED

NOVOLIN R FLEXPEN RELION SOPN NON_PREFERRED

HUMULIN N KWIKPEN SUPN PREFERRED

NOVOLIN N FLEXPEN SUPN NON_PREFERRED

NOVOLIN N FLEXPEN RELION SUPN NON_PREFERRED

HUMULIN N SUSP PREFERRED

NOVOLIN N SUSP NON_PREFERRED

NOVOLIN N RELION SUSP NON_PREFERRED

INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN SUPN NON_PREFERRED

NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN NON_PREFERRED

NOVOLOG MIX 70/30 PREFILLED FLEXPEN RELION SUPN NON_PREFERRED

INSULIN ASPART PROTAMINE/INSULIN ASPART SUSP NON_PREFERRED

ANTIDIABETICS : INSULIN

3/6/2023 8:01:09 AM Page 25 of 147

NOVOLOG MIX 70/30 SUSP NON_PREFERRED

NOVOLOG MIX 70/30 RELION SUSP NON_PREFERRED

HUMALOG MIX 50/50 KWIKPEN SUPN PREFERRED

HUMALOG MIX 75/25 KWIKPEN SUPN PREFERRED

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN SUPN PREFERRED

HUMALOG MIX 50/50 SUSP PREFERRED

HUMALOG MIX 75/25 SUSP PREFERRED

HUMULIN 70/30 KWIKPEN SUPN PREFERRED

NOVOLIN 70/30 FLEXPEN SUPN NON_PREFERRED

NOVOLIN 70/30 FLEXPEN RELION SUPN NON_PREFERRED

HUMULIN 70/30 SUSP PREFERRED

NOVOLIN 70/30 SUSP NON_PREFERRED

NOVOLIN 70/30 RELION SUSP NON_PREFERRED

SYMLINPEN 120 SOPN NON_PREFERRED

SYMLINPEN 60 SOPN NON_PREFERRED

AMARYL TABS NON_PREFERRED

GLIMEPIRIDE TABS PREFERRED

GLIPIZIDE TABS PREFERRED

GLIPIZIDE ER TB24 PREFERRED

GLIPIZIDE XL TB24 PREFERRED

GLUCOTROL XL TB24 NON_PREFERRED

GLYBURIDE TABS PREFERRED

GLYBURIDE MICRONIZED TABS PREFERRED

GLYNASE TABS NON_PREFERRED

METFORMIN HYDROCHLORIDE SOLN NON_PREFERRED

RIOMET SOLN NON_PREFERRED

RIOMET ER SRER NON_PREFERRED

METFORMIN HYDROCHLORIDE TABS PREFERRED

GLUMETZA TB24 NON_PREFERRED

METFORMIN HYDROCHLORIDE ER MODIFIED RELEASE TB24 NON_PREFERRED

METFORMIN HYDROCHLORIDE ER OSMOTIC TB24 NON_PREFERRED

METFORMIN HYDROCHLORIDE ER TB24 PREFERRED

NATEGLINIDE TABS PREFERRED

REPAGLINIDE TABS NON_PREFERRED

ZEGALOGUE SOAJ PREFERRED

ZEGALOGUE SOSY PREFERRED

BAQSIMI ONE PACK POWD PREFERRED

BAQSIMI TWO PACK POWD PREFERRED

GVOKE HYPOPEN 1-PACK SOAJ PREFERRED

ANTIDIABETICS : INSULIN

ANTIDIABETICS : MISC

3/6/2023 8:01:09 AM Page 26 of 147

GVOKE HYPOPEN 2-PACK SOAJ PREFERRED

GVOKE KIT SOLN PREFERRED

GVOKE PFS SOSY PREFERRED

GLUCAGON EMERGENCY KIT KIT NON_PREFERRED

GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR KIT NON_PREFERRED

GLUCAGEN HYPOKIT SOLR NON_PREFERRED

GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR SOLR NON_PREFERRED

DIAZOXIDE SUSP PREFERRED

PROGLYCEM SUSP PREFERRED

KORLYM TABS NON_PREFERRED

ACARBOSE TABS PREFERRED

MIGLITOL TABS PREFERRED

CYCLOSET TABS NON_PREFERRED

ACTOS TABS NON_PREFERRED

PIOGLITAZONE HCL TABS PREFERRED

PIOGLITAZONE HYDROCHLORIDE TABS PREFERRED

INVOKANA TABS PREFERRED

FARXIGA TABS PREFERRED

JARDIANCE TABS PREFERRED

STEGLATRO TABS NON_PREFERRED

DEFERASIROX PACK NON_PREFERRED

JADENU SPRINKLE PACK NON_PREFERRED

DEFERASIROX TABS NON_PREFERRED

JADENU TABS NON_PREFERRED

DEFERASIROX TBSO NON_PREFERRED

EXJADE TBSO NON_PREFERRED

FERRIPROX SOLN NON_PREFERRED

DEFERIPRONE TABS NON_PREFERRED

FERRIPROX TABS NON_PREFERRED

FERRIPROX TWICE-A-DAY TABS NON_PREFERRED

CHEMET CAPS PREFERRED

SYPRINE CAPS NON_PREFERRED

TRIENTINE HYDROCHLORIDE CAPS PREFERRED

CUPRIMINE CAPS NON_PREFERRED

PENICILLAMINE CAPS PREFERRED

DEPEN TITRATABS TABS PREFERRED

PENICILLAMINE TABS PREFERRED

ANZEMET TABS NON_PREFERRED

SANCUSO PTCH NON_PREFERRED

ANTIDIABETICS : MISC

ANTIDIABETICS : SODIUM-GLUCOSE CO-

TRANSPORTER 2 (SGLT2) INHIBITORS

ANTIDOTES AND SPECIFIC ANTAGONISTS

: ANTIDOTES - CHELATING AGENTS

ANTIEMETICS : 5-HT3 RECEPTOR

ANTAGONISTS

3/6/2023 8:01:09 AM Page 27 of 147

GRANISETRON HYDROCHLORIDE TABS NON_PREFERRED

ONDANSETRON ODT TBDP PREFERRED

ONDANSETRON HCL SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE SOLN PREFERRED

ONDANSETRON HYDROCHLORIDE TABS PREFERRED

ANTIVERT CHEW NON_PREFERRED

ANTIVERT TABS NON_PREFERRED

MECLIZINE HCL TABS PREFERRED

MECLIZINE HYDROCHLORIDE TABS PREFERRED

SCOPOLAMINE PT72 PREFERRED

TRANSDERM-SCOP PT72 PREFERRED

TRIMETHOBENZAMIDE HYDROCHLORIDE CAPS NON_PREFERRED

DRONABINOL CAPS NON_PREFERRED

MARINOL CAPS NON_PREFERRED

BONJESTA TBCR NON_PREFERRED

DICLEGIS TBEC NON_PREFERRED

DOXYLAMINE SUCCINATE/PYRIDOXINE HYDROCHLORIDE TBEC NON_PREFERRED

AKYNZEO CAPS NON_PREFERRED

APREPITANT CAPS PREFERRED

EMEND CAPS NON_PREFERRED

EMEND TRIPACK CAPS NON_PREFERRED

APREPITANT MISC PREFERRED

EMEND SUSR NON_PREFERRED

ANCOBON CAPS NON_PREFERRED

FLUCYTOSINE CAPS NON_PREFERRED

GRISEOFULVIN MICROSIZE SUSP PREFERRED

GRISEOFULVIN MICROSIZE TABS PREFERRED

GRISEOFULVIN ULTRAMICROSIZE TABS PREFERRED

NYSTATIN TABS PREFERRED

TERBINAFINE HCL TABS PREFERRED

TERBINAFINE HYDROCHLORIDE TABS PREFERRED

KETOCONAZOLE TABS PREFERRED

DIFLUCAN SUSR NON_PREFERRED

FLUCONAZOLE SUSR PREFERRED

DIFLUCAN TABS NON_PREFERRED

FLUCONAZOLE TABS PREFERRED

CRESEMBA CAPS NON_PREFERRED

ITRACONAZOLE CAPS PREFERRED

SPORANOX CAPS NON_PREFERRED

ANTIEMETICS : 5-HT3 RECEPTOR

ANTAGONISTS

ANTIEMETICS : MISC

ANTIEMETICS : SUBSTANCE

P/NEUROKININ 1 (NK1) RECEPTOR

ANTAGONISTS

ANTIFUNGALS

3/6/2023 8:01:09 AM Page 28 of 147

TOLSURA CAPS NON_PREFERRED

ITRACONAZOLE SOLN NON_PREFERRED

SPORANOX SOLN NON_PREFERRED

NOXAFIL PACK NON_PREFERRED

NOXAFIL SUSP NON_PREFERRED

NOXAFIL TBEC NON_PREFERRED

POSACONAZOLE TBEC NON_PREFERRED

POSACONAZOLE DR TBEC NON_PREFERRED

VFEND SUSR NON_PREFERRED

VORICONAZOLE SUSR NON_PREFERRED

VFEND TABS NON_PREFERRED

VORICONAZOLE TABS NON_PREFERRED

VIVJOA CPPK NON_PREFERRED

BREXAFEMME TABS NON_PREFERRED

CHOLESTYRAMINE PACK PREFERRED

QUESTRAN PACK NON_PREFERRED

CHOLESTYRAMINE POWD PREFERRED

QUESTRAN POWD NON_PREFERRED

CHOLESTYRAMINE LIGHT PACK PREFERRED

PREVALITE PACK PREFERRED

CHOLESTYRAMINE LIGHT POWD PREFERRED

PREVALITE POWD PREFERRED

QUESTRAN LIGHT POWD NON_PREFERRED

COLESEVELAM HYDROCHLORIDE PACK NON_PREFERRED

WELCHOL PACK NON_PREFERRED

COLESEVELAM HYDROCHLORIDE TABS NON_PREFERRED

WELCHOL TABS NON_PREFERRED

COLESTID GRAN NON_PREFERRED

COLESTID FLAVORED GRAN NON_PREFERRED

COLESTIPOL HCL GRAN NON_PREFERRED

COLESTID PACK NON_PREFERRED

COLESTID FLAVORED PACK NON_PREFERRED

COLESTIPOL HCL PACK NON_PREFERRED

COLESTID TABS NON_PREFERRED

COLESTIPOL HCL TABS NON_PREFERRED

COLESTIPOL HYDROCHLORIDE TABS NON_PREFERRED

FENOFIBRIC ACID DR CPDR PREFERRED

TRILIPIX CPDR NON_PREFERRED

FENOFIBRIC ACID TABS NON_PREFERRED

ANTIFUNGALS

ANTIHYPERLIPIDEMICS

3/6/2023 8:01:09 AM Page 29 of 147

FENOFIBRATE CAPS PREFERRED

LIPOFEN CAPS NON_PREFERRED

FENOFIBRATE TABS PREFERRED

FENOGLIDE TABS NON_PREFERRED

TRICOR TABS NON_PREFERRED

ANTARA CAPS NON_PREFERRED

FENOFIBRATE CAPS PREFERRED

FENOFIBRATE MICRONIZED CAPS PREFERRED

GEMFIBROZIL TABS PREFERRED

LOPID TABS NON_PREFERRED

EZETIMIBE TABS PREFERRED

ZETIA TABS NON_PREFERRED

PRALUENT SOAJ NON_PREFERRED

REPATHA SURECLICK SOAJ NON_PREFERRED

REPATHA PUSHTRONEX SYSTEM SOCT NON_PREFERRED

REPATHA SOSY NON_PREFERRED

LEQVIO SOSY NON_PREFERRED

NEXLETOL TABS NON_PREFERRED

ATORVASTATIN CALCIUM TABS PREFERRED

LIPITOR TABS NON_PREFERRED

FLUVASTATIN CAPS NON_PREFERRED

FLUVASTATIN SODIUM ER TB24 NON_PREFERRED

LESCOL XL TB24 NON_PREFERRED

LOVASTATIN TABS PREFERRED

ALTOPREV TB24 NON_PREFERRED

LIVALO TABS NON_PREFERRED

ZYPITAMAG TABS NON_PREFERRED

EZALLOR SPRINKLE CPSP NON_PREFERRED

CRESTOR TABS NON_PREFERRED

ROSUVASTATIN CALCIUM TABS PREFERRED

PRAVASTATIN SODIUM TABS PREFERRED

SIMVASTATIN TABS PREFERRED

ZOCOR TABS NON_PREFERRED

NIACIN ER TBCR NON_PREFERRED

JUXTAPID CAPS NON_PREFERRED

ICOSAPENT ETHYL CAPS NON_PREFERRED

VASCEPA CAPS NON_PREFERRED

LOVAZA CAPS NON_PREFERRED

OMEGA-3-ACID ETHYL ESTERS CAPS NON_PREFERRED

ANTIHYPERLIPIDEMICS

3/6/2023 8:01:09 AM Page 30 of 147

NEXLIZET TABS NON_PREFERRED

EZETIMIBE/SIMVASTATIN TABS NON_PREFERRED

VYTORIN TABS NON_PREFERRED

RUZURGI TABS NON_PREFERRED

FIRDAPSE TABS NON_PREFERRED

MESTINON SOLN NON_PREFERRED

PYRIDOSTIGMINE BROMIDE SOLN PREFERRED

MESTINON TABS NON_PREFERRED

PYRIDOSTIGMINE BROMIDE TABS PREFERRED

MESTINON TIMESPAN TBCR NON_PREFERRED

PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED

MYLERAN TABS PREFERRED

LEUKERAN TABS PREFERRED

CYCLOPHOSPHAMIDE CAPS PREFERRED

CYCLOPHOSPHAMIDE TABS PREFERRED

MELPHALAN TABS PREFERRED

TEMOZOLOMIDE CAPS PREFERRED

ONUREG TABS NON_PREFERRED

CAPECITABINE TABS NON_PREFERRED

XELODA TABS NON_PREFERRED

PURIXAN SUSP NON_PREFERRED

MERCAPTOPURINE TABS PREFERRED

XATMEP SOLN NON_PREFERRED

METHOTREXATE TABS PREFERRED

METHOTREXATE SODIUM TABS PREFERRED

TREXALL TABS PREFERRED

TABLOID TABS PREFERRED

LYSODREN TABS PREFERRED

ERLEADA TABS NON_PREFERRED

BICALUTAMIDE TABS PREFERRED

CASODEX TABS NON_PREFERRED

NUBEQA TABS NON_PREFERRED

XTANDI CAPS NON_PREFERRED

XTANDI TABS NON_PREFERRED

FLUTAMIDE CAPS PREFERRED

NILUTAMIDE TABS PREFERRED

SOLTAMOX SOLN PREFERRED

TAMOXIFEN CITRATE TABS PREFERRED

FARESTON TABS NON_PREFERRED

ANTIMYASTHENIC AGENTS

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ALKYLATING AGENTS

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTIMETABOLITES

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTINEOPLASTIC -

HORMONAL AND RELATED AGENTS

ANTIHYPERLIPIDEMICS

3/6/2023 8:01:09 AM Page 31 of 147

TOREMIFENE CITRATE TABS PREFERRED

ANASTROZOLE TABS PREFERRED

ARIMIDEX TABS NON_PREFERRED

AROMASIN TABS NON_PREFERRED

EXEMESTANE TABS PREFERRED

FEMARA TABS NON_PREFERRED

LETROZOLE TABS PREFERRED

EMCYT CAPS PREFERRED

ORSERDU TABS NON_PREFERRED

MEGESTROL ACETATE SUSP PREFERRED

MEGESTROL ACETATE TABS PREFERRED

ORGOVYX TABS NON_PREFERRED

ABIRATERONE ACETATE TABS PREFERRED

YONSA TABS NON_PREFERRED

ZYTIGA TABS NON_PREFERRED

TUKYSA TABS NON_PREFERRED

INLYTA TABS NON_PREFERRED

LENVIMA 10 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 12MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 14 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 18 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 20 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 24 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 4 MG DAILY DOSE CPPK NON_PREFERRED

LENVIMA 8 MG DAILY DOSE CPPK NON_PREFERRED

GILOTRIF TABS NON_PREFERRED

VIZIMPRO TABS NON_PREFERRED

ERLOTINIB HYDROCHLORIDE TABS PREFERRED

TARCEVA TABS NON_PREFERRED

IRESSA TABS PREFERRED

EXKIVITY CAPS NON_PREFERRED

TAGRISSO TABS NON_PREFERRED

AYVAKIT TABS NON_PREFERRED

ALECENSA CAPS NON_PREFERRED

ALUNBRIG TABS NON_PREFERRED

ALUNBRIG TBPK NON_PREFERRED

ZYKADIA TABS NON_PREFERRED

XALKORI CAPS NON_PREFERRED

LORBRENA TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTINEOPLASTIC -

HORMONAL AND RELATED AGENTS

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTINEOPLASTIC ENZYME

INHIBITORS

3/6/2023 8:01:09 AM Page 32 of 147

VERZENIO TABS NON_PREFERRED

IBRANCE CAPS NON_PREFERRED

IBRANCE TABS NON_PREFERRED

KISQALI TBPK NON_PREFERRED

ZOLINZA CAPS NON_PREFERRED

SCEMBLIX TABS NON_PREFERRED

BOSULIF TABS NON_PREFERRED

SPRYCEL TABS NON_PREFERRED

GLEEVEC TABS NON_PREFERRED

IMATINIB MESYLATE TABS NON_PREFERRED

TASIGNA CAPS NON_PREFERRED

ICLUSIG TABS NON_PREFERRED

TAFINLAR CAPS NON_PREFERRED

BRAFTOVI CAPS NON_PREFERRED

ZELBORAF TABS NON_PREFERRED

CALQUENCE CAPS NON_PREFERRED

CALQUENCE TABS NON_PREFERRED

IMBRUVICA CAPS NON_PREFERRED

IMBRUVICA SUSP NON_PREFERRED

IMBRUVICA TABS NON_PREFERRED

JAYPIRCA TABS NON_PREFERRED

BRUKINSA CAPS NON_PREFERRED

BALVERSA TABS NON_PREFERRED

LYTGOBI TBPK NON_PREFERRED

TRUSELTIQ CPPK NON_PREFERRED

PEMAZYRE TABS NON_PREFERRED

LUMAKRAS TABS NON_PREFERRED

AFINITOR TABS NON_PREFERRED

EVEROLIMUS TABS NON_PREFERRED

AFINITOR DISPERZ TBSO NON_PREFERRED

EVEROLIMUS TBSO NON_PREFERRED

COMETRIQ KIT NON_PREFERRED

CABOMETYX TABS NON_PREFERRED

XOSPATA TABS NON_PREFERRED

LAPATINIB DITOSYLATE TABS NON_PREFERRED

TYKERB TABS NON_PREFERRED

RYDAPT CAPS NON_PREFERRED

NERLYNX TABS NON_PREFERRED

VOTRIENT TABS PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTINEOPLASTIC ENZYME

INHIBITORS

3/6/2023 8:01:09 AM Page 33 of 147

TURALIO CAPS NON_PREFERRED

STIVARGA TABS NON_PREFERRED

QINLOCK TABS NON_PREFERRED

NEXAVAR TABS PREFERRED

SORAFENIB TABS PREFERRED

SORAFENIB TOSYLATE TABS PREFERRED

SUNITINIB MALATE CAPS PREFERRED

SUTENT CAPS PREFERRED

FOTIVDA CAPS NON_PREFERRED

CAPRELSA TABS PREFERRED

MEKTOVI TABS NON_PREFERRED

COTELLIC TABS NON_PREFERRED

KOSELUGO CAPS NON_PREFERRED

MEKINIST TABS NON_PREFERRED

TAZVERIK TABS NON_PREFERRED

TABRECTA TABS NON_PREFERRED

TEPMETKO TABS NON_PREFERRED

ROZLYTREK CAPS NON_PREFERRED

VITRAKVI CAPS NON_PREFERRED

VITRAKVI SOLN NON_PREFERRED

TIBSOVO TABS NON_PREFERRED

REZLIDHIA CAPS NON_PREFERRED

IDHIFA TABS NON_PREFERRED

ZEJULA CAPS NON_PREFERRED

LYNPARZA TABS NON_PREFERRED

RUBRACA TABS NON_PREFERRED

TALZENNA CAPS NON_PREFERRED

GAVRETO CAPS NON_PREFERRED

RETEVMO CAPS NON_PREFERRED

NINLARO CAPS NON_PREFERRED

INREBIC CAPS NON_PREFERRED

VONJO CAPS NON_PREFERRED

JAKAFI TABS PREFERRED

PIQRAY 200MG DAILY DOSE TBPK NON_PREFERRED

PIQRAY 250MG DAILY DOSE TBPK NON_PREFERRED

PIQRAY 300MG DAILY DOSE TBPK NON_PREFERRED

COPIKTRA CAPS NON_PREFERRED

ZYDELIG TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : ANTINEOPLASTIC ENZYME

INHIBITORS

3/6/2023 8:01:09 AM Page 34 of 147

LEUCOVORIN CALCIUM TABS PREFERRED

MESNEX TABS PREFERRED

DAURISMO TABS NON_PREFERRED

ODOMZO CAPS NON_PREFERRED

ERIVEDGE CAPS PREFERRED

POMALYST CAPS NON_PREFERRED

VENCLEXTA TABS NON_PREFERRED

VENCLEXTA STARTING PACK TBPK NON_PREFERRED

HYCAMTIN CAPS PREFERRED

XPOVIO TBPK NON_PREFERRED

XPOVIO 100 MG ONCE WEEKLY TBPK NON_PREFERRED

XPOVIO 40 MG ONCE WEEKLY TBPK NON_PREFERRED

XPOVIO 40 MG TWICE WEEKLY TBPK NON_PREFERRED

XPOVIO 60 MG ONCE WEEKLY TBPK NON_PREFERRED

XPOVIO 60 MG TWICE WEEKLY TBPK NON_PREFERRED

XPOVIO 80 MG ONCE WEEKLY TBPK NON_PREFERRED

XPOVIO 80 MG TWICE WEEKLY TBPK NON_PREFERRED

HYDREA CAPS NON_PREFERRED

HYDROXYUREA CAPS PREFERRED

MATULANE CAPS PREFERRED

TRETINOIN CAPS PREFERRED

BEXAROTENE CAPS PREFERRED

TARGRETIN CAPS NON_PREFERRED

INQOVI TABS NON_PREFERRED

KISQALI FEMARA 200 DOSE TBPK NON_PREFERRED

KISQALI FEMARA 400 DOSE TBPK NON_PREFERRED

KISQALI FEMARA 600 DOSE TBPK NON_PREFERRED

LONSURF TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : MITOTIC INHIBITORS

ETOPOSIDE CAPS PREFERRED

ALBENDAZOLE TABS NON_PREFERRED

ALBENZA TABS NON_PREFERRED

BENZNIDAZOLE TABS NON_PREFERRED

IVERMECTIN TABS NON_PREFERRED

STROMECTOL TABS NON_PREFERRED

EMVERM CHEW NON_PREFERRED

BILTRICIDE TABS NON_PREFERRED

PRAZIQUANTEL TABS PREFERRED

EGATEN TABS NON_PREFERRED

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : CHEMOTHERAPY RESCUE /

ANTIDOTE AGENTS

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES : MISC

ANTIPARASITICS : ANTHELMINTICS

3/6/2023 8:01:09 AM Page 35 of 147

CHLOROQUINE PHOSPHATE TABS PREFERRED

HYDROXYCHLOROQUINE SULFATE TABS PREFERRED

MEFLOQUINE HCL TABS PREFERRED

PRIMAQUINE PHOSPHATE TABS PREFERRED

DARAPRIM TABS NON_PREFERRED

PYRIMETHAMINE TABS NON_PREFERRED

QUALAQUIN CAPS NON_PREFERRED

QUININE SULFATE CAPS NON_PREFERRED

KRINTAFEL TABS NON_PREFERRED

COARTEM TABS NON_PREFERRED

ATOVAQUONE/PROGUANIL HCL TABS PREFERRED

MALARONE TABS NON_PREFERRED

BENZTROPINE MESYLATE TABS PREFERRED

TRIHEXYPHENIDYL HCL SOLN PREFERRED

TRIHEXYPHENIDYL HYDROCHLORIDE TABS PREFERRED

TASMAR TABS NON_PREFERRED

TOLCAPONE TABS NON_PREFERRED

COMTAN TABS NON_PREFERRED

ENTACAPONE TABS PREFERRED

ONGENTYS CAPS NON_PREFERRED

AMANTADINE HCL CAPS PREFERRED

AMANTADINE HYDROCHLORIDE CAPS PREFERRED

GOCOVRI CP24 NON_PREFERRED

AMANTADINE HCL SOLN PREFERRED

OSMOLEX ER T4PK NON_PREFERRED

AMANTADINE HCL TABS PREFERRED

AMANTADINE HYDROCHLORIDE TABS PREFERRED

OSMOLEX ER TB24 NON_PREFERRED

BROMOCRIPTINE MESYLATE CAPS PREFERRED

PARLODEL CAPS NON_PREFERRED

BROMOCRIPTINE MESYLATE TABS PREFERRED

PARLODEL TABS NON_PREFERRED

INBRIJA CAPS NON_PREFERRED

KYNMOBI FILM NON_PREFERRED

KYNMOBI TITRATION KIT KIT NON_PREFERRED

APOKYN SOCT NON_PREFERRED

APOMORPHINE HYDROCHLORIDE SOCT NON_PREFERRED

PRAMIPEXOLE DIHYDROCHLORIDE TABS PREFERRED

MIRAPEX ER TB24 NON_PREFERRED

ANTIPARASITICS : ANTIMALARIALS

ANTIPARKINSON AND RELATED THERAPY

AGENTS

3/6/2023 8:01:09 AM Page 36 of 147

PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 NON_PREFERRED

ROPINIROLE HCL TABS PREFERRED

ROPINIROLE HYDROCHLORIDE TABS PREFERRED

ROPINIROLE ER TB24 NON_PREFERRED

NEUPRO PT24 NON_PREFERRED

RYTARY CPCR NON_PREFERRED

CARBIDOPA/LEVODOPA TABS PREFERRED

DHIVY TABS NON_PREFERRED

SINEMET TABS NON_PREFERRED

CARBIDOPA/LEVODOPA ER TBCR PREFERRED

CARBIDOPA/LEVODOPA ODT TBDP NON_PREFERRED

CARBIDOPA/LEVODOPA/ENTACAPONE TABS NON_PREFERRED

STALEVO 100 TABS NON_PREFERRED

STALEVO 125 TABS NON_PREFERRED

STALEVO 150 TABS NON_PREFERRED

STALEVO 200 TABS NON_PREFERRED

STALEVO 50 TABS NON_PREFERRED

STALEVO 75 TABS NON_PREFERRED

AZILECT TABS NON_PREFERRED

RASAGILINE MESYLATE TABS NON_PREFERRED

XADAGO TABS NON_PREFERRED

SELEGILINE HCL CAPS PREFERRED

SELEGILINE HYDROCHLORIDE CAPS PREFERRED

SELEGILINE HCL TABS PREFERRED

SELEGILINE HYDROCHLORIDE TABS PREFERRED

ZELAPAR TBDP NON_PREFERRED

NOURIANZ TABS NON_PREFERRED

CARBIDOPA TABS PREFERRED

LODOSYN TABS NON_PREFERRED

FANAPT TABS NON_PREFERRED

FANAPT TITRATION PACK TABS NON_PREFERRED

INVEGA TB24 NON_PREFERRED

PALIPERIDONE ER TB24 NON_PREFERRED

INVEGA HAFYERA SUSY PREFERRED_WITH_PA

INVEGA SUSTENNA SUSY PREFERRED_WITH_PA

INVEGA TRINZA SUSY PREFERRED_WITH_PA

PERSERIS PRSY NON_PREFERRED

RISPERDAL SOLN NON_PREFERRED

RISPERIDONE SOLN PREFERRED

ANTIPARKINSON AND RELATED THERAPY

AGENTS

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

BENZISOXAZOLES

3/6/2023 8:01:09 AM Page 37 of 147

RISPERDAL TABS NON_PREFERRED

RISPERIDONE TABS PREFERRED

RISPERIDONE ODT TBDP NON_PREFERRED

RISPERDAL CONSTA SRER NON_PREFERRED

VERSACLOZ SUSP NON_PREFERRED

CLOZAPINE TABS PREFERRED

CLOZARIL TABS NON_PREFERRED

CLOZAPINE ODT TBDP NON_PREFERRED

QUETIAPINE FUMARATE TABS PREFERRED

SEROQUEL TABS NON_PREFERRED

QUETIAPINE FUMARATE ER TB24 PREFERRED

SEROQUEL XR TB24 NON_PREFERRED

LOXAPINE CAPS PREFERRED

LOXAPINE SUCCINATE CAPS PREFERRED

SECUADO PT24 NON_PREFERRED

ASENAPINE MALEATE SL SUBL NON_PREFERRED

SAPHRIS SUBL NON_PREFERRED

OLANZAPINE SOLR NON_PREFERRED

ZYPREXA SOLR NON_PREFERRED

OLANZAPINE TABS PREFERRED

ZYPREXA TABS NON_PREFERRED

OLANZAPINE ODT TBDP PREFERRED

ZYPREXA ZYDIS TBDP NON_PREFERRED

ZYPREXA RELPREVV SUSR NON_PREFERRED

HALOPERIDOL TABS PREFERRED

HALOPERIDOL CONC PREFERRED

MOLINDONE HYDROCHLORIDE TABS NON_PREFERRED

CHLORPROMAZINE HYDROCHLORIDE CONC PREFERRED

CHLORPROMAZINE HCL TABS PREFERRED

CHLORPROMAZINE HYDROCHLORIDE TABS PREFERRED

FLUPHENAZINE HCL CONC PREFERRED

FLUPHENAZINE HYDROCHLORIDE ELIX PREFERRED

FLUPHENAZINE HCL TABS PREFERRED

FLUPHENAZINE HYDROCHLORIDE TABS PREFERRED

PERPHENAZINE TABS PREFERRED

COMPRO SUPP PREFERRED

PROCHLORPERAZINE SUPP PREFERRED

PROCHLORPERAZINE MALEATE TABS PREFERRED

THIORIDAZINE HCL TABS PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

MISC

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

BENZISOXAZOLES

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

DIBENZAPINES

3/6/2023 8:01:09 AM Page 38 of 147

TRIFLUOPERAZINE HCL TABS PREFERRED

TRIFLUOPERAZINE HYDROCHLORIDE TABS PREFERRED

THIOTHIXENE CAPS PREFERRED

EQUETRO CP12 NON_PREFERRED

VRAYLAR CAPS NON_PREFERRED

VRAYLAR CPPK NON_PREFERRED

CAPLYTA CAPS NON_PREFERRED

LATUDA TABS NON_PREFERRED

LURASIDONE HYDROCHLORIDE TABS NON_PREFERRED

NUPLAZID CAPS NON_PREFERRED

NUPLAZID TABS NON_PREFERRED

GEODON CAPS NON_PREFERRED

ZIPRASIDONE HCL CAPS PREFERRED

ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED

GEODON SOLR NON_PREFERRED

ZIPRASIDONE MESYLATE SOLR NON_PREFERRED

LITHIUM CARBONATE CAPS PREFERRED

LITHIUM CARBONATE TABS PREFERRED

LITHIUM CARBONATE ER TBCR PREFERRED

LITHOBID TBCR NON_PREFERRED

ABILIFY MAINTENA PRSY PREFERRED_WITH_PA

ARIPIPRAZOLE SOLN NON_PREFERRED

ABILIFY MAINTENA SRER PREFERRED_WITH_PA

ABILIFY TABS NON_PREFERRED

ARIPIPRAZOLE TABS PREFERRED

ARIPIPRAZOLE ODT TBDP NON_PREFERRED

ABILIFY MYCITE MAINTENANCE KIT TBPK NON_PREFERRED

ABILIFY MYCITE STARTER KIT TBPK NON_PREFERRED

ARISTADA PRSY PREFERRED_WITH_PA

ARISTADA INITIO PRSY PREFERRED_WITH_PA

REXULTI TABS NON_PREFERRED

SELZENTRY SOLN NON_PREFERRED

MARAVIROC TABS NON_PREFERRED

SELZENTRY TABS NON_PREFERRED

TROGARZO SOLN PREFERRED_WITH_PA

RUKOBIA TB12 NON_PREFERRED

FUZEON SOLR NON_PREFERRED

APRETUDE SUER PREFERRED

TIVICAY TABS PREFERRED

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

MISC

ANTIPSYCHOTICS / ANTIMANIC AGENTS :

QUINOLINONE DERIVATIVES

ANTIVIRALS : ANTIRETROVIRALS (HIV)

3/6/2023 8:01:09 AM Page 39 of 147

TIVICAY PD TBSO PREFERRED

ISENTRESS CHEW PREFERRED

ISENTRESS PACK PREFERRED

ISENTRESS TABS PREFERRED

ISENTRESS HD TABS PREFERRED

ATAZANAVIR CAPS PREFERRED

ATAZANAVIR SULFATE CAPS PREFERRED

REYATAZ CAPS PREFERRED

REYATAZ PACK PREFERRED

PREZISTA SUSP PREFERRED

PREZISTA TABS PREFERRED

LEXIVA SUSP PREFERRED

FOSAMPRENAVIR CALCIUM TABS PREFERRED

LEXIVA TABS PREFERRED

VIRACEPT TABS PREFERRED

NORVIR PACK PREFERRED

NORVIR SOLN PREFERRED

NORVIR TABS PREFERRED

RITONAVIR TABS PREFERRED

INVIRASE TABS PREFERRED

APTIVUS CAPS PREFERRED

ABACAVIR SOLN PREFERRED

ZIAGEN SOLN PREFERRED

ABACAVIR TABS PREFERRED

ABACAVIR SULFATE TABS PREFERRED

ZIAGEN TABS NON_PREFERRED

DIDANOSINE CPDR PREFERRED

EMTRICITABINE CAPS PREFERRED

EMTRIVA CAPS PREFERRED

EMTRIVA SOLN PREFERRED

EPIVIR SOLN NON_PREFERRED

LAMIVUDINE SOLN PREFERRED

EPIVIR TABS NON_PREFERRED

LAMIVUDINE TABS PREFERRED

STAVUDINE CAPS PREFERRED

RETROVIR CAPS NON_PREFERRED

ZIDOVUDINE CAPS PREFERRED

RETROVIR SYRP NON_PREFERRED

ZIDOVUDINE SYRP PREFERRED

ANTIVIRALS : ANTIRETROVIRALS (HIV)

3/6/2023 8:01:09 AM Page 40 of 147

ZIDOVUDINE TABS PREFERRED

VIREAD POWD PREFERRED

TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

VIREAD TABS PREFERRED

PIFELTRO TABS NON_PREFERRED

EFAVIRENZ CAPS PREFERRED

SUSTIVA CAPS PREFERRED

EFAVIRENZ TABS PREFERRED

SUSTIVA TABS PREFERRED

ETRAVIRINE TABS PREFERRED

INTELENCE TABS PREFERRED

NEVIRAPINE SUSP PREFERRED

NEVIRAPINE TABS PREFERRED

NEVIRAPINE ER TB24 PREFERRED

VIRAMUNE XR TB24 NON_PREFERRED

EDURANT TABS PREFERRED

TYBOST TABS NON_PREFERRED

ABACAVIR SULFATE/LAMIVUDINE TABS PREFERRED

EPZICOM TABS NON_PREFERRED

EVOTAZ TABS NON_PREFERRED

CABENUVA SUER PREFERRED_WITH_PA

DOVATO TABS PREFERRED

PREZCOBIX TABS NON_PREFERRED

JULUCA TABS NON_PREFERRED

DESCOVY TABS PREFERRED

EMTRICITABINE/TENOFOVIR DISOPROXIL TABS PREFERRED

EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

TRUVADA TABS PREFERRED

CIMDUO TABS NON_PREFERRED

TEMIXYS TABS NON_PREFERRED

COMBIVIR TABS NON_PREFERRED

LAMIVUDINE/ZIDOVUDINE TABS PREFERRED

KALETRA SOLN NON_PREFERRED

LOPINAVIR/RITONAVIR SOLN PREFERRED

KALETRA TABS PREFERRED

LOPINAVIR/RITONAVIR TABS PREFERRED

TRIUMEQ TABS PREFERRED

TRIUMEQ PD TBSO PREFERRED

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS PREFERRED

ANTIVIRALS : ANTIRETROVIRALS (HIV)

3/6/2023 8:01:09 AM Page 41 of 147

TRIZIVIR TABS NON_PREFERRED

BIKTARVY TABS PREFERRED

DELSTRIGO TABS PREFERRED

ATRIPLA TABS PREFERRED

EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE TABS PREFERRED

EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE TABS NON_PREFERRED

SYMFI TABS PREFERRED

SYMFI LO TABS PREFERRED

ODEFSEY TABS PREFERRED

COMPLERA TABS PREFERRED

SYMTUZA TABS PREFERRED

GENVOYA TABS PREFERRED

STRIBILD TABS NON_PREFERRED

ADEFOVIR DIPIVOXIL TABS NON_PREFERRED

HEPSERA TABS NON_PREFERRED

BARACLUDE SOLN NON_PREFERRED

BARACLUDE TABS NON_PREFERRED

ENTECAVIR TABS PREFERRED

EPIVIR HBV SOLN NON_PREFERRED

EPIVIR HBV TABS NON_PREFERRED

LAMIVUDINE TABS NON_PREFERRED

VEMLIDY TABS NON_PREFERRED

PEGASYS SOLN NON_PREFERRED

PEGASYS SOSY NON_PREFERRED

RIBAVIRIN CAPS PREFERRED

RIBAVIRIN TABS PREFERRED

MODERIBA 1200 DOSE PACK TBPK NON_PREFERRED

SOVALDI PACK NON_PREFERRED

SOVALDI TABS NON_PREFERRED

ZEPATIER TABS NON_PREFERRED

MAVYRET PACK PREFERRED_WITH_PA

MAVYRET TABS PREFERRED_WITH_PA

HARVONI PACK NON_PREFERRED

HARVONI TABS NON_PREFERRED

LEDIPASVIR/SOFOSBUVIR TABS NON_PREFERRED

EPCLUSA PACK NON_PREFERRED

EPCLUSA TABS NON_PREFERRED

SOFOSBUVIR/VELPATASVIR TABS PREFERRED_WITH_PA

VOSEVI TABS NON_PREFERRED

ANTIVIRALS : ANTIRETROVIRALS (HIV)

ANTIVIRALS : HEPATITIS B AGENTS

ANTIVIRALS : HEPATITIS C AGENTS

3/6/2023 8:01:09 AM Page 42 of 147

VIEKIRA PAK TBPK NON_PREFERRED

PREVYMIS TABS NON_PREFERRED

LIVTENCITY TABS PREFERRED_WITH_PA

VALCYTE SOLR NON_PREFERRED

VALGANCICLOVIR HYDROCHLORIDE SOLR NON_PREFERRED

VALCYTE TABS NON_PREFERRED

VALGANCICLOVIR TABS PREFERRED

ACYCLOVIR CAPS PREFERRED

ACYCLOVIR SUSP PREFERRED

ZOVIRAX SUSP NON_PREFERRED

ACYCLOVIR TABS PREFERRED

SITAVIG TABS NON_PREFERRED

VALACYCLOVIR HCL TABS PREFERRED

VALACYCLOVIR HYDROCHLORIDE TABS PREFERRED

VALTREX TABS NON_PREFERRED

FAMCICLOVIR TABS NON_PREFERRED

FLUMADINE TABS NON_PREFERRED

RIMANTADINE HYDROCHLORIDE TABS NON_PREFERRED

XOFLUZA TBPK NON_PREFERRED

OSELTAMIVIR PHOSPHATE CAPS PREFERRED

TAMIFLU CAPS NON_PREFERRED

OSELTAMIVIR PHOSPHATE SUSR PREFERRED

TAMIFLU SUSR NON_PREFERRED

RELENZA DISKHALER AEPB PREFERRED

RIBAVIRIN SOLR PREFERRED

VIRAZOLE SOLR NON_PREFERRED

LAGEVRIO CAPS PREFERRED

PAXLOVID TBPK PREFERRED

AMLODIPINE BESYLATE/BENAZEPRIL HCL CAPS PREFERRED

AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE CAPS PREFERRED

LOTREL CAPS NON_PREFERRED

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR PREFERRED

BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS PREFERRED

BENAZEPRIL HYDROCHLORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED

LOTENSIN HCT TABS NON_PREFERRED

ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE TABS PREFERRED

VASERETIC TABS NON_PREFERRED

FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED

LISINOPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

ANTIVIRALS : HEPATITIS C AGENTS

ANTIVIRALS : MISC

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ACE INHIBITOR

COMBINATIONS

3/6/2023 8:01:09 AM Page 43 of 147

ZESTORETIC TABS NON_PREFERRED

ACCURETIC TABS NON_PREFERRED

QUINAPRIL/HYDROCHLOROTHIAZIDE TABS PREFERRED

BENAZEPRIL HCL TABS PREFERRED

BENAZEPRIL HYDROCHLORIDE TABS PREFERRED

LOTENSIN TABS NON_PREFERRED

CAPTOPRIL TABS PREFERRED

ENALAPRIL MALEATE SOLN NON_PREFERRED

EPANED SOLN NON_PREFERRED

ENALAPRIL MALEATE TABS PREFERRED

VASOTEC TABS NON_PREFERRED

FOSINOPRIL SODIUM TABS PREFERRED

QBRELIS SOLN NON_PREFERRED

LISINOPRIL TABS PREFERRED

ZESTRIL TABS NON_PREFERRED

MOEXIPRIL HCL TABS PREFERRED

PERINDOPRIL ERBUMINE TABS NON_PREFERRED

ACCUPRIL TABS NON_PREFERRED

QUINAPRIL HCL TABS PREFERRED

QUINAPRIL HYDROCHLORIDE TABS PREFERRED

ALTACE CAPS NON_PREFERRED

RAMIPRIL CAPS PREFERRED

TRANDOLAPRIL TABS PREFERRED

AMLODIPINE/OLMESARTAN MEDOXOMIL TABS NON_PREFERRED

AZOR TABS NON_PREFERRED

AMLODIPINE BESYLATE/VALSARTAN TABS NON_PREFERRED

EXFORGE TABS NON_PREFERRED

TELMISARTAN/AMLODIPINE TABS NON_PREFERRED

EDARBYCLOR TABS NON_PREFERRED

ATACAND HCT TABS NON_PREFERRED

CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

AVALIDE TABS NON_PREFERRED

IRBESARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED

HYZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED

BENICAR HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

MICARDIS HCT TABS NON_PREFERRED

TELMISARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ACE INHIBITOR

COMBINATIONS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ACE INHIBITORS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ANGIOTENSIN II

RECEPTOR BLOCKER COMBINATIONS

3/6/2023 8:01:09 AM Page 44 of 147

DIOVAN HCT TABS NON_PREFERRED

VALSARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED

AMLODIPINE/VALSARTAN/HCTZ TABS NON_PREFERRED

AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

EXFORGE HCT TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TABS NON_PREFERRED

TRIBENZOR TABS NON_PREFERRED

EDARBI TABS NON_PREFERRED

ATACAND TABS NON_PREFERRED

CANDESARTAN CILEXETIL TABS NON_PREFERRED

AVAPRO TABS NON_PREFERRED

IRBESARTAN TABS PREFERRED

COZAAR TABS NON_PREFERRED

LOSARTAN POTASSIUM TABS PREFERRED

BENICAR TABS NON_PREFERRED

OLMESARTAN MEDOXOMIL TABS NON_PREFERRED

MICARDIS TABS NON_PREFERRED

TELMISARTAN TABS NON_PREFERRED

DIOVAN TABS NON_PREFERRED

VALSARTAN TABS PREFERRED

CATAPRES-TTS-1 PTWK NON_PREFERRED

CATAPRES-TTS-2 PTWK NON_PREFERRED

CATAPRES-TTS-3 PTWK NON_PREFERRED

CLONIDINE HCL PTWK PREFERRED

CLONIDINE HYDROCHLORIDE TABS PREFERRED

CLONIDINE ER TB24 NON_PREFERRED

GUANFACINE HCL TABS PREFERRED

GUANFACINE HYDROCHLORIDE TABS PREFERRED

METHYLDOPA TABS PREFERRED

CARDURA TABS NON_PREFERRED

DOXAZOSIN TABS PREFERRED

DOXAZOSIN MESYLATE TABS PREFERRED

MINIPRESS CAPS NON_PREFERRED

PRAZOSIN HCL CAPS PREFERRED

PRAZOSIN HYDROCHLORIDE CAPS PREFERRED

TERAZOSIN HCL CAPS PREFERRED

TERAZOSIN HYDROCHLORIDE CAPS PREFERRED

ATENOLOL/CHLORTHALIDONE TABS PREFERRED

TENORETIC 100 TABS NON_PREFERRED

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ANGIOTENSIN II

RECEPTOR BLOCKER COMBINATIONS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ANGIOTENSIN II

RECEPTOR BLOCKERS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : ANTIADRENERGICS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : BETA-BLOCKER

COMBINATIONS

3/6/2023 8:01:09 AM Page 45 of 147

TENORETIC 50 TABS NON_PREFERRED

BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE TABS PREFERRED

ZIAC TABS NON_PREFERRED

METOPROLOL/HYDROCHLOROTHIAZIDE TABS PREFERRED

CORGARD TABS NON_PREFERRED

NADOLOL TABS PREFERRED

PINDOLOL TABS PREFERRED

INDERAL LA CP24 NON_PREFERRED

PROPRANOLOL HCL ER CP24 PREFERRED

PROPRANOLOL HYDROCHLORIDE ER CP24 PREFERRED

HEMANGEOL SOLN PREFERRED_WITH_PA

PROPRANOLOL HCL SOLN PREFERRED

PROPRANOLOL HYDROCHLORIDE SOLN PREFERRED

PROPRANOLOL HCL TABS PREFERRED

PROPRANOLOL HYDROCHLORIDE TABS PREFERRED

INDERAL XL CP24 NON_PREFERRED

INNOPRAN XL CP24 NON_PREFERRED

SOTYLIZE SOLN NON_PREFERRED

BETAPACE TABS NON_PREFERRED

SORINE TABS PREFERRED

SOTALOL HCL TABS PREFERRED

SOTALOL HYDROCHLORIDE TABS PREFERRED

BETAPACE AF TABS NON_PREFERRED

SOTALOL HCL (AF) TABS NON_PREFERRED

SOTALOL HCL AF TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE (AF) TABS NON_PREFERRED

SOTALOL HYDROCHLORIDE AF TABS NON_PREFERRED

TIMOLOL MALEATE TABS PREFERRED

ACEBUTOLOL HCL CAPS PREFERRED

ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED

FIRST-ATENOLOL SOLN NON_PREFERRED

ATENOLOL TABS PREFERRED

TENORMIN TABS NON_PREFERRED

BETAXOLOL HCL TABS PREFERRED

BISOPROLOL FUMARATE TABS PREFERRED

KAPSPARGO SPRINKLE CS24 NON_PREFERRED

METOPROLOL SUCCINATE ER TB24 PREFERRED

TOPROL XL TB24 NON_PREFERRED

FIRST - METOPROLOL SOLN NON_PREFERRED

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : BETA-BLOCKERS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : BETA-BLOCKER

COMBINATIONS

3/6/2023 8:01:09 AM Page 46 of 147

LOPRESSOR TABS NON_PREFERRED

METOPROLOL TARTRATE TABS PREFERRED

BYSTOLIC TABS NON_PREFERRED

NEBIVOLOL TABS NON_PREFERRED

NEBIVOLOL HYDROCHLORIDE TABS NON_PREFERRED

CARVEDILOL TABS PREFERRED

COREG TABS NON_PREFERRED

CARVEDILOL PHOSPHATE ER CP24 NON_PREFERRED

COREG CR CP24 NON_PREFERRED

LABETALOL HYDROCHLORIDE TABS PREFERRED

KATERZIA SUSP NON_PREFERRED

NORLIQVA SOLN NON_PREFERRED

AMLODIPINE BESYLATE TABS PREFERRED

NORVASC TABS NON_PREFERRED

DILTIAZEM HCL ER CP12 PREFERRED

DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED

DILT-XR CP24 PREFERRED

CARDIZEM TABS NON_PREFERRED

DILTIAZEM HCL TABS PREFERRED

DILTIAZEM HYDROCHLORIDE TABS PREFERRED

DILTIAZEM HCL ER CP24 PREFERRED

DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED

TAZTIA XT CP24 PREFERRED

TIADYLT ER CP24 PREFERRED

TIAZAC CP24 NON_PREFERRED

CARDIZEM CD CP24 NON_PREFERRED

CARTIA XT CP24 PREFERRED

DILTIAZEM HCL CD CP24 PREFERRED

DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED

CARDIZEM LA TB24 NON_PREFERRED

DILTIAZEM HCL ER TB24 PREFERRED

DILTIAZEM HYDROCHLORIDE ER TB24 PREFERRED

MATZIM LA TB24 PREFERRED

FELODIPINE ER TB24 PREFERRED

ISRADIPINE CAPS NON_PREFERRED

NICARDIPINE HCL CAPS NON_PREFERRED

NICARDIPINE HYDROCHLORIDE CAPS NON_PREFERRED

NIFEDIPINE CAPS PREFERRED

NIFEDIPINE ER TB24 PREFERRED

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : BETA-BLOCKERS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : CALCIUM

CHANNEL BLOCKERS

3/6/2023 8:01:09 AM Page 47 of 147

PROCARDIA XL TB24 NON_PREFERRED

NIMODIPINE CAPS PREFERRED

NYMALIZE SOLN NON_PREFERRED

NISOLDIPINE ER TB24 NON_PREFERRED

SULAR TB24 NON_PREFERRED

VERAPAMIL HCL ER CP24 PREFERRED

VERAPAMIL HCL SR CP24 PREFERRED

VERAPAMIL HYDROCHLORIDE ER CP24 PREFERRED

VERELAN CP24 NON_PREFERRED

VERELAN PM CP24 NON_PREFERRED

VERAPAMIL HCL TABS PREFERRED

VERAPAMIL HYDROCHLORIDE TABS PREFERRED

CALAN SR TBCR NON_PREFERRED

VERAPAMIL HCL ER TBCR PREFERRED

VERAPAMIL HYDROCHLORIDE ER TBCR PREFERRED

LEVAMLODIPINE TABS NON_PREFERRED

ALISKIREN TABS NON_PREFERRED

TEKTURNA TABS NON_PREFERRED

EPLERENONE TABS NON_PREFERRED

INSPRA TABS NON_PREFERRED

PHENOXYBENZAMINE HYDROCHLORIDE CAPS NON_PREFERRED

DEMSER CAPS PREFERRED

METYROSINE CAPS PREFERRED

HYDRALAZINE HCL TABS PREFERRED

HYDRALAZINE HYDROCHLORIDE TABS PREFERRED

MINOXIDIL TABS PREFERRED

VECAMYL TABS NON_PREFERRED

TEKTURNA HCT TABS NON_PREFERRED

DIGOXIN SOLN PREFERRED

DIGOX TABS PREFERRED

DIGOXIN TABS NON_PREFERRED

DIGOXIN TABS PREFERRED

ISORDIL TITRADOSE TABS NON_PREFERRED

ISOSORBIDE DINITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE TABS PREFERRED

ISOSORBIDE MONONITRATE ER TB24 PREFERRED

NITRO-BID OINT PREFERRED

GONITRO PACK NON_PREFERRED

NITRO-DUR PT24 NON_PREFERRED

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : CALCIUM

CHANNEL BLOCKERS

CARDIOVASCULAR AGENTS -

ANTIHYPERTENSIVES : MISC

CARDIOVASCULAR AGENTS -

CARDIOTONICS : CARDIAC GLYCOSIDES

CARDIOVASCULAR AGENTS :

ANTIANGINAL AGENTS

3/6/2023 8:01:09 AM Page 48 of 147

NITROGLYCERIN TRANSDERMAL PT24 PREFERRED

NITROGLYCERIN LINGUAL SOLN NON_PREFERRED

NITROLINGUAL PUMPSPRAY SOLN NON_PREFERRED

NITROGLYCERIN SUBL PREFERRED

NITROSTAT SUBL NON_PREFERRED

ASPRUZYO SPRINKLE PACK NON_PREFERRED

RANEXA TB12 NON_PREFERRED

RANOLAZINE ER TB12 NON_PREFERRED

DISOPYRAMIDE PHOSPHATE CAPS PREFERRED

NORPACE CAPS NON_PREFERRED

NORPACE CR CP12 PREFERRED

QUINIDINE GLUCONATE CR TBCR PREFERRED

QUINIDINE GLUCONATE ER TBCR PREFERRED

QUINIDINE SULFATE TABS PREFERRED

MEXILETINE HCL CAPS PREFERRED

MEXILETINE HYDROCHLORIDE CAPS PREFERRED

FLECAINIDE ACETATE TABS PREFERRED

PROPAFENONE HYDROCHLORIDE ER CP12 NON_PREFERRED

RYTHMOL SR CP12 NON_PREFERRED

PROPAFENONE HCL TABS PREFERRED

PROPAFENONE HYDROCHLORIDE TABS PREFERRED

AMIODARONE HCL TABS PREFERRED

AMIODARONE HYDROCHLORIDE TABS PREFERRED

PACERONE TABS PREFERRED

DOFETILIDE CAPS PREFERRED

TIKOSYN CAPS NON_PREFERRED

MULTAQ TABS NON_PREFERRED

ACETAZOLAMIDE ER CP12 PREFERRED

ACETAZOLAMIDE TABS PREFERRED

DICHLORPHENAMIDE TABS NON_PREFERRED

KEVEYIS TABS NON_PREFERRED

METHAZOLAMIDE TABS PREFERRED

BUMETANIDE TABS PREFERRED

BUMEX TABS NON_PREFERRED

EDECRIN TABS NON_PREFERRED

ETHACRYNIC ACID TABS PREFERRED

FUROSEMIDE SOLN PREFERRED

CARDIOVASCULAR AGENTS :

ANTIANGINAL AGENTS

CARDIOVASCULAR AGENTS :

ANTIARRHYTHMICS

CARDIOVASCULAR AGENTS : DIURETICS

3/6/2023 8:01:09 AM Page 49 of 147

FUROSEMIDE TABS PREFERRED

LASIX TABS NON_PREFERRED

TORSEMIDE TABS PREFERRED

AMILORIDE HCL TABS PREFERRED

AMILORIDE HYDROCHLORIDE TABS PREFERRED

CAROSPIR SUSP NON_PREFERRED

ALDACTONE TABS NON_PREFERRED

SPIRONOLACTONE TABS PREFERRED

TRIAMTERENE CAPS PREFERRED

DIURIL SUSP PREFERRED

CHLORTHALIDONE TABS PREFERRED

THALITONE TABS NON_PREFERRED

HYDROCHLOROTHIAZIDE CAPS PREFERRED

HYDROCHLOROTHIAZIDE TABS PREFERRED

INDAPAMIDE TABS PREFERRED

METOLAZONE TABS PREFERRED

AMILORIDE/HYDROCHLOROTHIAZIDE TABS PREFERRED

ALDACTAZIDE TABS NON_PREFERRED

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS PREFERRED

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS PREFERRED

MAXZIDE TABS NON_PREFERRED

MAXZIDE-25 TABS NON_PREFERRED

TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS PREFERRED

MIDODRINE HCL TABS PREFERRED

MIDODRINE HYDROCHLORIDE TABS PREFERRED

DROXIDOPA CAPS NON_PREFERRED

NORTHERA CAPS NON_PREFERRED

CAMZYOS CAPS NON_PREFERRED

CIALIS TABS NON_PREFERRED

TADALAFIL TABS NON_PREFERRED

VYNDAMAX CAPS NON_PREFERRED

VYNDAQEL CAPS NON_PREFERRED

CORLANOR SOLN NON_PREFERRED

CORLANOR TABS NON_PREFERRED

VERQUVO TABS PREFERRED_WITH_PA

ENTRESTO TABS PREFERRED

AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS NON_PREFERRED

CADUET TABS NON_PREFERRED

BIDIL TABS PREFERRED

CARDIOVASCULAR AGENTS : DIURETICS

CARDIOVASCULAR AGENTS : MISC

3/6/2023 8:01:09 AM Page 50 of 147

ISOSORBIDE DINITRATE/HYDRALAZINE HYDROCHLORIDE TABS PREFERRED

UPTRAVI SOLR NON_PREFERRED

UPTRAVI TABS NON_PREFERRED

UPTRAVI TITRATION PACK TBPK NON_PREFERRED

ADEMPAS TABS NON_PREFERRED

REVATIO SOLN NON_PREFERRED

SILDENAFIL SOLN NON_PREFERRED

REVATIO SUSR PREFERRED_WITH_PA

SILDENAFIL SUSR NON_PREFERRED

SILDENAFIL CITRATE SUSR NON_PREFERRED

REVATIO TABS NON_PREFERRED

SILDENAFIL CITRATE TABS PREFERRED_WITH_PA

TADLIQ SUSP NON_PREFERRED

ADCIRCA TABS PREFERRED_WITH_PA

ALYQ TABS PREFERRED_WITH_PA

TADALAFIL TABS PREFERRED_WITH_PA

AMBRISENTAN TABS NON_PREFERRED

LETAIRIS TABS PREFERRED_WITH_PA

BOSENTAN TABS NON_PREFERRED

TRACLEER TABS PREFERRED_WITH_PA

TRACLEER TBSO PREFERRED_WITH_PA

OPSUMIT TABS NON_PREFERRED

EPOPROSTENOL SODIUM SOLR PREFERRED_WITH_PA

FLOLAN SOLR PREFERRED_WITH_PA

VELETRI SOLR NON_PREFERRED

VENTAVIS SOLN NON_PREFERRED

TYVASO DPI MAINTENANCE KIT POWD NON_PREFERRED

TYVASO DPI TITRATION KIT POWD NON_PREFERRED

REMODULIN SOLN NON_PREFERRED

TREPROSTINIL SOLN NON_PREFERRED

TYVASO SOLN NON_PREFERRED

TYVASO REFILL SOLN NON_PREFERRED

TYVASO STARTER SOLN NON_PREFERRED

ORENITRAM TBCR NON_PREFERRED

TWIRLA PTWK PREFERRED

XULANE PTWK PREFERRED

ZAFEMY PTWK PREFERRED

ELURYNG RING PREFERRED

ETONOGESTREL/ETHINYL ESTRADIOL RING PREFERRED

CARDIOVASCULAR AGENTS : MISC

CARDIOVASCULAR AGENTS : PULMONARY

HYPERTENSION

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 51 of 147

HALOETTE RING PREFERRED

NUVARING RING PREFERRED

ANNOVERA RING PREFERRED

APRI TABS PREFERRED

CYRED TABS PREFERRED

CYRED EQ TABS PREFERRED

DESOGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

ENSKYCE TABS PREFERRED

ISIBLOOM TABS PREFERRED

JULEBER TABS PREFERRED

KALLIGA TABS PREFERRED

RECLIPSEN TABS PREFERRED

NEXTSTELLIS TABS PREFERRED

DROSPIRENONE/ETHINYL ESTRADIOL TABS PREFERRED

GIANVI TABS PREFERRED

JASMIEL TABS PREFERRED

LORYNA TABS PREFERRED

LO-ZUMANDIMINE TABS PREFERRED

NIKKI TABS PREFERRED

OCELLA TABS PREFERRED

SYEDA TABS PREFERRED

VESTURA TABS PREFERRED

YASMIN 28 TABS PREFERRED

YAZ TABS PREFERRED

ZUMANDIMINE TABS PREFERRED

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL TABS PREFERRED

KELNOR 1/35 TABS PREFERRED

KELNOR 1/50 TABS PREFERRED

ZOVIA 1/35 TABS PREFERRED

TYBLUME CHEW PREFERRED

AFIRMELLE TABS PREFERRED

ALTAVERA TABS PREFERRED

AUBRA TABS PREFERRED

AUBRA EQ TABS PREFERRED

AVIANE TABS PREFERRED

AYUNA TABS PREFERRED

CHATEAL TABS PREFERRED

CHATEAL EQ TABS PREFERRED

FALMINA TABS PREFERRED

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 52 of 147

KURVELO TABS PREFERRED

LARISSIA TABS PREFERRED

LESSINA TABS PREFERRED

LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

LEVORA 0.15/30-28 TABS PREFERRED

LILLOW TABS PREFERRED

LUTERA TABS PREFERRED

MARLISSA TABS PREFERRED

PORTIA-28 TABS PREFERRED

SRONYX TABS PREFERRED

VIENVA TABS PREFERRED

ALYACEN 1/35 TABS PREFERRED

BALZIVA TABS PREFERRED

BRIELLYN TABS PREFERRED

DASETTA 1/35 TABS PREFERRED

NECON 0.5/35-28 TABS PREFERRED

NORTREL 0.5/35 (28) TABS PREFERRED

NORTREL 1/35 TABS PREFERRED

NYLIA 1/35 TABS PREFERRED

PHILITH TABS PREFERRED

PIRMELLA 1/35 TABS PREFERRED

VYFEMLA TABS PREFERRED

WERA TABS PREFERRED

AUROVELA 1.5/30 TABS PREFERRED

AUROVELA 1/20 TABS PREFERRED

HAILEY 1.5/30 TABS PREFERRED

JUNEL 1.5/30 TABS PREFERRED

JUNEL 1/20 TABS PREFERRED

LARIN 1.5/30 TABS PREFERRED

LARIN 1/20 TABS PREFERRED

LOESTRIN 1.5/30-21 TABS PREFERRED

LOESTRIN 1/20-21 TABS PREFERRED

MICROGESTIN 1.5/30 TABS PREFERRED

MICROGESTIN 1/20 TABS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS PREFERRED

CRYSELLE-28 TABS PREFERRED

ELINEST TABS PREFERRED

LOW-OGESTREL TABS PREFERRED

ESTARYLLA TABS PREFERRED

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 53 of 147

FEMYNOR TABS PREFERRED

MILI TABS PREFERRED

MONO-LINYAH TABS PREFERRED

NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED

NYMYO TABS PREFERRED

PREVIFEM TABS PREFERRED

SPRINTEC 28 TABS PREFERRED

VYLIBRA TABS PREFERRED

BEYAZ TABS PREFERRED

DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM TABS PREFERRED

SAFYRAL TABS PREFERRED

TYDEMY TABS PREFERRED

BALCOLTRA TABS PREFERRED

FALESSA KIT PREFERRED

KAITLIB FE CHEW PREFERRED

LAYOLIS FE CHEW PREFERRED

NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE CHEW PREFERRED

NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED

WYMZYA FE CHEW PREFERRED

GEMMILY CAPS PREFERRED

MERZEE CAPS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE CAPS PREFERRED

TAYSOFY CAPS PREFERRED

TAYTULLA CAPS PREFERRED

CHARLOTTE 24 FE CHEW PREFERRED

FINZALA CHEW PREFERRED

MELODETTA 24 FE CHEW PREFERRED

MIBELAS 24 FE CHEW PREFERRED

MINASTRIN 24 FE CHEW PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE CHEW PREFERRED

AUROVELA 24 FE TABS PREFERRED

AUROVELA FE 1.5/30 TABS PREFERRED

AUROVELA FE 1/20 TABS PREFERRED

BLISOVI 24 FE TABS PREFERRED

BLISOVI FE 1.5/30 TABS PREFERRED

BLISOVI FE 1/20 TABS PREFERRED

HAILEY 24 FE TABS PREFERRED

HAILEY FE 1.5/30 TABS PREFERRED

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 54 of 147

HAILEY FE 1/20 TABS PREFERRED

JUNEL FE 1.5/30 TABS PREFERRED

JUNEL FE 1/20 TABS PREFERRED

JUNEL FE 24 TABS PREFERRED

LARIN 24 FE TABS PREFERRED

LARIN FE 1.5/30 TABS PREFERRED

LARIN FE 1/20 TABS PREFERRED

LOESTRIN FE 1.5/30 TABS PREFERRED

LOESTRIN FE 1/20 TABS PREFERRED

MICROGESTIN 24 FE TABS PREFERRED

MICROGESTIN FE 1.5/30 TABS PREFERRED

MICROGESTIN FE 1/20 TABS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS PREFERRED

TARINA 24 FE TABS PREFERRED

TARINA FE 1/20 TABS PREFERRED

TARINA FE 1/20 EQ TABS PREFERRED

AZURETTE TABS PREFERRED

BEKYREE TABS PREFERRED

DESOGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

KARIVA TABS PREFERRED

MIRCETTE TABS PREFERRED

PIMTREA TABS PREFERRED

SIMLIYA TABS PREFERRED

VIORELE TABS PREFERRED

VOLNEA TABS PREFERRED

LO LOESTRIN FE TABS PREFERRED

VELIVET TABS PREFERRED

ENPRESSE-28 TABS PREFERRED

LEVONEST TABS PREFERRED

LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

TRIVORA-28 TABS PREFERRED

ALYACEN 7/7/7 TABS PREFERRED

ARANELLE TABS PREFERRED

DASETTA 7/7/7 TABS PREFERRED

LEENA TABS PREFERRED

NORTREL 7/7/7 TABS PREFERRED

NYLIA 7/7/7 TABS PREFERRED

PIRMELLA 7/7/7 TABS PREFERRED

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 55 of 147

NORGESTIMATE/ETHINYL ESTRADIOL TABS PREFERRED

TRI FEMYNOR TABS PREFERRED

TRI-ESTARYLLA TABS PREFERRED

TRI-LINYAH TABS PREFERRED

TRI-LO-ESTARYLLA TABS PREFERRED

TRI-LO-MARZIA TABS PREFERRED

TRI-LO-MILI TABS PREFERRED

TRI-LO-SPRINTEC TABS PREFERRED

TRI-MILI TABS PREFERRED

TRI-NYMYO TABS PREFERRED

TRI-SPRINTEC TABS PREFERRED

TRI-VYLIBRA TABS PREFERRED

TRI-VYLIBRA LO TABS PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE TABS PREFERRED

TILIA FE TABS PREFERRED

TRI-LEGEST FE TABS PREFERRED

NATAZIA TABS PREFERRED

AMETHIA TABS PREFERRED

ASHLYNA TABS PREFERRED

CAMRESE TABS PREFERRED

CAMRESE LO TABS PREFERRED

DAYSEE TABS PREFERRED

FAYOSIM TABS PREFERRED

ICLEVIA TABS PREFERRED

INTROVALE TABS PREFERRED

JAIMIESS TABS PREFERRED

JOLESSA TABS PREFERRED

LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED

LEVONORGESTREL/ETHINYL ESTRADIOL TABS PREFERRED

LOJAIMIESS TABS PREFERRED

LOSEASONIQUE TABS PREFERRED

QUARTETTE TABS PREFERRED

RIVELSA TABS PREFERRED

SEASONIQUE TABS PREFERRED

SETLAKIN TABS PREFERRED

SIMPESSE TABS PREFERRED

AMETHYST TABS PREFERRED

DOLISHALE TABS PREFERRED

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 56 of 147

LEVONORGESTREL AND ETHINYL ESTRADIOL TABS PREFERRED

ECONTRA EZ TABS PREFERRED

ECONTRA ONE-STEP TABS PREFERRED

LEVONORGESTREL TABS PREFERRED

MY CHOICE TABS PREFERRED

MY WAY TABS PREFERRED

NEW DAY TABS PREFERRED

OPCICON ONE-STEP TABS PREFERRED

OPTION 2 TABS PREFERRED

ELLA TABS PREFERRED

CAMILA TABS PREFERRED

DEBLITANE TABS PREFERRED

ERRIN TABS PREFERRED

HEATHER TABS PREFERRED

INCASSIA TABS PREFERRED

JENCYCLA TABS PREFERRED

LYLEQ TABS PREFERRED

LYZA TABS PREFERRED

NORA-BE TABS PREFERRED

NORETHINDRONE TABS PREFERRED

NORLYDA TABS PREFERRED

SHAROBEL TABS PREFERRED

TULANA TABS PREFERRED

SLYND TABS PREFERRED

DEPO-PROVERA CONTRACEPTIVE SUSP PREFERRED

MEDROXYPROGESTERONE ACETATE SUSP PREFERRED

DEPO-PROVERA CONTRACEPTIVE SUSY PREFERRED

DEPO-SUBQ PROVERA 104 SUSY PREFERRED

MEDROXYPROGESTERONE ACETATE SUSY PREFERRED

ORTIKOS CP24 NON_PREFERRED

TARPEYO CPDR NON_PREFERRED

BUDESONIDE CPEP NON_PREFERRED

BUDESONIDE ER TB24 NON_PREFERRED

UCERIS TB24 NON_PREFERRED

CORTISONE ACETATE TABS NON_PREFERRED

EMFLAZA SUSP NON_PREFERRED

EMFLAZA TABS NON_PREFERRED

DEXAMETHASONE INTENSOL CONC PREFERRED

DEXAMETHASONE ELIX PREFERRED

CORTICOSTEROIDS

CONTRACEPTIVES : COMBINATION

CONTRACEPTIVES

CONTRACEPTIVES : EMERGENCY

CONTRACEPTIVES

CONTRACEPTIVES : PROGESTIN

CONTRACEPTIVES

3/6/2023 8:01:09 AM Page 57 of 147

DEXAMETHASONE SOLN PREFERRED

DEXAMETHASONE TABS PREFERRED

HEMADY TABS NON_PREFERRED

DEXAMETHASONE 10-DAY DOSE PACK TBPK PREFERRED

DEXAMETHASONE 13-DAY DOSE PACK TBPK PREFERRED

DEXAMETHASONE 6-DAY DOSEPACK TBPK PREFERRED

DEXAMETHASONE 6-DAY THERAPY PACK TBPK PREFERRED

TAPERDEX 12-DAY TBPK NON_PREFERRED

TAPERDEX 6-DAY TBPK NON_PREFERRED

TAPERDEX 7-DAY TBPK NON_PREFERRED

ALKINDI SPRINKLE CPSP NON_PREFERRED

CORTEF TABS NON_PREFERRED

HYDROCORTISONE TABS PREFERRED

MEDROL TABS NON_PREFERRED

METHYLPREDNISOLONE TABS PREFERRED

MEDROL DOSEPAK TBPK NON_PREFERRED

METHYLPREDNISOLONE DOSE PACK TBPK PREFERRED

PREDNISOLONE SOLN PREFERRED

MILLIPRED TABS PREFERRED

PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED

PREDNISOLONE SODIUM PHOSPHATE ODT TBDP NON_PREFERRED

PREDNISONE INTENSOL CONC PREFERRED

PREDNISONE SOLN PREFERRED

PREDNISONE TABS PREFERRED

RAYOS TBEC NON_PREFERRED

PREDNISONE TBPK PREFERRED

FLUDROCORTISONE ACETATE TABS PREFERRED

ADAPALENE CREA NON_PREFERRED

ADAPALENE GEL NON_PREFERRED

ADAPALENE PUMP GEL NON_PREFERRED

ADAPALENE SOLN NON_PREFERRED

AZELEX CREA NON_PREFERRED

WINLEVI CREA NON_PREFERRED

ABSORICA CAPS NON_PREFERRED

ACCUTANE CAPS NON_PREFERRED

AMNESTEEM CAPS NON_PREFERRED

CLARAVIS CAPS NON_PREFERRED

ISOTRETINOIN CAPS NON_PREFERRED

MYORISAN CAPS NON_PREFERRED

CORTICOSTEROIDS

DERMATOLOGICALS : ACNE PRODUCTS

3/6/2023 8:01:09 AM Page 58 of 147

ZENATANE CAPS NON_PREFERRED

ABSORICA LD CAPS NON_PREFERRED

FABIOR FOAM NON_PREFERRED

TAZAROTENE FOAM NON_PREFERRED

ARAZLO LOTN NON_PREFERRED

AVITA CREA PREFERRED

RETIN-A CREA NON_PREFERRED

TRETINOIN CREA PREFERRED

ATRALIN GEL NON_PREFERRED

AVITA GEL PREFERRED

RETIN-A GEL NON_PREFERRED

TRETINOIN GEL PREFERRED

ALTRENO LOTN NON_PREFERRED

RETIN-A MICRO GEL NON_PREFERRED

RETIN-A MICRO PUMP GEL NON_PREFERRED

TRETINOIN MICROSPHERE GEL NON_PREFERRED

TRETINOIN MICROSPHERE PUMP GEL NON_PREFERRED

CLINDACIN FOAM NON_PREFERRED

CLINDAMYCIN PHOSPHATE FOAM NON_PREFERRED

EVOCLIN FOAM NON_PREFERRED

CLINDAGEL GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE GEL PREFERRED

CLEOCIN-T LOTN NON_PREFERRED

CLINDAMYCIN PHOSPHATE LOTN PREFERRED

CLINDAMYCIN PHOSPHATE SOLN PREFERRED

CLINDACIN ETZ PLEDGETS SWAB PREFERRED

CLINDACIN-P SWAB PREFERRED

CLINDAMYCIN PHOSPHATE SWAB PREFERRED

ACZONE GEL NON_PREFERRED

DAPSONE GEL NON_PREFERRED

ERYGEL GEL NON_PREFERRED

ERYTHROMYCIN GEL PREFERRED

ERY PADS NON_PREFERRED

ERYTHROMYCIN SOLN PREFERRED

KLARON LOTN NON_PREFERRED

SODIUM SULFACETAMIDE LOTN NON_PREFERRED

SULFACETAMIDE SODIUM LOTN NON_PREFERRED

AMZEEQ FOAM NON_PREFERRED

ADAPALENE/BENZOYL PEROXIDE GEL NON_PREFERRED

DERMATOLOGICALS : ACNE PRODUCTS

3/6/2023 8:01:09 AM Page 59 of 147

ADAPALENE/BENZOYL PEROXIDE TOPICAL GEL GEL NON_PREFERRED

ADAPALENE/BENZOYL PEROXIDE PADS NON_PREFERRED

BENZAMYCIN GEL NON_PREFERRED

ERYTHROMYCIN/BENZOYL PEROXIDE GEL PREFERRED

AKTIPAK PACK PREFERRED

ACANYA GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED

CLINDAMYCIN/BENZOYL PEROXIDE GEL NON_PREFERRED

ONEXTON GEL NON_PREFERRED

CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL NON_PREFERRED

NEUAC GEL NON_PREFERRED

CLINDACIN ETZ KIT NON_PREFERRED

CLINDACIN PAC KIT NON_PREFERRED

CLINDAMYCIN PHOSPHATE/TRETINOIN GEL NON_PREFERRED

ZIANA GEL NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CREA NON_PREFERRED

SSS 10%-5% CREA NON_PREFERRED

BP 10-1 EMUL NON_PREFERRED

SSS 10-5 FOAM NON_PREFERRED

AVAR CLEANSER LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CLEANSER LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR WASH LIQD NON_PREFERRED

SUMADAN WASH LIQD NON_PREFERRED

SUMAXIN WASH LIQD NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR PADS NON_PREFERRED

SUMAXIN PADS NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR SUSP NON_PREFERRED

BP CLEANSING WASH EMUL NON_PREFERRED

SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA EMUL NON_PREFERRED

SUMADAN KIT KIT NON_PREFERRED

SUMAXIN CP KIT KIT NON_PREFERRED

SUMADAN XLT KIT NON_PREFERRED

NEUAC KIT KIT NON_PREFERRED

GENTAMICIN SULFATE CREA PREFERRED

GENTAMICIN SULFATE OINT PREFERRED

XEPI CREA NON_PREFERRED

CENTANY AT KIT NON_PREFERRED

CENTANY OINT NON_PREFERRED

DERMATOLOGICALS : ACNE PRODUCTS

DERMATOLOGICALS : ANTIBIOTICS

3/6/2023 8:01:09 AM Page 60 of 147

MUPIROCIN OINT PREFERRED

MUPIROCIN CREA NON_PREFERRED

NEO-SYNALAR CREA NON_PREFERRED

NEO-SYNALAR KIT KIT NON_PREFERRED

MENTAX CREA NON_PREFERRED

CICLOPIROX GEL NON_PREFERRED

CICLODAN SOLUTION KIT KIT NON_PREFERRED

CICLOPIROX TREATMENT KIT NON_PREFERRED

CICLOPIROX SHAM NON_PREFERRED

LOPROX SHAMPOO SHAM NON_PREFERRED

CICLODAN SOLN NON_PREFERRED

CICLOPIROX NAIL LACQUER SOLN NON_PREFERRED

CICLOPIROX OLAMINE CREA NON_PREFERRED

LOPROX CREA NON_PREFERRED

CICLOPIROX SUSP NON_PREFERRED

LOPROX SUSP NON_PREFERRED

LOPROX KIT NON_PREFERRED

LOPROX KIT KIT NON_PREFERRED

NAFTIFINE HCL CREA NON_PREFERRED

NAFTIFINE HYDROCHLORIDE CREA NON_PREFERRED

NAFTIFINE HYDROCHLORIDE GEL NON_PREFERRED

NAFTIN GEL NON_PREFERRED

NYSTATIN CREA PREFERRED

NYSTATIN OINT PREFERRED

NYAMYC POWD PREFERRED

NYSTATIN POWD PREFERRED

NYSTOP POWD PREFERRED

CLOTRIMAZOLE CREA PREFERRED

CLOTRIMAZOLE SOLN NON_PREFERRED

ECONAZOLE NITRATE CREA PREFERRED

JUBLIA SOLN NON_PREFERRED

KETOCONAZOLE CREA PREFERRED

EXTINA FOAM NON_PREFERRED

KETOCONAZOLE FOAM NON_PREFERRED

KETODAN FOAM NON_PREFERRED

KETOCONAZOLE SHAM PREFERRED

KETODAN KIT KIT NON_PREFERRED

LULICONAZOLE CREA NON_PREFERRED

LUZU CREA NON_PREFERRED

DERMATOLOGICALS : ANTIBIOTICS

DERMATOLOGICALS : ANTIFUNGALS

3/6/2023 8:01:09 AM Page 61 of 147

OXICONAZOLE NITRATE CREA NON_PREFERRED

OXISTAT LOTN NON_PREFERRED

ERTACZO CREA NON_PREFERRED

EXELDERM CREA NON_PREFERRED

SULCONAZOLE NITRATE CREA NON_PREFERRED

EXELDERM SOLN NON_PREFERRED

SULCONAZOLE NITRATE SOLN NON_PREFERRED

KERYDIN SOLN NON_PREFERRED

TAVABOROLE SOLN NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED

ZOLPAK KIT NON_PREFERRED

NYSTATIN/TRIAMCINOLONE CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE ACETONIDE CREA NON_PREFERRED

NYSTATIN/TRIAMCINOLONE OINT NON_PREFERRED

NYSTATIN/TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED

ECONASIL KIT NON_PREFERRED

MICONAZOLE NITRATE/ZINC OXIDE/WHITE PETROLATUM OINT NON_PREFERRED

VUSION OINT NON_PREFERRED

CALCIPOTRIENE CREA PREFERRED

DOVONEX CREA NON_PREFERRED

CALCIPOTRIENE FOAM NON_PREFERRED

SORILUX FOAM NON_PREFERRED

CALCIPOTRIENE OINT PREFERRED

CALCIPOTRIENE SOLN PREFERRED

CALCITRIOL OINT NON_PREFERRED

ZORYVE CREA NON_PREFERRED

TAZAROTENE CREA NON_PREFERRED

TAZAROTENE GEL NON_PREFERRED

VTAMA CREA NON_PREFERRED

ACITRETIN CAPS NON_PREFERRED

SILIQ SOSY NON_PREFERRED

SOTYKTU TABS NON_PREFERRED

TREMFYA SOPN NON_PREFERRED

TREMFYA SOSY NON_PREFERRED

TALTZ SOAJ NON_PREFERRED

TALTZ SOSY NON_PREFERRED

METHOXSALEN CAPS NON_PREFERRED

SKYRIZI PSKT NON_PREFERRED

DERMATOLOGICALS : ANTIFUNGALS

DERMATOLOGICALS : ANTIPSORIATICS

3/6/2023 8:01:09 AM Page 62 of 147

SKYRIZI PEN SOAJ NON_PREFERRED

SKYRIZI SOSY NON_PREFERRED

COSENTYX SENSOREADY PEN SOAJ PREFERRED_WITH_PA

COSENTYX SOSY PREFERRED_WITH_PA

ILUMYA SOSY NON_PREFERRED

STELARA SOLN NON_PREFERRED

STELARA SOSY NON_PREFERRED

ALCLOMETASONE DIPROPIONATE CREA PREFERRED

ALCLOMETASONE DIPROPIONATE OINT PREFERRED

AMCINONIDE CREA NON_PREFERRED

BETAMETHASONE DIPROPIONATE CREA NON_PREFERRED

BETAMETHASONE DIPROPIONATE LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED

BETAMETHASONE DIPROPIONATE AUGMENTED CREA NON_PREFERRED

BETAMETHASONE DIPROPIONATE AUGMENTED GEL NON_PREFERRED

BETAMETHASONE DIPROPIONATE AUGMENTED LOTN NON_PREFERRED

BETAMETHASONE DIPROPIONATE AUGMENTED OINT NON_PREFERRED

DIPROLENE OINT NON_PREFERRED

BETAMETHASONE VALERATE CREA PREFERRED

BETAMETHASONE VALERATE FOAM NON_PREFERRED

LUXIQ FOAM NON_PREFERRED

BETAMETHASONE VALERATE LOTN PREFERRED

BETAMETHASONE VALERATE OINT PREFERRED

CLOBETASOL PROPIONATE CREA PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

OLUX FOAM NON_PREFERRED

CLOBETASOL PROPIONATE GEL PREFERRED

TASOPROL KIT NON_PREFERRED

CLOBETASOL PROPIONATE LIQD NON_PREFERRED

CLOBETASOL PROPIONATE LOTN NON_PREFERRED

IMPEKLO LOTN NON_PREFERRED

CLOBETASOL PROPIONATE OINT PREFERRED

CLOBETASOL PROPIONATE SHAM NON_PREFERRED

CLODAN SHAM NON_PREFERRED

CLOBETASOL PROPIONATE SOLN PREFERRED

CLOBETASOL PROPIONATE CREA PREFERRED

CLOBETASOL PROPIONATE E CREA PREFERRED

CLOBETASOL PROPIONATE EMOLLIENT CREA PREFERRED

CLOBETASOL PROPIONATE FOAM NON_PREFERRED

DERMATOLOGICALS : ANTIPSORIATICS

DERMATOLOGICALS : CORTICOSTEROIDS -

TOPICAL

3/6/2023 8:01:09 AM Page 63 of 147

CLOBETASOL PROPIONATE EMOLLIENT FOAM NON_PREFERRED

OLUX-E FOAM NON_PREFERRED

TOVET FOAM NON_PREFERRED

TOVET KIT KIT NON_PREFERRED

CLOCORTOLONE PIVALATE CREA NON_PREFERRED

CLODERM CREA NON_PREFERRED

DESONIDE CREA PREFERRED

DESONIDE LOTN NON_PREFERRED

DESONIDE OINT PREFERRED

DESOXIMETASONE CREA NON_PREFERRED

TOPICORT CREA NON_PREFERRED

DESOXIMETASONE GEL NON_PREFERRED

TOPICORT GEL NON_PREFERRED

DESOXIMETASONE LIQD NON_PREFERRED

TOPICORT LIQD NON_PREFERRED

DESOXIMETASONE OINT NON_PREFERRED

TOPICORT OINT NON_PREFERRED

DIFLORASONE DIACETATE CREA PREFERRED

PSORCON CREA NON_PREFERRED

DIFLORASONE DIACETATE OINT PREFERRED

APEXICON E CREA NON_PREFERRED

FLUOCINOLONE ACETONIDE CREA PREFERRED

SYNALAR CREA NON_PREFERRED

DERMA-SMOOTHE/FS BODY OIL NON_PREFERRED

DERMA-SMOOTHE/FS SCALP OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE BODY OIL PREFERRED

FLUOCINOLONE ACETONIDE SCALP OIL PREFERRED

FLUOCINOLONE ACETONIDE OINT PREFERRED

SYNALAR OINT NON_PREFERRED

FLUOCINOLONE ACETONIDE SOLN PREFERRED

SYNALAR SOLN NON_PREFERRED

FLUOCINONIDE CREA PREFERRED

VANOS CREA NON_PREFERRED

FLUOCINONIDE GEL PREFERRED

FLUOCINONIDE OINT PREFERRED

FLUOCINONIDE SOLN PREFERRED

FLUOCINONIDE EMULSIFIED BASE CREA PREFERRED

FLUOCINONIDE EMULSIFIEDBASE CREA PREFERRED

FLURANDRENOLIDE CREA NON_PREFERRED

DERMATOLOGICALS : CORTICOSTEROIDS -

TOPICAL

3/6/2023 8:01:09 AM Page 64 of 147

FLURANDRENOLIDE LOTN NON_PREFERRED

FLURANDRENOLIDE OINT NON_PREFERRED

CORDRAN TAPE NON_PREFERRED

FLUTICASONE PROPIONATE CREA PREFERRED

BESER LOTN NON_PREFERRED

FLUTICASONE PROPIONATE LOTN NON_PREFERRED

FLUTICASONE PROPIONATE OINT PREFERRED

HALCINONIDE CREA NON_PREFERRED

HALOG CREA NON_PREFERRED

HALOG OINT NON_PREFERRED

HALOG SOLN NON_PREFERRED

HALOBETASOL PROPIONATE CREA PREFERRED

ULTRAVATE CREA NON_PREFERRED

HALOBETASOL PROPIONATE FOAM NON_PREFERRED

LEXETTE FOAM NON_PREFERRED

BRYHALI LOTN NON_PREFERRED

ULTRAVATE LOTN NON_PREFERRED

HALOBETASOL PROPIONATE OINT PREFERRED

ULTRAVATE OINT NON_PREFERRED

HYDROCORTISONE CREA PREFERRED

HYDROCORTISONE LOTN PREFERRED

HYDROCORTISONE OINT PREFERRED

TEXACORT SOLN NON_PREFERRED

HYDROCORTISONE VALERATE CREA PREFERRED

HYDROCORTISONE VALERATE OINT PREFERRED

PANDEL CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE LOTN NON_PREFERRED

LOCOID LOTN NON_PREFERRED

HYDROCORTISONE BUTYRATE OINT NON_PREFERRED

HYDROCORTISONE BUTYRATE SOLN NON_PREFERRED

HYDROCORTISONE BUTYRATE (LIPID) CREA NON_PREFERRED

HYDROCORTISONE BUTYRATE (LIPOPHILIC) CREA NON_PREFERRED

LOCOID LIPOCREAM CREA NON_PREFERRED

MOMETASONE FUROATE CREA PREFERRED

MOMETASONE FUROATE OINT PREFERRED

MOMETASONE FUROATE SOLN PREFERRED

PREDNICARBATE CREA NON_PREFERRED

PREDNICARBATE OINT NON_PREFERRED

DERMATOLOGICALS : CORTICOSTEROIDS -

TOPICAL

3/6/2023 8:01:09 AM Page 65 of 147

KENALOG AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE AERS NON_PREFERRED

TRIAMCINOLONE ACETONIDE CREA PREFERRED

TRIAMCINOLONE ACETONIDE LOTN PREFERRED

TRIAMCINOLONE ACETONIDE OINT NON_PREFERRED

TRIAMCINOLONE ACETONIDE OINT PREFERRED

TRIAMCINOLONE ACETONIDE IN ABSORBASE OINT NON_PREFERRED

RADIAURA CREA NON_PREFERRED

EPIFOAM FOAM NON_PREFERRED

ENSTILAR FOAM NON_PREFERRED

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE OINT NON_PREFERRED

TACLONEX OINT NON_PREFERRED

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP NON_PREFERRED

TACLONEX SUSP NON_PREFERRED

CLODAN KIT KIT NON_PREFERRED

SYNALAR TS KIT NON_PREFERRED

SYNALAR CREAM KIT KIT NON_PREFERRED

SYNALAR OINTMENT KIT KIT NON_PREFERRED

FLUOPAR KIT NON_PREFERRED

BESER KIT NON_PREFERRED

DUOBRII LOTN NON_PREFERRED

TRILOCICLO KIT NON_PREFERRED

TRIASIL THPK NON_PREFERRED

FINACEA FOAM NON_PREFERRED

AZELAIC ACID GEL NON_PREFERRED

FINACEA GEL NON_PREFERRED

BRIMONIDINE TARTRATE GEL NON_PREFERRED

DOXYCYCLINE CPDR NON_PREFERRED

IVERMECTIN CREA NON_PREFERRED

METRONIDAZOLE CREA PREFERRED

NORITATE CREA NON_PREFERRED

ROSADAN CREA PREFERRED

METRONIDAZOLE GEL PREFERRED

ROSADAN GEL PREFERRED

METRONIDAZOLE LOTN PREFERRED

ROSADAN KIT KIT NON_PREFERRED

ZILXI FOAM NON_PREFERRED

RHOFADE CREA NON_PREFERRED

LICART PT24 NON_PREFERRED

DERMATOLOGICALS : CORTICOSTEROIDS -

TOPICAL

DERMATOLOGICALS : MISC

3/6/2023 8:01:09 AM Page 66 of 147

DICLOFENAC EPOLAMINE PTCH NON_PREFERRED

FLECTOR PTCH NON_PREFERRED

DICLOFENAC SODIUM GEL NON_PREFERRED

VENNGEL ONE KIT NON_PREFERRED

DICLOFENAC SODIUM SOLN NON_PREFERRED

PENNSAID SOLN NON_PREFERRED

DERMACINRX LEXITRAL PHARMAPAK II THPK NON_PREFERRED

XRYLIX II THPK NON_PREFERRED

DICLOTREX THPK NON_PREFERRED

DICLOTREX II THPK NON_PREFERRED

DOXEPIN HYDROCHLORIDE CREA NON_PREFERRED

PRUDOXIN CREA NON_PREFERRED

ZONALON CREA NON_PREFERRED

EUCRISA OINT PREFERRED_WITH_PA

SELENIUM SULFIDE LOTN PREFERRED

SELENIUM SULFIDE SHAM NON_PREFERRED

SELENIUM SULFIDE SHAMPOO SHAM NON_PREFERRED

SODIUM SULFACETAMIDE GEL NON_PREFERRED

SODIUM SULFACETAMIDE WASH LIQD NON_PREFERRED

ACYCLOVIR CREA NON_PREFERRED

ZOVIRAX CREA NON_PREFERRED

ACYCLOVIR OINT NON_PREFERRED

ZOVIRAX OINT NON_PREFERRED

DENAVIR CREA NON_PREFERRED

PENCICLOVIR CREA NON_PREFERRED

XERESE CREA NON_PREFERRED

VALCHLOR GEL NON_PREFERRED

CARAC CREA NON_PREFERRED

EFUDEX CREA NON_PREFERRED

FLUOROURACIL CREA NON_PREFERRED

FLUOROURACIL SOLN NON_PREFERRED

DICLOFENAC SODIUM GEL NON_PREFERRED

AMELUZ GEL NON_PREFERRED

LEVULAN KERASTICK SOLR PREFERRED

BEXAROTENE GEL NON_PREFERRED

TARGRETIN GEL PREFERRED

SULFAMYLON CREA PREFERRED

MAFENIDE ACETATE PACK PREFERRED

SILVADENE CREA NON_PREFERRED

DERMATOLOGICALS : MISC

3/6/2023 8:01:09 AM Page 67 of 147

SILVER SULFADIAZINE CREA PREFERRED

SSD CREA PREFERRED

SILVER NITRATE SOLN NON_PREFERRED

ARZOL SILVER NITRATE APPLICATORS MISC NON_PREFERRED

GRAFCO SILVER NITRATE APPLICATOR MISC NON_PREFERRED

AMMONIUM LACTATE CREA NON_PREFERRED

AMMONIUM LACTATE LOTN PREFERRED

DERMACINRX UREA CREA PREFERRED

UREA CREA PREFERRED

UREA LOTN PREFERRED

UREA HYDRATING FOAM NON_PREFERRED

CONDYLOX GEL PREFERRED

PODOFILOX SOLN PREFERRED

PODOCON-25 SOLN NON_PREFERRED

SALICYLIC ACID FOAM NON_PREFERRED

SALICYLIC ACID GEL PREFERRED

SALICYLIC ACID WART REMOVER LIQD PREFERRED

BENSAL HP OINT NON_PREFERRED

SALICYLIC ACID OINT PREFERRED

SALEX LOTION KIT NON_PREFERRED

VEREGEN OINT NON_PREFERRED

IMIQUIMOD CREA NON_PREFERRED

IMIQUIMOD CREA PREFERRED

IMIQUIMOD PUMP CREA NON_PREFERRED

ZYCLARA CREA NON_PREFERRED

ZYCLARA PUMP CREA NON_PREFERRED

ELIDEL CREA PREFERRED_WITH_PA

PIMECROLIMUS CREA PREFERRED_WITH_PA

HYFTOR GEL NON_PREFERRED

PROTOPIC OINT PREFERRED_WITH_PA

TACROLIMUS OINT PREFERRED_WITH_PA

QUTENZA KIT NON_PREFERRED

LIDOCAINE OINT PREFERRED

LIDOCAINE PTCH PREFERRED

LIDOCAINE PATCH 5% PTCH PREFERRED

LIDODERM PTCH NON_PREFERRED

ZTLIDO PTCH NON_PREFERRED

LIDOCAINE 3% CREA PREFERRED

LIDOCAINE 4% CREA PREFERRED

DERMATOLOGICALS : MISC

3/6/2023 8:01:09 AM Page 68 of 147

LIDOCAINE HYDROCHLORIDE 4.12% CREA NON_PREFERRED

LIDOCAINE HYDROCHLORIDE 3% CREA PREFERRED

LIDOTRAL CREA NON_PREFERRED

LIDOTRAN CREA NON_PREFERRED

LYDEXA CREA NON_PREFERRED

DERMACINRX LIDOGEL GEL NON_PREFERRED

LIDOCAINE HCL JELLY GEL PREFERRED

LIDOREX GEL NON_PREFERRED

GLYDO PRSY PREFERRED

LIDOCAINE HCL PRSY PREFERRED

LIDOCAINE HCL JELLY PRSY PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOCAINE HYDROCHLORIDE SOLN PREFERRED

PLIAGLIS CREA NON_PREFERRED

SYNERA PTCH NON_PREFERRED

LIDOCAINE/PRILOCAINE CREA NON_PREFERRED

LIDOCAINE/PRILOCAINE KIT NON_PREFERRED

PRILO PATCH II KIT NON_PREFERRED

PRIZOTRAL II KIT NON_PREFERRED

APRIZIO PAK II KIT NON_PREFERRED

EMPRICAINE II KIT NON_PREFERRED

PRIZOPAK II KIT NON_PREFERRED

NUVAKAAN II KIT NON_PREFERRED

BPCO OINT NON_PREFERRED

QBREXZA PADS NON_PREFERRED

XERAC AC SOLN NON_PREFERRED

HYCLODEX SOLN NON_PREFERRED

HYPOCYN SOLN NON_PREFERRED

HYLAMIX CREA NON_PREFERRED

HYLATOPIC PLUS CREA NON_PREFERRED

TETRIX CREA NON_PREFERRED

ALADERM PLUS EMUL NON_PREFERRED

NUVAIL SOLN NON_PREFERRED

EURAX CREA PREFERRED

CROTAN LOTN NON_PREFERRED

EURAX LOTN NON_PREFERRED

IVERMECTIN LOTN NON_PREFERRED

LINDANE SHAM NON_PREFERRED

MALATHION LOTN NON_PREFERRED

DERMATOLOGICALS : MISC

DERMATOLOGICALS : SCABICIDES &

PEDICULICIDES

3/6/2023 8:01:09 AM Page 69 of 147

OVIDE LOTN NON_PREFERRED

PERMETHRIN CREA PREFERRED

GNP LICE TREATMENT LIQD PREFERRED

GOODSENSE LICE KILLING CREME RINSE LIQD PREFERRED

LICE TREATMENT CREME RINSE LIQD PREFERRED

SM LICE TREATMENT LOTN PREFERRED

NATROBA SUSP PREFERRED

SPINOSAD SUSP NON_PREFERRED

GNP LICE TREATMENT SHAM PREFERRED

HM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

LICE KILLING SHAMPOO SHAM PREFERRED

SM LICE KILLING MAXIMUM STRENGTH SHAM PREFERRED

CREON CPEP PREFERRED

PERTZYE CPEP NON_PREFERRED

ZENPEP CPEP PREFERRED

VIOKACE TABS NON_PREFERRED

ALENDRONATE SODIUM SOLN PREFERRED

ALENDRONATE SODIUM TABS PREFERRED

FOSAMAX TABS NON_PREFERRED

BINOSTO TBEF NON_PREFERRED

FOSAMAX PLUS D TABS NON_PREFERRED

BONIVA TABS NON_PREFERRED

IBANDRONATE SODIUM TABS NON_PREFERRED

ACTONEL TABS NON_PREFERRED

RISEDRONATE SODIUM TABS NON_PREFERRED

ATELVIA TBEC NON_PREFERRED

RISEDRONATE SODIUM DR TBEC NON_PREFERRED

CALCITONIN SALMON SOLN PREFERRED

CALCITONIN-SALMON SOLN PREFERRED

SKYTROFA CART NON_PREFERRED

GENOTROPIN CART PREFERRED_WITH_PA

HUMATROPE CART NON_PREFERRED

GENOTROPIN MINIQUICK PRSY PREFERRED_WITH_PA

OMNITROPE SOCT NON_PREFERRED

OMNITROPE SOLR NON_PREFERRED

ZOMACTON SOLR NON_PREFERRED

NORDITROPIN FLEXPRO SOPN NON_PREFERRED

NUTROPIN AQ NUSPIN 10 SOPN NON_PREFERRED

DERMATOLOGICALS : SCABICIDES &

PEDICULICIDES

DIGESTIVE ENZYMES

ENDOCRINE AND METABOLIC AGENTS :

BONE DENSITY REGULATORS

ENDOCRINE AND METABOLIC AGENTS :

GROWTH HORMONES

3/6/2023 8:01:09 AM Page 70 of 147

NUTROPIN AQ NUSPIN 20 SOPN NON_PREFERRED

NUTROPIN AQ NUSPIN 5 SOPN NON_PREFERRED

SAIZEN SOLR NON_PREFERRED

SAIZENPREP RECONSTITUTIONKIT SOLR NON_PREFERRED

SEROSTIM SOLR NON_PREFERRED

ZORBTIVE SOLR NON_PREFERRED

RECORLEV TABS NON_PREFERRED

ISTURISA TABS NON_PREFERRED

OSPHENA TABS NON_PREFERRED

EVISTA TABS NON_PREFERRED

RALOXIFENE HYDROCHLORIDE TABS NON_PREFERRED

SYNAREL SOLN NON_PREFERRED

ORILISSA TABS PREFERRED_WITH_PA

EGRIFTA SV SOLR NON_PREFERRED

INCRELEX SOLN NON_PREFERRED

LANREOTIDE ACETATE SOLN NON_PREFERRED

SOMATULINE DEPOT SOLN NON_PREFERRED

MYCAPSSA CPDR NON_PREFERRED

SANDOSTATIN LAR DEPOT KIT NON_PREFERRED

OCTREOTIDE ACETATE SOLN NON_PREFERRED

SANDOSTATIN SOLN NON_PREFERRED

BYNFEZIA PEN SOPN NON_PREFERRED

OCTREOTIDE ACETATE SOSY NON_PREFERRED

SIGNIFOR SOLN NON_PREFERRED

SIGNIFOR LAR SRER NON_PREFERRED

NOCDURNA SUBL NON_PREFERRED

DDAVP TABS NON_PREFERRED

DESMOPRESSIN ACETATE TABS PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

DDAVP SOLN NON_PREFERRED

DESMOPRESSIN ACETATE SOLN PREFERRED

KERENDIA TABS PREFERRED_WITH_PA

CABERGOLINE TABS PREFERRED

JYNARQUE TABS NON_PREFERRED

SAMSCA TABS NON_PREFERRED

TOLVAPTAN TABS NON_PREFERRED

JYNARQUE TBPK NON_PREFERRED

MIFEPREX TABS NON_PREFERRED

MIFEPRISTONE TABS NON_PREFERRED

ENDOCRINE AND METABOLIC AGENTS :

GROWTH HORMONES

ENDOCRINE AND METABOLIC AGENTS :

MISC

3/6/2023 8:01:09 AM Page 71 of 147

CARNITOR SOLN NON_PREFERRED

CARNITOR SF SOLN NON_PREFERRED

LEVOCARNITINE SOLN NON_PREFERRED

LEVOCARNITINE SF SOLN NON_PREFERRED

CARNITOR TABS NON_PREFERRED

LEVOCARNITINE TABS NON_PREFERRED

GALAFOLD CAPS NON_PREFERRED

NITISINONE CAPS PREFERRED

ORFADIN CAPS PREFERRED

ORFADIN SUSP NON_PREFERRED

NITYR TABS NON_PREFERRED

BETAINE ANHYDROUS POWD NON_PREFERRED

CYSTADANE POWD NON_PREFERRED

CINACALCET HYDROCHLORIDE TABS NON_PREFERRED

SENSIPAR TABS NON_PREFERRED

RAVICTI LIQD NON_PREFERRED

PHEBURANE PLLT NON_PREFERRED

BUPHENYL POWD NON_PREFERRED

SODIUM PHENYLBUTYRATE POWD NON_PREFERRED

BUPHENYL TABS NON_PREFERRED

SODIUM PHENYLBUTYRATE TABS NON_PREFERRED

CARBAGLU TBSO NON_PREFERRED

CARGLUMIC ACID TBSO NON_PREFERRED

CARGLUMIC ACID TBSO PREFERRED_WITH_PA

JAVYGTOR PACK NON_PREFERRED

KUVAN PACK NON_PREFERRED

SAPROPTERIN DIHYDROCHLORIDE PACK NON_PREFERRED

JAVYGTOR TABS NON_PREFERRED

KUVAN TABS NON_PREFERRED

SAPROPTERIN DIHYDROCHLORIDE TABS NON_PREFERRED

RAYALDEE CPCR NON_PREFERRED

CALCITRIOL CAPS PREFERRED

ROCALTROL CAPS NON_PREFERRED

CALCITRIOL SOLN PREFERRED

ROCALTROL SOLN NON_PREFERRED

DOXERCALCIFEROL CAPS PREFERRED

PARICALCITOL CAPS NON_PREFERRED

ZEMPLAR CAPS NON_PREFERRED

PREMARIN TABS PREFERRED

ENDOCRINE AND METABOLIC AGENTS :

VITAMIN D ANALOGS

ESTROGENS

ENDOCRINE AND METABOLIC AGENTS :

MISC

3/6/2023 8:01:09 AM Page 72 of 147

MENEST TABS PREFERRED

DIVIGEL GEL NON_PREFERRED

ELESTRIN GEL NON_PREFERRED

ESTRADIOL GEL NON_PREFERRED

DOTTI PTTW PREFERRED

ESTRADIOL PTTW PREFERRED

LYLLANA PTTW PREFERRED

MINIVELLE PTTW NON_PREFERRED

VIVELLE-DOT PTTW NON_PREFERRED

CLIMARA PTWK NON_PREFERRED

ESTRADIOL PTWK PREFERRED

MENOSTAR PTWK NON_PREFERRED

EVAMIST SOLN NON_PREFERRED

ESTRACE TABS NON_PREFERRED

ESTRADIOL TABS PREFERRED

DEPO-ESTRADIOL OIL NON_PREFERRED

DELESTROGEN OIL NON_PREFERRED

ESTRADIOL VALERATE OIL NON_PREFERRED

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE DS TABS PREFERRED

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE HS TABS PREFERRED

PREMPHASE TABS PREFERRED

PREMPRO TABS PREFERRED

COMBIPATCH PTTW PREFERRED

ACTIVELLA TABS NON_PREFERRED

AMABELZ TABS PREFERRED

ESTRADIOL/NORETHINDRONE ACETATE TABS PREFERRED

MIMVEY TABS PREFERRED

BIJUVA CAPS NON_PREFERRED

FYAVOLV TABS NON_PREFERRED

JINTELI TABS NON_PREFERRED

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS NON_PREFERRED

ANGELIQ TABS NON_PREFERRED

CLIMARA PRO PTWK NON_PREFERRED

PREFEST TABS NON_PREFERRED

ORIAHNN CPPK PREFERRED_WITH_PA

MYFEMBREE TABS PREFERRED_WITH_PA

DUAVEE TABS NON_PREFERRED

BALSALAZIDE DISODIUM CAPS PREFERRED

COLAZAL CAPS NON_PREFERRED

ESTROGENS

GASTROINTESTINAL AGENTS :

INFLAMMATORY BOWEL AGENTS

3/6/2023 8:01:09 AM Page 73 of 147

APRISO CP24 NON_PREFERRED

MESALAMINE ER CP24 NON_PREFERRED

MESALAMINE ER CPCR PREFERRED

PENTASA CPCR PREFERRED

DELZICOL CPDR NON_PREFERRED

MESALAMINE DR CPDR NON_PREFERRED

MESALAMINE ENEM PREFERRED

SFROWASA ENEM PREFERRED

CANASA SUPP NON_PREFERRED

MESALAMINE SUPP PREFERRED

ASACOL HD TBEC NON_PREFERRED

LIALDA TBEC NON_PREFERRED

MESALAMINE DR TBEC NON_PREFERRED

MESALAMINE KIT NON_PREFERRED

ROWASA KIT NON_PREFERRED

DIPENTUM CAPS NON_PREFERRED

AZULFIDINE TABS NON_PREFERRED

SULFASALAZINE TABS PREFERRED

AZULFIDINE EN-TABS TBEC NON_PREFERRED

SULFASALAZINE TBEC PREFERRED

CHENODAL TABS NON_PREFERRED

RELTONE CAPS NON_PREFERRED

URSODIOL CAPS PREFERRED

URSO 250 TABS NON_PREFERRED

URSO FORTE TABS NON_PREFERRED

URSODIOL TABS NON_PREFERRED

CROMOLYN SODIUM CONC PREFERRED

GASTROCROM CONC NON_PREFERRED

METOCLOPRAMIDE HCL SOLN PREFERRED

METOCLOPRAMIDE HYDROCHLORIDE SOLN PREFERRED

METOCLOPRAMIDE HCL TABS PREFERRED

METOCLOPRAMIDE HYDROCHLORIDE TABS PREFERRED

REGLAN TABS NON_PREFERRED

METOCLOPRAMIDE ODT TBDP NON_PREFERRED

ENULOSE SOLN PREFERRED

GENERLAC SOLN PREFERRED

LACTULOSE SOLN PREFERRED

AMITIZA CAPS NON_PREFERRED

LUBIPROSTONE CAPS NON_PREFERRED

GASTROINTESTINAL AGENTS :

INFLAMMATORY BOWEL AGENTS

GASTROINTESTINAL AGENTS : MISC

3/6/2023 8:01:09 AM Page 74 of 147

GATTEX KIT NON_PREFERRED

TRULANCE TABS NON_PREFERRED

ALOSETRON HYDROCHLORIDE TABS NON_PREFERRED

LOTRONEX TABS NON_PREFERRED

LINZESS CAPS NON_PREFERRED

VIBERZI TABS NON_PREFERRED

IBSRELA TABS NON_PREFERRED

MOTEGRITY TABS NON_PREFERRED

XERMELO TABS NON_PREFERRED

ALVIMOPAN CAPS NON_PREFERRED

ENTEREG CAPS NON_PREFERRED

RELISTOR SOLN NON_PREFERRED

RELISTOR TABS NON_PREFERRED

SYMPROIC TABS NON_PREFERRED

MOVANTIK TABS NON_PREFERRED

CHOLBAM CAPS NON_PREFERRED

OCALIVA TABS NON_PREFERRED

CALCIUM ACETATE CAPS PREFERRED

PHOSLYRA SOLN NON_PREFERRED

CALCIUM ACETATE TABS PREFERRED

AURYXIA TABS NON_PREFERRED

FOSRENOL CHEW NON_PREFERRED

LANTHANUM CARBONATE CHEW PREFERRED

FOSRENOL PACK PREFERRED

RENVELA PACK NON_PREFERRED

SEVELAMER CARBONATE PACK NON_PREFERRED

RENVELA TABS NON_PREFERRED

SEVELAMER CARBONATE TABS PREFERRED

RENAGEL TABS NON_PREFERRED

SEVELAMER HYDROCHLORIDE TABS PREFERRED

VELPHORO CHEW NON_PREFERRED

K-PHOS NO 2 TABS NON_PREFERRED

POTASSIUM CITRATE ER TBCR NON_PREFERRED

UROCIT-K 10 TBCR NON_PREFERRED

UROCIT-K 15 TBCR NON_PREFERRED

UROCIT-K 5 TBCR NON_PREFERRED

ORACIT SOLN PREFERRED

SODIUM CITRATE AND CITRIC ACID SOLN PREFERRED

SODIUM CITRATE/CITRIC ACID SOLN PREFERRED

GASTROINTESTINAL AGENTS : MISC

GASTROINTESTINAL AGENTS :

PHOSPHATE BINDER AGENTS

GENITOURINARY AGENTS : MISC

3/6/2023 8:01:09 AM Page 75 of 147

CYTRA K CRYSTALS PACK NON_PREFERRED

TARON-CRYSTALS PACK NON_PREFERRED

POTASSIUM CITRATE AND CITRIC ACID SOLN NON_PREFERRED

POTASSIUM CITRATE/CITRICACID SOLN NON_PREFERRED

POTASSIUM CITRATE/SODIUMCITRATE/CITRIC ACID SOLN NON_PREFERRED

TRICITRATES SOLN NON_PREFERRED

PHENAZOPYRIDINE HCL TABS PREFERRED

PHENAZOPYRIDINE HYDROCHLORIDE TABS PREFERRED

PYRIDIUM TABS NON_PREFERRED

CYSTAGON CAPS PREFERRED

PROCYSBI CPDR NON_PREFERRED

PROCYSBI PACK NON_PREFERRED

ELMIRON CAPS NON_PREFERRED

LITHOSTAT TABS NON_PREFERRED

THIOLA TABS NON_PREFERRED

TIOPRONIN TABS NON_PREFERRED

THIOLA EC TBEC NON_PREFERRED

AVODART CAPS NON_PREFERRED

DUTASTERIDE CAPS NON_PREFERRED

FINASTERIDE TABS PREFERRED

PROSCAR TABS NON_PREFERRED

ALFUZOSIN HCL ER TB24 PREFERRED

CARDURA XL TB24 NON_PREFERRED

RAPAFLO CAPS NON_PREFERRED

SILODOSIN CAPS NON_PREFERRED

FLOMAX CAPS NON_PREFERRED

TAMSULOSIN HYDROCHLORIDE CAPS PREFERRED

DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS NON_PREFERRED

JALYN CAPS NON_PREFERRED

ENTADFI CAPS NON_PREFERRED

DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT DEVI NON_PREFERRED

DEXCOM G4 PLATINUM PEDIATRIC RECEIVER KIT/SHARE DEVI NON_PREFERRED

DEXCOM G4 PLATINUM RECEIVER KIT DEVI NON_PREFERRED

DEXCOM G4 PLATINUM RECEIVER KIT/SHARE DEVI NON_PREFERRED

DEXCOM G5 MOBILE RECEIVERKIT DEVI NON_PREFERRED

DEXCOM G5 RECEIVER KIT DEVI NON_PREFERRED

DEXCOM G6 RECEIVER DEVI PREFERRED_WITH_PA

DEXCOM G7 RECEIVER DEVI PREFERRED_WITH_PA

FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM DEVI PREFERRED_WITH_PA

GENITOURINARY AGENTS : MISC

GENITOURINARY AGENTS : PROSTATIC

HYPERTROPHY AGENTS

GLUCOSE MONITORING SUPPLIES : CGMs

3/6/2023 8:01:09 AM Page 76 of 147

FREESTYLE LIBRE 2/READER/FLASH GLUCOSE MONITORING SYSTEM DEVI PREFERRED_WITH_PA

FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM DEVI NON_PREFERRED

GUARDIAN REAL-TIME REPLACEMENT MONITOR DEVI NON_PREFERRED

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI NON_PREFERRED

DEXCOM G4 SENSOR KIT MISC NON_PREFERRED

DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT MISC NON_PREFERRED

DEXCOM G6 SENSOR MISC PREFERRED_WITH_PA

DEXCOM G7 SENSOR MISC PREFERRED_WITH_PA

ENLITE GLUCOSE SENSOR MISC NON_PREFERRED

EVERSENSE SENSOR/HOLDER MISC NON_PREFERRED

FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM MISC PREFERRED_WITH_PA

FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE MONITORING SYSTEM MISC PREFERRED_WITH_PA

FREESTYLE LIBRE 3/SENSOR/GLUCOSE MONITORING SYSTEM MISC PREFERRED_WITH_PA

FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM MISC NON_PREFERRED

GUARDIAN SENSOR (3) MISC NON_PREFERRED

GUARDIAN SENSOR 3 MISC NON_PREFERRED

SOF-SENSOR MISC NON_PREFERRED

DEXCOM G4 PLATINUM TRANSMITTER KIT MISC NON_PREFERRED

DEXCOM G5 MOBILE TRANSMITTER KIT MISC NON_PREFERRED

DEXCOM G6 TRANSMITTER MISC PREFERRED_WITH_PA

EVERSENSE SMART TRANSMITTER MISC NON_PREFERRED

GUARDIAN CONNECT TRANSMITTER MISC NON_PREFERRED

GUARDIAN CONNECT TRANSMITTER KIT MISC NON_PREFERRED

GUARDIAN LINK 3 MISC NON_PREFERRED

GUARDIAN LINK 3 TRANSMITTER KIT MISC NON_PREFERRED

GUARDIAN TRANSMITTER MISC NON_PREFERRED

MINILINK REAL-TIME TRANSMITTER MISC NON_PREFERRED

MINIMED 630G GUARDIAN PRESS STARTER TRANSMITTER KIT MISC NON_PREFERRED

PARADIGM REAL-TIME TRANSMITTER MISC NON_PREFERRED

GUARDIAN REAL-TIME STARTER KIT KIT NON_PREFERRED

GUARDIAN REAL-TIME SYSTEM KIT NON_PREFERRED

GUARDIAN REAL-TIME SYSTEMPEDIATRIC KIT NON_PREFERRED

GUARDIAN RT STARTER KIT KIT NON_PREFERRED

GUARDIAN RT SYSTEM KIT NON_PREFERRED

PARADIGM REAL-TIME STARTER KIT KIT NON_PREFERRED

CGMS REPLACEMENT CABLE MISC NON_PREFERRED

CGMS SOFTWARE MISC NON_PREFERRED

GUARDIAN REAL-TIME CHARGER REPLACEMENT MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : CGMs

3/6/2023 8:01:09 AM Page 77 of 147

GUARDIAN REAL-TIME TEST PLUG REPLACEMENT MISC NON_PREFERRED

GUARDIAN RT SOFTWARE MISC NON_PREFERRED

OVAL TAPE MISC NON_PREFERRED

TEST PLUG MISC NON_PREFERRED

TRANSMITTER TAPE MISC NON_PREFERRED

ADVANCE INTUITION BLOOD GLUCOSE METER DEVI NON_PREFERRED

ADVANCE MICRO-DRAW METER DEVI NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ADVOCATE REDI-CODE DEVI NON_PREFERRED

ADVOCATE REDI-CODE+ BLOOD GLUCOSE SYSTEM/SPEAKING DEVI NON_PREFERRED

ADVOCATE REDI-CODE+ BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

AGAMATRIX AMP NO CODE ADVANCED BLOOD GLUCOSE MONITORING

SYST

DEVI NON_PREFERRED

AGAMATRIX PRESTO PRO METER DEVI NON_PREFERRED

ASSURE 4 BLOOD GLUCOSE METER DEVI NON_PREFERRED

ASSURE PLATINUM BLOOD GLUCOSE METER DEVI NON_PREFERRED

ASSURE PRISM MULTI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ASSURE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

BLOOD GLUCOSE MONITORINGSYSTEM 333 DEVI NON_PREFERRED

BLULINK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CARESENS N GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CARESENS N VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHEK AUTO CODE VOICE BLOOD GLUCOSE MONITORING

SYSTEM

DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHEK AUTO-CODE VOICE BLOOD GLUCOSE MONITORING

SYSTEM

DEVI NON_PREFERRED

CLEVER CHOICE AUTO-CODE PRO BLOOD GLUCOSE MONITORING

SYSTEM

DEVI NON_PREFERRED

CLEVER CHOICE MINI BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CLEVER CHOICE TALK BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CONTOUR BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

COOL BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE METER DEVI NON_PREFERRED

DIATHRIVE+ BLOOD GLUCOSEMONITORING SYSTEM/BLUETOOTH DEVI NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASY PLUS II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASY STEP BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

EASY TALK BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

EASY TRAK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : CGMs

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 78 of 147

EASY TRAK II BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

EASYMAX V BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

ELEMENT COMPACT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ELEMENT COMPACT V BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ELEMENT PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED

EMBRACE BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

EMBRACE EVO COMPACT BLOODGLUCOSE MONITOR DEVI NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

EVENCARE G2 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

EVENCARE G3 BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

EVENCARE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

EVOLUTION AUTOCODE DEVI NON_PREFERRED

FORA G30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GD20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GD50 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA GTEL BLOOD GLUCOSE MONITORING SYSTEM/MULTI-

FUNCTIONAL

DEVI NON_PREFERRED

FORA PREMIUM V10 BLE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA TEST N' GO VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA V10 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/NO-CODING DEVI NON_PREFERRED

FORA V12 BLOOD GLUCOSE MONITORING SYSTEM/TALKING DEVI NON_PREFERRED

FORA V20 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORA V30A BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORACARE GD40 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORACARE PREMIUM V10 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORACARE TEST N GO BLOODGLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM EMV3.1 DEVI NON_PREFERRED

FORTISCARE T1 SELF-MONITORING BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GE100 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GLUCO PERFECT 3 BLOOD GLUCOSE METER DEVI NON_PREFERRED

GLUCO PERFECT 3 BLOOD GLUCOSE MONITORING SYSTEM/VOICE DEVI NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOSE METER DEVI NON_PREFERRED

GLUCOCARD SHINE DEVI NON_PREFERRED

GLUCOCARD SHINE XL DEVI NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 79 of 147

GNP EASY TOUCH GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

GNP EASY TOUCH GLUCOSE MONITORING SYSTEM/NO CODING DEVI NON_PREFERRED

HW EMBRACE PRO BLOOD GLUCOSE METER DEVI NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

IN TOUCH DEVI NON_PREFERRED

LIBERTY BLOOD GLUCOSE METER DEVI NON_PREFERRED

LIBERTY NEXT GENERATION BLOOD GLUCOSE MONITOR DEVI NON_PREFERRED

NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ON CALL EXPRESS BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE METER DEVI NON_PREFERRED

ON CALL VIVID PAL BLOOD GLUCOSE METER DEVI NON_PREFERRED

OPTIUM BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PHARMACIST CHOICE MINI BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PIP BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

POGO AUTOMATIC BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRECISION QID MONITOR DEVI NON_PREFERRED

PRECISION SOF-TACT MONITOR DEVI NON_PREFERRED

PRECISION XTRA DEVI NON_PREFERRED

PRECISION XTRA MONITOR DEVI NON_PREFERRED

PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

QUINTET AC BLOOD GLUCOSEMONITORING SYSTEM DEVI NON_PREFERRED

QUINTET BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PREMIER BLU BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PREMIER CLASSIC BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PREMIER VOICE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RELION PRIME BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

RIGHTEST GT333 BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SMARTEST EJECT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SMARTEST PROTEGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM DEVI NON_PREFERRED

SURE EDGE BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SURECHEK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

SURE-TEST EASYPLUS MINI SELF MONITORING BLOOD GLUCOSE

METER

DEVI NON_PREFERRED

TRUE FOCUS BLOOD GLUCOSESELF MONITORING METER DEVI NON_PREFERRED

TRUE METRIX DEVI NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 80 of 147

TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH DEVI NON_PREFERRED

TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

ULTRATRAK ACTIVE DEVI NON_PREFERRED

ULTRATRAK PRO DEVI NON_PREFERRED

ULTRATRAK ULTIMATE MONITOR DEVI NON_PREFERRED

VERASENS BLOOD GLUCOSE MONITORING SYSTEM METER KIT DEVI NON_PREFERRED

VIVAGUARD INO BLOOD GLUCOSE METER DEVI NON_PREFERRED

VIVAGUARD INO SMART BLOOD GLUCOSE METER DEVI NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE MONITORING SYSTEM DEVI NON_PREFERRED

WAVESENSE KEYNOTE PRO METER DEVI NON_PREFERRED

ACCU-CHEK AVIVA PLUS KIT NON_PREFERRED

ACCU-CHEK GUIDE KIT NON_PREFERRED

ACCU-CHEK GUIDE ME KIT NON_PREFERRED

ACCU-CHEK NANO SMARTVIEW KIT NON_PREFERRED

ADVANCE INTUITION BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM/TALKING KIT NON_PREFERRED

ADVOCATE REDI-CODE/TALKING KIT NON_PREFERRED

ADVOCATE REDI-CODE+/ TALKING KIT NON_PREFERRED

AGAMATRIX JAZZ WIRELESS 2 KIT NON_PREFERRED

AGAMATRIX PRESTO KIT NON_PREFERRED

ASSURE 3 METER KIT NON_PREFERRED

BAYER CONTOUR LINK 2.4 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BD LATITUDE DIABETES MANAGEMENT SYSTEM KIT NON_PREFERRED

BD LOGIC BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

BIOTEL CARE BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

BIOTEL CARE CONNECTED BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

BLOOD GLUCOSE MONITORINGSYSTEM KIT NON_PREFERRED

BLOOD GLUCOSE MONITORINGSYSTEM PREMIUM KIT NON_PREFERRED

BLOOD GLUCOSE SYSTEM PAK KIT NON_PREFERRED

CAREONE BLOOD GLUCOSE MONITORING SYSTEM/PREMIUM KIT NON_PREFERRED

CAREONE BLOOD GLUCOSE MONITORING SYSTEM/VALUE KIT NON_PREFERRED

CARETOUCH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CHOICE DM DIABETES RISK IN-HOME TEST KIT KIT NON_PREFERRED

CLEVER CHEK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CLEVER CHOICE MICRO BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 81 of 147

CONTOUR NEXT GEN BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT LINK 2.4 WIRELESS BLOOD GLUCOSE MONITORING

SYST

KIT NON_PREFERRED

CONTOUR NEXT LINK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

CONTOUR NEXT LINK WIRELESS BLOOD GLUCOSE MONITORING SY KIT NON_PREFERRED

CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

COOL BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

CVS ADVANCED GLUCOSE METER KIT NON_PREFERRED

D-CARE GLUCOMETER KIT/GLUCOSE TEST STRIPS KIT NON_PREFERRED

DIABETES MONITORING DIGITAL SOLUTION KIT NON_PREFERRED

DIABETES MONITORING DIGITAL SOLUTION ADD-ON KIT NON_PREFERRED

EASY TOUCH GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASY TOUCH HEALTHPRO GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASYGLUCO KIT NON_PREFERRED

EASYGLUCO STARTER KIT KIT NON_PREFERRED

EASYMAX NG SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

EASYMAX V BLOOD GLUCOSE SYSTEM/TALKING KIT NON_PREFERRED

EASYPRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EASYPRO PLUS KIT NON_PREFERRED

ELEMENT AUTOCODE SYSTEM KIT NON_PREFERRED

EMBRACE EVO BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

EVENCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FIFTY50 GLUCOSE METER 2.0 KIT NON_PREFERRED

FORA G20 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FORA TN'G VOICE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FORA V10/V12/D10/D20 BLOOD GLUCOSE TEST STRIPS/LANCETS 30G KIT NON_PREFERRED

FORA V30A BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FORTISCARE SELF-MONITORING BLOOD GLUCOSE SYSTEM KIT NON_PREFERRED

FREESTYLE FLASH SYSTEM KIT NON_PREFERRED

FREESTYLE FREEDOM KIT NON_PREFERRED

FREESTYLE FREEDOM LITE KIT NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

FREESTYLE SIDEKICK II VALUEPACK KIT NON_PREFERRED

FREESTYLE SYSTEM KIT KIT NON_PREFERRED

GE100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 82 of 147

GHT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD 01 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD 01-MINI BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD EXPRESSION AUDIO-ENABLED BLOOD GLUCOSE

MONITORING

KIT NON_PREFERRED

GLUCOCARD SHINE KIT NON_PREFERRED

GLUCOCARD SHINE CONNEX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD SHINE EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLACK KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM BLUE KIT NON_PREFERRED

GLUCOCARD VITAL BLOOD GLUCOSE MONITORING SYSTEM PINK KIT NON_PREFERRED

GLUCOCARD X-METER KIT NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOCOM BLOOD GLUCOSE MONITORING SYSTEM VALUE KIT KIT NON_PREFERRED

GLUCONAVII BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

GNP TRUE METRIX AIR SELFMONITORING BLOOD GLUCOSE METER KIT NON_PREFERRED

GNP TRUE METRIX SELF MONITORING BLOOD GLUCOSE METER KIT NON_PREFERRED

GOODSENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

HEALTHPRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE MOITORING SYSTEM KIT NON_PREFERRED

INFINITY BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

INFINITY BLOOD GLUCOSE MONITORING SYSTEM/STARTER KIT KIT NON_PREFERRED

INFINITY VOICE KIT NON_PREFERRED

KROGER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

KROGER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

LDR BLOOD GLUCOSE TRUETEST KIT KIT NON_PREFERRED

MEIJER BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MEIJER ESSENTIAL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER PREMIUM BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MEIJER TRUE2GO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER TRUERESULT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MEIJER TRUETRACK BLOOD GLUCOSE MONITORING KIT KIT NON_PREFERRED

MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

MM EASY TOUCH BLOOD GLUCOSE METER KIT NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

NOVA MAX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 83 of 147

ON CALL EXPRESS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE METER KIT NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE METER KIT NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ON CALL VIVID PAL BLOOD GLUCOSE METER KIT NON_PREFERRED

ONE DROP BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

ONETOUCH SOLUTIONS RX STARTER KIT KIT NON_PREFERRED

ONETOUCH ULTRA 2 KIT PREFERRED

ONETOUCH ULTRA MINI KIT PREFERRED

ONETOUCH ULTRALINK SYSTEM (DEC) KIT NON_PREFERRED

ONETOUCH ULTRALINK SYSTEM (HEX) KIT NON_PREFERRED

ONETOUCH VERIO KIT PREFERRED

ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED

ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM KIT PREFERRED

ONETOUCH VERIO REFLECT KIT PREFERRED

ONETOUCH VERIO SYNC BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

OPTIUM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE METER KIT NON_PREFERRED

OPTUMRX BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PARADIGM LINK BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE MONITORING

SYSTEM

KIT NON_PREFERRED

POCKETCHEM EZ BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PRECISION LINK KIT NON_PREFERRED

PRECISION XTRA KIT NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING/TALKING KIT NON_PREFERRED

PRODIGY NO CODING BLOOD GLUCOSE KIT NON_PREFERRED

PRODIGY POCKET BLOOD GLUCOSE METER KIT KIT NON_PREFERRED

PRODIGY VOICE BLOOD GLUCOSE METER KIT KIT NON_PREFERRED

QUICKTEK KIT NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSEMONITORING SYSTEM KIT NON_PREFERRED

RELION CONFIRM BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION MICRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION PREMIER COMPACT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RELION TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH KIT NON_PREFERRED

RELION ULTIMA BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

REVEAL BLOOD GLUCOSE MONITOR KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

3/6/2023 8:01:09 AM Page 84 of 147

REXALL BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RIGHTEST GM100 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RIGHTEST GM300 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

RIGHTEST GM550 BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

SMART SENSE PREMIUM BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

SMART SENSE VALUE BLOODGLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

SMARTEST EJECT STARTER KIT KIT NON_PREFERRED

SMARTEST PERSONA STARTERKIT KIT NON_PREFERRED

SMARTEST PRONTO STARTERKIT KIT NON_PREFERRED

SMARTEST PROTEGE STARTERKIT KIT NON_PREFERRED

SOLUS V2 AUDIBLE BLOOD GLUCOSE MANAGEMENT SYSTEM KIT NON_PREFERRED

SURECHEK BLOOD GLUCOSE MONITORING SYSTEM STARTER KIT KIT NON_PREFERRED

TELCARE BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TEMPO REFILL KIT NON_PREFERRED

TEMPO WELCOME KIT NON_PREFERRED

TGT BLOOD GLUCOSE METER MONITORING SYSTEM KIT NON_PREFERRED

TGT BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TGT BLOOD GLUCOSE MONITORING SYSTEM PREMIUM KIT NON_PREFERRED

TRUE METRIX AIR BLOOD GLUCOSE METER/BLUETOOTH SMART KIT NON_PREFERRED

TRUE METRIX AIR W/BLUETOOTH SMART KIT NON_PREFERRED

TRUE METRIX BLOOD GLUCOSEMETER KIT NON_PREFERRED

TRUE METRIX GO BLOOD GLUCOSE METER KIT NON_PREFERRED

TRUERESULT BLOOD GLUCOSEMONITORING SYSTEM/NO CODING KIT NON_PREFERRED

TRUETRACK BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

TRUETRACK SMART SYSTEM KIT NON_PREFERRED

ULTIMA KIT NON_PREFERRED

ULTRA TRAK PRO BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

VERASENS BLOOD GLUCOSE MONITORING SYSTEM KIT NON_PREFERRED

WAVESENSE AMP KIT NON_PREFERRED

WAVESENSE KEYNOTE KIT NON_PREFERRED

RELION ALL-IN-ONE COMPACTBLOOD GLUCOSE TESTING SYSTEM DEVI NON_PREFERRED

SIDEKICK BLOOD GLUCOSE SYSTEM DEVI NON_PREFERRED

OMNIPOD 5 G6 INTRO KIT (GEN 5) KIT PREFERRED_WITH_PA

OMNIPOD CLASSIC PDM STARTER KIT (GEN 3) KIT PREFERRED_WITH_PA

OMNIPOD DASH INTRO KIT (GEN 4) KIT PREFERRED_WITH_PA

OMNIPOD DASH PDM KIT (GEN 4) KIT PREFERRED_WITH_PA

V-GO 20 KIT NON_PREFERRED

V-GO 30 KIT NON_PREFERRED

V-GO 40 KIT NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

DEVICES AND KITS

GLUCOSE MONITORING SUPPLIES :

INSULIN INFUSION DISPOSABLE PUMP

3/6/2023 8:01:09 AM Page 85 of 147

OMNIPOD 5 G6 PODS (GEN 5) MISC PREFERRED_WITH_PA

OMNIPOD CLASSIC PODS (GEN 3) MISC PREFERRED_WITH_PA

OMNIPOD DASH PODS (GEN 4) MISC PREFERRED_WITH_PA

1ST TIER UNIFINE PENTIPS/MINI/31GX5MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS29GX12MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS31GX6MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS31GX8MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS32GX4MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS32GX6MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPS33GX4MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS 31GX8MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS 32GX4MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS 33GX4MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM MISC NON_PREFERRED

1ST TIER UNIFINE PENTIPSPLUS/ULTRA SHORT/31GX6MM MISC NON_PREFERRED

ABOUTTIME PEN NEEDLE 32GX 5/32" MISC NON_PREFERRED

ABOUTTIME PEN NEEDLES 30GX 5/16" MISC NON_PREFERRED

ABOUTTIME PEN NEEDLES 31G X 3/16" MISC NON_PREFERRED

ABOUTTIME PEN NEEDLES 31G X 5/16" MISC NON_PREFERRED

ADVOCATE INSULIN PEN NEEDLES MISC NON_PREFERRED

ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM MISC NON_PREFERRED

ADVOCATE INSULIN PEN NEEDLES 31GX5MM MISC NON_PREFERRED

ADVOCATE INSULIN PEN NEEDLES 31GX8MM MISC NON_PREFERRED

ASSURE ID SAFETY PEN NEEDLES 30G X 3/16" MISC NON_PREFERRED

ASSURE ID SAFETY PEN NEEDLES 30G X 5/16" MISC NON_PREFERRED

ASSURE ID SAFETY PEN NEEDLES 31G X 3/16" MISC NON_PREFERRED

AUM INSULIN SAFETY PEN NEEDLE/31GX4MM MISC NON_PREFERRED

AUM INSULIN SAFETY PEN NEEDLE/31GX5MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/32GX4MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/32GX5MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/32GX6MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/32GX8MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/33GX4MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/33GX5MM MISC NON_PREFERRED

AUM MINI INSULIN PEN NEEDLE/33GX6MM MISC NON_PREFERRED

AUM PEN NEEDLE/32GX4MM MISC NON_PREFERRED

AUM PEN NEEDLE/32GX5MM MISC NON_PREFERRED

AUM PEN NEEDLE/32GX6MM MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN INFUSION DISPOSABLE PUMP

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 86 of 147

AUM PEN NEEDLE/33GX4MM MISC NON_PREFERRED

AUM PEN NEEDLE/33GX5MM MISC NON_PREFERRED

AUM PEN NEEDLE/33GX6MM MISC NON_PREFERRED

AUM READYGARD DUO SAFETYPEN NEEDLE/32GX4MM/DUAL AUTO

PROTEC

MISC NON_PREFERRED

AUM SAFETY PEN NEEDLE/31G X 4MM MISC NON_PREFERRED

AUM SAFETY PEN NEEDLE/31G X 5MM MISC NON_PREFERRED

AURORA PEN NEEDLES 29GX12MM MISC NON_PREFERRED

AURORA PEN NEEDLES 31G X6MM MISC NON_PREFERRED

AURORA PEN NEEDLES 31G X8MM MISC NON_PREFERRED

AURORA UNIFINE PENTIPS/32GX5/32" MISC NON_PREFERRED

AURORA UNIFINE PENTIPS/MINI/31GX3/16" MISC NON_PREFERRED

BD AUTOSHIELD 29G X 3/16" MISC NON_PREFERRED

BD AUTOSHIELD 29G X 5/16" MISC NON_PREFERRED

BD AUTOSHIELD DUO 30G X 5MM MISC NON_PREFERRED

BD PEN NEEDLE/MICRO/ULTRA-FINE/32G X 6MM MISC NON_PREFERRED

BD PEN NEEDLE/MINI/ULTRA-FINE/31G X 5MM MISC NON_PREFERRED

BD PEN NEEDLE/NANO 2ND GEN/32G X 4MM MISC NON_PREFERRED

BD PEN NEEDLE/NANO 2ND GEN/32G X 5/32" MISC NON_PREFERRED

BD PEN NEEDLE/NANO/ULTRA-FINE/32G X 4MM MISC NON_PREFERRED

BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM MISC NON_PREFERRED

BD PEN NEEDLE/SHORT/ULTRA-FINE/31G X 8MM MISC NON_PREFERRED

CAREFINE PEN NEEDLE 32GX4MM MISC NON_PREFERRED

CAREFINE PEN NEEDLES 29GX1/2" MISC NON_PREFERRED

CAREFINE PEN NEEDLES 30GX5/16" MISC NON_PREFERRED

CAREFINE PEN NEEDLES 31GX6MM MISC NON_PREFERRED

CAREFINE PEN NEEDLES 31GX8MM MISC NON_PREFERRED

CAREFINE PEN NEEDLES 32GX5MM MISC NON_PREFERRED

CAREFINE PEN NEEDLES 32GX6MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS 29GX12MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS 31GX5MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS 31GX6MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS 31GX8MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX5MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX6MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 31GX8MM MISC NON_PREFERRED

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 32GX4MM MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 87 of 147

CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES/33G X 5/32" MISC NON_PREFERRED

CARETOUCH PEN NEEDLE 29GX1/2" MISC NON_PREFERRED

CARETOUCH PEN NEEDLE 33GX5/32" MISC NON_PREFERRED

CARETOUCH PEN NEEDLES 31G X 6 MM MISC NON_PREFERRED

CARETOUCH PEN NEEDLES 31GX 5MM MISC NON_PREFERRED

CARETOUCH PEN NEEDLES 31GX 8MM MISC NON_PREFERRED

CARETOUCH PEN NEEDLES 32GX 4MM MISC NON_PREFERRED

CARETOUCH PEN NEEDLES 32GX 5MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 33GX4MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX5MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX6MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX4MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX5MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX6MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX8MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 33GX4MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 33GX5MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 33GX6MM MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZPEN NEEDLES 33GX8MM MISC NON_PREFERRED

CLICKFINE PEN NEEDLE 32GX5/32" MISC NON_PREFERRED

CLICKFINE PEN NEEDLE UNIVERSAL/31GX1/4" MISC NON_PREFERRED

CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16" MISC NON_PREFERRED

CLICKFINE PEN NEEDLES 31G X 1/4" MISC NON_PREFERRED

CLICKFINE PEN NEEDLES 31G X 3/16" MISC NON_PREFERRED

CLICKFINE PEN NEEDLES 31G X 5/16" MISC NON_PREFERRED

CLICKFINE PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

CLICKFINE PEN NEEDLES 32G X 5/32" MISC NON_PREFERRED

CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

COMFORT EZ MICRO/32G X 4MM MISC NON_PREFERRED

COMFORT EZ SHORT/31G X 8MM MISC NON_PREFERRED

COMFORT EZ/31G X 5MM MISC NON_PREFERRED

COMFORT EZ/31G X 6MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/31G X 4MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/31G X 5MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/31G X 6 MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/31G X 8 MM MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 88 of 147

COMFORT TOUCH PEN NEEDLES/32G X 4MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/32G X 5MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/32G X 6MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/32G X 8MM MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/33G X 5/32" MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/33GX 3/16" MISC NON_PREFERRED

COMFORT TOUCH PEN NEEDLES/33GX1/4" MISC NON_PREFERRED

DIATHRIVE PEN NEEDLE/31 G X 6MM MISC NON_PREFERRED

DIATHRIVE PEN NEEDLE/31 GX 8MM MISC NON_PREFERRED

DIATHRIVE PEN NEEDLE/31GX 5MM MISC NON_PREFERRED

DIATHRIVE PEN NEEDLE/32GX 4MM MISC NON_PREFERRED

DROPLET MICRON 34G X 9/64" MISC NON_PREFERRED

DROPLET PEN NEEDLES 29G X1/2" MISC NON_PREFERRED

DROPLET PEN NEEDLES 29GX10MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 29GX12MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 30G X 5/16" MISC NON_PREFERRED

DROPLET PEN NEEDLES 31G X3/16" MISC NON_PREFERRED

DROPLET PEN NEEDLES 31G X5/16" MISC NON_PREFERRED

DROPLET PEN NEEDLES 31GX5MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 31GX6MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 31GX8MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 32G X 1/4" MISC NON_PREFERRED

DROPLET PEN NEEDLES 32G X 3/16" MISC NON_PREFERRED

DROPLET PEN NEEDLES 32G X 5/16" MISC NON_PREFERRED

DROPLET PEN NEEDLES 32G X 5/32" MISC NON_PREFERRED

DROPLET PEN NEEDLES 32GX4MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 32GX5MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 32GX6MM MISC NON_PREFERRED

DROPLET PEN NEEDLES 32GX8MM MISC NON_PREFERRED

DROPSAFE SAFETY PEN NEEDLE/31GX5MM MISC NON_PREFERRED

DROPSAFE SAFETY PEN NEEDLES/31G X 5/16" MISC NON_PREFERRED

DROPSAFE SAFTEY PEN NEEDLES/31G X 1/4" MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPS 31GX5MM MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPS29G X 12MM MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPS31GX6MM MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPS31GX8MM MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPS32GX4MM MISC NON_PREFERRED

DRUG MART UNIFINE PENTIPSPLUS 32GX4MM MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES31GX1/4" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 89 of 147

EASY COMFORT PEN NEEDLES31GX3/16" MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES31GX5/16" MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES32GX5/32" MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES33G X 4MM MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES33G X 5MM MISC NON_PREFERRED

EASY COMFORT PEN NEEDLES33G X 6MM MISC NON_PREFERRED

EASY GLIDE PEN NEEDLES 33G X 5/32" MISC NON_PREFERRED

EASY TOUCH 32GX5MM MISC NON_PREFERRED

EASY TOUCH 32GX6MM MISC NON_PREFERRED

EASY TOUCH PEN NEEDLE 30G X 5/16" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLE/30G X 3/16" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 29GX1/2" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 32GX1/4" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 32GX3/16" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES 32GX5/32" MISC NON_PREFERRED

EASY TOUCH PEN NEEDLES/31G X 3/16" MISC NON_PREFERRED

EASY TOUCH SAFETY PEN NEEDLES/29G X 5MM MISC NON_PREFERRED

EASY TOUCH SAFETY PEN NEEDLES/29G X 8MM MISC NON_PREFERRED

EASY TOUCH SAFETY PEN NEEDLES/30G X 1/4" MISC NON_PREFERRED

EASY TOUCH SAFETY PEN NEEDLES/30G X 5/16" MISC NON_PREFERRED

EMBRACE PEN NEEDLES/29G X 12MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/30G X 5MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/30G X 8MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/31G X 5MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/31G X 6MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/31G X 8MM MISC NON_PREFERRED

EMBRACE PEN NEEDLES/32G X 4MM MISC NON_PREFERRED

EXCEL COMFORT POINT INSULIN PEN NEEDLES 31G X 4MM MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X 12MM MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

FIFTY50 PEN NEEDLES 31G X3/16" (5MM) MISC NON_PREFERRED

FIFTY50 PEN NEEDLES 31G X5/16" (8MM) MISC NON_PREFERRED

FIFTY50 PEN NEEDLES 31GX5MM MISC NON_PREFERRED

FIFTY50 PEN NEEDLES/31GX8MM MISC NON_PREFERRED

FIFTY50 PEN NEEDLES/32GX4MM MISC NON_PREFERRED

FIFTY50 PEN NEEDLES/32GX6MM MISC NON_PREFERRED

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FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC NON_PREFERRED

FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM MISC NON_PREFERRED

FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM MISC NON_PREFERRED

GLOBAL EASE INJECT PEN NEEDLES 29GX12MM MISC NON_PREFERRED

GLOBAL EASE INJECT PEN NEEDLES 31GX8MM MISC NON_PREFERRED

GLOBAL EASE INJECT PEN NEEDLES 32GX4MM MISC NON_PREFERRED

GLOBAL EASE INJECT PEN NEEEDLES 31GX5MM MISC NON_PREFERRED

GLOBAL EASY GLIDE PEN NEEDLES 32GX4MM MISC NON_PREFERRED

GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" MISC NON_PREFERRED

GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

GNP ULTICARE PEN NEEDLES/31GX5/16" MISC NON_PREFERRED

GNP ULTICARE PEN NEEDLES/32GX 5/32" MISC NON_PREFERRED

GNP ULTICARE PEN NEEDLES/32GX1/4" MISC NON_PREFERRED

GNP ULTICARE PEN NEEDLES31G X 5MM MISC NON_PREFERRED

GNP ULTIGUARD SAFEPACK/MICRO PEN NEEDLE/32GX4MM MISC NON_PREFERRED

GNP ULTIGUARD SAFEPACK/MINI PEN NEEDLE/31GX5MM MISC NON_PREFERRED

GNP ULTIGUARD SAFEPACK/MINI PEN NEEDLE/32GX6MM MISC NON_PREFERRED

GNP ULTIGUARD SAFEPACK/SHORT PEN NEEDLE/31GX8MM MISC NON_PREFERRED

GOODSENSE CLICKFINE SAFETY PEN NEEDLE/31G X 3/16" MISC NON_PREFERRED

GOODSENSE PEN NEEDLE/PENFINE CLASSIC/31G X 3/16" MISC NON_PREFERRED

GOODSENSE PEN NEEDLE/PENFINE CLASSIC/31G X 5/16" MISC NON_PREFERRED

GOODSENSE PEN NEEDLE/PENFINE CLASSIC/32G X 1/4" MISC NON_PREFERRED

GOODSENSE PEN NEEDLE/PENFINE CLASSIC/32G X 5/32" MISC NON_PREFERRED

HEALTHWISE MICRON PEN NEEDLES/32G X 5/32" MISC NON_PREFERRED

HEALTHWISE MINI PEN NEEDLES 31GX6MM MISC NON_PREFERRED

HEALTHWISE PEN NEEDLES 29GX12MM MISC NON_PREFERRED

HEALTHWISE SHORT PEN NEEDLES 31GX8MM MISC NON_PREFERRED

HEALTHWISE SHORT PEN NEEDLES/31G X 3/16" MISC NON_PREFERRED

HEALTHWISE SHORT PEN NEEDLES/31G X 5/16" MISC NON_PREFERRED

HEALTHWISE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC NON_PREFERRED

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 29GX12MM MISC NON_PREFERRED

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX5MM MISC NON_PREFERRED

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX6MM MISC NON_PREFERRED

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 31GX8MM MISC NON_PREFERRED

HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC NON_PREFERRED

H-E-B IN CONTROL PEN NEEDLE 31GX3/16" MISC NON_PREFERRED

H-E-B IN CONTROL PEN NEEDLES 31GX5MM MISC NON_PREFERRED

H-E-B IN CONTROL PEN NEEDLES 31GX6MM MISC NON_PREFERRED

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H-E-B IN CONTROL PEN NEEDLES 31GX8MM MISC NON_PREFERRED

H-E-B IN CONTROL PEN NEEDLES/NANO/32GX4MM MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX1/4" MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX3/16" MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX5/16" MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX5MM MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 32GX4MM MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 32GX5/32" MISC NON_PREFERRED

H-E-B IN CONTROL UNIFINEPENTIPS PLUS 33GX5/32" MISC NON_PREFERRED

H-E-B INCONTROL PEN NEEDLES 29GX12MM MISC NON_PREFERRED

HM ULTICARE MINI PEN NEEDLES/31G X 5MM (3/16") MISC NON_PREFERRED

HM ULTICARE SHORT PEN NEEDLES 31GX8MM MISC NON_PREFERRED

INCONTROL ULTICARE MINI PEN NEEDLES/31G X 6MM MISC NON_PREFERRED

INCONTROL ULTICARE MINI PEN NEEDLES/31GX8MM MISC NON_PREFERRED

INCONTROL ULTICARE MINI PEN NEEDLES/32G X 4MM MISC NON_PREFERRED

INSUPEN 29G X 12MM MISC NON_PREFERRED

INSUPEN 31G X 5MM MISC NON_PREFERRED

INSUPEN 31G X 8MM MISC NON_PREFERRED

INSUPEN 32G X 4MM MISC NON_PREFERRED

INSUPEN 33GX4MM MISC NON_PREFERRED

INSUPEN PEN NEEDLES 32G X4MM MISC NON_PREFERRED

INSUPEN SENSITIVE 32GX6MM MISC NON_PREFERRED

INSUPEN SENSITIVE 32GX8MM MISC NON_PREFERRED

INSUPEN ULTRAFIN 29GX12MM MISC NON_PREFERRED

INSUPEN ULTRAFIN 30GX8MM MISC NON_PREFERRED

INSUPEN ULTRAFIN 31GX6MM MISC NON_PREFERRED

INSUPEN ULTRAFIN 31GX8MM MISC NON_PREFERRED

KROGER PEN NEEDLES 29G X12MM MISC NON_PREFERRED

KROGER PEN NEEDLES 31G X8MM MISC NON_PREFERRED

KROGER PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

KROGER PEN NEEDLES/31G X1/4" MISC NON_PREFERRED

KROGER PEN NEEDLES/31G X3/16" MISC NON_PREFERRED

KROGER PEN NEEDLES/31G X5/16" MISC NON_PREFERRED

KROGER PEN NEEDLES/32G X5/32" MISC NON_PREFERRED

KROGER PEN NEEDLES/33G X5/32" MISC NON_PREFERRED

LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16" MISC NON_PREFERRED

LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16" MISC NON_PREFERRED

LEADER UNIFINE PENTIPS/MINI/31GX3/16" MISC NON_PREFERRED

LEADER UNIFINE PENTIPS/NANO/32GX5/32" MISC NON_PREFERRED

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LEADER UNIFINE PENTIPS/PLUS/32GX5/32" MISC NON_PREFERRED

LITETOUCH INSULIN PEN NEEDLES/32G X 4MM/MINI MISC NON_PREFERRED

LITETOUCH PEN NEEDLES 29GX12.7MM MISC NON_PREFERRED

LITETOUCH PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

LITETOUCH PEN NEEDLES 31G X 6MM/ULTRA SHORT MISC NON_PREFERRED

LITETOUCH PEN NEEDLES 31GX8MM SHORT MISC NON_PREFERRED

LITETOUCH PEN NEEDLES/31G X 3/16" MISC NON_PREFERRED

LITETOUCH PEN NEEDLES/31G X 5MM/MINI MISC NON_PREFERRED

LITETOUCH PEN NEEDLES/31G X 8MM/SHORT MISC NON_PREFERRED

MARATHON MEDICAL PENTIPS29GX12MM MISC NON_PREFERRED

MARATHON MEDICAL PENTIPS31GX5MM MISC NON_PREFERRED

MARATHON MEDICAL PENTIPS31GX8MM MISC NON_PREFERRED

MARATHON MEDICAL PENTIPS32GX4MM MISC NON_PREFERRED

MAXICOMFORT II PEN NEEDLES/31G X 1/4" MISC NON_PREFERRED

MAXI-COMFORT SAFETY PEN NEEDLE/29G X 3/16" MISC NON_PREFERRED

MAXI-COMFORT SAFETY PEN NEEDLE/29G X 5/16" MISC NON_PREFERRED

MEDICINE SHOPPE PEN NEEDLES 29G X 12MM MISC NON_PREFERRED

MEDICINE SHOPPE PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

MEDICINE SHOPPE PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

MEIJER PEN NEEDLES 29G X12MM MISC NON_PREFERRED

MEIJER PEN NEEDLES 31G X6MM MISC NON_PREFERRED

MEIJER PEN NEEDLES 31G X8MM MISC NON_PREFERRED

MICRODOT PEN NEEDLE/31G X 6 MM MISC NON_PREFERRED

MICRODOT PEN NEEDLE/32G X 4 MM MISC NON_PREFERRED

MICRODOT PEN NEEDLE/33G X 4 MM MISC NON_PREFERRED

MM PEN NEEDLES 31G X 1/4" MISC NON_PREFERRED

MM PEN NEEDLES 31G X 3/16" MISC NON_PREFERRED

MM PEN NEEDLES 31G X 5/16" MISC NON_PREFERRED

MM PEN NEEDLES 32G X 5/32" MISC NON_PREFERRED

NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8MM MISC NON_PREFERRED

NOVOFINE PEN NEEDLE 32G X 6MM MISC NON_PREFERRED

NOVOFINE PLUS PEN NEEDLE32G X 4MM MISC NON_PREFERRED

NOVOTWIST PEN NEEDLE 32GX 5MM MISC NON_PREFERRED

PC UNIFINE PENTIPS 29G X1/2" MISC NON_PREFERRED

PC UNIFINE PENTIPS 31G X5MM MINI MISC NON_PREFERRED

PC UNIFINE PENTIPS 31G X6MM ULTRA SHORT MISC NON_PREFERRED

PC UNIFINE PENTIPS 31G X8MM SHORT MISC NON_PREFERRED

PEN NEEDLES MISC NON_PREFERRED

PEN NEEDLES 29G X 12MM MISC NON_PREFERRED

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PEN NEEDLES 29GX1/2" MISC NON_PREFERRED

PEN NEEDLES 29GX12MM MISC NON_PREFERRED

PEN NEEDLES 30GX5/16" MISC NON_PREFERRED

PEN NEEDLES 30GX5MM MISC NON_PREFERRED

PEN NEEDLES 30GX8MM MISC NON_PREFERRED

PEN NEEDLES 31G X 1/4" SHORT MISC NON_PREFERRED

PEN NEEDLES 31G X 3/16" MISC NON_PREFERRED

PEN NEEDLES 31G X 5MM MISC NON_PREFERRED

PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

PEN NEEDLES 31GX6MM (1/4") MISC NON_PREFERRED

PEN NEEDLES 31GX8MM MISC NON_PREFERRED

PEN NEEDLES 31GX8MM (5/16") MISC NON_PREFERRED

PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

PEN NEEDLES 32G X 5MM MISC NON_PREFERRED

PEN NEEDLES 32G X 6MM MISC NON_PREFERRED

PEN NEEDLES 32GX4MM MISC NON_PREFERRED

PEN NEEDLES 33G X 5/32" MISC NON_PREFERRED

PEN NEEDLES/29G X 1/2" MISC NON_PREFERRED

PEN NEEDLES/31G X 1/4" MISC NON_PREFERRED

PEN NEEDLES/31G X 3/16" MISC NON_PREFERRED

PEN NEEDLES/31G X 5/16" MISC NON_PREFERRED

PEN NEEDLES/31G X 6MM MISC NON_PREFERRED

PEN NEEDLES/32G X 5/32" MISC NON_PREFERRED

PENTIPS 29G X 12MM MISC NON_PREFERRED

PENTIPS 29GX12MM MISC NON_PREFERRED

PENTIPS 31G X 5MM MISC NON_PREFERRED

PENTIPS 31G X 8MM MISC NON_PREFERRED

PENTIPS 31GX5MM MISC NON_PREFERRED

PENTIPS 31GX6MM MISC NON_PREFERRED

PENTIPS 31GX8MM MISC NON_PREFERRED

PENTIPS 32G X 4MM MISC NON_PREFERRED

PENTIPS 32GX4MM MISC NON_PREFERRED

PENTIPS 32GX6MM MISC NON_PREFERRED

PIP PEN NEEDLES 31G X 5MM MISC NON_PREFERRED

PIP PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM MISC NON_PREFERRED

PREFERRED PLUS UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC NON_PREFERRED

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PREFERRED PLUS UNIFINE PENTIPS 31G X 8MM SHORT MISC NON_PREFERRED

PREFERRED PLUS UNIFINE PENTIPS 32GX4MM MISC NON_PREFERRED

PREFERRED PLUS UNIFINE PENTIPS/MINI/31GX5MM MISC NON_PREFERRED

PREVENT DROPSAFE SAFETY PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

PREVENT DROPSAFE SAFETY PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

PREVENT SAFETY PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

PREVENT SAFETY PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

PRO COMFORT PEN NEEDLES/31G X 8MM MISC NON_PREFERRED

PRO COMFORT PEN NEEDLES/32G X 4MM MISC NON_PREFERRED

PRO COMFORT PEN NEEDLES/32G X 5MM MISC NON_PREFERRED

PRO COMFORT PEN NEEDLES/32G X 6MM MISC NON_PREFERRED

PURE COMFORT PEN NEEDLE 32G X6MM MISC NON_PREFERRED

PURE COMFORT PEN NEEDLE 32G X8MM MISC NON_PREFERRED

PURE COMFORT PEN NEEDLE/32G X 5MM MISC NON_PREFERRED

PURE COMFORT PEN NEEDLE/32G X4MM MISC NON_PREFERRED

PX EXTRA SHORT PEN NEEDLES 31GX6MM MISC NON_PREFERRED

PX MINI PEN NEEDLES 31GX5MM MISC NON_PREFERRED

PX PEN NEEDLE 29GX12MM MISC NON_PREFERRED

PX PEN NEEDLE 31GX8MM MISC NON_PREFERRED

PX SHORTLENGTH PEN NEEDLES/31GX8MM MISC NON_PREFERRED

QC PEN NEEDLES 29G X 12MM MISC NON_PREFERRED

QC PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

QC PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

QC UNIFINE PENTIPS 32GX4MM MISC NON_PREFERRED

RA PEN NEEDLES 31G X 5MM3/16" MISC NON_PREFERRED

RA PEN NEEDLES 31G X 8MM5/16" MISC NON_PREFERRED

RAYA SURE PEN NEEDLE 29GX 12MM MISC NON_PREFERRED

RAYA SURE PEN NEEDLE 31GX 4MM MISC NON_PREFERRED

RAYA SURE PEN NEEDLE 31GX 5MM MISC NON_PREFERRED

RAYA SURE PEN NEEDLE 31GX 6MM MISC NON_PREFERRED

RAYA SURE PEN NEEDLE 31GX 8MM MISC NON_PREFERRED

RELION MINI PEN NEEDLES 31GX6MM MISC NON_PREFERRED

RELION PEN NEEDLES 29GX12MM MISC NON_PREFERRED

RELION PEN NEEDLES 31G X6MM MISC NON_PREFERRED

RELION PEN NEEDLES 31G X8MM MISC NON_PREFERRED

RELION PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

RELION PEN NEEDLES 31GX6MM MISC NON_PREFERRED

RELION PEN NEEDLES 31GX8MM MISC NON_PREFERRED

RELION PEN NEEDLES 32G X4MM MISC NON_PREFERRED

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RELION PEN NEEDLES 32G X5/32" MISC NON_PREFERRED

RELION PEN NEEDLES 32GX4MM MISC NON_PREFERRED

RELION PEN NEEDLES/31G X1/4" MISC NON_PREFERRED

RELION SHORT PEN NEEDLES31GX8MM MISC NON_PREFERRED

SAFETY PEN NEEDLES/30G X3/16" MISC NON_PREFERRED

SAFETY PEN NEEDLES/30G X5/16" MISC NON_PREFERRED

SECURESAFE SAFETY PEN NEEDLES/30G X 5/16" MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PEN NEEDLES/MINI/31GX5MM MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PLUS PEN

NEEDLES/MICRO/REMOVR/32GX4MM

MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PLUS PEN

NEEDLES/MINI/REMOVER/31GX5MM

MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM MISC NON_PREFERRED

SHOPKO UNIFINE PENTIPS PLUS PEN

NEEDLES/SHORT/REMOVR/31GX8MM

MISC NON_PREFERRED

SURE COMFORT AUTOKEEPER SAFETY PEN NEEDLES 31GX1/4" MISC NON_PREFERRED

SURE COMFORT AUTOKEEPER SAFETY PEN NEEDLES 32GX5/32" MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES29GX1/2" 12.7MM MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES30GX5/16" SHORT MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES31GX3/16" (5MM) MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES31GX5/16" (8MM) MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES32GX5/32" MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES32GX5/32" (4MM) MISC NON_PREFERRED

SURE COMFORT PEN NEEDLES32GX6MM MISC NON_PREFERRED

SURE-FINE PEN NEEDLES 29GX1/2" 12.7MM MISC NON_PREFERRED

SURE-FINE PEN NEEDLES 31GX3/16" 5MM MISC NON_PREFERRED

SURE-FINE PEN NEEDLES 31GX5/16" 8MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES 29GX 10MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES 29GX 12 MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES 31GX 5MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/31GX 5MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/31GX 6 MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/31GX 8MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/32GX 4MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/32GX 6MM MISC NON_PREFERRED

TECHLITE PEN NEEDLES/32GX 8MM MISC NON_PREFERRED

TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4" MISC NON_PREFERRED

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TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" MISC NON_PREFERRED

TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" MISC NON_PREFERRED

TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" MISC NON_PREFERRED

TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" MISC NON_PREFERRED

TRUE COMFORT PEN NEEDLES31G X 5MM MISC NON_PREFERRED

TRUE COMFORT PEN NEEDLES31G X 6MM MISC NON_PREFERRED

TRUE COMFORT PEN NEEDLES32G X 4MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 31G X 5MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 32G X 5MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 32G X 6MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 33G X 4MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 33G X 5MM MISC NON_PREFERRED

TRUE COMFORT PRO PEN NEEDLES 33G X 6MM MISC NON_PREFERRED

TRUE COMFORT SAFETY PEN NEEDLES 31G X 5MM MISC NON_PREFERRED

TRUE COMFORT SAFETY PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

TRUE COMFORT SAFETY PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

TRUEPLUS 5-BEVEL PEN NEEDLES 29GX12.7MM MISC PREFERRED

TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM MISC PREFERRED

TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM MISC PREFERRED

TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM MISC PREFERRED

TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM MISC PREFERRED

TRUEPLUS PEN NEEDLES 29GX12MM MISC PREFERRED

TRUEPLUS PEN NEEDLES 31GX5MM MISC PREFERRED

TRUEPLUS PEN NEEDLES 31GX6MM MISC PREFERRED

TRUEPLUS PEN NEEDLES 31GX8MM MISC PREFERRED

TRUEPLUS PEN NEEDLES 32GX4MM MISC PREFERRED

ULTICARE MICRO PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

ULTICARE MICRO PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

ULTICARE MICRO PEN NEEDLES/31G X 1/4" MISC NON_PREFERRED

ULTICARE MICRO PEN NEEDLES/31G X 5/16" MISC NON_PREFERRED

ULTICARE MICRO PEN NEEDLES/32G X 4MM MISC NON_PREFERRED

ULTICARE MICRO PEN NEEDLES/32G X 5/32" MISC NON_PREFERRED

ULTICARE MINI PEN NEEDLES 31GX6MM MISC NON_PREFERRED

ULTICARE MINI PEN NEEDLES ULTI-FINE IV MISC NON_PREFERRED

ULTICARE MINI PEN NEEDLES/31G X 6MM MISC NON_PREFERRED

ULTICARE MINI PEN NEEDLES/32G X 1/4" MISC NON_PREFERRED

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ULTICARE MINI PEN NEEDLES31GX6MM MISC NON_PREFERRED

ULTICARE MINI SAFETY PENNEEDLES 30G X 3/16" MISC NON_PREFERRED

ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE MISC NON_PREFERRED

ULTICARE PEN NEEDLES 31GX 5MM/MINI MISC NON_PREFERRED

ULTICARE PEN NEEDLES/29GX 12.7MM MISC NON_PREFERRED

ULTICARE SHORT PEN NEEDLES 31GX8MM MISC NON_PREFERRED

ULTICARE SHORT PEN NEEDLES ULTI-FINE IV MISC NON_PREFERRED

ULTICARE SHORT PEN NEEDLES/31G X 8MM MISC NON_PREFERRED

ULTICARE SHORT SAFETY PEN NEEDLES 30G X 5/16" MISC NON_PREFERRED

ULTIGUARD SAFEPACK MINI PEN NEEDLE/31G X 3/16"/SHARPS CONTAI MISC NON_PREFERRED

ULTIGUARD SAFEPACK PEN NEEDLE/29G X 1/2"/SHARPS CONTAINER MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MICROPEN NEEDLE/32G X 4 MM MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MICROPEN NEEDLE/32G X 4MM/SHARPS

CONTAIN

MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MICROPEN NEEDLE/32G X 5/32" MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MICROPEN NEEDLE/32G X 5/32"/SHARPS CNTR MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MICROPEN NEEDLE/32G X 5/32"/SHARPS CONTA MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MINI PEN NEEDLE/31G X 1/4"/SHARPS CONTAIN MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MINI PEN NEEDLE/31G X 3/16"/SHARPS CONTAI MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MINI PEN NEEDLE/31G X 6MM/SHARPS CONTAIN MISC NON_PREFERRED

ULTIGUARD SAFEPACK/MINI PEN NEEDLE/32G X 1/4"/SHARPS CONTAIN MISC NON_PREFERRED

ULTIGUARD SAFEPACK/SHORTPEN NEEDLE/31G X 5/16"/SHARPS

CONTA

MISC NON_PREFERRED

ULTIGUARD SAFEPACK/SHORTPEN NEEDLE/31G X 8MM/SHARPS

CONTAIN

MISC NON_PREFERRED

ULTILET PEN NEEDLE 29GX12.7MM MISC NON_PREFERRED

ULTILET PEN NEEDLE 31GX5MM MISC NON_PREFERRED

ULTILET PEN NEEDLE 31GX8MM MISC NON_PREFERRED

ULTILET PEN NEEDLE 32GX4MM MISC NON_PREFERRED

ULTILET PEN NEEDLE 32GX4MM/SHORT MISC NON_PREFERRED

ULTILET SHORT PEN NEEDLES 31GX5/16" MISC NON_PREFERRED

ULTILET SHORT PEN NEEDLES31GX3/16" MISC NON_PREFERRED

ULTRA FLO INSULIN PEN NEEDLE 31GX5MM MISC NON_PREFERRED

ULTRA FLO INSULIN PEN NEEDLE 32GX4MM MISC NON_PREFERRED

ULTRA FLO INSULIN PEN NEEDLE 33GX4MM MISC NON_PREFERRED

ULTRA FLO INSULIN PEN NEEDLES MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 98 of 147

ULTRA FLO INSULIN PEN NEELE 31GX8MM MISC NON_PREFERRED

ULTRA THIN PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/31G X 1/4" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/31G X 3/16" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/31G X 5/16" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/32G X 1/14" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/32G X 3/16" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/32G X 5/32" MISC NON_PREFERRED

ULTRACARE PEN NEEDLES/33G X 5/32" MISC NON_PREFERRED

ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16" MISC NON_PREFERRED

ULTRA-THIN II PEN NEEDLES 29GX1/2" MISC NON_PREFERRED

ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16" MISC NON_PREFERRED

UNIFINE PEN NEEDLE/32G X4MM MISC NON_PREFERRED

UNIFINE PENTIPS 29GX12MM MISC NON_PREFERRED

UNIFINE PENTIPS 31G X 3/16" MISC NON_PREFERRED

UNIFINE PENTIPS 31GX5MM MISC NON_PREFERRED

UNIFINE PENTIPS 31GX6MM MISC NON_PREFERRED

UNIFINE PENTIPS 31GX8MM MISC NON_PREFERRED

UNIFINE PENTIPS 32GX4MM MISC NON_PREFERRED

UNIFINE PENTIPS 32GX6MM MISC NON_PREFERRED

UNIFINE PENTIPS 33GX4MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 29GX12MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 31GX5MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 31GX6MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 31GX8MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 32GX4MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 33GX 5/32" MISC NON_PREFERRED

UNIFINE PENTIPS PLUS 33GX4MM MISC NON_PREFERRED

UNIFINE PENTIPS PLUS/30GX 3/16" MISC NON_PREFERRED

UNIFINE PENTIPS/30G X 3/16" MISC NON_PREFERRED

UNIFINE SAFECONTROL PEN NEEDLE 32GX4MM MISC NON_PREFERRED

UNIFINE SAFECONTROL PEN NEEDLE/30G X 3/16" MISC NON_PREFERRED

UNIFINE SAFECONTROL PEN NEEDLE/30G X 5/16" MISC NON_PREFERRED

UNIFINE ULTRA PEN NEEDLE/31GX5MM MISC NON_PREFERRED

UNIFINE ULTRA PEN NEEDLE/31GX6MM MISC NON_PREFERRED

UNIFINE ULTRA PEN NEEDLE/31GX8MM MISC NON_PREFERRED

UNIFINE ULTRA PEN NEEDLE/32GX4MM MISC NON_PREFERRED

VALUMARK PEN NEEDLES 29GX12MM MISC NON_PREFERRED

VALUMARK PEN NEEDLES 31GX 6MM MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

3/6/2023 8:01:09 AM Page 99 of 147

VALUMARK PEN NEEDLES 31GX 8MM MISC NON_PREFERRED

VERIFINE INSULIN PEN NEEDLE 32G X 4MM MISC NON_PREFERRED

VIDA MIA UNIFINE PENTIPS32GX4MM MISC NON_PREFERRED

VIDA MIA UNIFINE PENTIPSMINI 31GX6MM MISC NON_PREFERRED

VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM MISC NON_PREFERRED

VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM MISC NON_PREFERRED

WEGMANS UNIFINE PENTIPS PLUS 32GX4MM MISC NON_PREFERRED

WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MM MISC NON_PREFERRED

WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MM MISC NON_PREFERRED

WEGMANS UNIFINE PENTIPS PLUS/ULTRA SHORT/31GX6MM MISC NON_PREFERRED

ZEVRX PEN NEEDLES 31G X 5MM MISC NON_PREFERRED

ZEVRX PEN NEEDLES 31G X 6MM MISC NON_PREFERRED

ZEVRX PEN NEEDLES 31G X 8MM MISC NON_PREFERRED

ZEVRX PEN NEEDLES 32G X 4MM MISC NON_PREFERRED

BD INSULIN SYRINGE LUER-LOK/U-100/1ML MISC NON_PREFERRED

BD INSULIN SYRINGE SLIP TIP/U-100/1ML MISC NON_PREFERRED

KMART VALU PLUS INSULIN SYRINGE/0.3ML/30G MISC NON_PREFERRED

KMART VALU PLUS INSULIN SYRINGE/0.5ML/29G MISC NON_PREFERRED

KMART VALU PLUS INSULIN SYRINGE/0.5ML/30G MISC NON_PREFERRED

KMART VALU PLUS INSULIN SYRINGE/1ML/29G MISC NON_PREFERRED

KMART VALU PLUS INSULIN SYRINGE/1ML/30G MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/1ML MISC NON_PREFERRED

MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.3ML/31GX5/16" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/30GX5/16" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/31GX5/16" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/1ML/30GX5/16" MISC NON_PREFERRED

ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" MISC NON_PREFERRED

ASSURE ID INSULIN SAFETYSYRINGE U-100/0.5ML/31G X 15/64" MISC NON_PREFERRED

ASSURE ID INSULIN SAFETYSYRINGE/1ML/31G X 15/64" MISC NON_PREFERRED

ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

BD LO-DOSE INSULIN SYRINGE MICROFINE IV/0.5ML/28G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/27G X 5/8" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN PEN NEEDLES

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

3/6/2023 8:01:09 AM Page 100 of 147

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X 5/8" MISC NON_PREFERRED

BD INSULIN SYRINGE MICROFINE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE HALF-UNIT/0.3ML/31G X 5/16" MISC NON_PREFERRED

B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16" MISC NON_PREFERRED

B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31G X 5/16" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X 1/2" MISC NON_PREFERRED

B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/0.3ML/30G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/0.3ML/31G X 8MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC NON_PREFERRED

B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G X 5/16" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/31G X 8MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/1/2 UNIT/0.3ML/31G X 8MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/1ML/30G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/1ML/30G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

BD INSULIN SYRINGE/0.3ML/29G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE/0.5ML/29G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE/1ML/27G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE/1ML/29G X 12.7MM MISC NON_PREFERRED

BD INSULIN SYRINGE/DETACHABLE NEEDLE/U-100/1ML/25G X 1" MISC NON_PREFERRED

BD INSULIN SYRINGE/DETACHABLE NEEDLE/U-100/1ML/25G X 5/8" MISC NON_PREFERRED

BD INSULIN SYRINGE/DETACHABLE NEEDLE/U-100/1ML/26G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC NON_PREFERRED

BD INSULIN SYRINGE/U-100/2ML/27.5G X 5/8" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G X 15/64" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

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BD SAFETY-GLIDE INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/0.5ML/31G X 15/64" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYRINGE/1ML/31G X 15/64" MISC NON_PREFERRED

BD SAFETYGLIDE INSULIN SYSYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

BD SAFETY-LOK INSULIN SYRINGE/PERM NEEDLE/UF/1ML/29G X 1/2" MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/0.3ML/31G X 6MM MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/0.5ML/31G X 6MM MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/1/2 UNIT/0.3ML/31G X 6MM MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/1ML/31G X 6MM MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/U-100/0.3ML/31G X 15/64" MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTRA-FINE/U-100/1ML/31G X 15/64" MISC NON_PREFERRED

BD VEO INSULIN SYRINGE ULTR-FINE/U-100/0.5ML/31G X 15/64" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/0.3ML/30G X 1/2" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/0.3ML/31G X 5/16" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/0.5ML/30G X 1/2" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/0.5ML/31G X 5/16" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/1ML/30G X 1/2" MISC NON_PREFERRED

CAREONE INSULIN SYRINGES/1ML/31GX5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/0.3ML/31GX5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/0.5ML/31GX5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/1ML/30GX5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/1ML/31GX5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/U-100/1ML/28G X 5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE/U-100/1ML/29G X 5/16" MISC NON_PREFERRED

CARETOUCH INSULIN SYRINGE0.5ML/30GX5/16" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/30G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/30G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1.0ML/30G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

3/6/2023 8:01:09 AM Page 102 of 147

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE 0.3ML/29G X 1/2" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

COMFORT ASSIST INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

COMFORT EZ INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

COMFORT EZ INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE 0.3ML/29G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE 0.5ML/29G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE 1ML/29G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.3/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.3ML/31G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/1ML/30G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/1ML/30G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/1ML/30G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/1ML/31G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE U-100/1ML/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/0.3ML/31G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/0.5ML/31G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/1ML/31G X 15/64" MISC NON_PREFERRED

DROPLET INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

3/6/2023 8:01:09 AM Page 103 of 147

EASY COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/1ML/32GX5/16" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

EASY COMFORT INSULIN SYRINGES/0.5ML/32GX5/16" MISC NON_PREFERRED

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC NON_PREFERRED

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX1/2" MISC NON_PREFERRED

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" MISC NON_PREFERRED

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/27G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/27G X 5/8" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

EASY TOUCH INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC NON_PREFERRED

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" MISC NON_PREFERRED

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" MISC NON_PREFERRED

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

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ELITE-THIN INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/1ML/29G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/29G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X 5/16" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

EQL INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

EQL INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

EXEL COMFORT POINT INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

GLOBAL EASY GLIDE INSULIN SYRINGE/0.3ML/31G X 15/64" MISC NON_PREFERRED

GLOBAL EASY GLIDE INSULIN SYRINGE/0.5ML/31G X 15/64" MISC NON_PREFERRED

GLOBAL EASY GLIDE INSULIN SYRINGE/1ML/31G X 15/64" MISC NON_PREFERRED

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GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOPRO INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGES/0.3ML/30GX5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGES/1/2ML/29GX1/2" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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GNP INSULIN SYRINGES/1ML/28GX1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGES/1ML/29GX1/2" MISC NON_PREFERRED

GNP INSULIN SYRINGES/1ML/30GX5/16" MISC NON_PREFERRED

GNP INSULIN SYRINGES/3ML/31GX5/16" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X 5/16" SHORT MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X 5/16" SHORT MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X 5/16" SHORT MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" SHORT MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X 5/16" SHORT MISC NON_PREFERRED

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/31G X 5/16" SHORT MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

HEALTHWISE INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

HM ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" MISC NON_PREFERRED

HM ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE 1ML/31G X1/4" MISC NON_PREFERRED

INSULIN SYRINGE/0.3ML/29G X 1" MISC NON_PREFERRED

INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/0.5ML/27G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/0.5ML/30G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 0.3ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 0.3ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 0.5ML/29G X 1/2" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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INSULIN SYRINGE/NEEDLE 0.5ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 0.5ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 1ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 1ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/NEEDLE 1ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

INSULIN SYRINGES MISC NON_PREFERRED

INSULIN SYRINGES 0.3ML/31G X 1/4" MISC NON_PREFERRED

INSULIN SYRINGES 0.5ML/31G X 1/4" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/27GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/28GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/29GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/30GX5/16" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/31GX 5/16" MISC NON_PREFERRED

INSULIN SYRINGES/0.5ML/31GX5/16" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/27GX/1/2" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/27GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/28GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/29GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/30GX1/2" MISC NON_PREFERRED

INSULIN SYRINGES/1ML/31GX5/16" MISC NON_PREFERRED

KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G X 5/16" MISC NON_PREFERRED

KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16" MISC NON_PREFERRED

KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X 5/16" MISC NON_PREFERRED

KINRAY INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

KROGER INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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LEADER INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

LEADER INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

LITETOUCH INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

LONGS INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" MISC NON_PREFERRED

MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2" MISC NON_PREFERRED

MAXICOMFORT INSULIN SYRINGES 27G X 1/2" MISC NON_PREFERRED

MEDIC INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

MEDIC INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

MM INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

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MM INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

MM INSULIN SYRINGE/U-100/1/2ML/30G X 5/16" MISC NON_PREFERRED

MM INSULIN SYRINGE/U-100/1/2ML/31G X 5/16" MISC NON_PREFERRED

MM INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

MM INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/DETACH NEEDLE/1ML/25G X 5/8" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/DETACH NEEDLE/1ML/27G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/PERM NEEDLE/1ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/PERM NEEDLE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SAFETY/PERM NEEDLE/0.3ML/29G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SAFETY/PERM NEEDLE/0.3ML/29GX1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SAFETY/PERM NEEDLE/0.5ML/29G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SAFETY/PERM NEEDLE/1ML/29G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

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

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

MS INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

MS INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

MS INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/30G X 3/8" MISC NON_PREFERRED

PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

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PRECISION SURE-DOSE PLUSINSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/0.5ML/30G X 1/2" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/0.5ML/30G X 5/16" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/0.5ML/31G X 5/16" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/1ML/30G X 1/2" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/1ML/30G X 5/16" MISC NON_PREFERRED

PRO COMFORT INSULIN SYRINGES/1ML/31G X 5/16" MISC NON_PREFERRED

PRODIGY INSULIN SYRING/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

PRODIGY INSULIN SYRINGE/1/2ML/31G X 5/16" MISC NON_PREFERRED

PRODIGY INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

RA INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

RA INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16" MISC NON_PREFERRED

REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

REALITY INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

REALITY INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

RELION INSULIN SYRINGE 0.5ML/31G X 15/64" MISC NON_PREFERRED

RELION INSULIN SYRINGE 1ML/31GX15/64" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-00/1ML/29G X 1/2" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/29G MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/30G MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/31G X 15/64" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.5ML/29G MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

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RELION INSULIN SYRINGE/U-100/0.5ML/30G MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/1ML/30G MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/1ML/31G X 15/64" MISC NON_PREFERRED

RELION INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

SAFESNAP INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

SAFESNAP INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

SAFESNAP INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" MISC NON_PREFERRED

SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" MISC NON_PREFERRED

SAFETY INSULIN SYRINGES 1ML/27GX1/2" MISC NON_PREFERRED

SAFETY INSULIN SYRINGES 1ML/29GX1/2" MISC NON_PREFERRED

SAFETY INSULIN SYRINGES 1ML/30GX1/2" MISC NON_PREFERRED

SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

SB INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

SB INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

SECURESAFE SAFETY INSULIN SYRINGES/U-100/0.5ML/29GX1/2" MISC NON_PREFERRED

SECURESAFE SAFETY INSULIN SYRINGES/U-100/1ML/29GX1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16 MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31GX1/4" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16 MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGES/0.5ML/31G X 6MM MISC NON_PREFERRED

SURE COMFORT INSULIN SYRINGES/U-100/1ML/31GX6MM MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

SURE-JECT INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.3ML/31G X 15/64" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.5ML/31G X 15/64" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/1ML/29G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/1ML/30G X 1/2" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/1ML/30G X 5/16" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/1ML/31G X 15/64" MISC NON_PREFERRED

TECHLITE INSULIN SYRINGEU-100/1ML/31G X 5/16" MISC NON_PREFERRED

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

TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X 5/16" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

TRUE COMFORT INSULIN SYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULIN SYRINGE/1ML/32GX5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/0.5ML/31G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/0.5ML/32G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/1ML/31G X 5/16" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

TRUE COMFORT PRO INSULINSYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC PREFERRED

TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC PREFERRED

ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.3ML/29G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.3ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.5ML/28G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.5ML/29G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.5ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/1ML/28G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/SHORT/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/SHORT/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

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ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE INSULIN SYRINGEULTRAFINE U-100/1ML/31G X 5/16" MISC NON_PREFERRED

ULTICARE U-100 INSULIN SYRINGES/0.3ML/31G X 1/4" MISC NON_PREFERRED

ULTICARE U-100 INSULIN SYRINGES/0.3ML/31G X1/4" MISC NON_PREFERRED

ULTICARE U-100 INSULIN SYRINGES/0.5ML/31G X 1/4" MISC NON_PREFERRED

ULTICARE U-100 INSULIN SYRINGES/1ML/31G X 1/4" MISC NON_PREFERRED

ULTICARE U-100 INSULIN SYRINGES/HALF UNIT/0.3ML/31G X1/4" MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE 0.3ML/30G X 1/2"/SHARPS C MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE 1/2ML 30G X 1/2"/SHARPS C MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 1/2"/SHARPS CON MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 5/16"/SHARPS CO MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE/0.3ML/30G X 1/2"/SHARPS C MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE/0.3ML/31G X 5/16"/SHARPS MISC NON_PREFERRED

ULTIGUARD SAFEPACK INSULIN SYRINGE/0.5ML/30G X 1/2"/SHARPS C MISC NON_PREFERRED

ULTIGUARD SAFEPACK/SYRINGE/NEEDLE/31G X 5/16"/SHARPS

CONTAIN

MISC NON_PREFERRED

ULTILET INSULIN SYRINGE 31X6MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/0.3ML/30G X 8MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/0.3ML/31G X 8MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/0.5ML/30G X 8MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/1ML/30G X 8MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/1ML/31G X 8MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 12.7MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X 5/16" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

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ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/U-100/0.5ML/31GX6MM MISC NON_PREFERRED

ULTILET INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

ULTILET U-100 INSULIN SYRINGES/1ML/31G X 6MM MISC NON_PREFERRED

ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.3ML/29G X 1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.3ML/30GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.3ML/30GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.3ML/31GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.5ML/29GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.5ML/30GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.5ML/30GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 0.5ML/31GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1/2 UNIT/0.3ML/30GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1/2 UNIT/0.3ML/30GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1/2 UNIT/0.3ML/31GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1M/29GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1ML/30GX1/2" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1ML/30GX5/16" MISC NON_PREFERRED

ULTRA FLO INSULIN SYRINGE 1ML/31GX5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

ULTRACARE INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16" MISC NON_PREFERRED

GLUCOSE MONITORING SUPPLIES :

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ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/31GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/30GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.5ML/31GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC NON_PREFERRED

ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC NON_PREFERRED

VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" MISC NON_PREFERRED

VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 3/16" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/1ML/29G X 5/16" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/1ML/30G X 3/16" MISC NON_PREFERRED

VANISHPOINT INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" MISC NON_PREFERRED

ZEVRX INSULIN SYRINGE/0.5ML/30G X 1/2" MISC NON_PREFERRED

ZEVRX INSULIN SYRINGE/0.5ML/30G X 5/16" MISC NON_PREFERRED

ZEVRX INSULIN SYRINGE/1ML/30G X 1/2" MISC NON_PREFERRED

ZEVRX INSULIN SYRINGE/1ML/30G X 5/16" MISC NON_PREFERRED

ACCU-CHEK AVIVA PLUS STRP NON_PREFERRED

ACCU-CHEK COMPACT PLUS STRP NON_PREFERRED

ACCU-CHEK GUIDE STRP NON_PREFERRED

ACCU-CHEK SMARTVIEW STRIPS STRP NON_PREFERRED

ACCUTREND GLUCOSE STRP NON_PREFERRED

ADVANCE INTUITION TEST STRIPS STRP NON_PREFERRED

ADVANCE MICRO-DRAW TEST STRIPS STRP NON_PREFERRED

ADVOCATE REDI-CODE STRP NON_PREFERRED

ADVOCATE REDI-CODE+ TESTSTRIPS STRP NON_PREFERRED

ADVOCATE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX AMP NO CODE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX JAZZ TEST STRIPS STRP NON_PREFERRED

AGAMATRIX KEYNOTE TEST STRIPS STRP NON_PREFERRED

AGAMATRIX PRESTO TEST STRIPS STRP NON_PREFERRED

ASSURE 3 TEST STRIPS STRP NON_PREFERRED

ASSURE 4 TEST STRIPS STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

GLUCOSE MONITORING SUPPLIES :

INSULIN SYRINGES

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ASSURE II STRP NON_PREFERRED

ASSURE II CHECK STRIP STRP NON_PREFERRED

ASSURE II TEST STRIPS STRP NON_PREFERRED

ASSURE PLATINUM TEST STRIPS STRP NON_PREFERRED

ASSURE PRISM MULTI TEST STRIPS STRP NON_PREFERRED

ASSURE PRO TEST STRIPS STRP NON_PREFERRED

BIOSCANNER GLUCOSE TEST STRIPS STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED

BLOOD GLUCOSE TEST STRIPS333 STRP NON_PREFERRED

BLULINK GLUCOSE TEST STRIPS STRP NON_PREFERRED

CAREONE BLOOD GLUCOSE TEST STRIPS/PREMIUM STRP NON_PREFERRED

CAREONE BLOOD GLUCOSE TEST STRIPS/VALUE STRP NON_PREFERRED

CARESENS N BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

CARETOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK AUTO-CODE VOICE TEST STRIPS STRP NON_PREFERRED

CLEVER CHEK TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE AUTO-CODE PRO TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE MICRO TESTSTRIPS STRP NON_PREFERRED

CLEVER CHOICE NO CODING TEST STRIPS STRP NON_PREFERRED

CLEVER CHOICE TALK NO CODING TEST STRIPS STRP NON_PREFERRED

CONTOUR BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CONTOUR NEXT BLOOD GLUCOSE TEST STRP NON_PREFERRED

COOL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

CVS ADVANCED GLUCOSE METER TEST STRIPS STRP NON_PREFERRED

CVS GLUCOSE METER TEST STRIPS STRP NON_PREFERRED

D-CARE BLOOD GLUCOSE STRP NON_PREFERRED

DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

DIATHRIVE+ BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

DIATRUE PLUS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

DUO-CARE TEST STRIPS STRP NON_PREFERRED

EASY PLUS II BLOOD GLUCOSE TEST STRP NON_PREFERRED

EASY STEP TEST STRIPS STRP NON_PREFERRED

EASY TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TALK PLUS II BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TOUCH HEALTHPRO GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASY TRAK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

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EASY TRAK II BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASYGLUCO STRP NON_PREFERRED

EASYGLUCO PLUS STRP NON_PREFERRED

EASYMAX 15 TEST STRIPS STRP NON_PREFERRED

EASYMAX TEST STRIPS STRP NON_PREFERRED

EASYPRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EASYPRO PLUS STRP NON_PREFERRED

ELEMENT COMPACT TEST STRIPS STRP NON_PREFERRED

ELEMENT TEST STRIPS STRP NON_PREFERRED

EMBRACE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EMBRACE EVO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

EMBRACE PRO BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EQ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVENCARE + BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED

EVENCARE BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED

EVENCARE G2 TEST STRIPS STRP NON_PREFERRED

EVENCARE G3 TEST STRIPS STRP NON_PREFERRED

EVENCARE MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVENCARE PROVIEW BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

EVOLUTION AUTOCODE STRP NON_PREFERRED

EXACTECH R-S-G TEST STRIPS STRP NON_PREFERRED

EXACTECH TEST STRIPS STRP NON_PREFERRED

FIFTY50 GLUCOSE TEST STRIP 2.0 STRP NON_PREFERRED

FORA 6 CONNECT STRP NON_PREFERRED

FORA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D15G BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA D40/G31 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA G20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA G30/PREMIUM V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA GD20 TEST STRIPS STRP NON_PREFERRED

FORA GD50 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA GTEL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA TN'G ADVANCE PRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA TN'G/TN'G VOICE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA V10 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA V12 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORA V20 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

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FORA V30A BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FORACARE GD40 STRP NON_PREFERRED

FORACARE PREMIUM V10 TESTSTRIPS STRP NON_PREFERRED

FORACARE TEST N GO TEST STRIPS STRP NON_PREFERRED

FORTISCARE BLOOD GLUCOSETEST STRIP STRP NON_PREFERRED

FORTISCARE G1 BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP NON_PREFERRED

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP NON_PREFERRED

FREESTYLE LITE TEST STRIPS STRP NON_PREFERRED

FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

FREESTYLE TEST STRIPS STRP NON_PREFERRED

GE100 BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

GENULTIMATE TEST STRIPS STRP NON_PREFERRED

GHT TEST STRIPS STRP NON_PREFERRED

GLUCO PERFECT 3 TEST STRIPS STRP NON_PREFERRED

GLUCOCARD 01 SENSOR PLUS STRP NON_PREFERRED

GLUCOCARD 01 SENSOR PLUSTEST STRIPS STRP NON_PREFERRED

GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GLUCOCARD SHINE TEST STRIPS STRP NON_PREFERRED

GLUCOCARD VITAL TEST STRIPS STRP NON_PREFERRED

GLUCOCARD X-SENSOR STRP NON_PREFERRED

GLUCOCOM TEST STRIPS STRP NON_PREFERRED

GLUCONAVII BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

GLUCOSE METER TEST STRIPS ADVANCED STRP NON_PREFERRED

GNP EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

GNP TRUE METRIX SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GNP TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GNP TRUETRACK SMART SYSTEM STRP NON_PREFERRED

GOJJI BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

GOJJI BLOOD GLUCOSE TESTSTRIPS/GOJJI STERILE LANCETS 30G STRP NON_PREFERRED

GOODSENSE PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HARMONY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

IGLUCOSE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

IN TOUCH BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

INFINITY BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

INFINITY VOICE STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

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KROGER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

KROGER HEALTHPRO GLUCOSETEST STRIPS STRP NON_PREFERRED

KROGER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

KROGER TEST STRIPS STRP NON_PREFERRED

LIBERTY NEXT GENERATION BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

LIBERTY TEST STRIPS STRP NON_PREFERRED

MEIJER BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

MEIJER ESSENTIAL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER TRUETEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MEIJER TRUETRACK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

MICRODOT TEST STRIPS STRP NON_PREFERRED

MICRODOT XTRA TEST STRIPS STRP NON_PREFERRED

MM EASY TOUCH GLUCOSE TEST STRIPS STRP NON_PREFERRED

MYGLUCOHEALTH BLOOD GLUCOSE TEST STRP NON_PREFERRED

NEUTEK 2TEK TEST STRIPS STRP NON_PREFERRED

NOVA MAX GLUCOSE TEST STRIPS STRP NON_PREFERRED

ON CALL EXPRESS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ON CALL PLUS BLOOD GLUCOSE TEST STRP NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE TEST STRP NON_PREFERRED

ON CALL VIVID BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ONE DROP BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

ONETOUCH ULTRA STRP PREFERRED

ONETOUCH VERIO TEST STRIPS STRP PREFERRED

OPTIUM TEST STRIPS STRP NON_PREFERRED

OPTIUMEZ TEST STRIPS STRP NON_PREFERRED

OPTUMRX BLOOD GLUCOSE TEST STRP NON_PREFERRED

PHARMACIST CHOICE AUTOCODE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PHARMACIST CHOICE NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PIP BLOOD GLUCOSE TEST STRIP STRP NON_PREFERRED

POCKETCHEM EZ BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PRECISION PCX STRP NON_PREFERRED

PRECISION PCX PLUS TEST STRIPS STRP NON_PREFERRED

PRECISION POINT OF CARE TEST STRIPS STRP NON_PREFERRED

PRECISION QID TEST STRIPS STRP NON_PREFERRED

PRECISION SOF-TACT TEST STRIPS STRP NON_PREFERRED

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PREMIUM BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PRO VOICE V8/V9 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

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PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

PTS PANELS EGLU STRP NON_PREFERRED

PTS PANELS GLUCOSE TEST STRP NON_PREFERRED

QUICKTEK TEST STRIPS STRP NON_PREFERRED

QUINTET AC BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

QUINTET BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

REFUAH PLUS BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

RELION BLOOD GLUCOSE TESTSTRIPS STRP NON_PREFERRED

RELION CONFIRM/MICRO TEST STRIPS STRP NON_PREFERRED

RELION PREMIER BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION PRIME BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION TRUE METRIX BLOODGLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION ULTIMA BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RELION ULTIMA TEST STRIPS STRP NON_PREFERRED

REVEAL BLOOD GLUCOSE TEST STRP NON_PREFERRED

REXALL BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GS100 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GS300 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GS333 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GS550 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

RIGHTEST GT333 BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SMART SENSE PREMIUM BLOODGLUCOSE STRIPS STRP NON_PREFERRED

SMART SENSE VALUE BLOOD GLUCOSE STRIPS STRP NON_PREFERRED

SMARTEST BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SOLUS V2 AUDIBLE TEST STRP NON_PREFERRED

SUPREME TEST STRIPS STRP NON_PREFERRED

SURE EDGE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SURECHEK BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

SURE-TEST EASYPLUS MINI BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TELCARE BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TGT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TGT BLOOD GLUCOSE TEST STRIPS PREMIUM STRP NON_PREFERRED

TRUE FOCUS SELF MONITORING BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP NON_PREFERRED

TRUE METRIX PRO GLUCOSE TEST STRIPS STRP NON_PREFERRED

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP NON_PREFERRED

TRUETEST BLOOD GLUCOSE TEST STRP NON_PREFERRED

TRUETEST STRIPS STRP NON_PREFERRED

TRUETRACK BLOOD GLUCOSE TEST STRP NON_PREFERRED

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

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TRUETRACK TEST STRP NON_PREFERRED

ULTIMA TEST STRIPS STRP NON_PREFERRED

ULTRATRAK PRO TEST STRIPS STRP NON_PREFERRED

ULTRATRAK ULTIMATE TEST STRIPS STRP NON_PREFERRED

UNISTRIP1 GENERIC STRP NON_PREFERRED

VERASENS BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

VOCAL POINT BLOOD GLUCOSE TEST STRIPS STRP NON_PREFERRED

WAVESENSE PRESTO TEST STRIPS STRP NON_PREFERRED

ALLOPURINOL TABS PREFERRED

COLCHICINE CAPS NON_PREFERRED

MITIGARE CAPS NON_PREFERRED

COLCHICINE TABS NON_PREFERRED

COLCRYS TABS NON_PREFERRED

FEBUXOSTAT TABS NON_PREFERRED

ULORIC TABS NON_PREFERRED

PROBENECID TABS PREFERRED

PROBENECID/COLCHICINE TABS PREFERRED

HEMOFIL M SOLR PREFERRED_WITH_PA

KOATE SOLR PREFERRED_WITH_PA

KOATE-DVI SOLR PREFERRED_WITH_PA

KOGENATE FS KIT PREFERRED_WITH_PA

RECOMBINATE SOLR PREFERRED_WITH_PA

NUWIQ KIT PREFERRED_WITH_PA

NUWIQ SOLR PREFERRED_WITH_PA

ADVATE SOLR PREFERRED_WITH_PA

KOVALTRY SOLR PREFERRED_WITH_PA

XYNTHA KIT PREFERRED_WITH_PA

XYNTHA SOLOFUSE KIT PREFERRED_WITH_PA

ELOCTATE SOLR PREFERRED_WITH_PA

NOVOEIGHT SOLR PREFERRED_WITH_PA

ESPEROCT SOLR PREFERRED_WITH_PA

ADYNOVATE SOLR PREFERRED_WITH_PA

JIVI SOLR PREFERRED_WITH_PA

OBIZUR SOLR PREFERRED_WITH_PA

AFSTYLA KIT PREFERRED_WITH_PA

WILATE KIT PREFERRED_WITH_PA

ALPHANATE SOLR PREFERRED_WITH_PA

HUMATE-P SOLR PREFERRED_WITH_PA

GLUCOSE MONITORING SUPPLIES : TEST

STRIPS

GOUT AGENTS

HEMATOLOGICAL AGENTS :

ANTIHEMOPHILIC PRODUCTS

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FEIBA SOLR PREFERRED_WITH_PA

NOVOSEVEN RT SOLR PREFERRED_WITH_PA

SEVENFACT SOLR PREFERRED_WITH_PA

ALPHANINE SD SOLR PREFERRED_WITH_PA

BENEFIX KIT PREFERRED_WITH_PA

IXINITY SOLR PREFERRED_WITH_PA

RIXUBIS SOLR PREFERRED_WITH_PA

IDELVION SOLR PREFERRED_WITH_PA

ALPROLIX SOLR PREFERRED_WITH_PA

REBINYN SOLR PREFERRED_WITH_PA

PROFILNINE SOLR PREFERRED_WITH_PA

COAGADEX SOLR PREFERRED_WITH_PA

TRETTEN SOLR PREFERRED_WITH_PA

CORIFACT KIT PREFERRED_WITH_PA

VONVENDI SOLR PREFERRED_WITH_PA

HEMLIBRA SOLN PREFERRED_WITH_PA

PENTOXIFYLLINE ER TBCR PREFERRED

TAVALISSE TABS NON_PREFERRED

CINRYZE SOLR NON_PREFERRED

HAEGARDA SOLR NON_PREFERRED

BERINERT KIT PREFERRED_WITH_PA

RUCONEST SOLR NON_PREFERRED

ENJAYMO SOLN NON_PREFERRED

EMPAVELI SOLN NON_PREFERRED

SOLIRIS SOLN NON_PREFERRED

ULTOMIRIS SOLN NON_PREFERRED

TAVNEOS CAPS NON_PREFERRED

FIRAZYR SOLN NON_PREFERRED

ICATIBANT ACETATE SOLN NON_PREFERRED

SAJAZIR SOLN NON_PREFERRED

ORLADEYO CAPS NON_PREFERRED

KALBITOR SOLN NON_PREFERRED

TAKHZYRO SOLN NON_PREFERRED

TAKHZYRO SOSY NON_PREFERRED

DIPYRIDAMOLE TABS PREFERRED

CILOSTAZOL TABS NON_PREFERRED

AGRYLIN CAPS NON_PREFERRED

ANAGRELIDE HYDROCHLORIDE CAPS PREFERRED

CLOPIDOGREL TABS PREFERRED

HEMATOLOGICAL AGENTS :

ANTIHEMOPHILIC PRODUCTS

HEMATOLOGICAL AGENTS : MISC

HEMATOLOGICAL AGENTS : PLATELET

AGGREGATION INHIBITORS

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PLAVIX TABS NON_PREFERRED

EFFIENT TABS NON_PREFERRED

PRASUGREL TABS NON_PREFERRED

BRILINTA TABS PREFERRED

YOSPRALA TBEC NON_PREFERRED

ASPIRIN/DIPYRIDAMOLE CP12 PREFERRED

ASPIRIN/DIPYRIDAMOLE ER CP12 PREFERRED

REBLOZYL SOLR NON_PREFERRED

ARANESP ALBUMIN FREE SOLN NON_PREFERRED

ARANESP ALBUMIN FREE SOSY NON_PREFERRED

EPOGEN SOLN PREFERRED_WITH_PA

PROCRIT SOLN PREFERRED_WITH_PA

RETACRIT SOLN NON_PREFERRED

MIRCERA SOSY NON_PREFERRED

ROLVEDON SOSY NON_PREFERRED

NEUPOGEN SOLN PREFERRED

NEUPOGEN SOSY PREFERRED

NIVESTYM SOLN NON_PREFERRED

NIVESTYM SOSY NON_PREFERRED

RELEUKO SOLN NON_PREFERRED

RELEUKO SOSY NON_PREFERRED

ZARXIO SOSY NON_PREFERRED

GRANIX SOLN NON_PREFERRED

GRANIX SOSY NON_PREFERRED

NEULASTA ONPRO KIT PSKT NON_PREFERRED

NEULASTA SOSY NON_PREFERRED

NYVEPRIA SOSY NON_PREFERRED

ZIEXTENZO SOSY NON_PREFERRED

UDENYCA SOSY NON_PREFERRED

STIMUFEND SOSY NON_PREFERRED

FULPHILA SOSY NON_PREFERRED

FYLNETRA SOSY NON_PREFERRED

LEUKINE SOLR PREFERRED

DOPTELET TABS NON_PREFERRED

PROMACTA PACK NON_PREFERRED

PROMACTA TABS NON_PREFERRED

MULPLETA TABS NON_PREFERRED

NPLATE SOLR NON_PREFERRED

ESTAZOLAM TABS PREFERRED

HEMATOLOGICAL AGENTS : PLATELET

AGGREGATION INHIBITORS

HEMATOPOIETIC AGENTS :

HEMATOPOIETIC GROWTH FACTORS

HYPNOTICS / SEDATIVES / SLEEP

DISORDER AGENTS : BENZODIAZEPINE

HYPNOTICS

3/6/2023 8:01:09 AM Page 125 of 147

MIDAZOLAM HCL SYRP NON_PREFERRED

MIDAZOLAM HYDROCHLORIDE SYRP NON_PREFERRED

RESTORIL CAPS NON_PREFERRED

TEMAZEPAM CAPS PREFERRED

HALCION TABS NON_PREFERRED

TRIAZOLAM TABS PREFERRED

PHENOBARBITAL ELIX PREFERRED

PHENOBARBITAL TABS PREFERRED

RAMELTEON TABS NON_PREFERRED

ROZEREM TABS NON_PREFERRED

HETLIOZ CAPS NON_PREFERRED

TASIMELTEON CAPS NON_PREFERRED

HETLIOZ LQ SUSP NON_PREFERRED

DOXEPIN HYDROCHLORIDE TABS NON_PREFERRED

SILENOR TABS NON_PREFERRED

QUVIVIQ TABS NON_PREFERRED

DAYVIGO TABS NON_PREFERRED

BELSOMRA TABS NON_PREFERRED

ESZOPICLONE TABS NON_PREFERRED

LUNESTA TABS NON_PREFERRED

ZALEPLON CAPS NON_PREFERRED

ZOLPIMIST SOLN NON_PREFERRED

EDLUAR SUBL NON_PREFERRED

ZOLPIDEM TARTRATE SUBL NON_PREFERRED

AMBIEN TABS NON_PREFERRED

ZOLPIDEM TARTRATE TABS PREFERRED

AMBIEN CR TBCR NON_PREFERRED

ZOLPIDEM TARTRATE ER TBCR NON_PREFERRED

CYCLOSPORINE CAPS PREFERRED

SANDIMMUNE CAPS NON_PREFERRED

SANDIMMUNE SOLN PREFERRED

CYCLOSPORINE MODIFIED CAPS PREFERRED

GENGRAF CAPS PREFERRED

NEORAL CAPS NON_PREFERRED

CYCLOSPORINE MODIFIED SOLN PREFERRED

GENGRAF SOLN PREFERRED

NEORAL SOLN NON_PREFERRED

LUPKYNIS CAPS NON_PREFERRED

CELLCEPT CAPS NON_PREFERRED

HYPNOTICS / SEDATIVES / SLEEP

DISORDER AGENTS : BENZODIAZEPINE

HYPNOTICS

HYPNOTICS / SEDATIVES / SLEEP

DISORDER AGENTS : MISC

HYPNOTICS / SEDATIVES / SLEEP

DISORDER AGENTS : NON -

BENZODIAZEPINE HYPNOTICS

IMMUNOSUPPRESSIVE AGENTS

3/6/2023 8:01:09 AM Page 126 of 147

MYCOPHENOLATE MOFETIL CAPS PREFERRED

CELLCEPT SUSR NON_PREFERRED

MYCOPHENOLATE MOFETIL SUSR PREFERRED

CELLCEPT TABS NON_PREFERRED

MYCOPHENOLATE MOFETIL TABS PREFERRED

MYCOPHENOLIC ACID DR TBEC PREFERRED

MYFORTIC TBEC NON_PREFERRED

EVEROLIMUS TABS NON_PREFERRED

ZORTRESS TABS NON_PREFERRED

RAPAMUNE SOLN NON_PREFERRED

SIROLIMUS SOLN PREFERRED

RAPAMUNE TABS NON_PREFERRED

SIROLIMUS TABS PREFERRED

PROGRAF CAPS NON_PREFERRED

TACROLIMUS CAPS PREFERRED

ASTAGRAF XL CP24 NON_PREFERRED

PROGRAF PACK NON_PREFERRED

ENVARSUS XR TB24 NON_PREFERRED

AZASAN TABS NON_PREFERRED

AZATHIOPRINE TAB 75MG TABS NON_PREFERRED

AZATHIOPRINE TAB 100MG TABS NON_PREFERRED

AZATHIOPRINE TAB 50MG TABS PREFERRED

IMURAN TABS NON_PREFERRED

QULIPTA TABS PREFERRED_WITH_PA

NURTEC TBDP PREFERRED_WITH_PA

UBRELVY TABS PREFERRED_WITH_PA

VYEPTI SOLN NON_PREFERRED

AIMOVIG SOAJ PREFERRED_WITH_PA

AJOVY SOAJ PREFERRED_WITH_PA

AJOVY SOSY PREFERRED_WITH_PA

EMGALITY SOAJ NON_PREFERRED

EMGALITY SOSY NON_PREFERRED

DIHYDROERGOTAMINE MESYLATE SOLN NON_PREFERRED

MIGRANAL SOLN NON_PREFERRED

TRUDHESA AERS NON_PREFERRED

DICLOFENAC POTASSIUM PACK NON_PREFERRED

ELYXYB SOLN NON_PREFERRED

SUMANSETRON TBPK NON_PREFERRED

MIGERGOT SUPP PREFERRED

IMMUNOSUPPRESSIVE AGENTS

MIGRAINE PRODUCTS : CALCITONIN GENE-

RELATED PEPTIDE (CGRP) RECEPTOR

ANTAG

MIGRAINE PRODUCTS : MISC

3/6/2023 8:01:09 AM Page 127 of 147

SUMATRIPTAN/NAPROXEN SODIUM TABS NON_PREFERRED

TREXIMET TABS NON_PREFERRED

ALMOTRIPTAN TABS NON_PREFERRED

ALMOTRIPTAN MALATE TABS NON_PREFERRED

ELETRIPTAN HYDROBROMIDE TABS NON_PREFERRED

RELPAX TABS NON_PREFERRED

FROVA TABS NON_PREFERRED

FROVATRIPTAN SUCCINATE TABS NON_PREFERRED

NARATRIPTAN HCL TABS NON_PREFERRED

MAXALT TABS NON_PREFERRED

RIZATRIPTAN BENZOATE TABS PREFERRED

MAXALT-MLT TBDP NON_PREFERRED

RIZATRIPTAN BENZOATE ODT TBDP PREFERRED

IMITREX SOLN NON_PREFERRED

SUMATRIPTAN SOLN PREFERRED

TOSYMRA SOLN NON_PREFERRED

ONZETRA XSAIL EXHP NON_PREFERRED

IMITREX STATDOSE SYSTEM SOAJ NON_PREFERRED

SUMATRIPTAN SUCCINATE SOAJ PREFERRED

ZEMBRACE SYMTOUCH SOAJ NON_PREFERRED

IMITREX STATDOSE REFILL SOCT NON_PREFERRED

SUMATRIPTAN SUCCINATE REFILL SOCT PREFERRED

SUMATRIPTAN SUCCINATE SOLN PREFERRED

IMITREX TABS NON_PREFERRED

SUMATRIPTAN SUCCINATE TABS PREFERRED

ZOLMITRIPTAN SOLN NON_PREFERRED

ZOMIG SOLN NON_PREFERRED

ZOLMITRIPTAN TABS NON_PREFERRED

ZOMIG TABS NON_PREFERRED

ZOLMITRIPTAN ODT TBDP NON_PREFERRED

ZOMIG ZMT TBDP NON_PREFERRED

REYVOW TABS NON_PREFERRED

THALOMID CAPS NON_PREFERRED

LENALIDOMIDE CAPS NON_PREFERRED

REVLIMID CAPS NON_PREFERRED

VYVGART SOLN NON_PREFERRED

REZUROCK TABS NON_PREFERRED

BENLYSTA SOAJ NON_PREFERRED

BENLYSTA SOSY NON_PREFERRED

MIGRAINE PRODUCTS : SELECTIVE

SEROTONIN AGONISTS 5-HT(1F)

MISCELLANEOUS THERAPEUTIC CLASSES

MIGRAINE PRODUCTS : MISC

3/6/2023 8:01:09 AM Page 128 of 147

SODIUM POLYSTYRENE SULFONATE POWD PREFERRED

SPS SUSP NON_PREFERRED

LOKELMA PACK NON_PREFERRED

VELTASSA PACK NON_PREFERRED

NYSTATIN SUSP PREFERRED

CLOTRIMAZOLE TROC PREFERRED

CHLORHEXIDINE GLUCONATE SOLN PREFERRED

ORALONE DENTAL PASTE PSTE PREFERRED

TRIAMCINOLONE ACETONIDE DENTAL PASTE PSTE PREFERRED

LIDOCAINE HCL SOLN PREFERRED

LIDOCAINE HCL VISCOUS SOLN PREFERRED

LIDOCAINE HYDROCHLORIDE VISCOUS SOLN PREFERRED

LIDOCAINE VISCOUS SOLN PREFERRED

DENTA 5000 PLUS CREA NON_PREFERRED

SF 5000 PLUS CREA NON_PREFERRED

SODIUM FLUORIDE 5000 PLUS CREA NON_PREFERRED

SODIUM FLUORIDE 5000 PPM CREA NON_PREFERRED

DENTAGEL GEL NON_PREFERRED

SF GEL NON_PREFERRED

SODIUM FLUORIDE GEL NON_PREFERRED

SODIUM FLUORIDE 5000 PPM DRY MOUTH GEL NON_PREFERRED

SODIUM FLUORIDE 5000 PPM PSTE NON_PREFERRED

SODIUM FLUORIDE SOLN NON_PREFERRED

SODIUM FLUORIDE 5000 PPM ENAMEL PROTECT GEL NON_PREFERRED

SODIUM FLUORIDE 5000 PPMSENSITIVE GEL NON_PREFERRED

AQUORAL SOLN NON_PREFERRED

CEVIMELINE HYDROCHLORIDE CAPS NON_PREFERRED

EVOXAC CAPS NON_PREFERRED

PILOCARPINE HYDROCHLORIDE TABS PREFERRED

GELX GEL NON_PREFERRED

VITAFOL STRIPS FILM NON_PREFERRED

PREMESISRX TABS NON_PREFERRED

PRENATE AM TABS NON_PREFERRED

PRENATE CHEW NON_PREFERRED

DERMACINRX PRETRATE TABS NON_PREFERRED

VITAFOL GUMMIES CHEW NON_PREFERRED

ENBRACE HR CAPS NON_PREFERRED

ELITE-OB TABS PREFERRED

OB COMPLETE TABS PREFERRED

MISCELLANEOUS THERAPEUTIC CLASSES

MOUTH / THROAT / DENTAL AGENTS

MULTIVITAMINS : PRENATAL VITAMINS

3/6/2023 8:01:09 AM Page 129 of 147

PNV TABS 29-1 TABS PREFERRED

THRIVITE RX TABS PREFERRED

PRENATE ELITE TABS NON_PREFERRED

OB COMPLETE/DHA CAPS NON_PREFERRED

OB COMPLETE PREMIER TABS NON_PREFERRED

COMPLETENATE CHEW PREFERRED

SE-NATAL 19 CHEW PREFERRED

M-NATAL PLUS TABS PREFERRED

NIVA-PLUS TABS PREFERRED

PRENATAL TABS PREFERRED

PRENATAL PLUS VITAMIN ANDMINERAL TABS PREFERRED

PRENATRIX TABS NON_PREFERRED

PRENATRYL TABS NON_PREFERRED

PREPLUS TABS PREFERRED

PRETAB TABS PREFERRED

TRICARE TABS PREFERRED

TRINATAL RX 1 TABS PREFERRED

VITAFOL-OB TABS PREFERRED

WESTAB PLUS TABS PREFERRED

C-NATE DHA CAPS NON_PREFERRED

RELNATE DHA CAPS NON_PREFERRED

VIRT-NATE DHA CAPS NON_PREFERRED

VP-PNV-DHA CAPS NON_PREFERRED

WESNATE DHA CAPS NON_PREFERRED

MULTI-MAC TABS NON_PREFERRED

PNV-SELECT TABS NON_PREFERRED

SELECT-OB CHEW NON_PREFERRED

VITAFOL-NANO TABS NON_PREFERRED

FOLIVANE-OB CAPS NON_PREFERRED

PNV-OMEGA CAPS NON_PREFERRED

VIRT-PN PLUS CAPS NON_PREFERRED

ZATEAN-PN PLUS CAPS NON_PREFERRED

NESTABS TABS NON_PREFERRED

NESTABS DHA MISC NON_PREFERRED

TRI-TABS DHA MISC NON_PREFERRED

SE-NATAL 19 TABS PREFERRED

CITRANATAL B-CALM MISC NON_PREFERRED

OB COMPLETE ONE CAPS NON_PREFERRED

MULTIVITAMINS : PRENATAL VITAMINS

3/6/2023 8:01:09 AM Page 130 of 147

OB COMPLETE PETITE CAPS NON_PREFERRED

VINATE DHA RF CAPS NON_PREFERRED

PRIMACARE CAPS NON_PREFERRED

CITRANATAL BLOOM TABS NON_PREFERRED

TARON-C DHA CAPS NON_PREFERRED

VIRT-C DHA CAPS NON_PREFERRED

WESCAP-C DHA CAPS NON_PREFERRED

COMPLETE NATAL DHA MISC NON_PREFERRED

WESNATAL DHA COMPLETE MISC NON_PREFERRED

VITAFOL-OB+DHA MISC NON_PREFERRED

TRISTART DHA CAPS NON_PREFERRED

TRISTART FREE CAPS NON_PREFERRED

TRISTART ONE CAPS NON_PREFERRED

WESTGEL DHA CAPS NON_PREFERRED

PNV-DHA CAPS NON_PREFERRED

PRENATE ENHANCE CAPS NON_PREFERRED

PRENATE RESTORE CAPS NON_PREFERRED

VIRT-PN DHA CAPS NON_PREFERRED

WESCAP-PN DHA CAPS NON_PREFERRED

ZATEAN-PN DHA CAPS NON_PREFERRED

PRENATE DHA CAPS NON_PREFERRED

PRENATE ESSENTIAL CAPS NON_PREFERRED

PRENATE PIXIE CAPS NON_PREFERRED

VITAFOL-ONE CAPS NON_PREFERRED

SELECT-OB+DHA MISC NON_PREFERRED

PRENAISSANCE PLUS CAPS NON_PREFERRED

PNV-DHA+DOCUSATE CAPS NON_PREFERRED

PRENAISSANCE CAPS NON_PREFERRED

TARON-PREX CAPS NON_PREFERRED

CITRANATAL 90 DHA MISC NON_PREFERRED

CITRANATAL ASSURE MISC NON_PREFERRED

CITRANATAL DHA MISC NON_PREFERRED

CITRANATAL ESSENCE THPK NON_PREFERRED

PRENATE MINI CAPS NON_PREFERRED

CITRANATAL HARMONY CAPS NON_PREFERRED

CITRANATAL MEDLEY CAPS NON_PREFERRED

VITAFOL FE+ CAPS NON_PREFERRED

VITAFOL ULTRA CAPS NON_PREFERRED

NESTABS ONE CAPS NON_PREFERRED

MULTIVITAMINS : PRENATAL VITAMINS

3/6/2023 8:01:09 AM Page 131 of 147

VITAFOL FE+ CPPK NON_PREFERRED

LYVISPAH PACK NON_PREFERRED

BACLOFEN SOLN NON_PREFERRED

FLEQSUVY SUSP NON_PREFERRED

BACLOFEN TABS PREFERRED

CARISOPRODOL TABS NON_PREFERRED

SOMA TABS NON_PREFERRED

CHLORZOXAZONE TABS PREFERRED

LORZONE TABS PREFERRED

AMRIX CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLORIDE ER CP24 NON_PREFERRED

CYCLOBENZAPRINE HYDROCHLORIDE TABS PREFERRED

FEXMID TABS PREFERRED

METAXALONE TABS NON_PREFERRED

METHOCARBAMOL TABS PREFERRED

ORPHENADRINE CITRATE ER TB12 PREFERRED

TIZANIDINE HCL CAPS NON_PREFERRED

TIZANIDINE HYDROCHLORIDE CAPS NON_PREFERRED

ZANAFLEX CAPS NON_PREFERRED

TIZANIDINE HCL TABS PREFERRED

TIZANIDINE HYDROCHLORIDE TABS PREFERRED

ZANAFLEX TABS NON_PREFERRED

DANTRIUM CAPS NON_PREFERRED

DANTROLENE SODIUM CAPS PREFERRED

CARISOPRODOL/ASPIRIN/CODEINE TABS NON_PREFERRED

NORGESIC FORTE TABS NON_PREFERRED

QNASL AERS NON_PREFERRED

QNASL CHILDRENS AERS NON_PREFERRED

BECONASE AQ SUSP NON_PREFERRED

ZETONNA AERS NON_PREFERRED

OMNARIS SUSP NON_PREFERRED

FLUNISOLIDE SOLN PREFERRED

XHANCE EXHU NON_PREFERRED

FLUTICASONE PROPIONATE SUSP PREFERRED

PROPEL MINI/STRAIGHT DELIVERY SYSTEM IMPL NON_PREFERRED

SINUVA IMPL NON_PREFERRED

MOMETASONE FUROATE SUSP NON_PREFERRED

IPRATROPIUM BROMIDE SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

MULTIVITAMINS : PRENATAL VITAMINS

MUSCULOSKELETAL THERAPY AGENTS

NASAL AGENTS - SYSTEMIC AND TOPICAL

: MISC

3/6/2023 8:01:09 AM Page 132 of 147

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

OLOPATADINE HCL SOLN PREFERRED

OLOPATADINE HYDROCHLORIDE SOLN PREFERRED

PATANASE SOLN NON_PREFERRED

AZELASTINE HYDROCHLORIDE/FLUTICASONE PROPIONATE SUSP NON_PREFERRED

DYMISTA SUSP NON_PREFERRED

RYALTRIS SUSP NON_PREFERRED

EXSERVAN FILM NON_PREFERRED

TIGLUTIK SUSP NON_PREFERRED

RILUTEK TABS NON_PREFERRED

RILUZOLE TABS PREFERRED

RADICAVA ORS SUSP NON_PREFERRED

RADICAVA ORS STARTER KIT SUSP NON_PREFERRED

BETAXOLOL HCL SOLN PREFERRED

BETOPTIC-S SUSP NON_PREFERRED

CARTEOLOL HCL SOLN PREFERRED

LEVOBUNOLOL HCL SOLN PREFERRED

BETIMOL SOLN NON_PREFERRED

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG PREFERRED

TIMOPTIC-XE SOLG NON_PREFERRED

ISTALOL SOLN NON_PREFERRED

TIMOLOL MALEATE PRESERVATIVE FREE SOLN NON_PREFERRED

TIMOLOL MALEATE SOLN PREFERRED

TIMOLOL MALEATE IN OCUDOSE SOLN NON_PREFERRED

TIMOPTIC SOLN NON_PREFERRED

TIMOPTIC OCUDOSE SOLN NON_PREFERRED

BRIMONIDINE TARTRATE/TIMOLOL MALEATE SOLN NON_PREFERRED

COMBIGAN SOLN NON_PREFERRED

COSOPT SOLN NON_PREFERRED

COSOPT PF SOLN NON_PREFERRED

DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN PREFERRED

DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF SOLN NON_PREFERRED

LACRISERT INST PREFERRED

BIMATOPROST SOLN NON_PREFERRED

LUMIGAN SOLN NON_PREFERRED

XELPROS EMUL NON_PREFERRED

LATANOPROST SOLN PREFERRED

XALATAN SOLN NON_PREFERRED

VYZULTA SOLN NON_PREFERRED

NASAL AGENTS - SYSTEMIC AND TOPICAL

: MISC

NEUROMUSCULAR AGENTS

OPHTHALMIC AGENTS : BETA-BLOCKERS -

OPHTHALMIC

OPHTHALMIC AGENTS : MISC

3/6/2023 8:01:09 AM Page 133 of 147

TAFLUPROST SOLN NON_PREFERRED

ZIOPTAN SOLN NON_PREFERRED

TRAVATAN Z SOLN NON_PREFERRED

TRAVOPROST SOLN NON_PREFERRED

ATROPINE SULFATE OINT PREFERRED

ATROPINE SULFATE SOLN PREFERRED

ISOPTO ATROPINE SOLN NON_PREFERRED

CYCLOGYL SOLN NON_PREFERRED

CYCLOPENTOLATE HCL SOLN PREFERRED

CYCLOPENTOLATE HYDROCHLORIDE SOLN PREFERRED

PHENYLEPHRINE HCL SOLN NON_PREFERRED

PHENYLEPHRINE HYDROCHLORIDE SOLN NON_PREFERRED

MYDRIACYL SOLN NON_PREFERRED

TROPICAMIDE SOLN PREFERRED

CYCLOMYDRIL SOLN PREFERRED

ISOPTO CARPINE SOLN NON_PREFERRED

PILOCARPINE HCL SOLN PREFERRED

PILOCARPINE HYDROCHLORIDE SOLN PREFERRED

VUITY SOLN NON_PREFERRED

PHOSPHOLINE IODIDE SOLR NON_PREFERRED

RHOPRESSA SOLN NON_PREFERRED

ROCKLATAN SOLN NON_PREFERRED

APRACLONIDINE SOLN NON_PREFERRED

IOPIDINE SOLN NON_PREFERRED

ALPHAGAN P SOLN PREFERRED

BRIMONIDINE TARTRATE SOLN PREFERRED

SIMBRINZA SUSP NON_PREFERRED

CYCLOSPORINE EMUL NON_PREFERRED

RESTASIS EMUL NON_PREFERRED

RESTASIS MULTIDOSE EMUL NON_PREFERRED

VERKAZIA EMUL NON_PREFERRED

CEQUA SOLN NON_PREFERRED

XIIDRA SOLN NON_PREFERRED

AKTEN GEL NON_PREFERRED

ALCAINE SOLN NON_PREFERRED

PROPARACAINE HCL SOLN NON_PREFERRED

TETRACAINE HCL SOLN NON_PREFERRED

TETRACAINE HYDROCHLORIDE SOLN NON_PREFERRED

OXERVATE SOLN NON_PREFERRED

OPHTHALMIC AGENTS : MISC

3/6/2023 8:01:09 AM Page 134 of 147

AZOPT SUSP NON_PREFERRED

BRINZOLAMIDE SUSP NON_PREFERRED

DORZOLAMIDE HCL SOLN PREFERRED

DORZOLAMIDE HYDROCHLORIDE SOLN PREFERRED

TRUSOPT SOLN NON_PREFERRED

BROMFENAC SOLN NON_PREFERRED

BROMSITE SOLN NON_PREFERRED

PROLENSA SOLN NON_PREFERRED

DICLOFENAC SODIUM SOLN PREFERRED

FLURBIPROFEN SODIUM SOLN PREFERRED

ACULAR SOLN NON_PREFERRED

ACULAR LS SOLN NON_PREFERRED

ACUVAIL SOLN NON_PREFERRED

KETOROLAC TROMETHAMINE SOLN PREFERRED

ILEVRO SUSP NON_PREFERRED

NEVANAC SUSP NON_PREFERRED

CYSTADROPS SOLN NON_PREFERRED

CYSTARAN SOLN NON_PREFERRED

FUL-GLO STRP NON_PREFERRED

GLOSTRIPS STRP NON_PREFERRED

FLUORESCEIN SODIUM/BENOXINATE HYDROCHLORIDE SOLN NON_PREFERRED

PAREMYD SOLN NON_PREFERRED

AZELASTINE HCL SOLN PREFERRED

AZELASTINE HYDROCHLORIDE SOLN PREFERRED

BEPOTASTINE BESILATE SOLN NON_PREFERRED

BEPREVE SOLN NON_PREFERRED

ZERVIATE SOLN NON_PREFERRED

CROMOLYN SODIUM SOLN PREFERRED

EPINASTINE HCL SOLN NON_PREFERRED

ALOMIDE SOLN NON_PREFERRED

ALOCRIL SOLN NON_PREFERRED

OLOPATADINE HCL SOLN NON_PREFERRED

OLOPATADINE HYDROCHLORIDE SOLN NON_PREFERRED

AZASITE SOLN NON_PREFERRED

BACITRACIN OINT PREFERRED

BESIVANCE SUSP NON_PREFERRED

CILOXAN OINT PREFERRED

CILOXAN SOLN NON_PREFERRED

CIPROFLOXACIN HYDROCHLORIDE SOLN PREFERRED

OPHTHALMIC AGENTS : MISC

OPHTHALMIC AGENTS : OPHTHALMIC

ANTIALLERGIC

OPHTHALMIC AGENTS : OPHTHALMIC

ANTI-INFECTIVES

3/6/2023 8:01:09 AM Page 135 of 147

ERYTHROMYCIN OINT PREFERRED

GATIFLOXACIN SOLN NON_PREFERRED

ZYMAXID SOLN NON_PREFERRED

GENTAK OINT PREFERRED

GENTAMICIN SULFATE SOLN PREFERRED

LEVOFLOXACIN SOLN PREFERRED

MOXIFLOXACIN HYDROCHLORIDE SOLN NON_PREFERRED

VIGAMOX SOLN NON_PREFERRED

OCUFLOX SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

TOBREX OINT PREFERRED

TOBRAMYCIN SOLN PREFERRED

TOBRAMYCIN SULFATE SOLN PREFERRED

TOBREX SOLN NON_PREFERRED

SULFACETAMIDE SODIUM OINT PREFERRED

SULFACETAMIDE SODIUM SOLN PREFERRED

ZIRGAN GEL PREFERRED

TRIFLURIDINE SOLN PREFERRED

NATACYN SUSP NON_PREFERRED

BETADINE OPHTHALMIC PREP SOLN NON_PREFERRED

AK-POLY-BAC OINT PREFERRED

BACITRACIN/POLYMYXIN B OINT PREFERRED

POLYCIN OINT PREFERRED

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN PREFERRED

POLYTRIM SOLN NON_PREFERRED

TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE SOLN PREFERRED

NEOMYCIN/BACITRACIN/POLYMYXIN OINT PREFERRED

NEOMYCIN/POLYMYXIN/BACITRACIN ZINC OINT PREFERRED

NEO-POLYCIN OINT PREFERRED

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN PREFERRED

DEXTENZA INST NON_PREFERRED

MAXIDEX SUSP PREFERRED

DEXAMETHASONE SODIUM PHOSPHATE SOLN PREFERRED

DIFLUPREDNATE EMUL NON_PREFERRED

DUREZOL EMUL NON_PREFERRED

FML OINT PREFERRED

FLUOROMETHOLONE SUSP PREFERRED

FML FORTE SUSP PREFERRED

FML LIQUIFILM SUSP NON_PREFERRED

OPHTHALMIC AGENTS : OPHTHALMIC

ANTI-INFECTIVES

OPHTHALMIC AGENTS : OPHTHALMIC

STEROIDS

3/6/2023 8:01:09 AM Page 136 of 147

FLAREX SUSP PREFERRED

LOTEMAX GEL NON_PREFERRED

LOTEMAX SM GEL NON_PREFERRED

LOTEPREDNOL ETABONATE GEL NON_PREFERRED

LOTEMAX OINT NON_PREFERRED

ALREX SUSP PREFERRED

EYSUVIS SUSP NON_PREFERRED

INVELTYS SUSP NON_PREFERRED

LOTEMAX SUSP NON_PREFERRED

LOTEPREDNOL ETABONATE SUSP PREFERRED

PRED FORTE SUSP NON_PREFERRED

PRED MILD SUSP PREFERRED

PREDNISOLONE ACETATE SUSP PREFERRED

PREDNISOLONE SODIUM PHOSPHATE SOLN PREFERRED

PRED-G S.O.P. OINT NON_PREFERRED

ZYLET SUSP NON_PREFERRED

BLEPHAMIDE S.O.P. OINT NON_PREFERRED

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN NON_PREFERRED

TOBRADEX OINT NON_PREFERRED

TOBRADEX SUSP NON_PREFERRED

TOBRADEX ST SUSP NON_PREFERRED

TOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED

MAXITROL OINT NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT PREFERRED

MAXITROL SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED

NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT PREFERRED

NEO-POLYCIN HC OINT PREFERRED

CIPROFLOXACIN SOLN NON_PREFERRED

FLOXIN OTIC SOLN NON_PREFERRED

OFLOXACIN SOLN PREFERRED

DERMOTIC OIL NON_PREFERRED

FLAC OIL NON_PREFERRED

FLUOCINOLONE ACETONIDE OIL NON_PREFERRED

HYDROCORTISONE/ACETIC ACID SOLN NON_PREFERRED

ACETIC ACID SOLN PREFERRED

CIPRODEX SUSP PREFERRED

CIPROFLOXACIN/DEXAMETHASONE SUSP PREFERRED

OTIC AGENTS

OTIC AGENTS : OTIC COMBINATIONS

OPHTHALMIC AGENTS : OPHTHALMIC

STEROIDS

3/6/2023 8:01:09 AM Page 137 of 147

CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF SOLN NON_PREFERRED

CIPRO HC SUSP NON_PREFERRED

NEOMYCIN/POLYMYXIN/HC SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SOLN PREFERRED

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP PREFERRED

CORTISPORIN-TC SUSP NON_PREFERRED

MEDROXYPROGESTERONE ACETATE TABS PREFERRED

PROVERA TABS NON_PREFERRED

MEGESTROL ACETATE SUSP NON_PREFERRED

AYGESTIN TABS NON_PREFERRED

NORETHINDRONE ACETATE TABS NON_PREFERRED

PROGESTERONE CAPS PREFERRED

PROMETRIUM CAPS NON_PREFERRED

PROGESTERONE OIL PREFERRED

ADUHELM SOLN NON_PREFERRED

LEQEMBI SOLN NON_PREFERRED

ADLARITY PTWK NON_PREFERRED

ARICEPT TABS NON_PREFERRED

DONEPEZIL HCL TABS PREFERRED

DONEPEZIL HYDROCHLORIDE TABS PREFERRED

DONEPEZIL HCL TBDP PREFERRED

DONEPEZIL HYDROCHLORIDE ODT TBDP PREFERRED

GALANTAMINE HYDROBROMIDEER CP24 NON_PREFERRED

RAZADYNE ER CP24 NON_PREFERRED

GALANTAMINE HYDROBROMIDE SOLN NON_PREFERRED

GALANTAMINE HYDROBROMIDE TABS NON_PREFERRED

EXELON PT24 NON_PREFERRED

RIVASTIGMINE TRANSDERMALSYSTEM PT24 NON_PREFERRED

RIVASTIGMINE TARTRATE CAPS NON_PREFERRED

MEMANTINE HYDROCHLORIDE ER CP24 NON_PREFERRED

NAMENDA XR CP24 NON_PREFERRED

MEMANTINE HYDROCHLORIDE SOLN NON_PREFERRED

MEMANTINE HCL TITRATION PAK TABS NON_PREFERRED

MEMANTINE HYDROCHLORIDE TABS PREFERRED

NAMENDA TABS NON_PREFERRED

NAMENDA TITRATION PAK TABS NON_PREFERRED

NAMZARIC C4PK NON_PREFERRED

NAMZARIC CP24 NON_PREFERRED

ERGOLOID MESYLATES TABS PREFERRED

OTIC AGENTS : OTIC COMBINATIONS

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : ANTIDEMENTIA

AGENTS

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : MISC

PROGESTINS

3/6/2023 8:01:09 AM Page 138 of 147

PIMOZIDE TABS PREFERRED

FLUOXETINE HYDROCHLORIDE TABS NON_PREFERRED

PAROXETINE CAPS NON_PREFERRED

AUSTEDO TABS PREFERRED_WITH_PA

AUSTEDO PATIENT TITRATION KIT TBPK NON_PREFERRED

TETRABENAZINE TABS NON_PREFERRED

XENAZINE TABS NON_PREFERRED

INGREZZA CAPS PREFERRED_WITH_PA

INGREZZA CPPK PREFERRED_WITH_PA

SODIUM OXYBATE SOLN NON_PREFERRED

XYREM SOLN NON_PREFERRED

XYWAV SOLN NON_PREFERRED

SAVELLA TITRATION PACK MISC NON_PREFERRED

SAVELLA TABS NON_PREFERRED

GRALISE MISC NON_PREFERRED

GRALISE TABS NON_PREFERRED

LYRICA CR TB24 NON_PREFERRED

PREGABALIN ER TB24 NON_PREFERRED

PENTICAN THPK NON_PREFERRED

GABAPAL THPK NON_PREFERRED

LIDOTIN THPK NON_PREFERRED

LIPRITIN THPK NON_PREFERRED

LIPRITIN II THPK NON_PREFERRED

PRILOPENTIN THPK NON_PREFERRED

HORIZANT TBCR NON_PREFERRED

NUEDEXTA CAPS NON_PREFERRED

TEGSEDI SOSY NON_PREFERRED

AMVUTTRA SOSY NON_PREFERRED

CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS PREFERRED

PERPHENAZINE/AMITRIPTYLINE TABS PREFERRED

LYBALVI TABS NON_PREFERRED

OLANZAPINE/FLUOXETINE CAPS NON_PREFERRED

SYMBYAX CAPS NON_PREFERRED

COPAXONE SOSY PREFERRED

GLATIRAMER ACETATE SOSY NON_PREFERRED

GLATOPA SOSY NON_PREFERRED

MAVENCLAD TBPK NON_PREFERRED

AVONEX PEN AJKT NON_PREFERRED

AVONEX PSKT NON_PREFERRED

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : MISC

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : MULTIPLE

SCLEROSIS AGENTS

3/6/2023 8:01:09 AM Page 139 of 147

REBIF REBIDOSE SOAJ PREFERRED

REBIF REBIDOSE TITRATIONPACK SOAJ PREFERRED

REBIF SOSY PREFERRED

REBIF TITRATION PACK SOSY PREFERRED

BETASERON KIT PREFERRED

EXTAVIA KIT NON_PREFERRED

PLEGRIDY SOPN NON_PREFERRED

PLEGRIDY STARTER PACK SOPN NON_PREFERRED

PLEGRIDY SOSY NON_PREFERRED

PLEGRIDY STARTER PACK SOSY NON_PREFERRED

AUBAGIO TABS NON_PREFERRED

LEMTRADA SOLN NON_PREFERRED

TYSABRI CONC NON_PREFERRED

OCREVUS SOLN NON_PREFERRED

KESIMPTA SOAJ NON_PREFERRED

BRIUMVI SOLN NON_PREFERRED

DIMETHYL FUMARATE CPDR NON_PREFERRED

TECFIDERA CPDR PREFERRED

DIMETHYL FUMARATE STARTERPACK MISC NON_PREFERRED

TECFIDERA STARTER PACK MISC PREFERRED

VUMERITY CPDR NON_PREFERRED

BAFIERTAM CPDR NON_PREFERRED

AMPYRA TB12 NON_PREFERRED

DALFAMPRIDINE ER TB12 NON_PREFERRED

FINGOLIMOD CAPS NON_PREFERRED

GILENYA 0.25MG CAPS NON_PREFERRED

GILENYA 0.5MG CAPS PREFERRED_WITH_PA

TASCENSO ODT TBDP NON_PREFERRED

ZEPOSIA CAPS NON_PREFERRED

ZEPOSIA 7-DAY STARTER PACK CPPK NON_PREFERRED

ZEPOSIA STARTER KIT CPPK NON_PREFERRED

PONVORY TABS NON_PREFERRED

PONVORY 14-DAY STARTER PACK TBPK NON_PREFERRED

MAYZENT TABS NON_PREFERRED

MAYZENT STARTER PACK TBPK NON_PREFERRED

BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED

NICOTROL INHALER INHA PREFERRED

NICOTINE TRANSDERMAL SYSTEM KIT PREFERRED

GNP NICOTINE TRANSDERMALSYSTEM PT24 PREFERRED

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : MULTIPLE

SCLEROSIS AGENTS

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : SMOKING

DETERRENTS

3/6/2023 8:01:09 AM Page 140 of 147

GNP NICOTINE TRANSDERMALSYSTEM STEP 2 PT24 PREFERRED

HM NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED

HM NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED

HM NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 1 PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 2 PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTEM STEP 3 PT24 PREFERRED

NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR PT24 PREFERRED

SM NICOTINE TRANSDERMAL SYSTEM/STEP 1/CLEAR PT24 PREFERRED

SM NICOTINE TRANSDERMAL SYSTEM/STEP 2/CLEAR PT24 PREFERRED

SM NICOTINE TRANSDERMAL SYSTEM/STEP 3/CLEAR PT24 PREFERRED

NICOTROL NS SOLN PREFERRED

GNP NICOTINE GUM GUM PREFERRED

GNP NICOTINE POLACRILEX GUM PREFERRED

GOODSENSE NICOTINE GUM GUM PREFERRED

GOODSENSE NICOTINE POLACRILEX GUM GUM PREFERRED

HM NICOTINE POLACRILEX GUM PREFERRED

NICOTINE POLACRILEX GUM PREFERRED

SM NICOTINE GUM PREFERRED

SM NICOTINE POLACRILEX GUM PREFERRED

GNP NICOTINE MINI LOZENGE LOZG PREFERRED

GNP NICOTINE POLACRILEX LOZG PREFERRED

GNP NICOTINE POLACRILEX MINI LOZG PREFERRED

GOODSENSE NICOTINE LOZG PREFERRED

GOODSENSE NICOTINE POLACRILEX LOZG PREFERRED

HM NICOTINE POLACRILEX LOZG PREFERRED

NICOTINE LOZG PREFERRED

NICOTINE MINI LOZENGE LOZG PREFERRED

NICOTINE POLACRILEX LOZG PREFERRED

NICOTINE POLACRILEX MINI LOZG PREFERRED

SM NICOTINE LOZG PREFERRED

SM NICOTINE POLACRILEX LOZG PREFERRED

CHANTIX TABS PREFERRED

CHANTIX CONTINUING MONTHPAK TABS PREFERRED

VARENICLINE TARTRATE TABS PREFERRED

CHANTIX STARTING MONTH PAK TBPK PREFERRED

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : SMOKING

DETERRENTS

3/6/2023 8:01:09 AM Page 141 of 147

VARENICLINE STARTING MONTH BOX TBPK PREFERRED

KALYDECO PACK NON_PREFERRED

KALYDECO TABS NON_PREFERRED

PULMOZYME SOLN PREFERRED

BRONCHITOL CAPS NON_PREFERRED

BRONCHITOL TOLERANCE TEST CAPS NON_PREFERRED

ORKAMBI PACK NON_PREFERRED

ORKAMBI TABS NON_PREFERRED

SYMDEKO TBPK NON_PREFERRED

TRIKAFTA TBPK NON_PREFERRED

ESBRIET CAPS NON_PREFERRED

PIRFENIDONE CAPS NON_PREFERRED

ESBRIET TABS NON_PREFERRED

PIRFENIDONE TABS NON_PREFERRED

OFEV CAPS NON_PREFERRED

ACAMPROSATE CALCIUM DR TBEC PREFERRED

DISULFIRAM TABS PREFERRED

LUCEMYRA TABS PREFERRED

SUBLOCADE SOSY PREFERRED

BUPRENORPHINE HCL SUBL PREFERRED

BUPRENORPHINE HYDROCHLORIDE SUBL PREFERRED

BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE FILM PREFERRED

SUBOXONE FILM PREFERRED

BUPRENORPHINE HCL/NALOXONE HCL SUBL PREFERRED

BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE SUBL PREFERRED

ZUBSOLV SUBL PREFERRED

NALMEFENE HYDROCHLORIDE SOLN PREFERRED

KLOXXADO LIQD PREFERRED

NALOXONE HYDROCHLORIDE LIQD PREFERRED

NARCAN LIQD PREFERRED

NALOXONE HYDROCHLORIDE SOCT PREFERRED

NALOXONE HCL SOLN PREFERRED

NALOXONE HYDROCHLORIDE SOLN PREFERRED

NALOXONE HCL SOSY PREFERRED

NALOXONE HYDROCHLORIDE SOSY PREFERRED

ZIMHI SOSY PREFERRED

VIVITROL SUSR PREFERRED

NALTREXONE HCL TABS PREFERRED

NALTREXONE HYDROCHLORIDE TABS PREFERRED

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS : SMOKING

DETERRENTS

RESPIRATORY AGENTS : CYSTIC

FIBROSIS AGENTS

RESPIRATORY AGENTS : MISC

SUBSTANCE USE DISORDER AGENTS

3/6/2023 8:01:09 AM Page 142 of 147

LEVOTHYROXINE SODIUM CAPS NON_PREFERRED

TIROSINT CAPS NON_PREFERRED

ERMEZA SOLN NON_PREFERRED

THYQUIDITY SOLN NON_PREFERRED

TIROSINT-SOL SOLN NON_PREFERRED

EUTHYROX TABS PREFERRED

LEVO-T TABS PREFERRED

LEVOTHYROXINE SODIUM TABS PREFERRED

LEVOXYL TABS PREFERRED

SYNTHROID TABS NON_PREFERRED

UNITHROID TABS PREFERRED

CYTOMEL TABS NON_PREFERRED

LIOTHYRONINE SODIUM TABS PREFERRED

ADTHYZA TABS PREFERRED

ARMOUR THYROID TABS PREFERRED

NP THYROID 120 TABS PREFERRED

NP THYROID 15 TABS PREFERRED

NP THYROID 30 TABS PREFERRED

NP THYROID 60 TABS PREFERRED

NP THYROID 90 TABS PREFERRED

METHIMAZOLE TABS PREFERRED

PROPYLTHIOURACIL TABS PREFERRED

ENTYVIO SOLR NON_PREFERRED

SKYRIZI SOCT NON_PREFERRED

SKYRIZI SOLN NON_PREFERRED

STELARA SOLN NON_PREFERRED

CIMZIA KIT NON_PREFERRED

CIMZIA PREFL KIT 200MG/M PSKT PREFERRED_WITH_PA

CIMZIA STARTER KIT PSKT PREFERRED_WITH_PA

INFLIXIMAB SOLR NON_PREFERRED

REMICADE SOLR NON_PREFERRED

RENFLEXIS SOLR NON_PREFERRED

AVSOLA SOLR NON_PREFERRED

INFLECTRA SOLR NON_PREFERRED

KINERET SOSY NON_PREFERRED

HUMIRA PEN PNKT PREFERRED_WITH_PA

HUMIRA PEN-CD/UC/HS STARTER PNKT PREFERRED_WITH_PA

HUMIRA PEN-PEDIATRIC UC STARTER PACK PNKT PREFERRED_WITH_PA

HUMIRA PEN-PS/UV STARTER PNKT PREFERRED_WITH_PA

THYROID AGENTS

TUMOR NECROSIS FACTOR ALPHA

INHIBITORS AND MISC

IMMUNOSUPPRESSIVES

3/6/2023 8:01:09 AM Page 143 of 147

HUMIRA PSKT PREFERRED_WITH_PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT PREFERRED_WITH_PA

AMJEVITA SOAJ NON_PREFERRED

AMJEVITA SOSY NON_PREFERRED

SIMPONI SOAJ NON_PREFERRED

SIMPONI ARIA SOLN NON_PREFERRED

SIMPONI SOSY NON_PREFERRED

ENBREL SURECLICK SOAJ PREFERRED_WITH_PA

ENBREL MINI SOCT PREFERRED_WITH_PA

ENBREL SOLN PREFERRED_WITH_PA

ENBREL SOLR PREFERRED_WITH_PA

ENBREL SOSY PREFERRED_WITH_PA

ORENCIA CLICKJECT SOAJ NON_PREFERRED

ORENCIA SOLR NON_PREFERRED

ORENCIA SOSY NON_PREFERRED

ARCALYST SOLR NON_PREFERRED

ILARIS SOLN NON_PREFERRED

KEVZARA SOAJ NON_PREFERRED

KEVZARA SOSY NON_PREFERRED

ACTEMRA ACTPEN SOAJ NON_PREFERRED

ACTEMRA SOLN NON_PREFERRED

ACTEMRA SOSY NON_PREFERRED

OLUMIANT TABS NON_PREFERRED

XELJANZ SOLN PREFERRED_WITH_PA

XELJANZ TABS PREFERRED_WITH_PA

XELJANZ XR TB24 PREFERRED_WITH_PA

RINVOQ TB24 NON_PREFERRED

OTEZLA TABS NON_PREFERRED

OTEZLA TBPK NON_PREFERRED

CIMETIDINE TABS PREFERRED

CIMETIDINE HCL SOLN PREFERRED

CIMETIDINE HYDROCHLORIDE SOLN PREFERRED

FAMOTIDINE SUSR PREFERRED

FAMOTIDINE TABS PREFERRED

PEPCID TABS NON_PREFERRED

NIZATIDINE CAPS PREFERRED

HYOSCYAMINE SULFATE ELIX PREFERRED

HYOSCYAMINE SULFATE SOLN PREFERRED

HYOSCYAMINE SULFATE SUBL PREFERRED

ULCER DRUGS / ANTISPASMODICS /

ANTICHOLINERGICS : H-2 ANTAGONISTS

ULCER DRUGS / ANTISPASMODICS /

ANTICHOLINERGICS : MISC

TUMOR NECROSIS FACTOR ALPHA

INHIBITORS AND MISC

IMMUNOSUPPRESSIVES

3/6/2023 8:01:09 AM Page 144 of 147

LEVSIN/SL SUBL NON_PREFERRED

OSCIMIN SUBL PREFERRED

HYOSCYAMINE SULFATE TABS PREFERRED

LEVSIN TABS NON_PREFERRED

OSCIMIN TABS PREFERRED

HYOSCYAMINE SULFATE ER TB12 PREFERRED

OSCIMIN SR TB12 PREFERRED

ED-SPAZ TBDP PREFERRED

HYOSCYAMINE SULFATE TBDP PREFERRED

HYOSCYAMINE SULFATE ODT TBDP PREFERRED

NULEV TBDP PREFERRED

CUVPOSA SOLN NON_PREFERRED

GLYCOPYRROLATE SOLN PREFERRED

GLYCATE TABS NON_PREFERRED

GLYCOPYRROLATE TABS PREFERRED

ROBINUL TABS NON_PREFERRED

ROBINUL FORTE TABS NON_PREFERRED

DARTISLA ODT TBDP NON_PREFERRED

METHSCOPOLAMINE BROMIDE TABS NON_PREFERRED

DICYCLOMINE HYDROCHLORIDE CAPS PREFERRED

DICYCLOMINE HCL SOLN PREFERRED

DICYCLOMINE HYDROCHLORIDE SOLN PREFERRED

DICYCLOMINE HYDROCHLORIDE TABS PREFERRED

BELLADONNA/OPIUM SUPP PREFERRED

CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS NON_PREFERRED

CHLORDIAZEPOXIDE HYDROCHLORIDE/CLIDINIUM BROMIDE CAPS NON_PREFERRED

LIBRAX CAPS NON_PREFERRED

CYTOTEC TABS NON_PREFERRED

MISOPROSTOL TABS PREFERRED

CARAFATE SUSP PREFERRED

SUCRALFATE SUSP PREFERRED

CARAFATE TABS NON_PREFERRED

SUCRALFATE TABS PREFERRED

PYLERA CAPS NON_PREFERRED

LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN MISC NON_PREFERRED

OMECLAMOX-PAK MISC NON_PREFERRED

TALICIA CPDR NON_PREFERRED

OMEPRAZOLE/SODIUM BICARBONATE CAPS NON_PREFERRED

ZEGERID CAPS NON_PREFERRED

ULCER DRUGS / ANTISPASMODICS /

ANTICHOLINERGICS : MISC

3/6/2023 8:01:09 AM Page 145 of 147

OMEPRAZOLE/SODIUM BICARBONATE PACK NON_PREFERRED

ZEGERID PACK NON_PREFERRED

DEXILANT CPDR NON_PREFERRED

DEXLANSOPRAZOLE CPDR NON_PREFERRED

ESOMEPRAZOLE MAGNESIUM CPDR NON_PREFERRED

NEXIUM CPDR NON_PREFERRED

ESOMEPRAZOLE MAGNESIUM PACK NON_PREFERRED

NEXIUM PACK NON_PREFERRED

LANSOPRAZOLE CPDR NON_PREFERRED

PREVACID CPDR NON_PREFERRED

LANSOPRAZOLE TBDD PREFERRED

LANSOPRAZOLE ODT TBDD PREFERRED

PREVACID SOLUTAB TBDD NON_PREFERRED

OMEPRAZOLE CPDR PREFERRED

OMEPRAZOLE DR CPDR PREFERRED

PRILOSEC PACK NON_PREFERRED

PANTOPRAZOLE SODIUM PACK NON_PREFERRED

PROTONIX PACK NON_PREFERRED

PANTOPRAZOLE SODIUM TBEC PREFERRED

PANTOPRAZOLE SODIUM DR TBEC PREFERRED

PROTONIX TBEC NON_PREFERRED

ACIPHEX TBEC NON_PREFERRED

RABEPRAZOLE SODIUM TBEC NON_PREFERRED

DARIFENACIN HYDROBROMIDEER TB24 NON_PREFERRED

FESOTERODINE FUMARATE ER TB24 NON_PREFERRED

TOVIAZ TB24 NON_PREFERRED

OXYTROL PTTW NON_PREFERRED

GELNIQUE GEL NON_PREFERRED

OXYBUTYNIN CHLORIDE SOLN PREFERRED

OXYBUTYNIN CHLORIDE SYRP PREFERRED

OXYBUTYNIN CHLORIDE TABS PREFERRED

DITROPAN XL TB24 NON_PREFERRED

OXYBUTYNIN CHLORIDE ER TB24 PREFERRED

VESICARE LS SUSP NON_PREFERRED

SOLIFENACIN SUCCINATE TABS PREFERRED

VESICARE TABS NON_PREFERRED

DETROL LA CP24 NON_PREFERRED

TOLTERODINE TARTRATE ER CP24 NON_PREFERRED

DETROL TABS NON_PREFERRED

ULCER DRUGS / ANTISPASMODICS /

ANTICHOLINERGICS : MISC

ULCER DRUGS / ANTISPASMODICS /

ANTICHOLINERGICS : PROTON PUMP

INHIBITORS

URINARY ANTISPASMODICS

3/6/2023 8:01:09 AM Page 146 of 147

TOLTERODINE TARTRATE TABS NON_PREFERRED

TROSPIUM CHLORIDE ER CP24 NON_PREFERRED

TROSPIUM CHLORIDE TABS NON_PREFERRED

MYRBETRIQ SRER NON_PREFERRED

MYRBETRIQ TB24 NON_PREFERRED

GEMTESA TABS NON_PREFERRED

BETHANECHOL CHLORIDE TABS PREFERRED

FLAVOXATE HCL TABS NON_PREFERRED

CLEOCIN CREA NON_PREFERRED

CLINDAMYCIN PHOSPHATE CREA PREFERRED

XACIATO GEL NON_PREFERRED

CLEOCIN SUPP PREFERRED

CLINDESSE CREA NON_PREFERRED

METRONIDAZOLE VAGINAL GEL PREFERRED

NUVESSA GEL NON_PREFERRED

VANDAZOLE GEL NON_PREFERRED

GYNAZOLE-1 CREA NON_PREFERRED

MICONAZOLE 3 SUPP PREFERRED

TERCONAZOLE CREA PREFERRED

TERCONAZOLE SUPP PREFERRED

PHEXXI GEL PREFERRED

ESTRACE CREA NON_PREFERRED

ESTRADIOL CREA PREFERRED

IMVEXXY MAINTENANCE PACK INST NON_PREFERRED

IMVEXXY STARTER PACK INST NON_PREFERRED

ESTRING RING NON_PREFERRED

ESTRADIOL TABS NON_PREFERRED

VAGIFEM TABS NON_PREFERRED

YUVAFEM TABS NON_PREFERRED

FEMRING RING NON_PREFERRED

PREMARIN CREA PREFERRED

CRINONE GEL NON_PREFERRED

ENDOMETRIN INST PREFERRED

INTRAROSA INST NON_PREFERRED

TRIMO-SAN GEL NON_PREFERRED

URINARY ANTISPASMODICS

VAGINAL PRODUCTS

3/6/2023 8:01:09 AM Page 147 of 147